Tofacitinib for Immune Skin Conditions in Down Syndrome

Study Overview
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Brief Summary
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People with Down syndrome (DS) display widespread immune dysregulation, including several immune skin conditions. This study hypothesizes that pharmacological inhibition of the increased interferon (IFN) signaling seen in DS is safe and could improve associated skin conditions. The study evaluates the safety and efficacy treatment with Tofacitinib, an FDA-approved drug known to block IFN signaling, in adolescents and adults with DS and an autoimmune and/or autoinflammatory skin condition. Investigators will also measure the impact of interferon inhibition on a variety of molecular markers, as well as the cognitive abilities and quality of life of participants.

Detailed Description
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Trisomy 21 (T21) is the most common human chromosomal disorder, occurring in  1/700 live births, leading to the condition known as Down syndrome (DS). Importantly, people with DS display widespread immune dysregulation and over half of adults with T21 are affected by one or more autoimmune conditions, including several immune skin conditions. The driving hypothesis for this study is that hyperactivation of interferon (IFN) signaling leads to myriad immune-driven diseases and immunological phenotypes in people with DS, and that pharmacological inhibition of IFN signaling could have multidimensional therapeutic benefits in this population. This study utilizes Tofacitinib, an FDA-approved drug known to block IFN signaling and several accompanying inflammatory pathways, to reduce IFN signaling in DS and to measure its effects via multidimensional endpoints. Previous studies and current clinical trials indicate that Janus kinase (JAK) inhibitors, such as Tofacitinib, can block inflammatory pathways and may have beneficial effects on immune skin conditions. Further, inhibition of chronically active IFN signaling in DS with Tofacitinib may attenuate other core drivers of immune dysregulation, leading to improvements in other immune diseases and conditions common to DS that are potentially driven by inflammation, such as cognitive deficits. Investigators will test these hypotheses using a battery of immune and molecular assessments, as well as cognitive testing and quality of life measures. This clinical trial evaluates adolescent and adult participants with DS during eight study visits over an approximate five month period. Specific Aims: To define the safety profile of JAK inhibition in people with DS, To determine the impact of JAK inhibition on the immune dysregulation caused by trisomy 21, To define the impact of JAK inhibition on immune skin conditions in DS, and To characterize the impact of JAK inhibition on cognition and quality of life in DS.

Official Title
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Safety and Efficacy of Tofacitinib for Immune Skin Conditions in Down Syndrome

Conditions
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Down Syndrome, Alopecia Areata, Atopic Dermatitis / Eczema, Hidradenitis Suppurativa, Vitiligo, Psoriasis

Intervention / Treatment
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* Drug: Tofacitinib


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Males or females with DS between 12 and 50 years of age who weigh at least 40 kg. Diagnosis of at least one active immune skin condition, including but not limited to: Moderate-to-severe atopic dermatitis Alopecia areata affecting at least 25% of the scalp Moderate-to-severe hidradenitis suppurativa Moderate-to-severe psoriasis Moderate-to-severe vitiligo. Be willing to avoid pregnancy or fathering children. Must present with a study partner or legal guardian who can complete, or assist with completing, study materials as appropriate. Exclusion Criteria Weigh less than 40 kg. Pregnancy or breast feeding. No study partner or legal guardian. Vaccination with live attenuated virus within six weeks of inclusion in the study or planned during the study. Clinically significant chronic or active viral infection including but not limited to HIV, hepatitis, CMV, EBV, HSV. Severe renal impairment. History of malignant solid tumor cancer within five years prior to study entry or where there is current evidence of recurrent or metastatic disease. Poor venous access not allowing repeated blood tests or non-compliance with venipuncture requirements. Prior treatment with a JAK inhibitor or with an investigational agent, device, or procedure within 21 days of enrollment. Concomitant treatment with other immunosuppressants (e.g. corticosteroids, methotrexate) or strong CP3A4 or CYP2C19 inhibitors or inducers (e.g. ketoconazole, fluconazole). Known allergies, hypersensitivity, or intolerance to Tofacitinib. History of thrombotic disorder. Superficial skin infection within 2 weeks of inclusion in the study. History of disseminated herpes zoster, disseminated herpes simplex, or recurrent localized dermatomal herpes zoster. Intravenous antimicrobial therapy within 3 months of inclusion in the study. Oral antimicrobials within 2 weeks of inclusion in the study. Participants may be excluded for other unforeseen reasons at the study doctor's discretion. Unable to provide assent in cases where informed consent is obtained from other authorized representative. Kidney transplant within the last two years Any history of heart attack or stroke. Any history of lymphoma. Past or current smokers. Not fully vaccinated against COVID-19 in accordance with current CDC definition.

Ages Eligible for Study
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Minimum Age: 12 Years
Maximum Age: 50 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Interventional Model Description: All participants will receive the investigational product, Tofacitinib.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: On Treatment<br>Tofacitinib 5mg oral tablets twice daily for 16 weeks | Drug: Tofacitinib<br>* Treatment with oral Tofacitinib for immune mediated skin conditions in adults with Down syndrome<br>* Other names: Xeljanz;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Safety as Assessed by Number of Serious Adverse Events (SAE) | Number of SAEs that are definitely related to Tofacitinib treatment | Up to Week 18 | 
| Change in Interferon (IFN) Scores in the Transcriptome of White Blood Cells | A composite score used to represent the change in activation of the interferon pathway. Possible scores increase from zero with higher scores indicating a more activated interferon pathway. | Baseline and 16 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Investigator's Global Assessment (IGA) | The IGA will be used to assess overall changes in severity across five skin conditions (alopecia, atopic dermatitis, vitiligo, psoriasis and hidradenitis suppurativa) scored from 0 (clear) to 4 - 5 (very severe). | Baseline and 16 weeks | 
| Change in Dermatology Life Quality Index (DLQI) | The DLQI will be used to assess participant-reported impact of skin conditions on self-image, relationships, and daily activities. Possible total scores range from 0-30, with higher scores indicating a more impaired quality of life. | Baseline and 16 weeks | 
| Change in Eczema Area and Severity Index (EASI) Score in Participants with Atopic Dermatitis | The EASI will be used to assess changes in the extent (area) and severity of atopic dermatitis (eczema). Each of four sites (head, upper limbs, trunk, and lower limbs), are weighted by overall contribution to body surface area and separately scored by using four parameters (erythema, infiltration, excoriations, lichenification), each of which is graded on a severity scale of 0 (none) to 4 (severe), as well as degree of involvement. Possible total scores range from 0-72, with higher scores indicating a more severe involvement. | Baseline and 16 weeks | 
| Change in Severity of Alopecia Tool (SALT) Score in Participants with Alopecia | The SALT will be used to assess changes in degree and extent (area) of hair loss due to alopecia on the head. Each of four scalp sites (left side, right side, top and back) are weighted by overall contribution to scalp surface area and rated for percent involvement. Possible total scores range from 0-72, with higher scores indicating a larger affected area. | Baseline and 16 weeks | 
| Change in Modified Sartorius Score (MSS) Score in Participants with Hidradenitis Suppurativa | The MSS will be used to assess changes in areas affected by hidradenitis suppurativa. Each of seven sites (right/left axillae, right/left groin, right/left gluteal, other) are scored by number of lesions, distance between lesions, and presence of normal skin between lesions. Possible total scores range up from 0 with no maximum, with higher scores indicating a more severe involvement. | Baseline and 16 weeks | 
| Change in Psoriasis Area and Severity Index (PASI) Score in Participants with Psoriasis | The PASI will be used to assess changes in extent (area) and severity of psoriasis. Each of four sites (head, upper limbs, trunk, and lower limbs) are weighted by overall contribution to body surface area and separately scored by degree of involvement and three additional parameters (erythema, induration and desquamation), each of which is graded on a severity scale of 0 (Not severe) to 4 (very severe). Possible total scores range from 0-72, with higher scores indicating a more severe involvement. | Baseline and 16 weeks | 
| Change in Vitiligo Extent Tensity Index (VETI) in Participants with Vitiligo | The VETI will be used to assess changes in extent (area) of skin affected by vitiligo. Each of five sites (head, trunk, upper limbs, lower limbs, genitalia) are weighted by overall contribution to body surface area and rated for degree of de-pigmentation scale of Stage 0 (normal skin) to Stage 5 (complete de-pigmentation plus significant hair whitening) and percent involvement. Possible scores range from 0-55.5, with a higher score indicating a higher degree of involvement. | Baseline and 16 weeks | 
| A composite score generated using the Meso Scale Discovery (MSD) platform used to assess inflammatory changes in plasma. | Possible total scores increase from zero, with higher scores indicating a higher inflammatory state. | Baseline and 16 weeks | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Interferon, Autoimmunity, Down syndrome, Skin disorder, JAK inhibitor, Inflammation, JAK/STAT, Dermatology