Sickle Cell Disease Treatment With Arginine Therapy (STArT) Trial
Phase: PHASE3
Conditions: Sickle Cell Disease
Sponsor: Claudia R. Morris

Study Protocol 
 
 
 Sickle Cell Disease Treatment with Arginine Therapy (STArT) Trial 
 
 
Protocol Date: December 1, 2020 
 
 
NCT04839354 

Sickle Cell Disease Treatment with Arginine
Therapy (STArT) Trial
PECARN Protocol Number 050
IND#66943
Pediatric Emergency Care Applied Research Network
Protocol Version 1.00
Version Date: December 1, 2020

Copyright c⃝2020. University of Utah School of Medicine on behalf of the Principal
Investigator, Claudia R. Morris, M.D. and the Pediatric Emergency Care Applied Research
Network (PECARN). All rights reserved.
This protocol is PECARN Protocol Number 050, and has been authored by Claudia
R. Morris, M.D., Emory University, for implementation with the PECARN investigators.
This study is supported by UG3HL148560 and U24HL148563 awarded to Emory Univer-
sity (PI:Claudia R. Morris, M.D.) by the National Heart, Lung, and Blood Institute (NHLBI).
The PECARN Research is supported by the Health Resources and Services Administration
(HRSA) of the U.S. Department of Health and Human Services (HHS), in the Maternal
and Child Health Bureau (MCHB), under the Emergency Medical Services for Children
(EMSC) program through the following cooperative agreements: DCC-University of Utah
(UJ5MC30824), GLEMSCRN-Nationwide Childrens Hospital (U03MC28844), HOMERUN-
Cincinnati Childrens Hospital Medical Center (U03MC22684), PEMNEWS- Columbia Univer-
sity Medical Center (U03MC00007), PRIME-University of California at Davis Medical Center
(U03MC00001), CHaMP node- State University of New York at Buﬀalo (U03MC33154),
WPEMR- Seattle Children’s Hospital (U03MC33156), and SPARC- Rhode Island Hospi-
tal/Hasbro Children’s Hospital (U03MC33155). This information or content and conclusions
are those of the author and should not be construed as the oﬃcial position or policy of, nor
should any endorsements be inferred by HRSA, HHS or the U.S. Government
This document was prepared by the PECARN Data Coordinating Center (DCC) located
at the University of Utah School of Medicine, Salt Lake City, Utah. The document was
written and typeset using LATEX2ε. The DCC at the University of Utah is supported by
Cooperative Agreement U03-MC00008 from the Emergency Medical Services for Children
(EMSC) Program, Maternal and Child Health Bureau, Health Resources and Services
Administration.

Protocol 050 (Morris)
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PROTOCOL TITLE:
Sickle Cell Disease Treatment with Arginine
Therapy (STArT) Trial
Short Title: STArT
PECARN Protocol Number: 050
Lead Investigator and Author:
Claudia R. Morris, M.D.
Emory University
IND#66943
Protocol Version: 1.00
Version Date: December 1, 2020
I conﬁrm that I have read this protocol, I understand it, and I will conduct the study according
to the protocol. I will also work consistently with the ethical principles that have their origin
in the Declaration of Helsinki and will adhere to the Ethical and Regulatory Considerations as
stated. I conﬁrm that if I or any of my staﬀare members of the Institutional Review Board,
we will abstain from voting on this protocol, its future renewals, and its future amendments.
Principal Investigator Name:
Principal Investigator Signature:
Date:
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STArT Protocol Version 1.00
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Contents
Contents
5
List of Tables
7
List of Figures
7
1
Study Summary
9
1.1
Synopsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
1.2
Schema
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
1.3
Hypotheses
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
1.4
Speciﬁc Aims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
1.5
Subject Eligibility, Accural and Study Duration . . . . . . . . . . . . . . . .
13
1.6
Eligibility Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14
2
Rationale and Background
14
2.1
The importance of novel approaches to vaso-occlusive pain in sickle cell disease
(SCD)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14
2.2
Critical Barriers to Care for Patients with Sickle Cell Disease and Pain in the
Emergency Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15
2.3
Mechanisms of Arginine Dysregulation
. . . . . . . . . . . . . . . . . . . . .
15
2.4
Why Arginine if NO gas does not treat VOE? . . . . . . . . . . . . . . . . .
17
2.5
Therapeutic Potential of Arginine Therapy . . . . . . . . . . . . . . . . . . .
18
2.6
Arginine eﬀect is dose-dependent in VOE: Rational for a
loading dose in the ED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20
2.7
R34 pharmacokinetic study
. . . . . . . . . . . . . . . . . . . . . . . . . . .
20
2.8
Results of a single-center, double-blinded, RCT of arginine therapy for children
with VOE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
22
2.9
Results of a phase 2 RCT of oral arginine in children with SCD/VOE in Nigeria 24
3
Overall Study Design
24
4
Study Procedures
26
4.1
Screening and Enrollment
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
26
4.2
Randomization
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26
4.3
Study Drug Administration
. . . . . . . . . . . . . . . . . . . . . . . . . . .
26
4.3.1
Preparation, Storage & Labeling and Accountability . . . . . . . . . .
26
4.3.2
Dosing Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26
4.3.3
Discontinuation of Study Drug
. . . . . . . . . . . . . . . . . . . . .
27
4.3.4
Maintaining Blinding during the Study . . . . . . . . . . . . . . . . .
27
4.4
Sample Collection and Processing . . . . . . . . . . . . . . . . . . . . . . . .
27
4.5
Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
28
4.5.1
Schedule of Events . . . . . . . . . . . . . . . . . . . . . . . . . . . .
31
4.6
Withdrawal from Study
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
32
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5
Data Analysis
32
5.1
Speciﬁc Aim Analyses
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
33
5.2
Sample Size Calculations and Statistical Power . . . . . . . . . . . . . . . . .
35
5.3
Subgroups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
35
5.4
Missing Data
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
36
5.5
Interim Analyses
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
36
6
Data Management
36
6.1
Clinical Site Data Management
. . . . . . . . . . . . . . . . . . . . . . . . .
36
6.2
Electronic Data Capture . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
37
6.3
Data Coordinating Center . . . . . . . . . . . . . . . . . . . . . . . . . . . .
37
6.3.1
Data Center Description . . . . . . . . . . . . . . . . . . . . . . . . .
37
6.3.2
Security, Support, Encryption and Conﬁdentiality . . . . . . . . . . .
38
6.4
Records Access
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
38
6.5
Study Monitoring
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
39
6.5.1
Site Monitoring Plan . . . . . . . . . . . . . . . . . . . . . . . . . . .
39
6.5.2
Clinical Site Monitoring
. . . . . . . . . . . . . . . . . . . . . . . . .
39
6.5.3
Remote Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . .
40
6.5.4
Pharmacy Monitoring
. . . . . . . . . . . . . . . . . . . . . . . . . .
40
7
Protection of Human Subjects
40
7.1
Institutional Review Board (IRB) Approval
. . . . . . . . . . . . . . . . . .
40
7.2
Informed Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
40
7.3
Waivers Requested . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
41
7.4
Potential Risks
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
41
7.5
Protections Against Potential Risks . . . . . . . . . . . . . . . . . . . . . . .
42
7.6
Potential Beneﬁts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
42
8
Data and Safety Monitoring Plan
42
8.1
Data Safety Monitoring Board (DSMB) . . . . . . . . . . . . . . . . . . . . .
42
8.2
Adverse Event Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
43
8.2.1
Deﬁnition of Adverse Event and Serious Adverse Event . . . . . . . .
43
8.2.2
Classiﬁcation of an Adverse Event (Relatedness, Severity, and Expect-
edness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
44
8.2.3
Time Period for Adverse Events . . . . . . . . . . . . . . . . . . . . .
46
8.2.4
Data Collection Procedures for Adverse Events
. . . . . . . . . . . .
47
8.2.5
Unanticipated Problems (UP) . . . . . . . . . . . . . . . . . . . . . .
47
8.2.6
Monitoring Serious Adverse Events . . . . . . . . . . . . . . . . . . .
47
8.2.7
Follow-up of Serious Adverse Events
. . . . . . . . . . . . . . . . . .
48
9
Study Training
49
10 Regulatory Considerations
49
10.1 Food and Drug Administration
. . . . . . . . . . . . . . . . . . . . . . . . .
49
10.2 Health Insurance Portability and Accountability Act
. . . . . . . . . . . . .
49
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10.3 Inclusion of Women and Minorities . . . . . . . . . . . . . . . . . . . . . . .
49
10.4 ClinicalTrials.gov Requirements . . . . . . . . . . . . . . . . . . . . . . . . .
49
10.5 Retention of Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
50
10.6 Public Use Data Set
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
50
11 Bibliography
50
List of Tables
1
Synopsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
2
Laboratory monitoring will be undertaken according to the schedule below .
28
3
Schedule of Events
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
31
4
Expected Adverse Events Related to Opioid Administration
. . . . . . . . .
45
5
Expected Adverse Events Related to Sickle Cell Disease Progression . . . . .
45
List of Figures
1
Mechanisms of Vasculopathy and Dysregulation of the Arginine Metabolome
16
2
Maximum % change in NOx . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
3
Arginine impact on mitochondrial activity
. . . . . . . . . . . . . . . . . . .
21
4
Impact of arginine therapy on total opioid use, pain scores, & LOS . . . . . .
23
5
Crisis Resolution = Pain Score < 4 . . . . . . . . . . . . . . . . . . . . . . .
25
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Abstract
Background: Vaso-occlusive painful episodes (VOE) in sickle cell disease (SCD)
are the leading cause of hospitalizations, emergency room (ED) visits, and missed
school, and are associated with an increased mortality rate. There are no current
therapies to relieve vaso-occlusion, with interventions limited to hydration and anal-
gesia. Nitric oxide (NO), produced by the 5-electron oxidation of L-arginine, is a
potent vasodilator and exerts pleiotropic eﬀects on vascular and circulating blood cells,
including the inhibition of platelet aggregation, down-regulation of adhesion molecules,
and modulation of ischemia-reperfusion injury, all pathways adversely aﬀected during
VOE. In previous trials it has been found that pediatric SCD patients admitted with
VOE have depleted plasma L-arginine levels. Additionally, a single-center randomized,
double-blinded, placebo-controlled trial of arginine therapy in 54 children with VOE
requiring hospitalization was completed. A reduction in total opioid use (mg/kg) by
54% and signiﬁcantly lower pain scores at discharge in children who received 5 days IV
L-arginine therapy every 8 hours compared to placebo, as well as a clinically relevant
trend in reduced length of hospital stay of approximately 17 hours was observed. In
pharmacokinetic studies, it was found that IV arginine induced a dose-dependent im-
provement in mitochondrial function in children with SCD hospitalized for pain.
Design and Methods: It is now proposed that these results are extended to
a pivotal phase 3 trial of L-arginine for VOE. It is hypothesized that arginine is a
safe intervention with opioid-sparing eﬀects in pediatric patients with SCD and VOE
that will decrease the time children experience severe pain. Aim 1 of this study will
determine the eﬃcacy of IV arginine therapy on the primary outcome, time-to-crisis
resolution, as well as total parenteral opioid use (mg/kg) and pain scores in children
with SCD and VOE compared to placebo (Eﬃcacy). Aim 2 will monitor for safety of
IV L-arginine (Safety). Aim 3 will characterize alterations in the arginine metabolome
and mitochondrial function in children with SCD and VOE, and evaluate how it is
impacted by IV arginine therapy (Exploratory).
Signiﬁcance: This proposal will provide essential data for product development
and FDA regulatory approval for use of arginine in SCD. Acute care of patients with
SCD and pain in the ED is a neglected area of research. The results of this study may
ultimately lead to change in clinical practice for children with SCD in both the ED and
inpatient hospital wards. ED-based studies and novel therapies that target mechanisms
of vaso-occlusion and pain are needed in SCD.
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1
Study Summary
1.1
Synopsis
Table 1: Synopsis
Title:
Sickle Cell Disease Treatment with Arginine Therapy (STArT)
Trial
Study Description:
The trial is designed as a double-blind, placebo controlled,
randomized, phase 3, multi-center trial of IV arginine therapy in
children with SCD and VOE to further knowledge on eﬃcacy
and safety of this orphan drug. The exploratory objective is to
more fully characterize the arginine metabolome in children with
SCD during VOE, and evaluate the eﬀects of arginine therapy on
global arginine bioavailability and mitochondrial function
together with important clinical outcomes (time to VOE
resolution, pain scores, total parenteral opioid use,
Patient-Reported Outcomes (PROs), and hospital length of stay)
in children with SCD and VOE
Objectives:
Objective 1:
• To determine the eﬃcacy of IV L-arginine, when added to
standard therapy, on the time-to-crisis resolution in
children with SCD and VOE compared to placebo.
Important secondary and tertiary outcomes include length
of hospital stay, total parenteral opioid use (mg/kg
morphine equivalents), pain scores, and patient reported
outcomes (PROs) for pain in children with SCD and VOE.
Objective 2:
• To determine the safety proﬁle of IV L-arginine in the
treatment of acute VOE in children with SCD. In
particular, rate of acute chest syndrome, requirement for
blood transfusion, oxygen use during study drug delivery,
clinical deterioration and 72-hour and 28-day return visits
to the ED or hospital admission will be analyzed in those
receiving arginine compared to placebo.
Continued on next page. . .
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Table 1 – continued from previous page. . .
Objective 3:
• To further characterize alterations in the arginine
metabolome and mitochondrial dysfunction in children
with SCD and VOE, and evaluate how it is impacted by
arginine therapy.
• Establish a SCD-VOE biorepository to explore future
mechanistic studies.
Outcomes:
Primary Outcome: time-to-crisis resolution
Secondary and Other Outcomes: Length of hospital stay,
total parenteral opioid use, pain scores, Patient Reported
Outcomes (PROs), oxygen saturation at discharge, rate of acute
chest syndrome, ED or hospital readmission rates, requirement
for blood transfusion, and pain medication MQS.
Study Population:
This study will enroll 360 patients in the United States that are
3–21 years old with an established diagnosis of sickle cell disease
(any genotype) that are requiring medical care in an acute care
setting (ED, hospital ward, day hospital, clinic) for pain not
attributable to non-sickle cell causes.
Phase:
Phase 3
Description of
Sites/Facilities
Enrolling
Participants:
10 sites total (United States):
• Children’s Hospital Los Angeles
• Children’s Healthcare of Atlanta at Egleston
• Children’s Healthcare of Atlanta at Hughes Spalding
• Children’s Hospital of Philadelphia
• Children’s National Medical Center
• Medical College of Wisconsin/Wisconsin Children’s
Hospital
• Nationwide Children’s Hospital
• Texas Children’s Hospital/Baylor College of Medicine
• UCSF BenioﬀChildren’s Hospital
• Washington University/St. Louis Children’s Hospital
Continued on next page. . .
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Table 1 – continued from previous page. . .
Description of
Study Intervention:
Arginine is a safe nutritional supplement that is FDA approved
in parenteral form for growth hormone stimulation testing, with
nearly 50 years of safety experience through its common use by
endocrinologists.
Route of administration: IV
Dose: Participants will be randomized to one of two study arms:
• A one-time L-arginine loading dose (200 mg/kg IV) +
standard dose (100 mg/kg IV TID); OR
• Placebo (normal saline) loading dose (2ml/kg IV) +
1ml/kg IV TID.
Study Duration:
6 years
Participant
Duration:
28 days after discharge
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1.2
Schema
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This phase 3 randomized controlled trial will investigate the eﬃcacy and safety of IV
arginine for the treatment of children with Sickle Cell Disease (SCD) and acute pain. Pain is
the clinical hallmark of SCD, and is the leading cause of hospitalizations, emergency room
visits, missed school, and is associated with an increased death rate. Arginine is a promising
new therapy that could change the way we treat acute pain in children with SCD.
1.3
Hypotheses
The hypotheses of this study are:
1. Arginine therapy will decrease time-to-crisis resolution in children with an acute sickle
cell vaso-occlusive pain episode compared to placebo.
2. Arginine therapy will lower total parenteral opioid use (mg/kg) compared to placebo.
3. Arginine therapy will improve pain scores compared to placebo.
4. Arginine will have a similar safety proﬁle as placebo.
5. Arginine therapy will improve global arginine bioavailability and mitochondrial activity.
1.4
Speciﬁc Aims
This project has the following Speciﬁc Aims:
Speciﬁc Aim 1. To determine the eﬃcacy of IV L-arginine, when added to standard
therapy, on the time-to-crisis resolution in children with SCD and VOE compared to
placebo. Important secondary and tertiary outcomes include length of hospital stay,
total parenteral opioid use (mg/kg morphine equivalents), pain scores, and patient
reported outcomes (PROs) for pain in children with SCD and VOE.
Speciﬁc Aim 2. To determine the safety proﬁle of IV L-arginine in the treatment of acute
VOE in children with SCD. In particular, rate of acute chest syndrome, requirement
for blood transfusion, oxygen use during study drug delivery, clinical deterioration and
72-hour and 28-day return visits to the ED or hospital admission will be analyzed in
those receiving arginine compared to placebo.
Exploratory Speciﬁc Aim 3.
3a.To further characterize alterations in the arginine metabolome and mitochondrial
dysfunction in children with SCD and VOE, and evaluate how it is impacted by arginine
therapy.
3b. Establish a SCD-VOE biorepository to explore future mechanistic studies.
1.5
Subject Eligibility, Accural and Study Duration
The trial will enroll up to 360 participants with VOE, requiring up to 6 years of accrual.
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1.6
Eligibility Criteria
Eligible participants will be identiﬁed by study staﬀ.
Inclusion criteria are:
1. Age 3–21 years of age, inclusive; AND
2. Established diagnosis of sickle cell disease (any genotype); AND
3. Pain requiring medical care in an acute care setting (ED, hospital ward, day hospital,
clinic) not attributable to non-sickle cell causes, treated with parenteral opioids.
Exclusion criteria are:
1. Responds to 2 doses of IV opioids suﬃciently for outpatient management
2. Greater than 12 hours from ﬁrst dose of intravenous opioids to treat current pain in
acute care setting
3. Hemoglobin less than 5 gm/dL or emergent need for red blood cell transfusion for
hemodynamically unstable patient; OR
4. Ketamine use in the emergency department for treatment of VOE; OR
5. Glutamine within 30 days; OR
6. New Hydroxyurea (HU) use < 3 months or HU dose change < 3 months; OR
7. Acute mental status or neurological changes; OR
8. Acute stroke or clinical concern for stroke; OR
9. Three or more ED visits for sickle cell related pain receiving parenteral opioids in
previous 7 days (not including current ED visit); OR
10. Hospital discharge within previous 7 days; OR
11. Hypotension requiring clinical intervention; hemodynamic instability; septic shock; OR
12. Previous randomization in this arginine phase 3 RCT; OR
13. Use of inhaled nitric oxide, sildenaﬁl or arginine within the last month; OR
14. Non-English speaking; requires translator for clinical care; OR
15. Pregnancy; OR
16. Allergy to arginine; OR
17. PI/clinical team concerns for compliance/issues that may adversely impact study
participation/outcome.
2
Rationale and Background
2.1
The importance of novel approaches to vaso-occlusive pain in
sickle cell disease (SCD)
Pain is a clinical hallmark of SCD, and a signiﬁcant problem in emergency medicine.1, 2 Vaso-
occlusive painful episodes (VOE) are common, debilitating, and a medical emergency. VOE
are the leading cause of hospitalizations, emergency department (ED) visits, missed school,
and are associated with an increased mortality rate.3 Symptomatic relief with analgesics and
hydration are the only currently available treatments, and these have not changed in decades.
Episodic periods of severe pain lead to high use of health care resources, with high readmission
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rates.3 A 2010 health care utilization report revealed that 20% of patients with SCD experi-
enced ≥3 ED encounters per year.3 Hospital admission rates for VOE are ∼60% for children
with SCD4 and VOE.5 Many children with SCD also live with daily pain to some extent that
their families try to control at home through various methods. It is when the pain becomes
acutely worse, and unbearable, that they present to the ED in acute distress. A signiﬁcant
evidence gap exists for best treatment of VOE. Novel approaches to SCD/VOE that
can be utilized in the ED and hospital ward are critically needed. Interventions that target
underlying mechanisms of SCD pain in addition to providing symptomatic relief are worth
pursuing.
A single-center, double-blinded, randomized, placebo-controlled trial (RCT) of arginine
therapy in 54 children with VOE requiring admission6 was completed. A marked reduction in
parenteral opioid usage by 54%, decreased pain scores at discharge and a clinically relevant
trend in reduced length of hospital stay of ∼17 hours in children treated with 5 days of
100 mg/kg/dose, three times a day (TID), L-arginine therapy compared to placebo6 was
observed. In pharmacokinetics (pK) studies, it was also demonstrated for the ﬁrst time,
a dose-dependent increase in platelet mitochondrial activity in children with SCD-VOE
receiving IV arginine.7 A deﬁnitive phase 3 RCT is now indicated.
2.2
Critical Barriers to Care for Patients with Sickle Cell Disease
and Pain in the Emergency Department
Acute care of patients with SCD and pain in the ED is a neglected area of
sickle cell research. Nationally, 78% of the nearly 200,000 annual ED visits for SCD are
for a complaint of pain.8 Given the high ED utilization rate for pain in both adults and
children with SCD,2, 3, 8 ED-based research has not received the amount of attention and
funding that it deserves.9 Funding support for pain research that begins in the ED will
help to remedy this disparity and potentially reduce the signiﬁcant economic burden of this
disease.10
Negative impact of opioids over time. Emerging data supports long-term multi-
organ side eﬀects of opioids in SCD not appreciated years ago, and the recurrent/chronic
use of large doses of opioids compounds the problem further. Opioid-induced endothelial-,
mast cell-, renal mesangial-, and epithelial-cell-speciﬁc eﬀects and proinﬂammatory signaling
has been reported. Experimental and clinical studies suggest that opioids may exacerbate
existent organ damage and also stimulate pathologies of their own.11 Opioid-sparing pain
therapies are needed; decreasing opioid use is a clinically important outcome of
SCD-related morbidity.
2.3
Mechanisms of Arginine Dysregulation
Vaso-occlusion is believed to be the root cause of sickle cell pain. Nitric oxide (NO) is a free
radical and a potent vasodilator12 that regulates vascular homeostasis and plays a role in
SCD vaso-occlusion.6, 13–19 NO has properties that can impact every aspect of SCD, from
decreasing platelet activation and adhesion receptor expression on the vascular endothelium,
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to decreasing vascular smooth muscle proliferation, limiting ischemia-reperfusion injury,
modulating endothelial proliferation, and regulating inﬂammation. NO dysregulation is a
common denominator among varied mechanisms of sickle vasculopathy.19–21 NO is produced
in the endothelium from its obligate substrate L-arginine, which is converted to citrulline
by a family of enzymes, the NO synthases (NOS). Although NOS expression and activity is
increased, SCD is characterized by a state of NO resistance, NO inactivation, and impaired
NO bioavailability.18, 22, 23 Under conditions of increased hemolysis, inﬂammation or oxidative
stress, the compensatory upregulation of NO likely becomes overwhelmed and ineﬀective. Vas-
cular dysfunction is the end result, due to complex and multifactorial interactions (Figure 1).19
Figure 1: Mechanisms of Vasculopathy and Dysregulation of the Arginine Metabolome
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SCD is an arginine deﬁciency syndrome.20, 24–26 Normal arginine metabolism is im-
paired27–32 for many reasons (Figure 1). Plasma arginine concentration decreases signiﬁcantly
in both adults and children with VOE and is associated with low NOx levels.29 It was ob-
served that lowest arginine levels were found in children requiring admission for VOE,29 with
arginine levels returning to baseline during convalescence in the hospital. Of interest, low
plasma arginine concentration alone was a sensitive predictor for admission,29
while NOx levels were not, suggesting a function for arginine bioavailability in VOE severity
that goes beyond NO. Although adults with SCD are arginine deﬁcient at steady-state,19, 29
children have plasma levels that are similar to normal controls.29 Alterations in the arginine
metabolome diﬀer in children vs. adults. An arginine deﬁciency develops with age and is
inﬂuenced by acute events and chronic end organ damage that worsens over time. Children
may therefore be more responsive to arginine therapy during an acute pain event compared
to adults.
L-glutamine was recently FDA approved to treat adults and children with SCD, and is an
arginine prodrug.20, 26, 33 Since glutamine supplementation improves arginine bioavailability,34
similar mechanisms of action may contribute to decreased pain for both arginine and glutamine
therapy.26 Low global arginine bioavailability (GAB) as deﬁned by the ratio of arginine to
ornithine+citrulline is associated with both early mortality in SCD27 and VOE.29, 35 Increased
arginase activity from both inﬂammatory triggers and more signiﬁcantly from erythrocyte-
arginase release during hemolysis,27 intracellular arginine transport inhibition, renal dys-
function (which impairs the major route for endogenous arginine biosynthesis),33 elevated
endogenous NO synthase (NOS) inhibitors like asymmetric dimethylarginine (ADMA),36–38
competitive inhibitors of arginine transport and all NOS isozymes,39 uncoupled NOS40 and
other consequences of oxidative stress41–44 lead to low GAB in SCD. These mechanisms may
impact an individual’s response to arginine therapy. Although mechanisms of arginine
dysregulation are complex and multifactorial,24–26 they can be overcome through
arginine supplementation.45 Arginine represents a novel NO-based therapy6, 31 that may
have greater therapeutic potential than NO gas because of its multi-faceted nature that
extends beyond its function as the obligate NO substrate.46
2.4
Why Arginine if NO gas does not treat VOE?
Hemolysis will drive arginine consumption, which will ultimately exacerbate NO sequestration
and decreased NO synthesis.19 Under conditions of hypoxia, high ADMA, low arginine, or low
essential NOS cofactors,47 NOS will uncouple, producing reactive oxygen species in lieu of NO,
further reducing NO bioavailability and adding to the milieu of oxidative stress. An imbalance
between eNOS-derived NO and superoxide generation exists in SCD.48 Upregulation of NOS
would therefore enhance oxidative stress when the local milieu favors NOS uncoupling. Indeed,
studies in transgenic SCD mice demonstrate that NOS activity is paradoxically increased
and uncoupled while NO bioavailability is low.40 With NOS uncoupling, inhaled NO gas will
be rapidly sequestered by superoxide, forming peroxinitrite known to cause lung damage and
cell death. It is plausible that the provision of NO in SCD may lack therapeutic
beneﬁt in the absence of suﬃcient arginine bioavailability. This is a potential
pitfall of sildenaﬁl therapy as well as inhaled NO gas.46, 49
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2.5
Therapeutic Potential of Arginine Therapy
Arginine is a safe nutritional supplement that is FDA approved in parenteral form for growth
hormone stimulation testing,50, 51 with nearly 50 years of safety experience through its com-
mon use by endocrinologists. Experience with both oral and parenteral arginine therapy in
sickle cell disease is growing.
In transgenic SCD mouse models, arginine supplementation inhibits the red cell Gar-
dos channels,47 reduces red cell density,52, 53 improves perfusion, and reduces lung injury,
microvascular vaso-occlusion and mortality.40, 43, 44, 54 Arginine increases erythrocyte glu-
tathione levels in both mouse43 and human trials.55 Independent of SCD, low global arginine
bioavailability is associated with major adverse cardiovascular events including mortality in
patients screened for cardiovascular disease,56 mortality risk in malaria,57 and is associated
with pulmonary hypertension (PH) risk.31, 58, 59 Rapid healing of leg ulcers was reported with
IV arginine-butyrate in both SCD and thalassemia.60 It was found that short term arginine
therapy improves PH in SCD,61 and acutely increases both plasma and exhaled NO when
administered to healthy controls and patients with VOE.62, 63 When arginine is given to SCD
patients at steady-state, a paradoxical decrease in NOx occurs that is not overcome by higher
doses (Fig 2A),62 clearly indicating that arginine is metabolized diﬀerently in SCD compared
to controls. However when arginine is given during VOE, a robust dose-dependent increase in
NOx is observed. (Fig 2 B and C)62 This indicates that arginine is also metabolized diﬀerently
in SCD at steady-state (baseline) compared to times of acute illness including pain.29, 62, 63
These early observations may account for the negative outcome of the Comprehensive Sickle
Cell Centers’ (CSCC) arginine trial, particularly since the primary outcome measure of that
study was an increase in plasma NOx levels, when published data in fact demonstrated a
decrease in NOx with arginine supplementation at baseline. Ultimately, nutritional therapy
like arginine may be most beneﬁcial during a deﬁcient state such as VOE.
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Figure 2: Maximum % change in NOx in A. SCD at steady-state vs. VOE, B. VOE after
low vs. standard dose L-Arginine, and C. Arginine dose response in representative adolescent
SCD patient during steady-state versus two (2) separate VOE events.
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2.6
Arginine eﬀect is dose-dependent in VOE: Rational for a
loading dose in the ED
Low dose arginine therapy is likely to be subtherapeutic in SCD, and may represent an
additional ﬂaw in the CSCC prophylactic arginine trial design, as doses used were close to
placebo based on the cardiovascular literature.64 Previous studies have shown that low-dose
arginine is unlikely to impact NO synthesis,64 an observation conﬁrmed in the CSCC study.
The capacity of arginine to increase NOx production in SCD is dose-dependent.62 Higher
levels of plasma arginine are likely needed to overcome multi-factorial eﬀects
including impact of arginase and ADMA on global arginine bioavailability, and
accelerated arginine consumption during VOE compared to baseline (Fig 2 B
and C). A 1-time dose of 500 mg/kg or 30 grams IV arginine is safe and commonly used
for growth hormone stimulation testing.65, 66 Since the arginine formula is L-arginine hy-
drochloride, the safety of multiple higher doses over time is unknown given the potential to
induce acidosis, and must be taken into consideration, although no such adverse events have
occurred in the Morris arginine trials. However using a one-time loading dose upon initial
presentation for pain should be safe based on endocrine experience with growth hormone
stimulation testing using 500 mg/kg/dose for children, would avoid risks of repeated higher
doses, and may theoretically be more eﬃcacious by quickly overcoming eﬀects of excess
arginase and ADMA. This is the rationale behind investigating clinical eﬀects of a loading
dose of 200 mg/kg. In addition, our R34-supported pK study reveals a greater increase in
mitochondrial activity utilizing a loading dose (Fig 2).7
Based on our preliminary pK studies,62, 63 peak plasma arginine concentration after oral
arginine (0.1 g/kg) is signiﬁcantly higher during SCD steady-state compared to VOE, al-
though levels are similar by 4 hours.
Normal controls reach a peak arginine level be-
tween 1-2 hours that is maintained at 4 hours, and does not trend down as in SCD.62
Accelerated arginine metabolism or consumption occurs during VOE compared
to steady-state despite the same arginine dose given, likely contributing to an acute
nutritional deﬁciency.
2.7
R34 pharmacokinetic study7
Twelve children with SCD hospitalized for VOE were randomized to treatment utilizing one
of 3 dosing schemes of L-arginine: 1) 100 mg/kg IV three times/day (TID; n=4); 2) loading
dose (200 mg/kg) then 100 mg/kg TID (n=4); or 3) loading dose (200mg/kg) followed by
continuous infusion (300mg/kg/day) until discharge (n=4). Platelet rich plasma was isolated
and stored 81 at baseline and discharge for each subject and mitochondrial electron transport
complex activities measured (Fig 3 on the following page).
Results: Mean age was 14±3 years, 75% had Hb-SS, 67% were male and all were on
Hydroxyurea (HU). Compared to SCD patients in steady state,7 all subjects with VOE had
a signiﬁcantly decreased complex V activity (Fig 3 A). Notably, complex V activity was
increased at discharge in children with VOE treated with Arginine in all 3 dosing schemes.
However, the increase in complex V activity was greatest with loading dose arms compared to
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Figure 3: Arginine impact on mitochondrial activity
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standard dose (Fig 3 B). While complex IV and citrate synthase activities were not changed
in platelets from subjects with VOE vs. steady state (data not shown), the activities of
these enzymes were also signiﬁcantly increased in VOE subjects after Arginine treatment
(loading dose then continuous infusion, Fig 3 C–D). These changes with arginine are not due
to increased mitochondrial number as quantiﬁcation of mitochondrial DNA before and after
arginine were similar (Fig 3 E). IV Arginine signiﬁcantly decreased levels of protein carbonyls
in the platelet-rich plasma, suggesting a decrease in oxidative stress (Fig 3 F). Conclusion:
Promising reports of oral and IV arginine use for complications of mitochondrial encephalomy-
opathy, lactic acidosis and stroke-like episodes (MELAS) have been described.67–73 Our
data demonstrate for the ﬁrst time that arginine supplementation increases mitochondrial
activity in SCD/VOE, which may mechanistically contribute to decreased pain and less opioid
requirement after IV arginine, as well as have further implications for improved metabolism
and oxidative signaling in these patients. Although this pilot work did not include a placebo
arm, the signiﬁcant dose-dependent eﬀect suggests a diﬀerential eﬀect of L-arginine in SCD.
In total, our data suggest higher arginine consumption during VOE compared to steady-state,
that perhaps can be circumvented by a loading dose of parenteral L-arginine at initial presen-
tation for treatment of VOE.
2.8
Results of a single-center, double-blinded, RCT of arginine
therapy for children with VOE
A total of 56 children > 3 years old admitted to for VOE were enrolled in this NIH-supported
arginine trial (NHLBI K23 award HL-04386-05). Mean age was 13.9 ± 4 years (range 3.6–19
years), and 52% were female; 73% had Hb-SS, 18% Hb-SC and 9% carried S-β thalassemia.
Patients received IV arginine (100mg/kg TID) or placebo during hospitalization. RESULTS:
Patient characteristics were similar between treatment and placebo groups. Mean time be-
tween ED triage and delivery of ﬁrst randomized study drug dose was 20.4 ± 11 hours, with no
diﬀerence between the placebo and treatment arm. A signiﬁcant reduction in opioid use
(deﬁned as total opioid use in morphine equivalents during hospitalization in mg/kg) by 54%
was observed in the arginine treatment arm compared to placebo (mean ± SEM: 1.9 ± 0.4
mg/kg vs. 4.1 ± 0.8mg/kg; p=0.02; Fig 4 A). Pain scores were similar at presentation, but
signiﬁcantly lower at discharge in the arginine arm vs. placebo (Fig 4 B). A clinically relevant
trend of decreased hospital length of stay (LOS) by 17 hours favored patients treated with
arginine. Total IV opioid use (mg/kg) correlated strongly to LOS (r=0.86, p < 0.0001), and
represents a surrogate biomarker of LOS to evaluate study drug eﬃcacy (Fig 4 C). Rates of
ACS, transfusion and AEs were similar in both arms. No drug-related AEs were observed.
No signiﬁcant diﬀerences were observed between pre and post therapy liver or renal function,
or hematological parameters in the arginine group vs. placebo.
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Figure 4: Impact of arginine therapy on total opioid use, pain scores, & LOS. A. Arginine
supplementation (unﬁlled circles) led to a signiﬁcant & clinically relevant reduction in total opioid use by 54% over the course
of the hospital stay compared to the placebo group (ﬁlled circles). The diﬀerence remains signiﬁcant even when the 2 outliers
with the largest total opioid use in the placebo arm are excluded from the analysis (p=0.04). B. Pain scores were signiﬁcantly
lower at discharge in the arginine group compared to placebo by 2 cm.6 C. Correlation between Total Opioid Use (mg/kg) and
Length of Hospital Stay (Days).
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Safety data from 83 children enrolled in a phase 2 RCT protocol utilizing this IND#66943
(Sponsor-Morris), registered with ClinicalTrials.gov (NCT02536170), found no drug-related
SAEs occurred and SAE/AE rates are similar across study arms, providing further support
for the safety of arginine therapy in children with SCD.74 Re-hospitalization rates within
72-hours are 6%, which is less than the 20% previously reported in the literature. ED-based
recruitment staﬀavailable to obtain consent prior to admission is essential for successful
enrollment into acute VOE studies, since guardians are often not available once the child is
transferred to the inpatient unit. Arginine is a safe, eﬃcacious and inexpensive intervention
with narcotic-sparing eﬀects.6
2.9
Results of a phase 2 RCT of oral arginine in children with
SCD/VOE in Nigeria
Results of a phase 2 RCT of oral arginine therapy in 68 Nigerian children were reported as
the “Best of ASH” in December 2019.75 Mean age was 10.6±0.4 years, 38% were male and
all participants had Hb-SS. The authors found than arginine deﬁciency plays a role in acute
pain requiring hospitalization in Nigerian children with sickle cell anemia, similar to what
has been reported in the US. Plasma arginine levels signiﬁcantly increased with arginine
supplementation, and improved global arginine bioavailability was inversely associated with
total analgesia and opioids used in VOE management. Total mean analgesia use and pain
scores were lower, while time-to-crisis-resolution (Figure 5 A on the next page) and LOS
(Figure 5 B on the next page) were shorter in children treated with arginine compared to
placebo. No serious adverse events occurred in the arginine arm, while rates of adverse
events were similar to placebo, providing further support for the safety of arginine therapy in
children with SCA. Oral arginine is a promising adjuvant therapy for sickle cell anemia-VOE
management.
3
Overall Study Design
The trial is designed as a double-blind, placebo controlled, randomized, phase 3, multi-center
trial of IV arginine therapy in children with SCD and VOE to further knowledge on eﬃcacy
and safety of this orphan drug. Our exploratory objective is to more fully characterize the
arginine metabolome in children with SCD during VOE, and evaluate the eﬀects of arginine
therapy on global arginine bioavailability and mitochondrial function together with important
clinical outcomes (time to VOE resolution, pain scores, total parenteral opioid use, PROs,
hospital length of stay) in children with SCD and VOE. All patients will receive standard of
care treatment for VOE based on NHLBI guidelines.76 This study will utilize the PECARN
network.77–79
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(a) Probability of Non-resolution of VOC vs. Time-To-Crisis Resolution
(Hours)
(b) Probability of Hospital Stay vs. Length of Hospital Stay (Hours)
Figure 5: Crisis Resolution = Pain Score < 4
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4
Study Procedures
4.1
Screening and Enrollment
Each of the sites identiﬁed by the PECARN Steering Committee and the Study PIs have
access to their respective ED Electronic Health Record (EHR) for real time screening along
with in person coverage in house for 5–7 days per week and from 18–24 hours each day. The
RCs may also be contacted by pager or cell phone should the clinical care team identify any
patients that were not identiﬁed using the EHR or by the onsite RC. Research staﬀwill
approach parents of children and or patients between the ages of 3 and 21 years old in the
ED or inpatient ward (by phone or in person) to gauge interest in participation in the study.
Recruitment and study procedures will occur during “down” times when the patient is not
actively engaged in treatment (e.g. waiting for testing to commence and/or results to return)
to avoid interfering with clinical care.
Patient information will be reviewed and eligibility assessed for all patients as appropriate.
Research staﬀwill approach eligible patients for consent (see Protections of Human Subjects
section for consent procedures). No study procedures will be performed until informed consent
is obtained.
4.2
Randomization
Subjects will be randomized to receive either IV arginine or placebo. Permuted-blocks,
stratiﬁed by clinical center and age group (<12 vs. ≥12), will be used. Equal allocation
randomization tables will be provided by the Data Coordinating Center to the site research
pharmacies. Randomization numbers will be delivered to the clinical center staﬀusing a
web-based system. This system will use each enrolled patient’s age group (<12 vs. ≥12) to
deliver the next assigned treatment. Each site research pharmacy will use a randomization
number to look up the treatment assignment and prepare the appropriate study drug. The
randomization number will be recorded in the database.
4.3
Study Drug Administration
4.3.1
Preparation, Storage & Labeling and Accountability
Study drug will be prepared and blinded from clinical staﬀand patients by each site research
pharmacist. All sites will be responsible for documentation of drug accountability including
storage and dispensing information.
4.3.2
Dosing Schedule
Patients age 3–21 years will be randomized to one of two study arms:
• A one-time L-arginine loading dose (200 mg/kg IV) + standard dose (100 mg/kg IV
TID); OR
• Placebo (normal saline) loading dose (2ml/kg IV) + 1ml/kg IV TID.
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The maximum loading dose will be 20 gm, with a standard dose maximum of 10 gm IV
TID, which will continue until ED or hospital discharge, or for 21 doses, whichever comes
ﬁrst. (Dosing can be ordered every 8 hours, but there is TID ﬂexibility)
4.3.3
Discontinuation of Study Drug
Study drug will be stopped if a patient meets any one of the following criteria:
1) Neurological dysfunction or development of stroke while on protocol
2) Allergic reaction to study medication
3) Patient’s request
4) Abnormal lab results:
• Hepatic dysfunction: SGPT (ALT) >6X upper value; OR
• Renal dysfunction: Creatinine >1.2; OR
• Acidosis with bicarbonate <16
Arginine/placebo will be terminated, but clinical data and research blood collection will
continue.
NOTE: This is diﬀerent than withdrawal from the study. The clinical or research teams
may stop study drug administration for development of AEs or SAEs as described above
without withdrawing from the study. The participant may also decide to stop study drug
without withdrawing consent to participate. See section 4.6 on page 32 (Withdrawal from
Study) for additional information
4.3.4
Maintaining Blinding during the Study
In the event of adverse events thought to be related to arginine (see above) providers should
assume that the subject is receiving active drug (arginine) and take appropriate steps. The
clinical team and investigators should not attempt to unblind themselves.
4.4
Sample Collection and Processing
Blood (for plasma, erythrocytes and platelets) will be drawn, processed and stored for future
batched analyses at the time of presentation prior to study drug delivery (pre-Dose), on day
1 and prior to discharge (or ED discharge, whichever comes ﬁrst) (Table 2 on the following
page). The impact of IV arginine therapy on global arginine bioavailability will be determined
and compared to the placebo arm. Mitochondrial respiratory complex activities will be
measured as an indicator of mitochondrial function in platelets; aconitase activity will be
measured as an index of mitochondrial oxidative damage.80 These samples will also serve to
establish a SCD-VOE biorepository to explore future mechanistic studies.
Urine or serum pregnancy test results will be reviewed prior to randomization for female
participants 13 years or older.
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Sample collection, processing, storage, and shipping instructions will be detailed in a
separate document.
Table 2: Laboratory monitoring will be undertaken according to the schedule below
Pre-Dose1
Day 22
Day 8 or Discharge3
CBC with retic count (clinical)*
X
X
X
Comprehensive metabolic panel
X**
X
BHCG (girls ≥13 yrs)
X
Research Labs (Aim 3)
X
X
X
1 – Pre-dose is before the start of study drug.
2 – Day 2 is the day after study drug is administered (starting at midnight of the day the study drug is
started)
3 – Day 8 is the day that the last dose #21 will be given for patients who have not yet been discharged
*when available clinically
**Last CMP in medical record will be reviewed prior to randomization (up to 12 months): if abnormal
(meeting criteria for discontinuation of study drug) or not available, a CMP will be obtained Pre-Dose
and reviewed before randomization. Patients with CMP obtained at pre-dose that meet criteria for
discontinuation of study drug will be excluded from participation. All other patients will have a CMP
obtained on day 2. Patients with ALT > 3X upper limit, creatinine >1.0 or bicarb of 16 pre-dose or
day 2 will have CMP repeated in 24 hours.
4.5
Data Collection
Primary Outcome Measure: Time-to-crisis resolution, deﬁned as the time in hours from
study drug delivery to time of last dose of parenteral opioid delivery.
• Data being collected: date and time of ﬁrst study drug administration and last IV
opioid treatment
Secondary Outcome Measures:
1) Total parenteral opioid use (morphine equivalents, mg/kg)
• Data being collected: time of IV placement, opioid monitoring
2) Pain scores at presentation vs. discharge; Daily highest and lowest pain scores recorded
• Data being collected: Pain Scores (0–10 scale)
3) Three Patient Reported Outcomes (PROs),81–83 performed within 12 hours of study
drug delivery and on the day of discharge.
(a) PROMIS Pain Interference
(b) PROMIS Pain Behavior
(c) PROMIS Fatigue
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Tertiary Outcome Measures:
1) Patients ages 8 years of age and older and parents of patients ages 3–17 years of age
will answer a general health question noted below:
At time of discharge from the hospital:
“Since you left the emergency department, how has your pain been? “No pain since
in the Emergency Department, “Much better, “A little better, “The same, “A little
worse, “Much worse
2) Oxygen saturation at discharge
• Data being collected: Vital Signs
3) Medication Quantiﬁcation Scale (MQS)84 pre-dose and on day of discharge; daily.
4) Other Patient Outcomes not listed as secondary outcomes
Patient Reported Outcome (PRO) Data Collected:
1) Pediatrics - Ages up to and including 17 years old
• Pediatric PROMIS: (35 items)
To be completed by patients ages 8–17 years of age and parents of children ages
5–17 years of age.
(a) pain behavior (8 items),
(b) pain interference (8 items),
(c) pain intensity (1 item),
(d) physical stress experiences (8 items), and
(e) fatigue domains (10 items)
• Peds QL SCD module: (19 items)
To be completed by children ages 5–17 years of age and parents of children ages
3–17 years of age
(a) Pain and Hurt (9 items) and
(b) Pain Impact (10 items) domains
Total Pediatric PRO items to complete: 54 + 1 general health question = 55 items
2) Adults – 18 years of age and older
(a) PROMIS:(25 items)
(a) pain behavior (8 items),
(b) pain interference (8 items),
(c) pain intensity (1 item), and
(d) fatigue (8 items)
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(a) PROMIS ASCQ-ME (48 items)
(a) Emotional Impact Short Form v2.0 (5 items),
(b) Pain Episode Frequency and Severity (5 items),
(c) Pain Impact Short Form v2.0 (5 items),
(d) Sickle Cell Medical History Checklist (9 items),
(e) Sleep Impact Short Form v2.0 (5 items),
(f) Social Functioning Impact Short Form v2.0 (5 items), and
(g) Stiﬀness Impact Short Form v2.0 (5 items)
Total adult PRO items to complete: 64 items + 1 general health item = 65 items
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4.5.1
Schedule of Events
The Schedule of Events (table 3) summarizes data collection for each time point in the study.
Table 3: Schedule of Events
Screening
Pre-
Dose1
Day 12
Day 23
Day 3–74
Day 8 or
Discharge5
Day 14
and/or
Day 286
I/E
X
X
Demographics and
Genotype
X
Study Treatment
Assignment
X
Medical History
X
X
Pain Crisis Start
Date
and timea
X
Time of Last IV
opioid/Pain Crisis
End date and time b
X
Number of ED
visits/hospitalizations
in last year
(excluding current)
X
ED admission
information
X
Time of IV placement
X
Conmeds
X
X
X
X
X
CMPd
Xd
Xd
Xd
BHCGe
X
Research Labs
X
X
X
Vital Signsf
X
X
X
X
X
Pain Scoref
X
X
X
X
X
PROs
(PROMIS/Peds)
QL/ASCQ-Me
(adults)
X
(within
12
hours)
X
MQS Score
X
X
X
X
X
X
Symptoms
Questionnaireg
X
X
X
X
X
Opioid Monitoringh
X
X
X
X
X
X
X
Maintenance Fluid
Monitoringh
X
X
X
X
X
AEi
X
X
X
X
X
X
SAEi
X
X
X
X
X
X
Study Drug
Administrationj
X
X
X
X
Continued on next page. . .
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Table 3 – continued from previous page. . .
1 – Predose is all information that is collected before the start of study drug.
2 – Day 1 is from the start of Study Drug to midnight of the day study drug is started. Pre-Dose and Day 1 may occur
on the same day.
3 – Day 2 is the day after study drug is administered (starting at midnight of the day the study drug is started).
4 – Individual patient hospitalization duration will vary. Patients may be discharged at any time between Day 1 through
Day 7.
5 – Day 8 is the day that the last dose #21 will be given for patients who have not yet been discharged.
6 – If patients are not discharged by Day 8, the an AE/SAE review will occur daily until Day 14. ED revisits and hospital
admissions will be captured through 28 days following hospital discharge.
a – Pain Crisis start date/time is deﬁned as the date/time the patient started experiencing pain (this could be before
ED visit).
b – Pain crisis end date/time is deﬁned as the date/time of last dose of parenteral opioid delivery.
c – Research labs: will be obtained with routine daily blood draws whenever possible and may be drawn on days when
the research and clinical team suspect the patient may be discharged to avoid multiple venipunctures. In the event the
patient is not discharged on that date, discharge labs should be drawn again prior to discharge. Baseline labs to be drawn
before the start of study drug.
d – Screening CMP from a clinically ordered CMP or the last CMP in the medical record within the last 12 months will
be reviewed. If there are any values within higher than protocol deﬁned cut oﬀs for study drug withdrawal, then a CMP
is to be drawn and reviewed prior to randomization. For participants with normal past CMP, a CMP will be done on
day 2.
e – Pregnancy test obtained at Pre-Dose for females 13 years and older.
f – The ﬁrst set of Vital Signs (including oxygen saturation) and Pain scores will be captured when the patient ﬁrst
presents to the Emergency Department. The highest and lowest pain scores will be recorded from Day 1 through Day
8 (or within 6 hours of Discharge). The ﬁrst set of vitals signs after 6 am will be collected up until Day 8/Discharge,
whichever comes ﬁrst. Ensure oxygen saturation is captured at Pre-Dose and within 6 hours of Discharge.
g – Symptoms Questionnaire will be completed daily through Day 14 or Discharge.
h – Use of Parenteral Opioids will be documented every shift by nursing staﬀper standard protocol, including opioids
delivered by the PCA device as well as any intravenous, intranasal and/or oral opioids used. Data on daily opioid use
will be collected and recorded.
i – AEs and SAEs will be monitored daily through discharge or through 14 days of hospitalization; Return ED visits and
hospitalizations will be followed for 28 days after hospital discharge.
j – Patients will be randomized within 12 hours of their initial dose of parenteral opioid in the ED or ward and Arginine
will be administered TID.
4.6
Withdrawal from Study
As noted in Section 4.3.3 on page 27, this is a distinct concept from stopping the study
intervention. Patients and/or guardians may decide to stop participating in the study at any
time. If someone says they want to stop being in the study, they USUALLY mean they want to
stop the intervention. Eﬀorts should be made to clarify their speciﬁc preferences (withdrawal
from the intervention, withdrawal from follow-up, withdrawal from data collection, etc.)
Attempts should be made to continue safety data collection.
5
Data Analysis
All analyses will be undertaken by the intention-to-treat (ITT) principle. Patients who drop
out (discontinue study drug) will be followed and included in the ITT analysis. All statistical
tests of hypotheses will be two-sided.
The hypotheses of this study are:
1. Arginine therapy will decrease time-to-crisis resolution in children with an acute sickle
cell vaso-occlusive pain episode compared to placebo.
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2. Arginine therapy will lower total parenteral opioid use (mg/kg) compared to placebo.
3. Arginine therapy will improve pain scores compared to placebo.
4. Arginine will have similar safety proﬁle than placebo.
5. Arginine therapy will improve global arginine bioavailability and mitochondrial activity.
5.1
Speciﬁc Aim Analyses
Speciﬁc Aim 1: To determine the eﬃcacy of IV L-arginine, when added to stan-
dard therapy, on the time-to-crisis resolution in children with SCD and VOE
compared to placebo.
The primary outcome (time-to-crisis resolution) will be analyzed by a Van Elteren test,
stratiﬁed by clinical center and age group. The signiﬁcance level for the primary comparison
will be set at 0.05. The total length of stay in the hospital will also be analyzed, and this is
expected to show the same result as the analysis of the primary outcome.
In addition to the assessment of the statistical signiﬁcance of the treatment eﬀect, the
distribution of the primary outcome in each treatment arm using standard summary measures
and an estimated diﬀerence in means between the two arms with a two-sided 95% conﬁdence
interval will be described.
The overall signiﬁcance level for statistical tests on the secondary outcomes will be set
at 0.05. Holms method will be used to adjust for multiple comparisons.85 The numeric
secondary outcomes (opioid use, change in pain, and PRO measures) will be analyzed in the
same manner as the primary outcome.
Speciﬁc Aim 2: To determine the safety proﬁle of IV L-arginine in the treat-
ment of acute VOE in children with SCD.
Analysis of safety outcomes (acute chest syndrome, requirement of blood transfusion,
oxygen use, return visits, and clinical deterioration) will be conducted using Mantel-Haenszel
chi-square tests, stratiﬁed by clinical center and age group.
Summaries of incidence rates (frequencies and percentages), intensity, and relationship
to study of individual Adverse Events (AEs) by System Organ Class and Preferred Term
(MedDRA) will be prepared. All AEs beginning after randomization through 14 days or until
hospital discharge (whichever comes ﬁrst) will be included. ED revisits and hospital admis-
sions will be tracked through day 28 after hospital discharge. The occurrence of any adverse
event will be considered as a dichotomous outcome and will be compared between groups
using a Mantel-Haenszel test, stratiﬁed by clinical center and age group. Adverse events
will be coded using the latest version of the Medical Dictionary for Regulatory Activities
(MedDRA).
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Speciﬁc Aim 3: (Exploratory) 3a.
To characterize alterations in the arginine
metabolome and mitochondrial function in children with SCD and VOE, and
evaluate how it is impacted by IV arginine therapy.
Arginine mechanisms of action are multifactorial and elusive in VOE, which is why
incorporating an exploratory mechanism aim is important. However, it likely involves NO
(Fig 1–2). SCD patients have an arginine deﬁciency that acutely worsens during VOE that
should be assessed and treated. The beneﬁt of arginine therapy may be in part- by simply
replenishing a deﬁcient nutrient. It was found that children are metabolically diﬀerent
during VOE compared to baseline with respect to the “arginine metabolome”, which includes
amino acids that are precursors to (i.e. glutamine) or byproducts of arginine metabolic
pathways (ornithine, citrulline, polyamines etc.). Hemolysis releases erythrocyte-arginase,
which contributes to arginine consumption (Fig 1). This showed that the degree of arginine
deﬁciency correlates with pain severity and need for hospitalization.5 It is essential from a
mechanistic perspective to measure arginine levels in an arginine RCT pre and post-treatment.
If arginine is working as a “drug”, there may be eﬀects for all patients. However if we are
merely treating an acute nutritional deﬁciency that has consequences (i.e. vaso-occlusion),
the most robust response may occur in patients who have the greatest deﬁciency.86 Argi-
nine bioavailability and the GABR will be determined pre and post treatment. GABR
is associated with SCD complications and mortality risk,11, 87 while others demonstrate a
link to mortality risk and adverse events in cardiovascular disease55 and malaria.56 This
mechanistic aim will determine whether GABR reﬂects an objective biomarker of pain
severity, or one that identiﬁes patients most likely to positively respond to arginine therapy.
Subgroup analyses of clinical outcomes will be performed in patients from each tertile of
GABR. Finding novel biomarkers that identify subgroup responders to drug therapies is
an FDA and American Society of Hematology priority recently discussed at the SCD Clin-
ical Endpoints Workshop.88 It was also demonstrated that IV arginine therapy increases
mitochondrial activity (Fig 3). This proposal oﬀers an opportunity to study the impact
of arginine on mitochondrial function in a placebo-controlled fashion, necessary to assign
causality. Improved mitochondrial function may be associated with decreased oxidative stress,
a concept supported by our pilot data showing decreased protein carbonyls levels. Arginine
is already used clinically in mitochondrial disorders;1, 67, 69–72 this would be an important
novel mechanism of arginine in SCD to elucidate further, could lead to a new area of research
and is easy to measure.66, 89 Blood (for plasma, erythrocytes and platelets) will be drawn,
processed and stored for future batched analyses at the time of presentation prior to study
drug delivery (day 0), on day 1 and prior to discharge (or ED discharge, whichever comes
ﬁrst). The study will analyze the correlation between GABR and pain scores/opioid use, and
the impact of IV arginine therapy on GABR compared to the placebo will be determined.
Platelet mitochondrial respiratory complex activities will be measured as an indicator of
mitochondrial function and aconitase activity as an index of mitochondrial oxidative damage.66
3b. This aim will establish a large SCD-VOE biorepository to explore future
mechanistic studies. Currently a biorepository of pediatric SCD-VOE samples does not
exist. Acute pain samples are challenging to acquire given the unpredictable nature of ED
visits. Blood is already being collected in this protocol to measure GABR and mitochondrial
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function; storing addition samples adds signiﬁcant value to the proposal at minimal cost, to
answer future mechanistic questions. Additional analyses may be of interest (like arginase,
ADMA, NOx, creatine etc.), but would require additional funding. This project would create
the largest biorepository of SCD/VOE samples in existence; it would be a missed opportunity
to not bank additional sample for future mechanistic studies given the eﬀort of evaluating
360 children with SCD and VOE as part of this protocol.
5.2
Sample Size Calculations and Statistical Power
Based on a previous small trial, the diﬀerence between arginine and placebo groups is approx-
imately 0.7 days (length of stay, which parallels time to crisis resolution). A Type I error
bound of 0.05 (alpha) for the primary hypothesis will be used and it will be assumed that
age is not informative of outcome (a conservative bound for sample size). A simulation-based
approach is used to determine the sample size required to detect a diﬀerence (shift in distri-
bution) of 0.7 days with 85% power. In order to simulate placebo outcomes, time-to-crisis
resolution data from the MAGiC trial90(both arms combined, as the treatment eﬀect did
not reach statistical signiﬁcance)was used. For the arginine arm, outcomes were simulated
from the same distribution, shifted down by 0.7 days. 5,000 trials were simulated. This
process resulted in a required sample size of 166 per arm. Accounting for withdrawal (∼1%),
interim eﬃcacy monitoring (inﬂation of 2%), and crossover/non-adherence (3%, for example,
arginine subjects who do not receive a suﬃcient amount of study drug) results in an overall
inﬂation of about 8% or a total of 180 per arm. Prior to the ﬁrst interim analysis (after
approximately 100 subjects), the DCC and CCC principal investigators, along with the
DSMB, will review, blinded to by-treatment results, summaries of the outcome distribution
(mean, median, IQR with both arms combined – to compare with MAGiC data), withdrawal
rate, and non-adherence rates and may adjust the target sample size accordingly, as funding
allows.
Given a total sample size of 180 per arm, the eﬀect size that will be detectable in subgroup
analyses of the primary outcome, for example, a diﬀerential treatment eﬀect based on gender
or hydroxyurea use will also be reported. With 85% power, it will be possible to detect an
eﬀect size (diﬀerence in diﬀerences) of about 1.3 days, or approximately 1.9 times the main
treatment eﬀect size for which the study is powered. With 80% power, it will be possible to
detect an eﬀect size of 1.2, or 1.7 times the main treatment eﬀect size.
5.3
Subgroups
The formal subgroups speciﬁed for this trial will be age group, hydroxyurea use, and sex.
The interaction between assigned treatment and each subgroup factor in a linear model, at
a signiﬁcance level of 0.05/3 will also be tested. The model will include a main eﬀect for
treatment, a main eﬀect for subgroup factor, and an interaction between the subgroup factor
and treatment. Secondary outcomes in similar models will also be observed.
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5.4
Missing Data
High levels of missing outcome data are not expected in the STArT trial, as the outcomes
are quite short-term and readily available. In the event that a substantial number of subjects
are withdrawn, baseline characteristics and available information on hospital course will be
reviewed and compared to subjects not withdrawn, to assess empirically if these subjects
diﬀer from those remaining in the study for the scheduled treatment and data collection.
Sensitivity analyses to assess whether the results are robust will also be performed.
5.5
Interim Analyses
The Data and Safety Monitoring Board and trial monitoring plan are discussed in detail in
the Data and Safety Monitoring Plan. A two formal interim eﬃcacy analyses of accumulating
data, after approximately 150 and 250 subjects are enrolled, to be reviewed by the DSMB is
proposed. Aside from these formal analyses, the DSMB will meet at least yearly to review
safety data.
Early stopping will be considered if eﬃcacy has been established. Two-sided O’Brien-
Fleming boundaries, implemented using a ﬂexible alpha-spending approach, will be used
for eﬃcacy monitoring. Speciﬁcally, the signiﬁcance levels that will be used at the ﬁrst and
second interim analyses are 0.001 and 0.014, respectively. If the trial reaches the anticipated
total sample size, a signiﬁcance level of 0.046 will be used for the ﬁnal test.
As the trial can provide valuable scientiﬁc information, even in the face of a non-signiﬁcant
primary result, early stopping for futility is not anticipated. However, the DSMB and NHLBI
will evaluate all aspects of the trial and determine at any point in time whether futility should
be considered. It is expected that an informal, conditional power approach will be used to
provide statistical information to guide the futility analysis if and when needed. Speciﬁcally,
the probability of the study ﬁnding a signiﬁcant eﬀect, if continued, will be calculated under a
range of plausible true eﬀect sizes. A conditional power less than 20%, given the most liberal
plausible eﬀect size will indicate futility. The DCC biostatistician will point out assumptions,
advantages, and limitations of the futility analysis approach to the DSMB. The DSMB will
consider other factors, including the burden of ﬁnishing the trial at its current point, in its
deliberations.
6
Data Management
6.1
Clinical Site Data Management
The Data Coordinating Center will create the electronic data capture (EDC) system and
worksheets that can be used by clinical site research coordinators and investigators.
Data will be entered via the Web into the EDC. Worksheets and study documents will be
maintained in secure locations at each site. The site will maintain an Essential Documents
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Binder, which may be in paper or electronic form. Copies of all informed consent documents
will be kept on ﬁle and be available for site monitoring inspection (on site or remote).
6.2
Electronic Data Capture
Under the direction of the DCC PI and biostatistician, and in collaboration with study
investigators, the DCC will be involved with the development of electronic data capture
(EDC) systems to collect information on screening and enrollment, survey responses, and
safety measures. The DCC uses a web-based interface designed speciﬁcally for clinical trials
and observational studies. The DCC has developed a sophisticated software system for
managing data discrepancy queries. This Query Management System allows for data checks
on individual data ﬁelds (e.g., for missing or out-of-range data) in addition to the validation
of data between diﬀerent forms. This helps ensure that data will be complete and valid.
6.3
Data Coordinating Center
6.3.1
Data Center Description
Overview
The Data Coordinating Center (DCC) in the Department of Pediatrics at the
University of Utah School of Medicine provides data coordination and management services
for a variety of national research networks. Anchoring these services is a state-of-the-art,
energy eﬃcient data center. The data center facility supports more than 3500 users around
the country and provides a secure, reliable, enterprise-wide infrastructure for delivering
mission critical DCC systems and services.
Facility, Hardware, Storage, Data Backup and System Availability
The data cen-
ter was built using industry standards and energy eﬃcient cooling solutions. The data center
is cooled by Liquid Cooling Package (LCP) inline cooling technology, providing the desired
eﬃciency, redundancy and the modularity. The LCP utilizes a hot/cold aisle design that
allows for even air distribution to minimize hot spots. The data centers electrical power
system contains an uninterruptible power supply (UPS) with a diesel backup generator. The
data center is protected with an FM-200 backed ﬁre suppression system, which provides
waterless ﬁre suppression without leaving behind residue or particulate. Enhanced security
measures are implemented to safeguard the equipment and the data within in it. Security
measures are enforced 24 hours a day, 7 days a week, 365 days a year by a combination of
on-premise security guards, University police oﬃcers and video surveillance.
The data center has a virtualized environment. This environment consists of more than
415 virtual servers across 25 host servers. Virtualization provides key advantages: High avail-
ability (HA) – in the event of hardware failure, virtual machines (VM) automatically restart
on healthy resources, minimizing impact to end-users; Flexible infrastructure – compute and
storage is seamlessly scaled as current needs change; Rapid deployment - new resources are
provisioned on-demand.
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Production servers running mission critical applications are clustered and conﬁgured
for failover events across multiple clusters. Entire servers are backed-up to a dedicated
infrastructure. The backup repositories are encrypted-at-rest using AES-256. The storage
area networking (SAN) applications, clusters, and switch-to-switch links are highly redundant.
Incremental backups of data occur Monday through Friday. A full data backup occurs weekly.
Full backups are sent oﬀ-site on a weekly basis to a secure secondary location. The data
center currently manages over 125 terabytes (TB) of data.
Information systems are available 24/7/365 unless a scheduled maintenance period or
mitigation of an unexpected event is required. Critical systems availability has exceeded
99.9% for the past 5 years.
6.3.2
Security, Support, Encryption and Conﬁdentiality
The data center coordinates the network infrastructure and security with University Infor-
mation Technology (UIT) at the University of Utah. This provides us with robust ﬁrewall
hardware, automatic network intrusion detection, and the expertise of dedicated security
experts working at the University. Centralized authentication and communication over public
networks are encrypted using transport layer security (TLS) and/or virtual private network
(VPN) technologies. Direct access to data center machines is only available while physically
on premise or via a VPN client.
All network traﬃc is monitored for intrusion attempts. Security scans are regularly run
against data center servers and IT staﬀare notiﬁed of intrusion alerts. Security is maintained
with Windows user/group domain-level security. Users are required to change their passwords
every 90 days. All ﬁles are protected at user/group levels and database security is handled in
a similar manner with group-level access to databases, tables, and views. Finally, all laptops
used by faculty and staﬀin the DCC are whole-disk encrypted.
The data center uses monitoring tools to continuously monitor applications and servers.
Environmental and network systems are also monitored to ensure up-time. System Adminis-
trators are on-call 24/7/365 to respond to urgent events.
All personnel involved with the DCC have signed conﬁdentiality agreements concerning
data encountered in the course of their daily work. All personnel (including administrative
staﬀ) have received Human Subjects Protection and Health Information Portability and
Accountability Act (HIPAA) education. We require all users to sign speciﬁc agreements
concerning security, conﬁdentiality, and use our information systems before access is provided.
6.4
Records Access
The medical record and study ﬁles (including informed consent, permission, and assent
documents) must be made available to authorized representatives of the Data Coordinating
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Center, upon request, for source veriﬁcation of study documentation. In addition, medical
information and data generated by this study must be available for inspection upon request
by representatives (when applicable) of the Food and Drug Administration (FDA), NIH,
other Federal funders or study sponsors, and the Institutional Review Board (IRB) for each
study site.
6.5
Study Monitoring
The investigators recognize the importance of ensuring data of excellent quality. Study moni-
toring is critical to this process. Monitoring has been a very eﬀective tool for maintaining
data quality in previous Pediatric Emergency Care Applied Research Network studies, and
this process will be utilized to ensure excellent quality data in the proposed study. The DCC
utilizes risk-based methodology to identify and correct problems that may arise at sites. The
risk-based approach to monitoring focuses on oversight activities and preventing or mitigating
key risks to data quality, as well as to processes critical to human subject protection and
integrity of the trial or study.
Study monitors must be provided with appropriate access to study materials and the
medical records for study subjects. If the medical records are in electronic form, the clinical
investigator or an authorized individual must provide any assistance necessary to facilitate
the study monitors review of data in the electronic medical record.
6.5.1
Site Monitoring Plan
A supplemental study-speciﬁc, risk-based monitoring plan, separate from the protocol will be
completed which outlines speciﬁc criteria for monitoring. This plan may include the number
of planned site visits, criteria for focused visits, additional visits or remote monitoring, a
plan for chart review and a follow up plan for non-compliant sites. The monitoring plan also
describes the type of monitoring that will take place (e.g., sample of all subjects within a
site; key data or all data), the schedule of visits, how they are reported and a time frame to
resolve any issues found.
6.5.2
Clinical Site Monitoring
Site monitoring visits will be performed by a trained site monitor during the study period to
ensure regulatory compliance, patient safety, and to monitor the quality of data collected.
Essential document binders, regulatory documents and data collection forms may be reviewed.
Interim visits will take place depending on grant budget, site enrollment, and compliance
issues identiﬁed. The site monitor will provide each site with a written report, and sites will
be required to follow up on any deﬁciencies. It is anticipated that the study monitoring visits
for this protocol will consist of a site initiation visit (prior to patient enrollment), interim
visits, and a close out visit. The site initiation may take place as group training made up of
site investigators and research assistants. Site monitoring visits may be conducted in-person
or virtually, in conjunction with remote monitoring activities, depending on the speciﬁc
monitoring activities being conducted.
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6.5.3
Remote Monitoring
The Data Coordinating Center may also conduct remote monitoring activities. Remote
monitoring involves detailed review of the data entered by the Clinical Center and consultations
with the Clinical Center investigator and/or research coordinator to review safety and data
quality. This may require uploading copies of medical records, patient study ﬁles, regulatory
documentation, or other source documents for the monitor to review. Alternatively, other
methods, such as remotely viewing source documentation, may be utilized. This helps
assure protocol compliance and accurate data collection. The Data Coordinating Center may
conduct more remote monitoring activities early in the trial to assure protocol compliance and
identify any training issues that may exist. Remote monitoring documents will be retained
in accordance with federal requirements. Safety of subjects will be monitored and ensured in
accordance with the Data and Safety Monitoring Board (DSMB) plan.
6.5.4
Pharmacy Monitoring
The Clinical Center pharmacy must maintain adequate study drug accountability records
of all dispensed study drug. Each pharmacy will be monitored and may be requested to
send copies of these documents to the Data Coordinating Center. Since this study will use
a central pharmacy, that pharmacy must also maintain adequate records and will also be
monitored.
7
Protection of Human Subjects
7.1
Institutional Review Board (IRB) Approval
The Data Coordinating Center and each clinical center must obtain IRB approval prior to
participating in the study. A Single IRB (sIRB) will be used for this study. The University
of Utah IRB will serve as the IRB of record.
The Data Coordinating Center will track IRB approval status at all participating centers
and will not permit subject enrollment without documentation of initial sIRB approval and
local review sign-oﬀ. The Data Coordinating Center will also track the maintenance of that
approval throughout subsequent years of the project.
7.2
Informed Consent
Parental Permission/Subject Consent
Written permission from parents or legal guardians will be required for participation for
subjects who are eligible for this study and are under 18 years of age. Documentation of
consent may be either in paper or electronic form due to safety precautions in place for
the COVID – 19 Pandemic. Patients 18 years and older will consent for themselves. After
determining that a subject is eligible, the site investigator or designee will approach the
parent or legal guardian to oﬀer participation for their child in the study. The parent or
legal guardian will be informed about the objectives of the study and the potential risks and
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beneﬁts of participation. Subject will only be enrolled if their parent or guardian provides
permission for their child to participate.
Child Assent
Children who are capable of giving assent and who are alert and competent, will be asked,
following an age-appropriate discussion of risks and beneﬁts, to give assent to the study or
further study procedures. Assent will be waived if the child is too young, has a severely
reduced mental age, decreased level of consciousness, psychological problems, is 6 years old
or younger, or other legitimate reasons as judged by the Institutional Review Board.
7.3
Waivers Requested
Waiver of Authorization
A waiver of authorization is requested in order to be able to pre-screen/establish eligibility
and medical review for subject prior to approaching, consenting, and enrolling a subject.
7.4
Potential Risks
The risks in this study are considered low. Loss of conﬁdentiality of the subject is a potential
risk of the study; however, safeguards are in place to protect against this.
All consented patients will undergo phlebotomy and IV placement as part of their clinical
care. Patients admitted to the ﬂoor may undergo additional study blood draws before
discharge. Blood samples for this study will be drawn at the time of other phlebotomies
whenever possible to limit discomfort to the patient. Discomfort from venipuncture will be
experienced, and bruising from the blood draws are a potential risk to the patient.
For patients randomized to study drug in the clinical trial, the risks of the study are
conﬁned to those associated with the arginine administration. As with any food or medication,
the risk of an allergic reaction is a small but possible complication. Arginine is a nutritional
supplement with a low toxicity and has been safely used in many human studies, including a
number of studies in both adults and children with SCD.51 Intravenous arginine is preferred
over oral due to mild stomach discomfort may be experienced at higher doses, and issues with
compliance with respect to ingesting a large number of pills. Intravenous arginine may cause
ﬂushing, headache or vomiting. Patients with known compromised liver or kidney functions
will be excluded from participation. A signiﬁcant overdose of L-arginine hydrochloride can
cause acidosis and hyperkalemia particularly among patients with renal failure.91 However,
doses 5X higher than the standard dose used in these studies is typically used for growth
hormone stimulation testing, and is considered safe.
There are no age-related risks associated with an arginine infusion. The majority of
experience outside SCD for use of IV arginine is in younger children undergoing growth
hormone stimulation testing. The amount of ﬂuid a patient receives is based on weight, and
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is 1-2ml/kg, which poses no risk for ﬂuid overload.
All patients enrolled in the study will also receive treatment for vaso-occlusive pain
episodes that has been standardized across all participating sites, based on 2014 NHLBI
guidelines76 and the expertise of hematology and emergency medicine specialists with vast
sickle cell clinical experience.
7.5
Protections Against Potential Risks
Regarding loss/breach of privacy and conﬁdentiality, all applicable parties (e.g. clinical sites,
DCC) will be responsible for ensuring that appropriate data security procedures are in place.
Subjects enrolled in the study will be monitored carefully for the development of any
potential complications as described above. Subjects will be evaluated frequently by the
treating team as part of standard of care and medical records will be reviewed by the site
investigator on a routine basis throughout each participants enrollment.
All subjects discontinued early from the study protocol will have a reason for the early
discontinuation recorded on the appropriate case report form, and the circumstances leading
to discontinuation will be brieﬂy described. All adverse events (as described) leading to
discontinuation of study interventions will be fully documented and followed up as appropriate.
7.6
Potential Beneﬁts
The study may result in decreased pain and decreased length of hospitalization for the
subjects involved. Furthermore, the information gained from the analysis may lead to further
understanding of the physiology and treatment of sickle cell pain crisis. This could lead to
new therapeutic options for future patients. Finally, this pediatric study may beneﬁt adult
patients in the future, as positive results from this study would be used to plan a future trial
in adult patients.
8
Data and Safety Monitoring Plan
8.1
Data Safety Monitoring Board (DSMB)
The STArT Trial will utilize an independent NHLBI-appointed Sickle Cell Disease DSMB.
The purpose of the DSMB is to advise the Federal funding agency (NHLBI) and the STArT
scientiﬁc Principal Investigators regarding the continuing safety of study subjects and the
continuing validity and scientiﬁc merit of the study. The DSMB is responsible for monitoring
accrual of study subjects, adherence to the protocol, assessments of data quality, performance
of individual clinical sites, review of serious adverse events and other subject safety issues.
The Data Coordinating Center will send reports relating to these topics to the NHLBI prior
to each DSMB meeting. It is anticipated that the DSMB will meet for two formal interim
eﬃcacy analyses, and review safety information at least yearly (by phone or in person), but
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the DSMB will have the ﬁnal say in determining meeting intervals.
The DSMB will meet once prior to the start of the STArT Trial, and will approve the ﬁnal
protocol prior to implementation. The DCC will draft a DSMB charter using the NHLBI
template as a resource to guide its function for the trial and the charter will be approved by
the DSMB. The charter will include rules of procedure, deﬁnitions of a meeting quorum, and
information about meeting logistics and frequency. After the DSMB has approved its charter
and the ﬁnal protocol, the Data Coordinating Center will send this information to the single
site IRB.
The DSMB can recommend whether or not to terminate enrollment in STArT because of
potential safety concerns or study feasibility issues. The DSMB will also examine interim
data analyses to make decisions as to whether or not to terminate based on high evidence of
eﬃcacy or low likelihood of ﬁnding an eﬀect (futility). Technical details on the parameters
around formal interim analysis can be found in the Statistical Analysis section.
Documentation of the DSMB meetings will follow the NHLBI processes for review and
approval of the minutes and recommendations. After approval or modiﬁcation by the NHLBI,
the NHLBI Program Oﬃcer will forward the determination and recommendation to the DCC,
and provide a memo for the sites and the sIRB. The DCC will forward the report to the single
site Institutional Review Board (IRB). In the unlikely event that the DSMB recommends
emergent cessation of enrollment in STArT because of safety concerns, this communication
will be made during the debrieﬁng segment of the DSMB meeting. If the NHLBI staﬀconcur
with this recommendation, the Data Coordinating Center will notify all STArT clinical sites
to cease enrollment immediately.
8.2
Adverse Event Reporting
The site investigator is responsible for evaluating all adverse events at their Clinical Center
and ensuring that they are properly reported. Adverse events that occur during this study
will be recorded. The nature of each experience, date and time (where appropriate) of onset,
outcome, course, and relationship to treatment will be documented.
8.2.1
Deﬁnition of Adverse Event and Serious Adverse Event
Adverse Event (AE)
means any untoward medical occurrence associated with the use of
an intervention in humans, whether or not considered intervention-related (21 CFR 312.32
(a)). An event constitutes a disease, a set of related signs or symptoms, or a single sign or
symptom.
Serious Adverse Event (SAE):
A serious adverse event (SAE) for this population is an
adverse event that:
• results in death; or
• is life-threatening (the patient was, in the view of the site investigator, in immediate
danger of death from the event as it occurred); or
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• requires inpatient hospitalization or prolongs an existing hospitalization; or
• results in persistent or signiﬁcant disability or incapacity; or
• results in congenital anomaly/birth defect; or
• any other event that, based upon appropriate medical judgment, may jeopardize the
subject’s health and may require medical or surgical intervention to prevent one of the
other outcomes listed in this deﬁnition.
8.2.2
Classiﬁcation of an Adverse Event (Relatedness, Severity, and Expected-
ness
Relatedness:
The suspected relationship between study interventions and any adverse
event will be determined by the site investigator using the criteria below. Relatedness must
be assessed by an investigator and may not be assessed by a research coordinator.
Not Related: The event is clearly related to other factors, such as the subject’s clinical
state, therapeutic interventions, or concomitant drugs administered to the subject.
Possibly Related: The event follows compatible temporal sequence from the time of begin-
ning the assigned study intervention, but could have been produced by other factors
such as the subject’s clinical state, therapeutic interventions, or concomitant drugs
administered to the subject.
Probably Related: The event follows a reasonable temporal sequence from the time of
beginning the assigned study intervention, and cannot be reasonably explained by other
factors such as the subject’s clinical state, therapeutic interventions, or concomitant
drugs administered to the subject.
Severity:
The severity, which is a measure of intensity, of clinical adverse events and
laboratory abnormalities will be recorded by the site investigator and categorized. The
following guidelines will be used to describe severity.
Mild: The event requires minimal or no treatment and does not interfere with the participants
daily activities.
Moderate: The event results in a low level of inconvenience or concern with the therapeutic
measures. Moderate events may cause some interference with functioning.
Severe: The event interrupts a participants usual daily activity and may require systemic
drug therapy or other treatment. Severe events are usually potentially life-threatening
or incapacitating. Of note, the term “severe” does not necessarily equate to “serious”.
Expectedness of the Event:
All adverse events, including serious adverse events, will
be evaluated as to whether their occurrence was expected or unexpected. An AE will be
considered unexpected if the nature, severity, or frequency of the event is not consistent with
the risk information described for the study intervention.
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Expected: An event is considered expected if it is known to be associated with the underlying
condition or is related to the study intervention and is mentioned in the protocol,
informed consent, or other study documents. An event may be expected despite the
study subjects clinical state immediately prior to the event.
Unexpected: An event is considered unexpected if there are no prior data linking this
event with either the condition or intervention under study or an event that occurred
unexpectedly in the course of treatment.
Expected complications of opioid administration and sickle cell anemia are summarized in
Tables 4 and 5. Other expected adverse events are reactions known to occur with arginine
administration, speciﬁcally nausea, vomiting, headache, ﬂushing, warmth at the infusion site.
Table 4: Expected Adverse Events Related to Opioid Administration
Anorexia
Headache
Apnea
Hypotension
Biliary tract pressure
Miosis
Blurred vision
Nausea
Bradycardia
Palpitations
Bruising
Pruritus
Cardiac arrest
Rash
Confusion
Respiratory arrest
Cramps
Respiratory depression
Diaphoresis
Sedation
Diplopia
Shock
Dizziness
Tinnitus
Drowsiness
Urinary retention
Euphoria
Urticaria
Flushing
Vomiting
Table 5: Expected Adverse Events Related to Sickle Cell Disease Progression
Angioedema
Leukocytosis
Aplastic crisis
Meningitis
Aplastic crisis/anemia
Metabolic acidosis
Arthralgia
Osteomyelitis
Appendicitis
Pyelonephritis
Bone Infarction
Pain, joint
Cardiomegaly
Pain, long bone
Cerebrovascular accident
Pain, severe abdominal
Cholecystitis, hepatic sequestration
Priapism
Continued on next page. . .
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Table 5 – continued from previous page. . .
Cranial nerve palsy
Pulmonary embolism
Decreased kidney function
Pulmonary hypertension
Decreased lung function
Pulmonary parenchymal inﬁltrates on
CXR
Delayed growth/puberty
Pneumonia
Depresses ESR
Rhabdomyolysis
Fever
Renal Failure
Headache
Renal Insuﬃciency/albuminuria
Hematuria
Renal papillary necrosis
Hemiplegia
Reticulocytosis (10%–20%)
Hemolysis
Retinal disease
Hepato/spleno megaly
Retinal hemorrhage
Hyperplastic bone marrow
Skin ulcers
Hyposthenuria
Splenic sequestration
Hypoxia (PO2 < 85 mm Hg)
Stroke
Hyperkalemia
Sepsis
Hypotension
Upper respiratory infection
Infection, pneumococcal
Urinary tract infection
Treatment or Action Taken:
For each adverse event, the site investigator will record
whether an intervention was required:
• Medical or surgical procedure
• Concomitant medication: started, changed, or discontinued
• Other, specify
• No action taken
Outcome of Event:
Finally, the site investigator will record the clinical outcome of each
adverse event as follows:
• Death
• Recovered and the patient returned to baseline status
• Recovered with permanent sequelae
• Symptoms persist
8.2.3
Time Period for Adverse Events
For purposes of this study, events that occur following randomization through 14 days after
study drug initiation or until hospital discharge (whichever comes ﬁrst) will be reported as
adverse events. ED revisits and hospital admissions will be tracked through 28 days following
hospital discharge. Speciﬁcally, events that occur following parental permission to participate
in the study, but prior to actual randomization, are not adverse events. These should be
recorded as baseline conditions.
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8.2.4
Data Collection Procedures for Adverse Events
After patient randomization all adverse events (including serious adverse events) will be
recorded according to relatedness, severity, and expectedness, as well as their duration and
any treatment prescribed. Any medical condition present at the time of randomization,
recorded in the patients baseline history at study entry, which remains unchanged or improves
(unless the clinician feels it is clinically relevant), will not be recorded as an adverse event at
subsequent evaluations. However, worsening of a medical condition that was present at the
time of randomization will be considered a new adverse event and reported.
Abnormal laboratory values that are clinically signiﬁcant will be recorded as adverse events
and the site investigator will assess the severity and relationship to the study. Laboratory
values that are abnormal at the time of randomization and that do not worsen will not be
recorded as adverse events.
Adverse events will be coded using the MedDRA coding vocabulary. Coding will be done
centrally at the Data Coordinating Center as this requires speciﬁc training.
8.2.5
Unanticipated Problems (UP)
Unanticipated problems (UP) are deﬁned as incidents, experiences, or outcomes that are
unexpected, related or possibly to participation in the study, and suggest that the research
places subjects at a greater risk of harm than was previously known or recognized. The
site investigator will report unanticipated problems to the Data Coordinating Center within
24 hours of becoming aware of the event. A detailed completed report will be required to
be sent to the Data Coordinating Center within 3 working days of becoming aware of the
event. After receipt of the complete report, the Data Coordinating Center will report these
unanticipated problems to the NHLBI Program Oﬃcial and the NHLBI Executive Secretary
for the DSMB in an expedited manner (as close to 24 hours as possible). In accordance with
local IRB requirements, the site investigator may be required to report such unanticipated
problems to the IRB in addition to notifying the Data Coordinating Center. In the event that
the medical monitor believes that such an event warrants emergent suspension of enrollment
in the trial, and NHLBI staﬀcannot be reached expeditiously, the Data Coordinating Center
will notify the study investigator (Dr. Morris) and all site investigators to cease enrollment
in the trial. Resumption of enrollment will not occur without consent of the NHLBI staﬀ
after discussion with the DSMB.
8.2.6
Monitoring Serious Adverse Events
A qualiﬁed physician will be designated to fulﬁll the function of the medical monitor for this
study. Site investigators and/or research coordinators will report serious adverse events to
the Data Coordinating Center within 24 hours of becoming aware of the event. A detailed
completed report will be required to be sent to the Data Coordinating Center within 3
working days of becoming aware of the event, and the medical monitor will assess all serious
adverse events reported from site investigators.
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For each of these serious adverse events, the site investigator will provide suﬃcient medical
history and clinical details for a safety assessment to be made with regard to continuation of
the trial. The medical monitor will sign oﬀon each SAE report after review. All SAE reports
will be retained at the Data Coordinating Center, and all SAE reports will be available for
review by DSMB members and NHLBI staﬀ. Grade 4–5 SAEs will be reported to NHLBI
and the DSMB in real time with a tabular summary of these attached to each report. The
SAE reporting process may be incorporated into the Electronic Data Capture (EDC) System
in use for the study.
In the unlikely event that the medical monitor believes an unexpected and study-related
SAE warrants emergent cessation of enrollment in the trial, NHLBI staﬀand the DSMB
chairperson will be immediately consulted. If these individuals concur with the judgment of
the medical monitor, or if the NHLBI staﬀand the DSMB chairperson cannot be reached
expeditiously, the Data Coordinating Center will notify the study investigator (Dr. Morris)
and all site investigators to cease enrollment in the trial. Resumption of enrollment will not
occur without consent of the NHLBI staﬀafter discussion with the DSMB.
In accordance with local IRB requirements, the site investigator may be required to report
such events to the IRB in addition to notifying the Data Coordinating Center.
After notiﬁcation of the NHLBI Program Oﬃcial or Project Oﬃcer, and the DSMB chair-
person, of serious, unexpected, and study-related adverse events or unanticipated problems
(UP), decisions will be made whether to continue the study without change, and whether
to convene the entire DSMB for an emergent meeting. If a decision is made to suspend
enrollment in the trial, this will be reported to the study investigator (Dr. Morris) and all
clinical investigators, who will be instructed to report this to their local IRB.
The DSMB will review all adverse events (not necessarily serious, unexpected, and study-
related) during scheduled DSMB meetings. The Data Coordinating Center will prepare a
Summary Report of Adverse Events for the DSMB meetings, classiﬁed with the MedDRA
coding system.
The IND Sponsor (Dr. Claudia R. Morris MD) will notify the FDA of all study related
Suspected, Unexpected, Serious Adverse Reactions (SUSARs) according to FDA guidelines
(within 7 days for death and life-threatening SAEs, 15 days for all others) via an IND safety
report
8.2.7
Follow-up of Serious Adverse Events
All serious adverse events (expected or unexpected), regardless of relatedness that are
unresolved at the time of the patients termination from the study or discharge from the
hospital, will be followed by the Clinical Center investigators until the events are resolved,
subject is lost to follow-up, the adverse event is otherwise explained or has stabilized, or 12
months have passed from the time of last study dose.
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9
Study Training
A formal training program for investigators and research staﬀwill be held prior to the start
of enrollment. The training program will cover regulatory topics and Good Clinical Practice.
The training will also provide in depth explanations regarding study procedures, clinical care,
adverse event reporting, data entry procedures, quality assurance, site monitoring, and the
informed consent process. A manual of operations will be provided to each investigator prior to
the start of enrollment. The manual will detail speciﬁc information about the study procedures,
regulatory information, safety reporting, and other necessary information. Updates and
revisions to the manual will be made available electronically. The Data Coordinating Center,
in collaboration with the study investigator, will be the main contact for study questions.
10
Regulatory Considerations
10.1
Food and Drug Administration
This trial is being conducted under an active Investigational New Drug (IND) application
approved by the Food and Drug Administration (IND#66943, to Sponsor – Morris). The
clinical investigator at each participating site will complete a Form FDA 1572, “Statement of
Investigator.
10.2
Health Insurance Portability and Accountability Act
Data elements collected include the date of birth and date of admission. Prior to statistical
analyses, dates will be used to calculate patient age at the time of the study events. The ﬁnal
data sets (used for study analyses and archived at the end of the study) will be de-identiﬁed,
and will exclude these speciﬁc dates.
Data elements for race, ethnicity, and gender are also being collected. These demographic
data are required for Federal reporting purposes to delineate subject accrual by race, ethnicity,
and gender.
For purposes of the DCC handling potential protected health information (PHI) and
producing the de-identiﬁed research data sets that will be used for analyses, all study sites
have been oﬀered a Business Associate Agreement with the University of Utah. Copies of
executed Business Associate Agreements are maintained at the DCC.
10.3
Inclusion of Women and Minorities
There will be no exclusion of patients based on gender, race, or ethnicity.
10.4
ClinicalTrials.gov Requirements
This study will be registered at ClinicalTrials.gov, as it is an interventional trial.
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10.5
Retention of Records
For federally funded studies subject to the Common Rule, records relating to the research
conducted shall be retained for at least 3 years after completion of the research. Completion
of the research for this protocol should be anticipated to include planned primary and
secondary analyses, as well as subsequent derivative analyses. Completion of the research also
entails completion of all publications relating to the research. All records shall be accessible
for inspection and copying by authorized representatives of the regulatory authorities at
reasonable times and in a reasonable manner [45 CFR §46.115(b)].
10.6
Public Use Data Set
After subject enrollment and follow up have been completed, the DCC will prepare a ﬁnal
study database for analysis. A releasable database will be produced and completely de-
identiﬁed in accordance with the deﬁnitions provided in the Health insurance Portability and
Accountability Act (HIPAA). Namely, all identiﬁers speciﬁed in HIPAA will be recoded in a
manner that will make it impossible to deduce or impute the speciﬁc identity of any patient.
The database will not contain any institutional identiﬁers.
The DCC will also prepare a data dictionary that provides a concise deﬁnition of every
data element included in the database. If speciﬁc data elements have idiosyncrasies that
might aﬀect interpretation or analysis, this will be discussed in the dictionary document. In
accordance with policies determined by the investigators and funding sponsors, the releasable
database will be provided to users in electronic form.
11
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of a conditionally essential nutrient: Sickle cell disease and trauma. paper presented
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arginine bioavailability in patients with sickle cell disease: Preliminary pharmacokinetics
results. Paper presented at: Foundation for Sickle Cell Disease Research 5th Annual
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are diminished in adult acute vaso-occlusive sickle cell crisis in the emergency department.
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of asymmetric dimethylarginine, an endogenous nitric oxide synthase inhibitor, are
elevated in sickle cell patients but do not increase further during painful crisis. American
journal of hematology., 83(7):577–579, 2008.
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and death. British journal of haematology., 145(4):506–513, 2009.
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drolase pathway in the regulation of nitric oxide generation. Clin Sci., 100:159–160,
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pulmonary hypertension due to global impairment in nitric oxide bioavailability. Blood.,
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