Lupus Nephritis, Systemic Lupus Erythematosus
Conditions
Keywords
mycophenolate mofetil, tacrolimus, steroid tapering, systemic lupus erythematosus, lupus nephritis
Brief summary
The goal of this clinical trial is to determine whether mycophenolate mofetil(MMF) combined with tacrolimus(TAC) can maintain remission in patients with lupus nephritis (LN) who have reached treatment targets after steroid tapering. The main question\[s\] it aims to answer are: * The efficacy, safety and tolerability of MMF combined with TAC regimen in the treatment of LN patients in the maintenance period. * The influence of low-dose steroid on carotid intima thickness (CIMT). * The omics and cell-free RNA (cfRNA) spectral differences related to lupus flare. * The differences in health economics between steroid tapering and steroid maintenance patients. Participants will be randomly assigned into 2 groups. In the steroid tapering group, participants will take MMF+TAC treatment without steroid for 1 year, and participants who stop steroid treatment without lupus flare will be randomly assigned to monotherapy with MMF or TAC. In the steroid maintenance group, participants will take MMF+TAC+steroid for 1 year, and participants without lupus flare will stop the use of steroid for 6 months. Participants without lupus flare after the stop of steroid will be randomly assigned to monotherapy with MMF or TAC.
Detailed description
According to the references, with the maintenance of steroid, 1-year lupus flare rate is 7%. Investigators plan to take a 2-year follow-up for participants, so the proportion of patients without flare in steroid maintenance group should be 86%. As this is a non-inferiority study, investigators hypothesize that in steroid tapering group, the proportion of patients without flare is also 86%. Investigators set α=0.05 (two-sided), 1-β=0.90, non-inferiority value = 15%, the dropout rate = 20%. The sample size of each group should be 110, the 220 in total.
Interventions
DRUGMycophenolate Mofetil
Participants in steroid tapering group will take MMF+TAC during the first 18 months. After 18 months, participants without lupus flare will randomly stop MMF or TAC. Participants in steroid maintenance group will take MMF+TAC during the first 24 months. After 24 months, participants without lupus flare will randomly stop MMF or TAC.
DRUGTacrolimus
Participants in steroid tapering group will take MMF+TAC during the first 18 months. After 18 months, participants without lupus flare will randomly stop MMF or TAC. Participants in steroid maintenance group will take MMF+TAC during the first 24 months. After 24 months, participants without lupus flare will randomly stop MMF or TAC.
DRUGGlucocorticoid
Participants in steroid tapering group will stop taking glucocorticoid after the first 6 months. Participants in steroid maintenance group will consistently take glucocorticoid for 18 months, and stop the use of glucocorticoid after 18 months if they do not flare.
Sponsors
Peking Union Medical College Hospital
Chinese SLE Treatment And Research Group
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Intervention model description
First, participants are randomly assigned into 2 groups: steroid tapering group and steroid maintenance group. In steroid tapering group, participants without flare will be assigned into 2 groups: mycophenolate mofetil group and tacrolimus group. In steroid maintenance group, participants without flare will stop the use of steroid for 6 months. Participants without lupus flare after the stop of steroid will be assigned into 2 groups: mycophenolate mofetil group and tacrolimus group.
Eligibility
Sex/Gender
ALL
Age
18 Years to 65 Years
Healthy volunteers
No
Inclusion criteria
* Systemic lupus erythematosus participants diagnosed with 2019 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria, fulfilled with American College of Rheumatology (ACR) lupus nephritis definition, and have reached treatment target (accord with lupus nephritis clinical remission and DORIS) for at least 6 months. The target is defined as: (1)24h urine protein ≤0.5g/d；(2)stable of improved renal function (baseline creatinine ±10% or decrease 15%)；(3)clinical SLE Disease Activity Index (cSLEDAI) =0 (all scores are required zero, except hypocomplementemia and anti-dsDNA antibody positivity)；(4)PGA score (Physician Global Assessment)\<0.5; (5)prednisone or equivalent steroid dose≤5mg/d；(6)stable use of immunosuppressants and antimalarial drugs; (7)no use of biological agents. * According to the physician, the participant can accept this treatment. * The participant is willing to join this clinical trial, has good compliance, and could understand and sign the informed consent before the study begins.
Exclusion criteria
* SLE complicated with important organ dysfunction, including consciousness disorder, cognitive disorder, renal dysfunction, heart dysfunction (NYHA class 3, 4), pulmonary arterial hypertension, and interstitial lung disease. * SLE with active vital organ disease (not satisfied with DORIS), including but not limited to active neuropsychiatric systemic lupus erythematosus, lupus nephritis, thrombocytopenia, hemolytic anemia, myocardial involvement, gastrointestinal involvement, etc. * Participants who are allergic to or intolerant with mycophenolate mofetil or tacrolimus. * Participants with acute and chronic infections requiring anti-infective treatment, including but not limited to tuberculosis infection, Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) infection, Human Immunodeficiency Virus (HIV) infection, and Cytomegalovirus (CMV) infection. * Participants who are pregnant or planning to become pregnant. * Participants who have used biological agents within 6 months before enrollment. * The researcher considers any condition that may cause the participant to be unable to complete the study or bring an obvious risk to the participant.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| The 1-year flare rate of lupus nephritis participants who reach the treatment target and accept MMF+TAC remedy tapering steroid in the maintenance period. | 6th~18th month | If the DORIS (Definition of Remission In SLE) is not sustained, the patient is considered to have lupus flare. Lupus flare can be further evaluated according to SELENA-SLEDAI Flare Index (SFI). Lupus nephritis flare can be further evaluated as flare of proteinuria and flare of nephritis. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Lupus flare (as assessed by SLEDAI and PGA) in SLE patients during the maintenance period after steroid tapering. | 6th~30th month | — |
| The changes of serum activity markers (anti-dsDNA antibody and C3 level) in SLE patients after steroid tapering. | 6th~30th month | — |
| Proportion of SLE patients with irreversible organ damage (assessed by SLICC/SDI) after steroid tapering. | 6th~30th month | — |
| The 1-year flare rate of lupus nephritis participants who accept MMF or TAC monotherapy. | 18th~30th month | If the DORIS (Definition of Remission In SLE) is not sustained, the patient is considered to have lupus flare. |
| Differences in medical charges between steroid tapering and steroid maintenance patients. | 6th~30th month | Obtain the information by questionnaire. |
| Differences in health-related quality of life between steroid tapering and steroid maintenance patients. | 6th~30th month | Evaluate health-related quality of life by Short-Form Six-Dimension (SF-6D) health index. SF-6D includes 6 dimensions: physical functioning, role limitations, social functioning, pain, mental health, and vitality. The minimum total value is 0. The maximum total value is 1. Higher scores mean a better outcome. |
| Changes in carotid intima-media thickness after steroid tapering. | 6th~30th month | — |
Countries
China
Contacts
Primary ContactCan Huang, MD
Outcome results
None listed