Efficacy and Safety of Fecal Microbiota Transplantation in Peripheral Psoriatic Arthritis (FLORA)

Efficacy and Safety of Fecal Microbiota Transplantation (FMT) in Patients With Peripheral Psoriatic Arthritis: a 6-month, Double-Blind, Randomized, Placebo-Controlled Trial

Region of Southern Denmark, University of Southern Denmark, The Danish Rheumatism Association, Odense Patient Data Explorative Network, The Psoriasis Association, Denmark, Manufacturer Vilhelm Pedersen Foundation, The Danish Regions (Medicinpuljen)

An abnormal intestinal microbiota may be the mediator of the common inflammatory pathways seen in psoriatic arthritis. This study will explore clinical aspects associated with modifying the intestinal microbiota by infusing fecal donor microbiota into the small intestine of psoriatic arthritis patients with a minimum of three swollen joints despite at least three months of methotrexate treatment.

Recent years have seen growing recognition of the complexity of the role of the microbiota in shaping the immune system and its potential effects for health and disease. In particular, the gut bacteria composition has been associated with the pathogenesis of autoimmune and inflammatory diseases. Intriguingly, presence of intestinal inflammation in psoriatic arthritis (PsA) patients has been documented in several studies. Also, in genetically predisposed patients reactive arthritis, which share some of the clinical manifestations of PsA, can be triggered by certain types of bacterial gut infections. Furthermore, a recent study has reported that several intestinal bacteria including Akkermansia and Ruminoccocus, which are known to play an important role in maintaining gut homeostasis, were practically absent in PsA patients. Mechanisms through which the microbiota may be involved in the pathogenesis of PsA include an abnormal activation of the gut-associated lymphoid tissue (GALT) and/or an altered mucosal permeability thus compromising the capacity of the intestine to provide adequate containment of luminal microorganisms and molecules. By conducting a double-blinded, randomized, placebo-controlled trial of a non-related donor fecal microbiota transplantation (FMT) infused into the small intestine, this study will reveal whether FMT is more effective than an identically appearing placebo (saline) in reducing disease activity in psoriatic arthritis patients presenting with a minimum of three swollen joints despite at least three months of methotrexate treatment (maximal tolerable dosis ≥ 15 mg/week). All patients will throughout the study continue their individual treatment with weekly methotrexate.

Fecal Microbiota Transplantation, FMT, Randomized Controlled Trial, Intestinal microbiome, RCT, Faecal microbiota transplantation

One fecal microbiota transplantation is performed at baseline using gastroscopic guidance. The transplant consists of 50 g feces obtained from a healthy non-related donor. The donor feces is suspended into NaCl (0.9%) and glycerol (10%), and will be stored at minus 80 degrees celsius until use. The total volume of the suspension is 250 mL and its temperature will be 37 degrees celsius when infused into the small intestine of the recipient.

One identical appearing sham procedure is performed at baseline using gastroscopic guidance. 250 mL saline (NaCl 0.9%) is infused into the small intestine of the recipient.

Proportion of patients in each group who experience treatment failure according to shared decision making between patient and rheumatologist defined as at least one of the following: Need for more than 1 intra-articular glucocorticoid injection due to disease activity. Need for change to other conventional DMARDs (at the moment oral leflunomide, sulfasalazin or ciclosporin) according to the updated Danish guideline treatment due to disease activity. Need for biologic treatment according to the updated Danish guideline treatment due to severe disease activity.

Proportion of patients in each group achieving ACR20 response criteria ACR50 response criteria ACR70 response criteria A patient will be considered as improved according to the ACR20/50/70 response criteria if she/he has at least 20/50/70% improvement in the two following measures: Tender joint count (68) and swollen joint count (66), and at least 3 of the following 5 measures: Patient's assessment of pain, patient's global assessment of disease activity, physician's global assessment of disease activity, Health Assessment Questionnaire (HAQ) score, acute phase reactant (CRP).

Proportion of patients in each group achieving PsARC response criteria. A patient will be considered as improved according to the PsARC response criteria if she/he has an improvement in either joint swelling or tenderness, and in any of 4 other measures: Patient global assessment of articular disease; physician global assessment of articular disease; joint pain or tenderness; joint swelling.

Change from baseline in SPARCC Enthesitis Index in the subset of patients who have enthesitis at baseline.

Change from baseline in the Psoriasis Area Severity Index (PASI) in the subset of patients who have psoriasis at baseline.

Change from baseline in the number of digits affected with dactylitis in the subset of patients who have dactylitis at baseline.

Inclusion Criteria: Diagnosis of psoriatic arthritis according to the Classification Criteria for Psoriatic Arthritis (CASPAR criteria). Presence of active peripheral psoriatic arthritis defined as ≥ 3 swollen joints. Methotrexate (≥ 15mg/week (maximal tolerable dosage)) for a minimum of 3 months prior to study inclusion. Exclusion Criteria: Other inflammatory rheumatic diseases than PsA. Current axial disease activity or severe peripheral joint activity demanding immediate change of treatment or contraindicating placebo treatment for 6 months. History of severe MTX toxicity or allergic reactions. Current biological treatment and biological treatment within the last 6 months. Inflammatory bowel disease, celiac disease, food allergy, or other intestinal diseases. Current cancer or severe chronic infections. Pregnant or breastfeeding women. Systemic and/or local intra-articular or peritendinous steroid injections within 3 months of inclusion. Non-MTX DMARD treatment within three months of inclusion. Antibiotics within 3 months of inclusion. Not wishing to participate or unsuited for project evaluation.

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