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Preliminary Communication |

Mexiletine for Symptoms and Signs of Myotonia in Nondystrophic Myotonia:  A Randomized Controlled Trial FREE

Jeffrey M. Statland, MD; Brian N. Bundy, PhD; Yunxia Wang, MD; Dipa Raja Rayan, MRCP; Jaya R. Trivedi, MD; Valeria A. Sansone, MD; Mohammad K. Salajegheh, MD; Shannon L. Venance, MD; Emma Ciafaloni, MD; Emma Matthews, MRCP; Giovanni Meola, MD; Laura Herbelin, BS; Robert C. Griggs, MD; Richard J. Barohn, MD; Michael G. Hanna, FRCP; for the Consortium for Clinical Investigation of Neurologic Channelopathies
[+] Author Affiliations

Author Affiliations: Department of Neurology, University of Rochester Medical Center, Rochester, New York (Drs Statland, Ciafaloni, and Griggs); Pediatrics Epidemiology Center, University of South Florida, Tampa (Dr Bundy); Department of Neurology, University of Kansas Medical Center, Kansas City (Drs Wang and Barohn and Ms Herbelin); Medical Research Council Centre for Neuromuscular Diseases, University College London, Institute of Neurology, London, England (Drs Rayan, Matthews, and Hanna); Department of Neurology, University of Texas Southwestern, Dallas (Dr Trivedi); Department of Neurology, University of Milan, Istituti di Ricovero e Cura a Carattere Scientifico, Policlinico San Donato, Milan, Italy (Drs Sansone and Meola); Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (Dr Salajegheh); and Department of Clinical Neurological Sciences, London Health Sciences Centre, London, Ontario, Canada (Dr Venance).


JAMA. 2012;308(13):1357-1365. doi:10.1001/jama.2012.12607.
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Published online

Context Nondystrophic myotonias (NDMs) are rare diseases caused by mutations in skeletal muscle ion channels. Patients experience delayed muscle relaxation causing functionally limiting stiffness and pain. Mexiletine-induced sodium channel blockade reduced myotonia in small studies; however, as is common in rare diseases, larger studies of safety and efficacy have not previously been considered feasible.

Objective To determine the effects of mexiletine for symptoms and signs of myotonia in patients with NDMs.

Design, Setting, and Participants A randomized, double-blind, placebo-controlled 2-period crossover study at 7 neuromuscular referral centers in 4 countries of 59 patients with NDMs conducted between December 23, 2008, and March 30, 2011, as part of the National Institutes of Health–funded Rare Disease Clinical Research Network.

Intervention Oral 200-mg mexiletine or placebo capsules 3 times daily for 4 weeks, followed by the opposite intervention for 4 weeks, with 1-week washout in between.

Main Outcome Measures Patient-reported severity score of stiffness recorded on an interactive voice response (IVR) diary (scale of 1 = minimal to 9 = worst ever experienced). Secondary end points included IVR-reported changes in pain, weakness, and tiredness; clinical myotonia assessment; quantitative measure of handgrip myotonia; and Individualized Neuromuscular Quality of Life summary quality of life score (INQOL–QOL, percentage of maximal detrimental impact).

Results Mexiletine significantly improved patient-reported severity score stiffness on the IVR diary. Because of a statistically significant interaction between treatment and period for this outcome, primary end point is presented by period (period 1 means were 2.53 for mexiletine and 4.21 for placebo; difference, −1.68; 95% CI, −2.66 to −0.706; P < .001; period 2 means were 1.60 for mexiletine and 5.27 for placebo; difference, −3.68; 95% CI, −3.85 to −0.139; P = .04). Mexiletine improved the INQOL–QOL score (mexiletine, 14.0 vs placebo, 16.7; difference, −2.69; 95% CI, −4.07 to −1.30; P < .001) and decreased handgrip myotonia on clinical examination (mexiletine, 0.164 seconds vs placebo, 0.494 seconds; difference, −0.330; 95% CI, −0.633 to −0.142; P < .001). The most common adverse effect was gastrointestinal (9 mexiletine and 1 placebo). Two participants experienced transient cardiac effects that did not require stopping the study (1 in each group). One serious adverse event was determined to be not study related.

Conclusion In this preliminary study of patients with NDMs, the use of mexiletine compared with placebo resulted in improved patient-reported stiffness over 4 weeks of treatment, despite some concern about the maintenance of blinding.

Trial Registration clinicaltrials.gov Identifier: NCT00832000

Figures in this Article

The nondystrophic myotonias (NDMs) are rare disorders (prevalence 1:100 0001) caused by mutations in skeletal muscle chloride and sodium channels with the common clinical feature of myotonia without muscle wasting.2 Myotonia causes functionally limiting stiffness, pain, fatigue, and weakness. Data on treatment of NDMs are largely anecdotal, consisting of case series and a single-blind, controlled trial of quinine,3 procainamide,3,4 phenytoin,4 tocainide,5 and mexiletine.6,7 A 2006 Cochrane review8 concluded there were not sufficient data to consider any treatment safe and effective for myotonia.

Mexiletine is a class 1b antiarrhythmic medication with a high affinity for muscle sodium channels. In vitro and animal models suggest mexiletine reduces muscle fiber excitability caused by common NDM mutations.912 A recent randomized controlled, crossover study showed mexiletine to be effective for reducing myotonia in patients with myotonic dystrophy type 1.13

A major impediment to randomized controlled trials in NDM is its rarity. The National Institutes of Health–funded Rare Disease Clinical Research Network (RDCRN) was designed to provide centralized infrastructure for investigations of rare diseases. In a natural history study, we used a novel interactive voice response (IVR) diary of patient symptoms and found stiffness was the most common and severe symptom reported in NDMs regardless of mutation.14 Herein, we report a phase 2 international randomized, placebo-controlled, crossover study of mexiletine in NDMs using the RDCRN and patient-reported stiffness severity score on the IVR diary as the primary outcome.

Trial Design

We conducted a randomized, double-blind, placebo-controlled, 2-period crossover trial at 7 centers in 4 countries (United States, Canada, England, and Italy). Treatment periods were 4 weeks in duration, separated by a 1-week washout period. The trial was approved by the institutional review boards at the 7 centers, and written informed consent was obtained from all participants. The National Institutes of Health established a data and safety monitoring board, which met every 6 months.

Participants

Eligible participants were aged at least 16 years, had clinical symptoms or signs of NDMs, and had myotonic potentials on electromyography. Participants were enrolled in the Consortium for Clinical Investigation of Neurologic Channelopathies NDM Natural History Study, or were a new patient with genetically confirmed NDMs, or had clinical features of NDMs but negative myotonic dystrophy DNA testing. Patients taking antimyotonic agents were required to discontinue medications for a washout period equal to 7 times the half-life of elimination before their baseline visit. Participants were ineligible if they had specific contraindications to taking mexiletine (cardiac conduction defects, hepatic or renal disease, or heart failure).

The trial was registered with clinicaltrials.gov (NCT00721942) in July 2008. Due to a duplicate registration number, records were consolidated in January 2009 (NCT00832000). The study was conducted between December 23, 2008, and March 30, 2011 (first patient enrolled December 23, 2008) at 7 RDCRN/Consortium for Clinical Investigation of Neurologic Channelopathies sites (University of Kansas Medical Center, Kansas City; University of Rochester Medical Center, Rochester, New York; Brigham and Women's Hospital, Boston, Massachusetts; University of Texas Southwestern, Dallas; London Health Sciences Center, London, Ontario, Canada; Medical Research Council for Neuromuscular Diseases, University College London Institute of Neurology, London, England; and the University of Milan, Istituti di Ricovero e Cura a Carattere Scientifico Policlinico San Donato, Milan, Italy).

Interventions

Participants were randomized to either 200-mg capsules of mexiletine 3 times a day or 200-mg capsules of placebo 3 times a day for 4 weeks. After a 1-week washout period, the participants were administered the opposite intervention for 4 weeks.

Mexiletine was purchased from TEVA Pharmaceutical. The placebo was microcrystalline cellulose (Avicel PH 102). The mexiletine and placebo were encapsulated at the University of Iowa Research Pharmacy (Iowa City) with Swedish orange capsule. A qualified person from Brecon inspected TEVA and the University of Iowa Research Pharmacy for the purpose of the European directive. Mexiletine drug level testing was performed at Mayo Medical Laboratory (Rochester, Minnesota). Random drug levels were collected before study visits at baseline and the end of weeks 4, 5, and 9.

Outcome Measures

Baseline characteristics included sex, age, and self-reported race/ethnicity. For the IVR diary, telephone calls were made daily for the entire 9-week study. All other outcome measurements were performed at baseline, the end of each treatment period, and the end of washout.

Primary End Points. The primary end point was defined as the severity score of stiffness reported by participants during the third and fourth week of each treatment period via the IVR diary. Participants called in to report symptom severity on a scale of 1 to 9, with 1 being minimal and 9 being the worst ever experienced (no symptom = 0 for analysis) (eFigure).14

Secondary End Points. Secondary end points included (1) participant-assessed pain, weakness, and tiredness as measured by the IVR diary from daily telephone calls made over the last 2 weeks of each period.14 (2) Clinical myotonia bedside assessment (participants were asked to squeeze their eyes closed for 5 seconds, then rapidly open them, and make a tight fist for 5 seconds, then rapidly open them). Five trials of each maneuver were performed in sequence at each visit and the time was measured by a stopwatch. (3) A quantitative measure of handgrip myotonia was obtained using a commercially available grip dynamometer and computerized capture system. Maximum voluntary contractions following forced right-hand grip were recorded and the time to relax from 90% to 5% of maximal force was determined using automated analysis software.15,16 (4) The maximal postexercise decrement in compound muscle action potential after short and long exercise was determined as previously described.17,18 (5) Myotonia on needle electromyography was graded on a 1+ to 3+ scale in the right abductor digiti minimi and right tibialis anterior.19 (6) Patients filled out the 36-Item Short-Form Health Survey (SF-36) and the Individualized Quality of Life questionnaire for neuromuscular disorders (INQOL).2022 The INQOL is composed of 10 sections (muscle locking, weakness, pain, fatigue, activities, social relationships, independence, emotions, body image, and effects of treatment) and a summary QOL score (INQOL–QOL).

Sample Size

The sample size goal was set to 54 participants with available primary end point measurements for both treatment periods. This sample size, determined by computer simulation, provided at least 93% power to detect an effect size of one-quarter of an SD (within-participant) in the primary end point with a 2-sided hypothesis test and an α = .05. The variation in power was due to varying the degree of between-participant SD; larger SDs lowered the power since the effect in the active treatment period for low-severity scores cannot be less than 0. The simulations were based on 500 Monte Carlo realizations, a mean for the placebo group of 3, a within-participant SD of 1.5, and a between-participant SD ranging from 1.5 to 3.0. The effect size of one-quarter of an SD was chosen to be conservative given the tentative assumptions in the simulation, to compensate for the unknown degree of participant adherence to treatment, and to have a sufficient sample size available for the secondary IVR diary end points for which some participants do not have the symptom.

Randomization and Blinding

Participants were randomly assigned the order of the 2 treatments in a 1:1 ratio, stratified by institution. Randomization was performed centrally at the data management coordinating center (University of South Florida, Tampa) using a computer-generated permuted block structure, initially with a block size of 4 then, toward the end of the trial, switching to a block size of 2. Each participant was assigned a “kit” number. In this kit, there were only 2 bottles of medication (“A” for period 1 and “B” for period 2). Only 1 bottle was dispensed at a time. Participants, physicians, and evaluators were blinded to medication assignment.

Statistical Analysis

Our study used the intention-to-treat principle modified to remove missing values that were assumed to be missing at random. All treatment effect analyses used the linear mixed-effects model (random effect for participant, independent and identically distributed random errors within participant) to adjust for any period effect and include data from dropouts.2325 One assumption required to produce valid Wald tests is that the residuals be normally distributed. To fulfill this assumption, the daily reported IVR severity scores (involving the 4 end points of stiffness, pain, tiredness, and weakness) were replaced with the weekly means, and QQ plots confirmed that this assumption was satisfied. Another assumption when modeling crossover study data and including only the main effects for period and treatment is that the treatment effect is the same across periods. The lack of consistency is often referred to as a “carryover” effect, although this term can be a misnomer.26

For the primary end point, the Wald test of the treatment-sequence group variable (treatment group) was significant (estimate, 0.997; P = .04). This result does not necessarily indicate that the second period data are invalid and should be ignored.25,27 However, it may indicate that the treatment effect in period 2 is biased and that the additive model may yield biased estimates. A fair presentation of the results is to include an interaction term for period 2 and treatment, in order to present the treatment effect estimates separately by period. The test for “carryover” effect was considered significant if P < .10.24 Significance was detected for 4 of the subscales of the SF-36: vitality, emotional role, mental health, and mental composite. Thus, these results and stiffness are displayed by period. The significance level displayed for period 2 is from the Wald test associated with the interaction term of period 2 and mexiletine and not the entire treatment effect, and the significance level displayed for period 1 is from the test of the main effect term for treatment variable. Most of the CIs were computed in the usual way using the SE of the estimate taken from the model results; the exceptions were the end points requiring a log transformation for which a bootstrap CI was computed. The effect size was the treatment effect estimate divided by the within-participant SD.

To test whether the overall treatment effect varies within mutation class, we used the log likelihood test contrasting the model with vs without the treatment and mutation class interaction terms as a homogeneity test.

For the electrographic myotonia assessment, the score was converted to a numeric value (absent = 0, 1+ = 1, 2+ = 2, and 3+ = 3). The end point was the sum of the numerical scores of the 2 muscles. Although the mixed model was used to provide mean estimates, the paired Wilcoxon test was used to test the treatment effect hypothesis. To fulfill the normality assumption for the clinical handgrip and eye closure times, we applied the following transformation: log(ti +0.1). Similarly, quantitative handgrip myometry required a log(ti) transformation; the model included a linear term for grip sequence number and a nested random effect for trial number.

All P values were 2-sided and .05 was considered the threshold of statistical significance for all tests except for the carryover effect. Because this trial identified a primary end point, all other P values presented were for secondary end points and are not adjusted for multiple testing. Analysis was performed using TIBCO Spotfire S+ version 8.1 (TIBCO Software Inc).

Participant Flow

Eligible participants were recruited between December 23, 2008, and January 25, 2011. Of 62 participants recruited, 3 were ineligible (1 had a prolonged QTc at screening visit, 1 had elevated transaminase levels, and 1 had no clinical myotonia on examination). Fifty-nine participants were randomized to receive either study medication or placebo. Two participants did not make expected telephone calls to the IVR diary system during weeks 3 to 4 of either period. There were 3 dropouts (1 secondary to migraine headaches, 1 secondary to gastric discomfort, and 1 for failure to comply with study visits). An additional 2 participants did not make telephone calls to the IVR diary system during weeks 3 to 4 of the second period, so only provided data for period 1 (Figure 1).

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Figure 1. Study Design and Disposition of Patients
Graphic Jump Location

IVR indicates interactive voice response.

Baseline Data

We studied 33 men and 26 women, with mean age of 42.9 years (range, 16-68 years). Participants were predominantly white (57/59 [96.6%]) and non-Hispanic (46/59 [78.0%]). Thirty-four participants had chloride channel mutations, 21 had sodium channel mutations, and 4 had no mutation identified. Seventeen participants were taking medications for myotonia before the start of the study, including 13 (22.0%) taking mexiletine (Table 1). Randomization between groups was balanced, with the exception of more men in the placebo followed by mexiletine group.

Table Graphic Jump LocationTable 1. Screening Baseline Characteristics of the 2 Treatment Sequence Groupsa
Numbers Analyzed and Drug Levels

Data from 57 participants who made telephone calls to the IVR diary in weeks 3 to 4 of period 1 or 2 were included in the analysis (Figure 1). Adherence for the primary end point, stiffness on the IVR diary, was achieved in 74.3% of possible telephone calls (78.6% in period 1 and 70.0% in period 2).

Pill adherence was similar between treatments (means for the ratio of the number of pills “taken” to the number of pills distributed were 90.2% for mexiletine vs 92.7% for placebo for period 1 and 93.0% for mexiletine vs 92.7% for placebo for period 2). Mexiletine levels at baseline, the end of washout, and the end of both placebo groups were not detectible. The mean (SD) mexiletine level at the end of mexiletine treatment periods was 0.54 (0.35) μg/mL (reference antiarrhythmic therapeutic range for 600-1200 mg/d, 0.5-2.0 μg/mL).

Outcomes and Estimations

Mexiletine was associated with significantly improved stiffness as reported on the IVR diary in both treatment periods. As explained in the Methods section, we estimated the treatment effect for each period separately. For period 1, the treatment effect was 2.53 for mexiletine vs 4.21 for placebo (difference, −1.68; 95% CI, −2.66 to −0.706; P < .001); and for period 2, 1.60 for mexiletine vs 5.27 for placebo (difference, −3.68; 95% CI, −3.85 to −0.139; P = .04) (Table 2 and Figure 2).

Table Graphic Jump LocationTable 2. Mixed Model Results Including Mean Estimate Under Both Treatments, the Difference of Treatments (Mexiletine Minus Placebo), Effect Size, and Significance Levela
Place holder to copy figure label and caption
Figure 2. Weekly Stiffness Severity Scores by Treatment Sequence
Graphic Jump Location

There were significant improvements with mexiletine in most other outcomes in the study, including patient-reported outcomes, QOL scales, and quantitative measures of myotonia (Table 2). Mexiletine improved the SF-36 physical composite score (mexiletine, 44.8 vs placebo, 39.2; difference, 5.58; 95% CI, 3.44-7.72; P < .001) and INQOL summary QOL score (mexiletine, 14.0 vs placebo, 16.7; difference, −2.69; 95% CI, −4.07 to −1.30; P < .001).

Mexiletine improved myotonia as measured on clinical examination by overall handgrip times in seconds (mexiletine, 0.164 seconds vs placebo, 0.494 seconds; difference, −0.330; 95% CI, −0.633 to −0.142; P < .001) (Figure 3) and overall QMA handgrip 90% to 5% relaxation times (mexiletine, 0.321 seconds vs placebo, 0.429 seconds; difference, −0.109; 95% CI, −0.177 to −0.0560; P <.001). Electrophysiological measures of myotonia showed a mixed response. Mexiletine significantly improved the severity of graded myotonia on electromyography (right abductor digiti minimi: difference, −0.568; 95% CI, −0.812 to −0.325; P < .001) (Figure 4). There was no statistically significant association with mexiletine and electrophysiological exercise testing.

Place holder to copy figure label and caption
Figure 3. Clinical Evaluation of Handgrip Myotonia Times by Treatment Sequence
Graphic Jump Location

Actual times displayed on log(t+0.1) scale to correspond with the normalizing transformation used for analysis. Zero times for some participants required the translation value of 0.1 to be added, then scaling with the natural log function.

Place holder to copy figure label and caption
Figure 4. Graded Myotonia on Electromyography for Right Abductor Digiti Minimi (n = 56) in Placebo and Mexiletine Treatment Groups
Graphic Jump Location

Myotonia grading: 0 = no myotonia; 1+ = myotonic discharges at least 500 ms and elicited in 3 areas of the muscle outside of the endplate zone; 2+ = myotonic discharge in more than ½ of needle locations; and 3+ = myotonic discharges with each needle movement in all examined areas.19

Ancillary Analyses

The reduction in the severity of stiffness score was more pronounced for participants with chloride mutations than sodium mutations in period 2 (chloride, −4.18; 95% CI, −5.25 to −3.12; vs sodium, −2.67; 95% CI, −3.84 to −1.51; P = .003) (eTable ), but showed to be the reverse in period 1 (chloride, −1.67; 95% CI, −2.73 to −0.614; vs sodium, −2.11; 95% CI, −3.28 to −0.933). In addition, the decrease in the clinical quantitative myotonia assessment handgrip times was greater for participants with chloride mutations than sodium mutations (chloride, −1.24 seconds; 95% CI, −1.77 to −0.711 seconds; vs sodium, −0.355 seconds; 95% CI, −1.03 to 0.316 seconds; P = .04).

Safety

There was 1 serious adverse event determined to be not study related (narcotic withdrawal). The most common adverse event was gastrointestinal in 9 participants in the mexiletine group and in 1 participant in the placebo group (Table 3). There were 2 reported cardiac adverse events both found incidentally on electrocardiogram at the end of week 4 (1 patient had bradycardia in the mexiletine group that resolved on follow-up electrocardiogram and 1 patient had premature ventricular complexes in the placebo group). Neither necessitated stopping the study.

Table Graphic Jump LocationTable 3. Adverse Events of the Mexiletine and Placebo Treatment Groups
Survey

A survey performed after the completion of each study period asked participants to guess their treatment allocation during the preceding period. The number of participants who guessed correctly was 18 (64%) in the mexiletine group and 20 (69%) in the placebo group during period 1, and 23 (79%) in the mexiletine group and 20 (80%) in the placebo group during period 2.

Our study provides preliminary evidence of the effectiveness of mexiletine for symptoms and signs of myotonia in NDMs. There was a significant increase in IVR diary treatment effect for stiffness in period 2 compared with period 1. This so called “carryover” effect is contrary to the usual definition of “the persistence of a treatment applied in one period in a subsequent period of treatment.”27 There was no evidence for a lingering effect of mexiletine into period 2. Washout of mexiletine was effective (drug levels zero or not detectible after washout).

There was no evidence of an unbalanced effect based on group assignment. The aggregate within participant difference between mexiletine and placebo groups was similar whether participants received mexiletine followed up by placebo (−2.55) or placebo followed up by mexiletine (−2.62). It is possible that unintentional unblinding of participants was associated with this increase.

The cause-effect mechanism can be explained in 1 of 2 ways: (1) unintentional unblinding was due to a true treatment effect, which suggests that additional benefit detected in period 2 is attributable to mexiletine; or (2) the adverse effects of mexiletine (or the absence of adverse effects for those participants receiving placebo) in period 2 lead to exaggerating the score to a lower (or higher) value. It is not possible to tease out from the data which explanation is correct. The effect for period 1 confirms its significance (P < .001) and represents the lower bound of the treatment effect in our trial. The fairest interpretation we can propose is that the treatment effect lies somewhere between the estimates from period 1 (−1.68) and period 2 (−3.68).

The clinical significance of the improvement in stiffness score on the IVR diary is supported by the broad improvement in clinical, quantitative, and electrophysiological measures of myotonia. Although patient-reported outcomes might be susceptible to exaggeration by participants who had guessed their treatment assignment, quantitative measures are not (mexiletine decreased myotonia on both quantitative handgrip testing and electromyography). Overall, most effect sizes were more than 0.5, which in the literature corresponds with moderate responsiveness, and more than 0.8, which corresponds with large responsiveness, for many outcomes (stiffness, weakness, and pain on the IVR diary, SF-36 physical composite score, clinical eye closure myotonia, and electrophysiological myotonia grades) (Table 2).2831 Many studies have suggested that statistically an effect size of 0.5 corresponds well to minimally clinically important differences in health-related QOL instruments.3235

Mexiletine was well tolerated in our study. Gastrointestinal discomfort was the most common adverse event, and there were no serious study-related adverse events.

Limitations to our study include the short duration of treatment, limited power for detecting adverse events, and the inclusion of participants with both chloride and sodium channel mutations in a single group to obtain necessary study power. Although there was an indication mexiletine resulted in greater improvement in stiffness score for participants with chloride channel mutations vs sodium channel mutations in period 2, the opposite was true in period 1. The clinical implications for this are not clear. Both groups appear to have improved with mexiletine, and the study is not powered to determine relative effectiveness by mutation.

In conclusion, our study provides preliminary evidence of the effectiveness of mexiletine for patients with myotonia. The RDCRN provided common data elements and the centralized infrastructure necessary for such a broad international collaboration, and serves as a model for future research of rare diseases.

Corresponding Author: Richard J. Barohn, MD, Department of Neurology, University of Kansas Medical Center, 3599 Rainbow Blvd, Kansas City, KS 66160 (rbarohn@kumc.edu).

Author Contributions: Dr Barohn had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Statland, Bundy, Wang, Trivedi, Griggs, Barohn, Hanna.

Acquisition of data: Wang, Rayan, Trivedi, Sansone, Salajegheh, Venance, Ciafaloni, Matthews, Meola, Herbelin, Griggs, Barohn.

Analysis and interpretation of data: Statland, Bundy, Trivedi, Salajegheh, Griggs, Barohn.

Drafting of the manuscript: Statland, Bundy, Wang, Salajegheh, Herbelin, Griggs, Barohn.

Critical revision of the manuscript for important intellectual content: Statland, Bundy, Wang, Rayan, Trivedi, Sansone, Salajegheh, Venance, Ciafaloni, Matthews, Meola, Herbelin, Griggs, Barohn, Hanna.

Statistical analysis: Bundy.

Obtained funding: Statland, Wang, Herbelin, Griggs, Barohn.

Administrative, technical, or material support: Bundy, Trivedi, Salajegheh, Herbelin, Griggs.

Study supervision: Wang, Rayan, Trivedi, Sansone, Salajegheh, Venance, Ciafaloni, Matthews, Meola, Herbelin, Griggs, Barohn, Hanna.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Venance reported receiving reimbursement for travel from Genzyme and royalties from Wiley Publishing for her role as coeditor of Neurology in Practice: Neuromuscular Disorders. Dr Meola reported being supported in part by AFM (the French Muscular Dystrophy Association). Dr Griggs reported serving as chair of executive committee of the Muscle Study Group, which receives support from pharmaceutical companies; serving on scientific advisory boards for The National Hospital Queen Square and PTC Therapeutics; serving on the editorial boards of NeuroTherapeutics and Current Treatment Opinions in Neurology; receiving royalties from the publication of Andreoli and Carpenter's Cecil Essentials of Medicine, Eighth Edition (W.B. Saunders Company, 2000, 2004, 2007, and 2010) and Cecil Textbook of Medicine, 24th Edition (W.B. Saunders Company, 2000, 2004, 2008, and 2010); and receiving research support from TaroPharma. Dr Barohn reported receiving support from Grifols and Genzyme speakers bureau, and being a consultant for Pfizer, MedImmune, Novartis, and NuFactor. No other authors reported any financial disclosures.

Funding/Support: This study was supported by grants RO1 FD 003454 from the Food and Drug Administration Orphan Products Division and U54 NS059065-05S1 from the National Center for Research Resources and the National Institutes of Health. Additional funding was provided in part by grants UL1 RR 033179 (which is now UL1 TR 000001) from the University of Kansas Medical Center Clinical and Translational Science Awards (CTSA), UL1 RR 024160 from the University of Rochester CTSA, G0601943 from the University College London Medical Research Council Centre, and UL1 RR 024982 NCRR/NIH from the University of Texas Southwestern CTSA. Dr Rayan is a Medical Research Council Clinical Training Fellow. Dr Statland is funded by grant T32 NS07338-20 from the National Institutes of Health Experimental Therapeutics in Neurological Disorders.

Role of the Sponsor: The funding sources had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.

Members of theConsortium for Clinical Investigation of Neurologic Channelopathies:University of Kansas Medical Center—Investigators: Richard J. Barohn, MD (principal investigator, steering committee, manuscript preparation); Yunxia Wang, MD (co-principal investigator, steering committee, manuscript preparation); Jeffrey Statland, MD (steering committee, manuscript preparation); Mazen Dimachkie, MD; Project Manager/Study Coordinator/Clinical Evaluator: Laura Herbelin, CCRP (steering committee, manuscript preparation); JoAnn Miller, BA, CCRP (regulatory program manager); Central Cardiologist: Rhea Pimental, MD.

University of Texas Southwestern Medical Center—Investigators: Jaya Trivedi, MD (manuscript preparation); Study Coordinator: Nina Gorham, CCRP; Clinical Evaluator: Rhonda McLin, PTA, Vivian Gonzales.

Brigham and Women's Hospital—Investigators: Mohammad Kian Salajegheh, MD (steering committee, manuscript preparation); Anthony A. Amato, MD; Study Coordinator: Kristen Roe, BS; Clinical Evaluator: Samantha Chused, MSPT; Essa Kayd, RT.

London Health Science Center (London, Ontario, Canada)—Investigators: Shannon Venance, MD (steering committee, manuscript preparation); Angelica Hahn, MD; Study Coordinators/Clinical Evaluators: Wilma Koopman; Jennifer Verheyden; Ashley Ten Haaf; Christine Piechowicz.

University of Rochester—Investigators: Robert C. Griggs, MD (steering committee, manuscript preparation); Emma Ciafaloni, MD (manuscript preparation); Paul Twydell, DO; Study Coordinators: Katherine Aronson; Kimberly Hart (steering committee); Patricia Smith; Barbara Herr; Kate Eichinger; Shree Pandya; Stephen Bean; Araya Puwanant; Quing Ke; Jill Scheltz; Laura Whitesell.

Institute of Neurology (London, England)—Investigators: Michael Hanna, MD (steering committee, manuscript preparation); Dipa L. Raja Rayan, MRCP (manuscript preparation); Emma Matthews, MRCP (manuscript preparation); Study Coordinators/Clinical Evaluator: Gisela Barreto; Veronica Tan; James Burge; Elizabeth Dewar; Daleen Lopez-Begum; Genetic Testing: Richa Sud; Andrea Haworth; Samuel McCall.

University of Milan (Milan, Italy)—Investigators: Valeria Sansone, MD (manuscript preparation); Giovanni Meola, MD (manuscript preparation); Alice Zanolini, MD; Matteo Ciocca, MD.

University of South Florida (DMCC)—Statistician: Brian Bundy, PhD (steering committee, data analysis, manuscript preparation); Jeffrey Krischer, PhD; Holly Ruhlig; Joseph Gomes; Rachel Richesson; Renee Leduc; Jennifer Pilger.

Data and Safety Monitoring Board Members: John W. Day, MD, PhD (Standford School of Medicine, Stanford, California); Robert T. Leshner, MD (UC San Diego, San Diego, California); Todd A. Mackenzie, PhD (Dartmouth Hitchcock Medical Center, Hanover, New Hampshire); Kathryn Wagner, MD, PhD (The Johns Hopkins School of Medicine, Baltimore, Maryland).

National Institute of Neurological Disorders and Stroke (Bethesda, Maryland) Staff: Joanne C. Odenkirchen, MPH (Clinical Research Project Manager); Randy Stewart, PhD (Program Director).

Additional Contributions: We thank the study participants and their families for their commitment and generosity—they are the impetus for this international collaboration.

Emery AE. Population frequencies of inherited neuromuscular diseases—a world survey.  Neuromuscul Disord. 1991;1(1):19-29
PubMed   |  Link to Article
Matthews E, Fialho D, Tan SV,  et al; CINCH Investigators.  The non-dystrophic myotonias: molecular pathogenesis, diagnosis and treatment.  Brain. 2010;133(Pt 1):9-22
PubMed   |  Link to Article
Leyburn P, Walton JN. The treatment of myotonia: a controlled clinical trial.  Brain. 1959;82(1):81-91
PubMed   |  Link to Article
Griggs RC, Davis RJ, Anderson DC, Dove JT. Cardiac conduction in myotonic dystrophy.  Am J Med. 1975;59(1):37-42
PubMed   |  Link to Article
Streib EW. Paramyotonia congenita: successful treatment with tocainide. Clinical and electrophysiologic findings in seven patients.  Muscle Nerve. 1987;10(2):155-162
PubMed   |  Link to Article
Jackson CE, Barohn RJ, Ptacek LJ. Paramyotonia congenita: abnormal short exercise test, and improvement after mexiletine therapy.  Muscle Nerve. 1994;17(7):763-768
PubMed   |  Link to Article
Kwieciński H, Ryniewicz B, Ostrzycki A. Treatment of myotonia with antiarrhythmic drugs.  Acta Neurol Scand. 1992;86(4):371-375
PubMed   |  Link to Article
Trip J, Drost G, van Engelen BG, Faber CG. Drug treatment for myotonia.  Cochrane Database Syst Rev. 2006;(1):CD004762
PubMed
De Luca A, Pierno S, Liantonio A,  et al.  New potent mexiletine and tocainide analogues evaluated in vivo and in vitro as antimyotonic agents on the myotonic ADR mouse.  Neuromuscul Disord. 2004;14(7):405-416
PubMed   |  Link to Article
Desaphy JF, De Luca A, Tortorella P, De Vito D, George AL Jr, Conte Camerino D. Gating of myotonic Na channel mutants defines the response to mexiletine and a potent derivative.  Neurology. 2001;57(10):1849-1857
PubMed   |  Link to Article
Mohammadi B, Jurkat-Rott K, Alekov A, Dengler R, Bufler J, Lehmann-Horn F. Preferred mexiletine block of human sodium channels with IVS4 mutations and its pH-dependence.  Pharmacogenet Genomics. 2005;15(4):235-244
PubMed   |  Link to Article
Wang GK, Russell C, Wang SY. Mexiletine block of wild-type and inactivation-deficient human skeletal muscle hNav1.4 Na+ channels.  J Physiol. 2004;554(Pt 3):621-633
PubMed   |  Link to Article
Logigian EL, Martens WB, Moxley RT IV,  et al.  Mexiletine is an effective antimyotonia treatment in myotonic dystrophy type 1.  Neurology. 2010;74(18):1441-1448
PubMed   |  Link to Article
Statland JM, Wang Y, Richesson R,  et al; Cinch Consortium.  An interactive voice response diary for patients with non-dystrophic myotonia.  Muscle Nerve. 2011;44(1):30-35
PubMed   |  Link to Article
Logigian EL, Blood CL, Dilek N,  et al.  Quantitative analysis of the “warm-up” phenomenon in myotonic dystrophy type 1.  Muscle Nerve. 2005;32(1):35-42
PubMed   |  Link to Article
Moxley RT III, Logigian EL, Martens WB,  et al.  Computerized hand grip myometry reliably measures myotonia and muscle strength in myotonic dystrophy (DM1).  Muscle Nerve. 2007;36(3):320-328
PubMed   |  Link to Article
Fournier E, Arzel M, Sternberg D,  et al.  Electromyography guides toward subgroups of mutations in muscle channelopathies.  Ann Neurol. 2004;56(5):650-661
PubMed   |  Link to Article
Tan SV, Matthews E, Barber M,  et al.  Refined exercise testing can aid DNA-based diagnosis in muscle channelopathies.  Ann Neurol. 2011;69(2):328-340
PubMed   |  Link to Article
Streib EW. AAEE minimonograph #27: differential diagnosis of myotonic syndromes.  Muscle Nerve. 1987;10(7):603-615
PubMed   |  Link to Article
Vincent KA, Carr AJ, Walburn J, Scott DL, Rose MR. Construction and validation of a quality of life questionnaire for neuromuscular disease (INQoL).  Neurology. 2007;68(13):1051-1057
PubMed   |  Link to Article
McHorney CA, Ware JE Jr, Raczek AE. The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs.  Med Care. 1993;31(3):247-263
PubMed   |  Link to Article
Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection.  Med Care. 1992;30(6):473-483
PubMed   |  Link to Article
Brown BW Jr. The crossover experiment for clinical trials.  Biometrics. 1980;36(1):69-79
PubMed   |  Link to Article
Grizzle JE. The two-period change-over design an its use in clinical trials.  Biometrics. 1965;21:467-480
PubMed   |  Link to Article
Willan AR, Pater JL. Carryover and the two-period crossover clinical trial.  Biometrics. 1986;42(3):593-599
PubMed   |  Link to Article
Piantadosi S. Crossover designs. In: Clinical Trials: A Methodological Perspective. 2nd ed. Hoboken, NJ: John Wiley & Sons; 2005:515-529
Senn S. Crossover trials. In: Statistical Issues in Drug Development. 2nd ed. Hoboken, NJ: John Wiley & Sons; 1997:237-248
de Vet HC, Terwee CB, Ostelo RW, Beckerman H, Knol DL, Bouter LM. Minimal changes in health status questionnaires: distinction between minimally detectable change and minimally important change.  Health Qual Life Outcomes. 2006;4:54
PubMed   |  Link to Article
Husted JA, Cook RJ, Farewell VT, Gladman DD. Methods for assessing responsiveness: a critical review and recommendations.  J Clin Epidemiol. 2000;53(5):459-468
PubMed   |  Link to Article
Kazis LE, Anderson JJ, Meenan RF. Effect sizes for interpreting changes in health status.  Med Care. 1989;27(3):(Suppl)  S178-S189
PubMed   |  Link to Article
Liang MH, Larson MG, Cullen KE, Schwartz JA. Comparative measurement efficiency and sensitivity of five health status instruments for arthritis research.  Arthritis Rheum. 1985;28(5):542-547
PubMed   |  Link to Article
Cella D, Eton DT, Fairclough DL,  et al.  What is a clinically meaningful change on the Functional Assessment of Cancer Therapy-Lung (FACT-L) questionnaire? results from Eastern Cooperative Oncology Group (ECOG) study 5592.  J Clin Epidemiol. 2002;55(3):285-295
PubMed   |  Link to Article
Norman GR, Sloan JA, Wyrwich KW. Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation.  Med Care. 2003;41(5):582-592
PubMed
Wyrwich KW, Nienaber NA, Tierney WM, Wolinsky FD. Linking clinical relevance and statistical significance in evaluating intra-individual changes in health-related quality of life.  Med Care. 1999;37(5):469-478
PubMed   |  Link to Article
Wyrwich KW, Tierney WM, Wolinsky FD. Further evidence supporting an SEM-based criterion for identifying meaningful intra-individual changes in health-related quality of life.  J Clin Epidemiol. 1999;52(9):861-873
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure 1. Study Design and Disposition of Patients
Graphic Jump Location

IVR indicates interactive voice response.

Place holder to copy figure label and caption
Figure 2. Weekly Stiffness Severity Scores by Treatment Sequence
Graphic Jump Location
Place holder to copy figure label and caption
Figure 3. Clinical Evaluation of Handgrip Myotonia Times by Treatment Sequence
Graphic Jump Location

Actual times displayed on log(t+0.1) scale to correspond with the normalizing transformation used for analysis. Zero times for some participants required the translation value of 0.1 to be added, then scaling with the natural log function.

Place holder to copy figure label and caption
Figure 4. Graded Myotonia on Electromyography for Right Abductor Digiti Minimi (n = 56) in Placebo and Mexiletine Treatment Groups
Graphic Jump Location

Myotonia grading: 0 = no myotonia; 1+ = myotonic discharges at least 500 ms and elicited in 3 areas of the muscle outside of the endplate zone; 2+ = myotonic discharge in more than ½ of needle locations; and 3+ = myotonic discharges with each needle movement in all examined areas.19

Tables

Table Graphic Jump LocationTable 1. Screening Baseline Characteristics of the 2 Treatment Sequence Groupsa
Table Graphic Jump LocationTable 2. Mixed Model Results Including Mean Estimate Under Both Treatments, the Difference of Treatments (Mexiletine Minus Placebo), Effect Size, and Significance Levela
Table Graphic Jump LocationTable 3. Adverse Events of the Mexiletine and Placebo Treatment Groups

References

Emery AE. Population frequencies of inherited neuromuscular diseases—a world survey.  Neuromuscul Disord. 1991;1(1):19-29
PubMed   |  Link to Article
Matthews E, Fialho D, Tan SV,  et al; CINCH Investigators.  The non-dystrophic myotonias: molecular pathogenesis, diagnosis and treatment.  Brain. 2010;133(Pt 1):9-22
PubMed   |  Link to Article
Leyburn P, Walton JN. The treatment of myotonia: a controlled clinical trial.  Brain. 1959;82(1):81-91
PubMed   |  Link to Article
Griggs RC, Davis RJ, Anderson DC, Dove JT. Cardiac conduction in myotonic dystrophy.  Am J Med. 1975;59(1):37-42
PubMed   |  Link to Article
Streib EW. Paramyotonia congenita: successful treatment with tocainide. Clinical and electrophysiologic findings in seven patients.  Muscle Nerve. 1987;10(2):155-162
PubMed   |  Link to Article
Jackson CE, Barohn RJ, Ptacek LJ. Paramyotonia congenita: abnormal short exercise test, and improvement after mexiletine therapy.  Muscle Nerve. 1994;17(7):763-768
PubMed   |  Link to Article
Kwieciński H, Ryniewicz B, Ostrzycki A. Treatment of myotonia with antiarrhythmic drugs.  Acta Neurol Scand. 1992;86(4):371-375
PubMed   |  Link to Article
Trip J, Drost G, van Engelen BG, Faber CG. Drug treatment for myotonia.  Cochrane Database Syst Rev. 2006;(1):CD004762
PubMed
De Luca A, Pierno S, Liantonio A,  et al.  New potent mexiletine and tocainide analogues evaluated in vivo and in vitro as antimyotonic agents on the myotonic ADR mouse.  Neuromuscul Disord. 2004;14(7):405-416
PubMed   |  Link to Article
Desaphy JF, De Luca A, Tortorella P, De Vito D, George AL Jr, Conte Camerino D. Gating of myotonic Na channel mutants defines the response to mexiletine and a potent derivative.  Neurology. 2001;57(10):1849-1857
PubMed   |  Link to Article
Mohammadi B, Jurkat-Rott K, Alekov A, Dengler R, Bufler J, Lehmann-Horn F. Preferred mexiletine block of human sodium channels with IVS4 mutations and its pH-dependence.  Pharmacogenet Genomics. 2005;15(4):235-244
PubMed   |  Link to Article
Wang GK, Russell C, Wang SY. Mexiletine block of wild-type and inactivation-deficient human skeletal muscle hNav1.4 Na+ channels.  J Physiol. 2004;554(Pt 3):621-633
PubMed   |  Link to Article
Logigian EL, Martens WB, Moxley RT IV,  et al.  Mexiletine is an effective antimyotonia treatment in myotonic dystrophy type 1.  Neurology. 2010;74(18):1441-1448
PubMed   |  Link to Article
Statland JM, Wang Y, Richesson R,  et al; Cinch Consortium.  An interactive voice response diary for patients with non-dystrophic myotonia.  Muscle Nerve. 2011;44(1):30-35
PubMed   |  Link to Article
Logigian EL, Blood CL, Dilek N,  et al.  Quantitative analysis of the “warm-up” phenomenon in myotonic dystrophy type 1.  Muscle Nerve. 2005;32(1):35-42
PubMed   |  Link to Article
Moxley RT III, Logigian EL, Martens WB,  et al.  Computerized hand grip myometry reliably measures myotonia and muscle strength in myotonic dystrophy (DM1).  Muscle Nerve. 2007;36(3):320-328
PubMed   |  Link to Article
Fournier E, Arzel M, Sternberg D,  et al.  Electromyography guides toward subgroups of mutations in muscle channelopathies.  Ann Neurol. 2004;56(5):650-661
PubMed   |  Link to Article
Tan SV, Matthews E, Barber M,  et al.  Refined exercise testing can aid DNA-based diagnosis in muscle channelopathies.  Ann Neurol. 2011;69(2):328-340
PubMed   |  Link to Article
Streib EW. AAEE minimonograph #27: differential diagnosis of myotonic syndromes.  Muscle Nerve. 1987;10(7):603-615
PubMed   |  Link to Article
Vincent KA, Carr AJ, Walburn J, Scott DL, Rose MR. Construction and validation of a quality of life questionnaire for neuromuscular disease (INQoL).  Neurology. 2007;68(13):1051-1057
PubMed   |  Link to Article
McHorney CA, Ware JE Jr, Raczek AE. The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs.  Med Care. 1993;31(3):247-263
PubMed   |  Link to Article
Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection.  Med Care. 1992;30(6):473-483
PubMed   |  Link to Article
Brown BW Jr. The crossover experiment for clinical trials.  Biometrics. 1980;36(1):69-79
PubMed   |  Link to Article
Grizzle JE. The two-period change-over design an its use in clinical trials.  Biometrics. 1965;21:467-480
PubMed   |  Link to Article
Willan AR, Pater JL. Carryover and the two-period crossover clinical trial.  Biometrics. 1986;42(3):593-599
PubMed   |  Link to Article
Piantadosi S. Crossover designs. In: Clinical Trials: A Methodological Perspective. 2nd ed. Hoboken, NJ: John Wiley & Sons; 2005:515-529
Senn S. Crossover trials. In: Statistical Issues in Drug Development. 2nd ed. Hoboken, NJ: John Wiley & Sons; 1997:237-248
de Vet HC, Terwee CB, Ostelo RW, Beckerman H, Knol DL, Bouter LM. Minimal changes in health status questionnaires: distinction between minimally detectable change and minimally important change.  Health Qual Life Outcomes. 2006;4:54
PubMed   |  Link to Article
Husted JA, Cook RJ, Farewell VT, Gladman DD. Methods for assessing responsiveness: a critical review and recommendations.  J Clin Epidemiol. 2000;53(5):459-468
PubMed   |  Link to Article
Kazis LE, Anderson JJ, Meenan RF. Effect sizes for interpreting changes in health status.  Med Care. 1989;27(3):(Suppl)  S178-S189
PubMed   |  Link to Article
Liang MH, Larson MG, Cullen KE, Schwartz JA. Comparative measurement efficiency and sensitivity of five health status instruments for arthritis research.  Arthritis Rheum. 1985;28(5):542-547
PubMed   |  Link to Article
Cella D, Eton DT, Fairclough DL,  et al.  What is a clinically meaningful change on the Functional Assessment of Cancer Therapy-Lung (FACT-L) questionnaire? results from Eastern Cooperative Oncology Group (ECOG) study 5592.  J Clin Epidemiol. 2002;55(3):285-295
PubMed   |  Link to Article
Norman GR, Sloan JA, Wyrwich KW. Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation.  Med Care. 2003;41(5):582-592
PubMed
Wyrwich KW, Nienaber NA, Tierney WM, Wolinsky FD. Linking clinical relevance and statistical significance in evaluating intra-individual changes in health-related quality of life.  Med Care. 1999;37(5):469-478
PubMed   |  Link to Article
Wyrwich KW, Tierney WM, Wolinsky FD. Further evidence supporting an SEM-based criterion for identifying meaningful intra-individual changes in health-related quality of life.  J Clin Epidemiol. 1999;52(9):861-873
PubMed   |  Link to Article
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Statland JM, Bundy BN, Wang Y, et al. Consortium for Clinical Investigation of Neurologic Channelopathies. Mexiletine for symptoms and signs of myotonia in nondystrophic myotonia: a randomized controlled trial. JAMA. doi:10.1001/jama.2012.12607.

eTable. Homogeneity Testing: Treatment Effect Mean Difference (Mexiletine - Placebo) With 95% Confidence Interval

eFigure. IVR Flow Diagram

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