Gentamicin for RDEB

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Brief Title

Gentamicin for RDEB

Official Title

Gentamicin Therapy for Recessive Dystrophic Epidermolysis Bullosa Patients With Nonsense Mutations

Brief Summary

      Recessive dystrophic epidermolysis bullosa (RDEB) is an incurable, devastating, inherited
      skin disease caused by mutations in the COL7A1 gene that encodes for type VII collagen (C7),
      the major component of anchoring fibrils (AFs), structures that mediate epidermal-dermal
      adherence. Thirty percent of RDEB patients have nonsense mutations. The investigators
      recently demonstrated in 5 such patients that intradermal and topical gentamicin induced
      "read-through" of their nonsense mutations and created robust and sustained new C7 and AFs at
      the dermal-epidermal junction (DEJ) of their skin and also stimulated wound closure and
      reduced new blister formation. No untoward side effects occurred. Herein, the investigators
      propose evaluating the safety and efficacy of intravenous gentamicin in these patients. In
      theory, this intravenous administration has the possibility of treating simultaneously all of
      the patients' skin wounds. The investigators also propose optimizing the concentration and
      manner of delivery of topical gentamicin. The unambiguous milestones will be increased C7 and
      AFs in the patients' DEJ, improved EB Disease Activity Scores, and absence of significant
      gentamicin side effects.
    

Detailed Description

      Aim 1. Evaluate the Safety and Efficacy of Short Term Intravenous Gentamicin for RDEB
      Patients.

      Overview & Rationale: The rationale for short-term systemic intravenous gentamicin in these
      patients is outlined in the sections above, namely the drug could treat multiple skin sites
      simultaneously including the esophagus. This approach has proven safe and efficacious in
      other genetic diseases such as CF and DMD22-25 Our HYPOTHESIS is that intravenous gentamicin
      will, like topical and intradermal gentamicin, create new C7 and AFs at the patient's DEJ,
      improve multiple skin sites simultaneously, improve the patient's clinical disease and
      improve his or her quality of life. In accordance with the enclosed letters from two
      experienced pediatricians, we believe this therapy will be safe. Because C7 and AFs are
      incredibly stable, we further hypothesize that newly induced C7 and AFs will persist for many
      months in the patient's skin. Using dosing regimens of gentamicin that have proven to be
      safe, we will: 1) determine the percentage increase of C7 expression in the patients' skin
      before and after treatment, 2) determine how durable and sustainable the new C7 and AFs are
      in the patients' skin after treatment, 3) determine if this treatment is safe in this patient
      population, 4) determine if this treatment improves the patients clinically and improves
      their quality of life and 5) generate data for a multi-centered Phase III study using a
      larger number of patients.

      Patients/Intervention: We have already lined up 3 well-characterized, adult RDEB patients
      with nonsense mutations who wish to participate in this study. These patients had positive
      responses to topical and intradermal gentamicin in our clinical trial (Table II). The
      patients will receive intravenous gentamicin (7.5 mgs per kilogram), in 100 ml of 5% dextrose
      in saline, for 14 consecutive days, a dose proven to not cause ototoxicity or
      neprhotoxicity28 and to be efficacious in inducing PTC read-through in DMD patients.22 The
      first few infusions will be done in the Infusion Center of the Keck Hospital of USC. We will
      measure gentamicin trough levels (24 hours after infusion) and gentamicin peak levels (30
      minutes after the infusion) during the second day and, if needed, adjust the gentamicin doses
      such that the peak level is between 20 and 40 μg/ml and the trough level <2 μg/ml. If no
      untoward side effects occur, the patients will then have their infusions in their home via a
      commercial infusion service.

      Safety Evaluation: Patients will be consented, enrolled and evaluated on Day 0 and then
      evaluated on post-treatment days 30, 90, and 180. On Day 0, the patients will have a complete
      medical history, review of systems (ROS), physical examination, vital signs, and weight. They
      will also have baseline urine analysis, complete blood count (CBC), electrolytes, glucose,
      comprehensive metabolic panel (CMP), and calculated creatinine clearance. Pure tone
      audiometry and a calculated creatinine clearance will be done on Days 0, 7, 14 and 30
      post-treatment. Stop criteria will be a decline of >15 dB on pure tone audiometry at 2
      consecutive frequencies and a creatinine clearance <60ml/min.28 Whenever there is new protein
      created in a patient, there is the possibility that the patient's immune system will raise
      autoantibodies against it. This did not occur in our clinical trial with topical and
      intradermal gentamicin, but it behooves us to evaluate this again with intravenous gentamicin
      and potentially more auto-antigenic protein created. Using indirect immunofluorescence and
      our anti-C7 ELISA, we will test the subject's serum for anti-C7 antibodies at each visit.

      Efficacy: A. Clinical Evaluations: At baseline Day 0 and at each follow-up visit, (days 30,
      90 and 180) the patients will complete a Quality of Life Assessment tool, a Pruritus Score
      tool, and a validated epidermolysis bullosa disease activity index (EBDASI)29,30. Patients
      will keep a daily diary using a self-ROS questionnaire. Patients will be telephoned weekly by
      a USC study member inquiring about any new signs, symptoms or ROS changes since the advent of
      the study. At baseline Day 0, we will identify four Test Sites at least 25 cm2 in size to
      follow sequentially. Two will be from areas that at baseline have blisters or erosions and
      the other two from intact skin areas. The two Test Sites with active blisters and erosions
      will be traced using a transparency sheet and the areas of the lesions calculated on a
      digitizing tablet. Likewise, all of the Test Sites will have standardized photographs and the
      lesional areas calculated by computer-assisted morphometry, as previously published.29-31
      Within the context of their daily diary, patients will note the number of new blisters and
      erosions that occur in the Test Sites. A USC study member will telephone the patient each
      week and inquire about the Test Sites and ask the patient to estimate the percentage area of
      the Test Site consumed by erosions and blisters. Also, at each follow-up visit, three
      dermatologists will observe the four Test Sites and count the number of bullae and erosions
      in each. The intact Test Site areas will be scored at each follow-up visit using the
      following 3-point scale: 0 = no lesions; +1 = any active lesions; +2 = active lesions
      consuming over 50% of the Test Site area. Tracings to evaluate the areas of blisters or open
      erosions will be done, and standardized photographs paired with computer-assisted morphometry
      to calculate the areas of any lesions will be performed. B. Evaluations of C7 and AF
      Expression: At each post-treatment time point, 8 mm punch biopsies from the four Test Sites
      will be divided into three parts for (i) H&E histology and quantitation of epidermal-dermal
      adherence, (ii) the expression of C7 at the DEJ relative to that of normal human skin using
      anti-C7 antibodies to the NC1 and NC2 domains of C7 and NIH J Image software. One major
      "milestone" of the study will be the expression of NC2 since this would clearly indicate
      restoration of full-length C7 and (III) evaluation of newly created AFs by immuno-EM and AF
      enumeration by computer-assisted morphometry. Performing these evaluations out to 6 months
      will determine how durable the newly created C7 and AFs are. In our recent clinical trial
      outlined above, it was surprising that gentamicin-induced C7 remained at a similar level at 3
      months post-treatment as that of 1 month for Patient #3 (Please see Figure 1 and Table II).

      Aim 2: Evaluate the Safety and Efficacy of Higher Dose Topical Gentamicin for RDEB Patients.

      Overview and Rationale: In our gentamicin clinical trial outlined earlier, there was
      significant variation in the production of new C7 and AFs, as shown in Table II. Patients #2
      and #5 only restored C7 to 20% of normal skin in response to gentamicin. We only used one
      concentration of gentamicin, 0.1% ointment, and our in vitro studies with RDEB fibroblasts
      from these same two patients showed that the C7 response to gentamicin was dose-dependent.26
      In these patients, there could have been sub-optimal dosing or sub-optimal access of the
      gentamicin to the patient's dermal fibroblasts and basal keratinocytes. In this aim, we will
      use 0.5% gentamicin ointment rather than 0.1% and determine if the C7 response is more robust
      in these two patients. Based on our encouraging data shown in Figure 2, we will also treat
      intact skin and determine if higher dose gentamicin can prophylactically prevent frank skin
      blisters and erosions from forming.

      Patients/Intervention: We will study two RDEB children tested in our previous trial for this
      study. In addition, we also have 2 other children and 2 other adult patients who have
      contacted us and wish to participate in this study (Table III). Two of these patients share
      the same mutations (R578X and R2814) as our current patients. We will select a total of four
      Test Sites (two with open wounds of at least 3 cm by 3 cm and two areas of intact skin nearby
      the Test Sites with blisters or erosions) and apply 0.5% gentamicin ointment two times a day
      under an occlusive dressing of the patients' choice for two weeks. This dose was used in
      combination with 15% paromomycin to ulcerative cutaneous leishmaniasis lesions once daily for
      20 days in two publications without renal or ototoxicity detected.32,33 Safety and Efficacy:
      We will essentially assess in these patients the safety and efficacy parameters outlined in
      Aim #1 at months 1, 3 and 6 after topical application. Potential renal toxicity and
      ototoxicity will be monitored by creatinine clearance and pure tone audiometry at day 0 and
      at each follow up visit.

      Aim 3: Evaluate the Safety and Efficacy of Intradermal Administration of Gentamicin with a
      MR2 Micro-needle Roller Device.

      Overview and Rationale: In our current clinical trial outlined above, there were excellent C7
      responses to intradermal injections of gentamicin solution in several patients (Table II).
      Nevertheless, these injections were very localized with diffusion of the drug probably less
      than an inch from the single injection site. Recent evidence has shown that a MR2 microneedle
      roller device can readily deliver lidocaine into the lower epidermis and upper papillary
      dermis over a wide area of skin with good efficacy, safety and excellent patient tolerance.34
      This may be an opportunity to deliver intradermal gentamicin solution (40 mg/ml) to wide
      areas of skin in a simple manner that can be done in an outpatient office with minimal
      logistical issues and avoidance of systemic exposure to the drug. Advantages include the
      possibility of delivering in a "pulse " fashion significant levels of gentamicin to the
      papillary dermis over wide areas of skin with minimal discomfort and minimal systemic
      exposure of gentamicin. Avoiding systemic exposure would be valuable for RDEB patients who
      have ototoxicity or renal compromise, poor venous access or cannot tolerate intravenous
      infusions.

      Patients & Interventions: We will enroll two new RDEB patients (either adults or children)
      shown in Table III in this "proof-of-principle" study. Skin Test Sites will be areas
      measuring at least 40 cm2, and we will test one site of intact unwounded skin and one site of
      skin with lesions (blisters or erosions). The areas will be cleansed with 4% Hibiclens and
      then the MR2 Microneedle Roller Device passed over the area in two directions at 90 degrees.
      This device induces tiny micro-wounds in the skin to the depth of the papillary dermis.
      Gentamicin sterile solution (40 mg/ml) will then be liberally applied over the area and the
      area immediately occluded with a polyrurethane membrane (Opsite). Another equal sized Test
      Site of intact skin will be tested without prior intervention with the Microneedle Roller.
      The same gentamicin solution will be applied to the site and immediately occluded with
      Opsite. This will determine if the gentamicin solution can penetrate intact skin.

      Safety and Efficacy: We will measure gentamicin in the serum of these patient 30 minutes
      after the microneedle delivery to determine if there is any systemic exposure when gentamicin
      is administered in this manner. Efficacy of the gentamicin administration will be assessed
      identically to those in Aim#1 by IF and immuno-EM analysis in conjunction with the patients
      keeping a daily diary of the treatment sites, weekly photographs of Test Sites, weekly staff
      interviews of the patients, and physician assessments at patient visits at months 1, 3 and 6
      after administration of gentamicin. Potential renal toxicity and ototoxicity will be
      monitored by creatinine clearance and pure tone audiometry at day 0 and each follow up visit.
    

Study Phase

Phase 1/Phase 2

Study Type

Interventional


Primary Outcome

Increased Expression of Full-length Type VII Collagen as Assessed by Immunofluorescence

Secondary Outcome

 Improved EBDASI Scores

Condition

Recessive Dystrophic Epidermolysis Bullosa

Intervention

Gentamicin Sulfate

Study Arms / Comparison Groups

 Gentamicin
Description:  Topical gentamicin; Topical gentamicin with microneedle roller assistance; IV gentamicin. While the intervention is the same drug, the topical gentamicin is compounded into a 0.5% ointment and the IV gentamicin is prepared to 7.5 mg/kg body weight and administered over a 30 minutes.

Publications

* Includes publications given by the data provider as well as publications identified by National Clinical Trials Identifier (NCT ID) in Medline.

Recruitment Information


Recruitment Status

Drug

Estimated Enrollment

6

Start Date

February 2, 2017

Completion Date

August 31, 2018

Primary Completion Date

May 5, 2018

Eligibility Criteria

        Inclusion Criteria:

        (i) RDEB patients with a nonsense mutation in COL7A1 in either one or two alleles (ii) An
        absence or decrease in C7 expression at their DEJ when compared to that of normal human
        skin.

        Exclusion Criteria:

        (i) Pre-existing renal or auditory impairment (ii) Allergies to aminoglycosides or sulfate
        compounds (iii) Pregnancy (iv) Exposure to gentamicin within the past 6 weeks.
      

Gender

All

Ages

N/A - N/A

Accepts Healthy Volunteers

No

Contacts

David Woodley, MD, , 

Location Countries

United States

Location Countries

United States

Administrative Informations


NCT ID

NCT03012191

Organization ID

HS-16-00788


Responsible Party

Principal Investigator

Study Sponsor

University of Southern California


Study Sponsor

David Woodley, MD, Principal Investigator, University of Southern California Department of Dermatology


Verification Date

July 2019