Systemic Juvenile Idiopathic Arthritis With Active Flare
Conditions
Keywords
Flare, arthritis, IL-1beta antagonist, systemic juvenile idiopathic arthritis, Juvenile rheumatoid
Brief summary
This two-part study assessed the sustained efficacy of canakinumab in the double-blind Part II and the ability to taper steroids in the open label Part I.
Interventions
Canakinumab 4 mg/kg dose subcutaneous injection supplied as 6 mL glass vials each containing 150 mg canakinumab as a lyophilized cake.
Placebo powder matching canakinumab supplied as 6 mL glass vials containing a lyophilized cake for subcutaneous injection every 4 weeks in Part II.
Sponsors
Study design
Eligibility
Inclusion criteria
* Confirmed diagnosis of systemic juvenile idiopathic arthritis as per International League Against Rheumatism (ILAR) definition that must have occurred at least 2 months prior to enrollment with onset of disease \< 16 years of age. -Arthritis in one or more joints with or preceded by fever of at least 2 weeks duration that is documented to be daily for at least 3 days with accompanying symptoms * Active disease at the time of enrollment defined as follows: * At least 2 joints with active arthritis (using American College of rheumatology) ACR definition of active joint) * Documented spiking, intermittent fever (body temperature \> 38oC) for at least 1 day during the screening period within 1 week before first study drug dose * C-reactive protein \> 30 mg/L (normal range \< 10 mg/L) * No concomitant use of second line agents such as disease-modifying and/ or immunosuppressive drugs will be allowed with the exception of: * Stable dose of methotrexate for at least 8 weeks prior to the screening visit, and/or folic/folinic acid per standard medical practice * Stable dose of no more than one non-steroidal anti-inflammatory drug for at least 2 weeks prior to the screening visit * Stable dose of steroid treatment \< or = to 1.0 mg/kg/day in 1-2 doses per day of oral prednisone or equivalent
Exclusion criteria
* Diagnosis of active macrophage-activation syndrome (MAS) within the last 6 months * Risk factors for tuberculosis * Patients with active or recurrent bacterial, fungal or viral infection at the time of enrollment, including patients with evidence of HIV infection, Hepatitis B and Hepatitis C infection Other protocol inclusion/
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Part I: Percentage of Patients Who Were on Steroids at Entry Into Part I and Who Were Able to Taper Steroid as Per Protocol in at Least 25% of the Patients Who Entered the Study Taking a Steroid | 32 Weeks | Ability to taper oral steroids: if dose reduced from start of Part I to end of Part Ic from \> 0.8 mg/kg/day to ≤ 0.5 mg/kg/day, or from ≥ 0.5 mg/kg/day and ≤ 0.8 mg/kg/day by at least 0.3 mg/kg, or from any initial dose to ≤ 0.2 mg/kg/day, while maintaining a minimum adapted ACR 30 pediatric criterion. Patients on oral steroids at study entry who did not enter Part 1c are considered steroid tapering failures. |
| Part II: Survival Estimate of Time to Flare | Part II was event driven. The study was stopped when the required number of 37 flares had occurred (88 weeks) | Kaplan Meier estimate of the probability to experience a flare. Flare was defined as at least 1 of the following. * Reappearance of fever (\>38°C, lasting for at least 2 consecutive days) not due to infections * Flare according to the JIA pediatric criteria for flare (all criteria must have been met): * ≥ 30% worsening in at least 3 of the first 6 response variables * ≥ 30% improvement in not more than 1 of the first 6 response variables Patients who discontinued the study while in Part II were counted as flared unless they discontinued because of inactive disease for at least 24 weeks in Part II. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Part I: Percentage of Participants on Steroids at the Start of 1c Who Were Able to Taper Steroids by the End of Part 1c | Start of Part Ic (After Week 8) to End of Part Ic (Week 28) | — |
| Part I: Percentage of Participants With Minimum American College of Rheumatology (ACR) 30/50/70/90/100 at the End of Part I | Baseline, 32 Weeks | Adapted ACR Pediatric 30/50/70/90/100 criteria are defined as meeting all of the following: * improvement from baseline of ≥ 30%, ≥ 50%, ≥ 70%, ≥ 90%, or 100%, in at least 3 of the first 6 response variables 1. Physician's global assessment of disease activity 2. CHAQ-patient's overall well-being 3. CHAQ-Functional ability 4. \# of joints with active arthritis 5. \# of joints with limitation of motion 6. C-Reactive Protein. * no intermittent fever in the preceding week * no more than one of the first 6 response variables worsening by more than 30% |
| Part I: Time to First Minimum American College of Rheumatology (ACR50) and Normal C-Reactive Protein | Baseline, Week 32 | Duration in days in the study to the first minimum adapted ACR Pediatric 50 criteria and a normal (\<10mg/L) C-Reactive Protein |
| Part I: Time to First Minimum American College of Rheumatology (ACR70) and Normal C-Reactive Protein | Baseline, Week 32 | Duration in days in the study to the first minimum adapted ACR Pediatric 70 criteria and a normal (\<10mg/L) C-Reactive Protein |
| Part I: Percentage of Participants With Body Temperature ≤ 38 Degrees Celsius at Day 3 in Part 1a | Day 3 | — |
| Part I: Change in Disability Over Time in the Child Health Assessment Questionnaire-Disability Index (CHAQ-DI) From Baseline to End of Part I | Baseline, End of Part I (Week 32) | The childhood health assessment questionnaire, CHAQ was used to assess physical ability and functional status of patients as well as quality of life. The disability dimension consists of 20 multiple choice items concerning difficulty in performing eight common activities of daily living; dressing and grooming, arising, eating, walking, reaching, personal hygiene, gripping and other activities. Parents choose from four response categories, ranging from 0(without any difficulty) to 3(unable to do). A negative change indicates improvement. |
| Part II: Change in Disability Over Time by the Child Health Assessment Questionnaire-Disability Index (CHAQ-DI) | Start of Part II (Week 32), End of Part II ( total duration-88 weeks) | CHAQ-DI assessed physical ability and functional status of patients and quality of life. 20 multiple choice items concerning difficulty in performing 8 common activities of daily living; dressing and grooming, arising, eating, walking, reaching, personal hygiene, gripping and other activities. Parents choose from 4 response categories, ranging from 0(without any difficulty) to 3(unable to do). Repeated measures Analysis of Covariance with treatment group, visit day, prednisone (or equivalent) dose and adapted ACR 70 response reached at the end of Part Id as covariates. |
| Part I: Change in Health Related Quality of Life Over Time by Child Health Questionnaire (CHQ-PF50) | Baseline, End of Part I ( Week 32) | The CHQ-PF50© is an instrument used to measure Health Related Quality of Life in children 5-18 from the parent's perspective. The questionnaire measures the following concepts: Physical functioning, Role/social emotional, Role/social behavior, Role/social physical, Bodily pain, General behavior, Mental health, Self-esteem, General health perception, Change in health, Parental impact - emotional, Parental impact - time, Family activities, and Family cohesion. Summaries are provided for Physical Health and Psychosocial Health. Scores range from 0-100. Increase in score represents improvement. |
| Part II: Change in Health Related Quality of Life Over Time by Child Health Questionnaire (CHQ-PF50) | Start Part II (Week 32), End Part II (total duration - 88 Weeks) | CHQ-PF50 measures Physical functioning, Role/social emotional, behavior and physical, Bodily pain, General behavior, Mental health, Self-esteem, General health perception, Change in health, Parental impact-emotional, Parental impact-time, Family activities and cohesion. Summaries are provided for Physical Health and Psychosocial Health. An increase in score indicates improvement. Repeated measures Analysis of Covariance change from start of Part II with treatment group, visit day, prednisone(or equivalent) dose and adapted ACR70 Pediatric response reached at the end of Part Id as covariates. |
| Part II: Survival Analysis of Time to a Worsening in American College of Rheumatology (ACR) Response | Part II was event driven. The study was stopped when the required number of 37 flares had occurred (88 weeks) | Kaplan Meier estimate of the time in days to the probability of worsening of the ACR response. ACR response is determined by the following items: 1. Physician's global assessment of disease activity 2. CHAQ-patient's overall wellbeing 3. CHAQ-Functional ability 4. Number of joints with active arthritis 5. Number of joints with limitation of motion 6. C-Reactive Protein. 7. No intermittent fever in the preceding week |
| Part I: Percentage of Patients on Steroids at Study Start Who Reached a Steroid Dose ≤0.2 mg/kg at End of Part Ic | 28 Weeks | — |
Countries
Argentina, Belgium, Brazil, Canada, France, Germany, Hungary, Israel, Italy, Netherlands, Norway, Peru, Poland, South Africa, Spain, Sweden, Switzerland, Turkey (Türkiye), United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Canakinumab In Part I participants received open label 4 mg/kg canakinumab subcutaneous injection every 4 weeks for up to 32 weeks. For the first 8 weeks Part Ia (4 weeks) and Ib (4 weeks) patients maintained a stable oral steroid dose (prednisone or equivalent) followed by Ic an up to 20 week steroid tapering period and then Id a 4 week stable steroid dose period. Participants were then randomized to receive either 4 mg/kg canakinumab subcutaneous injection or Placebo comparator in Part II and remained on the stable oral steroid dose for 24 weeks. At 24 weeks in Part II participants with a \>0.2 mg/kg and ≤ 0.5 mg/kg and no flare could restart steroid tapering. If the steroid dose was ≤ 0.2 mg/kg participants continued to maintain their current dose for the remainder of Part II. | 177 |
| Total | 177 |
Withdrawals & dropouts
| Period | Reason | FG000 | FG001 |
|---|---|---|---|
| Part II: Randomized Double Blind | Adverse Event | 0 | 4 |
| Part II: Randomized Double Blind | Protocol deviation | 0 | 1 |
| Part II: Randomized Double Blind | Unsatisfactory therapeutic effect | 11 | 20 |
| Part II: Randomized Double Blind | Withdrawal by Subject | 0 | 1 |
| Part I: Open Label | Adverse Event | 4 | 0 |
| Part I: Open Label | Death | 1 | 0 |
| Part I: Open Label | Unsatisfactory therapeutic effect | 72 | 0 |
Baseline characteristics
| Characteristic | Canakinumab |
|---|---|
| Age Continuous | 8.7 years STANDARD_DEVIATION 4.46 |
| Sex: Female, Male Female | 98 Participants |
| Sex: Female, Male Male | 79 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk |
|---|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — | — / — |
| other Total, other adverse events | 138 / 177 | 40 / 50 | 35 / 50 |
| serious Total, serious adverse events | 15 / 177 | 6 / 50 | 6 / 50 |
Outcome results
Part II: Survival Estimate of Time to Flare
Kaplan Meier estimate of the probability to experience a flare. Flare was defined as at least 1 of the following. * Reappearance of fever (\>38°C, lasting for at least 2 consecutive days) not due to infections * Flare according to the JIA pediatric criteria for flare (all criteria must have been met): * ≥ 30% worsening in at least 3 of the first 6 response variables * ≥ 30% improvement in not more than 1 of the first 6 response variables Patients who discontinued the study while in Part II were counted as flared unless they discontinued because of inactive disease for at least 24 weeks in Part II.
Time frame: Part II was event driven. The study was stopped when the required number of 37 flares had occurred (88 weeks)
Population: Full Analysis Set in Part II
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Canakinumab | Part II: Survival Estimate of Time to Flare | NA Days |
| Placebo | Part II: Survival Estimate of Time to Flare | 236.0 Days |
Part I: Percentage of Patients Who Were on Steroids at Entry Into Part I and Who Were Able to Taper Steroid as Per Protocol in at Least 25% of the Patients Who Entered the Study Taking a Steroid
Ability to taper oral steroids: if dose reduced from start of Part I to end of Part Ic from \> 0.8 mg/kg/day to ≤ 0.5 mg/kg/day, or from ≥ 0.5 mg/kg/day and ≤ 0.8 mg/kg/day by at least 0.3 mg/kg, or from any initial dose to ≤ 0.2 mg/kg/day, while maintaining a minimum adapted ACR 30 pediatric criterion. Patients on oral steroids at study entry who did not enter Part 1c are considered steroid tapering failures.
Time frame: 32 Weeks
Population: Participants from the Full Analysis Set who were taking oral steroids at the beginning of Part I.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Canakinumab | Part I: Percentage of Patients Who Were on Steroids at Entry Into Part I and Who Were Able to Taper Steroid as Per Protocol in at Least 25% of the Patients Who Entered the Study Taking a Steroid | 44.5 Percentage of participants |
Part I: Change in Disability Over Time in the Child Health Assessment Questionnaire-Disability Index (CHAQ-DI) From Baseline to End of Part I
The childhood health assessment questionnaire, CHAQ was used to assess physical ability and functional status of patients as well as quality of life. The disability dimension consists of 20 multiple choice items concerning difficulty in performing eight common activities of daily living; dressing and grooming, arising, eating, walking, reaching, personal hygiene, gripping and other activities. Parents choose from four response categories, ranging from 0(without any difficulty) to 3(unable to do). A negative change indicates improvement.
Time frame: Baseline, End of Part I (Week 32)
Population: Participants from the Full Analysis Set Part I with data at baseline and End of Part I.
| Arm | Measure | Value (MEDIAN) | Dispersion |
|---|---|---|---|
| Canakinumab | Part I: Change in Disability Over Time in the Child Health Assessment Questionnaire-Disability Index (CHAQ-DI) From Baseline to End of Part I | -0.8750 Score on a scale | Full Range 0.86492 |
Part I: Change in Health Related Quality of Life Over Time by Child Health Questionnaire (CHQ-PF50)
The CHQ-PF50© is an instrument used to measure Health Related Quality of Life in children 5-18 from the parent's perspective. The questionnaire measures the following concepts: Physical functioning, Role/social emotional, Role/social behavior, Role/social physical, Bodily pain, General behavior, Mental health, Self-esteem, General health perception, Change in health, Parental impact - emotional, Parental impact - time, Family activities, and Family cohesion. Summaries are provided for Physical Health and Psychosocial Health. Scores range from 0-100. Increase in score represents improvement.
Time frame: Baseline, End of Part I ( Week 32)
Population: Participants from the Full Analysis Set Part I-age 5 to 18 years.
| Arm | Measure | Group | Value (MEDIAN) | Dispersion |
|---|---|---|---|---|
| Canakinumab | Part I: Change in Health Related Quality of Life Over Time by Child Health Questionnaire (CHQ-PF50) | Physical Health Score | 21.8050 Score on a scale | Full Range 16.10377 |
| Canakinumab | Part I: Change in Health Related Quality of Life Over Time by Child Health Questionnaire (CHQ-PF50) | Psychosocial Health Score | 8.2223 Score on a scale | Full Range 11.50688 |
Part II: Change in Disability Over Time by the Child Health Assessment Questionnaire-Disability Index (CHAQ-DI)
CHAQ-DI assessed physical ability and functional status of patients and quality of life. 20 multiple choice items concerning difficulty in performing 8 common activities of daily living; dressing and grooming, arising, eating, walking, reaching, personal hygiene, gripping and other activities. Parents choose from 4 response categories, ranging from 0(without any difficulty) to 3(unable to do). Repeated measures Analysis of Covariance with treatment group, visit day, prednisone (or equivalent) dose and adapted ACR 70 response reached at the end of Part Id as covariates.
Time frame: Start of Part II (Week 32), End of Part II ( total duration-88 weeks)
Population: Full Analysis set Part II.
| Arm | Measure | Value (LEAST_SQUARES_MEAN) | Dispersion |
|---|---|---|---|
| Canakinumab | Part II: Change in Disability Over Time by the Child Health Assessment Questionnaire-Disability Index (CHAQ-DI) | 0.1184 Score on a scale | Standard Error 0.17592 |
| Placebo | Part II: Change in Disability Over Time by the Child Health Assessment Questionnaire-Disability Index (CHAQ-DI) | 0.1258 Score on a scale | Standard Error 0.18241 |
Part II: Change in Health Related Quality of Life Over Time by Child Health Questionnaire (CHQ-PF50)
CHQ-PF50 measures Physical functioning, Role/social emotional, behavior and physical, Bodily pain, General behavior, Mental health, Self-esteem, General health perception, Change in health, Parental impact-emotional, Parental impact-time, Family activities and cohesion. Summaries are provided for Physical Health and Psychosocial Health. An increase in score indicates improvement. Repeated measures Analysis of Covariance change from start of Part II with treatment group, visit day, prednisone(or equivalent) dose and adapted ACR70 Pediatric response reached at the end of Part Id as covariates.
Time frame: Start Part II (Week 32), End Part II (total duration - 88 Weeks)
Population: Full Analysis Set Part II-patients aged 5-18 years.
| Arm | Measure | Group | Value (LEAST_SQUARES_MEAN) | Dispersion |
|---|---|---|---|---|
| Canakinumab | Part II: Change in Health Related Quality of Life Over Time by Child Health Questionnaire (CHQ-PF50) | Physical Health Score | 3.9 Score on a scale | Standard Error 2.54 |
| Canakinumab | Part II: Change in Health Related Quality of Life Over Time by Child Health Questionnaire (CHQ-PF50) | Psychosocial Health Score | 2.5 Score on a scale | Standard Error 1.88 |
| Placebo | Part II: Change in Health Related Quality of Life Over Time by Child Health Questionnaire (CHQ-PF50) | Physical Health Score | -0.3 Score on a scale | Standard Error 2.53 |
| Placebo | Part II: Change in Health Related Quality of Life Over Time by Child Health Questionnaire (CHQ-PF50) | Psychosocial Health Score | -0.5 Score on a scale | Standard Error 1.86 |
Part II: Survival Analysis of Time to a Worsening in American College of Rheumatology (ACR) Response
Kaplan Meier estimate of the time in days to the probability of worsening of the ACR response. ACR response is determined by the following items: 1. Physician's global assessment of disease activity 2. CHAQ-patient's overall wellbeing 3. CHAQ-Functional ability 4. Number of joints with active arthritis 5. Number of joints with limitation of motion 6. C-Reactive Protein. 7. No intermittent fever in the preceding week
Time frame: Part II was event driven. The study was stopped when the required number of 37 flares had occurred (88 weeks)
Population: Full Analysis Set Part II
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Canakinumab | Part II: Survival Analysis of Time to a Worsening in American College of Rheumatology (ACR) Response | NA Days |
| Placebo | Part II: Survival Analysis of Time to a Worsening in American College of Rheumatology (ACR) Response | 141.0 Days |
Part I: Percentage of Participants on Steroids at the Start of 1c Who Were Able to Taper Steroids by the End of Part 1c
Time frame: Start of Part Ic (After Week 8) to End of Part Ic (Week 28)
Population: Participants from the Full Analysis set who were taking oral steroids at the start of Part Ic.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Canakinumab | Part I: Percentage of Participants on Steroids at the Start of 1c Who Were Able to Taper Steroids by the End of Part 1c | 62.0 Percentage of participants |
Part I: Percentage of Participants With Body Temperature ≤ 38 Degrees Celsius at Day 3 in Part 1a
Time frame: Day 3
Population: Participants from the Full Analysis Set Part I with temperature readings at Day 3.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Canakinumab | Part I: Percentage of Participants With Body Temperature ≤ 38 Degrees Celsius at Day 3 in Part 1a | 98.6 Percentage of participants |
Part I: Percentage of Participants With Minimum American College of Rheumatology (ACR) 30/50/70/90/100 at the End of Part I
Adapted ACR Pediatric 30/50/70/90/100 criteria are defined as meeting all of the following: * improvement from baseline of ≥ 30%, ≥ 50%, ≥ 70%, ≥ 90%, or 100%, in at least 3 of the first 6 response variables 1. Physician's global assessment of disease activity 2. CHAQ-patient's overall well-being 3. CHAQ-Functional ability 4. \# of joints with active arthritis 5. \# of joints with limitation of motion 6. C-Reactive Protein. * no intermittent fever in the preceding week * no more than one of the first 6 response variables worsening by more than 30%
Time frame: Baseline, 32 Weeks
Population: Participants from the full analysis set with an assessment at the given time-point.
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Canakinumab | Part I: Percentage of Participants With Minimum American College of Rheumatology (ACR) 30/50/70/90/100 at the End of Part I | Non-Responders | 22.9 Percentage of participants |
| Canakinumab | Part I: Percentage of Participants With Minimum American College of Rheumatology (ACR) 30/50/70/90/100 at the End of Part I | ACR 30 Response | 77.1 Percentage of participants |
| Canakinumab | Part I: Percentage of Participants With Minimum American College of Rheumatology (ACR) 30/50/70/90/100 at the End of Part I | ACR 50 Response | 73.1 Percentage of participants |
| Canakinumab | Part I: Percentage of Participants With Minimum American College of Rheumatology (ACR) 30/50/70/90/100 at the End of Part I | ACR 70 Response | 64.6 Percentage of participants |
| Canakinumab | Part I: Percentage of Participants With Minimum American College of Rheumatology (ACR) 30/50/70/90/100 at the End of Part I | ACR 90 Response | 51.4 Percentage of participants |
| Canakinumab | Part I: Percentage of Participants With Minimum American College of Rheumatology (ACR) 30/50/70/90/100 at the End of Part I | ACR 100 Response | 34.3 Percentage of participants |
Part I: Percentage of Patients on Steroids at Study Start Who Reached a Steroid Dose ≤0.2 mg/kg at End of Part Ic
Time frame: 28 Weeks
Population: Participants from the Full Analysis set who were taking oral steroids at the start of the study.
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Canakinumab | Part I: Percentage of Patients on Steroids at Study Start Who Reached a Steroid Dose ≤0.2 mg/kg at End of Part Ic | steroid free | 32.8 Percentage of participants |
| Canakinumab | Part I: Percentage of Patients on Steroids at Study Start Who Reached a Steroid Dose ≤0.2 mg/kg at End of Part Ic | >0 and ≤ 0.2 mg/kg/day | 18.8 Percentage of participants |
Part I: Time to First Minimum American College of Rheumatology (ACR50) and Normal C-Reactive Protein
Duration in days in the study to the first minimum adapted ACR Pediatric 50 criteria and a normal (\<10mg/L) C-Reactive Protein
Time frame: Baseline, Week 32
Population: Participants from the Full Analysis Set Part I with ACR 50 and a Normal CRP.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Canakinumab | Part I: Time to First Minimum American College of Rheumatology (ACR50) and Normal C-Reactive Protein | 20.4 Days | Standard Deviation 8.7 |
Part I: Time to First Minimum American College of Rheumatology (ACR70) and Normal C-Reactive Protein
Duration in days in the study to the first minimum adapted ACR Pediatric 70 criteria and a normal (\<10mg/L) C-Reactive Protein
Time frame: Baseline, Week 32
Population: Participants from the Full Analysis Set Part I with ACR 70 and a Normal CRP.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Canakinumab | Part I: Time to First Minimum American College of Rheumatology (ACR70) and Normal C-Reactive Protein | 24.5 Days | Standard Deviation 21.58 |