Evaluating the Effectiveness of Prednisone, Azathioprine, and N-acetylcysteine in Patients With IPF

Pulmonary Fibrosis Clinical Trial

— PANTHER-IPF  

Official title:

Prednisone, Azathioprine, and N-acetylcysteine: A Study That Evaluates Response in IPF

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT00650091
• Other study ID #: Pro00020066
• Secondary ID: U10HL080413-03
• Status: Completed
• Phase: Phase 3
• First received: March 28, 2008
• Last updated: May 27, 2015
• Start date: October 2009
• Est. completion date: January 2014

Study information

• Verified date: February 2015
• Source: Duke University
• Contact: n/a
• Is FDA regulated: No
• Health authority: United States: Food and Drug Administration
• Study type: Interventional

Clinical Trial Summary

Idiopathic pulmonary fibrosis (IPF) is a long-term lung disease that affects an individual's ability to breathe. In this randomized, double-blind, placebo-controlled trial, we assigned patients with idiopathic pulmonary fibrosis who had mild-to-moderate lung-function impairment to one of three groups — receiving a combination of prednisone, azathioprine, and NAC (combination therapy), NAC alone, or placebo — in a 1:1:1 ratio.

Description:

IPF is a disease with widespread and permanent scarring of lung tissue which eventually results in death. Individuals with IPF may experience breathing difficulties, cough, chest pain, and a decreased exercise capacity. Although the cause of IPF is unknown, it may be a result of an inflammatory response to an unknown substance. NAC, an antioxidant that is effective at loosening up mucus that forms in the lungs, may improve lung function. The purpose of this study is to evaluate the effectiveness of NAC at preventing the loss of lung function in people with IPF.

In the initial double-blind, placebo-controlled trial, subjects who have idiopathic pulmonary fibrosis with mild-to-moderate impairment in pulmonary function are randomly assigned to receive a three-drug regimen of prednisone, azathioprine, and acetylcysteine; acetylcysteine alone; or placebo.

After safety concerns were identified by the data and safety monitoring board, the three-drug regimen was stopped by the National Heart, Lung, and Blood Institute (NHLBI) on October 14, 2011, and a clinical alert was issued. After a brief period of interruption for modification of the protocol and approval by the institutional review boards, patients continued to be recruited for the acetylcysteine group and the placebo group and were followed for the pre-specified duration of 60 weeks.

Study visits will occur at baseline and Weeks 4, 15, 30, 45, and 60. At all study visits, a physical exam and blood collection will occur. At selected visits, the following study procedures will occur: lung function testing; urine collection; a 6-minute walk test, and questionnaires to assess health status, breathing, and quality of life. Participants will record medication usage and symptoms in a daily diary.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 264
• Est. completion date: January 2014
• Est. primary completion date: October 2013
• Accepts healthy volunteers: No
• Gender: Both
• Age group: 35 Years to 85 Years

Eligibility

Inclusion Criteria:

• Forced vital capacity (FVC) greater than or equal to 50% of predicted value

• Diffusion capacity (DLCO) greater than or equal to 30% of predicted value

• Diagnosis of IPF by modified American Thoracic Society (ATS) criteria in the 48 months before study entry

Exclusion Criteria:

• History of clinically significant environmental exposure known to cause pulmonary fibrosis

• Diagnosis of connective tissue disease as the likely cause of the interstitial disease

• Extent of emphysema greater than the extent of fibrotic change (i.e., honeycombing, reticular changes) on high resolution computed tomography (HRCT) scan

• Forced expiratory volume in 1 second (FEV1)/FVC ratio less than 0.65 at the time of screening (post-bronchodilator)

• Partial pressure of arterial oxygen (PaO2) less than 55 mm Hg (less than 50 mm Hg at Denver study site)

• Residual volume greater than 120% predicted at the time of screening (post-bronchodilator)

• Evidence of active infection

• Significant bronchodilator response on screening spirometry, defined as change in FEV1 greater than or equal to 12% and absolute change greater than 200 mL OR change in FVC greater than or equal to 12% and absolute change greater than 200 mL

• Screening and baseline FVC measurements (in liters, post-bronchodilator) differing by 11%

• Listed for lung transplantation

• History of unstable or deteriorating cardiac disease

• Heart attack, coronary artery bypass, or angioplasty in the 6 months before study entry

• Unstable angina pectoris or congestive heart failure requiring hospitalization in the 6 months before study entry

• Uncontrolled arrhythmia

• Severe uncontrolled high blood pressure

• Known HIV or hepatitis C

• Known cirrhosis and chronic active hepatitis

• Active substance and/or alcohol abuse

• Pregnant or breastfeeding

• Women of childbearing potential who are not using a medically approved means of contraception

• Any clinically relevant lab abnormalities, including the following:

1. Creatinine greater than twice the upper limit of normal (ULN)

2. Hematology outside of specified limits

1. White blood cells less than 3,500/mm3

2. Hematocrit less than 25% or greater than 59%

3. Platelets less than 100,000 mm3 at the time of screening

3. Any of the following liver function test criteria above specified limits

1. Total bilirubin greater than twice the ULN

2. Aspartate (AST) or alanine aminotransferases (ALT) greater than 1.5 the ULN

3. Alkaline phosphatase greater than three times the ULN

4. Albumin less than 3.0 mg/dL at the time of screening

• Known hypersensitivity to study medication

• Any condition other than IPF that, in the opinion of the site PI, is likely to result in death in the 1 year after study entry

• Any condition that, in the judgment of the PI, might cause participation in this study to be detrimental or makes the person a poor candidate for the study

Study Design

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

Related Conditions & MeSH terms

• Pulmonary Fibrosis

Intervention

Drug:
• N-acetylcysteine (NAC)
Participants will receive 600 mg of NAC three times a day.
• Placebo
Participants will receive placebo each day.

Locations

Country	Name	City	State
United States	University of Michigan	Ann Arbor	Michigan
United States	University of Alabama - Birmingham	Birmingham	Alabama
United States	Beth Israel Deaconess Medical Center	Boston	Massachusetts
United States	Brigham and Women's Hospital	Boston	Massachusetts
United States	Medical University of South Carolina	Charleston	South Carolina
United States	St. Luke's Hospital	Chesterfield	Missouri
United States	University of Chicago	Chicago	Illinois
United States	Cleveland Clinic	Cleveland	Ohio
United States	University of Texas Southwestern Medical Center	Dallas	Texas
United States	National Jewish Medical and Research Center	Denver	Colorado
United States	Duke Universtiy	Durham	North Carolina
United States	University of California - Los Angeles	Los Angeles	California
United States	University of Louisville	Louisville	Kentucky
United States	University of Miami Miller School of Medicine	Miami	Florida
United States	Vanderbilt University	Nashville	Tennessee
United States	Yale University School of Medicine	New Haven	Connecticut
United States	Tulane University	New Orleans	Louisiana
United States	Mount Sinai Hospital	New York	New York
United States	Weill Medical College of Cornell University	New York	New York
United States	Temple University	Philadelphia	Pennsylvania
United States	University of Pennsylvania Health System	Philadelphia	Pennsylvania
United States	Highland Hospital - University of Rochester Medical Center	Rochester	New York
United States	Mayo Clinic	Rochester	Minnesota
United States	University of Utah Health Research Center	Salt Lake City	Utah
United States	University of California - San Francisco	San Francisco	California
United States	University of Washington	Seattle	Washington

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
Primary	Overall Change in Forced Vital Capacity	Change from Baseline in Forced Vital Capacity at 60 weeks (units in liters)	Measured as the estimated change from baseline to Week 60	No
Secondary	Disease Progression	The time-to-death or a 10% decline in FVC will be defined as the time-to-disease progression.; The 10% decline in FVC from enrollment must be confirmed on 2 consecutive visits no less than 6 weeks apart. For subjects with 2 consecutive visits with a 10% decline in FVC, the time-to-disease progression will be defined as the time interval between enrollment and the initial visit with a 10% FVC decline.	Measured at Week 60	No
Secondary	Acute Exacerbations	The following 3 criteria will define acute exacerbations in subjects with acute worsening of their respiratory conditions: 1. Clinical (all of the following required): A) Unexplained worsening of dyspnea or cough within 30 days, triggering unscheduled medical care (e.g., emergency room, clinic, study visit, hospitalization). B) No clinical suspicion or overt evidence of cardiac event, pulmonary embolism, or deep venous thrombosis to explain acute worsening of dyspnea. C) No pneumothorax.	Measured at Week 60	No
Secondary	Respiratory Infections		Measured at Week 60	No
Secondary	Number of Participants With Maintained Forced Vital Capacity Response	Maintained forced vital capacity response was a binary variable taking on a value of 1 for participants with higher FVC % predicted at week 60 compared to baseline.	Measured at Week 60	No

External Links

•   Clinical Alert: Commonly used three-drug regimen for idiopathic pulmonary fibrosis found harmful