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Glycerol Phenylbutyrate Corrector Therapy For CF (Cystic Fibrosis) (GPBA)

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ClinicalTrials.gov Identifier: NCT02323100
Recruitment Status : Not yet recruiting
First Posted : December 23, 2014
Last Update Posted : October 18, 2018
Sponsor:
Collaborators:
University of Alabama at Birmingham
Children's Hospital of Philadelphia
Johns Hopkins University
Horizon Pharma Ireland, Ltd., Dublin Ireland
Information provided by (Responsible Party):
Pam Zeitlin, National Jewish Health

Brief Summary:
We propose to test the effectiveness of the combination of CF pancreatic enzyme replacement therapy (PERT) on absorption of Ravicti® and subsequent restoration of nasal epithelial cystic fibrosis transmembrane conductance regulator (CFTR)-mediated chloride transport during the nasal potential difference (NPD) test. Funding source FDA Office of Orphan Products Development.

Condition or disease Intervention/treatment Phase
Cystic Fibrosis Drug: Ravicti low dose Drug: Ravicti high dose Drug: Placebo Phase 1 Phase 2

Detailed Description:

We were the first to test 4-phenylbutyrate (Buphenyl) as a systemic corrector of these defects in F508del under an investigator-initiated Investigational New Drug (IND)application held by P. Zeitlin. In a series of Phase 1 and 2 trials we established the maximum tolerated dose as 20 gm daily divided t.i.d. and the maximum induction of cyclic AMP (cAMP)-mediated nasal epithelial chloride transport with 30 gm daily as a median of -10 millivolt (mV) on days 4 and 7 of treatment.1;2 Under those conditions there was no significant decrease in sweat chloride values or in amiloride-inhibited nasal potential difference (NPD). We interpreted these results as a proof of concept of corrector therapy, but corrector therapy alone was likely an insufficient therapy for this mutation in CF, and therefore closed the IND for 4-phenylbutyrate.

In the ensuing years, Vertex Pharmaceuticals, Inc. has had success with the development of ivacaftor3;3;4 (VX-770) as a potentiator of G551D CFTR and has studied the drug alone and in combination with their corrector lumacaftor5 (VX-809) and VX-661. We at Johns Hopkins University (JHU), University of Alabama at Birmingham (UAB) and Childrens' Hospital of Philadelphia/University of Pennsylvania (CHOP/Penn) have participated in many of the clinical trials and are pleased and encouraged by the success of VX-770. It is not yet certain that future combinations of corrector(s) and potentiator(s) will be safe and effective, and it is prudent to explore alternative correctors and potentiators. Furthermore, recent structural investigations in a number of laboratories support the idea that more than one corrector may be necessary to fully restore F508del to the trafficking pathway 6. Precedent for combination of 4PBA with other CFTR modulators has been established in vitro 7;8 4-Phenylbutyrate tablets are formulated for oral delivery, and we showed that the pharmacokinetics were similar in CF to that in patients with urea cycle disorders. However the large number of tablets that had to be ingested at each meal were somewhat daunting at the 30 gm daily dose. A new pro-drug of 4-phenylbutyrate, glycerol phenylbutyrate or Ravicti®(owned by Hyperion Pharmaceuticals, Inc.) was approved in February 2013 by the US FDA. This new formulation is a significant advance for patients with urea cycle disorders because it is an oral, odorless, tasteless liquid, that contains 3 molecules of 4-phenylbutyrate for every molecule of the triglyceride. Simple arithmetic would suggest that one mole equivalent of the pro-drug provides three moles of active drug. However, pancreatic lipase enzymes are required to break the covalent bonds and release the active drug in the intestines. Because most CF patients homozygous for F508del are pancreatic-insufficient and already on enzyme therapy, we propose to test the effectiveness of the combination of CF pancreatic enzyme replacement therapy (PERT) on absorption of Ravicti® and subsequent restoration of nasal epithelial CFTR-mediated chloride transport during the nasal potential difference (NPD) test.


Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 36 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary Purpose: Treatment
Official Title: A Double Blind, Placebo Controlled, Dose Escalation Trial of Glycerol Phenylbutyrate Corrector Therapy for Cystic Fibrosis
Estimated Study Start Date : November 15, 2018
Estimated Primary Completion Date : June 2019
Estimated Study Completion Date : April 2020


Arm Intervention/treatment
Active Comparator: Ravicti low dose
Low dose Ravicti® oral liquid at 6ml (6.6 gm) by mouth or gastrostomy tube at 8 am, 5.5 ml (6.05gm) at 4pm and midnight for 7 days.
Drug: Ravicti low dose
8 am, 4pm and midnight
Other Name: Ravicti, glycerol phenylbutyrate

Active Comparator: Ravicti high dose
Ravicti® oral liquid at 9ml (9.9 gm)at 8 am and 8.25ml (9.08 gm) at 4pm and midnight for 7 days.
Drug: Ravicti high dose
8 am, 4pm and midnight
Other Name: Ravicti, glycerol phenylbutyrate

Placebo Comparator: Placebo
Matching placebo taken at 8am, 4pm and midnight for 7 days.
Drug: Placebo
8 am, 4pm and midnight




Primary Outcome Measures :
  1. The primary biological endpoint will be the change in average measurement of nasal potential difference between day 7 and baseline. [ Time Frame: 7 days ]
    chloride and sodium transport in nasal epithelium


Secondary Outcome Measures :
  1. Change in other NPD measures from baseline and Days 4, 7, and 14 to include baseline PD, change in amiloride, low chloride, and low chloride plus isoproterenol. [ Time Frame: 14 days ]
    change between date and baseline in sodium and chloride transport

  2. Change in average sweat chloride measurement between days 4, 7, 14 and baseline. [ Time Frame: 14 days ]
    change between study time point and baseline in sweat chloride

  3. Safety and tolerability. [ Time Frame: 14 days ]
    standard safety and tolerability lab values

  4. Efficacy of PERT on absorption of Ravicti®. [ Time Frame: 14 days ]
    quantification of exogenous pancreatic enzyme effects on release of active drug from the pro-drug triglyceride form


Other Outcome Measures:
  1. Plasma will be sampled for pharmacokinetics (PK) studies [ Time Frame: 14 days ]
    blood pharmacokinetics

  2. Safety labs: hematology, complete metabolic panel (CMP), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), uric acid. Sputum microbiology and spirometry will be performed. [ Time Frame: 14 days ]
    blood counts, metabolic measures, CRP



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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  1. Male or female 18 years or older.
  2. Confirmed diagnosis of CF based on the following criteria:

    positive sweat chloride greater than 60 met/liter (by pilocarpine iontophoresis) and/or a genotype with two identifiable mutations consistent with F508del CFTR and one or more clinical features consistent with the CF phenotype.

  3. Taking pancreatic enzyme replacement therapy (PERT).
  4. Ability to perform acceptable spirometry.
  5. Ability to understand and sig a written informed consent and comply with the requirements of the study.

6 FEV1 greater than 30% predicted normal for age, gender, height (Hankinson standards) pre or post-bronchodilator at Screening.

7. Oxygen saturation by pulseoximetry 90% or greater breathing ambient air at screening and day 1.

8. Hematology and clinical chemistry of blood and urine results with no clinically significant abnormalities that would interfere with the study assessments (as judged by the principal investigator) at screening. If electrolyte abnormality at screening, values must be corrected prior to dosing.

9. Subjects on chronic inhaled antibiotic therapy are eligible if they can continue their usual antibiotic regimen, or remain on their off-cycle period, for the duration of study drug exposure.

10. Negative pregnancy test for women of child-bearing potential. Females of childbearing potential must agree to practice one highly effective method of birth control, including abstinence, from the time of consent through the Day 14 outpatient visit. Barrier contraceptives such as the male condom or diaphragm are acceptable if used in combination with spermicides or there is documentation of azoospermia vasectomy, hysterectomy, or tubal ligation.(Orkambi)

Exclusion Criteria:

1. Current use of ivacaftor (Kalydeco), lumacaftor/ivacaftor combination, or other corrector or potentiator (Symdeko) less than 30 days from Screening.

2 Any investigational drug or device within 30 days of Screening or within 6 half-lives of the investigational drug (whichever is longer).

3. History of any illness or condition that in the opinion of the investigator could confound the results of the study or pose additional risk to subjects.

4. Any acute infection, including acute upper or lower respiratory infections and pulmonary exacerbations that require treatment within 4 weeks of Study Day 1.

5. Any change in chronic therapies for CF lung disease (e.g., Ibuprofen, Pulmozyme®, hypertonic saline, Azithromycin, TOBI®, Cayston®) within 4 weeks of Study Day 1 6. Pregnant, planned pregnancy or breast feeding 7. Clinically significant cardiac, liver or kidney disease 8. Seizure disorder 9. Use of continuous 24 hour or nocturnal supplemental oxygen therapy 10. Acute upper respiratory infection within 2 weeks or acute pulmonary exacerbation requiring intravenous antibiotics within 4 weeks of Screening Visit 11. Sinus surgery within 6 weeks of Screening Visit 12. Respiratory culture positive for Burkholderia cepacia within 2 years of Screening 13. Abnormal renal function 14. Abnormal liver function, defined as ≥3x upper limit of normal (ULN) of aspartate aminotransferase (AST), alanine aminotransferase (ALT) or known cirrhosis.

15. Screening laboratory results which in the judgment of the investigator would interfere with completion of the study 16. History of or listed for solid organ or hematological transplantation


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): NCT02323100


Contacts
Contact: Jennifer Brandorff 303-398-1811 brandorffJ@NJHealth.org
Contact: Britany Zeglin, BS 443-287-8983 bzeglin1@jhmi.edu

Locations
United States, Alabama
University of Alabama at Birmingham Not yet recruiting
Birmingham, Alabama, United States, 35294-0006
Contact: Steven M Rowe, MD, MSPH    205-934-9640    smrowe@uab.edu   
Principal Investigator: Steven M Rowe, MD, MSPH         
United States, Colorado
National Jewish Health Not yet recruiting
Denver, Colorado, United States, 80206
Contact: Nadia Shive    303-270-2321    shiven@njhealth.org   
Principal Investigator: Noah Lechtzin, MD         
Sub-Investigator: Peter Mogazel, MD, PhD         
United States, Pennsylvania
Children's Hospital of Philadelphia Not yet recruiting
Philadelphia, Pennsylvania, United States, 19104
Contact: Ron Rubenstein, MD, PhD    215-590-1281    rrubenst@mail.med.upenn.edu   
Principal Investigator: Ron Rubenstein, MD, PhD         
Sponsors and Collaborators
National Jewish Health
University of Alabama at Birmingham
Children's Hospital of Philadelphia
Johns Hopkins University
Horizon Pharma Ireland, Ltd., Dublin Ireland
Investigators
Principal Investigator: Pamela L Zeitlin, MD, PhD National Jewish Health

Additional Information:
Responsible Party: Pam Zeitlin, Professor of Pediatrics, National Jewish Health
ClinicalTrials.gov Identifier: NCT02323100     History of Changes
Other Study ID Numbers: GPBA
FD-R-0005380 ( Other Grant/Funding Number: FDA Office of Orphan Products Development )
First Posted: December 23, 2014    Key Record Dates
Last Update Posted: October 18, 2018
Last Verified: October 2018
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: Undecided

Studies a U.S. FDA-regulated Drug Product: Yes
Studies a U.S. FDA-regulated Device Product: No

Keywords provided by Pam Zeitlin, National Jewish Health:
cystic fibrosis
corrector
glycerol phenylbutyrate
nasal potential difference

Additional relevant MeSH terms:
Fibrosis
Cystic Fibrosis
Pathologic Processes
Pancreatic Diseases
Digestive System Diseases
Lung Diseases
Respiratory Tract Diseases
Genetic Diseases, Inborn
Infant, Newborn, Diseases
Glycerol
4-phenylbutyric acid
Cryoprotective Agents
Protective Agents
Physiological Effects of Drugs
Antineoplastic Agents