A Study to Evaluate the Efficacy and Safety of Rituximab Versus Mycophenolate Mofetil (MMF) in Participants With Pemphigus Vulgaris (PV)

A Randomized, Double-Blind, Double-Dummy, Active-Comparator, Multicenter Study to Evaluate the Efficacy and Safety of Rituximab Versus MMF in Patients With Pemphigus Vulgaris

This is a Phase III, randomized, double-blind, double-dummy, active-comparator, parallel-arm, multicenter study to evaluate the efficacy and safety of rituximab compared with MMF in participants with moderate-to-severely active PV requiring 60-120 milligrams per day (mg/day) oral prednisone or equivalent. Participants must have a confirmed diagnosis of PV within the previous 24 months (by skin or mucosal biopsy and immunohistochemistry) and evidence of active disease at screening.

Approximately 135 participants will be enrolled at up to 60 centers worldwide. Participants will be randomized in a 1:1 ratio to receive either rituximab plus MMF placebo or rituximab placebo plus MMF. Randomization will be stratified by duration of illness.

The study will consist of three periods: a screening period of up to 28 days, a 52-week double-blind treatment period, and a 48-week safety follow up period that begins at the time of study treatment completion or discontinuation.

Study Overview

• Status: Completed
• Conditions: Pemphigus Vulgaris
• Intervention / Treatment: Drug: Mycophenolate Mofetil; Drug: Rituximab Placebo; Drug: Mycophenolate Mofetil Placebo; Drug: Rituximab

• Study Type: Interventional
• Enrollment (Actual): 135
• Phase: Phase 3

Contacts and Locations

Study Locations

• Argentina
  • Buenos Aires, Argentina, C1181ACH
    • Hospital Italiano
  • Florencio Varela, Argentina, 1888
    • Centro de Investigaciones Médicas - CIM
  • Mendoza, Argentina, 5500
    • Hospital Luis Lagomaggiore
  • Pilar, Pcia De Buenos Aires, Argentina, 1500
    • Hospital Austral
• Australia
  • New South Wales
    • Kogarah, New South Wales, New South Wales, Australia, 2217
      • St George Hospital
  • Queensland
    • Woolloongabba, Queensland, Australia, 4102
      • Veracity Clinical Research
• Brazil
  • SP
    • Botucatu, SP, Brazil, 18618-970
      • Faculdade de Medicina de Botucatu - Hospital das Clínicas
    • Sao Paulo, SP, Brazil, 05403-000
      • Hospital das Clinicas - FMUSP
    • São Paulo, SP, Brazil, 01221-020
      • Santa Casa de São Paulo Hospital Central X
• Canada
  • Alberta
    • Edmonton, Alberta, Canada, T6G 2G3
      • University of Alberta
  • British Columbia
    • Surrey, British Columbia, Canada, V3R 6A7
      • Guildford Dermatology
  • Ontario
    • Markham, Ontario, Canada, L3P 1X2
      • Lynde Institute for Dermatology
• France
  • Bobigny, France, 93000
    • Department of Dermatology Avicenne Hospital & University
  • CHU Hopitaux De Bordeaux, France, 33000
    • CHU Hopitaux de Bordeaux
  • Lille, France, 59037
    • Centre Hospitalier Régional Universitaire de Lille (CHRU) - Hôpital Claude Huriez
  • Lyon / Pierre Bénite, France, 69495
    • Les Hospices Civils de Lyon Dermatologie inflammatoire et médecine interne
  • Reims, France, 51100
    • CHU de Reims
  • Rennes, France, 35033
    • CHU de Rennes - Hopital de Pontchaillo
  • Rouen, France, 76031
    • CHU de Rouen - Hôpital Charles Nicolle
  • Saint Etienne, France, 42055
    • CHU Saint Etienne - Hôpital Nord
• Germany
  • Dresden, Germany, 01304
    • University Hospital for Dermatology
  • Freiburg, Germany, 79104
    • Kompetenzzentrum Fragile Haut Klinik fur Dermatologie und Venerologie
  • Heidelberg, Germany, 69120
    • Universitätsklinikum Heidelberg
  • Koeln, Germany, 50937
    • Klinik und Poliklinik für Dermatologie und Venerologie Universitätsklinikum Köln
  • Lübeck, Germany, 23538
    • University Hospital Schleswig-Holstein
  • Mainz, Germany, 55131
    • Universitaetsmedizin der Johannes Gutenberg-Universitaet Mainz KöR, Hautklinik und Poliklinik
  • Muenster, Germany, 48149
    • University of Munster
• Israel
  • Afula, Israel, 18341
    • HaEmek MC
  • Haifa, Israel, 31096
    • Rambam Medical Centre; Dept. of Dermatology
  • Petach Tikva, Israel, 49100
    • Rabin Medical Centre; Dept. of Dermatology
  • Ramat Gan, Israel, 5262100
    • Sheba Medical Center
  • Tel-Aviv, Israel, 6423906
    • Sourasky Medical Centre
• Italy
  • Lazio
    • Florence, Lazio, Italy, 50125
      • Ambulatorio di Malattie Rare e Immunopatologia Cutanea
    • Parma, Lazio, Italy
      • Università di Parma Clinica Dermatologica
    • Pavia, Lazio, Italy, 27100
      • U.O. Dermatologia Dipartimento Malattie Infettive Fondazione IRCCS Policlinico San Matteo
    • Rome, Lazio, Italy, 00167
      • Centro Clinico per le genodermatosi Dipartimento di Dermatologia dell'Immacolata - IRCCS
    • Turin, Lazio, Italy, 10126
      • S.C. Dermatologia 2 - Ambulatorio Malattie Rare
  • Lombardia
    • Brescia, Lombardia, Italy, 25123
      • ASST DEGLI SPEDALI CIVILI DI BRESCIA; Clinica Dermatologica
• Spain
  • Barcelona, Spain, 08036
    • Hospital Clinic. Barcelona
  • Madrid, Spain, 28007
    • Hosp. G. U Gregorio Marañón
  • Malaga, Spain, 29010
    • Hospital de la Victoria
  • Navarra
    • Pamplona, Navarra, Spain, 31008
      • Clinica Universitaria De Navarra
• Turkey
  • Ankara, Turkey
    • Gülhane Military Medical Academy in Ankara
  • Antalya, Turkey, 07059
    • Akdeniz University Medical Faculty
  • Gaziantep, Turkey
    • Gaziantep University Medical Faculty Sahinbey Hospital
  • Istanbul, Turkey, 34668
    • Haydarpasa Numune Training and Research Hospital
  • Istanbul, Turkey, 34093
    • Bezm-i Alem University Medical Faculty
  • Istanbul, Turkey, 34093
    • Istanbul Uni Istanbul Medical Faculty
  • Istanbul, Turkey
    • Marmara Uni
  • Manisa, Turkey, 45040
    • Celal Bayar University Medical Faculty Hafsa Sultan Hospital
  • Trabzon, Turkey
    • Karadeniz Teknik Üniversitesi Tıp Fakültesi Farabi Hastanesi
• Ukraine
  • Dnipropterovsk, Ukraine
    • Dnipropetrovsk State Medical Academy
  • Kyiv, Ukraine, 01032
    • Territorial Medical Association "Dermatovenerologia"
• United States
  • Alabama
    • Birmingham, Alabama, United States, 35294
      • University of Alabama Birmingham
  • Arizona
    • Tucson, Arizona, United States, 85724
      • University of Arizona Medical Research Office
  • California
    • Sacramento, California, United States, 95816
      • UC Davis Department of Dermatology
    • San Francisco, California, United States, 94115
      • Univ of Calif-San Francisco
    • Torrance, California, United States, 90502
      • Los Angeles Biomedical Research Institute
  • Illinois
    • Chicago, Illinois, United States, 60611
      • Northwestern University
  • Massachusetts
    • Boston, Massachusetts, United States, 02114
      • Massachusetts General Hospital Dermatology
  • Minnesota
    • Minneapolis, Minnesota, United States, 55455
      • University of Minnesota
  • Missouri
    • Saint Louis, Missouri, United States, 63104
      • St Louis University Hospital
  • New York
    • Buffalo, New York, United States, 14203
      • Uni of NY and Roswell Cancer
    • New York, New York, United States, 10029
      • Icahn School of Medicine at Mount Sinai
  • North Carolina
    • Winston-Salem, North Carolina, United States, 27104
      • Wake Forest Baptist Hospital Center for Dermatology Research
  • Ohio
    • Cleveland, Ohio, United States, 44195
      • Cleveland Clinic
  • Oregon
    • Portland, Oregon, United States, 97239
      • Oregon Health Sciences Uni
  • Pennsylvania
    • Philadelphia, Pennsylvania, United States, 19104
      • Penn University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 14 years to 71 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Confirmed diagnosis of PV within the previous 24 months, based on the presence of histological features of acantholysis via skin or mucosal biopsy and one of the following: tissue bound immunoglobulin G (IgG) antibodies by direct immunofluorescence on the surface of affected epithelium or serological detection of serum desmoglein-3 (DSg3) autoantibodies against epithelial cell surface either by indirect immunofluorescence microscopy or by enzyme-linked immunosorbent assay
• Presence of moderate-to-severely active disease, defined as overall PDAI activity score of greater than or equal to (>/=)15
• Receiving standard-of-care corticosteroids consisting of 60-120 mg/day oral prednisone or equivalent and, in the judgment of the investigator, expected to benefit from the addition of immunosuppressive therapy
• For women who are not postmenopausal (>/=12 months of non-therapy-induced amenorrhea) or surgically sterile (absence of ovaries and/or uterus): agreement to remain abstinent or use two effective methods of contraception, including at least one method with a failure rate of less than (<) 1 percent (%) per year, during the treatment period and for at least 12 months after the last dose of study treatment

Abstinence is acceptable only if it is in line with the preferred and usual lifestyle of the participant. Periodic abstinence (e.g., calendar, ovulation, symptothermal, or postovulation methods) and withdrawal are not acceptable methods of contraception

Barrier methods must always be supplemented with the use of a spermicide

Examples of contraceptive methods with a failure rate of < 1% per year (highly effective contraceptive methods) include tubal ligation, male sterilization, hormonal implants, established, proper use of combined oral or injected hormonal contraceptives, and certain intrauterine devices

• For men (including those who have undergone a vasectomy): agreement to remain abstinent or use a condom during the treatment period and for at least 12 months after the last dose of study treatment and agreement to refrain from donating sperm during this same period

Abstinence is only acceptable if it is in line with the preferred and usual lifestyle of the participant

Periodic abstinence (e.g., calendar, ovulation, symptothermal, or postovulation methods) and withdrawal are not acceptable methods of contraception. In addition to male contraception, agreement to advise female partners of childbearing potential to use highly effective contraception during the study and for at least 12 months after the last dose of study treatment

• Agreement to avoid excessive exposure to sunlight during study participation
• Able to comply with the study protocol, in the investigator's judgment

Exclusion Criteria:

• Diagnosis of pemphigus foliaceus or evidence of paraneoplastic pemphigus or other non-PV autoimmune blistering disease
• History of a severe allergic or anaphylactic reaction to humanized or murine monoclonal antibodies, or known hypersensitivity to any component of rituximab
• Known hypersensitivity or contraindication to MMF, mycophenolic acid, polysorbate, or oral corticosteroids
• Lack of peripheral venous access
• Pregnant or lactating, or intending to become pregnant during the study

Women who are not postmenopausal (>/=12 months of non-therapy-induced amenorrhea) or surgically sterile must have two negative results with a sensitivity of >/=25 milli-international units per milliliter (mIU/mL): one from a serum pregnancy test at Day -8 to Day -10 of screening and another from a urine pregnancy test at Day 1 prior to randomization

• Participated in another interventional clinical trial within 28 days prior to randomization
• Use of any investigational agent within 28 days or 5 elimination half-lives prior to randomization (whichever is the longer)
• Significant cardiovascular or pulmonary disease (including obstructive pulmonary disease)
• Evidence of any new or uncontrolled concomitant disease that, in the investigator's judgment, would preclude participant participation, including but not limited to nervous system, renal, hepatic, endocrine, malignant, or gastrointestinal disorders
• Any concomitant condition that required treatment with oral or systemic corticosteroids within 12 weeks prior to randomization
• Treatment with intravenous (IV) immunoglobulin (Ig), plasmapheresis, or other similar procedure within 8 weeks prior to randomization
• Treatment with immunosuppressive medications (e.g., azathioprine, MMF) within 1 week prior to randomization
• Treatment with cyclophosphamide within 12 weeks prior to randomization
• History of or currently active primary or secondary immunodeficiency, including known history of HIV infection and other severe immunodeficiency blood disorders
• Known active infection of any kind (excluding fungal infections of nail beds) or any major episode of infection requiring hospitalization or treatment with IV anti-infectives within 4 weeks prior to screening, or completion of oral anti-infectives within 2 weeks prior to randomization; entry into this study may be reconsidered once the infection has fully resolved
• History of or current cancer, including solid tumors, hematologic malignancies, and carcinoma in situ (except complete excision of basal cell of the skin and squamous cell carcinoma of the skin that have been treated or excised and cured)
• Currently active alcohol or drug abuse, or history of alcohol or drug abuse within 24 weeks prior to screening
• Major surgery within 4 weeks prior to randomization, excluding diagnostic surgery
• Treatment with rituximab or a B cell-targeted therapy (e.g., anti-cluster of differentiation [CD] 20 [CD20], anti CD22, or anti-B-lymphocyte stimulator [BLyS]) within 12 months prior to randomization
• Treatment with a live or attenuated vaccine within 28 days prior to randomization; it is recommended that a participant's vaccination record and the need for immunization prior to study entry be carefully investigated
• Evidence of abnormal liver enzymes or hematology laboratory values
• Positive test results for hepatitis B surface antigen (HBsAg), hepatitis B core antibody (HBcAb), or hepatitis C virus (HCV) serology at screening

Study Plan

How is the study designed?

Design Details

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

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Mycophenolate Mofetil (MMF); Participants will receive MMF orally twice daily (every 12 hours, Q12H) from Day 1 to Week 52. Participants will also receive rituximab matching placebo by intravenous (IV) infusion on Days 1 and 15 with repeat administration on Days 168 and 182 provided specific safety criteria have been met.	Drug: Mycophenolate Mofetil; MMF will be administered at a starting dose of 500 milligrams (mg) Q12H and the dose will be titrated to achieve a goal of 1 gram (gm) Q12H.; Other Names: MMF, CellCept; Drug: Rituximab Placebo; Rituximab matching placebo will be administered via IV infusion.; Other Names: MabThera/Rituxan
Experimental: Rituximab (RTX); Participants will receive rituximab by IV infusion on Days 1 and 15 with repeat administration on Days 168 and 182 provided specific safety criteria have been met. Participants will also receive MMF matching placebo orally twice daily Q12H from Day 1 to Week 52.	Drug: Mycophenolate Mofetil Placebo; MMF matching placebo will be administered orally Q12H.; Drug: Rituximab; Rituximab will be administered at a dose of 1000 mg via IV infusion.; Other Names: MabThera/Rituxan

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Percentage of Participants (Excluding Telemedicine [TM] Participants) Who Achieved Sustained Complete Remission, Evaluated by the Pemphigus Disease Area Index (PDAI) Activity Score	From Baseline up to 52 Weeks (up to clinical cut-off date (CCOD) of 28 November 2018)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Cumulative Oral Corticosteroid Dose		From Baseline up to 52 Weeks (up to CCOD of 28 November 2018)
Total Number of Protocol Defined Disease Flares	Disease flare is defined as appearance of three or more new lesions a month that do not heal spontaneously within 1 week, or by the extension of established lesions, in a participant who has achieved disease control.	From Baseline up to 52 Weeks (up to CCOD of 28 November 2018)
Time to Initial Sustained Complete Remission		From Baseline up to 52 Weeks (up to CCOD of 28 November 2018)
Time to Protocol Defined Disease Flare	Disease flare is defined as the appearance of three or more new lesions a month that do not heal spontaneously within 1 week or by the extension of established lesions in a participant who has achieved disease control.	From Baseline up to 52 Weeks (up to CCOD of 28 November 2018)
Change in Health-Related Quality of Life (HRQoL), as Measured by the Dermatology Life Quality Index (DLQI) Score	Total DLQI scores range from 0 to 30 with higher DLQI scores reflecting greater impairment in a participant's health-related quality of life. The DLQI score is calculated by summing the score of each question resulting in a maximum of 30 and a minimum of 0. The higher the score, the more quality of life is impaired. The measure type mean is the estimated mean from adjusted MMRM.	From Baseline up to 52 Weeks (up to CCOD of 28 November 2018)
Percentage of Participants With Adverse Events, Serious Adverse Events, and Corticosteroid-Related Adverse Events	An adverse event is any untoward medical occurrence in a participant to whom a medicinal product is administered and which does not necessarily have a causal relationship with this treatment. A serious adverse event is an adverse event that results in death or is life-threatening or requires/prolongs hospitalization or results in persistent/significant disability/incapacity or congenital abnormality/birth defect. Adverse events of Grade 3 of higher are severe and life-threatening adverse events CS-related adverse events - causality as determined by the investigator.	Baseline up to 52 Weeks (up to CCOD of 28 November 2018)
Percentage of Participants With Anti-Drug Antibodies (ADA)	Participants with treatment-induced and treatment-enhanced anti-drug antibodies. The clinical relevance of anti-rituximab antibody formation in RITUXAN treated pemphigus vulgaris (PV) participants is unclear.	Baseline up to 52 Weeks (up to CCOD of 28 November 2018)
Percentage of Participants With Immunoglobulin (Ig) Levels Below Lower Limit of Normal (LLN)		Baseline; Weeks 16, 24, 40 and 52; (end of treatment: up to Week 52) (up to CCOD of 28 November 2018)

Collaborators and Investigators

• Sponsor: Hoffmann-La Roche
• Collaborators: Genentech, Inc.

Publications and helpful links

General Publications

• Werth VP, Joly P, Mimouni D, Maverakis E, Caux F, Lehane P, Gearhart L, Kapre A, Pordeli P, Chen DM; PEMPHIX Study Group. Rituximab versus Mycophenolate Mofetil in Patients with Pemphigus Vulgaris. N Engl J Med. 2021 Jun 17;384(24):2295-2305. doi: 10.1056/NEJMoa2028564. Epub 2021 May 19.

Study record dates

Study Major Dates

• Study Start (Actual): May 26, 2015
• Primary Completion (Actual): November 28, 2018
• Study Completion (Actual): October 29, 2019

Study Registration Dates

• First Submitted: March 4, 2015
• First Submitted That Met QC Criteria: March 4, 2015
• First Posted (Estimate): March 9, 2015

Study Record Updates

• Last Update Posted (Actual): November 10, 2020
• Last Update Submitted That Met QC Criteria: October 16, 2020
• Last Verified: October 1, 2020

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Skin Diseases; Immune System Diseases; Autoimmune Diseases; Skin Diseases, Vesiculobullous; Pemphigus; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Anti-Infective Agents; Enzyme Inhibitors; Antirheumatic Agents; Antineoplastic Agents; Immunologic Factors; Antineoplastic Agents, Immunological; Anti-Bacterial Agents; Antibiotics, Antineoplastic; Antitubercular Agents; Antibiotics, Antitubercular; Rituximab; Mycophenolic Acid
• Other Study ID Numbers: WA29330; 2014-000382-41 (EudraCT Number)