Journal Article

Intravenous immunoglobulin and rituximab versus placebo treatment of antibody-associated psychosis: study protocol of a randomised phase IIa double-blinded placebo-controlled trial (SINAPPS2)

Harrower, Timothy, Dowling, Francis, Buckley, Camilla, Yu, Ly-Mee, Zandi, Michael, Jones, Peter B., Lennox, Belinda, Joyce, Eileen, Lingford Hughes, Anne, Coles, Alasdair, Tomei, Giuliano, Shimazaki, Mio, Barnes, Thomas R. E., Vincent, Sally-Anne, Yeeles, Ksenija, Kabir, Thomas, Pollard, Rebecca, Cairns, Iona, Hosseini, Akram A.

2019

Overview

Background Evidence is conflicting about a causal role of inflammation in psychosis and, specifically, regarding antibodies binding to neuronal membrane targets, especially N-methyl-D-aspartate receptors. NMDAR, LGI1 and GABA-A antibodies were found more prevalent in people with psychosis than in healthy controls. We aim to test whether these antibodies are pathogenic and may cause isolated psychosis. The SINAPPS2 phase IIa double-blinded randomised controlled trial will test the efficacy and safety of immunoglobulin and rituximab treatment versus placebo for patients with acute psychosis symptoms as added to psychiatric standard of care. Methods We will screen approximately 2500 adult patients with acute psychosis to identify 160 with antibody-positive psychosis without co-existing neurological disease and recruit about 80 eligible participants to the trial in the period from September 2017 to September 2021 across the UK. Eligible patients will be randomised 1:1 either to intravenous immunoglobulin (IVIG) followed by rituximab or to placebo infusions of 1% albumin followed by 0.9% sodium chloride, respectively. To detect a time-to-symptomatic-recovery hazard ratio of 0.322 with a power of 80%, 56 participants are needed to complete the trial, allowing for up to 12 participants to drop out of each group. Eligible patients will be randomised and assessed at baseline within 4 weeks of their eligibility confirmation. The treatment will start with IVIG or 1% albumin placebo infusions over 2–4 consecutive days no later than 7 days from baseline. It will continue 4–5 weeks later with a rituximab or sodium chloride placebo infusion and will end 2–3 weeks after this with another rituximab or placebo infusion. The primary outcome is the time to symptomatic recovery defined as symptomatic remission sustained for at least 6 months on the following Positive and Negative Syndrome Scale items: P1, P2, P3, N1, N4, N6, G5 and G9. Participants will be followed for 12 months from the first day of treatment or, where sustained remission begins after the first 6 months, for an additional minimum of 6 months to assess later response. Discussion The SINAPPS2 trial aims to test whether immunotherapy is efficacious and safe in psychosis associated with anti-neuronal membrane antibodies. Trial registration ISRCTN, 11177045. Registered on 2 May 2017. EudraCT, 2016-000118-31. Registered on 22 November 2016. ClinicalTrials.gov, NCT03194815. Registered on 21 June 2017.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Adolescent / Adult / Aged / Albumin / Antibodies / Antineoplastic agents / Antipsychotic Agents - administration & dosage / Antipsychotic Agents - adverse effects / Antipsychotics / Biomedicine / Causes of / Chlorides / Clinical trials / Clinical Trials, Phase II as Topic / Dosage and administration / Double-Blind Method / Drug dosages / Drug therapy / Feasibility studies / Female / GABA / Halides / Health Sciences / Hepatitis / Humans / Hypotheses / Immunoglobulins / Immunoglobulins, Intravenous - administration & dosage / Immunoglobulins, Intravenous - adverse effects / Immunotherapy / Inflammation / Infusions, Intravenous / Male / Medical research / Medicine / Medicine & Public Health / Middle Aged / Monoclonal antibodies / Multicenter Studies as Topic / N-methyl-D-aspartate / Nervous system diseases / Neurons / Psychosis / Psychotic disorders / Psychotic Disorders - diagnosis / Psychotic Disorders - drug therapy / Psychotic Disorders - immunology / Psychotic Disorders - psychology / Psychotropic drugs / Randomized Controlled Trials as Topic / Remission (Medicine) / Risk Factors / Rituximab / Rituximab - administration & dosage / Rituximab - adverse effects / Schizophrenia / Sodium chloride / Statistics for Life Sciences / Steroids / Study Protocol / Testing / Time Factors / Treatment Outcome / United Kingdom / Young Adult