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Randomized controlled trial of N-acetylcysteine therapy for RYR1-related myopathies
Joshua J Todd1, Tokunbor A Lawal1, Jessica W Witherspoon1
1From the Neuromuscular Symptoms Unit, National Institute of Nursing Research (J.J.T., T.A.L., J.W.W., I.C.C., M.S.R., M.P., J.S.E., F.T., A.K., M.O.S., C.A., M.M.C., M.L., M.E.-B., K.G.M.), Mark O. Hatfield Clinical Research Center, Rehabilitation Medicine Department (M.S.J., M.W., B.D.), and Neurogenetics Branch, National Institute of Neurological Disorders and Stroke (C.G.B.), NIH, Bethesda, MD; Hyperion Biotechnology Inc. (D.M.), San Antonio, TX; Biostatistics and Clinical Epidemiology Service (P.G.W.), NIH Clinical Center, Bethesda, MD; Division of Neurology and Program for Genetics and Genome Biology (J.J.D.) and Departments of Paediatrics and Molecular Genetics (J.J.D.), Hospital for Sick Children, Toronto, Canada.
Objective:
To investigate the efficacy of N-acetylcysteine (NAC) for decreasing elevated oxidative stress and increasing physical endurance in individuals with ryanodine receptor 1-related myopathies (RYR1-RM).
Methods:
In this 6-month natural history assessment (n = 37) followed by a randomized, double-blinded, placebo-controlled trial, 33 eligible participants were block-randomized (1:1) to receive NAC (n = 16) or placebo (n = 17), orally for 6 months (adult dose 2,700 mg/d; pediatric dose 30 mg/kg/d). The primary endpoint was urine 15-F2t isoprostane concentration and the clinically meaningful co-primary endpoint was 6-minute walk test (6MWT) distance.
Results:
When compared to the general population, participants had elevated baseline 15-F2t isoprostane concentrations and most had a decreased 6MWT distance (mean ± SD 3.2 ± 1.5 vs 1.1 ± 1.7 ng/mg creatinine and 468 ± 134 vs 600 ± 58 m, respectively, both p < 0.001). 15-F2t isoprostane concentration and 6MWT distance did not change over the 6-month natural history assessment (p = 0.98 and p = 0.61, respectively). NAC treatment did not improve 15-F2t isoprostane concentration (least squares means difference 0.1 [95% confidence interval [CI] -1.4 to 1.6] ng/mg creatinine, p = 0.88) or 6MWT distance (least squares means difference 24 [95% CI -5.5 to 53.4] m, p = 0.11). NAC was safe and well-tolerated at the doses administered in this study.
Conclusion:
In ambulatory RYR1-RM-affected individuals, we observed stable disease course, and corroborated preclinical reports of elevated oxidative stress and decreased physical endurance. NAC treatment did not decrease elevated oxidative stress, as measured by 15-F2t isoprostane.
Classification Of Evidence:
This study provides Class I evidence that, for people with RYR1-RM, treatment with oral NAC does not decrease oxidative stress as measured by 15-F2t isoprostane.
Clinicaltrialsgov Identifier:
NCT02362425.
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