Trial of Eflornithine Plus Sulindac in Patients With Familial Adenomatous Polyposis (FAP)

Study Overview
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Brief Summary
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The purpose of this randomized, double-blind, Phase III trial is to determine if the combination of eflornithine plus sulindac is superior to sulindac or eflornithine as single agents in delaying time to the first occurrence of any FAP-related event. This includes: 1) FAP related disease progression indicating the need for excisional intervention involving the colon, rectum, pouch, duodenum and/or 2) clinically important events which includes progression to more advanced duodenal polyposis, cancer or death.

Official Title
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Phase III Trial of the Safety and Efficacy of Eflornithine Combined With Sulindac Compared to Eflornithine, Sulindac as Single Agents in Patients With Familial Adenomatous Polyposis

Conditions
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Familial Adenomatous Polyposis

Intervention / Treatment
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* Drug: Eflornithine
* Drug: Eflornithine Placebo
* Drug: Sulindac 150 MG
* Drug: Sulindac placebo


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Diagnosis of phenotypic classical FAP with disease involvement of the duodenum and/or colon/rectum/pouch. Genotype: Adenomatous polyposis coli (APC) mutation (with or without family history) required Classical FAP Phenotype: 100's to 1,000's of colorectal adenomatous polyps, usually appearing in teenage years Upper gastrointestinal (UGI) endoscopy/ lower gastrointestinal (LGI) endoscopy (proctoscopy/colonoscopy) performed within 30 days of randomization. Patients with an intact colon/rectum, except for clinical polyposis, and prophylactic surgery is being considered as a stratification site. Rectal/pouch polyposis as a stratification site as follows: At least three years since colectomy with ileorectal anastamosis (IRA)/proctocolectomy with pouch, and demonstrating polyposis as defined by Stage 1, 2, 3, of the proposed InSiGHT 2011 Staging System (Appendix B) and summarized as follows: Stage 1: 10-25 polyps, all < 5 mm Stage 2: 10-25 polyps, at least one > 1 cm Stage 3: >25 polyps amenable to complete removal, or any incompletely removed sessile polyp, or any evidence of high grade dysplasia, even if completely removed. [Note: For staging purposes only.] For all subjects, any rectal/pouch polyps > 5 mm must be excised at baseline. Duodenal polyposis as a stratification site; one or more of the following: Current Spigelman Stage 3 or 4. Prior surgical endoscopic intervention within the past six months for Spigelman Stage 3 or 4 that may have been down staged to Spigelman Stage 1 or 2. Hematopoietic Status (within 30 days prior to randomization): No significant hematologic abnormalities White blood cell count (WBC) at least 3,000/mm3 Platelet count at least 100,000/mm3 Hemoglobin at least 10.0 g/dL No history of clinical coagulopathy Hepatic Status (within 30 days prior to randomization): Bilirubin no greater than 1.5 times ULN Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) no greater than 1.5 times ULN Alkaline phosphatase no greater than 1.5 times ULN Renal Status (within 30 days prior to randomization): a) Creatinine no greater than 1.5 times ULN Hearing: a) No clinically significant hearing loss, defined in Section 6.2, number 9. If female, neither pregnant nor lactating. Negative pregnancy test if female of child-bearing potential. Fertile patients must use effective contraception*. Absence of gross blood in stool; red blood on toilet paper only acceptable. No discrete gastric or duodenal ulcer greater than 5 mm within the past year except Helicobacter pylori-related peptic ulcer disease treated with antibiotics. No invasive malignancy within the past 5 years except resected non-melanomatous skin cancer, papillary thyroid cancer, or precancerous cervical dysplasia. No other significant medical or psychiatric problems that would preclude study participation or interfere with capacity to give informed consent. Use of 81-100 mg daily aspirin or up to 700 mg aspirin not more than once a week are eligible. No concurrent warfarin, fluconazole, lithium, Pradaxa® or other direct thrombin inhibitors, Plavix®, cyclosporine, other NSAIDs (such as ibuprofen, aspirin, diflunisal), diuretics (furosemide and thiazides), dimethylsulfoxide (DMSO), methotrexate, probenecid, propoxyphene hydrochloride, Tylenol® (acetaminophen) preparations containing aspirin or cytotoxic chemotherapy drugs. Willingness to forego concurrent use of supplements containing omega-3 fatty acids, corticosteroids, non-steroidal anti-inflammatory drugs or other FAP directed drug therapy. Able to provide informed consent and follow protocol requirements. Exclusion Criteria: Prior pelvic irradiation. Patients receiving oral corticosteroids within 30 days of enrollment. Treatment with other investigational agents in the prior 4 weeks. Use of other non-steroidal anti-inflammatory drugs (such as ibuprofen) exceeding 4 days per month, in the prior 6 weeks. Regular use of aspirin in excess of 700 mg per week. Treatment with other FAP directed drug therapy (including sulindac or celecoxib, fish oil) within 12 weeks of study enrollment. Hypersensitivity to cyclooxygenase-2 inhibitors, sulfonamides, NSAIDs, or salicylates; NSAID associated symptoms of gastritis. Patients must not have cardiovascular disease risk factors as defined below: Uncontrolled high blood pressure (systolic blood pressure > 150 mm Hg Unstable angina History of documented myocardial infarction or cerebrovascular accident New York Heart Association Class III or IV heart failure Known uncontrolled hyperlipidemia defined as LDL-C >= 190 mg/dL or triglycerides >= 500 mg/dL Patients with significant hearing loss are not eligible for study participation defined as hearing loss that affects everyday life and/or for which a hearing aid is required. Colon/rectum/pouch with high grade dysplasia or cancer on biopsy or a large polyp (>1 cm) not amenable to complete removal. Duodenal cancer on biopsy. Intra-abdominal desmoid disease, stage III or IV Inability to provide informed consent.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Eflornithine plus Sulindac<br>Eflornithine 750 mg and Sulindac 150 mg | Drug: Eflornithine<br>* Eflornithine [250 mg tablet, three tablets (750 mg) orally once a day]<br>* Other names: CPP-1X;Drug: Sulindac 150 MG<br>* Sulindac [one tablet orally once a day]<br>* Other names: Clinoril;|
| Active Comparator: Eflornithine plus Sulindac Placebo<br>Eflornithine 750 mg and Placebo | Drug: Eflornithine<br>* Eflornithine [250 mg tablet, three tablets (750 mg) orally once a day]<br>* Other names: CPP-1X;Drug: Sulindac placebo<br>* Sulindac placebo [one tablet orally once a day]<br>|
| Active Comparator: Sulindac plus Eflornithine Placebo<br>Sulindac 150 mg and Placebo | Drug: Eflornithine Placebo<br>* Eflornithine placebo [three tablets orally once a day]<br>* Other names: CPP-1X placebo;Drug: Sulindac 150 MG<br>* Sulindac [one tablet orally once a day]<br>* Other names: Clinoril;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Subjects With Any FAP-related Event. | Progression of disease by evaluation of FAP-related events over the course of study treatment | Up to 48 months from the start of treatment | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Improvement in Investigator Upper GI Assessment | Global assessment of change in upper GI polyp burden. These are binary outcomes derived from scores assigned by the investigator during each procedure, using a scale (-2, -1, 0, +1, +2) which corresponds, respectively, to the investigator's overall qualitative assessment of: much worse, worse, no change, improved, much improved. Summarizes the corresponding 6- and 12-month investigator change scores according to whether or not there was any positive improvement at either month 6 (compared to baseline) or at month 12 (compared to baseline or month 6), under the condition that there be no worsening at either timepoint. | through month 12 assessment | 
| Improvement in Investigator Lower GI Assessment | Global assessment of change in lower GI polyp burden. These are binary outcomes derived from scores assigned by the investigator during each procedure, using a scale (-2, -1, 0, +1, +2) which corresponds, respectively, to the investigator's overall qualitative assessment of: much worse, worse, no change, improved, much improved. Summarizes the corresponding 6- and 12-month investigator change scores according to whether or not there was any positive improvement at either month 6 (compared to baseline) or at month 12 (compared to baseline or month 6), under the condition that there be no worsening at either timepoint. | through month 12 assessment | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Eflornithine, Familial Adenomatous Polyposis, Sulindac