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Repurposing diflunisal for familial amyloid polyneuropathy: a randomized clinical trial.

ABSTRACT: Familial amyloid polyneuropathy, a lethal genetic disease caused by aggregation of variant transthyretin, induces progressive peripheral nerve deficits and disability. Diflunisal, a nonsteroidal anti-inflammatory agent, stabilizes transthyretin tetramers and prevents amyloid fibril formation in vitro.To determine the effect of diflunisal on polyneuropathy progression in patients with familial amyloid polyneuropathy.International randomized, double-blind, placebo-controlled study conducted among 130 patients with familial amyloid polyneuropathy exhibiting clinically detectable peripheral or autonomic neuropathy at amyloid centers in Sweden (Umeå), Italy (Pavia), Japan (Matsumoto and Kumamoto), England (London), and the United States (Boston, Massachusetts; New York, New York; and Rochester, Minnesota) from 2006 through 2012.Participants were randomly assigned to receive diflunisal, 250 mg (n=64), or placebo (n=66) twice daily for 2 years.The primary end point, the difference in polyneuropathy progression between treatments, was measured by the Neuropathy Impairment Score plus 7 nerve tests (NIS+7) which ranges from 0 (no neurological deficits) to 270 points (no detectable peripheral nerve function). Secondary outcomes included a quality-of-life questionnaire (36-Item Short-Form Health Survey [SF-36]) and modified body mass index. Because of attrition, we used likelihood-based modeling and multiple imputation analysis of baseline to 2-year data.By multiple imputation, the NIS+7 score increased by 25.0 (95% CI, 18.4-31.6) points in the placebo group and by 8.7 (95% CI, 3.3-14.1) points in the diflunisal group, a difference of 16.3 points (95% CI, 8.1-24.5 points; P?

SUBMITTER: Berk JL

PROVIDER: S-EPMC4139164 | biostudies-literature | 2013 Dec

REPOSITORIES: biostudies-literature

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Repurposing diflunisal for familial amyloid polyneuropathy: a randomized clinical trial.

Berk John L JL Suhr Ole B OB Obici Laura L Sekijima Yoshiki Y Zeldenrust Steven R SR Yamashita Taro T Heneghan Michael A MA Gorevic Peter D PD Litchy William J WJ Wiesman Janice F JF Nordh Erik E Corato Manuel M Lozza Alessandro A Cortese Andrea A Robinson-Papp Jessica J Colton Theodore T Rybin Denis V DV Bisbee Alice B AB Ando Yukio Y Ikeda Shu-ichi S Seldin David C DC Merlini Giampaolo G Skinner Martha M Kelly Jeffery W JW Dyck Peter J PJ

JAMA 20131201 24

<h4>Importance</h4>Familial amyloid polyneuropathy, a lethal genetic disease caused by aggregation of variant transthyretin, induces progressive peripheral nerve deficits and disability. Diflunisal, a nonsteroidal anti-inflammatory agent, stabilizes transthyretin tetramers and prevents amyloid fibril formation in vitro.<h4>Objective</h4>To determine the effect of diflunisal on polyneuropathy progression in patients with familial amyloid polyneuropathy.<h4>Design, setting, and participants</h4>In ...[more]

PMID: 24368466

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Project description:ObjectivesTo evaluate the efficacy and safety of 18 months of tafamidis treatment in patients with early-stage V30M transthyretin familial amyloid polyneuropathy (TTR-FAP).MethodsIn this randomized, double-blind trial, patients received tafamidis 20 mg QD or placebo. Coprimary endpoints were the Neuropathy Impairment Score-Lower Limbs (NIS-LL) responder analysis (<2-point worsening) and treatment-group difference in the mean change from baseline in Norfolk Quality of Life-Diabetic Neuropathy total score (TQOL) in the intent-to-treat (ITT) population (n = 125). These endpoints were also evaluated in the efficacy-evaluable (EE; n = 87) population. Secondary endpoints, including changes in neurologic function, nutritional status, and TTR stabilization, were analyzed in the ITT population.ResultsThere was a higher-than-anticipated liver transplantation dropout rate. No differences were observed between the tafamidis and placebo groups for the coprimary endpoints, NIS-LL responder analysis (45.3% vs 29.5% responders; p = 0.068) and change in TQOL (2.0 vs 7.2; p = 0.116) in the ITT population. In the EE population, significantly more tafamidis patients than placebo patients were NIS-LL responders (60.0% vs 38.1%; p = 0.041), and tafamidis patients had better-preserved TQOL (0.1 vs 8.9; p = 0.045). Significant differences in most secondary endpoints favored tafamidis. TTR was stabilized in 98% of tafamidis and 0% of placebo patients (p < 0.0001). Adverse events were similar between groups.ConclusionsAlthough the coprimary endpoints were not met in the ITT population, tafamidis was associated with no trend toward more NIS-LL responders and a significant reduction in worsening of most neurologic variables, supporting the hypothesis that preventing TTR dissociation can delay peripheral neurologic impairment.Classification of evidenceThis study provides Class II evidence that 20 mg tafamidis QD was associated with no difference in clinical progression in patients with TTR-FAP, as measured by the NIS-LL and the Norfolk QOL-DN score. Secondary outcomes demonstrated a significant delay in peripheral neurologic impairment with tafamidis, which was well tolerated over 18 months.

Dataset Information

Repurposing diflunisal for familial amyloid polyneuropathy: a randomized clinical trial.

Publications

Repurposing diflunisal for familial amyloid polyneuropathy: a randomized clinical trial.

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