Safety and Therapeutic Potential of the FDA-approved Drug Metformin for C9orf72 ALS/FTD

• ClinicalTrials.gov Identifier: NCT04220021
• Recruitment Status: Active, not recruiting
• First Posted: January 7, 2020
• Last Update Posted: May 6, 2024
• Sponsor: University of Florida
• Collaborator: ALS Association
• Information provided by (Responsible Party): University of Florida

Study Description

Brief Summary:

The primary objective is to assess the safety and tolerability of Metformin in subjects with C9orf72 amyotrophic lateral sclerosis administered for 24 weeks. The overall objective is to determine if Metformin is safe in C9orf72 ALS patients and is a potentially viable therapeutic treatment for C9-ALS that reduces repeat-associated non-canonical start codon - in DNA (non-ATG) (RAN) proteins that are produced by the C9orf72 repeat expansion mutation.

Condition or disease	Intervention/treatment	Phase
C9orf72 Amyotrophic Lateral Sclerosis (ALS); Frontotemporal Dementia	Drug: Metformin	Phase 2

Detailed Description:

The C9orf72 repeat expansion is the most common cause of amyotrophic lateral sclerosis and frontotemporal dementia (C9-ALS/FTD). Metformin, a well-tolerated diabetes drug, blocks a key pathway for expression of toxic proteins produced from the C9orf72 repeat expansion via repeat associated non-canonical start codon - in RNA (non-AUG) (RAN) translation. In mouse model of C9-ALS/FTD, metformin treatment decreases RAN protein levels and improves disease features. This current study is a small-scale clinical trial to assess the safety and potential efficacy of metformin for the treatment of C9-ALS/FTD.

Study Design

• Study Type: Interventional (Clinical Trial)
• Actual Enrollment: 18 participants
• Allocation: N/A
• Intervention Model: Single Group Assignment
• Intervention Model Description: All participants receive medication
• Masking: None (Open Label)
• Primary Purpose: Treatment
• Official Title: A Single-Center, Open Label Study to Assess the Safety and Tolerability of Metformin in Subjects With C9orf72 Amyotrophic Lateral Sclerosis Over 24 Weeks of Treatment
• Actual Study Start Date: January 10, 2020
• Estimated Primary Completion Date: August 26, 2024
• Estimated Study Completion Date: August 26, 2024

Arms and Interventions

Arm

Intervention/treatment

Experimental: C9orf72 positive ALS; Subjects with C9orf72 positive ALS will be instructed in the use of Metformin and receive the first dose of Metformin under supervision of the investigator during Visit 1, Day 2. Subjects will then continue on Metformin per the dose escalation schedule twice daily for 24 weeks.

Drug: Metformin; Metformin is a widely used, well-tolerated drug that has been used for decades as a first-line defense for treating type 2 diabetes. Its safety has been well established. Subjects will begin treatment with Metformin at a dosage of 500mg with an escalation of dosage by 500mg every week to a maximal dosage of 2000mg. Dosing will be twice daily.; Other Name: Metformin hydrochloride sustained-release (SR)

Outcome Measures

Primary Outcome Measures :

1. Number of subjects with treatment-emergent adverse events [Safety and Tolerability] [ Time Frame: Baseline through 24 weeks ]
   The safety and tolerability of Metformin in participants with C9orf72 ALS currently treated with Metformin will be evaluated by the number of subjects with treatment-emergent adverse events
2. Change in RAN protein levels [ Time Frame: baseline through week 24 ]
   Assess the RAN protein levels in cerebrospinal fluid (CSF) samples from participants at specific intervals.

Secondary Outcome Measures :

1. Change in ALS Functional Rating Scale (ALSFRS-R) score [ Time Frame: Baseline through Week 52 ]
   The ALSFRS-R is a quickly administered (5 minute) ordinal rating scale (ratings 0-4) used to determine subjects' assessment of their capability and independence in 12 functional activities/questions. Scores of 4 equaling 'normal' and scores of 0 equaling total lack of ability.

Eligibility Criteria

• Ages Eligible for Study: 18 Years to 80 Years (Adult, Older Adult)
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Criteria

Inclusion Criteria:

• Subjects have a diagnosis of probable or definite ALS in accordance with the Revisited El-Escorial Criteria.
• Subjects have a likely diagnosis of C9orf72 positive ALS/FTD.
• Subjects must be currently on an oral diet and able to take foods, pills and liquids by mouth equivalent to a score of 4 or above on the Functional Oral Intake Scale
• Subjects must have no known allergy to barium sulfate or Metformin.
• Subjects or subject's legally authorized representative must be willing and able to complete informed consent/assent and HIPAA authorization.
• Ability to comprehend and be informed of the nature of the study, as assessed by the PI or Co-Investigators.
• Subjects prescribed to take Metformin at or before the time of first dosing. (The study is open to subjects currently taking Metformin or subjects who have taken Metformin in the past).
• Availability to participate for the entire study duration.
• Female subjects of childbearing potential must have a negative urine pregnancy test prior to Videofluoroscopic Swallow Study (VFSS) exam during Visit 1, 3, and 4.

Exclusion Criteria:

• Subjects who score 3 or below on the Functional Oral Intake Scale
• Subjects who do not carry the C9ORF72 hexanucleotide repeat expansion as determined by laboratory analysis.
• Subjects with a history of clinically significant liver disease, renal disease, or any other medical condition judged to be exclusionary by the investigator.
• Subjects who are unwilling to sign informed consent or subjects who for any other reason in the judgment of investigator are unable to complete the study.
• Female subjects who have a positive urine pregnancy test (βhCG) at screening or visit 1, are trying to become pregnant or are breastfeeding.
• Subjects with active cancer within the previous 2 years, except treated basal cell carcinoma of the skin.
• Subjects who have taken any experimental drug within 30 days prior to enrollment or within 5 half-lives of the investigational drug -whichever is the longer period.
• Subjects with known history or presence of moderate or severe renal impairment as defined by an estimated glomerular filtration rate (eGFR) value below 30 mL/min/1.73 m2.
• Subjects with hepatic impairment as defined by baseline elevations of serum aminotransferases greater than 5 times upper limit of normal or evidence of liver dysfunction (e.g., elevated bilirubin).
• Use of potentially hepatotoxic drugs: (e.g., allopurinol, methyldopa, sulfasalazine).
• Subjects with clinically significant abnormal laboratory values in the judgment of the investigator.
• Subject with implanted electrical device (i.e. cardiac pacemaker or a neurostimulator), metal or metallic clip(s) in their body (i.e. an aneurysm clip in the brain) that will be damaged by participation in the MRI portion of the study.
• Anything else that, in the opinion of the investigator, would place the subject at increased risk or preclude the subject's full compliance with or completion of the study.

Contacts and Locations

Locations

United States, Florida

UF Health at the University of Florida

Gainesville, Florida, United States, 32610

Sponsors and Collaborators

University of Florida

ALS Association

Investigators

• Principal Investigator: Laura Ranum, PhD; University of Florida

More Information

Publications:

Cedarbaum JM, Stambler N, Malta E, Fuller C, Hilt D, Thurmond B, Nakanishi A. The ALSFRS-R: a revised ALS functional rating scale that incorporates assessments of respiratory function. BDNF ALS Study Group (Phase III). J Neurol Sci. 1999 Oct 31;169(1-2):13-21. doi: 10.1016/s0022-510x(99)00210-5.

Crary MA, Mann GD, Groher ME. Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients. Arch Phys Med Rehabil. 2005 Aug;86(8):1516-20. doi: 10.1016/j.apmr.2004.11.049.

Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale. Dysphagia. 1996 Spring;11(2):93-8. doi: 10.1007/BF00417897.

Watanabe H, Atsuta N, Nakamura R, Hirakawa A, Watanabe H, Ito M, Senda J, Katsuno M, Izumi Y, Morita M, Tomiyama H, Taniguchi A, Aiba I, Abe K, Mizoguchi K, Oda M, Kano O, Okamoto K, Kuwabara S, Hasegawa K, Imai T, Aoki M, Tsuji S, Nakano I, Kaji R, Sobue G. Factors affecting longitudinal functional decline and survival in amyotrophic lateral sclerosis patients. Amyotroph Lateral Scler Frontotemporal Degener. 2015 Jun;16(3-4):230-6. doi: 10.3109/21678421.2014.990036. Epub 2014 Dec 30.

• Responsible Party: University of Florida
• ClinicalTrials.gov Identifier: NCT04220021
• Other Study ID Numbers: IRB201800620; UF2019-001 ( Other Identifier: University of Florida ); OCR20620 ( Other Identifier: UF OnCore ); UF2019-001 ( Other Identifier: UF Protocol ID )
• First Posted: January 7, 2020
• Last Update Posted: May 6, 2024
• Last Verified: May 2024

Individual Participant Data (IPD) Sharing Statement:

• Plan to Share IPD: No

• Studies a U.S. FDA-regulated Drug Product: Yes
• Studies a U.S. FDA-regulated Device Product: No

Keywords provided by University of Florida:

ALS; FTD; Lou Gehrigs Disease

Additional relevant MeSH terms:

Amyotrophic Lateral Sclerosis; Metformin; Motor Neuron Disease; Frontotemporal Dementia; Aphasia, Primary Progressive; Pick Disease of the Brain; Sclerosis; Pathologic Processes; Dementia; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Neurocognitive Disorders; Mental Disorders; Neurodegenerative Diseases; Neuromuscular Diseases; Spinal Cord Diseases; TDP-43 Proteinopathies; Proteostasis Deficiencies; Metabolic Diseases; Frontotemporal Lobar Degeneration; Aphasia; Speech Disorders; Language Disorders; Communication Disorders; Neurobehavioral Manifestations; Neurologic Manifestations; Hypoglycemic Agents; Physiological Effects of Drugs