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  • HOOKWORM INFESTATION AS THERAPY IN CROHN’S DISEASE Fortun PJ1, Pritchard D2, Britton J3, Sithole JS4, Cole AT5, Hawkey CJ1 1 Wolfson Digestive Diseases Centre, University Hospital Nottingham, NG7 2UH 2 School of Pharmacy, University of Nottingham, University Park, NG7 2RD 3 Division of Epidemiology and Public Health, Nottingham University Medical School, Nottingham, NG7 2UH 4. Trent RDSU, University of Nottingham, School of Community Health Sciences, Nottingham University Medical School, Nottingham, NG7 2UH 5 Derby City General Hospital, Derby, DE22 3NE PROTOCOL VERSION 2.2 (23.03.06) Hookworm Protocol Version 2.2, 23/03/2006 1 of 36
  • Contents Abbreviations 3 Introduction 4 Principal Research Question 5 Secondary Research Goals 5 Proposed trial 5 Trial Design 6 Study population 6 Inclusion criteria 6 Exclusion criteria 6 Treatment allocation 6 Patients who require steroids at trial entry 7 Unblinding 7 Treatment 7 Proposed Outcome Measures 8 Study Flow Chart 9 Screening tests 10 Immunological methods 10 Foxp3 10 Safety Measures 11 Data Safety Monitoring 11 Reasons for discontinuation of study 11 Sample size 11 Statistical analysis 11 Rationale for the Study 12 References 13 Appendix 1 Crohn's Disease Activity Index 14 Appendix 2 Harvey Bradshaw Index (HBI, simple index) 15 Appendix 3 IBDQ 16 - 22 Appendix 4 EQ-5D 23 Appendix 5 Adverse Event Definitions 24 Appendix 6 – SOP 1 Adverse Event Reporting 25 - 32 Appendix 7 – SOP 2 Data Monitoring Committee 33 - 34 Appendix 8 – SOP 3 Optimal Clinical Practice 35 - 36 Hookworm Protocol Version 2.2, 23/03/2006 2 of 36
  • Abbreviations CD Crohn’s disease CDAI Crohn’s disease activity index CI Confidence interval CRF Case report form FBC full blood count Hb haemoglobin HBI Harvey Bradshaw Index IBD Inflammatory bowel disease IBDQ Inflammatory bowel disease questionnaire IFNγ gamma interferon IL interleukin LFT liver function tests Scid subacute combined immunodeficiency Th1 T helper 1 Th2 T helper 2 TNFα tumour necrosis factor alpha Treg regulatory T lymphocyte Tr1 regulatory T lymphocyte (type 1) UE urea and electrolytes Hookworm Protocol Version 2.2, 23/03/2006 3 of 36
  • Introduction Crohn’s disease (CD) is an idiopathic inflammatory condition of the gastrointestinal tract that most commonly presents during adolescence and early adult life. An aetiological paradigm in the immunogenicity of Crohn’s disease is that there is an imbalance between T cell networks that control inflammation and immune tolerance. The balance between T helper 1 (Th1) and Th2 appears to be important in inflammatory bowel disease. Th1 is associated with bacterial and viral infections and autoimmune diseases. Stimulated Th1 cells produce IL-2, IFNγ and TNFα. Th2 responses are associated with helminth infections and allergic diseases. Activated Th2 cells produce IL-4, IL-5, IL-10 and IL 13. The Th1 and Th2 cytokines reciprocally down-regulate the other T helper cell types. Evidence in humans points to an excessive mucosal Th1 response to the enteric flora in inflammatory bowel disease (IBD) [1], especially in Crohn’s disease, whereas in ulcerative colitis the T helper cells are less polarised. Treg T cell subsets Th1 Th2 Immunity Viral and Helminth bacterial infection infection Disease Crohn’s Allergy disease Cytokines involved IL-2 IFNγ TNFα IL-2 IL-5 IL-10 IL-13 Figure 1. The influence of Tcell subsets on immunity and the development of immunological disease Parasites such as hookworm have developed anti-inflammatory molecular strategies to evade the host immunological response, which result in suppression of the Th1 and stimulating Th2 (a “modified Th2 response) [1, 2]. Th1 suppression is associated with decreased macrophage activation, and reduced production of cytokines such as tumour necrosis factor (TNF)α, interleukin (IL)-2 and IL-12 and interferon (IFN) γ, which are central to the genesis of inflammation in Crohn’s Disease. They could therefore have similar therapeutic properties to current therapies such as infliximab, an antibody to TNF-α, and in the context of the Th1/Th2 paradigm, lead to switching from excessive Th1 to Th2. Helminth infection could therefore protect against Crohn’s Disease and epidemiological evidence is supportive of this hypothesis. There is a striking divergence between the incidence of helminth infection and IBD, for example in Africa, but a similar prevalence between Caucasians and African-Americans in the United States [3], suggesting a strong environmental influence. In animal models of IBD, various helminth infections have been shown to ameliorate colitis, including tapeworms, Trichinella, Schistosoma mansoni, Trichuris and H. polygyrus [4]. This has lead to several studies principally from the Weinstock’s group in Iowa into the effect of parasites on Crohn’s disease [5] and subsequently ulcerative colitis [6]. These have used pig whipworms (Trichuris suis) and have consistently reported substantial improvements although only the UC study was a randomised controlled study. Another concern is that there are few systematic data on the effect of pig whipworms on humans, safety evaluations have been limited and the studies have lacked an objective mechanistic assessment of Th1 - Th2 balance. Hookworm Protocol Version 2.2, 23/03/2006 4 of 36
  • Moreover, the Th1/Th2 paradigm is probably too simplistic. In addition to the Th cells which are active in the adaptive immune response, there is also a subset of negative regulators. The best characterised regulatory Tcells are the CD4+CD25+ regulatory T (Tr) cells and IL-10 producing Tr1 cells [7]. These serve to orchestrate the Th1 and Th2 responses [7]. Indeed, it has been demonstrated in a scid mouse model that low doses of Tr1 cells prevent IBD, whilst Th1 and Th2 cells had no effect [8]. An alternative strategy to Weinstock’s use of T. suis eggs in colitis would be to examine the effects of hookworm in humans with IBD. Necator americanus is a soil-based nematode which infects over 700 million humans. About 90% of these have no symptoms. People with heavy infestation may become anaemic. However, the average estimated blood loss is 0.1ml/day per worm. This would translate to 90 ml blood loss over a 3 month period. This is regularly a problem in already iron deficient populations, but unlikely to pose a problem in the well nourished. The parasite load required to cause anaemia is 3000 eggs per gram. Our dose will produce 500 eggs per gram, well below the threshold for producing anaemia [9]. A study of hookworms in Crohn’s disease has several attractions. Firstly it is an obligate human parasite so its biology and effects on the host are, in contrast to Trichuris suis, well understood. Secondly there is a wealth of experience in Nottingham both in parasitology, and more specifically from dose-ranging studies in healthy volunteers with a view to piloting a study of hookworms in asthmatic patients. In a study of hookworm in healthy volunteers at Nottingham University by Britton, Pritchard and co-workers, a range of 10-50 larvae was used. The lowest dose of 10 larvae was best tolerated, but was sufficient to achieve >50eggs/gram stool. This is the level required to produce eosinophilia (7-8 x 109), maximum at 6-7 weeks and found to be inversely related to the presence of wheeze in an Ethiopian study [10]. Side-effects experienced included local pruritis, mild abdominal discomfort and flatulence. With these data on optimal dosing in healthy volunteers, and in collaboration with Professors Pritchard and Britton, we intend to conduct a study of the tolerability and efficacy of induced hookworm infection in patients with moderate Crohn’s disease. Part of the drive comes from the interest that Weinstock’s work has generated in our patients, but also the strong tradition in Nottingham of collaborative clinical trials in IBD. Principal Research Question • Does a single dose of hookworm larvae reduce disease activity in Crohn’s disease (CD) (as measured by the CDAI, biochemical markers of severity) compared to placebo? Secondary Research Goals • Assess the safety profile of hookworm infestation in moderate Crohn’s disease. • Examine the cytokine profiles in subjects as a “proof of concept” that hookworms induce Th1/Th2 switching or upregulation of Treg and Tr1 populations. Proposed Trial Fifty six patients with moderately active Crohn’s disease will be recruited to take part in the study. Twenty eight patients (group A) will be randomised to receive the trial treatment (10 hookworm larvae, per patient) twenty eight (group B) will receive placebo, 2 µM of standard histamine solution under a plaster. Hookworm Protocol Version 2.2, 23/03/2006 5 of 36
  • At 3 months all will receive eradication with Mebendazole 100mg bd for 3 days, with efficacy checked by stool analysis. Patients will undergo disease assessment by CDAI, and inflammatory markers. Trial Design This will be a multicentre placebo-controlled trial, coordinated through the Clinical Trials Unit at University Hospital Nottingham. Study population Patients seen as gastroenterology inpatients or outpatients at one of the participating hospitals with a diagnosis of Crohn’s disease will be eligible if they satisfy the inclusion/exclusion criteria below: Inclusion criteria 1. Diagnosis of moderately active Crohn’s disease (CDAI between 220 and 450) requiring outpatient treatment. 2. Clinically acceptable baseline screening tests. 3. Aged between 18 and 80 4. Have given written informed consent Exclusion criteria 1. Positive stool culture for enteric pathogens or Clostridium difficile. 2. Bowel perforation, or obstructive symptoms not due substantially to active inflammation. 3. Patients whose diarrhoea is believed to be due to short bowel syndrome or bile salt malabsorption (making the CDAI invalid). 4. Female patients of child bearing potential who are not willing or able to use at least one highly effective contraceptive method throughout the study. In the context of this study, an effective method is defined as those which result in low failure rate (i.e. less than 1% per year) when used consistently and correctly such as: implants, injectables, combined oral contraceptives, sexual abstinence or vastectomised partner. 5. Concomitant immunosuppressive therapy (ciclosporin in the last three months, methotrexate in the last six months, prednisolone > 10mg/day) or infliximab in the past three months. Azathioprine is permitted if the patient has been on a stable dose for at least 2 months (see section on treatment allocation below). 6. Serious intercurrent infection or other active disease up to three months prior to treatment. 7. Known HIV infection. Treatment allocation Subjects will be randomised to either hookworm larvae or placebo on a block of four randomisation design, to ensure near-equal distribution of patients over the two treatment groups in each hospital. After every 4 patients, the number allocated to hookworm treatment will be the same as placebo. The trial coordinator, who will not be involved in the selection of patients, will allocate from coded sealed opaque envelopes and inform the technician from Prof. Pritchard’s laboratory who will administer hookworm or plaster only. A randomisation list will be prepared for each participating hospital. The random sequence of the permuted blocks will be generated by using random number tables. Hookworm Protocol Version 2.2, 23/03/2006 6 of 36
  • We will stratify by azathioprine positive (aza+) vs azathioprine negative (aza-) patients so that hookworm and placebo arms have an even mix of this variable. The use of azathioprine may mask the “immunological switch” or change in phenotype that we are looking for in response to hookworm. On the other hand, exclusion of azathioprine would significantly curtail recruitment, as many eligible patients from our clinic with moderately active Crohn’s disease would already be on azathioprine. Of note, Weinstock’s studies in IBD, and a small pilot study on 9 patients with Crohn’s disease in Queensland, Australia (personal communication) have included patients on azathioprine. Stratification will mean that both treatment arms are similarly represented with aza+ and aza- patients, so that we can control for this potential confounding variable. Patients who require steroids at trial entry Existing data suggest that an immune and therapeutic response to hook worm does not occur until 4-5 weeks. Consequently 1. Patients not needing corticosteroids, who are likely to be the majority, should be told not to expect a response in the first 4 weeks. 2. Patients whose symptoms warrant may receive prednisolone according to protocol (see table) during the first 5 weeks. 3. Patients on long term prednisolone may enter the study provided the dose is ≤ 10 mg daily. The dose should remain unchanged in these patients for the entire study because of revealing of adrenal suppression during prednisolone withdrawal. Patients experiencing a relapse of symptoms during the study should be managed as follows: 1. Week 0-5, treat with prednisolone according to protocol (Table 1) and ensure dose of prednisolone is ≤ 10 mg at week 6. Patients on prednisolone at week 6 should receive prednisolone 5 mg at week 7 and cease steroids by start of week 8. 2. Patients experiencing a flare of symptoms requiring initiation of corticosteroids or increase in dose after week 5 are treatment failures. For these patients, the CDAI is recorded and carried forward to 12 weeks and the patient is withdrawn from the study. However hook worm should not be eradicated until 12 weeks. Table 1: Protocol of steroid use (daily dose Prednisolone mg/day) Week Pre- 1 2 3 4 5 6 7 8 9 10 11 12 trial 0 30 20 15 10 5 - - - - - - - 0 30 20 15 10 5 - - - - - - 0 30 20 15 10 5 - - - - - 0 30 20 10 5 - - - - - 0 20 10 5 - - - - - 5-10 Continue at same dose through trial A need for steroids (prednisolone ≥ 10mg) in week 6 or later will be regarded as a treatment failure. Unblinding In the event of a clinician wishing to know if the patient is on active or placebo treatment arm, for example a serious adverse event (SAE), the code can be unbroken centrally (see contacts on page 1 of CRF). The patient will be withdrawn from the study. The patient should ideally have a further visit to document reason for withdrawal, and prescribe eradication therapy. Treatment Hookworm Protocol Version 2.2, 23/03/2006 7 of 36
  • A dose of 10 L3 larvae of N. americanus pipetted in solution onto a gauze pad and administered onto the skin under sticking plaster (see SOP 3, appendix 8). The placebo will consist of 2 µM of standard histamine solution, as used in skin prick testing, applied topically to the skin under a sealed dressing. This produces an itch lasting for approximately 10 seconds. The technician from Prof Pritchard’s laboratory, who has no role in data collection, will know the treatment given, but otherwise the study will be double-blind. Patients will be followed up for six months, but primary endpoints will be measured at three months reflecting the time course of infestation and maximum response. Proposed Outcome Measures The primary outcome measure will be change in the Crohn’s Disease Activity Index (CDAI) at week 12. The CDAI score is determined by of 8 variables: the number of liquid stools, the extent of abdominal pain, general well-being, the occurrence of extraintestinal symptoms, the need for antidiarrheal drugs, the presence of abdominal masses, hematocrit, and body weight. Scores range from 0 to approximately 600. In defining the limit between remission and active disease, investigators have assigned various cut-off values: < 150 is regarded as very well, 150-219 mildly active disease, 220-450 moderately active, >450 severe disease (appendix 1) [10]. This will be supplemented with a number of secondary measures of disease activity and mechanistic studies: 1. Disease activity by Harvey Bradshaw Index (HBI). The HBI is a simpler, validated [11] score of CD activity (appendix 2) 2. Inflammatory markers (ESR CRP), platelet count. 3. Circulating IL2 receptor and IL6 levels (measured by Elisa) will be used as an index of efficacy as well as of a switch between Th1 and Th2 responsiveness. 4. Patients’ Global Impression Of Change: an 11-point Numerical Rating Scale: 0 = much better, 5 = no change, and 10 = much worse 5. Cytokine profiles (IL2, IL4, IL5, IL10, TGFβ) and gamma interferon from peripheral blood mononuclear cells measured by Elisa and measured conjunction with Professor Pritchard to show evidence of a Th1/Th2 switch, and change in the Treg and Tr1 phenotype. 6. Quality of life – Inflammatory Bowel Disease Questionnaire (IBDQ). The IBDQ (appendix 3) is a self-administered Crohn’s Disease-specific quality of life instruments consisting of a 32-item questionnaire with 4 dimensions (bowel function, emotional status, systemic symptoms, social function); the total score on this index ranges from 32–224, with higher scores indicating better quality of life. The scores of patients in remission usually range from 170–190. The score correlates well with the CDAI [12]. 7. EQ-5D - this is a measure of health status for use in evaluating health and healthcare. It provides a simple descriptive profile and generates a single index value for heath status on which full health is assigned a value of 1 and death a value of 0. EQ-5D has been specially designed to complement other quality of life measures such as the SF-36, NHP, SIP or disease- specific measures, such as the IBDQ. It describes health status according to 5 dimensions, each divided into 3 levels. Hookworm Protocol Version 2.2, 23/03/2006 8 of 36
  • Table 2: Study flow chart Day 7 Telephone call ↓ Visit Baseline Day Day Wk Wk Wk Wk Wk Wk Withdrawal 1 7 3 6 9 12 13 24 as per wk12 Consent * Inclusion/exclusion criteria * Demographics * Pregnancy test * * Physical examination * * * Note: change of medication * * * * * * * * Adverse events * * * * * * * * Stool sample * a * e * e *e Provide pot for Stool sample for next * visit IgE N. Americanusd * * * Faecal egg counts * * * Cytokine profile * * * * * FBC * * * * * * * ESR, CRP * * * * * * * UE, LFT * * * * * * * Total IgE d * * * * * CDAI /HBI b c * * * * * Symptom diary * * * * * * * Height * Vital signs BP, P, RR +Weight * * * * * * * * IBDQ + EQ-5D questionnaires * * * * * Contact trial’s co-ordinator to enrol * patient and arrange delivery of Hookworm/Placebo and inform co- ordinator of the patient’s azathioprine status Hookworm/placebo application * Patient to return “Hookworm /placebo * plaster”– provide universal pot @ visit 2 Arrange script for Mebendazole * eradication of Hookworm at week 12 Mebendazole eradication * a Stool culture at entry* or within past 2 weeks b Crohn’s Disease Activity Index c Harvey Bradshaw Index d IgE N Americanus + Total IgE can be done at visit 2 prior to dosing e Stool sample for egg count *Allow 4 days for stool culture result PLEASE CONTACT UNIVERSITY OF NOTTINGHAM** TO INFORM THEM OF TIMES BLOOD SAMPLES WILL BE AVAILABLE PRIOR TO VISITS: • Day 1, wk 6, wk 12, wk 24 SAMPLES MUST BE TAKEN EARLY MORNING SO THAT THE SAMPLES CAN BE AT NOTTINGHAM BY 11.30AM TO ALLOW TIME FOR PROCESSING. • Randomise hookworm or placebo when screening results are available e.g. up to 7 days Hookworm Protocol Version 2.2, 23/03/2006 9 of 36
  • Patients will undergo baseline assessment, valuation visits at 3, 6, 9, 12 weeks post treatment, then follow up visit at 24 weeks. Results of screening bloods and stool microscopy are required to satisfy inclusion/ exclusion criteria, so an interval between baseline assessment and randomisation of 3-7 days is anticipated. Primary outcome measure will be the CDAI at 12 weeks. In addition, the patient will be contacted by the IBD/research nurse after 1 week treatment to enquire about any adverse events or concerns the patient may have. Baseline assessment will be as per flow chart above, with weight, height and clinical examination (required for CDAI assessment of abdomen). Informed consent is required prior to any activity. Ideally the patients will be recruited from outpatient clinic, have a verbal introduction to the trial by the physician or trial nurse, and be given a patient information leaflet to take away. They should have a “cooling off” period of 48 hours before proceeding to give consent and undergo baseline assessment. Data will be collected on date of diagnosis, site of CD, treatment and relapse history. In addition, current medication for CD and other data will be collected. There is a section in the CRF for recording changes to medication. Once recruited, the participants need to satisfy screening, and inclusion/exclusion criteria. Screening tests Full blood count (FBC): Exclude if Hb ≤ 9g/dl, haematocrit < 30%, platelets <100,000. Liver function tests: exclude if bilirubin >1.5 X upper limit of normal (ULN), aspartate transaminase (AST) > 1.5 X ULN, alkaline phosphatase (ALP) > 2 X ULN. Renal function: exclude if creatinine > 130 Stool microscopy: include if free of ova/parasites/C.difficile Immunological methods Serological and cytokine analyses will be conducted using standard procedures. For example, cytokine profiles from peripheral blood mononuclear cells, specifically IL2, 4, 5 and 10, TGFβ and γIFN will be assessed using paired antibodies in capture ELISA following induction with concanavalin A and with T cell receptor and co-stimulatory agonists, anti-CD3 and anti-CD28. We will measure basophil histamine release to determine cell competence in the presence of polyclonal IgE and potentially blocking anti-IgE autoantibodies. These immunological parameters have been chosen to reflect a consensus in the scientific literature that immunological responses induced by parasites may be counter-inflammatory in asthma and allergic disease. As the establishment of a regulatory T (Treg) cell network is considered to be a possible mechanism underlying the protective effect of infection with parasitic helminths, we will monitor foxp3 gene transcription in CD4+DC25+ and CD4+CD25- T cells purified from peripheral blood by FACS before and at 6 weeks after infection using quantitative RT-PCR. The percentage of CD24+CD25+ T cells will be evaluated by FACS as a measurement of Treg population expansion. Should we fail to find induction of Treg cells, we will measure IL-10 expression by RT-PCR and intracellular cytokine staining as an alternative hypothesis (establishment of Tr1 cells). Furthermore, our study will provide a unique opportunity to assess the potential contribution of regulatory T cells, generated by a well documented immune regulating human parasite, in down regulating and inflammatory phenotype using established immunological procedures. Together, this analysis will provide valuable information on the immunological phenotypes in IBD versus the parasitised patient cohorts, and assess the effect of parasite superimposition in IBD. All of the necessary methods are fully established in Professor Pritchard’s laboratory [13]. Hookworm Protocol Version 2.2, 23/03/2006 10 of 36
  • Eradication of Hookworm At 3 months all will receive eradication with mebendazole 100mg bd for 3 days, with efficacy checked by stool analysis. Patients will undergo disease assessment by CDAI, and inflammatory markers. Safety Measures • Overall incidence of adverse events (definition in appendix 5). • Assessment of GI symptoms (abdominal pain, diarrhoea, rectal bleeding, fever, extra intestinal symptoms and unanticipated rises in c-reactive protein, platelet count, circulating IL2 receptors and IL6). Deterioration in responses on inflammatory bowel disease questionnaire. • Colonoscopy will not form part of the assessment because, at this stage, the evidence for efficacy is not sufficient to justify such an invasive procedure. Data Safety Monitoring An Independent Data Safety Monitoring Committee (DMC), chaired by Dr M Langman, Heartlands Hospital, Birmingham, has been established to monitor the formal trial. The DMC will also receive all SAEs relating to patients entered into the trial. The DMC will assess of the trial should proceed if any of the following has occurred: 1. any death, 2. more than 4 similar SUSARs, 3. any pattern of serious unexpected events happening putting participants at risk and 4. any other unexpected developments. Reasons for discontinuation of study 1. Completion of the study 2. Failure to recruit sufficient subjects within a reasonable time period. 3. Availability of new information which renders continuation of the study unethical. 4. Decision by the DMC (see above) Sample size The pooled estimates of the placebo rates of remission and response in CD trials are 18% (95% confidence interval, 14%–24%; range, 0%–50%) and 19% (95% confidence interval, 13%–28%; range, 0%–46%), respectively [14]. The study is powered to detect a difference of 85 in the CDAI with hookworm treatment compared to control (see below). Based on a standard deviation of the change in the Crohn’s Disease Activity Index of 110 estimated from previous studies[15, 16]. To detect a difference of 85 in the CDAI scale with hookworm treatment compared to control with 80% power , α= 0.05, we would need 28 patients in each arm of the trial. This power calculation gives us 90% power to detect a difference of 98. Statistical analysis Hookworm Protocol Version 2.2, 23/03/2006 11 of 36
  • An unpaired t-test technique will be used to find out if there is a statistical difference between the two treatments. Multivariate analyses[ANCOVA] will be performed to examine the influence of differences between the groups at baseline, i.e. adjusting for age, centre, gender and so on. All analyses will be performed according to the intention to treat principle and we shall use the statistical package SAS version 9. Rationale for this study This study is worth conducting because primarily it will investigate an exciting new therapy, known from discussion with our own patients, to be acceptable to them. Secondly, it will throw light on themes of pathogenesis, in particular immunogenicity, in this important disease. We believe that providing insight to the interaction of environment (ie parasites) and immune response, with hope of new therapeutic strategies, is a core need for these patients. Hookworm Protocol Version 2.2, 23/03/2006 12 of 36
  • REFERENCES 1. Hunter MM, M.D., Helminths as therapeutic agents for inflammatory bowel disease. Alimentary Pharmacology & Therapeutics, 2004. 19(2): p. 167-177. 2. Maizels RM, Y.M., Immune regulation by helminth parasites: cellular and molecular mechanisms. Nature Reviews Immunology, 2003. 3: p. 733-44. 3. Farrokhyar F, S.E., Irvine EJ, et al, A critical review of epidemiological studies in inflammatory bowel disease. Scand J Gastroenterol, 2001. 36: p. 2-15. 4. Hunter MM, M.D., Review article: helminths as therapeutic agents for inflammatory bowel disease. Aliment Pharmacol Ther, 2003. 19: p. 167-177. 5. Summers RW, E.D., Qadir K., Trichuris suis seems to be safe and possibly effective in the treatment of inflammatory bowel disease. Am J Gastroenterol., 2003. 98(9): p. 2034-41. 6. Summers RW, E.D., Urban JF, et al, Trichuris suis therapy for active ulcerative colitis: a randomized controlled trial. Gastroenterology., 2005. 128(4): p. 825-32. 7. Thompson C, P.F., Regulatory T cells. Current opinion in pharmacology, 2004. 4: p. 408-14. 8. Foussat A, C.F., Brun V, et al, A comparative study between T regulatory type 1 and CD4+CD25+ T cells in the control of inflammation. Journal of Immunology., 2003. 171: p. 5018-26. 9. Pritchard D, et al, Hookworm infection and storage iron depletion. Trans. of the Royal Soc. Trop. Med. and Hygiene, 1991. 85: p. 235-238. 10. Sandborn WJ, F.B., Hanauer SB, et al, A review of activity indices and efficacy endpoints for clinical trials of medical therapy in adults with Crohn's disease. Gastroenterology, 2002. 122(2): p. 512-30. 11. de Dombal FT, S.A., IOIBD report no 1: Observer variation in calculating indices of severity and activity in Crohn's disease. International Organisation for the Study of Inflammatory Bowel Disease. Gut, 1987. 28: p. 474–481. 12. Irvine EJ, F.B., Rochon J, et al., Quality of life: a valid and reliable measure of therapeutic efficacy in the treatment of inflammatory bowel disease. Canadian Crohn's Relapse Prevention Trial Study Group. Gastroenterology, 1994. 106: p. 287–296. 13. Pritchard D. Sourcing a Chemical Success for ciclosporin from parasites and human pathogens. Drug Discovery Today, 2005. 10: p. 688-691. 14. Su C, L.G., Krok K, et al., A meta-analysis of the placebo rates of remission and response in clinical trials of active crohn’s disease. Gastroenterology, 2004. 126(5): p. 1257-69. 15. Hanauer SB, K.E., Robinson M, et al., Long-term management of Crohn's disease with mesalamine capsules (Pentasa). Pentasa Crohn's Disease Compassionate Use Study Group. Am J Gastroenterol, 1993. 88(9): p. 1343-1351. 16. Singleton JW, H.S., Gitnick GL, et al., Mesalamine capsules for the treatment of active Crohn's disease: results of a 16-week trial. Pentasa Crohn's Disease Study Group. Gastroenterology, 1993. 104(5): p. 1293-1301. Hookworm Protocol Version 2.2, 23/03/2006 13 of 36
  • Appendix 1 Crohn's Disease Activity Index Variable no. Variable description Multiplier Total 1 No. of liquid or soft stools (each day for 7 days) ×2 Abdominal pain, sum of 7 daily ratings (0 = none, 1 = 2 mild, 2 = moderate, 3 = severe) ×5 General well-being, sum of 7 daily ratings (0 = generally well, 1 = slightly under par, 2 = poor, 3 = very poor, 4 = 3 terrible) ×7 Number of listed complications (arthritis or arthralgia, iritis or uveitis, erythema nodosum or pyoderma gangrenosum or aphthous stomatitis, anal fissure or fistula or abscess, other fistula, fever over 37.8°C 4 [100°F]) ×20 Use of diphenoxylate or loperamide for diarrhea (0 = no, 5 1 = yes) ×30 6 Abdominal mass (0 = no, 2 = questionable, 5 = definite) ×10 7 Hematocrit (males, 47-Hct [%], females, 42-Hct [%]) ×6 Body weight (1-weight/standard weight) × 100 (add or 8 subtract according to sign) ×1 CDAI score Best WR, Becktel JM, Singleton JW. Rederived values of the eight coefficients of the Crohn's Disease Activity Index (CDAI). Gastroenterology 1979;77:843–846. Hookworm Protocol Version 2.2, 23/03/2006 14 of 36
  • Appendix 2 Harvey Bradshaw Index (HBI, simple index) Variable no. Variable description Total General well being (0 = very well, 1 = slightly below par, 2 = poor, 3 1 = very poor, 4 = terrible) 2 Abdominal pain (0 = none, 1 = mild, 2 = moderate, 3 = severe) 3 Number of liquid stools daily Abdominal mass (0 = none, 1 = dubious, 2 = definite, 3 = definite 4 and tender) Complications: arthralgia, uveitis, erythema nodosum, apthous ulcer, pyoderma gangrenosum, anal fissure, new fistula, abscess 5 (score 1 per item) HBI Score Harvey RF, Bradshaw JM. A simple clinical index of Crohn's disease activity. Lancet 1980;1:514. Hookworm Protocol Version 2.2, 23/03/2006 15 of 36
  • Appendix 3 QUALITY OF LIFE IN INFLAMMATORY BOWEL DISEASE QUESTIONNAIRE (IBDQ) This questionnaire is designed to find out how you have been feeling during the last 2 weeks. You will be asked about symptoms you have been having as a result of your inflammatory bowel disease, the way you have been feeling in general, and how your mood has been. 1.How frequent have your bowel movements been during the last two weeks? Please indicate how frequent your bowel movements have been during the last two weeks by picking one of the options from 1 BOWEL MOVEMENTS AS OR MORE FREQUENT THAN THEY HAVE EVER BEEN 2 EXTREMELY FREQUENT 3 VERY FREQUENT 4 MODERATE INCREASE IN FREQUENCY OF BOWEL MOVEMENTS 5 SOME INCREASE IN FREQUENCY OF BOWEL MOVEMENTS 6 SLIGHT INCREASE IN FREQUENCY OF BOWEL MOVEMENTS 7 NORMAL, NO INCREASE IN FREQUENCY OF BOWEL MOVEMENTS 2.How often has the feeling of fatigue or of being tired and worn out been a problem for you during the last 2 weeks? Please indicate how often the feeling of fatigue or tiredness has been a problem for you during the last 2 weeks by picking one of the options from 1 ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME 3.How often during the last 2 weeks have you felt frustrated, impatient, or restless? Please choose an option from 1 ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME 4.How often during the last 2 weeks have you been unable to attend school or do your work because of your bowel problem? Please choose an option from 1 ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME Hookworm Protocol Version 2.2, 23/03/2006 16 of 36
  • IBDQ 5.How much of the time during the last 2 weeks have your bowel movements been loose? Please choose an option from 1 ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME 6.How much energy have you had during the last 2 weeks? Please choose an option from 1 NO ENERGY AT ALL 2 VERY LITTLE ENERGY 3 A LITTLE ENERGY 4 SOME ENERGY 5 A MODERATE AMOUNT OF ENERGY 6 A LOT OF ENERGY 7 FULL OF ENERGY 7.How often during the last 2 weeks did you feel worried about the possibility of needing to have surgery because of your bowel problem. Please choose an option from 1 ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME 8.How often during the last 2 weeks have you had to delay or cancel a social engagement because of your bowel problem? Please choose an option from 1 ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME 9.How often during the last 2 weeks have you been troubled by cramps in your abdomen? Please choose an option from I ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME Hookworm Protocol Version 2.2, 23/03/2006 17 of 36
  • IBDQ 10.How often during the last 2 weeks have you felt generally Unwell? Please choose an option from 1 ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME 11.How often during the last 2 weeks have you been troubled because of fear of not finding a washroom? Please choose an option from 1 ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME 12.How much difficulty have you had, as a result of your bowel problems, doing leisure or sports activities you would have liked to have done during the last 2 weeks? Please choose an option from 1 A GREAT DEAL OF DIFFICULTY; ACTIVITIES MADE IMPOSSIBLE 2 A LOT OF DIFFICULTY 3 A FAIR BIT OF DIFFICULTY 4 SOME DIFFICULTY 5 A LITTLE DIFFICULTY 6 HARDLY ANY DIFFICULTY 7 NO DIFFICULTY; THE BOWEL PROBLEMS DID NOT LIMIT SPORTS OR LEISURE ACTIVITIES 13.How often during the last 2 weeks have you been troubled by pain in the abdomen? Please choose an option from 1 ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME 14.How often during the last 2 weeks have you had problems getting a good night's sleep, or been troubled by waking up during the night? Please choose an option from 1 ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME Hookworm Protocol Version 2.2, 23/03/2006 18 of 36
  • IBDQ 15.How often during the last 2 weeks have you felt depressed or discouraged? Please choose an option from 1 ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME 16.How often during the last 2 weeks have you had to avoid attending events where there was no washroom close at hand? Please choose an option from 1 ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME 17.Overall, in the last 2 weeks, how much of a problem have you had with passing large amounts of gas? Please choose an option from 1 A MAJOR PROBLEM 2 A BIG PROBLEM 3 A SIGNIFICANT PROBLEM 4 SOME TROUBLE 5 A LITTLE TROUBLE 6 HARDLY ANY TROUBLE 7 NO TROUBLE 18.Overall, in the last 2 weeks, how much a problem have you had maintaining or getting to, the weight you would like to be at. Please choose an option from 1 A MAJOR PROBLEM 2 A BIG PROBLEM 3 A SIGNIFICANT PROBLEM 4 SOME TROUBLE 5 A LITTLE TROUBLE 6 HARDLY ANY TROUBLE 7 NO TROUBLE Hookworm Protocol Version 2.2, 23/03/2006 19 of 36
  • IBDQ 19.Many patients with bowel problems often have worries and anxieties related to their illness. These include worries about getting cancer, worries about never feeling any better, and worries about having a relapse. In general, how often during the last 2 weeks have you felt worried or anxious? Please choose an option from 1 ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME 20.How much of the time during the last 2 weeks have you been troubled by a feeling of abdominal bloating? Please choose an option from 1 ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME 21.How often during the last 2 weeks have you felt relaxed and free of tension? Please choose an option from 1 NONE OF THE TIME 2 A LITTLE OF THE TIME 3 SOME OF THE TIME 4 A GOOD BIT OF THE TIME 5 MOST OF THE TIME 6 ALMOST ALL OF THE TIME 7 ALL OF THE TIME 22.How much of the time during the last 2 weeks have you had a problem with rectal bleeding with your bowel movements? Please choose an option from 1 ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME Hookworm Protocol Version 2.2, 23/03/2006 20 of 36
  • IBDQ 23.How much of the time during the last 2 weeks have you felt embarrassed as a result of your bowel problem? Please choose an option from I ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME 24.How much of the time during the last 2 weeks have you been troubled by a feeling of having to go to the bathroom even though your bowels were empty? Please choose an option from 1 ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME 25.How much of the time during the last 2 weeks have you felt tearful or upset? Please choose an option from 1 ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME 26.How much of the time during the last 2 weeks have you been troubled by accidental soiling of your underpants? Please choose an option from 1 ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME 27.How much of the time during the last 2 weeks have you felt angry as a result of your bowel problem? Please choose an option from 1 ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME b A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME Hookworm Protocol Version 2.2, 23/03/2006 21 of 36
  • IBDQ 28.To what extent has your bowel problem limited sexual activity during the last 2 weeks? Please choose an option from 1 NO SEX AS A RESULT OF BOWEL DISEASE 2 MAJOR LIMITATION AS A RESULT OF BOWEL DISEASE 3 MODERATE LIMITATION AS A RESULT OF BOWEL DISEASE 4 SOME LIMITATION AS A RESULT OF BOWEL DISEASE 5 A LITTLE LIMITATION AS A RESULT OF BOWEL DISEASE 6 HARDLY ANY LIMITATION AS A RESULT OF BOWEL DISEASE 7 NO LIMITATION AS A RESULT OF BOWEL DISEASE 29.How much of the time during the last 2 weeks have you been troubled by nausea or feeling sick to your stomach? Please choose an option. from 1 ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME 30.How much of the time during the last 2 weeks have you felt irritable? Please choose an option from 1 ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME 31.How often during the past 2 weeks have you felt a lack of understanding from others? Please choose an option from 1 ALL OF THE TIME 2 MOST OF THE TIME 3 A GOOD BIT OF THE TIME 4 SOME OF THE TIME 5 A LITTLE OF THE TIME 6 HARDLY ANY OF THE TIME 7 NONE OF THE TIME 32.How satisfied, happy, or pleased have you been with your personal life during the past 2 weeks? Please choose one of the following options from 1 VERY DISSATISFIED, UNHAPPY MOST OF THE TIME 2 GENERALLY DISSATISFIED, UNHAPPY 3 SOMEWHAT DISSATISFIED, UNHAPPY 4 GENERALLY SATISFIED, PLEASED 5 SATISFIED MOST OF THE TIME, HAPPY 6 VERY SATISFIED MOST OF THE TIME, HAPPY 7 EXTREMELY SATISFIED, COULD NOT HAVE BEEN MORE HAPPY OR PLEASED Hookworm Protocol Version 2.2, 23/03/2006 22 of 36
  • Appendix 4 EQ-5D MOBILITY I have no problems in walking about I have some problems in walking about I am confined to bed SELF-CARE I have no problems with self-care I have some problems washing or dressing myself I am unable to wash or dress myself USUAL ACTIVITIES (e.g. work, study, housework family or leisure activities) I have no problems with performing my usual activities I have some problems with performing my usual activities I am unable to perform my usual activities PAIN/DISCOMFORT I have no pain or discomfort I have moderate pain or discomfort I have extreme pain or discomfort ANXIETY/DEPRESSION I am not anxious or depressed I am moderately anxious or depressed I am extremely anxious or depressed Hookworm Protocol Version 2.2, 23/03/2006 23 of 36
  • Appendix 5 Adverse Event Definitions SEVERITY MILD Adverse event (AE) which is easily tolerated MODERATE Adverse event which is sufficiently discomforting to interfere with daily activity SEVERE Adverse event which prevents normal everyday activities CAUSALITY (Cause & effect relationship of adverse event to study treatment) RELATED A direct cause & effect relationship between the AE and the study treatment POSSIBLY RELATED A direct cause & effect relationship between the AE & the study treatment not demonstrated but possible or likely PROBABLY UNRELATED Cause & effect relationship between the AE & study treatment not demonstrated, improbable but not impossible UNRELATED The adverse event is definitely not related to the study treatment DEFINITION OF SERIOUS ADVERSE EVENT Any adverse event which :- prolongs a hospital stay or results in hospitalisation is incapacitating is permanently or temporarily disabling is life threatening is fatal In addition, any experience which the investigator regards as serious or which would suggest any significant hazard, contraindication, side-effect or precaution that may be associated with the use of the investigational study treatment should be reported as a serious adverse event. Hookworm Protocol Version 2.2, 23/03/2006 24 of 36
  • Appendix 6 – SOP 1 Standard Operating Procedure Applicable to: Hookworm and Crohn’s Disease Study SOP Number: HWCD SOP 01, Version 1 SOP Name: Adverse Event Reporting Author: Dr P J Fortun Signed: Trial Co-Ordinator Date: Approver: Prof. Chris Hawkey Signed: DM FRCP Chief Investigator Date: Effective date: 03 June 2005 Issue number: Hookworm Protocol Version 2.2, 23/03/2006 25 of 36
  • 1.0 Objective The objective of this SOP is to ensure the Pharmacovigilance responsibilities of the Study Sponsor (University of Nottingham), Chief Investigator (Professor Chris Hawkey) and the principal investigator at each participating site are met, in relation to Hookworm and Crohn’s Disease Study. 2.0 Definitions The European Directive 2001/20/EC defines the following: Adverse Event (AE): any untoward medical occurrence in a patient or clinical trial subject administered a medicinal product and which does not necessarily have a casual relationship with this treatment. Adverse Reaction (AR): all untoward and unintended responses to an investigational medicinal product related to any dose administered. Serious Adverse Event (SAE) or Serious Adverse Reaction (SAR): any untoward medical occurrence or effect that at any dose: o results in death, o is life-threatening, o requires hospitalisation or prolongation of existing hospitalisation, o results in persistent or significant disability or incapacity, o is a congenital anomaly or birth defect. Unexpected Adverse Reaction: an adverse reaction, the nature or severity of which is not consistent with the applicable product information (e.g. investigator’s brochure for an unauthorised investigational product or summary of product characteristics for an authorised product). The treatment in this trial is Hookworm. All other drugs used to treat the patients are established treatments for Crohn’s disease. Therefore, for the purpose of pharmacovigilance in this trial, only events related to Hookworm infection or Mebendazole will be considered adverse reactions. Adverse events known to be related to hookworm are listed in section 4.1 below.. Adverse events known to be related to mebendazole are listed in 4.2 for the Investigator’s information. Adverse events that may be related to drugs the patient may be concomitantly taking for their Crohn’s disease are shown in 4.3. 3.0 Procedures 3.1 Procedure for Reporting Adverse Events All adverse events reported spontaneously by the patients or in response to observation by the Investigator will be recorded in the patient’s case report form and the patient notes. The information that will be collected is provided in section 5 of this SOP (HWCD SOP 01, Version1). At baseline the investigator will ask the patient “Do you have any current symptoms?” During the study at each visit, the Investigator will inquire “Have you had any change in your symptoms since the last time you were asked?” In addition to this questioning during visits, each patient enrolled into the study will be provided with a card stating that they are participating in the study, and giving contact details for the local investigator responsible for their treatment. The card will also contain the telephone number of the study co-ordinating centre, Hookworm Protocol Version 2.2, 23/03/2006 26 of 36
  • to be used if the patient cannot contact their local investigator. This number will have an answer phone giving advice to patients calling outside normal working hours. This advice will be: • If you are worried about serious side-effects to the treatment, you should stop taking the study medication until you have spoken to your doctor • If your symptoms are serious enough for you to think you need to go to hospital, you should do this • If you leave your details, someone will contact you to discuss your concerns as soon as possible The patient, or anyone involved in their medical care, can use the contact numbers to report adverse events at any time while they are participating in the study. A record of all adverse events will be maintained by each centre in the individual Case Report Forms, and a central record of all adverse events will subsequently be filed in the Trial Master File. 3.2 Procedure for Reporting Serious Adverse Events Each Principal Investigator will be provided with contact details for the study co-ordinating centre in Nottingham (Chief Investigator and Trial Co-ordinator). If the Principal Investigator is informed of a Serious Adverse Event (SAE) they must inform the study co-ordinating centre within 24 hours of knowledge of the event, using the Serious Adverse Event form (included in CRF). In this form they must provide details of the event, and whether they consider it to be related to study treatment. If the study co-ordinating centre becomes aware of an SAE, they must inform the Principal Investigator responsible for that patient within 24 hours of knowledge of the event. 3.3 Procedure for categorising Serious Adverse Events, and for informing Regulatory Authorities, Ethics, and Research and Development Committees Following discussion with the Chief Investigator, serious adverse events considered to be related to study treatment will be defined as being either: • expected (event listed as a known adverse event to study treatment) or • unexpected (event can be considered a Suspected Unexpected Serious Adverse Reactions, SUSAR) The Chief Investigator will remain blinded when making this assessment. The Trial Co-ordinator, who is unblinded during the study, will then check the randomisation schedule to identify which treatment that patient received. If the patient was allocated to active treatment the Trial Co-ordinator will confirm that the event is a SUSAR. SUSARs that are fatal or life-threatening will be reported by the Trial Co-ordinator to the following groups, within 7 days: • Research Ethics Committee (MREC) • The relevant local ethics committee (LREC) • The relevant Research and Development office The Principal Investigator responsible for the patient will be copied into all relevant correspondence. Hookworm Protocol Version 2.2, 23/03/2006 27 of 36
  • All other SUSARs will be reported to the same groups as soon as possible, but within a maximum of 15 days. 3.4 Procedure for Unblinding when a Serious Adverse Event has occurred Randomisation codebreak envelopes containing the randomisation details for each patient will be stored at the study co-ordinating centre. If an adverse event occurs, and it is considered necessary to know what treatment that patient was allocated to in order to treat the adverse event appropriately, or Trial Co-ordinator will be able to provide this information. The decision to break the randomisation code must be documented in the study file and the site file. 3.5 Ongoing treatment for patients experiencing a Serious Adverse Event Patients who have experienced an SAE may be withdrawn from the study. The Chief Investigator and Principal Investigator responsible for their treatment will determine whether it is in the patient’s best interest to be withdrawn or to continue in the study. 3.6 Ongoing Safety Monitoring Throughout the study serious adverse event details will be reviewed by the independent Data Monitoring Committee, to assess the ongoing safety of the two treatment arms. The Data Monitoring Committee procedures are described in HWCD SOP 3, Data Monitoring Committee. In accordance with regulatory requirements an annual safety report will be prepared by the Trial Co-ordinator, and sent to the MREC and Research and Development committees. Hookworm Protocol Version 2.2, 23/03/2006 28 of 36
  • 4.0. Adverse Events Related to treatment 4.1 Adverse Events Related to Hookworm Skin – local irritation, pruritis. Respiratory – cough, wheeze. Gastrointestinal – diarrhoea, abdominal discomfort/pain/cramps, nausea, flatulence Haematological – anaemia. 4.2 Adverse Events Related to Mebendazole Mebendazole will be given at 24 weeks (end of study) to eradicate the hookworms. Adverse effects of mebendazole are listed below: Frequency estimate: Very Common: 10% Common: 1 - <10% Uncommon: 0.1 - <1% Rare: 0.01 - <0.1% Very Rare: <0.01% Side-effects: rarely abdominal pain, diarrhoea; hypersensitivity reactions (including exanthema, rash, urticaria, and angioedema) reported 4.3 Adverse Events Related to other likely concomitant drugs used in Crohn’s disease (to help differentiate between adverse effects due to the trial therapy eg, hookworm, mebendazole, and concomitant medication) 4.3.1 Prednisolone Mineralocorticoid side-effects include hypertension, sodium and water retention and potassium loss. Glucocorticoid side-effects include diabetes and osteoporosis), which is a danger, particularly in the elderly, as it may result in osteoporotic fractures for example of the hip or vertebrae; in addition high doses are associated with avascular necrosis of the femoral head. Mental disturbances may occur; a serious paranoid state or depression with risk of suicide may be induced, particularly in patients with a history of mental disorder. Euphoria is frequently observed. Muscle wasting (proximal myopathy) may also occur. Corticosteroid therapy is also weakly linked with peptic ulceration (the potential advantage of soluble or enteric-coated preparations to reduce the risk is speculative only). High doses of corticosteroids may cause Cushing's syndrome, with moon face, striae, and acne; it is usually reversible on withdrawal of treatment, but this must gastro-intestinal effects include dyspepsia, peptic ulceration (with perforation), abdominal distension, acute pancreatitis, oesophageal ulceration and candidiasis; musculoskeletal effects include proximal myopathy, osteoporosis, vertebral and long bone fractures, avascular osteonecrosis, tendon rupture; endocrine effects include adrenal suppression, menstrual irregularities and amenorrhoea, Cushing's syndrome (with high doses, usually reversible on withdrawal), hirsutism, weight gain, negative nitrogen and calcium balance, increased appetite; increased susceptibility to and severity of infection; neuropsychiatric effects include euphoria, psychological dependence, depression, insomnia, increased intracranial pressure with papilloedema in children (usually after withdrawal), psychosis and aggravation of schizophrenia, Hookworm Protocol Version 2.2, 23/03/2006 29 of 36
  • aggravation of epilepsy; ophthalmic effects include glaucoma, papilloedema, posterior subcapsular cataracts, corneal or scleral thinning and exacerbation of ophthalmic viral or fungal disease; other side-effects include impaired healing, skin atrophy, bruising, striae, telangiectasia, acne, myocardial rupture following recent myocardial infarction, fluid and electrolyte disturbance, leucocytosis, hypersensitivity reactions (including anaphylaxis), thromboembolism, nausea, malaise, hiccups. 4.3.2 Aminosalicylates Side-effects of the aminosalicylates include diarrhoea, nausea, vomiting, abdominal pain, exacerbation of symptoms of colitis, headache, hypersensitivity reactions (including rash and urticaria); side-effects that occur rarely include acute pancreatitis, hepatitis, myocarditis, pericarditis, lung disorders (including eosinophilia and fibrosing alveolitis), peripheral neuropathy, blood disorders (including agranulocytosis, aplastic anaemia, leucopenia, methaemoglobinaemia, neutropenia, and thrombocytopenia—see also recommendation above), renal dysfunction (interstitial nephritis, nephrotic syndrome), myalgia, arthralgia, skin reactions (including lupus erythematosus-like syndrome, Stevens-Johnson syndrome), alopecia. 4.3.3 Azathioprine Hypersensitivity reactions (including malaise, dizziness, vomiting, diarrhoea, fever, rigors, myalgia, arthralgia, rash, hypotension and interstitial nephritis— calling for immediate withdrawal); dose-related bone marrow suppression; liver impairment, cholestatic jaundice, hair loss and increased susceptibility to infections and colitis in patients also receiving corticosteroids; nausea; rarely pancreatitis, pneumonitis, hepatic veno-occlusive disease Hookworm Protocol Version 2.2, 23/03/2006 30 of 36
  • 5.0. ADVERSE EVENTS: INFORMATION TO BE COLLECTED Data Point Classification Definition Date AE Started Date Resolved Date of change in severity Severity Mild The AE does not limit usual activities; the patient may experience slight discomfort. Moderate The AE results in some limitation of usual activities; the patient may experience significant discomfort. Severe The AE results in an inability to carry out usual activities; the subject may experience intolerable discomfort or pain. Action Taken None Symptomatic Therapy Withdrawn from study, hookworm eradicated Patient hospitalised or hospitalisation prolonged Other Action (specify) Outcome Ongoing Resolved Permanent Residual Effect Death Relationship to None This category applies to those adverse Treatment experiences that, after careful consideration are clearly due to other causes (disease, environment, etc.) Unlikely An adverse event may be considered "unlikely" if, or when, two of the following apply: o It does not follow a reasonable temporal sequence from administration of the treatment o It could readily have been produced by the patient's clinical state, environmental or toxic factors, or other modes of therapy administered to the patient. o It does not follow a known or expected response pattern to the test treatment. o It does not reappear or worsen when the treatment is re-administered. Possible Possibly (must have two): An adverse event may be considered "possible" if or when two of the following apply: o It follows a reasonable temporal sequence from administration of the treatment. o It could readily have been produced by the patient's clinical state, environmental or toxic factors, or other modes of therapy administered to the patient o It follows a known response pattern to the treatment. Hookworm Protocol Version 2.2, 23/03/2006 31 of 36
  • Data Point Classification Definition Relationship to Probable Probably (must have three) Treatment An adverse event may be considered "probable" if or when three of the following apply: o It follows a reasonable temporal sequence from administration of the treatment. o It could not be reasonably explained by the known characteristics of the patient's clinical state, environmental or toxic factors or other modes of therapy administered to the patient. o It disappears or decreases on cessation of therapy. There are important exceptions when the adverse event does not disappear upon discontinuation of the treatment, yet relationship clearly exists. o It follows a known response pattern to the suspected treatment. Definite Definitely (must have all four) An adverse event may be assigned an attribution of "definite" if or when all four of the following apply: o It follows a reasonable temporal sequence from administration of the treatment. o It could not be reasonably explained by the known characteristics of the patient's clinical state, environmental or toxic factors, or other modes of therapy administered to the patient. o It disappears on cessation of therapy. o It follows a known response pattern to the suspected treatment. Hookworm Protocol Version 2.2, 23/03/2006 32 of 36
  • Appendix 7 – SOP 2 Effective date: Issue number: Standard Operating Procedure Applicable to: Hookworms and Crohn’s Disease Study SOP Number: HWCD SOP 2, Version 1 SOP Name: Data Monitoring Committee Author: Dr P J Fortun Signed: Trial Co-Ordinator Date: Approver: Prof. Chris Hawkey Signed: DM FRCP Chief Investigator Date: Hookworm Protocol Version 2.2, 23/03/2006 33 of 36
  • 1.0 Objective The objective of this SOP is to describe how the safety of the study will be monitored, to ensure that any unexpected safety risks are identified rapidly and the appropriate action taken. 2.0 Procedures 2.1 Composition of the Data Monitoring Committee The Data Monitoring Committee (DMC) will be made up of three independent doctors, who are not responsible for treating patients participating in the study, but who are familiar with the disease and treatments being used in the study. The DMC will be appointed before the first patient is enrolled into the trial, and if any of the members resign from the committee before the last patient completes the trial a replacement will be appointed promptly. 2.2 Responsibilities of the Data Monitoring Committee The DMC will meet after there have been 4 serious adverse events considered to be related to the study regime drug, or after there has been one death considered related to the study drug. Subsequent meetings will be held after a further 4 serious adverse events or one death since the last meeting, or at a frequency considered necessary by the members of the committee. Meetings may be carried out either in person or by teleconference. The Trial Co-ordinator is responsible for notifying the members of the DMC when the next meeting is due, and for providing them with details of the serious adverse events or deaths, and the treatment allocated to those patients. 2.3 Actions of the Data Monitoring Committee Following the review of adverse event data, the DMC may consider that the safety of the trial is no longer acceptable. If this happens, they should promptly inform the Chief Investigator and Trial Co-ordinator, who will make the necessary actions to alter or stop the trial. If the DMC consider that the trial should continue according to the protocol, they should inform the Trial Co-ordinator of this opinion in writing. Hookworm Protocol Version 2.2, 23/03/2006 34 of 36
  • Appendix 8 – SOP 3 Standard Operating Procedure Applicable to: Hookworm and Crohn’s Disease Study SOP Number: HWCD SOP 3, Version 2 SOP Name: Optimal Clinical Practice Author: DR P J Fortun Signed: BM MRCP Trial Co-Ordinator Date: Approver: Prof. Chris Hawkey Signed: DM FRCP Chief Investigator Date: Effective date: Issue number: Hookworm Protocol Version 2.2, 23/03/2006 35 of 36
  • 1.0 Objective The objective of this SOP is to describe how the requirements of the trial protocol will fit with the standard patient care routinely provided to patients with moderate Crohn’s disease who are not participating in the trial. 2.0 Principals of Optimal Patient Care All Principal Investigators (PIs) should treat their patients according to their own local procedures and medical judgement, and should schedule additional patient visits or tests over and above those described in the protocol if these are considered necessary. Patient safety should always be prioritised over adherence to the protocol. If at any stage the PI feels that it is in the patient’s best interests to be withdrawn from the trial then this should be done. 3.0 Recommended treatments 3.1 Hookworm application The hookworm larvae are transported live in a glucose solution in a clear container. The research assistant form Prof Pritchard’s laboratory will decant the larvae onto a gauze dressing, which is held in place with an occlusive dressing. The placebo treatment consists of the dressing with the glucose solution only. 3.2 Treatment of local skin irritation In most cases, no treatment is necessary. For severe irritation, topical hydrocortisone cream (1%) can be applied, maximum duration 7 days. Hookworm Protocol Version 2.2, 23/03/2006 36 of 36