Graves OphthalmopathyPhase 2TOGONCT04876534
Tocilizumab in Active Moderate-severe Graves' Orbitopathy
A Phase 2 study testing Tocilizumab 20 Mg/mL Intravenous Solution and MethylPREDNISolone Injectable Solution in people with Graves Ophthalmopathy, run by Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico at 4 sites in Italy.
Trial summary
To treat patientis with active moderate-severe GO with the anti-IL6 receptor monoclonal antibody tocilizubam with the purpose of assesing the efficacy of therapy on active GO and on the proportion of patiens with inactivation and reactivation of disease (Primary Objective) Effect of therapy on disease progression… Read more about this study
- Who is it for?
- Ages 18 to 75 years
- Conditions the study is for
- Graves Ophthalmopathy
- What is being tested?
- Tocilizumab 20 Mg/mL Intravenous Solution and MethylPREDNISolone Injectable Solution
- Type of treatment
- Injection or infusion
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 56 participants
- Where
- 4 sitesItaly
- Study dates
- 18 Dec 2019to 18 Mar 2026
- Phase
- Phase 2
- 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 to 75 years
- All sexes
- No healthy volunteers
- Adult, Older adult
Who may be able to join
- Written informed consent
- Male or female, 18-75 years old
- Women of childbearing potential should use effective contraception (abstinence or use contraceptive methods with a failure rate of <1%) throughout study and for a minimum of 6 months after study drug therapy and must have a negative serum pregnancy test at screening
- GO at first diagnosis or at the time of relapse of no more than 9 months' duration.
- Patients with moderate-severe active GO (clinical activity score 4/10 assessed at the end of the screening period) untreated or previously treated with i.v. steroids withdrawn for at least 3 months.
- Euthyroid for at least 6-8 weeks (serum free hormone concentrations within 20% of normal range), on either anti-thyroid medications (tyonamides) to control hyperthyroidism or L-thyroxine for replacement therapy for hypothyroidism.
- Patients will also be allowed to stay on propranolol treatment for the control of tachycardia.
Who cannot join
- Patients with sight-threatening Graves' orbitopathy (severe keratopathy, compression optic neuropathy and inflammatory optic neuropathy).
- Treatment with any biological therapy at any time.
- Previous oral or intravenous corticosteroid treatment in the last three months except for oral steroid not exceeding a cumulative dose of 1 gr.
- Plasmapheresis within 90 days prior to Day 0.
- Treatment with intravenous immunoglobulin.
- Azathioprine more than 100 mg/day within 30 days before screening.
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- Administration of live vaccines given within 30 days prior to administration of (Day 0) or concurrently with tocilizumab (during study).
- Splenectomy.
- Subjects at risk of bleeding that threatens a vital organ.
- History of a major organ transplant or hematopoietic stem cell/marrow transplant.
- History of malignant neoplasm within the last 5 years, except for adequately treated cancers of the skin (basal or squamous cell) or carcinoma in situ of the uterine cervix.
- Required management of infections, as follows: currently on any suppressive therapy for a chronic infection, hospitalization for treatment of infection within 60 days before Day 0, use of parenteral antibiotics within 60 days before Day 0, use of oral antibiotics within 30 days before Day 0.
- Pregnancy.
- Patients with reproductive potential not willing to use an effective method of contraception throughout study and for a minimum of 6 months after study drug therapy
- Breast feeding.
- Previous history of intestinal ulceration or diverticulitis or diverticular disease.
- Known unstable coronary artery disease.
- Significant cardiac arrhythmias.
- Severe congestive heart failure.
- Other serious chronic illness (including nervous system disease, pulmonary disease including obstructive pulmonary disease, renal disease).
- Active infection.
- History of recurrent clinically significant infection or recurrent bacterial infections.
- History of sarcoidosis.
- Primary or secondary immunodeficiency.
- History of IgE-mediated or non-IgE-mediated hypersensitivity.
- Positive PPD or quantiferon without documentation of treatment for TB infection.
- Denied consent to HIV testing.
- Previous orbital radiotherapy
- HBsAg positive test.
- HBcAb positive test, regardless of HBsAb status, will undergo HBV DNA which, if positive, will be excluded.
- Hepatitis C antibody positive test at screening.
- Positive test for Human Immunodeficiency Virus (HIV) antibody at screening or historically.
- Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) greater or equal to 1.5x upper limit of normal (ULN).
- Alkaline phosphatase and bilirubin>1.5xULN (isolated bilirubin >1.5xULN is acceptable if bilirubin is fractionated and direct bilirubin is<35%).
- Grade 3 / 4 IgG deficiency and IgA deficiency (IgA < 10mg/dL).
- History of sensitivity to any of the study medications, or components thereof or a history of drug or other allergy including a previous anaphylactic reaction to parenteral administration contrast agents, human or murine proteins or monoclonal antibodies.
- Major depression.
- Evidence of serious suicide risk including any history of suicidal behaviour in the last 6 months and/or any suicidal ideation in the last 2 months or who in the investigator's judgment, pose a significant suicide risk.
- Current drug or alcohol abuse or dependence.
- White blood cells < 3.0 x 109/L (3000/mm3)
- Absolute neutrophil count (ANC) < 2.0 x 109/L (2000/ mm3)
- Absolute lymphocyte count < 0.5 x 109/L (500/ mm3)
- Platelet count <100 x 109/L
- Serum creatinine > 1.4 mg/dl (124 µmol/L) in female patients and > 1.6 mg/dl (141 µmol/L) in male patients
- Hemoglobin <85 g/L (8.5 g/dL; 5.3 mmol/L)
- Demyelinating disorders
- Treatment with Methotrexate
Trial locations and contacts
4 sites in 1 country.
Italy4 sites
Istituto Auxologico Italiano
Milan, MI, 20149
Azienda Ospedaliero, Universitaria Pisana
Pisa, PI, 56126
Azienda Ospedaliera "Sant'Andrea"
Roma, RM, 00189
Mauriziano Umberto I Hospital
Torino, TO, 10128
About this study
Official title: Multicenter, Randomized, Observer-blind, Controlled Study of the Anti-IL-6 Receptor Antibody Tocilizumab (TCZ) or Methylprednisolone (MP) Treatment in Patients With Active Moderate-severe Graves' Orbitopathy
To treat patientis with active moderate-severe GO with the anti-IL6 receptor monoclonal antibody tocilizubam with the purpose of assesing the efficacy of therapy on active GO and on the proportion of patiens with inactivation and reactivation of disease (Primary Objective) Effect of therapy on disease progression, improvement of QoL, the degree of residual disease after the inflammatory phase and safety of treatment (Secondary Objective)
Read the detailed description
1 Primary Endpoint:
- Proportion of patients with CAS reduction of 3 points or disease inactivation (CAS<4) at 12 and 24 weeks
1.2 Secondary Endpoints:
- Proportion of patients improved at 24 weeks as assessed by the EUGOGO composite ophthalmic score (see below paragraph#5)
- Improvement of quality of life according to the GO-QoL questionnaire at 12 and 24 weeks.
- Safety of tocilizumab therapy in patients with GO compared to Methylprednisolone, evaluated on the basis of the following endpoints: Incidence and severity of adverse events, with severity determined according to NCI CTCAE v5.0,
- Changes of serum TSH receptor binding and stimulating antibodies, anti-TPO antibodies and serum concentrations of IL-6 and sIL-6 receptor at 12, 24 and 36 and 48weeks of follow up.
- Proportion of patients with disease reactivation (CAS > or =4) during follow-up at 24-48 weeks.
- Quantification of signs of residual motility abnormalities by motility tests and orbital imaging
- Number of rehabilitative surgical interventions at the end of follow-up
2.Study Design and Methods
Randomized, single blind (ophthalmologist), controlled study, IIb phase. The study will be conducted in 5 National centres dedicated to the management of Graves' orbitopathy
The present study will randomize GO patients, euthyroid for at least 6-8 weeks, to two treatments:
- Tocilizumab weight adjusted, 8 mg/kg, 1 intravenous infusion every four weeks (+/- 72 hours) for 12 weeks
- Methylprednisolone, 500 mg infusion weekly (+/- 48 hours) for 6 weeks, followed by 250 mg infusion weekly (+/- 48 hours) for another 6 weeks
The enrollment period is approximately 24 months
3.Phases of the study
- Screening phase (-4/-2 to 0 weeks): involves 1 to 2 visits
- Treatment phase (0 to 12 weeks): assessments at baseline and every 4 weeks
- Observation phase (12 to 24 weeks): assessments every 6 weeks
- Follow up (24 to 48 weeks): assessments every 12 weeks
Data from week 24 are used to determine primary and secondary endpoints
4.Definition of improvement, worsening or no change of the secondary end point criteria*
- Improvement, when at least two of the following outcome measures improve in one eye, without deterioration in any of the measure in either eyes: a) reduction in palpebral aperture by at least 3 mm; b) reduction in any of the class 2 signs of NOSPECS by at least 2 grades; c) reduction of proptosis by at least 2 mm; d) improvement of ≥8 degrees in any duction or in diplopia (Gorman score); e) improvement in CAS by at least 2 points
- Worsening, when optic neuropathy or two of the following occur: a) increase in palpebral aperture by at least 3 mm; b) increase in any of the class 2 signs of NOSPECS by at least 2 grades; c) increase of proptosis by at least 2 mm; d) deterioration of ≥8 degrees in any duction or in diplopia (Gorman score); e) worsening in CAS.
- No change, when there are no changes or changes smaller than the above defined parameters
- Study population
5.1 Withdrawal Rules
- Should patients become affected with any of the conditions outlined as exclusion criteria during the study period or follow-up, they will be withdrawn from the study
- Should patients require administration of any of the medications listed in the exclusion criteria, according to prohibited medication rules, they will be withdrawn from the study.
- Other reasons for study withdrawal are:
- refusal of continuing the study medication after having commenced it.
- diagnosis of major cardiovascular diseases or neoplasia once treatment has started.
- If patients present with a severe complication of GO, i.e. progression to dysthyroid optic neuropathy due to unresponsiveness to treatment, they will be considertreatment failure and will undergo urgent surgical orbital decompression.
Patients have the right to voluntarily withdraw from the study at any time for any reason. In addition, the investigator has the right to withdraw a patient from the study at any time. Reasons for withdrawal from the study may include, but are not limited to, the following:
Patient withdrawal of consent
Study termination or site closure
Patient non-compliance, defined as failure to comply with protocol requirements as determined by the investigator or Sponsor
Every effort should be made to obtain information on patients who withdraw from the study. The primary reason for withdrawal from the study should be documented on the appropriate eCRF. If a patient requests to be withdrawn from the study, this request must be documented in the source documents and signed by the investigator. Patients who withdraw from the study will not be replaced.
5.2 Study Arms
Arm 1: 32 patients with active moderate-severe GO treated with i.v. tocilizumab
Arm 2: 32 patients with active moderate-severe GO treated with i.v. methylprednisolone.
5.3 Study Medications and Dosing Regimen
Tocilizumab, the IMP-test, will be supplied and distribute by Roche packed and labelled.
Upon delivery to the site, site personnel should check for damage and verify proper identity, quantity, integrity of seals and temperature conditions. Site personnel should report any deviations or product complaints to the study monitor upon discovery.
For information on the formulation and handling of tocilizumab see the SmPC and Investigator's Brochure
Methylprednisolone is the IMP-comparator,
For information on the formulation, packaging, and handling of MP, see the SmPC.
Arm 1. Tocilizumab: i.v. infusion of, weight adjusted, 8 mg/kg of TCZ every four weeks (+/- 72 hours) for 12 weeks.
Arm 2. Methylprednisolone (MP): i.v. infusion of 500 mg of MP weekly (+/- 48 hours) for 6 weeks, followed by i.v. infusion of 250 mg of MP one a week (+/- 48 hours) for 6 weeks
5.4 Study duration
Duration of the study: 3 years (2 years for enrollment and one year for follow up)
5.5 Study Discontinuation
The Sponsor has the right to terminate this study at any time. Reasons for terminating the study may include, but are not limited to, the following:
The incidence or severity of adverse events in this or other studies indicates a potential health hazard to patients
Patient enrollment is unsatisfactory
The Sponsor will notify the investigator if the Sponsor decides to discontinue the study.
5.6 Site Discontinuation
The Sponsor has the right to close a site at any time. Reasons for closing a site may include, but are not limited to, the following:
Excessively slow recruitment
Poor protocol adherence
Inaccurate or incomplete data recording
Non-compliance with the International Council for Harmonisation (ICH) guideline for Good Clinical Practice
No study activity (i.e., all patients have completed the study and all obligations have been fulfilled)
- Statistical considerations and sample size calculation A sample size of 64 patients is planned to provide at least an 80% power if 32 patients per treatment arm were included for an anticipated (improvement) responder rate of 68% in steroid and 95% in tocilizumab treated patients, with a two-tail significance of 0.05.
No patients stratification is planned The calculation is based on the available literature on the significant decrease of the after rituximab and steroid therapy and after tocilizumab and placebo.
64 patients with active GO will be enrolled and an interim analysis of results will be carried out after the first 32 patients (16 in arm 1 and 16 in arm 2) will reach the 24 week endpoint.
All enrolled patients receiving at least one dose of study medication and withdrawing from the study for any reason will be analyzed as non-responder in an ITT population for the 24 weeks primary endpoint.
Statistical Analysis: repeated measures ANOVA and Spearman or Pearson rank test for clinical activity and severity scores; Wilcoxon rank sum test to assess differences between treatment groups; chi-square for response and relapse rates.
An interim analysis of results will be carried out after the first 16 enrolled patients in both arms reach 24 week point), in order to eventually plan for another study perhaps employing s.c. TCZ .
- Conditions
- Graves Ophthalmopathy
- Being tested
- Tocilizumab 20 Mg/mL Intravenous Solution, MethylPREDNISolone Injectable Solution
- Keywords
- Graves' orbitopathy, Graves' disease, Tocilizumab, Hyperthyroidism, Thyroid's disease
- Medical subject headings
- Graves Ophthalmopathy, Graves Disease, Hyperthyroidism
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Tocilizumab 20 Mg/mL Intravenous SolutionDrug
Also called Actemra
Intravenous administration
MethylPREDNISolone Injectable SolutionDrug
Also called Solumedrol
Intravenous administration
| Study group | Role | What they receive |
|---|---|---|
| Tocilizumab | Experimental | 32 patients with active moderate-severe GO treated with i.v. tocilizumab; Tocilizumab weight adjusted, 8 mg/kg, 1 intravenous infusion every four weeks (+/- 72 hours) for 12 weeks Receives: Drug: Tocilizumab 20 Mg/mL Intravenous Solution |
| Methylprednisolone | Active comparator | 32 patients with active moderate-severe GO treated with i.v. methylprednisolone; Methylprednisolone, 500 mg infusion weekly (+/- 48 hours) for 6 weeks, followed by 250 mg infusion weekly (+/- 48 hours) for another 6 weeks Receives: Drug: MethylPREDNISolone Injectable Solution |
What is being measured
The primary outcome is the main question the study is designed to answer.
Desease inactivation
Proportion of patients with CAS reduction of 3 points or disease inactivation (CAS<4) at 12 and 24 weeks
Measured: at 12 and 24 weeks
Secondary outcomes (7)
Desease improvement
Proportion of patients improved at 24 weeks as assessed by the EUGOGO composite ophthalmic score
Measured: 24 weeks
Improvement of quality of life
Improvement of quality of life according to the GO-QoL questionnaire at 12 and 24 weeks. All Go-QoL questions were scored as 'severely limited' (one point), a 'little limited' (two points), or 'not limited at all'(three points). The questions were transformed from 0 to 100 by the following formula: total score= (raw score- 8)/16 x100. Higher is the final score, better is health.
Measured: at 12 and 24 weeks
Incident of adverse events in tocilizumab therapy
Safety of tocilizumab therapy in patients with GO compared to Methylprednisolone, evaluated on the basis of the following endpoints: Incidence and severity of adverse events, with severity determined according to NCI CTCAE v5.0,
Measured: from 0 to 12 weeks
Immunological changes
Changes of serum TSH receptor binding and stimulating antibodies, anti-TPO antibodies and serum concentrations of IL-6 and sIL-6 receptor at 12, 24 and 36 and 48weeks of follow up.
Measured: at 12, 24 and 36 and 48weeks of follow up
Desease relapse
Proportion of patients with CAS reduction of 3 points from baseline CAS or disease inactivation (CAS<4) at 12 and 24 weeks.
The Clinical activated score (CAS) is a parameter to assess eye impairment in patients with GO. The maximum CAS value is 10.
Measured: at 24-48 weeks
Residual desease
Quantification of signs of residual motility abnormalities by motility tests and orbital imaging
Measured: at 48 weeks
Rehabilitative therapy
Number of rehabilitative surgical interventions at the end of follow-up
Measured: at 48 weeks
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted6 May 2021
- Study start18 Dec 2019
- Primary completion30 Sep 2023
- Study completion18 Mar 2026
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (21)Papers the sponsor has linked to this study.
- Other trials for Graves OphthalmopathyStudies of the same condition, open and under way.
- 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 2
- Primary purpose
- Treatment
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Model description
- 32 patients with active moderate-severe GO treated with i.v. tocilizumab; 32 patients with active moderate-severe GO treated with i.v. methylprednisolone.
- Masking
- Single blind
- Who is masked
- Care provider
- Enrolment
- 56 participants (actual)
Sponsor and investigators
- Lead sponsor
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico
- Sponsor type
- University, hospital or other
- Collaborators
- Mauriziano Umberto I Hospital, Istituto Auxologico Italiano, Azienda Ospedaliera "Sant'Andrea", Azienda Ospedaliero, Universitaria Pisana
- Responsible party
- Sponsor
- Investigators
- Mario MS Salvi, MD, Principal investigator, Fondazione IRCCS "Cà Granda" Ospedale Maggiore Policlinico
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT04876534
- Sponsor's protocol ID
- ML39921
- Acronym
- TOGO
- Status last verified
- Oct 2024
- First submitted
- 3 May 2021
- Last updated
- 23 Oct 2026
- Results posted
- No
- Data monitoring committee
- Yes
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- No
Publications
Bartalena L, Baldeschi L, Boboridis K, Eckstein A, Kahaly GJ, Marcocci C, Perros P, Salvi M, Wiersinga WM; European Group on Graves' Orbitopathy (EUGOGO). The 2016 European Thyroid Association/European Group on Graves' Orbitopathy Guidelines for the Management of Graves' Orbitopathy. Eur Thyroid J. 2016 Mar;5(1):9-26. doi: 10.1159/000443828. Epub 2016 Mar 2.
PubMed 27099835Campi I, Vannucchi G, Salvi M. THERAPY OF ENDOCRINE DISEASE: Endocrine dilemma: management of Graves' orbitopathy. Eur J Endocrinol. 2016 Sep;175(3):R117-33. doi: 10.1530/EJE-15-1164. Epub 2016 Mar 31.
PubMed 27032693Salvi M, Campi I. Medical Treatment of Graves' Orbitopathy. Horm Metab Res. 2015 Sep;47(10):779-88. doi: 10.1055/s-0035-1554721. Epub 2015 Sep 11.
PubMed 26361263Campi I, Tosi D, Rossi S, Vannucchi G, Covelli D, Colombo F, Trombetta E, Porretti L, Vicentini L, Cantoni G, Curro N, Beck-Peccoz P, Bulfamante G, Salvi M. B Cell Activating Factor (BAFF) and BAFF Receptor Expression in Autoimmune and Nonautoimmune Thyroid Diseases. Thyroid. 2015 Sep;25(9):1043-9. doi: 10.1089/thy.2015.0029. Epub 2015 Aug 13.
PubMed 26214745Salvi M, Vannucchi G, Curro N, Campi I, Covelli D, Dazzi D, Simonetta S, Guastella C, Pignataro L, Avignone S, Beck-Peccoz P. Efficacy of B-cell targeted therapy with rituximab in patients with active moderate to severe Graves' orbitopathy: a randomized controlled study. J Clin Endocrinol Metab. 2015 Feb;100(2):422-31. doi: 10.1210/jc.2014-3014. Epub 2014 Dec 15.
PubMed 25494967Salvi M. Immunotherapy for Graves' ophthalmopathy. Curr Opin Endocrinol Diabetes Obes. 2014 Oct;21(5):409-14. doi: 10.1097/MED.0000000000000097.
PubMed 25105999Curro N, Covelli D, Vannucchi G, Campi I, Pirola G, Simonetta S, Dazzi D, Guastella C, Pignataro L, Beck-Peccoz P, Ratiglia R, Salvi M. Therapeutic outcomes of high-dose intravenous steroids in the treatment of dysthyroid optic neuropathy. Thyroid. 2014 May;24(5):897-905. doi: 10.1089/thy.2013.0445. Epub 2014 Mar 6.
PubMed 24417307Vannucchi G, Covelli D, Campi I, Origo D, Curro N, Cirello V, Dazzi D, Beck-Peccoz P, Salvi M. The therapeutic outcome to intravenous steroid therapy for active Graves' orbitopathy is influenced by the time of response but not polymorphisms of the glucocorticoid receptor. Eur J Endocrinol. 2013 Nov 22;170(1):55-61. doi: 10.1530/EJE-13-0611. Print 2014 Jan.
PubMed 24128430Salvi M, Vannucchi G, Beck-Peccoz P. Potential utility of rituximab for Graves' orbitopathy. J Clin Endocrinol Metab. 2013 Nov;98(11):4291-9. doi: 10.1210/jc.2013-1804. Epub 2013 Sep 5.
PubMed 24009135Vannucchi G, Covelli D, Curro N, Dazzi D, Maffini A, Campi I, Bonara P, Guastella C, Pignataro L, Ratiglia R, Beck-Peccoz P, Salvi M. Serum BAFF concentrations in patients with Graves' disease and orbitopathy before and after immunosuppressive therapy. J Clin Endocrinol Metab. 2012 May;97(5):E755-9. doi: 10.1210/jc.2011-2614. Epub 2012 Mar 7.
PubMed 22399512Salvi M, Vannucchi G, Curro N, Introna M, Rossi S, Bonara P, Covelli D, Dazzi D, Guastella C, Pignataro L, Ratiglia R, Golay J, Beck-Peccoz P. Small dose of rituximab for graves orbitopathy: new insights into the mechanism of action. Arch Ophthalmol. 2012 Jan;130(1):122-4. doi: 10.1001/archopthalmol.2011.1215. No abstract available.
PubMed 22232486Salvi M, Vannucchi G, Campi I, Curro N, Dazzi D, Simonetta S, Bonara P, Rossi S, Sina C, Guastella C, Ratiglia R, Beck-Peccoz P. Treatment of Graves' disease and associated ophthalmopathy with the anti-CD20 monoclonal antibody rituximab: an open study. Eur J Endocrinol. 2007 Jan;156(1):33-40. doi: 10.1530/eje.1.02325.
PubMed 17218723Vannucchi G, Campi I, Bonomi M, Covelli D, Dazzi D, Curro N, Simonetta S, Bonara P, Persani L, Guastella C, Wall J, Beck-Peccoz P, Salvi M. Rituximab treatment in patients with active Graves' orbitopathy: effects on proinflammatory and humoral immune reactions. Clin Exp Immunol. 2010 Sep;161(3):436-43. doi: 10.1111/j.1365-2249.2010.04191.x.
PubMed 20529087Salvi M, Vannucchi G, Campi I, Curro N, Simonetta S, Covelli D, Pignataro L, Guastella C, Rossi S, Bonara P, Dazzi D, Ratiglia R, Beck-Peccoz P. Rituximab treatment in a patient with severe thyroid-associated ophthalmopathy: effects on orbital lymphocytic infiltrates. Clin Immunol. 2009 May;131(2):360-5. doi: 10.1016/j.clim.2008.12.005. Epub 2009 Feb 4.
PubMed 19195932Yanaba K, Bouaziz JD, Matsushita T, Magro CM, St Clair EW, Tedder TF. B-lymphocyte contributions to human autoimmune disease. Immunol Rev. 2008 Jun;223:284-99. doi: 10.1111/j.1600-065X.2008.00646.x.
PubMed 18613843
Study at a glance
From the registry record, last updated by the sponsor on 23 Oct 2026. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Multicenter, Randomized, Observer-blind, Controlled Study of the Anti-IL-6 Receptor Antibody Tocilizumab (TCZ) or Methylprednisolone (MP) Treatment in Patients With Active Moderate-severe Graves' Orbitopathy
- ClinicalTrials.gov ID
- NCT04876534
- Acronym / sponsor ID
- TOGO / ML39921
- Conditions
- Graves Ophthalmopathy
- Keywords
- Graves' orbitopathy, Graves' disease, Tocilizumab, Hyperthyroidism, Thyroid's disease
- Phase
- Phase 2
- Study type
- Interventional
- Recruitment status
- Completed
- Enrolment
- 56 participants (actual)
- Lead sponsor
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore PoliclinicoUniversity, hospital or other
- Collaborators
- Mauriziano Umberto I Hospital, Istituto Auxologico Italiano, Azienda Ospedaliera "Sant'Andrea", Azienda Ospedaliero, Universitaria Pisana
- Study start
- 18 Dec 2019 (actual)
- Primary completion
- 30 Sep 2023 (actual)
- Study completion
- 18 Mar 2026 (actual)
- First posted
- 6 May 2021 (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.
To treat patientis with active moderate-severe GO with the anti-IL6 receptor monoclonal antibody tocilizubam with the purpose of assesing the efficacy of therapy on active GO and on the proportion of patiens with inactivation and reactivation of disease (Primary Objective) Effect of therapy on disease progression, improvement of QoL, the degree of residual disease after the inflammatory phase and safety of treatment (Secondary Objective)
Detailed description
1 Primary Endpoint:
- Proportion of patients with CAS reduction of 3 points or disease inactivation (CAS<4) at 12 and 24 weeks
1.2 Secondary Endpoints:
- Proportion of patients improved at 24 weeks as assessed by the EUGOGO composite ophthalmic score (see below paragraph#5)
- Improvement of quality of life according to the GO-QoL questionnaire at 12 and 24 weeks.
- Safety of tocilizumab therapy in patients with GO compared to Methylprednisolone, evaluated on the basis of the following endpoints: Incidence and severity of adverse events, with severity determined according to NCI CTCAE v5.0,
- Changes of serum TSH receptor binding and stimulating antibodies, anti-TPO antibodies and serum concentrations of IL-6 and sIL-6 receptor at 12, 24 and 36 and 48weeks of follow up.
- Proportion of patients with disease reactivation (CAS > or =4) during follow-up at 24-48 weeks.
- Quantification of signs of residual motility abnormalities by motility tests and orbital imaging
- Number of rehabilitative surgical interventions at the end of follow-up
2.Study Design and Methods
Randomized, single blind (ophthalmologist), controlled study, IIb phase. The study will be conducted in 5 National centres dedicated to the management of Graves' orbitopathy
The present study will randomize GO patients, euthyroid for at least 6-8 weeks, to two treatments:
- Tocilizumab weight adjusted, 8 mg/kg, 1 intravenous infusion every four weeks (+/- 72 hours) for 12 weeks
- Methylprednisolone, 500 mg infusion weekly (+/- 48 hours) for 6 weeks, followed by 250 mg infusion weekly (+/- 48 hours) for another 6 weeks
The enrollment period is approximately 24 months
3.Phases of the study
- Screening phase (-4/-2 to 0 weeks): involves 1 to 2 visits
- Treatment phase (0 to 12 weeks): assessments at baseline and every 4 weeks
- Observation phase (12 to 24 weeks): assessments every 6 weeks
- Follow up (24 to 48 weeks): assessments every 12 weeks
Data from week 24 are used to determine primary and secondary endpoints
4.Definition of improvement, worsening or no change of the secondary end point criteria*
- Improvement, when at least two of the following outcome measures improve in one eye, without deterioration in any of the measure in either eyes: a) reduction in palpebral aperture by at least 3 mm; b) reduction in any of the class 2 signs of NOSPECS by at least 2 grades; c) reduction of proptosis by at least 2 mm; d) improvement of ≥8 degrees in any duction or in diplopia (Gorman score); e) improvement in CAS by at least 2 points
- Worsening, when optic neuropathy or two of the following occur: a) increase in palpebral aperture by at least 3 mm; b) increase in any of the class 2 signs of NOSPECS by at least 2 grades; c) increase of proptosis by at least 2 mm; d) deterioration of ≥8 degrees in any duction or in diplopia (Gorman score); e) worsening in CAS.
- No change, when there are no changes or changes smaller than the above defined parameters
- Study population
5.1 Withdrawal Rules
- Should patients become affected with any of the conditions outlined as exclusion criteria during the study period or follow-up, they will be withdrawn from the study
- Should patients require administration of any of the medications listed in the exclusion criteria, according to prohibited medication rules, they will be withdrawn from the study.
- Other reasons for study withdrawal are:
- refusal of continuing the study medication after having commenced it.
- diagnosis of major cardiovascular diseases or neoplasia once treatment has started.
- If patients present with a severe complication of GO, i.e. progression to dysthyroid optic neuropathy due to unresponsiveness to treatment, they will be considertreatment failure and will undergo urgent surgical orbital decompression.
Patients have the right to voluntarily withdraw from the study at any time for any reason. In addition, the investigator has the right to withdraw a patient from the study at any time. Reasons for withdrawal from the study may include, but are not limited to, the following:
Patient withdrawal of consent
Study termination or site closure
Patient non-compliance, defined as failure to comply with protocol requirements as determined by the investigator or Sponsor
Every effort should be made to obtain information on patients who withdraw from the study. The primary reason for withdrawal from the study should be documented on the appropriate eCRF. If a patient requests to be withdrawn from the study, this request must be documented in the source documents and signed by the investigator. Patients who withdraw from the study will not be replaced.
5.2 Study Arms
Arm 1: 32 patients with active moderate-severe GO treated with i.v. tocilizumab
Arm 2: 32 patients with active moderate-severe GO treated with i.v. methylprednisolone.
5.3 Study Medications and Dosing Regimen
Tocilizumab, the IMP-test, will be supplied and distribute by Roche packed and labelled.
Upon delivery to the site, site personnel should check for damage and verify proper identity, quantity, integrity of seals and temperature conditions. Site personnel should report any deviations or product complaints to the study monitor upon discovery.
For information on the formulation and handling of tocilizumab see the SmPC and Investigator's Brochure
Methylprednisolone is the IMP-comparator,
For information on the formulation, packaging, and handling of MP, see the SmPC.
Arm 1. Tocilizumab: i.v. infusion of, weight adjusted, 8 mg/kg of TCZ every four weeks (+/- 72 hours) for 12 weeks.
Arm 2. Methylprednisolone (MP): i.v. infusion of 500 mg of MP weekly (+/- 48 hours) for 6 weeks, followed by i.v. infusion of 250 mg of MP one a week (+/- 48 hours) for 6 weeks
5.4 Study duration
Duration of the study: 3 years (2 years for enrollment and one year for follow up)
5.5 Study Discontinuation
The Sponsor has the right to terminate this study at any time. Reasons for terminating the study may include, but are not limited to, the following:
The incidence or severity of adverse events in this or other studies indicates a potential health hazard to patients
Patient enrollment is unsatisfactory
The Sponsor will notify the investigator if the Sponsor decides to discontinue the study.
5.6 Site Discontinuation
The Sponsor has the right to close a site at any time. Reasons for closing a site may include, but are not limited to, the following:
Excessively slow recruitment
Poor protocol adherence
Inaccurate or incomplete data recording
Non-compliance with the International Council for Harmonisation (ICH) guideline for Good Clinical Practice
No study activity (i.e., all patients have completed the study and all obligations have been fulfilled)
- Statistical considerations and sample size calculation A sample size of 64 patients is planned to provide at least an 80% power if 32 patients per treatment arm were included for an anticipated (improvement) responder rate of 68% in steroid and 95% in tocilizumab treated patients, with a two-tail significance of 0.05.
No patients stratification is planned The calculation is based on the available literature on the significant decrease of the after rituximab and steroid therapy and after tocilizumab and placebo.
64 patients with active GO will be enrolled and an interim analysis of results will be carried out after the first 32 patients (16 in arm 1 and 16 in arm 2) will reach the 24 week endpoint.
All enrolled patients receiving at least one dose of study medication and withdrawing from the study for any reason will be analyzed as non-responder in an ITT population for the 24 weeks primary endpoint.
Statistical Analysis: repeated measures ANOVA and Spearman or Pearson rank test for clinical activity and severity scores; Wilcoxon rank sum test to assess differences between treatment groups; chi-square for response and relapse rates.
An interim analysis of results will be carried out after the first 16 enrolled patients in both arms reach 24 week point), in order to eventually plan for another study perhaps employing s.c. TCZ .
Study design
- Primary purpose
- Treatment
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Single blind (care provider)
- Number of arms
- 2
- Model description
- 32 patients with active moderate-severe GO treated with i.v. tocilizumab; 32 patients with active moderate-severe GO treated with i.v. methylprednisolone.
| Arm | Type | Receives |
|---|---|---|
| Tocilizumab | Experimental | Drug: Tocilizumab 20 Mg/mL Intravenous Solution32 patients with active moderate-severe GO treated with i.v. tocilizumab; Tocilizumab weight adjusted, 8 mg/kg, 1 intravenous infusion every four weeks (+/- 72 hours) for 12 weeks |
| Methylprednisolone | Active comparator | Drug: MethylPREDNISolone Injectable Solution32 patients with active moderate-severe GO treated with i.v. methylprednisolone; Methylprednisolone, 500 mg infusion weekly (+/- 48 hours) for 6 weeks, followed by 250 mg infusion weekly (+/- 48 hours) for another 6 weeks |
Who may qualify
- Ages
- 18 to 75 years
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
Key inclusion criteria (7 listed)
- Written informed consent
- Male or female, 18-75 years old
- Women of childbearing potential should use effective contraception (abstinence or use contraceptive methods with a failure rate of <1%) throughout study and for a minimum of 6 months after study drug therapy and must have a negative serum pregnancy test at screening
- GO at first diagnosis or at the time of relapse of no more than 9 months' duration.
- Patients with moderate-severe active GO (clinical activity score 4/10 assessed at the end of the screening period) untreated or previously treated with i.v. steroids withdrawn for at least 3 months.
Key exclusion criteria (47 listed)
- Patients with sight-threatening Graves' orbitopathy (severe keratopathy, compression optic neuropathy and inflammatory optic neuropathy).
- Treatment with any biological therapy at any time.
- Previous oral or intravenous corticosteroid treatment in the last three months except for oral steroid not exceeding a cumulative dose of 1 gr.
- Plasmapheresis within 90 days prior to Day 0.
- Treatment with intravenous immunoglobulin.
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 |
|---|---|---|
| Tocilizumab 20 Mg/mL Intravenous SolutionAlso: ActemraIntravenous administration | Drug | Tocilizumab |
| MethylPREDNISolone Injectable SolutionAlso: SolumedrolIntravenous administration | Drug | Methylprednisolone |
Primary outcome
Desease inactivation
Time frame: at 12 and 24 weeks
Proportion of patients with CAS reduction of 3 points or disease inactivation (CAS<4) at 12 and 24 weeks
7 secondary outcomes
Desease improvement
Time frame: 24 weeks
Improvement of quality of life
Time frame: at 12 and 24 weeks
Incident of adverse events in tocilizumab therapy
Time frame: from 0 to 12 weeks
Immunological changes
Time frame: at 12, 24 and 36 and 48weeks of follow up
Desease relapse
Time frame: at 24-48 weeks
Residual desease
Time frame: at 48 weeks
Rehabilitative therapy
Time frame: at 48 weeks
Results and safety
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 23 Oct 2026.
- Background: PubMed 27099835Bartalena L, Baldeschi L, Boboridis K, Eckstein A, Kahaly GJ, Marcocci C, Perros P, Salvi M, Wiersinga WM; European Group on Graves' Orbitopathy (EUGOGO). The 2016 European Thyroid Association/European Group on Graves' Orbitopathy Guidelines for the Management of Graves' Orbitopathy. Eur Thyroid J. 2016 Mar;5(1):9-26. doi: 10.1159/000443828. Epub 2016 Mar 2.
- Background: PubMed 27032693Campi I, Vannucchi G, Salvi M. THERAPY OF ENDOCRINE DISEASE: Endocrine dilemma: management of Graves' orbitopathy. Eur J Endocrinol. 2016 Sep;175(3):R117-33. doi: 10.1530/EJE-15-1164. Epub 2016 Mar 31.
- Background: PubMed 26361263Salvi M, Campi I. Medical Treatment of Graves' Orbitopathy. Horm Metab Res. 2015 Sep;47(10):779-88. doi: 10.1055/s-0035-1554721. Epub 2015 Sep 11.
- Background: PubMed 26214745Campi I, Tosi D, Rossi S, Vannucchi G, Covelli D, Colombo F, Trombetta E, Porretti L, Vicentini L, Cantoni G, Curro N, Beck-Peccoz P, Bulfamante G, Salvi M. B Cell Activating Factor (BAFF) and BAFF Receptor Expression in Autoimmune and Nonautoimmune Thyroid Diseases. Thyroid. 2015 Sep;25(9):1043-9. doi: 10.1089/thy.2015.0029. Epub 2015 Aug 13.
- Background: PubMed 25494967Salvi M, Vannucchi G, Curro N, Campi I, Covelli D, Dazzi D, Simonetta S, Guastella C, Pignataro L, Avignone S, Beck-Peccoz P. Efficacy of B-cell targeted therapy with rituximab in patients with active moderate to severe Graves' orbitopathy: a randomized controlled study. J Clin Endocrinol Metab. 2015 Feb;100(2):422-31. doi: 10.1210/jc.2014-3014. Epub 2014 Dec 15.
- Background: PubMed 25105999Salvi M. Immunotherapy for Graves' ophthalmopathy. Curr Opin Endocrinol Diabetes Obes. 2014 Oct;21(5):409-14. doi: 10.1097/MED.0000000000000097.
- Background: PubMed 24417307Curro N, Covelli D, Vannucchi G, Campi I, Pirola G, Simonetta S, Dazzi D, Guastella C, Pignataro L, Beck-Peccoz P, Ratiglia R, Salvi M. Therapeutic outcomes of high-dose intravenous steroids in the treatment of dysthyroid optic neuropathy. Thyroid. 2014 May;24(5):897-905. doi: 10.1089/thy.2013.0445. Epub 2014 Mar 6.
- Background: PubMed 24128430Vannucchi G, Covelli D, Campi I, Origo D, Curro N, Cirello V, Dazzi D, Beck-Peccoz P, Salvi M. The therapeutic outcome to intravenous steroid therapy for active Graves' orbitopathy is influenced by the time of response but not polymorphisms of the glucocorticoid receptor. Eur J Endocrinol. 2013 Nov 22;170(1):55-61. doi: 10.1530/EJE-13-0611. Print 2014 Jan.
- Background: PubMed 24009135Salvi M, Vannucchi G, Beck-Peccoz P. Potential utility of rituximab for Graves' orbitopathy. J Clin Endocrinol Metab. 2013 Nov;98(11):4291-9. doi: 10.1210/jc.2013-1804. Epub 2013 Sep 5.
- Background: PubMed 22399512Vannucchi G, Covelli D, Curro N, Dazzi D, Maffini A, Campi I, Bonara P, Guastella C, Pignataro L, Ratiglia R, Beck-Peccoz P, Salvi M. Serum BAFF concentrations in patients with Graves' disease and orbitopathy before and after immunosuppressive therapy. J Clin Endocrinol Metab. 2012 May;97(5):E755-9. doi: 10.1210/jc.2011-2614. Epub 2012 Mar 7.
- Background: PubMed 22232486Salvi M, Vannucchi G, Curro N, Introna M, Rossi S, Bonara P, Covelli D, Dazzi D, Guastella C, Pignataro L, Ratiglia R, Golay J, Beck-Peccoz P. Small dose of rituximab for graves orbitopathy: new insights into the mechanism of action. Arch Ophthalmol. 2012 Jan;130(1):122-4. doi: 10.1001/archopthalmol.2011.1215. No abstract available.
- Background: PubMed 17218723Salvi M, Vannucchi G, Campi I, Curro N, Dazzi D, Simonetta S, Bonara P, Rossi S, Sina C, Guastella C, Ratiglia R, Beck-Peccoz P. Treatment of Graves' disease and associated ophthalmopathy with the anti-CD20 monoclonal antibody rituximab: an open study. Eur J Endocrinol. 2007 Jan;156(1):33-40. doi: 10.1530/eje.1.02325.
- 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.
Mario MS Salvi, MD principal investigator
Fondazione IRCCS "Cà Granda" Ospedale Maggiore Policlinico
4 sites in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A Phase 2 study testing Tocilizumab 20 Mg/mL Intravenous Solution and MethylPREDNISolone Injectable Solution in people with Graves Ophthalmopathy, run by Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico at 4 sites in Italy.
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 7 inclusion and 47 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: finished, as of the sponsor's last update on 23 Oct 2026. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 4 sites in Italy. 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.
What does this phase mean?
Phase 2 studies give the treatment to a larger group to see whether it has the intended effect and to keep checking safety.
Not every study follows the same path, and some studies (observational studies, device studies) have no phase.
Are results available for this study?
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
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?
Desease inactivation (time frame: at 12 and 24 weeks). 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 NCT04876534, which also lists 21 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 23 Oct 2026.