Systemic Sclerosis-Associated PAHPhase 2NCT01086540
Rituximab for Treatment of Systemic Sclerosis-Associated Pulmonary Arterial Hypertension (SSc-PAH)
A Phase 2 study testing Rituximab, CMRI and prednisone in people with Systemic Sclerosis-Associated PAH, run by National Institute of Allergy and Infectious Diseases (NIAID) at 17 sites in United States.
Trial summary
Systemic sclerosis-associated pulmonary arterial hypertension (SSc-PAH) is a serious, life-threatening manifestation of systemic sclerosis (SSc), an autoimmune disease of the connective tissue characterized by scarring (fibrosis) and atrophy of the skin, joints and tendons, skeletal muscles, and internal organs, and… Read more about this study
- Who is it for?
- Ages 18 to 75 years
- Conditions the study is for
- Systemic Sclerosis-Associated PAH
- What is being tested?
- Rituximab, CMRI and prednisone
- Type of treatment
- Pill or oral medicine, Injection or infusion
- Could I receive a placebo?
- Yes, some participants may receive a placebo
- How many people
- 57 participants
- Where
- 17 sitesUnited States
- Study dates
- 24 Jun 2011to 15 Dec 2019
- Phase
- Phase 2
- Are there results?
- Yes, posted in the registrySummary in the doctors' view
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 18 to 75 years
- All sexes
- No healthy volunteers
- Adult, Older adult
Who may be able to join
- Subject has provided written informed consent.
- Clinical diagnosis of systemic sclerosis (either limited or diffuse cutaneous disease).
- Diagnosis of SSc-PAH within the past 5 years, with a mean pulmonary arterial pressure of ≥ 25 mmHg at entry.
- Mean Pulmonary Vascular Resistance (PVR) of > 3 Wood units.
- Screening 6-minute Walking Distance (6MWD) of at least 100 meters.
- New York Heart Association (NYHA) Functional Class II, III, or IV.
Show all 10Show fewer
- Subject must be able to maintain O2 saturation ≥ 90% at rest (with or without oxygen);
- --Oxygen use is permitted.
- Subject must be vaccinated with the pneumococcal vaccine at least one month prior to initiation of therapy, unless subject was vaccinated within 5 years of study entry.
- Subject must have been treated with background medical therapy for PAH (prostanoid, endothelin receptor antagonist, PDE-5 inhibitor, and/or guanylate cyclase stimulators) for a minimum of 8 weeks and have been on stable dose medical therapy for at least 4 weeks prior to randomization with no expectation of change for 24 weeks after randomization.
Who cannot join
- Documented PAH for greater than 5 years at the time of randomization defined as:
- Measurement of a mean Pulmonary Artery Pressure (PAP) > 25 mmHg by right heart catheterization at least 5 years previously, OR
- Treatment with targeted background PAH therapy for > 5 years.
- Pulmonary Capillary Wedge Pressure > 15 mmHg or Left Ventricular End Diastolic Pressure > 15 mmHg.
- Persistent hypotension with Systolic Blood Pressure (SBP) < 90 mmHg.
- Treatment with cyclophosphamide within 4 weeks of randomization.
Show all 32Show fewer
- Treatment with immunocompromising biologic agents within 4 weeks prior to treatment initiation or treatment with infliximab within 8 weeks prior to treatment initiation.
- If being treated with a non-biologic immunosuppressive or immunomodulating drug, changes in dosage within 4 weeks prior to randomization. Subjects taking prednisone or equivalent corticosteroid > 10mg daily are excluded.
- Previous exposure to any lymphocyte or B cell depleting agent.
- PAH for any reason other than SSc.
- History of coronary artery disease, significant ventricular tachy-arrhythmia, stent placement, coronary artery bypass surgery, and/or myocardial infarction.
- Moderate or severe interstitial lung disease.
- Chronic infections.
- Positive serology for infection with hepatitis B or C.
- A deep space infection within the past 2 years.
- Evidence of active infection within 2 weeks of randomization
- Presence of a positive tuberculosis (TB) skin test (e.g., PPD test) or positive QuantiFERON®-TB blood test, an indeterminate QuantiFERON®-TB blood test, or latent tuberculosis (TB).
- Significant renal insufficiency.
- Active, untreated SSc renal crisis at the time of enrollment.
- Recent administration of a live vaccine (< 8 weeks) or any other immunization within 4 weeks of treatment.
- History of anaphylaxis or Immunoglobulin E (IgE) -mediated hypersensitivity to murine proteins or any component of rituximab.
- Pregnancy.
- Lactation.
- History of malignancy within the last 5 years, except for resected basal or squamous cell carcinoma, treated cervical dysplasia, or treated in situ cervical cancer Grade I.
- A woman of childbearing potential who is unwilling to use a medically acceptable form of birth control
- History of non-compliance with other medical therapies.
- History of alcohol or drug abuse within 1 year of randomization.
- Receipt of any investigational drug or device within 4 weeks before the Screening Visit, with the exception of investigational prostanoids, endothelin receptor antagonists, and PDE-5 inhibitors, and guanylate cyclase stimulators.
- Recipient of lung transplant.
- Laboratory parameters at the screening visit showing any of the following abnormal results: Transaminases > 2x the upper limit of normal (ULN) and/or bilirubin > 2x ULN; Absolute neutrophil count < 1,500/mm^3; Platelet count < 100,000/mm^3; Hemoglobin < 9 g/dL.
- Concurrent treatment in a clinical research study using a non-FDA approved agent with the exception of an open-label study/study extension of investigational prostanoids, endothelin receptor antagonists, and PDE-5 inhibitors, and guanylate cyclase stimulators, provided the open-label investigational drug will be available and dose will remain stable through the trial's primary outcome time point of 24 weeks after randomization in this study, ASC01 (NCT01086540).
- Any condition or treatment, which in the opinion of the investigator, places the subject at unacceptable risk as a participant in the trial.
Trial locations and contacts
17 sites in 1 country.
17 sites in 1 country
United States17 sites
University of Michigan
Ann Arbor, Michigan, 48109
University of Colorado Health Sciences Center
Aurora, Colorado, 80045
Johns Hopkins University, Pulmonary and Critical Care Medicine
Baltimore, Maryland, 21205
Boston University Medical Center
Boston, Massachusetts, 02118
University of North Carolina at Chapel Hill: UNC Hospitals
Chapel Hill, North Carolina, 27514
Medical University of South Carolina
Charleston, South Carolina, 29425
Ohio State University
Columbus, Ohio, 43210
University of Texas Southwestern Medical Center-William P. Clements University Hospital
Dallas, Texas, 75390
University of Texas: Memorial Herman Hospital
Houston, Texas, 77030
University of Iowa
Iowa City, Iowa, 52242
University of Minnesota Health Clinics and Surgery Center
Minneapolis, Minnesota, 55455
Columbia University Medical Center
New York, New York, 10032
Weill Cornell Medical College
New York, New York, 10065
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania, 15261
University of Rochester Medical Center
Rochester, New York, 14642
University of Utah
Salt Lake City, Utah, 84132
Stanford Health Care
Stanford, California, 94305
About this study
Official title: A Randomized, Double-Blind, Placebo-Controlled, Phase II Multicenter Trial of a Monoclonal Antibody to CD20 (Rituximab) for the Treatment of Systemic Sclerosis-Associated Pulmonary Arterial Hypertension (SSc-PAH)
Systemic sclerosis-associated pulmonary arterial hypertension (SSc-PAH) is a serious, life-threatening manifestation of systemic sclerosis (SSc), an autoimmune disease of the connective tissue characterized by scarring (fibrosis) and atrophy of the skin, joints and tendons, skeletal muscles, and internal organs, and immunological disturbances. One-year survival for patients with SSc-PAH ranges from 50-81%. There is currently no cure for SSc-PAH and treatment is limited to vasodilator therapy used in all forms of PAH. In recent studies, immunotherapy was shown to be effective in treating SSc-interstitial lung disease, another serious, life-threatening manifestation of SSc. In addition, there are compelling pre-clinical data and anecdotal clinical reports that suggest modulation of the immune system may be an effective strategy for treating SSc-PAH. To test this approach, this trial will determine if rituximab, an immunotherapy, has a marked beneficial effect on clinical disease progression, with minimal toxicity, in patients with SSc-PAH when compared to placebo.
Read the detailed description
This prospective, double-blind, placebo-controlled, multi-center, randomized trial will evaluate the effect of rituximab on disease progression in subjects with SSc-PAH receiving concurrent stable-dose standard medical therapy with a prostanoid, endothelin receptor antagonist, and/or phosphodiesterase 5 (PDE-5) inhibitor. The study will focus on assessment of clinical response and safety measures longitudinally. In addition, the effects of treatment with rituximab on the underlying immune mechanisms associated with B-cell dysregulation and pathogenic autoantibody response in this disease will be investigated. 1000 mg of rituximab or placebo will be administered as two IV infusions given two weeks apart. Clinical assessments and sample collection will occur at monthly visits through Week 48. If a participant has not recovered B cells by Week 48, B cell studies will be conducted quarterly until reconstitution is documented or for 2 years after initial treatment.
This trial will include a sub-study, entitled "Right Ventricular Response to Rituximab in Systemic Sclerosis-Associated Pulmonary Arterial Hypertension - A Magnetic Resonance Imaging Sub-study" (RESTORE Sub-study). The objective of the RESTORE sub-study is to evaluate the therapeutic effect of rituximab on the right ventricle of patients with SSc-PAH. Changes in right ventricular end diastolic volume index (RVEDVI) and stroke volume (SV) determined by cardiac MRI will be used as surrogates of right ventricle function and prognosis. Enrollment for the RESTORE sub-study will parallel that of main trial. Twenty patients from each treatment arm, distributed among all participating sites, will be recruited for this sub-study. Each patient will be studied at baseline (i.e. prior to initiation of study drug) and after 24 weeks or at time of discontinuation. In addition to the data collection and testing specified in the main trial, participants in RESTORE will undergo comprehensive cardiac MRI evaluation. All main trial study inclusion and exclusion criteria apply, as well as additional exclusion criteria that pertain only to the RESTORE sub-study: 1) known hypersensitivity to Gadolinium; 2) inability to tolerate or cooperate with MRI; 3) morbid obesity; and 4) presence of metallic objects or pacemakers.
- Conditions
- Systemic Sclerosis-Associated PAH
- Being tested
- Rituximab, Placebo, CMRI, prednisone, methylprednisolone
- Keywords
- Pulmonary Arterial Hypertension (PAH), Autoimmune Disease, Systemic Scleroderma
- Medical subject headings
- Pulmonary Arterial Hypertension, Autoimmune Diseases, Scleroderma, Systemic
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
RituximabBiological
Also called Rituxan®
Participants receive rituximab intravenous (IV) infusions, 1000 mg each, 14 days apart (Day 0 and Week 2).
Rituximab is supplied as a sterile, clear, colorless, preservative-free liquid concentrate for intravenous (IV) administration in either 100 mg (10 mL) or 500 mg (50 mL) single-use vials, which must be diluted before administration
Standard rituximab pre-medications will be provided in preparation for the rituximab infusions.
PlaceboOther
Also called Placebo for rituximab
Participants receive placebo intravenous (IV) infusions 14 days apart (Day 0 and Week 2).
Standard pre-medications will be provided in preparation for the infusions.
CMRIDiagnostic test
Also called cardiac MRI, cardiac Magnetic Resonance Imaging
Up to 20 participants from each treatment arm will be assessed by CMRI at Baseline and at Week 24.
prednisoneDrug
Also called prednisone tablets, Rayos®
Prednisone dose of 40 mg (or equivalent) by mouth administered the night before and the morning of each study drug infusion.
Also called corticosteroid
Methylprednisolone (or equivalent corticosteroid) administered intravenously 30 minutes prior to each study drug infusion.
diphenhydramineDrug
Also called Benadryl®
Diphenhydramine 50 mg (or equivalent) administered by mouth approximately thirty to sixty minutes prior to each study drug infusion.
Dose may be repeated every four hours, as needed.
acetaminophenDrug
Also called Tylenol®
Acetaminophen 650 mg (or equivalent) administered by mouth approximately thirty to sixty minutes prior to each study drug infusion.
Dose may be repeated every four hours, as needed.
| Study group | Role | What they receive |
|---|---|---|
| Rituximab+PAH SOC | Experimental | Rituximab (1000 mg) will be administered as 2 intravenous infusions given 2 weeks apart.
Concurrent stable-dose Pulmonary Arterial Hypertension (PAH) medical therapy will be continued/managed as per standard of care (PAH SOC). Receives: Biological: Rituximab; Diagnostic Test: CMRI; Drug: prednisone; Drug: methylprednisolone; Drug: diphenhydramine; Drug: acetaminophen |
| Placebo + PAH SOC | Placebo comparator | Placebo will be administered as 2 intravenous infusions given 2 weeks apart.
Concurrent stable-dose Pulmonary Arterial Hypertension (PAH) medical therapy will be continued/managed as per standard of care (PAH SOC). Receives: Other: Placebo; Diagnostic Test: CMRI; Drug: prednisone; Drug: methylprednisolone; Drug: diphenhydramine; Drug: acetaminophen |
What is being measured
The primary outcome is the main question the study is designed to answer.
Change From Baseline in Distance Walked During a Six Minute Walk Test
The six minute walk test measures the distance a participant is able to walk over a total of six minutes on a hard, flat surface. The goal is for the participant to walk as far as possible in six minutes. The participant is allowed to self-pace and rest as needed as they traverse back and forth along a marked walkway. The total distance walked, in meters, was recorded for each participant. Longer distances indicate better outcomes.
Measured: Baseline (Pre Treatment Initiation) to Week 24
Secondary outcomes (18)
Change From Baseline in Pulmonary Vascular Resistance Measured by Right Heart Catheterization at Week 24
During a right heart catheterization, a catheter is guided to the right side of the heart and then into the pulmonary artery; blood flow through the heart is observed and is used to measure pressures in a participant's heart and lungs. The calculation of Pulmonary Vascular Resistance (PVR) is measured in Woods Units. Change is derived by measuring the difference between Baseline and Week 24 PVR (Week 24 minus Baseline). Higher PVR values indicate worse disease status.
Measured: Baseline (Pre Treatment Initiation) to Week 24
Change From Baseline in Distance Walked During a Six Minute Walk Test at Week 24 and Week 48
The six minute walk test measures the distance a participant is able to walk over a total of six minutes on a hard, flat surface. The goal is for the participant to walk as far as possible in six minutes. The participant is allowed to self-pace and rest as needed as they traverse back and forth along a marked walkway. The total distance walked, in meters, was recorded for each participant. Longer distances indicate better outcomes.
Measured: Baseline (Pre Treatment Initiation) to Week 24 and Week 48
Time to Clinical Worsening
Assessment of time to clinical worsening, censored at Week 48, defined as the first occurrence of any of the following:
- death,
- hospitalization for Systemic Sclerosis-Associated Pulmonary Arterial Hypertension (SSc-PAH),
- lung transplantation,
- atrial septostomy,
- addition of other Pulmonary Arterial Hypertension (PAH) therapeutic agents, or
- worsening of the six minute walk distance by > 20% and an increase in New York Heart Association functional class.
Time to clinical worsening was defined as the first date that met any of the above criteria and was calculated in study days as: date of first event minus (-) date of treatment randomization. If a participant did not experience any of the referenced events by Week 48 or, if the date of death was after the 48 week follow-up period, time to clinical worsening was equal to the participant's duration of follow-up in the study.
Measured: Baseline (Pre Treatment Initiation) to Week 48
Time to the Change or Addition of New Pulmonary Arterial Hypertension (PAH) Therapeutic Medications
Per protocol, from the time of study entry, participants were to remain on background PAH medical therapy with either a single agent or a combination of prostanoid, endothelin receptor antagonist, PDE-5 inhibitor, and/or guanylate cyclase stimulators as per the entry criteria. Doses should have remained stable through the Week 24 primary outcome/endpoint visit. If a dose of a background PAH medication was changed or a new PAH medication was added during the course of the trial, the date of the first dose change or additional medication was recorded. Time to the addition or modification of PAH medications was defined in study days as: date of the first time a PAH medication was modified or added minus (-) date of randomization.
Measured: Baseline (Pre Treatment Initiation) to Week 48
Change From Baseline in Quality of Life as Measured by the Short Form Health Survey (SF-36): Mental Component Summary Score
The SF-36 measures health-related quality of life. It has 36 items and 2 component scores, the Physical Component Score and the Mental Component Score. The SF-36 Mental Health component summary score is comprised of the Vitality Scale, the Social Functioning Scale, the Role-Emotional Scale, and the Mental Health Scale. It is scaled from 0 to 100 with a score of 0 equivalent to maximum disability and a score of 100 is equivalent to no disability. A negative value indicates a decrease in quality of life from Baseline.
Measured: Baseline (Pre Treatment Initiation) to Week 24 and Week 48
Change From Baseline in Quality of Life as Measured by the Short Form Health Survey (SF-36): Physical Component Summary Score
The SF-36 measures health-related quality of life. It has 36 items and 2 component scores, the Physical Component Score and the Mental Component Score. The SF-36 Physical component summary score is comprised of the Physical Functioning Scale, the Role-Physical Scale, the Bodily Pain Scale, and the General Health Scale. It is scaled from 0 to 100 with a score of 0 equivalent to maximum disability and a score of 100 is equivalent to no disability. A negative value indicates a decrease in quality of life from Baseline.
Measured: Baseline (Pre Treatment Initiation) to Week 48
Change in Quality of Life as Measured by the Disability Index of the Scleroderma Health Assessment Questionnaire (HAQ-DI)
The HAQ-DI is a self-reported questionnaire of functionality that includes questions in 8 domains (dressing/grooming, arising, eating, walking, hygiene, reach, grip, and activities) and addresses scleroderma related manifestations that contribute to disability. The final score ranges from 0 to 3, where a higher HAQ-DI score indicates a worse outcome.
Measured: Baseline (Pre Treatment Initiation) to Week 24 and Week 48
Number of New Digital Ulcers
The total number of digital ulcers present on the dorsal and palmar surfaces for both the left and right fingers were captured at the Baseline study visit. The number of new digital ulcers since the last study visit (including any ulcers that had appeared and healed since the last study visit) on the dorsal and palmar surfaces for both the left and right fingers were captured at the post-Baseline study visits. The total number of digital ulcers on both hands was summed from the number present on the dorsal and palmar surfaces for both the left and right fingers.
Measured: Baseline (Pre Treatment Initiation) to Week 24 and Week 48
Change in Severity of Raynaud's Phenomenon
Severity of Raynaud's phenomenon was measured by a Visual Analog Scale (VAS) of the Scleroderma Health Assessment Questionnaire (SHAQ). The SHAQ VAS includes a question asking, "In the past week, how much has your Raynaud's Phenomenon interfered with your activities?" Participants were asked to place a mark on a 15 cm line, scaled from 0 (does not interfere) to 100 (very severe limitation), to describe the severity of their Raynaud's phenomenon in the past week. The distance from the left edge of the line to the vertical line placed by the participant was measured in centimeters; VAS scores were converted to a 0 to 100 scale.
Measured: Baseline (Pre Treatment Initiation) to Week 24 and Week 48
Change in Carbon Monoxide Diffusing Capacity (DLCO)
Carbon Monoxide Diffusing Capacity (DLCO) is a measure of lung function. Predicted values for DLCO were computed according to the Global Lung Function Initiative (GLI) all-age reference values and corrected for hemoglobin. Lower DLCO values indicate worse disease activity.
DLCO (Diffusing Capacity of the Lungs for Carbon Monoxide)
Measured: Baseline (Pre Treatment Initiation) to Week 24 and Week 48
Oxygen Saturation Levels at Week 24 and Week 48
Oxygen saturation is the amount of oxygen that is in your bloodstream and is measured as the percentage of blood hemoglobin that is carrying oxygen. Normal oxygen saturation levels are considered to be 95-100 percent; low oxygen saturation values indicate worse disease. Room air oxygen saturation by pulse oximetry and/or amount of supplemental oxygen used, if saturation <90%, were recorded.
Measured: Week 24 , Week 48
Percent Change From Baseline in Pulmonary Vascular Resistance Measured by Right Heart Catheterization
During a right heart catheterization, a catheter is guided to the right side of the heart and then into the pulmonary artery; blood flow through the heart is observed and is used to measure pressures in a participant's heart and lungs. Pulmonary vascular resistance (PVR) is measured in Woods Units. Higher PVR values indicate worse disease status.
Change in PVR is determined by Baseline value minus (-) Week 24 value.
Measured: Baseline (Pre Treatment Initiation) to Week 24
Number of Infusion-Related Toxicities
The number of Grade 3, 4, and 5 Adverse Events (AEs), which were defined as possibly, probably, or definitely related to rituximab or placebo infusion.
This study graded the severity of adverse events according to the National Cancer Institute's Common Terminology Criteria for Adverse Events (NCI-CTCAE), Version 4.0.
Measured: Day 0 (Treatment Randomization) to Week 48
Number of Grade 3 or Higher Adverse Events (AEs) Through Week 48
Total number of Grade 3, 4, and 5 AEs. Ref: National Cancer Institute's Common Terminology Criteria for Adverse Events (NCI-CTCAE), Version 4.0.
Measured: Baseline (Pre Treatment Initiation) to Week 48
Number of Infection-Related Adverse Events (AEs) Through Week 48
Number of adverse events classified as infections. Reference: National Cancer Institute's Common Terminology Criteria for Adverse Events (NCI-CTCAE), Version 4.0.
Measured: Day 0 (Treatment Randomization) to Week 48
Treatment-Related Mortality: From Treatment Initiation to Week 48
Death occurring after randomization and ≤ Week 48, and possibly, probably, or definitely resulting from assigned study treatment.
Measured: Day 0 (Treatment Randomization) to Week 48
All-Cause Mortality: From Treatment Initiation to Week 48
Death from any cause occurring after randomization and ≤ Week 48.
Measured: Day 0 (Treatment Randomization) to Week 48
All-Cause Mortality: From Treatment Initiation to Week 104
Death from any cause occurring after randomization and ≤ Week 104.
Measured: Day 0 (Treatment Randomization) to Week 104
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted15 Mar 2010 (estimated)
- Study start24 Jun 2011
- Primary completion5 Jun 2018
- Study completion15 Dec 2019
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Posted resultsParticipant flow, outcome measures and adverse events reported by the sponsor.
- Publications (5)Papers the sponsor has linked to this study.
- Other trials for Systemic Sclerosis-Associated PAHStudies of the same condition, open and under way.
- More trials run by National Institute of Allergy and Infectious Diseases (NIAID)The sponsor's other registered studies.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase 2
- Primary purpose
- Treatment
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Quadruple blind
- Who is masked
- Participant, Care provider, Investigator, Outcomes assessor
- Enrolment
- 57 participants (actual)
Sponsor and investigators
- Sponsor type
- US National Institutes of Health
- Collaborators
- Autoimmunity Centers of Excellence, Rho Federal Systems Division, Inc.
- Responsible party
- Sponsor
- Investigators
- Mark Nicolls, M.D., Study chair, Stanford UniversityDavid B. Badesch, M.D., Study chair, University of Colorado Health Sciences Center (Aurora, CO)Thomas A. Medsger, Jr., M.D., Study chair, University of PittsburghLorinda Chung, MD, Study chair, Stanford UniversityRobyn Domsic, MD, Study chair, University of Pittsburgh: Division of Rheumatology and Clinical ImmunologyAryeh Fischer, MD, Study chair, National Jewish Health: University of Colorado School of MedicineRoham Zamanian, MD, Study chair, Stanford University
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT01086540
- Sponsor's protocol ID
- DAIT ASC01
- Status last verified
- Jan 2023
- First submitted
- 11 Mar 2010
- Last updated
- 21 Feb 2023
- Results posted
- Yes, on ClinicalTrials.gov
- Data monitoring committee
- Yes
Publications
Zamanian RT, Badesch D, Chung L, Domsic RT, Medsger T, Pinckney A, Keyes-Elstein L, D'Aveta C, Spychala M, White RJ, Hassoun PM, Torres F, Sweatt AJ, Molitor JA, Khanna D, Maecker H, Welch B, Goldmuntz E, Nicolls MR. Safety and Efficacy of B-Cell Depletion with Rituximab for the Treatment of Systemic Sclerosis-associated Pulmonary Arterial Hypertension: A Multicenter, Double-Blind, Randomized, Placebo-controlled Trial. Am J Respir Crit Care Med. 2021 Jul 15;204(2):209-221. doi: 10.1164/rccm.202009-3481OC.
PubMed 33651671Zhang Y, Michelakis ED. A Phase-2 NIH-sponsored Randomized Clinical Trial of Rituximab in Scleroderma-associated Pulmonary Arterial Hypertension Did Not Reach Significance for Its Endpoints: End of Story? Not So Fast! Am J Respir Crit Care Med. 2021 Jul 15;204(2):123-125. doi: 10.1164/rccm.202103-0612ED. No abstract available.
PubMed 33856964Andreasson K, Bengtsson MF, Bostrom C, Hesselstrand R, Volkmann ER. Multiple Manifestations of Systemic Sclerosis Affect Walk Distance. Am J Respir Crit Care Med. 2021 Aug 1;204(3):359. doi: 10.1164/rccm.202104-0938LE. No abstract available.
PubMed 34107236Zamanian RT, Pinckney A, Domsic RT, Medsger T, Keyes-Elstein L, Sweatt AJ, Welch B, Goldmuntz E, Nicolls MR, Chung L. Reply to Andreasson et al.: Multiple Manifestations of Systemic Sclerosis Affect Walk Distance. Am J Respir Crit Care Med. 2021 Aug 1;204(3):377-378. doi: 10.1164/rccm.202104-1023LE. No abstract available.
PubMed 34107229de Bourcy CFA, Dekker CL, Davis MM, Nicolls MR, Quake SR. Dynamics of the human antibody repertoire after B cell depletion in systemic sclerosis. Sci Immunol. 2017 Sep 29;2(15):eaan8289. doi: 10.1126/sciimmunol.aan8289.
PubMed 28963118
Study at a glance
From the registry record, last updated by the sponsor on 21 Feb 2023. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- A Randomized, Double-Blind, Placebo-Controlled, Phase II Multicenter Trial of a Monoclonal Antibody to CD20 (Rituximab) for the Treatment of Systemic Sclerosis-Associated Pulmonary Arterial Hypertension (SSc-PAH)
- ClinicalTrials.gov ID
- NCT01086540
- Acronym / sponsor ID
- DAIT ASC01
- Conditions
- Systemic Sclerosis-Associated PAH
- Keywords
- Pulmonary Arterial Hypertension (PAH), Autoimmune Disease, Systemic Scleroderma
- Phase
- Phase 2
- Study type
- Interventional
- Recruitment status
- Completed
- Enrolment
- 57 participants (actual)
- Lead sponsor
- National Institute of Allergy and Infectious Diseases (NIAID)US National Institutes of Health
- Collaborators
- Autoimmunity Centers of Excellence, Rho Federal Systems Division, Inc.
- Study start
- 24 Jun 2011 (actual)
- Primary completion
- 5 Jun 2018 (actual)
- Study completion
- 15 Dec 2019 (actual)
- First posted
- 15 Mar 2010 (estimated)
- Results
- Posted 21 Aug 2020
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
Systemic sclerosis-associated pulmonary arterial hypertension (SSc-PAH) is a serious, life-threatening manifestation of systemic sclerosis (SSc), an autoimmune disease of the connective tissue characterized by scarring (fibrosis) and atrophy of the skin, joints and tendons, skeletal muscles, and internal organs, and immunological disturbances. One-year survival for patients with SSc-PAH ranges from 50-81%. There is currently no cure for SSc-PAH and treatment is limited to vasodilator therapy used in all forms of PAH. In recent studies, immunotherapy was shown to be effective in treating SSc-interstitial lung disease, another serious, life-threatening manifestation of SSc. In addition, there are compelling pre-clinical data and anecdotal clinical reports that suggest modulation of the immune system may be an effective strategy for treating SSc-PAH. To test this approach, this trial will determine if rituximab, an immunotherapy, has a marked beneficial effect on clinical disease progression, with minimal toxicity, in patients with SSc-PAH when compared to placebo.
Detailed description
This prospective, double-blind, placebo-controlled, multi-center, randomized trial will evaluate the effect of rituximab on disease progression in subjects with SSc-PAH receiving concurrent stable-dose standard medical therapy with a prostanoid, endothelin receptor antagonist, and/or phosphodiesterase 5 (PDE-5) inhibitor. The study will focus on assessment of clinical response and safety measures longitudinally. In addition, the effects of treatment with rituximab on the underlying immune mechanisms associated with B-cell dysregulation and pathogenic autoantibody response in this disease will be investigated. 1000 mg of rituximab or placebo will be administered as two IV infusions given two weeks apart. Clinical assessments and sample collection will occur at monthly visits through Week 48. If a participant has not recovered B cells by Week 48, B cell studies will be conducted quarterly until reconstitution is documented or for 2 years after initial treatment.
This trial will include a sub-study, entitled "Right Ventricular Response to Rituximab in Systemic Sclerosis-Associated Pulmonary Arterial Hypertension - A Magnetic Resonance Imaging Sub-study" (RESTORE Sub-study). The objective of the RESTORE sub-study is to evaluate the therapeutic effect of rituximab on the right ventricle of patients with SSc-PAH. Changes in right ventricular end diastolic volume index (RVEDVI) and stroke volume (SV) determined by cardiac MRI will be used as surrogates of right ventricle function and prognosis. Enrollment for the RESTORE sub-study will parallel that of main trial. Twenty patients from each treatment arm, distributed among all participating sites, will be recruited for this sub-study. Each patient will be studied at baseline (i.e. prior to initiation of study drug) and after 24 weeks or at time of discontinuation. In addition to the data collection and testing specified in the main trial, participants in RESTORE will undergo comprehensive cardiac MRI evaluation. All main trial study inclusion and exclusion criteria apply, as well as additional exclusion criteria that pertain only to the RESTORE sub-study: 1) known hypersensitivity to Gadolinium; 2) inability to tolerate or cooperate with MRI; 3) morbid obesity; and 4) presence of metallic objects or pacemakers.
Study design
- Primary purpose
- Treatment
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Quadruple blind (participant, care provider, investigator, outcomes assessor)
- Number of arms
- 2
| Arm | Type | Receives |
|---|---|---|
| Rituximab+PAH SOC | Experimental | Biological: Rituximab, Diagnostic Test: CMRI, Drug: prednisone, Drug: methylprednisolone, Drug: diphenhydramine, Drug: acetaminophenRituximab (1000 mg) will be administered as 2 intravenous infusions given 2 weeks apart. Concurrent stable-dose Pulmonary Arterial Hypertension (PAH) medical therapy will be continued/managed as per standard of care (PAH SOC). |
| Placebo + PAH SOC | Placebo comparator | Other: Placebo, Diagnostic Test: CMRI, Drug: prednisone, Drug: methylprednisolone, Drug: diphenhydramine, Drug: acetaminophenPlacebo will be administered as 2 intravenous infusions given 2 weeks apart. Concurrent stable-dose Pulmonary Arterial Hypertension (PAH) medical therapy will be continued/managed as per standard of care (PAH SOC). |
Who may qualify
- Ages
- 18 to 75 years
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
Key inclusion criteria (10 listed)
- Subject has provided written informed consent.
- Clinical diagnosis of systemic sclerosis (either limited or diffuse cutaneous disease).
- Diagnosis of SSc-PAH within the past 5 years, with a mean pulmonary arterial pressure of ≥ 25 mmHg at entry.
- Mean Pulmonary Vascular Resistance (PVR) of > 3 Wood units.
- Screening 6-minute Walking Distance (6MWD) of at least 100 meters.
Key exclusion criteria (32 listed)
- Documented PAH for greater than 5 years at the time of randomization defined as:
- Pulmonary Capillary Wedge Pressure > 15 mmHg or Left Ventricular End Diastolic Pressure > 15 mmHg.
- Persistent hypotension with Systolic Blood Pressure (SBP) < 90 mmHg.
- Treatment with cyclophosphamide within 4 weeks of randomization.
- Treatment with immunocompromising biologic agents within 4 weeks prior to treatment initiation or treatment with infliximab within 8 weeks prior to treatment initiation.
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| RituximabAlso: Rituxan®Participants receive rituximab intravenous (IV) infusions, 1000 mg each, 14 days apart (Day 0 and Week 2). Rituximab is supplied as a sterile, clear, colorless, preservative-free liquid concentrate for intravenous (IV) administration in either 100 mg (10 mL) or 500 mg (50 mL) single-use vials, which must be diluted before administration Standard rituximab pre-medications will be provided in preparation for the rituximab infusions. | Biological | Rituximab+PAH SOC |
| PlaceboAlso: Placebo for rituximabParticipants receive placebo intravenous (IV) infusions 14 days apart (Day 0 and Week 2). Standard pre-medications will be provided in preparation for the infusions. | Other | Placebo + PAH SOC |
| CMRIAlso: cardiac MRI, cardiac Magnetic Resonance ImagingUp to 20 participants from each treatment arm will be assessed by CMRI at Baseline and at Week 24. | Diagnostic test | Placebo + PAH SOC, Rituximab+PAH SOC |
| prednisoneAlso: prednisone tablets, Rayos®Prednisone dose of 40 mg (or equivalent) by mouth administered the night before and the morning of each study drug infusion. | Drug | Placebo + PAH SOC, Rituximab+PAH SOC |
| methylprednisoloneAlso: corticosteroidMethylprednisolone (or equivalent corticosteroid) administered intravenously 30 minutes prior to each study drug infusion. | Drug | Placebo + PAH SOC, Rituximab+PAH SOC |
| diphenhydramineAlso: Benadryl®Diphenhydramine 50 mg (or equivalent) administered by mouth approximately thirty to sixty minutes prior to each study drug infusion. Dose may be repeated every four hours, as needed. | Drug | Placebo + PAH SOC, Rituximab+PAH SOC |
| acetaminophenAlso: Tylenol®Acetaminophen 650 mg (or equivalent) administered by mouth approximately thirty to sixty minutes prior to each study drug infusion. Dose may be repeated every four hours, as needed. | Drug | Placebo + PAH SOC, Rituximab+PAH SOC |
Primary outcome
Change From Baseline in Distance Walked During a Six Minute Walk Test
Time frame: Baseline (Pre Treatment Initiation) to Week 24
The six minute walk test measures the distance a participant is able to walk over a total of six minutes on a hard, flat surface. The goal is for the participant to walk as far as possible in six minutes. The participant is allowed to self-pace and rest as needed as they traverse back and forth along a marked walkway. The total distance walked, in meters, was recorded for each participant. Longer distances indicate better outcomes.
18 secondary outcomes
Change From Baseline in Pulmonary Vascular Resistance Measured by Right Heart Catheterization at Week 24
Time frame: Baseline (Pre Treatment Initiation) to Week 24
Change From Baseline in Distance Walked During a Six Minute Walk Test at Week 24 and Week 48
Time frame: Baseline (Pre Treatment Initiation) to Week 24 and Week 48
Time to Clinical Worsening
Time frame: Baseline (Pre Treatment Initiation) to Week 48
Time to the Change or Addition of New Pulmonary Arterial Hypertension (PAH) Therapeutic Medications
Time frame: Baseline (Pre Treatment Initiation) to Week 48
Change From Baseline in Quality of Life as Measured by the Short Form Health Survey (SF-36): Mental Component Summary Score
Time frame: Baseline (Pre Treatment Initiation) to Week 24 and Week 48
Change From Baseline in Quality of Life as Measured by the Short Form Health Survey (SF-36): Physical Component Summary Score
Time frame: Baseline (Pre Treatment Initiation) to Week 48
Change in Quality of Life as Measured by the Disability Index of the Scleroderma Health Assessment Questionnaire (HAQ-DI)
Time frame: Baseline (Pre Treatment Initiation) to Week 24 and Week 48
Number of New Digital Ulcers
Time frame: Baseline (Pre Treatment Initiation) to Week 24 and Week 48
Change in Severity of Raynaud's Phenomenon
Time frame: Baseline (Pre Treatment Initiation) to Week 24 and Week 48
Change in Carbon Monoxide Diffusing Capacity (DLCO)
Time frame: Baseline (Pre Treatment Initiation) to Week 24 and Week 48
Oxygen Saturation Levels at Week 24 and Week 48
Time frame: Week 24 , Week 48
Percent Change From Baseline in Pulmonary Vascular Resistance Measured by Right Heart Catheterization
Time frame: Baseline (Pre Treatment Initiation) to Week 24
Number of Infusion-Related Toxicities
Time frame: Day 0 (Treatment Randomization) to Week 48
Number of Grade 3 or Higher Adverse Events (AEs) Through Week 48
Time frame: Baseline (Pre Treatment Initiation) to Week 48
Number of Infection-Related Adverse Events (AEs) Through Week 48
Time frame: Day 0 (Treatment Randomization) to Week 48
Treatment-Related Mortality: From Treatment Initiation to Week 48
Time frame: Day 0 (Treatment Randomization) to Week 48
All-Cause Mortality: From Treatment Initiation to Week 48
Time frame: Day 0 (Treatment Randomization) to Week 48
All-Cause Mortality: From Treatment Initiation to Week 104
Time frame: Day 0 (Treatment Randomization) to Week 104
Results and safety
Loading the posted results from ClinicalTrials.gov…
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 21 Feb 2023.
- Posted resultsParticipant flow, baseline, all outcome measures and adverse events.
- Results publication: PubMed 33651671Zamanian RT, Badesch D, Chung L, Domsic RT, Medsger T, Pinckney A, Keyes-Elstein L, D'Aveta C, Spychala M, White RJ, Hassoun PM, Torres F, Sweatt AJ, Molitor JA, Khanna D, Maecker H, Welch B, Goldmuntz E, Nicolls MR. Safety and Efficacy of B-Cell Depletion with Rituximab for the Treatment of Systemic Sclerosis-associated Pulmonary Arterial Hypertension: A Multicenter, Double-Blind, Randomized, Placebo-controlled Trial. Am J Respir Crit Care Med. 2021 Jul 15;204(2):209-221. doi: 10.1164/rccm.202009-3481OC.
- Results publication: PubMed 33856964Zhang Y, Michelakis ED. A Phase-2 NIH-sponsored Randomized Clinical Trial of Rituximab in Scleroderma-associated Pulmonary Arterial Hypertension Did Not Reach Significance for Its Endpoints: End of Story? Not So Fast! Am J Respir Crit Care Med. 2021 Jul 15;204(2):123-125. doi: 10.1164/rccm.202103-0612ED. No abstract available.
- Results publication: PubMed 34107236Andreasson K, Bengtsson MF, Bostrom C, Hesselstrand R, Volkmann ER. Multiple Manifestations of Systemic Sclerosis Affect Walk Distance. Am J Respir Crit Care Med. 2021 Aug 1;204(3):359. doi: 10.1164/rccm.202104-0938LE. No abstract available.
- Results publication: PubMed 34107229Zamanian RT, Pinckney A, Domsic RT, Medsger T, Keyes-Elstein L, Sweatt AJ, Welch B, Goldmuntz E, Nicolls MR, Chung L. Reply to Andreasson et al.: Multiple Manifestations of Systemic Sclerosis Affect Walk Distance. Am J Respir Crit Care Med. 2021 Aug 1;204(3):377-378. doi: 10.1164/rccm.202104-1023LE. No abstract available.
- Derived from this study: PubMed 28963118de Bourcy CFA, Dekker CL, Davis MM, Nicolls MR, Quake SR. Dynamics of the human antibody repertoire after B cell depletion in systemic sclerosis. Sci Immunol. 2017 Sep 29;2(15):eaan8289. doi: 10.1126/sciimmunol.aan8289.
- The National Institute of Allergy and Infectious Diseases (NIAID)Link provided by the sponsor.
- The Division of Allergy, Immunology, and Transplantation (DAIT)Link provided by the sponsor.
Related trials for Systemic Sclerosis-Associated PAH
RecruitingObservational study
Hormonal, Metabolic, and Signaling Interactions in PAH
Idiopathic Pulmonary Arterial Hypertension, Heritable Pulmonary Arterial Hypertension
Active, not recruitingPhase 2
Oral Ifetroban to Treat Diffuse Cutaneous Systemic Sclerosis (SSc) or SSc-associated Pulmonary Arterial Hypertension
Scleroderma, Diffuse, Scleroderma, Systemic
RecruitingObservational study
Multicenter Study on the Development of Pulmonary Arterial Hypertension Screening Models Based on Artificial Intelligence for Patients With Systemic Sclerosis
Pulmonary Hypertension, Systemic Sclerosis (SSc)
Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Mark Nicolls, M.D. study chair
Stanford University
David B. Badesch, M.D. study chair
University of Colorado Health Sciences Center (Aurora, CO)
Thomas A. Medsger, Jr., M.D. study chair
University of Pittsburgh
17 sites in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A Phase 2 study testing Rituximab, CMRI and prednisone in people with Systemic Sclerosis-Associated PAH, run by National Institute of Allergy and Infectious Diseases (NIAID) at 17 sites in United States.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 10 inclusion and 32 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: finished, as of the sponsor's last update on 21 Feb 2023. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 17 sites in United States. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. Some participants in this study may receive a placebo. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
What does this phase mean?
Phase 2 studies give the treatment to a larger group to see whether it has the intended effect and to keep checking safety.
Not every study follows the same path, and some studies (observational studies, device studies) have no phase.
Are results available for this study?
Yes. Results are posted in the registry (first posted 21 Aug 2020). A summary is in the For doctors view, and the full results are on ClinicalTrials.gov.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Change From Baseline in Distance Walked During a Six Minute Walk Test (time frame: Baseline (Pre Treatment Initiation) to Week 24). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT01086540, which also lists 5 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 21 Feb 2023.