- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT05306873
Examining Distinct Immunophenotypes to Validate and Enhance Rational Treatment in Systemic Lupus (DIVERT)
A Phase 2, Double-Blind, Placebo-Controlled Trial of Mycophenolate Mofetil Alone or With Voclosporin for Systemic Lupus: Examining Distinct Immunophenotypes to Validate and Enhance Rational Treatment (DIVERT) (ALE10)
Study Overview
Status
Conditions
Detailed Description
The study was conducted in 3 stages with a maximum participant follow-up time of 56 weeks. Stage 1 was a treatment withdrawal period lasting up to 4 weeks where consenting participants receive up to 3 intramuscular injections of a long-acting corticosteroid to achieve amelioration of symptoms. In addition, participants withdraw from all other treatments for lupus with the following exceptions:
(i) as needed (PRN) nonsteroidal anti-inflammatory treatments may be started or continued, (ii) PRN topicals may be continued, (iii) hydroxychloroquine, chloroquine, or quinacrine may be continued at any stable dose, and (iv) prednisone, if<= 10 mg/day, may be continued at stable doses but not started.
Qualifying participants from Stage 1 were randomized (1:1) into Stage 2 to receive either MMF or placebo for MMF for up to 48 weeks. Participants who experienced a Stage 2 treatment failure at or before the Week 24 visit and a corticosteroid injection was deemed sufficient for treatment without new or increased lupus medication were eligible to re-randomize (1:1) into Stage 3 to receive either MMF + Voclosporin or MMF + Placebo for Voclosporin for up to 24 Weeks.
Participants who did not experience a Stage 2 treatment failure at or before the Stage 2 Week 48 visit were to return for an End of Study/Safety Follow-up visit 4 weeks after the final dose of study-provided medication. Similarly, participants who did not experience a Stage 3 treatment failure at or before the Stage 3 Week 24 visits were asked to return for an End of Study/Safety Follow-up visit 4 weeks after the final dose of study provided medication.
Study Type
Enrollment (Actual)
Phase
- Phase 2
Contacts and Locations
Study Locations
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California
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Los Angeles, California, United States, 90095
- UCLA Medical Center: Division of Rheumatology
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Connecticut
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New Haven, Connecticut, United States, 06519
- Yale University School of Medicine: Rheumatology, Allergy & Immunology
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Georgia
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Atlanta, Georgia, United States, 30307
- Emory University School of Medicine: Division of Rheumatology
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Atlanta, Georgia, United States, 30318
- Piedmont Healthcare: Rheumatology Atlanta
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Massachusetts
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Boston, Massachusetts, United States, 02114
- Massachusetts General Hospital: Rheumatology, Allergy and Immunology, Center for Immunology and Inflammatory Diseases
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New York
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Manhasset, New York, United States, 11030
- Feinstein Institute for Medical Research: Center for Autoimmune and Musculoskeletal Diseases
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New York, New York, United States, 10032
- Columbia University Medical Center: Department of Medicine, Division of Rheumatology
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North Carolina
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Chapel Hill, North Carolina, United States, 27599
- University of North Carolina at Chapel Hill; Thurston Arthritis Research Center: Division of Rheumatology, Allergy, and Immunology
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Oklahoma
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Oklahoma City, Oklahoma, United States, 73104
- Oklahoma Medical Research Foundation: Arthritis and Clinical Immunology Research Program
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Pennsylvania
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Hershey, Pennsylvania, United States, 17033
- PennState Health Milton S. Hershey Medical Center: Division of Rheumatology
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Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Description
Inclusion Criteria
Participants must meet all of the following criteria to be eligible for randomization as study participants.
- Aged ≥ 18 and ≤ 60 years at the time of informed consent.
- Meets EULAR/ACR 2019 criteria for SLE.
Moderately severe, active, but non-organ threatening disease. Specifically, signs or symptoms meeting criteria for a minimum of:
- 1 BILAG A (severe) score in the constitutional, musculoskeletal or mucocutaneous system at the time of screening. See Exclusion Criteria number 2 for additional detail.
- 2 BILAG B (moderate) activity scores in any organ systems; or
1 BILAG B (moderate) activity score in any organ systems and a SELENA-SLEDAI score of ≥ 6.
If there is only 1 BILAG B score:
- If a musculoskeletal BILAG B is scored due to moderate arthritis, where some loss off functional range of movements was present on several days over the last 4 weeks, there must also be a minimum of at least 3 joints that are both tender and swollen due to lupus disease activity in wrists, MCPs or PIPs for the participant to qualify.
- If a mucocutaneous BILAG B is scored due to acute or subacute cutaneous skin eruption, the rash must cover at least 4% of the body surface area for the participant to qualify. Any active discoid lesion or other form of chronic cutaneous lupus would be qualifying.
Approval, by an adjudication committee of a brief entry packet describing the type, severity and duration of symptoms meeting the minimal criteria for entry. The participant will meet this criterion if the committee is confident of all of the following:
- Convincing diagnosis of SLE,
- Active disease, due to SLE, warranting the potential of dual therapy with potent immune modulators,
- No medical or other condition to contraindicate participation in a placebo-controlled, outpatient study of this design.
- Women of childbearing potential must have a negative serum pregnancy test at screening.
Able or willing to use reliable methods of contraception, as outlined in the Mycophenolate REMS brochure for health care providers, from 4 weeks prior to first randomization to 6 weeks after completion of the study. This criterion applies to females of reproductive potential.
Inclusion Criteria Required Prior to Randomization
Participants who meet the following criterion at the Stage 2 Randomization Visit may proceed to randomization in Stage 2:
After completion of corticosteroid injection(s) and prior to randomization in Stage 2, the participant and his/her physician must agree that disease activity has improved sufficiently from screening such that randomization is acceptable.
The physician must score the CGI-C as "moderately better" or "much better" prior to randomization.
• The reference value for the CGI-C should be the investigator's determination of the participant's condition at the Screening Visit.
- The participant must agree that his/her symptoms have improved (yes/no).
Exclusion Criteria
Participants who meet any of the following criteria are not eligible for randomization as study participants:
- Inability or unwillingness of a participant to understand and provide written informed consent or comply with the study protocol.
- BILAG A (severe) disease in the Cardiorespiratory, Neuropsychiatric, Gastrointestinal, Ophthalmic, Renal, or Hematological Systems.
Severe or unstable nephritis defined as any of the following:
- History of confirmed Class 3-5 nephritis within the last 2 years,
- History of confirmed Class 3-5 nephritis > 2 years ago in the absence of documented treatment including both induction and maintenance therapy,
- UPCR > 1 g/g at screening, • If UPCR is > 0.5 g/g and ≤ 1 g/g at screening, then a second assessment must be completed with at least 1 week between assessments. If the second assessment is > 1 g/g or has increased by ≥ 0.3 g/g, then the participant is excluded.
- Evidence of chronic kidney disease defined as eGFR < 45 mL/min per 1.73 m2 at screening, where 175 x (Creatinine/88.4)-1.154 x (Age)-0.203 x (0.742 if female) x (1.212 if of African descent).
- History of cirrhosis or chronic liver disease unrelated to SLE other than fatty liver disease.
- History, within 1 year of the Screening Visit, of uncontrolled SLE that would have warranted a BILAG A (except mucocutaneous, constitutional, musculoskeletal) including, but not limited to, hemolytic anemia, neuropsychiatric lupus, or interstitial lung disease.
- Uncontrolled HTN at the Screening or Randomization Visits defined as a blood pressure > 150/100 with or without treatment, not to exceed 3 complementary antihypertensive treatments.
Any of the following laboratory values during screening:
- Hemoglobin (Hg) < 8.0 g/dL,
- WBC < 2.0 x 10^9 cells/L,
- ANC < 1.0 x 10^9 cells/L,
Platelets < 60 x 10^9 cells/L at screening,
• If platelets < 70 x 10^9 cells/L at screening, platelet count should be retested 2 weeks later. If platelets are < 60 x 10^9 cells/L at retest, participant will be excluded
- AST or ALT > 2.5 times the ULN,
- Serum IgG levels < 5 g/L
- Use of ≥ 40 mg/day of prednisone within 4 weeks prior to the Screening Visit or use of > 20 mg/day of prednisone at screening.
- Unwilling or unable to taper to ≤ 10 mg/day of prednisone or equivalent by the day of randomization.
- Use of hydroxychloroquine, chloroquine, or quinacrine, if taking, at a prescribed dose that has not been stable for at least 2 months prior to randomization.
- Use of MMF within 1 year of randomization.
- Use of CNIs within 3 months of randomization. Topical formulations applied stably for at least one month are allowed.
- Use of rituximab, obinutuzumab, ocrelizumab, or long-acting B cell depletion agents within 1 year of randomization. Use of agents ≥ 6 months and within 1 year of randomization is permitted if there is evidence of B cell reconstitution as defined as CD19+ counts of ≥ 50 cells/µL.
- History of intolerance or allergy to MMF, voclosporin, or long-acting corticosteroid preparations.
- Individuals with known hypersensitivity to Polysorbate 80 (Tween).
- A woman who is pregnant, breastfeeding, or planning pregnancy from the time of consent until 6 weeks after completion of the study.
- Any participant with plans for major surgery during the time of the trial.
- Active infections requiring hospitalization or intravenous antibiotics within 1 month prior to the Screening Visit.
- Any grade 2 infection or higher from 14 days prior to the Screening Visit and through the screening period that has not resolved by randomization.
- Acute herpes zoster within 4 months of the Screening Visit.
- Positive results from a SARS-CoV-2 antigen test administered 2 days prior to and on the day of first randomization.
Positive Quantiferon Gold (or equivalent) assay. Indeterminate Quantiferon Gold (or equivalent) assays must be repeated (with same or other interferon gamma release assay per local policy) and shown to be negative. Alternatively, if the Quantiferon Gold (or equivalent) assay remains indeterminate, a participant must have a negative PPD. Finally, if the participant has had the BCG vaccine or has some other condition complicating the interpretation of TB testing, consultation with infection disease specialist must be obtained.
• Participants diagnosed with latent TB are eligible but must have received appropriate prophylaxis for 30 days prior to initiation of Stage 2 treatment.
Serologic evidence at screening of chronic infections including:
- HIV infection.
- Hepatitis B as indicated by surface antigen or hepatitis B core antibody positivity; if a participant has an isolated positive hepatitis B core antibody, they will be eligible to participate in the study if they are negative for reflex viral load at Screening.
- Hepatitis C as indicated by anti-hepatitis C antibody positivity; if a participant is Hepatitis C antibody positive, they will be eligible to participate in the study if they are negative for viral load at Screening.
- Current, diagnosed, or self-reported drug or alcohol abuse within the last 6 months that, in the opinion of the investigator, would interfere with the ability to comply with study protocol.
- Recipient of live attenuated vaccine(s) within 8 weeks of the Screening Visit.
- Use of investigational drugs (excluding SARS-CoV-2 vaccinations or SARS-CoV2 therapeutics) within 8 weeks of the Screening Visit or 5 half-lives, whichever is longer.
- Past or current mental or physical problems or findings from physical examination or laboratory testing that are not listed above, which, in the opinion of the investigator, may pose additional risks from participation in the study, may interfere with the participant's ability to comply with study requirements, or may impact the quality or interpretation of the data obtained from the study.
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Triple
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
|---|---|
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Experimental: MMF
Participants will receive 500 mg mycophenolate mofetil (MMF) bid for 7 days, followed by 500mg and 1,000mg MMF in divided doses for 7 days.
They will then continue at a stable dose of 1,000mg MMF bid.
Visits to evaluate AEs, vital signs, hematology and chemistry, study medication compliance, medication use, disease status, participant reported outcomes, and to obtain biomarker samples will occur every 4 weeks after randomization
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Stage 2 Dosing: Week 1: Participants will receive 500mg MMF/Placebo twice daily Week 2: Participants will receive 500mg/Placebo in the morning and 1,000mg MMF/Placebo in the evening Weeks 3-48: Participants will receive 1000mg MMF/Placebo twice daily
Other Names:
Stage 3 Dosing: Participants who received placebo MMF in Stage 2:
Participants who received MMF in Stage 2 • Week 1-24: 1000mg MMF twice daily
Other Names:
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Placebo Comparator: Placebo for MMF
Participants will receive 500 mg corresponding mycophenolate mofetil (MMF) placebo bid for 7 days, followed by 500mg and 1,000mg corresponding MMF placebo in divided doses for 7 days.
They will then continue at a stable dose of 1,000mg corresponding MMF placebo bid.
Visits to evaluate AEs, vital signs, hematology and chemistry, study medication compliance, medication use, disease status, participant reported outcomes, and to obtain biomarker samples will occur every 4 weeks after randomization
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Stage 2 Dosing: Week 1: Participants will receive 500mg MMF/Placebo twice daily Week 2: Participants will receive 500mg/Placebo in the morning and 1,000mg MMF/Placebo in the evening Weeks 3-48: Participants will receive 1000mg MMF/Placebo twice daily
Other Names:
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Experimental: MMF+ Placebo for Voclosporin
Participants randomized in this arm will receive up to 24 weeks of mycophenolate mofetil (MMF) plus placebo for voclosporin, also during the first 2 weeks of treatment, a single intramuscular injection of a long-acting corticosteroid may be administered if needed to achieve amelioration of symptoms without meeting the definition of treatment failure in Stage 3 and without a requirement to stop Stage 3 study-provided medication
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Stage 2 Dosing: Week 1: Participants will receive 500mg MMF/Placebo twice daily Week 2: Participants will receive 500mg/Placebo in the morning and 1,000mg MMF/Placebo in the evening Weeks 3-48: Participants will receive 1000mg MMF/Placebo twice daily
Other Names:
Stage 3 Dosing: Participants who received placebo MMF in Stage 2:
Participants who received MMF in Stage 2 • Week 1-24: 1000mg MMF twice daily
Other Names:
Weeks 1-24: 23.7 mg Placebo for Voclosporin (3 x 7.9 capsules) twice daily
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Experimental: MMF+ Voclosporin
Participants randomized in this arm will receive up to 24 weeks of mycophenolate mofetil (MMF) plus voclosporin, also during the first 2 weeks of treatment, a single intramuscular injection of a long-acting corticosteroid may be administered if needed to achieve amelioration of symptoms without meeting the definition of treatment failure in Stage 3 and without a requirement to stop Stage 3 study-provided medication
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Stage 2 Dosing: Week 1: Participants will receive 500mg MMF/Placebo twice daily Week 2: Participants will receive 500mg/Placebo in the morning and 1,000mg MMF/Placebo in the evening Weeks 3-48: Participants will receive 1000mg MMF/Placebo twice daily
Other Names:
Stage 3 Dosing: Participants who received placebo MMF in Stage 2:
Participants who received MMF in Stage 2 • Week 1-24: 1000mg MMF twice daily
Other Names:
Weeks 1-24: 23.7 mg Voclosporin (3 x 7.9 capsules) twice daily
Other Names:
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What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
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The Percentage of Participants Who Experience a Stage 2 Treatment Failure at or Before the Stage 2 Week 24 Visit.
Time Frame: From Baseline to Stage 2 Week 24
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Treatment failure is defined as the first occurrence after randomization (Stage 2) of any of the following events:
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From Baseline to Stage 2 Week 24
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Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
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Clinical Response in Stage 2, Defined by the BILAG-based Combined Lupus Assessment (BICLA) at Stage 2 Week 24.
Time Frame: Stage 2 Week 24
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The BILAG-based Composite Lupus Assessment (BICLA) is a composite index used to assess disease activity in SLE. A BICLA response is defined as meeting all of the following criteria:
Participants who experience treatment failure prior to Stage 2 Week 24 visit are imputed as BICLA Non-responders at Stage 2 Week 24. Participants who do not have evaluable data at Stage 2 Week 24 for reasons other than a treatment failure are not imputed. |
Stage 2 Week 24
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The Proportion of Participants Who Experience a Stage 3 Treatment Failure, After Stage 3 Re-randomization at or Before Completing Stage 3 Week 24.
Time Frame: From re-randomization to Stage 3 Week 24
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Treatment failure is defined as the first occurrence after re-randomization (Stage 3) of any of the following events:
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From re-randomization to Stage 3 Week 24
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Time to Treatment Failure in Stage 3, Defined as the Interval From the Day of Stage 3 Randomization Until the Day of Treatment Failure.
Time Frame: Start of Stage 3 up to the day of treatment failure
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Treatment failure is defined as the first occurrence after re-randomization (Stage 3) of any of the following events:
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Start of Stage 3 up to the day of treatment failure
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Clinical Response in Stage 3, Defined by the BILAG-based Combined Lupus Assessment (BICLA) at Stage 3 Week 24.
Time Frame: Stage 3 Week 24
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The BILAG-based Composite Lupus Assessment (BICLA) is a composite index used to assess disease activity in SLE. A BICLA response is defined as meeting all of the following criteria:
Participants who experience treatment failure prior to Stage 3 Week 24 visit are imputed as BICLA Non-responders at Stage 2 Week 24. Participants who do not have evaluable data at Stage 3 Week 24 for reasons other than a treatment failure are not imputed. |
Stage 3 Week 24
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The Incidence of Grade 3 or Higher Related Adverse Events (AEs) in Stage 2
Time Frame: Stage 2 Day 0 up to Stage 2 Week 48
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Defined as adverse events that emerged during Stage 2 that are of Grade 3 or higher with a relationship to Stage 2 study drug of Possible or Definite.
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Stage 2 Day 0 up to Stage 2 Week 48
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The Incidence of Grade 3 or Higher Related Adverse Events (AEs) in Stage 3
Time Frame: After Stage 3 re-randomization Day 0 to Stage 3 Week 24
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Defined as adverse events that emerged during Stage 3 that are of Grade 3 or higher with a relationship to Stage 3 study drug of Possible or Definite.
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After Stage 3 re-randomization Day 0 to Stage 3 Week 24
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The Incidence of Grade 3 or Higher Infections in Stage 1
Time Frame: Day -28 to Day -1
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Defined as infection adverse events that emerged during Stage 1 and are of Grade 3 or higher.
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Day -28 to Day -1
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The Incidence of Grade 3 or Higher Infections in Stage 2
Time Frame: Stage 2 Day 0 up to Stage 2 Week 48
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Defined as infection adverse events that emerged during Stage 2 and are of Grade 3 or higher.
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Stage 2 Day 0 up to Stage 2 Week 48
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The Incidence of Grade 3 or Higher Infections in Stage 3
Time Frame: After Stage 3 re-randomization Day 0 to Stage 3 Week 24
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Defined as infection adverse events that emerged during Stage 3 and are of Grade 3 or higher.
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After Stage 3 re-randomization Day 0 to Stage 3 Week 24
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The Incidence of Renal Dysfunction in Stage 1
Time Frame: Day -28 to Day -1
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Defined as Grade 3 or higher chronic kidney disease with eGFR < 30 ml/min per 1.73 m^2
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Day -28 to Day -1
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The Incidence of Renal Dysfunction in Stage 2
Time Frame: Stage 2 Day 0 up to Stage 2 Week 48
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Defined as Grade 3 or higher chronic kidney disease with eGFR < 30 ml/min per 1.73 m^2
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Stage 2 Day 0 up to Stage 2 Week 48
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The Incidence of Renal Dysfunction in Stage 3
Time Frame: After Stage 3 re-randomization Day 0 to Stage 3 Week 24
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Defined as Grade 3 or higher chronic kidney disease with eGFR < 30 ml/min per 1.73 m^2
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After Stage 3 re-randomization Day 0 to Stage 3 Week 24
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The Incidence of Grade 3 or Higher Hypertension in Stage 1
Time Frame: Day -28 to Day -1
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Defined as a systolic blood pressure >= 160 mm Hg or a diastolic blood pressure of >= 100 mm Hg
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Day -28 to Day -1
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The Incidence of Grade 3 or Higher Hypertension in Stage 2
Time Frame: Stage 2 Day 0 up to Stage 2 Week 48
|
Defined as a systolic blood pressure >= 160 mm Hg or a diastolic blood pressure of >= 100 mm Hg
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Stage 2 Day 0 up to Stage 2 Week 48
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The Incidence of Grade 3 or Higher Hypertension in Stage 3
Time Frame: After Stage 3 re-randomization Day 0 to Stage 3 Week 24
|
Defined as a systolic blood pressure >= 160 mm Hg or a diastolic blood pressure of >= 100 mm Hg
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After Stage 3 re-randomization Day 0 to Stage 3 Week 24
|
Collaborators and Investigators
Investigators
- Study Chair: Joan Merrill, M.D., Oklahoma Medical Research Foundation: Arthritis and Clinical Immunology Research Program
Publications and helpful links
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Estimated)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
- Connective Tissue Diseases
- Autoimmune Diseases
- Immune System Diseases
- Skin and Connective Tissue Diseases
- Lupus Erythematosus, Systemic
- Organic Chemicals
- Substandard Drugs
- Pharmaceutical Preparations
- Fatty Acids
- Lipids
- Acids, Acyclic
- Carboxylic Acids
- Caproates
- Mycophenolic Acid
- Counterfeit Drugs
- voclosporin
Other Study ID Numbers
- DAIT ALE10
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
IPD Plan Description
IPD Sharing Time Frame
IPD Sharing Access Criteria
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
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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