Amyotrophic Lateral SclerosisPhase 2TUDCA-ALSNCT00877604
Efficacy and Tolerability of Tauroursodeoxycholic Acid in Amyotrophic Lateral Sclerosis
A Phase 2 study testing tauroursodeoxycholic acid (TUDCA) in people with Amyotrophic Lateral Sclerosis, run by Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta at 1 site in Italy.
Trial summary
The preclinical rationale for tauroursodeoxycholic acid (TUDCA) use in treating patients with amyotrophic lateral sclerosis (ALS) stems from the demonstration of antioxidant, antiapoptotic and neuroprotective properties of TUDCA in the central nervous system (CNS), both in vitro and in vivo models. Read more about this study
- Who is it for?
- Ages 18 to 75 years
- Conditions the study is for
- Amyotrophic Lateral Sclerosis
- What is being tested?
- tauroursodeoxycholic acid (TUDCA)
- Type of treatment
- Pill or oral medicine
- Could I receive a placebo?
- Yes, some participants may receive a placebo
- How many people
- 34 participants
- Where
- 1 siteItaly
- Study dates
- Jun 2008to Apr 2012
- Phase
- Phase 2
- Are there results?
- Yes, posted in the registrySummary in the doctors' view
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 18 to 75 years
- All sexes
- No healthy volunteers
- Adult, Older adult
Who may be able to join
- Caucasian male or female out-patients;
- aged 18 to 75 years inclusive;
- diagnosis of "probable" or "definite" amyotrophic lateral sclerosis according to the El Escorial revised criteria (1);
- first symptoms of ALS by no more than 1.5 years;
- in treatment with steady regimen of riluzole for a minimum of 3 months before study entry, and desiring its continuation;
- FVC ≥ 75% of predicted;
- no conditions known to be contraindications to the use of TUDCA;
- written informed consent.
Who cannot join
- subjects who underwent tracheostomy;
- subjects who underwent resection of gall bladder;
- subjects with signs of conduction blocks of motor nerves, sensory nerves or both on nerve conduction study;
- subjects with clinical signs of dementia;
- subjects with active peptic ulcer;
- subjects with active malignancy;
Show all 10Show fewer
- subjects with bulbar onset;
- female subjects who are pregnant or lactating
- subjects who have received an experimental drug or have participated in a clinical trial within 3 months prior to screening
- employees of the investigator or study centre with direct involvement in the proposed study or other studies under the direction of that investigator or study centre.
Trial locations and contacts
1 site in 1 country.
Italy1 site
Fondazione IRCCS Istituto neurologico Carlo Besta
Milan, Milan, 20133
About this study
Official title: A Randomized, Double-blind Multicenter Pilot Study vs. Placebo for the Evaluation of Efficacy and Tolerability of Tauroursodeoxycholic Acid Administered by Oral Route as Add on Treatment in Patients Affected by Amyotrophic Lateral Sclerosis
The preclinical rationale for tauroursodeoxycholic acid (TUDCA) use in treating patients with amyotrophic lateral sclerosis (ALS) stems from the demonstration of antioxidant, antiapoptotic and neuroprotective properties of TUDCA in the central nervous system (CNS), both in vitro and in vivo models.
This protocol is meant for assessing if the addition of TUDCA to the conventional therapy can improve the therapeutic outcome in patients affected by ALS.
Read more
Safety will be assessed for all subjects, for the entire duration of the study. 30 patients affected by ALS with site of onset in the limbs will be recruited.
All enrolled subjects will continue receiving riluzole at the same regimen as before entering the trial. Based on an appropriate random code, subjects will be divided into two groups of equal size treated, after a lead-in period of 3 months, by oral route with TUDCA at the dose 2 g daily for 1 year or with identical placebo by oral route at the same dosing schedule, under double-blind conditions.
Every concomitant and/or supportive therapy will be admitted.
Evaluation criteria:
Efficacy. The proportion of responder patients in the two treatment groups was the primary outcome measure of the study. Responder patients were defined as those subjects showing an improvement of at least 15% in the ALSFRS-R (2) slope during the treatment period as compared to the lead-in period. This threshold was chosen based according to the consensus conference on designing and implementing clinical trials in ALS (3).
Other parameters will include ALSFRS-R at study end, FVC%, the SF-36 quality of life rating scale, time to tracheotomy from starting of study medication dosing (if appropriate), survival Time from starting of study medication dosing (if appropriate), Medical Research Council scores for right and left muscle groups.
Safety. Incidence, severity and type of adverse events; changes in clinical laboratory findings.
Read the detailed description
Amyotrophic lateral sclerosis (ALS), or motor neuron disease (MND), is a rapidly progressive, fatal neurodegenerative condition characterized by loss of upper and lower motor neurons in the brain and spinal cord. The terms ALS and MND are often used inter-changeably to cover the different clinical syndromes, which include upper and lower motor neuron disorder, progressive bulbar palsy, and pseudo-polyneuritic form.
Degeneration of lower motor neurons (LMN) in the anterior horns of spinal cord and brainstem leads to progressive muscular atrophy and eventually to death within a few years due to respiratory insufficiency. During the course of the disease, the involvement of tongue and pharynx muscles causes swallowing impairment with marked drooling, need of parenteral or enteral feeding, and finally gastrostomy. Denervation of laryngeal muscles causes loss of speech. Cramps and fasciculation typically occur from the early phases of the disease. Degeneration of upper motor neurons (UMN) in the brain cortex causes pyramidal tract dysfunctions including clonus, Babinski sign, hypertonia, and loss of dexterity that further limit patients' daily activities.
The incidence of ALS varies from 0.2 to 2.5 cases per 100,000 per year, although estimates vary between countries, likely reflecting a combination of availability of medical services, diagnostic accuracy, and demo-graphic characteristics of the area. Increasing life expectancy and improvements in standards of treatment and care will also result in an increased incidence of ALS. Globally, the overall rate is approximately 2 per 100,000. Its prevalence is approximately of 7 per 100,000. In Italy, the reported incidence of ALS is 2.2 cases/100,000/year.
There is currently no cure for ALS. Despite initial positive results in preclinical and early clinical studies, large-scale clinical trials with all agents except riluzole failed to demonstrate a clinically meaningful therapeutic effect in patients with ALS. Riluzole at the dose of 100 mg/day showed a significant difference on survival (6.4%; gain of 3 months) and slowed deterioration in muscle strength.
Primary involvement of apoptotic mechanisms has important implications in selecting drug candidates for therapy in ALS. Recent preclinical studies have demonstrated that TUCA is endowed with antioxidant, antiapoptotic and neuroprotective activities. In particular, TUDCA can cross the blood-brain-barrier and has been shown to exert a significant therapeutic effect in a model of HD mice.
Tauroursodeoxycholic acid (TUDCA) is a hydrophilic bile acid that is normally produced endogenously in humans at very low levels. TUDCA is synthesized in the liver by conjugation of taurine to ursodeoxycholic acid (UDCA), which is commonly used as a bile acid replacement therapy for the treatment of certain cholestatic syndromes.
The main pharmacological activity of TUDCA consists in its ability in increasing the cholesterol solubilising activity of bile, thus transforming "lithogenic" bile in "non-lithogenic" or "litholytic" bile.
TUDCA inhibits mitochondrial-associated apoptosis via many pathways: 1) it inhibits the mitochondrial permeability transition (MPT) and cytochrome C release, 2) it inhibits mitochondrial membrane depolarization, and 3) it antagonizes Bax translocation from the mitochondria and caspase activation in hepatocytes and brain. TUDCA may also ease oxidative stress.Study relevant TUDCA pharmacology consists in its antioxidant, antiapoptotic and neuroprotective activities evidenced in preclinical studies.
Recent reports have shown that hydrophilic bile acids, such as UDCA and TUDCA, can prevent hepatic cytotoxicity through several mechanisms. For example, TUDCA prevents the production of reactive oxygen species and thus acts as an antioxidant. Additionally, TUDCA mitigates mitochondrial insufficiency and toxicity, and prevents apoptosis, in part, by inhibiting Bax translocation from cytosol to the mitochondria. In hepatocytes, this inhibition results in reduced mitochondrial membrane perturbation, release of cytochrome c, and activation of downstream caspases. TUDCA reduced cytotoxicity in neurons through similar mechanisms, as well as mitochondrial pathways that are independent of the permeability transition. TUDCA prevented striatal degeneration and ameliorated locomotor and cognitive deficits in the in vivo 3-nitropropionic acid (3-NP) rat model of HD. Intracellular inclusions were significantly reduced, and the TUDCA-treated mice showed improved locomotor and sensorimotor abilities.
In addition, the antiapoptotic and cytoprotective effects of TUDCA have been tested in models of acute stroke. The possibility that TUDCA exerts an antiapoptotic action by ameliorating mitochondrial function raises the issue whether other neurological disorders, including Friedreich's ataxia, amyotrophic lateral sclerosis, Parkinson's disease, and Alzheimer's disease, can benefit by the administration of TUDCA. This drug is a candidate neuroprotective agent for a variety of chronic neurodegenerative conditions.
- Conditions
- Amyotrophic Lateral Sclerosis
- Being tested
- tauroursodeoxycholic acid (TUDCA), Placebo
- Keywords
- ALS, Therapy, Tauroursodeoxycholic acid, TUDCA, antioxidant, antiapoptotic drug, neuroprotective drug
- Medical subject headings
- Amyotrophic Lateral Sclerosis
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
tauroursodeoxycholic acid (TUDCA)Drug
Also called Ursodiol, Actigall, Generic
Oral route at the dose of 1 g b.i.d. (2 g daily) for 1 year
PlaceboDrug
Also called Oral route at the dose of 1 g b.i.d. (2 g daily) for 1 year
identical placebo by oral route at the same dosing schedule
| Study group | Role | What they receive |
|---|---|---|
| TUDCA | Experimental | tauroursodeoxycholic acid di-hydrate Receives: Drug: tauroursodeoxycholic acid (TUDCA) |
| placebo | Placebo comparator | excipient lactose Receives: Drug: Placebo |
What is being measured
The primary outcome is the main question the study is designed to answer.
The Proportion of Responder Patients in the Two Treatment Groups According the Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS)-R Slope.
Responder patients were defined as those subjects showing an improvement of at least 15% in the ALSFRS-R slope during the treatment period as compared to the lead-in period.
Measured: 1 year
Secondary outcomes (7)
Forced Vital Capacity (FVC) %
Measured: 1 year
SF-36 Quality of Life Rating Scale
Measured: 1 year
Time to Tracheostomy From Starting of Study Medication Dosing (if Appropriate)
Measured: 1 year
Survival Time From Starting of Study Medication Dosing (if Appropriate)
Measured: 1 year
ALSFRS-R at Study End
Measured: 1 year
Incidence and Severity of Adverse Events, and Their Relationship to Treatment
laboratory tests, patients' reports and the investigator's judgments
Measured: 1 year
Medical Research Council Scores for Right and Left Muscle Groups
Measured: 1 year
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted8 Apr 2009 (estimated)
- Study startJun 2008
- Primary completionJul 2011
- Study completionApr 2012
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Posted resultsParticipant flow, outcome measures and adverse events reported by the sponsor.
- Publications (42)Papers the sponsor has linked to this study.
- Other trials for Amyotrophic Lateral SclerosisStudies of the same condition, open and under way.
- More trials run by Fondazione I.R.C.C.S. Istituto Neurologico Carlo BestaThe sponsor's other registered studies.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase 2
- Primary purpose
- Treatment
- Allocation
- Randomised
- Intervention model
- Single group
- Masking
- Quadruple blind
- Who is masked
- Participant, Care provider, Investigator, Outcomes assessor
- Enrolment
- 34 participants (actual)
Sponsor and investigators
- Sponsor type
- University, hospital or other
- Collaborators
- University of Palermo, Federico II University
- Responsible party
- Principal investigator, Alberto Albanese, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta
- Investigators
- Alberto Albanese, MD, Principal investigator, Fondazione IRCCS Istituto neurologico Carlo Besta
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT00877604
- Sponsor's protocol ID
- TUDCA200701
- Other IDs
- EudraCT No.: 2007-001592-10
- Acronym
- TUDCA-ALS
- Status last verified
- Nov 2014
- First submitted
- 7 Apr 2009
- Last updated
- 26 Nov 2014
- Results posted
- Yes, on ClinicalTrials.gov
- Data monitoring committee
- Yes
Publications
Brooks BR, Miller RG, Swash M, Munsat TL; World Federation of Neurology Research Group on Motor Neuron Diseases. El Escorial revisited: revised criteria for the diagnosis of amyotrophic lateral sclerosis. Amyotroph Lateral Scler Other Motor Neuron Disord. 2000 Dec;1(5):293-9. doi: 10.1080/146608200300079536. No abstract available.
PubMed 11464847Cedarbaum JM, Stambler N, Malta E, Fuller C, Hilt D, Thurmond B, Nakanishi A. The ALSFRS-R: a revised ALS functional rating scale that incorporates assessments of respiratory function. BDNF ALS Study Group (Phase III). J Neurol Sci. 1999 Oct 31;169(1-2):13-21. doi: 10.1016/s0022-510x(99)00210-5.
PubMed 10540002Leigh PN, Swash M, Iwasaki Y, Ludolph A, Meininger V, Miller RG, Mitsumoto H, Shaw P, Tashiro K, Van Den Berg L. Amyotrophic lateral sclerosis: a consensus viewpoint on designing and implementing a clinical trial. Amyotroph Lateral Scler Other Motor Neuron Disord. 2004 Jun;5(2):84-98. doi: 10.1080/14660820410020187.
PubMed 15204010Keene CD, Rodrigues CM, Eich T, Chhabra MS, Steer CJ, Low WC. Tauroursodeoxycholic acid, a bile acid, is neuroprotective in a transgenic animal model of Huntington's disease. Proc Natl Acad Sci U S A. 2002 Aug 6;99(16):10671-6. doi: 10.1073/pnas.162362299. Epub 2002 Jul 29.
PubMed 12149470Benz C, Angermuller S, Otto G, Sauer P, Stremmel W, Stiehl A. Effect of tauroursodeoxycholic acid on bile acid-induced apoptosis in primary human hepatocytes. Eur J Clin Invest. 2000 Mar;30(3):203-9. doi: 10.1046/j.1365-2362.2000.00615.x.
PubMed 10691996Schoemaker MH, Conde de la Rosa L, Buist-Homan M, Vrenken TE, Havinga R, Poelstra K, Haisma HJ, Jansen PL, Moshage H. Tauroursodeoxycholic acid protects rat hepatocytes from bile acid-induced apoptosis via activation of survival pathways. Hepatology. 2004 Jun;39(6):1563-73. doi: 10.1002/hep.20246.
PubMed 15185297Miller SD, Greene CM, McLean C, Lawless MW, Taggart CC, O'Neill SJ, McElvaney NG. Tauroursodeoxycholic acid inhibits apoptosis induced by Z alpha-1 antitrypsin via inhibition of Bad. Hepatology. 2007 Aug;46(2):496-503. doi: 10.1002/hep.21689.
PubMed 17559149Rodrigues CM, Sola S, Sharpe JC, Moura JJ, Steer CJ. Tauroursodeoxycholic acid prevents Bax-induced membrane perturbation and cytochrome C release in isolated mitochondria. Biochemistry. 2003 Mar 18;42(10):3070-80. doi: 10.1021/bi026979d.
PubMed 12627974Ramalho RM, Ribeiro PS, Sola S, Castro RE, Steer CJ, Rodrigues CM. Inhibition of the E2F-1/p53/Bax pathway by tauroursodeoxycholic acid in amyloid beta-peptide-induced apoptosis of PC12 cells. J Neurochem. 2004 Aug;90(3):567-75. doi: 10.1111/j.1471-4159.2004.02517.x.
PubMed 15255934Rodrigues CM, Sola S, Nan Z, Castro RE, Ribeiro PS, Low WC, Steer CJ. Tauroursodeoxycholic acid reduces apoptosis and protects against neurological injury after acute hemorrhagic stroke in rats. Proc Natl Acad Sci U S A. 2003 May 13;100(10):6087-92. doi: 10.1073/pnas.1031632100. Epub 2003 Apr 29.
PubMed 12721362Ramalho RM, Borralho PM, Castro RE, Sola S, Steer CJ, Rodrigues CM. Tauroursodeoxycholic acid modulates p53-mediated apoptosis in Alzheimer's disease mutant neuroblastoma cells. J Neurochem. 2006 Sep;98(5):1610-8. doi: 10.1111/j.1471-4159.2006.04007.x.
PubMed 16923170Ved R, Saha S, Westlund B, Perier C, Burnam L, Sluder A, Hoener M, Rodrigues CM, Alfonso A, Steer C, Liu L, Przedborski S, Wolozin B. Similar patterns of mitochondrial vulnerability and rescue induced by genetic modification of alpha-synuclein, parkin, and DJ-1 in Caenorhabditis elegans. J Biol Chem. 2005 Dec 30;280(52):42655-42668. doi: 10.1074/jbc.M505910200. Epub 2005 Oct 19.
PubMed 16239214Sola S, Castro RE, Laires PA, Steer CJ, Rodrigues CM. Tauroursodeoxycholic acid prevents amyloid-beta peptide-induced neuronal death via a phosphatidylinositol 3-kinase-dependent signaling pathway. Mol Med. 2003 Sep-Dec;9(9-12):226-34. doi: 10.2119/2003-00042.rodrigues.
PubMed 15208744Rudolph G, Kloeters-Plachky P, Sauer P, Stiehl A. Intestinal absorption and biliary secretion of ursodeoxycholic acid and its taurine conjugate. Eur J Clin Invest. 2002 Aug;32(8):575-80. doi: 10.1046/j.1365-2362.2002.01030.x.
PubMed 12190957Keene CD, Rodrigues CM, Eich T, Linehan-Stieers C, Abt A, Kren BT, Steer CJ, Low WC. A bile acid protects against motor and cognitive deficits and reduces striatal degeneration in the 3-nitropropionic acid model of Huntington's disease. Exp Neurol. 2001 Oct;171(2):351-60. doi: 10.1006/exnr.2001.7755.
PubMed 11573988
Study at a glance
From the registry record, last updated by the sponsor on 26 Nov 2014. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- A Randomized, Double-blind Multicenter Pilot Study vs. Placebo for the Evaluation of Efficacy and Tolerability of Tauroursodeoxycholic Acid Administered by Oral Route as Add on Treatment in Patients Affected by Amyotrophic Lateral Sclerosis
- ClinicalTrials.gov ID
- NCT00877604
- Acronym / sponsor ID
- TUDCA-ALS / TUDCA200701
- Conditions
- Amyotrophic Lateral Sclerosis
- Keywords
- ALS, Therapy, Tauroursodeoxycholic acid, TUDCA, antioxidant, antiapoptotic drug, neuroprotective drug
- Phase
- Phase 2
- Study type
- Interventional
- Recruitment status
- Completed
- Enrolment
- 34 participants (actual)
- Lead sponsor
- Fondazione I.R.C.C.S. Istituto Neurologico Carlo BestaUniversity, hospital or other
- Collaborators
- University of Palermo, Federico II University
- Study start
- Jun 2008
- Primary completion
- Jul 2011 (actual)
- Study completion
- Apr 2012 (actual)
- First posted
- 8 Apr 2009 (estimated)
- Results
- Posted 26 Nov 2014
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
The preclinical rationale for tauroursodeoxycholic acid (TUDCA) use in treating patients with amyotrophic lateral sclerosis (ALS) stems from the demonstration of antioxidant, antiapoptotic and neuroprotective properties of TUDCA in the central nervous system (CNS), both in vitro and in vivo models.
This protocol is meant for assessing if the addition of TUDCA to the conventional therapy can improve the therapeutic outcome in patients affected by ALS.
Safety will be assessed for all subjects, for the entire duration of the study. 30 patients affected by ALS with site of onset in the limbs will be recruited.
All enrolled subjects will continue receiving riluzole at the same regimen as before entering the trial. Based on an appropriate random code, subjects will be divided into two groups of equal size treated, after a lead-in period of 3 months, by oral route with TUDCA at the dose 2 g daily for 1 year or with identical placebo by oral route at the same dosing schedule, under double-blind conditions.
Every concomitant and/or supportive therapy will be admitted.
Evaluation criteria:
Efficacy. The proportion of responder patients in the two treatment groups was the primary outcome measure of the study. Responder patients were defined as those subjects showing an improvement of at least 15% in the ALSFRS-R (2) slope during the treatment period as compared to the lead-in period. This threshold was chosen based according to the consensus conference on designing and implementing clinical trials in ALS (3).
Other parameters will include ALSFRS-R at study end, FVC%, the SF-36 quality of life rating scale, time to tracheotomy from starting of study medication dosing (if appropriate), survival Time from starting of study medication dosing (if appropriate), Medical Research Council scores for right and left muscle groups.
Safety. Incidence, severity and type of adverse events; changes in clinical laboratory findings.
Detailed description
Amyotrophic lateral sclerosis (ALS), or motor neuron disease (MND), is a rapidly progressive, fatal neurodegenerative condition characterized by loss of upper and lower motor neurons in the brain and spinal cord. The terms ALS and MND are often used inter-changeably to cover the different clinical syndromes, which include upper and lower motor neuron disorder, progressive bulbar palsy, and pseudo-polyneuritic form.
Degeneration of lower motor neurons (LMN) in the anterior horns of spinal cord and brainstem leads to progressive muscular atrophy and eventually to death within a few years due to respiratory insufficiency. During the course of the disease, the involvement of tongue and pharynx muscles causes swallowing impairment with marked drooling, need of parenteral or enteral feeding, and finally gastrostomy. Denervation of laryngeal muscles causes loss of speech. Cramps and fasciculation typically occur from the early phases of the disease. Degeneration of upper motor neurons (UMN) in the brain cortex causes pyramidal tract dysfunctions including clonus, Babinski sign, hypertonia, and loss of dexterity that further limit patients' daily activities.
The incidence of ALS varies from 0.2 to 2.5 cases per 100,000 per year, although estimates vary between countries, likely reflecting a combination of availability of medical services, diagnostic accuracy, and demo-graphic characteristics of the area. Increasing life expectancy and improvements in standards of treatment and care will also result in an increased incidence of ALS. Globally, the overall rate is approximately 2 per 100,000. Its prevalence is approximately of 7 per 100,000. In Italy, the reported incidence of ALS is 2.2 cases/100,000/year.
There is currently no cure for ALS. Despite initial positive results in preclinical and early clinical studies, large-scale clinical trials with all agents except riluzole failed to demonstrate a clinically meaningful therapeutic effect in patients with ALS. Riluzole at the dose of 100 mg/day showed a significant difference on survival (6.4%; gain of 3 months) and slowed deterioration in muscle strength.
Primary involvement of apoptotic mechanisms has important implications in selecting drug candidates for therapy in ALS. Recent preclinical studies have demonstrated that TUCA is endowed with antioxidant, antiapoptotic and neuroprotective activities. In particular, TUDCA can cross the blood-brain-barrier and has been shown to exert a significant therapeutic effect in a model of HD mice.
Tauroursodeoxycholic acid (TUDCA) is a hydrophilic bile acid that is normally produced endogenously in humans at very low levels. TUDCA is synthesized in the liver by conjugation of taurine to ursodeoxycholic acid (UDCA), which is commonly used as a bile acid replacement therapy for the treatment of certain cholestatic syndromes.
The main pharmacological activity of TUDCA consists in its ability in increasing the cholesterol solubilising activity of bile, thus transforming "lithogenic" bile in "non-lithogenic" or "litholytic" bile.
TUDCA inhibits mitochondrial-associated apoptosis via many pathways: 1) it inhibits the mitochondrial permeability transition (MPT) and cytochrome C release, 2) it inhibits mitochondrial membrane depolarization, and 3) it antagonizes Bax translocation from the mitochondria and caspase activation in hepatocytes and brain. TUDCA may also ease oxidative stress.Study relevant TUDCA pharmacology consists in its antioxidant, antiapoptotic and neuroprotective activities evidenced in preclinical studies.
Recent reports have shown that hydrophilic bile acids, such as UDCA and TUDCA, can prevent hepatic cytotoxicity through several mechanisms. For example, TUDCA prevents the production of reactive oxygen species and thus acts as an antioxidant. Additionally, TUDCA mitigates mitochondrial insufficiency and toxicity, and prevents apoptosis, in part, by inhibiting Bax translocation from cytosol to the mitochondria. In hepatocytes, this inhibition results in reduced mitochondrial membrane perturbation, release of cytochrome c, and activation of downstream caspases. TUDCA reduced cytotoxicity in neurons through similar mechanisms, as well as mitochondrial pathways that are independent of the permeability transition. TUDCA prevented striatal degeneration and ameliorated locomotor and cognitive deficits in the in vivo 3-nitropropionic acid (3-NP) rat model of HD. Intracellular inclusions were significantly reduced, and the TUDCA-treated mice showed improved locomotor and sensorimotor abilities.
In addition, the antiapoptotic and cytoprotective effects of TUDCA have been tested in models of acute stroke. The possibility that TUDCA exerts an antiapoptotic action by ameliorating mitochondrial function raises the issue whether other neurological disorders, including Friedreich's ataxia, amyotrophic lateral sclerosis, Parkinson's disease, and Alzheimer's disease, can benefit by the administration of TUDCA. This drug is a candidate neuroprotective agent for a variety of chronic neurodegenerative conditions.
Study design
- Primary purpose
- Treatment
- Allocation
- Randomised
- Intervention model
- Single group
- Masking
- Quadruple blind (participant, care provider, investigator, outcomes assessor)
- Number of arms
- 2
| Arm | Type | Receives |
|---|---|---|
| TUDCA | Experimental | Drug: tauroursodeoxycholic acid (TUDCA)tauroursodeoxycholic acid di-hydrate |
| placebo | Placebo comparator | Drug: Placeboexcipient lactose |
Who may qualify
- Ages
- 18 to 75 years
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
Key inclusion criteria (8 listed)
- Caucasian male or female out-patients;
- aged 18 to 75 years inclusive;
- diagnosis of "probable" or "definite" amyotrophic lateral sclerosis according to the El Escorial revised criteria (1);
- first symptoms of ALS by no more than 1.5 years;
- in treatment with steady regimen of riluzole for a minimum of 3 months before study entry, and desiring its continuation;
Key exclusion criteria (10 listed)
- subjects who underwent tracheostomy;
- subjects who underwent resection of gall bladder;
- subjects with signs of conduction blocks of motor nerves, sensory nerves or both on nerve conduction study;
- subjects with clinical signs of dementia;
- subjects with active peptic ulcer;
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| tauroursodeoxycholic acid (TUDCA)Also: Ursodiol, Actigall, GenericOral route at the dose of 1 g b.i.d. (2 g daily) for 1 year | Drug | TUDCA |
| PlaceboAlso: Oral route at the dose of 1 g b.i.d. (2 g daily) for 1 yearidentical placebo by oral route at the same dosing schedule | Drug | placebo |
Primary outcome
The Proportion of Responder Patients in the Two Treatment Groups According the Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS)-R Slope.
Time frame: 1 year
Responder patients were defined as those subjects showing an improvement of at least 15% in the ALSFRS-R slope during the treatment period as compared to the lead-in period.
7 secondary outcomes
Forced Vital Capacity (FVC) %
Time frame: 1 year
SF-36 Quality of Life Rating Scale
Time frame: 1 year
Time to Tracheostomy From Starting of Study Medication Dosing (if Appropriate)
Time frame: 1 year
Survival Time From Starting of Study Medication Dosing (if Appropriate)
Time frame: 1 year
ALSFRS-R at Study End
Time frame: 1 year
Incidence and Severity of Adverse Events, and Their Relationship to Treatment
Time frame: 1 year
Medical Research Council Scores for Right and Left Muscle Groups
Time frame: 1 year
Results and safety
Loading the posted results from ClinicalTrials.gov…
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 26 Nov 2014.
- Posted resultsParticipant flow, baseline, all outcome measures and adverse events.
- Background: PubMed 11464847Brooks BR, Miller RG, Swash M, Munsat TL; World Federation of Neurology Research Group on Motor Neuron Diseases. El Escorial revisited: revised criteria for the diagnosis of amyotrophic lateral sclerosis. Amyotroph Lateral Scler Other Motor Neuron Disord. 2000 Dec;1(5):293-9. doi: 10.1080/146608200300079536. No abstract available.
- Background: PubMed 10540002Cedarbaum JM, Stambler N, Malta E, Fuller C, Hilt D, Thurmond B, Nakanishi A. The ALSFRS-R: a revised ALS functional rating scale that incorporates assessments of respiratory function. BDNF ALS Study Group (Phase III). J Neurol Sci. 1999 Oct 31;169(1-2):13-21. doi: 10.1016/s0022-510x(99)00210-5.
- Background: PubMed 15204010Leigh PN, Swash M, Iwasaki Y, Ludolph A, Meininger V, Miller RG, Mitsumoto H, Shaw P, Tashiro K, Van Den Berg L. Amyotrophic lateral sclerosis: a consensus viewpoint on designing and implementing a clinical trial. Amyotroph Lateral Scler Other Motor Neuron Disord. 2004 Jun;5(2):84-98. doi: 10.1080/14660820410020187.
- Background: PubMed 12149470Keene CD, Rodrigues CM, Eich T, Chhabra MS, Steer CJ, Low WC. Tauroursodeoxycholic acid, a bile acid, is neuroprotective in a transgenic animal model of Huntington's disease. Proc Natl Acad Sci U S A. 2002 Aug 6;99(16):10671-6. doi: 10.1073/pnas.162362299. Epub 2002 Jul 29.
- Background: PubMed 10691996Benz C, Angermuller S, Otto G, Sauer P, Stremmel W, Stiehl A. Effect of tauroursodeoxycholic acid on bile acid-induced apoptosis in primary human hepatocytes. Eur J Clin Invest. 2000 Mar;30(3):203-9. doi: 10.1046/j.1365-2362.2000.00615.x.
- Background: PubMed 15185297Schoemaker MH, Conde de la Rosa L, Buist-Homan M, Vrenken TE, Havinga R, Poelstra K, Haisma HJ, Jansen PL, Moshage H. Tauroursodeoxycholic acid protects rat hepatocytes from bile acid-induced apoptosis via activation of survival pathways. Hepatology. 2004 Jun;39(6):1563-73. doi: 10.1002/hep.20246.
- Background: PubMed 17559149Miller SD, Greene CM, McLean C, Lawless MW, Taggart CC, O'Neill SJ, McElvaney NG. Tauroursodeoxycholic acid inhibits apoptosis induced by Z alpha-1 antitrypsin via inhibition of Bad. Hepatology. 2007 Aug;46(2):496-503. doi: 10.1002/hep.21689.
- Background: PubMed 12627974Rodrigues CM, Sola S, Sharpe JC, Moura JJ, Steer CJ. Tauroursodeoxycholic acid prevents Bax-induced membrane perturbation and cytochrome C release in isolated mitochondria. Biochemistry. 2003 Mar 18;42(10):3070-80. doi: 10.1021/bi026979d.
- Background: PubMed 15255934Ramalho RM, Ribeiro PS, Sola S, Castro RE, Steer CJ, Rodrigues CM. Inhibition of the E2F-1/p53/Bax pathway by tauroursodeoxycholic acid in amyloid beta-peptide-induced apoptosis of PC12 cells. J Neurochem. 2004 Aug;90(3):567-75. doi: 10.1111/j.1471-4159.2004.02517.x.
- Background: PubMed 12721362Rodrigues CM, Sola S, Nan Z, Castro RE, Ribeiro PS, Low WC, Steer CJ. Tauroursodeoxycholic acid reduces apoptosis and protects against neurological injury after acute hemorrhagic stroke in rats. Proc Natl Acad Sci U S A. 2003 May 13;100(10):6087-92. doi: 10.1073/pnas.1031632100. Epub 2003 Apr 29.
- Background: PubMed 16923170Ramalho RM, Borralho PM, Castro RE, Sola S, Steer CJ, Rodrigues CM. Tauroursodeoxycholic acid modulates p53-mediated apoptosis in Alzheimer's disease mutant neuroblastoma cells. J Neurochem. 2006 Sep;98(5):1610-8. doi: 10.1111/j.1471-4159.2006.04007.x.
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Alberto Albanese, MD principal investigator
Fondazione IRCCS Istituto neurologico Carlo Besta
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A Phase 2 study testing tauroursodeoxycholic acid (TUDCA) in people with Amyotrophic Lateral Sclerosis, run by Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta at 1 site in Italy.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 8 inclusion and 10 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: finished, as of the sponsor's last update on 26 Nov 2014. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in Italy. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. Some participants in this study may receive a placebo. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
What does this phase mean?
Phase 2 studies give the treatment to a larger group to see whether it has the intended effect and to keep checking safety.
Not every study follows the same path, and some studies (observational studies, device studies) have no phase.
Are results available for this study?
Yes. Results are posted in the registry (first posted 26 Nov 2014). A summary is in the For doctors view, and the full results are on ClinicalTrials.gov.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
The Proportion of Responder Patients in the Two Treatment Groups According the Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS)-R Slope. (time frame: 1 year). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT00877604, which also lists 42 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 26 Nov 2014.