double blind double dummy placebo controlled randomized clincal trial of implantable naltrexone...
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DOUBLE BLIND DOUBLE DUMMY PLACEBO CONTROLLED
RANDOMIZED CLINCAL TRIAL OF IMPLANTABLE NALTREXONE
(PRODETOXONE) FOR HEROIN ADDICTION
Evgeny Krupitsky, MD, PhD, D.Med.Sci.
St.-Petersburg Bekheterv Research Psychoneurological Institute and
St.-Petersburg Pavlov State Medical University
CONFLICT OF INTERESTS
• Supported with NIDA grant R01-DA-017317
• Dr. Krupitsky has received funding as a consultant for Alkermes, Inc.
PHARAMCOTHERAPY OF HEROIN DEPENDENCE
Full agonists (methadone, LAAM)Partical agonists-antagonists
(buprenorphin)Full antagonists (naltrexone,
nalmefene)
NALTREXONENALTREXONE
Different drug Different drug formulations:formulations:
1. Oral1. Oral
2. Implantable2. Implantable
3. Injectable3. Injectable
Background
• Our previous studies with oral naltrexone demonstrated its superiority over placebo, however, the rate of abstinence was relatively low in six month of medication (Krupitsky et al, J. Substance Abuse Treatment, 2002, 23:273-283)
• Combination of oral naltrexone with antidepressants improved abstinence insignificantly (Krupitsky et al, J. Substance Abuse Treatment, 2006, 31:319-328)
The major problem with oral naltrexone is a poor compliance
Is there way to improve naltrexone therapy ?
DIFFICULTY WITH ORAL NTXN:POOR COMPLIANCE
OPPORTUNITY:EXTENDED RELEASE
FORMULATIONS
“The pessimist sees difficulty in every opportunity. The optimist sees opportunity in every difficulty”
Winston Churchill
Implantable Naltrexone: Route and Dosage
PRODETOXONEPRODETOXONE, , tablets for implantationtablets for implantation 1000 mg of naltrexone1000 mg of naltrexone
Pharmacokinetics of ProdetoxonePharmacokinetics of Prodetoxone(data from the manufacturer)(data from the manufacturer)
Blood samples were collected in one week, one and two months after implantationBlood samples were collected in one week, one and two months after implantation
010 20 30 40 50 60 70
Time after implantation, days
Co
nce
ntr
atio
n, n
g/m
l
Naltrexone metabolite Naltrexone
METHODS 306 male and female heroin addicts after detoxification, giving
informed consent and passing a Naloxone challenge had been randomly assigned to one of three treatment groups (102 PATIENTS EACH).
Three cell study design:1. Naltrexone Implant (1000 mg) (3 times, every 2 months) + Oral Placebo (OP+NI).
2. Oral Naltrexone (50mg/day) + Implant Placebo (3 times, every 2 months) (ON+PI). 3. Implant Placebo (3 times, every 2 months) + Oral Placebo (OP+PI).
All patients received biweekly clinical management / compliance enhancement counseling.
Treatment lasted 6 months. Control of abstinence, compliance, psychiatric symptoms, and side
effects – every other week. All patients had at least one family member who was able to
supervise medication compliance. Study design: Double blind double dummy placebo controlled
randomized clinical trial.
Assessments Assessments have been done at
baseline, at each biweekly appointment, and at 3 and 6 months following the end of treatment.
Assessments included: Psychiatric rating scales, Riboflavine control of compliance, Urine drug tests, Naloxone challenge.
Primary outcomes: Treatment retention and relapse to heroin dependence.
Secondary outcomes: Opiate negative urines, HIV risk, psychiatric symptoms, and other measures of adjustment.
Recruitment details
358 approached309 met inclusion criteria306 got randomized
Demographics and Clinical Characteristics
Group
OP+PI ON+PI OP+NI
N 102 102 102
Gender (female) 27,5% 27,5% 27,5%
Age (M±SEM) 28,0±0,40 27,9±0,40 28,7±0,45
Duration of heroin dependence (M±SEM)
7,8±0,38 7,9±0,41 8,3±0,39
Number of previous treatments (M±SEM) 3,8±0,31 4,3±0,37 4,9±0,41
*
*
*
* P<0.01 to placebo
* *
* * ** * *
***
Weeks
** *
***
**
***
*
Retention in treatment (Remission) (% of patients)
+ + + ++
+ + + + + ++ + + + + + + +
+ P<0.01 to ON+PI
Log Rank (Mantel-Cox) Sig.
P(NI+OP)- (PO+PI)<0,001 P(NI+OP)- (PI+ON) <0,001 P(ON+PI)- (PO+PI)=0,069
Kaplan-Meier Survival Functions: Drop out
Retention: End of treatmernt (6 months)
OP+NI > OP+PI (P<0,001)
OP+NI > ON+PI (P<0,001)
(P<0,001)
(P<0,001)
Remissions in 3 & 6 months after treatment *
*Follow ups collected for 46,5% of those who was randomized
(End of Treatment) (3 Month Follow Up) (6 Month Follow Up)
Relapses in Naltrexone implant group
WEEKS
P<0,001
P<0,001
P<0,001
**
* *
**
*
**
* *
*
Opiate negative visits
*- P<0,01 Fisher's Exact Test to placebo + - P<0,01 Fisher's Exact Test to Ntxn implant group
Genetic Analysis Thomas Kosten, MDDavid Nielsen, PhD
Baylor College of Medicine
I). Gens of µ-opiate receptors:1) OPRM11, 2) OPRM12, 3) OPRM13 II). Gene of κ-opiate receptor:
OPRK1
III). Gene of the enzyme COMT:COMT
Effect of genotype on the completion of the treatment: Uncertainty Coefficients (I)
[OPRM13,COMT,OPRK1]
0,0
0,1
0,2
0,3
0,4
0,5
0,6
PO/NI (p=0.9) ON/PI (p=0.056) PO/PI (p=0.031)
[AAAGTT] or [AGAGTT] the others
Effect of genotype on the completion of the
treatment: Uncertainty Coefficients (II)
[OPRM11,COMT,OPRK1]
0
0,1
0,2
0,3
0,4
0,5
0,6
PO/NI (p=0.89) ON/PI (p=0.075) PO/PI (p=0.056)
[CCAGTT] or [CTAGTT] the others
Effect of genotype on the completion of the treatment: Kaplan-Meier Survival
Functions
Cu m u la ti ve P ro p o rti o n S u rvi vi n g (K a p la n -M e ie r)[O P RM 1 3 ,CO M T ,O P RK 1 ] p =0 .0 3 7 (Co x's F-te st)
Co m p le te Ce n so re d
A A A G T T A G A G T T
th e o th e rs0 5 1 0 1 5 2 0 2 5 3 0
T im e
0 ,1
0 ,2
0 ,3
0 ,4
0 ,5
0 ,6
0 ,7
0 ,8
0 ,9
1 ,0
Cu
mu
lativ
e P
rop
ort
ion
Su
rviv
ing
Cu m u la ti ve P ro p o rti o n S u rvi v i n g (K a p la n -M e ie r)[O P RM 1 1 ,CO M T ,O P RK 1 ] p =0 .0 2 (Co x's F-te st)
Co m p le te Ce n so re d
CCA G T T CT A G T T
th e o th e rs 0 5 1 0 1 5 2 0 2 5 3 0
T im e
0 ,1
0 ,2
0 ,3
0 ,4
0 ,5
0 ,6
0 ,7
0 ,8
0 ,9
1 ,0
Cu
mu
lativ
e P
rop
ort
ion
Su
rviv
ing
(p=0.02) (p=0.03)
Effect of genotype on the completion of the treatment: Treatment Effectiveness Score
p=0.063 p=0.043
Use of other drugs
Fisher's Exact Test P=0,005to placeboFisher's Exact Test P=0,049to ON+PI
Benzos
THC
Amphetamines
Anxiety and Depression
Depression (Beck scale)State Anxiety (Spielberger scale)
Physical Anhedonia Social Anhedonia
Anhedonia (Chapman at al.)
Anhedonia (J. Ferguson et al.)
LACK OF INTEREST LACK OF PLEASURE
HIV Risk Assessement Battery
RAB drug risk RAB sex risk
AE (non-surgical) (% visits)
AE (surgical) (% implants)
PON+IP=0.0001
POP+IP=0.005
Most common AE
1. Abdominal discomfort2. Nausea3. Drowsiness
• None of them required any special medication.
• Two patients in NI+OP group were terminated from the study because of side effects (wound infection).
SAE
The was only one serious adverse event in PI+OP group – the holecystectomia due to the stones in gallbladder which was considered as probably not related to the study medication
OD at the follow-up
• Through the phone calls to patients or their relatives follow-up information was collected on 261 patient (85,3% of the study patients). According to this information, five patients died during the 12 month follow-up period, all of them died of overdose, four of them were in the PI+OP (double placebo) group and one – the PI+ON group.
ALT & AST
SummaryImplantable naltrexone demonstrated
greater effectiveness in the treatment of heroin dependence in comparison to oral naltrexone and placebo.
Implantable naltrexone is basically comparable to oral naltrexone and placebo in terms of safety and tolerability except surgical adverse events.
Genotyping is helpful to determine responders to treatment.
LIMITATIONS for PRODETOXONE
1. Surgical procedure2. Wound infections (particularly in HIV+
individuals)3. Cosmetic defects 4. Relatively easy to take out within the
first few weeks after implantation5. Dos not provide 2 months long
blockade in some patients (small proportion)
AKNOWLEDGEMNET
E. Zvartau, E. Blokhina, V. Egorova, D. Masalov, А. Burakov, М. Tsoy, N. Bushara, Т. Romanova,
Е. Verbitskaya, A. Tyurina, V. Palatkin, Ch. О’Brian, G. Woody, T. Kosten, D. Nielsen
St.-Petersburg Pavlov State Medical University, St.-Petersburg Bekheterev Research
Psychoneurological Institute, University of Pennsylvania, Baylor College of Medicine
Supported with NIDA grant R01-DA-017317
•Thank you for your attention