The Effect of Melatonin in Patients With Low Anterior Resection Syndrome

Phase 2

Active, not recruiting

• Conditions: Low Anterior Resection Syndrome
• Interventions: Drug: Melatonin; Drug: Placebo

• Registration Number: NCT05042700
• Lead Sponsor: Ismail Gögenur

Brief Summary

The primary objective of the study is to investigate whether treatment with melatonin has an alleviating effect on Low Anterior Resection Syndrome (LARS) symptoms. Secondarily, the effect of the treatment on bowel movements, other patient reported symptoms, quality of life, depression, anxiety, sleep disturbances, motilin levels, and microscopic changes in rectal mucosa will be investigated.

Detailed Description

This trial which will be conducted in two phases.

The first part of the study will be conducted as an internal feasibility test. Three patients with major LARS will be included. Patients will be recruited from the Department of Surgery, Zealand University Hospital. These patients will not be randomized nor blinded. They will receive a 4-week treatment with 25 mg melatonin and will undergo the same questionnaires and tests before and after treatment as in the randomized clinical trial. The preliminary results from the internal feasibility test will allow us to assess potential difficulties related to the administration or design, which then will be able to be corrected before the randomization part is initiated.

The second part of the will be conducted as a randomized, blinded, placebo-controlled, crossover study and will be testing whether treatment with melatonin has an alleviating effect on Low Anterior Resection Syndrome (LARS) symptoms.

Patients will be randomized to receive 4 weeks of treatment with melatonin, followed by a 4 week wash out period, and then 4 weeks of treatment with placebo (M-P) or 4 weeks of treatment with placebo, followed by a 4 week wash out period, and then 4 weeks of treatment with melatonin (P-M). Both participants and investigators will be blinded.

Patients will be given questionnaires before and after each treatment period to assess outcomes. Blood samples and rectal biopsies will be taken after each treatment period.

Study Timeline

• Study First Submitted: 2021-08-30
• Study First Submitted QC: 2021-09-06
• Study First Posted: 2021-09-13
• Study Start: 2021-10-13
• Status Verified: 2023-04
• Last Update Submitted: 2023-04-24
• Last Update Posted: 2023-04-25
• Primary Completion: 2023-12
• Study Completion: 2023-12

Recruitment & Eligibility

• Status: ACTIVE_NOT_RECRUITING
• Sex: All
• Target Recruitment: 21

Inclusion Criteria

1. Patients should have major LARS (LARS score >29).
2. Patients should have undergone bowel continuity restoring surgery between the last 3 to 24 months.
3. Participants should be 18 years or older.
4. Participants must sign an informed consent form.

Exclusion Criteria

1. Known allergic reaction to melatonin.
2. Dementia as determined by mini mental state examination score (MMSE) < 24.
3. Participation in another pharmacological intervention trial at the point of inclusion.
4. Completed any adjuvant oncological treatment within the last three months.
5. Ongoing oncological treatment.
6. Rotor or Dubin-Johnson syndrome, epilepsy, systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), Parkinson's disease, spinal cord injury and multiple sclerosis.
7. Severe liver disease defined as transaminases above 3 times the normal levels, and severe kidney disease defined as eGFR below 40 ml/min.
8. Daily ongoing hypnotic treatment.
9. Pre-existing medical sleep disorder diagnosed before the diagnosis of rectal cancer (i.e sleep apnea, restless legs, narcolepsy.)
10. Work involving nightshifts.
11. Daily alcohol consumption above 5 units of alcohol (1 unit = 12 g alcohol)
12. Predictable poor compliance (due to pre-existing psychiatric disease, dementia or not able to read or speak sufficient Danish)
13. Pregnant or breastfeeding.
14. Severe, life-threatening medical condition, that implies that the patient cannot participate in the study course. (e.g. metastatic disease, local recurrence, stroke, AMI).
15. Females not in menopause (defined as no menstruation during the last 12 months) should not be pregnant. Furthermore, reproductive females should use a secure birth control (intrauterine devices, hormonal contraceptives including - oral pills, patches, vaginal rings and injections) during the entire period of the trial.

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: CROSSOVER

Arm && Interventions

Group	Intervention	Description
Melatonin-Placebo sequence	Melatonin	50% of the included patients will receive 4 weeks of treatment with melatonin, followed by a 4 week wash out period, and then 4 weeks of treatment with placebo. The treatments are blinded.
Melatonin-Placebo sequence	Placebo	50% of the included patients will receive 4 weeks of treatment with melatonin, followed by a 4 week wash out period, and then 4 weeks of treatment with placebo. The treatments are blinded.
Placebo-Melatonin sequence	Melatonin	50% of the included patients will receive 4 weeks of treatment with placebo, followed by a 4 week wash out period, and then 4 weeks of treatment with melatonin. The treatments are blinded.
Placebo-Melatonin sequence	Placebo	50% of the included patients will receive 4 weeks of treatment with placebo, followed by a 4 week wash out period, and then 4 weeks of treatment with melatonin. The treatments are blinded.

Primary Outcome Measures

Name	Time	Method
Change in Low Anterior Resection Syndrome Score	4 weeks	The LARS Score questionnaire is filled out by the participants before and after each treatment period.

Secondary Outcome Measures

Name	Time	Method
Self-reported quality of life	4 weeks	EORTC Quality of Life Questionnaire for cancer patients and specifically colorectal cancer patients
Other patient reported symptoms	4 weeks	Measure Yourself Medical Outcome Profile (MYMOP) is a self-administered questionnaire. Patients are asked to specify one or two symptoms that concern them the most. Subsequently they evaluate the severity on a 7-point Likert scale. The second part of the questionnaire uses the same scale to assess whether the symptom limits or prevent any daily activity, and also to rate general well-being. Follow-up questionnaires address the original issues completed in the initial form. Symptom 1, symptom 2, activity, and wellbeing each have a separate score between 0 and 6 with 0 indicating "as good as it could be" and 6 "as bad as it could be". An overall score is calculated by taking the average of item scores.
Daily bowel function	4 weeks	The participants will fill out a diary on the daily bowel movements during the treatment phase
Anxiety	4 weeks	Hospital Anxiety and Depression Scale (HADS-A): The anxiety subscale consists of 7 questions which are graded on a 4 point scale (0-1-2-3) and is summed into a total score between 0-21. A score of 7 or lower is negative case, a score of 8 - 10 is a doubtful case, and a score of 11 or above is a positive case.
Multiplex gene assay - NanoString nCounter® Inflammation Panel analysis in blood	4 weeks	Difference in gene expressions between intervention and placebo groups
Depression	4 weeks	Hospital Anxiety and Depression Scale (HADS-D): The depression subscale consists of 7 questions which are graded on a 4 point scale (0-1-2-3) and is summed into a total score between 0-21. A score of 7 or lower is negative case, a score of 8 - 10 is a doubtful case, and a score of 11 or above is a positive case.
Sleep	4 weeks	Participants will wear an actigraph during the treatment phases and fill out a sleep diary and this will allow to asses sleep time (minutes).
Melatonin	4 weeks	Blood samples will be taken after each treatment ends.
Insomnia	4 weeks	Insomnia Severity Index (ISI)
Incidence of treatment-emergent Adverse Effects [Safety and reactions]	4 weeks	Participants will be systematically interviewed before and after the treatment periods.
Motilin	4 weeks	Blood samples will be taken after each treatment ends.
Pathological assessment of inflammation	4 weeks	Rectal biopsies will be taken after each treatment ends.The FFPE treated biopsies will be assessed by pathologist using a routine inflammatory grading system to asses inflammation
Multiplex gene assay - NanoString nCounter® Inflammation Panel analysis in biopsies	4 weeks	Difference in gene expressions between intervention and placebo groups
Motilin receptors	4 weeks	Rectal biopsies will be taken after each treatment ends.

Trial Locations

Locations (1)

Zealand University Hospital; 🇩🇰 Køge, Region Sjælland, Denmark