Clinical trial NCT01057537: UMPIRE - Use of a Multidrug Pill In Reducing Cardiovascular Events
Official title: A Randomised Controlled Trial of a Fixed-dose Combination Polypill Medication (the Red Heart Pill) and Usual Care in Those at High Risk of Cardiovascular Disease.
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: PHASE3
Conditions: Cardiovascular Diseases
Keywords: Polypill
Red Heart Pill
Cardiovascular disease
Adherence
Secondary prevention
Lead sponsor: Imperial College London
Sponsor class: OTHER
Collaborators: name: European Commission
name: Imperial College Healthcare NHS Trust
name: Royal College of Surgeons, Ireland
name: UMC Utrecht
name: The George Institute
name: Public Health Foundation of India
name: Dr. Reddy's Laboratories Limited
First posted: 2010-01-27
Enrollment: 2004
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: People with established cardiovascular disease need secondary prevention that addresses multiple risk factors. Complexity \& cost confer particularly difficult barriers to uptake of treatment; recovery from a stroke or heart attack typically necessitates multiple drugs for cholesterol, blood pressure and platelet function. A low-cost, fixed-dose, once-daily combination polypill, the Red Heart Pill, has been formulated by Dr Reddy's Laboratories. UMPIRE will evaluate whether provision of this polypill compared with usual medications improves adherence and clinical outcomes among high-risk patients in Europe and India. The results will be used to develop recommendations for equitable access.

Detailed description: The UMPIRE trial has been modelled on similar trials running concurrently in Australia and New Zealand. The design is straight forward in making comparisons between cardiovascular preventative therapy delivered as a polypill (the Red Heart Pill) on the one hand, and as separate component multiple tablets (usual care) on the other hand. In both groups (the polypill group and the usual care group,) the GP or managing physician will be able to adjust or add additional medications as appropriate to meet the targets for control of blood pressure, cholesterol and other risk factors as directed by local or national guidelines. The Primary endpoint - adherence to prescribed cardiovascular preventative medication at the end of the trial follow-up - will be evaluated by self reported use of anti-platelet, statin and blood pressure lowering therapy. This evaluation will be supported by the recording of blood pressure and cholesterol levels, and measuring the differences between the two groups at the end of the trial. Treatment allocation is open label - both investigator and subject will know which arm of the study they are on. Patients will be identified and recruited from GP surgeries or hospital clinics, and also via local advertisement. Recruitment into the study is planned to start in Summer 2010 with a 12 month recruitment phase. Recruited subjects will spend between 12 - 30 months (average 18 months) being followed up. The target study population is 1000 patients in European at sites in London, Dublin and Utrecht; and 1000 subjects in India at approximately 30 sites. Subjects will be randomly allocated to receive either the "polypill" or "usual care". If allocated to the polypill group, the study investigator will decide on the version of polypill to be prescribed, and adjust any current medications as necessary. If the subject is in the "usual care" group, they will be seen as needed by their usual doctor between study visits, and continue on their current medicines. Participants will have at least 5 study visits, but no more than 8 study visits, and these visits include registration, randomisation and follow-up visits at 1 month, 6 months, and 12 months, and depending on when the subject is recruited to the study, study visits at 18 and 24 months/end of trial visit. A substudy, PESCA (Protocol ID CR01656, NCT01326676), will be performed in the European participants to assess whether the polypill reduces progression of atherosclerosis. This will be assessed by measuring carotid intima-medial thickness and central systolic blood pressure using the PulseCor device. A second substudy, INPUT, is a process evaluation involving qualitative interviews of a sample of health practitioners and trial participants at the end of the trial (summer 2012) in London and India.

Eligibility criteria: Inclusion Criteria:

* Adults (≥ 18 years)
* The participant is able to give informed consent.
* Established atherothrombotic cardiovascular disease (CVD) or high cardiovascular risk, of for individuals without established cardiovascular disease, a calculated 5 year CVD risk of 15% or greater (calculated using the 1991 Anderson Framingham risk equation with adjustments as defined by the New Zealand Guidelines Group recommendations)
* The trial Investigator considers that each of the polypill components are indicated
* The trial Investigator is unsure as to whether a polypill-based strategy or usual care is better.

Exclusion Criteria:

* Contraindication to any of the components of the polypill (e.g. known intolerance to aspirin, statins, or ACE inhibitors,pregnancy or likely to become pregnant during the treatment period).
* The treating doctor considers that changing a participant's cardiovascular medications would put the participant at risk (e.g. symptomatic heart failure, high dose βblocker required to manage angina or for rate control in atrial fibrillation,accelerated hypertension, severe renal insufficiency, a history of severe resistant hypertension)
* Known situation where medication regimen might be altered for a significant length of time, e.g. current acute cardiovascular event, planned coronary bypass graft operation.
* Unlikely to complete the trial (e.g. lifethreatening condition other than cardiovascular disease) or adhere to the trial procedures or attend study visits (e.g. major psychiatric condition, dementia).

Primary outcomes:
measure: Adherence to medication; self-reported current use of antiplatelet, statin and combination (≥ 2) blood pressure lowering therapy
timeFrame: End of trial follow-up
measure: Change in blood pressure
timeFrame: End of trial follow-up
measure: Change in LDL cholesterol
timeFrame: End of trial follow-up
Secondary outcomes:
measure: Self reported current use of antiplatelet, statin and combination (>2) blood pressure lowering therapy
timeFrame: 12 months
measure: Reasons for stopping cardiovascular medications
timeFrame: Throughout trial
measure: Serious adverse events
timeFrame: Throughout trial
measure: New onset cardiovascular events
timeFrame: Throughout trial
measure: Participant 'Quality of Life' assessment
timeFrame: At 12 months and end of trial
measure: Changes in total cholesterol and other lipid fractions (HDL-cholesterol, triglycerides)
timeFrame: 12 months and end of trial
Other outcomes:
Locations:
city: Sydney
country: Australia
facility: George Institute Australia
state: New South Wales
city: Hyderabad
country: India
facility: George Institute for International Health - India
city: New Dehli
country: India
facility: Public Health Foundation of India
city: New Delhi
country: India
facility: Centre for Chronic Disease Control
city: Dublin
country: Ireland
facility: Royal College of Surgeons in Ireland Research Institute
city: Utrecht
country: Netherlands
facility: University Medical Center Utrecht
state: Heidelberglaan 100
city: Paddington
country: United Kingdom
facility: Clinical Investigation Unit, International Centre for Circulatory Health, Imperial College London
state: London
Study officials:
affiliation: Imperial College London
name: Simon A McG Thom, MD, FRCP
role: STUDY_DIRECTOR
affiliation: Imperial College London
name: Neil Poulter
role: PRINCIPAL_INVESTIGATOR
affiliation: The George Institute, India
name: Anushka Patel
role: PRINCIPAL_INVESTIGATOR
affiliation: Centre for Chronic Disease Control
name: Dorairaj Prabhakaran
role: PRINCIPAL_INVESTIGATOR
affiliation: UMC Utrecht
name: Michiel Bots
role: PRINCIPAL_INVESTIGATOR
affiliation: UMC Utrecht
name: Diederick Grobbee
role: PRINCIPAL_INVESTIGATOR
affiliation: Royal College of Surgeons in Ireland
name: Alice Stanton
role: PRINCIPAL_INVESTIGATOR
affiliation: The George Institute, Australia
name: Anthony Rodgers
role: PRINCIPAL_INVESTIGATOR
affiliation: Dr. Reddy's Laboratories Limited
name: Raghu Cidambi
role: PRINCIPAL_INVESTIGATOR
affiliation: Public Health Foundation of India
name: K Srinath Reddy
role: PRINCIPAL_INVESTIGATOR
References:
citation: Thom S, Field J, Poulter N, Patel A, Prabhakaran D, Stanton A, Grobbee DE, Bots ML, Reddy KS, Cidambi R, Rodgers A. Use of a Multidrug Pill In Reducing cardiovascular Events (UMPIRE): rationale and design of a randomised controlled trial of a cardiovascular preventive polypill-based strategy in India and Europe. Eur J Prev Cardiol. 2014 Feb;21(2):252-61. doi: 10.1177/2047487312463278. Epub 2012 Oct 4.
citation: Thom S, Poulter N, Field J, Patel A, Prabhakaran D, Stanton A, Grobbee DE, Bots ML, Reddy KS, Cidambi R, Bompoint S, Billot L, Rodgers A; UMPIRE Collaborative Group. Effects of a fixed-dose combination strategy on adherence and risk factors in patients with or at high risk of CVD: the UMPIRE randomized clinical trial. JAMA. 2013 Sep 4;310(9):918-29. doi: 10.1001/jama.2013.277064.