Upfront Autologous HSCT Versus Immunosuppression in Early Diffuse Cutaneous Systemic Sclerosis

Launched by UMC UTRECHT · Jul 6, 2020

Keywords

ClinConnect Summary

This clinical trial is looking at two different treatment approaches for patients with early diffuse cutaneous systemic sclerosis (dcSSc), a serious condition that affects the skin and can impact other organs. The study compares upfront autologous stem cell transplantation (HSCT), which involves using a patient's own stem cells to help reset their immune system, against a more traditional treatment that includes medications like cyclophosphamide and mycophenolate mofetil, where HSCT is only used if the initial treatments do not work. Researchers want to find out which approach is more effective and beneficial for patients.

To participate in the trial, individuals need to be between 18 and 65 years old and have been diagnosed with dcSSc within the last three years. They must also show certain signs of the disease, such as significant skin thickening or problems with vital organs like the lungs, kidneys, or heart. Participants will receive either the stem cell treatment right away or the standard medication approach, and they will be closely monitored throughout the study. This trial is important because it may help determine the best timing for HSCT, potentially improving care for people with this challenging condition.

Gender

ALL

Eligibility criteria

• Inclusion Criteria:
• • 1. Age between 18 and 65 years.
• • 2. Fulfilling the 2013 ACR-EULAR classification criteria for SSc
• • Either: 3.1 or 3.2 3.1. Disease duration ≤ 3 years (from onset of first non-Raynaud's symptoms) and diffuse cutaneous disease with
• • - progressive skin involvement with a mRSS ≥ 15 (in a diffuse pattern: involvement of skin on the upper limbs, chest and/or abdomen)
• • and/or
• - major organ involvement as defined by either:
• • a. clinically significant respiratory involvement = i. DLCO and/or (F)VC ≤ 85% (of predicted) and evidence of interstitial lung disease on HR-CT scan with clinically relevant obstructive disease and emphysema excluded. ii. Patients with a DCLO and/or FVC \> 85%, but with a progressive course of lung disease: defined as rela-tive decline of \>10% in FVC predicted and/or TLC predicted, or \>15% in DLCO predicted and evidence of interstitial lung disease on HR-CT scan with clinically relevant obstructive disease and emphysema ex-cluded, within 12 months. Intercurrent infections excluded.
• • b. clinically significant renal involvement = i. new renal insufficiency (serum creatinine \> upper limit of normal) AND
• • 1. persistent urinalysis abnormalities (proteinuria, haematuria, casts), AND/OR
• • 2. microangiopathic haemolytic anaemia AND/OR
• • 3. hypertension (two successive BP readings of either systolic ≥ 160 mm Hg or diastolic \> 110 mm Hg, at least 12 hours apart), ; non-scleroderma related causes (e.g. medication, infection etc.) must be reasonably excluded.
• • c. clinically significant cardiac involvement = any of the following criteria: i. reversible congestive heart failure, ii. atrial or ventricular rhythm disturbances such as atrial fibrillation or flutter, atrial paroxysmal tachycar-dia or ventricular tachycardia, 2nd or 3rd degree AV block, iii. pericardial effusion (not leading to hemodynamic problems), myocarditis; non-scleroderma related causes must have been reasonably excluded
• • 3.2. Disease duration ≤ 1 year (from onset of first non-Raynaud's symptoms) and diffuse cutaneous disease with mRSS ≥ 10 and
• • 1. High risk ANA for organ based disease: ATA or ARA positivity and/ or
• • 2. Acute phase response (ESR \> 25 mm/h and/or CRP \> 10.0 mg/L )
• • 4. Written Informed consent
• Exclusion Criteria:
• • 1. Pregnancy or unwillingness to use adequate contraception during study
• • 2. Concomitant severe disease =
• • 1. respiratory: resting mean pulmonary artery pressure (mPAP) \> 25 mmHg (by right heart catheterisation), DLCO \< 40% predicted, respiratory failure as defined by the primary endpoint
• • 2. renal: creatinine clearance \< 40 ml/min (measured or estimated)
• • 3. cardiac: clinical evidence of refractory congestive heart failure; LVEF \< 45% by cardiac echo or cardiac MR; chronic atrial fibrillation necessitating oral anticoagulation; uncontrolled ventricular arrhythmia; pericardial effusion with hemodynamic consequences
• • 4. liver failure as defined by a sustained 3-fold increase in serum transaminase or bilirubin, or a Child-Pugh score C
• • 5. psychiatric disorders including active drug or alcohol abuse
• • 6. concurrent neoplasms or myelodysplasia
• • 7. bone marrow insufficiency defined as leukocytopenia \< 4.0 x 109/L, thrombocytopenia \< 50x 10\^9/L, anaemia \< 8 gr/dL, CD4+ T lymphopenia \< 200 x 106/L
• • 8. uncontrolled hypertension
• • 9. uncontrolled acute or chronic infection, including HIV, HTLV-1,2 positivity
• • 10. ZUBROD-ECOG-WHO Performance Status Scale \> 2
• • 3. Previous treatments with immunosuppressants \> 12 months including MMF, methotrexate, azathioprine, rituximab, tocilizumab, glucocorticosteroids.
• • 4. Previous treatments with TLI, TBI or alkylating agents including CYC.
• • 5. Significant exposure to bleomycin, tainted rapeseed oil, vinyl chloride, trichlorethylene or silica;
• • 6. eosinophilic myalgia syndrome; eosinophilic fasciitis.
• • 7. Poor compliance of the patient as assessed by the referring physicians.