Treatment of Congenital Vascular Malformations Using Sirolimus: Improving Quality of Life

Vascular Malformations Clinical Trial

— Sirolimus  

Official title:

Treatment of Congenital Vascular Malformations Using Sirolimus: Improving Quality of Life

Clinical Trial Details — Status: Active, not recruiting

Administrative data

• NCT number: NCT03987152
• Other study ID #: 57911
• Secondary ID: 2016-002157-38
• Status: Active, not recruiting
• Phase: Phase 3
• Start date: September 18, 2017
• Est. completion date: March 1, 2023

Study information

• Verified date: October 2020
• Source: Radboud University
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Congenital vascular anomalies are uncommon and belong to the group of rare diseases.These vascular malformations can cause serious complications including obstruction of vital organs and their function, recurrent infection and significantly reduced quality of life of persons affected.Treatment options range from conservative to surgical extirpation or intralesional embolisation/sclerosis. Unfortunately, this is often not enough. Many patients still have complaints like severe pain and invalidation due to the lymphatic or venous malformation making a normal functional life impossible. Recent case reports mention the positive effects of refractory patients with Sirolimus. Sirolimus, also known as rapamycin, is currently the only FDA-approved mammalian target of rapamycin (mTOR) inhibitor.

Description:

Congenital vascular anomalies are uncommon and belong to the group of rare diseases. In 1996, the International Society of the Study of Vascular Anomalies adopted a new classification, distinguishing vascular malformations from vascular tumors. This classification was revised in 2014 and newly identified genetic features were taken into account. Vascular malformations feature dysplastic malformed vessels and are a consequence of a defective development of the embryonic vascular system. Vascular malformations can involve lymphatic vessels, capillaries, veins and arteries or even combinations. These vascular malformations are present at birth and grow with the child. Treatment options range from conservative to surgical extirpation or intralesional embolisation/sclerosis. Unfortunately, this is often not enough. Many patients still have complaints like severe pain and invalidation due to the lymphatic or venous malformation making a normal functional life impossible. These vascular malformations can cause serious complications including obstruction of vital organs and their function, recurrent infection and significantly reduced quality of life of persons affected. As the natural course of the disease affects multiple body systems, the therapeutic management is challenging. To date, no other medical treatment options are available. Although standard pain medication is given according the (inter) national pain protocols, patients still suffer pain and are not able to function normally in daily life. Majority (60-70% percent of the patients) of the patients is not able to have a normal life, with a normal job and normal social activities. Children are often not able to go to school normally, cannot play outside and have pain at the site of the malformation. The vast majority of literature reporting medical therapies for vascular anomalies consists of case reports and small series and is complicated by publication bias (negative findings are often not published), inconsistent use of nomenclature, and the absence of clinical trials. Recent case reports mention the positive effects of refractory patients with Sirolimus. Sirolimus, also known as rapamycin, is currently the only FDA-approved mammalian target of rapamycin (mTOR) inhibitor, indicated for prevention of kidney allograft rejection in adults and children 13 years or older, but is commonly used to manage organ rejection in younger children.

Recruitment information / eligibility

• Status: Active, not recruiting
• Enrollment: 75
• Est. completion date: March 1, 2023
• Est. primary completion date: September 18, 2021
• Accepts healthy volunteers: No
• Gender: All
• Age group: 1 Year and older

Eligibility

Inclusion Criteria:

• Diagnosis of Congenital venous malformation, or lymphatic malformation or combined.

• Age older than 1 yr.

• Patients (or legal guardians for children) have to be able to sign the informed consent

• Patients are either refractory to standard care such as medical treatment (low molecular weight heparins, pain medication etc.), surgical resection and/or sclerotherapy/embolization (ineffective or accompanied by major complications) or there is no possibility for surgical intervention anymore. Only patients that have a normal clinical screening (no signs for infection, normal bone marrow function, normal liver and kidney function, normal glucose metabolism etc.) can be included.

• Patients included have no cardiac impairment

• Patients have no gastrointestinal impairment as Sirolimus is absorbed gastro-intestinal and normal function is needed

• No other underlying medical disorder like Down syndrome or other syndromes

• Women of reproductive age have to be informed that contraceptive methods are

• mandatory during the study time, pregnant women are excluded

• Karnofsky score > 50

Exclusion Criteria:

• No written informed consent

• Known hypersensitivity to drugs or metabolites from similar classes as study treatment.

• Patient has other concurrent severe and /or uncontrolled medical condition that would, in the investigator's judgment, contraindicated participation in the clinical study (e.g. acute or chronic pancreatitis, liver cirrhosis, active chronic hepatitis, severely impaired lung function with a spirometry = 50% of the normal predicted value and/or O2 saturation = 88% at rest, etc.)

• Recent history of primary malignancy = 5 years

• Impaired cardiac function or clinically significant cardiac diseases

• Immunocompromised patients, including known seropositivity for HIV

• Patient with any other concurrent severe and /or uncontrolled medical condition that would,in the investigator's judgment, contraindicated participation in the clinical study.

• Pregnant or lactating women

• Karnofsky score < 50

Related Conditions & MeSH terms

• Congenital Abnormalities
• Vascular Malformations

Intervention

Drug:
• Sirolimus
Daily intake of Sirolimus during Challenge and Rechallenge phase

Locations

Country	Name	City	State
Netherlands	Radboudumc, HECOVAN workgroup	Nijmegen	Gelderland

Sponsors (1)

Lead Sponsor	Collaborator
Radboud University

Country where clinical trial is conducted

Netherlands, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Quality of life using Sirolimus measured with survey (TAPQOL)	Quality of life: Questionnaire for Preschool Children's Health-Related Quality of Life (TAPQOL). Preschool Children Quality of Life, parent-reported questionnaire clustered into 12 multi-item scales, with higher scores range 0-100) indicating better HRQOL)	Change from baseline Quality of life at 6 months QoL in challenge phase, and 12 months QoL in Rechallenge phase.
Primary	Quality of life using Sirolimus measured with survey (PedsQl)	Quality of life: Pediatric Quality of Life Inventory (PedsQl) (children) 23 items questionnaire, 0-100 scale, so that higher scores indicate better HRQOL (Health-Related Quality of Life). Psychosocial Health Summary Score, Physical Health Summary Score and Total score will be measured.	Change from baseline Quality of life at 6 months QoL in challenge phase, and 12 months QoL in Rechallenge phase.
Primary	Quality of life using Sirolimus measured with survey (Research and development Rand-36).	Quality of life: Rand-36 (adults) eight health domains; physical functioning, social functioning, role limitations due to physical health problems, role limitations due to emotional problems, mental health, vitality, pain and general health perception. Outcomes at each domain will be defined on a scale from a minimum score of 0 to a maximum score of 100. A higher score is equivalent to a better health.	hange from baseline Quality of life at 6 months QoL in challenge phase, and 12 months QoL in Rechallenge phase
Primary	Difference in pain scores after using Sirolimus measured with VAS score	Daily pain score (daily visual analogue scale (VAS-score 0-10) for children, and numeric rating scale (NRS-score 0-10) for adults)	Daily pain scores will be compared after 6 months in Challenge phase, after Challenge phase: starts the phase, and pain during 12 months in the Rechallenge phase
Primary	Difference in pain scores after using Sirolimus measured with NRS score	Daily pain score (daily numeric rating scale (NRS-score 0 no pain -10 extreme pain) for adults)	Daily pain scores will be compared after 6 months in Challenge phase, after Challenge phase: starts the phase without Sirolimus treatment, and pain during 12 months in the Rechallenge phase
Secondary	Return of pain after treatment and duration of lowered pain or pain free period in days	Amount of patients who have lowered pain or are pain free. Duration of lowered pain or pain free period in days.	After 6 months Sirolimus intake till one year follow up.
Secondary	Growth/progression of vascular malformation	MRI of the vascular malformation will be made at the beginning of the study and after six months of treatment with Sirolimus. An experienced radiologist will evaluate the evolution of the volume of the malformation.	MRI baseline compared with MRI after 6 months in challenge phase and 12 months in rechallenge phase
Secondary	Rate and occurence of adverse events related to Sirolimus	Adverse events: short and long term consequences of treatment with Sirolimus according to CTCAE version 5.0.	4 years
Secondary	Severity of adverse events related to Sirolimus	Adverse events: short and long term consequences of treatment with Sirolimus according to CTCAE version 5.0.	4 years
Secondary	Genetic mutations in the vascular malformation that can predict outcome of treatment with Sirolimus using Single Molecule Molecular Inversion Probes (smMIPs)	Secondary material that was obtained after surgery, stored in the HECOVAN biobank can be used for analyses. Comprehensive targeted Next Generation Sequencing screen using Unique Molecular Identifiers with a technical sensitivity of 1% mutant alleles was performed for frequently mutated positions using Single Molecule Molecular Inversion Probes. We will investigate if there is a correlation with a possible found mutation and painreduction or improvement of quality of life.	4 years
Secondary	Pharmacogenetic profile in the vascular malformation that can predict outcome of treatment with Sirolimus	Genotyping will be performed using Taqman assays or Kompetitive Allele Specific PCR (KASPTM) assays in saliva swabs. Pharmacogenetic profiles (slow, intermediate, and extensive metabolizer) will be determined. Subjects compared on the outcome of sirolimus effectiveness for pain, and QoL stratified by CYP3A4.	4 years
Secondary	Cost-effectiveness of administration of Sirolimus: Quality Adjusted Life Year (QALY) estimate for each patient	Via standardized questionnaires developed by the iMTA (institute for Medical Technology Assessment). The second part of the cost analysis consists of determining the cost prices for each volume of consumption.	4 years