EntrestoTM (LCZ696) In Advanced Heart Failure (LIFE Study)

Heart Failure Clinical Trial

— HFN-LIFE  

Official title:

EntrestoTM (LCZ696) In Advanced Heart Failure (LIFE Study)

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT02816736
• Other study ID #: Pro00071722
• Secondary ID: 5U01HL084904
• Status: Completed
• Phase: Phase 4
• Start date: March 2, 2017
• Est. completion date: September 29, 2020

Study information

• Verified date: December 2021
• Source: Duke University
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The primary objective of the study is to determine whether, in patients with symptomatic, advanced heart failure due to left ventricular systolic dysfunction, treatment with LCZ696 for 24 weeks will improve Pro-B-type Natriuretic Peptide (NT-proBNP) levels, which reflect hemodynamic and clinical status, compared to treatment with valsartan.

Description:

Patients with advanced heart failure with reduced ejection fraction (HFrEF) have extremely high morbidity and mortality with 1 year outcomes of death and hospitalization of approximately 50%. For the most advanced heart failure patients, the evidence base for medical treatment is limited with consensus guidelines recommending consideration for either cardiac transplant or ventricular assist device, or palliative care.

The PARADIGM-HF trial showed that LCZ696, which consists of the neprilysin inhibitor sacubitril and the ARB valsartan, improved morbidity and mortality in patients with chronic HFrEF in comparison to enalapril. However, limited experience with advanced heart failure patients was gained from patients enrolled in the trial. Because the information on the effects of sacubitril/valsartan in patients with NYHA class IV heart failure is limited, the updated 2016 ACC/AHA/HFSA guidelines for the treatment of heart failure do not yet endorse the use of sacubitril/valsartan in patients with NYHA class IV heart failure. Accordingly, experience is needed on the use of, and outcomes with LCZ696 in patients unable to tolerate target doses of angiotensin-converting enzyme inhibitor (ACEI)/ angiotensin receptor blocker (ARB).

This study will be a randomized, double-blinded trial of advanced heart failure subjects with 1:1 randomization to either LCZ696 (sacubitril and valsartan) or valsartan. Study drug will be administered in a double-dummy fashion, in which subjects take active (LCZ696 or valsartan) and placebo. Approximately 400 subjects will be randomized into the study.

Subjects will have an initial screening evaluation, including baseline laboratory tests as well as an assessment of left ventricular (LV) ejection fraction, at which time preliminary subject eligibility will be determined. The LV ejection fraction may have been obtained within the prior 12 months by 2-D echocardiogram, LV angiogram or radionuclide scintigraphy. Willing subjects meeting entry criteria will be consented. Those who meet all entry criteria and are interested in study participation will be enrolled.

Enrolled subjects will complete baseline assessments and undergo a run-in period of 3-7 days with LCZ696 50 mg (equivalent to Entresto™ 24/26 mg) po BID (taken by mouth twice a day) prior to randomization. For subjects taking an ACEI, the ACEI will be withheld for ≥ 36 hours prior to first dose of LCZ696.

Subjects who tolerate the run-in period with LCZ696 will be randomized 1:1 to LCZ696 or valsartan.

Study treatment will be titrated to the target dose of 200 mg LCZ696 (equivalent to Entresto™ 97/103 mg) as two 100 mg LCZ696 and 2 placebo tablets po BID or valsartan 160 mg (two 80 mg valsartan and 2 placebo tablets) po BID.*

Randomized subjects will receive the first dose of study drug as follows:

• For subjects not previously taking ACEI or ARB, previously taking ACEI or ARB at a low dose*, or subjects who have an eGFR < 30 mL/min/1.73m², the starting dose of valsartan will be 40 mg po BID and the starting dose of LCZ696 will be 50 mg po BID.

• For subjects taking an ARB at greater than low dose†, the starting dose of valsartan will be 80 mg po BID and the starting dose of LCZ696 will be 100 mg po BID.*

• For subjects taking an ACEI at greater than low dose†, the ACEI will be withheld for ≥ 36 hours prior to randomization. The starting dose of valsartan will be 80 mg po BID and the starting dose of LCZ696 will be 100 mg po BID.*

• At Investigator discretion, study drug may be started at the low dose (LCZ696/placebo 50 mg po BID or valsartan/placebo 40 mg po BID) if there are any concerns regarding tolerability at the 100 mg / 80 mg dose.)

Per package insert, the valsartan compounded in Entresto™ is more bioavailable than the valsartan in other marketed formulations. The dose equivalence for valsartan compounded in Entresto™ compared to valsartan prepared alone (Entresto™ dose = marketed valsartan dose) is as follows: 26 mg=40 mg, 51 mg=80 mg, 103 mg=160 mg.

† Low dose is defined as 24 hour dose of ≤ 10 mg lisinopril, ≤ 5 mg ramipril, ≤ 50 mg losartan, ≤ 10 mg olmesartan, or other dose equivalent.

Dose adjustments will be performed every 2 weeks by doubling the dose of LCZ696 or valsartan up to the target maximum dose. The doses of LCZ696 are 50 mg (one 50 mg active and 1 placebo tablet), 100 mg (one 100 mg active and 1 placebo tablet) and 200 mg (two 100 mg active and 2 placebo tablets). These doses are equivalent to 24/26 mg, 49/51 mg, and 97/103 mg commercial Entresto™, respectively. The doses of valsartan are 40mg (one 40 mg active and 1 placebo tablet), 80 mg (one 80 mg active and 1 placebo tablet), and 160 mg (two 80 mg active and 2 placebo tablets). The criteria for doubling the dose will be based on systolic blood pressure (a SBP > 90 mmHg is required for up titration), changes in renal function (maximum serum creatinine of 2.0 mg/dL), and the absence of symptoms of hypotension. For those not tolerating the current dose of study drug, the dose will be down-titrated to the previous tolerated dose. Subjects will return to clinic for follow-up visits at 2, 4, 8, 12, and 24 weeks after randomization.

Assessments at the follow-up visits include some or all of the following: interim medical history, review of medications, physical examination with the New York Heart Association (NYHA) class assessment, Kansas City Cardiomyopathy Questionnaire (KCCQ) quality of life questionnaire, local laboratory testing (creatinine, Blood Urea Nitrogen (BUN), electrolytes), Core laboratory testing (Cystatin C, BNP, NT-proBNP), adherence and tolerance assessment, and adverse event monitoring.

Follow-up phone calls will be made at 10, 16, and 20, weeks after randomization to assess dosing compliance, record the occurrence of applicable adverse events and events of interest, and remind the subject of the date and time of their next in-person visit.

A final phone visit is conducted approximately 2 weeks after study visit 10 (26 weeks after randomization) to assess clinical stability and any applicable adverse events.

During the consent process, subjects will be asked if interested in donating samples and data for research purposes via a biorepository and/or genetic study. Based on site and IRB preference, this optional part of the study may be incorporated into the main consent or may be a separate consent and Institutional Review Board (IRB) application.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 365
• Est. completion date: September 29, 2020
• Est. primary completion date: September 15, 2020
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years to 85 Years

Eligibility

Inclusion Criteria:

1. Advanced HFrEF defined as including ALL

1. LVEF= 35% documented during the preceding 12 months

2. NYHA class IV symptomatology, defined as chronic dyspnea or fatigue at rest or on minimal exertion in the previous 3 months, or patients who require chronic inotropic therapy

3. Minimum of 3 months GDMT for HF and/or intolerant to therapy

2. Systolic blood pressure = 90 mmHg

3. Serum NT-proBNP = 800 pg/mL OR BNP = 250 pg/mL (most recent - less than 3 months old)

4. Any one or more of the following objective findings of advanced HF including:

1. Current inotropic therapy or use of inotropes in the past 6 months

2. = 1 hospitalization for heart failure in the past 6 months (not including the index hospitalization for inpatient participants)

3. LVEF = 25% (within the past 12 months)

4. Peak VO2 < 55% predicted or peak VO2 = 16 for men or = 14 for women (Respiratory Exchange Ratio (RER) = 1.05) (within the past 12 months)

5. 6 min walk test distance < 300 m (within the past 3 months)

5. Age =18 years and = 85 years

6. Signed Informed Consent form

Exclusion Criteria:

1. Currently taking Entresto™

2. History of hypersensitivity or intolerance (unmodifiable) to Entresto™, an ACEI or ARB as well as known or suspected contraindications (including hereditary angioedema) to the study drugs.

3. Estimated glomerular filtration rate (eGFR) < 20 mL/min/1.73 m2 at baseline

4. Co-morbid conditions that may interfere with completing the study protocol (e.g. recent history of drug or alcohol abuse) or cause death within 1 year

5. Symptomatic hypotension at randomization or systolic blood pressure < 90 mmHg

6. Serum potassium > 5.5 mmol/L

7. Severe liver dysfunction (Childs-Pugh Class C)

8. Acute coronary syndrome within 4 weeks as defined by electrocardiographic (ECG) changes and biomarkers of myocardial necrosis (e.g. troponin) in an appropriate clinical setting (chest discomfort or anginal equivalent)

9. Planned or recent (= 4 weeks) PCI, coronary artery bypass grafting, or biventricular pacing

10. Currently hospitalized and listed status 1A, 1B or 1-4 for heart transplant

11. Current or scheduled for LVAD implantation within 30 days of study enrollment

12. Active infection (current use of oral or IV antimicrobial agents)

13. Primary hypertrophic or infiltrative cardiomyopathy, acute myocarditis, constrictive pericarditis or tamponade

14. Complex congenital heart disease

15. Concomitant use of aliskiren in patients with diabetes or renal impairment (eGFR <60 mL/min/1.73 m²)

16. Known pregnancy or anticipated pregnancy within the next 6 months or breastfeeding mothers

17. Enrollment in any other investigational clinical trial within 30 days prior to screening

18. Inability to comply with study procedures

Related Conditions & MeSH terms

• Heart Failure

Intervention

Drug:
• LCZ696
Subjects previously taking no or low-dose ACEI or ARB, or who have an eGFR < 30 mL/min/1.73m²: starting dose of LCZ696 = 50 mg po BID. Subjects taking an ARB at greater than low dose: starting dose of LCZ696 = 100 mg po BID. Subjects taking an ACEI at greater than low dose: starting dose of LCZ696 = 100 mg po BID. * At Investigator discretion, study drug may be started at the low dose if there are any concerns regarding tolerability. Dose adjustments will be performed every 2 weeks by doubling the dose of LCZ696 up to the target max dose of 200 mg po BID as tolerated. The doses of LCZ696 are 50mg (one low-dose (50mg) tablet), 100mg (one high-dose (100mg) tablet), and 200mg (two high-dose (100mg) tablets.) These doses are equivalent to 24/26 mg, 49/51 mg, and 97/103 mg commercial Entresto™, respectively.
• valsartan
Subjects previously taking no or low-dose ACEI or ARB, or who have an eGFR < 30 mL/min/1.73m²: the starting dose of valsartan = 40 mg po BID. Subjects taking an ARB at greater than low dose: starting dose of valsartan = 80 mg po BID. Subjects taking an ACEI at greater than low dose: starting dose of valsartan = 80 mg po BID. * At Investigator discretion, study drug may be started at the low dose if there are any concerns regarding tolerability. Dose adjustments will be performed every 2 weeks by doubling the dose of valsartan up to the target maximum dose of 160 mg po BID, as tolerated. The doses of valsartan are 40mg (one low-dose (40mg) tablet), 80mg (one high-dose (80mg) tablet), and 160mg (two high-dose (80mg) tablets).
• LCZ696 placebo
LCZ696 placebo tablets will be supplied to match the low-dose (50mg) and high-dose (100mg) active LCZ696 tablets. Dosing for LCZ696 placebo will mirror dosing for active valsartan (the same number of low or high-dose tablets will be given.)
• valsartan placebo
Valsartan placebo tablets will be supplied to match the low-dose (40mg) and high-dose (80mg) active valsartan tablets. Dosing for valsartan placebo will mirror dosing for active LCZ696 (the same number of low or high-dose tablets will be given.)

Locations

Country	Name	City	State
United States	University of Michigan Health System	Ann Arbor	Michigan
United States	Emory University School of Medicine	Atlanta	Georgia
United States	Piedmont Heart Institute	Atlanta	Georgia
United States	Johns Hopkins Hospital	Baltimore	Maryland
United States	Cedars-Sinai Heart Institute	Beverly Hills	California
United States	Brigham and Women's Hospital	Boston	Massachusetts
United States	Massachusetts General Hospital	Boston	Massachusetts
United States	Tufts Medical Center	Boston	Massachusetts
United States	Charlotte-Mecklenburg Hospital Authority	Charlotte	North Carolina
United States	The Christ Hospital	Cincinnati	Ohio
United States	Case Western Medical Center	Cleveland	Ohio
United States	Cleveland Clinic	Cleveland	Ohio
United States	Metro Health System	Cleveland	Ohio
United States	The Ohio State University Medical Center	Columbus	Ohio
United States	Duke University Medical Center	Durham	North Carolina
United States	Inova Heart and Vascular Insititute	Falls Church	Virginia
United States	Houston Methodist Research Institute	Houston	Texas
United States	St. Vincent Medical Group	Indianapolis	Indiana
United States	Vanderbilt University Medical Center	Nashville	Tennessee
United States	Ochsner Clinic Foundation	New Orleans	Louisiana
United States	Mount Sinai Hospital	New York	New York
United States	Sentara Norfolk General Hospital	Norfolk	Virginia
United States	Advocate Christ Medical Center	Oak Lawn	Illinois
United States	Integris Baptist Medical Center	Oklahoma City	Oklahoma
United States	Thomas Jefferson University Hospital	Philadelphia	Pennsylvania
United States	University of Pennsylvania	Philadelphia	Pennsylvania
United States	Allegheny General Hospital	Pittsburgh	Pennsylvania
United States	Oregon Health and Science University	Portland	Oregon
United States	Mayo Clinic	Rochester	Minnesota
United States	Sutter Health Mills-Peninsula Health Services	Sacramento	California
United States	Saint Louis University Hospital	Saint Louis	Missouri
United States	Washington University	Saint Louis	Missouri
United States	University of Utah School of Medicine	Salt Lake City	Utah
United States	San Diego Cardiac Center	San Diego	California
United States	University of Washington Medical Center	Seattle	Washington
United States	Stony Brook University Medical Center	Stony Brook	New York
United States	MedStar Washington Hospital Center	Washington	District of Columbia
United States	Geisinger Medical Center	Wilkes-Barre	Pennsylvania

Sponsors (2)

Lead Sponsor	Collaborator
Duke University	National Heart, Lung, and Blood Institute (NHLBI)

Country where clinical trial is conducted

United States, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Other	Time to Death	Time to death through 24 weeks	Randomization through 24 weeks
Other	Time to First Heart Failure (HF) Hospitalization	Time to first HF hospitalization through 24 weeks	Randomization through 24 weeks
Other	Time to Death and First Heart Failure (HF) Hospitalization	Time to death and first HF hospitalization through 24 weeks	Randomization through 24 weeks
Other	Total Number of Heart Failure (HF) Hospitalizations	Total number of HF hospitalization admissions through 24 weeks	Randomization through 24 weeks
Other	Inotropic Therapy	Number of subjects on continuous inotropic therapy >/= 7 days after discharge from the index hospitalization through 24 weeks	Randomization through 24 weeks
Other	Number of Subjects Listed for Transplant (Status 1A, 1B or 1-4), Transplanted or Implanted With an LVAD	Number of subjects listed for transplant (status 1A, 1B or 1-4), transplanted or implanted with an LVAD through 24 weeks.	Randomization through 24 weeks
Other	Change in eGFR and Cystatin C Levels	Change in eGFR and cystatin C levels compared to baseline. Renal function will be assessed at baseline, 4, 8, 12, and 24 weeks	Randomization through 24 weeks
Other	Unanticipated IV Diuretic Use	Number of subjects with unanticipated use of IV diuretics (outpatient, ER or inpatient) through 24 weeks.	Randomization through 24 weeks
Other	Change in AUC in the Kansas City Cardiomyopathy Questionnaire (KCCQ)	Difference in AUC of the KCCQ at 4, 12 and 24 weeks	Randomization through 24 weeks
Other	Change in AUC for the Ratio of NT-proBNP/BNP	The change in AUC for the ratio of NT-proBNP/BNP from baseline to weeks 2, 4, 8, 12 and 24 weeks	Randomization through 24 weeks
Primary	Change in NT-proBNP	The proportional change from baseline in the AUC for NT-proBNP levels measured at 2, 4, 8, 12, and 24 weeks. AUC was normalized for time and divided by the baseline value of NTproBNP so it has no unitshas no units. With the log-scale, the value of 0 indicates, on average, no change in NTproBNP from baseline. A value > 0 indicates an increase in log NT Pro BNP relative to baseline and a value < 0 indicates a decrease in log NT Pro BNP relative to baseline.	Baseline, 2, 4, 8, 12, and 24 weeks
Secondary	Composite Endpoint of the Effects of LCZ696 (Number of Days)	Composite endpoint of effects of LCZ696 compared to valsartan over 24 weeks will be compared based upon the number of days subjects are; alive and out of hospital; not listed for transplant (Status 1A, 1B or 1-4), or undergoing transplant; not implanted with an LVAD; not maintained or started on continuous inotropic therapy for = 7 days; not hospitalized twice for HF (following the index admission) The days alive and out of hospital will end on the day of the second HF readmission, if applicable.	Randomization through 24 weeks
Secondary	Tolerability - Target Dose	Tolerability as measured by number of subjects achieving a target dose of 0% (stopped study drug early or was never started on study drug), 25%, 50% or 100% of valsartan or LCZ696 (based on last dose of study drug taken prior to end of study)	Randomization through 24 weeks
Secondary	Tolerability - Hypotension	Tolerability as measured by number of subjects developing hypotension (SBP = 85 mmHg) with symptoms	Randomization through 24 weeks
Secondary	Tolerability - Renal Function	Tolerability as measured by number of subjects developing worsening renal function (eGFR < 20 ml/min/1.73 m²)	Randomization through 24 weeks
Secondary	Tolerability - Hyperkalemia	Tolerability as measured by number of subjects developing moderate (>/= 5.5 mmol/L-5.9 mmol/L) or severe (>/= 6 mmol/L) hyperkalemia	Randomization through 24 weeks