Atorvastatin Treatment of Cavernous Angiomas With Symptomatic Hemorrhage Exploratory Proof of Concept (AT CASH EPOC) Trial (AT CASH EPOC)

Phase I-II Randomized, Placebo-Controlled, Single-Blinded, Single-Site Clinical Trial of Atorvastatin in the Treatment of Cavernous Angiomas With Symptomatic Hemorrhage Exploratory Proof of Concept (AT CASH EPOC)

This phase I/II randomized, placebo-controlled, double-blinded, single-site clinical trial is designed to investigate the effect of a prolonged course of atorvastatin versus placebo on CCM lesional iron deposition assessed by validated quantitative susceptibility mapping (QSM) MRI studies in patients who suffered a symptomatic bleed within the preceding one year.

Study Overview

• Status: Active, not recruiting
• Conditions: Cerebral Cavernous Malformation
• Intervention / Treatment: Drug: Atorvastatin; Other: Placebo

Detailed Description

This phase I/II randomized, placebo-controlled, double-blinded, single-site clinical trial is designed to investigate the effect of a prolonged course of atorvastatin versus placebo on CCM lesional iron deposition assessed by validated quantitative susceptibility mapping (QSM) MRI studies in patients who suffered a symptomatic bleed within the preceding one year. Subjects will also be assessed by lesional and brain vascular permeability MRI using dynamic contrast enhanced quantitative perfusion (DCEQP) and a number of clinical evaluation tools. Subjects shall be followed for 2 years from randomization, the period of highest likelihood of rebleed after a recent CCM hemorrhage. Subjects will undergo clinical and MRI evaluations at baseline, and at 12 and 24 months during the study period. Enrolled subjects and the treating team will be blinded to treatment group allocation.

• Study Type: Interventional
• Enrollment (Actual): 80
• Phase: Phase 2; Phase 1

Contacts and Locations

Study Locations

• United States
  • Illinois
    • Chicago, Illinois, United States, 60637
      • University of Chicago

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years to 78 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Diagnosis of CCM of any genotype supported by relevant imaging studies.
2. Symptomatic CCM bleeding event within 1 year prior to enrollment.
3. Must be willing/able to travel to the study site for all study visits (baseline, 12 months, and 24 months) over the course of the study period.

Exclusion Criteria:

1. Pre-menopausal women who are breastfeeding, pregnant or likely to get pregnant during the study period.
2. Previous cranial irradiation or surgical/radiosurgical treatment of CCM lesion.
3. Failure to pass MRI safety screening (claustrophobia, metal implant . . . etc)
4. Known allergy or intolerance to gadolinium.
5. Severely impaired renal function (eGFR < 60ml/min), active renal disease or status post-kidney transplants.
6. Statin therapy, for any indication, for more than 7 continuous days or greater than 14 total days within 12 months preceding enrollment.
7. Indication to use statin medication for current approved indication, unrelated to CCM
8. Known allergy or intolerance to statins
9. Liver dysfunction or active liver disease (including chronic viral hepatitis) defined as baseline serum transaminases levels twice the upper range of normal.
10. Previous diagnosis of skeletal muscle disorders of any cause (myopathy), or baseline creatine kinase level five times the upper range of normal.
11. Currently treated with or likely to need treatment with one or more of prohibited medications listed in the protocol.
12. Active drug or alcohol use or dependence that, in the opinion of the site investigator, would interfere with adherence to study requirements.
13. Serious illness (requiring systemic treatment and/or hospitalization) until subject either completes therapy or is clinically stable on therapy, in the opinion of the site investigator, for at least 30 days prior to study entry.
14. Any other condition that the investigator believes would pose a significant hazard to the subject if the investigational therapy were initiated, including conditions resulting in or precipitating myopathy (e.g. HIV, uncontrolled hypothyroidism).
15. In the investigator's opinion, the patient is unstable, and would benefit from a specific intervention rather than treatment with atorvastatin.
16. Inability or unwillingness of subject or legal guardian/representative to give written informed consent.
17. No documentation of valid healthcare insurance.
18. No medical record confirmation of primary care physician.

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
Active Comparator: Treatment; Atorvastatin 80mg OD (optimal dose). Treatment dose will be de-escalated to 40mg based on reported adverse events.	Drug: Atorvastatin; 40-80 mg OD
Placebo Comparator: Placebo; Identically looking capsules containing no active ingredient	Other: Placebo; inactive

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
mean percent change in lesional QSM per year (called the change score)	Each patient contributes two outcome measurements (at year 1 and year 2) based on intention-to-treat. Evaluation of the intervention on this outcome will be performed as a time-averaged difference between two arms using a repeated measures analysis implemented as an unadjusted linear mixed model. Patients with outcome measurements in both periods will be included in the initial intention-to-treat analysis. In cases with multiple lesions, only QSM measurements in the lesion with initial hemorrhage (index lesion) shall be considered for the primary outcome assessment.	End of study (24-month) MRI scan
Percent QSM change per year	A secondary analysis of the percent QSM change per year shall be conducted per treatment rendered for all patients with at least one annual epoch of measurements.	End of study (24-month) MRI scan

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Changes in DCEQP vascular permeability measurements in the index lesion and in brain (white matter far from lesion)	Changes in DCEQP vascular permeability measurements in the index lesion and in brain (white matter far from lesion)	End of study (24-month) MRI scan
Rates of QSM and DCEQP biomarker events	Rates of QSM and DCEQP biomarker events, representing increases in index lesional QSM or DCEQP above previously articulated "biomarker thresholds"; rates of clinically overt hemorrhages in the index lesion per adjudicated criteria; and rates of lesional expansion, defined as an increase in maximum lesion diameter on T2 sequences by 2 or more mm	End of study (24-month) MRI scan
Adverse event rates		End of study (24-month) MRI scan
Serious adverse event rates		End of study (24-month) MRI scan
Drug compliance by tracking daily medication bottle opening	We plan to use a compliance device that would record every time the bottle was opened, thus allowing the study team to track compliance with the protocol and help keep subjects accountable.	End of study (24-month) MRI scan
Changes in functional outcome as measured using the modified Rankin scale which measures the degree of disability or dependence in patients with neurological disability.	Using the modified Rankin scale, we will track subjects' functional outcome changes over the course of the trial.	End of study (24-month) MRI scan
Impact of sex on primary and secondary outcomes (pre specified subgroup analyses)		End of study (24-month) MRI scan
Impact of genotype on primary and secondary outcomes (pre specified subgroup analyses)		End of study (24-month) MRI scan
Impact of lesion location on primary and secondary outcomes (pre specified subgroup analyses)		End of study (24-month) MRI scan

Collaborators and Investigators

• Sponsor: University of Chicago
• Collaborators: Johns Hopkins University
• Investigators: Study Chair: Issam A Awad, MD, Director of Neurovascular Surgery University of Chicago Medicine and Biological Sciences; Study Chair: Daniel F Hanley, MD, Director, Division of Brain Injury Outcomes Service The Johns Hopkins Medical Institutions

Study record dates

Study Major Dates

• Study Start (Actual): July 17, 2018
• Primary Completion (Estimated): December 31, 2024
• Study Completion (Estimated): June 30, 2025

Study Registration Dates

• First Submitted: November 9, 2015
• First Submitted That Met QC Criteria: November 9, 2015
• First Posted (Estimated): November 11, 2015

Study Record Updates

• Last Update Posted (Actual): October 6, 2023
• Last Update Submitted That Met QC Criteria: October 4, 2023
• Last Verified: October 1, 2023

More Information

Terms related to this study

• Keywords: MRI; Statins; Cerebral cavernous malformation; Permeability; Quantitative susceptibility mapping
• Additional Relevant MeSH Terms: Pathologic Processes; Cardiovascular Diseases; Vascular Diseases; Nervous System Diseases; Neoplasms by Histologic Type; Neoplasms; Hematologic Diseases; Hemorrhagic Disorders; Hemostatic Disorders; Cardiovascular Abnormalities; Hemangioma; Neoplasms, Vascular Tissue; Nervous System Malformations; Vascular Malformations; Central Nervous System Vascular Malformations; Hemorrhage; Congenital Abnormalities; Hemangioma, Cavernous, Central Nervous System; Hemangioma, Cavernous; Molecular Mechanisms of Pharmacological Action; Enzyme Inhibitors; Antimetabolites; Anticholesteremic Agents; Hypolipidemic Agents; Lipid Regulating Agents; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Atorvastatin
• Other Study ID Numbers: IRB18-0445

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: Yes
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No