Active Conventional Therapy Compared to Three Different Biologic Treatments in Early Rheumatoid Arthritis With Subsequent Dose Reduction

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Know the risks and potential benefits of clinical studies and talk to your health care provider before participating. Read our disclaimer for details. Identifier: NCT01491815
Recruitment Status : Recruiting
First Posted : December 14, 2011
Last Update Posted : December 4, 2017
Information provided by (Responsible Party):
Ronald van Vollenhoven, prof., Karolinska Institutet

Brief Summary:

This is an international (Nordic) trial designed to compare the safety and efficacy of active conventional therapy (ACT) and three biologic treatments in subjects with early rheumatoid arthritis (RA). The global aim of this study is to assess and compare

  1. the proportion of subjects who achieve remission with ACT versus three different biologic therapies (Certolizumab-pegol, Abatacept or Tocilizumab)
  2. two alternative de-escalation strategies in patients who respond to first-line therapy.

Condition or disease Intervention/treatment Phase
Rheumatoid Arthritis Drug: Non-biological DMARD's Biological: Cimzia Biological: Orencia Biological: RoActemra Phase 4

Detailed Description:
There are currently 592 patients included of which 195 have entered treatment part 2. 91 patients have exited the study after treatment part 1, 106 patients have had early termination, and 80 patients have completed the full study.

Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 800 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary Purpose: Treatment
Official Title: A Multicenter, Randomized, Open-label, Blinded-assessor, Phase 4 Study in Patients With Early Rheumatoid Arthritis to Compare Active Conventional Therapy Versus Three Biologic Treatments, and Two De-escalation Strategies in Patients Who Respond to Treatment
Study Start Date : December 2012
Estimated Primary Completion Date : March 2019
Estimated Study Completion Date : December 2021

Resource links provided by the National Library of Medicine

U.S. FDA Resources

Arm Intervention/treatment
Active Comparator: Active conventional therapy (ACT)
Non-biological DMARD's: Methotrexate plus steroids or Methotrexate plus Sulphasalazine and Hydroxychloroquine and steroids
Drug: Non-biological DMARD's
Methotrexate: 25mg/week. SSZ: 2 g/day. HCQ: 35 mg/kg/week (Finland and Denmark) Methotrexate: 25mg/week. Prednisolone 20 mg/day tapered in 9 weeks to 5 mg/day, discontinued after 9 months. (Sweden, Norway, and Iceland)
Active Comparator: Biologic agent 1
Cimzia: Certolizumab-pegol plus Methotrexate and steroids
Biological: Cimzia
Certolizumab-pegol: 200 mg s.c. every other week. Methotrexate: 25mg/week
Active Comparator: Biologic agent 2
Orencia: Abatacept plus Methotrexate and steroids
Biological: Orencia
Abatacept: 125 mg s.c. every week. Methotrexate: 25mg/week
Active Comparator: Biologic agent 3
RoActemra: Tocilizumab plus Methotrexate and steroids
Biological: RoActemra

Tocilizumab is given as 4-weekly infusions at dosage 8 mg/kg or 162 mg in solution s.c. every week.

Methotrexate: 25mg/week

Primary Outcome Measures :
  1. The proportion of patients in remission at week 24 from baseline according to CDAI [ Time Frame: 24 weeks from BL ]
    Treatment Part 1: The primary efficacy outcome is the proportion of patients in remission at week 24 from BL according to CDAI

  2. The proportion of patients in remission at week 24 after dose-reduction according to CDAI [ Time Frame: 24 weeks after dose-reduction ]
    Treatment Part 2: The primary efficacy outcome is the proportion of patients in remission according to CDAI, at the time point 24 weeks after the dose was first reduced

  3. The radiographic progression of total Sharp van der Heijde score after 48 weeks from baseline [ Time Frame: 48 weeks from BL ]
    The primary efficacy outcome is the progression of total Sharp van der Heijde score after 48 weeks from BL

Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years and older   (Adult, Senior)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  1. Subject is ≥18 years of age.
  2. Subject has a diagnosis of RA as defined by the newly established ACR/EULAR criteria, 2010. (Patients should also be classified according to the 1987-revised ACR-classification criteria, without this being an inclusion criteria).
  3. <24 months from arthritis symptom debut (symptom duration will be registered).
  4. Subject must have DAS28 (CRP) > 3.2.
  5. ≥ 2 swollen joints AND ≥ 2 tender joints.
  6. Subject must fulfill one of the following three criteria: RF positive OR ACPA positive OR CRP >10 mg/L.
  7. Female subject is either not of childbearing potential (postmenopausal, surgically sterile etc.), or is of childbearing potential and practicing one of the following methods of birth control throughout the study and for 150 days after study completion:

    • Intrauterine device (IUD)
    • Contraceptives (oral, parenteral, patch) for three months prior to study drug administration)
    • A vasectomized partner
  8. Female subjects of childbearing potential must have a negative serum pregnancy test at the Screening visit.
  9. Subject is judged to be in good general health as determined by the principal investigator based upon the results of medical history, laboratory profile, physical examination, chest X-ray (CXR), and 12-lead electrocardiogram (ECG) performed at Screening.
  10. Subjects must be able and willing to provide written informed consent and comply with the requirements of this study protocol.
  11. Subjects must be able and willing to self-administer s.c. injections or have a qualified person available to administer s.c. injections.

Exclusion Criteria:

  1. Subject has been previously treated with disease modifying antirheumatic drugs (DMARDs) for rheumatic diseases.
  2. Current active inflammatory joint disease other than RA.
  3. Subjects has had a dose of prednisone (or equivalent) >7.5 mg/day or has had a dose change within the preceding 4 weeks.
  4. Subject has been treated with intra-articular or parenteral administration of corticosteroids in the preceding 4 weeks. Inhaled corticosteroids for stable medical conditions are allowed.
  5. Subject has undergone joint surgery within the preceding two months (at joints to be assessed within the study).
  6. Subject has chronic arthritis diagnosed before age 17 years.
  7. Subject has a history of an allergic reaction or significant sensitivity to constituents of study drugs.
  8. Subject has been treated with any investigational drug within one month prior to screening visit.
  9. Active infection of any kind (excluding fungal infections of nail beds), or any major episode of infection requiring hospitalization within 4 weeks of screening.
  10. Subject has a poorly controlled medical condition, such as uncontrolled diabetes, unstable heart disease, congestive heart failure, recent cerebrovascular accidents and any other condition which, in the opinion of the investigator, would put the subject at risk by participation in the study.
  11. Subject has a history of clinically significant hematologic (e.g., severe anemia, leukopenia, thrombocytopenia), renal or liver disease (e.g., fibrosis, cirrhosis, hepatitis).
  12. Subject has history of neurologic symptoms suggestive of central nervous system (CNS) demyelinating disease and/or diagnosis of central demyelinating disease.
  13. Subject has history of cancer or lymphoproliferative disease. Allowable exceptions:

    1. Successfully treated cutaneous squamous cell or basal cell carcinoma
    2. Localized carcinoma in situ of the cervix
    3. Curatively treated malignancy (treatment terminated) > 5 years prior to screening
  14. Subject has a history of listeriosis, histoplasmosis, untreated TB, persistent chronic infections, or recent active infections requiring hospitalization or treatment with intravenous (iv) anti-infectives within 30 days or oral anti-infectives within 14 days prior to the BL visit.
  15. Subjects will be evaluated for latent TB infection with a PPD or QuantiFERON test and X-ray. Subjects with evidence for latent TB will not be enrolled but first assessed according to local guidelines.
  16. Subject is known to have immune deficiency, history of Human Immunodeficiency Virus (HIV) or is otherwise severely immunocompromised.
  17. Female subject who is pregnant or breast-feeding or considering becoming pregnant during the study or within 150 days after the last dose of study medication.
  18. Men who are planning to father a child during the time they are included in the study
  19. Subject has a history of clinically significant drug or alcohol usage in the last year.
  20. Subject has a chronic widespread pain syndrome.
  21. Subject is considered by the investigator, for any reason, to be an unsuitable candidate for the study.
  22. Subject is unwilling to comply with the study protocol.
  23. Screening clinical laboratory analyses show any of the following abnormal laboratory results:

    1. Aspartate transaminase (AST) or alanine transaminase (ALT) > 1.75 times upper limit of normal (ULN).
    2. Positive serum human chorionic gonadotropin (hCG).
    3. Positive tests for hepatitis B surface antigen (HBsAg) or hepatitis C serology indicative of current infection.
    4. Creatinine levels > 2x the ULN. If creatinine 1-2 times ULN, check GFR.
    5. Hemoglobin < 90 g/L.
    6. Absolute neutrophil count (ANC) < 1.5 x 10^3/microL.
    7. Serum total bilirubin > 1.5 mg/dL (>26 micromol/L).

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its identifier (NCT number): NCT01491815

Contact: Ronald van Vollenhoven, MD, Prof. +46(0)851776077
Contact: Monica Rydén Aulin, PhD +46(0)851771110

The Karolinska Institutet Recruiting
Stockholm, Sweden, 171 76
Contact: Ronald van Vollenhoven, MD, Prof.    +46(0)851776077   
Sponsors and Collaborators
Karolinska Institutet

Study Data/Documents: Study Protocol  This link exits the site
Publication of the protocol. Glinatsi et al. Trials (2017) 18:161

Publications automatically indexed to this study by Identifier (NCT Number):
Responsible Party: Ronald van Vollenhoven, prof., Principal Investigator, Karolinska Institutet Identifier: NCT01491815     History of Changes
Other Study ID Numbers: NORD-STAR
2011-004720-35 ( EudraCT Number )
2011/2069-31/4 ( Other Identifier: Regional Ethical Review Board )
First Posted: December 14, 2011    Key Record Dates
Last Update Posted: December 4, 2017
Last Verified: December 2017
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: No

Additional relevant MeSH terms:
Arthritis, Rheumatoid
Joint Diseases
Musculoskeletal Diseases
Rheumatic Diseases
Connective Tissue Diseases
Autoimmune Diseases
Immune System Diseases
Certolizumab Pegol
Abortifacient Agents, Nonsteroidal
Abortifacient Agents
Reproductive Control Agents
Physiological Effects of Drugs
Antimetabolites, Antineoplastic
Molecular Mechanisms of Pharmacological Action
Antineoplastic Agents
Dermatologic Agents
Enzyme Inhibitors
Folic Acid Antagonists
Immunosuppressive Agents
Immunologic Factors
Antirheumatic Agents
Nucleic Acid Synthesis Inhibitors