Safety and Effectiveness of Low-Dose Methotrexate for Reducing Inflammation in HIV-Infected Adults on ARV Medications
Condition: HIV Infections
MeSH terms: Infections; HIV Infections; Acquired Immunodeficiency Syndrome; Inflammation
Intervention: LDMTX; Placebo; Folic acid
Intervention description: LDMTX 5 mg: one 5-mg capsule by mouth once weekly
LDMTX 10 mg: two 5-mg capsules by mouth once weekly
LDMTX 15 mg: three 5-mg capsules by mouth once weekly; Placebo 5 mg: one 5-mg capsule by mouth once weekly
Placebo 10 mg: two 5-mg capsules by mouth once weekly
Placebo 15 mg: three 5-mg capsules by mouth once weekly; 1-mg tablet of folic acid by mouth once a day
Intervention MeSH terms: Folic Acid; Methotrexate
Phase: Phase 2
Study type: Interventional
Primary purpose: Treatment
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Enrollment: 176.0
Sex: All
Minimum age: 40 Years
Healthy volunteers: No

Summary:

      People with HIV infection who are taking antiretroviral therapy (ART) could be at risk for
      cardiovascular disease (CVD), which can be caused by inflammation. Methotrexate (MTX) is a
      medication used to treat inflammation in people with rheumatoid arthritis. This study
      evaluated the safety and effectiveness of low-dose methotrexate (LDMTX) at reducing
      inflammation in HIV-infected adults.
    

Eligibility criteria:

        Inclusion Criteria:

          -  HIV-1 infection, documented by any licensed rapid HIV test or HIV enzyme or
             chemiluminescence immunoassay (E/CIA) test kit at any time prior to study entry and
             confirmed by a licensed Western blot or a second antibody test by a method other than
             the initial rapid HIV and/or E/CIA, or by HIV-1 antigen, plasma HIV-1 RNA viral load.

          -  Had to be on continuous ART for greater than or equal to 24 weeks prior to study
             entry. This was defined as continuous active therapy for the 24-week period prior to
             study entry with no treatment interruption longer than 7 consecutive days and a total
             duration off treatment of no more than 14 days in the 90 days prior to study entry.

          -  CD4 T-cell count greater than or equal to 400 cells/mm^3 obtained within 60 days prior
             to study entry by any U.S. laboratory that has a Clinical Laboratory Improvement
             Amendments (CLIA) certification or its equivalent

          -  HIV-1 RNA level below the limit of quantification using a FDA-approved assay for at
             least 24 weeks prior to study entry and confirmed within 60 days prior to study entry.
             The assay used for eligibility could be performed by any U.S. laboratory that had a
             CLIA certification or its equivalent. NOTE: Single determinations that are between the
             assay quantification limit and 200 copies/mL were allowed as long as the preceding and
             subsequent determinations are below the level of quantification.

          -  The following laboratory values obtained within 60 days prior to study entry by any
             U.S. laboratory that has a CLIA certification or its equivalent:

               1. Fasting glucose less than 180 mg/dL

               2. Alanine aminotransferase (ALT) [serum glutamic pyruvic transaminase (SGPT)] less
                  than 2 times the upper limit of normal (ULN)

               3. Aspartate aminotransferase (AST) [serum glutamic oxaloacetic transaminase (SGOT)]
                  less than 2 times the ULN

               4. Estimated creatinine clearance (CrCl) greater than or equal to 50 mL/min by
                  Cockcroft-Gault. NOTE: Candidates who were taking tenofovir disoproxil fumarate
                  (TDF) as part of their ART regimen should have an estimated CrCl greater than or
                  equal to 60 mL/min.

               5. White blood cell (WBC) greater than 3,000/mm^3

               6. Hemoglobin greater than 12.0 g/dL

               7. Platelets greater than 150,000/mm^3

          -  Female candidates who were postmenopausal (i.e., of non-childbearing potential) were
             defined as having either:

               1. Appropriate medical documentation of prior hysterectomy and/or complete bilateral
                  oophorectomy (i.e., surgical removal of the ovaries, resulting in "surgical
                  menopause" and occurring at the age at which the procedure was performed), OR

               2. Permanent cessation of previously occurring menses as a result of ovarian failure
                  with documentation of hormonal deficiency by a certified healthcare provider
                  (i.e., "spontaneous menopause").

          -  Male candidates must agree not to participate in a conception process (i.e., active
             attempt to impregnate, sperm donation). If participating in sexual activity that could
             lead to pregnancy, the male participant must agree to the use of TWO reliable forms of
             contraceptives simultaneously while on study and for a minimum of 3 months after
             therapy.

          -  Candidates who were not of reproductive potential (defined as women who have been
             postmenopausal for at least 24 consecutive months or men who have documented
             vasectomy) were eligible for the study without requiring the use of contraceptives.

          -  Moderate or high CVD risk defined as:

        A) Documented CVD as assessed by meeting at least 1 of 3 criteria below:

          1. Coronary artery disease (CAD): prior myocardial infarction (MI) due to
             atherosclerosis, coronary artery bypass graft surgery, percutaneous coronary
             intervention, or angiographic CAD with luminal diameter stenosis of at least one
             coronary artery at least 50%.

          2. Cerebrovascular disease: prior ischemic stroke of carotid origin, carotid
             endarterectomy or stenting, or angiographic carotid stenosis of at least 50%.

          3. Peripheral arterial disease: prior lower extremity arterial surgical or percutaneous
             revascularization procedure, or angiographic lower extremity arterial stenosis of at
             least 50%.

        OR

        B) Controlled type II diabetes mellitus (HbA1C less than or equal to 8.0% within the past
        90 days prior to study entry, regardless of use of medications)

        OR

        C) Any one of the following CVD risk factors below:

          1. Current smoking: self-report of smoking at least a half a pack of cigarettes a day, on
             average, in the past month.

          2. Hypertension (HTN): two consecutive blood pressure (BP) readings with either systolic
             greater than 140 mm Hg or diastolic greater than 90 mm Hg; or on antihypertensive
             medications.

          3. Dyslipidemia: defined as non-high-density lipoprotein (HDL)-C greater than 160 mg/dL
             or HDL-C less than or equal to 40 mg/dL, regardless of medication use.

          4. High-sensitivity C-reactive protein (hsCRP) greater than or equal to 2 mg/L at
             screening

        Ability and willingness of candidate to provide informed consent

          -  Completion of the Flow-mediated Vasodilation (FMD) assessments. NOTE: The FMD must be
             performed at the site and confirmed as acceptable by the University of Wisconsin
             Atherosclerosis Imaging Research Program (UW AIRP) core lab prior to study entry. If
             the FMD is deemed unacceptable, a repeat scan must be performed prior to enrollment.

          -  Appropriate documentation from medical records of prior receipt of pneumococcal
             vaccination (with both the 13-valent conjugant vaccine [PCV13] and 23-valent
             pneumococcal polysaccharide vaccine [PPV23]) within the last 5 years. If no
             documentation is available, then the PCV13 and PPV23 series (PCV13 vaccine followed by
             PPV23 vaccine at least 8 weeks later) should be completed more than 14 days prior to
             study entry.

        Exclusion Criteria:

          -  Acute or serious illness requiring systemic treatment and/or hospitalization within 60
             days prior to study entry. NOTE: Treatment should have ended at least 60 days prior to
             study entry for eligibility.

          -  Documentation of any CDC category C AIDS-indicator condition or oropharyngeal
             candidiasis (thrush) within 90 days prior to study entry

          -  Receipt of antibiotic therapy within 30 days prior to study entry

          -  Latent tuberculosis (TB) infection (defined as a positive purified protein derivative
             [PPD] greater than or equal to 5 mm, positive interferon-gamma release assay, or
             positive T-spot test at any time in the past) or evidence of latent TB on the
             screening chest x-ray that had not been completely treated or was treated within the
             past 6 months prior to study entry

          -  TB disease that required treatment within 48 weeks prior to study entry

          -  Life-threatening fungal infection requiring treatment, in the opinion of the site
             investigator, within 48 weeks prior to study entry

          -  Herpes-zoster viral infection that required treatment within 90 days prior to study
             entry

          -  A history of or current, active hepatitis B infection defined as positive hepatitis B
             surface antigen (HBsAg) test or positive hepatitis B virus (HBV) DNA in candidates
             with isolated hepatitis B core antibody (HBcAb) positivity, defined as negative HBsAg,
             negative hepatitis B surface antibody (HBsAb), and positive HBcAb within 24 weeks
             prior to study entry. NOTE: Candidates who were positive for hepatitis B surface
             antigen but who were HBV DNA negative were permitted in the study.

          -  Chronic hepatitis C infection defined as a positive hepatitis C antibody and positive
             hepatitis C RNA at any time prior to study entry. NOTE: Candidates who were positive
             for hepatitis C antibody but whowerehepatitis C virus (HCV) RNA negative are permitted
             in the study. Candidates who had been treated for hepatitis C should be HCV RNA
             negative for at least 24 weeks after completion of therapy to be eligible for the
             study.

          -  Previously diagnosed myelodysplasia syndrome

          -  Treated lymphoproliferative disease less than or equal to 5 years prior to study entry

          -  Clinically significant lung disease on the screening chest x-ray that, in the opinion
             of the site investigator, places the candidate at increased risk of lung toxicity
             (e.g., history of pulmonary fibrosis, interstitial lung disease, or pulmonary
             lymphoproliferative disease)

          -  Use of immunomodulators (e.g., interleukins, interferons, cyclosporine), HIV vaccine,
             systemic cytotoxic chemotherapy, or investigational therapy within 30 days prior to
             study entry

          -  Change in the ART regimen in the 12 weeks prior to study entry or intended
             modification of ART during the study. NOTE: Modifications of ART doses during the 12
             weeks prior to study entry were permitted. In addition, the change in formulation
             (e.g., from standard formulation to fixed-dose combination) was allowed within 12
             weeks prior to study entry. A within class single drug substitution (e.g., switch from
             nevirapine to efavirenz or from atazanavir to darunavir) is allowed within 12 weeks
             prior to study entry, with the exception of a switch from any other nucleoside reverse
             transcriptase inhibitor (NRTI) to abacavir. No other changes in ART in the 12 weeks
             prior to study entry were permitted.

          -  Known allergy/sensitivity or any hypersensitivity to components of study drug(s) or
             their formulation

          -  Average daily consumption of three or more alcoholic beverages for 4 weeks prior to
             study entry or intention to consume an average of two or more alcoholic beverages a
             day during the study. NOTE: An alcohol-containing beverage is defined as 12 ounces of
             beer, 4 ounces of wine, or 1 ounce of spirits.

          -  Active drug or alcohol use or dependence that, in the opinion of the site
             investigator, would interfere with adherence to study requirements

          -  Changes in lipid-lowering or antihypertensive medication within 90 days prior to study
             entry or expected need to modify these medications during the study. NOTE:
             Lipid-lowering medication includes: statins, fibrates, niacin (dose greater than or
             equal to 250 mg daily), and fish-oil/omega 3 fatty acids (dose greater than 1000 mg of
             marine oils daily).

          -  Vaccination (e.g., influenza, pneumococcal polysaccharide) within 14 days prior to
             study entry

          -  Anticipated need to receive vaccination (e.g., influenza, pneumococcal polysaccharide)
             within 1 week prior to Week 4, 12, 24, or 36 study visits

          -  Excess extracompartmental fluids including ascites, pericardial fluid, and pleural
             effusions which, in the opinion of the study investigators, would result in difficulty
             in monitoring the dose of MTX

          -  Use of drugs that alter folic acid metabolism such as trimethoprim/sulfamethoxazole or
             reduce tubular excretion such as probenecid within 14 days prior to study entry

          -  New York Heart Association Class IV congestive heart failure

          -  Diabetes mellitus with HbA1C greater than 8.0% within the past 90 days prior to study
             entry