Capability of Tofacitinib or Etanercept to Accelerate Tapering of NSAID and Treat-to-target Guided De-escalation of Corticosteroids in RA Patients

Patients with active rheumatic arthritis (RA) and lack of efficacy of at least one csDMARD (Disease-modifying anti-rheumatic drug) treatment will be randomized to receive either Tofacitinib (TOFA) or etanercept (ETA). The study will be separated into two parts: The capability to decrease and discontinue pain-reducing treatment with a NSAID (non-steroidal anti-inflammatory drug) over the first 12 weeks of treatment will be measured for primary outcome measured using a visual analogue scale (VAS) at week 12 compared to baseline between the two treatment groups.

Starting at week 12, the capability to taper corticosteroid (CS) treatment using a treat-to-target strategy, i.e. when at least low disease activity (LDA-DAS28) is achieved, will be measured in both groups.

In this clinical study, a design was chosen to reflect European standards recommended by EULAR for treatment of active RA by comparison of a Treat-to- target (T2T) approach in two treatment groups: Patients with active RA and lack of efficacy of at least one csDMARD treatment will be randomized to receive either TOFA or ETA. The study will be separated into two parts: The capability to decrease and discontinue pain-reducing treatment with a NSAID (Celecoxib, two times 200 mg as maximum standard dosage for RA) over the first 12 weeks of treatment will be measured for primary outcome. The proportion of patients with successful discontinuation of Celecoxib and significant and clinical relevant decrease of pain-levels measured using a visual analogue scale (VAS) with a reduction of at least 30% at week 12 compared to baseline will be compared between the two treatment groups.

Starting at week 12, the capability to taper CS treatment using a treat-to-target strategy, i.e. when at least low disease activity (LDA-DAS28) is achieved, will be measured in both groups. In addition to efficacy assessments (DAS28, ACR-response, SJC, TJC), patient reported outcomes, Quality of Life (QoL) measurements and patient satisfaction will be evaluated. Safety (severity and frequency of adverse events) will be evaluated over the 24-week treatment period.

Eligibility Criteria:
Inclusion Criteria:

* Patients with active RA and an inadequate response to up to two previous conventional synthetic Disease modifying anti-rheumatic drug (csDMARD) treatments (methotrexate (MTX), leflunomide (LEF),sulfasalazine (SSZ)) with or without ongoing csDMARD therapy
* RA according to ACR classification criteria
* Age 18 - 65 years
* Active RA is defined as

  * DAS28 \> 3.2 and
  * TJC ≥ 3 and SJC ≥ 3
* VAS-pain ≥ 60 mm (0-100 mm)
* Accompanying CS treatment for RA with a stable dosage of ≥ 2mg/d and ≤ 10 mg/d 2 weeks prior to BL (not more than 30% of patients without CS)
* Accompanying need of NSAID or analgesic treatment due to arthritis and in dosages not exceeding the maximum dose according to Summary of Product characteristics (SmPC)
* If ongoing csDMARD treatment, stable treatment will be defined as either

  * MTX treatment with a dosage of ≥ 10 mg/week and ≤ 25 mg/week, continuously for at least 12 weeks prior to Screening (SCR) with a stable dose of MTX for at least 2 weeks prior to BL or
  * LEF treatment with a dosage between 10 to 20 mg/day, continuously for at least 12 weeks prior to SCR with a stable dose of LEF for at least 2 weeks prior to BL or
  * SSZ treatment with dosage between 1 to 3 g/day, continuously for at least 12 weeks prior to SCR with a stable dose of SSZ for at least 2 weeks prior to BL
* Presence of documented negative results for testing of Hepatitis B and C
* Completed SARS-CoV-2-immunisation as currently recommended by the Standing Committee of Vaccination
* Written informed consent obtained prior to the initiation of any protocol-required procedures
* Willingness to comply to study procedures and study protocol

Exclusion Criteria:

* Previous use of Tofacitinib or other Janus-Kinase (JAK)-inhibitors
* Previous use of Etanercept
* Previous use of any biological agent for RA

  * which was stopped due to lack of efficacy
  * one previous use of biological stopped due to intolerance will be allowed
* CS treatment with dosages \>10 mg at BL
* Known hypersensitivity to any component of the study medication (TOFA, ETA, Celecoxib)
* Previous use of Celecoxib as analgesic therapy which was stopped due to lack of efficacy or intolerance
* Concomitant diseases with chronic pain syndrome or need of extended dosages or long-term treatment with the maximum dosages of NSAID/analgesics (according to SmPC) due to other concomitant diseases/pain symptoms in discretion of the treating physician Exclusion criteria related to general health
* Patients with other chronic inflammatory articular disease or systemic autoimmune disease
* Patients with active Tuberculosis (Tb) (evaluation of Tb according to local standards in clinical care)
* Patients with latent Tb, that are not pre-treated for at least 1 month and planned to be treated 9 months in total with Isozid once a day
* Any active infection, a history of recurrent clinically significant infections (e.g. human immune deficiency virus (HIV)), or a history of recurrent bacterial infections with encapsulated organisms
* Primary or secondary immunodeficiency
* Current malignancy or history of malignancies except adequately treated or excised basal cell or squamous cell carcinoma or cervical carcinoma in situ.
* Patients of 50 years and older, if they have one or more cardiovascular risk factors (CVRF) defined as:

  * Current cigarette smoking,
  * Known diagnosis of hypertension,
  * HDL \<40 mg/dl,
  * Diabetes mellitus,
  * History of coronary artery disease: history of revascularization procedure, coronary artery bypass grafting, myocardial infarction, cardiac arrest, unstable angina, acute coronary syndrome or
  * History of premature coronary heart disease or sudden death documented in first degree relatives (male relative before 55 years, female relative before 65 years)
* Evidence of significant uncontrolled concomitant diseases or serious and/or uncontrolled diseases that are likely to interfere with the evaluation of the patient's safety and with the study outcome
* History of a severe psychological illness or condition
* Known hypersensitivity to sulfonamides
* Active peptic ulceration or gastrointestinal (GI) bleeding
* Patients who have experienced asthma, acute rhinitis, nasal polyps, angioneurotic oedema, urticaria or other allergic-type reactions after taking acetylsalicylic acid (aspirin) or other NSAIDs including Cyclooxigenase (COX)-2 inhibitors
* Risk for or history of thrombotic events (e.g. pulmonary embolism or thrombosis) Severe hepatic dysfunction (serum albumin \< 25 g/L or Child-Pugh score ≥ 10)
* Patients with estimated creatinine clearance \< 30 mL/min
* Inflammatory bowel disease
* Congestive heart failure (New York Heart Association (NYHA) II-IV)
* Established ischaemic heart disease, peripheral arterial disease and/or cerebrovascular disease
* Women lactating, pregnant, nursing or of childbearing potential with a positive pregnancy test
* Males or females of reproductive potential not willing to use effective contraception (e.g. contraceptive pill, intrauterine device (IUD), physical barrier)
* Alcohol, drug or chemical abuse Exclusion criteria related to prior treatments
* Current participation in another interventional clinical trial or participation within the last 90 days Exclusion criteria related to formal aspects
* Underage or incapable patients