Induction Therapy With Anti-TNFα vs Cyclophosphamide in Severe Behçet Disease

Vasculitis Clinical Trial

— ITAC  

Official title:

Multicenter, Randomized, Prospective Trial Comparing the Efficacy and Safety of Infliximab to That of Cyclophosphamide in Severe Behçet's Disease. ITAC : Induction Therapy With Anti-TNFα vs Cyclophosphamide in Severe Behçet Disease

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT03371095
• Other study ID #: P160932J
• Status: Completed
• Phase: Phase 3
• Start date: May 25, 2018
• Est. completion date: April 11, 2022

Study information

• Verified date: December 2017
• Source: Assistance Publique - Hôpitaux de Paris
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Behçet's disease (BD) is a systemic vasculitis of arterial and venous vessels of any size, involving young patients (from 15 to 45 years). BD significantly increases morbidity and mortality. Therapeutic management of BD depends on the clinical presentation and organ involved. Although colchicine, nonsteroidal antiinflammatory agents and topical treatments are often sufficient for mucocutaneous and joint involvement, more aggressive approach with immunosuppressive agents is warranted for severe manifestations. Early recognition and vigorous use of immunosuppressives with high dose steroids have changed the prognosis of patients with severe BD. BD is a severe systemic vasculitis leading to blindness in up to 20% at 4 years and a 5-year mortality rate of 15% in patients with major vessel or neurological involvement. Cyclophosphamide has been used for life-threatening BD for 40 years. However, the outcome of severe complications of BD is poor. The European League Against Rheumatism (EULAR) recommendation for the management of BD advocated cyclophosphamide plus glucocorticoids for life-threatening manifestations (i.e neurological and/or major vessel involvement). TNFa antagonists have been used with success in severe and/or resistant cases. In addition, the incidence of blindness in BD has been dramatically reduced in the recent years with the use of anti-TNF. However, there is no firm evidence or randomized controlled trials directly addressing the best induction immunosuppressive therapy in severe BD manifestations. The investigators therefore aimed to assess the best induction therapy in severe and difficult to treat BD patients. The investigators hypothesize that up to 70% of the patients with life-threatening manifestations of BD receiving these compounds [anti-TNFa or cyclophosphamide] will achieve a complete remission of BD at 6 months and with less than 0.1 mg/kg/day of prednisone.

ITAC, is the first randomized prospective, head to head study, comparing infliximab, to cyclophosphamide in severe manifestations of BD. There is no firm evidence or randomized controlled trials directly addressing the best induction immunosuppressive therapy in severe BD. Cyclophosphamide failed to demonstrate sustainable remission over 70 % of life threatening BD cases. There is little published information on use of immunosuppressants other than cyclophosphamide for severe BD. TNFa antagonists have been used with success in severe and/or resistant cases. TNFa expression correlates with BD activity and other immunological data provide a strong rationale for targeting BD with biologics. Despite a strong rationale, these compounds are not yet approved in BD, which guarantees the innovative nature of this study that aims selecting or dropping any arm when evidence of efficacy already exists.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 53
• Est. completion date: April 11, 2022
• Est. primary completion date: December 24, 2021
• Accepts healthy volunteers: No
• Gender: All
• Age group: 12 Years and older

Eligibility

Inclusion Criteria:

• Age = 12 years old

• Written inform consent (Informed Consent should be obtained from the legal guardian in accordance with regional laws or regulations for patients 12 to 17 years of age)

• Diagnosis of BD according to international criteria for BD (ICBD) (see Appendix 1).

• Life threatening active BD defined as 1 of the following disease categories and according to the validated international definition:

• Major vessel disease: arterial aneurysms or arterial stenosis, myocarditis and/or major deep vein thrombosis (i.e. inferior vena cava, superior vena cava, cardiac cavity thrombosis, pulmonary embolism, supra-hepatic vessels, renal and mesenteric vessels). Diagnosis of major vessel involvement will be done using vascular doppler sonography, echocardiography, angio-CT scan and/or cardiac magnetic resonance imaging (MRI).

• Central nervous system involvement: encephalitis or meningoencephalitis or myelitis. The diagnosis of neuro-Behçet's (CNS involvement) will be based on objective neurological symptoms that were associated with neuroimaging (CNS and/or medullar MRI) findings suggestive of BD-related CNS involvement. Cerebrospinal fluid (CSF) findings showing aseptic inflammation may be associated.

• Chest X-ray results (postero-anterior and lateral) within 12 weeks prior to inclusion with no evidence of active Tuberculosis, active infection, or malignancy

• For female subjects of child-bearing age, a negative pregnancy test

• For subjects with reproductive potential, a willingness to use contraceptive measures adequate to prevent the subject or the subject's partner from becoming pregnant during the study and 6 months after stopping therapy. Adequate contraceptive measures include hormonal methods used for two or more cycles prior to Inclusion (e.g., oral contraceptive pills, contraceptive patch, or contraceptive vaginal ring), barrier methods (e.g., contraceptive sponge, diaphragm used in conjunction with contraceptive foam or jelly, or condom used in conjunction with contraceptive foam or jelly), intrauterine methods (IUD), sterilization (e.g., tubal ligation or a monogamous relationship with a vasectomized partner), and abstinence.

• A potential subject with a positive interferon-gamma release assay (IGRA) (e.g., QuantiFERON®-TB Gold or T-spot TB® Test) or a positive tuberculin skin test (=6 months) is eligible if her/his chest X-ray does not show evidence suggestive of active tuberculosis (TB) disease and there are no clinical signs and symptoms of pulmonary and/or extra-pulmonary TB disease. These subjects with a latent TB infection who have not already received a prophylactic TB treatment must agree in advance to complete such a treatment course.

• HIV negative serology and negative HBs Ag test (=1 month)

Exclusion Criteria:

• Evidence of active Tuberculosis

• HIV or active HBV infection (HBs Ag+).

• Pregnancy or lactation

• Have been taking an oral daily dose of a glucocorticoid of more than 20 mg prednisone equivalent for more than 6 weeks continuously prior to the inclusion visit or taking more than 3000 mg methylprednisolone 4 weeks prior to the inclusion visit

• Alcohol or drug dependance

• Severe renal (creatinine clearance <30ml/min/1,73m2) or pre-existing hemorrhagic cystitis or liver insufficiency (hepatic encephalopathy) or urinary obstruction

• Heart failure = stage III / IV NYHA,

• History of malignancy within 5 years prior to Inclusion other than carcinoma in situ of the cervix or excised basal cell or squamous cell carcinoma of the skin.

• History of multiple sclerosis and/or demyelinating disorder

• History of severe allergic or anaphylactic reactions to cyclophosphamide or infliximab

• Infectious disease:

• Infection requiring treatment with intravenous antibiotics within 2 weeks prior to Inclusion

• History of recurrent infection

• Laboratory values assessed during Inclusion:

• Hemoglobin < 8 g/dL

• WBC < 2.0 x 103/mm3

• Platelet count < 70 x 103/mm3

• Use of the following systemic treatments during the specified periods:

• Treatment with systemic biologic therapy or with cyclophosphamide within 3 months prior to Inclusion

• if on azathioprine, mycophenolate mofetil, or methotrexate at the time of inclusion, these drugs must be withdrawn prior to receiving the cyclophosphamide or infliximab dose on Day 1

• Any live (attenuated) vaccine within 4 weeks prior inclusion; recombinant or killed virus vaccines are permitted.

• Lack of affiliation to a social security benefit plan (as a beneficiary or assignee), patients affiliated to universal medical coverage (CMU) are eligible for the study

Related Conditions & MeSH terms

• Behcet Syndrome
• Behcet's Disease
• Vasculitis

Intervention

Drug:
• Infliximab
Use of infliximab instead of cyclophosphamide
• Cyclophosphamide
Use of cyclophosphamide

Locations

Country	Name	City	State
France	CHRU Amiens	Amiens
France	Hôpital Avicenne	Bobigny
France	CHU Bordeaux	Bordeaux
France	Hôpital Saint André	Bordeaux
France	CH Ambroise Paré	Boulogne-Billancourt
France	CHU Caen	Caen
France	Henri Mondor Hospital	Créteil
France	CHU Dijon	Dijon
France	CHU Grenoble	Grenoble
France	CHU Bicêtre	Le Kremlin-Bicêtre
France	CHRU Lille	Lille
France	Hôpital de la Croix Rousse	Lyon
France	Hôpital Edouard Herriot	Lyon
France	Hôpital de La Timone	Marseille
France	CH Metz	Metz
France	CHU Bichat	Paris
France	CHU Tenon	Paris
France	Hôpital de La Pitié Salpetriere	Paris
France	Hôpital Foch	Paris
France	Hôpital Lariboisière	Paris
France	Hôpital Saint Antoine	Paris
France	Hôpital Saint Louis	Paris
France	CHU Poitiers	Poitiers
France	Hôpital Bois Guillaume	Rouen
France	CH Saint-Denis	Saint-Denis
France	CHU Purpan	Toulouse
France	CH Valenciennes	Valenciennes

Sponsors (1)

Lead Sponsor	Collaborator
Assistance Publique - Hôpitaux de Paris

Country where clinical trial is conducted

France, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Complete clinical response	The complete clinical response is defined by the remission of all affected organs involved at baseline with a prednisone = 0.1mg/kg per day	At week 22 after randomization
Secondary	Complete clinical response	The complete clinical response is defined by the remission of all affected organs involved at baseline with a prednisone = 0.1mg/kg per day	At week 12 after randomization
Secondary	Complete clinical response	The complete clinical response is defined by the remission of all affected organs involved at baseline with a prednisone = 0.1mg/kg per day	At week 48 after randomization
Secondary	Remission of CNS and/or cardiovascular involvement		At week 12 after randomization
Secondary	Remission of CNS and/or cardiovascular involvement		At week 22 after randomization
Secondary	Remission of CNS and/or cardiovascular involvement		At week 48 after randomization
Secondary	Percent meeting the target of = 0.1 mg/day/kg of prednisone		At week 22 after randomization
Secondary	Percent meeting the target of = 0.1 mg/day/kg of prednisone		At week 48 after randomization
Secondary	Mean dose of prednisone		At week 12 after randomization
Secondary	Mean dose of prednisone		At week 22 after randomization
Secondary	Mean dose of prednisone		At week 48 after randomization
Secondary	Cumulative dose of prednisone		At week 12 after randomization
Secondary	Cumulative dose of prednisone		At week 22 after randomization
Secondary	Cumulative dose of prednisone		At week 48 after randomization
Secondary	Time to response onset		At week 48 after randomization
Secondary	C-reactive protein	CRP in blood sample	Every 4 weeks
Secondary	Time to relapse	Relapse will be defined as the reappearance of clinical and/or paraclinical features of active disease or by the occurrence of new lesions at week 48	At week 48 after randomization
Secondary	Rate of relapse		At week 48 after randomization
Secondary	Time to occurrence of worsening	Worsening will be defined as the progression of preexisting lesions) at week 22 and 48	At week 48 after randomization
Secondary	Rate of worsening		At week 48 after randomization
Secondary	Overall survival		At week 22 after randomization
Secondary	Overall survival		At week 48 after randomization
Secondary	Event Free Survival		At week 22 after randomization
Secondary	Event Free Survival		At week 48 after randomization
Secondary	Frequency of adverse clinical events	Incidence of Treatment related Adverse Events	At week 22 after randomization
Secondary	Severity of adverse clinical events		At week 22 after randomization
Secondary	Change in quality of life	Change in quality of life (QOL) (SF-36V2TM Health Survey)	At week 12 after randomization
Secondary	Change in quality of life	Change in quality of life (QOL) (SF-36V2TM Health Survey)	At week 22 after randomization
Secondary	Changes in CNS involvement	Changes in CNS involvement on physical exam, and cerebral and/or medullar MRI.	At week 12 after randomization
Secondary	Changes in CNS involvement	Changes in CNS involvement on physical exam, and cerebral and/or medullar MRI.	At week 22 after randomization
Secondary	Changes in vascular involvement	Changes in vascular involvement on physical exam, vascular Doppler US, and angio-CT imaging and biologically (normalization of C reactive protein)	At week 12 after randomization
Secondary	Changes in vascular involvement	Changes in vascular involvement on physical exam, vascular Doppler US, and angio-CT imaging and biologically (normalization of C reactive protein)	At week 22 after randomization
Secondary	Changes in cardiological involvement	Changes in cardiological involvement on physical exam, echocardiography (normalization of left ventricular function and/or disappearance of cardiac thrombosis), and cardiac magnetic resonance imaging (disappearance of gadolinium enhancement and normalization of left ventricular function) and biologically (normalization of troponin and of C reactive protein)	At week 12 after randomization
Secondary	Changes in cardiological involvement	Changes in cardiological involvement on physical exam, echocardiography (normalization of left ventricular function and/or disappearance of cardiac thrombosis), and cardiac magnetic resonance imaging (disappearance of gadolinium enhancement and normalization of left ventricular function) and biologically (normalization of troponin and of C reactive protein)	At week 22 after randomization
Secondary	Serum concentration measurement of TNFa inhibitor at week 22		At week 12 after randomization
Secondary	Change in Behcet's Disease Current Activity Form		At week 12 after randomization
Secondary	Change in Behcet's Disease Current Activity Form		At week 22 after randomization