Sodium-glucose Linked Transporter 2 (SGLT-2) Inhibitors in Recurrent Ascites: a Pilot RCT
The development of ascites is a landmark event in the natural history of cirrhosis and signifies a grim prognosis. Portal hypertension and splanchnic arterial vasodilatation are the major contributors in the development of ascites. Vasodilatation with the consequential decrease in effective circulating volume leads to the activation of sympathetic nervous system and renin angiotensin aldosterone system (RAAS), leading to antinatriuretic effects and retention of sodium and water. This results in the formation of ascites. Management of ascites primarily consists of salt restrictrion and diuretics. Liver transplant is the ultimate panacea.
Dapaglifozin, a Sodium glucose linked transporter-2(SGLT-2) inhibitor, is a part of the routine armamentarium for treatment of patients with Diabetes Mellitus type-2. Its safety is well established in non-diabetic patients too where it has been shown to improve cardiovascular outcomes. The risk of hypoglycemia is negligible as its action is independent of insulin. By virtue of its natriuretic effect, it has been shown to reduce hospitalisations in patients with heart failure irrespective of the presence of diabetes. We hypothesise that a similar natriuretic effect may help in suppressing the renin-angiotensin axis with improved mobilization of ascites in patients with cirrhosis. Pharmacokinetic data on the use of Dapaglifozin suggest that there is no need for dose modification in cirrhosis. The AUC and Cmax for Dapaglifozin in Child Pugh C cirrhosis is 67% and 40%, respectively. In a recent small case series, SGLT-2 inhibitors including dapaglifozin led to improvement in fluid retention and serum sodium, without acute kidney injury or encephalopathy, in patients with cirrhosis. However, SGLT-2 inhibitors have not been evaluated in randomized controlled trials. In this pilot study, we plan to evaluate the efficacy and safety of dapaglifozin in cirrhotics patients with recurrent ascites.
研究概览
地位
研究类型
注册 (预期的)
阶段
- 阶段2
联系人和位置
学习联系方式
- 姓名:Virendra Singh, MD,DM,FASGE
- 电话号码:0172-275-6338
- 邮箱:virendrasingh100@hotmail.com
研究联系人备份
- 姓名:Rishav Aggarwal, MBBS
- 电话号码:9914032190
- 邮箱:rishavaggarwal90@gmail.com
学习地点
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Chandigarh、印度、160012
- 招聘中
- Dept of Hepatology, PGIMER
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接触:
- Virendra Singh, MD, DM
- 电话号码:+911722756338
- 邮箱:virendrasingh100@hotmail.com
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参与标准
资格标准
适合学习的年龄
接受健康志愿者
有资格学习的性别
描述
Inclusion Criteria:
- Age 18-70 years
- Cirrhosis as determined by clinical findings, hemogram and liver function tests, endoscopic findings and imaging
- Recurrent ascites: Recurrent ascites will be defined as tense ascites recurring at least thrice within the last 1-year despite optimal standard medical treatment including large volume paracentesis and diuretics
Exclusion Criteria:
- Presence of chronic kidney disease as defined by an estimated glomerular filtration rate of <60 ml/min for more than 3 months. The MDRD-6 equation will be used for estimating GFR.
- Portal vein thrombosis
- Hepatocellular carcinoma.
- Gastrointestinal bleed in the preceding 2-weeks
- Overt hepatic encephalopathy in the preceding 1-month
- Documented hypoglycemia in the preceding 1-month
- Serum sodium < 125 meq/l
- History of skeletal fracture in the preceding year or any past history of fragility fracture
- History of peripheral vascular disease
- Acute kidney injury as defined by the International Club of Ascites criteria
- Infection within 1-month preceding the study
- Anatomic urologic defects that predispose to urinary tract infection
- Mixed ascites (additional etiology of ascites apart from portal hypertension)
- Any severe extra hepatic condition including respiratory and cardiac failure
- Acute-on-chronic liver failure as per the APASL or CANONIC criteria
- Treatment with drug with known effects on systemic and renal hemodynamics within 7 days of inclusion excepting beta-blockers
- Patients opting for liver transplant or TIPS
- Refusal to give consent
学习计划
研究是如何设计的?
设计细节
- 主要用途:治疗
- 分配:随机化
- 介入模型:并行分配
- 屏蔽:四人间
武器和干预
参与者组/臂 |
干预/治疗 |
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有源比较器:Group A (Dapaglifozin)
Group A will receive oral Dapaglifozin (10 mg/day) along with standard medical therapy for 6 months
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Oral Dapaglifozin (10 mg/day) along with standard medical therapy will be given to Group A while a placebo of dapaglifozin along with standard medical therapy will be used in Group B
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安慰剂比较:Group B (Placebo)
Group B will receive placebo of Dapaglifozin along with standard medical therapy for 6 months
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Standard medical therapy will include dietary restriction of sodium, treatment with diuretics, repeated LVP as needed and other supportive care.
Patients on non-selective beta blockers will continue to do so with dose modifications/withdrawal as per Baveno VI guidelines.
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研究衡量的是什么?
主要结果指标
结果测量 |
措施说明 |
大体时间 |
---|---|---|
control of ascites at 6-months
大体时间:6 months
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Control of ascites will be defined as follows-
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6 months
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次要结果测量
结果测量 |
措施说明 |
大体时间 |
---|---|---|
Change in eGFR measured by MDRD-6 at 3 months and 6 months
大体时间:6 months
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eGFR will be measured by MDRD-6 formula
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6 months
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Change in urine output at 2-weeks, 3-months and 6-months
大体时间:6-months
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Change in 24-hour urine output (ml) at 6-months
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6-months
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Change in serum sodium (mEq/l) at 2-weeks, 3-months and 6 months
大体时间:6 months
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Change in serum sodium (mEq/l)
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6 months
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Change in 24-hours urinary sodium (mEq) at 2 weeks, 3 months and 6 months
大体时间:6 months
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Change in 24-hours urinary sodium (mEq)
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6 months
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Change in HbA1c at 3 and 6 months
大体时间:6 months
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Change in HbA1c
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6 months
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Change in Child-Turcotte-Pugh (CTP) score at 3 months and 6 months
大体时间:6 months
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Change in CTP score.
The CTP score incorporates the variables of serum bilirubin, albumin, prothrombin time-INR, grade of ascites and hepatic encephalopathy.
The score ranges from 5-15 and a higher score portends a worse prognosis
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6 months
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Change in model for end stage liver disease (MELD) score at 3 months and 6 months
大体时间:6 months
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Change in MELD score.
The MELD score incorporates the variables of serum bilirubin, creatinine and Internation Normalised Ratio (INR).
Higher MELD score indicates worse prognosis
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6 months
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Incidence of spontaneous bacterial peritonitis (SBP), urinary tract infection (UTI) and other infections
大体时间:6 months
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The diagnosis of SBP will be based on neutrophil count in ascitic fluid of >250/mm3 as determined by microscopy and positive ascitic fluid culture or >250 /mm3 with negative culture called as culture negative neutrocytic ascites.Other infections will be diagnosed as per CDC criteria.
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6 months
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Incidence of overt hepatic encephalopathy over 6-months
大体时间:6 months
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Over hepatic encephalopathy (HE) will be defined as grade II or higher HE as per the West haven classification
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6 months
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Incidence of acute kidney injury over 6-months
大体时间:6 months
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Acute kidney injury will be defined as per the International Club of Ascites criteria
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6 months
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Incidence of Hyponatremia (serum sodium <130 meq/L), hypokalemia (Serum potassium < 3.5 meq/L), hyperkalemia (Serum potassium >6meq/L) over 6-months.
大体时间:6 months
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Hyponatremia: serum sodium <130 meq/L hypokalemia: serum potassium < 3.5 meq/L hyperkalemia: serum potassium >6meq/L)
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6 months
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Incidence of skeletal fractures over 6-months
大体时间:6 months
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Incidence of skeletal fractures over 6-months
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6 months
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Change in bone densitometry as assessed by DEXA at 6-months
大体时间:6 months
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Bone densitometry will be assessed by DEXA
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6 months
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Incidence of diabetic ketoacidosis or hyperglycemic hyperosmolar nonketotic coma over 6-months
大体时间:6 months
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Incidence of diabetic ketoacidosis or hyperglycemic hyperosmolar nonketotic coma over 6-months
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6 months
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Incidence of hepatocellular carcinoma over 6-months
大体时间:6 months
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Hepatocellular carcinoma will be diagnosed based on imaging findings and AFP
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6 months
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Changes in plasma renin activity and aldosterone levels at 6- months
大体时间:6 months
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Changes in plasma renin activity (ng/ml/hr) and aldosterone (ng/dL) levels at 6- months
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6 months
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Frequency and volume of LVP over 6-months.
大体时间:6 months
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Frequency and volume of ascitic fluid removed (in litres) over 6-months.
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6 months
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Survival at 6-months
大体时间:Survival at 6-months
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Survival at 6-months after start of therapy
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Survival at 6-months
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Safety of dapaglifozin as assessed by adverse effects
大体时间:6 months
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Safety of dapaglifozin as assessed by adverse effects
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6 months
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Renal resistive index at 6 months
大体时间:6 months
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Renal resistive index will be measured using ultrasound doppler interrogation of intrarenal arteries using formula (peak systolic velocity - end-diastolic velocity) / peak systolic velocity
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6 months
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合作者和调查者
研究记录日期
研究主要日期
学习开始 (实际的)
初级完成 (预期的)
研究完成 (预期的)
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首次提交
首先提交符合 QC 标准的
首次发布 (实际的)
研究记录更新
最后更新发布 (实际的)
上次提交的符合 QC 标准的更新
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