Systemic Sclerosis (SSc) Vasculopathy: Improved Clinical Monitoring and Treatment

Study Overview
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Brief Summary
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Systemic sclerosis (SSc; scleroderma) is a multi-organ systemic disease characterized by activation of immune cells, which results in vascular dysfunction (vasculopathy) and subsequent scarring (fibrosis). SSc has a higher than expect prevalence in the US military. On a national level there are 5,766 SSc patients (ICD-9 710.1) presently cared for in the Veterans Health Administration (VHA). While there is no cure for SSc, studies of therapeutics that can help slow disease progression are valuable to our Veterans. This proposal addresses the solicitation for projects with attention to SSc requested by President Obama after reviewing potential contamination of water at Camp Lejeune. This proposal is a patient-centered outreach for our Veterans with SSc to inform and prevent catastrophic endstage vascular abnormalities, including digital ulcers, pulmonary arterial hypertension (PAH) and scleroderma renal crisis in SSc. The study proposes a novel application of a therapeutic for this disease. A better understanding of the initiating insult and natural progression of SSc vasculopathy is needed in order to develop therapeutics with a goal of curing/treating the underlying disease. This project has the potential to impact not only Veterans with SSc, but also those with vascular abnormalities including digital ulcers, PAH, and renal crisis. This proposal represents a potential major therapeutic advance for our Veterans with SSc.

Detailed Description
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Although SSc is heterogeneous in the extent of organ involvement and prognosis, it is accepted that all SSc cases have a progressive and usually devastating course. Since vasculopathy precedes fibrosis in this disease, a focus on understanding its natural history and preventative measures for vascular dysfunction has profound implications. This pilot work suggests that measurement of endothelial dysfunction with flow mediated dilatation (FMD) holds promise as novel method to assess disease progression as well as the therapeutic efficacy of the pharmacologic compound tetrahydrobiopterin (BH4) in SSc. The investigators believe that BH4, which targets the endothelium, has great promise to reduce SSc-related tissue hypoxia, end organ damage, and potentially may impact underlying disease progression. The first aim will adopt an integrative approach and validate a novel, non-invasive technique, FMD to define vasculopathy in SSc. The second aim and third aim (which is reported in this PRS report) will examine if BH4 is effective in ameliorating vascular dysfunction in patients with SSc and determine the role of oxidative stress in BH4-mediated improvements in vascular function in patients with SSc. The overarching goal of these aims is to improve vasculopathy detection and management in Veterans with SSc.

Official Title
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Systemic Sclerosis (SSc) Vasculopathy: Improved Clinical Monitoring and Treatment

Conditions
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Rheumatologic Disease

Intervention / Treatment
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* Drug: BH4
* Diagnostic Test: Vasculopathy assessment
* Drug: Placebo


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Diagnosis of systemic sclerosis (SSc, scleroderma) by ACR/EULAR 2013 criteria. Exclusion Criteria: Age < 18 Pregnant or breast feeding Unwillingness to consent

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 95 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Basic Science
Allocation: Randomized
Intervention Model: Crossover Assignment
Interventional Model Description: Twelve systemic sclerosis SSc patients were studied 5 hours after oral BH4 administration (10 mg/kg body weight) or placebo on separate days using controlled, counterbalanced, double-blind, crossover experimental design.
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Placebo before BH4<br>Six SSc received oral placebo 10 mg/kg and had flow mediated dilatation measured. After a five day washout they crossed over to oral BH4 10 mg/kg and had flow mediated dilatation measured. Blood samples were obtained from these SSc patients and assessed for oxidative stress. | Drug: BH4<br>* BH4 10 mg/kg/day given once to a total of 12 SSc patients<br>* Other names: Kuvan;Diagnostic Test: Vasculopathy assessment<br>* Non-invasive technique, flow mediated dilatation (FMD) to define vasculopathy in SSc.<br>* Other names: Kuvan;Drug: Placebo<br>* On the experimental days, patients reported to the laboratory after having consumed a standardized breakfast and oral BH4 (10mg/kg) or placebo five hours prior to their arrival. All measurements were taken at the same time of day to eliminate any diurnal effects. All participants abstained from alcohol, caffeine, and exercise for ≥12 hours prior to the study. Additionally, vasodilatory medications were discontinued 12 hours prior to study visit. In premenopausal women, measurements were performed during the early follicular phase of the menstrual cycle. All measurements were made under quiet, comfortable, ambient ( 22°C) laboratory conditions.<br>* Other names: Placebo from IDS;|
| Experimental: BH4 before Placebo<br>Six SSc received oral BH4 10 mg/kg and had flow mediated dilatation measured. After a five day washout they crossed over to oral placebo 10 mg/kg and had flow mediated dilatation measured. Blood samples were obtained from these SSc patients and assessed for oxidative stress. | Drug: BH4<br>* BH4 10 mg/kg/day given once to a total of 12 SSc patients<br>* Other names: Kuvan;Diagnostic Test: Vasculopathy assessment<br>* Non-invasive technique, flow mediated dilatation (FMD) to define vasculopathy in SSc.<br>* Other names: Kuvan;Drug: Placebo<br>* On the experimental days, patients reported to the laboratory after having consumed a standardized breakfast and oral BH4 (10mg/kg) or placebo five hours prior to their arrival. All measurements were taken at the same time of day to eliminate any diurnal effects. All participants abstained from alcohol, caffeine, and exercise for ≥12 hours prior to the study. Additionally, vasodilatory medications were discontinued 12 hours prior to study visit. In premenopausal women, measurements were performed during the early follicular phase of the menstrual cycle. All measurements were made under quiet, comfortable, ambient ( 22°C) laboratory conditions.<br>* Other names: Placebo from IDS;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Flow Mediated Dilatation (FMD)-Diameter of Artery | FMD diameter of artery (mm, higher better) | FMD was obtained on a single day at two different time points (after placebo and intervention) after a 5 day washout period. | 
| Flow Mediated Dilatation-shear Rate |  | FMD was obtained on a single day at two different time points (after placebo and intervention) after a 5 day wash out period. | 
| Flow Mediated Dilatation- Blood Velocity |  | FMD was obtained on a single day at two different time points (after placebo and intervention) after a 5 day wash out period. | 
| Flow Mediated Dilatation-blood Flow |  | FMD was obtained on a single day at two different time points (after placebo and intervention) after a 5 day wash out period. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Oxidative Stress Measurement-MDA: Malondialdehyde | MDA (lower better). Plasma malondialdehyde assessed by Oxis Research/Percipio Bioscience, Foster City, CA. | Oxidative stress measurements were obtained on a single day at two different time points (after placebo and intervention) after a 5-day wash out period. | 
| Oxidative Stress Measurement-catalase (CAT) | CAT (higher better) assessed by Cayman Chemical Company, Ann Arbor, MI. | Oxidative stress measurements were obtained on a single day at two different time points (after placebo and intervention) after a 5-day wash out period. | 
| Oxidative Stress Measurement- Protein Carbonyl | Protein carbonyl (lower better). Plasma protein carbonyl levels assessed by Northwest Life Science Specialties, LLC Vancouver, WA. | Oxidative stress measurements were obtained on a single day at two different time points (after placebo and intervention) after a 5-day wash out period. | 
| Oxidative Stress Measurement- Ferric Reducing Ability of Plasma (FRAP) | FRAP (higher better). FRAP assessed using the method described by Benzie and Strain. | Oxidative stress measurements were obtained on a single day at two different time points (after placebo and intervention) after a 5-day wash out period. | 
| Oxidative Stress Measurement- Superoxide Dismutase (SOD) | SOD (higher better). SOD assessed by Cayman Chemical Company, Ann Arbor, MI. | Oxidative stress measurements were obtained on a single day at two different time points (after placebo and intervention) after a 5-day wash out period. | 
| Oxidative Stress Measurement- Interleukin 6 (IL-6) | IL-6 (lower better), assessed by R&D Systems, Minneapolis, MN. | Oxidative stress measurements were obtained on a single day at two different time points (after placebo and intervention) after a 5-day wash out period. | 
| Oxidative Stress Measurement- Tumor Necrosis Factor Alpha (TNF-α, | TNF-α (lower better), assessed by R&D Systems, Minneapolis, MN. | Oxidative stress measurements were obtained on a single day at two different time points (after placebo and intervention) after a 5-day wash out period. | 
| Oxidative Stress Measurement- C-reactive Protein (CRP) | CRP (lower better). CRP assessed by R&D Systems, Minneapolis, MN. | Oxidative stress measurements were obtained on a single day at two different time points (after placebo and intervention) after a 5-day wash out period. |