Photobiomodulation & Ketogenic Diet for Treatment of Mid-periphery Retinal Disorders for Alzheimer's Disease Prevention

Age-related Macular Degeneration (AMD) Clinical Trial

Official title:

Photobiomodulation & Ketogenic Diet for Treatment of Mid-periphery Retinal Disorders (Diabetic Retinopathy, Dry AMD, Hard Drusen Formation) for Alzheimer's Disease Prevention

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT03859245
• Other study ID #: Bristlecone-002
• Status: Recruiting
• Phase: N/A
• Start date: February 23, 2019
• Est. completion date: September 30, 2020

Study information

• Verified date: February 2019
• Source: Bristlecone Health, Inc.
• Contact: Kelly Gibas, Doctorate
• Phone: 763-913-4600
• Email: kgibas[@]bristleconemedical.com
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The study will explore the impact of photobiomodulation (PBM), pulsating at frequencies of red (660nm) and near-infrared (810nm)(NIR), concurrent with a ketogenic dietary protocol (serum ketones @ .5 - 2.0 mmol/L) to mediate vascular features of diabetic retinopathy (DR), diabetic macular edema (DME), age-related macular degeneration (AMD), mid-peripheral drusens, visual acuity and retinal disorders. Red and near-infrared light via light-emitting diode (LED) treatment promotes retinal healing and improves visual acuity by augmenting cellular energy metabolism, enhancing mitochondrial function, increasing cytochrome C oxidase activity, stimulating antioxidant protective pathways and promoting cell survival. LED therapy directly benefits neurons in the retina, the lateral geniculate nucleus and the visual cortex; likewise, a ketogenic dietary protocol shows metabolic and neuro-modulatory benefits within the CNS, most notably as treatment for refractory epilepsy. Photobiomodulation has been approved as a non-significant risk (NSR) modality for the treatment of eye disorders.

Description:

As part of the central nervous system (CNS), the retina shares key structural and functional features with the brain, making it a potential portal into a patient's medical future. Since the cerebral and retinal microvasculature are strikingly similar, the condition of retinal vasculature has been considered a proxy for cerebral vascular health. Retinal nerve fiber layer thinning, loss of retinal ganglion cells and optic disc changes may be associated with Alzheimer's disease (AD). Additionally, drusen formation in the macula has been shown to potentially predict AD severity. While the macula has been the primary focus of research for retinal abnormalities, the peripheral retina may be the earliest predictor of neurodegeneration via dry AMD (age-related macular degeneration) and diabetic retinopathy (DR). Ultra-widefield (UWF) retinal imaging has been shown to identify early biomarkers for AD and its progression. Peripheral hard drusen formation and changes to the vasculature beyond the posterior pole are associated with the pathogenesis of AD. A recent clinical trial found a significantly higher prevalence of the hard drusen phenotype within the periphery of AD patients (14/55; 25.4%) compared to controls (2/48; 4.2%)[p = 0.04]. Analyzing the peripheral retina for biomarkers of neurodegeneration such as drusen formation and vascular pathology offers a foundational diagnostic standard for preventative care. The proposed intervention purposes to inhibit the pro-inflammatory cascade in the retinal and cerebral vasculature via restoration of mitochondrial signaling, metabolic substrate flexibility and reduction of oxidative stress using a clinically prescribed ketogenic dietary protocol concurrent with photobiomodulation.

Deterioration in metabolic energy pathways is a prominent feature of AD, Parkinson's disease (PD), retinitis pigmentosa (RP), diabetic retinopathy, dry AMD, glaucoma and cerebellar atrophy. Common etiological mechanisms of neurodegenerative disorders of the eye and the CNS include mutations in the DJ-1 and Myc-Modulator (MM-1) genes and impaired mitochondrial signaling. Photobiomodulation (PBM) therapy, pulsating frequencies of 660nm and 810nm, has been shown to generate vasoprotective, neuroprotective, immunomodulatory and regenerative effects on mitochondrial function, cellular respiration, and improve retinal and cerebral vascularity. Recent studies have shown significant outcomes using PBM in the treatment of AMD, diabetic retinopathy, Stargardt disease, Leber's hereditary optic neuropathy, Parkinson's disease and Alzheimer's disease. Common to the etiology of each of these disease states is oxidative stress, an inflammatory cascade and activation of apoptotic pathways. Photobiomodulation proves to be both pro-oxidant in the short-term and antioxidant in the long term to potentiate a hormetic dose response. Likewise, PBM modulates inflammation via the immune regulatory pathways, reduces risk for retinal vascular dysfunction and offers protection from photoreceptor cell death. In primary astrocytes, improved immune regulation attenuates cerebral inflammation and oxidative stress induced by beta amyloid and initiates reparative action on protein misfolding by activating/modulating metabolic control over folding/unfolding.

Neuro-modulatory outcomes are well documented for ketogenic nutritional protocols; most recently, dietary ketosis has been shown to mediate Type 2 Diabetes Mellitus (T2DM), significantly reduce systemic inflammation, restore endocrine homeostasis and improve peripheral and cerebral insulin sensitivity. A recent study demonstrating the neuroprotective effects of a ketogenic diet on glaucoma suggests that increased insulin sensitivity protects retinal ganglion cell structure and function, reduces NF-KB p65 nuclear translocation and inhibits expression of pro-inflammatory molecules. The 8-week ketogenic nutritional intervention resolved energy demand and ameliorated inflammation by stimulating HCAR1-ARRB2 (Hydroxycarboxylic acid receptors-Arrestin beta -2) signaling pathways.

The rapidly increasing demand for healthcare among America's aging population warrants novel, integrative strategies focused on non-invasive treatments to ensure patient compliance and maximize health span concurrent with lifespan. Photobiomodulation therapy combined with multidisciplinary lifestyle modifications, such as ketogenic nutritional protocols, offered to patients in the optometry setting provides a viable therapeutic approach for healthcare providers on the front-line of diabetes care. The PBM intervention features both a diagnostic tool for prevention and a treatment model for retinal/cerebral microvasculature diseases common to aging: AD, PD, diabetic retinopathy, AMD, glaucoma and retinitis.

The study will explore the impact of photobiomodulation, pulsating at frequencies of red (660nm) and near-infrared (810nm), concurrent with a ketogenic dietary protocol (serum ketones @ .5 - 2.0 mmol/L) to mediate vascular features of diabetic retinopathy, diabetic macular edema, age-related macular degeneration (AMD), mid-peripheral drusens, visual acuity and retinal disorders. Red and near-infrared light (NIR) via light-emitting diode (LED) treatment promotes retinal healing and improves visual acuity by augmenting cellular energy metabolism, enhancing mitochondrial function, increasing cytochrome C oxidase activity, stimulating antioxidant protective pathways and promoting cell survival. LED therapy directly benefits neurons in the retina, the lateral geniculate nucleus and the visual cortex; likewise, a ketogenic dietary protocol shows metabolic and neuro-modulatory benefits within the CNS, most notably as treatment for refractory epilepsy. Photobiomodulation has been approved as a non-significant risk (NSR) modality for the treatment of eye disorders.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 30
• Est. completion date: September 30, 2020
• Est. primary completion date: September 30, 2020
• Accepts healthy volunteers: Accepts Healthy Volunteers
• Gender: All
• Age group: 18 Years to 80 Years

Eligibility

Inclusion Criteria:

Male or Female (age 18-80)

Previously diagnosed with MetS and/or T2DM as measured by possessing at least 2 of the following physiological measures: type II diabetes, BMI >30, HgA1c > 5.7, waist/height ratio >.6, fasting glucose > 125

Previously diagnosed with at least one of the following: mid-peripheral drusen formation, diabetic retinopathy (DR), age-related macular degeneration (AMD) or diabetic macular edema

Exclusion Criteria:

Previously diagnosed with Alzheimer's disease (AD), dementia or Parkinson's disease

Related Conditions & MeSH terms

• Age-related Macular Degeneration (AMD)
• Alzheimer Disease
• Diabetic Macular Edema (DME)
• Diabetic Retinopathy
• Diabetic Retinopathy (DR)
• Macular Degeneration
• Macular Edema
• Mid-peripheral Drusen Formation
• Retinal Diseases

Intervention

Behavioral:
• Photobiomodulation
Photobiomodulation therapy, via Joovv red light/infrared LED device, three days/week, 20 minutes per session for experimental and control groups.
• Ketogenic diet
Experimental group will follow a clinically prescribed ketogenic diet.

Locations

Country	Name	City	State
United States	Yankee Eye Clinic	Eagan	Minnesota

Sponsors (2)

Lead Sponsor	Collaborator
Bristlecone Health, Inc.	University of Minnesota - Clinical and Translational Science Institute

Country where clinical trial is conducted

United States, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Diabetic Retinopathy (DR) pathology	Improvement in number and severity of hemorrhages and hard and soft exudates as measured by the Daytona Plus (Panoramic Ophthalmoscope P200T)	36 weeks
Primary	Diabetic Macular Edema (DME) pathology	Lower incidence of macular edema as measured by Optos Daytona Plus (Panoramic Ophthalmoscope P200T) and Optovue XR Avanti 3 OCT (Ocular Coherence Tomography) Imaging Systems	36 weeks
Primary	Dry Age-related Macular Degeneration (AMD) pathology	Reduction in size and number of drusen in early and intermediate stages of Dry AMD pathology as measured byOptos Daytona Plus (Panoramic Ophthalmoscope P200T) and Optovue XR Avanti 3 OCT (Ocular Coherence Tomography) Imaging Systems	36 weeks
Primary	Hard Drusen in the Mid-periphery pathology	Reduction in size and/or density of drusen as measured by the Optos Daytona Plus (Panoramic Ophthalmoscope P200T)	36 weeks
Secondary	HgA1c	Assessment of changes in HgA1c (Hemoglobin A1c) over time. Ranges: <5.7%	36 weeks
Secondary	Fasting Insulin	Assessment of changes in fasting insulin over time. Ranges: < 2.6-11.1 mU/L	36 weeks
Secondary	Fasting Glucose	Assessment of changes in fasting glucose over time. Ranges 74-100 mg/dL	36 weeks
Secondary	HOMA-IR	Assessment of changes in HOMA-IR over time. Ranges <1.0	36 weeks
Secondary	Triglycerides/HDL ratio	Assessment of changes in triglycerides/HDL ratio over time. Ranges <2.0	36 weeks