Study of the Effect of Eplerenone on Heart Function in Women Receiving Anthracycline Chemotherapy for Breast Cancer

NCT01708798 | Terminated Phase 2 DMC

• 1 other identifier: H12-00185
• Study Type: interventional
• Target: 44
• Locations: 1 country
• Sites: 1

Brief Summary

Doxorubicin and other anthracyclines are commonly used to treat breast cancer and other types of cancer. Unfortunately, they can cause heart muscle damage, resulting in scarring, abnormal contraction and relaxation, and heart failure symptoms. This side effect occurs more frequently at higher doses, and limits the total dose that can be given to cancer patients. Eplerenone is an oral medication that prevents or reverses heart damage in other disease states, and is commonly used to treat heart failure. This study will investigate the use of eplerenone to protect the heart from these harmful side effects of doxorubicin. Few therapies have been shown to prevent heart damage in patients receiving anthracyclines. Small studies have suggested that other heart failure medications (ACE inhibitors, beta-blockers) may reduce the incidence of cardiac toxicity, but eplerenone and other drugs in its class (aldosterone antagonists) have not previously been studied. Eplerenone inhibits enzyme pathways that cause scarring of the heart, and animal studies suggest that anthracyclines cause damage through these same pathways. This study aims to investigate whether eplerenone protects the heart from the harmful effects of doxorubicin chemotherapy. Specifically, it will measure the effect that eplerenone has on heart muscle relaxation. It will randomly assign women undergoing chemotherapy with doxorubicin to one of two groups: one group will receive eplerenone, and the other group will receive placebo (sugar) pills. The subjects will not know which type of pills they are taking. Heart muscle relaxation will be measured at baseline, after completion of chemotherapy (8-12 weeks), and after 6 months. There will also be various blood tests measured in the study subjects, to determine whether there might be certain blood tests that identify patients at particularly high risk of heart toxicity after doxorubicin therapy.

Conditions

Breast Cancer

Keywords

Diastolic heart failure

Outcome Measures

Primary Outcomes (1)

• Change in average E' (averaged septal E' and lateral E')

  The average early diastolic tissue velocity of the mitral valve annulus measured by tissue Doppler echocardiography (averaged velocities of the mitral annulus measured at the lateral edge and the septal edge)

  6 months

Secondary Outcomes (9)

• Development of worsening diastolic function

  6 months

• Development of worsening systolic function

  6 months

• Change in septal E'

  6 months

• Change in lateral E'

  6 months

• Change in E/E'

  6 months

Other Outcomes (7)

• Incidence of hyperkalemia

  6 months

• Incidence of adverse events leading to discontinuation of study drug

  6 months

• Signal-averaged ECG (SAECG) changes

  Baseline, 8-12 weeks, 6 months

Study Arms (2)

Placebo

PLACEBO COMPARATOR

One tablet by mouth daily. If serum potassium level is \<5.0 mmol/L at four weeks, increase to two tablets by mouth daily. If estimated glomerular filtration rate (eGFR) is between 30-49 ml per min per 1.73m2, initial dose is: one tablet by mouth every other day. If serum potassium level is \<5.0 mmol/L at four weeks, increase to one tablet by mouth daily.

Drug: Placebo

Eplerenone

EXPERIMENTAL

Eplerenone 25 mg tablet by mouth daily. If serum potassium level is \<5.0 mmol/L at four weeks, increase to two 25 mg tablets by mouth daily. If estimated glomerular filtration rate (eGFR) is between 30-49 ml per min per 1.73m2, initial dose is: eplerenone 25 mg tablet by mouth every other day. If serum potassium level is \<5.0 mmol/L at four weeks, increase to 25 mg tablet by mouth daily.

Drug: Eplerenone

Interventions

Eplerenone DRUG

Also known as: Inspra

Eplerenone

Placebo DRUG

Placebo

Eligibility Criteria

• Age: 18 Years+
• Sex: female
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Stage I-III breast cancer
• Scheduled to undergo treatment with doxorubicin-based chemotherapy regimen
• Able to provide informed consent

You may not qualify if:

• Use of anthracycline agents other than doxorubicin
• Baseline LVEF ≤50% by any modality (nuclear, echo, MRI)
• Atrial fibrillation or flutter
• Mitral valve disease (More than mild mitral stenosis or regurgitation, previous mitral valve replacement or repair)
• Inability to obtain adequate echo images for required analysis
• Hyperkalemia (K+ \>5.0)
• Glomerular filtration rate (GFR) \<30 ml/min/1.73m2
• Uncontrolled hypertension, defined as having a systolic blood pressure \> 180 mmHg and/or a diastolic blood pressure \>110 mmHg
• Symptomatic hypotension or systolic blood pressure \<85 mmHg
• History of hypersensitivity to eplerenone or spironolactone
• Significant hepatic disease (e.g., previously documented positive serology for viral hepatitis) or aspartate aminotransferase (AST) and/or alanine aminotransferase (ALT) \>3 times the upper limits of normal
• Concomitant treatment with spironolactone, potassium-sparing diuretics, potassium supplements, or strong inhibitors of cytochrome P450 3A4 (CYP3A4) (i.e. ketoconazole, itraconazole, nefazodone, troleandomycin, clarithromycin, ritonavir, nelfinavir)
• History of alcohol and/or any other drug abuse
• Women who are either pregnant, lactating or of childbearing potential and not using an acceptable method of contraception
• Other severe acute or chronic medical or psychiatric condition or laboratory abnormality that may increase the risk associated with trial participation or investigational product administration or may interfere with the interpretation of trial results and, in the judgment of the investigator, would make the subject inappropriate for entry into this trial

Sponsors & Collaborators

• University of British Columbia: lead
• Canadian Cancer Society (CCS): collaborator
• Pfizer: collaborator

Study Sites (1)

British Columbia Cancer Agency, Vancouver Centre

Vancouver, British Columbia, V5Z 4E6, Canada

Location

Related Publications (38)

• Von Hoff DD, Layard MW, Basa P, Davis HL Jr, Von Hoff AL, Rozencweig M, Muggia FM. Risk factors for doxorubicin-induced congestive heart failure. Ann Intern Med. 1979 Nov;91(5):710-7. doi: 10.7326/0003-4819-91-5-710.

  PMID: 496103 BACKGROUND

• Swain SM, Whaley FS, Gerber MC, Weisberg S, York M, Spicer D, Jones SE, Wadler S, Desai A, Vogel C, Speyer J, Mittelman A, Reddy S, Pendergrass K, Velez-Garcia E, Ewer MS, Bianchine JR, Gams RA. Cardioprotection with dexrazoxane for doxorubicin-containing therapy in advanced breast cancer. J Clin Oncol. 1997 Apr;15(4):1318-32. doi: 10.1200/JCO.1997.15.4.1318.

  PMID: 9193323 BACKGROUND

• Wouters KA, Kremer LC, Miller TL, Herman EH, Lipshultz SE. Protecting against anthracycline-induced myocardial damage: a review of the most promising strategies. Br J Haematol. 2005 Dec;131(5):561-78. doi: 10.1111/j.1365-2141.2005.05759.x.

  PMID: 16351632 BACKGROUND

• Kizaki K, Ito R, Okada M, Yoshioka K, Uchide T, Temma K, Mutoh K, Uechi M, Hara Y. Enhanced gene expression of myocardial matrix metalloproteinases 2 and 9 after acute treatment with doxorubicin in mice. Pharmacol Res. 2006 Apr;53(4):341-6. doi: 10.1016/j.phrs.2006.01.001. Epub 2006 Feb 7.

  PMID: 16455267 BACKGROUND

• Goetzenich A, Hatam N, Zernecke A, Weber C, Czarnotta T, Autschbach R, Christiansen S. Alteration of matrix metalloproteinases in selective left ventricular adriamycin-induced cardiomyopathy in the pig. J Heart Lung Transplant. 2009 Oct;28(10):1087-93. doi: 10.1016/j.healun.2009.06.025.

  PMID: 19782292 BACKGROUND

• Spallarossa P, Altieri P, Garibaldi S, Ghigliotti G, Barisione C, Manca V, Fabbi P, Ballestrero A, Brunelli C, Barsotti A. Matrix metalloproteinase-2 and -9 are induced differently by doxorubicin in H9c2 cells: The role of MAP kinases and NAD(P)H oxidase. Cardiovasc Res. 2006 Feb 15;69(3):736-45. doi: 10.1016/j.cardiores.2005.08.009. Epub 2005 Oct 6.

  PMID: 16213474 BACKGROUND

• Zhao Y, McLaughlin D, Robinson E, Harvey AP, Hookham MB, Shah AM, McDermott BJ, Grieve DJ. Nox2 NADPH oxidase promotes pathologic cardiac remodeling associated with Doxorubicin chemotherapy. Cancer Res. 2010 Nov 15;70(22):9287-97. doi: 10.1158/0008-5472.CAN-10-2664. Epub 2010 Sep 30.

  PMID: 20884632 BACKGROUND

• Clark JE, Sarafraz N, Marber MS. Potential of p38-MAPK inhibitors in the treatment of ischaemic heart disease. Pharmacol Ther. 2007 Nov;116(2):192-206. doi: 10.1016/j.pharmthera.2007.06.013. Epub 2007 Jul 24.

  PMID: 17765316 BACKGROUND

• Bellahcene M, Jacquet S, Cao XB, Tanno M, Haworth RS, Layland J, Kabir AM, Gaestel M, Davis RJ, Flavell RA, Shah AM, Avkiran M, Marber MS. Activation of p38 mitogen-activated protein kinase contributes to the early cardiodepressant action of tumor necrosis factor. J Am Coll Cardiol. 2006 Aug 1;48(3):545-55. doi: 10.1016/j.jacc.2006.02.072. Epub 2006 Jul 12.

  PMID: 16875982 BACKGROUND

• Martos R, Baugh J, Ledwidge M, O'Loughlin C, Conlon C, Patle A, Donnelly SC, McDonald K. Diastolic heart failure: evidence of increased myocardial collagen turnover linked to diastolic dysfunction. Circulation. 2007 Feb 20;115(7):888-95. doi: 10.1161/CIRCULATIONAHA.106.638569. Epub 2007 Feb 5.

  PMID: 17283265 BACKGROUND

• Klappacher G, Franzen P, Haab D, Mehrabi M, Binder M, Plesch K, Pacher R, Grimm M, Pribill I, Eichler HG, et al. Measuring extracellular matrix turnover in the serum of patients with idiopathic or ischemic dilated cardiomyopathy and impact on diagnosis and prognosis. Am J Cardiol. 1995 May 1;75(14):913-8. doi: 10.1016/s0002-9149(99)80686-9.

  PMID: 7733000 BACKGROUND

• Host NB, Jensen LT, Bendixen PM, Jensen SE, Koldkjaer OG, Simonsen EE. The aminoterminal propeptide of type III procollagen provides new information on prognosis after acute myocardial infarction. Am J Cardiol. 1995 Nov 1;76(12):869-73. doi: 10.1016/s0002-9149(99)80251-3.

  PMID: 7484822 BACKGROUND

• Di Zhang A, Nguyen Dinh Cat A, Soukaseum C, Escoubet B, Cherfa A, Messaoudi S, Delcayre C, Samuel JL, Jaisser F. Cross-talk between mineralocorticoid and angiotensin II signaling for cardiac remodeling. Hypertension. 2008 Dec;52(6):1060-7. doi: 10.1161/HYPERTENSIONAHA.108.117531. Epub 2008 Nov 3.

  PMID: 18981328 BACKGROUND

• Hori Y, Yoshioka K, Kanai K, Hoshi F, Itoh N, Higuchi S. Spironolactone decreases isoproterenol-induced ventricular fibrosis and matrix metalloproteinase-2 in rats. Biol Pharm Bull. 2011;34(1):61-5. doi: 10.1248/bpb.34.61.

  PMID: 21212518 BACKGROUND

• Rude MK, Duhaney TA, Kuster GM, Judge S, Heo J, Colucci WS, Siwik DA, Sam F. Aldosterone stimulates matrix metalloproteinases and reactive oxygen species in adult rat ventricular cardiomyocytes. Hypertension. 2005 Sep;46(3):555-61. doi: 10.1161/01.HYP.0000176236.55322.18. Epub 2005 Jul 25.

  PMID: 16043662 BACKGROUND

• Zannad F, Dousset B, Alla F. Treatment of congestive heart failure: interfering the aldosterone-cardiac extracellular matrix relationship. Hypertension. 2001 Nov;38(5):1227-32. doi: 10.1161/hy1101.099484.

  PMID: 11711528 BACKGROUND

• Zannad F, Alla F, Dousset B, Perez A, Pitt B. Limitation of excessive extracellular matrix turnover may contribute to survival benefit of spironolactone therapy in patients with congestive heart failure: insights from the randomized aldactone evaluation study (RALES). Rales Investigators. Circulation. 2000 Nov 28;102(22):2700-6. doi: 10.1161/01.cir.102.22.2700.

  PMID: 11094035 BACKGROUND

• Jensen BV, Skovsgaard T, Nielsen SL. Functional monitoring of anthracycline cardiotoxicity: a prospective, blinded, long-term observational study of outcome in 120 patients. Ann Oncol. 2002 May;13(5):699-709. doi: 10.1093/annonc/mdf132.

  PMID: 12075737 BACKGROUND

• Marchandise B, Schroeder E, Bosly A, Doyen C, Weynants P, Kremer R, Pouleur H. Early detection of doxorubicin cardiotoxicity: interest of Doppler echocardiographic analysis of left ventricular filling dynamics. Am Heart J. 1989 Jul;118(1):92-8. doi: 10.1016/0002-8703(89)90077-x.

  PMID: 2741800 BACKGROUND

• Ewer MS, Ali MK, Mackay B, Wallace S, Valdivieso M, Legha SS, Benjamin RS, Haynie TP. A comparison of cardiac biopsy grades and ejection fraction estimations in patients receiving Adriamycin. J Clin Oncol. 1984 Feb;2(2):112-7. doi: 10.1200/JCO.1984.2.2.112.

  PMID: 6699662 BACKGROUND

• Dodos F, Halbsguth T, Erdmann E, Hoppe UC. Usefulness of myocardial performance index and biochemical markers for early detection of anthracycline-induced cardiotoxicity in adults. Clin Res Cardiol. 2008 May;97(5):318-26. doi: 10.1007/s00392-007-0633-6. Epub 2008 Jan 14.

  PMID: 18193371 BACKGROUND

• Di Lisi D, Bonura F, Macaione F, Peritore A, Meschisi M, Cuttitta F, Novo G, D'Alessandro N, Novo S. Chemotherapy-induced cardiotoxicity: role of the tissue Doppler in the early diagnosis of left ventricular dysfunction. Anticancer Drugs. 2011 Jun;22(5):468-72. doi: 10.1097/CAD.0b013e3283443704.

  PMID: 21301318 BACKGROUND

• Nagy AC, Cserep Z, Tolnay E, Nagykalnai T, Forster T. Early diagnosis of chemotherapy-induced cardiomyopathy: a prospective tissue Doppler imaging study. Pathol Oncol Res. 2008 Mar;14(1):69-77. doi: 10.1007/s12253-008-9013-4. Epub 2008 Mar 15.

  PMID: 18347931 BACKGROUND

• Pudil R, Horacek JM, Strasova A, Jebavy L, Vojacek J. Monitoring of the very early changes of left ventricular diastolic function in patients with acute leukemia treated with anthracyclines. Exp Oncol. 2008 Jun;30(2):160-2.

  PMID: 18566583 BACKGROUND

• Tassan-Mangina S, Codorean D, Metivier M, Costa B, Himberlin C, Jouannaud C, Blaise AM, Elaerts J, Nazeyrollas P. Tissue Doppler imaging and conventional echocardiography after anthracycline treatment in adults: early and late alterations of left ventricular function during a prospective study. Eur J Echocardiogr. 2006 Mar;7(2):141-6. doi: 10.1016/j.euje.2005.04.009. Epub 2005 Jun 6.

  PMID: 15941672 BACKGROUND

• Nagueh SF, Sun H, Kopelen HA, Middleton KJ, Khoury DS. Hemodynamic determinants of the mitral annulus diastolic velocities by tissue Doppler. J Am Coll Cardiol. 2001 Jan;37(1):278-85. doi: 10.1016/s0735-1097(00)01056-1.

  PMID: 11153752 BACKGROUND

• Hayashi SY, Rohani M, Lindholm B, Brodin LA, Lind B, Barany P, Alvestrand A, Seeberger A. Left ventricular function in patients with chronic kidney disease evaluated by colour tissue Doppler velocity imaging. Nephrol Dial Transplant. 2006 Jan;21(1):125-32. doi: 10.1093/ndt/gfi075. Epub 2005 Oct 12.

  PMID: 16221719 BACKGROUND

• Kasner M, Westermann D, Steendijk P, Gaub R, Wilkenshoff U, Weitmann K, Hoffmann W, Poller W, Schultheiss HP, Pauschinger M, Tschope C. Utility of Doppler echocardiography and tissue Doppler imaging in the estimation of diastolic function in heart failure with normal ejection fraction: a comparative Doppler-conductance catheterization study. Circulation. 2007 Aug 7;116(6):637-47. doi: 10.1161/CIRCULATIONAHA.106.661983. Epub 2007 Jul 23.

  PMID: 17646587 BACKGROUND

• Edwards NC, Ferro CJ, Kirkwood H, Chue CD, Young AA, Stewart PM, Steeds RP, Townend JN. Effect of spironolactone on left ventricular systolic and diastolic function in patients with early stage chronic kidney disease. Am J Cardiol. 2010 Nov 15;106(10):1505-11. doi: 10.1016/j.amjcard.2010.07.018.

  PMID: 21059444 BACKGROUND

• Vizzardi E, D'Aloia A, Giubbini R, Bordonali T, Bugatti S, Pezzali N, Romeo A, Dei Cas A, Metra M, Dei Cas L. Effect of spironolactone on left ventricular ejection fraction and volumes in patients with class I or II heart failure. Am J Cardiol. 2010 Nov 1;106(9):1292-6. doi: 10.1016/j.amjcard.2010.06.052. Epub 2010 Sep 9.

  PMID: 21029826 BACKGROUND

• Mottram PM, Haluska B, Leano R, Cowley D, Stowasser M, Marwick TH. Effect of aldosterone antagonism on myocardial dysfunction in hypertensive patients with diastolic heart failure. Circulation. 2004 Aug 3;110(5):558-65. doi: 10.1161/01.CIR.0000138680.89536.A9. Epub 2004 Jul 26.

  PMID: 15277317 BACKGROUND

• Pitt B, Remme W, Zannad F, Neaton J, Martinez F, Roniker B, Bittman R, Hurley S, Kleiman J, Gatlin M; Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study Investigators. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med. 2003 Apr 3;348(14):1309-21. doi: 10.1056/NEJMoa030207. Epub 2003 Mar 31.

  PMID: 12668699 BACKGROUND

• Zannad F, McMurray JJ, Krum H, van Veldhuisen DJ, Swedberg K, Shi H, Vincent J, Pocock SJ, Pitt B; EMPHASIS-HF Study Group. Eplerenone in patients with systolic heart failure and mild symptoms. N Engl J Med. 2011 Jan 6;364(1):11-21. doi: 10.1056/NEJMoa1009492. Epub 2010 Nov 14.

  PMID: 21073363 BACKGROUND

• Pinto JT, Delman BN, Dutta P, Nisselbaum J. Adriamycin-induced increase in serum aldosterone levels: effects in riboflavin-sufficient and riboflavin-deficient rats. Endocrinology. 1990 Sep;127(3):1495-501. doi: 10.1210/endo-127-3-1495.

  PMID: 2387263 BACKGROUND

• Cardinale D, Sandri MT. Role of biomarkers in chemotherapy-induced cardiotoxicity. Prog Cardiovasc Dis. 2010 Sep-Oct;53(2):121-9. doi: 10.1016/j.pcad.2010.04.002.

  PMID: 20728699 BACKGROUND

• Jensen BV, Nielsen SL, Skovsgaard T. Treatment with angiotensin-converting-enzyme inhibitor for epirubicin-induced dilated cardiomyopathy. Lancet. 1996 Feb 3;347(8997):297-9. doi: 10.1016/s0140-6736(96)90469-9.

  PMID: 8569365 BACKGROUND

• Georgakopoulos P, Roussou P, Matsakas E, Karavidas A, Anagnostopoulos N, Marinakis T, Galanopoulos A, Georgiakodis F, Zimeras S, Kyriakidis M, Ahimastos A. Cardioprotective effect of metoprolol and enalapril in doxorubicin-treated lymphoma patients: a prospective, parallel-group, randomized, controlled study with 36-month follow-up. Am J Hematol. 2010 Nov;85(11):894-6. doi: 10.1002/ajh.21840.

  PMID: 20872550 BACKGROUND

• Seidman A, Hudis C, Pierri MK, Shak S, Paton V, Ashby M, Murphy M, Stewart SJ, Keefe D. Cardiac dysfunction in the trastuzumab clinical trials experience. J Clin Oncol. 2002 Mar 1;20(5):1215-21. doi: 10.1200/JCO.2002.20.5.1215.

  PMID: 11870163 BACKGROUND

MeSH Terms

Conditions

Breast Neoplasms; Heart Failure, Diastolic

Interventions

Eplerenone

Condition Hierarchy (Ancestors)

Neoplasms by Site; Neoplasms; Breast Diseases; Skin Diseases; Skin and Connective Tissue Diseases; Heart Failure; Heart Diseases; Cardiovascular Diseases

Intervention Hierarchy (Ancestors)

Lactones; Organic Chemicals; Pregnenes; Pregnanes; Steroids; Fused-Ring Compounds; Polycyclic Compounds

Study Officials

• Sean A Virani, MD, MSc, MPH

  University of British Columbia

  PRINCIPAL INVESTIGATOR

• Margot Davis, MD

  University of British Columbia

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: phase 2
• Allocation: RANDOMIZED
• Masking: TRIPLE
• Who Masked: PARTICIPANT, INVESTIGATOR, OUTCOMES ASSESSOR
• Purpose: PREVENTION
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: October 15, 2012
• First Posted: October 17, 2012
• Study Start: May 1, 2014
• Primary Completion: November 1, 2016
• Study Completion: November 1, 2016
• Last Updated: January 5, 2017

Record last verified: 2017-01

Data Sharing

• IPD Sharing: Will not share

Locations

CA (1)