Clinical trial NCT04984798: Vitamin E Efficacy in HI/HA
Official title: Efficacy of Vitamin E in Hyperinsulinism/Hyperammonemia Syndrome
Study type: INTERVENTIONAL
Overall status: WITHDRAWN
Phase: PHASE2
Conditions: Hyperinsulinism-Hyperammonemia Syndrome
Keywords: hypoglycemia
hyperinsulinism
vitamin E
Lead sponsor: Children's Hospital of Philadelphia
Sponsor class: OTHER
Collaborators: name: University of Pennsylvania
name: Lawson Wilkins Pediatric Endocrine Society
First posted: 2021-08-02
Enrollment: 0
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: NA
Intervention model: SINGLE_GROUP
Intervention model description: This single-group open-label dose-finding clinical study will use a before-and-after design, with repeated outpatient evaluations.
Primary purpose: TREATMENT

Brief summary: Congenital hyperinsulinism (HI) is a rare disorder of pancreatic beta cell insulin secretion that causes persistent and severe hypoglycemia starting at birth. Hyperinsulinism/hyperammonemia (HI/HA) syndrome is the second most common type of congenital HI and is caused by activating mutations in glutamate dehydrogenase (GDH). Patients with HI/HA exhibit fasting hyperinsulinemic hypoglycemia, protein-induced hypoglycemia, hyperammonemia, seizures, and intellectual disability independent of hypoglycemia. These effects result from abnormal GDH activity in the beta cells, liver and kidney cells, neurons, and astrocytes. The only available treatment for HI/HA syndrome is diazoxide, which acts on the beta cells to decrease insulin secretion but has no effect on GDH activity itself or on other cell types. Thus, there remains a significant unmet need for improved therapies for this disorder. Pre-clinical data show that vitamin E inhibits GDH activity in human cell lines and improves fasting hypoglycemia in a GDH HI mouse model. Pilot study data show that vitamin E supplementation with a moderate dose is well-tolerated in children and adults with HI/HA syndrome, while continuing diazoxide treatment. However, most subjects continued to exhibit protein-induced hyperinsulinemic hypoglycemia. We hypothesize that a higher vitamin E dose will inhibit GDH over-activity in subjects with HI/HA syndrome, resulting in improved hyperinsulinemic hypoglycemia, reduced blood ammonia concentration, and decreased seizure activity.

Detailed description: The primary objective of this study is to determine an effective dose of vitamin E to reduce protein-induced hyperinsulinemia in subjects with HI/HA syndrome. Secondary objectives are to assess the effects of vitamin E on plasma C-peptide concentrations, serum alpha-tocopherol concentrations, blood ammonia concentrations, hypoglycemic events, and seizure frequency. The effect of vitamin E on brain glutamate levels and electroencephalogram findings will be explored.

This single-group open-label dose-finding clinical study will use a before-and-after design to compare clinical and laboratory data before and after 2-3 weeks of escalating doses of oral vitamin E treatment in subjects with HI/HA syndrome.

This single-site outpatient study will recruit up to 5 adult participants (18 years of age or older) with HI/HA syndrome.

Each study visit will consist of blood tests, an IV leucine acute insulin response (AIR) test, home glucose meter and continuous glucose monitor (CGM) review, and a symptom questionnaire. The baseline and final visits will also include electroencephalogram (EEG) and brain magnetic resonance imaging (MRI) with glutamate chemical exchange saturation transfer (GluCEST) analysis. After baseline assessments, including a 2 week run-in period of CGM use, subjects will take twice daily oral vitamin E (alpha-tocopherol) at home. After steady-state of that dose of vitamin E has been achieved (i.e. at least 2 weeks on the dose of vitamin E), subjects will return for the next study visit. If there is no dose-limiting toxicity, then the twice daily vitamin E dose will be increased, and the subjects will return for a subsequent study visit after at least 2 weeks. If there is no dose-limiting toxicity at this visit, then the twice daily vitamin E dose will be increased again, and the subjects will return for a final study visit after at least 2 weeks. If toxicity is identified at any point, vitamin E will be discontinued and final study visit procedures will be performed.

Eligibility criteria: Inclusion Criteria:

* Males or females age ≥18 years.
* Diagnosis of HI/HA syndrome (based on glutamate dehydrogenase 1 \[GLUD1\] genetic test result and/or history of diazoxide-responsive hyperinsulinism with persistently elevated blood ammonia concentrations).
* Able to swallow softgels.
* Informed consent.

Exclusion Criteria:

* Vitamin E supplementation within 30 days prior to enrollment, including multivitamins containing vitamin E.
* Individuals who have experienced an allergic reaction to vitamin E.
* On concurrent therapy with a medication known to adversely interact with vitamin E.
* On concurrent therapy with a medication, supplement, or herbal remedy known to increase bleeding risk, including antiplatelet or anticoagulation therapy.
* Known increased risk of bleeding (coagulopathy, hemophilia, platelet defect, or platelet disorder) based on history, known or suspected vitamin K deficiency, baseline international normalized ratio (INR) \>1.5, baseline prothrombin time (PT) \>1.5 times the upper limit of normal, baseline partial thromboplastin time (PTT) \>1.5 times the upper limit of normal, or baseline abnormal platelet function test result (VerifyNow-Aspirin \<550 aspirin reactivity units \[ARU\], VerifyNow-adenosine diphosphate \[ADP\]/PRU \<180 P2Y12 reaction units \[PRU\]).
* Known clotting disorder, including prior episodes of deep vein thrombosis or pulmonary embolism within the past 6 months.
* Evidence of severe hematologic abnormality including severe anemia (Hgb \<10 g/dL) and/or thrombocytopenia (platelet count \<150,000/mm3).
* Abnormal score on International Society on Thrombosis and Haemostasis (ISTH)-Bleeding Assessment Tool (\>4 if male; \>5 if female).
* Planned elective surgical procedure during study period.
* Evidence of a medical condition that might alter results or compromise the interpretation of results, including active infection, kidney failure, severe liver dysfunction, severe respiratory or cardiac failure.
* Any investigational drug use within 30 days prior to enrollment.
* Current use of somatostatin analog.
* Current adherence to a ketogenic diet.
* Pregnant or lactating females. Females must have a negative urine pregnancy test and must use an acceptable method of contraception, including abstinence, a barrier method (diaphragm or condom), Depo-Provera, or an oral contraceptive, for the duration of the study and a minimum of 2 weeks after the last dose of study drug.
* Subjects who, in the opinion of the Investigator, may be non-compliant with study schedules or procedures.
* Unable to provide informed consent (e.g. impaired cognition or judgment).
* Limited English proficiency.

Primary outcomes:
measure: protein-induced hyperinsulinemia
timeFrame: 4-11 weeks
Secondary outcomes:
measure: mean glucose concentration
timeFrame: 4-11 weeks
measure: proportion of time spent with glucose <70 mg/dL
timeFrame: 4-11 weeks
measure: proportion of time spent with glucose <50 mg/dL
timeFrame: 4-11 weeks
measure: hypoglycemic episodes
timeFrame: 4-11 weeks
measure: protein-induced C-peptide release
timeFrame: 4-11 weeks
measure: vitamin E
timeFrame: 4-11 weeks
measure: ammonia
timeFrame: 4-11 weeks
measure: seizures
timeFrame: 4-11 weeks
Other outcomes:
measure: number of participants with EEG abnormalities
timeFrame: 8-11 weeks
measure: brain glutamate
timeFrame: 8-11 weeks
Locations:
city: Philadelphia
country: United States
facility: Children's Hospital of Philadelphia
state: Pennsylvania
Study officials:
affiliation: Children's Hospital of Philadelphia
name: Elizabeth A Rosenfeld, MD
role: PRINCIPAL_INVESTIGATOR
References:
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citation: Treberg JR, Clow KA, Greene KA, Brosnan ME, Brosnan JT. Systemic activation of glutamate dehydrogenase increases renal ammoniagenesis: implications for the hyperinsulinism/hyperammonemia syndrome. Am J Physiol Endocrinol Metab. 2010 Jun;298(6):E1219-25. doi: 10.1152/ajpendo.00028.2010. Epub 2010 Mar 23.
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