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HPS 3 / TIMI 55: REVEAL (Randomized Evaluation of the Effects of Anacetrapib Through Lipid-Modification)

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HPS 3 / TIMI 55: REVEAL (Randomized Evaluation of the Effects of Anacetrapib Through Lipid-Modification) HPS 3 / TIMI 55: REVEAL (Randomized EValuation of the Effects of Anacetrapib through Lipid-modification): A large-scale, randomized placebo-controlled trial of the clinical effects of anacetrapib among people with established vascular disease Does inhibition of cholesteryl ester transfer protein (CETP) with anacetrapib prevent vascular events in high-risk patients who are receiving intensive LDL cholesterol lowering treatment? Large-scale randomized trials have shown that lowering LDL cholesterol by about 1 mmol/L for 4-5 years reduces the risks of coronary events and of strokes by about one fifth. Furthermore, recent trials assessing more intensive versus standard statin regimens have demonstrated additional benefit with more intensive lowering of LDL cholesterol. Nevertheless, among individuals with a history of vascular disease or diabetes, cardiovascular risk remains elevated even after several years of intensive LDL-lowering treatment. For example, in 2 recent trials, over 10% of coronary heart disease (CHD) patients still suffered a major cardiovascular event during 4-5 years of intensive statin therapy. Observational studies indicate that lower concentrations of HDL cholesterol and of apolipoprotein (apo) A1 are associated with an elevated risk of CHD events. Cholesteryl ester transfer protein (CETP) facilitates the exchange of cholesteryl esters for triglycerides between HDL particles and apo B containing particles. CETP inhibition leads to increases in HDL cholesterol and apo A1 concentrations, and reductions in LDL cholesterol, apo B and triglyceride concentrations. However, the only reported outcome trial of a CETP inhibitor – torcetrapib – was stopped early: an unexpected excess risk of cardiovascular events and deaths was observed. It is unclear whether this was due to off-target increases in systemic blood pressure and plasma aldosterone levels induced by torcetrapib, or if it was attributable to some other effect of the drug or CETP inhibition. When used either as monotherapy or in combination with a statin, the CETP inhibitor anacetrapib increases HDL cholesterol and apo A1 concentrations by about 140% and 45% respectively, and reduces LDL cholesterol and apo B concentrations by about 30-40%. Anacetrapib has been well tolerated in early phase studies and, importantly, has no effects on blood pressure or aldosterone levels. The lipid changes that are produced by anacetrapib might well reduce the risk of vascular events substantially, but there is a clear need for large-scale randomized evidence to assess any benefits and hazards reliably. A streamlined international trial The present study will compare anacetrapib 100 mg once daily versus matching placebo in around 30,000 participants with pre-existing atherosclerotic vascular disease who are also receiving effective LDL-lowering therapy using atorvastatin. Follow-up for about 4 years will allow reliable assessments of any beneficial or adverse effects of anacetrapib on mortality and major morbidity. This important international study will be coordinated by the Central Coordinating Office at the University of Oxford (which will act as the trial Sponsor), with Regional Coordinating Centres responsible for the conduct of the trial in about 400 hospitals worldwide. The study design is streamlined: extra work for collaborating doctors and hospitals has been kept to a minimum, and only essential data will be collected directly using bespoke user-friendly computer-based systems. Central Coordinating Office, Clinical Trial Service Unit, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK Tel: +44(0)1865 743882, fax: +44 (0)1865 743988 Page 1 of 41 CTSUREVEAL1 [V2.0_2016-01-11] ISRCTN48678192, NCT01252953 Version History Version Date Summary 1.0 15 October 2010 First released version. 1.1 25 May 2012 Minor changes and updates to Steering Committee membership. 2.0 11 January 2016 The Steering Committee (which remains blind to analyses of the study results by treatment allocation) has agreed the following changes to the protocol: 1. Cancel any formal interim review of efficacy by the Data Monitoring Committee prior to 3 years’ median follow-up. (The interim review of efficacy originally scheduled to take place at 2.5 years after median randomization, was cancelled and has been removed from the protocol; section 2.5.2.2). 2. Revise the secondary assessments (section 2.3.1.2) to: (i) Major atherosclerotic events (defined as coronary death, myocardial infarction or presumed ischaemic stroke; the key secondary outcome); (ii) Presumed ischaemic stroke; and (iii) Major vascular events (defined as coronary death, myocardial infarction, coronary revascularization or presumed ischaemic stroke); 3. Make minor changes to the tertiary assessments (section 2.3.1.4) Power calculations for the new secondary endpoints have been added, based on the number of participants who have been randomized and the blinded event rates observed to date (section 2.4.3). A brief summary of relevant information that has emerged since the study background and rationale (section 1.1) were written has been added (section 1.2). A small number of administrative changes and clarifications have also been made. Page 2 of 41 CTSUREVEAL1 [V2.0_2016-01-11] ISRCTN48678192, NCT01252953 Table of contents 1 BACKGROUND AND RATIONALE ............................................................................................................... 5 1.1 DOES INHIBITION OF CHOLESTERYL ESTER TRANSFER PROTEIN (CETP) PREVENT MAJOR VASCULAR EVENTS IN PATIENTS WITH VASCULAR DISEASE? .......................................................................................... 5 1.1.1 Substantial residual cardiovascular risk even with intensive LDL-lowering treatment .................................. 5 1.1.2 Higher blood concentrations of HDL cholesterol and of apolipoprotein A1 are associated with lower cardiovascular risk throughout the usual range ................................................................................... 5 1.1.3 The clinical effects of currently available treatments for raising HDL cholesterol remain uncertain.............. 6 1.1.4 Inhibition of cholesteryl ester transfer protein as a possible therapeutic target ............................................. 6 1.1.5 Clinical safety and effectiveness of CETP inhibition is currently uncertain .................................................... 7 1.1.6 Rationale for intensive background LDL cholesterol-lowering ....................................................................... 8 1.2 BRIEF SUMMARY OF NEW INFORMATION SINCE PROTOCOL VERSION 1 ........................................................ 9 2 PLAN OF INVESTIGATION .......................................................................................................................... 10 2.1 STUDY AIMS ............................................................................................................................................ 10 2.2 TREATMENT COMPARISONS ..................................................................................................................... 10 2.2.1 Run-in period prior to randomization ........................................................................................................... 10 2.2.2 Randomization to anacetrapib versus placebo ............................................................................................ 10 2.3 DATA ANALYSIS PLAN .............................................................................................................................. 11 2.3.1 Main and subsidiary analyses ..................................................................................................................... 11 2.3.1.1 Primary assessment ................................................................................................................................ 11 2.3.1.2 Secondary assessments ......................................................................................................................... 11 2.3.1.3 Additional assessments requested by regulatory agencies ..................................................................... 11 2.3.1.4 Tertiary assessments .............................................................................................................................. 11 2.3.1.5 Additional safety assessments ................................................................................................................ 12 2.3.1.6 Analyses of biochemical efficacy............................................................................................................. 13 2.3.1.7 Exploratory assessments ........................................................................................................................ 13 2.3.1.8 Health economic assessments................................................................................................................ 13 2.3.2 Statistical analysis ....................................................................................................................................... 13 2.4 SAMPLE SIZE AND PREDICTED NUMBER OF EVENTS .................................................................................... 14 2.4.1 Initial assumptions (prior to study start) ....................................................................................................... 14 2.4.2 Statistical power (prior to study start) .........................................................................................................
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