Three-period Crossover Research Articles

A Phase 1, Randomized, Open-label, Three-period Crossover Study to Evaluate Pharmacokinetics, Dose Proportionality, and Safety After Single Intranasal Administration of Diazepam Nasal Spray (NRL-1) in Healthy Japanese Participants

A Phase 1, Randomized, Open-label, Three-period Crossover Study to Evaluate Pharmacokinetics, Dose Proportionality, and Safety After Single Intranasal Administration of Diazepam Nasal Spray (NRL-1) in Healthy Japanese Participants

Pharmacokinetic and pharmacodynamic bioequivalence of Gan & Lee insulin analogues aspart (rapilin®), lispro (prandilin®) and glargine (basalin®) with EU- und US-sourced reference insulins.

For the successful approval and clinical prescription of insulin biosimilars, it is essential to show pharmacokinetic (PK) and pharmacodynamic (PD) bioequivalence to the respective reference products sourced from the European Union and the United States. Three phase 1, randomized, double-blind, three-period crossover trials compared single doses of the proposed biosimilar insulin analogues aspart (GL-Asp, n = 36), lispro (GL-Lis, n = 38) and glargine (GL-Gla, n = 113), all manufactured by Gan & Lee pharmaceuticals, to the respective EU- and US-reference products in healthy male participants (GL-Asp and GL-Lis) or people with type 1 diabetes (GL-Gla). Study participants received 0.2 U/kg (aspart and lispro) or 0.5 U/kg (glargine) of each treatment under automated euglycaemic clamp conditions. The clamp duration was 12 h (aspart and lispro) or 30 h (glargine). Primary PK endpoints were the total area under the PK curves (AUCins.total ) and maximum insulin concentrations (Cins.max ). Primary PD endpoints were the total area under the glucose infusion rate curve (AUCGIR.total ) and maximum glucose infusion rate (GIRmax ). Bioequivalence to both EU- and US-reference products were shown for all three GL insulins. Least squares mean ratios for the primary PK/PD endpoints were close to 100%, and both 90% and 95% confidence intervals were within 80%-125% in all three studies. There were no noticeable differences in the safety profiles between test and reference insulins, and no serious adverse events were reported for the GL insulins. GL-Asp, GL-Lis and GL-Gla are bioequivalent to their EU- and US-reference products.

Effectiveness of a multimodal intervention and the simulation flow to improve empathy and attitudes towards older adults in nursing students: A crossover randomised controlled trial

AimThe aims of this study were (1) to develop a multimodal intervention according to the NLN Jeffries Simulation Theory planned to improve attitudes and empathy towards older adults in undergraduate nursing students using theoretical contents, age simulation suits, and storytelling of old participants, and (2) to evaluate the influence of the simulation flow on the effectiveness of this intervention in improving attitudes and empathy towards older adults. BackgroundThe increase in longevity in recent decades has led to an increase in the demand for professionals linked to the care of the older adults. Some studies indicate that health care professionals lack empathy and understanding toward older adults. Therefore, it is essential to introduce innovative teaching strategies to improve attitudes and empathy toward older adults in future health professionals. DesignA crossover randomised controlled trial. MethodsA three-period crossover randomised controlled trial with an experimental group, a control group (that transitions to a delayed experimental group) was conducted on 70 nursing students after the initial 73 were allocated. A multimodal intervention was used that, in addition to geriatric nursing theory, incorporated complex age simulation suit and student-older adult interaction. Pre-test and post-test data were obtained through the Jefferson Scale of Empathy and Kogan’s Attitudes towards Older People Scale. Thus, students in the experimental group 1 received the following simulation flow: Geriatric Nursing Theory + Seminar with age simulation suit + student-older adult interaction. The students in the delayed experimental group 2 received this order: Geriatric Nursing Theory +Seminar without Age simulation suit + student-older adult interaction + Age simulation suit. ResultsStatistically significant differences were observed in both empathy (t = 3.155, p = 0.001, d = 0.782), and attitudes (t=3.256, p=0.001, d=0.803) when comparing control group scores (who only received the theoretical contents of the seminar) and experimental group 1 scores after receiving the full multimodal simulation (i.e. a seminar wearing an age simulation suit + volunteer interaction with an older adult). Regarding the order of educational strategies in the simulation flow, there were significant differences in the empathy scores found when both groups had received the full intervention. Accordingly, training with age simulation suits followed by storytelling provides better scores in empathy than in the opposite direction (t = 2.028, p = 0.048, d = 0.54). ConclusionsThe use of a multimodal intervention, implementing an age simulation suit and the narration of an older adult's life experiences (in this order), improves attitudes and empathy.

Effects of Diets Enriched with Conventional or High-Oleic Canola Oils on Vascular Endothelial Function: A Sub-Study of the Canola Oil Multi-Centre Intervention Trial 2 (COMIT-2), a Randomized Crossover Controlled Feeding Study.

Partial replacement of saturated fatty acids (SFA) with unsaturated fatty acids is recommended to reduce cardiovascular disease (CVD) risk. Monounsaturated fatty acids (MUFA), including oleic acid, are associated with lower CVD risk. Measurement of flow-mediated dilation of the brachial artery (FMD) is the gold standard for measuring endothelial function and predicts CVD risk. This study examined the effect of partially replacing SFA with MUFA from conventional canola oil and high-oleic acid canola oil on FMD. Participants (n = 31) with an elevated waist circumference plus ≥1 additional metabolic syndrome criterion completed FMD measures as part of the Canola Oil Multi-Centre Intervention Trial 2 (COMIT-2), a multi-center, double-blind, three-period crossover, controlled feeding randomized trial. Diet periods were 6 weeks, separated by ≥4-week washouts. Experimental diets were provided during all feeding periods. Diets only differed by the fatty acid profile of the oils: canola oil (CO; 17.5% energy from MUFA, 9.2% polyunsaturated fatty acids (PUFA), 6.6% SFA), high-oleic acid canola oil (HOCO; 19.1% MUFA, 7.0% PUFA, 6.4% SFA), and a control oil blend (CON; 11% MUFA, 10% PUFA, 12% SFA). Multilevel models were used to examine the effect of the diets on FMD. No significant between-diet differences were observed for average brachial artery diameter (CO: 6.70 ± 0.15 mm, HOCO: 6.57 ± 0.15 mm, CON: 6.73 ± 0.14 mm; p = 0.72), peak brachial artery diameter (CO: 7.11 ± 0.15 mm, HOCO: 7.02 ± 0.15 mm, CON: 6.41 ± 0.48 mm; p = 0.80), or FMD (CO: 6.32 ± 0.51%, HOCO: 6.96 ± 0.49%, CON: 6.41 ± 0.48%; p = 0.81). Partial replacement of SFA with MUFA from CO and HOCO had no effect on FMD in participants with or at risk of metabolic syndrome.

Effect of single doses of citalopram and reboxetine on urethral pressure: A randomized, double-blind, placebo- and active-controlled three-period crossover study in healthy women.

AimsUrethral closure function is essential for urinary continence in women and decreased urethral pressure is associated with stress urinary incontinence (SUI). For decades, the effects of serotonergic drugs on central neural control of urethral closure have been investigated and discussed. Epidemiological studies suggest that the use of selective serotonin reuptake inhibitors (SSRIs), such as citalopram, is associated with SUI. However, the literature findings are conflicting. This study aimed to evaluate citalopram's effect on opening urethral pressure (OUP) in healthy women.MethodsWe conducted a randomized, double‐blind, placebo‐ and active‐controlled crossover study in 24 healthy women. On three study days, which were separated by 8 days of washout, the subjects received single doses of either 40 mg citalopram (and placeboreboxetine), 8 mg reboxetine (and placebocitalopram), or two placebos. Study drugs were administered at a 1‐h interval due to a difference in estimated time to peak plasma concentration (t max). We measured OUP with urethral pressure reflectometry under both resting and squeezing conditions of the pelvic floor at estimated t max for both study drugs (one timepoint).ResultsCompared to placebo, citalopram increased OUP by 6.6 cmH20 (95% confidence interval [CI] 0.04–13.1, p = 0.048) in resting condition. In squeezing condition, OUP increased by 7.1 cmH20 (95% CI: 1.3–12.9, p = 0.01). Reboxetine increased OUP by 30.0 cmH20 in resting condition compared to placebo (95% CI: 23.5–36.5, p < 0.001), and 27.0 cmH20 (95% CI: 21.2–32.8, p < 0.001) in squeezing condition.ConclusionCitalopram increased OUP slightly compared to placebo suggesting that SSRI treatment does not induce or aggravate SUI.

Acetylcysteine has No Mechanistic Effect in Patients at Risk of Contrast-Induced Nephropathy: A Failure of Academic Clinical Science.

Contrast‐induced nephropathy (CIN) is a major complication of imaging in patients with chronic kidney disease (CKD). The publication of an academic randomized controlled trial (RCT; n = 83) reporting oral (N)‐acetylcysteine (NAC) to reduce CIN led to > 70 clinical trials, 23 systematic reviews, and 2 large RCTs showing no benefit. However, no mechanistic studies were conducted to determine how NAC might work; proposed mechanisms included renal artery vasodilatation and antioxidant boosting. We evaluated the proposed mechanisms of NAC action in participants with healthy and diseased kidneys. Four substudies were performed. Two randomized, double‐blind, placebo‐controlled, three‐period crossover studies (n = 8) assessed the effect of oral and intravenous (i.v.) NAC in healthy kidneys in the presence/absence of iso‐osmolar contrast (iodixanol). A third crossover study in patients with CKD stage III (CKD3) (n = 8) assessed the effect of oral and i.v. NAC without contrast. A three‐arm randomized, double‐blind, placebo‐controlled parallel‐group study, recruiting patients with CKD3 (n = 66) undergoing coronary angiography, assessed the effect of oral and i.v. NAC in the presence of contrast. We recorded systemic (blood pressure and heart rate) and renal (renal blood flow (RBF) and glomerular filtration rate (GFR)) hemodynamics, and antioxidant status, plus biomarkers of renal injury in patients with CKD3 undergoing angiography. Primary outcome for all studies was RBF over 8 hours after the start of i.v. NAC/placebo. NAC at doses used in previous trials of renal prophylaxis was essentially undetectable in plasma after oral administration. In healthy volunteers, i.v. NAC, but not oral NAC, increased blood pressure (mean area under the curve (AUC) mean arterial pressure (MAP): mean difference 29 h⋅mmHg, P = 0.019 vs. placebo), heart rate (28 h⋅bpm, P < 0.001), and RBF (714 h⋅mL/min, 8.0% increase, P = 0.006). Renal vasodilatation also occurred in the presence of contrast (RBF 917 h⋅mL/min, 12% increase, P = 0.005). In patients with CKD3 without contrast, only a rise in heart rate (34 h⋅bpm, P = 0.010) and RBF (288 h⋅mL/min, 6.0% increase, P = 0.001) occurred with i.v. NAC, with no significant effect on blood pressure (MAP rise 26 h⋅mmHg, P = 0.156). Oral NAC showed no effect. In patients with CKD3 receiving contrast, i.v. NAC increased blood pressure (MAP rise 52 h⋅mmHg, P = 0.008) but had no effect on RBF (151 h⋅mL/min, 3.0% increase, P = 0.470), GFR (29 h⋅mL/min/1.73m², P = 0.122), or markers of renal injury. Neither i.v. nor oral NAC affected plasma antioxidant status. We found oral NAC to be poorly absorbed and have no reno‐protective effects. Intravenous, not oral, NAC caused renal artery vasodilatation in healthy volunteers but offered no protection to patients with CKD3 at risk of CIN. These findings emphasize the importance of mechanistic clinical studies before progressing to RCTs for novel interventions. Thousands were recruited to academic clinical trials without the necessary mechanistic studies being performed to confirm the approach had any chance of working.

Comparative acceptability of mini-tablets, fine granules, and liquid formulations in young children: An exploratory randomized crossover study

Age-appropriate paediatric formulations are needed to achieve optimal medication adherence in children. In Europe and the United States, the acceptability of mini-tablets was compared to that of liquid formulations, which are commonly used as paediatric formulations. In Japan, fine granules are also commonly administered to children. This study was performed to examine the acceptability of mini-tablets, fine granules, and liquid formulations by children. This prospective, single-centre, three-period crossover, randomised controlled trial included children aged 2–8 years who were visiting a paediatric department in Showa University Hospital and had experience in taking medicine. The primary endpoint was the measure of acceptability by observation of healthcare professionals according to pre-defined evaluation criteria. Sixty-five subjects including low-aged (2–<4 years, n = 12), mid-aged (4–<7 years, n = 29), and high-aged (7–<9 years, n = 24) children were enrolled. Most subjects accepted all formulations, although mini-tablets showed lower swallowability compared to fine granules and liquid formulations. Fine granules and liquid formulations showed good acceptability and swallowability, and mini-tablets were accepted by Japanese children, although the swallowability was lower, likely because children tend to chew on mini-tablets.

Supplementation of exogenous β-mannanase to low-protein diets improves feed conversion efficiency in lactating dairy cows

Context Supplementation of exogenous enzymes has been used to improve nutrient utilisation and reduce environmental impacts of excess nutrient release to the environment in swine, poultry and, to a lesser extent, ruminant production systems. Aims We aimed to determine effects of supplementation with a fibrolytic enzyme, β-mannanase, on feed conversion efficiency (FCE) and milk yield in cows fed a diet relatively low in crude protein (CP) concentration. Methods Twelve mid-lactation multiparous Holstein cows producing 40.5 ± 3.6 kg milk/day were assigned to three dietary treatments in a three-period crossover design. Treatment sequences were balanced using 3 × 3 Latin squares to mitigate possible carryover effects. Treatments, fed in a total mixed ration, were high CP (16.1%), low CP (14.6%), and low CP supplemented with commercially available β-mannanase at 0.1% of concentrate dry matter (DM). Key results β-Mannanase supplementation did not affect DM intake, milk yield, or milk component yield and composition. Milk urea-nitrogen was significantly lower in cows fed diets with low CP. Somatic cell counts were reduced in cows supplemented with β-mannanase compared with the other treatments. Apparent total tract digestibilities of DM, organic matter, CP, acid and neutral detergent fibre, starch and ash were unaffected by treatment. Cows receiving β-mannanase showed better FCE than those receiving high CP (13.4% improvement, P = 0.003) or unsupplemented low CP (11.0% improvement). Cows receiving β-mannanase used dietary CP more efficiently to synthesise milk protein than cows receiving high CP (milk protein:CP intake, 0.34 vs 0.30). Nitrogen intake was significantly reduced in the low CP treatments, leading to reduced fecal and urinary nitrogen excretions. Conclusion β-Mannanase supplementation at 0.1% of dietary DM improved FCE and lowered somatic cell counts of dairy cows without affecting milk yield or component yield and composition, while reducing nitrogen excretion. There were potential daily savings of US$1.03/cow compared with a high CP diet. Implications Improvement in FCE can be achieved along with reduced dietary CP content and somatic cell counts without compromising milk production through use of β-mannanase, suggesting a potential economic benefit. Furthermore, reductions in nitrogen excretions with low CP diets are beneficial to the environment.

PTC923 (sepiapterin) lowers elevated blood phenylalanine in subjects with phenylketonuria: a phase 2 randomized, multi-center, three-period crossover, open-label, active controlled, all-comers study

Background & aimPTC923 (formerly CNSA-001), an oral formulation of sepiapterin, a natural precursor of intracellular tetrahydrobiopterin (BH4), has been shown in humans to induce larger increases in circulating BH4 vs. sapropterin dihydrochloride. Sapropterin reduces blood phenylalanine (Phe) by ≥20–30% in a minority of subjects with PKU. This was a Phase 2 randomized, multicenter, three-period crossover, open-label, active controlled, all-comers [regardless of phenylalanine hydroxylase (PAH) variants] comparison of PTC923 60 mg/kg, PTC923 20 mg/kg and sapropterin 20 mg/kg in 24 adults with phenylketonuria (PKU) and hyperphenylalaninemia. MethodsEligible subjects were adult men or women (18–60 y) with PKU. Subjects enrolled received 7 days of once-daily oral treatment with PTC923 20 mg/kg/day, PTC923 60 mg/kg/day and sapropterin dihydrochloride 20 mg/kg/day each in a random order. Treatments were separated by a 7-day washout. Subjects maintained their usual pre-study diet, including consumption of amino acid mixtures. Blood Phe was measured on Day 1 (predose baseline), Day 3, Day 5, and Day 7 of each treatment period. ResultsLeast squares mean changes (SE) from baseline in blood Phe were: −206.4 (41.8) μmol/L for PTC923 60 mg/kg (p < 0.0001); −146.9 (41.8) μmol/L for PTC923 20 mg/kg (p = 0.0010); and − 91.5 (41.7) μmol/L for sapropterin (p = 0.0339). Effects of PTC923 60 mg/kg on blood Phe vs. sapropterin were significantly larger (p = 0.0098) and faster in onset with a significantly larger mean reduction in blood Phe at day 3 of treatment, p = 0.0135 (20 mg/kg) and p = 0.0007 (60 mg/kg). Only PTC923 60 mg/kg reduced blood Phe in classical PKU subjects (n = 11, p = 0.0287). The mean blood Phe reduction (PTC923 60 mg/kg) in a cofactor responder analysis (n = 8; baseline Phe ≥300 μmol/L and blood Phe reduction ≥30%) was −463.3 μmol/L (SE 51.5) from baseline. Adverse events were mostly mild to moderate, transient, and similar across treatment groups with no serious adverse events or discontinuations. ConclusionsThe substantially significantly better effect of PTC923 60 mg/kg on blood Phe reduction vs. sapropterin supports further clinical development of PTC923 for PKU; ANZCTR number, ACTRN12618001031257.

Pharmacokinetic Characterisation and Comparison of Bioavailability of Intranasal Fentanyl, Transmucosal, and Intravenous Administration through a Three-Way Crossover Study in 24 Healthy Volunteers.

Background For more than 60 years, the synthetic opioid fentanyl has been widely used in anaesthesia and analgesia. While the intravenous formulation is primarily used for general anaesthesia and intensive care settings, the drug's high lipophilic properties also allow various noninvasive routes of administration. Published data suggest that intranasal administration is also attractive for use as intranasal patient-controlled analgesia (PCA). A newly developed intranasal fentanyl formulation containing 47 μg fentanyl, intravenous fentanyl, and oral transmucosal fentanyl citrate were characterised, and bioavailability was compared to assess the suitability of the intranasal formulation for an intranasal PCA product. Methods 27 healthy volunteers were enrolled in a single-centre, open-label, randomised (order of treatments), single-dose study in a three-period crossover design. The pharmacokinetics of one intranasal puff of fentanyl formulation (47 μg, 140 mL per puff), one short intravenous infusion of 50 μg fentanyl, and one lozenge with an integrated applicator (200 μg fentanyl) were studied, and bioavailability was calculated. Blood samples were collected over 12 hours, and plasma concentrations of fentanyl were determined by HPLC with MS/MS detection. Results 24 volunteers completed the study. The geometric mean of AUC0-tlast was the highest with oral transmucosal administration (1106 h ∗ pg/ml, CV% = 32.86), followed by intravenous (672 h ∗ pg/ml, CV% = 32.18) and intranasal administration (515 h ∗ pg/ml, CV% = 30.10). Cmax was 886 pg/ml (CV% = 59.38) for intravenous, 338 pg/ml (CV% = 45.61) for intranasal, and 310 pg/ml (CV% = 29.58) for oral transmucosal administration. tmax was shortest for intravenous administration (0.06 h, SD = 0.056), followed by intranasal (0.21 h, SD = 0.078) and oral transmucosal administration (1.20 h, SD = 0.763). Dose-adjusted absolute bioavailability was determined to be 74.70% for the intranasal formulation and 41.25% for the oral transmucosal product. In total, 38 adverse events (AEs) occurred. Fourteen AEs were potentially related to the investigational items. No serious AE occurred. Conclusion Pharmacokinetic parameters and bioavailability of the investigated intranasal fentanyl indicated suitability for its intended use as an intranasal PCA option.

Reliability of mechanical ventilation during continuous chest compressions: a crossover study of transport ventilators in a human cadaver model of CPR

BackgroundPrevious studies have stated that hyperventilation often occurs in cardiopulmonary resuscitation (CPR) mainly due to excessive ventilation frequencies, especially when a manual valve bag is used. Transport ventilators may provide mandatory ventilation with predetermined tidal volumes and without the risk of hyperventilation. Nonetheless, interactions between chest compressions and ventilations are likely to occur. We investigated whether transport ventilators can provide adequate alveolar ventilation during continuous chest compression in adult CPR.MethodsA three-period crossover study with three common transport ventilators in a cadaver model of CPR was carried out. The three ventilators ‘MEDUMAT Standard²’, ‘Oxylog 3000 plus’, and ‘Monnal T60’ represent three different interventions, providing volume-controlled continuous mandatory ventilation (VC-CMV) via an endotracheal tube with a tidal volume of 6 mL/kg predicted body weight. Proximal airflow was measured, and the net tidal volume was derived for each respiratory cycle. The deviation from the predetermined tidal volume was calculated and analysed. Several mixed linear models were calculated with the cadaver as a random factor and ventilator, height, sex, crossover period and incremental number of each ventilation within the period as covariates to evaluate differences between ventilators.ResultsOverall median deviation of net tidal volume from predetermined tidal volume was − 21.2 % (IQR: 19.6, range: [− 87.9 %; 25.8 %]) corresponding to a tidal volume of 4.75 mL/kg predicted body weight (IQR: 1.2, range: [0.7; 7.6]). In a mixed linear model, the ventilator model, the crossover period, and the cadaver’s height were significant factors for decreased tidal volume. The estimated effects of tidal volume deviation for each ventilator were − 14.5 % [95 %-CI: −22.5; −6.5] (p = 0.0004) for ‘Monnal T60’, − 30.6 % [95 %-CI: −38.6; −22.6] (p < 0.0001) for ‘Oxylog 3000 plus’ and − 31.0 % [95 %-CI: −38.9; −23.0] (p < 0.0001) for ‘MEDUMAT Standard²’.ConclusionsAll investigated transport ventilators were able to provide alveolar ventilation even though chest compressions considerably decreased tidal volumes. Our results support the concept of using ventilators to avoid excessive ventilatory rates in CPR. This experimental study suggests that healthcare professionals should carefully monitor actual tidal volumes to recognise the occurrence of hypoventilation during continuous chest compressions.

Effects of protein supplementation to steers consuming low-quality forages on greenhouse gas emissions

Providing supplements that enhance the efficiency of feed utilization can reduce methane (CH4) emissions from ruminants. Protein supplementation is widely used to increase intake and digestion of low-quality forages, yet little is known about its impact on CH4 emissions. British-cross steers (n = 23; initial body weight [BW] = 344 ± 33.9 kg) were used in a three-period crossover design to evaluate the effect of protein supplementation to beef cattle consuming low-quality forage on ruminal CH4, metabolic carbon dioxide (CO2) emissions, forage intake, and ruminal fermentation. Steers individually had ad libitum access to low-quality bluestem hay (4.6% crude protein [CP]) and were provided supplemental protein based on (dry matter basis): cottonseed meal (CSM; 0.29% of BW daily; 391 g/d CP), dried distillers grains with solubles (DDGS; 0.41% of BW daily 563 g/d CP), or none (CON). Urea was added to DDGS to match rumen degradable protein provided by CSM. Ruminal CH4 and metabolic CO2 fluxes were obtained 2.4 ± 0.4 times per steer daily using an automated open-circuit gas quantification system (GreenFeed emission monitoring system; C-Lock Inc., Rapid City, SD). Forage intake increased (P < 0.01) with protein supplementation; however, no difference in forage intake (P = 0.14) was observed between CSM and DDGS treatments. Flux of CO2 (g/d) was greater (P < 0.01) for steers fed CSM and DDGS than for steers fed CON. Steers supplemented with CSM had greater (P < 0.01) CH4 emissions (211 g/d) than DDGS (197 g/d) both of which were greater (P < 0.01) than CON (175 g/d). Methane emissions as a proportion of gross energy intake (GEI) were lowest (P < 0.01) for DDGS (7.66%), intermediate for CSM (8.46%) steers, and greatest for CON (10.53%). Steers fed DDGS also had the lowest (P < 0.01) ruminal acetate:propionate ratio (3.60), whereas CSM (4.89) was intermediate, and CON (5.64) steers were greatest. This study suggests that the common practice of supplementing protein to cattle consuming low-quality forage decreases greenhouse gas emissions per unit of GEI.

Acarbose bioequivalence: Exploration of eligible protocol design.

Acarbose is a poorly absorbed α-glucosidase inhibitor that acts locally in the intestinal tract. Therefore, the evaluation of its bioequivalence (BE) should be based on pharmacodynamic (PD) rather than pharmacokinetic (PK) endpoints. Currently, there is no consensus on the best method for acarbose BE evaluation. The optimal protocol design regarding dosing time/dose and PD parameters requires further exploration. The aim of the study was to identify an optimum protocol for establishing acarbose BE in healthy Chinese volunteers using PD endpoints. Three pilot studies were conducted in healthy Chinese subjects. Study 1 was an open, randomized, two-period crossover study using the reference (R) drug at the dose of 1×50mg. Study 1 aimed to determine appropriate dosing time by comparing the PD effect of acarbose between two administration methods. One method was concomitant administration of sucrose and acarbose, and another method was acarbose administration 10min before sucrose. Study 2 was an open, randomized, three-period crossover study. Subjects were given the R drug at the dose of 1×50mg, 2×50mg or 3×50mg in a random sequence. The aim of Study 2 was to identify a reasonable dose of acarbose in the BE study. Study 3 was conducted with an open, randomized, three-period crossover design using the test (T) or R drug in an R-T-R sequence at the dose of 2×50mg. Study 3 aimed to compare the BE between the R and T drug and determine intra-individual variation. Twelve subjects were recruited in Study 1, Study 2 and Study 3, respectively, with a one-week washout period. Serum glucose and insulin concentrations were determined after sucrose administration (baseline) and sucrose/acarbose co-administration. In Study 1, no significant differences in PD parameters were found between the two administration methods. The results of Study 2 revealed that the optimal dose was between 1×50mg and 2×50mg. The comparison of PD parameters indicated that the rectifying method could distinguish between different formulations. Study 3 showed that the geometric mean ratios of Cmax, r , AUC0-2 h, r and AUC0-4 h, r were 90.06%, 84.55% and 84.21%, respectively, using the rectifying method. The 90% CIs of Cmax, r were within acceptance limits (80.00%-125.00%), whereas that of AUC0-2 h, r and AUC0-4 h, r were out of the range. The intra-individual variation was approximately 21% for R formulation. Based on the variation, the number of subjects needed to identify formulation differences in the pivotal study would be 55 with 90% power at the 5% level of significance. The results from our study manifested that a randomized, balanced, two-way crossover design was eligible to evaluate acarbose BE. The appropriate dosing time was concomitant administration of sucrose and acarbose, and the optimal dose was 2×50mg. The rectifying method exhibited preferable sensitivity and applicability in acarbose BE evaluation. A practical sample size of the pivotal study would be 55. These results may help to provide new insights into the protocol design of acarbose BE study.

Adaptive two-treatment three-period crossover design for normal responses

In adaptive crossover design, our goal is to allocate more patients to a promising treatment sequence. The present work contains a very simple three period crossover design for two competing treatments where the allocation in period 3 is done on the basis of the data obtained from the first two periods. Assuming normality of response variables we use a reliability functional for the choice between two treatments. We calculate the allocation proportions and their standard errors corresponding to the possible treatment combinations. We also derive some asymptotic results and provide solutions on related inferential problems. Moreover, the proposed procedure is compared with a possible competitor. Finally, we use a data set to illustrate the applicability of the proposed design.

Agreement Among Paper and Electronic Modes of the EQ-5D-5L.

IntroductionWhile the EQ-5D-5L has been migrated to several electronic modes, evidence supporting the measurement equivalence of the original paper-based instrument to the electronic modes is limited.ObjectivesThis study was designed to comprehensively examine the equivalence of the paper and electronic modes (i.e., handheld, tablet, interactive voice response [IVR], and web).MethodsAs part of the foundational work for this study, the test–retest reliability of the paper-based, UK English format of the EQ-5D-5L was assessed using a single-group, single-visit, two-period, repeated-measures design. To compare paper and electronic modes, three independent samples were recruited into a three-period crossover study. Each participant was assigned to one of six groups to account for order effects. Descriptive statistics, mean differences (i.e., split-plot analysis of variance [ANOVA]), and intraclass correlation coefficients (ICCs) were calculated.ResultsThe test–retest results showed mean differences near zero and ICC values > 0.90 for both the index and the EQ VAS scores. For the electronic comparisons, mean difference confidence intervals (CIs) for the EQ-5D index scores and EQ VAS scores reflected equivalence of the means across all modes, as the CIs were wholly contained inside the equivalence interval. Further, the ICC 95% lower CIs for the index and EQ VAS scores showed values above the thresholds for denoting equivalence across all comparisons in each sample. No significant mode-by-order interactions were present in any ANOVA model.ConclusionsOverall, our comparisons of the paper, screen-based, and phone-based formats of the EQ-5D-5L provided substantial evidence to support the measurement equivalence of these modes of data collection.

Effect of procyanidin on dietary iron absorption in hereditary hemochromatosis and in dysmetabolic iron overload syndrome: A crossover double-blind randomized controlled trial

Type I hereditary hemochromatosis (HH) and dysmetabolic iron overload syndrome (DIOS) are the two most prevalent iron overload diseases. Although many food components, particularly polyphenols, reduce iron bioavailability, there is no clinically validated nutritional strategy to reduce food-iron absorption in patients with these diseases. We aimed to determine whether supplementation with 100mg of procyanidins during a meal reduces dietary iron absorption in patients with HH or DIOS. 20 HH and 20 DIOS patients were enrolled in a double-blind three-period crossover randomized study. Basal serum iron level was measured following an overnight fast. Each patient consumed a standardized test iron-rich meal containing 43mg of iron with two capsules of placebo or procyanidin supplementation. Each period was separated by a 3-day wash-out period. The primary objective was a reduction of dietary iron absorption, assessed by a reduction of serum-iron area under the curve (AUC) corrected for baseline serum iron. All patients completed the study. The meal and the procyanidin supplements were well tolerated. In both HH and DIOS patients, the iron-rich meal induced a significant increase of serum iron compared with baseline at 120, 180, 240min, from 8 to 9.1% (p=0.002, 0.001 and 0.003, respectively) in DIOS and from 15.8 to 25.7% (p<0.001) in HH. Iron absorption was 3.5-fold higher in HH than in DIOS (p<0.001). Procyanidin supplementation did not significantly modify iron absorption in DIOS (AUC of added iron 332.87±649.55 vs 312.61±678.61μmol.h/L, p=0.916) or in HH (1168.62±652.87 vs 1148.54μmol.h/L±1290.05, p=0.917). An iron-rich test meal led to a marked increase in iron absorption in HH but a mild increase in DIOS. Procyanidin supplementation does not significantly reduce dietary iron absorption in either disease. CLINICAL TRIAL REGISTRY: clinicaltrials.gov (NCT03453918).

Effect of timing of levothyroxine administration on the treatment of hypothyroidism: a three-period crossover randomized study.

Hypothyroidism is a common clinical problem that is successfully treated with hormone substitutes in the form of levothyroxine (LT4). LT4 is a drug with a narrow therapeutic index and is usually administered by strict rules, standardly at least half an hour before breakfast. The aim of this study was to investigate a possible effect of different timings of administration on thyroid function status and lipid profile. The study included patients with the diagnosis of primary hypothyroidism, which were using a stable dose of levothyroxine. They were randomized into three different groups regarding the timing of LT4 administration in a crossover fashion. Each timing regimen lasted for at least 8 weeks; timing regimen A-half an hour before breakfast; timing regimen B-an hour before the main meal of the day; timing regimen C-at bedtime (minimally 2 h after dinner). The hormones (TSH, fT3, fT4) and lipid profile (triglycerides, HDL-, LDL-, and total cholesterol) were measured before the study, at the beginning of every timing regimen and at the end of the study. Altogether, 84 patients finished the study. Different timings of LT4 administration were non-inferior in comparison to the standard one and between each other. Median differences in TSH level between baseline and timing regimens were: baseline vs. A = -0.017 95% C.I. (-0.400-0.192); baseline vs. B = -0.325 95% C.I. (-0.562-0.023); baseline vs. C = -0.260 95% C.I. (-0.475-0.000). There were no statistically significant differences in either TSH, fT4, or fT3 when compared between all three timing regimens of LT4 administration and the baseline. There were no statistically significant differences in any of the lipid profile parameters (triglycerides, HDL-, LDL-, and total cholesterol) when compared between all three timing regimens of LT4 administration and the baseline. The three investigated timing regimens of LT4 administration were equally efficient and offer additional options regarding the treatment individualization.

The effects of alcohol on plasma lipid mediators of inflammation resolution in patients with Type 2 diabetes mellitus

BackgroundType 2 diabetes mellitus is characterized by peripheral insulin resistance and low-grade systemic inflammation. Inflammation resolution is recognised as an important process driven by specialised pro-resolving mediators of inflammation (SPMs) and has the potential to moderate chronic inflammation. Alcohol has the potential to affect synthesis of SPMs by altering key enzymes involved in SPM synthesis and may influence ongoing inflammation associated with Type 2 diabetes mellitus. Aims(i) To examine the effects of alcohol consumed as red wine on plasma SPM in men and women with Type 2 diabetes in a randomised controlled trial and (ii) compare baseline plasma SPM levels in the same patients with those of healthy volunteers. MethodsTwenty-four patients with Type 2 diabetes mellitus were randomized to a three-period crossover study with men drinking red wine 300 ml/day (∼31 g alcohol/day) and women drinking red wine 230 ml/day (∼24 g alcohol/day), or equivalent volumes of dealcoholized red wine (DRW) or water, each for 4 weeks. The SPM 18-hydroxyeicosapentaenoic acid (18-HEPE), E-series resolvins (Rv) (RvE1-RvE3), 17-hydroxydocosahexaenoic acid (17-HDHA), and D-series resolvins (RvD1, 17R-RvD1, RvD2, RvD5), 14-hydroxydocosahexaenoic acid (14-HDHA) and Maresin 1 were measured at the end of each period. A baseline comparison of plasma SPM, hs CRP, lipids and glucose was made with healthy volunteers. ResultsRed wine did not differentially affect any of the SPM measured when compared with DRW or water. Baseline levels of the hs-CRP and the SPM 18-HEPE, 17-HDHA, RvD1 and 17R-RvD1 in patients with Type 2 diabetes mellitus were all significantly elevated compared with healthy controls and remained so after adjusting for age and gender. ConclusionModerate alcohol consumption as red wine does not alter plasma SPM in patients with Type 2 diabetes mellitus. The elevation of SPM levels compared with healthy volunteers may be a homeostatic response to counter ongoing inflammation.

Abstract P382: Canola and High-Oleic Acid Canola Oils Improve Lipid/Lipoprotein Parameters Compared to an Oil Blend Characteristic of a Western Dietary Pattern in Individuals at Risk for Metabolic Syndrome: A Randomized Crossover Clinical Trial

Introduction: Identifying dietary interventions for cardiometabolic disease prevention in individuals with metabolic syndrome is relevant to a significant portion of the population. Numerous studies have investigated the effects of canola oil on cardiovascular disease risk; however, no studies have compared canola oil diets to a control diet with a fatty acid composition characteristic of Western intakes in individuals with metabolic syndrome risk factors. The objectives of this study were to evaluate effects of canola oil, high-oleic acid canola oil (HOCO), and a control oil (blend of butter, safflower, coconut, and flaxseed oils formulated to represent a Western diet fatty acid profile) on lipids, lipoproteins, and apolipoproteins. Hypothesis: We tested the hypothesis that the two canola oil diets would elicit beneficial effects on the total lipid/lipoprotein profile compared to the Western (control oil) diet. Methods: In a multi-center, double blind, randomized, three-period crossover, controlled feeding clinical trial, 119 individuals with an increased waist circumference plus at least one additional metabolic syndrome risk factor consumed prepared isocaloric, weight maintenance diets containing canola oil [17.5% E from monounsaturated fatty acids (MUFA), 9.2% polyunsaturated fatty acids (PUFA), 6.6% saturated fatty acids (SFA)], HOCO (19.1% E from MUFA, 7.0% PUFA, 6.4% SFA), or control oil (11% E from MUFA, 10% PUFA, 12% SFA) for six-weeks each separated by 4-12 week washouts. The differences at the end of 42 days of feeding were tested. Results: The canola oil and HOCO resulted in lower endpoint total cholesterol (TC), low-density lipoprotein-cholesterol (LDL-C), the TC: high-density lipoprotein-cholesterol (HDL-C) ratio, apolipoprotein (apo) B, the apoB: apoA1 ratio, and non-HDL-C compared to control oil ( P &lt;0.0001 for treatment effect), with no differences between HOCO and canola oil for these parameters. Endpoint apoA1 did not significantly differ between the two canola oils and control, but was higher after the HOCO compared to canola oil (1.46 ± 0.02 g/L vs. 1.43 ± 0.02 g/L, P = 0.0462). There were no differences among the three diets in endpoint triglycerides or HDL-C. Conclusions: Incorporating canola or high-oleic acid canola oils into the diet improves blood lipids and lipoproteins compared to a contemporary Western diet in individuals with at least two criteria for metabolic syndrome.

Dose-dependent quantitative effects of acute fructose administration on hepatic de novo lipogenesis in healthy humans.

Fructose feeding increases hepatic de novo lipogenesis (DNL) and is associated with nonalcoholic fatty liver disease. Little is known, however, about individual variation in susceptibility to fructose stimulation of DNL. In this three-period crossover study, 17 healthy male subjects were enrolled to evaluate the within- and between-subject variability of acute fructose feeding on hepatic fractional DNL. During each assessment, [1-13C1]acetate was infused to measure DNL in the fasting state and during fructose feeding. Subjects randomly received a high dose of fructose (10 mg·kg fat-free mass-1·min-1) on two occasions and a low dose (5 mg·kg fat-free mass-1·min-1) on another. Fructose solutions were administered orally every 30 min for 9.5 h. Ten subjects completed all three study periods. DNL was assessed as the fractional contribution of newly synthesized palmitate into very-low-density lipoprotein triglycerides using mass isotopomer distribution analysis. Mean fasting DNL was 5.3 ± 2.8%, with significant within- and between-subject variability. DNL increased dose dependently during fructose feeding to 15 ± 2% for low- and 29 ± 2% for high-dose fructose. The DNL response to high-dose fructose was very reproducible within an individual ( r = 0.93, P < 0.001) and independent of fasting DNL. However, it was variable between individuals and significantly correlated to influx of unlabeled acetyl-CoA ( r = 0.7, P < 0.001). Unlike fasting DNL, fructose-stimulated DNL is a robust and reproducible measure of hepatic lipogenic activity for a given individual and may be a useful indicator of metabolic disease susceptibility and treatment response.