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Rituximab plus leflunomide in rheumatoid arthritis: a randomized, placebo-controlled, investigator-initiated clinical trial (AMARA study)

Frank Behrens, Michaela Koehm, Tanja Rossmanith, Rieke Alten, Martin Aringer, Marina Backhaus, Gerd R Burmester, Eugen Feist, Eva Herrmann, Herbert Kellner, Klaus Krueger, Annette Lehn, Ulf Müller-Ladner, Andrea Rubbert-Roth, Hans-Peter Tony, Siegfried Wassenberg & Harald Burkhardt

abstract

OBJECTIVE
To investigate the efficacy and safety of rituximab + LEF in patients with RA.

METHODS
In this investigator-initiated, randomized, double-blind, placebo-controlled phase 3 trial, patients with an inadequate response to LEF who had failed one or more DMARD were randomly assigned 2:1 to i.v. rituximab 1000 mg or placebo on day 1 and 15 plus ongoing oral LEF. The primary efficacy outcome was the difference between ≥50% improvement in ACR criteria (ACR50 response) rates at week 24 (P ≤ 0.025). Secondary endpoints included ACR20/70 responses, ACR50 responses at earlier timepoints and adverse event (AE) rates. The planned sample size was not achieved due to events beyond the investigators' control.

RESULTS
Between 13 August 2010 and 28 January 2015, 140 patients received rituximab (n = 93) or placebo (n = 47) plus ongoing LEF. Rituximab + LEF resulted in an increase in the ACR50 response rate that was significant at week 16 (32 vs 15%; P = 0.020), but not week 24 (27 vs 15%; P = 0.081), the primary endpoint. Significant differences favouring the rituximab + LEF arm were observed in some secondary endpoints, including ACR20 rates from weeks 12 to 24. The rituximab and placebo arms had similar AE rates (71 vs 70%), but the rituximab arm had a higher rate of serious AEs (SAEs 20 vs 2%), primarily infections and musculoskeletal disorders.

CONCLUSION
The primary endpoint was not reached, but rituximab + LEF demonstrated clinical benefits vs LEF in secondary endpoints. Although generally well tolerated, the combination was associated with additional SAEs and requires monitoring.

TRIAL REGISTRATION
EudraCT: 2009-015950-39; ClinicalTrials.gov: NCT01244958.
   
citation Behrens F, Koehm M, Rossmanith T, Alten R, Aringer M, Backhaus M, Burmester G R, Feist E, Herrmann E, Kellner H, Krueger K, Lehn A, Müller-Ladner U, Rubbert-Roth A, Tony H P, Wassenberg S, Burkhardt H. Rituximab plus leflunomide in rheumatoid arthritis: a randomized, placebo-controlled, investigator-initiated clinical trial (AMARA study). Rheumatology (Oxford) 2021; 60:5318-5328.
   
type journal paper/review (English)
date of publishing 2021
journal title Rheumatology (Oxford) (60/11)
ISSN electronic 1462-0332
pages 5318-5328
PubMed 33738492
DOI 10.1093/rheumatology/keab153