rituximab in myositis (rim) study muscle study group september 28, 2012 chester v. oddis, md...
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Rituximab in Myositis (RIM) Study
Muscle Study GroupSeptember 28, 2012
Chester V. Oddis, MDDivision of Rheumatology and Clinical ImmunologyUniversity of Pittsburgh
Disclosures
• Genentech: Grant support and supply of study drug; Advisory Board
Where Were We in 2000?
• Lack of consistent design in published trials
• 26 prospective myositis trials reviewed 14 adult PM-DM; 5 adult IBM; 5 JDM; 2 adult PM/DM/IBM
• Problems with ‘current’ trials different myositis classification criteria used lack of uniformity with inclusion/exclusion criteria variability in concomitant therapies variability in trial durations and subsequent follow-up different intervals of assessment lack of uniformity in measures for outcome assessments
Myositis Clinical Trials: “Pieces of the Puzzle”
• Establishment of IMACS Adult/pediatric/multidisciplinary/international
• Agreed upon outcome measures [Miller]
• Definition(s) of improvement for myositis clinical trials [Rider]
• Consensus on conduct of adult and juvenile myositis clinical trials [Oddis/Rider]
• Assessment of disease activity and damage [Sultan/Isenberg]
Preliminary DOI for IIM Clinical Trials
3 of any 6 CSM improved by ≥ 20%, with
no more than 2 CSM worsening by ≥ 25%
(cannot include MMT)
Rider, Arth Rheum, 2004
DOI not just a consensus definition, but partially validated using previous adult trial
data (n=4) and pediatric natural history data
Rituximab in Myositis
Rituximab in the Treatment of Refractory Adult and Juvenile Dermatomyositis and Adult Polymyositis
Chester V. Oddis, MD
Ann M. Reed, MD
and the RIM Study Group
RIM Study: Aim
To examine the efficacy of rituximab, a B
cell depleting agent, in refractory adult and
juvenile myositis patients in a multicenter
44-week clinical trial enrolling 76 adult PM,
76 adult DM and 50 JDM patients
Inclusion Criteria
1. Definite or probable PM or JDM/DM (by Bohan and Peter criteria)
All patients with PM required verification of diagnosis by a 3-member Adjudication Committee
Included medical record review and muscle biopsy review by a neuropathologist
Inclusion Criteria
2. Refractory myositis = Intolerance to or an inadequate response to corticosteroids plus at least one other immunosuppressive (IS) agent
3. Adult PM or DM required Manual Muscle Testing-8 (MMT-8) score ≤ 125/150 and 2 other abnormal Core Set Measures (CSM)
JDM could enter by the same criteria as adults or if MMT-8 >125 then they required 3 other abnormal CSM
Muscle Groups Right (0 – 10) Left (0 – 10) Axial (0 – 10)
Axial Muscles (0 – 10)
Neck Flexors 0-10
Proximal Muscles (0 – 100)
Deltoid 0-10 0-10
Biceps brachii 0-10 0-10
Gluteus maximus 0-10 0-10
Gluteus medius 0-10 0-10
Quadriceps 0-10 0-10
Distal Muscles (0 – 40)
Wrist Extensors 0-10 0-10
Ankle dorsiflexors 0-10 0-10
MMT-8 score (0 – 150) 0-70 0-70 0-10
Set of 8 muscle groups with a maximum score = 150
Manual Muscle Testing-8 (MMT-8)
Domain Core Set Measures
Global ActivityPhysician global VAS ≥ 2.0 on 10cm scale
Patient/Parent global VAS ≥ 2.0 on 10cm scale
Physical Function CHAQ/HAQ disability index ≥ 0.25
LaboratoryAssessment
At least one muscle enzyme (CK/AST/ALT/LDH/aldolase) ≥ 1.3x ULN
Extramuscular Disease
Global extramuscular disease activity VAS ≥ 1.0 on the Myositis Disease Activity Assessment Tool (MDAAT) – constitutional, cutaneous, articular, GI, pulmonary, cardiac
RIM Study: 5 Additional Core Set Measures
Inclusion Criteria
4. Stable prednisone dose for 4 weeks prior to screening visit
5. Background therapy with at least 1 other IS agent at stable dose for at least 6 weeks prior to screening visit was encouraged
Randomized Placebo Phase Design(RPPD)
Rituximab
Placebo
Wk 0 Wk 1Wk 4
Wk 8 Wk 9
Placebo
Rituximab
Screen
Placebo-controlled Double Blind Phase
Wks 12 – 44(8 additional visits)
Rtx Early
Rtx Late
Wk 12 Wk 44
• Subjects randomly assigned, double-blind, to ‘Rtx Early’ or ‘Rtx Late’• ½ subjects receive drug early and ½ subjects receive drug 8 wks later• Week 8: reflects a ‘randomized placebo-controlled trial’ • No corticosteroids at time of the 4 infusions• 14 visits (specimens/CSM) over 44 weeks
Participant Flow Diagram
200 randomized and 195 included in final analysis
MMT>125Low IgG/IgM
Rituximab Dosing
• Children received 575mg/m2 up to a maximum dose of 1gm 1 week apart
• Adults received 750mg/m2 BSA up to a maximum dose of 1gm 1 week apart
. Patient Baseline Demographic and Clinical Characteristics
Baseline Core Set Measures (Mean/SD)
Characteristic Early Rituximab (n=96)
Late Rituximab (n=104) p value
MMT-8 ratio 71 (11.4) 71.7 (13.0) 0.70
MD Global VAS (0-100 mm) 51.4 (17.6) 49.2 (17.4) 0.37
Patient/Parent Global VAS (0-100mm) 65.4 (20.3) 65.6 (21.7) 0.94
HAQ/CHAQ Disability Index (0-3) 1.55 (.7) 1.53 (0.8) 0.84
Muscle enzyme x ULN 9.5 (14.9) 5.5 (9.0) 0.03
Extramuscular Score VAS (0-100 mm) 27.4 (20.4) 30.7 (19.5) 0.25
MMT-8 ratio refers to recorded MMT-8/total possible score for muscles tested
Data Quality
• Very low patient dropout
– 5 pts with baseline visit and no subsequent measurements
– 195 randomized pts included in analysis
• Excellent quality of data
• Very little missing data
– Percentage of missing values = 1.2%
B cell Numbers Before and After Rituximab
Early Rtx
LateRtx
DOI for RIM Study
≥ 20% improvement in 3 of any 6 CSM, no more than 2 CSM worsening by ≥ 25%
(excluding MMT)
To meet DOI subjects had to satisfy criteria on 2 consecutive visits
Primary Endpoint and Hypothesis
• Primary Endpoint: Compare the time to DOI
between the ‘Rtx Early’ and ‘Rtx Late’ groups
• Hypothesis: The time to DOI will be statistically
less (shorter) in early vs. late treatment groups
Primary Outcome: Entire CohortPrimary Outcome: Entire Cohort
Median time to DOI: Early Rtx = 20.0 weeks Late Rtx = 20.2 weeks
p = 0.74 (log rank)
Primary Outcome: Adult PM
Median time to DOI: Early Rtx = 21.8 weeks Late Rtx = 24.0 weeks
p = 0.43 (log rank)
Median time to DOI: Early Rtx = 20.4 weeks Late Rtx = 20.3 weeks
p = 0.70 (log rank)
Primary Outcome: Adult DM
Primary Outcome: JDM
Median time to DOI: Early Rtx = 11.7 weeks Late Rtx = 19.6 weeks
p = 0.32 (log rank)
Secondary Endpoints and Hypotheses
• Secondary Endpoint II: Compare the response rates (proportion of patients achieving DOI) at week 8 in early vs. late groups
Hypothesis: The response rate will be significantly higher in the early group at week 8
Secondary Endpoint IISecondary Endpoint II
Proportions of Patients Meeting DOI at Week 8
15%
20.6%
Early Rtx Late Rtx
Patients Meeting DOI During TrialPatients Meeting DOI During Trial
Overall, 83% (161/195) of subjects met the DOI during the course of the 44-week clinical trial
80% 85%
Early Rtx Late Rtx
Corticosteroid Sparing Effect
p < 0.001
There was a significant difference in the mean corticosteroid dose at baseline compared to the final visit
Retreatment With Rituximab
• 10 subjects (9 evaluable) met criteria for re-treatment with Rtx
• 4 were in ‘Early’ and 5 in ‘Late’ Rtx groups
Weeks to Initial DOI(mean, n=9)
Weeks from DOI to DOW
(mean, n=9)
Weeks to Re-treatment DOI
(mean, n=8)
12.4 16.5 19.9
Adverse Events
• 52/200 (26%) subjects had 68 serious adverse events (SAE)– 40% of those were reported as related to treatment
• Most common SAEs included:– infection (25%)
– musculoskeletal (18%)
– GI (12%)
– cardiac (7%)
• 1 death (unrelated to drug)
• No cases of PML
Summary
• The primary and secondary endpoints were not achieved in the RIM Study
• 83% of refractory adult and juvenile myositis patients met the DOI in this trial
• There was a significant corticosteroid sparing effect noted in this trial between the baseline dose and the dose at study conclusion
• Rituximab was generally well tolerated
RIM Study Conclusions
• Overestimate of the rituximab effect
– SC postulated >50% would meet DOI by 8 weeks One-half responded by 20 weeks (lower potency)
• Underestimate of placebo effect
• Short placebo phase of 8 weeks
• Heterogeneity of myositis– Increased variance around time to DOI in both arms
• Subjective CSM (partially validated)
What about more stringent criteria for improvement?
• At least 4 CSM improving by 40%
p=0.13 (Peto-Peto test) p=0.18 (log rank)
Entire Cohort: Time to Stringent DOI
Early Rtx Late Rtx
RIM Study Autoantibodies
Autoantibody Number (%)
Synthetase 32 (16%) - 28 Jo-1
SRP 25 (13%)
DM-associated 71 (35%) - 26 Mi-2 - 23 TIF1-gamma - 22 MJ
Overlap/other autoAb 24 (12%)
No MAA 40 (20%)
Undefined 9 (4%)
Total 200
Baseline Autoantibodies Predict Outcome
no autoAb (21%)
anti-SRP (13%)
other autoAb (14%)
DM:TIF-1/MJ/Mi-2 (33%)
anti-syn Ab (14%)
Autoantibody subsetsAutoantibody subsets• anti-SynAb anti-SynAb - HR 2.3 (1.3 – 4.2), p value = 0.01 - HR 2.3 (1.3 – 4.2), p value = 0.01 • DM Abs: TIF-1/MJ/Mi-2DM Abs: TIF-1/MJ/Mi-2 - HR 1.9 (1.2 – 3.1), p value = 0.01- HR 1.9 (1.2 – 3.1), p value = 0.01
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Time in weeks
Anti-syn & DM Abs predicted a better outcome, but anti-SRP and those without MAAs had a worse outcome
Median Time to Stringent DOI: Jo-1 vs non-Jo-1
Early vs Latep=0.12 (log rank)
Median time to stringent DOI in Early = 27.9 weeks
Other Univariate Predictors
• Caucasians showed a better response (p=0.04)
• Higher baseline VAS for extramuscular activity was only CSM predictive of better response (p=0.02)
• Higher baseline VAS muscle damage score predicted a poor response (p=0.05)
Aggarwal, Arth Rheum 62: S385, 2010
Future Directions
• Study the ‘immunology’ of the response in the specimens obtained from RIM and correlate this to the clinical outcomes
• Assess other biomarkers from the specimen repository
• Re-examination of the DOI and the response criteria
Participating Centers
Foreign Centers
Participating CentersAdult Sites Alabama (Fessler) Boston (Narayanaswami) Czechoslovakia (Vencovsky) Dallas (Olsen) Kansas City (Barohn/Latinis) Kentucky (Crofford) London (Isenberg) Mayo Clinic (Ytterberg) Miami (Sharma) Michigan (Seibold/Schiopu) Michigan State (Martin/Eggebeen) Milwaukee (Cronin) New York: North Shore (Marder) New York: HSS (DiMartino) NIH (Miller) Philadelphia (Kolasinski) Phoenix (Levine) Pittsburgh (Oddis/Ascherman) Stanford (Chung/Fiorentino) Sweden (Lundberg) UCLA (Weisman/Venuturupalli)
Pediatric Sites Boston (Kim) Cincinnati (Lovell) Duke (Rabinovich) Mayo Clinic (Reed) Miami (Rivas-Chacon) Michigan State (Martin/Eggebeen) NIH (Rider) Nova Scotia (Huber) Philadelphia (Sherry) Pittsburgh (Kietz) Stanford (Sandborg) Toronto (Feldman)
Our Patients!!!
AcknowledgementsCoordinating Center
Dana Ascherman, MD
Rohit Aggarwal, MD
Sherrie Pryber, Project Manager
Diane Koontz, Project Manager
Noreen Fertig, BS
Kelly Reckley, BS
Maureen Laffoon, BS
Xinyan Gu
IDS Pharmacy
David Lacomis, MD
Jonette Werley, BA, HT, HTL
Christopher Bise, MS, PT
Study PartnersStudy PartnersSupported by:
Steering CommitteeAnn Reed, MDSteve Ytterberg, MDDana Ascherman, MDDavid Lacomis, MDBrian Feldman, MDFred Miller, MD, PhDLisa Rider, MDTodd Levine, MDSteve Belle, PhDHoward Rockette, PhDMichael Harris-Love,MPT
Other CollaboratorsThe RIM Study GroupRIM Study CoordinatorsDavid Isenberg, MD, FRCPMyositis Working GroupThe Myositis AssociationRIM Publication Committee
Data CenterHoward Rockette, PhDSteven Belle, PhDSharon Lawlor, MBAStephanie Kelley, MS
IMACS