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    Clinical Trial Results:
    A Phase 3, Randomized, Double-blind, Placebo-controlled Study of Ralinepag to Evaluate Safety and Effects on Exercise Capacity Assessed by Cardiopulmonary Exercise Testing in Subjects with World Health Organization Group 1 Pulmonary Hypertension Who Recently Initiated Therapy

    Summary
    EudraCT number
    2019-003309-88
    Trial protocol
    GB   AT   DE   ES   PL   BE   IT   PT  
    Global end of trial date
    12 Apr 2023

    Results information
    Results version number
    v1(current)
    This version publication date
    28 Jun 2024
    First version publication date
    28 Jun 2024
    Other versions

    Trial information

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    Trial identification
    Sponsor protocol code
    ROR-PH-302
    Additional study identifiers
    ISRCTN number
    -
    US NCT number
    NCT04084678
    WHO universal trial number (UTN)
    -
    Other trial identifiers
    IND Number: 109021
    Sponsors
    Sponsor organisation name
    United Therapeutics Corp.
    Sponsor organisation address
    55 TW Alexander Drive, Durham, United States, 27709
    Public contact
    Global Medical Information, United Therapeutics Corp., 1 9194858350, clinicaltrials@unither.com
    Scientific contact
    Global Medical Information, United Therapeutics Corp., 1 9194858350, clinicaltrials@unither.com
    Paediatric regulatory details
    Is trial part of an agreed paediatric investigation plan (PIP)
    No
    Does article 45 of REGULATION (EC) No 1901/2006 apply to this trial?
    No
    Does article 46 of REGULATION (EC) No 1901/2006 apply to this trial?
    No
    Results analysis stage
    Analysis stage
    Final
    Date of interim/final analysis
    12 Apr 2023
    Is this the analysis of the primary completion data?
    Yes
    Primary completion date
    12 Apr 2023
    Global end of trial reached?
    Yes
    Global end of trial date
    12 Apr 2023
    Was the trial ended prematurely?
    Yes
    General information about the trial
    Main objective of the trial
    To evaluate the effects of ralinepag therapy on exercise capacity as assessed by change in peak oxygen consumption (VO2) derived from cardiopulmonary exercise testing (CPET) after 28 weeks of treatment
    Protection of trial subjects
    The study was conducted per the Declaration of Helsinki and sites were well-trained on the CPET procedures. The study protocol was approved by each site's IRB/IEC. Additionally, subjects were monitored continuously by ECG throughout the CPET testing and could request to terminate the exercise testing at any time.
    Background therapy
    Subjects could be treated with either 1 or 2 approved background PAH-specific therapies
    Evidence for comparator
    -
    Actual start date of recruitment
    20 Jan 2021
    Long term follow-up planned
    No
    Independent data monitoring committee (IDMC) involvement?
    Yes
    Population of trial subjects
    Number of subjects enrolled per country
    Country: Number of subjects enrolled
    Australia: 1
    Country: Number of subjects enrolled
    Brazil: 3
    Country: Number of subjects enrolled
    United States: 2
    Country: Number of subjects enrolled
    Spain: 1
    Country: Number of subjects enrolled
    Germany: 1
    Country: Number of subjects enrolled
    Italy: 2
    Worldwide total number of subjects
    10
    EEA total number of subjects
    4
    Number of subjects enrolled per age group
    In utero
    0
    Preterm newborn - gestational age < 37 wk
    0
    Newborns (0-27 days)
    0
    Infants and toddlers (28 days-23 months)
    0
    Children (2-11 years)
    0
    Adolescents (12-17 years)
    0
    Adults (18-64 years)
    7
    From 65 to 84 years
    3
    85 years and over
    0

    Subject disposition

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    Recruitment
    Recruitment details
    This study was discontinued by the Sponsor on 27 February 2023 due to slow enrollment. This decision was not related to reasons of safety or efficacy. The study was planned for 50 centers; however, only 9 study centers randomized a total of 10 subjects in Australia, Brazil, Germany, Spain, Italy, and the United States.

    Pre-assignment
    Screening details
    The Screening Visit(s) began no more than 28 days prior to randomization. Each subject must have met all the inclusion criteria and none of the exclusion criteria to be eligible for enrollment into the study.

    Period 1
    Period 1 title
    Baseline
    Is this the baseline period?
    Yes
    Allocation method
    Randomised - controlled
    Blinding used
    Double blind
    Roles blinded
    Subject, Investigator

    Arms
    Are arms mutually exclusive
    Yes

    Arm title
    Placebo
    Arm description
    Matching placebo tablets (oral)
    Arm type
    Placebo

    Investigational medicinal product name
    Placebo
    Investigational medicinal product code
    Other name
    Pharmaceutical forms
    Tablet
    Routes of administration
    Oral use
    Dosage and administration details
    The study drug (ie, ralinepag or matching placebo) was supplied as 50, 250, and 400 mcg tablets for oral administration. The starting dose of study drug was 50 mcg once daily for 1 week. Up titration of study drug occurred in 50-mcg increments each week up to a dose of 1400 mcg once daily or until the individual maximum tolerated dose was achieved. The dose of study drug was not titrated in the 7 days prior to Week 28.

    Arm title
    Ralinepag
    Arm description
    Ralinepag once daily extended-release tablets (oral) 50, 250, and 400 mcg titrated to the individual maximum tolerated dose (maximum dose of 1400 mcg)
    Arm type
    Experimental

    Investigational medicinal product name
    Ralinepag
    Investigational medicinal product code
    Other name
    Pharmaceutical forms
    Tablet
    Routes of administration
    Oral use
    Dosage and administration details
    The study drug (ie, ralinepag or matching placebo) was supplied as 50, 250, and 400 mcg tablets for oral administration. The starting dose of study drug was 50 mcg once daily for 1 week. Up titration of study drug occurred in 50-mcg increments each week up to a dose of 1400 mcg once daily or until the individual maximum tolerated dose was achieved. The dose of study drug was not titrated in the 7 days prior to Week 28.

    Number of subjects in period 1
    Placebo Ralinepag
    Started
    2
    8
    Completed
    2
    8
    Period 2
    Period 2 title
    Treatment Period
    Is this the baseline period?
    No
    Allocation method
    Randomised - controlled
    Blinding used
    Double blind
    Roles blinded
    Subject, Investigator

    Arms
    Are arms mutually exclusive
    Yes

    Arm title
    Placebo
    Arm description
    Matching placebo tablets (oral)
    Arm type
    Placebo

    Investigational medicinal product name
    Placebo
    Investigational medicinal product code
    Other name
    Pharmaceutical forms
    Tablet
    Routes of administration
    Oral use
    Dosage and administration details
    The study drug (ie, ralinepag or matching placebo) was supplied as 50, 250, and 400 mcg tablets for oral administration. The starting dose of study drug was 50 mcg once daily for 1 week. Up titration of study drug occurred in 50-mcg increments each week up to a dose of 1400 mcg once daily or until the individual maximum tolerated dose was achieved. The dose of study drug was not titrated in the 7 days prior to Week 28.

    Arm title
    Ralinepag
    Arm description
    Ralinepag once daily extended-release tablets (oral) 50, 250, and 400 mcg titrated to the individual maximum tolerated dose (maximum dose of 1400 mcg)
    Arm type
    Experimental

    Investigational medicinal product name
    Ralinepag
    Investigational medicinal product code
    Other name
    Pharmaceutical forms
    Tablet
    Routes of administration
    Oral use
    Dosage and administration details
    The study drug (ie, ralinepag or matching placebo) was supplied as 50, 250, and 400 mcg tablets for oral administration. The starting dose of study drug was 50 mcg once daily for 1 week. Up titration of study drug occurred in 50-mcg increments each week up to a dose of 1400 mcg once daily or until the individual maximum tolerated dose was achieved. The dose of study drug was not titrated in the 7 days prior to Week 28.

    Number of subjects in period 2
    Placebo Ralinepag
    Started
    2
    8
    Completed
    2
    2
    Not completed
    0
    6
         Consent withdrawn by subject
    -
    1
         Adverse event, non-fatal
    -
    1
         Study Terminated by Sponsor
    -
    4

    Baseline characteristics

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    Baseline characteristics reporting groups
    Reporting group title
    Placebo
    Reporting group description
    Matching placebo tablets (oral)

    Reporting group title
    Ralinepag
    Reporting group description
    Ralinepag once daily extended-release tablets (oral) 50, 250, and 400 mcg titrated to the individual maximum tolerated dose (maximum dose of 1400 mcg)

    Reporting group values
    Placebo Ralinepag Total
    Number of subjects
    2 8 10
    Age categorical
    Units: Subjects
        Adults (18-64 years)
    2 5 7
        From 65-84 years
    0 3 3
    Age continuous
    Units: years
        median (full range (min-max))
    45.0 (39 to 51) 59.0 (25 to 75) -
    Gender categorical
    Units: Subjects
        Female
    2 7 9
        Male
    0 1 1
    Race
    Units: Subjects
        White
    2 6 8
        Black or African American
    0 1 1
        Multiple
    0 1 1
    Weight at Baseline
    Units: kilograms
        median (full range (min-max))
    68.75 (57.1 to 80.4) 72.0 (56.8 to 88.0) -
    Height at Baseline
    Units: centimeters
        median (full range (min-max))
    157 (156 to 158) 165.5 (151 to 174) -
    BMI at Baseline
    Units: kilograms/meters squared
        median (full range (min-max))
    27.4 (22.7 to 32.1) 26.95 (20.3 to 37.0) -
    Subject analysis sets

    Subject analysis set title
    Safety Population
    Subject analysis set type
    Safety analysis
    Subject analysis set description
    All 10 subjects randomized into the study received at least 1 dose of study drug and were included in the Safety Population as part of this report.

    Subject analysis sets values
    Safety Population
    Number of subjects
    10
    Age categorical
    Units: Subjects
        Adults (18-64 years)
    7
        From 65-84 years
    3
    Age continuous
    Units: years
        median (full range (min-max))
    53.0 (25 to 75)
    Gender categorical
    Units: Subjects
        Female
    9
        Male
    1
    Race
    Units: Subjects
        White
    8
        Black or African American
    1
        Multiple
    1
    Weight at Baseline
    Units: kilograms
        median (full range (min-max))
    72.80 (56.8 to 88.0)
    Height at Baseline
    Units: centimeters
        median (full range (min-max))
    161.5 (151 to 174)
    BMI at Baseline
    Units: kilograms/meters squared
        median (full range (min-max))
    26.95 (20.3 to 37.0)

    End points

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    End points reporting groups
    Reporting group title
    Placebo
    Reporting group description
    Matching placebo tablets (oral)

    Reporting group title
    Ralinepag
    Reporting group description
    Ralinepag once daily extended-release tablets (oral) 50, 250, and 400 mcg titrated to the individual maximum tolerated dose (maximum dose of 1400 mcg)
    Reporting group title
    Placebo
    Reporting group description
    Matching placebo tablets (oral)

    Reporting group title
    Ralinepag
    Reporting group description
    Ralinepag once daily extended-release tablets (oral) 50, 250, and 400 mcg titrated to the individual maximum tolerated dose (maximum dose of 1400 mcg)

    Subject analysis set title
    Safety Population
    Subject analysis set type
    Safety analysis
    Subject analysis set description
    All 10 subjects randomized into the study received at least 1 dose of study drug and were included in the Safety Population as part of this report.

    Primary: Comparison of reported AEs

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    End point title
    Comparison of reported AEs [1]
    End point description
    Due to the early termination of the study, efficacy results were not summarized or discussed in the final abbreviated clinical study report. Safety event results were reported as the primary study result.
    End point type
    Primary
    End point timeframe
    Baseline to 28 weeks
    Notes
    [1] - No statistical analyses have been specified for this primary end point. It is expected there is at least one statistical analysis for each primary end point.
    Justification: Safety events were not analyzed statistically. Event totals in each treatment group were used for comparison.
    End point values
    Placebo Ralinepag
    Number of subjects analysed
    2
    8
    Units: Events
        AEs
    3
    77
        Treatment-related AEs
    1
    70
        AEs leading to discontinuation of study drug
    0
    2
        SAEs
    0
    1
        Treatment-related SAEs
    0
    0
    No statistical analyses for this end point

    Adverse events

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    Adverse events information
    Timeframe for reporting adverse events
    Subjects were instructed that they may report AEs at any time. AEs should be reported beyond this period if per the Investigator, they are considered possibly or probably related to the study drug.
    Adverse event reporting additional description
    Monitoring of nonserious AEs will be continued to 28 days after the last dose of study drug or until the 28-day Follow-up Visit, whichever is later. In the event that a nonserious AE is not resolved or stabilized by this time, the Sponsor in consultation with the Investigator will decide whether to continue to monitor the AE.
    Assessment type
    Systematic
    Dictionary used for adverse event reporting
    Dictionary name
    MedDRA
    Dictionary version
    26.0
    Reporting groups
    Reporting group title
    Ralinepag
    Reporting group description
    -

    Reporting group title
    Placebo
    Reporting group description
    -

    Serious adverse events
    Ralinepag Placebo
    Total subjects affected by serious adverse events
         subjects affected / exposed
    1 / 8 (12.50%)
    0 / 2 (0.00%)
         number of deaths (all causes)
    0
    0
         number of deaths resulting from adverse events
    0
    0
    Infections and infestations
    Submandibular abscess
         subjects affected / exposed
    1 / 8 (12.50%)
    0 / 2 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Frequency threshold for reporting non-serious adverse events: 0%
    Non-serious adverse events
    Ralinepag Placebo
    Total subjects affected by non serious adverse events
         subjects affected / exposed
    8 / 8 (100.00%)
    2 / 2 (100.00%)
    Investigations
    Electrocardiogram QT prolonged
         subjects affected / exposed
    1 / 8 (12.50%)
    0 / 2 (0.00%)
         occurrences all number
    1
    0
    Heart rate decreased
         subjects affected / exposed
    1 / 8 (12.50%)
    0 / 2 (0.00%)
         occurrences all number
    1
    0
    N-terminal prohormone brain natriuretic peptide increased
         subjects affected / exposed
    1 / 8 (12.50%)
    0 / 2 (0.00%)
         occurrences all number
    1
    0
    Brain natriuretic peptide increased
         subjects affected / exposed
    0 / 8 (0.00%)
    1 / 2 (50.00%)
         occurrences all number
    0
    1
    Vascular disorders
    Flushing
         subjects affected / exposed
    1 / 8 (12.50%)
    1 / 2 (50.00%)
         occurrences all number
    3
    1
    Nervous system disorders
    Headache
         subjects affected / exposed
    7 / 8 (87.50%)
    0 / 2 (0.00%)
         occurrences all number
    14
    0
    Dizziness
         subjects affected / exposed
    1 / 8 (12.50%)
    0 / 2 (0.00%)
         occurrences all number
    1
    0
    Somnolence
         subjects affected / exposed
    1 / 8 (12.50%)
    0 / 2 (0.00%)
         occurrences all number
    1
    0
    General disorders and administration site conditions
    Fatigue
         subjects affected / exposed
    1 / 8 (12.50%)
    0 / 2 (0.00%)
         occurrences all number
    1
    0
    Oedema peripheral
         subjects affected / exposed
    1 / 8 (12.50%)
    0 / 2 (0.00%)
         occurrences all number
    1
    0
    Peripheral swelling
         subjects affected / exposed
    1 / 8 (12.50%)
    0 / 2 (0.00%)
         occurrences all number
    1
    0
    Ear and labyrinth disorders
    Vertigo positional
         subjects affected / exposed
    0 / 8 (0.00%)
    1 / 2 (50.00%)
         occurrences all number
    0
    1
    Gastrointestinal disorders
    Diarrhoea
         subjects affected / exposed
    6 / 8 (75.00%)
    0 / 2 (0.00%)
         occurrences all number
    9
    0
    Nausea
         subjects affected / exposed
    4 / 8 (50.00%)
    0 / 2 (0.00%)
         occurrences all number
    7
    0
    Abdominal pain upper
         subjects affected / exposed
    1 / 8 (12.50%)
    0 / 2 (0.00%)
         occurrences all number
    1
    0
    Vomiting
         subjects affected / exposed
    1 / 8 (12.50%)
    0 / 2 (0.00%)
         occurrences all number
    1
    0
    Respiratory, thoracic and mediastinal disorders
    Nasal congestion
         subjects affected / exposed
    1 / 8 (12.50%)
    0 / 2 (0.00%)
         occurrences all number
    1
    0
    Skin and subcutaneous tissue disorders
    Pruritus
         subjects affected / exposed
    1 / 8 (12.50%)
    0 / 2 (0.00%)
         occurrences all number
    1
    0
    Psychiatric disorders
    Anxiety
         subjects affected / exposed
    1 / 8 (12.50%)
    0 / 2 (0.00%)
         occurrences all number
    1
    0
    Musculoskeletal and connective tissue disorders
    Myalgia
         subjects affected / exposed
    3 / 8 (37.50%)
    0 / 2 (0.00%)
         occurrences all number
    11
    0
    Pain in jaw
         subjects affected / exposed
    3 / 8 (37.50%)
    0 / 2 (0.00%)
         occurrences all number
    7
    0
    Arthralgia
         subjects affected / exposed
    2 / 8 (25.00%)
    0 / 2 (0.00%)
         occurrences all number
    4
    0
    Muscle spasms
         subjects affected / exposed
    2 / 8 (25.00%)
    0 / 2 (0.00%)
         occurrences all number
    2
    0
    Pain in extremity
         subjects affected / exposed
    1 / 8 (12.50%)
    0 / 2 (0.00%)
         occurrences all number
    1
    0
    Infections and infestations
    Submandibular abscess
         subjects affected / exposed
    1 / 8 (12.50%)
    0 / 2 (0.00%)
         occurrences all number
    2
    0
    Upper respiratory tract infection
         subjects affected / exposed
    1 / 8 (12.50%)
    0 / 2 (0.00%)
         occurrences all number
    1
    0
    Urinary tract infection
         subjects affected / exposed
    1 / 8 (12.50%)
    0 / 2 (0.00%)
         occurrences all number
    1
    0
    Metabolism and nutrition disorders
    Decreased appetite
         subjects affected / exposed
    1 / 8 (12.50%)
    0 / 2 (0.00%)
         occurrences all number
    2
    0

    More information

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    Substantial protocol amendments (globally)

    Were there any global substantial amendments to the protocol? Yes
    Date
    Amendment
    17 Jun 2021
    • Clarified that when a Study Drug Termination Visit occurred close in time to the next regular visit, the Study Drug Termination Visit could take the place of the next regularly scheduled visit. • Clarified CPET procedures and variables and the scope of the CPET core laboratory. • Added details around the full physical examination. • Removed echocardiogram as a required assessment. • Added CD4+ test to list of laboratory tests. • Added language to ensure subjects were not excluded due to a positive drug screen caused by prescription medication. • Changed timeframe of diagnostic right heart catheterization from 1 to 3 years before Screening. • Removed time restriction of ventilation-perfusion lung scan. • Updated number of centers to “50 to 60”. • Updated inclusion criterion for stable dose(s) of PAH-specific oral therapy to be defined as no change in dose or regimen for at least 120 days prior to Randomization. • Added that eligible male subjects must agree not to participate in sperm donation for 90 days after the last dose of study drug, and changed the timeframe for the prohibition on conception from 28 to 30 days. • Removed current unstable angina as an exclusion criterion. • Updated chronic renal insufficiency to be defined using estimated glomerular filtration rate using the Modification of Diet in Renal Disease Study equation instead of creatinine. • Updated exclusion criterion timeframe for diagnosed and/or treated malignancy from within 5 to 3 years of Screening. • Added clarification around how to deal with contact between scheduled clinic visits (timing of calls, what to do after Week 16, etc). • Added description that the Investigator would attempt to discuss unblinding with the Sponsor prior to unblinding. • Removed electrocardiogram response to exercise and duration of exercise from additional endpoints.
    29 Nov 2022
    • Aligned definition of PAH and risk categories with current European Society of Cardiology/European Respiratory Society guidelines. • Changed pulmonary vascular resistance requirement from ≥3 (240 dynes/sec/cm5) to >2 (160 dynes/sec/cm5) Wood units. • Clarified that the study would end when all subjects completed their final study visit. • Clarified that subjects did not need to have newly initiated therapy to be eligible. • Added that subjects must have completed ROR-PH-302 on study drug to be eligible for the OLE study. • Removed limitation of only 1 re-test for re-screened subjects. • Clarified that subjects who discontinued study drug after Week 24 would attend the Follow-up Visit. • Removed specifics for biological quality control test timing from protocol. • Clarified that only 1 CPET was required prior to randomization. • Clarified that electrocardiograms were recorded in triplicate using a device provided by the Sponsor unless not allowed by local regulations. • Clarified AE collection procedures. Updated nonserious AE monitoring procedures. • Revised urine human chorionic gonadotropin analysis for females of childbearing potential instead of only postmenopausal females. • Revised the requirement for stable doses of PAH-specific oral therapy prior to randomization from 120 days to 90 days. • Removed VE/VCO2 slope requirement for study entry. • Amended required peak VO2 from ≥10 to ≥9 mL/min/kg (upper limit remained <18 mL/min/kg). • Removed requirement for dosage of concomitant medications to remain unchanged throughout the study. • Updated exclusion criteria to allow prostacyclin pathway agents for PAH within 90 days of randomization. • Clarified that PAH-specific medications are not to be added or changed during the study. • Added that if study was terminated early for safety reasons, the Sponsor would inform regulatory authorities without delay in accordance with local reporting requirements.

    Interruptions (globally)

    Were there any global interruptions to the trial? No

    Limitations and caveats

    Limitations of the trial such as small numbers of subjects analysed or technical problems leading to unreliable data.
    None reported
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    The status and protocol content of GB trials is no longer updated since 1 January 2021. For the UK, as of 31 January 2021, EU Law applies only to the territory of Northern Ireland (NI) to the extent foreseen in the Protocol on Ireland/NI. Legal notice
    As of 31 January 2023, all EU/EEA initial clinical trial applications must be submitted through CTIS . Updated EudraCT trials information and information on PIP/Art 46 trials conducted exclusively in third countries continues to be submitted through EudraCT and published on this website.

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