Allopurinol in Diabetes Mellitus and Multivessel Coronary Artery Disease

Diabetes Mellitus Clinical Trial

Official title:

Allopurinol in the Treatment of Patients With Diabetes Mellitus and Multivessel Coronary Artery Disease Treated by Either PCI or CABG: Pilot Study

Clinical Trial Details — Status: Not yet recruiting

Administrative data

• NCT number: NCT03700645
• Other study ID #: TASMC-18-YA-354-18-CTIL
• Status: Not yet recruiting
• Phase: Phase 4
• Start date: December 1, 2018
• Est. completion date: January 31, 2020

Study information

• Verified date: November 2018
• Source: Tel-Aviv Sourasky Medical Center
• Contact: Natalia Kofman, M.D
• Phone: 97239673222
• Email: natalia.kofman[@]gmail.com
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Atherosclerosis is a progressive disease of the arterial wall, arising from the combination of endothelial dysfunction and inflammation. This link is exacerbated in diabetic patients.

Uric acid is known to generate oxidative stress and it's elevated levels has been shown to be associated with cardiac hypertrophy, inflammation, myocardial fibrosis and diastolic dysfunction. Allopurinol inhibits xanthine oxidase, an enzyme that regulates uric acid production. In observational studies it has been shown to reduce ischemia, inflammation and improve coronary flow. The aim of this study is to see whether treatment with Allopurinol in patients diagnosed with multivessel disease and undergoing treatment with either percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) , will reduce markers of inflammation and improve quality of life and major adverse cardiovascular effects (MACE).

Description:

This is a pilot study, PROBE design (prospective randomized open label blinded endpoints study), that will include 100 patients.

Patients will be recruited during their hospitalization in the cardiology department of Ichilov- Tel-Aviv Sourasky Medical Center.

It will include patients with known or newly diagnosed diabetes mellitus, hospitalized with diagnosis of acute coronary syndrome and multi-vessel coronary artery disease (CAD) that will be demonstrated by cardiac catheterization that the patients will undergo during their hospitalization in concordance with their diagnosis and practice guidelines.

The decision about intervention with either PCI or CABG will be accepted by a heart team after the initial demonstration of multi-vessel disease.

Study recruitment will take place either in the first 24 hours after PCI or before CABG.

All patients will sign an informed consent and randomized before any intervention is done.

After enrollment, patients will undergo the following baseline procedure (no later than 24 hours from PCI):

1. Physical examination and medical interview

2. Quality of life questionnaires (Seattle angina , EQ-5D)

3. Echocardiogram

4. Blood tests- see below for description

5. Endothelial function using the EndoPat®

Blood sampling will be done via IV cannula that will be placed in an antecubital vein. Blood sample analyses will be performed using reagents, calibrators and control materials in the local labs of each participating site. A 40 ml blood sample will be obtained for the following blood tests

1. Full chemistry including: lipid levels, thyroid function, liver enzymes function, Troponin, BNP, HbA1c, uric acid, creatinine and glucose levels.

2. Blood count

3. Inflammatory biomarker (hs-CRP, fibrinogen, IL-6, IL-1B, IL-18, MMP, IL-10, IL-35, TNFa, AchE , PAI-1, MPO, cholinergic status.)

4. Endothelial function markers: Endothelin-1, I-CAM, V-CAM, superoxide dismutase ADMA, and oxidized LDL

5. Oxidative Stress- superoxide dismutase ADMA, and oxidized LDL, Plasma protein carbonyls.

6. Urine samples- microalbuminuria, albumin/creatinine. Uric acid.

Endothelial function will be assessed using EndoPAT 2000 device (Itamar Medical Inc., Caesarea, Israel) that is a device that measures endothelial function using a sensor placed on the fingers. This device has been validated and used previously to assess peripheral arterial tone in other populations. EndoPAT bio-sensors are placed on the index fingers of both arms. EndoPAT quantifies the endothelium-mediated changes in vascular tone, elicited by a 5-minute occlusion of the brachial artery (using a standard blood pressure cuff). When the cuff is released, the surge of blood flow causes an endothelium-dependent Flow Mediated Dilatation (FMD). The dilatation, manifested as reactive hyperemia, is captured by EndoPAT as an increase in the PAT Signal amplitude. A post-occlusion to pre-occlusion ratio is calculated by the EndoPAT software, providing the EndoPAT index. In addition, the EndoPAT system will measure heart rate variability.

After randomization and assessment as described above, the patients will receive treatment according to the study arm they were assigned to which will include either standard medical therapy alone, or standard medical therapy and allopurinol.

Allopurinol will be given initially at 100 mg once daily dose, with dose escalation by 100 mg every 2 weeks till final dose of 300 mg daily will be reached.

After discharge, patients will be assessed several times:

1. One month after in cardiology clinic. Assessment will include all the tests as in the pre study exam (see above). also, patients will be monitored for the possible side effects of allopurinol treatment.

2. Three months- in cardiology clinic. Assessment will include all the tests as in the pre study exam (see above).

Recruitment information / eligibility

• Status: Not yet recruiting
• Enrollment: 100
• Est. completion date: January 31, 2020
• Est. primary completion date: December 31, 2019
• Accepts healthy volunteers: No
• Gender: All
• Age group: 40 Years to 99 Years

Eligibility

Inclusion Criteria:

1. Acute Coronary Syndrome with positive troponin

2. Patients with known or newly diagnosed diabetes mellitus with HbA1c above 7% and below 10%

3. Patients above the age of 40

4. Stable Hemodynamic state (At least 12 hours from presentation with acute coronary syndrome)

5. Uric Acid > 6mg/dl or 355 micromol/l (males) and >5mg/dl or 297 Micromol/l (females)

Exclusion Criteria:

1. HbA1c below 7% or above 10%

2. Severe valvular insufficiency/Stenosis

3. Major surgery within 30 days

4. Any medical condition that would impair participation (e.g. progressive neurological disorders, mental illness)

5. Known intolerance/ current use of allopurinol/colchicine

6. Chronic inflammatory diseases: e.g. Lupus, rheumatoid arthritis, etc.

7. Current treatment with steroids, NSAID, chemotherapy or biologic medications

8. Extra-cardiac illness that is expected to limit survival to less than 2 years.

9. Past Cancer within the past 5 years (excluding BCC and SCC).

Related Conditions & MeSH terms

• Coronary Artery Disease
• Coronary Disease
• Diabetes Mellitus
• Heart Diseases
• Ischemic Heart Disease
• Multi Vessel Coronary Artery Disease
• Myocardial Ischemia

Intervention

Drug:
• Allopurinol
Allopurinol

Locations

Country	Name	City	State
n/a

Sponsors (1)

Lead Sponsor	Collaborator
Tel-Aviv Sourasky Medical Center

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* Note: There are 39 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	hs-CRP	Change in inflammatory biomarkers	3 months.
Secondary	hs-CRP	Change in inflammatory biomarkers	one month
Secondary	Endothelial function markers	Endothelin-1, I-CAM, V-CAM, superoxide dismutase ADMA, and oxidized LDL, Change of RH-PAT	3 month
Secondary	Heart rate variability	Heart rate variability	3 month
Secondary	functional status and quality of life: the Seattle angina questionnaire	Quality of life evaluation- evaluates functional limitation in different activities due to chest pain and angina	3 month
Secondary	Uric acid levels	Uric acid levels	one month and 3 month
Secondary	functional status, quality of life: EuroQol EQ-5D questionnaire	evaluation of degree of limitation in different daily activities	3 month
Secondary	Reduction of peri-procedural myocardial infarction	Reduction of peri-procedural myocardial infarction	72 hours
Secondary	MACE	major adverse cardiac events	3 month
Secondary	Diastolic function	Diastolic function per echocardiogram- E/A	3 month
Secondary	Diastolic function	Diastolic function per echocardiogram-E/E' med	3 month
Secondary	Diastolic function	Diastolic function per echocardiogram- E/E' lat	3 month
Secondary	Diastolic function	Diastolic function per echocardiogram- DT time	3 month