Novel Smoking Cessation Drug for Schizophrenia (TRENDS)

The Development of of A Novel Therapeutic to Aid Tobacco Smoking Cessation in Persons With Schizophrenia or Schizoaffective Disorder

The investigators will evaluate effects of a novel drug that improves nicotinergic receptor function vs. placebo on short-term smoking abstinence in smokers with schizophrenia who have a high interest in quitting. The investigators predict that the novel drug will increase days of abstinence, compared with placebo, identifying potential evidence of efficacy for smoking cessation in smokers with schizophrenia. The investigators will also assess if this new drug decreases nicotine withdrawal, craving, and cognitive impairment during early abstinence, as well as evaluate adverse effects.

Objective: This is a Proof of Concept study planned over nearly 2 years to determine the potential efficacy of a novel drug for smokers with schizophrenia. This study will assess 60 smokers with a diagnosis of either schizophrenia or schizoaffective disorder with high quit interest on their ability to quit during a week-long attempt to abstain while receiving a novel drug vs. placebo, using a within-subjects cross-over design. Research Plan: Active drug or placebo will be provided to participants in double-blind fashion. Study participation will last 6 weeks after subjects enter the study following the screening and physical exam sessions (about 8 weeks total). Participants will engage in two identical study phases, each involving visits over 3 weeks and varying only in whether active drug or placebo is administered. The 3 weeks will involve: baseline visits, dose run-up (week 2), and week 3 (for abstinence assessments). The first week of each period will be a baseline week in which they smoke normally without any medication. During week 2, subjects will begin the dose run-up of active drug or placebo, increasing over 4 days from 1 tablet of 50 mg once daily to 100 mg b.i.d. (two 50 mg tablets twice/day), which will continue through the second and third weeks. Active drug or placebo will be administered in counter-balanced order in a cross-over design. During week 3, subjects will be instructed to try to abstain on each day, i.e. Mon-Friday. Most visits will last 60 mins and involve psychiatric assessments (including psychopathology and neurological and other side effects) ratings, providing an expired breath carbon monoxide (CO) measure that assesses smoking exposure in the past 24 hrs, as well as completing brief self-report measures of craving, withdrawal, and mood. On week 3 of each phase, one visit will involve cognitive testing. On Fri of week 3, subjects will discontinue all medication and resume ad lib smoking prior to the next study period, involving the same 3-week procedure (but with the other medication condition): baseline, dose run-up, full dose administration plus abstinence assessment. Note that active medication will be taken during only one period, with placebo taken during the other period. Pill counts will be used to measure adherence. Primary and secondary dependent measures are described separately in this report. Psychopathology will be assessed using standard rating scales to evaluate psychoses and general psychopathology and severity of illness ratings, and suicide rating scales. These and clinical impressions of patients in the study will assist in monitoring for stability or worsening of psychoses or suicidal behavior and/or the need to exit patients from the study. Laboratory and EKG monitoring at the beginning and end of the study will also be part of the subject safety procedures. Patients will be offered their choice of one of the FDA approved smoking cessation agents, i.e. nicotine replacement therapy, bupropion or varenicline for a 3-month period upon completion of the study. If patients decline open-label smoking cessation participation, they will be requested to come in for one post-study visit, 14 ± 4 days later. At the first post-study visit, if there are no adverse events, their participation will end. Methods: The novel drug or placebo will be administered double-blind in counter-balanced order in a cross-over design. This is not a clinical trial that assesses long term smoking cessation but a within-subjects comparison of the short-term effects of this drug on abstinence and abstinence symptoms over a week-long period, relative to placebo. Significance: This study addresses an important question of whether the novel drug shows potential efficacy for smoking cessation, relative to placebo, in smokers with schizophrenia. This procedure could have enormous implications for accelerating the development of this medication and similar compounds to help people quit smoking by increasing the efficiency of early medication evaluation.

200 mg (100 mg b.i.d.) Active JNJ Drug used to assess quitting for one week, as part of crossover design. This JNJ experimental compound has NO name, just a company number.

200 mg/day (100 mg b.i.d.) of Active JNJ Drug will be used for one week while attempting to briefly quit smoking on Mon-Fri of that week

Complete abstinence from smoking for 24 hr, assessed daily from Mon-Fri for just one week. This same Mon-Fri procedure for one week (only) is done for both drug phases (Number of days abstinent per each quit week) Numbers reported are collapsed across medication conditions for each medication order.

Severity of withdrawal symptoms will be assessed with standard self-report measures each day during the quit week only of each phase. Data will be analysed when quit criteria were met. Scale used was the Minnesota Nicotine Withdrawal Scale (MNWS), ranging from 0 to 100, with higher scores indicating greater levels of withdrawal symptoms. The MNWS was completed 5 times for each participant during the quit week of each phase. The mean score was used to aggregate across visits.

Performance on standardized cognitive tasks (Continuous Performance Task) to determine potential mechanisms of drug efficacy when CO < 10 smoking reduction criteria was met for both sessions. The Continuous Performance Test provides assesses sustained attention in milliseconds.

Psychiatric symptoms using Positive and Negative Syndrome Scale (PANSS) will be conducted at each visit in each 3 week phase of the study PANSS - Positive and Negative Syndrome Scale. Min value 30, Max value 210, higher scores are worse outcome. The mean score was used to aggregate across visits.

CSSRS: Columbia Suicide Severity rating Scale. The scale assesses treatment emergent suicidal ideation and/or behavior categorically as a YES/NO response (no min/max score). "No" responses indicate ideation/behaviors did not emerge "Yes" responses indicate there were ideation or behaviors We are reporting the number of participants that met criteria for suicidal ideation or behavior, based on their CSSRS assessment

Routine safety labs (included liver and renal labs) were done at baseline, Visit 9, and Visit 18 to determine whether there were treatment emergent clinically significant changes in any of the laboratory parameters. (no subject with abnormal labs at baseline were enrolled in the study) In addition, liver and renal labs were drawn at Visit 4 and Visit 13 to assess for treatment emergent, clinically significant abnormal liver and renal functions. The reported results in the data table below show the number of subjects that had treatment emergent clinically significant abnormal lab results at any of the time points. If labs were not within the normal range, they were reviewed by the physician investigators to determine whether they were clinically significant.

EKG measures were done at the screening visit and at the end of study to determine whether there were treatment emergent clinically significant changes in the EKG parameters. No subjects with abnormal EKGs at baseline were enrolled in the study The data table below shows the number of subjects with clinically significant abnormal EKG results at the end of the study.

Inclusion Criteria: List the specific criteria for inclusion of potential subjects. Men or women of any race, ages 18 to 65 years, (≥18 years, ≤ 66 years) Willing to provide written informed consent MINI (Sheehan et al 1998, 2008) chart and/or clinician consensus affirmed DSM IV TR or (DSM -V) diagnoses of schizophrenia or schizoaffective disorder. Patients whose PANSS total scores have been stable for ≥ 4 weeks (clinician and/or subject affirmed) and at ≤ 70 No recent ( ≤ 3months) hospitalization, aggression, or suicidal attempts Stable doses of antipsychotic medication, ≥ 4 weeks Smoking Inclusion Criteria: Smoke ≥ 5 cigarettes/day Smoking cigarettes ≥ 1 year Exclusion Criteria: Smoking/Nicotine Exclusions: Use of smokeless tobacco or snuff or chewing tobacco Use of e-cigarettes, or any non-tobacco nicotine products (e.g. nicotine gum, lozenges, patch, etc.) Current enrollment or plans to enroll in another smoking cessation program. (Bupropion use for depression will be assessed on a case by case basis) Alcohol/Illicit Substance Exclusion Criteria: Recent alcohol or substance dependence (≤ 3 months) Current alcohol consumption that exceeds 15 standard drinks/week or greater than 2 standard drinks daily Medical Exclusion Criteria: Women who are pregnant, planning a pregnancy, or lactating; all female participants shall undergo a pregnancy test at screening and will be excluded if positive. Serious or unstable medical disorder within the past 3 months (assessed by the investigators) Epilepsy Current diagnosis (within last 6-months) of abnormal cardiac rhythms; unstable cardiovascular disease e.g. stroke, myocardial infarction in the last 6 months Evidence impaired liver function test (LFT) defined as serum glutamate oxaloacetate transaminase (SGOT) (AST) or serum glutamate pyruvate transaminase (SGPT) (ALT) or alkaline phosphatase greater than 1x the upper limit of normal, or bilirubin 1x the upper limit of normal Evidence of kidney failure defined as: Serum creatinine > 1.8 mg/dl for males and 1.6 mg/dl for females. Any subject with a history of hematological cancers examples: leukemia, lymphoma etc. will be excluded. Any clinically significant hematological laboratory abnormality (chronic low-grade laboratory values just above or below the reference range that are without clinical significance will be permitted) will be grounds for exclusion. Medication Exclusion Criteria: Current use or recent discontinuation (within last 14-days) of the following medications: any form of smoking cessation medication (Bupropion except when used for Depressive Disorders on a case by case basis, Varenicline, NRT); and (b) opiate-containing medications for chronic pain. Potent CYP 3A4 inhibitors will be reviewed for exclusion, see below. In view of novel drug being a moderate CYP3A4 inhibitor, any subjects receiving the following narrow therapeutic index CYP3A4 substrates will be excluded: Alfentanil, astemizole, cisapride, cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, sirolimus, tacrolimus, terfenadine. In view of the impact of clozapine on smoking cessation, patients receiving clozapine will be excluded. Stable medical conditions examples: hypertension, diabetes, dyslipidemia etc that are treated and ongoing and patients are not receiving the exclusionary drugs noted above will be considered for inclusion on a case by case basis.