Immunomodulatory Treatment of Interstitial Lung Disease Associated With Surfactant Related Gene Variants

Overview

Scientific justification : Variants in surfactant-related genes (SRG) explain approximately 6% of familial pulmonary fibrosis (FPF). The pathophysiology is unknown and seems to involve endoplasmic reticulum stress in type 2 alveolar epithelial cells. Variable improvement in the prognosis of childhood and adult interstitial lung disease (ILD) associated with a variant of a SRG, initially reported to be lethal within months of diagnosis, has been observed since the consensual use of prednisone, azithromycin and hydroxychloroquine targeting endoplasmic reticulum stress, without demonstration of the efficacy of any of these treatments alone or in combination. The investigators hypothesize that a treatment combining prednisone, azithromycin and hydroxychloroquine is safe and could improve the prognosis of adult patients with ILD associated with SRG variant. Main objective and primary endpoint : Main objective: Evaluate the efficacy of triple immunomodulatory therapy (prednisone, azithromycin and hydroxychloroquine) for 12 months in patients with ILD associated with a variant of a surfactant-related gene. Primary endpoint: Difference in forced vital capacity decline between the 2 groups at one year. Secondary objectives and endpoints : Secondary objectives: 1. tolerance of the triple therapy, 2. correlation between the respiratory, radiological and clinical functional response, 3. quality of life of the patients, 4. overall survival, transplant-free survival, exacerbation free-survival, hospitalization-free survival Secondary endpoints: 1. Clinical and biological tolerance (occurrence of an adverse effect during treatment), ECG (at 3, 6, 9, 12 months after randomization) (only HCQ or AZI patients) and ophthalmological (at one year after randomization) 2. Thoracic CT scan and PFT at 6 months and one year after randomization 3. Quality of life questionnaire (EORTC QLQ-C30, v3.0) at 3 months, 6 months, 9 months and one year after randomization, 4. Collection of vital status, lung transplantation, hospitalization for pulmonary and non-pulmonary causes and episodes of exacerbation at each visit until the end of follow-up 12 months after randomization. Design of the study : Multicenter, randomized, controlled, two-arm, parallel, open-label superiority study comparing triple immunomodulatory therapy (prednisone, azithromycin, and hydroxychloroquine) to standard of care Category : Category 2 Population of study participants: Patients aged over 18 years with ILD and SRG variant Number of participants included : 30 Design of the study : Multicenter, randomized, controlled, two-arm, parallel, open-label superiority study comparing triple immunomodulatory therapy (prednisone, azithromycin, and hydroxychloroquine) to standard of care.

Interventions

• Drug Azithromycin 250 mg x3/week (3 tablets/week)
  Route of administration: oral route Duration of treatment: 12 months Market authorization: yes Use in their market authorization indication: no
• Drug Prednisone 10 mg/day
  Route of administration: oral route Duration of treatment: 12 months Market authorization: yes Use in their market authorization indication: no
• Drug Hydroxychloroquine 400 mg/day
  Route of administration: oral route Duration of treatment: 12 months Market authorization: yes Use in their market authorization indication: no
• Drug Active Comparator: Standard of care
  Standard of care: any symptomatic treatment to interstitial lung disease. No other experimental or off-label treatment (such as ivacaftor) will be allowed during the study.

Primary outcome measures

• Difference in forced vital capacity decline between the 2 groups at one year. [Time frame: 12 Months]

Secondary outcome measures (12)

• tolerance of the triple therapy [Time frame: 12 months]
• correlation between the respiratory, radiological and clinical functional response, [Time frame: 12 months]
• Quality of life of the patients [Time frame: 12 months]
• tolerance of the triple therapy [Time frame: 6 months]
• tolerance of the triple therapy [Time frame: 3 months]
• correlation between the respiratory, radiological and clinical functional response, [Time frame: 6 months]
• Quality of life of the patients [Time frame: 9 months]
• Quality of life of the patients [Time frame: 6 months]
• Quality of life of the patients [Time frame: 3 months]
• Overall survival [Time frame: 12 months]
• Transplant-free survival [Time frame: 12 months]
• Exacerbation free-survival [Time frame: 12 months]

Eligibility criteria

Inclusion criteria

• Age ≥ 18 years and <80 years
• Carrier of a variant classified as pathogenic or probably pathogenic or considered as eligible by the genetic multidisciplinary discussion in SFTPA1, SFTPA2, SFTPC, NKX2-1, SFTPB or two variants classified as pathogenic or probably pathogenic or considered as eligible by the genetic multidisciplinary discussion in ABCA3 or SFTPB
• ILD whatever the pattern corresponding to a volume > 10% of the total lung on a CT scan of less than 2 years

Exclusion criteria

• Contraindication to azithromycin and hydroxychloroquine and prednisone
• Pregnancy and breastfeeding
• Enrolment to another interventional study (clinical trial on medicinal product, medical device and interventional research involving human participants not concerning health product)
• Subject deprived of liberty or subject under legal protection measure
• No affiliation to any health insurance system
• Refusal to participate to the study

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Randomized

Model

Parallel assignment

Masking

Open label

Primary purpose

Treatment

Study locations

Center list to be confirmed — check the primary protocol.

Identifiers

NCT: NCT07443436 · APHP251230

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗