A Randomized, Clinical Trial of Vitamin E and Memantine in Alzheimer's Disease (TEAM-AD)

• ClinicalTrials.gov Identifier: NCT00235716
• Recruitment Status: Completed
• First Posted: October 10, 2005
• Results First Posted: January 29, 2014
• Last Update Posted: July 23, 2014
• Sponsor: US Department of Veterans Affairs
• Collaborators: Forest Laboratories; DSM Nutritional Products, Inc.
• Information provided by (Responsible Party): VA Office of Research and Development ( US Department of Veterans Affairs )

Study Description

Brief Summary:

The purpose of this study is to determine whether alpha-tocopherol, memantine (Namenda), or the combination will significantly delay clinical progression in mild to moderately demented patients with Alzheimer's disease compared to placebo.

Condition or disease	Intervention/treatment	Phase
Alzheimer's Disease	Drug: dl-alpha-tocopherol; Drug: Memantine; Drug: Placebo	Phase 3

Detailed Description:

Abstract: Alzheimer's disease (AD), a neurodegenerative disorder resulting in cognitive loss, behavioral problems, and functional decline, is characterized by well-established and well-known neuropathological changes in the brain. Cognitive deficits and behavioral symptoms are thought to be due to cholinergic neuronal degeneration and loss associated with oxidative stress and inflammatory responses.

Current therapeutic strategies include efforts to

1. enhance cholinergic neuronal function,
2. promote neuroprotective effects, and
3. block pathologic activity of excessive glutamate with a moderate-affinity NMDA antagonist.

A combination of pharmacological therapies directed at simultaneously improving neuronal function and neuroprotection would presumably be more effective than either treatment alone.

To test this hypothesis, this study will examine the efficacy of drug treatment with a combination of

1. any of three FDA approved cholinesterase inhibitors that facilitates central acetylcholine neurotransmission (donepezil, rivastigmine, galantamine);
2. alpha-tocopherol, a fat soluble vitamin that has been shown to slow the rate of progression of AD, presumably through neuroprotective mechanism that reduces oxidative stress; and
3. memantine, a moderate-affinity NMDA antagonist that blocks excessive stimulation of NMDA receptors by glutamate. CSP#546 will be a double-blind, placebo-controlled, randomized, clinical trial to assess the efficacy of adding alpha-tocopherol, memantine, and the combination for the treatment of functional decline in mild-to-moderately demented patients with Alzheimer's disease (MMSE 12-26) who are currently taking an acetylcholinesterase inhibitor (AchEI).

Eligible Veterans will be randomly assigned to either

1. 2,000 IU/d of alpha-tocopherol plus memantine placebo,
2. 20 mg/d of memantine (Namenda) plus alpha-tocopherol placebo,
3. 2,000 IU/d of alpha-tocopherol plus 20 mg/d of memantine, or
4. alpha-tocopherol placebo plus memantine placebo.

The primary outcome for the study will be progression of AD as measured by the Alzheimer's Disease Cooperative Study/Activities of Daily Living (ADCS/ADL) inventory. The ADCS/ADL inventory is an established outcome measure that was designed to assess functional capacity over a broad range of dementia severity and to be sensitive in measuring dementia progression. Secondary outcome measures will include the following five instruments: Alzheimer's Disease Assessment Scale - Cognitive Subscale (ADAS-cog) (cognition), MMSE (cognition), The Dependence Scale (function), Neuropsychiatric Inventory (NPI) (behavior), and Caregiver Activity Survey (CAS) (caregiver time). Outcomes and safety assessments will be obtained at baseline and every six months. The target sample size for the trial will be 620 patients (210 per treatment arm). This sample size will provide 90% power to detect a 4-point mean treatment difference in the ADCS/ADL inventory by the end of the average follow-up period, adjusted for losses. The effects to be detected are modest and translate into a 17.7% reduction in the annual rate of decline with each therapy given alone, and if the effects are additive, an approximate 35% reduction for combined therapy. These effects are equivalent to slowing the rate of progression of the disease by nearly 6 months for monotherapy and 12 months for combined therapy. To achieve the target sample size, Veterans will be recruited over a 3-year period with an estimated minimum follow-up of 1 year and a maximum of 4 years. A total of 10 to 15 VA sites will be established to enroll an average of one Veteran every 2 weeks. CSP#546 is designed to assess both a clinically and economically important treatment effect. If the study definitely determined that alpha-tocopherol, memantine, or the combination delays the progression of AD, the study would be tremendously valuable in reducing the financial and emotional costs of the disease in the VA and U.S. as a whole.

Study Design

• Study Type: Interventional (Clinical Trial)
• Actual Enrollment: 613 participants
• Allocation: Randomized
• Intervention Model: Factorial Assignment
• Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
• Primary Purpose: Treatment
• Official Title: CSP #546 - A Randomized, Clinical Trial of Vitamin E and Memantine in Alzheimer's Disease (TEAM-AD)
• Study Start Date: August 2007
• Actual Primary Completion Date: September 2012
• Actual Study Completion Date: October 2012

Arms and Interventions

Arm	Intervention/treatment
Experimental: Arm 1; 2,000 IU per day of dl-alpha-tocopherol plus placebo for memantine	Drug: dl-alpha-tocopherol; Alpha-tocopherol will be given as an oral dose of 1000 IU twice a day (morning and evening). The form of vitamin E that will be used in this study will be hard gel capsules of dl-alpha-tocopheryl acetate ("synthetic") vitamin E.; Other Name: Vitamin E
Experimental: Arm 2; 20 mg per day of memantine plus placebo for dl-alpha-tocopherol	Drug: Memantine; A moderate-affinity NMDA antagonist. Memantine will be titrated over four weeks to a maintenance dose of 10 mg twice a day. During week 1 patients will take one 5-mg memantine tablet in the morning. During week 2 patients will take one 5-mg memantine tablet in the morning and one in the evening. During week 3 patients will take two 5-mg memantine tablets in the morning and one 5-mg tablet in the evening. Beginning with week 4, participants will take four 5-mg tablets daily, two in the morning and two in the evening.; Other Name: Namenda (R)
Experimental: Arm 3; Combination of 2,000 IU per day of dl-alpha-tocopherol and 20 mg per day of memantine	Drug: dl-alpha-tocopherol; Alpha-tocopherol will be given as an oral dose of 1000 IU twice a day (morning and evening). The form of vitamin E that will be used in this study will be hard gel capsules of dl-alpha-tocopheryl acetate ("synthetic") vitamin E.; Other Name: Vitamin E; Drug: Memantine; A moderate-affinity NMDA antagonist. Memantine will be titrated over four weeks to a maintenance dose of 10 mg twice a day. During week 1 patients will take one 5-mg memantine tablet in the morning. During week 2 patients will take one 5-mg memantine tablet in the morning and one in the evening. During week 3 patients will take two 5-mg memantine tablets in the morning and one 5-mg tablet in the evening. Beginning with week 4, participants will take four 5-mg tablets daily, two in the morning and two in the evening.; Other Name: Namenda (R)
Placebo Comparator: Arm 4; Matching placebos for dl-alpha-tocopherol and memantine	Drug: Placebo; Matching placebos for dl-alpha-tocopherol and memantine.

Outcome Measures

Primary Outcome Measures :

1. Alzheimer's Disease Cooperative Study/Activities of Daily Living (ADCS/ADL) Inventory Change From Baseline [ Time Frame: 6, 12, 18, 24, 30, 36, 42 and 48 months minus baseline ]
   The primary outcome of the study was the Alzheimer's Disease Cooperative Study/Activities of Daily Living (ADCS/ADL) Inventory. The ADCS/ADL Inventory is designed to assess functional abilities to perform activities of daily living in Alzheimer patients with a broad range of dementia severity. The total score ranges from 0 to 78 with higher scores indicating greater abilities. Outcome analysis is average least square means change from baseline.
2. Mini-Mental State Examination Change From Baseline [ Time Frame: 6, 12, 18, 24, 30, 36, 42 and 48 months minus baseline ]
   The Mini-Mental State Examination (MMSE) briefly and objectively assess cognitive status in psychiatric patients with cognitive impairment. The MMSE questions are grouped into seven categories, each representing a different cognitive domain. The MMSE yields a total score that ranges from 0 for a patient who gives no correct response to a score of 30 for a patient who makes no errors. Outcome analysis is average least square means change from baseline.
3. Alzheimer's Disease Assessment Scale - Cognitive (ADAS-cog) Change From Baseline [ Time Frame: 6, 12, 18, 24, 30, 36, 42 and 48 months minus baseline ]
   The Alzheimer's Disease Assessment Scale (ADAS) is a 21-item scale designed to assess the severity of cognitive and non-cognitive behavioral impairments in patients with Alzheimer's disease. The cognitive portion of the scale (ADAS-cog) consists of 11 items to assess memory, language, and praxis functions. The ADAS-cog total score ranges from 0 (no errors) to 70 (severe cognitive impairment). Outcome analysis is average least square means change from baseline.
4. Neuropsychiatric Inventory Change From Baseline [ Time Frame: 6, 12, 18, 24, 30, 36, 42 and 48 months minus baseline ]
   The Neuropsychiatric Inventory (NPI) assesses psychological and behavioral problems in patients with dementia. For each of twelve domains, there are four scores: frequency, severity, total frequency x severity, and caregiver distress. The frequency x severity total scores from each domain are summed for an overall total score that ranges from 0 to 144. The total caregiver distress scores are also summed for an overall total caregiver distress score that ranges from 0 to 60. The secondary endpoint for the trial will be the overall frequency times severity total score. Outcome analysis is average least square means change from baseline.
5. Caregiver Activity Survey Change From Baseline [ Time Frame: 6, 12, 18, 24, 30, 36, 42 and 48 months minus baseline ]
   The Caregiver Activity Survey (CAS) was developed to measure the time caregivers spend aiding Alzheimer patients with their day-to-day activities. The CAS consists of six items that ask for an estimate in hours and minutes of the time that the caregiver spent during the previous 24 hours performing these particular activities. The six CAS items are as follows: 1) communication with the person, 2) using transportation, 3) dressing, 4) eating, 5) looking after one's appearance, and 6) supervising the person. The more caregiving hours the worse the patient's functioning level. Outcome analysis is average least square means change from baseline.

Secondary Outcome Measures :

1. Dependence Scale: Time to Event Analysis (Increase of of One Dependence Level) [ Time Frame: Every 6 months to a maximum of 4 years ]
   The Dependence Scale assesses the level of assistance needed by patients with Alzheimer's disease for activities of daily living. The scale yields six levels of dependence: no assistance required (Level 0); requires occasional reminders (Level 1); requires frequent reminders and/or help with household chores (Level 2); needs daily supervision (Level 3); needs to be dressed, toileted or fed (Level 4); needs to be transferred, diapered or tube fed (Level 5).

Other Outcome Measures:

1. All-cause Mortality [ Time Frame: up to 4 years ]
   Survival analysis of death from any cause.

Eligibility Criteria

• Ages Eligible for Study: 40 Years and older (Adult, Older Adult)
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Criteria

Inclusion Criteria:

1. Diagnoses of possible or probable Alzheimer's disease (NINCDS-ADRDA)
2. Presence of a caregiver (friend or relative) who can assume responsibility for medication compliance, can accompany the patient to all visits, and rate patient's condition
3. Written informed consent from both the patient (or surrogate) and caregiver
4. An MMSE score between 12 and 26 inclusive
5. Administration of a maintenance dosage of donepezil (5-10mg/d), rivastigmine (6-12mg/d) or rivastigmine (Exelon) patch (4.6 mg or 9.5 mg), galantamine or galantamine ER (16-24mg/d) for a minimum of 4 weeks prior to randomization
6. Agreement not to take vitamin E supplements and/or memantine outside of the study (daily multivitamin is permitted containing up to 100 IU alpha-tocopherol)

Exclusion Criteria:

1. A non-Alzheimer primary dementia (e.g., vascular dementia, Lewy body dementia, fronto-temporal dementia, vitamin B-12 deficiency, hypothyroidism)
2. Current major depression, delirium, alcohol or psychoactive substance abuse or dependency, schizophrenia, or delusional disorder as defined by DSM-IV
3. Presence of any uncontrolled systemic illness that would interfere with participation in the study or a life expectancy of less than one year
4. Pregnant or intention to become pregnant
5. Enrollment in another interventional clinical trial
6. Current prescription with more than one AChE inhibitor
7. Current prescription for warfarin
8. Use of vitamin E supplements in the past 2 weeks
9. Use of memantine in the past 4 weeks or known intolerance
10. Estimated creatinine clearance less than 5ml/min (Cockcroft-Gault formula)
11. Use of amantadine in the past 2 weeks

Contacts and Locations

Locations

United States, Florida

VA Medical Center, Bay Pines

Bay Pines, Florida, United States, 33708

VA Medical Center, Miami

Miami, Florida, United States, 33125

United States, Iowa

VA Medical Center, Iowa City

Iowa City, Iowa, United States, 52246-2208

United States, Maryland

VA Maryland Health Care System, Baltimore

Baltimore, Maryland, United States, 21201

United States, Massachusetts

VA Medical Center, Jamaica Plain Campus

Boston, Massachusetts, United States, 02130

United States, Michigan

VA Ann Arbor Healthcare System

Ann Arbor, Michigan, United States, 48113

United States, Minnesota

VA Medical Center, Minneapolis

Minneapolis, Minnesota, United States, 55417

United States, North Carolina

Salisbury VAMC

Salisbury, North Carolina, United States, 28144

United States, Ohio

VA Medical Center, Cleveland

Cleveland, Ohio, United States, 44106

United States, South Carolina

Ralph H Johnson VA Medical Center, Charleston

Charleston, South Carolina, United States, 29401-5799

United States, Texas

VA North Texas Health Care System, Dallas

Dallas, Texas, United States, 75216

United States, Washington

VA Puget Sound Health Care System, Seattle

Seattle, Washington, United States, 98108

United States, Wisconsin

Wlliam S. Middleton Memorial Veterans Hospital, Madison

Madison, Wisconsin, United States, 53705

Puerto Rico

VA Medical Center, San Juan

San Juan, Puerto Rico, 00921

Sponsors and Collaborators

US Department of Veterans Affairs

Forest Laboratories

DSM Nutritional Products, Inc.

Investigators

• Study Chair: Maurice Dysken; Minneapolis Veterans Affairs Medical Center

More Information

Publications of Results:

Dysken MW, Sano M, Asthana S, Vertrees JE, Pallaki M, Llorente M, Love S, Schellenberg GD, McCarten JR, Malphurs J, Prieto S, Chen P, Loreck DJ, Trapp G, Bakshi RS, Mintzer JE, Heidebrink JL, Vidal-Cardona A, Arroyo LM, Cruz AR, Zachariah S, Kowall NW, Chopra MP, Craft S, Thielke S, Turvey CL, Woodman C, Monnell KA, Gordon K, Tomaska J, Segal Y, Peduzzi PN, Guarino PD. Effect of vitamin E and memantine on functional decline in Alzheimer disease: the TEAM-AD VA cooperative randomized trial. JAMA. 2014 Jan 1;311(1):33-44. doi: 10.1001/jama.2013.282834. Erratum in: JAMA. 2014 Mar 19;311(11):1161.

Other Publications:

Dysken MW, Guarino PD, Vertrees JE, Asthana S, Sano M, Llorente M, Pallaki M, Love S, Schellenberg GD, McCarten JR, Malphurs J, Prieto S, Chen P, Loreck DJ, Carney S, Trapp G, Bakshi RS, Mintzer JE, Heidebrink JL, Vidal-Cardona A, Arroyo LM, Cruz AR, Kowall NW, Chopra MP, Craft S, Thielke S, Turvey CL, Woodman C, Monnell KA, Gordon K, Tomaska J, Vatassery G. Vitamin E and memantine in Alzheimer's disease: clinical trial methods and baseline data. Alzheimers Dement. 2014 Jan;10(1):36-44. doi: 10.1016/j.jalz.2013.01.014. Epub 2013 Apr 11.

• Responsible Party: US Department of Veterans Affairs
• ClinicalTrials.gov Identifier: NCT00235716
• Other Study ID Numbers: 546
• First Posted: October 10, 2005
• Results First Posted: January 29, 2014
• Last Update Posted: July 23, 2014
• Last Verified: July 2014

Keywords provided by VA Office of Research and Development ( US Department of Veterans Affairs ):

Alzheimer's Disease; clinical trial; randomized controlled trial; alpha-tocopherol; vitamin E; Namenda; memantine

Additional relevant MeSH terms:

Alzheimer Disease; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Neurodegenerative Diseases; Neurocognitive Disorders; Mental Disorders; Dementia; Tauopathies; Vitamins; Vitamin E; Tocopherols; Tocotrienols; alpha-Tocopherol; Memantine; Micronutrients; Physiological Effects of Drugs; Antioxidants; Molecular Mechanisms of Pharmacological Action; Protective Agents; Antiparkinson Agents; Anti-Dyskinesia Agents; Dopamine Agents; Neurotransmitter Agents; Excitatory Amino Acid Antagonists; Excitatory Amino Acid Agents