If you think this trial is relevant to your situation, please contact your Cancer Specialist to discuss further.
OXTOX is a randomised (2:1) phase II study in 90 people to evaluate whether ibudilast decreases the severity of acute neuropathy and enables people with metastatic colorectal cancer to get more oxaliplatin before needing dose modifications for CIPN.
Ibudilast or placebo starts 2 days before chemotherapy and continues until oxaliplatin stops. Acute neurotoxicity is measured at day 3 of each cycle and all other measures at day 1 of each cycle and then 1, 3, 6, 9 and 12 months after chemotherapy. Assessments include CIPN, functional status, quality of life, toxicity, oxaliplatin dose and modifications, and progression-free survival.
Oxaliplatin chemotherapy improves survival but causes acute neuropathy (pins and needles and pain on touching or swallowing cold objects or fluids) and chronic chemotherapy-induced peripheral neuropathy (CIPN) in most people receiving the drug. This causes numbness, discomfort, and pain especially in the hands and feet, which can last for months to years after stopping treatment. It has a major impact on quality of life, functional status and return to daily life, and there is no effective prevention or treatment. CIPN is the most common cause of people needing a reduction in their dose of oxaliplatin or having to stop the treatment early. Acute neurotoxicity is associated with more severe CIPN.
Studies done using animal models suggest ibudilast, a tablet, when given with oxaliplatin can prevent and treat neurotoxicity. This may mean more oxaliplatin can be delivered, thus improving survival in people with colorectal cancers.
In this study we will randomise (2:1) 90 people to receive either ibudilast or placebo with their chemotherapy to see whether ibudilast decreases the severity of acute neuropathy and enables people with metastatic colorectal cancer to get more oxaliplatin before needing dose modifications for CIPN. Acute neurotoxicity is measured at day 3 of each cycle and all other measures at day 1 of each cycle and then 1, 3, 6, 9 and 12 months after chemotherapy. Assessments include CIPN, functional status, quality of life, toxicity, oxaliplatin dose and modifications, and progression-free survival.
If you think this clinical trial may be relevant to your patient or to discuss further, please contact the Clinical Trial team.
To determine whether ibudilast has the potential to decrease the severity of acute neurotoxicity and CIPN in patients with metastatic CRC receiving oxaliplatin.
Oxaliplatin is commonly used to treat colorectal cancer (CRC) and upper gastrointestinal cancers (UGI). It improves survival but causes acute neuropathy (paraesthesias or dysesthesias) and chronic chemotherapy-induced peripheral neuropathy (CIPN) in almost all patients. The prevalence of moderate to severe acute neurotoxicity in patients receiving oxaliplatin is 85-95% (sensitivity touching cold items 79%, discomfort with cold drinks 72%, throat discomfort 59%, muscle cramps 40%, laryngo-pharyngeal dysesthesia 1-2%). Acute toxicity peaks on day 3 following infusion but may not fully resolve between cycles, and is worse in cycle 2 than cycle 1. The mechanism is believed to be slowed sodium channel inactivation. Severity of acute neurotoxicity predicts chronic sensory neuropathy.
Chronic CIPN from oxaliplatin results in sensory ataxia and dysesthesia. It is believed to be caused by accumulation of oxaliplatin in the dorsal root ganglion, potentially leading to axonal degeneration, mitochondrial disruption, and/or glial activation. CIPN is dose dependent and is the most common dose-limiting factor for patients receiving oxaliplatin. Knowing the optimal time to stop treatment early is problematic as CIPN can continue to worsen for a few months after stopping treatment (“coasting”). Recovery is often not complete, with residual deficits in most patients, minimal improvement on axonal excitability parameters, and 25% having sustained moderate severity CIPN. 1 Of the 136 CRC patients attending our Survivorship Clinic received oxaliplatin and 75% of them required dose reduction, and 37 stopped early, 24 (65%) due to CIPN. Of the 56 evaluable responses, 46% (26) of patients who received oxaliplatin reported at least moderate neuropathy, compared with 18% who did not receive oxaliplatin, a mean of 9 months after chemotherapy.16 CIPN has a major impact on quality of life (QOL), functional status, and return to daily life.
There are no preventative agents for CIPN and few treatment options. Prevention of neurotoxicity would lead to increased ability to deliver recommended doses of chemotherapy, and improve quality of life and functional status for many patients.
Ibudilast is a non-selective phosphodiesterase inhibitor with anti-inflammatory properties, approved for treatment of asthma and post stroke dizziness in Japan. It acts in the central and peripheral nervous system to reduce microglial activation. In vitro studies have shown ibudilast modulates glial activity and cytokine expression.
Clinical Trial Design
A randomised, non-comparative, calibrated phase II trial evaluating ibudilast (30mg PO bd) and placebo to determine whether ibudilast can decrease acute neurotoxicity severity and CIPN in patients with metastatic CRC receiving oxaliplatin with either FOLFOX or CAPOX, and to determine whether ibudilast will reduce dose modifications of oxaliplatin due to neurotoxicity.
Key Eligibility Criteria
1. Adults >18 years old with histologically confirmed metastatic adenocarcinoma CRC who are to commence chemotherapy with oxaliplatin (i.e. FOLFOX or CAPOX).
2. Sufficient written English to complete questionnaires.
3. Adequate organ function, defined as renal function with glomerular filtration rate >50mL/min, adequate bone marrow (platelets>100 X 109 L-1, neutrophil count >1.5 X 109 L-1), and hepatic (<1.5 X the upper limit of normal (ULN), with the exception that GGT may be elevated <3 X ULN as long as bilirubin is within normal range).
4. ECOG performance status of 0-2.
1. Existing peripheral neuropathy of any grade (e.g. due to diabetes mellitus, B12 deficiency, alcohol abuse, or use of nucleoside reverse transcriptase inhibitors).
2. Prior treatment with oxaliplatin within the past 6 months.
3. Any contraindication to taking ibudilast, including uncontrolled nausea or vomiting with chemotherapy.
Prof Janette Vardy