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Treatment of Ectopic Calcification in Fahr's Disease or Syndrome (CALCIFADE)

Primary Purpose

Fahr Disease, Fahr Syndrome, Primary Familial Brain Calcification

Status
Recruiting
Phase
Phase 2
Locations
Netherlands
Study Type
Interventional
Intervention
Etidronate
Placebo
Sponsored by
UMC Utrecht
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Fahr Disease

Eligibility Criteria

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

Inclusion criteria are: Age of 18 years or over, Clinical diagnosis of Fahr's disease or syndrome. No international accepted diagnostic criteria for Fahr's disease or syndrome exist yet. It is diagnosed mostly based on the clinical presentation. For the present study the following criteria are used: Clinical symptoms consistent with a clinical diagnosis of Fahr's disease or syndrome. Bilateral calcifications of the basal ganglia as seen on the computed tomography (CT) scan of the head. To rule out basal ganglia calcifications due to aging, a CT based calcification score will be used as proposed by Nicolas et al. Calcification is graded from 0 (no calcification) to 5 (serious and confluent) in specific locations of the brain; lenticular, caudate, thalamus nuclei, subcortical white matter, cortex, cerebellar hemispheres, vermis, midbrain, pons, and medulla. The total calcification score (ranging from 0 to 80) is obtained by adding all location-specific points, where a score higher than the age-specific threshold points at Fahr's disease or syndrome. Furthermore, the next criteria are supportive for the clinical diagnosis of PFBC: Frequently, the family history is consistent with autosomal dominant inheritance. A positive family history with at least one relative in the first or second degree with symptoms of PFBC is supportive for the clinical diagnosis of PFBC. The presence of a (likely) pathogenic mutation in one of the PFBC-related genes is supportive for the clinical diagnosis of PFBC. Mutations in up to now 4 known genes are associated with an autosomal dominant pattern of inheritance: solute carrier family 20 member 2 (SLC20A2) (OMIM#213600), xenotropic and polytropic retrovirus receptor 1 (XPR1) (OMIM#616413), platelet-derived growth factor b (PDGFB) (OMIM#615483), and platelet-derived growth factor receptor b (PDGFRB) (OMIM#615007). Autosomal recessively inherited PFBC is associated with mutations in two genes: myogenesis-regulating glycosidase (MYORG) (OMIM#618317) and junctional adhesion molecule 2 (JAM2) (OMIM#618824). Exclusion criteria are: unable or unwilling to sign an informed consent, severe renal impairment (estimated glomerular filtration rate (eGFR) of <30 ml/min/1.73m2 calculated using CKD-EPI equation), contraindication to receiving oral medication (for example severe dysphagia), known abnormality of the oesophagus that would interfere with the passage of the drug (for example oesophageal strictures or achalasia), known sensitivity to etidronate, pregnancy, women with an active pregnancy wish <1 year, or women who are breastfeeding at the time of inclusion, inability to undergo a Dutch neuropsychological assessment (for example, non-fluent Dutch speakers or severe visual, hearing or motor impairment), any other medical or social condition that puts the subject at risk of harm during the study or might adversely affect the interpretation of the study data, use of bisphosphonates during the last 5 years, hypocalcaemia (calcium <2.20 mmol/L), 25-OH vitamin D deficiency <35 nmol/L. After correction of hypocalcaemia or vitamin D deficiency, a participant is again suitable for participation.

Sites / Locations

  • University Medical Center UtrechtRecruiting

Arms of the Study

Arm 1

Arm 2

Arm Type

Active Comparator

Placebo Comparator

Arm Label

Etidronate

Placebo

Arm Description

Etidronate 20 mg/kg for two weeks on and ten weeks off during 12 months

Placebo for two weeks on and ten weeks off during 12 months

Outcomes

Primary Outcome Measures

Overall cognitive functioning
Montreal Cognitive Assessment (MoCA; range 0-30, higher scores mean better outcome)
Memory
Composite z-score of Rivermead Behavioral Memory Test (RBMT) Stories immediate and delayed recall, Rey complex figure test immediate and delayed recall
Attention and speed of information processing
Composite z-score of Wechsler Adult Intelligence Scale third edition (WAIS-III) Digit Span Forward, Trail Making Test A (TMT-A), Stroop I and II
Executive functioning
Composite z-score of Wechsler Adult Intelligence Scale third edition (WAIS-III) Digit Span Backward, Trail Making Test B (TMT-B), Stroop III, semantic and letter fluency
Social cognition
Facial Expressions of Emotion - Stimuli and Tests (FEEST; scored based on normative data)

Secondary Outcome Measures

Mobility
Condensed version of the Balance Evaluation Systems Test (Mini-BESTest), which is a composite test of gait and balance (range 0-28, higher scores mean better outcome)
Mobility
Unified Parkinson's Disease Rating Scale, part III (UPDRS; range 0-56, higher scores mean worse outcome)
Neuropsychiatric symptoms
Neuropsychiatric Inventory (NPI; range 0-144, higher scores mean worse outcome)
Activities of daily living
Katz-15 scale (range 0-15, higher scores mean worse outcome)
Quality of life questionnaire
36-item Short Form Health Survey (SF-36; range 0-100, higher scores mean better outcome)
Brain calcification volume
Volume of calcification quantified in computed tomography scan (milliliters)

Full Information

First Posted
November 16, 2022
Last Updated
April 13, 2023
Sponsor
UMC Utrecht
Collaborators
Netherlands Brain Foundation
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1. Study Identification

Unique Protocol Identification Number
NCT05662111
Brief Title
Treatment of Ectopic Calcification in Fahr's Disease or Syndrome
Acronym
CALCIFADE
Official Title
A Randomized, Placebo-controlled, Double-blind Trial to Study the Effects of Etidronate on Ectopic CALCIfication in FAhr's Disease or Syndrome
Study Type
Interventional

2. Study Status

Record Verification Date
April 2023
Overall Recruitment Status
Recruiting
Study Start Date
April 3, 2023 (Actual)
Primary Completion Date
October 2025 (Anticipated)
Study Completion Date
October 2025 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Principal Investigator
Name of the Sponsor
UMC Utrecht
Collaborators
Netherlands Brain Foundation

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
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
Fahr's disease or syndrome are neurodegenerative diseases in which patients present with bilateral vessel associated calcifications in the basal ganglia. The clinical penetration of Fahr's disease or syndrome is incomplete and heterogeneous comprising of neuropsychiatric signs, cognitive decline, movement disorders, and various other signs (migraine, speech disorders, pain, seizures). The symptoms start between 30 and 50 years and are (slowly) progressive. Symptomatic patients have an increased risk for dependence in activities of daily living and impaired quality of life. Currently, disease-modifying therapies are not available for patients with Fahr's disease or syndrome. However, in a small case series it was shown that alendronate was effective in the clinical treatment of several patients with Fahr's disease or syndrome. Now the time has come to investigate the effectiveness of treatment with bisphosphonates in patients with Fahr's disease or syndrome in a randomized controlled trial.
Detailed Description
Fahr's disease, scientifically known as primary familial brain calcification (PFBC), is a neurodegenerative disease in which all patients present with bilateral vessel associated calcifications in the basal ganglia in the absence of other secondary causes of brain calcifications. When a secondary cause is identified, the term Fahr's syndrome is often used. Dominantly-inherited PFBC is associated with mutations in four genes; solute carrier family 20 member 2 (SLC20A2), xenotropic and polytropic retrovirus receptor 1 (XPR1), platelet-derived growth factor b (PDGFB) and platelet-derived growth factor receptor b (PDGFRB). Recessively inherited PFBC is associated with mutations in two genes; myogenesis-regulating glycosidase (MYORG) and junctional adhesion molecule 2 (JAM2). Mutations in the known genes account for half of patients, suggesting genetic heterogeneity, with new genes yet to be discovered. The estimated minimal prevalence in studies with PFBC diagnosed with genetic and imaging studies is 2.1 to 6.6 per 1,000 suggesting that PFBC is actually not a rare disorder and is underdiagnosed. The clinical penetration of Fahr's disease or syndrome is incomplete and heterogeneous comprising of neuropsychiatric signs (depression, anxiety, psychosis), cognitive decline, movement disorders (ataxia, dystonia, Parkinsonism) and various other signs (migraine, speech disorders, pain, seizures). The symptoms start between 30 and 50 years and are (slowly) progressive. Symptomatic patients have an increased risk for dependence in activities of daily living and impaired quality of life. Histology shows small vessel and capillary calcifications, vascular insufficiency and blood-brain barrier damage. Neural pathology has been described and there are indications that calcifications could interfere with neural circuitry. It is not known how mutations in different genes lead to a common pathology. Yet PFBC belongs to a group of genetic diseases that due to different types of faulty phosphor metabolism leads to a shortage of inorganic pyrophosphate (PPi). PPi is the strongest inhibitor of ectopic calcification in the body. PPi can be replaced by etidronate, a stable molecular homologue of PPi and a well known bisphosphonate that has been used widely. Presently, the rare genetic diseases Pseudoxanthoma Elasticum (PXE), Generalized Arterial Calcification of Infancy (GACI) and Arterial Calcification due to Cluster of Designation 73 (CD73) deficiency (ACDC) are successfully treated with this medication. In PFBC, it was shown that due to mutations in the SLC20A2 gene the Pi Transporter 2 (PiT2) is compromised. The PiT2 transporter plays an important role in the maintenance of Pi homeostasis which is essential for adenosine triphosphate synthesis. Another mutation, XPR1 is responsible for phosphate efflux and mutations here lead to calcium deposition in endothelial cells. Recently, it was shown that mutations in the PDGFB and PDGFRB genes cause osteoblast like cells to mediate in the calcification process, as was also shown in PXE, GACI and ACDC patients. Currently, disease-modifying therapies are not available for patients with Fahr's disease or syndrome. However, in a small case series it was shown that alendronate was effective in the clinical treatment of several patients with Fahr's disease or syndrome. Now the time has come to investigate the effectiveness of treatment with bisphosphonates in patients with Fahr's disease or syndrome in a randomized controlled trial.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Fahr Disease, Fahr Syndrome, Primary Familial Brain Calcification

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 2
Interventional Study Model
Parallel Assignment
Model Description
A randomized placebo-controlled double blind trial using etidronate versus placebo
Masking
ParticipantCare ProviderInvestigatorOutcomes Assessor
Allocation
Randomized
Enrollment
98 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
Etidronate
Arm Type
Active Comparator
Arm Description
Etidronate 20 mg/kg for two weeks on and ten weeks off during 12 months
Arm Title
Placebo
Arm Type
Placebo Comparator
Arm Description
Placebo for two weeks on and ten weeks off during 12 months
Intervention Type
Drug
Intervention Name(s)
Etidronate
Other Intervention Name(s)
Etidronate disodium
Intervention Description
The dosage of etidronate is 20 mg/kg for twee weeks and ten weeks off. Etidronate is given in capsules of 200 mg. Etidronate capsules are administered orally. During the study, participants will receive etidronate in four periods of two weeks during the twelve months of follow-up.
Intervention Type
Drug
Intervention Name(s)
Placebo
Other Intervention Name(s)
Etidronate disodium
Intervention Description
Placebo is given in capsules and are administered orally. During the study, participants will receive placebo in four periods of two weeks during the twelve months of follow-up.
Primary Outcome Measure Information:
Title
Overall cognitive functioning
Description
Montreal Cognitive Assessment (MoCA; range 0-30, higher scores mean better outcome)
Time Frame
12 months
Title
Memory
Description
Composite z-score of Rivermead Behavioral Memory Test (RBMT) Stories immediate and delayed recall, Rey complex figure test immediate and delayed recall
Time Frame
12 months
Title
Attention and speed of information processing
Description
Composite z-score of Wechsler Adult Intelligence Scale third edition (WAIS-III) Digit Span Forward, Trail Making Test A (TMT-A), Stroop I and II
Time Frame
12 months
Title
Executive functioning
Description
Composite z-score of Wechsler Adult Intelligence Scale third edition (WAIS-III) Digit Span Backward, Trail Making Test B (TMT-B), Stroop III, semantic and letter fluency
Time Frame
12 months
Title
Social cognition
Description
Facial Expressions of Emotion - Stimuli and Tests (FEEST; scored based on normative data)
Time Frame
12 months
Secondary Outcome Measure Information:
Title
Mobility
Description
Condensed version of the Balance Evaluation Systems Test (Mini-BESTest), which is a composite test of gait and balance (range 0-28, higher scores mean better outcome)
Time Frame
12 months
Title
Mobility
Description
Unified Parkinson's Disease Rating Scale, part III (UPDRS; range 0-56, higher scores mean worse outcome)
Time Frame
12 months
Title
Neuropsychiatric symptoms
Description
Neuropsychiatric Inventory (NPI; range 0-144, higher scores mean worse outcome)
Time Frame
12 months
Title
Activities of daily living
Description
Katz-15 scale (range 0-15, higher scores mean worse outcome)
Time Frame
12 months
Title
Quality of life questionnaire
Description
36-item Short Form Health Survey (SF-36; range 0-100, higher scores mean better outcome)
Time Frame
12 months
Title
Brain calcification volume
Description
Volume of calcification quantified in computed tomography scan (milliliters)
Time Frame
12 months

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion criteria are: Age of 18 years or over, Clinical diagnosis of Fahr's disease or syndrome. No international accepted diagnostic criteria for Fahr's disease or syndrome exist yet. It is diagnosed mostly based on the clinical presentation. For the present study the following criteria are used: Clinical symptoms consistent with a clinical diagnosis of Fahr's disease or syndrome. Bilateral calcifications of the basal ganglia as seen on the computed tomography (CT) scan of the head. To rule out basal ganglia calcifications due to aging, a CT based calcification score will be used as proposed by Nicolas et al. Calcification is graded from 0 (no calcification) to 5 (serious and confluent) in specific locations of the brain; lenticular, caudate, thalamus nuclei, subcortical white matter, cortex, cerebellar hemispheres, vermis, midbrain, pons, and medulla. The total calcification score (ranging from 0 to 80) is obtained by adding all location-specific points, where a score higher than the age-specific threshold points at Fahr's disease or syndrome. Furthermore, the next criteria are supportive for the clinical diagnosis of PFBC: Frequently, the family history is consistent with autosomal dominant inheritance. A positive family history with at least one relative in the first or second degree with symptoms of PFBC is supportive for the clinical diagnosis of PFBC. The presence of a (likely) pathogenic mutation in one of the PFBC-related genes is supportive for the clinical diagnosis of PFBC. Mutations in up to now 4 known genes are associated with an autosomal dominant pattern of inheritance: solute carrier family 20 member 2 (SLC20A2) (OMIM#213600), xenotropic and polytropic retrovirus receptor 1 (XPR1) (OMIM#616413), platelet-derived growth factor b (PDGFB) (OMIM#615483), and platelet-derived growth factor receptor b (PDGFRB) (OMIM#615007). Autosomal recessively inherited PFBC is associated with mutations in two genes: myogenesis-regulating glycosidase (MYORG) (OMIM#618317) and junctional adhesion molecule 2 (JAM2) (OMIM#618824). Exclusion criteria are: unable or unwilling to sign an informed consent, severe renal impairment (estimated glomerular filtration rate (eGFR) of <30 ml/min/1.73m2 calculated using CKD-EPI equation), contraindication to receiving oral medication (for example severe dysphagia), known abnormality of the oesophagus that would interfere with the passage of the drug (for example oesophageal strictures or achalasia), known sensitivity to etidronate, pregnancy, women with an active pregnancy wish <1 year, or women who are breastfeeding at the time of inclusion, inability to undergo a Dutch neuropsychological assessment (for example, non-fluent Dutch speakers or severe visual, hearing or motor impairment), any other medical or social condition that puts the subject at risk of harm during the study or might adversely affect the interpretation of the study data, use of bisphosphonates during the last 5 years, hypocalcaemia (calcium <2.20 mmol/L), 25-OH vitamin D deficiency <35 nmol/L. After correction of hypocalcaemia or vitamin D deficiency, a participant is again suitable for participation.
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Birgitta MG Snijders, MD
Phone
0031 88 75 583 78
Email
b.m.g.snijders@umcutrecht.nl
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Huiberdina L Koek, MD, PhD
Organizational Affiliation
UMC Utrecht
Official's Role
Principal Investigator
Facility Information:
Facility Name
University Medical Center Utrecht
City
Utrecht
ZIP/Postal Code
3584 CX
Country
Netherlands
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Birgitta MG Snijders, MD

12. IPD Sharing Statement

Plan to Share IPD
No
IPD Sharing Plan Description
Data can be shared with other researchers upon request. Due to the fact that Fahr's disease or syndrome is rare, not all data will be published openly, since this data might be traceable to an individual person.

Learn more about this trial

Treatment of Ectopic Calcification in Fahr's Disease or Syndrome

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