Combination Antibiotic Treatment for Reactive Arthritis Caused by Chlamydia Bacteria

Condition(s) targeted: Arthritis, Reactive; Reiter Disease

Intervention: Doxycycline and Rifampin (Drug); Azithromycin and Rifampin (Drug); Placebo (Drug)

Phase: Phase 3

Status: Recruiting

Sponsored by: National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

Official(s) and/or principal investigator(s):
John D. Carter, MD, Principal Investigator, Affiliation: University of South Florida

Overall contact:
John D. Carter, MD, Phone: 813-974-2681, Email: jocarter@health.usf.edu

Reactive arthritis, also known as Reiter's syndrome, is a form of arthritis that occurs as a reaction to an infection elsewhere in the body. It is characterized by inflammation of the joints, tendons, urogenital tract, and eyes. Pain and swelling in the knees, ankles, and feet are common. This study will determine the effectiveness of antibiotic therapy in treating people with chlamydia-induced reactive arthritis that has lasted for more than 6 months.

Official title: Phase 3 Trial to Assess the Efficacy of Long-Term (6 Months) Combination Antibiotics as a Treatment for Chlamydia-Induced Reactive Arthritis

Study design: Treatment, Randomized, Double Blind (Subject, Investigator, Outcomes Assessor), Placebo Control, Parallel Assignment, Efficacy Study

Primary outcome: Number of responders in the combination antimicrobial groups versus number of responders in the placebo group

Secondary outcome:

Individual comparison of 6 "responder" criteria in the combination antimicrobial groups versus the placebo group

Comparison of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)

Psoriatic Arthritis Response Criteria (PsARC): swollen joint count, tender joint count, physician and patient global assessment

Disease Activity Score 44 (DAS44): Ritchie Articular Index (tender joint count), swollen joint count (out of 44 joints), ESR, patient global assessment (visual analog scale)

Dactylitis

Enthesitis (presence or absence of plantar fasciitis or Achilles tendonitis)

Health Assessment Questionnaire (HAQ)

Number of patients with a complete response (resolution of all symptoms)

Detailed description: The initial infection that causes reactive arthritis is caused by one of two bacteria: Chlamydia trachomatis, which is usually acquired through sexual contact, or Chlamydia pneumoniae, which can cause respiratory infections. Most people recover fully from the initial flare of arthritis symptoms. However, about 20% of people with reactive arthritis experience long-lasting symptoms. In these individuals, the Chlamydia bacteria exist in a persistent metabolically active state within the joint tissue, even years after the initial exposure. The bacteria produce heat shock proteins (HSPs), which are thought to play a key role in the chronic persistent state of Chlamydia and which may stimulate the immune inflammatory response seen in reactive arthritis. This indicates the need for antimicrobial therapy that can reduce Chlamydia's HSP production and block its metabolism. The purpose of this study is to determine the effectiveness of long-term combination antibiotic therapy in treating people with chronic reactive arthritis. The study will use two different combinations of common antibiotics: doxycycline paired with rifampin and azithromycin paired with rifampin.

This study will entail 6 months of treatment followed by 3 months of follow-up. After screening, eligible participants will be randomly assigned to one of three treatment groups: rifampin once a day plus doxycycline twice a day; rifampin once a day plus azithromycin once a day for 5 days, then twice weekly; or placebo. Study visits will occur at baseline and Months 1, 3, 6, and 9. At all visits, participants will undergo an interview, a physical examination, and blood collection. They will also complete a questionnaire related to their symptoms and functional status. At screening and Month 6, a synovial biopsy may be performed. This will involve taking a sample of the tissue that lines the joints.

Minimum age: 18 Years. Maximum age: 70 Years. Gender(s): Both.

Criteria:

Inclusion Criteria:

- Meet the following European Spondyloarthropathy Study Group Criteria:

1. inflammatory spinal pain OR

2. synovitis AND

3. one or more of the following:

1. positive family history

2. urethritis or cervicitis within 1 month prior to onset of arthritis

3. buttock pain

4. enthesopathy

5. sacroiliitis

- Disease duration of at least 6 months

- Negative pregnancy test at study baseline and willing to use an effective method of

contraception other than combined oral contraceptives for the duration of the study (for women of childbearing age)

Exclusion Criteria:

- Sensitivity or history of allergic reaction to rifampin, doxycycline, or azithromycin

- Currently taking any medications that may interact with the study medications,

specifically rifampin

- Liver transaminases greater than or equal to two times the normal level

- Significant abnormalities in the complete blood count (CBC)

- Pregnant

- Current psoriasis

- Diagnosis of inflammatory bowel disease

- Diagnosis of ankylosing spondylitis

- Previous prolonged exposure to antibiotics (more than 2 weeks) as a potential

treatment for reactive arthritis

John D. Carter, MD, Phone: 813-974-2681, Email: jocarter@health.usf.edu

University of South Florida, Tampa, Florida 33612, United States; Recruiting
John D. Carter, MD, Phone: 813-974-2681, Email: jocarter@health.usf.edu
John D. Carter, MD, Principal Investigator

Louisiana State University, New Orleans, Louisiana 70112, United States; Recruiting
Luis R. Espinoza, MD, Principal Investigator

University of Toronto, Toronto, Ontario M5T 2S8, Canada; Recruiting
Robert D. Inman, MD, Principal Investigator

Related publications:

Carter JD, Valeriano J, Vasey FB. Doxycycline versus doxycycline and rifampin in undifferentiated spondyloarthropathy, with special reference to chlamydia-induced arthritis. A prospective, randomized 9-month comparison. J Rheumatol. 2004 Oct;31(10):1973-80.

Starting date: May 2006
Ending date: November 2008
Last updated: December 20, 2007