Efficacy and Safety of DAPSone as a Second-line Option in Adult Immune Thrombocytopenia (DAPS-ITP)

Prospective Multicenter Randomized Open-label Controlled Trial Assessing Efficacy and Safety of DAPSone as a Second-line Option in Adult Immune Thrombocytopenia

Due to its expected efficacy based on the retrospective data available in ITP, its relatively good safety profile and its very low cost , dapsone could be a good steroid-sparing second-line option for adults with ITP.

This study is a phase III prospective multicenter randomized open trial comparing two treatment strategies:

• Arm A (experimental arm): prednisone at 1 mg/kg for 3 weeks + dapsone at 100 mg per day up to week 52 if an initial response is achieved.
• Arm B (control arm): prednisone alone at 1 mg/kg for 3 weeks followed by monitoring and "standard of care" The aim of the study is to demonstrate the efficacy of dapsone based on the overall response rate (including response and complete response) as a second-line treatment for adults with newly-diagnosed persistent or chronic (modified by amendment 08/11/2016) ITP not achieving a durable response with corticosteroids. The primary endpoint will be the overall response-rate (response or complete response according to standard definitions) in both arms at week 52 (1 year).

The secondary endpoints are the following :

• To assess the safety of dapsone over the study period and especially the incidence of cutaneous reactions.
• To analyze the overall response rate (platelet count > 30 x 109/L with at least a doubling of the pre-treatment count in the absence of any other ITP treatment) in both treatment arms at week 24.
• To compare the rate of complete response and failure in both arms at 24 and 52 weeks.
• To compare time to treatment failure (TTF) in both arms
• To investigate the mechanisms of action of dapsone in ITP in a subgroup of patients (ancillary study)

Study Overview

• Status: Unknown
• Conditions: Adult Immune Thrombocytopenia (ITP); Dapsone
• Intervention / Treatment: Drug: Dapsone (Disulone®); Drug: Prednisone (Cortancyl®); Drug: Prednisone (Cortancyl®) alone followed by monitoring and "standard of care"

• Study Type: Interventional
• Enrollment (Anticipated): 216
• Phase: Phase 3

Contacts and Locations

Study Locations

• France
  • Creteil, France, 94010
    • Recruiting
    • Henri Mondor Hospital

Participation Criteria

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:

• Age ≥ 18 years
• Diagnosis of primary ITP according to the standard definition and international guidelines.
• Previous transient response to corticosteroids ± intravenous immunoglobulin defined by an increase of the platelet count above 30 x 109/L with at least a twofold increase of the pre-treatment count.
• At least platelet count ≤ 30 x 109/L within the 2 weeks before inclusion with a platelet count at time of inclusion below 50 x 109/L, or platelet count < 50 x 109/L at any time point in patients requiring treatment (i.e., patients with bleeding symptoms, elderly patients with comorbidities and/or patients on aspirin for example, or other reason at the investigator discretion) (modified by amendment 8/11/2016)
• Normal marrow aspirate for patients aged of 60 and above.
• Negative pregnancy test and effective method of contraception for women of childbearing age over the study period.
• Informed consent.
• Patient affiliated to the French National Social Security System

Exclusion Criteria:

• Secondary ITP. Patients with positive antinuclear antibodies and/or positive antiphospholipid antibodies not fulfilling the classification criteria for systemic lupus erythematosus and/or antiphospholipid antibody syndrome will not be excluded.
• Platelet count ≥ 50 x 109/L or between 30 and 50 x 109/L and no bleeding symptoms and no need for treatment (modified by amendment 8/11/2016)
• Severe bleeding manifestations defined a bleeding score ≥ 8
• No previous transient response to corticosteroids ± intravenous immunoglobulin.
• Previous ITP treatment other than corticosteroids and intravenous immunoglobulin (including rituximab and splenectomy).
• Active severe infection or history of severe infection within 4 weeks before inclusion.
• History of allergy to sulfonamides.
• Glucose-6-phosphate dehydrogenase (G6PD) deficiency.
• History of methemoglobinemia
• Hemoglobin level < 11g/dL and/or neutrophil count < 1,500/ gL.
• History of autoimmune (Evans' syndrome) or hereditary haemolytic anemia.
• Liver or kidney function impairment (creatinine clearance < 30 ml/min, ALT, AST >2 times upper normal limit). (modified by amendment 8/11/2017)
• Hepatitis C virus (HCV) Ab, HIV Ab, HBsAg, seropositive status. (modified by amendment 8/11/2017)
• Concomitant medical condition requiring anticoagulation. (modified by amendment 8/11/2017)
• Pregnancy or lactation.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Dapsone: (Disulone®); Dapsone: Disulone® given orally at 100 mg per day	Drug: Dapsone (Disulone®); Experimental group will receive dapsone at a fixed dose of 100 mg per day for a total of 12 months unless they fail to respond to the treatment.; Other Names: experimental arm; Drug: Prednisone (Cortancyl®); Experimental group will receive prednisone at a daily dose of 1 mg per kg for 2 weeks and then tapered and stopped over a week for a total of 3 consecutive weeks.; Other Names: experimental arm
Active Comparator: Prednisone (Cortancyl®) alone and "standard of care"; Prednisone (Cortancyl®) alone at 1 mg/kg for 3 weeks followed by monitoring and "standard of care" (control arm)	Drug: Prednisone (Cortancyl®) alone followed by monitoring and "standard of care"; Patients randomized in the control arm will be treated only prednisone at a daily dose of 1 mg per kg for 2 weeks and then tapered and stopped over a week for a total of 3 consecutive weeks. After this 3 weeks period, patients from arm B will be left without treatment and monitored.; Other Names: control arm

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Overall response-rate.	at week 52

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Assess the safety of dapsone especially the incidence of cutaneous adverse effects.		over the study period (up to 52 weeks)
Compare the overall response rate .	platelet count > 30 x 109/L with at least a doubling of the pre-treatment count in the absence of any other ITP treatment in both arms	at week 24
Proportion of patients with complete response in both arms, defined as follows: - Proportion of patients with a platelet count > 100 x 109/L in the absence use of any other ITP directed therapies		at 24 and at 52 weeks
Proportion of non-responders patients (primary failure)	Patients will be considered as being non-responders if: Their platelet count at the end of the study is < 30 x 109/L, but also, in the setting of this study if:; They need a rescue therapy (a new course of corticosteroids and/or intravenous immunoglobulin) more than 6 weeks after inclusion.or; They receive any other treatment for ITP than dapsone or prednisone (including rituximab, splenectomy and Tpo-R agonists) over the study period	at 24 and at 52 weeks
Number of days to treatment failure in both arms		over the study period (up to 52 weeks)
Mechanisms of action of Dapsone: degree of phagocytosis of autologous platelets and red blood cells, cytokines profile expression (including IL-8), whole blood gene expression signature between responders and non-responders.		over the study period (52 weeks)

Collaborators and Investigators

• Sponsor: Assistance Publique - Hôpitaux de Paris
• Investigators: Principal Investigator: MARC MICHEL, Prof. M.D, Assistance Publique - Hôpitaux de Paris

Publications and helpful links

General Publications

• Durand JM, Lefevre P, Hovette P, Mongin M, Soubeyrand J. Dapsone for idiopathic autoimmune thrombocytopenic purpura in elderly patients. Br J Haematol. 1991 Jul;78(3):459-60. doi: 10.1111/j.1365-2141.1991.tb04467.x. No abstract available.
• Godeau B, Oksenhendler E, Bierling P. Dapsone for autoimmune thrombocytopenic purpura. Am J Hematol. 1993 Sep;44(1):70-2. doi: 10.1002/ajh.2830440117.
• Hernandez F, Linares M, Colomina P, Pastor E, Cervero A, Perez A, Perella M. Dapsone for refractory chronic idiopathic thrombocytopenic purpura. Br J Haematol. 1995 Jun;90(2):473-5. doi: 10.1111/j.1365-2141.1995.tb05179.x.
• Godeau B, Durand JM, Roudot-Thoraval F, Tenneze A, Oksenhendler E, Kaplanski G, Schaeffer A, Bierling P. Dapsone for chronic autoimmune thrombocytopenic purpura: a report of 66 cases. Br J Haematol. 1997 May;97(2):336-9. doi: 10.1046/j.1365-2141.1997.412687.x.
• Damodar S, Viswabandya A, George B, Mathews V, Chandy M, Srivastava A. Dapsone for chronic idiopathic thrombocytopenic purpura in children and adults--a report on 90 patients. Eur J Haematol. 2005 Oct;75(4):328-31. doi: 10.1111/j.1600-0609.2005.00545.x.

Study record dates

Study Major Dates

• Study Start: December 1, 2015
• Primary Completion (Anticipated): May 1, 2019
• Study Completion (Anticipated): May 1, 2019

Study Registration Dates

• First Submitted: November 3, 2015
• First Submitted That Met QC Criteria: December 8, 2015
• First Posted (Estimate): December 11, 2015

Study Record Updates

• Last Update Posted (Actual): July 26, 2017
• Last Update Submitted That Met QC Criteria: July 24, 2017
• Last Verified: July 1, 2017

More Information

Terms related to this study

• Keywords: Dapsone; ITP
• Additional Relevant MeSH Terms: Pathologic Processes; Immune System Diseases; Autoimmune Diseases; Hematologic Diseases; Hemorrhage; Hemorrhagic Disorders; Blood Coagulation Disorders; Skin Manifestations; Blood Platelet Disorders; Thrombotic Microangiopathies; Purpura, Thrombocytopenic; Purpura; Purpura, Thrombocytopenic, Idiopathic; Thrombocytopenia; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Anti-Infective Agents; Enzyme Inhibitors; Anti-Inflammatory Agents; Antineoplastic Agents; Glucocorticoids; Hormones; Hormones, Hormone Substitutes, and Hormone Antagonists; Antineoplastic Agents, Hormonal; Anti-Bacterial Agents; Leprostatic Agents; Antiprotozoal Agents; Antiparasitic Agents; Antimalarials; Folic Acid Antagonists; Prednisone; Dapsone
• Other Study ID Numbers: P140925