Atorvastatin to Treat Pulmonary Sarcoidosis
Atorvastatin to Treat Pulmonary Sarcoidosis
This study will determine if atorvastatin (Lipitor) can help patients with pulmonary (lung)
 sarcoidosis and replace or reduce the need for patients to take steroids, such as prednisone.
 Sarcoidosis is an inflammatory disease that can affect nearly any part of the body. Pulmonary
 sarcoidosis may resolve on its own or it may progress to irreversible lung damage,
 disability, and death. Many sarcoidosis patients are treated with prednisone, but the drug is
 not effective in all patients, and it can cause serious side effects, such as high blood
 pressure, sugar diabetes, eye cataracts, and bone thinning.

 Patients with stage II or III pulmonary sarcoidosis between 18 and 70 years of age who
 require prednisone may be eligible for this study. Candidates are screened with the tests and
 procedures described below.

 Participants are randomly assigned to one of two treatment groups: one group takes
 atorvastatin; the other takes a placebo (a look-alike pill that has no active ingredient to
 fight sarcoidosis). Both groups take the pills by mouth once a day for 12 months. When
 treatment begins, participants begin to have their prednisone dosage tapered (reduced). The
 tapering is done over 8 weeks until the dose is reduced by 90 percent. Patients are evaluated
 periodically to determine if the two groups differ in how long they can remain on the reduced
 dose of prednisone without having their symptoms recur, requiring an increase in the
 prednisone dose. A full battery of tests is done at the initial screening visit and at the
 26- and 52-week follow-up visits, requiring hospitalization for 3-5 days. Additional interim
 outpatient assessments are done at 6, 12, 18 and 36 weeks.

 The full battery of tests at the initial screening and the 26- and 52-week visits includes
 the following:

 -  Medical history, physical examination, blood and urine tests, assessment of disease
 severity and activity.

 -  Questionnaires.

 -  Chest x-ray (CXR) and computed tomography (CT) scan.

 -  Abdominal ultrasound.

 -  Six-minute walk test (6MWT)

 -  Exercise testing and blood gases

 -  Pulmonary function tests (PFT)

 -  Maximum incremental ventilatory performance test (MIVP)

 -  Exhaled nitric oxide and carbon monoxide (Exhaled NO and CO)

 -  Bronchoscopy and lavage

 Interim testing at 6, 12, 18 and 36 weeks includes PFT, MIVP, Exhaled NO and CO, CXR,
 questionnaire, blood tests, and 6MWT.

 Six months after completing the study, participants fill out a questionnaire.
Background

 Sarcoidosis is a multi-system granulomatous inflammatory disease. Pulmonary involvement is
 most common. Patients typically experience fatigue, weakness and dyspnea. Respiratory muscle
 weakness, which may be secondary to granulomatous inflammation, is associated with dyspnea
 and decreased quality of life (QOL). The disease can remit spontaneously or become chronic,
 with exacerbations and remissions. In some patients, it can progress to pulmonary fibrosis
 and death. Granulomatous inflammation is characterized primarily by accumulation of
 monocytes, macrophages and activated T-lymphocytes, with increased production of key
 inflammatory mediators, TNF-alpha, INF-gamma, IL-2 and IL-12, characteristic of a
 Th1-polarized response (T-helper lymphocyte-1 response). Corticosteroids are the current
 mainstay of treatment, but their long-term benefits are not certain. Because steroids often
 produce undesirable side effects, investigations to identify alternative therapies are
 warranted. There is sufficient evidence to test the proof of concept that pathways targeted
 by statins will have a therapeutic effect in sarcoidosis, since, in pre-clinical studies,
 statins blunt Th1-mediated inflammatory responses.

 Aims

 The study involves a double-blind placebo-controlled, randomized trial which aims to
 determine if atorvastatin administration results in less steroid use and longer steroid-free
 intervals in patients with pulmonary sarcoidosis who require prednisone treatment.

 Methods

 Patients, who are 18-70 years old, with stage II or III pulmonary sarcoidosis, diagnosed by a
 compatible clinical history and supported by a lung, lymph node, or tissue biopsy, will be
 enrolled in the study, if they require prednisone therapy. The patients will be randomly
 assigned to two groups; as prednisone is tapered, one group will receive placebo and the
 other, atorvastatin. The two study drugs will be administered for twelve months, during which
 time patients will be periodically evaluated as to their clinical status and prednisone
 requirements. Pill counts and patient diaries will be used to determine the amount of steroid
 use during the study period. Patients with pulmonary fibrosis greater than 50 percent of
 total lung volume or severe co-morbidities will be excluded from the trial.

 The primary endpoint is the duration of the steroid-sparing period. Secondary clinical and
 physiological endpoints are intended to analyze possible anti-inflammatory and beneficial
 effects of the drugs. Since there is no gold standard outcome measure in sarcoidosis, four
 categories of secondary endpoints will be used to characterize the effects of the therapeutic
 agent on the clinical course of the disease: imaging (high resolution chest CT); quality of
 life assessments (SF-36, and SGRQ), anti-inflammatory effects (biomarkers and relapse rates),
 and functional effects (CPET, PFTs). Finally, we will study the utility of exhaled nitric
 oxide and carbon monoxide in monitoring disease activity.
-  INCLUSION CRITERIA:

 Patients are eligible for the trial if they are 18-70 years old with radiographic stages II
 and III pulmonary sarcoidosis, and are on prednisone, methotrexate, or azathioprine for
 pulmonary sarcoidosis or who are steroid-requiring. Patients with extra-pulmonary
 sarcoidosis (except cardiac and neurosarcoidosis) may be eligible as long as they have
 active pulmonary (stage II or III) sarcoidosis.

 Steroid-Requiring History:

 A steroid-requiring patient is one who was previously stable but who ultimately experiences
 (a) increased symptoms associated with radiographic deterioration, and/or, (b) met the
 criteria for relapse and/or functional deterioration. In addition, patients who were
 prescribed prednisone for sarcoidosis, but have self-discontinued it (yet still have
 clinical and symptomatic disease and/or evidence of pulmonary functional deterioration)
 will be considered steroid-requiring.

 This latter group of steroid-requiring patients is eligible for enrollment if they are
 willing to resume taking their latest stabilizing dose of prednisone for at least four
 weeks prior to study entry. If their dose cannot be determined, then 40 mg will be used.

 Therefore, a history of symptomatic or clinical deterioration leading to therapy
 initiation, or a history of decline associated with attempts to decrease therapy should be
 established. Medical records review and discussion with the prescribing physician will be
 used to establish this history.

 Radiographic Stages of Pulmonary Sarcoidosis:

 STAGE< TAB> DESCRIPTION

 0< TAB> Normal Chest Radiograph

 I< TAB> Bilateral Hilar Lymphadenopathy

 II< TAB> Pulmonary Infiltration and Bilateral Hilar Lymphadenopathy

 III< TAB> Pulmonary Infiltration alone

 Steroid-requiring refers to one of three situations:

 Patients who meet relapse criteria or functional deterioration.

 Functional deterioration criteria that warrants prednisone therapy includes:

 If VC fell to 75% of the best recorded value for the patient before any treatment

 If VC fell to greater than 50% of predicted value

 IF DLCO fell to less than 60% of the best recorded value prior to their treatment

 Patients who are on a previously prescribed systemic steroid, or alternative agent such as
 methotrexate or azathioprine, primarily for pulmonary sarcoidosis. Alternative agents must
 first be changed to roughly equivalent anti-inflammatory dose of prednisone and the patient
 should be stable on this dose for at least four weeks prior to randomization.

 Patients who have substantial respiratory symptoms (distressing cough or dyspnea, which
 interferes with daily activities that would warrant therapy as per the standard of practice
 in the US.

 Extra Pulmonary Sarcoidosis:

 Patients with extra pulmonary sarcoidosis (except neurosarcoidosis and cardiac sarcoidosis)
 may be eligible as long as they have active pulmonary (stage II or III) sarcoidosis. All
 patients will be referred to an NIH ophthalmologist. Steroid therapy may be modified based
 upon the recommendations of the consultants, as well as per the lapse criteria described
 above.

 EXCLUSION CRITERIA:

 -  Moderate to severe pulmonary fibrosis (stage IV sarcoidosis greater than 50% fibrosis)

 -  Lung Disease such as asthma, COPD, ILD (other than sarcoid-related)

 -  History of significant beryllium or asbestos exposure

 -  Pregnancy; or Active lactation/ child-bearing age female without appropriate birth
 control methods

 -  HIV disease

 -  Hepatitis C and Active Hepatitis B

 -  Other intervention protocols

 -  Immunosuppressive therapy (systemic or inhaled) other than corticosteroids or
 methotrexate

 -  Significant cardiac disease (NYSHA class greater than III), or serious coronary
 disease (unstable angina)

 -  Use of statins within 12 weeks of enrollment

 -  Allergies or intolerance to statins

 -  Liver disease (transaminases greater than 1.5X upper limits of normal) or cirrhosis

 -  Bleeding diathesis that is not correctable

 -  Inability to perform CPET (cycle ergometer) or PFT maneuvers

 -  Inability to understand the risks of the trial and the inability to complete the
 questionnaire

 -  Malignancy-- requiring chemotherapy or radiation therapy; except certain types of skin
 cancer that have been excised and have not spread.

 -  Myopathy, diagnosed via muscle biopsy (other than sarcoid-related myopathy); CPK
 grater than 1.5 upper limits of normal

 -  Surgical Risk Category [American Society of Anesthesiologists (ASA) class IV

 -  Ingestion of grapefruit juice or certain herbal preparations (see below), or
 medications that are potent inhibitors or inducers of the CYP3A4 system (see section
 12.4 under precautions)

 -  Alcohol abuse (greater than 4 drinks/day)

 -  Bleeding into the brain or parts of the eyes (retina) (within the past year prior to
 enrollment)

 -  Uncontrolled Hypertension (SBP greater than 185 or DBP greater than 100 on two or more
 visits or assessments)

 -  Uncontrolled Diabetes Mellitus (Serum glucose level on two or more tests per day
 greater than 250 mg/dl or erratic blood sugar levels, noted on at least 2 or more
 assessments; and/or HgbA1C greater than 2x the upper limits of normal).

 -  Neurosarcoidosis

 -  Sarcoid Uveitis (Posterior Uveitis) or any Uveitis that cannot be managed with topical
 steroids alone, as determined by an ophthalmologist

 -  (Clinically apparent) Cardiac Sarcoidosis

 -  Active Smoker (Smoked within the past 2 months prior to randomization)

 -  Sickle cell disease (SS, SC, and sickle cell-beta thalassemia)

 -  Aseptic necrosis of the hip joints

 Patients taking the following preparations will not be allowed to participate in the study
 unless they agree to discontinue usage at least two weeks prior to randomization and for
 the duration of the study period: grapefruit juice and herbal remedies that may lead to
 severe liver injury and/or muscle injury if taken with atorvastatin, including: Skullcap,
 chaparral, Germander, Jin Bu Huan, Valerian, Comfrey, and Eucalyptus. Since other products
 such as St. John s Wort, oat bran, and pectin can reduce the effectiveness of atorvastatin,
 they and similar agents, should also be discontinued at least two weeks before
 randomization and for the duration of the study period.

 Subjects with inactive hepatitis B will require antiviral prophylaxis with an agent such as
 lamivudine, while on prednisone therapy.