E.1 Medical condition or disease under investigation |
E.1.1 | Medical condition(s) being investigated |
Esophageal Varices in NASH Cirrhosis |
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E.1.1.1 | Medical condition in easily understood language |
Varices (enlarged veins) in oesophagus (muscular tube connecting the throat with the stomach) in patients with liver cirrhosis (scarring) due to non-alcoholic fatty liver disease with inflammation. |
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E.1.1.2 | Therapeutic area | Diseases [C] - Nutritional and Metabolic Diseases [C18] |
MedDRA Classification |
E.1.2 Medical condition or disease under investigation |
E.1.2 | Version | 20.0 |
E.1.2 | Level | LLT |
E.1.2 | Classification code | 10009214 |
E.1.2 | Term | Cirrhosis of liver without mention of alcohol |
E.1.2 | System Organ Class | 100000004871 |
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E.1.2 Medical condition or disease under investigation |
E.1.2 | Version | 21.1 |
E.1.2 | Level | LLT |
E.1.2 | Classification code | 10055489 |
E.1.2 | Term | Esophageal varices in cirrhosis of liver |
E.1.2 | System Organ Class | 100000004856 |
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E.1.3 | Condition being studied is a rare disease | No |
E.2 Objective of the trial |
E.2.1 | Main objective of the trial |
To evaluate the efficacy of 2 mg/kg and 4 mg/kg lean body mass (LBM) of belapectin (GR MD 02) compared to placebo in preventing the development of esophageal varices. |
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E.2.2 | Secondary objectives of the trial |
To evaluate the effect of belapectin on composite clinical outcomes. |
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E.2.3 | Trial contains a sub-study | No |
E.3 | Principal inclusion criteria |
1.Male or female, ≥ 18 and ≤ 75 years old. 2.Willing and able to provide written informed consent. 3.Has evidence of portal hypertension, with either one: a.platelet count <150K/mm3 (from central laboratory or historical record, e.g. detailed chart notes providing platelet numbers or copies of laboratory reports showing platelet count[s] below 150K/mm3) OR b. documented HVPG measurement >6 mmHg OR c. at least two of the following: -spleen size ≥ 14 cm -abdominal collateral circulation -documented liver transient elastography ≥20 kPa -AST / ALT >1 4.History confirming NASH cirrhosis, with at least one: •Historical liver biopsy showing cirrhosis with steatohepatitis (if slides or blocks are not available, the biopsy report must clearly indicate cirrhosis with steatohepatitis). •Historical liver biopsy showing steatohepatitis (if slides or blocks are not available, the biopsy report must clearly indicate steatohepatitis), and there is evidence of cirrhosis from clinical or imaging data or a second liver biopsy showing cirrhosis without all features of NASH (as the histological NASH lesions may have burnt out). There is no evidence for a competing etiology. There is at least 1 co-existing or history of metabolic comorbidity at Screening: obesity (with either body mass index [BMI] ≥30 kg/m2 or waist circumference ≥102 cm [40 in, men] or ≥88 cm [35 in, women], or by ethnically appropriate cutpoints); hypertension (either on anti hypertensive drug therapy for at least 1 year or systolic/diastolic BP >140/80 mm Hg); Type 2 diabetes (glycated hemoglobin [HbA1c] ≥6.5%, or on anti-diabetic medication for at least 1 year); or dyslipidemia (triglycerides ≥150 mg/dL or on drug therapy for hypertriglyceridemia for at least 6 months; high-density lipoprotein cholesterol ≤40 mg/dL [men] or ≤50 mg/dL [women]) to corroborate a diagnosis of NAFLD. •Historical liver biopsy showing cirrhosis with steatosis but not steatohepatitis (if slides or blocks are not available, the biopsy report must clearly indicate cirrhosis with steatosis). •Historical liver biopsy showing steatosis (if slides or blocks are not available, the biopsy report must clearly indicate steatosis) but now with cirrhosis either by physical examination, imaging, or biopsy. If there is a current biopsy, it does not show evidence of steatosis or steatohepatitis as histological lesions may have burned out. There is no evidence for a competing etiology. There are at least 2 co existing (or history of) metabolic comorbidities (with obesity or diabetes being one of them) to corroborate a diagnosis of NAFLD. •Patient with cirrhosis with current or previous imaging showing steatosis. There is no liver histology available. There is no evidence for a competing etiology. There are at least two co-existing or history of metabolic comorbidities with obesity or diabetes being one of them to corroborate a diagnosis of NAFLD. •For patients not meeting the above mentioned criteria, a screening liver biopsy is necessary. 5.Absence of HCC by valid imaging within 6 months prior to randomization. 6.Patients with diabetes mellitus can be enrolled, if they are adequately controlled on a stable antidiabetic medication(s) for at least 3 months before Screening, and their screening HbA1c is ≤9.5%. 7.Patients on therapeutic doses of vitamin E or pioglitazone can be enrolled if they are on a stable regimen for at least 3 months before screening, and the regimen is expected to be held constant during the trial. 8.Patients on a statin can be enrolled if they are on a stable regimen for at least 3 months before Screening, and expected to be held stable during the trial. 9.Is not pregnant and must have a negative serum pregnancy test result prior to randomization. 10.Is of non-childbearing potential or if a fertile man or woman participating in heterosexual relations, agrees to use effective means of contraception (ie, 2 effective methods of contraception, one of which must be a physical barrier method). 11. Lactating woman: agrees to discontinue nursing before the start of study treatment and refrain from nursing 90 days after the last dose of study treatment. 12.Man: agrees to refrain from sperm donation throughout the study period and 90 days following the last dose of investigational medicinal product (IMP). Female: may not begin a cycle of ova donation or harvest throughout the study period and 90 days following the last dose of IMP. |
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E.4 | Principal exclusion criteria |
1.Presence of esophageal, gastroesophageal, or isolated gastric varices, based on an upper GI EGD exam conducted during Screening. Patients with portal hypertensive gastropathy could be enrolled. 2.History of hepatic cirrhosis decompensation including any episode of variceal bleeding, ascites not controlled by medication, spontaneous bacterial peritonitis or overt hepatic encephalopathy (West Haven grade ≥2 as assessed by the principal investigator), OR develops signs of hepatic cirrhosis decompensation during Screening. 3.Known or suspected abuse of alcohol, as per medical history. 4. Alcohol dependence. 5.Narcotics or any other drug abuse or dependence in the last 5 years 6.Prior trans-jugular intrahepatic portal-systemic (TIPS) shunt procedure 7.Documented causes of liver disease other than NASH, including but not restricted to: •Viral hepatitis, unless eradicated at least 3 years prior to Screening •acute hepatitis A infection (presence of hepatitis A immunoglobulin M [IgM] at Screening) •positive hepatitis B surface antigen •positive hepatitis C virus (HCV) ribonucleic acid (to be performed prior to randomization in case of positive HCV antibody) •Documented drug-induced liver disease •Alcoholic liver disease •Autoimmune hepatitis •Wilson’s disease •Hemochromatosis •Primary biliary cholangitis •Primary sclerosing cholangitis •Genetic hemochromatosis •History or planned liver transplantation •Alpha-1 antitrypsin deficiency 8.History of human immunodeficiency virus (HIV), or positive HIV test at Screening 9.Any of the following test or score •serum ALT > 5 × upper limit of normal (ULN) •serum AST > 5 × ULN •serum ALP > 2 × ULN •mean platelet count < 150,000/mm3 •albumin ≤ 3.5 g/dL •INR ≥1.5 (without anticoagulant therapy) •total bilirubin ≥ 2.0 mg/dL (subjects with a documented history of Gilbert’s syndrome can be enrolled if the direct bilirubin is within normal reference range) •MELD score >12 (patients on warfarin will be exempt from this criterion) •CTP Score ≥7 •estimated creatinine clearance < 45 mL/min 10.Taking an angiotensin converting enzyme inhibitor, angiotensin II receptor blocker, or β-1 selective adrenergic receptor inhibitor, unless on a stable regimen for at least 3 months prior to Screening, and no changes in the regimen are anticipated during the study. Subjects taking a non-selective beta blocker are not eligible to be enrolled (Investigators are encouraged to substitute another medication, if clinically warranted). 11.History of major surgery during the Screening. 12.History of a solid organ transplant requiring immunosuppressive therapy. 13.History of bariatric surgery within 1 year of randomization, or plan to undergo bariatric surgery during the study. 14.Has positive screening test for illicit drugs of abuse at Screening. Positive marijuana/cannabinoids (THC) usage is not an automatic exclusion but rather should be based upon local requirements where applicable. 15.Has participated in an investigational new drug study within 30 days or 5 half-lives whichever is longer, prior to randomization. 16.Has a history of malignancy within 5 years of randomization, except for basal cell carcinoma, squamous cell carcinoma and adequately treated in situ uterine cervical cancer. 17.Has clinically significant cardiovascular disease (eg, uncontrolled hypertension, myocardial infarction, unstable angina), New York Heart Association Grade II or greater congestive heart failure, serious cardiac arrhythmia requiring intervention (eg, pacemaker/ablation) or Grade II or greater peripheral vascular disease. 18.Has a history of clinically significant hematologic, renal, hepatic, pulmonary, neurological, psychiatric, gastrointestinal, systemic inflammatory, metabolic or endocrine disorder or any other condition that, in the opinion of the Investigator, renders the subject a poor candidate for inclusion into the study. 19.Has known allergies to the IMP or any of its excipients. 20.Has previously received belapectin within 6 months of randomization. 21.Is an employee or family member of the Investigator or study center personnel. Please refer to the protocol for full details. |
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E.5 End points |
E.5.1 | Primary end point(s) |
Proportion of patients in the belapectin treatment groups who develop esophageal varices at 78 weeks (18 months) of treatment compared to placebo |
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E.5.1.1 | Timepoint(s) of evaluation of this end point |
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E.5.2 | Secondary end point(s) |
Key Secondary Efficacy Endpoint Incidence rate of patients in the belapectin treatment groups, compared to placebo, who develop any of the following: 1) varices (esophageal or gastric) requiring treatment, 2) variceal bleed requiring hospitalization, 3) clinically significant ascites requiring hospitalization, 4) spontaneous bacterial peritonitis, 5) overt hepatic encephalopathy (West Haven score ≥2 and requiring hospitalization), 6) mortality (all-cause), 7) liver transplant, 8) model for end-stage liver disease (MELD) score ≥15 |
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E.5.2.1 | Timepoint(s) of evaluation of this end point |
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E.6 and E.7 Scope of the trial |
E.6 | Scope of the trial |
E.6.1 | Diagnosis | No |
E.6.2 | Prophylaxis | No |
E.6.3 | Therapy | No |
E.6.4 | Safety | Yes |
E.6.5 | Efficacy | Yes |
E.6.6 | Pharmacokinetic | Yes |
E.6.7 | Pharmacodynamic | Yes |
E.6.8 | Bioequivalence | No |
E.6.9 | Dose response | Yes |
E.6.10 | Pharmacogenetic | No |
E.6.11 | Pharmacogenomic | No |
E.6.12 | Pharmacoeconomic | No |
E.6.13 | Others | No |
E.7 | Trial type and phase |
E.7.1 | Human pharmacology (Phase I) | No |
E.7.1.1 | First administration to humans | No |
E.7.1.2 | Bioequivalence study | No |
E.7.1.3 | Other | No |
E.7.1.3.1 | Other trial type description | |
E.7.2 | Therapeutic exploratory (Phase II) | Yes |
E.7.3 | Therapeutic confirmatory (Phase III) | Yes |
E.7.4 | Therapeutic use (Phase IV) | No |
E.8 Design of the trial |
E.8.1 | Controlled | Yes |
E.8.1.1 | Randomised | Yes |
E.8.1.2 | Open | No |
E.8.1.3 | Single blind | No |
E.8.1.4 | Double blind | Yes |
E.8.1.5 | Parallel group | No |
E.8.1.6 | Cross over | No |
E.8.1.7 | Other | Yes |
E.8.1.7.1 | Other trial design description |
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E.8.2 | Comparator of controlled trial |
E.8.2.1 | Other medicinal product(s) | No |
E.8.2.2 | Placebo | Yes |
E.8.2.3 | Other | No |
E.8.2.4 | Number of treatment arms in the trial | 3 |
E.8.3 |
The trial involves single site in the Member State concerned
| No |
E.8.4 | The trial involves multiple sites in the Member State concerned | Yes |
E.8.4.1 | Number of sites anticipated in Member State concerned | 2 |
E.8.5 | The trial involves multiple Member States | Yes |
E.8.5.1 | Number of sites anticipated in the EEA | 41 |
E.8.6 Trial involving sites outside the EEA |
E.8.6.1 | Trial being conducted both within and outside the EEA | Yes |
E.8.6.2 | Trial being conducted completely outside of the EEA | No |
E.8.6.3 | If E.8.6.1 or E.8.6.2 are Yes, specify the regions in which trial sites are planned |
Argentina |
Chile |
Australia |
Belgium |
Brazil |
Canada |
France |
Germany |
Israel |
Korea, Republic of |
Mexico |
Poland |
Spain |
United Kingdom |
United States |
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E.8.7 | Trial has a data monitoring committee | Yes |
E.8.8 |
Definition of the end of the trial and justification where it is not the last
visit of the last subject undergoing the trial
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E.8.9 Initial estimate of the duration of the trial |
E.8.9.1 | In the Member State concerned years | 3 |
E.8.9.1 | In the Member State concerned months | 0 |
E.8.9.1 | In the Member State concerned days | 0 |
E.8.9.2 | In all countries concerned by the trial years | 3 |
E.8.9.2 | In all countries concerned by the trial months | 0 |
E.8.9.2 | In all countries concerned by the trial days | 0 |