Prospective Evaluation of Budesonide for Prevention of Esophageal Strictures After Endotherapy
Primary Purpose
Esophageal Stricture
Status
Completed
Phase
Phase 2
Locations
United States
Study Type
Interventional
Intervention
Budesonide
Sponsored by
About this trial
This is an interventional treatment trial for Esophageal Stricture focused on measuring Esophageal stricture formation, Endoscopic mucosal resection, Endoscopic submucosal dissection, Budesonide, Radical endoscopic mucosal resection, EMR, ESD
Eligibility Criteria
Inclusion Criteria:
- Age 18 years or older
- Diagnosis of esophageal lesion treated with ESD or EMR which involves ≥ 50% of the esophageal circumference.
Exclusion Criteria:
- Locally advanced disease
- Prior esophageal surgery
- Participation in another research protocol that could interfere or influence the outcome measures of the present study.
- The subject or legal representative is unable/unwilling to give informed consent. (study group)
- Medications or conditions for which there is a contraindication to use of budesonide (see pharmacology section below)
- Concomitant use of systemic steroids or other immune suppressive medication for a different condition 9. Pregnant women
Sites / Locations
- Mayo Clinic in Florida
Arms of the Study
Arm 1
Arm 2
Arm Type
Experimental
No Intervention
Arm Label
Esophageal stricture, Budesonide
Control group
Arm Description
Budesonide 1mg twice a day for a total of 8 weeks following endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR)
Retrospective collect data for subjects who undergo endoscopic submucosal dissection or endoscopic mucosal resection
Outcomes
Primary Outcome Measures
Dysplasia in Barrett Esophagus (BE)
Number of subjects with Non-dysplastic, low grade dysplasia, high grade dysplasia and T1a early esophageal adenocarcinoma. As measured by using the BE dysplasia grading system of Non-dysplastic (no cancerous tissue present), low-grade dysplasia (minor cell changes found), high-grade dysplasia (extensive cell changes found, but not yet cancer), and noninvasive cancer (T1a early esophageal adenocarcinoma)
Secondary Outcome Measures
Rate of Esophageal Stricture
Number of subjects with 50-74%, 75-99% and 100% esophageal stricture. Defined as the percentage of esophageal lumen narrowing requiring dilation prior to passage of the endoscope and/or presence of new dysphagia.
Full Information
1. Study Identification
Unique Protocol Identification Number
NCT02069847
Brief Title
Prospective Evaluation of Budesonide for Prevention of Esophageal Strictures After Endotherapy
Official Title
Prospective Evaluation of the Clinical Utility of Budesonide for the Prevention of Esophageal Strictures After Endotherapy
Study Type
Interventional
2. Study Status
Record Verification Date
May 2020
Overall Recruitment Status
Completed
Study Start Date
February 2014 (undefined)
Primary Completion Date
January 11, 2019 (Actual)
Study Completion Date
January 11, 2019 (Actual)
3. Sponsor/Collaborators
Responsible Party, by Official Title
Principal Investigator
Name of the Sponsor
Mayo Clinic
4. Oversight
Studies a U.S. FDA-regulated Drug Product
Yes
Studies a U.S. FDA-regulated Device Product
No
Data Monitoring Committee
No
5. Study Description
Brief Summary
Surgery has been historically the mainstay treatment for advanced pre-malignant lesions and early esophageal cancers. However, esophagectomy is associated with significant morbidity and mortality. With the advance of therapeutic endoscopy, there has been a growing interest and application of endoscopic resection and mucosal ablative techniques for the treatment of these diseases. Esophageal stricture (ES) formation has become an increasingly recognized complication of extensive endoscopic mucosal ablation and/or resection. The resultant symptomatic stricture development can significantly impair a patient's quality of life. Endoscopic therapy of esophageal strictures with balloon dilation and/or local steroid injection is invasive, costly, and associated with the potential risk of perforation. Recently, oral corticosteroids have been introduced for the prevention of esophageal stricture after endoscopic submucosal dissection.
Budesonide is a synthetic steroid with topical anti-inflammatory properties and high first-pass metabolism; thus, potentially less systemic absorption and side effects.
Hypothesis: Oral budesonide prevents esophageal stricture formation in patients who underwent radical endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) for advanced premalignant esophageal lesions or superficial esophageal cancers.
Detailed Description
Esophageal stricture (ES) formation is a widely recognized adverse event of radical EMR and ESD. Indeed, ES is the most common complication of radiofrequency ablation (RFA) for Barrett's esophagus (BE), with a reported incidence ranging from 5% to 12%. A single-center retrospective study reported ES formation in 67% of 73 patients with EMR of at least 50% of their esophageal circumference. Similarly, the incidence of ES development after ESD is between 70-90% when the mucosal defect involves more than three-quarters of the esophageal circumference. In aggregate, the extent of the esophageal mucosal defect following endotherapy appears to be the most consistent predictor of ES formation. Prevention of ES development following endotherapy can significantly improve a patient's quality of life and possibly reduce the potential risks and costs associated with treatment of ES with repeated endoscopic balloon dilations (EBD). Glucocorticoids have been evaluated as a potential preventive therapy for ES based on their anti-inflammatory properties and inhibitory effects on collagen deposition. Oral prednisolone has been shown to be effective as a preventive strategy for ES formation. However, prolonged use of systemic oral steroids can be associated with multiple adverse effects.
Budesonide is a synthetic steroid with topical anti-inflammatory properties and high first-pass metabolism; thus, potentially less systemic absorption and side effects. Most recently Mayo Clinic Rochester developed a new budesonide capsule formulation. Alike viscous budesonide the budesonide capsule can be opened and the powder can be mixed with honey or pancake syrup. A similar formulation is currently used in pilot studies for treatment of eosinophilic esophagitis. The advantage of budesonide capsule is the improve taste in comparison to viscous budesonide originating from budesonide respules which is unpalatable.
Study aims:
The aim of this study is to prospectively record our experience with budesonide for the prevention of esophageal stricture formation after endotherapy (mucosal resection, submucosal dissection) as part of routine medical care.
The data will be compared with outcomes with well-annotated historical controls that underwent similar procedure with similar follow up but without budesonide exposure.
If sufficient efficacy is seen, these data will be used to plan a prospective controlled clinical trial. All patients in the study group will receive standard medical care and no experimental interventions will be performed.
6. Conditions and Keywords
Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Esophageal Stricture
Keywords
Esophageal stricture formation, Endoscopic mucosal resection, Endoscopic submucosal dissection, Budesonide, Radical endoscopic mucosal resection, EMR, ESD
7. Study Design
Primary Purpose
Treatment
Study Phase
Phase 2
Interventional Study Model
Single Group Assignment
Masking
None (Open Label)
Allocation
Non-Randomized
Enrollment
90 (Actual)
8. Arms, Groups, and Interventions
Arm Title
Esophageal stricture, Budesonide
Arm Type
Experimental
Arm Description
Budesonide 1mg twice a day for a total of 8 weeks following endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR)
Arm Title
Control group
Arm Type
No Intervention
Arm Description
Retrospective collect data for subjects who undergo endoscopic submucosal dissection or endoscopic mucosal resection
Intervention Type
Drug
Intervention Name(s)
Budesonide
Other Intervention Name(s)
Budesonide, Entocort, Uceris
Intervention Description
Participants will be instructed to swallow budesonide 3mg twice daily for eight consecutive weeks following endotherapy with EMR or ESD. Budesonide will be provided in a capsule containing 3mg budesonide only by Mayo Clinic Pharmacy with full 8 weeks supply.
The patient will require opening the capsule and mixing the budesonide powder in 10ml (2 teaspoons) honey, or pancake syrup.
Patients will be instructed not to ingest any solid or liquids for 30 minutes before and after taking the budesonide. For purposes of this study, budesonide is used off-label but according to the same dose and efficacy as has been demonstrated in other esophageal inflammatory conditions. Patients will receive a handout with exact instructions how and when to take Budesonide.
Primary Outcome Measure Information:
Title
Dysplasia in Barrett Esophagus (BE)
Description
Number of subjects with Non-dysplastic, low grade dysplasia, high grade dysplasia and T1a early esophageal adenocarcinoma. As measured by using the BE dysplasia grading system of Non-dysplastic (no cancerous tissue present), low-grade dysplasia (minor cell changes found), high-grade dysplasia (extensive cell changes found, but not yet cancer), and noninvasive cancer (T1a early esophageal adenocarcinoma)
Time Frame
3 months
Secondary Outcome Measure Information:
Title
Rate of Esophageal Stricture
Description
Number of subjects with 50-74%, 75-99% and 100% esophageal stricture. Defined as the percentage of esophageal lumen narrowing requiring dilation prior to passage of the endoscope and/or presence of new dysphagia.
Time Frame
3 months
10. Eligibility
Sex
All
Minimum Age & Unit of Time
18 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria:
Age 18 years or older
Diagnosis of esophageal lesion treated with ESD or EMR which involves ≥ 50% of the esophageal circumference.
Exclusion Criteria:
Locally advanced disease
Prior esophageal surgery
Participation in another research protocol that could interfere or influence the outcome measures of the present study.
The subject or legal representative is unable/unwilling to give informed consent. (study group)
Medications or conditions for which there is a contraindication to use of budesonide (see pharmacology section below)
Concomitant use of systemic steroids or other immune suppressive medication for a different condition 9. Pregnant women
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Michael Wallace, MD
Organizational Affiliation
Mayo Clinic
Official's Role
Principal Investigator
Facility Information:
Facility Name
Mayo Clinic in Florida
City
Jacksonville
State/Province
Florida
ZIP/Postal Code
32224
Country
United States
12. IPD Sharing Statement
Links:
URL
https://www.mayo.edu/research/clinical-trials
Description
Mayo Clinic Clinical Trials
Learn more about this trial
Prospective Evaluation of Budesonide for Prevention of Esophageal Strictures After Endotherapy
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