Steroid Avoidance, Dexamethasone, and RAGE Inhibition for Perioperative Cerebral Edema Management in High-Grade Gliomas

This study is a randomized Phase II trial because it is designed to evaluate the preliminary efficacy, safety, and feasibility of steroid avoidance and azeliragon as alternatives to dexamethasone for perioperative cerebral edema management in high-grade glioma. The trial uses an intermediate imaging-based efficacy endpoint, enrolls a modest sample size, and is intended to identify promising strategies for subsequent confirmation in a definitive Phase III study.

The trial compares three perioperative strategies-standard dexamethasone, complete steroid avoidance, and RAGE inhibition with azeliragon-to determine their relative safety and effectiveness in controlling cerebral edema following tumor resection. In addition to edema control, the study evaluates clinical, functional, and immunologic outcomes associated with perioperative corticosteroid exposure.

Despite widespread use, dexamethasone lacks prospective evidence defining its optimal perioperative role in glioma patients. This study addresses that gap by rigorously evaluating steroid avoidance and a mechanistically targeted alternative, with the goal of improving patient outcomes while minimizing treatment-related toxicity.

Inclusion criteria

Age ≥18 years at the time of screening

• Newly diagnosed supratentorial tumor with imaging characteristics consistent with high-grade glioma
• Candidate for craniotomy with planned resection of more than 50% of the contrast-enhancing tumor
• Midline shift ≤10 mm on preoperative imaging
• Limited pre-enrollment corticosteroid exposure (≤10 mg dexamethasone total and no chronic steroid use within 30 days)
• Karnofsky Performance Status ≥60
• Adequate organ function to undergo surgery and postoperative care as determined by the investigator
• Ability to provide informed consent and comply with study procedures
• Agreement to use effective contraception, when applicable

Exclusion criteria

• Participants meeting any of the following will be excluded:

• Imaging or clinical features highly suggestive of primary CNS lymphoma or metastatic disease
• Posterior fossa tumors or lesions associated with high risk of brainstem compression
• Leptomeningeal or widely disseminated disease
• Clinical conditions requiring immediate corticosteroid therapy
• Prior exposure to high-dose corticosteroids (>10 mg dexamethasone) or chronic steroid use within 30 days
• Active systemic illness that increases surgical risk, including uncontrolled infection, coagulopathy, or severe cardiopulmonary disease
• Pregnancy or breastfeeding
• Known immunodeficiency or chronic infection requiring immunosuppressive therapy
• Use of investigational agents within 30 days or concurrent use of immunosuppressive medications not permitted by protocol
• Known hypersensitivity to azeliragon
• Inability to undergo MRI due to contraindications such as incompatible implants or severe claustrophobia
• Life expectancy less than 3 months as determined by the investigator
• Participation in another interventional clinical trial prior to initiation of standard adjuvant therapy Vulnerable Populations: This study will not enroll children, pregnant or breastfeeding individuals, or prisoners. Individuals with impaired decision-making capacity may be enrolled only when a legally authorized representative is available to provide consent in accordance with institutional and regulatory requirements.