Safety and Efficacy of Clenbuterol in Individuals With Late-onset Pompe Disease and Receiving Enzyme Replacement Therapy

Safety and Efficacy of Clenbuterol in Individuals With Late-onset Pompe Disease and Receiving Enzyme Replacement Therapy

A Clinical Investigation of the Safety and Efficacy of Clenbuterol on Motor Function in Individuals With Late-onset Pompe Disease and Receiving Enzyme Replacement Therapy

Funding Source- FDA OOPD The purpose of this study is to investigate the safety and efficacy of clenbuterol on motor function in individuals with late-onset Pompe disease (LOPD) who are treated with enzyme replacement therapy (ERT).

This is a 52 week Phase I/II double-blind, randomized, placebo-controlled study of adjunctive clenbuterol in LOPD (Table 2, Section 6). All subjects will be evaluated at Week 0 and Week 6 to establish a baseline for motor function testing. At Week 6, subjects will be randomized 3:2 to clenbuterol or placebo, and evaluated for safety and efficacy during the Week 12 and 18 visits. The Investigational Drug Service will maintain double-blinding by providing either the study drug or placebo (over-encapsulated tablets) directly to subjects. The drug (or placebo) will be initiated at the Week 6 visit in a staged manner (first once daily and later BID), and the dose will be increased at the Week 12 visit in a similarly staged manner to minimize AEs and related attrition. All subjects will return for a final visit after a total of 52 weeks in the study. In terms of standard of care, the subject will have two clinical visits (charged to the subject and/or the subject's insurance company), one at the initiation of the study drug (baseline) and one at the study completion (52 weeks). Study drug will be attempted to be initiated during the "off week", approximately one week following a dose of ERT, and ERT will continue throughout the duration of the study. Thereafter, study visits will be during the "off week". The 6, 12, and 18 week visits will be research visits (not charged to the subject and/or the subject's insurance company) in order to determine subject's overall health status and measure early signs of motor improvement. The initial dose of clenbuterol will be 40 mcg per oral each morning for one week, followed by 40 mcg BID for the next 5 weeks until the week 12 visit. If the 40 mcg BID per oral is well tolerated, the dose will be increased to 80 mcg each morning/40 mcg each evening for one week, followed by 80 mcg BID for the next 5 weeks until the Week 18 visit. If 80 mcg BID is tolerated at Week 18, the subject will continue on that dose until Week 52. Compliance will be discussed at the Week 6, Week 12, and Week 18 visits. The subject will have phone visits during Week 1, 7, 13, 36, and 52, and compliance will be discussed then. We will call subjects daily during the first week following initiation of study drug (Week 7) and dosage escalation (Week 13) to support subjects through the early adverse effects of tachyphylaxis that may lead to premature termination. An interim call will occur during Week 36 to monitor compliance. Subjects who admit non-compliance, missing >6 doses of the study drug, will be considered non-compliant and withdrawn from the study. Subjects will be called during Week 1 and Week 52, 3 days following the muscle biopsy. All phone calls will review AEs (Table). The efficacy of clenbuterol treatment during ERT in patients with LOPD will be evaluated with muscle and pulmonary function testing as the primary endpoints. A secondary endpoint, the urinary Glc4 biomarker, will be monitored when the subjects are evaluated at baseline, week 18 and week 52. The impact of enhanced CI-MPR-mediated uptake of GAA will be analyzed by comparing the muscle function, pulmonary function, and biochemical correction of muscle in subjects with LOPD treated with ERT, both prior to and during simultaneous β2 agonist therapy.

Initially, 40 mcg each morning for one week. Then, increase to 40 mcg BID for the next 5 weeks. If tolerated, will increase to 80 mcg in the morning and 40 mcg in the evening for one week. Then, last dose increase will be 80 mcg BID until week 52.

Initially, one capsule each morning for one week. Then, increase to one capsule BID for the next 5 weeks. If tolerated, will increase to two capsules in the morning and one capsule in the evening for one week. Then, last dose increase will be two capsules BID until week 52.

Number of Participants With a Change in Creatine Kinase (CK) Reflecting Worsening of Muscle Involvement

Worsening muscle involvement, as defined by >3x increase in CK from baseline that is >2x the upper limit of normal

Number of Participants With a Change in Aspartate Aminotransferase (AST), Alanine Transaminase (ALT), and Bilirubin Representing Liver Toxicity

Liver toxicity, as defined by a >3x increase in AST or ALT from the respective baseline values and/or an increase in direct, indirect or total bilirubin of >3x the upper limit of normal

Assess exercise tolerance in study patients; test administered by physical therapist. Subjects were asked to walk for 6 minutes, unassisted. The distance walked was recorded in meters.

Assess exercise tolerance in study patients; test administered by physical therapist. Subjects were asked to walk for 6 minutes, unassisted. The distance walked was recorded in meters.

The Glc4 biomarker is measured in urine and correlates with muscle glycogen content. It is a noninvasive measurement that serves as a biomarker for Pompe disease.

The GSGC is a criterion referenced assessment designed to measure functional status and change in gross motor function over time and, in particular, to measure clinically relevant change. Consists of 4 components: Gait, Climbing Stairs, Gower's Manuever, Arising From a Chair. Lowest score 4 = normal muscle function, highest score 27 = unable to perform motor function tests.

The QMFT is a criterion referenced assessment designed to measure functional status and change in gross motor function over time and, in particular, to measure clinically relevant change. Consists of 16 motor function tests. Lowest score 0 = unable to perform motor function tests, highest score 64 = normal muscle function.

The Late-Life Function & Disability Instrument (Late-Life FDI) is an evaluative outcome instrument for community-dwelling older adults. Highest score 240 = normal function and no disability, lowest score 0 = low levels of frequency of participating in life tasks.

MIP is a measurement of inspiratory muscle weakness, including weakness of the diaphragm. MIP is decreased in Pompe disease and reflects weakness of respiratory muscles.

Inclusion Criteria: Diagnosis of Pompe disease by blood acid alpha-glucosidase assay and acid alpha-glucosidase gene sequencing, Age: 18+ years at enrollment, Receiving ERT at standard dose (20 mg/kg every 2 weeks) for at least 52 weeks, Subjects are capable of giving written consent. Exclusion Criteria: Continuous invasive ventilation (via tracheostomy or endotracheal tube) Clinically relevant illness within two weeks of enrollment including fever > 38.2 C, vomiting more than once in 24 hours, seizure, or other symptom deemed contraindicative to new therapy. Chronic heart disease (Myocardial infarction, arrythmia, cardiomyopathy) Tachycardia History of seizure disorder Hyperthyroidism Pheochromocytoma Pregnancy History of diabetes History of hypersensitivity to beta 2-agonist drugs such as albuterol, levalbuterol (Xopenex), bitolterol (Tornalate), pirbuterol (Maxair), terbutaline, salmeterol (Serevent), Patients on a non-standard schedule for ERT; for example, weekly infusions as opposed to infusions every two weeks. Treatment for asthma in the previous 12 months. The use of the following concommitant meds is prohibited during the study: diuretics (water pill); digoxin (digitalis, Lanoxin); beta-blockers such as atenolol (Tenormin), metoprolol (Lopressor), and propranolol (Inderal); tricyclic antidepressants such as amitriptyline (Elavil, Etrafon), doxepin (Sinequan), imipramine (Janimine, Tofranil), and nortriptyline (Pamelor); Monoamine oxidase inhibitors such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate); or other bronchodilators such as albuterol, levalbuterol (Xopenex), bitolterol (Tornalate), pirbuterol (Maxair), terbutaline (Brethine, Bricanyl), salmeterol (Serevent), isoetherine (Bronkometer), metaproterenol (Alupent, Metaprel), or isoproterenol (Isuprel Mistometer).

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