Aberrations in Carnitine Homeostasis in Congenital Heart Disease With Increased Pulmonary Blood Flow
| Status: | Active, not recruiting |
|---|---|
| Conditions: | Cardiology |
| Therapuetic Areas: | Cardiology / Vascular Diseases |
| Healthy: | No |
| Age Range: | Any |
| Updated: | 1/6/2019 |
| Start Date: | December 2014 |
| End Date: | July 2020 |
Phase 1 Study of the Safety and Pharmacokinetics of Perioperative IV L-carnitine Administration in Patients With Congenital Heart Disease With Increased Pulmonary Blood Flow
Infants with congenital heart disease and increased pulmonary blood flow have altered
carnitine homeostasis that is associated with clinical outcomes; and L-carnitine treatment
will attenuate these alterations and improve clinical outcomes.
The investigators will pilot a trial assessing the safety and pharmacokinetics of
perioperative IV L-carnitine administration in these patients. To this end, a pilot clinical
trial is proposed. Infants with ventricular septal defects or atrioventricular septal defects
undergoing complete surgical repair will receive L-carnitine (25, 50, or 100 mg/kg, IV) just
prior to cardiopulmonary bypass (CPB) and 2hr after CPB. Carnitine levels will be measured
before CPB, and before and 0.5, 1.5, 3, 5, 9, 12, and 24h after the second dose. The safety,
pharmacokinetic profile, feasibility, and effect of L-carnitine administration on biochemical
parameters, as well as clinical outcomes will be determined. The investigators expect this
pilot to provide the data needed to proceed with a placebo-based randomized, controlled,
trial.
carnitine homeostasis that is associated with clinical outcomes; and L-carnitine treatment
will attenuate these alterations and improve clinical outcomes.
The investigators will pilot a trial assessing the safety and pharmacokinetics of
perioperative IV L-carnitine administration in these patients. To this end, a pilot clinical
trial is proposed. Infants with ventricular septal defects or atrioventricular septal defects
undergoing complete surgical repair will receive L-carnitine (25, 50, or 100 mg/kg, IV) just
prior to cardiopulmonary bypass (CPB) and 2hr after CPB. Carnitine levels will be measured
before CPB, and before and 0.5, 1.5, 3, 5, 9, 12, and 24h after the second dose. The safety,
pharmacokinetic profile, feasibility, and effect of L-carnitine administration on biochemical
parameters, as well as clinical outcomes will be determined. The investigators expect this
pilot to provide the data needed to proceed with a placebo-based randomized, controlled,
trial.
AIM: To pilot a trial assessing the safety and pharmacokinetics (PK) of perioperative IV
L-carnitine administration in these patients. To this end, a pilot clinical trial is
proposed. Infants with VSD or AVSD undergoing complete repair will receive L-carnitine, in
one of 3 doses (25, 50, or 100 mg/kg, IV), just prior to CPB, and again 2 hr after CPB.
Serial blood samples will be obtained to determine free, total, and acylcarnitine levels, and
plasma markers of mitochondrial function, oxidative stress, and bioavailable NO. Adverse
events will be sought, and clinical outcomes will be assessed.
Study design: The inclusion and exclusion criteria are as described in Aim 3A except only
infants with VSD or AVSD will be enrolled (no TOF). The safety profile of L-carnitine is
outstanding, with no reports of toxicity from overdose reported113. In fact, the only adverse
reactions reported are transient nausea and vomiting, and less commonly gastritis. However,
although rare, seizures have been reported to occur in patients receiving L-carnitine.
Therefore, the major adverse events that will be monitored include evidence of seizure
activity and GI bleeding. As per routine, any patient suspected of having seizures is
monitored with continuous EEG. Dosing is not well studied in children, particularly
critically ill children67, 114-116117. In addition, the effect of CPB on L-carnitine
clearance in children is not known. Therefore, a major goal of this sub-aim is to establish a
pharmacokinetic profile of L-carnitine in this patient population undergoing surgery with
CPB, in order to move forward with a larger randomized trial powered for efficacy in
prevention of increased PVR post-bypass in at-risk infants. Plasma concentration profiles
after IV bolus dosing in adults were described by a two-compartmental model67, 113, 114, 118.
Usual pediatric dosing is not well delineated, but recommendations include a 50 mg/kg bolus
followed by an infusion of 50mg/kg/day, that can be increased to 300 mg/kg/day113, 119.
Therefore, we will begin at a lower dose (25 mg/kg), and escalate the dose after each group
of 5. No intra-patient escalation will be allowed and the dose will not be escalated until
all patients in the current dose level have been followed to hospital discharge or 30 days
post-op and the safety and PK data have been analyzed. The DSMB will approve all dose
escalations. The dosing goal will be to achieve normal or supra-normal free carnitine levels
(~50 μmol/L) and low AC levels (~3 μmol/L) just before and for 24 hrs after CPB; the period
with the greatest risk of pulmonary vascular morbidity.
L-carnitine administration in these patients. To this end, a pilot clinical trial is
proposed. Infants with VSD or AVSD undergoing complete repair will receive L-carnitine, in
one of 3 doses (25, 50, or 100 mg/kg, IV), just prior to CPB, and again 2 hr after CPB.
Serial blood samples will be obtained to determine free, total, and acylcarnitine levels, and
plasma markers of mitochondrial function, oxidative stress, and bioavailable NO. Adverse
events will be sought, and clinical outcomes will be assessed.
Study design: The inclusion and exclusion criteria are as described in Aim 3A except only
infants with VSD or AVSD will be enrolled (no TOF). The safety profile of L-carnitine is
outstanding, with no reports of toxicity from overdose reported113. In fact, the only adverse
reactions reported are transient nausea and vomiting, and less commonly gastritis. However,
although rare, seizures have been reported to occur in patients receiving L-carnitine.
Therefore, the major adverse events that will be monitored include evidence of seizure
activity and GI bleeding. As per routine, any patient suspected of having seizures is
monitored with continuous EEG. Dosing is not well studied in children, particularly
critically ill children67, 114-116117. In addition, the effect of CPB on L-carnitine
clearance in children is not known. Therefore, a major goal of this sub-aim is to establish a
pharmacokinetic profile of L-carnitine in this patient population undergoing surgery with
CPB, in order to move forward with a larger randomized trial powered for efficacy in
prevention of increased PVR post-bypass in at-risk infants. Plasma concentration profiles
after IV bolus dosing in adults were described by a two-compartmental model67, 113, 114, 118.
Usual pediatric dosing is not well delineated, but recommendations include a 50 mg/kg bolus
followed by an infusion of 50mg/kg/day, that can be increased to 300 mg/kg/day113, 119.
Therefore, we will begin at a lower dose (25 mg/kg), and escalate the dose after each group
of 5. No intra-patient escalation will be allowed and the dose will not be escalated until
all patients in the current dose level have been followed to hospital discharge or 30 days
post-op and the safety and PK data have been analyzed. The DSMB will approve all dose
escalations. The dosing goal will be to achieve normal or supra-normal free carnitine levels
(~50 μmol/L) and low AC levels (~3 μmol/L) just before and for 24 hrs after CPB; the period
with the greatest risk of pulmonary vascular morbidity.
Inclusion Criteria:
- have unrestrictive VSD, AVSD
- are undergoing complete repair
- are between 2-12 months of age
- are corrected gestational age ≥34 weeks
- will have an indwelling arterial or venous line
- have not had enteral or parenteral nutrition for at least 6 hrs
Exclusion Criteria:
- have body weight < 2.0 kg
- pulmonary artery or vein abnormalities not being addressed surgically
- suspected or proven in-born error of metabolism
- have other major congenital abnormalities that affect the cardiopulmonary system
- are taking carnitine supplementation
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