New Treatment Strategies and Epigenetic Biomarker for Management of BPH
- Conditions
- BPH (Benign Prostatic Hyperplasia)
- Interventions
- Registration Number
- NCT06944145
- Lead Sponsor
- Beth Israel Deaconess Medical Center
- Brief Summary
SRD5A2 is a critical enzyme for prostatic development and growth, and the SRD5A2 inhibitor, finasteride, is used to treat benign prostatic hyperplasia (BPH). SRD5A2 is absent in 30% of normal adult men, which explains the resistance of a subset of patients to this commonly prescribed drug. This project proposes new combination therapies (5-ARI+raloxifene) and evaluates novel non-invasive biomarkers, based on alternative pathways that lead to prostatic enlargement.
- Detailed Description
Over 90% of adult males develop lower urinary tract symptoms (LUTS) secondary to bladder outlet obstruction by age 80 secondary to benign prostatic hyperplasia (BPH). BPH, the most common proliferative abnormality in humans, negatively impact the quality of life of 210 million men globally, accounting for significant life years lost. This study proposes to clinically evaluate the mechanisms of resistance to 5α-reductase inhibitor, finasteride, one of the more common drugs used to manage BPH and associated LUTS. Ongoing work has focused on steroid 5α-reductase 2 (SRD5A2, aka: 5α-reductase 2 \[5AR2\]), the enzyme responsible for prostatic development and growth. Investigations have revealed that expression of SRD5A2 is variable, and in fact, 30% of men do not express SRD5A2 in prostate tissues. Previous work, shows that somatic suppression of SRD5A2 during adulthood is dependent on epigenetic changes associated with methylation of the promoter region of the SRD5A2 gene. Studies indicate that (1) methylation of the SRDA2 is regulated by direct binding of the DNA-methyl transferase 1 (DNMT1) protein to the SRD5A2 promoter; (2) the inflammatory mediators TNF-α, NF-kB, and IL-6 regulate DNMT1 binding and subsequent methylation of the SRD5A2 promoter region; (3) clinical conditions associated with increased inflammation, age, and obesity, are associated with decreased expression of SRD5A via epigenetic modification; (4) in the absence of prostatic SRD5A2, alternate estrogenic pathways are upregulated, leading to an androgenic-to-estrogenic switch in the prostate gland, thus creating alternate pathways for prostatic growth. Therefore, it is hypothesized that (1) non- invasive assessment of SRD5A2 methylation status in peripheral blood can be an excellent indicator for resistance to 5ARI therapy, and (2) in men demonstrating hypermethylation of SRD5A2 and low protein expression (patients suspected of being resistant to 5ARI therapy), combination therapy (Selective Estrogen Receptor Modulators \[SERMs\]+5ARI) will serve as a better treatment strategy. To demonstrate the clinical significance of epigenetic changes to SRD5A2 and confirm its role in regulating sensitivity to 5ARI treatment, and to examine the role of estrogenic signaling blockade, a clinical trial is proposed with: Specific Aim 1: To assess the role of combination therapy (5ARI + SERM) in the treatment of BPH and to determine whether methylation of SRD5A2 promoter is a predictor for response to therapy. Specific Aim 2: To prospectively evaluate whether non-invasive radiologic prostate inflammatory markers can predict circulating WBCs SRD5A2 promoter methylation.
Recruitment & Eligibility
- Status
- NOT_YET_RECRUITING
- Sex
- Male
- Target Recruitment
- 242
Not provided
Not provided
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Finasteride Monotherapy Finasteride Participants may be randomized into the Finasteride Monotherapy arm. Finasteride + Raloxifene Combination Therapy raloxifene Participants may be randomized into the Finasteride + Raloxifene Combination Therapy arm. Finasteride + Raloxifene Combination Therapy Finasteride Participants may be randomized into the Finasteride + Raloxifene Combination Therapy arm.
- Primary Outcome Measures
Name Time Method Lower urinary tract changes by Uroflow studies Uroflow studies will be completed at baseline and at 6 month intervals during clinic visits. Uroflow studies will be used to assess efficacy of finasteride in the patient population. Based on previous randomized trials, it will be determined whether the patient is responsive or resistant to treatment at 12 months. For patients who are resistant to Finasteride, other medical or surgical treatments will be offered to the patients, and the patients will be removed from the study.
Lower urinary tract changes by the international prostate symptom score (IPSS) Assessment of urinary symptoms will be completed at baseline and at 6 month intervals during clinic visits. Validated questions, IPSS, will be used to assess efficacy of finasteride in our patient population. Based on previous randomized trials, it will be determined whether the patient is responsive or resistant to treatment at 12 months. For patients who are resistant to Finasteride, other medical or surgical treatments will be offered to the patients, and the patients will be removed from the study.
Quantifying the methylation status of circulating WBC SRD5A2 promoter Assessment will be done at baseline and at 1 year follow up during a clinic visit. The methylation status of the Circulating WBC SRD5A2 promoter region will be quantified.
Correlating the methylation status of circulating WBC SRD5A2 promoter methylation status Assessment will be done at baseline and at 1 year follow up during a clinic visit. The methylation status of the Circulating WBC SRD5A2 promoter region will be correlated with resistance to finasteride therapy and effectiveness of combination therapy (finasteride+raloxifene).
- Secondary Outcome Measures
Name Time Method Quantifying ferumoxytol uptake on MRI Assessment will be done at baseline. Ferumoxytol uptake will be quantified on MRI scans (which is a surrogate for tissue inflammation) at baseline.
Correlating ferumoxytol uptake on MRI with methylation status of Circulating WBC SRD5A2 promoter Assessment will be done at baseline. Ferumoxytol uptake on MRI scans (which is a surrogate for tissue inflammation) will be correlated with the methylation status of Circulating WBC SRD5A2 promoter region with a goal to devise a predictive model for finasteride therapy response.