HFrEF Polypill in Sri Lanka RCT
Heart Failure With Reduced Ejection Fraction Polypill in Sri Lanka: A Multi-Center Type I Hybrid Randomized Controlled Trial
The aim of this study is to evaluate, in adults with HFrEF in Sri Lanka, the effects of an HFrEF polypill implementation strategy on the composite rate of cardiovascular disease mortality and recurrent heart failure hospitalizations, compared with usual care over a minimum of 12-months of follow-up.
Primary outcome of the study:
1) Composite rate of cardiovascular disease mortality and recurrent heart failure hospitalizations over study duration
Secondary outcomes of the study:
- Rate of cardiovascular disease mortality over study duration
- Rate of recurrent heart failure hospitalizations over the study duration
- Rate of all-cause mortality over the study duration
- Change in left ventricular ejection fraction at 12-months and end of study assessed by transthoracic echocardiogram
- Change in BNP levels at 12 months and end of study
- Change in overall and domain specific health-related quality of life at 12-months and end of study assessed by a translated validated version of the Kansas City Cardiomyopathy Questionnaire (KCCQ-23)
- Change in physician-reported New York Heart Association class at 12-months and end of study
- Adherence to guideline-directed medical therapy assessed by pill count and MARS-5 questionnaire at baseline, 1-, 6-, 12-months, and end of study. Persistence assessed as continuation of assigned therapy at each follow-up visit. Dose optimization assessed as proportion achieving target doses (Strength 3 of the polypill, or comparable individual GDMT doses in the comparator arm) at 6-, 12-months, and end of study.
Safety outcomes:
- Proportion of participants with serious adverse events according to Good Clinical Practice guidelines over study duration
- Proportion of participants with adverse events of special interest over study duration
- Proportion of participants with adverse events leading to HF drug discontinuation over study duration
- Mean change from baseline to 12-months and end of study in serum potassium (mEq/L)
- Mean change from baseline to 12-months and end of study in serum creatinine (mg/dL)
Participants will be randomly assigned 1:1 stratified by sex and site to one of two groups, intervention (experimental arm) or usual care (control arm). The intervention group will be given four guideline-recommended medications for heart failure with reduced ejection fraction, combined in one over-encapsulated pill, with three dose strength options. Both groups will be observed over a minimum of 12-months of follow-up to assess key outcomes.
Study Overview
Status
Status
Conditions
Conditions
Intervention / Treatment
Intervention / Treatment
Detailed Description
The study intervention will be a heart failure with reduced ejection fraction (HFrEF) polypill consisting of bisoprolol (beta-blocker), losartan (ARB), eplerenone (MRA), and dapagliflozin (SGLT2i) manufactured using the over-encapsulation method and will undergo extensive stability testing to ensure quality. There will be 3 strengths of the HFrEF polypill available to facilitate initiation with low dose to prioritize clinical tolerability and laboratory safety and titration to higher doses of the HFrEF polypill. The dose of initiation and titration will be at the investigator's discretion. The HFrEF polypill will be delivered by licensed physicians responsible for managing heart failure at participating sites. Eligible providers must have formal medical qualifications in Sri Lanka and be actively involved in the care of patients with HFrEF. This includes cardiologists, internists, or general practitioners with experience in heart failure management. All participating physicians will receive standardized training on the study protocol including titration protocol, HFrEF polypill composition, and guidance for patient counseling prior to trial initiation to ensure consistent and accurate delivery of the intervention. Participants receiving the HFrEF polypill will also receive a "HFrEF polypill card" that delineates the drugs and doses included in the HFrEF polypill combination and contact information for the local study team in case of hospitalization at another facility.
HFrEF polypill combinations by strength:
HFrEF polypill strength 1: bisoprolol 2.5 mg + losartan 25 mg + eplerenone 25 mg + dapagliflozin 10 mg HFrEF polypill strength 2: bisoprolol 5 mg + losartan 50 mg + eplerenone 25 mg + dapagliflozin 10 mg HFrEF polypill strength 3: bisoprolol 10 mg + losartan 100 + eplerenone 50 mg + dapagliflozin 10 mg
Participants in the comparator control group will receive usual care from their healthcare providers. Providers will be encouraged to treat all participants according to international and local clinical practice guidelines. Participants in the intervention group will be provided with the HFrEF polypill by the study, and participants in the control group will be provided HFrEF medications through the pharmacy at the public hospital site(s) in Sri Lanka where they are generally free of cost.
Study Type
Study Type
Enrollment (Estimated)
Enrollment
Phase
Phase
- Phase 3
Contacts and Locations
Study Contact
Study Contact
- Name: Anubha Agarwal, MD MSc
- Phone Number: +1 314-362-1291
- Email: anubha@wustl.edu
Study Contact Backup
- Name: Asita de Silva, MBBS DPhil FRCP
- Phone Number: +94 11 2961241
- Email: asita@kln.ac.lk
Study Locations
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Central Province
-
Kandy, Central Province, Sri Lanka, 20000
- Recruiting
- National Hospital Kandy
-
Contact:
- Gnanamoorthy Mayurathan
- Phone Number: +94 812 222 261
- Email: gkmayurathan@yahoo.com
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Sub-Investigator:
- Zanoona Siddeek
-
-
North Western Province
-
Kurunegala, North Western Province, Sri Lanka, 60000
- Not yet recruiting
- Teaching Hospital Kurunegala
-
Contact:
- Thusitha Wijethunga
- Phone Number: +94 372 222 261
- Email: tjwijethunga@gmail.com
-
Sub-Investigator:
- Aruna Jayawarna
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Northern Province
-
Jaffna, Northern Province, Sri Lanka, 40000
- Recruiting
- Teaching Hospital Jaffna
-
Contact:
- Poopalan Lakshman
- Phone Number: +94 212 223 348
- Email: drplcc7@gmail.com
-
Sub-Investigator:
- Thepana Sasiharan
-
Sub-Investigator:
- Sebastian Heavenly
-
-
Ratnapura
-
Colombo, Ratnapura, Sri Lanka, 70000
- Not yet recruiting
- Rathnapura Teaching Hospital
-
Contact:
- Chinthaka Hathlahawatta
- Phone Number: +94 718036938
- Email: chinthaka.hat@gmail.com
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-
Southern Province
-
Galle, Southern Province, Sri Lanka, 80000
- Recruiting
- National Hospital Galle
-
Contact:
- Sandamali Premaratne
- Phone Number: +94 912 232 267
- Email: sandamali.premaratne@gmail.com
-
Sub-Investigator:
- Piumi Rajawardhana
-
Sub-Investigator:
- T.G Sandamali
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-
Western Province
-
Colombo, Western Province, Sri Lanka, 00100
- Not yet recruiting
- National Hospital of Sri Lanka
-
Contact:
- Gamini Galappatthy
- Phone Number: +94 112 691 111
- Email: gamini_galappatthy@hotmail.com
-
Sub-Investigator:
- Chandrike Ponnamperuma
-
Sub-Investigator:
- Thisal Semina
-
Sub-Investigator:
- Tanya Pereira
-
Sub-Investigator:
- Neranja Weerakoon
-
Sub-Investigator:
- Chandana Wijesingha
-
Sub-Investigator:
- Bhathiya Ranasinghe
-
Colombo, Western Province, Sri Lanka, 10290
- Not yet recruiting
- University Hospital - General Sir John Kotelawala Defence University
-
Contact:
- Namal Wijesinghe
- Phone Number: +94 112044555
- Email: namalw@gmail.com
-
Sub-Investigator:
- Subash Karunarathna
-
Sub-Investigator:
- Sandali Wijewardena
-
Sub-Investigator:
- Gishara Hemachandra
-
Sub-Investigator:
- Sashini Amarasinghe
-
Dehiwala, Western Province, Sri Lanka, 10350
- Recruiting
- Colombo South Teaching Hospital
-
Contact:
- M. B. F. Rahuman
- Phone Number: +94 112 832 950
- Email: faslurcard@yahoo.com
-
Sub-Investigator:
- Geethani Gunasekara
-
Gampaha, Western Province, Sri Lanka, 11000
- Not yet recruiting
- Gampaha District General Hospital
-
Contact:
- Suneth Karunarathne
- Phone Number: 94 332 222 261
- Email: suneth87@gmail.com
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Negombo, Western Province, Sri Lanka, 11500
- Not yet recruiting
- District General Hospital Negombo
-
Contact:
- Ajith Wanniarachchi
- Phone Number: +94 312 222 261
- Email: ajithwap@gmail.com
-
Sub-Investigator:
- Anusha de Silva
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Ragama, Western Province, Sri Lanka, 11010
- Recruiting
- Colombo North Teaching Hospital
-
Contact:
- Sanjeewa Rajapakse
- Phone Number: +94 11 2959261-4
- Email: sanjeewargs@yahoo.com
-
Sub-Investigator:
- Thushari Gunawardana
-
Sub-Investigator:
- Sinthi Sivarajah
-
Sub-Investigator:
- Anjalee Weerasuriya
-
-
Participation Criteria
Eligibility Criteria
Eligibility Criteria
Ages Eligible for Study
- Adult
- Older Adult
Accepts Healthy Volunteers
Description
Inclusion Criteria:
- Adults (≥18 years old)
- Diagnosis of heart failure with reduced ejection fraction (HFrEF) including clinical symptoms or clinical signs or natriuretic peptide elevation AND echocardiographic or other evidence of reduced left ventricular ejection fraction (EF ≤40%)
- New York Heart Association Class II, III, or IV symptoms
Exclusion Criteria:
- Known contraindication to any of the HFrEF polypill components (e.g., advanced renal disease, bradycardia, allergy, amongst others).
- Significant renal impairment (estimated glomerular filtration rate <30 mL/min/1.73 m2).
- Raised serum potassium >5 mEq/L.
- Symptomatic hypotension or systolic BP <100 mmHg as per the average of last 2 of the 3 measurements at visit 1.
- Symptomatic bradycardia or second or third-degree heart block without a pacemaker on ECG review at visit 1.
- History of type 1 diabetes mellitus.
- Women who are pregnant, breastfeeding or of childbearing potential and are not using and do not plan to continue using a highly acceptable form of contraception throughout the study (pharmacological or barrier methods).
- Concomitant illness, physical impairment or mental condition which in the opinion of the study team/ primary physician could interfere with the conduct of the study including outcome assessment.
- Participation in a concurrent interventional medical investigation or pharmacologic clinical trial. Patients in observational, natural history or epidemiological studies not involving an intervention are eligible.
- Participant's responsible physician believes it is not appropriate for participant to participate in the study.
- Inability or unwillingness to provide written informed consent.
- Involvement in the planning and/or conduct of the study.
- Unable to complete study procedures and/or plan to move out of the study site area in the next 12 months.
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Single
Number of Arms
Arms and Interventions
Participant Group / ArmParticipant Group / Arm |
Intervention / TreatmentIntervention / Treatment |
|---|---|
|
Active Comparator: Usual Care
Participants in the comparator control group will receive usual care from their healthcare providers.
Providers will be encouraged to treat all participants according to international and local clinical practice guidelines.
Participants will receive their HFrEF medications through the pharmacy at the sites, where guideline-directed medical therapy are dispensed without charge to participants when available on the public hospital formulary.
|
Participants in the comparator control group will receive usual care from their healthcare providers.
Providers will be encouraged to treat all participants according to international and local clinical practice guidelines.
Participants will receive their HFrEF medications through the pharmacy at the sites, where guideline-directed medical therapy are dispensed without charge to participants when available on the public hospital formulary.
|
|
Experimental: HFrEF Polypill
The study intervention is a HFrEF polypill consisting of bisoprolol (beta-blocker), losartan (ARB), eplerenone (MRA), and dapagliflozin (SGLT2i) manufactured using the over-encapsulation method. There will be 3 strengths of the HFrEF polypill available: Strength 1: bisoprolol 2.5 mg + losartan 25 mg + eplerenone 25 mg + dapagliflozin 10 mg Strength 2: bisoprolol 5 mg + losartan 50 mg + eplerenone 25 mg + dapagliflozin 10 mg Strength 3: bisoprolol 10 mg + losartan 100 mg + eplerenone 50 mg + dapagliflozin 10 mg Every intervention participant will be established on the highest tolerated strength of the HFrEF polypill, with Strength 3 as the target dose. Following initiation at the strength matched to the participant's background guideline-directed medical therapy, the polypill strength will be advanced by one level at each scheduled study visit aligned with the initiation and titration protocol. |
The study intervention is a HFrEF polypill consisting of bisoprolol (beta-blocker), losartan (ARB), eplerenone (MRA), and dapagliflozin (SGLT2i) manufactured using the over-encapsulation method.
There will be 3 strengths of the HFrEF polypill available: Strength 1: bisoprolol 2.5 mg + losartan 25 mg + eplerenone 25 mg + dapagliflozin 10 mg Strength 2: bisoprolol 5 mg + losartan 50 mg + eplerenone 25 mg + dapagliflozin 10 mg Strength 3: bisoprolol 10 mg + losartan 100 mg + eplerenone 50 mg + dapagliflozin 10 mg.
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What is the study measuring?
Primary Outcome Measures
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
|
Composite rate of cardiovascular disease mortality and recurrent heart failure hospitalizations over study duration
Time Frame: 1 month, 3 month, 6 month, 9 month, 12 month study visits, and every 3 months thereafter through study completion, an average of 18 months.
|
Cardiovascular disease mortality is defined as death due to acute myocardial infarction, worsening heart failure, stroke, sudden cardiac death, arrhythmia, pulmonary embolism, cardiovascular procedures or their complications, other vascular causes, or any death of unknown cause unless a non-cardiovascular etiology is clearly established. HF hospitalization is defined as any unplanned hospitalization for at least 24 hours, for which the primary cause is heart failure, accompanied by objective evidence of decompensation and requiring initiation or intensification of HF-specific therapy, occurring after a documented period of clinical stability of at least 12 hours since the prior HF event. Adjudicated by the blinded Outcome Adjudication Committee. |
1 month, 3 month, 6 month, 9 month, 12 month study visits, and every 3 months thereafter through study completion, an average of 18 months.
|
Secondary Outcome Measures
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
|
Rate of cardiovascular disease mortality over study duration
Time Frame: 1 month, 3 month, 6 month, 9 month, 12 month study visits, and every 3 months thereafter, through study completion, an average of 18 months.
|
Cardiovascular disease mortality is defined as death due to acute myocardial infarction, worsening heart failure, stroke, sudden cardiac death, arrhythmia, pulmonary embolism, cardiovascular procedures or their complications, other vascular causes, or any death of unknown cause unless a non-cardiovascular etiology is clearly established. Adjudicated by the blinded Outcome Adjudication Committee. |
1 month, 3 month, 6 month, 9 month, 12 month study visits, and every 3 months thereafter, through study completion, an average of 18 months.
|
|
Rate of recurrent heart failure hospitalizations over the study duration
Time Frame: 1 month, 3 month, 6 month, 9 month, 12 month visit, and thereafter every 3 months, through study completion, an average of 18 months.
|
HF hospitalization is defined as any unplanned hospitalization for at least 24 hours, for which the primary cause is heart failure, accompanied by objective evidence of decompensation and requiring initiation or intensification of HF-specific therapy, occurring after a documented period of clinical stability of at least 12 hours since the prior HF event. Adjudicated by the blinded Outcome Adjudication Committee. |
1 month, 3 month, 6 month, 9 month, 12 month visit, and thereafter every 3 months, through study completion, an average of 18 months.
|
|
Rate of all-cause mortality over the study duration
Time Frame: 1 month, 3 month, 6 month, 9 month, 12 month visit, and thereafter every 3 months, through study completion, an average of 18 months.
|
All-cause mortality is defined as death due to any cause.
|
1 month, 3 month, 6 month, 9 month, 12 month visit, and thereafter every 3 months, through study completion, an average of 18 months.
|
|
Change in left ventricular ejection fraction at 12-months and end of study assessed by transthoracic echocardiogram
Time Frame: Baseline, 12 months, and at study completion, an average of 18 months.
|
Baseline, 12 months, and at study completion, an average of 18 months.
|
|
|
Change in BNP levels at 12 months and end of study
Time Frame: Baseline, 12 months, and at study completion, an average of 18 months.
|
Baseline, 12 months, and at study completion, an average of 18 months.
|
|
|
Change in overall and domain specific health-related quality of life at 12-months and end of study
Time Frame: Baseline, 12 months, and at study completion, an average of 18 months.
|
Health-related quality of life (HRQoL) will be assessed by a translated validated Kansas City Cardiomyopathy Questionnaire-23 (KCCQ-23)
|
Baseline, 12 months, and at study completion, an average of 18 months.
|
|
Change in physician-reported New York Heart Association class at 12-months and end of study
Time Frame: Baseline, 12 months, and at study completion, an average of 18 months.
|
Baseline, 12 months, and at study completion, an average of 18 months.
|
|
|
Adherence to guideline-directed medical therapy, persistence and dose optimization
Time Frame: Baseline, 1, 6, 12 months, and at study completion, an average of 18 months
|
Adherence to guideline-directed medical therapy assessed by pill count and MARS-5 questionnaire. Persistence assessed as continuation of assigned therapy at each follow-up visit. Dose optimization assessed as proportion achieving target doses (Strength 3 of the polypill, or comparable individual GDMT doses in the comparator arm) at 6-, 12-months, and end of study. |
Baseline, 1, 6, 12 months, and at study completion, an average of 18 months
|
Other Outcome Measures
Other Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
|
Proportion of participants with serious adverse events according to Good Clinical Practice guidelines over study duration
Time Frame: 1 month, 3 month, 6 month, 9 month, 12 month visit, and thereafter every 3 months, through study completion, an average of 18 months.
|
Proportion of participants with serious adverse events according to Good Clinical Practice (GCP) guidelines (ICH E6 [R3]) over the study duration.
|
1 month, 3 month, 6 month, 9 month, 12 month visit, and thereafter every 3 months, through study completion, an average of 18 months.
|
|
Proportion of participants with adverse events of special interest over study duration
Time Frame: 1 month, 3 month, 6 month, 9 month, 12 month visit, and thereafter every 3 months, through study completion, an average of 18 months.
|
Adverse events of special interest:
|
1 month, 3 month, 6 month, 9 month, 12 month visit, and thereafter every 3 months, through study completion, an average of 18 months.
|
|
Proportion of participants with adverse events leading to HF drug discontinuation over study duration
Time Frame: 1 month, 3 month, 6 month, 9 month, 12 month visit, and thereafter every 3 months, through study completion, an average of 18 months.
|
1 month, 3 month, 6 month, 9 month, 12 month visit, and thereafter every 3 months, through study completion, an average of 18 months.
|
|
|
Mean change from baseline to 12-months and end of study in serum potassium (mEq/L)
Time Frame: Baseline, 1 month, 3 months, 6 months, 9 months, 12 months, and at study completion, an average of 18 months.
|
Baseline, 1 month, 3 months, 6 months, 9 months, 12 months, and at study completion, an average of 18 months.
|
|
|
Mean change from baseline to 12-months and end of study in serum creatinine (mg/dL)
Time Frame: Baseline, 1 month, 3 months, 6 months, 9 months, 12 months, and at study completion, an average of 18 months.
|
Baseline, 1 month, 3 months, 6 months, 9 months, 12 months, and at study completion, an average of 18 months.
|
Collaborators and Investigators
Sponsor
Sponsor
Collaborators
Collaborators
Publications and helpful links
Study record dates
Study Major Dates
Study Start (Actual)
Study Start
Primary Completion (Estimated)
Primary Completion
Study Completion (Estimated)
Study Completion
Study Registration Dates
First Submitted
First Submitted
First Submitted That Met QC Criteria
First Submitted That Met QC Criteria
First Posted (Actual)
First Posted
Study Record Updates
Last Update Posted (Actual)
Last Update Posted
Last Update Submitted That Met QC Criteria
Last Update Submitted That Met QC Criteria
Last Verified
Last Verified
More Information
Terms related to this study
Keywords
Additional Relevant MeSH Terms
Other Study ID Numbers
Other Study ID Numbers
- 202605087
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
IPD Plan Description
IPD Sharing Time Frame
IPD Sharing Access Criteria
IPD Sharing Supporting Information Type
- STUDY_PROTOCOL
- SAP
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
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