This study was a single-centre, open label, non-placebo, prospective intervention study aimed at assessing the safety of a combination of 5-ALA phosphate and SFC. It was conducted from June 2016 to December 2016. The study was approved by the institutional review board of Hiroshima University Hospital and registered in the University Hospital Medical Information Network-Clinical Trial Registry (UMIN-CTR) database (UMIN000022825) on 22/06/2016 and conducted at Hiroshima University Hospital in accordance with Ethical Guidelines for Medical and Health Research Involving Human Subjects issued by the Japanese Ministry of Health, Labour and Welfare. SBI Pharmaceuticals is a sponsor of this study and was involved in the study design, writing of the report, and has its own right to submit the report for publication.
A combination of 5-ALA phosphate (250 mg) and SFC (143.4 mg; 15 mg as Fe) was administered for 28 days to 22 healthy male and female volunteers aged 20 to 59 years. The compounds were orally administered once per day. Fourteen days after administration was set as the post-observation period. Health was monitored via interview, blood test, urinalysis, and physical examination conducted before administration, 2 and 4 weeks after the initiation of test compound administration, and two weeks after completion of administration. A ± 1 week allowance was set to each time point to diminish protocol aberration.
Eleven male and 11 female healthy volunteers were recruited from the local community in Hiroshima using advertisements by the Hiroshima University Hospital. The ethnicity of the volunteers was not ascertained. After written informed consent was obtained, eligibility of the subjects was confirmed within seven days of drug administration. Individuals were excluded if they regularly received drugs for a chronic disease, consumed food supplements that could affect the study, were currently participating in a clinical study or had participated in a study within the past three months, were pregnant or breastfeeding, had a history of serious illness or major surgery, had a history of hypersensitivity to 5-ALA or porphyrin, had been diagnosed with porphyria, had a family member with porphyria, or had severe anaemia characterized by haemoglobin less than 10 g/dL.
Test compound administration and subject management
Both 5-ALA phosphate (neo ALA Co., Ltd., Tokyo, Japan) and SFC (Mitsubishi-Chemical Foods Corporation, Tokyo, Japan; provided as Sanferol®) were administered orally. Each compound was prepared in capsules of 50 mg of 5-ALA phosphate and approximately 28.68 mg of SFC, and five capsules were administered once daily to yield a total dose of 250 mg 5-ALA phosphate and 143.4 mg SFC (15 mg as Fe) daily. The capsules also contained starch and microcrystalline cellulose as excipient, calcium stearate and fine silicon dioxide as lubricant, and titanium dioxide as colorant. The capsules were made of hydroxypropyl methylcellulose. Administration time was not specified. During the study period, subjects were advised to avoid administering antacids or tannic acid albumin concomitantly with the test compounds, and to avoid additional supplements containing iron and excessive dietary iron. Subjects were asked to keep a daily food diary and to abstain from excessive eating and drinking, food supplements, intense exercise, and donating blood.
Background check and physical examination
Name, gender, date of birth, age, height, body temperature, body weight, body fat percentage, blood pressure, pulse rate, drugs being taken, use of health food, medical history, family history of porphyria, current medical history, allergies, and life history (smoking/drinking) were recorded at the beginning of the trial.
At weeks 2, 4, and 6, the subjects were required to fast for 9 h prior to examination. Body temperature, body weight, body mass index (BMI), body fat percentage, systolic blood pressure, diastolic blood pressure, and pulse rate were recorded. Body fat percentage was measured using a BC-118E (TANITA Corporation, Tokyo, Japan) and blood pressure was measured using an HBP-9020 (Omron Healthcare Co., Ltd., Kyoto, Japan). Additionally, blood and urine samples were collected at these weeks 2, 4 and 6 time points. White blood cell count, red blood cell count, haemoglobin, haematocrit, mean corpuscular volume (MCV), mean corpuscular haemoglobin (MCH), mean corpuscular haemoglobin concentration (MCHC), platelet count, aspartate transaminase (AST), alanine transaminase (ALT), gamma-glutamyltransferase (γ-GTP), lactase dehydrogenase (LDH), cholinesterase, alkaline phosphatase (ALP), amylase, Na+, K+, Cl-, total protein, total bilirubin, albumin, uric acid, urea nitrogen, creatinine, estimated glomerular filtration rate (eGFR), total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, LDL/HDL ratio, triglyceride, fasting blood glucose, glycosylated haemoglobin (HbA1c), glycoalbumin, serum iron, and ferritin were recorded. Urine-specific gravity, pH, urobilinogen, bilirubin, ketone bodies, protein, glucose, and occult blood were also examined.
Severity of adverse events and their causal relationship to the test compounds were determined according to the Common Terminology Criteria for Adverse Events (CTCAE) v4.0 criteria. We assessed the presence or absence of adverse events and their grade based on inquiries, consultations during health interviews, subject diaries, and clinical / laboratory values. The grade of clinical laboratory values was judged, and the presence of adverse events was assessed based on the reference range of the clinical laboratory and CTCAE v4.0. All undesirable events that occurred to a subject during the test compounds administration period were recorded as adverse effects, regardless of relation to the test compounds intake. Adverse events were judged as not related, not related with slight possibility of causal relationship, not related where the possibility of causal relationship could not be ruled out, or related. Changes in subjective symptoms were individually evaluated for severity and causality from the diary in which daily health status was recorded. The incidence proportion of adverse events occurring and the incidence rate of adverse events during the administration period (person-years method) were calculated. For fluctuations in each laboratory test value, we compared the change from the baseline at each measurement point and evaluated the presence or absence of change.
Sample size and statistical analysis
As this was an exploratory trial, sample size was determined based on practical considerations. Means and standard deviation (SD) were used to describe variables of interest. Changes from baseline to week 4 or from week 4 to week 6 were assessed using a two-tailed paired Student’s t-test, with differences considered significant at P < 0.05. The statistically analysed set for safety covers all subjects who had ingested the test compounds at least once, and whose safety was evaluated at least once.