Clinical Trial Evaluating Methotrexate or Leflunomide + Targeted Therapy Versus Methotrexate or Leflunomide + Sulfasalazine + Hydroxychloroquine in Patients with Rheumatoid Arthritis and Insufficient Response to Methotrexate or Leflunomide

Phase 4

Recruiting

• Conditions: Rheumatoid Arthritis; Insufficient Response to Methotrexate or Leflunomide
• Interventions: Drug: Methotrexate + targeted therapy administration; Drug: methotrexate or leflunomide + sulfasalazine + hydroxychloroquine administration

• Registration Number: NCT02714634
• Lead Sponsor: University Hospital, Strasbourg, France

Brief Summary

Approximately, 40 to 50% of patients with rheumatoid arthritis (RA), the most frequent inflammatory arthritide, are non responders to the consensual 1st line of treatment : methotrexate. In these patients, it is well demonstrated that the addition of other immunomodulatory drug(s) often results in a significant improvement. However, the best option regarding the drug(s) to add remains unclear. Rheumatologists are currently used to adding a targeted therapy, such as anti-TNFα, and more recently abatacept or tocilizumab. Triple therapy using 3 conventional disease-modifying drugs (DMARDs), methotrexate or leflunomide+salazopyrine+hydroxychloroquine could be an alternative option to targeted therapies, all the more as they have a more favorable safety profile and a much lower cost. Uncertainty remains regarding the superiority of targeted therapies on triple therapy in methotrexate or leflunomide insufficient responders (IR). Investigators decided to address this issue by performing a randomized controlled pragmatic trial.

Detailed Description

Not available

Study Timeline

• Study First Submitted: 2016-02-01
• Study First Submitted QC: 2016-03-15
• Study First Posted: 2016-03-21
• Study Start: 2016-03-30
• Status Verified: 2025-03
• Last Update Submitted: 2025-03-10
• Last Update Posted: 2025-03-12
• Primary Completion: 2029-03
• Study Completion: 2029-03

Recruitment & Eligibility

• Status: RECRUITING
• Sex: All
• Target Recruitment: 286

Inclusion Criteria

• Patient with rheumatoid arthritis according to EULAR/ACR 2010 criteria
• DAS28-CRP>3.2
• Insufficient response to methotrexate at a weekly dose≥15mg after at least 3 months or to leflunomide at a dose of 10 (in case 20 mg are not well tolerated) to 20 mg per day after 3 months of treatment
• RA radiographic erosions and/or serum rheumatoid factor associated to anti-Cyclic Citrullinated Peptide (Anti-CCP)
• Age greater or equal to 18 years
• Written informed consent, dated and signed before initiating any trial-related procedure
• Affiliation to a social insurance system
• Women of child bearing potential, negative β-HCG assay (Human chorionic gonadotropin)
• Effective method of birth control during the study and continuing after the discontinuation of the investigational drug or study. The duration will depend on the drug used (referred to the summary product characteristic).

Exclusion Criteria

• Previous treatment with or contraindication to targeted therapies (biologic or JAK/STAT inhibitor)
• Previous treatment with triple therapy
• Other inflammatory arthritis except RA associated with Sjögren's syndrome
• Contraindication to all biologics/ JAK/STAT inhibitors or to methotrexate, leflunomide, sulfasalazine and hydroxychloroquine
• Corticosteroids at a dose >15 mg/d of equivalent prednisone for at least 4 weeks before the inclusion
• Absence of tuberculosis screening
• Patient who cannot be followed during 12 months
• Pregnancy, breastfeeding, desire of pregnancy in the 12 months
• Drug addiction, addiction to alcohol
• Participation in a clinical study with an investigational product within 4 weeks prior to the start of the study treatment
• Women of child bearing potential, unless they are using an effective method of birth control
• Patient under law protection
• Prisoners

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
methotrexate + targeted therapy group	Methotrexate + targeted therapy administration	Methotrexate or leflunomide + targeted therapy chosen by investigator
Triple therapy	methotrexate or leflunomide + sulfasalazine + hydroxychloroquine administration	Triple therapy using 3 conventional disease modifying drugs (DMARDs)

Primary Outcome Measures

Name	Time	Method
Numbers of participant with low disease activity (DAS28-CRP<3.2) and a daily dose ≤ 7.5 mg/day of equivalent prednisone	At 12 months

Secondary Outcome Measures

Name	Time	Method
QUALISEX score at inclusion, 6 months and at 12 months.	at inclusion, 6 months and at 12 months.
Serious adverse events rate	At 3, 6, 9 and at 12 months
Blood concentrations of hydroxychloroquine, leflunomide, sulfasalazine and methotrexate in the triple therapy group and methotrexate, leflunomide, biologic / JAK/STAT inhibitor and anti-drug antibody in the other group.	at 6, and 12 months
DAS 28 CRP score.	at inclusion, 3, 6, 9 and 12 months.
2010 ACR (American College of Rheumatology)/EULAR classification Criteria for RA, ACR 20, 50, 70 and boolean remission.	at 3, 6, 9 and 12 months.
Change in comedications (dose)	at 3, 6, 9 and 12 months
Change in comedications (route of administration)	at 3, 6, 9 and 12 months
Modified Sharp Van der Heijde score.	at inclusion and at 12 months
Change in comedications (drug)	at 3, 6, 9 and 12 months
Medico-economic costs.	at inclusion, 3, 6, 9 and at 12 months.
Treatment compliance	at 3, 6, 9 and 12 months	A questionnaire will be filled by patient
Clinical disease activity index (CDAI).	At inclusion, 3, 6, 9 and 12 months

Trial Locations

Locations (1)

Hôpitaux Universitaires de Strasbourg; 🇫🇷 Strasbourg, France