Effects of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) on RAdiographic Damage in Ankylosing Spondylitis

Phase 4

Completed

• Conditions: Ankylosing Spondylitis
• Interventions: Drug: diclophenac

• Registration Number: NCT00715091
• Lead Sponsor: Charite University, Berlin, Germany

Brief Summary

This is a randomised, controlled, multi-centre clinical trial on AS patients. Experimental intervention: continuous (daily) treatment with diclofenac cholestyramine 150 mg (Voltaren Resinate), divided into 75mg Voltaren twice dailyControl intervention: treatment on-demand (as needed) with diclofenac-cholestyramine 75 to 150 mg (Voltaren Resinate). The treatment strategy of the control intervention (on-demand) reflects current clinical practice in AS. Duration of intervention per patient: 2 years Follow-up per patient: safety assessment 3 months after termination of the trial.

Detailed Description

Ankylosing spondylitis (AS) is a common chronic inflammatory rheumatic disease with a prevalence of about 0.5%. First symptoms normally occur in young adulthood. Early in its course, AS is dominated by chronic pain, fatigue and morning stiffness, later on by ankylosis and loss of function. Nonsteroidal anti-inflammatory drugs (NSAID) and tumor necrosis factor (TNF) alpha blocking agents are the only drugs with proven efficacy for signs and symptoms. It is not clear, however, whether these drugs are also capable of retarding or stopping structural damage, i.e. prevention of bony ankylosis. Earlier investigations indicated that NSAIDs have, in addition to their anti-inflammatory, also an anti-osteoproliferative effect. In this study we will investigate whether treatment with 150 mg diclofenac, a non-selective NSAID, on a daily basis (continuous treatment) over 2 years is capable to slow down the development of bony ankylosis as compared to treatment with 75-150mg diclofenac as needed according to clinical symptoms (on-demand treatment). In this national multi-centre randomized trial patients with symptomatic AS and indication for NSAID therapy will be enrolled in about 40 centres. The primary outcome parameter is the proportion of patients with radiographic progression in the spine after 2 years in each treatment arm. If continuous NSAID treatment results in less radiographic progression as compared to on-demand treatment, a true disease modifying effect of NSAID has to be assumed which will most likely change the place of NSAID treatment in AS.

Study Timeline

• Study First Submitted: 2008-07-14
• Study First Submitted QC: 2008-07-14
• Study First Posted: 2008-07-15
• Study Start: 2008-09
• Primary Completion: 2013-12
• Study Completion: 2013-12
• Status Verified: 2014-08
• Last Update Submitted: 2014-08-22
• Last Update Posted: 2014-08-25

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 180

Inclusion Criteria

• AS according to mod. New York criteria
• Patients must have radiographic damage (at least one syndesmophyte) of the spine but no complete ankylosis of the cervical and lumbar spine (these are patients at risk for further and more rapid radiographic progression)
• Patients must have active disease at inclusion defined as BASDAI question 2 (related to back pain) >= 4 (VAS, range 0-10) without NSAID treatment and with a clinical indication for NSAID therapy based on signs and symptoms

Exclusion Criteria

• No radiographic damage (syndesmophyte) of the spine at baseline
• Complete ankylosis of the cervical and lumbar spine
• Inactive disease
• Evidence of current or past peptic ulcer
• Current or past coronary heart disease
• Stroke or transient ischemic attack
• Uncontrolled hypertension
• Chronic renal failure (creatinine > 1.5mg/dl)
• Impaired liver function
• Pregnancy
• Abnormal liver function (2x upper limit of normal)
• Active hepatitis B or C, chronic or acute heart failure (NYHA III or IV) -
• History of HIV infection
• History of neoplastic disease (details please refer to exclusion criteria)
• History of abuse of "hard" drugs or alcoholism
• Concomitant treatment with steroids, TNF-blockers, other DMARDs

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
2	diclophenac	treatment on-demand (as needed) with diclofenac-cholestyramine 75 to 150 mg (Voltaren Resinate). The treatment strategy of the control intervention (on-demand) reflects current clinical practice in AS.
1	diclophenac	continuous (daily) treatment with diclofenac cholestyramine 150 mg (Voltaren Resinate), divided into 75mg Voltaren twice daily

Primary Outcome Measures

Name	Time	Method
radiographic change (mean) of the spine after 2 years in the per-protocol population. Radiographs will be collected and centrally digitized. Scoring will be done by 2 readers who were blinded to treatment and sequence of the films	2 years

Secondary Outcome Measures

Name	Time	Method
the proportions of patients with any progression (change in the mSASSS ≥ 1) and change in the mSASSS > smallest detectable change (SDC), i.e. change in mSASSS which is greater than the measurement error.	2 years
ITT analysis of radiographic change.	2 years
Change in VAS back pain, BASDAI, BASFI, BASMI, CRP.	2 years
event rates of serious and non-serious adverse events will be documented and compared between the two groups.	2 years

Trial Locations

Locations (30)

Praxis Dr. Manger; 🇩🇪 Bamberg, Bayern, Germany

Praxis Dr. Ochs; 🇩🇪 Bayreuth, Bayern, Germany

Praxiszentrum St. Bonifazius; 🇩🇪 München, Bayern, Germany

Praxis Dr. Kellner; 🇩🇪 München, Bayern, Germany

Gemeinschaftspraxis Dr. Göttl; 🇩🇪 Passau, Bayern, Germany

Fachklinik Bad Bentheim; 🇩🇪 Bad Bentheim, Niedersachsen, Germany

Praxis Dr. Rockwitz; 🇩🇪 Goslar, Niedersachsen, Germany

Gemeinschaftspraxis Dr. von Hinüber; 🇩🇪 Hildesheim, Niedersachsen, Germany

Praxis Dr. Dockhorn; 🇩🇪 Weener, Niedersachsen, Germany

Rheumatologische Schwerpunktpraxis; 🇩🇪 Düsseldorf, Nordrhein-Westfalen, Germany

Praxis Dr. Schoo; 🇩🇪 Rheine, Nordrhein-Westfalen, Germany

Praxis Dr. Kramer; 🇩🇪 Remscheid, Nordrhein-Westfalen, Germany

Evangelisches Krankenhaus; 🇩🇪 Ratingen, Nordrhein-Westfalen, Germany

Rheumatologische Praxis Dr. Spieler; 🇩🇪 Zerbst, Sachsen-Anhalt, Germany

Praxis Mielke; 🇩🇪 Berlin, Germany

Praxis Zinke; 🇩🇪 Berlin, Germany

Praxis Dr. Pick; 🇩🇪 Grafschaft bei Bad Neuenahr-Ahrweiler, Germany

Praxis Dr. Kühne; 🇩🇪 Haldensleben, Germany

Gemeinschaftspraxis Dr. Schwenke; 🇩🇪 Dresden, Germany

Rheumazentrum Ruhrgebiet, St. Josefs Krankenhaus; 🇩🇪 Herne, Germany

St. Josefs-Krankenhaus, Rheumatologie; 🇩🇪 Herne, Germany

Praxis Dr. Kapelle; 🇩🇪 Hoyerswerda, Germany

Gemeinschaftspraxis Dr. Kolitsch; 🇩🇪 Katzhütte, Germany

Praxis Dr. Gräßler; 🇩🇪 Pirna, Germany

Praxis Bohl-Bühler; 🇩🇪 Potsdam, Germany

Medizinische Universitätsklinik Innere Medizin; 🇩🇪 Tübingen, Baden-Württemberg, Germany

Praxis Dr. Jacki; 🇩🇪 Tübingen, Baden-Württemberg, Germany

Brandt; 🇩🇪 Berlin, Germany

Gemeinschaftspraxis Dr. Gauler; 🇩🇪 Osnabrück, Niedersachsen, Germany

Universitätsklinikum DüsseldorfKlink für Endokrinologie, Diabetologie und Rheumatologie; 🇩🇪 Düsseldorf, Nordrhein-Westfalen, Germany