This trial aims to investigate the efficacy, safety and tolerability of sodium valproate in the treatment of patients with Wolfram syndrome. 70 paediatric and adult patients were initially planned to be randomised 2:1 to receive either sodium valproate or placebo at 6 international centres. 63 patients were recruited when a decision was made to stop the study recruitment in November 2022.
This phase II clinical trial is planned as a randomised, double-blind, placebo-controlled 3 year intervention Trial in 70 patients with Classical Wolfram Syndrome aged 6 years and over. The primary outcome of the Trial is considered to be clinically relevant and of sufficient magnitude to be beneficial, as a successful Trial outcome will mean that patients will retain a clinically useful degree of visual acuity and it will decline at a slower rate than in the untreated patients. The MRI Pons Volume change has been shown to correlate with changes in the Wolfram Unified Rating Scale. Patients will be randomised to balance the individual differences across the treatment and placebo groups, therefore reducing the potential for extraneous bias. This will ensure that the treatment effect can be established without the need to account for confounding factors. The value of a placebo arm adds robustness to the Trial by removing the potential for bias from both the investigator and patient perspectives. Investigators will be blinded to the results of the assessments. Certain assessments will be performed by subspecialists (such as ophthalmologists and neurologists), with the Principal Investigator prevented from having access to the results. This subspecialist-led treatment is in line with the current multi-disciplinary management of these patients and will not result in patients being denied access to effective treatment. Patients and investigators will be blinded to treatment. The Trial treatment will be a tablet formulation. This Trial involves 11 clinic visits and 7 follow up telephone calls to reduce the burden of additional travel to the patients.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
OTHER
Masking
QUADRUPLE
Enrollment
63
Treatment with twice-daily oral tablet(s)
Treatment with twice-daily oral 200mg tablet(s)
CHU de Montpellier, Hopital Gui de Chauliac
Montpellier, France
Hôpital Européen Georges-Pompidou
Paris, France
Medical University of Lodz
Lodz, Poland
Unidad de Gestión Clínica Almería Periferia. Distrito Sanitario Almería
Almería, Spain
Visual acuity (VA)
Visual acuity (VA) is measured on the logMAR scale by sight tests in clinic using Early treatment diabetic retinopathy study (ETDRS) charts. Values are taken for each eye separately, both uncorrected, and corrected with glasses or contact lenses, and can range from 0, which represents perfect vision i.e. 20/20 (values of -0.1 and -0.2 are also possible representing better than perfect vision), to +2 which represents near blindness i.e. 20/2000. Increases in logMAR represent deterioration.
Time frame: 36 months
Safety - adverse events
measured by adverse events frequency, type and grade according to CTCAE v4
Time frame: 37 months
Tolerability - highest treatment dose
measured by dose achieved
Time frame: 36 months
Tolerability - duration of treatment
measured by days of treatment
Time frame: 36 months
Tolerability - dosing modifcation
measured by treatment-related dose reductions and discontinuations
Time frame: 36 months
Pons Volume
a surrogate marker for neurodegeneration, measured and recorded in mm3 by standardised analysis of MRI images of the Pons, and brain substructure volumes.
Time frame: 37 months (+/- 6 months)
Brainstem volume
measured by MRI as with Pons Volume
Time frame: 37 months (+/- 6 months)
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University Hospitals Birmingham
Birmingham, United Kingdom
Birmingham Women's and Children's Hospital
Birmingham, United Kingdom
Retinal nerve thickness
measured by Optical Coherence Tomography
Time frame: 37 months
Colour vision
measured by Hardy Rand and Rittler test
Time frame: 37 months
Visual fields
measured by the local centre standard process (the same technique must be used throughout the patient participation to the study)
Time frame: 37 months
Data on cataracts
measured by incidence and frequency of cataracts
Time frame: 37 months
Afferent pupillary defects
measured by incidence and frequency of afferent pupillary defects. Afferent pupillary defects are recorded as present or absent.
Time frame: 37 months
Strabismus
measured by incidence and frequency of strabismus. Presence or absence of strabismus will be recorded. Strabismus will also be graded for type and size.
Time frame: 37 months
Nystagmus
measured by incidence and frequency of nystagmus. Presence or absence of nystagmus will be recorded. Nystagmus will also be graded for size, amplitude and direction.
Time frame: 37 months
Visual evoked potentials
measured by changes in visual evoked potentials (if available)
Time frame: 37 months
Sleep - sleeping habits parent report for patients under 18 years
measured by the Sleep-related Breathing disorder scale extracted from the Pediatric Sleep Questionnaire (PSQ) Parent Questionnaire 2014. This report is a Parent Report for patients under 18. This questionnaire records usual sleep habits.
Time frame: 37 months
Sleep - sleeping habits, self-report
measured by the Pittsburg Sleep Quality Index (PSQI) Self-Report. This questionnaire is completed by the patient. This questionnaire records usual sleep habits during the past month.
Time frame: 37 months
Balance
measured by Mini-BESTest
Time frame: 37 months
Hearing
measured by pure tone audiometry
Time frame: 37 months
Wolfram Unified Rating Scale
Wolfram Unified Rating Scale (WURS). Assessments are performed in five areas (physical; seizure; behavioral; capability and clinical) by scoring listed items 0-2, 0-3, 0-4, 0-5 or 0-6 depending on the scale. Totals for each category are recorded and the WURS total, summing physical and behavioral categories, is also recorded. A low score would be considered a better outcome in all areas apart from capability where a high score would be considered a better outcome. A Wolfram Syndrome history is also recorded detailing incidence and onset of listed symptoms.
Time frame: 37 months
Mood
measured by Kidscreen for patients aged 8-18 or the Hospital Axiety and Depression Scale (HADS) for adult patients. Kidscreen records the patients mood and feeling in 5 areas (physical activities and health; general mood and feelings about self; family and free time; friends; school and learning). HADS records how the patient has been feeling over the past week by scoring feelings relating to anxiety or depression. A total score for Anxiety and a total score for depression is recorded. A score of 0-7 = normal; 8-10 = borderline abnormal (borderline case) and 11-21 = abnormal (case).
Time frame: 36 months
Quality of life - PedsQL
measured by PedsQL questionnaire (pediatric quality of life inventory) for paediatric patients. PedsQL 8-12 and PedsQL 13-18 and respective parent reports. PedsQL records how much of a problem each situation causes the patient; each situation is scored from 0 (never a problem) to 4 (always a problem). A score of 0 would be considered a better outcome.
Time frame: 37 months
Quality of life - ICIQ-FLUTS
measured by the ICIQ-FLUTS questionnaire: ICIQ-FLUTS (adult females), ICIQ-MLUTS (adult males), or ICIQ-CLUTS (children and caregiver forms). This questionnaire records urinary symptoms in three categories (filling, voiding and incontinence) from 0-4 and how much each symptom bothers the patient from 0 (not at all) to 10 (a great deal). Scores for each category are totalled. Low scores would be considered a better outcome.
Time frame: 37 months
Quality of life - VQoL_C/ YP
measured by the vision related quality of life questionnaire for children and for young people. This questionnaire records how patients feel about their eyesight in relation to the listed statements. Each statement is scored from 1 (not at all true) to 4 (completely true). The score denoting a better outcome is dependent on the question.
Time frame: 37 months
Quality of life - VFQ-25
measured by the National Eye Institute Visual Function Questionnaire 25 (VFQ-25). This questionnaire records information in three categories. Questions in the general health and vision category are scored 1-5 or 6 and a low score would be considered a better outcome. Questions in the difficulty with activities category are scored 1 (no difficulty at all) to 6 (stopped doing this for other reasons or not interested in doing this); a low score would be considered a better outcome. Questions in the vision problems category are scored 1 (all of the time) to 5 (none of the time); a high score would be considered a better outcome.
Time frame: 37 months
Pancreatic beta cell reserve - glycated haemoglobin or equivalent
measured by percentage glycated haemoglobin or equivalent
Time frame: 37 months