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Mineralocorticoid Receptor Antagonism Clinical Evaluation in Atherosclerosis Add-On (MAGMAAddOn)

Primary Purpose

Type2 Diabetes, Hyperkalemia

Status

Terminated

Phase

Phase 4

Locations

United States

Study Type

Interventional

Intervention

Spironolactone

About this trial

This is an interventional treatment trial for Type2 Diabetes

Eligibility Criteria

45 Years - undefined (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria

Male or female patients >= 45 years and able to provide informed consent (females must be either post-menopausal for one year, surgically sterile, or using effective contraception. Oral contraceptives are disallowed.)
Patients with type II diabetes with HbA1c ≤ 9.0 on stable anti-glycemic regimen that may include oral and/or injectable therapy (GLP-1/Insulin etc.). Changes in dose of glycemic regimen is allowed during the course of the trial if felt to be clinically appropriate.
Glomerular filtration rate (GFR) <90 and evidence of proteinuria (Urine Albumin/Creatinine Ratio of >30 mg/g or equivalent) in a urine specimen within 12 months OR GFR <60 mg/g regardless of proteinuria
Patients must be on angiotensin-converting-enzyme inhibitor (ACE) and/or angiotensin-resistance-blocker (ARB) therapy with no planned dose adjustments.
Hyperkalemia defined as serum K+≥ 5.1 meq/L at visit 0 (screening).

Exclusion Criteria

Uncontrolled hypertension (Systolic Blood Pressure (SBP)>160 and/or Diastolic Blood Pressure (DBP)>95 mmHg at visit 0 (screening) and SBP >145 mm Hg at visit 2).
GFR (MDRD) of <20 at visit 0 (screening)
Hyperkalemia defined as serum K+ <5.1 meq/L at visit 0 (screening).
LDL cholesterol >150 mg/dL
Plasma triglycerides > 400 mg/dl
Contraindications to MRI (metallic implants, severe claustrophobia).
Acute coronary syndrome, Transient ischemic attack, cardiovascular accident (CVA) or critical limb ischemia during the last 6 months or coronary/peripheral revascularization within the last 3 months.
Evidence of a secondary form of hypertension.
Initiation of new therapy with statins, ACE/ARB, antioxidants, calcium channel blockers (CCBs), diuretics, β blockers.
Type I diabetes mellitus
Known contraindication, including history of allergy to Spironolactone or Patiromer
Any surgical or medical condition which might alter pharmacokinetics of drug (e.g. renal transplant, liver failure, liver transplant)
Concurrent potentially life threatening arrhythmia or symptomatic arrhythmia.
Significant hyponatremia defined as Na <130 meq/L.
History of prior malignancy including leukemia and lymphoma (but not basal cell skin cancer, cured squamous cell cancer and cured prostate cancer).
History of any severe, life-threatening disease.
Any surgical or medical conditions which place the patient at higher risk derived from his/her participation into the study, or likely to prevent patient from complying with requirements.
History of drug abuse within the last 2 years, noncompliance and unwillingness/inability to consent.
Pregnant women and nursing mothers
Class III or IV Congestive Heart Failure
Primary Hyperaldosteronism

Sites / Locations

University Hospitals Cleveland Medical Center

Arms of the Study

Arm 1

Arm Type

Experimental

Arm Label

Patiromer Add-On

Arm Description

Single arm experimental study in 50 diabetic patients with chronic kidney disease and hyperkalemia.

Outcomes

Primary Outcome Measures

Left Ventricular Mass

Change in left ventricular mass from baseline to 12 months.

Secondary Outcome Measures

Full Information

NCT ID

NCT03597035

First Posted

March 5, 2018

Last Updated

April 21, 2022

Sponsor

University Hospitals Cleveland Medical Center

Collaborators

Relypsa, Inc.

1. Study Identification

Unique Protocol Identification Number

NCT03597035

Brief Title

Mineralocorticoid Receptor Antagonism Clinical Evaluation in Atherosclerosis Add-On

Acronym

MAGMAAddOn

Official Title

Mineralocorticoid Receptor Antagonism Clinical Evaluation in Atherosclerosis Add-On

Study Type

Interventional

2. Study Status

Record Verification Date

April 2022

Overall Recruitment Status

Terminated

Why Stopped

The study could not enroll patients owing to the inclusion exclusion criteria

Study Start Date

July 17, 2018 (Actual)

Primary Completion Date

July 23, 2020 (Actual)

Study Completion Date

July 31, 2020 (Actual)

3. Sponsor/Collaborators

Responsible Party, by Official Title

Principal Investigator

Name of the Sponsor

University Hospitals Cleveland Medical Center

Collaborators

Relypsa, Inc.

4. Oversight

Studies a U.S. FDA-regulated Drug Product

Yes

Studies a U.S. FDA-regulated Device Product

Product Manufactured in and Exported from the U.S.

Yes

Data Monitoring Committee

Yes

5. Study Description

Brief Summary

Patiromer add-on to a mineralocorticoid receptor antagonist (MRA) in patients with Type 2 diabetes mellitus and chronic kidney disease (CKD) will reduce blood pressure and left ventricular (LV) mass to a greater extent compared to patients with MRA alone and favorably affect key secondary hemodynamic and inflammatory variables including atherosclerosis progression. Atherosclerosis is the leading cause of morbidity and mortality in Type II diabetes. A cell type called the monocyte/macrophage is critical to development and complications of atherosclerosis. This project will evaluate the effectiveness of a medication called Spironolactone in addition to Patiromer in preventing atherosclerosis in Type II diabetes through its effects on cells such as the monocyte. Spironolactone has been demonstrated to be effective for the treatment of patients after a heart attack and stroke. The investigators will evaluate the impact of Spironolactone in combination with Patiromer in reducing atherosclerosis plaque and additionally evaluate its potential in changing inflammation. The investigators envision that a strategy of simultaneously probing effect of a drug combined with analysis of mechanisms of action and predictive response will likely provide key information with which to design hard event (heart attack, stroke etc.) based trials.

Detailed Description

There is substantial interest in preventing cardiovascular (CV) and renal disease progression in the Type 2 diabetic. Activation of the renin angiotensin aldosterone axis (RAS) and the mineralocorticoid receptor (MR) results in pro-inflammatory effects. Further the phenomenon of aldosterone escape provides a rationale for MR antagonism in addition to an ACEI/ARB agent. Agents that target the renin-angiotensin aldosterone system (RAAS) cascade have shown benefit in Type 2 Diabetics although combined RAS blockade such as using ACEI+ARB or ACEI/ARB+Renin inhibition have met with failure primarily owing to adverse effects such as hypotension and renal failure/hyperkalemia requiring dialysis. It has been speculated that dual RAS blockade or use of ACEI/ARB in conjunction with MRA may potentially be beneficial if one controls hyperkalemia and/or avoid excess hypotension. As a foundation for this current proposal, the investigators have demonstrated an important role for RAAS and MR antagonism in reducing atherosclerosis and inflammation in experimental animal models and limited studies in humans. The investigators are currently testing the efficacy of Spironolactone in reducing atherosclerosis on top of ACEI/ARB in high-risk patients with type 2 diabetes (T2DM) with concomitant CKD as part of a Randomized Double-blind controlled clinical trial. Given the fact that as much as 20-40% of a diabetic patient population with CKD may have problems of hyperkalemia on spironolactone, particularly those already on angiotensin converting enzyme inhibitor (ACEI)/ARB therapy, that would preclude their participation in this trial, the investigators would like to propose an open label supplemental arm to where patients who are ineligible for participation owing to baseline hyperkalemia or hyperkalemia on the dose escalation phase will be eligible to participate in the PRIMARY-Add on trial. The addition of Patiromer will enable introduction of MRA therapy at therapeutic doses and avoidance of hyperkalemia. The investigators thus propose a prospective open label trial with blinded assessment of end-points (PROBE) study which test the relative safety and efficacy of Patiromer on top of Spironolactone in T2DM on LV mass regression and occurrence of hypokalemia (Co-Primary End-points) as well as its effect on 24-hour ambulatory blood pressure (ABP) at 6 weeks, central aortic blood pressure at 6 weeks, atherosclerosis progression at 12 months and measures of monocyte inflammatory potential. If successful, the studies outlined in this proposal will extend the utility of Patiromer in high-risk diabetics at risk for future CV events and provide new information.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study

Type2 Diabetes, Hyperkalemia

7. Study Design

Primary Purpose

Treatment

Study Phase

Phase 4

Interventional Study Model

Single Group Assignment

Model Description

An open label proof-of-concept clinical trial in 50 patients with Type II diabetes evaluating the effects of MRA + Patiromer on LV mass and plaque regression over 12 months of treatment by magnetic resonance imaging (MRI).

Masking

None (Open Label)

Allocation

N/A

Enrollment

8 (Actual)

8. Arms, Groups, and Interventions

Arm Title

Patiromer Add-On

Arm Type

Experimental

Arm Description

Single arm experimental study in 50 diabetic patients with chronic kidney disease and hyperkalemia.

Intervention Type

Drug

Intervention Name(s)

Spironolactone

Other Intervention Name(s)

Veltassa

Intervention Description

The study participants will receive concomitant treatment with Veltassa 8.4 grams per day and Spironolactone 25 mg per day or maximum tolerated dose. If dictated by the potassium level, Veltassa can be increased to 16.8 grams per day.

Primary Outcome Measure Information:

Title

Left Ventricular Mass

Description

Change in left ventricular mass from baseline to 12 months.

Time Frame

Time 0: study baseline, beginning of treatment. Time 1: 12 months follow-up, end of treatment.

10. Eligibility

Sex

All

Minimum Age & Unit of Time

45 Years

Accepts Healthy Volunteers

Eligibility Criteria

Inclusion Criteria Male or female patients >= 45 years and able to provide informed consent (females must be either post-menopausal for one year, surgically sterile, or using effective contraception. Oral contraceptives are disallowed.) Patients with type II diabetes with HbA1c ≤ 9.0 on stable anti-glycemic regimen that may include oral and/or injectable therapy (GLP-1/Insulin etc.). Changes in dose of glycemic regimen is allowed during the course of the trial if felt to be clinically appropriate. Glomerular filtration rate (GFR) <90 and evidence of proteinuria (Urine Albumin/Creatinine Ratio of >30 mg/g or equivalent) in a urine specimen within 12 months OR GFR <60 mg/g regardless of proteinuria Patients must be on angiotensin-converting-enzyme inhibitor (ACE) and/or angiotensin-resistance-blocker (ARB) therapy with no planned dose adjustments. Hyperkalemia defined as serum K+≥ 5.1 meq/L at visit 0 (screening). Exclusion Criteria Uncontrolled hypertension (Systolic Blood Pressure (SBP)>160 and/or Diastolic Blood Pressure (DBP)>95 mmHg at visit 0 (screening) and SBP >145 mm Hg at visit 2). GFR (MDRD) of <20 at visit 0 (screening) Hyperkalemia defined as serum K+ <5.1 meq/L at visit 0 (screening). LDL cholesterol >150 mg/dL Plasma triglycerides > 400 mg/dl Contraindications to MRI (metallic implants, severe claustrophobia). Acute coronary syndrome, Transient ischemic attack, cardiovascular accident (CVA) or critical limb ischemia during the last 6 months or coronary/peripheral revascularization within the last 3 months. Evidence of a secondary form of hypertension. Initiation of new therapy with statins, ACE/ARB, antioxidants, calcium channel blockers (CCBs), diuretics, β blockers. Type I diabetes mellitus Known contraindication, including history of allergy to Spironolactone or Patiromer Any surgical or medical condition which might alter pharmacokinetics of drug (e.g. renal transplant, liver failure, liver transplant) Concurrent potentially life threatening arrhythmia or symptomatic arrhythmia. Significant hyponatremia defined as Na <130 meq/L. History of prior malignancy including leukemia and lymphoma (but not basal cell skin cancer, cured squamous cell cancer and cured prostate cancer). History of any severe, life-threatening disease. Any surgical or medical conditions which place the patient at higher risk derived from his/her participation into the study, or likely to prevent patient from complying with requirements. History of drug abuse within the last 2 years, noncompliance and unwillingness/inability to consent. Pregnant women and nursing mothers Class III or IV Congestive Heart Failure Primary Hyperaldosteronism

Overall Study Officials:

First Name & Middle Initial & Last Name & Degree

Sanjay Rajagopalan, MBBS

Organizational Affiliation

University Hospitals Cleveland Medical Center

Official's Role

Principal Investigator

Facility Information:

Facility Name

University Hospitals Cleveland Medical Center

City

Cleveland

State/Province

Ohio

ZIP/Postal Code

44106

Country

United States

12. IPD Sharing Statement

Plan to Share IPD

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Mineralocorticoid Receptor Antagonism Clinical Evaluation in Atherosclerosis Add-On

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