Empagliflozin in the Prevention of Cardiotoxicity in Cancer Patients Undergoing Chemotherapy Based on Anthracyclines

Phase 3

Recruiting

• Conditions: Cardiotoxicity
• Interventions: Drug: Empagliflozin 10 MG; Other: Placebo

• Registration Number: NCT05271162
• Lead Sponsor: Maria Sklodowska-Curie National Research Institute of Oncology

Brief Summary

EMPACT (EMPAgliflozin in prevention of chemotherapy-related CardioToxicity) study is a randomized, multi-center, placebo-controlled, double-blind trial to evaluate efficacy of empagliflozin in prevention of left ventricular (LV) dysfunction in patients receiving high cumulative doses of anthracyclines. Diagnosed with cancer, 220 patients without history of heart failure and LV ejection fraction (EF) ≥ 50%, scheduled for high dose anthracyclines (doxorubicin ≥240 mg/m2 or epirubicin ≥540 mg/m2), will be included in the study. They will be randomized to a 10 mg of empagliflozin once daily or to matching placebo in a 1:1 ratio. The primary objective of the EMPACT study is to assess whether prophylactic SGLT-2 inhibitors may prevent a reduction in LVEF after high doses anthracyclines, as evaluated by serial echocardiography on each visit and cardiovascular magnetic resonance (CMR) performed at randomization and on its completion. The secondary composite endpoint includes: all-cause death, cardiovascular (CV) death, myocardial infarction and ischemic stroke. Additional secondary outcome measures include structural myocardial alterations assessed by CMR, decrease in GLS (global longitudinal strain) in echocardiography and changes in cardiac biomarkers. The study will be carried out in accordance with GCP and monitoring will be outsourced to a subcontractor - CRO. The examination will be insured and will begin as soon as the required approvals are obtained.

Detailed Description

Malignant neoplasms are the second most common cause of death in Poland. Cancer mortality decreased by 27% over the past 25 years. Improved survival in cancer patients is related to several factors, such as prevention, early detection and the introduction of new chemotherapy regimens. However, the benefits of administration of anti-cancer drugs are partially limited by their adverse effects on the cardiovascular system, resulting in increased morbidity and mortality from complications of this treatment. The most serious toxic effect of chemotherapy is damage to the heart muscle leading to its failure, often referred to as 'cardiotoxicity'. This serious complication remains an unresolved clinical problem. The use of doxorubicin is associated with the development of congestive heart failure even in 48% of patients at the doxorubicin total dose of 700 mg/m2. The only drug approved for the prophylactic treatment of cardiac complications is dexrazoxane. However, it is only recommended for patients with advanced breast cancer receiving doxorubicin or epirubicin who have previously received a cumulative dose of 300 mg/m2 of doxorubicin or a cumulative epirubicin dose of 540 mg/m2, when further anthracycline therapy is required. Dexrazoxane is an expensive drug and may influence the effectiveness of chemotherapy. Routine prophylaxis of myocardial dysfunction is not currently recommended due to insufficient data from randomized clinical trials. So far, the prophylactic effects of such cardiological drugs as: angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), beta-blockers, statins and ranolazine have been studied. The results of these studies are contradictory. Therefore, at present, only symptomatic patients with decreased left ventricular ejection fraction or elevated levels of cardiac biomarkers are eligible for treatment with heart failure medications. Empagliflozin is an orally administered once-daily, highly selective sodium-glucose cotransporter 2 (SGLT2) inhibitor proven to treat patients with chronic heart failure of different aetiologies, also with preserved left ventricle systolic function. This drug also has additional nephroprotective, anti-inflammatory and metabolic effects. In recent animal studies, the cardioprotective effect of empagliflozin during the use of anthracyclines was demonstrated.

EMPACT (EMPAgliflozin in prevention of chemotherapy-related CardioToxicity) study is a randomized, multi-center, placebo-controlled, double-blind trial to evaluate efficacy of empagliflozin in prevention of left ventricular (LV) dysfunction in patients receiving high cumulative doses of anthracyclines. Diagnosed with cancer, 220 patients without history of heart failure and LV ejection fraction (EF) ≥ 50%, scheduled for high dose anthracyclines (doxorubicin ≥240 mg/m2 or epirubicin ≥540 mg/m2), will be included in the study. They will be randomized to a 10 mg of empagliflozin once daily or to matching placebo in a 1:1 ratio. The primary objective of the EMPACT study is to assess whether prophylactic SGLT-2 inhibitors may prevent a reduction in LVEF after high doses anthracyclines, as evaluated by serial echocardiography on each visit and cardiovascular magnetic resonance (CMR) performed at randomization and on its completion. The secondary composite endpoint includes: all-cause death, cardiovascular (CV) death, myocardial infarction and ischemic stroke. Additional secondary outcome measures include structural myocardial alterations assessed by CMR, decrease in GLS (global longitudinal strain) in echocardiography and changes in cardiac biomarkers. This is the first study of this type in the world, we hope that the results of this project will change the standards of management of oncological patients and contribute to the improvement of their survival and quality of life.

Study Timeline

• Study First Submitted: 2022-02-20
• Study First Submitted QC: 2022-03-05
• Study First Posted: 2022-03-08
• Study Start: 2023-09-30
• Status Verified: 2024-11
• Last Update Submitted: 2024-11-25
• Last Update Posted: 2024-11-27
• Primary Completion: 2028-01-01
• Study Completion: 2028-02-01

Recruitment & Eligibility

• Status: RECRUITING
• Sex: All
• Target Recruitment: 220

Inclusion Criteria

1. Eastern Cooperative Oncology Group (ECOG) performance status from 0 to 2.
2. Age ≥18 years at the time of signing the informed consent.
3. Known neoplastic disease prior to the initiation of chemotherapy with a high dose of anthracyclines (doxorubicin ≥ 240 mg / m2 b.w. or epirubicin ≥ 540 mg / m2 b.w.)
4. No history of heart failure (left ventricular ejection fraction ≥ 50% as assessed by echocardiography).
5. Women of child-bearing age must have a negative serum or urine pregnancy test.
6. All males and females must consent to the use of effective contraception throughout the study period and after study medication is discontinued.
7. Sexually active women of childbearing potential must use 2 effective methods of contraception (abstinence, IUD, oral contraceptive or double barrier device) from informed consent and for at least 6 months after study drug discontinuation
8. Sexually active men and their sexual partners must use effective methods of contraception from the moment they sign their informed consent to participate in the study and for at least 3 months after discontinuation of the study drug.

Exclusion Criteria

1. History of heart failure
2. Left ventricle systolic dysfunction assessed by echocardiography (LVEF <50%)
3. Significant valve disease
4. Previous chemotherapy or radiation to the chest
5. Symptomatic hypotension and / or SBP <100 mmHg at Visit 1 or Visit 2
6. Liver disease, as determined by ALT, AST, or alkaline phosphatase levels above 3 x upper limit of normal (ULN) at visit 1.
7. Renal impairment, defined as eGFR <20 mL / min / 1.73 m2 or dialysis requirement, as determined at Visit 1.
8. History of ketoacidosis
9. Gastrointestinal surgery or gastrointestinal disturbance that could impair drug absorption
10. Presence of any disease with a life expectancy <1 year in the opinion of the investigator.
11. Treatment with any SGLT-2 inhibitor for up to 3 months prior to study enrollment.
12. Pregnancy or breastfeeding
13. Drug or alcohol abuse
14. Suspected non-compliance and irregular use of study drug
15. Inability to perform CMR, e.g. claustrophobia, weight> 120 kg, etc.

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Empagliflozin	Empagliflozin 10 MG	Empagliflozin, 10 mg q.d; p.o
Placebo	Placebo	Placebo 1 tabl q.d; p.o

Primary Outcome Measures

Name	Time	Method
Number of participants with left ventricular systolic dysfunction	from date of randomization until the end of study, up to 24 months	echocardiography, cardiovascular magnetic resonance

Secondary Outcome Measures

Name	Time	Method
Rate of episodes of all-cause death, cardiovascular death, myocardial infarction, and stroke	from date of randomization until the end of study, up to 24 months	medical records
Percentage decrease in left ventricular ejection fraction, GLS (global longitudinal strain)	from date of randomization until the end of study, up to 24 months	echocardiography
Rate of structural myocardial alterations in CMR	from date of randomization until the end of study, up to 24 months	cardiovascular magnetic resonance
Changes in the concentration of biomarkers	from date of randomization until the end of study, up to 24 months	blood samples, Troponina, NTproBNP
The difference in scores in the KCCQ (Kansas City Cardiomyopathy Questionnaire) assessing the quality of life of patients.	from date of randomization until the end of study, up to 24 months	Kansas City Cardiomyopathy Questionnaire, the minimum and maximum values:0-100, higher scores mean a better outcome.

Trial Locations

Locations (2)

Institute of Hematology and Transfusion Medicine; 🇵🇱 Warsaw, Poland

National Institute of Oncology; 🇵🇱 Warsaw, Poland