RESEARCH
Initial evidence of safety and clinical effect of recombinant streptokinase suppository in acute hemorrhoidal disease. Open, proof-of-concept, pilot trial
Evidencia inicial de la seguridad y el efecto clínico del supositorio de estreptoquinasa recombinante en la enfermedad hemorroidal aguda. Estudio piloto, abierto, de prueba de concepto
Liván Quintero1, Francisco Hernández2, Maria Acelia3, Carmen María2, Manuel López1, Silvia Barcelona2, Rafael Ibargollín4, Hailen Bobillo5, Ana Aguilera5, Yilian Bermúdez5, Rolando Páez5, Eduardo Martínez5, Herminia Rodríguez1, Armando Aguiar6, Ramón Ramírez6, Pedro López2, P2 for the THERESA (Treatment of Hemorrhoids with Recombinant Streptokinase Application ) Researchers Group
1 Camilo Cienfuegos University Hospital Bartolomé Massó, Sancti Spíritus
2 Clinical Trials Division, Center for Biological Research, Havana Street 134 / 23 and 25, Playa, PO Box 6332, Havana, Cuba ]]>
3 National Center for the Coordination of Clinical Trials Street 200 / 19 and 21, Allotment Atabey, Playa, CP 11600, Havana, Cuba
4 Center for Genetic Engineering and Biotechology, CIGB Circunvalante norte s/n, Facultad de Ciencias Médicas, Sancti Spíritus
5 Development Direction, Center for Genetic Engineering and Biotechnology, CIGB Ave. 31 / 158 and 190, Cubanacán, Playa, PO Box 6162, Havana, Cuba
6 Enrique Cabrera University Hospital Calzada de Aldabó y Calle E, No. 11117, CP 10800, Havana, Cuba
ABSTRACT
A proof-of-concept, pilot clinical trial was carried out in 2 hospitals, to evaluate the safety of recombinant streptokinase (rSK) administered by the rectal route in patients with acute hemorrhoidal disease (AHD). Suppositories containing 200 000 IU rSK were given every 6 hours, up to 4 applications. The patients, after discharge, were seen daily in follow-up visits up to 10 days. Symptoms, lesion size, edema and inflammation were evaluated. Ten patients were included. The rSK suppository was safe and tolerable. The adverse events reported were minimal (only ardor and anal itching in only one patient), both with minor intensity which did not require treatment, and with low causality relationship of the product since they could be explained by the underlying disease as well. Symptoms disappeared at 24 hours in 7 patients. Complete recovery was achieved in most of the patients (90%) in 5 days. Only one patient needed surgical thrombectomy. rSK suppositories are safe and showed initial efficacy data. It could become a new therapeutic option for hemorrhoidal crisis if results are confirmed in further and controlled studies.
Keywords: streptokinase, thrombolysis, suppository, hemorrhoidal crisis.
RESUMEN
Se realizó un ensayo clínico piloto, prueba de concepto en 2 hospitales, con el objetivo primario de evaluar la seguridad de la estreptoquinasa recombinante administrada por vía rectal en pacientes con enfermedad hemorroidal aguda. Se administraron 4 supositorios de 200 000 IU de rSK distribuidos cada 6 horas. Los pacientes, tras el alta, fueron vistos a diario (en las visitas de seguimiento) hasta 10 días. Se evaluaron los síntomas, el tamaño de la lesión, el edema y la inflamación. Diez pacientes fueron incluidos. El supositorio de rSK fue seguro y tolerable. Fueron mínimos los eventos adversos reportados (sólo ardor y prurito anal en un solo paciente), ambos de intensidad leve, que cedieron espontáneamente y con baja relación de causalidad con el producto objeto de estudio. Los síntomas desaparecieron a las 24 horas en 7 pacientes. Se obtuvo respuesta completa en la mayoría de los pacientes (90%) a los 5 días. Sólo un paciente requirió trombectomía. Los supositorios de rSK son seguros y muestran datos iniciales de eficacia. Podría convertirse en una nueva opción terapéutica para la crisis hemorroidal si los resultados se confirman en sucesivos estudios, controlados, en un mayor número de pacientes.
]]> Palabras clave: estreptoquinasa, trombolisis, supositorio, crisis hemorroidal.
INTRODUCTION
Although the exact incidence of hemorrhoidal disease is unknown, 10% to 25% of the adult population is thought to be affected. Symptoms seem to be more common in older individuals, with a prevalence peak at 45 to 65 years (1). Studies evaluating the epidemiology of hemorrhoids showed that 10 million people in the United States reported hemorrhoids, for a prevalence of 4.4%. In both genders, a peak is noted between 45 and 65 years of age; development of hemorrhoids before the age of 20 is unusual, and Caucasians are affected more frequently than African-Americans (2, 3).
The initial treatment of the hemorrhoidal illness consists of general conservative measures (hygienic- dietetic, life style changes, symptomatic treatment) directed mainly to restore the intestinal habit and to diminish the local symptoms. Although several medicines have been tested for the specific treatment, significant benefits have not been obtained to control this condition (4-8). Therefore, in an important group of patients, the surgical procedure becomes the final solution (9). Management of the hemorrhoidal crisis depends on the intensity of the signs and symptoms and can change in patients with thrombosis, important prolapse or profuse hemorrhage. In such cases, the surgical solution is indicated (hemorrhoidectomy, thrombectomy, ligation, sclerotherapy, infrared photoclotting, cryo and laser therapy) (9-11).
Streptokinase (SK) is an indirect fibrinolytic drug that interacts with plasminogen, forming an active complex with protease action that activates plasminogen into plasmin. The efficacy of SK to reduce the mortality in the acute myocardial infarction has been demonstrated in large clinical trials (12-15) and is currently used for that purpose (16, 17) as well as, other thrombotic diseases (18, 19).
Venous thrombosis have been also treated successfully with thrombolytics (20-23). At the same time, an anti-inflammatory action has been reported for SK, based on lysis of microthrombi, present at the inflammation site. Therefore, the local application of SK on acute hemorrhoid episodes, where inflammation and eventually thrombosis are present, seemed rational. The concept was first tested, in an experimental model for hemorrhoidal disease in rabbits, where illness resolution was evidenced and no SK could be detected in the general circulation (unpublished results). The purpose of this work was to evaluate the safety of this procedure in patients with acute hemorrhoidal disease. The first evidences of efficacy are also reported.
MATERIALS AND METHODS
A pilot clinical trial was carried out in 2 hospitals. Patients older than 18 years-old presenting with acute hemorrhoidal illness, who gave their written informed consent to participate were eligible. Exclusion criteria were SK administration in the previous 6 months, antecedents of intracranial hemorrhage, allergy to SK or salicylates, stroke, intracranial surgery or skull trauma less than 3 months before and any other condition where there is risk of bleeding or it would be difficult to handle because of its location. Patients with hemorrhoidal disease caused by portal hypertension, with septic or active hemorrhagic complications or associated with abscesses, fistula or cancer, were also excluded. The protocol followed the Declaration of Helsinki guidelines and was approved by the Ethics Committees of the participating hospitals and by the Cuban Regulatory Authority.
]]> Recombinant streptokinase was produced in Escherichia coli at the Center for Genetic Engineering and Biotechnology, Havana (24). Suppositories were prepared containing 200 000 IU of rSK, thimerosal, sorbitan monostearate (Span 60), sodium salicylate, and hard fat (Witepsol W25). All patients received them by the rectal route, one every 6 hours up to 4 suppositories. The patients were hospitalized during the first 24 hours and were evaluated 48 hours after discharge and at 10 days follow-up. Concomitant treatment included high-fiber diet, abundant liquid ingestion, rest in decubitus position; local hygiene, sits bath with warm water 3 times per day, and oral analgesics if pain.The aim of the trial was to evaluate the safety of the product, since it was the first-in-man use, so the type, duration, severity, outcome, and causality relationship of the adverse events were carefully registered. A qualitative assessment was used to classify the causal relationship as definite, probable, possible or doubtful (25). The severity of the adverse events was classified upon three levels: (a) mild, if no therapy was necessary, (b) moderate, if specific treatment was needed, and (c) severe, when hospitalization or its prolongation was required, and if the reaction was life-threatening or contributed to patient´s death.
For this purpose, patients were evaluated through interview and physical examination, both general and local, upon arrival, at 24, 48 hours and 10 days post-discharge and at any other moment when adverse events appeared. Adverse reactions known for SK (fever, shakes, tremors, nausea, vomiting, low blood pressure, hemorrhages and allergy), were specially searched. Hemostasis (thrombin time, fibrinogen, and fibrinogen degradation products (FDP)) was checked at 0, 24 and 48 h. The presence of anti-streptokinase antibodies was determined at the beginning and 10 days after discharge using a sandwich type ELISA method previously described (26).
Clinical effect on the illness was evaluated according to pain intensity (measured with a 10-level analogue visual scale), edema (presence or not), and lesion size (larger and smaller diameters). The clinical response was assessed at 48 hours according to the following criteria: a) Complete response: disappearance of pain and edema, and lesion size reduction; b) Partial response: two-level reduction of pain intensity or disappearance of edema, or lesion size reduction; c) No response: if no changes or any worsening occurred. Healing was considered during the 10-day follow-up. A therapeutic failure was given by no response, treatment interruptions, need for any surgical procedure, or not healing at 10 days post-release. The confidence intervals and the probabilities of cure and complete response were estimated using a Bayesian logistic model for fixed effects in WinBUGS14 package.
RESULTS
Ten patients were included, all completed the treatment schedule and 10-day follow-up. Table 1 shows the characteristics of the patients. Most were male (80%), white (80%), 32 to 49 years old, from 1 to 11 days ill. All patients had external hemorrhoids (in one also internal, grade III); 8 of them had anal pain (4 moderate); 8 anal edema; lesion diameters ranged between 0.6 and 3.0 cm. Only 2 patients referred the use of analgesics.
The product was well tolerated. Severe or unexpected adverse events were not reported and there were no withdrawals for this cause. Only 2 adverse events were registered in the same patient. Those were ardor (24 and 48 hours after the treatment) and anal pruritus (10 days after the hospital release), both mild. Their causal relationship with the product under evaluation was doubtful, since both symptoms could be also explained by the underlying illness. There were no alterations of the hemostasis parameters (thrombin time, fibrinogen, and FDP) measured. Anti-SK antibodies titers did not increase significantly with respect to basal values, 10 days after treatment (results not shown).
Clinical evolution is also shown in Table 1. The main initial signs and symptoms were anal discomfort (80%), tenesmus (60%), constipation (50%), anal pruritus (40%), and mass feeling (40%). Ardor and bleeding were present in two and one patient, respectively. At 24 hours after treatment onset, most symptoms had already disappeared. All patients had achieved a response at 48 hours after the beginning of treatment (6 complete), and 9 had healed at the 10-days follow-up. Only one patient (No. 1), who had partial response needed thrombectomy. The estimated probability of complete response at 48 hours was 0.58 ± 0.14 and the probability of healing was 0.83 ± 0.10. Median time to healing was 5 days.
DISCUSSION
The study treatment (streptokinase suppository) was administered in all cases during the first 24 hours (1 suppository every 6 hours). In terms of safety, which was the main purpose of the trial, the results indicated that the recombinant streptokinase suppository is safe and tolerable. The adverse events reported were minimal (only ardor and anal itching in only one patient), both mild, resolved spontaneously and with low causality relation with the product. Hemostasis was not altered either, probably due to scarce systemic absorption of SK since the fibrinolytic action could be exerted after local activation in the hemorrhoidal plexus, directly on the thrombi. The total SK dose administered (800 000 IU) at 24 hours is much less hemostasis disturbing than the one used for other indications such as acute myocardial infarction (1 500 000 IU intravenously in one hour) were significant alterations of coagulation parameters have been reported (27). Therefore, hemorrhagic adverse events are less likely to be expected with this product. The low systemic exposure can also explain the fact that anti-SK antibody titers did not increase with treatment, contrary to the larger dose, intravenous administration (26).
]]> Twenty hours of treatment were sufficient to achieve, in most of the patients, a complete and sustained improvement of all the main signs and symptoms of the illness. Ninety percent of the patients healed their hemorrhoidal crisis in approximately 5 days (pain relief before 48 hours). Other studies have reported longer healing periods with control standard treatments and other agents such as nifedipine or surgery (28- 34). The patients of this study faced inflammation, pain and an irreducible mass as the most important symptoms, also indicated by some authors (35). The thrombolytic effect of the SK suppository on the local capillary structure could improve permeability and its action on the lymphatic local system could diminish the inflammation, exudates, and local edema and its action on blood viscosity, determines a rapid improvement in the first 24 hours after the product is applied (31). In this study, although the sample was very small, typical complications of the disease such as anal abscess, vulvoperineal cellulitis, perianal fistula, among others, were not reported. Further, controlled trials are needed to confirm this initial efficacy data. Other doses and schedules should be explored as well.The treatment of the hemorrhoidal crisis depends on the intensity of the signs and symptoms and can change in patients with thrombosis, important prolapse or profuse hemorrhage. In such cases, the surgical solution should be evaluated (hemorrhoidectomy, thrombectomy, ligature, sclerotherapy, infrared photoclotting, cryotherapy, therapy with laser). However, few randomized controlled trials have been performed to evaluate these procedures (6, 9-11).
In this work, only one patient did not improve his condition and needed thrombectomy. This patient presented hemorrhoidal thrombosis as first diagnosis, which improved without the need for analgesics. From the point of view of the clinical trial evaluation, he was considered a therapeutic failure due to the thrombus persistence. The surgical treatment of the hemorrhoids is indicated in grades III-IV, symptomatic, that have not responded to the conservative treatment to an associate illness (fissure, fistula, big skin flaps) and in the hemorrhoidal thrombosis (9, 35).
This is the first report in human of the recombinant streptokinase use in a rectal formulation (suppository). The results indicate that it is unlikely that any systemic action of the thrombolytic agent (SKr), and thus adverse events on other organs or systems can appear. This will have to be confirmed in further studies.
ACKNOWLEDGEMENTS
Authors: FHB, CV, SB and PLS are employees of the Center for Biological Research, which is part of the Center for Genetic Engineering and Biotechnology, Havana Network, where rSK is produced and the new formulation was developed. HB, AA, YB, RP and EM belong to the latter organization. The other authors have no conflict of interests. The study was financed by Heber Biotec, Havana (products, reagents) and the Ministry of Public Health of Cuba (hospital facilities and general medical care of the patients). The authors wish to thank Dr. Iraldo Bello Rivero, Olga Pantaleón Bernal, technicians Dunia Gómez Chávez, Maria de la C Hernández, Teresa Álvarez Padrón, Maria Isabel Nuñez and BSc, Magalys Cabro Cruz for their participation in the laboratory work. They also give thanks to the Dr. Luis Villasana Roldós for his advice.
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Received in April, 2010.
Accepted for publication in September, 2010.
Francisco Hernández, Clinical Trials Division, Center for Biological Research, Havana Street 134 / 23 and 25, Playa, PO Box 6332, Havana, Cuba. E-mail: hernandez.bernal@cigb.edu.cu
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