Glioblastoma MultiformePhase 1KGDinGBMNCT01865162
Ketogenic Diet as Adjunctive Treatment in Refractory/End-stage Glioblastoma Multiforme: a Pilot Study
A Phase 1 study testing ketogenic diet in people with Glioblastoma Multiforme, run by Mid-Atlantic Epilepsy and Sleep Center, LLC at 1 site in United States.
Trial summary
The first weekly KD meal package will be given to the patient at the study site. The patient will be instructed in how to process the week-long meal plan package content. Participants will measure urine ketone bodies with Ketostix 2x day and blood for glucose and ketone levels using self-administered Precision Xtra®… Read more about this study
- Who is it for?
- Ages 18 to 65 years
- Conditions the study is for
- Glioblastoma Multiforme
- What is being tested?
- ketogenic diet
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 6 participants
- Where
- 1 siteUnited States
- Study dates
- Jan 2013to Jan 2021
- Phase
- Phase 1
- Are there results?
- None posted in the registry
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 65 years
- All sexes
- No healthy volunteers
- Adult, Older adult
Who may be able to join
- Age 18-65
- Ability and willingness to signed informed consent form.
- Astrocytoma grade 4 (glioblastoma multiforme, GBM, histologically confirmed, WHO criteria)
- Documented recurrence or progression after surgical resection/debulking, radiation and temozolamide chemotherapy.
- Measurable contrast-enhancing progressive or recurrent GBM by MRI imaging ≤ two weeks before screening.
- (a) ≥ 3months after completion of radiation; (b) 6 weeks from a nitrosourea chemotherapy; (c) ≥ weeks from a non-nitrosourea chemotherapy (all [a-c] in order to allow recovery from the potential of severe toxicity related to these treatments)
- Karnovsky Performance Score of 70 or more.
Who cannot join
- Acute intracranial or intratumoral hemorrhage > Grade 1 either by MRI or CT scan ≤2 weeks of screening. (Subjects with resolving hemorrhage changes, punctate hemorrhage, or hemosiderin may enter the study)
- Prior treatment with any of the following: (a) small-molecule kinase inhibitor; (b) non-cytotoxic hormonal agent; (c) KD ≤6 months of enrollment
- Planned continued use of glucocorticoids
- Anticoagulation treatment with ≥ 1 mg/day coumadin ≤ 7 days prior to screening (low-dose [≤ 1 mg/day] coumadin, heparin, and low-molecular-weight heparin are permitted
- Any systemic illness or unstable medical condition that might pose additional risk, including: cardiac, unstable metabolic or endocrine disturbances, renal or liver disease, past history of renal calculi, hyperuricemia, hypercalcemia, mitochondrial disease, known disorder of fatty acid metabolism, porphyria, carnitine deficiency and pancreatitis
- History of non-glioma malignancy other than:
Show all 15Show fewer
- Surgically excised non-melanoma skin cancer or in situ carcinoma of the cervix.
- A malignancy diagnosed ≥2 years ago if the subject has had no evidence of disease for 2 years prior to screening.
- History of uncontrolled hyperlipidemia.
- Active drug or alcohol dependence or any other factors that, in the opinion of the site investigators would interfere with adherence to study requirements
- History of human immunodeficiency virus, or hepatitis C
- Failure to recover from <CTCAE grade 2 toxicities related to prior therapy
- Pregnancy or breastfeeding
- Use of any investigational drug within 1 months of enrollment
- Inability or unwillingness of subject to give written informed consent
Trial locations and contacts
1 site in 1 country.
United States1 site
MidAtlantic Epilepsy and Sleep Center
Bethesda, Maryland, 20817
About this study
The first weekly KD meal package will be given to the patient at the study site. The patient will be instructed in how to process the week-long meal plan package content. Participants will measure urine ketone bodies with Ketostix 2x day and blood for glucose and ketone levels using self-administered Precision Xtra® Meter (Abbot Diabetes Care, Alameda, CA, USA) starting with the first day of the diet. Self-administered blood checks for glucose and ketone bodies will be done in fasted state in the morning and 2 hours post-prandially in the evening. Participants will be seen on day 7 of treatment by the study nutritionist and a study investigator-physician (separately) to review possible AEs, and for further education about the diet. Study staff will review and evaluate the participant's method of urine ketone and blood glucose and ketone levels testing. Subsequently, participants will be seen at one, 2 weeks, and 4 weeks after KG diet initiation, and then monthly. KD treatment will last until exit criteria are met or for 6 months, whichever comes first. Exit criteria are the primary outcome measures, the first of either (a) cerebral edema requiring steroid rescue therapy or (b) death.
Treatment will occur in outpatient office setting at the Mid-Atlantic Epilepsy and Sleep Center, Bethesda, MD. The location of subsequent treatment administration may change to hospital setting at Holy Cross Hospital should a patient need hospitalization during the study for any reason, as determined by the patient's clinical care needs.
Read the detailed description
Malignant gliomas are the most common type of brain tumor in adults. They are the second leading cause of cancer mortality in people under the age of 35 and the fourth leading cause in those under the age of 54. Standard therapy for glioblastoma multiforme (GBM) includes surgery followed by radiation and chemotherapy. Despite optimal treatment the prognosis remains poor. Patients with GBM have a median survival of approximately 10-15 months. Essentially all patients suffer recurrent disease, usually within 8 months of diagnosis. For patients with malignant glioma whose tumors recur, the median time to tumor progression is 9-13 weeks with the current standard of treatment for recurrent glioblastoma, bevacizumab (AVASTIN®). There is an urgent need for more effective therapies.
GBM cancer cells depend on glucose for energy supply and survival. When glucose levels are reduced, normal brain cells metabolize ketone bodies for energy. Brain tumor cells cannot do so. This makes the tumor cells vulnerable to death using therapies that target glucose metabolism. In brain cancer patients, high blood glucose levels are associated with reduced survival. In mice, reduction in circulating glucose levels through ketogenic diet (KD) reduces tumor growth
Ketogenic diet (KD) reduces blood glucose levels while elevating levels of ketone bodies, and may thus be beneficial in the treatment of GBM as a non-toxic metabolic therapy. KD is a high fat, low carbohydrate diet used for treatment of refractory seizures. There have been two case reports of KD use in patients with GBM showing slowing of tumor progression.
Ketogenic diet (KD) is a high fat, low protein, low carbohydrate diet that is an effective treatment of refractory epilepsy in children. The diet consists of long chain saturated triglycerides with a 3:1 or 4:1 [fat] : [protein + carbohydrate] ratio by weight, with 87-90% of calories derived from fat. The investigators have recently evaluated KD with caloric restriction of 1600 kcal /day in adults with refractory epilepsy. The diet was well tolerated. Side effects included mild nausea (n=2), mild diarrhea (n= 2), and mild constipation (n=2). No subjects stopped treatment because of side effects. Mild transient hunger was experienced by 3 subjects but there was no clinically significant hunger.
The goal of the present study is to evaluate efficacy, safety and tolerability of 4:1 KD in a small number of patients with GBM progressing or recurring after standard treatment of surgery, radiation and chemotherapy with temozolamide and, after further rescue threrapy with bevacizumab (AVASTIN®), as the first step in evaluation of therapeutic potential of KD in the treatment of GBM. This will be a small, open label pilot study. 6 patients with GBM recurring or progressing after surgery, radiation and chemotherapy (temazolamide) and after further rescue treatment with bevacizumab will be treated with 4:1 [fat]:[protein+carbohydrate] ratio, 1600 kcal/day diet. Survival, time to steroid rescue treatment and progression free survival will be compared to historical controls with life expectancy of ≤ 3 months.
The diet (KD) will consist of pre-made meals, including breakfast, lunch, dinner and two snacks, one each between breakfast and lunch and lunch and dinner, with a 2 week-long meal plan consisting of different recipes for each day of the month, with repeating 2-week-long cycles. The diet will be supplemented with vitamins, calcium and phosphorus supplements to meet the requirements of US Dietary Reference Intakes (DRI) standard. Treatment will last 6 months. Primary aims of the study will be to (1) obtain pilot data on efficacy of ketogenic diet as adjunctive treatment of treatment-refractory glioblastoma multiforme, (2) evaluate the safety of ketogenic diet as adjunctive treatment of treatment-refractory glioblastoma multiforme, and (3) evaluate tolerability of ketogenic diet as adjunctive treatment of treatment-refractory glioblastoma multiforme.
Participants will be evaluated in face-to face visit during weeks 1, 2 and 4 of the study, then monthly. Primary outcome measures will include (a) survival time and (b) time to dexamethasone rescue therapy for cerebral edema, determined by treating physician, and (c) adverse events. Secondary outcome measures will include MRI progression, treatment compliance, hunger scale scores, fasting serum glucose and BOH levels.
- Conditions
- Glioblastoma Multiforme
- Being tested
- ketogenic diet
- Keywords
- Glioblastoma multiforme, ketogenic diet, neoplasm
- Medical subject headings
- Glioblastoma, Neoplasms
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
ketogenic dietOther
Treatment will consist of ketogenic diet. KD will consist of 4:1 [fat] : [protein+carbohydrate] weight ratio with 1600 kcal restriction. The diet will be supplemented with vitamins, calcium, phosphorus, zinc and selenium supplements to meet the requirements of US Dietary Reference Intakes (DRI) standard.
| Study group | Role | What they receive |
|---|---|---|
| ketogenic diet | Experimental | Treatment will consist of ketogenic diet. KD will consist of 4:1 [fat] : [protein+carbohydrate] weight ratio with 1600 kcal restriction. The diet will be supplemented with vitamins, calcium, phosphorus, zinc and selenium supplements to meet the requirements of US Dietary Reference Intakes (DRI) standard. Receives: Other: ketogenic diet |
What is being measured
The primary outcome is the main question the study is designed to answer.
To evaluate the safety of ketogenic diet as adjunctive treatment of treatment-refractory glioblastoma multiforme.
Early treatment discontinuation, treatment compliance, 7-point Licker hunger scale, fasting lipid levels and fasting serum glucose and insulin levels
Measured: one year
Secondary outcomes (2)
To obtain pilot data on efficacy of ketogenic diet as adjunctive treatment of treatment-refractory glioblastoma multiforme
The secondary outcome measures will be (i) survival time and (ii) time to cerebral edema requiring steroid rescue treatment
Measured: one year
To evaluate tolerability of ketogenic diet as adjunctive treatment of treatment-refractory glioblastoma multiforme.
the incidence of treatment-emergent AEs during treatment.
Measured: one year
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted30 May 2013 (estimated)
- Study startJan 2013
- Primary completionJan 2021
- Study completionJan 2021
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (1)Papers the sponsor has linked to this study.
- Other trials for Glioblastoma MultiformeStudies of the same condition, open and under way.
- 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 1
- Primary purpose
- Treatment
- Allocation
- Not applicable
- Intervention model
- Single group
- Masking
- None (open label)
- Enrolment
- 6 participants (estimated)
Sponsor and investigators
- Lead sponsor
- Mid-Atlantic Epilepsy and Sleep Center, LLC
- Sponsor type
- University, hospital or other
- Collaborators
- University of Pittsburgh Medical Center
- Responsible party
- Sponsor
- Investigators
- Pavel Klein, M.D., Principal investigator, Director Mid-Atlantic Epilepsy and Sleep Center
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT01865162
- Sponsor's protocol ID
- maes 002
- Acronym
- KGDinGBM
- Status last verified
- Nov 2022
- First submitted
- 24 May 2013
- Last updated
- 9 Nov 2022
- Results posted
- No
- Data monitoring committee
- No
- Individual data sharing
- Undecided
Publications
Klein P, Tyrlikova I, Zuccoli G, Tyrlik A, Maroon JC. Treatment of glioblastoma multiforme with "classic" 4:1 ketogenic diet total meal replacement. Cancer Metab. 2020 Nov 9;8(1):24. doi: 10.1186/s40170-020-00230-9.
PubMed 33292598
Study at a glance
From the registry record, last updated by the sponsor on 9 Nov 2022. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Ketogenic Diet as Adjunctive Treatment in Refractory/End-stage Glioblastoma Multiforme: a Pilot Study
- ClinicalTrials.gov ID
- NCT01865162
- Acronym / sponsor ID
- KGDinGBM / maes 002
- Conditions
- Glioblastoma Multiforme
- Keywords
- Glioblastoma multiforme, ketogenic diet, neoplasm
- Phase
- Phase 1
- Study type
- Interventional
- Recruitment status
- Completed
- Enrolment
- 6 participants (estimated)
- Lead sponsor
- Mid-Atlantic Epilepsy and Sleep Center, LLCUniversity, hospital or other
- Collaborators
- University of Pittsburgh Medical Center
- Study start
- Jan 2013
- Primary completion
- Jan 2021 (actual)
- Study completion
- Jan 2021 (actual)
- First posted
- 30 May 2013 (estimated)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
The first weekly KD meal package will be given to the patient at the study site. The patient will be instructed in how to process the week-long meal plan package content. Participants will measure urine ketone bodies with Ketostix 2x day and blood for glucose and ketone levels using self-administered Precision Xtra® Meter (Abbot Diabetes Care, Alameda, CA, USA) starting with the first day of the diet. Self-administered blood checks for glucose and ketone bodies will be done in fasted state in the morning and 2 hours post-prandially in the evening. Participants will be seen on day 7 of treatment by the study nutritionist and a study investigator-physician (separately) to review possible AEs, and for further education about the diet. Study staff will review and evaluate the participant's method of urine ketone and blood glucose and ketone levels testing. Subsequently, participants will be seen at one, 2 weeks, and 4 weeks after KG diet initiation, and then monthly. KD treatment will last until exit criteria are met or for 6 months, whichever comes first. Exit criteria are the primary outcome measures, the first of either (a) cerebral edema requiring steroid rescue therapy or (b) death.
Treatment will occur in outpatient office setting at the Mid-Atlantic Epilepsy and Sleep Center, Bethesda, MD. The location of subsequent treatment administration may change to hospital setting at Holy Cross Hospital should a patient need hospitalization during the study for any reason, as determined by the patient's clinical care needs.
Detailed description
Malignant gliomas are the most common type of brain tumor in adults. They are the second leading cause of cancer mortality in people under the age of 35 and the fourth leading cause in those under the age of 54. Standard therapy for glioblastoma multiforme (GBM) includes surgery followed by radiation and chemotherapy. Despite optimal treatment the prognosis remains poor. Patients with GBM have a median survival of approximately 10-15 months. Essentially all patients suffer recurrent disease, usually within 8 months of diagnosis. For patients with malignant glioma whose tumors recur, the median time to tumor progression is 9-13 weeks with the current standard of treatment for recurrent glioblastoma, bevacizumab (AVASTIN®). There is an urgent need for more effective therapies.
GBM cancer cells depend on glucose for energy supply and survival. When glucose levels are reduced, normal brain cells metabolize ketone bodies for energy. Brain tumor cells cannot do so. This makes the tumor cells vulnerable to death using therapies that target glucose metabolism. In brain cancer patients, high blood glucose levels are associated with reduced survival. In mice, reduction in circulating glucose levels through ketogenic diet (KD) reduces tumor growth
Ketogenic diet (KD) reduces blood glucose levels while elevating levels of ketone bodies, and may thus be beneficial in the treatment of GBM as a non-toxic metabolic therapy. KD is a high fat, low carbohydrate diet used for treatment of refractory seizures. There have been two case reports of KD use in patients with GBM showing slowing of tumor progression.
Ketogenic diet (KD) is a high fat, low protein, low carbohydrate diet that is an effective treatment of refractory epilepsy in children. The diet consists of long chain saturated triglycerides with a 3:1 or 4:1 [fat] : [protein + carbohydrate] ratio by weight, with 87-90% of calories derived from fat. The investigators have recently evaluated KD with caloric restriction of 1600 kcal /day in adults with refractory epilepsy. The diet was well tolerated. Side effects included mild nausea (n=2), mild diarrhea (n= 2), and mild constipation (n=2). No subjects stopped treatment because of side effects. Mild transient hunger was experienced by 3 subjects but there was no clinically significant hunger.
The goal of the present study is to evaluate efficacy, safety and tolerability of 4:1 KD in a small number of patients with GBM progressing or recurring after standard treatment of surgery, radiation and chemotherapy with temozolamide and, after further rescue threrapy with bevacizumab (AVASTIN®), as the first step in evaluation of therapeutic potential of KD in the treatment of GBM. This will be a small, open label pilot study. 6 patients with GBM recurring or progressing after surgery, radiation and chemotherapy (temazolamide) and after further rescue treatment with bevacizumab will be treated with 4:1 [fat]:[protein+carbohydrate] ratio, 1600 kcal/day diet. Survival, time to steroid rescue treatment and progression free survival will be compared to historical controls with life expectancy of ≤ 3 months.
The diet (KD) will consist of pre-made meals, including breakfast, lunch, dinner and two snacks, one each between breakfast and lunch and lunch and dinner, with a 2 week-long meal plan consisting of different recipes for each day of the month, with repeating 2-week-long cycles. The diet will be supplemented with vitamins, calcium and phosphorus supplements to meet the requirements of US Dietary Reference Intakes (DRI) standard. Treatment will last 6 months. Primary aims of the study will be to (1) obtain pilot data on efficacy of ketogenic diet as adjunctive treatment of treatment-refractory glioblastoma multiforme, (2) evaluate the safety of ketogenic diet as adjunctive treatment of treatment-refractory glioblastoma multiforme, and (3) evaluate tolerability of ketogenic diet as adjunctive treatment of treatment-refractory glioblastoma multiforme.
Participants will be evaluated in face-to face visit during weeks 1, 2 and 4 of the study, then monthly. Primary outcome measures will include (a) survival time and (b) time to dexamethasone rescue therapy for cerebral edema, determined by treating physician, and (c) adverse events. Secondary outcome measures will include MRI progression, treatment compliance, hunger scale scores, fasting serum glucose and BOH levels.
Study design
- Primary purpose
- Treatment
- Allocation
- Not applicable
- Intervention model
- Single group
- Masking
- None (open label)
- Number of arms
- 1
| Arm | Type | Receives |
|---|---|---|
| ketogenic diet | Experimental | Other: ketogenic dietTreatment will consist of ketogenic diet. KD will consist of 4:1 [fat] : [protein+carbohydrate] weight ratio with 1600 kcal restriction. The diet will be supplemented with vitamins, calcium, phosphorus, zinc and selenium supplements to meet the requirements of US Dietary Reference Intakes (DRI) standard. |
Who may qualify
- Ages
- 18 to 65 years
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
Key inclusion criteria (7 listed)
- Age 18-65
- Ability and willingness to signed informed consent form.
- Astrocytoma grade 4 (glioblastoma multiforme, GBM, histologically confirmed, WHO criteria)
- Documented recurrence or progression after surgical resection/debulking, radiation and temozolamide chemotherapy.
- Measurable contrast-enhancing progressive or recurrent GBM by MRI imaging ≤ two weeks before screening.
Key exclusion criteria (15 listed)
- Acute intracranial or intratumoral hemorrhage > Grade 1 either by MRI or CT scan ≤2 weeks of screening. (Subjects with resolving hemorrhage changes, punctate hemorrhage, or hemosiderin may enter the study)
- Prior treatment with any of the following: (a) small-molecule kinase inhibitor; (b) non-cytotoxic hormonal agent; (c) KD ≤6 months of enrollment
- Planned continued use of glucocorticoids
- Anticoagulation treatment with ≥ 1 mg/day coumadin ≤ 7 days prior to screening (low-dose [≤ 1 mg/day] coumadin, heparin, and low-molecular-weight heparin are permitted
- Any systemic illness or unstable medical condition that might pose additional risk, including: cardiac, unstable metabolic or endocrine disturbances, renal or liver disease, past history of renal calculi, hyperuricemia, hypercalcemia, mitochondrial disease, known disorder of fatty acid metabolism, porphyria, carnitine deficiency and pancreatitis
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 |
|---|---|---|
| ketogenic dietTreatment will consist of ketogenic diet. KD will consist of 4:1 [fat] : [protein+carbohydrate] weight ratio with 1600 kcal restriction. The diet will be supplemented with vitamins, calcium, phosphorus, zinc and selenium supplements to meet the requirements of US Dietary Reference Intakes (DRI) standard. | Other | ketogenic diet |
Primary outcome
To evaluate the safety of ketogenic diet as adjunctive treatment of treatment-refractory glioblastoma multiforme.
Time frame: one year
Early treatment discontinuation, treatment compliance, 7-point Licker hunger scale, fasting lipid levels and fasting serum glucose and insulin levels
2 secondary outcomes
To obtain pilot data on efficacy of ketogenic diet as adjunctive treatment of treatment-refractory glioblastoma multiforme
Time frame: one year
To evaluate tolerability of ketogenic diet as adjunctive treatment of treatment-refractory glioblastoma multiforme.
Time frame: one year
Results and safety
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 9 Nov 2022.
- Derived from this study: PubMed 33292598Klein P, Tyrlikova I, Zuccoli G, Tyrlik A, Maroon JC. Treatment of glioblastoma multiforme with "classic" 4:1 ketogenic diet total meal replacement. Cancer Metab. 2020 Nov 9;8(1):24. doi: 10.1186/s40170-020-00230-9.
- Individual participant dataSharing planned: Undecided
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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.
Pavel Klein, M.D. principal investigator
Director Mid-Atlantic Epilepsy and Sleep Center
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A Phase 1 study testing ketogenic diet in people with Glioblastoma Multiforme, run by Mid-Atlantic Epilepsy and Sleep Center, LLC at 1 site in United States.
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 7 inclusion and 15 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 9 Nov 2022. 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 United States. 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. 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 1 studies test a treatment in a small group of people for the first time or in a new way, mainly to check safety and find the right dose.
Not every study follows the same path, and some studies (observational studies, device studies) have no phase.
Are results available for this study?
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
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?
To evaluate the safety of ketogenic diet as adjunctive treatment of treatment-refractory glioblastoma multiforme. (time frame: one 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 NCT01865162, which also lists 1 linked publication.
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 9 Nov 2022.