Clinical trial NCT02006121: Clinical Trial of Apomorphine Subcutaneous Infusion in Patients With Advanced Parkinson's Disease
Official title: Multicentre,Parallel-group,Double-blind,Placebo-controlled Phase III Study to Evaluate the Efficacy and Safety of Apomorphine sc Infusion in Parkinson's Disease Patients With Motor Complications Not Well Controlled on Medical Treatment
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: PHASE3
Conditions: Parkinson's Disease
Keywords: Parkinson's disease
motor fluctuations
not well controlled
medical treatment
apomorphine
Lead sponsor: Britannia Pharmaceuticals Ltd.
Sponsor class: INDUSTRY
First posted: 2013-12-09
Enrollment: 107
Sex: ALL
Minimum age (years): 30
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: The primary objective of the trial was to investigate the efficacy of apomorphine continuous subcutaneous infusion compared to placebo in Parkinson's Disease patients with motor fluctuations not well controlled on medical treatment.

The secondary objective of the study was to investigate the safety and tolerability of apomorphine continuous subcutaneous therapy.

Detailed description: The primary efficacy variable is the mean change in time spent "OFF" from baseline (start of blinded treatment) to the end of a 12 weeks' double-blind treatment period based on patient diaries. Patients recorded their motor symptoms in half-hour blocks as OFF, ON without dyskinesia, ON without troublesome dyskinesia, or sleeping using the Hauser Parkinson's Disease home diary.

Key secondary Endpoints (tested hierarchically):

* Change in time spent "ON without troublesome dyskinesia"
* Patient Global Impression of Change

Other Endpoints:

* Percentage of patients with response to therapy, defined as a mean OFF time reduction of at least 2 hours
* Change in oral levodopa and levodopa equivalent dose

Eligibility criteria: Inclusion Criteria:

* Male or female patients aged ≥30 years
* Diagnosis of idiopathic PD of \>3 years' duration, defined by the UK Brain Bank criteria (with the exception of \>1 affected relative being allowed), without any other known or suspected cause of Parkinsonism
* Hoehn \& Yahr stage up to 3 in the ON and 2 to 5 in the OFF state
* Motor fluctuations not adequately controlled on medical treatment including levodopa which was judged by the treating physician to be optimal
* Average of OFF time \> 3 hours/day based on screening and baseline diary entries with no day with \< 2 hours of OFF time recorded
* Stable medication regimen, with a stable dose of levodopa administered in at least 4 intakes, for at least 28 days prior to baseline. All oral or transdermal antiparkinsonian drugs were permitted, with the exception of budipine. This regimen might include the use of levodopa/DDCI rescue medication, if this occurred up to 2 times a day, at doses of up to 200 mg levodopa/day
* Patients must be able to differentiate between the ON and OFF state and between troublesome and non-troublesome dyskinesias
* Male and female patients must be compliant with a highly effective contraceptive method (oral hormonal contraception alone is not considered highly effective and must be used in combination with a barrier method) during the study and for the 12-month OLP, if sexually active
* Females of childbearing potential must have a negative serum human chorionic gonadotropin (hCG) or urine pregnancy test at screening
* Ability to accurately complete a paper diary on designated days (with assistance from caregivers, if required), recording periods when they are "ON without troublesome dyskinesia", "ON with troublesome dyskinesia", OFF, and sleeping
* Written informed consent prior to enrolment, after being provided with detailed information about the nature, risks, and scope of the clinical trial as well as the expected desirable and adverse effects of the study treatments
* Patients considered reliable and capable of adhering to the protocol, visit schedule, and medication intake according to the judgment of the investigator

Exclusion Criteria:

* History of respiratory depression
* Hypersensitivity to apomorphine or any excipients of the medicinal product
* High suspicion of other parkinsonian syndromes
* Presence of severe freezing or clinically relevant postural instability leading to falls during the ON state
* Concomitant therapy or within 28 days prior to baseline with: apomorphine pen injections; alpha-methyl dopa, metoclopramide, reserpine, neuroleptics, methylphenidate, or amphetamine; intrajejunal levodopa
* Previous use of apomorphine pump treatment
* History of deep brain stimulation or lesional surgery for PD
* Any medical condition that is likely to interfere with an adequate participation in the study, including e.g. current diagnosis of unstable epilepsy; clinically relevant cardiac dysfunction and/or myocardial infarction or stroke within the last 12 months
* Symptomatic, clinically relevant and medically uncontrolled orthostatic hypotension
* Patients with a borderline QT interval corrected for heart rate according to Bazett's formula (QTcB) of \>450 msec for male and \>470 msec for female at screening or history of long QT syndrome; or \>450 msec absolute duration
* Clinically relevant hepatic dysfunction (total bilirubin \>2.0 mg/dL, alanine transaminase \[ALT\] and aspartate transaminase \[AST\] \>2 times the upper limit of normal)
* Clinically relevant renal dysfunction (serum creatinine \>2.0 mg/dL)
* Pregnant and breastfeeding women
* Clinically relevant cognitive decline, defined as MMSE ≤24 or according to Diagnostic and Statistical Manual of Mental Disorders (DSM) IV criteria for dementia
* Active psychosis or history of at least moderate psychosis in the past year, or with medically uncontrolled severe depression; very mild illusions or hallucinations in the sense of "feelings of passage or presence" with fully retained insight are not an exclusion criterion
* Known history of melanoma
* Any investigational therapy in the 4 weeks prior to randomization
* History or current drug or alcohol abuse or dependencies

Primary outcomes:
measure: Mean Change in Daily OFF Time From Baseline (Start of Blinded Treatment) to the End of Double-blind Phase (Visit 10) Based on Patient Diaries Using MMRM mITT Population
timeFrame: Baseline and 12 weeks
Secondary outcomes:
measure: Mean Change in Daily Time Spent "ON Without Troublesome Dyskinesia" From Baseline to the End of the Double-blind Phase (Visit 10), Based on Patient Diaries Using MMRM mITT Population
timeFrame: Baseline and 12 weeks
measure: Patient Global Impression of Change (PGIC), Using the mITT Population
timeFrame: Baseline and 12 weeks
measure: Mean Change in Oral Levodopa Dose From Baseline to Visit 10 Using MMRM for the mITT Population
timeFrame: Baseline and 12 weeks
measure: Mean Change in Levodopa Equivalent Dose From Baseline to Visit 10 (Week 12) Using MMRM in the mITT Population
timeFrame: Baseline and 12 weeks
Other outcomes:
Locations:
city: Graz
country: Austria
facility: Medizinische Universität Graz / Univ. Klinik für Neurologie
city: Innsbruck
country: Austria
facility: Medizinische Universität Innsbruck
city: Vienna
country: Austria
facility: Donauspital / SMZ-Ost, Abteilung für Neurologie, Sekretariat (Stock 1, Ebene 4)
city: Copenhagen
country: Denmark
facility: Bispebjerg University Hospital, Movement Disorder Centre
city: Clermont-Ferrand Cedex 1
country: France
facility: CHRU Clermont- Ferrand Gabriel-Montpied
city: Rennes Cedex 9
country: France
facility: CHU de Rennes, Hôpital Pontchaillou
city: Toulouse Cedex 9
country: France
facility: CHU Toulouse, Hôpital Purpan, Centre d'Investigation Clinique
city: Beelitz-Heilstätten
country: Germany
facility: Neurologisches Fachkrankenhausfür Bewegungsstörungen / Parkinson
city: Bremerhaven
country: Germany
facility: Klinikum Bremerhaven-Reinkenheide gGmbH, Neurologische Klinik
city: Kassel
country: Germany
facility: Paracelsus Elena-Klinik Kassel
city: München
country: Germany
facility: Schön Klinik München Schwabing / Neurologie und Klinische Neurophysiologie
city: Groningen
country: Netherlands
facility: Universitair Medisch Centrum
city: Heerlen
country: Netherlands
facility: Atrium MC parkstad
city: Rotterdam
country: Netherlands
facility: Erasmus MC
city: Barcelona
country: Spain
facility: Hospital Clínic de Barcelona
city: Madrid
country: Spain
facility: Hospital Universitario Fundación Jiménez Díaz
city: Liverpool
country: United Kingdom
facility: The Walton Centre Nhs Foundation Trust
city: London
country: United Kingdom
facility: Kings College Hospital NHS Foundation Trust
city: London
country: United Kingdom
facility: St George's Heathcare NHS Trust
city: Newcastle
country: United Kingdom
facility: Newcastle University, Clinical Ageing Research Unit (CARU)
Study officials:
affiliation: Donauspital KH SMZ Ost, Neurologie
name: Regina Katzenschlager, Doz. Dr.
role: PRINCIPAL_INVESTIGATOR
References:
citation: Katzenschlager R, Poewe W, Rascol O, Trenkwalder C, Deuschl G, Chaudhuri KR, Henriksen T, van Laar T, Lockhart D, Staines H, Lees A. Long-term safety and efficacy of apomorphine infusion in Parkinson's disease patients with persistent motor fluctuations: Results of the open-label phase of the TOLEDO study. Parkinsonism Relat Disord. 2021 Feb;83:79-85. doi: 10.1016/j.parkreldis.2020.12.024. Epub 2021 Jan 12.
citation: Katzenschlager R, Poewe W, Rascol O, Trenkwalder C, Deuschl G, Chaudhuri KR, Henriksen T, van Laar T, Spivey K, Vel S, Staines H, Lees A. Apomorphine subcutaneous infusion in patients with Parkinson's disease with persistent motor fluctuations (TOLEDO): a multicentre, double-blind, randomised, placebo-controlled trial. Lancet Neurol. 2018 Sep;17(9):749-759. doi: 10.1016/S1474-4422(18)30239-4. Epub 2018 Jul 25.