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SNIFF - Combo INI+EMPA Trial

Primary Purpose

Mild Cognitive Impairment, Cognitive Impairment, Alzheimer Disease

Status
Recruiting
Phase
Phase 2
Locations
United States
Study Type
Interventional
Intervention
Insulin (Humulin® R U-100)
Empagliflozin 10 MG
Aptar Pharma CPS Intranasal Delivery Device
Placebo (Insulin Diluent)
Placebo (Capsules)
Sponsored by
Wake Forest University Health Sciences
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Mild Cognitive Impairment focused on measuring Intranasal Delivery of Insulin, Cognitive Testing, Nasal Insulin

Eligibility Criteria

55 Years - 85 Years (Adult, Older Adult)All SexesAccepts Healthy Volunteers

Inclusion Criteria:

  1. Age 55 to 85 (inclusive)
  2. Fluent in English
  3. Cognitively normal or diagnosis of amnestic mild cognitive impairment (aMCI) or mild Alzheimer's disease (AD)
  4. Amyloid positive by positron emission tomography (PET) or cerebrospinal fluid (CSF) criteria
  5. Stable medical condition for 3 months prior to screening visit
  6. Stable medications for 4 weeks prior to the screening and study visits (exceptions may be made on a case by case basis by the study physician)
  7. Clinical laboratory values must be within normal limits or, if abnormal, must be judged to be clinically insignificant by the study physician

Exclusion Criteria:

  1. A diagnosis of dementia other than Alzheimer's disease (AD)
  2. History of a clinically significant stroke
  3. Current evidence or history in past two years of epilepsy, head injury with loss of consciousness, any major psychiatric disorder including psychosis, major depression, bipolar disorder
  4. Diabetes (type I or type II) insulin-dependent and non-insulin-dependent diabetes mellitus
  5. Current or past regular use of insulin or any other anti-diabetic medication within 2 months of screening visit
  6. History of seizure within past five years
  7. Pregnancy or possible pregnancy
  8. Use of anticoagulants
  9. Residence in a skilled nursing facility at screening
  10. Use of an investigational agent within two months of screening visit
  11. Regular use of alcohol, narcotics, anticonvulsants, anti-parkinsonian medications, or any other exclusionary medications (exceptions may be made on a case by case basis by the study physician)

Sites / Locations

  • Wake Forest University Health Sciences / Wake Forest School of MedicineRecruiting

Arms of the Study

Arm 1

Arm 2

Arm 3

Arm 4

Arm Type

Experimental

Experimental

Experimental

Placebo Comparator

Arm Label

Intranasal Insulin and Empagliflozin Placebo

Empagliflozin and Intranasal Insulin Placebo

Intranasal Insulin and Empagliflozin

Placebo

Arm Description

40 IU of intranasal insulin administered using the Aptar CPS device 30 minutes prior to eating and 30 minutes before bedtime for a total of four (4) times daily Placebo capsules taken by mouth 30 minutes before breakfast once daily

Empagliflozin 10 mg capsules taken by mouth 30 minutes before breakfast once daily 40 IU of intranasal insulin diluent (placebo) administered using the Aptar CPS device 30 minutes prior to eating and 30 minutes before bedtime for a total of four (4) times daily

40 IU of intranasal insulin administered using the Aptar CPS device 30 minutes prior to eating and 30 minutes before bedtime for a total of four (4) times daily Empagliflozin 10 mg capsules taken by mouth 30 minutes before breakfast once daily

40 IU of intranasal insulin diluent (placebo) administered using the Aptar CPS device 30 minutes prior to eating and 30 minutes before bedtime for a total of four (4) times daily Placebo capsules taken by mouth 30 minutes before breakfast once daily

Outcomes

Primary Outcome Measures

Number of Participants with Treatment-related Serious Adverse Events as Assessed by CTCAE v5.0
Adverse events will be assessed using Common Terminology Criteria for Adverse Events (CTCAE v5.0). The number of participants with grade 3 or greater adverse events that were deemed to be possibly, probably, or definitely related to study treatment will be reported.

Secondary Outcome Measures

Change in the Preclinical Alzheimer Cognitive Composite 5 (PACC5) Z-Score
Cognition will be measured using the PACC5 scale, which includes the free/cued selective reminding test, delayed paragraph recall, digit-symbol substitution, mini mental state score, and the category fluency task. The PACC5 is a composite score comprised of measures of global cognition, memory, and executive function. The score reflects an averaged z-score, with higher scores indicating better cognitive performance.
Change in the 14-item Alzheimer's Disease Assessment Scale-Cognitive subscale (ADAS-Cog 14) Score
A psychometric instrument that evaluates memory, attention, reasoning, language, orientation, and praxis. A higher score indicates more impairment. Scores from the original portion of the test range from 0 (best) to 65 (worse), and are added to the mean of the words not immediately recalled (max of 10) and the number of items not recalled after a delay (ranging from 0-10) all total the maximum score of 85. A positive change indicates cognitive worsening.
Change in amyloid β-peptide (Aβ) 40 (Aβ40) in Cerebrospinal Fluid (CSF)
Cerebrospinal fluid (CSF) samples will be used to measure the levels of amyloid β-peptide (Aβ) 40. CSF Aβ40 is a key Alzheimer's disease (AD) biomarker that reflects pathological aggregation of amyloid in the brain.
Change in amyloid β-peptide (Aβ) 42 (Aβ42) in Cerebrospinal Fluid (CSF)
Cerebrospinal fluid (CSF) samples will be used to measure the levels of amyloid β-peptide (Aβ) 42. CSF Aβ42 is a key Alzheimer's disease (AD) biomarker that reflects pathological aggregation of amyloid in the brain.
Change in Cerebrospinal Fluid (CSF) Levels of Total Tau
Cerebrospinal fluid (CSF) samples will be used to measure the levels of total tau protein in the brain to assess impact on brain tau as a relevant Alzheimer's Disease (AD) biomarker.
Change in Cerebrospinal Fluid (CSF) Levels of Phospho-Tau 181
Cerebrospinal fluid (CSF) samples will be used to measure the levels of phospho-tau 181 protein in the brain to assess impact on brain tau as a relevant Alzheimer's Disease (AD) biomarker.
Change in Total Cerebral Blood Flow (CBF) Using MRI Pseudocontinuous Arterial Spin Labeling (ASL)
Change in CBF in mL/100g/min, calculated as the difference between the pre- and post- ASL flow in response to the study intervention.

Full Information

First Posted
October 4, 2021
Last Updated
October 11, 2023
Sponsor
Wake Forest University Health Sciences
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1. Study Identification

Unique Protocol Identification Number
NCT05081219
Brief Title
SNIFF - Combo INI+EMPA Trial
Official Title
Study of Nasal Insulin to Fight Forgetfulness - Combination Intranasal Insulin and Empagliflozin Trial
Study Type
Interventional

2. Study Status

Record Verification Date
October 2023
Overall Recruitment Status
Recruiting
Study Start Date
October 14, 2021 (Actual)
Primary Completion Date
October 2026 (Anticipated)
Study Completion Date
October 2028 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
Wake Forest University Health Sciences

4. Oversight

Studies a U.S. FDA-regulated Drug Product
Yes
Studies a U.S. FDA-regulated Device Product
Yes
Data Monitoring Committee
No

5. Study Description

Brief Summary
The proposed pilot study will provide safety and efficacy preliminary data regarding singular and combined effects of two therapeutic approaches, intranasal insulin and treatment with the sodium-glucose cotransporter type 2 inhibitor (SGLT2i) empagliflozin, to correct bioenergetic and vascular dysfunction in adults with preclinical Alzheimer's disease (AD) and amnestic mild cognitive impairment (aMCI) or early AD.
Detailed Description
The study will consist of a single site, randomized, double-blind trial comparing the effects of 4 weeks of intranasal insulin(40 International Units four times daily), empagliflozin (10 mg daily) and combined intranasal insulin (INI) and empagliflozin (empa) compared with placebo on cerebrospinal fluid (CSF) biomarkers and cognition. At study entry, participants will be randomized to one of 4 conditions: INI, empa, INI+empa or placebo. Participants who are cognitively normal but have abnormal elevations of brain amyloid or who have mild cognitive impairment (MCI) or early Alzheimer's disease (AD) will be enrolled. The primary outcome measure will consist of safety (treatment-related serious adverse events). Secondary outcome measures will consist of cerebrospinal fluid (CSF) biomarkers, cognition, and cerebral blood flow.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Mild Cognitive Impairment, Cognitive Impairment, Alzheimer Disease
Keywords
Intranasal Delivery of Insulin, Cognitive Testing, Nasal Insulin

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 2
Interventional Study Model
Parallel Assignment
Masking
ParticipantCare ProviderInvestigatorOutcomes Assessor
Masking Description
Neither participants nor site personnel involved in assessing participants will know which dose of insulin is being administered. Exceptions will be the study nurse who is directly involved in preparing the insulin.
Allocation
Randomized
Enrollment
60 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
Intranasal Insulin and Empagliflozin Placebo
Arm Type
Experimental
Arm Description
40 IU of intranasal insulin administered using the Aptar CPS device 30 minutes prior to eating and 30 minutes before bedtime for a total of four (4) times daily Placebo capsules taken by mouth 30 minutes before breakfast once daily
Arm Title
Empagliflozin and Intranasal Insulin Placebo
Arm Type
Experimental
Arm Description
Empagliflozin 10 mg capsules taken by mouth 30 minutes before breakfast once daily 40 IU of intranasal insulin diluent (placebo) administered using the Aptar CPS device 30 minutes prior to eating and 30 minutes before bedtime for a total of four (4) times daily
Arm Title
Intranasal Insulin and Empagliflozin
Arm Type
Experimental
Arm Description
40 IU of intranasal insulin administered using the Aptar CPS device 30 minutes prior to eating and 30 minutes before bedtime for a total of four (4) times daily Empagliflozin 10 mg capsules taken by mouth 30 minutes before breakfast once daily
Arm Title
Placebo
Arm Type
Placebo Comparator
Arm Description
40 IU of intranasal insulin diluent (placebo) administered using the Aptar CPS device 30 minutes prior to eating and 30 minutes before bedtime for a total of four (4) times daily Placebo capsules taken by mouth 30 minutes before breakfast once daily
Intervention Type
Drug
Intervention Name(s)
Insulin (Humulin® R U-100)
Intervention Description
Participants will administer 40 IU of Humulin® U-100 insulin four times per day with an intranasal delivery device.
Intervention Type
Drug
Intervention Name(s)
Empagliflozin 10 MG
Intervention Description
Participants will be assigned to receive Empagliflozin 10 mg capsules to be taken by mouth once daily.
Intervention Type
Device
Intervention Name(s)
Aptar Pharma CPS Intranasal Delivery Device
Intervention Description
Participants will be assigned to receive Humulin® insulin or placebo administered through the Aptar Pharma CPS intranasal delivery device.
Intervention Type
Drug
Intervention Name(s)
Placebo (Insulin Diluent)
Intervention Description
Participants will administer placebo (insulin diluent) four times per day with an intranasal delivery device.
Intervention Type
Drug
Intervention Name(s)
Placebo (Capsules)
Intervention Description
Participants will be assigned to receive placebo capsules (Empagliflozin 10 mg) to be taken by mouth once daily.
Primary Outcome Measure Information:
Title
Number of Participants with Treatment-related Serious Adverse Events as Assessed by CTCAE v5.0
Description
Adverse events will be assessed using Common Terminology Criteria for Adverse Events (CTCAE v5.0). The number of participants with grade 3 or greater adverse events that were deemed to be possibly, probably, or definitely related to study treatment will be reported.
Time Frame
Week 8
Secondary Outcome Measure Information:
Title
Change in the Preclinical Alzheimer Cognitive Composite 5 (PACC5) Z-Score
Description
Cognition will be measured using the PACC5 scale, which includes the free/cued selective reminding test, delayed paragraph recall, digit-symbol substitution, mini mental state score, and the category fluency task. The PACC5 is a composite score comprised of measures of global cognition, memory, and executive function. The score reflects an averaged z-score, with higher scores indicating better cognitive performance.
Time Frame
Baseline to Week 8
Title
Change in the 14-item Alzheimer's Disease Assessment Scale-Cognitive subscale (ADAS-Cog 14) Score
Description
A psychometric instrument that evaluates memory, attention, reasoning, language, orientation, and praxis. A higher score indicates more impairment. Scores from the original portion of the test range from 0 (best) to 65 (worse), and are added to the mean of the words not immediately recalled (max of 10) and the number of items not recalled after a delay (ranging from 0-10) all total the maximum score of 85. A positive change indicates cognitive worsening.
Time Frame
Baseline to Week 8
Title
Change in amyloid β-peptide (Aβ) 40 (Aβ40) in Cerebrospinal Fluid (CSF)
Description
Cerebrospinal fluid (CSF) samples will be used to measure the levels of amyloid β-peptide (Aβ) 40. CSF Aβ40 is a key Alzheimer's disease (AD) biomarker that reflects pathological aggregation of amyloid in the brain.
Time Frame
Baseline to Week 8
Title
Change in amyloid β-peptide (Aβ) 42 (Aβ42) in Cerebrospinal Fluid (CSF)
Description
Cerebrospinal fluid (CSF) samples will be used to measure the levels of amyloid β-peptide (Aβ) 42. CSF Aβ42 is a key Alzheimer's disease (AD) biomarker that reflects pathological aggregation of amyloid in the brain.
Time Frame
Baseline to Week 8
Title
Change in Cerebrospinal Fluid (CSF) Levels of Total Tau
Description
Cerebrospinal fluid (CSF) samples will be used to measure the levels of total tau protein in the brain to assess impact on brain tau as a relevant Alzheimer's Disease (AD) biomarker.
Time Frame
Baseline to Week 8
Title
Change in Cerebrospinal Fluid (CSF) Levels of Phospho-Tau 181
Description
Cerebrospinal fluid (CSF) samples will be used to measure the levels of phospho-tau 181 protein in the brain to assess impact on brain tau as a relevant Alzheimer's Disease (AD) biomarker.
Time Frame
Baseline to Week 8
Title
Change in Total Cerebral Blood Flow (CBF) Using MRI Pseudocontinuous Arterial Spin Labeling (ASL)
Description
Change in CBF in mL/100g/min, calculated as the difference between the pre- and post- ASL flow in response to the study intervention.
Time Frame
Baseline to Week 8

10. Eligibility

Sex
All
Minimum Age & Unit of Time
55 Years
Maximum Age & Unit of Time
85 Years
Accepts Healthy Volunteers
Accepts Healthy Volunteers
Eligibility Criteria
Inclusion Criteria: Age 55 to 85 (inclusive) Fluent in English Cognitively normal or diagnosis of amnestic mild cognitive impairment (aMCI) or mild Alzheimer's disease (AD) Amyloid positive by positron emission tomography (PET) or cerebrospinal fluid (CSF) criteria Stable medical condition for 3 months prior to screening visit Stable medications for 4 weeks prior to the screening and study visits (exceptions may be made on a case by case basis by the study physician) Clinical laboratory values must be within normal limits or, if abnormal, must be judged to be clinically insignificant by the study physician Exclusion Criteria: A diagnosis of dementia other than Alzheimer's disease (AD) History of a clinically significant stroke Current evidence or history in past two years of epilepsy, head injury with loss of consciousness, any major psychiatric disorder including psychosis, major depression, bipolar disorder Diabetes (type I or type II) insulin-dependent and non-insulin-dependent diabetes mellitus Current or past regular use of insulin or any other anti-diabetic medication within 2 months of screening visit History of seizure within past five years Pregnancy or possible pregnancy Use of anticoagulants, unless documentation received from prescribing clinician that anticoagulant medication can be held before LP, and approved by study clinician Residence in a skilled nursing facility at screening Use of an investigational agent within two months of screening visit Regular use of alcohol, narcotics, anticonvulsants, anti-parkinsonian medications, or any other exclusionary medications (exceptions may be made on a case by case basis by the study physician)
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Deborah Dahl, RN
Phone
336-713-3432
Email
ddahl@wakehealth.edu
First Name & Middle Initial & Last Name or Official Title & Degree
Sarah Bohlman, MSL
Phone
336-716-7354
Email
sarabrow@wakehealth.edu
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Suzanne Craft, PhD
Organizational Affiliation
Wake Forest University Health Sciences / Wake Forest School of Medicine
Official's Role
Principal Investigator
Facility Information:
Facility Name
Wake Forest University Health Sciences / Wake Forest School of Medicine
City
Winston-Salem
State/Province
North Carolina
ZIP/Postal Code
27157
Country
United States
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Deborah Dahl, RN
Phone
336-713-3432
Email
ddahl@wakehealth.edu
First Name & Middle Initial & Last Name & Degree
Sarah Bohlman, MSL
Phone
336-716-7354
Email
sarabrow@wakehealth.edu
First Name & Middle Initial & Last Name & Degree
Suzanne Craft, PhD

12. IPD Sharing Statement

Plan to Share IPD
No
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