Phase 3 Study to Evaluate the Safety and Efficacy of Galnobax® in Treating Diabetic Foot Ulcers

The current study is a Prospective, Multicenter, Randomized, Double-Blind, Phase 3 Study to Evaluate the Safety and Efficacy of a Gel Formulation of Esmolol Hydrochloride (Galnobax®) in Treating Diabetic Foot Ulcers. The study evaluates the safety and effectiveness of Galnobax® plus Standard of Care versus only Standard of Care, in treating Diabetic Foot Ulcers (DFU). In addition, Study is designed to investigate the safety of Galnobax® vehicle for establishing non-deleterious effects of Vehicle on wound healing in the Subjects with DFU.

• Esmolol Hydrochloride (Drug), also known as Galnobax: Galnobax-14% gel application along with Standard of Care
• Only Standard of Care (Other): Only Standard of Care treatment
• Vehicle Gel (Other): Vehicle gel application along with Standard of Care

Primary outcomes

• Proportion of Subjects Achieving Target Ulcer Closure Within 12-week Treatment Phase, as Assessed by Blinded Investigator [Wound closure assessed up to week 12 and confirmed by 2 visits 2 weeks apart; only participants with wound closure at or before Week 12 and who maintained closure after 4-weeks of follow-up reported]: Proportion of complete closure of wounds within 12-week treatment phase where Complete wound closure is defined as complete skin re-epithelialization that is without drainage or dressing requirements evaluated in two visits two weeks apart from first observation of closure.

Secondary outcomes

• Proportion of Subjects Achieving Target Ulcer Closure Till End of Study, as Assessed by the Blinded Investigator. [24-weeks. The ulcers achieving complete closure till end of study]: Proportion of complete closure of wounds at 24-weeks or End of Study where Complete wound closure is defined as complete skin re-epithelialization that is without drainage or dressing requirements.

Other outcomes

• Proportion of Subjects With Treatment Emergent Adverse Events (TEAEs) [24-weeks]: Proportion of Treatment emergent adverse events (TEAEs) in all the groups

Sex: All, ages: 18 Years to 75 Years

Inclusion Criteria:

1. Subjects, male or female, aged 18 to 75 years (inclusive) with Type 1 or Type 2 diabetes undergoing therapy for glycemic control
2. Subject has glycosylated hemoglobin, HbA1C, ≤ 12%
3. Subject with diagnosis of neuropathic foot ulcer by 10g monofilament test
4. Subject has adequate vascular perfusion of the affected limb, confirmed by Ankle-Brachial Index (ABI) ≥ 0.65 and ≤ 1.3
5. Presence of at least one DFU that meets all of the following criteria:

   1. A full-thickness ulcer of Grade A1 as per Texas classification system;
   2. Ulcer is located below or up to 5 cm above the malleoli (excluding ulcers between the toes);
   3. Ulcer size (area) is ≥ 2 cm2 and ≤ 15 cm2 (post-debridement);
   4. There is a minimum 3 cm margin between the qualifying Target Ulcer and any other ulcers on the specified foot, post-debridement;
   5. No exposed bone, tendon, muscle, ligament or joint capsule, and no tunneling, undermining, or sinus tracts;
   6. Unresponsive to ulcer care and open for at least 6 weeks at the time of the Screening Visit;
   7. Ulcer is non-infected as determined by clinical assessment and complete hemogram;
   8. Ulcer has a clean, granulating base free of adherent slough to the greatest extent possible as per Investigator;
   9. Ulcer area reduction < 30% from the Screening Visit to Baseline visit
6. Clinically normal resting 12-lead ECG at Screening Visit or, if abnormal, considered not clinically significant by the Investigator
7. Subject, if female of child-bearing potential, has a negative urine pregnancy test at Screening and willing to use acceptable methods of contraception (birth control pills, barriers) or abstinence throughout the Study
8. Subject is able and willing to comply with Study procedures including the use of an off-loading device (as applicable for the location of the ulcer) and adhere to protocol during the Study in the opinion of Investigator
9. A Subject or LAR agrees to sign informed consent form and allow audio visual recording of consent, if applicable

Exclusion Criteria:

1. Actively infected ulcers with or without purulent discharge, ulcers with exposed bone or associated with osteomyelitis
2. Subjects with more than three ulcers below knee
3. Subjects with Target Ulcer requiring off-loading that cannot be effectively off-loaded; or unable to tolerate the off-loading method
4. Subject has ulcers caused by a disease other than diabetes, e.g., fungal ulcerations, malignant ulcerations, and ulcerations due to venous or arterial insufficiency, or due to hematological disorders, in the opinion of the Investigator
5. Ulcer, about which the Investigator is suspicious for cancer
6. Subjects with a gangrenous or ischemic ulcer
7. Subject with ulcer that in the opinion of the Investigator, may need amputation
8. Subject with Target ulcer where wound measurement is not possible, such as ulcers between toes
9. Body mass index (BMI) > 40 kg/m2
10. Laboratory values at Screening of:

    1. Hemoglobin < 10.0 g/dL
    2. White Blood Cells (WBC) < 2.0 X 109 cells/L
    3. Liver function studies \[Total bilirubin, aspartate aminotransferase (AST) and alanine transaminase (ALT)\] > 3x the upper limit of normal
    4. Albumin < 2.5 g/dL
    5. eGFR < 25 mL/min
11. Presence of any existing clinically significant medical condition(s) that, in the opinion of the Investigator, could interfere with wound healing
12. Subject has received or is currently receiving or scheduled to receive any medication or therapies during the course of the Study that will modulate wound healing
13. Subject with intolerance to β-blockers at any time in the past
14. Has any other factor which may, in the opinion of the Investigator, compromise participation and/or follow-up in the Study

Participant flow

Outcome results

• Proportion of Subjects Achieving Target Ulcer Closure Within 12-week Treatment Phase, as Assessed by Blinded Investigator (Primary), Count of participants, Participants: Galnobax® 14% Gel Plus SoC 41; SoC Only 30; Vehicle Plus SoC 10 (p 0.0276)
• Proportion of Subjects Achieving Target Ulcer Closure Till End of Study, as Assessed by the Blinded Investigator. (Secondary), Count of participants, Participants: Galnobax® 14% Gel Plus SoC 44; SoC Only 35; Vehicle Plus SoC 9 (p 0.0126)
• Proportion of Subjects With Treatment Emergent Adverse Events (TEAEs) (Other pre specified), Count of participants, Participants: Galnobax® 14% Gel Plus SoC 10; SoC Only 14; Vehicle Plus SoC 9

Adverse events

Time frame: 24 weeks i.e. till end of study

Serious adverse events by term

Other adverse events by term

• Results publication: Rastogi A, Kulkarni SA, Agarwal S, Akhtar M, Arsule S, Bhamre S, Bhosle D, Desai S, Deshmukh M, Giriraja KV, Jagannath J, Kashiva RY, Kesavan R, Khandelwal D, Kolte S, Kongara S, Darivemula AK, Madhusudan C, Pyare Saheb Qureshi MAH, Ramu M, Rathod G, Yalamanchi SR, Shakya S, Shetty P, Singh S, Deshpande SK, Viswanathan V, Unnikrishnan AG. Topical Esmolol Hydrochloride as a Novel Treatment Modality for Diabetic Foot Ulcers: A Phase 3 Randomized Clinical Trial. JAMA Netw Open. 2023 May 1;6(5):e2311509. doi: 10.1001/jamanetworkopen.2023.11509. PMID 37184839

• Study Protocol and Statistical Analysis Plan (PDF, 2019-11-28)

• Ashu Rastogi, MD, Principal investigator, Post Graduate Institute of Medical Education and Research, Chandigarh