Effect of Alpha-lipoic Acid on Regression of Low-grade Squamous Intraepithelial Lesions (LSIL)
Condition: Low-Grade Squamous Intraepithelial Lesions
MeSH terms: Squamous Intraepithelial Lesions of the Cervix
Study type: Interventional

Summary: 
      Low-grade squamous intraepithelial lesions (LSIL) are premalignant changes on the cervix that
      can lead to malignant changes, i. e. cervical cancer. Alpha-lipoic acid is a fatty acid that
      is naturally found in food, and due to its proven antioxidant and anti-inflammatory effects,
      it is increasingly used as a dietary supplement, most often to alleviate the symptoms of
      various neuropathic conditions.

      The purpose of this study was to demonstrate efficiency, safety, and clinical benefit of
      alpha lipoic acid (ALA) in inducing regression of LSIL. The hypothesis is based on the proven
      role of oxidative stress and inflammation in formation of LSIL and anti-inflammatory and
      antioxidative efficiency of ALA.

      The study was designed as randomized, double-blind, two-arm, placebo-control trial recruiting
      100 female patients with diagnosed LSIL. Patients received 600 mg/day of ALA or placebo for 3
      months. Progression/regression of LSIL has been defined as primary outcome of the study;
      inflammation markers and oxidative stress parameters have been defined as secondary outcomes
      of the study.
    

Detailed description: 
      Cervical intraepithelial neoplasia (CIN) is premalignant change on the cervix that can lead
      to malignant changes, i.e., cervical cancer. Today, this term has been replaced by the more
      recent term squamous intraepithelial lesion (SIL). With the introduction of the term SIL into
      use (as proposed by Bethesda system), two grades are used to classify premalignant changes of
      the cervix: SIL of low grade (LSIL) which includes condylomas and mild dysplasia (CIN I), and
      high-grade squamous intraepithelial lesion (HSIL) that includes changes in terms of medium
      and high-grade dysplasia (CIN II and CIN III). The main etiological factor that leads to the
      formation of cervical neoplasia is the human papilloma virus (HPV). Other etiological factors
      such as smoking, oral therapy contraceptives, sexual habits, chemicals, immunosuppressive
      therapy, immunodeficiency diseases, socioeconomic living conditions and nutritional status of
      patients also play a role in the progression of the disease. In addition to the above,
      inflammation and oxidative stress are also important etiological factors in the development
      of SIL. Namely, malignant changes on the cervix do not appear on a completely healthy cervix
      but are always associated with chronic cervicitis.

      Alpha-lipoic acid (ALA) is a non-essential fatty acid with numerous metabolic roles and its
      therapeutic potential is being investigated in many pathophysiological conditions. In
      addition to acting as a cofactor of numerous signalling pathways in the cell, ALA also has a
      standard redox potential of -0.32 V, which gives it the ability to regenerate the most
      important physiological antioxidants in vivo (e.g. vitamin C and E) and makes it one of the
      most potent natural antioxidants. Given that it is implicated as a modulator of various
      inflammatory signalling pathways, its anti-inflammatory properties have been investigated by
      a large number of clinical studies. T This impressive array of cellular and molecular
      functions has led to significant interest in the research and use of ALA as a dietary
      supplement. ALA has been proven to improve insulin resistance, relieve symptoms of diabetic
      neuropathy, combine with phototherapy in the treatment of vitiligo, improve wound healing and
      increase the effectiveness of reduction diets. Its use as a dietary supplement is currently
      being investigated in dementia, burning mouth syndrome, carpal syndrome, glaucoma, cataracts,
      hypertension, and peripheral arterial disease. For therapeutic purposes, ALA is administered
      orally in doses of 300-1800 mg/day, and for some indications its topical and parenteral
      administration has been investigated. The safety of oral administration in the mentioned
      doses has been investigated in many clinical studies lasting from 4 months to 4 years. The
      effectiveness of ALA in premalignant changes of the cervix has not been investigated to date.
      Considering the proven effectiveness of oral supplementation with other antioxidants (such as
      green tea polyphenols or Se) in patients with LSIL, the aim of this research is to
      investigate, for the first time, the effectiveness of ALA in regression of LSIL.

      The study was designed as double-blind, randomized, placebo-controlled trial where
      participants were asked to self-administer either 600 mg of ALA in form of 2 capsules
      containing 300 mg of ALA (donated by Zada Pharmaceuticals, Lukavac, Bosnia and Herzegovina)
      or a placebo (provided as identical oral capsules containing rice starch, also donated by
      Zada Pharmaceuticals) per os daily for 3 months. The research protocol for this study has
      been approved by the Ethics Committee of the University of Zagreb, Faculty of Pharmacy and
      Biochemistry and the Ethics Committee of the University Clinical Centre Tuzla. The trial was
      performed in accordance with the international, national, and institutional guidelines
      pertaining to clinical studies and biodiversity rights and it complied with the CONSORT
      guidelines.

      At the initial appointment eligible patients were introduced to the study design. They were
      informed about the study protocol: aim and the purpose of the study, general methodology,
      expected roles of the participants, potential risks of participating in the study, potential
      benefits of the participation in the study, data confidentiality issues, and contact details
      of investigators who, when necessary, provided any kind of additionally needed information.
      In case patient agreed to participate in the study, they l signed informed consent form. All
      participants were asked to give their written informed consent for the inclusion in the
      study. After inclusion in the study patients filled a baseline questionnaire and provided
      information on basic anthropometric characteristics, reproductive history, current
      medication, and major lifestyle characteristics (smoking, level of physical activity).
      Examination of patients' eating and living habits was conducted using a standardized and
      validated semiquantitative food frequency questionnaire (FFQ) with the help of trained staff.
      Patients were advised not to change their diet during the study.

      Participants were randomized in the ratio 1:1 for ALA: placebo. Patients were randomly
      allocated a patient number that determined their supplement allocation. They received two
      bottles of capsules prelabelled with their study number containing either capsules of ALA
      sufficient for 3 months of supplementation, or identical capsules of placebo (rice starch)
      sufficient for 3 months of supplementation. Patients were asked to return the remaining
      capsules after the 3-month period to assess the adherence. During the supplementation period
      participants were contacted twice by telephone by a research team member to check possible
      adverse effects and to improve the adherence. Compliance after enrolment was measured as the
      percentage of pills taken between visits. Subjects who took less than 75% of pills after
      randomization were considered as noncompliant and were taken off the study. 3 months after
      the entry participants were invited to a follow up appointment.

      At both initial and follow-up appointment cytological screening, colposcopy and targeted
      biopsy and histological confirmation of cytological-colposcopic diagnosis wasconducted and
      blood samples were taken and analysed (assessment of primary and secondary outcomes of the
      study). The samples were collected at the Gynaecology and Obstetrics Clinic of the University
      Clinical Centre Tuzla over a period of 18 months. Sample analyses were conducted at the
      University Clinical Centre Tuzla and University of Zagreb, Faculty of Pharmacy and
      Biochemistry. Statistical processing, analysis and interpretation of the study results was
      completed within 6 months from the end of the analysis of the biological samples.

      Patients' personal data, data on their lifestyle and eating habits (obtained from the FFQ)
      and measurements of the primary and secondary outcomes of the study were stored and processed
      in electronic form of the patients' registry. Data dictionary containing detailed
      descriptions of each variable used by the registry, including the source of the variable was
      developed. The registry was operated according to standard operative procedures of the
      University Clinical Centre Tuzla. Project manager and his associates were obliged to fully
      comply with the prescribed procedures for the protection of personal data. Patients' data
      were entered into project databases according to the initials of patients first and last name
      and using a special code. Their medical documentation was only reviewed by the project
      manager and his associates, and patients' name was never revealed to third parties. Patients'
      documentation was accessible to representatives of the Ethics Committee at the institution
      where clinical study was conducted (University Clinical Centre Tuzla) and representatives of
      the Committee for the Ethics of Experimental Work of the Faculty of Pharmacy and Biochemistry
      of the University of Zagreb, which is responsible for approving and supervising the conduct
      of this research.

      Block randomization of patients was performed to ensure balance using an in-house computer
      program. To determine the sample size, a randomized clinical trial sample size formula was
      used, where type one (α) error was set at 5% and the study power was set at 90%. Ratio of
      case to control was 1, and expected dropout was 2%. LSIL wasthe main outcome of the study;
      expected proportion of LSIL in control group was 50%, and in the treated group 40%. Assuming
      a dropout 2% the target sample size has been determined to be 96 (48 subjects per group). The
      research results (qualification of cervical squamous epithelium lesions, parameters of
      inflammation, parameters of oxidative stress) was statistically processed using the MedCalc
      software package. The basic features of the variables were tested using descriptive analysis.
      The normality of data distribution was tested using the Kolmogorov-Smirnov test, and
      parametric or non-parametric statistical tests were used for further analysis of the results.
    

Intervention name(s): DL-alpha lipoic acid; placebo (rice starch)
Intervention type(s): Dietary Supplement; Other
Intervention description(s): Treatment group recieves 600 mg of DL-alpha lipoic acid daily, per os, for 3 months.; Placebo group recieves 600 mg (2x300 mg) of placebo (rice starch) daily, per os, for 3 months
Intervention MeSH terms: Thioctic Acid
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Care Provider, Investigator)
Primary purpose: Treatment
Keywords: alpha-lipoic acid; low-grade squamous intraepithelial lesions; LSIL; CIN; cervical intraepithelial neoplasia.