Conditions: Arthritis, Rheumatoid
Keywords: rheumatoid arthritis
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 159
Healthy volunteers: no

Brief summary:
In a randomized controlled clinical trial, investigators will compare the effects on \[18F\]-fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET/CT) from two treatment regimens in rheumatoid arthritis (RA) patients deemed methotrexate inadequate responders (MTX-IRs). Two common RA treatments will be compared: triple therapy (sulfasalazine, methotrexate, and hydroxychloroquine) versus tumor necrosis factor (TNF) inhibitor (etanercept or adalimumab, plus background methotrexate for all subjects and hydroxychloroquine for subjects who were taking this at screening).

Detailed description:
Consenting subjects will be screened for eligibility and randomized to a treatment arm. Subjects will be randomized to a treatment arm with either synthetic disease-modifying antirheumatic drugs (DMARDs) \[triple therapy: sulfasalazine, methotrexate, and hydroxychloroquine\] or biologic DMARDs \[etanercept or adalimumab, plus background methotrexate for all subjects and hydroxychloroquine for subjects who were taking this at screening\].

Once randomized, a baseline visit will be conducted with each subject. Baseline data collection includes questionnaires, disease activity score, and the first FDG-PET/CT imaging. After the baseline at week 0, subjects will visit with their rheumatologist at weeks 6, 12, 18, and 24 for safety labs and further collection of disease activity scores and questionnaires. The second FDG-PET/CT will be performed at week 24. Blood specimens will be collected at weeks 0, 6, 18, and 24 for bioassays. Subject participation will end after the week 24 visit.

Patients and care providers will be unblinded. The FDG-PET/CT image readers will be blinded to treatment arm as well as timepoint of image acquisition.

Arms:
arm 1: Sulfasalazine (SSZ) 1 g bid and hydroxychloroquine (HCQ) 200 mg twice daily, not to exceed 6.5mg/kg HCQ (in addition to concomitant methotrexate \[MTX\]). arm 2: etanercept 50 mg subcutaneously weekly or adalimumab 40 mg subcutaneously every other week (in addition to concomitant methotrexate, plus hydroxychloroquine, for subjects who were taking this at screening). Biologic treatment will be assigned randomly.

Interventions: intervention 1: Methotrexate intervention 2: Sulfasalazine intervention 3: Hydroxychloroquine intervention 4: Etanercept intervention 5: Adalimumab
Intervention descriptions: intervention 1: Subjects entering trial will continue on MTX dose of at least 15mg MTX/week. At the discretion of the treating rheumatologist, may be switched to SQ route. intervention 2: 1 gm bid intervention 3: 200 mg twice daily, not to exceed 6.5mg/kg intervention 4: 50 mg SC weekly intervention 5: 40 mg SQ every other week

Protocol document:
Prot_000.pdf: 
1 
Treatments Against RA and Effect on FDG PET-CT: The TARGET Trial 
 
Clinical Trial Protocol  
 
Principal Investigators: 
Joan M Bathon, MD (PD/PI) 
 
Daniel H Solomon, MD, MPH (PD/PI) 
 
 
Version Number:  16 
June 22, 2021  
 


 
2 
Table of Contents 
STATEMENT OF COMPLIANCE ............................................................................................... 5 
SIGNATURE PAGE ................................................................................................................... 6 
LIST OF ABBREVIATIONS ........................................................................................................ 7 
PROTOCOL SUMMARY ............................................................................................................ 8 
1. 
KEY ROLES AND CONTACT INFORMATION ..................................................................13 
1.1 
Study Organization and Roster ...................................................................................13 
1.2 
Administrative Core .....................................................................................................14 
1.3 
Executive Committee ..................................................................................................14 
1.4 
Steering Committee ....................................................................................................14 
1.5 
Imaging Core ..............................................................................................................14 
1.6 
Data Coordinating Center ...........................................................................................14 
1.7 
Data and Safety Monitoring Board ..............................................................................15 
1.8 
Funding Sources .........................................................................................................15 
1.9 
Central IRB .................................................................................................................15 
1.10 
Clinical Sites ...............................................................................................................15 
1.11 
Imaging Sites ..............................................................................................................16 
1.12 
Laboratories ................................................................................................................16 
2. 
BACKGROUND AND RATIONALE ....................................................................................16 
2.1 
Background Information ..............................................................................................16 
2.2 
Rationale ....................................................................................................................21 
3. 
STUDY DESIGN ................................................................................................................22 
3.1 
Overview .....................................................................................................................22 
3.2 
Study Population .........................................................................................................22 
3.3 
Inclusion Criteria .........................................................................................................23 
3.4 
Exclusion Criteria ........................................................................................................23 
3.5     Recruitment and Retention ..........................................................................................24 
3.6     Subject Retention ........................................................................................................25 
3.7     Subject Withdrawal ......................................................................................................25 
3.8     Premature Termination or Suspension of Study ...........................................................26 
3.9     Bioethics Ancillary Study .............................................................................................26 
4. 
TREATMENT AND STUDY PROCEDURES .....................................................................27 
4.1 
Acquisition of Randomized Treatment .........................................................................27 


 
3 
4.2 
Description of Treatment Medications .........................................................................27 
4.3 
Treatment Algorithm ...................................................................................................27 
4.4 
Concomitant Medications ............................................................................................28 
4.5 
Medication Monitoring .................................................................................................28 
4.6      Study Procedures .......................................................................................................30 
5. 
ADVERSE EVENTS ..........................................................................................................32 
5.1 
Definition of an Adverse Event ....................................................................................32 
5.2 
Serious Adverse Event ...............................................................................................32 
5.3 
Relationship of an Adverse Event to Study Intervention ..............................................32 
5.4     Severity of an Adverse Event .......................................................................................33 
5.5     Unanticipated Problems ...............................................................................................33 
5.6     Reporting of Adverse Events, Serious Adverse Events, and Unanticipated Problems .33 
6. 
TRAINING AND MONITORING OF SITES ........................................................................35 
6.1 
Training of Site Investigators and Staff for the Study Protocol .....................................35 
6.2 
Training for Electronic Data Capture ...........................................................................35 
6.3 
Training for Joint Count Assessment...........................................................................36 
6.4 
Imaging Core Training ................................................................................................36 
6.5 
Monitoring of Sites ......................................................................................................36 
7. 
STUDY OBJECTIVES AND STATISTICAL ANALYSIS PLAN ...........................................38 
7.1 
Primary and Secondary Objectives .............................................................................38 
7.2 
Study Hypothesis ........................................................................................................38 
7.3 
Study Design ..............................................................................................................38 
7.4 
Number of Subjects ....................................................................................................39 
7.5 
Analysis Sets ..............................................................................................................40 
7.6 
Safety Analysis ...........................................................................................................40 
7.7 
Analysis Methods ........................................................................................................40 
7.8 
Data Management ......................................................................................................42 
7.9 
Handling of Missing Data ............................................................................................43 
7.10    Bioethics Ancillary…………………………………………………………………………... 43 
    7.11 Neuroimaging Measures Ancillary Study…………………………………………………... 44 
8. 
REGULATORY CONSIDERATIONS .................................................................................44 
8.1 
Informed Consent .......................................................................................................44 
8.2 
Data and Safety Monitoring Board ..............................................................................44 


 
4 
8.3 
Institutional Review Board ...........................................................................................44 
8.4 
Pre-Study Documentation Requirements ....................................................................44 
 
 
Figures and Tables 
FIGURE 1. STUDY DESIGN  ................................................................................................... .10 
TABLE 1. SCHEDULE OF STUDY VISITS AND PROCEDURES .............................................11 
FIGURE 2. TREATMENT ALGORITHM ....................................................................................12 
FIGURE 3: STUDY ORGANIZATION .......................................................................................13 
TABLE 3: CAUTION AND EXTREME VALUES FOR LAB TEST MONITORING ......................29 
TABLE 4: POWER CALCULATION FOR AIM 1 ........................................................................39 
TABLE 5: POWER CALCULATION FOR AIM 2 ........................................................................40 
 
 
 
 
 
 
 
 
 
 


 
5 
STATEMENT OF COMPLIANCE 
The study will be conducted in accordance with the International Conference on 
Harmonisation guidelines for Good Clinical Practice (ICH E6) and the Code of Federal 
Regulations on the Protection of Human Subjects (45 CFR Part 46). All personnel 
involved in the conduct of this study have completed human subjects protection training. 
 
 
 


 
6 
SIGNATURE PAGE 
 
The signature below constitutes the approval of this protocol and the attachments, and 
provides the necessary assurances that this trial will be conducted according to all 
stipulations of the protocol, including all statements regarding confidentiality, and 
according to local legal and regulatory requirements and applicable US federal 
regulations and ICH guidelines. 
 
Principal Investigator or Co-Principal Site Investigators: 
 
Signed: 
 
Date: 
 
 
Name:  
 
Title:  
Signed: 
 
Date: 
 
 
Name:  
 
Title:  
 
 
 


 
7 
 
 
LIST OF ABBREVIATIONS 
 
 
 
 
 


 
8 
PROTOCOL SUMMARY 
Title:  
Treatments Against RA and Effect on FDG PET-CT:  
The TARGET Trial 
Précis: 
The overarching goal of this trial is to examine the effect of RA disease 
modifying drugs (DMARDs) on vascular inflammation.  We will accomplish 
this goal by comparing two treatment regimens for RA in the setting of an 
RCT in patients with inadequate response to methotrexate (MTX).  These 
are:  a tumor necrosis factor inhibitor (TNFi) + MTX + hydroxychloroquine 
(HCQ [if subject was taking HCQ at study entry]) versus triple therapy (MTX 
+ sulfasalazine [SSZ] + hydroxychloroquine [HCQ]). The trial design is a two-
arm RCT with blinded joint assessment and blinded FDG PET/CT readers.  
Subjects and rheumatologists will be unblinded to treatment assignment 
but will be blinded to FDG PET/CT results. Joint count assessors will be 
blinded to treatment assignment. The trial will be conducted at multiple 
sites across the US, with a duration of six months.  Recruitment will be 
over 24 months with six more months of follow-up.   
Objectives: 
 
Primary: To compare the effects on vascular inflammation of TNFi + MTX 
versus triple therapy in subjects with RA who are inadequate responders 
to MTX using FDG PET/CT as a tool for detecting vascular (arterial) 
inflammation. 
 
Secondary: To compare the effects on vascular inflammation of 
achieving low disease activity or remission (LDAR) vs moderate-high 
disease activity (MHDA). 
Exploratory Aim 1: To determine researchers’ attitudes and beliefs 
regarding their ethical obligation to return and manage incidental 
research findings from whole body FDG PET/CT imaging, including what 
to report, when to report, and how to report, as well as how to manage 
and to what extent. 
Exploratory Aim 2: To determine the prevalence of incidental research 
findings on whole body FDG PET/CT in RA and detection rate of 
previously unknown malignancies. 
Exploratory Aim 3: To investigate associations between stress-associated 
neurobiological activity and articular and arterial treatment response in 
RA.   
 
 
 


 
9 
Population: 
Subjects for this trial will be RA patients who are deemed methotrexate-
inadequate responders (MTX-IRs, DAS28>3.2) by their treating 
rheumatologist, and who have not yet started treatment with a biologic 
DMARD and are currently not receiving any other DMARD than MTX or 
MTX and HCQ.  In order to enrich our trial subjects for atherosclerosis, 
male RA patients must be at least 45 years old, and women at least 50 
years old.  Additional inclusion and exclusion criteria are listed in Section 3 
of this document. 
 
Phase: 
Phase IV 
Number of Sites: 
This will be a multicenter study. The lead sites will be Brigham & Women’s 
Hospital and Columbia University Medical Center. 
Participating sites will be selected based on the following criterion: 
adequate number of RA patients; access to an FDG-PET scanner; 
availability of trial staff (i.e. coordinator, nurse, trained joint count 
assessor (metrologist); and experience enrolling and following subjects in 
previous clinical trials.    
Description of  
Intervention: 
Enrolled subjects will be asked to take 6 months of RA medication 
according to the treatment arm to which they are randomized, which will 
be either be triple therapy or a TNFi. 
 
Subjects will be evaluated every six weeks for clinical response. For 
subjects receiving a TNFi, if good treatment response (CDAI ≤10) is not 
achieved by 18 weeks, then treatment will be adjusted.  For subjects 
receiving adalimumab, this medication will be discontinued and switched 
to etanercept 50 mg every week.   If the subject is receiving etanercept, 
this medication will be discontinued and switched to adalimumab 40 mg 
every other week. Subjects will remain on this new medication until the 
end of the study.  
Subjects assigned to the triple therapy arm will begin SSZ 500 mg twice 
daily and HCQ 200 mg twice daily, not to exceed 6.5 mg/kg. At 6 weeks, 
the dose of SSZ will increase from 500 mg twice daily to 1 g twice daily for 
all patients. At 18 weeks, if a good treatment response (CDAI ≤ 10) has not 
been achieved, MTX will be stopped and leflunomide 20 mg daily started.  
The participant will remain on leflunomide (and concomitant SSZ + HCQ) 
for the remaining six weeks of the study. 
As part of a bioethics ancillary study, we will survey the TARGET 
investigators to determine researchers' attitudes and beliefs regarding 


 
10 
their ethical obligation to return and manage incidental research findings 
from whole body PET/CT imaging studies and determine the prevalence of 
incidental extra cardiac findings on whole body PET/CT scans in 
rheumatoid arthritis (RA) and detection rate of previously unknown 
malignancies. 
 
Study Duration: 
48 months 
Subject Participation 
Duration: 
6 months 
Estimated Time to 
Complete Enrollment: 
24 months 
 
 
 
FIGURE 1. STUDY DESIGN 
 
 
Triple therapy (Methotrexate, 
sulfasalazine, hydroxychloroquine)
Activities:
Screen,          FDGPET, 
STJC, 
STJC, 
STJC,
FDGPET,
DAS, Hx,      Randomize,            Labs 
Labs 
Labs
STJC,
Labs
STJC
Labs
R
Eligible study 
population
S
Weeks            -2
0
6
12                      18
24
Visits            V(1)
V(2)
V(3)                      V(4)
V(5)
V(6)
Methotrexate + TNF inhibitor (TNFi) ±HCQ 


11 
 
TABLE 1. SCHEDULE OF STUDY VISITS AND PROCEDURES 
Visits shall occur ± 2 weeks according to the visit schedule
Table 1: Visit Schedule 
Screen 
V1 
[Wk-2] 
Scan 1 
[Wk-1] 
Call to 
Randomize  
 [Wk-0.5] 
Baseline 
V2 
[Wk0] 
V3 
[Wk6] 
V4 
[Wk12] 
V5  
[Wk18] 
V6 
[Wk24] 
Eligibility & consent 
x 
 
 
 
 
 
 
 
CRP 
x 
 
 
 
 
 
 
 
TB, HBV, HCV test 
x 
 
 
 
 
 
 
 
CXR 
x 
 
 
 
 
 
 
 
HbA1c (Type II Diabetics only) 
x 
 
 
 
 
 
 
 
FDG PET/CT 
 
x 
 
 
 
 
 
x 
Pregnancy test  
 
x 
 
 
 
 
 
x 
Glucose test 
 
x 
 
 
 
 
 
x 
Randomize 
 
 
x 
 
 
 
 
 
Blood pressure/Clinical 
Parameters 
x 
 
 
 
x 
x 
x 
x 
CBC, CMP (or LFTs and BMP) 
x 
 
 
 
x 
x 
x 
x 
Biospecimen collection 
 
 
 
x 
x 
 
x 
x 
Joint count 
x 
 
 
x 
x 
x 
x 
x 
Questionnaires 
x 
 
 
x 
x 
x 
x 
x 


12 
FIGURE 2. TREATMENT ALGORITHM 
 
* Subjects entering the study on concomitant HCQ and assigned to the TNFi arm will continue to take HCQ at its original 
dose.  
**Subjects entering the study on concomitant HCQ at <200mg BID who are assigned to triple therapy will increase their 
HCQ dose to 200mg BID, provided this new dose does not exceed 6.5mg/kg. 
 
 
Eligible Patients 
Screening Visit (V1) 
Randomization at Baseline (V2) 
Triple Therapy 
MTX (injectable or oral) 
SSZ 0.5 g BID 
HCQ 200 mg BID 
MTX+ ± HCQ* + TNF inhibitor 
MTX (injectable or oral) ± HCQ* + etanercept 50 mg weekly 
Or 
MTX (injectable or oral) ± HCQ* + adalimumab 40 mg every other week  
V3 (6 weeks) all patients 
increase SSZ to 1 g BID 
V4 (12 weeks) Evaluate tolerability and 
safety with current treatment 
V5 (18 weeks) If patient CDAI >10, drop 
MTX and switch to 20 mg leflunomide 
daily 
V6 (24 weeks) Completion of Study: 
Further management as per standard of 
care. 
V3 (6 weeks) Evaluate tolerability 
and safety with current treatment 
V4 (12 weeks) Evaluate tolerability and 
safety with current treatment 
V5 (18 weeks) If patient CDAI >10, switch over:  
etanercept à adalimumab 40 mg every other 
week 
adalimumab à etanercept 50 mg weekly 
V6 (24 weeks) Completion of Study: 
Further management as per standard of 
care. 


13 
 
1. KEY ROLES AND CONTACT INFORMATION 
1.1    Study Organization and Roster 
 
A diagram of the study organization is shown below.  Each of the individual elements is discussed in the following 
sections. 
FIGURE 3: STUDY ORGANIZATION 
 
 
1.1.1 
Study Staff Roster 
For a list of the TARGET PIs, co-investigators, and key study staff see the MOOP. 
 
 


14 
 
1.2    Administrative Core 
The Administrative Core consists of the TARGET PIs (Drs. Solomon and Bathon), as well as their co-investigators (Drs. 
Giles and Liao), Dr. Lu (Project Manager), Mr. Zartoshti (Project Coordinator), Ms. Donnelly (Grants Administrator, BWH), 
and research assistants and coordinators whole will act as TARGET site liaisons.  It will be run jointly by Dr. Solomon 
from BWH and Dr. Bathon of CUMC.  This Core is responsible for overseeing study administration. The responsibilities of 
the Administrative Core include:   
• 
Development and maintenance of the Clinical Trial Protocol and MOOP 
• 
Assuring the study is conducted according to the Protocol and MOOP 
• 
Communications with clinical sites, scheduling of meetings and training sessions, responding to and 
documenting ad hoc communications 
• 
Distribution of all changes, updates and policies of reports and documents to participating clinical sites 
• 
Maintaining the study binder (regulatory and clinical documents) 
• 
Participating in protocol finalization and preparing study materials 
1.3    Executive Committee 
This committee will be made up of the co-PIs; Dr. Giles and Dr. Liao; as well as Dr. Rist, PhD who leads the DCC; and Dr. 
Tawakol and Dr. Fayad, of the Imaging Core. This committee will meet weekly for the first six months of the trial, then 
monthly thereafter. Any concerns voiced by other study staff members will be brought to the attention of this 
committee. The progress of the study will be reviewed by the Executive Committee, and any issues will be identified and 
resolved through this Committee.  The executive committee will be responsible for making strategic decisions regarding 
study protocol, resource allocation, recruitment, and protocol adherence.  They will have final say on decisions for the 
entire trial.  If conflicts arise between the Co-PIs, issues will be brought to the entire Executive Committee for resolution. 
1.4    Steering Committee  
The Steering Committee will meet regularly to discuss progress of the trial and provide critical feedback to the Executive 
Committee regarding clinical, conceptual, methodological, and feasibility issues that arise through the duration of the 
trial. The Steering Committee will include the two Co-PIs (Joan Bathon and Dan Solomon) and several key co-
Investigators.  
1.5    Imaging Core 
The Imaging Core will be co-led by Dr. Tawakol (Massachusetts General Hospital) and Dr. Fayad (Mt. Sinai School of 
Medicine). They will be responsible for overseeing all matters related to collection and assessment of the FDG-PET/CT 
readings. This will include training imaging sites in standardized protocol techniques, monitoring consistency and quality 
of the scans, managing transmission and assessment of scans, and facilitating corrective actions for imaging sites as 
needed. Drs. Tawakol and Fayad will sit on the Executive Committee to ensure communication between the radiologists 
and cardiologists and to ensure seamless resolution of any technical and quality assurance issues. 
1.6    Data Coordinating Center 
The Data Coordinating Center (DCC) will be run by Pamela Rist, PhD of the Division of Preventive Medicine at Brigham 
and Women’s Hospital.  Robert Glynn, PhD, ScD will serve as Senior Biostatistician.  The DCC is responsible for oversight 
of data collection and analysis. The responsibilities of the DCC include: 
• 
Randomization scheme and procedures 
• 
Development and implementation of the data flow, schedules for transferring data from sites, and data 
tracking 
• 
Development of procedures for data entry, error identification, and error correction 


15 
• 
Adverse event monitoring and reporting to the DSMB 
• 
Site monitoring via the Electronic Data Capture (EDC) to ensure adherence to the protocol and procedures  
• 
Quality control procedures 
• 
Creating reports - enrollment, adverse events, participant status (e.g., withdrawals) by site 
• 
Trial analyses 
1.7    Data and Safety Monitoring Board 
The DSMB is discussed in more detail in Section 8.2 of this document.  Briefly, the DSMB will be appointed by the NIH.  
We anticipate that its membership will include: a trial biostatistician; a cardiologist with trial experience; several 
rheumatologists with trial experience; and a bioethicist.  The DSMB will need to approve the study protocol prior to 
commencement.  The DSMB will meet every 6-12 months during the trial to review the conduct of the trial and the 
safety experience of subjects.  Blinded (and if necessary unblinded) reports will be provided to them by the DCC. 
1.8    Funding Sources  
The NIH will provide the majority of funds for this trial. These funds will be supplemented by funds raised by the fNIH.  
As stakeholders of this trial, we anticipate that funders will have a responsibility in the oversight of the trial; specific 
arrangement may differ by funding agency.  They will be updated at regular timepoints with reports of trial progress 
such as recruitment status, unforeseen problems, and updates to specimen collection. 
1.9    Central IRB  
The Partners HealthCare IRB will play the role of central IRB for this trial. Those sites that are able to rely on the central 
IRB will do so through the signing of a reliance agreement. Those sites unable to use a central IRB will be required to 
obtain their institutional approval for conduct of the trial.  The Administrative Core and Executive Committee will be 
responsible for handling all communication with the central IRB. The DCC will provide all necessary reports for 
submission to the central IRB. 
1.10 Clinical Sites 
Approximately forty clinical sites will participate in enrolling subjects for the TARGET study. The study sites play an 
essential role in answering the questions posed by this study.  Each site will be responsible for enrolling participants, 
carrying out the study protocol, recording and transmitting study information, satisfying regulatory requirements, and 
providing clinical oversight.  The DCC and Administrative Core will support Sites in these efforts, from training through 
implementation.  As well, the Imaging Core will support the FDG PET/CT acquisition.   
Site Requirements for Eligibility include: 
• 
Prior experience with clinical trials 
• 
At least 150 active RA patients  
• 
Easy access to FDG-PET CT imaging acquisition facility 
• 
Easy access to standard clinical laboratory assessments 
• 
Joint count assessor 
The Roles and Responsibilities of the PI, co-PIs and Study Coordinator are outlined in the MOOP, Section 2. 
1.11 Imaging Sites 
All of the clinical sites are in close proximity to an imaging facility with a PET/CT scanner.  The TARGET Imaging Core will 
evaluate each facility first to ensure that it has the necessary equipment and data transfer capabilities, and will then 
embark on a Site Initiation procedure.  Once the local imaging site qualifies, training on the TARGET protocol will ensue.  


16 
Sites will transmit the completed scan data via the FTP System at the Imaging Core. Quality control/assurance 
procedures will be managed by the Imaging Core. 
1.12 Laboratories 
1)  Safety laboratory studies drawn at Visits 1 and 3-6 will be assayed at local labs.  
2)  The Biorepository at the BWH Division of Preventive Medicine will be responsible for overseeing procurement and 
processing of all sera and plasma biospecimens.  Whole and frozen blood will be sent directly from clinical sites to the 
biorepository.  Sera and plasma will be spun and frozen in 1 ml aliquots and stored at -80C at the biorepository.  The 
aliquots stored in the Biorepository are being collected in expectation of considerable interest in Ancillary Studies. The 
Biorepository will be responsible for retrieval of aliquots needed for the proteomic assays, the assays performed at the 
Harvard CTSA, and for funded ancillary proposals involving biomarkers. 
3)  The Harvard CTSA laboratory will perform assays of analytes collected at visits 2, 3, 5, and 6 that will be used to 
assess several CV risk factors (lipids, insulin, and glucose).  These assays will take place at the end of the study on 
batched samples.  This will assure uniformity in these measurements.  
4) Crescendo/Myriad has agreed to perform two proteomic assays (VECTRA DA and RBM Discovery Panel 3.3) on 
aliquots from visit 2, visit 3, visit 5, and visit 6. 
2. BACKGROUND AND RATIONALE 
2.1 Background Information 
2.1.1 
Patients with RA are at increased risk for CVD.  
RA is one of the most common autoimmune rheumatic conditions, affecting 0.5-1.0% of the adult population1,2. 
Remarkable progress in the treatment of RA has occurred in the past 2 decades with earlier and more aggressive 
treatment utilizing combinations of non-biologic and newer targeted biologic agents3-5, resulting in less disability and 
fewer joint replacements in RA6.  RA also has significant adverse effects on other organ systems, most notably the 
CV system.  RA is associated with a 1.5-3-fold increase in mortality compared to non-RA controls7, with CVD 
consistently the leading cause of these excess deaths8.  The direct cost of CVD in RA in the US is estimated at $500M 
per year9.  In contrast to the successful management of articular disease in RA, mortality rates have not declined 
despite marked improvements in survival in the general US population over the past 2-3 decades10.  Rates of non-
fatal CV events such as myocardial infarction (MI) and stroke, as well as the prevalence of subclinical atherosclerosis 
in coronary and carotid arterial beds are also higher in RA compared to non-RA controls11,12. Management of CVD 
risk in RA is based on general population guidelines without tailoring.  These data emphasize the urgency of 
developing strategies to identify and better manage the increased CV risk in RA. 
2.1.2 
The increased CV risk in RA is likely due to enhanced vascular and/or systemic inflammation. 
Atherosclerosis in the general population is recognized as a low-grade inflammatory process13, as reflected by 
the presence of macrophages, T and B cells in plaque, and the association of plaque with elevated circulating levels 
of inflammatory cytokines14. ‘Vulnerable plaque’ likely to rupture is characterized by increased numbers of activated 
inflammatory cells, particularly macrophages.  These macrophages elaborate matrix metalloproteinases (MMPs) 
that in turn erode the plaque’s fibrous cap leading to extrusion of thrombogenic material into the vessel lumen and 
acute thrombosis14.  Modest elevations of systemic measures of inflammation – such as C-reactive protein (CRP), 
interleukin-6 (IL-6) and soluble vascular endothelial molecules – are independent predictors of future CV events in 
the general population15-17. 


17 
RA is a chronic inflammatory disease characterized by high serum levels of the same inflammatory cytokines 
that have been implicated in the pathogenesis and rupture of atherosclerotic plaque (e.g. IL-1, TNF-α, IL-6)14. This 
highly inflammatory milieu is hypothesized to accelerate the atherosclerotic process in patients with RA.   Attempts 
to prove this hypothesis have predominantly correlated single measures of inflammation with CV events, but only 
one CRP study approached statistical significance (HR 1.10; 95% CI 0.99-1.22)18, and two sedimentation rate (ESR) 
studies showed correlation with CVD18,19.  Other studies have correlated clinical indices of RA disease activity and 
RA-associated autoantibodies with atherosclerotic plaque as well as incident CV events20-22.  These prior study 
approaches were indirect, non-experimental and often retrospective. 
With the advent of PET scanning and the development of radioisotopes that are avidly taken up by 
monocytes/macrophages (e.g., FDG), the ability to detect inflammation within vessel walls and specifically within 
atherosclerotic plaque has been realized23. In this proposal, we will - for the first time in the setting of an RCT in RA – 
directly assess inflammation in the vascular walls of patients with RA, using vascular FDG PET/CT imaging.  We will 
also correlate DMARD associated changes in vascular inflammation with changes in RA disease activity as measured 
by clinical (DAS28), biomarker (MBDA) and joint imaging (FDG PET/CT) measures, as well as separately with changes 
in systemic inflammation as measured by CRP and IL-6 levels. 
2.1.3 
Currently available CV risk tools underperform in identifying CV risk in RA .  
In the general population, CVD risk prediction tools (e.g., Framingham, FRS,24 and Reynolds, RRS25) have been 
developed to estimate an individual’s future risk for a CV event.  These risk tools perform well at the population 
level, but they do not discriminate risk well in women and younger individuals26, groups heavily represented in RA.   
In fact, Crowson et al27 reported that the observed CVD risk in 525 RA was 2-fold higher in women and 65% higher in 
men than the FRS predicted risk, with similar findings from the RRS despite its inclusion of CRP.  CV risk in RA may be 
associated with lower, not higher, levels of total and LDL cholesterol, further illustrating the problems with 
conventional CV risk measures in stratifying CV risk in RA18,28-30. A CV risk assessment tool has been endorsed by the 
European League Against Rheumatology (EULAR), but its evidence base is weak and its performance poor31.  These 
deficiencies of currently available CV risk tools in RA populations underscore the pressing need for identification of 
biomarkers of CV risk tailored for the RA patient.     
Prior efforts aimed at developing risk scores in the general population have used imaging biomarkers, coronary 
artery calcium and carotid intima medial thickness (cIMT).  However, a recent meta-analysis of prospective RCTs 
suggested that cIMT changes did not correlate well with rates of future clinical CVD32. In contrast, FDG PET/CT is 
being increasingly used in RCTs because inflammation within vascular walls and within plaque is believed to 
represent one of the critical early and reversible steps of atherosclerosis33,34. In fact, several recent studies have 
demonstrated that the presence of arterial inflammation (measured by FDG uptake) identified individuals at higher 
risk for future CV events than those without inflammation35,36. 
2.1.4 
FDG PET/CT is a sensitive method for detecting vascular inflammation  
Although most widely used for detection of cancer, FDG PET/CT imaging represents a novel modality for direct 
detection of inflammation in the vasculature.  Cellular FDG uptake reflects the rate of tissue glycolysis, which is 
higher in areas containing inflamed tissues. Activated macrophages have remarkably elevated glycolytic flux 37,38  
and hence avidly accumulate FDG 39. Moreover, FDG uptake in atherosclerotic plaques correlates with the density of 
macrophages determined histologically 23,40-43. Indeed, FDG PET/CT is now used clinically to evaluate inflamed 
tissues, and has recently been the focus of guidelines from American and European Societies for Nuclear Medicine 
and Molecular Imaging44. 


18 
FDG PET/CT for Imaging Atherosclerosis: In atherosclerosis, disease activity can be defined as progression of 
atherosclerotic plaque or development of atherothrombotic events.  In a multi-center trial employing both PET/CT 
and MRI imaging, changes in the PET/CT signal predicted the rate of plaque expansion eighteen months later45. In 
another study, the arterial PET signal predicted the subsequent rate of atherosclerotic plaque progression, based on 
CT imaging46. Additionally, several studies have shown an association between the FDG signal and CV risk factors or 
risk scores35,47-49. Higher arterial FDG uptake was also associated with a substantially increased risk for subsequent 
stroke and MI36,50. Thus, there is substantial evidence to support the utility of FDG PET/CT imaging to predict 
atherosclerotic disease progression and subsequent CV events. This imaging modality is responsive to changes to CV 
risk as a result of treatment.  High dose statin therapy reduced FDG PET/CT signal to a greater extent than low dose 
statins51,52; clinical outcome studies have found a 28% reduction in CV events among high dose statin users versus 
low dose53.  
FDG PET/CT as a Tool to Measure Changes in Tissue Inflammation after Interventions: FDG PET/CT imaging is a 
well-established tool for evaluating treatment-related changes in inflammation after interventions in humans. 
Several groups have shown that statin therapy (a well-described anti-inflammatory treatment in atherosclerosis) 
results in a significant reduction in arterial FDG uptake after 3 months52,54,55. Using FDG PET/CT, Tawakol (co-I) et al 
observed a relatively rapid reduction in arterial inflammation in individuals randomized to atorvastatin 80 
(compared to atorvastatin 10mg)52. More recently, van Wijk et al56,57 demonstrated in individuals with familial 
hypercholesterolemia that non-pharmacologic lipid lowering by Lipoprotein Apheresis induces a rapid reduction in 
arterial inflammation within one week of the intervention.  Additionally, FDG PET/CT imaging has been used to study 
the impact on arterial inflammation of therapies that do not substantially impact serum LDL. Recently completed 
multi-center PET/CT imaging trials evaluated the anti-inflammatory efficacy of p38 MAP kinase antagonism58, a 
novel innate-immune modulator lecinoxoid59, Lipoprotein-associated phospholipase A2 (Lp-PLA2) antagonist60, and a 
cholesteryl ester transfer protein (CETP) antagonist61. Others have reported on the impact of tumor necrosis factor 
antagonists62 and    pioglitazone 63. 
 
Relationship between FDG PET/CT Imaging Trial Findings and Clinical Endpoint Trial Results: Currently, results of 
both clinical endpoint studies and FDG PET/CT imaging trials are available for 4 drug classes. Such paired results 
(albeit from different RCTs) allow the evaluation of the degree to which FDG PET/CT trial results are predictive of 
clinical endpoint studies. The 4 drug classes are 1) statins, 2) pioglitazone, 3) CETP antagonist, and 4) Lp-PLA2 
antagonists. As previously stated, each of the published PET/CT studies evaluating the impact of statins on the 
vasculature demonstrate a reduction in atherosclerotic inflammation, hence those findings parallel the well-
described reduction in CVD events associated with statins. Similarly, pioglitazone is associated with both a reduction 
in arterial FDG63 and a reduced incidence of atherothrombotic events.64,65 Hence for statins and pioglitazone, 
findings of reduced arterial inflammation in FDG PET/CT imaging trials are consistent with the findings of clinical 
endpoint trials. On the other hand, the dal-PLAQUE imaging trial which evaluated the effect of dalcetrapib (a CETP 
modulator) on arterial plaque showed no difference between dalcetrapib and placebo (p=0.51) on the primary or 
secondary FDG PET/CT imaging end-point 66. The subsequently published dal-OUTCOMES trial evaluating the effect 
of dalcetrapib on major coronary events similarly demonstrated no clinical benefit.67 Likewise, an FDG PET/CT 
imaging trial evaluating an inhibitor of Lp-PLA2, rilapladib, showed no beneficial impact of Lp-PLA2 antagonism on 
arterial inflammation60. Subsequently, the STABILITY trial of nearly 16,000 individuals showed no beneficial effect of 
darapladib, also a Lp-PLA2 antagonist, to reduce the primary composite endpoint of CV death, MI, or stroke.68 Thus 
for all 4 drug classes for which there are both FDG PET/CT data and clinical endpoint data (atorvastatin, 
darapladib/rilapladib, dalcetrapib, and pioglitazone), the imaging trial findings have been consistent with the results 
from clinical endpoint studies. While the FDA has not yet accepted FDG PET/CT as a validated surrogate measure of 
CVD, the use of FDG PET/CT imaging may provide a pathway for predicting the potential efficacy of CV therapeutics 


19 
using a relatively small number of patients and with short observation periods of 1 to 3 months. The current trial 
may provide supportive information to move forward with an outcomes trial. 
 
 
 
Arterial FDG PET/CT studies in RA. Recently, Maki-Petaja et al62 reported higher aortic FDG uptake in 17 RA 
patients compared to 34 non-RA controls with stable CAD (target-to-background ratio [TBR] 2.02±0.22 vs 1.74±0.22, 
respectively, p=0.0001).  Moreover, open label treatment of the RA patients with a TNFi (etanercept or adalimumab) 
over only 8 weeks was associated with an 18% decrease in FDG uptake (2.51±0.33 to 2.05±0.33, p<0.0001 in the 
most diseased segment) that correlated with decreases in CRP and DAS28 levels.  A cross-sectional study of 10 
psoriasis and 5 RA patients also demonstrated higher FDG uptake at all levels of the aorta compared to uptake in 10 
healthy subjects after adjusting for conventional CV risk factors69.  These data are limited by very small sample sizes 
and absence of RA treatment placebo or comparator groups.  However, they do suggest the potential value of FDG 
PET/CT to assess vascular inflammation in RA.   We have conducted a retrospective study of 33 RA patients who 
underwent PET/CT imaging for non-CVD indications (in press), and a cross-sectional observational study of 71 RA 
patients who have undergone aortic PET/CT imaging.  Taken together, these studies strongly support the feasibility 
of enrolling adequate numbers of RA patients with elevated vascular FDG uptake for the purposes of the proposed 
RCT. 
2.1.5 
The effect of RA treatments on CVD is unclear. 
To date, there is no level A evidence (i.e., double blind RCTs) that any RA DMARDs reduces frequency of CV 
events in patients with RA.  However, there is a strong body of experimental data that lay the groundwork for this 
hypothesis, and these data are by far most robust for the TNFi’s at every level (in vitro, animal models, human 
observational data). 
TNFα and TNFi effects on vasculature.   Vascular endothelium is a select target for TNFα in which it induces an 
array of pro-inflammatory, pro-coagulant, and pro-apoptotic genes that damage endothelium and increases 
thrombotic potential, while simultaneously inhibiting synthesis of the vasodilator nitric oxide70.  TNFα also induces 
endothelial adhesion molecules which mediate attachment and transmigration of inflammatory cells to the arterial 
walls71. The monocyte influx takes up oxidized LDL, activating release of TNFα and further promoting LDL uptake via 
induction of acyl-CoA-cholesterol transferase 172.  This feed forward loop results in foam cell accumulation, an early 
stage of atherosclerosis72. These effects can be reversed by TNFi’s in vitro73. Mice deficient for both TNFα and apoE 
exhibit reduced atherosclerotic lesions compared to wild type controls74. Therapy with TNFi’s as an anti-atherogenic 
strategy is strongly supported by experimental data. 
Given these data and the observation by Feldman and Maini that TNFα is also the primary cytokine driving joint 
and systemic inflammation in RA75, there has been intense interest in investigating inhibition of TNF as a strategy in 
RA for reducing CVD.  In small studies of RA patients, the prevalence of endothelial dysfunction and aortic stiffness 
were observed to be higher than in controls. TNFi treatment transiently and partially reversed these measures76,77  
At the macrovascular level, several cohort studies suggested that TNFi’s also slow progression of asymptomatic 
carotid atherosclerosis compared to conventional DMARDs78,79.  As to whether TNFi’s reduced CV events in cohort-
based epidemiological studies in RA, the data are somewhat more mixed.   For example, several large registry 
studies showed a reduction in CV events in TNFi users compared to non-users80,81, but studies from other large 
databases such as the US VA health system and the Swedish and British Rheumatology Registries82-84 did not 
demonstrate reductions in rates of composite CVD endpoints with exposure to TNFi’s.  Many of these registry and 
administrative data studies lack detailed information on traditional CV risk factors and RA characteristics. Thus, 
confounding by indication and other unmeasured confounders threaten their validity, severely limiting the causal 
inference.   The time is right therefore to move the field forward in RA via an RCT to directly evaluate the effect of 


20 
TNF inhibition on a vascular measure (i.e., arterial inflammation) that is an integral feature of atherosclerosis and 
plaque rupture. 
Effect of non-biologic DMARDs on the vasculature.  In contrast to the robust data suggesting a therapeutic role 
for TNFi’s in treating atherosclerosis, data for SSZ and HCQ are extremely limited.   Despite decades of SSZ use as a 
treatment for RA, and anti-inflammatory actions that have potential relevance to atherosclerosis (e.g., inhibition of 
activation of NFkB and scavenging of reactive oxygen species85,86), there is almost no information regarding a 
potential effect on reducing CVD.  A small RCT in non-RA patients with stable CAD evaluated the efficacy of SSZ vs 
placebo for improving endothelial function87 but no significant difference was observed.  In a large multinational RA 
cohort in Europe, comparing users of various DMARDs to non-users, SSZ was associated with only a modest 
reduction in CV morbidity (HR 0.92, 95% CI 0.87-98) compared to MTX (HR 0.85), leflunomide (HR 0.59), 
glucocorticoids (HR 0.95) and TNFi’s (HR 0.42)88.  
HCQ is an anti-malarial drug with modest anti-inflammatory effects in RA but a disease modifying capacity has 
never been definitively confirmed.  It has effects on both the adaptive as well as innate immune pathways. HCQ 
raises the intracellular pH of lysozomes which impairs protein processing, causing downstream impairment of 
immune functions such as antigen presentation to CD4+ cells, interaction of intracellular toll-like receptors (TLRs) 
with cognate ligands, and production of proinflammatory cytokines89-91.  These mechanisms could play a role in 
treating/preventing atherosclerosis but there are no data to support this at present.  Interesting data do support an 
effect of HCQ in reducing metabolic risk.  Gu et al92 showed that anti-malarials suppress lipid accumulation in 
macrophages through their effect on TLR-9.  However, in a recent meta-analysis of nine studies in SLE, evidence 
suggesting that anti-malarials reduce lipid levels was weak93  although another study reported a protective effect in 
SLE against metabolic syndrome94.  In two RA cohort studies, treatment with HCQ was associated with a decrease in 
incident diabetes95,96, while a third study did not show a significant reduction30.  There are no data on the effect of 
HCQ in reducing CV events. 
Taken together, these data strongly support our hypothesis that TNFi therapy will have a more potent effect on 
arterial inflammation than combined SSZ+HCQ (with both given on MTX background).  While our study design does 
not allow us to investigate the effect of MTX on arterial inflammation, our preliminary data and that of Maki-Petaja62 
strongly suggest that MTX-IRs will have more than sufficient arterial inflammation to measure a drug effect. 
2.1.6 
Blood-derived biomarkers of CV risk in RA are also needed. 
Blood-derived biomarkers of CV risk (e.g., SNPs, gene arrays, soluble proteins, cell subtypes) are also desirable 
and a focus of great interest.  Advantages of blood-derived biomarkers of CV risk include: 1) easy accessibility, 2) lack 
of radiation exposure, and 3) ability to standardize assays that enable widespread commercial use.  As with imaging 
biomarkers, blood-derived biomarkers would ideally identify asymptomatic RA patients at intermediate to high CV 
risk who would not be identified by current conventional CV risk models such as the FRS.  This would enable a risk-
stratified approach combining conventional CV risk factors and RA-specific factors which could substantially reduce 
CV associated morbidity and mortality in patients with RA. 
Correlations of a single non-specific biomarker of inflammation (e.g., CRP, sedimentation rate [ESR] or IL-6) with 
CVD in patients with RA have been modest97-99.  Similarly, clinical indices of RA disease activity, and RA-associated 
autoantibodies, have met with similarly limited success as ‘biomarkers’ of CVD20-22. A broad array of biomarkers 
reflecting systemic inflammation, endothelial activation, lipid metabolism and pro-inflammatory cytokines have 
been shown in the general population to be associated with prevalent and/or incident CVD.   These include CRP, IL-
6, serum amyloid protein (SAA), vascular cell adhesion molecule (VCAM), apolipoprotein B and others100.   A 
substantial number of these CV risk biomarkers also reflect biological pathways that are activated in RA and 


21 
correlate with RA disease activity.  For example, of the twelve proteins that comprise a commercially available 
MBDA known as ‘Vectra-DA’ (Crescendo Bioscience), all are also recognized as CVD biomarkers, such as CRP, SAA, IL-
6, TNF-R1, MMP-1 and -3, leptin, resistin, VCAM, vascular endothelial growth factor-A, epidermal growth factor, and 
human cartilage glycoprotein-39 (YKL-40)101 Thus, the MBDA is a very promising biomarker for investigation of CV 
risk in patients with RA. It was derived from studies of 130 biomarkers; of these, 25 were selected for algorithm 
training, and the final MBDA consisted of the 12 biomarkers noted above102.   The MBDA has been found to have 
strong correlation with the DAS28-CRP (r2=0.60), significantly better than the CRP (r2=0.38)102.  In an Area Under the 
Receiver Operating Curve  (AUROC) analysis examining the ability of the MBDA to classify patients into low disease 
activity vs moderate-high disease, the average AUROC was 0.89102. MBDA scores range between 1 and 100. 
Performance characteristics of the MBDA have been confirmed in independent cohorts, and with additional 
validated RA disease activity measures including the SDAI, CDAI and RAPID3103.  Finally, data suggest that the MBDA 
‘molecular remission’ may be superior to clinically defined remission in predicting progression of radiographic joint 
damage104.  If the MBDA is also found to predict change in vascular inflammation in RA, this could enhance current 
CVD risk models in RA with potential clinical value. 
2.1.7 
FDG PET/CT can also be used to assess treatment-associated changes in joint inflammation. 
FDG is taken up by inflamed joints, and several small pilot studies assessing disease activity in RA have shown 
promising correlations between FDG uptake and disease activity. Palmer et al105 found excellent anatomical 
correlation in the wrists of 12 RA patients between region of greatest FDG uptake with volume of pannus 
determined by MRI sequences.   Beckers et al106 found a strong association between FDG uptake in 356 joints of 21 
RA patients with clinical and ultrasound derived measures of joint activity.  In a further study by the same 
investigators of 16 RA patients treated with a TNF antagonist107, reduction in FDG uptake in the knees at four weeks 
was highly correlated with changes observed in all MRI parameters and with MMP-3 levels, but less well with serum 
CRP levels.  Okamura et al 108 also studied change in FDG uptake in 22 RA patients treated for 6 months with a TNFi; 
average decrease in maximal standardized uptake value (SUVmax) after six months was 22% and was positively 
correlated with change in DAS28-CRP levels (r=0.66, p=0.001).  Roivainen et al109 examined change in FDG uptake 
after initiation of triple therapy plus low dose prednisone in 17 patients with RA.  76% and 81% of patients showed 
reductions in SUVmax at weeks 2 and 4, respectively; mean decreases in SUVmax were 22±13% and 29±13%, 
respectively. While encouraging, these studies were extremely small and open label.  In the proposed study, we will 
for the first time utilize FDG PET/CT in an RCT to evaluate change in joint inflammation between two treatment 
regimens for RA. 
2.1.8 Bioethics Ancillary Study 
There is a lack of information available on researchers’ attitudes and beliefs regarding incidental research 
findings and the prevalence of incidental research findings from state of the art imaging studies, such as whole body 
FDG PET/CT in those without known malignancy, and to our knowledge, no such information available in 
rheumatology. The Treatments Against RA (Rheumatoid Arthritis) and Effect on FDG PET/CT (TARGET) study 
provides an unprecedented and unique opportunity to examine the ethics around incidental findings from whole 
body FDG PET/CT in RA patients without known malignancy. 
2.1.9 Neuroimaging Measures Ancillary Study 
           Neuroimaging has revolutionized the study of neuropsychiatric conditions, including conditions along the 
stress axis (anxiety, stress, PTSD, and depression). Imaging with functional MRI and FDG PET provide insights into 
regional reactivity (fMRI) or resting metabolism (FDG PET) of regions of the brain that are critically involved in stress 
conditions (including the prefrontal cortex and amygdala). FDG-PET assessments of regional brain activity has been 
performed for decades, and leverages the fact that FDG localizes to areas of active glycolysis. This signal is 


22 
reproducibly quantified using PET images that are co-registered to CT for anatomical localization. Higher rAmygA 
may be a more accurate reflection of chronic stress, higher trait-anxiety, and persistent negative affect110, and has 
repeatedly been shown to associate with anxious temperament111 perceived stress112, and PTSD113. Furthermore, 
this signal is physiologically important, as it links to diseases that are independently associated with stress, such as 
cardiovascular disease112. Moreover, higher rAmygA was shown to link to future CVD events through upregulated 
activity in bone marrow and heightened arterial inflammation in series.   
        Rheumatoid Arthritis is associated with an Elevated Chronic Stress Burden, and an Exaggerated Stress Response. 
RA patients commonly report that disease flares occur during or after periods of increased psychological stress114.  
However, studies attempting to causally link stress with RA disease activity and/or systemic inflammation have been 
inconsistent115, hampered by using self-reported measures of psychosocial stress, difficulty establishing temporality, 
and the inability to evaluate the contribution of RA symptoms, pain, and disability to stress.  Few studies in RA have 
utilized neuroimaging to investigate links between the brain, immune system, and joints, and no studies have explored 
the links between neuroimaged reactivity in the amygdala and related brain structures and vascular inflammation in 
RA patients, despite compelling associations between self-reported psychosocial stress and coronary calcification in 
this population.  Establishing these associations will inform mechanistic follow-up studies, validate the performance 
of self-reported psychosocial stressors as proxy measures, and support the testable concept of psychosocial stress 
management as an intervention for reducing CVD and disease activity in RA. 
2.2 Rationale 
We considered several alternative designs.  We first considered a clinical outcomes trial with CV events as the 
endpoint.  This design was part of our original NIH planning grant application, and it was rejected by the Study Section 
because of feasibility.  While an outcomes trial would be most clinically relevant, we have come to agree that it is not 
feasible.  Based on an assumed 25% difference in CV event rates and a 2% annual event rate, we calculated a sample size 
of ~10,000 followed for a median of 3 years. Maintaining the original treatment arms in an RA trial for 3 years is 
impractical.  The total cost would be approximately $70M.  If we could enroll a very high-risk RA population (e.g., 
immediately post-MI), then fewer subjects would be required.  However, since IL-6 blockers and JAK inhibitors raise LDL, 
the ethics of this trial are unclear. Thus, a surrogate endpoint trial with FDG PET/CT is the preferred design. 
We considered several potential treatment comparisons. We pursued designing a treat to target (TTT) trial with the 
Technical Expert Panel (TEP) through a formal Delphi Panel process.  This involved extensive literature reviews, protocol 
development, and consensus voting on 10 key aspects of the protocol.  This process is outlined in a submitted 
manuscript110.  While we reached consensus on all issues, there were a multitude of operational issues raised by the 
TEP.  Several of the most difficult issues include: how to ensure that usual care would differ substantially from TTT; the 
clinically appropriate drug dosing and visit regimens for TTT that would facilitate separation of the disease activity curves 
for TTT versus usual care; the use of glucocorticoids in the TTT regimen, and the strong potential for contamination 
across arms.  After considering these issues, we determined that it would be extremely difficult to conduct a rigorous 
TTT trial focused on the CV endpoint described above. We considered several comparisons for a treatment trial. 
We chose to pursue a TNFi + MTX versus triple therapy for several reasons. 1) While there are strong data to suggest 
that these treatments produce similar clinical outcomes by 12-24 months111-113, triple therapy is a strategy that is not 
being widely used in typical practice.  Thus, further information comparing these strategies may help clinicians and 
patients make treatment decisions. 2) TNFi + MTX appears to have a quicker onset of action with greater disease control 
at 6 months based on several published trials111,113.  Thus, there is ample evidence to support a superiority hypothesis 
for the proposed trial. 3) Both treatment options are considered standard of care, enhancing patient and provider 
acceptability. 4) The ability to adjust doses over the 6-month trial for both regimens will facilitate patient retention.  The 
doses of MTX, SSZ and several TNFi can be titrated. 


23 
Finally, we considered a longer trial originally with the desire to provide information over a longer treatment course.  
However, there are two critical problems with a longer trial.  First, as noted above, some patients will not respond to 
treatment regimens.  We believe that it is ethical and feasible to keep patients on dose-adjusted treatments for 6 
months, but not longer.  Second, 6 months will allow for improvement in FDG PET/CT.  This has been demonstrated in 
prior trials using statins with an FDG PET/CT assessment after 12 weeks52,114. 
3. STUDY DESIGN 
3.1 Overview 
This is a multi-center, phase IV, 24-week, two arm randomized clinical trial to evaluate the effects of DMARD associated 
changes in vascular inflammation in patients with RA.  The overall study design is shown in Figure 1.  Two hundred 
patients with RA who are inadequate responders to MTX (MTX-IRs, DAS28>3.2) will be randomized in a 1:1 ratio to 
receive either a TNFi or SSZ + HCQ, while continuing background MTX (and HCQ if applicable), for 24 weeks.   Although 
the joint count assessors and imaging readers will be blinded to treatment assessment, the subjects and investigators 
will not be blinded.  
3.2 Study Population  
This will be a multicenter study with approximately 40 study sites. 400 RA patients will be recruited over a planned 
recruitment period of 24 month, 200 will be randomized. The target population consists of patients who are deemed 
methotrexate-inadequate responders (MTX-IRs, DAS28>3.2) by their treating rheumatologist, and who have not yet 
stepped up to additional treatment with a biologic DMARD. 
 Patients will be identified for potential recruitment by methods that may include using physician referral, pre-screening 
enrollment logs, IRB or Sponsor approved sources, such as newspaper/radio advertisements and/or mailing lists.  
Informed consent will be obtained by the Principal Investigator, co-investigator, or Study Coordinator at each site. Study 
procedures including screening procedures will not begin until signed informed consent has been obtained. 
3.3 Inclusion Criteria 
Subjects who meet all of the following criteria at Screening are eligible for enrollment into the study: 
• 
Written informed consent signed by the subject;  
• 
Fulfill ACR/EULAR 2010 criteria for RA; 
• 
Men ≥ 45 years and women ≥ 50 years; 
• 
MTX for ≥ 8 weeks at ≥ 15mg weekly or on at least 7.5mg of methotrexate weekly for ≥8 weeks with a 
documented intolerance of higher MTX doses, and on a stable dose for the previous 4 weeks; 
• 
DAS28 score > 3.2; 
• 
Able to swallow pills; 
• 
Males and females with reproductive potential must agree to practice effective measures of birth control;   
• 
If taking prednisone (or equivalent corticosteroid), the dose must be ≤ 10 mg/day at the time of the baseline 
FDG PET/CT scan and must NOT change by more than ±3.0 mg for the four weeks prior to the baseline FDG 
PET/CT; (please see Corticosteroids Section 4.4.1 for further details); 
• 
If taking a low- or moderate-intensity statin, the dose must be stable for six weeks prior to screening and must 
not change during the six months of the trial (please see Statins and PCSK9 Inhibitors Section 4.4.2 for further 
details);  
• 
Willing to comply with all study procedures and be available for the duration of the study; 
• 
Rheumatoid arthritis diagnosis without psoriasis or with psoriasis if rheumatoid factor ≥ 2x ULN or anti-CCP ≥ 2x 
ULN. 


24 
3.4 Exclusion Criteria  
• 
Prior use of biologic DMARD or small molecule DMARD (i.e. tofacitinib) in the past 6 months, use of Rituximab 
ever; 
• 
If a subject is considered to be an etanercept (Enbrel) or adalimumab (Humira) failure by their primary 
rheumatologist; 
• 
Non-biologic DMARDs other than MTX or HCQ for two months prior to Screening; 
• 
Current use or use within the past 12 months of a high-intensity statin lipid lowering drug (atorvastatin/Lipitor 
40mg or higher, rosuvastatin/Crestor 10mg or higher) or a PCSK9 inhibitor (alirocumab/Praluent, 
Evolocumab/Repatha, or Bococizumab); 
• 
Prior patient reported, physician diagnosed clinical CV event: myocardial infarction or heart attack, angina, 
stroke, uncompensated or severe heart failure (NYHA class III or IV), prior vascular procedure (coronary artery 
angioplasty or stenting, carotid endarterectomy, coronary artery bypass surgery); 
• 
Demyelinating disease; 
• 
Any of the following forms of arthritis that may otherwise explain the subject’s RA symptoms: Psoriatic Arthritis, 
Reactive Arthritis, Juvenile Idiopathic Arthritis, Ankylosing Spondylitis, Polymyalgia Rheumatica 
• 
Any of the following other autoimmune and/or chronic inflammatory diseases: Inflammatory Bowel Disease, 
Crohn’s disease, Cutaneous or Systemic Lupus, Systemic  
Vasculitis, Giant Cell Arteritis, Polymyositis, Dermatomyositis, Sarcoidosis, or Scleroderma; 
• 
Transient ischemic attack (TIA); 
• 
Revascularization for peripheral artery disease; 
• 
Cancer treated in last five years (except basal and squamous cell) or any lymphoma or melanoma; 
• 
Type I diabetes mellitus or type II diabetes mellitus treated with insulin or uncontrolled with HbA1c ≥7%; 
• 
Known pregnancy, HIV, hepatitis B, hepatitis C, active (or untreated latent) TB; 
• 
Known sulfa allergy or other known hypersensitivity to any of the trial agents or G6PD deficiency; 
• 
Known macular disease or known retinal disease;  
• 
Baseline blood count, renal or liver abnormalities as follows:  WBC < 3.5 x 1000 n/ul, Hematocrit < 30%, Platelet 
count < 90 x 1,000 n/ul, estimated glomerular filtration rate < 50 ml/min/1.7m2, AST >60 U/L, ALT>84 U/L; 
• 
Intra-articular injection within the 4 weeks prior to the potential baseline FDG PET/CT; and 
• 
Two or more of the following high dose radiation scans in the past year: CT scan with contrast, angiogram, SPECT 
nuclear medicine scan, myocardial (cardiac) perfusion scan. 
3.5 Recruitment and Retention 
3.5.1 Recruitment Plan 
The target population to be recruited is men aged 45 and older or women aged 50 and older with a clinical diagnosis 
of RA who are deemed methotrexate-inadequate responders (MTX-IR) by their treating rheumatologist.  Patients 
will be recruited from participating rheumatology and arthritis clinics and practices at participating sites across the 
United States.  A recommended method for identifying and recruiting patients is described in the following sections 
and in more detail in the MOOP.  Sites will generate and maintain a list of patients that may become eligible for the 
study based on a HIPAA-compliant review of medical records of existing RA patients.  The treating rheumatologists 
will alert study staff when a patient is deemed a MTX-IR, prior to a switch or escalation of DMARDs. The Site 
Coordinator will speak with the patient to go over pre-screening inclusion/exclusion criteria, explain the trial, and 
assess interest (Recruitment training will be provided). The Study Brochure can be given to interested patients. 
If the patient is interested in participating, a Site PI, Co-I, or Site Coordinator must obtain informed consent prior to 
any screening procedures. The research protocol will be explained in detail, including all possible risks and benefits. 
During the consent process, the study coordinator or investigator probes the patient’s understanding of the 


25 
protocol.   All participants will be told that the study is voluntary, that they have no obligation to participate, and 
that they may decline or withdraw at any time without compromising their care.  Subjects will have ample 
opportunity to ask questions prior to signing the consent form.  Eligible subjects will be allowed as much time as 
necessary to determine whether they wish to participate in the study. 
3.5.2 Schedule of Study Events 
Consent will be obtained at the beginning of the Screening Visit (Visit 1).  Patients who meet eligibility criteria and 
provide informed consent will be considered enrolled and will undergo the additional screening procedures outlined 
above in Table 1, including completion of questionnaires, screening laboratory tests including hepatitis B and C 
screens and tuberculosis screening (if none in the past six months),hemoglobin A1c test only for Type II diabetics if 
none from the past six months, and chest x-ray without evidence of interstitial lung disease (if none in past 12 
months). Subjects found at Screening to have active hepatitis or active infection (including tuberculosis) or 
interstitial lung disease will be excluded.  If the additional required screening blood work was completed by the 
subject within 1 week of the screening visit (see 3.4 above), these tests do not need to be repeated. If the subject 
has been on stable methotrexate or prednisone for the 8 weeks preceding the screening visit, then safety labs 
performed during those 8 weeks do not need to be repeated at the screening visit. CRP testing must be completed 
at the date of Screening when a joint count is done to determine the subject’s eligibility for study inclusion. If these 
additional laboratory- and imaging-based eligibility criteria are met and eligibility is confirmed, the FDG PET/CT scan 
will be scheduled. For the FDG PET/CT, the subject will be given instructions for an overnight fast for the purposes of 
the PET/CT scan. If nothing is found on the FDG PET/CT that would preclude the subject from randomization, the 
subject will be randomized and a baseline visit will be conducted.  The subject will complete additional 
questionnaires at baseline. All subsequent study visits are performed at six week intervals and should be conducted 
within 14 days prior to or after the designated date (calculated from the subject’s randomization date).  Blood will 
be drawn at each visit for safety monitoring; additional fasting blood specimens will be drawn at Visits 2, 3, 5 and 6 
for the research biospecimen repository.  Safety labs may be deferred in extreme circumstances (i.e. COVID-19 
pandemic). During this period when patients and clinicians are trying to minimize contact with the health care 
system, we will rely on site PIs’ clinical judgement for the appropriate frequency of safety laboratory 
testing.  However, this should be no less than every six months and no greater than every six weeks. A repeat FDG 
PET-CT scan will be performed between 24 and 36 weeks.  
3.5.3 Randomization and Blinding 
Upon confirmation of subject eligibility, the Site Coordinator will determine treatment assignment through a 
randomization function of the electronic data capture (EDC).  Randomization will be performed centrally by the DCC 
using a permuted block design.  Metrologists performing joint counts will be blinded to treatment assignment, as 
will the FDG-PET/CT imaging readers.  Laboratory staff who run bioassays on biospecimen samples will also be 
blinded to treatment assignment.  Subjects will be instructed NOT to discuss their treatment with the metrologist, 
and the metrologist will not be a part of the subject’s care team.  The metrologist will also be instructed to remind 
the subject before each joint examination that treatment should not be discussed. In addition, the metrologist 
should not discuss treatment with the site PI or other study staff.   
3.6 Subject Retention 
We aim to have a 90% retention rate in order to meet the guidelines established by the NIH. Once enrolled, a proactive 
plan for retention will be implemented that includes elements such as regular phone and mailed reminders for each 
study visit, parking and meal vouchers, complimentary items such as pens and canvas totes with the study logo, birthday 
and holiday cards, etc.   Arguably, most importantly, we will train sites to follow major principles and commonly used 
strategies to maximize retention and minimize loss to follow-up.  These are outlined in detail in the MOOP and include 


26 
building subject relations and subject satisfaction, with the study coordinator taking a central role in this effort, 
emphasizing the importance of congeniality, respectfulness and friendliness in interactions with participants. 
3.7 Subject Withdrawal 
All subjects receive active therapy and the trial is relatively short in duration; thus, we anticipate few withdrawals and/or 
cross-overs.   Furthermore, the ability to titrate the regimens will limit withdrawal and/or cross-over.   As noted above, 
great effort will be made to retain subjects in the study.  Nonetheless, subjects have the right to refuse treatment or 
completely withdraw from the study at any time for any reason. An explanation of why the subject is withdrawing from 
the study should be recorded on the withdrawal eCRF. The investigator also has the right to withdraw subjects from the 
study treatment in the event of AE, protocol violations, administrative reasons, or for other reasons. When applicable, 
subjects should be informed of circumstances under which their participation may be terminated by the investigator 
without the subject’s consent.  Any administrative or other reasons for withdrawal must be documented and explained 
to the subject.  If the reason for removal of a subject from the study is an adverse event, the principal specific event will 
be recorded on the CRF. The subject should be followed until the AE has resolved.  If it appears that a subject is lost to 
follow-up, the investigator must attempt to contact the subject or a responsible relative by telephone, to determine if 
any new AEs occurred, follow-up of any ongoing AE, and to establish as completely as possible the reason for the 
withdrawal. 
Study treatment may be discontinued for any subject who experiences any of the following: 
• 
Extreme laboratory value (see Section 4.5.1 Abnormal Lab Values) 
• 
Malignancy other than basal or squamous cell 
• 
Repeated subject non-compliance or loss to follow-up. 
• 
The subject withdraws consent 
• 
The investigator or DSMB believes it is in the best interest of the subject 
• 
The study is terminated 
If study treatment is discontinued (e.g., for an adverse event) and there is no safety issue precluding it, the subject will 
be asked to return for the follow-up FDG PET/CT scan if he/she has received at least eight weeks of the randomized 
treatment prior to withdrawal.   
In addition, if the subject decides to withdraw from treatment assignment before trial completion, the subject will be 
asked to come in for a follow-up FDG PET/CT scan within 2 weeks of stopping their randomized treatment assignment 
and before initiating any new treatment. Subjects will only be asked to come for a follow-up FDG PET/CT if they have 
been on the trial assigned treatment for at least 8 weeks.  If they have been on less than 8 weeks of study treatment 
before wanting to withdraw, they will not undergo a second scan. 
If the subject withdraws consent, all study related visits, exams, procedures and data collection are terminated. 
3.8 Premature Termination or Suspension of Study 
This study may be suspended or prematurely terminated by the DSMB or by the NIH if there is sufficient reasonable 
cause.  Written notification, documenting the reason for study suspension or termination, will be provided by the 
suspending or terminating party to investigators, funding agency and regulatory authorities.  If the study is prematurely 
terminated or suspended, the principal investigator will promptly inform the IRB and will provide the reason(s) for the 
termination or suspension.  


27 
3.9 Bioethics Ancillary Study 
We will survey the TARGET investigators to determine researchers' attitudes and beliefs regarding their ethical 
obligation to return and manage incidental research findings from whole body PET/CT imaging studies and determine 
the prevalence of incidental extra cardiac findings in whole body PET/CT scans in rheumatoid arthritis (RA) and detection 
rate of previously unknown malignancies.  
Dr. Kang, a bioethicist with training in survey methods, will develop the survey. The survey design will be created and 
informed using the existing literature, previously used surveys on incidental findings from research and in consultation 
with advisors who are Columbia University faculty members with extensive experience with survey methods. The survey 
would include Likert scale, forced choice, rank order, and open-ended questions. The open-ended questions will provide 
participants an opportunity to provide additional information that may not be adequately captured in the other 
components of the survey, and will also provide qualitative data.  
Once developed, the survey would be entered into REDCap (Research Electronic Data Capture) for distribution. 
Responses will be collected anonymously via REDCap. All surveys will initially be distributed through email, which 
includes a link to the electronic version of the survey. If there is no response to an initial email, the participants will 
receive a total of 3 email reminders. To increase the response rate, if there is no response via email, a paper copy of the 
survey will be mailed to participants. Site PIs will be compensated for their participation in the proposed survey. 
4. TREATMENT AND STUDY PROCEDURES 
4.1 Acquisition of Randomized Treatment 
All study medications will be provided to participating subjects excluding methotrexate. As participants entering the 
study are already taking methotrexate and will be continuing to take that medication for the duration of the study, 
subjects will continue to obtain their methotrexate through their previously utilized source.  
Upon completion of screening procedures and determination that the subject is eligible for inclusion in the trial, the 
subject will be randomized to trial treatment through the Data Coordinating Center. Once a subject has been assigned to 
treatment, the coordinating center will be alerted. The coordinating center will then immediately notify the drug 
distribution center of the appropriate treatment that must be sent out. A drug kit will be sent from the drug distribution 
center to the site. The subject will then return to the study site to pick-up the drug and complete a baseline visit. 
Subjects will begin their treatment arm on the date of receipt of the medications. 
4.2 Description of Treatment Medications 
A brief description of each of the study medications (all of which, as noted above, are FDA approved) is provided below.  
More detailed descriptions of each drug are provided in the following links to the FDA approved package inserts:  
1) Adalimumab: http://www.rxabbvie.com/pdf/humira.pdf 
2) Etanercept: http://pi.amgen.com/united_states/enbrel/derm/enbrel_pi.pdf 
3) Sulfasalazine: http://labeling.pfizer.com/ShowLabeling.aspx?id=524 
4) Hydroxychloroquine: http://www.accessdata.fda.gov/drugsatfda_docs/label/2007/009768s041lbl.pdf 
5) Leflunomide: http://products.sanofi.us/arava/arava.html 
6) Methotrexate Injection: http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/011719s117lbl.pdf 
7) Methotrexate tablets: http://www.rheumatrex.info/pdf/RheumatrexPackageInsert.pdf 
 
Etanercept.   The standard dose of etanercept is 50 mg SC once weekly.  The drug is provided already diluted to the 
appropriate concentration in pre-filled syringes.  It is typically injected into the abdomen or thigh.  The medication 
must be refrigerated.   


28 
Adalimumab.  The standard initial dose of adalimumab is 40 mg SC once every other week.  Like etanercept, it is 
provided already diluted to the appropriate concentration in pre-filled syringes.  It is also injected into the abdomen 
or thigh and must be refrigerated. 
Sulfasalazine.   SSZ is formulated as tablets for oral use. Maximum dosing is usually 1500 mg bid. Patients with Sulfa 
allergies or G6PD deficiency should not be prescribed this medication and are excluded from the study. 
Hydroxychloroquine.   The approved dose of HCQ is either 200 mg once daily or twice daily. HCQ dose shall not 
exceed 6.5 mg/kg to conform to current guidelines for retinal safety.  The most recent recommendations from the 
American Academy of Ophthalmology advise a baseline screening examination within the first twelve months of 
treatment115.   
Leflunomide.  Leflunomide is approved at doses of 10 mg and 20 mg once daily. We will use 20 mg daily as it is the 
most common effective dose. 
4.3 Treatment Algorithm 
• 
See Figure 2 
 
Subjects randomized to the TNFi treatment arm will (based on randomization) receive either etanercept 50 mg SC 
weekly or adalimumab 40 mg SQ every other week (in addition to concomitant MTX and HCQ for subjects who entered 
the study on HCQ).  Subjects will continue the same dose of their concomitant background MTX and HCQ, if applicable.  
If the subject’s CDAI score is greater than 10 at 18 weeks, a good treatment response has not been achieved116, then 
treatment will be switched to the other TNFi of interest for this trial. Subjects who initially started etanercept will be 
switched to adalimumab 40 mg SQ every other week. Subjects who initially started adalimumab will be switched to 
entanercept 50 mg SQ weekly.   Subjects will remain on this new medication until the end of the study.  
Subjects assigned to the triple therapy arm will begin SSZ 500 mg bid and HCQ 200 mg twice daily, not to exceed 
6.5mg/kg HCQ (in addition to concomitant MTX). Subjects who enter the study on HCQ at a dose <200mg BID and are 
randomized to triple therapy will increase their dose to 200 mg BID HCQ, provided this new dose does not exceed 
6.5mg/kg. At 6 weeks, SSZ will be increased to 1 g bid for all subjects. If the subject’s CDAI score is greater than 10 at 18 
weeks, a good treatment response116 has not been achieved, and MTX will be switched to leflunomide 20 mg daily. The 
participant will remain on leflunomide (and concomitant SSZ + HCQ) for the remaining six weeks of the study. 
4.4 Concomitant Medications 
4.4.1 
Corticosteriods 
Patients who are not receiving corticosteroids and those receiving low dose steroids (≤ 10 mg/day of prednisone or 
equivalent) will be considered eligible for the study provided other entry criteria are met. Excessive dosages of 
steroids may suppress vascular FDG uptake independently of the randomized treatment. Prednisone (or equivalent) 
doses should not be altered by more than ±3.0 mg during the six months of the study. Two intra-articular injections 
of <40 mg triamcinolone (or equivalent) will be allowed during the study, but cannot be within one month of the 
second FDG PET/CT at the final visit.  No oral corticosteroid “bursts” will be allowed unless there is reason that an 
intra-articular injection is impossible. If a burst is required, it can be no more than 10mg per day (prednisone 
equivalent) at maximum and no longer tha 
n 14 days in duration before returning to +/- 3 mg of the original dose (or no use). Corticosteroid bursts cannot occur 
within one month of either of the FDG PET/CT scans. 


29 
4.4.2 
Statins & PCSK9 Inhibitors 
High-intensity statins and PCSK9 inhibitors have been shown to reduce arterial FDG uptake52.  Therefore, patients 
who have been treated with a high-intensity statin or a PCSK9 inhibitor in the past 12 months or are currently on a 
high-intensity statin or a PCSK9 inhibitor are not eligible for the study.  Patients taking a low-or moderate-intensity  
statin must be stable on their dose for six weeks prior to study entry and remain stable for the duration of the trial in 
order to eliminate a potential effect on arterial FDG uptake due to initiation or dose change of a low-dose statin. 
Patients likely to need a statin or PCSK9 inhibitor (e.g., insulin-dependent or uncontrolled diabetics and those with 
prior clinical CV events) are excluded from participation. Initiation of statins or PCSK9 inhibitors should be avoided if 
at all possible during the six month study period.  If this is not deemed safe by the study site investigator and one of 
the two cardiologists working on the trial (Drs. Tawakol and Ridker), then the subject will be asked to come in for a 
follow-up FDG PET/CT before a statin or PCSK9 inhibitor is initiated. Subjects must have been on study treatment for 
at least 8 weeks in order for the FDG PET/CT to take place. If the subject has been on study treatment for less than 8 
weeks, the subject will be dropped from the trial without completion of the follow-up PET scan. If a subject initiates 
a statin or PCSK9 inhibitor before a follow-up FDG PET/CT takes place, the subject will be dropped from the trial 
without follow-up imaging.  This information will be included in the primary trial analysis. 
4.5 Medication Monitoring 
Two study investigators will take primary responsibility for Medication Monitoring (Drs. Liao and Giles).  Both are board 
certified rheumatologists with experience using all of the study drugs.  The ongoing integrity of the Medication 
Monitoring program will be assured by Drs. Liao and Giles.  In addition, one of the two will always be on call to assist 
sites with medication related questions or concerns regarding side effects.  A complete list of potential side effects can 
be found in the package inserts. 
Per the American College of Rheumatology guidelines for the treatment of RA4, we will obtain complete blood count, 
liver panel and basic metabolic panel on all subjects at six week intervals.  Subjects will be instructed to bring in 
medication bottles to review medication adherence with site coordinators.  Safety monitoring for each of the prescribed 
medications is well understood by practicing rheumatologists as these medications have been on the market for over a 
decade (TNFi’s) or for several decades (SSZ and HCQ).  Since this treatment study utilizes usual and approved 
medications for RA, standards of monitoring are well understood by the treating rheumatologists. If the study physician 
determines that a significant medication related toxicity has occurred, the drug can be temporarily withheld and 
restarted at the same or lower dose.  If the toxicity recurs, the medication will be discontinued or the dose further 
lowered.  If the medication is discontinued, the subject will be treated with the next drug listed in the treatment 
algorithm (Figure 2).  See Section 4.5.1 for guidelines regarding adjustment of study medication doses due to lab 
abnormalities.   In the case of the TNFi’s, etanercept can be switched to adalimumab and vice versa.  In the case of triple 
therapy, if one of the medications has to be discontinued, leflunomide 20 mg can be substituted before 18 weeks. 
4.5.1 
Abnormal Lab Values 
All subjects recruited will have been on methotrexate and tolerated it.  Thus, abnormalities in laboratory values 
outlined in the Table below will initially be assumed secondary to sulfasalazine in the triple therapy arm.  As noted 
below in Table 3, two levels of laboratory abnormalities will be defined – caution and extreme values. Caution 
values will prompt re-testing in two weeks.  If caution values persist, the total daily SSZ dose will be reduced by 500 
mg and labs retested in two weeks; testing every two weeks will be continued and SSZ adjusted as needed until 
values normalize.  If they do not normalize, then other factors including methotrexate will be assessed. Extreme 
values will prompt a temporary stop of sulfasalazine with re-testing at two weeks and be reported as an adverse 
event. If values remain in the extreme range on re-testing the subject will be withdrawn from the study. If extreme 
values improve to the caution range, then sulfasalazine will be resumed at a dose 500 mg lower than the previous 
dose and re-tested in two weeks.  


30 
 
Table 3: Caution and Extreme Values for Relevant Monitoring Laboratory Tests 
 
Est GFR 
(ml/min/1.7m2) 
WBC 
(x1000n/uL) 
Platelet 
(x1000n/uL) 
Hct 
(%) 
AST* 
(U/L) 
ALT* 
(U/L) 
Caution 
30-40 
3 - <3.5 
50-75 
<30-27% 
>80 
>112 
Extreme 
< 30 
< 3 
< 50 
< 27% 
>120  
>168  
 
* Local laboratory range. ULN, upper limit of normal. 
 
4.5.2 
Surgery or Infection 
The following guidelines apply for subjects undergoing surgery during the course of the trial: 
 
Emergency surgery 
Temporary stop of study medications during surgery and during the 
post-operative period or until subject is clinically stable and off 
antibiotics 
Planned surgery 
Temporary stop of study medications for at least one week prior to 
surgery and during the post-operative period or until subject is 
clinically stable and off antibiotics. 
 
 
The following guidelines apply for subjects experiencing infection during the course of the trial: 
 
Acute infections 
Hold study medications during the antibiotic course 
Chronic infections 
These subjects would be excluded, except if the chronic infection is 
diagnosed during the trial. If infection is diagnosed during the trial, 
then the risks and benefits of continuing trial treatment would be 
weighed on a case-by-case basis. 
 
 
4.6 Study Procedures 
4.6.1 General Overview 
An overview of the schedule of clinical assessments and study procedures is outlined in Table I and detailed further 
in the MOOP.  Briefly, a complete evaluation of the subject’s RA history and of CV risk factors will be ascertained at 
the Screening and Baseline visits.  Subsequent visits will be conducted every six weeks to assess safety and to 
determine whether a change in medication is indicated.  Medication adherence will also be assessed using subject 
self-report and pill counts. Relevant study procedures and definitions are described below. 
4.6.2 Joint Count  
Assessment of the number of painful and swollen joints by a trained joint count assessor (an investigator or a 
trained research coordinator/nurse) is a standard element of all RA trials and of rheumatology clinical practice.  Each 
of 44 joints (shoulders, elbows, wrists, MCPs, PIPs, hips, knees, ankles, MTPs) will be examined for tenderness 
(subject ‘yes’ or ‘no’) and swelling (metrologist ‘yes’ or ‘no’).  Although 44 joints will be examined, only 28 joints 
(shoulders, elbows, wrists, MCPs, PIPs, knee) are used to define the DAS-28 score (see below) and CDAI and will be 
used to calculate the EULAR ‘good’ response (see below).  The information of all 44 joints is collected, however, 
because of interest in comparing clinically-defined level of joint disease activity vs level of FDG-PET/CT-defined joint 
disease activity.   


31 
4.6.3 RA Disease Activity 
The ‘DAS’ (Disease Activity Measure) is a combined index to assess disease activity in RA117 and is used routinely in 
clinical trials and clinical practice.  It combines information from swollen joints, tender joints, the acute phase 
response (measured either by erythrocyte sedimentation rate or CRP), and general health into one continuous 
measure.  A modification of this measure is the DAS-28 which includes only 28 of the total peripheral joints 
(shoulders, elbows, wrists, MCPs, PIPs and knees) and correlates well with assessments of more joints118.   We will 
calculate the DAS-28-CRP at screening. During follow-up visits we will calculate disease activity using the Clinical 
Disease Activity Index (CDAI)120 to evaluate treatment response. Good treatment response will be determined as 
CDAI ≤ 10, corresponding to low disease activity or remission120. 
4.6.4 CV Risk Factors 
It will be confirmed during the Screening Visit that the subject has no self-reported, physician diagnosed prior clinical 
CV events. These include history of myocardial infarction, angina, stroke, heart failure, prior vascular procedure 
(coronary artery angioplasty or stenting, carotid endarterectomy, coronary artery bypass surgery, peripheral 
revascularization).  In addition, patients with diabetes or fasting blood glucose >126mg/dl or non-fasting blood 
glucose >200mg/dl, and subjects who are currently or within the past 12 months have been treated with high-
intensity statins or PCSK9 inhibitors are excluded. Once a patient is enrolled, the following conventional CV risk 
factors will also be assessed:  1) at each visit - blood pressure, serum glucose; 2) at the Baseline Visit – detailed 
smoking history, subject reported history of hyperlipidemia (if on a high-intensity statin for this, subject would have 
been excluded), physical activity, menopausal state, family history of heart disease, anthropomorphic 
measurements (weight, height, waist and hip circumference).   
4.6.5 Laboratory Procedures 
Screening labs (listed in Table 1) will be either performed at the study visit or abstracted from previous medical 
records if available and performed within the specified timeframe (see Section 3.5.2 Schedule of Study Procedures).  
Follow-up labs for medication safety monitoring will be performed at each visit, unless they are deferred in extreme 
circumstances (i.e. COVID-19 pandemic), in which case site PIs should use clinical judgement for the appropriate 
frequency of safety laboratory testing.  However, this should be no less than every six months and no greater than 
every six weeks.  Additional blood will be drawn for research (biomarker) purposes at the Baseline visit and at Visits 
2, 3, 5 and 6; these will be collected in the fasting state. If samples collected for research are determined to be non-
testable directly after their collection, the subject will be asked to come back in to have the research blood re-drawn 
as close to the original draw date as possible. Subjects must provide verbal consent for the re-draw.   
Usual care safety laboratory measures at each visit are:  complete blood count (CBC), basic metabolic panel (BMP), 
hepatic panel. Sites may choose to perform a comprehensive metabolic panel (CMP) if available, which includes 
both a BMP and LFTs.  
Research laboratory measures.   At the completion of the study, several analytes will be measured in the Harvard 
CTSA lab on batched subject samples from visits 2, 3, 5, and 6. These include rheumatoid factor (RF), anti-cyclic 
citrullinated peptide antibody (anti-CCP), high sensitivity CRP, lipids (total-, LDL-, HDL-cholesterol and triglycerides), 
and insulin and glucose.  The latter two analytes will be used to assess level of insulin resistance. Measurement of 
these values in our research lab will ensure assay consistency across sites and subjects.   
Research Biorepository. Whole blood will be sent directly from Clinical Sites to the BWH Biorepository. Sites that 
have processing capabilities, will processes some blood on site which will be sent frozen to the BWH Biorepository. 
Aliquots of sera and plasma will be processed at the Biorepository from the whole blood and stored for the above 
research laboratory measures and for potential Ancillary Studies.  These samples will be frozen in 1 ml aliquots and 


32 
stored at -80C. Samples frozen at sites will also be stored by the Biorepository for future testing. All biospecimen 
procurement and processing will be overseen by the Biorepository at the BWH Division of Preventive Medicine (see 
Resources) and all aliquots samples will be stored, labeled and inventoried at this facility.  A Laboratory Manual for 
the clinical sites will be prepared to ensure uniform and high quality preparation of the samples for mailing.  The 
Biorepository will perform routine quality control on the freezers to ensure temperature control, back-up power, 
back-up cooled freezers in the event of power outage. The Biorepository will also be responsible for retrieving and 
shipping aliquots to other labs for specific analyte measurement (e.g., to the Harvard CTSA and to Crescendo 
Biosciences). 
4.6.6 FDG PET/CT Scan 
The FDG PET/CT scans will assess arterial FDG uptake in the ascending aorta and in the bilateral carotid arteries.  
Subjects will undergo FDG-PET/CT scans at baseline and between 24 and 36 weeks at their local facility.  A detailed 
protocol prepared by the PIs of the Imaging Core (Drs. Tawakol and Fayad) is available as Appendix B.   The 
procedure is summarized briefly here and is identical for the baseline and the follow-up scans.    Subjects will fast for 
10 hours the night before each of the two PET/CT scans and will abstain from carbohydrates, dairy, and fruit/candy 
at their last meal.  The allowable foods after 5PM are limited to meat/fish/soy, eggs, green vegetables, cheese, 
water/coffee/tea (no milk, sugar).  A serum glucose will be obtained at the imaging site prior to the scan and must 
be <150 mg/dL to proceed; if ≥150 mg/dL but <170 mg/dL, the serum glucose can be repeated in an hour to see if it 
is <150 mg/dL, if still ≥150 mg/dL the scan should be canceled & rescheduled as appropriate; if ≥170 at the initial 
reading, the patient should not be scanned and should be excluded from the study. This screening test may unmask 
undiagnosed diabetes which is an exclusion criterion for TARGET (A persistently elevated glucose indicative of newly 
diagnosed diabetes, coupled with the exclusion from undergoing the PET/CT scan, would make these subjects 
ineligible for the TARGET study). 
If the subject’s glucose is <150 mg/dL, he/she then receives the FDG injection and waits 90 minutes for the FDG to 
distribute through the body. The subject will sit quietly in the imaging waiting room (or other suitable nearby area) 
and limit muscle activity during this time.  The subject will empty their bladder just before the scan is performed. At 
90 minutes post-FDG injection, the CT attenuation correction scan, followed by the PET scan, for the chest is 
performed (Chest CT Scan and Chest PET Scan in the imaging protocol); this is followed by the CT attenuation 
correction and PET scans for the neck (Neck CT Scan and Neck PET Scan); this is followed by the CT attenuation 
correction and PET scans for the joints (Whole Body CT Scan and Whole Body PET Scan). 
Sites will be required to perform a wet read after each FDG-PET/CT scan to look for any incidental findings of 
concern. This should be performed as soon as possible after the completion of the FDG-PET/CT. Sites will be 
required to report that this read took place and will need to report any findings of concern to the coordinating 
center via the EDC. Randomization will not take place until the wet read has been completed and it is confirmed that 
the subject can safely be randomized.  
5. ADVERSE EVENTS  
5.1  Definition of an Adverse Event  
An adverse event (AE) is any untoward or unfavorable medical occurrence in a human subject, including any abnormal 
sign (for example, abnormal physical exam or laboratory finding), symptom, or disease, temporally associated with the 
subject’s participation in the research, whether or not considered related to the subject’s participation in the research. 
5.1 Serious Adverse Event 
A serious adverse event (SAE) is one that meets one or more of the following criteria: 


33 
• 
Results in death 
• 
Is life-threatening (places the subject at immediate risk of death from the event as it occurred) 
• 
Results in inpatient hospitalization or prolongation of existing hospitalization 
• 
Results in a persistent or significant disability or incapacity 
• 
Results in a congenital anomaly or birth defect   
• 
An important medical event that may not result in death, be life threatening, or require hospitalization may be 
considered an SAE when, based upon appropriate medical judgment, the event may jeopardize the subject and 
may require medical or surgical intervention to prevent one of the outcomes listed in this definition. 
5.2 Relationship of an Adverse Event to Study Intervention 
To assess the relationship of an event to study intervention, the following guidelines are used: 
1. Related (Possible, Probable, Definite) 
a. 
The event is known to occur with the study intervention. 
b. 
There is a temporal relationship between the intervention and event onset. 
c. 
The event abates when the intervention is discontinued. 
d. 
The event reappears upon a re-challenge with the intervention. 
2. Not Related (Unlikely, Not Related) 
a. 
There is no temporal relationship between the intervention and event onset. 
b. 
An alternate etiology has been established 
5.4 Severity of an Adverse Event 
The following scale will be used to grade adverse events: 
1. Mild: no intervention required; no impact on activities of daily living (ADL) 
2. Moderate: minimal, local, or non-invasive intervention indicated; moderate impact on ADL 
3. Severe: significant symptoms requiring invasive intervention; subject seeks medical attention, needs major 
assistance with ADL. 
 
5.5 Unanticipated Problems 
The Office for Human Research Protections (OHRP) considers unanticipated problems involving risks to subjects or 
others to include, in general, any incident, experience, or outcome that meets all of the following criteria: 
• 
Unexpected in terms of nature, severity, or frequency given (a) the research procedures that are described 
in the protocol-related documents, such as the IRB-approved research protocol and informed consent 
document; and (b) the characteristics of the subject population being studied; 
• 
Related or possibly related to participation in the research (“possibly related” means there is a reasonable 
possibility that the incident, experience, or outcome may have been caused by the procedures involved in 
the research); and 


34 
• 
Suggests that the research places subjects or others at a greater risk of harm (including physical, 
psychological, economic, or social harm) than was previously known or recognized. 
5.6 Reporting of Adverse Events, Serious Adverse Events, and Unanticipated Problems  
The DCC and Administrative Core will submit to the central IRB all adverse events. All adverse events that are 
unanticipated and related or possibly related to the research will be reported promptly to the BWH IRB.  Sites will be 
responsible for reporting all events to the coordinating center via the EDC. Adverse events that are anticipated or 
unrelated will be reported to the BWH central IRB at the time of continuing review for all sites relying on the Partners 
HealthCare central IRB. Participants that sign a consent form will be considered enrolled until their participation is 
terminated or they withdraw consent. AEs will be reported on all those enrolled.  
All Serious Adverse Events (SAEs) (regardless of expectedness, relatedness, or if they meet the definition for 
unanticipated problems) must be reported to the DSMB Safety Officer, and the NIAMS through KAI within 48 hours of 
the PI receiving notification of the event. The report should include a description of the event, as well as the 
Investigator’s assessment of expectedness, relatedness and other information, as relevant.  Any action taken by the 
investigative team should be provided in the report. The DSMB Safety Officer will be provided with this information but 
will provide an independent assessment on attribution and expectedness, as well as whether further action is 
recommended (e.g. collection of follow up information). 
Anticipated adverse events are specified on the package inserts of all study drugs. Those adverse events that occur, 
which are not specified on the package inserts, will be considered unanticipated problems and will require reporting to 
the coordinating center and the IRB.  
Sites using their local institutional IRBs will submit AE reports to the EDC, but must also report AEs to their own IRB 
according to institutional policies. Sites using the central IRB should adhere to the reporting timelines as follows:  
Reports for unanticipated adverse events are to be submitted within 5 working days/7 calendar days of the date the 
investigator first becomes aware of the problem. Initial reports for SAEs should be submitted within 24 hours of initial 
awareness of the event, with a complete report to follow within 7 calendar days of initial awareness. 
All AEs (anticipated and unanticipated) will be collected, analyzed, and monitored by using the Adverse Event Form 
within the EDC, which will also be used to generate the AE tracking log. AEs and/or extreme ‘value laboratory 
abnormalities identified in the protocol as critical to participant safety must be reported. All AEs experienced by the 
participant from the time of study enrollment through the end of study participation are to be reported. The site staff 
will record all reportable events with start dates occurring any time after informed consent is obtained until 7 (for non-
serious AEs) or 30 days (for SAEs) after the last day of study participation.  At each study visit, the investigator will 
inquire about the occurrence of AE/SAEs since the last visit.  Events will be followed for outcome information until 
resolution or stabilization.  
Some incidental findings are likely to be identified in the PET/CT scans, or at other points throughout the study.  Sites 
will be required to have an on-site radiology interpretation of the scan as soon as possible for safety purposes.  The Site 
PI will be responsible for communicating any incidental findings to the participant’s primary care physician.  If the 
incidental finding is of an immediate nature (a medical emergency that requires immediate notification) such as 
suspected malignancy, notification to the primary care physician should occur within 24 hours of the availability of the 
on-site radiology report; urgent findings (abnormalities that require medical attention but not on an emergency basis) 
should be reported within 7 business days to the primary care physician. The Site PI will also be responsible for following 
up with this physician to determine whether any of the incidental findings will require withdrawal of the participant 
from the study.   Incidental findings will only be recorded as AEs in the data collection system if they are considered to 
be related to study treatment. 


35 
The following delineates specific responsibilities of staff members:  
• 
The Site Research Coordinator will complete the Adverse Event Form (and Unanticipated 
Problems on the corresponding form) in the EDC; assist the PI to notify the IRB and Safety Officer 
of all SAEs, and assist them to prepare SAE reports to IRB and/or the Safety Officer. 
 
• 
The Site Principal Investigator will confirm that all AEs and UPs are correctly entered into the 
EDC by the coordinator; be available to answer any questions that the coordinators may have 
concerning AEs; assist the DCC and Administrative Core to notify the IRB, and/or the DSMB of all 
SAEs and AEs as appropriate. If the originating site is using their institutional IRB, the site will be 
responsible for submitting the adverse event report according to institutional policies, with 
assistance from the DCC and Administrative Core as needed. 
 
• 
The DCC and Administrative Core Staff will confirm that the AEs are correctly entered into the 
EDC. They will confirm that the adverse events are consistent with the source documents and are 
reported to the appropriate regulatory bodies, as required. If the originating site is using the central 
IRB, the DCC and Administrative Core will submit the adverse event report to the central IRB.  
Additionally, the DSMB will receive safety tables every 6 months during the study period that 
include AE and SAE reports. 
 
6. TRAINING AND MONITORING OF SITES 
6.1 Training of Site Investigators and Staff for the Study Protocol 
Site training will be done by Webinar. All sites will be required to complete a set of training modules prior to 
recruitment, on the following topics: Introduction to the Study, Study Protocol, Study Recruitment and Consent, Study 
Drugs, the EDC, Imaging Protocol, Joint Assessments, Labs, Monitoring and Reporting, and Abnormal Situations. All of 
these modules will be delivered as live webinars.  Each webinar will be recorded and available for download from the 
trial website. Study coordinators must attend or view all of the modules.  Site PIs and co-investigators will need to view 
several modules, including: Introduction to the Study, Study Protocol, Monitoring and Reporting, and Abnormal 
Situations. At the webinars, key components of the trial design and implementation will be presented, and site staff will 
have the opportunity to ask questions.  Topics that will be covered include protocol details, recruitment, 
inclusion/exclusion criteria, EDC training and joint count assessment.  Sites will also receive additional individualized 
support while enrolling their first participants in the form of frequent phone calls from Central staff as well as the 
opportunity to complete the first visits while central staff are on the phone to answer any questions. DCC staff will also 
be available for personal site training on the EDC as needed and to answer questions as they arise. 
The investigators and all staff involved in the study will have completed their required Collaborative IRB Training 
Initiative (CITI). Each study staff member will be trained in the protocol and specific procedures for each study visit by 
the study investigators. New study staff members will be trained on the protocol and, if necessary, spend a visit 
shadowing another trained staff member before carrying out protocol tasks on their own.    Prior to conducting subject 
visits, investigators will be asked to sign off that the site staff members have been appropriately trained in the study 
protocol.  
Training and delegation of responsibility will be documented in the Delegation of Responsibility Log and tracked via the 
trial website (where the training modules will be posted). 


36 
6.2 Training for Electronic Data Capture 
One of the key training modules will focus on use of the EDC.  Topics covered will include: 
• 
Appropriate use of credentials to log-in  
• 
EDC security 
• 
Navigating the EDC 
• 
Recording information on the eCRFs 
• 
Screening 
• 
Enrollment and Baseline 
• 
Randomization 
• 
Concomitant Medication 
• 
Follow-up Visits 
• 
Source documentation 
• 
Submitting adverse event reports 
• 
Revising data and audit trails 
 
Additional one-on-one training will be provided to sites on an as-needed basis, as well as guidance for each site to get 
registered on the EDC. 
The EDC also includes an online EDC Manual, which provides information on EDC functions as well as additional 
documentation for the study forms. These will be available to study staff when logged into the EDC system. 
6.3 Training for Joint Count Assessment 
Only sites that already have trained and experienced joint count assessors will be invited to participate.  In the event 
that the joint count assessor has not been trained or a refresher is needed, a video of a standardized joint count 
assessment for swollen and tender joints will be made available to the sites. 
6.4 Imaging Core Training 
To ensure consistency in scan acquisitions across all imaging centers, a primary technologist will be appropriately trained 
by Imaging Core (in the imaging protocol also called the Icahn School of Medicine-Massachusetts General Hospital 
ISMMS-MGH Imaging core (IMIC)) on all relevant aspects of this study prior to scanning study subjects. The site Imaging 
Centers are also encouraged to identify a back-up technologist who will undergo the same training. The Imaging Core 
will require PET/CT Technologists to participate in training via webinar prior to the initiation of the study. All study 
coordinators will be required to complete a training module about the imaging that will provide important information 
they will need to convey to the patient about scan day. Additional Investigators Site personnel will also be invited and 
are encouraged to attend the training session. 
Training will be held via online webinar.  The Imaging Core will provide login information prior to all training sessions.  
Additionally, each Site Imaging Center will be required to submit image sets of standardized PET/CT phantoms prior to 
approval for imaging.  Initial phantom data will undergo a preliminary quality control (QC) review by the imaging core 
team to ensure that images transferred are in proper format, that both PET and CT series are present, and the images 
appear to be of acceptable quality.  This will ensure correct application of training principles. 
A protocol for the FDG PET/CT is provided in Appendix B. 
6.5 Monitoring of Sites 
Monitoring will occur throughout the study period. Internal reports will be generated regularly to identify missed visits, 
missing data, and other data clarifications.  Additionally, automatic queries will be programmed into the EDC to identify 


37 
missing data at the time of visits entry and out of range values. Reports examining consistency of responses of time will 
also be generated and clarification requested as necessary. Virtual monitoring will also occur throughout the study. Core 
staff will periodically request that a site provide additional documentation and regulatory files. This documentation will 
be mailed, or faxed by the site and reviewed at the Coordinating Center. 
The DCC will be able to track a site’s progress via the EDC. Should a site consistently deviate from the protocol or not 
perform to a sufficient level, the DCC will recommend intervention by the Administrative Core.  The Administrative Core 
will investigate the source of the deviations, and will provide additional training or coaching as needed, as well as decide 
to drop an enrollment site if necessary.  While existing enrollment sites may be dropped for substandard performance, 
new enrollment sites may be added during the course of the study.  Many of the investigator trainings will be recorded, 
and the Administrative Core will facilitate support for one-on-one site trainings as needed. 
6.5.1 
Clinical Sites 
Use of the EDC will enable frequent monitoring of study sites to ensure protocol adherence. The DCC will have 
immediate access to all data that is entered on the EDC, and will be alerted to any issues, including the ones listed 
below: 
• 
Non-compliance with protocol 
• 
Missing data 
• 
Out-of-range data 
• 
Out-of-window visits 
• 
Data clarification  
• 
Consistent and logical dates over time  
• 
All fields of a "completed form" actually completed or reason for no data noted 
• 
All required forms completed or reason for no data noted 
• 
Data consistent across forms and visits 
 
The DCC will provide regular protocol adherence and data monitoring reports to the Administrative Core, and the 
Administrative Core will pursue corrective action from sites as needed.  As well, the EDC will be developed in such a 
way that sites will be alerted to correct out of range values or missing data as they are entering it, thereby reducing 
the occurrence of data and protocol violations. 
6.5.2 
Imaging Sites 
In addition to the initial quality check of phantom images used to train and certify imaging sites, the imaging core 
has a well developed and successful protocol for monitoring image quality.  Details are provided in the imaging 
protocol (Appendix B).  Briefly, upon receipt of PET/CT images to the Imaging Core within 1 day of image acquisition 
(via FTP transfer), a Clinical Research Associate (CRA) confirms image set completeness and proper 
labeling/anonymizaton.  Quality control (QC) is performed to verify that the image acquisition guidelines were 
followed.  If the CRA identifies an artifact that could impair the ability to interpret images, the Site Imaging Center is 
notified of actions that need to be taken.   The Site is required to resolve the query and/or send the 


38 
missing/discrepant information to the Imaging Core within two business days.  Once resolved, an Acceptance 
Notification is issued.  Any deviation from the protocol, or change in parameters, must be pre-approved by the 
Imaging Core in advance and noted on the Image Record Forms. 
 
The FDG PET/CT and image reader case report forms (CRF) will be used to assess adherence to the imaging protocol.  
These data include:  a) tracer circulation time; b) intra-subject difference in circulation time (between scans); c) 
fasting blood glucose; d) injected minus residual FDG activity; e) scanner used; f) arm position; g) reconstruction 
method; h) time per bed position; i) acquisition mode; j) slice thickness.   
 
Image Quality will be graded as excellent, marginal, and unacceptable. Data analysis will be performed first on data 
derived from excellent quality scan only, then excellent and marginal quality scans combined. 
7. STUDY OBJECTIVES AND STATISTICAL ANALYSIS PLAN 
7.1 Primary and Secondary Objectives 
The primary objective is to compare the effects on vascular inflammation of TNFi + MTX ± HCQ versus triple therapy in 
subjects with RA who are inadequate responders to MTX using FDG-PET/CT as a tool for detecting vascular (arterial) 
inflammation. 
The secondary objective is to compare the effects on vascular inflammation of achieving low disease activity or 
remission (LDAR) versus moderate-high disease activity (MHDA). 
The exploratory objective of the TARGET Bioethics Ancillary study is to gather data on researchers’ attitudes and beliefs 
regarding incidental findings and the prevalence of incidental findings from whole body FDG PET/CT in RA.  
 
The exploratory objective of the Neuroimaging Measures Ancillary Study is to investigate associations between stress-
associated neurobiological activity and articular and arterial treatment response in RA.   
7.2 Study Hypothesis 
The primary aim of the Treatments Against RA and Effect on FDG PET/CT (TARGET) trial is to test whether treatment 
with a TNF inhibitor (TNFi) in addition to methotrexate (MTX) with or without concomitant HCQ (only for subjects 
entering the study on concomitant HCQ) among RA subjects who are inadequate responders to MTX reduces 
cardiovascular inflammation compared to triple therapy (MTX+SSZ+HCQ) as measured by the mean of the maximum 
target-to-background ratio (TBR) of FDG uptake at the 6 month follow-up for the most diseased segment (MDS) 
identified at baseline. 
The primary hypothesis is that TNFi +MTX + HCQ (only for subjects entering the study on concomitant HCQ) will 
reduce vascular inflammation to a greater extent than triple therapy when measured at 6 months. 
 
Additional planned analyses in the second aim test whether the follow-up value in cardiovascular inflammation is 
correlated with measures of disease progression. The markers of disease progression include: 1) disease activity as 
measured by the DAS28-CRP score, with achievement of low disease activity or remission considered to be a DAS28-CRP 
score of less than 3.2 at the 6-month follow-up (all participants enter the trial with a DAS28 above 3.2); 2) a 
commercially available MBDA (Vectra-DA) which will be measured at baseline and 6 months; and 3) joint inflammation 
defined as the average standardized uptake value (by FDG PET/CT) in the same joints used in the calculation of the DAS-
28,  and measured at baseline and 6 months using the images collected for the primary endpoint as described in the 
Imaging Section. 


39 
The secondary hypotheses are as follows: 
• 
We hypothesize that subjects in DAS-28 defined LDAR at 6 months will have less vascular inflammation than 
those with persistent MHDA. 
• 
We hypothesize that subjects in Vectra DA-defined LDAR at 6 months will have less vascular inflammation than 
those with persistent MHDA.   
• 
We hypothesize that subjects in articular FDG defined LDAR at 6 months will have less vascular inflammation 
than those with persistent MHDA.  We will also compare the correlations of the articular FDG uptake and DAS-
28 with vascular inflammation to determine if they are independent. 
• 
We hypothesize that the exploratory objective of the TARGET Bioethics Ancillary study will help develop clear 
policies and procedures for reporting and managing incidental findings in imaging research, refine the informed 
consent process and standardize reporting, evaluation, and follow up of incidental imaging findings. 
• 
We hypothesize that the higher levels of stress-associated neurobological activity, measured objectively as 
rAmygA, associate with a blunted response to RA immunomodulatory treatment in the joints and 
vasculature as assessed with measures of articular response (i.e. patient self-assessment and change 
in joint counts) and objectively with change in articular and arterial FDG uptake.   
• 
We hypothesize that the link between stress and blunted response will be reflected in enhanced hematopoietic 
tissue activity in the bone marrow, and in circulating inflammatory biomarkers. 
 
7.3 Study Design 
TARGET is a randomized, open-label, multi-center trial.  Eligible participants will be randomly allocated, 1:1, to TNFi + 
MTX + HCQ (only for subjects entering the study on concomitant HCQ) or triple therapy. Baseline imaging will be done at 
the time of randomization and subjects will be followed for 6 months, at which time the follow-up imaging will be done. 
TARGET Investigators will be surveyed via a REDCap link regarding their attitudes and beliefs surrounding the return of 
incidental findings from whole body PET/CT scans..  
7.4 Number of Subjects 
We plan to randomize 200 participants to achieve an effective sample size of 170 people with complete follow-up and 
measurements of both the baseline and 6-month MDS TBRmax. We estimate over 90% power to detect a difference of 
0.15 in 6-month MDS meanmax TBR between the two arms, even allowing for a 10% dropout rate.  A between group 
difference of 0.15 also corresponds to the expected observed effect if the between group difference were 0.17 and 
there was a 10% crossover rate. 
Sample size and power were calculated using several alternative scenarios for dropout rates and cross over.  All cross 
over was assumed to be from the triple therapy arm into the TNFi arm and these participants would be included in the 
main intention-to-treat analysis set under their assigned treatment group. Drop outs consist of participants for whom 
imaging results were unavailable at the baseline or 6-month timepoint. These participants would be unable to 
contribute to the analysis and would directly reduce the sample size available. Previous data in the RA population found 
a baseline MDS meanmax TBR of 2.51 (SD of 0.33) and a 0.46 reduction after 8 weeks of a TNFi (correlation of 0.5 
between baseline and 8 weeks).  
The method that we intend to use for our primary analysis is an ANCOVA model estimating the final index vessel MDS 
meanmax TBR as a function of baseline index vessel MDS meanmax TBR and treatment group. The resulting treatment 
group coefficient will then estimate the change in MDS meanmax TBR associated with treatment assignment after 
adjusting for baseline differences.  
Power for the ANCOVA analysis was calculated using the sampsi function in Stata. This function uses the method laid out 


40 
by Frison and Pocock in Statistics in Medicine in 1992. We performed the power calculations using a correlation between 
the baseline and final MDS TBR meanmax of conservative correlation estimates of 0.4 and 0.3 and have included the 
results in the Tables 4A and 4B below.  
 
TABLE 4a: Power Calculation for Aim 1 for Correlation of 0.4 (ANCOVA adjusting for 
baseline)  
 
 
Dropout Rate 
Between group difference 
0% (N=200) 
5% (N=190) 
10% (N=180) 
0.17 
98% 
97% 
96% 
0.16 (5% crossover into TNFi) 
96% 
95% 
94% 
0.15 (10% crossover into TNFi) 
94% 
93% 
91% 
TABLE 4b: Power Calculation for Aim 1 for Correlation of 0.3 (ANCOVA adjusting for 
baseline)  
 
 
Dropout Rate 
Between group difference 
0% (N=200) 
5% (N=190) 
10% (N=180) 
0.17 
97% 
96% 
95% 
0.16 (5% crossover into TNFi) 
95% 
94% 
93% 
0.15 (10% crossover into TNFi) 
92% 
91% 
89% 
 
Power for the secondary aims 
The secondary aim compares 6-month MDS meanmax TBR by LDAR achievement. The primary analysis will use ANCOVA 
to adjust for baseline MDS meanmax TBR as well as other baseline characteristics related to LDAR achievement (age, 
gender, disease duration, smoking status, serologic status) and treatment assignment.  Assuming 30% reaching LDAR in 
both groups111-113, and the parameters of MDS meanmax TBR from Aim 1, we use a t-test of 6-month MDS meanmax TBR 
as a conservative power estimate. The proposed trial will have 90% power to detect an absolute difference between 
those reaching LDAR and those not of 0.18 in MDS meanmax TBR with a dropout rate of up to 10%; this would be 
clinically significant based on the aforementioned statin study52. 
 
TABLE 5: POWER CALCULATION FOR AIM 2 
 
Dropout Rate 


41 
Between group difference 
0% (N=200) 
5% (N=190) 
10% (N=180) 
0.18 
94% 
93% 
92% 
0.17 
91% 
90% 
88% 
0.16  
88% 
86% 
84% 
 
7.5 Analysis Sets 
The primary analysis for efficacy will be defined as all randomized subjects with complete imaging results at baseline and 
6 months, according to their randomized treatment assignment. Safety analyses will be done using all subjects entering 
the study, according to the treatment received. Per-protocol analyses will also be done for participants who remained 
on their randomized treatment assignment for the duration of follow-up. 
7.6 Safety Analysis  
All participating subjects will be included in safety analyses, regardless of their completion of the imaging studies. The 
two arms of the trial both use standard of care treatments, so serious unanticipated adverse events are unlikely.  
Reports of adverse events by randomized treatment assignment and actual treatment will be generated for the DSMB at 
regular intervals of approximately 6 months.  We will also present frequency analyses for withdrawals and compliance 
with protocol. 
7.7 Analysis Methods 
Aim 1: 
The main analysis for Aim 1 will use ANCOVA to compare the 6-month arterial MDS meanmax TBR between assigned 
treatment groups, adjusting for baseline values and statin initiation, with a null hypothesis of no association between 
treatment assignment and 6-month MDS meanmax TBR. A p-value threshold of 0.05 for a two-sided test will be used to 
determine statistical significance.  Additional analyses will explore secondary imaging measures including meanmax 
overall TBR.  We will also repeat the main analysis in the subgroup per-protocol compliance.  Other important subgroups 
will also be analyzed within assigned treatment groups using an interaction term, including achievement of LDAR, 
serologic status, known CV risk factors, and excluding statin initiators.  
The primary analysis will be based on assigned treatment group, only including participants with imaging data at 
baseline and 6-month follow-up. A sensitivity analysis for the impact of any missing data will also be done using the 
same assigned treatment categories, but using all randomized participants with [multiple imputations using a Markov 
chain Monte Carlo technique119. We anticipate few missing data because: 1) adequate staff (2 Research Assistants) in the 
Administrative Core will closely monitor weekly data entry; 2) 24-week trial allows for detection of significant 
differences in vascular FDG PET/CT but will reduce drop-out that may occur in a longer trial; 3) recruitment of 
experienced sites with site coordinators; 4) providing transportation reimbursement to subjects whenever necessary; 
and 5) providing reminder mailing cards to sites to send to subjects.  2 secondary analyses were added based on 
reviewers’ comments: excluding subjects who escalated dosing; and, in an exploratory secondary analysis, we will 
compare the 6-month MDS meanmax TBR between adalimumab and etanercept users. 
 


42 
Sample Size: Power to detect alternate absolute differences in 
6 month MDS 
meanmax TBR is presented in Figure 2 for a study with 100 
participants in 
each arm (200 total randomized target).  Previous data in RA 
pts found a 
baseline MDS meanmaxTBR of 2.51 (SD of 0.33) and a 0.46 
reduction 
after 8 weeks of a TNFi62. Using a t-test to compare MDS 
meanmax TBR 
in the two arms at 6-months generates a conservative power 
estimate. 
With an effective sample size of 170 (200-30; 15% drop-out or 
cross-over), 
the proposed trial has a 90% power to detect an absolute 
difference of 
0.17 between the 2 arms.  This difference corresponds to the 
effect 
observed in the prior study by Maki-Petaja for TNFi’s62.  It 
would be a 
clinically important difference, on the same order for what 
was observed 
between a low-dose statin and a high-dose statin52, a contrast 
with known 
clinical significance53. [Power will be sufficient for secondary endpoints.  The pre-specified secondary analysis focusing 
on approximately 75% of subjects remain on the original drug dosages will include an estimated 64 subjects per arm and 
will have 90% power to detect a difference of 0.19 in MDS meanmax TBR.  Since these are pre-specified secondary 
endpoints, p-values will not be adjusted.] 
Aim 2a: 
This aim compares 6-month MDS meanmax TBR by LDAR achievement. The primary analysis will use ANCOVA to adjust 
for baseline MDS meanmax TBR as well as other baseline characteristics related to LDAR achievement (age, gender, 
disease duration, smoking status, serologic status) and treatment assignment.  Using a conservative estimate of 30% 
reaching LDAR in both groups111-113, and an effective sample size of 170, we ran a t-test of 6-month MDS meanmax TBR 
as a conservative power estimate. The proposed trial will have 90% power to detect an absolute difference between 
those reaching LDAR and those not of 0.19 in MDS meanmax TBR; this difference would be clinically significant based on 
the aforementioned statin study52. 
Aims 2b and 2c: These exploratory aims will examine the relationship between the Vectra-DA and articular FDG uptake 
(respectively), and 6-month change in arterial MDS meanmax TBR. The analytic strategies will be very similar to Aim 2a.  
Relationships between Vectra-DA disease activity categories and articular FDG PET/CT disease activity and 6-month 
change in MDS meanmax TBR will be analyzed similar to Aim 2a.  The statistical power for Aims 2b and 2c will be very 
similar to Aim 2a.  Exploratory analyses will examine: 1) alternative thresholds for disease activity using the Vectra-DA 
and articular FDG PET/CT; 2) using the Vectra-DA and articular FDG PET/CT as continuous measures; and 3) including the 
Vectra-DA and articular FDG PET/CT continuous measures as covariates in the ANCOVA conducted for Aim 2a. 
7.8 Data Management 
7.8.1 
Clinical Data 
Most study forms will be completed using an EDC system that is managed by the DCC.  The EDC system is a web-
based software application where all study data from sites will be recorded, managed, and stored.  Data will be 
collected by site study staff and, where possible, entered directly into the electronic case report forms (eCRFs) 
housed on the EDC.  When data are first recorded through the EDC, the EDC record shall serve as the source 
document.  The eCRFs will replace traditional paper CRFs, and should be used to capture data for all enrolled 
subjects. This model has been used in other trials and has resulted in low rates of data errors and protocol 
violations, and rapid resolution of problems. The EDC will be hosted and maintained by StudyTRAX (ScienceTRAX, 
Macon, GA).  In addition to security procedures including encryption, prevention of data corruption and multiple 
secure backups, the EDC will be FDA regulation 21 CFR part 11 and HIPAA compliant. 
Figure 2: Statistical power  estimate


43 
 
Once recorded in the EDC, the data is immediately accessible by the DCC for review, verification, data queries, and 
to be locked when appropriate.  Review of the data will allow the DCC to monitor protocol adherence and ensure 
clean data, as well as addressing problems in this regard as they arise.  The EDC will also be instrumental in 
generating reports, including recruitment progress, status of follow-up visits, and adverse event tracking. Automatic 
and manual data checks will be performed routinely. 
 
Whenever original observations and data are first collected and entered directly into the EDC system, the electronic 
record is the source document.  The EDC system will serve as source documentation for most forms in this protocol.  
However, if a visit is performed using paper forms and those papers are used to later enter data into the EDC, the 
paper forms will be the source documentation and must be kept for records. We will not permit the substitution of 
the EDC with paper forms. We will allow sites to keep notes and then enter information within 72 hours into the 
EDC. 
 
Prior to any subject enrollment, each site will receive training and guidance from the DCC to be active on the EDC.  
As a web-based application, the EDC system will be accessible through any computer or device with internet access 
and a non-mobile web browser.  No downloads or installations are necessary to access the EDC.  Each member of 
the study staff who interacts with the EDC to collect or verify data will be issued a unique username and password, 
and staff will log-in using those credentials any time data is entered or modified.  In this way, the EDC will track 
changes and create an audit trail for each piece of data.  The Delegation of Responsibility Log will be maintained 
through the EDC, and it will be used to designate roles and access for each study staff member. 
 
All study records will be retained for seven years (or longer if required by local IRBs). 
 
7.8.2 
Imaging Data  
Imaging data will be managed by the Imaging Core.  Imaging data will be transferred to the Imaging Core over a 
secure FTP server.  All images will be assigned a unique ID number and are anonymized at the Site Imaging Centers.  
Details are provided in the Imaging Protocol (Appendix B). 
7.9 Handling of Missing Data 
The primary analysis will be based on assigned treatment group and will only include participants with imaging data at 
baseline and the 6-month follow-up. A sensitivity analysis for the impact of any missing data will also be done using the 
same assigned treatment categories, but using all randomized participants with all missing baseline values set to the trial 
average and all missing change values set to zero (or no change).  We anticipate few missing data because: 1) adequate 
staff (2 Research Assistants) in the Administrative Core will closely monitor weekly data entry ; 2) 24-week trial allows 
for detection of significant differences in vascular FDG PET/CT but will reduce drop-out that may occur in a longer trial; 
3) recruitment of experienced sites with site coordinators; 4) providing transportation reimbursement to subjects 
whenever necessary; and 5) providing reminder mailing cards to sites to send to subjects. 
 
7.10 Bioethics Ancillary 
We will survey the TARGET investigators to determine researchers' attitudes and beliefs regarding their ethical 
obligation to return and manage incidental research findings from whole body PET/CT imaging studies and determine 
the prevalence of incidental research findings on whole body FDG PET/CT imaging in rheumatoid arthritis (RA) and 
detection rate of previously unknown malignancies. There is a lack of information available on researchers’ attitudes 


44 
and beliefs regarding incidental research findings and the prevalence of incidental research findings from state of the art 
imaging studies, such as whole body FDG PET/CT in those without known malignancy, and to our knowledge, no such 
information available in rheumatology. The Treatments Against RA and Effect on FDG PET/CT (TARGET) study provides 
an unprecedented and unique opportunity to examine the ethics around incidental findings from whole body FDG 
PET/CT in RA patients without known malignancy. Gathering data on researchers’ attitudes and beliefs regarding 
incidental findings and the prevalence of incidental findings from state of the art imaging studies will help develop clear 
policies and procedures for reporting and managing incidental findings in imaging research, refine the informed consent 
process and standardize reporting, evaluation, and follow up of incidental imaging findings. 
7.11 Neuroimaging Measures Ancillary Study 
PET/CT Brain image analysis, is performed while blinded to subject data and temporal identifiers, using a dedicated 
workstation that enables multi-modal standard image fusion (Leonardo–TrueD, Siemens Solutions). The amygdala is 
localized on the CT images using anatomic landmarks, as described previously11218F-FDG uptake in amygdala was 
determined by placing a circular region of interest (ROI) in the defined structure bilaterally, and mean and maximum tracer 
accumulation were recorded as standardized uptake value (SUV) for each ROI. Amygdalar activity is corrected for brain 
background activity, using cerebral (temporal lobe). The primary analysis for the study was the average of the mean right 
and left amygdalar SUVs divided by the cerebral background.  
PET/CT Bone marrow and splenic activities, are measured according to previously validated methods127. Bone marrow 
18F-FDG uptake was determined by placing ROIs in axial sections of individual vertebrae from T1 to L5. The maximum SUV 
was recorded for each vertebra, and bone marrow activity was calculated as the average of the registered SUVmax of all 
measured vertebrae. Splenic 18F-FDG uptake was determined by placing a ROI in each of axial, sagittal, and coronal 
sections. The SUVmax was recorded for each section, and splenic activity was calculated as the average of the three 
registered SUVmax values. 
8. REGULATORY CONSIDERATIONS 
8.1 Informed Consent 
Site investigators are responsible for obtaining informed consent before any subject may participate in the TARGET trial.  
Informed consent requires adequate explanation of the aims, methods, anticipated benefits, and potential hazards of 
the study.  No protocol-specific screening procedures or any study medications will be prescribed prior to obtaining 
informed consent.   Acquisition of informed consent will be documented in the subject’s medical records and the 
informed consent form should be signed and personally dated by the subject as well as by the person who conducted 
the informed consent discussion.   The signed consent form will be retained according to institutional policy.  A copy of 
the signed consent form will be provided to the subject.  Ancillary studies that require study procedures additional to 
the parent TARGET Trial will require separate consent forms.  The subject may withdraw consent to participate in the 
study at any time. For the bioethics survey, the completion of the survey will serve as the consent for the TARGET 
investigators who participate. 
8.2 Data and Safety Monitoring Board 
A Data and Safety Monitoring Board (DSMB) will be appointed by the NIH to monitor and evaluate safety and scientific 
issues related to the study.  We anticipate that its membership will include: a biostatistician; a cardiologist with trial 
experience; 1-2 rheumatologists with trial experience; and a bioethicist.  Persons outside of CUMC and BWH and who 
have no conflict of interest with the TARGET Study will be chosen to assure independence.  The DSMB will meet before 
the study starts and every 6 months thereafter; additional ad hoc sessions can be convened in the event of more urgent 
issues.  The DSMB will compile and approve a written charter.  The NIH Project Officer will attend the DSMB meetings 
and will receive copies of all reports. The biostatistician will be the DSMB Executive Secretary and one member, 


45 
designated by NIAMS, will serve as DSMB chair. Topics to be discussed at DSMB meetings are recruitment, adverse 
events, and consideration of protocol modifications to assure safety.   DSMB members will be blinded to treatment 
assignment when monitoring safety data, unless an event necessitating un-blinding occurs.  These blinded (and if 
necessary unblinded) reports will be provided to them quarterly by the DCC.  
In addition to participant safety, the DSMB will also be charged with data monitoring.  For this, the DSMB must: ensure 
data integrity and confidentiality, assist NIAMS by commenting on any problems with study conduct or enrollment, 
sample size, statistics, and/or data collection; and review and evaluate requests for protocol modifications after the trial 
begins. 
8.3 Institutional Review Board 
The study will be conducted at each site under the monitoring of a local or central Institutional Review Board (IRB) 
(depending on the individual sites capabilities).  Partners HealthCare IRB at Brigham and Women’s Hospital has been 
selected as the central IRB and will oversee IRB responsibilities.  This protocol has been approved by them.   
Each Site PI will be responsible for submitting the clinical trial protocol, the Informed Consent form, any advertisements, 
and all other relevant study related documents to their local IRB for approval. For sites using the trial’s central IRB, these 
documents will be submitted through the Administrative Core. Documentation of each site’s IRB approval must be 
provided to the Administrative Core before study enrollment can commence.  All unanticipated problems, as well as 
protocol deviations and violations, that occur during the conduct of the trial will be reported by the Site PIs to their 
respective IRBs and to the TARGET Administrative Core.  A full list of all adverse events (most of them will not be 
unanticipated) will be submitted regularly to the DSMB and the responsible IRBs.  The IRB must approve all protocol 
changes prior to implementation unless emergency action is clinically indicated.  Site PIs will be responsible for 
preparing annual reports to the IRB (or more frequently if required locally) and a final report upon study completion. 
Support for the Sites for these IRB functions will be provided by the Executive Committee. 
8.4 Pre-Study Documentation Requirements 
Before a site not relying on the central IRB can begin enrolling, the Administrative Core must receive the following 
documents: 
• 
Copy of stamped IRB approved consent form 
• 
Copy of the IRB approval letter for the protocol and consent form. 
• 
CV of the PI and co-investigators 
• 
Signed and dated protocol signature page 
 
Before a site that is relying on the central IRB can begin enrollment approval must be granted from the BWH central IRB 
for the addition of the site. 
 
 
 
 
 
 


46 
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Barrett LF, Bliss-Moreau E, Duncan SL, Rauch SL and Wright CI. The amygdala and the experience of affect. Social 
cognitive and affective neuroscience. 2007;2:73-83.  
111.     Fox AS, Oler JA, Shelton SE, Nanda SA, Davidson RJ, Roseboom PH and Kalin NH. Central amygdala nucleus (Ce) 
gene expression linked to increased trait-like Ce metabolism and anxious temperament in young primates. Proc 
Natl Acad Sci U S A. 2012;109:18108-13. 
112.     Tawakol A, Ishai A, Takx RA, Figueroa AL, Ali A, Kaiser Y, Truong QA, Solomon CJ, Calcagno C, Mani V, Tang CY, 
Mulder WJ, Murrough JW, Hoffmann U, Nahrendorf M, Shin LM, Fayad ZA and Pitman RK. Relation between 
resting amygdalar activity and cardiovascular events: a longitudinal and cohort study. Lancet. 2017;389:834-845. 
113.     Bremner JD, Vermetten E, Schmahl C, Vaccarino V, Vythilingam M, Afzal N, Grillon C and Charney DS. Positron 
emission tomographic imaging of neural correlates of a fear acquisition and extinction paradigm in women with 
childhood sexual-abuse-related post-traumatic stress disorder. Psychological medicine. 2005;35:791-806. 
114.     Herrmann M, Scholmerich J and Straub RH. Stress and rheumatic diseases. Rheum Dis Clin North Am. 
2000;26:737-63, viii. 
115.     Overman CL, Bossema ER, van Middendorp H, Wijngaards-de Meij L, Verstappen SM, Bulder M, Jacobs JW, 
Bijlsma JW and Geenen R. The prospective association between psychological distress and disease activity in 
rheumatoid arthritis: a multilevel regression analysis. Ann Rheum Dis. 2012;71:192-7. 
116.     Liao KP, Giles JT, Weissman J, et al. Recommendations for a Treat to Target algorithm to reduce cardiovascular 
risk in rheumatoid arthritis. Submitted. 2014:25. 
117van Vollenhoven RF, Ernestam S, Geborek P, et al. Addition of infliximab compared with addition of sulfasalazine and 
hydroxychloroquine to methotrexate in patients with early rheumatoid arthritis (Swefot trial): 1-year results of a 
randomised trial. Lancet. 2009;374(9688):459-466. 
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Moreland LW, O'Dell JR, Paulus HE, et al. A randomized comparative effectiveness study of oral triple therapy 
versus etanercept plus methotrexate in early aggressive rheumatoid arthritis: the treatment of Early Aggressive 
Rheumatoid Arthritis Trial. Arthritis and rheumatism. 2012;64(9):2824-2835. 
119. 
O'Dell JR, Mikuls TR, Taylor TH, et al. Therapies for active rheumatoid arthritis after methotrexate failure. The 
New England journal of medicine. 2013;369(4):307-318. 
120. 
Tawakol A, Fayad ZA, Mogg R, et al. High Dose Statin Results in a Further Reduction in Atherosclerotic 
Inflammation Compared with Low Dose Statin: Results of a Multi-Center PET-CT Study. Circulation. 
2011;124:A18242. 
121. 
Marmor MF, Kellner U, Lai TY, Lyons JS, Mieler WF. Revised recommendations on screening for chloroquine and 
hydroxychloroquine retinopathy. Ophthalmology. 2011;118(2):415-422. 
122. 
van Gestel AM, Prevoo ML, van 't Hof MA, van Rijswijk MH, van de Putte LB, van Riel PL. Development and 
validation of the European League Against Rheumatism response criteria for rheumatoid arthritis. Comparison 
with the preliminary American College of Rheumatology and the World Health Organization/International 
League Against Rheumatism Criteria. Arthritis and rheumatism. 1996;39(1):34-40. 
123. 
Prevoo ML, van 't Hof MA, Kuper HH, van Leeuwen MA, van de Putte LB, van Riel PL. Modified disease activity 
scores that include twenty-eight-joint counts. Development and validation in a prospective longitudinal study of 
patients with rheumatoid arthritis. Arthritis and rheumatism. 1995;38(1):44-48. 


52 
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van Gestel AM, Haagsma CJ, van Riel PL. Validation of rheumatoid arthritis improvement criteria that include 
simplified joint counts. Arthritis and rheumatism. 1998;41(10):1845-1850. 
125. 
Horton NJ, Kleinman KP. Much ado about nothing: A comparison of missing data methods and software to fit 
incomplete data regression models. The American statistician. 2007;61(1):79-90. 
126. 
Aletaha D, Smolen J. The Simplified Disease Activity Index (SDAI) and the Clinical Disease Activity Index (CDAI): a  
               review of their usefulness and validity in rheumatoid arthritis. Clin Exp Rheumatol. 2005 Sep-Oct;23(5 Suppl39): 
               S100-8. Review. PubMed PMID: 16273793. 
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               humans. JACC Cardiovascular imaging. 2015;8:121-30. 
   
 
 
 


53 
APPENDIX B: 
Imaging Protocol 
 
 


- 54 - 
 
Imaging Protocol 
 
Treatments Against RA and Effect on FDG PET-CT: The 
TARGET Trial 
 
 
 
Imaging Core Principal Investigators: 
 
Ahmed Tawakol, MD (Co-I) 
 
Zahi Fayad, PhD (Co-I) 
 
Principal Investigators: 
 
Joan M Bathon, MD (PD/PI) 
 
Daniel H Solomon, MD, MPH (PD/PI) 
 
 
Version Number:  6.0 
 
 4 December 2017 
 


- 55 - 
 
 
 
ATTESTATION PAGE 
Protocol v6.0, 4 December 2017 
 
The below signature of the physician overseeing the imaging at the TARGET Trial Imaging Site attests that 
this imaging protocol has been reviewed and that the imaging site is in agreement with the TARGET Trial 
Radiation Safety Monitoring Plan (see Appendix D). 
 
Imaging Site: _____________________________________________________________________ 
Imaging for TARGET Clinical Site: _____________________________________________________ 
Physician Overseeing TARGET Trial Imaging or Radiation Safety Officer (print name): 
________________________________________________________________________________ 
Email: _______________________________Phone #: ___________________________________ 
  
I attest that I have reviewed the TARGET Trial Imaging Protocol and agree to the TARGET Trial Radiation 
Safety Monitoring Plan. I understand that a safety read for incidental findings will determine TARGET 
eligibility and that I will provide a safety read for incidental findings within 72 hours to the clinical site 
involved in the TARGET trial.  
 
Signature: ______________________________________ 
 
Date: __________________________________________ 
 
 


- 56 - 
 
Table of Contents 
1. IMAGING 
PROTOCOL………………………………………………………………………………………………
………… ..................................................................................................................5 
1.0 IMAGE ACQUISITION GUIDELINES, PRE-IMAGING PREPARATION, 18FDG-PET/CT
................................................................................................................................ 6 
1.1 CHEST PET/CT ........................................................................................... 8 
1.2 NECK PET/CT ............................................................................................. 10 
1.3 JOINTS PET/CT .......................................................................................... 12 
1.4 IMAGE ACQUISITION GUIDELINES, POST-IMAGING .............................. 14 
1.5 SAFETY READ FOR INCIDENTAL FINDINGS ........................................... 15 
1.6 RESCANNING GUIDELINES ...................................................................... 15 
 
2. SITE TRAINING, IMAGE QUALIFICATION AND IMAGE SUBMISSION GUIDELINES 15 
2.0 INTRODUCTION .................................................................................................... 15 
2.1 STUDY DESIGN .......................................................................................... 16 
2.2 DEFINITIONS .............................................................................................. 16 
2.3 SITE QUALIFICATION PROCEDURES ...................................................... 16 
2.3.a SITE CONTACT INFORMATION ....................................................................16 
2.3.b IMAGING SURVEYS ......................................................................................16 
2.3.c SITE INITIATION TRACKING .........................................................................16 
2.3.d SITE RADIATION SAFETY OFFICER/COMMITTEE ATTESTATION ..................17 
2.4 STUDY IMAGING BINDER .......................................................................... 17 
2.5 OPERATIONS SUMMARY .......................................................................... 17 
2.5.a PET/CT PHANTOM IMAGE DATA TRANSFER ...............................................17 
2.5.b IMAGING TRAINING ....................................................................................18 
2.5.c IMAGING AND DATA COLLECTION ..............................................................19 
2.5.d DATA AND IMAGE QUALITY EVALUATION ..................................................21 
2.5.e RADIATION DOSE MONITORING .................................................................22 
2.6 sFTP DATA TRANSFER INSTRUCTIONS .................................................. 22 
 
ATTACHMENT A: DIETARY INSTRUCTIONS FOR SUBJECTS ......................................................... 26 


57 
 
ISMMS-MGH Imaging Core Charter 
 
1. Imaging protocol  
 
ISMMS-MGH Imaging core (ICL) has developed the following acquisition guidelines for standardization 
of the study imaging components across imaging centers participating in the TARGET trial. Provided 
here are image acquisition guidelines for 18-FDG-PET/CT imaging of vascular inflammation. The 
protocol provides a guide for participating centers and acknowledges that variations in the technical 
abilities of the scanners used may introduce minor variations in the settings used for this study.  
 
Regularly scheduled imaging for this study should be acquired in strict adherence to these guidelines. 
Please ensure the blinding of all confidential subject/site information on all images. Only combination 
PET/CT scanners should be used to acquire data for this study. Please notify ICL immediately of any 
changes (including upgrades) to the PET/CT scanner hardware or software. 
 
The table below shows the schedule for the imaging timepoints for evaluating vascular 
inflammation: 
 
 
Baseline Visit 
Followup Visit 
 
 
 
 
Modalities 
 
18FDG-PET/CT 
18FDG-PET/CT 
 
 
 
 
Anatomy 
of interest 
Chest (aorta) 
CT Scan & PET Scan 
CT Scan & PET Scan 
Neck  (carotids) 
CT Scan & PET Scan 
CT Scan & PET Scan 
Peripheral joints 
CT Scan & PET Scan 
CT Scan & PET Scan 
 
Protocol Overview 
 
Scan 
Coverage 
Positioning 
Minutes    
per scan 
Scan 1 (Chest) 
Shoulders to diaphragm 
Arms up 
Approx 
12.5 
Scan 2 (Neck) 
Top of eyes to sternal notch 
Arms down 
Approx 
2.5 
Scan 3 (Joints) 
Above shoulders to toes 
Arms down 
Approx  
28 
  
Time between scans  
Approx 7 
  
Total Time 
Approx 
60 
 
 


58 
 
 
 
 
1.0   IMAGE ACQUISITION GUIDELINES, PRE-IMAGING PREPARATION, 18FDG-PET/CT 
 
• 
All subjects need to adhere to an induction phase low-carbohydrate diet (see Attachment A: 
Dietary Instructions for Subjects), especially for their dinner meal preceding the FDG-PET scan.  
o The clinical site will provide the subject with this information.  
• 
Subjects should be encouraged to drink plenty of water while fasting. 
 
 
Instructions 
Morning Imaging 
Subjects being imaged in the morning must have fasted for at least 10 
hours the previous night. 
Afternoon Imaging 
Subjects being imaged in the afternoon must have fasted for at least 10 
hours the previous night but may have a breakfast from the recommended 
menu and then fast for at least 4 hours prior to the 18FDG injection. 
~5 minutes prior to IV injection of 
18FDG 
A blood glucose (BG) measurement (mg/dl) will be taken*:   
• if BG<150: proceed with imaging 
• if BG>150 but ≤ 170: reschedule or may repeat BG within 1 
hr to see if it comes down to <150 
i.if BG is still >150, patient should not be scanned and 
should be excluded from the study – site 
coordinator should contact TARGET Central 
• if BG>170: patient should not be scanned and should be 
excluded from the study – site coordinator should contact 
TARGET Central 
 
*Glucose measurements should be made using a CLIA approved, CLIA cleared, or equivalent glucose 
measurement technique. 
 
 
 
 
 
 
 
 
 
 
 
 
 


59 
 
 
• 
Synchronize clocks 
o Ensure clocks used to record times for the study procedures on the imaging day are 
synchronized with the scanner and dose calibrator clocks. 
 
• 
Obtain Subject height and weight 
o Record subject height (without shoes) at first visit 
o Weigh subject (without shoes, jackets or sweaters) and record weight at each visit. 
 
• 
All pre-imaging steps should be followed:  
1. Obtain IV access  
 
2. Check fasting blood glucose (mg/dl) 
• if glucose<150: proceed with imaging 
• if glucose 150-170: reschedule or may repeat BG within 1 hr to see if it comes down to 
<150 
i.if glucose still >150: patient should not be scanned and should be excluded from 
the study 
• if BG>170: patient should not be scanned and should be excluded from the study – site 
coordinator should contact TARGET Central 
 
3. Draw 10 mCi  of 18FDG and assay with a dose calibrator.   
a. Record on the Image Record Form (IRF): 
i. Assay time to the nearest minute 
ii.  Initial 18FDG dose (in mCi) to the nearest tenth. 
 
4. Inject the 18FDG through the subject’s IV line.  Record this time to the nearest minute. 
 
5. Flush the syringe and line with approx 20cc of normal saline. 
 
6. Repeat assay of syringe and measure residual activity within syringe. 
 
7. Record 18FDG injected dose (initial-residual activity) to the nearest tenth of mCi.  
 
• 
Target circulation time is 90 minutes 
o Shortly before bringing the subject to the scanner, have the subject use the restroom to 
empty the bladder. 
o Subject should be placed in the PET/CT scanner approximately 10 minutes before 
imaging should commence. Ask the subject to remain reclining or supine in a quiet, 
room temperature area. 
o The subject may watch television but should limit muscle activity (advise against 
reading, conversing, chewing, etc.). 
o Place warm blanket on subject to reduce brown fat activation. 
o Scanning should commence 90 minutes after injection 
Important: 
For subsequent PET/CT visits, make sure to repeat the following parameters: 
• 
Same FDG dose (± 5%) 


60 
 
• 
Same FDG circulation time (± 10 minutes) 
• 
Same time of imaging (time of day ± 60 minutes) 
• 
For the 2nd Scan (Visit 6), CT Parameters will depend on BMI at the initial imaging visit - 
Acquisition will not change based on a subject gaining or losing a few pounds. 
 
 
1.1 PET/CT Chest  
 
Chest – CT Scan 
 
Subject Orientation:  
• 
Arms UP, Supine position. 
• 
Use the sagittal laser and the subject’s nipples as a landmark to 
ensure that there is no rotation of the chest to either side. 
• 
Velcro straps and/or tape may also be used to maintain subject 
positioning.   
• 
Mid-breath breath hold or quiet breathing 
Scan Locations/Coverage: 
• 
Entire chest 
o The superior landmark: top of shoulders 
o Inferior landmark: base of the diaphragm  
Pitch 
variable, dependent on scanner type. 
Tube voltage 
120 kVp 
Tube current 
Use auto mA for chest acquisition: 
 
Goal of 40 or 45 mAS depending on BMI:  
• 
For BMI<30 kg/m2: 40 mAS 
• 
For BMI>30 kg/m2: 45 mAS 
 
*Note:  
➢ For Siemens and Philips cameras, set reference mAS to goal 
mAS above. 
➢ For GE cameras, set maximum and minimum to +5% and -5%, 
respectively, to goal mAS above 
 
IMPORTANT: In the event that a patient has hardware such as a pacemaker, 
do not use auto mA. Instead, set goal effective mAS to 40. 
 
Replicate tube current used for subsequent scans. 
Scan FOV  
Large  
Display FOV 
Unique to subject size  
Slice Thickness (collimation) 
3mm 


61 
 
Reconstruction Interval / 
Increment (distance between 
adjacent slice locations) 
3mm 
Gap (slice spacing) 
None (i.e. contiguous) 
 
 
 


62 
 
Chest – PET Scan 
 
Subject Orientation:  
 
• 
Same as Chest CT Scan 
Scan Locations/Coverage: 
 
• 
Entire chest 
o The superior landmark: top of shoulders 
o Inferior landmark: base of the diaphragm 
Data Acquisition Mode 
• 
3D  
Scan FOV  
Large  
Display FOV 
Unique to subject size  
Slice Thickness (collimation) 
3 mm 
Matrix Size 
128 X 128, plus 256 X 256 (or in some cases, another matrix size that is 
optimized for your scanner type. If 256 X 256 matrix size is not available, 
please consult with the Imaging Core)  
Scan time 
5 min per bed position 
 
Gap (slice spacing) 
None (i.e. contiguous) 
Reconstruction  
• 
Use your standard OSEM construction for your scanner and ensure 
SAME RECONSTRUCTION PROTOCOL IS USED EACH TIME 
• 
Attenuation-correct all images 
• 
Correct all projection data for non-uniformity of detector responses, 
dead time, random coincidences, and scattered radiation. 
• 
In plane resolution should be better than 5mm FWHM. 
 
 
 
 
 
 
 


63 
 
1.2 PET/CT Neck 
 
Neck – CT Scan 
Subject Orientation:  
• 
Supine position 
• 
Arms down fully extended with palms resting on anterior thighs, 
with minimal/no flexion of the elbows.  
• 
With the subject in the supine position, place the neck in a neck 
holder.  Keep the neck straight and be sure that it is not extended or 
flexed.   
• 
Use the axial laser across the orbital meatal line to ensure that there 
is no rotation of the head to either side. 
• 
Velcro straps and/or tape may also be used to maintain subject 
positioning.   
Scan Locations/Coverage: 
• 
Entire neck  
o The superior landmark: Top of the eyes 
o Inferior landmark: sternal notch  
Pitch 
variable, dependent on scanner type. 
Tube voltage 
120 kVp 
Tube current 
Use auto mA for neck acquisition: 
 
Goal of 40 or 45 mAS depending on BMI:  
• 
For BMI<30 kg/m2: 40 mAS 
• 
For BMI>30 kg/m2: 45 mAS 
 
*Note:  
➢ For Siemens and Philips cameras, set reference mAS to goal 
mAS above. 
➢ For GE cameras, set maximum and minimum to +5% and -5%, 
respectively, to goal mAS above 
 
IMPORTANT: In the event that a patient has hardware such as a pacemaker, 
do not use auto mA. Instead, set goal effective mAS to 40. 
 
• 
Replicate tube current used for subsequent scans. 
Scan FOV  
Large  
Display FOV 
Unique to subject size  
Slice Thickness (collimation) 
3mm 
Reconstruction Interval / 
Increment (distance between 
adjacent slice locations) 
3mm 


64 
 
Gap (slice spacing) 
None (i.e. contiguous) 
 
 
 


65 
 
 
Neck – PET Scan 
 
Subject Orientation:  
 
• 
Same as Neck CT Scan 
Scan Locations/Coverage: 
 
o Entire neck  
o The superior landmark: Top of the eyes 
o Inferior landmark: sternal notch 
Data Acquisition Mode 
• 
3D  
Scan FOV  
Large  
Display FOV 
Unique to subject size  
Slice Thickness (collimation) 
3 mm 
Matrix Size 
128 X 128, plus 256 X 256 (or in some cases, another matrix size that is 
optimized for your scanner type. If 256 X 256 matrix size is not available, 
please consult with the Imaging Core)  
Scan time 
5 min per bed position 
Gap (slice spacing) 
None (i.e. contiguous) 
Reconstruction  
• 
Use your standard OSEM construction for your scanner and ensure 
SAME RECONSTRUCTION PROTOCOL IS USED EACH TIME 
• 
Attenuation-correct all images 
• 
Correct all projection data for non-uniformity of detector responses, 
dead time, random coincidences, and scattered radiation. 
• 
In plane resolution should be better than 5mm FWHM. 
 


66 
 
1.3 Joints PET/CT  
CT Scan – Joints: above shoulders to toes 
Subject Orientation:  
• 
Supine position 
• 
Arms down, fully extended with palms resting on anterior thighs, 
with minimal/no flexion of the elbows. Please see pictures below. 
• 
Large restraint (immobilizer, usually with Velcro straps) across the 
forearms including elbows and hands. 
• 
Use the sagittal laser and the subject’s nipples as a landmark to 
ensure that there is no rotation of the chest to either side. 
• 
Quiet breathing 
• 
Another large restraint across the knees. Feet to be positioned 
adjacent to each other (pigeon toe), wrapped with a sheet and 
covered with paper tape. 
• 
Subjects should also remove rings and other accessories on hands 
and feet. 
Scan Locations/Coverage: 
• 
From ~4cm above shoulders to toes  
Pitch 
variable, dependent on scanner type. 
Tube voltage 
120 kVp 
Tube current 
• 
Use fixed mA of 40 mAs 
• 
Goal: effective mAs = 40  
o Effective mAs = Average mA * Rotation Time/Pitch 
o Exact parameters will vary by scanner manufacturer and 
model, adjust Auto mA settings accordingly to achieve our 
goal 
• 
Use fixed mA for subsequent scans. 
Scan FOV  
Large  
Display FOV 
Unique to subject size  
Slice Thickness (collimation) 
4mm 
Reconstruction Interval / 
Increment (distance between 
adjacent slice locations) 
4mm 
Gap (slice spacing) 
None (i.e. contiguous) 


67 
 
Positioning Images for PET/CT of Joints: 
Pigeon Toe Position of 
Feet, Covered with 
Sheet & Paper Tape 


68 
 
 PET Scan – Joints: above shoulders to toes 
 
Subject Orientation:  
 
• 
Same as Joints CT Scan 
Scan Locations/Coverage: 
• 
From ~4cm above the shoulders to the toes 
Data Acquisition Mode 
• 
3D  
Scan FOV  
Large  
Display FOV 
Unique to subject size  
Slice Thickness (collimation) 
4 mm 
Matrix Size 
128 X 128, plus 256 X 256 (or in some cases, another matrix size that is 
optimized for your scanner type. If 256 X 256 matrix size is not available, 
please consult with the Imaging Core)  
Scan time 
 
• 
Scan time per bed position is determined by the subject size: 
o 2 .0 min  per bed position for BMI<30 kg/m2  
o 2.5  min  per bed position for BMI>30 kg/m2 (but may 
depend on scanner type) 
Replicate scan time per bed position for subsequent scans. 
Gap (slice spacing) 
None (i.e. contiguous) 
Reconstruction  
• 
Use your standard OSEM construction for your scanner and ensure 
SAME RECONSTRUCTION PROTOCOL IS USED EACH TIME 
• 
Attenuation-correct all images 
• 
Correct all projection data for non-uniformity of detector responses, 
dead time, random coincidences, and scattered radiation. 
• 
In plane resolution should be better than 5mm FWHM. 
 
 
 
 
 
 
 
 
 
1.4   IMAGE ACQUISITION GUIDELINES, POST-IMAGING  


69 
 
 
• 
Remove the subject from the scanner and encourage him/her to use the bathroom and empty 
the bladder.   
• 
The subject should be instructed to drink fluids and void frequently throughout the remainder 
of the day. 
 
 
 
 
1.5 safety read for incidental findings 
A safety read for incidental findings in the whole body scan is to be conducted by a local radiologist 
within 72 hours of image acquisition and the report submitted to the clinical investigative site 
immediately thereafter. Local radiologists should look for findings that might be of clinical significance 
that should be shared with the site investigator – e.g., increased focal uptake of tracer that may 
Digital Image Transfer only:  
o 
The images must be contiguous (no gaps).  
o 
Images should be in DICOM format  
o 
All images must be in an uncompressed format. 
o 
Transfer:  
1) attenuation corrected PET data reconstructed with 128X128 Matrix, (neck, chest, and joints) plus 256 X 256 (or in 
some cases, another matrix size that is optimized for your scanner type. If 256 X 256 matrix size is not available, please 
consult with the Imaging Core) 
2) non-corrected PET data, reconstructed with 128X128 Matrix, (neck, chest, and joints) plus 256 X 256 (or in some 
cases, another matrix size that is optimized for your scanner type. If 256 X 256 matrix size is not available, please 
consult with the Imaging Core) 
3) CT-AC scans, (neck, chest, and joints) 
4) Dose report 
• 
Images  (including raw/original data) should remain digitally archived at the site throughout the entirety of the 
clinical trial.  
• 
Retain raw data on the scanner until confirmation of acceptable data has been received  
• 
Keep a source disc (CD or DVD) containing images  at the clinical site 
• 
Prepare images for transfer to imaging core lab 
• 
See ‘Image Submission Guidelines’ for further instructions 


70 
 
represent infectious, immune or malignant processes, or any other pattern of uptake that may cause 
clinical concern. The report should be provided to the clinical site involved in the TARGET Trial within 72 
hours, as any incidental findings may impact TARGET eligibility. 
1.6 Rescanning Guidelines 
Occasionally, the quality of the scans will be inadequate to provide quantitative data and consideration 
will be given to re-scanning. The Imaging Core will ALWAYS determine the need for a repeat scan; the 
decision to repeat a scan should never be determined by the local imaging site. See Section 2.5.d. for 
more information about quality assessment.  
• 
Baseline Visit: The only time that a repeat scan may be requested by the Imaging Core 
is if both vascular scans (neck and chest) at the Baseline visit are inadequate to provide 
quantitative data.  This determination will be made by the Imaging Core within 48 hours 
of submission of the scan, and a request for a repeat scan(s) will be made by the 
Imaging Core to the local imaging site.  If a patient had a repeat scan(s) at the Baseline 
visit, the following protocol must be followed at the Month 6 follow-up scan session: 
o No whole body scan will be performed 
o Only one vascular (neck or chest) scan will be performed.  The scan type will 
be determined by the Imaging Core.  Only the vascular scan that provided 
adequate (or higher quality) quantitative data at the Baseline visit will be 
performed at Month 6 visit.  The local imaging site will be informed by the 
Imaging Core, in advance of the patient’s appointment, as to which scan (neck or 
chest) to perform.  
 
• 
Month 6 Visit:  In patients who had a technically adequate Baseline Scan (1 Neck, 1 
Chest, and 1 Whole Body acquisition) but had a technically inadequate Month 6 vascular 
scan (either chest or neck), as determined by the Imaging Core, a repeat scan may be 
requested.  In this case repeat scanning will be requested of either the neck, the chest, 
or both.  As above, the whole body scan should never be repeated at this visit, 
regardless of quality. 
 
2. Site training, Image Qualification and Image Submission Guidelines  
2.0   Introduction 
This Site Qualification and Image Submission Guidelines document is provided by the Icahn School of 
Medicine- Massachusetts General Hospital Imaging Core Laboratory for the TARGET Trial (ICL).  It is 
intended for Imaging Centers participating in TARGET and is designed to provide detailed information 
regarding the process for qualifying an Investigator Site for participation in the imaging component of 
TARGET and all of the accompanying start-up procedures.   
Items such as imaging training, image submission, query response and resolution, and study design will 
be covered in these guidelines.  These guidelines will used as a supplement to regular procedures already 
in place at qualifying sites. For details regarding the imaging protocols, please refer to Image Acquisition 
Guidelines (also provided).  


71 
 
Each site must be qualified before submitting study exams as this process ensures that sites are capable 
of following study protocol.  Careful and well-documented training of all staff is also required before 
imaging may begin at the clinical site. Details regarding Site Qualification are discussed in Section 2.3. 
2.1  Study Design 
The objective of this Imaging Study is to determine vascular inflammation in subjects by implementing 
18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (FDG-PET/CT) imaging, 
to subjects participating in this trial. 
2.2. 
  Definitions 
Imaging Core Lab (ICL): A collaboration between  the Icahn School of Medicine and Massachusetts General 
Hospital Imaging Core Laboratories : Centralized coordination facility for all procedures associated with 
PET/CT image acquisition, processing and review. The facility is responsible for receiving, tracking, and 
archiving PET/CT images that are associated with this study.  The Imaging Core Lab also performs quality 
control (QC) checks on all PET/CT examinations and related documentation received. PET/CT images are 
checked for consistency, completeness and protocol compliance.  
 
Investigator Sites: The institutions responsible for enrolling clinical study subjects and obtaining clinical 
data associated with study subjects. The Investigator Site is also responsible for managing imaging 
scheduling and for preparing and forwarding images acquired to the ICL, as per protocol. In addition, they 
are responsible to ensure responses to any queries generated. 
 
Imaging Centers:  These centers are generally either a physical part of the main Investigator Site, or 
function as a satellite site, and are responsible for acquiring images associated with clinical study subjects. 
PET/CT images will be obtained according to the study protocol and the study Image Acquisition 
Guidelines provided.   
2.3  Site Qualification Procedures 
2.3.a.  Site Contact Information 
Investigator Sites will provide ICL with a list of contact information for study staff (Principal 
Investigator and Study Coordinator). This listing will be sent on a weekly basis during start-up phase, 
and on an as-needed basis thereafter.  
2.3.b.  Imaging Surveys 
ICL will be responsible for distributing Imaging Surveys. Imaging surveys collect contact information 
from the technologists at the Imaging Centers and identify the types of scanners, scanning 
capabilities, and data transfer capabilities available at the sites.  Instructions regarding the 
completion of the imaging survey will be sent by ICL to the primary contact at each imaging center.  
 
ICL will download reports from the online survey system on a weekly basis. All completed records of 
site contact information and Imaging Surveys will be filed in a site folder on the study-specific Master 
Study File.  Imaging Survey responses will be reviewed on weekly basis by a Clinical Research Associate 
(CRA) for completeness and compatibility with the core lab systems. If any information is missing or 


72 
 
incorrect, the CRA will follow up with the Investigator Site to resolve the issue. Any issues regarding 
the site’s equipment or abilities to comply with the imaging protocol will be raised by ICL to the 
Investigator Site. 
2.3.c.  Site Initiation Tracking 
The core lab CRA will create a study-specific Site Qualification Spreadsheet, stored on an electronic 
file to track the status of all qualification steps for each Imaging Center participating in the study.  
Upon completion of each of the tasks described in this section, the spreadsheet will be updated to 
show the dates that sites completed each step in site initiation. The Imaging Center name and contact 
information provided by Sponsor will also be entered into the spreadsheet, along with the clinical site 
PI(s) associated with each Imaging Center. 
2.3.d.  Site Radiation Safety Officer/Committee Attestation 
The Radiation Safety Officer or Commitee at each imaging site must sign the attestion form at the 
beginning of this protocol to state that they have reviewed this Imaging Protocol and that they 
agree with the Radiation Safety Monitoring Plan.  This must be completed before trial imaging 
commences. 
 
2.4  Study Imaging Binder 
The ICL will provide the imaging centers with forms to be kept in a Study Imaging Binder at their site for 
PET/CT imaging. Please note that the ICL will not be providing a physical binder. These forms should be 
kept at the imaging site. Below is a description of these materials: 
• 
The Image Acquisition Guidelines (IAG) are generated by the ICL in an effort to standardize the 
imaging associated with the clinical trial. The standardized guidelines are distributed to each Imaging 
Facility and details the imaging protocol.  
 
• 
The PET Adjunctive Data Forms (ADFs) is to be completed and signed by the person submitting 
images.  Complete ADFs can be transmitted via email at the time images are submitted. 
 
• 
The Image Delivery Receipt is an automatically generated e-mail sent from the ICL sFTP site notifying 
the sender that delivery of images was successful. The delivery receipt lists the item downloaded, the 
download date and time, recipient, and transferred file size. An example of a delivery receipt is 
included in the Sample Forms tab of the Study Imaging Binder.  The binder also includes a tab for 
storage of Image Delivery Receipts that are received for subjects participating in the trial. 
 
• 
The Case Acceptance Notification (CAN) is sent from ICL to the primary contacts at the Investigator 
Site and Imaging Center.  This form serves to inform the study staff that the entire PET/CT image set 
and IRF for a subject have been received and checked for completeness and acceptable quality by the 
ICL staff. A sample of the CAN is provided in the Study Imaging Binder.  The binder also includes a tab 
for storage of CANs that are received for subjects participating in the trial. 
 


73 
 
• 
The Case Query Notification (CQN) is sent from ICL to the primary point of contact at the Investigator 
Site and the Imaging Center within 2 business days of receipt of an unacceptable/incomplete PET/CT 
dataset.  The form is sent via e-mail and will describe the query and indicate the action(s) required to 
be taken towards submission resolution of the issue described. A sample of the CQN is provided in 
the Study Imaging Binder.  The binder also includes a tab for storage of CQNs that are received for 
subjects participating in the trial. 
2.5  Operations Summary 
The following is an overview of operational activities relating to the trial.  This section describes the 
activities at the Investigator Sites and the ICL, which includes review by an independent, central reader. 
 
For all image transfers, ICL sFTP System will be used. A log-in and password to this system will be provided 
to the primary contact at each imaging center, generally a lead technologist, unless an alternate point of 
contact is designated by the site.  Detailed instructions on submitting data via the sFTP system can be 
found in Section 2.6 of this document. 
2.5.a.   PET/CT Phantom Image Data Transfer 
Each Imaging Center will be required to submit image sets of standardized PET/CT phantoms prior to 
approval for imaging.  An American College of Radiology (ACR) phantom produced during the most 
recent quarterly assessment performed at the Imaging Center would suffice. 
 
Initial phantom data will undergo a preliminary quality control (QC) review by the imaging CRA to 
ensure that images transferred are in proper format, that both PET and CT series are present, and the 
images appear to be of acceptable quality. Initial phantom datasets will then be forwarded from the 
Osirix workstation to the Reader workstation for quantitative analysis. ICL CRA will e-mail the reader 
that the data has been sent and is available for review.  The reader will reply via e-mail within 3 
business days with the results of quantitative analysis of the phantom data.  Results of the review 
should be in binary form: either positive (pass) or negative (fail). Additional recommendations on how 
to achieve auto mA based on your scanner may be provided after submission of the phantom images. 
Failure to meet any of the criteria above, or a negative review by the reader, will result in a query to 
the site. If the initial phantom dataset received from a site is determined by the Reader to not be of 
acceptable quality, ICL will request a rescan of phantom data and note the parameters described in 
the Image Acquisition Guidelines that should be adjusted to optimize the quality. The date of query 
sent and reason for query are tracked in RIS and are associated to the specific phantom data timepoint 
from which they originated.  In cases where queries are necessary, the CRA will NOT archive the study 
to ICL PACS and instead select “No Image” when prompted to link to a dataset PACS.  After tracking is 
complete, the RIS record can be closed. 
Upon determination that the dataset is acceptable, data will be archived to ICL PACS and associated 
with the corresponding timepoint record in RIS.  
The study-specific site qualification spreadsheet is updated to indicate the date of receipt of phantom 
data transfer. 


74 
 
Once an imaging center has been approved, all subsequently received quarterly phantom data will 
undergo QC by the imaging CRA only.  Subsequent phantom images are permitted to be done under 
the normal quality assurance (QA) procedures and protocols in place at the Imaging Center.  
Processing of these phantom scans will follow the procedures described in this section.  Subsequent 
phantom datasets from sites can be entered under the same subject in RIS as an additional timepoint.   
2.5.b.   Imaging Training 
To ensure consistency in scan acquisitions across all imaging centers, a primary technologist will be 
appropriately trained by ICL on all relevant aspects of this study prior to scanning study subjects. The 
participating Imaging Center is also encouraged to identify a back-up technologist who will undergo 
the same training. ICL will require PET/CT Technologists to participate in an online video training prior 
to the onset of the study. Additional Site personnel will also be invited and are encouraged, to attend 
the training session. 
 
Training will include reading the Imaging Protocol, watching a training video, and attending a Question 
& Answer teleconference with personnel from your assigned Imaging Core Lab (Mount Sinai or MGH).  
ICL will provide login information prior to all training sessions. 
 
 
 
 
 
 
 
2.5.c.   Imaging and Data Collection 
The figure below summarizes the expectations of the Investigator Site and/or Imaging Center in 
support of the imaging component of the trial. Following the figure are detailed instructions for 
imaging data collection. 


75 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1. The Investigator Site will refer subjects to the Imaging Center for PET/CT imaging exams.  All 
imaging exams must be conducted by trained Technologists in accordance with the Image 
Acquisition Guidelines. 
 
2. The Investigator Site, or a designee in the Imaging Center, will initiate PET Adjunctive Data Forms 
(ADFs) for each subject to be imaged. The ADFs are to be completed and signed by the person 
submitting images.  ADFs can be transmitted via fax or email to ICL (contact details will be 
provided). 
 
3. Images must be anonymized prior to submission to ICL according to the following guidelines: 
 
i. 
Subject Name replaced with Study ID (Site (xx digit) – Subject (xx digit)) 
ii. 
Year of birth should remain, if permitted by local regulation, and serve as a key identifier 
for the record 
iii. 
Date of Scan must be included on the image 
iv. 
Medical Record number replaced with a 7-digit standard code of zeros (e.g. 0000000) 
v. 
Any other protected health information (PHI) removed from any additional fields  
 
4. The complete and anonymized PET/CT images will be sent to ICL via secure File Transfer Protocol 
(sFTP).  See Section 2.6: sFTP Data Transfer Instructions for details regarding submission of 
images. All images must be submitted in DICOM format. Images should be sent on the day of 
acquisition, or within 2 business days should it not be possible to send on same day.  If it is not 
possible to transfer the images within that time frame and/or if there are any technical difficulties 
in transferring images, please alert ICL via e-mail or phone.    
 
Specifically, invitations will be sent to imaging sites allowing external users to utilize a web 
browser to submit data to the ICL FTP site.  The data is received at ICL, after which the data is sent 


76 
 
to a RIS/PACS (Radiological Information System/Picture Archiving and Communication System).  
This technical infrastructure is displayed in the graphic below. 
 
SITES
sFTP server
QA/QC
Workstation
PACS
Archive
Reader
Workstation
Reader
Workstation
Reader
Workstation
MGH CVIC
OFF-SITE REPLICATION
(within MGH firewall)
PACS
Archive
RIS
 
5. After PET/CT images are received at ICL, a Clinical Research Associate (CRA) will confirm image set 
completeness and proper labeling/anonymization of images.  Subject and timepoint information 
will be verified on the Image Record Form. A quality control (QC) will be performed to verify that 
the Image Acquisition Guidelines were followed. If the imaging associate finds an artifact that 
could impair the ability to interpret images, the nature of the artifact will be discussed with ICL 
medical staff before being escalated to external study personnel.  
 
6. ICL will notify the Investigator Site and Imaging Centers of the results of the QC of each image set 
submitted in the form of either a Case Acceptance or a Case Query Notification. 
 
7. The Case Acceptance Notification informs the Study Coordinator and Imaging Center that PET/CT 
imaging for the timepoint is complete and of acceptable quality.  Any deviation from the 
guidelines should be discussed with ICL in advance.  Any change in parameters must be pre-
approved and noted on the Image Record Forms.  
 
8. If a Case Query Notification is issued, the notification will indicate actions that need to be taken 
by the Imaging Center. The site is required to resolve the query and/or send the 
missing/discrepant information to ICL within 2 business days. This short turnaround time is 
necessary due to the time-sensitive nature of some imaging visits.  If resolution of the query 
cannot be completed, the site will be required to notify ICL (via email) within the two-business 
day time frame. This notification must include a definitive date for query resolution.   
ICL 


77 
 
 
Once the query has been resolved, a Case Acceptance Notification will be issued to notify the 
Investigator Site and Imaging Center that the images are now complete and of acceptable quality. 
 
9. Flow of subject information from clinical sites and corresponding images is shown in the figure 
below.    
 
 
 


78 
 
2.5.d   Data and Image Quality Evaluation 
(A) Data quality will include evaluation of CRF data as well as image quality. CRF data will be used to 
assess adherence to the protocol. Data evaluated to assess adherence to the imaging protocol will 
include: i) tracer circulation time (ii) intra-subject difference in circulation time (between scans) (iii) 
fasting blood glucose (iv) injected minus residual activity, iv) scanner used, v) arm position, vi) 
reconstruction method, vii) time per bed position, viii) acquisition mode, ix) slice thickness as well as 
other characteristics provided in the CRF. 
 (B) Image Quality Images will be graded as: 1 (Excellent), 2 (Marginal), and 3 (Unacceptable) in each 
of the three vessel beds. An example of a marginal image set is one where it was deemed difficult to 
derive measurements, whereby some confidence in the measured values is lost. An example of an 
unacceptable image set is one where image quality precludes measuring the image (e.g. excess 
motion, artifact, spill-over). Data analysis will be performed first on data derived from Excellent quality 
scans only, then Excellent and Marginal quality scans combined. 
2.5.e   Radiation Dose Monitoring 
Radiation exposure for each subject will be monitored by the imaging core lab, the IRB, and the 
DSMB. Please see Appendix D: Radiation Safety Monitoring Plan (RSMP) for more details. 
 
2.6  sFTP Data Transfer Instructions 
The copy of data for submission can be transferred to ICL over a secure FTP server. The steps for 
transferring the data via secure FTP are different depending on your Core Lab assignment (Mount Sinai or 
MGH): 
For Sites Assigned to the Mount Sinai Core Lab: 
1) All DICOM Images should be copied into single folder. Set the folder name as the patient 
ID. 
2) Zip or compress the patient data folder. 
3) Type https://tmii.brickftp.com into a browser window. 


79 
 
 
4) Log in using your site-specific username and password (will be provided to you by ICL). 
 
 
 
 
 
5) Click on the “Upload Files” button. 


80 
 
 
 
6) Select the compressed or zipped patient data folder and click “Open”. 
 
 
 
 


81 
 
7) The zipped patient data folder will be visible in the browser once the data has been 
uploaded. 
 


82 
 
For Sites Assigned to the MGH Core Lab: 
1. Create a folder on your desktop  
2. Copy DICOM data from CD into the desktop folder  
3. Right click folder > Send To > Compressed (zipped) folder  
4. Log in to the system : 
https://transfer.partners.org/courier/web/1000@/wmLogin.html  
5. Select Send File tab  
6. Enter < mitc@partners.org > into the To field  
7. Select Choose File > browse for the zipped file on your desktop  
8. Add any notes pertaining to the scan or assessment (optional)  
9. Select notification preferences from the Additional Options field (optional)  
10. Click Send  
11. Click OK after receiving confirmation that the files have been sent  
 
 


83 
 
ATTACHMENT A.   DIETARY INSTRUCTIONS FOR SUBJECTS 
 
• 
It is essential that the subjects follow a low-carbohydrate diet starting with the evening meal 
or 5 pm (whichever comes first) on the evening before imaging, and that they refrain from 
exercise for 24 hours prior to imaging. 
 
After 5:00pm on the day before the imaging study: 
Eat and drink ONLY the food listed below: 
o 
Meat 
o 
Fish 
o 
Eggs 
o 
Green Vegetables 
o 
Soy 
o 
Cheese (small amounts) 
o 
Water (no soda, fruit juice, or alcoholic beverages) 
o 
Coffee or tea (as long as no milk or sugar is added) 
 
Be careful to avoid the food listed below: 
o 
Fruit 
o 
Bread (including muffins, crackers, and pastries) 
o 
Cereal 
o 
Pasta 
o 
Rice 
o 
Potatoes, Carrots, and Corn 
o 
Salad Dressing with added sugar or sweetener 
o 
Candy 
o 
Milk and yogurt 
 
 
 
 
 
 
 
 
 
 
 
When in doubt, check 
the nutrition label!
Keep this number as low as possible. 
On the day of the imaging study: 
• 
No carbohydrates (bread, cereal, milk, juice, coffee with cream, etc). Water or 
coffee/tea (without sugar or milk) is ok. 
• 
Morning Imaging:  Subjects being imaged in the morning must have fasted for at least 
10 hours the previous night.   
• 
Afternoon Imaging: Subjects being imaged in the afternoon must have fasted for at 
least 10 hours the previous night but may have a breakfast from the recommended 
menu above and then fast for at least 4 hours prior to imaging appointment. 
• 
Diabetics are permitted to take their medications on the morning of the imaging.  
 

SAP_001.pdf: 
1 
 
Study Title: Treatments Against RA and Effect on FDG-PET/CT (TARGET) Trial 
Document Name: Statistical Analysis Plan, v14 
Date: May 8, 2021 
ClinicalTrials.gov Identifier: NCT02374021 
 
 
 
 


2 
 
Glossary of Abbreviations 
MTX
Methotrexate
SSZ 
Sulfasalazine 
HCQ
Hydroxychloroquine
TNFi 
TNF inhibitor 
RA
Rheumatoid arthritis
MHDA 
Moderate or high disease activity 
LDAR
Low disease activity or remission
FDG PET/CT
FDG positron emission tomography/computed tomography
DMARD 
Disease modifying anti-rheumatic drug 
MTX-IR
Methotrexate inadequate responder
ROI 
Region of interest 
SUV
Standardized uptake value
TBR 
Total to background ratio 
MDS
Most diseased segment
ANCOVA
Analysis of covariance
SQ 
Subcutaneous 
TJC
Tender joint count
SJC 
Swollen joint count 
PtG
Patient global arthritis activity
CRP 
C-reactive protein 
BMI
Body mass index
 
 
I. AIMS 
 
Aim 1. To compare the effects on vascular inflammation of TNFi + MTX versus triple therapy 
[MTX+SSZ+HCQ] in patients with RA who are inadequate responders to MTX monotherapy.  We 
hypothesize that TNFi +MTX will reduce vascular inflammation to a greater extent than triple therapy when 
measured at 6 months.   
 
Aim 2. To compare the effects on vascular inflammation of achieving low disease activity or remission 
(LDAR) vs remaining in moderate-high disease activity (MHDA).  These pre-specified secondary analyses 
will pool the treatment arms to examine whether achievement of a disease activity target is associated with 
greater reduction in vascular inflammation.  
2a. To use the Disease Activity Score-CRP-28 (DAS-28-CRP1) to categorize treatment response and 
correlate it with vascular inflammation.  We hypothesize that subjects in DAS-28-CRP defined LDAR at 6 
months will have less vascular inflammation than those with persistent MHDA.  
2b. To use a multi-biomarker of RA disease activity (Vectra-DA) to categorize treatment response and 
correlate it with vascular inflammation.  We hypothesize that subjects in Vectra DA-defined LDAR at 6 
months will have less vascular inflammation than those with persistent MHDA.  All 12 proteins in Vectra-DA are 
also recognized CVD biomarkers2, thus, each one will also be analyzed alone and in combinations to 
determine whether a different algorithm of the Vectra-DA components may better correlate with vascular 
inflammation.  We will also compare the correlations of the Vectra-DA and the DAS-28-CRP with vascular 
inflammation to determine if they are independent.   
2c. In this exploratory sub-aim, we will use joint inflammation as measured by articular FDG PET/CT to 
categorize treatment response and correlate it with vascular inflammation.  We hypothesize that subjects 
in articular FDG defined LDAR at 6 months will have less vascular inflammation than those with persistent 
MHDA.  We will also compare the correlations of the articular FDG uptake and DAS-28-CRP with vascular 
inflammation to determine if they are independent.    
 
II. STUDY POPULATION 
 


3 
 
Subjects for this trial all fulfilled ACR/EULAR criteria for RA and were deemed methotrexate-inadequate 
responders (MTX-IRs, DAS28>3.2) by their treating rheumatologist. They could not be current or recent (in the 
past 6 months) users of a biologic DMARD and could not have previously been deemed inadequate 
responders to a TNF antagonist. To enrich our trial subjects for vascular disease, we required patients to be at 
least 45 years old for men, and 50 years old for women. Detailed inclusion and exclusion criteria are listed in 
Table 1. 
 
Table 1: Detailed Eligibility Criteria 
(Subjects who meet all of the following criteria at Screening are eligible for enrollment into the study)
Inclusion 
 
 
Written informed consent signed by the subject;  
 
Fulfill ACR/EULAR 2010 criteria for RA; 
 
Men ≥ 45 years and women ≥ 50 years; 
 
MTX for ≥ 8 weeks at ≥ 15mg weekly or on at least 7.5mg of methotrexate weekly for ≥8 weeks with a documented 
intolerance of higher MTX doses, and stable dose for the previous 4 weeks; 
 
DAS28 score > 3.2; 
 
Able to swallow pills; 
 
Males and females with reproductive potential must agree to practice effective measures of birth control;   
 
If taking prednisone (or equivalent corticosteroid), the dose must be ≤ 10 mg/day at the time of the baseline FDG 
PET/CT scan and must NOT change by more than ±3.0 mg for the four weeks prior to the baseline FDG PET/CT (If 
subjects are taking steroids every other day, divide dose by 2 to evaluate eligibility.);  
 
If taking a low- or moderate-intensity statin, the dose must be stable for six weeks prior to screening and must not 
change during the six months of the trial; and 
 
Willing to comply with all study procedures and be available for the duration of the study 
 
Rheumatoid arthritis without psoriasis or with psoriasis if rheumatoid factor ≥2x ULN or anti-CCP ≥2x ULN.  
Exclusion 
• 
Use of biologic DMARD or small molecule DMARD (i.e. tofacitinib) in the past 6 months, use of Rituximab ever; 
• 
Non-biologic DMARDs other than MTX or HCQ for two months prior to Screening  
• 
Considered to be an etanercept (Enbrel) or adalimumab (Humira) failure by their primary rheumatologist; 
•     Current use of > 10mg per day of prednisone; 
• 
Current use or use within the previous 12 months of a high-intensity statin (atorvastatin/Lipitor 40mg or higher, 
rosuvastatin/Crestor 10mg or higher) or PCSK9 inhibitor (Alirocumab/ Praluent, Evolocumab/Repatha, or Bococizumab); 
• 
Prior patient reported, physician diagnosed clinical CV event: myocardial infarction, angina, stroke, uncompensated or 
severe heart failure (NYHA class III or IV), prior vascular procedure (coronary artery angioplasty or stenting, carotid 
endarterectomy, coronary artery bypass surgery); 
• 
Demyelinating disease; 
•     Any of the following forms of arthritis that may otherwise explain the subject’s RA symptoms: Psoriatic Arthritis, Reactive 
Arthritis, Juvenile Idiopathic Arthritis, Ankylosing Spondylitis, Polymyalgia Rheumatica; 
•     Any of the following other autoimmune and/or chronic inflammatory diseases: Inflammatory Bowel Disease, Crohn’s 
disease, Cutaneous or Systemic Lupus, Systemic Vasculitis, Giant Cell Arteritis, Polymyositis, Dermatomyositis, 
Sarcoidosis, or Scleroderma ; 
• 
Cancer treated in last five years (except basal and squamous cell) or any lymphoma or melanoma; 
• 
Type I diabetes mellitus or Type II diabetes treated with insulin or uncontrolled with HbA1c ≥ 7% from the past 6 months; 
• 
Known history of transient ischemic attack (TIA), stroke, myocardial infarction, or revascularization for coronary or 
peripheral artery disease; 
• 
Known pregnancy, HIV, hepatitis B, hepatitis C, active (or untreated latent) TB; 
• 
Known sulfa allergy or other known hypersensitivity to any of the trial agents or G6PD deficiency; 
• 
Known macular disease or known retinal disease; 
• 
Baseline blood count, renal or liver abnormalities as follows:  WBC < 3.5 X1000 n/ul, Hematocrit < 30%, Platelet count < 
90 x1000 n/ul, estimated glomerular filtration rate < 50 ml/min, AST (liver function test) > 60 U/L, ALT (liver function test) 
>84 U/L; 
• 
Intra-articular injection of corticosteroids within the 4 weeks prior to the potential baseline FDG PET/CT; or 
• 
Two or more of the following high dose radiation scans: CT scan with contrast, angiogram, SPECT nuclear medicine 
scan, myocardial (cardiac) perfusion scan in the past year. 
 
 
 


4 
 
III. INTERVENTIONS 
 
Treatments. Patients assigned to the TNFi arm received either etanercept 50 mg SQ qwk or adalimumab 40 
mg SQ every other week.  At 12 weeks, if the patient had not achieved a EULAR good response3 (DAS28 ≤ 
3.2 AND improvement in DAS28 from baseline ≥ 1.2) the dose was increased (adalimumab 40 mg every other 
to every week) or the medication will be switched (etanercept to adalimumab 40 mg every other week).  The 
patient remained on that medication/dose to the end of the study.  Patients assigned to triple therapy began 
SSZ 1 gm bid and HCQ 200 mg bid (not to exceed 6.5mg/kg).  At 6 weeks, if they have not achieved a good 
EULAR response, SSZ was increased to 1.5 gm bid.  If a good EULAR response has not been achieved by 12 
weeks, MTX was switched to a SQ route and/or the dose increased (if dose at enrollment is ≤ 25 mg/wk).  At 
18 weeks, if the patient was not in low disease activity or remission, the investigator could offer several 
possible modifications in treatment: for patients taking triple therapy, MTX would be substituted with 
leflunomide; for patients taking adalimumab every other week, the frequency could be increased to weekly; 
and for patients taking etanercept, they could switch to adalimumab. 
 
Withdrawal Criteria. We conservatively assumed 15% withdrawal or cross-over and observed approximately 
15% withdrawal and no cross-over. Withdrawal from the study was indicated for a cautionary laboratory value, 
a new malignancy other than basal or squamous cell, repeated subject non-compliance, or loss to follow-up. If 
study treatment was stopped (e.g., for an adverse event) and there is no safety issue precluding it, the patient 
underwent FDG PET/CT scan within 8 weeks of the last dose of randomized treatment. 
 
IV. OUTCOMES 
 
Primary outcome definition – change in vascular FDG uptake: Imaging was performed prior to 
randomization and at week 24 while on study drug using methods reported previously4-8, and following detailed 
image acquisition guidelines.. In brief, FDG was administered (10 mCi) after an over-night fast. Imaging was 
performed 90 minutes later using a PET/CT scanner (with at least 8 CT detectors; most have 16) with the 
patient supine and head and chest adjusted to a standardized position by use of laser as outlined in the 
Imaging Protocol. Imaging was performed across 3-4 bed positions, covering the neck and chest. CT 
attenuation correction was performed using tube voltage of 120 kVp, and current of ~ 40mAs. PET data were 
acquired in 3-D mode over 10 minutes per bed position and stored on 256x256 matrix. Attenuation-corrected 
images were reconstructed yielding ~4 mm effective resolution. Following neck and chest scans, a whole-body 
PET/CT scan was performed for articular FDG uptake using the same voltage parameters.  The arms were 
reoriented in an extended position with palms on anterior thighs. 
 
Patient identifiers were removed by the imaging site investigators and transferred to the Imaging Core, using 
secure FTP. The system for image transfer has been validated through several prior multi-center trials. Each of 
the baseline and week 24 images was sent to the Imaging Core for quality control as soon as it is obtained.  
Upon receipt by the Imaging Core, images are assessed for protocol compliance and image quality, then 
transferred to a dedicated multi-modality workstation. Image analysis was performed by an experienced reader 
with paired attenuation image sets of the vessels of interest (right and left carotid and aorta), evaluated side-
by-side with scrambled time-points and blinding to treatment as previously reported9.  The target tissues were 
matched so that the same locations are measured for both time-points. Thereafter, regions of interest (ROIs) 
were drawn around the target vessel (in axial orientation) to provide maximum standardized uptake values 
(SUV) for each ROI. The SUV is the decay-corrected tissue concentration of FDG (in kBq/ml) divided by the 
injected dose per body weight (kBq/g). Drawing of ROIs was repeated along the length of the vessel (every 
~3.5 mm along the long axis of the vessel) to provide a stack that compose the whole vessel9. Background 
(using the SVC blood pool) corrected maximum SUVs are averaged to provide a whole vessel target-to-
background ratio (TBR). Absence of correction for partial volume effect has not been a limitation in assessment 
of larger vessels, such as the carotids and the aorta, as shown by published validation studies10.   
 
The primary PET/CT parameter used to evaluate vascular inflammation will be the mean of the maximum TBR 
of the MDS of the index vessel (index vessel MDS TBRmeanmax), based on work showing that this endpoint 
provides the most sensitive measure of treatment effect 6,9. The index vessel is the vessel (either aorta, left 


5 
 
carotid, or right carotid) with the highest average mean of max TBR at baseline. The MDS is defined as the 1.5 
cm segment within the artery that demonstrates the highest FDG activity. The MDS TBRmeanmax is 
calculated as a mean of maximum TBR values derived from 3 contiguous axial segments.  
 
Secondary outcome definitions:  
Change in vascular FDG-uptake: In addition to examining the MDS TBRmeanmax, five secondary vascular 
imaging endpoints will also be examined in exploratory analyses: 1) the TBRmeanmax across the entire index 
vessel; 2) carotid MDS TBRmeanmax; 3) aortic MDS TBRmeanmax, 4) TBRmeanmax across the entire 
carotid vessel (R and L averaged); and 5) TBRmeanmax across the entire aorta.  These provide 
complementary information to the primary outcome. As a sensitivity analysis, we will also examine the target 
measures alone for the MDS of the index vessel, the entire index vessel, the carotid MDS, the aortic MDS, the 
entire carotid, and the entire aorta. 
 
Change in DAS28: The DAS28 is calculated as noted below.  The TJC and SJC were assessed by a blinded 
metrologist, and the patient rated their PtG based on a 0-100 VAS scale. The CRP (mg/dl) will be estimated in 
the central lab at the end of the study.  The change in DAS28 will be calculated as the measure at the time of 
the final FDG PET/CT scan minus the baseline measure: 
 
DAS-28-CRP = (0.56 x TJC28) + (0.28 x SJC28) + (0.36 x ln(CRP+1)) + (0.014 x PtG) + 0.96 
In addition to analyzing the full DAS28 score, each component of the DAS28 will be analyzed separately. 
 
Change in biomarker levels: We will primarily test the Vectra-DA platform as it has been found to be a valid 
correlate of disease activity in RA11 and is already used in clinical rheumatology practice.  The Vectra-DA 
consists of 12 individual markers.  All have been noted to also be markers of CVD risk12. Testing procedures 
for the Vectra-DA platform have been well described in the literature13. These assays will be run by Crescendo/ 
Myriad.  The Vectra-DA will be used in Aim 2b to categorize disease activity as follows: remission < 25 or low 
26-29 versus moderate 30-44 or high > 44 according to the manufacturer’s algorithm11,14.  However, this 
algorithm may not be optimal for assessing relationships to vascular inflammation.  Since Cresendo/Myriad will 
provide us with the data for each individual protein at each measured timepoint, in a series of exploratory 
analyses, we will analyze each of the 12 components alone as a continuous variable and in various 
combinations to determine whether a different algorithm of the Vectra-DA components may be a better 
correlate of vascular inflammation.   
 
Given the limited number of proteins in Vectra-DA, examination of a broader array of proteins involved in 
inflammation, endothelial activation, lipid processing, immunological pathways, etc, is desirable to enable the 
development of a novel multi-marker of vascular inflammation in RA. We will also examine a broader multi-
analyte panel, the RBM Discovery Map. This will include targeted study of candidate markers based on 
systematic literature review, as well as a secondary analysis using a biomarker discovery approach. 
 
Change in articular FDG uptake:  While methods for analyzing articular FDG uptake are just emerging, there 
has been a validated methodology published during the conduct of the TARGET trial. 15   We will use the 
method as described below.  This measure includes the following steps: 
1. View all images in three orthogonal planes (axial, coronal, and sagittal); 
2. Determine if a joint has synovitis by examining for increased FDG uptake in the anatomic region of the 
synovium compared with normal regional tracer accumulation; 
3. Overlay a volume of interest (VOI) for FDG positive joints over the joint synovium on the PET images; 
4. Create an iso-contour VOI for FDG positive joints that included all voxels above 42% of maximum; 
5. Calculate SUVmax using the following formula: 
a. SUVmax = maximum activity in the VOI (MBq/mL) 
Injected dose (MBq)/body weight (g) 
6. Calculate SUVmax including 68 joints, except DIP in the hands and mid-tarsal joints; and 
7. Repeat this process independently by another nuclear medicine physician or the same physician 
separated in time. 
 
Based on the above steps, several measures will be calculated: 


6 
 
a. PET28: # of FDG positive joints out of 28 – primary articular endpoint 
b. PET68: # of FDG positive joints out of 68 
c. SUV28: mean SUVmax of 28 joints 
d. SUV68: mean SUVmax of 68 joints 
 
Thus, we will use the change in PET28 (final FDG PET/CT scan minus baseline FDG PET/CT) as the primary 
articular outcome (one of the secondary trial outcomes) and change in the other measures (b – d above) as 
secondary articular outcomes. 
 
 
V. SAMPLE SIZE (Re-estimated) 
 
In our original grant application, we proposed a sample size of 100 participants in each arm (200 total 
recruitment target) using information from previous data in RA patients which observed a baseline MDS 
TBRmax of 2.51 (SD of 0.33) and a 0.46 reduction after 8 weeks of a TNFi16. After discussions with the DSMB, 
we re-estimated sample size using blinded data from 45 subjects in the TARGET trial to estimate the SD and 
found a standard deviation across scans of 0.291. Thus, we re-estimated the required sample size during 
the trial using a t-test to compare MDS TBRmeanmax in the two arms at 6-months to generate a conservative 
power estimate with various sample sizes (see Table 2). 
 
With an effective sample size of 126 (150 randomized minus 24 subjects (~16%) who we anticipated will drop-
out or cross-over), the trial has a 99% power to detect an absolute difference of 0.17 between the 2 arms.  This 
difference corresponds to the effect observed in the prior study by Maki-Petaja for TNFi’s16.  This difference 
between the arms would be a clinically important difference, 
on the same order for what was observed between a low-
dose statin and a high-dose statin17, a contrast with known 
clinical significance18. Power will be sufficient for the per 
protocol secondary analysis, including only the 
approximately 75% of subjects who remain compliant with 
study treatment. This pre-specified analysis will include an 
estimated 56 subjects per arm and will have 99% power to 
detect a difference of 0.17 in MDS TBRmeanmax.  Since 
these are pre-specified secondary endpoints, p-values will 
not be adjusted. 
 
 
VI. ANALYSIS PLAN 
 
We will compare the baseline characteristics of those randomized to TNFi + MTX versus triple therapy using 
chi-squared tests (or Fisher’s exact tests when cell counts were <5) for categorical variables and Wilcoxon 
rank sum tests for continuous variables.  We will use the same methods to compare the baseline 
characteristics of individuals who completed the study protocol to those who did not. 
 
We describe the analyses below with respect to the expected publications.  While all of the aspects of the 
Specific Aims are included, they have been slightly re-organized and enhanced with more state-of-the-art 
statistical analyses (i.e. causal mediation analyses). 
 
Analysis 1 
This analysis will address the goals specified in Aim 1 and Aim 2a. Overall, this analysis will determine the 
effects on vascular inflammation of TNFi + MTX versus triple therapy (Part I) and explore whether these effects 
are mediated by changes in disease activity (Parts II and III).  We will follow an approach similar to that used in 
the recent mediation analyses of the CANTOS trial anemia data19,20.  
 
Table 2:  Power Calculation for Aim 1 (ANCOVA 
adjusting for baseline) 
Between group 
difference
N=150 
N=126 
N=112 
0.19 
99% 
99% 
99% 
0.18 
99% 
99% 
99% 
0.17 
99% 
99% 
99% 
0.16  
99% 
99% 
98% 
0.15  
98% 
98% 
96% 


7 
 
Part I: The first part of this analysis will use an ANCOVA model estimating the change in index vessel MDS 
TBRmeanmax as a function of the baseline index vessel MDS TBRmeanmax, treatment group, and the 
randomization strata: 1) statin use at baseline, 2) oral steroid use at baseline, and 3) HCQ use at baseline.  
The null hypothesis is no association between treatment assignment and follow-up MDS TBRmeanmax.  A p-
value threshold of 0.05 for a two-sided test will be used to determine statistical significance.  The primary 
analysis will only include participants with imaging data at baseline and follow-up.  As a sensitivity analysis, we 
will exclude outliers defined as individuals with an Extreme Studentized Deviate (ESD) statistic for change in 
MDS TBRmaxman of greater than 3.46 21. We will also examine whether there were statistically significant 
changes in MDS TBRmeanmax within each arm from baseline to follow-up.  
 
Not all participants will have a follow-up MDS TBRmeanmax because some participants will fail to complete 
the study protocol.  We will perform a series of sensitivity analyses to explore how robust our results are to 
these missing data. First, we will impute the average MDS TBRmeanmax from all individuals with available 
follow-up MDS TBRmeanmax as the follow-up MDS TBRmaxmax for any individual missing this value.  
Second, we will perform multiple imputations using a Markov chain Monte Carlo technique22 to impute follow-
up MDS TBRmeanmax, including baseline MDS TBRmeanmax, randomized treatment assignment, and other 
baseline characteristics in our imputation model. Third, we will compare the baseline characteristics of 
individuals who complete the protocol and those who do not complete the protocol using t-tests and Fisher’s 
exact tests as appropriate.  If we observe any p-values <0.10, we will include that variable as a covariate in an 
ANCOVA model estimating the change in index vessel MDS TBRmeanmax as a function of the baseline index 
vessel MDS TBRmeanmax among individuals who completed the protocol. 
 
Due to COVID-19, we amended our protocol in April 2020 and allowed individuals to receive their follow-up 
scan after up to 36 weeks of treatment. We will perform additional analyses controlling for length of time 
between PET/CT scans as well as analyses restricting to those who received their follow-up scan between 22-
26 weeks as specified in the original protocol. Additional analyses will explore secondary vascular imaging 
endpoints.  We will repeat the main analysis of the primary outcome in the subgroup compliant with study 
treatment (threshold of >80% of treatment days covered for all medications).  Several secondary per protocol 
adherence analyses will also be pursued.  If baseline imbalances are observed between the per protocol 
treatment groups, these variables will be included as covariates in our regression models We will also include 
analyses stratified by the following factors:  achievement of LDAR; serologic status (seropositive versus 
seronegative); at least one CV risk factor (e.g., hypertension, diabetes, tobacco use, or hyperlipidemia); steroid 
use at baseline, gender, age (< median age versus ≥ median age), disease duration (< 5 years versus ≥ 5 
years) and statin use at baseline (yes versus no). We will formally test for interaction between randomized 
treatment assignment and these factors by using an interaction term. An additional secondary analysis will 
compare the primary vascular inflammation outcome (MDS TBRmeanmax) change between adalimumab and 
etanercept users. These subgroup analyses will be underpowered and exploratory; we will report nominal p-
values. 
 
A sensitivity analysis for the impact of any missing covariate data will also be done using the same assigned 
treatment categories, but using all randomized participants with multiple imputations using a Markov chain 
Monte Carlo technique22. This will be most relevant for the subgroup analyses.  
 
Part II: The next part of this analysis will address whether the magnitude of the treatment response achieved 
by individuals is related to their vascular inflammation response (baseline to final scan). This analysis will 
divide the participants into four groups according to randomized treatment assignment and whether they 
achieved low disease activity or remission (LDAR; DAS-28-CRP ≤ 3.2) versus remaining at moderate-high 
disease activity (MHDA; DAS-28-CRP > 3.2) as defined by the DAS-28-CRP at 18 weeks.  The four groups will 
be defined as: (1) triple therapy remaining in MHDA (reference group); (2) triple therapy achieving LDAR; (3) 
TNFi + MTX remaining in MHDA; and (4) TNFi + MTX achieving LDAR. We chose to examine the DAS-28-
CRP at 18 weeks as the mediator because we want to capture the effects of the treatment during the course of 
the study but also have the DAS-28-CRP measured prior to the assessment of the outcome. In the event that a 
participant drops out of the study prior to the 18-week assessment, we will use the DAS-28-CRP measure from 
the visit prior to the final imaging assessment.  


8 
 
 
We will use an ANCOVA model estimating the change in index vessel MDS TBRmeanmax as a function of the 
baseline index vessel MDS TBRmeanmax, randomization strata, the four groups combining information on 
treatment assignment and treatment response described above, a term for length of time between baseline 
and follow-up PET/CT scan, and the following potential confounders as measured at baseline: age, gender, 
disease duration, smoking status, serologic status, and body mass index. 
 
Part III: This final part will use formal causal mediation analysis to control for baseline characteristics that might 
independently influence treatment response and to control for the effect of treatment. We see Part III as a 
complement to Part II, where Part II may be easiest to communicate to readers and Part III is statistically more 
sophisticated.  Recent causal inference literature has highlighted potentially limitations to methods traditionally 
used to study mediation and have proposed new methodological approaches23. To implement these 
approaches, we will use Valeri and Vanderweele’s SAS macro for causal mediation analysis. Because 
mediation analysis is sensitive to distributional assumptions, we will separately consider both a dichotomous 
and continuous measure of treatment response.  First, we will use as a mediator an indicator of whether a 
randomly assigned participant achieves LDAR at 18 weeks (dichotomous mediator). Alternatively, as the DAS-
28-CRP is a continuous measure of change in disease activity, we will calculate the natural log of the DAS-28-
CRP at 18 weeks minus the DAS-28-CRP at baseline.  For both measures of mediation, we will include a term 
for length of time between baseline and follow-up PET/CT scan and control for the following potential 
confounders as measured at baseline: age, gender, disease duration, smoking status, serologic status, 
prednisone use, statin use, and BMI.   
 
Analysis 2 
We will use a similar overall methodology as described in Analysis 1, but the outcome of interest will be 
change in joint inflammation as measured by articular FDG PET/CT (PET-28).  While this analysis was not 
called out as a Specific Aim, it will be of great interest to the rheumatology community, because articular FDG 
PET/CT is of increasing interest as an RA trial outcome. First, we will perform the same analyses as described 
in Part I above which will examine the effect of randomized treatment assignment on change in articular 
inflammation.  Next, we will perform the analyses described in Part II using either DAS-28-CRP or Vectra-DA 
measured at 18 weeks as our mediator.  As described above, we will consider both a dichotomous and 
continuous measure of the DAS-28-CRP.  For Vectra-DA, our dichotomous definition of the mediator will be 
Vectra-DA score less than or equal to 29 at 18 weeks versus a score of 30 or greater at 18 weeks.  As a 
normalized, continuous measure of the mediator, we will calculate the natural log of Vectra-DA at 18 weeks 
minus Vectra-DA at baseline. 
 
Analysis 3 
While prior work has explored the association between Vectra-DA and DAS-28-CRP, less is known about the 
association between Vectra-DA and measures of vascular inflammation and articular inflammation. Our third 
set of analyses are exploratory and will leverage data from the TARGET trial to obtain additional insights into 
potential associations between biomarkers and vascular and articular inflammation. 
 
These analyses will pool data across both treatment arms of the trial.  We will compare several aspects of the 
Vectra-DA to several aspects of the MDS TBRmeanmax vascular assessment.  The Vectra-DA consists of 12 
analytes that are typically combined as a continuous score or put into three categories (low, moderate, and 
high).  In addition, each of the 12 analytes that comprise the Vectra-DA can be considered as individual 
predictors. 
 
Several analyses are planned. First, baseline (pre-treatment) measurements of the continuous Vectra-DA will 
be compared with the baseline vascular inflammation assessment. This cross-sectional relationship will be 
assessed using linear regression with vascular inflammation as the dependent variable and continuous Vectra-
DA as the independent variable of interest. The following baseline variables will be considered as covariates:, 
age, sex, blood pressure, low-density lipoprotein cholesterol, diabetes (yes/no), RA disease duration, smoking 
status, serologic status, baseline disease activity (DAS-28-CRP), prednisone use, statin use (none, low, or 
moderate intensity), and BMI.   


9 
 
 
Second, changes in Vectra-DA over time (continuous measurement) will be compared with the 6-month 
change in MDS TBRmeanmax. We will use linear mixed models and include all Vectra-DA assessments as 
independent variables. The same set of covariates as noted above will be included as well as baseline MDS 
TBRmeanmax, treatment arm, and length of time between baseline and follow-up PET/CT scan.  
  
In a series of exploratory analyses, we will also consider each of the 12 analytes in separate models. These 
models will include all of the above covariates. 
 
The above analyses will be repeated using the measures of articular inflammation (PET-28) as the outcomes 
instead of MDS TBRmeanmax. 
 
Analysis 4 
These analyses are exploratory and were not described as Specific Aims. We will compare change in vascular 
inflammation (MDS TBRmeanmax) with change in articular inflammation (PET-28). This will be examined 
across both treatment arms and then individually, by treatment arm. The change in articular inflammation 
(PET-28) will be considered the independent variable and the change in MDS TBRmeanmax will be the 
dependent variable. These analyses will use linear regression and will include the same set of covariates as 
noted in Analysis 3. We will also examine subgroups, including by prednisone use (yes/no), statin use (yes/no), 
treatment arm (triple therapy/TNF antagonist), serologic status, and sex.  We will also explore whether there is 
a treatment interaction by including an interaction term between treatment and articular inflammation. 
 
VII. SAFETY 
 
Since we tested FDA approved medications for their approved indications, there were no safety concerns to be 
addressed by an interim analysis and possible trial cessation.  There are strong arguments against stopping 
small trials because of interim analyses24,25. The DSMB did not choose to impose stopping rules. Two sample 
tests of proportion will compare safety data across treatment groups, including infection and cancer events. We 
monitored the distribution of baseline variables across treatment groups and compliance with study protocol. 
These analyses were performed by the DCC and provided to the DSMB.  
 
 
 


10 
 
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