Abatacept in Juvenile Dermatomyositis
Condition: Dermatomyositis
MeSH terms: Dermatomyositis
Intervention: Abatacept
Intervention description: Study participation will consist of a screening visit and 5 protocol visits over six months (week 0, week 6, week 12, week 18, and week 24) for each subject, and phone follow-up (week 2, week 4, week 8, week 10, week 14, week 16, week 20, and week 22). At Visit 1, which will be treatment initiation, eligible subjects will be instructed on the use and side effects of subcutaneous abatacept and will be started on the study drug (abatacept 125 mg SQ weekly for subjects with body weight ≥ 50 KG or abatacept 87.5mg SQ for subjects with body weight < 50 KG).
Intervention MeSH terms: Abatacept
Phase: Phase 4
Study type: Interventional
Primary purpose: Treatment
Intervention model: Single Group Assignment
Masking: None (Open Label)
Enrollment: 10.0
Sex: All
Minimum age: 7 Years
Healthy volunteers: No
Keywords: Juvenile dermatomyositis; inflammatory myopathies; Orencia; Abatacept

Summary:

      The purpose of this study is to assess the safety and efficacy of subcutaneous abatacept in
      10 patients seven years of age and older with refractory JDM.
    

Eligibility criteria:

        Inclusion Criteria:

          1. Adults with definite or probable JDM and pediatric patients 7 years of age and older
             with definite or probable JDM.

          2. Body weight of at least 25 kg (or at least 55 lbs) and age ≥ 7 years of age.

          3. Patients must reside within the United States or Canada.

          4. Refractory myositis, as defined by the intolerance to or an inadequate response to
             corticosteroids plus an adequate regimen of at least one other immunosuppressive
             agent, including azathioprine, methotrexate, IVIG, mycophenolate mofetil,
             cyclophosphamide, tacrolimus or cyclosporine A, or a biologic therapy. The definition
             of intolerance is: side effects that require discontinuation of the medication or an
             underlying condition that precludes the further use of the medication.

          5. At least moderately active disease as documented by:

               -  MD global VAS with a minimum value of 2.5 cm on a 10 cm scale AND

               -  At least 2 other abnormal core set measures listed below:

          6. Therapy with prednisone or another glucocorticoid is required, unless there is
             documented intolerance in the medical record or a medical condition that
             contraindicates further use of prednisone. The prednisone dose must be stable for at
             least 4 weeks prior to the screening visit.

          7. Background therapy with at least 1 non-corticosteroid immunosuppressive agent is
             required at a stable dose for at least 6 weeks prior to the screening visit unless
             there is documentation that the patient is intolerant, which is defined as side
             effects that require discontinuation of the medication(s) or an underlying condition
             that precludes the further use of the IS medication.

          8. If an immunosuppressive agent was discontinued prior to the screening visit then there
             must be a:

               -  4 week washout for prednisone or methotrexate

               -  8 week washout for any other IS agent

               -  For discontinuation of biologic therapies, a washout of 5 terminal half lives

          9. If on hydroxychloroquine or colchicine, the dose should be stable for 6 weeks prior to
             Visit 1.

         10. If on statin or fibric acid derivative agents, the dose should be stable for 6 weeks
             prior to Visit 1.

         11. Ability of patient or parent to complete self-report questionnaires.

         12. Men and women of reproductive potential must agree to use a reliable method of birth
             control during the 24 week duration of the trial described in the reproductive risks
             section of this protocol (section 4.3). They must also agree to use a reliable method
             of birth control for 100 days after the last dose of study drug is administered.

         13. Patients must agree to forgo immunization with a live vaccine during the course of the
             study or within 3 months after discontinuation.

         14. Patients must have a letter from the referring rheumatologist or specialist
             supervising the care of the JDM, agreeing to the patient's participation in the study
             and to continuing to provide care for the patient, including emergency care during the
             trial.

        Core Set Measures:

          -  An MMT-8 score that is no greater than 125/150

          -  Patient/Parent Global VAS with a minimum value of 2.0 cm on a 10cm scale

          -  CHAQ/HAQ disability index with a minimum value of 0.25

          -  Elevation of at least one of the muscle enzymes [which includes creatine kinase (CK),
             aldolase, lactate dehydrogenase (LDH), alanine aminotransferase (ALT) and aspartate
             aminotransferase (AST)] at a minimum level of 1.3 x the upper limit of normal.

          -  Global extra-muscular disease activity score with a minimum value of 2.0 cm on a 10 cm
             VAS scale

        Exclusion Criteria:

          1. Drug-induced myositis (myositis in patients taking medications known to induce
             myositis-like syndromes, including, but not limited to, statin agents, fibric acid
             derivatives, and colchicine).

          2. Juvenile polymyositis; inclusion body myositis; cancer-associated myositis, defined as
             the diagnosis of myositis within 2 years of the diagnosis of cancer except basal or
             squamous cell skin cancer or carcinoma in situ of the cervix if at least 5 years since
             excision

          3. Myositis in overlap with another connective tissue disease (CTD) that precludes the
             accurate assessment of a treatment response (for example, difficulty in assessing
             muscle strength in a scleroderma patient with associated myositis)

          4. History of receiving a live vaccine 4 weeks prior to initiation of study treatment

          5. Joint disease, severe calcinosis, or other musculoskeletal condition, which precludes
             the ability to quantitate muscle strength.

          6. Wheelchair bound patients.

          7. Known hypersensitivity to abatacept or prior receipt of abatacept

          8. Concomitant illness that would prevent adequate patient assessment or in the
             investigators opinion pose an added risk for study participants:

          9. Recurrent or chronic infections, including HIV, tuberculosis, hepatitis B and C, or TB
             infection, including contact with a household contact with active tuberculosis (TB)
             and who did not receive appropriate and documented prophylaxis for TB. (a documented
             negative Hepatitis B surface antigen and Hepatitis C antibody completed at the
             screening visit or within 6 weeks prior to screening visit is required)

         10. Have had symptomatic herpes zoster or herpes simplex infection (not including simple
             oral HSV lesions) within 12 weeks prior to entry or during screening period

         11. Have a history of disseminated/complicated herpes zoster (for example,
             multi-dermatomal involvement, ophthalmic zoster, central nervous system (CNS)
             involvement, post-herpetic neuralgia)

         12. Known liver disease (i.e. cirrhosis or other conditions compromising the synthetic
             function of the liver)

         13. Disorders that would preclude accurate assessment of neuromuscular function

         14. Cardiomyopathy or arrhythmias that in the investigators opinion poses an additional
             risk for study participants

         15. New York Heart Association Classification III or IV for congestive heart failure

         16. Psychiatric illness that precludes compliance or neuromuscular assessment

         17. Serum creatinine > 2.0mg/dl

         18. Pregnant females or nursing mothers

         19. Life threatening illness that would interfere with the patient's ability to complete
             the study.

         20. Known or suspected history of drug or alcohol abuse within the past 6 months as
             determined by the medical record or patient interview

         21. Anticipated poor compliance

         22. Participation in another clinical experimental therapeutic study within 30 days of
             screening visit.

         23. Any history or evidence of severe illness or any other condition that would make the
             patient, in the opinion of the investigator unsuitable for the study.

         24. Low total WBC <2.000, platelets < 100,000/mm3; hemoglobin <10 gm/dl

         25. History of recurrent infection including active skin infections with calcinosis

         26. Subjects with a history of cancer in the last 5 years

         27. Subjects who have at any time received treatment with any investigational drug within
             28 days (or less than 5 terminal half-lives of elimination) of the day 1 dose of study
             drug, including waiting until CD19 returns to a detectable level and IgG level is
             within normal limits (normal serum levels of IgG per reference lab: 7-9 years ≥572
             mg/dl, 10-11 yrs ≥698 mg/dl, 12-13 yrs ≥759 mg/dl, 14-15 yrs ≥716 mg/dl,16-19 yrs ≥549
             mg/dl, >19 yrs ≥700 mg/dl) for those patients who have received rituximab

         28. Concomitant treatment with anti-TNF therapies, rituximab or anakinra or other biologic
             therapies.

         29. Initiation of colchicine and hydroxychloroquine as new drugs during study
             participation is not allowed.

         30. Initiation of statins or fibric acid derivatives during study participation is not
             allowed.

         31. Initiation of an exercise program within 4 weeks of the screening visit. Only a
             stretching program may be initiated during the study (See section 5.4 Other
             Restrictions)

         32. Prisoners or subjects who are involuntarily incarcerated.

         33. Subjects who are compulsorily detained for treatment of either a psychiatric or
             physical (e.g., infectious disease) illness.