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Evaluation of Levels of Triamcinolone Acetonide in Human Perilymph and Plasma After Intratympanic Application in Patients Receiving Cochlear Implants

Evaluation of Levels of Triamcinolone Acetonide in Human Perilymph and Plasma After Intratympanic... IMPORTANCE The use of intratympanically applied steroids is of increasing interest. Supplemental content Consequently, research has focused on finding an ideal drug that diffuses through the round CME Quiz at window membrane and can be retained in the perilymph. jamacmelookup.com and CME Questions page 1012 OBJECTIVE To compare levels of triamcinolone acetonide (TAC) in perilymph and plasma after intratympanic injection. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial included 40 patients receiving cochlear implants at a single tertiary care center in Vienna, Austria. Patients were randomized to 1 of 4 treatment groups receiving 1 of 2 intratympanic doses of TAC (10 mg/mL or 40 mg/mL) at 1 of 2 approximate time points (24 hours or 1 hour) before sampling the perilymph. Inclusion was carried out between November 2017 and January 2020, and data were analyzed in December 2020. INTERVENTIONS All patients underwent intratympanic injection of TAC. During cochlear implantation, perilymph and plasma were sampled for further analysis. MAIN OUTCOMES AND MEASURES Levels of TAC measured in perilymph and plasma. RESULTS Among the 37 patients (median [range] age, 57 [26-88] years; 18 [49%] men) included in the analysis, TAC was present at a median (range) level of 796.0 (46.4-7706.7) ng/mL. In the majority of patients (n = 29; 78%), no drug was detectable in the plasma after intratympanic injection. Levels above the limit of detection were less than 2.5 ng/mL. The 1-factorial analysis of variance model showed lower TAC levels in the group that received TAC, 10 mg/mL, 24 hours before surgery (median, 271 ng/mL) compared with the group that received TAC, 10 mg/mL, 1 hour before surgery (median, 2877 ng/mL), as well as in comparison with the groups receiving TAC, 40 mg/mL, 24 hours before surgery (median, 2150 ng/mL) and 1 hour before surgery (median, 939 ng/mL). The 2-factorial analysis of variance model showed lower TAC levels in the group receiving TAC, 10 mg/mL, 24 hours before surgery than the group receiving TAC, 10 mg/mL, 1 hour before surgery, and higher TAC levels in the group receiving TAC, 40 mg/mL, 24 hours before surgery compared with the Author Affiliations: Department of group receiving TAC, 10 mg/mL, 24 hours before surgery. Patients with thickening of the Otorhinolaryngology–Head and Neck middle ear had statistically significantly higher plasma levels (median, 1.4 ng/mL vs 0 ng/mL) Surgery, Medical University of and lower perilymph levels (median, 213.1 ng/mL vs 904 ng/mL) than individuals with Vienna, Vienna, Austria (Dahm, Auinger, Honeder, Riss, Arnoldner); unremarkable middle ear mucosa. Department of Pharmaceutical Technology and Biopharmaceutics, CONCLUSIONS AND RELEVANCE In this randomized clinical trial, TAC was shown to be a University of Vienna, Austria promising drug for intratympanic therapies, with similar levels in perilymph 1 hour and 24 (Gausterer, Gabor); Department of hours after injection (distinctly in the groups receiving the 40 mg/mL dose). There was also Pharmacognosy, University of minimal dissemination to the plasma, especially in patients with unremarkable middle ear Vienna, Vienna, Austria (Reznicek); Center for Medical Statistics, mucosa. Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03248856 Austria (Kaider). Corresponding Author: Christoph Arnoldner, Department of Otorhinolaryngology–Head and Neck Surgery, Medical University of Vienna, Waehringer Guertel 18-20, JAMA Otolaryngol Head Neck Surg. 2021;147(11):974-980. doi:10.1001/jamaoto.2021.2492 1090 Vienna, Austria (christoph. Published online September 30, 2021. arnoldner@meduniwien.ac.at). 974 (Reprinted) jamaotolaryngology.com Levels of Triamcinolone Acetonide in Human Perilymph and Plasma After Intratympanic Application Original Investigation Research any inner ear diseases are treated with systemic cor- ticosteroids. However, owing to minimal blood flow Key Points 1,2 M to the cochlea and the blood-perilymph barrier, Question How much intratympanically injected triamcinolone only a small proportion of intravenously applied predniso- acetonide diffuses to the perilymph and plasma? 3,4 lone reaches the perilymphatic fluid. Studies investigating Findings In this randomized clinical trial of 40 patients glucocorticoid absorption and distribution have mainly been undergoing cochlear implantation, there were similar levels of 5,6 conducted in animals. Bird et al investigated perilymph con- triamcinolone acetonide in the perilymph 1 hour and 24 hours after centrations 0.5 to 3 hours after intratympanic (IT) applica- injection, and triamcinolone acetonide could be quantified in all tionofmethylprednisoloneordexamethasoneinhumans.Con- analyzed patients at a median (range) level of 796.0 (46.4-7706.7) centrations of methylprednisolone and dexamethasone were ng/mL. There was minimal dissemination to the plasma, especially in patients with unremarkable middle ear mucosa. 33- to 260-fold higher after IT than after intravenous applica- 5,6 tion depending on the dose and drug. Application via a Meaning Triamcinolone acetonide can be found in the perilymph transtympanic approach has received increasing interest in re- after intratympanic application, even on the day after injection. cent years. Drugs, however, have been optimized for intrave- nous, intradermal, or intramuscular application and absorp- follows: otosclerosis (n = 1), Meniere disease (n = 2), labyrin- tion but lack adaptation for this new treatment method. The thitis (n = 1), progressive hearing loss after cytomegalovirus in- goalofthisrandomizedclinicaltrialwastoinvestigateandcom- fection (n = 1), progressive sensorineural hearing loss (n = 24), pare perilymph and plasma concentrations of triamcinolone sudden sensorineural hearing loss (n = 5), and vestibular acetonide (TAC) after IT application, which, to the best of our schwannoma (n = 3). knowledge, has not been previously evaluated in humans. Intratympanic Application of Triamcinolone Acetonide On the day before cochlear implantation, patients were placed in a supine position. Xylocaine spray, 10 mg/puff, was used as Methods local anesthesia. The suspension (TAC) was applied using a 25- Study Population gauge (0.50 × 90 mm, 3.50 in) needle through the tympanic Each patient provided written informed consent to partici- membrane. Patients were asked to stay in the position for 20 pate in this prospective study, which was approved by the eth- minutes and instructed not to speak or swallow. ics committee of the Medical University of Vienna. Inclusion Patients receiving TAC on the day of surgery were admin- criteria were that patients were between 18 and 90 years old, istered general anesthesia and positioned for cochlear implan- undergoing cochlear implantation, and willing to participate tation. The injection was then performed as previously de- in the study. Exclusion criteria were that patients were younger scribed. The patient’s position was not altered after the than 18 years, were receiving steroids on a regular basis or had injection. Patients were blinded to the dose given, while phy- received steroids intravenously or orally preoperatively, had sicians were not. contraindications against the administration of TAC, or had contraindications against IT injections (Supplement 1). Surgery and Perilymph Sampling Forty patients were randomly assigned to 1 of 4 groups. In all 40 patients, cochlear implantation was carried out via a Groups 1 and 2 received IT TAC approximately 24 hours be- standard mastoidectomy and facial recess approach, during fore surgery, whereas groups 3 and 4 received the injection ap- which irrigation was used. The bony overhang of the round proximately 1 hour before surgery (Table 1). Groups 1 and 3 were window was reduced with no irrigation to avoid dilution ef- treated with TAC, 10 mg/mL, and groups 2 and 4 with TAC, 40 fect of the perilymph sample. The intact round window mem- mg/mL (Figure 1). Causes of hearing loss were distributed as brane was perforated with a sterile disposable aspirator Table 1. Characteristics of the 4 Different Groups and the Timing of Intratympanic TAC Application, Dose, and Volume Median (range) Characteristic Group 1 Group 2 Group 3 Group 4 P value No. of patients 9 10 9 9 NA TAC dose, mg/mL 10 40 10 40 NA Age, y 57 (47-82) 62 (46-78) 41 (26-68) 64 (40-88) .004 Injection volume, mL 0.65 (0.30-1.00) 0.60 (0.20-1.00) 0.40 (0.35-0.90) 0.40 (0.15-1.00) .55 BMI 25.4 (19.0-29.3) 29.6 (24.1-50.0) 28.4 (21.8-41.3) 27.0 (22.5-31.8) .10 Actual time between injection and sample Hours 21.6 (19.0-25.8) 20.9 (14.6-25.1) 1.7 (1.0-2.2) 1.6 (0.9-2.2) <.001 Minutes 1297 (1140-1545) 1255 (875-1505) 104 (58-130) 96 (51-130) Abbreviations: BMI, body mass index, calculated as weight in kilograms divided For group comparison, P values were calculated using a 1-factorial analysis of by height in meters squared; NA, not applicable; TAC, triamcinolone acetonide. variance model. Three patients had to be excluded owing to a sample volume less than 1 μL. jamaotolaryngology.com (Reprinted) JAMA Otolaryngology–Head & Neck Surgery November 2021 Volume 147, Number 11 975 Research Original Investigation Levels of Triamcinolone Acetonide in Human Perilymph and Plasma After Intratympanic Application Figure 1. CONSORT Diagram 102 Assessed for eligibility 62 Excluded 42 Did not meet inclusion criteria 11 Declined to participate 9 Other reasons 40 Randomized 10 Randomized to group 1 10 Randomized to group 2 10 Randomized to group 3 10 Randomized to group 4 (TAC, 10 mg/mL, 24 h (TAC, 40 mg/mL, 24 h (TAC, 10 mg/mL, 1 h (TAC, 40 mg/mL, 1 h before sampling) before sampling) before sampling) before sampling) 40 Included in follow-up 3 Excluded from further analysis owing to a perilymph sample volume <1 μL 37 Analyzed TAC indicates triamcinolone acetonide. (MediPlast [Curad], 0.4 x 70 mm, 27 gauge). The aspirated peri- chromatography–mass spectrometry analysis in triplicate (di- lymph (approximately 20 μL) was immediately transferred to lution range, 1:4 to 1:21). Traces of protein precipitates were a sterile 0.2-mL safe lock tube and stored at −80 °C. In 3 pa- removed by centrifugation, and the supernatants were col- tients, less than 1 μL could be sampled, which is why no fur- lected and stored at 4 °C. For preparation of plasma samples, ther analysis was possible. 100 μL of plasma was precipitated by the addition of 300 μL of ice-cold methanol, followed by centrifugation for 10 min- utes at 20 800 relative centrifugal force and 4 °C. Plasma was Blood Sample Simultaneously with aspiration of perilymph, a blood sample collected and stored at 4 °C. All samples were kept on ice dur- was taken in the standard fashion. Blood was drawn in a hep- ing sample preparation. arin tube (9 mL). The vacutainer was gently swiveled 5 times. The sample was then centrifuged for 20 minutes at 20 °C with Quantification of Triamcinolone Acetonide 2000 relative centrifugal force. Plasma was transferred to a Triamcinolone acetonide was quantified by high-perfor- 2-mL safe lock tube and stored at −80 °C. mance liquid chromatography. The samples were analyzed using liquid chromatography–mass spectrometry on an Ulti- Mate 3000 RSLC series system (Thermo Fisher Scientific) Triamcinolone Acetonide In this study, patients received IT TAC (Volon A [Derma- coupled to a triple quadrupole mass spectrometer (API 4000 pharm GmbH]) containing either 40 mg/mL or 10 mg/mL of [AB Sciex]) equipped with an orthogonal electrospray ioniza- TAC. In preliminary experiments, the particle-size distribu- tion source operated in positive mode. tion of TAC was determined in 0.9% sodium chloride/0.1% Liquid chromatography separation was performed on an polysorbate 80 by laser-light scattering using a Mastersizer Acclaim RSLC 120 C18 column (3 μm, 100 × 2.1 mm; Thermo 3000 (Malvern Instruments). Triamcinolone acetonide, 10 mg/ Fisher Scientific) preceded by an Acclaim 120 C18 guard car- mL, had a pH of 6.27 and an osmolality of 318 mOsm/kg; 90% tridge (5 μm, 10 × 2 mm; Thermo Fisher Scientific) at a flow of particles had a mean (SD) particle size less than 23.8 (1.0) rate of 0.5 mL/min and a column temperature of 25 °C. The mo- μm, 50% of particles were below and above 12.8 (0.9) μm, and bile phase consisted of a linear gradient mixed from 0.1% aque- 10% of the particle population were less than 5.6 (0.8) μm. Tri- ous formic acid (mobile phase A) and acetonitrile (mobile phase amcinolone acetonide, 40 mg/mL, had a pH of 6.19 and an os- B). The gradient ranged from 20% mobile phase B at 0 min- molality of 331 mOsm/kg. The mean (SD) size of 90% of par- utes to 95% mobile phase B in 5 minutes, purging with 95% ticles was less than 22.1 (1.6) μm, 50% of particles were below mobile phase B for 1 minute, then 20% mobile phase B to equili- andabove11.6(1.4)μm,and10%oftheparticlepopulationwere brate the column for 4 minutes before applying the next sample less than 4.8 (1.1) μm. Both formulations contained 9.9 mg of (total analysis time, 10 minutes). Triamcinolone acetonide benzyl alcohol per 1 mL, as well as sodium carboxymethyl cel- eluted at 4.13 minutes. Triamcinolone acetonide was selec- lulose, polysorbate 80, sodium chloride, and water. tively and sensitively detected and quantified using tandem mass spectrometry fragmentation of TAC, giving a quasimo- lecular ion at mass-to-charge ratio (m/z) of 435.4 [M+H] . Mul- Sample Preparation Perilymph samples were prepared by diluting a definite vol- tiple reaction monitoring m/z 435.4/415.0 (quantifier) and m/z ume ofperilymph withice-coldmethanol toobtain a totalmini- 435.4/213.1 (qualifier) were used for calibration curves with ex- mum volume of 20 μL to allow for high-performance liquid ternal standard TAC (injection volume, 5 μL) to obtain a lin- 976 JAMA Otolaryngology–Head & Neck Surgery November 2021 Volume 147, Number 11 (Reprinted) jamaotolaryngology.com Levels of Triamcinolone Acetonide in Human Perilymph and Plasma After Intratympanic Application Original Investigation Research ear concentration range from 0.1 to 5000 ng/mL To quantify the strength of the effects on TAC levels, the geo- (y = 559x + 3050; correlation coefficient, 0.9986). The lower metric mean ratios (GMRs) with 95% CIs were determined by limit of detection was 0.1 ng/mL, and the lower limit of quan- retransforming mean differences from the logarithmic to the tification was set at 0.5 ng/mL. The triple quadrupole mass original scale. To compare the TAC levels in patients with an spectrometer operated with the following parameters: ESI pos, aerated middle ear to patients with mucosal disease, the IS 5500, EP 10, CUR 10, GS1 40, GS2 40, TEM 500 °C, CAD 4, 2-sample t test was used for perilymph (log10 transformed) and CEM 3000, DF −100. MRM m/z 435.4/415.0: DP 66, CE 11, CXP the exact Wilcoxon rank sum test for plasma. Analysis was con- 26; MRM, m/z 435.4/213.1: DP 81, CE 37, CXP 34; dwell time ducted using SAS statistical software, version 9.4 (SAS Insti- for each MRM150 ms (ESI indicates electrospray ionization; IS, tute), and a 2-sided P < .05 was considered statistically sig- ion spray voltage; EP, entrance potential; CUR, curtain gas; GS1, nificant. ion source gas 1; GS2, ion source gas 2; TEM, temperature; CAD, collisionallyactivateddissociation;CEM,channelelectronmul- tiplier; DF, deflector; MRM, multiple reaction monitoring; DP, Results declustering potential; CE, collision energy; CXP, collision cell exit potential). Triamcinolone Acetonide Levels in Perilymph In this study, 40 patients undergoing cochlear implantation re- ceived IT TAC. In 3 patients, the perilymph sample volume was Sample-Size Calculation The primary aim of the study was to determine and compare less than 1 μL, which was not sufficient for further analysis. perilymph and plasma levels of IT-injected TAC. The re- The remaining 37 patients (median [range] age, 57 [26-88] quired sample size was calculated based on the paired t test years; 18 [49%] men) had perilymph samples with a quantifi- and a 2-sided significance level of 5%. Perilymph and blood able concentration of TAC. The median (range) TAC level in the concentrations of dexamethasone are known from the litera- perilymph was 796.0 (46.4-7706.7) ng/mL. ture in 12 patients, and log10-transformed values were used for calculations owing to the skew distribution. Retransform- Triamcinolone Acetonide Levels in Plasma ing the mean log values to the original scale resulted in geo- Triamcinolone acetonide concentrations in the plasma were metric mean values of 1.26 mg/L for perilymph levels and 0.001 lower than the lower limit of detection in 29 of 37 patients. The mg/L for plasma levels. The SD of the paired differences of the median (range) plasma TAC level in the remaining 8 patients log10-transformed values was calculated as 0.81. To detect an was 1.7 (1.1-2.5) ng/mL. The median (range) TAC level in the effect size of 0.5 SDs, which is a difference of 0.4 on the log plasma for all patients was 0 (0-2.4) ng/mL. All 8 patients with scale (a difference in the geometric means of 1.26-0.50) with detectable levels of TAC in the plasma were in 1 of the 2 groups a statistical power of 86%, a total of 40 patients needed to be receiving TAC, 10 mg/mL. The TAC levels in perilymph were a included in the study (nQuery Advisor, version 7.0 [Statisti- median (range) of 796.0 (44.8-7705.4) ng/mL higher than in cal Solutions]). The primary study aim was to determine and plasma. compare perilymph and plasma levels of IT-applied TAC; there- fore, sample-size calculation was based on this objective. Ad- Effect of Triamcinolone Acetonide Dose and Time Point ditionally, the comparison of different doses and sampling The median (range) TAC concentrations in perilymph in the 4 schemes is an unanswered question, so we decided to ran- different treatment groups were 271.0 (46.4-670.7) ng/mL in domize the sample in the 4 different groups. The power to de- group 1; 2149.7 (51.9-5916.0) ng/mL in group 2; 2877.3 (396.4- tect relevant differences between the groups is small. 7706.7) ng/mL in group 3; and 939.0 (329.4-4641.0) ng/mL in group 4. The 1-factorial ANOVA model showed that the differ- ence between the 4 groups was statistically significant: group Statistical Analysis Median values with ranges (presented as minimum to maxi- 1 had statistically significantly lower TAC levels in perilymph mum) are given for continuous variables. The nonparametric than the other 3 groups (GMR: group 1 vs group 2, 0.15 [95% Wilcoxon signed rank test was used to compare TAC levels in CI, 0.04-0.62]; group 1 vs group 3, 0.12 [95% CI, 0.03-0.51]; and perilymph and plasma. Analysis of variance (ANOVA) models group 1 vs group 4, 0.22 [95% CI, 0.05-0.95]). There were no were used for group comparisons of the TAC levels in peri- statistically significant differences between any other 2 groups lymph. First, groups 1 to 4 were compared using a 1-factorial (GMR: group 2 vs group 3, 0.79 [95% CI, 0.19-3.25]; group 2 vs ANOVA design. The Tukey-Kramer method was used for mul- group 4, 1.47 [95% CI, 0.36-6.04]; and group 3 vs group 4, 1.86 tiplicity-adjusted pairwise group comparisons. Second, two [95% CI, 0.44-7.91]). 1-factorial ANOVA models were applied, testing for the over- The median (range) TAC level in perilymph in the 2 groups all dose (10 mg/mL vs 40 mg/mL) and the overall time point (1 given TAC, 10 mg/mL, was 440.0 (46.4-7706.7) ng/mL and in hour vs 24 hours) effects. Third, a 2-factorial ANOVA model the 2 groups given TAC, 40 mg/mL, was 1046.1 (51.9-5916.0) was used, including the 2 factors of dose and time between ap- ng/mL.The1-factorialANOVAmodeltestingfortheoveralldose plication and sampling, together with an interaction term to (10 mg/mL vs 40 mg/mL) effect showed that the comparison test for a dose-dependent time effect and a time-dependent was not statistically significant (GMR, 0.52 [95% CI, 0.21- dose effect, respectively. Due to the skew distribution of the 1.29]). TAC levels in perilymph, log10-transfomed values were used The median (range) TAC levels in perilymph were 670.7 as dependent variables for all ANOVA and regression models. (46.4-5916.0) ng/mL in groups 1 and 2 (TAC given 24 hours be- jamaotolaryngology.com (Reprinted) JAMA Otolaryngology–Head & Neck Surgery November 2021 Volume 147, Number 11 977 Research Original Investigation Levels of Triamcinolone Acetonide in Human Perilymph and Plasma After Intratympanic Application Figure 2. Box Plots of Triamcinolone Acetonide (TAC) Concentrations Figure 3. Box Plot of Triamcinolone Acetonide (TAC) Concentrations in Perilymph in the Perilymph Among the 4 Treatment Groups A TAC concentration by dose B TAC concentration by time after injection 8000 8000 7000 7000 6000 6000 5000 5000 4000 4000 3000 3000 2000 2000 1000 1000 Group 1 Group 2 Group 3 Group 4 0 0 10 40 1 24 The horizontal line in the boxes indicates the median. The boundaries of the Dose, mg/mL Time, h boxes represent the lower and upper quartiles. The whiskers are drawn from the edge of the boxes to the largest and smallest values that are outside of the The horizontal line in the boxes indicates the median. The boundaries of the box but within 1.5 SDs. Circles depict outliers. Group 1 was given TAC, 10 boxes represent the lower and upper quartiles. The whiskers are drawn from mg/mL, 24 hours before surgery; group 2, TAC, 40 mg/mL, 24 hours before the edge of the boxes to the largest and smallest values that are outside of the surgery; group 3, TAC, 10 mg/mL, 1 hour before surgery; group 4, TAC, 40 boxes but within 1.5 SDs. Circles depict outliers. mg/mL, 1 hour before surgery. Denotes statistical significance according to the 2-factorial analysis of variance model. fore surgery) and 1086.0 (329.4-7706.7) ng/mL in groups 3 and Table 2. Triamcinolone Acetonide (TAC) Values for the 4 Patients 4 (TAC given 1 hour before surgery). The difference between With Mucosal Disease the time points of the groups was not statistically significant TAC, ng/mL (GMR, 0.44 [95% CI, 0.18-1.07]; Figure 2). Patient Group Perilymph Plasma A 2-factorial ANOVA model was used, including the 2 fac- 1 1 46.4 1.6 torsofdoseandtimebetweenapplicationandsampling.Within 2 1 96.8 1.1 the groups that received the lower dose, the TAC concentra- 3 3 396.4 2.5 tion was statistically significantly lower after 24 hours than af- 4 4 329.4 ND ter 1 hour (GMR, 0.12 [95% CI, 0.04-0.36]). There was no sta- tistically significant difference between the groups receiving Abbreviation: ND, not detectable. 40 mg/mL (GMR, 1.47 [95% CI, 0.51-4.26]). On the other hand, TAC levels in the perilymph of patients who underwent sam- pling 1 hour after IT injection were not statistically signifi- Injected Volume cantly different between dose groups (GMR, 0.54 [95% CI, 0.18- The median (range) injected volume across all groups was 0.50 1.60]). However, TAC concentrations in the perilymph were (0.2-1.0) mL (Table 1). The distribution of TAC levels in peri- statistically significantly higher in the group receiving the 40 lymph, when compared with a given dose of TAC, did not show mg/mL dose than the group receiving the 10 mg/mL dose when a correlation (r = 0.187). TAC was injected 24 hours before the surgery (GMR, 6.63 [95% CI, 2.29-19.16]). The results of all 4 groups according to time point and dose are depicted in Figure 3. Discussion Chronic Middle Ear Disease To our knowledge, this is the first study in humans in which In 4 patients, the middle ear was filled with scar tissue and/or IT-injected TAC was measured in the perilymph, as well as its distribution to the plasma. Comparable with previous stud- thickened mucosa (Table 2). The TAC levels in perilymph for these patients were 46.4, 96.8, 396.4, and 329.4 ng/mL. The ies on other glucocorticoids, the range of drug concentra- 5,6 tions in the perilymph varies substantially. median (range) perilymph TAC level in these patients was 213.1 (46.4-396.4) ng/mL compared with 904.0 (51.9-7706.7) ng/mL In the present study, 4 patients had some form of middle ear pathology with scaring and/or thickened mucosa, which in the remaining 33 patients with a healthy middle ear. The dif- ference was statistically significant (GMR, 0.14 [95% CI, 0.04- lead to lower TAC levels in the perilymph and higher TAC lev- 0.52]). The TAC levels in plasma were statistically signifi- els in plasma. Chronic middle ear disease can lead to thicken- cantly higher in the group with mucosal disease (median ing of the middle ear mucosa, as well as angiogenesis. Two of [range], 1.4 [0-2.5] ng/mL) than in the patients with an unre- the 4 patients with middle ear pathologies were in group 1, 1 markable middle ear (median [range], 0 [0-2.3] ng/mL). was in group 3, and 1 in group 4. The influence of chronic 978 JAMA Otolaryngology–Head & Neck Surgery November 2021 Volume 147, Number 11 (Reprinted) jamaotolaryngology.com TAC concentration, ng/mL TAC concentration, ng/mL TAC concentration, ng/mL Levels of Triamcinolone Acetonide in Human Perilymph and Plasma After Intratympanic Application Original Investigation Research middle ear disease on the perilymph and plasma levels of an cently conducted a simulation study showing that TAC has fa- intratympanically applied drug has, to the best of our knowl- vorable pharmacological properties compared with steroids, edge, not been shown thus far and obviously has important which are mainly used for IT application. Triamcinolone ace- implications for clinical routine. First, levels of a substance in tonide was proposed as a promising IT steroid owing to the high the perilymph after IT application will not reach the same lev- permeabilityoftheroundwindowmembraneandthelonghalf- els as in patients with a healthy middle ear. In addition, the life of its metabolite triamcinolone. However, in a more recent distribution of drugs to the plasma may be increased in pa- studyinguineapigs,aswellasasimulationofsequentialsample tients with mucosal disease. It is important to note that these data, Salt et al supported the use of triamcinolone instead of results have only been shown in a small sample size in the pre- TAC because it is retained in the perilymph longer and may re- sent study and need to be confirmed in larger series. sult in improved distribution to the cochlear apex. In that study, The main advantage of IT application is the avoidance of only 2 guinea pigs were treated with a somewhat comparable systemic adverse effects. This study could prove that local ap- setupasthepresentstudy;aTACsolution(asopposedtoaloaded plication leads to a considerably higher TAC level in the peri- gel)wasappliedtotheroundwindow,circumventingabsorption lymph than the plasma. Although serial samples were not and throughthethinoticcapsule.Theperilymphwassampled1hour could not be performed, TAC levels in the perilymph were not later and contained 710 ng/mL of TAC. Loading and sampling of statistically significantly lower in the group that received TAC the lateral semicircular canal were measured to determine how 24 hours before surgery compared with the group that re- muchTACwasretainedintheperilymph.Theresultsshowedan ceived TAC 1 hour before surgery, which may be an indication extremely high elimination rate, which was calculated by simu- of the suspected depot effect occurring due to the crystalline lation(eliminationhalf-timewas12minutesinthescalatympani 8-10 suspension of TAC, which dissolves slowly. To evaluate a and 34 minutes in the scala vestibuli). Although serial sampling possible interaction effect between the dose and delay be- could not be performed, overall, the present results show that tween IT injection and sampling, a 2-factorial ANOVA model TAC levels were similar 1 hour and 24 hours after IT application, was applied and showed a statistically significant interac- whichmeansthateithertheeliminationismuchslowerthancal- tion. In the group that received TAC, 10 mg/mL, 1 hour before culatedpreviously ortheremainingsolutioncontinuouslydif- surgery, TAC levels were statistically significantly higher. The fuses through the round window membrane. Honeder et al re- group receiving TAC, 40 mg/mL, 24 hours before surgery had ported a TAC half-life of 44.9 hours when the drug was applied statistically significantly higher TAC levels. Although contain- intratympanically with a poloxamer 407 hydrogel. ingdifferentconcentrationsofTAC,thesolubilityofTACinboth It is important to note that this study’s primary aim was formulations (10 mg/mL vs 40 mg/mL) is equally limited by to determine and compare IT-applied TAC levels in peri- the molecule’s lipophilic nature, meaning that the amount of lymph and plasma; therefore, sample size calculation was dissolved TAC is the same regardless of the formulation and based on this objective. Additionally, the comparison of dif- that both formulations represent supersaturated solutions. ferent doses and sampling schemes is an unanswered ques- Without knowledge of the exact composition of the formula- tion, so we decided to randomize the sample into the 4 differ- tions (eg, sodium chloride, polysorbate 80), the 13 mM higher ent groups. Of course, the power to detect relevant differences osmolality in the TAC, 40 mg/mL, formulation cannot be at- between the groups is small, and an additional study pow- tributed to the presence of a higher concentration of dis- ered for this comparison is needed. solved TAC. The higher intracochlear TAC levels in perilymph after 24 hours could be because of the 40-mg/mL dose con- Limitations taining 75% more TAC than the 10-mg/mL dose, resulting in One of the limitations of the current study is the small sample an increased viscosity and probably improving adhesion to the size of each group. A further important topic is that physi- round window membrane and limiting drainage via the eu- cians applying IT TAC were not blinded to the doses, which stachian tube, which are both required for successful intra- might have affected the dose given. Sampling of perilymph was tympanic drug delivery to the inner ear. This effect on viscos- carried out during cochlear implantation. During mastoidec- ity is further pronounced by the presence of sodium tomy and the facial recess approach, irrigation is used, which carboxymethylcellulose, which probably contributes to pro- might influence TAC levels in perilymph. longed contact between the dissolved TAC fraction and the round window membrane. Previous studies led to the assumption that longer drug Conclusions maintenance in the basal region of the cochlea leads to a higher chance of extending into apical regions. The TAC suspen- Results of this randomized clinical trial showed that TAC is a sion used in the present study is combined with benzyl alco- promising drug for intratympanic therapies with similar lev- hol, which has been shown to increase round window mem- els in perilymph 1 hour and 24 hours after injection (dis- brane permeability by a factor of 3 to 5. Benzyl alcohol also tinctly in the group receiving TAC, 40 mg/mL). Additionally, keeps substances from being cleared from the middle ear space it leads to minimal dissemination to the plasma, especially as quickly, which may also enhance the suspected depot ef- in patients with unremarkable middle ear mucosa. There- fect of the crystalline suspension of TAC. fore, TAC remains an important drug for treating inner ear It remains unclear if any active transporters increase or de- disorders via IT injection and should be evaluated further in crease perilymph levels of certain drugs. Salt and Plontke re- future studies. jamaotolaryngology.com (Reprinted) JAMA Otolaryngology–Head & Neck Surgery November 2021 Volume 147, Number 11 979 Research Original Investigation Levels of Triamcinolone Acetonide in Human Perilymph and Plasma After Intratympanic Application ARTICLE INFORMATION Role of the Funder/Sponsor: The funder had no perilymph. Otol Neurotol. 2007;28(8):1124-1130. role in the design and conduct of the study; doi:10.1097/MAO.0b013e31815aee21 Accepted for Publication: July 28, 2021. collection, management, analysis, and 7. Salt AN, Plontke SK. Pharmacokinetic principles Published Online: September 30, 2021. interpretation of the data; preparation, review, or in the inner ear: influence of drug properties on doi:10.1001/jamaoto.2021.2492 approval of the manuscript; and decision to submit intratympanic applications. Hear Res. 2018;368:28- Open Access: This is an open access article the manuscript for publication. 40. doi:10.1016/j.heares.2018.03.002 distributed under the terms of the CC-BY License. Data Sharing Statement: See Supplement 2. 8. Honeder C, Engleder E, Schöpper H, et al. ©2021DahmVetal. JAMA Otolaryngology–Head & Sustained release of triamcinolone acetonide from Neck Surgery. REFERENCES an intratympanically applied hydrogel designed for Author Contributions: Ms Dahm and Mr Arnoldner 1. Nakashima T, Naganawa S, Sone M, et al. the delivery of high glucocorticoid doses. Audiol had full access to all the data in the study and take Disorders of cochlear blood flow. Brain Res Brain Neurootol. 2014;19(3):193-202. doi:10.1159/ responsibility for the integrity of the data and the Res Rev. 2003;43(1):17-28. doi:10.1016/S0165-0173 000358165 accuracy of the data analysis. (03)00189-9 9. Ye Q, Tillein J, Hartmann R, Gstoettner W, Kiefer Concept and design: Dahm, Honeder, Gabor, 2. Yang Y, Dai M, Wilson TM, et al. Na+/K+-ATPase J. Application of a corticosteroid (Triamcinolon) Arnoldner. α1 identified as an abundant protein in the protects inner ear function after surgical Acquisition, analysis, or interpretation of data: blood-labyrinth barrier that plays an essential role intervention. Ear Hear. 2007;28(3):361-369. doi:10. Dahm, Gausterer, Auinger, Reznicek, Kaider, Riss. in the barrier integrity. PLoS One. 2011;6(1):e16547. 1097/01.aud.0000261655.30652.62 Drafting of the manuscript: Dahm, Kaider, doi:10.1371/journal.pone.0016547 Arnoldner. 10. Salt AN, Hartsock JJ, Hou J, Piu F. Comparison Critical revision of the manuscript for important 3. Oertel R, Kirch W, Klemm E. Prednisolone of the pharmacokinetic properties of triamcinolone intellectual content: Gausterer, Auinger, Honeder, concentration in the cochlea of patients with and dexamethasone for local therapy of the inner Gabor, Reznicek, Riss, Arnoldner. perilymph fistula. Pharmazie. 2007;62(3):239-240. ear. Front Cell Neurosci. 2019;13:347. doi:10.3389/ Statistical analysis: Reznicek, Kaider, Arnoldner. fncel.2019.00347 4. Niedermeyer HP, Zahneisen G, Luppa P, Busch R, Obtained funding: Dahm, Arnoldner. Arnold W. Cortisol levels in the human perilymph 11. Mikulec AA, Hartsock JJ, Salt AN. Permeability Administrative, technical, or material support: after intravenous administration of prednisolone. of the round window membrane is influenced by Gausterer, Auinger, Riss. Audiol Neurootol. 2003;8(6):316-321. doi:10.1159/ the composition of applied drug solutions and by Supervision: Honeder, Gabor, Arnoldner. 000073516 common surgical procedures. Otol Neurotol. 2008; Conflict of Interest Disclosures: Dr Honeder 29(7):1020-1026. doi:10.1097/MAO. 5. Bird PA, Murray DP, Zhang M, Begg EJ. reported receiving grants from MED-EL outside the 0b013e31818658ea Intratympanic versus intravenous delivery of submitted work. Dr Riss reported receiving grants dexamethasone and dexamethasone sodium 12. Mikulec AA, Plontke SK, Hartsock JJ, Salt AN. from MED-EL paid to his institution outside the phosphate to cochlear perilymph. Otol Neurotol. Entry of substances into perilymph through the submitted work. No other disclosures were 2011;32(6):933-936. doi:10.1097/MAO. bone of the otic capsule after intratympanic reported. 0b013e3182255933 applications in guinea pigs: implications for local Funding/Support: This work was funded by the drug delivery in humans. Otol Neurotol. 2009;30 6. Bird PA, Begg EJ, Zhang M, Keast AT, Murray DP, Medical Scientific Fund of the Mayor of the City of (2):131-138. doi:10.1097/MAO.0b013e318191bff8 Balkany TJ. Intratympanic versus intravenous Vienna. delivery of methylprednisolone to cochlear 980 JAMA Otolaryngology–Head & Neck Surgery November 2021 Volume 147, Number 11 (Reprinted) jamaotolaryngology.com Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 CLINICAL STUDY PROTOCOL Triamcinolone levels in cochlear perilymph Triamcinolone levels Version 1.0 / Date 28.07.2017 Project number: 1456/2017 Confidentiality Statement The information contained in this document, especially unpublished data, is the property of the sponsor of this study. It is therefore provided to you in confidence as an Investigator, potential Investigator, or consultant, for review by you, your staff, and an Independent Ethics Committee or Institutional Review Board. It is understood that this information will not be disclosed to others without written authorization from the sponsor or the study personnel except to the extent necessary to obtain informed consent from those persons to whom the study drug may be administered. Triamcinolone levels in cochlear perilymph Page 1 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 Test drug (IMP) and Triamcinolone acetonide (Volon A crystal suspension) Pharmaceutical Dermapharm GmbH Company Protocol author Dr. Valerie Dahm Investigator Assoc. Prof. PD Dr. Christoph Arnoldner Document type Clinical study protocol Study phase Phase I Document status Final Date 28.07.2017 Number of pages 38 Triamcinolone levels in cochlear perilymph Page 2 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 1. SPONSOR, INVESTIGATOR, MONITOR AND SIGNATURES Sponsor/or representative (OEL) (AMG §§ 2a, 31,32) Univ. Prof. Dr. Wolfgang Gstöttner, Department of Otorhinolaryngology Medical University of Vienna, Austria ________________ ___________ Signature (OEL) Date Investigator (AMG §§ 2a, 35,36) Assoc. Prof. PD Dr. Christoph Arnoldner, Department of Otorhinolaryngology Medical University of Vienna, Austria _________________ ___________ Signature Date Monitor/ or Representative of CRO (AMG §§ 2a, 33,34) DI Rudolfs Liepins Study coordinator Department of Otorhinolaryngology Medical University of Vienna, Austria _________________ ___________ Signature Date Triamcinolone levels in cochlear perilymph Page 3 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 Clinical Trials Centers: Department of Otorhinolaryngology Medical University of Vienna, Austria Associated Departments Department of Pharmaceutical Technology & Biopharmaceutics, University of Vienna, Austria Mag. Pharm Julia Clara Gausterer a.o. Univ. Prof. Dr. Franz Gabor Triamcinolone levels in cochlear perilymph Page 4 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 2. PROTOCOL SYNOPSIS TITLE Triamcinolone levels in cochlear perilymph - a prospective, randomized clinical trial OBJECTIVES Primary Objective Demonstrate absorption of Triamcinolone acetonide in cochlear perilymph in comparison to dissemination to the blood circulation Secondary Objectives Assess the stability of triamcinolone acetonide levels in the cochlear perilymph Assess perilymph concentrations and blood concentrations of triamcinolone acetonide after administration of different Triamcinolone acetonide doses. DESIGN / PHASE Prospective phase I study. STUDY PLANNED First patient 4Q Last patient 3Q Last patient 4Q DURATION First visit 2017 First visit 2019 Last visit 2019 CENTER(S) One center. / COUNTRY(IES) Austria PATIENTS / GROUPS 10 patients/group 4 groups: Group 1: Volon 10mg - sampling 24h after administration Group 2 Volon 40mg - sampling 24h after administration Group 3 Volon 10mg - sampling 1h after administration Group 4 Volon 40mg - sampling 1h after administration Group 5 Volon 40mg sampling 24h after administration - RWM, SCC and CSF 1:1:1:1 (Group 1-4) INCLUSION CRITERIA Patients between 18 and 90 years will be included in the study, who will undergo a cochlear implantation and are willing to participate in the study EXCLUSION CRITERIA Patients younger than 18 years Patients who receive cortisone on a regular basis or receive cortisone i.v. or p.o. preoperatively Patients with contraindications against the administration of Volon A STUDY PERIODS Patients will be included in the study over a time period of two years. The active study phase of each patient will be a maximum of nine days. INVESTIGATIONAL Triamcinolone acetonide (Volon A crystal suspension) DRUG 40mg Dose: 1ml Triamcinolone levels in cochlear perilymph Page 5 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 Triamcinolone acetonide (Volon A crystal suspension) 10mg Dose: 1ml COMPARATIVE DRUG none /CONTROL CONDITION CONCOMITANT Allowed all concomitant medication is allowed MEDICATION Patients who take cortisone on a regular basis will not be included in the study EFFICACY ENDPOINTS not applicable TOLERABILITY / not applicable SAFETY ENDPOINTS PHARMACOKINETIC / Concentration of Triamcinolone e acetonide in perilymph and PHARMACODYNAMIC blood samples ENDPOINTS QUALITY OF LIFE / not applicable PHARMACOECONOMIC ENDPOINTS STATISTICAL Primary objective: METHODOLOGY The paired t-test will be used to compare the log-transformed perilymphatic and blood concentrations of triamcinolone, and a 95% confidence interval will be calculated for the geometric mean ratio. Secondary objective: Descriptive statistical methods will be used for the secondary (hypotheses generating) objective to compare the 4 groups of patients. Perilymphatic and blood concentrations of triamcinolone of the 4 groups will be graphically presented by boxplots, both on the original and on the log-transformed scale. Median (quartile) concentrations and means ± standard deviations of the log-transformed concentrations will be calculated. Triamcinolone levels in cochlear perilymph Page 6 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 3. LIST OF ABBREVATIONS ITC Intratympanic cortisone i.v. Intravenous p.o. Per os SNHL Sensorineural hearing loss CI Cochlear implant AE Adverse event RWM Round window membrane SCC Semicircular canal CSF Cerebrospinal fluid SAE Serious adverse event SUSAR Suspected unexpected serious adverse event Triamcinolone levels in cochlear perilymph Page 7 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 4. TABLE OF CONTENTS CLINICAL STUDY PROTOCOL 1 1. SPONSOR, INVESTIGATOR, MONITOR AND SIGNATURES 3 2. PROTOCOL SYNOPSIS 5 3. LIST OF ABBREVATIONS 7 4. TABLE OF CONTENTS 8 5. BACKGROUND INFORMATION 12 BACKGROUND 12 STUDY RATIONALE 12 6. STUDY OBJECTIVES (HYPOTHESIS) 13 PRIMARY OBJECTIVE (HYPOTHESIS) 13 SECONDARY OBJECTIVES (HYPOTHESIS) 13 7. STUDY DESIGN 13 STUDY POPULATION 15 7.1.1 SUBJECT POPULATION 15 7.1.2 INCLUSION CRITERIA 15 7.1.3 EXCLUSION CRITERIA 15 7.1.4 FEMALES OF CHILDBEARING POTENTIAL 15 7.1.5 STUDY DURATION 15 7.1.6 WITHDRAWAL AND REPLACEMENT OF SUBJECTS 15 7.1.7 PREMATURE TERMINATION OF THE STUDY 16 8. METHODOLOGY 16 8.1 STUDY MEDICATION 18 8.1.1 DOSAGE AND ADMINISTRATION 19 8.1.2 STUDY-DRUG UP- AND DOWN TITRATION 19 8.1.3 STUDY-DRUG DELIVERY & DRUG STORAGE CONDITIONS 19 8.1.4 STUDY DRUG PACKAGING AND LABELING 19 8.1.5 IMP ADMINISTRATION & HANDLING 19 Triamcinolone levels in cochlear perilymph Page 8 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 8.1.6 DRUG ACCOUNTABILITY 19 8.1.7 PROCEDURES TO ASSESS SUBJECTS COMPLIANCE 20 8.1.8 CONCOMITANT MEDICATION 20 8.2 RANDOMIZATION AND STRATIFICATION 20 8.3 BLINDING 20 8.4 BENEFIT AND RISK ASSESSMENT 20 8.5 STUDY PROCEDURES 20 8.5.1 GENERAL RULES FOR TRIAL PROCEDURES 20 8.5.2 SCREENING INVESTIGATION 21 8.5.3 END-OF-STUDY (EOS) EXAMINATION 21 9. SAFETY DEFINITIONS AND REPORTING REQUIREMENTS 21 ADVERSE EVENTS (AES) 21 9.1.1 SUMMARY OF KNOWN AND POTENTIAL RISKS OF THE STUDY DRUG 21 9.1.2 DEFINITION OF ADVERSE EVENTS 23 SERIOUS ADVERSE EVENTS (SAES) 24 9.1.3 HOSPITALIZATION PROLONGATION OF EXISTING HOSPITALIZATION 25 9.1.4 SAES RELATED TO INVESTIGATIONAL DRUG 25 9.1.5 SUSPECTED UNEXPECTED SERIOUS ADVERSE REACTIONS (SUSARS) 25 9.1.6 PREGNANCY 25 SEVERITY OF ADVERSE EVENTS 26 RELATIONSHIP TO STUDY DRUG 27 REPORTING PROCEDURES 28 9.1.7 REPORTING PROCEDURES FOR SAES 28 9.1.8 REPORTING PROCEDURES FOR SUSAR 29 9.1.9 DEVELOPMENT SAFETY UPDATE REPORT 30 10. FOLLOW-UP 30 FOLLOW-UP OF STUDY PARTICIPANTS INCLUDING FOLLOW-UP OF ADVERSE EVENTS 30 TREATMENT AFTER END OF STUDY 30 11. STATISTICAL METHODOLOGY AND ANALYSIS 30 ANALYSIS SETS 31 SAMPLE SIZE CONSIDERATIONS 31 RELEVANT PROTOCOL DEVIATIONS 31 ENDPOINTS ANALYSIS 31 11.1.1 PRIMARY ENDPOINT ANALYSIS 31 11.1.2 SECONDARY ENDPOINT ANALYSIS 32 INTERIM ANALYSIS 32 12. DOCUMENTATION AND DATA MANAGEMENT 32 Triamcinolone levels in cochlear perilymph Page 9 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 DOCUMENTATION OF STUDY RESULTS 32 12.1.1 CASE REPORT FORM (CRF) 32 12.1.2 DATA COLLECTION 33 SAFEKEEPING 33 QUALITY CONTROL AND QUALITY ASSURANCE 33 12.1.3 PERIODIC MONITORING 33 12.1.4 AUDIT AND INSPECTIONS 34 REPORTING AND PUBLICATION 34 12.1.5 PUBLICATION OF STUDY RESULTS 34 13. ETHICAL AND LEGAL ASPECTS 34 INFORMED CONSENT OF SUBJECTS 34 ACKNOWLEDGEMENT / APPROVAL OF THE STUDY 35 13.1.1 CHANGES IN THE CONDUCT OF THE STUDY 35 INSURANCE 36 CONFIDENTIALITY 36 ETHICS AND GOOD CLINICAL PRACTICE (GCP) 37 14. REFERENCES 38 Triamcinolone levels in cochlear perilymph Page 10 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 TABLE 1. VISIT AND ASSESSMENT SCHEDULE Screening Treatment Sampling Follow Up Duration 1 day 1 day 1 week Visits Number 1 2 3 4 5 6 7 Name Screening Randomization Application Sampling Control 1 Control 2 Control 3 Time day 0 day 0 (gr. 1+2) day 1 day 2 day 3 1 week day 1 (gr. 3+4) +/- 2d Informed Consent x Inclusion / Exclusion Criteria x x Medical History x x Concomitant medication x x ENT Status x x Ear microscopy x x x x x Body weight and height x Puretonaudiogramm x x x Intratympanic Triamcinolone Application x Perilymph Sample x Blood Sample x Adverse Events x x x x x Triamcinolone levels in cochlear perilymph Page 11 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 5. BACKGROUND INFORMATION Background Over the past few years intratympanic cortisone application has been established additionally to intravenous cortisone application in the therapy of sudden sensorineural hearing loss (SNHL), toxic acute middle ear infections and preoperatively before operations of the inner ear (Cochlear implantation). Intratympanic application leads to a higher steroid concentration in the cochlear perilymph than i.v. administration does [1, 2]. Steroids are known for having several otoprotective qualities. When performing a cochlear implantation corticosteroid therapy can protect the residual hearing [3]. Hair cells of the inner ear are protected by steroids, when a trauma is induced [4]. Studies have shown that glucocorticoids reduce the impedance needed by the cochlear implant (CI). By the reduction of impedances needed a battery sparing function of the CI is made possible [5]. Inflammation, which leads to fibrosis in the cochlea and around the electrode, can also be reduced by steroids [5]. The intratympanic application of steroids is used as salvage therapy in patients with sudden SNHL [6] or as primary treatment option for patients who cannot be treated systemically. When applying steroids intratympanically the effect seems to be in the applied area and systemic side effects can be avoided. At our department a similar study was conducted on guinea pigs. The method of detection of Triamcinolone acetonide in the perilymph has already been established [7]. Study rationale Two studies have been published so far analyzing perilymph concentrations of prednisolon e after intravenous administration [8, 9]. Both studies could show that higher prednisolone doses result in higher perilymphatic concentrations. Two further studies examined blood and perilymphatic levels after intratympanic administration one using methylprednisolone and the other one using dexamethasone [10] [2]. Both studies could show that intratympanic application leads to a very small dissemination of the medication to the blood circulation and to high perilymphatic concentrations compared to intravenous application. When administering liquids to the middle ear they are rapidly drained via the Eustachian tube and the effect is lost. None of those studies investigated a crystalline/depot compound. Triamcinolone levels in cochlear perilymph Page 12 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 In Austria Triamcinolone acetonide (Volon A) is the steroid of choice for intratympanic application. As for other glucocorticoids applied intratympanically (IT) the application of Volon -Label- application has already been integrated in treatment guidelines of sudden SNHL and therefor is carried out at our department as part of routine procedures. Because of the crystalline compound of Volon A a depot effect is presumed. The otoprotective value of Triamcinolone acetonide could already be shown in studies [11, 12]. Up to now, no study has shown how much Triamcinolone acetonide is absorbed by the perilymph. Furthermore, the presumed depot effect is only proven for other uses. If Triamcinolone acetonide leads to a longer lasting and higher perilymph level has not been proven so far. To what extent Triamcinolone acetonide is disseminated to the blood circulation after intratympanic application has not been investigated yet. 6. STUDY OBJECTIVES (HYPOTHESIS) Primary Objective (Hypothesis) Demonstrate concentration of Triamcinolone in cochlear perilymph in comparison to concentrations in the blood. Secondary Objectives (Hypothesis) Assess the stability of triamcinolone acetonide levels in the cochlear perilymph. Assess the difference of triamcinolone acetonide levels in the cochlear perilymph and blood after administration of different doses of Triamcinolone acetonide. 7. STUDY DESIGN At the ENT department of the university hospital Vienna (AKH Wien) patients are treated with intratympanic triamcinolone acetonide before cochlea implantation to reduce inflammation and in some cases to protect residual hearing. Triamcinolone acetonide levels in cochlear perilymph will be evaluated in an open prospective clinical study. Patients scheduled for cochlear implant surgery between 18 and 90 years will be included. Patients who are treated with steroids preoperatively will be excluded from the study. Patients will be randomized after inclusion to one of four groups. The randomization is carried out to generate hypothesis for the needed dose and best time of application in the future. Triamcinolone acetonide will then be applied 20-24h before surgery or at the beginning of the surgery, depending on randomization (see below). About 20 μl of perilymph will be sampled simultaneously to a Triamcinolone levels in cochlear perilymph Page 13 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 blood sample during cochlear implant surgery. The first twenty patients will be randomized to Triamcinolone acetonide 40mg to allow for a first analysis of the samples. Patients 21 to forty will be randomized to Triamcinolone acetonide 10mg. The probes will be stored at -80°C . Triamcinolone acetonide levels of the blood and perilymph will be determined by the pharmaceutical laboratory (Department of Pharmaceutical Technology and Biopharmaceutics, University of Vienna). The patients will be randomized to 4 groups. Group 1 - Volon A 10mg administration 20 - 24 hours before sampling. Group 2 Volon A 40mg administration 20 - 24 hours before sampling. Group 3 Volon A 10mg administration 1 to 2 hours before sampling. Group 4 Volon A 40mg administration 1 to 2 hours before sampling. The time interval of application (1 to 2 hours and 20 to 24 hours before sampling) are a result of varying time of surgery depending on surgeons and patient anatomy as well as day to day clinical organization. Patients can withdraw consent at any time of the study. The active phase of each patient will be between 6 and 9 days depending on time of follow- up visit. Triamcinolone levels in cochlear perilymph Page 14 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 Study population 7.1.1 Subject population Patients, between 18 and 90 years, will be included in the study, who are scheduled to receiving a cochlear implant and who are willing to participate in the study. 7.1.2 Inclusion criteria Patients between 18 and 90 years receiving a cochlear implant and who are willing to participate in the study. 7.1.3 Exclusion criteria Patients younger than 18 years Patients who receive cortisone regularly or receive cortisone i.v. or p.o. preoperatively Patients with contraindications against the administration of Volon A 7.1.4 Females of childbearing potential Females of childbearing potential will be included in the study, if birth control is carried out (hormonal contraception, intrauterine or barrier contraception) or a pregnancy can be ruled out completely. 7.1.5 Study duration Patients will be recruited over a time period of 2 years. The active phase of each patient will last for up to 9 days. 7.1.6 Withdrawal and replacement of subjects Criteria for withdrawal Subjects may prematurely discontinue from the study at any time. Subjects must be withdrawn under the following circumstances: at their own request if the Investigator feels it would not be in the best interest of the subject to continue Triamcinolone levels in cochlear perilymph Page 15 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 if the subject violates conditions laid out in the consent form or disregards instructions by the study personal In all cases, the reason why subjects are withdrawn must be recorded in detail in the CRF materials (completed, partially completed and empty CRFs) will be retained. Follow-up of patients withdrawn from the study Patients routinely receive intratympanic Triamcinolone acetonide. The study only consists of the calculation of Triamcinolone acetonide concentration in the perilymph and blood. Patients will be asked for adverse events at routine post-operative follow-up visits. No further follow up visits are necessary or planned within this study. 7.1.7 Premature termination of the study The sponsor has the right to close this study at any time. The IEC and the competent regulatory authority must be informed within 15 days of early termination. The trial or single dose steps will be terminated prematurely in the following cases: If adverse events occur which are so serious that the risk-benefit ratio is not acceptable. If the number of dropouts is so high that proper completion of the trial cannot realistically be expected. 8. METHODOLOGY At the department of the Medical University of Vienna patients routinely receive intratympanic application of triamcinolone acetonide. 1 mL suspension containing 10mg (Groups 1 and 3) or 40mg (Groups 2 and 4) of triamcinolone acetonide is applied intratympanically via a 25G (0.50x90mm, 3.50 IN) needle after local anesthesia with xylocaine spray (10mg/Puff). During the cochlear implant surgery, the cochlea is entered mostly via round window approach. Alternatively, if the round window cannot be identified, a cochleostomy is performed. After entering the cochlea, about 20μL of perilymph are sampled using a sterile disposable aspirator with a diameter of 0.4mm. A sterile insulin syringe is used to aspirate the perilymph. The perilymph sampling method has been performed similarly in other studies [2, 10]. Triamcinolone levels in cochlear perilymph Page 16 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 Simultaneously a blood sample of 4ml is drawn in a heparin blood tube with a standard butterfly needle. The sample of perilymph is stored in an eppendorf vial (volume 0,2ml) and frozen to approx. -80°. The blood sample is centrifuged at 3000g, 20°C for 3 minutes at. The plasma is removed and stored in eppendorf vials (volume 2ml) and also frozen to approx.-80°. Both vials will be labeled with the patient number. Patients will be numbered with a randomly assigned three- digit number. Quantification of Triamcinolone acetonide Samples will be diluted with mobile phase consisting of acetonitrile/2 mM aqueous am- monium acetate (60:40) adjusted to pH 3.2 with formic acid [13] and stored at +4 ° C until analysis by high-performance liquid chromatography/mass spectrometry, comprising an Ulti- mate RSLC 3000 series System (Thermo Fisher Scientific, Vienna, Austria) and an API 4000 Triple Quadrupole Mass Spectrometer (AB Sciex instruments, Vienna, Austria) equipped with an electro- spray ionization ion source and controlled by the Analyst 1.5 soft- ware (Dionex, Vienna, Austria). The chromatographic separation of samples will be conducted by isocratic elution using an Acclaim 120 C reversed-phase LC column (2.1 × 150 mm, 3 m; Thermo Fisher Scientific, Vienna, Austria) at 25 ° C. The run time will be 15 min at a flow rate of 0.5 ml/min, and the retention time of TAAc is about 1.28 min. Released TAAc will be selectively detected and quantified by tandem mass spectrometry fragmentation giving a quasimolecular ion at m/z 435 [M-H]+. Each sample series will be monitored by quality control samples containing certain amounts of TAAc within the range of the calibration graph. Triamcinolone levels in cochlear perilymph Page 17 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 Screening Inclusion Day 0 Randomization Day 0 Volon A10mg Volon A10 mg Volon A40mg Volon A40mg 20-24h 1-2h 20-24h 1-2h Sampling Day 1 Follow-up Day 2, Day 3, 1 Week +/- 2 Days 8.1 Study medication Active agent and characteristics: Triamcinolone acetonide Trade name of the agent: Volon A crystal suspension Manufacturer: Mibe GmbH Arzneimittel Triamcinolone levels in cochlear perilymph Page 18 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 Drug supply: Dermapharm GmbH Storage Instructions: Freezing is not allowed. Volon A should be stored in the box to protect in from light. Route of administration: Intratympanic Information can be found in the invest . 8.1.1 Dosage and administration Dose: 1mL of Volon A 10mg or 40mg Route of administration: intratympanic Duration: single administration 8.1.2 Study-drug up- and down titration Not feasible 8.1.3 Study-drug delivery & drug storage conditions Triamcinolone acetonide is delivered at room temperature. The content has to be stored shielded from light, in the boxing. Triamcinolone acetonide should not be frozen. It will be stored in the packaging at room temperature at the ENT department (ward 15J or 15I). 8.1.4 Study drug packaging and labeling Since Triamcinolone acetonide is a registered drug it will be stored in the original package. 8.1.5 IMP administration & handling 1 mL Triamcinolone acetonide is applied intratympanically via a 25GA (0.50x90mm, 3.50 IN) needle after local anesthesia with Xylocaine spray (10mg/Puff). Triamcinolone acetonide should be inspected before use. If agglomerations occur the drug should not be administered. 8.1.6 Drug Accountability The batch number will be documented on the Case Report Form. Triamcinolone acetonide will be administered at a single time point by a medical doctor intratympanically. Triamcinolone levels in cochlear perilymph Page 19 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 8.1.7 Procedures to assess compliance Not applicable 8.1.8 Concomitant medication Allowed: All concomitant medication is allowed. Patients who have to take cortisone preoperatively will not be included in the study. 8.2 Randomization and stratification For Randomization https://www.meduniwien.ac.at/randomizer will be used. The first twenty patients will be randomized to the 40mg groups. The second half will be randomized to the 10mg groups. On day 0 participants will be randomized to one of 2 groups and the intratympanic application of triamcinolone will be administered accordingly on day 0 or day 1. Block randomization will be used in groups of 8. The method of permuted blocks randomization will be used with an equally weighted allocation to the 4 treatment groups (resulting in 10 patients per group). 8.3 Blinding No blinding is required in this study. 8.4 Benefit and risk assessment This study consists of a perilymph and a blood sample during cochlear implantation. Patients included in the study are deaf or profoundly hearing impaired. As previously shown in other studies sampling of the perilymph is a safe method. This study can give us information on the absorption of Triamcinolone acetonide by perilymph as well as information on the stability of Triamcinolone acetonide after absorption of the perilymph. Since Triamcinolone acetonide is used in the treatment of sudden SNHL and preoperatively, this study can deliver necessary information on the best timing of drug application and the necessary dose. Additionally, a blood sample is taken, which can lead to known risks such as infections and hematoma. 8.5 Study procedures 8.5.1 General rules for trial procedures All study measures like blood sampling and measurements have to be documented with date (dd:mm:yyyy). In case several study procedures are scheduled at the same time point, there is no specific sequence that should be followed. Triamcinolone levels in cochlear perilymph Page 20 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 The dates of all procedures should be according to the protocol. The time margins mentioned in the study flow chart are admissible. If for any reason, a study procedure is not performed within scheduled margins a protocol deviation should be noted, and the procedure should be performed as soon as possible or as adequate. If it is necessary for organizational reasons, it is admissible to perform procedures, which are scheduled for one visit at two different time points. Allowed time margins should thereby not be exceeded. 8.5.2 Screening investigation Patients scheduled for cochlear implantation will be asked to participate in the study. Inclusion and exclusion criteria will be evaluated at the end department. If patients fulfill inclusion and exclusion criteria and consent to the study is given a reevaluation on day 0 will be carried out. If the second evaluation has a positive outcome patients will then be included in the study on day 0. 8.5.3 End-of-study (EOS) examination One week after surgery patients routinely are scheduled for wound examination and stitch removal as well as scheduling of cochlear implant fitting. During this examination adverse events will be evaluated. Additionally, ear microscopy is carried out. 9. SAFETY DEFINITIONS AND REPORTING REQUIREMENTS Adverse events (AEs) 9.1.1 Summary of known and potential risks of the study drug Known side effects: Cardiovascular Arrhythmia, heart failure Musculoskeletal Aseptic necrosis of femoral and humeral heads, loss of muscle mass, muscle weakness, osteoporosis, pathologic fracture of long bones, tendon rupture, and vertebral compression Triamcinolone levels in cochlear perilymph Page 21 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 fractures, bone mineral density loss and osteoporosis, steroid myopathy, vasculitis Gastrointestinal Peptic ulcer with potential perforation and hemorrhage, perforation of small and large bowel, pancreatitis, abdominal distention and ulcerative esophagitis Dermatologic Impaired wound healing, thin, fragile skin, petechiae and ecchymoses, facial erythema, increased sweating, and suppressed reactions to skin tests, purpura, striae rubrae, hyperpigmentation, steroidakne, allergic dermatitis Nervous system Convulsions, increased intracranial pressure with papilledema, vertigo and headache, pseudotumor cerebri, manifestation of a latent epilepsie, sleeping disorders, neuritis, paresthesia Endocrine Menstrual irregularities, postmenopausal vaginal bleeding, hirsutism, suppression of growth in children, manifestations of latent diabetes, increased requirements for insulin or oral hypoglycemic agents in diabetics, decreased carbohydrate tolerance, and secondary adrenocortical and pituitary unresponsiveness, impotence, pseudo-cushing syndrome, weight gain, negative protein and calcium balance, increased appetite Ocular Cataract, glaucoma, increased intraocular pressure, glaucoma and exophthalmos, cornea perforation Hypersensitivity Anaphylactoid reactions, anaphylaxis, and angioedema Vascular diseases Necrotizing angiitis, higher risk of artheriosis and thrombosis Electrolyte dysbalance Natrium retention, water retention, higher potassium excretion, hypokalemic alkalosis, Triamcinolone levels in cochlear perilymph Page 22 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 hypertension, hyperglycemia, glukosuria Other Anaphylactic reaction, feeling of heat Medications with potential interactions: Cardiac glycosides ACE inhibitors Chloroquine, Hydrochloroquine, Mefloquine Aspirin NSAIDs Oral Anticoagulants Bupropion Methotrexate 9.1.2 Definition of adverse events An AE is any untoward adverse change from the subject's baseline condition, i.e., any unfavorable and unintended sign including an abnormal laboratory finding, symptom or disease which is considered to be clinically relevant by the physician that occurs during the course of the study, whether or not considered related to the study drug. Adverse events include: Exacerbation of a pre-existing disease. Increase in frequency or intensity of a pre-existing episodic disease or medical condition. Disease or medical condition detected or diagnosed after study drug administration even though it may have been present prior to the start of the study. Continuous persistent disease or symptoms present at baseline that worsen following the start of the study. Lack of efficacy in the acute treatment of a life-threatening disease. Events considered by the Investigator to be related to study-mandated procedures. Abnormal assessments, e.g., ECG and physical examination findings, must be reported as AEs if they represent a clinically significant finding that was not present at baseline or worsened during the course of the study. Triamcinolone levels in cochlear perilymph Page 23 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 Laboratory test abnormalities must be reported as AEs if they represent a clinically significant finding, symptomatic or not, which was not present at baseline or worsened during the course of the study or led to dose reduction, interruption or permanent discontinuation of study drug. Adverse events do not include: Pre-planned interventions or occurrence of endpoints specified in the study protocol are not considered AE´s, if not defined otherwise (eg.as a result of overdose) Medical or surgical procedure, e.g., surgery, endoscopy, tooth extraction, transfusion. However, the event leading to the procedure is an AE. If this event is serious, the procedure must be described in the SAE narrative. Pre-existing disease or medical condition that does not worsen. Situations in which an adverse change did not occur, e.g., hospitalizations for cosmetic elective surgery or for social and/or convenience reasons. Overdose of either study drug or concomitant medication without any signs or symptoms. However, overdose must be mentioned in the Study Drug Log. Serious Adverse Events (SAEs) A Serious Adverse Event (SAE) is defined by the International Conference on Harmonization (ICH) guidelines and GCP guidelines as any AE fulfilling at least one of the following criteria: Results in deaths. Life-threatening defined as an event in which the subject was, in the judgment of the Investigator, at risk of death at the time of the event; Requiring subject's hospitalization or prolongation of existing hospitalization Resulting in persistent or significant disability or incapacity (i.e., a substantial ns). Congenital anomaly or birth defect. Optional: Is medically significant or requires intervention to prevent at least one of the outcomes listed above Life threatening refers to an event in which the subject was at risk of death at the time of the event. It does not refer to an event that hypothetically might have caused death if it were more severe. Important medical events that may not immediately result in death, be life-threatening, or require hospitalization may be considered as SAEs (optional!) when, based upon appropriate Triamcinolone levels in cochlear perilymph Page 24 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 medical judgment, they may jeopardize the subject and may require medical or surgical intervention to prevent one of the outcomes listed in the definitions above. This means an individual case decision. 9.1.3 Hospitalization Prolongation of existing hospitalization Hospitalization is defined as an overnight stay in a hospital unit and/or emergency room. An additional overnight stay defines a prolongation of existing hospitalization. The following is not considered an SAE and should be reported as an AE only: Treatment on an emergency or outsubject basis for an event not fulfilling the definition of seriousness given above and not resulting in hospitalization. The following reasons for hospitalizations are not considered AEs, and therefore not SAEs: Hospitalizations for cosmetic elective surgery, social and/or convenience reasons. Elective treatment of a pre-existing disease or medical condition that did not worsen, e.g., hospitalization for chemotherapy for cancer, elective hip replacement for arthritis. 9.1.4 SAEs related to investigational drug Such SAEs are defined as SAEs that appear to have a reasonable possibility of causal relationship. 9.1.5 Suspected unexpected serious adverse reactions (SUSARs) SUSARs are all serious adverse reactions with suspected causal relationship to the study drug that is unexpected (not previously described in the Summary of Product Characteristics or Investigator SUSARs will be reported within 24hours. 9.1.6 Pregnancy Any pregnancy that occurs during study participation must be reported to the Investigator/sponsor. To ensure subject safety, each pregnancy must be reported to the Sponsor immediately. The pregnancy must be followed up to determine outcome (including premature termination) and status of mother and child. Pregnancy complications and Triamcinolone levels in cochlear perilymph Page 25 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 elective terminations for medical reasons must be reported as an AE or SAE. Spontaneous abortions must be reported as an SAE. Any SAE occurring in association with a pregnancy brought to the Investigator after the subject has completed the study and considered by the Investigator as possibly related to the investigational product, must be promptly reported to the Investigator/sponsor. In addition, the Investigator must attempt to collect pregnancy information on any female partners of male study subjects who become pregnant while the subject is enrolled in the study. Pregnancy information must be reported to the Investigator/sponsor as described above. Severity of adverse events The severity of clinical AEs is graded on a three-point scale: mild, moderate, severe, and reported on specific AE pages of the CRF. If the severity of an AE worsens during study drug administration, only the worst intensity should be reported on the AE page. If the AE lessens in intensity, no change in the severity is required. If an AE occurs during a washout or placebo run-in phase and afterwards worsens during the treatment phase, a new AE page must be filled in with the intensity observed during study drug administration. Mild Event may be noticeable to subject; does not influence daily activities; the AE resolves spontaneously or may require minimal therapeutic intervention; Moderate Event may make subject uncomfortable; performance of daily activities may be influenced; intervention may be needed; the AE produces no sequelae. Severe Event may cause noticeable discomfort; usually interferes with daily activities; subject may not be able to continue in the study; the AE produces sequelae, which require prolonged therapeutic intervention. Triamcinolone levels in cochlear perilymph Page 26 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 A mild, moderate or severe AE may or may not be serious. These terms are used to describe the intensity of a specific event (as in mild, moderate, or severe myocardial infarction). However, a severe event may be of relatively minor medical significance (such as severe headache) and is not necessarily serious. For example, nausea lasting several hours may be rated as severe, but may not be clinically serious. Fever of 39°C that is not considered severe may become serious if it prolongs hospital discharge by a day. Seriousness rather than severity serves as a guide for defining regulatory reporting obligations. Relationship to study drug For all AEs, the Investigator will assess the causal relationship between the study drug and the AE using his/her clinical expertise and judgment according to the following algorithm that best fits the circumstances of the AE: Not related May or may not follow a temporal sequence from administration of the study product Is biologically implausible and does not follow known response pattern to the suspect study drug (if response pattern is previously known). modes of therapy administered to the subject. Unlikely There is a reasonable temporal relation between the AE and the intake of the study medication, but there is a plausible other explanation for the occurrence of the AE. Possibly The AE has a reasonable temporal relationship with drug administration. environmental or toxic factors, or concomitant therapy administered to the study subject. The relationship between study drug and AE may also be pharmacologically or clinically plausible. Probably Triamcinolone levels in cochlear perilymph Page 27 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 There is a reasonable temporal relation between the AE and the intake of the study medication, and plausible reasons point to a causal relation with the study medication. Related Reasonable temporal relation between the AE and the intake of the study medication and there is no other explanation for the AE and subsidence or disappearance of the AE on withdrawal of the study medication and recurrence of the symptoms on restart at previous dose (only applies for re-institution of mediation). Not assessable The causal relationship between the study drug and the AE cannot be judged. Reporting procedures A special section is designated to adverse events in the case report form. The following details must thereby be entered: Type of adverse event Start (date and time) End (date and time) Severity (mild, moderate, severe) Serious (no / yes) Unexpected (no / yes) Outcome (resolved, resolving, not resolved, resolved with sequelae, unknown, fatal) Relation to study drug (Related/ Probably/ Possibly/ Unlikely/ Not related/ Not assessable) Adverse events are to be documented in the case report form in accordance with the above- mentioned criteria. 9.1.7 Reporting procedures for SAEs Triamcinolone levels in cochlear perilymph Page 28 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 In case of a serious Adverse event, the Investigator has to use all supportive measures for best patient treatment. A written report is also to be prepared and should at least contain the following: Patient number Patient: sex The suspected investigational medical product (IMP) The adverse event assessed as serious Short description of the event and outcome If applicable, the initial report should be followed by the Follow up report, indicating the outcome of the SAE. 9.1.8 Reporting procedures for SUSAR It must be remembered that the regulatory authorities, and the Institutional Review Board / Independent Ethics Committee (IRB / IEC) must be informed about all SUSAR. Such reports shall be made by the sponsor and should content at least the following details: Patient number (study code/screening number) Patient: age in years, sex Name of Investigator and investigating site Period of administration The suspected investigational medical product (IMP) The adverse event assessed as serious and unexpected, and for which there is a suspected causal relationship to the IMP Concomitant disease and medication Short description of the event: Description Onset and if applicable, end Therapeutic intervention Causal relationship Seriousness criteria or reportable reason Electronic reporting should be the expected method for reporting of SUSARs to the competent authority. In that case, the format and content as defined by the regulatory requirements should be adhered to. The latest version of MedDRA should be applied. Lower level terms (LLT) should be used. Triamcinolone levels in cochlear perilymph Page 29 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 9.1.9 Development Safety Update Report A Development Safety Update Report (DSUR) will be provided by the Sponsor annually. This report will also be presented annually to the Independent Ethics (IEC) and to the competent authorities by the sponsor. 10. FOLLOW-UP Follow-up of study participants including follow-up of adverse events Patients will be at the hospital at least two days after surgery (surgery = day 1). During this time patients will be asked for any adverse events on a daily basis. Additionally, patients will be followed up one week after surgery for wound inspection and stitch removal. At this follow-up visit patients will be asked for adverse events as well. Treatment after end of study There will be no treatment after end of study. 11. STATISTICAL METHODOLOGY AND ANALYSIS Statistical methodology Primary objective: The paired t-test will be used to compare the log-transformed perilymphatic and blood concentrations of Triamcinolone acetonide, and a 95% confidence interval will be calculated for the geometric mean ratio. Secondary objective: Descriptive statistical methods will be used for the secondary (hypotheses generating) objective to compare the 4 groups of patients. Perilymphatic and blood concentrations of Triamcinolone levels in cochlear perilymph Page 30 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 Triamcinolone acetonide of the 4 groups will be graphically presented by boxplots, both on the original and on the log-transformed scale. Median (quartile) concentrations and means ± standard deviations of the log-transformed concentrations will be calculated. Data handling Case report forms will be copied and stored separately. Data will be double-checked and saved in an excel sheet on a computer to which only study personnel has access to. Patients will be randomly assigned a three-digit number and the further data analysis will be carried out anonymously. Analysis sets Intention to treat set This analysis set includes subjects who were randomized (and received at least one dose study drug). Sample size considerations The sample size calculation is based on the paired t-test and a two-sided significance level of 5%. Perilymphatic and blood concentrations of 12 patients are known from the literature (Bird et al, 2011) with geometric mean values of 1.26 and 0.001, respectively, and the standard deviation of the paired differences of the log10-transformed values was calculated as 0.81. To detect an effect size of 0.5 standard deviations, which is a difference of 0.4 on the log- scale (a difference in the geometric means of 1.26 to 0.5) with a statistical power of 86%, a total number of 40 patients have to be included in the study (nQuery Advisore 7.0). Relevant protocol deviations All protocol deviations will be listed in the study report and noted on case report forms. Endpoints analysis 11.1.1 Primary endpoint analysis Perilymphatic and blood concentration of Triamcinolone acetonide Primary objective: The paired t-test will be used to compare the log-transformed perilymphatic and blood concentrations of Triamcinolone acetonide, and a 95% confidence interval will be calculated for the geometric mean ratio. Triamcinolone levels in cochlear perilymph Page 31 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 11.1.2 Secondary endpoint analysis Secondary objective: Descriptive statistical methods will be used for the secondary (hypotheses generating) objective to compare the 4 groups of patients. Perilymphatic and blood concentrations of Triamcinolone acetonide of the 4 groups will be graphically presented by boxplots, both on the original and on the log-transformed scale. Median (quartile) concentrations and means ± standard deviations of the log-transformed concentrations will be calculated. Interim analysis Not applicable Criteria for the termination of the trial See 7.1.7 12. DOCUMENTATION AND DATA MANAGEMENT Documentation of study results A subject screening and identification log will be completed for all screened subjects with the reasons for exclusion. 12.1.1 Case report form (CRF) For each subject enrolled, regardless of study drug initiation, a CRF must be completed and signed by the Investigator or a designated sub-Investigator. This also applies to those subjects who fail to complete the study. If a subject withdraws from the study, the reason must be noted on the CRF. Case report forms are to be completed on an ongoing basis. CRF entries and corrections will only be performed by study site staff, authorized by the Investigator. In a paper based CRF all forms should be completed and must be legible. Entry errors have to be corrected according the ICH-GCP Guidelines. Triamcinolone levels in cochlear perilymph Page 32 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 The entries will be checked by trained personnel (Monitor) and any errors or inconsistencies will be corrected immediately. The monitor will collect original completed and signed CRFs at the end of the study. A copy of the completed and signed CRFs will remain on site, as will the original data. Original CRFs will be passed to study personnel (Data Manager). Paper based CRFs will be used. 12.1.2 Data Collection Data collected at all visits are entered into an interactive form. The CRFs will be source documents verified following guidelines established before study onset as detailed in the Monitoring Plan. Maintenance of the study database will be performed by study personnel. Safekeeping The Investigator will maintain adequate and accurate records to enable the conduct of the study to be fully documented and the study data to be subsequently verified (according to ICH- will be classified into two different categories: Investigator's study site file (ISF) with all essential documents regarding the study conduct, and subject clinical source documents. The Investigator's file will contain all essential documents listed in ICH-GCP Guidelines section 8. Subject clinical source documents include all patient hospital clinical records in original version, such as original laboratory reports, ECG, X-ray prints and other reports. These two categories of documents must be kept on file by the Investigator for as long as needed to comply with the regulatory requirements. Quality Control and Quality Assurance 12.1.3 Periodic Monitoring The designated monitor will contact and visit the Investigator on a regularly basis and will be allowed to have direct access to all source documents needed to verify the entries in the Triamcinolone levels in cochlear perilymph Page 33 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 CRFs and other protocol-related documents provided that subject confidentiality is maintained in agreement with local regulations. It will be the monitor's responsibility to inspect the CRFs at regular intervals according to the monitoring plan throughout the study, to verify the adherence to the protocol and the completeness, consistency and accuracy of the data being entered on them. A qualified staff member of the ENT department will perform monitoring. An initiation visit, a control visits and a close out visit will be carried out. The monitor will randomly check source data, all patient consent forms, storage of study medication and accordance to study protocol. 12.1.4 Audit and Inspections Upon request, the Investigator will make all study-related source data and records available to a qualified quality assurance auditor mandated by the sponsor or to competent authority inspectors. The main purposes of an audit or inspection are to confirm that the rights and welfare of the subjects have been adequately protected, and that all data relevant for assessment of safety and efficacy of the investigational product have appropriately been reported to the sponsor. Reporting and Publication 12.1.5 Publication of study results The findings of this study will be published by the sponsor (Investigators) in a scientific journal and presented at scientific meetings. The manuscript will be circulated to all co - Investigators before submission. Confidentiality of subjects in reports/publications will be guaranteed. 13. ETHICAL AND LEGAL ASPECTS Informed consent of subjects Following comprehensive instruction regarding the nature, significance, impact and risks of this clinical trial, the patient must give written consent to participation in the study. Triamcinolone levels in cochlear perilymph Page 34 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 During the instruction the trial participants are to be made aware of the fact that they can withdraw their consent without giving reasons at any time without their further medical care being influenced in any way. In addition to the comprehensive instructions given to the trial participants by the Investigator, the trial participants also receive a written patient information sheet in comprehensible language, explaining the nature and purpose of the study and its progress. The patients must agree to the possibility of study-related data being passed on to relevant authorities. The patients must be informed in detail of their obligations in relation to the trial participants insurance in order not to jeopardize insurance cover. Acknowledgement / approval of the study The Investigator (or a designated CRO) will submit this protocol and any related document provided to the subject (such as subject information used to obtain informed consent) to an Ethics Committee (EC) or Institutional Review Board (IRB). Approval from the committee must be obtained before starting the study. The clinical trial shall be performed in full compliance with the legal regulations according to the Drug Law (AMG - Arzneimittelgesetz) of the Republic of Austria. An application must also be submitted to the Austrian Competent Authorities (Bundesamt für Sicherheit im Gesundheitswesen (BASG) represented by the Agency for Health and Food Safety (AGES Medizinmarktaufsicht) and registered to the European Clinical Trial Database (EudraCT) using the required forms. The timelines for (silent) approval set by national law must be followed before starting the study. 13.1.1 Changes in the Conduct of the Study Protocol amendments Proposed amendments must be submitted to the appropriate CA and ECs. Substantial amendments may be implemented only after CA/EC approval has been obtained. Amendments that are intended to eliminate an apparent immediate hazard to subjects may be implemented prior to receiving CA/EC approval. However, in this case, approval must be obtained as soon as possible after implementation. Study Termination Triamcinolone levels in cochlear perilymph Page 35 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 If the sponsor or the Investigator decides to terminate the study before the planned completion, they will notify each other in writing stating the reasons of early termination. Both the sponsor and the investigator will ensure the protection of the wellbeing. The sponsor will notify the regulatory authority as well as the ethics committee about the premature termination. Documentation will be filed in the Trial Master File as well as in the Investigator Site File. Clinical Study Report (CSR) Within one year after the final completion of the study, a full CSR will be prepared by the sponsor and submitted to the EC and the competent authority. The Investigator will be asked to review and sign the final study report. Insurance During their participation in the clinical trial the patients will be insured as defined by legal requirements. The Investigator of the clinical trial will receive a copy of the insurance conditions of the ' insurance'. The sponsor is providing insurance in order to indemnify (legal and financial coverage) the Investigator/center against claims arising from the study, except for claims that arise from malpractice and/or negligence. The compensation of the subject in the event of study-related injuries will comply with the applicable regulations. Details on the existing insurance are given in the patient information sheet. Patients will be insured according to the general agreement of the Medical university of Vienna: Zürich Versicherungs AG Schwarzenbergplatz 15 1010 Wien Tel.: 0043 (01) 50125-0 Confidentiality The information contained in this document, especially unpublished data, is the property of the sponsor of this study. It is therefore provided to you in confidence as an Investigator, potential Investigator, or consultant, for review by you, your staff, and an Ethics Committee or Institutional Review Board. It is understood that this information will not be disclosed to others without written authorization from the Sponsor of this study (Prof. W. Gstöttner). Triamcinolone levels in cochlear perilymph Page 36 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 Ethics and Good Clinical Practice (GCP) The Investigator will ensure that this study is conducted in full conformance with the principles of the "Declaration of Helsinki" (as amended at the 64th WMA General Assembly, Fortaleza, Brazil, 2013) and with the laws and regulations of the country in which the clinical research is conducted. The Investigator of the clinical trial shall guarantee that only appropriately trained personnel will be involved in the study. All studies must follow the ICH GCP Guidelines and the regulatory requirements. Therefore, this study follows the EU Directive embedded in the Austrian drug act. Triamcinolone levels in cochlear perilymph Page 37 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 14. REFERENCES 1. Hobson, C.E., T.H. Alexander, and J.P. Harris, Primary treatment of idiopathic sudden sensorineural hearing loss with intratympanic dexamethasone. Curr Opin Otolaryngol Head Neck Surg, 2016. 24(5): p. 407-12. 2. Bird, P.A., et al., Intratympanic versus intravenous delivery of dexamethasone and dexamethasone sodium phosphate to cochlear perilymph. Otol Neurotol, 2011. 32(6): p. 933-6. 3. Rajan, G.P., et al., The role of preoperative, intratympanic glucocorticoids for hearing preservation in cochlear implantation: a prospective clinical study. Laryngoscope, 2012. 122(1): p. 190-5. 4. van de Water, T.R., et al., Mechanisms of hearing loss from trauma and inflammation: otoprotective therapies from the laboratory to the clinic. Acta Otolaryngol, 2010. 130(3): p. 308-11. 5. Wilk, M., et al., Impedance Changes and Fibrous Tissue Growth after Cochlear Implantation Are Correlated and Can Be Reduced Using a Dexamethasone Eluting Electrode. PLoS One, 2016. 11(2): p. e0147552. 6. O'Connell, B.P., J.B. Hunter, and D.S. Haynes, Current concepts in the management of idiopathic sudden sensorineural hearing loss. Curr Opin Otolaryngol Head Neck Surg, 2016. 24(5): p. 413-9. 7. Honeder, C., et al., Sustained release of triamcinolone acetonide from an intratympanically applied hydrogel designed for the delivery of high glucocorticoid doses. Audiol Neurootol, 2014. 19(3): p. 193-202. 8. Oertel, R., W. Kirch, and E. Klemm, Prednisolone concentration in the cochlea of patients with perilymph fistula. Pharmazie, 2007. 62(3): p. 239-40. 9. Niedermeyer, H.P., et al., Cortisol levels in the human perilymph after intravenous administration of prednisolone. Audiol Neurootol, 2003. 8(6): p. 316-21. 10. Bird, P.A., et al., Intratympanic versus intravenous delivery of methylprednisolone to cochlear perilymph. Otol Neurotol, 2007. 28(8): p. 1124-30. 11. Guzman, J., et al., Triamcinolone acetonide protects auditory hair cells from 4- hydroxy-2,3-nonenal (HNE) ototoxicity in vitro. Acta Otolaryngol, 2006. 126(7): p. 685-90. 12. Kiefer, J., et al., Conservation of low-frequency hearing in cochlear implantation. Acta Otolaryngol, 2004. 124(3): p. 272-80. 13. Cesar, I.C., et al., Determination of triamcinolone in human plasma by a sensitive HPLC-ESI-MS/MS method: application for a pharmacokinetic study using nasal spray formulation. J Mass Spectrom, 2011. 46(3): p. 320-6. Triamcinolone levels in cochlear perilymph Page 38 of 38 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Otolaryngology - Head & Neck Surgery American Medical Association

Evaluation of Levels of Triamcinolone Acetonide in Human Perilymph and Plasma After Intratympanic Application in Patients Receiving Cochlear Implants

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Publisher
American Medical Association
Copyright
Copyright 2021 Dahm V et al. JAMA Otolaryngology–Head & Neck Surgery.
ISSN
2168-6181
eISSN
2168-619X
DOI
10.1001/jamaoto.2021.2492
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See Article on Publisher Site

Abstract

IMPORTANCE The use of intratympanically applied steroids is of increasing interest. Supplemental content Consequently, research has focused on finding an ideal drug that diffuses through the round CME Quiz at window membrane and can be retained in the perilymph. jamacmelookup.com and CME Questions page 1012 OBJECTIVE To compare levels of triamcinolone acetonide (TAC) in perilymph and plasma after intratympanic injection. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial included 40 patients receiving cochlear implants at a single tertiary care center in Vienna, Austria. Patients were randomized to 1 of 4 treatment groups receiving 1 of 2 intratympanic doses of TAC (10 mg/mL or 40 mg/mL) at 1 of 2 approximate time points (24 hours or 1 hour) before sampling the perilymph. Inclusion was carried out between November 2017 and January 2020, and data were analyzed in December 2020. INTERVENTIONS All patients underwent intratympanic injection of TAC. During cochlear implantation, perilymph and plasma were sampled for further analysis. MAIN OUTCOMES AND MEASURES Levels of TAC measured in perilymph and plasma. RESULTS Among the 37 patients (median [range] age, 57 [26-88] years; 18 [49%] men) included in the analysis, TAC was present at a median (range) level of 796.0 (46.4-7706.7) ng/mL. In the majority of patients (n = 29; 78%), no drug was detectable in the plasma after intratympanic injection. Levels above the limit of detection were less than 2.5 ng/mL. The 1-factorial analysis of variance model showed lower TAC levels in the group that received TAC, 10 mg/mL, 24 hours before surgery (median, 271 ng/mL) compared with the group that received TAC, 10 mg/mL, 1 hour before surgery (median, 2877 ng/mL), as well as in comparison with the groups receiving TAC, 40 mg/mL, 24 hours before surgery (median, 2150 ng/mL) and 1 hour before surgery (median, 939 ng/mL). The 2-factorial analysis of variance model showed lower TAC levels in the group receiving TAC, 10 mg/mL, 24 hours before surgery than the group receiving TAC, 10 mg/mL, 1 hour before surgery, and higher TAC levels in the group receiving TAC, 40 mg/mL, 24 hours before surgery compared with the Author Affiliations: Department of group receiving TAC, 10 mg/mL, 24 hours before surgery. Patients with thickening of the Otorhinolaryngology–Head and Neck middle ear had statistically significantly higher plasma levels (median, 1.4 ng/mL vs 0 ng/mL) Surgery, Medical University of and lower perilymph levels (median, 213.1 ng/mL vs 904 ng/mL) than individuals with Vienna, Vienna, Austria (Dahm, Auinger, Honeder, Riss, Arnoldner); unremarkable middle ear mucosa. Department of Pharmaceutical Technology and Biopharmaceutics, CONCLUSIONS AND RELEVANCE In this randomized clinical trial, TAC was shown to be a University of Vienna, Austria promising drug for intratympanic therapies, with similar levels in perilymph 1 hour and 24 (Gausterer, Gabor); Department of hours after injection (distinctly in the groups receiving the 40 mg/mL dose). There was also Pharmacognosy, University of minimal dissemination to the plasma, especially in patients with unremarkable middle ear Vienna, Vienna, Austria (Reznicek); Center for Medical Statistics, mucosa. Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03248856 Austria (Kaider). Corresponding Author: Christoph Arnoldner, Department of Otorhinolaryngology–Head and Neck Surgery, Medical University of Vienna, Waehringer Guertel 18-20, JAMA Otolaryngol Head Neck Surg. 2021;147(11):974-980. doi:10.1001/jamaoto.2021.2492 1090 Vienna, Austria (christoph. Published online September 30, 2021. arnoldner@meduniwien.ac.at). 974 (Reprinted) jamaotolaryngology.com Levels of Triamcinolone Acetonide in Human Perilymph and Plasma After Intratympanic Application Original Investigation Research any inner ear diseases are treated with systemic cor- ticosteroids. However, owing to minimal blood flow Key Points 1,2 M to the cochlea and the blood-perilymph barrier, Question How much intratympanically injected triamcinolone only a small proportion of intravenously applied predniso- acetonide diffuses to the perilymph and plasma? 3,4 lone reaches the perilymphatic fluid. Studies investigating Findings In this randomized clinical trial of 40 patients glucocorticoid absorption and distribution have mainly been undergoing cochlear implantation, there were similar levels of 5,6 conducted in animals. Bird et al investigated perilymph con- triamcinolone acetonide in the perilymph 1 hour and 24 hours after centrations 0.5 to 3 hours after intratympanic (IT) applica- injection, and triamcinolone acetonide could be quantified in all tionofmethylprednisoloneordexamethasoneinhumans.Con- analyzed patients at a median (range) level of 796.0 (46.4-7706.7) centrations of methylprednisolone and dexamethasone were ng/mL. There was minimal dissemination to the plasma, especially in patients with unremarkable middle ear mucosa. 33- to 260-fold higher after IT than after intravenous applica- 5,6 tion depending on the dose and drug. Application via a Meaning Triamcinolone acetonide can be found in the perilymph transtympanic approach has received increasing interest in re- after intratympanic application, even on the day after injection. cent years. Drugs, however, have been optimized for intrave- nous, intradermal, or intramuscular application and absorp- follows: otosclerosis (n = 1), Meniere disease (n = 2), labyrin- tion but lack adaptation for this new treatment method. The thitis (n = 1), progressive hearing loss after cytomegalovirus in- goalofthisrandomizedclinicaltrialwastoinvestigateandcom- fection (n = 1), progressive sensorineural hearing loss (n = 24), pare perilymph and plasma concentrations of triamcinolone sudden sensorineural hearing loss (n = 5), and vestibular acetonide (TAC) after IT application, which, to the best of our schwannoma (n = 3). knowledge, has not been previously evaluated in humans. Intratympanic Application of Triamcinolone Acetonide On the day before cochlear implantation, patients were placed in a supine position. Xylocaine spray, 10 mg/puff, was used as Methods local anesthesia. The suspension (TAC) was applied using a 25- Study Population gauge (0.50 × 90 mm, 3.50 in) needle through the tympanic Each patient provided written informed consent to partici- membrane. Patients were asked to stay in the position for 20 pate in this prospective study, which was approved by the eth- minutes and instructed not to speak or swallow. ics committee of the Medical University of Vienna. Inclusion Patients receiving TAC on the day of surgery were admin- criteria were that patients were between 18 and 90 years old, istered general anesthesia and positioned for cochlear implan- undergoing cochlear implantation, and willing to participate tation. The injection was then performed as previously de- in the study. Exclusion criteria were that patients were younger scribed. The patient’s position was not altered after the than 18 years, were receiving steroids on a regular basis or had injection. Patients were blinded to the dose given, while phy- received steroids intravenously or orally preoperatively, had sicians were not. contraindications against the administration of TAC, or had contraindications against IT injections (Supplement 1). Surgery and Perilymph Sampling Forty patients were randomly assigned to 1 of 4 groups. In all 40 patients, cochlear implantation was carried out via a Groups 1 and 2 received IT TAC approximately 24 hours be- standard mastoidectomy and facial recess approach, during fore surgery, whereas groups 3 and 4 received the injection ap- which irrigation was used. The bony overhang of the round proximately 1 hour before surgery (Table 1). Groups 1 and 3 were window was reduced with no irrigation to avoid dilution ef- treated with TAC, 10 mg/mL, and groups 2 and 4 with TAC, 40 fect of the perilymph sample. The intact round window mem- mg/mL (Figure 1). Causes of hearing loss were distributed as brane was perforated with a sterile disposable aspirator Table 1. Characteristics of the 4 Different Groups and the Timing of Intratympanic TAC Application, Dose, and Volume Median (range) Characteristic Group 1 Group 2 Group 3 Group 4 P value No. of patients 9 10 9 9 NA TAC dose, mg/mL 10 40 10 40 NA Age, y 57 (47-82) 62 (46-78) 41 (26-68) 64 (40-88) .004 Injection volume, mL 0.65 (0.30-1.00) 0.60 (0.20-1.00) 0.40 (0.35-0.90) 0.40 (0.15-1.00) .55 BMI 25.4 (19.0-29.3) 29.6 (24.1-50.0) 28.4 (21.8-41.3) 27.0 (22.5-31.8) .10 Actual time between injection and sample Hours 21.6 (19.0-25.8) 20.9 (14.6-25.1) 1.7 (1.0-2.2) 1.6 (0.9-2.2) <.001 Minutes 1297 (1140-1545) 1255 (875-1505) 104 (58-130) 96 (51-130) Abbreviations: BMI, body mass index, calculated as weight in kilograms divided For group comparison, P values were calculated using a 1-factorial analysis of by height in meters squared; NA, not applicable; TAC, triamcinolone acetonide. variance model. Three patients had to be excluded owing to a sample volume less than 1 μL. jamaotolaryngology.com (Reprinted) JAMA Otolaryngology–Head & Neck Surgery November 2021 Volume 147, Number 11 975 Research Original Investigation Levels of Triamcinolone Acetonide in Human Perilymph and Plasma After Intratympanic Application Figure 1. CONSORT Diagram 102 Assessed for eligibility 62 Excluded 42 Did not meet inclusion criteria 11 Declined to participate 9 Other reasons 40 Randomized 10 Randomized to group 1 10 Randomized to group 2 10 Randomized to group 3 10 Randomized to group 4 (TAC, 10 mg/mL, 24 h (TAC, 40 mg/mL, 24 h (TAC, 10 mg/mL, 1 h (TAC, 40 mg/mL, 1 h before sampling) before sampling) before sampling) before sampling) 40 Included in follow-up 3 Excluded from further analysis owing to a perilymph sample volume <1 μL 37 Analyzed TAC indicates triamcinolone acetonide. (MediPlast [Curad], 0.4 x 70 mm, 27 gauge). The aspirated peri- chromatography–mass spectrometry analysis in triplicate (di- lymph (approximately 20 μL) was immediately transferred to lution range, 1:4 to 1:21). Traces of protein precipitates were a sterile 0.2-mL safe lock tube and stored at −80 °C. In 3 pa- removed by centrifugation, and the supernatants were col- tients, less than 1 μL could be sampled, which is why no fur- lected and stored at 4 °C. For preparation of plasma samples, ther analysis was possible. 100 μL of plasma was precipitated by the addition of 300 μL of ice-cold methanol, followed by centrifugation for 10 min- utes at 20 800 relative centrifugal force and 4 °C. Plasma was Blood Sample Simultaneously with aspiration of perilymph, a blood sample collected and stored at 4 °C. All samples were kept on ice dur- was taken in the standard fashion. Blood was drawn in a hep- ing sample preparation. arin tube (9 mL). The vacutainer was gently swiveled 5 times. The sample was then centrifuged for 20 minutes at 20 °C with Quantification of Triamcinolone Acetonide 2000 relative centrifugal force. Plasma was transferred to a Triamcinolone acetonide was quantified by high-perfor- 2-mL safe lock tube and stored at −80 °C. mance liquid chromatography. The samples were analyzed using liquid chromatography–mass spectrometry on an Ulti- Mate 3000 RSLC series system (Thermo Fisher Scientific) Triamcinolone Acetonide In this study, patients received IT TAC (Volon A [Derma- coupled to a triple quadrupole mass spectrometer (API 4000 pharm GmbH]) containing either 40 mg/mL or 10 mg/mL of [AB Sciex]) equipped with an orthogonal electrospray ioniza- TAC. In preliminary experiments, the particle-size distribu- tion source operated in positive mode. tion of TAC was determined in 0.9% sodium chloride/0.1% Liquid chromatography separation was performed on an polysorbate 80 by laser-light scattering using a Mastersizer Acclaim RSLC 120 C18 column (3 μm, 100 × 2.1 mm; Thermo 3000 (Malvern Instruments). Triamcinolone acetonide, 10 mg/ Fisher Scientific) preceded by an Acclaim 120 C18 guard car- mL, had a pH of 6.27 and an osmolality of 318 mOsm/kg; 90% tridge (5 μm, 10 × 2 mm; Thermo Fisher Scientific) at a flow of particles had a mean (SD) particle size less than 23.8 (1.0) rate of 0.5 mL/min and a column temperature of 25 °C. The mo- μm, 50% of particles were below and above 12.8 (0.9) μm, and bile phase consisted of a linear gradient mixed from 0.1% aque- 10% of the particle population were less than 5.6 (0.8) μm. Tri- ous formic acid (mobile phase A) and acetonitrile (mobile phase amcinolone acetonide, 40 mg/mL, had a pH of 6.19 and an os- B). The gradient ranged from 20% mobile phase B at 0 min- molality of 331 mOsm/kg. The mean (SD) size of 90% of par- utes to 95% mobile phase B in 5 minutes, purging with 95% ticles was less than 22.1 (1.6) μm, 50% of particles were below mobile phase B for 1 minute, then 20% mobile phase B to equili- andabove11.6(1.4)μm,and10%oftheparticlepopulationwere brate the column for 4 minutes before applying the next sample less than 4.8 (1.1) μm. Both formulations contained 9.9 mg of (total analysis time, 10 minutes). Triamcinolone acetonide benzyl alcohol per 1 mL, as well as sodium carboxymethyl cel- eluted at 4.13 minutes. Triamcinolone acetonide was selec- lulose, polysorbate 80, sodium chloride, and water. tively and sensitively detected and quantified using tandem mass spectrometry fragmentation of TAC, giving a quasimo- lecular ion at mass-to-charge ratio (m/z) of 435.4 [M+H] . Mul- Sample Preparation Perilymph samples were prepared by diluting a definite vol- tiple reaction monitoring m/z 435.4/415.0 (quantifier) and m/z ume ofperilymph withice-coldmethanol toobtain a totalmini- 435.4/213.1 (qualifier) were used for calibration curves with ex- mum volume of 20 μL to allow for high-performance liquid ternal standard TAC (injection volume, 5 μL) to obtain a lin- 976 JAMA Otolaryngology–Head & Neck Surgery November 2021 Volume 147, Number 11 (Reprinted) jamaotolaryngology.com Levels of Triamcinolone Acetonide in Human Perilymph and Plasma After Intratympanic Application Original Investigation Research ear concentration range from 0.1 to 5000 ng/mL To quantify the strength of the effects on TAC levels, the geo- (y = 559x + 3050; correlation coefficient, 0.9986). The lower metric mean ratios (GMRs) with 95% CIs were determined by limit of detection was 0.1 ng/mL, and the lower limit of quan- retransforming mean differences from the logarithmic to the tification was set at 0.5 ng/mL. The triple quadrupole mass original scale. To compare the TAC levels in patients with an spectrometer operated with the following parameters: ESI pos, aerated middle ear to patients with mucosal disease, the IS 5500, EP 10, CUR 10, GS1 40, GS2 40, TEM 500 °C, CAD 4, 2-sample t test was used for perilymph (log10 transformed) and CEM 3000, DF −100. MRM m/z 435.4/415.0: DP 66, CE 11, CXP the exact Wilcoxon rank sum test for plasma. Analysis was con- 26; MRM, m/z 435.4/213.1: DP 81, CE 37, CXP 34; dwell time ducted using SAS statistical software, version 9.4 (SAS Insti- for each MRM150 ms (ESI indicates electrospray ionization; IS, tute), and a 2-sided P < .05 was considered statistically sig- ion spray voltage; EP, entrance potential; CUR, curtain gas; GS1, nificant. ion source gas 1; GS2, ion source gas 2; TEM, temperature; CAD, collisionallyactivateddissociation;CEM,channelelectronmul- tiplier; DF, deflector; MRM, multiple reaction monitoring; DP, Results declustering potential; CE, collision energy; CXP, collision cell exit potential). Triamcinolone Acetonide Levels in Perilymph In this study, 40 patients undergoing cochlear implantation re- ceived IT TAC. In 3 patients, the perilymph sample volume was Sample-Size Calculation The primary aim of the study was to determine and compare less than 1 μL, which was not sufficient for further analysis. perilymph and plasma levels of IT-injected TAC. The re- The remaining 37 patients (median [range] age, 57 [26-88] quired sample size was calculated based on the paired t test years; 18 [49%] men) had perilymph samples with a quantifi- and a 2-sided significance level of 5%. Perilymph and blood able concentration of TAC. The median (range) TAC level in the concentrations of dexamethasone are known from the litera- perilymph was 796.0 (46.4-7706.7) ng/mL. ture in 12 patients, and log10-transformed values were used for calculations owing to the skew distribution. Retransform- Triamcinolone Acetonide Levels in Plasma ing the mean log values to the original scale resulted in geo- Triamcinolone acetonide concentrations in the plasma were metric mean values of 1.26 mg/L for perilymph levels and 0.001 lower than the lower limit of detection in 29 of 37 patients. The mg/L for plasma levels. The SD of the paired differences of the median (range) plasma TAC level in the remaining 8 patients log10-transformed values was calculated as 0.81. To detect an was 1.7 (1.1-2.5) ng/mL. The median (range) TAC level in the effect size of 0.5 SDs, which is a difference of 0.4 on the log plasma for all patients was 0 (0-2.4) ng/mL. All 8 patients with scale (a difference in the geometric means of 1.26-0.50) with detectable levels of TAC in the plasma were in 1 of the 2 groups a statistical power of 86%, a total of 40 patients needed to be receiving TAC, 10 mg/mL. The TAC levels in perilymph were a included in the study (nQuery Advisor, version 7.0 [Statisti- median (range) of 796.0 (44.8-7705.4) ng/mL higher than in cal Solutions]). The primary study aim was to determine and plasma. compare perilymph and plasma levels of IT-applied TAC; there- fore, sample-size calculation was based on this objective. Ad- Effect of Triamcinolone Acetonide Dose and Time Point ditionally, the comparison of different doses and sampling The median (range) TAC concentrations in perilymph in the 4 schemes is an unanswered question, so we decided to ran- different treatment groups were 271.0 (46.4-670.7) ng/mL in domize the sample in the 4 different groups. The power to de- group 1; 2149.7 (51.9-5916.0) ng/mL in group 2; 2877.3 (396.4- tect relevant differences between the groups is small. 7706.7) ng/mL in group 3; and 939.0 (329.4-4641.0) ng/mL in group 4. The 1-factorial ANOVA model showed that the differ- ence between the 4 groups was statistically significant: group Statistical Analysis Median values with ranges (presented as minimum to maxi- 1 had statistically significantly lower TAC levels in perilymph mum) are given for continuous variables. The nonparametric than the other 3 groups (GMR: group 1 vs group 2, 0.15 [95% Wilcoxon signed rank test was used to compare TAC levels in CI, 0.04-0.62]; group 1 vs group 3, 0.12 [95% CI, 0.03-0.51]; and perilymph and plasma. Analysis of variance (ANOVA) models group 1 vs group 4, 0.22 [95% CI, 0.05-0.95]). There were no were used for group comparisons of the TAC levels in peri- statistically significant differences between any other 2 groups lymph. First, groups 1 to 4 were compared using a 1-factorial (GMR: group 2 vs group 3, 0.79 [95% CI, 0.19-3.25]; group 2 vs ANOVA design. The Tukey-Kramer method was used for mul- group 4, 1.47 [95% CI, 0.36-6.04]; and group 3 vs group 4, 1.86 tiplicity-adjusted pairwise group comparisons. Second, two [95% CI, 0.44-7.91]). 1-factorial ANOVA models were applied, testing for the over- The median (range) TAC level in perilymph in the 2 groups all dose (10 mg/mL vs 40 mg/mL) and the overall time point (1 given TAC, 10 mg/mL, was 440.0 (46.4-7706.7) ng/mL and in hour vs 24 hours) effects. Third, a 2-factorial ANOVA model the 2 groups given TAC, 40 mg/mL, was 1046.1 (51.9-5916.0) was used, including the 2 factors of dose and time between ap- ng/mL.The1-factorialANOVAmodeltestingfortheoveralldose plication and sampling, together with an interaction term to (10 mg/mL vs 40 mg/mL) effect showed that the comparison test for a dose-dependent time effect and a time-dependent was not statistically significant (GMR, 0.52 [95% CI, 0.21- dose effect, respectively. Due to the skew distribution of the 1.29]). TAC levels in perilymph, log10-transfomed values were used The median (range) TAC levels in perilymph were 670.7 as dependent variables for all ANOVA and regression models. (46.4-5916.0) ng/mL in groups 1 and 2 (TAC given 24 hours be- jamaotolaryngology.com (Reprinted) JAMA Otolaryngology–Head & Neck Surgery November 2021 Volume 147, Number 11 977 Research Original Investigation Levels of Triamcinolone Acetonide in Human Perilymph and Plasma After Intratympanic Application Figure 2. Box Plots of Triamcinolone Acetonide (TAC) Concentrations Figure 3. Box Plot of Triamcinolone Acetonide (TAC) Concentrations in Perilymph in the Perilymph Among the 4 Treatment Groups A TAC concentration by dose B TAC concentration by time after injection 8000 8000 7000 7000 6000 6000 5000 5000 4000 4000 3000 3000 2000 2000 1000 1000 Group 1 Group 2 Group 3 Group 4 0 0 10 40 1 24 The horizontal line in the boxes indicates the median. The boundaries of the Dose, mg/mL Time, h boxes represent the lower and upper quartiles. The whiskers are drawn from the edge of the boxes to the largest and smallest values that are outside of the The horizontal line in the boxes indicates the median. The boundaries of the box but within 1.5 SDs. Circles depict outliers. Group 1 was given TAC, 10 boxes represent the lower and upper quartiles. The whiskers are drawn from mg/mL, 24 hours before surgery; group 2, TAC, 40 mg/mL, 24 hours before the edge of the boxes to the largest and smallest values that are outside of the surgery; group 3, TAC, 10 mg/mL, 1 hour before surgery; group 4, TAC, 40 boxes but within 1.5 SDs. Circles depict outliers. mg/mL, 1 hour before surgery. Denotes statistical significance according to the 2-factorial analysis of variance model. fore surgery) and 1086.0 (329.4-7706.7) ng/mL in groups 3 and Table 2. Triamcinolone Acetonide (TAC) Values for the 4 Patients 4 (TAC given 1 hour before surgery). The difference between With Mucosal Disease the time points of the groups was not statistically significant TAC, ng/mL (GMR, 0.44 [95% CI, 0.18-1.07]; Figure 2). Patient Group Perilymph Plasma A 2-factorial ANOVA model was used, including the 2 fac- 1 1 46.4 1.6 torsofdoseandtimebetweenapplicationandsampling.Within 2 1 96.8 1.1 the groups that received the lower dose, the TAC concentra- 3 3 396.4 2.5 tion was statistically significantly lower after 24 hours than af- 4 4 329.4 ND ter 1 hour (GMR, 0.12 [95% CI, 0.04-0.36]). There was no sta- tistically significant difference between the groups receiving Abbreviation: ND, not detectable. 40 mg/mL (GMR, 1.47 [95% CI, 0.51-4.26]). On the other hand, TAC levels in the perilymph of patients who underwent sam- pling 1 hour after IT injection were not statistically signifi- Injected Volume cantly different between dose groups (GMR, 0.54 [95% CI, 0.18- The median (range) injected volume across all groups was 0.50 1.60]). However, TAC concentrations in the perilymph were (0.2-1.0) mL (Table 1). The distribution of TAC levels in peri- statistically significantly higher in the group receiving the 40 lymph, when compared with a given dose of TAC, did not show mg/mL dose than the group receiving the 10 mg/mL dose when a correlation (r = 0.187). TAC was injected 24 hours before the surgery (GMR, 6.63 [95% CI, 2.29-19.16]). The results of all 4 groups according to time point and dose are depicted in Figure 3. Discussion Chronic Middle Ear Disease To our knowledge, this is the first study in humans in which In 4 patients, the middle ear was filled with scar tissue and/or IT-injected TAC was measured in the perilymph, as well as its distribution to the plasma. Comparable with previous stud- thickened mucosa (Table 2). The TAC levels in perilymph for these patients were 46.4, 96.8, 396.4, and 329.4 ng/mL. The ies on other glucocorticoids, the range of drug concentra- 5,6 tions in the perilymph varies substantially. median (range) perilymph TAC level in these patients was 213.1 (46.4-396.4) ng/mL compared with 904.0 (51.9-7706.7) ng/mL In the present study, 4 patients had some form of middle ear pathology with scaring and/or thickened mucosa, which in the remaining 33 patients with a healthy middle ear. The dif- ference was statistically significant (GMR, 0.14 [95% CI, 0.04- lead to lower TAC levels in the perilymph and higher TAC lev- 0.52]). The TAC levels in plasma were statistically signifi- els in plasma. Chronic middle ear disease can lead to thicken- cantly higher in the group with mucosal disease (median ing of the middle ear mucosa, as well as angiogenesis. Two of [range], 1.4 [0-2.5] ng/mL) than in the patients with an unre- the 4 patients with middle ear pathologies were in group 1, 1 markable middle ear (median [range], 0 [0-2.3] ng/mL). was in group 3, and 1 in group 4. The influence of chronic 978 JAMA Otolaryngology–Head & Neck Surgery November 2021 Volume 147, Number 11 (Reprinted) jamaotolaryngology.com TAC concentration, ng/mL TAC concentration, ng/mL TAC concentration, ng/mL Levels of Triamcinolone Acetonide in Human Perilymph and Plasma After Intratympanic Application Original Investigation Research middle ear disease on the perilymph and plasma levels of an cently conducted a simulation study showing that TAC has fa- intratympanically applied drug has, to the best of our knowl- vorable pharmacological properties compared with steroids, edge, not been shown thus far and obviously has important which are mainly used for IT application. Triamcinolone ace- implications for clinical routine. First, levels of a substance in tonide was proposed as a promising IT steroid owing to the high the perilymph after IT application will not reach the same lev- permeabilityoftheroundwindowmembraneandthelonghalf- els as in patients with a healthy middle ear. In addition, the life of its metabolite triamcinolone. However, in a more recent distribution of drugs to the plasma may be increased in pa- studyinguineapigs,aswellasasimulationofsequentialsample tients with mucosal disease. It is important to note that these data, Salt et al supported the use of triamcinolone instead of results have only been shown in a small sample size in the pre- TAC because it is retained in the perilymph longer and may re- sent study and need to be confirmed in larger series. sult in improved distribution to the cochlear apex. In that study, The main advantage of IT application is the avoidance of only 2 guinea pigs were treated with a somewhat comparable systemic adverse effects. This study could prove that local ap- setupasthepresentstudy;aTACsolution(asopposedtoaloaded plication leads to a considerably higher TAC level in the peri- gel)wasappliedtotheroundwindow,circumventingabsorption lymph than the plasma. Although serial samples were not and throughthethinoticcapsule.Theperilymphwassampled1hour could not be performed, TAC levels in the perilymph were not later and contained 710 ng/mL of TAC. Loading and sampling of statistically significantly lower in the group that received TAC the lateral semicircular canal were measured to determine how 24 hours before surgery compared with the group that re- muchTACwasretainedintheperilymph.Theresultsshowedan ceived TAC 1 hour before surgery, which may be an indication extremely high elimination rate, which was calculated by simu- of the suspected depot effect occurring due to the crystalline lation(eliminationhalf-timewas12minutesinthescalatympani 8-10 suspension of TAC, which dissolves slowly. To evaluate a and 34 minutes in the scala vestibuli). Although serial sampling possible interaction effect between the dose and delay be- could not be performed, overall, the present results show that tween IT injection and sampling, a 2-factorial ANOVA model TAC levels were similar 1 hour and 24 hours after IT application, was applied and showed a statistically significant interac- whichmeansthateithertheeliminationismuchslowerthancal- tion. In the group that received TAC, 10 mg/mL, 1 hour before culatedpreviously ortheremainingsolutioncontinuouslydif- surgery, TAC levels were statistically significantly higher. The fuses through the round window membrane. Honeder et al re- group receiving TAC, 40 mg/mL, 24 hours before surgery had ported a TAC half-life of 44.9 hours when the drug was applied statistically significantly higher TAC levels. Although contain- intratympanically with a poloxamer 407 hydrogel. ingdifferentconcentrationsofTAC,thesolubilityofTACinboth It is important to note that this study’s primary aim was formulations (10 mg/mL vs 40 mg/mL) is equally limited by to determine and compare IT-applied TAC levels in peri- the molecule’s lipophilic nature, meaning that the amount of lymph and plasma; therefore, sample size calculation was dissolved TAC is the same regardless of the formulation and based on this objective. Additionally, the comparison of dif- that both formulations represent supersaturated solutions. ferent doses and sampling schemes is an unanswered ques- Without knowledge of the exact composition of the formula- tion, so we decided to randomize the sample into the 4 differ- tions (eg, sodium chloride, polysorbate 80), the 13 mM higher ent groups. Of course, the power to detect relevant differences osmolality in the TAC, 40 mg/mL, formulation cannot be at- between the groups is small, and an additional study pow- tributed to the presence of a higher concentration of dis- ered for this comparison is needed. solved TAC. The higher intracochlear TAC levels in perilymph after 24 hours could be because of the 40-mg/mL dose con- Limitations taining 75% more TAC than the 10-mg/mL dose, resulting in One of the limitations of the current study is the small sample an increased viscosity and probably improving adhesion to the size of each group. A further important topic is that physi- round window membrane and limiting drainage via the eu- cians applying IT TAC were not blinded to the doses, which stachian tube, which are both required for successful intra- might have affected the dose given. Sampling of perilymph was tympanic drug delivery to the inner ear. This effect on viscos- carried out during cochlear implantation. During mastoidec- ity is further pronounced by the presence of sodium tomy and the facial recess approach, irrigation is used, which carboxymethylcellulose, which probably contributes to pro- might influence TAC levels in perilymph. longed contact between the dissolved TAC fraction and the round window membrane. Previous studies led to the assumption that longer drug Conclusions maintenance in the basal region of the cochlea leads to a higher chance of extending into apical regions. The TAC suspen- Results of this randomized clinical trial showed that TAC is a sion used in the present study is combined with benzyl alco- promising drug for intratympanic therapies with similar lev- hol, which has been shown to increase round window mem- els in perilymph 1 hour and 24 hours after injection (dis- brane permeability by a factor of 3 to 5. Benzyl alcohol also tinctly in the group receiving TAC, 40 mg/mL). Additionally, keeps substances from being cleared from the middle ear space it leads to minimal dissemination to the plasma, especially as quickly, which may also enhance the suspected depot ef- in patients with unremarkable middle ear mucosa. There- fect of the crystalline suspension of TAC. fore, TAC remains an important drug for treating inner ear It remains unclear if any active transporters increase or de- disorders via IT injection and should be evaluated further in crease perilymph levels of certain drugs. Salt and Plontke re- future studies. jamaotolaryngology.com (Reprinted) JAMA Otolaryngology–Head & Neck Surgery November 2021 Volume 147, Number 11 979 Research Original Investigation Levels of Triamcinolone Acetonide in Human Perilymph and Plasma After Intratympanic Application ARTICLE INFORMATION Role of the Funder/Sponsor: The funder had no perilymph. Otol Neurotol. 2007;28(8):1124-1130. role in the design and conduct of the study; doi:10.1097/MAO.0b013e31815aee21 Accepted for Publication: July 28, 2021. collection, management, analysis, and 7. Salt AN, Plontke SK. Pharmacokinetic principles Published Online: September 30, 2021. interpretation of the data; preparation, review, or in the inner ear: influence of drug properties on doi:10.1001/jamaoto.2021.2492 approval of the manuscript; and decision to submit intratympanic applications. Hear Res. 2018;368:28- Open Access: This is an open access article the manuscript for publication. 40. doi:10.1016/j.heares.2018.03.002 distributed under the terms of the CC-BY License. Data Sharing Statement: See Supplement 2. 8. Honeder C, Engleder E, Schöpper H, et al. ©2021DahmVetal. JAMA Otolaryngology–Head & Sustained release of triamcinolone acetonide from Neck Surgery. REFERENCES an intratympanically applied hydrogel designed for Author Contributions: Ms Dahm and Mr Arnoldner 1. Nakashima T, Naganawa S, Sone M, et al. the delivery of high glucocorticoid doses. Audiol had full access to all the data in the study and take Disorders of cochlear blood flow. Brain Res Brain Neurootol. 2014;19(3):193-202. doi:10.1159/ responsibility for the integrity of the data and the Res Rev. 2003;43(1):17-28. doi:10.1016/S0165-0173 000358165 accuracy of the data analysis. (03)00189-9 9. Ye Q, Tillein J, Hartmann R, Gstoettner W, Kiefer Concept and design: Dahm, Honeder, Gabor, 2. Yang Y, Dai M, Wilson TM, et al. Na+/K+-ATPase J. Application of a corticosteroid (Triamcinolon) Arnoldner. α1 identified as an abundant protein in the protects inner ear function after surgical Acquisition, analysis, or interpretation of data: blood-labyrinth barrier that plays an essential role intervention. Ear Hear. 2007;28(3):361-369. doi:10. Dahm, Gausterer, Auinger, Reznicek, Kaider, Riss. in the barrier integrity. PLoS One. 2011;6(1):e16547. 1097/01.aud.0000261655.30652.62 Drafting of the manuscript: Dahm, Kaider, doi:10.1371/journal.pone.0016547 Arnoldner. 10. Salt AN, Hartsock JJ, Hou J, Piu F. Comparison Critical revision of the manuscript for important 3. Oertel R, Kirch W, Klemm E. Prednisolone of the pharmacokinetic properties of triamcinolone intellectual content: Gausterer, Auinger, Honeder, concentration in the cochlea of patients with and dexamethasone for local therapy of the inner Gabor, Reznicek, Riss, Arnoldner. perilymph fistula. Pharmazie. 2007;62(3):239-240. ear. Front Cell Neurosci. 2019;13:347. doi:10.3389/ Statistical analysis: Reznicek, Kaider, Arnoldner. fncel.2019.00347 4. Niedermeyer HP, Zahneisen G, Luppa P, Busch R, Obtained funding: Dahm, Arnoldner. Arnold W. Cortisol levels in the human perilymph 11. Mikulec AA, Hartsock JJ, Salt AN. Permeability Administrative, technical, or material support: after intravenous administration of prednisolone. of the round window membrane is influenced by Gausterer, Auinger, Riss. Audiol Neurootol. 2003;8(6):316-321. doi:10.1159/ the composition of applied drug solutions and by Supervision: Honeder, Gabor, Arnoldner. 000073516 common surgical procedures. Otol Neurotol. 2008; Conflict of Interest Disclosures: Dr Honeder 29(7):1020-1026. doi:10.1097/MAO. 5. Bird PA, Murray DP, Zhang M, Begg EJ. reported receiving grants from MED-EL outside the 0b013e31818658ea Intratympanic versus intravenous delivery of submitted work. Dr Riss reported receiving grants dexamethasone and dexamethasone sodium 12. Mikulec AA, Plontke SK, Hartsock JJ, Salt AN. from MED-EL paid to his institution outside the phosphate to cochlear perilymph. Otol Neurotol. Entry of substances into perilymph through the submitted work. No other disclosures were 2011;32(6):933-936. doi:10.1097/MAO. bone of the otic capsule after intratympanic reported. 0b013e3182255933 applications in guinea pigs: implications for local Funding/Support: This work was funded by the drug delivery in humans. Otol Neurotol. 2009;30 6. Bird PA, Begg EJ, Zhang M, Keast AT, Murray DP, Medical Scientific Fund of the Mayor of the City of (2):131-138. doi:10.1097/MAO.0b013e318191bff8 Balkany TJ. Intratympanic versus intravenous Vienna. delivery of methylprednisolone to cochlear 980 JAMA Otolaryngology–Head & Neck Surgery November 2021 Volume 147, Number 11 (Reprinted) jamaotolaryngology.com Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 CLINICAL STUDY PROTOCOL Triamcinolone levels in cochlear perilymph Triamcinolone levels Version 1.0 / Date 28.07.2017 Project number: 1456/2017 Confidentiality Statement The information contained in this document, especially unpublished data, is the property of the sponsor of this study. It is therefore provided to you in confidence as an Investigator, potential Investigator, or consultant, for review by you, your staff, and an Independent Ethics Committee or Institutional Review Board. It is understood that this information will not be disclosed to others without written authorization from the sponsor or the study personnel except to the extent necessary to obtain informed consent from those persons to whom the study drug may be administered. Triamcinolone levels in cochlear perilymph Page 1 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 Test drug (IMP) and Triamcinolone acetonide (Volon A crystal suspension) Pharmaceutical Dermapharm GmbH Company Protocol author Dr. Valerie Dahm Investigator Assoc. Prof. PD Dr. Christoph Arnoldner Document type Clinical study protocol Study phase Phase I Document status Final Date 28.07.2017 Number of pages 38 Triamcinolone levels in cochlear perilymph Page 2 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 1. SPONSOR, INVESTIGATOR, MONITOR AND SIGNATURES Sponsor/or representative (OEL) (AMG §§ 2a, 31,32) Univ. Prof. Dr. Wolfgang Gstöttner, Department of Otorhinolaryngology Medical University of Vienna, Austria ________________ ___________ Signature (OEL) Date Investigator (AMG §§ 2a, 35,36) Assoc. Prof. PD Dr. Christoph Arnoldner, Department of Otorhinolaryngology Medical University of Vienna, Austria _________________ ___________ Signature Date Monitor/ or Representative of CRO (AMG §§ 2a, 33,34) DI Rudolfs Liepins Study coordinator Department of Otorhinolaryngology Medical University of Vienna, Austria _________________ ___________ Signature Date Triamcinolone levels in cochlear perilymph Page 3 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 Clinical Trials Centers: Department of Otorhinolaryngology Medical University of Vienna, Austria Associated Departments Department of Pharmaceutical Technology & Biopharmaceutics, University of Vienna, Austria Mag. Pharm Julia Clara Gausterer a.o. Univ. Prof. Dr. Franz Gabor Triamcinolone levels in cochlear perilymph Page 4 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 2. PROTOCOL SYNOPSIS TITLE Triamcinolone levels in cochlear perilymph - a prospective, randomized clinical trial OBJECTIVES Primary Objective Demonstrate absorption of Triamcinolone acetonide in cochlear perilymph in comparison to dissemination to the blood circulation Secondary Objectives Assess the stability of triamcinolone acetonide levels in the cochlear perilymph Assess perilymph concentrations and blood concentrations of triamcinolone acetonide after administration of different Triamcinolone acetonide doses. DESIGN / PHASE Prospective phase I study. STUDY PLANNED First patient 4Q Last patient 3Q Last patient 4Q DURATION First visit 2017 First visit 2019 Last visit 2019 CENTER(S) One center. / COUNTRY(IES) Austria PATIENTS / GROUPS 10 patients/group 4 groups: Group 1: Volon 10mg - sampling 24h after administration Group 2 Volon 40mg - sampling 24h after administration Group 3 Volon 10mg - sampling 1h after administration Group 4 Volon 40mg - sampling 1h after administration Group 5 Volon 40mg sampling 24h after administration - RWM, SCC and CSF 1:1:1:1 (Group 1-4) INCLUSION CRITERIA Patients between 18 and 90 years will be included in the study, who will undergo a cochlear implantation and are willing to participate in the study EXCLUSION CRITERIA Patients younger than 18 years Patients who receive cortisone on a regular basis or receive cortisone i.v. or p.o. preoperatively Patients with contraindications against the administration of Volon A STUDY PERIODS Patients will be included in the study over a time period of two years. The active study phase of each patient will be a maximum of nine days. INVESTIGATIONAL Triamcinolone acetonide (Volon A crystal suspension) DRUG 40mg Dose: 1ml Triamcinolone levels in cochlear perilymph Page 5 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 Triamcinolone acetonide (Volon A crystal suspension) 10mg Dose: 1ml COMPARATIVE DRUG none /CONTROL CONDITION CONCOMITANT Allowed all concomitant medication is allowed MEDICATION Patients who take cortisone on a regular basis will not be included in the study EFFICACY ENDPOINTS not applicable TOLERABILITY / not applicable SAFETY ENDPOINTS PHARMACOKINETIC / Concentration of Triamcinolone e acetonide in perilymph and PHARMACODYNAMIC blood samples ENDPOINTS QUALITY OF LIFE / not applicable PHARMACOECONOMIC ENDPOINTS STATISTICAL Primary objective: METHODOLOGY The paired t-test will be used to compare the log-transformed perilymphatic and blood concentrations of triamcinolone, and a 95% confidence interval will be calculated for the geometric mean ratio. Secondary objective: Descriptive statistical methods will be used for the secondary (hypotheses generating) objective to compare the 4 groups of patients. Perilymphatic and blood concentrations of triamcinolone of the 4 groups will be graphically presented by boxplots, both on the original and on the log-transformed scale. Median (quartile) concentrations and means ± standard deviations of the log-transformed concentrations will be calculated. Triamcinolone levels in cochlear perilymph Page 6 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 3. LIST OF ABBREVATIONS ITC Intratympanic cortisone i.v. Intravenous p.o. Per os SNHL Sensorineural hearing loss CI Cochlear implant AE Adverse event RWM Round window membrane SCC Semicircular canal CSF Cerebrospinal fluid SAE Serious adverse event SUSAR Suspected unexpected serious adverse event Triamcinolone levels in cochlear perilymph Page 7 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 4. TABLE OF CONTENTS CLINICAL STUDY PROTOCOL 1 1. SPONSOR, INVESTIGATOR, MONITOR AND SIGNATURES 3 2. PROTOCOL SYNOPSIS 5 3. LIST OF ABBREVATIONS 7 4. TABLE OF CONTENTS 8 5. BACKGROUND INFORMATION 12 BACKGROUND 12 STUDY RATIONALE 12 6. STUDY OBJECTIVES (HYPOTHESIS) 13 PRIMARY OBJECTIVE (HYPOTHESIS) 13 SECONDARY OBJECTIVES (HYPOTHESIS) 13 7. STUDY DESIGN 13 STUDY POPULATION 15 7.1.1 SUBJECT POPULATION 15 7.1.2 INCLUSION CRITERIA 15 7.1.3 EXCLUSION CRITERIA 15 7.1.4 FEMALES OF CHILDBEARING POTENTIAL 15 7.1.5 STUDY DURATION 15 7.1.6 WITHDRAWAL AND REPLACEMENT OF SUBJECTS 15 7.1.7 PREMATURE TERMINATION OF THE STUDY 16 8. METHODOLOGY 16 8.1 STUDY MEDICATION 18 8.1.1 DOSAGE AND ADMINISTRATION 19 8.1.2 STUDY-DRUG UP- AND DOWN TITRATION 19 8.1.3 STUDY-DRUG DELIVERY & DRUG STORAGE CONDITIONS 19 8.1.4 STUDY DRUG PACKAGING AND LABELING 19 8.1.5 IMP ADMINISTRATION & HANDLING 19 Triamcinolone levels in cochlear perilymph Page 8 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 8.1.6 DRUG ACCOUNTABILITY 19 8.1.7 PROCEDURES TO ASSESS SUBJECTS COMPLIANCE 20 8.1.8 CONCOMITANT MEDICATION 20 8.2 RANDOMIZATION AND STRATIFICATION 20 8.3 BLINDING 20 8.4 BENEFIT AND RISK ASSESSMENT 20 8.5 STUDY PROCEDURES 20 8.5.1 GENERAL RULES FOR TRIAL PROCEDURES 20 8.5.2 SCREENING INVESTIGATION 21 8.5.3 END-OF-STUDY (EOS) EXAMINATION 21 9. SAFETY DEFINITIONS AND REPORTING REQUIREMENTS 21 ADVERSE EVENTS (AES) 21 9.1.1 SUMMARY OF KNOWN AND POTENTIAL RISKS OF THE STUDY DRUG 21 9.1.2 DEFINITION OF ADVERSE EVENTS 23 SERIOUS ADVERSE EVENTS (SAES) 24 9.1.3 HOSPITALIZATION PROLONGATION OF EXISTING HOSPITALIZATION 25 9.1.4 SAES RELATED TO INVESTIGATIONAL DRUG 25 9.1.5 SUSPECTED UNEXPECTED SERIOUS ADVERSE REACTIONS (SUSARS) 25 9.1.6 PREGNANCY 25 SEVERITY OF ADVERSE EVENTS 26 RELATIONSHIP TO STUDY DRUG 27 REPORTING PROCEDURES 28 9.1.7 REPORTING PROCEDURES FOR SAES 28 9.1.8 REPORTING PROCEDURES FOR SUSAR 29 9.1.9 DEVELOPMENT SAFETY UPDATE REPORT 30 10. FOLLOW-UP 30 FOLLOW-UP OF STUDY PARTICIPANTS INCLUDING FOLLOW-UP OF ADVERSE EVENTS 30 TREATMENT AFTER END OF STUDY 30 11. STATISTICAL METHODOLOGY AND ANALYSIS 30 ANALYSIS SETS 31 SAMPLE SIZE CONSIDERATIONS 31 RELEVANT PROTOCOL DEVIATIONS 31 ENDPOINTS ANALYSIS 31 11.1.1 PRIMARY ENDPOINT ANALYSIS 31 11.1.2 SECONDARY ENDPOINT ANALYSIS 32 INTERIM ANALYSIS 32 12. DOCUMENTATION AND DATA MANAGEMENT 32 Triamcinolone levels in cochlear perilymph Page 9 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 DOCUMENTATION OF STUDY RESULTS 32 12.1.1 CASE REPORT FORM (CRF) 32 12.1.2 DATA COLLECTION 33 SAFEKEEPING 33 QUALITY CONTROL AND QUALITY ASSURANCE 33 12.1.3 PERIODIC MONITORING 33 12.1.4 AUDIT AND INSPECTIONS 34 REPORTING AND PUBLICATION 34 12.1.5 PUBLICATION OF STUDY RESULTS 34 13. ETHICAL AND LEGAL ASPECTS 34 INFORMED CONSENT OF SUBJECTS 34 ACKNOWLEDGEMENT / APPROVAL OF THE STUDY 35 13.1.1 CHANGES IN THE CONDUCT OF THE STUDY 35 INSURANCE 36 CONFIDENTIALITY 36 ETHICS AND GOOD CLINICAL PRACTICE (GCP) 37 14. REFERENCES 38 Triamcinolone levels in cochlear perilymph Page 10 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 TABLE 1. VISIT AND ASSESSMENT SCHEDULE Screening Treatment Sampling Follow Up Duration 1 day 1 day 1 week Visits Number 1 2 3 4 5 6 7 Name Screening Randomization Application Sampling Control 1 Control 2 Control 3 Time day 0 day 0 (gr. 1+2) day 1 day 2 day 3 1 week day 1 (gr. 3+4) +/- 2d Informed Consent x Inclusion / Exclusion Criteria x x Medical History x x Concomitant medication x x ENT Status x x Ear microscopy x x x x x Body weight and height x Puretonaudiogramm x x x Intratympanic Triamcinolone Application x Perilymph Sample x Blood Sample x Adverse Events x x x x x Triamcinolone levels in cochlear perilymph Page 11 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 5. BACKGROUND INFORMATION Background Over the past few years intratympanic cortisone application has been established additionally to intravenous cortisone application in the therapy of sudden sensorineural hearing loss (SNHL), toxic acute middle ear infections and preoperatively before operations of the inner ear (Cochlear implantation). Intratympanic application leads to a higher steroid concentration in the cochlear perilymph than i.v. administration does [1, 2]. Steroids are known for having several otoprotective qualities. When performing a cochlear implantation corticosteroid therapy can protect the residual hearing [3]. Hair cells of the inner ear are protected by steroids, when a trauma is induced [4]. Studies have shown that glucocorticoids reduce the impedance needed by the cochlear implant (CI). By the reduction of impedances needed a battery sparing function of the CI is made possible [5]. Inflammation, which leads to fibrosis in the cochlea and around the electrode, can also be reduced by steroids [5]. The intratympanic application of steroids is used as salvage therapy in patients with sudden SNHL [6] or as primary treatment option for patients who cannot be treated systemically. When applying steroids intratympanically the effect seems to be in the applied area and systemic side effects can be avoided. At our department a similar study was conducted on guinea pigs. The method of detection of Triamcinolone acetonide in the perilymph has already been established [7]. Study rationale Two studies have been published so far analyzing perilymph concentrations of prednisolon e after intravenous administration [8, 9]. Both studies could show that higher prednisolone doses result in higher perilymphatic concentrations. Two further studies examined blood and perilymphatic levels after intratympanic administration one using methylprednisolone and the other one using dexamethasone [10] [2]. Both studies could show that intratympanic application leads to a very small dissemination of the medication to the blood circulation and to high perilymphatic concentrations compared to intravenous application. When administering liquids to the middle ear they are rapidly drained via the Eustachian tube and the effect is lost. None of those studies investigated a crystalline/depot compound. Triamcinolone levels in cochlear perilymph Page 12 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 In Austria Triamcinolone acetonide (Volon A) is the steroid of choice for intratympanic application. As for other glucocorticoids applied intratympanically (IT) the application of Volon -Label- application has already been integrated in treatment guidelines of sudden SNHL and therefor is carried out at our department as part of routine procedures. Because of the crystalline compound of Volon A a depot effect is presumed. The otoprotective value of Triamcinolone acetonide could already be shown in studies [11, 12]. Up to now, no study has shown how much Triamcinolone acetonide is absorbed by the perilymph. Furthermore, the presumed depot effect is only proven for other uses. If Triamcinolone acetonide leads to a longer lasting and higher perilymph level has not been proven so far. To what extent Triamcinolone acetonide is disseminated to the blood circulation after intratympanic application has not been investigated yet. 6. STUDY OBJECTIVES (HYPOTHESIS) Primary Objective (Hypothesis) Demonstrate concentration of Triamcinolone in cochlear perilymph in comparison to concentrations in the blood. Secondary Objectives (Hypothesis) Assess the stability of triamcinolone acetonide levels in the cochlear perilymph. Assess the difference of triamcinolone acetonide levels in the cochlear perilymph and blood after administration of different doses of Triamcinolone acetonide. 7. STUDY DESIGN At the ENT department of the university hospital Vienna (AKH Wien) patients are treated with intratympanic triamcinolone acetonide before cochlea implantation to reduce inflammation and in some cases to protect residual hearing. Triamcinolone acetonide levels in cochlear perilymph will be evaluated in an open prospective clinical study. Patients scheduled for cochlear implant surgery between 18 and 90 years will be included. Patients who are treated with steroids preoperatively will be excluded from the study. Patients will be randomized after inclusion to one of four groups. The randomization is carried out to generate hypothesis for the needed dose and best time of application in the future. Triamcinolone acetonide will then be applied 20-24h before surgery or at the beginning of the surgery, depending on randomization (see below). About 20 μl of perilymph will be sampled simultaneously to a Triamcinolone levels in cochlear perilymph Page 13 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 blood sample during cochlear implant surgery. The first twenty patients will be randomized to Triamcinolone acetonide 40mg to allow for a first analysis of the samples. Patients 21 to forty will be randomized to Triamcinolone acetonide 10mg. The probes will be stored at -80°C . Triamcinolone acetonide levels of the blood and perilymph will be determined by the pharmaceutical laboratory (Department of Pharmaceutical Technology and Biopharmaceutics, University of Vienna). The patients will be randomized to 4 groups. Group 1 - Volon A 10mg administration 20 - 24 hours before sampling. Group 2 Volon A 40mg administration 20 - 24 hours before sampling. Group 3 Volon A 10mg administration 1 to 2 hours before sampling. Group 4 Volon A 40mg administration 1 to 2 hours before sampling. The time interval of application (1 to 2 hours and 20 to 24 hours before sampling) are a result of varying time of surgery depending on surgeons and patient anatomy as well as day to day clinical organization. Patients can withdraw consent at any time of the study. The active phase of each patient will be between 6 and 9 days depending on time of follow- up visit. Triamcinolone levels in cochlear perilymph Page 14 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 Study population 7.1.1 Subject population Patients, between 18 and 90 years, will be included in the study, who are scheduled to receiving a cochlear implant and who are willing to participate in the study. 7.1.2 Inclusion criteria Patients between 18 and 90 years receiving a cochlear implant and who are willing to participate in the study. 7.1.3 Exclusion criteria Patients younger than 18 years Patients who receive cortisone regularly or receive cortisone i.v. or p.o. preoperatively Patients with contraindications against the administration of Volon A 7.1.4 Females of childbearing potential Females of childbearing potential will be included in the study, if birth control is carried out (hormonal contraception, intrauterine or barrier contraception) or a pregnancy can be ruled out completely. 7.1.5 Study duration Patients will be recruited over a time period of 2 years. The active phase of each patient will last for up to 9 days. 7.1.6 Withdrawal and replacement of subjects Criteria for withdrawal Subjects may prematurely discontinue from the study at any time. Subjects must be withdrawn under the following circumstances: at their own request if the Investigator feels it would not be in the best interest of the subject to continue Triamcinolone levels in cochlear perilymph Page 15 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 if the subject violates conditions laid out in the consent form or disregards instructions by the study personal In all cases, the reason why subjects are withdrawn must be recorded in detail in the CRF materials (completed, partially completed and empty CRFs) will be retained. Follow-up of patients withdrawn from the study Patients routinely receive intratympanic Triamcinolone acetonide. The study only consists of the calculation of Triamcinolone acetonide concentration in the perilymph and blood. Patients will be asked for adverse events at routine post-operative follow-up visits. No further follow up visits are necessary or planned within this study. 7.1.7 Premature termination of the study The sponsor has the right to close this study at any time. The IEC and the competent regulatory authority must be informed within 15 days of early termination. The trial or single dose steps will be terminated prematurely in the following cases: If adverse events occur which are so serious that the risk-benefit ratio is not acceptable. If the number of dropouts is so high that proper completion of the trial cannot realistically be expected. 8. METHODOLOGY At the department of the Medical University of Vienna patients routinely receive intratympanic application of triamcinolone acetonide. 1 mL suspension containing 10mg (Groups 1 and 3) or 40mg (Groups 2 and 4) of triamcinolone acetonide is applied intratympanically via a 25G (0.50x90mm, 3.50 IN) needle after local anesthesia with xylocaine spray (10mg/Puff). During the cochlear implant surgery, the cochlea is entered mostly via round window approach. Alternatively, if the round window cannot be identified, a cochleostomy is performed. After entering the cochlea, about 20μL of perilymph are sampled using a sterile disposable aspirator with a diameter of 0.4mm. A sterile insulin syringe is used to aspirate the perilymph. The perilymph sampling method has been performed similarly in other studies [2, 10]. Triamcinolone levels in cochlear perilymph Page 16 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 Simultaneously a blood sample of 4ml is drawn in a heparin blood tube with a standard butterfly needle. The sample of perilymph is stored in an eppendorf vial (volume 0,2ml) and frozen to approx. -80°. The blood sample is centrifuged at 3000g, 20°C for 3 minutes at. The plasma is removed and stored in eppendorf vials (volume 2ml) and also frozen to approx.-80°. Both vials will be labeled with the patient number. Patients will be numbered with a randomly assigned three- digit number. Quantification of Triamcinolone acetonide Samples will be diluted with mobile phase consisting of acetonitrile/2 mM aqueous am- monium acetate (60:40) adjusted to pH 3.2 with formic acid [13] and stored at +4 ° C until analysis by high-performance liquid chromatography/mass spectrometry, comprising an Ulti- mate RSLC 3000 series System (Thermo Fisher Scientific, Vienna, Austria) and an API 4000 Triple Quadrupole Mass Spectrometer (AB Sciex instruments, Vienna, Austria) equipped with an electro- spray ionization ion source and controlled by the Analyst 1.5 soft- ware (Dionex, Vienna, Austria). The chromatographic separation of samples will be conducted by isocratic elution using an Acclaim 120 C reversed-phase LC column (2.1 × 150 mm, 3 m; Thermo Fisher Scientific, Vienna, Austria) at 25 ° C. The run time will be 15 min at a flow rate of 0.5 ml/min, and the retention time of TAAc is about 1.28 min. Released TAAc will be selectively detected and quantified by tandem mass spectrometry fragmentation giving a quasimolecular ion at m/z 435 [M-H]+. Each sample series will be monitored by quality control samples containing certain amounts of TAAc within the range of the calibration graph. Triamcinolone levels in cochlear perilymph Page 17 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 Screening Inclusion Day 0 Randomization Day 0 Volon A10mg Volon A10 mg Volon A40mg Volon A40mg 20-24h 1-2h 20-24h 1-2h Sampling Day 1 Follow-up Day 2, Day 3, 1 Week +/- 2 Days 8.1 Study medication Active agent and characteristics: Triamcinolone acetonide Trade name of the agent: Volon A crystal suspension Manufacturer: Mibe GmbH Arzneimittel Triamcinolone levels in cochlear perilymph Page 18 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 Drug supply: Dermapharm GmbH Storage Instructions: Freezing is not allowed. Volon A should be stored in the box to protect in from light. Route of administration: Intratympanic Information can be found in the invest . 8.1.1 Dosage and administration Dose: 1mL of Volon A 10mg or 40mg Route of administration: intratympanic Duration: single administration 8.1.2 Study-drug up- and down titration Not feasible 8.1.3 Study-drug delivery & drug storage conditions Triamcinolone acetonide is delivered at room temperature. The content has to be stored shielded from light, in the boxing. Triamcinolone acetonide should not be frozen. It will be stored in the packaging at room temperature at the ENT department (ward 15J or 15I). 8.1.4 Study drug packaging and labeling Since Triamcinolone acetonide is a registered drug it will be stored in the original package. 8.1.5 IMP administration & handling 1 mL Triamcinolone acetonide is applied intratympanically via a 25GA (0.50x90mm, 3.50 IN) needle after local anesthesia with Xylocaine spray (10mg/Puff). Triamcinolone acetonide should be inspected before use. If agglomerations occur the drug should not be administered. 8.1.6 Drug Accountability The batch number will be documented on the Case Report Form. Triamcinolone acetonide will be administered at a single time point by a medical doctor intratympanically. Triamcinolone levels in cochlear perilymph Page 19 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 8.1.7 Procedures to assess compliance Not applicable 8.1.8 Concomitant medication Allowed: All concomitant medication is allowed. Patients who have to take cortisone preoperatively will not be included in the study. 8.2 Randomization and stratification For Randomization https://www.meduniwien.ac.at/randomizer will be used. The first twenty patients will be randomized to the 40mg groups. The second half will be randomized to the 10mg groups. On day 0 participants will be randomized to one of 2 groups and the intratympanic application of triamcinolone will be administered accordingly on day 0 or day 1. Block randomization will be used in groups of 8. The method of permuted blocks randomization will be used with an equally weighted allocation to the 4 treatment groups (resulting in 10 patients per group). 8.3 Blinding No blinding is required in this study. 8.4 Benefit and risk assessment This study consists of a perilymph and a blood sample during cochlear implantation. Patients included in the study are deaf or profoundly hearing impaired. As previously shown in other studies sampling of the perilymph is a safe method. This study can give us information on the absorption of Triamcinolone acetonide by perilymph as well as information on the stability of Triamcinolone acetonide after absorption of the perilymph. Since Triamcinolone acetonide is used in the treatment of sudden SNHL and preoperatively, this study can deliver necessary information on the best timing of drug application and the necessary dose. Additionally, a blood sample is taken, which can lead to known risks such as infections and hematoma. 8.5 Study procedures 8.5.1 General rules for trial procedures All study measures like blood sampling and measurements have to be documented with date (dd:mm:yyyy). In case several study procedures are scheduled at the same time point, there is no specific sequence that should be followed. Triamcinolone levels in cochlear perilymph Page 20 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 The dates of all procedures should be according to the protocol. The time margins mentioned in the study flow chart are admissible. If for any reason, a study procedure is not performed within scheduled margins a protocol deviation should be noted, and the procedure should be performed as soon as possible or as adequate. If it is necessary for organizational reasons, it is admissible to perform procedures, which are scheduled for one visit at two different time points. Allowed time margins should thereby not be exceeded. 8.5.2 Screening investigation Patients scheduled for cochlear implantation will be asked to participate in the study. Inclusion and exclusion criteria will be evaluated at the end department. If patients fulfill inclusion and exclusion criteria and consent to the study is given a reevaluation on day 0 will be carried out. If the second evaluation has a positive outcome patients will then be included in the study on day 0. 8.5.3 End-of-study (EOS) examination One week after surgery patients routinely are scheduled for wound examination and stitch removal as well as scheduling of cochlear implant fitting. During this examination adverse events will be evaluated. Additionally, ear microscopy is carried out. 9. SAFETY DEFINITIONS AND REPORTING REQUIREMENTS Adverse events (AEs) 9.1.1 Summary of known and potential risks of the study drug Known side effects: Cardiovascular Arrhythmia, heart failure Musculoskeletal Aseptic necrosis of femoral and humeral heads, loss of muscle mass, muscle weakness, osteoporosis, pathologic fracture of long bones, tendon rupture, and vertebral compression Triamcinolone levels in cochlear perilymph Page 21 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 fractures, bone mineral density loss and osteoporosis, steroid myopathy, vasculitis Gastrointestinal Peptic ulcer with potential perforation and hemorrhage, perforation of small and large bowel, pancreatitis, abdominal distention and ulcerative esophagitis Dermatologic Impaired wound healing, thin, fragile skin, petechiae and ecchymoses, facial erythema, increased sweating, and suppressed reactions to skin tests, purpura, striae rubrae, hyperpigmentation, steroidakne, allergic dermatitis Nervous system Convulsions, increased intracranial pressure with papilledema, vertigo and headache, pseudotumor cerebri, manifestation of a latent epilepsie, sleeping disorders, neuritis, paresthesia Endocrine Menstrual irregularities, postmenopausal vaginal bleeding, hirsutism, suppression of growth in children, manifestations of latent diabetes, increased requirements for insulin or oral hypoglycemic agents in diabetics, decreased carbohydrate tolerance, and secondary adrenocortical and pituitary unresponsiveness, impotence, pseudo-cushing syndrome, weight gain, negative protein and calcium balance, increased appetite Ocular Cataract, glaucoma, increased intraocular pressure, glaucoma and exophthalmos, cornea perforation Hypersensitivity Anaphylactoid reactions, anaphylaxis, and angioedema Vascular diseases Necrotizing angiitis, higher risk of artheriosis and thrombosis Electrolyte dysbalance Natrium retention, water retention, higher potassium excretion, hypokalemic alkalosis, Triamcinolone levels in cochlear perilymph Page 22 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 hypertension, hyperglycemia, glukosuria Other Anaphylactic reaction, feeling of heat Medications with potential interactions: Cardiac glycosides ACE inhibitors Chloroquine, Hydrochloroquine, Mefloquine Aspirin NSAIDs Oral Anticoagulants Bupropion Methotrexate 9.1.2 Definition of adverse events An AE is any untoward adverse change from the subject's baseline condition, i.e., any unfavorable and unintended sign including an abnormal laboratory finding, symptom or disease which is considered to be clinically relevant by the physician that occurs during the course of the study, whether or not considered related to the study drug. Adverse events include: Exacerbation of a pre-existing disease. Increase in frequency or intensity of a pre-existing episodic disease or medical condition. Disease or medical condition detected or diagnosed after study drug administration even though it may have been present prior to the start of the study. Continuous persistent disease or symptoms present at baseline that worsen following the start of the study. Lack of efficacy in the acute treatment of a life-threatening disease. Events considered by the Investigator to be related to study-mandated procedures. Abnormal assessments, e.g., ECG and physical examination findings, must be reported as AEs if they represent a clinically significant finding that was not present at baseline or worsened during the course of the study. Triamcinolone levels in cochlear perilymph Page 23 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 Laboratory test abnormalities must be reported as AEs if they represent a clinically significant finding, symptomatic or not, which was not present at baseline or worsened during the course of the study or led to dose reduction, interruption or permanent discontinuation of study drug. Adverse events do not include: Pre-planned interventions or occurrence of endpoints specified in the study protocol are not considered AE´s, if not defined otherwise (eg.as a result of overdose) Medical or surgical procedure, e.g., surgery, endoscopy, tooth extraction, transfusion. However, the event leading to the procedure is an AE. If this event is serious, the procedure must be described in the SAE narrative. Pre-existing disease or medical condition that does not worsen. Situations in which an adverse change did not occur, e.g., hospitalizations for cosmetic elective surgery or for social and/or convenience reasons. Overdose of either study drug or concomitant medication without any signs or symptoms. However, overdose must be mentioned in the Study Drug Log. Serious Adverse Events (SAEs) A Serious Adverse Event (SAE) is defined by the International Conference on Harmonization (ICH) guidelines and GCP guidelines as any AE fulfilling at least one of the following criteria: Results in deaths. Life-threatening defined as an event in which the subject was, in the judgment of the Investigator, at risk of death at the time of the event; Requiring subject's hospitalization or prolongation of existing hospitalization Resulting in persistent or significant disability or incapacity (i.e., a substantial ns). Congenital anomaly or birth defect. Optional: Is medically significant or requires intervention to prevent at least one of the outcomes listed above Life threatening refers to an event in which the subject was at risk of death at the time of the event. It does not refer to an event that hypothetically might have caused death if it were more severe. Important medical events that may not immediately result in death, be life-threatening, or require hospitalization may be considered as SAEs (optional!) when, based upon appropriate Triamcinolone levels in cochlear perilymph Page 24 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 medical judgment, they may jeopardize the subject and may require medical or surgical intervention to prevent one of the outcomes listed in the definitions above. This means an individual case decision. 9.1.3 Hospitalization Prolongation of existing hospitalization Hospitalization is defined as an overnight stay in a hospital unit and/or emergency room. An additional overnight stay defines a prolongation of existing hospitalization. The following is not considered an SAE and should be reported as an AE only: Treatment on an emergency or outsubject basis for an event not fulfilling the definition of seriousness given above and not resulting in hospitalization. The following reasons for hospitalizations are not considered AEs, and therefore not SAEs: Hospitalizations for cosmetic elective surgery, social and/or convenience reasons. Elective treatment of a pre-existing disease or medical condition that did not worsen, e.g., hospitalization for chemotherapy for cancer, elective hip replacement for arthritis. 9.1.4 SAEs related to investigational drug Such SAEs are defined as SAEs that appear to have a reasonable possibility of causal relationship. 9.1.5 Suspected unexpected serious adverse reactions (SUSARs) SUSARs are all serious adverse reactions with suspected causal relationship to the study drug that is unexpected (not previously described in the Summary of Product Characteristics or Investigator SUSARs will be reported within 24hours. 9.1.6 Pregnancy Any pregnancy that occurs during study participation must be reported to the Investigator/sponsor. To ensure subject safety, each pregnancy must be reported to the Sponsor immediately. The pregnancy must be followed up to determine outcome (including premature termination) and status of mother and child. Pregnancy complications and Triamcinolone levels in cochlear perilymph Page 25 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 elective terminations for medical reasons must be reported as an AE or SAE. Spontaneous abortions must be reported as an SAE. Any SAE occurring in association with a pregnancy brought to the Investigator after the subject has completed the study and considered by the Investigator as possibly related to the investigational product, must be promptly reported to the Investigator/sponsor. In addition, the Investigator must attempt to collect pregnancy information on any female partners of male study subjects who become pregnant while the subject is enrolled in the study. Pregnancy information must be reported to the Investigator/sponsor as described above. Severity of adverse events The severity of clinical AEs is graded on a three-point scale: mild, moderate, severe, and reported on specific AE pages of the CRF. If the severity of an AE worsens during study drug administration, only the worst intensity should be reported on the AE page. If the AE lessens in intensity, no change in the severity is required. If an AE occurs during a washout or placebo run-in phase and afterwards worsens during the treatment phase, a new AE page must be filled in with the intensity observed during study drug administration. Mild Event may be noticeable to subject; does not influence daily activities; the AE resolves spontaneously or may require minimal therapeutic intervention; Moderate Event may make subject uncomfortable; performance of daily activities may be influenced; intervention may be needed; the AE produces no sequelae. Severe Event may cause noticeable discomfort; usually interferes with daily activities; subject may not be able to continue in the study; the AE produces sequelae, which require prolonged therapeutic intervention. Triamcinolone levels in cochlear perilymph Page 26 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 A mild, moderate or severe AE may or may not be serious. These terms are used to describe the intensity of a specific event (as in mild, moderate, or severe myocardial infarction). However, a severe event may be of relatively minor medical significance (such as severe headache) and is not necessarily serious. For example, nausea lasting several hours may be rated as severe, but may not be clinically serious. Fever of 39°C that is not considered severe may become serious if it prolongs hospital discharge by a day. Seriousness rather than severity serves as a guide for defining regulatory reporting obligations. Relationship to study drug For all AEs, the Investigator will assess the causal relationship between the study drug and the AE using his/her clinical expertise and judgment according to the following algorithm that best fits the circumstances of the AE: Not related May or may not follow a temporal sequence from administration of the study product Is biologically implausible and does not follow known response pattern to the suspect study drug (if response pattern is previously known). modes of therapy administered to the subject. Unlikely There is a reasonable temporal relation between the AE and the intake of the study medication, but there is a plausible other explanation for the occurrence of the AE. Possibly The AE has a reasonable temporal relationship with drug administration. environmental or toxic factors, or concomitant therapy administered to the study subject. The relationship between study drug and AE may also be pharmacologically or clinically plausible. Probably Triamcinolone levels in cochlear perilymph Page 27 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 There is a reasonable temporal relation between the AE and the intake of the study medication, and plausible reasons point to a causal relation with the study medication. Related Reasonable temporal relation between the AE and the intake of the study medication and there is no other explanation for the AE and subsidence or disappearance of the AE on withdrawal of the study medication and recurrence of the symptoms on restart at previous dose (only applies for re-institution of mediation). Not assessable The causal relationship between the study drug and the AE cannot be judged. Reporting procedures A special section is designated to adverse events in the case report form. The following details must thereby be entered: Type of adverse event Start (date and time) End (date and time) Severity (mild, moderate, severe) Serious (no / yes) Unexpected (no / yes) Outcome (resolved, resolving, not resolved, resolved with sequelae, unknown, fatal) Relation to study drug (Related/ Probably/ Possibly/ Unlikely/ Not related/ Not assessable) Adverse events are to be documented in the case report form in accordance with the above- mentioned criteria. 9.1.7 Reporting procedures for SAEs Triamcinolone levels in cochlear perilymph Page 28 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 In case of a serious Adverse event, the Investigator has to use all supportive measures for best patient treatment. A written report is also to be prepared and should at least contain the following: Patient number Patient: sex The suspected investigational medical product (IMP) The adverse event assessed as serious Short description of the event and outcome If applicable, the initial report should be followed by the Follow up report, indicating the outcome of the SAE. 9.1.8 Reporting procedures for SUSAR It must be remembered that the regulatory authorities, and the Institutional Review Board / Independent Ethics Committee (IRB / IEC) must be informed about all SUSAR. Such reports shall be made by the sponsor and should content at least the following details: Patient number (study code/screening number) Patient: age in years, sex Name of Investigator and investigating site Period of administration The suspected investigational medical product (IMP) The adverse event assessed as serious and unexpected, and for which there is a suspected causal relationship to the IMP Concomitant disease and medication Short description of the event: Description Onset and if applicable, end Therapeutic intervention Causal relationship Seriousness criteria or reportable reason Electronic reporting should be the expected method for reporting of SUSARs to the competent authority. In that case, the format and content as defined by the regulatory requirements should be adhered to. The latest version of MedDRA should be applied. Lower level terms (LLT) should be used. Triamcinolone levels in cochlear perilymph Page 29 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 9.1.9 Development Safety Update Report A Development Safety Update Report (DSUR) will be provided by the Sponsor annually. This report will also be presented annually to the Independent Ethics (IEC) and to the competent authorities by the sponsor. 10. FOLLOW-UP Follow-up of study participants including follow-up of adverse events Patients will be at the hospital at least two days after surgery (surgery = day 1). During this time patients will be asked for any adverse events on a daily basis. Additionally, patients will be followed up one week after surgery for wound inspection and stitch removal. At this follow-up visit patients will be asked for adverse events as well. Treatment after end of study There will be no treatment after end of study. 11. STATISTICAL METHODOLOGY AND ANALYSIS Statistical methodology Primary objective: The paired t-test will be used to compare the log-transformed perilymphatic and blood concentrations of Triamcinolone acetonide, and a 95% confidence interval will be calculated for the geometric mean ratio. Secondary objective: Descriptive statistical methods will be used for the secondary (hypotheses generating) objective to compare the 4 groups of patients. Perilymphatic and blood concentrations of Triamcinolone levels in cochlear perilymph Page 30 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 Triamcinolone acetonide of the 4 groups will be graphically presented by boxplots, both on the original and on the log-transformed scale. Median (quartile) concentrations and means ± standard deviations of the log-transformed concentrations will be calculated. Data handling Case report forms will be copied and stored separately. Data will be double-checked and saved in an excel sheet on a computer to which only study personnel has access to. Patients will be randomly assigned a three-digit number and the further data analysis will be carried out anonymously. Analysis sets Intention to treat set This analysis set includes subjects who were randomized (and received at least one dose study drug). Sample size considerations The sample size calculation is based on the paired t-test and a two-sided significance level of 5%. Perilymphatic and blood concentrations of 12 patients are known from the literature (Bird et al, 2011) with geometric mean values of 1.26 and 0.001, respectively, and the standard deviation of the paired differences of the log10-transformed values was calculated as 0.81. To detect an effect size of 0.5 standard deviations, which is a difference of 0.4 on the log- scale (a difference in the geometric means of 1.26 to 0.5) with a statistical power of 86%, a total number of 40 patients have to be included in the study (nQuery Advisore 7.0). Relevant protocol deviations All protocol deviations will be listed in the study report and noted on case report forms. Endpoints analysis 11.1.1 Primary endpoint analysis Perilymphatic and blood concentration of Triamcinolone acetonide Primary objective: The paired t-test will be used to compare the log-transformed perilymphatic and blood concentrations of Triamcinolone acetonide, and a 95% confidence interval will be calculated for the geometric mean ratio. Triamcinolone levels in cochlear perilymph Page 31 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 11.1.2 Secondary endpoint analysis Secondary objective: Descriptive statistical methods will be used for the secondary (hypotheses generating) objective to compare the 4 groups of patients. Perilymphatic and blood concentrations of Triamcinolone acetonide of the 4 groups will be graphically presented by boxplots, both on the original and on the log-transformed scale. Median (quartile) concentrations and means ± standard deviations of the log-transformed concentrations will be calculated. Interim analysis Not applicable Criteria for the termination of the trial See 7.1.7 12. DOCUMENTATION AND DATA MANAGEMENT Documentation of study results A subject screening and identification log will be completed for all screened subjects with the reasons for exclusion. 12.1.1 Case report form (CRF) For each subject enrolled, regardless of study drug initiation, a CRF must be completed and signed by the Investigator or a designated sub-Investigator. This also applies to those subjects who fail to complete the study. If a subject withdraws from the study, the reason must be noted on the CRF. Case report forms are to be completed on an ongoing basis. CRF entries and corrections will only be performed by study site staff, authorized by the Investigator. In a paper based CRF all forms should be completed and must be legible. Entry errors have to be corrected according the ICH-GCP Guidelines. Triamcinolone levels in cochlear perilymph Page 32 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 The entries will be checked by trained personnel (Monitor) and any errors or inconsistencies will be corrected immediately. The monitor will collect original completed and signed CRFs at the end of the study. A copy of the completed and signed CRFs will remain on site, as will the original data. Original CRFs will be passed to study personnel (Data Manager). Paper based CRFs will be used. 12.1.2 Data Collection Data collected at all visits are entered into an interactive form. The CRFs will be source documents verified following guidelines established before study onset as detailed in the Monitoring Plan. Maintenance of the study database will be performed by study personnel. Safekeeping The Investigator will maintain adequate and accurate records to enable the conduct of the study to be fully documented and the study data to be subsequently verified (according to ICH- will be classified into two different categories: Investigator's study site file (ISF) with all essential documents regarding the study conduct, and subject clinical source documents. The Investigator's file will contain all essential documents listed in ICH-GCP Guidelines section 8. Subject clinical source documents include all patient hospital clinical records in original version, such as original laboratory reports, ECG, X-ray prints and other reports. These two categories of documents must be kept on file by the Investigator for as long as needed to comply with the regulatory requirements. Quality Control and Quality Assurance 12.1.3 Periodic Monitoring The designated monitor will contact and visit the Investigator on a regularly basis and will be allowed to have direct access to all source documents needed to verify the entries in the Triamcinolone levels in cochlear perilymph Page 33 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 CRFs and other protocol-related documents provided that subject confidentiality is maintained in agreement with local regulations. It will be the monitor's responsibility to inspect the CRFs at regular intervals according to the monitoring plan throughout the study, to verify the adherence to the protocol and the completeness, consistency and accuracy of the data being entered on them. A qualified staff member of the ENT department will perform monitoring. An initiation visit, a control visits and a close out visit will be carried out. The monitor will randomly check source data, all patient consent forms, storage of study medication and accordance to study protocol. 12.1.4 Audit and Inspections Upon request, the Investigator will make all study-related source data and records available to a qualified quality assurance auditor mandated by the sponsor or to competent authority inspectors. The main purposes of an audit or inspection are to confirm that the rights and welfare of the subjects have been adequately protected, and that all data relevant for assessment of safety and efficacy of the investigational product have appropriately been reported to the sponsor. Reporting and Publication 12.1.5 Publication of study results The findings of this study will be published by the sponsor (Investigators) in a scientific journal and presented at scientific meetings. The manuscript will be circulated to all co - Investigators before submission. Confidentiality of subjects in reports/publications will be guaranteed. 13. ETHICAL AND LEGAL ASPECTS Informed consent of subjects Following comprehensive instruction regarding the nature, significance, impact and risks of this clinical trial, the patient must give written consent to participation in the study. Triamcinolone levels in cochlear perilymph Page 34 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 During the instruction the trial participants are to be made aware of the fact that they can withdraw their consent without giving reasons at any time without their further medical care being influenced in any way. In addition to the comprehensive instructions given to the trial participants by the Investigator, the trial participants also receive a written patient information sheet in comprehensible language, explaining the nature and purpose of the study and its progress. The patients must agree to the possibility of study-related data being passed on to relevant authorities. The patients must be informed in detail of their obligations in relation to the trial participants insurance in order not to jeopardize insurance cover. Acknowledgement / approval of the study The Investigator (or a designated CRO) will submit this protocol and any related document provided to the subject (such as subject information used to obtain informed consent) to an Ethics Committee (EC) or Institutional Review Board (IRB). Approval from the committee must be obtained before starting the study. The clinical trial shall be performed in full compliance with the legal regulations according to the Drug Law (AMG - Arzneimittelgesetz) of the Republic of Austria. An application must also be submitted to the Austrian Competent Authorities (Bundesamt für Sicherheit im Gesundheitswesen (BASG) represented by the Agency for Health and Food Safety (AGES Medizinmarktaufsicht) and registered to the European Clinical Trial Database (EudraCT) using the required forms. The timelines for (silent) approval set by national law must be followed before starting the study. 13.1.1 Changes in the Conduct of the Study Protocol amendments Proposed amendments must be submitted to the appropriate CA and ECs. Substantial amendments may be implemented only after CA/EC approval has been obtained. Amendments that are intended to eliminate an apparent immediate hazard to subjects may be implemented prior to receiving CA/EC approval. However, in this case, approval must be obtained as soon as possible after implementation. Study Termination Triamcinolone levels in cochlear perilymph Page 35 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 If the sponsor or the Investigator decides to terminate the study before the planned completion, they will notify each other in writing stating the reasons of early termination. Both the sponsor and the investigator will ensure the protection of the wellbeing. The sponsor will notify the regulatory authority as well as the ethics committee about the premature termination. Documentation will be filed in the Trial Master File as well as in the Investigator Site File. Clinical Study Report (CSR) Within one year after the final completion of the study, a full CSR will be prepared by the sponsor and submitted to the EC and the competent authority. The Investigator will be asked to review and sign the final study report. Insurance During their participation in the clinical trial the patients will be insured as defined by legal requirements. The Investigator of the clinical trial will receive a copy of the insurance conditions of the ' insurance'. The sponsor is providing insurance in order to indemnify (legal and financial coverage) the Investigator/center against claims arising from the study, except for claims that arise from malpractice and/or negligence. The compensation of the subject in the event of study-related injuries will comply with the applicable regulations. Details on the existing insurance are given in the patient information sheet. Patients will be insured according to the general agreement of the Medical university of Vienna: Zürich Versicherungs AG Schwarzenbergplatz 15 1010 Wien Tel.: 0043 (01) 50125-0 Confidentiality The information contained in this document, especially unpublished data, is the property of the sponsor of this study. It is therefore provided to you in confidence as an Investigator, potential Investigator, or consultant, for review by you, your staff, and an Ethics Committee or Institutional Review Board. It is understood that this information will not be disclosed to others without written authorization from the Sponsor of this study (Prof. W. Gstöttner). Triamcinolone levels in cochlear perilymph Page 36 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 Ethics and Good Clinical Practice (GCP) The Investigator will ensure that this study is conducted in full conformance with the principles of the "Declaration of Helsinki" (as amended at the 64th WMA General Assembly, Fortaleza, Brazil, 2013) and with the laws and regulations of the country in which the clinical research is conducted. The Investigator of the clinical trial shall guarantee that only appropriately trained personnel will be involved in the study. All studies must follow the ICH GCP Guidelines and the regulatory requirements. Therefore, this study follows the EU Directive embedded in the Austrian drug act. Triamcinolone levels in cochlear perilymph Page 37 of 38 Triamcinolone levels in cochlear perilymph Department of Otorhinolaryngology EUDRACT Nr: 2017-002377-19 14. REFERENCES 1. Hobson, C.E., T.H. Alexander, and J.P. Harris, Primary treatment of idiopathic sudden sensorineural hearing loss with intratympanic dexamethasone. Curr Opin Otolaryngol Head Neck Surg, 2016. 24(5): p. 407-12. 2. Bird, P.A., et al., Intratympanic versus intravenous delivery of dexamethasone and dexamethasone sodium phosphate to cochlear perilymph. Otol Neurotol, 2011. 32(6): p. 933-6. 3. Rajan, G.P., et al., The role of preoperative, intratympanic glucocorticoids for hearing preservation in cochlear implantation: a prospective clinical study. Laryngoscope, 2012. 122(1): p. 190-5. 4. van de Water, T.R., et al., Mechanisms of hearing loss from trauma and inflammation: otoprotective therapies from the laboratory to the clinic. Acta Otolaryngol, 2010. 130(3): p. 308-11. 5. Wilk, M., et al., Impedance Changes and Fibrous Tissue Growth after Cochlear Implantation Are Correlated and Can Be Reduced Using a Dexamethasone Eluting Electrode. PLoS One, 2016. 11(2): p. e0147552. 6. O'Connell, B.P., J.B. Hunter, and D.S. Haynes, Current concepts in the management of idiopathic sudden sensorineural hearing loss. Curr Opin Otolaryngol Head Neck Surg, 2016. 24(5): p. 413-9. 7. Honeder, C., et al., Sustained release of triamcinolone acetonide from an intratympanically applied hydrogel designed for the delivery of high glucocorticoid doses. Audiol Neurootol, 2014. 19(3): p. 193-202. 8. Oertel, R., W. Kirch, and E. Klemm, Prednisolone concentration in the cochlea of patients with perilymph fistula. Pharmazie, 2007. 62(3): p. 239-40. 9. Niedermeyer, H.P., et al., Cortisol levels in the human perilymph after intravenous administration of prednisolone. Audiol Neurootol, 2003. 8(6): p. 316-21. 10. Bird, P.A., et al., Intratympanic versus intravenous delivery of methylprednisolone to cochlear perilymph. Otol Neurotol, 2007. 28(8): p. 1124-30. 11. Guzman, J., et al., Triamcinolone acetonide protects auditory hair cells from 4- hydroxy-2,3-nonenal (HNE) ototoxicity in vitro. Acta Otolaryngol, 2006. 126(7): p. 685-90. 12. Kiefer, J., et al., Conservation of low-frequency hearing in cochlear implantation. Acta Otolaryngol, 2004. 124(3): p. 272-80. 13. Cesar, I.C., et al., Determination of triamcinolone in human plasma by a sensitive HPLC-ESI-MS/MS method: application for a pharmacokinetic study using nasal spray formulation. J Mass Spectrom, 2011. 46(3): p. 320-6. Triamcinolone levels in cochlear perilymph Page 38 of 38

Journal

JAMA Otolaryngology - Head & Neck Surgery – American Medical Association

Published: Nov 30, 2021

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