Study of Salvage Therapy to Treat Patients with Granulomatosis with Polyangiitis

Phase 3

Not yet recruiting

• Conditions: Granulomatosis with Polyangiitis; Anti-neutrophil Cytoplasmic Antibody-associated Vasculitis
• Interventions: Drug: Rituximab; Drug: Tocilizumab; Drug: Tofacitinib

• Registration Number: NCT04871191
• Lead Sponsor: Assistance Publique - Hôpitaux de Paris

Brief Summary

The purpose of this study is to identify the most promising therapeutic strategy for patients with granulomatosis with polyangiitis and inadequate response to standard of care therapy. It will evaluate the efficacy to induce remission of three different salvage strategies including: a combination of rituximab with addition of a conventional disease-modifying antirheumatic drugs (either methotrexate, azathioprine or mycophenolate mofetil, but preferentially methotrexate); tocilizumab; or tofacitinib.

Detailed Description

Granulomatosis with polyangiitis (GPA) is an anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV).

Combination of glucocorticoids and either cyclophosphamide or rituximab is the standard of care for remission-induction of new-onset organ-threatening or life-threatening GPA. Few patients fail to respond to both cyclophosphamide and rituximab, but it is not uncommon for patients to have persistent disease activity resulting in inability to taper glucocorticoids, which is also considered refractory disease. The current recommendations for patients with GPA refractory to remission-induction therapy are to switch from cyclophosphamide to rituximab or from rituximab to cyclophosphamide. However, there are no recommendations for the management of patients with inadequate response after both treatments. Treatment with a biologic disease-modifying antirheumatic drugs (DMARD) or a combination of rituximab and a cDMARD are potential treatments options but have not been properly evaluated in such cases. Among biologic DMARD that have been evaluated in AAV, some have shown promising results, including tocilizumab and tofacitinib.

Identifying the most promising therapeutic strategy for patients with GPA and inadequate response to standard of care therapy may improve management of GPA.

Study Timeline

• Study First Submitted: 2021-02-26
• Study First Submitted QC: 2021-05-03
• Study First Posted: 2021-05-04
• Status Verified: 2025-01
• Last Update Submitted: 2025-01-30
• Last Update Posted: 2025-02-03
• Study Start: 2025-03
• Primary Completion: 2028-09
• Study Completion: 2029-01

Recruitment & Eligibility

• Status: NOT_YET_RECRUITING
• Sex: All
• Target Recruitment: 42

Inclusion Criteria

• Newly diagnosed or relapsing granulomatosis with polyangiitis according to American College of Rheumatology criteria, EMA classification algorithm and/or the 2012 revised Chapel Hill Consensus Conference definition.

• Aged 18 years or older

• Active clinical manifestations attributable to GPA

• An inadequate response to previous standard of care therapy including either :

  1. A combination of glucocorticoids plus cyclophosphamide
  2. AND /OR a combination of glucocorticoids plus rituximab

• An inadequate response to treatment defined as follows:

  1. A progressive disease unresponsive to previous standard of care therapy after 12 weeks of treatment
  2. Or a lack of response, defined as < 50% reduction in the disease activity score, after 12 weeks of treatment
  3. Or a persistent active disease attributable to either a vasculitic or a granulomatous manifestation of GPA that requires the maintenance of corticosteroids ≥ 7.5 mg/day of equivalent prednisone after ≥ 12 weeks of treatment.

• A stable dose of oral glucocorticoids of ≥ 7.5 mg/day of equivalent prednisone within the 4 weeks before enrollment. Pulses of methylprednisolone (1 to 3 pulses of 7.5 to 15 mg/kg each; ≤ 1000 mg) are allowed if necessary, according to severity before starting the experimental treatment.

• A stable dose of conventional disease-modifying anti-rheumatic drugs (cDMARD) within 4 weeks before enrollment if the patient is currently treated with a cDMARD

• Patients must have the ability to understand the requirements of the study, provide written informed consent prior to participation in the study (including consent for the use and disclosure of research-related health information) and comply with the study protocol procedures (including required study visits)

• Patients must have an affiliation with a mode of social security (profit or being entitled)

Exclusion Criteria

• An allergy or hypersensitivity to monoclonal antibodies or either of the study drugs (rituximab, abatacept or tocilizumab) or to their excipients

• A previous treatment with a combination of rituximab plus a cDMARD, with tofacitinib, or with tocilizumab

• A contraindication to a combination of rituximab plus a cDMARD, to tofacitinib, or to tocilizumab (including an ongoing infection; history of recent cancer <5 years before enrollment, except for cured non-melanoma skin cancer); pregnancy; and breastfeeding.

• Patients with severe vasculitis manifestations that requires plasma exchange therapy including severe renal failure with a creatinine level ≥350 µmol/L or severe alveolar haemorrhage

• Patients with vasculitis in remission

• Patients with symptoms attributable to chronic and non-active GPA

• Patients with severe cardiac failure defined as class IV in New York Heart Association

• Patients with acute infections or chronic active infections (including HIV, HBV or HCV)

• Patients with active cancer or recent cancer (<5 years), except basocellular carcinoma and prostatic cancer of low activity controlled by hormonal treatment

• Pregnant women and lactation. All women with childbearing potential are required to have a negative serum pregnancy test before treatment and must agree to maintain highly effective contraception from the date of consent through the end of the study, and for women who are taking tocilizumab or tofacitinib through 3 months after the last treatment administration, for women who are taking rituximab in combination with methotrexate through 6 months after the last treatment administration, for women who are taking rituximab in combination with mycofenolate mofetil or with azathioprine through 3 months after the last treatment administration

• Patients with other uncontrolled diseases, including drug or alcohol abuse, severe psychiatric diseases, that could interfere with participation in the trial according to the protocol

• Patients included in other investigational therapeutic study within the previous 3 months

• Patients suspected not to be observant to the proposed treatments

• Laboratory parameter exclusions

  1. aspartate or alanine aminotransferase (AST/SGOT or ALT/SGPT) > 5 times upper limit of normal
  2. Platelet count <100.000/mm3
  3. White blood cell count <2000/mm3

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Rituximab + cDMARD	Rituximab	Rituximab will be administered at 375 mg/m²/week for four consecutive weeks. Maintenance rituximab at a fixed dose of 500 mg will be administered at week 24 and at week 52. The choice of the cDMARD will be left to the treating clinician and will include either methotrexate, azathioprine or mycophenolate mofetil, but the choice will be preferably methotrexate. Methotrexate will be administered orally or subcutaneously at 0.3 mg/kg/week, azathioprine orally at 2-3 mg/kg/d and mycophenolate mofetil orally at 2-3 g/d.
Tocilizumab	Tocilizumab	Tocilizumab will be administered subcutaneously every week at a fixed dose of 162 mg per week.
Tofacitinib	Tofacitinib	Tofacitinib will be administered orally at 5 mg twice daily. Tofacitinib will start at week 0. Treatment will continue until week 52.

Primary Outcome Measures

Name	Time	Method
Proportion of patients with a response or a remission	week 12	defined according to the EULAR recommendations. Remission is defined as the absence of disease activity attributable to active disease qualified by the need for ongoing stable maintenance immunosuppressive therapy. The term ''active disease'' is not restricted to vasculitis only, but also includes other inflammatory features like granulomatous inflammation. Response is defined as a 50% reduction of disease activity score and absence of new manifestations.

Secondary Outcome Measures

Name	Time	Method
Proportion of patients with a response or a remission at week 26 and 52.	week 26 and 52	according to the EULAR recommendations
Physician's and patient's global assessment of disease activity	week 12 and 52	The difference between the physician's and patient's global assessment of disease activity between baseline and week 12 and between baseline and week 52 using a scale ranging from 0 to 100, with higher scores indicating more activity.
Patient-reported outcomes	week 12, 24 and 52	The patient-reported outcomes (PRO) including the ANCA-associated vasculitis patient-reported outcomes (AAV-PRO) questionnaire, a 29-item profile measure comprising six domains, with higher scores meaning more active disease, at week 12, 24, and 52 after randomization, and during the long-term follow-up.
Adverse events	week 26 and 52	The number of adverse events, expressed as adverse events according to the CTCAE toxicity grading system per patient-year at week 26 and 52 for the following adverse events combined: death (all causes), grade 2 or higher leukopenia or thrombocytopenia, grade 3 or higher infections, hemorrhagic cystitis, malignancies, venous thromboembolic events, hospitalization resulting either from the disease or from a complication due to the study treatment, infusion reactions (within 24 hours of infusion) that result in the cessation of further infusions
Corticosteroids use	week 26 and 52	The area under the curve for corticosteroids at week 26 and 52
Vasculitis Damage Index	week 26 and 52	The Vasculitis Damage Index (VDI, scoring from 0 to 58, higher scores indicating more damage) at week 26 and 52
Health Assessment Questionnaire (HAQ)	week 26 and 52	ranging from 0 to 3, with higher scores indicating worse functional impairment
Short Form 36 (SF-36) Health questionnaire	week 26 and 52	scores range from 0 to 100 for each component, with lower scores indicating greater impairment of quality of life
ANCA titers	week 26 and 52	Evolution of ANCA titers in the treatment groups

Trial Locations

Locations (1)

Hôpital de la Croix Saint Simon; 🇫🇷 Paris, France