Down Syndrome
Conditions
Keywords
Down syndrome, JAK inhibition, Tofacitinib
Brief summary
This protocol describes a phase 2, double-blind, randomized, placebo-controlled clinical trial for Janus kinase (JAK) inhibition in Down syndrome (DS). This trial will evaluate the safety and efficacy of a 6-month treatment with the JAK1/3 inhibitor tofacitinib in individuals ages 6-22 (inclusive) with DS. There will be two main arms for this study: a treatment arm and a placebo control arm. Participants will be randomized into the treatment or placebo arm. Those completing 6 months in the placebo arm may be eligible to participate in a cross-over, open-label extension arm to receive 6 months of tofacitinib treatment. Participants will be evaluated during a Screening visit to determine eligibility, complete a Baseline visit if eligible, and be monitored via safety clinical laboratories and in-person evaluations by study doctors at 1 month, 3 months (mid-point visit) and 6 months (endpoint visit). An interim analysis of safety will be completed by an independent Data and Safety Monitoring Board (DSMB) after 40 participants have completed 6 months of treatment or placebo (20 in each arm).
Detailed description
This is a phase 2 randomized, double-blind, placebo-controlled clinical trial for Janus kinase (JAK) inhibition in Down syndrome (DS). After successful enrollment, including informed consent and assessment of inclusion and exclusion criteria, participants will be enrolled and randomized into the treatment or placebo arms and complete identical activities over the course of 6 months. Briefly, the study recruitment goal is 80 participants (n=40 per treatment and placebo arm) with up to 92 participants enrolled. Participants enrolled in the treatment arm will receive a 6-month treatment with the JAK1/3 inhibitor tofacitinib to define the safety and efficacy of this medicine relative to placebo. Safety monitoring will be completed over the 6-month period through a combination of self-reporting, laboratory testing, and study doctor assessment. AEs will be annotated by the study team and classified per Common Terminology Criteria for Adverse Events (CTCAE 6.0). Diverse metrics of neurodevelopment and overall health will be obtained at the Baseline visit, 3-month visit (midpoint) and 6-month visit (endpoint). The data obtained after 6 months of treatment or placebo will be used for all endpoint analyses. Participants enrolled in the placebo arm will be eligible to continue in the trial for an additional 6 months of tofacitinib treatment in a cross-over, open-label extension arm. Data collected during the cross-over, open-label extension arm will not contribute to any of the primary endpoint analyses. Rather, the cross-over dataset will be used to complete exploratory analyses of longitudinal intra-individual variability while on placebo and tofacitinib. Activities during 6 months of treatment in the cross-over arm will be identical to the main treatment arm. The cross-over arm will also serve to incentivize participation by ensuring that all eligible participants will be able to receive the medicine at some point during the trial.
Interventions
JAK1/3 inhibitor
DRUGPlacebo
The placebo will be compounded by Children's Hospital of Colorado Investigational Drug Services using commercially available syrup with added flavoring to mimic the active product.
Sponsors
University of Colorado, Denver
Anschutz Acceleration Initiative
GLOBAL Down Syndrome Foundation
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
QUADRUPLE (Subject, Caregiver, Investigator, Outcomes Assessor)
Masking description
All participants, caregivers, and study team members will remain blinded to the intervention. The only personnel who will be unblinded will be the study specialist running the randomization algorithm and personnel at the Investigational Drug Services Pharmacy at Children's Hospital of Colorado. Unblinding will occur at the conclusion of the month 6 visit (all clinical procedures must be complete prior to unblinding) to define whether the participant had been assigned to the treatment or placebo arms to determine eligibility for the open-label extension.
Intervention model description
Phase 2, double-blind, randomized, placebo-controlled clinical trial
Eligibility
Sex/Gender
ALL
Age
6 Years to 22 Years
Healthy volunteers
No
Inclusion criteria
1. Individuals with DS aged 6 years (inclusive) to 22 years (inclusive). All forms of DS will qualify, including complete trisomy 21, Robertsonian translocation trisomy 21, partial trisomy 21 (segmental duplication), and/or mosaic trisomy 21. 2. Available parent(s) or guardian(s) legally able to sign the consent form and who can complete study materials as appropriate. 3. Body weight is at least 10 kgs.
Exclusion criteria
1. Prior treatment with a JAK inhibitor or with an investigational agent, device, or procedure within 21 days of enrollment. 2. Current or planned use of a JAK inhibitor during the 6-month study period. 3. Known allergies, hypersensitivity, or intolerance to tofacitinib. 4. Active, uncontrolled, or life-threatening infection that at the determination of the treating physician would preclude safe use of tofacitinib. 5. History of gastrointestinal perforation. 6. Vaccination with live attenuated virus within six weeks of inclusion in the study or planned during the study. Note on vaccines: Participants not yet vaccinated for MMR-V should consider their timeline for MMR-V vaccination. Specifically, the study team recommends MMR-V vaccination as soon as possible and delay study start until 6 weeks after MMR-V vaccinations. 7. Concomitant treatment with any of the following: 1. Concomitant treatment with other immunosuppressants (e.g., methotrexate, azathioprine, tacrolimus, cyclosporine). 2. Strong CYP3A4 inhibitors (e.g., ketoconazole). 3. Strong CYP3A4 Inducers (e.g., rifampin). 4. Moderate CYP3A4 inhibitor(s) with a strong CYP2C19 inhibitor(s) (e.g., fluconazole). 5. Other supplements or medications that at the determination of the treating physician would preclude safe use of tofacitinib. 8. Evidence of severe organ dysfunction, including significantly abnormal laboratory values or severe renal impairment, that at the determination of the treating physician would preclude safe administration of tofacitinib. 9. Any history of leukemia, lymphoma, or unresolved transient myeloproliferative disorder. 10. Any current, recurrent, or metastatic forms of cancer. 11. Any cancer treatment within five years prior to study entry. 12. Known personal history of thrombosis or bleeding disorder. 13. History of tuberculosis, disseminated herpes zoster, disseminated herpes simplex, or recurrent localized herpes zoster. 14. Intravenous antimicrobial therapy within 3 months of inclusion in the study. 15. History of organ or bone marrow transplant. 16. History of myocardial infarction or stroke. 17. Evidence of lipid disorder, including but not limited to LDL \> 190 mg/dL, per discretion of the treating physician. 18. Participant received blood or plasma products within 30 days of the Baseline visit. 19. Treatment with intravenous immunoglobulin (IVIG) within 8 weeks of the Baseline visit. 20. Hospitalization longer than 6 months in the last year. 21. History of neurological syndrome that in the opinion of the study doctors would inhibit successful participation in the study. 22. Less than 6 weeks post-surgery at Baseline appointment. 23. Total vision or hearing loss (with no corrective devices available). 24. Participant must be able to attempt the neurodevelopment assessment battery at Baseline and caregiver must be able to complete proxy reports for neurodevelopmental assessments. 25. Poor venous access not allowing repeated blood tests or non-compliance with venipuncture requirements. 26. Participants may be excluded for other unforeseen reasons at the study doctor's discretion. 27. Pregnancy or breastfeeding. 28. Use of estrogen-containing oral contraceptives.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Number and percentage of subjects experiencing treatment-emergent adverse events. | From screening to 1 month after end of treatment | Number, percentage, type, and severity of treatment-emergent adverse events (TEAEs) will be annotated over the 6-month period in the treatment arm and placebo arm. |
| Change in Kaufman Brief Intelligence Test, 2nd Edition Revised (KBIT-2 Revised) - Verbal Intelligence | Baseline, 6 months | Verbal Intelligence score, made up of the Verbal Knowledge and Riddles subtest, is a standardized measure of verbal cognitive ability. Raw scores,will be employed. Increase in scores indicate improvement in verbal cognitive performance. |
| Change in Kaufman Brief Intelligence Test, 2nd Edition Revised (KBIT-2 Revised) - Nonverbal Intelligence | Baseline, 6 months | The KBIT-2 Revised Nonverbal Intelligence score is a standardized measure of nonverbal reasoning ability and is made up of the Matrices subtest. We will be using the raw score. Increase in scores indicate improvement in nonverbal cognitive performance. |
| Change in Leiter 3 - Attention Sustained subtest | Baseline, 6 months | The Leiter-3 Attention Sustained subtest is a measure of inhibitory control. The raw score, calculated as the correct number of targets minus errors made across four trials, will be used. Increase in scores indicate improvement. |
| Change in Vineland Adaptive Behavior Scales 3 (VABS-3) - Sum of Domain Raw Scores | Baseline, 6 months | The Vineland Adaptive Behavior Scales, Third Edition (VABS-3) assesses adaptive functioning across communication, daily living skills, socialization, and motor domains. Domain raw scores will be summed to produce a composite raw score. . Increase in scores indicate improvement in adaptive functioning. |
| Change in Clinical Global Impressions (CGI) Scale - Improvement in Health (CGI-I-H) | Baseline, 6 months | The CGI-I scale, which ranges from 1 to 7, with 1 being "very much improved" and 7 being "very much worse" to assess changes in global health during the 6-month intervention period. Noteworthy, we will also collect the CGI-S score (severity) at each time point (baseline, 3 months - midpoint visit, and 6 months - endpoint visit). The CGI-I will be collected at 3 months and 6 months. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Change in Peabody Picture Vocabulary Test, Fifth Edition (PPVT-5) | Baseline, 6 months | The Peabody Picture Vocabulary Test, Fifth Edition (PPVT-5) assesses receptive vocabulary. Growth Scale Values (GSV) are used to determine an individual's absolute progress over time and is sensitive to small changes . Increase in scores indicate improvement in receptive vocabulary ability. A Naturalistic Language Sample will be utilized to measure spontaneous expressive language. We will analyze total utterances and mean length of utterance. Increase in scores indicate improvement in expressive language skills |
| Change in Naturalistic Language Sample | Baseline, 6 months | This measure evaluates spontaneous expressive language narration. We will analyze total utterances and mean length of utterance. |
| Change in Developmental Behavior Checklist 2 (DBC-2) or Achenbach Child (or Adult) Behavior Checklist | Baseline, 6 months | The DBC-2 reports a statistically significant change in Developmental Behavioral Checklist-2 (DBC-2) T-scores within or between treatment arms. A decrease in score indicates improvement. Or the Achenbach is a caregiver-report measure of maladaptive behavior. This is a standardized questionnaire with available score norms by chronological age resulting in T-scores. We will analyze change in the internalizing and externalizing T-scores. |
| Change in Social Responsiveness Scale 2 (SRS-2), School Age and Adult | Baseline, 6 months | The Social Responsiveness Scale, Second Edition (SRS-2) generates T-scores with a mean of 50 and a standard deviation of 10. . Increase in scores indicates greater severity of autism-related symptoms (worse outcome). Both total and social communication T-scores will be analyzed. |
| Change in Modified Corsi Test | Baseline, 6 months | The Modified Corsi Test assesses working memory. Scores are summed based on total performance across all trials. Increase in scores indicates improvement in working memory performance. |
| Change in Dimensional Change Card Sort test | Baseline, 6 months | The Dimensional Change Card Sort Test measures cognitive flexibility. The total number of correct post-switch responses will be calculated across the last two trials. Increase in scores indicates improvement in cognitive flexibility. |
| Change in Beery Visual Motor Integration Scales (Beery VMI) | Baseline, 6 months | The Beery VMI, assesses visual-motor integration skills. Increase in scores indicates improvement in visual-motor integration ability. |
| Change in Vineland Adaptive Behavior Scales, Third Edition (VABS-3) - Sum of Raw Scores | Baseline, 6 months | The Vineland-3 is composed of four domains: Communication, Daily Living Skills, Socialization, and Motor. Each domain score represents summed raw scores from subdomains. We will evaluate changes in the raw scores of the four domains.. Increase in scores indicate improvement of adaptive skills in communication, daily living skills, socialization, and motor skills. |
| Change in Composite Neurodevelopmental Improvement Scores | Baseline, 6 months | This composite score aggregates standardized changes across multiple assessments. Individual measures are transformed into standardized differences before averaging. The composite score is not bounded by a fixed range. Higher values indicate greater overall improvement in neurodevelopmental functioning |
| Change in Clinical Global Impression - Improvement in Neurodevelopment (CGI-I-ND) | Baseline, 6 months | This composite score aggregates standardized changes across multiple assessments. Individual measures are transformed into standardized differences before averaging. The composite score is not bounded by a fixed range. Higher values indicate greater overall improvement in neurodevelopmental functioning. CGI-I-ND is a scale to rate improvement. |
Countries
United States
Contacts
CONTACTConstance Brecl
CONTACTErika Chelales, PhD
PRINCIPAL_INVESTIGATORJoaquin Espinosa, PhD
Linda Crnic Institute for Down Syndrome, CU Anschutz
Outcome results
None listed