In follow-up of the previous SynBioSe Study the present study is a randomized controlled trial designed to further investigate the long-term clinical and imunological efficacy of combination B-cell targeting by starting treatment with belimumab (anti-BAFF) followed by rituximab(anti-CD20) in lupus nephritis patients.
Rationale: The SynBioSe-1 study is the first study to comprehensively describe the clinical and immunological effects of combining rituximab (RTX) and belimumab (BLM) in patients with systemic lupus erythematosus (SLE). From the pioneering SynBioSe-1 study, we have learned that combining RTX+BLM was safe and well-tolerated with important clinical responses. Immunologically, we unexpectedly observed that long-term B-cell depletion was not achieved due to migration of mature B-cells triggered by depletion of BAFF serum levels. The latter observation was in contrast to the study's null-hypothesis that combination therapy would lead to long-term B-cell depletion. The contrary was demonstrated, namely the relative early recirculation of mature B-cells. As such, the immunological and clinical lessons from the SynBioSe-1 study in conjunction with accumulating data from several large studies on combination B-cell targeted treatment have led to the postulation that starting treatment with RTX+BLM would result in an improved B-cell targeting strategy, notably on tissue-resident autoreactive B-cells, associated with improved long-term clinical disease amelioration. Therefore, the present SynBioSe-2 study is designed to further investigate the long-term clinical and imunological efficacy of combination B-cell targeting by starting treatment with belimumab followed by rituximab. Objectives: The primary objective is to assess whether combination treatment BLM+RTX will lead to reduced treatment failure and the improvement of pivotal, SLE-specific autoimmune phenomena compared to SLE patients treated with standard of care. Study design: a multi-center, randomized, controlled, open-label study Study population: SLE patients with a severe flare with major organ involvement or persistent high disease activity despite conventional treatment Intervention: In addition to standard therapy, SLE patients will receive self-administered, subcutaneous injections of belimumab every week for the entire study period and 2 infusions of rituximab 1000 mg on day 28 (week 4) and day 42 (week 6). Main study parameters: The primary clinical efficacy parameter is the treatment failure rate during the 2 years study period. Secondary endpoints are clinical and non-biased immunological effects of the treatment summarized as follows: reduction of disease relevant autoantibodies, in particular anti-dsDNA autoantibody production at 28 weeks, total renal response rate at 28 weeks, regression of immune complex-mediated excessive neutrophil extracellular traps (NET) formation at 28 weeks; sustained, long-term B-cell depletion during 104 weeks; sustained reduction of relevant anti-nuclear autoantibodies, including seroconversion during 104 weeks; and sustained regression of immune complex-mediated excessive neutrophil extracellular traps (NET) formation during 104 weeks. Additionally, the study will perform safety and toxicity monitoring according to Common toxicity Criteria (CTC) developed by the National Cancer Institute (NCI) with the use of Common Terminology Criteria for Adverse Events (CTCAE) and evaluate the reduction of concomitant immunosuppression and the number of moderate and severe flares during study follow-up. Study duration: 104 weeks. Nature and extent of the burden and risks associated with participation and potential benefits: The study will include SLE patients with a severe flare necessitating remission induction treatment with intensive immunosuppression. The use of belimumab followed by rituximab can ameliorate disease activity even more than conventional treatment in the short-term and contribute to the successful tapering of concomitant immunosuppressive treatment. The latter will possibly lead to the reduction of infectious complication as compared to conventional treatment. The risks are predominantly related to the side effect profile of rituximab and belimumab and infectious complications of long-term B-cell depletion.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
70
Weekly injection of belimumab prior to two infusions of rituximab with continuation of the belimumab as maintenance therapy
University Medical Center Groningen
Groningen, Netherlands
Leiden University Medical Center
Leiden, Netherlands
Radboud University Medical Center
Nijmegen, Netherlands
HagaZiekenhuis
The Hague, Netherlands
Treatment failure rate
The treatment failure rate will be measured at 104 weeks in both treatment arms with the hypothesis that lower treatment failure rates will be obtained in the RTX+BLM arm.
Time frame: 2 years
Change of disease relevant auto-antibodies present at baseline, in particular anti-dsDNA
All disease relevant auto-antibodies will be measured at 28 weeks and compared to baseline with the hypothesis that a better reduction will be obtained in the RTX+BLM arm.
Time frame: 28 weeks
Sustained change of autoantibody production
The sustained reduction of pathogenic autoantibodies, in particular anti-dsDNA autoantibodies
Time frame: 2 years
Seroconversion of disease relevant auto-antibodies
Seroconversion of pathogenic autoantibodies, in particular anti-dsDNA autoantibodies
Time frame: 2 years
Change of memory B-cell numbers
The detection of (autoreactive) memory B-cells by standardized flowcytometry and in B-cell culture assays
Time frame: 28 weeks
Sustained change of memory B-cell numbers
The detection of (autoreactive) memory B-cells by standardized flowcytometry and in B-cell culture assays
Time frame: 2 years
Change of immune complex-mediated excessive neutrophil extracellular traps (NET) formation
The quantification of ex vivo NET induction with a 3-dimensional, confocal microscopy technique
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Time frame: 28 weeks
Sustained change of immune complex-mediated excessive neutrophil extracellular traps (NET) formation
The quantification of ex vivo NET induction with a 3-dimensional, confocal microscopy technique
Time frame: 2 years
Evaluation of the renal response
The number of partial and complete renal responders in case of lupus nephritis
Time frame: 2 years
Evaluation of the clinical response by SLEDAI
Patients will be monitored at frequent timepoints by the The Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K), with a minimum score of 0 and a maximum score of 105, with a higher score indicating a higher disease activity
Time frame: 2 years
Evaluation of the clinical response by SLICC
SLICC damage score (System Lupus International Collaborating Clinics/American College of Rheumatology Damage Index for Systemic Lupus Erythematosus) will be assesed at baseline, one year and two years, with a minimum score of 0 and a maximum score of 47, with a higher score indicating more damage
Time frame: 2 years
Evaluation of the clinical response by QoL questionnaires
QoL questionnaires will be assessed at multiple time points by the SF-36 (ShortForm-36) questionnaire, with a minimum score of 0 and a maximum score of 100, with a higher score indicating a higher quality of life
Time frame: 2 years
Evaluation of the clinical response by the amount of moderate and severe flares.
Patients will be monitored at frequent timepoints
Time frame: 2 years
Evaluation of the clinical response by the ability to reduce concomitant immunosuppression without flares
Patients will be monitored at frequent timepoints
Time frame: 2 years
Incidence of Treatment-Emergent Adverse Events [Safety and Tolerability]
Patients will be monitored at frequent timepoints
Time frame: 2 years