Impact of the Combined Treatment of Liposomed Polyphenols With G04CB02 on the ALS Patients

Study Overview
=================
Brief Summary
-----------------
Amyotrophic lateral sclerosis (ALS) is a disease of an inflammatory nature, which causes progressive muscle weakness associated with cognitive and behavioural disorders. Pathogenically, it is characterised by loss of oxidative control, excitotoxicity due to excess glutamate and intestinal dysbiosis. In the absence of curative treatment, the aim of the study is to assess the impact at a clinical level of the combination of liposomed polyphenols to improve their effectiveness, with the drug G04CB02 which shows great anti-ALS properties by Molecular Topology methodology. A prospective, longitudinal, mixed, analytical, experimental and double-blind study is proposed, with a population sample of 60 patients distributed randomly in 30 patients in the intervention group who will receive treatment for 4 months, and 30 patients in the control group who will receive a placebo for the same period. The assessment will be at time 0, and at 2 months and 4 months after treatment, with functional, cognitive and behavioural tests, and of the state of inflammation and oxidation; and at time 0 and 4 months, of the intestinal microbiota.

Detailed Description
-----------------
Amyotrophic lateral sclerosis (ALS) is the most common neurodegenerative disease of an inflammatory nature among those affecting motor neurons, with a life expectancy of 3 to 5 years. It is characterised by the loss of motor neurons, and can be of the bulbar type when the pathology begins to affect the motor neurons located in the spinal bulb, or of the medullary type when it begins with a loss of strength and weakness in the extremities. Both types eventually lead to an affectation of both motor neurons that results in progressive paralysis of the voluntary muscles until the patient dies. In addition, the pathology presents cognitive and behavioural alterations. Specifically, deficits have been described in verbal fluency, memory, emotional processing or social cognition, which appear to be mainly associated with hypoperfusion of the prefrontal area or hypometabolism. Pathogenically, ALS is characterised by an alteration in mitochondrial energy use at a neuronal level, mainly linked to a lower activity of the enzymes of the electron transport chain in the spinal cord. This alteration is a consequence of loss of oxidative control, excessive generation of oxidative free radicals, accumulation of neurofilaments, and excitotoxicity linked to an increase in the neurotransmitter glutamate. In this respect, it has been suggested that bacterial dysbiosis, related to cognitive and behavioural worsening, could also contribute to this adverse neuroinflammatory state, having been associated with a greater risk of suffering from neurodegenerative diseases. Specifically in ALS, a variation in intestinal microbial composition has recently been observed, with an increased abundance of E. coli and enterobacteria, and a low abundance of total yeast, in patients suffering from ALS; and lower levels of non-butyrate producing bacteria needed to maintain the integrity of the intestinal barrier, immune competition and energy metabolism. In contrast, increased Akkermansia muciniphila has been associated with higher levels of nicotinamide and improved disease symptoms in the animal model of the disease. This evidence, associated with the lack of medical treatment to cure the disease, makes it necessary to look for new therapeutic alternatives of a non-pharmacological nature. These include the administration of effective antioxidants, which reverse the high oxidative stress and inflammation characteristic of the disease. This type of treatment (specifically the association of the antioxidants Pterostilbene and Nicotinamide riboside) has already been applied by our research group to patients with ALS, achieving significant clinical improvements such as: greater functional capacity, greater respiratory capacity, increased muscle strength and electrical activity in the upper and lower limbs, as well as an increase in the percentage of skeletal muscle associated with fat loss. In this sense, several polyphenols have also been tested in animal models, among which the activity shown by Resveratrol stands out, with a high antioxidant power and great neuroprotective capacity, which is associated with an increase in the expression and activation of SIRT1 and AMPK in the ventral part of the spinal cord after its administration. Both mediators promoted the normalization of autophage flow and, more importantly, increased mitochondrial biogenesis in SOD1-G93A mice. However, their beneficial effects are strongly limited by their low availability. This limitation can be overcome by administering Resveratrol and its natural analogues, incorporated in liposomes or nanoparticles, as this is the best option for guaranteeing stability and bioavailability, after administration and absorption of the antioxidant. Moreover, the effects of the polyphenol Curcumin have already been studied in ALS. In a paper by Chico et al, its effects were studied in ALS patients at doses of 600mg/day for 6 months. In this study they found that Curcumin generated a slight slowdown in the progression of the disease, improving aerobic metabolism and oxidative damage. Furthermore, the use of nanobiotechnology with Curcumin (80mg/day) in the treatment of ALS patients obtained positive results showing that nanocurcumin is safe and could improve the probability of survival as an additional treatment in these patients, especially those with existing bulbar symptoms. In short, the use of both antioxidants in liposome form improves the bioavailability and effects of both, and their liposome combination has already been successfully tested in vivo in prostate cancer patients. These anti-ALS effects of the two molecules could be complemented by their action in improving the microbiota. To obtain the bioactive products of Curcumin, biotransformation by the human intestinal microflora is necessary; in a bidirectional manner, it has been demonstrated that Curcumin has beneficial effects on the intestinal microbiota by increasing the number of bacterial families such as: Prevotellaceae, Bifidobacterium, Lactobacilli, Bacteroidaceae and Rikenellaceae, and reducing the number of pro-inflammatory bacterial families such as: Enterobacteria and Enterococci. With regard to Resveratrol, as occurs with Curcumin, the intestinal microflora contributes to its metabolism; and also stands out in the increased production of anti-inflammatory bacteria of the Lactobacillus or Bifidobacterium genera. In addition, it has been found to increase levels of the bacterium Akkermansia Muciniphila, which is associated with an improvement in the prognosis of the disease. Finally, the use of these two antioxidants in ALS would be combined synergistically by repositioning G04CB02, a drug selected after a molecular topology scan of more than 30,000 drugs from two databases: CMC and Drugbank. It is currently marketed for the treatment of different pathologies, such as benign prostatic hyperplasia and androgenic alopecia. According to the in silico studies based on Molecular Topology carried out by Dr. Gálvez's team, a very promising anti-ALS effect has been identified for G04CB02, linked to the TDP-43 RNA mediator, among others. Drug design using molecular topology consists of applying topological descriptors to identify and describe, using a specific mathematical pattern, molecules and/or drugs related to a specific disease, in this case ALS. Using molecules with proven anti-ALS activity (Edaravone and Riluzole) and the TDP-43 RNA mediator, this mathematical pattern was identified and the databases mentioned above were traced with the aim of identifying drugs that share the same pattern and therefore have potential anti-ALS activity. In addition, considering the current shortage of effective treatments for ALS, other mathematical patterns related to anti-inflammatory, antioxidant, neuroprotective and analgesic activity were taken into account when selecting the G04CB02 candidate. To date, molecular topology has enabled the identification of new treatments for CNS diseases such as Alzheimer's, cancer and very recently SARS-Cov-2, among others.

Official Title
-----------------
Impact of the Combined Treatment of Curcumin and Resveratrol Liposomed Polyphenols With G04CB02 on the Clinical Improvement of ALS Patients

Conditions
-----------------
Amyotrophic Lateral Sclerosis

Intervention / Treatment
-----------------
* Dietary Supplement: Liposomed polyphenols resveratrol and curcumin
* Other: Placebo for liposomed resveratrol and curcumin
* Dietary Supplement: Isocaloric Diet
* Drug: G04CB02
* Other: Placebo microcrystalline methylcellulose


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: All ALS patients, over 18 years of age and with a clear diagnosis and symptomatology of ALS since at least 6 months. Exclusion Criteria: Women under 50 years of age and childbearing age. Tracheotomy patients. Patients with invasive or non-invasive ventilation with positive ventilatory pressure Patients with evidence of dementia. Patients with alcohol or drug abuse dependency. Patients infected with B or C hepatitis, or HIV positive Renal patients with creatinine levels twice as high as normal markers. Liver patients with liver markers (ALT, AST) elevated 3 times above normal levels. Patients included in other research with drugs or therapies in the experimental phase. Patients treated with anticoagulants or with haemostatic problems

Ages Eligible for Study
-----------------
Minimum Age: 18 Years
Maximum Age: 75 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Supportive Care
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Intervention group: 30 patients will be administered daily the combination of Resveratrol (75mg) and Curcumin (200mg) liposomes with G04CB02 (0.5mg), in a single dose for 4 months. Control group: 30 patients, who will receive a placebo with the same dosage pattern and for the same period of time. The placebo will consist of water with sucrose replacing the liposomed polyphenols, and a soft capsule of microcrystalline methylcellulose instead of G04CB02. Both the packaging and the capsule format will be identical to those of the treatment administered in the intervention group.
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Intervention group<br>30 patients will be given the combination of resveratrol and curcumin liposomed with G04CB02, in a single daily dose for 4 months. | Dietary Supplement: Liposomed polyphenols resveratrol and curcumin<br>* Combination of resveratrol (75mg) and curcumin (200mg) liposomed<br>Dietary Supplement: Isocaloric Diet<br>* 40% carbohydrates, 40% lipids and 20% proteins<br>Drug: G04CB02<br>* G04CB02, in a single daily dose for 4 months<br>|
| Placebo Comparator: Control group<br>30 patients, who will receive a placebo with the same dosage pattern and for the same period of time. The placebo will consist of water with sucrose replacing the liposomal polyphenols, and a soft capsule of microcrystalline methylcellulose instead of G04CB02. Both the packaging and the capsule format will be identical to those of the treatment administered in the intervention group | Other: Placebo for liposomed resveratrol and curcumin<br>* Water with sucrose replacing the liposomed polyphenols<br>Dietary Supplement: Isocaloric Diet<br>* 40% carbohydrates, 40% lipids and 20% proteins<br>Other: Placebo microcrystalline methylcellulose<br>* Placebo replacing G04CB02<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Revised Amyotrophic Lateral Sclerosis Functional Rating Scale associated with ALS | Maximum value: 48 points; Means better outcome motor variables Minimum value: 0 points | Time 0 | 
| Revised Amyotrophic Lateral Sclerosis Functional Rating Scale associated with ALS | Maximum value: 48 points; Means better outcome motor variables Minimum value: 0 points | 2 months | 
| Revised Amyotrophic Lateral Sclerosis Functional Rating Scale associated with ALS | Maximum value: 48 points; Means better outcome motor variables Minimum value: 0 points | 4 months | 
| Electromyography | Motor Variables | Time 0 | 
| Electromyography | Motor Variables | 2 months | 
| Electromyography | Motor Variables | 4 months | 
| Measurement of forced vital capacity | Motor Variables | Time 0 | 
| Measurement of forced vital capacity | Motor Variables | 2 months | 
| Measurement of forced vital capacity | Motor Variables | 4 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Quantitative measurement of plasma IL-6 and TNF-alpha. | Variables related to inflammation and oxidation | Time 0 | 
| Quantitative measurement of plasma IL-6 and TNF-alpha. | Variables related to inflammation and oxidation | 2 months | 
| Quantitative measurement of plasma IL-6 and TNF-alpha. | Variables related to inflammation and oxidation | 4 months | 
| Quantitative measurement of plasma PCR. | Variables related to inflammation and oxidation | Time 0 | 
| Quantitative measurement of plasma PCR. | Variables related to inflammation and oxidation | 2 months | 
| Quantitative measurement of plasma PCR. | Variables related to inflammation and oxidation | 4 months | 
| Quantitative measurement of plasma haptoglobin. | Variables related to inflammation and oxidation | Time 0 | 
| Quantitative measurement of plasma haptoglobin. | Variables related to inflammation and oxidation | 2 months | 
| Quantitative measurement of plasma haptoglobin. | Variables related to inflammation and oxidation | 4 months | 
| Quantitative measurement of TEAC (oxidation). | Variables related to inflammation and oxidation | Time 0 | 
| Quantitative measurement of TEAC (oxidation). | Variables related to inflammation and oxidation | 2 months | 
| Quantitative measurement of TEAC (oxidation). | Variables related to inflammation and oxidation | 4 months | 
| Quantitative measurement of plasma 8-oxoG. | Variables related to inflammation and oxidation | Time 0 | 
| Quantitative measurement of plasma 8-oxoG. | Variables related to inflammation and oxidation | 2 months | 
| Quantitative measurement of plasma 8-oxoG. | Variables related to inflammation and oxidation | 4 months | 
| Quantitative measurement of plasma MDA. | Variables related to inflammation and oxidation | Time 0 | 
| Quantitative measurement of plasma MDA. | Variables related to inflammation and oxidation | 2 months | 
| Quantitative measurement of plasma MDA. | Variables related to inflammation and oxidation | 4 months | 
| Edinburgh Cognitive and Behavioral ALS Screen | Variable for cognitive and behavioural assesment Maximum value: 136 points; Means better outcome Minimum value: 0 points Includes a behavioural test to interview the care provider | Time 0 | 
| Edinburgh Cognitive and Behavioral ALS Screen | Variable for cognitive and behavioural assesment Maximum value: 136 points; Means better outcome Minimum value: 0 points Includes a behavioural test to interview the care provider | 2 months | 
| Edinburgh Cognitive and Behavioral ALS Screen | Variable for cognitive and behavioural assesment Maximum value: 136 points; Means better outcome Minimum value: 0 points Includes a behavioural test to interview the care provider | 4 months | 
| Frontal Assessment Battery | Variable for cognitive and behavioural assesment Maximum value: 18 points; Means better outcome 16-15 points means frontosubcortical deficit 13-12 points means frontosubcortical dementia Minimum value: 0 points Includes a behavioural test to interview the care provider | Time 0 | 
| Frontal Assessment Battery | Variable for cognitive and behavioural assesment Maximum value: 18 points; Means better outcome 16-15 points means frontosubcortical deficit 13-12 points means frontosubcortical dementia Minimum value: 0 points Includes a behavioural test to interview the care provider | 2 months | 
| Frontal Assessment Battery | Variable for cognitive and behavioural assesment Maximum value: 18 points; Means better outcome 16-15 points means frontosubcortical deficit 13-12 points means frontosubcortical dementia Minimum value: 0 points Includes a behavioural test to interview the care provider | 4 months |