Mechanistic Studies of B- and T-Cell Function in RA Patients Treated With TNF Antagonists, Tocilizumab, or Abatacept
Condition: Rheumatoid Arthritis (RA)
MeSH terms: Arthritis; Arthritis, Rheumatoid
Intervention: TNF Antagonist (enbrel, humire, remicade, cimzia, symponi); Abatacept; Tocilizumab
Intervention description: TNF Antagonist; treating rheumatologist selects specifics for the therapy chosen.; Abatacept; SQ; specifics to be determined by the treating rheumatologist.; Tocilizumab; SQ; specifics determined by the treating rheumatologist.
Intervention MeSH terms: Etanercept; Infliximab; Certolizumab Pegol; Tumor Necrosis Factor Inhibitors; Abatacept
Phase: Phase 4
Study type: Interventional
Primary purpose: Basic Science
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Enrollment: 10.0
Sex: All
Minimum age: 18 Years
Maximum age: 64 Years
Healthy volunteers: No
Keywords: Rheumatoid arthritis; TNF inhibitors

Summary:

      An Agency for Healthcare Research and Quality executive summary indicated that better
      comparative effectiveness trial designs are needed to determine the relative merits of
      existing versus new and expensive biologic drug therapies for rheumatoid arthritis (RA).
      There are now 9 biologic therapies approved for treating RA. Four classes of biologics (TNF
      antagonists, B-cell inhibitors, T-cell co-stimulator blocker, and Interleukin-6 receptor
      blocker) are approved for use in RA patients with moderate or severe disease activity.
      Several critical questions have arisen, such as 1) what therapy should be prescribed after
      failure of methotrexate and/or other oral disease modifying antirheumatic drugs (DMARDs) to
      adequately control disease activity; 2) what is the level of efficacy of the various biologic
      therapies when compared in head-to-head trials; and 3) what are the mechanisms associated
      with failure of methotrexate and/or other oral DMARD therapy and responsiveness to biologic
      therapies. The MAZERATI study will provide the foundation for answering these questions and
      determining the mechanisms associated with these biologic therapies.
    

Eligibility criteria:

        Inclusion Criteria:

          -  Diagnosis of RA by a physician as defined by the 1987 and/or 2010 ACR criteria.

          -  18 years of age or less than or equal to 64 at the time of diagnosis of RA.

          -  RA Disease Activity CDAI > 10

          -  If using oral corticosteroids, must have been on stable dose (≤ 10 mg/day) for at
             least 2 weeks prior to study drug initiation.

          -  PPD negative or if PPD positive documentation of therapy with INH for at least 1 month
             prior to study initiation and negative chest x-ray.

          -  Must have been treated within the past year with either methotrexate (MTX),
             leflunomide (LEF), hydrochloroquine (HCQ) and/or sulfasalazine (SSZ) for ≥ 3 months.

          -  Prior or concurrent use of other oral DMARD therapy, including MTX, leflunomide, SSZ,
             and HCQ, is permitted. Patients taking oral DMARDs must be on stable doses of DMARDs
             for at least 4 weeks prior to study drug initiation. Subjects are not required to be
             taking an oral DMARD.

        Exclusion Criteria:

          -  Use of cyclophosphamide, penicillamine, cyclosporine A, tacrolimus or gold therapy is
             not permitted in the 6 months prior to enrollment.

          -  Patients who are using or have used other biologic agents or tofacitinib concomitantly
             or prior to this study

          -  History of active and/or chronic infection such as hepatitis, pneumonia,
             pyelonephritis,herpetic infections or chronic skin infections and any active
             opportunistic infection, including but not limited to evidence of active
             cytomegalovirus, active Pneumocystis carinii, aspergillosis, histoplasmosis or
             atypical mycobacterium infection.

          -  Active TB or evidence of latent TB (positive PPD skin test or a history of old or
             latent TB on chest x-ray) without adequate therapy for TB.

          -  Pregnant or lactating women.

          -  Patients with current signs or symptoms of uncontrolled renal, gastrointestinal,
             endocrine, pulmonary, cardiac, neurologic or cerebral disease.

          -  Diagnosis of liver disease or elevated hepatic enzymes, as defined by ALT, AST or both
             >1.5 x the upper limit of normal (ULN) or total bilirubin > ULN.

          -  Any of the following hematologic abnormalities, confirmed by repeat tests:

               1. White blood count < 3,000/µL or > 14,000/µL

               2. Lymphocyte count <500/µL

               3. Platelet count < 100,000/µL

               4. Hemoglobin < 8.0 g/dL

               5. Neutrophil count < 2,000 cells/µL

          -  Major surgery (including joint surgery) within 8 weeks prior to screening or planned
             major surgery within 6 months following randomization.

          -  Immunization with a live/attenuated vaccine within 2 months prior to baseline or 3
             months of last study visit.

          -  History of severe allergic or anaphylactic reactions to human, humanized, or murine
             monoclonal antibodies

          -  History of other malignancy within 5 years prior to screening, except for
             appropriately treated carcinoma in situ of the cervix, non-melanoma skin carcinoma, or
             Stage I uterine cancer

          -  Patients with reproductive potential not willing to use an effective method of
             contraception

          -  History of alcohol, drug or chemical abuse with 1 year prior to screening