Safety and Effectiveness of Live Zoster Vaccine in Anti-Tumor Necrosis Factor (TNF) Users (VERVE Trial)

Rheumatoid Arthritis Clinical Trial

Official title:

Safety and Effectiveness of Live Zoster Vaccine in Anti-TNF Users (VERVE Trial)

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT02538341
• Other study ID #: VERVE-UM1
• Status: Completed
• Phase: Phase 2
• Start date: May 2016
• Est. completion date: December 2020

Study information

• Verified date: October 2021
• Source: University of Alabama at Birmingham
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The VaricElla zosteR VaccinE (VERVE) trial evaluates the safety and effectiveness of the Herpes zoster (HZ) vaccine for shingles, Zostavax, in patients over 50 years old with arthritis and other diseases who are using anti-tumor necrosis factor (TNF) therapy and who have not previously received the vaccine.

Description:

Herpes zoster (HZ), also known as "shingles", is caused by reactivation and multiplication of the ubiquitous varicella zoster virus (VZV) that remains latent in everyone's sensory neurons following varicella, or "chickenpox". Among individuals who live to age 85, the lifetime risk for herpes zoster (HZ) is 50%, and more than one in five individuals affected by zoster develop post-herpetic neuralgia, resulting in chronic pain. Other serious complications include encephalitis, permanent vision loss, or more rarely, dissemination and death. Fortunately, a live attenuated vaccine is available and can reduce herpes zoster (HZ) risk by up to 70%. For patients with rheumatoid arthritis (RA), this vaccine has great potential to provide improved quality of life by reducing the incidence and complications associated with zoster. Due to the underlying disease and/or treatments (e.g. steroids) for rheumatoid arthritis (RA), the risk of herpes zoster (HZ) in rheumatoid arthritis patients is approximately double in the general population. This increased risk should make prevention of zoster and vaccination exceedingly important for rheumatoid arthritis patients. In fact, because of a higher overall absolute risk for herpes zoster (HZ) in rheumatoid arthritis, the vaccine yields a comparable or even greater absolute risk reduction to reduce the risk of shingles and post-herpetic neuralgia in a rheumatoid arthritis population as it does in the general population. However, the use of the herpes zoster (HZ) in rheumatoid arthritis, patients is very low (< 5%), and less frequently used than for the general population.

National guidelines from the Centers for Disease Control's (CDC) Advisory Committee on Immunization Practices (ACIP) recommend a single dose of the herpes zoster (HZ) vaccine for all individuals age 60 or older, with the vaccine more recently gaining Federal Drug Administration (FDA) -approval for administration to persons age 50 and older. While a large number of rheumatoid arthritis patients would otherwise be recommended to receive this vaccine on the basis of age, theoretical safety concerns related to vaccination likely explain the very low vaccination rates observed. Currently, the Federal Drug Administration (FDA), the Advisory Committee on Immunization Practices (ACIP), and the American College of Rheumatology (ACR) consider the live zoster vaccine contraindicated in patients receiving immunosuppressive medications, such as biologic therapies. Such contraindication stems from the theoretical safety concern that these individuals could develop a varicella-like infection from the vaccine virus strain. However, investigators hypothesize that this vaccine can safely be given in this setting, as no published data is available to suggest that these safety concerns are warranted. A growing body of observational data suggests that vaccinating rheumatoid arthritis patients receiving biologic therapies with this vaccine may in fact be safe. Moreover, and similarly with little or no evidence, the Advisory Committee on Immunization Practices (ACIP) considers the vaccine safe and acceptable for patients using methotrexate at doses commonly used to treat rheumatoid arthritis (e.g. <= 25mg/week) and for patients using glucocorticoids at prednisone-equivalent doses of ≤ 20 mg/day.

In light of 1) a substantial elevated herpes zoster (HZ) risk among rheumatoid arthritis patients; 2) national data showing most rheumatoid arthritis patients are not vaccinated for herpes zoster (HZ) ; and 3) the high effectiveness of this vaccine in the general population, the investigators propose to conduct the Varicella zostER VaccinE (VERVE) trial, a randomized, double-blind, placebo-controlled study to evaluate the safety, tolerability, and long-term effectiveness of the live herpes zoster (HZ) vaccine. This study will recruit 1,000 individuals age 50 years or older currently receiving anti-tumor necrosis factor (TNF) therapy for rheumatoid arthritis or other diseases. Within a relevant 6-week safety window, the investigators will collect serious adverse events (satisfying a regulatory definition of a Serious Adverse Event) including non-serious events of vaccine-strain varicella-like infection or herpes zoster (HZ). Beyond the key public health importance of the clinical question addressed, clinical trial methodological innovations anticipated for this unique large pragmatic trial. Additionally, the investigators will study vaccine tolerability and long-term effectiveness through a linkage to health plan data to allow for cost-effective follow-up while minimizing participant and study-site burden. Results from this study will facilitate the parent trial and change rheumatoid arthritis management by demonstrating the clinical safety and immunogenicity of the live zoster vaccine among current anti-tumor necrosis factor (TNF) users. Rheumatologists and other providers will be able to improve the care, outcomes, and quality of life for patients using anti-tumor necrosis factor (TNF) therapy, substantially decreasing the morbidity of herpes zoster and its complications over a lifetime.

Other known NCT identifiers

• NCT01967316
• NCT02538757

Recruitment information / eligibility

• Status: Completed
• Enrollment: 617
• Est. completion date: December 2020
• Est. primary completion date: December 2019
• Accepts healthy volunteers: No
• Gender: All
• Age group: 50 Years and older

Eligibility

Inclusion Criteria:

• Must be 50 years of age or older

• Must be currently treated with an anti-tumor necrosis factor (TNF) therapy** at the time of study drug administration, allowing for small deviations in dosing frequency and logistic feasibility (e.g. study visits to occur on a week day). Date of previous dose of medication is required. Specifically, meets one of the following: Etanercept dose within 9 days (1 week + 2 days), Adalimumab dose within 16 days (2 weeks + 2 days), Certolizumab Subcutaneous (SC) dose within 16 to 32 days depending on frequency schedule (2 weeks + 2 days, or 4 weeks and 4 days), Golimumab Subcutaneous (SC) dose within 32 days (4 weeks + 4 days), Golimumab Intravenous (IV) dose within 64 days (9 weeks + 1 day), Infliximab IV dose within last 64 days (9 weeks + 1 day)

**any form of biosimilar for the above listed anti-tumor necrosis factor (TNF) medications is acceptable

• Diagnosis of rheumatoid arthritis or another inflammatory arthritis (Phase 1A); or other inflammatory condition (e.g. psoriasis) requiring use of anti-tumor necrosis factor (TNF) therapy (Phase 1B and II)

• Phase I subjects must test positive for varicella-zoster virus (VZV) antibody immunoglobulin G (IgG)

• Subjects should have a self-reported history of prior varicella infection (i.e. chicken pox) or long-term residence (>30 years) in the continental United States.

• Phase IA subjects must not have received any oral or systemic glucocorticoids within 30 days prior to vaccination. Intra-articular glucocorticoid injections and inhaled glucocorticoids within the previous 30 days are acceptable.

• Subjects should be on stable doses of all biologic and non-biologic Disease-modifying antirheumatic drugs (DMARDs) for a minimum of 30 days prior to vaccination.

• Eligible women must be post-menopausal (> 1 year since last menstrual period) or have a surgical history of bilateral oophorectomy or hysterectomy.

• Subjects should be ambulatory, community dwelling and capable of giving informed consent.

Exclusion Criteria:

• Documented varicella-zoster virus (VZV) antibody immunoglobulin G (IgG) negative result

• Prior use of the zoster vaccine (Zostavax®, Merck)

• Glucocorticoids at a prednisone-equivalent daily dose > 10mg/day (for Phase 1B and Phase II participants; all systemic glucocorticoid use is prohibited for Phase 1A patients)

• Any known contraindication to Zostavax® vaccine, including allergy or sensitivity to gelatin or any other vaccine component

• Known human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS)

• Currently receiving radiation or chemotherapy for any type of malignancy

• Any current use (within the last 30 days) of acyclovir, valacyclovir, famciclovir, or foscarnet

• Receipt of any other immunizations within one month before study vaccination (2 weeks in the case of inactivated influenza vaccines or other non-replicating immunization products [e.g., diphtheria-tetanus (dT), pneumococcal vaccine, hepatitis A vaccine, hepatitis B vaccine]), or scheduled within 6 weeks after recruitment.

• Active infection or inter-current illness (e.g., urinary tract infection, influenza)

• Participated in an investigational study within 1 month prior to study entry

• Active drug or alcohol use, dependence, or any other reason that, in the opinion of the site investigator, would interfere with the study

• Significant underlying illness that would be expected to prevent completion of the study (e.g., life-threatening disease likely to limit survival to less than 3 years)

• Any other reason that, in the opinion of the site investigator, would interfere with required study related evaluations (e.g. uncontrolled comorbidity, life expectancy < 1 year)

• Patients who have household contact with varicella-susceptible pregnant women or severely immunosuppressed individuals without history of primary varicella.

Related Conditions & MeSH terms

• Ankylosing Spondylitis
• Arthritis
• Arthritis, Psoriatic
• Crohn Disease
• Crohn's Disease
• Enteropathic Arthritis
• Inflammatory Arthritis
• Psoriasis
• Psoriatic Arthritis
• Rheumatoid Arthritis
• Spondylitis
• Spondylitis, Ankylosing

Intervention

Biological:
• Herpes Zoster (HZ) Vaccine

Drug:
• Placebo

Locations

Country	Name	City	State
United States	The Center for Rheumatology, LLP	Albany	New York
United States	Ochsner Clinic Baton Rouge	Baton Rouge	Louisiana
United States	Rheumatology Associates, PC	Birmingham	Alabama
United States	Total Skin and Beauty Dermatology Center, PC	Birmingham	Alabama
United States	University of Alabama at Birmingham	Birmingham	Alabama
United States	Boston Medical Center	Boston	Massachusetts
United States	The Ohio State University	Columbus	Ohio
United States	Mary Imogene Bassett Hospital, Bassett Research Institute	Cooperstown	New York
United States	Altoona Center for Clinical Research	Duncansville	Pennsylvania
United States	St. Paul Rheumatology	Eagan	Minnesota
United States	Pine Hollow Partners	East Lansing	Michigan
United States	Arthritis Associates, PLLC	Hixson	Tennessee
United States	Rheumatology Associates of North Alabama, PC	Huntsville	Alabama
United States	West Tennessee Research Institute	Jackson	Tennessee
United States	North Georgia Rheumatology Group	Lawrenceville	Georgia
United States	Rheumatology Consultants of Delaware dba Delaware Arthritis	Lewes	Delaware
United States	Arthritis Association of Southern California	Los Angeles	California
United States	The Regents of the University of California Los Angeles	Los Angeles	California
United States	Southwest Rheumatology Research, LLC	Mesquite	Texas
United States	Center for Arthritis and Rheumatic Diseases	Miami	Florida
United States	Coral Research Clinic Corp	Miami	Florida
United States	Carolina Health Specialists	Myrtle Beach	South Carolina
United States	Ochsner Clinic Foundation, New Orleans	New Orleans	Louisiana
United States	University of Nebraska Medical Center	Omaha	Nebraska
United States	Arthritis Research of Florida, Inc	Palm Harbor	Florida
United States	SunValley Arthritis Center, Ltd	Peoria	Arizona
United States	Oregon Health & Science University	Portland	Oregon
United States	University of Texas Health Science Center at San Antonio	San Antonio	Texas
United States	Sarasota Arthritis Research Center	Sarasota	Florida
United States	Rheumatology & Osteoporosis Specialists	Shreveport	Louisiana
United States	West Virginia Research Institute, PLLC	South Charleston	West Virginia
United States	West Broward Rheumatology Associates, Inc	Tamarac	Florida
United States	Clinical and Translational Research Center of Alabama, PC	Tuscaloosa	Alabama
United States	Arthritis Research Center Foundation, NDB	Wichita	Kansas

Sponsors (2)

Lead Sponsor	Collaborator
University of Alabama at Birmingham	Oregon Health and Science University

Country where clinical trial is conducted

United States, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	GMFR (Geometric Mean Fold Rise ) in Varicella Zoster Virus (VZV) Glycoprotein Enzyme-linked Immunosorbent Assay (gpELISA) Immunoglobulin G (IgG) Levels From Baseline at 6 Weeks	Study protocol defined measure for immunogenicity samples.	6 weeks post vaccination
Primary	GMFR (Geometric Mean Fold Rise ) in Varicella Zoster Virus (VZV) Enzyme-linked Immune Absorbent Spot (ELISpot) Interferon Gamma (IFNg) Levels From Baseline at 6 Weeks	Study protocol defined measure for immunogenicity samples.	6 weeks post vaccination
Secondary	GMFR (Geometric Mean Fold Rise ) in Varicella Zoster Virus (VZV) Glycoprotein Enzyme-linked Immunosorbent Assay (gpELISA) Immunoglobulin G (IgG) Levels From Baseline at 1 Year	Study defined measure from labs. GMFR (Geometric Mean Fold Rise ) in varicella zoster virus (VZV) glycoprotein enzyme-linked immunosorbent assay (gpELISA) immunoglobulin G (IgG) levels	Baseline to 1 year
Secondary	GMFR (Geometric Mean Fold Rise ) in Varicella Zoster Virus (VZV) Enzyme-linked Immune Absorbent Spot (ELISpot) Interferon Gamma (IFNg) Levels From Baseline at 1 Year	Study defined measures from labs. GMFR (Geometric Mean Fold Rise ) in Varicella Zoster Virus (VZV) enzyme-linked immune absorbent spot (ELISpot) interferon gamma (IFNg)	Baseline to 1 year
Secondary	Number of Samples With Confirmed Varicella	Evaluated all serious adverse events (SAEs) AND non-serious varicella zoster virus (VZV) events	"Placebo Normal Saline Arm/Group was assessed up to 6 months and the "Zoster Vaccine Live (Zostavax)" Arm/Group was assessed up to 1 year
Secondary	Vaccine Tolerability Within 42 Days Following Vaccination.	Patient self report data in the form of a diary to include injection site reactions; symptoms of swelling, redness or tenderness. Diary was completed from study injection administration up to 6 week visit	42 days post vaccination
Secondary	Evaluate Rheumatoid Arthritis Disease Activity Using the Clinical Disease Activity Index (CDAI)	Rheumatoid arthritis disease activity will be measured using the clinical disease activity index (CDAI). Clinical disease activity index (CDAI) is a measure of rheumatoid arthritis disease activity and is scored on a scale ranging from 0-76, with lower numbers indicated better control of disease. Values <=10 are consistent with low disease activity or remission.	42 days post vaccination