Atorvastatin to Treat Pulmonary Sarcoidosis

Sarcoidosis, Pulmonary Clinical Trial

Official title:

Atorvastatin as a Disease Modifying Agent in Stage II and III Pulmonary Sarcoidosis: A Randomized, Double-Blind, Placebo-Controlled Trial

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT00279708
• Other study ID #: 060072
• Secondary ID: 06-H-0072
• Status: Completed
• Phase: Phase 2
• First received: January 18, 2006
• Last updated: March 11, 2016
• Start date: January 2006
• Est. completion date: December 2015

Study information

• Verified date: March 2016
• Source: National Institutes of Health Clinical Center (CC)
• Contact: n/a
• Is FDA regulated: No
• Health authority: United States: Federal Government
• Study type: Interventional

Clinical Trial Summary

This study will determine if atorvastatin (Lipitor), a widely used cholesterol-lowering drug, can help patients with pulmonary (lung) sarcoidosis and replace or reduce the need for patients to take steroids, such as prednisone. Sarcoidosis is an inflammatory disease that can affect nearly any part of the body. Pulmonary sarcoidosis may resolve on its own or it may progress to irreversible lung damage, disability, and death. Many sarcoidosis patients are treated with prednisone, but the drug is not effective in all patients, and it can cause serious side effects, such as high blood pressure, sugar diabetes, eye cataracts, and bone thinning.

Patients with stage II or III pulmonary sarcoidosis between 18 and 70 years of age who require prednisone may be eligible for this study. Candidates are screened with the tests and procedures described below.

Participants are randomly assigned to one of two treatment groups: one group takes atorvastatin; the other takes a placebo (a look-alike pill that has no active ingredient to fight sarcoidosis). Both groups take the pills by mouth once a day for 12 months. When treatment begins, participants begin to have their prednisone dosage tapered (reduced). The tapering is done over 8 weeks until the dose is reduced by 90 percent. Patients are evaluated periodically to determine if the two groups differ in how long they can remain on the reduced dose of prednisone without having their symptoms recur, requiring an increase in the prednisone dose. A full battery of tests is done at the initial screening visit and at the 26- and 52-week follow-up visits, requiring hospitalization for 3-5 days. Additional interim outpatient assessments are done at 6, 12, 18 and 36 weeks.

The full battery of tests at the initial screening and the 26- and 52-week visits includes the following:

• Medical history, physical examination, blood and urine tests, assessment of disease severity and activity.

• Questionnaires.

• Chest x-ray (CXR) and computed tomography (CT) scan.

• Abdominal ultrasound.

• Six-minute walk test (6MWT): test to see how far the subject can walk in 6 minutes.

• Exercise testing and blood gases: Patients exercise on a stationary bicycle or treadmill while their heart and lung function are monitored. During the test, arterial blood gases are measured to determine the amount of oxygen and carbon dioxide in the blood.

• Pulmonary function tests (PFT): Patients are asked to breathe deeply and, occasionally, to hold their breath. They may be given a medicine called albuterol that dilates the airways.

• Maximum incremental ventilatory performance test (MIVP): Patients breathe normally through a mouth piece. The test system makes it increasingly difficult to inhale. Patients stop when they feel fatigued.

• Exhaled nitric oxide and carbon monoxide (Exhaled NO and CO): Patients breathe out into a tube that collects exhaled air (gases).

• Bronchoscopy and lavage: The patient's mouth and throat are numbed with lidocaine; a sedative and morphine-like drug are given for comfort. A tube is passed through the nose or mouth into the lung airways to examine the airways. Saline (salt water) is then injected through the bronchoscope into the air passage, and a sample of fluid is withdrawn for microscopic examination. Patients who do not have confirmation of their lung disease may also undergo biopsy at the time of lavage. For the biopsy, a small piece of tissue is extracted from the wall of the breathing tubes (bronchi) or the lymph nodes.

Interim testing at 6, 12, 18 and 36 weeks includes PFT, MIVP, Exhaled NO and CO, CXR, questionnaire, blood tests, and 6MWT.

Six months after completing the study, participants fill out a questionnaire.

Description:

Background

Sarcoidosis is a multi-system granulomatous inflammatory disease. Pulmonary involvement is most common. Patients typically experience fatigue, weakness and dyspnea. Respiratory muscle weakness, which may be secondary to granulomatous inflammation, is associated with dyspnea and decreased quality of life (QOL). The disease can remit spontaneously or become chronic, with exacerbations and remissions. In some patients, it can progress to pulmonary fibrosis and death. Granulomatous inflammation is characterized primarily by accumulation of monocytes, macrophages and activated T-lymphocytes, with increased production of key inflammatory mediators, TNF-alpha, INF-gamma, IL-2 and IL-12, characteristic of a Th1-polarized response (T-helper lymphocyte-1 response). Corticosteroids are the current mainstay of treatment, but their long-term benefits are not certain. Because steroids often produce undesirable side effects, investigations to identify alternative therapies are warranted. There is sufficient evidence to test the proof of concept that pathways targeted by statins will have a therapeutic effect in sarcoidosis, since, in pre-clinical studies, statins blunt Th1-mediated inflammatory responses.

Aims

The study involves a double-blind placebo-controlled, randomized trial which aims to determine if atorvastatin administration results in less steroid use and longer steroid-free intervals in patients with pulmonary sarcoidosis who require prednisone treatment.

Methods

Patients, who are 18-70 years old, with stage II or III pulmonary sarcoidosis, diagnosed by a compatible clinical history and supported by a lung, lymph node, or tissue biopsy, will be enrolled in the study, if they require prednisone therapy. The patients will be randomly assigned to two groups; as prednisone is tapered, one group will receive placebo and the other, atorvastatin. The two study drugs will be administered for twelve months, during which time patients will be periodically evaluated as to their clinical status and prednisone requirements. Pill counts and patient diaries will be used to determine the amount of steroid use during the study period. Patients with pulmonary fibrosis greater than 50 percent of total lung volume or severe co-morbidities will be excluded from the trial.

The primary endpoint is the duration of the steroid-sparing period. Secondary clinical and physiological endpoints are intended to analyze possible anti-inflammatory and beneficial effects of the drugs. Since there is no gold standard outcome measure in sarcoidosis, four categories of secondary endpoints will be used to characterize the effects of the therapeutic agent on the clinical course of the disease: imaging (high resolution chest CT); quality of life assessments (SF-36, and SGRQ), anti-inflammatory effects (biomarkers and relapse rates), and functional effects (CPET, PFTs). Finally, we will study the utility of exhaled nitric oxide and carbon monoxide in monitoring disease activity.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 56
• Est. completion date: December 2015
• Est. primary completion date: December 2015
• Accepts healthy volunteers: No
• Gender: Both
• Age group: 18 Years to 70 Years

Eligibility

• INCLUSION CRITERIA:

Patients are eligible for the trial if they are 18-70 years old with radiographic stages II and III pulmonary sarcoidosis, and are on prednisone, methotrexate, or azathioprine for pulmonary sarcoidosis or who are steroid-requiring. Patients with extra-pulmonary sarcoidosis (except cardiac and neurosarcoid) may be eligible as long as they have active pulmonary (stage II or III) sarcoidosis.

Steroid-Requiring History:

A steroid-requiring patient is one who was previously stable but who ultimately experiences (a) increased symptoms associated with radiographic deterioration, and/or, (b) met the criteria for relapse and/or functional deterioration. In addition, patients who were prescribed prednisone for sarcoidosis, but have self-discontinued it (yet still have clinical and symptomatic disease and/or evidence of pulmonary functional deterioration) will be considered steroid-requiring.

This latter group of steroid-requiring patients is eligible for enrollment if they are willing to resume taking their latest stabilizing dose of prednisone for at least four weeks prior to study entry. If their dose cannot be determined, then 40 mg will be used.

Therefore, a history of symptomatic or clinical deterioration leading to therapy initiation, or a history of decline associated with attempts to decrease therapy should be established. Medical records review and discussion with the prescribing physician will be used to establish this history.

Radiographic Stages of Pulmonary Sarcoidosis:

STAGE< TAB> DESCRIPTION

0< TAB> Normal Chest Radiograph

I< TAB> Bilateral Hilar Lymphadenopathy

II< TAB> Pulmonary Infiltration and Bilateral Hilar Lymphadenopathy

III< TAB> Pulmonary Infiltration alone

Steroid-requiring refers to one of three situations:

Patients who meet relapse criteria or functional deterioration.

Functional deterioration criteria that warrants prednisone therapy includes:

If VC fell to 75% of the best recorded value for the patient before any treatment

If VC fell to greater than 50% of predicted value

IF DLCO fell to less than 60% of the best recorded value prior to their treatment

Patients who are on a previously prescribed systemic steroid, or alternative agent such as methotrexate or azathioprine, primarily for pulmonary sarcoidosis. Alternative agents must first be changed to roughly equivalent anti-inflammatory dose of prednisone and the patient should be stable on this dose for at least four weeks prior to randomization.

Patients who have substantial respiratory symptoms (distressing cough or dyspnea, which interferes with daily activities that would warrant therapy as per the standard of practice in the US.

Extra Pulmonary Sarcoidosis:

Patients with extra pulmonary sarcoidosis (except neurosarcoid and cardiac sarcoid) may be eligible as long as they have active pulmonary (stage II or III) sarcoidosis. All patients will be referred to an NIH ophthalmologist. Steroid therapy may be modified based upon the recommendations of the consultants, as well as per the lapse criteria described above.

EXCLUSION CRITERIA:

• Moderate to severe pulmonary fibrosis (stage IV sarcoidosis greater than 50% fibrosis)

• Lung Disease such as asthma, COPD, ILD (other than sarcoid-related)

• History of significant beryllium or asbestos exposure

• Pregnancy; or Active lactation/ child-bearing age female without appropriate birth control methods

• HIV disease

• Hepatitis C and Active Hepatitis B

• Other intervention protocols

• Immunosuppressive therapy (systemic or inhaled) other than corticosteroids or methotrexate

• Significant cardiac disease (NYSHA class greater than III), or serious coronary disease (unstable angina)

• Use of statins within 12 weeks of enrollment

• Allergies or intolerance to statins

• Liver disease (transaminases greater than 1.5X upper limits of normal) or cirrhosis

• Bleeding diathesis that is not correctable

• Inability to perform CPET (cycle ergometer) or PFT maneuvers

• Inability to understand the risks of the trial and the inability to complete the questionnaire

• Malignancy-- requiring chemotherapy or radiation therapy; except certain types of skin cancer that have been excised and have not spread.

• Myopathy, diagnosed via muscle biopsy (other than sarcoid-related myopathy); CPK grater than 1.5 upper limits of normal

• Surgical Risk Category [American Society of Anesthesiologists (ASA) class IV

• Ingestion of grapefruit juice or certain herbal preparations (see below), or medications that are potent inhibitors or inducers of the CYP3A4 system (see section 12.4 under precautions)

• Alcohol abuse (greater than 4 drinks/day)

• Bleeding into the brain or parts of the eyes (retina) (within the past year prior to enrollment)

• Uncontrolled Hypertension (SBP greater than 185 or DBP greater than 100 on two or more visits or assessments)

• Uncontrolled Diabetes Mellitus (Serum glucose level on two or more tests per day greater than 250 mg/dl or erratic blood sugar levels, noted on at least 2 or more assessments; and/or HgbA1C greater than 2x the upper limits of normal).

• Neurosarcoidosis

• Sarcoid Uveitis (Posterior Uveitis) or any Uveitis that cannot be managed with topical steroids alone, as determined by an ophthalmologist

• (Clinically apparent) Cardiac Sarcoidosis

• Active Smoker (Smoked within the past 2 months prior to randomization)

• Sickle cell disease (SS, SC, and sickle cell-beta thalassemia)

• Aseptic necrosis of the hip joints

Patients taking the following preparations will not be allowed to participate in the study unless they agree to discontinue usage at least two weeks prior to randomization and for the duration of the study period: grapefruit juice and herbal remedies that may lead to severe liver injury and/or muscle injury if taken with atorvastatin, including: Skullcap, Chapparal, Germander, Jin Bu Huan, Valerian, Comfrey, and Eucalyptus. Since other products such as St. John s Wort, oat bran, and pectin can reduce the effectiveness of atorvastatin, they and similar agents, should also be discontinued at least two weeks before randomization and for the duration of the study period.

Subjects with inactive hepatitis B will require antiviral prophylaxis with an agent such as lamivudine, while on prednisone therapy.

Study Design

Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Single Group Assignment, Masking: Double Blind (Subject, Caregiver, Investigator, Outcomes Assessor), Primary Purpose: Treatment

Related Conditions & MeSH terms

• Sarcoidosis
• Sarcoidosis, Pulmonary

Intervention

Drug:
• Atorvastatin
Placebo vs. Atorvastatin

Locations

Country	Name	City	State
United States	National Institutes of Health Clinical Center, 9000 Rockville Pike	Bethesda	Maryland

Sponsors (1)

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

Country where clinical trial is conducted

United States, 

References & Publications (3)

Newman LS, Rose CS, Maier LA. Sarcoidosis. N Engl J Med. 1997 Apr 24;336(17):1224-34. Review. Erratum in: N Engl J Med 1997 Jul 10;337(2):139. — View Citation

Statement on sarcoidosis. Joint Statement of the American Thoracic Society (ATS), the European Respiratory Society (ERS) and the World Association of Sarcoidosis and Other Granulomatous Disorders (WASOG) adopted by the ATS Board of Directors and by the ERS Executive Committee, February 1999. Am J Respir Crit Care Med. 1999 Aug;160(2):736-55. Review. — View Citation

Thomas KW, Hunninghake GW. Sarcoidosis. JAMA. 2003 Jun 25;289(24):3300-3. Review. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	The duration of the steroid sparing period.		1 year	No
Secondary	Pulmonary function		1 year	No

External Links

•   NIH Clinical Center Detailed Web Page