The Role of Bacterial Overgrowth and Delayed Intestinal Transit in Hepatic Encephalopathy - Full Text View

Sponsor:	Weill Medical College of Cornell University
Collaborator:	Salix Pharmaceuticals
Information provided by:	Weill Medical College of Cornell University
ClinicalTrials.gov Identifier:	NCT00281502

Purpose

The study will be conducted in two phases. Phase A will evaluate the contribution of bacterial overgrowth and colonic inertia to development of Hepatic Encephalopathy (HE)in 50 ambulatory subjects with HE and hepatitis C cirrhosis. This phase will include a Screening and Evaluation Visit.

Phase B will evaluate the effect of rifaximin on bacterial outgrowth and severity of HE in 20 of the subjects enrolled in Phase A who have a somewhat greater degree of encephalopathy.

The purpose of this study is to evaluate the following:

the relationship between bacterial overgrowth and the presence and severity of HE in patients with hepatitis C cirrhosis;
the effectiveness and tolerability of rifaximin relative to placebo in treatment of HE associated with hepatitis C cirrhosis;
the relationship between bacterial overgrowth and the presence and severity of HE before and after rifaximin treatment.

Condition	Intervention	Phase
Hepatic Encephalopathy Hepatitis C Liver Cirrhosis	Drug: Rifaximin (drug)	Phase II

Study Type:	Interventional
Study Design:	Treatment, Randomized, Double Blind (Subject, Investigator, Outcomes Assessor), Placebo Control, Crossover Assignment, Efficacy Study
Official Title:	The Role of Bacterial Overgrowth and Delayed Intestinal Transit in Hepatic Encephalopathy. Phase A: Breath Testing and Colonic Transit in Hepatic Encephalopathy. Phase B: A Randomized Double Blind, Placebo Controlled Trial of Rifaximin for Hepatic Encephalopathy

Resource links provided by NLM:

MedlinePlus related topics: Cirrhosis Hepatitis Hepatitis C

Drug Information available for: Rifaximin

U.S. FDA Resources

Further study details as provided by Weill Medical College of Cornell University:

Primary Outcome Measures:

Phase A: Degree of bacterial overgrowth and its correlation with the grade of hepatic encephalopathy (if present) [ Time Frame: 3 months ] [ Designated as safety issue: No ]
Phase B: Improvement in the psychometric scores and proportion of patients who change of HE stage [ Time Frame: 3 months ] [ Designated as safety issue: No ]

Secondary Outcome Measures:

Improved Intestinal transit time [ Time Frame: 3 months ] [ Designated as safety issue: No ]
Improvement in bacterial overgrowth [ Time Frame: 3 months ] [ Designated as safety issue: Yes ]
Improved insomnia [ Time Frame: 3 months ] [ Designated as safety issue: No ]
Improved flatulence [ Time Frame: 3 months ] [ Designated as safety issue: No ]
Improved quality of life. [ Time Frame: 3 months ] [ Designated as safety issue: No ]

Estimated Enrollment:	50
Study Start Date:	December 2005
Estimated Study Completion Date:	December 2012
Estimated Primary Completion Date:	December 2012 (Final data collection date for primary outcome measure)

Intervention Details:

Rifaximin 400mg three (3) times daily

Detailed Description:

Hepatic encephalopathy is a frequent and occasionally refractory complication of cirrhosis and is associated with impaired quality of life. Its severity may not correlate with other parameters of liver dysfunction. Although multiple pathogenic mechanisms for the condition have been proposed, most include the participation of bacterial toxins, especially ammonia, produced in the gastrointestinal tract. Treatment options for hepatic encephalopathy at this time are limited to lactulose and neomycin. Lactulose is frequently poorly tolerated, and many patients are non-compliant with its use. In patients with renal insufficiency in whom hepatic encephalopathy is frequently problematic, use of neomycin is contraindicated due to ototoxicity and nephrotoxicity.

Autonomic dysfunction is common in patients with cirrhosis and could contribute to the development of hepatic encephalopathy by impairment of intestinal motility, leading to bacterial overgrowth and colonic inertia.

The following questions will be addressed:

A. Is impaired intestinal transit and bacterial overgrowth associated with the presence and severity of hepatic encephalopathy?

50 patients will undergo a detailed clinical evaluation for severity of liver disease, hepatic encephalopathy and assessment of intestinal transit and bacterial overgrowth with radiographic marker study and breath test analysis. Multivariate analysis will then be performed to determine the relationship of intestinal transit and evidence of bacterial overgrowth with the presence and severity of hepatic encephalopathy.

B. Does treatment with rifaximin improve bacterial overgrowth and hepatic encephalopathy?

20 patients from the above population with significant encephalopathy will be randomized to receive either rifaximin or placebo. Post-treatment evaluation for severity of hepatic encephalopathy and breath test analysis for bacterial overgrowth will then be performed. The effect of treatment on changes in hepatic encephalopathy and bacterial overgrowth and the relationship between changes in bacterial overgrowth and severity of hepatic encephalopathy will also be assessed.

Phase A Endpoints: Degree of bacterial overgrowth and its correlation with the grade of hepatic encephalopathy (if present).

Phase B Endpoints: To demonstrate improvement in degree of HE with treatment of Rifaximin

Efficacy Endpoints The primary efficacy endpoint for Phase B of the study will be the change from baseline in the proportion of patients with no HE, minimal HE (no symptoms, abnormal psychometric testing), mild persistent HE (mild symptoms), and persistent Stage II HE (presence of asterixis, history of hospitalization for spontaneous Stage III or IV HE).

Secondary efficacy endpoints for Phase B will be the following:

To demonstrate improvement in intestinal transit time for patients (based on Lactulose Hydrogen Breath Test) To demonstrate improvement in bacterial overgrowth, improved insomnia, flatulence, and quality of life.

To demonstrate that rifaximin improved patients' symptoms of insomnia, flatulence, and quality of life measure with the degree of bacterial overload and the impaired intestinal transit time.

Eligibility

Ages Eligible for Study:	18 Years to 75 Years
Genders Eligible for Study:	Both
Accepts Healthy Volunteers:	No

Criteria

Phase A Inclusion Criteria:

Subject is 18 to 70 years of age, inclusive.
Subject has cirrhosis due to chronic HCV infection as documented by:
Subject has evidence of hepatic encephalopathy as evidenced by:
Neuro-psychometric Testing (Number Connection Test, Trails Test, etc.)
Subject is non-azotemic (creatinine <1.5mg/dL) and ambulatory at screening.
Subject has cirrhosis due to chronic HCV as documented by: pathologic or clinical and radiographic evidence of cirrhosis with a positive HCV RNA PCR level.

Phase A Exclusion Criteria:

Subject has received active interferon therapy within 2 weeks of enrollment.
Subject is pregnant or lactating.
Subject has a life expectancy of less than 100 days.
Subject has a history of alcohol abuse within 6 months of enrollment.
Subject has active gastrointestinal bleeding at time of enrollment.
Subject has used an agent that alters intestinal motility, eg, methadone, cholestyramine, tricyclic antidepressants.
Subject is unable to take oral medication.
Subject has used neomycin or other antibiotic within 2 weeks of enrollment or is actively using lactulose at time of enrollment.
Subject is taking or has hypersensitivity or allergy to rifaximin or rifampin.
Subject requires long term antibiotic therapy (eg, Lyme Disease, tuberculosis).
Subject has known or suspected alcohol abuse or illicit drug use within 1 year of enrollment.
Subject has participated in an investigational drug or device study within the 30 days prior to randomization.
Subject has received rifaximin within the last 30 days.
Subject has concomitant disease or condition that could interfere with, or for which treatment could interfere with the conduct of the study, or could in the opinion of the investigator increase the risk of AEs for the subject's participation in the study.
Subject is unwilling or unable to comply with the study protocol for any other reason.
Subject has been diagnosed with other forms of liver disease, including those with HIV and HBV co-infection, as determined by history, serological parameters, and histology when available.
Subject has been diagnosed with a major psychiatric illness, chronic renal and/or respiratory insufficiency, intercurrent infections, treatment with sedatives within 7 days of enrollment.
Subject shows presence of intestinal obstruction or inflammatory bowel disease, antacids or cathartics within the 12h before study start; antibiotics during 7 days before start of dosing; or treated with encephalopathy-causing agents.
Subjects with bad vision or neurological diseases since they could have difficulty completing the neuropsychological assessments.

Phase B Inclusion Criteria

Subject successfully participated in and continues to meet all eligibility criteria required in Phase A of the study based on completion of tests, Breath Tests, and Radiological Marker.
Subject has a Number Connection Test score >50 sec at time of enrollment.

Phase B Exclusion Criteria

A subject will not be eligible for inclusion in Phase B if (s)he meets any of the exclusion criteria for Phase A of the study.

Contacts and Locations

Please refer to this study by its ClinicalTrials.gov identifier: NCT00281502

Contacts

Contact: Sam Sigal, M.D.

646 962-5483

shs2015@med.cornell.edu

Locations

United States, New York
New York Presbyterian Hospital: Weill Medical College of Cornell University	Recruiting
New York, New York, United States, 10021
Contact: Sam Sigal, M.D. 212-746-4129 shs2015@med.cornell.edu
Principal Investigator: Sam Sigal, M.D.
Sub-Investigator: Brian P. Bosworth, M.D.
Sub-Investigator: Ilan Weisberg, M.D.

Sponsors and Collaborators

Weill Medical College of Cornell University

Salix Pharmaceuticals

Investigators

Principal Investigator:

Sam Sigal, M.D.

Weill Medical College of Cornell University

More Information

Publications:

Ferenci P, Lockwood A, Mullen K, Tarter R, Weissenborn K, Blei AT. Hepatic encephalopathy--definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th World Congresses of Gastroenterology, Vienna, 1998. Hepatology. 2002 Mar;35(3):716-21.

Arguedas MR, DeLawrence TG, McGuire BM. Influence of hepatic encephalopathy on health-related quality of life in patients with cirrhosis. Dig Dis Sci. 2003 Aug;48(8):1622-6.

Groeneweg M, Moerland W, Quero JC, Hop WC, Krabbe PF, Schalm SW. Screening of subclinical hepatic encephalopathy. J Hepatol. 2000 May;32(5):748-53.

Groeneweg M, Quero JC, De Bruijn I, Hartmann IJ, Essink-bot ML, Hop WC, Schalm SW. Subclinical hepatic encephalopathy impairs daily functioning. Hepatology. 1998 Jul;28(1):45-9.

Amodio P, Del Piccolo F, Marchetti P, Angeli P, Iemmolo R, Caregaro L, Merkel C, Gerunda G, Gatta A. Clinical features and survivial of cirrhotic patients with subclinical cognitive alterations detected by the number connection test and computerized psychometric tests. Hepatology. 1999 Jun;29(6):1662-7.

Bustamante J, Rimola A, Ventura PJ, Navasa M, Cirera I, Reggiardo V, Rodes J. Prognostic significance of hepatic encephalopathy in patients with cirrhosis. J Hepatol. 1999 May;30(5):890-5.

Responsible Party:	Weill Medical College of Cornell University ( Sam Sigal )
Study ID Numbers:	Salix-RifaxPSE-BactOvrGrwth-01
Study First Received:	January 20, 2006
Last Updated:	April 30, 2009
ClinicalTrials.gov Identifier:	NCT00281502 History of Changes
Health Authority:	United States: Food and Drug Administration

Keywords provided by Weill Medical College of Cornell University:

Hepatic Encephalopathy
Hepatitis C
Liver Cirrhosis
Bacterial Overgrowth

Additional relevant MeSH terms:

Anti-Infective Agents
Liver Diseases
Neurotoxicity Syndromes
Flaviviridae Infections
Fibrosis
Brain Damage, Chronic
Disorders of Environmental Origin
Hepatitis, Viral, Human
Central Nervous System Viral Diseases
Liver Cirrhosis
Brain Diseases
Signs and Symptoms
Pathologic Processes
Mental Disorders
Therapeutic Uses

Hepatitis C
Neurobehavioral Manifestations
Hepatic Insufficiency
Delirium
Liver Failure
RNA Virus Infections
Metabolic Diseases
Nervous System Diseases
Gastrointestinal Agents
Poisoning
Central Nervous System Diseases
Confusion
Pharmacologic Actions
Encephalitis
Hepatitis

ClinicalTrials.gov processed this record on February 08, 2010