Repurposing 5-Azacytidine for the Treatment of Muscle Contractures in Children With Cerebral Palsy

In this controlled dose-escalation study, we will study the initial safety, biological properties, and potential efficacy of 5-azacytidine (AZA). Our overarching aspiration is for AZA to evolve into an approved pharmacological treatment, fostering muscle growth and enhancing body movement, ultimately contributing to an improved quality of life in children with CP.

The main questions this study aims to answer are:

1. What is the optimal dose of AZA injection that can be used safely in children with CP?
2. Can the optimal safe dose of AZA improve the function of muscle-generating stem cells in children with CP?

Each participant will have up to five research visits over the course of the study duration, in which they will participate in: blood draws, pregnancy test(s) (if applicable), medical assessments, and a muscle biopsy during a surgery for muscle contractures.

Researchers will compare participants with four different dosages of AZA injections to those with four different dosages of placebo injections. A placebo is a look-alike substance that contains no active drug. They will see if a single injection of AZA at a standard concentration currently approved by the FDA to treat myelodysplastic syndromes, can also safely improve muscle growth and function in children with CP.

Study Overview

• Status: Enrolling by invitation
• Conditions: Cerebral Palsy; Contracture
• Intervention / Treatment: Drug: 5-Azacytidine 10mg/m^2; Drug: 5-Azacytidine 20mg/m^2; Drug: 5-Azacytidine 35mg/m^2; Drug: 5-Azacytidine 75mg/m^2; Drug: Placebo for the AZA 10mg/m^2; Drug: Placebo for the AZA 20mg/m^2; Drug: Placebo for the AZA 35mg/m^2; Drug: Placebo for the AZA 75mg/m^2

Detailed Description

Cerebral palsy (CP) has an enduring impact on the development of the muscles after birth. Research showed that a drug that is currently approved by the FDA to treat myelodysplastic syndromes in adults and children, can be potentially adapted ("repurposed") to support muscle growth. In a controlled dose-escalation study, we will study the preliminary safety, biological properties, and efficacy of this drug, called 5-Azacytidine (AZA). Our hope and overarching expectations are that one day AZA will become a new approved pharmacological treatment to support muscle growth and improve body movement and quality of life in children with CP.

Research participants will have five study visits.

1. The first study visit will be a screening within 30 days of the baseline visit and will determine eligibility for the study. The participant will have their blood drawn to check for normal kidney and liver functioning, do a pregnancy test (if applicable), and then the researcher will complete a medical assessment.
2. If the participant is eligible, they will be invited to a second study visit approximately 15 days prior to their scheduled surgery for contracture release. At this visit, the participants will get their blood drawn, do a pregnancy test (if applicable), have a medical assessment performed, and receive their injection. The injection will be a single sub-cutaneous shot in their leg, near the muscle group that will undergo surgical repair.
3. The third visit will be at the participant's scheduled surgery. A small sample of the muscle (i.e., about the size of a pencil eraser) will be surgically removed by the researcher from a muscle group that is already exposed during the procedure. The biopsy will add approximately two to five minutes to the overall procedure time. The participant will also have their blood drawn.
4. The participants will be seen approximately one week after their surgery to complete a medical assessment.
5. The last visit will be about four weeks after the surgery at their post-operative appointment. At this visit, the participant will have their blood drawn and complete a medical assessment to test their range of motion following the surgery.

The amount of blood drawn at each time point will be approximately 3 mL, equating to 12 mL of blood total (less than a tablespoon). The purpose of the blood draws is to evaluate safety and biological efficacy of the study drug. The medical assessment will consist of range of motion assessment and wound check performed by the clinicians. These are the same assessments that the clinicians would typically do as part of usual care prior to and after surgery. The purpose of the medical assessment is to evaluate the efficacy of the study drug and ensure the surgical site is healing.

• Study Type: Interventional
• Enrollment (Estimated): 27
• Phase: Phase 1

Contacts and Locations

Study Locations

• United States
  • California
    • San Diego, California, United States, 92123
      • Rady Children's Hospital - San Diego

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Diagnosis of cerebral palsy.
2. Either achilles or hamstring spasticity with contracture necessitation surgical lengthening.
3. Between 2 and 18 years of age

4. Normal renal and liver function as defined by NCI-CTCAE criteria.71

   a. Renal Function (Grade 0 - Normal): i. Creatinine: Within the normal range or ≤ 1.0 times the upper limit of normal (ULN).

   ii. Glomerular filtration rate (GFR): No significant decrease. b. Liver Function (Grade 0 - Normal): i. Aspartate aminotransferase (AST) or alanine aminotransferase (ALT): Within the normal range or ≤ ULN.

   ii. Total bilirubin: Within the normal range or ≤ 1.0 times ULN

5. A negative pregnancy test for females of childbearing potential*.

6. Females of childbearing potential must agree to use contraception consistently from screening to 6 months after their injection. Highly effective methods of contraception are required for females of childbearing potential:

   1. Total abstinence from sexual intercourse.
   2. Intrauterine device (IUD) or intrauterine hormone-releasing system (IUS).
   3. Combined (estrogen and progestogen containing) hormonal contraception associated with inhibition of ovulation, which may be oral, intravaginal, or transdermal used in accordance with medical direction.
   4. Progestogen-only hormonal contraception associated with inhibition of ovulation, which may be oral, injected, or implanted, and used in accordance with medical direction.

7. Males of childbearing potential** must agree to use contraception consistently from screening until 3 months after the injection. Acceptable methods of contraception for males of childbearing potential are:

   1. Total abstinence from sexual intercourse.

   2. Condom with spermicide (cream, spray, foam, gel, suppository, or polymer film).

      • Female of childbearing potential is defined as a female capable of becoming pregnant, which includes patients who have had their first menstrual cycle (menarche).

        • Male of childbearing potential is defined as a subject who has reached spermarche.

Exclusion Criteria:

1. Active infection.
2. Cardiac disease.
3. Allergy to AZA or mannitol.
4. Patient or family who is non-compliant.
5. Received chemotherapy in the preceding three months.
6. Evidence of a hematologic precondition or other malignancy.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Non-Randomized
• Interventional Model: Sequential Assignment
• Masking: Triple

Number of Arms

8

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: AZA 10mg/m^2; 5-Azacytidine, subcutaneous injection, 10mg/m^2, one subcutaneous injection for duration of study (estimated at 46 - 76 days)	Drug: 5-Azacytidine 10mg/m^2; 5-Azacytidine 10mg/m^2, one-time subcutaneous injection
Experimental: AZA 20mg/m^2; 5-Azacytidine, subcutaneous injection, 20mg/m^2, one subcutaneous injection for duration of study (estimated at 46 - 76 days)	Drug: 5-Azacytidine 20mg/m^2; 5-Azacytidine 20mg/m^2, one-time subcutaneous injection
Experimental: AZA 35mg/m^2; 5-Azacytidine, subcutaneous injection, 35mg/m^2, one subcutaneous injection for duration of study (estimated at 46 - 76 days)	Drug: 5-Azacytidine 35mg/m^2; 5-Azacytidine 35mg/m^2, one-time subcutaneous injection
Experimental: AZA 75mg/m^2; 5-Azacytidine, subcutaneous injection, 75mg/m^2, one subcutaneous injection for duration of study (estimated at 46 - 76 days)	Drug: 5-Azacytidine 75mg/m^2; 5-Azacytidine 75mg/m^2, one-time subcutaneous injection
Placebo Comparator: Placebo for 10mg/m^2; Placebo, subcutaneous injection, 10mg/m^2, one subcutaneous injection without the active treatment for duration of study (estimated at 46 - 76 days)	Drug: Placebo for the AZA 10mg/m^2; Placebo control group for the 10mg/m^2, one-time subcutaneous injection without the active treatment.
Placebo Comparator: Placebo for 20mg/m^2; Placebo, subcutaneous injection, 20mg/m^2, one subcutaneous injection without the active treatment for duration of study (estimated at 46 - 76 days)	Drug: Placebo for the AZA 20mg/m^2; Placebo control group for the 20mg/m^2, one-time subcutaneous injection without the active treatment.
Placebo Comparator: Placebo for 35mg/m^2; Placebo, subcutaneous injection, 35mg/m^2, one subcutaneous injection without the active treatment for duration of study (estimated at 46 - 76 days)	Drug: Placebo for the AZA 35mg/m^2; Placebo control group for the 35mg/m^2, one-time subcutaneous injection without the active treatment.
Placebo Comparator: Placebo for 75mg/m^2; Placebo, subcutaneous injection, 75mg/m^2, one subcutaneous injection without the active treatment for duration of study (estimated at 46 - 76 days)	Drug: Placebo for the AZA 75mg/m^2; Placebo control group for the 75mg/m^2, one-time subcutaneous injection without the active treatment.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Dose-limiting toxicity (DLT).	The percentage of patients experiencing DLT at the predefined dose level will be calculated. This will determine the Maximum Tolerated Dose (MTD), which will be the highest dose level at which ≤ 33% of patients experience a DLT. DLT is defined as toxic effects, presumably related to AZA, considered unacceptable due to their severity and/or irreversibility, thereby limiting further dose escalation. Thus, the total number of toxicities and the DLT at each step of dose escalation and possible de-escalation will be reported. The scale for the primary endpoint is binary (occurrence of DLT or not). It is measured as a single endpoint, as it is focused on whether or not the predefined dose level causes DLT. The currently recommended clinical dose is 75 mg/m2. For the present study, the following AZA concentrations will be evaluated: 10 mg/m2, 20 mg/m2, 35 mg/m2 and 75 mg/m2. For each dose, 3 experimental and 3 placebo subjects will be recruited.	Through study completion, an average of 2 years.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Satellite Cell Fusion Index.	Resident muscle-forming stem cells, called Satellite Cells, will be isolated from the muscle biopsy obtained from subjects and cultured in vitro. Satellite Cell Fusion Index quantifies the proportion of these stem cells that will fuse to form new muscle fibers in vitro (multinucleated structures called myotubes). It provides a measure of the efficiency of subjects' satellite cells to contribute to muscle growth, repair and regeneration.	Through study completion, an average of 2 years.
DNA methylation quantification in Satellite Cells and Blood Mononucleated Cells.	Global DNA methylation analysis will be quantified (% tot DNA in ng) using DNA from Satellite Cell cultures and Blood Mononucleated Cells (isolated form blood) using an ELISA-based global DNA methylation kit.	Through study completion, an average of 2 years.
DNA methylation profiling in Satellite Cells.	Following Satellite Cell isolation, expansion in culture and DNA extractions, qualitative methylation analysis procedures will be conducted using an Infinium Human MethylationEPIC Beadchip array (Illumina Inc., CA), which targets over 850,000 DNA methylation sites at the dinucleotide (CpG) level throughout the entire genome.	Through study completion, an average of 2 years.

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Chromatin immunoprecipitation sequencing (ChIP-seq), and assay for transposase-accessible chromatin sequencing (ATAC-seq)	ChIP-seq will facilitate the genome-wide profiling of changes in chromatin structure and transcription factor binding events in response to AZA treatment and muscle contracture development. This technique is particularly as it can identify alterations in DNA methylation patterns and histone modifications associated with Satellite Cell dysfunction and impaired muscle regeneration. Furthermore, ATAC-seq will offer a complementary approach to ChIP-seq by providing information on chromatin accessibility, which reflects regulatory elements such as enhancers and promoters involved in gene expression control.	Through study completion, an average of 2 years.

Collaborators and Investigators

• Sponsor: Shirley Ryan AbilityLab
• Collaborators: Rady Children's Hospital, San Diego
• Investigators: Principal Investigator: Andrea Domenighetti, PhD, Shirley Ryan AbilityLab; Principal Investigator: Patrick Curran, MD, Rady Children's Hospital, San Diego; Principal Investigator: Richard L. Lieber, PhD, Shirley Ryan AbilityLab

Study record dates

Study Major Dates

• Study Start (Estimated): July 1, 2025
• Primary Completion (Estimated): December 1, 2026
• Study Completion (Estimated): July 1, 2027

Study Registration Dates

• First Submitted: March 5, 2024
• First Submitted That Met QC Criteria: April 16, 2024
• First Posted (Actual): April 22, 2024

Study Record Updates

• Last Update Posted (Actual): July 3, 2025
• Last Update Submitted That Met QC Criteria: June 30, 2025
• Last Verified: June 1, 2025

More Information

Terms related to this study

• Keywords: Azacitidine; Muscle; Contracture; 5-Azacytidine
• Additional Relevant MeSH Terms: Musculoskeletal Diseases; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Muscular Diseases; Joint Diseases; Brain Damage, Chronic; Cerebral Palsy; Contracture; Antineoplastic Agents; Molecular Mechanisms of Pharmacological Action; Enzyme Inhibitors; Antimetabolites, Antineoplastic; Antimetabolites; Azacitidine
• Other Study ID Numbers: 809325

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
• product manufactured in and exported from the U.S.: Yes