Treatment With Metformin and Combination of Metformin and Pioglitazone in Polycystic Ovarian Syndrome
Condition: Polycystic Ovarian Syndrome
MeSH terms: Polycystic Ovary Syndrome; Syndrome
Study type: Interventional
Phase: Early Phase 1

Summary: 
      Objective:

        1. To investigate the changes in the levels of interleukin-6 and interleukin-8 after 3
           months treatment with metformin alone and combination of metformin and pioglitazone in
           patients with polycystic ovarian syndrome (PCOS).

        2. To evaluate insulin resistance in all the groups at baseline and after 3 months of
           treatment.

      Design: Two-Arm Randomized Clinical trial.

      Setting: Out-Patient Department (OPD) of Mardan Medical Complex, Khyber Medical University.

      Patient(s): One hundred and two patients with PCOS.

      Intervention(s): 51 women will receive metformin according to the body weight with maximum
      dose of 1000 mg (BD) daily. Remaining 51 will receive metformin and pioglitazone combination
      according to the body weight with maximum dose of 1000 mg and 30 mg (BD) daily.

      Main outcomes measure(s): Serum concentrations of fasting blood glucose, insulin, homeostatic
      model assessment for insulin resistance (HOMA-IR), follicle stimulating hormone (FSH),
      luteinizing hormone (LH), interleukin-6 (IL-6) and i-nterleukin-8 (IL-8).
    

Detailed description: 
      Effects of metformin and combination of metformin and pioglitazone on plasma IL-6 and IL-8
      levels in polycystic ovarian syndrome

      Sponsor:

      Office of Research, Innovation and Commercialization (ORIC)

      Khyber Medical University (KMU), Peshawar, Pakistan

      Hayatabad, Phase 5.

      Collaborations:

      This study is a collaborative project between Khyber Medical University Peshawar; Mardan
      Medical Complex, Mardan and Department of Human Pathology in Adulthood and Childhood "Gaetano
      Barresi", University of Messina (Italy).

      Coordinating Center:

      Clinical Trial Unit (CTU), Khyber Medical University, Peshawar

      Pakistan

      Email: CTU@kmu.edu.pk

      Study Chair

      Dr. Mohsin Shah

      Collaborative Group Chairs

      Dr. Farhat Rehman, Dr. Salvatore Giovanni Vitale M.D.

      CTU KMU Staff:

      Clinical Lead: Dr. Asif Ali

      Statistician: Dr. Muhammad Naseem/Dr. Zia Ul Haq

      Project Manager: Dr. Mohsin Shah, Dr. Dur-e- Shehwar Ali

      Emergency contact:

      Name: Dr. Farhat Rehman; Phone: 0301 8192880

        1. Introduction:

           Polycystic ovarian syndrome (PCOS) is a common endocrinopathy affecting women of
           reproductive age, with a frequency of about 4 to 7% (11). The syndrome is characterized
           by chronic oligo-anovulation, polycystic ovaries and hyperandrogenism (1). The patient
           has signs and symptoms of infertility, increased risk of insulin resistance, irregular
           menstruation (oligo-amenorrhea), hyperinsulinemia, type II diabetes mellitus, insulin
           resistance, increase hair growth (1).

           Metformin, basically a biguanide, is an anti-hyperglycemic agent that improves glucose
           tolerance, increases the action of insulin at cellular levels without affecting insulin
           secretion (2). Metformin has been used in the management of insulin resistance,
           hyperinsulinemia and lipid abnormalities (2). A positive effect of metformin is proved
           by several studies on both metabolic and reproductive aspects in PCOS women (9).
           Metformin reduces obesity and decreases serum c-reactive protein levels in PCOS women
           (10). Pioglitazone is a thiazolidinedione (TZD) with hypoglycemic (anti-hyperglycemic,
           antidiabetic) action in the management of diabetes. It is also useful for reducing the
           cardiovascular risks associated with polycystic ovarian syndrome, having both
           anti-inflammatory and anti-arteriosclerotic properties (3). Pioglitazone was suggested
           to reduce the incidence of diabetes mellitus by more than 50% with administration of
           pioglitazone in PCOS (3). Interestingly, the protection from developing diabetes
           mellitus in these patients remained even when pioglitazone was stopped (3).

           IL-6, a major pro-inflammatory cytokine, shows an essential part in endocrine system,
           particularly related to ovarian growth and the course of fertilization and implantation
           (1). IL-6 plays an important role in facilitating low grade chronic inflammation in
           patients with PCOS (1). IL-6 has been shown to be closely related to insulin resistance
           and cardiovascular abnormalities (4). Obesity, a major risk factor for type II diabetes,
           was reported to be associated with elevated IL-6 levels (4).

           IL-8 is a chemokine formed via macrophages and other cell types like endothelial cells,
           airway smooth muscle cells and epithelial cells (6). The levels of IL-6 and IL-8 were
           decreased in patients of PCOS after they reduced their insulin resistance and body
           weight (4). The manifestation of increased markers such as c-reactive protein, IL-6,
           IL-8 levels and raised leukocyte count is indication of low grade inflammation in women
           with PCOS (8). Elevated levels of IL-6 and IL-8 were related with an increased risk of
           atherosclerosis and future myocardial infarction (4).

           The investigators designed this study to elucidate the role of metformin and combination
           of metformin and pioglitazone in reducing the levels of IL-6 and IL-8 in patients with
           PCOS. The study will help in deciding a better treatment regimen for patients with PCOS.
           IL-6 and IL-8 may emerge as predictive biomarkers of treatment response.

        2. Aims and objectives

      Objectives:

      The objectives of this study are

        1. Primary

           To investigate the changes in the levels of IL-6 and IL-8 after 3 months treatment with
           metformin alone and combination of metformin and pioglitazone in patients with PCOS.

        2. Secondary

           To evaluate insulin resistance in all the groups at baseline and after 3 months of
           treatment.

        3. Hypothesis:

      Combination of metformin and pioglitazone may decrease the levels of IL-6 and IL-8 in women
      with PCOS better than metformin.

      5. Materials and Methods:

        1. Study design: Two-Arm Randomized Clinical trial.

        2. Study settings: Out-Patient Department (OPD) of Mardan Medical Complex, Khyber Medical
           University

        3. Study duration: Six Months after approval of proposal

        4. Sample size:

           The sample size was calculated using OpenEpi software. With an expected reduction in
           IL-6 and IL-8 values of 15% in the metformin arm, the investigators would need 102 women
           with PCOS to demonstrate a 40% reduction in IL-6 and IL-8 in the metformin and
           pioglitazone arm with a power of at least 80% and a ratio of 1 in the two arms.

           Arm#1: 51 women with PCOS will be selected based on the inclusion and exclusion
           criteria. The participants will receive metformin according to the body weight with
           maximum dose of 1000 mg (BD) daily.

           Arm#2: 51 women with PCOS will be selected based on the inclusion and exclusion
           criteria. The participants will receive metformin and pioglitazone combination according
           to the body weight with maximum dose of 1000 mg and 30mg (BD) daily.

        5. Sampling techniques: Blood samples will be taken from ante cubital vein after an
           overnight fast. Samples will be taken from all groups at the initiation and at the end
           of 3 months. Serum levels luteinizing hormone (LH), follicle stimulating hormone (FSH),
           prolactin, testosterone, IL-6, IL-8 and insulin will be analyzed by ELISA method.
           Fasting glucose will be performed by chemistry analyzer. Evaluation of insulin
           resistance will be performed by using HOMA-IR Index (Homeostasis model assessment for
           insulin resistance) with following formula. :

           HOMA-IR= fasting plasma insulin (µIU/mL) x fasting plasma glucose (mmol/L) /22.5

           6. Subject Population:

           6.1 Target population

           Women with PCOS visiting the outpatient department of participating hospitals.

           6.2 Sample selection:

           Participants will be recruited in the study based on inclusion and exclusion criteria.

           6.3 Screening:

           Before the study-specific screening and investigations, patient will sign a written
           informed consent and the investigator will also sign the consent with date.

           6.4 Registration:

           Subjects will be registered before starting study treatment and a registration number
           will be allotted. Requests for registration will only be accepted from authorized
           investigators at sites that have received ethical approval. Treatment would be planned
           to start after registration. Registration would be done according to the instructions in
           the protocol only after all screening assessments have been performed and the
           responsible investigator has both verified the subject's eligibility and signed the
           completed registration form.

           Once the registration process has completed as per the instructions in the protocol, the
           subject will be assigned a subject, study number, and written confirmation of
           registration will be provided to the site. Individuals must be registered once in this
           trial.

           6.5 Randomization:

           Randomization will be performed using Block Randomization technique using online
           software Sealed Envelope.

           7. Data Collection Procedure:

           7.1 Patient Recruitment:

           Approval of the study will be obtained from the Khyber Medical University, Ethics Board.
           Potential participants will be identified in the participatory center. Purpose and
           components of the study will be explained to each potential participant. Once the
           participant has agreed to take part, the participant will be screened for eligibility
           criteria. All eligible participants will be asked to give a written informed consent.
           Data regarding age, weight, height, menstrual irregularity, hirsutism, past medical and
           surgical history, serum testosterone and fasting insulin will be taken. Each participant
           will undergo ultrasound for assessment of ovarian changes. The study participants will
           be grouped in the following two arms.

           Arm#1: 51 women with PCOS will be selected based on the inclusion and exclusion
           criteria. The participants will receive metformin according to the body weight with
           maximum dose of 1000 mg (BD) daily.

           Arm#2: 51 women with PCOS will be selected based on the inclusion and exclusion
           criteria. The participants will metformin and pioglitazone according to the body weight
           with maximum dose of 1000 mg and 30 mg (BD) daily.

           Arm 1 metformin (1000 mg)

           Arm 2 metformin (1000 mg)

           and pioglitazone (30 mg)

           7.2 Concomitant medication reporting and treatment:

           Concomitant medications will not be recorded during the study. The following medications
           and treatment are recommended during the study.

           7.2.1 Permitted

           The following medications are permitted during the study: Nonsteroidal Antiinflammatory
           Drugs (NSAIDs), multivitamins, antibiotics and proton pump inhibitors (PPIs).

           7.2.2 Use with caution

           There are no medications that should specifically be used with caution in this study.

           7.2.3 Prohibited

           There are no medications and treatments that are specifically prohibited in this study.

           7.2.4 Compliance

           Subject medication compliance will be determined at each visit after 1 month and the
           patient will be counseled appropriately if significant non-compliance is determined.

           7.2.5 Treatment discontinuation

           The treatment of the patient or study on the subject will be discontinued in case of
           pregnancy or any disease given in exclusion criteria and in patient with
           hypersensitivity to drugs. There is no serious adverse effect observed after treatment
           discontinuation.

           Data Analysis Procedure:

           Mean ± SD will be used for numeric data generated from our work. In each arm the mean
           difference in the IL-6 and IL-8 values will be calculated using paired sample t test.
           For between arms analysis, mean difference in the IL-6 and IL-8 values will be
           calculated using independent sample t test. Non-parametric statistics will be used if
           the data is skewed. A cut-off will be calculated for IL-6 and IL-8 separately using ROC
           curve analysis. Based on the cut-off, a binary logistic regression analysis will be
           performed to evaluate the predictive significance of the two treatment arms in reducing
           the levels of inflammatory markers IL-6 and IL-8. P-value of < 0.05 will be considered
           significant. Results will be presented in form of tables & figures. Statistical Package
           for the Social Sciences (SPSS), version 21 will be used for all the statistical
           analysis.
    

Intervention name(s): Metformin; Metformin, Pioglitazone
Intervention type(s): Drug; Drug
Intervention description(s): Metformin (1000 mg); Metformin (1000 mg) Pioglitazone (30 mg)
Other intervention name(s): Glucophage; Glucophage, Zolid
Intervention MeSH terms: Metformin; Pioglitazone
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Care Provider, Investigator)
Primary purpose: Treatment
Keywords: PCOS