Protocol of a randomized, double-blind, placebo-controlled, parallel-group, multicentre study of the efficacy and safety of nicotinamide in patients with Friedreich ataxia (NICOFA)

Kathrin Reetz, Ralf-Dieter Hilgers, Susanne Isfort, Marc Dohmen, Claire Didszun, Kathrin Fedosov, Jennifer Kistermann, Caterina Mariotti, Alexandra Durr, Sylvia Boesch, Thomas Klopstock, Francisco Javier Rodríguez de Rivera Garrido, Ludger Schöls, Thomas Klockgether, Massimo Pandolfo, Rudolf Korinthenberg, Philip Lavin, Geert Molenberghs, Vincenzo Libri, Paola Giunti, Richard Festenstein, Jörg B Schulz, EFACTS or NICOFA study group, Wolfgang Nachbauer, Andreas Eigentler, Elisabetta Indelicato, Matthias Amprosi, Perrine Charles, Claire Ewenczyk, Anna Heinzmann, Florian Holtbernd, Ilaria A Giordano, Okka Kimmich, Florentine Radelfahr, Claudia Stendel, Stefanie Hayer, Mario Fichera, Lorenzo Nanetti, Anna Castaldo, Javier Arpa, Irene Sanz-Gallego, Daphne Babalis, Margarita Durkina, Kathrin Reetz, Ralf-Dieter Hilgers, Susanne Isfort, Marc Dohmen, Claire Didszun, Kathrin Fedosov, Jennifer Kistermann, Caterina Mariotti, Alexandra Durr, Sylvia Boesch, Thomas Klopstock, Francisco Javier Rodríguez de Rivera Garrido, Ludger Schöls, Thomas Klockgether, Massimo Pandolfo, Rudolf Korinthenberg, Philip Lavin, Geert Molenberghs, Vincenzo Libri, Paola Giunti, Richard Festenstein, Jörg B Schulz, EFACTS or NICOFA study group, Wolfgang Nachbauer, Andreas Eigentler, Elisabetta Indelicato, Matthias Amprosi, Perrine Charles, Claire Ewenczyk, Anna Heinzmann, Florian Holtbernd, Ilaria A Giordano, Okka Kimmich, Florentine Radelfahr, Claudia Stendel, Stefanie Hayer, Mario Fichera, Lorenzo Nanetti, Anna Castaldo, Javier Arpa, Irene Sanz-Gallego, Daphne Babalis, Margarita Durkina

Abstract

Introduction: Currently, no treatment that delays with the progression of Friedreich ataxia is available. In the majority of patients Friedreich ataxia is caused by homozygous pathological expansion of GAA repeats in the first intron of the FXN gene. Nicotinamide acts as a histone deacetylase inhibitor. Dose escalation studies have shown, that short term treatment with dosages of up to 4 g/day increase the expression of FXN mRNA and frataxin protein up to the levels of asymptomatic heterozygous gene carriers. The long-term effects and the effects on clinical endpoints, activities of daily living and quality of life are unknown.

Methods: The aim of the NICOFA study is to investigate the efficacy and safety of nicotinamide for the treatment of Friedreich ataxia over 24 months. An open-label dose adjustment wash-in period with nicotinamide (phase A: weeks 1-4) to the individually highest tolerated dose of 2-4 g nicotinamide/day will be followed by a 2 (nicotinamide group): 1 (placebo group) randomization (phase B: weeks 5-104). In the nicotinamide group, patients will continue with their individually highest tolerated dose between 2 and 4 g/d per os once daily and the placebo group patients will be receiving matching placebo. Safety assessments will consist of monitoring and recording of all adverse events and serious adverse events, regular monitoring of haematology, blood chemistry and urine values, regular measurement of vital signs and the performance of physical examinations including cardiological signs. The primary outcome is the change in the Scale for the Assessment and Rating of Ataxia (SARA) over time as compared with placebo in patients with Friedreich ataxia based on the linear mixed effect model (LMEM) model. Secondary endpoints are measures of quality of life, functional motor and cognitive measures, clinician's and patient's global impression-change scales as well as the up-regulation of the frataxin protein level, safety and survival/death.

Perspective: The NICOFA study represents one of the first attempts to assess the clinical efficacy of an epigenetic therapeutic intervention for this disease and will provide evidence of possible disease modifying effects of nicotinamide treatment in patients with Friedreich ataxia.

Trial registration: EudraCT-No.: 2017-002163-17, ClinicalTrials.gov NCT03761511.

Keywords: Ataxia; Clinical study design; Clinical trials; Frataxin; Outcome.

Conflict of interest statement

Competing interestsThe authors declare that they have no competing interests.

© The Author(s) 2019.

Figures

Fig. 1
Fig. 1
NICOFA centres
Fig. 2
Fig. 2
Study Flow Chart

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