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Low Dose Naltrexone to Improve Physical Health in Patients With Vasculitis (LoDoNaVasc)

Primary Purpose

Eosinophilic Granulomatosis With Polyangiitis (EGPA), Churg-Strauss Syndrome (CSS), Giant Cell Arteritis

Status
Recruiting
Phase
Phase 2
Locations
United States
Study Type
Interventional
Intervention
Naltrexone Hydrochloride
Placebo Comparator
Sponsored by
University of Pennsylvania
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Eosinophilic Granulomatosis With Polyangiitis (EGPA)

Eligibility Criteria

18 Years - undefined (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

Patients must meet all of the following criteria in order to be eligible for enrollment:

1. Criteria for diagnosis of giant cell arteritis (GCA), Takayasu's arteritis (TAK), polyarteritis nodosa (PAN), granulomatosis with polyangiitis (GPA, Wegener's), microscopic polyangiitis (MPA), or eosinophilic granulomatosis with polyangiitis (EGPA, Churg-Strauss), as used for the VCRC longitudinal studies

a. Giant cell arteritis: According to the American College of Rheumatology (ACR) criteria for classification of GCA, meeting at least 2 of the following 5 remaining criteria at the time of diagnosis of GCA: Age of disease onset >50 years (required) i. New onset or new type of localized pain in the head ii. Temporal artery abnormality (i.e. temporal artery tenderness to palpation or decreased pulsation, unrelated to arteriosclerosis of cervical arteries) iii. ESR of >40 mm in the first hour by Westergren method iv. Temporal artery biopsy showing vasculitis characterized by a predominance of mononuclear cell infiltration or granulomatous inflammation, usually with multinucleated giant cells v. Large Vessel Vasculitis (LVV) by angiogram or biopsy not explained by something else

b. Takayasu's arteritis: According to an adaption of the American College of Rheumatology criteria, meeting at least 2 of the following 5 remaining criteria at the time of inclusion of TAK: Arteriogram abnormalities compatible with TAK (includes conventional dye angiography or MR angiography or CT angiography) (required) i. Age at disease onset ≤50 years ii. Claudication of extremities iii. Decreased brachial artery pulse (one or both arteries) iv. Blood pressure difference of >10mm Hg between the arms v. Bruit over subclavian arteritis or aorta

c. Polyarteritis nodosa: An adaption of the America College of Rheumatology criteria will be used for the diagnosis of PAN. At the time of inclusion, one major and one minor criteria or two major criteria or isolated cutaneous PAN must be met.

i. Major criteria (not explained by other causes):

  1. Arteriographic abnormality
  2. Presence of granulocyte or mixed leukocyte infiltrate in an arterial wall on biopsy
  3. Mononeuropathy or polyneuropathy ii. Minor criteria (not explained by other causes)

1. Weight loss > 4 kg 2. Livedo reticularis, cutaneous ulcerations, or skin nodules 3. Testicular pain or tenderness 4. Myalgias 5. Diastolic blood pressure >90mm Hg 6. Elevated BUN or serum creatinine levels 7. Ischemic abdominal pain iii. Isolated cutaneous polyarteritis nodosa

  1. Biopsy-proven cutaneous PAN

    d. Granulomatosis with polyangiitis: Participants can be enrolled if two of the five modified American College of Rheumatology criteria are met: i. Nasal or oral inflammation: painful or painless oral ulcers or purulent or blood nasal discharge ii. Abnormal chest radiograph: nodules, fixed infiltrates, or cavities iii. Urinary sediment: microhematuria or red cell casts iv. Granulomatous inflammation on biopsy: granulomatous inflammation within the wall of an artery or in the perivascular area v. ANCA positivity by enzyme immunoassay for either PR3- or MPO-ANCA e. Microscopic polyangiitis: The following Chapel Hill Consensus Conference Definitions for MPA need to be met: i. Necrotizing vasculitis with few or no immune deposits affects small vessel (i.e., capillaries, venules, or arterioles) ii. Necrotizing arteritis involving small and medium-sized arteritis may be present iii. Necrotizing glomerulonephritis is very common iv. Pulmonary capillaritis often occurs

    f. Eosinophilic granulomatosis with polyangiitis: An adaptation of the American College of Rheumatology criteria will be used for the diagnosis of EGPA. At the time of inclusion, four of the six items must have documented evidence: i. Asthma ii. Peak peripheral blood eosinophilia of >10% of total WBC iii. Peripheral neuropathy attributable to vasculitis iv. Transient pulmonary infiltrates on chest imaging studies v. Paranasal sinus abnormalities or nasal polyposis vi. Eosinophilic inflammation on tissue biopsy If patients have 4 of the above 6 criteria but lack clear-cut documentation of small vessel vasculitis, they are also eligible for enrollment.

  2. Baseline normalized score on PROMIS Global Physical Health of 40 or lower.
  3. Vasculitis in remission or very low disease activity, as defined by Physician Global Assessment 0-1 for at least 12 weeks
  4. Stable immunosuppressive therapy (including prednisone) related to vasculitis for at least 12 weeks
  5. No change in medications in the past 12 weeks made with the expectation of improving pain, fatigue, or mood
  6. No plan to change medication or a non-pharmacologic treatment regimen likely to affect pain, fatigue, mood, or vasculitis activity during the next 12 weeks
  7. Age of 18 years or older
  8. Willingness and ability to comply with treatment and follow-up procedures, including receipt of weekly phone calls from the study coordinator
  9. Willingness and ability to provide informed consent -

Exclusion Criteria:

  1. Change in any medication related to control of vasculitis, pain, fatigue, or mood within the past 12 weeks (medications taken as needed must be in a stable pattern per the patient's estimation)
  2. Use of another investigational agent as part of a clinical trial within 30 days of enrollment
  3. Current use of any opioid agonist including tramadol or suboxone
  4. Change in vasculitis activity in the past 12 weeks, as defined by a change in Physician Global Assessment greater than 1
  5. Baseline normalized score more than 40 on PROMIS Global Physical Health
  6. New major medical problem or surgery in past 12 weeks
  7. Pregnancy or breastfeeding
  8. Inability to provide informed consent or comply with study procedures
  9. Schizophrenia or bipolar disorder
  10. Poorly controlled depression or anxiety, as defined by a score of ≥ 20 on PHQ-9
  11. Liver cirrhosis
  12. Significant kidney disease, defined as glomerular filtration rate <30ml/min

Sites / Locations

  • Brigham and Women's Hospital
  • Mayo ClinicRecruiting
  • Cleveland Clinic
  • University of PennsylvaniaRecruiting
  • University of PennsylvaniaRecruiting
  • University of Pittsburgh
  • University of Utah

Arms of the Study

Arm 1

Arm 2

Arm Type

Experimental

Placebo Comparator

Arm Label

Naltrexone Hydrochloride

Placebo Comparator

Arm Description

Naltrexone hydrochloride for oral use, 4.5 mg per capsule, taken once a day for 6 weeks.

Placebo to match naltrexone for oral use to be taken once a day for 6 weeks.

Outcomes

Primary Outcome Measures

PROMIS Global Physical Health
Questionnaire about improved health related quality of life to a greater extent than placebo.

Secondary Outcome Measures

PROMIS Global Physical Health
Questionnaire about improved health related quality of life to a greater extent than placebo.
SF-36 (physical component subscore)
Health related quality of life measured by a questionnaire.
PROMIS Questionnaires
Questions will ask about anxiety, depression, and sleep disturbance on the PROMIS short form, PROMIS Global Mental Health, and on PROMIS-CAT will ask about physical function, fatigue, satisfaction with social roles, and pain interference, as well in the pain intensity item.
Clinical Global Impression of Severity (CGI-S)
7-point scale of patients' self-reporting of severity during the study.
Clinical Global Impression of Improvement (CGI-I)
7-point scale of patients' self-reporting of severity during the study.

Full Information

First Posted
March 22, 2018
Last Updated
December 14, 2022
Sponsor
University of Pennsylvania
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1. Study Identification

Unique Protocol Identification Number
NCT03482479
Brief Title
Low Dose Naltrexone to Improve Physical Health in Patients With Vasculitis
Acronym
LoDoNaVasc
Official Title
Low Dose Naltrexone to Improve Physical Health in Patients With Vasculitis
Study Type
Interventional

2. Study Status

Record Verification Date
December 2022
Overall Recruitment Status
Recruiting
Study Start Date
February 4, 2019 (Actual)
Primary Completion Date
December 31, 2023 (Anticipated)
Study Completion Date
December 31, 2023 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
University of Pennsylvania

4. Oversight

Studies a U.S. FDA-regulated Drug Product
Yes
Studies a U.S. FDA-regulated Device Product
No
Product Manufactured in and Exported from the U.S.
No
Data Monitoring Committee
Yes

5. Study Description

Brief Summary
Naltrexone is an FDA approved drug (for alcoholism) that has found widespread use "off-label" to treat pain and improve quality of life at much lower doses than are used for the approved indication. There are a few scientific studies in three conditions (fibromyalgia, Crohn's disease, and multiple sclerosis) that suggest that this drug has benefit and is safe. However, considering the extent of use in other conditions, and uncertainty about the mechanism of action study is needed in a diverse set of diseases, including vasculitis. The purpose of this clinical trial is to determine if low dose naltrexone is effective in improving health-related quality of life (HRQoL) among patients with vasculitis. Although it is a pilot study, a placebo-controlled component is used because of the prominent placebo group effect seen in studies with self-reported subjective outcomes.
Detailed Description
This is a multi-center, randomized, double-blind, cross-over, placebo-controlled trial to evaluate the efficacy of low-dose naltrexone (LDN) 4.5 mg nightly in improving self-reported physical health in patients with vasculitis. At study enrollment, each patient will be randomized to receive either LDN for 6 weeks followed by oral placebo for 6 weeks, or placebo for 6 weeks followed by LDN for 6 weeks. The primary outcome measure and some secondary outcome measures are patient-reported and will be recorded every 3 weeks, or every 6 weeks

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Eosinophilic Granulomatosis With Polyangiitis (EGPA), Churg-Strauss Syndrome (CSS), Giant Cell Arteritis, Granulomatosis With Polyangiitis, Microscopic Polyangiitis, Polyarteritis Nodosa, Takayasu Arteritis

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 2
Interventional Study Model
Crossover Assignment
Masking
ParticipantCare ProviderInvestigatorOutcomes Assessor
Allocation
Randomized
Enrollment
36 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
Naltrexone Hydrochloride
Arm Type
Experimental
Arm Description
Naltrexone hydrochloride for oral use, 4.5 mg per capsule, taken once a day for 6 weeks.
Arm Title
Placebo Comparator
Arm Type
Placebo Comparator
Arm Description
Placebo to match naltrexone for oral use to be taken once a day for 6 weeks.
Intervention Type
Drug
Intervention Name(s)
Naltrexone Hydrochloride
Intervention Description
Naltrexone Hydrochloride will be taken daily (dose 4.5 mg) for six weeks
Intervention Type
Other
Intervention Name(s)
Placebo Comparator
Intervention Description
A placebo tablet which matches the drug will be taken daily for 6 weeks.
Primary Outcome Measure Information:
Title
PROMIS Global Physical Health
Description
Questionnaire about improved health related quality of life to a greater extent than placebo.
Time Frame
Week 12.
Secondary Outcome Measure Information:
Title
PROMIS Global Physical Health
Description
Questionnaire about improved health related quality of life to a greater extent than placebo.
Time Frame
9 weeks
Title
SF-36 (physical component subscore)
Description
Health related quality of life measured by a questionnaire.
Time Frame
12 weeks
Title
PROMIS Questionnaires
Description
Questions will ask about anxiety, depression, and sleep disturbance on the PROMIS short form, PROMIS Global Mental Health, and on PROMIS-CAT will ask about physical function, fatigue, satisfaction with social roles, and pain interference, as well in the pain intensity item.
Time Frame
12 weeks
Title
Clinical Global Impression of Severity (CGI-S)
Description
7-point scale of patients' self-reporting of severity during the study.
Time Frame
12 weeks
Title
Clinical Global Impression of Improvement (CGI-I)
Description
7-point scale of patients' self-reporting of severity during the study.
Time Frame
12 weeks

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Patients must meet all of the following criteria in order to be eligible for enrollment: 1. Criteria for diagnosis of giant cell arteritis (GCA), Takayasu's arteritis (TAK), polyarteritis nodosa (PAN), granulomatosis with polyangiitis (GPA, Wegener's), microscopic polyangiitis (MPA), or eosinophilic granulomatosis with polyangiitis (EGPA, Churg-Strauss), as used for the VCRC longitudinal studies a. Giant cell arteritis: According to the American College of Rheumatology (ACR) criteria for classification of GCA, meeting at least 2 of the following 5 remaining criteria at the time of diagnosis of GCA: Age of disease onset >50 years (required) i. New onset or new type of localized pain in the head ii. Temporal artery abnormality (i.e. temporal artery tenderness to palpation or decreased pulsation, unrelated to arteriosclerosis of cervical arteries) iii. ESR of >40 mm in the first hour by Westergren method iv. Temporal artery biopsy showing vasculitis characterized by a predominance of mononuclear cell infiltration or granulomatous inflammation, usually with multinucleated giant cells v. Large Vessel Vasculitis (LVV) by angiogram or biopsy not explained by something else b. Takayasu's arteritis: According to an adaption of the American College of Rheumatology criteria, meeting at least 2 of the following 5 remaining criteria at the time of inclusion of TAK: Arteriogram abnormalities compatible with TAK (includes conventional dye angiography or MR angiography or CT angiography) (required) i. Age at disease onset ≤50 years ii. Claudication of extremities iii. Decreased brachial artery pulse (one or both arteries) iv. Blood pressure difference of >10mm Hg between the arms v. Bruit over subclavian arteritis or aorta c. Polyarteritis nodosa: An adaption of the America College of Rheumatology criteria will be used for the diagnosis of PAN. At the time of inclusion, one major and one minor criteria or two major criteria or isolated cutaneous PAN must be met. i. Major criteria (not explained by other causes): Arteriographic abnormality Presence of granulocyte or mixed leukocyte infiltrate in an arterial wall on biopsy Mononeuropathy or polyneuropathy ii. Minor criteria (not explained by other causes) 1. Weight loss > 4 kg 2. Livedo reticularis, cutaneous ulcerations, or skin nodules 3. Testicular pain or tenderness 4. Myalgias 5. Diastolic blood pressure >90mm Hg 6. Elevated BUN or serum creatinine levels 7. Ischemic abdominal pain iii. Isolated cutaneous polyarteritis nodosa Biopsy-proven cutaneous PAN d. Granulomatosis with polyangiitis: Participants can be enrolled if two of the five modified American College of Rheumatology criteria are met: i. Nasal or oral inflammation: painful or painless oral ulcers or purulent or blood nasal discharge ii. Abnormal chest radiograph: nodules, fixed infiltrates, or cavities iii. Urinary sediment: microhematuria or red cell casts iv. Granulomatous inflammation on biopsy: granulomatous inflammation within the wall of an artery or in the perivascular area v. ANCA positivity by enzyme immunoassay for either PR3- or MPO-ANCA e. Microscopic polyangiitis: The following Chapel Hill Consensus Conference Definitions for MPA need to be met: i. Necrotizing vasculitis with few or no immune deposits affects small vessel (i.e., capillaries, venules, or arterioles) ii. Necrotizing arteritis involving small and medium-sized arteritis may be present iii. Necrotizing glomerulonephritis is very common iv. Pulmonary capillaritis often occurs f. Eosinophilic granulomatosis with polyangiitis: An adaptation of the American College of Rheumatology criteria will be used for the diagnosis of EGPA. At the time of inclusion, four of the six items must have documented evidence: i. Asthma ii. Peak peripheral blood eosinophilia of >10% of total WBC iii. Peripheral neuropathy attributable to vasculitis iv. Transient pulmonary infiltrates on chest imaging studies v. Paranasal sinus abnormalities or nasal polyposis vi. Eosinophilic inflammation on tissue biopsy If patients have 4 of the above 6 criteria but lack clear-cut documentation of small vessel vasculitis, they are also eligible for enrollment. Baseline normalized score on PROMIS Global Physical Health of 40 or lower. Vasculitis in remission or very low disease activity, as defined by Physician Global Assessment 0-1 for at least 12 weeks Stable immunosuppressive therapy (including prednisone) related to vasculitis for at least 12 weeks No change in medications in the past 12 weeks made with the expectation of improving pain, fatigue, or mood No plan to change medication or a non-pharmacologic treatment regimen likely to affect pain, fatigue, mood, or vasculitis activity during the next 12 weeks Age of 18 years or older Willingness and ability to comply with treatment and follow-up procedures, including receipt of weekly phone calls from the study coordinator Willingness and ability to provide informed consent - Exclusion Criteria: Change in any medication related to control of vasculitis, pain, fatigue, or mood within the past 12 weeks (medications taken as needed must be in a stable pattern per the patient's estimation) Use of another investigational agent as part of a clinical trial within 30 days of enrollment Current use of any opioid agonist including tramadol or suboxone Change in vasculitis activity in the past 12 weeks, as defined by a change in Physician Global Assessment greater than 1 Baseline normalized score more than 40 on PROMIS Global Physical Health New major medical problem or surgery in past 12 weeks Pregnancy or breastfeeding Inability to provide informed consent or comply with study procedures Schizophrenia or bipolar disorder Poorly controlled depression or anxiety, as defined by a score of ≥ 20 on PHQ-9 Liver cirrhosis Significant kidney disease, defined as glomerular filtration rate <30ml/min
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Carol McAlear, MA
Phone
7813214567
Email
cmcalear@pennmedicine.upenn.edu
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Peter A Merkel, MD, MPH
Organizational Affiliation
University of Pennsylvania
Official's Role
Study Director
Facility Information:
Facility Name
Brigham and Women's Hospital
City
Boston
State/Province
Massachusetts
ZIP/Postal Code
02115
Country
United States
Individual Site Status
Completed
Facility Name
Mayo Clinic
City
Rochester
State/Province
Minnesota
ZIP/Postal Code
55905
Country
United States
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Michael Stachowitz
Email
stachowitz.michael@mayo.edu
Facility Name
Cleveland Clinic
City
Cleveland
State/Province
Ohio
ZIP/Postal Code
44195
Country
United States
Individual Site Status
Completed
Facility Name
University of Pennsylvania
City
Philadelphia
State/Province
Pennsylvania
ZIP/Postal Code
19104
Country
United States
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Peter Merkel, MD, MPH
Phone
215-614-4401
Facility Name
University of Pennsylvania
City
Philadelphia
State/Province
Pennsylvania
ZIP/Postal Code
19104
Country
United States
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Sarah Hopkins
Email
Sarah.Hopkins@Pennmedicine.upenn.edu
Facility Name
University of Pittsburgh
City
Pittsburgh
State/Province
Pennsylvania
ZIP/Postal Code
15260
Country
United States
Individual Site Status
Completed
Facility Name
University of Utah
City
Salt Lake City
State/Province
Utah
ZIP/Postal Code
84112
Country
United States
Individual Site Status
Completed

12. IPD Sharing Statement

Plan to Share IPD
No

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Low Dose Naltrexone to Improve Physical Health in Patients With Vasculitis

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