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N-Acetylcysteine and Milk Thistle for Treatment of Diabetic Nephropathy (CGDN)

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details.
 
ClinicalTrials.gov Identifier: NCT01265563
Recruitment Status : Completed
First Posted : December 23, 2010
Results First Posted : March 31, 2017
Last Update Posted : October 19, 2018
Sponsor:
Collaborator:
National Center for Complementary and Integrative Health (NCCIH)
Information provided by (Responsible Party):
VA Office of Research and Development

Study Description
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Brief Summary:
The study is done to find out whether the combined use of the nutritional supplements N-acetylcysteine and Siliphos (milk thistle extract) corrects the shedding of urine protein and oxidative damage (damage to cells and organs often compared to fast aging) in patients with Type 2 Diabetes Mellitus (T2DM) and diabetic kidney disease.

Condition or disease Intervention/treatment Phase
Diabetic Nephropathy Proteinuria Oxidative Stress Drug: N-acetylcysteine placebo and silibin placebo Drug: N-acetylcysteine active and silibin placebo Drug: N-acetylcysteine placebo and silibin active Drug: N-acetylcysteine active and silibin active Drug: N-acetylcysteine active + high-dose silibin active Phase 2

Detailed Description:

Oxidative stress and glutathione (GSH) imbalance are major contributors to the pathogenesis of diabetic nephropathy. Current options for the treatment of oxidative stress in diabetic nephropathy are limited and only partially effective, thus interest in the development of new strategies is high.

The study intends to test the hypothesis that combined oral supplementation of the antioxidants N-acetylcysteine (NAC) and milk thistle flavonolignan silibin (as silibin-phosphatidylcholine) will reduce proteinuria and urinary and systemic manifestations of oxidative stress and inflammation, which are characteristically observed in patients with T2DM and related nephropathy. The investigators expect these effects to be achieved with minimal or no side effects, and with good patient tolerance.

The trial is designed as a two-center, double-blind, placebo-controlled, randomized, modified-factorial dose-ranging design, five-arm pilot study in patients with Type 2 diabetes mellitus and advanced diabetic nephropathy with proteinuria.

Intervention consists of three-month oral administration of NAC, silibin, and/or respective placebos for three months. Subjects are randomized to the following five intervention arms: (A) placebo; (B) NAC; (C) silibin; (D) NAC + silibin; and (E) NAC + double-dose silibin.

The primary outcome measure is urinary excretion of albumin, a marker of glomerular injury. Secondary outcome measures are alpha-1 microglobulin, a marker of tubular injury, and urinary excretion of inflammatory cytokines and C-C chemokines, i.e. markers of renal inflammation. In addition, peripheral blood monocytes from the same patients are analyzed for GSH content and activity of GSH metabolizing enzymes. All outcome measures are monitored in relation to both treatment allocation and prevalent blood and urine levels of the active treatment. Safety and tolerability of this combination treatment are monitored throughout the trial.

Study Design
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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 108 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple (Participant, Care Provider, Investigator)
Primary Purpose: Treatment
Official Title: Correction of Glutathione Deficiency for Treatment of Diabetic Nephropathy
Study Start Date : January 2011
Actual Primary Completion Date : February 2015
Actual Study Completion Date : December 2016

Resource links provided by the National Library of Medicine


Arms and Interventions
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Arm Intervention/treatment
Placebo Comparator: NAC placebo and Silibin placebo
Drug: N-acetylcysteine placebo and Drug: Silibin placebo
 Drug: N-acetylcysteine placebo and silibin placebo
Dietary Supplement: N-acetylcysteine placebo excipient and silibin placebo orally twice daily for three months
Other Name: NAC placebo, Silibin-phosphatidylcholine placebo, Siliphos placebo
Experimental: NAC active and Silibin placebo
Drug: N-acetylcysteine and Drug: Silibin placebo
 Drug: N-acetylcysteine active and silibin placebo
Dietary Supplement: N-acetylcysteine 600 mg orally twice daily and silibin placebo orally twice a day for three months
Other Name: NAC, Silibin-phosphatidylcholine placebo, Siliphos placebo
Experimental: NAC placebo and Silibin active
Drug: N-acetylcysteine placebo and Drug: Silibin active
 Drug: N-acetylcysteine placebo and silibin active
Dietary Supplement: silibin 480 mg orally twice daily and N-acetylcysteine placebo orally twice a day for three months
Other Name: NAC Placebo, Silibin-phosphatidylcholine, Siliphos
Experimental: NAC active and Silibin active
Drug: N-acetylcysteine active and Drug: Silibin active
 Drug: N-acetylcysteine active and silibin active
Dietary Supplement: N-acetylcysteine 600 mg orally twice daily and silibin 480 mg orally twice daily for three months
Other Name: NAC, Silibin-phosphatidylcholine, Siliphos
Experimental: NAC active and High-dose Silibin active
Drug: N-acetylcysteine active and Drug: Silibin higher dose active
 Drug: N-acetylcysteine active + high-dose silibin active
Dietary Supplement: N-acetylcysteine 600 mg orally twice daily and silibin 960 mg orally twice daily for three months
Other Name: NAC, Silibin-phosphatidylcholine, Siliphos


Outcome Measures
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Primary Outcome Measures :
  1. Change From Baseline in Urinary Albumin Excretion [ Time Frame: Baseline and 3 months ]
    Urine albumin to creatinine ratio was assessed at the end of run in period and after 3 months administration of study intervention.


Secondary Outcome Measures :
  1. Change From Baseline in Hemoglobin-A1c [ Time Frame: Baseline and 3 months ]
    Hemoglobin A1C was assessed at the end of the run in period and after 3 months of administration of study interventions. Here is delta HgA1C is reported between the two periods

  2. Urinary Alpha-1 Microglobulin, Inflammatory Cytokines and C-C Chemokines [ Time Frame: Baseline and 3 months ]
    Urinary alpha-1 microglobulin, inflammatory cytokines and C-C chemokines were never measured and analyzed.


Eligibility Criteria
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Ages Eligible for Study:   18 Years to 76 Years   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Males or females age 18-76 years old
  • Type 2 diabetes mellitus

  • Diabetic nephropathy, as defined by:

    • estimated GFR between 60 and 15 ml/min
    • presence of proteinuria
  • Current medical treatment with low dose aspirin

  • Treatment of hypertension with (but not limited to):

    • one diuretic
    • one beta-blocker
    • and one medication from the classes Angiotensin Receptor Blockers (ARBs) or Angiotensin Converting Enzyme inhibitors (ACE-I)
  • Treatment of hyperglycemia with (but not limited to) glipizide and the medication class insulin
  • Treatment of hypercholesterolemia with (but not limited to) one medication from the class statins

Exclusion Criteria:

  • Type 1 diabetes mellitus
  • Glycosylated hemoglobin (HbA1C) > 10%
  • >20% variation in estimated GFR, during last 6 months
  • Systolic Blood Pressure >170 mmHg or Diastolic Blood Pressure >100 mmHg on medications
  • Other secondary forms of hypertension (endocrine, renovascular)

  • History of intolerance to:

    • Both ACE-I and ARBs
    • The investigational supplements
    • Iodinated radiologic contrast material
  • Known non diabetic renal disease
  • or history of solid organ transplantation
  • Hepatitis virus or Human Immunodeficiency virus infections

  • Use of one of the following medications within 2 months prior to enrollment in the study:

    • Metformin
    • Thiazolidinediones (pioglitazone or rosiglitazone)
    • Phenytoin
    • Warfarin
    • Prescription-grade vitamin E, vitamin C, systemic steroids, and/or non-steroidal anti-inflammatory agents
    • Over-the-counter vitamin E, vitamin C, and/or non-steroidal anti-inflammatory agents

    • Over-the-counter antioxidants supplements including:

      • Lipoic acid
      • Coenzyme Q10
      • N-acetyl-cysteine (NAC)
      • Glutathione (GSH)
      • Chromium
      • Fish-oil extracts (omega-3 fatty acids)
      • Soy extracts (isoflavones)
      • Milk thistle extract (silymarin)
      • Green-tea preparations
      • Pomegranate extracts
      • Grape extracts
      • Prickly pear extract
  • Active coronary artery disease or cerebral vascular disease within 3 months prior to signing the informed consent
  • Hepatic dysfunction as defined by abnormal total bilirubin or liver enzymes (ALT, AST) >2 times upper limit of normal range
  • Active malignancy
  • History of drug or alcohol dependency
  • Psychiatric or neurological condition, preventing aware consent to the study and/or adherence to the study protocol
  • Unwillingness to practice birth control throughout the study
  • Participation to another clinical study within 1 month prior to signing the informed consent form
  • Planned move to outside the study area, surgery or radiographic studies utilizing iodine-based contrast material within the next one year
Contacts and Locations
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Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT01265563


Locations
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United States, Texas
South Texas Health Care System, San Antonio, TX
San Antonio, Texas, United States, 78229
Sponsors and Collaborators
VA Office of Research and Development
National Center for Complementary and Integrative Health (NCCIH)
Investigators
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Principal Investigator: Paolo Fanti, MD South Texas Health Care System, San Antonio, TX
More Information
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Publications of Results:

Other Publications:

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Responsible Party: VA Office of Research and Development
ClinicalTrials.gov Identifier: NCT01265563    
Other Study ID Numbers: CLIN-004-10S
1R21AT004490-01A1 ( U.S. NIH Grant/Contract )
VA 1I01CX000264-01A2 ( Registry Identifier: VA )
First Posted: December 23, 2010    Key Record Dates
Results First Posted: March 31, 2017
Last Update Posted: October 19, 2018
Last Verified: September 2018
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: Undecided
Keywords provided by VA Office of Research and Development:
silymarin
glutathione
diabetic nephropathies
 oxidative stress
N-acetylcysteine
protein tholation
Additional relevant MeSH terms:
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Kidney Diseases
Diabetic Nephropathies
Proteinuria
Urologic Diseases
Diabetes Complications
Diabetes Mellitus
Endocrine System Diseases
Urination Disorders
Urological Manifestations
Acetylcysteine
Silybin
N-monoacetylcystine
 Antiviral Agents
Anti-Infective Agents
Expectorants
Respiratory System Agents
Free Radical Scavengers
Antioxidants
Molecular Mechanisms of Pharmacological Action
Protective Agents
Physiological Effects of Drugs
Antidotes
Antineoplastic Agents, Phytogenic
Antineoplastic Agents