Conversion of Maintenance Prograf to Envarsus in Liver Transplant Recipients

Liver Transplant Rejection Clinical Trial

Official title:

Prograf/Envarsus Conversion Study in Liver Transplant Recipients to Improve Side Effects, Adherence and Quality of Life: A Single-centre Randomized Controlled Trial

Clinical Trial Details — Status: Not yet recruiting

Administrative data

• NCT number: NCT05655273
• Other study ID #: 22-5210
• Status: Not yet recruiting
• Phase: Phase 4
• Start date: June 1, 2023
• Est. completion date: October 31, 2024

Study information

• Verified date: May 2023
• Source: University Health Network, Toronto
• Contact: Erin Winter, BSC
• Phone: 416-340-4800
• Email: erin.winter[@]uhn.ca
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Prograf and Envarsus are two different formulations of Tacrolimus which is used as an immunosuppressant in liver transplant (LT) patients. Prograf is currently used as part of the standard immunosuppression regimen for LT recipients at UHN. This study will compare the use of Prograf and Envarsus and their effects on liver and renal function, trough tacrolimus levels, drug-related adverse effects, and patient adherence. Trial design is a pilot randomized trial. The study aims to recruit 40 patients from UHN's LT program and they will be randomized 1:1 to either stay on their current dose of Prograf or be converted to a once-daily equivalent dose of Envarsus. Both groups of patients will be followed for 48 weeks. This study will compare the change from baseline to week 48 in liver and renal function, tacrolimus-related side effects and patient reported outcomes between the two study groups.

Description:

Tacrolimus (Prograf ©) has become part of the standard of care for patients receiving solid organ transplants and is part of the immunosuppressive protocol (along with prednisone and mycophenolate mofetil [CellCept ©]) used by liver transplant recipients at University Health Network (UHN). Tacrolimus is associated with several toxicities including renal injury, tremor, pancreatic islet β-cell injury (leading to diabetes) and hyperlipidemia. As a result of these potential toxicities, careful therapeutic drug monitoring of tacrolimus is a key component of post-transplant management. Tacrolimus trough levels are known to correlate with total tacrolimus exposure, as shown from formal pharmacokinetic assessments. Accordingly, trough serum concentrations of tacrolimus are measured routinely in all recipients and are used to guide dosing. The Prograf formulation of tacrolimus has a short serum half-life and must be dosed twice daily to maintain therapeutic serum concentrations. Further, Prograf administration results in a high peak tacrolimus level. Peak tacrolimus levels have been shown to correlate with toxicity; thus, avoidance of high peaks may be desirable to minimize tacrolimus toxicity. Envarsus is an extended-release formulation of tacrolimus that provides similar drug exposure to tacrolimus at a 30% lower dose but with a once daily dosing regimen. Envarsus dosing also results in a lower peak tacrolimus level compared to Prograf. In this way, it is hoped that Envarsus may provide similar therapeutic efficacy as Prograf but with fewer adverse effects. In addition, the simpler dosing regimen is expected to enhance patient adherence and quality of life. The present study is aimed at evaluating the impact of a switch from Prograf to Envarsus on liver and renal function, trough tacrolimus levels, drug-related adverse effects and adherence. It hypothesizes that once daily Envarsus can be substituted at reduced daily dose for twice daily Prograf in stable liver transplant recipients without clinically meaningful changes in liver allograft function while reducing tacrolimus side effects, reducing cumulative daily dose of the drug and increasing adherence to treatment and quality of life.The results of this study have the potential to change current practice. Trial design is a pilot randomized trial. The study aims to recruit 40 patients from UHN's LT program and they will be randomized 1:1 to either stay on their current dose of Prograf or be converted to a once-daily equivalent dose of Envarsus. Both groups of patients will be followed for 48 weeks. This study will compare the change from baseline to week 48 in liver and renal function, tacrolimus-related side effects and patient reported outcomes between the two study groups.

Recruitment information / eligibility

• Status: Not yet recruiting
• Enrollment: 40
• Est. completion date: October 31, 2024
• Est. primary completion date: December 31, 2023
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years to 99 Years

Eligibility

Inclusion Criteria:

• Adult (>18 years) prevalent liver transplant recipient
• >12 months after liver transplant
• Prograf-based maintenance immunosuppression with targeted tacrolimus trough level of 5-10 ug/L
• Stable liver allograft function (defined as ASL & ALT <30, Bilirubin <20 & ALP<150 at baseline visit or within 4 weeks of baseline visit)
• Stable renal function (creatinine < 180 µmol/l and eGFR > 40 ml/min) at baseline visit (or within 4 weeks of baseline visit)
• No episode of acute rejection within 6 months of baseline visit
• Elevated creatinine (defined as >ULN) OR Significant symptoms (by patient self-report) potentially associated with tacrolimus (eg. tremor, difficulty to concentrate, insomnia) OR difficulty to adhere to a twice daily regimen

Exclusion Criteria:

• Multiorgan transplant;
• severe intercurrent illness;
• severe cognitive impairment (all as determined by clinical team);
• unwilling to consent.

Related Conditions & MeSH terms

• Immune System Suppression
• Liver Transplant Rejection

Intervention

Drug:
• Prograf
Participants randomized to the Prograf (control) arm will continue with their current twice daily dosing of Prograf.
• Envarsus
Participants randomized to Envarsus arm will have their current daily dose of Prograf converted to once-daily Envarsus dose according to the following ratio: 0.7 x the current daily Prograf dose. Envarsus is available in 3 dose strengths- 0.75mg, 1.0mg, and 4.0mg. The actual dose of Envarsus will be rounded to an amount that can be administered using the above tablet strengths.

Locations

Country	Name	City	State
n/a

Sponsors (2)

Lead Sponsor	Collaborator
University Health Network, Toronto	Paladin Labs Inc.

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Change in AST levels		Baseline to week 12
Primary	Change in ALT levels		Baseline to week 12
Primary	Change in ALP levels		Baseline to week 12
Primary	Change in Bilirubin blood levels		Baseline to week 12
Primary	Change in tacrolimus trough levels		Baseline to week 12
Primary	Change in overall daily dose of tacrolimus		Baseline to week 12
Secondary	Change in Systolic Blood Pressure		Baseline to week 24 and week 48
Secondary	Change in Diastolic Blood Pressure		Baseline to week 24 and week 48
Secondary	Change in Renal function (eGFR)		Baseline to week 24 and week 48
Secondary	Change in tremor severity (for subset of patients who report significant tremor at baseline)		Baseline to week 24 and week 48
Secondary	Change in glycemic control (HbA1c)		Baseline to week 24 and week 48
Secondary	Change in lipid profile		Baseline to week 24 and baseline to week 48
Secondary	Change in Patient-Reported Outcomes Measurement Information Systems' Pain Interference Bank 2.0		Baseline to Week 48 (inclusive)
Secondary	Change in Patient-Reported Outcomes Measurement Information Systems' (PROMIS) Sleep Disturbance Bank 1.0		Baseline to Week 48 (inclusive)
Secondary	Change in Patient-Reported Outcomes Measurement Information Systems' (PROMIS) Anxiety Bank 1.0		Baseline to Week 48 (inclusive)
Secondary	Change in Patient-Reported Outcomes Measurement Information Systems' (PROMIS) Depression Bank 1.0		Baseline to Week 48 (inclusive)
Secondary	Change in Patient-Reported Outcomes Measurement Information Systems' (PROMIS) Global Health Scale version 1.2		Baseline to Week 48 (inclusive)
Secondary	Change in Patient-Reported Outcomes Measurement Information Systems' (PROMIS) Fatigue bank 1.0		Baseline to Week 48 (inclusive)
Secondary	Change in Patient-Reported Outcomes Measurement Information Systems' (PROMIS) Ability to Participate in Social Roles and Activities		Baseline to Week 48 (inclusive)