Preventive Efficacy and Safety of Yiqi-Wenjing-Fang Granules on Oxaliplatin-Induced Peripheral Neuropathy: A Protocol for a Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial

Background. Oxaliplatin-induced peripheral neuropathy (OIPN) is one of the most common side effects of oxaliplatin, which can cause reduction and cessation of oxaliplatin-based chemotherapy and significantly affect patients' quality of life. However, no drug has got recognition to prevent or treat OIPN. Yiqi-Wenjing-Fang (YWF) is a joint name of Chinese medicine prescriptions with similar effects of tonifying qi and warming meridians, represented by Huangqi Guizhi Wuwu decoction (HGWD) and Danggui Sini decoction (DSD), both from “Treatise on Cold Pathogenic and Miscellaneous Diseases.” YWF granules, including HGWD granules and DSD granules, have been, respectively, demonstrated to be effective in preventing OIPN in previous small-sample observations. The purpose of this study is to enlarge the sample size for further evaluation of the preventive efficacy and safety of YWF granules on OIPN. Methods and Analysis. This study is a randomized, double-blind, placebo-controlled, and multicenter clinical trial. 360 postoperative patients with stage IIa-IIIc colorectal cancer will be randomly assigned into placebo-control group, intervention group I, and intervention group II, taking the mimetic granules of YWF as placebo, HGWD granules and DSD granules, respectively. All subjects will receive oxaliplatin-based chemotherapy regimen at the same time. EORTC QLQ-CIPN20 will be used to assess the degree of OIPN as the primary outcome measure. The grades of OIPN, quality of life, chemotherapeutic efficacy, and the number of completed chemotherapy cycles are selected as the secondary outcome measures. Discussion. Based on the condition of no recognized effective drugs in preventing OIPN, evidence-based medical study will be conducted for seeking a breakthrough in the field of Chinese herb medicine. This protocol could provide reliable and systemic research basis about the efficacy of YWF granules and the differentiation of two classical prescriptions of YWF on preventing OIPN objectively. Trial Registration. This study was registered at ClinicalTrials.gov on 26 December 2020 (ID: https://clinicaltrials.gov/ct2/show/NCT04690283).


Introduction
Oxaliplatin is a prime drug in the first-line standard chemotherapy regimens of colorectal cancer, included in mFOLFOX6, FOLFOX4, XELOX, and so on. e main side effect is dose-dependent neurotoxicity, namely, oxaliplatin-induced peripheral neuropathy (OIPN), which is the primary cause of reduction and cessation of platinum-based chemotherapy. Acute OIPN usually will develop in hours of oxaliplatin infusion and peaks 3 days later. About 90% of patients will undergo acute OIPN symptoms, characterized by abnormal sensations and muscle spasm of perioral region, tongue, throat, jaw, and limbs, triggered by cold stimulation. ese acute symptoms can alleviate in a week or so but will recur as the next chemotherapy cycle comes subsequently [1,2]. Chronic OIPN will gradually develop and aggravate after approximately 3 months of repeated administration, usually with more than 540 mg/m 2 cumulative dose of oxaliplatin. Clinical manifestations of chronic OIPN are bilateral symmetric paresthesia, dysesthesia and/or allodynia of limbs ("glove-sock" distribution), disorder of fine motor coordination, sensory ataxia, and autonomic nervous dysfunction, persisting as long as 6 months or even years after the termination of treatment [2][3][4].
According to the clinical characteristics, OIPN corresponds with "Bizheng" from the theory of traditional Chinese medicine (TCM), interpreted as arthromyodynia. Considering the hypoimmunity of patients receiving chemotherapy, deficiency of qi and meridian impassability are regarded as the vital pathogenesis of OIPN [29]. Yiqi-Wenjing-Fang (YWF) is a joint name of TCM prescriptions with similar effects of tonifying qi and warming meridians, represented by Huangqi Guizhi Wuwu decoction (HGWD) and Danggui Sini decoction (DSD), both from "Treatise on Cold Pathogenic and Miscellaneous Diseases." Comparing the two representative prescriptions, HGWD is better at tonifying qi, while DSD is better at warming meridians. Our previous small-sample-size randomized controlled clinical trial (n � 72) showed that HGWD could effectively prevent OIPN through reducing the incidence and alleviating the symptoms of OIPN without affecting the chemotherapy efficacy [30]. Further mechanistic studies preliminarily revealed the correlation between HGWD and platinum transport and accumulation in dorsal root ganglion (DRG), as well as inflammatory responses, oxidative stress, axonal lesions, and neuronal and mitochondrial dysfunctions induced by platinum chelate [31,32]. We conducted another randomized controlled clinical trial (n � 48) about DSD, which showed that DSD could significantly decrease the incidence and severity of acute OIPN [33]. Mechanistic studies demonstrated that the protective effects of DSD could be related to suppressing inflammatory lesions, improving ultramicrostructures, and enhancing amounts of Nissl bodies in DRG [34]. Although YWF has a strong clinical research basis in the efficacy and safety of OIPN prevention, further studies are necessary due to the insufficient sample size and the lack of placebo and parallel controls previously.

Method and Analysis
2.1. Objective. YWF have been empirically used to treat arthromyodynia for a long time in China, represented by HGWD and DSD, but there is a lack of evidence-based medical study. Small-sample-size clinical studies and animal experiments have been conducted and indicated positive efficacy of YWF granules on OIPN. To enlarge the sample size for further evaluation, 360 subjects for eligibility will be recruited. In addition, in order to compare the preventive efficacy on OIPN between HGWD granules and DSD granules, two paratactic treatment groups will be set according to the theory of treatment based on syndrome differentiation.

Study Design.
is study is designed as a randomized, double-blind, placebo-controlled, and multicenter clinical trial that will last for 18 months from January 2021 to June 2022. It will be conducted in 30 clinical centers in China, and each center will have an investigator for enrolling the patients and collecting the data. e centers and their investigators are listed in Table 1.
e trial was registered at ClinicalTrials.gov (ID: NCT04690283), and the protocol version is 1.2/ 20200506. e flow chart is shown in Figure 1. e schedule of enrollment, interventions, and assessments is shown in Figure 2. (v) Subject without severe damage of the heart, liver, kidney, or hematopoietic system.

Exclusion Criteria
(i) Subject with any grade of peripheral neuropathy.
(ii) Subject who has ever received treatment of neurotoxic chemotherapeutics, such as oxaliplatin, cisplatin, taxanes, or vinca alkaloids. (iii) Subject who is receiving agents with potential preventive or therapeutic effects to neuropathy, such as duloxetine, carbamazepine, venlafaxine, gabapentin, pregabalin, phenytoin, valproate, milnacipran, or tricyclic antidepressant. (iv) Subject who is participating or have participated in other clinical trials. (v) Subject with a family history of hereditary/familial neuropathy.

Sample Size Calculation.
is study is suitable for superiority test. Although without positive-control group, the method of sample size calculation is equal to the three-arm trial. Based on the incidence of OIPN, the incidence of the placebo-control group was assumed as 40%, and the incidences of two intervention groups were both assumed as 20%. e Pearson chi-square test was used to calculate the appropriate sample size for each group. Taking the 20% shedding rate into account and rounding off, each group needs 120 samples and a total of 360 samples.

Randomization, Allocation, and Blinding.
Randomization and blinding are controlled from the drug production source. All the test drugs are designed with the same appearance, dose, and smell, and each drug package has a corresponding drug number. Every six drug numbers are formed into a group, randomly corresponding to six test drugs, which necessarily include two mimetic granules of YWF, two HGWD granules, and two DSD granules, so that the whole is in accordance with the ratio of 1:1:1. Each center must recruit subjects in units of six (at least six subjects), and each recruited subject will be randomly assigned a sequential number and a corresponding drug number. Although the sequential and drug numbers are public, the specific properties of the drug are unknown to anyone, including subjects, investigators, and third-party inspectors.
2.6. Intervention. All subjects will receive FOLFOX4 or mFOLFOX6 or XELOX chemotherapy regimen, listed in Table 2, and YWF granules or placebo at the same time. In order to control the dosage of Chinese herbal medicine, the standard granules will be used as the intervention dosage form in this study, provided by Tianjin Hongri Kangrentang     Table 3. Besides, any other drugs potentially affecting the results of the experiment will be forbidden in the whole trial process, such as ganglioside, calcium and magnesium mixture agent, glutathione, mecobalamine, and injections containing astragalus.

Placebo-Control Group.
From the beginning of chemotherapy, subjects in this group will take the mimetic granules of YWF brewed by warm water after meal twice a day (once 1 bag, 1 hour after breakfast and dinner) for at least 3 months. e mimetic granules of YWF, which contain 2.5% HGWD granules, 2.5% DSD granules, bitter principle, food colouring, and starch, are designed with the same appearance and dosage and similar smell and taste to YWF granules.

Intervention Group I.
From the beginning of chemotherapy, subjects in this group will take HGWD granules brewed by warm water after meal twice a day (once 1 bag, 1 hour after breakfast and dinner) for at least 3 months.

Intervention Group II.
From the beginning of chemotherapy, subjects in this group will take DSD granules brewed by warm water after meal twice a day (once 1 bag, 1 hour after breakfast and dinner) for at least 3 months.

Outcomes.
In order to observe the dynamic change of OIPN severity and quality of life (QOL) to give evidencebased evaluations, this trial sets multiple measure time points.

Primary Outcome
(i) e degree of oxaliplatin-induced peripheral neuropathy will be evaluated according to the score of European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-CIPN twenty-item scale (EORTC QLQ-CIPN20, 20-80 scores, with higher scores meaning a worse outcome), which is evaluated by the subject on 1 day before and 3 consecutive days after the first time of oxaliplatin administration. Subsequent assessments will be made every one time from cycle 2 to cycle 6, 1 month after the end of cycle 6, and then every 3 months up to 1 year.

Secondary Outcome
(i) e grades of oxaliplatin-induced peripheral neuropathy will be evaluated according to the grades of National Cancer Institute-Common Terminology Criteria for Adverse Events Version 5.0 (NCI-CTCAE 5.0, 0-5 grades, with higher grade meaning a worse outcome), which is evaluated by the doctor on 1 day before the oxaliplatin administration from cycle 1 to cycle 6, 1 month after the end of cycle 6, and then every 3 months up to 1 year.
(ii) QOL will be evaluated according to the score of European Organization for Research and Treatment of Cancer's Core Quality of Life Questionnaire (EORTC QLQ-C30, 28-112 scores, with higher scores meaning a worse outcome) on 1 day before the oxaliplatin administration from cycle 1 to cycle 6, 1 month after the end of cycle 6, and then every 3 months up to 1 year. (iii) Chemotherapeutic efficacy will be evaluated according to Response Evaluation Criteria in Solid Tumors Version 1.1 (RECIST 1.1) at the end of cycle 3 (and cycle 6 if it exists). (iv) e number of completed chemotherapy cycles will be recorded at the end of cycle 6 or after the last chemotherapy. If the result is less then 6, the specific reason should be noted.

Safety Assessment.
All adverse events and reactions will be recorded in detail, including the variety, occurrence time, incidence, severity, duration, therapeutic measures, and outcomes. Some examinations should be taken to monitor the adverse events and reactions, including blood routine examination, stool routine examination, liver function test, renal function test, electrocardiograph (ECG), computed tomography (CT), and magnetic resonance imaging (MRI). It should be highlighted and analyzed in particular about the abnormal inspection indicators, cases of study suspension due to adverse events, and the causality between the adverse events and the test drugs.

Data Management and Monitoring.
For efficient and convenient statistics, this study will adopt electronic case report form (eCRF) to record data. e data inputter in each center should timely and accurately record data and upload it to the statistical system after requesting and obtaining the sequential number and the random grouping code. After being reviewed by the inspectors and checked by the data administrator, the data will be locked for statistical analysis subsequently.
is clinical trial will introduce a third-party monitoring team to strengthen the research quality control during the whole process. In accordance with the Good Clinical Practice (GCP) requirements issued by the State Food and Drug Administration (SFDA), a dedicated inspector will be assigned to make regular on-site monitoring visits to the clinical centers to ensure strict adherence to the protocol and correct filling of the test data.

Statistical Analysis.
is study cooperates with Statistics Department of Nanjing University of Traditional Chinese Medicine. After the test trial is determined, a special statistician will be employed for making the statistical analysis plan. All data will be statistically analyzed by SAS 9.3 software. Enumeration data will be expressed as percentage, while measurement data will be expressed as mean ± standard deviation. For comparison of count or grade data, chi-square test will be used. Two logistic multiple regressions (Enter method) will be used to analyze the factors affecting the objective curative effect.

Discussion
Oxaliplatin is a standard chemotherapy drug for colorectal cancer, and its toxic and side effects must be taken seriously. OIPN is the most common side effect which significantly affects the curative efficacy of chemotherapy and patients' quality of life and remains a refractory problem despite receiving extensive attention from researchers.
For seeking potential effective therapy, the pathogenesis of OIPN has been studied for a long time. Analysis of recent literature suggested that the alteration of voltage-gated Na + channels, K + channels, Ca 2+ channels, and transient receptor potential (TRP) channels could be related to acute OIPN [2]. On the other hand, platinum accumulating in dorsal root ganglion so as to cause a series of neuronal damage, including nuclear DNA damage, mitochondrial dysfunction, oxidative stress, and axonopathy, is considered as the main mechanism of chronic OIPN [2,35]. Regarding platinum accumulation, organic cation transporter 2 (OCT2) has been demonstrated to play an important role in platinum uptake and is expected to be a new target for prevention and treatment of OIPN [36,37].
A number of agents have been proposed with potential therapeutic or preventive effects to OIPN. However, none of them have got recognition by further studies [1,23]. Combining the theory of TCM, this study attributes OIPN to "arthromyodynia" [29]. YWF granules are a category of prescription granules with similar effects of tonifying qi and warming meridians, and they have been empirically used to treat arthromyodynia in China. In order to obtain scientific and precise evidence, several animal studies and randomized controlled clinical trials with small sample size have been conducted previously. Results showed that YWF granules can ameliorate OIPN syndrome without affecting the antitumor activity of oxaliplatin [30,33]. us, we have designed the protocol for a randomized, placebo-controlled, double-blind, multicenter trial to enlarge the sample size for further evaluation of the preventive efficacy and safety of YWF granules. is study will provide objective evidence for the clinical application of YWF granules in preventing OIPN.
Data Availability e data and materials are available upon request from the corresponding author.

Ethical Approval
Ethical approval was obtained from the Ethics Committee of Jiangsu Provincial Hospital of Traditional Chinese and Western Medicine in Nanjing, China (approval no. 2020LAKY014). e study protocol is in accordance with the guidelines of the Declaration of Helsinki, formulated by the World Medical Association.

Consent
Patients meeting the inclusion criteria and/or their legal representatives will be required to attend the discussion about this study and will be given sufficient time to consider whether to participate. Written informed consent will be obtained from patients or their legal representatives, and personal information will be kept with utmost secrecy. Disclosure e funders have no role in research design, data collection, management, analysis or interpretation, report writing, or submission decisions, and they have no final authority over any of these activities.

Conflicts of Interest
e authors declare that they have no conflicts of interest regarding the publication of this paper.