The Role of Secondary Bile Acids in Intestinal Inflammation

Launched by STANFORD UNIVERSITY · Oct 26, 2018

Keywords

ClinConnect Summary

This clinical trial is studying a potential treatment for patients with ulcerative colitis or pouchitis, which is inflammation of a surgical pouch created after the removal of a diseased colon. Researchers want to see if a medication called ursodeoxycholic acid (UDCA) can help reduce inflammation and improve the quality of life for people who continue to have symptoms despite antibiotic treatment. The trial is focused on understanding how certain bile acids, which are substances produced in the body, can influence inflammation in the gut.

To be eligible for this trial, participants must be at least 18 years old and have a history of pouchitis, with specific symptoms and scores indicating active inflammation. They should also have had a specific surgical procedure for ulcerative colitis. If you join the study, you will receive the medication and be monitored for changes in your symptoms and overall health over several weeks. It’s important to know that certain medications and conditions may prevent participation, so if you’re interested, discussing this with your healthcare provider will help determine if you qualify.

Gender

ALL

Eligibility criteria

• Inclusion Criteria:
• • 1. Written informed consent;
• • 2. Male or female subjects, ≥18 years of age who have undergone an ileal pouch-anal anastomosis (IPAA) for UC.
• • 3. History of pouchitis
• Documented evidence of active pouchitis, based on endoscopy, symptoms and histopathology, as follows:
• • 4. Endoscopic score \>=2 on the endoscopic component of a modified Mayo endoscopic score (where friability is scored as \>2) Note: the area within 1 cm of the pouch staple, or pouch suture line, is not considered evaluable
• 5. Symptomatic disease (stool frequency):
• • Subjects must demonstrate increased stool frequency compared to what is considered "normal" after their IPAA operation ("baseline"). Stool frequency must be an absolute value of \> 6 stools per day, and \> 3 stools per day above the post-IPAA "baseline". Note: The measurement of stool frequency will be a 7-day average rounded to the nearest integer. The most recent 7 days of data will be used to calculate the average.
• • 6. Histology: evidence of disease.
• • 7. Modified PDAI (mPDAI) score \>= 5. The mPDAI consists of the symptom (range: 0-6) and endoscopy (range: 0-6) subscores.
• • 8. Must have chronic antibiotic refractory or antibiotic dependent pouchitis.
• Exclusion Criteria:
• • 1. Lack of effective contraception Women of childbearing potential may not participate unless they are surgically sterile or are using adequate contraception.
• • The following contraceptive methods are acceptable: hormonal (eg oral, injection, transdermal patch, implant, cervical ring), barrier (eg condom or diaphragm with spermicidal agent), intrauterine system or intrauterine device. If hormonal contraceptives are used by female subjects, they must be established for 6 weeks before the first administration of test product. Male sterilization is considered an acceptable form of contraception if the appropriate post-vasectomy documentation (absence of sperm) is provided in the subject's medical notes. Sexual abstinence is considered acceptable if this is in line with the preferred and usual lifestyle of the subject; periodic abstinence (eg calendar, ovulation, symptothermal, post-ovulation methods) and withdrawal are not acceptable methods of contraception.
• • Male subjects with female partners of child-bearing potential and female subjects who are neither surgically sterilized nor post-menopausal (defined as no menses for one year or a follicle-stimulating hormone value \> 40 IU/L) will be required to use effective contraception throughout the study and for 30 days after.
• • 2. Women who are pregnant or breastfeeding;
• • 3. History of allergy or adverse event to UDCA;
• Stable use of concomitant medications for pouchitis is generally permitted, doses of concomitant medication, where taken, should be optimised in accordance with local/national practice guidelines, and dose levels and types of baseline medications for pouchitis will be documented and any changes during the study will be recorded. Changes in use of medications for pouchitis and high doses of oral steroids are not permitted. It is particularly important to maintain stable medication through to measurement of the primary end-point at Week 10. Criteria which would lead to exclusion of subjects from the study are described below:
• • 4. Changes in dose to strong analgesia, such as opioid containing compounds within 4 weeks of the Screening Visit.
• • 5. History of regular nonsteroidal anti-inflammatory drugs (NSAID) use.
• • 6. Oral 5-aminosalicylate (5-ASA) compounds; exclude subjects who have discontinued or changed doses of oral 5-ASA within 4 weeks of the Screening Visit.
• • 7. Oral budesonide \> 6.0 mg/day is not permitted; exclude subjects who have received budesonide for \< 6 weeks, or who have changed doses of budesonide within 4 weeks of the Screening Visit.
• • 8. Oral steroids other than budesonide: exclude subjects who exceed a daily dose of 15 mg prednisolone or equivalent, who have received oral steroids for \< 6 weeks, or who have changed dose within 4 weeks of the Screening Visit.
• • 9. Use of rectal compounds is not permitted; these agents must be discontinued at the Screening Visit.
• • 10. Immunosuppressant therapy (azathioprine, 6- mercaptopurine, methotrexate, cyclosporin); exclude subjects who have received treatment for \< 12 weeks, or who have changed doses within 8 weeks of the Screening Visit.
• • 11. Biological agents (Anti-tumour necrosis factor (anti - TNF) therapy, vedolizumab and / or ustekinumab); exclude subjects who have received biological agents for \<6 months prior to the screening visit, or who changed doses of the biological agent within 6 months prior to the screening visit.
• • 12. Previous use of UDCA is permitted: treatment course must have completed at least 12 weeks prior to the Screening Visit.
• • 13. All other agents targeted to pouchitis, including experimental agents, must have been discontinued at least 8 weeks prior to the Screening Visit, or for a period equivalent to 5 half-lives (t1⁄2) of the agent (whichever is longer) It is acceptable to recruit subjects who remain on optimised, stable doses of oral 5-ASA, oral steroids (below the doses stipulated above) and immunosuppressants.
• • It is acceptable to recruit subjects who terminated treatment with oral 5-ASA or oral steroids 4 weeks before the Screening Visit, or immunosuppressants 8 weeks before the Screening Visit.
• • Note: Analgesic use should remain stable throughout the trial where possible. Paracetamol is the analgesic of choice.
• • Note: VSL#3 probiotic treatment (and other probiotic treatments) will be permitted as long as maintained stable for 4 weeks prior to the Screening Visit, and maintained at a stable dose throughout the trial
• Also excluded are subjects with:
• • 14. Anastomotic stricture
• • 15. Unable to undertake endoscopic evaluation
• • 16. Faecal incontinence due to anal sphincter dysfunction
• • 17. Infections to cytomegalovirus or Clostridium Difficile
• • 18. Faecal transplantation within 12 weeks of screening
• • 19. Intestinal malabsorption
• • 20. Pancreatic maldigestion
• • 21. Suspected irritable pouch syndrome
• • 22. Cuffitis (inflammation of the anal mucosa). Subjects with active antibiotic refractory pouchitis as the predominant condition, but who also have cuffitis, may be enrolled
• • 23. Crohn's disease of the pouch; defined as either: a) complex perianal or pouch fistula and/or b) extensive pre-pouch ileitis with deep ulceration
• • 24. Subjects with a history of neoplastic disease except for basal cell carcinoma or nonmetastatic squamous cell carcinoma of the skin
• • 25. Subjects who are receiving or have received nasogastric/nasoenteric bottle feeding, an elemental diet, or total parenteral nutrition within the 2 weeks prior to Day 1
• • 26. Subjects with a history of clinically significant and/or persistent haematologic, renal, hepatic, metabolic, psychiatric, central nervous system, pulmonary or cardiovascular disease; which in the investigator's opinion, would exclude entry into the study
• • 27. Subjects with any laboratory tests considered clinically significant at screening
• • 28. Subjects who may be unavailable for the duration of the trial, likely to be noncompliant with the protocol, or who are felt to be unsuitable by the Investigator for any other reason including, for example, inability to retain an enema formulation
• • 29. Pelvic sepsis should be excluded