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STTEPP: Safety, Tolerability and Dose Limiting Toxicity of Lacosamide in Patients With Painful Chronic Pancreatitis (STTEPP)

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ClinicalTrials.gov Identifier: NCT05603702
Recruitment Status : Recruiting
First Posted : November 3, 2022
Last Update Posted : September 25, 2023
Sponsor:
Collaborator:
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
Information provided by (Responsible Party):
Evan Fogel, Indiana University

Study Description
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Brief Summary:
The investigators propose to conduct a dose-escalation trial of an FDA-approved antiepileptic drug, lacosamide, added to opioid therapy in patients with chronic abdominal pain from chronic pancreatitis (CP). This pilot trial will test the feasibility of the study design and provide reassurance regarding the tolerability and safety of lacosamide used concomitantly with opioids in this patient population to reduce the condition known clinically as opioid-induced hyperalgesia (OIH).

Condition or disease Intervention/treatment Phase
Chronic Pain Chronic Pain Syndrome Chronic Pancreatitis Hyperalgesia Opioid Use Disorder Opioid-Related Disorders Opioid Dependence Chronic Abdominal Pain ERCP Pancreatic Surgery Drug: Lacosamide Phase 1

Detailed Description:

One rather pronounced adverse off-target effect of opioids is an increasing sensitivity to noxious stimuli, even evolving a painful response to previously non-noxious stimuli, known clinically as opioid-induced hyperalgesia (OIH). Based on pre-clinical published data, therapeutic targeting of the sodium channel NaV1.7 may address one of the mechanisms that limits opioid efficacy for controlling pain. The investigators hypothesize that lacosamide, an FDA-approved antiepileptic drug that targets NaV1.7, used concomitantly with opioids will improve the opioid efficacy for controlling pain in patients with chronic pancreatitis (CP). However, there are no preliminary data available evaluating lacosamide in this patient population. Therefore, a phase 1 trial is necessary.

The investigators will employ the Bayesian optimal interval (BOIN) design to find the Maximum Tolerated Dose (MTD). The investigators will enroll and treat patients in cohorts of size 3. The initial dose will be 50mg po bid (100mg/day), followed by incremental increases of 100mg/day in two divided doses. The maximum daily dose of lacosamide will be 400mg/day. Duration of lacosamide administration will be 7 days at each dose level. Follow-up laboratory parameters (as obtained at study entry) will be obtained on day 8 (with a 3 day window) after therapy is completed. A follow-up phone visit will occur on day 21 (with a 3-day window) to assess for adverse events and medication changes.

It is anticipated that lacosamide will prove to be safe and well-tolerated. The results of this pilot study will then support proceeding with a subsequent phase 2 trial assessing the efficacy of lacosamide added to opioid therapy to alleviate abdominal pain from CP. The investigators further anticipate that lacosamide combined with opiates will substantially lower the opioid dose necessary for adequate pain relief and serve to substantially improve the safety profile of opioid use for CP.

Study Design
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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 24 participants
Allocation: N/A
Intervention Model: Single Group Assignment
Intervention Model Description:
  1. Patients in the first cohort are treated at dose level 1.
  2. Once a cohort of three patients has been recruited at a given dose level, recruitment will temporarily be held until all three patients have been evaluated for delayed adverse events, at 21 ±3 days following completion of drug therapy.
  3. To assign a dose to the next cohort of patients, conduct dose escalation/de-escalation according to BOIN design rules.
  4. Repeat step 2 until the maximum sample size of 24 is reached or stop the trial if the number of patients treated at the current dose reaches 15.
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: STTEPP: Safety, Tolerability and Dose Limiting Toxicity of Lacosamide in Patients With Painful Chronic Pancreatitis
Actual Study Start Date : March 17, 2023
Estimated Primary Completion Date : December 31, 2024
Estimated Study Completion Date : December 31, 2024

Resource links provided by the National Library of Medicine

MedlinePlus related topics: Pancreatitis
Drug Information available for: Lacosamide

Arms and Interventions
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Arm Intervention/treatment
Experimental: Dose Escalation Level
In the first 3-patient cohort, the dose of lacosamide given is 50mg/d BID. Enrollment to the next higher dose cohort will be initiated only if none of the 3 participants exhibits a DLT in the 21 ±3 days following completion of the 7 day drug therapy. Dose escalation will proceed according to the Bayesian optimal interval (BOIN) design at incremental increase of 100mg/day in two divided doses. The maximum daily dose of lacosamide will be 400mg/day.
 Drug: Lacosamide
Study Visit 1: Baseline study assessments will be made and questionnaires completed in person, on day 0. Drug treatment days will then occur on days 1-7. Study Visit 2: Following completion of the 7-day drug treatment period, participants will have a face-to-face clinic visit on day 8 (with a 3 day grace period), where similar assessments and questionnaires will again be completed. Participants will return all unused drug at this visit, for disposal and to monitor compliance. A follow-up phone visit will occur on day 21 (with a 3 day window) to assess for adverse events and medication changes
Other Name: VIMPAT


Outcome Measures
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Primary Outcome Measures :
  1. Dose-limiting toxicity of lacosamide in combination with opioids in CP patients will be measured by the number of grade 3 or4 toxicities reported via the CTCAE v5.0, between Day 1 through 21 day follow up. [ Time Frame: Day 1, 21 day follow up ]
    Dose-limiting toxicity of combination lacosamide and opioids. Patients will be examined and graded for subjective/objective evidence of developing grade 3 or 4 toxicities according to the NCI Common Terminology Criteria for Adverse Events (CTCAE) v5.0.

  2. Tolerability of lacosamide in combination with opioids in CP patients will be evaluated by the percentage of compliance in taking lacosamide pills as directed between Day 1 and Day 7. [ Time Frame: Day 1, Day 7 ]
    Tolerability will be assessed by compliance with the intervention. Subjects will be evaluated for completing the 7-day trial. The percent of subjects taking 100%, 75%, 50% and <50% of tablets will be recorded.

  3. Feasibility of performance of a pilot study adding lacosamide to opioid therapy in CP patients based on recruitment rate: measured by the proportion of eligible patients who continue from the screening visit to the enrollment visit. [ Time Frame: Screening visit, Enrollment visit ]
    Recruitment rate (proportion of eligible patients approached who agree to participate)

  4. Feasibility of performance of a pilot study adding lacosamide to opioid therapy in CP patients based on retention rate measured by the change from the screening visit to the 21 day follow-up visit. [ Time Frame: Screening visit, 21 day follow-up ]
    Dropout rate, including qualitative assessment of barriers to retention.


Secondary Outcome Measures :
  1. Efficacy of adding lacosamide to opioid therapy for the treatment of abdominal pain due to CP by a 50% decrease in the VAS score from the Screening visit to the Follow-up visit day 8.. [ Time Frame: Screening visit, Day 8 ]

    Visual Analog Score (VAS) - a 50% decrease in score from Screening visit to Follow-up visit day 8.

    The visual analog scale (VAS) is a validated, subjective measure for acute and chronic pain. Scores are recorded by making a handwritten mark on a 10-cm line that represents a continuum between "no pain" and "worst pain."


  2. Efficacy of adding lacosamide to opioid therapy for the treatment of abdominal pain due to CP by a 50% decrease in BPI-SF average pain score from the Screening visit to the Day 8 visit. [ Time Frame: Screening visit, Day 8 ]
    Brief Pain Inventory (BPI), short form average score - a 50% decrease in total score from Screening visit to Follow-up visit day 8 The BPI-SF is a validated self-reported tool that evaluates pain severity and pain interference with daily activities at the time of assessment. Possible scores for pain severity range from 0 to 10 (higher scores reflect more severe pain)

  3. Efficacy of adding lacosamide to opioid therapy for the treatment of abdominal pain due to CP by a 50% decrease in total score of the Compat-SF pain severity from the Screening visit to Follow-up visit day 8. [ Time Frame: Screening visit, Day 8 ]
    Compat-SF total score - a 50% decrease in total score from Screening visit to Follow-up visit day 8 The COMPAT-SF is a validated self-reported tool specifically designed for patients with pancreatic disease. Scores for pain severity (average, worst, and least) range from 0 to 10 (higher corresponds to more pain); scores for pain triggers (including food, exercise, and thermal changes) are scored on a scale from never to always (never, rarely, sometimes, very often, always); scores for pain symptom characteristics (cramping, shooting, stabbing) are scored on a scale from 0 (none) to 10 (worst possible).

  4. Efficacy of adding lacosamide to opioid therapy for the treatment of abdominal pain due to CP by a 25% decrease in morphine milligram equivalents (MME) of opioid use from the Screening visit to Follow-up visit day 8. [ Time Frame: Screening visit, Day 8 ]
    Opioid use will decrease by 25% from screening visit to Follow-up visit day 8. Patients will be asked to track all opioids taken on a drug diary from the screening visit through day 8 of study intervention. MME will be calculated to compare level of MME from screening visit to day 8.


Eligibility Criteria
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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  1. written informed consent and HIPAA authorization for release of personal health information;
  2. ≥ 18 years old at the time of informed consent;
  3. suspected (YELLOW 2 or 3) or definite diagnosis of CP, as per CPDPC PROCEED study definition with ongoing symptoms of abdominal pain;
  4. patients must be maintained on an opioid (except methadone or suboxone) for 4 weeks prior to enrollment for treatment of abdominal pain related to pancreatitis, with a daily morphine equivalent dose of 20-120mg;
  5. ongoing symptoms of abdominal pain even with opioid use (VAS and BPI average score ≥4, at enrollment);
  6. ECOG Performance Status of 0-2;(Oken et al., 1982)
  7. ability to swallow and tolerate oral tablets;
  8. females of childbearing potential must have a negative pregnancy test;
  9. the following laboratory parameters must be met: WBC count ≥ 3.0 K/mm3, absolute neutrophil count ≥ 1.5 K/mm3, hemoglobin ≥ 9 g/dL, platelets ≥ 75 K/mm3, creatinine ≤ 1.5 mg/dl, bilirubin ≤ 1.5 x ULN, AST ≤ 3 x ULN, ALT ≤ 3 x ULN; normal PR interval on baseline 12-lead EKG.

Exclusion Criteria:

  1. subjects with indeterminate CP (YELLOW 1) as per PROCEED criteria;
  2. treatment with any investigational agent within 30 days prior to registration, or concurrent participation in a clinical trial which involves another investigational agent;
  3. rapidly escalating pain that requires hospitalization or intravenous opioid therapy;
  4. known hypersensitivity/allergic reaction to lacosamide, carbamazepine or oxcarbazepine;
  5. pregnant or breastfeeding;
  6. patient who has a diagnosis of epilepsy and/or is currently taking anti-epileptic drugs;
  7. abdominal surgery or pain intervention (ERCP with sphincterotomy/stent/stone removal; celiac plexus block) within 90 days of enrollment.
  8. hospitalization for pancreatitis exacerbation or pain management within 90 days of enrollment
  9. patient who currently takes Suboxone or Methadone.
  10. other factors which might explain the patient's ongoing symptoms, at the discretion of the enrolling physician.
  11. history of autoimmune or traumatic pancreatitis, or sentinel attack of acute necrotizing pancreatitis which results in suspected disconnected duct syndrome.
  12. primary pancreatic tumors- pancreatic ductal adenocarcinoma, suspected cystic neoplasm (>1cms in size or main duct involvement), neuroendocrine tumors, and other uncommon tumors.
  13. pancreatic metastasis from other malignancies.
  14. history of solid organ transplant, HIV/AIDS.
  15. known isolated pancreatic exocrine insufficiency (e.g. in the absence of any eligible inclusion criteria).
  16. participants must not have medical or psychiatric illnesses or ongoing substance abuse that in the investigator's opinion would compromise their ability to tolerate study interventions or participate in follow-up.
Contacts and Locations
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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): NCT05603702


Contacts
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Contact: Evan L Fogel, MD, MSc 317-944-2816 efogel@iu.edu
Contact: Fletcher A White, MS, PhD 317-274-5164 fawhite@iu.edu

Locations
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United States, California
Stanford University Recruiting
Stanford, California, United States, 94305
Contact: Lorena Pineda    650-725-2767    ljpineda@stanford.edu   
Principal Investigator: Walter Park, MS, MD         
United States, Indiana
Indiana University Recruiting
Indianapolis, Indiana, United States, 46202
Contact: Vanessa Patrick, RN    317-278-0692    vpatrick@iu.edu   
Contact: Suzette Schmidt, RN    317-278-0691    suschmid@iu.edu   
Principal Investigator: Evan Fogel, MD, MSc         
Principal Investigator: Fletcher White, MS, PhD         
United States, Minnesota
Mayo Clinic Recruiting
Rochester, Minnesota, United States, 55905
Contact: Heidi Gage    507-266-6482    gage.heidi@mayo.edu   
Contact: Dureti Doto    507-293-5688    doto.dureti@mayo.edu   
Principal Investigator: Santhi Vege, MD         
United States, Ohio
Ohio State University Recruiting
Columbus, Ohio, United States, 43210
Contact: Luke Roberts, BS    614-293-8546    Luke.Roberts@osumc.edu   
Contact: Zoe Krebs, BA    614-685-3619    zoe.krebs@osumc.edu   
Principal Investigator: Samuel Y. Han, MD, MS         
United States, Pennsylvania
University of Pittsburgh Medical Center Recruiting
Pittsburgh, Pennsylvania, United States, 15213
Contact: Kelley Wood    412-647-1458    etheringtonka@upmc.edu   
Principal Investigator: Dhiraj Yadav, MD, MPH         
Sponsors and Collaborators
Indiana University
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
Investigators
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Study Director: Aynur Unalp-Arida, MD, PhD National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
More Information
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Publications of Results:
Venier J, Herrick R, Norris C, Liu S, Zhang L, Yuan Y Bayesian Optimal Interval (BOIN) Phase I Design (PID-862): Version 1.0.4. In. Houston, TX: The University of Texas MD Anderson Cancer Center.
Wonder C (2016) Multiple cause of death data on CDC WONDER. In. Atlanta, GA US Department of Health and Human Services.

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Responsible Party: Evan Fogel, Stuart Sherman Professor in Gastroenterology & Hepatology, Lehman, Bucksot and Sherman Section of Pancreatobiliary Endoscopy Professor of Medicine, Indiana University
ClinicalTrials.gov Identifier: NCT05603702    
Other Study ID Numbers: SHHBRBAPSM35
1R01DK132709-01 ( U.S. NIH Grant/Contract )
First Posted: November 3, 2022    Key Record Dates
Last Update Posted: September 25, 2023
Last Verified: September 2023
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: Yes
Plan Description: De-identified patient data may be shared with investigators from outside institutions for ancillary studies upon request. Requests should be made to study principal investigator at efogel@iu.edu.
Time Frame: Data will be available at the close of the study and for 5 years subsequent.
Access Criteria: Individual requests for data sharing can be made to: efogel@iu.edu

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Studies a U.S. FDA-regulated Drug Product: Yes
Studies a U.S. FDA-regulated Device Product: No
Product Manufactured in and Exported from the U.S.: Yes
Keywords provided by Evan Fogel, Indiana University:
Pancreatitis
Pancreatitis, chronic
Chronic pain
 Pain
Pancreatic Diseases
Digestive System Diseases
Additional relevant MeSH terms:
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Pancreatitis
Pancreatitis, Chronic
Hyperalgesia
Chronic Pain
Abdominal Pain
Opioid-Related Disorders
Pain
Neurologic Manifestations
Pancreatic Diseases
Digestive System Diseases
Narcotic-Related Disorders
Substance-Related Disorders
Chemically-Induced Disorders
Mental Disorders
 Signs and Symptoms, Digestive
Chronic Disease
Disease Attributes
Pathologic Processes
Somatosensory Disorders
Sensation Disorders
Nervous System Diseases
Lacosamide
Anticonvulsants
Voltage-Gated Sodium Channel Blockers
Sodium Channel Blockers
Membrane Transport Modulators
Molecular Mechanisms of Pharmacological Action