Autologous Tolerogenic Dendritic Cells for Rheumatoid Arthritis-2 (AuToDeCRA-2) Study: Protocol for a single-centre, experimental medicine study investigating the route of delivery and potential efficacy of autologous tolerogenic dendritic cell (TolDC) therapy for Rheumatoid Arthritis

Autologous Tolerogenic Dendritic Cells for Rheumatoid Arthritis-2 (AuToDeCRA-2) Study: Protocol for a single-centre, experimental medicine study investigating the route of delivery and potential efficacy of autologous tolerogenic dendritic cell (TolDC) therapy for Rheumatoid Arthritis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Autologous Tolerogenic Dendritic Cells for Rheumatoid Arthritis-2 (AuToDeCRA-2) Study: Protocol for a single-centre, experimental medicine study investigating the route of delivery and potential efficacy of autologous tolerogenic dendritic cell (TolDC) therapy for Rheumatoid Arthritis Ema-Louise Long, James Stanway, Michael White, Nicola Goudie, and 13 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6222488/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Aug, 2025 Read the published version in Trials → Version 1 posted 5 You are reading this latest preprint version Abstract Background: Dendritic cells are professional antigen presenting cells with the ability, in their immature state, to induce tolerance in T-cells. A protocol to develop phenotypically stable tolerogenic dendritic cells (TolDC) was developed in Newcastle and cells administered to participants in the phase I AuToDeCRA study, demonstrating that TolDC were safe and well tolerated. More knowledge of the TolDC product is now needed, such as optimal dose, route of administration and antigen loading. Establishing this and developing a biomarker profile to demonstrate favourable immunomodulation is the focus of AuToDeCRA-2. Methods: AuToDeCRA-2 is a non-commercial, phase IIa, 5-arm, randomised, unblinded, single centre study. It is designed to demonstrate and compare immunomodulation achieved by TolDC administered via three distinct routes: intra-nodal, intra-articular, intra-dermal and, in the case of intra-nodal administration, at 2 doses. Participants will be randomised to one of these four active intervention arms or standard care. Participants in intervention arms will receive a single dose of TolDC loaded with synthetic citrullinated peptides (TolDC CitPep ) representing disease relevant autoantigens. 20 Anti-Citrullinated Peptide Antibody (ACPA) positive, shared epitope positive Rheumatoid Arthritis patients with nil-to-moderate disease activity will be randomised in an allocation ratio of 1:1:1:1:1. Participants will be followed up with immune state monitoring performed on peripheral blood samples at baseline, 1, 3 and 6 weeks and lymph node aspirates at baseline and 1 week, alongside clinical assessment performed throughout and additionally at 12 weeks. Discussion: TolDC therapy is an emerging cellular therapy aimed at reversing the underlying abnormality in autoimmune disease by inducing tolerance to autoantigen. Expected challenges to this study include recruitment of potentially asymptomatic participants to a complex and intensive experimental medicine study. Limitations include the relatively small number of participants although adequate to address the aims of the study. Establishing acceptable route(s) of administration as well as demonstrating favourable immunomodulation via the development of a biomarker profile is the focus of AuToDeCRA-2, which aims to address some of the existing scientific gaps necessary for the development of TolDC therapy in autoimmune disease. Trial registration: ISRCTN, ISRCTN14999554. Registered on 27 th September 2023, https://doi.org/10.1186/ISRCTN14999554 Rheumatoid Arthritis (RA) Tolerogenic dendritic cells (TolDC) Shared epitope (SE) Anti-Citrullinated Peptide Antibody (ACPA) Immunomodulation Leukapheresis Intra-nodal Intra-articular Intra-dermal Lymph node Figures Figure 1 Figure 2 Administrative information Note: the numbers in curly brackets in this protocol refer to SPIRIT checklist item numbers. The order of the items has been modified to group similar items (see http://www.equator-network.org/reporting-guidelines/spirit-2013-statement-defining-standard-protocol-items-for-clinical-trials/). Title {1} A single-centre, experimental medicine study investigating the route of delivery and potential efficacy of autologous tolerogenic dendritic cell (TolDC) therapy for Rheumatoid Arthritis-2 (AuToDeCRA-2) Trial registration {2a and 2b}. ISRCTN14999554. Registered on 27 th September 2023. https://doi.org/10.1186/ISRCTN14999554 Protocol version {3} V5.0 31 st July 2024 Funding {4} Versus Arthritis (formally Arthritis Research UK) ref: 21811 RTCure (Rheuma Tolerance for Cure) as part of the Innovative Medicines Initiative 2 Joint Undertaking ref:777357 Author details {5a} 1 Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, United Kingdom 2 Department of Rheumatology, Freeman Hospital, Newcastle upon Tyne, United Kingdom 3 Newcastle Clinical Trials Unit, Newcastle University, United Kingdom 4 Clinical Research Facility, Royal Victoria infirmary, Newcastle upon Tyne, United Kingdom 5 Department of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom 6 NIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne, United Kingdom Name and contact information for the trial sponsor {5b} The Newcastle upon Tyne Hospitals NHS Foundation Trust Sponsor reference: 08669 [email protected] Role of sponsor {5c} The sponsor has no role in the study design; collection, management, analysis and interpretation of data; writing of the report or the decision to submit for publication Introduction Background and rationale {6a} Autoimmune disease such as Rheumatoid Arthritis (RA) results from a breakdown of immunological tolerance; the immune system mistakenly recognises healthy, self-tissue as a threat, leading to inflammation and eventually structural damage. No current treatment option for RA represents a cure and medication is required indefinitely, carrying with it the risks of generalised immunosuppression. It is desirable to develop ‘tolerogenic’ treatments, which reverse the underlying abnormality of the immune system rather than continuous non-specific suppression of inflammation and immunity. Tolerogenic dendritic cells (TolDC) have emerged as one such possibility (1-7). CD4 + helper T-cells are a key driver of disease in RA, in keeping with their established role as orchestrators of adaptive immune responses through their interaction with professional antigen presenting cells (APC). As key APC, dendritic cells (DC) instruct CD4 + T-cells how to respond to a given antigen by modulating the co-stimulation they provide. Depending on context, DCs can induce either proinflammatory or regulatory (tolerogenic) characteristics in the T-cells (8). If an antigen is encountered in the context of threat, the DC in question ‘matures’ and will present antigen with co-stimulatory signals, which leads to the generation of antigen-specific T-cells with pro-inflammatory characteristics. Conversely, if the antigen is encountered in a non-threatening microenvironment, the DC remains ‘immature’ and upon interaction with the T-cell, may induce a regulatory phenotype, anergy (a state of hyporesponsiveness) or even apoptosis. With their ability to influence the adaptive immune system in an antigen-specific way, DCs are an exciting potential therapeutic tool which could ‘reset’ autoimmunity. Whilst immature DCs can induce T-cell tolerance, their phenotype is unstable, and they may develop into immunogenic, mature DCs in the presence of pro-inflammatory cytokines. As such, a variety of protocols have been developed for the generation of phenotypically stable TolDC which retain their tolerogenic characteristics, even in a pro-inflammatory microenvironment. We have established such a protocol (9-12) and these cells were administered safely to patients with inflammatory arthritis in the earlier phase I AuToDeCRA study (1). In AuToDeCRA, TolDC were loaded with autologous synovial fluid as a source of antigen and administered arthroscopically into an inflamed knee joint following saline wash-out. The lack of a subsequent disease flare following administration suggested that, as shown by in vitro studies, the TolDC phenotype was stable. These findings have been corroborated by several other international studies using TolDC in patients with RA and other autoimmune diseases such as multiple sclerosis and type 1 diabetes (3-7, 13). Although no TolDC trial has yet demonstrated robust clinical efficacy, TolDC appear to be a safe and well tolerated intervention. There is now a need to demonstrate the ability of TolDC to achieve immunomodulation. Tolerogenic therapies are not necessarily anti-inflammatory in the short-term (14) and biomarkers of the immune state that are influenced more rapidly by such treatments are urgently needed, not least to guide clinical protocol development relating to aspects such as optimal dose, route of administration and antigen loading. AuToDeCRA-2 was developed to begin to address some of these questions. Objectives {7} AuToDeCRA-2 is designed to demonstrate and compare immunomodulation using synthetic citrullinated peptide loaded TolDC (TolDC CitPep ) administered via three distinct routes: intra-nodal, intra-articular, intra-dermal and in the case of intra-nodal administration, at a low and a high dose. The rationale for loading TolDC with citrullinated peptides is explained in section {11a}. Table 1 outlines the study objectives which will be achieved by comparing baseline data with follow-up data at 1, 3, 6 and 12 weeks. Table 1: Study objectives Primary Objectives Secondary Objectives Exploratory Objectives To seek signals of immune modulation when TolDC CitPep are administered to participants with RA using immune state biomarkers performed on peripheral blood samples at baseline, 1, 3 and 6 week follow-up and participant lymph node aspirates at baseline and 1 week follow-up To seek signs of clinical efficacy when TolDC CitPep are administered to participants with RA using ACR 20, 50 and 70, DAS-28, and components thereof at baseline and 1, 3, 6 and 12 week follow-up To provide further evidence of TolDC CitPep safety using reported adverse events (AEs) at baseline, 1, 3, 6 and 12 week follow-up To provide further evidence of participant acceptability of TolDC CitPep therapy for RA using a Participant Acceptability questionnaire at 12 week follow -up To link signals of immune modulation with signs of potential efficacy of TolDC CitPep using potential associations between immune modulation measures and evidence of efficacy for the three different routes of TolDC CitPep administration (and, in the case of intra-nodal injection, for the two doses administered) To compare intra-nodal (low and high dose), intra-dermal and intra-articular injection with regards to primary and secondary objectives, and feasibility Trial Design {8} AuToDeCRA-2 is a non-commercial, exploratory, unblinded, randomised experimental medicine study with 5 parallel groups of ACPA-positive RA participants in an allocation ratio of 1:1:1:1:1, with the aim of demonstrating and comparing immunomodulation by TolDC CitPep . The study protocol follows the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 statement. The study has been registered with ISRCTN (14999554). Methods: Participants, interventions and outcomes Study Setting {9} The single centre study will be undertaken at Newcastle upon Tyne Hospitals NHS Foundation Trust (NuTH) in the UK. All study visits will take place within a designated Clinical Research Facility at the Royal Victoria Infirmary, Newcastle upon Tyne, with the exception of leukapheresis visits which will take place in the Leukapheresis Day Unit at the Freeman Hospital, Newcastle upon Tyne. Eligibility Criteria {10} Inclusion Criteria Patients are eligible for the study if all of the following apply at screening: Adults aged 18 years old or over RA fulfilling 1987 ARA criteria or 2010 ACR/EULAR Classification Criteria ACPA > 3x upper limit of normal, can include historical measurements providing the result remains positive at screening Able and willing to give informed consent and to comply with the study protocol Disease duration of at least 4 months and less than 10 years ACR Functional Class I-III DAS-28 6 months ago), TNF-alpha inhibitors and IL6 receptor antagonists, provided stable dosing for at least 4 weeks Possess at least one copy of a shared epitope (SE) HLA DRB1 allele (0101; 0102; 0105; 0401; 0404; 0405; 0408; 0409; 0410; 0413; 0416; 0419; 0421; 1001; 1402; 1406; 1409; 1413; 1417; 1419; 1420; 1421) Exclusion Criteria Patients are excluded from the study if any of the following apply at screening: Use of other investigational medicinal products within 30 days prior to study entry (defined as date of consent into study) Any changes to RA treatment within 4 weeks of study entry Current treatment with Janus kinase inhibitors or leflunomide. Previous treatment is permitted provided at least 12 weeks have elapsed at study entry since discontinuation Receiving glucocorticoids by any route within 4 weeks of study entry, apart from topical, intra-nasal or inhaled Serious or unstable co-morbidity that prohibits participation in the study at the discretion of the investigator e.g. significant chronic obstructive pulmonary disease, significant cardiac failure, active malignancy Active infection at study entry (except fungal nail infection) Infection requiring hospitalisation or intravenous antibiotics within 4 weeks prior to study entry Immunisation with live, attenuated vaccines planned within 14 days of baseline visit (administration of TolDC CitPep ) and with non-live vaccines planned within 7 days of baseline visit History of hepatitis B or C, HIV, or HTLV-1/2 infection(s) Recent history of Cytomegalovirus (CMV) infection (positive for CMV IgM antibodies) or syphilis infection (positive PCR test) Major surgery within 8 weeks prior to study entry or planned within 12 weeks of baseline visit Pregnancy, or women planning to become pregnant within the study period, or women who are breast feeding Females of childbearing potential engaging in heterosexual relationships unwilling to use adequate contraception for the duration of the study Patients taking anticoagulants that cannot be interrupted and are, in the judgement of the investigator, likely to interfere with study procedures Known hypersensitivity to local anaesthetic Poor venous access or medical condition precluding leukapheresis e.g. unstable cardiac arrythmia (atrial fibrillation permitted) Haemoglobin<10g/dL; neutrophils< 1.00 x10 9 /L; platelets <100x10 9 /L Radiologists performing ultrasound-guided lymph node aspiration and intra-nodal tolDC administration will be competent in the procedure. Rheumatologists performing intra-articular administration will be competent at performing ultrasound guided intra-articular (knee) injection. Clinicians performing intra-dermal administration will be competent at intra-dermal injections and have received training on the use of the specific intra-dermal needle selected for use. Who will take informed consent? {26a} Following initial contact, and at least 24 hours after provision of participant information documents, interested participants will attend a screening visit. At the screening visit a member of the study team will ensure the participant information sheet (PIS) has been read and understood and answer any questions. If the participant wishes to enter the study, written informed consent will be obtained by a medically qualified member of the study team delegated to the task. Additional consent provisions for collection and use of participant data and biological specimens {26b} There are 4 optional consent clauses which form part of the informed consent form (ICF) but do not affect eligibility to participate in the study. Agreeing to contact by the study team about participation in additional follow up visits in the future, should additional research funding be obtained for these visits. Agreeing that any research samples remaining at the end of the study can be anonymised and sent to a biobank for long term storage and use in future research outside of the study. Agreeing that any samples left over from TolDC manufacture can be anonymised and sent to a biobank for long term storage and use in future research outside of the study. Agreeing to be sent a summary of the results when the study has finished. Interventions Explanation for the choice of comparators {6b} The optimal route for TolDC administration is not clear. The DC-T-cell interaction is believed to occur primarily in lymph nodes. We hypothesise that the route of injection most likely to ensure the TolDC reach a lymph node is direct injection into lymph nodes, but intra-nodal injection is a less convenient route of delivery, requiring ultrasound equipment and a trained operator. AuToDeCRA-2 will therefore compare direct intra-nodal injection with alternative routes that should enable cells to reach disease-relevant lymph nodes. Intra-dermal is the most well studied route of administration (5, 6, 15) for therapeutic DC and does not require specialised equipment. In contrast, intra-articular injection requires specialised equipment and operators, but it is possible that the joint-relevant immune system is best accessed via this route. 10 7 TolDC will be administered via all routes to provide a direct comparison, being the highest dose that was administered in AuToDeCRA. A lower dose of 10 5 TolDC will also be administered intra-nodally as injecting directly into a lymph node may require fewer cells to achieve a therapeutic effect. The fifth arm is standard care. Standard care was chosen over placebo so that participants would not need to undergo unnecessary leukapheresis or administration procedures. Standard care involves no leukapheresis visit and no administration of TolDC CitPep but all other study procedures remain the same. Intervention description {11a} Eligible participants will be randomised in equal proportions to one of four intervention arms or standard care. Participants’ usual medication will be continued alongside for all groups. Participants randomised to an intervention arm will attend for leukapheresis at day -8 to extract CD14 + monocytes for the generation of TolDC CitPep . Leukapheresis products will be transferred to Newcastle Advanced Therapies Good Manufacturing Practice (GMP) Facility where the TolDC CitPep will be manufactured. In AuToDeCRA and AuToDeCRA-2, TolDC manufacture is identical aside from the antigen loaded into TolDC. In AuToDeCRA-2 the TolDC will be loaded with synthetic citrullinated peptides (TolDC CitPep ) representing disease-relevant epitopes (16-19) rather than autologous synovial fluid as in AuToDeCRA. Knowledge of the loaded antigen enables more sophisticated immune monitoring assays that incorporate measures of antigen specificity, allowing the profiling of the cells the treatment is designed to target. Furthermore, treatment is no longer limited to patients with a knee joint effusion, enabling treatment of participants with lower disease activity that may benefit most from tolerance inducing strategies. In vitro validation work has confirmed the immunological equivalence of AuToDeCRA and AutoDeCRA-2 TolDC. TolDC CitPep loaded with Cit-alpha-enolase (326-340), Cit-cartilage intermediate layer protein-2 (297-311), Cit-vimentin (59-78) and Cit-tenascin-C 22 (1012-1026) will be diluted to a final volume of 200ml, aspirated into a syringe and undergo quality control and QP release. The syringe will be stored at 2-8 °C in a validated and monitored refrigerator until administration. Administration by all injection routes will be carried out immediately after (inguinal) lymph node aspiration (for biomarker analysis), following which participants will be observed for at least 90 minutes. • Intra-nodal injection of TolDC CitPep (10 5 or 10 7 cells) TolDC CitPep will be injected into up to 5 inguinal lymph nodes under ultrasound visualisation, on the ipsilateral side to the lymph node aspiration as per intra-nodal aspiration and injection Standard Operating Procedure (SOP). • Intra-articular injection of TolDC CitPep (10 7 cells) TolDC CitPep will be administered as a single injection into a knee joint under ultrasound visualisation as per intra-articular injection SOP. The knee selected should be the least inflamed, and ipsilateral to the aspirated lymph node where possible. • Intra-dermal injection of TolDC CitPep (10 7 cells) Intra-dermal injection will be administered as one or two injections to the upper, anterior thigh (within 5cm of the inguinal crease) on the ipsilateral side as the lymph node aspiration using an intra-dermal 1.2mm silicon needle as per intra-dermal injection SOP. Criteria for discontinuing or modifying allocated interventions {11b} There are no plans to modify or permit modification of allocated interventions. The intervention will not be administered if the TolDC CitPep do not meet stringent release criteria. Strategies to improve adherence to interventions {11c} The intervention is administered as a single dose in a clinical research facility. It is felt unlikely that a participant would not attend for administration having undergone leukapheresis. Relevant concomitant care permitted or prohibited during the trial {11d} Any medication or concomitant care not specifically listed is presumed to be permitted. Permitted concomitant care: Permitted treatments for RA include methotrexate, sulfasalazine, azathioprine, hydroxychloroquine, abatacept, rituximab (last dose >6 months ago), TNF-alpha inhibitors and IL6 receptor antagonists, alone or in combination, at a stable dose for at least 4 weeks Anticoagulants unless these are, in the view of the investigator, likely to interfere with study procedures and cannot be interrupted Prohibited concomitant care: Glucocorticoids (apart from topical, intra-nasal, inhaled) Janus kinase inhibitors Leflunomide Live, attenuated vaccines within 2 weeks of and non-live vaccines within 1 week of the baseline visit Provisions for post-trial care {30} Any unexpected or abnormal test results will be discussed with the participant and any necessary follow-up arranged with their rheumatologist, GP or another specialist. Participants will continue to access their usual health practitioners in the normal way throughout and after the study. No additional TolDC product will be made available post-trial. NHS indemnity for clinical trials will apply for clinical negligence that harms individuals towards whom the NHS has a duty of care. Outcomes {12} Primary Endpoint/Outcome There is currently no agreed biomarker for tolerance induction. Pragmatically, we shall seek evidence of favourable immunomodulation by selecting from a variety of different modalities including: Increase in proportional abundance of regulatory T-cells in peripheral blood by high dimensional cytometry Induction or increase in Interleukin-10 production in peripheral blood mononuclear cells (PBMCs) following citrullinated peptide stimulation, using ELISpot or intracellular flow cytometry Reduction in interferon gamma production in PBMCs following citrullinated peptide stimulation Change in proliferative response of PBMCs to citrullinated peptide stimulation, combined with phenotypic (surface marker, cytokine production) correlation A reduction in ACPA titre or diversity of ACPA specificities Changes in circulating cytokine levels Secondary Endpoints/Outcomes Secondary outcome measures for the study are: Change in ACR 20, 50 and 70, DAS-28, and components thereof at weeks 1, 3, 6 and 12 compared to baseline Number of reported AEs. AEs will be collected at each timepoint (baseline, 1, 3, 6 and 12 weeks) from clinical assessment and routine blood testing Participant reported acceptability of the TolDC CitPep product and study related procedures including leukapheresis and mode of administration. Data will be collected at the 12 week visit via the Participant Acceptability questionnaire Exploratory Endpoint/Outcome Measures Exploratory outcome measures for the study are: Enumeration and phenotypic analysis of autoreactive T-cells by major histocompatibility complex class II tetramer staining Single cell RNA sequencing of peripheral blood T-cells and lymph node aspirates Potential associations between immune modulation (as defined by primary outcome measures) and evidence of efficacy (as defined by secondary outcome measures) for (1) the different routes of TolDC CitPep administration (intra-articular, intra-dermal and intra-nodal) and (2) the different doses of TolDC CitPep administered via the intra-nodal route (10 5 and 10 7 ) Comparison of (1) the different routes of TolDC CitPep administration (intra-articular, intra-dermal and intra-nodal) and (2) the different doses of TolDC CitPep administered via the intra-nodal route (10 5 and 10 7 ), for evidence of immune modulation and potential efficacy Participant timeline {13} The study flowchart (figure 1) outlines the participant journey through the study and the schedule of events (figure 2) outlines the activities at each study visit. Screening will take place between day -150 and day -10. If screening takes place between day -150 and day -39 then a secondary screening visit will occur between day -38 and day -10. This is to ensure that the participant remains eligible and to allow for safety blood sampling in line with leukapheresis and TolDC production facility SOPs. After screening and randomisation (and leukapheresis for those receiving TolDC CitPep ), participants will attend for baseline (day 0) clinical and immunological assessments. All participants will provide a blood sample and an ultrasound-guided fine needle aspirate from inguinal lymph nodes. These blood and lymph node aspirate samples will contribute to the immunological endpoints described above. Participants in intervention arms will then receive TolDC CitPep at the allocated dose and via the allocated administration route. Participants will be followed up on four occasions at 1, 3, 6 and 12 weeks after the baseline visit. Clinical assessment and blood sampling will take place at each visit. At the week 1 follow-up visit all participants will undergo a second lymph node ultrasound-guided fine needle aspirate. If, during the follow up period, a participant suffers deterioration in their arthritis symptoms, they will attend for a ‘flare visit’. A full clinical assessment will be performed and, if a flare of RA is diagnosed, the participant managed appropriately at the discretion of the investigator, according to standard care. If therapeutic intervention is required for the flare, final samples will be taken for immunological endpoints and the participant will exit the study. Sample size {14} There are no relevant background data available to power this study, which is exploratory and not powered for statistical significance. The sample size of 20 is based upon expected feasible recruitment into a complex experimental medicine protocol, based on prior experience from AuToDeCRA. Recruitment {15} A number of strategies will be implemented to identify potential participants: Identification by usual Rheumatology care team Identification via local Rheumatology departmental databases followed by a mailed study invitation letter from their usual care team and PIS. The letter will include a tear off slip and a stamped return envelope to express a wish for no further contact if applicable Identification via National Institute for Health Research immune-mediated inflammatory diseases BioResource with consent for contact passed on by BioResource team Ethically-approved advertisement via posters and leaflets including study contact details displayed in the Rheumatology out-patient department and via collaboration with relevant charities, patient groups and Clinical Research networks Participant Identification Centre sites may be utilised to maximise recruitment via the Northern Regional Rheumatology Network, a group of rheumatology centres within the North East of England Assignment of interventions: allocation Sequence generation {16a} Eligible participants will be randomly allocated to one of five groups. Randomisation will be computer generated and performed by delegated and trained members of the research team using a 24-hour, central, secure, web-based system (Sealed Envelope TM ). Group 1 will receive 10 5 TolDC CitPep administered into inguinal lymph node/s Group 2 will receive 10 7 TolDC CitPep administered into inguinal lymph node/s Group 3 will receive 10 7 TolDC CitPep administered intra-articularly into a knee Group 4 will receive 10 7 TolDC CitPep administered intra-dermally into the thigh Group 5 will receive standard care and no active intervention (control group) Concealment mechanism {16b} Allocation concealment will be ensured by the use of a centralised web-based service for randomisation (Sealed Envelope TM ). Implementation {16c} Participants will be enrolled and randomised by delegated and trained members of the research team. The allocation sequence will be generated by Sealed Envelope TM . Assignment of interventions: blinding Who will be blinded {17a} The study is not blinded. Due to the need for those receiving TolDC CitPep to undergo leukapheresis and TolDC CitPep administration procedures via distinct routes, it is not practical to perform a blinded study. Procedure for unblinding if needed {17b} The study is unblinded throughout. Data collection and management Plans for assessment and collection of outcomes {18a} All assessments will be performed by a qualified healthcare professional delegated to the task. Demographics, medical history and medication history will be collected at screening. Clinical assessment will occur at screening, baseline, week 1, 3, 6 and 12 and any flare visit as required, and include discussion of any new or relevant clinical history including medications, physical examination, RA assessment and vital signs. Physical examination may vary in detail depending upon individual clinical history and will be selected to ensure a comprehensive understanding of participant health. Assessment of the participant’s RA condition will include the following: Participant global assessment of disease activity Visual Analogue Scale (VAS) – score 0-100mm Physician global assessment of disease activity VAS – score 0-100mm Pain VAS – score 0-100mm 66/68 Swollen and Tender Joint Count Health Assessment Questionnaire Disability Index (HAQ-DI) (not required at screening) – score 0-3 rounded to one decimal place Participant reported acceptability will take place at week 12 via a study specific participant completed Acceptability Questionnaire consisting of sequential questions with a score to denote acceptability and a free text box where participants are invited to comment on any aspect of their involvement. Full details of blood and lymph node aspirate sample collection are provided in section {33}. The described assessments alongside the biological specimens will enable the collection of outcomes as set out in section {12}. Plans to promote participant retention and complete follow-up {18b} The clinical research team will discuss appointment dates with participants to ensure suitability, provide appointment dates in advance and address any transport or accessibility needs. Dates and times can be provided in writing. Reminder phone calls will be made prior to leukapheresis and baseline appointments. Future appointment dates and times will be re-discussed at each appointment. Participants can withdraw from the study at any time without providing a specific reason. Data collected to the point of withdrawal will be retained and utilised, although participants may request to have stored samples destroyed. Participants withdrawing will be asked for written permission to collect and use data from routine clinical follow-up for the period of their intended participation. Where the TolDC CitPep have been administered, contact in line with a participant’s week 12 assessment will be attempted to check for adverse reactions (ARs). Data management {19} All data for an individual participant will be recorded in the study-specific electronic Case Report Form (eCRF) set up using Sealed Envelope’s TM Red Pill system which will include tested range checks for numerical data values. Access to the study database will be password-limited, with task-specific restrictions. Only staff formally delegated to do so will have access to the database. Data will be handled, computerised and stored in accordance with the UK Data Protection Act 2018, UK GDPR, the latest GCP Directive (2005/28/EC) and local site policy. Paper copies of study-related documentation will be annotated, signed, dated and filed in the Investigator Site File (ISF). The signed ICF, eligibility forms, GP letter and RA assessments will be uploaded to the participant’s medical notes. All study documentation will be archived for 30 years in accordance with UK GCP legislation and local SOPs. Confidentiality {27} Participant identification on the eCRF will be via a unique study identifier number. A record linking the participant’s name to the unique study identifier number will be held in a locked room at the study site. Only the Principal Investigator (PI) and appropriately delegated staff will have access to source data and the ISF for the purpose of conducting the study. Plans for collection, laboratory evaluation and storage of biological specimens for genetic or molecular analysis in this trial/ future use {33} NHS laboratory and tissue typing bloods Participants will provide NHS laboratory blood samples, which will be analysed in local Trust laboratories and then discarded. These will be collected and tested as per the table below. Table 2: NHS laboratory blood samples Blood set Tests to be performed Time points collected Participants Set 1 Cyclic Citrullinated Peptide Antibody (Anti- CCP) Rheumatoid Factor (RhF) Full Blood Count (FBC) Erythrocyte Sedimentation Rate (ESR) Coagulation Screen (with derived Fibrinogen) International Normalised Ratio (INR) Urea and Electrolytes (U+E) Magnesium (Mg) Adjusted calcium Liver Function Test (LFT) C-reactive Protein (CRP) Human Immunodeficiency Virus (HIV) Hepatitis B+C Human T cell Leukemia Virus (HTLV) 1+2 Syphilis Cytomegalovirus (CMV) HLA DRB1 tissue type (except where tissue type is already known) Follicle Stimulating Hormone (FSH) * Screening All * FSH can be considered to prove post menopausal state in women < 50y who have been amenorrhoeic for 12 months and would prefer testing to using contraception for the duration of the study on discussion with the investigator Set 1B HIV Hepatitis B +C HTLV 1+2 Syphilis CMV Secondary screening visit Those screened > 38 days before scheduled baseline visit Set 2 FBC U&E LFT Phosphate Mg Adjusted calcium Group + Save HIV Hepatitis B+C HTLV 1+2 Syphilis Leukapheresis visit All, except participants randomised to Group 5 (control group) Set 3 FBC U&E LFT CRP ESR Baseline, follow-up visits 1, 2 and 3 All Set 4 FBC U&E LFT CRP ESR RhF ACPA Follow-up visit 4 All Set 5 FBC U&E LFT CRP ESR any additional test at the discretion of the investigator Flare visit Those completing a flare visit Peripheral blood research biomarkers Research blood samples will be obtained at baseline and weeks 1, 3, and 6. This will involve the collection at each visit of 108ml of blood in a combination of EDTA and serum separator tubes. Some of this sample will be studied immediately within the research laboratory and the remainder processed and cryopreserved for analysis following study completion. Lymph node aspirate samples Lymph node aspirate samples will be obtained by an experienced radiologist using direct ultrasound visualisation to aspirate up to 5 lymph nodes using a 23 Gauge needle and 3ml syringe under tension. Samples will be immediately passed to a member of the study team for processing and cryopreservation for analysis following study completion. Statistical methods Statistical methods for primary and secondary outcomes {20a} AuToDeCRA-2 is not powered for formal statistical significance. Nonetheless, a statistical analysis plan will be developed during the study. The analysis population will include all subjects who have received their allocated intervention. For AE reporting, the analysis population will be all individuals who provide consent, whether or not they subsequently receive TolDC CitPep . Demographic characteristics, medical history and clinical characteristics collected at screening will be summarised descriptively and tabulated. For categorical variables the frequency and percentage in each group will be reported. For continuous variables the mean, standard deviation and/or median and interquartile range will be reported. Within each arm (n=4) we will assess whether there are any consistent trends in the parameters being measured, both for primary and secondary outcomes, and we will compare each of the 4 intervention arms against the control group and each other for primary and secondary outcomes. Summary statistics capturing differences in immune biomarkers (expressed as percentages, stimulation indices, titres etc) and clinical outcomes (descriptive and numeric) will be tabulated and presented graphically. Longitudinal analysis will be performed to compare samples following TolDC CitPep administration at baseline. Given the low participant number in each group (4), no formal statistical testing will be performed other than to explore analysis methods, identify prospective transformations of the data, identify key prospective time points, and obtain estimates of the variability in both primary and secondary measures to inform the design of a future efficacy study. Estimates of variability will be based on a mixed effects model including participant, route of administration and sampling time point. Interim analyses {21b} There is no planned formal interim analysis. Participant flow through the study will be presented using a CONSORT diagram and updated monthly throughout recruitment as a guide. Methods for additional analyses (eg subgroup analyses) {20b} We will assess for any potential relationships between primary immune outcomes and secondary clinical outcomes. Methods in analysis to handle protocol non-adherence and any statistical methods to handle missing data {20c} An investigation of missing data will be undertaken to understand study withdrawals or missing appointments and whether these could be related to baseline factors or AEs. Where data are incomplete, existing data will be used for all analyses. There will be no attempt to impute missing data. Plans to give access to the full protocol, participant level-data and statistical code {31c} The full protocol is available from the corresponding author on reasonable request. Until publication of the study results, access to the full dataset will be limited to the Trial Management Group (TMG). Requests for data sharing with bona fide study teams outside of Newcastle University or NuTH will be considered by a Data Access Committee, with representation from the sponsor and Chief Investigator (CI). Data transfer will be subject to completion of a Data Sharing Agreement between Newcastle University and the end users. There is no relevant statistical code to access. Oversight and monitoring Composition of the coordinating centre and trial steering committee {5d} Study conduct at site will be led by the PI and supported by GCP trained and appropriately delegated research clinicians and nurses. Newcastle Clinical Trials Unit (NCTU) manage the trial on behalf of the sponsor and will provide day-to-day support for the site and training, site initiation activities and routine monitoring activities. The TMG will be responsible for the day-to-day running of the study and will consist of the CI, PI and delegated researchers, members of NCTU, sponsor and, as required, other members of the study team. The TMG will monitor all aspects of the conduct and progress of the study. TMG meetings will occur approximately monthly. The Trial Steering Committee (TSC) will provide overall independent oversight of the study and will oversee study conduct and progress. The TSC will consist of an independent chair, together with at least two other independent members, a Patient and Public Involvement (PPI) representative and the CI. The TSC will meet approximately 6-monthly throughout the study. Composition of the data monitoring committee, its role and reporting structure {21a} The Data Monitoring Committee (DMC) will consist of at least three independent members including an Independent Chair, an Independent Statistician and an Independent Clinician and will meet approximately 6-monthly throughout the study. The DMC will make recommendations to the TSC as to whether there are any ethical or safety issues that may necessitate changes to the study. Adverse event reporting and harms {22} Participants will be asked to report AEs at every study visit and encouraged to contact the study team for any concerns between visits via 24-hour telephone numbers. All AEs occurring from point of consent to end of the last study related assessment will be recorded in the AE eCRF and the participant’s medical records. All Serious AEs will also be reported to sponsor and to the MHRA if applicable. All SARs occurring from administration of TolDC CitPep to last study related assessment will be reported to sponsor and recorded in the eCRF and medical records. The assessment of expectedness will be performed by the CI on behalf of the sponsor against the approved Reference Safety Information for the study. Any Suspected Unexpected Serious ARs will be reported to the MHRA and Research Ethics Committee (REC) by the sponsor. Frequency and plans for auditing trial conduct {23} A Site Delegation Log will detail the responsibilities of each member of site staff working on the study. Quality control will be maintained through adherence to sponsor and NCTU SOPs, study protocol, GCP principles, research governance and clinical trial regulations. Monitoring to ensure appropriate trial conduct and data collection will be carried out by NCTU according to a documented monitoring plan. Electronic data will be stored in secure, password-protected computers. NCTU staff will use a combination of central monitoring, off-site monitoring and on-site monitoring visits to ensure the study is conducted in accordance with GCP and the study protocol. The study will permit audit by representatives of the sponsor or inspection by regulatory authorities as required. Plans for communicating important protocol amendments to relevant parties (e.g. trial participants, ethical committees) {25} It is the responsibility of the sponsor to determine if an amendment is substantial or not and study procedures must not be changed without the mutual agreement of the CI, sponsor and the TMG. Substantial amendments will be submitted to the REC and/or MHRA (as appropriate) and will not be implemented until such approval(s) is/are in place. Non-substantial amendments will be submitted to the Health Research Authority and will not be implemented until authorisation is received. Substantial amendments and those minor amendments which may impact site will be submitted to the relevant NHS Research & Development Department. Amendment documentation will be provided to sites by NCTU. Dissemination plans {31a} A final report will be provided to the sponsor and REC within 1 year of the end of the study, defined as completion of all study related activities including completion of biomarker sample analysis for all participants. Study results will be made publicly available on the ISRCTN trial registry within 1 year of the end of the study. Discussion TolDC therapy is an emerging cellular therapy aimed at reversing the fundamental abnormality of immune dysregulation in autoimmune disease, but more knowledge of the TolDC product is needed. TolDC CitPep are autologous monocyte-derived tolerogenic dendritic cells loaded with citrullinated self-peptides, an investigational advanced therapy medicinal product. In the phase I AuToDeCRA study, autologous synovial fluid was used as the autoantigen for TolDC loading but carried limitations, including the need for participants to have a knee joint effusion and uncertainty as to which antigen specific T-cells were targeted. Extensive work over the last two decades has identified numerous candidate autoantigens in RA. In AuToDeCRA-2, TolDC will be loaded with synthetic peptides, meaning more sophisticated immune monitoring tools can be leveraged alongside the recruitment of participants with lower disease activity, who may benefit most from tolerance-inducing strategies. One challenge for the study is choosing appropriate outcome measures. Clinical tolerance is difficult to measure in autoimmunity, as it may not correlate with clinical measures in the short-term (14). At present, there is no universally accepted tolerance biomarker, but measures of autoantigen-specific immunity may provide the most important insights. Early phase studies of tolerogenic therapies have demonstrated changes to antigen specific cellular immunity after treatment, including alteration of cytokine profiles, reduced proliferative responses following in vitro stimulation (5, 7), and changes in circulating frequencies of autoreactive T-cells (20). Global changes to T-cell populations (e.g. regulatory and effector subsets) may also occur, and would be more practical as a ‘companion biomarker’ than measuring autoreactive T-cells. Whilst the exact signature of tolerance induction remains uncertain, the ability of a candidate therapy to induce immunomodulation is a prerequisite for efficacy. In AuToDeCRA-2, multiple technologies will be used to monitor the immune state and, whilst changes previously observed by others will support the efficacy of TolDC CitPep , the wealth of data produced in the study will be interpreted with a view to identifying novel candidate biomarkers. We anticipate that recruitment of participants with few or no symptoms may present another challenge due to the intensive monitoring, the use of an experimental advanced therapy medicinal product (ATMP) and the involvement of procedures including leukapheresis. Consequently, a robust and multi-faceted recruitment plan has been developed. Limitations include the small number of participants, however this is felt to be a realistic recruitment goal and adequate to address the aims of the study. In summary, AuToDeCRA-2 is an early phase experimental medicine study of an ATMP with the main objectives being to compare routes of administration and to demonstrate the ability of TolDC CitPep to induce immunomodulation. Knowledge gathered from this study will help define biomarker outcomes and address existing scientific gaps necessary to inform the design of future TolDC studies for RA and other conditions where restoration of immune tolerance is desired. Trial status Recruitment commenced on 15 th January 2024 and is expected to complete by April 2025. The current protocol is version 5.0, dated 31 st July 2024. Abbreviations ACPA ACR AE Anti Citrullinated Peptide Antibodies American College of Rheumatology Adverse Event APC AR ARA ATMP AuToDeCRA CI Antigen Presenting Cells Adverse Reaction American Rheumatism Association Advanced Therapy Medicinal Product Autologous Tolerogenic Dendritic Cells for Rheumatoid Arthritis Chief Investigator Cit CMV Citrullinated Cytomegalovirus CRP C-reactive Protein DAS DC Disease Activity Score Dendritic Cell DMC Data Monitoring Committee eCRF EDTA ESR Electronic Case Report Form Ethylenediaminetetraacetic acid Erythrocyte Sedimentation Rate EULAR FBC FSH GCP GDPR GMP HIV HTLV European Alliance of Associations for Rheumatology Full Blood Count Follicle Stimulating Hormone Good Clinical Practice General Data Protection Regulation Good Manufacturing Practice Human Immunodeficiency Virus Human T-cell Lymphotrophic Virus HLA Human Leukocyte Antigen ICF INR Informed Consent Form International Normalised Ratio ISF Investigator Site File ISRCTN LFT International Standard Randomised Controlled Trials Number Liver Function Test MHRA Mg Medicines and Healthcare products Regulatory Agency Magnesium NCTU Newcastle Clinical Trials Unit NHS NIHR NuTH National Health Service National Institute of Health and Care Research Newcastle upon Tyne Hospitals NHS Foundation Trust PBMC PI Peripheral Blood Mononuclear Cell Principal Investigator PIS Participant Information Sheet RA Rheumatoid Arthritis REC Research Ethics Committee RhF Rheumatoid Factor SE Shared Epitope SOP SPIRIT Standard Operating Procedure Standard Protocol Items: Recommendations for Interventional Trials TMG TolDC TolDC CitPep Trial Management Group Tolerogenic Dendritic Cells Tolerogenic Dendritic Cells loaded with citrullinated self-peptides TSC Trial Steering Committee TNF U&E Tumour Necrosis Factor Urea and Electrolytes VAS Visual Analogue Scale Declarations Acknowledgements This work was supported by the National Institute of Health and Care Research (NIHR) Newcastle Biomedical Research Centre and the NIHR Newcastle Clinical Research Facility. The NIHR had no role in the study design, collection, analysis, interpretation of data, writing of the manuscript or the decision to submit the paper for publication. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. Authors' contributions {31b} ELL contributed to study design, development of the protocol and writing of the manuscript. JS, MW, NG, JP, MM, GH, JT, JD, AA, AP and CH contributed to study design and development of the protocol. AAM, PB, RJ and CN contributed to protocol amendments. JI is the CI/PI; he conceived the study and led the proposal and protocol development. All authors read and approved the final manuscript. Funding {4} This study is funded by Versus Arthritis (formally Arthritis Research UK) ref: 21811 and RTCure (Rheuma Tolerance for Cure) as part of the Innovative Medicines Initiative 2 Joint Undertaking ref:777357. The funders had no role in the study design, collection, analysis, interpretation of data, writing of the manuscript or the decision to submit the paper for publication. The study has had full external peer review. Availability of data and materials {29} Until publication of the study results, access to the full dataset will be limited to the Trial Management Group. Ethics approval and consent to participate {24} Ethical approval has been granted by the NHS Health Research Authority Research Ethics Committee 23/LO/0494 in collaboration with MHRA CTA 17136/0304/001-0001. Written, informed consent to participate will be obtained from all participants. Consent for publication {32} A model consent form will be made available on request. Competing interests {28} The authors declare that they have no competing interests. References Bell GM, Anderson AE, Diboll J, Reece R, Eltherington O, Harry RA, et al. Autologous tolerogenic dendritic cells for rheumatoid and inflammatory arthritis. Ann Rheum Dis. 2017;76(1):227-34. Stanway JA, Isaacs JD. Tolerance-inducing medicines in autoimmunity: rheumatology and beyond. Lancet Rheumatol. 2020;2(9):e565-e75. Giannoukakis N, Phillips B, Finegold D, Harnaha J, Trucco M. Phase I (safety) study of autologous tolerogenic dendritic cells in type 1 diabetic patients. Diabetes Care. 2011;34(9):2026-32. Jauregui-Amezaga A, Cabezón R, Ramírez-Morros A, España C, Rimola J, Bru C, et al. Intraperitoneal Administration of Autologous Tolerogenic Dendritic Cells for Refractory Crohn's Disease: A Phase I Study. J Crohns Colitis. 2015;9(12):1071-8. Nikolic T, Zwaginga JJ, Uitbeijerse BS, Woittiez NJ, de Koning EJ, Aanstoot HJ, et al. Safety and feasibility of intradermal injection with tolerogenic dendritic cells pulsed with proinsulin peptide-for type 1 diabetes. Lancet Diabetes Endocrinol. 2020;8(6):470-2. Willekens B, Presas-Rodríguez S, Mansilla MJ, Derdelinckx J, Lee WP, Nijs G, et al. Tolerogenic dendritic cell-based treatment for multiple sclerosis (MS): a harmonised study protocol for two phase I clinical trials comparing intradermal and intranodal cell administration. BMJ Open. 2019;9(9):e030309. Zubizarreta I, Flórez-Grau G, Vila G, Cabezón R, España C, Andorra M, et al. Immune tolerance in multiple sclerosis and neuromyelitis optica with peptide-loaded tolerogenic dendritic cells in a phase 1b trial. Proc Natl Acad Sci U S A. 2019;116(17):8463-70. STEINMAN RM, HAWIGER D, LIU K, BONIFAZ L, BONNYAY D, MAHNKE K, et al. Dendritic Cell Function in Vivo during the Steady State: A Role in Peripheral Tolerance. Annals of the New York Academy of Sciences. 2003;987(1):15-25. Anderson AE, Sayers BL, Haniffa MA, Swan DJ, Diboll J, Wang XN, et al. Differential regulation of naïve and memory CD4+ T cells by alternatively activated dendritic cells. J Leukoc Biol. 2008;84(1):124-33. Anderson AE, Swan DJ, Sayers BL, Harry RA, Patterson AM, von Delwig A, et al. LPS activation is required for migratory activity and antigen presentation by tolerogenic dendritic cells. J Leukoc Biol. 2009;85(2):243-50. Harry RA, Anderson AE, Isaacs JD, Hilkens CM. Generation and characterisation of therapeutic tolerogenic dendritic cells for rheumatoid arthritis. Ann Rheum Dis. 2010;69(11):2042-50. Anderson AE, Swan DJ, Wong OY, Buck M, Eltherington O, Harry RA, et al. Tolerogenic dendritic cells generated with dexamethasone and vitamin D3 regulate rheumatoid arthritis CD4(+) T cells partly via transforming growth factor-β1. Clin Exp Immunol. 2017;187(1):113-23. Benham H, Nel HJ, Law SC, Mehdi AM, Street S, Ramnoruth N, et al. Citrullinated peptide dendritic cell immunotherapy in HLA risk genotype–positive rheumatoid arthritis patients. Science Translational Medicine. 2015;7(290):290ra87-ra87. Morgan AW, Hale G, Rebello PR, Richards SJ, Gooi HC, Waldmann H, et al. A pilot study of combination anti-cytokine and anti-lymphocyte biological therapy in rheumatoid arthritis. Qjm. 2008;101(4):299-306. Ridolfi R, Riccobon A, Galassi R, Giorgetti G, Petrini M, Fiammenghi L, et al. Evaluation of in vivo labelled dendritic cell migration in cancer patients. J Transl Med. 2004;2(1):27. Gerstner C, Dubnovitsky A, Sandin C, Kozhukh G, Uchtenhagen H, James EA, et al. Functional and Structural Characterization of a Novel HLA-DRB1*04:01-Restricted α-Enolase T Cell Epitope in Rheumatoid Arthritis. Front Immunol. 2016;7:494. James EA, Rieck M, Pieper J, Gebe JA, Yue BB, Tatum M, et al. Citrulline-specific Th1 cells are increased in rheumatoid arthritis and their frequency is influenced by disease duration and therapy. Arthritis Rheumatol. 2014;66(7):1712-22. Schwenzer A, Jiang X, Mikuls TR, Payne JB, Sayles HR, Quirke A-M, et al. Identification of an immunodominant peptide from citrullinated tenascin-C as a major target for autoantibodies in rheumatoid arthritis. Annals of the Rheumatic Diseases. 2016;75(10):1876-83. Snir O, Rieck M, Gebe JA, Yue BB, Rawlings CA, Nepom G, et al. Identification and functional characterization of T cells reactive to citrullinated vimentin in HLA–DRB1*0401–positive humanized mice and rheumatoid arthritis patients. Arthritis & Rheumatism. 2011;63(10):2873-83. Sonigra A, Nel HJ, Wehr P, Ramnoruth N, Patel S, van Schie KA, et al. Randomized phase I trial of antigen-specific tolerizing immunotherapy with peptide/calcitriol liposomes in ACPA+ rheumatoid arthritis. JCI Insight. 2022;7(20). Cite Share Download PDF Status: Published Journal Publication published 07 Aug, 2025 Read the published version in Trials → Version 1 posted Reviewers agreed at journal 28 May, 2025 Reviewers invited by journal 28 May, 2025 Editor assigned by journal 25 Mar, 2025 First submitted to journal 24 Mar, 2025 Editorial decision: Minor revision 17 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6222488","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":463150070,"identity":"5a159f3e-903d-441a-8103-0028541dabe5","order_by":0,"name":"Ema-Louise 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If not receiving TolDC\u003csub\u003eCitPep\u003c/sub\u003e only the Secondary Screening questionnaire requires completion and can be done by telephone\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003e Vital signs to include diastolic and systolic blood pressure, heart rate, temperature\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3 \u003c/sup\u003eOnly for those allocated to receive TolDC\u003csub\u003eCitPep\u003c/sub\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003e RA assessment to include Patient VAS, Physician VAS, 66/68 Swollen and Tender Joint Count, pain score and HAQ-DI index. HAQ-DI index to be excluded from RA assessment for screening visit\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6222488/v1/f38c863fb09f8c764b0057a1.png"},{"id":88814161,"identity":"2e4f1054-21a9-4775-bc3a-45c1d3f8a620","added_by":"auto","created_at":"2025-08-11 16:07:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1992266,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6222488/v1/5310f721-aedd-4de8-84d2-df761df11e90.pdf"}],"financialInterests":"","formattedTitle":"Autologous Tolerogenic Dendritic Cells for Rheumatoid Arthritis-2 (AuToDeCRA-2) Study: Protocol for a single-centre, experimental medicine study investigating the route of delivery and potential efficacy of autologous tolerogenic dendritic cell (TolDC) therapy for Rheumatoid Arthritis","fulltext":[{"header":"Administrative information","content":"\u003cp\u003eNote: the numbers in curly brackets in this protocol refer to SPIRIT checklist item numbers. The order of the items has been modified to group similar items (see http://www.equator-network.org/reporting-guidelines/spirit-2013-statement-defining-standard-protocol-items-for-clinical-trials/).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"3\" cellpadding=\"0\" width=\"606\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTitle {1}\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA single-centre, experimental medicine study investigating the route of delivery and potential efficacy of autologous tolerogenic dendritic cell (TolDC) therapy for Rheumatoid Arthritis-2 (AuToDeCRA-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTrial registration {2a and 2b}.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eISRCTN14999554. Registered on 27\u003csup\u003eth\u003c/sup\u003e September 2023.\u003c/p\u003e\n \u003cp\u003ehttps://doi.org/10.1186/ISRCTN14999554\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eProtocol version {3}\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eV5.0 31\u003csup\u003est\u003c/sup\u003e July 2024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFunding {4}\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVersus Arthritis (formally Arthritis Research UK) ref: 21811\u003c/p\u003e\n \u003cp\u003eRTCure (Rheuma Tolerance for Cure) as part of the Innovative Medicines Initiative 2 Joint Undertaking ref:777357\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAuthor details {5a}\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003csup\u003e1\u003c/sup\u003eTranslational \u0026amp; Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, United Kingdom\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e2\u003c/sup\u003eDepartment of Rheumatology, Freeman Hospital, Newcastle upon Tyne, United Kingdom\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e3\u003c/sup\u003eNewcastle Clinical Trials Unit, Newcastle University, United Kingdom\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e4\u003c/sup\u003eClinical Research Facility, Royal Victoria infirmary, Newcastle upon Tyne, United Kingdom\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e5\u003c/sup\u003eDepartment of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e6\u003c/sup\u003eNIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne, United Kingdom\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eName and contact information for the trial sponsor {5b}\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThe Newcastle upon Tyne Hospitals NHS Foundation Trust\u003c/p\u003e\n \u003cp\u003eSponsor reference: 08669\u0026nbsp;\u003c/p\u003e\n \u003cp\[email protected]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRole of sponsor {5c}\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThe sponsor has no role in the study design; collection, management, analysis and interpretation of data; writing of the report or the decision to submit for publication\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Introduction","content":"\u003cp\u003e\u003cstrong\u003eBackground and rationale {6a}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAutoimmune disease such as Rheumatoid Arthritis (RA) results from a breakdown of immunological tolerance; the immune system mistakenly recognises healthy, self-tissue as a threat, leading to inflammation and eventually structural damage. No current treatment option for RA represents a cure and medication is required indefinitely, carrying with it the risks of generalised immunosuppression. It is desirable to develop \u0026lsquo;tolerogenic\u0026rsquo; treatments, which reverse the underlying abnormality of the immune system rather than continuous non-specific suppression of inflammation and immunity. Tolerogenic dendritic cells (TolDC) have emerged as one such possibility (1-7).\u003c/p\u003e\n\u003cp\u003eCD4\u003csup\u003e+\u0026nbsp;\u003c/sup\u003ehelper T-cells are a key driver of disease in RA, in keeping with their established role as orchestrators of adaptive immune responses through their interaction with professional antigen presenting cells (APC). As key APC, dendritic cells (DC) instruct CD4\u003csup\u003e+\u0026nbsp;\u003c/sup\u003eT-cells how to respond to a given antigen by modulating the co-stimulation they provide. Depending on context, DCs can induce either proinflammatory or regulatory (tolerogenic) characteristics in the T-cells (8). If an antigen is encountered in the context of threat, the DC in question \u0026lsquo;matures\u0026rsquo; and will present antigen with co-stimulatory signals, which leads to the generation of antigen-specific T-cells with pro-inflammatory characteristics. Conversely, if the antigen is encountered in a non-threatening microenvironment, the DC remains \u0026lsquo;immature\u0026rsquo; and upon interaction with the T-cell, may induce a regulatory phenotype, anergy (a state of hyporesponsiveness) or even apoptosis. With their ability to influence the adaptive immune system in an antigen-specific way, DCs are an exciting potential therapeutic tool which could \u0026lsquo;reset\u0026rsquo; autoimmunity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhilst immature DCs can induce T-cell tolerance, their phenotype is unstable, and they may develop into immunogenic, mature DCs in the presence of pro-inflammatory cytokines. As such, a variety of protocols have been developed for the generation of phenotypically stable TolDC which retain their tolerogenic characteristics, even in a pro-inflammatory microenvironment. We have established such a protocol (9-12) and these cells were administered safely to patients with inflammatory arthritis in the earlier phase I AuToDeCRA study (1).\u003c/p\u003e\n\u003cp\u003eIn AuToDeCRA, TolDC were loaded with autologous synovial fluid as a source of antigen and administered arthroscopically into an inflamed knee joint following saline wash-out. The lack of a subsequent disease flare following administration suggested that, as shown by \u003cem\u003ein vitro\u003c/em\u003e studies, the TolDC phenotype was stable. These findings have been corroborated by several other international studies using TolDC in patients with RA and other autoimmune diseases such as multiple sclerosis and type 1 diabetes (3-7, 13). Although no TolDC trial has yet demonstrated robust clinical efficacy, TolDC appear to be a safe and well tolerated intervention.\u003c/p\u003e\n\u003cp\u003eThere is now a need to demonstrate the ability of TolDC to achieve immunomodulation. Tolerogenic therapies are not necessarily anti-inflammatory in the short-term (14) and biomarkers of the immune state that are influenced more rapidly by such treatments are urgently needed, not least to guide clinical protocol development relating to aspects such as optimal dose, route of administration and antigen loading. AuToDeCRA-2 was developed to begin to address some of these\u0026nbsp;questions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives {7}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuToDeCRA-2 is designed to demonstrate and compare immunomodulation using synthetic citrullinated peptide loaded TolDC (TolDC\u003csub\u003eCitPep\u003c/sub\u003e) administered via three distinct routes: intra-nodal, intra-articular, intra-dermal and in the case of intra-nodal administration, at a low and a high dose. The rationale for loading TolDC with citrullinated peptides is explained in section {11a}.\u003c/p\u003e\n\u003cp\u003eTable 1 outlines the study objectives which will be achieved by comparing baseline data with follow-up data at 1, 3, 6 and 12 weeks.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Study objectives\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003ePrimary Objectives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSecondary Objectives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eExploratory Objectives\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eTo seek signals of immune modulation when TolDC\u003csub\u003eCitPep\u003c/sub\u003e are administered to participants with RA using immune state biomarkers performed on peripheral blood samples at baseline, 1, 3 and 6 week follow-up and participant lymph node aspirates at baseline and 1 week follow-up\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eTo seek signs of clinical efficacy when TolDC\u003csub\u003eCitPep\u003c/sub\u003e are administered to participants with RA using ACR 20, 50 and 70, DAS-28, and components thereof at baseline and 1, 3, 6 and 12 week follow-up\u003c/li\u003e\n \u003cli\u003eTo provide further evidence of TolDC\u003csub\u003eCitPep\u003c/sub\u003e safety using reported adverse events (AEs) at baseline, 1, 3, 6 and 12 week follow-up\u003c/li\u003e\n \u003cli\u003eTo provide further evidence of participant acceptability of TolDC\u003csub\u003eCitPep\u003c/sub\u003e therapy for RA using a Participant Acceptability questionnaire at 12 week follow -up\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eTo link signals of immune modulation with signs of potential efficacy of TolDC\u003csub\u003eCitPep\u0026nbsp;\u003c/sub\u003eusing potential associations between immune modulation measures and evidence of efficacy for the three different routes of TolDC\u003csub\u003eCitPep\u003c/sub\u003e administration (and, in the case of intra-nodal injection, for the two doses administered)\u003c/li\u003e\n \u003cli\u003eTo compare intra-nodal (low and high dose), intra-dermal and intra-articular injection with regards to primary and secondary objectives, and feasibility\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Design {8}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuToDeCRA-2 is a non-commercial, exploratory, unblinded, randomised experimental medicine study with 5 parallel groups of ACPA-positive RA participants in an allocation ratio of 1:1:1:1:1, with the aim of demonstrating and comparing immunomodulation by TolDC\u003csub\u003eCitPep\u003c/sub\u003e.\u003c/p\u003e\n\u003cp\u003eThe study protocol follows the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) \u0026nbsp;2013 statement. The study has been registered with ISRCTN (14999554).\u003c/p\u003e"},{"header":"Methods: Participants, interventions and outcomes","content":"\u003cp\u003e\u003cstrong\u003eStudy Setting {9}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe single centre study will be undertaken at Newcastle upon Tyne Hospitals NHS Foundation Trust (NuTH) in the UK. All study visits will take place within a designated Clinical Research Facility at the Royal Victoria Infirmary, Newcastle upon Tyne, with the exception of leukapheresis visits which will take place in the Leukapheresis Day Unit at the Freeman Hospital, Newcastle upon Tyne.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEligibility Criteria {10}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInclusion Criteria\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatients are eligible for the study if all of the following apply at screening: \u0026nbsp;\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eAdults aged 18 years old or over\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"2\" type=\"1\"\u003e\n \u003cli\u003eRA fulfilling 1987 ARA criteria or 2010 ACR/EULAR Classification Criteria \u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"3\" type=\"1\"\u003e\n \u003cli\u003eACPA \u0026gt; 3x upper limit of normal, can include historical measurements providing the result remains positive at screening\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"4\" type=\"1\"\u003e\n \u003cli\u003eAble and willing to give informed consent and to comply with the study protocol \u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"5\" type=\"1\"\u003e\n \u003cli\u003eDisease duration of at least 4 months and less than 10 years\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"6\" type=\"1\"\u003e\n \u003cli\u003eACR Functional Class I-III \u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"7\" type=\"1\"\u003e\n \u003cli\u003eDAS-28 \u0026lt;5.1\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"8\" type=\"1\"\u003e\n \u003cli\u003eIf receiving Disease Modifying Anti-Rheumatic Drugs these can include any combination of methotrexate, sulphasalazine, azathioprine, hydroxychloroquine, abatacept, rituximab (last dose \u0026gt;6 months ago), TNF-alpha inhibitors and IL6 receptor antagonists, provided stable dosing for at least 4 weeks\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"9\" type=\"1\"\u003e\n \u003cli\u003ePossess at least one copy of a shared epitope (SE) HLA DRB1 allele (0101; 0102; 0105; 0401; 0404; 0405; 0408; 0409; 0410; 0413; 0416; 0419; 0421; 1001; 1402; 1406; 1409; 1413; 1417; 1419; 1420; 1421)\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eExclusion Criteria\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatients are excluded from the study if any of the following apply at screening:\u0026nbsp;\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eUse of other investigational medicinal products within 30 days prior to study entry (defined as date of consent into study) \u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"2\" type=\"1\"\u003e\n \u003cli\u003eAny changes to RA treatment within 4 weeks of study entry\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"3\" type=\"1\"\u003e\n \u003cli\u003eCurrent treatment with Janus kinase inhibitors or leflunomide. Previous treatment is permitted provided at least 12 weeks have elapsed at study entry \u0026nbsp;since discontinuation\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"4\" type=\"1\"\u003e\n \u003cli\u003eReceiving glucocorticoids by any route within 4 weeks of study entry, apart from topical, intra-nasal or inhaled\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"5\" type=\"1\"\u003e\n \u003cli\u003eSerious or unstable co-morbidity that prohibits participation in the study at the discretion of the investigator e.g. significant chronic obstructive pulmonary disease, significant cardiac failure, active malignancy \u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"6\" type=\"1\"\u003e\n \u003cli\u003eActive infection at study entry (except fungal nail infection)\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"7\" type=\"1\"\u003e\n \u003cli\u003eInfection requiring hospitalisation or intravenous antibiotics within 4 weeks prior to study entry \u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"8\" type=\"1\"\u003e\n \u003cli\u003eImmunisation with live, attenuated vaccines planned within 14 days of baseline visit (administration of TolDC\u003csub\u003eCitPep\u003c/sub\u003e) and with non-live vaccines planned within 7 days of baseline visit\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"9\" type=\"1\"\u003e\n \u003cli\u003eHistory of hepatitis B or C, HIV, or HTLV-1/2 infection(s) \u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"10\" type=\"1\"\u003e\n \u003cli\u003eRecent history of Cytomegalovirus (CMV) infection (positive for CMV IgM antibodies) or syphilis infection (positive PCR test)\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"11\" type=\"1\"\u003e\n \u003cli\u003eMajor surgery within 8 weeks prior to study entry or planned within 12 weeks of baseline visit\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"12\" type=\"1\"\u003e\n \u003cli\u003ePregnancy, or women planning to become pregnant within the study period, or women who are breast feeding\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"13\" type=\"1\"\u003e\n \u003cli\u003eFemales of childbearing potential engaging in heterosexual relationships unwilling to use adequate contraception for the duration of the study\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"14\" type=\"1\"\u003e\n \u003cli\u003ePatients taking anticoagulants that cannot be interrupted and are, in the judgement of the investigator, likely to interfere with study procedures\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"15\" type=\"1\"\u003e\n \u003cli\u003eKnown hypersensitivity to local anaesthetic \u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"16\" type=\"1\"\u003e\n \u003cli\u003ePoor venous access or medical condition precluding leukapheresis e.g. unstable cardiac arrythmia (atrial fibrillation permitted)\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"17\" type=\"1\"\u003e\n \u003cli\u003eHaemoglobin\u0026lt;10g/dL; neutrophils\u0026lt; 1.00 x10\u003csup\u003e9\u003c/sup\u003e/L; platelets \u0026lt;100x10\u003csup\u003e9\u003c/sup\u003e/L\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eRadiologists performing ultrasound-guided lymph node aspiration and intra-nodal tolDC administration will be competent in the procedure.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRheumatologists performing intra-articular administration will be competent at performing ultrasound guided intra-articular (knee) injection.\u003c/p\u003e\n\u003cp\u003eClinicians performing intra-dermal administration will be competent at intra-dermal injections and have received training on the use of the specific intra-dermal needle selected for use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWho will take informed consent? {26a}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing initial contact, and at least 24 hours after provision of participant information documents, interested participants will attend a screening visit. At the screening visit a member of the study team will ensure the participant information sheet (PIS) has been read and understood and answer any questions. If the participant wishes to enter the study, written informed consent will be obtained by a medically qualified member of the study team delegated to the task.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdditional consent provisions for collection and use of participant data and biological specimens {26b}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are 4 optional consent clauses which form part of the informed consent form (ICF) but do not affect eligibility to participate in the study.\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eAgreeing to contact by the study team about participation in additional follow up visits in the future, should additional research funding be obtained for these visits.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAgreeing that any research samples remaining at the end of the study can be anonymised and sent to a biobank for long term storage and use in future research outside of the study.\u003c/li\u003e\n \u003cli\u003eAgreeing that any samples left over from TolDC manufacture can be anonymised and sent to a biobank for long term storage and use in future research outside of the study.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAgreeing to be sent a summary of the results when the study has finished.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eInterventions\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExplanation for the choice of comparators {6b}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe optimal route for TolDC administration is not clear. The DC-T-cell interaction is believed to occur primarily in lymph nodes. We hypothesise that the route of injection most likely to ensure the TolDC reach a lymph node is direct injection into lymph nodes, but intra-nodal injection is a less convenient route of delivery, requiring ultrasound equipment and a trained operator. AuToDeCRA-2 will therefore compare direct intra-nodal injection with alternative routes that should enable cells to reach disease-relevant lymph nodes. Intra-dermal is the most well studied route of administration (5, 6, 15) for therapeutic DC and does not require specialised equipment. In contrast, intra-articular injection requires specialised equipment and operators, but it is possible that the joint-relevant immune system is best accessed via this route. 10\u003csup\u003e7\u003c/sup\u003e TolDC will be administered via all routes to provide a direct comparison, being the highest dose that was administered in AuToDeCRA. A lower dose of 10\u003csup\u003e5\u003c/sup\u003e TolDC will also be administered intra-nodally as injecting directly into a lymph node may require fewer cells to achieve a therapeutic effect.\u003c/p\u003e\n\u003cp\u003eThe fifth arm is standard care. Standard care was chosen over placebo so that participants would not need to undergo unnecessary leukapheresis or administration procedures. Standard care involves no leukapheresis visit and no administration of TolDC\u003csub\u003eCitPep\u003c/sub\u003e but all other study procedures remain the same.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntervention description {11a}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEligible participants will be randomised in equal proportions to one of four intervention arms or standard care. Participants\u0026rsquo; usual medication will be continued alongside for all groups.\u003c/p\u003e\n\u003cp\u003eParticipants randomised to an intervention arm will attend for leukapheresis at day -8 to extract CD14\u003csup\u003e+\u0026nbsp;\u003c/sup\u003emonocytes for the generation of TolDC\u003csub\u003eCitPep\u003c/sub\u003e. \u0026nbsp;Leukapheresis products will be transferred to Newcastle Advanced Therapies Good Manufacturing Practice (GMP) Facility where the TolDC\u003csub\u003eCitPep\u003c/sub\u003e will be manufactured.\u003c/p\u003e\n\u003cp\u003eIn AuToDeCRA and AuToDeCRA-2, TolDC manufacture is identical aside from the antigen loaded into TolDC. In AuToDeCRA-2 the TolDC will be loaded with synthetic citrullinated peptides (TolDC\u003csub\u003eCitPep\u003c/sub\u003e) representing disease-relevant epitopes (16-19)\u0026nbsp;rather than autologous synovial fluid as in AuToDeCRA. Knowledge of the loaded antigen enables more sophisticated immune monitoring assays that incorporate measures of antigen specificity, allowing the profiling of the cells the treatment is designed to target. Furthermore, treatment is no longer limited to patients with a knee joint effusion, enabling treatment of participants with lower disease activity that may benefit most from tolerance inducing strategies. \u003cem\u003eIn vitro\u003c/em\u003e validation work has confirmed the immunological equivalence of AuToDeCRA and AutoDeCRA-2 TolDC.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTolDC\u003csub\u003eCitPep\u003c/sub\u003e loaded with Cit-alpha-enolase (326-340), Cit-cartilage intermediate layer protein-2 (297-311), Cit-vimentin (59-78) and Cit-tenascin-C 22 (1012-1026) will be diluted to a final volume of 200ml, aspirated into a syringe and undergo quality control and QP release. The syringe will be stored at 2-8 \u0026deg;C in a validated and monitored refrigerator until administration. Administration by all injection routes will be carried out immediately after (inguinal) lymph node aspiration (for biomarker analysis), following which participants will be observed for at least 90 minutes.\u003c/p\u003e\n\u003cp\u003e\u0026bull;\u0026nbsp; Intra-nodal injection of TolDC\u003csub\u003eCitPep\u003c/sub\u003e (10\u003csup\u003e5\u003c/sup\u003e or 10\u003csup\u003e7\u003c/sup\u003e cells)\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTolDC\u003csub\u003eCitPep\u003c/sub\u003e will be injected into up to 5 inguinal lymph nodes under ultrasound visualisation, on the ipsilateral side to the lymph node aspiration as per intra-nodal aspiration and injection Standard Operating Procedure (SOP).\u003c/p\u003e\n\u003cp\u003e\u0026bull; Intra-articular injection of TolDC\u003csub\u003eCitPep\u003c/sub\u003e (10\u003csup\u003e7\u0026nbsp;\u003c/sup\u003ecells)\u003c/p\u003e\n\u003cp\u003eTolDC\u003csub\u003eCitPep\u003c/sub\u003e will be administered as a single injection into a knee joint under ultrasound visualisation as per intra-articular injection SOP. The knee selected should be the least inflamed, and ipsilateral to the aspirated lymph node where possible.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026bull; Intra-dermal injection of TolDC\u003csub\u003eCitPep\u003c/sub\u003e (10\u003csup\u003e7\u003c/sup\u003e cells)\u003c/p\u003e\n\u003cp\u003eIntra-dermal injection will be administered as one or two injections to the upper, anterior thigh (within 5cm of the inguinal crease) on the ipsilateral side as the lymph node aspiration using an intra-dermal 1.2mm silicon needle as per intra-dermal injection SOP.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCriteria for discontinuing or modifying allocated interventions {11b}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are no plans to modify or permit modification of allocated interventions. The intervention will not be administered if the TolDC\u003csub\u003eCitPep\u003c/sub\u003e do not meet stringent release criteria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrategies to improve adherence to interventions {11c}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe intervention is administered as a single dose in a clinical research facility. It is felt unlikely that a participant would not attend for administration having undergone leukapheresis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRelevant concomitant care permitted or prohibited during the trial {11d}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAny medication or concomitant care not specifically listed is presumed to be permitted.\u003c/p\u003e\n\u003cp\u003ePermitted concomitant care:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003ePermitted treatments for RA include methotrexate, sulfasalazine, azathioprine, hydroxychloroquine, abatacept, rituximab (last dose \u0026gt;6 months ago), TNF-alpha inhibitors and IL6 receptor antagonists, alone or in combination, at a stable dose for at least 4 weeks\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAnticoagulants unless these are, in the view of the investigator, likely to interfere with study procedures and cannot be interrupted\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eProhibited concomitant care:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eGlucocorticoids (apart from topical, intra-nasal, inhaled)\u003c/li\u003e\n \u003cli\u003eJanus kinase inhibitors\u003c/li\u003e\n \u003cli\u003eLeflunomide\u003c/li\u003e\n \u003cli\u003eLive, attenuated vaccines within 2 weeks of and non-live vaccines within 1 week of the baseline visit\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eProvisions for post-trial care {30}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAny unexpected or abnormal test results will be discussed with the participant and any necessary follow-up arranged with their rheumatologist, GP or another specialist. Participants will continue to access their usual health practitioners in the normal way throughout and after the study.\u003c/p\u003e\n\u003cp\u003eNo additional TolDC product will be made available post-trial.\u003c/p\u003e\n\u003cp\u003eNHS indemnity for clinical trials will apply for clinical negligence that harms individuals towards whom the NHS has a duty of care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcomes {12}\u003c/strong\u003e\u003c/p\u003e\n\u003ch3 id=\"_Toc134002066\"\u003ePrimary Endpoint/Outcome\u003c/h3\u003e\n\u003cp\u003eThere is currently no agreed biomarker for tolerance induction. Pragmatically, we shall seek evidence of favourable immunomodulation by selecting from a variety of different modalities including:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eIncrease in proportional abundance of regulatory T-cells in peripheral blood by high dimensional cytometry\u003c/li\u003e\n \u003cli\u003eInduction or increase in Interleukin-10 production in peripheral blood mononuclear cells (PBMCs) following citrullinated peptide stimulation, using ELISpot or intracellular flow cytometry\u003c/li\u003e\n \u003cli\u003eReduction in interferon gamma production in PBMCs following citrullinated peptide stimulation\u003c/li\u003e\n \u003cli\u003eChange in proliferative response of PBMCs to citrullinated peptide stimulation, combined with phenotypic (surface marker, cytokine production) correlation\u003c/li\u003e\n \u003cli\u003eA reduction in ACPA titre or diversity of ACPA specificities\u003c/li\u003e\n \u003cli\u003eChanges in circulating cytokine levels\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch3 id=\"_Toc134002067\"\u003eSecondary Endpoints/Outcomes\u003c/h3\u003e\n\u003cp\u003eSecondary outcome measures for the study are:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eChange in ACR 20, 50 and 70, DAS-28, and components thereof at weeks 1, 3, 6 and 12 compared to baseline\u003c/li\u003e\n \u003cli\u003eNumber of reported AEs. AEs will be collected at each timepoint (baseline, 1, 3, 6 and 12 weeks) from clinical assessment and routine blood testing\u003c/li\u003e\n \u003cli\u003eParticipant reported acceptability of the TolDC\u003csub\u003eCitPep\u003c/sub\u003e product and study related procedures including leukapheresis and mode of administration. Data will be collected at the 12 week visit via the Participant Acceptability questionnaire\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch3\u003eExploratory Endpoint/Outcome Measures\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eExploratory outcome measures for the study are:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eEnumeration and phenotypic analysis of autoreactive T-cells by major histocompatibility complex class II tetramer staining\u003c/li\u003e\n \u003cli\u003eSingle cell RNA sequencing of peripheral blood T-cells and lymph node aspirates\u003c/li\u003e\n \u003cli\u003ePotential associations between immune modulation (as defined by primary outcome measures) and evidence of efficacy (as defined by secondary outcome measures) for (1) the different routes of TolDC\u003csub\u003eCitPep\u003c/sub\u003e administration (intra-articular, intra-dermal and intra-nodal) and (2) the different doses of TolDC\u003csub\u003eCitPep\u003c/sub\u003e administered via the intra-nodal route (10\u003csup\u003e5\u003c/sup\u003e and 10\u003csup\u003e7\u003c/sup\u003e)\u003c/li\u003e\n \u003cli\u003eComparison of (1) the different routes of TolDC\u003csub\u003eCitPep\u003c/sub\u003e administration (intra-articular, intra-dermal and intra-nodal) and (2) the different doses of TolDC\u003csub\u003eCitPep\u003c/sub\u003e administered via the intra-nodal route (10\u003csup\u003e5\u003c/sup\u003e and 10\u003csup\u003e7\u003c/sup\u003e), for evidence of immune modulation and potential efficacy\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eParticipant timeline {13}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study flowchart (figure 1) outlines the participant journey through the study and the schedule of events (figure 2) outlines the activities at each study visit.\u003c/p\u003e\n\u003cp\u003eScreening will take place between day -150 and day -10. If screening takes place between day -150 and day -39 then a secondary screening visit will occur between day -38 and day -10. This is to ensure that the participant remains eligible and to allow for safety blood sampling in line with leukapheresis and TolDC production facility SOPs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAfter screening and randomisation (and leukapheresis for those receiving TolDC\u003csub\u003eCitPep\u003c/sub\u003e), participants will attend for baseline (day 0) clinical and immunological assessments. All participants will provide a blood sample and an ultrasound-guided fine needle aspirate from inguinal lymph nodes. These blood and lymph node aspirate samples will contribute to the immunological endpoints described above. Participants in intervention arms will then receive TolDC\u003csub\u003eCitPep\u003c/sub\u003e at the allocated dose and via the allocated administration route.\u003c/p\u003e\n\u003cp\u003eParticipants will be followed up on four occasions at 1, 3, 6 and 12 weeks after the baseline visit. Clinical assessment and blood sampling will take place at each visit. At the week 1 follow-up visit all participants will undergo a second lymph node ultrasound-guided fine needle aspirate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIf, during the follow up period, a participant suffers deterioration in their arthritis symptoms, they will attend for a \u0026lsquo;flare visit\u0026rsquo;. A full clinical assessment will be performed and, if a flare of RA is diagnosed, the participant managed appropriately at the discretion of the investigator, according to standard care. If therapeutic intervention is required for the flare, final samples will be taken for immunological endpoints and the participant will exit the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample size {14}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are no relevant background data available to power this study, which is exploratory and not powered for statistical significance. The sample size of 20 is based upon expected feasible recruitment into a complex experimental medicine protocol, based on prior experience from AuToDeCRA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecruitment {15}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA number of strategies will be implemented to identify potential participants:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eIdentification by usual Rheumatology care team\u003c/li\u003e\n \u003cli\u003eIdentification via local Rheumatology departmental databases followed by a mailed study invitation letter from their usual care team and PIS. The letter will include a tear off slip and a stamped return envelope to express a wish for no further contact if applicable\u003c/li\u003e\n \u003cli\u003eIdentification via National Institute for Health Research immune-mediated inflammatory diseases BioResource with consent for contact passed on by BioResource team\u003c/li\u003e\n \u003cli\u003eEthically-approved advertisement via posters and leaflets including study contact details displayed in the Rheumatology out-patient department and via collaboration with relevant charities, patient groups and Clinical Research networks\u003c/li\u003e\n \u003cli\u003eParticipant Identification Centre sites may be utilised to maximise recruitment via the Northern Regional Rheumatology Network, a group of rheumatology centres within the North East of England\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eAssignment of interventions: allocation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSequence generation {16a}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEligible participants will be randomly allocated to one of five groups. \u0026nbsp;Randomisation will be computer generated and performed by delegated and trained members of the research team using a 24-hour, central, secure, web-based system (Sealed Envelope\u003csup\u003eTM\u003c/sup\u003e).\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eGroup 1 will receive 10\u003csup\u003e5\u0026nbsp;\u003c/sup\u003eTolDC\u003csub\u003eCitPep\u003c/sub\u003e administered into inguinal lymph node/s\u003c/li\u003e\n \u003cli\u003eGroup 2 will receive 10\u003csup\u003e7\u003c/sup\u003e TolDC\u003csub\u003eCitPep\u003c/sub\u003e administered into inguinal lymph node/s\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGroup 3 will receive 10\u003csup\u003e7\u0026nbsp;\u003c/sup\u003eTolDC\u003csub\u003eCitPep\u003c/sub\u003e administered intra-articularly into a knee\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGroup 4 will receive 10\u003csup\u003e7\u003c/sup\u003e TolDC\u003csub\u003eCitPep\u003c/sub\u003e administered intra-dermally into the thigh\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGroup 5 will receive standard care and no active intervention (control group)\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eConcealment mechanism {16b}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAllocation concealment will be ensured by the use of a centralised web-based service for randomisation (Sealed Envelope\u003csup\u003eTM\u003c/sup\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplementation {16c}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants will be enrolled and randomised by delegated and trained members of the research team. The allocation sequence will be generated by Sealed Envelope\u003csup\u003eTM\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eAssignment of interventions: blinding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWho will be blinded {17a}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study is not blinded. Due to the need for those receiving TolDC\u003csub\u003eCitPep\u003c/sub\u003e to undergo leukapheresis and TolDC\u003csub\u003eCitPep\u003c/sub\u003e administration procedures via distinct routes, it is not practical to perform a blinded study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedure for unblinding if needed {17b}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study is unblinded throughout.\u003c/p\u003e\n\u003cp\u003eData collection and management\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePlans for assessment and collection of outcomes {18a}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll assessments will be performed by a qualified healthcare professional delegated to the task.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDemographics, medical history and medication history will be collected at screening.\u003c/p\u003e\n\u003cp\u003eClinical assessment will occur at screening, baseline, week 1, 3, 6 and 12 and any flare visit as required, and include discussion of any new or relevant clinical history including medications, physical examination, RA assessment and vital signs. Physical examination\u0026nbsp;may vary in detail depending upon individual clinical history and will be selected to ensure a comprehensive understanding of participant health.\u003c/p\u003e\n\u003cp\u003eAssessment of the participant\u0026rsquo;s RA condition will include the following:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eParticipant global assessment of disease activity Visual Analogue Scale (VAS) \u0026ndash; score 0-100mm\u003c/li\u003e\n \u003cli\u003ePhysician global assessment of disease activity VAS \u0026ndash; score 0-100mm\u003c/li\u003e\n \u003cli\u003ePain VAS \u0026ndash; score 0-100mm\u003c/li\u003e\n \u003cli\u003e66/68 Swollen and Tender Joint Count\u003c/li\u003e\n \u003cli\u003eHealth Assessment Questionnaire Disability Index (HAQ-DI) (not required at screening) \u0026ndash; score 0-3 rounded to one decimal place\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eParticipant reported acceptability will take place at week 12 via a study specific participant completed Acceptability Questionnaire consisting of sequential questions with a score to denote acceptability and a free text box where participants are invited to comment on any aspect of their involvement.\u003c/p\u003e\n\u003cp\u003eFull details of blood and lymph node aspirate sample collection are provided in section {33}.\u003c/p\u003e\n\u003cp\u003eThe described assessments alongside the biological specimens will enable the collection of outcomes as set out in section {12}.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePlans to promote participant retention and complete follow-up {18b}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe clinical research team will discuss appointment dates with participants to ensure suitability, provide appointment dates in advance and address any transport or accessibility needs. Dates and times can be provided in writing. Reminder phone calls will be made prior to leukapheresis and baseline appointments. Future appointment dates and times will be re-discussed at each appointment.\u003c/p\u003e\n\u003cp\u003eParticipants can withdraw from the study at any time without providing a specific reason. Data collected to the point of withdrawal will be retained and utilised, although participants may request to have stored samples destroyed. Participants withdrawing will be asked for written permission to collect and use data from routine clinical follow-up for the period of their intended participation. Where the TolDC\u003csub\u003eCitPep\u003c/sub\u003e have been administered, contact in line with a participant\u0026rsquo;s week 12 assessment will be attempted to check for adverse reactions (ARs).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData management {19}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data for an individual participant will be recorded in the study-specific electronic Case Report Form (eCRF) set up using Sealed Envelope\u0026rsquo;s\u003csup\u003eTM\u003c/sup\u003e Red Pill system which will include tested range checks for numerical data values. Access to the study database will be password-limited, with task-specific restrictions. Only staff formally delegated to do so will have access to the database.\u003c/p\u003e\n\u003cp\u003eData will be handled, computerised and stored in accordance with the UK Data Protection Act 2018, UK GDPR, the latest GCP Directive (2005/28/EC) and local site policy. Paper copies of study-related documentation will be annotated, signed, dated and filed in the Investigator Site File (ISF). The signed ICF, eligibility forms, GP letter and RA assessments will be uploaded to the participant\u0026rsquo;s medical notes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll study documentation will be archived for 30 years in accordance with UK GCP legislation and local SOPs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConfidentiality {27}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipant identification on the eCRF will be via a unique study identifier number. A record linking the participant\u0026rsquo;s name to the unique study identifier number will be held in a locked room at the study site. Only the Principal Investigator (PI) and appropriately delegated staff will have access to source data and the ISF for the purpose of conducting the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePlans for collection, laboratory evaluation and storage of biological specimens for genetic or molecular analysis in this trial/ future use {33}\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eNHS laboratory and tissue typing bloods\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eParticipants will provide NHS laboratory blood samples, which will be analysed in local Trust laboratories and then discarded. These will be collected and tested as per the table below.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: NHS laboratory blood samples\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eBlood set\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003eTests to be performed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eTime points collected\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eParticipants\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eSet 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eCyclic Citrullinated Peptide Antibody\u0026nbsp;(Anti-\u0026nbsp;CCP)\u003c/li\u003e\n \u003cli\u003eRheumatoid Factor (RhF)\u003c/li\u003e\n \u003cli\u003eFull Blood Count (FBC)\u003c/li\u003e\n \u003cli\u003eErythrocyte Sedimentation Rate (ESR)\u003c/li\u003e\n \u003cli\u003eCoagulation Screen (with derived Fibrinogen)\u003c/li\u003e\n \u003cli\u003eInternational Normalised Ratio (INR)\u003c/li\u003e\n \u003cli\u003eUrea and Electrolytes (U+E)\u003c/li\u003e\n \u003cli\u003eMagnesium (Mg)\u003c/li\u003e\n \u003cli\u003eAdjusted calcium\u003c/li\u003e\n \u003cli\u003eLiver Function Test (LFT)\u003c/li\u003e\n \u003cli\u003eC-reactive Protein (CRP)\u003c/li\u003e\n \u003cli\u003eHuman Immunodeficiency Virus (HIV)\u003c/li\u003e\n \u003cli\u003eHepatitis B+C\u003c/li\u003e\n \u003cli\u003eHuman T cell Leukemia Virus (HTLV) 1+2\u003c/li\u003e\n \u003cli\u003eSyphilis\u003c/li\u003e\n \u003cli\u003eCytomegalovirus (CMV)\u003c/li\u003e\n \u003cli\u003eHLA DRB1 tissue type (except where tissue type is already known)\u003c/li\u003e\n \u003cli\u003eFollicle Stimulating Hormone (FSH) *\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eScreening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eAll\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e* FSH can be considered to prove post menopausal state in women \u0026lt; 50y who have been amenorrhoeic for 12 months and would prefer testing to using contraception for the duration of the study on discussion with the investigator\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eSet 1B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eHIV\u003c/li\u003e\n \u003cli\u003eHepatitis B +C\u003c/li\u003e\n \u003cli\u003eHTLV 1+2\u003c/li\u003e\n \u003cli\u003eSyphilis\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCMV\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eSecondary screening visit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eThose screened \u0026gt; 38 days before scheduled baseline visit\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eSet 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eFBC\u003c/li\u003e\n \u003cli\u003eU\u0026amp;E\u003c/li\u003e\n \u003cli\u003eLFT\u003c/li\u003e\n \u003cli\u003ePhosphate\u003c/li\u003e\n \u003cli\u003eMg\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAdjusted calcium\u003c/li\u003e\n \u003cli\u003eGroup + Save\u003c/li\u003e\n \u003cli\u003eHIV\u003c/li\u003e\n \u003cli\u003eHepatitis B+C\u003c/li\u003e\n \u003cli\u003eHTLV 1+2\u003c/li\u003e\n \u003cli\u003eSyphilis\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eLeukapheresis visit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eAll, except participants randomised to Group 5 (control group)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eSet 3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eFBC\u003c/li\u003e\n \u003cli\u003eU\u0026amp;E\u003c/li\u003e\n \u003cli\u003eLFT\u003c/li\u003e\n \u003cli\u003eCRP\u003c/li\u003e\n \u003cli\u003eESR\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eBaseline, follow-up visits 1, 2 and 3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eAll\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eSet 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eFBC\u003c/li\u003e\n \u003cli\u003eU\u0026amp;E\u003c/li\u003e\n \u003cli\u003eLFT\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCRP\u003c/li\u003e\n \u003cli\u003eESR\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRhF\u003c/li\u003e\n \u003cli\u003eACPA\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eFollow-up visit 4\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eAll\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eSet 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eFBC\u003c/li\u003e\n \u003cli\u003eU\u0026amp;E\u003c/li\u003e\n \u003cli\u003eLFT\u003c/li\u003e\n \u003cli\u003eCRP\u003c/li\u003e\n \u003cli\u003eESR\u003c/li\u003e\n \u003cli\u003eany additional test at the discretion of the investigator\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eFlare visit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eThose completing a flare visit\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cul\u003e\n \u003cli\u003ePeripheral blood research biomarkers\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eResearch blood samples will be obtained at baseline and weeks 1, 3, and 6. This will involve the collection at each visit of 108ml of blood in a combination of EDTA and serum separator tubes. Some of this sample will be studied immediately within the research laboratory and the remainder processed and cryopreserved for analysis following study completion.\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eLymph node aspirate samples\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eLymph node aspirate samples will be obtained by an experienced radiologist using direct ultrasound visualisation to aspirate up to 5 lymph nodes using a 23 Gauge needle and 3ml syringe under tension. Samples will be immediately passed to a member of the study team for processing and cryopreservation for analysis following study completion.\u003c/p\u003e\u003cp\u003eStatistical methods\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical methods for primary and secondary outcomes {20a}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuToDeCRA-2 is\u0026nbsp;not powered for formal statistical significance. Nonetheless,\u0026nbsp;a statistical analysis plan will be developed during the study.\u003c/p\u003e\n\u003cp\u003eThe analysis population will include all subjects who have received their allocated intervention. For AE reporting, the analysis population will be all individuals who provide consent, whether or not they subsequently receive TolDC\u003csub\u003eCitPep\u003c/sub\u003e.\u003c/p\u003e\n\u003cp\u003eDemographic characteristics, medical history and clinical characteristics collected at screening will be summarised descriptively and tabulated. For categorical variables the frequency and percentage in each group will be reported. For continuous variables the mean, standard deviation and/or median and interquartile range will be reported.\u003c/p\u003e\n\u003cp\u003eWithin each arm (n=4) we will assess whether there are any consistent trends in the parameters being measured, both for primary and secondary outcomes, and we will compare each of the 4 intervention arms against the control group and each other for primary and secondary outcomes.\u003c/p\u003e\n\u003cp\u003eSummary statistics capturing differences in immune biomarkers (expressed as percentages, stimulation indices, titres etc) and clinical outcomes (descriptive and numeric) will be tabulated and presented graphically. Longitudinal analysis will be performed to compare samples following TolDC\u003csub\u003eCitPep\u003c/sub\u003e administration at baseline. Given the low participant number in each group (4), no formal statistical testing will be performed other than to explore analysis methods, identify prospective transformations of the data, identify key prospective time points, and obtain estimates of the variability in both primary and secondary measures to inform the design of a future efficacy study. Estimates of variability will be based on a mixed effects model including participant, route of administration and sampling time point.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterim analyses {21b}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is no planned formal interim analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipant flow through the study will be presented using a CONSORT diagram and updated monthly throughout recruitment as a guide.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods for additional analyses (eg subgroup analyses) {20b}\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe will assess for any potential relationships between primary immune outcomes and secondary clinical outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods in analysis to handle protocol non-adherence and any statistical methods to handle missing data {20c}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn investigation of missing data will be undertaken to understand study withdrawals or missing appointments and whether these could be related to baseline factors or AEs. Where data are incomplete, existing data will be used for all analyses. There will be no attempt to impute missing data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePlans to give access to the full protocol, participant level-data and statistical code {31c}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe full protocol is available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUntil publication of the study results, access to the full dataset will be limited to the Trial Management Group (TMG).\u0026nbsp;Requests for data sharing with bona fide study teams outside of Newcastle University or NuTH will be considered by a Data Access Committee, with representation from the sponsor and Chief Investigator (CI). Data transfer will be subject to completion of a Data Sharing Agreement between Newcastle University and the end users.\u003c/p\u003e\n\u003cp\u003eThere is no relevant statistical code to access.\u003c/p\u003e\n\u003cp\u003eOversight and monitoring\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComposition of the coordinating centre and trial steering committee {5d}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy conduct at site will be led by the PI and supported by GCP trained and appropriately delegated research clinicians and nurses.\u003c/p\u003e\n\u003cp\u003eNewcastle Clinical Trials Unit (NCTU) manage the trial on behalf of the sponsor and will provide day-to-day support for the site and training, site initiation activities and routine monitoring activities.\u003c/p\u003e\n\u003cp\u003eThe TMG will be responsible for the day-to-day running of the study and will consist of the CI, PI and delegated researchers, members of NCTU, sponsor and, as required, other members of the study team. The TMG will monitor all aspects of the conduct and progress of the study. TMG meetings will occur approximately monthly.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Trial Steering Committee (TSC) will provide overall independent oversight of the study and will oversee study conduct and progress. The TSC will consist of an independent chair, together with at least two other independent members, a Patient and Public Involvement (PPI) representative and the CI. The TSC will meet approximately 6-monthly throughout the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComposition of the data monitoring committee, its role and reporting structure {21a}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Data Monitoring Committee (DMC) will consist of at least three independent members including an Independent Chair, an Independent Statistician and an Independent Clinician and will meet approximately 6-monthly throughout the study. The DMC will make recommendations to the TSC as to whether there are any ethical or safety issues that may necessitate changes to the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdverse event reporting and harms {22}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants will be asked to report AEs at every study visit\u0026nbsp;and encouraged to contact the study team for any concerns between visits via 24-hour telephone numbers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll AEs occurring from point of consent to end of the last study related assessment will be recorded in the AE eCRF and the participant’s medical records. All Serious AEs will also be reported to sponsor and to the MHRA if applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll SARs occurring from administration of TolDC\u003csub\u003eCitPep\u003c/sub\u003e to last study related assessment will be reported to sponsor and recorded in the eCRF and medical records.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe assessment of expectedness will be performed by the CI on behalf of the sponsor against the approved Reference Safety Information for the study.\u003c/p\u003e\n\u003cp\u003eAny Suspected Unexpected Serious ARs will be reported to the MHRA and Research Ethics Committee (REC) by the sponsor.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFrequency and plans for auditing trial conduct {23}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA Site Delegation Log will detail the responsibilities of each member of site staff working on the study.\u003c/p\u003e\n\u003cp\u003eQuality control will be maintained through adherence to sponsor and NCTU SOPs, study protocol, GCP principles, research governance and clinical trial regulations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMonitoring to ensure appropriate trial conduct and data collection will be carried out by NCTU according to a documented monitoring plan. Electronic data will be stored in secure, password-protected computers. NCTU staff will use a combination of central monitoring, off-site monitoring and on-site monitoring visits to ensure the study is conducted in accordance with GCP and the study protocol.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study will permit audit by representatives of the sponsor or inspection by regulatory authorities as required.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePlans for communicating important protocol amendments to relevant parties (e.g. trial participants, ethical committees) {25}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt is the responsibility of the sponsor to determine if an amendment is substantial or not and study procedures must not be changed without the mutual agreement of the CI, sponsor and the TMG.\u003c/p\u003e\n\u003cp\u003eSubstantial amendments will be submitted to the REC and/or MHRA (as appropriate) and will not be implemented until such approval(s) is/are in place.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNon-substantial amendments will be submitted to the Health Research Authority and will not be implemented until authorisation is received.\u003c/p\u003e\n\u003cp\u003eSubstantial amendments and those minor amendments which may impact site will be submitted to the relevant NHS Research \u0026amp; Development Department. \u0026nbsp;Amendment documentation will be provided to sites by NCTU.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDissemination plans {31a}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA final report will be provided to the sponsor and REC within 1 year of the end of the study, defined as completion of all study related activities including completion of biomarker sample analysis for all participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStudy results will be made publicly available on the ISRCTN trial registry within 1 year of the end of the study.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTolDC therapy is an emerging cellular therapy aimed at reversing the fundamental abnormality of immune dysregulation in autoimmune disease, but more knowledge of the TolDC product is needed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTolDC\u003csub\u003eCitPep\u003c/sub\u003e are autologous monocyte-derived tolerogenic dendritic cells loaded with citrullinated self-peptides, an investigational advanced therapy medicinal product. In the phase I AuToDeCRA study, autologous synovial fluid was used as the autoantigen for TolDC loading but carried limitations, including the need for participants to have a knee joint effusion and uncertainty as to which antigen specific T-cells were targeted. Extensive work over the last two decades has identified numerous candidate autoantigens in RA. In AuToDeCRA-2, TolDC will be loaded with synthetic peptides, meaning more sophisticated immune monitoring tools can be leveraged alongside the recruitment of participants with lower disease activity, who may benefit most from tolerance-inducing strategies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne challenge for the study is choosing appropriate outcome measures. Clinical tolerance is difficult to measure in autoimmunity, as it may not correlate with clinical measures in the short-term (14). At present, there is no universally accepted tolerance biomarker, but measures of autoantigen-specific immunity may provide the most important insights. Early phase studies of tolerogenic therapies have demonstrated changes to antigen specific cellular immunity after treatment, including alteration of cytokine profiles, reduced proliferative responses following \u003cem\u003ein vitro\u003c/em\u003e stimulation (5, 7), and changes in circulating frequencies of autoreactive T-cells (20). Global changes to T-cell populations (e.g. regulatory and effector subsets) may also occur, and would be more practical as a ‘companion biomarker’ than measuring autoreactive T-cells. Whilst the exact signature of tolerance induction remains uncertain, the ability of a candidate therapy to induce immunomodulation is a prerequisite for efficacy. In AuToDeCRA-2, multiple technologies will be used to monitor the immune state and, whilst changes previously observed by others will support the efficacy of TolDC\u003csub\u003eCitPep\u003c/sub\u003e, the wealth of data produced in the study will be interpreted with a view to identifying novel candidate biomarkers. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe anticipate that recruitment of participants with few or no symptoms may present another challenge due to the intensive monitoring, the use of an experimental advanced therapy medicinal product (ATMP) and the involvement of procedures including leukapheresis. Consequently, a robust and multi-faceted recruitment plan has been developed. Limitations include the small number of participants, however this is felt to be a realistic recruitment goal and adequate to address the aims of the study.\u003c/p\u003e\n\u003cp\u003eIn summary, AuToDeCRA-2 is an early phase experimental medicine study of an ATMP with the main objectives being to compare routes of administration and to demonstrate the ability of TolDC\u003csub\u003eCitPep\u003c/sub\u003e to induce immunomodulation. Knowledge gathered from this study will help define biomarker outcomes and address existing scientific gaps necessary to inform the design of future TolDC studies for RA and other conditions where restoration of immune tolerance is desired.\u003c/p\u003e\n\u003cp\u003eTrial status\u003c/p\u003e\n\u003cp\u003eRecruitment commenced on 15\u003csup\u003eth\u003c/sup\u003e January 2024 and is expected to complete by April 2025. The current protocol is version 5.0, dated 31\u003csup\u003est\u003c/sup\u003e July 2024.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eACPA\u003c/p\u003e\n \u003cp\u003eACR\u003c/p\u003e\n \u003cp\u003eAE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eAnti Citrullinated Peptide Antibodies\u003c/p\u003e\n \u003cp\u003eAmerican College of Rheumatology\u003c/p\u003e\n \u003cp\u003eAdverse Event\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eAPC\u003c/p\u003e\n \u003cp\u003eAR\u003c/p\u003e\n \u003cp\u003eARA\u003c/p\u003e\n \u003cp\u003eATMP\u003c/p\u003e\n \u003cp\u003eAuToDeCRA\u003c/p\u003e\n \u003cp\u003eCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eAntigen Presenting Cells\u003c/p\u003e\n \u003cp\u003eAdverse Reaction\u003c/p\u003e\n \u003cp\u003eAmerican Rheumatism Association\u003c/p\u003e\n \u003cp\u003eAdvanced Therapy Medicinal Product\u003c/p\u003e\n \u003cp\u003eAutologous Tolerogenic Dendritic Cells for Rheumatoid Arthritis\u003c/p\u003e\n \u003cp\u003eChief Investigator\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eCit\u003c/p\u003e\n \u003cp\u003eCMV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eCitrullinated\u003c/p\u003e\n \u003cp\u003eCytomegalovirus\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eCRP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eC-reactive Protein\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eDAS\u003c/p\u003e\n \u003cp\u003eDC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eDisease Activity Score\u003c/p\u003e\n \u003cp\u003eDendritic Cell\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eDMC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eData Monitoring Committee\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eeCRF\u003c/p\u003e\n \u003cp\u003eEDTA\u003c/p\u003e\n \u003cp\u003eESR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eElectronic Case Report Form\u003c/p\u003e\n \u003cp\u003eEthylenediaminetetraacetic acid\u003c/p\u003e\n \u003cp\u003eErythrocyte Sedimentation Rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eEULAR\u003c/p\u003e\n \u003cp\u003eFBC\u003c/p\u003e\n \u003cp\u003eFSH\u003c/p\u003e\n \u003cp\u003eGCP\u003c/p\u003e\n \u003cp\u003eGDPR\u003c/p\u003e\n \u003cp\u003eGMP\u003c/p\u003e\n \u003cp\u003eHIV\u003c/p\u003e\n \u003cp\u003eHTLV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eEuropean Alliance of Associations for Rheumatology\u003c/p\u003e\n \u003cp\u003eFull Blood Count\u003c/p\u003e\n \u003cp\u003eFollicle Stimulating Hormone\u003c/p\u003e\n \u003cp\u003eGood Clinical Practice\u003c/p\u003e\n \u003cp\u003eGeneral Data Protection Regulation\u003c/p\u003e\n \u003cp\u003eGood Manufacturing Practice\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHuman Immunodeficiency Virus\u003c/p\u003e\n \u003cp\u003eHuman T-cell Lymphotrophic Virus\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eHLA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eHuman Leukocyte Antigen\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eICF\u003c/p\u003e\n \u003cp\u003eINR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eInformed Consent Form\u003c/p\u003e\n \u003cp\u003eInternational Normalised Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eISF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eInvestigator Site File\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eISRCTN\u003c/p\u003e\n \u003cp\u003eLFT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eInternational Standard Randomised Controlled Trials Number\u003c/p\u003e\n \u003cp\u003eLiver Function Test\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eMHRA\u003c/p\u003e\n \u003cp\u003eMg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eMedicines and Healthcare products Regulatory Agency\u003c/p\u003e\n \u003cp\u003eMagnesium\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eNCTU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eNewcastle Clinical Trials Unit\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eNHS\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNIHR\u003c/p\u003e\n \u003cp\u003eNuTH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eNational Health Service\u003c/p\u003e\n \u003cp\u003eNational Institute of Health and Care Research\u003c/p\u003e\n \u003cp\u003eNewcastle upon Tyne Hospitals NHS Foundation Trust\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003ePBMC\u003c/p\u003e\n \u003cp\u003ePI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003ePeripheral Blood Mononuclear Cell\u003c/p\u003e\n \u003cp\u003ePrincipal Investigator\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003ePIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eParticipant Information Sheet\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eRA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eRheumatoid Arthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eREC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eResearch Ethics Committee\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eRhF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eRheumatoid Factor\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eSE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eShared Epitope\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eSOP\u003c/p\u003e\n \u003cp\u003eSPIRIT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eStandard Operating Procedure\u003c/p\u003e\n \u003cp\u003eStandard Protocol Items: Recommendations for Interventional Trials\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eTMG\u003c/p\u003e\n \u003cp\u003eTolDC\u003c/p\u003e\n \u003cp\u003eTolDC\u003csub\u003eCitPep\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eTrial Management Group\u003c/p\u003e\n \u003cp\u003eTolerogenic Dendritic Cells\u003c/p\u003e\n \u003cp\u003eTolerogenic Dendritic Cells loaded with citrullinated self-peptides\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eTSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eTrial Steering Committee\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eTNF\u003c/p\u003e\n \u003cp\u003eU\u0026amp;E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eTumour Necrosis Factor\u003c/p\u003e\n \u003cp\u003eUrea and Electrolytes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eVAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 445px;\"\u003e\n \u003cp\u003eVisual Analogue Scale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National Institute of Health and Care Research (NIHR) Newcastle Biomedical Research Centre and the NIHR Newcastle Clinical Research Facility. The NIHR had no role in the study design, collection, analysis, interpretation of data, writing of the manuscript or the decision to submit the paper for publication. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions {31b}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eELL contributed to study design, development of the protocol and writing of the manuscript. JS, MW, NG, JP, MM, GH, JT, JD, AA, AP and CH contributed to study design and development of the protocol. AAM, PB, RJ and CN contributed to protocol amendments. JI is the CI/PI; he conceived the study and led the proposal and protocol development. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding {4}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is funded by Versus Arthritis (formally Arthritis Research UK) ref: 21811 and RTCure (Rheuma Tolerance for Cure) as part of the Innovative Medicines Initiative 2 Joint Undertaking ref:777357. The funders had no role in the study design, collection, analysis, interpretation of data, writing of the manuscript or the decision to submit the paper for publication. The study has had full external peer review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials {29}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUntil publication of the study results, access to the full dataset will be limited to the Trial Management Group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate {24}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval has been granted by the NHS Health Research Authority Research Ethics Committee 23/LO/0494 in collaboration with MHRA CTA 17136/0304/001-0001. Written, informed consent to participate will be obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication {32}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA model consent form will be made available on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests {28}\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBell GM, Anderson AE, Diboll J, Reece R, Eltherington O, Harry RA, et al. Autologous tolerogenic dendritic cells for rheumatoid and inflammatory arthritis. Ann Rheum Dis. 2017;76(1):227-34.\u003c/li\u003e\n\u003cli\u003eStanway JA, Isaacs JD. Tolerance-inducing medicines in autoimmunity: rheumatology and beyond. Lancet Rheumatol. 2020;2(9):e565-e75.\u003c/li\u003e\n\u003cli\u003eGiannoukakis N, Phillips B, Finegold D, Harnaha J, Trucco M. Phase I (safety) study of autologous tolerogenic dendritic cells in type 1 diabetic patients. Diabetes Care. 2011;34(9):2026-32.\u003c/li\u003e\n\u003cli\u003eJauregui-Amezaga A, Cabez\u0026oacute;n R, Ram\u0026iacute;rez-Morros A, Espa\u0026ntilde;a C, Rimola J, Bru C, et al. Intraperitoneal Administration of Autologous Tolerogenic Dendritic Cells for Refractory Crohn\u0026apos;s Disease: A Phase I Study. J Crohns Colitis. 2015;9(12):1071-8.\u003c/li\u003e\n\u003cli\u003eNikolic T, Zwaginga JJ, Uitbeijerse BS, Woittiez NJ, de Koning EJ, Aanstoot HJ, et al. Safety and feasibility of intradermal injection with tolerogenic dendritic cells pulsed with proinsulin peptide-for type 1 diabetes. Lancet Diabetes Endocrinol. 2020;8(6):470-2.\u003c/li\u003e\n\u003cli\u003eWillekens B, Presas-Rodr\u0026iacute;guez S, Mansilla MJ, Derdelinckx J, Lee WP, Nijs G, et al. Tolerogenic dendritic cell-based treatment for multiple sclerosis (MS): a harmonised study protocol for two phase I clinical trials comparing intradermal and intranodal cell administration. BMJ Open. 2019;9(9):e030309.\u003c/li\u003e\n\u003cli\u003eZubizarreta I, Fl\u0026oacute;rez-Grau G, Vila G, Cabez\u0026oacute;n R, Espa\u0026ntilde;a C, Andorra M, et al. Immune tolerance in multiple sclerosis and neuromyelitis optica with peptide-loaded tolerogenic dendritic cells in a phase 1b trial. Proc Natl Acad Sci U S A. 2019;116(17):8463-70.\u003c/li\u003e\n\u003cli\u003eSTEINMAN RM, HAWIGER D, LIU K, BONIFAZ L, BONNYAY D, MAHNKE K, et al. Dendritic Cell Function in Vivo during the Steady State: A Role in Peripheral Tolerance. Annals of the New York Academy of Sciences. 2003;987(1):15-25.\u003c/li\u003e\n\u003cli\u003eAnderson AE, Sayers BL, Haniffa MA, Swan DJ, Diboll J, Wang XN, et al. Differential regulation of na\u0026iuml;ve and memory CD4+ T cells by alternatively activated dendritic cells. J Leukoc Biol. 2008;84(1):124-33.\u003c/li\u003e\n\u003cli\u003eAnderson AE, Swan DJ, Sayers BL, Harry RA, Patterson AM, von Delwig A, et al. LPS activation is required for migratory activity and antigen presentation by tolerogenic dendritic cells. J Leukoc Biol. 2009;85(2):243-50.\u003c/li\u003e\n\u003cli\u003eHarry RA, Anderson AE, Isaacs JD, Hilkens CM. Generation and characterisation of therapeutic tolerogenic dendritic cells for rheumatoid arthritis. Ann Rheum Dis. 2010;69(11):2042-50.\u003c/li\u003e\n\u003cli\u003eAnderson AE, Swan DJ, Wong OY, Buck M, Eltherington O, Harry RA, et al. Tolerogenic dendritic cells generated with dexamethasone and vitamin D3 regulate rheumatoid arthritis CD4(+) T cells partly via transforming growth factor-\u0026beta;1. Clin Exp Immunol. 2017;187(1):113-23.\u003c/li\u003e\n\u003cli\u003eBenham H, Nel HJ, Law SC, Mehdi AM, Street S, Ramnoruth N, et al. Citrullinated peptide dendritic cell immunotherapy in HLA risk genotype\u0026ndash;positive rheumatoid arthritis patients. Science Translational Medicine. 2015;7(290):290ra87-ra87.\u003c/li\u003e\n\u003cli\u003eMorgan AW, Hale G, Rebello PR, Richards SJ, Gooi HC, Waldmann H, et al. A pilot study of combination anti-cytokine and anti-lymphocyte biological therapy in rheumatoid arthritis. Qjm. 2008;101(4):299-306.\u003c/li\u003e\n\u003cli\u003eRidolfi R, Riccobon A, Galassi R, Giorgetti G, Petrini M, Fiammenghi L, et al. Evaluation of in vivo labelled dendritic cell migration in cancer patients. J Transl Med. 2004;2(1):27.\u003c/li\u003e\n\u003cli\u003eGerstner C, Dubnovitsky A, Sandin C, Kozhukh G, Uchtenhagen H, James EA, et al. Functional and Structural Characterization of a Novel HLA-DRB1*04:01-Restricted \u0026alpha;-Enolase T Cell Epitope in Rheumatoid Arthritis. Front Immunol. 2016;7:494.\u003c/li\u003e\n\u003cli\u003eJames EA, Rieck M, Pieper J, Gebe JA, Yue BB, Tatum M, et al. Citrulline-specific Th1 cells are increased in rheumatoid arthritis and their frequency is influenced by disease duration and therapy. Arthritis Rheumatol. 2014;66(7):1712-22.\u003c/li\u003e\n\u003cli\u003eSchwenzer A, Jiang X, Mikuls TR, Payne JB, Sayles HR, Quirke A-M, et al. Identification of an immunodominant peptide from citrullinated tenascin-C as a major target for autoantibodies in rheumatoid arthritis. Annals of the Rheumatic Diseases. 2016;75(10):1876-83.\u003c/li\u003e\n\u003cli\u003eSnir O, Rieck M, Gebe JA, Yue BB, Rawlings CA, Nepom G, et al. Identification and functional characterization of T cells reactive to citrullinated vimentin in HLA\u0026ndash;DRB1*0401\u0026ndash;positive humanized mice and rheumatoid arthritis patients. Arthritis \u0026amp; Rheumatism. 2011;63(10):2873-83.\u003c/li\u003e\n\u003cli\u003eSonigra A, Nel HJ, Wehr P, Ramnoruth N, Patel S, van Schie KA, et al. Randomized phase I trial of antigen-specific tolerizing immunotherapy with peptide/calcitriol liposomes in ACPA+ rheumatoid arthritis. JCI Insight. 2022;7(20).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"trials","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"trls","sideBox":"Learn more about [Trials](http://trialsjournal.biomedcentral.com/)","snPcode":"13063","submissionUrl":"https://www.editorialmanager.com/trls","title":"Trials","twitterHandle":"MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Rheumatoid Arthritis (RA), Tolerogenic dendritic cells (TolDC), Shared epitope (SE), Anti-Citrullinated Peptide Antibody (ACPA), Immunomodulation, Leukapheresis, Intra-nodal, Intra-articular, Intra-dermal, Lymph node","lastPublishedDoi":"10.21203/rs.3.rs-6222488/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6222488/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u0026nbsp;\u003c/strong\u003eDendritic cells are professional antigen presenting cells with the ability, in their immature state, to induce tolerance in T-cells. A protocol to develop phenotypically stable tolerogenic dendritic cells (TolDC) was developed in Newcastle and cells administered to participants in the phase I AuToDeCRA study, demonstrating that TolDC were safe and well tolerated. More knowledge of the TolDC product is now needed, such as optimal dose, route of administration and antigen loading. Establishing this and developing a biomarker profile to demonstrate favourable immunomodulation is the focus of AuToDeCRA-2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u0026nbsp;\u003c/strong\u003eAuToDeCRA-2 is a non-commercial, phase IIa, 5-arm, randomised, unblinded, single centre study. It is designed to demonstrate and compare immunomodulation achieved by TolDC administered via three distinct routes: intra-nodal, intra-articular, intra-dermal and, in the case of intra-nodal administration, at 2 doses. Participants will be randomised to one of these four active intervention arms or standard care. Participants in intervention arms will receive a single dose of TolDC loaded with synthetic citrullinated peptides (TolDC\u003csub\u003eCitPep\u003c/sub\u003e) representing disease relevant autoantigens. 20 Anti-Citrullinated Peptide Antibody (ACPA) positive, shared epitope positive Rheumatoid Arthritis patients with nil-to-moderate disease activity will be randomised in an allocation ratio of 1:1:1:1:1.\u003c/p\u003e\n\u003cp\u003eParticipants will be followed up with immune state monitoring performed on peripheral blood samples at baseline, 1, 3 and 6 weeks and lymph node aspirates at baseline and 1 week, alongside clinical assessment performed throughout and additionally at 12 weeks.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion:\u0026nbsp;\u003c/strong\u003eTolDC therapy is an emerging cellular therapy aimed at reversing the underlying abnormality in autoimmune disease by inducing tolerance to autoantigen. Expected challenges to this study include recruitment of potentially asymptomatic participants to a complex and intensive experimental medicine study. Limitations include the relatively small number of participants although adequate to address the aims of the study. Establishing acceptable route(s) of administration as well as demonstrating favourable immunomodulation via the development of a biomarker profile is the focus of AuToDeCRA-2, which aims to address some of the existing scientific gaps necessary for the development of TolDC therapy in autoimmune disease.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e\u0026nbsp;ISRCTN, ISRCTN14999554. Registered on 27\u003csup\u003eth\u003c/sup\u003e\u0026nbsp;September 2023, https://doi.org/10.1186/ISRCTN14999554\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Autologous Tolerogenic Dendritic Cells for Rheumatoid Arthritis-2 (AuToDeCRA-2) Study: Protocol for a single-centre, experimental medicine study investigating the route of delivery and potential efficacy of autologous tolerogenic dendritic cell (TolDC) therapy for Rheumatoid Arthritis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-03 07:04:44","doi":"10.21203/rs.3.rs-6222488/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2025-05-28T14:26:30+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-28T14:19:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-25T06:32:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"Trials","date":"2025-03-24T10:19:54+00:00","index":"","fulltext":""},{"type":"decision","content":"Minor revision","date":"2025-03-18T01:01:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"trials","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"trls","sideBox":"Learn more about [Trials](http://trialsjournal.biomedcentral.com/)","snPcode":"13063","submissionUrl":"https://www.editorialmanager.com/trls","title":"Trials","twitterHandle":"MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a59d08d4-2e47-4b29-8d41-bab657675dce","owner":[],"postedDate":"June 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-11T16:01:50+00:00","versionOfRecord":{"articleIdentity":"rs-6222488","link":"https://doi.org/10.1186/s13063-025-08972-x","journal":{"identity":"trials","isVorOnly":false,"title":"Trials"},"publishedOn":"2025-08-07 15:57:33","publishedOnDateReadable":"August 7th, 2025"},"versionCreatedAt":"2025-06-03 07:04:44","video":"","vorDoi":"10.1186/s13063-025-08972-x","vorDoiUrl":"https://doi.org/10.1186/s13063-025-08972-x","workflowStages":[]},"version":"v1","identity":"rs-6222488","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6222488","identity":"rs-6222488","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}