Long-Term Treatment with Telotristat Ethyl in Patients with Carcinoid Syndrome Symptoms: Results from the TELEPATH Study.

INTRODUCTION: Telotristat ethyl is indicated for use in combination with somatostatin analogs (SSAs) to treat carcinoid syndrome (CS) diarrhea uncontrolled by SSAs alone in adults, but long-term safety and efficacy data beyond 48 weeks are needed. OBJECTIVES: The aims of the study were to evaluate the long-term safety and tolerability of telotristat ethyl and its effect on quality of life (QOL) in patients with CS. METHODS: In this phase 3, nonrandomized, multicenter, open-label, long-term extension study (TELEPATH), patients who participated in phase 2 or 3 trials of telotristat ethyl continued treatment at their present dose level (250 or 500 mg thrice daily) for 84 weeks. Safety and tolerability, the primary endpoint, were assessed by monitoring adverse events (AEs), serious AEs, AEs of special interest (AESIs; including liver-related AEs, depression, and gastrointestinal AEs), and deaths. The secondary objective was to evaluate changes in patients' QOL using validated cancer questionnaires and a subjective global assessment of CS symptoms. RESULTS: In 124 patients exposed to telotristat ethyl for a mean of 102.6 ± 53.2 weeks, the type and frequency of AEs were consistent with those reported in previous trials. The occurrence of AESIs was not related to dosage or duration of therapy. Most AEs were mild to moderate in severity, and no deaths were related to telotristat ethyl. QOL scores remained stable, and the majority of patients reported adequate symptom relief throughout the study. CONCLUSIONS: Safety results of TELEPATH support the long-term use of telotristat ethyl in patients with CS diarrhea. Telotristat ethyl was well-tolerated and associated with sustained improvement in QOL scores (NCT02026063).

Results of two Phase 1, Randomized, Double-blind, Placebo-controlled, Studies (Ascending Single-dose and Multiple-dose Studies) to Determine the Safety, Tolerability, and Pharmacokinetics of Orally Administered LX9211 in Healthy Participants.

PURPOSE: For neuropathic pain, current therapies do not provide relief for most patients; less than half achieve a 50% pain reduction. Current analgesics have adverse effects. We present 2 Phase I studies of LX9211, a new small-molecule AP2-associated kinase 1 inhibitor with preclinical effectiveness in pain relief. METHODS: Both randomized, placebo-controlled studies' primary objectives evaluated the tolerability and pharmacokinetic properties of oral LX9211. In the single-ascending dose (SAD) study, single, oral, liquid doses of 5, 10, 15, 20, 30, 40, 80, 120, 160, 200, and 300 mg of LX9211 or placebo were administered in the fasted state and 40 mg in a fed group. In the multiple-ascending dose (MAD) study, a loading dose was administered on day 1 and maintenance doses were administered daily on days 2 to 14. The treatment groups were designated as: 25/2.5, 50/5.0, 100/10, 150/15, and 200/20 mg. The secondary objectives included ECG evaluation. FINDINGS: The SAD study enrolled 96 participants 19 to 61 years of age (86.5% male) in 12 cohorts (2:6 placebo:LX9211), and the MAD study enrolled 50 participants 20 to 63 years of age (78% male) in 5 cohorts (2:8 placebo:LX9211). Both studies had a good LX9211 safety profile. No deaths or serious adverse events occurred. All treatment-emergent adverse events (TEAEs) were mild, except for moderate nausea and vomiting reported in 1 participant in the SAD 300-mg cohort. All TEAEs were considered recovered or resolved, except for blurred vision (n = 1 in the SAD 300-mg group), which was ongoing at the last visit. One participant in the MAD study (50/5 mg group) discontinued participation in the study early because of TEAEs (angioedema, dermatitis allergic, and urticaria). Headache, dizziness, constipation, and nausea were the most common TEAEs. In the SAD study, 4 participants in the 200-mg cohort developed headache approximately 24 hours after dosing, lasting 24 to 48 hours. Only 1 required treatment (acetaminophen). No notable ECG changes from baseline were found in either study. After both single- and multiple-dose administration, plasma exposure of LX9211 was approximately dose proportional. Steady-state LX9211 plasma concentrations were rapidly attained and maintained by a dosing regimen of a loading dose, followed by daily maintenance doses (1/10 the loading dose). No accumulation was as seen after multiple dosing. IMPLICATIONS: These studies found that LX9211 was safe and well tolerated in healthy participants. These findings suggest it is appropriate to take LX9211 forward into Phase II studies of patients with diabetic peripheral neuropathic pain and postherpetic neuralgia. LX9211 has received fast track designation by the US Food and Drug Administration.

Long-Term Safety Experience with Telotristat Ethyl Across Five Clinical Studies in Patients with Carcinoid Syndrome.

BACKGROUND: Patients with neuroendocrine tumors (NETs) and carcinoid syndrome experience considerable morbidity and mortality; carcinoid syndrome may be associated with shorter survival. Carcinoid syndrome is linked to tumoral secretion of serotonin and other bioactive substances. The subsequent debilitating diarrhea and urgency to defecate pose significant health risks. In previous studies, telotristat ethyl, a tryptophan hydroxylase inhibitor, was effective and well tolerated in treating carcinoid syndrome diarrhea. We present pooled safety data from five clinical trials with telotristat ethyl in patients with carcinoid syndrome. SUBJECTS, MATERIALS, AND METHODS: Adverse events reported during telotristat ethyl treatment were pooled from two phase II and three phase III clinical trials in 239 patients with carcinoid syndrome. Long-term safety of telotristat ethyl and causes of hospitalization and death were reviewed; overall survival was estimated. RESULTS: Mean (median; range) duration of exposure and follow-up was 1.3 years (1.1 years; 1 week to 5.7 years), with 309 total patient-years of exposure. Leading causes of hospitalization were gastrointestinal disorders or were related to the underlying tumor and related treatment. Survival estimates at 1, 2, and 3 years were 93%, 88%, and 77%. Nearly all deaths were due to progression or complication of the underlying disease; none were attributable to telotristat ethyl. There was one death in year 4. CONCLUSION: Based on long-term safety data, telotristat ethyl is well tolerated and has a favorable long-term safety profile in patients with carcinoid syndrome. IMPLICATIONS FOR PRACTICE: Carcinoid syndrome can cause persistent diarrhea, even in patients treated with somatostatin analogs. Across five clinical trials in patients with carcinoid syndrome, telotristat ethyl has been well tolerated and efficacious, providing clinicians with a new approach to help control carcinoid syndrome diarrhea, in addition to somatostatin analog therapy. By reducing the stool frequency in patients with carcinoid syndrome whose diarrhea is refractory to anticholinergics, such as loperamide and atropine/diphenoxylate, and somatostatin analog dose escalation, improvement in quality of life becomes an achievable goal.

Telotristat ethyl in carcinoid syndrome: safety and efficacy in the TELECAST phase 3 trial.

Telotristat ethyl, a tryptophan hydroxylase inhibitor, was efficacious and well tolerated in the phase 3 TELESTAR study in patients with carcinoid syndrome (CS) experiencing ≥4 bowel movements per day (BMs/day) while on somatostatin analogs (SSAs). TELECAST, a phase 3 companion study, assessed the safety and efficacy of telotristat ethyl in patients with CS (diarrhea, flushing, abdominal pain, nausea or elevated urinary 5-hydroxyindoleacetic acid (u5-HIAA)) with <4 BMs/day on SSAs (or ≥1 symptom or ≥4 BMs/day if not on SSAs) during a 12-week double-blind treatment period followed by a 36-week open-label extension (OLE). The primary safety and efficacy endpoints were incidence of treatment-emergent adverse events (TEAEs) and percent change from baseline in 24-h u5-HIAA at week 12. Patients (N = 76) were randomly assigned (1:1:1) to receive placebo or telotristat ethyl 250 mg or 500 mg 3 times per day (tid); 67 continued receiving telotristat ethyl 500 mg tid during the OLE. Through week 12, TEAEs were generally mild to moderate in severity; 5 (placebo), 1 (telotristat ethyl 250 mg) and 3 (telotristat ethyl 500 mg) patients experienced serious events, and the rate of TEAEs in the OLE was comparable. At week 12, significant reductions in u5-HIAA from baseline were observed, with Hodges-Lehmann estimators of median treatment differences from placebo of -54.0% (95% confidence limits, -85.0%, -25.1%, P < 0.001) and -89.7% (95% confidence limits, -113.1%, -63.9%, P < 0.001) for telotristat ethyl 250 mg and 500 mg. These results support the safety and efficacy of telotristat ethyl when added to SSAs in patients with CS diarrhea (ClinicalTrials.gov identifier: Nbib2063659).

Insulin pen needles: effects of extra-thin wall needle technology on preference, confidence, and other patient ratings.

BACKGROUND: Pen needles (PNs) are essential for insulin injections using pen devices. PN characteristics affect patients' injection experience. OBJECTIVE: The goal of this study was to evaluate the impact of a new extra-thin wall (XTW) PN versus usual PNs on overall patient preference, ease of injection, perceived time to complete the full dose, thumb button force to deliver the injection, and dose delivery confidence in individuals with diabetes mellitus (DM). Subjects injected insulin with the KwikPen(TM) (Eli Lilly and Company, Indianapolis, Indiana), SoloSTAR(®) (sanofi-aventis U.S. LLC, Bridgewater, New Jersey), and FlexPen(®) (Novo Nordisk A/S, Bagsvaerd, Denmark) insulin pens, and included some with impaired hand dexterity. METHODS: We first performed quantitative testing of XTW and comparable PNs with the 3 insulin pens for thumb force, flow rate, and time to deliver medication. A prospective, randomized, 2-period, open-label, crossover trial was then conducted in patients aged 35 to 80 years with type 1 or type 2 DM who injected insulin by pen for ≥2 months, with at least 1 daily dose ≥10 U. Patients who used 4- to 8-mm length PNs with 31- to 32-G diameter were randomly assigned to use their current PN or the same/similar size XTW PN at home for ~1 week and the other PN the second week. They completed several comparative 150-mm visual analog scales and direct questions at the end of period 2. RESULTS: XTW PNs had statistically significant better performance for each studied PN characteristic (thumb force, flow, and time to deliver medication) for all pens combined and each individual pen brand (all, P ≤ 0.05). Of 216 patients randomized to study groups (80, SoloSTAR; 77, FlexPen; 59, KwikPen), 209 completed both periods; 198 were evaluable. Baseline characteristics revealed a mean (SD) age of 60.8 (9.3) years, insulin pen use duration of 4.3 (4.1) years, and mean total daily dose of 75.1 (52.3) U (range, 10-420 U). Approximately 50% of patients were female; 81.5% were white and 14.8% were black; and 89.8% had type 2 DM. Nearly 99% used a single PN: 8 mm, 49.5%; 5 mm, 24.1%; 6 mm, 14.4%; and 4 mm, 12.0%. Patients rated the XTW PNs (mean [95% CI]) as preferable by a mean of 31.9 mm (27.2-36.6), P < 0.001; XTW PNs required less thumb force, less time to inject the dose, and were rated as providing greater confidence in full dose delivery by 28.4 mm (23.7-33.2), 21.7 mm (17.0-26.4), and 24.4 mm (19.7-29.1), respectively; all, P < 0.001. Results were similar for each of the 3 pens, those with impaired hand dexterity, and for all users of 4-mm PNs. Skin leakage and insulin dripping from the needle tip were rated as less frequent with the XTW PNs (P < 0.05). The most common adverse events were hypoglycemia in 8.3% and 6.0% of patients using XTW PNs and current PNs (P = NS), respectively; hyperglycemia occurred in 2.9% and 4.1% (P = NS). None of the adverse events was serious or considered device related. CONCLUSIONS: XTW PNs were preferred overall, rated as requiring less time and less thumb force to inject, and providing greater confidence in completing a full dose compared with usual PNs in this group of patients with type 1 or type 2 DM. ClinicalTrials.gov identifier: NCT01852136.

Evaluation of a new safety peripheral IV catheter designed to reduce mucocutaneous blood exposure.

OBJECTIVES: We evaluated performance and clinical acceptability of a new peripheral intravenous catheter (PIVC) designed to reduce blood exposure. METHODS: A two phased, unblinded, randomized controlled trial was conducted at a clinical research center in New Jersey, USA. In Phase 1, clinicians were asked to evaluate two devices: a PIVC with blood control (BD Insyte Autoguard * BC [Blood Control] Shielded IV Catheter), and a reference conventional PIVC (BD Insyte Autoguard Shielded IV Catheter). In Phase 2, clinicians compared two insertions of the investigational PIVC with blood control (PIVC-BC); one with venous compression and one without. The PIVC-BC was evaluated for superiority to the conventional PIVC with regard to blood exposure and for equivalence in general performance characteristics. RESULTS: Seventy-eight clinicians (mean age: 41.4 years; 89.7% female) and 234 healthy volunteers (mean age: 40.2 years; 61.5% female) were enrolled. Blood leakage occurred significantly more in the conventional PIVC group (39.1%) as compared to the PIVC-BC group (2.0%) (difference: 37.1% [95% CI: 28.8%; 45.15%]). Blood leakage rates for the PIVC-BC with or without use of venous compression were similar, 2.6% and 1.3% respectively (difference: 1.3% [95% CI: -7.8%; 4.7%]). A total of 98.7% of clinicians rated the PIVC-BC as clinically acceptable compared to 89.6% with the reference PIVC (difference: -9.1; 95% CI: -18; -1.5%) and 98.7% agreed it replaced the need for venous compression during catheter insertion (95% CI: 92.8%; 100%). Although the inability to blind clinicians to the investigational product was a potential source of bias, this was unlikely to affect assessments of observed blood leakage. CONCLUSIONS: The PIVC with blood control demonstrated reduced blood leakage during insertion and was rated no different for clinical acceptability and insertion performance compared to the conventional PIVC. Clinicians agreed that the new design replaced the need for venous compression to control blood flow during IV catheter insertion.

Comparative glycemic control, safety and patient ratings for a new 4 mm x 32G insulin pen needle in adults with diabetes.

OBJECTIVE: Pen needles (PN) for subcutaneous insulin therapy have become smaller; 5 mm PNs are now the shortest in use. We evaluated the safety, efficacy and patient ratings of a new 4 mm x 32 gauge (G) PN. RESEARCH DESIGN AND METHODS: Subjects with type 1 and type 2 diabetes and HbA1c 5.5% to 9.5% participated in a randomized non-inferiority cross-over trial, at four U.S. centers. Subjects used 4 mm x 32G PNs and either 5 mm x 31G PNs (4/5 mm) or 8 mm x 31G PNs (4/8 mm) in two, 3-week treatment periods; order of needle use was controlled. Subjects were either 'low dose' or 'regular dose' users (highest single insulin dose

The economics of end-stage renal disease care in Canada: incentives and impact on delivery of care.

Examining international differences in health outcomes for end-stage renal disease (ESRD) patients requires an understanding of ESRD funding structures. In Canada, funding for all aspects of dialysis and transplant care, with the exception of drugs (for which supplementary insurance can be purchased), is provided for all citizens. Although ESRD programs across Canada's 10 provinces differ in funding structure, they share important economic characteristics, including being publicly funded and universal, and providing most facets of ESRD care for free. This paper explains how ESRD care fits into the Canadian health care system, describes the epidemiology of ESRD in Canada, and offers economic explanations for international discrepancies.

Predialysis psychoeducational intervention extends survival in CKD: a 20-year follow-up.

BACKGROUND: Predialysis psychoeducational interventions increase patient knowledge about chronic kidney disease (CKD) and its treatment and extend time to dialysis therapy without compromising physical well-being in the short run. The present research examines long-term survival after predialysis psychoeducational intervention. In addition, we examined whether survival differed because of early (ie, > or = 3 months) versus late referral to nephrology. METHODS: We collected follow-up data for patients with CKD who participated in a multicenter randomized controlled trial of predialysis psychoeducational interventions in the mid-1980s. We gathered 20-year survival data from clinical records and databases. RESULTS: Participants included 335 patients with CKD, including 172 patients randomly assigned to receive predialysis psychoeducational interventions (63.0% men; mean age, 50.8 years) and 163 patients assigned to usual care (62.1% men; mean age, 52.7 years). Two hundred forty-six patients (66.8%) died during the course of the study. Mean duration of follow-up was 8.5 +/- 7.23 (SD) years. Analyses were by intention to treat. Adjusting for age, general nonrenal health at inception, and time between identification and predialysis psychoeducational intervention or usual care, Cox proportional hazards multiple regression analyses indicated that median survival was 2.25 years longer after patients with CKD received predialysis psychoeducational interventions compared with usual care (chi-square-change [1] = 3.75; P = 0.053; hazard ratio, 1.32; 95% confidence interval, 1.0 to 1.74). Predialysis psychoeducational intervention recipients survived a median of 8.0 months longer than usual-care patients after the initiation of dialysis therapy (chi-square-change [1] = 4.39; P = 0.036; hazard ratio, 1.35; 95% confidence interval, 1.02 to 1.775). No significant survival advantage was evident for early referral to nephrology or the combination of early referral plus predialysis psychoeducational interventions. CONCLUSION: Predialysis psychoeducational intervention is a safe and useful intervention that contributes valuably to multidisciplinary predialysis care.

Convergence of health ratings across nephrologists, nurses, and patients with end-stage renal disease.

We evaluated a health rating for renal failure patients that was completed by patients, nurses, and nephrologists. The study was a prospective inception-cohort follow-up design. Measurements were taken before initiating dialysis (n=206) or at the initiation of dialysis (n=200) and at 18 (n=225), 30 (n=181), 42 (n=162), 54 (n=137), and 66 (n=112) months after initiating dialysis. Patients, nurses, and nephrologists independently rated patients' health at each measurement occasion. Objective measures of health status, abstracted from the medical record, included emergency and non-emergency admissions, smoking, diabetes mellitus, pulmonary edema, history and number of myocardial infarctions (MI), basal rales, comorbid illnesses, and uremic symptoms. Simultaneous multiple regression analyses examined the correspondence between objective measures of health status and subjective health ratings separately for each rater and measurement occasion. Health ratings were averaged and submitted to the same analyses. Raters showed good agreement (average Pearson r=.43 overall), although agreement was higher between nephrologists and nurses (average r=.64) than between health professional and patients (average r=.34 and .31, respectively). All three ratings and the combined rating corresponded significantly to objective measures of health status. Uremic symptoms, emergency hospital admissions, diabetes mellitus, and recent MI correlated uniquely and most consistently with subjective health ratings. Despite overall convergence, objective measures of health status related to the groups' ratings in a complementary fashion. The health rating is reliable and relates to the current status of the patient. Performance was superior for the combined score that incorporated ratings by patients, nurses, and nephrologists.

Recurrent pain, illness intrusiveness, and quality of life in end-stage renal disease.

Repeated episodes of headache and muscle cramp were hypothesized to contribute to increased patient perceptions of illness intrusiveness and to compromised quality of life. Standard measures of pain, illness intrusiveness, and quality of life were obtained on 2 occasions, each 6 weeks apart, from 100 end-stage renal disease patients. The impact of recurrent muscle cramps on perceptions of illness intrusiveness was conditional upon the occurrence of headache symptoms. Perceptions of illness intrusiveness were significantly higher when both muscle cramp and headache symptoms occurred during one or more assessment intervals as compared to when muscle cramps or headaches, only, occurred. Illness-related concerns and general feelings of pessimism were also significantly higher among patients who experienced recurrent episodes of muscle cramp. Although no direct relations were observed between pain and other quality of life indicators, previous research has documented a relation between illness intrusiveness and quality of life. Recurrent pain problems, thus, appear to contribute to increased illness intrusiveness and to reduced quality of life in end-stage renal disease patients.