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Trial registered on ANZCTR


Registration number
ACTRN12619000765123
Ethics application status
Approved
Date submitted
18/04/2019
Date registered
22/05/2019
Date last updated
22/05/2019
Date data sharing statement initially provided
22/05/2019
Type of registration
Prospectively registered

Titles & IDs
Public title

The effect of functional foods intervention on common symptoms such as fatigue and depression in patients with multiple sclerosis
Scientific title
Researching the Effectiveness of a nutraceuticaL Intervention for multiplE sclerosis-related Fatigue
Secondary ID [1] 297989 0
APP1152317
Universal Trial Number (UTN)
Trial acronym
RELIEF (Researching the Effectiveness of a nutraceuticaL Intervention for multiplE sclerosis-related Fatigue)
Linked study record

Health condition
Health condition(s) or problem(s) studied:
Multiple Sclerosis 312409 0
Fatigue 312410 0
Condition category
Condition code
Neurological 310970 310970 0 0
Multiple sclerosis

Intervention/exposure
Study type
Interventional
Description of intervention(s) / exposure
Nine oral capsules containing a combination of:
1. N-Acetyl-cysteine (1000mg),
2. Acetyl L Carnitine (1000mg),
3. CoenzymeQ10 (600mg),
4. alpha lipoic acid (800mg),
5. combination capsule containing: Ascorbic acid (250mg), d-alpha-Tocopherol (equiv. vitamin E) 33.3 mg (52 IU), Thiamine nitrate (25 mg), Riboflavin (vitamin B2; 20 mg), Nicotinamide (vitamin B3; 20 mg), Biotin (vitamin H; 100 mg), Folinic acid (vitamin B9, 400 mcg)
Capsule 1-4 will be consumed twice a day, morning and evening Capsule 5 will only be consumed in the morning.
Capsules will be taken at the same time. These will be consumed each day for 16 weeks.

The study coordinator or site-specific research staff will make phone/in person contact at 2, 4, 8, and 12 weeks post-baseline to ensure adverse events and any relapses are captured, to review concomitant medications, and to promote participant adherence to the intervention.
If the participant experiences a serious adverse event (SAE) that is suspected to be linked to the study medication or compromises the participant’s ability to adhere to the intervention, the intervention will be ceased; however, the participant will remain in the trial and will be followed-up through to the end of the study.
Intervention code [1] 314211 0
Treatment: Drugs
Comparator / control treatment
1. Hard HPMC Capsule Biotin placebo: Calcium hydrogen phosphate dihydrate, Microcystalline cellulose, Magnesium Stearate
2. Hard HPMC Capsule Acetyl L Carnitine: microcystalline celluloce, Magnesium Stearate
3. Hard HPMC Capsule NAC placebo: Microcystalline cellulose, Colloidal anhydrous sillica, Forest Berry
4. Hard HPMC Capsule Lipoec 400 Placebo :microcystalline cellulose, silica colloidal anhydrous
5. Hard HPMC Capsule Ubiquinol Bioactive 300 Placebo: microcystalline cellulose, Magnesium Stearate, Calcium hydrogen phospate dihydrate
Control group
Placebo

Outcomes
Primary outcome [1] 319771 0
We will use the Fatigue Severity Scale (FSS), and the Modified Fatigue Impact Scale (MFIS) as the primary measure. Both the FSS and the MFIS are sensitive to changes in fatigue due to disease progression. The FSS measures functional outcomes of fatigue and has been shown to have high sensitivity and internal consistency (Cronbach’s alpha 0.88 and 0.89 respectively). The FSS is comprised of 9 items, each scored from 1-7 on a Likert scale, where 1 signifies no symptoms of fatigue and 7 indicates severe fatigue. The MFIS is a 21-item measure that has valid and reliable separate domains for physical, cognitive and psychosocial fatigue.
Timepoint [1] 319771 0
consent and screening visit then further follow up at 2weeks after screening visit, Baseline, 4 weeks after baseline (primary endpoint), 16 weeks after baseline, 20 weeks after baseline
Primary outcome [2] 319772 0
Depression outcomes will be assessed using the Hospital Anxiety and Depression Scale (HADS), Quick Inventory of Depression Scale (QIDS)
Timepoint [2] 319772 0
baseline then follow up at 4 weeks after baseline (primary endpoint), 16 weeks after baseline, 20 weeks after baseline
Secondary outcome [1] 369483 0
To investigate the effect of the intervention on total antioxidant capacity. Plasma TAC increases with the improvement of mitochondrial function and can be a biomarker of a successful response to the treatment with mitochondrial agents. It will be measured using a TAC kit (K274-100; Biovision, Mountain View, CA) according to the manufacturer’s instructions.
Timepoint [1] 369483 0
Blood samples will be collected at baseline, 16 weeks and 20 weeks.
Secondary outcome [2] 369484 0
Targeted metabolomic plasma analyses of four metabolites within the kynurenine pathway (tryptophan, kynurenine, kynurenic acid, and quinolinic acid) will be undertaken with high performance liquid chromatography mass spectrometry. Non-targeted metabolomic analyses of plasma will be performed using the gas chromatography time-of-flight mass spectrometry - 144 major metabolic compounds from various biological pathways, including the kynurenine pathway, are selected for metabolomics analysis. Urine samples will also be collected for metabolomic analyses.
Timepoint [2] 369484 0
Blood samples will be collected at baseline, 16 weeks and 20 weeks.
Secondary outcome [3] 369485 0
Microbiome profile
Microbiome analyses: The V4 region of the 16S rRNA gene will be sequenced at the Australian Genome Research Facility (AGRF) using the Illumina MiSeq platform (microbiome composition analysis). The SILVA reference database will be used to establish phylogenetic structure of the gastrointestinal microbiome communities. Bioinformatic analysis will be conducted using QIIME2 and Phyloseq software to establish a number of metrics regarding the microbiome. These include alpha and beta-diversity as well as relative abundance differences across all taxonomic levels specifically, Akkermansia muciniphila, Acinetobacter calcoaceticus, and Parabacteroides distasonis. If the analyses does not produce clear results for these taxa, we will employ PCR analysis for individual taxa of interest
Timepoint [3] 369485 0
Blood samples will be collected at baseline and 16 weeks.
Secondary outcome [4] 369486 0
Genomic profile
DNA will be extracted and stored. Whole genome SNP typing, using the Illumina CytoSNP platform to measure 850,000 nuclear SNPs will be conducted by the Australian Genome Research Facility. Whole mitochondrial genotyping will be conducted at the Victorian Genetic Health Services using MiSeq with long range PCR spanning all mtDNA a NexteraXT library prep and MiSeq 2x150bp sequencing.
Timepoint [4] 369486 0
Blood samples will be collected at baseline, 16 weeks and 20 weeks.
Secondary outcome [5] 369487 0
Cognitive fatigue
We will use CogEval, a modified online version of the modified version of the symbol digit modalities test (mSDMT) which measures concentration and sustained attention
Timepoint [5] 369487 0
Baseline, 16 weeks and 20 weeks.

Eligibility
Key inclusion criteria
• Aged 18-65 years;
• Diagnosed with RRMS by a neurologist;
• EDSS of less than 6 within last 12 months (measurement recorded in the absence of an acute relapse or illness);
• English speaking or non-English speaking patients that can ensure external interpreter assistance (e.g. from a relative, spouse or friend) for the onsite clinical visits and for the phone follow-up timepoints.
• On stable MS therapy for more than/ equal to 8 weeks prior to enrolment;
• Available to attend clinic visits within 1 week of each time point (baseline, week 16, and week 20);
• Clinical fatigue (as evidenced by a FSS score more than 4 on two occasions when completing the test serially online over a fortnight);
• Basic confidence and literacy with using a computer (e.g. able to use web browser, receive SMS messages).
Minimum age
18 Years
Maximum age
65 Years
Gender
Both males and females
Can healthy volunteers participate?
No
Key exclusion criteria
• Known or suspected systemic medical disorder such as rheumatoid arthritis and kidney disease OR any medical condition (e.g. cognitive disorders, intellectual disability, Alzheimer’s disease) that investigators determine may affect participant adherence to the trial intervention
• Previous cardiac event including angina, Coronary Artery Bypass Grafting (CABG), non- and ST elevated myocardial infarction (biotin can disrupt measurement of cardiac enzymes)
• Currently prescribed thyroid-related medication (e.g. thyroxine) or diagnosed thyroid-related disorder
• Currently prescribed any psychotropic medication (e.g. antidepressants)
• Pregnant or at risk of pregnancy (if female);
• Current lactation;
• Commenced or are scheduled to commence iron supplementation
• Acute suicidality (score more than 1 on item 12 of a self-reported Quick Inventory of Depressive Symptomology Tool);
• A current diagnosis of substance abuse/dependence;
• Currently taking any illicit substances including any cannabis product (e.g. cannabis oil)
• Recent gastrointestinal ulcers or renal stones;
• Diagnosis of epilepsy;
• Current use of any of the study preparations OR any multivitamin (eligible following a 3-week washout period);
• Using more than200 mcg of selenium/day (antioxidant properties that are mechanistically similar to the study treatment).
• Prescribed warfarin or phenytoin;
• Allergy/intolerance to any study components;
• No internet access;
• Unable or unlikely to attend the required study visits at the required timepoints or unable to complete the study protocol (e.g. upcoming travel, surgery)

Study design
Purpose of the study
Treatment
Allocation to intervention
Randomised controlled trial
Procedure for enrolling a subject and allocating the treatment (allocation concealment procedures)
Participant randomization will be stratified within each site using a randomisation code. An independent statistician will provide the randomisation schedules to the site pharmacies. Upon enrolment of a participant, the site nurse will receive a randomization code and product from the site pharmacy.
At the screening visit, participants will be assigned a unique participant Screening Number.
Methods used to generate the sequence in which subjects will be randomised (sequence generation)
Permuted block randomisation
Masking / blinding
Blinded (masking used)
Who is / are masked / blinded?
The people receiving the treatment/s
The people administering the treatment/s
The people assessing the outcomes
The people analysing the results/data
Intervention assignment
Parallel
Other design features
Phase
Phase 2
Type of endpoint(s)
Efficacy
Statistical methods / analysis
The RCT of n=150 (n=75 per arm) has been designed to detect a moderate reduction in fatigue. The trial has been powered to have 95% power to detect fatigue reduction in the order of 15% as this magnitude will still be of clinical significance.

Statistical analysis: For all outcomes, an intent to treat analysis will be conducted. Because of the study design advantage of serial longitudinal measures, we will use multi-level models to account for the correlation between outcomes measured repeatedly on the same participant. The continuous primary and secondary outcome data will be analysed using mixed model, hierarchical linear modelling, nested within treatment groups, taking time as a within subjects and group as a between subjects effect. We will evaluate differing distributions between the two arms in baseline or post-randomisation confounders and adjust as required using multivariable models. This includes adjusting for non-MS related factors that may cause fatigue such as sleep quality and exercise.

Metabolomic analyses: To discover changes in plasma metabolites due to CMA treatment, and infer the involvement of specific metabolic pathways, we will compare the metabolic measurements from individuals between the two arms of the trial. We will apply the latest techniques for analysing metabolomic data, such as partial least squares-based methods, as well as explore the use of other multivariate classification methods. These will include considering metabolites individually as well as grouped by their known biological pathways (pathway analyses). As a secondary aim, we will build a predictive model of individuals’ response to treatment based on their baseline variables (metabolomic and other), to determine whether such a model would be clinically useful for targeting mitochondrial treatment.

Genomic analyses: we will use a range of genomic network approaches including the GLMNet approach. Briefly, GLMNet fits a generalized linear model via penalized maximum likelihood and is akin to a step-wise forward regression with the added feature of being able to perform internal cross-validation. GLMNet allows for rapid discovery of panels of related genomic sites likely to be associated with outcome. Follow-up analyses using standard GLM methods will be performed to factor in other factors as covariates.

Recruitment
Recruitment status
Not yet recruiting
Date of first participant enrolment
Anticipated
Actual
Date of last participant enrolment
Anticipated
Actual
Date of last data collection
Anticipated
Actual
Sample size
Target
Accrual to date
Final
Recruitment in Australia
Recruitment state(s)
NSW,QLD,TAS,VIC
Recruitment hospital [1] 13626 0
John Hunter Hospital - New Lambton
Recruitment hospital [2] 13627 0
Royal Melbourne Hospital - City campus - Parkville
Recruitment hospital [3] 13628 0
The Alfred - Prahran
Recruitment hospital [4] 13629 0
Box Hill Hospital - Box Hill
Recruitment hospital [5] 13630 0
Royal Hobart Hospital - Hobart
Recruitment hospital [6] 13631 0
Griffith Base Hospital - Griffith
Recruitment hospital [7] 13632 0
Austin Health - Austin Hospital - Heidelberg
Recruitment postcode(s) [1] 26294 0
2305 - New Lambton
Recruitment postcode(s) [2] 26295 0
3050 - Parkville
Recruitment postcode(s) [3] 26296 0
3004 - Prahran
Recruitment postcode(s) [4] 26297 0
3128 - Box Hill
Recruitment postcode(s) [5] 26298 0
7000 - Hobart
Recruitment postcode(s) [6] 26299 0
2680 - Griffith
Recruitment postcode(s) [7] 26300 0
3084 - Heidelberg

Funding & Sponsors
Funding source category [1] 302513 0
Government body
Name [1] 302513 0
Medical Research Future Fund, National Health and Medical Research Council, Department of Health
Address [1] 302513 0
Level 5, 20 Allara street, Canberra City, ACT 2600
Country [1] 302513 0
Australia
Primary sponsor type
University
Name
Australian National University
Address
Canberra ACT 0200
Country
Australia
Secondary sponsor category [1] 302422 0
None
Name [1] 302422 0
Address [1] 302422 0
Country [1] 302422 0

Ethics approval
Ethics application status
Approved
Ethics committee name [1] 303169 0
MELBOURNE HEALTH HUMAN RESEARCH ETHICS COMMITTEE
Ethics committee address [1] 303169 0
Office for Research
The Royal Melbourne Hospital
Level 2 South West
300 Grattan Street
Parkville VIC 3050
Australia
Ethics committee country [1] 303169 0
Australia
Date submitted for ethics approval [1] 303169 0
Approval date [1] 303169 0
19/02/2019
Ethics approval number [1] 303169 0
HREC/46758/MH-2018

Summary
Brief summary
Multiple sclerosis (MS) is rare but increasing in incidence. Our Australian work shows that five years of a first demyelinating event, 41% of people will have clinical fatigue with depression frequently comorbid. Single nutrient therapy with antioxidants directed to mitochondrial support have shown some benefit for fatigue and depression, oxidant damage prevention and improved clinical course in multiple sclerosis. This double-blind randomised controlled trial will run a 20-week therapy of combined mitochondrial support agents against placebo. The therapy will include coenzyme Q10, alpha-lipoic acid, N acetyl cysteine, biotin and other agents. Trial participants will be people with relapsing remitting multiple sclerosis with fatigue. The trial will assess the extent that these therapies reduce fatigue, depression, and metabolomic abnormalities in MS.
Trial website
Trial related presentations / publications
Public notes

Contacts
Principal investigator
Name 92722 0
Prof Anne-Louise Ponsonby
Address 92722 0
Murdoch Childrens Research Institute
Royal Children’s Hospital,
Flemington Rd,
Parkville VIC 3052
Country 92722 0
Australia
Phone 92722 0
+613 8341 6430
Fax 92722 0
Email 92722 0
anne-louise.ponsonby@mcri.edu.au
Contact person for public queries
Name 92723 0
Prof Anne-Louise Ponsonby
Address 92723 0
Murdoch Childrens Research Institute
Royal Children’s Hospital,
Flemington Rd,
Parkville VIC 3052
Country 92723 0
Australia
Phone 92723 0
+613 8341 6430
Fax 92723 0
Email 92723 0
anne-louise.ponsonby@mcri.edu.au
Contact person for scientific queries
Name 92724 0
Prof Anne-Louise Ponsonby
Address 92724 0

Murdoch Childrens Research Institute
Royal Children’s Hospital,
Flemington Rd,
Parkville VIC 3052
Country 92724 0
Australia
Phone 92724 0
+613 8341 6430
Fax 92724 0
Email 92724 0
anne-louise.ponsonby@mcri.edu.au

Data sharing statement
Will individual participant data (IPD) for this trial be available (including data dictionaries)?
Yes
What data in particular will be shared?
All outcome data excluding genomic data
When will data be available (start and end dates)?
2018-2022
Available to whom?
Researchers by request
Available for what types of analyses?
IPD meta-analyses and to achieve the aims in the approved proposal
How or where can data be obtained?
Research request to the principal investigator
What supporting documents are/will be available?
Study protocol
How or where can supporting documents be obtained?
Type [1] 1888 0
Study protocol
Citation [1] 1888 0
Link [1] 1888 0
Email [1] 1888 0
Other [1] 1888 0
This will be made public as a published manuscript
Attachment [1] 1888 0
Summary results
No Results