LiveSMART Trial to Prevent Falls in Patients With Cirrhosis
LiveSMART: A Sequential, Multiple Assignment Randomized Trial to Prevent Falls in Patients With Cirrhosis
This multicenter trial is being conducted to determine if sequential lactulose and Tele (virtual) Tai-Chi reduces the rate of injurious fall, non-injurious falls, incident overt Hepatic Encephalopathy (HE), and death or liver transplant over 24 weeks.
Participants that are enrolled will be randomized to stage one of this project for approximately 12 weeks. After completing stage one, participants will be re-randomized to stage 2 of the project that will last approximately 12 more weeks.
The study hypothesizes that sequential lactulose/TeleTai-Chi will reduce falls, incident overt HE, death and physical frailty and will improve cognitive function, and Health Related Quality of Life (HRQOL) over 24 weeks compared to other treatment combinations.
As detailed below, an observational component that enrolls caregivers of the trial participants is being conducted. Upon completion, Participants listed in the record here only include trial participants; and the observational component was moved to a new registration for clarity, NCT07140120.
Study Overview
Status
Status
Conditions
Conditions
Intervention / Treatment
Intervention / Treatment
Detailed Description
The Clinicaltrials.gov registration record was updated as requested by Patient-Centered Outcomes Research Institute (PCORI) based on protocol amendment version 3.0 after approval by the Institutional Review Board. These changes included: the additional aim for a supplemental observational study to assess social determinants of health, financial burdens, etc., and includes recruitment of the caregivers for this supplemental study along with the trial participants, as well as updated outcomes for the trial. After further discussion with PCORI, these changes were removed from this record and used to create a separate record for the supplemental study focused on caregivers (NCT07140120).
The caregivers that are enrolled are not in the clinical trial. All clinical trial information is provided in this record, but upon completion of enrollment and consideration of transparent results reporting, it was decided to move all the items related to the observational supplemental study to its own record.
To improve clarity in the record, the two arms representing stage 1 of the project were incorporated into the remaining four representing stage 2, so the remaining arms now represent both stage 1 and stage 2.
Study Type
Study Type
Enrollment (Actual)
Enrollment
Phase
Phase
- Phase 3
Contacts and Locations
Study Contact
Study Contact
- Name: Samantha Nikirk
- Phone Number: 734-232-4182
- Email: samjwalk@med.umich.edu
Study Locations
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Michigan
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Ann Arbor, Michigan, United States, 48109
- University of Michigan
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Pennsylvania
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Philadelphia, Pennsylvania, United States, 19104
- University of Pennsylvania
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Texas
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Dallas, Texas, United States, 75246
- Baylor Scott & White Research Institute (BSW)
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-
Participation Criteria
Eligibility Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Description
Inclusion Criteria:
- Clinical diagnosis of cirrhosis based on histology and/or imaging specified in the protocol.
Evidence of portal hypertension - must meet at least one of the following criteria:
- Ascites (present or within past 2 years)
- Varices (seen by Esophagogastroduodenoscopy or by Ultrasound(US) or cross-sectional imaging)
- Fibroscan Liver stiffness measurement (LSM) >25 kilopascals (kPa) (if no other factors present)
- Magnetic resonance elastography (MRE) LSM > 5 kPa (if no other factors present)
- Acoustic radiation force impulse LSM > 17kpa (if no other factors present)
- Hepatic vein pressure gradient > 10 millimetres of mercury (mmHg)
- Portal hypertensive gastropathy seen on Esophagogastroduodenoscopy
- Platelet count < 80/ units per liter (uL)
- Recanalized umbilical vein (by US or cross-sectional imaging)
- Access to Wireless Fidelity (Wi-Fi) at home
- Owns or access to a smartphone, tablet or computer
- English or Spanish speaking
- Willing to participate in exercise program
Exclusion Criteria:
- Overt hepatic encephalopathy (HE) within 6 months, requiring >28 days total of lactulose
- Took lactulose for non - HE reasons for >28 days total in last 6 months
- Took Rifaximin for > 28 days total in last 6 months
- Model for End Stage Liver Disease (MELD) > 25 (Exception: MELD > 25 with clinically stable End-Stage Renal Disease (ESRD) for whom the bilirubin is < 5 g/dL)
- Barcelona Clinic Liver Cancer (BCLC) > C Hepatocellular Carcinoma (HCC)
- Currently taking Sorafenib, Atezolizumab/Bevacizumab, Regorafinib, or Cabozatinib
- Greater than (>) 3 paracentesis/month in last 2 months
- Active Metastatic solid malignancy or acute leukemia within last 3 years
- Severe cognitive, vision, or hearing impairment (without use of corrective lenses or hearing assist devices) or psychiatric illness precluding study participation
- Currently participates in Tai-Chi or performs >150 min/week vigorous physical activity
- Currently receiving lower body physical and/or occupational therapy
- Living in an assisted living facility
- Hemoglobin A1C > 12 (within past 12 months)
- Requires a low galactose diet
- Deemed unsuitable by the study investigator
Inclusion Criteria for the Caregivers of the participants:
- Adult > 18 years of age
- Informal caregiver of a participant enrolled in LIVE-SMART
- English speaking
Exclusion Criteria for the Caregivers of the participants:
- Non-English speaking
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Sequential Assignment
- Masking: None (Open Label)
Number of Arms
Arms and Interventions
Participant Group / ArmParticipant Group / Arm |
Intervention / TreatmentIntervention / Treatment |
|---|---|
|
Active Comparator: Enhanced Usual Care group followed by investigator recommended exercise
Enhanced Usual Care (EUC) at Stage 1 (12 weeks) and then re-randomization to EUC then Investigator-Recommended Exercise at Stage 2
|
Patients will be provided and counseled on two methods which will enhance care.
The first is a handout on nutrition recommendations and protein supplementation.
This will include the recommendation of both high protein snacks during the daytime (e.g., protein bars) and a high-protein night-time snack (e.g., peanut butter and crackers).
The second will be to counsel participants on falls prevention methods that can be enacted in day-to-day life.
All participants will be provided with a standard hand-out of Centers for Disease Control and Prevention (CDC)-endorsed fall-risk reduction measures.
Participants randomized to enhanced usual care will be reminded of standard fall precautions outlined in the Fall Prevention Primer that were provided in Stage 1 and will receive exercise recommendations.
|
|
Experimental: Treatment (Lactulose) plus Enhanced Usual Care then TeleTai-Chi exercise classes
Lactulose plus Enhanced Usual Care (EUC) at Stage 1 (12 weeks) and then re-randomization to Lactulose plus EUC then TeleTai-Chi exercise classes at Stage 2
|
Patients will be provided and counseled on two methods which will enhance care.
The first is a handout on nutrition recommendations and protein supplementation.
This will include the recommendation of both high protein snacks during the daytime (e.g., protein bars) and a high-protein night-time snack (e.g., peanut butter and crackers).
The second will be to counsel participants on falls prevention methods that can be enacted in day-to-day life.
All participants will be provided with a standard hand-out of Centers for Disease Control and Prevention (CDC)-endorsed fall-risk reduction measures.
Patients will be prescribed lactulose and will also receive enhanced usual care. Lactulose will be taken on a specific schedule based on the average number of bowel movements on average per day. It will be started at 15 milliliter (mL) dose and will be instructed to slowly increase the lactulose dose over the course of the first week of Stage 1 participation. The prescribed maximum dose will be 30 mL (20g) twice daily. The dose will slowly increase toward the maximum or until participants reach 2-3 soft bowel movements daily. Participants that receive Lactulose during stage 1 will continue this in stage 2.
TeleTai-Chi will be taught remotely via live Zoom classes of up to 15 patients by a certified TeleTai-Chi instructor three times per week (for approximately 12 weeks).
Classes will be conducted via a HIPAA-compliant Zoom server through the University of Michigan.
Participants will be instructed to use Zoom by smartphone, tablet, or computer.
High-Definition Multimedia Interface (HDMI) cables and other device specific equipment to connect devices to televisions will be provided.
|
|
Experimental: Enhanced Usual Care group followed by Tele-Tai Chi exercise classes
Enhanced Usual Care (EUC) at Stage 1 (12 weeks) and then re-randomization to EUC then Tele-Tai Chi exercise classes at Stage 2
|
Patients will be provided and counseled on two methods which will enhance care.
The first is a handout on nutrition recommendations and protein supplementation.
This will include the recommendation of both high protein snacks during the daytime (e.g., protein bars) and a high-protein night-time snack (e.g., peanut butter and crackers).
The second will be to counsel participants on falls prevention methods that can be enacted in day-to-day life.
All participants will be provided with a standard hand-out of Centers for Disease Control and Prevention (CDC)-endorsed fall-risk reduction measures.
TeleTai-Chi will be taught remotely via live Zoom classes of up to 15 patients by a certified TeleTai-Chi instructor three times per week (for approximately 12 weeks).
Classes will be conducted via a HIPAA-compliant Zoom server through the University of Michigan.
Participants will be instructed to use Zoom by smartphone, tablet, or computer.
High-Definition Multimedia Interface (HDMI) cables and other device specific equipment to connect devices to televisions will be provided.
|
|
Experimental: Treatment (Lactulose) plus Enhanced Usual Care then recommended exercise
Lactulose plus Enhanced Usual Care (EUC) at Stage 1 (12 weeks) and then re-randomization to Lactulose plus EUC then Investigator-Recommended Exercise at Stage 2
|
Patients will be provided and counseled on two methods which will enhance care.
The first is a handout on nutrition recommendations and protein supplementation.
This will include the recommendation of both high protein snacks during the daytime (e.g., protein bars) and a high-protein night-time snack (e.g., peanut butter and crackers).
The second will be to counsel participants on falls prevention methods that can be enacted in day-to-day life.
All participants will be provided with a standard hand-out of Centers for Disease Control and Prevention (CDC)-endorsed fall-risk reduction measures.
Participants randomized to enhanced usual care will be reminded of standard fall precautions outlined in the Fall Prevention Primer that were provided in Stage 1 and will receive exercise recommendations.
Patients will be prescribed lactulose and will also receive enhanced usual care. Lactulose will be taken on a specific schedule based on the average number of bowel movements on average per day. It will be started at 15 milliliter (mL) dose and will be instructed to slowly increase the lactulose dose over the course of the first week of Stage 1 participation. The prescribed maximum dose will be 30 mL (20g) twice daily. The dose will slowly increase toward the maximum or until participants reach 2-3 soft bowel movements daily. Participants that receive Lactulose during stage 1 will continue this in stage 2. |
What is the study measuring?
Primary Outcome Measures
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
|
Number of Participants Experiencing a Hierarchical Composite of Events Over 24 Weeks: Injurious Falls, Non-injurious Falls, Incident Hepatic Encephalopathy, Liver Transplant, and Death/Transplant
Time Frame: Baseline to 24 weeks
|
Composite outcome is defined as any of the following: • Injurious Fall: Fracture, dislocation, cut, head injury, soft - tissue injury requiring medical intervention including: Hospitalization or overnight observation in the Emergency Room (ER); surgery, transfusion, stitches
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Baseline to 24 weeks
|
Secondary Outcome Measures
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
|
Injurious Falls
Time Frame: Baseline to 24 weeks
|
Results reflect the number of participants who experienced at least one injurious fall.
Injurious falls include: Fracture, dislocation, cut, head injury, soft - tissue injury requiring hospitalization.
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Baseline to 24 weeks
|
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Non-Injurious Falls
Time Frame: Baseline to 24 weeks
|
Results reflect the number of participants who experienced at least one non-injurious fall.
Non- injurious falls include: Inadvertently coming to rest on the floor or lower level.
|
Baseline to 24 weeks
|
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Incident Overt Hepatic Encephalopathy (HE)
Time Frame: Baseline to 24 weeks
|
Incident Overt HE includes: Acute disorientation requiring hospitalization or the initiation of HE - directed therapy, confirmed by a gastroenterologist or study investigator.
|
Baseline to 24 weeks
|
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Death/Transplant for Acute-on-Chronic Liver Failure (ACLF)
Time Frame: Baseline to 24 weeks
|
Results reflect participants who died, or who received a liver transplant because of ACLF.
|
Baseline to 24 weeks
|
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Incident of Liver Transplant for Non-ACLF Reason
Time Frame: Baseline to 24 weeks
|
Results reflect the number of participants who received replacement of a diseased liver with the healthy liver from another person for any reason other than ACLF.
|
Baseline to 24 weeks
|
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Days-alive and Out-of-the-hospital
Time Frame: Approximately 26 Weeks
|
Days-alive and out-of-the-hospital is a continuous value, 1 for each day alive, 0 for days in hospital.
Participants were queried and data was also abstracted from the Electronic Medical Record (EMR).
Results reflect the average number of days participants were alive and out of the hospital.
|
Approximately 26 Weeks
|
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Change in Cognitive Function Based on the Animal Naming Test (ANT)
Time Frame: Baseline to 24 weeks
|
The animal naming test assesses cognitive function.
It is a timed test that that consists of participants listing as many unique animals as possible in 60 seconds.
This is a validated test used for the assessment of hepatic encephalopathy.
The score is the number of unique animals named (higher is better).
Results reflect change from baseline.
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Baseline to 24 weeks
|
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Change in Visual Analog Scale (VAS)
Time Frame: Baseline to 24 weeks
|
This was a 1-item global rating of health scored 0-100.
A score of 100 means the best health and 0 means the worst health imagined.
Results reflect change from baseline.
|
Baseline to 24 weeks
|
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Change in The Patient Reported Outcome Measurement Information System (PROMIS)-29+2 v2.1 Profile (PROPr)
Time Frame: Baseline to 24 weeks
|
PROPr is the combined score of the two scales in the PROMIS 29+2, a quality-of-life scale and a pain-rating scale, and is used to calculate a preference score.
The scores from both scales provide an overall summary of health-related quality of life based on multiple domains summarizing a metric ranging from 0 (as bad as dead) to 1 (perfect or ideal health).
Results reflect change from baseline.
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Baseline to 24 weeks
|
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Change in Depression Based on The Patient Reported Outcome Measurement Information System (PROMIS)-29+2 v2.1
Time Frame: Baseline to 24 weeks
|
There were 4 questions that participants completed regarding depression.
The scores were converted to t scores, which were normalized from the raw scores.
The t score ranged from 0-100 with 0 denoting worst depression and 100 indicating no depression.
Results reflect the change from baseline.
|
Baseline to 24 weeks
|
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Change in Sleep Quality Based on the PROMIS-29+2 v2.1
Time Frame: Baseline to 24 weeks
|
There were 4 questions that participants completed regarding sleep quality.
The scores were converted to t scores, which were normalized from the raw scores.
The t score ranged from 0-100 with 0 denoting worst sleep quality and 100 indicating best sleep quality.
Results reflect change from baseline.
|
Baseline to 24 weeks
|
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Physical Frailty Based on the Liver Frailty Index
Time Frame: Baseline to 24 weeks
|
Physical frailty was assessed with this index and was a composite of handgrip, timed chair-stands, and balance.
The index ranged from -1.26 (robust) to 6.9 (frail), 50th percentile is 3.9.
For individuals enrolled remotely, the study team assessed chair-stands.
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Baseline to 24 weeks
|
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Change in Physical Frailty Based on the Activities of Daily Living (ADLs)
Time Frame: Baseline to 24 weeks
|
Activities of daily living (ADLs), is a validated self-reported measure (disability is defined as >1 ADL deficit) recommended by the American Society for Transplantation and AASLD.
The score ranged from 0 to 6 (6 indicating full independence, 4 moderate impairment, and 2 or less severe functional impairment).
Results reflect change from baseline.
|
Baseline to 24 weeks
|
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Intervention Fidelity
Time Frame: 24 weeks
|
Evaluation of intervention fidelity was assessed at 50% and 100% of study completion.
Results reflect participants who maintained fidelity by completing at least one of the following key intervention components: coordinator trainings, lactulose prescriptions ordered, enhanced usual care components delivered, Short Message Service (SMS) assessments sent, study visits completed, or exercise sessions completed.
|
24 weeks
|
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Participant Adherence
Time Frame: 24 weeks
|
Adherence to lactulose, Tai-Chi, and nighttime protein supplementation was monitored.
Results reflect the number of participants who discontinued their assigned intervention.
|
24 weeks
|
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Participant Satisfaction With the Trial and Interventions Based on the Patient Global Impression of Change (PGIC)
Time Frame: 12 weeks and 24 weeks
|
Satisfaction with the trial was assessed using the 6-item Patient Global Impression of Change (PGIC).
Participants selected from 1 (very much improved) to 7 (very much worse).
Lower scores indicated higher satisfaction.
|
12 weeks and 24 weeks
|
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Change in Short Form (SF) - 8
Time Frame: 24 weeks
|
The SF-8 is an abbreviated 8-item version of an original 36-item health survey (SF-36).
It is a generic multipurpose quality of life instrument.
It contains psychometrically based physical and mental health summary measures.
The eight domains include general health, physical functioning, role physical, bodily pain, vitality, social functioning, mental health and role emotional.
The scores were converted to t scores, which were normalized from the raw scores.
The t score ranged from 0-100 with 0 denoting worst quality of life and 100 indicating best quality of life.
Results reflect change from baseline.
|
24 weeks
|
Collaborators and Investigators
Sponsor
Sponsor
Collaborators
Collaborators
Investigators
Investigators
- Principal Investigator: Elliott Tapper, MD, University of Michigan
- Principal Investigator: Marina Serper, MD, MS, University of Pennsylvania
Study record dates
Study Major Dates
Study Start (Actual)
Study Start
Primary Completion (Actual)
Primary Completion
Study Completion (Actual)
Study Completion
Study Registration Dates
First Submitted
First Submitted
First Submitted That Met QC Criteria
First Submitted That Met QC Criteria
First Posted (Actual)
First Posted
Study Record Updates
Last Update Posted (Actual)
Last Update Posted
Last Update Submitted That Met QC Criteria
Last Update Submitted That Met QC Criteria
Last Verified
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
Other Study ID Numbers
- HUM00225275
- CER-2021C3-24907 (Other Identifier: PCORI)
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
IPD Plan Description
IPD Sharing Time Frame
IPD Sharing Access Criteria
IPD Sharing Supporting Information Type
- STUDY_PROTOCOL
- SAP
- ANALYTIC_CODE
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
product manufactured in and exported from the U.S.
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.