E.1 Medical condition or disease under investigation |
E.1.1 | Medical condition(s) being investigated |
short bowel syndrome, intestinal failure (SBS-IF), colon-in-continuity (CIC) |
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E.1.1.1 | Medical condition in easily understood language |
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E.1.1.2 | Therapeutic area | Diseases [C] - Digestive System Diseases [C06] |
MedDRA Classification |
E.1.2 Medical condition or disease under investigation |
E.1.2 | Version | 20.1 |
E.1.2 | Level | PT |
E.1.2 | Classification code | 10049416 |
E.1.2 | Term | Short-bowel syndrome |
E.1.2 | System Organ Class | 10017947 - Gastrointestinal disorders |
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E.1.3 | Condition being studied is a rare disease | Yes |
E.2 Objective of the trial |
E.2.1 | Main objective of the trial |
To evaluate the efficacy of apraglutide in increasing intestinal energy absorption assessed by bomb calorimetry in relation to metabolic balance assessments. |
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E.2.2 | Secondary objectives of the trial |
• To evaluate fluid, electrolytes and macronutrients absorption indicative of clinical efficacy
• To evaluate the efficacy of apraglutide in reducing the administered volume per week of PS from baseline
• To evaluate the safety and tolerability of apraglutide
• To assess apraglutide plasma concentrations to inform the population pharmacokinetic (PopPK) model
• To evaluate citrulline plasma concentrations to inform the PopPK / pharmacodynamic (PD) analysis |
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E.2.3 | Trial contains a sub-study | No |
E.3 | Principal inclusion criteria |
1. Signed informed consent for this trial prior to any trial specific assessment
2. Male and female subjects with SBS-IF and CIC (at least 28% [Cummings, 1973] and no colostomy), receiving PS, secondary to surgical resection of the small intestine with <200 cm from duodeno-jejunal flexure, based on available medical/surgical records and with the latest intestinal resection being at least 12 months prior to Screening
3. Subject considered stable with regards to PS and weight. Stability is defined as a subject meeting all the following criteria in the 3 months preceding screening:
a) Weight change ≤ 5%
b) PS volume change not exceeding 10-25%
c) PS energy content change not exceeding 10-25%
d) Actual PS usage in terms of volume and content matches prescribed PS (±10%)
4. Average fecal wet weight excretion of ≥500 g/day during the baseline metabolic balance study
5. Urine volume is ≥0.8 L and ≤2.5 L per day during baseline metabolic balance study
6. Parenteral support requirement of at least 2 days perweek as assessed at Screening
7. Willingness to remain in clinic for metabolic study on three occasions for 5 days, adhere to an individual pre-defined drinking menu and urine measurements during the 48-hour fluid balance periods
8. No restorative surgery intended to change PS requirements planned during the trial period
9. Age ≥18 years at screening
10. Women of childbearing potential must agree to practice effective contraception and to use a highly effective method of contraception during the trial and for 4 weeks after the End of Trial (EOT) visit. Such methods include combined (estrogen and progestogen containing) hormonal contraception associated with inhibition of ovulation (oral, intravaginal, transdermal); progestogen-only hormonal contraception associated with inhibition of ovulation (oral, injectable, implantable); intrauterine device, intrauterine hormone-releasing system, bilateral tubal occlusion, vasectomized partner. To be considered sterilized or infertile, females must have undergone surgical sterilization (bilateral tubectomy, hysterectomy or bilateral ovariectomy) or be post-menopausal (defined as at least 12 months amenorrhea may be confirmed with follicle-stimulating hormone test if there is doubt). Women who do not engage in heterosexual intercourse, during the trial and 4 weeks after the EoT Visit, will be allowed to join the trial without contraception following a thorough discussion with the Investigator to determine if this is feasible for the subject. The following methods are not considered acceptable methods of contraception: calendar, ovulation, symptothermal, post-ovulation methods), withdrawal (coitus interruptus), spermicides only, and lactational amenorrhea method (LAM)
11. Male subjects with a female partner of childbearing potential must commit to practice highly effective methods of contraception (e.g., condom, vasectomy, etc.) and abstain from sperm donation during the trial and for 2 weeks after the EOT Visit. Their partners, if they are women of childbearing potential, must agree to practice effective contraception and to use a highly effective method of contraception during the trial and for 4 weeks after the EOT visit. Such methods include combined (estrogen and progestogen containing) hormonal contraception associated with inhibition of ovulation (oral, intravaginal, transdermal); progestogen-only hormonal contraception associated with inhibition of ovulation (oral, injectable, implantable); intrauterine device, intrauterine hormone-releasing system |
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E.4 | Principal exclusion criteria |
1. Pregnancy or lactation
2. Body mass index equal or higher than 30 kg/m2 at Screening
3. Major abdominal surgery (more than 10% intestinal resection or surgery that changes anatomy group) in the last 6 months prior to screening. Surgery for feeding tube placement allowed
4. A history of clinically significant intestinal adhesions which have not been treated surgically, increasing the risk of GI obstruction
5. Severe constipation which is not managed by dietary recommendations or laxatives
6. Enterocutaneous fistula
7. History of cancer (including colon carcinoma) or clinically significant lymphoproliferative disease within ≤5 years, except for adequately treated basal cell skin cancer
8. History of cholecystitis or biliary obstruction, unless cholecystectomy was performed prior to screening and resolved the issues
9. Evidence of active IBD in the previous 6 months prior to Screening
10. Central venous catheter sepsis experienced within the previous 8 weeks, prior to screening or use of systemic antibiotics within the last 30 days, prior to screening, due to catheter infection
11. Decompensated heart failure (New York Heart Association class III–IV) [NYHA] and/or known coronary heart disease defined as unstable angina pectoris and/or myocardial infarction within the previous 6 months prior to Screening
12. Radiation enteritis, scleroderma or other condition of severe intestinal dysmotility unrelated to SBS, coeliac disease, refractory or tropical sprue
13. History of alcohol and/or drug abuse within the previous 12 months prior to Screening
14. Child-Pugh score Class C
15. Inadequate renal function as defined by estimated glomerular filtration rate (eGFR) using the Chronic Kidney Disease Epidemiology (CKD-EPI) formula at screening visit <30 mL/min/1.73m2
16. Unplanned hospitalization of >24 hours duration within 30 days prior to Screening
17. More than two changes in systemic corticosteroids, methotrexate, cyclosporine, tacrolimus, sirolimus, infliximab, or other biologic therapy/immunomodulators within 30 days of Screening
18. Use of glutamine, or growth factors such as growth hormone (GH), somatostatin analogs, native GLP-1, GLP-2, or GLP-1 or GLP-2 analogs in the previous 6ºmonths prior to Screening
19. Known or suspected hypersensitivity to GLP-1 or GLP-2 analogs or apraglutide excipients
20. Known neutralizing antibodies (nAb) against GLP-1 or GLP-2 analogs
21. Participation in another clinical trial within 12 weeks prior to Screening and during this trial (studies with catheter locks, COVID-19 vaccines and observational trials, which are not a burden on the subject and do not interfere with the participation in this trial, are allowed)
22. Donation of blood or plasma >500 mL within 12ºweeks prior to Screening
23. Positive results for human immunodeficiency virus, hepatitis A, B and/or C tests*
24. Subject not capable of understanding or not willing to adhere to the trial visit schedules and other protocol requirements
25. Judged not eligible by the Investigator for any other reason
*Subjects recovered from hepatitis A, B or C can be enrolled; i.e., they have markers of the infection, but the viral load for hepatitis B and/or C is equal to zero. Subjects with evidence of an acute or chronically active hepatitis B or C infection should be excluded. Subjects experiencing acute hepatitis A are excluded. |
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E.5 End points |
E.5.1 | Primary end point(s) |
Change in absolute energy absorption over metabolic balance periods from baseline to end of treatment at Week 48 |
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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) |
Efficacy endpoints related to PS volume
• Relative change from baseline in actual weekly PS volume at Weeks 24 and 52
• Absolute change from baseline in actual weekly PS volume at Weeks 24 and 52
• Subjects who achieve a reduction of at least 1 day per week of PS from baseline at Weeks 24 and 52
• Clinical responders (20% reduction of PS volume from baseline) at Weeks 24 and 52
• Subjects reaching enteral autonomy at Weeks 24 and 52
• Energy reduction in the PN from baseline at Weeks 24 and 52
Efficacy endpoint related to nutritional, fluid (wet weight) and electrolyte absorption
• Relative change in absorption of energy, over metabolic balance periods from baseline at Week 48
• Change in absorption of macronutrients, over metabolic balance periods from baseline at Week 48
• Change in absolute absorption of energy over metabolic balance periods from baseline at Week 4
• Change in absorption of macronutrients, over metabolic balance periods from baseline at Week 4
• Changes in urine output and urinary electrolytes (sodium, potassium, calcium and magnesium) over metabolic balance periods, from baseline at Week 4 and at Week 48
Patient reported outcomes
• Changes from baseline in Pittsburgh Sleep Quality Inventory (PSQI) at Weeks 24 and 52
• Patient Global Impression of Change (PGIC) at Weeks 24 and 52
• Changes from baseline in Patient Global Impression of Severity (PGIS) at Weeks 24 and 52
PK/PD related endpoints
• Trough plasma concentration (Ctrough)
• Plasma citrulline levels
Safety endpoints
• Adverse events of special interest (AESIs)
• Clinical chemistry, hematology, hemostasis, anti-drug antibodies (ADA) and urine analysis
• Adverse events |
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E.5.2.1 | Timepoint(s) of evaluation of this end point |
As per information provided in E.5.2.
PK/PD related endpoints and Safety endpoints are being evaluated on an ongoing basis as per the study schedule given in the protocol. |
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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 | No |
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) | No |
E.7.4 | Therapeutic use (Phase IV) | No |
E.8 Design of the trial |
E.8.1 | Controlled | No |
E.8.1.1 | Randomised | No |
E.8.1.2 | Open | Yes |
E.8.1.3 | Single blind | No |
E.8.1.4 | Double blind | No |
E.8.1.5 | Parallel group | No |
E.8.1.6 | Cross over | No |
E.8.1.7 | Other | No |
E.8.2 | Comparator of controlled trial |
E.8.2.1 | Other medicinal product(s) | No |
E.8.2.2 | Placebo | No |
E.8.2.3 | Other | No |
E.8.2.4 | Number of treatment arms in the trial | 1 |
E.8.3 |
The trial involves single site in the Member State concerned
| Yes |
E.8.4 | The trial involves multiple sites in the Member State concerned | No |
E.8.5 | The trial involves multiple Member States | Yes |
E.8.5.1 | Number of sites anticipated in the EEA | 3 |
E.8.6 Trial involving sites outside the EEA |
E.8.6.1 | Trial being conducted both within and outside the EEA | No |
E.8.6.2 | Trial being conducted completely outside of the EEA | No |
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 | 1 |
E.8.9.1 | In the Member State concerned months | 10 |
E.8.9.1 | In the Member State concerned days | 0 |
E.8.9.2 | In all countries concerned by the trial years | 1 |
E.8.9.2 | In all countries concerned by the trial months | 11 |
E.8.9.2 | In all countries concerned by the trial days | 0 |