A Randomised, Double Blind, Placebo Controlled Trial of Doxycycline in Lymphangioleiomyomatosis.

Summary

We will perform a 2 year double blind, placebo controlled trial of doxycycline in 40 patients with LAM. The main endpoints will be change in FEV1, other measures of efficacy, safety and dose required to suppress MMP activity. After clinical evaluation, lung function, shuttle walk, QoL assessment, blood tests, serum and urine MMPs (termed full assessment) plus baseline chest X-ray patients will be randomised to doxycycline 50 mg od or placebo. Patients will be assessed at 2 weeks for a safety screen, every 3 months for clinical evaluation and spirometry and at 12 and 24 months for full assessment. At 3 months urine zymography will be performed to see if MMPs are present in urine at the prescribed dose. Doxycycline will be increased to 100 mg bd at three months after urine zymography has been performed. To avoid withholding treatment from those who decline rapidly, patients who, on two occasions, have either a fall from baseline FEV1 of 300 ml or fall in resting SaO2 of 3% will be assessed by an independent expert (AET). Patients receiving placebo will be given the option of doxycycline according to protocol. Those receiving doxycycline the option of continuing in the study or withdrawal. These patients and those withdrawn due to recurrent pneumothorax, increase in chylous effusion or bleeding angiomyolipoma will be included in a composite safety endpoint and analysed on an intention to treat basis. Power calculations based on retrospective cohorts(Johnson and Tattersfield 1999) show that 20 patients per group will give 80% power to detect a 70 ml/year difference in FEV1 based an assumed SD for a fall in FEV1 of 75 ml/year. The mean slope of regression lines for FEV1 and FVC, plus change DLCO, shuttle walk distance and QoL in the doxycycline and placebo groups will be compared by parametric or non-parametric analysis dependent on data, time to composite safety endpoint by Caplan-Meier analysis, complications and adverse events by Chi Square test.

1. Introduction

Lymphangioleiomyomatosis Lymphangioleiomyomatosis (LAM) is a disease of the lungs and lymphatics, which can occur sporadically or in association with tuberous sclerosis complex (TSC). The disease is rare, occurring in 1-2 / million of the population but in up to 40% of women with TSC LAM almost exclusively affects women, generally developing before the menopause. The disease is characterised by progressive pulmonary cystic change, recurrent pneumothorax, chylous pleural collections and, in most cases, progressive respiratory failure. Abdominal manifestations caused by obstruction and dilation of the axial lymphatics include lymphadenopathy, cystic lymphatic masses (lymphangioleiomyomas), chylous ascites and angiomyolipoma (a benign tumour). Survival in LAM is, 70 90% at 10 yrs, although this is highly variable since long-term survivors have been described. Diagnosis is made by a combination of clinical features and computed tomography scanning or, in cases of doubt, lung biopsy. In patients with rapidly progressive disease, hormone treatment (predominantly progesterone) has been used, although no firm evidence supports its use. Otherwise, treatment is aimed at complications including pneumothorax, chylous collections and extra-pulmonary manifestations. The only treatment for severe LAM is currently lung transplantation(Johnson 2006). Recently identification of abnormalities in the tuberous sclerosis complex (TSC) genes in sporadic and TSC associated LAM have identified dysregulation of the mTOR pathway in LAM (Carsillo, Astrinidis et al. 2000; Sato, Seyama et al. 2002) and have lead to clinical trials of mTOR inhibitors such as rapamycin in LAM and TSC. At the time of writing these have not been reported but appear promising.

Background and preliminary data Cystic lung destruction is the hallmark of pulmonary LAM and generally results in respiratory failure over a variable period of time(Johnson 2006). Over-activity of proteases including elastase, trypsin and the matrix metalloproteinases (MMPs) is responsible for parenchymal destruction in emphysema and other lung diseases. The MMPs are a family of zinc dependent proteolytic enzymes with proteolytic activities against extra-cellular matrix proteins. The MMPs are overexpressed in inflammatory and neoplastic diseases where in addition to processing extra-cellular matrix they also have roles in metastasis, angiogenesis, growth factor activation and inactivation(Stamenkovic 2003). MMPs -1, -2, and -9 are involved in the sequential digestion of collagen and gelatin and are strongly expressed in the walls of cysts where it is thought they contribute to parenchymal destruction in LAM(Matsui, Takeda et al. 2000). Further, MMPs can be detected by gelatin zymography in the urine of patients with LAM but not controls. Doxycycline is a tetracycline antibiotic in common clinical use. In addition to its antimicrobial action it inhibits the synthesis and activity of several MMPs and inhibits proliferation of a range of cell types including arterial smooth muscle, cancer cells and cancer model systems(Bendeck, Conte et al. 2002; Duivenvoorden, Popovic et al. 2002; Onoda, Ono et al. 2004). In preliminary experiments we have demonstrated that primary LAM derived and angiomyolipoma cells produce MMP-2 and -7 and that MMP expression and proliferation in these cells in inhibited by doxycycline.