Clinical trial NCT03528902
Conditions: Hypertension Pulmonary Arterial Hypertension Familial Primary Pulmonary Hypertension Primary Pulmonary Hypertension Lung Diseases Tamoxifen Estrogen Receptor Antagonist Hormone Antagonists Estrogens
Sponsor: Vanderbilt University Medical Center
Start date: 2018-10-01; Completion date: 2023-06-14
Enrollment: 18 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
The main purpose of this clinical trial is to examine the feasibility and effects of tamoxifen in subjects with pulmonary arterial hypertension (PAH). The study will evaluate how well the drug is tolerated, and its impact on functional condition and selected biomarkers. Changes in tricuspid annular plane systolic excursion (TAPSE) and other parameters determined by transthoracic echocardiography will be evaluated as well as changes in additional metrics such as six minute walk test distance, quality of life assessments, and hormone levels.

Detailed description:
Pulmonary arterial hypertension (PAH) is characterized by progressive loss of function by the pulmonary vascular bed due to a variety of factors including obliterative vascular lesions, vasoconstriction, and thrombotic occlusion of the pulmonary arteries. Ultimately, right-sided heart failure ensues with severe limitation of exercise and eventual progression to death or lung transplantation. While there are multiple FDA-approved therapies for PAH representing 3 major pathways of interest, no treatments are curative, and have additional limitations including high expense, multiple side effects, and dosing inconveniences.

The strongest established risk factor for the progressively fatal disease pulmonary arterial hypertension (PAH) is female sex (\~3:1 female:male ratio). We and others have found higher circulating estrogen levels, and enhanced estrogen signaling, in PAH patients. Preclinical work by our group and others supports the concept that anti-estrogen therapy, is effective for both prevention and treatment in PAH. Recent and ongoing clinical studies are underway to assess these approaches in humans, including a recent study demonstrating the safety of estrogen reduction in postmenopausal women.

Tamoxifen is the most commonly used selective estrogen receptor modulator (SERM). Due to its extensive use in humans for over three decades, it has an excellent safety profile and its long-term sequelae are well characterized. Furthermore, it is a generic drug which has been FDA-approved for treatment and prevention of breast cancer, particularly those with estrogen receptor-positive neoplasms.

To help to determine whether tamoxifen may be a safe and effective treatment for PAH in women and men, we will conduct a single-center, randomized, double-blind, placebo-controlled Phase II study of subjects with PAH. All subjects will also be treated with background standard of care therapy at the discretion of their PAH care physician.

Arms: arm 1: 20 mg po TID for 24 weeks arm 2: Placebo arm
Interventions: intervention 1: Tamoxifen intervention 2: Placebo Oral Tablet
Intervention descriptions: intervention 1: Tamoxifen 20 mg po daily for 24 weeks. intervention 2: Placebo

Protocol documents:
Prot_SAP_000.pdf: 
 
 
 
 
 
 
 
 
“Tamoxifen Therapy to Treat Pulmonary Arterial Hypertension” 
PI: Dr. Eric Austin 
Vanderbilt University Medical Center 
 
NCT #: NCT03528902 
Most recent IRB Approval Date: 8/25/2024 
 
 
 
 


Tamoxifen Therapy to Treat PAH (T3PAH)                                               Protocolv5.0  
 
 
 
 
 
 
 
 
 
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Tamoxifen Therapy to Treat Pulmonary Arterial Hypertension 
(T3PAH) 
 
 
Protocol 
 
January 2, 2018 
 
Version Number:  5.0 
Version Date:   09/23/2020 
 
 
 
 
 
 
Eric D. Austin, MD, MSCI 
Vanderbilt University Medical Center 
 
Co-Investigators 
Anna R. Hemnes, MD 
John H. Newman, MD 
Evan L. Brittain, MD, MSCI 
Joshua P. Fessel, MD PhD 
Meredith E. Pugh, MD, MSCI  
Ivan M. Robbins, MD 
James West, PhD 
 
 
Lead Statistician 
Chang Yu, PhD 
 
 
 
 
 


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Revision History 
 
Version 1.0 
 
 
 
11/28/2017 
Version 1.1 
 
 
 
12/4/2017 
Version 2.0 
 
 
 
12/16/2017 
Version 2.1 
 
 
 
01/02/2018 
Version 3.0 
 
 
 
02/28/2018 
Version 4.0 
 
 
 
08/09/2018 
Version 5.0 
 
 
 
09/23/2020 
 


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Abstract 
 
Title 
Tamoxifen Therapy to Treat Pulmonary Arterial 
Hypertension (T3PAH) 
 
Patient population 
Pre- or post-menopausal women, as well as men, over 18 
years of age with pulmonary arterial hypertension (PAH) on 
existing standard of care therapy for PAH. 
Hypothesis 
Estrogen antagonism with tamoxifen is safe and will improve 
function in humans with PAH. 
Primary Objective 
To evaluate the change (Week 0 to 24) in tricuspid annular 
plane systolic excursion (TAPSE), determined by 
transthoracic echocardiography (TTE), in tamoxifen vs. 
placebo. 
Secondary 
Objectives 
• 
To evaluate the change (Week 0 to 24) in other 
echocardiographic metrics of right ventricular 
function determined by TTE in tamoxifen vs. placebo. 
• 
To evaluate the effect of tamoxifen vs. placebo on 
TAPSE at Week 12 by TTE. 
• 
To evaluate the effect of tamoxifen vs. placebo on 
other echocardiographic metrics of right ventricular 
function at Week 12 by TTE. 
• 
To evaluate the effect of tamoxifen vs. placebo on 
6MWD at Week 12 and Week 24. 
• 
To evaluate the effect of tamoxifen vs. placebo on 
the SF36 and emPHasis-10 at Week 12 and 24. 
• 
To evaluate the effect of tamoxifen vs. placebo on 
plasma BNP level at Week 24.  
• 
To evaluate the effect of tamoxifen vs. placebo on 
metabolism-related biomarkers at Week 24. 
• 
To evaluate the change (Week 0 to 24) in sex 
hormone, and sex hormone metabolite, levels in the 


Tamoxifen Therapy to Treat PAH (T3PAH)                                               Protocolv5.0  
 
 
 
 
 
 
 
 
 
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urine and plasma (Week 0 to 24) in tamoxifen vs. 
placebo. 
• 
To evaluate the change (Week 0 to 24) in estrogen 
receptor (ESR) density, as determined by 18FES 
PET, in tamoxifen vs. placebo. 
• 
To evaluate the safety and side effects associated 
with tamoxifen administration in subjects with PAH. 
Study Design 
Single-center, randomized, double-blind, placebo-controlled 
Phase II study of 24 subjects with PAH. Eligible subjects will 
be randomized to treatment with a 1:1 ratio using a 
permuted-block randomization algorithm. 
All subjects will also be treated with background standard of 
care therapy at the discretion of their PAH care physician. 
Number of patients 
24 patients; 12 will be allocated to tamoxifen and 12 will be 
allocated to placebo. 
Duration of Therapy 
24 weeks 
Study Drug 
Tamoxifen: 20 mg 
Tamoxifen is an oral selective estrogen receptor modulator 
(SERM). 
Study Observations 
• 
Subjects will be evaluated in person at baseline, 12 
weeks, and 24 weeks. 
• 
Subjects will have telephone follow-up at 1, 3, 6, 9, 
15, 18, 21 weeks. 
• 
Laboratory tests including a complete blood count, 
routine chemistry tests (creatinine and electrolytes), 
liver function tests, coagulation studies, calcium, and  
• 
BNP levels and other biomarkers will be assessed at 
baseline and 24 months. 
• 
Subjects will undergo a six minute walk test at 
baseline, 12, and 24 weeks. 


Tamoxifen Therapy to Treat PAH (T3PAH)                                               Protocolv5.0  
 
 
 
 
 
 
 
 
 
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• 
Subjects will have a transthoracic echocardiogram at 
baseline, 12 and 24 weeks. 
• 
Estrogen receptor (ESR) density, as determined by 
18FES PET, will be assessed at baseline and 24 
weeks. 
• 
Quality of life will be assessed by SF36 and 
emPHasis-10 at baseline, 12 and 24 weeks. 
Safety Assessments 
Analyses will be performed for all patients having received at 
least one dose of study drug.  General safety endpoints such 
as adverse events will be reported according to FDA 
guidelines. 
Sample Size and 
Power 
A total of 24 subjects will be enrolled with 1:1 randomization 
to either tamoxifen or placebo. Should a randomized patient 
drop-out before 24 weeks of treatment, that patient will be 
replaced to ensure at least 12 patients complete 24 weeks of 
treatment in each arm.  For the primary study endpoint of 
TAPSE, we will have 71% and 88% power, respectively, to 
detect a drop from 1.80 cm or 1.85 cm at baseline to 1.60 
cm (the risk boundary for RV dysfunction) using an SD for 
the within-subject difference of 0.25 cm.  
Data Analysis 
Continuous endpoints will be analyzed using the Wilcoxon 
Rank Sum test to assess between treatment arms difference 
and using the signed rank test for within-group change from 
baseline. For binary endpoints, Fischer’s exact test will be 
used to assess between treatment arms difference. For the 
primary endpoint, TAPSE, an exploratory analysis using 
mixed effects model will be conducted to assess the time 
trend and treatment effect (tamoxifen vs placebo).  The 
mixed effects models will have a random subject effect and 
we will use an autoregressive model of order 1 (AR1) or 
other plausible covariance structures for the error 
covariance. In addition, the association between baseline 


Tamoxifen Therapy to Treat PAH (T3PAH)                                               Protocolv5.0  
 
 
 
 
 
 
 
 
 
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(pre-tamoxifen or placebo) lung ESR density and response 
to treatment quantified by TAPSE and 6MWT distance will 
also be evaluated using the mixed effects models. These 
analyses will be of particular interest since they will help us a 
priori to identify patients who will be most likely responders 
to tamoxifen in the next-phase studies should this proof-of-
concept study be a success.  
  
 


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Table of Contents   
 
 
TABULAR ABSTRACT………………………………………………………………… 
3 
 
NARRATIVE ABSTRACT……………………………………………………………... 
8 
 
CHAPTER 1: Background and Significance………………………………………… 
9 
 
CHAPTER 2: Objectives and Specific Aims………………………………….……… 
11 
 
CHAPTER 3: Screening, Subject Selection and Randomization………………….. 
13 
 
CHAPTER 4: Treatments……………………………………………………………… 
15 
 
CHAPTER 5: Data Collection………………………………………………………..... 
18 
 
CHAPTER 6: Assessment of Efficacy and Outcome Measures…………………… 
25 
 
CHAPTER 7: Statistical Considerations………………………………………………. 
27 
 
CHAPTER 8: Quality Control…………………………………………………………... 
29 
 
CHAPTER 9: Participant Safety and Confidentiality…………………………………. 
30 
 
REFERENCES...……………………………………………………………………….... 
39 
 
 
 


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NARRATIVE ABSTRACT 
 
 
Pulmonary arterial hypertension (PAH) is characterized by progressive loss of 
function by the pulmonary vascular bed due to a variety of factors including obliterative 
vascular lesions, vasoconstriction, and thrombotic occlusion of the pulmonary arteries. 
Ultimately, right-sided heart failure ensues with severe limitation of exercise and 
eventual progression to death or lung transplantation. While there are multiple FDA-
approved therapies for PAH representing 3 major pathways of interest, no treatments 
are curative, and have additional limitations including high expense, multiple side effects, 
and dosing inconveniences. 
 
The strongest established risk factor for the progressively fatal disease pulmonary 
arterial hypertension (PAH) is female sex (~3:1 female:male ratio)1-3. We and others 
have found higher circulating estrogen levels, and enhanced estrogen signaling, in PAH 
patients. Our evidence suggests that exuberant estrogen signaling causes a perturbation 
of mitochondrial function and energy substrate utilization in both sexes, which promotes 
PAH pathogenesis4-19.   Preclinical work by our group and others supports the concept 
that anti-estrogen therapy, is effective for both prevention and treatment in murine PAH7, 
9, 12, 20, 21 
 
The strong human and experimental evidence supporting the concept that estrogens 
drive PAH also demonstrates that this occurs at least in part via signaling through the 
estrogen receptors (ESRs)4, 9, 16, 17, 22. Reduced estrogen production with the aromatase 
inhibitor (AI) anastrozole was recently shown to be safe in PAH in a small phase II 
clinical trial (RCT NCT01545336)15. However, premenopausal women, who may have 
the most benefit from estrogen antagonism, were not included, and the reduction in E2 
levels was highly variable (range -70 to +1pg/ml reduction at 3 months). This may be 
because the pattern of estrogen levels for patients on anastrozole and other AIs may be 
unpredictable23. Therefore, anastrozole is not sufficient to reduce estrogen signaling for 
all patients with PAH—and, in pre-menopausal females it may actually increase 
estrogen production. 
 
Tamoxifen is the most commonly used selective estrogen receptor modulator 
(SERM). Due to its extensive use in humans for over three decades, it has an excellent 
safety profile and its long-term sequelae are well characterized.  Furthermore, it is a 
generic drug which has been FDA-approved for treatment and prevention of breast 
cancer, particularly those with estrogen receptor positive neoplasms. 
 
To help to determine whether tamoxifen may be a safe and effective treatment for 
PAH in women and men, we propose a single-center, randomized, double-blind, 
placebo-controlled Phase II study of 24 subjects with PAH. Eligible subjects will be 
randomized to treatment with a 1:1 ratio using a permuted-block randomization 
algorithm.  All subjects will also be treated with background standard of care therapy at 
the discretion of their PAH care physician. The results of this study may support a larger 
Phase II, and ultimately Phase III, study if the results are promising. 
 


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Chapter 1. Background and Significance 
 
1.1 Definition and characterization of PAH 
 
Pulmonary arterial hypertension (PAH) is defined by a mean pulmonary artery pressure 
> 25 mm Hg, a pulmonary vascular resistance > 3 WU, and a normal pulmonary 
capillary wedge pressure in the absence of other etiology of pulmonary hypertension24. 
While the histopathologic findings demonstrate endothelial cell expansion, smooth 
muscle hypertrophy, and in situ thrombosis within the smallest pulmonary arteries, the 
disease mechanism is unknown25, 26. Current therapies promote vasodilation of 
residually functional vessels, but are not curative. Survival from death or lung 
transplantation remains low, approximately 60% at three years, and 50% at five years.  
 
1.2 Traditional and novel therapeutic concepts 
 
PAH is a rare disease; however it may affect up to 30,000 Americans. No current 
therapies attack the pathogenic mechanisms of PAH; they are only vasodilatory. Thus, 
there is a critical need for novel therapeutics, as recently highlighted by a NIH workshop 
on pulmonary vascular diseases which called for the exploration of novel therapeutic 
approaches27. None of the current FDA-approved treatments for PAH target hormone 
levels, signaling, or downstream consequences.   
 
There is strong human and experimental evidence supporting the concept that estrogens 
drive PAH, and do so via signaling through the ESRs4, 9, 16, 17, 22. Reduced estrogen 
production with the AI anastrozole was recently shown to be safe, as noted above15. 
However, premenopausal women, who may have the most benefit from estrogen 
antagonism, were not included, and the reduction in E2 levels was highly variable (range 
-70 to +1pg/ml reduction at 3 months). This may be because the pattern of estrogen 
levels for patients on anastrozole and other AIs may be unpredictable23. Therefore, 
anastrozole is not sufficient to reduce estrogen signaling for all patients with PAH—and, 
in pre-menopausal females it can increase estrogen production. 
 
While the preponderance of data support a ‘proof of concept’ safety study of estrogen 
receptor blockade in humans, safety must be of paramount concern given two complex 
issues related to estrogens and PAH:  
 
1. The ‘estrogen paradox’ in PAH28, which is anchored in several observations, 
including: 
 
a. Estrogens are beneficial in some models but detrimental in others7, 9, 14, 29-33. 
 
b. Human PAH registry data show enhanced female susceptibility with higher 
incidence and prevalence. 
 
c. Females may live longer after diagnosis than males diagnosed after age 60 
years34-36. 
2. Right ventricular (RV) function is a major determinant of functional status and survival 
in PAH34, 36-38. Of note, estrogens, estrogen metabolism and androgen signaling appear 
to be important pathways related to RV function, although the precise relationship of sex, 
sex hormones, and RV function requires further study.18 


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1.3 Tamoxifen for use in PAH 
 
Thus, a safety trial of estrogen antagonism, using a direct ESR antagonist, is needed in 
PAH. We have chosen tamoxifen due to benefits, including: (1) a long track record of 
safety in humans, (2) ease of daily oral dosing, (3) low cost, (4) does not cause 
menopause in menstruating females, and (4) ability to directly antagonize the ESRs and 
reduce estrogen signaling directly at the tissue level.  
 
As previously mentioned, there are experimental and clinical data suggesting that 
estrogen antagonism may be useful in treating PAH, a rare disease which 
disproportionately affects women. In addition, a research group in Scotland recently 
published several studies showing the presence of estrogen receptor α and aromatase 
in the pulmonary arteries of female patients with PAH and in animal models of PAH.12, 14, 
20, 22 They showed that the initiation of anti-estrogen therapy after the establishment of 
PAH in the experimental models showed improvement in pulmonary artery pressure and 
RV morphology.12 
 
Finally, while not employing tamoxifen, results of a recent small, proof of concept, 
double-blind, placebo-controlled RCT of anastrozole found significant reduction in 
estradiol (~40%) but no effect on testosterone, cortisol, or sex hormone binding 
globulin.39 While anastrozole did not have a significant effect on tricuspid annular plane 
systolic excursion (TAPSE), it did significantly increase the six minute walk test distance 
(6MWTD) at 12 weeks compared to placebo (median change of +26 meters in the 
anastrozole group compared to median change of -12 meters in the placebo group, P = 
0.042). Anastrozole had no significant effect on NT-proBNP levels, SF-36 scores, or IL-6 
levels. There were no significant differences in side effects in patients randomized to 
anastrozole or placebo, and both were well tolerated. Overall, this study suggested that 
estrogen antagonism is same, and perhaps effective for PAH.  However, as noted 
above, anastrozole is restricted in use to post-menopausal females and males, and 
results in variable reductions in estrogen levels.15 
 
1.4 Summary 
 
Preclinical data suggest that tamoxifen may be an effective treatment in patients with 
PAH, while over 30 years of clinical data of tamoxifen in humans suggests an excellent 
safety profile.  In fact, tamoxifen has been safely used in many patients with breast 
cancer over multiple decades, with no reported ventricular dysfunction. If effective, the 
mechanism of action by which tamoxifen improves PAH is likely to include a reduction in 
metabolic dysfunction at the molecular and systemic levels, including reduced insulin 
resistance.   
 
 
 
 
 
 


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Chapter 2. Objectives and Specific Aims 
 
2.1 Objective 
 
To evaluate the change (Week 0 to 24) in tricuspid annular plane systolic excursion 
(TAPSE), determined by transthoracic echocardiography (TTE), in tamoxifen versus 
placebo. 
 
2.2 Specific Aims 
 
Primary Aims:  
 
1.  To determine whether tamoxifen improves TAPSE at 24 weeks in subjects with 
PAH. 
 
Secondary Aims: 
 
a. To evaluate the change (Week 0 to 24) in other echocardiographic metrics of 
right ventricular function determined by TTE in tamoxifen vs. placebo. 
b. To evaluate the effect of tamoxifen vs. placebo on TAPSE at Week 12 by TTE. 
c. To evaluate the effect of tamoxifen vs. placebo on other echocardiographic 
metrics of right ventricular function at Week 12 by TTE. 
d. To evaluate the effect of tamoxifen vs. placebo on 6MWD at Week 12 and Week 
24. 
e. To evaluate the effect of tamoxifen vs. placebo on the SF36 and emPHasis-10 at 
Week 12 and 24. 
f. 
To evaluate the effect of tamoxifen vs. placebo on plasma BNP level at Week 24.  
g. To evaluate the effect of tamoxifen vs. placebo on metabolism-related 
biomarkers at Week 24. 
h. To evaluate the change (Week 0 to 24) in sex hormone, and sex hormone 
metabolite, levels in the urine and plasma (Week 0 to 24) in Tamoxifen vs. 
placebo. 
i. 
To evaluate the change (Week 0 to 24) in estrogen receptor (ESR) density, as 
determined by 18FES PET, in tamoxifen vs. placebo. 
j. 
To evaluate the safety and side effects associated with tamoxifen administration 
in subjects with PAH. 
k. To demonstrate the feasibility of studying tamoxifen in PAH. 


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l. 
To determine the sample size necessary to conduct a larger study of tamoxifen in 
PAH. 
 
  


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Chapter 3. Screening, Subject Selection and Randomization 
 
3.1 Recruitment 
 
3.1.1 Identification and screening process 
 
Subjects will be identified by the medical staff who care for patients with PAH at 
Vanderbilt University Medical Center.  We expect to pre-screen 60 subjects per year 
over 4 years, totaling ~200 patients with PAH pre-screened over 4 years. Potentially 
eligible subjects will then undergo the screening process.  This number, approximately 
60 total subjects who undergo telephone screening, will be informed about the study to 
determine if they have an interest in enrolling. After the initial screening, the subject will 
provide informed consent before any study procedures are performed.  
 
3.2 Subject selection criteria 
 
3.2.1 Inclusion criteria 
 
• 
Previous documentation of mean pulmonary artery pressure ≥ 25 mm Hg with a 
pulmonary capillary wedge pressure (or left ventricular end-diastolic pressure) ≤ 
18 mm Hg and PVR ≥ 3 WU at any time before study entry, consistent Group 1 
PAH classified by accepted international classification24. 
• 
Diagnosis of PAH which is idiopathic, heritable, drug- or toxin-induced, or 
associated with connective tissue disease.  
• 
Age 18 years and older. 
• 
WHO Functional Class I, II, or III status.  
• 
Ability to perform a six minute walk test without significant limitations in 
musculoskeletal function or coordination, with distance ≥150m and ≤550m. 
• 
Informed consent. 
 
3.2.2 Exclusion criteria 
 
• 
Current treatment with estrogen, progesterone, or any form of sex hormone 
therapy. 
• 
Current treatment with anti-sex hormone therapy (e.g., anastrozole, fulvestrant, 
tamoxifen, leuprolide acetate (luporon) or other centrally-acting hormone agents. 
• 
WHO Functional Class IV status. 
• 
History of, or current, breast, uterine, ovarian, or testicular cancer. 
• 
Current pregnancy, or prior pregnancy within 3 months of enrollment. 
• 
Initiation of PAH therapy (prostacyclin analogues, endothelin-1 receptor 
antagonists, phosphodiesterase-5 inhibitors, riociguat, selexipag) within three 
months of enrollment; the dose must be stable for at least three months prior to 
Baseline Visit. Of note, PAH therapy, including diuretics, which is stopped and 
then restarted or has dose changes which are not related to initiation and up 
titration will be allowed within 3 months prior to the Baseline Visit, and during the 
trial for subjects. 


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• 
History of thromboembolic event. 
• 
Hospitalized or acutely ill. 
• 
Hypercalcemia. 
• 
Enrollment in a clinical trial or concurrent use of another investigational drug (non 
FDA approved) or device therapy within 30 days of screening visit. 
• 
Enrollment in any pharmacologic clinical trial within one month of screening.  
• 
Due to potential drug interactions with tamoxifen, subjects using bosentan 
(CYP3A4) or selexipag (CYP2C8) will be excluded.  
• 
Due to the concerns of pregnancy during PAH and with tamoxifen use, pre-
menopausal female subjects will be excluded who do not use at least two forms 
of contraception (e.g., non-hormonal IUD plus the use of a barrier contraceptive 
method). 
 
3.3 Randomization  
 
The Research Pharmacy at Vanderbilt University Medical Center will prepare numbered 
drug kits containing 12 week supplies of tamoxifen or placebo and these will be used 
sequentially.  Tamoxifen or Placebo Distribution will occur at baseline and week 12.  
Subjects will be randomized to treatment with a 1:1 ratio (tamoxifen : placebo) using a 
permuted-block randomization algorithm.   
 
3.4 Maintenance of treatment randomization code and procedures for breaking the        
      code 
 
The treatment randomization code will be maintained by the research pharmacist at 
Vanderbilt University Medical Center. The code is to be broken only if knowledge of 
treatment assignment for that subject is required to initiate appropriate therapy of an 
adverse event (AE) or if the safety of the subject is at serious risk if treatment is 
continued without knowledge of the treatment assignment. The decision to unmask will 
be made by the PI (Dr. James E. Loyd), Dr. Eric D. Austin, and the Chair (or co-Chair) of 
the Data Safety Monitoring Board. 
 
Unblinding may only occur for emergency purposes which would affect clinical care.  
Investigators should note that the occurrence of a serious adverse event or progressive 
disease should not routinely precipitate the immediate unblinding of the label. Even with 
unblinding, the number of unblinded individuals should be limited to only those who need 
to know the treatment identity (e.g., only the local physician caring for the subject). 


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Chapter 4. Treatments 
 
4.1 Tamoxifen 
 
This study will utilize tamoxifen 20 mg by mouth each day or placebo. This is the 
approved dose for the treatment of breast cancer, as well as its prevention in healthy but 
at risk subjects40. Each tablet contains 30.4 mg of tamoxifen citrate, which is equivalent 
to 20 mg of tamoxifen. 
 
Classification 
Non-steroidal anti-estrogen 
 
Specifically, tamoxifen is the most commonly used selective estrogen receptor 
modulator (SERM) and competes with estrogen at the ESRs in all types of breast and 
other tissues.41 Tamoxifen is well tolerated and due to its extensive use, its toxicities and 
long-term sequelae are well characterized. It can thus be used by people of all ages and 
both sexes. 
 
Pharmacokinetics and Pharmacodynamics 
Following a single oral dose of 20 mg tamoxifen, an average peak plasma concentration 
of 40 ng/mL (range 35 to 45 ng/mL) occurred approximately 5 hours after dosing. The 
decline in plasma concentrations of tamoxifen is biphasic with a terminal elimination half-
life of about 5 to 7 days. The average peak plasma concentration of its major metabolite 
N-desmethyl tamoxifen is 15 ng/mL (range 10 to 20 ng/mL). After initiation of therapy, 
steady state concentrations for tamoxifen are achieved in about 4 weeks, suggesting a 
half-life of approximately 7 days. Steady-state concentrations for N-desmethyl tamoxifen 
are achieved in about 8 weeks, suggesting a half-life of approximately 14 days for this 
metabolite42.  
 
Metabolism 
Tamoxifen is extensively metabolized after oral administration. N-desmethyl tamoxifen is 
the major metabolite found in patients' plasma. The biological activity of N-desmethyl 
tamoxifen appears to be similar to that of tamoxifen. 4-Hydroxytamoxifen and a side 
chain primary alcohol derivative of tamoxifen have been identified as minor metabolites 
in plasma42.  
Multiple enzymes are responsible for the metabolism of tamoxifen and its active 
metabolites including CYP3A4, CYP2C9, and CYP2D6 (it is a substrate of these 
enzymes).  In contrast, tamoxifen inhibits P-glycoprotein. In vitro evidence suggests that 
tamoxifen and one of its primary active metabolites, 4-hydroxy-tamoxifen, are inducers 
of CYP3A4 enzymes.   
Bosentan, an agent used in the treatment of PAH, is an inducer of CYP3A4.  While there 
are no human studies of the interaction of tamoxifen and bosentan, bosentan may 
reduce the concentration of tamoxifen.  
In vitro evidence suggests that tamoxifen inhibits CYP2C8.  Inhibition of CYP2C8 may 
increase the serum concentration of selexipag and its active metabolites. While there are 


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no human studies of the interaction of tamoxifen and selexipag, tamoxifen may increase 
the concentration of selexipag and its active metabolites. 
 
Excretion 
Studies in women receiving 20 mg of tamoxifen have shown that approximately 65% of 
the administered dose was excreted from the body over a period of 2 weeks with fecal 
excretion as the primary route of elimination. The drug is excreted mainly as polar 
conjugates, with unchanged drug and unconjugated metabolites accounting for less than 
30% of the total fecal excretion. 
 
Side Effects 
Tamoxifen is the most commonly used selective estrogen receptor modulator (SERM). It 
is currently used in the prevention of breast cancer, to treat ductal carcinoma in situ, and 
to treat HR positive invasive breast cancer in the early and advanced stage settings. 
Tamoxifen is generally well tolerated and due to its extensive use, its toxicities and long-
term sequelae are well characterized. Women treated with tamoxifen may experience 
flushing (similar to the flushing women experience during menopause), vaginal dryness 
and vaginal discharge.  
 
The most serious side effect of tamoxifen is the slightly increased risk of thromboembolic 
events. This has been extensively studied in other medical populations.  For example, in 
a trial involving 900 women treated with either tamoxifen or letrozole, 9 out of 455 
patients experienced a thromboembolic event (2%), compared to 3 patients out of 455 in 
the group treated with letrozole (<1%).  Given the deleterious nature of 
thromboembolism for all individuals, including those with PAH, this issue (and all 
potential side effects) will be emphasized with patients at the time of consent. 
 
Other side effects included hot flashes (25%), headaches (5%), fatigue (5%) and nausea 
(8%)43, 44. The occurrence of endometrial cancer (<0.5%) has been predominantly 
observed when tamoxifen is used long term for breast cancer in the preventive or 
adjuvant setting45. Hence, the cumulative administration of tamoxifen is rarely hampered 
by toxicity.  However, it is unclear how side effects may manifest in PAH patients. 
 
Contraindications 
Tamoxifen is contraindicated in patients with known hypersensitivity to the drug or its 
ingredients. 
 
Study Supply 
Commercial supplies of tamoxifen (generic) will be used in this study and billed to the 
study budget. Of note, AstraZeneca has discontinued the commercial manufacture and 
distribution of branded NOLVADEX® tablets in the United States as of June 2006. 
 
4.2 Placebos and study drug packaging 
 


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Tamoxifen and placebo tablets will be overencapsulated by the Investigational Drug 
Pharmacy at Vanderbilt University Medical Center. At the Investigational Drug 
Pharmacy, capsules will be packaged into HDPE bottles with a liner, cotton, and 
childproof cap.  Bottles will be fully labeled to meet state and FDA requirements, and 
packaged into labeled kits. There will be one bottle of drug product dispensed to study 
subjects at the baseline study visit and at the 12 week visit during the treatment phase. 
Study drug must be stored at room temperature and protected from moisture. Subjects 
will be asked to bring bottles at the 12 week and 24 week study visits to allow for 
tracking of adherence and medication control. At the end of the study, after 
accountability has been completed, study product will be destroyed at the Investigational 
Drug Pharmacy. 
 
 
4.4  Management of other medical therapies during the trial 
 
Subjects with PAH are often treated with a combination of medicinal therapies.  Those 
include diuretics, digoxin, phosphodiesterase-5 inhibitors, endothelin receptor 
antagonists, calcium channel blockers, soluble guanylate cyclase activators, and 
prostacyclin or prostacyclin analogues or prostacyclin receptor agonists. Withholding 
therapy which is the current standard of care is unethical in PAH, considering the high 
risk of morbidity and mortality. In addition, new drugs should add incremental benefit to 
established therapies to really improve outcomes. The subjects’ pre-study medical 
regimen will therefore be continued after enrollment in the study. There will be no 
constraints on the management of the subjects’ PAH medications during the study 
period.   
 
As noted above, Bosentan, an agent used in the treatment of PAH, is an inducer of 
CYP3A4.  While there are no studies of the interaction of tamoxifen and bosentan, 
bosentan may reduce the concentration of tamoxifen. 
 
Excluded concomitant therapy: 
• 
Bosentan 
• 
Selexipag 
• 
Hormone therapy (including estrogen, progesterone, testosterone, DHEA), other 
selective estrogen receptor modulators, and aromatase inhibitors. 
 
4.5 Treatment masking 
 
All study personnel and subjects will be masked for the duration of the study until the last 
subject completes follow-up assessments. The VUMC Investigational Drug Pharmacist, 
the unblinded statistical analyst, and the DSMB will be unmasked; the Investigational 
Drug Pharmacist will supply the DSMB and the identified biostatistician with the 
drug/placebo identifier. This review will occur only in a closed meeting.
4.6 Drug Logistics and Accountability 


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All study drugs will be stored in accordance with Good Clinical Practice (GCP) and Good 
Manufacturing Practices (GMP) requirements and the instructions given by the clinical 
supplies department at Vanderbilt University Medical Center.  Study drugs will not be 
accessible to unauthorized personnel. 
4.6.1 Accountability 
The lead study investigator at VUMC must maintain a careful record of the inventory and 
disposition of the investigational agent using the drug accountability form. 
4.6.2 Destruction and Return 
At the end of the study, unused supplies of tamoxifen should be destroyed according to 
institutional policies. Destruction will be documented in the drug accountability record. 


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Chapter 5. Data Collection 
 
5.1 Study Visits and Contacts 
 
5.1.1 Screening  Phone Call 
 
Potentially eligible subjects will be identified by pre-screening or if there is expressed 
interest in enrolling.  The subject will be contacted by telephone or in person by the 
research coordinator.  The following procedures will be performed: 
  
• 
Review of inclusion/exclusion criteria 
• 
Review medical history 
• 
Review current medications 
• 
Determine WHO functional class based upon providers most recent clinic note. 
• 
Provide instructions on participation in the study, including how to record the use 
of new medication (tamoxifen) administration 
• 
Instruct subjects to bring routine medications to baseline visit, do not eat or drink 
(except water) 12 hours before baseline visit, and to avoid heavy exercise for 12 
hours before the baseline visit 
 
Subjects will be reminded that pregnancy is a known complication in subjects with PAH, 
with a high risk of heart failure and death (mortality rates exceed 50%) among those 
PAH patients who proceed with pregnancy46.  As a result, pregnancy is strongly 
discouraged in patients with PAH47.  As a result, effective and safe contraception is of 
fundamental importance and these aspects are discussed in depth with every woman of 
childbearing potential diagnosed with PAH in our care program at Vanderbilt University 
Medical Center. In addition, several of the medications used for PAH (e.g., bosentan) 
are potentially teratogenic and require demonstration of two forms of birth control for 
their continued use, and monthly monitoring for pregnancy.  Thus, the females eligible 
for this trial should all be on at least two forms of contraception (e.g., IUD plus the use of 
a barrier contraceptive method) at the time of screening and review for inclusion.  
However, as part of the informed consent process, this will be reviewed with patients at 
length.  All female subjects of childbearing potential should be on at least two forms of 
contraception (e.g., non-hormonal IUD plus the use of a barrier contraceptive method). 
 
After the screening phone call, the subject will be scheduled for a baseline study visit 
within 21 days at the study center.  
 
5.1.2 Study Day – Visit 1 (Baseline)  
 
Informed consent will occur at the time of the baseline visit.   
 
The research coordinator will call the subject 1-2 days before the visit as a reminder. 
The coordinator will instruct the subject to not eat or drink (except water) and to avoid 
heavy exercise for 12 hours before the study day assessment. Subjects will be 
instructed to take their routine medications on the morning of the visit and to bring their 


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medications and a snack or meal with them to the visit to take at the center after blood 
draw.   
  
Baseline information will be used to characterize the participants and to compare the 
experimental groups with regards to demographics and other variables. Eligibility criteria 
will be confirmed prior to randomization to treatment group. 
 
The subject will arrive at the study site outpatient clinic or clinical research center. The 
following procedures will be performed: 
 
• 
Phlebotomy 
• 
Urine collection 
• 
Electrocardiogram 
• 
Echocardiography 
• 
Eat a small snack 
• 
Interim medical history 
• 
Review current medications 
• 
WHO functional class assessment 
• 
Vital signs 
• 
Physical exam 
• 
Review of inclusion/exclusion criteria  
• 
ESR-specific PET study 
• 
Complete SF-36 and emPHasis-10 forms 
• 
Six minute walk test 
• 
Randomization to treatment group 
• 
Provide diary and instructions 
• 
Dispense supply of study drug 
• 
Reinforce instructions on recording of new medications and dose changes 
• 
Reinforce instructions on bringing the subject’s routine and study medications to 
all visits 
• 
Reinforce counseling regarding birth control with premenopausal female subjects 
 
Fasting serumpregnancy test will be performed. Fasting urine sample and fasting blood 
samples for study assays will be processed and banked. Echocardiography will be 
performed. After the electrocardiogram and echocardiogram, the subject will have the 
opportunity to eat a snack. The investigator or research nurse will take a history/interim 
history, check vital signs, and review current medications. A physician will perform a 
physical examination and review current medications.  ESR-specific PET study will be 
conducted. The subject will complete the SF36 and emPHasis-10.  The subject will then 
perform a six minute walk test (6MWT).  
 
All inclusion/exclusion criteria confirmed by an investigator before the subject can be 
formally randomized. The subject will be randomized to a treatment group. A pre-
packaged 13 week supply of study medication (tamoxifen 20 mg or placebo) will be 
given to the subject. The subject will be instructed to take one tablet in the morning once 
each day with or without food starting the day after the baseline visit (i.e., if the 
baseline visit is on a Tuesday, the subject should start study mediation the next day, 


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Wednesday). After study drug is dispensed, the research coordinator will provide 
instructions on how to complete the study drug diary.  
 
Once all procedures are complete and study drug provided, the research coordinator will 
thank the subject for his/her attendance and reinforce compliance with the study 
medication and protocol. The subject’s primary PAH physician and medical doctor will be 
alerted to the subject’s participation in the clinical trial. 
 
The research coordinator will call the subject on the morning of study day 1 to remind 
the subject to begin taking the study medication.  
 
5.1.3 Phone Call (Week 1 ± 2 days; Week 3 ± 2 days; Week 6 ± 2 days; Week 9 ± 2 
days) 
 
The research coordinator will call the subject. Symptoms and potential side effects will 
be assessed and changes in medications will be reviewed/recorded.  Pregnancy 
avoidance will be stressed. Medication compliance will be assessed and reinforced.  
Subject questions will be answered. 
 
5.1.4 Study Day – Visit 2 (Week 12 ± 7 days) 
 
The research coordinator will call the subject 1-2 days before the visit as a reminder. 
The coordinator will instruct the subject that they may maintain their typical enteral intake 
but to avoid heavy exercise for 12 hours before the study day assessment. Subjects will 
be instructed to take their routine medications on the morning of the visit and to bring 
their medications and a snack or meal with them to the visit to take at the center as 
needed.   
  
The subject will arrive at the study site outpatient clinic or clinical research center. The 
following procedures will be performed: 
 
• 
Electrocardiogram 
• 
Echocardiography 
• 
Interim medical history 
• 
Review current medications 
• 
WHO functional class assessment 
• 
Vital signs 
• 
Physical exam 
• 
Review of inclusion/exclusion criteria  
• 
Complete SF-36 and emPHasis-10 forms 
• 
Six minute walk test 
• 
Review study drug compliance 
• 
Review diary and instructions 
• 
Dispense supply of study drug 
• 
Reinforce instructions on recording of new medications and dose changes 
• 
Reinforce instructions on bringing the subject’s routine and study medications to 
all visits 


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• 
Reinforce counseling regarding birth control 
 
Echocardiography will be performed. The investigator or research nurse will take a 
history/interim history and perform a physical examination (examination by physician) 
including checking vital signs, and review current medications. The subject will complete 
the SF36 and emPHasis-10.  The subject will then perform a six minute walk test 
(6MWT).  
 
Once all procedures are complete and study drug provided, the research coordinator will 
thank the subject for his/her attendance and reinforce compliance with the study 
medication and protocol. The subject’s primary PAH physician and medical doctor will be 
alerted to the subject’s continuing participation in the clinical trial. 
 
5.1.5 Phone Call (Week 15 ± 2 days; Week 18 ± 2 days; Week 21 ± 2 days) 
 
The research coordinator will call the subject. Symptoms and potential side effects will 
be assessed and changes in medications will be reviewed/recorded.  Pregnancy 
avoidance will be stressed. Medication compliance will be assessed and reinforced. 
 
5.1.6 Study Day – Visit 3 (Week 24 ± 3 days) 
 
The research coordinator will call the subject 1-2 days before the visit as a reminder. 
The coordinator will instruct the subject to not eat or drink (except water) and to avoid 
heavy exercise for 12 hours before the study day assessment. Subjects will be 
instructed to take their routine medications on the morning of the visit and to bring their 
medications and a snack or meal with them to the visit to take at the center after blood 
draw.   
  
The subject will arrive at the study site outpatient clinic or clinical research center. The 
following procedures will be performed: 
 
• 
Phlebotomy 
• 
Urine collection 
• 
Electrocardiogram 
• 
Echocardiography 
• 
Eat a small snack 
• 
Interim medical history 
• 
Review current medications 
• 
WHO functional class assessment 
• 
Vital signs 
• 
Physical exam 
• 
ESR-specific PET study 
• 
Complete SF-36 and emPHasis-10 forms 
• 
Six minute walk test 
• 
Review study drug compliance 
• 
Turn in study diary and any remaining study medication 
 


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Fasting urine sample and blood samples for study assays will be processed and banked. 
Echocardiography will be performed. After the echocardiogram, the subject will have the 
opportunity to eat a snack. The investigator or research nurse will take a history/interim 
history and perform a physical examination including checking vital signs, and review 
current medications.  ESR-specific PET study will be conducted. The subject will 
complete the SF36 and emPHasis-10.  The subject will then perform a six minute walk 
test (6MWT).  
 
Once all procedures are complete the research coordinator will thank the subject for 
his/her attendance and study participation. The subject’s primary PAH physician and 
medical doctor will be alerted to the subject’s completed participation in the clinical trial. 
 
5.1.7 Telephone follow-up (Week 25) 
 
The research coordinator will call the subject approximately 1 week after the Week 24 
visit.  Symptoms and potential ongoing side effects after stopping study drug will be 
assessed. Serious adverse events will continue to be followed until resolution.  The 
research coordinator will once again thank the subject for participation in the study. 
 
 


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5.2 Schedule of Study Procedures and Assessments 
 
The table below summarizes the study assessments and procedures. 
 
Table 1. Study Assessments and Procedures 
Procedure 
 
Bas
eline 
Wk 
1 
Wk 
3 
Wk 
6 
Wk 
9 
Wk 
12 
Wk 
15 
Wk 
18 
Wk 
21 
Wk 
24 
Wk 
25 
Call # 
 
 
1 
2 
3 
4 
 
5 
6 
7 
 
8 
Visit # 
 
1 
 
 
 
 
2 
 
 
 
3 
 
Informed 
Consent 
 
x 
 
 
 
 
 
 
 
 
 
 
Clinical Assessments 
 
Medical Hx 
 
x 
 
 
 
 
 
 
 
 
 
 
Symptoms 
assessment 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Medications 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
Vital Signs 
 
x 
 
 
 
 
x 
 
 
 
x 
 
Physical Exam 
 
x 
 
 
 
 
x 
 
 
 
x 
 
WHO Functional 
Class 
 
x 
 
 
 
 
x 
 
 
 
x 
 
Testing 
 
Urine collection 
 
x 
 
 
 
 
 
 
 
 
x 
 
Phlebotomy 
 
x 
 
 
 
 
 
 
 
 
x 
 
6MWTD 
 
x 
 
 
 
 
x 
 
 
 
x 
 
ECG 
 
x 
 
 
 
 
x 
 
 
 
x 
 
SF-36 and 
emphasis-10 
 
x 
 
 
 
 
x 
 
 
 
x 
 
Imaging 
 
Echocardiogram 
 
x 
 
 
 
 
x 
 
 
 
x 
 
ESR-specific 
PET study 
 
x 
 
 
 
 
 
 
 
 
x 
 
Study Procedures 
 
Dispense study 
drug or placebo 
 
x 
 
 
 
 
x 
 
 
 
 
 
Review adverse 
events 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Review study 
drug/placebo 
diary & 
compliance 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 


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 5.3 Subjects’ retention and drug compliance 
 
We will enforce subject retention in several ways. We will record extensive contact 
information for each subject at their enrollment in the trial. This will include home, work, 
and cellular telephone numbers. The research coordinator will call before each study 
visit to remind the subject to attend. Subjects will be reimbursed for time at the clinic for 
research procedures and reasonable travel expenses necessary for their participation in 
the study.  Subjects will receive $200 for the Baseline Visit and $250 for the remaining 
study visits (week 12 and week 24). 
 
The research coordinator and physician will explain the importance of compliance with 
the study protocol at each subject contact. If a subject fails to comply with a study visit, 
the coordinator will contact him or her by telephone. If this fails, the coordinator will send 
two letters, one week apart, to request follow-up. 
 
We have considered how to minimize difficulties with adherence to the study drug (or 
placebo). We will strongly emphasize the importance of complying with the study drug 
treatment. Nonetheless, we will perform pill counts at visits and record episodes when 
medication is withheld for any reason. If a subject wishes to drop-out from the treatment 
phase of the study or has a serious adverse event (SAE) (whether related to study drugs 
or not), we will continue to follow-up with the subject for study assessments to assist with 
safety monitoring and to avoid the problems introduced by missing data. The inclusion of 
such follow-up data will allow for analysis by intention-to-treat. 
 
If a subject is withdrawn from the treatment portion of the study for any reason, the 
subject will be strongly encouraged to continue with the remainder of the study 
assessments, as scheduled. 


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Chapter 6. Assessment of Efficacy and Outcome Measures 
 
6.1 Assessments of efficacy 
 
Primary  
To evaluate the change (Week 0 to 24) in tricuspid annular plane systolic excursion 
(TAPSE), determined by transthoracic echocardiography (TTE), in tamoxifen vs. 
placebo. 
 
Secondary 
There are several secondary objectives of this study. They include: 
• 
To evaluate the change (Week 0 to 24) in other echocardiographic metrics of 
right ventricular function determined by TTE in tamoxifen vs. placebo. 
• 
To evaluate the effect of tamoxifen vs. placebo on TAPSE at Week 12 by TTE. 
• 
To evaluate the effect of tamoxifen vs. placebo on other echocardiographic 
metrics of right ventricular function at Week 12 by TTE. 
• 
To evaluate the effect of tamoxifen vs. placebo on 6MWD at Week 12 and Week 
24. 
• 
To evaluate the effect of tamoxifen vs. placebo on the SF36 and emPHasis-10 at 
Week 12 and 24. 
• 
To evaluate the effect of tamoxifen vs. placebo on plasma BNP level at Week 24.  
• 
To evaluate the effect of tamoxifen vs. placebo on metabolism-related 
biomarkers at Week 24. 
• 
To evaluate the change (Week 0 to 24) in sex hormone, and sex hormone 
metabolite, levels in the urine and plasma (Week 0 to 24) in tamoxifen vs. 
placebo. 
• 
To evaluate the change (Week 0 to 24) in estrogen receptor (ESR) density, as 
determined by 18FES PET, in tamoxifen vs. placebo. 
• 
To evaluate the safety and side effects associated with tamoxifen administration 
in subjects with PAH. 
 
6.2  Information on select secondary outcome measures 
 
6.2.1 ESR-specific PET tracer to determine lung ESR density. 
 
In vivo evaluation of ESR expression using 18F-FES uptake by positron emission 
tomography (PET) is an established non-invasive, real-time measure of the activity of 
ESR modulators such as tamoxifen48, which has been used extensively by Co-I Dr. 
Manning and colleagues11. In fact, 18F-FES has been evaluated in numerous cancer 
clinical studies as a promising method for quantifying in vivo ESR expression, predicting 
response to hormone therapy, and evaluating effective ESR blockade. It correlates well 
with traditional in vitro immunohistochemical methods and has shown potential for 
evaluating, and predicting, an individual’s drug response48. In preliminary studies, we 
evaluated lung ESR density in females pre- and during therapy with tamoxifen for breast 
cancer. Women (n=7) were evaluated at baseline, with standardized uptake values 
(SUVs) determined in the total lung and at standardized regions of interest (ROI, m3). 
Baseline lung SUV levels were similar among the women (0.95 ± 0.17). Three women 


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were evaluated after 6 weeks or longer of tamoxifen therapy, with a reduction in lung 
SUV levels demonstrating suppression of lung FES uptake due to ESR antagonism by 
tamoxifen. Thus, 18F-FES PET not only has the ability to quantify lung ESR expression, it 
demonstrates effective ESR blockade due to tamoxifen exposure. As in cancers, this 
may help to identify patients with a high or low burden of ESR expression in the lung a 
priori, providing the opportunity to more precisely select patients for tamoxifen therapy.  
 
6.2.2 Quality of life questionnaires (SF36 & emPHasis –10) 
 
The SF36 is one of the most widely used generic measures of subjective health status. 
The SF36 includes one multi-item scale that assesses eight health concepts: 1) 
limitations in physical activities because of health problems; 2) limitations in social 
activities because of physical and emotional problems; 3) limitations in usual role 
activities because of physical health problems; 4) bodily pain; 5) general mental health 
(psychological distress and well-being); 6) limitations in usual role activities because of 
emotional problems; 7) vitality (energy and fatigue); and 8) general health perceptions. 
Subjects will complete the SF36 at baseline and each subsequent clinic visit during the 
therapy phase of the study. The emPHasis-10 is a pulmonary hypertension-specific 
questionnaire which is scored from 0-50 (with higher scores indicating worse quality of 
life.)49 
 
6.2.3 WHO functional class 
 
The WHO functional classification for PAH has been modified from the well-known New 
York Heart Association functional classification. This functional classification is based on 
symptoms, with Class I being defined by no symptoms, Class II as having mild limitation 
in physical activity, Class III as having markedly limited physical activity and Class IV as 
being unable to perform any physical activity. The WHO functional class will be 
assessed at every visit. 
 
 


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Chapter 7. Statistical Considerations 
 
7.1 Study design 
 
Single-center, randomized, double-blind, placebo-controlled Phase II study of 24 
subjects with PAH. Eligible subjects will be randomized to treatment with a 1:1 ratio 
using a permuted-block randomization algorithm. 
All subjects will also be treated with background standard of care therapy at the 
discretion of their PAH care physician. 
 
7.2 Disposition of subjects and baseline comparisons  
 
Summaries of all subjects screened, recruited, and randomized and the number who 
complete visits will be provided, according to guidelines. The treatment groups will be 
compared at baseline with respect to demographics and baseline measurements related 
to efficacy and safety without formal statistical testing. 
 
7.3 Statistical procedures  
 
7.3.1 Data analysis 
 
The intent-to-treat analysis will include all randomized subjects. Hypothesis testing will 
use two-sided α= 0.05 without correction for multiplicity.  
 
The primary and secondary endpoints are described in Chapter 6.  
 
Continuous endpoints will be analyzed using the Wilcoxon Rank Sum test to assess 
between treatment arms difference and using the signed rank test for within-group 
change from baseline. For binary endpoints, Fischer’s exact test will be used to assess 
between treatment arms difference. 
 
For the primary endpoint, TAPSE, an exploratory analysis using mixed effects model will 
be conducted to assess the time trend and treatment effect (tamoxifen vs placebo).  The 
mixed effects models will have a random subject effect and we will use an 
autoregressive model of order 1 (AR1) or other plausible covariance structures for the 
error covariance. In addition, the association between baseline (pre-tamoxifen or 
placebo) lung ESR density and response to treatment quantified by TAPSE and 6MWT 
distance will also be evaluated using the mixed effects models. These analyses will be of 
particular interest since they will help us a priori to identify patients who will be most 
likely responders to tamoxifen in the next-phase studies should this proof-of-concept 
study be a success.  
 
7.3.2 Univariate analysis 
 
We will characterize subjects with regard to baseline and follow-up TAPSE and other 
endpoints. We will summarize demographics and other predictors of clinical status. 
Continuous variables will be summarized by the mean, median, standard deviation, and 


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range, as appropriate. We will use contingency tables for discrete and dichotomous 
variables.  
 
7.3.3 Missing data and dropouts 
 
We will attempt to minimize missing data, however we have planned for its occurrence. 
For subjects lost to follow-up, we will use all of the information available until the end of 
follow-up. 
 
This protocol will continue to follow subjects and perform test procedures as prescribed 
even if a subject drops-out from the therapeutic portion of the study. That is, if a subject 
decides that he/she does not wish to continue taking the study drug(s), the subject will 
stop the investigational treatment, but will still be strongly encouraged to continue to 
follow-up with the study personnel for all scheduled study procedures, so that missing 
data (and assumptions regarding these data) will be minimized. 
 
7.4 Sample size and power calculations  
 
A total of 24 subjects will be enrolled with 1:1 randomization to either tamoxifen or 
placebo. Should a randomized patient drop-out before 24 weeks of treatment, that 
patient will be replaced to ensure at least 12 patients complete 24 weeks of treatment in 
each arm.  For the primary study endpoint of TAPSE, we will have 71% and 88% power, 
respectively, to detect a drop from 1.80 cm or 1.85 cm at baseline to 1.60 cm (the risk 
boundary for RV dysfunction) using an SD for the within-subject difference of 0.25 cm. 
 
7.5 Interim monitoring guidelines 
 
We have not planned for formal interim analyses for efficacy and therefore there are no 
stopping rules for efficacy for this trial. This is a ‘proof of concept’, early Phase II trial 
which will be useful in supporting future studies of the intervention even if null. 
 
7.6 Protocol violations 
 
Serious protocol violations such as discontinuation of experimental treatment unrelated 
to AEs will be carefully recorded and regularly reviewed by the lead study investigators 
Drs. Loyd and Austin. Remedial changes in procedure will be recommended where 
feasible to reduce the incidence of such violations. The causes and circumstances of all 
violations will be documented where known for purposes of future secondary analyses 
and interpretation. Because all primary analyses will be intent-to-treat, it is essential that 
violations be kept to a minimum especially where it is possible to influence their rate of 
occurrence. 
 
 
7.7 Safety and masking analysis 
 
All subjects will be assessed for toxicity and included in the safety analysis. This analysis 
will include summaries of the incidence and grade of toxicities. Safety interim analyses 
will be performed and reported to the DSMB. Subjects will be evaluated for SAEs. 
 


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Chapter 8. Quality Control 
 
Design strategies and monitoring activities throughout the study will ensure the integrity 
and high quality of the data. Design strategies include randomization of treatment 
assignment, masking, and training and certification of personnel. The rigorous 
monitoring program includes data queries and performance monitoring over the time of 
the trial.  
 
8.1 Personnel training  
 
Prior to randomization of the first subject in the study protocol, the lead investigators will 
ensure that staff has completed appropriate training and that all documentation including 
IRB approval  is completed and available. The purpose of training is to ensure that study 
personnel are carrying out the protocol in a consistent way and are adhering to good 
clinical practice guidelines. Staff will have current Human Subjects Training Certification 
on file. Before enrollment begins, study coordinators and research assistants who will 
perform the outcome assessments will be trained in all procedures, including completion 
of case-report forms (CRFs).  
 
The lead investigators and research staff will constitute the first line of monitoring of the 
safety of the human participants. Surveillance for AEs will consist of questioning subjects 
about potential AEs at every study contact, having subjects report any adverse event to 
the study team, and having subjects undergo vital sign checks and physical exams 
during each study visit. Laboratories will be performed at designated visits and checked. 
 
All study personnel are required to read the consent form, the protocol and the manual 
of procedures (MOP).  
 
8.2 Data quality  
 
The lead investigators, Drs. Loyd and/or Austin, will perform continuous monitoring of 
data quality and completion of CRFs.  
  
Periodic audits will be conducted.  The research staff will review database forms and 
source documents to ensure that the information on the forms is complete and 
consistent with the source documents. All consent forms and screening logs will be 
audited.  
 
 
 
 
 
 
 


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Chapter 9. Participant Safety and Confidentiality 
 
9.1 Consent 
 
Written consent will be obtained for enrollment from participants. For each consent 
process, study personnel will discuss the details of the study, the risks and benefits, and 
the subject’s rights and responsibilities if they choose to participate in the trial and their 
right to refuse to participate.  It will be made clear that their clinical care will not be 
affected by their decision.  Subjects will be permitted to provide verbal consent over the 
phone prior to being scheduled for a baselinevisit.  A consent script will be provided and 
documentation of verbal consent will be noted.  When the subject arrives for the baseline 
visit, written consent will be obtained.   
 
9.2 Institutional Review Board (IRB) process  
 
The Vanderbilt University Medical Center IRB program will be the approving IRB for this 
study, and its maintenance. 
 
9.3 Laboratory values 
 
The following clinical laboratory tests will be measured at baseline.  
 
9.3.1 Hematology 
Complete blood count, including hemoglobin, hematocrit, and platelets. 
 
9.3.2 Chemistry 
Basic metabolic panel including blood urea nitrogen, creatinine, and calcium.  
 
9.3.3 Liver Function Tests 
Hepatic panel including alanine aminotransferase, aspartate aminotransferase, total bilirubin 
and albumin. 
 
9.3.4 Coagulation Studies  
Prothrombin time, international normalized ratio (INR). 
 
9.3.5 Cardiac-related 
BNP level. 
 
9.3.6. Urine 
Urine will be performed. 
 
9.3.7. Pregnancy Testing 
Serum HcG 
 
9.4 Safety and Adverse events  
 
9.4.1 Definitions of Adverse Events 
 


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9.4.1.1 Adverse Event 
An adverse event (also known as an adverse experience) is defined as any untoward 
medical occurrence associated with the use of a drug in humans, whether or not 
considered drug related. More specifically, an adverse event (can be any unfavorable 
and unintended sign (e.g., an abnormal laboratory finding), symptom, or disease 
temporally associated with the use of a drug, without any judgment about causality. An 
adverse event can arise from any use of the drug (e.g., off-label use, use in combination 
with another drug) and from any route of administration, formulation, or dose, including 
an overdose. 
 
Adverse event (AE):  Any symptom, sign, illness or experience that develops or 
worsens in severity during the course of the study.  Intercurrent illnesses or injuries 
should be regarded as AEs.  Abnormal results of diagnostic procedures are considered 
to be AEs if the abnormality: 
• results in study withdrawal 
• is associated with a serious AE 
• is associated with clinical signs or symptoms 
• leads to additional treatment or to further diagnostic tests 
• is considered by the investigator to be of clinical significance 
 
9.4.1.2 Serious adverse event (SAE): Adverse reactions are classified as serious or 
non-serious.  A serious adverse event is any AE that is:  
• fatal 
• life-threatening 
• requires or prolongs hospital stay 
• results in persistent or significant disability or incapacity 
• a congenital anomaly or birth defect 
• an important medical event 
 
Events not considered to be serious adverse events are hospitalizations for:  
• routine treatment or monitoring of the studied indication, not associated with any 
deterioration in condition, or for elective procedures  
• elective or pre-planned treatment for a pre-existing condition that did not worsen  
• emergency outpatient treatment for an event not fulfilling the serious criteria outlined 
above and not resulting in inpatient admission  
• respite care 
 
Important medical events are those that may not be immediately life threatening, but are 
clearly of major clinical significance. They may jeopardize the subject, and may require 
intervention to prevent one of the other serious outcomes noted above.  For example, 
drug overdose or abuse, a seizure that did not result in in-subject hospitalization or 
intensive treatment of bronchospasm in an emergency department would typically be 
considered serious.  
 
All AEs that do not meet any of the criteria for serious should be regarded as non-
serious AEs.  
 


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9.4.1.3 Adverse reaction 
An adverse reaction is defined as any adverse event caused by the use of a drug. 
Adverse reactions are a subset of all suspected adverse reactions for which there is 
reason to conclude that the drug caused the event. 
 
9.4.1.4 Suspected adverse reaction: is any adverse event for which there is a 
reasonable possibility that the drug caused the adverse event.  For reporting purposes, 
"reasonable possibility" means there is evidence to suggest a causal relationship 
between the drug/investigational product and the adverse event. 
 
9.4.2. Classifying AEs 
 
Severity of the AE 
The intensity of the AE is classified according to the CTCAEv4.0 
(https://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-
14_QuickReference_5x7.pdf) Grade refers to the severity (intensity) of the AE:  
 
If the intensity of an AE worsens during study drug administration, only the worst 
intensity should be reported on the AE page. If the AE lessens in intensity, no change in 
the severity is required. 
 
CTCAEv4 Grade 1: mild; asymptomatic or mild symptoms; clinical or diagnostic 
observations only; intervention is not indicated. 
CTCAEv4 Grade 2: moderate; minimal, local, or noninvasive intervention is 
indicated; limiting to age-appropriate instrumental activities of daily living (ADL; 
instrumental ADL refers to preparing meals, shopping for groceries or clothes, 
using the telephone, managing money, etc). 
CTCAEv4 Grade 3: severe or medically significant but not immediately life 
threatening; hospitalization or prolongation of hospitalization is indicated; 
disabling; limiting to self-care ADL (self-care ADL refers to bathing, dressing and 
undressing, feeding self, using the toilet, taking medications, and not bedridden). 
CTCAEv4 Grade 4: life-threatening consequences; urgent intervention is indicated. 
CTCAEv4 Grade 5: death due to an AE. 
 
In this grading system, severity is not equivalent to seriousness.  For example, a SAE 
would be any event which was life-threatening or disabling (Grade 4) or fatal (Grade 5) 
or was moderate-severe (Grade 2-3) and required or prolonged hospitalization. 
 
9.4.3 Expectedness 
 
AEs must be assessed as to whether they were expected to occur or were unexpected, 
meaning not anticipated based on current knowledge found in the protocol, investigator 
brochure, product insert, or label. 
 
Expected: an AE known to be associated with the intervention or condition under study. 
 


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The Office of Human Protections (OHRP) (https://www.hhs.gov/ohrp/) defines an 
unexpected AE as any AE occurring in one or more subjects participating in a research 
protocol, the nature, severity, or frequency of which is not consistent with either: 
1) the known or foreseeable risk of AEs associated with the procedures involved in 
the research that are described in a) the protocol-related documents, such as the 
IRB-approved research protocol, any applicable investigator brochure, and the 
current IRB-approved informed consent document, and b) other relevant sources 
of information, such as product labeling and package inserts; or 
 
2)  the expected natural progression of any underlying disease, disorder, or 
condition   of the subject(s) experiencing the AE and the subject’s predisposing 
risk factor profile for the AE. 
 
9.4.4 Attribution 
 
 
1) Definite: the AE is clearly related to the research procedures 
 
2) Probably: the AE is likely related to the research procedures 
 
3) Possible: the AE may be related to the research procedures 
 
4) Unlikely: the AE is doubtfully related to the research procedures 
 
5) Unrelated: the AE is clearly not related to the research procedures 
 
Possibly related to participation in the research: There is a reasonable possibility 
that the adverse event, experience, or outcome may have been caused by the 
procedures involved in the research.   
 
For each identified AE, an AE form will be completed. Reporting procedures should be 
started immediately (within 24 hours) upon learning of a SAE or UP.  
 
9.4.5 Adverse Event List(s) for Commercial Agent(s) – Tamoxifen 
The most common adverse events experienced with use of tamoxifen include hot 
flashes, night sweats, and vaginal discharge. Venous thromboembolic disease and 
endometrial cancer are rare risks of tamoxifen. The package inserts for tamoxifen can be 
found at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2005/17970s053lbl.pdf  
 
9.4.6 Interpretation of definitions 
 
AE and UP Reporting Period 
The study period during which AEs must be reported is normally defined as the period 
from the initiation of any study procedures to the end of the study treatment follow-up.  
For this study, the study treatment follow-up is defined as 14 days following the last 
administration of study treatment (week 25 phone call follow up).  
 
Preexisting Condition 
A preexisting condition is one that is present at the start of the study.  A preexisting 
condition should be recorded as an AE if the frequency, intensity, or the character of the 
condition worsens during the study period. 
 
General Physical Examination Findings 


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At screening, any clinically significant abnormality should be recorded as a preexisting 
condition.  At the end of the study, any new clinically significant findings/abnormalities 
that meet the definition of an AE must also be recorded and documented as an AE.  
 
Post-study AE 
All unresolved AEs should be followed by the investigator until the events are resolved, 
the subject is lost to follow-up, or the AE is otherwise explained.  At the last scheduled 
visit, the investigator should instruct each subject to report any subsequent event(s) that 
the subject, or the subject’s personal physician, believes might reasonably be related to 
participation in this study.  The investigator should notify the study sponsor of any death 
or AE occurring at any time after a subject has discontinued or terminated study 
participation that may reasonably be related to this study.  The sponsor should also be 
notified if the investigator should become aware of the development of cancer or of a 
congenital anomaly in a subsequently conceived offspring of a subject that has 
participated in this study.  
 
Abnormal Laboratory Values 
A clinical laboratory abnormality should be documented as an AE if any one of the 
following conditions is met:  
• The laboratory abnormality is not otherwise refuted by a repeat test to confirm the 
abnormality 
• The abnormality suggests a disease and/or organ toxicity 
• The abnormality is of a degree that requires active management; e.g. change of 
dose, discontinuation of the drug, more frequent follow-up assessments, further 
diagnostic investigation, etc. 
 
Hospitalization, Prolonged Hospitalization or Surgery 
Any AE that results in hospitalization or prolonged hospitalization should be documented 
and reported as a serious AE unless specifically instructed otherwise in this protocol.  
Any condition responsible for surgery should be documented as an AE if the condition 
meets the criteria for an AE.  
 
Neither the condition, hospitalization, prolonged hospitalization, nor surgery are reported 
as an AE in the following circumstances: 
• Hospitalization or prolonged hospitalization for diagnostic or elective surgical 
procedures for a preexisting condition.  Surgery should not be reported as an 
outcome of an AE if the purpose of the surgery was elective or diagnostic and the 
outcome was uneventful. 
 
9.4.7 Reporting procedures for AEs 
 
Lead study investigators, Drs. Loyd or Austin, will notify the IRB in an expedited manner, 
of those events related to study participation that are unforeseen and indicate that 
participants or others are at increased risk of harm. Researchers should submit reports 
of the following problems: 
 


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• Any AE or UP (regardless of whether the event is serious or non-serious, on-site 
or off-site) that occurs any time during or after the research study, which in the 
opinion of the principal investigator is: 
1.) Unexpected (An event is “unexpected” when its specificity and severity are not 
accurately reflected in the protocol-related documents, such as the IRB-
approved research protocol, any applicable investigator brochure, and the 
current IRB-approved informed consent document and other relevant sources 
of information, such as product labeling and package inserts.) 
 AND 
2.) Related to the research procedures (An event is “related to the research 
procedures” if in the opinion of the principal investigator or sponsor, the event 
was more likely than not to be caused by the research procedures.) 
AND 
3.) suggests that the research places subjects or others at a greater risk of harm 
(including physical, psychological, economic, or social harm) than was 
previously known or recognized 
 
Serious and unanticipated AEs which are fatal and indicates that participants or others 
are at increased risk of harm must be reported within 24 hours to the IRB for 
assessment.  
 
Other Reportable events: 
The following events are also reportable to the IRB: 
• Any adverse experience that, even without detailed analysis, represents an 
unexpected SAE that is rare in the absence of drug exposure (such as 
agranulocytosis, hepatic necrosis, Stevens-Johnson syndrome). 
• Any AE that would cause the sponsor to modify the investigators brochure, 
protocol or informed consent form, or would prompt other action by the IRB to 
assure protection of human subjects. 
• Information that indicates a change to the risks or potential benefits of the 
research, in terms of severity or frequency. For example:  
– An interim analysis indicates that participants have a lower rate of response to 
treatment than initially expected. 
– Safety monitoring indicates that a particular side effect is more severe, or 
more frequent than initially expected. 
– A paper is published from another study that shows that an arm of your 
research study is of no therapeutic value. 
• Change in FDA safety labeling or withdrawal from marketing of a drug, device, or 
biologic used in a research protocol. 
• Breach of confidentiality 
• Change to the protocol taken without prior IRB review to eliminate apparent 
immediate hazard to a research participant. 
• Complaint of a participant when the complaint indicates unexpected risks or the 
complaint cannot be resolved by the research team. 


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• Protocol violation (meaning an accidental or unintentional deviation from the IRB 
approved protocol) that in the opinion of the investigator placed one or more 
participants at increased risk, or affects the rights or welfare of subjects. 
• Incarceration of a participant enrolled in the trial. 
 
9.4.8 Subject withdrawal  
 
A subject has the right to withdraw from the study entirely at any time for any reason 
without prejudice to future medical care by the investigator or other physician. The 
investigator also has the right to withdraw subjects from the study in the event of 
concurrent illness, AEs, or other reasons deemed to be in the subject’s best interest. 
 
A subject should be withdrawn from the study if there is: 
 
• 
Withdrawal of consent 
• 
Termination of the study by the sponsor  
• 
PI determination that the subject should be withdrawn for safety 
 
In order to preserve the integrity of the intention-to-treat analysis, even if the subject is 
withdrawn from the treatment portion of the protocol (either due to subject, physician, or 
investigator decision), it is imperative to continue with the scheduled follow-up 
assessments both for the safety of the subject and for completeness of data collection. 
This will be explained to potential subjects at the time of informed consent. The 
importance of compliance with study visits will be reinforced throughout the trial.  
 
In the event of clinical worsening, subjects will be continued on their assigned study 
medication. There is no strong evidence that the medication under study is effective in 
subjects with PAH, so that there is neither reason to unmask the study therapy nor to 
initiate treatment with AN in such subjects. If the subject develops an indication for AN 
therapy (such as breast cancer), the subject would be withdrawn from the treatment 
portion of the trial (but continue being assessed as per the trial protocol). 
 
9.5 Confidentiality of study data   
 
In this study, each patient will be assigned a unique ID number when his/her 
demographic and race/ethnicity information is entered for the first time. Follow-up data 
are subsequently entered as needed when a patient has a clinic visit. The unique ID 
number remains with each patient permanently and is matched with all new data 
entered. The ID number and patient identifiers are directly linked in the study database. 
Global Unique Identifiers (GUID) will be created for each subject using the NIH/NCATS 
generator program (https://rarediseases.info.nih.gov/radar/global-unique-identifier-
generator). This GUID will allow linkage of the patient’s data to other studies in which the 
patient participates and will allow the potential for posting these data in the Global Rare 
Diseases Patient Registry. The potential for this data sharing has been included in the 
informed consent.  Each subject’s GUID will be linked to the local ID used for our 
ongoing human cohort studies, as well (VUMC IRB 9401). 
 


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Information about study subjects will be kept confidential and managed according to the 
requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  
Those regulations require a signed subject authorization informing the subject of the 
following:  
• What protected health information (PHI) will be collected from subjects in this 
study 
• Who will have access to that information and why 
• Who will use or disclose that information 
• The rights of a research subject to revoke their authorization for use of their PHI.  
 
In the event that a subject revokes authorization to collect or use PHI, the investigator, 
by regulation, retains the ability to use all information collected prior to the revocation of 
subject authorization. For subjects that have revoked authorization to collect or use PHI, 
attempts should be made to obtain permission to collect at least vital status (i.e. that the 
subject is alive) at the end of their scheduled study period. 
Several mechanisms will be in place to maintain confidentiality. All of the data will be 
reported in aggregate. Each subject in all phases of the study will be assigned a unique 
study code number to be used on all data forms, study records, and blood samples. A 
list of patient names and code numbers will be maintained separately in locked file 
cabinets or on password protected computers. Only the investigators and project staff 
will have access to this information. No other personally identifiable information will be 
available. We will also obtain a Certificate of Confidentiality from the NIH for this study 
before consent of the first patient. 
 
9.6 Potential risks 
 
There are several areas of potential risk in this study.  We will obtain several blood 
samples from each subject. There is a risk of bruising, hematoma, and infection after 
phlebotomy, which are possible but not considered serious AEs. Fainting may occur 
which is unlikely, but considered a serious AE. The removal of <71 cc of blood four times 
during one year is a potential risk; however this amount is routinely taken from subjects 
for clinical indications without adverse effect. Study medications will be delayed until 
after phlebotomy on each study day. 
 
The 6MWT may cause light-headedness, chest pain, or musculoskeletal discomfort; 
however the risks of this study to subjects are minimal. In addition, subjects with PAH 
routinely undergo 6MWT for clinical indications, so this study procedure does not 
increase risk above usual clinical care. As subjects will be allowed to continue their other 
therapy, there are no alternative therapies to the ones being studied. 
 
The risks associated with an echocardiogram are that the probe used on the chest 
during the echocardiogram may lead to mild soreness in the area for about a day. 
For the PET scans, a radioactive drug (tracer) will be put into the body. Because the 
amount of radiation exposure to is small, the risk of negative effects from it is low. But 
the tracer itself could cause an allergic reaction, in rare instances. 


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The administration of tamoxifen is associated with risks, noted above.  
 
The other risk to the subjects is the potential loss of confidentiality during data collection, 
although as noted above steps will be taken to maintain confidentiality completely. 
 
9.7 Potential benefits 
 
The results from the study could be applied in the future to subjects (including those in 
the study) who stand to benefit from the information. There may be clinical benefits to 
the use of tamoxifen in subjects with PAH. As the study involves the risks of 
randomization to tamoxifen, phlebotomy, exercise testing, and loss of confidentiality, and 
there is a potential for future benefit for both subjects in the study and for future subjects, 
the risk/benefit ratio is favorable. 
 
9.8 Alternatives 
 
The use of the medications for this study requires that other medications including 
hormone therapy not be used. Therefore, the alternative is to not participate in this study 
and to continue having the option to take these medications.  
 
9.9 Ethical Considerations 
 
This study is to be conducted in accordance with applicable US government regulations 
and international standards of Good Clinical Practice, and applicable institutional 
research policies and procedures. 
 
This protocol and any amendments will be submitted to a properly constituted IRB 
(Vanderbilt University Medical Center, VUMC) in agreement with local legal prescriptions 
for formal approval of the study conduct.  The decision of the IRB concerning the 
conduct of the study will be made in writing to the investigator per VUMC protocols, and 
a copy of this decision will be provided to the NIH before commencement of this study.   
 
All subjects for this study will be provided a consent form describing this study and 
providing sufficient information for subjects to make an informed decision about their 
participation in this study. The formal consent of a subject, using the IRB-approved 
consent form, must be obtained before that subject undergoes any study procedure.  
The consent form must be signed by the subject or legally acceptable surrogate, and the 
investigator-designated research professional obtaining the consent.  
 
 


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