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Safety of Urate Elevation in Amyotrophic Lateral Sclerosis (ALS) (SURE-ALS2)

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details.
ClinicalTrials.gov Identifier: NCT03168711
Recruitment Status : Completed
First Posted : May 30, 2017
Results First Posted : February 18, 2021
Last Update Posted : February 18, 2021
The Salah Foundation
MGH cure ALS Fund
Information provided by (Responsible Party):
Sabrina Paganoni, M.D., Massachusetts General Hospital

Brief Summary:

This is a multi-center, 20-week study of inosine treatment.

Study Objectives and Endpoints The primary objective of the study is to determine the safety and tolerability of oral administration of inosine (administered daily) dosed to moderately elevate serum urate over 20 weeks.

The primary outcome measures will be

  1. Safety, as measured by adverse events
  2. Tolerability, defined as the ability of subjects to complete the entire 20-week study.

As an exploratory objective, we will test the feasibility and utility of a smartphone application for monitoring symptoms and disease progression in patients with amyotrophic lateral sclerosis (ALS).

Condition or disease Intervention/treatment Phase
Amyotrophic Lateral Sclerosis Drug: Inosine Drug: Placebo Phase 2

Detailed Description:

Amyotrophic lateral sclerosis (ALS) is a fatal, neurodegenerative disease for which there is no cure. Multiple lines of evidence have implicated oxidative stress in the pathophysiology of ALS. Urate (uric acid) is an endogenous antioxidant system, and urate may serve as a major defense against oxidative stress. Urate has emerged as a promising neuro-protectant and therapeutic target based on convergent epidemiological, laboratory, and clinical data in multiple neurodegenerative diseases, most notably Parkinson's disease (PD). In PD, urate elevation has been pursued as a potential therapy by administration of inosine, a urate precursor that is available as an over-the-counter supplement. Administration of inosine results in a predictable elevation of urate levels and has been shown to be safe and well tolerated in PD.

Analysis of ALS databases revealed that higher urate levels are an independent predictor of slower progression and prolonged survival in ALS. However, whether elevating urate in people with ALS would result in better outcomes is unknown.

The Principal Investigator has recently concluded a Pilot Study of Inosine in ALS, which was a short, open label, single center study involving 25 subjects [NCT02288091]. The study assessed safety and feasibility of urate elevation in patients with ALS. The Principal Investigator is now pursuing a multi-center Phase II trial to assess the findings of the open label study with longer exposure time.

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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 48 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary Purpose: Treatment
Official Title: Safety of Urate Elevation in Amyotrophic Lateral Sclerosis (ALS)
Actual Study Start Date : October 1, 2017
Actual Primary Completion Date : December 10, 2019
Actual Study Completion Date : January 7, 2020

Arm Intervention/treatment
Experimental: Inosine
Subjects will be administered oral inosine daily. The dose of inosine will be titrated to obtain serum urate levels of 7 - 8 mg/dL.
Drug: Inosine
Subjects on inosine will receive 1-6 capsules a day of 500 mg inosine titrated to target urate levels of 7 - 8 mg/dL.

Placebo Comparator: Placebo
Subjects will be administered oral placebo daily. The dose of placebo will be titrated to obtain serum urate levels of 7 - 8 mg/dL.
Drug: Placebo
Subjects on placebo will receive 1-6 capsules a day of 500 mg placebo (sugar pill) titrated to target urate levels of 7 - 8 mg/dL.

Primary Outcome Measures :
  1. Number of Participants With Adverse Events [ Time Frame: Baseline to Week 24 ]
    Safety will be assessed by the occurrence of adverse events such as kidney stones and gout (expected adverse events) in all participants receiving at least 1 dose of study drug

  2. Tolerability to Complete the Entire 20 Week Study on Study Drug [ Time Frame: Baseline to Week 20 ]
    Tolerance of study drug will be defined as the number of participants who able to complete the 20-week study without permanently discontinuing study drug or suspending study drug for greater than 28 days

Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years to 85 Years   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  1. Age 18-85.
  2. Sporadic or familial ALS diagnosed as possible, laboratory-supported probable, probable, or definite as defined by revised El Escorial criteria (Appendix 1).
  3. Slow vital capacity (SVC) ≥ 60% of predicted for age, height, and gender at the Screening Visit.
  4. Capable of providing informed consent and following trial procedures.
  5. Serum urate < 5.5 mg/dL at screening (i.e. below the population median serum urate levels).
  6. Women must not be able to become pregnant (e.g. post menopausal, surgically sterile, or using adequate birth control methods) for the duration of the study and 3 months after study completion. Adequate contraception includes: abstinence, hormonal contraception (oral contraception, implanted contraception, injected contraception or other hormonal (patch or contraceptive ring, for example) contraception), intrauterine device (IUD) in place for ≥ 3 months, barrier method in conjunction with spermicide, or another adequate method.
  7. Is able and willing to participate in the Mobile app study procedures.

Exclusion Criteria:

  1. History of urolithiasis.
  2. Urine pH < 5.5 at screening (as acidic urine is a major determinant of uric acid urolithiasis).
  3. History of gout.
  4. History of stroke or myocardial infarction.
  5. History of symptomatic coronary artery disease (e.g. angina pectoris) or symptomatic peripheral arterial disease within 1 year prior to Screening.
  6. Symptomatic congestive heart failure with a documented ejection fraction below 45%.
  7. Poorly controlled arterial hypertension (SBP>160mmHg or DBP>100mmHg at Screening).
  8. Women who are pregnant or lactating.
  9. The presence of unstable psychiatric disease, cognitive impairment, or dementia that would impair ability of the subject to provide informed consent, according to Site Investigator judgment, or a history of active substance abuse within the prior year.
  10. Anything that, in the opinion of the Site Investigator, would place the subject at increased risk or preclude the subject's full compliance with or completion of the study.
  11. Use of the following within 30 days prior to Screening: inosine, allopurinol, probenecid, more than 300mg vitamin C daily (note that a subject may take a standard multivitamin up to one tablet or capsule daily). Use of thiazides is permissible as long as the subject is on a stable dose from 1 week prior to Screening.
  12. Known hypersensitivity or intolerability to inosine.
  13. Renal insufficiency as defined by eGFR < 60 mL/min/1.73m2 at the time of screening.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT03168711

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United States, Florida
Holy Cross Hospital
Fort Lauderdale, Florida, United States, 33308
United States, Massachusetts
Massachusetts General Hospital
Boston, Massachusetts, United States, 02114
United States, Minnesota
University of Minnesota
Minneapolis, Minnesota, United States, 55455
Sponsors and Collaborators
Massachusetts General Hospital
The Salah Foundation
MGH cure ALS Fund
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Principal Investigator: Sabrina Paganoni, MD, PhD Massachusetts General Hospital
  Study Documents (Full-Text)

Documents provided by Sabrina Paganoni, M.D., Massachusetts General Hospital:
Informed Consent Form  [PDF] July 1, 2019

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):
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Responsible Party: Sabrina Paganoni, M.D., Principal Investigator, Massachusetts General Hospital
ClinicalTrials.gov Identifier: NCT03168711    
Other Study ID Numbers: SURE-ALS2
First Posted: May 30, 2017    Key Record Dates
Results First Posted: February 18, 2021
Last Update Posted: February 18, 2021
Last Verified: February 2021
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: No

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Studies a U.S. FDA-regulated Drug Product: Yes
Studies a U.S. FDA-regulated Device Product: No
Keywords provided by Sabrina Paganoni, M.D., Massachusetts General Hospital:
Uric acid
Oxidative stress
Oxidative damage
Additional relevant MeSH terms:
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Motor Neuron Disease
Amyotrophic Lateral Sclerosis
Pathologic Processes
Neurodegenerative Diseases
Nervous System Diseases
Neuromuscular Diseases
Spinal Cord Diseases
Central Nervous System Diseases
TDP-43 Proteinopathies
Proteostasis Deficiencies
Metabolic Diseases