Clinical trial NCT02466477: Pharmacogenomic Decision Support With GeneSight Psychotropic to Guide the Treatment of Major Depressive Disorder
Official title: A Three-arm, Parallel Group, Multicentre, Double-blind, Randomized Controlled Trial Evaluating the Impact of GeneSight Psychotropic and Enhanced-GeneSight Psychotropic, on Response to Psychotropic Treatment in Outpatients Suffering From a Major Depressive Disorder (MDD) and Having Had - Within the Current Episode - an Inadequate Response to at Least One Psychotropic Medication Included in GeneSight Psychotropic
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: PHASE4
Conditions: Depressive Disorder, Major
Depression
Depressive Disorder
Keywords: Pharmacogenomic
Pharmacogenomic Testing
Pharmacogenomics
Genetic Testing
Genetics
Major Depressive Disorder
GeneSight
Enhanced GeneSight
Psychotropic
Lead sponsor: Assurex Health Inc.
Sponsor class: INDUSTRY
Collaborators: name: Programs for Assessment of Technology in Health Research Institute
name: Centre for Addiction and Mental Health
name: Genome Canada
name: Assurex Health Ltd.
name: Mars Excellence in Clinical Innovation and Technology Evaluation
First posted: 2015-06-09
Enrollment: 542
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: Evidence exists supporting the ability of genetic variations to influence patient drug response and side effects. Previous studies utilizing an open-label design have shown significant improvement in major depressive disorder (MDD) patient outcomes following use of the GeneSight Psychotropic (GEN) test. The first objective of this trial is to utilize a double-blinded, randomized clinical trial design to replicate previous findings of improvement in clinical outcomes in MDD subjects whose medication therapy was guided by GEN testing. Another objective is to determine the added benefit of Enhanced-GeneSight (E-GEN) compared to GEN for the pharmacogenomic guidance of treatment selections. Furthermore, this trial intends to develop an evidence-based case for the value of GEN and E-GEN to Canadian healthcare payers.

Detailed description: The primary objectives of this study are 1) to compare the efficacy of GEN to treatment as usual (TAU) in improving response to psychotropic treatment in outpatients suffering from a MDD and having had - within the current episode - an inadequate response to at least one psychotropic medication included in GEN; and 2) to validate the utility of the new CAMH markers and demonstrate the superior predictive capabilities and greater clinical utility of E-GEN as compared to GEN.

This study is designed as a three-arm multi-centre, double-blind (participants and raters), randomized controlled trial to compare the clinical and economic outcomes of GEN, E-GEN and TAU for patients suffering from a MDD and having had - within the current episode - an inadequate response to at least one psychotropic medication included in GEN. Participants will be randomized in a 1:1:1 ratio to each of the three treatment arms. Recruitment will be 24 months. Follow-up will be 12 months.

Subjects will complete short diagnostic interviews specific to their clinical diagnosis, basic metabolic measures (eg. blood pressure, weight), and provide buccal swab samples for genetic analysis (the unanalyzed buccal swabs and associated DNA will be biobanked). During the first visit, blood and urine samples will be required for laboratory panel screening and blood biobanking. Subjects will be monitored over a one year period and clinical measures and healthcare resource utilization will be obtained. Treating clinicians in the GEN and E-GEN arms will receive an easy to implement report providing pharmacogenomic guidance for prescribing psychotropic medications to their patients.

The study will recruit subjects from 10 sites, stratified into 2 clusters. Nine study sites altogether will form one of the two stratified clusters. CAMH will constitute the tenth study site and the second stratified cluster.The sample size required for this study was calculated using effect size estimates drawn from a previous study conducted by Hall-Flavin et al \[Pharmacogenetics Genomics 2013; 23(10)\]. Assuming an effect size of 0.30 in HAM-D17 score favoring the treatment group, intra class coefficient between clusters of 20%, statistical power of 90%, an alpha level of 0.05, and an expected 16.7% rate of premature discontinuation by Week 8 (primary endpoint), a total of 570 subjects (i.e., 190 per treatment arm) are required to detect the same effect in this study.

Eligibility criteria: Inclusion Criteria:

* 18 years of age or older;
* Suffer from a Major Depressive Episode meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria;
* Have had an inadequate response within the current episode to at least one psychotropic treatment in GEN. Inadequate response is defined as inadequate efficacy after 6 weeks of a psychotropic treatment or discontinuation of a psychotropic treatment due to adverse events (AEs) or intolerability;
* Have each a score on the 16-item Clinician Quick Inventory of Depressive Symptomatology (QIDS-C16) and 16-item Self-Report Quick Inventory of Depressive Symptomatology (QIDS-SR16) rating scales ≥ 11;
* Be able to understand the requirements of the study and provide written informed consent to participate in this study;
* Agree to abide by the study protocol and its restrictions and be able to complete all aspects of the study, including all visits and tests.

Exclusion Criteria:

* Patients posing a serious suicidal risk and/or in need of immediate hospitalization as judged by the Investigator;
* Patients with a diagnosis of Bipolar I or II disorder;
* Patients with a current Axis I diagnosis of:

  * Delirium
  * Dementia
  * Amnestic and/or other cognitive disorder
  * Schizophrenia or other psychotic disorder;
* Patients having experienced hallucinations, delusions, or any psychotic symptomatology within the current depressive episode or during prior depressive episodes;
* Patient is currently in an inpatient facility;
* Patients with a history of hypothyroidism unless taking a stable dose of thyroid medication and asymptomatic or euthyroid for at least 6 months;
* Patients who meet DSM-IV-TR criteria for any significant current substance use disorder;
* Patients with:

  * hepatic insufficiency (three times the upper limit of normal (ULN) for aspartate aminotransferase (AST) and/or alanine aminotransferase (ALT)); liver transplant recipient; cirrhosis of the liver;
  * malignancy (except basal cell carcinoma) and/or chemotherapy within 1 year prior to screening; malignancy more than 1 year prior to screening must have been local and without metastasis and/or recurrence, and if treated with chemotherapy, without nervous system complications;
  * significant unstable medical condition or life threatening disease with - need for therapies that may obscure the results of treatment and/or of the study;
* Participation in another clinical trial within 30 days of the screening visit;
* Anticipated inability to attend scheduled study visits;
* Patients who in the judgment of the Investigator may be unreliable or uncooperative with the evaluation procedure outlined in this protocol;
* Patients with a history of prior pharmacogenomic testing;
* Any change in psychotropic medication (including change in dosage) between screening and baseline;
* Patients currently receiving electroconvulsive therapy (ECT), deep brain stimulation (DBS) or transcranial magnetic stimulation (TMS) treatments, or currently scheduled to receive maintenance treatments of ECT, DBS, or TMS during the course of the study;
* Patients who self-report to be pregnant or lactating;
* Patients with a history of gastric bypass surgery.

Primary outcomes:
measure: Change in depressive symptoms as assessed by the 17-item Hamilton Depression (HAM-D17) score
timeFrame: From baseline to Week 8
Secondary outcomes:
measure: Change in depressive symptoms as assessed by the 16-Item Clinician Quick Inventory of Depressive Symptomatology (QIDS-SR16)
timeFrame: Baseline, Weeks 8 and 12, and Month 12
measure: Change in depressive symptoms as assessed by the 9-Item Patient Health Questionnaire (PHQ-9)
timeFrame: Baseline, Weeks 8 and 12, and Month 12
measure: Change in anxiety symptoms as assessed by theGeneralized Anxiety Disorder 7-Item (GAD-7) Scale
timeFrame: Baseline, Weeks 8 and 12, and Month 12
measure: Change in severity of illness as assessed by the Clinical Global Impression of Severity (CGI-S)
timeFrame: Baseline, Week 12 and Month 12
measure: Change in global improvement as assessed by the Clinical Global Impression of Improvement (CGI-I)
timeFrame: Week 12, and Month 12
measure: Change in global therapeutic benefit and global severity of side effects as assessed by the Clinical Global Impression Efficacy Index
timeFrame: Week 12 and Month 12
measure: Changes to initial prescribing based on availability of pharmacogenomic data
timeFrame: Screening and Baseline
measure: Response rates to psychotropic medication
timeFrame: Baseline, Weeks 8 and 12, Months 6, 9 and 12
measure: Remission rates
timeFrame: Baseline, Weeks 8 and 12, Months 6, 9 and 12
measure: Time to response
timeFrame: Baseline, Weeks 8 and 12, Months 6, 9 and 12
measure: Time to remission
timeFrame: Baseline, Weeks 8 and 12, Months 6, 9 and 12
measure: Change in psychotropic medication side effects as assessed by the Udvalg for Kliniske Undersogeler (UKU) Side Effect Rating Scale
timeFrame: Baseline, Weeks 8 and 12, and Month 12
measure: Change in global measure of side effects (frequency, intensity, and burden domains) as assessed by the Frequency, Intensity, and Burden of Side Effects Ratings (FIBSER)
timeFrame: Baseline, Weeks 8 and 12, and Month 12
measure: Weight gain
timeFrame: Baseline, Weeks 8 and 12, and Month 12
measure: Waist-to-hip ratio
timeFrame: Baseline, Weeks 8 and 12, and Month 12
measure: Change in health related quality of life as assessed by the EuroQol (EQ-5D-5L)
timeFrame: Baseline, Week 12, Months 6, 9 and 12
measure: Change in health related quality of life as assessed by the Short Form (36) Health Survey (SF-36)
timeFrame: Baseline, Week 12, Months 6, 9 and 12
measure: Pharmacogenetics in Psychiatry Follow-up Questionnaire (PIPFQ)
timeFrame: Baseline, when prescription changes are made (expected average of every 4 weeks), and Month 12
measure: Healthcare resource utilization (Composite measure of healthcare costs): physician visits, hospital utilization, emergency department visits, medication use, and laboratory tests
timeFrame: Baseline, Weeks 8 and 12, Months 6, 9 and 12
measure: Productivity losses (measured as economic costs)
timeFrame: Baseline, Weeks 8 and 12, Months 6, 9 and 12
Other outcomes:
Locations:
city: Chatham
country: Canada
facility: Chatham-Kent Clinical Trials Research Center
state: Ontario
city: Hamilton
country: Canada
facility: Hamilton Community Health Centre Family Health Organization
state: Ontario
city: Hamilton
country: Canada
facility: Hamilton Medical Research Group
state: Ontario
city: Hamilton
country: Canada
facility: St. Joseph's Healthcare Hamilton (SJHH)
state: Ontario
city: London
country: Canada
facility: Milestone Research
state: Ontario
city: London
country: Canada
facility: London Health Sciences Centre
state: Ontario
city: London
country: Canada
facility: Parkwood Institute, London
state: Ontario
city: Ottawa
country: Canada
facility: Hopital Montfort
state: Ontario
city: Thornhill
country: Canada
facility: Thornhill Medical Centre
state: Ontario
city: Toronto
country: Canada
facility: Canadian Phase Onward Inc.
state: Ontario
city: Toronto
country: Canada
facility: Women's College Hospital
state: Ontario
city: Toronto
country: Canada
facility: Sinai Health System
state: Ontario
city: Toronto
country: Canada
facility: Centre for Addiction and Mental Health (CAMH)
state: Ontario
city: Toronto
country: Canada
facility: Manna Research
state: Ontario
Study officials:
affiliation: Centre for Addiction and Mental Health
name: James L Kennedy, MD
role: PRINCIPAL_INVESTIGATOR
affiliation: Assurex Health Inc.
name: Bryan Dechairo, PhD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Tiwari AK, Zai CC, Altar CA, Tanner JA, Davies PE, Traxler P, Li J, Cogan ES, Kucera MT, Gugila A, Braganza N, Emmerson H, Zai G, Muller DJ, Levitan R, Kloiber S, Daskalakis ZJ, Frey BN, Bowen JM, Tarride JE, Tytus R, Chandrasena R, Voudouris N, Taylor VH, Tempier R, Sharma V, Vasudev A, Dzongowski P, Pliamm L, Greenspoon T, Dechairo BM, Kennedy JL. Clinical utility of combinatorial pharmacogenomic testing in depression: A Canadian patient- and rater-blinded, randomized, controlled trial. Transl Psychiatry. 2022 Mar 14;12(1):101. doi: 10.1038/s41398-022-01847-8.