Study design
The ILIFE trial is a three-arm, multicenter, open-label, randomized controlled trial (RCT) to assess efficacy of low-dose corticosteroids and HCQ combined with anticoagulation in treating UCTD women with recurrent pregnancy loss.
Patients will be enrolled at rheumatology outpatient clinics in six university-affiliated, tertiary hospitals in China, including Shanghai Renji Hospital, the First Affiliated Hospital of Anhui Medical University, China-Japan Union Hospital of Jilin University, the Affiliated Wuxi No.2 People’s Hospital of Nanjing Medical University, Jiangsu Province Hospital and Xiangya Hospital of Central South University. The study design is presented in the flowchart in Fig. 1. Standard protocol items: recommendations for interventional trials (SPIRIT) are provided as an additional file 1. This study was approved by institutional review boards (IRB) of study sites.
Recruitment
The study population consists of UCTD women who had experienced at least two miscarriages and try to conceive. Rheumatologists in each study site will check inclusion and exclusion criteria of UCTD women. A research assistant will present the study information during recruitment. Eligible patients who provide informed consents will be enrolled to the trial.
The anticipated duration of recruitment is 2 years, and the duration of participation of each patient is about 2 years.
Inclusion criteria
Women who meet the following inclusion criteria will be eligible to participate in the study:
- At reproductive age (20-40 years old).
- Trying to conceive.
- Diagnosed with UCTD[2]: at least one symptoms or signs suggesting CTD and with at least one presence of auto-antibodies, including antinuclear antibody (ANA), anti-SSA antibody, while not fulfilling any classification criteria of a defined CTD.
- Diagnosed with RSA[42]: two or more failed pregnancies of unknown origin in all trimesters.
- Providing written informed consent.
Exclusion criteria
Women who meet any of the following criteria will be excluded from the study:
- Any known etiology of previous pregnancy loss:
- Diagnosis of antiphospholipid antibody syndrome.
- Known paternal, maternal or embryo chromosome abnormality.
- Maternal endocrine dysfunction: corpus luteal insufficiency; polycystic ovarian syndrome; premature ovarian failure (follicle stimulating hormone, FSH ≥20uU/L in follicular phase); hyperprolactinemia; thyroid disease; diabetes mellitus; other hypothalamic–pituitary–adrenal axis abnormality.
- Maternal anatomical abnormality: uterine malformation; Asherman syndrome; cervical incompetence; uterine fibrosis more than 5 cm.
- Vaginal infection.
- Any known severe cardiac, hepatic, renal, hematological or endocrinal diseases:
- Alanine transaminase (ALT) or aspartate transaminase (AST) more than twice the upper limit of normal.
- Clearance of creatinine less than 30mL/min.
- Leucocytes less than 2.5*10^9/L, or Hemoglobine less than 85g/L, or Platelet less than 50~10^9/L.
- Active viral hepatitis including hepatitis B virus (HBV), hepatitis C virus (HCV).
- Active infection including V aricella-zostervirus(VZV), human immunodeficiency virus (HIV), syphilis or tuberculosis.
- Allergic to prednisone, hydroxychloroquine, LMWH or aspirin.
- Disease history as follows:
- Past history of digestive ulcers or upper gastrointestinal hemorrhage.
- Past history of malignancy.
- Past history of epilepsia or psychotic disorders.
- Woman unable to consent or impossible to follow-up.
Randomization and blinding
The primary objective of this trial is to investigate the superiority of low-dose corticosteroids and HCQ combined with anticoagulation compared with anti-coagulant only in UCTD women with RSA. A third arm of using hydroxychloroquine combined with anticoagulant for a secondary comparison only. It’s an open-label trial. After obtaining the written informed consent, eligible patients will be randomized to one of the three treatment arms with a ratio of 1:1:1 stratified by site. Randomized numbers will be generated through SAS software at the trial methods centre located in Shanghai Renji Hospital. A special designed sealed opaque two-couplet random allocation envelope will be used for the randomization and allocation. The first couplet is to collect the enroll information and the second couplet is to show the allocation information. The content of the first couplet can be completely copied to the second couplet. Each time a new patient is enrolled in the study, a new envelope will be opened in order. Once the envelope is opened, it can’t be resealed.
Treatments
Included patients are randomized to three treatment groups: 1) low-dose prednisone (10mg once daily orally), HCQ (the maximal tolerance dose ranges from 100mg to 400mg daily orally), and anticoagulants using low-dose aspirin (50mg once daily orally) and subcutaneously administered LMWH once daily with preventive dose (enoxaparin 40mg or dalteparin 5000IU or nadroparin calcium 4100U); 2) HCQ (the maximal tolerance dose ranges from 100mg to 400mg daily orally), and the same anticoagulant treatments as in the first group; and 3) the anticoagulant treatments only. Treatments are initiated before conception (recommended 3-6 months) and stopped at 6 weeks’ post-gestation or miscarriage or after 1 years of treatment in the absence of pregnancy. Supplements such as folic acid, calcium tablet and vitamins are allowed throughout pregnancy.
Assessments and data collection
The assessments will be conducted at the screening and preparation phases and then routinely throughout the trial. The screening phase will last for 4 weeks. General profiles including age, height, weight, ethnicity, occupation, obstetric and rheumatology histories, medication uses, allergy and antecedents will be recorded during the screening phase. Following the screening phase is the 1 year pre-conception phase. If participants are not pregnant within 1 year, the treatment and their participation will be terminated. Once pregnancy is confirmed, the pregnancy assessments will start and the index time is set to week 0. Pregnant women will be followed once every 4 weeks in the next 42 weeks gestation period. The last visit will be conducted at 6 weeks after delivery. The assessment will be terminated when spontaneous pregnancy loss or childbirth takes place. Children’s observations will last for one year after the end of the study, including vision, hearing and growth parameters. The schedules for assessments and data collection are showed in Fig. 2. Data will be collected in paper case report forms (CRFs) stored at a secure place and double entered into the electronic trial database.
Outcome measures
Primary outcome
The primary outcome is the rate of live births after at least 26 completed weeks of gestation.
Secondary outcomes
The secondary outcomes include adverse pregnancy outcomes and progression of UCTDs:
- The rate of conception. The rate of miscarriage (before 24 weeks).
- The rate of stillbirth (intrauterine death at≥24 weeks).
- Premature birth (live birth between 28 and 37 weeks of gestations).
- Concerning the child: intrauterine growth retardation, gestational age and weight at birth, survival at 28 days, safety data at 42 days of life and congenital abnormality (congenital heart conduction block, neonatal lupus or malformation).
- Concerning the mother: eclampsia (new-onset hypertension after 20 weeks of gestation, with or without proteinuria more than 300mg/24h, obstetric bleeding (antepartum haemorrhage, postpartum haemorrhage), and placental abnormalities (placenta praevia), with or without any organ damage with seizures), infection(infections of upper and lower respiratory tract, gestational source, urinary tract and skin), gestational diabetes mellitus (diabetes diagnosed in the second or third trimester of pregnancy).
- Concerning the UCTD: activity of UCTD (the presence of new clinical symptoms like arthritis, rash, Reynolds phenomenon, proteinuria with or without serological activity, which requires a new treatment or an increase of current dose or even hospitalization due to disease activity), progression of UCTD ( evolution to SLE, APS, Sjogren's syndrome, systemic sclerosis and other defined CTD diagnosed by classification criteria of American College of Rheumatology).
Sample size
There is very limited evidence on the spontaneous pregnancy loss in pregnancies of women with UCTD and the reported risk rates for RSA varied substantially across studies. The live-birth rate of a randomized trial enrolling 364 women with a history of unexplained recurrent miscarriage was 69.1% in the group receiving aspirin plus nadroparin[43]. In another cohort study of women with positive aPL, HCQ can improve the live birth rate from 57% to 67%[38]. A double-blind placebo randomized control trial involving 160 patients with unexplained recurrent miscarriage showed that the addition of prednisolone to heparin and aspirin might be beneficial, with 70.3 % of women in the prednisolone group having successful pregnancy outcome versus 9.2 % in the placebo group[30]. Data from 68 pregnancies in our department showed that the live birth rate was 97.1% in UCTD women with RSA treated by hydroxychloroquine plus low-dose prednisone combined with anticoagulation.
Our primary comparison is between the combined use of prednisone, HCQ and anticoagulant with the anticoagulant only. Based on our pilot and limited published data, we hypothesize that the proportion of live birth rates with the treatment strategy using prednisone, HCQ, aspirin and LMWH is 85% vs 70% for anticoagulant only. We need to enroll 363 women (121 in each group and for the third arm as well) to allow us to detect the difference in spontaneous pregnancy loss between the treatment groups with a power of 0.8 at a two-sided P value of 0.05. Since not all women would get pregnant during the trial, we planned to include about 426 participants (142 in each group) on the assumption of 90% of pregnant rate within 1 year and 5% loss to follow-up[44].
Data analysis
Our primary comparison is between the combined use of prednisone, HCQ and anticoagulant with the anticoagulant only. All data will be analyzed according to the intention-to-treat approach in which all randomized patients are included and supplemented by per-protocol analysis. A secondary comparison will be made between hydroxychloroquine combined with low-dose prednisone and anticoagulation and hydroxychloroquine combined with anticoagulant. A sensitivity analysis using multiple imputation will assess the robustness of the results to variation in the missing data assumptions. For categorical data, frequencies and percentages will be presented. Continuous data will be presented as the mean and standard deviation or median and interquartile range. The primary outcome will be summarized as the proportion of live birth in each group. Occurrences of the primary and secondary endpoints are compared between the treatment groups. Results are presented as risk ratios with corresponding 95% confidence intervals. A two-tailed P< 0.05 is considered statistically significant.
Trial management
A steering committee comprised of local principal investigator at each participating hospital will manage the trial. Screening and recruitment will be reviewed regularly at steering committee meetings; protocol deviations (e.g. late administration) will be distinguished from protocol violations (e.g., missed doses). Enrollment or adherence barriers will be addressed by implementing improvement strategies. Relevant clinical and laboratory data submitted to the steering committee will be checked for the completeness and accuracy. All investigators will undertake a standardized training for study procedures, data collection and adverse event reporting. The plans to promote participant retention and complete follow-up include: giving specific follow-up schedule and obtaining at least two phone contacts to ensure communication. The research assistant will contact participants by telephone regularly to improve adherence to medication and assessments. To maintain confidentiality, CRFs and other records will be identified by a coded number and initials only. Data tools and instruments are stored securely and access restricted to authorized study team members.
Safety monitoring
An independent data and safety monitoring board (DSMB) will meet regularly to ensure patient safety and data quality. Interim analyses of principal safety and effectiveness outcomes will be performed on behalf of DSMB by the trial statistician who are blind to the treatment assignments. Vital signs, which include blood pressure, heart rate, temperature and respiration rate, adverse events will be monitored regularly throughout the trial. Safety monitoring and surveillance will be collected, processed, reviewed, evaluated, reported and discussed, including clinical pregnancy outcomes, identified risks of drugs (additional file 2), laboratory abnormalities and imaging changes. If serious adverse outcomes or rare possible risks occur, a multidisciplinary Safety Management Team (SMT) will be established in each participating hospital and the results will be communicated with DSMB. After assessing severity and causality, rheumatologists are responsible for adjusting further treatment plan accordingly and adverse events will be communicated with DSMB as soon as possible.
Dissemination
The research team will make the data and the full study protocol available to the public. The findings of the study will be disseminated in academic journals and conference presentations.