Ignite Creation Date:
2024-05-06 @ 4:38 PM
Last Modification Date:
2024-10-26 @ 2:13 PM
Study NCT ID:
NCT05049603
Status:
NOT_YET_RECRUITING
Last Update Posted:
2023-03-15
First Post:
2021-09-02
Brief Title:
A Randomized Clinical Trial to Evaluate the Effects of Atorvastatin on Graves Orbitopathy GO the STAGO-2 Study
Sponsor:
University of Pisa
Organization:
University of Pisa
Study Overview
Official Title:
Phase III Double-blinded Multicenter Randomized Clinical Trial to Evaluate the Effects of Atorvastatin on Moderate-to-severe and Active Graves Orbitopathy GO Treated With Intravenous Glucocorticoids the STAGO-2 Study
Status:
NOT_YET_RECRUITING
Status Verified Date:
2023-03
Last Known Status:
None
Delayed Posting:
No
If Stopped, Why?:
Not Stopped
Has Expanded Access:
False
If Expanded Access, NCT#:
N/A
Has Expanded Access, NCT# Status:
N/A
Acronym:
STAGO-2
Brief Summary:
Graves orbitopathy GO is the most common extra-thyroidal manifestation of Graves disease GD Based on its clinical signs and symptoms GO is graded as mild moderate-to-severe or severe and active or inactive the latter feature being established on a 57-scale score named Clinical Activity Score CAS
The European Group on Graves Orbitopathy EUGOGO has recently formulated and published up-to-date guidelines for the management of GO according to which high dose intravenous iv glucocorticoids GC ivGC is the first line treatment for moderate-to-severe and active GO A protective effect of atorvastatin on the development of GO in patients with GD has been reported based on which we recently conducted a phase II randomized open label clinical trial and found that atorvastatin improves the response of GO to ivGCs in hypercholesterolemic patients The effect was unrelated to cholesterol levels suggesting that it may be the consequence of a direct action of atorvastatin To investigate this issue further and to introduce atorvastatin in the clinical practice we designed the present Phase III double-blinded multicenter randomized adaptive superiority no profit clinical trial to evaluate the effects of atorvastatin on Graves Orbitopathy GO in patients with moderate-to-severe and active GO subjected to intravenous glucocorticoid therapy regardless of cholesterol levels
The European Group on Graves Orbitopathy EUGOGO has recently formulated and published up-to-date guidelines for the management of GO according to which high dose intravenous iv glucocorticoids GC ivGC is the first line treatment for moderate-to-severe and active GO A protective effect of atorvastatin on the development of GO in patients with GD has been reported based on which we recently conducted a phase II randomized open label clinical trial and found that atorvastatin improves the response of GO to ivGCs in hypercholesterolemic patients The effect was unrelated to cholesterol levels suggesting that it may be the consequence of a direct action of atorvastatin To investigate this issue further and to introduce atorvastatin in the clinical practice we designed the present Phase III double-blinded multicenter randomized adaptive superiority no profit clinical trial to evaluate the effects of atorvastatin on Graves Orbitopathy GO in patients with moderate-to-severe and active GO subjected to intravenous glucocorticoid therapy regardless of cholesterol levels
Detailed Description:
Graves orbitopathy GO is the most common extra-thyroidal manifestation of Graves disease GD GO profoundly impairs the quality of life of affected patients The pathogenesis is autoimmune reflecting cross-reactivity against antigens shared by thyroid epithelial cells and orbital fibroblasts Once the autoimmune reaction is initiated a series of molecular mechanisms involving T and B cells antibodies cytokines and oxidative stress lead to fibroblast proliferation and release of glycosaminoglycans resulting in the clinical manifestations of the disease namely exophthalmos or proptosis soft tissue inflammation diplopia and in the most severe cases sight reduction or loss due to corneal damage or to compression of the optic nerves the so called optic neuropathy Based on its clinical signs and symptoms GO is graded as mild moderate-to-severe or severe and active or inactive the latter feature being established on a 57-scale score named Clinical Activity Score CAS
The European Group on Graves Orbitopathy EUGOGO a scientific Society involving several European Centers including some of the Centers participating in the present study has formulated and published up-to-date guidelines for the management of GO which is referred to across the present study protocol
According to EUGOGO guidelines high dose intravenous iv glucocorticoids GC ivGC is the first line treatment for moderate-to-severe and active GO The use of systemic glucocorticoids takes advantage from their immunosuppressive and anti-inflammatory actions resulting in an overall beneficial effect ranging from 35 to 60 of patients in various studies Recent studies have provided evidence for the best balance in terms of effectivenessrisks for a total methylprednisolone dose of 45 g given in 12 weekly administrations six of 500 and six of 250 mg which is therefore recommended
Besides genetic and demographical variables risk factors associated with the development of GO in GD patients are known to be inadequate control of hyperthyroidism radioiodine treatment and smoking In a large retrospective study conducted in more than 8000 individuals with GD it was reported that treatment with 3-hydroxy-3-methylglutaryl-coenzyme reductase inhibitors better known as statins especially atorvastatin is associated with a 40 reduced risk of developing GO in GD patients The findings were interpreted as the consequence of the anti-inflammatory action of statins being GO an autoimmune inflammatory condition Statins influence autophagic events and it has been shown that they induce cell death of human fibroblasts through a complex mechanism involving co-regulation of apoptosis autophagy and unfolded protein response UPR Thus statins may reduce GO risk by modulating both apoptosis and autophagy activities The molecular mechanisms that determine autophagy apoptosis and their interaction are not fully established but the impact of statins on these two processes and their interplay in different cell types may provide a novel explanation for their pleiotropic effects in GO Shih et al found a positive correlation between macrophage count in the Mullers muscle and severity of upper lid retraction and concluded that the degree of inflammatory cell infiltration of Mullers muscle is associated with clinical severity of upper eyelid retraction in GO Because some statins potently affect macrophage viability in vitro through the induction of apoptotic process it is plausible that the early autophagic flux induced by statin treatment may be a potential mechanism to induce apoptosis of Mullers muscle infiltrating macrophages in patients with GO thus eliciting a beneficial effect
In addition to a possible direct action of statins on the eye the possibility exists that the action of statins in GO may additionally reflect lowering of cholesterol Thus in a recent cross-sectional study a direct correlation between total and LDL-cholesterol levels and the presence and activity of GO in unselected patients with a GD of recent onset was observed suggesting a direct link between cholesterol and GO In addition LDL-cholesterol was found to be a predictor of response to treatment The mechanisms responsible for the relation between the presence of GO and cholesterol may be related to the altered inflammatory state of hypercholesterolemia Thus it is well known that disorders of lipid metabolism are associated with a state of mild-to-moderate systemic chronic inflammation The increase load of free fatty acids on the liver present in hyperlipemic states causes dysfunction of the mitochondria and endoplasmic reticulum of hepatocytes leading to the release of reactive oxygen radical species In addition free fatty acid can indirectly cause the release of pro-inflammatory cytokines namely interleukin-6 and tumor necrosis factor-α both involved in the pathogenetic mechanisms of GO
Based on these findings the investigators recently conducted a phase II randomized open label external ophthalmological investigator-blinded pilot clinical trial to determine whether administration of statins increases the efficacy of ivGC in patients with moderate-to-severe active GO Atorvastatin improved the response of GO to ivGCs in hypercholesterolemic patients The effect was unrelated to cholesterol levels suggesting that it may be the consequence of a direct action of atorvastatin To investigate this issue further and to introduce atorvastatin in the clinical practice the present Phase III double-blinded multicenter randomized adaptive superiority no profit clinical trial was designed to evaluate the effects of atorvastatin on Graves Orbitopathy GO in patients with moderate-to-severe and active GO subjected to intravenous glucocorticoid therapy regardless of cholesterol levels
The European Group on Graves Orbitopathy EUGOGO a scientific Society involving several European Centers including some of the Centers participating in the present study has formulated and published up-to-date guidelines for the management of GO which is referred to across the present study protocol
According to EUGOGO guidelines high dose intravenous iv glucocorticoids GC ivGC is the first line treatment for moderate-to-severe and active GO The use of systemic glucocorticoids takes advantage from their immunosuppressive and anti-inflammatory actions resulting in an overall beneficial effect ranging from 35 to 60 of patients in various studies Recent studies have provided evidence for the best balance in terms of effectivenessrisks for a total methylprednisolone dose of 45 g given in 12 weekly administrations six of 500 and six of 250 mg which is therefore recommended
Besides genetic and demographical variables risk factors associated with the development of GO in GD patients are known to be inadequate control of hyperthyroidism radioiodine treatment and smoking In a large retrospective study conducted in more than 8000 individuals with GD it was reported that treatment with 3-hydroxy-3-methylglutaryl-coenzyme reductase inhibitors better known as statins especially atorvastatin is associated with a 40 reduced risk of developing GO in GD patients The findings were interpreted as the consequence of the anti-inflammatory action of statins being GO an autoimmune inflammatory condition Statins influence autophagic events and it has been shown that they induce cell death of human fibroblasts through a complex mechanism involving co-regulation of apoptosis autophagy and unfolded protein response UPR Thus statins may reduce GO risk by modulating both apoptosis and autophagy activities The molecular mechanisms that determine autophagy apoptosis and their interaction are not fully established but the impact of statins on these two processes and their interplay in different cell types may provide a novel explanation for their pleiotropic effects in GO Shih et al found a positive correlation between macrophage count in the Mullers muscle and severity of upper lid retraction and concluded that the degree of inflammatory cell infiltration of Mullers muscle is associated with clinical severity of upper eyelid retraction in GO Because some statins potently affect macrophage viability in vitro through the induction of apoptotic process it is plausible that the early autophagic flux induced by statin treatment may be a potential mechanism to induce apoptosis of Mullers muscle infiltrating macrophages in patients with GO thus eliciting a beneficial effect
In addition to a possible direct action of statins on the eye the possibility exists that the action of statins in GO may additionally reflect lowering of cholesterol Thus in a recent cross-sectional study a direct correlation between total and LDL-cholesterol levels and the presence and activity of GO in unselected patients with a GD of recent onset was observed suggesting a direct link between cholesterol and GO In addition LDL-cholesterol was found to be a predictor of response to treatment The mechanisms responsible for the relation between the presence of GO and cholesterol may be related to the altered inflammatory state of hypercholesterolemia Thus it is well known that disorders of lipid metabolism are associated with a state of mild-to-moderate systemic chronic inflammation The increase load of free fatty acids on the liver present in hyperlipemic states causes dysfunction of the mitochondria and endoplasmic reticulum of hepatocytes leading to the release of reactive oxygen radical species In addition free fatty acid can indirectly cause the release of pro-inflammatory cytokines namely interleukin-6 and tumor necrosis factor-α both involved in the pathogenetic mechanisms of GO
Based on these findings the investigators recently conducted a phase II randomized open label external ophthalmological investigator-blinded pilot clinical trial to determine whether administration of statins increases the efficacy of ivGC in patients with moderate-to-severe active GO Atorvastatin improved the response of GO to ivGCs in hypercholesterolemic patients The effect was unrelated to cholesterol levels suggesting that it may be the consequence of a direct action of atorvastatin To investigate this issue further and to introduce atorvastatin in the clinical practice the present Phase III double-blinded multicenter randomized adaptive superiority no profit clinical trial was designed to evaluate the effects of atorvastatin on Graves Orbitopathy GO in patients with moderate-to-severe and active GO subjected to intravenous glucocorticoid therapy regardless of cholesterol levels
Study Oversight
Has Oversight DMC:
None
Is a FDA Regulated Drug?:
False
Is a FDA Regulated Device?:
False
Is an Unapproved Device?:
None
Is a PPSD?:
None
Is a US Export?:
False
Is an FDA AA801 Violation?:
None