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Transcriptional and Immine Parameters of Response to Belinumab

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ClinicalTrials.gov Identifier: NCT04570306
Recruitment Status : Not yet recruiting
First Posted : September 30, 2020
Last Update Posted : December 7, 2020
Sponsor:
Information provided by (Responsible Party):
DIMITRIOS BOUMPAS, Biomedical Research Foundation, Academy of Athens

Brief Summary:
The investigators propose to perform RNA-sequencing of the whole blood initially, in a cohort of 80 SLE patients who will receive belimumab as part of standard clinical practice, in order to assess intra-patient longitudinal (baseline, 1, 3 and 6 months) transcriptome changes and examine whether treatment can ameliorate the activity/flare, severity and major organ disease gene signatures. The investigators will also obtain preliminary information on molecular signatures predicting clinical responses and the impact of belimumab on gene signatures of host defense against viral and bacterial (including mycobacterial) pathogens. Using modules of cell type-specific genes and co-expression gene networks, The investigators will deconvolute our data to define pertinent molecular alterations in specific immune cell types. Results will be validated and functionally characterized by single-cell mass cytometry (performed at the aforementioned time points), which enables investigation of the cell identity (including subsets of B-cells and myeloid cells of particular relevance to the disease) and activation status at protein level (e.g. phosphorylation) through next-generation, high-dimensional flow cytometry. Through a focused analysis followed by targeted gene expression and function studies in purified monocytes, the investigators will determine whether belimumab can restore "SLE-primed" monocytes thus, alleviating their inflammatory and pro-atherogenic phenotype and enhancing their bactericidal activity. Collectively, these studies will provide novel mechanistic insights on the beneficial efficacy/toxicity ratio of belimumab therapy in SLE.

Condition or disease Intervention/treatment
Systemic Lupus Erythematosus Drug: Belimumab

Detailed Description:

B-cell activating factor (BAFF) excess causes lupus disease by exerting costimulatory effects on the B-cell compartment but also on a variety of non-B-cell subsets such as T-helper cells and monocytes/dendritic cells. The 2019 updated European League Against Rheumatism (EULAR) recommendations for SLE recommend usage of belimumab (anti-BAFF mAb) in persistently active or flaring disease based upon evidence for efficacy, reduction of flares and organ damage accrual without increasing the risk of infections. Still, belimumab is usually reserved for established, refractory cases. It is conceivable that earlier usage may halt the progression of the disease, especially prevent flares and dysfunction in major organs. The investigators have completed a combined genetic and transcriptomic analysis in the peripheral blood of SLE patients and have characterized distinct gene signatures for disease activity/flare and severity. Using machine learning techniques, the investigators can predict SLE patients likely to develop major organ involvement. In vitro and gene profiling studies in purified lupus monocytes indicate that these cells exist - under the effect of type I interferon - in a "high alert" autoreactive and metabolic state (reminiscent of 'trained immunity'), which may contribute to risk of flares, tissue injury but also major comorbidities seen in SLE, particularly accelerated atherosclerosis and infections. Based upon the clinical experience accumulated thus far, it is likely that belimumab may neutralize these molecular signatures for flares and disease progression without interfering with host defense immune pathways.

The investigators propose to perform RNA-sequencing of the whole blood initially, in a cohort of 80 SLE patients who will receive belimumab as part of standard clinical practice, in order to assess intra-patient longitudinal (baseline, 1, 3 and 6 months) transcriptome changes and examine whether treatment can ameliorate the identified activity/flare, severity and major organ disease signatures. The investigators will also obtain preliminary information on molecular signatures predicting clinical responses and the impact of belimumab on gene signatures of host defense against viral and bacterial (including mycobacterial) pathogens. Using modules of cell type-specific genes and co-expression gene networks, the investigators will deconvolute our data to define pertinent molecular alterations in specific immune cell types. Results will be validated and functionally characterized by single-cell mass cytometry (performed at the aforementioned time points), which enables investigation of the cell identity (including subsets of B-cells and myeloid cells of particular relevance to the disease) and activation status at protein level (e.g. phosphorylation) through next-generation, high-dimensional flow cytometry. Through a focused analysis of the deconvoluted RNA-seq and mass cytometry data followed by targeted gene expression and function studies in purified monocytes, the investigators will determine whether belimumab can restore "SLE-primed" monocytes thus, alleviating their inflammatory and pro-atherogenic phenotype and enhancing their bactericidal activity. Collectively, these studies will provide novel mechanistic insights on the beneficial efficacy/toxicity ratio of belimumab therapy in SLE, while supporting the early use of the drug.

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Study Type : Observational
Estimated Enrollment : 80 participants
Observational Model: Cohort
Time Perspective: Prospective
Official Title: Whole Blood Transcriptional and Mass Cytometry Immune Profiling in Systemic Lupus Erythematosus (SLE) Patients to Discern the Salutary Effects of Belimumab on Halting Disease Progression and Flares Without Compromising Host Fitness
Estimated Study Start Date : December 31, 2020
Estimated Primary Completion Date : December 30, 2023
Estimated Study Completion Date : December 30, 2023

Resource links provided by the National Library of Medicine

MedlinePlus related topics: Lupus
Drug Information available for: Belimumab

Group/Cohort Intervention/treatment
Belimumab-treated SLE patients
SLE patients with active disease who will be started on add-on treatment with belimumab on top of standard of care.
Drug: Belimumab
The study will involve 80 adult patients diagnosed with SLE who will be started on belimumab (standard approved dose of i.v. 10 mg/kg or subcutaneous 200 mg/week) due to active disease. The intention to start belimumab will be made by the treating Rheumatologist(s), in accordance to the current standard of care, and on the basis of shared physician-patient decision making.




Primary Outcome Measures :
  1. Changes in blood transcriptome in relation to clinical response induced by belimumab [ Time Frame: 1, 3 and 6 months ]
    To evaluate changes in SLE blood transcriptome that are induced by treatment with belimumab with emphasis on the reversibility of previously-defined gene signatures for disease activity/flare, severity/progression and major organ involvement. Results will be correlated with validated patient outcomes such as clinical response (defined according to SLE Responder Index-4).


Secondary Outcome Measures :
  1. Changes in blood transcriptome in relation to low disease activity induced by belimumab [ Time Frame: 3 and 6 months ]
    To evaluate changes in SLE blood transcriptome that are induced by treatment with belimumab with emphasis on the reversibility of previously-defined gene signatures for disease activity/flare, severity/progression and major organ involvement. Results will be correlated with low disease activity in SLE (according to the Low Disease Activity State definition)

  2. Changes in blood transcriptome in relation to remission induced by belimumab [ Time Frame: 6 months ]
    To evaluate changes in SLE blood transcriptome that are induced by treatment with belimumab with emphasis on the reversibility of previously-defined gene signatures for disease activity/flare, severity/progression and major organ involvement. Results will be correlated with remission in SLE (according to the Definition of Remission [DORIS] in SLE)


Biospecimen Retention:   Samples With DNA
Blood RNA tubes, ethylenediaminetetraacetic acid (EDTA) tubes for genomic DNA extraction


Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years to 65 Years   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Sampling Method:   Non-Probability Sample
Study Population
The study will involve 80 adult patients diagnosed with SLE (according to the SLICC 2012 and/or EULAR/ACR 2019 classification criteria) who will be started on belimumab (standard approved dose of i.v. 10 mg/kg or subcutaneous 200 mg/week) due to active disease. The intention to start belimumab will be made by the treating Rheumatologist(s), in accordance to the current standard of care, and on the basis of shared physician-patient decision making. Active SLE is defined as the combination of clinical (i.e., excluding serology) SLEDAI-2K ≥6 and physician global assessment (PhGA) ≥1.5. Both flaring (acute exacerbation) and persistent disease activity will be considered.
Criteria

Inclusion Criteria: SLE patients:

  • who meet the Systemic Lupus International Collaborating Clinics (SLICC) 2012 and/or European League Against Rheumatism/American College of Rheumatology (EULAR/ACR) 2019 classification criteria;
  • have active disease defined as the combination of clinical (i.e., excluding serology) SLEDAI-2000 ≥6 and physician global assessment (PhGA) ≥1.5. Both flaring (acute exacerbation) and persistent disease activity will be considered;
  • are started belimumab (standard approved dose of i.v. 10 mg/kg or subcutaneous 200 mg/week) due to active disease. The intention to start belimumab will be made by the treating Rheumatologist(s), in accordance to the current standard of care, and on the basis of shared physician-patient decision making.

Exclusion Criteria:

  • age <18 years
  • co-existing rheumatic or other autoimmune disease
  • pregnancy
  • active infection
  • history of malignant disorder

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 ClinicalTrials.gov identifier (NCT number): NCT04570306


Contacts
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Contact: Dimitrios T BOUMPAS, MD +306937212025 boumpasd@uoc.gr

Sponsors and Collaborators
Biomedical Research Foundation, Academy of Athens
Investigators
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Study Chair: Dimitrios T Boumpas, MD Biomedical Research Foundation, Academy of Athens
Publications:
Steri M, Orrù V, Idda ML, Pitzalis M, Pala M, Zara I, Sidore C, Faà V, Floris M, Deiana M, Asunis I, Porcu E, Mulas A, Piras MG, Lobina M, Lai S, Marongiu M, Serra V, Marongiu M, Sole G, Busonero F, Maschio A, Cusano R, Cuccuru G, Deidda F, Poddie F, Farina G, Dei M, Virdis F, Olla S, Satta MA, Pani M, Delitala A, Cocco E, Frau J, Coghe G, Lorefice L, Fenu G, Ferrigno P, Ban M, Barizzone N, Leone M, Guerini FR, Piga M, Firinu D, Kockum I, Lima Bomfim I, Olsson T, Alfredsson L, Suarez A, Carreira PE, Castillo-Palma MJ, Marcus JH, Congia M, Angius A, Melis M, Gonzalez A, Alarcón Riquelme ME, da Silva BM, Marchini M, Danieli MG, Del Giacco S, Mathieu A, Pani A, Montgomery SB, Rosati G, Hillert J, Sawcer S, D'Alfonso S, Todd JA, Novembre J, Abecasis GR, Whalen MB, Marrosu MG, Meloni A, Sanna S, Gorospe M, Schlessinger D, Fiorillo E, Zoledziewska M, Cucca F. Overexpression of the Cytokine BAFF and Autoimmunity Risk. N Engl J Med. 2017 Apr 27;376(17):1615-1626. doi: 10.1056/NEJMoa1610528.

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Responsible Party: DIMITRIOS BOUMPAS, Professor and Chairman Department of Medicine, Medical School, National and Kapodestrian University of Athens, Biomedical Research Foundation, Academy of Athens
ClinicalTrials.gov Identifier: NCT04570306    
Other Study ID Numbers: DB11
First Posted: September 30, 2020    Key Record Dates
Last Update Posted: December 7, 2020
Last Verified: December 2020
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: Undecided

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Studies a U.S. FDA-regulated Drug Product: Yes
Studies a U.S. FDA-regulated Device Product: No
Product Manufactured in and Exported from the U.S.: No
Keywords provided by DIMITRIOS BOUMPAS, Biomedical Research Foundation, Academy of Athens:
transcriptome
trained immunity
host-pathogen defense
Additional relevant MeSH terms:
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Lupus Erythematosus, Systemic
Connective Tissue Diseases
Autoimmune Diseases
Immune System Diseases
Belimumab
Immunosuppressive Agents
Immunologic Factors
Physiological Effects of Drugs