Acute Liver Failure, Acute Liver Injury
Conditions
Keywords
ornithine, phenylacetate, acetaminophen toxicity, acute liver failure, hepatitis B, autoimmune hepatitis, drug-induced liver injury
Brief summary
This Phase 2a clinical study is designed to provide data on OCR-002 in patients with acute liver failure/acute liver injury (ALF/ALI) in regard to: * safety and tolerability; * metabolism of the compound to glutamine and phenylacetylglutamine (PAGN); * its effect on circulating ammonia levels and neurological function in patients with and without impaired renal function after continuous infusion at different infusion rates. Subjects will receive up to 120 hours (5 days) of drug infusion, followed by a 30 day follow-up visit post infusion. It is anticipated that this early safety and tolerability study, with appropriate PK/PD data, will lead to a development program for the use of OCR-002 in the treatment of hyperammonemia either due to ALF or possibly other liver conditions. The hypotheses are: * Treatment with OCR-002 is safe and tolerable in patients with acute liver failure/acute liver injury due to acetaminophen overdose or drug-induced liver injury, autoimmune hepatitis, viral hepatitis or indeterminate etiologies. * A dose of 10-20g/24h (0.42-.83g/h) will achieve steady state plasma concentrations within 6-12h with little additional accumulation in the ALI/ALF setting. * Treatment with OCR-002 will reduce ammonia and improve neurological function in patients with acute liver failure/severe acute liver injury.
Detailed description
There is strong experimental and clinical rationale for the use of ammonia-lowering therapies in ALF. Ammonia is normally produced in the gut and transformed by the liver into urea. As the liver fails, ammonia increases in the systemic circulation and enters into the brain. The result of a rapid rise in ammonia or related compounds in the cerebral circulation is hepatic encephalopathy (HE), a reversible neuropsychiatric condition that ranges in severity from mild impairment in attention, to delirium, the development of cerebral edema, coma and death. This is a Phase 2a, multi-center, open-label study, conducted in two cohorts in patients diagnosed with acute liver failure/acute liver injury (ALF/ALI) who meet inclusion/exclusion criteria. This study is designed to provide data on OCR-002 with regards to * the effect on circulating ammonia levels in patients with acute liver failure with and without impaired renal function at different doses after single and continuous infusion * safety and dose tolerability as well as * providing data on the metabolites, glutamine and phenylacetylglutamine in this patient population. It is anticipated that this early efficacy, safety, tolerability, Pharmacokinetic/Pharmacodynamic (PK/PD) and dose-ranging study will lead to a Phase 3 development program for the use of OCR-002 in the treatment of hyperammonemia due to ALF. No clinical outcome measures will be formally studied because of the small sample size.
Interventions
Up to 36 patients will be enrolled into 2 groups \[\ 18 with minimal renal dysfunction (Cohort 1) & \ 18 w/ comprised renal function (Cohort 2)\] and receive OCR-002 infusion for at least 72 hrs. OCR-002 will be administered in the vein and pharmacokinetics (pk) assessed for all subjects who receive the infusion. The first 24 enrolled subjects received OCR-002 at 3 ascending dose levels (DLs 1-3) with a maximum target infusion rate equivalent to 10g/24h. The remaining 12 patients (\ 6 Cohort 1 & \ 6 Cohort 2) will be enrolled and receive identical quantities of OCR-002 at 20g/24hr continuously for 5 days (Dose Level 4).
Sponsors
Medical University of South Carolina
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
Ocera Therapeutics
William Lee
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to 65 Years
Healthy volunteers
No
Inclusion criteria
1. Men and women, ages 18-65 (have not reached their 66th birthday). 2. Acute liver failure, defined as the development of coagulopathy (International normalized ratio \[INR\] ≥1.5) with encephalopathy in a patient with no prior history of liver disease, with onset of symptoms within 28 days of the inciting event. Patients may have either a history of acetaminophen overdose (defined as \>4 g/day within 7 days of presentation) and/or detectable acetaminophen levels in the serum, with a pattern of liver function tests typical for acetaminophen toxicity (bilirubin \< 10 mg/dL and alanine aminotransferase (ALT) ≥1000 IU/L), or a diagnosis of hepatitis A, hepatitis B, drug-induced liver injury, autoimmune hepatitis or indeterminate cause based on standard criteria. 3. ALI patients may also be enrolled (those meeting the above criteria plus coagulopathy (INR ≥ 2.0) and no evidence of encephalopathy) 4. Written informed consent from the patient (ALI) or patient's legally authorized representative or family member if he/she is considered encephalopathic (ALF). 5. Ammonia level ≥60 μmol/L at baseline (within 8h prior to T0/initiation of infusion). 6. Serum creatinine levels as follows: 1. Cohort 1: Creatinine ≤1.5 mg/dL; and 2. Cohort 2: Creatinine \>1.5 mg/dL and \<10mg/dL. 7. Mean arterial pressure of \>65 mmHg.
Exclusion criteria
1. History of chronic liver disease. 2. Signs of overt cerebral herniation, or uncontrolled intracranial hypertension by intracranial pressure (ICP) monitoring (if applicable). 3. Evidence of Wilson's disease, alcoholic hepatitis, biliary obstruction, ischemic hepatitis, severe acute renal tubular necrosis (ATN) due to shock, or any patient with ongoing hypotension. 4. Significant gastrointestinal bleeding (coffee grounds per nasogastric tube and/or melena). 5. Hemodynamic instability, defined by a mean arterial pressure of \<65 mmHg. 6. Cardiopulmonary complications such as pulmonary edema, aspiration pneumonia, heart failure. 7. QT interval of \>500msec at baseline EKG. 8. Pregnancy. 9. History of malignancy that has not been cured or any cancer in remission for less than 1 within the past 5 year. Non-melanoma skin cancers do not preclude participation in the trial. 10. Concomitant administration of drugs known to interfere with renal excretion of phenylacetylglutamine or those medications that may induce hyperammonemia such as haloperidol, valproic acid and systemic corticosteroids (prohibited during the study). Alternative ammonia modifying agents such as lactulose and rifaximin are not considered standard of care and are prohibited during the study period. 11. Any other health condition that would preclude participation in the study in the judgment of the principal investigator.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Number of Participants That do Not Tolerate the Administered Dose and Had Grade 3 or 4 Treatment Emergent Adverse Events as a Measure of Safety and Tolerability | 30 Days | To evaluate the safety and tolerability of OCR-002 in patients with acute liver failure/severe acute liver injury |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Measurement of OCR-002 Plasma Concentration | 24 Hours after last infusion | To evaluate the steady state pharmacokinetic and pharmacodynamic profile of OCR-002 in patients with impaired and intact renal function using urinary phenylacetylglutamine (PAGN) as a surrogate marker |
| Change in Ammonia | Baseline and 72 Hours | To evaluate the effect of OCR-002 on ammonia levels in patients with acute liver failure/severe acute liver injury |
| Neurological Function Measured by the West Haven Criteria (WHC) for Hepatic Encephalopathy | 120 hours from start of infusion | The West Haven Criteria (WHC) for Hepatic Encephalopathy measures the severity of encephalopathy and patient's level of consciousness. The scale ranges from 0 to 4; a minimum score of 0 represents a better outcome, and a maximum total score of 4 represents a worse outcome. A score of 0 corresponds to normal consciousness and behavior and normal neurological examination. A score of 1 corresponds to mild lack of awareness, shortened attention span, and impaired addition or subtraction; mild asterixis or tremor. A score of 2 corresponds to lethargy, disorientated or inappropriate behavior, obvious asterixis; slurred speech. A score of 3 corresponds to somnolent but arousable, gross disorientation or bizarre behavior, muscle rigidity and clonus; hyperreflexia. A score of 4 corresponds to coma and decerebrate posturing. |
| Neurological Function Measured by the Orientation Log (O-log) | 30 Days | The orientation log focuses on orientation to place, time, and circumstance. There are 10 items on the orientation log, which are scored 0-3. A spontaneous correct response is awarded 3 points. A spontaneous response that is lacking or incorrect, but a correct response is provided following a logical cue is awarded 2 points. A score of 1 is given if spontaneous and cued responses are lacking or incorrect, but a correct response is provided in a recognition format. A score of 0 is given if the spontaneous, cued, or recognition format does not generate a correct answer. Scores from the 10 items are summed and the final score ranges from 0 to 30. |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Maximum Dose Level 3.33 g/24h Initial infusion of study drug at 0.139 g/h for the first 12 hours (approximately 3.33 g/24h) and maintained at this rate for up to 120 hours. | 9 |
| Maximum Dose Level 6.65 g/24h Initial infusion of study drug at a dose of 0.139 g/h for the first 12 hours (approximately 3.33 g/24h); dose increased to 0.277 g/h for the remaining 108 hours (approximately 6.65 g/24h) for a total treatment period of up to 120 hours. | 10 |
| Maximum Dose Level 10 g/24h Initial infusion of study drug at a dose of 0.139 g/h for the first 12 hours (approximately 3.33 g/24h); dose increased to 0.277 g/h for the next 12 hours; dose then increased to 0.416 g/h (approximately 10 g/24h) and maintained at this rate for the remaining 96 hours for a total treatment period of up to 120 hours. | 13 |
| Maximum Dose Level 20g/24h Study drug infused at a dose of 20g/24h from initiation of infusion for up to 120 hours. | 15 |
| Total | 47 |
Baseline characteristics
| Characteristic | Total | Maximum Dose Level 20g/24h | Maximum Dose Level 10 g/24h | Maximum Dose Level 6.65 g/24h | Maximum Dose Level 3.33 g/24h |
|---|---|---|---|---|---|
| Age, Continuous | 35.0 years | 35.0 years | 42.0 years | 30.0 years | 32.0 years |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 2 Participants | 0 Participants | 2 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Black or African American | 11 Participants | 5 Participants | 2 Participants | 3 Participants | 1 Participants |
| Race (NIH/OMB) More than one race | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 2 Participants | 0 Participants | 1 Participants | 0 Participants | 1 Participants |
| Race (NIH/OMB) White | 32 Participants | 10 Participants | 8 Participants | 7 Participants | 7 Participants |
| Region of Enrollment United States | 47 Participants | 15 Participants | 13 Participants | 10 Participants | 9 Participants |
| Sex: Female, Male Female | 31 Participants | 11 Participants | 9 Participants | 5 Participants | 6 Participants |
| Sex: Female, Male Male | 16 Participants | 4 Participants | 4 Participants | 5 Participants | 3 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk | EG003 affected / at risk |
|---|---|---|---|---|
| deaths Total, all-cause mortality | 2 / 9 | 3 / 10 | 2 / 13 | 4 / 15 |
| other Total, other adverse events | 8 / 9 | 5 / 10 | 9 / 13 | 7 / 15 |
| serious Total, serious adverse events | 5 / 9 | 3 / 10 | 4 / 13 | 4 / 15 |
Outcome results
Primary
Number of Participants That do Not Tolerate the Administered Dose and Had Grade 3 or 4 Treatment Emergent Adverse Events as a Measure of Safety and Tolerability
To evaluate the safety and tolerability of OCR-002 in patients with acute liver failure/severe acute liver injury
Time frame: 30 Days
Population: All patients who consented to the study, completed screening and had the intravenous infusion of study drug initiated
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Maximum Dose Level 3.33 g/24h | Number of Participants That do Not Tolerate the Administered Dose and Had Grade 3 or 4 Treatment Emergent Adverse Events as a Measure of Safety and Tolerability | 0 Participants |
| Maximum Dose Level 6.65 g/24h | Number of Participants That do Not Tolerate the Administered Dose and Had Grade 3 or 4 Treatment Emergent Adverse Events as a Measure of Safety and Tolerability | 0 Participants |
| Maximum Dose Level 10 g/24h | Number of Participants That do Not Tolerate the Administered Dose and Had Grade 3 or 4 Treatment Emergent Adverse Events as a Measure of Safety and Tolerability | 0 Participants |
| Maximum Dose Level 20g/24h | Number of Participants That do Not Tolerate the Administered Dose and Had Grade 3 or 4 Treatment Emergent Adverse Events as a Measure of Safety and Tolerability | 0 Participants |
Secondary
Change in Ammonia
To evaluate the effect of OCR-002 on ammonia levels in patients with acute liver failure/severe acute liver injury
Time frame: Baseline and 72 Hours
Population: All patients who consented to the study and had the intravenous infusion of study drug initiated for up to 72 hours and available venous or arterial ammonia levels.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Maximum Dose Level 3.33 g/24h | Change in Ammonia | 41.2 Percent Change | Standard Deviation 21.1 |
| Maximum Dose Level 6.65 g/24h | Change in Ammonia | 16.6 Percent Change | Standard Deviation 51.4 |
| Maximum Dose Level 10 g/24h | Change in Ammonia | 41.8 Percent Change | Standard Deviation 35.8 |
| Maximum Dose Level 20g/24h | Change in Ammonia | 38.4 Percent Change | Standard Deviation 31.1 |
Secondary
Measurement of OCR-002 Plasma Concentration
To evaluate the steady state pharmacokinetic and pharmacodynamic profile of OCR-002 in patients with impaired and intact renal function using urinary phenylacetylglutamine (PAGN) as a surrogate marker
Time frame: 24 Hours after last infusion
Population: All patients who consented to the study and had the intravenous infusion of study drug initiated for up to 120 hours and had results available from serum and urine samples measuring the pharmacokinetic (PK), pharmacodynamic profile (phenylacetic acid (PAA), ornithine) and urinary phenylacetylglutamine (PAGN) levels.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Maximum Dose Level 3.33 g/24h | Measurement of OCR-002 Plasma Concentration | 65.6 micrograms per millileter | Standard Deviation 82.5 |
| Maximum Dose Level 6.65 g/24h | Measurement of OCR-002 Plasma Concentration | 32.2 micrograms per millileter | Standard Deviation 31.4 |
| Maximum Dose Level 10 g/24h | Measurement of OCR-002 Plasma Concentration | 33.4 micrograms per millileter | Standard Deviation 24.1 |
| Maximum Dose Level 20g/24h | Measurement of OCR-002 Plasma Concentration | 104.9 micrograms per millileter | Standard Deviation 104.5 |
Secondary
Neurological Function Measured by the Orientation Log (O-log)
The orientation log focuses on orientation to place, time, and circumstance. There are 10 items on the orientation log, which are scored 0-3. A spontaneous correct response is awarded 3 points. A spontaneous response that is lacking or incorrect, but a correct response is provided following a logical cue is awarded 2 points. A score of 1 is given if spontaneous and cued responses are lacking or incorrect, but a correct response is provided in a recognition format. A score of 0 is given if the spontaneous, cued, or recognition format does not generate a correct answer. Scores from the 10 items are summed and the final score ranges from 0 to 30.
Time frame: 30 Days
Population: All patients who consented to the study and had the intravenous infusion of study drug initiated and Orientation log (O-log) assessment scores available.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Maximum Dose Level 3.33 g/24h | Neurological Function Measured by the Orientation Log (O-log) | 23.8 units on a scale | Standard Deviation 0.4 |
| Maximum Dose Level 6.65 g/24h | Neurological Function Measured by the Orientation Log (O-log) | 24.0 units on a scale | Standard Deviation 0 |
| Maximum Dose Level 10 g/24h | Neurological Function Measured by the Orientation Log (O-log) | 24.0 units on a scale | Standard Deviation 0 |
| Maximum Dose Level 20g/24h | Neurological Function Measured by the Orientation Log (O-log) | 24.0 units on a scale | Standard Deviation 0 |
Secondary
Neurological Function Measured by the West Haven Criteria (WHC) for Hepatic Encephalopathy
The West Haven Criteria (WHC) for Hepatic Encephalopathy measures the severity of encephalopathy and patient's level of consciousness. The scale ranges from 0 to 4; a minimum score of 0 represents a better outcome, and a maximum total score of 4 represents a worse outcome. A score of 0 corresponds to normal consciousness and behavior and normal neurological examination. A score of 1 corresponds to mild lack of awareness, shortened attention span, and impaired addition or subtraction; mild asterixis or tremor. A score of 2 corresponds to lethargy, disorientated or inappropriate behavior, obvious asterixis; slurred speech. A score of 3 corresponds to somnolent but arousable, gross disorientation or bizarre behavior, muscle rigidity and clonus; hyperreflexia. A score of 4 corresponds to coma and decerebrate posturing.
Time frame: 120 hours from start of infusion
Population: All patients who consented to the study and had the intravenous infusion of study drug initiated and West Haven Criteria (WHC) for Hepatic Encephalopathy assessment scores available.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Maximum Dose Level 3.33 g/24h | Neurological Function Measured by the West Haven Criteria (WHC) for Hepatic Encephalopathy | 2.4 units on a scale | Standard Deviation 1.9 |
| Maximum Dose Level 6.65 g/24h | Neurological Function Measured by the West Haven Criteria (WHC) for Hepatic Encephalopathy | 3.2 units on a scale | Standard Deviation 2 |
| Maximum Dose Level 10 g/24h | Neurological Function Measured by the West Haven Criteria (WHC) for Hepatic Encephalopathy | 1.6 units on a scale | Standard Deviation 1.4 |
| Maximum Dose Level 20g/24h | Neurological Function Measured by the West Haven Criteria (WHC) for Hepatic Encephalopathy | 1.8 units on a scale | Standard Deviation 1.6 |