Functional Constipation Clinical Trial
Official title:
Dose-response Effectiveness of 6-week Multistrain Probiotic Supplementation on Whole Gut Transit Time, Quality of Life, and Gastrointestinal Symptoms in Adults With Functional Constipation
Subjects will be screened and will enter a placebo-only 2-week run-in period during which constipation symptoms will be evaluated and any disallowed products (e.g. probiotics) must be discontinued. Following successful completion of the run-in period, subjects will be randomized to probiotic (high or low-dose groups) or placebo. Subjects will then consume their assigned product daily for 6 weeks. Subjects will undergo abdominal x-rays on study days 0 and 42 to assess transit time with each examination preceded by 6 days of radiopaque Sitz marker ingestion. Subject diaries will be used to collect bowel movement frequency, stool consistency, concomitant medications, and adverse events each day during the trial. Stool samples will be collected at baseline and end of study to assess fecal probiotic count. PAC-QOL, WCS, and GSRS questionnaires will be administered at baseline and day 42. 24-hour food recalls will be administered at day 0 and 42 and the following parameters will be assessed: total calories, carbohydrate, fat, protein, fiber, and liquid intake. Weekly physical activity recalls will be completed.
Primary Endpoint: Whole gut transit time
The primary endpoint of this clinical trial is whole gut transit time, which will be
assessed using abdominal x-rays (supine anteroposterior kidney-ureter-bladder, KUB) on days
0 and 42. Each subject will ingest 24 radiopaque Sitz markers each day for 6 consecutive
days at the same time of the day prior to abdominal x-rays on days 0 and 42, also taken at
the same time of the day that the markers were taken. The number of markers present in the
right, left, and rectosigmoid colon will be summed to yield a total marker count. Whole gut
transit time will be calculated using the classic film estimate as described in the
following formula:
WGTT = ni x (t/N) 19, 20
where ni is the number of markers observed on x-ray, t is the time between marker ingestions
in hours, and N is the total number of markers ingested each day. Thus, in this study, t/N
equals 1 (24 markers per capsule/24 hours between marker ingestions), and WGTT is,
therefore, equal to the total marker count 19, 20.
Marker counts will be identified by a single radiologist at each site who will remain
blinded to subject treatment assignment.
The methodology above is safe, noninvasive, and the two abdominal x-rays required for this
study collectively expose each subject to radiation doses of approximately 140 millirem
(equivalent to 1.4 millisievert). The overall lifetime risk that this radiation dosage may
cause cancer is approximately 1 in 4,000 for women aged 18 years, 1 in 6,000 for men aged 18
years, 1 in 20,000 for women aged 70 years, and 1 in 25,000 for men aged 70 years. Similar
abdominal x-ray methodology has been utilized in similar studies in adults aged 18 years and
older 21, 22.
Secondary Endpoint: Patient Assessment of Constipation Quality of Life (PAC-QoL) The PAC-QoL
(Appendix A) is a 28-question survey that measures the impact that constipation has on daily
life over the past 2 weeks. The questions are comprised of four subscales (worries and
concerns, physical discomfort, psychosocial discomfort, and satisfaction) and an overall
scale. Multinational studies have demonstrated that the PAC-QoL is internally consistent,
reproducible, valid, and responsive to improvements over time 23. Subjects will complete the
PAC-QoL at days 0 and 42.
Secondary Endpoint: Wexner Constipation Score (WCS) The Wexner Constipation Score (WCS)
(Appendix B) is an 8-question survey that assesses frequency of bowel movements, straining,
incomplete evacuation, abdominal pain, time needed for defecation, assistance for
defecation, unsuccessful attempts, and duration of constipation. The WCS is a validated
questionnaire since WCS scores correlate well with objective physiologic findings in
constipated patients 24. Subjects will complete the WCS at days 0 and 42.
Secondary Endpoint: Gastrointestinal Symptom Rating Scale (GSRS) The GSRS (Appendix C) is a
15-item instrument designed to assess common GI symptoms 25. It has five subscales (reflux,
diarrhea, constipation, indigestion, and abdominal pain) with subscale scores ranging from 1
(no discomfort) to 7 (severe discomfort). Higher scores represent higher symptom burden.
Subjects will complete the GSRS at days 0 and 42.
Secondary Endpoint: Stool frequency Throughout the study, subjects will record the number of
defecations per day in a diary throughout the study. The stool frequency endpoint will be
the absolute change in weekly stools in each group from the second week of the run-in period
to the sixth study week.
Secondary Endpoint: Stool Consistency Stool consistency will be rated with the Bristol Stool
Scale Form 26 (Appendix D). Subjects will grade each stool using a daily diary throughout
the study. The stool consistency endpoint will be the mean change in each group from the
second week of the run-in period to the sixth study week.
Secondary Endpoint: Fecal Probiotic Count Stool samples will be collected at baseline and
end of study to assess fecal probiotic count via live culture, which will include total
lactobacillis count and total bifidobacterium count. At the Day 0 visit following
randomization, subjects will be provided two separate stool collection kits—one to be used
at baseline and one to be used at the end of the supplementation period.
After receipt of the kits, subjects must provide the first stool sample before taking the
first dose of study product, regardless of the length of time needed to have a bowel
movement. The stool sample can be provided at the study site on Day 0 or the subject may
collect their first stool thereafter and ship the sample in a provided refrigerated
container to the laboratory for analysis. Once the first stool sample is provided, the
subject may then begin consuming study product.
During the final 3 days of the supplementation period (i.e. Day 40, 41, or 42), subjects
must provide another stool sample and ship the sample in a provided refrigerated container
to the laboratory for analysis. This must be completed before returning to the site for the
Day 42 assessments.
Secondary Endpoint: Adverse Events Adverse events (AEs) will be assessed throughout this
clinical study. The main safety endpoint will be the proportion of subjects in each group
that report one of more AEs at any time during the study. Please see Section 6 for
additional details on the AE assessment.
Ancillary Outcome: International Physical Activity Questionnaire (IPAQ)-short version The
International Physical Activity Questionnaire (IPAQ)-short version is a validated
questionnaire suitable for quantifying physical activity levels in adults (Appendix E) 27.
Ancillary Outcome: 24-hour Food Recall A 24-hour food recall will be completed in order to
quantify total calories, carbohydrate (g), fat (g), protein (g), fiber (g), and liquid
intake (ml). The food recall must take place on a weekday (Monday through Thursday).
Subjects must record all foods and beverages consumed as well as the quantity of each
(recorded as weight or volume).
Ancillary Outcome: Concomitant medication use Throughout the study, subjects will record use
of any concomitant medication and, if required, the need for rescue medication each day in a
diary.
;
Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Double Blind (Subject, Caregiver, Investigator, Outcomes Assessor), Primary Purpose: Supportive Care
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