E.1 Medical condition or disease under investigation |
E.1.1 | Medical condition(s) being investigated |
Symptomatic Transthyretin Amyloid Cardiomyopathy (ATTR-CM) |
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E.1.1.1 | Medical condition in easily understood language |
Symptomatic Transthyretin Amyloid Cardiomyopathy (ATTR-CM) is a rare disease that occurs when a protein, called transthyretin, is accumulated in the heart. |
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E.1.1.2 | Therapeutic area | Diseases [C] - Cardiovascular Diseases [C14] |
MedDRA Classification |
E.1.2 Medical condition or disease under investigation |
E.1.2 | Version | 20.0 |
E.1.2 | Level | LLT |
E.1.2 | Classification code | 10002020 |
E.1.2 | Term | Amyloid cardiomyopathy |
E.1.2 | System Organ Class | 100000004849 |
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E.1.3 | Condition being studied is a rare disease | Yes |
E.2 Objective of the trial |
E.2.1 | Main objective of the trial |
Part A
• To determine the efficacy of acoramidis (AG10) in the treatment of
subjects with symptomatic transthyretin amyloid cardiomyopathy
(ATTR-CM) by evaluating the difference between the acoramidis and
placebo groups in the change from baseline in the Six-Minute Walk test
(6MWT)
Part B:
• To determine the efficacy of acoramidis in the treatment of subjects
with symptomatic ATTR-CM by evaluating the difference between the
acoramidis and placebo groups in the combined endpoint of All-Cause
Mortality and the cumulative frequency of cardiovascular (CV)-related
hospitalization, and change from baseline in 6MWT
Key Secondary
Part A
• To evaluate the effects of acoramidis on quality of life (QoL) in
subjects with symptomatic ATTR-CM
Part B:
• To evaluate the effects of acoramidis on 6MWT
• To evaluate the effects of acoramidis on health-related QoL as
measured by a heart failure (HF)-specific instrument (KCCQ) in subjects
with symptomatic ATTR-CM |
|
E.2.2 | Secondary objectives of the trial |
Part A
• To assess safety and tolerability of acoramidis in subjects with
symptomatic ATTR-CM
• To assess the pharmacodynamic (PD) effects of acoramidis as
assessed by
- circulating prealbumin (transthyretin, TTR) concentration as an in vivo
biomarker of stabilization and
- established ex vivo assays of TTR stabilization
Part B
• To determine the efficacy of acoramidis treatment as measured by the
components of the primary endpoint
• To determine the efficacy of acoramidis in reducing CV mortality in
subjects with symptomatic ATTR-CM
• To evaluate the safety and tolerability of acoramidis administered for
30 months to subjects with symptomatic ATTR-CM
• To assess the pharmacodynamic (PD) effects of acoramidis as
assessed by
- circulating prealbumin (transthyretin, TTR) concentration as an in vivo
biomarker of stabilization and
- established ex vivo assays of TTR stabilization |
|
E.2.3 | Trial contains a sub-study | No |
E.3 | Principal inclusion criteria |
To be eligible to participate in the study, subjects must meet all the following criteria:
1.Have the ability to understand and sign a written informed consent form, which must be obtained prior to initiation of study procedures.
2.Male or female ≥18 to ≤90 years of age at time of randomization.
3.Have an established diagnosis of ATTR-CM with either wild-type TTR or a variant TTR genotype (confirmed by genotyping) based on either
1. endomyocardial biopsy with confirmatory TTR amyloid typing by either mass spectrometry immunoelectron microscopy, or immunohistochemistry; or
2. positive technetium-99m (99mTc)-pyrophosphate (PYP) or bisphosphonate (DPD or HMDP/HDP) scan, combined with accepted laboratory criteria excluding a diagnosis of AL amyloidosis (based on both immunofixation electrophoresis (IFE) of serum and urine, and serum free light chain (sFLC) analysis). Subjects with concurrent monoclonal gammopathy of undetermined significance (MGUS) may require confirmation of the diagnosis of ATTR-CM by tissue biopsy with confirmatory TTR amyloid typing by either mass spectrometric analysis or immunoelectron microscopy or immunohistochemistry.
4.Have
a.a history of heart failure evidenced by at least one prior hospitalization for heart failure or
b.clinical evidence of heart failure without prior heart failure hospitalization manifested by signs or symptoms of volume overload or elevated intracardiac pressures (e.g., elevated jugular venous pressure, shortness of breath or signs of pulmonary congestion on x-ray or auscultation, or peripheral edema) or
c.heart failure symptoms that required or require ongoing treatment with a diuretic.
5.Have NYHA Class I-III symptoms due to ATTR-CM.
6.Female subjects of childbearing potential who engage in heterosexual intercourse must agree to use highly effective method of contraception beginning with randomization and continuing for 30 days after the last dose of IMP. A male subject who is sexually active with a female of childbearing potential and has not had a vasectomy must agree to use a double-barrier method of birth control
7.For subjects taking cardiovascular medical therapy, with the exception of diuretic dosing, must be on stable doses (defined as no greater than 50% dose adjustment and no categorical changes of medications) for at least 2 weeks prior to Screening.
8.Have completed ≥150 m on the 6MWT on at least 2 tests > 24 hours to < 3 weeks apart and prior to randomization. The distance walked must be
within 15% on two tests.
If one of the first two tests is not ≥150 m or the first two tests are not within 15% of distance walked, a third test must be conducted ≤3 weeks of the first test. If the third test is still not ≥150 m or within 15% of one of the first two tests, the subject will not be eligible for participation.
9.Must have NT-proBNP levels ≥300 pg/mL at Screening.
10.Must have LV wall (interventricular septum or LV posterior wall) thickness ≥12 mm as measured by transthoracic echocardiogram (ECHO) or cardiac magnetic resonance (CMR) documented in medical history within 10 years of Screening or at Screening ECHO or CMR. |
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E.4 | Principal exclusion criteria |
Subjects who meet any of the following criteria at the Screening visit will not be eligible to participate in the study:
1.Acute myocardial infarction, acute coronary syndrome or coronary revascularization within 90 days prior to Screening.
2. Stroke or transient ischemic attack (TIA) within 90 days prior to Screening.
3.Has hemodynamic instability at Screening or Randomization that, in the judgment of the Investigator, would pose too great a risk for participation in the study.
4.Is likely to undergo heart transplantation within a year of Screening.
5.Has confirmed diagnosis of light-chain (AL) amyloidosis.
6.Has abnormal liver function tests at Screening, defined as alanine aminotransferase (ALT) or aspartate aminotransferase (AST) >3 × upper limit of normal (ULN) or total bilirubin >3 × ULN.
7.Has NT-proBNP levels ≥8500 pg/mL at Screening.
8.Has estimated glomerular filtration rate (eGFR) by modification of diet for renal disease (MDRD) formula < 15 mL/min/1.73 m2 at Screening.
9.Known hypersensitivity to IMP (acoramidis or placebo), its metabolites, or formulation excipients.
10.Treatment for ATTR-CM with tafamidis, with marketed drug products lacking a labeled indication for ATTR-CM (e.g., diflunisal, doxycycline), or with natural products or derivatives used as unproven therapies for ATTR-CM (e.g., green tea extract, tauroursodeoxycholic acid [TUDCA]/ursodiol) within 14 days prior to dosing; treatment with patisiran, inotersen, or other gene silencing agent: within 90 days for patisiran, 180 days for inotersen, and 5 half-lives for any other gene silencing agent, prior to dosing. If, during participation in the study, subjects gain access to tafamidis, they will be permitted to initiate therapy with tafamidis as a concomitant medication if they have completed at least 12 months of blinded study therapy
11.Requires treatment with calcium channel blockers with conduction system effects (e.g., verapamil, diltiazem). The use of dihydropyridine calcium channel blockers is allowed. The use of digitalis will only be allowed if required for management of atrial fibrillation with rapid ventricular response
12.Females who are pregnant or breastfeeding. Lactating females must agree to discontinue nursing before IMP is administered. A negative urine pregnancy test at Screening and at Randomization are required for female subjects of childbearing potential.
13.In the judgment of the Investigator or Medical Monitor, has any clinically important ongoing medical condition or laboratory abnormality or condition that might jeopardize the subject’s safety, increase their risk from participation, or interfere with the study.
14.Participation in another investigational clinical trial within 30 days prior to dosing with potential residual effects that might confound the results of this study. Participation in observational and/or registry studies should be discussed with the Medical Monitor.
15.Has any condition that, in the opinion of the Investigator or Medical Monitor, would preclude compliance with the study protocol such as a history of substance abuse, alcoholism or a psychiatric condition.
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E.5 End points |
E.5.1 | Primary end point(s) |
Part A Change from baseline to Month 12 of treatment in distance walked during the 6MWT
Part B A hierarchical combination of All-Cause mortality, CV-related hospitalization, and change from baseline in 6MWT over a 30-month period |
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E.5.1.1 | Timepoint(s) of evaluation of this end point |
Part A
-Distance walked during the 6MWT: Prior to randomization, Month 6, 9, 12
Part B
-Distance walked during the 6MWT, prior to randomization, Month 6, 9, 12, 18, 24, and 30
-All-cause mortality and CV-related hospitalization: Month 0-30 |
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E.5.2 | Secondary end point(s) |
Key Secondary
Part A
-Change from baseline to Month 12 of treatment in Kansas City Cardiomyopathy Questionnaire Overall Score (KCCQ-OS)
Part B:
-Change from baseline to Month 30 of treatment in distance walked during the 6MWT
-Change from baseline to Month 30 of treatment in KCCQ-OS
Other secondary
Part A
-Change from baseline in TTR (prealbumin) level (an in vivo measure of
TTR stabilization) at Month 12
-TTR stabilization as measured in established ex-vivo assays
(fluorescent probe exclusion [FPE] and Western blot) at Month 12 in the
PK-PD substudy
Part B
-A hierarchical combination of All-Cause mortality and CV-related
hospitalization over a 30-month period
-All-Cause Mortality by Month 30 Cumulative frequency of CV-related
hospitalization by Month 30
-Cumulative frequency of CV-related hospitalization by Month 30
-CV Mortality by Month 30
-Change from baseline in TTR (prealbumin) level (an in vivo measure of
TTR stabilization) at Month 30
-TTR stabilization as measured in established ex-vivo assays
(fluorescent probe exclusion [FPE] and Western blot) in the PK-PD
substudy |
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E.5.2.1 | Timepoint(s) of evaluation of this end point |
Key secondary
Part A
-KCCQ-OS: Day 1, Month 3, 6, 9, 12
Part B
-Distance walked during the 6MWT: Prior to randomization, Month 6, 9, 12, 18, 24, 30
-KCCQ-OS: Day 1, Month 3, 6, 9, 12, 15, 18, 21, 24, 27, 30
Other secondary
Part A
- TTR (prealbumin) level and ex vivo assays of TTR stabilization: Day 1, Day 28, Month 3, 6, 9, 12
Part B
- All-Cause Mortality: Month 0-30
- Cumulative frequency of CV-related hospitalization: Month 0-30
- CV Mortality: Month 0-30
- TTR (prealbumin) level ex vivo assays of TTR stabilization: Day 1, Day 28, Month 3, 6, 9, 12, 15, 18, 21, 24, 27, 30
- PK PD assessments: Day 1, Day 28, Month 3, 6, 9, 12, 15, 18, 21, 24, 27, 30 (ONLY for US and UK)
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E.6 and E.7 Scope of the trial |
E.6 | Scope of the trial |
E.6.1 | Diagnosis | No |
E.6.2 | Prophylaxis | No |
E.6.3 | Therapy | No |
E.6.4 | Safety | Yes |
E.6.5 | Efficacy | Yes |
E.6.6 | Pharmacokinetic | No |
E.6.7 | Pharmacodynamic | No |
E.6.8 | Bioequivalence | No |
E.6.9 | Dose response | No |
E.6.10 | Pharmacogenetic | No |
E.6.11 | Pharmacogenomic | No |
E.6.12 | Pharmacoeconomic | No |
E.6.13 | Others | No |
E.7 | Trial type and phase |
E.7.1 | Human pharmacology (Phase I) | No |
E.7.1.1 | First administration to humans | No |
E.7.1.2 | Bioequivalence study | No |
E.7.1.3 | Other | No |
E.7.1.3.1 | Other trial type description | |
E.7.2 | Therapeutic exploratory (Phase II) | No |
E.7.3 | Therapeutic confirmatory (Phase III) | Yes |
E.7.4 | Therapeutic use (Phase IV) | No |
E.8 Design of the trial |
E.8.1 | Controlled | Yes |
E.8.1.1 | Randomised | Yes |
E.8.1.2 | Open | No |
E.8.1.3 | Single blind | No |
E.8.1.4 | Double blind | Yes |
E.8.1.5 | Parallel group | No |
E.8.1.6 | Cross over | No |
E.8.1.7 | Other | No |
E.8.2 | Comparator of controlled trial |
E.8.2.1 | Other medicinal product(s) | No |
E.8.2.2 | Placebo | Yes |
E.8.2.3 | Other | No |
E.8.2.4 | Number of treatment arms in the trial | 2 |
E.8.3 |
The trial involves single site in the Member State concerned
| Yes |
E.8.4 | The trial involves multiple sites in the Member State concerned | No |
E.8.5 | The trial involves multiple Member States | Yes |
E.8.5.1 | Number of sites anticipated in the EEA | 30 |
E.8.6 Trial involving sites outside the EEA |
E.8.6.1 | Trial being conducted both within and outside the EEA | Yes |
E.8.6.2 | Trial being conducted completely outside of the EEA | No |
E.8.6.3 | If E.8.6.1 or E.8.6.2 are Yes, specify the regions in which trial sites are planned |
Australia |
Brazil |
Canada |
Israel |
Korea, Republic of |
New Zealand |
United States |
Belgium |
Denmark |
Greece |
Ireland |
Italy |
Poland |
Portugal |
United Kingdom |
Netherlands |
Spain |
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E.8.7 | Trial has a data monitoring committee | Yes |
E.8.8 |
Definition of the end of the trial and justification where it is not the last
visit of the last subject undergoing the trial
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E.8.9 Initial estimate of the duration of the trial |
E.8.9.1 | In the Member State concerned years | 4 |
E.8.9.1 | In the Member State concerned months | 0 |
E.8.9.1 | In the Member State concerned days | |
E.8.9.2 | In all countries concerned by the trial years | 4 |
E.8.9.2 | In all countries concerned by the trial months | 0 |