UMPIRE - Use of a Multidrug Pill In Reducing Cardiovascular Events (UMPIRE)

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.

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.

Study Overview

• Status: Completed
• Conditions: Cardiovascular Diseases
• Intervention / Treatment: Drug: polypill; Drug: Usual cardiovascular medications

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.

• Study Type: Interventional
• Enrollment (Actual): 2004
• Phase: Phase 3

Contacts and Locations

Study Locations

• Australia
  • New South Wales
    • Sydney, New South Wales, Australia, 2050
      • George Institute Australia
• India
  • Hyderabad, India, 500033
    • George Institute for International Health - India
  • New Dehli, India, 110049
    • Public Health Foundation of India
  • New Delhi, India, 110016
    • Centre for Chronic Disease Control
• Ireland
  • Dublin, Ireland, Dublin 9
    • Royal College of Surgeons in Ireland Research Institute
• Netherlands
  • Heidelberglaan 100
    • Utrecht, Heidelberglaan 100, Netherlands, 3584 CX
      • University Medical Center Utrecht
• United Kingdom
  • London
    • Paddington, London, United Kingdom, W2 1LA
      • Clinical Investigation Unit, International Centre for Circulatory Health, Imperial College London

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

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).

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: polypill; Red Heart Pill Version 1 and Red Heart Pill Version 2. In general, participants with a history of coronary heart disease will be given version 1, and those with a history of stroke or cerebrovascular disease will be given version 2.	Drug: polypill; The polypill will be taken once/day in the form of a hard capsule, to be taken orally. There are two versions of the polypill (Red Heart Pill): Version 1 contains aspirin 75mg, simvastatin 40mg, Lisinopril 10mg and Atenolol 50mg; Version 2 contains aspirin 75mg, simvastatin 40mg, Lisinopril 10mg and Hydrochlorothiazide 12.5mg.; Other Names: Red Heart Pill
Active Comparator: Usual Care; Participants in the usual care arm will take their usual cardiovascular medications. The participants will be seen as needed by their usual doctor between study visits.	Drug: Usual cardiovascular medications; Participants in the 'Usual Care' arm will continue to take the separate, individual medications prescribed by their usual doctor, e.g. aspirin, blood pressure lowering drugs, statins.; Other Names: Usual cardiovascular disease prevention medication

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Adherence to medication; self-reported current use of antiplatelet, statin and combination (≥ 2) blood pressure lowering therapy	End of trial follow-up
Change in blood pressure	End of trial follow-up
Change in LDL cholesterol	End of trial follow-up

Secondary Outcome Measures

Outcome Measure	Time Frame
Self reported current use of antiplatelet, statin and combination (>2) blood pressure lowering therapy	12 months
Reasons for stopping cardiovascular medications	Throughout trial
Serious adverse events	Throughout trial
New onset cardiovascular events	Throughout trial
Participant 'Quality of Life' assessment	At 12 months and end of trial
Changes in total cholesterol and other lipid fractions (HDL-cholesterol, triglycerides)	12 months and end of trial

Collaborators and Investigators

• Sponsor: Imperial College London
• Collaborators: UMC Utrecht; Dr. Reddy's Laboratories Limited; Royal College of Surgeons, Ireland; Public Health Foundation of India; European Commission; Imperial College Healthcare NHS Trust; The George Institute
• Investigators: Study Director: Simon A McG Thom, MD, FRCP, Imperial College London; Principal Investigator: Neil Poulter, Imperial College London; Principal Investigator: Anushka Patel, The George Institute, India; Principal Investigator: Dorairaj Prabhakaran, Centre for Chronic Disease Control; Principal Investigator: Diederick Grobbee, UMC Utrecht; Principal Investigator: Anthony Rodgers, The George Institute, Australia; Principal Investigator: Raghu Cidambi, Dr. Reddy's Laboratories Limited; Principal Investigator: K Srinath Reddy, Public Health Foundation of India

Publications and helpful links

General Publications

• 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.
• 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. Erratum In: JAMA. 2013 Oct 9;310(14):1507. Naik, Nitish [added]; Reddy, Srinivas [added]; Balaji, Sham [corrected to Achuthan, Shyambalaji]; Damodra Rao, Modem [corrected to Damodra Rao, Kodem].

Helpful Links

• Single Pill to Avert Cardiovascular Events (SPACE) website for multinational polypill (RHP) trials

Study record dates

Study Major Dates

• Study Start: June 1, 2010
• Primary Completion (Actual): July 1, 2012
• Study Completion (Actual): September 1, 2012

Study Registration Dates

• First Submitted: January 26, 2010
• First Submitted That Met QC Criteria: January 26, 2010
• First Posted (Estimate): January 27, 2010

Study Record Updates

• Last Update Posted (Estimate): November 27, 2012
• Last Update Submitted That Met QC Criteria: November 26, 2012
• Last Verified: November 1, 2012

More Information

Terms related to this study

• Keywords: Cardiovascular disease; Adherence; Secondary prevention; Polypill; Red Heart Pill
• Additional Relevant MeSH Terms: Cardiovascular Diseases
• Other Study ID Numbers: 241849; 2009-016278-34 (EudraCT Number)