Docstoc

Rituximab as a second line treatment for ITP (DOC)

Document Sample
Rituximab as a second line treatment for ITP (DOC) Powered By Docstoc
					Protocol nr. ITP 001        Version 8               Date: 18.01.2011




          Rituximab as second line treatment for ITP:
          A Multicentre, Randomized, Double blind,
            Placebo-controlled, Phase III study.
                    “The RITP study”




                       Clinical Study protocol

                            Protocol version 8

                       EudraCT no: 2005-005918-20




                                                                       1
Protocol nr. ITP 001                 Version 8                   Date: 18.01.2011


Sponsor:
                           Rikshospitalet
                           0027- Oslo
                           Norway
                           Sponsor‘s representative: Pål André Holme, MD, PhD




Coordinating investigators:
                           Waleed Ghanima, MD, PhD
                           Dept. of medicine
                           Sykehuset Øsfold, Fredrikstad
                           N-1603 Fredrikstad, Norway




Principle investigators:
                           Prof. Geir E. Tjønnfjord, MD, PhD
                           Section of hematology, Dept. of medicine
                           Rikshospitalet-Radiumhospitalet University Hospital
                           N-0027 Oslo, Norway.


                           Prof. Finn Wisløff, MD, PhD
                           Dept. of haematology
                           Ullevål University Hospital
                           N-0407 Oslo, Norway


                           Prof. Anders Waage, MD, PhD
                           Section of hematology, Dept. of medicine
                           St-Olavs University Hospital
                           N-7004 Trondheim; Norway


                                                                                    2
Protocol nr. ITP 001             Version 8                    Date: 18.01.2011




                       Lorentz Brinch, MD, PhD
                       Section of hematology, Dept. of medicineRikshospitalet-
                       Radiumhospitalet University Hospital
                       N- 0027 Oslo, Norway


                       Prof. Peter Meyer, MD, PhD
                       Dept. of Hematooncology
                       Rogaland central hospital


                       Johannes Kahrs, MD
                       Dept. of medicine
                       Sykehuset Øsfold, Fredrikstad
                       N-1603 Fredrikstad, Norway


                       Prof. Hans Wadenvik, MD, PhD
                       Dept. of medicine
                       Sahlgreska university hospital
                       Gothenburg- Sweden


                       Prof. Marc Michel, MD
                       Dept. of Internal medicine
                       Henri Mondor University Hospital
                       Créteil- France
     Statistician:     Mikael Abdelnoor MPH, PhD
                       Kompetanse senter for klinisk forskning,
                       Ullevål University Hospital
                       N-0407 Oslo, Norway



                                                                                 3
Protocol nr. ITP 001                Version 8                    Date: 18.01.2011




Test product:           Rituximab

Protocol number:        ITP 001
EudraCT number:         2005-005918-20


Approved by the following:




Sponsor’s representative        Signature: ___________________________________
Title: Dr. Pål Andre Holme      Date: 18.01.2011




Coordinating investigator       Signature: ___________________________________
      Dr. Waleed Ghanima        Date: 18.01.2011




                                                                                    4
Protocol nr. ITP 001                                        Version 8                                           Date: 18.01.2011


         Table of contents
  Protocol summary ............................................................................................................................. 7
  List of Abbreviations/Definition of Terms...................................................................................... 11
  1- Introduction .............................................................................................................................. 13
  2- Current treatment options ........................................................................................................ 14
  3- Rationale, study design, objectives and endpoints ................................................................... 20
    3.1 Rationale............................................................................................................................ 20
    3.2 Study design ...................................................................................................................... 21
    3.3 Study objectives ................................................................................................................ 24
    3.4 Endpoints ........................................................................................................................... 24
  4- Study population ..................................................................................................................... 26
    4.1 Study patients .................................................................................................................... 26
    4.2 Inclusion criteria (for randomisation) ................................................................................ 26
    4.3 Exclusion criteria............................................................................................................... 27
  5- Study Procedure and Treatment Plan ...................................................................................... 29
    5.1 Diagnosis ........................................................................................................................... 29
    5.2 Prerandomization treatment .............................................................................................. 29
    5.3 Baseline ............................................................................................................................. 30
    5.4 Informed Consent .............................................................................................................. 30
    5.5 Randomization .................................................................................................................. 31
    5.6 Treatment Plan .................................................................................................................. 32
    5.8 Concomitant and rescue therapy ....................................................................................... 33
  6- Safety Issues............................................................................................................................ 37
    6.1 Definition of adverse events .............................................................................................. 37
    6.2 Prevention and treatment of adverse events ...................................................................... 38
    6.3 Registration of adverse events........................................................................................... 39
    6.4 Definition and reporting of serious adverse events (SAE) ............................................... 40
    6.5 Premature study drug discontinuation ............................................................................... 40
    6.6 Patient withdrawal or discontinuation ................................................................................ 41
  7- Measurements and definitions ................................................................................................. 43
    7.1 Previous episode and concurrent ITP ................................................................................ 43
    7.2 Response criteria ................................................................................................................ 43
    7.3 Relapse and duration of response ...................................................................................... 44
    7.4 Bleeding ............................................................................................................................ 44
    7.5 Infectious complications ................................................................................................... 47
  8- Study Drug Supply and Handling ........................................................................................... 48
    8.1 Study drug supply............................................................................................................... 48
    8.2 Packaging and Labelling (for Drugs Supplied by the Sponsor) ......................................... 48
    8.3 Study drug storage conditions ............................................................................................ 49
    8.4 On Site Drug Accountability and Dispensing .................................................................... 50
    8.5 Unused Drug and Destruction ............................................................................................ 50
  9- Statistics and Data Management .............................................................................................. 51
    9.1 Number of patients ............................................................................................................ 51
    9.2 Randomization .................................................................................................................. 54
    9.3 Enrolment period ............................................................................................................... 56
    9.4 Data management .............................................................................................................. 56
  10- Trial organization ................................................................................................................... 56
    10.1 Committees...................................................................................................................... 57
  11- Ethics..................................................................................................................................... 58



                                                                                                                                                  5
Protocol nr. ITP 001                                           Version 8                                          Date: 18.01.2011

  12- Regulatory considerations ......................................................................................................... 59
     12.1- Regulatory Approval / Authorization ................................................................................ 59
     12-2 Investigators Obligations .................................................................................................... 59
     12.3- Change in the conduct of the study .................................................................................... 59
     12.4 Insurance Policy .................................................................................................................. 62
  13- QUALITY CONTROL AND QUALITY ASSURANCE ..................................................... 62
     13.1 Source Data and Documents ............................................................................................... 62
     13.2 Periodic Monitoring ............................................................................................................ 63
     13.3 Audit and Inspection ........................................................................................................... 63
  14.- Data Handling and Record Keeping ........................................................................................ 64
     14.1- Information ........................................................................................................................ 64
     14.2- Case Report Forms ............................................................................................................. 64
     14.3- Changes to CRF Data......................................................................................................... 64
     14.4- Provision of Additional Information .................................................................................. 65
  15- Reporting and Publication......................................................................................................... 65
     15.1- Clinical Study Report(s) .................................................................................................... 65
     15.2- Confidentiality of Study Data ............................................................................................ 65
     15.3- Publication Policy .............................................................................................................. 66
  16- Archiving .................................................................................................................................. 66
     16.1- Investigator Site File .......................................................................................................... 66
     16.2- Study Master File ............................................................................................................... 67
17. References ..................................................................................................................................... 67
  Appendix 1- Drug Administration and Storage .......................................................................... 72
     Infusion duration ......................................................................................................................... 72
     Infusion related events ................................................................................................................ 73
  Appendix 2- ACR Classification Criteria Used for SLE ........................................................... 74
  Appendix 3- Rituximab. Summary of Product Characteristics ................................................... 75




                                                                                                                                                     6
Protocol nr. ITP 001                          Version 8                      Date: 18.01.2011




                                         Protocol summary

                     Rituximab as second line treatment for ITP ―The RITP study‖
                     Protocol version 4- 13.10.2008   EudraCT no: 2005-005918-20

                     A prospective, randomized, placebo-controlled, double-blind, multi-
Design




                     centre, phase III trial, to compare in two arms (Rituximab vs.
Study




                     placebo/ standard treatment) the frequency of treatment failure in
                     patients with ITP.

                     Primary objective: To assess in both treatment arms the rate of
                     treatment failure during observation period of 1.5 years.
                     Secondary objectives: 1- Response rates 2- Relapse rates and
Objectives




                     duration of response 3- Mortality rate 4- Complications rate:
                     bleeding, infection and thromboembolic events 5- Cost-effectiveness
                     analysis 6- Cumulative dose of corticosteroids and/or IVIG in both
                     arms 7- Immune-reconstruction at 1.5 and 5 years.


                     1- ITP defined according to the ASH criteria with a platelet count at
                     time of inclusion < 30 x 109 /l or between 30 -50 if a higher platelet
                     count is required*
                     2- Previous treatment with corticosteroids for a minimum duration of
                     2 weeks as recommended by the protocol (prednisolone or prednisone
Inclusion Criteria




                     1-2 mg/kg/day) with either no response (i.e. failed to achieve an
                     initial increase in Platelet count >30 x 109 /l or relapse (Platelet count
                     falls to< 30 x 109 /l) during the dose tapering period or after
                     discontinuation of corticosteroids
                     3- Age ≥ 18 years 4- Subject has signed and dated written informed
                     consent 5- Subject is able to understand and comply with protocol
                     requirements and instructions, and intends to complete the study as
                     planned 6- Females in child-bearing age should accept to use of
                     contraceptive means for at least 6 months following the
                     administration of the study drugs.




                                                                                                  7
Protocol nr. ITP 001                         Version 8                       Date: 18.01.2011


                     1- Previous splenectomy, chemotherapy, treatment with anti-D Ig,
                     rituximab, or immune-suppressive treatments other than
                     corticosteroids, Dapsone or Danazol 2- Underlying malignancy or
                     previous history of malignancy in the past 5 years (except skin
                     carcinoma) 3- Pregnancy and lactation 4- Not willing to participate in
                     the study 5- Expected survival of < 2 years 6- Known intolerance to
                     murine antibodies 7- Females in child-bearing age not willing to use
                     contraception for 6 months 8- HIV-positive/AIDS-, Hepatitis -B virus
                     positive- or Hepatitis -C virus positive -9- Patients with a definite
                     Systemic Lupus Erythematosus (SLE) (> 4 of the American College
                     of Rheumatology Criteria) -10- Patients currently involved in another
                     clinical trial with evaluation of drug treatment -11- Bacterial
                     infections, viral infections, fungal infections, myco-bacterial
Exclusion criteria




                     infections (excluding ungeal fungal infections) or other evolutive
                     infections or any other infections episode requiring hospitalisation or
                     treatment with an antibiotics 4 weeks before selection for IV route or
                     within 2 weeks before selection for oral route -12- History of soft
                     tissue, bone or joint infections (fascitis, abscess, osteomyelitis, septic
                     arthritis) during the last year prior to inclusion in the study -13-
                     Medical history of relapsing or chronic severe infectious diseases or
                     any other underlying pathology predisposing to serious infections -
                     14- Known Primary or secondary immune deficiency syndromes -15-
                     Administration of a living vaccine within 4 weeks preceding the
                     inclusion in the study -16- Previous treatment with any lymphocytes
                     depleting medication (e.g.: MabCampath®) -17- Previous treatment
                     with inhibitors of leucocytes transmigration (e.g.: Tysabri®) -18-
                     Known intolerance to human monoclonal antibodies -19- Known
                     severe chronic pulmonary obstructive Disease (FEV < 50% or
                     functional dyspnoea grade 3) -20- Known congestive heart failure
                     NYHA (New York Heart Association classification of heart failure)
                     class III and IV -21- Recent episode (<6 months) of acute coronary
                     syndrome.
                     Primary end point: Treatment failure (splenectomy or reaching
                     criteria for splenectomy at or after week 12) during the follow-up
Endpoints




                     period after randomisation.
                     Secondary endpoints: 1-Death during follow-up period 2-Relapse
                     defined as platelet count <30 x 109/l following an initial response and
                     duration of response. 3- Episodes of bleeding, infection and
                     thromboembolic events.




                                                                                                  8
Protocol nr. ITP 001                                                                           Version 8                      Date: 18.01.2011


Study hypothesis and                                                    The study hypothesis is that the rate of treatment failure at 18 months
                                                                        will be reduced from 70 % in the placebo arm to 40 % in the
                                                                        rituximab arm, which corresponds to a hazard ratio rituximab/placebo
    Sample size

                                                                        of 2.57. Based on this assumption, using a two-sided log-rank test, a
                                                                        power of 80 % and type 1 error of 5%, 41 events are needed
                                                                        corresponding to around 46 patients randomized in each treatment
                                                                        arm. To accommodate for drop-outs the sample size was multiplied
                                                                        by 1.2 resulting in 110 included patients.

                                                                        Recommended initial treatment: Prednisolone (or prednisone)- 1
                                                    Pretreatment




                                                                        mg/kg for at least 2 weeks, followed by gradual tapering by 5-10 mg
                                                                        /week until reaching the lowest dose to maintain platelet count >20.
                                                                        Rapid tapering by 10-20 mg /week is recommended in case of no
                                                                        response to prednisolone (or prednisone) after 3 weeks of treatment.

                                                                        Completed randomization form should be faxed to the randomization
   Study Procedure and Treatment Plan

                                                    Randomization




                                                                        centre (Hospital Pharmacy in SØF- fax number: +47 69 38 50 01).
                                                                        The randomization result will be forwarded to the local pharmacy for
                                                                        its implementation.




                                                                        The study treatment (Rituximab or placebo) will be supplied blinded
                                                    Study Medications




                                                                        by the respective local hospital pharmacy.
                                                                        a- Rituximab (Mabthera; Roche) 375 mg/m2 IV, given once weekly
                                                                        for four consecutive weeks OR b- Placebo- ml Nacl 0.9 mg/ml in
                                                                        corresponding infusion volume AND c- Premedication- including
                                                                        oral acetaminophen (paracetamol) 1000 mg and diphenhydramine
                                                                        50 mg or equivalent should be given prior to i.v. infusion.
                                                    Splenectomy




                                                                        Splenectomy is recommended in case of treatment failure which is
                                                                        defined as: failure to achieve platelet count >20 or need to pursue a
                                                                        daily dose of prednisone / prednisolone > 7.5 mg to maintain a
                                                                        platelet count >20 x 109/L.
                                        Follow-up




                                                                        Patients will be followed-up every 6 weeks for 1.5 years after
                                                                        randomization, then every 3 months until the termination of the trial.




                                                                                                                                                  9
Protocol nr. ITP 001                    Version 8                    Date: 18.01.2011


                       Study coordinators                    Coordinating study nurse

     Waleed Ghanima                  Pål Andre Holme                 Siv Foyn
 Med avd. Sykehuset Østfold         Med avd, Seksjon for     Med avd. Sykehuset Østfold
        Fredrikstad                    blodsykdommer.               Fredrikstad
   Tlf: +47 69 86 00 00                 Rikshospitalet         Tlf: +47 69 86 00 00
   Mob: +47 41 30 34 40             Radiumhospitalet HF        Fax: +47 69 86 09 52
 waleed.ghanima@so-hf.no             Tlf: +47 23 07 00 00
                                    Mob:+47 90 13 0306
                                   holme@rikshospitalet.no




                                                                                          10
Protocol nr. ITP 001                Version 8                      Date: 18.01.2011


                       List of Abbreviations/Definition of Terms

ACR
AE         Adverse event
ALP        Alkaline phosphatase
ALT (SGPT) Alanine amino transferase (serum glutamic pyruvic
           transaminase)
ANA        Antinuclear antibody
APTT       Activated partial thromboplastin time
ASH        American Society of Hematology
AST        Aspartate amino transferase (serum glutamic oxalo-acetic
(SGOT)     transaminase)
CA         Competent Authorities
CHU        Centre Hospitalier Universitaire (University Hospital)
CR         Complete response
CRA        Clinical research associate
CRF        Case report form
CRP        C-reactive protein
CTCAE      Common terminology criteria for adverse events
DAT        Direct antiglobulin test
FR         France
GCP        Good clinical practice
GGT        Gamma glutamyl transferase
HCV        Hepatitis C virus
HDD        High dose dexamethasone
HIV        Human immuno-deficiency virus
Ig         immunoglobulin
i.v.       Intravenous
IVIG       Intravenous immunoglobulin
ICH        International Conference on Harmonisation
IEC        Independent Ethics Committee
IRB        Institutional Review Board (US Ethics Committee)
ITP        Immune Thrombocytopenic purpura
ITT        Intent to treat
LDH        Lactate dehydrogenase
MedDRA     Medical dictionary for regulatory activities
NHL        Non-Hodgkin‘s Lymphoma
MR         Minor response
NR         No response
PR         Partial response
RBC        Red blood cell(s)
SAE        Serious adverse event
SLE        Systemic lupus erythematous

                                                                                      11
Protocol nr. ITP 001                     Version 8                        Date: 18.01.2011


SmPC             Summary Product Characteristics
WBC              White blood cell(s)
WHO              World Health Organization




                                            Definitions
Date of registration: date patient signs the informed consent form.
Date of randomisation: date of reply from the sponsor with a randomisation number.




                                                                                             12
Protocol nr. ITP 001                 Version 8                     Date: 18.01.2011


1-     Introduction

Immune thrombocytopenic purpura (ITP) is an autoimmune disorder characterized by
the formation of autoantibodies, usually of IgG class, against platelet epitopes, causing
premature platelet destruction in the reticuloendothelial system. This results in
persistent thrombocytopenia, which can lead to bleeding in patients with platelets
counts of less than 30 x 109/l. The frequency of death from hemorrhage in patients
with platelet counts of < 30 x 109/l is estimated to be between 1.6 and 3.9% per
patient-year (Cohen, 2000). The incidence of ITP is estimated to range from 1.6 – 6.6
/105/ year in the United States and Europe and with approximately twice as many
women as men affected (Cines & McMillan, 2005;Neylon et al, 2003;Frederiksen &
Schmidt, 2004).

ITP is classified as primary or as secondary to an underlying disorder, and is also
classified as either acute (< 6 months) or chronic (> 6 months). Acute ITP occurs
predominantly in childhood, and in most cases the illness is transient in nature and
requires no treatment and recovery is spontaneous. By contrast, ITP in adults is
generally chronic, the onset is often insidious and spontaneous recovery is uncommon.

The diagnosis remains one of exclusion; other thrombocytopenic disorders should be
ruled-out by medical history, physical examination, and laboratory evaluation (Cines
& McMillan, 2005). Secondary forms of the disease occur in association with SLE, the
antiphospholipid syndrome, immunodeficiency states (IgA deficiency and common
variable hypogammaglobulinemia), lymphoproliferative disorders (CLL, LGL
leukemia and lymphoma), infections with HIV and hepatitis C virus, and drug therapy.

The goal of treatment is to raise the platelet count to a hemostatically safe level. The
disorder is usually chronic with a considerable variation in the clinical course, but
most patients will eventually attain safe platelet counts. However, a subset of patients
suffers from a severe disease, refractory to all treatment modalities, and these patients
are prone to considerable morbidity and mortality.

                                                                                      13
Protocol nr. ITP 001                  Version 8                      Date: 18.01.2011


Persistent platelet counts of < 30 x 109/l are associated with an increased incidence of
bruising, mucosal bleeding and intracranial hemorrhage (Cines, 2002) (Frederiksen &
Schmidt, 2004;Stasi et al, 1995). The risk is greatest in the elderly, those with a history
of bleeding, and those who have no response to therapy (Cortelazzo et al, 1991). In the
small subgroup of patients with severe thrombocytopenia, the predicted five-year
mortality rate from bleeding range from 2.2 percent for those younger than 40 years of
age to 47.8 percent for those over 60 years of age indicating a need for persistent
therapy for severe disease (Portielje et al, 2001).



2-     Current treatment options
The current management of ITP is largely based on the guidelines published by the
American society of Hematology in 1996, and by the British Haematology Task Force
published in 2003 (Provan et al, 2003).

The majority of authors agree on treating all patients with persistent platelet counts of
< 30 x 109/l and patients with platelet counts between 30 x 109/l and 50 x 109/l in the
presence of predisposing bleeding comorbid conditions (Provan et al, 2003;Cines &
Bussel, 2005, Godeau B et al, 2007; Ruggeri et al, 2008) .

First line therapy therapy comprises oral corticosteroids and intravenous
immunoglobulin (IVIG).


2.1    Prednisolone:
Prednisolone (or prednisone) in a dose of 1-2 mg/kg/d still is the first line treatment in
ITP. It increases the platelet count to a hemostatically effective level in 75% of the
patients. Most responses occur within the first three weeks (den Ottolander et al,
1984), but there is no consensus concerning the appropriate duration of treatment.
Only 10-20% of the responses are sustained, and most patients will ultimately relapse
(Cines & McMillan, 2005;George et al, 1994;George et al, 1996).


                                                                                        14
Protocol nr. ITP 001                 Version 8                      Date: 18.01.2011


Furthermore, patients receiving high-dose corticosteroids commonly report heartburn,
anxiety, sleeping difficulty, fluid retention and, over time, develop Cushingoid
features, osteoporosis, diabetes mellitus and an increased risk of infection.

2.2    High Dose Dexamethasone (HDD):

Studies of a small number of patients with resistant or refractory ITP have shown a
variable responses to HDD (Khouri et al, 2002;Wali et al, 2002;Warner et al, 1997). A
recently published trial reported a good initial response; 50 % after 4 days of treatment
with Dexamethasone 40 mg daily. The platelet count increased by at least 20 x 109/l
by the third day of treatment. 50% had a sustained response that lasted > 6 months. A
platelet count of less than 90 x 109/l on day 10 was associated with a high risk of
relapse.(Cheng et al, 2003)

2.3    Intravenous immunoglobulin:

IVIG (1g/kg/day for two days or 0.4 g/kg/day for 5 days) is used in patients with on
going bleeding, when the platelet count is below 5 x 109/l or prior to splenectomy if
the platelet count is <30 x 109/l in patients unresponsive to corticosteroids.
Approximately 80 % of patients respond within 1 week, but sustained remission is
infrequent, (Bussel & Pham, 1987), and the cost is considerable. Renal failure and
pulmonary insufficiency may occur.

2.4    Splenectomy:

Splenectomy is appropriate for most adults with relapse, who do not respond to
corticosteroids or require high doses of corticosteroids to maintain a platelet count >30
x 109/l. Results of numerous studies indicate that approximately two thirds of patients
respond and usually within days (Cheng et al, 2003; Provan et al, 2003; Kojouri et al,
2004; Ruggeri et al, 2008).

Postoperative complications, including infections, sepsis, major bleeding and
thrombotic events, are reported to occur in approximately 10% of patients following

                                                                                       15
Protocol nr. ITP 001                Version 8                      Date: 18.01.2011


splenectomy. Laparoscopic splenectomy appears to have lower mortality and
complications rate (0,25%,     9,6%) compared to open splenectomy (1%, 12,6%)
(Kojouri et al, 2004; Dolan et al, 2008). The use of laparoscopic surgery also speeds
recovery and shortens hospitalization. The major known long-term risk of
splenectomy is overwhelming bacterial sepsis, which occurs in approximately 1% of
adults with uncomplicated ITP (Lortan JE, 1993).

2.5    Anti-D immunoglobulin:
Anti-D Ig (75 µg/kg) is efficacious in Rh-positive patients. It elevates platelet counts
by 70- 90% (Mead et al, 2003). Anti-D Ig is indicated in unsplenectomized patients
who are intolerant to or have failed initial treatment with corticosteroids. It causes a
mild hemolytic anemia which is generally well tolerated (Cines & McMillan, 2005).


2.6.   Other modalities:
When patients are refractory to treatment with corticosteroids, IVIG and/ or
splenectomy, they may be considered for alternative therapies, including vinca-
alkaloids, danazol, azathioprine, cyclophosphamide, ciclosporine A, and dapsone.
However, there are limited data to support the use of these agents. Recently
thrombopoietin receptor agonists have demonstrated promising results in difficult to
treat ITP patients. (Bussel et al, 2006;Bussel et al, 2007). However, the exact role of
these agents is still not well defined and they are not yet registered in Europe for the
treatment of ITP. Romiplostim and eltrombopag are two of these agents that have
completed phase 3 studies and were approved in Europe in 2009 and 2010
respectively. In randomized controlled trials, these agents have demonstrated
unequivocal superiority over placebo in the treatment of ITP in splenectomized and in
non-splenectomized patients—an effect that seems to be durable while treatment
continues and at an acceptable short-/intermediate- term safety profile. These agents
are approved for treatment refractory ITP (after splenectomy) and in chronic ITP when
splenectomy is contraindicated.


                                                                                      16
Protocol nr. ITP 001                 Version 8                     Date: 18.01.2011




2.7    Rituximab:
A chimeric anti-CD20 antibody with a B-cell depleting effect is indicated in the
treatment of Non-Hodgkin‘s lymphoma (NHL) and severe active rheumatoid arthritis
and, has entered clinical trials in several autoimmune conditions (Summary of Product
Characteristics 2008). It has recently emerged as a promising treatment for ITP.
There are two systematic reviews published on clinical studies performed with
rituximab in ITP. In spite of a considerable heterogeneity in the studies included in
these reviews, however the main conclusions regarding efficacy and safety were
identical (Arnold et al, 2007;Garvey, 2008). Up to now prospective data have been
published for over 200 adults with ITP. Of the 19 studies included in the systematic
review none included a control group. The estimated overall response rate (platelet
count > 50 x 109 cells/l) was 62.5%, with a complete response rate (platelet count >
150 x 109 cells/l) of 46.3% and a median duration of response of 10.5 months (Arnold
et al, 2007).
The majority of responses were durable and maintained for > 1 year – the longest
reported response was ongoing at 3.2 years. Most of the studies employed the same
dose as is used to treat lymphoma (375 mg/m² weekly for 4 weeks). Saleh et al (2000)
undertook a dose-ranging study, utilizing rituximab doses ranging from 50 to 375
mg/m². Although the number of patients was small, Garvey (2008) agreed that their
results suggested that patients treated with lower doses of rituximab were less likely to
achieve an objective response than those receiving higher doses.


Among the 29 reports (306 patients) that described toxicities, including the studies
enrolling fewer than 5 patients, 66 (21.6%) patients experienced mild or moderate
adverse events (AE) (grade 1 to 2 as per the National Cancer Institute Common
Terminology Criteria for adverse events, version 3.0 [CTCAE]) (Arnold et al, 2007).
Close to 60% of patients in the largest prospective study (57 patients) experienced


                                                                                      17
Protocol nr. ITP 001                 Version 8                      Date: 18.01.2011


mild infusional side effects with rituximab (Cooper et al, 2004); however, across all
studies, infusional reactions were far less common, occurring in 55 of 306 patients
(18%) overall (Arnold et al, 2007). Reporting bias and non standardized data
collection account for some of the discrepancy.
Serious toxicities resulting in treatment discontinuation were rare, but included
thrombocytosis, a severe anaphylactoid reaction, serum sickness and infusion-related
hypotension (Giagounidis et al 2002; Braendstrup et al, 2005; Wang et al, 2005,
Bennett et al, 2006).
Among the 29 published studies included in the systematic review for analysis of
safety (306 patients), 10 patients (3.7%) experienced severe or life-threatening events
(grade 3 to 4), and 9 patients died (2.9%) (grade 5) (Arnold et al, 2007). Causes of
death were respiratory insufficiency 6 days after the administration of rituximab in a
71-year-old woman with severe chronic respiratory disease (Braendstrup et al, 2005);
pneumonia 13 weeks after rituximab treatment in a 73-year-old man with severe
chronic obstructive lung disease (Braendstrup et al, 2005); central nervous system
hemorrhage less than 1 week after rituximab treatment (Shanafelt et al, 2003);
hemorrhagic complications within 3 weeks of receipt of rituximab (Shanafelt et al,
2003); infection (no time frame provided) (Lieb et al, 2003); bleeding and
polymicrobial infection (no time frame provided) (Grossi et al, 2000); pulmonary
embolism 2 days after surgical drainage of a hepatic abscess and 4 months after
rituximab treatments (Lalayanni et al, 2004); hepatic failure characterized by marked
cholestasis and loss of bile ducts 4 months after re-treatment with rituximab (Jacoub et
al, 2004); and death from unknown cause within 3 weeks of receipt of rituximab
(Shanafelt et al, 2003). The mortality rate observed in the systematic review and as
stated by the authors probably overestimate the number of deaths attributable to
rituximab as a result of bias inherent to these observational studies. More likely, these
deaths were the result of long courses of complex treatment regimens or the selection
of patients with advanced disease (Arnold et al, 2007). Authors assessed attribution
for 2 of the 9 reported deaths; rituximab administration was not felt to be related to the


                                                                                       18
Protocol nr. ITP 001                  Version 8                      Date: 18.01.2011


case of fatal pneumonia (Braendstrup et al, 2005) but was thought to be possibly
related to the case of fatal hepatic failure (Jacoub et al, 2004).
The mortality rate observed in the systematic review and as reported by the authors
was similar to that in 2 of the largest retrospective cohort studies in ITP: Portieljie et
al (2001) reported 6 ITP-related deaths among 152 patients (3.9%) followed up over a
10 year period, and Stasi et al (1995) reported 5 deaths among 208 patients (2.4%).


Similarly, an overview of ITP studies uncovered 49 cases of fatal haemorrhage among
1 817 patients (2.7%) (Cohen et al, 2000). Portieljie et al (2001) found that more ITP
patients died of infection than of bleeding. In patients with lymphoma, the number of
deaths directly attributable to rituximab is far lower than the number of death reported
here, estimated at 4 to 7 per 10 000 patients treated (Grillo-López et al, 2002).
To date 76 cases of Progressive Multifocal Leucoencephalopathy (PML) have been
reported in patients previously treated with rituximab. PML is a rare, progressive,
serious demyelinating disease of the CNS that often results in death or in profound
disability, caused by the activation of JC-virus. Most of these cases were reported in
patients that have received rituximab for oncological indications (69 cases). No known
case has so far been reported following treatment of ITP.




                                                                                         19
Protocol nr. ITP 001                 Version 8                     Date: 18.01.2011


3-     Rationale, study design, objectives and endpoints


3.1    Rationale
Standard treatment for chronic ITP failing corticosteroid therapy is splenectomy.
Based on the available data, 1/3 of the patients treated with Rituximab achieve
sustained remissions. However, these studies were conducted predominantly on
patients with refractory ITP including a substantial number of splenectomized
patients. Thus the exact effect and duration of response in non-splenectomized patient
is unknown and might be higher than that reported in other studies for patients with
refractory ITP. Splenectomy induces sustained responses that last over 2 years in
approximately 70% of the patients. However, splenectomy is an invasive procedure
that requires hospitalisation and may necessitates expensive preoperative preparation
with IVIG and/or platelet transfusions. Moreover, the procedure is associated with a
significant short and long term morbidity and mortality. Rituximab, on the other hand,
is also a costly treatment, but is almost free from serious short-term side effects.
However, little is known about its long-term side effects. In the published studies
there is no significant difference in response rate between splenectomised and non-
splenectomized patients (Cooper N et al, 2007). Early treatment with Rituximab to
patients failing the initial corticosteroid treatment can be justified if it can induce a
convincing rate of durable responses that will ultimately result in the avoidance of
splenectomy.
The newly introduced thrombopoietin receptor agonists offer a new therapeutic option
for patients with ITP. Because these agents could be considered in certain patients as
an alternative to splenectomy, it would be unethical to deny study patients this
therapeutic option. In addition, splenectomy may not be performed because of a co-
morbidity or patients‘ refusal. As a result, the study endpoint, Splenectomy, is
amended to Treatment Failure, which is a composite endpoint of splenectomy or
meeting criteria for splenectomy at or after week 12 if splenectomy for any reason is
not performed.


                                                                                      20
Protocol nr. ITP 001                 Version 8                       Date: 18.01.2011


Our hypothesis is that treatment with Rituximab prior to splenectomy would result in
an at least 30% reduction in the rate of splenectomy at 1.5 years.
Knowledge of whether or not a patient had received rituximab could bias the decision
of the physician regarding the indication for splenectomy. For that reason, a
randomized, placebo- controlled design is adopted.


The rituximab administered dose will be the same dose as is used to treat lymphoma
and most often used in published studies of rituximab in adults with ITP: 375 mg/m²
weekly for 4 weeks.


3.2    Study design
A prospective, randomized, placebo-controlled, double-blind, multi-centre, phase III
trial, to determine the efficacy of rituximab as second line treatment in patients with
ITP.


The schedule of events is displayed in the table hereafter




                                                                                        21
Protocol nr. ITP 001                         Version 8                              Date: 18.01.2011
    Table: Schedules of event
                        Baseline          Study                                         Follow-up phase
                                        treatment
                                          phase                              To be performed at schedule ± 4 days
                                      g
Visit                     1         2      3 4 5     6   7    8    9    10    11 12 13 14 15 16 17                  18   19   20
Study week                <0        0      1 2 3     6   12   18   24   30    36 42 48 54 60 66 72                  78   84   90   >90
Informed consent          X
Demografic data           X
Medical history           X
Request for
                           X
Randomisation
Physical
                           X
examination a
Bleeding score             X                         X   X    X    X    X      X    X      X   X    X     X    X    X    X    X     X
Haematology /
                           X
Blood chemistryb
                                                                    f                                                          f
Platelet count             X                         X   X    X    X    X      X    X      X   X    X     X    X    X    X    X     X
Blood smear at time
                           X
of ITP diagnosis
Bone marrow              If none
aspiration              available
DAT                          X
Immunoglobulin
                           X                                       X                                                          X
quantification c,d
Serology e                 X
Inclusion / exclusion      X
criteria
Study drug                           g
                                    X    X   X   X
administration
Recording of other
medical treatment          X        X    X   X   X   X   X    X    X    X      X    X      X   X    X     X    X    X    X    X     X
of ITP
Other concomitant
                           X        X    X   X   X   X   X    X    X    X      X    X      X   X    X     X    X    X    X    X
medication
Response
                                                     X   X    X    X    X      X    X      X   X    X     X    X    X    X    X
evaluationf
Medical care
                                                     X   X    X    X    X      X    X      X   X    X     X    X    X    X    X
utilization
AE / SAEd                           X    X   X   X   X   X    X    X    X      X    X      X   X    X     X    X    X    X    X
After meeting
criteria for                                                  X    X    X      X    X      X   X    X     X    X    X    X    X     X
splenectomy h



                                                                                                                                         22
Protocol nr. ITP 001                               Version 8                                 Date: 18.01.2011
                          Baseline            Study                                             Follow-up phase
                                            treatment
                                              phase                                   To be performed at schedule ± 4 days
              i
Splenectomy                                                                          As clinically indicated


   a.         Including spleen palpation and clinical features
   b.         Hematology: haemoglobin, whole blood cell count, differentials, haptoglobin. Blood chemistry: creatinin, ALT, AST, LDH, Alkaline Phosphatase, CRP.
   c.         IgG, IgM and IgA
   d.         In case of serious infectious AE record whole blood cell count, differentials, quantitative Ig (see point c above) within 1 week of the event becoming serious
   e.         HBV, HCV, HIV and ANA, Antilupus antibodies, anticardiolilipin antibodies and Helicobacter Pylori IgG titre and C13 urea breath test
   f.         For response evaluation at week 24 and 90 the platelet count to be confirmed by two tests 1 week apart. For all other visits, in case of PR, CR or MR a second
              platelet count 1 week apart has to be performed to confirm the response.
   g.         First study drug administration within 4 days following randomisation
   h.         Patients meeting criteria for splenectomy will be followed-up until the end of the study or until splenectomy is performed.
   i.         If splenectomy is performed an additional follow-up visit has to be performed after 90 days. Platelet count, response evaluation, pneumococcal antibody titre and
              assessment of post-splenectomy complications should be performed.




                                                                                                                                                                              23
Protocol nr. ITP 001                    Version 8                  Date: 18.01.2011


3.3      Study objectives
Primary objective:
To assess in both treatment arms the rate of treatment failure (splenectomy or
meeting criteria for splenectomy after week 12).


Secondary objectives:
      1. Response rates.
      2. Relapse rate and duration of response.
      3. Mortality rate.
      4. Complications` rate: bleeding, infection and thromboembolic events.
      5. Cost-effectiveness analysis.
      6. Consumption of corticosteriods and IVIG in both arms.
      7. Immune-reconstruction at 1.5 years.

3.4      Endpoints
Primary endpoint:
The primary endpoint is treatment failure as defined by a composite end point
of Splenectomy performed at any time after randomization or Meeting the
predefined Criteria for Splenectomy at or after week 12 that is if splenectomy
is not performed because of any reason including contraindication or patients`
refusal.
The criteria for splenectomy are not modified and are either:
       >7.5 mg/day prednisone/prednisolone are needed to maintain platelet
         count >20 x 109/l or,
       Platelet count <20 x 109/l




                                                                                 24
Protocol nr. ITP 001                 Version 8                     Date: 18.01.2011


.


Secondary endpoints:
    1. Death during follow-up period.
    2. Relapse defined as platelet count <30 x 109/l following an initial response
       and duration of response.
    3. Secondary rate of splenectomy (splenectomy not performed at time of
       treatment failure and performed secondarily).
    4. Episodes of bleeding, infection and thromboembolic events.
    5. Consumption of glucocorticosteriods and IVIG.
    6. Number of days (Day>6hours) in hospital (after randomization)
    7. Number of out-patient (<6-hours) consultations (doctor, nurse).
    8. Duration of sick-leaves.




                                                                                25
Protocol nr. ITP 001                    Version 8                       Date: 18.01.2011


4-       Study population


4.1      Study patients
The target population is unsplenectomized male and female with ITP, >18 years
of age, failing or relapsing after initial treatment with corticoids.
ITP diagnosis criteria are derived from the American Society of Hematology
(ASH). (George et al, 1996).


4.2      Inclusion criteria (for randomisation)

      1. ITP with platelet count <30 x 109 /l or 30-50 x 109 /l if a higher platelet
         count is considered necessary because of any of the following:
            a. Concomitant medical illness predisposing to bleeding (gastric ulcer,
               bleeding diathesis, previous history of bleeding).
            b. Concomitant medical condition requiring aspirin and/or clopidogrel
               intake or anticoagulation.
            c. Persistent bleeding manifestations despite platelets > 30 x 109 /l.
            d. Other patient related factors necessitating higher platelet count as
               occupation, hobby, psychological intolerability.
            e. Age >75 years.
      2. Previous treatment with corticosteroids for a minimum duration of 2
         weeks as recommended by the protocol (prednisone or prednisolone 1-2
         mg/kg/day) with either no response (i.e. failed to achieve an initial
         increase in Platelet count >30 x 109 /l) or relapse (Platelet count falls to <
         30 x 109 /l) during the dose tapering period or after discontinuation of
         corticosteroids.
      3. Subject is >18 years.
      4. Subject has signed and dated written informed consent.




                                                                                     26
Protocol nr. ITP 001                      Version 8                    Date: 18.01.2011


      5. Subject is able to understand and comply with protocol requirements and
         instructions, and intends to complete the study as planned.
      6. Females in child-bearing age should accept to use of contraceptive means
         for at least 6 months following the administration of the study drugs.


4.3      Exclusion criteria


      1. Previous splenectomy, chemotherapy, treatment with anti-D Ig, rituximab,
         or immune-suppressive treatments other than corticosteroids, Dapsone or
         Danazol.
      2. Underlying malignancy or previous history of malignancy in the past 5
         years (except skin carcinoma).
      3. Pregnancy and lactation.
      4. Not willing to participate in the study.
      5. Expected survival of < 2 years.
      6. Known intolerance to murine antibodies.
      7. Females in child-bearing age not willing to use contraception for 6
         months.
      8. HIV/AIDS-, Hepatitis -B virus antigen positive- or Hepatitis -C virus
         antibodies positive- patients.
      9. Patients with Systemic Lupus Erythematosus (SLE) (> 4 of the American
         College of Rheumatology Criteria) (Tan et al, 1982;Hochberg, 1997).
      10.Patients currently involved in another clinical trial with evaluation of drug
         treatment
      11.Bacterial infections, viral infections, fungal infections, myco-bacterial
         infections (excluding ungeal fungal infections) or other evolutive
         infections or any other infections episode requiring hospitalisation or
         treatment with an antibiotics 4 weeks before selection for IV route or
         within 2 weeks before selection for oral route


                                                                                    27
Protocol nr. ITP 001                  Version 8                       Date: 18.01.2011


   12.History of soft tissue, bone or joint infections (fascitis, abscess,
       osteomyelitis, septic arthritis) during the last year prior to inclusion in the
       study.

   13. Medical history of relapsing or chronic severe infectious diseases or any
      other underlying pathology predisposing to serious infections.
   14. Known Primary or secondary immune deficiency syndromes.
   15. Administration of a living vaccine within 4 weeks preceding the
      inclusion in the study.
   16. History of soft tissue, bone or joint infections (fascitis, abscess,
      osteomyelitis, septic arthritis) during the last year prior to inclusion in the
      study.
   17. Previous treatment with inhibitors of leucocytes transmigration (e.g.:
      Tysabri®).
   18. Known intolerance to human monoclonal antibodies
   19. Known severe chronic pulmonary obstructive Disease (FEV < 50% or
      functional dyspnoea grade 3).
   20. Known congestive heart failure NYHA (New York Heart Association
      classification of heart failure) class III and IV.
   21. Recent episode (<6 months) of acute coronary syndrome.




                                                                                   28
Protocol nr. ITP 001                   Version 8                     Date: 18.01.2011


5-       Study Procedure and Treatment Plan


5.1      Diagnosis
ITP is an autoimmune disorder characterized by persistent thrombocytopenia
(peripheral blood platelet count < 150 x 10 9 ⁄ l). The diagnosis of ITP is based
principally on the exclusion of other causes of thrombocytopenia by means of
medical history, physical examination, blood count, peripheral blood film,
autoimmune profile, bone marrow aspiration and other investigations when
clinically indicated (George et al, 1996).


5.2      Prerandomization treatment
To be included in the trial all patients should have been previously treated with
prednisone for at least 2 weeks with an initial daily dose of 1-2 mg/kg. However,
dose can be rounded up according to the available tablet dosage.


The usual recommendations for treatment are reminded below:
      - Prednisone or prednisolone is recommended at the initial daily dose of 1-2
         mg/kg for at least 2 weeks, followed by gradual tapering by 5-10 mg
         /week until reaching the lowest dose to maintain platelet count >20. Rapid
         tapering (10-20 mg /week) until discontinuation is recommended in case
         of no response to prednisone/prednisolone following 3 weeks of
         treatment.
      - IVIG- 1g/kg daily for 2 consecutive days, or 0.4 g/kg iv daily for 5 days is
         recommended in case of extreme thrombocytopenia or life threatening
         bleeding.


The decision to restart steroids and/or IVIG in relapsed patients is left to the
decision of the investigator.



                                                                                  29
Protocol nr. ITP 001                    Version 8                   Date: 18.01.2011


5.3     Baseline
        - Tests required prior to request for randomization.
        Available results of sample performed within 2 weeks (except for Bone
        Marrow aspirate) are acceptable:
.
           a. Complete blood counts.
           b. Blood smear: results at time of diagnosis of ITP.
           c. Bone marrow aspiration if none is available (any previous result
              allowing to confirm the diagnosis of ITP is acceptable).
           d. Renal and Liver function tests.
           e. Serologic tests for hepatitis B (HBsAg), hepatitis C (anti-HCV) and
              HIV.
           f. Direct Antiglobulin Test (DAT).
           g. Immunoglobulin quantification.
           h. Anti Nuclear Antibodies (ANA), anti-lupus anticoagulant and anti-
              cardiolipin antibodies.
           i. Helicobacter Pylori IgG titre and C13 urea breath test.
All laboratory tests will be performed in local laboratory.
When results are available the request for randomization form is faxed to the
coordinating pharmacy in Sykehuset Østfold Fredrikstad (SØF) (see section
5.5).


5.4     Informed Consent
A written consent should be obtained from each patient in accordance with the
recommendation of the revised Declaration of Helsinki.
Written informed consent will be obtained from the patient before any study
specific procedure is undertaken.




                                                                                 30
Protocol nr. ITP 001                 Version 8                     Date: 18.01.2011


Patients will be informed about the study, both verbally and by reviewing the
patient information sheet and consent form. The patient must be given the
opportunity to ask questions and given time to consider his or her participation.
The investigator and the patient will both sign and personally date the consent
form as confirmation of consent.


5.5    Randomization
The randomization process will be administrated by the coordinating pharmacy
in Sykehuset Østfold Fredrikstad (SØF).
A completed randomization form should be faxed to the randomization centre
(Hospital Pharmacy in Østfold Hospital Trust in Fredrikstad -fax number:
+47 69 38 50 01) to carry on the randomization process after checking the

eligibility criteria. Results of randomization will be forwarded to the local
hospital pharmacy for its implementation.




                                                                                31
Protocol nr. ITP 001                            Version 8                               Date: 18.01.2011


5.6     Treatment Plan




                                    Prerandomization Treatment
                 Prednisolone/prednisone 1 - 2mg /kg/ day for 2 weeks, followed
                                 by gradual tapering (5-10 mg/week)*


                                      Platelet count <30 (-50)**
                 After a minimum of 2 weeks treatment with prednisone/ Prednisolone


                                          Randomization




                                  Rituximab                     Placebo
                           Continue or reintroduce Prednisolon(e) at the
                         lowest dose required to maintain platelet count >20




                                             Follow-up
                                Every 6 weeks for 18 months, then every
                              3 months until the conclusion of the study.


                                             Treatment Failure
                              Predefined criteria for Splenectomy:
                                If >7.5 mg/day prednisone/prednisolone
                                 needed to maintain Platelet count >20
                                          OR Platelet count <20
* Rapid tapering (10-20 mg /week) and discontinuation in case of no response to prednisone/ prednisolone
following 3 weeks of treatment.
**Patients with a platelet count between 30 - 50 x 109 /l can also be included if a higher platelet count is
considered indicated or necessary.




                                                                                                         32
Protocol nr. ITP 001                   Version 8                  Date: 18.01.2011

5.7     Study treatment
The study treatment (Rituximab or placebo infusion) will be supplied blinded by
the respective local hospital pharmacy. Study treatment should be initiated as
soon as possible within 4 days after randomization.
a- Rituximab (Mabthera; Roche) 375 mg/m2 IV, given once weekly for four
consecutive weeks (for administration details and labels, see appendix).
b- Placebo- 250 ml or 500 ml Nacl 0.9 mg/ml will be provided by the local
hospital pharmacy.
c- Premedication- including oral acetaminophen (paracetamol) 1000 mg and
diphenhydramine 50 mg or equivalent should be given prior to i.v. infusion.


Administration of study treatment will be performed the same day of the week
for a given patient. In case of temporary contra-indication of rituximab infusion
(e.g. flu) the treatment infusion will be delayed. Nevertheless, maximum delay
authorized between two study drug infusions cannot exceed two weeks. The
reason for delay will be reported in an adverse event (AE) form. See also
Section 6.2 ―Prevention and treatment of adverse events‖.


5.8     Concomitant and rescue therapy
      - Prednisone or prednisolone: Dose tapering should continue (5-10 mg
         /week) after randomization until discontinuation or until reaching the
         lowest dose to maintain platelet count >20. Rapid tapering (10-20 mg
         /week) is recommended in case of no response to prednisone/prednisolone
         after 3 weeks of treatment. Steroids can be reintroduced after its
         discontinuation in case of relapse.
      - IVIG (1g/kg daily for 2 consecutive days, or 0.4 g/kg iv daily for 5 ) ±
         platelet concentrates can be given in case of severe thrombocytopenia
         with mucocutaneous bleeding manifestations, in case of life threatening



                                                                               33
Protocol nr. ITP 001                 Version 8                       Date: 18.01.2011


       bleeding complications or in preparation for an unplanned surgical
       procedure.
All treatments given in addition to the study treatments after inclusion in the
study or at any time during the study are regarded as concomitant treatments and
must be documented on the appropriate pages of the CRF.


Any of the following concomitant treatments when administered at the time of
inclusion or at any time before inclusion is a non inclusion criteria:
    Chemotherapy,
    Treatment with anti-D Ig,
    Treatment with Rituximab other than the study treatment,
       Immuno-suppressive treatments other than corticosteroids, Dapsone or
       Danazol,
    Any treatment inducing lymphocyte depletion,
    Any attenuated vaccine.


After inclusion any of the above listed concomitant treatments are to be avoided
throughout the duration of the follow-up of the patient. However, patients who
reach the study endpoint (Treatment failure) are allowed to receive any
treatment for ITP. Patients who develop severe thrombocytopenia or bleeding
are recommended to be treated with IVIG, until splenectomy can be performed.
Otherwise one may either increase the dose of steroid or watch the patient
without any treatment until splenectomy is performed.


Patients are not allowed to participate in another clinical trial involving drug
treatment throughout the duration of follow-up of 1.5 years unless the study end-
point is reached. However, patients who fulfil the criteria for splenectomy
should be followed-up until the end of study or for 90 days after splenectomy
has been performed.


                                                                                  34
Protocol nr. ITP 001                   Version 8                  Date: 18.01.2011


Vaccination:
The vaccination status of eligible patients for this study should be verified at
inclusion. The national guidelines for vaccination in each country must be
complied with before administration of rituximab. Except if contra-indicated
anti-pneumococcal and anti-haemophilus influezae vaccines are recommended
before start of rituximab treatment.
Pneumococcal vaccine and haemophilus influezae vaccine are recommended to
be administered at least 2 weeks prior to splenectomy except if contraindicated.
Pneumococcal antibody titre should be determined 3 months after splenectomy.
Revaccination is recommended if the antibody titre is low.
Plan a delay of 28 days between any vaccination and the first administration of
rituximab.


5.9    Splenectomy
Splenectomy is recommended in case of treatment failure which is defined as:
failure to achieve platelet count >20 109/L or need to pursue a daily dose of
prednisone / prednisolone > 7.5 mg to maintain a platelet count >20 x 10 9/L
(Cine et al, 2005;Godeau et al, 2007). Splenectomy should under no
circumstances, apart from the presence of a vital indication, be performed before
6 weeks from the first day of the administration of study medication.
Splenectomy can be performed at the local hospital or at a secondary referral
centre. The choice of procedure type, laparoscopic or laparotomy, will be made
by the operating centre according to their experience.
It is recommended to wait 6 months after diagnosis of ITP, before performing
splenectomy (Godeau B., Provan D., & Bussel J. (2007) Immune
thrombocytopenic purpura in adults. Curr.Opin.Hematol., 14, 535-556).
Pneumococcal vaccine is recommended to be administered at least 2 weeks prior
to splenectomy. Pneumococcal antibody titre should be determined 3 months
after splenectomy. Revaccination is recommended if the antibody titre is low.


                                                                                35
Protocol nr. ITP 001                   Version 8                     Date: 18.01.2011


5.10 Follow-up
-a- Study drug administration:
The first study drug administration must be within 4 days following receipt of
the randomization fax.
Concomitant treatment and adverse events if any will be recorded before and
after each study drug administration.


-b- Follow-up after the last study drug administration:
Follow-up visits are required at an interval of 6 weeks (+ 4 day) for 1.5 years,
then every 3 months (+ 7 day) until the conclusion of the trial. The first visit will
be performed 6 weeks after randomization. Follow-up information includes:
          a.    Platelet count (local laboratory) and response to treatment (For
               response evaluation at week 24 and 90 the platelet count and date
               for blood test have to be confirmed by two tests at least 1 week
               apart).
          b. Other treatments for ITP including splenectomy.
          c.    Prednisone /Prednisolone dosage.
          d. Changes in concomitant medications.
          e.    Registration of adverse events (except platelet count or
               splenectomy) (according to Common Terminology Criteria (CTC)
               for adverse events, version 3).
          f.    Bleeding manifestations: according to WHO classification,
               bleeding score for ITP, see 7.4 a-b.
          g. Thrombotic and infectious complications according to CTC.
          h. Contacts with health care providers and hospital admissions
          i.    Sick leaves.
-c- Follow-up after the primary end point has been reached: patients who fulfil
the criteria for splenectomy should be followed-up for 90 days after



                                                                                  36
Protocol nr. ITP 001                    Version 8                    Date: 18.01.2011


splenectomy has been performed or until the end of the study if splenectomy is
not performed.


If the patient undergoes splenectomy a visit will be performed 90 (+ 7 days)
after the splenectomy for:
     Date of splenectomy,
     Laparoscopic approach or conventional open surgical approach,
     Assessment of post-splenectomy complications,
     Platelet count,
     Response evaluation,
     Pneumococcal vaccine titre

6-       Safety Issues

6.1      Definition of adverse events
An Adverse Event (AE) is any untoward medical occurrence in a patient
administered a pharmaceutical product and which does not necessarily have to
have a causal relationship with this treatment. It can therefore be any
unfavourable and unintended sign, symptom, or disease temporally associated
with the use of a medicinal product, whether or not considered related to the
medicinal product.
All toxicity (except platelet count and splenectomy) will be graded according to
CTCAE v 3.0 guidelines.


Adverse events will be graded using the following criteria:
         Grade 1 (Mild): Discomfort noticed but no disruption of normal daily
         activity.
         Grade 2 (Moderate): Discomfort sufficient to reduce or affect normal
         daily activity.
         Grade 3 (Severe): Inability to work or perform normal daily activity.

                                                                                  37
Protocol nr. ITP 001                  Version 8                     Date: 18.01.2011


       Grade 4 (Life-threatening or disabling): Represents an immediate threat to
       life. Such events should also be reported as serious adverse event.


6.2    Prevention and treatment of adverse events
It is recommended that all patients should be pre-medicated with oral
paracetamol 1000 mg and diphenhydramine 50 mg or equivalent should be
given 30 to 60 minutes prior to the start of an infusion to reduce the potential for
infusion reactions. Patients administered an antihistamine should be given
appropriate warnings about drowsiness and impairment of driving ability or
operating machinery prior to discharge.
If the patient experiences an infusion reaction, it is recommended to interrupt
the infusion followed by the use of oral paracetamol 1000 mg, plus
intramuscular      or   slow   i.v.   antihistamine    administration,    such   as
diphenhydramine HCL (25 mg to 100 mg i.v. saline), i.v steroids and/or a
bronchodilator, may be needed.
For mild (non-allergic) infusion reactions, the infusion rate may be reduced or
the infusion may be temporarily interrupted at the investigator‘s discretion. The
infusion rate may gradually be increased in case of improvement of symptoms.
Patients who experience a severe infusion-related reaction like dyspnoea or
bronchospasm should have their infusion interrupted immediately and should
receive aggressive symptomatic treatment. The infusion should not be re-started
until all the symptoms have disappeared and after the normalization of
biochemical and /or radiological tests like chest X-ray. On re-starting the
infusion, the rate should be half that which precipitated the reaction.
For life-threatening events, including anaphylaxis, for which all appropriate
standard measures, including full resuscitation medications and equipment, must
be available and should be used as clinically indicated. In case of life-threatening
events definitive withdrawal of rituximab should be considered.



                                                                                 38
Protocol nr. ITP 001                 Version 8                      Date: 18.01.2011


Adverse events, especially those for which the relationship to test ―drug‖ is
considered ―related‖ by the Investigator or not listed in the Summary of Product
characteristics of rituximab and not commonly related to ITP, should be
followed up until they have returned to baseline status or stabilized.
PML usually manifests with subacute neurologic deficits including altered
mental status, motor deficits (hemiparesis or monoparesis), limb ataxia, gait
ataxia, and visual symptoms such as hemianopia and diplopia. Patients should
be made aware of and be informed to immediately report such symptoms. In
such case immediate referral to neurologists for MRI and lumbar puncture is
mandated. Cerebrospinal fluid should be tested for DNA of JC- virus.
(Mabthera/Procedure steps taken and specific information after the authorization
changes made after 01/01/2005 emea2008
www.emea.europa.eu/humandocs/PDFs/EPAR/Mabthera/025998en8b.pdf; last
access: 12.12.2008).


6.3    Registration of adverse events
All clinical AEs and/or clinically significant laboratory abnormality (except
platelet count) encountered during the study period will be reported on the AE
form of the CRF.
All infectious adverse events will be collected, irrespective of causality. Because
rituximab depletes peripheral CD20+ B-cells, particular attention should be
directed toward early identification and treatment of infections. Therefore, for
all serious infectious adverse events reported Complete Blood Counts,
differentials, quantitative Ig will be determined within 1 week of the event
becoming serious. Relationship of the adverse event to the treatment should
also be assessed.




                                                                                 39
Protocol nr. ITP 001                   Version 8                      Date: 18.01.2011


6.4      Definition and reporting of serious adverse events (SAE)
Any clinical adverse event or abnormal laboratory test value that is serious
occurring during the course of the study, irrespective of the treatment received
by the patient. Serious adverse events (SAE) must be reported within 24 hours
of the site observing or learning of the event to
In Norway and Sweden: Roche Norway (Fax: + 47 22789099).
Other countries: Roche France (Fax: +33 (0) 1 46 40 42 50) and the sponsor
Rikshospitalet, att: Dr Pål Andre Holme (Fax: +47 23074670)
A serious adverse event is any experience that suggests a significant hazard,
contraindication, side effect or precaution. This includes any experience which:

          -threatening
               -patient hospitalization or prolongation of existing hospitalization
 results in persistent or significant disability/incapacity
                                            rvention to prevent one or other of the
      outcomes listed above


6.5      Premature study drug discontinuation
The study treatment should be discontinued permanently under the following
circumstances:
      - Life threatening allergic reaction to rituximab.

      - Related adverse events: study treatment can be stopped following a severe
         or life-threatening adverse experience at the discretion of the treating
         investigator.

      - Non-related adverse events: study treatment can be stopped following a
         severe or life-threatening adverse experience at the discretion of the
         treating investigator.

      - In the case of irrevocable decision by the patient and/or the responsible


                                                                                   40
Protocol nr. ITP 001                     Version 8                  Date: 18.01.2011


          investigator. These patients will be asked their authorisation to undergo
          the standard study follow-up performed (as treatment refusal does not
          imply a complete study discontinuation).
      -   If emergency splenectomy is performed as a life saving measure for rapid
          elevation of the platelet count.
The reason of premature study drug discontinuation must be documented in the
CRF with the date of the last study drug administration.
In case of premature study drug discontinuation (See also Section 6.6 Patient
withdrawal or discontinuation) for details on procedures to follow in case of
study drug discontinuation.

All patients who have received at least one dose of double-blind treatment will
be evaluable for safety analysis.

6.6       Patient withdrawal or discontinuation
A patient may voluntarily discontinue his or her consent to the participation in
this study at any time. The investigator may also, at his or her discretion,
discontinue the patient from participating in this study at any time.
If a patient is prematurely discontinued from the study for any reason, before the
first study drug administration the investigator must complete the End of Study
Form.
If a patient is prematurely discontinued from the study for any reason, after the
first study drug administration, the investigator must make every effort to
perform the assessments as outlined in the end-of-study evaluation. These data
should be recorded in the medical record and CRF, as they consist of an
essential evaluation that should be done prior to discharging any patient from the
study.
The primary reason for withdrawal will be clearly documented in the patient‘s
medical record and recorded in the CRF.



                                                                                 41
Protocol nr. ITP 001                   Version 8                  Date: 18.01.2011


If a patient has a premature treatment discontinuation, he/she should stay in the
study except if the patient withdraws consent.


Patients will be withdrawn from the study for the following administrative
and/or medical reasons:
 Splenectomy: after the visit planned in the protocol 90 days after the
    splenectomy

 Withdrawal of consent by the patient: data will be collected and included in
    the analysis up to the date of consent withdrawal.

 Patient refusal of further treatment (except splenectomy): reason for refusal
    must be clearly documented in the patient‘s medical records and CRF.

 Death.

 Major protocol deviations: to be documented.

 Investigator‘s decision: to be documented.

 After 1.5 year of follow-up if study is not closed and the investigator would
    like to include the patient in another clinical trial.

 Other reason: to be documented.

6.7 Pregnancy and lactation
    Pregnancy
    IgG immunoglobulins are known to cross the placental barrier. B cell
    levels in human neonates following maternal exposure to MabThera
    have not been studied in clinical trials. There are no adequate data
    from studies in pregnant women, however transient B-cell depletion
    and lymphocytopenia have been reported in some infants born to
    mothers exposed to rituximab during pregnancy. For these reasons
    MabThera should not be administered to pregnant women.
    Developmental studies revealed no evidence of embryotoxicity in

                                                                               42
Protocol nr. ITP 001                 Version 8                  Date: 18.01.2011


      utero, but offspring of maternal animals exposed to MabThera were
      noted to have depleted B cell populations during the post natal
      phase.
      Due to the long retention time of rituximab in B cell depleted patients,
      women of childbearing potential should use effective contraceptive
      methods during treatment and for 12 months following MabThera
      therapy.
      Lactation
      Whether rituximab is excreted in human milk is not known. However,
      because maternal IgG is excreted in human milk, and rituximab was
      detectable in milk from lactating monkeys, women should not
      breastfeed while treated with MabThera and for 12 months following
      MabThera treatment.

7-      Measurements and definitions

7.1     Previous episode and concurrent ITP
The disease is considered as previous episode of ITP if sustained complete
remission (platelet count > 150x 109/l) remained for >3 months without any
platelet elevating medications. Otherwise, the ITP is considered as part of the
concurrent episode.


7.2     Response criteria

- Complete response (CR) is defined as an increase in platelet counts to >150
 x 109/l on two consecutive occasions, at least 1 week apart.

- Partial response (PR) is defined as an increase in the platelet count to >50
 x 109/l with at least a twofold increase from baseline, on two consecutive
 occasions, at least 1 week apart.



                                                                             43
Protocol nr. ITP 001                     Version 8                Date: 18.01.2011


- Minor response (MR) is defined as an increase in the platelet count to
 between 30 and 50 x 109/l on two consecutive occasions, at least 1 week apart
 in a patient with platelet count < 30 x 109/l at inclusion.

- No response (NR): none of the above condition is met by the patient
 throughout the follow-up of the patient. There will be no distinction between
 worsening and NR.

The best overall response for a given patient will be included in the statistical
analysis.


7.3    Relapse and duration of response

- Relapse is defined as platelet count <30 x 109/l after achieving an initial
 response (CR, PR or MR).

- Duration of response is defined from the date of achieving a platelet level
 >30 (or > 50 x 109/l depending on the platelet count at randomization) on two
 consecutive measurements at least 1 week apart to the first date of a platelet
 count <30 x 109/l on two consecutive measurements with 1 week apart or to
 time of analysis.

7.4    Bleeding
A-     Bleeding manifestations/complications are required to be reported
according to WHO criteria for bleeding at inclusion, at every follow-up visit and
prior to splenectomy if applicable:


Grade 0                no bleeding
Grade I                Petechiae
Grade II               Mild blood loss



                                                                               44
Protocol nr. ITP 001                   Version 8   Date: 18.01.2011


Grade III              Gross blood loss
Grade IV               Debilitating blood loss




                                                                45
Protocol nr. ITP 001                        Version 8                       Date: 18.01.2011


B- The Bleeding score (Khellaf et al, 2005) for ITP has to be reported at
     inclusion, at the follow-up visits.


                                      Age
> 65 years                                                                        2
>75 years                                                                         5
                             Cutaneous bleeding
Localized petechial purpura (legs)                                                1
Localized ecchymotic purpura                                                      2
2 locations of petechial purpura                                                  2
Generalized petechial purpura                                                     3
Generalized ecchymotic purpura                                                    4
                                Mucosal bleeding
Unilateral epistaxis                                                              2
Bilateral epistaxis                                                               3
Hemorrhagic oral bullae, spontaneous gingival bleeding or both                    5
                          Gastrointestinal bleeding
Gastrointestinal haemorrhage without anaemia                                      4
Gastrointestinal hemorrhage with acute anemia (>2 g Hb fall in 24 hours)          15
and/or shock
                                Urinary bleeding
Macroscopic hematuria without anemia                                              4
Macroscopic hematuria with acute anemia                                           10
                        Genitourinary tract bleeding
Major meno/metrorrhagia without anemia                                            4
Major meno/metrorrhagia with acute anemia                                         10
                       Central nervous system bleeding
Central nervous system bleeding and /or life threatening bleeding                 15
                                                                    Total score




                                                                                         46
Protocol nr. ITP 001                Version 8                     Date: 18.01.2011




7.5    Infectious complications
Infectious complications are required to be reported according to CTC criteria
(CTCAE v. 3.0), at every follow-up control:




                                                                                 47
Protocol nr. ITP 001                   Version 8                   Date: 18.01.2011


8-     Study Drug Supply and Handling
8.1    Study drug supply
Rituximab will be provided in boxes containing either one bottle of rituximab
500 mg or two bottles of rituximab 100mg

8.2       Packaging and Labelling (for Drugs Supplied by the Sponsor)

Ritiximab is supplied in bottles that are packed in cardboard boxes
The labels are:

               - Primary label on the bottle

               - Secondary packaging label

               - Label for perfusion
Primary label on the bottle and secondary label should contain the following
information:

 Brand name of the Drug Product
 Drug substance name and dosage
 Route of Administration
 Sponsor name (Rikshospitalet),
 Storage conditions,
 Specific legal statements if any and according to the country,
 Pharmaceutical form
 Eudract number,
 Batch number and expiry date


On the non-transparent bag the label for perfusion will contain the following
information:
 Study number
 Sponsor name (Rikshospitalet),



                                                                                48
Protocol nr. ITP 001                   Version 8                   Date: 18.01.2011


 Ritxumab or Placebo,
 For Intravenous use only
 Storage conditions,
 Specific legal statements if any and according to the country,
 Eudract number,
 Total volume of the perfusion bag
 Dosage/ml: to be completed by the pharmacist
 Centre number: to be completed by the pharmacist
 Patient number: to be completed by the pharmacist
 Date and hour of dilution: to be completed by the pharmacist
 Date and hour of administration: to be completed at the start of infusion


8.3    Study drug storage conditions

Rituximab vials are stable at 2-8 ºC (36-46 ºF) and should be protected from
direct sunlight. Vials should not be used beyond the expiration date stamped on
the carton.
Rituximab solution after preparation for infusion is biologically and chemically
stable at 2-8 ºC (36-46 ºF) for 24 hours. Rituximab solution for infusion has been
shown to be stable for an additional 12 hours at room temperature, however,
since Rituximab solution do not contain a preservatives, diluted solutions should
be stored refrigerated 2-8 ºC. No incompatibilities between rituximab and
polyvinylchloride or polyethylene bags have been observed.
Study drug prepared for infusion will be masked in a sealed opaque pocket to
guarantee the double-blind. The pocket will be identified by the study number
and patient number with the mention ‗to be used before‘ date and hour of
expiration‘.




                                                                                49
Protocol nr. ITP 001                     Version 8                   Date: 18.01.2011


8.4      On Site Drug Accountability and Dispensing

The study drugs will be provided free of charge by the Sponsor.
The hospital pharmacist or investigator will be responsible for adequate storage
of the study medications according to the manufacturer recommendations and
for dispensing the treatment to the patients. The study medication will have to be
used in accordance with the protocol and only by the Investigator or properly
trained delegated representative.
The Investigator and/or pharmacist will have to maintain adequate and accurate
records, showing the receipt and distribution of all supplies of the study
medication delivered by the Sponsor and the storage temperature.

These records will include:

 all the accompanying letters, which list the batch number of the medication,
      the quantities received, and the date of receipt,

 the Drug Accountability Forms, which include:

       - the patient‘s identification,
       - the date of dispensation,
       - each quantity dispensed and,
       - the identification of the dispenser.
The original will be kept by the Sponsor and two copies will be left on site: one
in the pharmacist‘s file and one in the investigator‘s file.
A summary document entitled ―Accountability of investigational products on
site‖ will be produced, which describes all the movements of investigational
products during the study. The original will be left in the pharmacist‘s file; one
copy will be kept in the study file and one copy in the investigator‘s file.


8.5      Unused Drug and Destruction



                                                                                  50
Protocol nr. ITP 001                 Version 8                     Date: 18.01.2011


Unused study medications have to be kept by the investigator or returned to the
hospital pharmacist. All unused drugs must be either destroyed or returned to the
sponsor. Destruction will be performed according to both sponsor and
investigator centre procedures. It is the Investigator‘s or pharmacist‘s
responsibility to insure that the study medication used by the patients plus the
left over unused study medication equal the total amount received from the
Sponsor. Any discrepancy should be explained.




9-     Statistics and Data Management


9.1    Number of patients
       Recent publications indicate that the rate of splenectomy after treatment
       with Rituximab is 40 % at 2 years (Godeau et al, 2008). On the other
       hand it is known that up to 30 % of patients with ITP can achieve durable
       responses after treatment with steroids (Godeau et al, 2007).
       Based on this information we assessed the sample size by assuming a rate
       of treatment failure at 18 months of 70 % in the placebo arm and 40 % in
       rituximab arm, corresponding to a hazard ratio rituximab/placebo of 2.57.
       With a two-sided log-rank test, a power of 80 % and type 1 error of 5%,
       41 events are needed corresponding to around 46 patients randomized in
       each treatment group.     Assuming 10-20 % dropouts before treatment
       failure (those patients will be considered as censored at the time of drop-
       out), the sample size is multiplied by 1.2 leading to 110 included patients.
       Trial will be stopped after 41 events have been observed. Patients will be
       followed up to 18 months. As for the secondary endpoints, the difference
       in response rates will be analyzed using Kaplan-Meier and log-rank test.
       No interim analysis will be performed.



                                                                                51
Protocol nr. ITP 001                      Version 8                   Date: 18.01.2011




       Data analysis and statistical tests
       Three different populations will be defined:
   1. Full Analysis Set (FAS) will be defined as all patients having received at
         least one dose of study drug treatment. Main analysis will be statistical
         analysis on full analysis set.
   2. Per protocol population will be defined as all patients included in the FAS
         populations with no major protocol violations. Statistical analysis on per
         protocol population will be performed if PP represents less than 80% of
         the FAS population.
   3. Safety population corresponding to all patients having received at least
         one study drug dose.


All data at inclusion will be described in each treatment group. No statistical
comparison will be performed on data at baseline.
The following statistics will be used for the descriptive analyses:
        For quantitative variables: mean, standard deviation, median and ranges,
         total number and number of missing data
        For qualitative variables: numbers and percentages, number of missing
         data.


All statistical tests will be two-sided. Significant statistical threshold will be set
at 5%.
A detailed statistical analysis plan will be established before the freezing of the
database and the start of the statistical analysis.


Main criterion of efficacy




                                                                                   52
Protocol nr. ITP 001                Version 8                     Date: 18.01.2011


The proportion of surviving (no treatment failure) patients in each group will be
estimated using Kaplan-Meier method and plots of survival free proportions in
each group according to time will be displayed.
The 95% Confidence Intervals of median time to treatment failure and survival
free event rate of treatment failure at 18 months will be estimated in each
treatment group by Kaplan-Meier method.
Hazard rates of the 2 randomisation groups will be compared by a two-sided
log-rank test.


Adjusted effect
If the hazard rates are proportional a multivariate analysis using Cox
proportional hazard model will be performed to adjust for the risk factors of the
major outcome.


Safety analysis
The adverse events (AE) will be coded using the latest version of the Medical
Dictionary for Regulatory Activities (MedDRA).
Splenectomy will not be included in the AEs as it is regarded as an efficacy
criterion.
All AE‘s will be listed and summarised by treatment group using the number
and percentage of patients for the safety population. A general summary of AE‘s
will be presented. This summary table will include the number and percentage
of patients with at least one AE, and the number of discontinuations due to an
AE, the number of SAEs and the number of deaths due to an AE.


The incidence and frequency of AE‘s will be summarised by system organ class
(SOC) and preferred term in a separate table.
No formal comparison will be made between the treatment groups since the
power of these comparisons would certainly be very weak. Instead the two-sided


                                                                                 53
Protocol nr. ITP 001                Version 8                     Date: 18.01.2011


95% confidence intervals of the proportion of patient having reported each AE
will be computed by treatment group (provided the rate of these AEs would be
at least 5%).



9.2    Randomization
Sequence generation
The randomization list will be generated by the unit of epidemiology and
biostatistics, centre of clinical research, Ullevål University Hospital. Permuted
block randomization with stratification on country outside Norway and in
Norway on treatment centre or centre region (for small centres) will be used to
generate random allocation sequence. The block size is kept confidential.
No replacement of randomized patient will be performed.


Allocation concealment
Treatment assignment is placed in sealed opaque envelopes. The envelopes are
marked by the randomization number and centre number. A new patient will be
allocated the lowest numbered envelope. The investigator, the participant,
personnel administrating the intervention and those assessing the outcome are
blinded to group assignment. The sealed envelopes will be kept and
administrated d by the coordinating pharmacy in SØF. The allocation sequence
is concealed. Study coordinator and /or study investigators have no access to the
envelopes.
In each site only the pharmacist is unblinded to the treatment and if the
investigator requires for safety reason the breaking of the code then this
unblinding must be documented with the date and the hour and the name of the
people having requested the break of the code and the name of the person having
broken the code. The sponsor should be informed within one working day (fax
number: see page 2) so as the CRA in charge of the site.


                                                                                54
Protocol nr. ITP 001                  Version 8                     Date: 18.01.2011


Allocation of study treatment outside Norway
As subjects are screened for the study, they must be allocated a
registration/identification number.      The identification number is a 5-digit
number made up of the centre number and the subject number within that
particular centre (eg, the first subject screened at centre number 001 would be
assigned the identification number 01001, the second subject screened would be
01002 and so on). This number is the subject‘s unique identifier and is used to
identify the subject on the case report form (CRF).


All screened subjects are assigned an identification number irrespective of
whether or not they are subsequently randomised to receive study treatment.


Subject eligibility will be established before treatment randomisation. Subjects
will be randomised strictly sequentially, as subjects are eligible for
randomisation. If a subject discontinues from the study, the subject number will
not be reused, and the subject will not be allowed to re-enter the study.
All inclusion/exclusion criteria will be checked at screening by the investigator
in accordance with Good Clinical Practice (GCP). A reduced set of information
on patients not included after the screening period will be entered in screening
log file: especially patients screening number and reason for non-inclusion.
Patients withdrawn from the study after inclusion will retain their patient
number. New patients must always be allocated a new patient number.
The randomisation will be generated upon satisfaction of all inclusion criteria,
including the procurement of written informed consent.
Patients having failed at screening and before randomisation can be re-screened
later on providing that they fulfil inclusion/exclusion criteria.


To request allocation of study drug treatment the investigator will send by fax
the completed request of randomization form to:


                                                                                  55
Protocol nr. ITP 001                  Version 8                     Date: 18.01.2011


 The Hospitalpharmacy in Østfold hospital Trust –Fredrikstad,
      fax number: + 47 69 38 50 01.
 Monitoring Force France, fax number: + 33 1 39 62 15 27

Within 2 working days the sponsor will send back a fax of randomization with
the randomization number to:
 The pharmacist of the investigator centre with the allocated treatment
 The investigator with no identification of the study treatment, to confirm the
      randomization
 To Monitoring Force France, with no identification of the study treatment,
      fax number: + 33 1 39 62 15 27 to confirm the randomization
If the randomization is refused by the sponsor the same procedure will be
followed with the reason why the patient cannot be randomized.


9.3      Enrolment period
We have estimated an accrual period of 5 years and total study duration of 6,5
years.

9.4      Data management
CRF´s should be completed prospectively and copies should be mailed to the co-
ordinating centre.



10-      Trial organization


The study is an investigator initiated study which will run independently of the
pharmaceutical industry. The study will be a major collaborative effort among
hospitals in all health regions in Norway and other European centres.




                                                                                 56
Protocol nr. ITP 001                  Version 8                        Date: 18.01.2011


10.1 Committees


Executive committee
           Pål Andre Holme
           Waleed Ghanima


Steering committee


           Geir E. Tjønnfjord
           Johannes Kahrs
           Per Morten Sandset
           Lorentz Brinch
           Anders Waage
           Michael Abdelnoor
           Hans Wadenvik
           Marc Michel
           Other members from collaborating hospitals/regions


Safety and monitoring committee.
           Per Morten Sandset
           Tobias Gedde-Dahl
The function of the safety and monitoring committee is to a- monitor the
progress of trial, b- to review on a regular basis the accumulated research data
and c- to advise the sponsor and/or researcher regarding the continuing safety of
trial subjects and those yet to be recruited into the research trial




                                                                                    57
Protocol nr. ITP 001                 Version 8                    Date: 18.01.2011


11-    Ethics


The study will recruit patients with ITP refractory to corticosteroid treatment.
Even though the efficacy of Rituximab in the treatment of ITP remains to be
established, many centres currently offer Rituximab to selected patients with
ITP despite the lack of proper documentation of its effect.
The study will be performed in accordance with the revised Helsinki Declaration
and Good Clinical Practice. The study will only start after approval with the
Regional Ethics Committee and the Norwegian Medical Agency. Outside
Norway, the study will only start after all local Regulatory requirements have
been fulfilled. All patients will be given study specific identification codes and
all data will be stored and handled in a secured database.




                                                                               58
Protocol nr. ITP 001                 Version 8                     Date: 18.01.2011



12- Regulatory considerations

This study will be conducted in accordance with:

 The Declaration of Helsinki adopted by the World Medical Association,
 ICH GCP guidelines, and
 Local regulatory requirements.

12.1- Regulatory Approval / Authorization
The regulatory permission for conducting the study will be obtained in
accordance with local regulatory requirements. All approvals must be obtained
before a patient is exposed to a study-related procedure or even screening tests
for eligibility.

12-2 Investigators Obligations
Before the study starts, the investigator shall supply the sponsor or its
representative with his/her curriculum vitae and complete a list giving the
names, functions and authorized activities of all persons who will exercise any
kind of responsibility in carrying out of the study.
The investigator ensures the quality of the study through strict observance of the
ICH GCP and the protocol. The investigator must ensure that the study has been
approved by all required institutional ethics and scientific committees prior to
enrolling patients and on an ongoing basis as required by each committee. The
investigator is required to obtain written informed consent from each patient
prior to study entry


12.3- Change in the conduct of the study


12.3.1- Protocol Amendment
Neither the investigator nor the sponsor may alter the protocol without the
permission of the other party.


                                                                                59
Protocol nr. ITP 001                 Version 8                    Date: 18.01.2011


All changes to the protocol will be subject to an amendment which must be
dated and signed by both parties and must appear as an addendum to the
protocol.
Substantial amendments will be submitted for approval / authorisation to
relevant Ethics Committees and CA.
Urgent amendments will be submitted for approval / authorisation to relevant
Ethics Committees and CA, but can be implemented immediately under specific
conditions defined by the Sponsor.


12.3.2- Study Termination
Upon completion of the study, the following activities, when applicable, must be
conducted by the monitor in conjunction with the investigator, as appropriate:

 Return of all study data to the sponsor,
 Data clarifications and/or resolutions,
 Accounting, reconciliation, and final disposition of used and unused study
   drugs,
 Review of site study records for completeness,


12.3.3- Early Study Termination Decided by the Sponsor
The sponsor may discontinue the study at any time for reasons such as:

 Emerging AEs of such a serious nature that continuation of the study
   becomes unacceptable,
 Recruitment rate too low to allow completion of the study within the planned
   period.


If the study is prematurely discontinued, all study data must be returned to the
sponsor. In addition, the site must conduct final disposition of all unused study
drugs in accordance with the sponsor procedures for the study.


                                                                                 60
Protocol nr. ITP 001               Version 8                    Date: 18.01.2011


All efforts should be done to perform for each relevant patient an End-of-Study
Evaluation before study termination.




                                                                             61
Protocol nr. ITP 001                   Version 8                   Date: 18.01.2011




12.4 Insurance Policy

In accordance with the provisions of the law and ICH GCP, the sponsor has an
insurance policy intended to guarantee against possible damages resulting from
research.
The studies and/or experiments performed on behalf of the sponsor are
specifically and expressly guaranteed. It is advisable to underline that non-
compliance with the research legal conditions are clauses of guarantee
exclusion.
The insurance policy will be provided as a separate document.



13-    Quality Control and Quality Assurance

13.1 Source Data and Documents

Source data are defined as all information available in the original source
document or certified copies of the source document of any clinical findings,
observations, or other activities that are necessary for the reconstruction and
evaluation of the study.
For each patient included, the investigator will indicate in the source documents
that the patient participates in this study, and will record the appropriate
information. This will include (non-exhaustive list): patient name, date of birth,
sex, medical history, information that the patient is included in the study, visit
dates, product administration, primary evaluation criteria, nature of AEs with
date of start and related treatment.
Criteria of efficacy evaluation for which the CRF is considered as source
document will be stated by the sponsor by mail.
The investigator will permit study-related monitoring, audit(s), and regulatory
inspection(s), with a direct access to all the required source documents each time

                                                                                62
Protocol nr. ITP 001                   Version 8                       Date: 18.01.2011


it is necessary provided that patient confidentiality is protected. The extent of
source data verification performed by the monitor is 100% of critical data
(regarding eligibility criteria, treatment administration, safety and efficacy
assessment) to be verified per CRF.
Source documents will be preserved for the maximum period of time requested
by local recommendation or ICH, whichever occurs the last.


13.2 Periodic Monitoring
In addition to the initial visit for site-initiation, the monitor will contact and visit
the investigator periodically to evaluate the study progress and the compliance
of the study site with GCPs, regulations and the study protocol as well as to
verify and collect data reported in the CRF. The investigator as well as any
study staff member will cooperate with the monitor to ensure that any problem
that may be identified is resolved.
The first monitoring visit will occur as soon as possible after the first patient
inclusion. Intervals may be adjusted according to patient accruals, protocol
changes or site performance.


13.3 Audit and Inspection
The investigator will make all study-related source data and documents available
to a quality assurance auditor mandated by the sponsor, or to domestic or foreign
regulatory inspectors, after appropriate notification. The main purposes of an
audit or inspection are to confirm that the rights and well-being of the patients
have been adequately protected, and that all data relevant for the evaluation of
the study drug have been processed and reported in compliance with ICH GCP
and applicable regulatory requirements.




                                                                                     63
Protocol nr. ITP 001                 Version 8                      Date: 18.01.2011


14.- Data Handling and Record Keeping


14.1- Information
The site personnel, e.g. residents, nurses, laboratory technicians and any other
personnel providing care to the study patients or handling biological specimen
will be informed by the sponsor and/or the investigator of the characteristics of
the study design, study drug and receive safety instructions.


14.2- Case Report Forms
For each patient included, a CRF must be completed, in English, by the
investigator or designee and signed by the investigator. If a patient is withdrawn
from the study, the reason must be noted in the CRF. If a patient is withdrawn
from the study because of a treatment-limiting AE, thorough efforts will be
made to clearly document the outcome.
All CRFs will be completed in a neat, legible manner to ensure adequate
interpretation of data. A black ballpoint pen will be used to ensure clarity of all
reproduced CRFs.
A reduced set of information on patients not included after the screening period
will be entered in screening log file: especially patients screening number and
reason for non-inclusion.


14.3- Changes to CRF Data
Errors occurring in CRFs will be crossed out with a single line without
obscuring the initial entry, the correction will be written alongside the initial
entry, and the change will be initialled and dated by the investigator or designee.
If not obvious, the reason of the change will be given on the additional
comments place in the CRF. Correction fluid or any other means of obliteration
of entries must not be used. Any correction made on the original CRF page must
also appear clearly on all CRF pages copies.


                                                                                 64
Protocol nr. ITP 001                  Version 8                    Date: 18.01.2011


When changes to CRF data are necessary following the removal of an original
CRF from the study site, such changes will be documented on a query form that
will be signed by the investigator or designee.


14.4- Provision of Additional Information
On request, the investigator will provide the sponsor or its representative with
additional data relating to the study, or copies of relevant source documents,
duly anonymised. This is important for example when CRFs are illegible or
when errors in data transcription are encountered.


In case of particular issues or governmental queries, it may be necessary to have
access to the complete source documents, provided that the patients‘
confidentiality is protected in accordance with applicable requirements.



15- Reporting and Publication

15.1- Clinical Study Report(s)

Data analyses, statistical reporting and clinical research report(s) preparation
will be the responsibility of the sponsor.
Upon completion of the data analysis, a final report, including a review of the
objectives and methods, a presentation and discussion of the results will be
drawn up. This report will be signed by the sponsor representative(s) and the
coordinating investigator(s).


15.2- Confidentiality of Study Data
Any confidential information relating to the study, including any data and results
from the study is the property of the sponsor. Documents are supplied to the
investigators under conditions of strict confidentiality. Neither the investigator


                                                                                65
Protocol nr. ITP 001                 Version 8                      Date: 18.01.2011


nor any person working on his/her behalf may disclose any of the information
therein without having obtained prior written consent from the sponsor.


15.3- Publication Policy
The results of this study may be published or presented at scientific meetings. If
this is envisaged, the investigators agree to submit all manuscripts or abstracts to
the sponsor prior to scientific meeting or journal submission. This allows the
sponsor to protect proprietary information and to provide comments based on
information from other studies that may not yet be available to the investigator.
The publication rules will follow the recruitment rate: coordinator Waleed
Ghanima -first name, the following names according to recruitment rate in the
study; Pål Andre Holme- last name.
In accordance with consistent editorial practice, the sponsor supports publication
of multi-centre studies in their entirety and not as individual centre data unless
ancillary study/data. A publication in which the contribution of the sponsor‘s
personnel exceeded that of conventional monitoring will be considered as a joint
publication by the investigator and this person.


16- Archiving

16.1- Investigator Site File
The investigator is responsible for maintaining all records that enable the
conduct of the study at the site to be fully documented, in accordance with the
ICH GCP standard and applicable legal requirements.
This documentation will be kept by the investigator for at least 5 years following
the end of the trial.      If a longer archiving period is required, the local
law/regulation must be followed.
No study site document may be destroyed without prior written agreement
between the investigator and the sponsor. Should the investigator elect to assign



                                                                                 66
Protocol nr. ITP 001                   Version 8                       Date: 18.01.2011


the study documentation to another party, or move it to another location, the
sponsor must be notified.
If the investigator cannot guarantee this archiving requirement on site for any or
all of the documents, special arrangements must be made between the
investigator and the sponsor to store these in a sealed container away from the
site so it can be returned sealed to the investigator in case of an audit/inspection.


16.2- Study Master File
The sponsor will archive the study master file in accordance with GCP and
applicable regulatory requirements.




17. References

Arnold DM, Dentali F, Crowther MA, Meyer RM, Cook RJ et al. (2007) Systematic
      review: efficacy and safety of rituximab for adults with idiopathic
      thrombocytopenic purpura. Ann Intern Med, 146,25-33;

Braenstrup P, Bjerrum OW, Nielsen OJ, Jensen BA, Clausen NT, Hansen B, et al.
      (2005) Rituximab chimeric anti-CD20 monoclonal antibody treatment for adult
      refractory idiopathic thrombocytopenic purpura (ITP). Am J Hematol 78, 275-
      280.

Bussel J.B., Cheng G., Saleh M.N., Psaila B., Kovaleva L., Meddeb B., Kloczko J.,
       Hassani H., Mayer B., Stone N.L., Arning M., Provan D., & Jenkins J.M. (2007)
       Eltrombopag for the treatment of chronic idiopathic thrombocytopenic purpura.
       N.Engl.J.Med., 357, 2237-2247.

Bussel J.B., Kuter D.J., George J.N., McMillan R., Aledort L.M., Conklin G.T., Lichtin
       A.E., Lyons R.M., Nieva J., Wasser J.S., Wiznitzer I., Kelly R., Chen C.F., &
       Nichol J.L. (2006) AMG 531, a thrombopoiesis-stimulating protein, for chronic
       ITP. N.Engl.J.Med., 355, 1672-1681.

Bussel J.B. & Pham L.C. (1987) Intravenous treatment with gammaglobulin in adults
       with immune thrombocytopenic purpura: review of the literature. Vox Sang., 52,
       206-211.

Cheng Y., Wong R.S., Soo Y.O., Chui C.H., Lau F.Y., Chan N.P., Wong W.S., & Cheng
      G. (2003) Initial treatment of immune thrombocytopenic purpura with high-dose
      dexamethasone. N.Engl.J.Med., 349, 831-836.



                                                                                     67
Protocol nr. ITP 001                    Version 8                        Date: 18.01.2011

Cines DB & Bussel JB (2005) How I treat idiopathic thrombocytopenic purpura (ITP).
       Blood , 106,2244-2251

Cines,D.B. & McMillan,R. (2005) Management of Adult Idiopathic Thrombocytopenic
       Purpura. Annu.Rev.Med., 56, 425-442.

Cohen YC, Djulbegovic B, Shamai-Lubovitz O, Mozes B. (2000) The bleeding risk and
      natural history of idiopathic thrombocytopenic purpura in patients with
      persistent low platelet counts. Arch Intern Med, 160, 1630-1638.

Cooper N, Evangelista ML, Amdori S & Stasi R. (2007) Should rituximab be used
      before or after splenectomy in patients with immune thrombocytopenic purpura?
      Curr Opin Hematol, 14:642-646.

Cooper,N., Stasi,R., Cunningham-Rundles,S., Feuerstein,M.A., Leonard,J.P.,
      Amadori,S., & Bussel,J.B. (2004) The efficacy and safety of B-cell depletion with
      anti-CD20 monoclonal antibody in adults with chronic immune
      thrombocytopenic purpura. Br.J.Haematol., 125, 232-239.

Cortelazzo,S., Finazzi,G., Buelli,M., Molteni,A., Viero,P., & Barbui,T. (1991) High risk
       of severe bleeding in aged patients with chronic idiopathic thrombocytopenic
       purpura. Blood, 77, 31-33.

den Ottolander,G.J., Gratama,J.W., de,K.J., & Brand,A. (1984) Long-term follow-up
      study of 168 patients with immune thrombocytopenia. Implications for therapy.
      Scand.J.Haematol., 32, 101-110.

Dolan JP, Sheppard BC, DeLoughery TG. (2008) Spenectomy for immune
      thrombocytopenic purpura: surgery for the 21st century. Am J Hematol 83,93-96.

El-Najjar I, Rule SAJ & Nokes TJC . (2006) A fixed, low-dose of anti-CD20 antibody
       (Rituximab) is an effective treatment for patients with chronic immune
       thrombocytopenia. Br J Haematol, 133 (suppl. 1), 79 (Abstract 196)

Frederiksen,H. & Schmidt,K. (2004) Incidence of idiopathic thrombocytopenic purpura
      among adults. Br.J.Haematol., 125, 90-91.

Garvey B. (2008) Rituximab in the treatment of autoimune haematological disorders. Br
      J Haematol, 141, 149-169.

George,J.N., El-Harake,M.A., & Raskob,G.E. (1994) Chronic idiopathic
      thrombocytopenic purpura. N.Engl.J.Med., 331, 1207-1211.

George J.N., Woolf S.H., Raskob G.E., Wasser J.S., Aledort, L.M., Ballem P.J.,
      Blanchette V.S., Bussel J.B., Cines D.B., Kelton J.G., Lichtin A.E., McMillan R.,
      Okerbloom J.A., Regan D.H., & Warrier I. (1996) Idiopathic thrombocytopenic
      purpura: a practice guideline developed by explicit methods for the American
      Society of Hematology. Blood, 88, 3-40.

Giagounidis A.A., Anhuf J., Schneider P., Germing U., Sohngen D., Quabeck K., & Aul
      C. (2002) Treatment of relapsed idiopathic thrombocytopenic purpura with the



                                                                                       68
Protocol nr. ITP 001                          Version 8                          Date: 18.01.2011

        anti-CD20 monoclonal antibody rituximab: a pilot study. Eur.J.Haematol., 69,
        95-100.

Godeau B., Porcher R., Fain O., Lefrere F., Fenaux P., Cheze S., Vekhoff A.,
     Chauveheid M.P., Stirnemann J., Galicier L., Bourgeois E., Haiat S., Varet B.,
     Leporrier M., Papo T., Khellaf M., Michel M., & Bierling P. (2008) Rituximab
     efficacy and safety in adult splenectomy candidates with chronic immune
     thrombocytopenic purpura - results of a prospective multicenter phase 2 study.
     Blood.

Godeau B., Provan D., & Bussel J. (2007) Immune thrombocytopenic purpura in adults.
     Curr.Opin.Hematol., 14, 535-556.

Grillo-López AJ, Hedrick E, Rashford M, Benyunes M, (2002) Rituximab: ongoing and
       future clinical development. Semin Oncol, 29,105-112.

Grossi A, Santini V, Longo G, Balestri F, Ferrini P. (2000) Treatment with anti-CD 20
       antibodies of patients with autoimmune thrombocytopenia with or without
       hamolytic anelmia: worsening in hemoglobin level [Abstract]. Blood, 96 (suppl),
       253a.

Hochberg,M.C. (1997) Updating the American College of Rheumatology revised criteria
     for the classification of systemic lupus erythematosus. Arthritis Rheum., 40, 1725.

Jacoub J, Mchlayeh W, Tabbara I, Dave H, Siegel R, Schecter G. (2004) The use of anti-
      cd20 chimeric monoclonal antibody, rituximab in adult patients with treatment
      refractory immune thrombocytopenia [Abstract]. Blood, 104:3950.

Khellaf,M., Michel,M., Schaeffer,A., Bierling,P., & Godeau,B. (2005) Assessment of a
       therapeutic strategy for adults with severe autoimmune thrombocytopenic
       purpura based on a bleeding score rather than platelet count. Haematologica, 90,
       829-832.

Khouri,I., Tuan,B., & Grant,K. (2002) Immune thrombocytopenic purpura.
      N.Engl.J.Med., 347, 449-450.

Kojouri,K., Vesely,S.K., Terrell,D.R., & George,J.N. (2004) Splenectomy for adult
      patients with idiopathic thrombocytopenic purpura: a systematic review to assess
      long-term platelet count responses, prediction of response, and surgical
      complications. Blood, 104, 2623-2634.

Lalayanni C, Stavroyianni N, Saloum R, Tsompanakou A, Anagnostopoulos A. (2004).
      Rituximab is effective for selected patients with chronic steroid-refractory
      immune thrombocytopenic purpura. Hematology 9,287-289.

Lieb J, Rossetti J, Shadduck R, Gryn J, Kaplan R, Zeigler Z et al. (2003) Rituximab
       therapy for relapsed or refractory autoimmune thrombocytopenia [Abstract].
       Blood 102,4038.

Lortan JE (1993). Management of asplenic patients. Br J Haematol. 84(4):566-9.




                                                                                              69
Protocol nr. ITP 001                    Version 8                         Date: 18.01.2011

Mabthera/Procedure steps taken and specific information after the authorization
     changes made after 01/01/2005 emea2008
     www.emea.europa.eu/humandocs/PDFs/EPAR/Mabthera/025998en8b.pdf; last
     acces: 12.12.2008.

Mead A.J., Newland A.C., & Provan D. (2003) Adult idiopathic thrombocytopenic
     purpura. Hematology., 8, 345-357.

National Institute of Health. National Cancer Institute Common Terminology Criteria
      for adverse events, version 3.0. Available at
      http://ctep.info.nih.gov/reporting/ctc.html. Last access on 27 August 2008.

Neylon A.J., Saunders P.W., Howard M.R., Proctor S.J., & Taylor P.R. (2003) Clinically
      significant newly presenting autoimmune thrombocytopenic purpura in adults: a
      prospective study of a population-based cohort of 245 patients. Br.J.Haematol.,
      122, 966-974.

Provan D, Newlan A, Norfolk D, Bolton-Maggs B, Lilleyman J, Greer I, et al. (2003)
      Guidelines for the investigation and management of idiopathic thrombocytopenic
      purpura (ITP) in adults, children and pregnacy. Br J Haematol,120, 574-96.

Portielje,J.E., Westendorp,R.G., Kluin-Nelemans,H.C., & Brand,A. (2001) Morbidity
       and mortality in adults with idiopathic thrombocytopenic purpura. Blood, 97,
       2549-2554.

Ruggeri M, Fortuna S & Rodeghiero F. (2008) Heterogeneity of terminology and clinical
      defintions in adult idiopathic thrombocytopenic purpura: a criticical appraisal
      from a systematic review of the litterature. Haematologica 93;98-103.

Saleh MN, Gutheil J, Moore M, Bunch PW, Butler J, Kunkel L et al. (2000) A pilot
      study of the anti-CD20 monoclonal antibody rituximab in patients with
      refractory immune thrombocytopenia. Sem Oncol, 27 (suppl 12), 99-103.

Shanafelt TD, Madueme HL, Wolf RC & Tefferi A. (2003). Rituximab for immune
      cytopenia in adults: idiopathic thrombocytopenic purpura, autoimmune
      hemolytic anemia, and Evans syndrome. Mayo Clin Proc, 78, 1340-1346.

Stasi R, DelPoeta G, Stipa E, Evangelista ML, Trawinska MM, Cooper &Amadori S.
       (2007) Response to B-cell-depleting therapy with rituximab reverts the
       abnormalities of T-cell subsets in patients with idiopathic thrombocytopenic
       purpura. Blood, 110, 2924-2930

Stasi,R., Pagano,A., Stipa,E., & Amadori,S. (2001) Rituximab chimeric anti-CD20
       monoclonal antibody treatment for adults with chronic idiopathic
       thrombocytopenic purpura. Blood, 98, 952-957.

Stasi,R., Stipa,E., Masi,M., Cecconi,M., Scimo,M.T., Oliva,F., Sciarra,A., Perrotti,A.P.,
       Adomo,G., Amadori,S., & . (1995) Long-term observation of 208 adults with
       chronic idiopathic thrombocytopenic purpura. Am.J.Med., 98, 436-442.




                                                                                        70
Protocol nr. ITP 001                   Version 8                        Date: 18.01.2011

Rituximab.( MabThera) Summary of Product characteristics. Available at
 www.emea.europa.eu/humandocs/Humans/EPAR/mabthera/mabthera.htm. Last
 access 27 August 2008

Tan,E.M., Cohen,A.S., Fries,J.F., Masi,A.T., McShane,D.J., Rothfield,N.F.,
      Schaller,J.G., Talal,N., & Winchester,R.J. (1982) The 1982 revised criteria for
      the classification of systemic lupus erythematosus. Arthritis Rheum., 25, 1271-
      1277.

Wali,Y.A., Al,L.Z., Shah,W., Zacharia,M., & Hassan,A. (2002) Pulsed high-dose
      dexamethasone therapy in children with chronic idiopathic thrombocytopenic
      purpura. Pediatr.Hematol.Oncol., 19, 329-335.

Warner,M., Wasi,P., Couban,S., Hayward,C., Warkentin,T., & Kelton,J.G. (1997)
     Failure of pulse high-dose dexamethasone in chronic idiopathic immune
     thrombocytopenia. Am.J.Hematol., 54, 267-270.




                                                                                        71
Protocol nr. ITP 001                 Version 8                      Date: 18.01.2011



                Appendix 1-       Drug Administration and Storage

Administration
Rituximab: 375 mg/m2 in NaCl 9 mg/ml, concentration 2 mg/ml for iv infusion.
The volume of the infusion bag (250 ml or 500 ml) depends on the prescribed
dosage of rituximab and on the allowed added volume to the bag.
Placebo: NaCl 9 mg/ml will be prepared by local pharmacy. The volume of the
infusion should be determined as described above to create identical infusions to
those prepared for active drug.
Example: If the prescribed dosage of Rituximab/placebo is 750 mg, the end-
volume in the bag should be 375 ml. In that case, 250 ml bags can be used if the
infusion bag allows for the addition of 125 ml NaCl 9mg/ml or 500ml bag after
withdrawing 125 ml from the bag.


The infusions bag should be labelled and delivered to treating unit packed in
labelled non-transparent bag in order to blind the content of the infusion.

Infusion duration


First infusion: The solution for infusion should be administered intravenously at
an initial rate of 50 mg/hr. Rituximab should not be mixed or diluted with other
drugs. If an infusion related events do not occur, the infusion rate can be
escalated in 50 mg/hr increments every 30 minutes, to a maximum of 400 mg/hr.
If an infusion-related event develops, see section 6.2 of protocol ―Prevention
and treatment of adverse events‖.


Subsequent infusions: Subsequent infusions can be administered at an initial rate
of 100 mg/hr, and increased by 100 mg/hr increments at 30 minute intervals, to a
maximum of 400 mg/hr as tolerated.


                                                                                 72
Protocol nr. ITP 001                Version 8                     Date: 18.01.2011


Storage conditions

Rituximab vials are stable at 2-8 ºC (36-46 ºF) and should be protected from
direct sunlight. Vials should not be used beyond the expiration date stamped on
the carton. Rituximab solution for infusion is biologically and chemically stable
at 2-8 ºC (36-46 ºF) for 24 hours. Rituximab solution for infusion has been
shown to be stable for an additional 12 hours at room temperature, however,
since Rituximab solution do not contain a preservatives, diluted solutions should
be stored refrigerated 2-8 ºC. No incompatibilities between rituximab and
polyvinylchloride or polyethylene bags have been observed.




Infusion related events
Refer to Summary Product Characteristics (SmPC).




                                                                               73
Protocol nr. ITP 001                     Version 8                          Date: 18.01.2011


          Appendix 2-           ACR Classification Criteria Used for SLE
   Criterion               Definition
  Malar Rash               Rash over the cheeks
  Discoid Rash             Red raised patches
  Photosensitivity         Reaction to sunlight, resulting in the development of
                           or increase in skin rash
  Oral Ulcers              Ulcers in the nose or mouth, usually painless
  Arthritis                Nonerosive arthritis involving two or more peripheral
                           joints (arthritis in which the bones around the joints
                           do not become destroyed)
  Serositis                Pleuritis or pericarditis (inflammation of the lining of
                           the lung or heart)
  Renal Disorder           Excessive protein in the urine (greater than 0.5
                           gm/day or 3+ on test sticks) and/or cellular casts
                           (abnormal elements the urine, derived from red and/or
                           white cells and/or kidney tubule cells)
  Neurologic               Seizures (convulsions) and/or psychosis in the
  Disorder                 absence of drugs or metabolic disturbances which are
                           known to cause such effects
  Hematologic              Hemolytic anemia or leukopenia (white blood count
  Disorder                 below 4,000 cells per cubic millimeter) or
                           lymphopenia (less than 1,500 lymphocytes per cubic
                           millimeter) or thrombocytopenia (less than 100,000
                           platelets per cubic millimeter). The leukopenia and
                           lymphopenia must be detected on two or more
                           occasions. The thrombocytopenia must be detected in
                           the absence of drugs known to induce it.
  Antinuclear              Positive test for antinuclear antibodies (ANA) in the
  Antibody                 absence of drugs known to induce it.
  Immunologic              Positive anti-double stranded anti-DNA test, positive
  Disorder                 anti-Sm test, positive antiphospholipid antibody such
                           as anticardiolipin, or false positive syphilis test
                           (VDRL).
 Adapted from: Tan, E.M., et. al. The 1982 Revised Criteria for the Classification of SLE.
 Arth Rheum 25: 1271-1277.




                                                                                             74
Protocol nr. ITP 001            Version 8                   Date: 18.01.2011



       Appendix 3-     Rituximab. Summary of Product Characteristics




                                                                         75