This is a study that invites adults with Crohn's disease and have been responding well to Adalimumab (Humira ®) for at least 6 months. Patients frequently discontinue maintenance medications in Crohn's disease, particularly when in remission. Patients want to know that they truly need to take a medication, yet they don't want to have flares. The purpose of this study is to see that if we monitor the patient, along with looking at changes in their stool samples, we can safely stop the maintenance medication Adalimumab for up to 48 weeks, or add as-needed dosing only, and keep them in remission.
Patients frequently discontinue maintenance medications in Crohn's disease, particularly when in remission. Patients want to know that they truly need to take a medication, yet they don't want to have flares. As a biomarker, fecal calprotectin \< 167 has a 100% negative predictive value for flare within the next 12 weeks (Gisbert, 2009). Adalimumab has low antigenicity, and can be safely stopped and restarted later with good clinical effect (Colombel, 2007). Patients want intermittent therapy, if it can be delivered in a timely fashion when pre-clinical inflammation starts, in order to avoid clinically-significant flares. This study will combine monitoring for pre-clinical inflammation with fecal calprotectin and as-needed dosing with Adalimumab to maintain remission in patients who have obtained remission with Adalimumab. This will be compared to two comparator arms: standard maintenance therapy and complete cessation of therapy (Step-Down approach).
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
TRIPLE
Adalimumab 40 mg q 2 weeks, with placebo loading of 3 syringes/1 syringe at Weeks 0/2, 12/14, 24/26, and 36/38
160 mg/80 mg Adalimumab at Weeks 0 and 2, followed by 1 syringe SC placebo q 2 weeks (except at Weeks 12/14, 24/26, and 36/38), with * PRNLOADing of 160 mg/80 mg Adalimumab at Weeks 12/14, 24/26, or 36/38 if most recent FCP is ≥167 mcg/gram of stool, * Or, placebo loading of 4 syringes/2 syringes at Weeks 12/14, 24/26, and 36/38 if most recent FCP is \< 167 mcg/gram of stool.
1 syringe of placebo SC q 2 weeks, with additional placebo loading of 3 syringes/1 syringe at Weeks 0/2, 12/14, 24/26, and 36/38 Weeks.
University of Michigan Health System
Ann Arbor, Michigan, United States
Percent Time in Remission (PTIR) in PRNLOAD vs. Placebo arms
Determine whether adding as-needed q 12 weeks Adalimumab re-loading (160 mg/80 mg) when FCP ≥167 mcg/gram of stool can improve the maintenance of remission in Crohn's disease patients who stop Adalimumab therapy (PRNLOAD Arm) compared to the placebo arm. Endpoint: Percent time in remission (q 4 week evaluation for 48 weeks).
Time frame: 48 weeks
Percent Time in Remission MAINT vs. PRNLOAD
Compare the percent of monitoring visits in which the subject is in remission in each arm between the MAINT and PRNLOAD arms.
Time frame: 48 weeks
Percent Time in Remission MAINT vs. PBO
Compare the percent of monitoring visits in which the subject is in remission in each arm between the MAINT and PBO arms.
Time frame: 48 weeks.
Strict Biologic Remission Rates
Percent of visits with strict biologic remission (FCP \<50 and CRP \<0.5) with 3 comparisons: PRNLOAD vs. PBO, MAINT vs. PRNLOAD, MAINT vs. PBO
Time frame: 48 weeks
Subject acceptability
Measure subject acceptability of repeated stool sampling.
Time frame: 48 weeks
Subject preference
Measure subject preference for the MAINT versus PRNLOAD regimen.
Time frame: 48 weeks
Equivalence of Percent Time in Remission
Compare percent time in remission (CDAI \<150) over 48 weeks, evaluation every 4 weeks across 3 arms (chi square test).
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Time frame: 48 weeks
Comparison of Average CDAI
Compare average CDAI over 48 weeks, evaluation every 4 weeks across 3 arms (ANOVA).
Time frame: 48 weeks
Comparison of average IBDQ
Compare average IBDQ over 48 weeks, evaluation every 4 weeks across 3 arms (ANOVA).
Time frame: 48 weeks
Comparison of average FCP
Compare average FCP over 48 weeks, evaluation every 12 weeks across 3 arms (ANOVA).
Time frame: 48 weeks
Comparison of average CRP
Compare average CRP over 48 weeks, evaluation every 12 weeks across 3 arms (ANOVA).
Time frame: 48 weeks
Comparison of Rates of Hospitalization
Comparison of Rates of Hospitalization across all 3 arms - hospital admissions per patient over 48 weeks (ANOVA).
Time frame: 48 Weeks
Comparison of Rates of Emergency Department visits
Comparison of Rates of Emergency Department visits across all 3 arms - hospital admissions per patient over 48 weeks (ANOVA).
Time frame: 48 Weeks
Comparison of Rates of Physician visits
Comparison of Rates of Physician visits across all 3 arms - hospital admissions per patient over 48 weeks (ANOVA).
Time frame: 48 Weeks
Comparison of mg prednisone prescribed
Comparison of average milligrams of prednisone prescribed across all 3 arms - over 48 weeks (ANOVA).
Time frame: 48 Weeks