Clinical trial NCT02627417: Efficacy and Safety of DAPSone as a Second-line Option in Adult Immune Thrombocytopenia
Official title: Prospective Multicenter Randomized Open-label Controlled Trial Assessing Efficacy and Safety of DAPSone as a Second-line Option in Adult Immune Thrombocytopenia
Study type: INTERVENTIONAL
Overall status: UNKNOWN
Phase: PHASE3
Conditions: Adult Immune Thrombocytopenia (ITP)
Dapsone
Keywords: ITP
Dapsone
Lead sponsor: Assistance Publique - Hôpitaux de Paris
Sponsor class: OTHER
First posted: 2015-12-11
Enrollment: 216
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: Due to its expected efficacy based on the retrospective data available in ITP, its relatively good safety profile and its very low cost , dapsone could be a good steroid-sparing second-line option for adults with ITP.

This study is a phase III prospective multicenter randomized open trial comparing two treatment strategies:

* Arm A (experimental arm): prednisone at 1 mg/kg for 3 weeks + dapsone at 100 mg per day up to week 52 if an initial response is achieved.
* Arm B (control arm): prednisone alone at 1 mg/kg for 3 weeks followed by monitoring and "standard of care" The aim of the study is to demonstrate the efficacy of dapsone based on the overall response rate (including response and complete response) as a second-line treatment for adults with newly-diagnosed persistent or chronic (modified by amendment 08/11/2016) ITP not achieving a durable response with corticosteroids. The primary endpoint will be the overall response-rate (response or complete response according to standard definitions) in both arms at week 52 (1 year).

The secondary endpoints are the following :

* To assess the safety of dapsone over the study period and especially the incidence of cutaneous reactions.
* To analyze the overall response rate (platelet count \> 30 x 109/L with at least a doubling of the pre-treatment count in the absence of any other ITP treatment) in both treatment arms at week 24.
* To compare the rate of complete response and failure in both arms at 24 and 52 weeks.
* To compare time to treatment failure (TTF) in both arms
* To investigate the mechanisms of action of dapsone in ITP in a subgroup of patients (ancillary study)


Eligibility criteria: Inclusion Criteria:

* Age ≥ 18 years
* Diagnosis of primary ITP according to the standard definition and international guidelines.
* Previous transient response to corticosteroids ± intravenous immunoglobulin defined by an increase of the platelet count above 30 x 109/L with at least a twofold increase of the pre-treatment count.
* At least platelet count ≤ 30 x 109/L within the 2 weeks before inclusion with a platelet count at time of inclusion below 50 x 109/L, or platelet count \< 50 x 109/L at any time point in patients requiring treatment (i.e., patients with bleeding symptoms, elderly patients with comorbidities and/or patients on aspirin for example, or other reason at the investigator discretion) (modified by amendment 8/11/2016)
* Normal marrow aspirate for patients aged of 60 and above.
* Negative pregnancy test and effective method of contraception for women of childbearing age over the study period.
* Informed consent.
* Patient affiliated to the French National Social Security System

Exclusion Criteria:

* Secondary ITP. Patients with positive antinuclear antibodies and/or positive antiphospholipid antibodies not fulfilling the classification criteria for systemic lupus erythematosus and/or antiphospholipid antibody syndrome will not be excluded.
* Platelet count ≥ 50 x 109/L or between 30 and 50 x 109/L and no bleeding symptoms and no need for treatment (modified by amendment 8/11/2016)
* Severe bleeding manifestations defined a bleeding score ≥ 8
* No previous transient response to corticosteroids ± intravenous immunoglobulin.
* Previous ITP treatment other than corticosteroids and intravenous immunoglobulin (including rituximab and splenectomy).
* Active severe infection or history of severe infection within 4 weeks before inclusion.
* History of allergy to sulfonamides.
* Glucose-6-phosphate dehydrogenase (G6PD) deficiency.
* History of methemoglobinemia
* Hemoglobin level \< 11g/dL and/or neutrophil count \< 1,500/ gL.
* History of autoimmune (Evans' syndrome) or hereditary haemolytic anemia.
* Liver or kidney function impairment (creatinine clearance \< 30 ml/min, ALT, AST \>2 times upper normal limit). (modified by amendment 8/11/2017)
* Hepatitis C virus (HCV) Ab, HIV Ab, HBsAg, seropositive status. (modified by amendment 8/11/2017)
* Concomitant medical condition requiring anticoagulation. (modified by amendment 8/11/2017)
* Pregnancy or lactation.

Primary outcomes:
measure: Overall response-rate.
timeFrame: at week 52
Secondary outcomes:
measure: Assess the safety of dapsone especially the incidence of cutaneous adverse effects.
timeFrame: over the study period (up to 52 weeks)
measure: Compare the overall response rate .
timeFrame: at week 24
measure: Proportion of patients with complete response in both arms, defined as follows: - Proportion of patients with a platelet count > 100 x 109/L in the absence use of any other ITP directed therapies
timeFrame: at 24 and at 52 weeks
measure: Proportion of non-responders patients (primary failure)
timeFrame: at 24 and at 52 weeks
measure: Number of days to treatment failure in both arms
timeFrame: over the study period (up to 52 weeks)
measure: Mechanisms of action of Dapsone: degree of phagocytosis of autologous platelets and red blood cells, cytokines profile expression (including IL-8), whole blood gene expression signature between responders and non-responders.
timeFrame: over the study period (52 weeks)
Other outcomes:
Locations:
city: Creteil
country: France
facility: Henri Mondor Hospital
Study officials:
affiliation: Assistance Publique - Hôpitaux de Paris
name: MARC MICHEL, Prof. M.D
role: PRINCIPAL_INVESTIGATOR
References:
citation: Durand JM, Lefevre P, Hovette P, Mongin M, Soubeyrand J. Dapsone for idiopathic autoimmune thrombocytopenic purpura in elderly patients. Br J Haematol. 1991 Jul;78(3):459-60. doi: 10.1111/j.1365-2141.1991.tb04467.x. No abstract available.
citation: Godeau B, Oksenhendler E, Bierling P. Dapsone for autoimmune thrombocytopenic purpura. Am J Hematol. 1993 Sep;44(1):70-2. doi: 10.1002/ajh.2830440117.
citation: Hernandez F, Linares M, Colomina P, Pastor E, Cervero A, Perez A, Perella M. Dapsone for refractory chronic idiopathic thrombocytopenic purpura. Br J Haematol. 1995 Jun;90(2):473-5. doi: 10.1111/j.1365-2141.1995.tb05179.x.
citation: Godeau B, Durand JM, Roudot-Thoraval F, Tenneze A, Oksenhendler E, Kaplanski G, Schaeffer A, Bierling P. Dapsone for chronic autoimmune thrombocytopenic purpura: a report of 66 cases. Br J Haematol. 1997 May;97(2):336-9. doi: 10.1046/j.1365-2141.1997.412687.x.
citation: Damodar S, Viswabandya A, George B, Mathews V, Chandy M, Srivastava A. Dapsone for chronic idiopathic thrombocytopenic purpura in children and adults--a report on 90 patients. Eur J Haematol. 2005 Oct;75(4):328-31. doi: 10.1111/j.1600-0609.2005.00545.x.