Clinical trial NCT00720538: Thalidomide in Pediatric Inflammatory Bowel Diseases.
Official title: Randomized Controlled Double-blind Vs. Placebo Multicentre Study on the Safety and Effectiveness of Thalidomide in the Treatment of Refractory Crohn's Disease and Ulcerative Colitis.
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: PHASE3
Conditions: Inflammatory Bowel Diseases
Crohn's Disease
Ulcerative Colitis
Keywords: Inflammatory bowel diseases.
Crohn disease.
Ulcerative, colitis.
Randomised controlled trial.
Therapy.
Thalidomide.
Children.
Lead sponsor: IRCCS Burlo Garofolo
Sponsor class: OTHER
Collaborators: name: Ospedale Meyer
name: Pediatric Gastroenterology Unit, IRCCS Gaslini, Genoa.
name: Vittore Buzzi Children's Hospital
name: University of Pisa
name: University of Messina
name: Università degli Studi di Brescia
name: University of Trieste
First posted: 2008-07-22
Enrollment: 84
Sex: ALL
Minimum age (years): 2
Maximum age (years): 18
Standard ages: CHILD
ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: Several open-label studies reported thalidomide efficacy in inducing clinical remission and steroid tapering in refractory Inflammatory Bowel diseases (IBD), both in adults and in children.

This is a randomized placebo controlled (RCT) double blind study, to evaluate the efficacy of thalidomide in inducing clinical remission at 8 weeks in refractory IBD patients aged 2-20 years.

The primary hypotheses of the study is that thalidomide would be more effective than placebo in inducing clinical remission.

The RCT phase is followed by a open-label phase, to further evaluate efficacy and safety of thalidomide in thalidomide responders, with a total follow up of one year.

Detailed description: Inflammatory bowel diseases (IBD) are particularly debilitating. They present chronic-recurrent symptoms which often seriously affects the patient's quality of life, acute complications which may need surgical interventions and long-term risks as evolution in cancer for ulcerative colitis.

Although onset is most common in the third decade of life, more than one third of IBD cases are diagnosed before age sixteen, and these younger patients, especially with Crohn's disease, are increasing in Western countries. Recent studies in the United Kingdom, Sweden and the United States report an incidence of 5-7 new cases of IBD every year per 100,000 subjects \< 16 years of age, with an increasing trend over the last two decades.

IBD-related morbidity causes special concern in childhood-onset cases, since the disease can compromise height and weight development. This is even worsened in patients with poor disease control, which need steroid treatment in multiple courses and/or for a long period of time.

There are various drugs and treatments available for the management of IBD, but some patients, during the course of the illness, become resistant to conventional treatment, or develop serious adverse effects to immunosuppressive drugs.

A particular challenge is represented by those patients (especially children) who fail to respond to conventional treatment, or are steroid-dependent, or suffer from serious side effects from steroids use.

Thalidomide was first marketed in the early 1960s as a sedative drug and sadly gained notoriety because of its teratogenic effect. After few years from this tragedy, thalidomide was rediscovered both as an immunomodulator and as an anti-inflammatory drug, with anti tumor necrosis factor-alfa properties.

Thalidomide is now approved for the treatment of multiple myeloma and erythema nodosum leprorum. It has also been tested, with beneficial effects, in a variety of inflammatory diseases, especially those involving the skin and mucous membranes: recurrent aphthous stomatitis, oral and oesophageal ulcers in HIV, oral and genital ulcers and intestinal symptoms in Behcet's syndrome, graft versus host disease, skin manifestations in systemic lupus erythematosus, sarcoidosis, and tuberculosis. In these diseases, especially in those cases resistant to conventional treatments, thalidomide seems to have a promising role as a secondary therapeutic option.

The safety and efficacy of thalidomide in IBD has been recently evaluated in several open-label studies both adults and children, some of which with a long-term follow up. A total of approximately 200 patients with steroid-resistant or steroid-dependent IBD were treated with thalidomide. Overall, the drug was effective in inducing clinical remission in 20-70% of patients (average of 40%). 60-100% patients (average of 70%) had some clinical response. Steroid-tapering was possible in 60-100% of cases.

The most frequent side effect of thalidomide in IBD cases was neuropathy, which mainly reported as cumulative dose-dependent. Other possible side effects are constipation, sedation, dermatitis, mood disturbance, vertigo, cephalea, hypertension, hormonal alterations.

In the experience of our center, thalidomide was effective in achieving clinical remission in several children, adolescents, and young adults with intractable IBD. From 1998 to 2004 twenty-eight patients with refractory moderate-severe IBD (19 CD, 9 UC) received thalidomide 1.5-2.5 mg/kg/day. Remission was achieved with thalidomide in 21 of 28 (75%) patients (17 with CD, 4 with UC). Mean duration of remission was 34.5 months. Sixteen of 20 (80%) patients suspended steroids. Reversible neuropathy occurred in seven of 28 (25%) patients, but only with cumulative doses over 28 g. Other side effects requiring thalidomide suspension were vertigo/somnolence (one case), and agitation/ hallucinations (one case).

The aim of this study is to evaluate the efficacy of thalidomide therapy in children, adolescents and young adults with refractory Crohn's disease (CD) and ulcerative colitis (UD), with a total follow up of one year.

The study is divided in two phases:

* Phase I: randomized placebo controlled double blind study, to evaluate efficacy of thalidomide in refractory IBD patients, at 8 weeks.
* Phase II: open-label study, to evaluate efficacy and safety of thalidomide in patients responders to Thalidomide in Phase I, with a total follow up of one year.

Analysis will be stratified for Crohn's disease and ulcerative colitis. Given the hypotheses that thalidomide will be effective in inducing clinical remission at 8 weeks in 60% of patients with Crohn's disease, and 55% of patients with ulcerative colitis, compared to 20% of patients with placebo, with a significance of 0.05% and a power of 80%, estimated needed sample size is of 124 patients.

Eligibility criteria: Inclusion Criteria:

* Children, adolescents and young adults aged 2 to 20 with chronic refractory moderate to severe inflammatory bowel disease, referred by the six pediatric gastroenterological centres participating in the study.

Definition of patient with refractory disease:

* Patients with active disease despite steroid therapy (prednisone at a dose 2 mg/kg/die, maximum 60mg/day, or equivalent) for 8 weeks and/or an immunosuppressive of proven efficacy (azathioprine o 6-mercaptopurine for 4 months; methotrexate for 3 months; Infliximab at the dose of 5 mg/kg at week 0,2,6 weeks; cyclosporine at the dose of 2mg/kg/day for 4 weeks or 1 week at 1m/kg/day EV) or patients exhibiting intolerance to these drugs which prevent them from continuing treatment.

Exclusion Criteria:

* Patients with ileostomy or colostomy.
* Disease requiring immediate surgical intervention.
* Severe ulcerative colitis or toxic megacolon.
* Contraindications to using thalidomide (on-going pregnancy, neuropathy) .
* Any of the following conditions: active infection, stool culture positive for enteric pathogens, tumors, HIV, transplanted organ, or non-controlled disease of the kidney, liver, endocrine system, heart, blood, nervous system or brain.
* Patients being treated with other drugs as part of an experimental study.
* Patients treated with infliximab in the previous eight weeks.

Primary outcomes:
measure: Clinical Remission
timeFrame: 8°, 12°, 26, 52° weeks
Secondary outcomes:
measure: Clinical response
timeFrame: 4°, 8° weeks
measure: Steroid dose reduction
timeFrame: 8°, 12°, 26, 52° weeks
measure: Endoscopic remission
timeFrame: 12°, 26, 52° weeks
measure: Adverse effects
timeFrame: 4°, 8°, 12°, 26, 52° weeks
measure: Nutritinal indicators
timeFrame: 8°, 52°
Other outcomes:
Locations:
city: Florence.
country: Italy
facility: Department of Pediatrics, Ospedale Meyer.
state: Florence
city: Brescia
country: Italy
facility: Anatomy and Hystology, Spedali Civili di Brescia, University of Brescia.
city: Genoa
country: Italy
facility: Pediatric Gastroenterology Unit, IRCCS Gaslini.
city: Messina
country: Italy
facility: Pediatric Gastroenterology Unit, University of Messina.
city: Milan.
country: Italy
facility: Department of Pediatrics, Ospedali Buzzi.
city: Pisa
country: Italy
facility: Gastroenterology and Hepatology, University of Pisa.
city: Triest
country: Italy
facility: Unit of Biochemistry and Pharmacology, University of Triest.
Study officials:
affiliation: IRCCS Burlo Garofolo
name: Alessandro Ventura, MD
role: STUDY_CHAIR
affiliation: IRCCS Burlo Garofolo
name: Marzia Lazzerini, MD
role: STUDY_DIRECTOR
References:
citation: Lazzerini M, Martelossi S, Marchetti F, Scabar A, Bradaschia F, Ronfani L, Ventura A. Efficacy and safety of thalidomide in children and young adults with intractable inflammatory bowel disease: long-term results. Aliment Pharmacol Ther. 2007 Feb 15;25(4):419-27. doi: 10.1111/j.1365-2036.2006.03211.x.
citation: Lazzerini M, Martelossi S, Magazzu G, Pellegrino S, Lucanto MC, Barabino A, Calvi A, Arrigo S, Lionetti P, Lorusso M, Mangiantini F, Fontana M, Zuin G, Palla G, Maggiore G, Bramuzzo M, Pellegrin MC, Maschio M, Villanacci V, Manenti S, Decorti G, De Iudicibus S, Paparazzo R, Montico M, Ventura A. Effect of thalidomide on clinical remission in children and adolescents with refractory Crohn disease: a randomized clinical trial. JAMA. 2013 Nov 27;310(20):2164-73. doi: 10.1001/jama.2013.280777.