Efficacy and Safety of Reparixin in Pancreatic Islet Auto-transplantation

Phase 2

Completed

Conditions: Pancreatectomy for Chronic Pancreatitis

Interventions: Drug: Placebo
Drug: Reparixin

Registration Number: NCT01967888

Lead Sponsor: Dompé Farmaceutici S.p.A

Brief Summary: The study is a phase 2/3, multicenter, double-blind, parallel assignment study. It involves 100 adult recipients of an intra-hepatic pancreatic Islet Auto-Transplantation (IAT).

The objective of this clinical trial is to assess whether reparixin leads to improved transplant outcome as measured by the proportion of insulin-independent patients following IAT. The safety of reparixin in the specific clinical setting will be also evaluated.

Detailed Description: In contrast to allo-transplantation in type 1 diabetes patients, where immunological mechanisms involving allo- and auto-antibodies affect long-term graft function, outcome in IAT (Islet Auto-Transplantation) is independent from immunological processes and does not require immunosuppression management. On the other hand, early inflammatory events intrinsic to the intra-portal islet infusion have been demonstrated to impact islet engraftment. Among possible mechanisms, PMNs have been found to be the predominant cell types infiltrating the liver in a syngeneic model of islet transplantation in mice.

Data obtained in experimental models of islet transplantation in mice demonstrate a clear effect of reparixin in improving graft survival and function. Protection from the loss and/or deterioration of transplanted islets was evident regardless of the immunological mechanisms involved in islet damage, suggesting that the ability of reparixin to modulate early inflammatory responses readily impact graft outcome.

Thus, the use of reparixin may emerge as a potential useful medication in the control of non specific inflammatory events surrounding the early phases of IAT.

The goal of this study is to reach a total of 100 adult patients who are randomized and receive IAT after total or completion pancreatectomy. Patients will be randomly (1:1) assigned to receive either reparixin \[continuous i.v. infusion for 7 days (168hrs)\], or matched placebo (control group),starting approximately 12hrs before islet infusion. The two groups will be balanced within each centre. All patients who are randomized and receive the Investigational Product (either reparixin or placebo) will be included in the ITT analysis. Patients will be in the ITT analysis whether or not they receive IAT, because exclusions cannot be made for events occurring after randomization that could be influenced by the randomized assignment.

Recruitment will be competitive among the study sites, until the planned number of patients is enrolled. Competitive recruitment has been chosen to increase the speed of recruitment and to account for any difference in transplant rate among study sites. Each centre will enroll patients as rapidly as possible, up to a maximum of 40 patients (as per the randomization list). A maximum of 48 patients is allowed for the site of the Primary Investigator.

Each patient will be involved in the study for 7 day hospital stay during pancreatectomy followed by islet transplantation, for all required measurements up to hospital discharge and for 2 post-transplant visits scheduled @ day 75+14 and 365+14 after the transplant.

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 104

Inclusion Criteria

Patients eligible for an IAT following total (or completion) pancreatectomy.
Ages > 18 years.
Patients willing and able to comply with the protocol procedures for the duration of the study, including scheduled follow-up visits and examinations.
Patients who have given written informed consent, prior to any study-related procedure not part of normal medical care, with the understanding that consent may be withdrawn by the patient at any time without prejudice to their future medical care.

Exclusion Criteria

Recipients of a previous IAT (if completion pancreatectomy).
Patients undergoing total pancreatectomy due to either pancreatic cancer or pancreatic benign diseases other than chronic pancreatitis, including insulinomas, etc.
Patients with inadequate renal reserve as per calculated creatinine clearance (CLcr) < 60 mL/min according to the Cockcroft-Gault formula (1976).
Patients with hepatic dysfunction as defined by increased ALT/AST > 3 x upper limit of normal (ULN) or increased total bilirubin above the upper limit at local laboratory). Patients with Gilbert's syndrome (elevated unconjugated bilirubin levels in the absence of any evidence of hepatic or biliary tract disease) are not excluded.
Patients with a preoperative International Normalized Ratio (INR) > 1.5 or any known coagulopathy.
Hypersensitivity to:
1. ibuprofen or to more than one non steroidal anti-inflammatory drug (NSAID).
2. medications belonging to the class of sulfonamides, such as sulfamethazine, sulfamethoxazole, sulfasalazine, nimesulide or celecoxib.
Concurrent sepsis (as per positive blood culture(s) and/or fever associated with other signs of systemic sepsis syndrome).
Treatment with systemic steroids in the 2 weeks prior to enrolment (except for the use of <5mg prednisone daily or equivalent dose of hydrocortisone, for physiological replacement only) or with any immune modulators in the 4 weeks prior to enrolment.
Patients with pre-existing diabetes or evidence of impaired β-cells function, based on pre-operative fasting blood glucose >115 mg/dL and/or a HbA1c > 6.5%, or requiring treatment with any anti-diabetic medication (e.g. insulin, metformin, etc) within the 2 weeks prior to enrolment.
Use of any investigational agent in the 4 weeks prior to enrolment, including any anti-cytokine/chemokine agents.
Pregnant or breast-feeding women; unwillingness to use effective contraceptive measures (females and males). (NB: pregnancy should be avoided in patients or partners during the first month after completing the treatment with the Investigational Product; no other specific warnings are described, considering the treatment course of the Investigational Product, its PK profile, and the lack of significant adverse effects on mating performance and fertility in animal studies).
Patients with past or current history of alcohol abuse based on clinical history and/or past treatment for alcohol addiction.
Patients with evidence of pre-operative portal hypertension as per clinical history and abdominal/liver imaging by ultrasound techniques.

Sites will comply with any additional or more restrictive exclusion criteria locally accepted, as per centre practice.

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Placebo	Placebo	Physiologic solution
Reparixin	Reparixin	Solution for intravenous (IV) infusion with active compound

Primary Outcome Measures

Name	Time	Method
Percentage of Patients Who Were Insulin Independent After Islet Autotransplantation (IAT) at Day 365±14 Days After Transplant.	day 365±14 after the transplant	Insulin-independence is defined as freedom from the need to take exogenous insulin for 14 or more consecutive days, with adequate glycemic control, as defined by: * a glycated hemoglobin (HbA1c) level \<6.5%; * fingerstick fasting blood glucose not exceeding 126 mg/dL more than three times in the past week (based on a minimum of one daily measurement; * a 2 hour post-prandial blood glucose not exceeding 180 mg/dL more than four times in the past week (based on a minimum of one daily measurement); * a laboratory fasting glucose in the non-diabetic range (\<126 mg/dL).

Secondary Outcome Measures

Name	Time	Method
Area Under the Curve (AUC) for the Serum C-peptide Level at Day 75±14 After the Transplant	day 75±14 after the transplant	AUC for the serum C-peptide level is calculated during the first 4 hours of an MMTT, normalized by the number of Islet Equivalent (IEQ)/kg
Area Under the Curve (AUC) for the Serum C-peptide Level at Day 365±14 After the Transplant	day 365±14 after the transplant	AUC for the serum C-peptide level is calculated during the first 4 hours of a mixed meal tolerance test (MMTT), normalized by the number of Islet Equivalent (IEQ)/kg
Average Daily Insulin Requirements at Day 75±14 After the Transplant	day 75±14 after the transplant	Daily insulin is reported as IU/kg and intake averaged over the previous week.
Average Daily Insulin Requirements at Day 365±14 After the Transplant	day 365±14 after the transplant	Daily insulin is reported as IU/kg and intake averaged over the previous week.
β-cell Function at Day 365±14 After the Transplant	day 365±14 after the transplant	This variable is assessed by β-score (assessment of β-cell function after islet transplantation). The total score is calculated on a 0-8 scoring system (higher is a better outcome) that gives 0-2 points each for glucose, HbA1c, stimulated C-peptide and insulin requirement subscales. The higher the total score the better the outcome. * Fasting (or before breakfast) plasma glucose (mg/dL) : ≤99, Score 2; 100-124, Score 1; ≥ 125, Score 0 (the higher the subscore the better the outcome) * HbA1c (%): ≤6.1, Score 2; 6.2-6.9, Score 1; ≥ 7.0, Score 0 (the higher the subscore the better the outcome) * Daily average (previous week) insulin (IU/kg/day): ---, Score 2; 0.01-0.24, Score 1; ≥ 0.25, Score 0 (the higher the subscore the better the outcome) * Stimulated C-peptide (ng/mL): ≥ 0.9, Score 2; 0.3-0.89, Score 1; ≤0.3, Score 0 (the higher the subscore the better the outcome)
Cumulative Number of Severe Hypoglycemic Events From Day 75±14 to Day 365±14 After the Transplant	from day 75±14 to day 365±14 after the transplant	A severe hypoglycemic event is defined as an event with one of the following symptoms: "memory loss, confusion, uncontrollable behavior, irrational behavior, unusual difficulty in awakening, suspected seizure, seizure, loss of consciousness, or visual symptoms", in which the subject was unable to treat him/herself and which was associated with either a blood glucose level \<54mg/dL or prompt recovery after oral carbohydrate, i.v. glucose, or glucagon administration.
Proportion of Patients by Steatorrhea Severity at Day 75±14 After the Transplant	day 75±14 after the transplant	Levels of steatorrhea severity (evaluated in the 4 weeks prior to day 75±14 and 365±14), are defined as: * No steatorrhea; * Steatorrhea few times per week; * Steatorrhea daily; * Stool incontinence.
Peak C-peptide at Day 75 After the Transplant	Day 75±14 after the transplant	Peak C-peptide (C-P) is a known predictor of Type 1 Diabetes.
Peak C-peptide at Day 365 After the Transplant	Day 365±14 after the transplant	Peak C-peptide (C-P) is a known predictor of Type 1 Diabetes.
Proportion of Patients by Steatorrhea Severity at Day 365±14 After the Transplant	day 365±14 after the transplant	Levels of steatorrhea severity (evaluated in the 4 weeks prior to day 75±14 and 365±14), are defined as: * No steatorrhea; * Steatorrhea few times per week; * Steatorrhea daily; * Stool incontinence.
Time Course From Basal to 240 Min of Insulin Derived From the Mixed Meal Tolerance Test (MMTT) at Day 75±14 After the Transplant	day 75±14 after the transplant	Data are reported as "model estimates over all timepoints". This parameter was assessed at the following timepoints on the following numbers of patients for Reparixin and placebo, respectively: * basal; N=43; 48 (Basal is: 2 basal samples taken separately between -20 to 0 minutes before the meal followed by samples through 240 minutes after the meal). * 15 min; N=43; 47 * 30 min; N=41; 47 * 60 min; N=41; 47 * 90 min; N=41; 47 * 120 min; N=42; 47 * 180 min; N=41; 47 * 240 min; N=40; 44
Time Course From Basal to 240 Min of Insulin Derived From the Mixed Meal Tolerance Test (MMTT) at Day 365±14 After the Transplant	day 365±14 after the transplant	Data are reported as "model estimates over all timepoints". This parameter was assessed at the following timepoints on the following numbers of patients for Reparixin and placebo, respectively: * basal; N=34; 41 (Basal is: 2 basal samples taken separately between -20 to 0 minutes before the meal followed by samples through 240 minutes after the meal) * 15 min; N=34; 41 * 30 min; N=34; 41 * 60 min; N=34; 41 * 90 min; N=34; 41 * 120 min; N=34; 41 * 180 min; N=33; 41 * 240 min; N=33; 40
Proportion of Patients Falling Into One of the Following Malnutrition Risk Levels (Poor Prognosis, Significant Risk, Increased Risk, Normal) According to Pre-albumin Level at Day 365±14 After the Transplant	day 365±14 after the transplant	Malnutrition risk levels are defined as: * Poor prognosis = pre-albumin level \<5.0 mg/dL * Significant risk = pre-albumin level 5.0 to 10.9 mg/dL * Increased risk = pre-albumin level 11.0 to 15.0 mg/dL * Normal = pre-albumin level \> 15.0 (up to 35.0) mg/dL
Cumulative Number of Episodes of Documented Asymptomatic Hypoglycemia From Day 75±14 to Day 365±14 After the Transplant	from day 75±14 to day 365±14 after the transplant	The following definition applies: - Asymptomatic hypoglycemia = An event not accompanied by typical symptoms of hypoglycemia but with a measured plasma glucose concentration \<70mg/dL.
Cumulative Number of Diabetic Ketoacidosis-related Events	from day 75±14 to day 365±14 after the transplant	A diabetic ketoacidosis event is defined as the presence of: * hyperglycemia (blood glucose \>200 mg/dL); * pH \<7.3 or HCO3 \<15; * ketones positive in the serum or urine.
Time Course From Basal to 240 Min of Glucose Derived From the Mixed Meal Tolerance Test (MMTT) at Day 75±14 After the Transplant	day 75±14 after the transplant	Data of this outcome are reported as "model estimates over all timepoints". This parameter was assessed at the following timepoints on the following numbers of patients for Reparixin and placebo, respectively: * basal; N=43; 48 (Basal is: 2 basal samples taken separately between -20 to 0 minutes before the meal followed by samples through 240 minutes after the meal). * 15 min; N=42; 46 * 30 min; N=40; 46 * 60 min; N=40; 46 * 90 min; N=40; 46 * 120 min; N=41; 46 * 180 min; N=40; 46 * 240 min; N=39; 44
Time Course From Basal to 240 Min of Glucose Derived From the Mixed Meal Tolerance Test (MMTT) at Day 365±14 After the Transplant	day 365±14 after the transplant	Data are reported as "model estimates over all timepoints" This parameters was assessed at the following timepoints on the following numbers of patients for Reparixin and placebo, respectively: * basal; N=34; 42 (Basal is: 2 basal samples taken separately between -20 to 0 minutes before the meal followed by samples through 240 minutes after the meal). * 15 min; N=34; 41 * 30 min; N=34; 41 * 60 min; N=34; 41 * 90 min; N=34; 41 * 120 min; N=34; 41 * 180 min; N=33; 41 * 240 min; N=33; 41
Time Course From Basal to 240 Min of C-peptide Derived From the Mixed Meal Tolerance Test (MMTT) at Day 75±14 After the Transplant	day 75±14 after the transplant	Data are reported as "model estimates over all timepoints". This parameters was assessed at the following timepoints on the following numbers of patients for Reparixin and placebo, respectively: * basal; N=44; 48 (Basal is: 2 basal samples taken separately between -20 to 0 minutes before the meal followed by samples through 240 minutes after the meal). * 15 min; N=43; 47 * 30 min; N=41; 47 * 60 min; N=42; 47 * 90 min; N=42; 47 * 120 min; N=42; 47 * 180 min; N=41; 47 * 240 min; N=40; 44
Time Course From Basal to 240 Min of C-peptide Derived From the Mixed Meal Tolerance Test (MMTT) at Day 365±14 After the Transplant	day 365±14 after the transplant	Data are reported as "model estimates over all timepoints". This parameters was assessed at the following timepoints on the following numbers of patients for Reparixin and placebo, respectively: * basal; N=33; 41 (Basal is: 2 basal samples taken separately between -20 to 0 minutes before the meal followed by samples through 240 minutes after the meal). * 15 min; N=34; 41 * 30 min; N=34; 41 * 60 min; N=33; 41 * 90 min; N=34; 41 * 120 min; N=34; 41 * 180 min; N=33; 40 * 240 min; N=33; 41
β-cell Function at Day 75±14 After the Transplant	day 75±14 after the transplant	This variable is assessed by β-score (assessment of β-cell function after islet transplantation). The total score is calculated on a 0-8 scoring system (higher is a better outcome) that gives 0-2 points each for: * fasting plasma glucose, * HbA1c, * stimulated C-peptide * insulin requirement subscales. The higher the total score, the better the outcome. * Fasting (or before breakfast) plasma glucose (mg/dL) : ≤99, Score 2; 100-124, Score 1; ≥ 125, Score 0 (the higher the subscore the better the outcome) * HbA1c (%): ≤6.1, Score 2; 6.2-6.9, Score 1; ≥ 7.0, Score 0 (the higher the subscore the better the outcome) * Daily average (previous week) insulin (IU/kg/day): ---, Score 2; 0.01-0.24, Score 1; ≥ 0.25, Score 0 (the higher the subscore the better the outcome) * Stimulated C-peptide (ng/mL): ≥ 0.9, Score 2; 0.3-0.89, Score 1; ≤0.3, Score 0 (the higher the subscore the better the outcome)
Proportion of Patients With an HbA1c <6.5% at Day 365±14 After the Transplant	day 365±14 after the transplant	Percentage of patients with a glycated haemoglobin (HbA1c) \<6.5% at day 365±14 after the transplant.
Proportion of Patients With an HbA1c <6.5% at Day 365±14 After the Transplant AND Free of Severe Hypoglycemic Events From Day 75±14 to Day 365±14 After the Transplant Inclusive	from day 75±14 to day 365±14 after the transplant	Percentage of patients with an HbA1c \<6.5% at day 365±14 after the transplant AND free of severe hypoglycemic events from day 75±14 to day 365±14 after the transplant inclusive.A severe hypoglycemic event is defined as an event with one of the following symptoms: "memory loss, confusion, uncontrollable behavior, irrational behavior, unusual difficulty in awakening, suspected seizure, seizure, loss of consciousness, or visual symptoms", in which the subject was unable to treat him/herself and which was associated with either a blood glucose level \<54mg/dL or prompt recovery after oral carbohydrate, i.v. glucose, or glucagon administration.
Incidence and Severity of Adverse Events and Serious Adverse Events Throughout the Study	up to day 365±14 after the transplant	The percentages of patients with any treatment emergent adverse events (TEAE, serious and non serious) and with serious TEAE by severity are presented. Patients with multiple events within a particular system organ class or preferred term were counted only under the category of their most severe event within that system organ class or preferred term. A serious AE was defined as any untoward medical occurrence that at any dose: * Resulted in death * Was life-threatening (ie, the patient was at risk of death at the time of the event) * Required inpatient hospitalization or prolongation of existing hospitalization * Resulted in persistent or significant disability/incapacity * Was a congenital anomaly/birth defect * Was an important medical event that, based upon appropriate medical judgment, may have jeopardized the patient and may have required medical or surgical intervention to prevent one of the outcomes listed above
Cumulative Number of Episodes of Documented Symptomatic Hypoglycemia From Day 75±14 to Day 365±14 After the Transplant	from day 75±14 to day 365±14 after the transplant	The following definition applies: - Documented symptomatic hypoglycemia = An event during which typical symptoms of hypoglycemia are accompanied by a measured plasma glucose concentration \<70mg/dL.
Proportion of Patients Falling Into One of the Following Malnutrition Risk Levels (Poor Prognosis, Significant Risk, Increased Risk, Normal) According to Pre-albumin Level at Day 75±14 After the Transplant	day 75±14 after the transplant	Malnutrition risk levels are defined as: * Poor prognosis = pre-albumin level \<5.0 mg/dL * Significant risk = pre-albumin level 5.0 to 10.9 mg/dL * Increased risk = pre-albumin level 11.0 to 15.0 mg/dL * Normal = pre-albumin level \> 15.0 (up to 35.0) mg/dL
Time-to-peak C-peptide at Day 75 After the Transplant	day 75±14 and day 365±14 after the transplant	The time-to-peak value in minutes was computed as the time of the peak value (HH:MM on a 24-hour clock) minus the end time of the mixed meal (HH:MM on a 24-hour clock) as recorded on the mixed meal tolerance test Case Report Form.
Time-to-peak C-peptide at Day 365 After the Transplant	Day 365±14 after the transplant	The time to peak value in minutes will be computed as the time of the peak value (HH:MM on a 24-hour clock) minus the end time of the mixed meal (HH:MM on a 24-hour clock) as recorded on the mixed meal tolerance test CRF.
Change From Baseline in Post-transplant Alanine Aminotransferase (ALT)	Baseline, Days 2, 3, 7, 75 ±14 after the transplant	Data are reported as "model estimates over all timepoints". This safety parameter was assessed at the following timepoints on the following numbers of patients for Reparixin and placebo, respectively: * baseline; N=50; 52 * Day 2 post-transplant; N=49; 51 * Day 3 post-transplant; N=47; 50 * Day 7 post-transplant; N=47; 50 * Day 75 post-transplant; N=44; 47
Change From Baseline in Post-transplant Aspartate Aminotransferase (AST)	Baseline, Days 2, 3, 7, 75±14 after the transplant	Data are reported as "model estimates over all timepoints". This safety parameter was assessed at the following timepoints on the following numbers of patients for Reparixin and placebo, respectively: * baseline; N=50; 52 * Day 2 post-transplant; N=49; 51 * Day 3 post-transplant; N=47; 50 * Day 7 post-transplant; N=47; 50 * Day 75 post-transplant; N=44; 47
Number of Treatment Emergent Adverse Events Related to Investigational Product	Throughout the study From Day -1 to hospital discharge	Treatment emergent adverse events - possibly, probably and highly probably - related to investigational product are called "Adverse reactions" (ADR). An adverse reaction is defined as any untoward medical occurrence in a patient or clinical investigation patient, which has a causal relationship with the administered medicinal product.
Number of Serious Treatment Emergent Adverse Events Related to Investigational Product	Throughout the study From Day -1 to hospital discharge for all adverse events, and from then to day 365 post-transplantation only for serious adverse events	Serious Treatment emergent adverse events - possibly, probably and highly probably - related to investigational product are called serious "Adverse reactions". A serious adverse reaction is defined as any untoward medical occurrence with a causal relationship with the administered medicinal product, that at any dose: * Resulted in death * Was life-threatening (ie, the patient was at risk of death at the time of the event; it does not refer to an event that hypothetically might have caused death if it were more severe.) * Required patient hospitalization or prolongation of existing hospitalization * Resulted in persistent or significant disability/incapacity * Was an important medical event that, based upon appropriate medical judgment, may have jeopardized the patient and may have required medical or surgical intervention to prevent one of the outcomes listed above

Trial Locations

Locations (9): Thomas E. Starzl Transplantation Institute University of Pittsburgh Medical Center
🇺🇸
Pittsburgh, Pennsylvania, United States
Baylor University Medical Center
🇺🇸
Dallas, Texas, United States
University of California. Department of Surgery, Division of Transplantation
🇺🇸
San Francisco, California, United States
The University of Chicago Medical Center
🇺🇸
Chicago, Illinois, United States
Schulze Diabetes Institute University of Minnesota Medical School
🇺🇸
Minneapolis, Minnesota, United States
Dartmouth-Hitchcock Medical Center
🇺🇸
Lebanon, New Hampshire, United States
The University of Cincinnati Medical Center
🇺🇸
Cincinnati, Ohio, United States
Medical University of South Carolina
🇺🇸
Charleston, South Carolina, United States
University of Alberta, Clinical Islet Transplant Program
🇨🇦
Edmonton, Alberta, Canada