Long-term Outcome of N-Carbamylglutamate Treatment in Propionic Acidemia and Methylmalonic Acidemia - Full Text View

Purpose

Background: Very few drugs exist that treat hyperammonemia, specifically PA and MMA. Diet restrictions and alternate pathway agents are the current primary treatments, but they frequently fail to prohibit brain damage.

Orthotopic liver transplantation cures the hyperammonemia of urea cycle disorders, but organ availability is limited and the procedure is highly invasive and requires life-long immunosuppression.

A drug that could repair or stimulate a dysfunctional urea cycle such as this would have several advantages over current therapy. A drug called N-carbamyl-L-glutamate, Carglumic acid (NCG or Carbaglu)has recently been found to be virtually curative of another urea cycle defect called NAGS deficiency. In this disorder, treatment with NCG alone normalizes ureagenesis, blood ammonia and glutamine levels, allows normal protein tolerance and restores health. Knowledge from this study is being applied to acquired hyperammonemia, specifically in patients with propionic PA and MMA, to try and improve neurodevelopmental outcomes by improving the hyperammonemia.

Aims: The overall objective of this project is to determine whether treatment of acute hyperammonemia with Carglumic acid in propionic acidemia (PA), methylmalonic acidemia (MMA) changes the long-term outcome of disease and to determine if it is effective in restoring urine ammonia levels to normal levels.

Condition	Intervention	Phase
Propionic Acidemia (PA) Methylmalonic Acidemia (MMA)	Drug: N-carbamylglutamate Other: Standard of Care	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:	Long-term Outcome of N-Carbamylglutamate Treatment in Propionic Acidemia and Methylmalonic Acidemia

Resource links provided by NLM:

Genetics Home Reference related topics: N-acetylglutamate synthase deficiency argininosuccinic aciduria citrullinemia methylmalonic acidemia ornithine translocase deficiency propionic acidemia

Drug Information available for: Carglumic acid

Genetic and Rare Diseases Information Center resources: Propionic Acidemia Methylmalonic Acidemia Inborn Amino Acid Metabolism Disorder

U.S. FDA Resources

Further study details as provided by Children's Research Institute:

Primary Outcome Measures:

Neurodevelopment [ Time Frame: Intake through 7 days or discharge ] [ Designated as safety issue: No ]
Neurodevelopmental outcome as measured by Cognitive Composite (Bayley III), Motor Composite (Bayley III) and Functional Status Scale and safety of NCG treatment as measured by adverse events and laboratory blood tests

Secondary Outcome Measures:

Safety and Efficacy [ Time Frame: Intake through 7 days or discharge ] [ Designated as safety issue: Yes ]
Safety as measured by adverse events. Efficacy as measured by resolution of hyperammonemia.


Enrollment:	1
Study Start Date:	September 2012
Study Completion Date:	February 2015
Primary Completion Date:	February 2015 (Final data collection date for primary outcome measure)

Arms	Assigned Interventions
Experimental: Carbaglu Active NCG & Standard of Care	Drug: N-carbamylglutamate Active NCG & Standard of Care Chemical Composition: N-carbamyl-L-glutamic acid (NCG) The daily dose will be 100 mg/kg/ day. The doses are to be divided into 2 equal doses and administered orally or enterally by nasogastric or gastrostomy tube (standard of care will prevail when choosing the mode of drug administration). The tablets must be dispersed in a minimum of 2.5-10 ml of water and ingested immediately or administered by fast push through a syringe via a nasogastric or gastrostomy tube. The suspension has a slightly acidic taste. This drug will be administered for 7 days after admission or until discharge (whichever is sooner). Other Names: Carbaglu NCG Other: Standard of Care Standard of Care
Placebo Comparator: Placebo Standard of Care therapy	Other: Standard of Care Standard of Care

Arms

Assigned Interventions

Experimental: Carbaglu

Active NCG & Standard of Care

Drug: N-carbamylglutamate

Active NCG & Standard of Care Chemical Composition: N-carbamyl-L-glutamic acid (NCG) The daily dose will be 100 mg/kg/ day. The doses are to be divided into 2 equal doses and administered orally or enterally by nasogastric or gastrostomy tube (standard of care will prevail when choosing the mode of drug administration).

The tablets must be dispersed in a minimum of 2.5-10 ml of water and ingested immediately or administered by fast push through a syringe via a nasogastric or gastrostomy tube. The suspension has a slightly acidic taste.

This drug will be administered for 7 days after admission or until discharge (whichever is sooner).

Other Names:

Carbaglu
NCG

Other: Standard of Care

Standard of Care

Placebo Comparator: Placebo

Standard of Care therapy

Other: Standard of Care

Standard of Care

Detailed Description:

Methods/Design This 5-year, Phase II, double-blind study aims to recruit and enroll 34 PA and MMA patients during acute episodes of hyperammonemia.

The primary aim is to circumvent the long-term neurodevelopmental decline due to having a prolonged levels of ammonia during crisis in the blood and urine. After treatment and crisis resolution with Carbaglu or placebo and standard of care therapy, measures of neurodevelopmental outcomes (Bayley II and Functional Status Scale) are being measured at 9, 15,21 and 30 months post-discharge from the hospital. Safety of NCG treatment will also be monitored as measured by close examination of adverse events and laboratory blood tests. To test for the effectiveness of NCG, longitudinal models to evaluate the groupwise difference (NCG vs. Placebo) in the trajectory of change in neurodevelopmental outcomes and safety analyses between drug and placebo patients.

Subsequent Episodes At any time after the initial episode, participants may present to the hospital with PA- or MMA-associated symptoms. If the plasma ammonia level verified as a bonafide episode of HA (plasma ammonia is ≥ 100 µmol/l), that participant will receive the same study medication that they received during their initial episode in a double-blinded fashion, (i.e. If the participant received NCG at the time of initial randomization, he/she will continue to receive NCG at each subsequent HA episode. If the participant received PLBO at the time of initial randomization, he/she will continue to receive PLBO at each subsequent HA episode). Only the pharmacist will know if the participant receives NCG or PLBO. The same study assessments (previously stated) will be conducted at each qualifying HSA episode.

Eligibility


Ages Eligible for Study:	up to 4 Weeks (Child)
Genders Eligible for Study:	Both
Accepts Healthy Volunteers:	No

Criteria

Inclusion Criteria

Aged 4 weeks or younger (0-28 days)
>36 weeks gestational age at birth
Birth weight ≥2500 g
Plasma ammonia level at presentation >150 mcmol/L
PA or MMA presumed or established diagnosis as follows (one of the following):
1. Acidosis at presentation, pH <7.3 OR
2. Plasma acylcarnitine analysis either alone or as part of newborn screening, demonstrating C3 >4 mcmol/L OR
3. Diagnosed, or sibling diagnosed with PA by semi-quantitative urine organic acid analysis, defined as presence of elevated methylcitric acid and no evidence of biotin related disorders in the organic acid analysis OR
4. Diagnosed, or sibling diagnosed with MMA by semi-quantitative urine organic acid analysis, defined as elevation of methylmalonic acid and no evidence of vitamin B12 dependent disorder on plasma amino acid analysis
Able to receive medications orally, by nasogastric (NG)-tube or by gastric (G)-tube
No concomitant illness which would preclude safe participation as judged by the investigator
Signed informed consent by the subject's legally acceptable representative
After initial enrollment, criteria 3 or 4 (definitive diagnosis of the patient) must be fulfilled prior to discharge from initial admission in order to remain in the study.

Exclusion Criteria

Had any prior hyperammonemic episode
Administration of NCG within 7 days of participation in the study
Use of any other investigational drug, biologic, or therapy, with the exception of sodium benzoate or sodium phenylacetate if the latter were administered prior to diagnosis by acylcarnitine analysis (diagnostic inclusion criterion 2), or organic acid analysis (diagnostic inclusion criteria 3 & 4)
Planned participation in any other clinical trial
Diagnosis of any medical condition causing hyperammonemia which is not PA or MMA.
Any clinical or laboratory abnormality or medical condition that, at the discretion of the investigator, may put the subject at an additional risk by participating in this study
Had a liver transplant or is scheduled for a liver transplant
Is not expected to be compliant with this study in terms of returning to site for subsequent episodes of hyperammonemia crises or for long-term follow-up

Contacts and Locations

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT01597440

Locations


United States, California
University of California Los Angeles
Los Angeles, California, United States, 90095
Lucile Packard Children's Hospital at Stanford
Palo Alto, California, United States, 94304
United States, Colorado
The Children's Hospital of Colorado
Aurora, Colorado, United States, 80045
United States, District of Columbia
Children's National Medical Center
Washington, District of Columbia, United States, 20010
United States, Massachusetts
Children's Hospital Boston
Boston, Massachusetts, United States, 02115
United States, Ohio
University Hospitals of Cleveland/Rainbow Babies and Children's Hospital
Cleveland, Ohio, United States, 44106
United States, Pennsylvania
The Children's Hospital of Philadelphia
Philadelphia, Pennsylvania, United States, 19104

Sponsors and Collaborators

Mendel Tuchman

Children's Research Institute

Boston Children’s Hospital

University Hospitals Cleveland Medical Center

University of California, Los Angeles

Children's Hospital of Philadelphia

Lucile Packard Children's Hospital

University of Colorado, Denver

Investigators


Principal Investigator:	Mendel Tuchman, MD	Children's Research Institute

More Information


Responsible Party:	Mendel Tuchman, MD, Children's Research Institute
ClinicalTrials.gov Identifier:	NCT01597440 History of Changes
Other Study ID Numbers:	NCGC 0007
Study First Received:	May 10, 2012
Last Updated:	December 8, 2015
Health Authority:	United States: Food and Drug Administration

Keywords provided by Children's Research Institute:


Propionic acidemia (PA) Methylmalonic acidemia (MMA) Carbaglu NCG Hyperammonia

Additional relevant MeSH terms:


Acidosis Amino Acid Metabolism, Inborn Errors Propionic Acidemia Acid-Base Imbalance	Metabolic Diseases Metabolism, Inborn Errors Genetic Diseases, Inborn

ClinicalTrials.gov processed this record on September 28, 2016