TNF and IL23 Blocking Agents Gene Expression Ratios in the Psoriatic Arthritis Synovium_(TIGERS) Study
TNF and IL23 Blocking Agents Gene Expression Ratios in the Psoriatic Arthritis Synovium_(TIGERS) Study
This study compare the genomics profiles in synovial biopsies obtained prior to, and 24 weeks
 after a biologic disease modifying anti-rheumatic drugs (DMARDs)(Adalimumab, Ustekinumab,
 Guselkumab) in patients with active psoriatic arthritis despite a treatment with a
 conventional synthetic DMARDs (such as methotrexate).
1. STUDY SYNOPSIS 1.1 Rationale Psoriatic arthritis (PsA) is a chronic inflammatory
 disease, leading to impaired function, reduced quality of life, comorbidities and
 increased mortality. Fortunately, improved knowledge about disease mechanisms catalyzed
 rapid development of effective targeted therapies for this disease. PsA is a clinically
 heterogenous disease. Connections between clinical manifestations, disease activity,
 disease severity and entheseal/synovial molecular patterns are still not understood. In
 addition, although many treatments targeting different molecules or cytokines are now
 available, clinicians are still facing difficulties in the treatment choice, owing to
 the lack of reliable markers improving patients stratification. In the present project,
 we want to take advantage of our expertise in the field to compare global molecular
 profiles up- or down-regulated in synovitis of patients with PsA resistant to
 conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs), before and
 after administration of targeted therapies, in order to identify molecular markers
 associated with response to therapy. This may allow us to move further towards precision
 medicine.

 1.2 Aim of the study We intend to evaluate global transcriptomic effects of ustekinumab
 (IL-12/IL-23/p40 blocker) and guselkumab (IL-23/p19 blocker) in synovial biopsies from
 csDMARD-resistant, biologic-naive patients with PsA, obtained prior to and 24 weeks
 after initiation of therapy. In parallel, synovial biopsies will be obtained before and
 after initiation of adalimumab (a widely used TNFα blocker) to evaluate the different
 molecular pathways affected by the different drugs. In order to deliver, this project
 will be based on the use of an Affymetrix platform (GeneChip HGU133 Plus2.0 chips). We
 and others amply demonstrated the power of this analytical approach in identifying
 synovial pathways associated with disease activity and response to therapy in the past
 (resulting in the development of a diagnostic and theranostic commercial kit). However,
 the material collected throughout the study will be a unique opportunity to carry out a
 more exploratory single cell RNASeq procedure on our samples, thereby potentially
 unravelling molecular effects of therapies in specific cell populations. Identification
 of the synovial effects of those treatments in psoriatic arthritis will be a step
 forward in understanding not only the mode of action of the drug at the site of
 inflammation, but also in the identification of molecular patterns associated with good
 response to therapy. The main advantage of our approach compared to other biomarker
 studies, is that we use synovial material as such, and not peripheral blood, which is a
 more remote location in terms of cellular targets of the drug. This project takes
 advantage of our strong experience in the field of molecular profiling of synovial
 biopsies, and evaluation of responses to biological agents. Key to the success of our
 translational approach is the association of reliable molecular techniques with a
 well-validated clinical evaluation of disease activity and response to therapy, using a
 panel of clinical, biological and imaging techniques.

 1.3 Study design Dual centre, 24-week open-label randomised study in subjects with
 clinically active peripheral PsA receiving treatment with the relevant drugs. Synovial
 biopsies will be obtained from patients before and after 24 weeks of treatment with the
 different drugs.

 1.4 Study population DMARD-resistant, biological naive patients with a diagnosis of
 psoriatic arthritis according to the CASPAR criteria with at least one swollen joint
 (either small or big joint) who are planning to receive treatment with one of the
 targeted drugs. In total, 36 patients will be included. Patients will be randomized
 1:1:1 between: Group 1 (n=12): ustekinumab 45 mg (or 90 mg for patients > 100 kg)
 subcutaneously at baseline (W0), 4 weeks later (W4), and every 12 weeks until week 24
 (i.e. W0, W4, and W16). Group 2 (n=12): guselkumab 100 mg subcutaneously (regardless of
 the weight of the patient) at weeks 0 and 4, followed by a maintenance dose every 8
 weeks through week 24 (i.e. W0, W4, W12 and W20). Group 3 (n=12): adalimumab 40 mg
 (regardless of the weight of the patient), subcutaneously every other week, starting
 from the baseline until week 24 (i.e.W0, W2, W4, W6, W8, W10, W12, W14, W16, W18, W20
 and W22).

 1.5 Synovial biopsy procedure Synovial biopsies will be harvested either by ultrasound
 guided biopsy (USGB) for small joints (wrist, MCP, PIP), or large joints (elbow, knee,
 ankle) or by needle-arthroscopy procedure (NAP) for large joints such as the knee.

 In the case of large joint involvement, the same joint will be biopsied at W0 and W24.
 Based on our experience, repeating the procedure in a large joint, even if it is not
 swollen, is readily achieved by NAP.

 In the case of small joint involvement, the choice of the joint to biopsy will be based
 on ultrasound (US) examination. An US assessment with a score of more than 2 on Grey
 Scale/Power Doppler (see data on US scoring below in appendices) increases the amount of
 gradable synovial tissue after the procedure, and the quality of the RNA extracted from
 the synovial tissue.

 If the small joint biopsied at W0 is not clinically affected and/or has low US Grey
 Scale/Power Doppler scores lower by W24, another small joint will be considered for the
 biopsy if clinically affected. However, At W24 the procedure will be done preferably in
 the same joint, in order to avoid bias or too much heterogeneity in the analyses of the
 data.

 A window of no more than 15 days is allowed around the baseline (W0) and W24 visit.

 1.6 Main study parameters/endpoints

 Primary endpoints:

 -  identification of molecular pathways targeted by ustekinumab, guselkumab versus
 TNF-blockade in synovial biopsies (total and single cells) from PsA patients with
 active disease despite a csDMARDs, obtained prior to and 24 weeks after initiation
 of therapy.

 Secondary endpoints:

 - clinical response at W24, by using DAS-44 or ACR20/50/70 response criteria.

 - identification of candidate synovial markers/pathways associated with response to
 ustekinumab, guselkumab, and anti-TNFalpha therapy in PsA by correlating molecular
 signals at baseline with the clinical response observed at week 24.

 - composite analyses of the association between molecular changes induced by anti-IL23,
 anti-IL23/12 and anti-TNF in the synovium, and core or non-core (clinical, biological,
 imaging) variables informative about response to therapy.

 1.7 Clinical Assessment of disease activity Disease activity will be evaluated at
 screening, baseline (week 0), week 6, week 12, week 18, and week 24. Response to therapy
 will be evaluated at the same time using validated clinical measures of joint, enthesis
 and skin disease activity and global health assessment questionnaires.

 1.8 Laboratory Analyses Biochemical analysis will be performed at each visit (W0, W6,
 W12, W18, W24). This include C-reactive protein, liver enzymes (GOT, GPT, GGT, Alk.
 Phosphatase), renal function (urea, creatinin, glomerular filtration), hemogram,
 glycemia, lipid's profile (total cholesterol, LDL, HDL, Triglycerids).

 HLA-B27 and viral infection (hepatitis B and C, HIV) status will be checked at the
 screening or baseline, as well as skin PPD test or blood quantiferon-TB GOLD test.

 Blood samples (Serum, plasma, EDTA, PaxGene tubes Peripheral blood mononuclear cell
 (PBMC) analysis) will also be taken and or stored for further analysis 1.9 Synovial
 tissue analyses Affymetrix Platform (will be performed by UCL_SSS/IREC/RUMA and CUSL
 Site team for both sites) (at least 4 biopsy fragments/individual) RNA will be extracted
 from the material (at least 4 pieces) and used for hybridization of high-density
 oligonucleotide-spotted microarrays (Genechip U133 Plus 2.0 slides). Clustering and
 statistical analyses will be performed using Genespring® software in order to identify
 transcripts regulated by the administration of ustekinumab, guselkumab and TNF-blockade,
 and to identify transcripts associated with response to either of these drugs. Web-based
 GO and KEGG pathways mining tools will be used in order to identify potential groups of
 genes belonging to the same family.

 Single-cell RNA sequencing (will be performed by UZGhent Site team for both sites) (2 to
 4 biopsies) If there are enough biopsies obtained, single cell analyses will be
 performed by UZG team. Single-cell RNA sequencing has emerged as an indispensable tool
 to dissect the cellular heterogeneity and decompose tissues into cell types and/or cell
 states, which offers enormous potential for de novo discovery. Single-cell
 transcriptomic atlases provide unprecedented resolution to reveal complex cellular
 events and deepen our understanding of biological systems.

 Histology / Immunohistochemistry (2 to 4 biopsies will be performed by CUSL Site) If
 there is enough tissue, part of the samples (2 biopsies) will be used for pathological
 examinations and standard immunohistochemistry (CD3, CD4, CD8, CD15, CD20, CD68 and
 CD138 immunostainings). Additional stains will be performed in order to confirm the
 transcriptomic results, or based on pre-established questions (Th1, Th17-specific
 markers).

 1.10 Imaging

 -  Chest x-ray A posterior-anterior view chest x-ray will be obtained locally at
 screening, unless results from a chest x-ray obtained no more than 3 months prior
 to the screening (or baseline) according to the general recommendations related to
 the use of biologics.

 The chest x-ray will be reviewed by the investigator or designee to exclude patients
 with active TB infection.

 Investigators should follow local guidelines for monitoring patients for TB if a patient
 is at high risk for acquiring TB or reactivation of latent TB

 • Ultrasound: In parallel to clinical assessment, musculoskeletal ultrasound (US) will
 be performed at baseline (W0), W6, W12, and W24 to evaluate disease activity, with a
 specific focus on joints and enthesis.

 • Magnetic resonance imaging: Whole-body magnetic resonance imaging (WBMRI) evaluation
 will be performed at two time points, prior to initiation of therapy and 24 weeks after
 treatment onset, as an additional assessment tool of disease activity. Patients with any
 contraindications to MRI (e.g. pacemakers, aneurysm clips, artificial heart valves, ear
 implants, metal fragments, foreign objects in the eyes, skin or body or severe
 claustrophobia) will not performed this procedure MRI scans will be acquired using
 routine scanning techniques appropriate for measurement of inflammation, bone marrow
 edema and erosion. The images will be analyzed locally. The readings of the scan will be
 performed locally.

 1.11 Study duration Study duration: 2 to 3 years

 • Screening period will start: december 2019

 • Estimated first patient inclusion (FPI): january 2020

 • Estimated last patient inclusion (LPI): june 2022

 • Estimated last patient last visit (LPLV): december 2022

 • End of Study : march 2023

 -  Publication summary: July 2023

 -  Final report: sept 2023
Inclusion Criteria:

 Patients eligible for inclusion in this study have to fulfil all of the following criteria:

 1. Patient must be able to understand and communicate with the investigator and comply
 with the requirements of the study and must give a written, signed and dated informed
 consent before any study assessment is performed.

 2. Male or non-pregnant, non-nursing female patients at least 18 years of age. Before
 randomization, a woman of childbearing potential must be on a highly effective method
 of birth control consistent with local regulations regarding the use of birth control
 methods for subjects participating in clinical studies: eg, established use of oral,
 injected or implanted hormonal methods of contraception associated with inhibition of
 ovulation; placement of an intrauterine device (IUD) or intrauterine system (IUS);
 male partner sterilization (the vasectomized partner should be the sole partner for
 that subject); true abstinence (when this is in line with the preferred and usual
 lifestyle of the subject).

 A woman of childbearing potential must have a negative serum (β-human chorionic
 gonadotropin [β-hCG]) at baseline before randomization. A woman must agree not to
 donate ovocytes for the purposes of assisted reproduction during the study and for 3
 months after receiving the last dose of study agent.

 Note: If the childbearing potential changes after start of the study (eg, woman who is
 not heterosexually active becomes active, premenarchal woman experiences menarche)
 that woman must begin a highly effective method of birth control, as described above.

 A man who is sexually active with a woman of childbearing potential and has not had a
 vasectomy must agree to use a barrier method of birth control eg, either condom with
 spermicidal foam/gel/film/cream/suppository or partner with occlusive cap (diaphragm
 or cervical/vault caps) with spermicidal foam/gel/film/cream/suppository, and all men
 must also not donate sperm during the study and for 3 months after receiving the last
 dose of study agent

 The method of birth control will be clearly documented in patient file.

 3. Patients with active PsA according to CASPAR criteria for ≥6 months, despite ≥3 months
 of csDMARD therapy, and ≥4 weeks of non-steroidal anti- inflammatory drugs (NSAIDs)
 therapy.

 4. At least 1 swollen joint at screening or baseline (despite csDMARD therapy) with
 ability to perform a synovial biopsy at W0.

 5. Patients with newly documented latent TB are eligible provided initiation of
 appropriate treatment.

 6. Concomitant MTX or SSZ is permitted if started ≥3 months prior to study start and at a
 stable dose (≤25 mg/week for MTX and ≤ 3 g/day for SSZ) for ≥4 weeks.

 7. Patients on MTX must be on stable folic acid supplementation before randomization.

 8. Concomitant NSAIDs and oral corticosteroids (≤10 mg prednisone/day) are permitted if
 stable for at least 2 weeks.

 9. Allowed concomitant medications are to remain stable through week 24.

 10. Patients cannot have previously received any biologic agent

 11. DMARDs other than MTX or sulfasalazine (SSZ) must be interrupted. DMARDs other than
 MTX are not allowed within 4 weeks prior to or during trial participation. A washout
 period needs to be considered. (8 weeks for leflunomide).

 12. At least one joint (small or large) to biopsy in order to get synovial tissue. Small
 joints must have an US grey-scale score > 2 on Doppler

 Exclusion Criteria:

 Patients fulfilling any of the following criteria are not eligible for inclusion in this
 study.

 1. Contraindications for needle-arthroscopy such as joint replacement (in the affected
 knee or ankle joint) or anticoagulation.

 2. Use of any investigational drug and/or devices within 4 weeks of baseline, or a period
 of 5 half-lives of the investigational drug, whichever is longer.

 3. Conditions/situations such as:

 1. Patients with conditions/concomitant diseases making them non evaluable for the
 primary endpoint

 2. Impossibility to meet specific protocol requirements (e.g. blood sampling)

 3. Patient is the Investigator or any sub-investigator, research assistant,
 pharmacist, study coordinator, other staff or relative thereof directly involved
 in the conduct of the protocol

 4. Uncooperative or any condition that could make the patient potentially
 noncompliant to the study procedures

 4. Any therapy by intra-articular injections (e.g. corticosteroid) within 4 weeks before
 baseline.

 5. Any intramuscular corticosteroid injection within 2 weeks before baseline.

 6. Prior treatment with a biologic agent.

 7. A history of active tuberculosis (TB).