Primary Objective: To assess the efficacy of AMG 714 in treating RCD-II in adult patients Secondary Objective: To assess the safety and tolerability of AMG 714 when administered to adult patients with RCD-IIExploratory Objective: To assess the…
ID
Source
Brief title
Condition
- Gastrointestinal inflammatory conditions
Synonym
Research involving
Sponsors and support
Intervention
Outcome measures
Primary outcome
Primary efficacy endpoint:
* Immunological Response 1: Reduction from baseline in the % of aberrant
intestinal intraepithelial lymphocytes (IELs) vs total IELs as assessed by
flow-cytometry
Secondary outcome
Secondary efficacy endpoints:
* Immunological Response 2: Reduction from baseline in the % of aberrant IELs
vs intestinal epithelial cells
* Histological Response: Improvement from baseline in small intestinal villous
height to crypt depth (VH:CD) ratio, Marsh score or total IEL counts
* Clinical response: Change from baseline in clinical symptoms
o Bristol Stool Form Scale (BSFS)
o Gastrointestinal Symptom Rating Scale (GSRS), including the celiac disease
GSRS (CeD-GSRS)
Exploratory endpoints:
* Reduction in aberrant and abnormal IELs by immunohistochemistry and T cell
receptor (TcR) clonality analyses
* Physician Global Assessment of Disease (PGA) and Patient Global Assessment of
Disease (PtGA)
* Quality of Life Assessments:
o SF-12 v. 2
o EQ-5D
* Biomarkers of disease activity
* Pharmacokinetics (PK), Pharmacodynamics (PD) and Exposure/Response (PK/PD)
* Celiac Disease Patient Reported Outcome (CeD PRO)
Safety endpoints:
* Adverse events
* Clinical laboratory tests
* Physical examination
* Vital signs
* Immunogenicity
Background summary
Protocol section 1
The disease to be treated is Refractory Celiac Disease Type II (RCD-II), an in
situ small bowel T cell lymphoma. RCD-II appears in ~0.5% of patients with
celiac disease and has ~50% probability of progression to a systemic
Enteropathy-Associated T cell Lymphoma (EATL).
The treatment-resistant EATL has dismal prognosis with <20% survival at 5 years.
Section 1.2. Celiac disease is a systemic autoimmune disease triggered by
gluten consumption in genetically susceptible individuals (Green and Cellier,
2007). Currently approximately 1% of the western population is affected by
celiac disease, albeit the vast majority of patients remain undiagnosed. The
prevalence is twice that in countries with very high hygiene standards and/or
very high gluten consumption. Presently it is estimated that 15-20 million
patients are affected by celiac disease and approximately 1.0-1.5 million
patients are diagnosed. This number has been reported to be doubling every 20
years (Riddle et al, 2012).
The pathophysiology of celiac disease is characterized by an abnormal immune
response to gluten. Gluten, which is normally a well-tolerated dietary
component, elicits innate and adaptive immune responses in celiac patients
(Green and Cellier, 2007). Humans lack enzymes to fully digest gluten, which
against the right genetic background triggers inflammation and autoimmunity in
the intestine and in other organs.
Section 1.2.1 A rare but specific complication of persistent diet
non-responsive celiac disease is the development of Refractory Celiac Disease
(RCD), which affects approximately 1% of celiac patients (Lebwohl et al, 2013)
and is characterized by severe gastrointestinal symptoms in the absence of
gluten consumption and in the presence of small bowel aberrant intraepithelial
lymphocytes (IELs) (reviewed in Verbeek et al 2008, and in van Wanrooij et al,
2014).
When the numbers of aberrant IELs exceed the 20% threshold, referred to as Type
II RCD (RCD-II), the risk of developing EATL is dramatically increased to >50%
(Nijeboer et al, 2015a, 2015b). EATL has a very poor 5-year survival of <20%
(Nijeboer et al, 2015a) and its prevalence is increasing (Sharaiha et al, 2012).
For the purpose of this study, and in agreement with leading experts in RCD-II
(Malamut et al, 2010; Nijeboer et al, 2015a, 2015b), aberrant IELs will be
defined as surface CD3-negative, surface TCR-, intra-cellular CD3-positive IELs
(sCD3-, sTCR-, icCD3+). The cut-off chosen for diagnosis of RCD-II is 20% in
accordance with most recent studies (Nijeboer et al, 2015b).
Additionally, standard flow diagrams for the diagnosis of RCD-II (e.g.,
Rubio-Tapia et al, 2013) and exclusion of conditions that could simulate RCD-II
clinically and histologically are considered in the inclusion/exclusion
criteria.
Study objective
Primary Objective: To assess the efficacy of AMG 714 in treating RCD-II in
adult patients
Secondary Objective: To assess the safety and tolerability of AMG 714 when
administered to adult patients with RCD-II
Exploratory Objective: To assess the pharmacokinetics (PK), pharmacodynamics
(PD), and PK/PD correlations of AMG 714
Study design
Protocol CELIM-RCD-002 is designed to be a Phase 2a randomized, double-blind,
placebo-controlled, parallel group study to evaluate the efficacy and safety of
AMG 714 for the treatment of adult patients with RCD-II.
Should AMG 714 show adequate efficacy and safety, as determined by the Sponsor,
subjects in the study, including those in the placebo arm, may be offered
participation in an open label extension study of AMG 714 in due course, but
under no circumstances prior to study completion. In the interim, between the
end of the study for an individual subject and the start of the possible open
label extension, the Sponsor intends to provide a bridging program to allow
objective study responders to have access to AMG 714 as determined by their
site investigator or physician. The open label extension study and interim
bridging program will be described in independent protocols.
Intervention
After signing consent subjects will be screened for the study. All subjects who
meet the study entry criteria will be randomized at a 2:1 ratio to receive
either 8 mg/kg AMG 714 or placebo a total of 7 times over 10 weeks, with
evaluation of the primary endpoint at Week 12. AMG 714 (N=16) or placebo (N=8)
will be administered at the clinical site in a double-blind fashion via
intravenous (IV) infusion over 120 minutes.
Concomitant therapy with steroids at a maximum dose of 20 mg of prednisone,
prednisolone or equivalent per day or oral budesonide at a maximum dose of 9 mg
per day will be accepted. These doses will need to be stable for 4 weeks prior
to randomization and remain stable for the duration of the study.
A study staff member will contact the subject by phone one day after the first
dose of study drug to assess for any new or worsening AEs. Subjects will return
to the clinic for the next administration of study drug after 1 week (Visit 2,
Week 1/Day 7). After Visit 2, subjects will return to the clinic for follow-up
and study drug administration at Visit 3 (Week 2/Day 14) and every two weeks
thereafter as indicated in the study schedule of events (Table 1). The final
study dose will be administered at Visit 7 (Week 10/Day 70). An end-of-study
efficacy visit will be conducted at Visit 8 (Week 12/Day 84). The final study
visit will be conducted 6 weeks after the last dose of study drug at Visit 9
(Week 16/Day 112).
Study burden and risks
- Patients will receive the drug via IV, and blood will be taken (see section
E6 and J for details)
- Patient could be assigned to the placebo arm
- Daily completion of a diary, and many questionnaires
- Subjects will be expected to maintain total adherence to a strict gluten-free
diet (GFD) from 6 months before randomization through the final study visit
(Visit 9, Week 16/Day 112).
- All study subjects will undergo upper gastrointestinal endoscopy with mucosal
biopsy prior to baseline (i.e., prior to Visit 1, Week 0/Day 0) and within 7
days of Visit 8 (Week 12/Day 84)
Adverse events:
- When giving AMG 714 to people via an injection, some experienced
redness/swelling of the injection site.
- Patients might develop antibodies to AMG 714
- Patients can be allergic to the drug
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Age
Inclusion criteria
1. Adult males or females 18 years of age or older.
2. Demonstrated willingness to participate in the study as documented by signed informed consent.
3. Females of non-childbearing potential defined as postmenopausal (>45 years of age with amenorrhea for at least 12 months or any age with amenorrhea for at least 6 months and a serum follicle stimulating hormone [FSH] level >40 IU/L at Screening); or permanently sterilized (e.g., bilateral tubal occlusion, hysterectomy, bilateral salpingectomy, oophorectomy); or otherwise incapable of pregnancy
OR
Females of child bearing potential (FOCBP) or males who agree to practice two highly effective methods of birth control (as determined by the Investigator; one of the methods must be a barrier technique) from Screening through the end of study participation (Visit 9, Week 16/Day 112).
4. Prior confirmed diagnosis of RCD-II defined by the following criteria: celiac disease confirmed by histology, endoscopy or serology; with persistent and recurrent symptoms (e.g., diarrhea, weight loss, abdominal pain); with abnormal small bowel histology; with aberrant intraepithelial lymphocytosis of > 20 aberrant intraepithelial lymphocytes (IEL) per 100 CD45+ cells as determined by flow cytometry (or >50% if determined by immunohistochemistry); despite adherence to a strict GFD for at least 6 months; and after exclusion of other potential causes of symptomatic non-response (e.g., microscopic colitis, bacterial overgrowth, lactose intolerance, exocrine pancreatic insufficiency, hyperthyroidism, etc.) and intestinal histological abnormality (autoimmune enteropathy, giardiasis, immunodeficiency, collagenous sprue, Whipple*s disease, etc.).;NOTE: Subjects who have been treated for RCD-II must continue to have increased aberrant IELs (>20% by flow cytometry or 50% by IHC) and abnormal small bowel histology (Marsh *1) and must have had prior history of symptoms, however symptoms are not required of previously treated subjects, or subjects being treated with steroids, at the time of study entry. ;5. Total attempted adherence to a GFD for at least 6 consecutive months prior to screening. Subjects must also agree to make no changes to their current GFD for the duration of study participation.
6. Anti-tissue transglutaminase (IgA and IgG) at screening <2 x the diagnostic level for celiac disease (weak positive or negative).
7. Human leukocyte antigen DQ (HLA-DQ) typing compatible with celiac disease provided or obtained prior to baseline biopsy.
8. Life expectancy > 4 months.
9. Laboratory values:
a) Estimated creatinine clearance (CCr) > 30 mL/min/1.73m2 using the Cockcroft-Gault equation
b) Serum alkaline phosphatase (AP), alanine transaminase (ALT/SGPT), and aspartate aminotransferase (AST/SGOT) less than 3x the upper limits of normal (ULN)
c) Total bilirubin of less than 2.5 x ULN
d) Total white blood cell count (WBC) > 300/mm3
e) Platelet count > 85,000/mm3
f) INR less than 1.5
g) Albumin of more than 10 g/L (i.e., 1 g/dL or 1.45 mol/L)
10. Subjects receiving systemic steroids must be on a stable dose for at least 4 weeks prior to randomization, the dose should not exceed 20 mg of prednisone, prednisolone or equivalent per day. Oral budesonide will be accepted at a maximum dose of 9 mg per day.
11. Willingness and ability to comply with study procedures and protocol stipulated concomitant medication guidelines.
12. Willingness to return for all scheduled follow-up visits.
Exclusion criteria
1. Diagnosis of Type I Refractory Celiac Disease (RCD-I) or enteropathy-associated T cell lymphoma (EATL, excluded by the site*s standard imaging techniques for this purpose).
2. Presence of any of the following related to infection:
a) Active acute infection requiring systemic antibiotic, parenteral antifungal, or systemic antiviral treatments
b) Severe infection within the 3 months prior to screening
c) History of tuberculosis (TB)
d) Positive Interferon Gamma Release Assay (IGRA) test at screening OR known recent exposure (within 6 months prior to screening) to a patient with active TB; the subject can be enrolled if he or she has been successfully treated with appropriate chemoprophylaxis.
e) History within the 3 years prior to screening of an opportunistic infection typical of those seen in immunocompromised subjects (e.g., systemic candida infection, or systemic fungal infection).
3. Current diagnosis or history of cancer within the past 5 years, except RCD-II, successfully-treated basal cell or squamous cell carcinoma, cervical carcinoma-in-situ, or early stage prostate cancer
4. History or presence of clinically significant disease that in the opinion of the Investigator would confound the subject*s participation and follow-up in the clinical trial or put the subject at unnecessary risk including but not limited to:
a) Cardiovascular disease [e.g., uncontrolled hypertension (defined as office systolic blood pressure [BP] equal to or greater than 180 mmHg or office diastolic BP equal or greater than 110 mm/Hg), unstable angina, congestive heart failure worse than the New York Heart Association Class II, coronary angioplasty or myocardial infarction within the last 6 months, uncontrolled atrial or ventricular cardiac arrhythmias clinically significant pleural or pericardial effusion or ascites)
b) pulmonary disease (e.g., severe chronic pulmonary disease)
c) renal, hematological, gastrointestinal, endocrine (e.g., poorly controlled diabetes), immunologic, dermatologic, neurological, or psychiatric disease
5. History of significant immune suppression:
- Bone marrow transplant (BMT) or cladribine therapy less than 6 months prior to baseline. In other words, cladribine and bone marrow transplant naïve, primary non-responders (treatment resistant), secondary non-responders (relapse after response/remission) and incomplete responders may be enrolled in the study if cladribine therapy and/or BMT were not provided within the 6 months prior to randomization.
- Potent systemic immune suppressants (e.g., azathioprine) in the 3 months prior to baseline.
6. History of alcohol or drug abuse that would interfere with the ability to comply with the study protocol.
7. History of clinically significant hypersensitivity to the study drug or any related drugs or to any of the excipients.
8. Positive hepatitis B (Hep B), hepatitis C (Hep C), or Human immunodeficiency virus (HIV) infection test results at the time of screening.
9. Females who are pregnant or are planning to become pregnant during the study participation period or 6 months after last dose, or are currently breastfeeding.
10. Participation in another investigational drug or device study or treatment with an investigational drug within 30 days or 5 half-lives, whichever is longer, prior to randomization
11. Any additional reason, which in the opinion of the Investigator, would prevent the subject from safely participating in the study or complying with protocol requirements.
Design
Recruitment
Medical products/devices used
Followed up by the following (possibly more current) registration
No registrations found.
Other (possibly less up-to-date) registrations in this register
No registrations found.
In other registers
Register | ID |
---|---|
EudraCT | EUCTR2015-004063-36-NL |
ClinicalTrials.gov | NCT02633020 |
CCMO | NL56033.029.15 |