Clinical trial NCT01928082: The Effects of Estrogen Replacement Therapy in Postmenopausal Women With Hypercalciuria and Low Bone Mass
Official title: The Effects of Estrogen Replacement Therapy in Postmenopausal Women With Hypercalciuria and Low Bone Mass
Study type: INTERVENTIONAL
Overall status: TERMINATED
Phase: PHASE2
Conditions: Hypercalciuria
Hypercalciuria, Familial Idiopathic
Osteopenia
Osteoporosis
Keywords: Hypercalciuria, Familial Idiopathic
Hypercalciuria
Osteopenia
Osteoporosis
Postmenopausal women
Lead sponsor: University of Chicago
Sponsor class: OTHER
First posted: 2013-08-23
Enrollment: 1
Sex: FEMALE
Minimum age (years): 40
Maximum age (years): 69
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: NA
Intervention model: SINGLE_GROUP
Primary purpose: TREATMENT

Brief summary: The purpose of this study is to assess if estrogen replacement normalizes urinary calcium excretion in postmenopausal women with hypercalciuria and low bone mass and to assess for differences in response to estrogen replacement in women with familial hypercalciuria compared to nonfamilial hypercalciuria.

Detailed description: Subjects will primarily be recruited from the subjects of protocol 12-1421. Subjects may also be identified through chart review of patients seen by Dr. Favus in the Bone Clinic at the University of Chicago. These subjects will be mailed a letter describing the study and a request to contact us if they are willing to participate in the study.

We plan to enroll 20 subjects to obtain complete data on 16 subjects. We aim to have 10 subjects who will have confirmed familial idiopathic hypercalciuria (IH) and 10 subjects who will have no family history of hypercalciuria.

Subjects will be brought into the Clinical Research Center at the University of Chicago where blood samples will be collected by phlebotomy to obtain the following screening tests: complete metabolic panel; including calcium, phosphate, magnesium, creatinine, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and albumin; parathyroid hormone, 25-hydroxyvitamin D, follicle stimulating hormone (FSH), and estradiol. A twenty-four hour urine collection starting with second void of the day will be collected for calcium, phosphate, magnesium, citrate, oxalate, sodium, ammonia, sulfate, and creatinine. Subjects on diuretics will be screened after a 2 week washout period, provided this can be discontinued safely. If subjects have participated in study protocol number 12-1421, these screening tests do not have to be repeated and the results from protocol number 12-1421 will be used to determine eligibility.

Screening subjects who meet inclusion criteria can proceed to the observational study. Screening subjects who are vitamin D depleted (serum 25-hydroxyvitamin D less than 35 ng/mL) may be rescreened after repletion of vitamin D.

A letter describing the study aims, protocols, and risks and benefits will be sent to their primary care physicians and gynecologists. Upon completion of the study, a summary letter will be sent as well.

Prior to the baseline visit a twenty-four hour urine collection starting with the second void of the day will be collected for calcium, phosphate, magnesium, citrate, oxalate, sodium, ammonia, sulfate, and creatinine. Subjects on diuretics will require a 2 week washout period, provided this can be discontinued safely. During the baseline visit a medical history will be taken and a physical exam will be performed. Venous blood will be collected for 1,25-dihydroxyvitamin D3, osteocalcin, bone-specific alkaline phosphatase, C-telopeptides of type 1 collagen (CTX), procollagen type 1 N-terminal propeptide (P1NP), bone morphogenetic protein 2 (BMP-2), and sclerostin. If the subject has had these blood tests performed in the preceding four months for protocol 12-1421, the blood tests will not be repeated. 18F sodium fluoride PET/CT bone scan will be performed. The protocol for the radionuclide imaging is attached.

All subjects will be started on transdermal 17-beta-estradiol 0.05 mg/d, which is equivalent to the standard dose of conjugated estrogen dose of 0.625 mg, for 4 weeks and increased to 0.1 mg for subsequent 4 weeks. Given the short duration of this study, progesterone will not be provided, as 8 weeks is not of sufficient duration to significantly increase the risk of endometrial cancer (Strom, Schinnar et al. 2006).

For the entire study, diuretics will be discontinued if it has been deemed safe to do so by the principle investigator or prescribing physician. Throughout the study, subject will maintain 900-1200 mg of dietary calcium daily. To monitor dietary calcium intake, a 5 day diet diary will be kept from Sunday to Thursday of the fourth week of each medication dose. Compliance of the study medication will be assessed by estrogen patch counts.

The following blood tests will be repeated 4 and 8 weeks after starting estradiol patch: complete metabolic panel (including calcium, phosphate, potassium, bicarbonate, chloride, magnesium, creatinine, and albumin), 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D3, parathyroid hormone, estradiol, osteocalcin, bone-specific alkaline phosphatase, C-telopeptides of type 1 collagen (CTX), procollagen type 1 N-terminal propeptide (P1NP), bone morphogenetic protein 2 (BMP-2), and sclerostin. In addition, 4 and 8 weeks after starting estradiol patch, 24 hour urine collection will be performed for calcium, phosphate, magnesium, citrate, oxalate, sodium, ammonia, sulfate, and creatinine.

Eligibility criteria: Inclusion Criteria:

* Postmenopausal women
* Diagnosis of hypercalciuria
* Diagnosis of low bone mass
* Vitamin D replete (serum 25-hydroxyvitamin D level \>35 ng/mL)

Exclusion Criteria:

* Secondary causes of hypercalciuria (primary hyperparathyroidism, sarcoidosis, vitamin D excess, malignant neoplasm, and renal tubular acidosis)
* Other metabolic bone disease (primary hyperparathyroidism, hyperthyroidism, hypercortisolemia, severe gastrointestinal disorders, liver cirrhosis, renal failure (Cr \>1.5), active malignancy including multiple myeloma, rheumatological diseases, and Paget's disease of bone)
* Use of medications affecting bone and calcium metabolism (corticosteroids in the previous 3 months, suppressive dose of thyroid hormone, calcium channel blockers, anti-convulsants, aromatase inhibitors, thiazolidinediones, and cyclosporine A)
* History of coronary artery disease
* Breast cancer or suspected estrogen-dependent neoplasia
* Previous venous thromboembolic event
* Stroke
* Active liver disease
* Tobacco use within the past 6 months
* Negative colonoscopy within the previous 10 years or sigmoidoscopy within the previous 5 years
* Negative mammogram within the previous 2 years
* Negative Pap smear within the previous 3 years in women \< or = 65 years old with an intact cervix
* No vaginal bleeding within the prior 5 months.
* Age \> or = 70
* \> or = 20 years since last menstrual period or use of hormone replacement therapy

Primary outcomes:
measure: Absolute Change in 24 Hour Urinary Calcium Excretion
timeFrame: 4 weeks, 8 weeks
Secondary outcomes:
measure: Serum 1,25-dihydroxyvitamin D3
timeFrame: 4 weeks, 8 weeks
measure: Serum Bone Morphogenetic Protein 2
timeFrame: 4 weeks, 8 weeks
measure: Serum Sclerostin
timeFrame: 4 weeks, 8 weeks
Other outcomes:
measure: Serum Estradiol
timeFrame: 4 weeks, 8 weeks
measure: Serum Total Calcium
timeFrame: 4 weeks, 8 weeks
measure: Calculated Serum Ionized Calcium
timeFrame: 4 weeks, 8 weeks
measure: Calculated Tubular Resorption of Calcium
timeFrame: 4 weeks, 8 weeks
measure: Serum 25 Hydroxyvitamin D
timeFrame: 4 weeks, 8 weeks
measure: Serum Parathyroid Hormone
timeFrame: 4 weeks, 8 weeks
measure: Serum Phosphorus
timeFrame: 4 weeks, 8 weeks
measure: Serum Osteocalcin
timeFrame: 4 weeks, 8 weeks
measure: Serum Bone-specific Alkaline Phosphatase
timeFrame: 4 weeks, 8 weeks
measure: Serum C-telopeptides of Type 1 Collagen
timeFrame: 4 weeks, 8 weeks
measure: Serum Procollagen Type 1 N-terminal Propeptide
timeFrame: 4 weeks, 8 weeks
Locations:
city: Chicago
country: United States
facility: The University of Chicago
state: Illinois
Study officials:
affiliation: University of Chicago
name: Murray J Favus, MD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Cerda Gabaroi D, Peris P, Monegal A, Albaladejo C, Martinez MA, Muxi A, Martinez de Osaba MJ, Suris X, Guanabens N. Search for hidden secondary causes in postmenopausal women with osteoporosis. Menopause. 2010 Jan-Feb;17(1):135-9. doi: 10.1097/gme.0b013e3181ade8e5.
citation: Christiansen C, Riis BJ, Rodbro P. Prediction of rapid bone loss in postmenopausal women. Lancet. 1987 May 16;1(8542):1105-8. doi: 10.1016/s0140-6736(87)91671-0.
citation: Deutschmann HA, Weger M, Weger W, Kotanko P, Deutschmann MJ, Skrabal F. Search for occult secondary osteoporosis: impact of identified possible risk factors on bone mineral density. J Intern Med. 2002 Nov;252(5):389-97. doi: 10.1046/j.1365-2796.2002.01040.x.
citation: Favus MJ, Karnauskas AJ, Parks JH, Coe FL. Peripheral blood monocyte vitamin D receptor levels are elevated in patients with idiopathic hypercalciuria. J Clin Endocrinol Metab. 2004 Oct;89(10):4937-43. doi: 10.1210/jc.2004-0412.
citation: Frumar AM, Meldrum DR, Geola F, Shamonki IM, Tataryn IV, Deftos LJ, Judd HL. Relationship of fasting urinary calcium to circulating estrogen and body weight in postmenopausal women. J Clin Endocrinol Metab. 1980 Jan;50(1):70-5. doi: 10.1210/jcem-50-1-70.
citation: Giannini S, Nobile M, Dalle Carbonare L, Lodetti MG, Sella S, Vittadello G, Minicuci N, Crepaldi G. Hypercalciuria is a common and important finding in postmenopausal women with osteoporosis. Eur J Endocrinol. 2003 Sep;149(3):209-13. doi: 10.1530/eje.0.1490209.
citation: Lobo RA, Roy S, Shoupe D, Endres DB, Adams JS, Rude RK, Singer FR. Estrogen and progestin effects on urinary calcium and calciotropic hormones in surgically-induced postmenopausal women. Horm Metab Res. 1985 Jul;17(7):370-3. doi: 10.1055/s-2007-1013545.
citation: McKane WR, Khosla S, Burritt MF, Kao PC, Wilson DM, Ory SJ, Riggs BL. Mechanism of renal calcium conservation with estrogen replacement therapy in women in early postmenopause--a clinical research center study. J Clin Endocrinol Metab. 1995 Dec;80(12):3458-64. doi: 10.1210/jcem.80.12.8530583.
citation: Nordin BE, Horowitz M, Need A, Morris HA. Renal leak of calcium in post-menopausal osteoporosis. Clin Endocrinol (Oxf). 1994 Jul;41(1):41-5. doi: 10.1111/j.1365-2265.1994.tb03782.x.
citation: Nordin BE, WIshart JM, Clifton PM, McArthur R, Scopacasa F, Need AG, Morris HA, O'Loughlin PD, Horowitz M. A longitudinal study of bone-related biochemical changes at the menopause. Clin Endocrinol (Oxf). 2004 Jul;61(1):123-30. doi: 10.1111/j.1365-2265.2004.02066.x.
citation: Nordin BE, Need AG, Morris HA, Horowitz M. Biochemical variables in pre- and postmenopausal women: reconciling the calcium and estrogen hypotheses. Osteoporos Int. 1999;9(4):351-7. doi: 10.1007/s001980050158.
citation: Nordin BE, Need AG, Morris HA, Horowitz M, Robertson WG. Evidence for a renal calcium leak in postmenopausal women. J Clin Endocrinol Metab. 1991 Feb;72(2):401-7. doi: 10.1210/jcem-72-2-401.
citation: Puche RC, Roveri E, Perez Jimeno N, Roberti A, Poudes G, Bocanera R, Tozzini R. Hypercalciuria and urinary saturation measurements in climacteric women. Maturitas. 1993 Jan;16(1):39-47. doi: 10.1016/0378-5122(93)90132-2.
citation: Stock JL, Coderre JA, Mallette LE. Effects of a short course of estrogen on mineral metabolism in postmenopausal women. J Clin Endocrinol Metab. 1985 Oct;61(4):595-600. doi: 10.1210/jcem-61-4-595.
citation: Voetberg GA, Netelenbos JC, Kenemans P, Peters-Muller ER, van de Weijer PH. Estrogen replacement therapy continuously combined with four different dosages of dydrogesterone: effect on calcium and lipid metabolism. J Clin Endocrinol Metab. 1994 Nov;79(5):1465-9. doi: 10.1210/jcem.79.5.7962344.