FK506 (Tacrolimus) in Pulmonary Arterial Hypertension
Condition: Pulmonary Arterial Hypertension
MeSH terms: Pulmonary Arterial Hypertension; Familial Primary Pulmonary Hypertension; Hypertension
Intervention: Placebo; FK506 level < 2 ng/ml; FK506 level 2-3 ng/ml; FK506 level 3-5 ng/ml
Intervention description: placebo pill; FK506 goal trough blood level < 2 ng/ml; FK506 goal trough blood level 2-3 ng/ml; FK506 goal trough blood level 3-5 ng/ml
Intervention MeSH terms: Tacrolimus
Phase: Phase 2
Study type: Interventional
Primary purpose: Treatment
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Enrollment: 23.0
Sex: All
Minimum age: 18 Years
Maximum age: 70 Years
Healthy volunteers: No
Keywords: PAH WHO group 1

Summary:

      Mutations in bone morphogenetic protein receptor 2 (BMPR2) are present in >80% of familial
      and ~20% of sporadic pulmonary arterial hypertension (PAH) patients. Furthermore
      dysfunctional BMP signaling is a general feature of pulmonary hypertension even in
      non-familial PAH.

      We therefore hypothesized that increasing BMP signaling might prevent and reverse the
      disease. We screened > 3500 FDA approved drugs for their propensity to increase BMP signaling
      and found FK506 (Tacrolimus) to be a strong activator of BMP signaling. Tacrolimus restored
      normal function of pulmonary artery endothelial cells, prevented and reversed experimental
      PAH in mice and rats.

      Given that Tacrolimus is already FDA approved with a known side-effect profile, it is an
      ideal candidate drug to use in patients with pulmonary arterial hypertension.

      The aims of our trial are:

        1. Establish the Safety of FK506 in patients with PAH.

        2. Evaluate the Efficacy of FK506 in PAH

        3. Identify ideal candidates for future FK506 phase III clinical trial.
    

Eligibility criteria:

        Inclusion Criteria:

          1. Age ≥ 18 and < 70 years

          2. Diagnosis of WHO Group I Pulmonary Arterial Hypertension (PAH) (Idiopathic (I)PAH,
             Heritable PAH (including Hereditary Hemorrhagic Telangiectasia), Associated (A)PAH
             (including collagen vascular disorders, drugs+toxins exposure, congenital heart
             disease, and portopulmonary disease).

          3. Stable on active PAH treatment including any prostacycline or phosphodiesterase
             inhibitors and the endothelin antagonist Ambrisentan alone or in combination
             (stability defined as: <10% change in 6MWD, no change in NYHA class, no
             hospitalization or addition of PAH therapy for at least 3 months).

          4. Previous Right Heart Catheterization that documented:

               1. Mean PAP ≥ 25 mmHg.

               2. Pulmonary capillary wedge pressure < 15 mmHg.

               3. Pulmonary Vascular Resistance ≥ 3.0 Wood units or 240 dynes/sec/cm5

          5. WHO functional class I to IV as judged by the investigator.

        Exclusion Criteria:

          1. WHO Group II - V Pulmonary Hypertension.

          2. Current or prior experimental PAH treatments within the last 6 months (including but
             not limited to tyrosine kinase inhibitors, rho-kinase inhibitors, or cGMP modulators).

          3. Current active treatment with the dual endothelin receptor antagonist bosentan.

          4. TLC < 60% predicted; if TLC b/w 60 and 70% predicted, high resolution computed
             tomography must be available to exclude significant interstitial lung disease.

          5. FEV1 / FVC < 70% predicted and FEV1 < 60% predicted

          6. Significant left-sided heart disease (based on screening Echocardiogram):

               1. Significant aortic or mitral valve disease

               2. Diastolic dysfunction ≥ Grade II

               3. LV systolic function < 45%

               4. Pericardial constriction

               5. Restrictive cardiomyopathy

               6. Significant coronary disease with demonstrable ischemia.

          7. Chronic renal insufficiency defined as an estimated creatinine clearance < 30 ml/min
             (by MDRD equation).

          8. Current atrial arrhythmias not under optimal control.

          9. Uncontrolled systemic hypertension: SBP > 160 mm or DBP > 100mm

         10. Severe hypotension: SBP < 80 mmHg.

         11. Pregnant or breast-feeding.

         12. Psychiatric, addictive, or other disorder that compromises patient's ability to
             provide informed consent, follow study protocol, and adhere to treatment instructions.

         13. Active cyclosporine use.

         14. Known allergy or hypersensitivity to FK-506.

         15. Planned initiation of cardiac or pulmonary rehabilitation during period of study.

         16. Human Immunodeficiency Virus infection.

         17. Moderate to severe hepatic dysfunction with a Pugh score >10.

         18. Hyperkalemia defined as Potassium > 5.1 mEq/L at screening .

         19. Known active infection requiring antibiotic, antifungal, or antiviral therapies.

         20. Co-morbid conditions that would impair a patient's exercise performance and ability to
             assess WHO functional class, including but not limited to chronic low-back pain or
             peripheral musculoskeletal problems.