Effect of Combination l-Citrulline and Metformin Treatment on Motor Function in Patients With Duchenne Muscular Dystrophy: A Randomized Clinical Trial

Abstract

Importance: Nitric oxide precursors, such as the amino acid l-arginine and the biguanide antidiabetic drug metformin, have been associated with metabolism and muscle function in patients with Duchenne muscular dystrophy (DMD). The treatment of DMD remains an unmet medical need.

Objective: To evaluate the benefits and harms of a combination of l-citrulline and metformin treatment among patients with DMD.

Design, setting, and participants: A single-center randomized double-blind placebo-controlled parallel-group clinical trial was conducted between December 12, 2013, and March 30, 2016, at the University Children's Hospital Basel in Switzerland. A total of 47 ambulant male patients aged 6.5 to 10 years with genetically confirmed DMD were recruited locally and from the patient registries of Switzerland, Germany, Austria, and France. Data were analyzed from April 6, 2016, to September 5, 2019.

Interventions: Patients in the treatment group received 2500 mg of l-citrulline and 250 mg of metformin (combination therapy) 3 times a day for 26 weeks compared with patients in the control group, who received placebo.

Main outcomes and measures: The primary end point was the change in transfer and standing posture, as assessed by the first dimension of the Motor Function Measure, version 32, from baseline to week 26. Secondary end points included assessments of timed function, quantitative muscle force, biomarkers for muscle necrosis, and adverse events. The 2 prespecified subgroups comprised patients who were able to walk 350 m or more in 6 minutes (stable subgroup) and patients who were not able to walk 350 m in 6 minutes (unstable subgroup) at baseline.

Results: Among 49 ambulant male children with DMD who were screened for eligibility, 47 patients with a mean (SD) age of 8.2 (1.1) years were randomized to a treatment group receiving combination therapy (n = 23) or a control group receiving placebo (n = 24), and 45 patients completed the study. No significant differences between groups were found in the results of timed function and muscle force tests for overall, proximal and axial, and distal motor function. Among patients receiving combination therapy, the Motor Function Measure first dimension subscore decrease was 5.5% greater than that of patients receiving placebo (95% CI, -1.0% to 12.1%; P = .09). The administration of combination therapy had significantly favorable effects on the first dimension subscore decrease among the 29 patients in the stable subgroup (6.7%; 95% CI, 0.9%-12.6%; P = .03) but not among the 15 patients in the unstable subgroup (3.9%; 95% CI, -13.2% to 20.9%; P = .63). Overall, the treatment was well tolerated with only mild adverse effects.

Conclusions and relevance: Treatment with combination therapy was not associated with an overall reduction in motor function decline among ambulant patients with DMD; however, a reduction in motor function decline was observed among the stable subgroup of patients treated with combination therapy. The statistically nonsignificant difference of distal motor function in favor of combination therapy and the reduced degeneration of muscle tissue appear to support the treatment concept, but the study may have lacked sufficient statistical power. Further research exploring this treatment option with a greater number of patients is warranted.

Trial registration: ClinicalTrials.gov identifier: NCT01995032.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Laugel reported receiving personal fees from Biogen, PTC Therapeutics, AveXis, Roche, and Sarepta Therapeutics outside the submitted work. Dr Gueven reported receiving grants and personal fees from Santhera Pharmaceuticals outside the submitted work. Dr Fischer reported receiving grants from the Swiss National Science Foundation and the Thomi-Hopf-Stiftung Foundation during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.. CONSORT Flow Diagram

aIndicates the same patient.

Figure 2.. Effect Sizes for Primary End Point and Selected Secondary End Points

In end points for which a decrease indicated an improvement of a test result, a sign reversal was performed to allow comparison. AA indicates amino acids; BCAA, branch chain amino acids; Cit/Met, citrulline and metformin combination therapy; D1, first dimension of the MFM, referring to transfer and standing posture; EAA, essential amino acids; FF, fat fraction; MFM, Motor Function Measure; NEAA, nonessential amino acids; qMRI, quantitative magnetic resonance imaging; 6-MWD, 6-minute walking distance; and T2, transverse weighted relaxation time.