Early Adalimumab Induction for Immune Checkpoint Inhibitor Associated Inflammatory Arthritis

Study Overview
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Brief Summary
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This study will examine the effectiveness of administering adalimumab as a treatment for patients in the early stages of steroid-dependent immune checkpoint Inhibitor associated inflammatory arthritis (ir-IA). Adalimumab (ADA) is a TNF inhibitor (TNFi) that is well established as a standard of care treatment for numerous types of inflammatory arthritis. It is hoped that adalimumab at the early stages of the ir-IA will reduce the symptoms and therefore reduce the need for steroids. This study is a pragmatic randomized clinical trial. Patients will be randomized 1:1 to each treatment group. To evaluate the steroid sparing effect of early induction six doses of Adalimumab will be administered to patients in the study treatment arm as compared to the usual standard of care of a predefined corticosteroid regimen and taper at 12 weeks administered in the control group.

Official Title
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Early Adalimumab Induction for Treatment of Steroid Dependent Immune Checkpoint Inhibitor Associated Inflammatory Arthritis: A Pragmatic Randomized Clinical Trial

Conditions
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Inflammatory Arthritis, Immune-related Adverse Event

Intervention / Treatment
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* Drug: Adalimumab
* Drug: Prednisone


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: • Patients are deemed eligible for study participation if they meet all the following: Adult patients (age 18 or older) New (within the last 6 months prior to enrollment) inflammatory arthritis defined by any of the following at the time of screening (either on physical exam or by ultrasound) by a certified rheumatologist: 1 or more swollen joints OR 1 or more tenosynovitis OR 1 or more enthesitis Arthritis onset with taking ICI therapy OR within 4 weeks of stopping ICI therapy including CTLA-4, PD-1, and PDL-1 inhibitors Initiation of ICI therapy must predate the onset of inflammatory arthritis Arthritis either does not respond completely to prednisone doses of 10mg (equivalent) OR recurs with prednisone taper below 10mg daily. Negative tuberculosis (TB) status within the past 12 months (TB skin test or quantiferon) for the patients in the adalimumab group. If not available, the status should be confirmed within 6 months of enrollment in the study (adalimumab group only) Written informed consent provided by patient or power of attorney Exclusion Criteria: Patients are excluded if they meet any of the following: Previous diagnosis of inflammatory arthritis or other rheumatic disease (prior to current acute episode) Including but not limited to: rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, Sjogren's syndrome, psoriatic arthritis, reactive arthritis, ankylosing spondylitis, systemic vasculitis, undifferentiated inflammatory arthritis, undifferentiated connective tissue disease Tenosynovitis, synovitis or enthesitis attributed to another cause, fracture or acute gout/CPPD flare. Presence of a contraindication to adalimumab therapy Any of the following in the 7 days prior to initiation of adalimumab: positive tuberculin skin test (>5mm induration within 48 to 72 hours) or positive quantiferon, evidence of untreated active infection including fungal infection, opportunistic infection, hepatitis B/C, or HIV Personal history of congestive heart failure Personal or family history of demyelinating neurologic disease History of previous TNF inhibitor use Current use of other disease modifying agents including: Chloroquine, Sulfasalazine, Azathioprine, 6-MP, and Leflunomide Presence of a concomitant non-rheumatic irAE which required systemic immunosuppression within the past 3 months e.g. pneumonitis, hepatitis, colitis, scleritis, nephritis Require chronic steroid treatment for adrenal insufficiency or another medical reason other than ir-IA Pregnancy, breastfeeding or childbearing potential without practicing highly effective contraception. Inability to participate in follow-up visits

Ages Eligible for Study
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Minimum Age: 18 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
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Standard of care group<br>Prednisone 10 mg daily for 2 weeks, then taper by 2.5 mg every 2 weeks until stopped. | Drug: Prednisone<br>* Prednisone as per standard of care.<br>|
| Active Comparator: Adalimumab group<br>Adalimumab 40 mg subcutaneous every 2 weeks for 6 doses (12 weeks) + Prednisone 10 mg daily for 2 weeks, tapering by 2.5 mg every 2 weeks until stopped. | Drug: Adalimumab<br>* Participants will be randomized 1:1 (non-blinded) to receive either adalimumab (40 mg subcutaneous every 2 weeks for 12 weeks) and prednisone vs prednisone alone. Addition of methotrexate (MTX) and/or hydroxychloroquine (HCQ) is permitted, as needed, at the discretion of the treating rheumatologist. No additional conventional synthetic, targeted synthetic or biologic DMARDs are permitted during the trial.<br>Drug: Prednisone<br>* Prednisone as per standard of care.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| percentage of participants on prednisone | Definition of success: Thirty percent fewer participants on prednisone in Group 2 vs Group 1. | at 12 weeks | 
| Cumulative prednisone dose | Definition of success: Thirty percent reduction in the cumulative dose of steroids in Group 2 compared to Group 1. | at 12 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| percentage of participants on prednisone | Definition of success: Thirty percent difference between the two groups | 24 weeks | 
| Cumulative prednisone dose | Definition of success: Thirty percent difference between the two groups | 24 weeks | 
| percentage of dose reduction of prednisone | Definition of success: Thirty percent difference between the two groups | At 12 and 24 weeks | 
| percentage of participants with immune-related inflammatory arthritis in remission (based on opinion of investigator) | Definition of success: Thirty percent difference between the two groups | at 12 and 24 weeks | 
| percentage of participants with immune-related inflammatory arthritis resolution (based on opinion of investigator) | Definition of success: Thirty percent difference between the two groups | at 12 and 24 weeks | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Immune Checkpoint Inhibitor, Adalimumab, TNF-alpha inhibitor