Rotation or Change of Biotherapy After TNF Blocker Treatment Failure for Axial Spondyloarthritis

Overview

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease characterized by inflammatory arthritis and enthesitis involving the spine. AxSpA prevalence is around 0.17% of the French population. Tumor necrosis factor (TNF) was the first target defined in axSpA. Since one third of axSpA patients failed to the first TNF blocker, many axSpA patients received a second biological Disease-Modifying AntiRheumatic Drugs (bDMARDs). Until few months, the only choice was to use a second TNF blocker.Since 2003, pharmaceutical companies investigated efficacy of TNF blockers already used in rheumatoid arthritis. Etanercept is a fusion protein with TNF receptor type II p75 and IgG1 Fc fragment, whereas adalimumab, infliximab, and golimumab are monoclonal antibodies. Certolizumab is a fusion between a fab fragment targeting TNF and a Peg fraction. All demonstrated efficacy versus placebo in a randomized double blinded study In case of failure to the first TNF blockers, rheumatologists will follow the "Treat-to-Target" principle. This approach already demonstrated its benefit in rheumatoid arthritis or in psoriatic arthritis. This concept was also suggested for axSpA with low levels of evidence and recommendation. So rheumatologist will provide the best treatment in case of failure to the first TNF blockers, which is a daily clinical situation. Since few months, rheumatologists have the choice between targeting IL-23/17 axis compared to a second TNF blocker.

Study Type

  • Study Type: Interventional
  • Study Design
    • Allocation: Randomized
    • Intervention Model: Parallel Assignment
    • Primary Purpose: Treatment
    • Masking: None (Open Label)
  • Study Primary Completion Date: November 2023

Interventions

  • Drug: Secukinumab
    • Secukinumab : 150 mg per week for 5 weeks, and then every month by subcutaneous injection
  • Drug: TNF blocker
    • TNF blocker (originator or biosimilar) : infliximab: 5mg/kg per IV infusion at weeks 0, 2, 6, and then every 6 weeks, etanercept: 50mg per week in subcutaneous injection, adalimumab: 40mg every other week in subcutaneous injection, certolizumab: 400mg every other week 3 times, and then 200mg every other week or 400mg per month in subcutaneous injections, golimumab: 50mg every month in subcutaneous injection, in case of overweight (>100kg) an inadequate response, 100mg every month is allow.
  • Biological: blood specimen
    • Blood specimen at each visits for measurement of bDMARS blockers concentration and anti-drug antibody concentration

Arms, Groups and Cohorts

  • Experimental: targeting IL-23/17 axis
    • The experimental group (targeting IL-23/17 axis) receiving secukinumab in compliance with the marketing authorization regimen: 150 mg per week for 5 weeks, and then every month by subcutaneous injection. Blood specimen at each visits
  • Active Comparator: TNF blocker
    • • The control group receiving a second TNF blocker in compliance with the marketing authorization regimen: The TNF blocker (originator or biosimilar) will be different to the TNF used before the inclusion and will be chose by the investigator: infliximab: 5mg/kg per IV infusion at weeks 0, 2, 6, and then every 6 weeks, etanercept: 50mg per week in subcutaneous injection, adalimumab: 40mg every other week in subcutaneous injection, certolizumab: 400mg every other week 3 times, and then 200mg every other week or 400mg per month in subcutaneous injections, golimumab: 50mg every month in subcutaneous injection, in case of overweight (>100kg) an inadequate response, 100mg every month is allow. Blood specimen at each visits

Clinical Trial Outcome Measures

Primary Measures

  • Proportion of axSpA patients with a clinical response Assessments in Ankylosing Spondylitis International Society 40 (ASAS 40) at week 24
    • Time Frame: 24 weks
    • ASAS 40 is defined as an improvement of at least 40% and absolute improvement of at least 2 units on a numerical rating scale of 10 in at least 3 of the following domains compared to values at inclusion: Patient global assessment : numerical rating scale with extremes labelled “none” and “severe.” Pain assessment : average of total and nocturnal pain scores, both measured on a numerical rating scale with extremes labelled “no pain” and “most severe pain.” Function : BASFI average of 10 questions measured by numerical rating scale with extremes labelled “easy” and “impossible.” Morning stiffness, represented by the average of the last 2 questions on the 6-question BASDAI measured by numerical rating scale: one with extremes labelled “none” and “very severe”; the other marking duration of morning stiffness between “0” and “2 or more hours.” Additionally, no worsening at all in remaining domain

Secondary Measures

  • Proportion of axSpA patients with a clinical response ASAS 40 at week 12
    • Time Frame: 12 weeks
    • ASAS 40 is defined as an improvement of at least 40% and absolute improvement of at least 2 units on a numerical rating scale of 10 in at least 3 of the following domains compared to values at inclusion: Patient global assessment : numerical rating scale with extremes labelled “none” and “severe.” Pain assessment : average of total and nocturnal pain scores, both measured on a numerical rating scale with extremes labelled “no pain” and “most severe pain.” Function : BASFI average of 10 questions measured by numerical rating scale with extremes labelled “easy” and “impossible.” Morning stiffness, represented by the average of the last 2 questions on the 6-question BASDAI measured by numerical rating scale: one with extremes labelled “none” and “very severe”; the other marking duration of morning stiffness between “0” and “2 or more hours.” Additionally, no worsening at all in remaining domain
  • Proportion of axSpA patients with a clinical response ASAS 40 at week 52
    • Time Frame: 52 weeks
    • ASAS 40 is defined as an improvement of at least 40% and absolute improvement of at least 2 units on a numerical rating scale of 10 in at least 3 of the following domains compared to values at inclusion: Patient global assessment : numerical rating scale with extremes labelled “none” and “severe.” Pain assessment : average of total and nocturnal pain scores, both measured on a numerical rating scale with extremes labelled “no pain” and “most severe pain.” Function : BASFI average of 10 questions measured by numerical rating scale with extremes labelled “easy” and “impossible.” Morning stiffness, represented by the average of the last 2 questions on the 6-question BASDAI measured by numerical rating scale: one with extremes labelled “none” and “very severe”; the other marking duration of morning stiffness between “0” and “2 or more hours.” Additionally, no worsening at all in remaining domain
  • Proportion of axSpA patients with a clinical response ASAS 20 at week 12
    • Time Frame: 52 weeks
    • ASAS 20 is defined as an improvement of at least 20% and absolute improvement of at least 1 unit on a numerical rating scale of 10 in at least 3 of the following domains compared to values at inclusion: Patient global assessment : numerical rating scale with extremes labelled “none” and “severe.” Pain assessment : average of total and nocturnal pain scores, both measured on a numerical rating scale with extremes labelled “no pain” and “most severe pain.” Function : BASFI average of 10 questions regarding measured by numerical rating scale with extremes labelled “easy” and “impossible.” Morning stiffness, represented by the average of the last 2 questions on the 6-question BASDAI measured by numerical rating scale: one with extremes labelled “none” and “very severe”; the other marking duration of morning stiffness between “0” and “2 or more hours.” Additionally, no worsening in a similar amount in the fourth domain
  • Proportion of axSpA patients with a clinical response ASAS 20 at week 24
    • Time Frame: 24 weeks
    • ASAS 20 is defined as an improvement of at least 20% and absolute improvement of at least 1 unit on a numerical rating scale of 10 in at least 3 of the following domains compared to values at inclusion: Patient global assessment : numerical rating scale with extremes labelled “none” and “severe.” Pain assessment : average of total and nocturnal pain scores, both measured on a numerical rating scale with extremes labelled “no pain” and “most severe pain.” Function : BASFI average of 10 questions regarding measured by numerical rating scale with extremes labelled “easy” and “impossible.” Morning stiffness, represented by the average of the last 2 questions on the 6-question BASDAI measured by numerical rating scale: one with extremes labelled “none” and “very severe”; the other marking duration of morning stiffness between “0” and “2 or more hours.” Additionally, no worsening in a similar amount in the fourth domain
  • Proportion of axSpA patients with a clinical response ASAS20 at week 52
    • Time Frame: 52 weeks
    • ASAS 20 is defined as an improvement of at least 20% and absolute improvement of at least 1 unit on a numerical rating scale of 10 in at least 3 of the following domains compared to values at inclusion: Patient global assessment : numerical rating scale with extremes labelled “none” and “severe.” Pain assessment : average of total and nocturnal pain scores, both measured on a numerical rating scale with extremes labelled “no pain” and “most severe pain.” Function : BASFI average of 10 questions regarding measured by numerical rating scale with extremes labelled “easy” and “impossible.” Morning stiffness, represented by the average of the last 2 questions on the 6-question BASDAI measured by numerical rating scale: one with extremes labelled “none” and “very severe”; the other marking duration of morning stiffness between “0” and “2 or more hours.” Additionally, no worsening in a similar amount in the fourth domain
  • Proportion of axSpA patients with a partial remission rate at week 12
    • Time Frame: 12 weeks
    • Partial remission is defined by values lower than 2/10 in each 4 domains: Patient global assessment measured on a numerical rating scale with extremes labelled “none” and “severe.” Pain assessment represented by the average of total and nocturnal pain scores, both measured on a numerical rating scale with extremes labelled “no pain” and “most severe pain.” Function represented by BASFI average of 10 questions regarding ability to perform specific tasks as measured by numerical rating scale with extremes labelled “easy” and “impossible.” Morning stiffness, represented by the average of the last 2 questions on the 6-question BASDAI regarding morning stiffness as measured by numerical rating scale: one with extremes labelled “none” and “very severe”; the other marking duration of morning stiffness between “0” and “2 or more hours.”
  • Proportion of axSpA patients with a partial remission rate at week 24
    • Time Frame: 24 weeks
    • Partial remission is defined by values lower than 2/10 in each 4 domains: Patient global assessment measured on a numerical rating scale with extremes labelled “none” and “severe.” Pain assessment represented by the average of total and nocturnal pain scores, both measured on a numerical rating scale with extremes labelled “no pain” and “most severe pain.” Function represented by BASFI average of 10 questions regarding ability to perform specific tasks as measured by numerical rating scale with extremes labelled “easy” and “impossible.” Morning stiffness, represented by the average of the last 2 questions on the 6-question BASDAI regarding morning stiffness as measured by numerical rating scale: one with extremes labelled “none” and “very severe”; the other marking duration of morning stiffness between “0” and “2 or more hours.”
  • Proportion of axSpA patients with a partial remission rate at week 52
    • Time Frame: 52 weeks
    • Partial remission is defined by values lower than 2/10 in each 4 domains: Patient global assessment measured on a numerical rating scale with extremes labelled “none” and “severe.” Pain assessment represented by the average of total and nocturnal pain scores, both measured on a numerical rating scale with extremes labelled “no pain” and “most severe pain.” Function represented by BASFI average of 10 questions regarding ability to perform specific tasks as measured by numerical rating scale with extremes labelled “easy” and “impossible.” Morning stiffness, represented by the average of the last 2 questions on the 6-question BASDAI regarding morning stiffness as measured by numerical rating scale: one with extremes labelled “none” and “very severe”; the other marking duration of morning stiffness between “0” and “2 or more hours.”
  • Proportion of axSpA patients with a ASDAS major improvement at week 12
    • Time Frame: 12 weeks
    • ASDAS major improvement was defined by a variation of ASDAS-CRP≥2
  • Proportion of axSpA patients with a ASDAS major improvement at week 24
    • Time Frame: 24 weeks
    • ASDAS major improvement was defined by a variation of ASDAS-CRP≥2
  • Proportion of axSpA patients with a ASDAS major improvement at week 52
    • Time Frame: 52 weeks
    • ASDAS major improvement was defined by a variation of ASDAS-CRP≥2
  • Proportion of axSpA patients with biological Disease-Modifying AntiRheumatic Drugs (bDMARDs) treatment at week 12
    • Time Frame: 12 weeks
    • Patient with the same bDAMRs treatment at inclusion and week 12
  • Proportion of axSpA patients with biological Disease-Modifying AntiRheumatic Drugs (bDMARDs) treatment at week 24
    • Time Frame: 24 weeks
    • Patient with the same biological Disease-Modifying AntiRheumatic Drug (bDAMR) treatment at inclusion and week 24
  • Proportion of axSpA patients with bDMARDs treatment at week 52
    • Time Frame: 52 weeks
    • Patient with the same biological Disease-Modifying AntiRheumatic Drug (bDAMR) treatment at inclusion and week 52
  • Number of adverse events
    • Time Frame: 52 weeks
    • Number of adverse events
  • Correlation between concentration of antibodies to bDMARS blockers and clinical response according to treatment
    • Time Frame: From baseline to 52 weeks
    • Concentration of antibodies to bDMARS blockers is measured by Enzyme Linked ImmunoSorbent Assay (ELISA) low disease activity is defined by BASDAI <4 and ASDAS <2.1
  • Correlation between concentration of anti-drug antibodies and clinical response according to treatment
    • Time Frame: From baseline to 52 weeks
    • Concentration of anti-drug antibodies is measured by Enzyme Linked ImmunoSorbent Assay (ELISA) low disease activity is defined by BASDAI <4 and ASDAS <2.1

Participating in This Clinical Trial

Inclusion Criteria

  • Active axSPA with BASDAI>4 or ASDAS>3.5, who need change in TNF blocker treatment – Aged over 18 years – Inadequate response after at least 3 months to the 1st TNF blocker – If non biologic DMARD treatment : stable dose for at least on month before inclusion – If oral corticosteroids treatment : stable dose for at least on month before inclusion – If NSAIDs treatment : stable dose for at least on month before inclusion – Ability to complete questionnaires – Social security affiliation – Informed written consent given Exclusion Criteria:

  • Any contra-indication to TNF blocker and/or secukinumab – Inflammatory bowel diseases – Existing pregnancy, lactation, or intended pregnancy within the next 15 months Active tuberculosis or other severe infections such as sepsis or opportunistic infections – Active infections, including chronic or localised infections. – Moderate to severe heart failure (NYHA classes III/IV) – Impossibility to give informed consent – Impossibility to be followed for 12 months

Gender Eligibility: All

Minimum Age: 18 Years

Maximum Age: N/A

Are Healthy Volunteers Accepted: No

Investigator Details

  • Lead Sponsor
    • Centre Hospitalier Universitaire de Saint Etienne
  • Collaborator
    • Ministry of Health, France
  • Provider of Information About this Clinical Study
    • Sponsor
  • Overall Official(s)
    • Hubert MAROTTE, MD, Study Director, CHU Saint-Etienne
  • Overall Contact(s)
    • Hubert MAROTTE, MD, 04 77 12 76 49, hubert.marotte@chu-st-etienne.fr

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