Atherosclerosis, Cardiovascular Diseases, Dyslipidemias, HIV Infections
Conditions
Brief summary
This is a randomized placebo-controlled study in treated and suppressed HIV-infected individuals aged ≥40 years with either known CVD or 1 CVD risk factor to study the effect of Bempedoic acid (BA) on safety, arterial inflammation as assessed by FDG-PET/CT, lipids, inflammation, immune activation, cardiometabolic indices, and non-calcified plaque (NCP) in the coronary arteries (assessed by coronary CT angiography, CCTA). This trial will be enrolled at UCSF and UCLA. Collaborators at Massachusetts General Hospital (MGH) will serve as the core facility for imaging.
Detailed description
Persons living with HIV infection (PLWH) have a 2-fold higher risk of myocardial infarction and are twice as likely to develop cardiovascular disease accounting for a significant global burden of disease. While the mechanism underlying this excess risk remains poorly understood, studies demonstrate that atherosclerosis in the setting of HIV is distinct and characterized by heightened arterial inflammation as assessed by FDG-PET/CT. HIV and antiretroviral medication can worsen cardiometabolic parameters. Thus a therapeutic strategy that can lower lipids, inflammation, and improve glycemic parameters may be even more advantageous in HIV. Bempedoic acid (BA, an inhibitor of ATP citrate lyase), is safely tolerated, significantly lowers LDL-C and inflammatory markers (on top of statin therapy), and is FDA approved for individuals with heterozygous familial hypercholesterolemia or with established ASCVD who require additional LDL-C lowering. Additionally, BA has a protective effect on glycemic parameters and may reduce adiposity. Given the key role of lipids and inflammation in atherosclerosis in HIV, the purpose of this proof-of-concept mechanistic trial is to evaluate the impact of BA on the biology of HIV-associated atherosclerosis. This is a randomized placebo controlled study of effectively treated PLWH aged 40 years and older with either known CVD or 1 CVD risk factor to study the effect of BA on arterial inflammation (assessed by FDG-PET/CT), lipid levels, biomarkers of inflammatory/immune activation, cardiometabolic indices, and non-calcified plaque in the coronary arteries (assessed by CCTA). This multicenter trial will include PLWH enrolled at UCSF and UCLA. Long term collaborators at MGH will serve as the core facility for the imaging end-points. There are three specific aims for the: Cholesterol and inflammation Lowering via BEmpedoic Acid, an ACL-inhibiting Regimen in HIV Trial (CLEAR HIV Trial): Aim 1: To determine whether BA can safely reduce arterial inflammation including carotid plaque as assessed by FDG-PET/CT; Aim 2: To determine whether BA improves cardiometabolic measures (lipid, inflammatory, glycemic and adipose parameters) among PLWH. Exploratory objectives will be to assess BA's effect (vs. placebo) on glycemic as well as adipose tissue measures (HbA1c, HOMA IR, and adipose tissue volumes); Aim 3: To evaluate the impact of BA on non-calcified coronary plaque volume as measured by coronary CT angiography (CCTA).
Interventions
DRUGBempedoic acid
Bempedoic Acid is an oral first-in-class small molecular adenosine triphosphate (ATP)-citrate lyase (ACL) inhibitor which lowers LDL-C by inhibition of cholesterol synthesis in the liver. ACL is an enzyme upstream of 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase in the cholesterol biosynthesis pathway. Inhibition of ACL by bempedoyl-CoA results in decreased cholesterol synthesis in the liver and lowers LDL-C in blood via upregulation of LDL receptors and concomitant suppression of hepatic fatty acid biosynthesis. BA has been studied in \>4300 individuals and is currently being studied in \>14,000 individuals in CLEAR Outcomes (NCT02993406).
OTHERPlacebo
Placebo
Sponsors
University of California, Los Angeles
Massachusetts General Hospital
Priscilla Hsue, MD
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
QUADRUPLE (Subject, Caregiver, Investigator, Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
40 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Documented HIV infection * On continuous antiretroviral therapy and virologically suppressed HIV infection for ≥12 weeks prior to study entry * CD4 T-cell count ≥ 200 cells/mm3 * Male or female between the ages ≥ 40 years of age * LDL-C ≥ 50 mg/dL * Documented cardiovascular disease as defined by: 1. Prior myocardial infarction, 2. Prior cerebrovascular disease, 3. Prior peripheral arterial disease, 4. History of percutaneous coronary intervention, 5. History of coronary artery bypass graft OR 6. Angiographic evidence of \>50% stenosis in at least one coronary artery\] OR 1 CVD risk factor (T2DM, current smoking, hypertension, dyslipidemia, hsCRP≥2mg/L, family history) * TBR of \>1.6 of the MDS of the carotid/aorta at baseline. This baseline arterial TBR cutoff excludes the rare individual that lacks appreciable arterial inflammation. It is notable that while 5-10% of uninfected individuals will have lower TBRs, it is rare that an HIV infected individual will fall below this range. * Female subjects must either be of non-childbearing potential (defined as post-menopausal or amenorrhea \> 12 months) or agree to use two forms of contraception (one hormonal and one barrier) throughout the study and for at least one month following study completion and have a negative pregnancy test at screening and prior to the first dose of drug. * Males must use at least one method of contraception throughout the study.
Exclusion criteria
* Pregnant/nursing women (as there is no data on bempedoic acid in this setting) * Diabetes requiring insulin (as insulin treatment alters the uptake of 18FDG) * Uncontrolled HTN as defined by baseline blood pressure reading of ≥160 mmHg systolic OR ≥100 mmHg diastolic (
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| FDG PET/CT Endpoint | Baseline and Week 52 | Change in Target-to-background ratio from baseline to follow-up study at 52 weeks. The main arterial endpoint is the most diseased segment of the index vessel. These findings will be correlated to measurements in the secondary endpoint. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| hsCRP Endpoint | Baseline, Week 24 and Week 52 | Change in hsCRP from baseline to follow-up at weeks 24 and 52. |
| T-cell Endpoint | Baseline, Week 24 and Week 52 | Change in T-cell marker from baseline to follow up at weeks 24 and 52. |
| B-cell Endpoint | Baseline, Week 24 and Week 52 | Change in B-cell marker from baseline to follow up at weeks 24 and 52. |
| Monocyte activation Endpoint | Baseline, Week 24 and Week 52 | Change in monocyte activation marker from baseline to follow up at weeks 24 and 52. |
| HDL Endpoint | Baseline, Week 24 and Week 52 | Change in HDL will be assessed from baseline to week 24 and week 52. |
| LDL Endpoint | Baseline, Week 24 and Week 52 | Change in LDL will be assessed from baseline to week 24 and week 52. |
| Triglycerides Endpoint | Baseline, Week 24 and Week 52 | Change in triglycerides will be assessed from baseline to week 24 and week 52. |
| Apolipoprotein B Endpoint | Baseline, Week 24 and Week 52 | Change in apolipoprotein B will be assessed from baseline to week 24 and week 52. |
| Hb A1c Endpoint | Baseline, Week 24 and Week 52 | Change in HbA1c from baseline to week 24 and week 52. |
| Fasting glucose Endpoint | Baseline, Week 24 and Week 52 | Change in fasting glucose measurements from baseline to week 24 and week 52. |
| Insulin Endpoint | Baseline, Week 24 and Week 52 | Change in insulin measurements from baseline to week 24 and week 52. |
| Total Cholesterol Endpoint | Baseline, Week 24 and Week 52 | Change in total cholesterol will be assessed from baseline to week 24 and week 52. |
| homeostatic Model Assessment for Insulin Resistance (HOMA-IR) Endpoints | Baseline, Week 24 and Week 52 | The change in Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), a calculation based on insulin and glucose, will also be assessed from baseline to week 24 and 52. The equation simplifies to \[HOMA-IR = fasting insulin \*fasting glucose /22.5\] where fasting plasma insulin is measured in (µIU/mL) and fasting plasma glucose is measured in (mmol/L). Values below 1.0 are generally considered optimal. |
| Adipose Volume Endpoint | Baseline and Week 52 | Change in adipose tissue volumes will be assessed by FDG PET/CT (as measured in primary outcome) from baseline to week 52. |
| IL-1B Endpoint | Baseline, Week 24 and Week 52 | Change in IL-1B from baseline to follow-up at weeks 24 and 52. |
| IL-18 Endpoint | Baseline, Week 24 and Week 52 | Change in IL-18 from baseline to follow-up at weeks 24 and 52. |
| SAA Endpoint | Baseline, Week 24 and Week 52 | Change in SAA from baseline to follow-up at weeks 24 and 52. |
| Lp-PLA2 Endpoint | Baseline, Week 24 and Week 52 | Change in Lp-PLA2 from baseline to follow-up at weeks 24 and 52. |
| sCD163 Endpoint | Baseline, Week 24 and Week 52 | Change in sCD163 from baseline to follow-up at weeks 24 and 52. |
| IL-6 Endpoint | Baseline, Week 24 and Week 52 | Change in IL-6 from baseline to follow-up at weeks 24 and 52. |
| D-Dimer Endpoint | Baseline, Week 24 and Week 52 | Change in D-Dimer from baseline to follow-up at weeks 24 and 52. |
| Fibrinogen Endpoint | Baseline, Week 24 and Week 52 | Change in fibrinogen from baseline to follow-up at weeks 24 and 52. |
Other
| Measure | Time frame | Description |
|---|---|---|
| Coronary CTA Coronary Plaque Incidence Endpoint | Baseline and Week 52 | Incidence of new coronary lesions as measured by Coronary CTA from baseline to follow-up study at 52 weeks |
| Coronary CTA Non-calcified Plaque Endpoint | Baseline and Week 52 | Change in non-calcified plaque as measured by Coronary CTA from baseline to follow-up study at 52 weeks |
| Coronary CTA High-risk Plaque Endpoint | Baseline and Week 52 | Change in high-risk plaque as measured by Coronary CTA from baseline to follow-up study at 52 weeks. |
Countries
United States
Contacts
Primary ContactMarta Levkova
Outcome results
None listed