Study of the Optimal Protocol for Methotrexate and Adalimumab Combination Therapy in Early Rheumatoid Arthritis
- Conditions
- Rheumatoid Arthritis
- Interventions
- Registration Number
- NCT00420927
- Lead Sponsor
- Abbott
- Brief Summary
This study compared the safety and efficacy of combination therapy with adalimumab plus methotrexate (MTX) to that of MTX monotherapy (i.e., placebo plus MTX) in subjects with early rheumatoid arthritis (RA).
- Detailed Description
This was a 78-week, multicenter, randomized, double-blind, double-treatment period study designed to compare the safety and efficacy of adalimumab and MTX with placebo and MTX in subjects with early RA. Subjects were randomized to receive adalimumab 40 mg every other week (eow) or placebo subcutaneous injections in combination with orally administered MTX for 26 weeks (Period 1). All subjects in all arms received open-label MTX weekly throughout the study (both Period 1 and Period 2).
At Weeks 22 and 26, subjects were assessed for achievement of low disease activity, defined as a DAS28 score below 3.2. DAS28 is a measure of RA disease activity calculated using the number of tender and swollen joints (out of a total of 28), C-reactive protein level (CRP, a blood marker of inflammation), and the patient's global assessment of disease activity (indicated by marking a 10 cm line between very good and very bad). Subjects who achieved low disease activity at Week 22 and 26 in the adalimumab arm at the end of Period 1 were randomized to receive MTX monotherapy (placebo and MTX) or combination therapy (adalimumab and MTX) in a 1:1 ratio for the duration of Period 2 (52 weeks, i.e., to Week 78 of the study). Subjects achieving low disease activity at Week 22 and 26 in the placebo arm (MTX monotherapy) at the end of Period 1 continued to receive MTX monotherapy (and placebo injections in a blinded fashion) for the duration of Period 2. Subjects failing to achieve low disease activity at Week 22 and 26 at the end of Period 1 received open-label combination therapy during Period 2 regardless of treatment assignment in Period 1.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 1032
Not provided
Not provided
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description ADA+MTX/PBO+MTX (Arm 1) adalimumab Combination therapy with methotrexate (MTX) and blinded adalimumab (ADA) during Period 1, MTX monotherapy plus blinded placebo (PBO) during Period 2 ADA+MTX/PBO+MTX (Arm 1) placebo Combination therapy with methotrexate (MTX) and blinded adalimumab (ADA) during Period 1, MTX monotherapy plus blinded placebo (PBO) during Period 2 ADA+MTX/ADA+MTX (Arm2) adalimumab Combination therapy with methotrexate (MTX) and blinded adalimumab (ADA) during Period 1 and Period 2 ADA+MTX/OL ADA+MTX (Arm 3) adalimumab Combination therapy with methotrexate (MTX) and blinded adalimumab (ADA) during Period 1, open-label combination therapy with ADA + MTX during Period 2 ADA+MTX/OL ADA+MTX (Arm 3) methotrexate Combination therapy with methotrexate (MTX) and blinded adalimumab (ADA) during Period 1, open-label combination therapy with ADA + MTX during Period 2 PBO+MTX/PBO+MTX (Arm 4) placebo Methotrexate (MTX) monotherapy plus blinded placebo (PBO) during Period 1 and Period 2 PBO+MTX/OL ADA+MTX (Arm 5) adalimumab Methotrexate (MTX) monotherapy plus blinded placebo (PBO) during Period 1, open-label combination therapy with adalimumab (ADA) and MTX during Period 2. PBO+MTX/OL ADA+MTX (Arm 5) placebo Methotrexate (MTX) monotherapy plus blinded placebo (PBO) during Period 1, open-label combination therapy with adalimumab (ADA) and MTX during Period 2. ADA+MTX/ADA+MTX (Arm2) methotrexate Combination therapy with methotrexate (MTX) and blinded adalimumab (ADA) during Period 1 and Period 2 ADA+MTX/PBO+MTX (Arm 1) methotrexate Combination therapy with methotrexate (MTX) and blinded adalimumab (ADA) during Period 1, MTX monotherapy plus blinded placebo (PBO) during Period 2 PBO+MTX/PBO+MTX (Arm 4) methotrexate Methotrexate (MTX) monotherapy plus blinded placebo (PBO) during Period 1 and Period 2 PBO+MTX/OL ADA+MTX (Arm 5) methotrexate Methotrexate (MTX) monotherapy plus blinded placebo (PBO) during Period 1, open-label combination therapy with adalimumab (ADA) and MTX during Period 2.
- Primary Outcome Measures
Name Time Method Number of Subjects With Low Disease Activity (DAS28 Less Than 3.2) and No Radiographic Progression From Baseline (Change in mTSS Less Than or Equal to 0.5) at Week 78, Arm 2 vs. Arm 4 Week 78 The Disease Activity Score (DAS28) is calculated using the number of tender and swollen joints (out of 28 counted), C-reactive protein level, and the patient's global assessment of disease activity. The calculated range of DAS28 is 0.49 to 9.07, with scores below 3.2 indicating low disease activity. For the modified Total Sharp score (mTSS), x-rays of hand/wrist and feet joints are scored for erosions (0 to 5) and joint space narrowing (0 to 4). The erosion score and the narrowing score are added to determine the total score, which ranges from 0 (no damage) to 448.
- Secondary Outcome Measures
Name Time Method Number of Subjects With Simplified Disease Activity Index (SDAI) Low Disease Activity (SDAI Less Than or Equal to 11) at Week 78 Week 78 The SDAI is calculated using number of swollen joints (28 joints assessed), number of tender joints (28 joints assessed), patient's global assessment of disease activity, physician's global assessment of disease activity, and acute phase reactant (C-reactive protein). Scores range from 0.1 to 86.0, with a higher score reflecting worsening disease.
Number of Subjects With Low Disease Activity (DAS28 Less Than 3.2) and No Radiographic Progression From Baseline (Change in mTSS Less Than or Equal to 0.5) at Week 78, Arm 2 vs. Arm 1 Week 78 The Disease Activity Score (DAS28) is calculated using the number of tender and swollen joints (out of 28 counted), C-reactive protein level, and the patient's global assessment of disease activity. The calculated range of DAS28 is 0.49 to 9.07, with scores below 3.2 indicating low disease activity. For the modified Total Sharp score (mTSS), x-rays of hand/wrist and feet joints are scored for erosions (0 to 5) and joint space narrowing (0 to 4). The erosion score and the narrowing score are added to determine the total score, which ranges from 0 (no damage) to 448.
Number of Subjects With DAS28 Low Disease Activity (DAS28 Less Than 3.2) at Week 78 Week 78 The Disease Activity Score (DAS28) is calculated using the number of tender and swollen joints (out of 28 counted), C-reactive protein level, and the patient's global assessment of disease activity. The calculated range of DAS28 is 0.49 to 9.07. A DAS28 less than 2.6 indicates clinical remission, DAS28 2.6 to 3.2 indicates low disease activity, DAS28 3.2 to less than 5.1 indicates moderate disease activity, and DAS28 of 5.1 or greater indicates high disease activity.
Number of Subjects With DAS28 Remission (DAS28 Less Than 2.6) at Week 78 Week 78 The Disease Activity Score (DAS28) is calculated using the number of tender and swollen joints (out of 28 counted), C-reactive protein level, and the patient's global assessment of disease activity. The calculated range of DAS28 is 0.49 to 9.07. A DAS28 less than 2.6 indicates clinical remission, DAS28 2.6 to 3.2 indicates low disease activity, DAS28 3.2 to less than 5.1 indicates moderate disease activity, and DAS28 of 5.1 or greater indicates high disease activity.
Number of Subjects With No Radiographic Progression (Change From Baseline in mTSS Less Than or Equal to 0.5) at Week 78 Week 78 For the modified Total Sharp score (mTSS), x-rays of hand/wrist and feet joints are scored for erosions (0 to 5) and joint space narrowing (0 to 4). The erosion score and the narrowing score are added to determine the total score, which ranges from 0 (no damage) to 448. An increase in mTSS from baseline represents disease progression and/or joint worsening, no change represents halting of disease progression, and a decrease represents improvement.
Number of Subjects Meeting American College of Rheumatology 20% (ACR20) Response Criteria at Week 78 Week 78 Subjects were responders if they had greater than or equal to 20% improvement in tender joint count; greater than or equal to 20% improvement in swollen joint count; and greater than or equal to 20% improvement in at least 3 of 5 remaining ACR core measures: patient assessment of pain; patient global assessment of disease activity; physician global assessment of disease activity; self-assessed disability (disability index of the Health Assessment Questionnaire \[HAQ\]); and acute phase reactant (C-reactive protein).
Number of Subjects Meeting American College of Rheumatology 50% (ACR50) Response Criteria at Week 78 Week 78 Subjects were responders if they had: greater than or equal to 50% improvement in tender joint count; greater than or equal to 50% improvement in swollen joint count; and greater than or equal to 50% improvement in at least 3 of 5 remaining ACR core measures: patient assessment of pain; patient global assessment of disease activity; physician global assessment of disease activity; self-assessed disability (disability index of the Health Assessment Questionnaire \[HAQ\]); and acute phase reactant (C-reactive protein).
Number of Subjects Meeting American College of Rheumatology 70% (ACR70) Response Criteria at Week 78 Week 78 Subjects were responders if they had: greater than or equal to 70% improvement in tender joint count; greater than or equal to 70% improvement in swollen joint count; and greater than or equal to 70% improvement in at least 3 of 5 remaining ACR core measures: patient assessment of pain; patient global assessment of disease activity; physician global assessment of disease activity; self-assessed disability (disability index of the Health Assessment Questionnaire \[HAQ\]); and acute phase reactant (C-reactive protein).
Change From Baseline in DAS28 Score at Week 78 Baseline to Week 78 The Disease Activity Score (DAS28) is calculated using the number of tender and swollen joints (out of 28 counted), C-reactive protein level, and the patient's global assessment of disease activity. The calculated range of DAS28 is 0.49 to 9.07. A DAS28 less than 2.6 indicates clinical remission, DAS28 2.6 to 3.2 indicates low disease activity, DAS28 3.2 to less than 5.1 indicates moderate disease activity, and DAS28 of 5.1 or greater indicates high disease activity.
Number of Subjects With Clinical Disease Activity Index (CDAI) Low Disease Activity (CDAI Less Than or Equal to 10) at Week 78 Week 78 The CDAI is calculated using number of swollen joints (28 joints assessed), number of tender joints (28 joints assessed), patient's global assessment of disease activity, and physician's global assessment of disease activity. Scores range from 0 to 76.0, with a higher score reflecting worsening disease.
Number of Subjects With Clinical Disease Activity Index (CDAI) Remission (CDAI Less Than or Equal to 2.8) at Week 78 Week 78 The CDAI is calculated using number of swollen joints (28 joints assessed), number of tender joints (28 joints assessed), patient's global assessment of disease activity, and physician's global assessment of disease activity. Scores range from 0 to 76.0, with a higher score reflecting worsening disease.
Number of Subjects With Simplified Disease Activity Index (SDAI) Remission (SDAI Less Than or Equal to 3.3) at Week 78 Week 78 The SDAI is calculated using number of swollen joints (28 joints assessed), number of tender joints (28 joints assessed), patient's global assessment of disease activity, physician's global assessment of disease activity, and acute phase reactant (C-reactive protein). Scores range from 0.1 to 86.0, with a higher score reflecting worsening disease.
Change From Baseline in CDAI Score at Week 78 Baseline to Week 78 The CDAI is calculated using number of swollen joints (28 joints assessed), number of tender joints (28 joints assessed), patient's global assessment of disease activity, and physician's global assessment of disease activity. Scores range from 0 to 76.0, with a higher score reflecting worsening disease.
Change From Baseline in SDAI Score at Week 78 Baseline to Week 78 The SDAI is calculated using number of swollen joints (28 joints assessed), number of tender joints (28 joints assessed), patient's global assessment of disease activity, physician's global assessment of disease activity, and acute phase reactant (C-reactive protein). Scores range from 0.1 to 86.0, with a higher score reflecting worsening disease.
Change From Baseline in Synovitis Score According to the Rheumatoid Arthritis Magnetic Resonance Imaging (RA MRI) Scoring System (RAMRIS) at Week 78 Baseline to Week 78 Synovitis was assessed using high-field magnetic resonance imaging (MRI) of the hand and wrist. Images were read and scored according to the Outcomes Measures in Rheumatology Clinical Trials' Rheumatoid Arthritis MRI Scoring System (OMERACT RAMRIS). Synovitis in the wrist and finger joints in the most affected hand was scored from 0 (normal) to 3 (severe), for a maximum total score of 21.
Number of Subjects With No Radiographic Progression (Change From Baseline in mTSS of Less Than or Equal to 0.5) and Normal Function (HAQ-DI Less Than 0.5) at Week 78 Week 78 In the Health Assessment Questionnaire Disability Index (HAQ-DI), participants rated their ability to perform daily tasks on a scale of 0 (without any difficulty) to 3 (unable to do). A mean score of 0-1 represents mild to moderate functional disability, 1-2 represents moderate to severe, 2-3 severe to very severe disability. For the modified Total Sharp score (mTSS), x-rays of hand/wrist and feet joints are scored for erosions (0 to 5) and joint space narrowing (0 to 4). The erosion score and the narrowing score are added to determine the total score, which ranges from 0 (no damage) to 448.
Number of Subjects With No Radiographic Progression (Change From Baseline in mTSS of Less Than or Equal to 0.5), Normal Function (HAQ-DI Less Than or Equal to 0.5), and ACR70 Response at Week 78 Week 78 In the Health Assessment Questionnaire Disability Index (HAQ-DI), a score of 0-1 represents mild to moderate, 1-2 moderate to severe, 2-3 severe to very severe disability. The modified Total Sharp score (mTSS) ranges from 0 (no joint damage) to 448 (worst joint damage). American College of Rheumatology 70% (ACR70) response indicates at least 70% improvement in tender and swollen joint counts and at least 3 of 5 remaining ACR core measures: patient assessment of pain; patient global assessment of disease activity; physician global assessment of disease activity; HAQ-DI; and C-reactive protein.
Number of Subjects With No Radiographic Progression (Change From Baseline in mTSS of Less Than or Equal to 0.5), Normal Function (HAQ-DI Less Than 0.5), and DAS28 Remission (DAS28 Less Than 2.6) at Week 78 Week 78 In the Health Assessment Questionnaire Disability Index (HAQ-DI), a score of 0-1 represents mild to moderate, 1-2 moderate to severe, 2-3 severe to very severe disability. The modified Total Sharp score (mTSS) ranges from 0 (no joint damage) to 448 (severe joint damage). The Disease Activity Score (DAS28) ranges from 0.49 to 9.07, with scores less than 2.6 indicating clinical remission.
Trial Locations
- Locations (170)
Site Reference ID/Investigator# 4548
🇺🇸Chicago, Illinois, United States
Site Reference ID/Investigator# 4538
🇺🇸Houston, Texas, United States
Site Reference ID/Investigator# 4605
🇺🇸Wichita, Kansas, United States
Site Reference ID/Investigator# 4016
🇸🇪Malmoe, Sweden
Site Reference ID/Investigator# 10744
🇺🇸Seattle, Washington, United States
Site Reference ID/Investigator# 4568
🇺🇸La Jolla, California, United States
Site Reference ID/Investigator# 12821
🇺🇸Bronx, New York, United States
Site Reference ID/Investigator# 4561
🇺🇸Dover, New Hampshire, United States
Site Reference ID/Investigator# 11222
🇺🇸Freehold, New Jersey, United States
Site Reference ID/Investigator# 4600
🇺🇸Smithtown, New York, United States
Site Reference ID/Investigator# 4544
🇺🇸Albuquerque, New Mexico, United States
Site Reference ID/Investigator# 6227
🇺🇸Bend, Oregon, United States
Site Reference ID/Investigator# 4549
🇺🇸Mayfield Village, Ohio, United States
Site Reference ID/Investigator# 4546
🇺🇸Duncansville, Pennsylvania, United States
Site Reference ID/Investigator# 9324
🇺🇸Plainview, New York, United States
Site Reference ID/Investigator# 4536
🇺🇸Dallas, Texas, United States
Site Reference ID/Investigator# 8489
🇩🇪Hofheim, Germany
Site Reference ID/Investigator# 8380
🇦🇺Campsie, Sydney, Australia
Site Reference ID/Investigator# 3978
🇩🇪Damp, Germany
Site Reference ID/Investigator# 4534
🇺🇸Orchard Park, New York, United States
Site Reference ID/Investigator# 4564
🇺🇸West Reading, Pennsylvania, United States
Site Reference ID/Investigator# 6381
🇺🇸Tyler, Texas, United States
Site Reference ID/Investigator# 7197
🇨🇦Halifax, Canada
Site Reference ID/Investigator# 3926
🇩🇪Bad Nauheim, Germany
Site Reference ID/Investigator# 3923
🇩🇪Munich, Germany
Site Reference ID/Investigator# 3887
🇦🇷Quilmes, Argentina
Site Reference ID/Investigator# 3924
🇩🇪Duesseldorf, Germany
Site Reference ID/Investigator# 6940
🇦🇺Malvern East, Australia
Site Reference ID/Investigator# 6834
🇨🇦Edmonton, Canada
Site Reference ID/Investigator# 4572
🇺🇸Oak Creek, Wisconsin, United States
Site Reference ID/Investigator# 6954
🇦🇺Clayton, Australia
Site Reference ID/Investigator# 3905
🇨🇦Winnipeg, Canada
Site Reference ID/Investigator# 3928
🇩🇪Berlin-Buch, Germany
Site Reference ID/Investigator# 3882
🇨🇦Victoria, Canada
Site Reference ID/Investigator# 3916
🇦🇹Vienna, Austria
Site Reference ID/Investigator# 3910
🇧🇪Yvoir, Belgium
Site Reference ID/Investigator# 4048
🇬🇧Leeds, United Kingdom
Site Reference ID/Investigator# 3907
🇨🇦Montreal, Canada
Site Reference ID/Investigator# 3903
🇨🇦Montreal, Canada
Site Reference ID/Investigator# 8524
🇪🇸Madrid, Spain
Site Reference ID/Investigator# 3930
🇪🇸Elche (Alicante), Spain
Site Reference ID/Investigator# 3920
ðŸ‡ðŸ‡ºDebrecen, Hungary
Site Reference ID/Investigator# 3822
🇲🇽Leon, Guanajuato, Mexico
Site Reference ID/Investigator# 3943
🇪🇸Madrid, Spain
Site Reference ID/Investigator# 8483
🇩🇪Osnabrueck, Germany
Site Reference ID/Investigator# 13661
🇪🇸Bilbao, Spain
Site Reference ID/Investigator# 8485
🇳🇿Auckland 6, New Zealand
Site Reference ID/Investigator# 7174
🇿🇦Soweto, South Africa
Site Reference ID/Investigator# 3890
🇲🇽Mexico City, Mexico
Site Reference ID/Investigator# 7506
🇳🇴Levanger, Norway
Site Reference ID/Investigator# 3957
🇪🇸Oviedo, Spain
Site Reference ID/Investigator# 4047
🇬🇧Oxford, United Kingdom
Site Reference ID/Investigator# 3956
🇪🇸Madrid, Spain
Site Reference ID/Investigator# 3955
🇪🇸A Coruna, Spain
Site Reference ID/Investigator# 8496
🇳🇿Timaru, New Zealand
Site Reference ID/Investigator# 3891
🇲🇽Mexico City, Mexico
Site Reference ID/Investigator# 7935
🇳🇴Kristiansand S, Norway
Site Reference ID/Investigator# 4046
🇬🇧Newcastle upon Tyne, United Kingdom
Site Reference ID/Investigator# 3954
🇪🇸Santiago de Compostela, Spain
Site Reference ID/Investigator# 7607
🇳🇴Alesund, Norway
Site Reference ID/Investigator# 3959
🇸🇰Piestany, Slovakia
Site Reference ID/Investigator# 4015
🇸🇪Eskilstuna, Sweden
Site Reference ID/Investigator# 8495
🇬🇧Huddersfield, United Kingdom
Site Reference ID/Investigator# 3931
🇪🇸Madrid, Spain
Site Reference ID/Investigator# 7175
🇿🇦Cape Town, South Africa
Site Reference ID/Investigator# 3984
🇸🇪Falun, Sweden
Site Reference ID/Investigator# 4012
🇬🇧Bath, United Kingdom
Site Reference ID/Investigator# 4013
🇬🇧London, United Kingdom
Site Reference ID/Investigator# 3932
🇪🇸Zaragoza, Spain
Site Reference ID/Investigator# 3982
🇫🇷Amiens, France
Site Reference ID/Investigator# 3979
🇫🇷Le Mans, France
Site Reference ID/Investigator# 3983
🇫🇷Paris Cedex 14, France
Site Reference ID/Investigator# 3918
🇫🇷Strasbourg, France
Site Reference ID/Investigator# 3985
🇬🇧Southampton, United Kingdom
Site Reference ID/Investigator# 7977
🇬🇧York, United Kingdom
Site Reference ID/Investigator# 4547
🇺🇸Birmingham, Alabama, United States
Site Reference ID/Investigator# 4560
🇺🇸Birmingham, Alabama, United States
Site Reference ID/Investigator# 4559
🇺🇸Denver, Colorado, United States
Site Reference ID/Investigator# 6899
🇺🇸San Antonio, Texas, United States
Site Reference ID/Investigator# 4014
🇸🇪Stockholm, Sweden
Site Reference ID/Investigator# 4017
🇸🇪Uppsala, Sweden
Site Reference ID/Investigator# 3901
🇨🇦Sarnia, Canada
Site Reference ID/Investigator# 6701
🇨🇦Burlington, Canada
Site Reference ID/Investigator# 3883
🇨🇦Hamilton, Canada
Site Reference ID/Investigator# 5178
🇨🇦Ottawa, Canada
Site Reference ID/Investigator# 3912
🇨🇦Sainte-Foy, Quebec, Canada
Site Reference ID/Investigator# 3906
🇨🇦St. John's, Canada
Site Reference ID/Investigator# 6542
🇨🇦Toronto, Canada
Site Reference ID/Investigator# 5616
🇨🇦Windsor, Canada
Site Reference ID/Investigator# 5847
🇨🇦Winnipeg, Canada
Site Reference ID/Investigator# 3919
🇩🇪Vogelsang-Gommern, Germany
Site Reference ID/Investigator# 6637
🇩🇪Zerbst, Germany
Site Reference ID/Investigator# 6222
🇺🇸Huntsville, Alabama, United States
Site Reference ID/Investigator# 4535
🇺🇸Palm Desert, California, United States
Site Reference ID/Investigator# 4537
🇺🇸Mobile, Alabama, United States
Site Reference ID/Investigator# 9323
🇺🇸Hemet, California, United States
Site Reference ID/Investigator# 6758
🇺🇸Tuscaloosa, Alabama, United States
Site Reference ID/Investigator# 9271
🇺🇸Torrance, California, United States
Site Reference ID/Investigator# 4571
🇺🇸Santa Monica, California, United States
Site Reference ID/Investigator# 10746
🇺🇸Victorville, California, United States
Site Reference ID/Investigator# 6229
🇺🇸Aventura, Florida, United States
Site Reference ID/Investigator# 9325
🇺🇸Orange Park, Florida, United States
Site Reference ID/Investigator# 10603
🇺🇸Lake Mary, Florida, United States
Site Reference ID/Investigator# 4550
🇺🇸Palm Harbor, Florida, United States
Site Reference ID/Investigator# 4570
🇺🇸Sarasota, Florida, United States
Site Reference ID/Investigator# 4601
🇺🇸Tampa, Florida, United States
Site Reference ID/Investigator# 4557
🇺🇸Springfield, Illinois, United States
Site Reference ID/Investigator# 4552
🇺🇸Vero Beach, Florida, United States
Site Reference ID/Investigator# 10745
🇺🇸Meridian, Idaho, United States
Site Reference ID/Investigator# 10741
🇺🇸Wheaton, Maryland, United States
Site Reference ID/Investigator# 4533
🇺🇸Charleston, South Carolina, United States
Site Reference ID/Investigator# 6417
🇺🇸Fall River, Massachusetts, United States
Site Reference ID/Investigator# 4545
🇺🇸Glendale, Wisconsin, United States
Site Reference ID/Investigator# 4558
🇺🇸Wexford, Pennsylvania, United States
Site Reference ID/Investigator# 3971
🇨🇿Hradec Kralove, Czech Republic
Site Reference ID/Investigator# 3884
🇨🇦Hamilton, Canada
Site Reference ID/Investigator# 5548
🇨🇿Uherske Hradiste, Czech Republic
Site Reference ID/Investigator# 3904
🇨🇦Richmond, Canada
Site Reference ID/Investigator# 3925
🇩🇪Freiburg, Germany
Site Reference ID/Investigator# 8486
🇩🇪Ratingen, Germany
Site Reference ID/Investigator# 3965
🇩🇪Frankfurt, Germany
Site Reference ID/Investigator# 3927
🇩🇪Frankfurt/Main, Germany
Site Reference ID/Investigator# 4291
🇩🇪Halle, Germany
Site Reference ID/Investigator# 3948
🇳🇱Hilversum, Netherlands
Site Reference ID/Investigator# 8488
🇳🇿Hamilton, New Zealand
Site Reference ID/Investigator# 8511
🇳🇿Wellington, New Zealand
Site Reference ID/Investigator# 7511
🇳🇴Lillehammer, Norway
Site Reference ID/Investigator# 3962
🇵🇱Katowice, Poland
Site Reference ID/Investigator# 5560
🇵🇱Lublin, Poland
Site Reference ID/Investigator# 7500
🇳🇴Trondheim, Norway
Site Reference ID/Investigator# 3961
🇵🇱Wroclaw, Poland
Site Reference ID/Investigator# 3944
🇵🇷Caguas, Puerto Rico
Site Reference ID/Investigator# 3937
🇵🇷Ponce, Puerto Rico
Site Reference ID/Investigator# 7177
🇿🇦Berea, Durban, South Africa
Site Reference ID/Investigator# 3935
🇵🇷San Juan, Puerto Rico
Site Reference ID/Investigator# 7178
🇿🇦Cape Town, South Africa
Site Reference ID/Investigator# 7176
🇿🇦Port Elizabeth, South Africa
Site Reference ID/Investigator# 7172
🇿🇦Pretoria, South Africa
Site Reference ID/Investigator# 3886
🇦🇷Buenos Aires, Argentina
Site Reference ID/Investigator# 3888
🇦🇷Buenos Aires, Argentina
Site Reference ID/Investigator# 3889
🇦🇷San Miguel de Tucuman, Argentina
Site Reference ID/Investigator# 3880
🇦🇹Vienna, Austria
Site Reference ID/Investigator# 3885
🇦🇹Vienna, Austria
Site Reference ID/Investigator# 7792
🇦🇹Vienna, Austria
Site Reference ID/Investigator# 3914
🇧🇪Brussels, Belgium
Site Reference ID/Investigator# 3376
🇧🇪Liege, Belgium
Site Reference ID/Investigator# 6720
🇧🇪Mechelen, Belgium
Site Reference ID/Investigator# 6718
🇧🇪Sint-Niklaas, Belgium
Site Reference ID/Investigator# 5559
🇨🇿Ostrava, Czech Republic
Site Reference ID/Investigator# 3963
🇵🇱Bydgoszcz, Poland
Site Reference ID/Investigator# 3960
🇸🇰Piestany, Slovakia
Site Reference ID/Investigator# 6228
🇺🇸Passaic, New Jersey, United States
Site Reference ID/Investigator# 6346
🇦🇷Buenos Aires, Argentina
Site Reference ID/Investigator# 4562
🇺🇸Nashville, Tennessee, United States
Site Reference ID/Investigator# 7482
🇺🇸Greenville, South Carolina, United States
Site Reference ID/Investigator# 3911
🇦🇹Graz, Austria
Site Reference ID/Investigator# 10743
🇺🇸Jackson, Tennessee, United States
Site Reference ID/Investigator# 3915
🇦🇹Graz, Austria
Site Reference ID/Investigator# 3968
🇨🇿Brno, Czech Republic
Site Reference ID/Investigator# 3824
🇲🇽Aguascallentes, Mexico
Site Reference ID/Investigator# 3951
🇲🇽Mexico City, Mexico
Site Reference ID/Investigator# 3934
🇵🇷San Juan, Puerto Rico
Site Reference ID/Investigator# 3909
🇧🇪Genk, Belgium
Site Reference ID/Investigator# 3881
🇧🇪Gilly, Belgium
Site Reference ID/Investigator# 3969
🇨🇿Prague 2, Czech Republic
Site Reference ID/Investigator# 3825
🇲🇽Mexico City, Mexico
Site Reference ID/Investigator# 3921
ðŸ‡ðŸ‡ºBudapest, Hungary
Site Reference ID/Investigator# 3823
🇲🇽Mexico City, Mexico
Site Reference ID/Investigator# 3947
🇳🇱Arnem, Netherlands
Site Reference ID/Investigator# 3922
ðŸ‡ðŸ‡ºBudapest, Hungary