Phase II Study of Perindopril and Regorafenib in mCRC
Condition: Metastatic Colorectal Cancer
MeSH terms: Colorectal Neoplasms
Intervention: Regorafenib; Perindopril
Intervention description: Stivarga® will be used as per the marketed indication ("on label"), Coversyl will be used off-label and as such a Clinical Trial Application will be filed with Health Canada.
Regorafenib will be administered 160 mg daily for 21 days of a 28 day cycle. Regorafenib will be administered with low fat breakfast, one hour after perindopril. A low fat breakfast as defined by the Stivarga ® (regorafenib) Product Monograph is one that is <30% fat, ~300-550 calories.; COVERSYL® (perindopril erbumine) 4 mg will be administered daily for 21 days of a 28 day cycle. Perindopril will be administered orally, first thing in the morning on an empty stomach.
Intervention MeSH terms: Perindopril
Phase: Phase 2
Study type: Interventional
Primary purpose: Treatment
Intervention model: Single Group Assignment
Masking: None (Open Label)
Enrollment: 12.0
Sex: All
Minimum age: 18 Years
Healthy volunteers: No
Keywords: Metastatic colorectal cancer; Metastatic colorectal carcinoma; mCRC; Regorafenib; Stivarga; Perindopril; Perindopril erbumine; Coversyl

Summary:

      The purpose of this study is to find out what effects the combination of regorafenib and
      perindopril has on hand-foot skin reaction (HFSR), on high blood pressure (hypertension) and
      on any other types of side-effects and compare it to the published incidence of the
      side-effects with regorafenib alone.

      This research is being done in an attempt to reduce the side-effects associated with
      regorafenib.
    

Eligibility criteria:

        Inclusion Criteria:

        Patients with metastatic colorectal cancer (mCRC) who have progressed on/after, or are
        intolerant to all approved drugs for CRC and are eligible for regorafenib.

        In order to be eligible, all inclusion criteria must be met.

        A patient must:

          -  Understand, be willing to give consent, and sign a written informed consent form (ICF)
             prior to undergoing any study-specific procedure

          -  Be male or female and ≥ 18 years of age

          -  Histological or cytological documentation of adenocarcinoma of the colon or rectum.

          -  Patients with metastatic colorectal cancer (Stage IV) previously treated with
             fluoropyrimidine-based chemotherapy, oxaliplatin, irinotecan, an anti-VEGF therapy,
             and, if KRAS wild type, an anti-EGFR therapy.

          -  Progression during or within 3 months following the last administration of approved
             standard therapies, or have experienced intolerance to previous therapy.

          -  Metastatic CRC patients with measurable or non-measurable disease

          -  Life expectancy of at least 3 months

          -  Have an Eastern Cooperative Oncology Group performance status of 0 or 1 (within 14
             days prior to the initiation of study treatment)

          -  Have adequate bone marrow, liver function, and renal function as measured by the
             following laboratory assessments conducted within 7 days prior to the initiation of
             study treatment:

               -  Total bilirubin < 1.5 times the upper limit of normal (ULN)

               -  Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) < 2.5 times
                  the ULN (< 5 times ULN for patients with liver involvement of their cancer)

               -  Lipase < 1.5 times the ULN

               -  Serum creatinine < 1.5 times the ULN

               -  Glomerular filtration rate > 30 mL/min/1.73 m2 according to the modified diet in
                  renal disease abbreviated formula

               -  International normalized ratio (INR) of prothrombin time (PT; PT-INR) and partial
                  thromboplastin time (PTT) < 1.5 times the ULN

               -  Platelet count > 100000 /mm3, hemoglobin > 9 g/dL, absolute neutrophil count >
                  1500/mm3.

               -  Alkaline phosphatase limit ≤ 2.5 times the ULN (< 5 times ULN for patients with
                  liver involvement of their cancer)

          -  If female and of childbearing potential, have a NEGATIVE result on a pregnancy test
             performed a maximum of 7 days before initiation of study treatment.

          -  If female and of childbearing potential or if male, must agree to use adequate
             contraception (e.g., abstinence, intrauterine device, oral contraceptive, or
             double-barrier method) based on the judgment of the investigator or a designated
             associate from the date on which the ICF is signed until 6 months after the last dose
             of study drug.

        Exclusion Criteria:

        Patients who meet the following criteria at the time of screening will be excluded:

          -  Patients with hypotension (less than 90/60mm Hg) or at risk of symptomatic hypotension
             (fainting or dizziness) will be excluded.

          -  Prior treatment with regorafenib or any VEGFR-targeting kinase inhibitor.

          -  Previous assignment to treatment during this study. Patients permanently withdrawn
             from study participation will not be allowed to re-enter the study.

          -  Concurrent cancer requiring treatment that is distinct in primary site or histology
             from colorectal cancer.

          -  Major surgical procedure, open biopsy, or significant traumatic injury within 28 days
             before start of study medication.

          -  Unstable/uncontrolled cardiac disease including: congestive heart failure > New York
             Heart Association (NYHA) class 2; unstable angina (angina symptoms at rest), new-onset
             angina (begun within the last 3 months); myocardial infarction less than 6 months
             before start of study drug; cardiac arrhythmias requiring anti-arrhythmic therapy
             (beta blockers or digoxin are permitted).

          -  Uncontrolled hypertension. (Systolic blood pressure > 150 mmHg or diastolic pressure >
             90 mmHg despite optimal medical management).

          -  Patients with phaeochromocytoma.

          -  Arterial or venous thrombotic or embolic events such as cerebrovascular accident
             (including transient ischemic attacks), deep vein thrombosis or pulmonary embolism
             within the 6 months before start of study medication.

          -  Ongoing infection > grade 2 NCI-CTCAE version 4.03

          -  Known history of human immunodeficiency virus (HIV) infection.

          -  Known history of chronic hepatitis B or C.

          -  Patients with seizure disorder requiring medication.

          -  Symptomatic metastatic brain or meningeal tumors unless the patient is > 6 months from
             definitive therapy, has a negative imaging study within 4 weeks of study entry and is
             clinically stable with respect to the tumor at the time of study entry. Also the
             patient must not be undergoing acute steroid therapy or taper (chronic steroid therapy
             is acceptable provided that the dose is stable for one month prior to and following
             screening radiographic studies)

          -  History of organ allograft

          -  Patients with evidence or history of bleeding diasthesis, including patients who have
             had a transfusion and/or radiographic endoscopic or elective operative interaction to
             control the bleeding or hemorrhage event within four weeks prior to the study

          -  Non-healing wound, ulcer, or bone fracture.

          -  Renal impairment or failure requiring hemo-or peritoneal dialysis.

          -  Patients with severe hepatic impairment.

          -  Dehydration NCI-CTC version 4.03 grade > 1.

          -  Substance abuse, medical, psychological or social conditions that may interfere with
             the patient's participation in the study or evaluation of the study results

          -  Any illness or medical conditions that are unstable or could jeopardize the safety of
             the study

          -  Interstitial lung disease with ongoing signs and symptoms at the time of informed
             consent.

          -  Persistent proteinuria of Common Terminology Criteria (CTC) Grade 3 or higher.
             Quantification of proteinuria done by urinary protein/creatinine ratio on a random
             urine sample preferably taken at mid-morning. If protein/creatinine ratio is greater
             than 30g/mol Creat, then a 24-hour urine protein test should be performed to confirmed
             Grade 3 or higher proteinuria (> 3.5 g/24 hours).

          -  Patients unable to swallow oral medications

          -  Any malabsorption condition

          -  Unresolved toxicity higher than NCI-CTCAE (version 4.03) Grade 1 attributed to any
             prior therapy/procedure excluding alopecia and oxaliplatin induced neurotoxicity
             ≤Grade 2

          -  Patients who are hypersensitive to perindopril, as well as those hypersensitive to
             regorafenib, sorafenib, drugs in the same class or any ingredient in the formulation.

          -  Patients who cannot tolerate the full dose of perindopril (4 mg) for any reason.

          -  Patients receiving systemic anticancer therapy including cytotoxic therapy, signal
             transduction inhibitors, immunotherapy, hormonal therapy and experimental or approved
             therapies during this trial or within 14 days before starting to receive study
             medication.

        In addition, patients will be excluded for the following reasons (From perindopril
        monograph).

          -  Patients with a history of hereditary/idiopathic angioedema, or angioedema related to
             previous treatment with an angiotensin converting enzyme inhibitor.

          -  Pregnant women or those planning to become pregnant, nursing women.

          -  Patients with hereditary problems of galactose intolerance, glucose-galactose
             malabsorption, or the Lapp lactase deficiency.

          -  Patients with pre-existing anti-hypertension treatment with an angiotensin-converting
             enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) are to be excluded.
             Co-administration of ACE inhibitors, including COVERSYL®, with other agents blocking
             the Renin-Angiotensin System (RAS), such as ARBs or aliskiren-containing drugs, will
             not be allowed, since such treatment has been associated with an increased incidence
             of severe hypotension, renal failure, and hyperkalemia.