Vasodilator Therapy with Isosorbide Mononitrate or Diltiazem to Reduce Vasotoxicity in Patients with Gastrointestinal Cancer receiving Fluoropyrimidine Therapy

Inclusion Criteria

• REGISTRATION: Age ≥ 18 years
• REGISTRATION: Histologically or cytologically confirmed gastrointestinal malignancy (colon, rectal, gastric, esophageal, or other GI cancer) for which fluoropyrimidine therapy (5-FU or capecitabine) is indicated, either as single agent or in combination with other systemic therapy
• REGISTRATION: Planned initiation of 5-FU (infusional) or oral capecitabine therapy, either as standard chemotherapy or as a radiosensitizer
• REGISTRATION: Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0, 1, or 2
• REGISTRATION: Ability to return to Mayo Clinic for baseline and follow-up EndoPAT testing, electrocardiogram (ECG), Holter monitoring, and blood draws
• REGISTRATION: Provide written informed consent
• REGISTRATION: Adequate baseline hemodynamic status: systolic blood pressure ≥ 120 mmHg and resting heart rate ≥ 70 beats/minute (to ensure safety for potential vasodilator therapy in Phase II)
• RANDOMIZATION: Completed all phase I baseline and follow-up assessments, including EndoPAT, ECG, high-sensitivity cardiac troponin T (hs-TnT), and Holter monitoring
• RANDOMIZATION: Demonstrated a ≥ 20% decline in reactive hyperemia index (RHI) from baseline at either phase I follow-up assessment as measured by EndoPAT
• RANDOMIZATION: Adequate hemodynamic status prior to randomization: systolic blood pressure ≥ 120 mmHg and resting heart rate ≥ 70 beats/minute
• RANDOMIZATION: Ability to tolerate and comply with study medication (isosorbide mononitrate, diltiazem, or placebo) per investigator assessment
• RANDOMIZATION: Willingness to initiate study medication 5 days before and continue through the assigned fluoropyrimidine treatment cycle
• RANDOMIZATION: Provide written informed consent for randomization phase

Exclusion Criteria

• REGISTRATION: Current or planned treatment with long-acting nitrates or calcium channel blockers at the time of fluoropyrimidine initiation
• REGISTRATION: Known hypersensitivity or contraindication to nitrates or calcium channel blockers
• REGISTRATION: Baseline systolic blood pressure < 120 mmHg or resting heart rate < 70 beats/minute
• REGISTRATION: History of myocardial infarction ≤ 6 months prior to registration, or symptomatic heart failure (decompensated or New York Heart Association [NYHA] III-IV) requiring ongoing therapy
• REGISTRATION: Recent acute coronary syndrome or coronary revascularization within 3 months of enrollment
• REGISTRATION: High-grade atrioventricular (AV) block without pacemaker
• REGISTRATION: Use of PDE-5 inhibitors (e.g. sildenafil [Viagra]) within 48 hours of enrollment
• REGISTRATION: Uncontrolled intercurrent illness including but not limited to: unstable angina, symptomatic arrhythmias, uncontrolled infection, or psychiatric/social conditions limiting compliance with study requirements
• REGISTRATION: Physical inability to undergo EndoPAT testing (e.g., digital amputation, severe hand deformity, or other limiting condition)
• REGISTRATION: Pregnant or nursing persons
• REGISTRATION: Concurrent enrollment in another interventional clinical trial that, in the opinion of the investigator, would interfere with study endpoints