Rheumatoid Arthritis: Comparison of Active Therapies in Patients With Active Disease Despite Methotrexate Therapy (RACAT)

November 7, 2013 updated by: US Department of Veterans Affairs

CSP #551 - Rheumatoid Arthritis: Comparison of Active Therapies in Patients With Active Disease Despite Methotrexate Therapy

Rheumatoid arthritis (RA) is a chronic inflammatory disease of the joints leading to joint destruction, with significant long-term morbidity and mortality. Early treatment of RA patients with disease-modifying antirheumatic drugs (DMARDs) significantly decreases these complications. Methotrexate (MTX) is an excellent, economical first-line DMARD used to treat a majority of RA patients. While most patients respond well to MTX, many continue to have active disease. Therefore, understanding how to best treat RA patients with active disease despite MTX therapy is critically important. Although a number of therapies with significantly different economic implications have been shown to be effective when added to MTX, no trial has directly compared active therapies. This study will compare therapeutic strategies using two regimens with proven efficacy when added to MTX therapy; a) hydroxychloroquine and sulfasalazine (cost ~ $1000 per year); b) the tumor necrosis factor inhibitor, etanercept (cost ~ $12,000 per year).

We propose a bi-national multi-center randomized, double-blind equivalency trial comparing (A) the strategy of initially adding hydroxychloroquine and sulfasalazine to MTX in patients with active disease despite MTX, with a switch at 24 weeks to etanercept in nonresponders to (B) a strategy of adding etanercept to MTX, with a switch to hydroxychloroquine and sulfasalazine in nonresponders at 24 weeks. If we find that the strategy of first adding hydroxychloroquine and sulfasalazine to MTX identifies a subset of responsive patients and that there is no harm to nonresponders because of early rescue with etanercept, then this less expensive option should become the standard treatment for MTX resistant patients.

Four hundred and fifty RA patients with active disease despite treatment with MTX as indicated by a Disease Activity Score with 28 joints (DAS28) of >4.4 units will be randomized. A DAS improvement of <1.2 (validated as clinically significant) at 24 weeks will be used to identify early nonresponder who will switch therapy. Subjects with a DAS28 improvement of > 1.2 at 24 weeks will remain on their initial therapy. The primary endpoint is the change of DAS 28 scores from baseline to 48 weeks. The secondary endpoint is comparison of radiographic progression of disease at 48 weeks, as measured by the change in Sharp score. Economic and functional outcomes will be assessed and a serum and DNA bank will be established to evaluate potential biomarkers predictive of treatment response/toxicity and disease progression. This trial will recruit 450 subjects over 40 months. At the end of the 48 week blinded active therapy portion of the trial, the blind will be broken and data will be collected in an open fashion until all 450 patients have completed the 48 week portion of the trial.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

The main objective of this proposal is to compare two successful treatment strategies that have significantly different economic implications head-to-head in patients with rheumatoid arthritis who have active disease despite methotrexate therapy.

Rheumatoid arthritis (RA) is a chronic inflammatory disease of the joints leading to joint destruction, with significant long-term morbidity and mortality. Early treatment of RA patients with disease-modifying antirheumatic drugs (DMARDs) significantly decreases these complications. Methotrexate (MTX) is an excellent, economical first-line DMARD used to treat a majority of RA patients. While most patients respond well to MTX, many continue to have active disease. Therefore, understanding how to best treat RA patients with active disease despite MTX therapy is critically important. Although a number of therapies with significantly different economic implications have been shown to be effective when added to MTX, no trial has directly compared active therapies. This study will compare therapeutic strategies using two regimens with proven efficacy when added to MTX therapy; a) hydroxychloroquine and sulfasalazine (cost ~ $1000 per year); b) the tumor necrosis factor inhibitor, etanercept (cost ~ $12,000 per year).

We propose a bi-national multi-center randomized, double-blind equivalency trial comparing (A) the strategy of initially adding hydroxychloroquine and sulfasalazine to MTX in patients with active disease despite MTX, with a switch at 24 weeks to etanercept in nonresponders to (B) a strategy of adding etanercept to MTX, with a switch to hydroxychloroquine and sulfasalazine in nonresponders at 24 weeks. If we find that the strategy of first adding hydroxychloroquine and sulfasalazine to MTX identifies a subset of responsive patients and that there is no harm to nonresponders because of early rescue with etanercept, then this less expensive option should become the standard treatment for MTX resistant patients.

Four hundred and fifty RA patients with active disease despite treatment with MTX as indicated by a Disease Activity Score with 28 joints (DAS28) of greater than or equal to 4.4 units will be randomized. A DAS improvement of greater than or equal to 1.2 (validated as clinically significant) at 24 weeks will be used to identify early nonresponder who will switch therapy. Subjects with a DAS28 improvement of ≥ 1.2 at 24 weeks will remain on their initial therapy. The primary endpoint is the change of DAS 28 scores from baseline to 48 weeks. The secondary endpoint is comparison of radiographic progression of disease at 48 weeks, as measured by the change in Sharp score. Economic and functional outcomes will be assessed and a serum and DNA bank will be established to evaluate potential biomarkers predictive of treatment response/toxicity and disease progression. This trial will recruit 450 subjects over 40 months. At the end of the 48 week blinded active therapy portion of the trial, the blind will be broken and data will be collected in an open fashion until all 450 patients have completed the 48 week portion of the trial.

Study Type

Interventional

Enrollment (Actual)

353

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Canada
    • Alberta
      • Calgary, Alberta, Canada, T2N 4N1
        • University of Calgary (CRRC)
    • Manitoba
      • Winnipeg, Manitoba, Canada, R3A 1M4
        • University of Manitoba (CRRC)
    • Ontario
      • Brampton, Ontario, Canada, L6T 3J1
        • Brampton (CRRC)
      • Missassauga, Ontario, Canada, L5M 2V8
        • Credit Valley Rheumatology
      • Newmarket, Ontario, Canada, L3Y 3R7
        • Newmarket (CRRC)
      • Toronto, Ontario, Canada, M5T 3L9
        • Mount Sinai Hospital (CRRC)
      • Windsor, Ontario, Canada, N8X 5A6
        • Clinical Research and Arthritis Center
    • Quebec
      • Montreal, Quebec, Canada, H2L 4M1
        • Hopital Notre Dame (CRRC)
      • Sherbrooke, Quebec, Canada, J1H 5N4
        • Crc-Chus (Crrc)
  • United States
    • California
      • Loma Linda, California, United States, 92357
        • VA Medical Center, Loma Linda
      • Long Beach, California, United States, 90822
        • VA Medical Center, Long Beach
      • San Francisco, California, United States, 94121
        • VA Medical Center, San Francisco
      • Santa Maria, California, United States, 93454-6945
        • Pacific Arthritis Center (RAIN)
      • Sepulveda, California, United States, 91343
        • VA Greater Los Angeles HCS, Sepulveda
    • District of Columbia
      • Washington, District of Columbia, United States, 20422
        • VA Medical Center, DC
    • Minnesota
      • Duluth, Minnesota, United States, 55804
        • St. Mary's/ Duluth Clinic Health System (RAIN)
      • Minneapolis, Minnesota, United States, 55417
        • VA Medical Center, Minneapolis
      • Minneapolis, Minnesota, United States, 55417
        • Park Nicollet (RAIN)
      • Rochester, Minnesota, United States, 55905
        • Mayo Clinic
    • Missouri
      • St Louis, Missouri, United States, 63106
        • VA Medical Center, St Louis
    • Nebraska
      • Lincoln, Nebraska, United States, 68506
        • Lincoln Medical Center
      • Omaha, Nebraska, United States, 68105-1873
        • VA Medical Center, Omaha
      • Omaha, Nebraska, United States, 68198
        • Univesity of Nebraska Medical Center
    • North Dakota
      • Bismarck, North Dakota, United States, 58501
        • Bone, Spine Sports Clinic (RAIN)
      • Fargo, North Dakota, United States, 58102
        • VA Medical Center, Fargo
    • Oregon
      • Portland, Oregon, United States, 97201
        • VA Medical Center, Portland
    • Pennsylvania
      • Danville, Pennsylvania, United States, 17822
        • Geisinger Medical Center
      • Philadelphia, Pennsylvania, United States, 19104
        • VA Medical Center, Philadelphia
      • Pittsburgh, Pennsylvania, United States, 15240
        • VA Pittsburgh Health Care System
      • State College, Pennsylvania, United States, 16801
        • Geisinger Medical Group - State College
      • Wyoming Valley, Pennsylvania, United States, 18711
        • Geisinger Medical Group- Wilkes Barre
    • South Carolina
      • Charleston, South Carolina, United States, 29401-5799
        • Ralph H Johnson VA Medical Center, Charleston
    • South Dakota
      • Rapid City, South Dakota, United States, 57701
        • Rapid City Medical Center (RAIN)
      • Sioux Falls, South Dakota, United States, 57117-5046
        • Avera Research Institute (RAIN)
    • Texas
      • Dallas, Texas, United States, 75216
        • VA North Texas Health Care System, Dallas
    • Utah
      • Salt Lake City, Utah, United States, 84148
        • VA Salt Lake City Health Care System, Salt Lake City
    • Vermont
      • White River Junction, Vermont, United States, 05009-0001
        • VA Medical & Regional Office Center, White River

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • All patients must fulfill ACR classification criteria for rheumatoid arthritis.
  • All patients must have been 16 years of age or older at time of diagnosis of rheumatoid arthritis.
  • All patients must be 18 years of age or older at the time of entry into the study.
  • All patients will have been receiving oral or subcutaneous methotrexate 15 to 25 mg/week (unless intolerant and on a minimum 10 mg/week) at a constant dose for at least 4 weeks, and on any methotrexate for no less than 12 weeks.
  • All patients will have active disease as defined by a DAS28 of greater than or equal to 4.4.
  • If patients are receiving corticosteroids, they must have been on stable dose (less than or equal to 10 mg prednisone or equivalent) for at least two weeks prior to screening.
  • If patients are using non-steroidal anti-inflammatory drugs (NSAIDs), they must be on stable doses for at least one week prior to screening.
  • If patients have taken leflunomide, cyclosporine, gold, Anakinra, azathioprine, or penicillamine in combination with methotrexate, they must have stopped this therapy at least 8 weeks prior to randomization.

  • Laboratory tests must meet the following criteria within 2 weeks of randomization:

    • Serum creatinine 1.8 mg/dL
    • Hemoglobin 9 g/dL
    • WBC 3000 mc/L
    • Neutrophils 1000 mc/L
    • Platelets 100,000 mc/L
    • Serum transaminase level (AST or ALT, whichever is followed at the site) not exceeding 1.2 times upper limit of normal.
    • Albumin no less than 1.0 g/dL (10 g/L) below lower limit of normal. Anything below lower limit of normal must have been stable (or improving) for no less than 90 days. Stable is defined as changes of no more than 0.2 g/dL (2 g/L).
  • All patients must be capable of giving informed consent and able to adhere to study visit schedule.
  • Subject or designee must have the ability to self-inject investigational product or have a caregiver who can inject subcutaneous injections

  • Subjects must meet one of the following criteria with regard to tuberculosis. PPD must be within 180 days of randomization if the patient has no recent exposure/travel history, or within 90 days if the patient has a recent exposure/travel history.

    • Negative PPD; or
    • Positive PPD <5 mm, with a negative chest x-ray; or
    • Positive PPD >5mm, treated for at least 28 days with INH.
  • Subjects with an Erythrocyte sedimentation rate (ESR) of less than or equal to 10 and a tender and swollen joint count of at least 10 and does not qualify for the study using the DAS28, will be allowed to use the DAS28-CRP rather than the traditional DAS28 to determine eligibility.

Exclusion Criteria:

  • Previous intolerance to methotrexate (unless able to tolerate at least 10 mg/week)
  • Sensitivity to study medications
  • Previous treatment with methotrexate, sulfasalazine or hydroxychloroquine in combination with each other for longer than 4 weeks duration. No combination use is allowed within 4 weeks of screening.
  • No bed or wheelchair-bound patients

  • Previous treatment with a TNF- inhibitor (etanercept, infliximab or adalimumab) for more than 5 weeks of therapy. Previous treatment with TNF- inhibitor must have been stopped for reasons other than toxicity or efficacy. No TNF- inhibitor therapy is allowed within the following time frames:

    • Last dose of etanercept must have been at least 4 weeks before screening.
    • Last dose of adalimumab or infliximab must have been at least 8 weeks prior to screening.

Example of an eligible patient: A patient found he could not afford the co-pays for a TNF inhibitor after two doses and stopped taking the medication two months before being evaluated for this trial.

  • Evidence of important acute or chronic infections (no IV antibiotics within 1 month, and no PO antibiotics within 2 weeks)
  • Pregnant or nursing women
  • Women of childbearing potential or their partners who are not practicing an acceptable form of birth control as defined by investigator
  • Active substance abuse or psychiatric illness likely to interfere with protocol completion
  • History of multiple sclerosis, transverse myelitis, or optic neuritis
  • History of macular degeneration unless patient has letter from their ophthalmologist that will allow for participation in trial
  • New York Heart Association Class III or IV congestive heart failure
  • Active malignancy (other than in situ cervical cancer or non-melanoma skin cancer), or history of lymphoma
  • History of HIV
  • History of any opportunistic infection - to include but not limited to Pneumocystis carinii, aspergillosis, histoplasmosis, or atypical mycobacterium
  • History of porphyria
  • Diagnosis of SLE or seronegative spondyloarthropathy or any other form of concomitant arthritis (osteoarthritis is permitted)
  • Diagnosis of psoriasis unless rheumatoid factor positive
  • Any significant unstable medical condition considered a contraindication by investigator
  • Any participation in another investigational drug study during the 90 days preceding randomization.
  • Receipt of a live vaccine within 90 days of study entry.
  • History of oral or IV cyclophosphamide use
  • Life expectancy less than 2 years
  • Receipt of steroid injection, intravenous, intramuscular, or intraarticular, within 30 days of randomization.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Quadruple

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Active Comparator: Arm 1
Etanercept and Methotrexate. Participants also received placebo hydroxychloroquine and sulfasalazine
Drug: Etanercept
etanercept, subcutaneous injection
Other Names:
  • Enbrel
Drug: methotrexate
baseline methotrexate is maintained throughout the study and is not provided by the sponsor
Drug: Placebo, triple
Participants in Etanercept arm (Arm 1) were given placebo hydroxychloroquine and sulfasalazine pills.
Active Comparator: Arm 2
Hydroxychloroquine, sulfasalazine and methotrexate. Participants also received placebo etanercept.
Drug: methotrexate
baseline methotrexate is maintained throughout the study and is not provided by the sponsor
Drug: Sulfasalazine
sulfasalazine, oral
Drug: Hydroxychloroquine
hydroxychloroquine, oral
Other Names:
  • Plaquenil
Drug: Placebo, etanercept
Participants in triple arm (Arm 2) were given placebo etanercept injections.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Mean 48-week Change in DAS28
Time Frame: 48 weeks after baseline assessment

Average difference between 48-week and Baseline DAS28.

The Disease Activity Score for 28 Joints (DAS28) is a well-validated composite outcome measure ranging from 2-10 (higher scores indicating more disease) that incorporates a tender and swollen joint count of 28 joints, a laboratory measure of systemic inflammation (ESR) and a patient-reported general assessment of health on a visual analog scale (ranging from 0-10cm) all into one measure.

Low disease activity is defined as DAS28 ≤ 3.2 units.
48 weeks after baseline assessment

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

US Department of Veterans Affairs

Collaborators

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
Canadian Institutes of Health Research (CIHR)
Rheumatoid Arthritis Investigational Network (RAIN)

Investigators

  • Study Chair: James R. O'Dell, VA Medical Center, Omaha

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start

July 1, 2007

Primary Completion (Actual)

December 1, 2011

Study Completion (Actual)

May 1, 2012

Study Registration Dates

First Submitted

November 29, 2006

First Submitted That Met QC Criteria

November 29, 2006

First Posted (Estimate)

November 30, 2006

Study Record Updates

Last Update Posted (Estimate)

December 3, 2013

Last Update Submitted That Met QC Criteria

November 7, 2013

Last Verified

November 1, 2013

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 551
  • Y1-AR-0048-01 (Other Identifier: Inter Agency Agreement between NIAMS and DVA)

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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