Sarcoidosis, Pulmonary
Conditions
Keywords
Sarcoidosis, Hydroxychloroquine, steroid-sparing agent, Extra pulmonary sarcoidosis
Brief summary
Sarcoidosis is a systemic granulomatous disease of unknown aetiology, mainly affecting the lungs and lymphatics. It affects people worldwide (incidence, 4.7-64/100000; prevalence, 1-36/100000/year). Although it is most often a benign acute or subacute condition, sarcoidosis may progress to a disabling chronic disease in 25% of the cases, with severe complications in about 5%, such as lung fibrosis, cardiac or neurosarcoidosis, defacing lupus pernio or blindness due to uveitis. When indicated, corticosteroids (CS) are the mainstay of treatment. Due to the kinetics of granuloma resolution, the usual and quite 'dogmatic' duration of treatment is said to be one year, following four classical steps. The long-term use of CS is hindered by cumulative toxicity and efforts have to be made to taper them, as quickly as possible, to the lowest effective dose. A recent report mentioned 39% of the CS-treated patients requiring a steroid-sparing agent. Chloroquine (CQ) and hydroxychloroquine (HCQ) are anti-malarial drugs that have been used since the 1960's as steroidsparing agents on the basis of a landmark study by Siltzbach reporting their efficacy in 43 patients with skin and intrathoracic sarcoidosis. Subsequently, two small randomized controlled trials have shown significant and prolonged improvement on pulmonary symptoms. Only small case series/reports have shown CQ/HCQ efficacy on extra-pulmonary sarcoidosis with response rates ranging from 67 to 100%. Nevertheless, CQ/HCQ are daily used for skin, bone, and joint sarcoidosis, as well as hypercalcemia. Nowadays, HCQ is preferred over CQ because of a lower incidence of gastrointestinal and ocular adverse reactions, which can be minimized by close attention to the dosage and regular retinal examination. Its profile of safety is well-known since it has long been employed to treat systemic lupus erythematous or rheumatoid arthritis. Its action is thought to rely on its ability to accumulate in lysosomes of phagocytic cells, to affect antigen presentation and reduce pro-inflammatory cytokines. The investigator hypothesize that HCQ may be an efficacious add-on therapy for extra-pulmonary sarcoidosis leading to a significant steroid-sparing effect.
Interventions
DRUGHydroxychloroquine
Hydroxychloroquine (200-400 mg /day during a 12 months double blind placebo-controlled period)
DRUGPlacebo
Placebo during a 12 months double blind placebo-controlled period
Sponsors
Hospices Civils de Lyon
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
QUADRUPLE (Subject, Caregiver, Investigator, Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Inclusion Criteria : * at least 18 years of age * pathologically proven sarcoidosis as defined by the American Thoracic Society (ATS)/European Respiratory Society (ERS)/World Association of Sarcoidosis and Other Granulomatous Disorders (WASOG) criteria * non severe ocular sarcoidosis requiring systemic treatment * non severe skin sarcoidosis requiring systemic treatment * non severe osseous sarcoidosis requiring systemic treatment * non severe sarcoidosis with joint involvement requiring systemic treatment * non severe sarcoidosis-related hypercalcemia requiring systemic treatment * non severe peripheral nervous system sarcoidosis requiring systemic treatment * non severe sarcoidosis-related non-severe Ear, Nose and Throat (ENT) involvement requiring systemic treatment * symptomatic hypercalciuria \>200 mg/24h (24 h urine) OR * \- \> 20 mg/mmol creatinine on urine sample * \- \> 180 mg/g creatinine on urine sample * signed informed consent * affiliated to National French social security system *
Exclusion criteria
: * severe sarcoidosis involvement requiring another immunosuppressant or anti-TNF antibody or methylprednisolone i.v. pulses * previous (\<3 months before screening) or concurrent treatment with immunosuppressants * previous treatment with corticoid (patient weaned for 3 months before inclusion) * previous treatment with antimalarial drugs (HCQ/CQ) (patient must have been off plaquenil for at least 12 months) * treatment with citalopram, escitalopram, hydroxyzin, domperidone and piperaquine * known hypersensitivity or intolerance to HCQ/CQ or 4-aminoquinoline derivatives and prednisone * heart rhythm disorders on EKG (QT prolongation) (except atrial fibrillations) * severe ophthalmological impairment or ophthalmological impairment that does not allow ophthalmic monitoring; previous history of maculopathy or retinopathy * end-stage lung, liver, cardiac, or renal disease * sarcoidosis with central nervous system involvement * cardiac sarcoidosis * clinical evidence of active infection (including infection with herpes virus and varicella-zoster virus) or severe/unstabilized comorbidity (e.g. moderate to severe heart failure) or unstabilized psychosis * chronic viral (HIV or HBV) infection * untreated latent/active tuberculosis * pregnancy or lactation (βHCG will be test by blood analysis at inclusion) * concurrent vaccination with live vaccines during therapy * inability to understand information about the protocol and to sign informed consent or not suitable candidate to comply with the requirements of this study * patient participating in other interventional research * persons under court protection * Use of effective contraception for the duration of the study . (Contraception is considered effective when it consists of one of the following: use of a male condom during all sexual activity and/or efficient oral hormonal contraception (better considered combined contraception) and/or an intrauterine device (IUD) and/or hormone-releasing intrauterine system (IUS) and/or history of bilateral tubal ligation and/or history of vasectomy, provided the male partner is the trial participant's only sexual partner and/or sexual abstinence)
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Evaluate the steroid-sparing effect of hydroxychloroquine as an add-on therapy in patients with non severe extra-pulmonary sarcoidosis requiring a systemic treatment. | at Year 1 | The primary endpoint is the percentage of patients in remission and off prednisone at month 9, without relapse until month 12. The primary endpoint will thus be assessed at M12. Remission is defined by either complete or partial response. Complete response is defined as the absence of clinical or paraclinical sign of disease activity. Partial response is defined as the persistence of clinical or paraclinical sign of disease activity, which do not require substantial treatment modification (high dose CS, immunosuppressant or anti-Tumor Necrosis Factor (TNF) drugs). Relapse is defined as the persistence, or recurrence of existing manifestations and/or the occurrence of new sarcoidosis manifestations requiring substantial treatment modification. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Organ-specific response assessed by the extra-pulmonary Physician Organ Severity Tool (ePOST) | at Month 0, Month 1, Month 3, Month 6, Month 12, Month 18 and Month 24. | score comprised between 0 and 6 |
| rate of complete, partial, stable or progression of the disease | at Month 0, Month 1, Month 3, Month 6, Month 12, Month 18 and Month 24. | Global clinical response will be assessed by the physician as complete, partial, stable, or progression |
| Assess the total dose of local steroid treatments | at Month 0, Month 1, Month 3, Month 6, Month 12, Month 18 and Month 24. | Total dose in Gramme of local steroid treatments |
| Assess the efficacy of HCQ in maintaining the relapse-free survival over a prolonged period | at Month 0, Month 1, Month 3, Month 6, Month 12, Month 18 and Month 24. | Relapse rate |
| Assess and compare the eventual reduction of steroid-related toxicity (side effects) | at Month 0, Month 1, Month 3, Month 6, Month 12, Month 18 and Month 24. | Frequencies of steroid-associated side-effects monitored clinically and biologically |
| Assess HCQ safety | at Month 3, Month 6 and Month 12 | HCQ safety will be assessed through initial and annual electroretinogram |
| Assess patients' adherence | at Month 3, Month 6 and Month 12 | Patient's adherence will be controlled by patient notebooks |
| Assess quality of life by the Study Short Form 36 questionnaire (SF-36 questionnaire). | at Month 0, Month 1, Month 3, Month 6, Month 12, Month 18 and Month 24. | 11 questions are asked, the minimum score is 36 and the maximum score is 149. Statistical analysis of the SF-36 questionnaire will be performed by a statician, analysis is more complex than only higher score means better health. |
Countries
France
Contacts
CONTACTThomas El Jammal, Dr
CONTACTCamille BOUCHENY
Outcome results
None listed