A Double-Blind, Randomized, Multicenter Pilot Study to Evaluate the Efficacy and Safety of Etanercept 50mg SC Twice Weekly in the Treatment of Moderate to Severe Lichen Planus
Overview
- Phase
- Phase 2
- Intervention
- Placebo
- Conditions
- Lichen Planus
- Sponsor
- Stanford University
- Enrollment
- 27
- Locations
- 12
- Primary Endpoint
- The Percentage of Patients Achieving a Response in Mucosal Disease (or Cutaneous Disease if no Mucosal Disease) at 12 Weeks
- Status
- Terminated
- Last Updated
- 8 years ago
Overview
Brief Summary
The purpose is to assess the response of subjects to etanercept (as compared to placebo) in treating the physical signs of mucosal and cutaneous lichen planus. The investigators also wish to assess the effect of etanercept on disease-related itching, pain, and serious adverse events in patients with lichen planus.
Detailed Description
Lichen planus affects up to 1% of the worldwide population. Recent estimates suggest approximately 0.44% of the US population suffers from this disease. Oral or genital involvement occurs in 60-70% of patients, and it may be the sole manifestation of disease in 20-30% of patients. Lichen planus is a mucocutaneous disorder that can involve the skin, oral or genital mucosa, conjunctiva, and nails. On the skin, the disease presents as multiple papules, which can be localized or generalized, that are often extremely itchy. Mucosal disease can consist of either asymptomatic plaques or extremely painful erosive lesions. The disease course is unpredictable and typically lasts 1-2 years but can follow a chronic, relapsing course. Erosive mucosal disease is important to aggressively treat for many reasons: First, the associated pain can be debilitating for the patient. Patients with severe oral lichen planus can become malnourished due to pain associated with eating. Vulvar disease can cause dyspareunia, burning pain, and discharge; second, the disease tends to be chronic, with little chance for self-resolution; third, erosive disease is associated with an increased risk of squamous cell carcinoma in the affected areas. These cancers occur in up to 1% of patients over a 3-year period, and they can be aggressive and even-life threatening for the patient if not recognized and treated early. Several lines of evidence suggest that TNF-alpha plays a role in the pathogenesis of lichen planus. It has been shown that there are increased levels of TNF-alpha in the serum of these patients. In addition, skin and mucosal biopsies show increased TNF-alpha produced by the infiltrating lymphocytes as well as the basal keratinocytes. It has been suggested that the expression of TNF-alpha receptor on the basal keratinocytes may contribute to apoptosis. Also, TNFR1 (a TNF-alpha receptor) is expressed by the infiltrating mononuclear cells as well as the keratinocytes. Increased levels of soluble TNF receptors are also found in the serum of patients with lichen planus. A recent report also has shown that polymorphisms in the TNF-alpha gene are associated with both oral and cutaneous lichen planus. Finally, thalidomide, which partly functions as a potent inhibitor of TNF-alpha transcription, has been shown to be effective (in small case series and reports) in selected patients for the treatment of oral and genital lichen planus. However, thalidomide is a potent teratogen and cannot be used in women of childbearing potential. In addition, thalidomide usage not uncommonly results in neurotoxicity, which can be permanent, and thus limits use of this drug. Despite the evidence for a role of TNF-alpha in LP there are no reports of any TNF inhibitors being used for this disease. This is a double-blind, placebo-controlled pilot study to observe the safety and efficacy of etanercept in patients with lichen planus. This study will consist of 3 periods: first, a double-blind period (weeks 0-12) in which subjects will be randomized to etanercept 50 mg twice weekly or placebo; second, an open-label period (weeks 12-24) in which subjects who were randomized to placebo treatment, who have not achieved a complete remission, will be rolled over to use etanercept at 50 mg twice weekly. Subjects who previously received etanercept during weeks 0-12, who have not achieved a complete remission, will be continued on etanercept at a lower dosage of 25 mg twice weekly for weeks 12-24; third, an 8 week follow-up period for all subjects.
Investigators
David Fiorentino
Principle Investigator
Stanford University
Eligibility Criteria
Inclusion Criteria
- •At least 18 years old.
- •Must carry a diagnosis of lichen planus as determined by biopsy
- •Patients must have a score of 3 or greater on the physician global assessment (PGA).
- •Patient must be considered appropriate for systemic therapy based upon fulfilling one of the following criteria:
- •inability to maintain weight due to pain with eating, chewing, or swallowing;
- •dyspareunia or dysuria due to genital lesions;
- •itch/pain of sufficient severity that activities of daily living are significantly affected
- •Must be off systemic lichen planus treatment for 4 weeks prior to starting etanercept
- •If using topical corticosteroid to the affected areas, the dose and frequency must be unchanged for 2 weeks prior to beginning the study agent and during the course of the study.
- •Must be off topical cyclosporine, tacrolimus, or pimecrolimus for 2 weeks prior to starting the study drug and for the entire duration of the study.
Exclusion Criteria
- •Subject is currently enrolled in another investigational device or drug trial(s), or subject has received investigational agent(s) within 90 days of baseline visit.
- •Known HIV-positive status, any other immuno-suppressive disease, or inability to practice safe sex during the length of the study
- •Subject has been diagnosed with a malignancy within the past 5 years
- •Subject has signs or symptoms of a lymphoproliferative disease.
- •Other skin or mucosal disease that might interfere with lichen planus assessments.
- •Lichen planus variants including hypertrophic, atrophic, follicular (including lichen planopilaris), and bullous cutaneous forms.
- •Patients with lichen sclerosis et atrophicus (LS\&A)
- •Clinical history and lesion distribution suspicious for a lichenoid drug eruption
- •Severe co-morbidities
- •History of tuberculosis (TB) or positive PPD at screening. Known history of active hepatitis B or C, or lupus, SLE, history of multiple sclerosis or prior episode of central nervous system demyelination, transverse myelitis, optic neuritis, epilepsy, psychiatric condition, or other chronic serious medical illnesses.
Arms & Interventions
Placebo injection
patients receive normal saline injection twice weekly for weeks 1-12
Intervention: Placebo
Etanercept
patients receive etanercept injection twice weekly for weeks 1-12.
Intervention: Etanercept
Outcomes
Primary Outcomes
The Percentage of Patients Achieving a Response in Mucosal Disease (or Cutaneous Disease if no Mucosal Disease) at 12 Weeks
Time Frame: 12 weeks
Physician global assessment of disease scores: 0=clear; 1=minimal disease; 2=mild disease; 3=moderate disease; 4=severe disease. Subjects had a level \>=3 at baseline. To be considered a responder, the subject must achieve a level of 0 or 1, or, at least a 2 point improvement in the scale.
Secondary Outcomes
- Count of Patients Achieving a Response in Cutaneous or Mucosal Disease at 24 Weeks(Baseline; Week 24)
- The Physician Assessment of Surface Area of Disease (PSAD) for Oral Disease at 12 and 24 Weeks(Baseline; Week 12; Week 24)
- The Physician Assessment of Surface Area of Disease (PSAD) for Genital Disease at 12 and 24 Weeks(Baseline; Week 12; Week 24)
- The Physician Assessment of Surface Area of Disease (PSAD) for Skin Disease at 12 and 24 Weeks(Baseline; Week 12; Week 24)
- Cutaneous Target Lesion Scores - Erythema, at 12 and 24 Weeks(Week 12; Week 24)
- Cutaneous Target Lesion Scores - Elevation, at 12 and 24 Weeks(Week 12; Week 24)
- Cutaneous Target Lesion Scores - Scale, at 12 and 24 Weeks(Week 12; Week 24)
- The Count of Subjects Experiencing Serious Adverse Events (SAEs) by Week 12 and Week 24(Baseline; Week 12; Week 24)
- Patient Assessment of Pain on a Visual Analogue Scale (VAS) at 12 and 24 Weeks(Baseline; Week 12; Week 24)
- Patient Assessment of Pruritus (Itching) on a Visual Analogue Scale (VAS) at 12 and 24 Weeks(Baseline; Week 12; Week 24)
- Patient Assessment of Overall Disease Severity (Patient Global Assessment) at 12 and 24 Weeks(Baseline; Week 12; Week 24)
- The Count of Placebo Patients Who do Not Have a Complete Response (Defined as a Physician Global Assessment of "Clear") at 12 Weeks(12 weeks)
- Cutaneous Target Lesion Scores - Total, at 12 and 24 Weeks(Week 12; Week 24)
- The Percentage of Placebo and Study-drug Patients Able to Discontinue Use of Topical Corticosteroids Through Week 24(24 weeks)