A Randomized, Open-label, Comparative Study to Evaluate an Intermittent Dosing Regimen of Fluticasone Propionate 0.05% Cream (Twice Per Week) in Reducing the Risk of Relapse When Added to Regular Daily Moisturization Using PHYSIOGEL Lotion in Paediatric Subjects With Stabilized Atopic Dermatitis
Condition: Skin Diseases
MeSH terms: Dermatitis, Atopic; Dermatitis; Skin Diseases
Study type: Interventional
Phase: Phase 4

Summary: 
      This is an open-label, randomized, comparative study, including 4 phases: SCREENING, ACUTE,
      MAINTENANCE and FOLLOW-UP.

      Subjects will complete the SCREENING phase to check the eligibility within 7 days after they
      sign the written informed consent form. All eligible subjects will be enrolled in ACUTE phase
      to receive twice daily Fluticasone propionate (FP) 0.05% cream up to 4 weeks. The efficacy
      and safety in ACUTE phase will be assessed every 2 weeks up to 4 weeks or until Treatment
      Success which depends on which time point comes first. Then subject can get into the
      MAINTENANCE phase receiving either emollient twice daily plus FP 0.05% cream once daily twice
      a week (Group A), or emollient twice daily (Group B), by 1:1 randomization. The treatment
      duration in MAINTENANCE phase will be up to 20 weeks. The efficacy and safety in MAINTENANCE
      phase will be assessed every 4 weeks up to 20 weeks or until AD relapse that depends on which
      time point comes first. If subjects don't experience relapse during MAINTENANCE phase,
      subsequent FOLLOW-UP phase applying emollient twice daily won't be longer than another 12
      weeks.

      Total study duration is up to 37 weeks. All subjects receive FP 0.05% cream twice daily up to
      4 weeks to all affected sites and any newly occurring sites in ACUTE phase. After
      randomization in MAINTENANCE phase, subjects either receive emollient twice daily extendedly
      plus FP 0.05% cream once daily twice a week to all healed sites and any newly occurring sites
      (Group A), or emollient twice daily extendedly (Group B), up to 20 weeks. In FOLLOW-UP phase,
      all subjects apply emollient twice daily up to 12 weeks.

      This study will enrol 120 subjects, and propose at least 80 subjects to be randomized.

      Study Endpoints/Assessments:

      Primary endpoint is to observe the median time to the first relapse of AD during MAINTENANCE
      phase.

      Secondary endpoints are:

        1. Median time to the first relapse of AD during the whole study (including maintenance
           phase and follow-up phase.

        2. Numbers of recurrent patients at the end of MAINTENANCE phase;

        3. Numbers of recurrent patients at the end of FOLLOW-UP phase;

        4. The effective rates (proportion of "treatment success" patients) during ACUTE phase (V3,
           W-2±2days;V4, W0±2days )

        5. Evaluate the safety during the whole study duration (ACUTE phase, MAINTENANCE phase,
           FOLLOW-UP phase respectively);

        6. Evaluate visual skin assessment for signs of cutaneous atrophy, epidermal thickening /
           lichenification and abnormal pigmentation changes during the whole study duration (ACUTE
           phase, MAINTENANCE phase, FOLLOW-UP phase respectively);

        7. The change of Quality of Life (QoL) from baseline at the end of MAINTENANCE phase;

        8. The change of Quality of Life (QoL) from baseline at the end of FOLLOW-UP phase;

        9. Subjects' post-study evaluation to drugs.
    

Detailed description: 
      Background Atopic dermatitis (AD) is a chronic relapsing skin disease caused by the
      intervention of plural unspecific stimulation or specific allergens accompanied with
      cutaneous physiologic dysfunction. AD is one of the most common skin diseases which effects
      up to 20% of Children and 1-3% of adults in most of countries of the world. The data from a
      Chinese epidemiologic research shows the prevalence rate of AD is 10.9%in school-age
      adolescent and 15.3% in preschool children in 2010.

      Around 65% patients with AD develop the symptoms in the first year of life; and 90% patients
      develop the symptoms before 5 years of age. Onset of atopic dermatitis in adolescence or
      later is uncommon.

      The objective of treatment in AD is to relief symptoms and reduces the cutaneous
      inflammation. Emollients as the mainstay of maintenance therapy are able to restore skin
      barrier function. Topical glucocorticoids recommended as first line treatment are important
      anti-inflammatory drugs to be used in AD, especially in the acute phase.

      One of the most troublesome features of AD is its chronic relapsing nature suggesting the
      need for a long-term therapy of this disease. The common long-term treatment of AD is a
      reactive treatment approach based on the daily application of emollients accompanied by the
      application of topical glucocorticoids (TCS) or calcineurin inhibitors (TCI) 'as needed'.
      However, a new alternative treatment 'proactive therapy' has been proven its effective and
      well-tolerated to reduce AD relapse in clinical trials and recommended by guidelines.

      This proactive therapy starts with an intensive topical anti-inflammatory therapy until all
      lesions have virtually cleared, followed by long-term, low-dose intermittent application of
      anti-inflammatory drugs to previous affected and now clinically healthy-looking skin combined
      with daily application of emollients to always unaffected areas.

      Latest Chinese guideline of AD recommends the application of emollients or moisturizers in
      both the acute and maintenance phase, and intermittent application of topical corticosteroids
      with daily use of emollients and moisturizers as the first-line option of AD therapy.

      However, the concept of 'proactive therapy' of AD has not been well accepted by Chinese
      dermatologists. In context, the studies demonstrated 'proactive therapy' efficacy has been
      done mainly in Caucasian subjects instead of in Chinese population. For this reason, there
      still exist unmet medical needs to generate data on combination use of fluticasone propionate
      with moisturizer in AD maintenance therapy in China.

      Rationale Fluticasone propionate (FP) is a synthetic fluorinated corticosteroid of medium
      strength for the topical treatment of skin disease. The established glucocorticoids showed
      anti-inflammatory, anti-proliferative and immunosuppressive effects. FP has been demonstrated
      havinga moderate anti-inflammatory effect associated with good compliance among patients, a
      low incidence of cross-sensitivity reactions and a weak atrophogenicity.

      FP does not show a significant effect on the hypothalamic pituitary axis (HPA), due to its
      lipophilicity, and its rapid hepatic biotransformation, reflecting a favourable ratio between
      topical and systemic activity. The results from a clinical trial with moderate to severe AD
      demonstrate that FP does not cause any major local side-effect. First-line therapy of AD in
      paediatric patients consist of the application of a mildly to moderately potent topical
      glucocorticoid combined with emollients . FP cream 0.05% has also been proven safe for the
      treatment of moderate to severe AD for up to 4 weeks in children 3 months of age and older.

      More than one study has been demonstrated the efficacy and safety of FP 0.05% cream for
      proactive therapy of AD. A large multicentre study compared an intermittent dosing regimen of
      FP 0.05% cream (twice per week) with its drug-free vehicle in reducing the risk of relapse in
      adults and children (44% and 66% respectively) aged 3 months to 65 years with moderate or
      severe, but stabilized AD. Both regimens were added to regular daily emollient. The results
      showed patients receiving intermittent FP cream in the maintenance phase were 7.7 times
      (paediatric patients even 8.1 times) less likely to have an AD relapse compared with patients
      under vehicle cream. And the maintenance therapy with FP turned out to be safe and
      well-tolerated.

      Subsequent similar large scale study was to compare the efficacy and safety of both FP 0.05%
      cream and 0.005% ointment in reducing the risk of relapses. The difference was that only
      patients aged 12-65 years with moderate to severe AD who were experiencing a flare were
      enrolled. FP 0.05% was more effective in reducing relapses than FP 0.005%: the former
      reducing the risk of relapses six fold and the latter two fold compared with emollient alone.
      Median time to relapse was 6 weeks for emollient alone compared with more than 16 weeks for
      additional FP. Both medications were well-tolerated with a low risk of local adverse effects.

      First-line therapy of AD in paediatric patients consist of the application of a mildly to
      moderately potent topical glucocorticoid combined with emollients . Except for topical
      glucocorticoid, emollients are the basic treatment of AD, which have been recommended and
      emphasized by almost all the AD guidelines. PHYSIOGEL lotion, as a hypoallergenic emollient,
      contains physiological lipids, which mimics the structure and composition of the skin's
      protective lipid barrier with DMS (Dermal Membrane Structure) technique. PHYSIOGEL lotion
      provides immediate and long lasting moisture to prevent skin dryness, which has been
      recommended by dermatologists in AD adjunctive daily care. It is advised to apply a thin film
      of PHYSIOGEL lotion once to twice daily ideally for people of all ages with dry, sensitive
      and barrier dysfunction skin (including people suffering from AD).

      In summary, a superiority of a proactive therapy with combination of FP and emollient over
      the drug-free vehicle or emollient alone has been demonstrated. Proactive therapy with FP
      prevented, delayed, and reduced the occurrence of exacerbations and AD relapses without any
      obvious safety concerns. Besides, PHYSIOGEL lotion, an emollient with physiological lipids
      and DMS technology, has good efficacy in repairing skin barrier. In this regard, it is
      possibly meaningful to demonstrate the efficacy and safety of a FP and PHYSIOGEL lotion
      combination in reducing AD relapse.

      OBJECTIVE(S) This study is aimed to demonstrate the risk of AD relapse can be significantly
      reduced by extended intermittent dosing with Fluticasone propionate (FP) 0.05% cream in
      addition to regular emollient therapy (PHYSIOGEL lotion) in the maintenance treatment (20
      weeks) of atopic dermatitis (AD) as compared with application of emollient alone.

      The secondary objective is to evaluate the safety of FP 0.05% cream and emollient combination
      usage in AD maintenance treatment and determine the optimal treatment regimen in Chinese
      paediatric patients with AD.

      Study Design This is an open-label, randomized, comparative study. The study includes 4
      phases: SCREENING, ACUTE, MAINTENANCE and FOLLOW-UP.

      After subjects sign the written informed consent form (Visit 1), they will enter the
      SCREENING phase to check the eligibility within 7 days before the 1st dose of FP 0.05% cream.
      During SCREENING phase, investigator will collect subjects' demographic data, medical
      history, Atopic Dermatitis' diagnosis and treatment history, concomitant medications.
      Investigator needs to assess AD Severity and conduct physical examination. Substance abuse
      will be evaluated. And pregnant test must be conducted to check for Women of childbearing
      potential (WOCBP).

      -Women of childbearing potential (WOCBP) must be using an adequate method of contraception to
      avoid pregnancy throughout the study (and for up to 6 weeks after the last dose of
      investigational product) in such a manner that the risk of pregnancy is minimized.

      WOCBP include any female who has experienced menarche and who has not undergone successful
      surgical sterilization (hysterectomy, bilateral tubal ligation, or bilateral oophorectomy) or
      is not postmenopausal.

      Women who are using oral contraceptives, other hormonal contraceptives (vaginal products,
      skin patches, or implanted or injectable products), or mechanical products such as an
      intrauterine device or barrier methods (diaphragm, condoms, spermicides) to prevent
      pregnancy, or are practicing abstinence or here their partner is sterile (e.g., vasectomy)
      should be considered to be of childbearing potential.

      The Visit 2 will be occurred before the 1st dose of FP 0.05% cream. At Visit 2, investigator
      needs to evaluate Eczema Area, AD Severity and Visual Skin Assessment. Vital signs will be
      measured and recorded. Subjects need to complete the questionnaire of QoL under the
      investigator's instruction. Investigator must confirm subjects' eligibility for ACUTE phase
      after all of inclusion and exclusion criteria have been checked.

      All subjects eligible for ACUTE phase will receive twice daily FP 0.05% cream. FP 0.05% cream
      will be applied to affected sites and any newly occurring AD sites.

      The efficacy and safety in ACUTE phase will be assessed every 2 weeks up to 4 weeks or until
      Treatment Success dependent on which time point comes first. At each visit (Visit 3,
      W-2±2days; Visit 4, W0±2days) in ACUTE phase, investigator needs to assess Eczema Area, AD
      Severity, Visual Skin Assessment, and conduct physical examination, vital sign measurement.
      Randomization will be processed once investigator confirms the subject's eligibility for
      MAINTENANCE phase.

      The day of randomization is D0 in MAINTENANCE phase. If patients achieve Treatment Success
      and meet the criteria of MAINTENANCE phase during the visit intervals of ACUTE phase, Visit 4
      can be moved earlier than scheduled date. If the time of treatment success is within 2 weeks
      after Visit 2, the subject can enter Visit 4 directly by skipping Visit 3.

      If patients don't achieve Treatment Success for 4-week FP 0.05% cream treatment, they will be
      discontinued study treatment and conduct End of Therapy Visit. The subjects eligible for
      MAINTENANCE phase will be 1:1 randomized to receive either emollient twice daily plus FP
      0.05% cream once daily twice a week (Group A), or emollient twice daily (Group B). FP 0.05%
      cream will be applied to all healed sites and any newly occurring sites.

      The efficacy and safety in MAINTENANCE phase will be assessed every 4 weeks up to 20 weeks or
      until AD relapse dependent on which time point comes first. At each visit (V5, W4±2days; V6,
      W8±2days; V7, W12±2days; V8,W16±2days;V9,W20±2days), Investigator needs to evaluate Eczema
      Area, AD Severity, Visual Skin Assessment, and conduct physical examination, vital sign
      measurement. The questionnaire of QoL needs to be completed by subjects at the end of
      maintenance phase.

      In MAINTENANCE phase, once subjects experience AD Relapse, they will be discontinued study
      treatment and conduct End of Therapy Visit.

      On the contrary, if subjects don't experience relapse during MAINTENANCE phase, all of them
      will enter FOLLOW-UP phase applying emollient twice daily.

      The efficacy and safety in FOLLOW-UP phase will be assessed every 4 weeks up to 12 weeks or
      until AD relapse dependent on which time point comes first. At each visit (V10, W24±5days;
      V11, W28±5days; V12, W32±5days), investigator needs to evaluate Eczema Area, AD Severity,
      Visual Skin Assessment, and conduct physical examination, vital sign measurement.In FOLLOW-UP
      phase, once subjects experience AD relapse, they will be discontinued study treatment and
      conduct End of Therapy Visit.

      At End of Therapy Visit, investigator needs to evaluate Eczema Area, AD Severity, Visual Skin
      Assessment, and conduct physical examination, vital sign measurement. Subjects need to
      complete the questionnaire of QoL and Subjects' post-study evaluation to drug.

      Subjects need to conduct Early Withdrawal Visit once they meet Withdrawal Criteria. At Early
      Withdrawal Visit, investigator needs to evaluate Eczema Area, AD Severity, Visual Skin
      Assessment, and conduct physical examination, vital sign measurement. Subjects need to
      complete the questionnaire of QoL and Subjects' post-study evaluation to drug.

      At each study visit, concomitant medications will be collected after receiving subject's
      written informed consent form, and AEs should be collected and documented after the first
      dose of FP. For the female subjects who has experienced menarche, urine pregnant test need to
      be done when subjects enter the study and be repeated at the end of the entire study. If the
      result is positive, the subject will quit from the study. The treatment compliance will be
      evaluated at each visit after the 1st dose of FP 0.05% cream.

      Total study duration is up to 37 weeks.
    

Intervention name(s): Fluticasone propionate
Intervention type(s): Drug
Intervention description(s): All subjects receive FP 0.05% cream twice daily up to 4 weeks to all affected sites and any newly occurring sites in ACUTE phase. After randomization in MAINTENANCE phase, subjects either receive emollient (Physiogel) twice daily extendedly plus FP 0.05% cream once daily twice a week to all healed sites and any newly occurring sites (Group A), or emollient (Physiogel) twice daily extendedly (Group B), up to 20 weeks. In FOLLOW-UP phase, all subjects apply emollient (Physiogel) twice daily up to 12 weeks.
Intervention MeSH terms: Fluticasone; Xhance
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment