Efficacy and Safety of Ramelteon Sublingual as Adjunctive Therapy for Maintenance Treatment of Bipolar I Disorder

A Randomized, Double-Blind, Placebo-Controlled, Phase 3 Study to Evaluate the Efficacy and Safety of Once a Day, TAK-375SL as an Adjunctive Therapy to Treatment-as-Usual in the Maintenance Treatment of Bipolar I Disorder in Adult Patients

The purpose of this study is to determine the efficacy and safety of ramelteon, once nightly before bedtime (QHS), sublingual (SL), in the maintenance treatment of Bipolar I Disorder in adult patients.

Study Overview

• Status: Terminated
• Conditions: Bipolar Disorder
• Intervention / Treatment: Drug: Placebo; Drug: Ramelteon SL

Detailed Description

TAK-375SL (ramelteon sublingual formulation) is being developed by Takeda Pharmaceutical Company Limited as an adjunctive treatment in the maintenance therapy of bipolar I disorder.

Participants will be seen twice a month for the first two months and then once every month up to the end of the 9-month treatment period. Participants who complete the 9-month treatment period will have a follow-up visit approximately seven days after the last visit. A safety followup phone call will be made 30 days after completion of the 9-month treatment period.

Based on the recommendation of the Independent Data Monitoring Committee which determined that the study data had met pre-determined criteria for futility, Takeda has made a decision to terminate the study. No safety concerns were identified by the Independent Data Monitoring Committee

• Study Type: Interventional
• Enrollment (Actual): 642
• Phase: Phase 3

Contacts and Locations

Study Locations

• Argentina
  • Buenos Aires, Argentina
  • Cordoba, Argentina
  • Mendoza, Argentina
  • Santa Fe, Argentina
• Chile
  • Antofagasta, Chile
  • Arauco, Chile
  • Elqui, Chile
  • Santiago, Chile
• Colombia
  • Antioquia, Colombia
  • Barranquilla, Colombia
  • Bogotá, Colombia
  • Antioquia
    • Bello, Antioquia, Colombia
• Mexico
  • Mexico, Mexico
  • Baja California
    • Mexicali, Baja California, Mexico
  • DF
    • Mexico, DF, Mexico
  • Guanajuato
    • Leon, Guanajuato, Mexico
  • Nuevo Leon
    • Monterrey, Nuevo Leon, Mexico
  • Yucatan
    • Merida, Yucatan, Mexico
• United States
  • Alabama
    • Birmingham, Alabama, United States
    • Dothan, Alabama, United States
    • Muscle Shoals, Alabama, United States
  • Arizona
    • Phoenix, Arizona, United States
  • Arkansas
    • Little Rock, Arkansas, United States
  • California
    • Bellflower, California, United States
    • Costa Mesa, California, United States
    • Garden Grove, California, United States
    • Harbor City, California, United States
    • Huntington Park, California, United States
    • Irvine, California, United States
    • Lomita, California, United States
    • Long Beach, California, United States
    • Los Angeles, California, United States
    • Murrieta, California, United States
    • National City, California, United States
    • Oceanside, California, United States
    • Orange, California, United States
    • Paramount, California, United States
    • Rancho Cucamonga, California, United States
    • Redondo Beach, California, United States
    • Riverside, California, United States
    • Sacramento, California, United States
    • San Diego, California, United States
    • San Jose, California, United States
    • San Ramon, California, United States
    • Sherman Oaks, California, United States
    • Torrance, California, United States
    • Wildomar, California, United States
  • Colorado
    • Colorado Springs, Colorado, United States
    • Denver, Colorado, United States
  • Connecticut
    • Norwalk, Connecticut, United States
  • District of Columbia
    • Washington, District of Columbia, United States
  • Florida
    • Clearwater, Florida, United States
    • Coral Gables, Florida, United States
    • Coral Springs, Florida, United States
    • Edgewater, Florida, United States
    • Hialeah, Florida, United States
    • Jacksonville, Florida, United States
    • Leesburg, Florida, United States
    • Miami, Florida, United States
    • Miami Beach, Florida, United States
    • Miami Lakes, Florida, United States
    • Orange City, Florida, United States
    • Orlando, Florida, United States
    • Pembroke Pines, Florida, United States
    • Plantation, Florida, United States
    • Port Charlotte, Florida, United States
    • Saint Cloud, Florida, United States
    • Tampa, Florida, United States
    • Vero Beach, Florida, United States
  • Georgia
    • Atlanta, Georgia, United States
    • Dunwoody, Georgia, United States
    • East Point, Georgia, United States
    • Smyrna, Georgia, United States
    • Suwanee, Georgia, United States
  • Hawaii
    • Honolulu, Hawaii, United States
  • Illinois
    • Chicago, Illinois, United States
    • Chicago, Illinois, United States, 60610
    • Gurnee, Illinois, United States, 60610
    • Libertyville, Illinois, United States
    • Skokie, Illinois, United States
  • Indiana
    • Brownsburg, Indiana, United States
  • Kansas
    • Manhattan, Kansas, United States
    • Topeka, Kansas, United States
    • Wichita, Kansas, United States
  • Kentucky
    • Elizabethtown, Kentucky, United States
    • Lexington, Kentucky, United States
    • Paducah, Kentucky, United States
  • Louisiana
    • Mandeville, Louisiana, United States
    • Metairie, Louisiana, United States
  • Maryland
    • Baltimore, Maryland, United States
  • Massachusetts
    • Boston, Massachusetts, United States
    • Fall River, Massachusetts, United States
  • Michigan
    • Bloomfield Hills, Michigan, United States
    • Detroit, Michigan, United States
    • Kalamazoo, Michigan, United States
  • Mississippi
    • Flowood, Mississippi, United States
  • Missouri
    • Hazelwood, Missouri, United States
    • St Louis, Missouri, United States
    • St. Charles, Missouri, United States
    • Washington, Missouri, United States
  • Nebraska
    • Lincoln, Nebraska, United States
  • Nevada
    • Las Vegas, Nevada, United States
  • New Jersey
    • Cherry Hill, New Jersey, United States
  • New Mexico
    • Albuquerque, New Mexico, United States
  • New York
    • Brooklyn, New York, United States
    • Cedarhurst, New York, United States
    • Fresh Meadows, New York, United States
    • New York, New York, United States
    • Rochester, New York, United States
    • Staten Island, New York, United States
  • North Carolina
    • Charlotte, North Carolina, United States
    • Columbiana, North Carolina, United States
    • Durham, North Carolina, United States
    • Greensboro, North Carolina, United States
    • Raleigh, North Carolina, United States
    • Salisbury, North Carolina, United States
    • Wilmington, North Carolina, United States
  • North Dakota
    • Fargo, North Dakota, United States
  • Ohio
    • Cincinnati, Ohio, United States
    • Cleveland, Ohio, United States
    • Dayton, Ohio, United States
    • Franklin, Ohio, United States
  • Oklahoma
    • Oklahoma City, Oklahoma, United States
  • Oregon
    • Portland, Oregon, United States
  • Pennsylvania
    • Allentown, Pennsylvania, United States
    • Duncansville, Pennsylvania, United States
    • Harleysville, Pennsylvania, United States
    • McMurray, Pennsylvania, United States
    • Media, Pennsylvania, United States
    • Philadelphia, Pennsylvania, United States
    • Pittsburgh, Pennsylvania, United States
  • Rhode Island
    • Lincoln, Rhode Island, United States
  • South Carolina
    • Columbia, South Carolina, United States
    • Greer, South Carolina, United States
    • Indian Land, South Carolina, United States
  • Tennessee
    • Clarksville, Tennessee, United States
    • Knoxville, Tennessee, United States
    • Memphis, Tennessee, United States
  • Texas
    • Austin, Texas, United States
    • Bellaire, Texas, United States
    • Corpus Christi, Texas, United States
    • Dallas, Texas, United States
    • Irving, Texas, United States
    • Nassau Bay, Texas, United States
    • Plano, Texas, United States
    • San Antonio, Texas, United States
  • Utah
    • Bountiful, Utah, United States
  • Virginia
    • Newport News, Virginia, United States
    • Norfolk, Virginia, United States
    • Richmond, Virginia, United States
    • Virginia Beach, Virginia, United States
  • Washington
    • Kirkland, Washington, United States
    • Richland, Washington, United States
    • Seattle, Washington, United States
  • West Virginia
    • Clarksburg, West Virginia, United States
  • Wisconsin
    • Milwaukee, Wisconsin, United States

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 75 years (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. In the opinion of the investigator, the participant is capable of understanding and complying with protocol requirements.
2. The participant or, when applicable, the participant's legally acceptable representative signs and dates a written, informed consent form and any required privacy authorization prior to the initiation of any study procedures.
3. The participant suffers from bipolar I disorder, according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria and is confirmed by the Structured Clinical Interview for DSM Disorders (SCID).
4. The participant is a man or woman aged between 18 and 75 years, inclusive.
5. The participant has an identified caregiver or person responsible (e.g. family member, spouse, case worker or nurse at a residential living (facility) that is considered reliable by the investigator.
6. The most recent mood episode (depression, mania, mixed episode) is within the past 9 months from screening.
7. The participant has been in remission in the opinion of the principal investigator (PI) for at least 8 weeks prior to baseline from their most recent mood episode.
8. The participant has a Montgomery-Åsberg Depression Rating Scale (MADRS) total score ≤12 at the Screening and Baseline visits.
9. The participant has a Young Mania Rating Scale (YMRS) score of ≤10 both at the Screening and Baseline visits.
10. The participant has a Clinical Global Impression Scale - Severity (CGI-S) score of ≤2 at the Screening and Baseline visits.
11. Hamilton Rating Scale for Anxiety (HAM-A) score is ≤21 at Screening and Baseline visits.
12. The participant's medications for bipolar I disorder are stable i.e., no dose adjustment has been made for at least 8 weeks prior to the randomization
13. A male participant who is nonsterilized and sexually active with a female partner of childbearing potential agrees to use adequate contraception from signing of informed consent through the duration of the study and for 30 days after the last dose.
14. A female participant of childbearing potential who is sexually active with a non sterilized male partner agrees to use routinely adequate contraception from signing of informed consent throughout the duration of the study and for 30 days after the last dose.

Exclusion Criteria:

1. The participant has received any investigational compound <30 days before Screening or 5 half-lives prior to Screening.
2. The participant has ever received ramelteon in a previous clinical study or has ever used ramelteon.
3. The participant is an immediate family member, study site employee, or is in a dependent relationship with a study site employee who is involved in conduct of this study (eg, spouse, parent, child, sibling) or may consent under duress.

4. The participant has one or more of the following:

   • Any current psychiatric disorder which is the primary focus of treatment other than bipolar I disorder as defined in the DSM-IV-TR, as assessed by the SCID.
   • Current or history of: schizophrenia or any other psychotic disorder, including major depression with psychotic features, bipolar depression with psychotic features (with the exception of psychosis associated with a manic or mixed episode), obsessive-compulsive disorder (OCD), mental retardation, organic mental disorders, or mental disorders due to a general medical condition as defined in the DSM-IV-TR.
   • Current diagnosis or history of alcohol or other substance abuse (excluding nicotine or caffeine) as defined in the DSM-IV-TR that has not been in full and sustained remission for at three months from the day of screening (Participant must also have negative urine drug screen at Screening and Baseline; only exception is for benzodiazepines and opiates provided the participant has a valid prescription).
   • Current diagnosis or history of alcohol or other substance dependence (excluding nicotine or caffeine) as defined in the DSM-IV-TR that has not been in full and sustained remission for at six months from the day of screening.(Participant must also have negative urine drug screen at Screening and Baseline; only exception is for benzodiazepines and opiates provided the participant has a valid prescription).
   • Presence or history of a clinically significant neurological disorder (including epilepsy) as determined by the investigator.
   • Neurodegenerative disorder (Alzheimer disease, Parkinson disease, multiple sclerosis, Huntington disease, etc).
   • Any Axis II disorder that might compromise the study.
   • History of Rapid Cycling bipolar disorder: Patients who have more than 8 episodes of mood disorder per year.
5. The participant experienced the first episode of mood disorder after the age of 65 years.
6. The participant is on any other medications other than antidepressants (except fluvoxamine), mood stabilizers (lithium, valproate, lamotrigine), or atypical antipsychotics (risperidone, lithium and/or valproate, the levels should be in the specified range: lithium (serum levels up to 1.2 mEq/L); valproate (serum levels up to 125 mcg/ml) at screening.
7. The participant has received electroconvulsive therapy, vagal nerve stimulation, or repetitive transcranial magnetic stimulation within 6 months prior to Screening.
8. The participant has started receiving formal cognitive or behavioral therapy, systematic psychotherapy within 30 days from screening or plans to initiate such therapy during the study (supportive therapy, marital therapy and bereavement counseling are allowed).
9. The participant has a significant risk of suicide according to the investigator's clinical judgment or has a score ≥5 on item 10 (suicidal thoughts) of the MADRS or has made a suicide attempt in the previous 6 months.
10. The participant is required to take excluded medications or it is anticipated that the participant will require treatment with at least 1 of the disallowed concomitant medications during the study.
11. The participant has a clinically significant unstable illness, for example hepatic impairment or renal insufficiency, or a cardiovascular, pulmonary, gastrointestinal, endocrine, neurological, rheumatologic, immunologic, hematological, infectious, dermatological disorder or metabolic disturbance.
12. The participant has a history or current diagnosis of Fibromyalgia, Chronic Fatigue Syndrome, Chronic Pain Syndrome and Sleep apnea.
13. The participant has a previous history of cancer that had been in remission for less than 5 years prior to the first dose of study medication. This criterion does not include those participants with basal cell or stage I squamous cell carcinoma of the skin.

14. The participant has 1 or more laboratory value outside the normal range, based on the blood or urine samples taken at the Screening Visit, that are considered by the investigator to be clinically significant; or the participant has any of the following values at the Screening Visit:

    • A serum creatinine value >1.5 times the upper limits of normal (xULN).
    • A serum total bilirubin value >1.5 xULN.
    • A serum alanine aminotransferase (ALT) or aspartate aminotransferase (AST) value >2 xULN.
15. The participant has glycosylated hemoglobin (HbA1C) ≥7% at screening and no prior diagnosis of diabetes and/or treatment for diabetes. NOTE: Participants with known diabetes are not excluded.
16. The participant has a thyroid stimulating hormone (TSH) value outside the normal range at the Screening Visit that is deemed clinically significant by the investigator. NOTE: T4 will be checked if TSH is out of range. If T4 is abnormal the participant will be excluded.
17. The participant has clinically significant abnormal vital signs as determined by the investigator.
18. The participant has an abnormal electrocardiogram as determined by the central reader and confirmed as clinically significant by the investigator.
19. The participant has a disease or takes medication that, in the opinion of the investigator, could interfere with the assessments of safety, tolerability, or efficacy.
20. The participant has a positive urine drug screen. NOTE: Positive urine drug screens for benzodiazepines and opiates for which the participant has a valid prescription will be allowed.
21. The participant has a disease or takes medication that, in the opinion of the investigator, could interfere with the assessments of safety, tolerability, or efficacy.
22. The participant has a positive urine drug screen. NOTE: Positive urine drug screens for benzodiazepines and opiates for which the participant has a valid prescription will be allowed.
23. The participant, in the opinion of the investigator, is unlikely to comply with the clinical study protocol or is unsuitable for any reason.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: RANDOMIZED
• Interventional Model: PARALLEL
• Masking: QUADRUPLE

Number of Arms

4

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
PLACEBO_COMPARATOR: Placebo; Ramelteon SL placebo-matching, tablets, sublingual (SL) [dissolved under the tongue], once daily, every night at bedtime for up to 9 months.	Drug: Placebo; Ramelteon sublingual (SL) placebo-matching tablets
EXPERIMENTAL: Ramelteon SL 0.1 mg; Ramelteon SL 0.1 mg, tablets, sublingual, once daily, every night at bedtime for up to 9 months.	Drug: Ramelteon SL; Ramelteon sublingual (SL) tablets; Other Names: TAK-375SL
EXPERIMENTAL: Ramelteon SL 0.4 mg; Ramelteon SL 0.4 mg, tablets, sublingual, once daily, every night at bedtime for up to 9 months.	Drug: Ramelteon SL; Ramelteon sublingual (SL) tablets; Other Names: TAK-375SL
EXPERIMENTAL: Ramelteon SL 0.8 mg; Ramelteon SL 0.8 mg, tablets, sublingual, once daily, every night at bedtime for up to 9 months.	Drug: Ramelteon SL; Ramelteon sublingual (SL) tablets; Other Names: TAK-375SL

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Time From Randomization to Any Relapse	The time from randomization to relapse over 12 months double-blind treatment period as determined by the Principal Investigator (PI) or defined by any of the following criteria: depression [Montgomery-Åsberg Depression Rating Scale (MADRS) score ≥16]; mania/hypomania [Young Mania Rating Scale (YMRS) total score ≥14]; mixed episode [MADRS score ≥16 and YMRS total score ≥16]; or, whether participant receives psychiatric hospitalization for bipolar disorder, electroconvulsive therapy (ECT) or any psychotropic medication change prescribed for the treatment of depression, mania/hypomania or mixed episodes.	Randomization to Month 12 double-blind treatment period

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Time From Randomization to Relapse Due to Depression	Relapse due to depression determined by any of the following criteria during the 12-month double-blind treatment period: PI judgment, MADRS ≥16, psychiatry hospitalization, ECT or any psychotropic medication change prescribed for the treatment of depressive episodes.	Randomization to Month 12 double-blind treatment period
Time From Randomization to Relapse Due to Mania/Hypomania or Mixed Episode	Relapse due to mania/hypomania or mixed episode is determined by any of the following criteria: PI judgment, mania/hypomania [YMRS ≥16], mixed episode [MADRS ≥16 and YMRS ≥16], psychiatry hospitalization, ECT or any psychotropic medication change prescribed for the treatment of mania/hypomania or mixed episodes.	Randomization to Month 12 double-blind treatment period
Time From Randomization to Relapse Due to Depression From PI Judgement and/or MADRS ≥16	The time from randomization to relapse event during the 12 month double-blind treatment period due to depression, determined by the PI judgement and/or a MADRS score ≥16. MADRS is a 10-item clinician rated scale to measure overall severity of depressive symptoms (i.e., apparent sadness, reported sadness, inner tension, etc.) rated on a 7-point Likert scale from 0 (normal) to 6 (most abnormal) with a total score range from 0 to 60. Higher scores indicate greater severity of symptoms.	Randomization to Month 12 double-blind treatment period
Time From Randomization to Relapse Due to Mania/Hypomania	Relapse due to mania/hypomania is determined by the primary investigator (PI) judgement and/or a YMRS total score ≥16. YMRS is a 11 item scale with four items scale to assess manic symptoms, rated on a scale from 0 (symptom not present) to 8 (symptom extremely severe), with 7 items rated on a scale from 0 (symptom not present) to 4 (symptom extremely severe) with higher scores reflecting greater levels of mania. The YMRS total score is calculated as the sum of the 11 individual item scores and ranges from 0-60.	Randomization to 12 Month double-blind treatment period
Time From Randomization to Relapse Due to Mixed Episode	Relapse due to Mixed episode is determined by PI judgement and/or MADRS score ≥16 and YMRS total score ≥16. MADRS is a 10-item scale that measures overall severity of depressive symptoms rated on a 7-point Likert scale from 0 (normal) to 6 (most abnormal) with a total score range from 0 to 60. YMRS is a four item scale to assess manic symptoms, rated on a scale from 0 (symptom not present) to 8 (symptom extremely severe), with 7 items rated on a scale from 0 (symptom not present) to 4 (symptom extremely severe). The YMRS total score is calculated as the sum of the 11 individual item scores and ranges from 0-60.	Randomization to Month 12 double-blind treatment period
Time From Randomization to Relapse Due to Psychiatric Hospitalization for Bipolar Disorder	The time from randomization to relapse event during the 12 months double-blind treatment period due to psychiatric hospitalization for bipolar disorder.	Randomization to Month 12 double-blind treatment period
Time From Randomization to Relapse Due to Electroconvulsive Therapy (ECT) Administration	The time from randomization to relapse event during the 12 month double-blind treatment period due to ECT.	Randomization to Month 12 double-blind treatment period
Time From Randomization to Relapse Due to Psychotropic Medication Change Prescribed for the Treatment of Depression, Mania/Hypomania or Mixed Episodes	The time from randomization to relapse event during the 12 month double-blind treatment period due to any psychotropic medication change prescribed for the treatment of depression, mania/hypomania or mixed episode(s).	Randomization to Month 12 double-blind treatment period
Time From Randomization to Study Withdrawal for Any Reason	The time from randomization to study withdrawal during the 12 month double-blind treatment period. Withdrawal includes pretreatment event/adverse event; liver function test abnormalities; major protocol deviation; lost to follow-up; voluntary withdrawal; study termination; pregnancy; lack of efficacy; participant has a depressive, mania/hypomania or mixed episode; is hospitalized for psychiatric reasons; receives electroconvulsive therapy for bipolar disorder; receives any psychotropic medication change prescribed for the treatment of depression, mania/hypomania or mixed episodes; or any other reason.	Randomization to Month 12 double-blind treatment period
Quality of Life, Enjoyment and Satisfaction Questionnaire Short Form (Q-LES-Q-SF) Total Score	Q-LES-Q-SF is a self-administered 16-item questionnaire to assess the degree of enjoyment and satisfaction experienced by patients in various areas of daily functioning. It includes 30 items across five subscales (daily activities, clothing, diet/food habits, relationship, psychological well-being and distress), scored on a 6-point Likert scale with subscale and total score ranging from 0 (none) to 5 (all the time). For reporting purposes, the scores are reversed and higher scores reflect improved quality of life and positive changes relative to baseline indicate improved quality of life.	Baseline and Months 1, 2, 3, 4, 5, 6, 7, 8, 10 and 12

Collaborators and Investigators

• Sponsor: Takeda

Publications and helpful links

General Publications

• Mahableshwarkar AR, Calabrese JR, Macek TA, Budur K, Adefuye A, Dong X, Hanson E, Sachs GS. Efficacy and safety of sublingual ramelteon as an adjunctive therapy in the maintenance treatment of bipolar I disorder in adults: A phase 3, randomized controlled trial. J Affect Disord. 2017 Oct 15;221:275-282. doi: 10.1016/j.jad.2017.06.044. Epub 2017 Jun 20.

Study record dates

Study Major Dates

• Study Start: December 1, 2011
• Primary Completion (ACTUAL): March 1, 2015
• Study Completion (ACTUAL): March 1, 2015

Study Registration Dates

• First Submitted: November 4, 2011
• First Submitted That Met QC Criteria: November 4, 2011
• First Posted (ESTIMATE): November 9, 2011

Study Record Updates

• Last Update Posted (ESTIMATE): May 16, 2016
• Last Update Submitted That Met QC Criteria: April 8, 2016
• Last Verified: April 1, 2016

More Information

Terms related to this study

• Keywords: Drug Therapy
• Additional Relevant MeSH Terms: Mental Disorders; Bipolar and Related Disorders; Bipolar Disorder
• Other Study ID Numbers: TAK-375SL_203; U1111-1124-4675 (REGISTRY: WHO)