Pulmonary Arterial Hypertension
Conditions
Keywords
Pulmonary arterial hypertension (PAH), Pulmonary hypertension (PH), Clinical Worsening, Freedom, Freedom-EV, Treprostinil, UT-15C, 6 Minute walk test
Brief summary
This is an international, multicenter, randomized, double-blind, placebo-controlled, event driven study in subjects with pulmonary arterial hypertension.
Detailed description
Study TDE-PH-310 is an international, multicenter, randomized (1:1 oral treprostinil (UT-15C): placebo), double-blind, placebo-controlled study in subjects with pulmonary arterial hypertension (PAH) who are receiving background oral monotherapy for PAH for at least 30 days at randomization. Subjects are randomly allocated to receive oral treprostinil extended-release tablets or placebo by a stratified randomization by type of background therapy (Strata 1: phosphodiesterase type 5 inhibitor \[PDE5-I\] or soluble guanylate cyclase \[sGC\] stimulator; Strata 2: endothelin receptor antagonist \[ERA\]. Subjects are also stratified by baseline 6-minute walk distance (6MWD) less than or equal to 350 m or greater than 350 m. Subjects receive their first dose of study drug (0.125 mg) or matching placebo on the day of randomization. Oral dosing of study drug is continued at 0.125 mg 3 times daily (TID; every 6 to 8 hours) with food. The dose (or matching placebo) is titrated throughout the study up to a maximum dose of 12 mg TID to reach and maintain a tolerated dosing regimen that provided optimal clinical benefit. Once randomized, subjects return for study visits every 4 weeks for the first 12 weeks, then every 12 weeks for the duration of the study. Subjects continue in the study until experiencing clinical worsening, the number of adjudicated events necessary for study closure occurr, or prematurely discontinue participation in the study for any reason other than protocol-specified clinical worsening. At each scheduled visit, subjects undergo efficacy assessments for clinical worsening, exercise capacity (6MWD and Borg dyspnea score), WHO functional class (FC), and plasma N-Terminal pro-brain natriuretic peptide (NT-proBNP). Subjects could participate in an optional hemodynamic sub-study (assessed by RHC). Safety assessments consist of adverse events (AEs), physical examinations, vital signs, 12-lead electrocardiograms (ECGs), and clinical laboratory parameters. Patients who complete all required assessments are eligible to enter a long-term, open-label, extension study (TDE-PH-311).
Interventions
Active
DRUGPlacebo
Placebo
Sponsors
United Therapeutics
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
QUADRUPLE (Subject, Caregiver, Investigator, Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to 75 Years
Healthy volunteers
No
Inclusion criteria
Subject Inclusion Criteria: 1. Voluntarily gave informed consent to participate in the study. 2. Are 18 to 75 years of age (inclusive) at Screening. 3. Women of childbearing potential must practice abstinence from intercourse when in line with their preferred and usual lifestyle, or use 2 different forms of highly effective contraception for the duration of the study, and for at least 30 days after discontinuing study medication. A negative urine pregnancy test is required at Screening and Baseline prior to initiating study medication. 4. Male subjects must consent to use a condom during intercourse for the duration of the study, and for at least 48 hours after discontinuing study medication. 5. Have a diagnosis of symptomatic idiopathic or heritable PAH, PAH associated with connective tissue disease (CTD), PAH associated with HIV infection, PAH associated with repaired congenital systemic-to-pulmonary shunt, or PAH associated with appetite suppressant or toxin use. 6. If known to be positive for HIV infection, have a CD4 lymphocyte count of at least 200 cells/mm\^3 assessed at Screening and are receiving current standard of care anti retroviral or other effective medication for the treatment of HIV infection. 7. Have a baseline 6MWD greater than or equal to 150 m in the absence of a concurrent injury, illness, or other confounding factor including, but not limited to, use of an aid for ambulation or connection to a nonportable machine, that would have prevented the accurate assessment of the subject's exercise capacity. 8. Are optimally treated with conventional pulmonary hypertension therapy with no additions, discontinuations, or dose changes for a minimum of 10 days prior to randomization. The exceptions are the discontinuation or dose changes of anticoagulants and/or dose change of diuretics. 9. Are receiving a PAH-approved oral monotherapy at a minimum dose that complies with the approved prescribing information for the product for at least 30 days prior to randomization and are receiving a stable dose for at least 10 days prior to randomization. 10. Have had previously undergone a cardiac catheterization within 3 years prior to the start of Screening or during the Screening Period, and the most recent assessment documented a pulmonary artery pressure mean of at least 25 mmHg, a pulmonary capillary wedge pressure (PCWP) (or in the event a PCWP could not be reliably obtained, a left ventricular end diastolic pressure \[LVEDP\]) less than or equal to 15 mmHg, and absence of unrepaired congenital heart disease (other than patent foramen ovale). If a reliable PCWP or LVEDP are unable to be obtained during cardiac catheterization, subjects with clinically normal left heart function and absence of clinically relevant mitral valve disease on echocardiography are eligible for enrollment. 11. Undergo echocardiography with evidence of clinically normal systolic and diastolic left ventricular function and absence of any clinically significant left sided heart disease (eg, mitral valve disease). Subjects with clinically insignificant left ventricular diastolic dysfunction due to the effects of right ventricular overload (ie, right ventricular hypertrophy and/or dilatation) are eligible. 12. Have a previous ventilation perfusion lung scan, high-resolution computerized tomography scan of the chest, and/or pulmonary angiography that are consistent with the diagnosis of PAH. 13. Have pulmonary function tests conducted within 6 months before Screening or during the Screening Period to confirm the following: 1. Total lung capacity is at least 60% 2. Forced expiratory volume at 1 second is at least 50% 14. In the opinion of the Principal Investigator, is able to communicate effectively with study personnel and is considered reliable, willing, and likely to cooperate with protocol requirements, including attending all study visits. Subject
Exclusion criteria
1. Is pregnant or lactating. 2. Have previously received oral treprostinil. 3. Have received a PGI2 (except if used during acute vasoreactivity testing) within 30 days prior to randomization or have previous intolerance or significant lack of efficacy to any PGI2 or PGI2 analogue that resulted in discontinuation or inability to titrate that therapy effectively. 4. Have any background conventional therapies for PAH added, removed, or dose-adjusted within 10 days prior to randomization. The exceptions are removal or dose adjustments of anticoagulants and/or dose adjustments of diuretics. 5. Receive their first dose of a PAH-approved oral monotherapy less than 30 days prior to randomization, or have their PAH-approved oral monotherapy dose changed within 10 days prior to randomization, or the subject discontinues any PAH approved therapy within 30 days prior to Screening, or the subject has previously received 2 PAH approved oral therapies at the same time (specifically, a PDE5-I, an ERA, or a sGC stimulator) concomitantly for more than 90 days cumulatively. 6. Have any disease associated with PAH other than CTD, HIV infection, repaired (for at least 1 year) congenital systemic-to-pulmonary shunt, PAH associated with appetite suppressant/toxin use, or have an atrial septostomy. 7. Have a current diagnosis of uncontrolled sleep apnea as defined by their physician. 8. Have a history of ischemic heart disease, including a previous myocardial infarction or symptomatic coronary artery disease within 6 months prior to Screening or a history of left-sided myocardial disease as evidenced by a mean PCWP (or a LVEDP) greater than 15 mmHg or left ventricular ejection fraction less than 40% as assessed by either multigated angiogram, angiography, or echocardiography. 9. Have uncontrolled systemic hypertension as evidenced by systolic blood pressure (BP) greater than 160 mmHg or diastolic BP greater than 100 mmHg. 10. Have alanine aminotransferase or aspartate aminotransferase levels at least 3 times greater than the upper limit of normal, clinically significant liver disease/dysfunction, or known Child-Pugh Class C hepatic disease at Screening. 11. Have any other disease or condition that would interfere with the interpretation of study assessments. 12. Have a musculoskeletal disorder, is using a device to assist walking, or any disease that is likely to limit ambulation, or is connected to a machine that is nonportable. 13. Have an unstable psychiatric condition or is mentally incapable of understanding the objectives, nature, or consequences of the study, or has any condition which in the Investigator's opinion would constitute an unacceptable risk to the subject's safety. 14. Is receiving an investigational drug, have an investigational device in place, or have participated in an investigational drug or device study within 30 days prior to Screening. 15. Have chronic renal insufficiency as defined by either a Screening creatinine value greater than 2.5 mg/dL or the requirement for dialysis. 16. Does not have 3 or more of the following left ventricular disease/dysfunction risk factors: 1. Body mass index at least 30 kg/m\^2 2. History of essential hypertension 3. Diabetes mellitus (any type) 4. Historical evidence of significant coronary artery disease established by any 1 of the following: history of myocardial infarction, percutaneous coronary intervention, or angiographic evidence of coronary artery disease; positive stress test with imaging; previous coronary artery bypass graft; or stable angina.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Time to First Clinical Worsening Event | From randomization to approximately 4 years | Clinical worsening was assessed continuously from randomization until the subject's last study visit. Clinical worsening events were defined as death (all causes), hospitalizations due to worsening pulmonary arterial hypertension (PAH), initiation of an inhaled or infused prostacyclin (PGI2) for the treatment of worsening PAH, disease progression, or unsatisfactory long-term clinical response. All clinical worsening events reported by the study sites were reviewed by the Sponsor Medical Monitors. Once a clinical worsening event occurred, it was entered in the eCRF and a narrative was submitted for review by the Sponsor's Medical Monitor within 48 hours after the event became known to the Investigator or designee. Subsequently, the narratives for subjects with the reported clinical worsening events were sent to an independent adjudication committee. The independent adjudication committee reviewed and adjudicated all clinical worsening events throughout the study. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Change in 6-Minute Walk Distance | From Baseline to Week 24 | The intent of the 6-Minute Walk Test (6MWT) is to evaluate exercise capacity associated with carrying out activities of daily living. A baseline 6MWT was performed prior to initiation of study drug on the day of randomization. 6MWTs were conducted at Weeks 4, 8, 12, 24, and every 12 weeks thereafter. The change between Baseline and Week 24 is reported. |
| Change in Plasma N-Terminal Pro-brain Natriuretic Peptide (NT-proBNP) From Baseline to Week 24 | From Baseline to Week 24 | Plasma NT-proBNP concentration is a useful biomarker for the severity of PAH as it is associated with changes in right heart morphology and function. NT-proBNP sample collection occurred at Baseline (prior to starting study drug), Week 12, Week 24, the first Continued Visit, and every other Continued Visit thereafter (ie, Continued Visits 3, 5, 7, etc). NT-proBNP was also assessed at the Study Drug Termination Visit. The change between Baseline and Week 24 is reported. |
| Change in World Health Organization Functional Class (WHO FC) From Baseline to Week 48 | Baseline to Week 48 | The WHO FC for PAH was assessed at Baseline prior to starting study drug, at all subsequent scheduled study visits, and every time the 6MWT was performed for purposes of assessing clinical worsening status. |
Countries
Argentina, Australia, Austria, Brazil, Canada, Chile, China, Denmark, France, Germany, Greece, India, Israel, Italy, Mexico, Netherlands, Poland, Singapore, South Korea, Sweden, Taiwan, United Kingdom, United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| UT-15C Treprostinil diolamine extended-release tablets (oral) 0.125 to 12 mg TID
Treprostinil Diolamine: Active | 346 |
| Placebo Matching placebo tablets (oral)
Placebo: Placebo | 344 |
| Total | 690 |
Baseline characteristics
| Characteristic | Total | UT-15C | Placebo |
|---|---|---|---|
| 6MWD at Baseline | 395.7 meters STANDARD_DEVIATION 96.3 | 392.9 meters STANDARD_DEVIATION 92.5 | 398.5 meters STANDARD_DEVIATION 100 |
| Age, Categorical <=18 years | 0 Participants | 0 Participants | 0 Participants |
| Age, Categorical >=65 years | 104 Participants | 54 Participants | 50 Participants |
| Age, Categorical Between 18 and 65 years | 586 Participants | 292 Participants | 294 Participants |
| Age, Continuous | 45.2 years STANDARD_DEVIATION 15.5 | 45.6 years STANDARD_DEVIATION 15.7 | 44.8 years STANDARD_DEVIATION 15.4 |
| Etiology of PAH Collagen Vascular Disease | 178 Participants | 94 Participants | 84 Participants |
| Etiology of PAH Congenital Heart Defect | 47 Participants | 20 Participants | 27 Participants |
| Etiology of PAH HIV Infection | 9 Participants | 2 Participants | 7 Participants |
| Etiology of PAH Idiopathic or Heritable PAH | 435 Participants | 219 Participants | 216 Participants |
| Etiology of PAH Other | 21 Participants | 11 Participants | 10 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 306 Participants | 150 Participants | 156 Participants |
| Race (NIH/OMB) Black or African American | 21 Participants | 8 Participants | 13 Participants |
| Race (NIH/OMB) More than one race | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 3 Participants | 1 Participants | 2 Participants |
| Race (NIH/OMB) White | 360 Participants | 187 Participants | 173 Participants |
| Region of Enrollment Europe | 99 Participants | 55 Participants | 44 Participants |
| Region of Enrollment North America | 93 Participants | 39 Participants | 54 Participants |
| Region of Enrollment South America | 176 Participants | 90 Participants | 86 Participants |
| Region of Enrollment Southeast Asia | 322 Participants | 162 Participants | 160 Participants |
| Sex: Female, Male Female | 544 Participants | 275 Participants | 269 Participants |
| Sex: Female, Male Male | 146 Participants | 71 Participants | 75 Participants |
| Time since Diagnosis | 1.35 years STANDARD_DEVIATION 2.54 | 1.34 years STANDARD_DEVIATION 2.5 | 1.37 years STANDARD_DEVIATION 2.58 |
| WHO Functional Class at Baseline I | 22 Participants | 9 Participants | 13 Participants |
| WHO Functional Class at Baseline II | 433 Participants | 205 Participants | 228 Participants |
| WHO Functional Class at Baseline III | 234 Participants | 131 Participants | 103 Participants |
| WHO Functional Class at Baseline IV | 1 Participants | 1 Participants | 0 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 17 / 346 | 18 / 344 |
| other Total, other adverse events | 342 / 346 | 328 / 344 |
| serious Total, serious adverse events | 116 / 346 | 110 / 344 |
Outcome results
Primary
Time to First Clinical Worsening Event
Clinical worsening was assessed continuously from randomization until the subject's last study visit. Clinical worsening events were defined as death (all causes), hospitalizations due to worsening pulmonary arterial hypertension (PAH), initiation of an inhaled or infused prostacyclin (PGI2) for the treatment of worsening PAH, disease progression, or unsatisfactory long-term clinical response. All clinical worsening events reported by the study sites were reviewed by the Sponsor Medical Monitors. Once a clinical worsening event occurred, it was entered in the eCRF and a narrative was submitted for review by the Sponsor's Medical Monitor within 48 hours after the event became known to the Investigator or designee. Subsequently, the narratives for subjects with the reported clinical worsening events were sent to an independent adjudication committee. The independent adjudication committee reviewed and adjudicated all clinical worsening events throughout the study.
Time frame: From randomization to approximately 4 years
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| UT-15C | Time to First Clinical Worsening Event | 60.58 weeks | Standard Deviation 42.93 |
| Placebo | Time to First Clinical Worsening Event | 49.31 weeks | Standard Deviation 46.28 |
p-value: 0.027595% CI: [0.56, 0.97]Cox proportion-hazard model
p-value: 0.0391Log Rank
Secondary
Change in 6-Minute Walk Distance
The intent of the 6-Minute Walk Test (6MWT) is to evaluate exercise capacity associated with carrying out activities of daily living. A baseline 6MWT was performed prior to initiation of study drug on the day of randomization. 6MWTs were conducted at Weeks 4, 8, 12, 24, and every 12 weeks thereafter. The change between Baseline and Week 24 is reported.
Time frame: From Baseline to Week 24
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| UT-15C | Change in 6-Minute Walk Distance | Week 24 | 395.4 meters | Standard Deviation 120 |
| UT-15C | Change in 6-Minute Walk Distance | Baseline | 392.9 meters | Standard Deviation 92.5 |
| Placebo | Change in 6-Minute Walk Distance | Week 24 | 372.3 meters | Standard Deviation 163 |
| Placebo | Change in 6-Minute Walk Distance | Baseline | 398.5 meters | Standard Deviation 100 |
p-value: 0.091395% CI: [0, 16]ANCOVA
Secondary
Change in Plasma N-Terminal Pro-brain Natriuretic Peptide (NT-proBNP) From Baseline to Week 24
Plasma NT-proBNP concentration is a useful biomarker for the severity of PAH as it is associated with changes in right heart morphology and function. NT-proBNP sample collection occurred at Baseline (prior to starting study drug), Week 12, Week 24, the first Continued Visit, and every other Continued Visit thereafter (ie, Continued Visits 3, 5, 7, etc). NT-proBNP was also assessed at the Study Drug Termination Visit. The change between Baseline and Week 24 is reported.
Time frame: From Baseline to Week 24
Population: Subjects who did not have a valid NT-proBNP measurement at Baseline or Week 24 were excluded from the analysis.
| Arm | Measure | Value (LEAST_SQUARES_MEAN) | Dispersion |
|---|---|---|---|
| UT-15C | Change in Plasma N-Terminal Pro-brain Natriuretic Peptide (NT-proBNP) From Baseline to Week 24 | 0.7859 Ratio to baseline | Standard Error 1.0547 |
| Placebo | Change in Plasma N-Terminal Pro-brain Natriuretic Peptide (NT-proBNP) From Baseline to Week 24 | 1.1230 Ratio to baseline | Standard Error 1.05439 |
p-value: <0.0001ANCOVA
Secondary
Change in World Health Organization Functional Class (WHO FC) From Baseline to Week 48
The WHO FC for PAH was assessed at Baseline prior to starting study drug, at all subsequent scheduled study visits, and every time the 6MWT was performed for purposes of assessing clinical worsening status.
Time frame: Baseline to Week 48
| Arm | Measure | Category | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| UT-15C | Change in World Health Organization Functional Class (WHO FC) From Baseline to Week 48 | Improved | 46 Participants |
| UT-15C | Change in World Health Organization Functional Class (WHO FC) From Baseline to Week 48 | No change | 203 Participants |
| UT-15C | Change in World Health Organization Functional Class (WHO FC) From Baseline to Week 48 | Deteriorated | 66 Participants |
| Placebo | Change in World Health Organization Functional Class (WHO FC) From Baseline to Week 48 | Improved | 38 Participants |
| Placebo | Change in World Health Organization Functional Class (WHO FC) From Baseline to Week 48 | No change | 170 Participants |
| Placebo | Change in World Health Organization Functional Class (WHO FC) From Baseline to Week 48 | Deteriorated | 103 Participants |
p-value: 0.0028Fisher Exact