Irritable Bowel Syndrome With ConstipationPhase 2NCT03763175
Efficacy and Safety of SYN-010 in IBS-C
A Phase 2 study testing SYN-010 21 mg and SYN-010 42 mg in people with Irritable Bowel Syndrome With Constipation, run by Cedars-Sinai Medical Center at 1 site in United States.
Trial summary
Irritable bowel syndrome (IBS) is a gastrointestinal (GI) syndrome characterized by chronic abdominal pain and altered bowel habits in the absence of any organic cause. The symptoms of IBS not only adversely affect a patient's health-related quality of life (QoL), but also place a significant financial burden on… Read more about this study
- Who is it for?
- Ages 18 to 65 years
- Conditions the study is for
- Irritable Bowel Syndrome With Constipation
- What is being tested?
- SYN-010 21 mg and SYN-010 42 mg
- Could I receive a placebo?
- Yes, some participants may receive a placebo
- How many people
- 59 participants
- Where
- 1 siteUnited States
- Study dates
- 24 Dec 2018to 9 Oct 2020
- Phase
- Phase 2
- Are there results?
- Yes, posted in the registrySummary in the doctors' view
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 18 to 65 years
- All sexes
- No healthy volunteers
- Adult, Older adult
Who may be able to join
- Male or female participants aged between 18 and 65 years inclusive.
- Patient must be willing and able to participate in the study for the required duration, understand and sign the informed consent (ICF), and be willing to comply with all protocol-related visits and procedures.
- Patient has had IBS-C symptoms (as defined by Rome III diagnostic criteria) for at least 6 months prior to diagnosis.
- Patient has an average score of ≥ 3.0 for daily abdominal pain at its worst (11-point numerical rating scale [NRS]) during and up to the 17 days immediately before randomization (i.e. Pre-treatment Period).
- Patient has an average of ≤ 3 CSBMs per week or ≤ 5 SBMs per week during the 17 days immediately before randomization (i.e. Pre-treatment Period).
- Patient has a breath methane level ≥ 10 ppm on a lactulose breath test administered at Screening.
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- Patient may be on a stable, continuous regimen of fiber or probiotics one month before the Screening Visit; however, they must maintain a stable dose regimen through Week 12.
- Patient must agree to refrain from starting a new diet, changing stable dose of supplemental fiber, or changing exercise pattern that may affect IBS-C symptoms from the time of Screening through the end of the study. If the patient takes food products that are strong inhibitors of cytochrome P450 3A (CYP3A) (e.g. grapefruit juice, Seville orange juice, St. John's Wort), he/she must agree to refrain from taking these from the time of Screening through the end of the study.
- Patient must agree to use an acceptable method of contraception from the time of signing the ICF to 30 days after the final dose of study drug if the patient is a sexually active female of child-bearing potential (defined as any female who has experienced menarche and who is NOT permanently sterile or postmenopausal. Postmenopausal is defined as 12 consecutive months with no menses without an alternative medical cause). Adequate contraceptive measures include: oral contraceptives (stable use for two or more cycles before Screening); intrauterine device; Depo-Provera®; Norplant® System implants; partner with a vasectomy; double-barrier birth control (e.g. use of a condom plus diaphragm or condom plus either contraceptive sponge, foam, or jelly); or abstinence. According to drug research standards, male patient must agree to use an acceptable method of contraception and refrain from donating sperm from the time of signing the ICF to 90 days after the final dose of study drug.
- A female patient of child-bearing potential must be non-pregnant and non-lactating and have negative pregnancy tests at the Screening Visit and on Day 1 prior to dosing with study drug.
- Patients must be able to understand and be willing to sign the written informed consent form. A signed informed consent form must be appropriately obtained prior to the conduct of any trial-specific procedure.
- Willing and able to comply with the protocol, including follow-up visits and examinations.
Who cannot join
- Patient has loose (mushy) or watery stools for > 25% of their bowel movements (BMs) during the 12 weeks before Screening or during the Screening and Pre-treatment Periods.
- Patient has a history of cathartic colon, laxative, or enema abuse.
- Patient has a history of ischemic colitis.
- Patient has a history of pelvic floor dysfunction.
- Patient has a history of bariatric surgery for the treatment of obesity.
- Patient has a history of surgery to remove a segment of the gastrointestinal (GI) tract at any time before the Screening Visit.
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- Patient has any history of myopathy, rhabdomyolysis, chronic myalgia, or familial history of hereditary muscular disorders.
- Patient has been diagnosed with or has a family history of familial adenomatous polyposis, hereditary nonpolyposis colorectal cancer, or any other form of familial colorectal cancer.
- Patient currently has any structural abnormality of the GI tract or a disease or condition that can affect GI motility, or any unexplained and clinically significant symptoms such as lower GI bleeding, rectal bleeding, heme-positive stool, iron-deficiency anemia, weight loss, or systemic signs of infection.
- Patient has had any previous surgery involving the abdomen, pelvis, or retroperitoneal region during the last 12 months prior to Screening, with the exclusion of laparoscopic gallbladder surgery or appendix removal.
- Patient has a history of diverticulitis or any chronic condition that could be associated with abdominal pain or discomfort and could confound the assessments in the study (e.g. inflammatory bowel disease, chronic pancreatitis, polycystic kidney disease, ovarian cysts, endometriosis, or lactose intolerance).
- Patient has history of severe renal insufficiency defined as an actual or estimated glomerular filtration rate of < 30 mL/min/1.73 m2 within the 6 months prior to Screening Visit.
- Patient has any history of a medical condition or a concomitant medical condition that, in the opinion of the investigator, would compromise the patient's ability to complete the study safely or could confound the assessments in this study (e.g. uncontrolled hypothyroidism).
- Patient is known to have elevated liver enzyme levels (aspartate aminotransferase [AST], alanine aminotransferase [ALT], alkaline phosphatase [ALP]) or creatine kinase levels that are ≥ 1.5 times the upper limit of normal (ULN) that have not been resolved within the 4 weeks prior to consent and/or these elevated levels are present at the Screening Visit laboratory assessment.
- Patient has any abnormal laboratory results, electrocardiogram (ECG) findings, or physical examination findings deemed clinically significant by the investigator during the Screening Period.
- Within 14 days prior to the Screening Visit, patient has used concomitant medications that are: (1) moderate-to-strong inhibitors of cytochrome P450 3A (CYP3A) and/or organ anion transporting polypeptide (OATP)1B1 (e.g. cyclosporine, verapamil, dronedarone, diltiazem, amiodarone, itraconazole, ketoconazole, posaconazole, voriconazole, clarithromycin, telithromycin, human immunodeficiency virus protease inhibitors, boceprevir, telaprevir, nefazodone, erythromycin, cobicistat-containing products); (2) other concomitant medications that are excluded from the lovastatin label (e.g. rifampin, colchicine, ranolazine); or (3) metformin or GLP-1 agonists. Patients should not take any of these concomitant medications during the treatment phase of the study without contacting the investigator.
- Patient has hypersensitivity to statins; or has used any statins, fibrates, > 1 g/day of niacin, or gemfibrozil within the 3 months prior to the Screening Visit.
- Patient reports current chronic or frequent use of drugs known to cause constipation (e.g. narcotics) for the 3 months prior to Screening.
- Patient has taken over-the-counter IBS treatments (e.g. laxatives) or proton pump inhibitors within 3 days prior to the Screening Visit.
- Certain drugs used for the treatment of IBS (e.g. low dose tricyclic antidepressants) may be allowed at the discretion of the Medical Monitor provided the patient remains on a stable dose for one month prior to the Screening Visit and throughout the study with the exception of tegaserod, lubiprostone, linaclotide, metoclopramide, prucalopride, domperidone, or antibiotics within 2 months prior to the Screening Visit. Certain drugs used for the treatment of IBS (e.g. low dose tricyclic antidepressants) may be allowed at the discretion of the Medical Monitor provided the patient remains on a stable dose for one month prior to the Screening Visit and throughout the study with the exception of tegaserod, lubiprostone, linaclotide, metoclopramide, prucalopride, domperidone, CandiBactin, Atrantil, Allimax/Allimed within 2 weeks prior to the Screening Visit or antibiotics within 2 months prior to the Screening Visit.
- Patient has used an opioid chronically or frequently within the 3 months prior to the Screening Visit and for the duration of the study.
- Patient is currently enrolled in, or plans to enroll in, another clinical study or has used any investigational drug or device within 1 month before signing the ICF through the completion of the study.
- Patient has previously participated in a SYN-010 study.
- Patient has a history of alcohol or drug abuse within the 12 months prior to the Screening Visit.
Trial locations and contacts
1 site in 1 country.
United States1 site
Cedars-Sinai Medical Center
Los Angeles, California, 90048
About this study
Official title: Evaluation of the Efficacy and Safety of Single, Daily Oral Doses of SYN-010 Compared to Placebo in Adult Patients With Irritable Bowel Syndrome With Constipation (EASE-DO)
Irritable bowel syndrome (IBS) is a gastrointestinal (GI) syndrome characterized by chronic abdominal pain and altered bowel habits in the absence of any organic cause. The symptoms of IBS not only adversely affect a patient's health-related quality of life (QoL), but also place a significant financial burden on society due to reduced work productivity and increased use of healthcare-related resources. Patients with IBS frequently complain of abdominal bloating and increased gas production in the form of flatulence or belching. The prevalence in North America and Europe is approximately 10-15%. Irritable bowel syndrome affects all ages and genders however there is a 2:1 female predominance in North America. Irritable bowel syndrome is classified into 4 subtypes based on stool pattern: IBS with constipation (IBS-C), IBS with diarrhea, mixed IBS, and un-subtyped IBS. Irritable bowel syndrome with constipation is defined as the presence of hard or lumpy stools with ≥ 25 percent of bowel movements and loose or watery stools with < 25% of bowel movements.
SYN-010 is a modified release, oral formulation of lovastatin being developed for the treatment of IBS-C. The SYN-010 program is based predominantly on research by Dr. Mark Pimentel and collaborators hypothesizing that reduction in intestinal methane (methane) production can reverse constipation and improve global symptoms in IBS-C. Methane production in humans is due to methanogenic archaea in the intestine, predominantly Methanobrevibacter smithii (M. smithii). Methane, the key product of anaerobic respiration of methanogens, had been perceived to produce no ill effects in humans aside from gaseous distention. However, several research groups worldwide have shown that a significant percentage of patients with IBS-C excrete methane, and elevated methane production by methanogens correlates with constipation and related symptoms in both IBS-C and chronic idiopathic constipation. A direct causative role for methane in IBS-C was demonstrated in a recent case report, wherein a woman undergoing fecal microbiota transplantation (FMT) for C. difficile infection unknowingly received stool containing a high concentration of methanogens. The FMT recipient rapidly developed severe symptoms of IBS-C that were subsequently reversed by ablation of methane production.
Read the detailed description
SYN-010 has previously been evaluated in consecutive Phase 2a clinical trials. Sixty-three (63) IBS-C patients with high breath methane (>10 ppm) at screening were enrolled in a multicenter, randomized, controlled, double-blinded clinical trial (RCT) in which they received SYN-010 21 mg, SYN-010 42 mg or Placebo once daily for 4 weeks. Fifty-four (54) subjects who completed the RCT continued into an open-label extension (EXT) in which all subjects received SYN-010 42 mg once daily for an additional 8 weeks.
The SYN-010 Phase 2a studies were intentionally designed as mechanistic proof-of-concept studies, wherein reductions in breath methane were employed as a rapid and cost-effective means by which to determine if SYN-010 could be effective in treating an underlying cause of symptoms in IBS-C. Breath methane was reduced relative to baseline in SYN-010 treatment groups, and lower breath methane levels correlated with an increased number of complete spontaneous bowel movements (CSBMs) at week 12, consistent with the proposed methane-inhibiting action of lovastatin lactone.
Since lovastatin has not previously been used to treat IBS-C patients, the SYN-010 Phase 2a studies were also focused on the safety of the SYN-010 dosage form. Daily doses of SYN-010 were well-tolerated by IBS-C patients over the 12-week treatment period (at least 8 weeks of SYN-010 42 mg). SYN-010 did not cause clinically meaningful or persistent changes in serum liver and muscle markers in IBS-C patients at daily doses of 21 mg and 42 mg. Modest decreases from baseline in lipid parameters observed after 7 days of SYN-010 21 mg or 42 mg had largely faded by 28 days and were not evident after 12 weeks of dosing. Very few adverse events were reported over 12 weeks of SYN-010 treatment and all were of mild or moderate intensity. No serious adverse events were reported and there were no incidences of drug-related diarrhea, which is an important potential benefit of SYN-010 as an IBS-C therapy.
Although the Phase 2a studies were not prospectively powered for formal statistical evaluation of clinical endpoints, compelling improvements in CSBMs, abdominal pain, and bloating were observed in SYN-010 treatment groups. These clinical findings have been presented in multiple public forums and a panel of clinical advisors affirmed that the Phase 2a data validate the need to evaluate optimal dosing of SYN-010 in a larger patient population over a longer dosing period.
Based on the potential clinical benefit observed in Phase 2a, this Phase 2b clinical study will evaluate in more detail the clinical effects of two dose strengths of SYN-010 administered over a longer treatment period (12 weeks per FDA guidelines) to a larger number of IBS-C patients. The study will seek more definitive evidence regarding potential symptom improvements and safety in IBS-C patients. The study also seeks to provide new information of relevance to both efficacy and safety by measuring changes to the microbiome in patient stool samples; serum level of cytokine markers of inflammation; and expanded breath gas measurements.
SYN-010 is a hydroxypropyl methylcellulose (HPMC) capsule filled with enteric-coated tablets from which lovastatin is released at different intestinal pH values. The tablets are designed to pass through the stomach unchanged then release a small amount of lovastatin into the duodenum and the majority of the lovastatin dose into the ileocecal junction and colon. The amount of lovastatin to be released into the small and large intestine is anticipated to be consistent with the relative levels of methane-producing archaea in each location of the intestine.
Methane production (methanogenesis) is a ubiquitous process in the human intestine, disposing of hydrogen and other by-products formed during bacterial fermentation. Methane production in humans is almost entirely due to the archeon M. smithii. Elevated intestinal methane production reduces intestinal motility and is a cause of constipation, pain and bloating in IBS-C.
Interest in lovastatin as a potential inhibitor of methanogenesis originated with recognition that the rate-limiting step in the synthesis of archaeal lipid membranes is catalyzed by HMG-CoA reductase (HMGR) which is the target enzyme for cholesterol-lowering statins. Subsequent in vitro studies (described above) and computational studies have since determined that HMGR is not the target for lovastatin anti-methanogenic activity; rather, lovastatin lactone appears to exert a direct effect on methanogenesis enzymes. The mechanism by which lovastatin lactone inhibits methane production by M. smithii has not been conclusively determined; however, detailed computational studies showed that lovastatin lactone may competitively inhibit F420-dependent methylenetetrahydromethanopterin dehydrogenase (mtd), an enzyme that is integral to the M. smithii methanogenesis pathway.
Methanogenic archaea reside predominantly in the human colon, with lower methanogen levels measured in the small intestine of some patients. Methane production at both sites contributes to reduced gastrointestinal motility and rat studies suggest that the ileocecal region may be of particular significance. SYN-010 utilizes a dual-pulse release profile to deliver a portion of the lovastatin dose to the small intestine and the majority of the dose to the ileocecal junction and colon where the most methane-producing organisms are found; the relative amounts of lovastatin released into the small and large intestine are consistent with the anticipated relative levels of methanogens in each location.
Lovastatin lactone exerts its methane-reducing effect in the intestinal lumen and systemic absorption of lovastatin is not required for its therapeutic effect in IBS-C.
- Being tested
- SYN-010 21 mg, SYN-010 42 mg, Placebo
- Keywords
- Irritable Bowel Syndrome with Constipation, Lovastatin, SYN-010
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
SYN-010 21 mgDrug
Also called lovastatin
21 mg lovastatin will be administered to patients diagnosed with IBS-C to evaluate whether the medication and dose is effective in increasing frequency of completely spontaneous bowel movements. The secondary objectives of the study are to assess the role of lovastatin lactone in increasing overall stool frequency and reducing abdominal pain severity, bloating severity, and rescue medication use. Additional endpoints include improvement in reported adequate relief and the effect of the study drug in lowering exhaled methane levels.
SYN-010 42 mgDrug
Also called lovastatin
42 mg lovastatin will be administered to patients diagnosed with IBS-C to evaluate whether the medication and dose is effective in increasing frequency of completely spontaneous bowel movements. The secondary objectives of the study are to assess the role of lovastatin lactone in increasing overall stool frequency and reducing abdominal pain severity, bloating severity, and rescue medication use. Additional endpoints include improvement in reported adequate relief and the effect of the study drug in lowering exhaled methane levels.
PlaceboDrug
A placebo will be administered to patients diagnosed with IBS-C to evaluate whether the medication and dose is effective in increasing frequency of completely spontaneous bowel movements. The secondary objectives of the study are to assess the role of lovastatin lactone in increasing overall stool frequency and reducing abdominal pain severity, bloating severity, and rescue medication use. Additional endpoints include improvement in reported adequate relief and the effect of the study drug in lowering exhaled methane levels.
| Study group | Role | What they receive |
|---|---|---|
| SYN-010 21 mg | Active comparator | Enrolled subjects will be screened and randomized into the three study arms in a 1:1:1 ratio. 50 subjects with constipation-predominant irritable bowel syndrome (IBS-C) will be administered a 12-week course of lovastatin (21 mg PO QD). Study activities will be the same across all three arms. Receives: Drug: SYN-010 21 mg |
| SYN-010 42 mg | Active comparator | Enrolled subjects will be screened and randomized into the three study arms in a 1:1:1 ratio. 50 subjects with constipation-predominant irritable bowel syndrome (IBS-C) will be administered a 12-week course of lovastatin (42 mg PO QD). Study activities will be the same across all three arms. Receives: Drug: SYN-010 42 mg |
| Placebo | Placebo comparator | Enrolled subjects will be screened and randomized into the three study arms in a 1:1:1 ratio. 50 subjects with constipation-predominant irritable bowel syndrome (IBS-C) will be administered a 12-week course of placebo. Study activities will be the same across all three arms. Receives: Drug: Placebo |
What is being measured
The primary outcome is the main question the study is designed to answer.
Change From Baseline in the Weekly Average Number of Completely Spontaneous Bowel Movements (CSBM) Compared to the 12-week Treatment Period
Subjects will record their daily bowel movements throughout the duration of the study. Change in weekly average number of CSBMs will be evaluated by comparing reported values pre- and post-treatment.
Measured: After completing 12-week course of SYN-010
Secondary outcomes (5)
Proportion of Overall Responders During the 12-week Treatment Period
An overall 12-week responder is defined as a patient with a weekly response in at least 50% of the weeks of treatment (6 of 12 weeks). A weekly response is defined as a decrease in the patient's weekly average score for worst abdominal pain in the past 24 hours of at least 30% compared to baseline and a stool frequency increase of 1 or more CSBMs per week compared with baseline.
Measured: After completing 12-week course of SYN-010
Proportion of Overall Stool Frequency Responders During the 12-week Treatment Period
An overall stool frequency responder is defined as a patient with a weekly stool frequency response in at least 50% of the weeks of treatment (6 of 12 weeks). A weekly stool frequency response is defined as a stool frequency increase of 1 or more CSBMs per week compared with baseline, with abdominal pain unchanged or improved compared with baseline.
Measured: After completing 12-week course of SYN-010
Proportion of Overall Abdominal Pain Intensity Responders During the 12-week Treatment Period
An overall abdominal pain intensity responder is defined as a patient with a weekly abdominal pain intensity response in at least 50% of the weeks of treatment (6 of 12 weeks). A weekly response abdominal pain intensity response is defined as a decrease in the patient's weekly average score for worst abdominal pain in the past 24 hours of at least 30% compared to baseline, with stool frequency unchanged or improved compared with baseline.
Measured: After completing 12-week course of SYN-010
Proportion of Overall Bloating Responders During the 12-week Treatment Period
An overall bloating responder is defined as a patient with a weekly bloating response in at least 50% of the weeks of treatment (6 of 12 weeks). A weekly bloating response is defined as a weekly average bloating score of at least 30% improvement compared to baseline, with stool frequency unchanged or improved compared with baseline.
Measured: After completing 12-week course of SYN-010
Proportion of Patients Using Rescue Medication
Subjects will record their use of rescue medication throughout the study period. Proportion of patients using rescue medication after completing the 12-week course of treatment will be compared to those reporting usage at baseline screening period.
Measured: After completing 12-week course of SYN-010
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted4 Dec 2018
- Study start24 Dec 2018
- Primary completion9 Oct 2020
- Study completion9 Oct 2020
Why it stopped: Interim Futility Analysis
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Posted resultsParticipant flow, outcome measures and adverse events reported by the sponsor.
- Publications (28)Papers the sponsor has linked to this study.
- Other trials for Irritable Bowel Syndrome With ConstipationStudies of the same condition, open and under way.
- More trials run by Cedars-Sinai Medical CenterThe sponsor's other registered studies.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase 2
- Primary purpose
- Treatment
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Quadruple blind
- Who is masked
- Participant, Care provider, Investigator, Outcomes assessor
- Enrolment
- 59 participants (actual)
Sponsor and investigators
- Lead sponsor
- Cedars-Sinai Medical Center
- Sponsor type
- University, hospital or other
- Collaborators
- Theriva Biologics, Inc.
- Responsible party
- Principal investigator, Ali Rezaie, MD, Cedars-Sinai Medical Center
- Investigators
- Ali Rezaie, MD MSc, Principal investigator, Cedars-Sinai Medical Center
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT03763175
- Sponsor's protocol ID
- 54792
- Status last verified
- Jul 2022
- First submitted
- 30 Nov 2018
- Last updated
- 13 Jul 2022
- Results posted
- Yes, on ClinicalTrials.gov
- Data monitoring committee
- Yes
- FDA-regulated drug
- Yes
- FDA-regulated device
- No
Publications
Cash B, Sullivan S, Barghout V. Total costs of IBS: employer and managed care perspective. Am J Manag Care. 2005 Apr;11(1 Suppl):S7-16.
PubMed 15926759Drossman DA, Camilleri M, Mayer EA, Whitehead WE. AGA technical review on irritable bowel syndrome. Gastroenterology. 2002 Dec;123(6):2108-31. doi: 10.1053/gast.2002.37095. No abstract available.
PubMed 12454866Hungin AP, Whorwell PJ, Tack J, Mearin F. The prevalence, patterns and impact of irritable bowel syndrome: an international survey of 40,000 subjects. Aliment Pharmacol Ther. 2003 Mar 1;17(5):643-50. doi: 10.1046/j.1365-2036.2003.01456.x.
PubMed 12641512Drossman DA, Dumitrascu DL. Rome III: New standard for functional gastrointestinal disorders. J Gastrointestin Liver Dis. 2006 Sep;15(3):237-41.
PubMed 17013448American College of Gastroenterology Task Force on Irritable Bowel Syndrome; Brandt LJ, Chey WD, Foxx-Orenstein AE, Schiller LR, Schoenfeld PS, Spiegel BM, Talley NJ, Quigley EM. An evidence-based position statement on the management of irritable bowel syndrome. Am J Gastroenterol. 2009 Jan;104 Suppl 1:S1-35. doi: 10.1038/ajg.2008.122. No abstract available.
PubMed 19521341Talley NJ, Zinsmeister AR, Van Dyke C, Melton LJ 3rd. Epidemiology of colonic symptoms and the irritable bowel syndrome. Gastroenterology. 1991 Oct;101(4):927-34. doi: 10.1016/0016-5085(91)90717-y.
PubMed 1889716Pimentel M, Gunsalus RP, Rao SSC, Zhang H. Methanogens in human health and disease. Am J Gastroenterol. 2012 Jul;1(1) Suppl:28-33.
Pimentel M, Mayer AG, Park S, Chow EJ, Hasan A, Kong Y. Methane production during lactulose breath test is associated with gastrointestinal disease presentation. Dig Dis Sci. 2003 Jan;48(1):86-92. doi: 10.1023/a:1021738515885.
PubMed 12645795Kunkel D, Basseri RJ, Makhani MD, Chong K, Chang C, Pimentel M. Methane on breath testing is associated with constipation: a systematic review and meta-analysis. Dig Dis Sci. 2011 Jun;56(6):1612-8. doi: 10.1007/s10620-011-1590-5. Epub 2011 Feb 1.
PubMed 21286935Furnari M, Savarino E, Bruzzone L, Moscatelli A, Gemignani L, Giannini EG, Zentilin P, Dulbecco P, Savarino V. Reassessment of the role of methane production between irritable bowel syndrome and functional constipation. J Gastrointestin Liver Dis. 2012 Jun;21(2):157-63.
PubMed 22720304Ghoshal U, Shukla R, Srivastava D, Ghoshal UC. Irritable Bowel Syndrome, Particularly the Constipation-Predominant Form, Involves an Increase in Methanobrevibacter smithii, Which Is Associated with Higher Methane Production. Gut Liver. 2016 Nov 15;10(6):932-938. doi: 10.5009/gnl15588.
PubMed 27458176Lee KM, Paik CN, Chung WC, Yang JM, Choi MG. Breath methane positivity is more common and higher in patients with objectively proven delayed transit constipation. Eur J Gastroenterol Hepatol. 2013 Jun;25(6):726-32. doi: 10.1097/MEG.0b013e32835eb916.
PubMed 23395994Suri J, Kataria R, Malik Z, Parkman HP, Schey R. Elevated methane levels in small intestinal bacterial overgrowth suggests delayed small bowel and colonic transit. Medicine (Baltimore). 2018 May;97(21):e10554. doi: 10.1097/MD.0000000000010554.
PubMed 29794732Chang BW, Rezaie A. Irritable Bowel Syndrome-Like Symptoms Following Fecal Microbiota Transplantation: A Possible Donor-Dependent Complication. Am J Gastroenterol. 2017 Jan;112(1):186-187. doi: 10.1038/ajg.2016.472. No abstract available.
PubMed 28050036Park YM, Lee YJ, Hussain Z, Lee YH, Park H. The effects and mechanism of action of methane on ileal motor function. Neurogastroenterol Motil. 2017 Sep;29(9). doi: 10.1111/nmo.13077. Epub 2017 Apr 18.
PubMed 28417537
Study at a glance
From the registry record, last updated by the sponsor on 13 Jul 2022. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Evaluation of the Efficacy and Safety of Single, Daily Oral Doses of SYN-010 Compared to Placebo in Adult Patients With Irritable Bowel Syndrome With Constipation (EASE-DO)
- ClinicalTrials.gov ID
- NCT03763175
- Acronym / sponsor ID
- 54792
- Keywords
- Irritable Bowel Syndrome with Constipation, Lovastatin, SYN-010
- Phase
- Phase 2
- Study type
- Interventional
- Recruitment status
- TerminatedReason stopped: Interim Futility Analysis
- Enrolment
- 59 participants (actual)
- Lead sponsor
- Cedars-Sinai Medical CenterUniversity, hospital or other
- Collaborators
- Theriva Biologics, Inc.
- Study start
- 24 Dec 2018 (actual)
- Primary completion
- 9 Oct 2020 (actual)
- Study completion
- 9 Oct 2020 (actual)
- First posted
- 4 Dec 2018 (actual)
- Results
- Posted 5 Sep 2021
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
Irritable bowel syndrome (IBS) is a gastrointestinal (GI) syndrome characterized by chronic abdominal pain and altered bowel habits in the absence of any organic cause. The symptoms of IBS not only adversely affect a patient's health-related quality of life (QoL), but also place a significant financial burden on society due to reduced work productivity and increased use of healthcare-related resources. Patients with IBS frequently complain of abdominal bloating and increased gas production in the form of flatulence or belching. The prevalence in North America and Europe is approximately 10-15%. Irritable bowel syndrome affects all ages and genders however there is a 2:1 female predominance in North America. Irritable bowel syndrome is classified into 4 subtypes based on stool pattern: IBS with constipation (IBS-C), IBS with diarrhea, mixed IBS, and un-subtyped IBS. Irritable bowel syndrome with constipation is defined as the presence of hard or lumpy stools with ≥ 25 percent of bowel movements and loose or watery stools with < 25% of bowel movements.
SYN-010 is a modified release, oral formulation of lovastatin being developed for the treatment of IBS-C. The SYN-010 program is based predominantly on research by Dr. Mark Pimentel and collaborators hypothesizing that reduction in intestinal methane (methane) production can reverse constipation and improve global symptoms in IBS-C. Methane production in humans is due to methanogenic archaea in the intestine, predominantly Methanobrevibacter smithii (M. smithii). Methane, the key product of anaerobic respiration of methanogens, had been perceived to produce no ill effects in humans aside from gaseous distention. However, several research groups worldwide have shown that a significant percentage of patients with IBS-C excrete methane, and elevated methane production by methanogens correlates with constipation and related symptoms in both IBS-C and chronic idiopathic constipation. A direct causative role for methane in IBS-C was demonstrated in a recent case report, wherein a woman undergoing fecal microbiota transplantation (FMT) for C. difficile infection unknowingly received stool containing a high concentration of methanogens. The FMT recipient rapidly developed severe symptoms of IBS-C that were subsequently reversed by ablation of methane production.
Detailed description
SYN-010 has previously been evaluated in consecutive Phase 2a clinical trials. Sixty-three (63) IBS-C patients with high breath methane (>10 ppm) at screening were enrolled in a multicenter, randomized, controlled, double-blinded clinical trial (RCT) in which they received SYN-010 21 mg, SYN-010 42 mg or Placebo once daily for 4 weeks. Fifty-four (54) subjects who completed the RCT continued into an open-label extension (EXT) in which all subjects received SYN-010 42 mg once daily for an additional 8 weeks.
The SYN-010 Phase 2a studies were intentionally designed as mechanistic proof-of-concept studies, wherein reductions in breath methane were employed as a rapid and cost-effective means by which to determine if SYN-010 could be effective in treating an underlying cause of symptoms in IBS-C. Breath methane was reduced relative to baseline in SYN-010 treatment groups, and lower breath methane levels correlated with an increased number of complete spontaneous bowel movements (CSBMs) at week 12, consistent with the proposed methane-inhibiting action of lovastatin lactone.
Since lovastatin has not previously been used to treat IBS-C patients, the SYN-010 Phase 2a studies were also focused on the safety of the SYN-010 dosage form. Daily doses of SYN-010 were well-tolerated by IBS-C patients over the 12-week treatment period (at least 8 weeks of SYN-010 42 mg). SYN-010 did not cause clinically meaningful or persistent changes in serum liver and muscle markers in IBS-C patients at daily doses of 21 mg and 42 mg. Modest decreases from baseline in lipid parameters observed after 7 days of SYN-010 21 mg or 42 mg had largely faded by 28 days and were not evident after 12 weeks of dosing. Very few adverse events were reported over 12 weeks of SYN-010 treatment and all were of mild or moderate intensity. No serious adverse events were reported and there were no incidences of drug-related diarrhea, which is an important potential benefit of SYN-010 as an IBS-C therapy.
Although the Phase 2a studies were not prospectively powered for formal statistical evaluation of clinical endpoints, compelling improvements in CSBMs, abdominal pain, and bloating were observed in SYN-010 treatment groups. These clinical findings have been presented in multiple public forums and a panel of clinical advisors affirmed that the Phase 2a data validate the need to evaluate optimal dosing of SYN-010 in a larger patient population over a longer dosing period.
Based on the potential clinical benefit observed in Phase 2a, this Phase 2b clinical study will evaluate in more detail the clinical effects of two dose strengths of SYN-010 administered over a longer treatment period (12 weeks per FDA guidelines) to a larger number of IBS-C patients. The study will seek more definitive evidence regarding potential symptom improvements and safety in IBS-C patients. The study also seeks to provide new information of relevance to both efficacy and safety by measuring changes to the microbiome in patient stool samples; serum level of cytokine markers of inflammation; and expanded breath gas measurements.
SYN-010 is a hydroxypropyl methylcellulose (HPMC) capsule filled with enteric-coated tablets from which lovastatin is released at different intestinal pH values. The tablets are designed to pass through the stomach unchanged then release a small amount of lovastatin into the duodenum and the majority of the lovastatin dose into the ileocecal junction and colon. The amount of lovastatin to be released into the small and large intestine is anticipated to be consistent with the relative levels of methane-producing archaea in each location of the intestine.
Methane production (methanogenesis) is a ubiquitous process in the human intestine, disposing of hydrogen and other by-products formed during bacterial fermentation. Methane production in humans is almost entirely due to the archeon M. smithii. Elevated intestinal methane production reduces intestinal motility and is a cause of constipation, pain and bloating in IBS-C.
Interest in lovastatin as a potential inhibitor of methanogenesis originated with recognition that the rate-limiting step in the synthesis of archaeal lipid membranes is catalyzed by HMG-CoA reductase (HMGR) which is the target enzyme for cholesterol-lowering statins. Subsequent in vitro studies (described above) and computational studies have since determined that HMGR is not the target for lovastatin anti-methanogenic activity; rather, lovastatin lactone appears to exert a direct effect on methanogenesis enzymes. The mechanism by which lovastatin lactone inhibits methane production by M. smithii has not been conclusively determined; however, detailed computational studies showed that lovastatin lactone may competitively inhibit F420-dependent methylenetetrahydromethanopterin dehydrogenase (mtd), an enzyme that is integral to the M. smithii methanogenesis pathway.
Methanogenic archaea reside predominantly in the human colon, with lower methanogen levels measured in the small intestine of some patients. Methane production at both sites contributes to reduced gastrointestinal motility and rat studies suggest that the ileocecal region may be of particular significance. SYN-010 utilizes a dual-pulse release profile to deliver a portion of the lovastatin dose to the small intestine and the majority of the dose to the ileocecal junction and colon where the most methane-producing organisms are found; the relative amounts of lovastatin released into the small and large intestine are consistent with the anticipated relative levels of methanogens in each location.
Lovastatin lactone exerts its methane-reducing effect in the intestinal lumen and systemic absorption of lovastatin is not required for its therapeutic effect in IBS-C.
Study design
- Primary purpose
- Treatment
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Quadruple blind (participant, care provider, investigator, outcomes assessor)
- Number of arms
- 3
| Arm | Type | Receives |
|---|---|---|
| SYN-010 21 mg | Active comparator | Drug: SYN-010 21 mgEnrolled subjects will be screened and randomized into the three study arms in a 1:1:1 ratio. 50 subjects with constipation-predominant irritable bowel syndrome (IBS-C) will be administered a 12-week course of lovastatin (21 mg PO QD). Study activities will be the same across all three arms. |
| SYN-010 42 mg | Active comparator | Drug: SYN-010 42 mgEnrolled subjects will be screened and randomized into the three study arms in a 1:1:1 ratio. 50 subjects with constipation-predominant irritable bowel syndrome (IBS-C) will be administered a 12-week course of lovastatin (42 mg PO QD). Study activities will be the same across all three arms. |
| Placebo | Placebo comparator | Drug: PlaceboEnrolled subjects will be screened and randomized into the three study arms in a 1:1:1 ratio. 50 subjects with constipation-predominant irritable bowel syndrome (IBS-C) will be administered a 12-week course of placebo. Study activities will be the same across all three arms. |
Who may qualify
- Ages
- 18 to 65 years
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
Key inclusion criteria (12 listed)
- Male or female participants aged between 18 and 65 years inclusive.
- Patient must be willing and able to participate in the study for the required duration, understand and sign the informed consent (ICF), and be willing to comply with all protocol-related visits and procedures.
- Patient has had IBS-C symptoms (as defined by Rome III diagnostic criteria) for at least 6 months prior to diagnosis.
- Patient has an average score of ≥ 3.0 for daily abdominal pain at its worst (11-point numerical rating scale [NRS]) during and up to the 17 days immediately before randomization (i.e. Pre-treatment Period).
- Patient has an average of ≤ 3 CSBMs per week or ≤ 5 SBMs per week during the 17 days immediately before randomization (i.e. Pre-treatment Period).
Key exclusion criteria (24 listed)
- Patient has loose (mushy) or watery stools for > 25% of their bowel movements (BMs) during the 12 weeks before Screening or during the Screening and Pre-treatment Periods.
- Patient has a history of cathartic colon, laxative, or enema abuse.
- Patient has a history of ischemic colitis.
- Patient has a history of pelvic floor dysfunction.
- Patient has a history of bariatric surgery for the treatment of obesity.
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| SYN-010 21 mgAlso: lovastatin21 mg lovastatin will be administered to patients diagnosed with IBS-C to evaluate whether the medication and dose is effective in increasing frequency of completely spontaneous bowel movements. The secondary objectives of the study are to assess the role of lovastatin lactone in increasing overall stool frequency and reducing abdominal pain severity, bloating severity, and rescue medication use. Additional endpoints include improvement in reported adequate relief and the effect of the study drug in lowering exhaled methane levels. | Drug | SYN-010 21 mg |
| SYN-010 42 mgAlso: lovastatin42 mg lovastatin will be administered to patients diagnosed with IBS-C to evaluate whether the medication and dose is effective in increasing frequency of completely spontaneous bowel movements. The secondary objectives of the study are to assess the role of lovastatin lactone in increasing overall stool frequency and reducing abdominal pain severity, bloating severity, and rescue medication use. Additional endpoints include improvement in reported adequate relief and the effect of the study drug in lowering exhaled methane levels. | Drug | SYN-010 42 mg |
| PlaceboA placebo will be administered to patients diagnosed with IBS-C to evaluate whether the medication and dose is effective in increasing frequency of completely spontaneous bowel movements. The secondary objectives of the study are to assess the role of lovastatin lactone in increasing overall stool frequency and reducing abdominal pain severity, bloating severity, and rescue medication use. Additional endpoints include improvement in reported adequate relief and the effect of the study drug in lowering exhaled methane levels. | Drug | Placebo |
Primary outcome
Change From Baseline in the Weekly Average Number of Completely Spontaneous Bowel Movements (CSBM) Compared to the 12-week Treatment Period
Time frame: After completing 12-week course of SYN-010
Subjects will record their daily bowel movements throughout the duration of the study. Change in weekly average number of CSBMs will be evaluated by comparing reported values pre- and post-treatment.
5 secondary outcomes
Proportion of Overall Responders During the 12-week Treatment Period
Time frame: After completing 12-week course of SYN-010
Proportion of Overall Stool Frequency Responders During the 12-week Treatment Period
Time frame: After completing 12-week course of SYN-010
Proportion of Overall Abdominal Pain Intensity Responders During the 12-week Treatment Period
Time frame: After completing 12-week course of SYN-010
Proportion of Overall Bloating Responders During the 12-week Treatment Period
Time frame: After completing 12-week course of SYN-010
Proportion of Patients Using Rescue Medication
Time frame: After completing 12-week course of SYN-010
Results and safety
Loading the posted results from ClinicalTrials.gov…
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 13 Jul 2022.
- Posted resultsParticipant flow, baseline, all outcome measures and adverse events.
- Background: PubMed 15926759Cash B, Sullivan S, Barghout V. Total costs of IBS: employer and managed care perspective. Am J Manag Care. 2005 Apr;11(1 Suppl):S7-16.
- Background: PubMed 12454866Drossman DA, Camilleri M, Mayer EA, Whitehead WE. AGA technical review on irritable bowel syndrome. Gastroenterology. 2002 Dec;123(6):2108-31. doi: 10.1053/gast.2002.37095. No abstract available.
- Background: PubMed 12641512Hungin AP, Whorwell PJ, Tack J, Mearin F. The prevalence, patterns and impact of irritable bowel syndrome: an international survey of 40,000 subjects. Aliment Pharmacol Ther. 2003 Mar 1;17(5):643-50. doi: 10.1046/j.1365-2036.2003.01456.x.
- Background: PubMed 17013448Drossman DA, Dumitrascu DL. Rome III: New standard for functional gastrointestinal disorders. J Gastrointestin Liver Dis. 2006 Sep;15(3):237-41.
- Background: PubMed 19521341American College of Gastroenterology Task Force on Irritable Bowel Syndrome; Brandt LJ, Chey WD, Foxx-Orenstein AE, Schiller LR, Schoenfeld PS, Spiegel BM, Talley NJ, Quigley EM. An evidence-based position statement on the management of irritable bowel syndrome. Am J Gastroenterol. 2009 Jan;104 Suppl 1:S1-35. doi: 10.1038/ajg.2008.122. No abstract available.
- Background: PubMed 1889716Talley NJ, Zinsmeister AR, Van Dyke C, Melton LJ 3rd. Epidemiology of colonic symptoms and the irritable bowel syndrome. Gastroenterology. 1991 Oct;101(4):927-34. doi: 10.1016/0016-5085(91)90717-y.
- BackgroundPimentel M, Gunsalus RP, Rao SSC, Zhang H. Methanogens in human health and disease. Am J Gastroenterol. 2012 Jul;1(1) Suppl:28-33.
- Background: PubMed 12645795Pimentel M, Mayer AG, Park S, Chow EJ, Hasan A, Kong Y. Methane production during lactulose breath test is associated with gastrointestinal disease presentation. Dig Dis Sci. 2003 Jan;48(1):86-92. doi: 10.1023/a:1021738515885.
- Background: PubMed 21286935Kunkel D, Basseri RJ, Makhani MD, Chong K, Chang C, Pimentel M. Methane on breath testing is associated with constipation: a systematic review and meta-analysis. Dig Dis Sci. 2011 Jun;56(6):1612-8. doi: 10.1007/s10620-011-1590-5. Epub 2011 Feb 1.
- Background: PubMed 22720304Furnari M, Savarino E, Bruzzone L, Moscatelli A, Gemignani L, Giannini EG, Zentilin P, Dulbecco P, Savarino V. Reassessment of the role of methane production between irritable bowel syndrome and functional constipation. J Gastrointestin Liver Dis. 2012 Jun;21(2):157-63.
- Background: PubMed 27458176Ghoshal U, Shukla R, Srivastava D, Ghoshal UC. Irritable Bowel Syndrome, Particularly the Constipation-Predominant Form, Involves an Increase in Methanobrevibacter smithii, Which Is Associated with Higher Methane Production. Gut Liver. 2016 Nov 15;10(6):932-938. doi: 10.5009/gnl15588.
- Background: PubMed 23395994Lee KM, Paik CN, Chung WC, Yang JM, Choi MG. Breath methane positivity is more common and higher in patients with objectively proven delayed transit constipation. Eur J Gastroenterol Hepatol. 2013 Jun;25(6):726-32. doi: 10.1097/MEG.0b013e32835eb916.
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Ali Rezaie, MD MSc principal investigator
Cedars-Sinai Medical Center
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A Phase 2 study testing SYN-010 21 mg and SYN-010 42 mg in people with Irritable Bowel Syndrome With Constipation, run by Cedars-Sinai Medical Center at 1 site in United States.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 12 inclusion and 24 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: stopped early, as of the sponsor's last update on 13 Jul 2022. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in United States. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. Some participants in this study may receive a placebo. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
What does this phase mean?
Phase 2 studies give the treatment to a larger group to see whether it has the intended effect and to keep checking safety.
Not every study follows the same path, and some studies (observational studies, device studies) have no phase.
Are results available for this study?
Yes. Results are posted in the registry (first posted 5 Sep 2021). A summary is in the For doctors view, and the full results are on ClinicalTrials.gov.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Change From Baseline in the Weekly Average Number of Completely Spontaneous Bowel Movements (CSBM) Compared to the 12-week Treatment Period (time frame: After completing 12-week course of SYN-010). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT03763175, which also lists 28 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 13 Jul 2022.