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Baricitinib in Patients With Relapsing or naïve Dermatomyositis (BIRD)

Primary Purpose

Dermatomyositis

Status
Recruiting
Phase
Phase 3
Locations
France
Study Type
Interventional
Intervention
Baricitinib
Placebo
Sponsored by
Assistance Publique - Hôpitaux de Paris
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Dermatomyositis focused on measuring Dermatomyositis, baricitinib, steroid sparing

Eligibility Criteria

18 Years - 74 Years (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  • Adult subjects (≥ 18 years old) < 75 years old
  • Dermatomyositis defined according to the 239th ENMC criteria either naïve or non-naïve DM
  • Active disease (ACR/EULAR criteria) defined as :

    • Manual Muscle Testing (MMT-8) <145/150 and at least two additional abnormal corset measurements (CSM): >3/10 cm on Visual Analogue Scale (VAS) of patient global, physician global and extra-muscular disease activity, Health Assessment Questionnaire Disability Index >0.25, or elevated muscle enzymes.
    • Or cutaneous CDASI > 20 and at least two additional abnormal corset measurements (CSM): >3/10 cm on Visual Analogue Scale (VAS) of patient global, physician global and extra-muscular disease activity, Health Assessment Questionnaire Disability Index >0.25, or elevated muscle enzymes
  • for relapsing/non naïve DM patients :

    • in case of corticosteroid exposure patient must receive a stable dose < 30 mg/d prednisone with or without additional immunosuppressive therapy for at least 4 weeks before the baseline visit.
    • Stable dose of immunosuppressive therapy for at least 3 months before
  • Affiliation to a social security regime
  • Written informed consent

Exclusion Criteria:

  • Life-threatening complications :

    • Severe swallowing troubles defined as: food swallowed the wrong way and/or time to drink a glass of 200 ml water above 30 seconds
    • Interstitial lung disease related to the DM with one among the following complications (complications must be related to the ILD): dyspnea NYHA III, hypoxemia with PaO2≤65 mmHg, and/or DLCOc/Alveolar Volume ≤70% (pulmonary function test)
    • Symptomatic myocarditis o Loss of walking ability
  • Deep vein thrombosis/pulmonary embolism in past medical history in absence of anticoagulant
  • Pregnant or lactating, or women planning to become pregnant or initiating breastfeeding
  • No effective contraception during the study and one week after for women of childbearing age
  • Renal impairment defined as clearance < 60 ml
  • Strong Organic Anion Transporter 3 (OAT3) inhibitors
  • A new cancer or malignancy except for basal and squamous cell carcinoma of the skin or in situ carcinoma of the cervix treated and considered cured by the investigator
  • Active severe infection including active hepatitis
  • Evidence of latent tuberculosis (as documented by a positive QuantiFERON-TB Gold plus test)
  • Absolute Neutrophil Count < 1x109 cells/L
  • Haemoglobin (Hb) < 8 g/dL
  • Severe hepatic impairment attested by FV (coagulation factor)<30%
  • Liver insufficiency (Prothrombin time <60%)
  • Previous treatment exposure defined as follow : • Rituximab treatment within 6months before inclusion

    • IVIg, or cyclophosphamide infusion within the month before inclusion
    • both methotrexate (0.3 mg/kg/w) and azathioprine exposure for at least 3 months each and at the 0.3 mg/kg/w and 2-3 mg/kg/d dosages respectively. (but exposure to either of these two drugs alone is not an exclusionary criterion)
    • for naïve DM patients only, more than 2 weeks treatment duration with corticosteroids at the dose of 1 mg/kg/d before the inclusion.
  • Hypersensitivity to the active substance (baricitinib) or to any of the excipients
  • Contraindication to Methotrexate and/or Azathioprine including hypersensitivity to the active substances or to any of the excipients
  • Conditions affecting the outcomes (Expected poor compliance)
  • Severe disease damages: e.g. muscle weakness mainly related to muscle damage such as fat replacement of muscle) defined as persistent changes in anatomy, physiology, pathology or function which result from previously active disease and from complications of therapy or other events (e.g.; muscle atrophy, fatty replacement; skin scars, poikiloderma ). Severe disease damage is considered when the patient condition has no or minor ability to improve with the treatment.
  • Significant uncontrolled cardiovascular, cerebrovascular, respiratory, hepatic, renal, gastrointestinal, endocrine, hematologic, or neuropsychiatric disorders, or abnormal laboratory values that developed during a qualifying study that, in the opinion of the investigator, poses an unacceptable risk for the patient's participation
  • Chest imaging (CT scan or radiograph) showing abnormalities not related with the DM in the last 12 weeks judged by the investigator as clinically significant.
  • Diagnosis of Covid 19 infection (SARSCoV-2 positive PCR)
  • Participants included in other intervention research involving humans
  • Patient under tutorship or guardianship, and incapable to give informed consent

Sites / Locations

  • Pitie-Salpêtrière hospital APHPRecruiting

Arms of the Study

Arm 1

Arm 2

Arm Type

Experimental

Placebo Comparator

Arm Label

baricitinib arm

placebo arm

Arm Description

Patients receive baricitinib plus prednisone taper plus one immunosuppressive drug (either methotrexate or azathioprine) for a duration of 24 weeks. Corticosteroids are tapered following a predefined protocol.

Patients receive placebo plus prednisone taper plus one immunosuppressive drug (either methotrexate or azathioprine) for a duration of 24 weeks. Corticosteroids are tapered following a predefined protocol.

Outcomes

Primary Outcome Measures

Moderate improvement at 24 weeks without prednisone: prednisone-free moderate improvement.
The rate of patients with a moderate improvement at 24 weeks, defined as a total improvement score superior or equal to 40 following ACR/EULAR definition. The investigator will consider that patients following the planned prednisone tapering scheme (corticosteroids 0 mg/d at W24) will be prednisone-free.

Secondary Outcome Measures

Dermatomyositis minimal improvement
The rate of patients with a minimal improvement, defined as a total improvement score ≥20 points (ACR/EULAR definition)
Dermatomyositis moderate improvement
The rate of patients with a moderate improvement, defined as a total improvement score ≥40 points (ACR/EULAR definition)
Dermatomyositis major improvement
The rate of patients with a major improvement, defined as a total improvement score ≥60 points (ACR/EULAR definition)
Primary endpoint prednisone-free moderate improvement at Weeks 24 in subgroups
DM naive patients at baseline vs others DM with a severe muscle weakness (MMT8 baseline <125/150) vs others
Cutaneous disease activity and damage
Cutaneous disease activity and damage evaluated using the Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI) - Activity and CDASI damages (from 0 to 48, 48 is the maximum disease severity)
Cumulative incidence of relapse
Cumulative incidence of relapse with the time to first relapse
Cumulative dose of corticosteroids
Cumulative dose of corticosteroids at 24 weeks
Average prednisone dose per day through the last 4 weeks (0 mg per day, of more than 0 mg to not more than 4.0 mg per day, of more than 4.0 mg to not more than 7.5 mg per day, and of more than 7.5 mg per day).
Proportion of participants with an average prednisone dose of 0 mg per day, of more than 0 mg to not more than 4.0 mg per day, of more than 4.0 mg to not more than 7.5 mg per day, and of more than 7.5 mg per day through the last 4 weeks.
Adverse events
Incidence, nature, and severity of adverse events and serious adverse events and laboratory abnormalities

Full Information

First Posted
June 14, 2021
Last Updated
September 6, 2022
Sponsor
Assistance Publique - Hôpitaux de Paris
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1. Study Identification

Unique Protocol Identification Number
NCT04972760
Brief Title
Baricitinib in Patients With Relapsing or naïve Dermatomyositis
Acronym
BIRD
Official Title
Baricitinib in Patients With Relapsing or naïve Dermatomyositis: a Multicenter Randomized Controlled Trial (BIRD)
Study Type
Interventional

2. Study Status

Record Verification Date
May 2022
Overall Recruitment Status
Recruiting
Study Start Date
August 31, 2022 (Actual)
Primary Completion Date
February 28, 2026 (Anticipated)
Study Completion Date
February 28, 2026 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
Assistance Publique - Hôpitaux de Paris

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
No
Data Monitoring Committee
Yes

5. Study Description

Brief Summary
Dermatomyositis (DM) is a rare and disabling condition with an important impairment of quality of life and possible life-threatening complications. Treatment is based on high doses of corticosteroids but this exposes patients to adverse events (cardiovascular mortality, glucocorticoids-induced muscle and skin damages). Corticosteroids taper is associated with disease relapses. Although there is no evidence from the literature, clinical practice guidelines recommends the use of DMARDs such as methotrexate. However, response is not complete and these DMARDS take time to act. The interferon type I (IFN-I) pathway is involved in the pathophysiology of DM. Janus kinase 1 and 2 transduces IFN-I signals. In addition, JAK2 inhibition enhances muscle repair and force generation. JAK 1/2 inhibitors permitted to dramatically and rapidly improve relapsing DM patients (n=4, case series). Our hypothesis is that Janus kinase 1 and 2 (JAK1/2) inhibitors (baricitinib) will permit to obtain dermatomyositis (DM) improvement with a steroid sparing effect as compared to usual care. Our primary objective is to evaluate the efficacy of baricitinib (JAK1/2 inhibitor) to obtain prednisone-free moderate improvement (ACR/EULAR ≥ 40) of DM as compared to placebo in addition to usual care. BIRD is a multicenter phase III double blind randomized placebo-controlled trial with two parallel arms (1:1). This is an add-on trial to usual care with rapid corticoid taper. This is a multicenter trial in different medical departments in hospitals across France in different regions. Out- and in patients will be recruited in hospital departments involved in management and diagnosis of DM: departments of dermatology, rheumatology and internal medicine.
Detailed Description
Dermatomyositis (DM) is a rare and disabling condition with an important impairment of quality of life and possible life-threatening complications. Treatment is based on high doses of corticosteroids but this exposes patients to adverse events (cardiovascular mortality, glucocorticoids-induced muscle and skin damages). Corticosteroids taper is associated with disease relapses. Although there is no evidence from the literature, clinical practice guidelines recommends the use of DMARDs such as methotrexate. However, response is not complete and these DMARDS take time to act.The interferon type I (IFN-I) pathway is involved in the pathophysiology of DM. Janus kinase 1 and 2 transduces IFN-I signals. In addition, JAK2 inhibition enhances muscle repair and force generation . JAK 1/2 inhibitors permitted to dramatically and rapidly improve relapsing DM patients (n=4, case series) . BIRD is a multicenter phase III double blind randomized placebo-controlled trial with two parallel arms (1:1). This is an add-on trial to usual care with rapid corticoid taper. Both groups (experimental and control groups) will receive corticosteroids and the conventional immunosuppressive drug (either azathioprine or methotrexate) Our primary objective is to evaluate the efficacy of baricitinib (JAK1/2 inhibitor) to obtain prednisone-free DM moderate improvement as compared to placebo, in addition to usual care. Primary endpoint: moderate improvement (defined as a total improvement score superior or equal to 40 following ACR/EULAR definition) without corticosteroids at week 24 (prednisone-free moderate improvement). This multicenter trial involves different medical departments in hospitals across France in different regions. Out- and in patients will be recruited in hospital departments involved in management and diagnosis of DM: departments of dermatology, rheumatology and internal medicine. Eligible patients will sign a written informed consent after full oral and written information about the trial. They will be randomized in 1:1 ratio to receive baricitinib plus prednisone taper plus one immunosuppressive drug (either methotrexate or azathioprine) (experimental group) or placebo plus prednisone taper plus one immunosuppressive drug (either methotrexate or azathioprine) (control group) for a duration of 24 weeks. In both groups, corticosteroids are tapered following a predefined protocol. 5 visits are planned: screening visit (W-4 to D-1) baseline visit (W0) follow-up visit 1 (W5 +/-5 days) follow-up visit 2 (W12 +/-5 days) end of study visit 3 (W24+/-5 days) Data will be collected by investigator and clinical research associate on an electronic case report form (eCRF) via a web browser. The primary analysis will be the comparison between experimental and control groups of the rate of prednisone-free moderate improvement at 24 weeks in the intent to treat population. In order to demonstrate a difference in the rate of primary outcome at 24 weeks from 30% in the control group to 70% in the experimental group, with a power of 80%, a bilateral alpha risk of 5%, and a 15% rate of loss of follow-up, 62 patients are necessary.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Dermatomyositis
Keywords
Dermatomyositis, baricitinib, steroid sparing

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 3
Interventional Study Model
Parallel Assignment
Masking
ParticipantCare ProviderInvestigatorOutcomes Assessor
Allocation
Randomized
Enrollment
62 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
baricitinib arm
Arm Type
Experimental
Arm Description
Patients receive baricitinib plus prednisone taper plus one immunosuppressive drug (either methotrexate or azathioprine) for a duration of 24 weeks. Corticosteroids are tapered following a predefined protocol.
Arm Title
placebo arm
Arm Type
Placebo Comparator
Arm Description
Patients receive placebo plus prednisone taper plus one immunosuppressive drug (either methotrexate or azathioprine) for a duration of 24 weeks. Corticosteroids are tapered following a predefined protocol.
Intervention Type
Drug
Intervention Name(s)
Baricitinib
Intervention Description
Baricitinib, 4 mg/d, oral route for 24 weeks
Intervention Type
Drug
Intervention Name(s)
Placebo
Intervention Description
Placebo, 4 mg/d, oral route for 24 weeks
Primary Outcome Measure Information:
Title
Moderate improvement at 24 weeks without prednisone: prednisone-free moderate improvement.
Description
The rate of patients with a moderate improvement at 24 weeks, defined as a total improvement score superior or equal to 40 following ACR/EULAR definition. The investigator will consider that patients following the planned prednisone tapering scheme (corticosteroids 0 mg/d at W24) will be prednisone-free.
Time Frame
24 weeks
Secondary Outcome Measure Information:
Title
Dermatomyositis minimal improvement
Description
The rate of patients with a minimal improvement, defined as a total improvement score ≥20 points (ACR/EULAR definition)
Time Frame
5, 12 and 24 weeks
Title
Dermatomyositis moderate improvement
Description
The rate of patients with a moderate improvement, defined as a total improvement score ≥40 points (ACR/EULAR definition)
Time Frame
5, 12 and 24 weeks
Title
Dermatomyositis major improvement
Description
The rate of patients with a major improvement, defined as a total improvement score ≥60 points (ACR/EULAR definition)
Time Frame
5, 12 and 24 weeks
Title
Primary endpoint prednisone-free moderate improvement at Weeks 24 in subgroups
Description
DM naive patients at baseline vs others DM with a severe muscle weakness (MMT8 baseline <125/150) vs others
Time Frame
24 weeks
Title
Cutaneous disease activity and damage
Description
Cutaneous disease activity and damage evaluated using the Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI) - Activity and CDASI damages (from 0 to 48, 48 is the maximum disease severity)
Time Frame
5, 12 and 24 weeks
Title
Cumulative incidence of relapse
Description
Cumulative incidence of relapse with the time to first relapse
Time Frame
up to 24 weeks
Title
Cumulative dose of corticosteroids
Description
Cumulative dose of corticosteroids at 24 weeks
Time Frame
24 weeks
Title
Average prednisone dose per day through the last 4 weeks (0 mg per day, of more than 0 mg to not more than 4.0 mg per day, of more than 4.0 mg to not more than 7.5 mg per day, and of more than 7.5 mg per day).
Description
Proportion of participants with an average prednisone dose of 0 mg per day, of more than 0 mg to not more than 4.0 mg per day, of more than 4.0 mg to not more than 7.5 mg per day, and of more than 7.5 mg per day through the last 4 weeks.
Time Frame
24 weeks
Title
Adverse events
Description
Incidence, nature, and severity of adverse events and serious adverse events and laboratory abnormalities
Time Frame
up to 24 weeks

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Maximum Age & Unit of Time
74 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Adult subjects (≥ 18 years old) < 75 years old Dermatomyositis defined according to the 239th ENMC criteria either naïve or non-naïve DM Active disease (ACR/EULAR criteria) defined as : Manual Muscle Testing (MMT-8) <145/150 and at least two additional abnormal corset measurements (CSM): >3/10 cm on Visual Analogue Scale (VAS) of patient global, physician global and extra-muscular disease activity, Health Assessment Questionnaire Disability Index >0.25, or elevated muscle enzymes. Or cutaneous CDASI > 20 and at least two additional abnormal corset measurements (CSM): >3/10 cm on Visual Analogue Scale (VAS) of patient global, physician global and extra-muscular disease activity, Health Assessment Questionnaire Disability Index >0.25, or elevated muscle enzymes for relapsing/non naïve DM patients : in case of corticosteroid exposure patient must receive a stable dose < 30 mg/d prednisone with or without additional immunosuppressive therapy for at least 4 weeks before the baseline visit. Stable dose of immunosuppressive therapy for at least 3 months before Affiliation to a social security regime Written informed consent Exclusion Criteria: Life-threatening complications : Severe swallowing troubles defined as: food swallowed the wrong way and/or time to drink a glass of 200 ml water above 30 seconds Interstitial lung disease related to the DM with one among the following complications (complications must be related to the ILD): dyspnea NYHA III, hypoxemia with PaO2≤65 mmHg, and/or DLCOc/Alveolar Volume ≤70% (pulmonary function test) Symptomatic myocarditis o Loss of walking ability Deep vein thrombosis/pulmonary embolism in past medical history in absence of anticoagulant Pregnant or lactating, or women planning to become pregnant or initiating breastfeeding No effective contraception during the study and one week after for women of childbearing age Renal impairment defined as clearance < 60 ml Strong Organic Anion Transporter 3 (OAT3) inhibitors A new cancer or malignancy except for basal and squamous cell carcinoma of the skin or in situ carcinoma of the cervix treated and considered cured by the investigator Active severe infection including active hepatitis Evidence of latent tuberculosis (as documented by a positive QuantiFERON-TB Gold plus test) Absolute Neutrophil Count < 1x109 cells/L Haemoglobin (Hb) < 8 g/dL Severe hepatic impairment attested by FV (coagulation factor)<30% Liver insufficiency (Prothrombin time <60%) Previous treatment exposure defined as follow : • Rituximab treatment within 6months before inclusion IVIg, or cyclophosphamide infusion within the month before inclusion both methotrexate (0.3 mg/kg/w) and azathioprine exposure for at least 3 months each and at the 0.3 mg/kg/w and 2-3 mg/kg/d dosages respectively. (but exposure to either of these two drugs alone is not an exclusionary criterion) for naïve DM patients only, more than 2 weeks treatment duration with corticosteroids at the dose of 1 mg/kg/d before the inclusion. Hypersensitivity to the active substance (baricitinib) or to any of the excipients Contraindication to Methotrexate and/or Azathioprine including hypersensitivity to the active substances or to any of the excipients Conditions affecting the outcomes (Expected poor compliance) Severe disease damages: e.g. muscle weakness mainly related to muscle damage such as fat replacement of muscle) defined as persistent changes in anatomy, physiology, pathology or function which result from previously active disease and from complications of therapy or other events (e.g.; muscle atrophy, fatty replacement; skin scars, poikiloderma ). Severe disease damage is considered when the patient condition has no or minor ability to improve with the treatment. Significant uncontrolled cardiovascular, cerebrovascular, respiratory, hepatic, renal, gastrointestinal, endocrine, hematologic, or neuropsychiatric disorders, or abnormal laboratory values that developed during a qualifying study that, in the opinion of the investigator, poses an unacceptable risk for the patient's participation Chest imaging (CT scan or radiograph) showing abnormalities not related with the DM in the last 12 weeks judged by the investigator as clinically significant. Diagnosis of Covid 19 infection (SARSCoV-2 positive PCR) Participants included in other intervention research involving humans Patient under tutorship or guardianship, and incapable to give informed consent
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
YVES ALLENBACH, MD, PhD
Phone
00 33 1 42 16 10 68
Email
yves.allenbach@aphp.fr
First Name & Middle Initial & Last Name or Official Title & Degree
SARRA POCHON
Phone
00 33 1 42 16 75 74
Email
sarra.pochon@aphp.fr
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
YVES ALLENBACH, MD, PhD
Organizational Affiliation
Assistance Publique - Hôpitaux de Paris
Official's Role
Principal Investigator
Facility Information:
Facility Name
Pitie-Salpêtrière hospital APHP
City
Paris
ZIP/Postal Code
75013
Country
France
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
SARRA POCHON
Phone
00 33 1 42 16 75 74
Email
sarra.pochon@aphp.fr

12. IPD Sharing Statement

Plan to Share IPD
Yes
IPD Sharing Plan Description
Data are available upon reasonable request. The procedures carried out with the French data privacy authority (CNIL, Commission nationale de l'informatique et des libertés) do not provide for the transmission of the database, nor do the information and consent documents signed by the patients. Consultation by the editorial board or interested researchers of individual participant data that underlie the results reported in the article after deidentification may nevertheless be considered, subject to prior determination of the terms and conditions of such consultation and in respect for compliance with the applicable regulations.
IPD Sharing Time Frame
Beginning 3 months and ending 3 years following article publication. Requests out of these time frame can also be submitted to the sponsor
IPD Sharing Access Criteria
Researchers who provide a methodological sound proposal.

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Baricitinib in Patients With Relapsing or naïve Dermatomyositis

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