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Comparative Study of Strategies for Management of Duchenne Myopathy (DM)

Primary Purpose

Myopathy

Status
Unknown status
Phase
Phase 4
Locations
Study Type
Interventional
Intervention
Sildenafil (Phosphodiesterase inhibitors)
Prednisolone (Steroids)
Mesenchymal stem cell transplantation
Sponsored by
Assiut University
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Myopathy

Eligibility Criteria

5 Years - 15 Years (Child)MaleDoes not accept healthy volunteers

Inclusion Criteria:

  • Diagnosis of DMD confirmed by electromyogram (EMG) , Creatine phosphokinase (CPK) level and/ or DNA analysis or muscle biopsy.
  • Male patients
  • Age 5-15y.
  • Ambulatory (loss of ambulation was only seen in those with baseline 6 Minute Walk Distance {6MWD} <325 meters.)
  • No clinical evidence of heart failure.

Exclusion Criteria:

  • Female patients
  • Any injury which may impact functional testing, e.g. upper or lower limb fracture.
  • hypertension, diabetes,
  • Wheelchair bound.
  • Cardiac rhythm disorder, specifically: rhythm other than sinus, supraventricular tachycardia (SVT), atrial fibrillation, ventricular tachycardia.or heart failure (left ventricle ejection fraction {LVEF < 50%}.
  • Continuous ventilatory support.
  • Liver disease (acute, chronic liver disease)
  • Renal impairment

Sites / Locations

    Arms of the Study

    Arm 1

    Arm 2

    Arm 3

    Arm Type

    Active Comparator

    Active Comparator

    Experimental

    Arm Label

    Steroid

    Phosphodiestrase inhibitors

    Mesenchymal stem cell transplantation

    Arm Description

    prednisolone 20 mg tablet by mouth taken once daily for 10 days each month for 2 years

    sildenafil 25 mg tablet by mouth once daily for 2 years

    The cells can be injected intramuscular in several points in the muscle alternatively they can be injected in the motor point of the muscle. A motor point is the point at which the motor branch of the innervating nerve enters the muscle). This injection is repeated every 6 month up to 2 years.

    Outcomes

    Primary Outcome Measures

    6 Minute Walk Distance (6MWD)
    It is used as measure of motor strength in patients with Duchenne Myopathy. A baseline 6MWD of <350 meters was associated with greater functional decline, and loss of ambulation was only seen in those with baseline 6MWD <325 meters

    Secondary Outcome Measures

    Full Information

    First Posted
    August 12, 2018
    Last Updated
    August 15, 2018
    Sponsor
    Assiut University
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    1. Study Identification

    Unique Protocol Identification Number
    NCT03633565
    Brief Title
    Comparative Study of Strategies for Management of Duchenne Myopathy (DM)
    Official Title
    A Comparative Study of Strategies for Management of Duchenne Myopathy in Assiut University Children Hospital
    Study Type
    Interventional

    2. Study Status

    Record Verification Date
    August 2018
    Overall Recruitment Status
    Unknown status
    Study Start Date
    September 2018 (Anticipated)
    Primary Completion Date
    September 2021 (Anticipated)
    Study Completion Date
    November 2021 (Anticipated)

    3. Sponsor/Collaborators

    Responsible Party, by Official Title
    Principal Investigator
    Name of the Sponsor
    Assiut University

    4. Oversight

    Studies a U.S. FDA-regulated Drug Product
    No
    Studies a U.S. FDA-regulated Device Product
    No

    5. Study Description

    Brief Summary
    Comparing different lines of treatment of Duchenne Myopathy (DM) and assessment of new lines of treatment (mesenchymal stem cell, phosphodiesterase inhibitors) in reducing the impact of disability in the patients with Duchenne Myopathy and slowing the progression of cardiomyopathy Upsetting and implementation of the best treatment plan for those children with Duchenne myopathy which is suitable for the available resources in Assiut University Children Hospital
    Detailed Description
    Duchenne muscular dystrophy(DMD) is the most commonly inherited pediatric muscular disorder. It is an X-linked genetic progressive and degenerative myopathy characterized by progressive weakness, which can lead to loss of motor functions in puberty as well as cardiac,respiratory involvement and premature death. The disease is one of a group of myopathies that differ depending on the degree of severity and the affected muscle types. It occurs at a rate of approximately 1:3500 male births and arises due to spontaneous mutations in the Dystrophin gene (locus Xp21.2); 65% of causative mutations are intragenic deletions, 6-10% are intragenic duplications and 30-35% are point mutations (along with other sequence variations). The disease is caused by a deficiency of Dystrophin or the synthesis of functionally impotent Dystrophin, a critical protein component of the Dystrophin glycoprotein complex acting as a link between the cytoskeleton and the extracellular matrix in skeletal and cardiac muscles. A consequence of Dystrophin glycoprotein complex inefficiency is muscle fragility, contraction-induced damage, necrosis and inflammation. Glucocorticoid can prolong ambulation by 2 to 3 years, reduce scoliosis, and temper pulmonary and cardiac decline in the second decade of life. However, glucocorticoids causes well-known side effects, which are intolerable in more than 25% of patients. Thus, a disease-specific treatment is a major unmet need. Investigators have proposed various possibilities for the beneficial effects of corticosteroid based mainly on observations in mouse models of muscular dystrophy and on a limited number of studies in patients. These possibilities include Reducing cytotoxic T lymphocytes Increasing Laminin expression and myogenic repair Retarding muscle apoptosis and cellular infiltration Enhancing Dystrophin expression Affecting neuromuscular transmission Some patients with Duchenne Myopathy treated early with steroids appear to have an improved long-term prognosis in muscle, myocardial outcome, and can help keep patients ambulatory for more years than expected without treatment. One protocol gives prednisone (0.75 mg/kg/day) for the 1st 10 days of each month to avoid chronic complications. Deflazacort, administered as 0.9 mg/kg/day, may be more effective than prednisone. The American Academy of Neurology and the Child Neurology Society recommend administering corticosteroids during the ambulatory stage of the disease.Published recommendations suggest starting therapy between 2 and 5 years of age in boys whose strength has plateaued or is declining, but earlier treatment may be more beneficial. Skeletal muscle has a great capacity to regenerate following muscle wasting caused by trauma or disease.This regenerative potential is attributed primarily to skeletal-muscle resident stem cells called satellite cells. In Duchenne Myopathy, satellite cells are exhausted following many rounds of muscle degeneration and regeneration. Hence, satellite cells and their progeny (myoblasts) have been considered as a promising candidate for cell replacement therapy for DMD and other types of muscle disease. Small quantities of adult stem cells exist in most tissues throughout the body where they remain quiescent for long periods of time prior to being activated in response to disease or tissue injury. Adult stem cells can be isolated from cells of the hematopoietic, neural, dermal, muscle and hepatic systems. Adult stem cells give rise to cell types of the tissue from which they originated, but according to scientific reports, they can differentiate into lineages other than their tissue of origin, e.g. transplanted bone marrow or enriched hematopoietic stem cells (HSCs) were reported to give rise to cells of the mesoderm, endoderm and ectoderm. Two main types of stem cells usually derived from adult bone marrow are HSCs and mesenchymal stem cells (MSC). They can sometimes be obtained from fat, skin, periosteum, synovial membrane and muscle as well. MSCs are multipotent and capable of differentiating into several connective tissue types including osteocytes, chondrocytes, adipocytes, tenocytes and myoblasts. They can also impose an additional anti-inflammatory and paracrine effect on differentiation and tissue regeneration via cytokine pathways and have anti-apoptotic features. These genetically determined pluripotent cells may be easily isolated from bone marrow because they have membrane proteins (marker called cluster of differentiation (CD34 +) and specific marker STRO-I). Compared with pluripotent embryonic stem cells or induced pluripotent stem cells, mesenchymal stem cell have a greater biosafety profile and lower risk of tumorigenicity, and perhaps that is why numerous -mesenchymal stem cell based therapies have made it to the clinical trial stage. Stem cell based therapies for the treatment of Duchenne Myopathy can proceed via two strategies. The first is autologous stem cell transfer involving cells from a patient with Duchenne Myopathy that are genetically altered in vitro to restore dystrophin expression and are subsequently re-implanted. The second is allogenic stem cell transfer, containing cells from an individual with functional dystrophin, which are transplanted into a dystrophic patient. Intramuscular route of administration can be considered most appropriate as muscular dystrophy is primarily a muscle disease. The cells can be injected in several points in the muscle alternatively they can be injected in the motor point of the muscle. A motor point is the point at which the motor branch of the innervating nerve enters the muscle. It is the point with the highest concentration of motor endplates and myoneural synapses. Due to high numbers of neuromuscular junctions at this point, a muscle contraction can be easily elicited using minimal electric stimulus. Motor points can therefore be identified as superficial points directly over the points on the muscles with help of external electrical stimulation. Limitation of this method is that only superficial muscles can be stimulated using this method. In an open study, Sharma and colleagues demonstrated the efficacy of autologous bone marrow mononuclear transplantation by intramuscularly to patients with Duchenne Myopathy, Becker muscular dystrophy and limb girdle muscular dystrophy. However, they did not provide the molecular diagnosis of these dystrophies. No significant adverse events were noted. An increase in trunk muscle strength was seen in 53% of the cases, 48% showed an increase in upper limb strength, 59% showed an increase in lower limb strength and approximately 10% showed improved gait. Eighty seven percent of 150 patients had functional improvement upon physical examination and electromyogram studies after 12 month.

    6. Conditions and Keywords

    Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
    Myopathy

    7. Study Design

    Primary Purpose
    Treatment
    Study Phase
    Phase 4
    Interventional Study Model
    Parallel Assignment
    Masking
    None (Open Label)
    Allocation
    Randomized
    Enrollment
    45 (Anticipated)

    8. Arms, Groups, and Interventions

    Arm Title
    Steroid
    Arm Type
    Active Comparator
    Arm Description
    prednisolone 20 mg tablet by mouth taken once daily for 10 days each month for 2 years
    Arm Title
    Phosphodiestrase inhibitors
    Arm Type
    Active Comparator
    Arm Description
    sildenafil 25 mg tablet by mouth once daily for 2 years
    Arm Title
    Mesenchymal stem cell transplantation
    Arm Type
    Experimental
    Arm Description
    The cells can be injected intramuscular in several points in the muscle alternatively they can be injected in the motor point of the muscle. A motor point is the point at which the motor branch of the innervating nerve enters the muscle). This injection is repeated every 6 month up to 2 years.
    Intervention Type
    Drug
    Intervention Name(s)
    Sildenafil (Phosphodiesterase inhibitors)
    Other Intervention Name(s)
    sildenafil, viagra
    Intervention Description
    tablet 25mg
    Intervention Type
    Drug
    Intervention Name(s)
    Prednisolone (Steroids)
    Other Intervention Name(s)
    Prednisolone 20 mg
    Intervention Description
    tablet 20 mg
    Intervention Type
    Procedure
    Intervention Name(s)
    Mesenchymal stem cell transplantation
    Intervention Description
    stem cell transplantation intramuscular
    Primary Outcome Measure Information:
    Title
    6 Minute Walk Distance (6MWD)
    Description
    It is used as measure of motor strength in patients with Duchenne Myopathy. A baseline 6MWD of <350 meters was associated with greater functional decline, and loss of ambulation was only seen in those with baseline 6MWD <325 meters
    Time Frame
    6 month

    10. Eligibility

    Sex
    Male
    Gender Based
    Yes
    Gender Eligibility Description
    only male
    Minimum Age & Unit of Time
    5 Years
    Maximum Age & Unit of Time
    15 Years
    Accepts Healthy Volunteers
    No
    Eligibility Criteria
    Inclusion Criteria: Diagnosis of DMD confirmed by electromyogram (EMG) , Creatine phosphokinase (CPK) level and/ or DNA analysis or muscle biopsy. Male patients Age 5-15y. Ambulatory (loss of ambulation was only seen in those with baseline 6 Minute Walk Distance {6MWD} <325 meters.) No clinical evidence of heart failure. Exclusion Criteria: Female patients Any injury which may impact functional testing, e.g. upper or lower limb fracture. hypertension, diabetes, Wheelchair bound. Cardiac rhythm disorder, specifically: rhythm other than sinus, supraventricular tachycardia (SVT), atrial fibrillation, ventricular tachycardia.or heart failure (left ventricle ejection fraction {LVEF < 50%}. Continuous ventilatory support. Liver disease (acute, chronic liver disease) Renal impairment
    Central Contact Person:
    First Name & Middle Initial & Last Name or Official Title & Degree
    Duaa Mahmoud, Assistant professor
    Phone
    01223112124
    Email
    duaa-raafat@hotmail.com
    First Name & Middle Initial & Last Name or Official Title & Degree
    Mervat Youssef, Lecturer
    Phone
    01142606221
    Email
    mamuosif2000@gmail.com
    Overall Study Officials:
    First Name & Middle Initial & Last Name & Degree
    Emad EL Daly, Professor
    Organizational Affiliation
    Assiut University
    Official's Role
    Study Director

    12. IPD Sharing Statement

    Plan to Share IPD
    No
    Citations:
    PubMed Identifier
    23465426
    Citation
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    Comparative Study of Strategies for Management of Duchenne Myopathy (DM)

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