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Bella ED, Tramacere I, Antonini G, Borghero G, Capasso M, Caponnetto C, Chiò A, Corbo M, Eleopra R, Filosto M, Giannini F, Granieri E, Bella VL, Lunetta C, Mandrioli J, Mazzini L, Messina S, Monsurrò MR, Mora G, Riva N, Rizzi R, Siciliano G, Silani V, Simone I, Sorarù G, Volanti P, Lauria G. Protein misfolding, amyotrophic lateral sclerosis and guanabenz: protocol for a phase II RCT with futility design (ProMISe trial). BMJ Open 2017; 7:e015434. [PMID: 28801400 PMCID: PMC5724081 DOI: 10.1136/bmjopen-2016-015434] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Recent studies suggest that endoplasmic reticulum stress may play a critical role in the pathogenesis of amyotrophic lateral sclerosis (ALS) through an altered regulation of the proteostasis, the cellular pathway-balancing protein synthesis and degradation. A key mechanism is thought to be the dephosphorylation of eIF2α, a factor involved in the initiation of protein translation. Guanabenz is an alpha-2-adrenergic receptor agonist safely used in past to treat mild hypertension and is now an orphan drug. A pharmacological action recently discovered is its ability to modulate the synthesis of proteins by the activation of translational factors preventing misfolded protein accumulation and endoplasmic reticulum overload. Guanabenz proved to rescue motoneurons from misfolding protein stress both in in vitro and in vivo ALS models, making it a potential disease-modifying drug in patients. It is conceivable investigating whether its neuroprotective effects based on the inhibition of eIF2α dephosphorylation can change the progression of ALS. METHODS AND ANALYSES Protocolised Management In Sepsis is a multicentre, randomised, double-blind, placebo-controlled phase II clinical trial with futility design. We will investigate clinical outcomes, safety, tolerability and biomarkers of neurodegeneration in patients with ALS treated with guanabenz or riluzole alone for 6 months. The primary aim is to test if guanabenz can reduce the proportion of patients progressed to a higher stage of disease at 6 months compared with their baseline stage as measured by the ALS Milano-Torino Staging (ALS-MITOS) system and to the placebo group. Secondary aims are safety, tolerability and change in at least one biomarker of neurodegeneration in the guanabenz arm compared with the placebo group. Findings will provide reliable data on the likelihood that guanabenz can slow the course of ALS in a phase III trial. ETHICS AND DISSEMINATION The study protocol was approved by the Ethics Committee of IRCCS 'Carlo Besta Foundation' of Milan (Eudract no. 2014-005367-32 Pre-results) based on the Helsinki declaration.
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Affiliation(s)
- Eleonora Dalla Bella
- 3rd Neurology Unit and ALS Centre, IRCCS ‘Carlo Besta’ Neurological Institute, Milan, Italy
| | - Irene Tramacere
- Scientific Direction, IRCCS ‘Carlo Besta’ Neurological Institute, Milan, Italy
| | - Giovanni Antonini
- Neuromuscular Disease Unit, Sant’Andrea Hospital and University of Rome ‘Sapienza’, Rome, Italy
| | - Giuseppe Borghero
- Neurologic Unit, Monserrato University Hospital, Cagliari University, Cagliari, Italy
| | | | - Claudia Caponnetto
- Department of Neurosciences, Rehabilitatioņ Ophthalmology, Genetics, Mother and Child Disease, IRCCS University Hospital San Martino IST, Genova, Italy
| | - Adriano Chiò
- Department of Neurosciences, ALS Centre, ‘Rita Levi Montalcini’, University of Turin and Azienda Ospedaliero Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Massimo Corbo
- Department of Neurorehabilitation, Casa Cura Policlinico, Milan, Italy
| | - Roberto Eleopra
- Neurology Unit, S Maria della Misericordia University Hospital, Udine, Italy
| | | | - Fabio Giannini
- Department of Medical and Surgery Sciences and Neurosciences, University of Siena, Siena, Italy
| | | | | | | | - Jessica Mandrioli
- Department of Neurosciences, S Agostino-Estense Hospital, Modena, Italy
| | - Letizia Mazzini
- ALS Centre, Neurologic Clinic, Maggiore della Carità University Hospital, Novara;, Italy
| | | | | | - Gabriele Mora
- ALS Center, ‘Salvatore Maugeri’ Clinical-Scientific Institutes, Milan, Italy
| | - Nilo Riva
- Department of Neurology IRCCS ‘San Raffaele’ Hospital, Milan, Italy
| | - Romana Rizzi
- Neurology Unit, Department of Neuro-Motor Diseases, IRCCS Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Gabriele Siciliano
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Pisa, Italy
| | - Vincenzo Silani
- Department of Neurology and Laboratory of Neuroscience, IRCCS Istituto Auxologico Italiano - Department of Pathophysiology and Transplantation, "Dino Ferrari" Center, Università degli Studi di Milano, Milan, Italy
| | - Isabella Simone
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Gianni Sorarù
- Department of Neurosciences, University of Padua, Padua, Italy
| | - Paolo Volanti
- Intensive Neurorehabilitation Unit, IRCCS ‘Salvatore Maugeri’ Foundation, Mistretta, Italy
| | - Giuseppe Lauria
- 3rd Neurology Unit and ALS Centre, IRCCS ‘Carlo Besta’ Neurological Institute, Milan, Italy
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