Clinical Study to Evaluate the Efficacy and Safety of Givinostat in Ambulant Patients With Duchenne Muscular Dystrophy

Duchenne Muscular Dystrophy Clinical Trial

Official title:

Randomised, Double Blind, Placebo Controlled, Multicentre Study to Evaluate the Efficacy and Safety of Givinostat in Ambulant Patients With Duchenne Muscular Dystrophy

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT02851797
• Other study ID #: EPYDIS (DSC/14/2357/48)
• Secondary ID: 2016-000401-36
• Status: Completed
• Phase: Phase 3
• Start date: June 6, 2017
• Est. completion date: February 22, 2022

Study information

• Verified date: January 2023
• Source: Italfarmaco
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Primary Objective

The primary objective of the study was to establish the effects of givinostat versus placebo administered chronically over 18 months to slow disease progression in ambulant DMD subjects.

Secondary Objectives

The secondary objectives of this study were:

• To assess the safety and tolerability of givinostat versus placebo administered chronically in DMD subjects

• To evaluate the PK profile of givinostat administered chronically in DMD subjects

• To evaluate the impact on quality of life (QoL) and activities of daily living of givinostat versus placebo administered chronically.

Description:

This was a phase 3, randomised, double-blind, placebo-controlled, multicentre study to evaluate the efficacy and safety of givinostat in ambulant subjects with DMD. This study included ambulant male paediatric subjects aged ≥ 6 years at baseline affected by DMD.

A total of 179 male ambulant subjects was randomized 2:1 (givinostat: placebo).

Subjects were stratified for their concomitant use of steroids in 4 strata:

1. Deflazacort daily regimen

2. Deflazacort intermittent regimen

3. Other steroids daily regimen

4. Other steroids intermittent regimen. The study duration was planned to be 19 months.

Givinostat or placebo oral suspension (10 mg/mL) was administered orally as 2 oral doses daily while the subject were in fed state, according to the child's weight.

Study drug should have been permanently stopped if any of the following occurred:

• severe drug-related diarrhoea;

• any drug-related Serious Adverse Event;

• QTcF >500 msec;

• platelets count ≤50 x 10^9/L.

• white blood cells ≤2.0 x 10^9/L

• hemoglobin ≤8.0 g/dL

Study drug should have been temporarily stopped if any of the following occurred:

• moderate or severe diarrhoea.

• platelets count <75 x 10^9/L but >50 x 10^9/L (the treatment should been temporarily stopped and a platelets count was to be performed and re-tested until platelets normalized);

• white blood cell <3.0 x 10^9/L but >2.0 x 10^9/L (the treatment should be temporarily stopped and white blood cells had to be measured by 1 week and re-tested until white blood cells normalized);

• hemoglobin <10.0 g/dL but > 8.0 g/dL (the treatment should be temporarily stopped and hemoglobin had to be measured by 1 week and re-tested until hemoglobin normalized);

• Triglycerides >300 mg/dL (3.42 mmol/L) in fasting condition (the treatment should be temporarily stopped and triglycerides measured every 2 weeks until triglycerides returned to levels below 300mg/dL (3.42 mmol/L)

In case the study drug was temporarily stopped, the study drug could be resumed at a level 20% smaller than the one at which the Adverse Event leading to temporary stop occurred, once platelets and/or white blood cell and/or hemoglobin normalized and/or triglycerides returned to levels below 300 mg/dL (3.42 mmol/L) or diarrhoea was mild.

In addition, in case a subject had a consistent (e.g., at least 2 consecutive evaluations) platelets count ≤150 x 10^9/L and didn't meet the stopping criteria for platelets, the Investigator should have to reduce the dose by 20% of the current dose.

Only one dose reduction was allowed during the treatment period.

This trial design a single planned interim analysis. The interim was governed by an IDMC in order to solely assess futility.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 179
• Est. completion date: February 22, 2022
• Est. primary completion date: February 22, 2022
• Accepts healthy volunteers: No
• Gender: Male
• Age group: 6 Years to 17 Years

Eligibility

Inclusion Criteria:

1. Are an ambulant male aged =6 years at randomisation with DMD characteristic clinical symptoms or signs (e.g., proximal muscle weakness, Gowers' maneuver, elevated serum creatinine kinase level) already present at screening;

2. Have DMD diagnosis confirmed by genetic testing;

3. Are able to give informed assent and/or consent in writing signed by the subject and/or parent/legal guardian (according to local regulations);

4. Are able to complete 2 Four Stairs Climb test (4SC) screening assessments; the results of these tests must be within ±1 second of each other;

5. Have the mean of 2 screening 4SC assessments =8 seconds;

6. Have time to rise from floor between =3 and <10 seconds at screening

7. Have manual muscle testing (MMT) of quadriceps at screening Grade =- 3;

8. Have used systemic corticosteroids for a minimum of 6 months immediately prior to the start of study treatment, with no significant change in corticosteroids type or dosage or dosing regimen (excluding changes related to body weight change) for a minimum of 6 months immediately prior to start of study treatment and a reasonable expectation that dosage and dosing regimen will not change significantly for the duration of the study.

9. Subjects must be willing to use adequate contraception.

Exclusion Criteria:

1. Have exposure to another investigational drug within 3 months prior to the start of study treatment;

2. Have exposure to idebenone within 3 months prior to the start of study treatment;

3. Have exposure to any dystrophin restoration product (e.g., Ataluren, Exon skipping) within 6 months prior to the start of study treatment;

4. Use of any pharmacologic treatment, other than corticosteroids, that might have had an effect on muscle strength or function within 3 months prior to the start of study treatment (e.g., growth hormone); Vitamin D, calcium, and any other supplements will be allowed as long as their intake has been stable for 3 months prior to the start of study treatment; Testosterone will also be allowed if it is used as a replacement therapy for the treatment of delayed puberty, and testosterone dose and regimen have been stable for at least 6 months and circulating testosterone levels are within the normal ranges for the subject's age;

5. Have surgery that might have an effect on muscle strength or function within 3 months before study entry or planned surgery at any time during the study;

6. Loss of =30 degrees of plantar flexion from the normal range of movement at the ankle joint due to contracture (i.e. fixed loss of more than 10 degrees of plantar flexion from plantigrade, assuming normal range of dorsiflexion of 20 degrees;

7. Change in contracture treatment such as serial casting, contracture control devices, night splints, stretching exercises (passive, active, self) within 3 months prior to enrollment, or expected need for such intervention during the study;

8. Have presence of other clinically significant disease, which, in the Investigator's opinion, could adversely affect the safety of the subject, making it unlikely that the course of treatment or follow-up would be completed, or could impair the assessment of study results;

9. Have a diagnosis of other uncontrolled neurological diseases or presence of relevant uncontrolled somatic disorders that are not related to DMD;

10. Have platelets count at screening < Lower Limit of Normal (LLN);

11. Have symptomatic cardiomyopathy or heart failure (New York Heart Association Class III or IV) or left ventricular ejection fraction <50% at screening;

12. Have a current or history of liver disease or impairment;

13. Have inadequate renal function, as defined by serum Cystatin C >2 x the upper limit of normal (ULN);

14. Have Triglycerides > 300 mg/dL (3.42 mmol/L) in fasting condition at screening visit;

15. Have a positive test for hepatitis B surface antigen, hepatitis C antibody, or human immunodeficiency virus at screening15.

16. Have a baseline QTcF >450 msec, or history of additional risk factors for torsades de pointes (e.g., heart failure, hypokalemia, or family history of long QT syndrome);

17. Have a psychiatric illness/social situations rendering the potential subject unable to understand and comply with the muscle function tests and/or with the study protocol procedures;

18. Have any hypersensitivity to the components of study medication;

19. Have a sorbitol intolerance or sorbitol malabsorption, or have the hereditary form of fructose intolerance.

20. Have contraindications to MRI or MRS (e.g., claustrophobia, metal implants, or seizure disorder).

At the discretion of the Investigator, subjects not meeting inclusion/exclusion criteria may be re-screened twice with an interval of at least 3 months between assessments.

Related Conditions & MeSH terms

• Duchenne Muscular Dystrophy
• Muscular Dystrophies
• Muscular Dystrophy, Duchenne

Intervention

Drug:
• givinostat
The oral suspension of givinostat (10 mg/mL) was to be dosed in fed condition as described below: Givinostat or placebo starting dose > or =10 and < 12.5 kg of weight: 13.3 mg bid = 1.3 ml oral suspension bid > or =12.5 and < 20 kg: 16.7 mg bid =1.7 ml oral suspension bid > or = 20 and < 25 kg: 20 mg bid = 2.0 ml oral suspension bid > or = 25 and < 30 kg: 23.3 mg bid = 2.3 ml oral suspension bid > or = 30 and < 40 kg: 26.7 mg bid = 2.7 ml oral suspension bid > or = 40 and < 50 kg: 33.3 mg bid = 3.3 ml oral suspension bid > or = 50 and < 60 kg: 36.7 mg bid = 3.7 ml oral suspension bid > or = 60 and < 70 kg: 40 mg bid = 4 ml oral suspension bid > or = 70 kg: 46.7 mg bid = 4.7 ml oral suspension bid
• placebo
The oral suspension of placebo, manufactured to mimic givinostat, was to be dosed in fed condition as described for givinostat.

Locations

Country	Name	City	State
Belgium	University Hospitals Leuven, Neuromuscular Reference Centre, Child Neurology	Leuven
Belgium	Hospital de La Citadelle, Centre de Référence des Maladies Neuromuscolaires (CRMN)	Liege
Canada	Kinsmen Research Centre - Alberta Children's Hospital - Alberta Health Services	Calgary	Alberta
Canada	Holland Bloorview Kids Rehabilitation Hospital	Toronto	Ontario
Canada	The University of British Columbia, Children's and Womens Health Centre of BC Branch	Vancouver	British Columbia
France	CHU de Nantes - Hotel-Dieu - Hopital Nord Laennec, rez-de-chausse haut ail Ouest	Nantes
France	Hopital Armand Trousseau I-Motion, Plateforme d'essais cliniques pédiatriques	Paris
Germany	Universitatsklinikum Essen - Kinder und Jugendmedizin Neuropadiatrie	Essen
Germany	Klinik un Policlinik fur Kinder und Jugendmedizin - Universitatsklinikum Hamburg Eppendorf	Hamburg
Germany	Klinikum der Uniersitat Munchen - Campus Innenstadt	Munchen
Israel	Institute of Neurology - Schneider Children's Medical Center of Israel Kaplan, 14	Petach-Tikva
Italy	IRCCS Istituto G.Gaslini, U.O.S.D. Centro Traslazionale di Miologia e Patologie Neurodegenerative	Genova
Italy	A.O.U. Policlinico G. Martino, U.O.C. Neurologia e Malattie Neuromuscolari	Messina
Italy	Centro Clinico NeMO Fondazione Serena ONLUS Area SUD	Milano
Italy	Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, UOS di Neurologia Pediatrica	Milano
Italy	Fondazione IRCCS Istituto Neurologico Carlo Besta	Milano
Italy	Fondazione Policlinico Universitario "A.Gemelli", UOC Neuropsichiatria Infantile	Roma
Italy	Ospedale Pediatrico Bambin Gesù, Malattie Neuromuscolari e Neurodegenerative	Roma
Netherlands	Leiden University Medical Center LUMC	Leiden
Netherlands	Radboud University Medical Centre	Nijmegen
Serbia	Clinic of Neurology and Psychiatry for Children and Youth - Neurology Department Dr. Subotic 6a,	Belgrade
Spain	Hospital Materno-Infantil - Passeig de la Vall d'Hebron	Barcelona
Spain	Hospital Sant Joan de Déu - Neuromuscular Pathology Unit	Esplugues de Llobregat	Barcelona
Spain	Hospital Universitario Virgen del Rocio	Sevilla
Spain	Hospital Universitari i Politécnic de la Fe - Servicio Neurologia	Valencia
United Kingdom	Alder Hey Children's Hospital NHS Trust	Liverpool
United Kingdom	UCL Great Ormond Street Institute of Child Health, Dubowitz Neuromuscular Centre and MRC Centre for NMD	London
United Kingdom	The John Walton Muscular Dystrophy Research Centre - Freeman Hospital - Newcastle University - Institute of Genetic Medicine	Newcastle upon Tyne
United Kingdom	The Robert Jones and Agnes Hunt Orthopaedic Hospital - NHS Foundation Trust	Oswestry
United States	MD Rare Disease Research, LLC	Atlanta	Georgia
United States	Children's Hospital Colorado	Aurora	Colorado
United States	Neuromuscular Research Center UC Davis Department of Physical Medicine and Rehabilitation	Davis	California
United States	Child Health Research Institute - Department of Pediatrics	Gainesville	Florida
United States	Connecticut Children's Medical Center - Division Neurology	Hartford	Connecticut
United States	University of Iowa Children's Hospital	Iowa City	Iowa
United States	University of Minnesota - Department of Neurology	Minneapolis	Minnesota
United States	Nemours Children's Hospital	Orlando	Florida
United States	The Children's Hospital of Philadelphia Colket Translational Research Building	Philadelphia	Pennsylvania
United States	Shriners Hospitals for Children	Portland	Oregon
United States	Virginia Commonwealth University Childrens Hospital of Richmond at Virginia Commonwealth University	Richmond	Virginia
United States	Washington University School of Medicine in St Louis - Department of Neurology	Saint Louis	Missouri
United States	Rady Children's Hospital center - UCSD Department of Neuroscience	San Diego	California

Sponsors (2)

Lead Sponsor	Collaborator
Italfarmaco	Syneos Health

Countries where clinical trial is conducted

United States,  Belgium,  Canada,  France,  Germany,  Israel,  Italy,  Netherlands,  Serbia,  Spain,  United Kingdom, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Mean Change From Baseline in 4 Standard Stairs (4SC) Climb After 18 Months of Treatment	The time (in seconds) to climb 4 standard-sized stairs is a TFT that represents stair-climbing ability. The test was evaluated by qualified functional evaluators (ie, physiotherapists) who were different from the site personnel who reviewed subjects' safety results. The test was performed in a standardised manner described in a specific site manual. Baseline 4SC was the measurement taken at the randomization assessment, unless this was missing, in which case baseline was taken as the last non missing value recorded prior to or on the date of first study treatment. The shorter the time, the better the outcome.	Baseline and 18 months
Secondary	Mean Change From Baseline in Time to Rise From Floor After 18 Months of Treatment	An analysis of time (in seconds) to rise from the floor by change from baseline at 18 months is presented for the Target Population in the ITT analysis set. The shorter the time, the better the outcome.	Baseline and 18 months
Secondary	Mean Change From Baseline in the Six-minute Walking Test (6MWT) After 18 Months of Treatment	This test measures the distance that a patient can quickly walk on a flat, hard surface in a period of 6 minutes.; The 6-Minute Walk Test is a useful measure of functional capacity targeted at people with at least moderately severe impairment. A modified version of the 6MWT recommended by American Thoracic Society (2002) for use in adults was performed.; The longer the walked distance the better the outcome.	Baseline and 18 months
Secondary	Mean Change From Baseline in Total North Star Ambulatory Assessment (NSAA) Score After 18 Months of Treatment	The total North Star Ambulatory Assessment (NSAA) is a 17-item rating scale that is used to measure functional motor abilities in ambulant children with Duchenne Muscular Dystrophy (DMD). It is usually used to monitor the progression of the disease and treatment effects. The 17 items of the NSAA, ranging from standing to running 10 meters, were graded using the standard score card with each assessment rated as 0 - unable to achieve independently, 1 - modified method but achieves goal independent of physical assistance from another, or 2 - normal with no obvious modification of activity. This scale is ordinal with 0 as the minimum score (indicating full disfunctionality, i.e. the worst outcome) and with 34 as the maximum score indicating fully-independent function (the best outcome).	Baseline and 18 months
Secondary	Cumulative Loss of Function on the NSAA	Subject cumulative number of failures across all postbaseline visits was the endpoint of interest for analysis.; For each subject at each postbaseline visit, failure to perform each of the 17 items of the NSAA was assessed, where "failure" was defined as a score transition from 2 or 1 at baseline to 0 at the respective visit. The total number of failed items for the visit was calculated (maximum of 17 failed items per visit per subject). The subject's cumulative number of failures across all visits was the sum of the total failures at each postbaseline visit.	over 18 months
Secondary	Mean Change From Baseline of Muscle Strength Normalized Overtime	The mean change of muscle strength normalized was evaluated by knee extension and elbow flexion normalized by subject weight, both measured by hand-held myometry (HHM).	Baseline and 18 months
Secondary	Mean Change From Baseline in Vastus Lateralis Muscle Fat Fraction (VL MFF) at 18 Months	Vastus lateralis muscle fat fraction (VL MFF) was expressed as fat infiltration in this muscle. Fat infiltration was assessed by Magnetic Resonance (MRS).	Baseline and 18 months
Secondary	Number of Subjects Experiencing Treatment-emergent AEs (TEAEs), Serious AEs (SAEs), Mild TEAE Moderate TEAE, Severe TEAE	Adverse Events are unfavorable changes in health, including abnormal laboratory findings, that occur in trial participants during the clinical trial or within a specified period following the trial.; Serious Adverse Events include adverse events that result in death, require either inpatient hospitalization or the prolongation of hospitalization, are life-threatening, result in a persistent or significant disability/incapacity or result in a congenital anomaly/birth defect. Other important medical events, based upon appropriate medical judgment, may also be considered Serious Adverse Events if a trial participant's health is at risk and intervention is required to prevent an outcome mentioned.	Baseline through end of study, that is the end of 18° month
Secondary	Evaluation of Acceptability/Palatability of the Oral Suspension	Acceptability and palatability of the oral suspension over time are presented. More in details, child perception of the medicine at the three timepoints hereunder specified; parent perception of the medicine based on the child's reaction at the same three timepoints; and parent problems administering the medication at the same timepoints are reported.	Week 4, EOS, early withdrawal