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Cardiovascular Inflammation Reduction Trial (CIRT)

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ClinicalTrials.gov Identifier: NCT01594333
Recruitment Status : Completed
First Posted : May 9, 2012
Results First Posted : July 24, 2020
Last Update Posted : July 24, 2020
Sponsor:
Collaborator:
National Heart, Lung, and Blood Institute (NHLBI)
Information provided by (Responsible Party):
Paul Ridker, Brigham and Women's Hospital

Study Description
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Brief Summary:
The Cardiovascular Inflammation Reduction Trial (CIRT) is a randomized clinical trial investigating whether taking low-dose methotrexate reduces heart attacks, strokes, or death in people with type 2 diabetes or metabolic syndrome that have had a heart attack or multiple coronary blockages. This trial is funded by the National Heart, Lung, and Blood Institute (NHLBI)/National Institutes of Health (NIH).

Condition or disease Intervention/treatment Phase
Cardiovascular Disease Drug: Methotrexate Drug: Placebo Phase 3

Detailed Description:
While inflammation contributes crucially to atherothrombosis, it is unknown whether inhibition of inflammation per se will lower vascular event rates. The primary aim of the Cardiovascular Inflammation Reduction Trial (CIRT) is to directly test the inflammatory hypothesis of atherothrombosis by evaluating whether or not low-dose methotrexate (LDM) will reduce rates of myocardial infarction, stroke, and cardiovascular death among stable coronary artery disease patients with type 2 diabetes or metabolic syndrome, conditions associated with an enhanced pro-inflammatory response. CIRT is a randomized, double-blind, placebo-controlled, multi-center, event-driven trial that will randomize 7,000 men and women from the United States and Canada. Following a five- to six-week open-label run-in (maximum 8 weeks), eligible participants who have either suffered documented myocardial infarction in the past or have angiographically demonstrated multivessel coronary artery disease in the past will be randomly allocated over a three to four year period to usual care plus placebo or usual care plus LDM. The target methotrexate dose among those allocated to active therapy is 15 to 20 mg po per week, a dose within the range of that commonly used for the treatment of rheumatoid arthritis. All study participants will additionally receive 1.0 mg oral folate to be taken daily six days per week. LDM complications will be minimized through education programs for all investigators and coordinators, through enhanced communication with study participants, by limiting enrollment to those with no evidence of malignancy, hepatitis, renal dysfunction, chronic infection, pulmonary disease, or other risk factors for toxicity; by conducting an initial 5- to 6-week active-therapy run-in (maximum 8 weeks) designed to eliminate individuals who are either intolerant of or unable to adhere to treatment before randomization; and through regular monitoring of liver function and hematologic indices using a centralized methodology designed to ensure participant safety, allow for dose adjustments while maintaining the study blind, and provide an efficient method to address issues of compliance and follow-up on a cost-effective centralized basis. The primary trial endpoint is the rate of myocardial infarction, stroke, or cardiovascular death. Secondary and tertiary endpoints include all-cause mortality, coronary revascularization, incident congestive heart failure, incident peripheral artery disease, incident venous thrombosis, clinically significant aortic stenosis, incident atrial fibrillation, incident diabetes among those with metabolic syndrome but not diabetes at study entry, and hemoglobin A1c (HbA1c) control among those with diabetes at study entry. The trial is event driven such that in the absence of extreme effects, the trial will conclude after accrual of at least 530 primary endpoints, an effect estimated to provide 90 percent power to detect a 25 percent relative risk reduction. The potential clinical impact of CIRT is broad as it has sufficient power to directly address core issues in the inflammatory hypothesis of atherothrombosis, and thus, if successful, will open major new directions for cardiovascular treatment.
Study Design
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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 4786 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple (Participant, Care Provider, Investigator)
Primary Purpose: Treatment
Official Title: A Randomized, Double-blind, Placebo-controlled, Event-driven Trial of Weekly Low-dose Methotrexate (LDM) in the Prevention of Cardiovascular Events Among Stable Coronary Artery Disease Patients With Type 2 Diabetes or Metabolic Syndrome
Study Start Date : April 2013
Actual Primary Completion Date : April 15, 2019
Actual Study Completion Date : October 30, 2019

Resource links provided by the National Library of Medicine


Arms and Interventions
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Arm Intervention/treatment
Experimental: Methotrexate
Methotrexate: Tablet, Oral, Target dose 15-20mg weekly plus 1.0 mg folic acid 6 days/week
 Drug: Methotrexate
Tablet, Oral, Target dose 15-20 mg weekly plus 1.0 mg folic acid 6 days/week
Other Name: Trexall, TEVA Inc (brand of methotrexate)
Placebo Comparator: Placebo
Placebo: Tablet, Oral weekly plus 1.0mg folic acid 6 days/week
 Drug: Placebo
Tablet, Oral, weekly plus 1.0 mg folic acid 6 days/week


Outcome Measures
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Primary Outcome Measures :
  1. Number of Subjects With Major Adverse Cardiovascular Events [ Time Frame: From randomization to trial end (April 2, 2018) up to a maximum of 5 years ]
    The first occurrence of Major Adverse Cardiovascular Event which is defined as the occurrence of one or more of the following: Cardiovascular Death, Non-Fatal Myocardial Infarction or Non-Fatal Stroke.

  2. Number of Subjects With Major Adverse Cardiovascular Event or Hospitalization for Unstable Angina That Led to Urgent Coronary Revascularization [ Time Frame: From randomization to trial end (April 2, 2018) - up to a maximum of 5 years ]
    The first occurrence of Major Adverse Cardiovascular Event or Hospitalization for Unstable Angina that led to Urgent Coronary Revascularization.


Secondary Outcome Measures :
  1. Number of Subjects With All-cause Mortality [ Time Frame: From randomization to the trial end (April 2, 2018) up to a maximum of 5 years ]
    Subjects who died from any cause.

  2. Number of Subjects With Major Adverse Cardiovascular Event or Any Coronary Revascularization [ Time Frame: From randomization to the trial end (April 2, 2018) - up to a maximum of 5 years ]
    The first occurrence of Major Adverse Cardiovascular Event or Any Coronary Revascularization.

  3. Number of Subjects With Hospitalization for Congestive Heart Failure [ Time Frame: From randomization to trial end (April 2, 2018) up to a maximum of 5 years ]
    The first occurrence of Hospitalization for Congestive Heart Failure

  4. Number of Subjects With Major Adverse Cardiovascular Event, Coronary Revascularization, Hospitalization for Congestive Heart Failure or All Cause Mortality [ Time Frame: From randomization to trial end (April 2, 2018) up to a maximum of 5 years ]
    The first occurrence of Major Adverse Cardiovascular Event, Coronary Revascularization, Hospitalization for Congestive Heart Failure or All Cause Mortality.

  5. Number of Subjects With New Onset Type 2 Diabetes [ Time Frame: From randomization to the trial end (April 2, 2018) - up to 5 years ]
    New onset type 2 diabetes among those without diabetes at baseline. Baseline diabetes is defined as any of the following prior to randomization: clinician report of diabetes, use of antidiabetic medication, hbA1c >=6.5 or fasting plasma glucose >=126.


Other Outcome Measures:
  1. Number of Subjects With Hospitalization for Unstable Angina That Led to Unplanned Coronary Revascularization [ Time Frame: From randomization to the trial end (April 2, 2018) up to 5 years ]
    The first occurrence of hospitalization for unstable angina that led to unplanned coronary revascularization

  2. Number of Subjects With Coronary Revascularization [ Time Frame: From randomization to trial end (April 2, 2018) up to 5 years ]
    The first occurrence of coronary revascularization

  3. Number of Subjects With Peripheral Artery Disease [ Time Frame: From randomization to the trial end (April 2, 2018) - up to 5 years ]
    The first occurrence of new or worsening of peripheral artery disease

  4. Number of Subjects With Deep Vein Thrombosis or Pulmonary Embolism [ Time Frame: From randomization to the trial end (April 2, 2018) - up to 5 years ]
    The first occurrence of symptomatic deep vein thrombosis or pulmonary embolism

  5. Number of Subjects With Aortic Stenosis [ Time Frame: From randomization to the trial end (April 2, 2018) - up to 5 years ]
    The first occurrence of clinically significant aortic stenosis

  6. Number of Subjects With Atrial Fibrillation [ Time Frame: From randomization to the trial end (April 2, 2018) - up to 5 years ]
    The first occurrence of new or worsening of atrial fibrillation


Eligibility Criteria
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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Age ≥ 18 years at screening

  • Documented past history of myocardial infarction OR past evidence of multivessel coronary artery disease by angiography.

    • To qualify on the basis of past history of myocardial infarction, the event must be documented either by hospital records or by evidence on current ECG of Q waves in two contiguous leads and/or an imaging test demonstrating wall motion abnormality or scar. The patient must also have completed any planned coronary revascularization procedures associated with the qualifying event, and be clinically stable for at least 60 days prior to screening.
    • To qualify on the basis of multivessel coronary disease, there must be past angiographic evidence of atherosclerosis in at least 2 major epicardial vessels defined either as the presence of a stent, a coronary bypass graft, or an angiographic lesion of 60% or greater. Left main coronary artery disease that has been revascularized with a stent or bypass graft will qualify as multivessel disease, as will the presence of a 50% or greater isolated left main stenosis. The patient must also have completed any planned coronary revascularization procedures associated with the qualifying event, and be clinically stable for at least 60 days prior to screening.
  • History of type 2 diabetes or metabolic syndrome at time of study enrollment
  • Willingness to participate as evidenced by signing the study informed consent

Exclusion Criteria:

  • Prior history of chronic infectious disease, tuberculosis, or severe fungal disease; chronic hepatitis B or C infection; renal insufficiency; interstitial pneumonitis, bronchiectasis, or pulmonary fibrosis; known chronic pericardial effusion, pleural effusion, or ascites; chronic liver disease; myeloproliferative disorders in the past 5 years; non-basal cell malignancy or treated lymphoproliferative disease within the past 5 years; known HIV positive; life expectancy of < 3 years;
  • Chronic inflammatory condition such as lupus or rheumatoid arthritis, ulcerative colitis or Crohn's disease
  • White blood cell count < 3,500/ul, hematocrit < 32 percent, or platelet count < 75,000/ul
  • Liver transaminase levels (AST or ALT) >upper limit of normal (ULN) or albumin < the lower limit of normal (LLN);
  • Creatinine clearance < 40 ml/min as estimated with the Cockcroft-Gault equation;
  • History of alcohol abuse or unwillingness to limit alcohol consumption to less than 4 drinks per week
  • Women of child bearing potential, even if they are currently using contraception, and women intending to breastfeed.
  • Men who plan to father children during the study period or who are unwilling to use effective forms of contraception.
  • Requirement for use of drugs that alter folate metabolism (trimethoprim/sulfamethoxazol) or reduce tubular excretion (probenecid) or known allergies to antibiotics making avoidance of trimethoprim impossible;
  • Current indication for methotrexate therapy;
  • Chronic use of oral steroid therapy or other immunosuppressive or biologic response modifiers. Eligible study participants will be encouraged to have up to date pneumococcal and influenza vaccinations as recommended based on their age and underlying medical conditions.
  • Chest X-ray evidence in the past 12 months of interstitial pneumonitis, bronchiectasis, or pulmonary fibrosis. For participants who do not have a chest X-ray in the prior 12 months, a chest X-ray will be obtained at baseline as part of the study protocol.
  • New York Heart Association Class IV congestive heart failure.
Contacts and Locations
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Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT01594333


Locations
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Sponsors and Collaborators
Brigham and Women's Hospital
National Heart, Lung, and Blood Institute (NHLBI)
Investigators
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Principal Investigator: Paul Ridker, MD, MPH Brigham and Women's Hospital
  Study Documents (Full-Text)

Documents provided by Paul Ridker, Brigham and Women's Hospital:
Study Protocol and Statistical Analysis Plan  [PDF] October 30, 2014

More Information
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Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):

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Responsible Party: Paul Ridker, Director, Center for Cardiovascular Disease and Prevention, Brigham and Women's Hospital, Brigham and Women's Hospital
ClinicalTrials.gov Identifier: NCT01594333    
Other Study ID Numbers: 2012P-000857
U01HL101422 ( U.S. NIH Grant/Contract )
U01HL101389 ( U.S. NIH Grant/Contract )
First Posted: May 9, 2012    Key Record Dates
Results First Posted: July 24, 2020
Last Update Posted: July 24, 2020
Last Verified: July 2020
Keywords provided by Paul Ridker, Brigham and Women's Hospital:
Myocardial Infarction
Stroke
Cardiovascular death
Type 2 Diabetes
 Metabolic Syndrome
Cardiovascular Inflammation
Atherothrombosis
Additional relevant MeSH terms:
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Cardiovascular Diseases
Methotrexate
Abortifacient Agents, Nonsteroidal
Abortifacient Agents
Reproductive Control Agents
Physiological Effects of Drugs
Antimetabolites, Antineoplastic
Antimetabolites
Molecular Mechanisms of Pharmacological Action
 Antineoplastic Agents
Dermatologic Agents
Enzyme Inhibitors
Folic Acid Antagonists
Immunosuppressive Agents
Immunologic Factors
Antirheumatic Agents
Nucleic Acid Synthesis Inhibitors