Evolocumab for PCSK9 Lowering in Early Acute Sepsis (The PLEASe Study)

Sepsis Clinical Trial

— PLEASe  

Official title:

Randomized, Double-blind, Placebo-controlled Phase 2a Trial of Efficacy and Safety of Evolocumab for PCSK9 Lowering in Early Acute Sepsis

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT03869073
• Other study ID #: H18-00917
• Status: Recruiting
• Phase: Phase 2
• Start date: February 11, 2019
• Est. completion date: February 11, 2021

Study information

• Verified date: March 2020
• Source: University of British Columbia
• Contact: Genevieve L Rocheleau
• Phone: 604-682-2344
• Email: grocheleau[@]providencehealth.bc.ca
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

This study evaluates using evolocumab, a currently approved and marketed biologic drug, in a novel way. Patients who present to the emergency room or intensive care unit (ICU) with severe infection are eligible. Either the patient or their designated decision maker will be approached for consent. If they choose to participate they will be given either a single dose of evolocumab, a higher single dose of evolocumab,or a single dose of placebo. Participants will be followed during their stay in the ICU and will receive follow up phone calls at Day 28 and 90.

Description:

Evolocumab is currently approved and marketed in USA and Canada for lowering cholesterol levels. Evolocumab is an anti-PSCK9 monoclonal antibody, and functions by binding PSCK9 (an inhibitor of LDL removal) and blocking its function. Evidence suggests that since evolocumab increases the removal rate of low-density lipoproteins from the body, it might also help increase the removal of bacterial components that are attached to circulating lipids during sepsis. Quickly removing these bacterial components could prevent a strong and rapid immune response that often leads to organ failure and death in sepsis patients.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 36
• Est. completion date: February 11, 2021
• Est. primary completion date: February 11, 2021
• Accepts healthy volunteers: No
• Gender: All
• Age group: 19 Years and older

Eligibility

Inclusion Criteria:

• Signed informed consent

• At least 19 years of age

• Known or suspected infection

• AND one or more of the following organ dysfunctions judged due to sepsis:

1. Cardiovascular- refractory hypotension (a systolic blood pressure (SBP) < 90 mm Hg or mean arterial pressure (MAP) < 60 mm Hg despite an IV fluid challenge of at least 30 ml/kg fluids), or use of vasopressor(s) to maintain SAP > 90 mm Hg or MAP > 60 mm Hg, or;

2. Respiratory: PaO2/FiO2 < 300 or PaO2/FiO2 < 200 if lung is the only organ dysfunction or SaO2:FiO2 150

Exclusion Criteria:

• Known pregnancy

• Underlying severe congestive heart failure (New York Heart Association (NYHA) IV), severe COPD (need for chronic oxygen or mechanical ventilation), severe liver disease (Child-Pugh Class C), cancer requiring chemotherapy, or transplantation (bone marrow, heart, lung, liver, pancreas, or small bowel) in the past 6 months or likely within the next 6 months

• Previous episode of sepsis during that hospital admission

• Absolute Neutrophil Count < 500/mm³

• CD4 count < 50/mm³

• Treating physician deems aggressive care unsuitable (i.e. no commitment to active care)

• Participation in another interventional drug study within previous 1 month

• Allergic to the study drug or any of its components

• Lactation

• Have signed a Do No Resuscitate (DNR) Form

Related Conditions & MeSH terms

• Sepsis
• Toxemia

Intervention

Drug:
• Evolocumab
Three pre-filled shrouded syringes for subcutaneous injection in abdomen.
• Placebo
Preservative free 0.9% sodium chloride. Three pre-filled shrouded syringes for subcutaneous injection in abdomen.

Locations

Country	Name	City	State
Canada	Surrey Memorial Hospital	Surrey	British Columbia
Canada	St. Paul's Hospital	Vancouver	British Columbia
Canada	Vancouver General Hospital	Vancouver	British Columbia

Sponsors (1)

Lead Sponsor	Collaborator
University of British Columbia

Country where clinical trial is conducted

Canada, 

References & Publications (8)

Boyd JH, Fjell CD, Russell JA, Sirounis D, Cirstea MS, Walley KR. Increased Plasma PCSK9 Levels Are Associated with Reduced Endotoxin Clearance and the Development of Acute Organ Failures during Sepsis. J Innate Immun. 2016;8(2):211-20. doi: 10.1159/000442976. Epub 2016 Jan 13. Review. — View Citation

Cirstea M, Walley KR, Russell JA, Brunham LR, Genga KR, Boyd JH. Decreased high-density lipoprotein cholesterol level is an early prognostic marker for organ dysfunction and death in patients with suspected sepsis. J Crit Care. 2017 Apr;38:289-294. doi: 10.1016/j.jcrc.2016.11.041. Epub 2016 Dec 7. — View Citation

Levels JH, Abraham PR, van Barreveld EP, Meijers JC, van Deventer SJ. Distribution and kinetics of lipoprotein-bound lipoteichoic acid. Infect Immun. 2003 Jun;71(6):3280-4. — View Citation

Levels JH, Abraham PR, van den Ende A, van Deventer SJ. Distribution and kinetics of lipoprotein-bound endotoxin. Infect Immun. 2001 May;69(5):2821-8. — View Citation

Levels JH, Marquart JA, Abraham PR, van den Ende AE, Molhuizen HO, van Deventer SJ, Meijers JC. Lipopolysaccharide is transferred from high-density to low-density lipoproteins by lipopolysaccharide-binding protein and phospholipid transfer protein. Infect Immun. 2005 Apr;73(4):2321-6. — View Citation

Roveran Genga K, Lo C, Cirstea M, Zhou G, Walley KR, Russell JA, Levin A, Boyd JH. Two-year follow-up of patients with septic shock presenting with low HDL: the effect upon acute kidney injury, death and estimated glomerular filtration rate. J Intern Med. 2017 May;281(5):518-529. doi: 10.1111/joim.12601. Epub 2017 Mar 19. — View Citation

Topchiy E, Cirstea M, Kong HJ, Boyd JH, Wang Y, Russell JA, Walley KR. Lipopolysaccharide Is Cleared from the Circulation by Hepatocytes via the Low Density Lipoprotein Receptor. PLoS One. 2016 May 12;11(5):e0155030. doi: 10.1371/journal.pone.0155030. eCollection 2016. Erratum in: PLoS One. 2016;11(7):e0160326. — View Citation

Walley KR, Thain KR, Russell JA, Reilly MP, Meyer NJ, Ferguson JF, Christie JD, Nakada TA, Fjell CD, Thair SA, Cirstea MS, Boyd JH. PCSK9 is a critical regulator of the innate immune response and septic shock outcome. Sci Transl Med. 2014 Oct 15;6(258):258ra143. doi: 10.1126/scitranslmed.3008782. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Area under the plasma LTA and LPS curves	Determine whether evolocumab decreases plasma levels of bacterial LPS and LTA, at 6, 24, 48 and 72 hours, and day 7 by comparing the area under the operating curve between arms.	7 days or less (as data is collected from participants only while they are admitted to critical care, they may be discharged or moved to a different ward before day 7 and therefore subsequent time points would be not be collected)
Secondary	Levels of LDL-C	Measure levels (concentration; e.g. ug/mL) of low-density lipoprotein-cholesterol (LDL-C) at 24, 48, and 72 hours, and day 7, and compare area under the plasma cytokine curve between arms.	7 days or less (as data is collected from participants only while they are admitted to critical care, they may be discharged or moved to a different ward before day 7 and therefore subsequent time points would be not be collected)
Secondary	Levels of cytokines IL-6, TNF-alpha and IL-8	Measure levels (concentration; e.g. ug/mL) of cytokines (IL-6, TNF-alpha and IL-8) at 24, 48, and 72 hours, and day 7, and compare area under the plasma cytokine curve between arms.	7 days or less (as data is collected from participants only while they are admitted to critical care, they may be discharged or moved to a different ward before day 7 and therefore subsequent time points would be not be collected)
Secondary	Concentration of circulating evolocumab and circulating free PCSK9 in septic patients	Assess the concentration (e.g. umol/L) of circulating evolocumab and free (unbound by antibody) PCSK9 in evolocumab-treated patients with sepsis and compare to placebo controls.	7 days or less (may be discharged from critical care before day 7)
Secondary	Cmax of circulating evolocumab and circulating free PCSK9 in septic patients	Assess the Cmax of circulating evolocumab and free (unbound by antibody) PCSK9 in evolocumab-treated patients with sepsis and compare to placebo controls.	7 days or less (may be discharged from critical care before day 7)
Secondary	Days alive	Determine if changes in days alive over 28 days are associated with treatment arm.	28 days or less (may be discharged from critical care before day 28)
Secondary	Changes in 28-day mortality	Determine whether differences in mortality rates at 28 days exist between treatment arms.	28 days
Secondary	Level of organ dysfunction	Determine if changes in days free of organ dysfunction (cardiovascular, respiratory, renal, hematologic, and hepatic) over 28 days are associated with treatment arm.	28 days or less (may be discharged from critical care before day 28)
Secondary	Level of organ support	Determine if changes in days free of organ support (vasopressor, ventilation and renal replacement therapy (RRT)) over 28 days are associated with treatment arm.	28 days or less (may be discharged from critical care before day 28)
Secondary	Changes in Vitals: lactate	Determine if changes in plasma lactate levels (mmol/L) are associated with treatment arm.	28 days or less (may be discharged from critical care before day 28)
Secondary	Changes in Vitals: norepinephrine dose	Determine if changes in norepinephrine levels (mcg/min) are associated with treatment arm.	28 days or less (may be discharged from critical care before day 28)
Secondary	Changes in Vitals: mean arterial pressure	Determine if changes in mean arterial pressure levels (mm Hg) are associated with treatment arm.	28 days or less (may be discharged from critical care before day 28)
Secondary	Changes in Vitals: heart rate	Determine if changes in heart rate (beats per minute) are associated with treatment arm.	28 days or less (may be discharged from critical care before day 28)
Secondary	Changes in Vitals: respiratory rate	Determine if changes in respiratory rate (breaths per minute) are associated with treatment arm.	28 days or less (may be discharged from critical care before day 28)
Secondary	Changes in Vitals: temperature	Determine if changes in temperature (degrees Celsius) are associated with treatment arm.	28 days or less (may be discharged from critical care before day 28)
Secondary	Changes in Vitals: fluid balance	Determine if changes in fluid balance (Liters) are associated with treatment arm.	28 days or less (may be discharged from critical care before day 28)
Secondary	Changes in Vitals: urine output	Determine if changes in urine output (Liters) are associated with treatment arm.	28 days or less (may be discharged from critical care before day 28)
Secondary	Safety outcomes: Number of treatment-related adverse events as ranked by severity	Monitor and count by category, and evaluate severity and seriousness of any adverse events related to the intervention that occurs in this critical and previously untested population.	Day 1 to Day 90
Secondary	Safety outcomes: changes in blood cell counts	Document changes in blood cell counts (cells/ml) including white blood cells, red blood cells, and platelets, and determine whether clinically significant changes are associated with treatment.	28 days or less (may be discharged from critical care before day 28)
Secondary	Safety outcomes: changes in coagulation	Document changes in coagulation of blood by measuring Prothrombin Time (PT) and Partial Thromboplastin Time (PTT). Both measurements determine time to clotting (in seconds) of different clotting factors and are then used to calculate International Normalized Ratio (INR) which helps monitor effects of blood thinning medication, and determine whether clinically significant changes are associated with treatment.	28 days or less (may be discharged from critical care before day 28)
Secondary	Safety outcomes: changes in blood analytes	Document changes in concentration (e.g. umol/mL) of blood analytes, including hemoglobin, glucose, glycated hemoglobin, potassium, sodium, chloride, bicarbonate, creatinine, calcium, triponine, magnesium, aminotransferase, and alanine aminotransferase, and determine whether clinically significant changes are associated with treatment.	28 days or less (may be discharged from critical care before day 28)
Secondary	Safety outcomes: changes in urine density	Document changes in urine specific gravity (density relative to water) and determine whether clinically significant changes are associated with treatment.	28 days or less (may be discharged from critical care before day 28)
Secondary	Safety outcomes: changes in urine pH	Document changes in urine pH and determine whether clinically significant changes are associated with treatment.	28 days or less (may be discharged from critical care before day 28)
Secondary	Safety outcomes: changes in concentration of ketones in urine	Document changes in concentration of ketones (e.g. umol/L) in the urine and determine whether clinically significant changes are associated with treatment.	28 days or less (may be discharged from critical care before day 28)
Secondary	Safety outcomes: document other urine abnormalities if required	Document presence of blood, nitrites, bacteria, or urinary casts in the urine (yes or no) and determine whether clinically significant changes are associated with treatment.	28 days or less (may be discharged from critical care before day 28)

External Links

•   Evolocumab Product Monograph - 10 August 2018