Clinical trial NCT00106184: Rituximab for the Treatment of Refractory Adult and Juvenile Dermatomyositis (DM) and Adult Polymyositis (PM)
Official title: Rituximab Therapy in Refractory Adult and Juvenile Idiopathic Inflammatory Myopathy (IIM)
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: PHASE2
Conditions: Myositis
Dermatomyositis
Polymyositis
Juvenile Dermatomyositis
Keywords: rituximab
myositis
dermatomyositis
polymyositis
refractory
Juvenile Dermatomyositis
Lead sponsor: University of Pittsburgh
Sponsor class: OTHER
Collaborators: name: National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
name: Genentech, Inc.
name: Biogen
First posted: 2005-03-22
Enrollment: 200
Sex: ALL
Minimum age (years): 5
Standard ages: CHILD
ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: Rituximab is a man-made antibody used to treat certain types of cancer. This study will determine whether rituximab is an effective treatment for adult and pediatric patients with dermatomyositis or polymyositis.

Study hypotheses: 1) The time to improvement in Group A patients (receiving rituximab first) will occur significantly earlier than in Group B patients (receiving rituximab later). 2) The proportion of patients improved at Week 8 of the treatment phase will be significantly greater in Group A than in Group B.

Detailed description: Rituximab is a chimeric, murine-human, genetically engineered monoclonal antibody directed against the CD20 (cluster of differentiation antigen 20) antigen found on the surface of B-lymphocytes and is known to deplete B cells when administered intravenously. It is approved to treat non-Hodgkin's lymphoma. Rituximab has been used for autoimmune diseases such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and immune-mediated hematologic disorders. It has also been studied and used in small numbers of patients with myositis. This study will evaluate the efficacy of rituximab in treating refractory adult and pediatric patients with dermatomyositis and adult polymyositis.

A patient's participation in this study will last approximately 45 weeks. At screening, participants will have a physical exam, muscle strength assessment, an electrocardiogram, and blood and urine collection; they will also be asked to complete several questionnaires. All participants will receive 2 infusions of rituximab and 2 infusions of placebo. Participants will be randomly assigned to one of two groups. Group A will receive rituximab at Weeks 0 and 1 and placebo at Weeks 8 and 9. Group B will receive placebo at Weeks 0 and 1 and rituximab at Weeks 8 and 9. Each infusion will be given on an outpatient basis over a minimum of approximately 5 hours' time.

There will be a total of 14 study visits. All participants will visit the outpatient clinic at selected time points for muscle strength testing, a physical exam, disease activity measurements, and blood collection. During the study, participants will be monitored closely for improvement or worsening of their disease and for serious drug related side effects. Some participants will be asked if they are willing to undergo 2 muscle biopsy procedures, 1 prior to receiving study medication and 1 after receiving study medication, to determine the effects of rituximab on muscle tissue.

If a participant is unable to locate a near-by clinical center, the adult and pediatric centers at the National Institute of Health located in Bethesda, Maryland have funds available to assist with travel costs.

NIH SUB-STUDY: "Rituximab to Treat Dermatomyositis and Polymyositis"

* This study is currently recruiting patients.
* Sponsored by: National Institute of Environmental Health Sciences (NIEHS)
* Information provided by: National Institutes of Health Clinical Center (CC)
* Expected Total Enrollment: 30
* Study start: October 2006
* Location and Contact Information: Patient Recruitment and Public Liaison Office;(800) 411-1222; prpl@mail.cc.nih.gov; Phone: 1-866-411-1010

The NIH sub-study will take advantage of the multi-center core RIM trial to identify changes in gene expression patterns in muscle, skin, and peripheral blood and the imaging features and immunopathology of muscle, skin, and peripheral cells before (week 0) and after (week 16) therapy. These changes will also be correlated with the large number of clinical, laboratory, and research variables already planned to be collected in the core RIM Study. Furthermore, knowing specifically which gene expression patterns are altered in resistant patients before rituximab, and which are changed after rituximab therapy - in conjunction with flow cytometry of peripheral cells and immunopathology of the tissues - will help in understanding more about the pathogenesis of myositis and the possible contribution of B lymphocytes and their subsets.

Patients with dermatomyositis and polymyositis who meet the inclusion/exclusion criteria for the core RIM trial may be eligible for this sub-study. The following procedures will be conducted in addition to the core RIM trial procedures during the 13 clinic visits over a period of 44 weeks:

* Weeks 0, 16: Muscle and skin biopsy (adult only). Small samples of muscle and skin tissue will be surgically removed for examination under a microscope.
* Weeks 0, 8, 16, 44: Skin evaluation and photography. The effect of the disease on the skin will be thoroughly evaluated and photographs of any rashes and of the skin around the nails will be taken.
* Weeks 0, 8, 16, 44: Magnetic resonance imaging (MRI). All participants will have MRI scans of the skin and of the muscle in the legs. Adults will also have an MRI to examine blood flow in the muscle.

Eligibility criteria: Inclusion Criteria:

* Adults with definite or probable dermatomyositis or polymyositis and pediatric patients five years of age and over with definite or probable juvenile dermatomyositis (JDM) by Bohan and Peter criteria. Diagnosis of JDM based on an age of onset (i.e., first symptom of myositis or dermatomyositis rash) is less 18 years of age
* Refractory myositis, defined by intolerance to or inadequate response to corticosteroids plus an adequate regime of at least one other immunosuppressive agent. Intolerance is defined as side effects that require discontinuation of the medication or an underlying condition that precludes further use of the medication.
* Baseline manual muscle testing which is based on a maximum MMT-8 (Manual Muscle Test) score of 150:Adult subjects with dermatomyositis (DM) or polymyositis (PM) must have a score that is no greater than 125/150 in conjunction with 2 other abnormal core set measures.

Subjects with a diagnosis of Juvenile Dermatomyositis (JDM) must meet either of the following criteria:

1. An MMT-8 (Manual Muscle Test) score that is no greater than 125/150 in conjunction with 2 other abnormal core set measures.

   OR
2. If MMT (Manual Muscle Test) score is greater than 125/150 the patient MUST meet at least 3 abnormal core set measures.

   * Background therapy with at least 1 non-corticosteroid immunosuppressive agent at a stable dose for at least 6 weeks prior to screening
   * Able and willing to complete self-report questionnaires. Parents of pediatric participants will be required to complete the questionnaires on behalf of their children.
   * Willing to use acceptable forms of contraception for the duration of the study for patients of reproductive potential.
   * Parent willing to provide informed consent, if applicable
   * Willing to forgo immunization with a live vaccine for the duration of the study

Exclusion Criteria:

* Drug-induced myositis. Patients who have myositis or myopathic syndromes caused by taking medications known to induce myositis-like syndromes, including but not limited to statin agents, fibric acid derivatives, colchicine, and hydroxychloroquine.
* Juvenile polymyositis
* Inclusion body myositis
* Cancer-associated myositis, defined as the diagnosis of myositis within 2 years of the diagnosis of cancer. Patients with basal or squamous cell skin cancer or carcinoma in situ of the cervix are not excluded, if it has been at least 5 years since excision.
* Myositis in overlap with another connective tissue disease that may preclude the accurate assessment of a treatment response
* Live viral vaccine within 4 weeks prior to study entry
* Any joint disease or other musculoskeletal condition that may interfere with muscle strength testing
* Known hypersensitivity to mouse proteins
* Any concomitant or life-threatening non-myositis illness that, in the opinion of the investigator, may interfere with the study
* Known or suspected history of drug or alcohol abuse within the last 6 months prior to study entry, as determined by medical record or patient interview
* Anticipated poor compliance with study requirements
* Participation in another clinical trial within 30 days prior to screening
* Any history or evidence of any severe illness or other condition that, in the opinion of the investigator, may interfere with the study
* Previously received rituximab
* Evidence of prior infection with hepatitis B or hepatitis C virus
* Initiation of an exercise program within 4 weeks of screening OR initiation of an exercise program during the study
* Consumed any creatine-containing, over-the-counter products in the form of dietary supplements 30 days prior to screening visit and for the duration of the study

Primary outcomes:
measure: Comparison Between the Time to Improvement Between the Two Groups of IIM (Idiopathic Inflammatory Myopathy) Patients
timeFrame: Week 44 of treatment phase
Secondary outcomes:
measure: Response Rates (Proportion of Improved Patients) Between Groups A (Rituximab Wks 0 and 1) and B (Rituximab Wks 8 and 9) at Week 8
timeFrame: Week 8 of the treatment phase
measure: 20% Improvement in Manual Muscle Testing (MMT) Over Baseline on Two Consecutive Time Points (Muscle is the Primary Organ of Involvement, and MMT is the One Objective Measurement of the Definition of Improvement [DOI])
timeFrame: Week 44 of treatment phase
Other outcomes:
Locations:
city: Birmingham
country: United States
facility: University of Alabama Arthritis Intervention Program (Adult Site)
state: Alabama
city: Phoenix
country: United States
facility: Phoenix Neurological Associates, LTD (Adult Site)
state: Arizona
city: Los Angeles
country: United States
facility: Cedars-Sinai Medical Center (Adult Site)
state: California
city: Stanford
country: United States
facility: Stanford University (Adult Site)
state: California
city: Stanford
country: United States
facility: Stanford University (Pediatric Site)
state: California
city: Miami
country: United States
facility: University of Miami School of Medicine (Adult Site)
state: Florida
city: Miami
country: United States
facility: Miami Children's Hospital (Pediatric Site)
state: Florida
city: Kansas City
country: United States
facility: University of Kansas Medical Center (Adult Site)
state: Kansas
city: Lexington
country: United States
facility: Kentucky Clinic (Adult Site)
state: Kentucky
city: Bethesda
country: United States
facility: National Institute of Health (Adult Site)
state: Maryland
city: Bethesda
country: United States
facility: National Institute of Health (Pediatric Site)
state: Maryland
city: Boston
country: United States
facility: Children's Hospital of Boston (Pediatric Site)
state: Massachusetts
city: Boston
country: United States
facility: Beth Israel Deaconess Medical Center (Adult Site)
state: Massachusetts
city: Ann Arbor
country: United States
facility: University of Michigan Health System (Adult Site)
state: Michigan
city: Grand Rapids
country: United States
facility: Michigan State University (Adult and Pediatric Site)
state: Michigan
city: Rochester
country: United States
facility: Mayo Clinic (Adult Site)
state: Minnesota
city: Rochester
country: United States
facility: Mayo Clinic (Pediatric Site)
state: Minnesota
city: Lake Success
country: United States
facility: North Shore Long Island Jewish Health System (Adult Site)
state: New York
city: New York
country: United States
facility: Hospital for Special Surgery (Adult Site)
state: New York
city: Durham
country: United States
facility: Duke University Medical Center (Pediatric Site)
state: North Carolina
city: Cincinnati
country: United States
facility: Cincinnati's Children's Hospital (Pediatric Site)
state: Ohio
city: Philadelphia
country: United States
facility: Children's Hospital of Philadelphia (Pediatric Site)
state: Pennsylvania
city: Philadelphia
country: United States
facility: University of Pennsylvania (Adult Site)
state: Pennsylvania
city: Pittsburgh
country: United States
facility: Children's Hospital of Pittsburgh (Pediatric Site)
state: Pennsylvania
city: Pittsburgh
country: United States
facility: University of Pittsburgh / UPMC (Adult Site)
state: Pennsylvania
city: Dallas
country: United States
facility: University of Texas Southwestern Medical Center (Adult)
state: Texas
city: Milwaukee
country: United States
facility: Medical College of Wisconsin / Froedtert Memorial Luthern Hospital (Adult Site)
state: Wisconsin
city: Halifax
country: Canada
facility: IWK Health Centre
state: Nova Scotia
city: Toronto
country: Canada
facility: Hospital for Sick Children (Pediatric Site)
state: Ontario
city: Prague
country: Czech Republic
facility: Institute of Rheumatology
city: Stockholm
country: Sweden
facility: Karolinska Institute
Study officials:
affiliation: University of Pittsburgh
name: Chester V. Oddis, MD
role: PRINCIPAL_INVESTIGATOR
affiliation: Mayo Clinic
name: Ann M. Reed, MD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Feldman B, Wang E, Willan A, Szalai JP. The randomized placebo-phase design for clinical trials. J Clin Epidemiol. 2001 Jun;54(6):550-7. doi: 10.1016/s0895-4356(00)00357-7.
citation: Levine TD. Rituximab in the treatment of dermatomyositis: an open-label pilot study. Arthritis Rheum. 2005 Feb;52(2):601-7. doi: 10.1002/art.20849.
citation: Oddis CV, Reed AM, Aggarwal R, Rider LG, Ascherman DP, Levesque MC, Barohn RJ, Feldman BM, Harris-Love MO, Koontz DC, Fertig N, Kelley SS, Pryber SL, Miller FW, Rockette HE; RIM Study Group. Rituximab in the treatment of refractory adult and juvenile dermatomyositis and adult polymyositis: a randomized, placebo-phase trial. Arthritis Rheum. 2013 Feb;65(2):314-24. doi: 10.1002/art.37754.