Glutathione in Diabetic Nephropathy (CGDN)
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Purpose
The study is done to find out whether the combined use of the nutritional supplements N-acetylcysteine and Siliphos (milk thistle extract) corrects the shedding of urine protein and oxidative damage (damage to cells and organs often compared to fast aging) in patients with Type 2 Diabetes Mellitus (T2DM) and diabetic kidney disease.
| Condition | Intervention | Phase |
|---|---|---|
|
Diabetic Nephropathy Proteinuria Oxidative Stress |
Drug: N-acetylcysteine placebo + silibin placebo Drug: N-acetylcysteine active + silibin placebo Drug: N-acetylcysteine placebo + silibin active Drug: N-acetylcysteine active + silibin active Drug: N-acetylcysteine active + high-dose silibin active |
Phase 2 |
| Study Type: | Interventional |
| Study Design: | Allocation: Randomized Endpoint Classification: Safety/Efficacy Study Intervention Model: Parallel Assignment Masking: Double Blind (Subject, Caregiver, Investigator, Outcomes Assessor) Primary Purpose: Treatment |
| Official Title: | Correction of Glutathione Deficiency for Treatment of Diabetic Nephropathy |
- Change from baseline in urinary albumin excretion [ Time Frame: 3-month ] [ Designated as safety issue: No ]
- Change from baseline in urinary alpha-1 microglobulin excretion [ Time Frame: 3-month ] [ Designated as safety issue: No ]
- Change from baseline in urinary C-C-chemokines excretion [ Time Frame: 3-month ] [ Designated as safety issue: No ]
- Change from baseline in peripheral blood monocyte glutathione content [ Time Frame: 3-month ] [ Designated as safety issue: No ]
- adverse events [ Time Frame: 1-month ] [ Designated as safety issue: Yes ]
- Change from baseline in hemoglobin level [ Time Frame: 1-month ] [ Designated as safety issue: Yes ]
- Change from baseline in serum electrolytes [ Time Frame: 1-month ] [ Designated as safety issue: Yes ]
- Change from baseline in estimated glomerular filtration rate [ Time Frame: 1-month ] [ Designated as safety issue: Yes ]
- Change from baseline in measured glomerular filtration rate [ Time Frame: 3-month ] [ Designated as safety issue: Yes ]
- Change from baseline in hemoglobin-A1c [ Time Frame: 1-month ] [ Designated as safety issue: Yes ]
| Estimated Enrollment: | 110 |
| Study Start Date: | January 2011 |
| Estimated Study Completion Date: | December 2014 |
| Estimated Primary Completion Date: | June 2014 (Final data collection date for primary outcome measure) |
| Arms | Assigned Interventions |
|---|---|
|
Placebo Comparator: Arm 1
N-acetylcysteine placebo + silibin placebo Dietary Supplement: N-acetylcysteine placebo excipient orally twice daily for three months Other Name: NAC placebo Dietary Supplement: silibin placebo excipient orally twice daily for three months Other Name: silibin-phosphatidylcholine placebo, Siliphos placebo
|
Drug: N-acetylcysteine placebo + silibin placebo
Dietary Supplement: N-acetylcysteine placebo excipient orally twice daily for three months
Other Name: NAC placebo Dietary Supplement: silibin placebo excipient orally twice daily for three months Or silibin-phosphatidylcholine placebo, Siliphos placebo
|
|
Experimental: Arm 2
N-acetylcysteine active + silibin placebo Dietary Supplement: N-acetylcysteine 600 mg orally twice daily for three months Other Name: NAC Dietary Supplement: silibin placebo excipient orally twice daily for three months Other Name: silibin-phosphatidylcholine placebo, Siliphos placebo
|
Drug: N-acetylcysteine active + silibin placebo
Dietary Supplement: N-acetylcysteine 600 mg orally twice daily for three months
Other Name: NAC Dietary Supplement: silibin placebo excipient orally twice daily for three months Or Silibin-phosphatidylcholine placebo, Siliphos placebo
|
|
Experimental: Arm 3
N-acetylcysteine placebo + silibin active Dietary Supplement: silibin 480 mg orally twice daily for three months Other Name: silibin-phosphatidylcholine, Siliphos Dietary Supplement: N-acetylcysteine placebo excipient orally twice daily for three months Other Name: NAC placebo Dietary Supplement: silibin placebo excipient orally twice daily for three months Other Name: silibin-phosphatidylcholine placebo, Siliphos placebo
|
Drug: N-acetylcysteine placebo + silibin active
Dietary Supplement: silibin 480 mg orally twice daily for three months
Other Name: Silibin-phosphatidylcholine, Siliphos Dietary Supplement: N-acetylcysteine placebo excipient orally twice daily for three months
|
|
Experimental: Arm 4
N-acetylcysteine active + silibin active Dietary Supplement: N-acetylcysteine 600 mg orally twice daily for three months Other Name: NAC Dietary Supplement: silibin 480 mg orally twice daily for three months Other Name: silibin-phosphatidylcholine, Siliphos Dietary Supplement: silibin placebo excipient orally twice daily for three months Other Name: silibin-phosphatidylcholine placebo, Siliphos placebo
|
Drug: N-acetylcysteine active + silibin active
Dietary Supplement: N-acetylcysteine 600 mg orally twice daily for three months
Other Name: Silibin-phosphatidylcholine placebo, Siliphos placebo
|
|
Experimental: Arm 5
N-acetylcysteine active + high-dose silibin active Dietary Supplement: N-acetylcysteine 600 mg orally twice daily for three months Other Name: NAC Dietary Supplement: high-dose silibin 960 mg orally twice daily for three months Other Name: silibin-phosphatidylcholine, Siliphos
|
Drug: N-acetylcysteine active + high-dose silibin active
Dietary Supplement: N-acetylcysteine 600 mg orally twice daily for three months
Other Name: NAC Dietary Supplement: high-dose silibin 960 mg orally twice daily for three months Or Other Name: Silibin-phosphatidylcholine, Siliphos
|
Detailed Description:
Oxidative stress and glutathione (GSH) imbalance are major contributors to the pathogenesis of diabetic nephropathy. Current options for the treatment of oxidative stress in diabetic nephropathy are limited and only partially effective, thus interest in the development of new strategies is high.
The study intends to test the hypothesis that combined oral supplementation of the antioxidants N-acetylcysteine (NAC) and milk thistle flavonolignan silibin (as silibin-phosphatidylcholine) will reduce proteinuria and urinary and systemic manifestations of oxidative stress and inflammation, which are characteristically observed in patients with T2DM and related nephropathy. We expect these effects to be achieved with minimal or no side effects, and with good patient tolerance.
The trial is designed as a two-center, double-blind, placebo-controlled, randomized, modified-factorial dose-ranging design, five-arm pilot study in patients with Type 2 diabetes mellitus and advanced diabetic nephropathy with proteinuria.
Intervention consists of three-month oral administration of NAC, silibin, and/or respective placebos for three months. Subjects are randomized to the following five intervention arms: (A) placebo; (B) NAC; (C) silibin; (D) NAC + silibin; and (E) NAC + double-dose silibin.
The primary outcome measure is urinary excretion of albumin, a marker of glomerular injury. Secondary outcome measures are alpha-1 microglobulin, a marker of tubular injury, and urinary excretion of inflammatory cytokines and C-C chemokines, i.e. markers of renal inflammation. In addition, peripheral blood monocytes from the same patients are analyzed for GSH content and activity of GSH metabolizing enzymes. All outcome measures are monitored in relation to both treatment allocation and prevalent blood and urine levels of the active treatment. Safety and tolerability of this combination treatment are monitored throughout the trial.
Eligibility| Ages Eligible for Study: | 18 Years to 76 Years |
| Genders Eligible for Study: | Both |
| Accepts Healthy Volunteers: | No |
Inclusion Criteria:
- Males or females age 18-76 years old
- Type 2 diabetes mellitus
Diabetic nephropathy, as defined by:
- estimated GFR between 60 and 15 ml/min
- presence of proteinuria
- Current medical treatment with low dose aspirin
Treatment of hypertension with (but not limited to):
- one diuretic
- one beta-blocker
- and one medication from the classes Angiotensin Receptor Blockers (ARBs) or Angiotensin Converting Enzyme inhibitors (ACE-I)
- Treatment of hyperglycemia with (but not limited to) glipizide and the medication class insulin
- Treatment of hypercholesterolemia with (but not limited to) one medication from the class statins
Exclusion Criteria:
- Type 1 diabetes mellitus
- Glycosylated hemoglobin (HbA1C) > 10%
- >20% variation in estimated GFR, during last 6 months
- Systolic Blood Pressure >170 mmHg or Diastolic Blood Pressure >100 mmHg on medications
- Other secondary forms of hypertension (endocrine, renovascular)
History of intolerance to:
- Both ACE-I and ARBs
- The investigational supplements
- Iodinated radiologic contrast material
- Known non diabetic renal disease
- or history of solid organ transplantation
- Hepatitis virus or Human Immunodeficiency virus infections
Use of one of the following medications within 2 months prior to enrollment in the study:
- Metformin
- Thiazolidinediones (pioglitazone or rosiglitazone)
- Phenytoin
- Warfarin
- Prescription-grade vitamin E, vitamin C, systemic steroids, and/or non-steroidal anti-inflammatory agents
- Over-the-counter vitamin E, vitamin C, and/or non-steroidal anti-inflammatory agents
Over-the-counter antioxidants supplements including:
- Lipoic acid
- Coenzyme Q10
- N-acetyl-cysteine (NAC)
- Glutathione (GSH)
- Chromium
- Fish-oil extracts (omega-3 fatty acids)
- Soy extracts (isoflavones)
- Milk thistle extract (silymarin)
- Green-tea preparations
- Pomegranate extracts
- Grape extracts
- Prickly pear extract
- Active coronary artery disease or cerebral vascular disease within 3 months prior to signing the informed consent
- Hepatic dysfunction as defined by abnormal total bilirubin or liver enzymes (ALT, AST) >2 times upper limit of normal range
- Active malignancy
- History of drug or alcohol dependency
- Psychiatric or neurological condition, preventing aware consent to the study and/or adherence to the study protocol
- Unwillingness to practice birth control throughout the study
- Participation to another clinical study within 1 month prior to signing the informed consent form
- Planned move to outside the study area, surgery or radiographic studies utilizing iodine-based contrast material within the next one year
Contacts and Locations| Contact: Sue Cunningham, PhD | (210) 567-8836 | cunninghams@uthscsa.edu |
| Contact: Lih-Lan Hu, MPH | (210) 567-5882 | hus@livemail.uthscsa.edu |
| United States, Texas | |
| VA South Texas Health Care System, San Antonio | Recruiting |
| San Antonio, Texas, United States, 78229 | |
| Contact: Sue Cunningham, PhD 210-567-8836 cunninghams@uthscsa.edu | |
| Contact: Lih-Lan Hu, MPH (210) 567-5882 hus@livemail.uthscsa.edu | |
| Principal Investigator: Paolo Fanti, MD | |
| Principal Investigator: | Paolo Fanti, MD | VA South Texas Health Care System, San Antonio |
More Information
Publications:
| Responsible Party: | Department of Veterans Affairs |
| ClinicalTrials.gov Identifier: | NCT01265563 History of Changes |
| Other Study ID Numbers: | CLIN-004-10S, 1R21AT004490-01A1, VA 1I01CX000264-01A2 |
| Study First Received: | December 10, 2010 |
| Last Updated: | February 1, 2013 |
| Health Authority: | United States: Federal Government |
Keywords provided by Department of Veterans Affairs:
|
silymarin glutathione diabetic nephropathies oxidative stress |
Additional relevant MeSH terms:
|
Proteinuria Diabetic Nephropathies Kidney Diseases Urologic Diseases Diabetes Complications Diabetes Mellitus Endocrine System Diseases Urination Disorders Urological Manifestations Signs and Symptoms Acetylcysteine N-monoacetylcystine Silybin |
Antiviral Agents Anti-Infective Agents Therapeutic Uses Pharmacologic Actions Expectorants Respiratory System Agents Free Radical Scavengers Antioxidants Molecular Mechanisms of Pharmacological Action Protective Agents Physiological Effects of Drugs Antidotes |
ClinicalTrials.gov processed this record on May 19, 2013