Clinical trial NCT03850730: Pazopanib for the Treatment of Epistaxis in Hereditary Hemorrhagic Telangiectasia
Official title: An Open-label, Non-randomized Study of the Efficacy of Pazopanib for the Treatment of Epistaxis in Hereditary Hemorrhagic Telangiectasia (HHT)
Study type: INTERVENTIONAL
Overall status: NOT_YET_RECRUITING
Phase: PHASE1
PHASE2
Conditions: Hereditary Hemorrhagic Telangiectasia
Epistaxis
Keywords: osler-weber-rendu
nose bleeds
open label
HHT
Pazopanib
Lead sponsor: Cure HHT
Sponsor class: OTHER
Collaborators: name: University of North Carolina
First posted: 2019-02-22
Enrollment: 30
Sex: ALL
Minimum age (years): 18
Maximum age (years): 75
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: NA
Intervention model: SINGLE_GROUP
Intervention model description: After at least a 6 week baseline, patients will be placed on very low dose Pazopanib \[25mg-similar\], for 8 weeks.. If the primary bleeding duration endpoint is achieved, than the patient will continue for another 8wks, or a total of 16 weeks on the same dose. Lack of any response will result in a dose advance to 50mg for another 3mths. If a moderate change has occurred, than the 25mg dose will be continued for another 4 weeks, and if primary endpoint achieved, continue for another 12 weeks... Lack of endpoint achievement, will augment dose to 50mg and extend study for 12 weeks, or a total of 24 weeks.
Primary purpose: TREATMENT

Brief summary: Investigators will test the value of very low dose Pazopanib administered to patients with hereditary hemorrhagic telangiectasia for the reduction in the severity of nose bleeds in those with frequent and long duration bleeding episodes.

Detailed description: Based on frequency and nose bleed duration, a non-randomized, single arm, open label study of 30 hereditary hemorrhagic telangiectasia patients will be treated with very low dose Pazopanib \[25mg-similar\] for between 16 and 24 weeks.. The primary endpoint is a reduction in bleeding duration of 50% or more, along with multiple secondary related endpoints, including bleed frequency, blood counts and quality of life; as compared to 6-12 weeks of baseline characteristics. If after the first 8 weeks of therapy benefit is suboptimal, dose advance to 50mg-similar daily can be considered.

Eligibility criteria: Inclusion Criteria:

* a definite diagnosis of hereditary hemorrhagic telangiectasia defined as having at least 3 of the following criteria:

  * Spontaneous and recurrent epistaxis.
  * Multiple telangiectasias at characteristic sites: lips, oral cavity, fingers, nose.
  * Visceral lesions: GI telangiectasia, pulmonary, hepatic, cerebral or spinal AVMs.
  * A first degree relative with hereditary hemorrhagic telangiectasia according to these criteria.
  * OR a gene sequencing diagnosis of hereditary hemorrhagic telangiectasia

    2. Epistaxis due to hereditary hemorrhagic telangiectasia at least 2x per week, for a cumulative duration of at least 25 minutes per week

    3. Epistaxis is clinically stable during the 12 weeks prior to screening in the clinical judgment of the investigator (i.e. no major changes in frequency or duration of epistaxis).

    4. Participant agrees not to undergo cautery of nasal telangiectasias or take any experimental therapies for hereditary hemorrhagic telangiectasia other than the study drug while participating in the study.

    5. Male or female \[non-child bearing potential\]

Exclusion Criteria:

1. Participant has known immediate or delayed hypersensitivity reaction or idiosyncrasy to drugs chemically related to pazopanib that in the opinion of the investigator contradicts their participation.
2. Currently has untreated cerebral arterio-venous malformations (AVMs), cerebral arteriovenous fistulae, or cerebral cavernous malformations (CCMs) (Note: MRI scan does not need to be repeated at screening if AVMs, arterio-venous fistulas and CCMs were absent on a scan at age ≥18 years).
3. Currently has perfused pulmonary AVMs with feeding artery diameter \>3mm.
4. Known significant bleeding sources other than nasal or gastrointestinal.
5. Systemic use of a vascular endothelial growth factor inhibitor in the past 3 months or previous enrollment in this study.
6. Active and recent onset of clinically significant diarrhea.
7. Current or recent (in the last 5 years) malignancies (except non-melanoma skin cancers)
8. Participant has had major surgery (e.g. surgical ligation of an AVM) or trauma within 28 days or had minor surgical procedures (e.g. central venous access line removal) within 7 days prior to dosing, the latter representing a recent wound, fracture or ulcer
9. Participant has a planned surgery during the period to include active treatment and 6 weeks of follow up.
10. Participant has clinically significant gastrointestinal abnormalities (other than hereditary hemorrhagic telangiectasia related vascular lesions)
11. Participant during the 6 months prior to first dose of study drug has a history of cerebrovascular accident (including transient ischemic attacks), pulmonary embolism, untreated deep vein thrombosis (DVT), myocardial infarction, or any other thrombotic event.
12. QTc ≥450 msec, based on averaged QTc values of triplicate ECGs obtained over a brief recording period \[The QTc is the QT interval corrected for heart rate according to either Bazett's formula (QTcB), Fridericia's formula (QTcF), or another method, machine or manual overread. The same QT correction formula must be used for each individual participant to determine eligibility for and withdrawal from the study.\]
13. Hgb \<6 g/dL.
14. Platelets \< 100x109/L.
15. International normalized ratio (INR) \>1.2x upper limit of normal and activated partial thromboplastin time (aPTT)\>1.2x upper limit of normal.
16. Alanine Transaminase \>2x upper limit of normal.
17. Bilirubin \>1.5x upper limit of normal (isolated bilirubin \>1.5x upper limit of normal is acceptable if bilirubin is fractionated and direct bilirubin \<35%).
18. Participant has poorly controlled hypertension \[defined as systolic blood pressure (SBP) ≥ 140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg. Initiation or adjustment of antihypertensive medication(s) is permitted prior to study entry \[between screen and baseline\]. At Screening, blood pressure must be assessed three times and the mean SBP/DBP must be \<140/90 mmHg in order for a participant to be eligible for the study.\]
19. Substantive renal disease (eGFR \<30 mL/min/1.73m2calculated using the Cockcroft-Gault formula)
20. Echo derived left ventricular ejection fraction \<30%.
21. Thyroid stimulating hormone \> upper limit of normal.
22. Urine protein to creatinine ratio \>0.3.
23. Neutrophil count \<1500/mm3.

Primary outcomes:
measure: Percent change in epistaxis duration in minutes
timeFrame: Summed minutes of bleeding at baseline 3 weeks and the last 3 weeks of dosing, over16-24 weeks of dosing
Secondary outcomes:
measure: Percent change in average gushing frequency
timeFrame: Last 3 weeks of drug period vs baseline 3 weeks; over 16-24 weeks of dosing
measure: Percent change in average bleed frequency
timeFrame: Last 3 weeks compared to the baseline 3 weeks; over 16-24 weeks of dosing
measure: Absolute [gm/dl] change in serum hemoglobin
timeFrame: comparing last 6 weeks to baseline 3-6 weeks; over 16-24 weeks of drug dosing
measure: Change in the frequency of blood transfusions
timeFrame: Final 6 weeks of study, compared to baseline 3-6 weeks; over 16- 24 weeks of dosing
measure: Change in the frequency of IV iron infusions
timeFrame: Last 6 weeks of dosing to first 6 weeks; over 16-24 weeks of drug administration
measure: Percent change in the per bleed average epistaxis severity
timeFrame: The final 3 weeks to the baseline 3 weeks of the study; for a16-24 week duration study
measure: Daily monitoring for change in systolic blood pressure [mm mercury] using daily recordings
timeFrame: Daily from baseline through up to 24 weeks till on-drug study completion.
measure: Daily monitoring for change in diastolic blood pressure [mm mercury]
timeFrame: Daily from baseline through up to 24 weeks till on-drug study completion
measure: Number of participants with changes in alanine aminotransferase [liver function test]
timeFrame: Baseline and throughout the 16-24 week dosing period
measure: Monitor for active and safe trough serum drug concentrations
timeFrame: Over 16-24 week duration of study; once at steady state for each administered dose
measure: Evaluate for change in composite mental quality of life scores
timeFrame: baseline, week 12 and at study drug-dosing end; 16, 20 or 24weeks
measure: Evaluate for change in composite physical quality of life scores
timeFrame: baseline, week 12 and at study drug-dosing end; up to 24 weeks.
measure: Evaluate for change in fatigue composite scores
timeFrame: baseline and study end; up to 24 weeks
Other outcomes:
measure: Interrogate levels of Iron stores
timeFrame: baseline and at on-drug study end; 16, 20 or 24 weeks depending on study duration
measure: Characterize change in left ventricular stress
timeFrame: baseline and on-drug study end; 16, 20 or 24 weeks depending on study duration]
Locations:
Study officials:
affiliation: University of North Carolina
name: Raj Kasthuri, MD
role: PRINCIPAL_INVESTIGATOR
References: