Clinical trial NCT03862950: A Trial of Metformin in Individuals With Fragile X Syndrome (Met)
Official title: A Double-Blind, Placebo-Controlled Trial of Metformin in Individuals With Fragile X Syndrome (FXS)
Study type: INTERVENTIONAL
Overall status: RECRUITING
Phase: PHASE2
Conditions: Fragile X Syndrome
Fragile X Mental Retardation Syndrome
Mental Retardation, X-Linked
Genetic Diseases, X-Linked
Trinucleotide Repeat Expansion
Fra(X) Syndrome
Intellectual Disability
FXS
Neurobehavioral Manifestations
Sex Chromosome Disorders
Keywords: Congenital Abnormalities
Metformin
Nervous System Diseases
Chromosome Disorders
Lead sponsor: University of Alberta
Sponsor class: OTHER
Collaborators: name: St. Justine's Hospital
First posted: 2019-03-05
Enrollment: 120
Sex: ALL
Minimum age (years): 6
Maximum age (years): 35
Standard ages: CHILD
ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: This study is a controlled trial of metformin in individuals with fragile X syndrome between the ages of 6 and 35 years. Participants will be randomized in a double-blind design to either drug or placebo and will attend three visits to the study site in a 4-month period for a series of tests. The primary objectives are to assess safety, tolerability, and efficacy of metformin in the treatment of language deficits, behavior problems, and obesity/excessive appetite in individuals with fragile X syndrome.

Detailed description: This is a multi-center study at the University of Alberta and CHU Sainte-Justine for fragile X syndrome (FXS) patients aged 6 to 35 years inclusive. It is a randomized, double-blind, placebo-controlled trial of metformin (also known as Glumetza, Glucophage, Fortamet), a type 2 diabetes medication that can also improve obesity and excessive appetite.

Metformin has emerged as a candidate drug for the targeted treatment of FXS based on animal studies showing rescue of multiple phenotypes in the FXS model. Metformin may contribute to normalizing signaling pathways in FXS in the central nervous system, which may include activities of mTOR and PI3K, both of which have shown to be pathogenically overactive in FXS. In addition, metformin inhibits phosphodiesterase, which would lead to correction of cAMP levels, and MMP9 production, which is also elevated in FXS. Looking at the potential signaling pathways, metformin appears to be a good candidate for targeting several of the intracellular functions in neurons disrupted in FXS and, therefore, has potential to rescue several types of symptoms in individuals with FXS. Researchers have utilized metformin in the clinical treatment of over 20 individuals with FXS between the ages of 4 and 58 years and have found the medication to be well tolerated and to provide benefits not only in lowering weight gain and normalizing appetite but also in language and behavior. In this controlled trial, the researchers hope to further assess metformin's safety and benefits in the areas of language and cognition, eating and weight loss, and overall behavior.

Each participant will be involved in this trial for a period of 4 months. This will include 3 visits to one of the sites and 5 phone calls. At each visit, the researchers will assess behavioral, cognitive, and language development. The researchers will also assess the side effects of the study medication throughout the trial.

Eligibility criteria: Inclusion Criteria:

* Subject has Fragile X syndrome with a molecular genetic confirmation of the full FMR1 mutation (\>200 CGG repeats) or the other loss of function mutations of the FMR1 gene (SNVs and deletions of the gene).
* Subject is a male or non-pregnant, non-lactating female age 6 through 35 years, inclusive.
* Subjects who are capable of becoming pregnant must use an acceptable method of birth control for the duration of the study. Acceptable forms of birth control include abstinence (only for subjects who are not sexually active), intrauterine devices in place for at least 3 months, oral contraceptives, surgical sterilization, or adequate barrier methods.
* Subject must have a caregiver (parent, guardian, or other legally authorized representative) who is willing to participate in the whole study.
* Subject and caregiver are able to attend the clinic regularly and reliably.
* Subject and/or subject's caregiver is able to understand, read, write and speak English or French fluently to complete study-related materials.
* For subjects who are not their own legal guardian, subject's caregiver is able to understand and sign an informed consent to participate in the study.
* The use of concomitant medication must be stable, in terms of dose and dosing regimen, for at least 4 weeks prior to Screening and must remain stable during the period between first visit (Screening) and the commencement of the study; every effort should be made to maintain stable regimens of allowed concomitant medications from the time of commencement of double-blind study medication until the last study assessment.
* Behavioral/educational treatments must be stable for 4 weeks prior to first visit (Screening) and must remain stable during the period between Screening and the commencement of randomized double-blind study medication.
* 10. Overall age equivalent is not higher than 13 and IQ is not higher than 85, as assessed at Screening on the Leiter-III, and subject must speak at least occasional 3-word phrases.

Exclusion Criteria:

* Families that are not cooperative and will not follow through with the demands of this study.
* Subject has a life-threatening medical problem or other major systemic illness that compromises health or safety and/or would interfere with this study.
* Age younger than 6 or older than 35 years.
* History of intolerable adverse events with metformin.
* Current or recent metformin treatment (within the past 4-months).
* BMI inferior to 2 standard deviations below the mean for age using the World Health Organization scale.
* Serum creatinine \> 1.4 mg/dl (female) or \> 1.5 mg/dl (male).
* History of metabolic acidosis or a condition with lactic acidosis.
* Severe Vitamin B12 deficiency.
* Pregnancy at screening or unwillingness to use acceptable method of birth control, if applicable.
* Age equivalent higher than 13 or IQ higher than 85 on the Leiter-III at Screening.

Primary outcomes:
measure: Change from baseline in the Expressive Language Sampling (ELS) mean Number of Different Words (NDW) score
timeFrame: Baseline, End of Treatment/Week 16
Secondary outcomes:
measure: Change from baseline in the FXS-normed Aberrant Behavior Checklist - Community Edition (ABC-C)
timeFrame: Baseline, Week 8, End of Treatment/Week 16
measure: Improvement of symptoms in FXS using the Clinical Impression - Improvement (CGI-I) scale
timeFrame: Baseline, Week 8, End of Treatment/Week 16
measure: Change from baseline in the Visual Analog Scale (VAS)
timeFrame: Baseline, Week 8, End of Treatment/Week 16
measure: Change from baseline in the Vineland Adaptive Behavior Scales-Third Edition (VABS-III) Adaptive Behavior Composite Score
timeFrame: Baseline, End of Treatment/Week 16
measure: Change from baseline in the Anxiety Depression and Mood Screen (ADAMS) overall score
timeFrame: Baseline, Week 8, End of Treatment/Week 16
measure: Change from baseline in the Swanson, Nolan and Pelham Questionnaire (SNAP-IV) overall score
timeFrame: Baseline, Week 8, End of Treatment/Week 16
measure: Change from baseline in the Pediatric Quality of Life Questionnaire (PedsQL) Parent Proxy overall score
timeFrame: Baseline, Week 8, End of Treatment/Week 16
measure: Change from baseline in the EuroQol-5D (EQ-5D) overall score
timeFrame: Baseline, Week 8, End of Treatment/Week 16
measure: Change from baseline in the Care Related Quality of Life (CarerQoL) overall score
timeFrame: Baseline, Week 8, End of Treatment/Week 16
measure: Change from baseline in The Memory Game
timeFrame: Baseline, End of Treatment/Week 16
measure: Change from baseline in the Child Sleep Habits Questionnaire (CSHQ) overall score
timeFrame: Baseline, Week 8, End of Treatment/Week 16
measure: Change from baseline in the NIH Toolbox Picture Sequence Memory Test
timeFrame: Baseline, End of Treatment/Week 16
measure: Change from baseline in the NIH Toolbox Flanker Inhibitory Control and Attention Test
timeFrame: Baseline, End of Treatment/Week 16
measure: Change from baseline in the NIH Toolbox Dimensional Change Card Sort Test
timeFrame: Baseline, End of Treatment/Week 16
measure: Change from baseline in the NIH Toolbox List Sorting Working Memory Test
timeFrame: Baseline, End of Treatment/Week 16
measure: Change from baseline in the NIH Toolbox Pattern Comparison Processing Speed Test
timeFrame: Baseline, End of Treatment/Week 16
measure: Change from baseline in the NIH Toolbox Oral Reading Recognition Test
timeFrame: Baseline, End of Treatment/Week 16
measure: Change from baseline in the NIH Toolbox Picture Vocabulary Test
timeFrame: Baseline, End of Treatment/Week 16
measure: Change from baseline in the NIH Toolbox Speeded Matching Test
timeFrame: Baseline, End of Treatment/Week 16
measure: Change from baseline in Eye Tracking
timeFrame: Baseline, End of Treatment/Week 16
measure: Change from baseline in Event Related Potentials during the Auditory Oddball Paradigm and Pseudoword Paradigm
timeFrame: Baseline, End of Treatment/Week 16
measure: Change from baseline in the Sensory Profile-2 or Sensory Profile Adolescents/Adults
timeFrame: Baseline, Week 8, End of Treatment/Week 16
Other outcomes:
Locations:
city: Edmonton
country: Canada
facility: University of Alberta
state: Alberta
city: Montreal
country: Canada
facility: CHU Sainte-Justine
state: Quebec
Study officials:
affiliation: University of Alberta
name: Francois Bolduc, MD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Dy ABC, Tassone F, Eldeeb M, Salcedo-Arellano MJ, Tartaglia N, Hagerman R. Metformin as targeted treatment in fragile X syndrome. Clin Genet. 2018 Feb;93(2):216-222. doi: 10.1111/cge.13039. Epub 2017 Sep 25.
citation: Monyak RE, Emerson D, Schoenfeld BP, Zheng X, Chambers DB, Rosenfelt C, Langer S, Hinchey P, Choi CH, McDonald TV, Bolduc FV, Sehgal A, McBride SMJ, Jongens TA. Insulin signaling misregulation underlies circadian and cognitive deficits in a Drosophila fragile X model. Mol Psychiatry. 2017 Aug;22(8):1140-1148. doi: 10.1038/mp.2016.51. Epub 2016 Apr 19.
citation: Gantois I, Khoutorsky A, Popic J, Aguilar-Valles A, Freemantle E, Cao R, Sharma V, Pooters T, Nagpal A, Skalecka A, Truong VT, Wiebe S, Groves IA, Jafarnejad SM, Chapat C, McCullagh EA, Gamache K, Nader K, Lacaille JC, Gkogkas CG, Sonenberg N. Metformin ameliorates core deficits in a mouse model of fragile X syndrome. Nat Med. 2017 Jun;23(6):674-677. doi: 10.1038/nm.4335. Epub 2017 May 15.