Efficacy and safety of deferoxamine, deferasirox and deferiprone triple iron chelator combination therapy for transfusion-dependent β-thalassaemia with very high iron overload: a protocol for randomised controlled clinical trial

INTRODUCTION

Despite the improvement in medical management, many patients with transfusion-dependent β-thalassaemia die prematurely due to transfusion-related iron overload. As per the current guidelines, the optimal chelation of iron cannot be achieved in many patients, even with two iron chelators at their maximum therapeutic doses. Here, we evaluate the efficacy and safety of triple combination treatment with deferoxamine, deferasirox and deferiprone over dual combination of deferoxamine and deferasirox on iron chelation in patients with transfusion-dependent β-thalassaemia with very high iron overload.

METHODS AND ANALYSIS

This is a single-centre, open-label, randomised, controlled clinical trial conducted at the Adult and Adolescent Thalassaemia Centre of Colombo North Teaching Hospital, Ragama, Sri Lanka. Patients with haematologically and genetically confirmed transfusion-dependent β-thalassaemia are enrolled and randomised into intervention or control groups. The intervention arm will receive a combination of oral deferasirox, oral deferiprone and subcutaneous deferoxamine for 6 months. The control arm will receive the combination of oral deferasirox and subcutaneous deferoxamine for 6 months. Reduction in iron overload, as measured by a reduction in the serum ferritin after completion of the treatment, will be the primary outcome measure. Reduction in liver and cardiac iron content as measured by T2* MRI and the side effect profile of trial medications are the secondary outcome measures.

ETHICS AND DISSEMINATION

Ethical approval for the study has been obtained from the Ethics Committee of the Faculty of Medicine, University of Kelaniya (Ref. P/06/02/2023). The trial results will be disseminated in scientific publications in reputed journals.

TRIAL REGISTRATION NUMBER

The trial is registered in the Sri Lanka Clinical Trials Registry (Ref: SLCTR/2023/010).

Changes in weight, body composition and metabolic parameters after switch to dolutegravir/lamivudine compared with continued treatment with dolutegravir/abacavir/lamivudine for virologically suppressed HIV infection (The AVERTAS trial): a randomised, open-label, superiority trial in Copenhagen, Denmark

INTRODUCTION

With longer life expectancy in people living with HIV (PLWH) on antiretroviral therapy, cardiovascular disease (CVD) has become a common cause of mortality among them. Abacavir has been associated with an increased risk of myocardial infarction, but the mechanism is unknown. Additionally, abacavir may be obesogenic which could mediate an additional risk factor of CVD. We aim to investigate if discontinuation of abacavir will have a favourable impact on body weight and cardiac parameters in PLWH.

METHODS AND ANALYSIS

Randomised, controlled, superiority trial of virologically suppressed PLWH on dolutegravir, abacavir and lamivudine (DTG/ABC/3TC) for ≥6 months. In total, 70 PLWH will be randomised 1:2 to either continue DTG/ABC/3TC or to switch to dolutegravir and lamivudine (DTG/3TC) providing the power of 80% at alpha 5% to detect a mean difference in weight change of 2 kg (Δ) given an SD of 2.7 kg. Follow-up will be 48 weeks. Data will be collected at baseline and week 48. Primary outcome will be change in mean body weight from baseline to week 24 and 48 evaluated in a linear mixed model. Secondary outcomes will be changes in cardiac, inflammatory and metabolic parameters, fat distribution, coagulation, endothelial, platelet function, quality of life and virological control from baseline to week 48. Measurements include CT of thorax and abdomen, external carotid artery ultrasound, liver elastography and dual energy X-ray absorptiometry and blood analysis. Plasma HIV RNA will be measured at baseline, week 4, 24 and 48. Forty participants (20 from each arm) will be included in a substudy involving cardiac MRI at baseline and week 48. Twenty non-HIV-infected controls will be included with a single scan to compare with baseline scan data.

ETHICS AND DISSEMINATION

Result from this study will lead to a better understanding of the association between antiretroviral therapy and the impact on weight and risk of CVD. Findings will be useful for both clinicians and PLWH in the guidance of a more individualised HIV treatment. Results from the main study and the substudies will be submitted for publication in a peer-reviewed journal(s). The AVERTAS study is approved by the Ethics Committee of the Capital Region, Denmark (H-20011433), Danish Medicines Agency (EudraCT no. 2019-004999-19) and Regional Data Protection Centre (P-2020-207).

TRIAL REGISTRATION NUMBER

Pre-results registration at ClinicalTrials.gov Identifier: NCT04904406, registered 27 May 2021.

PROTOCOL VERSION

Protocol version 9.0, 4 April 2023, approved 10-05-2023 by Ethics Committee of the Capital Region, Denmark (H-20011433). Danish Medicines Agency (EudraCT no. 2019-004999-19). Regional Data Protection Centre (P-2020-207) ClinicalTrials.gov.

Inpatient hospitalisation and mortality rate trends from 2004 to 2014 in the USA: a propensity score-matched case-control study of hyperkalaemia

OBJECTIVE

To study the trends of hyperkalaemia in USA inpatient hospitalisation records with heart failure (HF), chronic kidney disease (CKD), acute kidney injury (AKI) and/or type II diabetes mellitus (T2DM) from 2004 to 2014 with respect to prevalence and inpatient mortality.

DESIGN

Observational cross-sectional and propensity score-matched case-control study.

SETTING

The National Inpatient Sample (representing up to 97% of inpatient hospital discharge records in the USA) from 2004 to 2014 PARTICIPANTS: 120 513 483 (±2 312 391) adult inpatient hospitalisation records with HF, CKD/end-stage renal disease (ESRD), AKI and/or T2DM.

EXPOSURE

Hyperkalaemia, defined as the presence of an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code of '276.7' in any of the first 15 diagnostic codes.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcomes of interest are the annual rates of hyperkalaemia prevalence and inpatient mortality.

RESULTS

Among 120 513 483 (±2 312 391) adult inpatient hospitalisations with HF, CKD/ESRD, AKI and/or T2DM, we found a 28.9% relative increase of hyperkalaemia prevalence from 4.94% in 2004 to 6.37% in 2014 (p<0.001). Hyperkalaemia was associated with an average of 4 percentage points higher rate of inpatient mortality (1.71 post-matching, p<0.0001). Inpatient mortality rates decreased from 11.49%±0.17% to 6.43%±0.08% and 9.67%±0.13% to 5.05%±0.07% for matched cases with and without hyperkalaemia, respectively (p<0.001).

CONCLUSIONS

Hyperkalaemia prevalence increased over time and was associated with greater inpatient mortality, even after accounting for presentation characteristics. We detected a decreasing trend in inpatient mortality risk, regardless of hyperkalaemia presence.

Association of self-reported snoring and hyperuricaemia: a large cross-sectional study in Chongqing, China

OBJECTIVE

To examine the relationship between self-reported snoring and hyperuricaemia in a large-scale population in Chongqing, China.

SETTING

Face-to-face electronic questionnaire survey, physical examination and biological sample testing were conducted in 13 districts of Chongqing. Chongqing is a municipality in southwest China.

PARTICIPANTS

In this study, 23 308 Han ethnicity permanent residents aged 30-79 years were recruited. Individuals missing data were excluded, 22 389 subjects were included in final analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

Serum uric acid (UA) was measured using an oxidase method. Hyperuricaemia was defined as serum UA >420 µmol/L in men and >360 µmol/L in women. Information about self-reported snoring was obtained by questionnaire survey. All participants were divided into 'no snoring' 'snoring occasionally' and 'snoring frequently'. Multivariable logistic regression analysis was performed to assess the relationship between self-reported snoring and hyperuricaemia.

RESULTS

The prevalence of hyperuricaemia was 14.43%, and snorers were more likely to have hyperuricaemia than non-snorer in different age and gender groups. For the total population, those who snore occasionally or frequently were more likely to be hyperuricaemia (OR 1.19, 95% CI 1.07 to 1.31; OR 1.33, 95% CI 1.19 to 1.47) compared with no snoring people. Stratification by age, gender and body mass index (BMI), we found that the positive association between snoring frequently and hyperuricaemia was insisted in different age, gender and high BMI groups, and the strength of association varied with different age, gender and BMI category.

CONCLUSION

Snoring frequency was positively associated with higher risk of hyperuricaemia. Snoring frequently may be a signal for hyperuricaemia, especially for women, those over 59 years of age, or those who are overweight or obese.

Does non-invasive ventilation change metabolic markers in children with obstructive sleep apnoea? A systematic review and meta-analysis study protocol

INTRODUCTION

Obstructive sleep apnoea (OSA) is not only common within paediatrics but is associated with critical childhood metabolic morbidity such as obesity, cardiovascular disease and glucose tolerance impairment. Increasing evidence suggests an association between childhood OSA and metabolic syndrome such as markers of cardiovascular disease, systemic hypertension, glucose intoleranceand increased lipid profile. Recent studies have targeted changes in metabolic markers in children using non-invasive ventilation (NIV) but no systematic reviews are available to summarise this emerging evidence. The purpose of this systematic review is to provide systematic synthesis of the evidence on the effect of NIV use on metabolic markers in children with OSA.

METHODS AND ANALYSIS

A systematic search of electronic databases and grey literature will include paediatric interventional studies (random controlled trials, cohort studies) with and without a comparison group. Two reviewers will independently undertake the two step process of title/abstract and full-text screening. Data will be extracted and assessed, with aggregate data being reported. When the data allow, meta-analysis will be performed.

ETHICS AND DISSEMINATION

There are no ethical concerns with this systematic review, as data have previously been published. This review will inform clinicians taking care of children with OSA and obesity/metabolic syndrome about the potential effects of NIV therapies on metabolic markers and has the potential to change the approach to childhood OSA and obesity. Results of this systematic review will be submitted for dissemination in abstract and manuscript form.

Does chronic hyperglycaemia increase the risk of kidney stone disease? results from a systematic review and meta-analysis

DESIGN

Systematic review and meta-analysis of observational studies was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for studies reporting on diabetes mellitus (DM) or metabolic syndrome (MetS) and kidney stone disease (KSD).

OBJECTIVE

To examine the association between chronic hyperglycaemia, in the form of DM and impaired glucose tolerance (IGT) in the context of MetS and KSD.

SETTING

Population-based observational studies. Databases searched: Ovid MEDLINE without revisions (1996 to June 2018), Cochrane Library (2018), CINAHL (1990 to June 2018), ClinicalTrials.gov, Google Scholar and individual journals including the Journal of Urology, European Urology and Kidney International.

PARTICIPANTS

Patients with and without chronic hyperglycaemic states (DM and MetS).

MAIN OUTCOME MEASURES

English language articles from January 2001 to June 2018 reporting on observational studies.

EXCLUSIONS

No comparator group or fewer than 100 patients. Unadjusted values were used for meta-analysis, with further meta-regression presented as adjusted values. Bias was assessed using Newcastle-Ottawa scale.

RESULTS

2340 articles were screened with 13 studies included for meta-analysis, 7 DM (three cohort) and 6 MetS. Five of the MetS studies provided data on IGT alone. These included: DM, n=28 329; MetS, n=31 767; IGT, n=12 770.

CONTROLS

DM, n=5 89 791; MetS, n=1 78 050; IGT, n=2 93 852 patients. Adjusted risk for DM cohort studies, RR=1.23 (0.94 to 1.51) (p<0.001). Adjusted ORs for: DM cross-sectional/case-control studies, OR=1.32 (1.21 to 1.43) (p<0.001); IGT, OR=1.26 (0.92 to 1.58) (p<0.0001) and MetS, OR=1.35 (1.16 to 1.54) (p<0.0001). There was no significant difference between IGT and DM (cross-sectional/case-control), nor IGT and MetS. There was a moderate risk of publication bias. Statistical heterogeneity remained significant in adjusted DM cohort values and adjusted IGT (cross-sectional/case-control), but non-signficant for adjusted DM (cross-sectional/case-control).

CONCLUSION

Chronic hyperglycaemia increases the risk of developing kidney stone disease. In the context of the diabetes pandemic, this will increase the burden of stone related morbidity and mortality.

PROSPERO REGISTRATION NUMBER

CRD42018093382.

Does supplementation with carnosine improve cardiometabolic health and cognitive function in patients with pre-diabetes and type 2 diabetes? study protocol for a randomised, double-blind, placebo-controlled trial

INTRODUCTION

Carnosine, an over-the-counter food supplement, has a promising potential for the prevention and treatment of chronic diseases such as type 2 diabetes (T2DM), cardiovascular and neurodegenerative diseases through its anti-inflammatory, antiglycation, antioxidative and chelating effects. We have previously shown that supplementation with carnosine preserves insulin sensitivity and secretion in non-diabetic overweight and obese individuals. The effect of carnosine on cardiometabolic risk and related cognitive outcomes in patients with pre-diabetes and T2DM has thus far not been studied. We therefore aim to investigate whether supplementation with carnosine improves cardiometabolic health and cognitive function in patients with pre-diabetes and T2DM.

METHODS AND ANALYSIS

We will employ a parallel design randomised controlled trial. Fifty participants with pre-diabetes (impaired fasting glycaemia and impaired glucose tolerance) and T2DM (with HbA1c level < 8%) aged between 18 to 70 years will be randomly assigned to the intervention or control group. At baseline, participants will undergo a medical review and series of tests including anthropometric measurements (body mass index, a dual X-ray absorptiometry and peripheral quantitative computed tomography scan), an oral glucose tolerance test, cardiovascular measurements (central blood pressure, endothelial function and arterial stiffness), cognitive function, physical activity measurement, heart rate variability and liver fibroscan as well as questionnaires to assess dietary habits, sleep quality, depression and quality of life. The intervention group will receive 2 g of carnosine daily in two divided doses while the control group will receive identical placebo capsules for 14 weeks. All baseline measurements will be repeated at the end of the intervention. The change in glycaemic, cardiovascular and cognitive parameters as well as other measures will be compared between the groups.

ETHICS AND DISSEMINATION

This study is approved by the Human Research Ethics Committee of Monash Health and Monash University, Australia. The findings will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION

NCT02917928; Pre-results.