Randomized, triple-masked, parallel arm clinical trial of empagliflozin versus placebo in pulmonary arterial hypertension (PAH) participants on stable approved PAH-targeted medical therapy.

The central hypothesis is that treatment with empagliflozin will improve right ventricular (RV) function and other key outcomes in patients with PAH. To test this hypothesis, the EmPATH team will conduct a multicenter Phase 2 clinical trial of empagliflozin to improve right ventricular (RV) function in pulmonary arterial hypertension (PAH). Participants will be randomized in a 1:1 ratio into two arms: empagliflozin 10 mg or matching placebo orally daily for 6 months. Randomization will be stratified by enrollment site and blocked with randomly varying block sizes. The analysis plan includes no formal interim analysis of treatment efficacy or futility.

Inclusion Criteria:

• In order to be eligible to participate in this study, an individual must meet all the following criteria:

  1. Provision of signed and dated informed consent form
  2. Ability and stated willingness to comply with all study procedures and availability for the duration of the study
  3. Ability to read and write in English
  4. Male or female, aged 18 years or older, with group 1 PAH, idiopathic, heritable, associated with drugs and toxins, associated with connective tissue disease and with congenital heart disease (simple repaired or unrepaired defects) according to the current guidelines and adjudicated by the local PI
  5. PAH confirmed by right heart catheterization in the last 5 years
  6. RV dysfunction defined FAC ≤ 34.0% on echocardiography performed during the screening visit. In PVDOMICS, FAC has a strong correlation with CMR RV ejection fraction, and FAC < 34% predicts a CMR RV ejection fraction <37% with a large c-statistic of 0.9. CMR RV ejection fraction <37% is strongly associated with increased mortality and classifies PAH as high risk under the current guidelines. We do not expect this will curtail recruitment as the mean FAC in the PVDOMICS cohort is 30 ± 10%, a population like the one that will be enrolled in this study.
  7. On FDA-approved PAH-targeted therapy (any combination including infused prostacyclin analogues and sotatercept) with stable doses for at least 8 weeks or 24 weeks for sotatercept prior to the screening visit and no clinical plans to change this therapy
  8. Diuretic doses stable for at least 4 weeks prior to screening. After screening, diuretic doses may be changed as directed by the site PIs and/or the treating physician.
  9. Ability to take oral medication and willingness to adhere to the study drug regimen.
  10. For females of reproductive potential: use of highly effective contraception for at least 4 weeks prior to screening and agreement to use such a method during study participation and for an additional 2 weeks after the end of study drug administration
  11. Able to have baseline and week 24 CMR according to Imaging Core criteria, as adjudicated by the Site PI

Exclusion Criteria:

• An individual who meets any of the following criteria will be excluded from participation in this study:

  1. Current use of insulin, insulin secretagogues (sulfonylureas and meglitinides), lithium or an SGLT2 inhibitor
  2. Use of an SGLT2 inhibitor within the past 3 months prior to screening
  3. Prior documented inability to tolerate an SGLT2 inhibitor
  4. Volume depletion, as ascertained by the site PI, at screening or baseline
  5. History of diabetic ketoacidosis or type 1 diabetes mellitus
  6. Chronic alcohol or drug abuse
  7. More than one bacterial or yeast genitourinary tract infection in the year prior to enrollment
  8. Estimated glomerular filtration rate under 30 mL/minute/1.73m2 or on renal replacement therapy
  9. Pregnancy or lactation
  10. Known allergy or hypersensitivity to empagliflozin or another SGLT-2 inhibitor
  11. Currently taking or has taken another investigational drug within the past 4 weeks
  12. Enrollment in another randomized intervention trial. (Participants participating in observational trials will not be excluded).
  13. Decompensated right heart failure, as adjudicated by the site PI.
  14. Screening HbA1c >10% with symptoms such as polyuria and polydipsia

After the study is completed, the de-identified, archived data will be transmitted to and stored at the NHLBI BioData Catalyst (BDC) or to the data repository designated by the NHLBI when the study ends. Data and samples could be used in research. Blood samples will be stored in the EmPATH biorepository for future studies. Some of this research might take place before the EmPATH Trial close out. The research will be approved by the Steering Committee (which includes the NHLBI). At a date agreed upon with the NIH BioLINCC, the EmPATH residual blood samples accepted for storage will be shipped to BioLINCC. After the EmPATH Trial ends, members of the PAH community including members of the EmPATH Steering Committee members may request biological samples from BioLINCC.

Available per NIH data management

Researchers can access NHLBI data and biospecimens through the BioLINCC website, requesting access to data and biospecimens in the Biorepository, and utilizing the BioData Catalyst ecosystem.