Role of Antisecretory Factor in Dihydropyrimidine Treatment of Colorectal Cancer (SALFLADMET)

A Randomized Phase 2 and Pilot Pharmacodynamic Trial Investigating the Effect of Salovum™ and SPC-flakes on Dihydropyrimidine Induced Gastrointestinal Toxicity and Tumour Perfusion in Colorectal Cancer

One debilitating, and sometimes even life-threatening, toxicity from dihydropyrimidines, e g 5-FU and capecitabine, is gastrointestinal mucositis resulting in, eg severe diarrhoea necessitating in-hospital care including periods of support with iv fluids. The efficacy of current treatment for this adverse effect include iv fluids, loperamide and opioids po and octreotide sc is moderate and new treatment principles or, preferably, ways to prevent such toxicity, are urgently needed. Cholera induced diarrhoea, as well as other forms of diarrhoea-inducing agents, has been shown to elicit a stimulated, endogenous production of a protein, named "antisecretory factor", ASF. ASF acts by modulating secretion of water and ions but also counteracts inflammatory processes.

ASF is also produced by hens fed on a diet of fermented grains or a specific diet of sugars and amino acids, leading to an accumulation of the ASF protein in the egg yolk. Spray dried yolk in the form of a powder is commercialized as Salovum registered by the EU authorities as "Food for specific medical purposes". Another way to increase ASF and, thus, to achieve benefit, is to induce its production/ conversion by ingestion of oat flakes, specially processed (similar to malting) to contain the proper mix of sugars and amino acids. Such flakes are also commercially available (SPC-flakes) as "Food for specific medical purposes".

Salovum has been shown to rapidly, ie within hours to a few days, antagonize diarrhoeal diseases of various etiologies. It has also been used against high fluid passages and inflammation in Crohns disease, Colitis ulcerosa and carcinoids in adults. SPC-flakes have similar effects but need weeks of administration to emerge. Interestingly from an oncological perspective, provision of exogenous ASF and induction of endogenous ASF has been shown to reduce interstitial fluid pressure (IFP) in tumours, increase tumour uptake of cytotoxic drugs and improve survival in animal tumour models.

With this background the present study will investigate if administration of ASF in the form of Salovum combined with induction of endogenous ASF by intake of SPC-flakes might be beneficial in colorectal cancer (CRC) patients to prevent dihydropyrimidine based chemotherapy induced gastrointestinal mucositis and to reduce tumor interstitial fluid pressure .

Study Overview

• Status: Recruiting
• Conditions: Dihydropyrimidine Induced Gastrointestinal Toxicity in Colorectal Cancer
• Intervention / Treatment: Dietary supplement: Salovum and SPC-flakes active or placebo

Detailed Description

The pyrimidine analogue 5-fluorouracil (5-FU) has a history in oncology for more than 50 years, and is still the backbone in chemotherapy regimens, in particular for gastrointestinal cancer although it is now often substituted with the oral prodrug capecitabine. Since colorectal cancer is the third most common cancer in Europe and the US a great number of patients will be exposed to 5-FU either as part of a curative intent, ie (neo)adjuvant, or with a palliative intention.

One debilitating, and sometimes even life-threatening, toxicity from dihydropyrimidines, e g 5-FU and capecitabine, is gastrointestinal mucositis resulting in, eg severe diarrhoea necessitating in-hospital care including periods of support with iv fluids. The efficacy of current treatment for this adverse effect include iv fluids, loperamide and opioids po and octreotide sc is moderate and new treatment principles or, preferably, ways to prevent such toxicity, are urgently needed. Mucositis is a common adverse effect also from a number of other cancer drugs as well as from radiotherapy.

Cholera induced diarrhoea, as well as other forms of diarrhoea-inducing agents, has been shown to elicit a stimulated, endogenous production of a protein, named "antisecretory factor", ASF. This protein has been chemically characterized in detail. ASF acts by modulating secretion of water and ions but also counteracts inflammatory processes. One of the biologically active peptides of the ASF protein is AF 16, a 16 amino acids long peptide which can easily be synthesized, is chemically very stable, and is therefore used for experimental purposes.

ASF is also produced by hens fed on a diet of fermented grains or a specific diet of sugars and amino acids, leading to an accumulation of the ASF protein in the egg yolk. Spray dried yolk in the form of a powder is commercialized as Salovum registered by the EU authorities as "Food for specific medical purposes", i e is not a drug from a regulatory perspective. Therefore, clinical studies with Salovum (or SPC-flakes, see below) do not need approval from the Medical Products Agency.

Salovum rapidly increase the plasma ASF-concentration. Another way to increase ASF and, thus, to achieve benefit, is to induce its production/conversion by ingestion of oat flakes, specially processed (similar to malting) to contain the proper mix of sugars and amino acids. Such flakes are also commercially available (SPC-flakes) as "Food for specific medical purposes" and has been recommended or considered for a number of secretory pathological conditions, e g for treatment of Mb Meniére.

Salovum has been shown to rapidly, ie within hours to a few days, antagonize diarrhoeal diseases of various etiologies. It has also been used against high fluid passages and inflammation in Crohns disease, Colitis ulcerosa and carcinoids in adults. SPC-flakes have similar effects but need weeks of administration to emerge. Importantly, to raise body ASF, by Salovum or SPC-flakes, for the above indications has not been associated with adverse effects.

Interestingly from an oncological perspective, provision of exogenous ASF and induction of endogenous ASF has been shown to reduce interstitial fluid pressure (IFP) in tumours, increase tumour uptake of cytotoxic drugs and improve survival in animal tumour models.

Thus, to raise body ASF by administration of ASF in the form of Salovum or its endogenous induction by SPC-flakes is seemingly a promising strategy worthwhile to investigate in cancer, both for treatment and counteraction of adverse effects, notably gastrointestinal mucositis, and for improvement of drug cancer treatment. While a clinical trial on administration of ASF as a strategy to improve cancer therapy, notably in glioblastoma, is in a pilot early phase, there is no study ongoing with the aim to counteract chemotherapy induced mucositis.

With this background the present study will investigate if administration of ASF in the form of Salovum combined with induction of endogenous AF by intake of SPC-flakes might be beneficial in colorectal cancer (CRC) patients to prevent dihydropyrimidine based chemotherapy induced gastrointestinal mucositis. Since the study team has also experience from measurements in patients of tumour IFP using 15O-labeled water PET, a pharmacodynamic pilot study for assessement of Salovum/SPC induced changes in tumour IFP will be included as an add on to the main study and open for 10 patients with liver metastatic disease.

• Study Type: Interventional
• Enrollment (Anticipated): 73
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Peter Nygren, MD; Phone Number: +46 70 4250719; Email: peter.nygren@igp.uu.se

Study Locations

• Sweden
  • Uppsala, Sweden, 75185
    • Recruiting
    • University Hospital
    • Contact: Peter Nygren, MD; Phone Number: +46 70 4250719; Email: peter.nygren@igp.uu.se

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. Age ≥ 18 years.
2. Histologically confirmed diagnosis of colorectal cancer.
3. Planned to start 1st line dihydropyrimidine (i e 5-FU or capecitabine) based chemotherapy in the adjuvant, neoadjuvant or palliative setting.
4. Planned duration of chemotherapy ≥ 2 months.
5. Signed informed consent.
6. Liver metastatic disease (pharmacodynamics study only).

Exclusion Criteria:

1. Contraindications to the investigational product, e g known or suspected hypersensitivity to the investigational products or expected inability to their use in accordance with the protocol.
2. Lack of suitability for participation in the study, e g expected difficulties to follow the protocol procedures, as judged by the investigator.
3. Prior exposure to 5-FU based chemotherapy.
4. Prior exposure to Salovum or SPC-flakes.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Active; Salovum egg powder high in antisecretory factor, 4 g/sachet. Four sachets, ie 16 g q 8 h for 6 days starting 6 days before 1st cycle of chemotherapy. SPC-flakes flat dose of 75 g/d divided in 2 - 4 doses started in parallel with Salovum to be continued during the first 8 weeks of chemotherapy.	Dietary supplement: Salovum and SPC-flakes active or placebo; Foods for specific medical purposes or corresponding placebo
Placebo Comparator: Control; Salovum placebo powder without antisecretory factor, 4 g/sachet. Four sachets, ie 16 g q 8 h for 6 days starting 6 days before 1st cycle of chemotherapy. SPC placebo flakes flat dose of 75 g/d divided in 2 - 4 doses started in parallel with Salovum placebo to be continued during the first 8 weeks of chemotherapy.	Dietary supplement: Salovum and SPC-flakes active or placebo; Foods for specific medical purposes or corresponding placebo

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Incidence of diarrhoea CTCAEv5.0 ≥ grade 2.	Chemotherapy induced toxicity to be counteracted by intervention	During first 2 months of chemotherapy

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Incidence of in-patient care for chemotherapy induced gastrointestinal mucositis including number of days in hospital and with parenteral fluids.	Chemotherapy induced toxicity to be counteracted by intervention	During first 2 months of chemotherapy
Change from baseline in patient reported hQoL and abdominal symptoms assessed by EORTC QLQ-30 and the colorectal cancer specific Q29 subscale.	Patient reported chemotherapy induced toxicity to be counteracted by intervention	During first 2 months of chemotherapy
Incidence and severity of other chemotherapy induced adverse effects according to CTCAEv5.0.	Chemotherapy induced toxicity to be counteracted by intervention	During first 2 months of chemotherapy
Increase in P-ASF concentration from baseline to day 7 from start of investigational product/placebo and just prior to treatment cycle 2, 3 and 4 (as applicable).	To reflect study products pharmacodynamics and patient compliance	During first 2 months of chemotherapy
Relationships between P-ASF concentration and adverse effects.	Assessment of biomarker related to potential benefit	During first 2 months of chemotherapy
Tumour response rate according to RECIST v1.1 (locally advanced and metastatic settings only).	Assessment of benefit, if any, from ASF elevation on drug efficacy	At 1st radiological tumor response evaluation, approximately 2 months from start of chemotherapy
Incidence of adverse events CTCAEv5.0 grade ≥ 3 considered probably related to investigational products/placebo.	Assessment of study product safety when combined with chemotherapy	During first 2 months of chemotherapy

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in liver metastasis water perfusion.	Assessment of change in tumor interstitial fluid pressure by antisecretory factor	One week prior to start of chemotherapy
Change in liver metastasis tumor blood flow.	Assessment of change in tumor interstitial fluid pressure by antisecretory factor	One week prior to start of chemotherapy

Collaborators and Investigators

• Sponsor: Uppsala University Hospital
• Collaborators: Swedish Cancer Society; Lantmännen AB; Sjöbergstiftelsen; Onkologiska klinikens forskningsfond

Publications and helpful links

General Publications

• Zaman S, Aamir K, Lange S, Jennische E, Silfverdal SA, Hanson LA. Antisecretory factor effectively and safely stops childhood diarrhoea: a placebo-controlled, randomised study. Acta Paediatr. 2014 Jun;103(6):659-64. doi: 10.1111/apa.12581. Epub 2014 Mar 10.
• Ulgheri C, Paganini B, Rossi F. Antisecretory factor as a potential health-promoting molecule in man and animals. Nutr Res Rev. 2010 Dec;23(2):300-13. doi: 10.1017/S0954422410000193. Epub 2010 Aug 5.
• Al-Olama M, Wallgren A, Andersson B, Gatzinsky K, Hultborn R, Karlsson-Parra A, Lange S, Hansson HA, Jennische E. The peptide AF-16 decreases high interstitial fluid pressure in solid tumors. Acta Oncol. 2011 Oct;50(7):1098-104. doi: 10.3109/0284186X.2011.562240. Epub 2011 Mar 4.
• Johansson E, Jennische E, Lange S, Lonnroth I. Antisecretory factor suppresses intestinal inflammation and hypersecretion. Gut. 1997 Nov;41(5):642-5. doi: 10.1136/gut.41.5.642.
• Bjorck S, Bosaeus I, Ek E, Jennische E, Lonnroth I, Johansson E, Lange S. Food induced stimulation of the antisecretory factor can improve symptoms in human inflammatory bowel disease: a study of a concept. Gut. 2000 Jun;46(6):824-9. doi: 10.1136/gut.46.6.824.
• Ilkhanizadeh S, Sabelstrom H, Miroshnikova YA, Frantz A, Zhu W, Idilli A, Lakins JN, Schmidt C, Quigley DA, Fenster T, Yuan E, Trzeciak JR, Saxena S, Lindberg OR, Mouw JK, Burdick JA, Magnitsky S, Berger MS, Phillips JJ, Arosio D, Sun D, Weaver VM, Weiss WA, Persson AI. Antisecretory Factor-Mediated Inhibition of Cell Volume Dynamics Produces Antitumor Activity in Glioblastoma. Mol Cancer Res. 2018 May;16(5):777-790. doi: 10.1158/1541-7786.MCR-17-0413. Epub 2018 Feb 5.

Study record dates

Study Major Dates

• Study Start (Actual): December 15, 2020
• Primary Completion (Anticipated): December 1, 2024
• Study Completion (Anticipated): June 1, 2025

Study Registration Dates

• First Submitted: April 14, 2022
• First Submitted That Met QC Criteria: April 14, 2022
• First Posted (Actual): April 21, 2022

Study Record Updates

• Last Update Posted (Actual): May 25, 2022
• Last Update Submitted That Met QC Criteria: May 18, 2022
• Last Verified: May 1, 2022

More Information

Terms related to this study

• Keywords: Colorectal cancer; Diarrhoea; Dihydropyrimidine; Antisecretory factor
• Additional Relevant MeSH Terms: Digestive System Diseases; Neoplasms; Neoplasms by Site; Gastrointestinal Neoplasms; Digestive System Neoplasms; Gastrointestinal Diseases; Colonic Diseases; Intestinal Diseases; Intestinal Neoplasms; Rectal Diseases; Colorectal Neoplasms
• Other Study ID Numbers: ASF 2

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No
• IPD Plan Description: To be considered.

Drug and device information, study documents

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