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Cardiac Sarcoidosis Randomized Trial (CHASM-CS-RCT)

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ClinicalTrials.gov Identifier: NCT03593759
Recruitment Status : Recruiting
First Posted : July 20, 2018
Last Update Posted : September 17, 2019
Sponsor:
Collaborator:
Canadian Institutes of Health Research (CIHR)
Information provided by (Responsible Party):
Ottawa Heart Institute Research Corporation

Brief Summary:

Prospective randomized controlled trial comparing low dose Prednisone/Methotrexate combination to standard dose Prednisone in patients diagnosed with acute active clinically manifest cardiac sarcoidosis and not yet treated.

The Investigators hypothesize that low dose Prednisone/Methotrexate combination will be as effective as standard dose Prednisone, and result in significantly better quality of life and less toxicity than standard dose Prednisone.


Condition or disease Intervention/treatment Phase
Cardiac Sarcoidosis Sarcoidosis Drug: Prednisone Drug: Methotrexate Phase 3

Detailed Description:

Subjects meeting the study inclusion/exclusion criteria will be randomized equally to receive either:

  1. Prednisone 0.5 mg kg/day for 6-months (MAX dose 30 mg per day) or
  2. Methotrexate 15-20 mg po, sc, or IM once a week for 6-months + Folic Acid 2 mg OD for 6 months + Prednisone 20 mg day for 1 month, then 10 mg OD for 1 month, then 5 mg OD for one month then STOP

Methotrexate will be initiated at a dose of 15 mg once a week and increased to 20 mg once a week after 4 weeks if tolerated. In case of Methotrexate-induced side-effects general guidelines will be provided, however specific management will be left to the treating physicians. Folic acid will be taken to help reduce methotrexate side-effects.

Prior to randomization and study treatment all subjects will have the following baseline tests done: baseline safety blood work; FDG-PET scan with myocardial perfusion imaging; ECG; echo; and a bone scan. Cardiac MRI (CMR) is optional but strongly encouraged. Blood will be obtained for biomarker core-lab analysis. Biomarkers to be assayed will include highly sensitive Troponin I. Samples will be stored for future novel biomarker discovery. Quality of LIfe (QOL) questionnaires (KSQ, SAT and SF-36) will be completed prior to treatment start.

After therapy initiation subjects will be seen at 4 weeks, 8 weeks (methotrexate arm only), and 12 weeks, with a final visit at 6 months. Safety bloodwork and assessment for medication side effects, using a medication side-effect questionnaire, will be completed at all visits. At 12 weeks QOL questionnaires will be completed. The primary endpoint will be assessed at 6-months, when FDG-PET with myocardial perfusion imaging, ECG, echo, bone scan, QOL questionnaires, blood for biomarkers and device interrogation will be done. CMR may be repeated. Skin, muscle strength testing and neuropsychiatric assessment will be completed at 6 months as part of the composite glucocorticoid toxicity index.

After the 6 month visit. further management will be at the treating physician's discretion. Details of the physicians planned treatment following the 6-month PET scan will be collected.

Standardized protocols for all aspects of FDG-PET scans (i.e. patient preparation, image acquisition, image processing, transfer to the core lab and analysis at core lab) will be followed.


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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 194 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Intervention Model Description: Prospective, open-label, non-inferiority, randomized controlled with blinded end-point analysis.
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Cardiac Sarcoidosis Multi-Center Randomized Controlled Trial
Actual Study Start Date : January 15, 2019
Estimated Primary Completion Date : December 2022
Estimated Study Completion Date : December 2023

Resource links provided by the National Library of Medicine

MedlinePlus related topics: Sarcoidosis Steroids

Arm Intervention/treatment
Active Comparator: Prednisone
Prednisone 0.5 mg kg/day for 6 months (max dose 30 mg)
Drug: Prednisone
Oral prednisone tablet

Experimental: Methotrexate
Methotrexate 15-20 mg orally, sc, or IM once a week for 6 months + prednisone 20 mg po daily for one month then 10 mg po daily for one month then 5 mg po daily for one month and then stop. Also Folic Acid 2 mg po daily for 6 months.
Drug: Prednisone
Oral prednisone tablet

Drug: Methotrexate
Oral, subcutaneous, or intramuscular methotrexate




Primary Outcome Measures :
  1. Summed perfusion rest score (SPRS) on FDG-PET scan [ Time Frame: 6 months ]
    Measure of myocardial scarring and fibrosis (blinded core lab analysis)


Secondary Outcome Measures :
  1. Mortality [ Time Frame: 6 months ]
    All cause deaths

  2. Cardiovascular hospitalizations [ Time Frame: 6 months ]
    Cardiovascular related only

  3. Medication related adverse events [ Time Frame: 6 months ]
    Using clinical assessment, medication side-effect and adverse event reporting

  4. Modified Cleveland Clinic Glucocorticoid Toxicity Score [ Time Frame: 6 months ]
    Summed score of new/worsening diabetes;new/worsening HTN; osteoporosis; change in height and weight (combined and reported as BMI in kg/m2)

  5. Glucocorticoid Toxicity Index [ Time Frame: 6 months ]
    Composite scoring (improvement; no significant change; worsening) compared to baseline

  6. Patient reported symptoms related to medication [ Time Frame: 6 months ]
    Using medication side-effect questionnaire ( symptom present, yes or no; frequency; intensity)

  7. Medication compliance [ Time Frame: 6 months ]
    % of days where treatment was taken as prescribed

  8. Generic Quality of Life (SF 36) [ Time Frame: 6 months ]
    Measuring general QOL using SF-36 questionnaire

  9. Disease Specific Quality of Life (KSQ and SAT) [ Time Frame: 6 months ]
    Using Kings Sarcoidosis questionnaire and Sarcoidosis Assessment Tool

  10. BMI [ Time Frame: 6 months ]
    Weight and height combined to report BMI in kg/m2, absolute and delta compared to baseline

  11. Blood pressure [ Time Frame: 6 months ]
    Systolic and diastolic, absolute and delta compared to baseline

  12. HbA1C [ Time Frame: 6 months ]
    Absolute and delta compared to baseline

  13. T-score on bone density scan [ Time Frame: 6 months ]
    Absolute and delta compared to baseline

  14. FDG-PET and myocardial perfusion [ Time Frame: 6 month scan ]
    SPRS in mismatched segments; SUVmax, SUVmean and COI; LVEF, RVEF; whole body disease activity

  15. Ventricular arrhythmia burden [ Time Frame: 6 months ]
    Episodes of sustained ventricular arrhythmia or episodes requiring appropriate ICD therapy (shock or anti-tachycardia pacing)

  16. Complete heart block [ Time Frame: 6 months ]
    Percentage of patients who are in CHB

  17. LVEF and RVEF assessed on echocardiogram [ Time Frame: 6 months ]
    Ejection fraction, absolute and delta compared to baseline

  18. Highly sensitive Troponin I levels and BNP levels [ Time Frame: 6 months ]
    Absolute and delta compared to baseline

  19. CMR Endpoints [ Time Frame: 6 months ]
    Volume of delayed enhancement



Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

(i) Cardiac sarcoidosis presenting with one or more of the following clinical findings:

  • advanced conduction system disease (defined as Mobitz II AV block or third degree AV block)
  • significant sinus node dysfunction (defined as average HR less than 40bpm when awake and/or sustained atrial arrhythmias)
  • non- sustained or sustained ventricular arrhythmia
  • left ventricular dysfunction (LVEF < 50%)
  • right ventricular dysfunction (RVEF < 40%)

AND

(ii) No alternative explanation for clinical features

AND

(iii) FDG-PET uptake suggestive of active CS within two months of enrollment (confirmed by PET core lab read)

AND ONE OR BOTH OF FOLLOWING

(iv) Positive biopsy for Sarcoid (either EMB or extra-cardiac)

(v) CT Chest showing features consistent with pulmonary sarcoidosis and/or mediastinal and/or hilar lymphadenopathy

Exclusion Criteria:

  1. Current or recent (within two months) non-topical treatment for sarcoidosis
  2. Currently taking Methotrexate or Prednisone for another health condition
  3. Intolerance or contra-indication to Methotrexate or Prednisone
  4. Patient does not meet all of the above listed inclusion criteria
  5. Patient is unable or unwilling to provide informed consent
  6. Patient is included in another randomized clinical trial
  7. Patient has a contraindication to PET imaging or is unlikely to tolerate due to severe claustrophobia
  8. Pregnancy (all women of child bearing age and potential will have a negative BHCG test before enrollment)
  9. Breastfeeding
  10. Women of childbearing age who refuse to use a highly effective and medically acceptable form of contraception throughout the study
  11. Patients for whom the investigator believes that the trial is not in the interest of the patient

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT03593759


Contacts
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Contact: David H Birnie, MD 613-696-7269 dbirnie@ottawaheart.ca
Contact: Karen MacDonald, RN 613-696-7000 ext 17077 kmacdonald@ottawaheart.ca

Locations
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United States, Michigan
University of Michigan-Michigan Medicine Cardiovascular Center Not yet recruiting
Ann Arbor, Michigan, United States, 48109-5853
Principal Investigator: Todd Koelling, MD         
United States, Virginia
Virginia Commonwealth University Recruiting
Richmond, Virginia, United States, 23298-0053
Contact: Jordana Kron, MD    804-828-7565    jordana.kron@vcuhealth.org   
Principal Investigator: Jordana Kron, MD         
Canada, Alberta
Libin Cardiovascular Institute of Alberta Not yet recruiting
Calgary, Alberta, Canada, T2N 2T9
Contact: Russell Quinn, MD    403-220-5500    frquinn@ucalgary.ca   
Principal Investigator: Russell Quinn, MD         
Canada, British Columbia
St. Paul's Hospital Not yet recruiting
Vancouver, British Columbia, Canada, V5Z 1M9
Contact: Mustafa Toma, MD    604 806 9986    MToma@providencehealth.bc.ca   
Principal Investigator: Mustafa Toma, MD         
Canada, Ontario
Hamilton Health Sciences Centre Not yet recruiting
Hamilton, Ontario, Canada, L8L 2X2
Contact: Jeff Healey, MD    905-527-4322 ext 40319    jeffrey.healey@phri.ca   
Principal Investigator: Jeff Healey, MD         
University of Ottawa Heart Institute Recruiting
Ottawa, Ontario, Canada, K1Y 4W7
Contact: David H Birnie, MD    613-696-7269    dbirnie@ottawaheart.ca   
Principal Investigator: David Birnie, MD         
University Health Network Not yet recruiting
Toronto, Ontario, Canada, M5G 2C4
Contact: Andrew Ha, MD    416-340-5206    andrew.ha@uhn.ca   
Principal Investigator: Andrew Ha, MD         
Canada, Quebec
Montreal Heart Institute Not yet recruiting
Montreal, Quebec, Canada, H1T 1C8
Contact: Lena Rivard, MD    514-376-3330    lena.rivard@gmail.com   
Principal Investigator: Lena Rivard, MD         
Sponsors and Collaborators
Ottawa Heart Institute Research Corporation
Canadian Institutes of Health Research (CIHR)
Investigators
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Principal Investigator: David H Birnie, MD Ottawa Heart Institute Research Corporation

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Responsible Party: Ottawa Heart Institute Research Corporation
ClinicalTrials.gov Identifier: NCT03593759     History of Changes
Other Study ID Numbers: UOttawaHI
First Posted: July 20, 2018    Key Record Dates
Last Update Posted: September 17, 2019
Last Verified: September 2019
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: No

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Studies a U.S. FDA-regulated Drug Product: Yes
Studies a U.S. FDA-regulated Device Product: No
Product Manufactured in and Exported from the U.S.: No
Keywords provided by Ottawa Heart Institute Research Corporation:
Cardiac Sarcoidosis
Prednisone
Methotrexate
Additional relevant MeSH terms:
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Sarcoidosis
Lymphoproliferative Disorders
Lymphatic Diseases
Prednisone
Methotrexate
Abortifacient Agents, Nonsteroidal
Abortifacient Agents
Reproductive Control Agents
Physiological Effects of Drugs
Antimetabolites, Antineoplastic
Antimetabolites
Molecular Mechanisms of Pharmacological Action
Antineoplastic Agents
Dermatologic Agents
Enzyme Inhibitors
Folic Acid Antagonists
Immunosuppressive Agents
Immunologic Factors
Antirheumatic Agents
Nucleic Acid Synthesis Inhibitors
Anti-Inflammatory Agents
Glucocorticoids
Hormones
Hormones, Hormone Substitutes, and Hormone Antagonists
Antineoplastic Agents, Hormonal