Primary immune thrombocytopenia (ITP) is an autoimmune disease mainly mediated by autoreactive B cells and the presence of pathogenic anti-platelet auto-antibodies that enhance platelet destruction and impair platelet production. There are approximately 4,000 newly diagnosed ITP cases each year in France. For patients with a platelet count of less than 30x109/L and/or bleeding symptoms, corticosteroids alone or in combination with intravenous immunoglobulin (IVIg) is the standard first-line treatment. However, approximately two-thirds of adult patients responding to this first-line treatment relapse within days or weeks after corticosteroids withdrawal and overall, the course of the disease is chronic in about 70% of the cases. The anti-CD20 monoclonal antibody rituximab is commonly used off-label as a second-line therapy in many European countries including France for adults with persistent (i.e., disease duration of more than 3 months) or chronic (disease duration of more than 12 months) ITP. Rituximab leads to an overall response rate of only 40 % at 1 year but 29.5% of lasting (5 years and more) response The investigators have shown that the absence of response to rituximab in ITP could be explained by the settlement and expansion of long-lived autoreactive plasma cells in the spleen made possible by the high amount of BAFF. Belimumab is a fully humanized anti-BAFF/Blys monoclonal Ab licensed for SLE. Based on the preliminary results of a phase 2 open prospective pilot study performed in our center combining rituximab with i.v belimumab seems highly promising We hypothesized that combining subcutaneous belimumab weekly over a 24 weeks period (Arm A) with rituximab is superior to rituximab and subcutaneous placebo weekly over 24 weeks period (Arm B) to achieve an overall response at W52. The study design will be a prospective randomized, double-blind, multicenter (international), superiority phase III clinical study
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
QUADRUPLE
Enrollment
132
Belimumab 200 mg subcutaneous weekly (i.e., every 7 days ±1 day) starting from day 0 through week 24 with 1 g intravenous of Rituximab 7 days and 21 days after the randomization.
Placebo subcutaneous weekly (i.e., every 7 days ±1 day starting from day 0) starting from day 0 through week 24 with 1 g intravenous of Rituximab 7 days and 21 days after the randomization.
Henri Mondor Hospital
Créteil, France
RECRUITINGThe overall response rate (CR + R) in both arms at W52
To assess the superiority at W52 of a combination subcutaneous belimumab weekly over a 24 weeks period (Arm A) or subcutaneous placebo weekly during 24 weeks period (Arm B) with rituximab (or biosimilar) (at a fixed dose of 1,000 mg on Day 7 and Days 21).
Time frame: Week 52
Number of patients developing a severe hypogammaglobulinemia in both arms
(gammaglobulin level \< 4 g/dl)
Time frame: at Week 12, Week 24, Week 36, Week 52, Week 88, Week 104
Duration of a severe hypogammaglobulinemia
Duration of a severe hypogammaglobulinemia in patients with such complication
Time frame: up to Week 104
Variation in gammaglobulin
Variation in gammaglobulin classes and subclass levels
Time frame: Frame throughout the study (Week 0, Week 12, Week 24, Week 36, Week 52, Week 88, Week 104)
Number of severe infections
Number of severe infections requiring hospitalization
Time frame: up to Week 104
Platelet levels
Time frame: at Week 6, Week 12, Week 24, Week 36, Week 52, Week 88, Week 104
Total number of responders
Time frame: at Week 6, Week 12, Week 24, Week 36, Week 52, Week 88, Week 104
Number of haemorrhagic events
Time frame: at Week 6, Week 12, Week 24, Week 36, Week 52, Week 88, Week 104.
Percentage of each B-cell subpopulation, T Follicular helper population and levels of cytokines including BAFF and anti-platelet antibodies
Time frame: at Week 12, Week 24, Week 36, Week 52, Week 88, Week 104
This platform is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional.