Clinical Investigation Into Inhaled Treprostinil Sodium in Patients With Severe Pulmonary Arterial Hypertension (PAH) (TRIUMPH)

TRIUMPH I: Double Blind Placebo Controlled Clinical Investigation Into the Efficacy and Tolerability of Inhaled Treprostinil Sodium in Patients With Severe Pulmonary Arterial Hypertension

This is a double-blind placebo-controlled clinical investigation into the efficacy and tolerability of inhaled treprostinil in patients with severe pulmonary arterial hypertension. The primary outcome is the change in 6-minute walk distance from baseline to week 12.

Study Overview

• Status: Completed
• Conditions: Pulmonary Hypertension
• Intervention / Treatment: Drug: Inhaled treprostinil; Drug: Placebo inhalation solution

Detailed Description

Patients who have been on a stable dose of 125 mg twice daily (bid) of bosentan or any stable dose of sildenafil for at least three months prior to study start were randomized to either treprostinil inhalation solution or matching placebo.

Administration of study medication was performed by inhalation with the OPTINEB™ ultrasonic nebulizer.

The proposed dosing regimen was four times daily-upon awakening, at midday, evening (dinner time) and bedtime.

After a patient has completed the twelve-week study period, they were given the option of enrolling into an open-label extension study.

• Study Type: Interventional
• Enrollment (Actual): 235
• Phase: Phase 3

Contacts and Locations

Study Locations

• Austria
  • Graz, Austria
    • Medical University Graz
  • Vienna
    • Wein, Vienna, Austria, 1090
      • Universitatsklinikfur Innere Medizin II
• Belgium
  • Brussels, Belgium, 1070
    • Université libre de Bruxelles
  • Leuven, Belgium
    • University Hospital Gasthuisburg
• France
  • Paris, France, 92141
    • Hospital Antoine Beclere
• Germany
  • Geissen, Germany, D-35392
    • Univesitatsklinikum Giessen und Marburg GmbH
• Ireland
  • Dublin 7, Ireland
    • Pulmonary Hypertension Unit
• Israel
  • Haifa, Israel, 31096
    • Rambam Medical Center
  • Jerusalem 91120, Israel
    • The Pulmonary Institute
  • Petach Tikvah 49100, Israel
    • The Pulmonary Institute
• Italy
  • Bologna, Italy
    • Instituto Malattie dell'Apparato Vascolare
• Spain
  • Barcelona, Spain, 08036
    • University of Barcelona
• United Kingdom
  • Cambridge, United Kingdom, CB3 8RE
    • Papworth Hospital
  • Glasgow GII 6NT, United Kingdom
    • Scottish Pulmonary Vascular Unit
  • London, United Kingdom
    • Royal Fee Hospital
• United States
  • Alabama
    • Birmingham, Alabama, United States, 35294-0006
      • University of Alabama
  • Arizona
    • Tucson, Arizona, United States, 85724
      • University of Arizona
  • California
    • La Jolla, California, United States, 92037
      • UCSD Medical Center
    • Torrance, California, United States, 90502
      • UCLA Medical Center
  • Colorado
    • Aurora, Colorado, United States, 80045
      • University of Colorado
  • Florida
    • Orlando, Florida, United States, 32806
      • Orlando Heart Center
  • Kansas
    • Kansas City, Kansas, United States, 66160
      • Kansas University Medical Center
  • Maryland
    • Baltimore, Maryland, United States, 21205
      • Johns Hopkins University
  • Massachusetts
    • Boston, Massachusetts, United States, 02111
      • Tufts Medical Center
  • Michigan
    • Ann Arbor, Michigan, United States, 48109-5853
      • University of Michigan
  • New York
    • New York, New York, United States, 10003
      • Bethe Israel Medical Center
  • North Carolina
    • Durham, North Carolina, United States, 27710
      • Duke University Medical Center
  • Pennsylvania
    • Pittsburgh, Pennsylvania, United States, 15212
      • Allegheny General Hospital
  • Tennessee
    • Nashville, Tennessee, United States, 37232-2650
      • Vanderbilt University Medical Center
  • Texas
    • Dallas, Texas, United States, 75235
      • UTSW Medical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 75 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Clinically stable, pulmonary arterial hypertension diagnosed as either idiopathic or familial PAH, collagen vascular disease associated PAH, HIV PAH, or PAH induced by anorexigens, New York Heart Association (NYHA) Class III or Class IV.
• Been on a stable dose of 125 mg twice daily (bid) of bosentan OR any stable dose of sildenafil for at least three months prior to study start
• An unencouraged six minute walk test (6MWT) of between 200 and 450 meters at screening
• Cardiac catheterization within the past 13 months consistent with PAH, specifically mean pulmonary artery pressure (PAPm) ≥25 mmHg (at rest), pulmonary capillary wedge pressure (PCWP) (or left ventricular end diastolic pressure) ≤15 mmHg, and pulmonary vascular resistance (PVR) >3 mmHg/L/min
• Within the past 12 months, patients must have had a chest radiograph consistent with the diagnosis of PAH
• Willing and able to follow all study procedures

Exclusion Criteria:

• Considering pregnancy, are pregnant and/or lactating
• PAH due to conditions other than noted in the above inclusion criteria.
• Have had any change in or discontinued any PAH medication within the last three months, including but not limited to endothelin receptor antagonist (ERA), or calcium channel blockers (CCB) (with the exception of anticoagulants)
• Have received any prostanoid within the 30 days before screening or are scheduled to receive any during the course of the study
• Have received any investigational medication within 30 days prior to the start of this study or are scheduled to receive another investigational drug during the course of this study
• Have a known intolerance to any drug, especially to treprostinil sodium or prostanoids
• Have an increased risk of hemorrhage
• Have a new type of chronic therapy (e.g., a different category of vasodilator, diuretic) for PAH added within the last month, except anticoagulants
• Have any musculoskeletal disease or any other disease that would limit ambulation.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Inhaled treprostinil; 0.9 mg/mL treprostinil for inhalation supplied in 2.9mL ampoules for use in ultra sonic nebulizer	Drug: Inhaled treprostinil; Doses are titrated to 9 breaths four times daily. Each breath produces an 18 mcg dose of inhaled treprostinil.; Other Names: Tyvaso
Placebo Comparator: Placebo; Placebo inhalation solution for use in ultrasonic nebulizer	Drug: Placebo inhalation solution; Doses are titrated to 9 breaths four times daily.; Other Names: Placebo

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Peak 6-minute Walk Distance	Change in peak 6-minute walk distance from baseline to Week 12. Peak 6MWD was defined as a 6-minute walk test (6MWT) within 10 to 60 minutes after study drug inhalation	12 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Clinical Worsening Events	Clinical worsening was defined as the first incidence of clinical worsening from randomization to the first occurrence of death, transplantation, hospitalization for PAH, or initiation of additional approved PAH therapy.	12 weeks
Borg Dyspnea Score	The Borg dyspnea score is a patient reported number between 0 (no perceived shortness of breath) and 10 (maximum perceived shortness of breath), obtained at the completion of each 6MWT.	12 weeks
New York Heart Association (NYHA) Functional Classification	Change in NYHA functional class at Week 12. NYHA classifications: Class I - Patients with pulmonary hypertension but without resulting limitation of physical activity. Ordinary physical activity does not cause undue dyspnea or fatigue, chest pain or near syncope. Class II - Patients with pulmonary hypertension resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity causes undue dyspnea or fatigue, chest pain or near syncope. Class III - Patients with pulmonary hypertension resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes undue dyspnea or fatigue, chest pain or near syncope. Class IV - Patients with pulmonary hypertension in the inability to carry out any physical activity without symptoms. These patients manifest signs of right heart failure. Dyspnea and/or fatigue may even be present at rest. Discomfort is increased by any physical activity.	12 weeks
Trough 6MWD at Week 12	Change in 6MWD from Baseline to trough 6MWD at Week 12. Trough was defined as a 6MWT conducted at least 4 hours following study drug inhalation.	12 Weeks
Peak 6MWD at Week 6	Change in peak 6MWD between Baseline and Week 6.	6 weeks
Quality of Life (Minnesota Living With Heart Failure)	Quality of life as measured by the Minnesota Living With Heart Failure (MLWHF) questionnaire was evaluated at baseline and at Week 12. The MLWHF questionnaire consists of 21 questions assessing how the patient's heart failure has prevented them from living the way they wanted during the defined time period. Each question was graded by the patient with a numeric value between 0 (No/none) and 5 (very much). These scores were then summed across the 21 questions for a Global Score. Global scores ranged from 0 to 105. These questions were further grouped into Physical (8 of the questions) and Emotional (5 of the questions) dimensions to further characterize the effect of heart failure on the patient's life. Physical scores ranged from 0 to 40, and emotional scores ranged from 0 to 25. For all 3 categories, the lower the score, the better the outcome. Values presented as change from Baseline.	12 weeks
Change in Signs and Symptoms of PAH	Signs and symptoms of PAH (Loud P2 sound, Ascites, Right ventricular S3 sound, Dyspnea, Right ventricular S4 sound, Orthopnea, Right ventricular heave, Dizziness, Murmur of tricuspid insufficiency, Syncope, Murmur of pulmonic insufficiency, Chest pain, Hepatomegaly, Palpitations, Jugular venous distension at 45 degrees, Fatigue, Edema) were assessed at Baseline and Week 12. The status of each sign and symptom ("absent" or "present") was assessed at each visit. To assess overall change from baseline in signs and symptoms, a "1" was assigned for each sign and symptom that was "present" at the Week 12 but was "absent" at baseline, a "-1" was assigned for each sign and symptom that was "absent" at Week 12 but was "present" at baseline, and a "0" was assigned for no change. An overall change score at each post-baseline assessment was then calculated by summing these values for all signs and symptoms. The overall change score had the potential to range from -17 to 17.	12 weeks
N-terminal Pro-B-Type Natriuretic Peptide (NT Pro-BNP)	Change in NT pro-BNP from Baseline to Week 12. Plasma samples were collected from patients at Baseline and Week 12 in order to measure any change over time in circulating plasma levels of this biomarker.	12 weeks

Collaborators and Investigators

• Sponsor: United Therapeutics

Publications and helpful links

General Publications

• McLaughlin VV, Benza RL, Rubin LJ, Channick RN, Voswinckel R, Tapson VF, Robbins IM, Olschewski H, Rubenfire M, Seeger W. Addition of inhaled treprostinil to oral therapy for pulmonary arterial hypertension: a randomized controlled clinical trial. J Am Coll Cardiol. 2010 May 4;55(18):1915-22. doi: 10.1016/j.jacc.2010.01.027.

Helpful Links

• The mission of the Pulmonary Hypertension Association is to seek a cure, and to provide hope, support and education, and to promote awareness and to advocate for the pulmonary hypertension community.

Study record dates

Study Major Dates

• Study Start: June 1, 2005
• Primary Completion (Actual): October 1, 2007
• Study Completion (Actual): October 1, 2007

Study Registration Dates

• First Submitted: September 2, 2005
• First Submitted That Met QC Criteria: September 2, 2005
• First Posted (Estimated): September 7, 2005

Study Record Updates

• Last Update Posted (Actual): January 2, 2024
• Last Update Submitted That Met QC Criteria: December 12, 2023
• Last Verified: July 1, 2013

More Information

Terms related to this study

• Keywords: Pulmonary Arterial Hypertension
• Additional Relevant MeSH Terms: Cardiovascular Diseases; Vascular Diseases; Respiratory Tract Diseases; Lung Diseases; Hypertension; Pulmonary Arterial Hypertension; Hypertension, Pulmonary; Antihypertensive Agents; Treprostinil
• Other Study ID Numbers: LRX-TRIUMPH 001