Hemolysis Related Complications in SCD. A Phase II Study With Voxelotor

Study Overview
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Brief Summary
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Intro: Sickle cell disease is a genetic disorder caused by a mutation of the β hemoglobin called HbS, which causes red blood cell (RBC) abnormalities responsible for hemolysis, mainly intravascular, leading to chronic anemia. Intravascular hemolysis is responsible for severe inflammation and endothelial dysfunction. Maintaining hemoglobin in its oxygenated R-conformation is one of the strategies for inhibiting the polymerization of HbS. Previous experimental therapeutic approaches having this effect have been discontinued due to poor pharmaceutical properties or toxicity. Nevertheless, they proved the validity of the concept by demonstrating an increase in oxyhemoglobin and a decrease in biomarkers of hemolysis. Voxelotor binds to the α chain of globin and maintains Hb in its R conformation, thereby inhibiting the polymerization of HbS while increasing the affinity of Hb for oxygen. Because of its mechanism of action affecting anemia and hemolysis, Voxelotor is a promising treatment for the prevention and treatment of renal and cerebral arterial disease. Hypothesis/Objective : Investigator hypothesis is that the treatment by Voxelotor (GBT440) will improve intra vascular hemolysis and will increase the total mass of hemoglobin with beneficial effects on organ function. The primary objective of the study is to evaluate the biological activity of Voxelotor on the reduction of intra vascular hemolysis measured by plasma hemoglobin. The secondary objectives of the study will aim at characterizing the effects of GBT 440 Voxelotor on: Intra vascular hemolysis measured by plasma Heme Total hemoglobin mass (MHb) RBCs lifespan Blood volumes (plasma volume (PV), red blood cell mass (RBCM), total blood volume (BV)) Blood viscosity Cerebral perfusion Cerebrovascular vaso-reactivity Cognitive function (MoCA) Six minute walk test Renal perfusion and iron deposits in renal cortex Measurement of Glomerular filtration rate Estimation of glomerular filtration rate (CKD/EPI equation) Urine albumin/creatinine ratio Ability to decrease or stop erythropoietin in patients under EPO treatment Safety (VOC, ACS, Priapism) and tolerability of voxelotor RBC properties Method: This is an open-label, single-arm, single-stage phase II trial in patients treated with Voxelotor 1500 mg daily for 48 weeks. Assessments will be done during the study at week 0, week 6, week 12, week 24, week 36 and week 48.

Official Title
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HEMolyse and Organ Damage imPROvement in Sickle Cell Disease by VoxElotor. An Open-label One Stage Phase II Design

Conditions
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Sickle Cell Disease

Intervention / Treatment
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* Drug: Voxelotor 1500 mg oral per day (GBT440) for 48 weeks in patients with sickle-cell disease


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: SS or S-β0 major sickle cell syndrome Hemoglobin level < 9 g/dL Aged 18 years or older Stable dose for at least 3 months if treated with HU, EPO, angiotensin-converting enzyme (ACE) or inhibitor/angiotensin receptor blocker (ARB) therapy; at least after 6 months after initiating HU treatment Patient with social security Female patient must have a negative serum pregnancy test (betaHCGat inclusion W0-V1D1) or evidence of post-menopausal status Effective methods of birth control (e.g., condom, spermicidal gel, oral contraceptive, indwelling intrauterine device, hormonal implant/patch, injections, approved cervical ring) or abstinence from screening through 4 weeks after last Voxelotor dose. Exclusion Criteria: -If patient does not have any of the following treatments (HU, Crizanlizumab) he will then be excluded if: Patient meets, at screening, Hydroxyurea/ Crizanlizumab indications of treatment (recurrent painful vaso-occlusive crises, including acute chest syndrome), even if these treatments are inappropriate (e.g. hematologic toxicity antecedent) or if the patient refuses these treatments Patients in chronic transfusion program or transfused < 3 months before enrolment Patient with severe organ involvement: hepatic (TP <50%), renal (eGFR<30 ml / ml/1.73m2 according to CKD/EPI or cardiac (LVEF <45%) Transplant patients. Pregnancy. Breast feeding patients Homeless patient Patient deprived of liberty by judicial or administrative decision or patient under guardianship Patient unable to understand the purpose and conditions of the study and unable to give consent Chronic use of NSAIDs (more than 10 days by month) Auto immune disease or infection not controlled or cancer VIH, HBV, HCV current infection Prior drug hypersensitivity to Voxelotor or excipients Known allergy or hypersensitivity to imaging contrast product Ongoing therapeutic study

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Interventional Model Description: This is an open-label, single-arm, single-stage phase II trial in patients treated with Voxelotor 1500 mg daily for 48 weeks. Assessments will be done during the study at week 0, week 6, week 12, week 24, week 36 and week 48.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Voxelotor 1500 mg oral per day (GBT440) for 48 weeks<br>Voxelotor 1500 mg oral per day (GBT440) for 48 weeks, in case of discontinuation due to patient's wishes and/or adverse event above grade 2 : 1000mg during 14 days then complete discontinuation if no resolution. In case of sudden discontinuation a therapeutic phlebotomy will be authorized. | Drug: Voxelotor 1500 mg oral per day (GBT440) for 48 weeks in patients with sickle-cell disease<br>* This is an open-label, single-arm, single-stage phase II trial of voxelotor in patients with sickle-cell disease. Voxelotor 500mg tablets. Voxelotor will be administered as 500mg tablets orally once daily. The participant should always take all 3 tablets in a row at the same time each day, unless the study doctor has instructed them to adjust the dose.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Evaluation of the biological activity of voxelotor on the change of intra vascular hemolysis measured by decrease of plasma hemoglobin. | Change of Intravascular hemolysis, as defined by a ≥20% decrease of plasma Hemoglobin (µmol/l) | Change from Baseline at Week 48 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Intra vascular hemolysis measured by plasma Heme | Absolute and relative (%) changes in plasma Hemoglobin (µmol/l) and free plasma Heme (µmol/l) | Week 0, Week 24, Week 48 | 
| Total hemoglobin mass (MHb) | Measurement of total hemoglobin mass based on the CO rebreathing technique (g of Hb / kg), or a stable evolution (i.e. decrease ≤ 10%) in patients initially under EPO therapy and who decreased or discontinued EPO during the study period. | Week 0, Week 24, Week 48 | 
| RBCs lifespan | RBC lifespan by measurement of alveolar CO (in days). | Week 0, Week 24, Week 48 | 
| Change of blood volumes (plasma volume (PV) and total blood volume (BV)) | Blood volumes by CO rebreathing method (Total blood volume (L), Plasma Volume (L) ) | Week 0, Week 24, Week 48 | 
| Change of red blood cell mass (RBCM) | RBC mass (g) | Week 0, Week 24, Week 48 | 
| Change of Total Mass of Hemoglobin | Total Mass of Hemoglobin (g of Hb) | Week 0, Week 24, Week 48 | 
| Change of blood viscosity | Blood viscosity (cP) | Week 0, Week 24, Week 48 | 
| Cerebral perfusion | Cerebral perfusion measured by MRI | Week 0, Week 24, Week 48 | 
| Change of cerebrovascular vaso-reactivity measured by transcranial Doppler | Transcranial Doppler (Breath holding test) | Week 0, Week 24, Week 48 | 
| Change of cerebrovascular vaso-reactivity measured by Near Infra Red Spectroscopy | Cerebral vaso-reactivity measured by Near Infra Red Spectroscopy | Week 0, Week 24, Week 48 | 
| Cognitive function (MoCA) | Cognitive performance measured by MoCA Improvement in the 6 minutes walk test on : Time spent under Sp02 88 and 90%, Borg Rating of Perceived Exertion (RPE), distance. | Week 0, Week 24, Week 48 | 
| Measurement of renal perfusion and amount of deoxyhemoglobin | Amount of deoxyhemoglobin by MRI | Week 0, Week 24, Week 48 | 
| Study of iron deposits in renal cortex | Iron deposits in renal cortex measured by MRI | Week 0, Week 24, Week 48 | 
| Measurement of Glomerular filtration rate | Estimation of glomerular filtration rate (CKD/EPI equation) | Week 0, Week 24, Week 48 | 
| Ability to decrease or stop erythropoietin in patients under EPO treatment | Concomitant treatment observation: decrease / interruption of EPO dose | From Week 0 to Week48 | 
| Incidence of Treatment-Adverse Events VOC, ACS and Priapism | Presence/Absence of adverse Events VOC, ACS, Priapism | From Week 0 to Week48 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Sickle Cell Disease, Hemolysis, Plasma Hemoglobin