Conditions: Wolfram Syndrome Diabetes Mellitus Optic Nerve Atrophy Ataxia
Keywords: Wolfram syndrome Diabetes Mellitus Optic Nerve Atrophy Ataxia Endoplasmic Reticulum Stress
Allocation: NON_RANDOMIZED | Intervention model: SINGLE_GROUP
Enrollment: 21
Healthy volunteers: no

Brief summary:
Wolfram syndrome is a rare genetic disorder characterized by juvenile-onset diabetes mellitus, diabetes insipidus, optic nerve atrophy, hearing loss, and neurodegeneration. The purpose of this study is to assess the safety and tolerability of dantrolene sodium in patients with Wolfram syndrome. In addition, we will assess the efficacy of dantrolene sodium on the cardinal manifestations of Wolfram syndrome, including visual acuity, remaining beta cell functions, and neurological functions.

There is a screening period up to 56 days, a 6-month treatment period with an optional extension phase up to 24 months, and a 4-week safety follow-up period. Study assessments include medical \& medication history, physical exams, neurological exams, eye exams, endocrine exams, vital signs, height, weight, electrocardiograms, blood and urine tests, pregnancy test if applicable, and questionnaires.

Detailed description:
The Primary Objective of this study is:

To assess the safety and tolerability of dantrolene sodium administered orally at upper end of therapeutic dose range for 6 months in patients with Wolfram syndrome with an optional extension phase up to 24 months. Patients who express the wish to continue in the optional extension phase on dantrolene sodium will be offered this possibility.

The Secondary Objectives of this study are:

* Determine the effect of dantrolene sodium on remaining beta cell functions using a mixed-meal tolerance test and monitoring base-line C-peptide levels, blood glucose levels, proinsulin/C-peptide ratios, hemoglobin A1c levels, and urine glucose levels.
* To determine the efficacy of dantrolene sodium on visual acuity (LogMar scores)
* To determine the efficacy of dantrolene sodium on visual functions using Visual Functioning Questionnaire - 25.
* To evaluate the efficacy of dantrolene sodium on neurological functions using the Wolfram Unified Rating Scale (WURS) and standard neurological assessments.

Arms:
arm 1: Pediatric patients treated with dantrolene sodium arm 2: Adult patients treated with dantrolene sodium

Interventions: intervention 1: dantrolene sodium
Intervention descriptions: intervention 1: The purpose of this study is to assess the safety and tolerability of dantrolene sodium in patients with Wolfram syndrome. In addition, we will assess the efficacy of dantrolene sodium on the cardinal manifestations of Wolfram syndrome, including visual acuity, remaining beta cell functions, and neurological functions.

There is a screening period up to 56 days, a 6-month treatment period with an optional extension phase up to 24 months, and a 4-week safety follow-up period. Study assessments include medical \& medication history, physical exams, neurological exams, eye exams, endocrine exams, vital signs, height, weight, electrocardiograms, blood and urine tests, pregnancy test if applicable, and questionnaires.

Protocol document:
Prot_SAP_000.pdf: 
Wolfram Clinical Trial Protocol Version 30, 05/30/2017
 
 
1 
A SAFETY TRIAL OF DANTROLENE SODIUM IN PEDIATRIC AND ADULT PATIENTS WITH 
WOLFRAM SYNDROME 
 
 
Study Phase: Phase 1b 
 
Product name: Dantrolene Sodium 
 
Indication: Wolfram syndrome  
 
Sponsor: Washington University School of Medicine 
 
Sponsor contact: Fumihiko Urano, MD 
 
IRB ID #: 201607006 
 
FDA IND #: 133439 
 
 
Protocol synopsis 
 
Title 
A Safety Trial of Dantrolene Sodium in Pediatric and Adult Patients 
with Wolfram Syndrome.  
Protocol number 
 
Investigational product 
Dantrolene Sodium for oral administration 
Study objectives 
The Primary Objective of this study is:  
To assess the safety and tolerability of dantrolene sodium 
administered orally at upper end of therapeutic dose range 
for 6 months in patients with Wolfram syndrome with an 
optional extension phase up to 24 months. Patients who 
express the wish to continue in the optional extension phase 
on dantrolene sodium will be offered this possibility. 
The Secondary Objectives of this study are:  
• Determine the effect of dantrolene sodium on remaining 
beta cell functions using a mixed-meal tolerance test and 
monitoring base-line C-peptide levels, blood glucose levels, 
proinsulin/C-peptide ratios, hemoglobin A1c levels, and 
urine glucose levels. 
• To determine the efficacy of dantrolene sodium on visual 
acuity (LogMar scores) 
• To determine the efficacy of dantrolene sodium on visual 
functions using Visual Functioning Questionnaire – 25. 
• To evaluate the efficacy of dantrolene sodium on 
neurological functions using the Wolfram Unified Rating 
Scale (WURS) and standard neurological assessments. 
 
The Exploratory Objectives of this study are:  
• To further explore potential relationships between 
predefined biomarkers and endocrine and neurological 
symptoms, including serum levels of mesencephalic 


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astrocyte-derived neurotrophic factor (MANF), myelin basic 
proteins, and circulating insulin DNA. 
• To evaluate the effects of dantrolene sodium on functional 
activities of daily living by assessing health related quality of 
life using PedsQL (pediatric patients) and SF-36v2 (adult 
patients). 
 
Study endpoints 
The Primary Endpoint of this study is: 
• To assess the safety and tolerability of dantrolene sodium 
administered orally up to 100 mg b.i.d. (adults) and up to 2 
mg/kg b.i.d. (pediatric patients, up to 50 kg) for 6 months 
with an optional extension phase up to 24 months in patients 
with Wolfram syndrome. 
• Safety will be assessed by adverse events (by type and 
severity) and changes in clinical laboratory testing (including 
liver function tests). 
• This will be assessed by monitoring of serum chemistry 
including liver function tests and ammonia. 
• Safety will be also assessed by complete physical exam 
(PE), vital signs (vs)/weight (wt) at each visit  
 
The Secondary Endpoints include:  
• Determine the effect of dantrolene sodium on on remaining 
beta cell functions using a mixed-meal tolerance test and 
monitoring base-line C-peptide levels, blood glucose levels, 
proinsulin/C-peptide ratios, hemoglobin A1c levels, and 
urine glucose levels. 
• To determine the efficacy of dantrolene sodium on visual 
acuity (LogMar scores) 
• To determine the efficacy of dantrolene dosicum on visual 
functions using Visual Functioning Questionnaire – 25. 
• To evaluate the efficacy of dantrolene sodium on 
neurological functions using the Wolfram Unified Rating 
Scale (WURS) and standard neurological assessments. 
 
Inclusion criteria 
Patients must meet all of the following criteria to be eligible for 
enrolment:  
 
1. The patient has a definitive diagnosis of Wolfram syndrome, 
as determined by the following:  
a. Documented functionally relevant recessive mutations on 
both alleles of the WFS1 gene or dominant mutation on 
one allele of the WFS1 gene based on historical test 
results (if available) or from a qualified laboratory at 
screening.  
2. The patient is at least 5 years of age (biological age) at the 
time of written informed consent.  
3. The patient, patient’s parent(s), or legally authorized 
guardian(s) must have voluntarily signed an Institutional 
Review Board/Independent Ethics Committee-approved 


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informed consent form after all relevant aspects of the study 
have been explained and discussed with the patient. The 
guardians’ consent and patient’s assent, as relevant, must 
be obtained.   
 
Exclusion criteria 
Patients who meet any of the following criteria are not eligible for 
this study:  
1. The patient has clinically significant non-Wolfram related 
CNS involvement which is judged by the investigator to be 
likely to interfere with the accurate administration and 
interpretation of protocol assessments.  
2. The patient has a known defect in oxidative phosphorylation 
(such as a confirmed mitochondrial myopathy) 
3. The patient has abnormal liver function (defined as serum 
transaminases more than twice the upper limit of normal for 
the reference laboratory) 
4. The patient has a significant medical or psychiatric co-
morbidity that might affect study data or confound the 
integrity of study results.  
5. The patient has received treatment with any investigational 
drug within the 30 days prior to study entry.  
6. The patient has received blood product transfusions within 
90 days prior to screening.  
7. The patient is unable to comply with the protocol, (e.g. has a 
clinically relevant medical condition making implementation 
of the protocol difficult, unstable social situation, known 
clinically significant psychiatric/behavioral instability, is 
unable to return for safety evaluations, or is otherwise 
unlikely to complete the study), as determined by the 
Investigator.  
8. The patient has a known history of central apnea and/or 
ventilation requirements.  
9. The patient has a known history of chronic obstructive 
pulmonary disease, pleural effusion, and/or myocardial 
disease. 
Number of patients 
planned and duration 
of study participation 
Up to 50 patients (25 adults and 25 children) will be enrolled to 
provide a total of a) 46 evaluable patients who complete the study 
(23 adults and 23 children), based on an anticipated drop-out rate 
of 10%;  
 
The planned duration of oral dantrolene sodium administration in 
this study is 6 months with an optional extension phase up to 24 
month. The planned overall duration of each patient’s participation 
in this study is 9 months. For participants who continue in the 
optional extension phase, the planned overall duration is up to 27 
months (screening, study drug dose maximization, outcome 
measure evaluation, and final safety follow-up).  
Treatment 
administered and 
treatment schedule 
Patients who receive study drug will undergo a run-in period (3 
weeks) for dose maximization. 
 
Adults 


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Up to 25 mg once daily for seven days as prescribed by the 
physician, then 
Up to 25 mg b.i.d. for seven days 
Up to 50 mg b.i.d. for seven days 
Up to100 mg b.i.d. 
 
Pediatric Patients (a patient with an age < 18 years) up to 50 kg 
Up to 0.5 mg/kg once daily for seven days as prescribed by the 
physician, then 
Up to 0.5 mg/kg b.i.d. for seven days 
Up to 1 mg/kg b.i.d. for seven days 
Up to 2 mg/kg b.i.d. 
 
No dose changes if weight change is within ± 3% of the original 
dosing weight. 
 
Dantrolene sodium for oral use will be provided by the Washington 
University’s clinical trials pharmacy 
Study duration 
The duration of this study will be approximately 9 months. For 
participants who continue in the optional extension phase, the 
duration of the study is up to 27 months.  
Study methodology 
This is a single center, dose-escalation study designed to evaluate 
the safety, and tolerability of maximal dose level of dantrolene 
sodium administered orally over 6 months with an optional 
extension phase up to 24 months in patients with Wolfram 
syndrome. 
 
The study will have ‘x’ periods as follows:  
• Baseline and confirmatory screening (all patients): within 56 
days prior to treatment.  
• Dose maximization period (weeks 0-3 for each patient).  
• Treatment period (weeks 1-) for all patients. 
• Week 0 through week 3 (+/- 2 days): dose escalation up to 
the maximum recommended. Assessments for safety at 
months 1 (+/- 2 days), 2 (+/- 7 days), 4 (+/- 7 days), and 6 
(+/- 7 days); and clinical examination, including ophthalmic, 
neurologic, endocrine, and laboratory assessments at 
months 0 and 6 (+/- 7 days). For participants who continue 
in the optional extension phase, additional assessments for 
safety at months 12 (+/- 7 days), 18 (+/- 7 days), and 24 (+/- 
7 days); and additional clinical examinations, including 
ophthalmic, neurologic, endocrine, and laboratory 
assessments at months 12 (+/- 7 days), 18 (+/- 7 days) and 
24 (+/- 7 days). 
• Outcome measure evaluations (all patients): month 6 (+/- 7 
days) after the last dantrolene sodium administration for 
participants who complete the study, month 24 (+/- 7 days) 
after the last dantrolene sodium administration for 
participants who complete the optional extension phase, and 
within 28 days (+/- 7 days) after the last dantrolene sodium 


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administration for patients who discontinue prior to the end 
of the study.  
• Final Safety Follow-Up (all patients): within 28 days  (+/- 7 
days) following discontinuation of study drug. 
 
Patient eligibility will be based on a diagnosis of Wolfram 
syndrome. Eligibility will be confirmed during the baseline 
screening visit. Patients who have provided written informed 
consent/assent to participate in this study will undergo baseline 
screening procedures, which will include a review of the study entry 
criteria and standard laboratory tests (serum chemistry, 
hematology and urinalysis), genetic testing confirmation, 
ophthalmic examination, standardized neurological and 
endocrinology evaluations. When central apnea is suspected in a 
participant, baseline screening will include the confirmation of the 
absence of central apnea based on the result of most 
recent polysomnography. Patients who are confirmed eligible 
based on the results of the baseline screening assessments will be 
enrolled to receive study drug.  
 
Baseline procedures will include complete physical exam, standard 
clinical laboratory tests (serum chemistry, liver function tests, 
hematology and urinalysis, bone chemistry), protocol-specific 
laboratory testing (e.g.), 12 lead ECG. If there are no safety 
concerns, patients will begin the 3-week dose maximization period 
of the study drug.  
 
We will perform ECG before and 4 hours after the first dose of 
dantrolene sodium, then again at months 2 and 6. For participants 
in the optional extension phase, we will also perform ECG at 
months 12, 18, and 24. 
 
All patients will undergo outcome measure evaluations at month 6. 
Participants in the optional extension phase undergo outcome 
measure evaluations at months 12, 18, and 24.  
 
Outcome measure evaluations will include standard clinical 
laboratory tests (serum chemistry, haematology and urinalysis), 12-
lead ECG, vision assessments, neurological examination, 
remaining beta cell function assessment (boost test), protocol-
specific laboratory testing, and standardized functional activities of 
daily living tests. 
 
A Final Safety Follow-Up visit will be conducted at 28 days (+/- 7 
days) after the outcome measure evaluations to collect updated 
information on adverse events and concomitant medications, 
therapies and procedures. For patients who discontinue prior to the 
outcome measure evaluations, this will be conducted within 28 
days (+/- 7 days) after the last dantrolene sodium administration. 
 


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Administration of dantrolene sodium will be contingent upon normal 
results of the relevant safety laboratory tests and measures (i.e., 
LFTs). 
 
All adverse events, safety lab results and use of concomitant 
medications will be monitored closely by the PI throughout the 
study and for 30 days following discontinuation of study 
medication. If any clinically significant laboratory or clinical 
abnormality occurs, the subjects will be monitored closely until 
resolution or clinically stable. Study medication will be discontinued 
if indicated. Progress of the trial will be determined following 
periodic reviews by a Data and Safety Monitoring Board (DSMB) of 
the safety data in all previously enrolled patients. 
 
Statistical Methodology The first aim of the statistical analysis will be to assess safety and 
tolerability of dantrolene sodium in this patient population. The 
analysis will be based on all enrolled patients and will not include 
any formal statistical tests. To evaluate safety, the number and 
percentage experiencing each adverse event will be tabulated and 
compared by treatment status. Adverse events will be summarized 
by severity and by category. Vital signs, and serum chemistries, 
hematology and urinalysis safety monitoring will be listed for each 
patient and abnormal values will be flagged. The maximum dose 
received by patients, duration of treatment and reasons for dose 
reductions or early withdrawal will be reported to assess tolerability 
of treatment. 
 
The second aim of the statistical analysis will be to assess efficacy 
in terms of the secondary outcome measures of residual beta cell 
functions, visual acuity, and neurological function. Each variable will 
be quantified as a change from the baseline value. The trajectory of 
change for each variable will be assessed between baseline and 6-
month assessments. For participants in the optional extension 
phase, the trajectory of change for each variable will be assessed 
between baseline, 6-month, 12-month, 18-month, and 24-month 
assessments..  
 
As this is a rare disease and the trial involves only a small numbers 
of patients, statistical inferences will be based on estimation rather 
than hypothesis testing. Specifically a Bayesian approach to 
estimation will be used based on both non-informative and 
informative priors as appropriate. This type of approach has been 
endorsed for trials of rare diseases. Drop-outs may be replaced, 
such that an adequate number of evaluable patients complete the 
study. 
 
  
Individual stopping 
criteria 
1. 
If a participant experiences more than a few but not more 
than 10 diarrhea stools in a single day while taking dantrolene 
sodium, a temporary withdrawal (48 h or longer) should be 
discussed with a PI. A patient with Wolfram syndrome tends to 


Wolfram Clinical Trial Protocol Version 30, 05/30/2017
 
 
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have diarrhea due to autonomic dysfunction. Thus, the temporary 
withdrawal is determined by the discretion of the PI. If a patient 
experiences more than 10 diarrhea stools in a single day, a 
temporary withdrawal (48 h or longer) should be immediately done. 
After the temporary withdrawal, a participant should use the 
previously tolerated dosing regimen. 
2. 
If a participant experiences significant muscle weakness 
while taking dantrolene sodium, a participant should use the 
previously tolerated dosing regimen. Muscle weakness is 
examined at every study visit as part of the physical exam. Muscle 
weakness is assessed by the following methods. 
• 
Rise to stand from floor without using hands. If a participant 
cannot do this due to neurological dysfunction of Wolfram 
syndrome, the order in which we would like a participant to attempt 
is the following: From floor with hands, from a chair without using 
hands, from a chair with hands. 
• 
Hand grip strength using a hand dynamometer, left and 
right. 
If a participant cannot rise to stand with the method he/she used or 
a participant’s total hand grip strength (sum of right- and left-hand 
grip strength) is decreased by more than 20% with the current 
dosing regimen, a patient should use the previously tolerated 
dosing regimen. 
 
Two failures in either of these two steps would constitute stopping 
the drug permanently. 
 
3. ALT or AST >8xUpper Limits of Normal (ULN) 
4. ALT or AST >5xULN for more than 2 weeks 
5. ALT or AST >3xULN and (serum total bilirubin >2xULN or 
international normalized ratio >1.5) 
6. ALT or AST >3xULN with the appearance of fatigue, nausea, 
vomiting, right upper quadrant pain or tenderness, fever, rash, 
and/or eosinophilia (>5%) 
 
Study stopping criteria 
We define the study stopping criteria based on established adverse 
event criteria, the National Cancer Institute (NCI) Common 
Terminology Criteria for Adverse Events (CTCAE), Version 4. The 
study may need to be stopped if ≥2 patients on drug develop the 
same CTCAE Grade 3 or if 1 patient develops a CTCAE Grade 4 
or higher. 
 
 
 
 


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8 
FIGURE: CLINICAL TRIAL DIAGRAM 
 
 
Screening 
Visit 1, 
Week -1  
 
 
 
  
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
Dose Escalation  
Study Visits 2-5; 
Weeks 0-3  
 
 
 
 
 
 
Study Visit 6, Month1 
 
 
 
  
 
 
 
 
 
 
 
 
Study Visits 7, 8 
Months 2, 4 
 
 
 
 
 
  
 
 
 
 
 
 
 
Study Visit 9 
Month 6  
 
 
 
 
 
 
 
 
 
 
• 
Obtain informed consent & assent (age appropriate forms)  
• 
Screen subjects by criteria; medical history, genetic testing, physical exam (PE), ECG, 
safety labs, pregnancy test  
• 
Baseline beta cell functions, ophthalmology (visual acuity) & neurological assessments 
(WURS), visual functioning questions, QOL questions, baseline lab assessments, myelin 
basic protein and MANF assays (ELISA) 
Administer oral study med per dose escalation guidelines; Complete physical exam (PE), 
VS/Wt, and liver enzyme testing (ALT, AST, alkaline phosphatase, bilirubin), blood glucose 
levels, CBC with differential, comprehensive metabolic panel at each visit; adverse event 
monitoring) at each visit; adverse event (AE) monitoring; Evaluative labs visit 4, wk 2 HbA1c, 
C-peptide (C-P), serum osmolality (osm), Phosphorus (phos), Ammonia (Am), UA 
(micro/macro)  
 Continue Study med at determined dose. AE monitoring, Review medication diary, 
Complete PE, VS/Wt, pregnancy test, and Safety labs: liver enzyme testing (ALT, 
AST, alkaline phosphatase, bilirubin), Eval labs: blood glucose levels, CBC with 
differential, comprehensive metabolic panel, proinsulin, C-peptide, HBA1C, myelin 
basic protein and MANF levels (ELISA), circulating insulin DNA,, osm, phos, Am, 
UA(micro/macro, glucose)  
Continue Study med at determined dose.  AE monitoring, Review medication diary, complete 
PE, VS/Wt, pregnancy test, Safety labs liver enzyme testing (ALT, AST, alkaline 
phosphatase, bilirubin), Eval labs: blood glucose levels, CBC with differential, comprehensive 
metabolic panel, proinsulin, C-peptide, HBA1C, myelin basic protein and MANF levels 
(ELISA), osm, phos, Am, UA(micro/macro, glucose)  
50 eligible subjects (25 adults and 25children) 
Dantrolene PO 
Assessment of Study Outcome Measures 
Discontinue study med or placebo; Complete PE, VS/Wt, all safety labs and evaluative labs: 
liver enzyme testing (ALT, AST, alkaline phosphatase, bilirubin), Eval labs: blood glucose levels, 
CBC with differential, comprehensive metabolic panel, proinsulin, C-peptide, HBA1C, myelin 
basic protein and MANF levels (ELISA), osm, phos, Am, UA(micro/macro, glucose); ECG, beta 
cell functions, neurological and ophthalmology exam, visual functioning questions, QOL 
questions. 


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9 
For participants who continue in the optional extension phase 
 
 
Study Visits 10,  
11, and 12 
Month 12, 18, 
and 24 
 
 
 
 
 
 
 
Final Follow up 
Assessment of Clinical Outcome Measures 
Discontinue study med or placebo; Complete PE, VS/Wt, all safety labs and evaluative labs: 
liver enzyme testing (ALT, AST, alkaline phosphatase, bilirubin), Eval labs: blood glucose levels, 
CBC with differential, comprehensive metabolic panel, proinsulin, C-peptide, HBA1C, myelin 
basic protein and MANF levels (ELISA), osm, phos, Am, UA(micro/macro, glucose); ECG, beta 
cell functions, neurological and ophthalmology exam, visual functioning questions, QOL 
questions. 
Safety labs, AE monitoring, complete PE, VS/Wt