- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT05653895
Independent and Additive Effects Of Micronutrients With Metformin In Patients With PCOS
Independent and Additive Effects Of Micronutrients With Metformin In Patients With PCOS:A Double Blind Randomized Placebo Controlled Trial
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Polycystic ovary syndrome is a condition which is manifested by certain polycystic ovarian morphologic features, hyperandrogenism and ovulatory dysfunction. As per the revised diagnostic criteria by National Institute of Health 2012, about 6 to 10% women of the reproductive age are affected by the classic polycystic ovarian syndrome, the prevalence of which is twice as more according to the broader Rotterdam standards . One important cause of distress in patients with this syndrome is the excessive expression of androgens (e.g., hirsutism) which leads to infertility. A number of reports based on PCOS suggest that genetic anomalies of follicular maturation and ovarian steroidogenesis also have a crucial role in the development and occurrence of PCOS. This disorder is polygenic in nature and contributes towards metabolic diseases like obesity . About 50 to 80% women having PCOS are obese . Not only has this but PCOS also had a connection with an elevated risk of cardiovascular disease . Type-2 diabetes amongst women with this syndrome is reported to be 8 to 10%, and the compromised glucose tolerance cases are reported as high as 30 to 35% of US. Moreover, the chances of occurrence of this disease is highly associated with changes in age, history of diabetes in family and obesity . PCOS is a multifaceted health issue having several short and long term effects on woman's health. These include cardiovascular diseases, metabolic and sexual dysfunction, depression and anxiety that effects the overall quality of life. The present study documents the impact of PCOS and its complications on overall quality of life and how new treatment options can help minimize the signs and symptoms associated with the disease condition. Some of the recent focused therapeutic compounds reported in this context are Resveratrol, L-Carnitine, Co-Q10, L-Arginine and Decanoic acid as naturally occurring nutraceuticals and metformin as standard therapeutic drug against PCOS.
Resveratrol (3,5,4-trihydroxystilbene)-A naturally occurring polyphenol, found in grapes, peanuts, red wine and many medicinal plants . According to studies, this compound may have many antidiabetic, anti-inflammatory and antioxidant actions . Kong et al. highlighted that resveratrol decreases the atretic follicles which significantly increase the number of oocytes . This leads to an inhibition of both, apoptosis and primordial to the developing follicle in rats of different age groups . Resveratrol has been reported to interact with multiple cell targets, but its major effects are brought about by the activation of SIRT1 (silent information regulator 1) . SIRT1, which is a key player in energy metabolism and homeostasis, is a mammalian homologue of Sir2 (yeast) which deacetylates many mammalian cell targets. The SIRT1 is basically expressed in oocytes and human granulosa nuclei cells at multiple developmental stages of the follicles. It is also responsible for suppressing inflammation. Moreover, SIRT1 is also involved in protecting the oocytes from age dependent insufficiencies through oxidative stress . Resveratrol has a tendency to suppress inflammation by activating SIRT1 and as a result the symptoms of inflammation are reduced in many autoimmune disease models like rheumatoid arthritis, colitis, encephalomyelitis and type I diabetes L-Carnitine is involved in fatty acid oxidation by long chain fatty acids transport inside the mitochondria for oxidation to produce metabolic energy and have effects on glucose metabolism in tissues. L-Carnitine is known to regulate energy production . Studies have shown that patients treated with L-Carnitine have improved ovulation and pregnancy rates and is very well tolerated by the patients .
Coenzyme Q10 (CoQ10) a lipid soluble coenzyme which is an important component of the inner membrane of mitochondria. It is a key regulator of oxidative phosphorylation in the electron transport chain for ATP synthesis. A number of studies have reported a protective role of CoQ10 in ovaries by restoring aging of ovaries and improving mitochondrial function . According to a recent finding, administration of 20 mg/kg of CoQ10 in a rat model led to increased insulin sensitivity, suggesting its antidiabetic potential .
Decanoic acid- is naturally occurring fatty acid present in palm and coconut oils . Lee et al suggested that decanoic acid along with metformin altered cAMP signaling and normalized the androgen synthesis. Moreover, in a diabetic mouse model, treatment with decanoic acid led to improved glucose sensitivity. In another study, letrozole-induced rat PCOS model, the administration of decanoic acid reduced the levels of androgen and 3-HSD which led to restoration of the estrous cycle . These studies suggest a positive role of decanoic acid in management and treatment of insulin resistance and hyperandrogenism in PCOS patients.
L-Arginine is an amino acid that plays a role in a number of metabolic pathways and serves as a substrate for NOS (Nitric Oxide synthase) enzyme which is essentially involved in normal insulin signaling and endothelial function . In other findings, it is proposed that L-Arginine also enhances metabolic profile, β-cell function and has anti-oxidant potential . The ovarian health was also improved along with follicular growth, luteal function and oocyte development by the administration of L-Arginine. According to a previous study, PCOS patients had lowered levels of NO (nitric oxide) due to reduced expression of NOS which consequently led to a decline in arginine bioavailability. Therefore, L-arginine supplementation can have a therapeutic potential .
Metformin a biguanide which is used in type 2 diabetes and is mostly used as a gold standard drug for PCOS therapy . The mechanism of action is such that it helps in inhibition of hepatic gluconeogenesis and intestinal glucose absorption which ultimately improves insulin signaling .
Metformin has a direct and important role in human ovarian steroidogenesis. It inhibits insulin stimulated progesterone and gonadotrophin dose dependently in granulosa cells . According to a recent research report, it was reported that metformin treatment in infertile, anovulatory PCOS women, resulted in pregnancy, higher ovulation and live birth rates as compared to placebo . PCOS is a systemic condition, an endocrinopathy whose etiology is still not understood, correct treatment regimens of PCOS will not only improve menstrual cycle irregularities of the patients but will also improve the metabolic or endocrinological parameters . PCOS sufferers are also known to have increased levels of perceived stress which will be considered in the study. Very little evidence is available on combination therapy for treatment of PCOS patients. In this study the investigators goal will be to come up with a better treatment option to treat the disease effectively.
Study Type
Enrollment (Actual)
Phase
- Not Applicable
Contacts and Locations
Study Contact
- Name: Mohsin Shah, PHD
- Phone Number: +92-3429620074
- Email: mohsin.ibms@kmu.edu.pk
Study Contact Backup
- Name: Musarrat Zahra, MPHIL
- Phone Number: +92-3009592256
- Email: drmzahra@yahoo.com
Study Locations
-
-
Khyber Pukhtunkhwa
-
Swabi, Khyber Pukhtunkhwa, Pakistan, 23340
- Bacha Khan Medical Complex Swabi
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Description
Inclusion Criteria:
PCOS women aged 16 -45 years.Diagnosis of PCOS will be made according to NIH 2012 extension of ESHRE/ASRM 2003 criteria Identification of specific phenotype will be included
- HA+OD+PCOM (Hyperandrogenism, Ovulatory dysfunctions, Polycystic ovarian morphology)
- HA+OD
- HA+PCOM
- PCOM+OD
Exclusion Criteria:
- Women with hyperprolactenemia
- Diabetes Mellitus
- Cushing syndrome
- Androgen secreting tumours
- Non classical congenital adrenal hyperplasia
- History of seizures
- Patients on anti coagulants, anti platelets ,isoproterenol ,antidepressants, potassium sparing diuretics
- Pregnancy or use of contraceptives
- Patients with thyroid disease
- Patients on hormonal therapy -
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Supportive Care
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Triple
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Active Comparator: Arm 1
Resveratrol (2 gm daily) 50 patients with PCOS will receive Resveratrol 1000mg BD daily
|
Resveratrol
|
Active Comparator: Arm 2
Metformin (1000mg daily),Resveratrol(2 gm daily) 50 patients with PCOS will receive Metformin 500mg,Resveratrol 1000 mg BD daily
|
Metformin
Resveratrol
|
Active Comparator: Arm 3
L-Arginine(3 gm daily), Acetyl L-Carnitine (3 gm daily),CoQ10(200 mg daily) 50 patients with PCOS will receive L Arginine 1500mg,Acetyl L Carnitine 1500mg ,COQ10 100mg BD daily respectively
|
Treatment of PCOS with combination of Acetyl-L-Carnitin, L Arginine, Co-Q10
|
Active Comparator: Arm 4
L-Arginine(3 gm daily), Acetyl L-Carnitine (3 gm daily),CoQ10(200 mg daily),Metformin (1000mg daily) 50 patients with PCOS will receive L Arginine 1500mg,Acetyl L Carnitine 1500mg,COQ10 100mg BD daily respectively
|
Metformin
Treatment of PCOS with combination of Acetyl-L-Carnitin, L Arginine, Co-Q10
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Insulin Resistance
Time Frame: 6 months
|
PCOS associated insulin resistance and hyperinsulinemia by HOMA-IR
|
6 months
|
Menstural Irregularities
Time Frame: 6 months
|
Oligo/Anovulation, Questionnaire based history taking of each participant
|
6 months
|
Anti mullerian Hormone
Time Frame: 6 months
|
Measurement of Anti mullerian hormone by ELISA
|
6 months
|
Dehydroepiandrosterone
Time Frame: 6 months
|
Measurement of Dehydroepiandrosterone using ELISA
|
6 months
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Antioxidant Assays
Time Frame: 6 months
|
Measuring Total AntiOxidant Capacity by FRAP ASSAY
|
6 months
|
Anti oxidant Assays
Time Frame: 6 months
|
Measuring MDA (Malondialdehyde) by TBARS
|
6 months
|
Mental health questionnaire
Time Frame: 6 months
|
Will be assessed by using Polycystic Ovarian Syndrome Quality Of Life Tool
|
6 months
|
Molecular characterisation
Time Frame: 6 months
|
SNP genotyping of THADA and DENNDIA
|
6 months
|
perceived stress response (PSS-14) questionnaire
Time Frame: 6 months
|
Stress response
|
6 months
|
profile of mood stress (POMS) by structured questionnaire
Time Frame: 6 months
|
Stress response
|
6 months
|
Collaborators and Investigators
Investigators
- Principal Investigator: Mohsin Shah, PHD, Department of Physiology ,Khyber Medical University ,Peshawar, Pakistan
Publications and helpful links
General Publications
- Boger RH. The pharmacodynamics of L-arginine. J Nutr. 2007 Jun;137(6 Suppl 2):1650S-1655S. doi: 10.1093/jn/137.6.1650S.
- Legro RS, Kunselman AR, Dodson WC, Dunaif A. Prevalence and predictors of risk for type 2 diabetes mellitus and impaired glucose tolerance in polycystic ovary syndrome: a prospective, controlled study in 254 affected women. J Clin Endocrinol Metab. 1999 Jan;84(1):165-9. doi: 10.1210/jcem.84.1.5393.
- Velazquez EM, Mendoza S, Hamer T, Sosa F, Glueck CJ. Metformin therapy in polycystic ovary syndrome reduces hyperinsulinemia, insulin resistance, hyperandrogenemia, and systolic blood pressure, while facilitating normal menses and pregnancy. Metabolism. 1994 May;43(5):647-54. doi: 10.1016/0026-0495(94)90209-7.
- Victor VM, Rocha M, Banuls C, Alvarez A, de Pablo C, Sanchez-Serrano M, Gomez M, Hernandez-Mijares A. Induction of oxidative stress and human leukocyte/endothelial cell interactions in polycystic ovary syndrome patients with insulin resistance. J Clin Endocrinol Metab. 2011 Oct;96(10):3115-22. doi: 10.1210/jc.2011-0651. Epub 2011 Jul 21.
- Dumesic DA, Oberfield SE, Stener-Victorin E, Marshall JC, Laven JS, Legro RS. Scientific Statement on the Diagnostic Criteria, Epidemiology, Pathophysiology, and Molecular Genetics of Polycystic Ovary Syndrome. Endocr Rev. 2015 Oct;36(5):487-525. doi: 10.1210/er.2015-1018.
- Wild RA, Carmina E, Diamanti-Kandarakis E, Dokras A, Escobar-Morreale HF, Futterweit W, Lobo R, Norman RJ, Talbott E, Dumesic DA. Assessment of cardiovascular risk and prevention of cardiovascular disease in women with the polycystic ovary syndrome: a consensus statement by the Androgen Excess and Polycystic Ovary Syndrome (AE-PCOS) Society. J Clin Endocrinol Metab. 2010 May;95(5):2038-49. doi: 10.1210/jc.2009-2724. Epub 2010 Apr 7.
- Ehrmann DA, Barnes RB, Rosenfield RL, Cavaghan MK, Imperial J. Prevalence of impaired glucose tolerance and diabetes in women with polycystic ovary syndrome. Diabetes Care. 1999 Jan;22(1):141-6. doi: 10.2337/diacare.22.1.141.
- Ortega I, Duleba AJ. Ovarian actions of resveratrol. Ann N Y Acad Sci. 2015 Aug;1348(1):86-96. doi: 10.1111/nyas.12875.
- Rege SD, Kumar S, Wilson DN, Tamura L, Geetha T, Mathews ST, Huggins KW, Broderick TL, Babu JR. Resveratrol protects the brain of obese mice from oxidative damage. Oxid Med Cell Longev. 2013;2013:419092. doi: 10.1155/2013/419092. Epub 2013 Sep 15.
- Guo S, Yao Q, Ke Z, Chen H, Wu J, Liu C. Resveratrol attenuates high glucose-induced oxidative stress and cardiomyocyte apoptosis through AMPK. Mol Cell Endocrinol. 2015 Sep 5;412:85-94. doi: 10.1016/j.mce.2015.05.034. Epub 2015 Jun 6.
- Kong XX, Fu YC, Xu JJ, Zhuang XL, Chen ZG, Luo LL. Resveratrol, an effective regulator of ovarian development and oocyte apoptosis. J Endocrinol Invest. 2011 Dec;34(11):e374-81. doi: 10.3275/7853. Epub 2011 Jul 7.
- Borra MT, Smith BC, Denu JM. Mechanism of human SIRT1 activation by resveratrol. J Biol Chem. 2005 Apr 29;280(17):17187-95. doi: 10.1074/jbc.M501250200. Epub 2005 Mar 4.
- Lee D, Goldberg AL. SIRT1 protein, by blocking the activities of transcription factors FoxO1 and FoxO3, inhibits muscle atrophy and promotes muscle growth. J Biol Chem. 2013 Oct 18;288(42):30515-30526. doi: 10.1074/jbc.M113.489716. Epub 2013 Sep 3.
- Xuzhu G, Komai-Koma M, Leung BP, Howe HS, McSharry C, McInnes IB, Xu D. Resveratrol modulates murine collagen-induced arthritis by inhibiting Th17 and B-cell function. Ann Rheum Dis. 2012 Jan;71(1):129-35. doi: 10.1136/ard.2011.149831. Epub 2011 Sep 27.
- Bentinger M, Brismar K, Dallner G. The antioxidant role of coenzyme Q. Mitochondrion. 2007 Jun;7 Suppl:S41-50. doi: 10.1016/j.mito.2007.02.006. Epub 2007 Mar 16.
- Amin MM, Asaad GF, Abdel Salam RM, El-Abhar HS, Arbid MS. Novel CoQ10 antidiabetic mechanisms underlie its positive effect: modulation of insulin and adiponectine receptors, Tyrosine kinase, PI3K, glucose transporters, sRAGE and visfatin in insulin resistant/diabetic rats. PLoS One. 2014 Feb 20;9(2):e89169. doi: 10.1371/journal.pone.0089169. eCollection 2014.
- Elson CE. Tropical oils: nutritional and scientific issues. Crit Rev Food Sci Nutr. 1992;31(1-2):79-102. doi: 10.1080/10408399209527562.
- Malapaka RRV, Khoo S, Zhang J, Choi JH, Zhou XE, Xu Y, Gong Y, Li J, Yong EL, Chalmers MJ, Chang L, Resau JH, Griffin PR, Chen YE, Xu HE. Identification and mechanism of 10-carbon fatty acid as modulating ligand of peroxisome proliferator-activated receptors. J Biol Chem. 2012 Jan 2;287(1):183-195. doi: 10.1074/jbc.M111.294785. Epub 2011 Oct 28.
- Wu G, Bazer FW, Davis TA, Kim SW, Li P, Marc Rhoads J, Carey Satterfield M, Smith SB, Spencer TE, Yin Y. Arginine metabolism and nutrition in growth, health and disease. Amino Acids. 2009 May;37(1):153-68. doi: 10.1007/s00726-008-0210-y. Epub 2008 Nov 23.
- Piatti PM, Monti LD, Valsecchi G, Magni F, Setola E, Marchesi F, Galli-Kienle M, Pozza G, Alberti KG. Long-term oral L-arginine administration improves peripheral and hepatic insulin sensitivity in type 2 diabetic patients. Diabetes Care. 2001 May;24(5):875-80. doi: 10.2337/diacare.24.5.875.
- An H, He L. Current understanding of metformin effect on the control of hyperglycemia in diabetes. J Endocrinol. 2016 Mar;228(3):R97-106. doi: 10.1530/JOE-15-0447. Epub 2016 Jan 7.
- Mansfield R, Galea R, Brincat M, Hole D, Mason H. Metformin has direct effects on human ovarian steroidogenesis. Fertil Steril. 2003 Apr;79(4):956-62. doi: 10.1016/s0015-0282(02)04925-7.
- Morley LC, Tang T, Yasmin E, Norman RJ, Balen AH. Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility. Cochrane Database Syst Rev. 2017 Nov 29;11(11):CD003053. doi: 10.1002/14651858.CD003053.pub6.
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- KhyberMU
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
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