Systemic Lupus Erythematosus (SLE)CYCLONESNCT03492255
CYCLONES - CYClophosphamide LOw Dose and No Extra Steroid
A study testing Cyclophosphamide, Methylprednisolone and Prednisone in people with Systemic Lupus Erythematosus (SLE), run by University of Sao Paulo General Hospital at 2 sites in Brazil.
Trial summary
Glucocorticoids (GC) use has increased survival of patients with systemic lupus erythematosus (SLE), particularly in cases of nephritis and a more significant improvement to 80% with the introduction of therapy combined with immunosuppressants. Read more about this study
- Who is it for?
- Ages 18 years and older
- Conditions the study is for
- Systemic Lupus Erythematosus (SLE)
- What is being tested?
- Cyclophosphamide, Methylprednisolone and Prednisone
- Type of treatment
- Pill or oral medicine
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 49 participants
- Where
- 2 sitesBrazil
- Study dates
- 12 Apr 2018to 2 Jul 2021
- Phase
- Interventional
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 18 years and older
- All sexes
- No healthy volunteers
- Adult, Older adult
Who may be able to join
- All the criteria below have to be completed:
- Systemic lupus erythematosus (SLE) according to the American College of Rheumatology (ACR) classification criteria and/or SLICC: according to the thematic protocol (Petri M, et al., Arthritis Rheum, 2012);
- Age ≥18 years;
- Lupus Glomerulonephritis Class III, IV or V according to the International Society of Nephrology (ISN)/Renal Pathology Society (RPS) Classification confirmed on renal biopsy (according to the routine protocol of our outpatient clinic) performed up to 3 months to 1 year prior to selection;
- Menopause or use contraception method;
- Informed consent.
Who cannot join
- Creatinine clearance < 40 ml/min calculated (Cockcroft \& Gault);
- Intolerance to medication;
- Absolute neutrophil count < 1,000/mm3;
- Pregnancy or breastfeeding;
- Infection requiring hospitalization;
- Patients who used Cyclophosphamide in the last 6 months or biological in the last year;
Show all 12Show fewer
- Thrombotic renal microangiopathy;
- Chronic terminal renal disease and/or class VI biopsy;
- Non-adhesion profile;
- Need to use another therapeutic scheme;
- GC dose in the last 3 months not greater than 20mg/day.
- 11.Central nervous system (CNS) disorders or hemolytic anemia and severe thrombocytopenia (< 50,000 platelets/mm3).
Trial locations and contacts
2 sites in 1 country.
Brazil2 sites
Rheumatology Division of Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo
São Paulo, São Paulo, 05403-000
Hospital das Clinicas da Faculdade de Medicina da USP
São Paulo, 05403-000
About this study
Glucocorticoids (GC) use has increased survival of patients with systemic lupus erythematosus (SLE), particularly in cases of nephritis and a more significant improvement to 80% with the introduction of therapy combined with immunosuppressants. This therapeutic scheme, however, results in a very high incidence of irreversible damage that is associated in more than 70% of the cases to GC use and in a smaller proportion to the use of high dose cyclophosphamide.
CYCLONES is a Controlled Randomized Clinical Trial with the aim of evaluating the efficacy of a regimen for lupus nephritis treatment using only intravenous corticosteroid administration. This intravenous corticosteroid regimen has already been tested (with Rituximab instead of Cyclophosphamide) with high response rates for lupus nephritis and significant reduction of side effects.
Read more
After selection, patients will be randomized in two arms: 116 patients will receive Euro-Lupus nephritis regimen and other 116 will undergo treatment with CYCLONES regimen.
The primary endpoint is the partial response (protein/creatinine ratio < 3 with decrease at least of 50% of the initial value and increase of creatinine not higher than 15% of the initial value) or complete response (protein/creatinine ratio < 500 with decrease at least of 50% of the initial value and increase of creatinine not higher than 15% of the initial value in 6 months. Secondary outcome measures will be evaluated such as osteoporosis and bone metabolism parameters, ophthalmologic evaluation of the collateral effects related to glucocorticoids, lipid profile and therapy adherence.
Read the detailed description
The use of glucocorticoids (GC) greatly increased the survival of patients with SLE, particularly in cases of nephritis and a more significant improvement to 80% with the introduction of therapy combined with immunosuppressants in the late 1960s. This therapeutic regimen, however, results in a very high incidence of irreversible damage to the patient that is associated in more than 70% of the cases to GC use and in a smaller proportion to the use of a high dose of cyclophosphamide. In the last years, some less toxic schemes have been proposed. The use of low-dose cyclophosphamide has been shown to have equal efficacy as high dose for the induction of remission of lupus nephritis with a fifteen-year follow-up.
Regarding GC, lower doses of methylprednisolone (MP) pulse have been shown to have similar efficacy and lower risk of infection. In addition, retrospective studies have found that high doses of oral GC during the induction period are associated with a higher incidence of side effects without a corresponding increase in efficacy . But it was only in 2013 that the first study was published that did not use oral GC in the treatment of lupus nephritis induction with excellent results.
In transplantation area, there are already several trials minimizing the use of GC proposing in the first days after transplantation the use the methylprednisolone (MP) IV pulse (day 1, 500mg, day 2, 250mg and day 3, 125mg) followed by oral GC for 4 days (60mg, 40mg, 30mg and 20mg). In this study, the same incidence of acute rejection occurred when compared to patients who were treated with oral GC for a prolonged period.
Regarding the route of administration of GC, it is important to emphasize that MP is three times more active through non-genomic pathway than through genomic pathway, which, in theory, results in a higher efficiency and lower collateral effect, when compared to the GC oral route that has similar potency through the two pathways. In addition, MP has a simpler and dose-proportional pharmacokinetics, whereas for oral prednisolone this kinetics is more complex and difficult to predict the dose required to achieve a specific concentration.
Therefore, the present study intends to evaluate the efficacy and adverse effects of cyclophosphamide (EUROLUPUS scheme) associated to usual GC dose compared with EUROLUPUS with no extra oral GC regimen.
The estimated number of patients was 116 patients for each arm (considering an error α = 0.05 and a power (1-β) of 80%).
In moderate flares, due to other systemic manifestations, the use of a maximum of 20mg / day of prednisone for 1 month and a progressive reduction of 5mg every 15 days until withdrawal is allowed. Other immunosuppressive, biological, intravenous immunoglobulin or plasmapheresis will be prohibited.
Regarding statistics, an Intention-To-Treat (ITT) analysis will be performed for the randomized patients, so that patients presenting side effects or low adherence to treatment will remain in the randomized group and will be evaluated at week 24.
The proportion of patients achieving complete and partial remission at week 24 will be compared by the chi-square test or the Fisher's exact test, as appropriate. The same statistical methodology will be applied to compare the number of events listed as secondary endpoints.
- Conditions
- Systemic Lupus Erythematosus (SLE)
- Being tested
- Cyclophosphamide, Methylprednisolone, Prednisone, Mycophenolate Mofetil
- Medical subject headings
- Lupus Erythematosus, Systemic
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
CyclophosphamideDrug
Patients in both EUROLUPUS group and CYCLONES Group will receive for 3 months Cyclophosphamide (6 doses of 500mg/biweekly)
Patients in EUROLUPUS group will receive Methylprednisolone [750 mg for three consecutive days).
Patients in CYCLONES Group will receive Methylprednisolone [500 mg (day 0 and day 15), 250 mg (day 30 and day 45) and 125 mg (day 60 and day 75).
PrednisoneDrug
Patients in EUROLUPUS group will receive oral prednisone ≤ 30 mg/day with a reduction of 5mg/month until complete withdrawal.
From the third month of protocol, patients in both EUROLUPUS group and CYCLONES Group will receive mycophenolate mofetil (2-3 g/day) until the sixth month of study.
| Study group | Role | What they receive |
|---|---|---|
| Eurolupus: Cyclophosphamide + Methylprednisolone + oral GC | Active comparator | The EUROLUPUS group will receive Cyclophosphamide (6 doses of 500 mg / fortnightly) + 3 doses of Methylprednisolone (750 mg) initial + oral glucocorticoid (GC) (prednisone) ≤ 30 mg/day with a gradual reduction of 5 mg/month (EUROLUPUS). From the 3rd month, the group will receive oral mycophenolate mofetil (MMF) (2-3 g) until 6 months with gradual reduction of GC from 5 mg/month until the minimum dose of 5 mg/month. Receives: Drug: Cyclophosphamide; Drug: Methylprednisolone; Drug: Prednisone; Drug: Mycophenolate Mofetil |
| Cyclones Group: Cyclophosphamide+Methylprednisolone no oral GC | Experimental | CYCLONES Group will receive for 3 months Cyclophosphamide (6 doses of 500mg / fortnightly) + Methylprednisolone [500 mg (day 0 and day 15), 250 mg (day 30 and day 45) and 125 mg (day 60 and day 75)] without oral glucocorticoid (GC). From the third month, the group will receive only oral MMF (2-3 g) until the 6th month. Patients using GC ≤ 20 mg/day may enter the protocol with immediate reduction to 15 mg/day with a reduction of 5mg/month until complete withdrawal. Receives: Drug: Cyclophosphamide; Drug: Methylprednisolone; Drug: Mycophenolate Mofetil |
What is being measured
The primary outcome is the main question the study is designed to answer.
Partial renal response
The primary endpoint is partial renal response, a composition of: urinary protein/creatinine ratio < 3g/g with decrease of at least 50% of the initial value and increase of creatinine (mg/dL) not higher than 15% of the initial value
Measured: Six months
Complete renal response
Complete renal response, according to a composition of: urinary protein/creatinine ratio < 0,5 (g/g) with decrease of at least 50% of the initial value and increase of creatinine (mg/dL) not higher than 15% of the initial value.
Measured: Six months
Secondary outcomes (11)
Osteoporosis evaluation
Evaluation of osteoporosis by bone densitometry (DXA)
Measured: 6 months
Bone structure evaluation
Evaluation of bone structure by high resolution peripheral quantitative computed tomography (HRpQCT)]
Measured: 6 months
Glaucoma evaluation
Ophthalmologic evaluation for glaucoma secondary to glucocorticoids use
Measured: 15 days, 30 days and 3 months
Cataract evaluation
Ophthalmologic evaluation for cataract secondary to glucocorticoids use
Measured: 3 months
Change from baseline Total cholesterol at 6 months
Lipid profile evaluation including total cholesterol in mg/dL
Measured: Baseline and 6 months
Change from baseline Low-density lipoprotein (LDL) at 6 months
Lipid profile evaluation including Low-density lipoprotein (LDL) in mg/dL
Measured: Baseline and 6 months
Change from baseline High-density lipoprotein (HDL) at 6 months
Lipid profile evaluation including High-density lipoprotein (HDL) in mg/dL
Measured: Baseline and 6 months
Change from baseline Triglycerides at 6 months
Lipid profile evaluation including triglycerides in mg/dL
Measured: Baseline and 6 months
Change from baseline Anti-High-density lipoprotein (anti-HDL) at 6 months
Lipid profile evaluation including anti-High-density lipoprotein (anti-HDL)
Measured: Baseline and 6 months
Therapy adherence by a self-report medication adherence measure (8-item Morisky Medication Adherence Scale)
Therapy adherence will be evaluated by a self-report medication adherence measure (8-item Morisky Medication Adherence Scale). A total score of all items are calculated with a sum score ranging from 0 to 8 for adherence. The scores will be trichotomized into the following 3 levels of adherence: high adherence (score 8), medium adherence (score 6 to <8), and low adherence (score <6).
Measured: Baseline
Change from baseline Serum levels of prednisone using Area Under the Curve [AUC] at 30 days, 3 months and 6 months
Serum levels of prednisone will be measured along the follow up using Area Under the Curve [AUC]
Measured: Baseline, 30 days, 3 months and 6 months
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted10 Apr 2018
- Study start12 Apr 2018
- Primary completion2 Jul 2021
- Study completion2 Jul 2021
Why it stopped: Significative difference between percentage of renal response (primary outcome) between the two study arms.
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (16)Papers the sponsor has linked to this study.
- Other trials for Systemic Lupus Erythematosus (SLE)Studies of the same condition, open and under way.
- More trials run by University of Sao Paulo General HospitalThe sponsor's other registered studies.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase N/A
- Primary purpose
- Treatment
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- None (open label)
- Enrolment
- 49 participants (actual)
Sponsor and investigators
- Lead sponsor
- University of Sao Paulo General Hospital
- Sponsor type
- University, hospital or other
- Collaborators
- Fundação de Amparo à Pesquisa do Estado de São Paulo
- Responsible party
- Sponsor
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT03492255
- Sponsor's protocol ID
- CYCLONES
- Acronym
- CYCLONES
- Status last verified
- Apr 2021
- First submitted
- 16 Mar 2018
- Last updated
- 21 Jul 2021
- Results posted
- No
- Data monitoring committee
- Yes
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- No
Publications
Costenbader KH, Desai A, Alarcon GS, Hiraki LT, Shaykevich T, Brookhart MA, Massarotti E, Lu B, Solomon DH, Winkelmayer WC. Trends in the incidence, demographics, and outcomes of end-stage renal disease due to lupus nephritis in the US from 1995 to 2006. Arthritis Rheum. 2011 Jun;63(6):1681-8. doi: 10.1002/art.30293.
PubMed 21445962Gladman DD, Urowitz MB, Rahman P, Ibanez D, Tam LS. Accrual of organ damage over time in patients with systemic lupus erythematosus. J Rheumatol. 2003 Sep;30(9):1955-9.
PubMed 12966597Houssiau FA, Vasconcelos C, D'Cruz D, Sebastiani GD, Garrido Ed Ede R, Danieli MG, Abramovicz D, Blockmans D, Mathieu A, Direskeneli H, Galeazzi M, Gul A, Levy Y, Petera P, Popovic R, Petrovic R, Sinico RA, Cattaneo R, Font J, Depresseux G, Cosyns JP, Cervera R. Immunosuppressive therapy in lupus nephritis: the Euro-Lupus Nephritis Trial, a randomized trial of low-dose versus high-dose intravenous cyclophosphamide. Arthritis Rheum. 2002 Aug;46(8):2121-31. doi: 10.1002/art.10461.
PubMed 12209517Ruiz-Arruza I, Lozano J, Cabezas-Rodriguez I, Medina JA, Ugarte A, Erdozain JG, Ruiz-Irastorza G. Restrictive Use of Oral Glucocorticoids in Systemic Lupus Erythematosus and Prevention of Damage Without Worsening Long-Term Disease Control: An Observational Study. Arthritis Care Res (Hoboken). 2018 Apr;70(4):582-591. doi: 10.1002/acr.23322. Epub 2018 Mar 7.
PubMed 28704598Condon MB, Ashby D, Pepper RJ, Cook HT, Levy JB, Griffith M, Cairns TD, Lightstone L. Prospective observational single-centre cohort study to evaluate the effectiveness of treating lupus nephritis with rituximab and mycophenolate mofetil but no oral steroids. Ann Rheum Dis. 2013 Aug;72(8):1280-6. doi: 10.1136/annrheumdis-2012-202844. Epub 2013 Jun 5.
PubMed 23740227Petri M, Orbai AM, Alarcon GS, Gordon C, Merrill JT, Fortin PR, Bruce IN, Isenberg D, Wallace DJ, Nived O, Sturfelt G, Ramsey-Goldman R, Bae SC, Hanly JG, Sanchez-Guerrero J, Clarke A, Aranow C, Manzi S, Urowitz M, Gladman D, Kalunian K, Costner M, Werth VP, Zoma A, Bernatsky S, Ruiz-Irastorza G, Khamashta MA, Jacobsen S, Buyon JP, Maddison P, Dooley MA, van Vollenhoven RF, Ginzler E, Stoll T, Peschken C, Jorizzo JL, Callen JP, Lim SS, Fessler BJ, Inanc M, Kamen DL, Rahman A, Steinsson K, Franks AG Jr, Sigler L, Hameed S, Fang H, Pham N, Brey R, Weisman MH, McGwin G Jr, Magder LS. Derivation and validation of the Systemic Lupus International Collaborating Clinics classification criteria for systemic lupus erythematosus. Arthritis Rheum. 2012 Aug;64(8):2677-86. doi: 10.1002/art.34473.
PubMed 22553077Then Bergh F, Kumpfel T, Schumann E, Held U, Schwan M, Blazevic M, Wismuller A, Holsboer F, Yassouridis A, Uhr M, Weber F, Daumer M, Trenkwalder C, Auer DP. Monthly intravenous methylprednisolone in relapsing-remitting multiple sclerosis - reduction of enhancing lesions, T2 lesion volume and plasma prolactin concentrations. BMC Neurol. 2006 May 23;6:19. doi: 10.1186/1471-2377-6-19.
PubMed 16719908Ruiz-Irastorza G, Danza A, Khamashta M. Glucocorticoid use and abuse in SLE. Rheumatology (Oxford). 2012 Jul;51(7):1145-53. doi: 10.1093/rheumatology/ker410. Epub 2012 Jan 23.
PubMed 22271756Rohatagi S, Barth J, Mollmann H, Hochhaus G, Soldner A, Mollmann C, Derendorf H. Pharmacokinetics of methylprednisolone and prednisolone after single and multiple oral administration. J Clin Pharmacol. 1997 Oct;37(10):916-25. doi: 10.1002/j.1552-4604.1997.tb04266.x.
PubMed 9505983Levic Z, Micic D, Nikolic J, Stojisavljevic N, Sokic D, Jankovic S, Kendereski A, Mavra M. Short-term high dose steroid therapy does not affect the hypothalamic-pituitary-adrenal axis in relapsing multiple sclerosis patients. Clinical assessment by the insulin tolerance test. J Endocrinol Invest. 1996 Jan;19(1):30-4. doi: 10.1007/BF03347855.
PubMed 8851689Barkhof F, Tas MW, Frequin ST, Scheltens P, Hommes OR, Nauta JJ, Valk J. Limited duration of the effect of methylprednisolone on changes on MRI in multiple sclerosis. Neuroradiology. 1994 Jul;36(5):382-7. doi: 10.1007/BF00612124.
PubMed 7936181Contreras G, Pardo V, Leclercq B, Lenz O, Tozman E, O'Nan P, Roth D. Sequential therapies for proliferative lupus nephritis. N Engl J Med. 2004 Mar 4;350(10):971-80. doi: 10.1056/NEJMoa031855.
PubMed 14999109Petri M, Buyon J, Kim M. Classification and definition of major flares in SLE clinical trials. Lupus. 1999;8(8):685-91. doi: 10.1191/096120399680411281.
PubMed 10568907Gladman DD, Urowitz MB, Goldsmith CH, Fortin P, Ginzler E, Gordon C, Hanly JG, Isenberg DA, Kalunian K, Nived O, Petri M, Sanchez-Guerrero J, Snaith M, Sturfelt G. The reliability of the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index in patients with systemic lupus erythematosus. Arthritis Rheum. 1997 May;40(5):809-13. doi: 10.1002/art.1780400506.
PubMed 9153540Appel GB, Contreras G, Dooley MA, Ginzler EM, Isenberg D, Jayne D, Li LS, Mysler E, Sanchez-Guerrero J, Solomons N, Wofsy D; Aspreva Lupus Management Study Group. Mycophenolate mofetil versus cyclophosphamide for induction treatment of lupus nephritis. J Am Soc Nephrol. 2009 May;20(5):1103-12. doi: 10.1681/ASN.2008101028. Epub 2009 Apr 15.
PubMed 19369404
Study at a glance
From the registry record, last updated by the sponsor on 21 Jul 2021. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- CYCLONES - CYClophosphamide LOw Dose and No Extra Steroid
- ClinicalTrials.gov ID
- NCT03492255
- Acronym / sponsor ID
- CYCLONES / CYCLONES
- Conditions
- Systemic Lupus Erythematosus (SLE)
- Study type
- Interventional
- Recruitment status
- TerminatedReason stopped: Significative difference between percentage of renal response (primary outcome) between the two study arms.
- Enrolment
- 49 participants (actual)
- Lead sponsor
- University of Sao Paulo General HospitalUniversity, hospital or other
- Collaborators
- Fundação de Amparo à Pesquisa do Estado de São Paulo
- Study start
- 12 Apr 2018 (actual)
- Primary completion
- 2 Jul 2021 (actual)
- Study completion
- 2 Jul 2021 (actual)
- First posted
- 10 Apr 2018 (actual)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
Glucocorticoids (GC) use has increased survival of patients with systemic lupus erythematosus (SLE), particularly in cases of nephritis and a more significant improvement to 80% with the introduction of therapy combined with immunosuppressants. This therapeutic scheme, however, results in a very high incidence of irreversible damage that is associated in more than 70% of the cases to GC use and in a smaller proportion to the use of high dose cyclophosphamide.
CYCLONES is a Controlled Randomized Clinical Trial with the aim of evaluating the efficacy of a regimen for lupus nephritis treatment using only intravenous corticosteroid administration. This intravenous corticosteroid regimen has already been tested (with Rituximab instead of Cyclophosphamide) with high response rates for lupus nephritis and significant reduction of side effects.
After selection, patients will be randomized in two arms: 116 patients will receive Euro-Lupus nephritis regimen and other 116 will undergo treatment with CYCLONES regimen.
The primary endpoint is the partial response (protein/creatinine ratio < 3 with decrease at least of 50% of the initial value and increase of creatinine not higher than 15% of the initial value) or complete response (protein/creatinine ratio < 500 with decrease at least of 50% of the initial value and increase of creatinine not higher than 15% of the initial value in 6 months. Secondary outcome measures will be evaluated such as osteoporosis and bone metabolism parameters, ophthalmologic evaluation of the collateral effects related to glucocorticoids, lipid profile and therapy adherence.
Detailed description
The use of glucocorticoids (GC) greatly increased the survival of patients with SLE, particularly in cases of nephritis and a more significant improvement to 80% with the introduction of therapy combined with immunosuppressants in the late 1960s. This therapeutic regimen, however, results in a very high incidence of irreversible damage to the patient that is associated in more than 70% of the cases to GC use and in a smaller proportion to the use of a high dose of cyclophosphamide. In the last years, some less toxic schemes have been proposed. The use of low-dose cyclophosphamide has been shown to have equal efficacy as high dose for the induction of remission of lupus nephritis with a fifteen-year follow-up.
Regarding GC, lower doses of methylprednisolone (MP) pulse have been shown to have similar efficacy and lower risk of infection. In addition, retrospective studies have found that high doses of oral GC during the induction period are associated with a higher incidence of side effects without a corresponding increase in efficacy . But it was only in 2013 that the first study was published that did not use oral GC in the treatment of lupus nephritis induction with excellent results.
In transplantation area, there are already several trials minimizing the use of GC proposing in the first days after transplantation the use the methylprednisolone (MP) IV pulse (day 1, 500mg, day 2, 250mg and day 3, 125mg) followed by oral GC for 4 days (60mg, 40mg, 30mg and 20mg). In this study, the same incidence of acute rejection occurred when compared to patients who were treated with oral GC for a prolonged period.
Regarding the route of administration of GC, it is important to emphasize that MP is three times more active through non-genomic pathway than through genomic pathway, which, in theory, results in a higher efficiency and lower collateral effect, when compared to the GC oral route that has similar potency through the two pathways. In addition, MP has a simpler and dose-proportional pharmacokinetics, whereas for oral prednisolone this kinetics is more complex and difficult to predict the dose required to achieve a specific concentration.
Therefore, the present study intends to evaluate the efficacy and adverse effects of cyclophosphamide (EUROLUPUS scheme) associated to usual GC dose compared with EUROLUPUS with no extra oral GC regimen.
The estimated number of patients was 116 patients for each arm (considering an error α = 0.05 and a power (1-β) of 80%).
In moderate flares, due to other systemic manifestations, the use of a maximum of 20mg / day of prednisone for 1 month and a progressive reduction of 5mg every 15 days until withdrawal is allowed. Other immunosuppressive, biological, intravenous immunoglobulin or plasmapheresis will be prohibited.
Regarding statistics, an Intention-To-Treat (ITT) analysis will be performed for the randomized patients, so that patients presenting side effects or low adherence to treatment will remain in the randomized group and will be evaluated at week 24.
The proportion of patients achieving complete and partial remission at week 24 will be compared by the chi-square test or the Fisher's exact test, as appropriate. The same statistical methodology will be applied to compare the number of events listed as secondary endpoints.
Study design
- Primary purpose
- Treatment
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- None (open label)
- Number of arms
- 2
| Arm | Type | Receives |
|---|---|---|
| Eurolupus: Cyclophosphamide + Methylprednisolone + oral GC | Active comparator | Drug: Cyclophosphamide, Drug: Methylprednisolone, Drug: Prednisone, Drug: Mycophenolate MofetilThe EUROLUPUS group will receive Cyclophosphamide (6 doses of 500 mg / fortnightly) + 3 doses of Methylprednisolone (750 mg) initial + oral glucocorticoid (GC) (prednisone) ≤ 30 mg/day with a gradual reduction of 5 mg/month (EUROLUPUS). From the 3rd month, the group will receive oral mycophenolate mofetil (MMF) (2-3 g) until 6 months with gradual reduction of GC from 5 mg/month until the minimum dose of 5 mg/month. |
| Cyclones Group: Cyclophosphamide+Methylprednisolone no oral GC | Experimental | Drug: Cyclophosphamide, Drug: Methylprednisolone, Drug: Mycophenolate MofetilCYCLONES Group will receive for 3 months Cyclophosphamide (6 doses of 500mg / fortnightly) + Methylprednisolone [500 mg (day 0 and day 15), 250 mg (day 30 and day 45) and 125 mg (day 60 and day 75)] without oral glucocorticoid (GC). From the third month, the group will receive only oral MMF (2-3 g) until the 6th month. Patients using GC ≤ 20 mg/day may enter the protocol with immediate reduction to 15 mg/day with a reduction of 5mg/month until complete withdrawal. |
Who may qualify
- Ages
- 18 years and older
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
Key inclusion criteria (6 listed)
- Systemic lupus erythematosus (SLE) according to the American College of Rheumatology (ACR) classification criteria and/or SLICC: according to the thematic protocol (Petri M, et al., Arthritis Rheum, 2012);
- Age ≥18 years;
- Lupus Glomerulonephritis Class III, IV or V according to the International Society of Nephrology (ISN)/Renal Pathology Society (RPS) Classification confirmed on renal biopsy (according to the routine protocol of our outpatient clinic) performed up to 3 months to 1 year prior to selection;
- Menopause or use contraception method;
- Informed consent.
Key exclusion criteria (12 listed)
- Creatinine clearance < 40 ml/min calculated (Cockcroft \& Gault);
- Intolerance to medication;
- Absolute neutrophil count < 1,000/mm3;
- Pregnancy or breastfeeding;
- Infection requiring hospitalization;
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| CyclophosphamidePatients in both EUROLUPUS group and CYCLONES Group will receive for 3 months Cyclophosphamide (6 doses of 500mg/biweekly) | Drug | Cyclones Group: Cyclophosphamide+Methylprednisolone no oral GC, Eurolupus: Cyclophosphamide + Methylprednisolone + oral GC |
| MethylprednisolonePatients in EUROLUPUS group will receive Methylprednisolone [750 mg for three consecutive days). Patients in CYCLONES Group will receive Methylprednisolone [500 mg (day 0 and day 15), 250 mg (day 30 and day 45) and 125 mg (day 60 and day 75). | Drug | Cyclones Group: Cyclophosphamide+Methylprednisolone no oral GC, Eurolupus: Cyclophosphamide + Methylprednisolone + oral GC |
| PrednisonePatients in EUROLUPUS group will receive oral prednisone ≤ 30 mg/day with a reduction of 5mg/month until complete withdrawal. | Drug | Eurolupus: Cyclophosphamide + Methylprednisolone + oral GC |
| Mycophenolate MofetilFrom the third month of protocol, patients in both EUROLUPUS group and CYCLONES Group will receive mycophenolate mofetil (2-3 g/day) until the sixth month of study. | Drug | Cyclones Group: Cyclophosphamide+Methylprednisolone no oral GC, Eurolupus: Cyclophosphamide + Methylprednisolone + oral GC |
Primary outcome
Partial renal response
Time frame: Six months
The primary endpoint is partial renal response, a composition of: urinary protein/creatinine ratio < 3g/g with decrease of at least 50% of the initial value and increase of creatinine (mg/dL) not higher than 15% of the initial value
Complete renal response
Time frame: Six months
Complete renal response, according to a composition of: urinary protein/creatinine ratio < 0,5 (g/g) with decrease of at least 50% of the initial value and increase of creatinine (mg/dL) not higher than 15% of the initial value.
11 secondary outcomes
Osteoporosis evaluation
Time frame: 6 months
Bone structure evaluation
Time frame: 6 months
Glaucoma evaluation
Time frame: 15 days, 30 days and 3 months
Cataract evaluation
Time frame: 3 months
Change from baseline Total cholesterol at 6 months
Time frame: Baseline and 6 months
Change from baseline Low-density lipoprotein (LDL) at 6 months
Time frame: Baseline and 6 months
Change from baseline High-density lipoprotein (HDL) at 6 months
Time frame: Baseline and 6 months
Change from baseline Triglycerides at 6 months
Time frame: Baseline and 6 months
Change from baseline Anti-High-density lipoprotein (anti-HDL) at 6 months
Time frame: Baseline and 6 months
Therapy adherence by a self-report medication adherence measure (8-item Morisky Medication Adherence Scale)
Time frame: Baseline
Change from baseline Serum levels of prednisone using Area Under the Curve [AUC] at 30 days, 3 months and 6 months
Time frame: Baseline, 30 days, 3 months and 6 months
Results and safety
The study was stopped early (reason given: Significative difference between percentage of renal response (primary outcome) between the two study arms.). Results are not available in the source record.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 21 Jul 2021.
- Background: PubMed 21445962Costenbader KH, Desai A, Alarcon GS, Hiraki LT, Shaykevich T, Brookhart MA, Massarotti E, Lu B, Solomon DH, Winkelmayer WC. Trends in the incidence, demographics, and outcomes of end-stage renal disease due to lupus nephritis in the US from 1995 to 2006. Arthritis Rheum. 2011 Jun;63(6):1681-8. doi: 10.1002/art.30293.
- Background: PubMed 12966597Gladman DD, Urowitz MB, Rahman P, Ibanez D, Tam LS. Accrual of organ damage over time in patients with systemic lupus erythematosus. J Rheumatol. 2003 Sep;30(9):1955-9.
- Background: PubMed 12209517Houssiau FA, Vasconcelos C, D'Cruz D, Sebastiani GD, Garrido Ed Ede R, Danieli MG, Abramovicz D, Blockmans D, Mathieu A, Direskeneli H, Galeazzi M, Gul A, Levy Y, Petera P, Popovic R, Petrovic R, Sinico RA, Cattaneo R, Font J, Depresseux G, Cosyns JP, Cervera R. Immunosuppressive therapy in lupus nephritis: the Euro-Lupus Nephritis Trial, a randomized trial of low-dose versus high-dose intravenous cyclophosphamide. Arthritis Rheum. 2002 Aug;46(8):2121-31. doi: 10.1002/art.10461.
- Background: PubMed 28704598Ruiz-Arruza I, Lozano J, Cabezas-Rodriguez I, Medina JA, Ugarte A, Erdozain JG, Ruiz-Irastorza G. Restrictive Use of Oral Glucocorticoids in Systemic Lupus Erythematosus and Prevention of Damage Without Worsening Long-Term Disease Control: An Observational Study. Arthritis Care Res (Hoboken). 2018 Apr;70(4):582-591. doi: 10.1002/acr.23322. Epub 2018 Mar 7.
- Background: PubMed 23740227Condon MB, Ashby D, Pepper RJ, Cook HT, Levy JB, Griffith M, Cairns TD, Lightstone L. Prospective observational single-centre cohort study to evaluate the effectiveness of treating lupus nephritis with rituximab and mycophenolate mofetil but no oral steroids. Ann Rheum Dis. 2013 Aug;72(8):1280-6. doi: 10.1136/annrheumdis-2012-202844. Epub 2013 Jun 5.
- Background: PubMed 22553077Petri M, Orbai AM, Alarcon GS, Gordon C, Merrill JT, Fortin PR, Bruce IN, Isenberg D, Wallace DJ, Nived O, Sturfelt G, Ramsey-Goldman R, Bae SC, Hanly JG, Sanchez-Guerrero J, Clarke A, Aranow C, Manzi S, Urowitz M, Gladman D, Kalunian K, Costner M, Werth VP, Zoma A, Bernatsky S, Ruiz-Irastorza G, Khamashta MA, Jacobsen S, Buyon JP, Maddison P, Dooley MA, van Vollenhoven RF, Ginzler E, Stoll T, Peschken C, Jorizzo JL, Callen JP, Lim SS, Fessler BJ, Inanc M, Kamen DL, Rahman A, Steinsson K, Franks AG Jr, Sigler L, Hameed S, Fang H, Pham N, Brey R, Weisman MH, McGwin G Jr, Magder LS. Derivation and validation of the Systemic Lupus International Collaborating Clinics classification criteria for systemic lupus erythematosus. Arthritis Rheum. 2012 Aug;64(8):2677-86. doi: 10.1002/art.34473.
- Background: PubMed 16719908Then Bergh F, Kumpfel T, Schumann E, Held U, Schwan M, Blazevic M, Wismuller A, Holsboer F, Yassouridis A, Uhr M, Weber F, Daumer M, Trenkwalder C, Auer DP. Monthly intravenous methylprednisolone in relapsing-remitting multiple sclerosis - reduction of enhancing lesions, T2 lesion volume and plasma prolactin concentrations. BMC Neurol. 2006 May 23;6:19. doi: 10.1186/1471-2377-6-19.
- Background: PubMed 22271756Ruiz-Irastorza G, Danza A, Khamashta M. Glucocorticoid use and abuse in SLE. Rheumatology (Oxford). 2012 Jul;51(7):1145-53. doi: 10.1093/rheumatology/ker410. Epub 2012 Jan 23.
- Background: PubMed 9505983Rohatagi S, Barth J, Mollmann H, Hochhaus G, Soldner A, Mollmann C, Derendorf H. Pharmacokinetics of methylprednisolone and prednisolone after single and multiple oral administration. J Clin Pharmacol. 1997 Oct;37(10):916-25. doi: 10.1002/j.1552-4604.1997.tb04266.x.
- Background: PubMed 8851689Levic Z, Micic D, Nikolic J, Stojisavljevic N, Sokic D, Jankovic S, Kendereski A, Mavra M. Short-term high dose steroid therapy does not affect the hypothalamic-pituitary-adrenal axis in relapsing multiple sclerosis patients. Clinical assessment by the insulin tolerance test. J Endocrinol Invest. 1996 Jan;19(1):30-4. doi: 10.1007/BF03347855.
- Background: PubMed 7936181Barkhof F, Tas MW, Frequin ST, Scheltens P, Hommes OR, Nauta JJ, Valk J. Limited duration of the effect of methylprednisolone on changes on MRI in multiple sclerosis. Neuroradiology. 1994 Jul;36(5):382-7. doi: 10.1007/BF00612124.
- Background: PubMed 14999109Contreras G, Pardo V, Leclercq B, Lenz O, Tozman E, O'Nan P, Roth D. Sequential therapies for proliferative lupus nephritis. N Engl J Med. 2004 Mar 4;350(10):971-80. doi: 10.1056/NEJMoa031855.
- Individual participant dataSharing planned: No
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
The record lists no contact. Use the official record to reach the sponsor.
2 sites in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A study testing Cyclophosphamide, Methylprednisolone and Prednisone in people with Systemic Lupus Erythematosus (SLE), run by University of Sao Paulo General Hospital at 2 sites in Brazil.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 6 inclusion and 12 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: stopped early, as of the sponsor's last update on 21 Jul 2021. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 2 sites in Brazil. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
The study was stopped early (reason given: Significative difference between percentage of renal response (primary outcome) between the two study arms.). Results are not available in the source record.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Partial renal response (time frame: Six months). The study lists 2 primary outcomes in all. It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT03492255, which also lists 16 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 21 Jul 2021.