Clinical trial NCT03954782: Efficacy of Nintedanib Per os as a Treatment for Epistaxis in HHT Disease.
Official title: Efficacy of Nintedanib Per os as a Treatment for Epistaxis in HHT Disease. A National, Randomized, Multicentre Phase II Study
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: PHASE2
Conditions: Telangiectasia, Hereditary Hemorrhagic
Rendu Osler Disease
Keywords: Hereditary Hemorrhagic Telangiectasia (HHT)
antiangiogenic therapy
Tyrosine Kinase Inhibitor
Nintedanib
Lead sponsor: Hospices Civils de Lyon
Sponsor class: OTHER
First posted: 2019-05-17
Enrollment: 61
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: The recognized manifestations of HHT are all due to abnormalities in vascular structure. Epistaxis are spontaneous, very variable, may occur as often as several times every day, and are recurrent in 90% of patients and associated with chronic and severe anemia in 2-10%. They also significantly reduce quality of life.

Blood transfusions are sometimes required in 10-30% of patients. Previous studies showed that antiangiogenic treatments such as anti-VEGF treatment (bevacizumab) administered intravenously was efficient on epistaxis and dramatically reduced nosebleeds.

Tyrosine kinase inhibitors are anti-angiogenic molecules which are available orally and could therefore overcome the difficulties encountered with bevacizumab. The investigator hypothesized that nintedanib, acting by indirect inhibition of the VEGF receptor should allow a reduction of epistaxis in HHT patient.

Nintedanib has been used in one HHT patient following the diagnosis of Insterstitial Pulmonary Fibrosis (published case report in 2017, Kovacs et al) with encouraging results.

The aim is to evaluate efficacy of nintedanib for the treatment of epistaxis in HHT patients


Eligibility criteria: Inclusion Criteria:

* Age \> 18 years old
* Patients who have given their free informed and signed consent
* Patients affiliated to a social security scheme or similar
* Patients monitored for clinically confirmed HHT and/or with molecular biology confirmation
* Patient with an Epistaxis Severity Score (ESS) \> 4

Exclusion Criteria:

* Pregnant woman or woman of child bearing potential
* Woman who are breast feeding.
* Patient who is protected adults under the terms of the law (French Public Health Code).
* Participation in another interventional clinical trial which may interfere with the proposed trial
* Active infection.
* (AST, ALT \> 1,5 fold upper limit of normal (ULN) and/or Bilirubin \> 1,5 fold upper limit of normal (ULN).
* Severe renal impairment
* Presence of non-treated pulmonary arteriovenous malformations accessible to a treatment on CT scan within 5 years.
* Patients with hemoptysis or hematuria within 12 weeks prior to inclusion.
* Patients with active gastro-intestinal (GI) bleeding or GI ulcers within 12 months prior to inclusion.
* Presence of cerebral arteriovenous malformation.
* Patients who require full-dose therapeutic anticoagulation (e.g. vitamin K antagonist or heparin, dabigatran) or high dose antiplatelet therapy, , patients under anticoagulation with rivaroxaban, apixaban and epixaban.
* Patients with P-glycoprotein (P-gp) substrates/inducers/inhibitors (e.g.: ketoconazole, erythromycin, cyclosporine, rifampicin, carbamazepine, phenytoin, and St. John's Wort).
* Patients with known coronary artery disease or recent history of myocardial infarction (within 1 year).
* Known inherited predisposition to thrombosis or thrombotic events( including stroke and transient ischemic attack, excluded superficial venous thrombosis) within 12 months prior to inclusion.
* Patients with QTc prolongation
* Hypersensitivity to nintedanib, peanut or soya, or to any of the excipients.
* Patient who incompletely filled in epistaxis grids within 8 weeks prior to inclusion.
* Patient who have received intravenous bevacizumab within 6 months prior to inclusion.
* Patient who had surgery (including ENT (Ear, Nose and Throat Specialist) surgery) within 12 weeks prior to inclusion.
* Unhealed wound.
* Planned major surgery within the next 3 months, including liver transplantation, major abdominal or intestinal surgery.

Primary outcomes:
measure: Epistaxis duration assessed on epistaxis grids completed by the patients.
timeFrame: 12 weeks
Secondary outcomes:
measure: number of adverse events
timeFrame: 6 months
measure: number of adverse events
timeFrame: 12 weeks
measure: number of adverse events
timeFrame: 24 weeks
measure: Efficacy or nintedanib assessed by ESS (Epistaxis Severity Score) questionnaire
timeFrame: 12 weeks
measure: Efficacy or nintedanib assessed by ESS questionnaire
timeFrame: 24 weeks
measure: duration of epistaxis all over the study. Assessment on epistaxis grids completed by the patients.
timeFrame: 12 weeks
measure: duration of epistaxis assessed on epistaxis grids completed by the patients.
timeFrame: 24 weeks
measure: duration of epistaxis assessed on epistaxis grids completed by the patients.
timeFrame: 12 weeks
measure: frequency of epistaxis assessed on epistaxis grids completed by the patients.
timeFrame: 24 weeks
measure: Quality of life assessed by SF36 (Short Form 36) questionnaire
timeFrame: 12 weeks
measure: Quality of life assessed by SF36 questionnaire
timeFrame: 24 weeks
measure: number of red blood cell transfusions
timeFrame: 12 weeks
measure: number of red blood cell transfusions
timeFrame: 24 weeks
measure: number of iron infusions
timeFrame: 12 weeks
measure: number of iron infusions
timeFrame: 24 weeks
measure: hemoglobin level
timeFrame: 12 weeks
measure: hemoglobin level
timeFrame: 24 weeks
measure: ferritin level
timeFrame: 12 weeks
measure: ferritin level
timeFrame: 24 weeks
Other outcomes:
Locations:
city: Angers
country: France
facility: CHU d'Angers
city: Bron
country: France
facility: Hôpital Femme-Mère-Enfant-Centre de Référence pour la maladie de Rendu-Osler
city: Clermont-Ferrand
country: France
facility: CHU Clermont Ferrand
city: Marseille
country: France
facility: CHU de Marseille-Hôpital la conception
city: Montpellier
country: France
facility: CHU de Montpellier-Hôpital St Eloi
city: Paris
country: France
facility: Hôpital Tenon
city: Poitiers
country: France
facility: CHRU - Hôpital J.Bernard
city: Rennes
country: France
facility: CHU de Rennes-Hôpital Pontchaillou
Study officials:
affiliation: Hospices Civils de Lyon
name: Sophie DUPUIS-GIROD
role: PRINCIPAL_INVESTIGATOR
References: