A Randomized, Double-blind, Placebo-controlled, Event-driven Trial of Weekly Low-dose Methotrexate (LDM) in the Prevention of Cardiovascular Events Among Stable Coronary Artery Disease Patients With Type 2 Diabetes or Metabolic Syndrome
Phase: PHASE3
Conditions: Cardiovascular Disease
Sponsor: Brigham and Women's Hospital

Cardiovascular Inflammation Reduction Trial (CIRT) 
 
A randomized, double-blind, placebo-controlled, event-driven trial of weekly 
low-dose methotrexate (LDM) in the prevention of recurrent cardiovascular events 
among stable post-myocardial infarction patients with 
type 2 diabetes or metabolic syndrome 
 
NCT01594333 
 
October 30, 2014 
 
This document contains the following items: 
1. Original protocol (March 6, 2013), final protocol (October 30, 2014), summary of 
changes 
2. Original statistical analysis plan (March 25, 2013), this is the original and final version 
(no changes were made) 

 
1 
 
 
 
 
 
 
 
 
 
 
 
PROTOCOL 
 
 
 
Cardiovascular Inflammation Reduction Trial (CIRT): 
 
 
A randomized, double-blind, placebo-controlled, event-driven trial of weekly 
low-dose methotrexate (LDM) in the prevention of recurrent cardiovascular events 
among stable post-myocardial infarction patients with 
type 2 diabetes or metabolic syndrome 
 
 
 
 
 
Center for Cardiovascular Disease Prevention 
Brigham and Women’s Hospital 
 
 
Funding: National Heart Lung and Blood Institute 
 
 
 
March 6, 2013 
 
IND 116831 
 

 
2 
 
Abbreviations 
 
 
ABCA1 
ATP-binding cassette, sub-family A (ABC1), member 1 
AE 
 
Adverse event 
AHA  
American Heart Association 
ALT  
Alanine aminotrasferase 
AST  
Aspartate aminotransferase 
CBC  
Complete blood count 
CCC  
Clinical Coordinating Center 
CEC  
Clinical Endpoints Committee 
CIRT  
Cardiovascular Inflammation Reduction Trial 
CrCl  
Creatinine clearance 
CRP  
C reactive protein 
DCC  
Data Coordinating Center 
DSMB  
Data and Safety Monitoring Board 
DVT  
Deep venous thrombosis 
eGFR  
Estimate glomerular filtration rate 
HbA1c  
Hemoglobin A1c 
HDL-C  
High density lipoprotein cholesterol 
HY27  
Cholesterol 27-hydroxylase 
IL-1  
Interleukin-1 
IL1ra  
Interleukin-1 receptor antagonist 
IL-6  
Interleukin-6 
IRB  
Institutional review board 
GFR  
Glomerular filtration rate 
LDM  
Low dose methotrexate 
LDL-C  
Low density lipoprotein cholesterol 
LLN  
Lower limit of normal 
NHLBI  
National Heart Lung and Blood Institute 
PE 
 
Pulmonary embolus 
RA 
 
Rheumatoid arthritis 
SAE  
Serious adverse event 
TNF  
Tumor necrosis factor 
ULN  
Upper limit of normal 
WBC  
White blood cell count  
 

 
3 
1.0. TRIAL OVERVIEW 
............................................................................................................. 4 
2.0. SPECIFIC AIMS.................................................................................................................. 4 
2.1. Primary Aim 
..................................................................................................................... 5 
2.2. Secondary Aims 
.............................................................................................................. 5 
2.3. Tertiary Aims 
................................................................................................................... 5 
2.4. Proposed Exploratory and Mechanistic Studies 
............................................................... 6 
3.0. BACKGROUND AND SIGNIFICANCE 
............................................................................... 6 
3.1. The Inflammatory Hypothesis of Atherothrombosis ......................................................... 6 
3.2. Low-Dose Methotrexate (LDM) and Cardiovascular Disease .......................................... 7 
3.3. Diabetes, Metabolic Syndrome, and Inflammation 
........................................................... 8 
3.4. Pharmacology of Low Dose Methotrexate (LDM) ............................................................ 9 
3.5. Safety of LDM and Efforts to Reduce In-Trial Toxicity ....................................................10 
4.0. INVESTIGATIONAL PLAN 
................................................................................................11 
4.1. Study Design - Overview 
................................................................................................11 
4.2. Study Population 
............................................................................................................13 
4.3. Inclusion Criteria ............................................................................................................13 
4.4. Exclusion Criteria ...........................................................................................................13 
4.5. Open Label Run-In 
.........................................................................................................14 
4.6. Randomization Procedures 
............................................................................................15 
4.7. Cohort Follow up and Clinic Visits 
..................................................................................15 
4.8. Monitoring Participant Laboratory Values and Subsequent Dose Adjustments 
...............16 
4.9. Monitoring Participant Symptoms and Subsequent Dose Adjustments 
...........................16 
4.10. Medical Monitor 
............................................................................................................17 
4.11. Endpoint Definitions and Documentation 
......................................................................17 
4.12. Procedures for Emergency Unblinding 
.........................................................................18 
4.13. Investigator Education Programs 
..................................................................................18 
4.14. Drug Compliance Monitoring 
........................................................................................18 
4.15. Central Laboratory and Bio-bank 
..................................................................................18 
4.16. Serious Adverse Events (SAEs) 
...................................................................................19 
4.17. Data Coordination and Treatment Masking ..................................................................19 
4.18. Data and Safety Monitoring Board 
................................................................................19 
4.19. Trial Conclusion and Close Out Visits 
...........................................................................20 
5.0. DATA ANALYSIS PLAN ...................................................................................................20 
5.1. Statistical Analysis 
..........................................................................................................20 
5.2. Sample Size and Power 
.................................................................................................21 
5.3. Stratification and Randomization 
....................................................................................23 
5.4. Interim Feasibility Analysis 
.............................................................................................23 
5.5. Interim DSMB Analyses .................................................................................................23 
5.6. Secondary Analysis 
........................................................................................................24 
5.7. Subgroup Analyses 
........................................................................................................25 
5.8. Ancillary Studies 
.............................................................................................................25 
6.0. REFERENCES ..................................................................................................................26 
 

 
4 
 
1.0. TRIAL OVERVIEW 
 
 
While inflammation contributes crucially to atherothrombosis, it is unknown whether 
inhibition of inflammation per se will lower vascular event rates. The primary aim of the 
Cardiovascular Inflammation Reduction Trial (CIRT) is to directly test the inflammatory 
hypothesis of atherothrombosis by evaluating whether or not low-dose methotrexate (LDM) will 
reduce rates of recurrent myocardial infarction, stroke, and cardiovascular death among stable 
post-myocardial infarction patients with type 2 diabetes or metabolic syndrome, conditions 
associated with an enhanced pro-inflammatory response.  CIRT is a randomized, double-blind, 
placebo-controlled, multi-center, event-driven trial that will randomize 7,000 men and women 
from the United States and Canada. Following a five- to six-week open-label run-in (maximum 8 
weeks), eligible participants who have suffered documented myocardial infarction in the past 
five years will be randomly allocated over a three to four year period to usual care plus placebo 
or usual care plus LDM. The target methotrexate dose among those allocated to active therapy 
is 15 to 20 mg po per week, a dose within the range of that commonly used for the treatment of 
rheumatoid arthritis.  All study participants will additionally receive 1.0 mg oral folate to be taken 
daily six days per week. LDM complications will be minimized through education programs for 
all investigators and coordinators, through enhanced communication with study participants, by 
limiting enrollment to those with no evidence of malignancy, hepatitis, renal dysfunction, chronic 
infection, pulmonary disease, or other risk factors for toxicity; by conducting an initial 5- to 6-
week active-therapy run-in (maximum 8 weeks) designed to eliminate individuals who are either 
intolerant of or unable to adhere to treatment before randomization; and through regular 
monitoring of liver function and hematologic indices using a centralized methodology designed 
to ensure participant safety, allow for dose adjustments while maintaining the study blind, and 
provide an efficient method to address issues of compliance and follow-up on a cost-effective 
centralized basis. The primary trial endpoint is the rate of recurrent myocardial infarction, stroke, 
or cardiovascular death. Secondary and tertiary endpoints include all-cause mortality, coronary 
revascularization, incident congestive heart failure, incident peripheral artery disease, incident 
venous thrombosis, clinically significant aortic stenosis, incident atrial fibrillation, incident 
diabetes among those with metabolic syndrome but not diabetes at study entry, and hemoglobin 
A1c (HbA1c) control among those with diabetes at study entry. The trial is event driven such 
that in the absence of extreme effects, the trial will conclude after accrual of at least 530 primary 
endpoints, an effect estimated to provide 90 percent power to detect a 25 percent relative risk 
reduction. The potential clinical impact of CIRT is broad as it has sufficient power to directly 
address core issues in the inflammatory hypothesis of atherothrombosis, and thus, if successful, 
will open major new directions for cardiovascular treatment.  
2.0. SPECIFIC AIMS 
 
 
Abundant laboratory and translational data demonstrate that inflammation plays a major 
role in all stages of the atherothrombotic process
1,2. These observations have generated the 
hypothesis that targeted anti-inflammatory therapy can lower vascular event rates. To date, 
however, no clinical trial has directly addressed this critical biologic hypothesis3,4. 
 
The primary scientific aim of CIRT is to directly test the inflammatory hypothesis of 
atherothrombosis. Specifically, CIRT will evaluate whether LDM will reduce rates of recurrent 
myocardial infarction, stroke, or cardiovascular death among patients with a recent history of 

 
5 
myocardial infarction and either type 2 diabetes or metabolic syndrome, conditions associated 
with an enhanced pro-inflammatory response. LDM is an effective anti-inflammatory therapy 
widely used to treat rheumatoid arthritis that lowers plasma levels of interleukin-6 (IL-6), tumor 
necrosis factor (TNF), and C-reactive protein (CRP) but does not otherwise have beneficial 
effects on lipids or biomarkers of hemostasis and thrombosis. Thus, a randomized trial of LDM 
provides an innovative approach to target inflammation while minimizing confounding effects 
that might accrue from activation or inhibition of alternative vascular pathways. The wide use of 
LDM as a mainstay in current therapy for rheumatoid arthritis provides both guidelines for safety 
monitoring and strong evidence that off-target toxicity is unlikely to be uncovered during the 
course of this trial.   
 
2.1. Primary Aim 
 
a. To determine in a randomized, double-blind, placebo-controlled setting whether LDM 
given at a target dose of 15 to 20 mg po weekly will reduce rates of recurrent myocardial 
infarction, stroke, or cardiovascular death among patients with a prior history of 
myocardial infarction and either type 2 diabetes or metabolic syndrome. 
2.2. Secondary Aims 
 
a. To determine in a randomized, double-blind, placebo-controlled setting whether LDM will 
reduce rates of all-cause mortality among patients with a prior history of myocardial 
infarction and either type 2 diabetes or metabolic syndrome. 
b. To determine in a randomized, double-blind, placebo-controlled setting whether LDM will 
reduce rates of the primary endpoint plus coronary revascularization. 
c. To determine in a randomized, double-blind, placebo-controlled setting whether LDM will 
reduce the rates of hospitalization for congestive heart failure. 
d. To determine in a randomized, double-blind, placebo-controlled setting whether LDM will 
reduce rates of the primary endpoint plus all-cause mortality plus coronary 
revascularization plus congestive heart failure. 
e. To determine in a randomized, double-blind, placebo-controlled setting the side effect 
profile of LDM in a non-rheumatologic population at risk for recurrent vascular events. By 
so doing, CIRT will evaluate the net clinical benefit or harm that might accrue from the 
hypothesized use of LDM as a novel method for the secondary prevention of myocardial 
infarction, stroke, and cardiovascular death.  
f. To determine in a randomized, double-blind, placebo-controlled setting whether LDM will 
reduce the rate of new onset type 2 diabetes among those with metabolic syndrome but 
not diabetes at study entry.  
2.3. Tertiary Aims 
 
In addition, we will determine in a randomized, double-blind, placebo-controlled setting whether 
LDM will  
 
a. reduce rates of the individual components of the primary endpoint 
b. reduce rates of the primary endpoint plus unstable angina requiring unplanned coronary 
revascularization 
c. reduce rates of coronary revascularization 
d. reduce rates of peripheral artery disease 

 
6 
e. reduce rates of symptomatic deep vein thrombosis or pulmonary embolism, including 
those considered to be provoked and those considered to be idiopathic 
f. reduce rates of clinically significant aortic stenosis 
g. reduce rates of atrial fibrillation 
h. have positive or negative effects on standardized measures of quality of life and global 
health status 
 
2.4. Proposed Exploratory and Mechanistic Studies 
 
CIRT will include 7,000 patients with myocardial infarction within the past five years who have 
either type 2 diabetes or metabolic syndrome. Clinical endpoints of interest that will be 
prospectively evaluated include incident age-related macular degeneration, sleep apnea, and 
nephropathy and retinopathy.  In addition, a plasma and DNA bank will be established as part of 
the trial protocol. Thus, cohort accrual and biobanking also allows for the evaluation of several 
tertiary aims that relate to mechanisms of effect using measured plasma biomarkers of 
inflammation and glucose metabolism, as well as potential genetic determinants of LDM activity. 
 
a. To evaluate the effect of LDM as compared to placebo on a series of inflammatory 
biomarkers such as IL-6, TNF, CRP, interleukin-1 (IL-1), and interleukin-1 receptor 
antagonist (IL1ra), and to ascertain whether any effects on these biomarkers mediate 
observed benefits or risks of LDM on clinical outcomes in the trial. 
b. To evaluate whether genetic polymorphisms associated with vascular risk, inflammation, 
thrombosis, or LDM metabolism modify any benefits or risks of LDM on clinical 
outcomes observed in the trial. 
c. Among subjects with baseline diabetes, to evaluate the effect of LDM as compared to 
placebo on indices of diabetic progression and glycemic control such as need for 
diabetes treatment intensification, proportion of subjects achieving optimal glycemic 
control (HbA1c<7.0%), and change in HbA1c overall and by study visit. 
3.0. BACKGROUND AND SIGNIFICANCE 
3.1. The Inflammatory Hypothesis of Atherothrombosis 
 
Abundant laboratory evidence indicates that inflammation plays a major role in all stages 
of atherothrombosis1,2. With regard to the translation of inflammation biology to practice, as 
demonstrated in a comprehensive 2010 meta-analysis, clinical evidence from 54 prospective 
cohort studies demonstrates that inflammatory biomarkers independently predict vascular risk 
with a magnitude of effect at least as large as that of blood pressure or cholesterol
5. However, 
while the attributable vascular risk associated with inflammation is large and while animal 
models using targeted anti-inflammatory therapies have shown promise, it remains unknown 
whether inhibition of inflammation per se will lower vascular event rates.  
Despite the importance of this question, no endpoint trial addressing these issues has 
been initiated. However, the recent JUPITER investigation comparing rosuvastatin to placebo 
among 17,802 individuals with low levels of low-density lipoprotein cholesterol (LDL-C) but who 
were at elevated vascular risk on the basis of a pro-inflammatory response reinforces the need 
for such a trial
6. In brief, JUPITER demonstrated a 44 percent reduction in major vascular 
events, which included a 54 percent reduction in myocardial infarction, a 48 percent reduction in 
stroke, a 46 percent reduction in arterial revascularization, a 43 percent reduction in deep 
venous thrombosis/pulmonary embolism (DVT/PE), and a 20 percent reduction in mortality. 

 
7 
Underscoring the importance of inflammation as a pathophysiologic factor in selecting this study 
population, the placebo event rate in JUPITER was higher than that of prior prevention trials 
limited to those with overt hyperlipidemia
7,8.  Further, within JUPITER, the greatest absolute risk 
and the greatest absolute risk reduction was observed among those with the highest levels of 
persistent pro-inflammatory response
9.  
From an inflammatory biology perspective, prospective analyses from JUPITER also 
suggest that achieving low levels of inflammation may be an important treatment goal in a 
manner analogous to achieving low levels of LDL-C. In pre-specified analyses designed to 
evaluate the relative effects of inflammation reduction as compared to LDL-C reduction, the 
JUPITER data suggest that the benefits of statin therapy are magnified among those who not 
only reduce LDL-C, but who also substantially reduce inflammatory biomarkers10. As such, 
JUPITER prospectively confirms prior data from the CARE11,12, AFCAPS/TexCAPS
13, PROVE 
IT – TIMI 2214, A to Z
15, and REVERSAL
16 trials that best clinical outcomes accrue in statin 
treated patients who achieve low levels of inflammation as well as cholesterol. All of these data 
corroborate laboratory evidence of anti-inflammatory properties of statins including reduced cell 
adhesion and monocyte recruitment to the arterial wall; reduced prenylation of small G proteins 
and augmented expression of the transcription factor KLF2 with consequent mitigation of 
inflammatory and thrombotic mediators; altered smooth muscle migration in developing plaques; 
favorable effects on metalloproteinase expression; and in human hepatocytes, reductions in IL-6 
and other cytokines17,18. However, statins markedly lower LDL-C as well as reduce 
inflammation. Thus, although suggestive, these data cannot address whether lowering 
inflammation alone will lower vascular risk.  
3.2. Low-Dose Methotrexate (LDM) and Cardiovascular Disease 
 
A direct test of the inflammatory hypothesis of atherothrombosis requires an agent that 
(a) inhibits inflammation without having major impact on other components of the 
atherothrombotic process, and (b) has an acceptable safety profile for evaluation in a large-
scale randomized trial3,4. LDM has multiple attributes that make it an appropriate agent to test 
directly the inflammatory hypothesis of atherothrombosis.  
First, LDM (range 10 to 30 mg per week) is widely used, has an enviable safety profile 
among patients with rheumatoid arthritis and psoriasis, and comprehensive guidelines from the 
American College of Rheumatology exist regarding dosing regimens, drug monitoring, and the 
identification of high-risk patient subgroups
19-21. This experience greatly reduces the potential for 
unanticipated off-target toxicity. The target methotrexate dose in CIRT is 15 to 20 mg po per 
week, a dose within the range commonly used for the treatment of rheumatoid arthritis.   
Second, LDM reduces several inflammatory biomarkers including CRP, IL-6, and TNF-
alpha in populations of patients with rheumatoid arthritis (RA) and psoriasis, patient groups at 
elevated vascular risk on an inflammatory basis. Further, LDM does not have substantive 
effects on lipid levels, hemostasis, or platelet function. Thus, LDM provides a mechanism to test 
the inflammatory hypothesis of atherothrombosis without confounding effects on other vascular 
pathways. 

 
8 
Third, among both rheumatoid arthritis and psoriasis patients assessed in seven cohort 
and case-control settings
22-28, available observational epidemiologic data suggest that exposure 
to LDM is associated with reductions in cardiovascular morbidity and mortality, even though 
those receiving LDM have worse vascular risk factor profiles, data strongly mitigating against 
indication bias (Table 1). These data have been verified in a recent systematic overview29. Of 
interest, the 
cardiovascular benefit 
of LDM was observed 
despite the fact that 
patients initiating 
treatment (mean dose 
= 13 mg/week) had 
significantly worse 
prognostic factors for 
mortality and 
significantly worse RA 
symptoms than did 
patients not being 
treated with LDM. 
Other observational 
studies of RA patients 
taking LDM have 
shown improvement 
in heart failure
30 and 
reduction in carotid 
intima media 
thickness
28. The 
consistent observation of excess vascular risk unexplained by traditional risk factors among 
those with rheumatoid arthritis or psoriasis also supports the conceptual basis for a trial of anti-
inflammatory therapy among those with a persistent enhancement of the innate immune 
response
31-33. 
Fourth, mechanistic studies suggest that atheroprotective effects of methotrexate may 
accrue from enhanced release of adenosine which in turn leads to facilitation of cholesterol 
efflux and reverse cholesterol transport from arterial wall foam cells
34 via upregulated 
expression of cholesterol 27-hydroxylase (HY27) and the ATP-binding cassette transporter 
(ABCA1)
35,36. Recent data indicating enhanced gene expression of HY27 and ABCA1 with 
clinical use of methotrexate also supports this emerging hypothesis37. Other work suggests that 
methotrexate has direct effects on apoptosis and on the suppression of adhesion molecule 
function, both of which play relevant roles in atherothrombosis
38,39. 
Finally, LDM is a generic, inexpensive therapy given orally as a once-weekly agent 
allowing for the efficient and safe conduct of a large simple trial. This simplicity has been 
incorporated into CIRT in such a way that ongoing safety evaluations can use a centralized 
methodology that improves participant safety, maintains the study blind while allowing for in-trial 
dose adjustments, and provides an efficient method to address issues of compliance and follow-
up on a cost-effective centralized basis. 
3.3. Diabetes, Metabolic Syndrome, and Inflammation 
 
Post-myocardial infarction patients with diabetes or metabolic syndrome have an 
enhanced pro-inflammatory response and are at high vascular risk, thus providing an excellent 
target population for CIRT
Low Dose 
Low Dose Methotrexate
Methotrexate and CVD: Observational Evidence
and CVD: Observational Evidence
Cohort
Group
HR* (95 % CI)
Endpoint
Exposure
Wichita
RA
0.4   (0.2 -0.8)
Total Mortality
LDM
Choi2002
0.3   (0.2 -0.7)
CV Mortality 
LDM
0.4   (0.3 –0.8)
CV Mortality 
LDM < 15 mg/wk
Netherlands
RA
0.3   (0.1 –0.7)
CVD
LDM
van Helm 2006
Miami VA 
Psoriasis 
0.7   (0.6 –0.9)
CVD
LDM
Pradanovich2005
0.5   (0.3 –0.8)
CVD
LDM < 15 mg/wk
RA
0.8   (0.7 –1.0)
CVD
LDM
0.6   (0.5 –0.8)
CVD
LDM < 15 mg/wk
CORRONA
RA
0.6   (0.3 –1.2)
CVD
LDM
Solomon 2006
QUEST-RA 
RA
0.85  (0.8 –0.9)
CVD
LDM
Narango2008
0.82  (0.7 –0.9)
MI
LDM
0.89  (0.8 -1.0) 
Stroke
LDM
Insurance
Hochberg 2008
RA
0.65  (0.59-0.72)
CVD
LDM
UK Norfolk 
RA, PSA 
0.6   (0.4 –1.0)
Total Mortality
LDM
2008
0.5   (0.3 –1.1) 
CV Mortality 
LDM
. Further, as is the case for atherothrombosis, the core 
Table 1. 

 
9 
pathophysiologic basis underlying insulin resistance and diabetes is hypothesized to entail 
fundamental abnormalities of the innate immune response
40. From a clinical perspective, 
plasma levels of several inflammatory biomarkers increase with increasing numbers of 
components of metabolic syndrome and several inflammatory biomarkers including IL-6 predict 
incident type 2 diabetes
41.  
 With regard to the ability of metabolic syndrome to define a secondary prevention 
population at increased risk of recurrent vascular events, Table 2 presents data from the 4S, 
MIRACL, WIZARD, and TNT trials42-45. As shown, among those with metabolic syndrome as 
compared to those without, the hazard ratios for recurrent cardiovascular disease all 
approximate 1.4 (95%CI 1.2-1.7). Similarly, in a recent meta-analysis of 87 studies, metabolic 
syndrome was associated with a 2-fold increase in cardiovascular events and a 1.5 fold 
increase in all-cause mortality
46. 
 
 
With regard to the ability of diabetes to define a secondary prevention population at high 
risk of recurrent vascular events, Table 3 presents data from the 4S, CARE, LIPID, and HPS 
trials
42,47-49. As shown, among those with diabetes as compared to those without, the hazard 
ratios for recurrent cardiovascular disease are again in a range 1.4 to 1.6 when compared to 
that of individuals without diabetes. 
 
Table 3.  Summary of Association between Diabetes and Subsequent CVD Events in Secondary Prevention Trials 
Study 
Population 
Cohort 
Inception 
Year 
Sample 
Size 
Average 
Follow-
Up (yr) 
Baseline 
DM 
Prevalence 
Outcome 
Event 
Rate 
DM 
Event 
Rate 
No DM 
RR/HR 
4S 
1988 
2223* 
5.4 
10.4 
CVD 
NA 
NA 
1.62 (1.29-2.03) 
CARE 
1989 
4159 
5.0 
14.1 
CHD 
19.1 
10.5 
NA 
LIPID 
1990 
9014 
6.1 
11.9 
CVD 
48.9 
36.5 
1.4 (1.3-1.5) 
HPS 
1994 
20536 
5.0 
29.0 
CHD 
35.6 
22.7 
NA 
* Estimates provided for placebo arm only; NA - not available 
 
3.4. Pharmacology of Low Dose Methotrexate (LDM) 
 
LDM is taken weekly by tens of thousands of patients with similar age and co-morbidity 
profiles as those likely to be enrolled in CIRT. Introduced as a treatment for rheumatoid arthritis 
in 1951, LDM has an enviable safety and efficacy profile that has allowed it to remain the 
dominant disease modifying therapy for RA. A clinically relevant anti-inflammatory effect is 
rapidly achieved for the majority of RA patients at weekly oral doses between 10 and 30 mg.  
Food minimally affects LDM absorption so the drug can be taken in fasting or non-fasting states. 
Circulating methotrexate is less than 50 percent protein bound and has minimal interaction with 
most concomitant medications, including statins, aspirin, beta-blockers, and inhibitors of the 
renin-angiotensin system. However, there is increased risk when methotrexate is used in 
Table 2.  Summary of the Association between MetS and Subsequent Cardiovascular Events in Secondary Prevention Trials 
 
 
 
 
 
 
Event Rate 
 
Study 
Population 
Cohort 
Inception 
Year 
Sample 
Size 
Average 
Follow-Up (yr) 
Baseline 
Prevalence Outcome 
 MetS 
 
No MetS 
RR/HR 
4S 
1988 
2223* 
5.4 
20% 
CVD 
7.2 per 
1000 
person-
months 
5.2 per 
1000 
person- 
months 
1.41 (1.16-1.71 
MIRACL 
1997 
3038 
0.3 
38% 
CHD 
19.2% 
14.3% 
1.40 (1.16-1.67) 
WIZARD 
1997 
3319 
3.1 
53.3 
CHD 
28.1% 
21.1% 
1.33 (1.15-1.53) 
TNT 
1998 
10001 
4.9 
56% 
CVD 
11.3% 
8.0% 
1.44 (1.26-1.64) 
* Estimates provided for placebo arm only 

 
10 
combination with folate depleting drugs such as bactrim (trimethoprim-sulfamethoxazole) or 
drugs that affect tubular secretion (probenecid). Thus, study participants will be alerted to this 
potential toxicity and those with allergies that make use of alternative agents impossible will be 
excluded.  
All study participants (including those on placebo) will receive supplementary folic acid 
(1.0 mg 6 days per week), a simple adjunct known to reduce side-effects of LDM and improve 
long-term compliance that itself has no direct effect on vascular risk.  
Methotrexate is primarily cleared by the kidneys, with 80 to 90 percent being excreted in 
urine. As such, reduction in creatinine clearance (CrCl) is a determinant of serum levels and 
systemic toxicity. Patients with baseline CrCl less than 40 ml/min will not be entered into CIRT, 
and follow-up CrCl will be measured on a regular basis so that drug can be discontinued or 
dose-reduced in the event of incident renal failure; this safety criterion is conservative as the 
American College of Rheumatology allows LDM use even when CrCl is reduced to 30 ml/min. 
3.5. Safety of LDM and Efforts to Reduce In-Trial Toxicity 
 
The wide use of LDM in clinical practice makes it unlikely that any unknown off-target 
toxicities will appear during the conduct of CIRT. Further, risk factors associated with LDM 
toxicity are well known and formal guidelines have been issued by the American College of 
Rheumatology outlining patient groups where therapy is ill-advised19. Broadly, patients with 
hepatitis, renal dysfunction, chronic infections, and certain pulmonary conditions have increased 
risk, and these groups are excluded from study participation, as are patients with a significant 
history of alcohol consumption. As methotrexate can sequester in fluid spaces, participants with 
known chronic pericardial effusion, pleural effusion, or ascites will not be included in the trial. 
Because of the fetopathic and teratogenic effects of methotrexate, women of childbearing 
potential or who intend to breastfeed will not be included in the trial.   
The vast majority of life-threatening hepatotoxicity, pulmonary damage, and 
myelosuppression that have been reported with methotrexate occur at the very high doses used 
during treatment of malignancy (where methotrexate is dosed cyclically by the gram or more). In 
the dose range to be used in CIRT (target dose 15 to 20 mg per week), such life-threatening 
complications are rare. Nonetheless, to reduce the chance of such occurrence within CIRT, 
screening for hepatitis B and C will be conducted before enrollment and patients who are 
positive for chronic infection will be excluded. In addition, monitoring of alanine 
aminotransferase (ALT), aspartate aminotransferase (AST), albumin, creatinine clearance 
(CrCl), and complete blood count (CBC) will be done throughout the study (monthly for the first 
6 months after randomization, then at least bi-monthly for the trial duration). Rarely, in the 
setting of high dose methotrexate (as used in chemotherapy), hypospermia and the potential for 
chromosomal damage to sperm has been reported. While it is uncertain if these effects occur 
with low dose methotrexate, to protect the safety of all study participants and their sexual 
partners, effective contraception will be recommended during the trial and for six months after a 
participant completes the trial.  Men who intend to father children during the trial period will not 
be enrolled. 
All participants must lack significant pulmonary disease at enrollment, and surveillance 
questionnaires seeking symptoms of pulmonary disease will be given every four months during 
study follow-up. A chest X-ray in the 12 months prior to enrollment must be free of evidence of 
interstitial pneumonitis, bronchiectasis, or pulmonary fibrosis. In instances where a chest X-ray 
is not available in the prior 12 months, a baseline chest X-ray will be obtained as part of the 
study protocol. With regard to potential nephrotoxicity, enrollment will be limited to those with 
CrCl ≥ 40 ml/min with dose adjustments or discontinuation built into the protocol in the event of 
renal deterioration. The protocol also incorporates short-term suspension of LDM for patients 
with intercurrrent infections, those receiving antibiotic therapy, those undergoing surgery, and 

 
11 
those who develop new clinically significant pericardial effusion, pleural effusion, or ascites. All 
of these steps are consistent with or more conservative than guidelines issued by the American 
College of Rheumatology for use of LDM19.  
Five aspects of the CIRT protocol are specifically designed to minimize these issues and 
maximize long-term follow-up and compliance. First, an active therapy 5- to 6-week run-in 
(maximum 8 weeks) has been incorporated into CIRT so that any individuals with short-term 
intolerance to LDM will be excluded prior to randomization. Second, the CIRT protocol targets a 
maximal methotrexate dose of 15 to 20 mg po weekly, a dose well within the range of that 
commonly used in the treatment of rheumatoid arthritis. Titration to the 20 mg weekly dose will 
only occur among those trial participants who have tolerated without complication the 15 mg 
weekly dose for a minimum of three months. Third, the protocol titration algorithms and drug 
packaging (calendar blister packs) have been designed in such a way that in response to either 
clinical need, participant report of adverse effects, or to any monitored laboratory evidence of 
hepatic, renal, acute infection, or hematologic abnormality, dosing for individual participants can 
be discontinued on a short term basis or reduced to either a 5, 10 or 15 mg dose/wk as 
tolerated. After clinical resolution and a return of all laboratory abnormalities to a safe range, 
study drug will be re-initiated and up-titrated in 5 mg increments toward the maximal target dose 
of 20 mg po weekly. Fourth, targeted face-to-face education programs will be required for all 
study investigators at the investigator meetings, followed by mandatory web-based safety 
seminars; these educational programs will be provided by the rheumatologic members of the 
CIRT Steering Committee and will ensure a high level of drug safety awareness among all trial 
physicians and staff. Fifth, an ongoing communication program is incorporated into CIRT which 
allows the investigative team to stay in regular contact with trial participants, withhold study drug 
for fevers or inter-current infection, systematically evaluate subjective symptoms, and ensure an 
almost continuous flow of safety data throughout the trial experience. This regular 
communication will also improve compliance and a sense of community for individual 
participants.  
 
4.0. INVESTIGATIONAL PLAN 
4.1. Study Design - Overview 
 
 
CIRT is a randomized, double-blind, placebo-controlled, event-driven trial of LDM (target 
dose 15 to 20 mg/wk) in the secondary prevention of myocardial infarction, stroke, and 
cardiovascular death among stable post myocardial infarction patients who have either 
diagnosed type 2 diabetes or who meet the formal 2004 American Heart Association (AHA) / 
National Heart Lung and Blood Institute (NHLBI) definition of metabolic syndrome which 
includes any 3 of the following 5 diagnostic criteria: waist circumference ≥ 102 cm in men or 88 
cm in women; triglycerides ≥ 150 mg/dl or on drug treatment for elevated triglycerides; high-
density lipoprotein cholesterol (HDL-C)< 40 mg/dL in men or < 50 mg/dL in women or on drug 
treatment for reduced HDL-C; systolic blood pressure ≥ 130 mm Hg or diastolic blood pressure 
≥ 85 mm Hg or on drug treatment for hypertension; and elevated fasting glucose ≥ 100 mg/dL or 
on drug treatment for elevated glucose. All trial participants will have had a documented 
myocardial infarction in the 5 years prior to enrollment and be clinically stable for at least 60 
days after the qualifying event. The qualifying myocardial infarction is the most recent 
myocardial infarction that meets criteria for the diagnosis of myocardial infarction. Any planned 
coronary revascularization procedures associated with the qualifying event must also be 
completed at least 60 days prior to enrollment. 

 
12 
In addition to LDM or matching placebo, all study participants (including those on 
placebo) will receive folic acid 1.0 mg 6 days per week, a therapy known to reduce nuisance 
side effects that can be associated with LDM but that has been shown in multiple major trials to 
have no vascular benefit so there will be no confounding due to folate use.  
Following American College of Rheumatology Guidelines for use of LDM
19, acceptable 
levels of white blood cell count, hematocrit, platelets, CrCl, and liver function (cutoffs provided in 
Exclusion Criteria, section 4.4), as well as negative screens for hepatitis B and C will be 
required prior to active run-in. Individuals with known hepatic disease, chronic pulmonary 
disease (specifically: interstitial pneumonitis, bronchiectasis, or pulmonary fibrosis), or HIV 
related disease will be excluded. A chest X-ray in the 12 months prior to enrollment must be free 
of evidence of interstitial pneumonitis, bronchiectasis, or pulmonary fibrosis. Individuals with 
known chronic pericardial effusion, pleural effusion, or ascites will be excluded. To further 
ensure safety and improve long-term compliance, the trial design incorporates a 5- to 6-week 
open-label, active-therapy run-in (maximum 8 weeks) for all potentially eligible participants so 
that those unable to initially tolerate LDM are excluded prior to randomization. During the 5- to 
6- week open-label run-in, all potentially eligible study participants will initiate LDM at a dose of 
5 mg in week one. In the absence of adverse effects or intolerance, this 5 mg dose will be 
increased to 10 mg for the second and third week of the run-in phase, and then to 15 mg for the 
fourth week. At the end of this 5- to 6-week run-in period safety labs will be repeated. Only 
those participants who demonstrate compliance during this one-month run in and who are free 
of side effects with no significant changes in hematologic or hepatic indices will be considered 
randomizable to active therapy or to placebo.  
Once randomized to active therapy or placebo, all study participants over the first 6 
months of the trial will undergo monthly evaluation for CBC, ALT, AST, albumin, and CrCl using 
blinded and centralized study procedures that have been designed both to ensure patient safety 
and allow for drug discontinuation or dose-adjustment, as well as ongoing evaluations of study 
compliance. At 4 months, those participants randomly allocated to active LDM who have 
tolerated the 15 mg dose without complication will be titrated up to the target dose of 20 mg 
LDM weekly. Six months after randomization, the blood-based safety evaluations will occur at 
least bi-monthly until trial completion. Pre-labeled calendar blister packs similar in design to that 
used in the run-in will be used throughout the study to improve compliance and reduce 
complexity. To maintain the blind as much as possible, sham titrations will be conducted in the 
placebo group proportionate to the number of actual titrations required in the active treatment 
group.  
For any participants developing side effects or in whom laboratory abnormalities 
develop, the protocol allows for drug discontinuation and/or down-titration. The protocol also 
builds in procedures for short-term discontinuation of LDM in circumstances such as fever, 
antibiotic therapy for bacterial infections, during and immediately after surgical procedures, or if 
new clinically significant pericardial effusion, pleural effusion, or ascites develops. Most of these 
steps will be managed centrally to protect the study blind, ensure common compliance across 
study sites, and allow centralized rapid management of any safety issues on an immediate 
basis. After clinical resolution of any events that lead to drug discontinuation and after a return 
of all laboratory abnormalities to a safe range, study drug will be re-initiated and up-titrated over 
time back toward the maximal target dose of 20 mg po weekly, as tolerated. Procedures for 
these dose adjustments, temporary drug discontinuation, and re-initiation of study drug are 
described in detail in the trial algorithms.   
An electronic data capture (EDC) system will be developed and used to collect and 
transmit source data throughout the course of the trial. This system is 21 CFR part 11 compliant 
and meets all relevant governmental regulations. The system will be maintained at SOCAR 
Research, an independent clinical research organization. System functionality will be thoroughly 
tested and validated prior to implementation. Furthermore, to ensure compliance with standards 

 
13 
of use of electronic trial data, standard operating procedures will be maintained for the use of 
the system, an audit trail of data changes will ensure that there is no modification of entered 
data without documentation, and security systems will be maintained to protect against 
unauthorized access. Furthermore, adequate procedures will be used to backup the data and 
safeguard the blinding of the study. As original observations are entered by clinic staff directly 
into the computerized system, the electronic record is considered the source document. The 
EDC system will thus be used in each of the following steps to create, modify, maintain, archive, 
retrieve and/or transmit source data: 1) creation of case report forms, 2) resolution of data 
discrepancies through data queries and checks, 3) implementation of the study drug titration, 4) 
monitoring of drug distribution, 5) reporting of adverse events and endpoints, and 6) endpoint 
adjudication 
 
4.2. Study Population 
 
CIRT will randomize 7,000 men and women, age 18 years and over, who have suffered 
a documented myocardial infarction in the past five years, have completed any planned 
coronary revascularization procedures associated with the qualifying event, have been on a 
stable secondary prevention regimen for a minimum of 60 days, and have either a clinical 
diagnosis of type 2 diabetes or metabolic syndrome.  
For purposes of this trial, the formal 2004 AHA/NHLBI definition of metabolic syndrome 
will be used and requires evidence that any 3 of the following 5 diagnostic criteria are present: 
waist circumference ≥ 102 cm in men or ≥ 88 cm in women; triglycerides ≥ 150 mg/dl (1.7 
mmol/L) or on drug treatment for elevated triglycerides (fibrates, nicotinic acid, or omega 3 fatty 
acids ); HDL-C < 40 mg/dL in men or < 50 mg/dL in women or on drug treatment for reduced 
HDL-C (fibrates or nicotinic acid); systolic blood pressure ≥130 mm Hg or diastolic blood 
pressure ≥ 85 mm Hg or on drug treatment for hypertension; and elevated fasting glucose ≥ 100 
mg/dL or on drug treatment for elevated glucose. 
4.3. Inclusion Criteria 
 
a. Age ≥ 18 years at screening;  
b. Documented myocardial infarction within the past five years, completed any 
planned coronary revascularization procedures associated with the qualifying 
event, and have been clinically stable for at least 60 days prior to screening; the 
qualifying prior myocardial infarction must be documented either by hospital 
records or by evidence on current ECG of Q waves in two contiguous leads 
and/or an imaging test demonstrating wall motion abnormality or scar;  
c.   History of type 2 diabetes or metabolic syndrome at time of study enrollment; 
d.   Willingness to participate as evidenced by signing the study informed consent.  
4.4. Exclusion Criteria 
 
a. Prior history of chronic infectious disease, tuberculosis, or severe fungal disease; 
chronic hepatitis B or C infection; renal insufficiency; interstitial pneumonitis, 
bronchiectasis, or pulmonary fibrosis; known chronic pericardial effusion, pleural 
effusion, or ascites; chronic liver disease; myeloproliferative disorders in the past 
5 years; non-basal cell malignancy or treated lymphoproliferative disease within 
the past 5 years; known HIV positive; life expectancy of < 3 years;  
b. Chronic inflammatory condition such as lupus or rheumatoid arthritis, ulcerative 
colitis or Crohn’s disease 

 
14 
c. White blood cell count < 4,000/ul, hematocrit < 32 percent, or platelet count < 
75,000/ul 
d. Liver transaminase levels (AST or ALT) >upper limit of normal (ULN) or albumin 
< the lower limit of normal (LLN);  
e. Creatinine clearance < 40 ml/min as estimated with the Cockroft-Gault equation;  
f. History of alcohol abuse or unwillingness to limit alcohol consumption to less 
than 4 drinks per week 
g. Women of child bearing potential, even if they are currently using contraception, 
and women intending to breastfeed. 
h. Men who plan to father children during the study period or who are unwilling to 
use effective forms of contraception. 
i. Requirement for use of drugs that alter folate metabolism 
(trimethoprim/sulfamethoxazol) or reduce tubular excretion (probenecid) or 
known allergies to antibiotics making avoidance of trimethoprim impossible;  
j. Current indication for methotrexate therapy;   
k. Chronic use of oral steroid therapy or other immunosuppressive or biologic 
response modifiers (see Exclusionary Medication List in Manual of Operations). 
Eligible study participants will be encouraged to have up to date pneumococcal 
and influenza vaccinations as recommended based on their age and underlying 
medical conditions. 
l. Chest X-ray evidence in the past 12 months of interstitial pneumonitis, 
bronchiectasis, or pulmonary fibrosis. For participants who do not have a chest 
X-ray in the prior 12 months, a chest X-ray will be obtained at baseline as part of 
the study protocol.  
m. New York Heart Association Class IV congestive heart failure.  
4.5. Open Label Run-In 
 
For all potentially eligible patients who provide informed consent and declare interest in 
participation, baseline ALT, AST, hepatitis screens, CrCl, albumin, and CBC will be obtained 
prior to the 5- to 6-week active run-in phase to ensure they meet trial enrollment criteria. A urine 
sample will be assayed for albumin and creatinine.  A blood sample for plasma and buffy coat 
will also be shipped to the central lab for long-term storage and to provide a bank for future 
blood-based biomarker and genetic sub-studies. Quality of life questionnaires will also be 
administered. 
A 5 to 6-week (maximum 8 week) course of open-label LDM will then be given to all 
eligible study participants in a pre-randomization compliance and tolerability run-in. During this 
run-in, participants will be given an initial 5 mg oral weekly LDM dose along with an adequate 
supply of 1.0 mg folic acid to be taken 6 days per week using similar drug calendar packs to 
those used throughout the active trial period. In the absence of adverse effects or intolerance, 
this 5 mg dose will be increased to 10 mg for the second and third week of the run-in phase, 
and then to 15 mg for the fourth and subsequent weeks. This run-in will allow subjects who are 
poorly compliant, who develop any immediate side effects, or who withdraw informed consent to 
be excluded before randomization. Participants must tolerate LDM 15 mg two weeks in a row in 
order to continue in the trial.  All subjects who successfully tolerate LDM 15 mg two weeks in a 
row and are still willing to be randomized will have repeat blood evaluation for AST, ALT, 
albumin, CBC, and CrCl, and any individuals with substantive changes in these parameters will 
be excluded prior to randomization. Urine for albumin and creatinine will also be collected.  The 
run-in will thus enhance long-term compliance and eliminate risk of exposure for any individuals 
with immediate intolerance to LDM.  

 
15 
4.6. Randomization Procedures 
 
All participants who successfully complete the run-in will be eligible for randomization to 
the study drug calendar blister packages that contain either active LDM or placebo as well as 
active tablets containing 1.0 mg folic acid to be taken daily 6 days per week. The randomization 
visit will involve collection of key medical, social, and anthropometric information from the 
participant, as well as a brief physical examination including assessment of the participant’s 
level of physical function.  The responsible site investigator will use an interactive computer 
system for randomization.  The randomization process will involve stratifying participants by 
time since the qualifying myocardial infarction (< 6 months, ≥ 6 months), by presence of either 
diabetes or metabolic syndrome, and by site. All post-randomization safety monitoring and dose 
adjustments will be performed using a standardized centrally run system that has been 
designed to ensure patient safety, maintain double-blinding while allowing for dose titration or 
discontinuation in both the active and placebo groups, provide a central mechanism for tracking 
patient compliance, and that will allow for efficient follow-up and eventual study close-out. To 
reduce inadvertent trial unblinding and further ensure patient safety, procedures have been 
designed to allow for more frequent blood ascertainment at all clinical sites on an as needed 
basis such as might occur during a concomitant infection or change in participant status (see 
Manual of Operations).  
4.7. Cohort Follow up and Clinic Visits 
 
 
All subjects will be seen by the study physician at the time of randomization. From that 
point forward throughout the trial, all participants will be required to see a member of the 
randomizing physician’s study team at least once every 4 months in addition to the regularly 
scheduled laboratory and symptom monitoring procedures described below. At those visits, 
compliance (measured by pill count) as well as evidence of side effects will be ascertained by 
self-report, and in the absence of a study endpoint or laboratory abnormality, a new 4-month 
supply of study drug (or blinded placebo) provided. A Patient Contact Information Form will be 
updated at each of these 4-month visits to facilitate long-term follow-up.  
Cohort follow-up will include a visit form filled out at each of these appointments.  
Information will similarly be sought concerning trial endpoints, issues of compliance will be 
reviewed, anthropometric measures and brief physical examination including reassessment of 
physical function will be performed, participant questions answered, the drug supply ensured, 
and any outstanding study forms completed and/or updated.  In addition, signs or symptoms of 
early drug toxicity will be assessed, as well as the occurrence of any primary or secondary trial 
endpoints or other clinical events of interest. Nephropathy, a clinical event of interest, will be 
assessed by collecting urine for albumin and creatinine at 8 months, 12 months, and then every 
6 months after randomization. Since these data will be obtained in an identical manner from 
participants randomly allocated to LDM as well as to placebo, this procedure will also provide a 
mechanism for monitoring by the Data Coordinating Center (DCC) and reports to the Data and 
Safety and Monitoring Board (DSMB) of any differences between treatment groups with regard 
to side effects or efficacy. At each regularly scheduled safety lab visit (once a month for the first 
6 months after randomization, then at least bi-monthly), participants will be asked about clinical 
symptoms and side effects of the study medication so that study drug dosage may be adjusted 
or temporarily stopped if necessary.  In order to better understand the toxicities of methotrexate, 
at 6 months a blood sample will be collected for the measurement of key metabolites of 
methotrexate.  
For the first 6 months post-randomization, monthly blinded laboratory evaluations for 
ALT, AST, albumin, CBC, and CrCl will be obtained; after that time, evaluation will be done on 
at least a bi-monthly basis until trial completion. As described in the study algorithms, laboratory 

 
16 
values that cross a pre-defined safety threshold (for example, a decline in the total WBC count 
to < 3,000/ul) will trigger a call to the subject to inform the participant not to take the following 
week’s dose of LDM and to ascertain any signs or symptoms of potential toxicity. As described 
in the study algorithms, temporary suspension of study drug will occur whenever subjects are 
being treated with antibiotics, have a clinical infection, develop new clinically significant effusion 
or ascites, or are scheduled for surgery. Similarly, patients will be informed not to take the next 
scheduled study medication if they develop a serious unexplained cough or shortness of breath 
suggestive of interstitial lung disease, or if they develop stomatitis, vomiting, or persistent fever. 
Details of the methotrexate titration algorithm, including up- and down-titration, temporary study 
drug interruption, and permanent study drug discontinuation are included in the trial algorithms. 
The responsible physician will be informed of any changes in study drug dosing. 
After any temporary discontinuation of study drug, study algorithms will be used to 
determine if and when re-initiation of study medication can occur. If a participant’s study 
medication is repeatedly stopped because of laboratory abnormalities or clinical symptoms, the 
medical monitor will review the case to consider a permanent discontinuation of study 
medication. As described in the study algorithms, permanent drug discontinuation can also be 
done at the discretion of the responsible physician. 
 
4.8. Monitoring Participant Laboratory Values and Subsequent Dose Adjustments 
 
In addition to the algorithms designed for safety monitoring in this trial, an additional 
safety feature of CIRT is that when certain laboratory thresholds are crossed, the physician 
responsible for the subject will be notified. 
The specific thresholds for drug discontinuation, re-initiation, down-titration, and up-
titration are described in detail in the trial algorithms that will be used to monitor safety and 
make dose changes across the study on a central and consistent basis. No increase in weekly 
dose will occur unless all of the following criterion are met: the WBC count is ≥ 4000/ul, the 
platelet count is ≥ 75,000/ul, the CrCl is ≥ 40ml/min, ALT/AST levels are ≤ 1.5x ULN, hematocrit 
is ≥ 27 percent, and there are no clinically important symptoms (defined as stomatitis, diarrhea, , 
vomiting, or cough either productive of sputum or associated with a fever or with severe 
shortness of breath). As also described in the study algorithms, a reduction in dose will occur if 
there are changes in some of these parameters that may suggest early toxicity but that are not 
severe enough to warrant drug discontinuation. For example, for a subject taking 20 mg of the 
study drug, while a drop in the platelet count below 50,000 will lead to temporary drug 
discontinuation, a reduction below 75,000 but above 50,000 would lead to a 5 mg decrease in 
the current weekly dosing. After clinical resolution of any events that lead to drug 
discontinuation and after a return of all laboratory abnormalities to a safe range, study drug will 
be re-initiated and up-titrated over time in 5 mg increments back toward the maximal target dose 
of 20 mg po weekly, as tolerated.  Responsible physicians will be informed of any changes in 
study drug dosing recommended by the clinical coordinating center.  Adverse events, patient 
symptoms, laboratory abnormalities, or other reasons for discontinuation of or reduction in dose 
of study drug will be collected through case report forms and monitored centrally by the Data 
Coordinating Center (DCC).  
4.9. Monitoring Participant Symptoms and Subsequent Dose Adjustments 
 
Participants will have regularly scheduled visits with the local investigator during which 
the study staff will carefully assess the patients for any signs or symptoms of drug toxicity, in 
addition to the occurrence of any trial endpoints.  A questionnaire designed to capture 
information about drug toxicity (including symptoms of a pulmonary, infectious, gastrointestinal, 

 
17 
hematologic, dermatologic, and other toxicities), intercurrent hospitalizations, and elective or 
planned surgical procedures will be administered to all study participants at the time of regularly 
scheduled safety lab draws (once a month for the first 6 months after randomization, then at 
least bi-monthly).   
The questionnaire will be administered both by local study staff via the telephone or in 
person.  Study algorithms will combine data from recent laboratory safety evaluations with 
patient reported symptoms to determine study drug dosing and/or cessation, including sham 
placebo dose adjustments.  Responsible physicians will be informed of any changes in the 
study medication dosing.  As noted above, adverse events, patient symptoms, laboratory 
abnormalities, or other reasons for discontinuation of or reduction in dose of study drug will be 
collected through case report forms and monitored centrally by the Data Coordinating Center 
(DCC). 
 Study coordinators are given instructions to contact the Medical Monitor for symptoms 
or signs that raise the possibility of drug toxicity, including the development of new clinically 
significant effusions or ascites. As noted above, in order to better understand the toxicities of 
methotrexate, at 6 months a blood sample will be collected from all participants for the 
measurement of key metabolites of methotrexate. Furthermore, if requested by the DSMB, 
aggregate data on adverse events, stratified by blinded treatment group, will be reviewed on a 
quarterly basis by the Chair of the DSMB, who may then request a more detailed analysis 
and/or forward the data to the full Board.    
4.10. Medical Monitor 
 
A Medical Monitor will be on call 24 hours a day 7 days each week. A senior board-
certified rheumatologist with expertise in drug safety (Senior Rheumatologist) will supervise the 
Monitors. The Monitors will be rheumatologists (fellows or junior faculty) who will be trained by 
the Senior Rheumatologist and will be accessible via pager.  The Monitors will be referred 
subjects based on the pre-laboratory questionnaire or laboratory abnormalities and will have 
access to the subjects’ laboratory data and clinical information via the EDC system.  The 
Monitors will have the option of unblinding the treatment allocation of a subject, if the symptoms 
and acuity of illness make doing so warranted. 
Monitors will help sites determine whether the symptoms being described by patients are 
concerning, whether interruptions in study drug are warranted, and whether re-initiating study 
drug is safe.  While all Monitors will have experience with methotrexate prescribing, the Senior 
Rheumatologist will compile a list of scenarios as they occur that will allow the Monitors to have 
a consistent approach.  The Monitors as a group will meet monthly with the Senior 
Rheumatologist to discuss these scenarios.  As the trial progresses, these meetings are 
anticipated to occur every quarter. 
4.11. Endpoint Definitions and Documentation 
 
The primary endpoint is defined as the time to the first adjudication committee confirmed 
major adverse cardiovascular event (MACE) occurring during the double-blind treatment period, 
which is a composite of CV death, non-fatal MI, and stroke.  
An independent Clinical Endpoints Committee (CEC) will review and adjudicate all 
clinical events that constitute the primary composite endpoint (CV deaths, non-fatal MI, and 
stroke).  In addition, the CEC will adjudicate a number of secondary endpoints, including all 
deaths, all hospitalizations for unstable angina requiring unplanned revascularization, all 
hospitalizations for congestive heart failure, and all arterial revascularization procedures. The 
CEC will be blinded to treatment assignment. Formal definitions for the individual components of 
the primary endpoint, hospitalization for unstable angina requiring unplanned revascularization, 

 
18 
hospitalizations for congestive heart failure, and arterial revascularization are provided in the 
Clinical Endpoint Committee (CEC) Charter. The secondary and tertiary endpoints listed in 
sections 2.2 and 2.3 not adjudicated by the CEC will be validated by non-CEC staff.  For 
example, incident diabetes will be confirmed by a combination of patient or physician report, 
new anti-diabetic medications, or by protocol-based measures of glucose and HbA1c performed 
at least twice annually. Incident venous thromboembolism will be confirmed using 
documentation of imaging studies including a venous ultrasound or venogram showing deep 
venous thrombosis or a pulmonary arteriogram, CT scan, or ventilation-perfusion scan showing 
pulmonary embolism.  
Other non-adjudicated clinical events of interest include microvascular disease 
(nephropathy and retinopathy), sleep apnea, and age-related macular degeneration. 
Full descriptions of the methods for endpoint ascertainment and the specific definitions 
of each adjudicated trial endpoint are contained in the Clinical Endpoint Charter (CEC). 
4.12. Procedures for Emergency Unblinding 
 
As part of the trial monitoring structure, a medical monitor will also be available on a 24 
hour basis who has the ability to electronically access individual patient data files should 
unblinding be needed. All of these instances will be tracked within the EDC system. 
4.13. Investigator Education Programs 
 
To ensure that all investigators and study coordinators are comfortable with LDM 
regardless of specialty area, a face-to-face targeted education program will be provided as part 
of the trial Investigator Meetings and a series of on-line teleconference/webinars will be 
provided every 6 months where educational information regarding LDM will be updated and 
reinforced.  
4.14. Drug Compliance Monitoring 
 
The primary measure of compliance will be based on the return of calendar packs to the 
physician at each of the 4-month office visits (at which time new calendar packs will be issued 
as long as no trial endpoint or major side-effects have occurred).  
As an additional measure of compliance, washed packed red blood cells collected 6 
months after randomization will be stored in a central laboratory for measures of methotrexate 
levels. This will be done using a methotrexate polyglutamate assay that provides a semi-
quantitative method of evaluating methotrexate absorption and metabolism.  The results of this 
assay will not be available to blinded study staff until after the study has completed and the 
database has been locked. 
4.15. Central Laboratory and Bio-bank 
 
Blood samples for storage in a bio-bank at Brigham and Women’s Hospital will be 
obtained at the pre-run-in, randomization, and at 8 and 24 months after randomization. 
Processing and long-term storage of these samples will be done in a liquid nitrogen biobank 
facility in Boston, which has been used for this purpose in multiple prior NIH-funded trials and 
large cohort studies. White blood cells from the pre-run-in sample will also be stored in this 
facility to allow for DNA extraction at a later date. As described in the informed consent 
documents, participation in the genetic bio-banking portions of CIRT will be on an “opt-out” 
basis and are not a requirement for participation in the main trial.  

 
19 
4.16. Serious Adverse Events (SAEs) 
 
All subjects will be monitored at the local study sites on a regular basis during the course 
of study involvement.  All SAEs will be reported within 24 hours of local event awareness (but 
no later than the next business day) to the Data Coordinating Center (DCC).  Initial reports will 
often not be complete.  Central study staff will guide the site regarding the completion of a SAE 
form along with retrieval of the pertinent medical records for determination of a final diagnosis.  
An updated full written report will be filed as additional information becomes available within 10 
working days (14 calendar days).  The report will include a complete description of the event, 
use of all concomitant medications, and the local investigator’s assessment of causality of the 
SAE to study therapy.  All serious adverse events will be recorded in the core study database 
within 1 week of report by the local study site personnel.  SAE reporting for all subjects will 
occur in accordance with the central institutional review board (IRB) requirements. Study staff 
may contact patients directly to determine the resolution of adverse events.    
 
4.17. Data Coordination and Treatment Masking 
 
The DCC is responsible for the facilitation of prompt evaluation of reported adverse 
events and symptoms.  Upon receipt from a site of a report of specific adverse events, 
combinations of symptoms, or symptoms persisting over time that meet pre-specified criteria, 
the data will be combined with recent laboratory assays and the safety monitor will be notified 
that there is a report requiring evaluation.  
The DCC will also provide monthly reports to the Executive Committee.  The Progress 
Report will include: enrollment and randomization rates, overall and by sex and race; reasons 
for randomization ineligibility; number of completed follow-up visits; number of completed interim 
safety bloods; number of blood specimens sent to the central repository; number of dose 
changes; current distribution of doses; number of patients off drug; reasons for discontinuation; 
number of unblindings and reasons for the unblindings.  The Quality Control Report will include 
tables on inappropriate randomizations; number of missed visits; reasons for missed visits; 
number of visits taking place outside of the designated time windows; and rates of missing data 
broken down by form.  Both the Progress Report and the Quality Control Report will pool 
participants across treatment groups to maintain the study blind. 
The DCC also assumes responsibility for maintenance of blinded treatment 
assignments.  Data files with these assignments will be kept on a secure, password protected 
server housed in a locked, climate-controlled room with restricted access or on a password 
protected encrypted laptop.  To preserve the integrity of the trial, unblinded DCC staff will not 
participate in decisions to modify the trial protocol after participants have been randomized.  The 
Steering Committee will obtain statistical input for such decisions from other academic 
statisticians, blinded to treatment assignment, who also work at Harvard Medical School. 
 
4.18. Data and Safety Monitoring Board 
 
Due to the potential risks to study subjects, the size and multi-site nature of the study, 
and the fact that this is a Phase III clinical trial, the study will have a formal, and independent, 
Data and Safety Monitoring Board (DSMB). The DSMB will be constituted by the NHLBI and will 
include at a minimum members from the following general areas: 1) physicians with specific 
expertise in the management of patients’ cardiovascular disease 2) a biostatistician with specific 
expertise in the design, analysis, and safety monitoring of multi-center clinical trials 3) a medical 
ethicist, and 4) a physician with specific expertise in rheumatologic disease.  The DSMB will 

 
20 
report directly to the NHLBI, and would have the responsibility of monitoring outcome 
measurements/endpoints, adverse events (AE’s), and serious adverse events, and 
recommending termination of the study if it appeared at any point during the trial that subjects 
(or a subgroup of subjects) were being placed at undue risk as a result of their participation.  
Aggregate data on adverse events, stratified by blinded treatment group, will be reviewed on a 
bimonthly basis by the Chair of the DSMB, and can be brought before the entire DSMB for 
further review if requested by the Chair. 
The DSMB will meet (face-to-face or by teleconference) at designated intervals (semi-
annually) to review accumulated data on safety and efficacy, and if appropriate, conduct an 
interim analysis of the data. Data will be prepared by the Data Coordinating Center (DCC) prior 
to each meeting of the DSMB. Serious Adverse Events (SAEs) will be initially reviewed with 
DSMB members blinded to treatment group. If, however, aggregate data suggested a trend 
toward more frequent SAEs among one treatment group, an unblinded interim analysis would 
be reviewed by the DSMB.  Guidelines for the possible early termination of the study will be 
formulated by the DSMB and a formal charter agreed upon prior to trial enrollment.  The 
proceedings of each meeting of the DSMB will be recorded in minutes. Any patient-specific 
protected health information reviewed by the DSMB would be kept completely confidential. 
Access to the unblinded minutes of the DSMB meetings by Executive/Operations Committee 
Members, Clinical Site Investigators, or members of the DCC, will be prohibited until after the 
database for the study has been locked and the study has been unblinded. A formal report will 
be submitted by the DSMB to the NHLBI, with a recommendation that the study be continued, 
modified in a manner to enhance subject safety, or terminated. 
 
4.19. Trial Conclusion and Close Out Visits 
 
 
At the close of the trial, all randomized participants will be asked to return to the local 
study sites to see a member of the physician’s study team.  Compliance, side effects, and 
patient contact information will be collected, and study end points will again be assessed by the 
local study staff.  Therapy with study drug will be discontinued, and the patient’s remaining 
calendar packs of study drug will be collected. While no observational registry is currently 
planned, the Clinical Coordinating Center may request that local study sites approach study 
participants about enrolling in a post-trial observational registry.    
To assess the impact of LDM withdrawal on diabetes incidence and glycemic control, 
participants will have one final laboratory evaluation for ascertainment of HbA1c 3 months after 
discontinuing study drug therapy.  
5.0. DATA ANALYSIS PLAN 
5.1. Statistical Analysis 
 
 
The randomized design and large sample size of CIRT should provide balanced 
distributions of baseline characteristics between the two treatment groups.  Nonetheless, initial 
analyses will be conducted to identify any chance imbalances in these distributions.  In 
particular, these analyses will form part of the routine monitoring of the trial and will be regularly 
reported to the DSMB.  For continuous and ordinal variables, including age and baseline levels 
of risk factors including lipid levels, blood pressure, and body mass index, comparisons will use 
the Wilcoxon rank-sum test.  For categorical variables, including sex, race, current and former 
cigarette smoking, diabetes, greater than 1 prior myocardial infarction, stroke, congestive heart 
failure, atrial fibrillation, peripheral vascular disease, hypertension, and concomitant therapy with 

 
21 
statins, aspirin, clopidogrel, warfarin, beta blockers, ACE inhibitors, and angiotensin receptor 
blockers, comparisons will use Chi-square tests. These hypothesis tests are intended for data 
monitoring and quality control, and not to determine which baseline covariates to include in 
efficacy analyses50. 
The primary endpoint of the trial is the time from randomization to the first occurrence of 
any component of the clinical composite endpoint including myocardial infarction, stroke and 
cardiovascular death.  The primary analysis of the trial will use a likelihood ratio test based on a 
proportional hazards model stratified on time since index myocardial infarction (≥ 6 months vs. < 
6 months) to test the null hypothesis of no association between assignment to active 
methotrexate and the rate of the primary endpoint.  All analyses will classify patients according 
to their randomized treatment assignment, i.e. according to the intention to treat principle, and 
will base evaluation of statistical significance on a two-sided test with level 0.05.  Secondary 
analyses will further stratify on study site, although these analyses will likely be less efficient 
because of sparse strata that will arise because of small numbers of participants from some 
sites.  The estimated relative hazard in the methotrexate group compared to the placebo group 
with an accompanying 95% confidence interval will quantify the treatment effect51.  If this 
relative hazard is less than 1, then 100*(1-estimated relative hazard) will be defined as the 
percent reduction in hazard associated with methotrexate treatment. 
Rates of occurrence of the primary endpoint will be defined as the total number of 
subjects who have this event in a treatment group per 100 person-years of follow-up, counting 
all time from randomization until the first of the event, death, end of trial, or withdrawal of 
consent.  Estimates of the probability of the primary endpoint by time after randomization within 
treatment groups will be based on the method of Kaplan and Meier
52.  We will also use the 
proportional hazards model to control for baseline factors that might influence the rate of the 
primary endpoint (e.g. age, race, gender, baseline comorbidities, and concomitant medications), 
as control for these variables may yield more efficient estimates of relative treatment effects53.  
If Kaplan-Meier plots of event free survival by study time, or related plots of log(-log)(survival), 
indicate violations of the proportional hazards assumption, or a formal test of trend in the scaled 
Schoenfeld residuals indicates such a violation, then weighted log-rank tests will be used 
according to strategies described by Pecková and Fleming54.  However, even in the presence of 
an apparent violation of the proportional hazards assumption, the primary analysis described 
above gives a valid (although perhaps not optimal) test of the main trial hypothesis and will 
remain the primary analytic strategy, with these weighted log-rank tests serving as sensitivity 
analyses.   
5.2. Sample Size and Power 
 
 
Sample size and power for CIRT have been estimated under several alternative 
assumptions about the rate of the primary endpoint in the placebo group and the likely reduction 
in this rate among those in the methotrexate group.  All estimates are based on a two-sided log-
rank test comparing the time to recurrence between two treatment groups at the 0.05 
significance level.  These estimates use the approach of Lachin and Foulkes under the 
assumption of a uniform hazard and to account for attrition due to drop-out55.  The following 
assumptions have been made: 
(a) Based on previous trials in individuals with a prior myocardial infarction, and 
considering the increased rate of major cardiovascular events associated with either 
diabetes or metabolic syndrome, it is anticipated that annual event rates between 
3.25 and 4.0 per 100 person-years in the placebo group.  
(b) A clinically meaningful reduction in the rate of the primary endpoint is assumed to be 
in the range from 25% to 35%.   

 
22 
(c) The recruitment period will be split into a ramp-up period, followed by steady-state 
randomization.  Each randomized patient will be asked to continue blinded treatment 
until study completion.   
(d) As these patients have strong affiliations with their treatment centers and will have 
been tested in a run-in period, low rates of loss to follow-up are anticipated.  Power 
calculations assume a 5% annual rate of loss to follow-up.   
 
Under these assumptions Lachin and Foulkes show that the power of the trial with N total 
randomized subjects in the methotrexate and placebo groups combined is 














c
e
1/2
e
c
1
-
2
 
+
 
2
/
3.92
-
-
N
 
=
 
Power




 
 
where Φ is the standard normal distribution function,
 


5 
[exp(2( .05) exp(-4( +
.05)]
/(2( +
.05))
( )
 =
 
  +
 
.0 /1-
,



 



 

 
e
 
 is the incidence rate in the methotrexate group,
c
 
 is the incidence rate in the placebo group



 = 
.5 +
.5
e
 
c
 
 
follow-up for uncensored subjects without events ranges from 2 to 4 years. 
Table 4 shows the power of CIRT to detect alternative relative hazard rates in an active 
treatment group with 3500 patients compared to 3500 patients who receive placebo.  The trial 
has good power (>90%) to detect hazard reductions of 25% or greater for the range of 
reasonable event rates in the placebo group, and power of 95% or greater to detect a reduction 
of 25% or greater if event rates in the placebo group are 4.0 per 100 person-years or greater.  
These power calculations are based on intention to treat analyses of observed event 
rates. As such, they incorporate the effects of non-compliance.  We estimate, based on 
experience observed in other trials, that, in addition to those who drop out, 10% of the 
methotrexate group will discontinue active therapy but that none of the placebo group will initiate 
open-label therapy (drop-in).  The impact of non-compliance on power can be evaluated from 
interpolation using Table 4.  For example, if the true rate of major cardiovascular events in 
persons meeting eligibility criteria but not on methotrexate is 3.5 per 100-person years, and fully 
compliant methotrexate reduces this rate by 30%, we estimate a rate of the primary endpoint of 
2.555 per 100 person-years in the methotrexate group and 3.5 per 100 person-years in the 
placebo group.  This would correspond to an observed 27% reduction in the active treatment 
group relative to placebo with the above non-compliance and drop-in rates.  The proposed trial 
would thus have power above 90% to detect such a true effect.  However, we base primary 
evaluation of study 
power on observed 
event rates and 
intention to treat 
analyses, as 
summarized in Table 
4. 
 
Another perspective on sample size estimation based on the above formulation of 
enrollment indicates that, regardless of the rate of major cardiovascular events in the placebo 
group, the trial must accrue 514 total confirmed major cardiovascular events in order to have 
90% power to detect a 25% reduction in this rate, based on a two-sided test with alpha=0.05. 
Given a conservative interim monitoring plan such as that described below, then the approach 
of Reboussin et al56 indicates that sample size needs to be increased by 1.9% to maintain 90% 
power in the presence of monitoring.  We therefore stipulate that the trial will require accrual of  
530 total primary events. With respect to the above assumptions on accrual and drop out, and 
the range of event rates in the placebo group shown in the above table, the proposed trial with 
Table 4. Power of CIRT for alternative event rates and effect sizes in this proposal 
 
Rate of Major Cardiovascular Events in the Placebo Group 
 (per 100 person-years) 
Relative Rate 
3.25 
3.5 
3.75 
4.0 
.75 
91% 
93% 
94% 
95% 
.7 
98% 
99% 
99% 
99% 
.65 
>99% 
>99% 
>99% 
>99% 

 
23 
7,000 randomized subjects would be expected to accrue between 529 endpoints (placebo event 
rate=0.0325/100 person-years) and 645 endpoints (placebo event rate=0.040/100 person-
years) under the assumption of a 25% reduction in hazard associated with methotrexate. 
5.3. Stratification and Randomization 
 
Patients willing and eligible to be randomized will be stratified by time since their 
confirmed index myocardial infarction (< 6 months vs.> 6 months), the presence of diabetes or 
metabolic syndrome at entry, and by site. 
5.4. Interim Feasibility Analysis 
 
Per NHLBI agreement, an interim feasibility analysis will be performed jointly by the 
DSMB and the NHLBI after 1000 patients have been randomized and followed for at least 6 
months. At this time, trial feasibility and safety will be reviewed, the trial dose range will be 
evaluated, suitability of the trial algorithms considered, and recommendations will be made to 
the investigators with regard to any needed protocol changes at that time.    
Thus, for purposes of the feasibility analysis, the investigators will submit a report to the 
NHLBI including the cumulative recruitment experience to date, the adherence among 
randomized participants, the rates of adverse events both overall and according to the major 
disease categories and the percent of participants willing to continue.  It is expected that this 
report will pool information across treatment groups (i.e. maintain the treatment blind).  
However, a parallel report with information by treatment group will be submitted simultaneously 
to the trial’s Independent Data and Safety Monitoring Board. 
5.5. Interim DSMB Analyses 
 
Interim analyses of rates of the primary outcome, as well as rates of the individual 
components of the composite endpoint, and the pre-specified secondary endpoints will be 
prepared for presentation to the Data and Safety Monitoring Board (DSMB).  Reports to the 
DSMB will also include comparisons of baseline characteristics between treatment groups, 
displays of cumulative recruitment by study time, comparisons of post-randomization laboratory 
values by treatment group, and rates of adverse events, both overall and within systems, by 
treatment group.  The frequency of the meetings will be determined by the independent DSMB 
appointed by the NHLBI.   
While the frequency of meetings and the approach to interim monitoring will be the 
choice of the DSMB, we anticipate at least twice yearly meetings to monitor recruitment and 
retention, with quarterly safety reports. To preserve alpha and to minimize the likelihood of an 
inflated effect estimate associated with early stopping, pre-planned efficacy analyses will occur 
only upon accrual of 50% and 75% of the planned study endpoints, i.e. 265 and 398 confirmed 
primary endpoints.  Additional interim analyses of efficacy data may be carried out by the 
DSMB.  The design of the trial, including evaluation of the implications of interim monitoring on 
study power, considered that stopping boundaries would be based on an alpha-spending 
function that approximates an O’Brien-Fleming boundary.  Specifically, efficacy monitoring 
would utilize the Lan-DeMets procedure with spending function α(t*)=2-2Φ(Zα/2/√t*), where t* is 
the information fraction, Φ is the standard normal distribution function, α is the two-sided type 1 
error rate, and Zα/2  is its 100(1-α/2)th percentile.  Under this approach, the Z-values for the 
boundaries at the 50% and 75% information times would be ±2.963 and ±2.359, respectively, 
corresponding to two-sided P-values of 0.0030 and 0.0183, and observed hazard ratios of 0.695 
and 0.789, respectively.   

 
24 
The DSMB has voted to prefer more conservative boundaries, and chose a P-value of 
0.0001 at both information times, which corresponds to a Z-value of ±3.891.  Approximate 
hazard ratios associated with this Z-value are 0.620 at 50% information and 0.677 at 75% 
information. 
As a guideline for considering a recommendation to stop the study early because of 
convincing evidence of inefficacy (futility), pre-planned inefficacy bounds will also be considered 
upon accrual of 50% and again upon accrual of 75% of the targeted numbers of confirmed 
primary endpoints, i.e. upon accrual of 265 and 398 confirmed primary endpoints.  Based upon 
the Linear 20% Inefficacy Boundary approach described by Freidlin, Korn, and Gray (Clin Trials 
2010; 7: 197-208), the inefficacy boundary will be crossed if the observed relative hazard of the 
primary endpoint associated with methotrexate assignment is greater than 0.99 at the first 
interim futility analysis, or is greater than 0.97 at the second interim futility analysis.  Simulations 
performed by Freidlin et al indicate that their Linear 20% Inefficacy Boundary approach is 
associated with a less than 1% loss of power due to inefficacy monitoring.  Further, their 
approach is more conservative than a 10 or 30% conditional power approach in later follow-up 
(i.e. after 70% of information is accrued).  However, the Linear 20% Inefficacy Boundary 
approach is more aggressive than a 10% (or even a 20%) conditional power rule at the 50% 
information accrual point, so a more conservative boundary of an observed relative hazard 
associated with methotrexate assignment greater than 1.11 at the first interim futility analysis 
(the cutpoint associated with conditional power below 10%), may be preferred at that time, 
especially as use of this cutpoint will preserve power. 
 
5.6. Secondary Analysis 
 
 
In addition to the primary comparisons of methotrexate treatment with placebo, pre-
specified secondary endpoints (Section 2.2) will also be compared between treatment groups.  
Additional analyses will separately evaluate whether the relative effects of methotrexate 
versus placebo on primary and secondary endpoints is uniform over the follow-up period.  
These evaluations will be based on the tests for significant interactions between study time and 
treatments proposed by Cox
51 as well as consideration of trends in scaled Schoenfeld residuals 
in the proportional hazards model.  Specifically, residuals will be plotted and a significant rank 
correlation of residuals with time will be indicative of a changing effect60.  In the presence of 
significant correlation, separate effects by time period will be reported.  However, even with a 
significant correlation of residuals with time, the best overall estimate of the effect of treatment 
will be the estimate obtained from the proportional hazards model without the interaction.   
Separate proportional hazards models will also be used to compare the effects of 
methotrexate treatment on time to each of the individual components of the composite endpoint.  
Analyses will use methods of competing risks survival analysis and compare the relative effects 
of randomized treatments on the different components of the composite outcome61,62.  The 
approach of Lunn and McNeil61 provides a readily accessible implementation of a classical 
approach to competing risk analysis developed by Kalbfleisch and Prentice63. 
 
While all primary analyses are on an intention-to-treat basis, CIRT is also functioning as 
a proof of concept trial and thus analyses of those compliant with the respective LDM or placebo 
regimens will also be conducted in secondary analyses. 
 
Longitudinal analyses will quantify the impact of methotrexate on lipid levels, biomarkers 
of inflammation, and change in HbA1c, with the latter analyses stratified by presence of 
diabetes at baseline. We will also assess whether any effects on these biomarkers mediate 
observed benefits or risks of LDM on clinical outcomes in the trial. 
 

 
25 
5.7. Subgroup Analyses 
 
Additional planned exploratory analyses include evaluation of whether treatment effects 
vary across categories of baseline covariates including age, gender, race, presence of diabetes 
or metabolic syndrome at baseline, baseline lipid levels, baseline inflammatory biomarker levels, 
baseline background treatments including those known to interact with LDM therapy, and 
nutritional measures related to adenosine function such as estimated daily total caffeine intake.  
Within each subgroup, we will use proportional hazards models to estimate the relative rate of 
the primary endpoint associated with active treatment versus placebo.  Both crude analyses and 
models including limited baseline covariates will be fitted.  To test for the significance of 
modification of treatment effects by a baseline characteristic, we will include interaction terms 
between this characteristic and treatment in the proportional hazards model, with statistical 
significance determined by a likelihood ratio test comparing models with and without the 
interaction terms between treatment and the categories of a specific covariate.   
We will conduct these subgroup analyses regardless of whether or not the overall 
analyses of treatment effects are significant.  Our approach to interpretation of subgroup 
analyses has always been very cautious and recognizes that, even in large trials, it is not likely 
to be possible to identify reliably subgroups of patients in whom treatment is especially effective 
or ineffective.  In the absence of prior evidence for real heterogeneity, the overall trial result may 
provide the best evidence for the presence of a benefit in a subgroup.  Our approach thus 
corresponds to an informal empirical Bayes procedure in which effects in an outlying subgroup 
require interpretation in light of the overall treatment effect. 
 
5.8. Ancillary Studies 
 
 
A number of CIRT ancillary studies are planned.  These studies include but are not 
limited to a proposal to develop an evidence-based approach to monitoring the safety of LDM in 
a large population; a proposal to examine lipid, inflammatory, metabolic, and myocardial 
biomarkers as determinants of risk in a secondary prevention population; a proposal to 
determine the effect of LDM on echocardiographic indices of aortic stenosis; a proposal to 
determine the effect of LDM on the ankle brachial index and incident peripheral artery disease; 
a proposal to examine the genetic determinants of LDM safety and efficacy; and a proposal to 
examine the impact of LDM on non-alcoholic fatty liver disease and hepatic inflammation. 
Additional planned ancillary studies include proposals focused on anemia, cognitive decline, 
depression, and vascular function.  For any ancillary study that requires participant interactions 
beyond that described in the main trial, additional IRB approval and informed consent will be 
obtained. 
 

 
26 
 
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Cox D. Regression models and life tables (with discussion). J Roy Statist Soc Ser B. 
1972;34(2):187-220. 
52. 
Kaplan E, Meir P. Nonparametric estimation from incomplete observations. J Am Statist Assoc. 
1958;53:457-481. 
53. 
Pocock SJ, Assmann SE, Enos LE, Kasten LE. Subgroup analysis, covariate adjustment and 
baseline comparisons in clinical trial reporting: current practice and problems. Stat Med. 
2002;21(19):2917-2930. 
54. 
Peckova M, Fleming TR. Adaptive test for testing the difference in survival distributions. Lifetime 
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55. 
Lachin JM, Foulkes MA. Evaluation of sample size and power for analyses of survival with 
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Biometrics. 1986;42(3):507-519. 
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Reboussin DM, DeMets DL, Kim KM, Lan KK. Computations for group sequential boundaries 
using the Lan-DeMets spending function method. Control Clin Trials. 2000;21(3):190-207. 
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Lan K, DeMets D. Discrete sequential boundaries for clinical trials. Biometrika. 1983;76:659-663. 
58. 
Freidlin B, Korn EL, Gray R. A general inefficacy interim monitoring rule for randomized clinical 
trials. Clin Trials. 2010;7(3):197-208. 
59. 
Boden WE, Probstfield JL, Anderson T, et al. Niacin in patients with low HDL cholesterol levels 
receiving intensive statin therapy. The New England Journal of Medicine. 2011;365(24):2255-
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Grambsch PM, Therneau TM. Proportional hazards tests and diagnostics based on weighted 
residuals. Biometrika. 1994;81(3):515-526. 
61. 
Lunn M, McNeil D. Applying Cox regression to competing risks. Biometrics. 1995;51:524-532. 
62. 
Glynn RJ, Rosner B. Comparison of risk factors for the competing risks of coronary heart disease, 
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63. 
Kalbfleisch J, Prentice R. The Statistical Analysis of Failure Time Data. New York: John Wiley 
and Sons; 1980. 
 

 
29 
 

 
1 
 
 
 
 
 
 
 
 
 
 
 
PROTOCOL 
V1.7 
 
 
 
Cardiovascular Inflammation Reduction Trial (CIRT): 
 
 
A randomized, double-blind, placebo-controlled, event-driven trial of weekly 
low-dose methotrexate (LDM) in the prevention of cardiovascular events among stable 
coronary artery disease patients with 
type 2 diabetes or metabolic syndrome 
 
 
 
 
 
Center for Cardiovascular Disease Prevention 
Brigham and Women’s Hospital 
 
 
Funding: National Heart Lung and Blood Institute 
 
 
 
October 30, 2014 
 
IND 116831 
 

 
2 
Abbreviations 
 
 
ABCA1  
ATP-binding cassette, sub-family A (ABC1), member 1 
AE    
Adverse event 
AHA   
American Heart Association 
ALT    
Alanine aminotrasferase 
AST   
Aspartate aminotransferase 
CBC   
Complete blood count 
CCC   
Clinical Coordinating Center 
CEC   
Clinical Endpoints Committee 
CIRT   
Cardiovascular Inflammation Reduction Trial 
CrCl   
Creatinine clearance 
CRP   
C reactive protein 
DCC   
Data Coordinating Center 
DSMB   
Data and Safety Monitoring Board 
DVT   
Deep venous thrombosis 
eGFR   
Estimate glomerular filtration rate 
HbA1c   
Hemoglobin A1c 
HDL-C   
High density lipoprotein cholesterol 
HY27   
Cholesterol 27-hydroxylase 
IL-1    
Interleukin-1 
IL1ra   
Interleukin-1 receptor antagonist 
IL-6    
Interleukin-6 
IRB    
Institutional review board 
GFR   
Glomerular filtration rate 
LDM   
Low dose methotrexate 
LDL-C   
Low density lipoprotein cholesterol 
LLN    
Lower limit of normal 
NHLBI   
National Heart Lung and Blood Institute 
PE    
Pulmonary embolus 
RA    
Rheumatoid arthritis 
SAE   
Serious adverse event 
TNF   
Tumor necrosis factor 
ULN   
Upper limit of normal 
WBC   
White blood cell count  
 

 
3 
1.0. TRIAL OVERVIEW ............................................................................................................. 4 
2.0. SPECIFIC AIMS.................................................................................................................. 4 
2.1. Primary Aim ..................................................................................................................... 5 
2.2. Secondary Aims .............................................................................................................. 5 
2.3. Tertiary Aims ................................................................................................................... 5 
2.4. Proposed Exploratory and Mechanistic Studies ............................................................... 6 
3.0. BACKGROUND AND SIGNIFICANCE ............................................................................... 6 
3.1. The Inflammatory Hypothesis of Atherothrombosis ......................................................... 6 
3.2. Low-Dose Methotrexate (LDM) and Cardiovascular Disease .......................................... 7 
3.3. Diabetes, Metabolic Syndrome, and Inflammation ........................................................... 8 
3.4. Pharmacology of Low Dose Methotrexate (LDM) ............................................................ 9 
3.5. Safety of LDM and Efforts to Reduce In-Trial Toxicity ....................................................10 
4.0. INVESTIGATIONAL PLAN ................................................................................................11 
4.1. Study Design - Overview ................................................................................................11 
4.2. Study Population ............................................................................................................13 
4.3. Inclusion Criteria ............................................................................................................13 
4.4. Exclusion Criteria ...........................................................................................................14 
4.5. Open Label Run-In 
.........................................................................................................14 
4.6. Randomization Procedures ............................................................................................15 
4.7. Cohort Follow up and Clinic Visits ..................................................................................15 
4.8. Monitoring Participant Laboratory Values and Subsequent Dose Adjustments ...............16 
4.9. Monitoring Participant Symptoms and Subsequent Dose Adjustments ...........................17 
4.10. Medical Monitor ............................................................................................................17 
4.11. Endpoint Definitions and Documentation ......................................................................18 
4.12. Procedures for Emergency Unblinding .........................................................................18 
4.13. Investigator Education Programs ..................................................................................18 
4.14. Drug Compliance Monitoring ........................................................................................18 
4.15. Central Laboratory and Bio-bank 
..................................................................................19 
4.16. Serious Adverse Events (SAEs) ...................................................................................19 
4.17. Data Coordination and Treatment Masking ..................................................................19 
4.18. Data and Safety Monitoring Board ................................................................................20 
4.19. Trial Conclusion and Close Out Visits ...........................................................................20 
5.0. DATA ANALYSIS PLAN ...................................................................................................21 
5.1. Statistical Analysis..........................................................................................................21 
5.2. Sample Size and Power .................................................................................................22 
5.3. Stratification and Randomization ....................................................................................23 
5.4. Interim Feasibility Analysis .............................................................................................23 
5.5. Interim DSMB Analyses .................................................................................................23 
5.6. Secondary Analysis ........................................................................................................24 
5.7. Subgroup Analyses ........................................................................................................25 
5.8. Ancillary Studies .............................................................................................................26 
6.0. REFERENCES ..................................................................................................................27 
 
 
 

 
4 
1.0. TRIAL OVERVIEW 
 
  
While inflammation contributes crucially to atherothrombosis, it is unknown whether 
inhibition of inflammation per se will lower vascular event rates. The primary aim of the 
Cardiovascular Inflammation Reduction Trial (CIRT) is to directly test the inflammatory 
hypothesis of atherothrombosis by evaluating whether or not low-dose methotrexate (LDM) will 
reduce rates of myocardial infarction, stroke, and cardiovascular death among stable coronary 
artery disease patients with type 2 diabetes or metabolic syndrome, conditions associated with 
an enhanced pro-inflammatory response.  CIRT is a randomized, double-blind, placebo-
controlled, multi-center, event-driven trial that will randomize 7,000 men and women from the 
United States and Canada. Following a five- to six-week open-label run-in (maximum 8 weeks), 
eligible participants who have either suffered documented myocardial infarction in the past or 
have angiographically demonstrated multivessel coronary artery disease in the past will be 
randomly allocated over a three to four year period to usual care plus placebo or usual care plus 
LDM. The target methotrexate dose among those allocated to active therapy is 15 to 20 mg po 
per week, a dose within the range of that commonly used for the treatment of rheumatoid 
arthritis.  All study participants will additionally receive 1.0 mg oral folate to be taken daily six 
days per week. LDM complications will be minimized through education programs for all 
investigators and coordinators, through enhanced communication with study participants, by 
limiting enrollment to those with no evidence of malignancy, hepatitis, renal dysfunction, chronic 
infection, pulmonary disease, or other risk factors for toxicity; by conducting an initial 5- to 6-
week active-therapy run-in (maximum 8 weeks) designed to eliminate individuals who are either 
intolerant of or unable to adhere to treatment before randomization; and through regular 
monitoring of liver function and hematologic indices using a centralized methodology designed 
to ensure participant safety, allow for dose adjustments while maintaining the study blind, and 
provide an efficient method to address issues of compliance and follow-up on a cost-effective 
centralized basis. The primary trial endpoint is the rate of myocardial infarction, stroke, or 
cardiovascular death. Secondary and tertiary endpoints include all-cause mortality, coronary 
revascularization, incident congestive heart failure, incident peripheral artery disease, incident 
venous thrombosis, clinically significant aortic stenosis, incident atrial fibrillation, incident 
diabetes among those with metabolic syndrome but not diabetes at study entry, and hemoglobin 
A1c (HbA1c) control among those with diabetes at study entry. The trial is event driven such 
that in the absence of extreme effects, the trial will conclude after accrual of at least 530 primary 
endpoints, an effect estimated to provide 90 percent power to detect a 25 percent relative risk 
reduction. The potential clinical impact of CIRT is broad as it has sufficient power to directly 
address core issues in the inflammatory hypothesis of atherothrombosis, and thus, if successful, 
will open major new directions for cardiovascular treatment.  
2.0. SPECIFIC AIMS 
 
  
Abundant laboratory and translational data demonstrate that inflammation plays a major 
role in all stages of the atherothrombotic process
1,2. These observations have generated the 
hypothesis that targeted anti-inflammatory therapy can lower vascular event rates. To date, 
however, no clinical trial has directly addressed this critical biologic hypothesis3,4. 
  
The primary scientific aim of CIRT is to directly test the inflammatory hypothesis of 
atherothrombosis. Specifically, CIRT will evaluate whether LDM will reduce rates of myocardial 
infarction, stroke, or cardiovascular death among patients with a recent history of coronary 
artery disease and either type 2 diabetes or metabolic syndrome, conditions associated with an 
enhanced pro-inflammatory response. LDM is an effective anti-inflammatory therapy widely 

 
5 
used to treat rheumatoid arthritis that lowers plasma levels of interleukin-6 (IL-6), tumor necrosis 
factor (TNF), and C-reactive protein (CRP) but does not otherwise have beneficial effects on 
lipids or biomarkers of hemostasis and thrombosis. Thus, a randomized trial of LDM provides an 
innovative approach to target inflammation while minimizing confounding effects that might 
accrue from activation or inhibition of alternative vascular pathways. The wide use of LDM as a 
mainstay in current therapy for rheumatoid arthritis provides both guidelines for safety 
monitoring and strong evidence that off-target toxicity is unlikely to be uncovered during the 
course of this trial.   
 
2.1.Primary Aim 
 
a. To determine in a randomized, double-blind, placebo-controlled setting whether LDM 
given at a target dose of 15 to 20 mg po weekly will reduce rates of myocardial 
infarction, stroke, or cardiovascular death among patients with a prior history of coronary 
artery disease and either type 2 diabetes or metabolic syndrome. 
2.2. Secondary Aims 
 
a. To determine in a randomized, double-blind, placebo-controlled setting whether LDM will 
reduce rates of all-cause mortality among patients with a prior history of coronary artery 
disease and either type 2 diabetes or metabolic syndrome. 
b. To determine in a randomized, double-blind, placebo-controlled setting whether LDM will 
reduce rates of the primary endpoint plus coronary revascularization. 
c. To determine in a randomized, double-blind, placebo-controlled setting whether LDM will 
reduce the rates of hospitalization for congestive heart failure. 
d. To determine in a randomized, double-blind, placebo-controlled setting whether LDM will 
reduce rates of the primary endpoint plus all-cause mortality plus coronary 
revascularization plus congestive heart failure. 
e. To determine in a randomized, double-blind, placebo-controlled setting the side effect 
profile of LDM in a non-rheumatologic population at risk for vascular events. By so doing, 
CIRT will evaluate the net clinical benefit or harm that might accrue from the 
hypothesized use of LDM as a novel method for the secondary prevention of myocardial 
infarction, stroke, and cardiovascular death. 
f. To determine in a randomized, double-blind, placebo-controlled setting whether LDM will 
reduce the rate of new onset type 2 diabetes among those with metabolic syndrome but 
not diabetes at study entry. 
2.3. Tertiary Aims 
 
In addition, we will determine in a randomized, double-blind, placebo-controlled setting whether 
LDM will  
 
a. reduce rates of the individual components of the primary endpoint 
b. reduce rates of the primary endpoint plus unstable angina requiring unplanned coronary 
revascularization 
c. reduce rates of coronary revascularization 
d. reduce rates of peripheral artery disease 
e. reduce rates of symptomatic deep vein thrombosis or pulmonary embolism, including 
those considered to be provoked and those considered to be idiopathic 
f. reduce rates of clinically significant aortic stenosis 

 
6 
g. reduce rates of atrial fibrillation 
h. have positive or negative effects on standardized measures of quality of life and global 
health status 
 
2.4.Proposed Exploratory and Mechanistic Studies 
 
CIRT will include 7,000 patients with either myocardial infarction within the past or 
angiographically demonstrated multivessel coronary artery disease within the past who have 
either type 2 diabetes or metabolic syndrome. Clinical endpoints of interest that will be 
prospectively evaluated include incident age-related macular degeneration, sleep apnea, and 
nephropathy and retinopathy.  In addition, a plasma and DNA bank will be established as part of 
the trial protocol. Thus, cohort accrual and biobanking also allows for the evaluation of several 
tertiary aims that relate to mechanisms of effect using measured plasma biomarkers of 
inflammation and glucose metabolism, as well as potential genetic determinants of LDM activity. 
 
a. To evaluate the effect of LDM as compared to placebo on a series of inflammatory 
biomarkers such as IL-6, TNF, CRP, interleukin-1 (IL-1), and interleukin-1 receptor 
antagonist (IL1ra), and to ascertain whether any effects on these biomarkers mediate 
observed benefits or risks of LDM on clinical outcomes in the trial. 
b. To evaluate whether genetic polymorphisms associated with vascular risk, inflammation, 
thrombosis, or LDM metabolism modify any benefits or risks of LDM on clinical 
outcomes observed in the trial. 
c. Among subjects with baseline diabetes, to evaluate the effect of LDM as compared to 
placebo on indices of diabetic progression and glycemic control such as need for 
diabetes treatment intensification, proportion of subjects achieving optimal glycemic 
control (HbA1c<7.0%), and change in HbA1c overall and by study visit. 
3.0. BACKGROUND AND SIGNIFICANCE 
3.1. The Inflammatory Hypothesis of Atherothrombosis 
 
Abundant laboratory evidence indicates that inflammation plays a major role in all stages 
of atherothrombosis1,2. With regard to the translation of inflammation biology to practice, as 
demonstrated in a comprehensive 2010 meta-analysis, clinical evidence from 54 prospective 
cohort studies demonstrates that inflammatory biomarkers independently predict vascular risk 
with a magnitude of effect at least as large as that of blood pressure or cholesterol5. However, 
while the attributable vascular risk associated with inflammation is large and while animal 
models using targeted anti-inflammatory therapies have shown promise, it remains unknown 
whether inhibition of inflammation per se will lower vascular event rates.  
Despite the importance of this question, no endpoint trial addressing these issues has 
been initiated. However, the recent JUPITER investigation comparing rosuvastatin to placebo 
among 17,802 individuals with low levels of low-density lipoprotein cholesterol (LDL-C) but who 
were at elevated vascular risk on the basis of a pro-inflammatory response reinforces the need 
for such a trial
6. In brief, JUPITER demonstrated a 44 percent reduction in major vascular 
events, which included a 54 percent reduction in myocardial infarction, a 48 percent reduction in 
stroke, a 46 percent reduction in arterial revascularization, a 43 percent reduction in deep 
venous thrombosis/pulmonary embolism (DVT/PE), and a 20 percent reduction in mortality. 
Underscoring the importance of inflammation as a pathophysiologic factor in selecting this study 
population, the placebo event rate in JUPITER was higher than that of prior prevention trials 

 
7 
limited to those with overt hyperlipidemia
7,8.  Further, within JUPITER, the greatest absolute risk 
and the greatest absolute risk reduction was observed among those with the highest levels of 
persistent pro-inflammatory response9.  
From an inflammatory biology perspective, prospective analyses from JUPITER also 
suggest that achieving low levels of inflammation may be an important treatment goal in a 
manner analogous to achieving low levels of LDL-C. In pre-specified analyses designed to 
evaluate the relative effects of inflammation reduction as compared to LDL-C reduction, the 
JUPITER data suggest that the benefits of statin therapy are magnified among those who not 
only reduce LDL-C, but who also substantially reduce inflammatory biomarkers10. As such, 
JUPITER prospectively confirms prior data from the CARE11,12, AFCAPS/TexCAPS
13, PROVE 
IT – TIMI 22
14, A to Z
15, and REVERSAL
16 trials that best clinical outcomes accrue in statin 
treated patients who achieve low levels of inflammation as well as cholesterol. All of these data 
corroborate laboratory evidence of anti-inflammatory properties of statins including reduced cell 
adhesion and monocyte recruitment to the arterial wall; reduced prenylation of small G proteins 
and augmented expression of the transcription factor KLF2 with consequent mitigation of 
inflammatory and thrombotic mediators; altered smooth muscle migration in developing plaques; 
favorable effects on metalloproteinase expression; and in human hepatocytes, reductions in IL-6 
and other cytokines17,18. However, statins markedly lower LDL-C as well as reduce 
inflammation. Thus, although suggestive, these data cannot address whether lowering 
inflammation alone will lower vascular risk.  
3.2. Low-Dose Methotrexate (LDM) and Cardiovascular Disease 
 
A direct test of the inflammatory hypothesis of atherothrombosis requires an agent that 
(a) inhibits inflammation without having major impact on other components of the 
atherothrombotic process, and (b) has an acceptable safety profile for evaluation in a large-
scale randomized trial3,4. LDM has multiple attributes that make it an appropriate agent to test 
directly the inflammatory hypothesis of atherothrombosis.  
First, LDM (range 10 to 30 mg per week) is widely used, has an enviable safety profile 
among patients with rheumatoid arthritis and psoriasis, and comprehensive guidelines from the 
American College of Rheumatology exist regarding dosing regimens, drug monitoring, and the 
identification of high-risk patient subgroups
19-21. This experience greatly reduces the potential for 
unanticipated off-target toxicity. The target methotrexate dose in CIRT is 15 to 20 mg po per 
week, a dose within the range commonly used for the treatment of rheumatoid arthritis.   
Second, LDM reduces several inflammatory biomarkers including CRP, IL-6, and TNF-
alpha in populations of patients with rheumatoid arthritis (RA) and psoriasis, patient groups at 
elevated vascular risk on an inflammatory basis. Further, LDM does not have substantive 
effects on lipid levels, hemostasis, or platelet function. Thus, LDM provides a mechanism to test 
the inflammatory hypothesis of atherothrombosis without confounding effects on other vascular 
pathways. 

 
8 
Third, among both rheumatoid arthritis and psoriasis patients assessed in seven cohort 
and case-control settings22-28, available observational epidemiologic data suggest that exposure 
to LDM is associated with reductions in cardiovascular morbidity and mortality, even though 
those receiving LDM have worse vascular risk factor profiles, data strongly mitigating against 
indication bias (Table 1). These data have been verified in a recent systematic overview29. Of 
interest, the 
cardiovascular benefit 
of LDM was observed 
despite the fact that 
patients initiating 
treatment (mean dose 
= 13 mg/week) had 
significantly worse 
prognostic factors for 
mortality and 
significantly worse RA 
symptoms than did 
patients not being 
treated with LDM. 
Other observational 
studies of RA patients 
taking LDM have 
shown improvement 
in heart failure
30 and 
reduction in carotid 
intima media 
thickness
28. The 
consistent observation of excess vascular risk unexplained by traditional risk factors among 
those with rheumatoid arthritis or psoriasis also supports the conceptual basis for a trial of anti-
inflammatory therapy among those with a persistent enhancement of the innate immune 
response
31-33. 
Fourth, mechanistic studies suggest that atheroprotective effects of methotrexate may 
accrue from enhanced release of adenosine which in turn leads to facilitation of cholesterol 
efflux and reverse cholesterol transport from arterial wall foam cells34 via upregulated 
expression of cholesterol 27-hydroxylase (HY27) and the ATP-binding cassette transporter 
(ABCA1)
35,36. Recent data indicating enhanced gene expression of HY27 and ABCA1 with 
clinical use of methotrexate also supports this emerging hypothesis37. Other work suggests that 
methotrexate has direct effects on apoptosis and on the suppression of adhesion molecule 
function, both of which play relevant roles in atherothrombosis
38,39. 
Finally, LDM is a generic, inexpensive therapy given orally as a once-weekly agent 
allowing for the efficient and safe conduct of a large simple trial. This simplicity has been 
incorporated into CIRT in such a way that ongoing safety evaluations can use a centralized 
methodology that improves participant safety, maintains the study blind while allowing for in-trial 
dose adjustments, and provides an efficient method to address issues of compliance and follow-
up on a cost-effective centralized basis. 
3.3. Diabetes, Metabolic Syndrome, and Inflammation 
 
Low Dose 
Low Dose Methotrexate
Methotrexate and CVD: Observational Evidence
and CVD: Observational Evidence
Cohort
Group
HR* (95 % CI)
Endpoint
Exposure
Wichita
RA
0.4   (0.2 -0.8)
Total Mortality
LDM
Choi2002
0.3   (0.2 -0.7)
CV Mortality 
LDM
0.4   (0.3 –0.8)
CV Mortality 
LDM < 15 mg/wk
Netherlands
RA
0.3   (0.1 –0.7)
CVD
LDM
van Helm 2006
Miami VA 
Psoriasis 
0.7   (0.6 –0.9)
CVD
LDM
Pradanovich2005
0.5   (0.3 –0.8)
CVD
LDM < 15 mg/wk
RA
0.8   (0.7 –1.0)
CVD
LDM
0.6   (0.5 –0.8)
CVD
LDM < 15 mg/wk
CORRONA
RA
0.6   (0.3 –1.2)
CVD
LDM
Solomon 2006
QUEST-RA 
RA
0.85  (0.8 –0.9)
CVD
LDM
Narango2008
0.82  (0.7 –0.9)
MI
LDM
0.89  (0.8 -1.0) 
Stroke
LDM
Insurance
Hochberg 2008
RA
0.65  (0.59-0.72)
CVD
LDM
UK Norfolk 
RA, PSA 
0.6   (0.4 –1.0)
Total Mortality
LDM
2008
0.5   (0.3 –1.1) 
CV Mortality 
LDM
Coronary artery disease patients with diabetes or metabolic syndrome have an 
enhanced pro-inflammatory response and are at high vascular risk, thus providing an excellent 
target population for CIRT. Further, as is the case for atherothrombosis, the core 
Table 1. 

 
9 
pathophysiologic basis underlying insulin resistance and diabetes is hypothesized to entail 
fundamental abnormalities of the innate immune response
40. From a clinical perspective, 
plasma levels of several inflammatory biomarkers increase with increasing numbers of 
components of metabolic syndrome and several inflammatory biomarkers including IL-6 predict 
incident type 2 diabetes
41.  
 With regard to the ability of metabolic syndrome to define a secondary prevention 
population at increased risk of vascular events, Table 2 presents data from the 4S, MIRACL, 
WIZARD, and TNT trials42-45. As shown, among those with metabolic syndrome as compared to 
those without, the hazard ratios for recurrent cardiovascular disease all approximate 1.4 (95%CI 
1.2-1.7). Similarly, in a recent meta-analysis of 87 studies, metabolic syndrome was associated 
with a 2-fold increase in cardiovascular events and a 1.5 fold increase in all-cause mortality46. 
 
 
With regard to the ability of diabetes to define a secondary prevention population at high 
risk of vascular events, Table 3 presents data from the 4S, CARE, LIPID, and HPS trials
42,47-49. 
As shown, among those with diabetes as compared to those without, the hazard ratios for 
cardiovascular events are again in a range 1.4 to 1.6 when compared to that of individuals 
without diabetes. 
 
Table 3.  Summary of Association between Diabetes and Subsequent CVD Events in Secondary Prevention Trials 
Study 
Population 
Cohort 
Inception 
Year 
Sample 
Size 
Average 
Follow-
Up (yr) 
Baseline 
DM 
Prevalence 
Outcome 
Event 
Rate 
DM 
Event 
Rate 
No DM 
RR/HR 
4S 
1988 
2223* 
5.4 
10.4 
CVD 
NA 
NA 
1.62 (1.29-2.03) 
CARE 
1989 
4159 
5.0 
14.1 
CHD 
19.1 
10.5 
NA 
LIPID 
1990 
9014 
6.1 
11.9 
CVD 
48.9 
36.5 
1.4 (1.3-1.5) 
HPS 
1994 
20536 
5.0 
29.0 
CHD 
35.6 
22.7 
NA 
* Estimates provided for placebo arm only; NA - not available 
 
3.4. Pharmacology of Low Dose Methotrexate (LDM) 
 
LDM is taken weekly by tens of thousands of patients with similar age and co-morbidity 
profiles as those likely to be enrolled in CIRT. Introduced as a treatment for rheumatoid arthritis 
in 1951, LDM has an enviable safety and efficacy profile that has allowed it to remain the 
dominant disease modifying therapy for RA. A clinically relevant anti-inflammatory effect is 
rapidly achieved for the majority of RA patients at weekly oral doses between 10 and 30 mg.  
Food minimally affects LDM absorption so the drug can be taken in fasting or non-fasting states. 
Circulating methotrexate is less than 50 percent protein bound and has minimal interaction with 
most concomitant medications, including statins, aspirin, beta-blockers, and inhibitors of the 
renin-angiotensin system. However, there is increased risk when methotrexate is used in 
combination with folate depleting drugs such as bactrim (trimethoprim-sulfamethoxazole) or 
Table 2.  Summary of the Association between MetS and Subsequent Cardiovascular Events in Secondary Prevention Trials 
 
 
 
 
 
 
Event Rate 
 
Study 
Population 
Cohort 
Inception 
Year 
Sample 
Size 
Average 
Follow-Up (yr) 
Baseline 
Prevalence Outcome 
 MetS 
 
No MetS 
RR/HR 
4S 
1988 
2223* 
5.4 
20% 
CVD 
7.2 per 
1000 
person-
months 
5.2 per 
1000 
person- 
months 
1.41 (1.16-1.71 
MIRACL 
1997 
3038 
0.3 
38% 
CHD 
19.2% 
14.3% 
1.40 (1.16-1.67) 
WIZARD 
1997 
3319 
3.1 
53.3 
CHD 
28.1% 
21.1% 
1.33 (1.15-1.53) 
TNT 
1998 
10001 
4.9 
56% 
CVD 
11.3% 
8.0% 
1.44 (1.26-1.64) 
* Estimates provided for placebo arm only 

 
10 
drugs that affect tubular secretion (probenecid). Thus, study participants will be alerted to this 
potential toxicity and those with allergies that make use of alternative agents impossible will be 
excluded.  
All study participants (including those on placebo) will receive supplementary folic acid 
(1.0 mg 6 days per week), a simple adjunct known to reduce side-effects of LDM and improve 
long-term compliance that itself has no direct effect on vascular risk.  
Methotrexate is primarily cleared by the kidneys, with 80 to 90 percent being excreted in 
urine. As such, reduction in creatinine clearance (CrCl) is a determinant of serum levels and 
systemic toxicity. Patients with baseline CrCl less than 40 ml/min will not be entered into CIRT, 
and follow-up CrCl will be measured on a regular basis so that drug can be discontinued or 
dose-reduced in the event of incident renal failure; this safety criterion is conservative as the 
American College of Rheumatology allows LDM use even when CrCl is reduced to 30 ml/min. 
3.5. Safety of LDM and Efforts to Reduce In-Trial Toxicity 
 
The wide use of LDM in clinical practice makes it unlikely that any unknown off-target 
toxicities will appear during the conduct of CIRT. Further, risk factors associated with LDM 
toxicity are well known and formal guidelines have been issued by the American College of 
Rheumatology outlining patient groups where therapy is ill-advised19. Broadly, patients with 
hepatitis, renal dysfunction, chronic infections, and certain pulmonary conditions have increased 
risk, and these groups are excluded from study participation, as are patients with a significant 
history of alcohol consumption. As methotrexate can sequester in fluid spaces, participants with 
known chronic pericardial effusion, pleural effusion, or ascites will not be included in the trial. 
Because of the fetopathic and teratogenic effects of methotrexate, women of childbearing 
potential or who intend to breastfeed will not be included in the trial. 
The vast majority of life-threatening hepatotoxicity, pulmonary damage, and 
myelosuppression that have been reported with methotrexate occur at the very high doses used 
during treatment of malignancy (where methotrexate is dosed cyclically by the gram or more). In 
the dose range to be used in CIRT (target dose 15 to 20 mg per week), such life-threatening 
complications are rare. Nonetheless, to reduce the chance of such occurrence within CIRT, 
screening for hepatitis B and C will be conducted before enrollment and patients who are 
positive for chronic infection will be excluded. In addition, monitoring of alanine 
aminotransferase (ALT), aspartate aminotransferase (AST), albumin, creatinine clearance 
(CrCl), and complete blood count (CBC) will be done throughout the study (monthly for the first 
6 months after randomization, then at least bi-monthly for the trial duration). Rarely, in the 
setting of high dose methotrexate (as used in chemotherapy), hypospermia and the potential for 
chromosomal damage to sperm has been reported. While it is uncertain if these effects occur 
with low dose methotrexate, to protect the safety of all study participants and their sexual 
partners, effective contraception will be recommended during the trial and for six months after a 
participant completes the trial.  Men who intend to father children during the trial period will not 
be enrolled. 
All participants must lack significant pulmonary disease at enrollment, and surveillance 
questionnaires seeking symptoms of pulmonary disease will be given every four months during 
study follow-up. A chest X-ray in the 12 months prior to enrollment must be free of evidence of 
interstitial pneumonitis, bronchiectasis, or pulmonary fibrosis. In instances where a chest X-ray 
is not available in the prior 12 months, a baseline chest X-ray will be obtained as part of the 
study protocol. With regard to potential nephrotoxicity, enrollment will be limited to those with 
CrCl≥ 40 ml/min with dose adjustments or discontinuation built into the protocol in the event of 
renal deterioration. The protocol also incorporates short-term suspension of LDM for patients 
with intercurrrent infections, those receiving antibiotic therapy, those undergoing surgery, and 
those who develop new clinically significant pericardial effusion, pleural effusion, or ascites. All 

 
11 
of these steps are consistent with or more conservative than guidelines issued by the American 
College of Rheumatology for use of LDM19.  
Five aspects of the CIRT protocol are specifically designed to minimize these issues and 
maximize long-term follow-up and compliance. First, an active therapy 5- to 6-week run-in 
(maximum 8 weeks) has been incorporated into CIRT so that any individuals with short-term 
intolerance to LDM will be excluded prior to randomization. Second, the CIRT protocol targets a 
maximal methotrexate dose of 15 to 20 mg po weekly, a dose well within the range of that 
commonly used in the treatment of rheumatoid arthritis. Titration to the 20 mg weekly dose will 
only occur among those trial participants who have tolerated without complication the 15 mg 
weekly dose for a minimum of three months. Third, the protocol titration algorithms and drug 
packaging (calendar blister packs) have been designed in such a way that in response to either 
clinical need, participant report of adverse effects, or to any monitored laboratory evidence of 
hepatic, renal, acute infection, or hematologic abnormality, dosing for individual participants can 
be discontinued on a short term basis or reduced to either a 5, 10 or 15 mg dose/wk as 
tolerated. After clinical resolution and a return of all laboratory abnormalities to a safe range, 
study drug will be re-initiated and up-titrated in 5 mg increments toward the maximal target dose 
of 20 mg po weekly. Fourth, targeted face-to-face education programs will be required for all 
study investigators at the investigator meetings, followed by mandatory web-based safety 
seminars; these educational programs will be provided by the rheumatologic members of the 
CIRT Steering Committee and will ensure a high level of drug safety awareness among all trial 
physicians and staff. Fifth, an ongoing communication program is incorporated into CIRT which 
allows the investigative team to stay in regular contact with trial participants, withhold study drug 
for fevers or inter-current infection, systematically evaluate subjective symptoms, and ensure an 
almost continuous flow of safety data throughout the trial experience. This regular 
communication will also improve compliance and a sense of community for individual 
participants.  
 
4.0. INVESTIGATIONAL PLAN 
4.1. Study Design - Overview 
 
  
CIRT is a randomized, double-blind, placebo-controlled, event-driven trial of LDM (target 
dose 15 to 20 mg/wk) in the secondary prevention of myocardial infarction, stroke, and 
cardiovascular death among stable coronary artery disease patients who have either diagnosed 
type 2 diabetes or who meet the formal 2004 American Heart Association (AHA) / National 
Heart Lung and Blood Institute (NHLBI) definition of metabolic syndrome which includes any 3 
of the following 5 diagnostic criteria: waist circumference ≥ 102 cm in men or 88 cm in women; 
triglycerides ≥ 150 mg/dl or on drug treatment for elevated triglycerides; high-density lipoprotein 
cholesterol (HDL-C)< 40 mg/dL in men or < 50 mg/dL in women or on drug treatment for 
reduced HDL-C; systolic blood pressure ≥ 130 mm Hg or diastolic blood pressure ≥ 85 mm Hg 
or on drug treatment for hypertension; and elevated fasting glucose ≥ 100 mg/dL or on drug 
treatment for elevated glucose. All trial participants will have had either a documented 
myocardial infarction within the past or angiographically demonstrated multivessel coronary 
artery disease in the past and be clinically stable for at least 60 days after the qualifying event. 
The qualifying myocardial infarction is the most recent myocardial infarction that meets criteria 
for the diagnosis of myocardial infarction. The qualifying coronary angiogram is the most recent 
angiogram that meets the criteria for the diagnosis of multivessel coronary artery disease, 
defined as the presence of a stent, bypass graft, or ≥ 60 percent stenosis in at least two major 
epicardial vessels. Left main coronary artery disease that has been revascularized with a stent 

 
12 
or bypass graft will qualify as multivessel disease, as will the presence of a 50% or greater 
isolated left main stenosis. Any planned coronary revascularization procedures associated with 
the qualifying myocardial infarction or angiogram must also be completed at least 60 days prior 
to enrollment. 
In addition to LDM or matching placebo, all study participants (including those on 
placebo) will receive folic acid 1.0 mg 6 days per week, a therapy known to reduce nuisance 
side effects that can be associated with LDM but that has been shown in multiple major trials to 
have no vascular benefit so there will be no confounding due to folate use.  
Following American College of Rheumatology Guidelines for use of LDM19, acceptable 
levels of white blood cell count, hematocrit, platelets, CrCl, and liver function (cutoffs provided in 
Exclusion Criteria, section 4.4), as well as negative screens for hepatitis B and C will be 
required prior to active run-in. Individuals with known hepatic disease, chronic pulmonary 
disease (specifically: interstitial pneumonitis, bronchiectasis, or pulmonary fibrosis), or HIV 
related disease will be excluded. A chest X-ray in the 12 months prior to enrollment must be free 
of evidence of interstitial pneumonitis, bronchiectasis, or pulmonary fibrosis. Individuals with 
known chronic pericardial effusion, pleural effusion, or ascites will be excluded. To further 
ensure safety and improve long-term compliance, the trial design incorporates a 5- to 6-week 
open-label, active-therapy run-in (maximum 8 weeks) for all potentially eligible participants so 
that those unable to initially tolerate LDM are excluded prior to randomization. During the 5- to 
6- week (maximum 8-week) open-label run-in, all potentially eligible study participants will 
initiate LDM at a dose of 5 mg in week one. In the absence of adverse effects or intolerance, 
this 5 mg dose will be increased to 10 mg for the second and third week of the run-in phase, 
and then to 15 mg for the fourth week. At the end of this 5- to 6-week run-in period safety labs 
will be repeated. Only those participants who demonstrate compliance during this one-month 
run in and who are free of side effects with no significant changes in hematologic or hepatic 
indices will be considered randomizable to active therapy or to placebo.  
Once randomized to active therapy or placebo, all study participants over the first 6 
months of the trial will undergo monthly evaluation for CBC, ALT, AST, albumin, and CrCl using 
blinded and centralized study procedures that have been designed both to ensure patient safety 
and allow for drug discontinuation or dose-adjustment, as well as ongoing evaluations of study 
compliance. At 4 months, those participants randomly allocated to active LDM who have 
tolerated the 15 mg dose without complication will be titrated up to the target dose of 20 mg 
LDM weekly. Six months after randomization, the blood-based safety evaluations will occur at 
least bi-monthly until trial completion. Pre-labeled calendar blister packs similar in design to that 
used in the run-in will be used throughout the study to improve compliance and reduce 
complexity. To maintain the blind as much as possible, sham titrations will be conducted in the 
placebo group proportionate to the number of actual titrations required in the active treatment 
group.  
For any participants developing side effects or in whom laboratory abnormalities 
develop, the protocol allows for drug discontinuation and/or down-titration. The protocol also 
builds in procedures for short-term discontinuation of LDM in circumstances such as fever, 
antibiotic therapy for bacterial infections, during and immediately after surgical procedures, or if 
new clinically significant pericardial effusion, pleural effusion, or ascites develops. Most of these 
steps will be managed centrally to protect the study blind, ensure common compliance across 
study sites, and allow centralized rapid management of any safety issues on an immediate 
basis. After clinical resolution of any events that lead to drug discontinuation and after a return 
of all laboratory abnormalities to a safe range, study drug will be re-initiated and up-titrated over 
time back toward the maximal target dose of 20 mg po weekly, as tolerated. Procedures for 
these dose adjustments, temporary drug discontinuation, and re-initiation of study drug are 
described in detail in the trial algorithms.   
An electronic data capture (EDC) system will be developed and used to collect and 

 
13 
transmit source data throughout the course of the trial. This system is 21 CFR part 11 compliant 
and meets all relevant governmental regulations. The system will be maintained at SOCAR 
Research, an independent clinical research organization. System functionality will be thoroughly 
tested and validated prior to implementation. Furthermore, to ensure compliance with standards 
of use of electronic trial data, standard operating procedures will be maintained for the use of 
the system, an audit trail of data changes will ensure that there is no modification of entered 
data without documentation, and security systems will be maintained to protect against 
unauthorized access. Furthermore, adequate procedures will be used to backup the data and 
safeguard the blinding of the study. As original observations are entered by clinic staff directly 
into the computerized system, the electronic record is considered the source document.The 
EDC system will thus be used in each of the following steps to create, modify, maintain, archive, 
retrieve and/or transmit source data: 1) creation of case report forms, 2) resolution of data 
discrepancies through data queries and checks, 3) implementation of the study drug titration, 4) 
monitoring of drug distribution, 5) reporting of adverse events and endpoints, and 6) endpoint 
adjudication 
 
4.2. Study Population 
 
CIRT will randomize 7,000 men and women, age 18 years and over, who have either 
suffered a documented myocardial infarction within the past or have multivessel coronary 
disease by angiography in the past, have completed any planned coronary revascularization 
procedures associated with the qualifying event, have been on a stable secondary prevention 
regimen for a minimum of 60 days, and have either a clinical diagnosis of type 2 diabetes or 
metabolic syndrome.  
For purposes of this trial, the formal 2004 AHA/NHLBI definition of metabolic syndrome 
will be used and requires evidence that any 3 of the following 5 diagnostic criteria are present: 
waist circumference ≥102 cm in men or≥ 88 cm in women; triglycerides ≥ 150 mg/dl (1.7 
mmol/L) or on drug treatment for elevated triglycerides (fibrates, nicotinic acid, or omega 3 fatty 
acids ); HDL-C < 40 mg/dL in men or < 50 mg/dL in women or on drug treatment for reduced 
HDL-C (fibrates or nicotinic acid); systolic blood pressure ≥130 mm Hg or diastolic blood 
pressure ≥ 85 mm Hg or on drug treatment for hypertension; and elevated fasting glucose ≥ 100 
mg/dL or on drug treatment for elevated glucose. 
4.3. Inclusion Criteria 
 
a. Age ≥ 18 years at screening;  
b. Documented past history of myocardial infarction OR past evidence of 
multivessel coronary artery disease by angiography. 
i. To qualify on the basis of a past history myocardial infarction, the event 
must be documented either by hospital records or by evidence on current 
ECG of Q waves in two contiguous leads and/or an imaging test 
demonstrating wall motion abnormality or scar.  The patient must also 
have completed any planned coronary revascularization procedures 
associated with the qualifying event, and be clinically stable for at least 60 
days prior to screening. 
ii. To qualify on the basis of multivessel coronary disease, there must be 
past angiographic evidence of atherosclerosis in at least 2 major 
epicardial vessels defined either as the presence of a stent, a coronary 
bypass graft, or an angiographic lesion of 60% or greater.  Left main 
coronary artery disease that has been revascularized with a stent or 

 
14 
bypass graft will qualify as multivessel disease, as will the presence of a 
50% or greater isolated left main stenosis.  The patient must also have 
completed any planned coronary revascularization procedures associated 
with the qualifying event, and be clinically stable for at least 60 days prior 
to screening. 
c.   History of type 2 diabetes or metabolic syndrome at time of study enrollment; 
d.   Willingness to participate as evidenced by signing the study informed consent.  
4.4. Exclusion Criteria 
 
a. Prior history of chronic infectious disease, tuberculosis, or severe fungal disease; 
chronic hepatitis B or C infection; renal insufficiency; interstitial pneumonitis, 
bronchiectasis, or pulmonary fibrosis; known chronic pericardial effusion, pleural 
effusion, or ascites; chronic liver disease; myeloproliferative disorders in the past 
5 years; non-basal cell malignancy or treated lymphoproliferative disease within 
the past 5 years; known HIV positive; life expectancy of < 3 years;  
b. Chronic inflammatory condition such as lupus or rheumatoid arthritis, ulcerative 
colitis or Crohn’s disease 
c. White blood cell count <3,500/ul, hematocrit < 32 percent, or platelet count < 
75,000/ul 
d. Liver transaminase levels (AST or ALT) >upper limit of normal (ULN) or albumin 
< the lower limit of normal (LLN);  
e. Creatinine clearance < 40 ml/min as estimated with the Cockroft-Gault equation;  
f. History of alcohol abuse or unwillingness to limit alcohol consumption to less 
than 4 drinks per week 
g. Women of child bearing potential, even if they are currently using contraception, 
and women intending to breastfeed. 
h. Men who plan to father children during the study period or who are unwilling to 
use effective forms of contraception. 
i. Requirement for use of drugs that alter folate metabolism 
(trimethoprim/sulfamethoxazol) or reduce tubular excretion (probenecid) or 
known allergies to antibiotics making avoidance of trimethoprim impossible;  
j. Current indication for methotrexate therapy;   
k. Chronic use of oral steroid therapy or other immunosuppressive or biologic 
response modifiers (see Exclusionary Medication List in Manual of Operations). 
Eligible study participants will be encouraged to have up to date pneumococcal 
and influenza vaccinations as recommended based on their age and underlying 
medical conditions. 
l. Chest X-ray evidence in the past 12 months of interstitial pneumonitis, 
bronchiectasis, or pulmonary fibrosis. For participants who do not have a chest 
X-ray in the prior 12 months, a chest X-ray will be obtained at baseline as part of 
the study protocol.  
m. New York Heart Association Class IV congestive heart failure.  
4.5. Open Label Run-In 
 
For all potentially eligible patients who provide informed consent and declare interest in 
participation, baseline ALT, AST, hepatitis screens, CrCl, albumin, and CBC will be obtained 
prior to the 5- to 6-week (maximum 8-week) active run-in phase to ensure they meet trial 
enrollment criteria. A urine sample will be assayed for albumin and creatinine.  A blood sample 
for plasma and buffy coat will also be shipped to the central lab for long-term storage and to 

 
15 
provide a bank for future blood-based biomarker and genetic sub-studies. Quality of life 
questionnaires will also be administered. 
A 5- to 6-week (maximum 8-week) course of open-label LDM will then be given to all 
eligible study participants in a pre-randomization compliance and tolerability run-in. During this 
run-in, participants will be given an initial 5 mg oral weekly LDM dose along with an adequate 
supply of 1.0 mg folic acid to be taken 6 days per week using similar drug calendar packs to 
those used throughout the active trial period. In the absence of adverse effects or intolerance, 
this 5 mg dose will be increased to 10 mg for the second and third week of the run-in phase, 
and then to 15 mg for the fourth and subsequent weeks. This run-in will allow subjects who are 
poorly compliant, who develop any immediate side effects, or who withdraw informed consent to 
be excluded before randomization. Participants must tolerate LDM 15 mg two weeks in a row in 
order to continue in the trial.  All subjects who successfully tolerate LDM 15 mg two weeks in a 
row and are still willing to be randomized will have repeat blood evaluation for AST, ALT, 
albumin, CBC, and CrCl, and any individuals with substantive changes in these parameters will 
be excluded prior to randomization. Urine for albumin and creatinine will also be collected.  The 
run-in will thus enhance long-term compliance and eliminate risk of exposure for any individuals 
with immediate intolerance to LDM.  
4.6. Randomization Procedures 
 
All participants who successfully complete the run-in will be eligible for randomization to 
the study drug calendar blister packages that contain either active LDM or placebo as well as 
active tablets containing 1.0 mg folic acid to be taken daily 6 days per week. The randomization 
visit will involve collection of key medical, social, and anthropometric information from the 
participant, as well as a brief physical examination including assessment of the participant’s 
level of physical function.  The responsible site investigator will use an interactive computer 
system for randomization.  The randomization process will involve stratifying participants by 
time since the qualifying event (< 6 months or ≥ 6 months from either the date of the MI or most 
recent angiogram), type of event (myocardial infarction or multivessel coronary disease), 
presence of either diabetes or metabolic syndrome, and by site. All post-randomization safety 
monitoring and dose adjustments will be performed using a standardized centrally run system 
that has been designed to ensure patient safety, maintain double-blinding while allowing for 
dose titration or discontinuation in both the active and placebo groups, provide a central 
mechanism for tracking patient compliance, and that will allow for efficient follow-up and 
eventual study close-out. To reduce inadvertent trial unblinding and further ensure patient 
safety, procedures have been designed to allow for more frequent blood ascertainment at all 
clinical sites on an as needed basis such as might occur during a concomitant infection or 
change in participant status (see Manual of Operations). 
4.7. Cohort Follow up and Clinic Visits 
 
 
All subjects will be seen by the study physician at the time of randomization. From that 
point forward throughout the trial, all participants will be required to see a member of the 
randomizing physician’s study team at least once every 4 months in addition to the regularly 
scheduled laboratory and symptom monitoring procedures described below. At those visits, 
compliance (measured by pill count) as well as evidence of side effects will be ascertained by 
self-report, and in the absence of a study endpoint or laboratory abnormality, a new 4-month 
supply of study drug (or blinded placebo) provided. A Patient Contact Information Form will be 
updated at each of these 4-month visits to facilitate long-term follow-up.  
Cohort follow-up will include a visit form filled out at each of these appointments.  
Information will similarly be sought concerning trial endpoints, issues of compliance will be 

 
16 
reviewed, anthropometric measures and brief physical examination including reassessment of 
physical function will be performed, participant questions answered, the drug supply ensured, 
and any outstanding study forms completed and/or updated.  In addition, signs or symptoms of 
early drug toxicity will be assessed, as well as the occurrence of any primary or secondary trial 
endpoints or other clinical events of interest. Nephropathy, a clinical event of interest, will be 
assessed by collecting urine for albumin and creatinine at 8 months, 12 months, and then every 
6 months after randomization. Since these data will be obtained in an identical manner from 
participants randomly allocated to LDM as well as to placebo, this procedure will also provide a 
mechanism for monitoring by the Data Coordinating Center (DCC) and reports to the Data and 
Safety and Monitoring Board (DSMB) of any differences between treatment groups with regard 
to side effects or efficacy. At each regularly scheduled safety lab visit (once a month for the first 
6 months after randomization, then at least bi-monthly), participants will be asked about clinical 
symptoms and side effects of the study medication so that study drug dosage may be adjusted 
or temporarily stopped if necessary.  In order to better understand the toxicities of methotrexate, 
at 6 months a blood sample will be collected for the measurement of key metabolites of 
methotrexate. 
For the first 6 months post-randomization, monthly blinded laboratory evaluations for 
ALT, AST, albumin, CBC, and CrCl will be obtained; after that time, evaluation will be done on 
at least a bi-monthly basis until trial completion. As described in the study algorithms, laboratory 
values that cross a pre-defined safety threshold (for example, a decline in the total WBC count 
to < 3,000/ul) will trigger a call to the subject to inform the participant not to take the following 
week’s dose of LDM and to ascertain any signs or symptoms of potential toxicity. As described 
in the study algorithms, temporary suspension of study drug will occur whenever subjects are 
being treated with antibiotics, have a clinical infection, develop new clinically significant effusion 
or ascites, or are scheduled for surgery. Similarly, patients will be informed not to take the next 
scheduled study medication if they develop a serious unexplained cough or shortness of breath 
suggestive of interstitial lung disease, or if they develop stomatitis, vomiting, or persistent fever. 
Details of the methotrexate titration algorithm, including up- and down-titration, temporary study 
drug interruption, and permanent study drug discontinuation are included in the trial algorithms.  
The responsible physician will be informed of any changes in study drug dosing. 
After any temporary discontinuation of study drug, study algorithms will be used to 
determine if and when re-initiation of study medication can occur. If a participant’s study 
medication is repeatedly stopped because of laboratory abnormalities or clinical symptoms, the 
medical monitor will review the case to consider a permanent discontinuation of study 
medication. As described in the study algorithms, permanent drug discontinuation can also be 
done at the discretion of the responsible physician. 
 
4.8. Monitoring Participant Laboratory Values and Subsequent Dose Adjustments 
 
In addition to the algorithms designed for safety monitoring in this trial, an additional 
safety feature of CIRT is that when certain laboratory thresholds are crossed, the physician 
responsible for the subject will be notified. 
The specific thresholds for drug discontinuation, re-initiation, down-titration, and up-
titration are described in detail in the trial algorithms that will be used to monitor safety and 
make dose changes across the study on a central and consistent basis. No increase in weekly 
dose will occur unless all of the following criterion are met: the WBC count is ≥ 3,500/ul, the 
platelet count is ≥ 75,000/ul, the CrCl is ≥40ml/min, ALT/AST levels are ≤ 1.5x ULN, hematocrit 
is ≥27 percent, and there are no clinically important symptoms (defined as stomatitis, diarrhea, 
vomiting, or cough either productive of sputum or associated with a fever or with severe 
shortness of breath). As also described in the study algorithms, a reduction in dose will occur if 

 
17 
there are changes in some of these parameters that may suggest early toxicity but that are not 
severe enough to warrant drug discontinuation. For example, for a subject taking 20 mg of the 
study drug, while a drop in the platelet count below 50,000 will lead to temporary drug 
discontinuation, a reduction below 75,000 but above 50,000 would lead to a 5 mg decrease in 
the current weekly dosing. After clinical resolution of any events that lead to drug 
discontinuation and after a return of all laboratory abnormalities to a safe range, study drug will 
be re-initiated and up-titrated over time in 5 mg increments back toward the maximal target dose 
of 20 mg po weekly, as tolerated.  Responsible physicians will be informed of any changes in 
study drug dosing recommended by the clinical coordinating center.  Adverse events, patient 
symptoms, laboratory abnormalities, or other reasons for discontinuation of or reduction in dose 
of study drug will be collected through case report forms and monitored centrally by the Data 
Coordinating Center (DCC).  
4.9. Monitoring Participant Symptoms and Subsequent Dose Adjustments 
 
Participants will have regularly scheduled visits with the local investigator during which 
the study staff will carefully assess the patients for any signs or symptoms of drug toxicity, in 
addition to the occurrence of any trial endpoints.  A questionnaire designed to capture 
information about drug toxicity (including symptoms of a pulmonary, infectious, gastrointestinal, 
hematologic, dermatologic, and other toxicities), intercurrent hospitalizations, and elective or 
planned surgical procedures will be administered to all study participants at the time of regularly 
scheduled safety lab draws (once a month for the first 6 months after randomization, then at 
least bi-monthly).   
The questionnaire will be administered both by local study staff via the telephone or in 
person.  Study algorithms will combine data from recent laboratory safety evaluations with 
patient reported symptoms to determine study drug dosing and/or cessation, including sham 
placebo dose adjustments.  Responsible physicians will be informed of any changes in the 
study medication dosing.  As noted above, adverse events, patient symptoms, laboratory 
abnormalities, or other reasons for discontinuation of or reduction in dose of study drug will be 
collected through case report forms and monitored centrally by the Data Coordinating Center 
(DCC). 
 Study coordinators are given instructions to contact the Medical Monitor for symptoms 
or signs that raise the possibility of drug toxicity, including the development of new clinically 
significant effusions or ascites. As noted above, in order to better understand the toxicities of 
methotrexate, at 6 months a blood sample will be collected from all participants for the 
measurement of key metabolites of methotrexate. Furthermore, if requested by the DSMB, 
aggregate data on adverse events, stratified by blinded treatment group, will be reviewed on a 
quarterly basis by the Chair of the DSMB, who may then request a more detailed analysis 
and/or forward the data to the full Board.    
4.10. Medical Monitor 
 
A Medical Monitor will be on call 24 hours a day 7 days each week.  A senior board-
certified rheumatologist with expertise in drug safety (Senior Rheumatologist) will supervise the 
Monitors. The Monitors will be rheumatologists (fellows or junior faculty) who will be trained by 
the Senior Rheumatologist and will be accessible via pager.  The Monitors will be referred 
subjects based on the pre-laboratory questionnaire or laboratory abnormalities and will have 
access to the subjects’ laboratory data and clinical information via the EDC system.  The 
Monitors will have the option of unblinding the treatment allocation of a subject, if the symptoms 
and acuity of illness make doing so warranted. 

 
18 
Monitors will help sites determine whether the symptoms being described by patients are 
concerning, whether interruptions in study drug are warranted, and whether re-initiating study 
drug is safe.  While all Monitors will have experience with methotrexate prescribing, the Senior 
Rheumatologist will compile a list of scenarios as they occur that will allow the Monitors to have 
a consistent approach.  The Monitors as a group will meet monthly with the Senior 
Rheumatologist to discuss these scenarios.  As the trial progresses, these meetings are 
anticipated to occur every quarter. 
4.11. Endpoint Definitions and Documentation 
 
The primary endpoint is defined as the time to the first adjudication committee confirmed 
major adverse cardiovascular event (MACE) occurring during the double-blind treatment period, 
which is a composite of CV death, non-fatal MI, and stroke.  
An independent Clinical Endpoints Committee (CEC) will review and adjudicate all 
clinical events that constitute the primary composite endpoint (CV deaths, non-fatal MI, and 
stroke).  In addition, the CEC will adjudicate a number of secondary endpoints, including all 
deaths, all hospitalizations for unstable angina requiring unplanned revascularization, all 
hospitalizations for congestive heart failure, and all arterial revascularization procedures. The 
CEC will be blinded to treatment assignment. Formal definitions for the individual components of 
the primary endpoint, hospitalization for unstable angina requiring unplanned revascularization, 
hospitalizations for congestive heart failure, and arterial revascularization are provided in the 
Clinical Endpoint Committee (CEC) Charter.  The secondary and tertiary endpoints listed in 
sections 2.2 and 2.3 not adjudicated by the CEC will be validated by non-CEC staff.  For 
example, incident diabetes will be confirmed by a combination of patient or physician report, 
new anti-diabetic medications, or by protocol-based measures of glucose and HbA1c performed 
at least twice annually. Incident venous thromboembolism will be confirmed using 
documentation of imaging studies including a venous ultrasound or venogram showing deep 
venous thrombosis or a pulmonary arteriogram, CT scan, or ventilation-perfusion scan showing 
pulmonary embolism.  
Other non-adjudicated clinical events of interest include microvascular disease 
(nephropathy and retinopathy), sleep apnea, and age-related macular degeneration. 
Full descriptions of the methods for endpoint ascertainment and the specific definitions 
of each adjudicated trial endpoint are contained in the Clinical Endpoint Charter (CEC). 
4.12. Procedures for Emergency Unblinding 
 
As part of the trial monitoring structure, a medical monitor will also be available on a 24 
hour basis who has the ability to electronically access individual patient data files should 
unblinding be needed. All of these instances will be tracked within the EDC system. 
4.13. Investigator Education Programs 
 
To ensure that all investigators and study coordinators are comfortable with LDM 
regardless of specialty area, a face-to-face targeted education program will be provided as part 
of the trial Investigator Meetings and a series of on-line teleconference/webinars will be 
provided every 6 months where educational information regarding LDM will be updated and 
reinforced.  
4.14. Drug Compliance Monitoring 
 

 
19 
The primary measure of compliance will be based on the return of calendar packs to the 
physician at each of the 4-month office visits (at which time new calendar packs will be issued 
as long as no trial endpoint or major side-effects have occurred).  
As an additional measure of compliance, washed packed red blood cells collected 6 
months after randomization will be stored in a central laboratory for measures of methotrexate 
levels. This will be done using a methotrexate polyglutamate assay that provides a semi-
quantitative method of evaluating methotrexate absorption and metabolism.  The results of this 
assay will not be available to blinded study staff until after the study has completed and the 
database has been locked. 
4.15. Central Laboratory and Bio-bank 
 
Blood samples for storage in a bio-bank at Brigham and Women’s Hospital will be 
obtained at the pre-run-in, randomization, and at 8 and 24 months after randomization. 
Processing and long-term storage of these samples will be done in a liquid nitrogen biobank 
facility in Boston, which has been used for this purpose in multiple prior NIH-funded trials and 
large cohort studies. White blood cells from the pre-run-in sample will also be stored in this 
facility to allow for DNA extraction at a later date. As described in the informed consent 
documents, participation in the genetic bio-banking portions of CIRT will be on an “opt-out” 
basis and are not a requirement for participation in the main trial.  
4.16. Serious Adverse Events (SAEs) 
 
All subjects will be monitored at the local study sites on a regular basis during the course 
of study involvement.  All SAEs will be reported within 24 hours of local event awareness (but 
no later than the next business day) to the Data Coordinating Center (DCC).  Initial reports will 
often not be complete.  Central study staff will guide the site regarding the completion of a SAE 
form along with retrieval of the pertinent medical records for determination of a final diagnosis.  
An updated full written report will be filed as additional information becomes available within 10 
working days (14 calendar days).  The report will include a complete description of the event, 
use of all concomitant medications, and the local investigator’s assessment of causality of the 
SAE to study therapy.  All serious adverse events will be recorded in the core study database 
within 1 week of report by the local study site personnel.  SAE reporting for all subjects will 
occur in accordance with the central institutional review board (IRB) requirements.  Study staff 
may contact patients directly to determine the resolution of adverse events. 
 
4.17. Data Coordination and Treatment Masking 
 
The DCC is responsible for the facilitation of prompt evaluation of reported adverse 
events and symptoms.  Upon receipt from a site of a report of specific adverse events, 
combinations of symptoms, or symptoms persisting over time that meet pre-specified criteria, 
the data will be combined with recent laboratory assays and the safety monitor will be notified 
that there is a report requiring evaluation.  
The DCC will also provide monthly reports to the Executive Committee.  The Progress 
Report will include: enrollment and randomization rates, overall and by sex and race; reasons 
for randomization ineligibility; number of completed follow-up visits; number of completed interim 
safety bloods; number of blood specimens sent to the central repository; number of dose 
changes; current distribution of doses; number of patients off drug; reasons for discontinuation; 
number of unblindings and reasons for the unblindings.  The Quality Control Report will include 
tables on inappropriate randomizations; number of missed visits; reasons for missed visits; 

 
20 
number of visits taking place outside of the designated time windows; and rates of missing data 
broken down by form.  Both the Progress Report and the Quality Control Report will pool 
participants across treatment groups to maintain the study blind. 
The DCC also assumes responsibility for maintenance of blinded treatment 
assignments.  Data files with these assignments will be kept on a secure, password protected 
server housed in a locked, climate-controlled room with restricted access or on a password 
protected encrypted laptop.  To preserve the integrity of the trial, unblinded DCC staff will not 
participate in decisions to modify the trial protocol after participants have been randomized.  The 
Steering Committee will obtain statistical input for such decisions from other academic 
statisticians, blinded to treatment assignment, who also work at Harvard Medical School. 
 
4.18. Data and Safety Monitoring Board 
 
Due to the potential risks to study subjects, the size and multi-site nature of the study, 
and the fact that this is a Phase III clinical trial, the study will have a formal, and independent, 
Data and Safety Monitoring Board (DSMB). The DSMB will be constituted by the NHLBI and will 
include at a minimum members from the following general areas: 1) physicians with specific 
expertise in the management of patients’ cardiovascular disease 2) a biostatistician with specific 
expertise in the design, analysis, and safety monitoring of multi-center clinical trials 3) a medical 
ethicist, and 4) a physician with specific expertise in rheumatologic disease.  The DSMB will 
report directly to the NHLBI, and would have the responsibility of monitoring outcome 
measurements/endpoints, adverse events (AE’s), and serious adverse events, and 
recommending termination of the study if it appeared at any point during the trial that subjects 
(or a subgroup of subjects) were being placed at undue risk as a result of their participation.  
Aggregate data on adverse events, stratified by blinded treatment group, will be reviewed on a 
bimonthly basis by the Chair of the DSMB, and can be brought before the entire DSMB for 
further review if requested by the Chair. 
The DSMB will meet (face-to-face or by teleconference) at designated intervals (semi-
annually) to review accumulated data on safety and efficacy, and if appropriate, conduct an 
interim analysis of the data. Data will be prepared by the Data Coordinating Center (DCC) prior 
to each meeting of the DSMB. Serious Adverse Events (SAEs) will be initially reviewed with 
DSMB members blinded to treatment group. If, however, aggregate data suggested a trend 
toward more frequent SAEs among one treatment group, an unblinded interim analysis would 
be reviewed by the DSMB.  Guidelines for the possible early termination of the study will be 
formulated by the DSMB and a formal charter agreed upon prior to trial enrollment.  The 
proceedings of each meeting of the DSMB will be recorded in minutes. Any patient-specific 
protected health information reviewed by the DSMB would be kept completely confidential. 
Access to the unblinded minutes of the DSMB meetings by Executive/Operations Committee 
Members, Clinical Site Investigators, or members of the DCC, will be prohibited until after the 
database for the study has been locked and the study has been unblinded. A formal report will 
be submitted by the DSMB to the NHLBI, with a recommendation that the study be continued, 
modified in a manner to enhance subject safety, or terminated. 
 
4.19. Trial Conclusion and Close Out Visits 
 
  
At the close of the trial, all randomized participants will be asked to return to the local 
study sites to see a member of the physician’s study team.  Compliance, side effects, and 
patient contact information will be collected, and study end points will again be assessed by the 
local study staff.  Therapy with study drug will be discontinued, and the patient’s remaining 

 
21 
calendar packs of study drug will be collected.  While no observational registry is currently 
planned, the Clinical Coordinating Center may request that local study sites approach study 
participants about enrolling in a post-trial observational registry.    
To assess the impact of LDM withdrawal on diabetes incidence and glycemic control, 
participants will have one final laboratory evaluation for ascertainment of HbA1c 3 months after 
discontinuing study drug therapy.  
5.0. DATA ANALYSIS PLAN 
5.1. Statistical Analysis 
  
 
The randomized design and large sample size of CIRT should provide balanced 
distributions of baseline characteristics between the two treatment groups.  Nonetheless, initial 
analyses will be conducted to identify any chance imbalances in these distributions.  In 
particular, these analyses will form part of the routine monitoring of the trial and will be regularly 
reported to the DSMB.  For continuous and ordinal variables, including age and baseline levels 
of risk factors including lipid levels, blood pressure, and body mass index, comparisons will use 
the Wilcoxon rank-sum test.  For categorical variables, including sex, race, current and former 
cigarette smoking, diabetes, greater than 1 prior myocardial infarction, stroke, congestive heart 
failure, atrial fibrillation, peripheral vascular disease, hypertension, and concomitant therapy with 
statins, aspirin, clopidogrel, warfarin, beta blockers, ACE inhibitors, and angiotensin receptor 
blockers, comparisons will use Chi-square tests. These hypothesis tests are intended for data 
monitoring and quality control, and not to determine which baseline covariates to include in 
efficacy analyses50. 
The primary endpoint of the trial is the time from randomization to the first occurrence of 
any component of the clinical composite endpoint including myocardial infarction, stroke and 
cardiovascular death.  The primary analysis of the trial will use a likelihood ratio test based on a 
proportional hazards model stratified on time since qualifying event (≥ 6 months vs. < 6 months), 
type of event (myocardial infarction vs. multivessel coronary disease), and presence of either 
diabetes or metabolic syndrome to test the null hypothesis of no association between 
assignment to active methotrexate and the rate of the primary endpoint.  All analyses will 
classify patients according to their randomized treatment assignment, i.e. according to the 
intention to treat principle, and will base evaluation of statistical significance on a two-sided test 
with level 0.05.  Secondary analyses will further stratify on study site, although these analyses 
will likely be less efficient because of sparse strata that will arise because of small numbers of 
participants from some sites.  The estimated relative hazard in the methotrexate group 
compared to the placebo group with an accompanying 95% confidence interval will quantify the 
treatment effect
51.  If this relative hazard is less than 1, then 100*(1-estimated relative hazard) 
will be defined as the percent reduction in hazard associated with methotrexate treatment. 
Rates of occurrence of the primary endpoint will be defined as the total number of 
subjects who have this event in a treatment group per 100 person-years of follow-up, counting 
all time from randomization until the first of the event, death, end of trial, or withdrawal of 
consent.  Estimates of the probability of the primary endpoint by time after randomization within 
treatment groups will be based on the method of Kaplan and Meier
52.  We will also use the 
proportional hazards model to control for baseline factors that might influence the rate of the 
primary endpoint (e.g. age, race, gender, baseline comorbidities, and concomitant medications), 
as control for these variables may yield more efficient estimates of relative treatment effects53.  
If Kaplan-Meier plots of event free survival by study time, or related plots of log(-log)(survival), 
indicate violations of the proportional hazards assumption, or a formal test of trend in the scaled 
Schoenfeld residuals indicates such a violation, then weighted log-rank tests will be used 

 
22 
according to strategies described by Pecková and Fleming54.  However, even in the presence of 
an apparent violation of the proportional hazards assumption, the primary analysis described 
above gives a valid (although perhaps not optimal) test of the main trial hypothesis and will 
remain the primary analytic strategy, with these weighted log-rank tests serving as sensitivity 
analyses.   
5.2. Sample Size and Power 
  
 
Sample size and power for CIRT have been estimated under several alternative 
assumptions about the rate of the primary endpoint in the placebo group and the likely reduction 
in this rate among those in the methotrexate group.  All estimates are based on a two-sided log-
rank test comparing the time to recurrence between two treatment groups at the 0.05 
significance level.  These estimates use the approach of Lachin and Foulkes under the 
assumption of a uniform hazard and to account for attrition due to drop-out55.  The following 
assumptions have been made: 
(a) Based on previous trials in individuals with a prior myocardial infarction or 
multivessel coronary disease, and considering the increased rate of major 
cardiovascular events associated with either diabetes or metabolic syndrome, it is 
anticipated that annual event rates between 3.25 and 4.0 per 100 person-years in 
the placebo group.  
(b) A clinically meaningful reduction in the rate of the primary endpoint is assumed to be 
in the range from 25% to 35%.   
(c) The recruitment period will be split into a ramp-up period, followed by steady-state 
randomization.  Each randomized patient will be asked to continue blinded treatment 
until study completion.   
(d) As these patients have strong affiliations with their treatment centers and will have 
been tested in a run-in period, low rates of loss to follow-up are anticipated.  Power 
calculations assume a 5% annual rate of loss to follow-up.   
 
Under these assumptions Lachin and Foulkes show that the power of the trial with N total 
randomized subjects in the methotrexate and placebo groups combined is 
 
 
where Φ is the standard normal distribution function, 
 
 is the incidence rate in the methotrexate group, 
 is the incidence rate in the placebo group 
 
follow-up for uncensored subjects without events ranges from 2 to 4 years. 
Table 4 shows the power of CIRT to detect alternative relative hazard rates in an active 
treatment group with 3500 patients compared to 3500 patients who receive placebo.  The trial 
has good power (>90%) to detect hazard reductions of 25% or greater for the range of 
reasonable event rates in the placebo group, and power of 95% or greater to detect a reduction 
of 25% or greater if event rates in the placebo group are 4.0 per 100 person-years or greater. 














c
e
1/2
e
c
1
-
2
 
+
 
2
/
3.92
-
-
N
 
=
 
Power




These power calculations are based on intention to treat analyses of observed event 
rates. As such, they incorporate the effects of non-compliance.  We estimate, based on 
experience observed in other trials, that, in addition to those who drop out, 10% of the 
methotrexate group will discontinue active therapy but that none of the placebo group will initiate 
open-label therapy (drop-in).  The impact of non-compliance on power can be evaluated from 
interpolation using Table 4.  For example, if the true rate of major cardiovascular events in 
persons meeting eligibility criteria but not on methotrexate is 3.5 per 100-person years, and fully 
 


5 
[exp(2( .05) exp(-4( +
.05)]
/(2( +
.05))
( )
 =
 
  +
 
.0 /1-
,



 



 

e
c



 = 
.5 +
.5
e
 
c

 
23 
compliant methotrexate reduces this rate by 30%, we estimate a rate of the primary endpoint of 
2.555 per 100 person-years in the methotrexate group and 3.5 per 100 person-years in the 
placebo group.  This would correspond to an observed 27% reduction in the active treatment 
group relative to placebo with the above non-compliance and drop-in rates.  The proposed trial 
would thus have power above 90% to detect such a true effect.  However, we base primary 
evaluation of study 
power on observed 
event rates and 
intention to treat 
analyses, as 
summarized in Table 
4. 
 
Another perspective on sample size estimation based on the above formulation of 
enrollment indicates that, regardless of the rate of major cardiovascular events in the placebo 
group, the trial must accrue 514 total confirmed major cardiovascular events in order to have 
90% power to detect a 25% reduction in this rate, based on a two-sided test with alpha=0.05. 
Given a conservative interim monitoring plan such as that described below, then the approach 
of Reboussin et al56 indicates that sample size needs to be increased by 1.9% to maintain 90% 
power in the presence of monitoring.  We therefore stipulate that the trial will require accrual of  
530 total primary events. With respect to the above assumptions on accrual and drop out, and 
the range of event rates in the placebo group shown in the above table, the proposed trial with 
7,000 randomized subjects would be expected to accrue between 529 endpoints (placebo event 
rate=0.0325/100 person-years) and 645 endpoints (placebo event rate=0.040/100 person-
years) under the assumption of a 25% reduction in hazard associated with methotrexate. 
5.3. Stratification and Randomization 
 
Patients willing and eligible to be randomized will be stratified by time since their 
confirmed index event (< 6 months vs. > 6 months), the presence of diabetes or metabolic 
syndrome at entry, type of index event (myocardial infarction or multivessel coronary disease), 
and by site. 
5.4. Interim Feasibility Analysis 
 
Per NHLBI agreement, an interim feasibility analysis will be performed jointly by the 
DSMB and the NHLBI after 1000 patients have been randomized and followed for at least 6 
months. At this time, trial feasibility and safety will be reviewed, the trial dose range will be 
evaluated, suitability of the trial algorithms considered, and recommendations will be made to 
the investigators with regard to any needed protocol changes at that time.  
Thus, for purposes of the feasibility analysis, the investigators will submit a report to the 
NHLBI including the cumulative recruitment experience to date, the adherence among 
randomized participants, the rates of adverse events both overall and according to the major 
disease categories and the percent of participants willing to continue.  It is expected that this 
report will pool information across treatment groups (i.e. maintain the treatment blind).  
However, a parallel report with information by treatment group will be submitted simultaneously 
to the trial’s Independent Data and Safety Monitoring Board. 
5.5. Interim DSMB Analyses 
 
Table 4. Power of CIRT for alternative event rates and effect sizes in this proposal 
 
Rate of Major Cardiovascular Events in the Placebo Group 
 (per 100 person-years) 
Relative Rate 
3.25 
3.5 
3.75 
4.0 
.75 
91% 
93% 
94% 
95% 
.7 
98% 
99% 
99% 
99% 
.65 
>99% 
>99% 
>99% 
>99% 

 
24 
Interim analyses of rates of the primary outcome, as well as rates of the individual 
components of the composite endpoint, and the pre-specified secondary endpoints will be 
prepared for presentation to the Data and Safety Monitoring Board (DSMB).  Reports to the 
DSMB will also include comparisons of baseline characteristics between treatment groups, 
displays of cumulative recruitment by study time, comparisons of post-randomization laboratory 
values by treatment group, and rates of adverse events, both overall and within systems, by 
treatment group.  The frequency of the meetings will be determined by the independent DSMB 
appointed by the NHLBI.   
While the frequency of meetings and the approach to interim monitoring will be the 
choice of the DSMB, we anticipate at least twice yearly meetings to monitor recruitment and 
retention, with quarterly safety reports. To preserve alpha and to minimize the likelihood of an 
inflated effect estimate associated with early stopping, pre-planned efficacy analyses will occur 
only upon accrual of 50% and 75% of the planned study endpoints, i.e. 265 and 398 confirmed 
primary endpoints.  Additional interim analyses of efficacy data may be carried out by the 
DSMB.  The design of the trial, including evaluation of the implications of interim monitoring on 
study power, considered that stopping boundaries would be based on an alpha-spending 
function that approximates an O’Brien-Fleming boundary.  Specifically, efficacy monitoring 
would utilize the Lan-DeMets procedure with spending function α(t*)=2-2Φ(Zα/2/√t*), where 
t* is the information fraction, Φ is the standard normal distribution function, α is the two-sided 
type 1 error rate, and Zα/2  is its 100(1-α/2)th percentile.  Under this approach, the Z-values for 
the boundaries at the 50% and 75% information times would be ±2.963 and ±2.359, 
respectively, corresponding to two-sided P-values of 0.0030 and 0.0183, and observed hazard 
ratios of 0.695 and 0.789, respectively.   
The DSMB has voted to prefer more conservative boundaries, and chose a P-value of 
0.0001 at both information times, which corresponds to a Z-value of ±3.891.  Approximate 
hazard ratios associated with this Z-value are 0.620 at 50% information and 0.677 at 75% 
information. 
As a guideline for considering a recommendation to stop the study early because of 
convincing evidence of inefficacy (futility), pre-planned inefficacy bounds will also be considered 
upon accrual of 50% and again upon accrual of 75% of the targeted numbers of confirmed 
primary endpoints, i.e. upon accrual of 265 and 398 confirmed primary endpoints.  Based upon 
the Linear 20% Inefficacy Boundary approach described by Freidlin, Korn, and Gray (Clin Trials 
2010; 7: 197-208), the inefficacy boundary will be crossed if the observed relative hazard of the 
primary endpoint associated with methotrexate assignment is greater than 0.99 at the first 
interim futility analysis, or is greater than 0.97 at the second interim futility analysis.  Simulations 
performed by Freidlin et al indicate that their Linear 20% Inefficacy Boundary approach is 
associated with a less than 1% loss of power due to inefficacy monitoring.  Further, their 
approach is more conservative than a 10 or 30% conditional power approach in later follow-up 
(i.e. after 70% of information is accrued).  However, the Linear 20% Inefficacy Boundary 
approach is more aggressive than a 10% (or even a 20%) conditional power rule at the 50% 
information accrual point, so a more conservative boundary of an observed relative hazard 
associated with methotrexate assignment greater than 1.11 at the first interim futility analysis 
(the cutpoint associated with conditional power below 10%), may be preferred at that time, 
especially as use of this cutpoint will preserve power. 
 
5.6. Secondary Analysis 
  
 
In addition to the primary comparisons of methotrexate treatment with placebo, pre-
specified secondary endpoints (Section 2.2) will also be compared between treatment groups. 

 
25 
Additional analyses will separately evaluate whether the relative effects of methotrexate 
versus placebo on primary and secondary endpoints is uniform over the follow-up period.  
These evaluations will be based on the tests for significant interactions between study time and 
treatments proposed by Cox
51 as well as consideration of trends in scaled Schoenfeld residuals 
in the proportional hazards model.  Specifically, residuals will be plotted and a significant rank 
correlation of residuals with time will be indicative of a changing effect60.  In the presence of 
significant correlation, separate effects by time period will be reported.  However, even with a 
significant correlation of residuals with time, the best overall estimate of the effect of treatment 
will be the estimate obtained from the proportional hazards model without the interaction.   
Separate proportional hazards models will also be used to compare the effects of 
methotrexate treatment on time to each of the individual components of the composite endpoint.  
Analyses will use methods of competing risks survival analysis and compare the relative effects 
of randomized treatments on the different components of the composite outcome61,62.  The 
approach of Lunn and McNeil61 provides a readily accessible implementation of a classical 
approach to competing risk analysis developed by Kalbfleisch and Prentice63. 
  
While all primary analyses are on an intention-to-treat basis, CIRT is also functioning as 
a proof of concept trial and thus analyses of those compliant with the respective LDM or placebo 
regimens will also be conducted in secondary analyses. 
  
Longitudinal analyses will quantify the impact of methotrexate on lipid levels, biomarkers 
of inflammation, and change in HbA1c, with the latter analyses stratified by presence of 
diabetes at baseline. We will also assess whether any effects on these biomarkers mediate 
observed benefits or risks of LDM on clinical outcomes in the trial. 
 
5.7. Subgroup Analyses 
 
Additional planned exploratory analyses include evaluation of whether treatment effects 
vary across categories of baseline covariates including age, gender, race, presence of diabetes 
or metabolic syndrome at baseline, index event ≤6 vs. >6 months prior, type of index event 
(myocardial infarction or multivessel coronary disease), baseline lipid levels, baseline 
inflammatory biomarker levels, baseline background treatments including those known to 
interact with LDM therapy, and nutritional measures related to adenosine function such as 
estimated daily total caffeine intake.  Within each subgroup, we will use proportional hazards 
models to estimate the relative rate of the primary endpoint associated with active treatment 
versus placebo.  Both crude analyses and models including limited baseline covariates will be 
fitted.  To test for the significance of modification of treatment effects by a baseline 
characteristic, we will include interaction terms between this characteristic and treatment in the 
proportional hazards model, with statistical significance determined by a likelihood ratio test 
comparing models with and without the interaction terms between treatment and the categories 
of a specific covariate.   
We will conduct these subgroup analyses regardless of whether or not the overall 
analyses of treatment effects are significant.  Our approach to interpretation of subgroup 
analyses has always been very cautious and recognizes that, even in large trials, it is not likely 
to be possible to identify reliably subgroups of patients in whom treatment is especially effective 
or ineffective.  In the absence of prior evidence for real heterogeneity, the overall trial result may 
provide the best evidence for the presence of a benefit in a subgroup.  Our approach thus 
corresponds to an informal empirical Bayes procedure in which effects in an outlying subgroup 
require interpretation in light of the overall treatment effect. 
 

 
26 
5.8. Ancillary Studies 
 
  
A number of CIRT ancillary studies are planned.  These studies include but are not 
limited to a proposal to develop an evidence-based approach to monitoring the safety of LDM in 
a large population; a proposal to examine lipid, inflammatory, metabolic, and myocardial 
biomarkers as determinants of risk in a secondary prevention population; a proposal to 
determine the effect of LDM on echocardiographic indices of aortic stenosis; a proposal to 
determine the effect of LDM on the ankle brachial index and incident peripheral artery disease; 
a proposal to examine the genetic determinants of LDM safety and efficacy; and a proposal to 
examine the impact of LDM on non-alcoholic fatty liver disease and hepatic inflammation. 
Additional planned ancillary studies include proposals focused on anemia, cognitive decline, 
depression, and vascular function.  For any ancillary study that requires participant interactions 
beyond that described in the main trial, additional IRB approval and informed consent will be 
obtained. 
 
 
 

 
27 
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suppression of activation and adhesion molecules. Clinical immunology (Orlando, Fla.). 
2005;114(2):154-163. 
39.  
Gerards AH, de Lathouder S, de Groot ER, Dijkmans BA, Aarden LA. Inhibition of cytokine 
production by methotrexate. Studies in healthy volunteers and patients with rheumatoid arthritis. 
Rheumatology (Oxford, England). 2003;42(10):1189-1196. 
40.  
Donath MY, Shoelson SE. Type 2 diabetes as an inflammatory disease. Nat Rev 
Immunol.11(2):98-107. 
41.  
Pradhan AD, Manson JE, Rifai N, Buring JE, Ridker PM. C-reactive protein, interleukin 6, and risk 
of developing type 2 diabetes mellitus. JAMA. 2001;286(3):327-334. 
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Girman CJ, Rhodes T, Mercuri M, et al. The metabolic syndrome and risk of major coronary 
events in the Scandinavian Simvastatin Survival Study (4S) and the Air Force/Texas Coronary 
Atherosclerosis Prevention Study (AFCAPS/TexCAPS). Am J Cardiol. 2004;93(2):136-141. 

 
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Schwartz GG, Olsson AG, Szarek M, Sasiela WJ. Relation of characteristics of metabolic 
syndrome to short-term prognosis and effects of intensive statin therapy after acute coronary 
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Lowering (MIRACL) trial. Diabetes Care. 2005;28(10):2508-2513. 
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'Connor CM, et al. Metabolic syndrome, C-reactive protein, and prognosis 
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Goldberg RB, Mellies MJ, Sacks FM, et al. Cardiovascular events and their reduction with 
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and Sons; 1980. 
 
 

Summary of Changes 
 
Protocol Amendment 1 
 
• To extend CIRT enrollment criterion to include those with multi-vessel coronary 
artery disease 
• To reduce the screening inclusion criterion and threshold for up-titration of drug 
for the total white blood cell (WBC) count from >= 4,000 to >= 3500 
 
Protocol Amendment 2 
 
• To extend CIRT enrollment criterion to include those with qualifying evens at any 
time in the past, rather than simply within past 5 years.   
 

 
Statistical Analysis Plan 
 
Introduction  As described in the CIRT primary report, at trial initiation, the primary cardiovascular 
endpoint was the first occurrence of major adverse cardiovascular events (MACE, inclusive of nonfatal 
myocardial infarction, nonfatal stroke, or cardiovascular death) in a time-to-event analysis. In July 2016, 
the investigative team petitioned the NHLBI to consider an expansion of the trial primary endpoint to 
additionally include hospitalization for unstable angina requiring urgent coronary revascularization 
(MACE-plus) as this endpoint would have greater power and allow for smaller overall enrollment. It was 
jointly decided to wait for the outcome of CANTOS to see if such a change had scientific merit; when the 
CANTOS data became available in August of 2017, the NHLBI convened an External Advisory Panel which 
approved the expanded endpoint in January 2018. Other than the unblinded members of the Data 
Coordinating Center, who did not participate in this process, no members of the investigative team or 
the External Advisory Panel were aware of any unblinded trial data.  
As a consequence of these intended changes, the anticipated trial sample size was reduced from 7,000 
to 5,500 and the targeted number of primary endpoints (now MACE-plus) was increased from 530 to 
634 to have 90% power to detect a 23% reduction in the hazard of MACE-plus. However, while approved 
by the NHLBI External Advisory panel, the formal amendment to alter the protocol had yet to be 
submitted for IRB approval at the time of the first formal IDSMB meeting occurred to address efficacy 
and futility (upon accrual of half of the required MACE and MACE-plus endpoints) on March 13, 2018. At 
that meeting, the IDSMB recommended early termination of the trial based on crossing a pre-specified 
boundary for futility and absence of evidence for reduction in hsCRP with LD-MTX treatment. The IDSMB 
further asked for a formal safety follow-up visit for all participants after an additional 6 months of 
follow-up. These recommendations were accepted by the NHLBI in April 2018.  
For the above reasons, the original Statistical Analysis Plan for the trial did not undergo formal revision 
(and is presented in full below). However, to be consistent with investigator intent and actions taken by 
the IDSMB, both the MACE and MACE-plus endpoints are presented in the primary report.  

 
1	  
 
 
 
 
 
 
 
 
 
 
 
 
Statistical Analysis Plan 
 
 
 
Cardiovascular Inflammation Reduction Trial (CIRT): 
 
 
A randomized, double-blind, placebo-controlled, event-driven trial of weekly 
low-dose methotrexate (LDM) in the prevention of recurrent cardiovascular events 
among stable post-myocardial infarction patients with 
type 2 diabetes or metabolic syndrome 
 
 
 
 
 
Center for Cardiovascular Disease Prevention 
Brigham and Women’s Hospital 
 
 
Funding: National Heart Lung and Blood Institute 
 
 
 
March 25, 2013 
 
 
 

 
2	  
Abbreviations 
 
ALT   
Alanine aminotrasferase 
AST   
Aspartate aminotransferase 
CIRT   
Cardiovascular Inflammation Reduction Trial 
CRP   
C reactive protein 
DSMB  
 
Data Safety and Monitoring Board 
HbA1c  
Hemoglobin A1c 
HDL-C  
High density lipoprotein cholesterol 
ITT   
Intention to Treat 
LDM   
Low dose methotrexate 
LDL-C  
 
Low density lipoprotein cholesterol 
MACE  
 
Major Adverse Cardiovascular Event 
NHLBI  
National Heart Lung and Blood Institute 
SAE   
Serious adverse event 
SD   
Standard deviation 
WBC   
White blood cell count  
 
	  
	  

 
3	  
Table of Contents	  
	  
1.0. STUDY DETAILS ............................................................................................................... 4 
1.1. Study Objectives 
.............................................................................................................. 4 
1.2. Study Design ................................................................................................................... 4 
1.3. Number of Subjects 
......................................................................................................... 5 
2.0. ANALYSIS SETS ............................................................................................................... 6 
2.1. Definition of Analysis Sets ................................................................................................. 6 
2.2. Violations and Deviations 
................................................................................................... 6 
3.0. PRIMARY, SECONDARY AND TERTIARY AIMS 
................................................................ 7 
Primary Aim .............................................................................................................................. 7 
Secondary Aims 
........................................................................................................................ 7 
Tertiary Aims 
............................................................................................................................. 7 
Proposed Exploratory and Mechanistic Studies ....................................................................... 8 
4.0. ANALYSIS METHODS 
.......................................................................................................... 8 
4.1. General Principles 
.............................................................................................................. 8 
4.2. Demography ...................................................................................................................... 8 
4.3. Efficacy .............................................................................................................................. 9 
4.4. Safety 
............................................................................................................................... 
11 
4.5. Other Analysis 
.................................................................................................................. 
12 
5.0. INTERIM ANALYSES ......................................................................................................... 
12 
5.1. Interim Feasibility Analysis 
............................................................................................... 
12 
5.2. DSMB Analyses 
............................................................................................................... 
13 
6.0. REFERENCES .................................................................................................................... 
14 
	  
 

 
4	  
1.0. STUDY DETAILS 
1.1. 
Study Objectives 
 
The primary aim of the Cardiovascular Inflammation Reduction Trial (CIRT) is to directly 
test the inflammatory hypothesis of atherothrombosis by evaluating whether or not low-dose 
methotrexate (LDM) will reduce rates of recurrent myocardial infarction, stroke, and 
cardiovascular death among stable post-myocardial infarction patients with type 2 diabetes or 
metabolic syndrome, conditions associated with an enhanced pro-inflammatory response. 
The primary trial endpoint is the rate of recurrent myocardial infarction, stroke, or 
cardiovascular death. Secondary endpoints include: all-cause mortality, primary endpoint plus 
coronary revascularization, hospitalization for congestive heart failure, primary endpoint plus all-
cause mortality plus coronary revascularization plus congestive heart failure, net clinical benefit 
or harm, and new onset type 2 diabetes. Tertiary endpoints include: individual components of 
the primary endpoint, the primary endpoint plus unstable angina requiring unplanned coronary 
revascularization, coronary revascularization, peripheral artery disease, symptomatic deep vein 
thrombosis or pulmonary embolism, including those considered to be provoked and those 
considered to be idiopathic, clinically significant aortic stenosis, atrial fibrillation, and 
standardized measures of quality of life and global health status. 
Additional planned exploratory and mechanistic analyses include evaluation of whether 
treatment effects vary across categories of baseline covariates including age, gender, race, 
presence of diabetes or metabolic syndrome at baseline, baseline lipid levels, baseline 
inflammatory biomarker levels including high-sensitivity C-reactive protein, revascularization 
status, baseline background treatments which affect adenosine function, and nutritional 
measures related to adenosine function such as estimated daily total caffeine intake.  Clinical 
endpoints of interest that will be prospectively evaluated include incident age-related macular 
degeneration, sleep apnea, and nephropathy and retinopathy.  Analyses are planned that will 
evaluate the effect of LDM as compared to placebo on a series of inflammatory biomarkers 
(hsCRP, IL-6, and others); evaluate whether common genetic variants associated with vascular 
risk, inflammation, thrombosis, or LDM metabolism modify any benefits of LDM; and evaluate 
the effect of LDM as compared to placebo on indices of diabetes progression (among those with 
baseline diabetes).   
Mediation analyses exploring treatment effect differences by plasma measures of LDM 
metabolism, by reported LDM adherence, and by achieved reduction in inflammation, are also 
planned.  Longitudinal analyses will quantify the impact of LDM on lipid levels, biomarkers of 
inflammation, and change in HbA1c, with the latter analyses stratified by presence of diabetes 
at baseline.  Analyses will also evaluate whether genetic polymorphisms associated with 
vascular risk, inflammation, thrombosis, or LDM metabolism modify any benefits or risks of LDM 
on clinical outcomes observed in the trial.   
 
1.2. 
 Study Design 
 
CIRT is a randomized, double-blind, placebo-controlled, multi-center, event-driven trial. 
Following an open-label run-in, eligible participants who have suffered documented myocardial 
infarction in the past five years will be randomly allocated, 1:1, to usual care plus placebo or 
usual care plus LDM (target dose 15 to 20 mg per week). All study participants will additionally 
receive 1.0 mg of folic acid 6 days per week.  Subjects will be followed over a three to four year 
period 

 
5	  
1.3. 
 Number of Subjects 
  
 
Approximately 7,000 men and women from the United States and Canada will be enrolled.  
The trial is event driven such that in the absence of extreme effects, the trial will conclude after 
accrual of at least 530 primary endpoints, the number needed to provide 90 percent power to 
detect a 25 percent relative risk reduction with a conservative interim monitoring plan.  
Sample size and power for CIRT have been estimated under several alternative 
assumptions about the rate of the primary endpoint in the placebo group and the likely reduction 
in this rate among those in the methotrexate group.  All estimates are based on a two-sided log-
rank test comparing the time to recurrence between two treatment groups at the 0.05 
significance level.  These estimates use the approach of Lachin and Foulkes under the 
assumption of a uniform hazard and to account for attrition due to drop-out1.  The following 
assumptions have been made: 
(a) Based on previous trials in individuals with a prior myocardial infarction, and 
considering the increased rate of major cardiovascular events associated with either 
diabetes or metabolic syndrome, it is expected that annual event rates will be 
between 3.25 and 4.0 per 100 person-years in the placebo group.  
(b) A clinically meaningful reduction in the rate of the primary endpoint is assumed to be 
in the range from 25% to 35%.   
(c) The recruitment period will be split into a ramp-up period, followed by steady-state 
randomization.  Each randomized patient will be asked to continue blinded treatment 
until study completion.   
(d) As these patients have strong affiliations with their treatment centers and will have 
been tested in a run-in period, low rates of loss to follow-up are anticipated.  Power 
calculations assume a 5% annual rate of loss to follow-up.   
 
Under these assumptions Lachin and Foulkes show that the power of the trial with N total 
randomized subjects in the methotrexate and placebo groups combined is 
 
 
where Φ is the standard normal distribution function, 
 
 is the incidence rate in the methotrexate group, 
 is the incidence rate in the placebo group 
 
follow-up for uncensored subjects without events ranges from 2 to 4 years. 
 
 
 
Table 1 shows the power of CIRT to detect alternative relative hazard rates in an active 
treatment group with 3500 patients compared to 3500 patients who receive placebo.  The trial 
has good power (>90%) to 
detect hazard reductions of 
25% or greater for the range of 
reasonable event rates in the 
placebo group, and power of 
95% or greater to detect a 
reduction of 25% or greater if 
( )
(
)
( ) 
( )
(
)
(
)
λ
λ
λ
λ
λ
c
e
1/2
e
c
1
-
2
 
+
 
2
/
3.92
-
-
N
 
=
 
Power
Ψ
Ψ
Ψ
Φ
( 
) (
)
5
[exp(2( .05) exp(-4( +
.05)]/(2( +
.05))
( )
 =
   +
 
.0 /1-
,
λ
λλ
λ
λ 
λ
Ψ
−
+
−
e
λ
c
λ
λ
λ 
λ
  =  .5 +.5
e 
c
Table 1. Power of CIRT for alternative event rates and effect sizes in this proposal 
 
Rate of Major Cardiovascular Events in the Placebo Group 
 (per 100 person-years) 
Relative Rate 
3.25 
3.5 
3.75 
4.0 
.75 
91% 
93% 
94% 
95% 
.7 
98% 
99% 
99% 
99% 
.65 
>99% 
>99% 
>99% 
>99% 

 
6	  
event rates in the placebo group are 4.0 per 100 person-years or greater. 
These power calculations are based on intention to treat analyses of observed event 
rates. As such, they incorporate the effects of non-compliance.  We estimate, based on 
experience observed in other trials, that, in addition to those who drop out, 10% of the 
methotrexate group will discontinue active therapy but that none of the placebo group will initiate 
open-label therapy (drop-in).  The impact of non-compliance on power can be evaluated from 
interpolation in the above table.  For example, if the true rate of major cardiovascular events in 
persons meeting eligibility criteria but not on methotrexate is 3.5 per 100-person years, and fully 
compliant methotrexate reduces this rate by 30%, we estimate a rate of the primary endpoint of 
2.555 per 100 person-years in the methotrexate group and 3.5 per 100 person-years in the 
placebo group.  This would correspond to an observed 27% reduction in the active treatment 
group relative to placebo with the above non-compliance and drop-in rates.  The proposed trial 
would thus have power above 90% to detect such a true effect.  However, we base primary 
evaluation of study power on observed event rates and intention to treat analyses, as 
summarized in the above table. 
Another perspective on sample size estimation based on the above formulation of 
enrollment indicates that, regardless of the rate of major cardiovascular events in the placebo 
group, the trial must accrue 514 total confirmed major cardiovascular events in order to have 
90% power to detect a 25% reduction in this rate, based on a two-sided test with alpha=0.05. 
Given a conservative interim monitoring plan such as that described below, then the approach 
of Reboussin et al2 indicates that sample size needs to be increased by 1.9% to maintain 90% 
power in the presence of monitoring.  We therefore stipulate that the trial will require accrual of 
530 total primary events. With respect to the above assumptions on accrual and drop out, and 
the range of event rates in the placebo group shown in the above table, the proposed trial with 
7,000 randomized subjects would be expected to accrue between 529 endpoints (placebo event 
rate=3.25/100 person-years) and 645 endpoints (placebo event rate=4.0/100 person-years) 
under the assumption of a 25% reduction in hazard associated with methotrexate. 
2.0. ANALYSIS SETS 
2.1. Definition of Analysis Sets 
 
 
The efficacy analyses will be based on an Intention to Treat (ITT) population, defined as 
all randomized subjects with any follow-up data, analyzed according to their randomized 
treatment group. Safety analyses will be based upon the Safety population, defined as all 
subjects entering the study, analyzed according to treatment actually received. Safety analyses 
will be presented separately for the run-in period and the period after randomization.  
 
Compliance analyses will be based on the Compliance population, defined as all 
randomized subjects with compliance measures, analyzed according to compliance levels. The 
primary measure of compliance will be based on pill counts, with participants characterized 
according to the percent of study pills taken (with denominator that accounts for the directed 
dose changes) in the interval since the last compliance assessment. 
2.2. Violations and Deviations 
  
 
Violations of entry criteria will be reported to the Data Safety and Monitoring Board (DSMB). 

 
7	  
3.0. PRIMARY, SECONDARY AND TERTIARY AIMS 
 
Primary Aim 
 
a. To determine in a randomized, double-blind, placebo-controlled setting whether LDM 
given at a target dose of 15 to 20 mg po weekly will reduce rates of recurrent myocardial 
infarction, stroke, or cardiovascular death among patients with a prior history of 
myocardial infarction and either type 2 diabetes or metabolic syndrome. 
Secondary Aims 
 
a. To determine in a randomized, double-blind, placebo-controlled setting whether LDM will 
reduce rates of all-cause mortality among patients with a prior history of myocardial 
infarction and either type 2 diabetes or metabolic syndrome. 
b. To determine in a randomized, double-blind, placebo-controlled setting whether LDM will 
reduce rates of the primary endpoint plus coronary revascularization. 
c. To determine in a randomized, double-blind, placebo-controlled setting whether LDM will 
reduce the rates of hospitalization for congestive heart failure. 
d. To determine in a randomized, double-blind, placebo-controlled setting whether LDM will 
reduce rates of the primary endpoint plus all-cause mortality plus coronary 
revascularization plus congestive heart failure. 
e. To determine in a randomized, double-blind, placebo-controlled setting the side effect 
profile of LDM in a non-rheumatologic population at risk for recurrent vascular events. By 
so doing, CIRT will evaluate the net clinical benefit or harm that might accrue from the 
hypothesized use of LDM as a novel method for the secondary prevention of myocardial 
infarction, stroke, and cardiovascular death.  
f. To determine in a randomized, double-blind, placebo-controlled setting whether LDM will 
reduce the rate of new onset type 2 diabetes among those with metabolic syndrome but 
not diabetes at study entry.  
Tertiary Aims 
 
In addition, we will determine in a randomized, double-blind, placebo-controlled setting whether 
LDM will  
 
a. reduce rates of the individual components of the primary endpoint 
b. reduce rates of the primary endpoint plus unstable angina requiring unplanned coronary 
revascularization 
c. reduce rates of coronary revascularization 
d. reduce rates of peripheral artery disease 
e. reduce rates of symptomatic deep vein thrombosis or pulmonary embolism, including 
those considered to be provoked and those considered to be idiopathic 
f. reduce rates of clinically significant aortic stenosis 
g. reduce rates of atrial fibrillation 
h. have positive or negative effects on standardized measures of quality of life and global 
health status 

 
8	  
Proposed Exploratory and Mechanistic Studies 
 
Clinical endpoints of interest that will be prospectively evaluated include incident age-related 
macular degeneration, sleep apnea, and nephropathy and retinopathy.  In addition, a plasma 
and DNA bank will be established as part of the trial protocol. Thus, cohort accrual and 
biobanking also allows for the evaluation of several exploratory aims that relate to mechanisms 
of effect using measured plasma biomarkers of inflammation and glucose metabolism, as well 
as potential genetic determinants of LDM activity.  Analyses are planned that will 
 
a. Evaluate the effect of LDM as compared to placebo on a series of inflammatory 
biomarkers such as IL-6, TNF, CRP, interleukin-1 (IL-1), and interleukin-1 receptor 
antagonist (IL1ra), and to ascertain whether any effects on these biomarkers mediate 
observed benefits or risks of LDM on clinical outcomes in the trial. 
b. Evaluate whether genetic polymorphisms associated with vascular risk, inflammation, 
thrombosis, or LDM metabolism modify any benefits or risks of LDM on clinical outcomes 
observed in the trial. 
c. Among subjects with baseline diabetes, evaluate the effect of LDM as compared to 
placebo on indices of diabetic progression and glycemic control such as need for 
diabetes treatment intensification, proportion of subjects achieving optimal glycemic 
control (HbA1c<7.0%), and change in HbA1c overall and by study visit. 
 
Variables for safety assessment will include: 
a. adverse events 
b. transaminase levels  
c. hematology 
d. creatinine clearance 
e. reported symptoms 
 
4.0. ANALYSIS METHODS 
4.1. General Principles 
  
 
In the analysis of efficacy, subjects will be grouped by the treatment to which they were 
randomized. In the analyses of safety, subjects will be grouped by the treatment received. 
All analyses will be stratified by time since the confirmed index myocardial infarction (≤ 6 
months vs > 6 months) as well as presence of diabetes or metabolic syndrome at entry. 
 
4.2. Demography 
  
 
The following will be reported on all randomized subjects: age, sex, race, weight, height, 
BMI, waist circumference, medication use, vital signs, CHD risk factors, education, exercise, 
alcohol consumption, revascularization status, and significant medical history. We will also 
collect information on other risk factors for recurrent cardiovascular events, such as severity of 
the index event, functional status, and relevant comorbidities. For continuous variables (e.g. 
age), the mean, standard deviation (SD), minimum, maximum, and n will be presented.  For 
categorical variables (e.g sex), frequency counts and percentages in each category will be 

 
9	  
provided. Data will be given by center, treatment, and subject. The randomized design and large 
sample size of CIRT should provide balanced distributions of baseline characteristics between 
the two treatment groups.  Nonetheless, initial analyses will be conducted to identify any chance 
imbalances in these distributions using Wilcoxon rank-sum tests for continuous variables and 
Chi-square tests for categorical variables.  These hypothesis tests are intended for data 
monitoring and quality control, and not to determine which baseline covariates to include in 
efficacy analyses3. In particular, these analyses will form part of the routine monitoring of the 
trial and will be regularly reported to the Data and Safety Monitoring Board.   
4.3. Efficacy 
 
Efficacy analyses of the primary and secondary endpoints of the trial will focus on time 
from randomization to the first occurrence of the event.  These analyses will use a likelihood 
ratio test based on a proportional hazards model stratified on time since index myocardial 
infarction (≥ 6 months vs < 6 months) and diabetes mellitus vs metabolic syndrome alone at 
baseline, to test the null hypothesis of no association between assignment to active 
methotrexate and the rate of the endpoint.  Estimation will use the exact method to handle ties4.  
Although randomization is also stratified by site, we judge the potential loss of information 
associated with additional stratification on this variable to be a greater concern than any 
associated gain, so that stratification by site will not be part of the primary analysis.    All primary 
and pre-specified secondary analyses will classify patients according to their randomized 
treatment assignment, i.e. according to the intention to treat principle, and will base evaluation 
of statistical significance on a two-sided test with level 0.05.  The estimated relative hazard in 
the methotrexate group compared to the placebo group with an accompanying 95% confidence 
interval will quantify the treatment effect5.  If this relative hazard is less than 1, then 100*(1-
estimated relative hazard) will be defined as the percent reduction in hazard associated with 
methotrexate treatment. 
Rates of occurrence of the endpoint will be defined as the total number of subjects who 
have this event in a treatment group per 100 person-years of follow-up, counting all time from 
randomization until the first of the event, death, end of trial, or withdrawal of consent.  The 
primary analysis will estimate the probability of the endpoint by time after randomization within 
treatment groups based on the method of Kaplan and Meier6.	  
As an additional analysis, we will 
also use the proportional hazards model to control for baseline factors that might influence the 
rate of the endpoint (e.g. age, race, gender, severity of index event, baseline comorbidities, and 
concomitant medications), as control for these variables may yield more efficient estimates of 
relative treatment effects
7.  However, these analyses are secondary, and the logrank test, 
stratified on time since index MI and baseline diabetes without adjustment for covariates, is the 
pre-specified, primary analytic approach. If Kaplan-Meier plots of event free survival by study 
time, or related plots of log(-log)(survival), indicate violations of the proportional hazards 
assumption, or a formal test of trend in the scaled Schoenfeld residuals indicates such a 
violation8, then weighted log-rank tests will be used according to strategies described by 
Pecková and Fleming9.  However, even in the presence of an apparent violation of the 
proportional hazards assumption, the analysis described above gives a valid (although perhaps 
not optimal) test of the main trial hypothesis and will remain the primary analytic strategy, with 
these weighted log-rank tests serving as sensitivity analyses.   
Separate proportional hazards models will also be used to compare the effects of 
methotrexate treatment on time to each of the individual components of the composite endpoint.  
The null hypothesis of no effect of methotrexate on an individual component will be evaluated by 
the logrank test, stratified on time since index MI and baseline diabetes status.  Analyses will 

 
10	  
use methods of competing risks survival analysis and compare the relative effects of 
randomized treatments on the different components of the composite outcome
10,11.  The 
approach of Lunn and McNeil10 provides a readily accessible implementation of a classical 
approach to competing risk analysis developed by Kalbfleisch and Prentice12. 
 
While all primary and secondary endpoint analyses are on an intention-to-treat basis, 
CIRT is also functioning as a proof of concept trial and thus secondary analyses of those 
compliant with the respective LDM or placebo regimens will also be conducted.  These analyses 
will use time-varying proportional hazards models, with an individual’s level of adherence 
updated at each study visit.  Adherence will be examined on a time-varying basis using a metric 
based on percent of study drug taken at last visit, such as half or more vs. less than half, and 
will also be analyzed cumulatively.  Similar analyses will also be conducted on the basis of 
plasma levels of LDM metabolism. 
We will explore in subgroup analyses whether treatment effects vary across categories 
of baseline covariates including age, gender, race, presence of diabetes or metabolic syndrome 
at baseline, index MI ≤6 vs >6 months prior, baseline lipid levels, CHF at baseline, baseline 
inflammatory biomarker levels including high-sensitivity C-reactive protein, revascularization 
status, baseline background treatments including those known to affect adenosine, such as 
aggrenox, methylxanthines, and fioricet, nutritional measures related to adenosine function such 
as estimated daily total caffeine intake, and by plasma measures of LDM metabolism. Cutpoints 
for analyses will be determined after the final distribution of patients has been established. 
Within each subgroup, we will use proportional hazards models to estimate the relative 
rate of the primary endpoint associated with active treatment versus placebo.  Both crude 
analyses and models including limited baseline covariates will be fitted.  To test for the 
significance of modification of treatment effects by a baseline characteristic, we will include 
interaction terms between this characteristic and treatment in the proportional hazards model, 
with statistical significance determined by a likelihood ratio test comparing models with and 
without the interaction terms between treatment and the categories of a specific covariate.   
We will conduct these subgroup analyses regardless of whether or not the overall 
analyses of treatment effects are significant.  Our approach to interpretation of subgroup 
analyses has always been very cautious and recognizes that, even in large trials, it is not likely 
to be possible to identify reliably subgroups of patients in whom treatment is especially effective 
or ineffective.  In the absence of prior evidence for real heterogeneity, the overall trial result may 
provide the best evidence for the presence of a benefit in a subgroup13.  Our approach thus 
corresponds to an informal empirical Bayes procedure in which effects in an outlying subgroup 
require interpretation in light of the overall treatment effect
14. 
The pre-specified secondary endpoints (all-cause mortality, primary endpoint plus 
coronary revascularization, hospitalization for congestive heart failure, primary endpoint plus all-
cause mortality plus coronary revascularization plus congestive heart failure, net clinical benefit 
or harm, and new onset type 2 diabetes) will be evaluated using the same procedures described 
above for the primary endpoints. The net clinical benefit or harm endpoint will be presented as a 
table of the incidence of adverse events occurring with greater than 1% frequency in either 
treatment group, as well as a test of proportions for comparing the incidence in each treatment 
group. The overall rate of any serious adverse event during the randomized treatment period will 
also be compared between the methotrexate and placebo groups.  Pre-specified tertiary 
endpoints will also be evaluated using the same procedures described for the primary endpoint. 
Measures of quality of life and global health status, assessed at baseline, 1-year and 
closeout visits, will be analyzed in a mixed-effects linear regression model with subject as a 
random effect.  Of particular interest in this model will be a time by treatment interaction.  The 

 
11	  
model will use two indicators of post-randomization (1-year and final visit) to evaluate a possible 
non-linear effect of treatment on outcomes by time. 
To enhance interpretation for clinicians through consideration of absolute treatment 
effects, we will also estimate the number needed to treat or the number needed to harm, for 
both primary and secondary endpoints.  Specifically, we will use the approach of Altman and 
Andersen15 to obtain these estimates based on the Kaplan-Meier estimates of time-specific 
treatment effects. 
Longitudinal analyses will quantify the impact of methotrexate on biomarkers including 
lipid levels, inflammatory markers, creatinine, and change in HbA1c, with the latter analyses 
stratified by presence of diabetes at baseline. Additional longitudinal analyses will evaluate the 
time course of methotrexate treatment on important biomarkers of safety including serum 
creatinine and estimated glomerular filtration rate.  
Mediation analyses exploring treatment effect differences by achieved reduction in 
inflammation and level of adherence to assigned treatment are also planned.  Following 
approaches used in previous analyses of the relationship of changes in lipids and hs-CRP with 
effects of statin therapy on outcomes
16-18, we will group subjects into achieved target levels of 
biomarkers and relate these achieved levels to treatment outcomes. This will also be combined 
with an analysis of compliance to explore whether observed treatment effects are compliance 
driven. 
We also plan to evaluate whether genetic polymorphisms associated with vascular risk, 
inflammation, thrombosis, or LDM metabolism modify any benefits or risks of LDM on clinical 
outcomes observed in the trial. 
 
4.4. Safety 
  
 
Data from all subjects who enter the run-in period will be included in the evaluation of 
safety. Results from the run-in period will be presented separately from the results after 
randomization. Adverse events will also be reported separately for the two periods. 
 
Treatment emergent adverse effects are defined as adverse events that start after 
initiation of study drug or adverse events ongoing from screening which worsen in intensity. The 
definitions of adverse events and serious adverse events are given in the protocol (Sections 4.9, 
4.10, and 4.17).  
 
The proportion of subjects experiencing adverse events will be tabulated by treatment 
received.  In the case of adverse events leading to withdrawal or dose changes, the incidence 
will also be tabulated and reported by treatment group for all events observed during the 
randomized treatment phase. Summaries of all treatment emergent adverse events, treatment 
emergent adverse events leading to death, and treatment emergent serious adverse events will 
also be presented by treatment group.  
 
Laboratory measures and changes from baseline will be summarized by mean, median, 
SD, minimum, maximum, and number of subject at each visit at which measurements are taken. 
Pre-specified alterations in laboratory values will be highlighted and summarized by treatment 
group, including: 
1. Increase in transaminase levels (ALT or AST)  
a.  >1.5to <2 times the upper limit of normal 
b. more than 2 times the upper limit of normal 
2. Platelets  
a. < 75,000 to 50,000/mm3 
b. < 50,000/mm3 

 
12	  
3. WBC  
a. < 4,000 to 3,000/mm3 
b. < 3,000/mm3 
4. Reduction in creatinine clearance to 
a. 30 to < 40 ml/min/1.75m2 
b. < 30 ml/min  
5. Hematocrit  
a. < 27% 
6. Albumin 
a. < 0.8 times the lower limit of normal  
 
Vital signs and weight will be summarized at each visit. Physical exam abnormalities at 
baseline and new or aggravated physical exam abnormalities will be listed, including fevers, 
cough, shortness of breath, nausea, vomiting, and painful and open mouth sores.  
Safety results will be summarized both by randomized treatment assignment and by 
actual treatment at time of occurrence of an adverse event or measurement of a laboratory 
value. For the latter, treatment groups are LDM, placebo, and Off Randomized Treatment.  Off 
Randomized Treatment is defined as subjects who have withdrawn from randomized treatment 
but continue to be followed.    
4.5. Other Analysis 
  
 
The following will be summarized by randomized treatment with frequency counts and 
percentages: 
• Completion and withdrawal from the randomized treatment period 
• Reason for withdrawal from the randomized treatment period 
• Compliance 
• Prior and concomitant medication 
• Misrandomization 
5.0. INTERIM ANALYSES 
5.1. Interim Feasibility Analysis 
 
An interim feasibility analysis will be performed jointly by the DSMB and the NHLBI after 
1000 patients have been randomized and followed for at least 6 months. At this time, trial 
feasibility and safety will be reviewed, the trial dose range will be evaluated, suitability of the trial 
algorithms considered, and recommendations will be made to the investigators with regard to 
any needed protocol changes at that time. 
Thus, for the purposes of the feasibility analysis, the investigators will submit a report to 
the NHLBI including the cumulative recruitment experience to date, the adherence among 
randomized participants, the rates of adverse events both overall and according to the major 
disease categories and the percent of participants willing to continue.  It is expected that this 
report will pool information across treatment groups (i.e. maintain the treatment blind).  
However, a parallel report with information by treatment group will be submitted simultaneously 
to the trial’s Independent Data and Safety Monitoring Board. 

 
13	  
5.2. DSMB Analyses 
Interim analyses of rates of the primary outcome, as well as rates of the individual 
components of the composite endpoint, and the pre-specified secondary endpoints will be 
prepared for presentation to the Data and Safety Monitoring Board (DSMB).  Reports to the 
DSMB will also include comparisons of baseline characteristics between treatment groups, 
displays of cumulative recruitment by study time, comparisons of post-randomization laboratory 
values by treatment group, and rates of adverse events, both overall and within systems, by 
treatment group.  The frequency of the meetings will be determined by the independent DSMB 
appointed by the NHLBI.   
Specifically, the blinded portion of the report will display, by treatment group and visit 
number, the number of subjects with an expected visit (i.e. those whose window for that visit 
closed at least 4 weeks before database lock for the particular interim report), the number and 
percent of those who remained on drug at that visit, and secondary tables which display the 
numbers of subjects who gave scheduled blood samples.  An additional table will display by 
treatment group the numbers of subjects who remain in study and on drug, and, for those who 
have discontinued, the reason for discontinuation.  Categories for reasons for stopping which we 
have used in the past are: Adverse Event, Endpoint, Deceased, Medication Use, Investigator 
Decision, Site Closure, Protocol Noncompliance, Lost to Follow-up, Withdrew Consent, Other, 
and Unknown.  Additional tables will display, by treatment group and visit number, the rates of 
adherence based on self-reported pill counts.  These last tables will be shown two ways: first, 
restricted to subjects who attended a visit, and then with 0 imputed for adherence for subjects 
who missed a visit and whose visit window closed more than 12 weeks before database lock for 
that interim report.  Overall, power for the trial was estimated under the assumption of a 5% 
annual drop-out and loss to follow-up rate.  If the rate exceeds this amount at a scheduled 
interim report, study power will be re-estimated based on the observed rate.  
While the frequency of meetings and the approach to interim monitoring will be the 
choice of the DSMB, we anticipate at least twice yearly meetings to monitor recruitment and 
retention, with quarterly safety reports.  With respect to efficacy monitoring and possible 
stopping for benefit, we will recommend to the DSMB monitoring via the Lan-DeMets 
procedure19 with spending function α(t*)=2-2Φ(Zα/2/√t*), where t* is the information fraction, 
Φ is the standard normal distribution function, α is the two-sided type 1 error rate, and Zα/2  is 
its 100(1-α/2)th percentile.  To preserve alpha and to minimize the likelihood of an inflated effect 
estimate associated with early stopping, we recommend pre-specification of only two formal 
evaluations of efficacy.  With an event-driven trial targeting 530 total confirmed endpoints, these 
evaluations would occur upon accrual of 199 and 398 confirmed primary endpoints.The Z-
values for the boundaries would be ±3.4786 at the first interim analysis and ±2.3431 at the 
second efficacy analysis.  Based on the formula of Schoenfeld20, the Z-value is related to the 
expected value of the log-rank statistic by the formula
, where HR is the 
hazard ratio, and D is the overall number of events.  Thus, with D=199 and 398, the hazard 
ratios at the boundary would be 0.611 and 0.791, respectively. 
The DSMB has voted to prefer more conservative boundaries, and chose a P-value of 
0.0001 at both information times, which corresponds to a Z-value of ±3.891.  Approximate 
hazard ratios associated with this Z-value are 0.620 at 50% information and 0.677 at 75% 
information. 
As a guideline for considering a recommendation to stop the study early because of 
convincing evidence of inefficacy (futility), pre-planned inefficacy bounds will also be considered 
upon accrual of 50% and again upon accrual of 75% of the targeted numbers of confirmed 
primary endpoints, i.e. upon accrual of 265 and 398 confirmed primary endpoints.  These time 
log( ) / 4
Z
HR
D
=

 
14	  
points agree with the cutpoints used in the AIM-HIGH trial21, and are chosen to mitigate the 
possibility of stopping early with an imprecisely estimated treatment effect.  Based upon the 
Linear 20% Inefficacy Boundary approach described by Freidlin et al22,  the inefficacy boundary 
will be crossed if the observed relative hazard of the primary endpoint associated with 
methotrexate assignment is greater than 0.99 at the first interim futility analysis, or is greater 
than 0.97 at the second interim futility analysis.  Simulations performed by Freidlin et al indicate 
that their Linear 20% Inefficacy Boundary approach is associated with a less than 1% loss of 
power due to inefficacy monitoring.  Further, their approach is more conservative than a 10 or 
30% conditional power approach in later follow-up (i.e. after 70% of information is accrued).  
However, the Linear 20% Inefficacy Boundary approach is more aggressive than a 10% (or 
even a 20%) conditional power rule at the 50% information accrual point, so a more 
conservative boundary of an observed relative hazard associated with methotrexate assignment 
greater than 1.11 at the first interim futility analysis (the cutpoint associated with conditional 
power below 10%), may be preferred at that time, especially as use of this cutpoint will preserve 
power. 
 
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