Intra-Erythrocyte Dexamethasone Sodium Phosphate in Ataxia Telangiectasia Patients (ATTeST)

Multi-center, Randomized, Double-blind, Placebo-controlled Trial to Evaluate the Effects of Intra-Erythrocyte Dexamethasone Sodium Phosphate on Neurological Symptoms in Patients With Ataxia Telangiectasia

Objectives:

The objective of study was to evaluate the safety and the efficacy of EryDex (Dexamethasone sodium phosphate encapsulated in autologous erythrocytes, using the EryDex System - EDS) at two dose levels (low dose and high dose DSP/infusion), compared to placebo, on Neurological Symptoms in Patients With Ataxia Telangiectasia.

Initial Double-Blind Treatment Period (0 to 6 Months)

Primary Efficacy Objective:

• Evaluate the effect of EryDex at two dose levels (low dose and high dose DSP/infusion), compared to placebo, on central nervous system (CNS) symptoms measured by the change in the Modified International Cooperative Ataxia Rating Scale (mICARS) from baseline to Month 6 (Visit 9) in patients with ataxia telangiectasia (A-T).

Secondary Efficacy Objectives:

• Evaluate the effect of EryDex, compared to placebo, on the Clinical Global Impression of Change (CGI-C) in patients with A-T from baseline to Month 6 (Visit 9).
• Evaluate the effect of EryDex, compared to placebo, on measures of Clinical Global Impression of Severity (CGI-S; structured) in patients with A-T from baseline to Month 6 (Visit 9)
• Evaluate the effect of EryDex, compared to placebo, on measures of Adaptive behavior measures in patients with A-T by the Vineland Adaptive Behavior Scales (VABS) from baseline to Month 6 (Visit 9).

Safety Objectives:

• Evaluate the safety and tolerability of two non-overlapping doses of EryDex, compared to placebo, in patients with A-T over the 12-month double-blind study duration.

Extension Treatment Period (6-12 Months):

Primary Objective:

• Evaluate the efficacy of EryDex at two dose levels (low dose and high dose DSP/infusion) compared to placebo, in treating CNS symptoms in A-T patients during longer-term treatment (up to 12 months), as measured by the mICARS.

Secondary Objectives:

• Evaluate the longer-term (up to 12 months) safety and tolerability of EryDex in A-T patients.
• Compare the effects of EryDex on the CGI-C and CGI-S (structured), VABS, and QoL using the EQ-5D-5L scale.

Study Overview

• Status: Completed
• Conditions: Genetic Syndrome; Nervous System Disease
• Intervention / Treatment: Drug: EryDex Low dose DSP; Drug: EryDex High dose DSP; Drug: Pooled Placebo

Detailed Description

This was an international, multi-center, one-year, randomized, prospective, double-blind, placebo-controlled, phase III study.

This study was divided into three periods: Screening (Days -30 to -1), 6-month Initial Treatment Period (Months 1-6; Visits 1-9), and 6-month Extension Treatment Period (Months 7-12; Visits 10-15).

A total of 175 patients, of the 180 planned, met all selection criteria at baseline, and were randomized in a 1:1:1 fashion to one of the two EDS-EP dose levels or placebo.

These patients were randomly assigned to receive one of the two doses of EDS-EP or placebo, as follows:

• Group 1: EDS-EP dose range of ~5-10 mg DSP/infusion (low dose), 59 pts
• Group 2: EDS-EP dose range of ~14-22 mg DSP/infusion (high dose), 57 pts
• Group 3: Placebo EDS infusion, 59 pts

The initial 6-month treatment period was considered complete when the endpoint assessment (at Visit 9/Month 6 or at early discontinuation) was performed for all patients. All patients who completed the assessments over the initial 6 months of the trial were eligible to continue in an additional 6-month, double-blind, placebo- controlled extension, designed to collect information on the longer-term safety and efficacy of the trial treatments.

Following completion of the 6-month Initial Treatment Period, patients that met all entry criteria were re-randomized and treated as follows:

• Patients originally randomized to one of the two dose levels of EryDex (low dose or high dose; Groups 1 or 2) continued in the same treatment arm.

• Patients originally randomized to the Placebo group (Group 3) were re-allocated as defined at the initial randomization in equal proportions (1:1) and received either the EryDex low dose or high dose as follows:

  • Following 6 months of treatment, one third of the placebo patients were switched to treatment with EryDex, as described above.
  • After 9 months of treatment, another third of the placebo patients were switched to treatment with EryDex, as described above.
  • At 12 months, all remaining placebo patients were eligible to switch to open-label treatment with EryDex, as described above.

• Study Type: Interventional
• Enrollment (Actual): 176
• Phase: Phase 3

Contacts and Locations

Study Locations

• Australia
  • Victoria
    • Melbourne, Victoria, Australia, 3052
      • Royal Children's Hospital
• Belgium
  • Leuven, Belgium, 3000
    • Laboratoriumgeneeskunde
• Germany
  • Hessen
    • Frankfurt, Hessen, Germany, 60590
      • Klinik für Kinder- und Jugendmedizin Pädiatrische Allergologie, Pneumologie und Mukoviszidose, Universitätsklinikum Frankfurt
• India
  • New Delhi, India, 110029
    • All India Institute of Medical Sciences
  • Karnataka
    • Bangalore, Karnataka, India, 560 029
      • National Institute of Mental Health and Neurosciences
  • Kerala
    • Kochi, Kerala, India, 682041
      • Amrita Institute of Medical Sciences and Research Centre
  • Maharashtra
    • Mumbai, Maharashtra, India, 400026
      • Jaslok Hospital and Research Centre
  • Mumbai
    • Mahim, Mumbai, India, 400016
      • PD Hinduja National Hospital and Medical Research
  • Tamil Nadu
    • Chennai, Tamil Nadu, India, 600026
      • Vijaya Health Centre, Department of Neurology
  • Telangana
    • Hyderabad, Telangana, India, 500082
      • Nizam's Institute of Medical Sciences
• Israel
  • Tel HaShomer, Israel, 52621
    • Sheba Medical Center
• Italy
  • Brescia, Italy, 25123
    • U.O. Neurologia e Psichiatria dell'Infanzia e dell' Adolescenza. ASST Spedali Civili, Piazzale Spedali Civili, 1
  • Rome, Italy, 00185
    • Dipartimento di Pediatria e Neuropsichiatria Infantile, Università Sapienza di Roma, Azienda Policlinico Universitario Umberto I
• Norway
  • Oslo, Norway
    • Norwegian National Unit for Newborn Screening, Division of Pediatric and Adolescent Medicine, Oslo University Hospital
• Poland
  • Warsaw, Poland, 04-730
    • Department of Clinical Immunology The Children's Memorial Health Institute
• Spain
  • Madrid, Spain
    • Hospital Universitario La Paz.
• Tunisia
  • Manouba, Tunisia, 2010
    • El Razi Hospital
• United Kingdom
  • Nottinghamshire
    • Nottingham, Nottinghamshire, United Kingdom
      • Nottingham University Hospitals NHS Trust - Queen's Medical Centre
• United States
  • California
    • Los Angeles, California, United States, 900951694
      • UCLA-Ataxia Center and HD Center of Exellence
  • Maryland
    • Baltimore, Maryland, United States, 21287-3923
      • The Ataxia-Telangiectasia Clinical Center, The Johns Hopkins Hospital
  • Ohio
    • Cincinnati, Ohio, United States, 45229-3039
      • Cincinnati Children's Hospital Medical Center
  • Texas
    • Houston, Texas, United States, 77030
      • UT Health

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 2 years and older (Child, Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Patient met clinical criteria for diagnosis of A-T. The neurological signs of A-T (incoordination of the head and eyes in lateral gaze deflection, gait ataxia associated with an inappropriately narrow base) must have been documented. Such signs of A-T illustrated the body systems in which changes were confirmed, but the listed changes were examples and other changes in those systems may have been observed and documented to confirm the diagnosis of A-T.
2. Patient was in autonomous gait or was helped by periodic use of a support (i.e., score for Item 1 of the full ICARS - Walking Capacities between 0 and 4, included).
3. Patient was investigated for the proven genetic diagnosis of A-T (prior documentation or by central laboratory test report).
4. Patient was at least 6 years of age.
5. Body weight was >15 kg.
6. The patient and parent/caregiver (if below the age of consent), or a legal representative, provided written informed consent to participate. If consent was provided solely by the caregiver in accordance with local regulations, the patient must have provided assent to participate in the study.

Exclusion criteria

General

1. Females that were:

   1. Pregnant or breast-feeding (for European Union [EU] countries only).
   2. Of childbearing potential, pregnant, or breast-feeding (for US and Rest of World countries) not using adequate birth control, as determined by their Healthcare Provider.
2. A disability that may have prevented the patient from completing all study requirements.

3. Current participation in another clinical study.

   Medical History and Current Status

4. Cluster differential 4 positive (CD4+) lymphocytes count <400/mm3 (for patients 6 years of age) or <150/mm3 (for patients >6 years). In presence of oral infections, like oral candidiasis, documented at the screening or recurrent as per medical history documentation, the limit increased to <200/mm3 (for patients >6 years).
5. Loss/removal of 250 mL or more of blood within the past 4 weeks prior to screening.
6. Current neoplastic disease or previous neoplastic disease not in remission for at least 2 years.
7. History of severe impairment of the immunological system.
8. Severe or unstable pulmonary disease.
9. Uncontrolled diabetes.
10. Any other severe, unstable, or serious disease or condition that in the Investigator's opinion put the patient at risk for imminent life-threatening morbidity, need for hospitalization, or mortality.
11. Any clinically significant abnormality on standard laboratory examinations (hematology, biochemistry, urinalysis) at screening that remains abnormal on repeat testing. Eligibility of patients with abnormal laboratory test values was determined by the Investigator in consultation with the Medical Monitor.
12. Confirmed hemoglobinopathies, e.g., hemoglobin C disease, sickle cell anemia, or thalassemia.

13. Moderate or severe renal and/or hepatic impairment.

    Prior/Concomitant Medication

14. Any previous oral or parenteral steroid use within 4 weeks before Baseline. Treatment with inhaled or intranasal steroids for asthma or allergies, as well as use of topical steroids will be permitted.
15. Chronic condition or prior allergic reaction representing a contraindication to the use of dexamethasone or other steroid drugs.
16. Has participated in any other trial with an investigational drug and received a dose within 30 days or 10 half-lives (whichever is greater) from the start of the 30-day Screening Period.
17. Has participated in a previous trial with EryDex.
18. Requires any concomitant medication prohibited by the protocol.
19. Has taken a drug or treatment known to cause major organ system toxicity during the past year.
20. Used of any drug that is a strong inducer/inhibitor of cytochrome P450 3A4 (CYP3A4) within 4 weeks before baseline.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Triple

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: EryDex Low Dose DSP; EDS-EP dose range of ~5-10 mg DSP/infusion. This study treatment was to be administered by IV infusion once per month for 12 consecutive months (6 months Initial Treatment Period + 6 months Extension Treatment Period). Each patient underwent a 30-day Screening Period, during which any previous treatments with other corticosteroid compounds were withdrawn (washout from previous treatment). Other Names: EryDex System end product Low dose DSP	Drug: EryDex Low dose DSP; EDS-EP dose range of ~5-10 mg DSP/infusion; Other Names: EryDex System end product
Experimental: EryDex High Dose DSP; EDS-EP dose range of ~14-22 mg DSP/infusion. This study treatment was to be administered by IV infusion once per month for 12 consecutive months (6 months Initial Treatment Period + 6 months Extension Treatment Period). Each patient underwent a 30-day Screening Period, during which any previous treatments with other corticosteroid compounds were withdrawn (washout from previous treatment). Other Names: EryDex System end product High dose DSP	Drug: EryDex High dose DSP; EDS-EP dose range of ~14-22 mg DSP/infusion; Other Names: EryDex System end product
Placebo Comparator: Placebo; Patients were treated with autologous erythrocytes prepared with the EDS process using a placebo solution. Placebo was to be administered by IV infusion once per month for 12 consecutive months (6 months Initial Treatment Period + 6 months Extension Treatment Period). Each patient underwent a 30-day Screening Period, during which any previous treatments with other corticosteroid compounds were withdrawn (washout from previous treatment).	Drug: Pooled Placebo; EDS processed autologous erythrocytes using a sodium chloride [NaCl] solution.; Other Names: Placebo EDS infusion

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change From Baseline in Modified International Cooperative Ataxia Rating Scale (mICARS)	The International Cooperative Ataxia Rating Scale (ICARS) was an assessment of the degree of impairment in patients with cerebellar ataxia and was administered in its entirety; however, the primary efficacy assessment was based on the modified (m)ICARS, which excluded the Oculomotor domain (items 17 to 19) and items 8 to 12 of the Kinetic Functions domain of the ICARS. The mICARS was a 54 points maximum score (min 0) questionnaire divided into 3 sections: Posture and Gait Disturbance section-7 items (min score 0, max score 34); Kinetic Function-2 items (min score 0, max score 12); Speech Disorder- 2 items (min score 0, max score 8). The assessment was designed to be completed within 30 minutes, and higher scores - both for total and subscores - indicate a higher level of disease impairment. The subscores are added to give the total score.	to Month 6 (Visit 9)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Patients With Improving, Stable or Worsening Score Using a Clinical Global Impression of Change (CGI-C)	The CGI-C scale assesses the change in the patient's clinical status from baseline using a 7-point scale, ranging from 1 (very much improved) to 7 (very much worse), with a score of 4 indicating no change. Clinicians were required to conduct a full clinical interview and examination of the patient. The interview and examination assessed various aspects of the patient's appearance (grooming, evidence of falls, etc.), ataxia, cognition (orientation, calculation ability, language, ability to follow commands, memory, etc.), apraxia, dysarthria, extrapyramidal motor symptoms, activities of daily living, and mood. The higher the score the worse the outcome.	to Month 6 (Visit 9)
Number of Patients With None to Severe (0 to 4) Scores in Clinical Global Impression of Severity (CGI-S)-Structured of Neurological Symptoms of AT	The CGI-S scale measures global severity of illness at a given point in time, and is usually rated on a 7-point, Likert-type scale ranging from 1 (normal, not ill at all) to 7 (among the most extremely ill patients). No version of the CGI-S exists which has been specifically adapted for use in patients with A-T; therefore, a 5-point version was developed that considered the severity of the following symptoms of A-T: ataxia (walking), dysarthria, dysmetria, extrapyramidal symptoms (chorea, myoclonus, dystonia, and tremor), and eye movements. Ratings of none (0), mild (1), moderate (2), severe (3), and very severe (4) were selected based on the level of symptomatology. The higher the score the worse the outcome.	to Visit 9 (Month 6)
Change From Baseline of Vineland Adaptive Behavior Scale (VABS-II) Scores - Last Observation Carried Forward (LOCF)	VABS-II was a questionnaire to assess adaptive behavior. It contained 4 domains each with 2-3 subdomains, every subdomain contained various items (questions): A) communication (receptive, expressive, written) B) daily living skills (personal, domestic, community) C) socialization (interpersonal relationships, play and leisure time, coping skills) D) motor skills (gross motor, fine motor). The expanded version of the VABS consisted of 540 items, 261 of which used in this trial. The possible score for each item was from 0 to 4 based on whether the patient performed the activity "never", "rarely", "sometimes", "often" or "almost always". At the end of each domain section, a total score (the sum of the score for each item) was calculated. Domain A: min score 0, max score 572. Domain B: 0 - 800. Domain C: 0 - 580. Domain D: 0 - 424. A grand total score (A+B+C+D scores) was provided (range:0-2376) The lower the score the higher the disability at each level (domains and subdomains).	to Visit 9 (Month 6)
Number of Patients With at Least One Treatment-Emergent Adverse Event (TEAE) at Month 6	TEAE = Treatment Emergent Adverse Events were any AEs started on or after the day of the first infusion through the day just prior to the day of the Visit 9 ("Month 6") infusion, or <=60 days after last dose if the subject never continued past this period.	to Visit 9 (Month 6)
Number of Patients With at Least One Treatment-Emergent Adverse Event (TEAE) at Month 12	TEAE = Treatment Emergent Adverse Events were any AEs started on or after the day of the first infusion through the day just prior to the day of the Visit 15 ("Month 12") infusion. Placebo patients who switched to EryDex treatment at 6 and 9 months were not added to the Extension Treatment Period safety data so that the results reported here under are for those patients who remained on placebo from the start of the study till the end of it.	to Visit 15 (Month 12)

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Quality of Life (QoL) EQ-5D-5L scale	Change from baseline	3 months, 6 months, 9 months, 12 months
Number of Treatment-Emergent Adverse Events (TEAEs)	Change from baseline	3 months, 6 months, 9 months, 12 months
Vital Signs	Change from baseline - results will be summarized descriptively, with abnormal and clinically notable values/findings being identified	3 months, 6 months, 9 months, 12 months
Laboratory parameters	Change from baseline - results will be summarized descriptively, with abnormal and clinically notable values/findings being identified	3 months, 6 months, 9 months, 12 months
ECGs	Change from baseline - results will be summarized descriptively, with abnormal and clinically notable values/findings being identified	3 months, 6 months, 9 months, 12 months
Number of participants with abnormal physical findings assessed per system	Change from baseline - questionnaire will be used to assess as normal or abnormal physical findings per system	3 months, 6 months, 9 months, 12 months
Number of participants with abnormal neurological findings assessed per cranial, motor, sensory, coordination nerves	Change from baseline - questionnaire will be used to assess as normal or abnormal physical findings per nerve	3 months, 6 months, 9 months, 12 months
Columbia-Suicide Severity Rating Scale (C- SSR S) Columbia-Suicide Severity Rating Scale (C- SSR S)	Change from baseline analyzed using ANCOVA	3 months, 6 months, 9 months, 12 months

Collaborators and Investigators

• Sponsor: Quince Therapeutics S.p.A.
• Investigators: Study Director: Guenter R. Janhofer, MD, PhD, EryDel S.p.A

Study record dates

Study Major Dates

• Study Start (Actual): March 2, 2017
• Primary Completion (Actual): May 13, 2021
• Study Completion (Actual): May 13, 2021

Study Registration Dates

• First Submitted: May 2, 2016
• First Submitted That Met QC Criteria: May 10, 2016
• First Posted (Estimated): May 12, 2016

Study Record Updates

• Last Update Posted (Actual): May 10, 2024
• Last Update Submitted That Met QC Criteria: May 9, 2024
• Last Verified: May 1, 2024

More Information

Terms related to this study

• Keywords: Dexamethasone; Ataxia Teleangiectasia; AT; EryDex system; Dexamethasone sodium phosphate
• Additional Relevant MeSH Terms: Cardiovascular Diseases; Vascular Diseases; Metabolic Diseases; Brain Diseases; Central Nervous System Diseases; Immunologic Deficiency Syndromes; Immune System Diseases; Neurologic Manifestations; Genetic Diseases, Inborn; Dyskinesias; DNA Repair-Deficiency Disorders; Neurocutaneous Syndromes; Cerebellar Diseases; Primary Immunodeficiency Diseases; Spinocerebellar Ataxias; Cerebellar Ataxia; Nervous System Diseases; Ataxia; Telangiectasis; Ataxia Telangiectasia
• Other Study ID Numbers: IEDAT-02-2015; 2015-005241-31 (EudraCT Number)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: Yes
• Studies a U.S. FDA-regulated device product: No