An Open-label, Prospective, Single Centre Study of the Effects of Riociguat on RIght VEntricular Size and Function in Pulmonary Arterial Hypertension and Chronic Thromboembolic Pulmonary Hypertension
Overview
- Phase
- Phase 4
- Intervention
- Riociguat
- Conditions
- Primary Pulmonary Arterial Hypertension
- Sponsor
- Heidelberg University
- Enrollment
- 30
- Locations
- 1
- Primary Endpoint
- Change in RV (right ventricular) area
- Status
- Terminated
- Last Updated
- 7 months ago
Overview
Brief Summary
This is an open-label, single-armed, prospective single-centre clinical study to evaluate the effect of riociguat on right heart size and function in patients with manifest PAH and CTEPH.
Detailed Description
Right heart size and function are of utmost prognostic importance in PAH/CTEPH. RV performance measured by echocardiography and enlarged RA area have been shown to be independent prognostic factors in PAH. Recently, a retrospective single centre study has shown that riociguat treatment was associated with a significant reduction of RV and RA area after 3, 6 and 12 months compared to baseline. RA area significantly decreased after 12 months and RV systolic function assessed with tricuspid annular plane systolic excursion (TAPSE) improved after 6 and 12 months of riociguat therapy. The results were confirmed by a recent retrospective multicentre study. It is therefore reasonable to assume a beneficial effect of riociguat on right heart size and function. The primary efficacy endpoint in this study is the change in RV and RA area from baseline to 24 weeks. Treatment will be initiated and individually adjusted according to systolic blood pressure and tolerability. Patients who discontinue medication prematurely will be asked to continue with study assessments and perform study visits as outlined in the protocol. Medical examinations comprise medical history, physical examination, electrocardiogram (ECG), blood gas analyses, lung function tests, laboratory testing (including NT-proBNP), echocardiography at rest, and right heart catheterization (RHC) according to clinical practice of the PH centre. The prospective period of data collection comprises a 24-week study period a follow-up phase of about 30±7 days. Outcome (survival and transplant-free survival) of all patients will be assessed when the last patient has terminated his/her 24-week observation period.
Investigators
Prof. Dr. med. Ekkehard Gruenig
Head of centre for pulmonary hypertension
Heidelberg University
Eligibility Criteria
Inclusion Criteria
- •≥18 years of age at time of inclusion.
- •Male and female patients with symptomatic PAH with a mean pulmonary artery pressure (mPAP) \>20 mmHg and pulmonary vascular resistance (PVR) ≥2 Wood Units (WU), pulmonary arterial wedge pressure (PAWP) ≤15 mmHg (Group I / Nice Clinical Classification of Pulmonary Hypertension) or CTEPH (Group IV / Nice Clinical Classification of Pulmonary Hypertension) defined as inoperable measured at least 3 months after start of full anticoagulation and mPAP \>20 mmHg and PVR ≥2 WU, PAWP ≤15 mmHg; or with persisting or recurrent PH after pulmonary endarterectomy (mPAP \>20 mmHg and PVR ≥2 WU, PAWP ≤15 mmHg measured at least 6 months after surgery (acc. to Simonneau et al. 2018).
- •Treatment naïve patients (with respect to PAH specific medication) and patients pre-treated with an endothelin receptor antagonist or a prostacyclin analogue, pre-treated for 2 months before screening at most (according to upfront combination treatment).\*
- •\*Pre-treated patients need to be stable on endothelin receptor antagonists or prostacyclin treatment for at least two weeks prior to Visit
- •"Stable" is defined as no change in the type of endothelin receptor antagonists or prostacyclin analogue and the respective daily dose.
- •A patient may also be enrolled, if a persisting phosphodiesterase type 5 (PDE-5) inhibitor treatment (pre-treated for 2 months before screening at most) with or without combination treatment with an endothelin receptor antagonist or prostacyclin analogue is to be switched to riociguat by clinical indication, particularly when the patient´s risk-profile remained in intermediate risk group despite adequate initial treatment including PDE5i (defined as at least 3 of the following parameters: clinical signs of progression, persistent WHO-FC III, 6MWD between 165-440m, peak V02 11-15ml/min/kg (35-65% predicted), NTproBNP 300-1400 ng/l, RA-area 18-26cm2,RAP 8-14mmHg, CI 2,0-2,4 l/min) or in case of PDE5i intolerance. Any decision to switch will be made by the clinicians at a regular clinical follow-up visit.
- •Unspecific treatments which may also be used for the treatment of PH such as oral anticoagulants, diuretics, digitalis, calcium channel blockers or oxygen supplementation are permitted. However, treatment with anticoagulants (if indicated) must have been started at least 1 month before visit in patients with PAH
- •RHC results must not be older than 6 months at screening (will be considered as baseline values) and must have been measured in the participating centre under standardized conditions (refer to the study specific Swan Ganz catheterization manual). If the respective measurements have not been performed in context with the patient's regular diagnostic workup, they have to be performed as a part of the study during the pre-study phase (after the patient signed the informed consent).
- •Women without childbearing potential defined as postmenopausal women aged 50 years or older, women with bilateral tubal ligation, women with bilateral ovariectomy, and women with hysterectomy can be included in the study.
- •Women of childbearing potential can only be included in the study if all of the following applies (listed below): a. Negative serum pregnancy test at Screening and a negative urine pregnancy test at study start (visit 1). b. Agreement to undertake monthly urine pregnancy tests during the study and up to at least 30 days after study treatment discontinuation. These tests should be performed by the patient at home. c. Agreement to follow the contraception scheme as specified from Screening until at least 30 days after study treatment discontinuation.
Exclusion Criteria
- •Pregnant women, or breast-feeding women, or women of childbearing potential not able or willing to comply with study-mandated contraception methods specified above.
- •Patients with PH specific treatment \<2 months before screening.
- •Patients with a medical disorder, condition, or history of such that would impair the patient's ability to participate or complete this study in the opinion of the investigator.
- •Patients with underlying medical disorders with an anticipated life expectancy below 2 years (e.g. active cancer disease with localized and/or metastasized tumour mass).
- •Patients with a history of severe or multiple drug allergies
- •Patients with hypersensitivity to the investigational drug or any of the excipients.
- •Patients unable to perform a valid 6MWD test (e.g. orthopaedic disease, peripheral artery occlusive disease, which affects the patient´s ability to walk).
- •The following specific medications for concomitant treatment of PH or medications which may exert a pharmacodynamic interaction with the study drug are not allowed:
- •Parenteral prostacyclin analogues
- •Specific phosphodiesterase inhibitors (e.g. sildenafil or tadalafil): may be switched to riociguat but not be given in addition to the study drug
Arms & Interventions
Riociguat
Riociguat (1 mg, 1.5 mg, 2 mg and 2.5 mg three times daily) starting at 1.0 mg three times daily at the beginning of the study. Dosage will be individually up-titrated up to a maximum dosage of 2.5 mg three times daily after 8 weeks. Study medication will be provided orally with or without food. Tablets should be taken three times daily approximately 6 to 8 hours apart.
Intervention: Riociguat
Outcomes
Primary Outcomes
Change in RV (right ventricular) area
Time Frame: Baseline to 24 weeks
echocardiographic analysis right atrial (RA) area, measured by echocardiography.
Change in RA (right atrial) area
Time Frame: Baseline to 24 weeks
echocardiographic analysis
Secondary Outcomes
- Change in RA Area(baseline to 12 weeks)
- Change in RV fractional area change (FAC)(baseline to 12 weeks)
- Change in inferior vena cava (IVC) diameter and IVC collapse(baseline to 12 weeks)
- Change in Eccentricity index (EI)(baseline to 12 weeks)
- Change in right atrial pressure (RAP)(baseline and after 24 weeks)
- Change in RV Area(baseline to 12 weeks)
- Change in systolic pulmonary artery pressure (sPAP)(baseline to 24 weeks)
- Change in Peak velocity of tricuspid regurgitation (TRV)(baseline to 24 weeks)
- Change in Right Ventricle Outflow Tract Velocity Time Integral (RVOT VTI)(baseline to 24 weeks)
- Change in Tricuspid Annular Plane Systolic Excursion (TAPSE)(baseline to 24 weeks)
- Change in Right ventricular pump function (qualitative)(baseline to 12 weeks)
- Change in left ventricular pump function (qualitative)(baseline to 12 weeks)
- Change in Diameters of pulmonary artery(baseline to 24 weeks)
- Change in cardiac output(baseline and after 24 weeks)
- Change in dPAP(baseline and after 24 weeks)
- creatinine changes(baseline to 24 weeks)
- Change in PVR(baseline and after 24 weeks)
- Change in Left Atrial (LA) diameter(baseline to 24 weeks)
- Change in LV diastolic function(baseline to 12 weeks)
- Change in cardiac index(baseline and after 24 weeks)
- Change in sPAP(baseline and after 24 weeks)
- Change in mPAP(baseline and after 24 weeks)
- Change in PAWP(baseline and after 24 weeks)
- Change in diffusion-limited carbon monoxide (DLCO)(baseline to 12 weeks)
- Change in partial pressure of carbon dioxide(baseline to 24 weeks)
- Change in Central venous saturation from pulmonary artery(baseline and after 24 weeks)
- Change in 6-minute walking distance(baseline to 24 weeks)
- forced vital capacity (FVC)(baseline to 24 weeks)
- Change in forced expiratory volume in one second (FEV1)(baseline to 24 weeks)
- Change in FEV1% of maximal vital capacity (VC max)(baseline to 24 weeks)
- Change in residual volume(baseline to 24 weeks)
- Bilirubin changes(baseline to 24 weeks)
- CRP changes(baseline to 24 weeks)
- Change in total lung capacity (TLC)(baseline to 24 weeks)
- Change in DLCO/VA (Krogh) factor(baseline to 24 weeks)
- Change in partial pressure of oxygen(baseline to 24 weeks)
- Change in SaO2(baseline to 24 weeks)
- Change in Blood pressure(baseline to 24 weeks)
- Change in respiratory equivalents for oxygen(baseline to 24 weeks)
- Change in respiratory equivalents for carbon dioxide(baseline to 24 weeks)
- Change in respiratory reserve(baseline to 24 weeks)
- WHO FC(baseline to 24 weeks)
- SF-36(baseline to 24 weeks)
- NT-proBNP(baseline to 24 weeks)
- haemoglobin changes(baseline to 24 weeks)
- haematocrit changes(baseline to 24 weeks)
- AST changes(baseline to 24 weeks)
- ALT changes(baseline to 24 weeks)
- Change in pH(baseline to 12 weeks)
- Change in heart rate(baseline to 24 weeks)
- Change in workload(baseline to 24 weeks)
- Change in oxygen consumption as total and per kg body weight(baseline to 24 weeks)
- Change in exhaled carbon dioxide (VCO2)(baseline to 24 weeks)
- Change in oxygen saturation(baseline to 24 weeks)
- Change in oxygen pulse(baseline to 24 weeks)
- Change in minute ventilation(baseline to 24 weeks)
- creatinine clearance changes(baseline to 24 weeks)
- sodium changes(baseline to 24 weeks)
- Urea changes(baseline to 24 weeks)