Teriparatide for Joint Erosions in Rheumatoid Arthritis: The TERA Trial
Condition: Rheumatoid Arthritis
MeSH terms: Arthritis; Arthritis, Rheumatoid
Intervention: Teriparatide; calcium citrate; Vitamin D; TNF antagonist
Intervention description: 20 μg, subcutaneous injection, 1 injection per day; 1000 mg of calcium citrate; 800 IU of Vitamin D; TNF antagonist as prescribed in clinical practice (such as etanercept or adalimumab)
Intervention MeSH terms: Vitamin D; Teriparatide; Tumor Necrosis Factor Inhibitors; Calcium
Phase: Phase 4
Study type: Interventional
Primary purpose: Treatment
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Enrollment: 26.0
Sex: All
Minimum age: 45 Years
Healthy volunteers: No
Keywords: Rheumatoid Arthritis; Bone erosion; Osteopenia

Summary:

      Summary:

      The investigators propose a randomized controlled open label study of teriparatide in men or
      women with rheumatoid arthritis and joint erosions. Specifically, the investigators will
      examine whether teriparatide in combination with a biologic can retard the development of
      joint erosions. The study will be conducted at Brigham and Women's Hospital Arthritis Center,
      several Brigham and Women's Hospital Arthritis Center satellite practices, the University of
      Massachusetts Medical Center, and Massachusetts General Hospital.

      Hypothesis:

      The investigators hypothesize that the combination of teriparatide with biologic will be much
      more effective at retarding erosion progression then a biologic alone.
    

Eligibility criteria:

        Inclusion Criteria:

        All men and women 45 years of age or older with RA and joint erosions by plain x-ray who
        are taking a biologic for at least three months and who have not taken more than two weeks
        of a bone active agent in the last 12 months will be eligible and screened for their
        interest in participating in the proposed randomized trial.

          1. RA will be defined according to the 2010 American College of Rheumatology/European
             League Against Rheumatism diagnostic and classification criteria.

          2. Osteopenic bone mineral density will be defined as a t-score between -1.0 and -2.5 on
             either a DXA of the posteroanterior (PA) or lateral lumbar spine or the femoral neck
             or total hip. Potential subjects with prior minimal trauma fractures will be excluded.

             2.Subjects must be able to give written informed consent.

        Exclusion Criteria:

          1. A switch in DMARD in the last 3 months;

          2. Current use of chronic oral glucocorticoids > 5 milligrams per day;

          3. A prior history of intolerance to teriparatide;

          4. T-score < -2.5 or a prior minimal trauma fracture;

          5. Use of a bone active agent for over 2 weeks in the last 12 months (these agents
             include oral and intravenous bisphosphonates, hormone replacement therapy, calcitonin,
             raloxifene, teriparatide, suppressive doses of thyroxine, lithium, pharmacological
             doses of vitamin D (greater than 2000 IU/day or anticonvulsants);

          6. History of significant cardiac, hepatic, current alcohol abuse, or major psychiatric
             disorders;

          7. Evidence of active malignant disease, malignancies diagnosed within the previous 10
             years (including hematologic malignancies and solid tumors, except basal cell
             carcinoma of the skin that has been excised and cured), or breast cancer diagnosed
             within the previous 20 years;

          8. No current diagnoses of disorders known to affect bone metabolism including
             hyperthyroidism, hyperparathyroidism, osteomalacia, or Paget's disease. All
             participants will be required to have normal serum levels of 25-OH vitamin D (> 20
             ng/ml), intact PTH, and thyroid stimulating hormone (TSH). If PTH and/or 25-hydroxy
             vitamin D (25-OH D) levels are abnormal, subjects may be given calcium and/or
             multivitamin supplements and be re-tested in 2-12 weeks;

          9. Serum calcium (Ca) > 10.6 mg/dl,and 24-hour urine calcium > 400 mg. If minor
             abnormalities are detected in any of these parameters, the test may be repeated;

         10. Patients who have had external beam radiation; and

         11. Patients currently on digoxin.

         12. Women that are currently pregnant or breast-feeding or plan on becoming pregnant over
             the course of participation in the study