Protocol Title : A Randomised, open labelled study in anti ... - EME
Protocol Title : A Randomised, open labelled study in anti ... - EME
Protocol Title : A Randomised, open labelled study in anti ... - EME
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1.3 Cl<strong>in</strong>ical Data<br />
1.3.1 Rituximab<br />
Cl<strong>in</strong>ical outcomes<br />
The efficacy and safety of Rituximab <strong>in</strong> alleviat<strong>in</strong>g the symptoms and signs of rheumatoid arthritis<br />
<strong>in</strong> patients with an <strong>in</strong>adequate response to TNF-<strong>in</strong>hibitiors was demonstrated <strong>in</strong> a pivotal<br />
randomized, controlled, double-bl<strong>in</strong>d, multicenter <strong>study</strong> (REFLEX).<br />
REFLEX evaluated 517 patients that had experienced an <strong>in</strong>adequate response or <strong>in</strong>tolerance to<br />
one or more TNF <strong>in</strong>hibitor therapies. Eligible patients had active rheumatoid arthritis, diagnosed<br />
accord<strong>in</strong>g to the criteria of the American College of Rheumatology (ACR). Rituximab was<br />
adm<strong>in</strong>istered as two IV <strong>in</strong>fusions separated by an <strong>in</strong>terval of 15 days. Patients received 2 x 1000<br />
mg <strong>in</strong>travenous <strong>in</strong>fusions of Rituximab or placebo <strong>in</strong> comb<strong>in</strong>ation with MTX. The primary endpo<strong>in</strong>t<br />
was the proportion of patients who achieved an ACR20 response at week 24. Patients were<br />
followed beyond week 24 for long term endpo<strong>in</strong>ts, <strong>in</strong>clud<strong>in</strong>g radiographic assessment at 56 weeks<br />
and at 104 weeks. Dur<strong>in</strong>g this time, 81% of patients, from the orig<strong>in</strong>al placebo group received<br />
rituximab between weeks 24 and 56, under an <strong>open</strong> label extension <strong>study</strong> protocol.<br />
Radiographic outcomes<br />
Structural jo<strong>in</strong>t damage was assessed radiographically and expressed as change <strong>in</strong> modified total<br />
Sharp Score (mTSS) and its components, the erosion score and jo<strong>in</strong>t space narrow<strong>in</strong>g score.<br />
In the REFLEX <strong>study</strong>, conducted <strong>in</strong> patients with <strong>in</strong>adequate response or <strong>in</strong>tolerance to one or<br />
more TNF <strong>in</strong>hibitor therapies, receiv<strong>in</strong>g Rituximab <strong>in</strong> comb<strong>in</strong>ation with methotrexate demonstrated<br />
significantly less radiographic progression than patients orig<strong>in</strong>ally receiv<strong>in</strong>g methotrexate alone at<br />
56 weeks. Of the patients orig<strong>in</strong>ally receiv<strong>in</strong>g methotrexate alone, 81 % received rituximab either<br />
as rescue between weeks 16-24 or <strong>in</strong> the extension trial, before week 56. A higher proportion of<br />
patients receiv<strong>in</strong>g the orig<strong>in</strong>al Rituximab/MTX treatment also had no erosive progression over 56<br />
weeks<br />
Quality of life outcomes<br />
Significant reductions <strong>in</strong> disability <strong>in</strong>dex (HAQ-DI) and fatigue (FACIT-Fatigue) scores were<br />
observed <strong>in</strong> patients treated with Rituximab compared to patients treated with methotrexate alone.<br />
The proportions of rituximab treated patients show<strong>in</strong>g a m<strong>in</strong>imal cl<strong>in</strong>ically important difference<br />
(MCID) <strong>in</strong> HAQ-DI (def<strong>in</strong>ed as an <strong>in</strong>dividual total score decrease of >0.22) was also higher than<br />
among patients receiv<strong>in</strong>g methotrexate alone<br />
1.3.2 Tocilizumab<br />
!<br />
Cl<strong>in</strong>ical outcomes<br />
In a number of studies, patients treated with tocilizumab had statistically significant higher ACR 20,<br />
50, 70 response rates at 6 months compared to control. In The AMBITION <strong>study</strong>, superiority of<br />
tocilizumab was demonstrated aga<strong>in</strong>st the active comparator MTX.<br />
The treatment effect was similar <strong>in</strong> patients <strong>in</strong>dependent of rheumatoid factor status, age, gender,<br />
race, number of prior treatments or disease status. Time to onset was rapid (as early as week 2)<br />
and the magnitude of response cont<strong>in</strong>ued to improve with duration of treatment. Cont<strong>in</strong>ued durable<br />
responses were seen for over 3 years <strong>in</strong> the ongo<strong>in</strong>g <strong>open</strong> label extension of a number of cl<strong>in</strong>ical<br />
trials - AMBITION, LITHE, OPTION, TOWARD and RADIATE. Patients <strong>in</strong> the afore mentioned<br />
studies had a mean Disease Activity Score (DAS28) of 6.5–6.8 at basel<strong>in</strong>e. Significant reduction <strong>in</strong><br />
DAS28 from basel<strong>in</strong>e (mean improvement) of 3.1–3.4 were observed <strong>in</strong> tocilizumab-treated<br />
patients compared to control patients (1.3-2.1). The proportion of patients achiev<strong>in</strong>g a DAS28<br />
cl<strong>in</strong>ical remission (DAS28 < 2.6) was significantly higher <strong>in</strong> patients receiv<strong>in</strong>g tocilizumab (28–34%)<br />
compared to 1–12% of control patients at 24 weeks. In <strong>study</strong> II, 65% of patients achieved a DAS28<br />
< 2.6 at week 104 compared to 48% at 52 weeks and 33% of patients at week 24.<br />
Radiographic response<br />
In the LITHE <strong>study</strong>, patients with an <strong>in</strong>adequate response to MTX, <strong>in</strong>hibition of structural jo<strong>in</strong>t<br />
damage was assessed radiographically and expressed as change <strong>in</strong> modified Sharp score and its<br />
Study: R4RA EudraCT: 2012-002535-28 13 / 34