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Treatment of Supine Hypertension in Autonomic Failure

Primary Purpose

Hypertension

Status
Completed
Phase
Phase 1
Locations
United States
Study Type
Interventional
Intervention
Clonidine
Nitroglycerin transdermal
Dipyridamole/ Aspirin (Aggrenox)
Desmopressin (DDAVP)
Sildenafil
Nifedipine
Hydralazine
Hydrochlorothiazide
Placebo
Bosentan
Diltiazem
Eplerenone
guanfacine
L-arginine
captopril
carbidopa
losartan
metoprolol tartrate
nebivolol hydrochloride
prazosin hydrochloride
tamsulosin hydrochloride
Head-up tilt.
aliskiren
Local heat stress
Sponsored by
Vanderbilt University
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Hypertension focused on measuring Supine Hypertension, Hypertension, Treatment, Autonomic failure, Pure autonomic failure, Multiple System Atrophy, Shy-Drager Syndrome

Eligibility Criteria

18 Years - 80 Years (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria: Patients with autonomic failure and with supine hypertension from all races Exclusion Criteria: All medical students Pregnant women High-risk patients (e.g. heart failure, symptomatic coronary artery disease, liver impairment, history of stroke or myocardial infarction) History of serious allergies or asthma.

Sites / Locations

  • Vanderbilt University

Arms of the Study

Arm 1

Arm 2

Arm Type

Experimental

Placebo Comparator

Arm Label

1: Active drug or intervention

2: Placebo

Arm Description

Clonidine, Nitroglycerin transdermal, Dipyridamole/ Aspirin (Aggrenox), Desmopressin (DDAVP), Sildenafil, Nifedipine, Hydralazine, Hydrochlorothiazide, Bosentan, Diltiazem, Eplerenone, guanfacine, L-arginine, captopril, carbidopa, losartan, metoprolol tartrate, nebivolol hydrochloride, prazosin hydrochloride, tamsulosin hydrochloride, Head-up tilt, aliskiren, local heat stress

placebo pill or patch

Outcomes

Primary Outcome Measures

Decrease in supine systolic blood pressure

Secondary Outcome Measures

Decrease in pressure natriuresis

Full Information

First Posted
September 14, 2005
Last Updated
October 12, 2017
Sponsor
Vanderbilt University
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1. Study Identification

Unique Protocol Identification Number
NCT00223717
Brief Title
Treatment of Supine Hypertension in Autonomic Failure
Official Title
The Pathophysiology and Treatment of Supine Hypertension in Patients With Autonomic Failure
Study Type
Interventional

2. Study Status

Record Verification Date
October 2017
Overall Recruitment Status
Completed
Study Start Date
January 2001 (undefined)
Primary Completion Date
January 2017 (Actual)
Study Completion Date
January 2017 (Actual)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Principal Investigator
Name of the Sponsor
Vanderbilt University

4. Oversight

Data Monitoring Committee
No

5. Study Description

Brief Summary
Supine hypertension is a common problem that affects at least 50% of patients with primary autonomic failure. Supine hypertension can be severe, and complicates the treatment of orthostatic hypotension. Drugs used for the treatment of orthostatic hypotension (eg, fludrocortisone and pressor agents), worsen supine hypertension. High blood pressure may also cause target organ damage in this group of patients. The pathophysiologic mechanisms causing supine hypertension in patients with autonomic failure have not been defined. In a study, we, the investigators at Vanderbilt University, examined 64 patients with AF, 29 with pure autonomic failure (PAF) and 35 with multiple system atrophy (MSA). 66% of patients had supine systolic (systolic blood pressure [SBP] > 150 mmHg) or diastolic (diastolic blood pressure [DBP] > 90 mmHg) hypertension (average blood pressure [BP]: 179 ± 5/89 ± 3 mmHg in 21 PAF and 175 ± 5/92 ± 3 mmHg in 21 MSA patients). Plasma norepinephrine (92 ± 15 pg/mL) and plasma renin activity (0.3 ± 0.05 ng/mL per hour) were very low in a subset of patients with AF and supine hypertension. (Shannon et al., 1997). Our group has showed that a residual sympathetic function contributes to supine hypertension in patients with severe autonomic failure and that this effect is more prominent in patients with MSA than in those with PAF (Shannon et al., 2000). MSA patients had a marked depressor response to low infusion rates of trimethaphan, a ganglionic blocker; the response in PAF patients was more variable. At 1 mg/min, trimethaphan decreased supine SBP by 67 +/- 8 and 12 +/- 6 mmHg in MSA and PAF patients, respectively (P < 0.0001). MSA patients with supine hypertension also had greater SBP response to oral yohimbine, a central alpha2 receptor blocker, than PAF patients. Plasma norepinephrine decreased in both groups, but heart rate did not change in either group. This result suggests that residual sympathetic activity drives supine hypertension in MSA; in contrast, supine hypertension in PAF. It is hoped that from this study will emerge a complete picture of the supine hypertension of autonomic failure. Understanding the mechanism of this paradoxical hypertension in the setting of profound loss of sympathetic function will improve our approach to the treatment of hypertension in autonomic failure, and it could also contribute to our understanding of hypertension in general.
Detailed Description
Overnight Medication Trials: Patients will be studied on the GCRC while in 150 mEq/day sodium balance and on a diet free of substances which interfere with catecholamine determination. Subjects will be asked to use the bathroom to empty their bladder at 8:00 PM. They will be given a randomly chosen medication aliskiren (Tekturna) 150-300mg po, bosentan (Tracleer) 62.5 -125 mg po, captopril 25-50mg po, carbidopa 25-200mg po, clonidine 0.1-0.2mg po, desmopressin 0.2 - 0.6mg po (DDAVP), -diltiazem 30-60 mg po, dipyridamole 200 mg and aspirin 25 mg po (Aggrenox), eplerenone (Inspra) 50-100 mg po, guanfacine (Tenex) 1-3 mg po, hydralazine 10-50 mg po, hydrochlorothiazide 12.5-100 mg po, L- arginine 6-17 g po, losartan 25-100mg po, metoprolol tartrate (Lopressor) 25-100 mg po, nebivolol hydrochloride (Bystolic) 2.5-40 mg po, nitroglycerin-transdermal 0.05-0.2 mg patch, nifedipine (adalat) doses 10-30 mg, prazosin hydrochloride 0.5-1 mg po, sildenafil (Viagra) 25- 100 mg po, tamsulosin hydrochloride (Flomax) 0.4-0.8 mg po. The combination desmopressin 0.2 mg po (DDAVP) and nitroglycerin-transdermal 0.05-0.2 mg. The combinations desmopressin 0.2 mg po and nifedipine (10-30 mg). A placebo pill or skin patch will be done as a control to measure their supine blood pressure without medication intervention. They will then be asked to lie down with the head of the bed elevated 10 degrees. An automated blood pressure cuff (Dinamap) will be wrapped around an upper arm and blood pressure will be measured automatically 2 times in a row every 2 hours. At 8 AM the following morning the study ends. The subjects will then stand at the bedside as motionless as possible for 30 minutes for blood pressure and heart rate determination. Urine will be collected for 24 hours for determination of volume and sodium, potassium and catecholamines (for some medication trials) in 12 hour segments, from 8 a.m. to 8 p.m. and 8 p.m. to 8 a.m. to ascertain how the medications affect urine production. For medication trials affecting renal Na and/or water regulation (e.g. desmopressin, carbidopa), blood samples will be collected (5 mL, 1 teaspoon) at 8 PM and 8 AM for determination of a basic metabolic panel. Raising the head of the bed during the night is a non-pharmacologic measure that may reduce supine blood pressure, nocturnal natriuresis and improve orthostatic hypotension the following morning in autonomic failure patients with supine hypertension. However, it is not known if tilting the bed with the head up is better than raising only the head of the bed. To compare the effect of these two ways of raising the head of the bed on nighttime blood pressure and nocturnal natriuresis, some patients will undergo two additional tests. On two separate nights (either consecutive or not), patients will receive the placebo and will be assigned by simple randomization to lie down in one of two different bed positions: The head of the bed elevated 10 degrees (~ 7 inches); or The whole bed tilted head-up 5 degrees in reverse trendelenburg (head of the bed elevated ~7 inches). Blood pressure, orthostatic tolerance at 8 AM and urine collections will be performed as described above. Blood Pressure Lowering Effect of Local Heat Stress in Supine Hypertension: Heat stress due to high environmental temperatures lowers blood pressure in autonomic failure patients. The mechanisms underlying this phenomenon are not fully understood but it could be associated with 2 factors: First, heart stress is more likely to increase core temperature in this patient population because heat dissipation is impaired due to inability to sweat. Second, autonomic failure patients lack the compensatory sympathetic splanchnic vasoconstriction and tachycardia that normally maintain blood pressure in response to heat stress in healthy subjects. We hypothesize, therefore, that even moderate levels of local heat stress will lower blood pressure in patients with autonomic failure and supine hypertension. We propose a pilot study to evaluate the effect of local (abdominal) heat stress on blood pressure in autonomic failure patients, something that has not been previously done, and to assess its potential use in the treatment of supine hypertension This pilot study is optional and will be conducted in patients already enrolled in the "Evaluation and Treatment of Autonomic Failure" and the medication trial part of this protocol. Subjects will be studied in the supine position on two study days (with and without heat stress). Each study day will last ~3 hours. Core body and skin temperature will be monitored throughout the study using an ingestible telemetry pill and dermal patches. Blood pressure and heart rate will be measured intermittently with an automated blood pressure sphygmomanometer wrapped around an upper arm. Segmental body fluid shifts will be estimated using bioelectrical Impedance and hemodynamic parameters using body impedance and the rebreathing test (Innocor). After obtaining normothermic baseline measurements, we apply passive heat-stress with a commercial heating pad that covers all the abdomen and part of the torso to provide local heating at ~44ºC continuously for 2 hr. Outcome measurements are obtained at 1 and 2 hours after passive heat-stress, or when the CBT increases ~1ºC above baseline, whichever occurs first. For the control (non-heating) study day, the heating pad will be applied on patients but we will not turn it on, and data collection will be performed at the one-hour intervals for 2 hours, to provide a time control. Circadian Hemodynamic Changes in Autonomic Failure Patients with Supine Hypertension: This study is optional and will be conducted in patients already enrolled in the "Evaluation and Treatment of Autonomic Failure" and the medication trial part of this protocol. A separate consent form (addendum) will be provided. In the present study, we propose the following: Monitor BP and HR in patients with AF and supine hypertension during a 24-hour period, which includes fixed periods of supine rest during the day, with strict control of physical activities, meals, water ingestion and other confounding factors. This will allow us to learn more about the intrinsic circadian variation of BP in our patients without the influence of "external factors". Characterize the hemodynamic changes underlying the dipping phenomenon and the morning BP surge, and Assess changes in plasma volume (measured by changes in hematocrit), calculated plasma osmolality and hormones that regulate blood pressure and blood volume, in order to learn more about the mechanisms responsible for the dipping phenomenon and morning BP surge in autonomic failure patients with supine hypertension. These parameters will be compared with the circadian rhythm of body temperature, a marker of the central circadian rhythm, to determine whether these diurnal changes are synchronized to the circadian pacemaker. The duration of the study day will be 24 hours and can start any time during the day. Typically, the study will start ~ 8AM. Therapeutic trials for orthostatic hypotension and/or supine hypertension as well as other study procedures related to the above mentioned protocols may be performed while participating in this study. If an overnight medication trial is performed during the study, patients may be offered to participate in a second study day without any medication.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Hypertension
Keywords
Supine Hypertension, Hypertension, Treatment, Autonomic failure, Pure autonomic failure, Multiple System Atrophy, Shy-Drager Syndrome

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 1
Interventional Study Model
Crossover Assignment
Masking
Participant
Allocation
Randomized
Enrollment
152 (Actual)

8. Arms, Groups, and Interventions

Arm Title
1: Active drug or intervention
Arm Type
Experimental
Arm Description
Clonidine, Nitroglycerin transdermal, Dipyridamole/ Aspirin (Aggrenox), Desmopressin (DDAVP), Sildenafil, Nifedipine, Hydralazine, Hydrochlorothiazide, Bosentan, Diltiazem, Eplerenone, guanfacine, L-arginine, captopril, carbidopa, losartan, metoprolol tartrate, nebivolol hydrochloride, prazosin hydrochloride, tamsulosin hydrochloride, Head-up tilt, aliskiren, local heat stress
Arm Title
2: Placebo
Arm Type
Placebo Comparator
Arm Description
placebo pill or patch
Intervention Type
Drug
Intervention Name(s)
Clonidine
Other Intervention Name(s)
Catapres
Intervention Description
0.1-0.2mg po. Single dose.
Intervention Type
Drug
Intervention Name(s)
Nitroglycerin transdermal
Other Intervention Name(s)
Nitro-Dur
Intervention Description
0.05-0.2 mg patch. 1 application. Alone or in combination with DDAVP.
Intervention Type
Drug
Intervention Name(s)
Dipyridamole/ Aspirin (Aggrenox)
Other Intervention Name(s)
Aggrenox
Intervention Description
dipyridamole 200 mg and aspirin 25 mg po. Single dose.
Intervention Type
Drug
Intervention Name(s)
Desmopressin (DDAVP)
Other Intervention Name(s)
DDAVP
Intervention Description
0.2 - 0.6mg po. Single dose. Alone or in combination with nitroglycerin transdermal or nifedipine
Intervention Type
Drug
Intervention Name(s)
Sildenafil
Other Intervention Name(s)
Viagra
Intervention Description
25- 100 mg po. Single dose.
Intervention Type
Drug
Intervention Name(s)
Nifedipine
Other Intervention Name(s)
Adalat
Intervention Description
10-30 mg po. Single dose.
Intervention Type
Drug
Intervention Name(s)
Hydralazine
Intervention Description
10-50 mg po. Single dose
Intervention Type
Drug
Intervention Name(s)
Hydrochlorothiazide
Other Intervention Name(s)
Microzide
Intervention Description
12.5-100 mg po. Single dose.
Intervention Type
Drug
Intervention Name(s)
Placebo
Intervention Description
Po or patch. Single dose.
Intervention Type
Drug
Intervention Name(s)
Bosentan
Other Intervention Name(s)
Tracleer
Intervention Description
62.5 -125 mg po. Single dose.
Intervention Type
Drug
Intervention Name(s)
Diltiazem
Other Intervention Name(s)
Cardizem
Intervention Description
30-60 mg po. Single dose.
Intervention Type
Drug
Intervention Name(s)
Eplerenone
Other Intervention Name(s)
Inspra
Intervention Description
50-100 mg po. Single dose.
Intervention Type
Drug
Intervention Name(s)
guanfacine
Other Intervention Name(s)
Tenex
Intervention Description
1-3 mg po. Single dose.
Intervention Type
Dietary Supplement
Intervention Name(s)
L-arginine
Intervention Description
6-17 g po. Single dose
Intervention Type
Drug
Intervention Name(s)
captopril
Other Intervention Name(s)
capoten
Intervention Description
25-50 mg PO. Single dose.
Intervention Type
Drug
Intervention Name(s)
carbidopa
Other Intervention Name(s)
Lodosyn
Intervention Description
25-200 mg PO. Single dose.
Intervention Type
Drug
Intervention Name(s)
losartan
Other Intervention Name(s)
cozaar
Intervention Description
25-200 mg PO. Single dose.
Intervention Type
Drug
Intervention Name(s)
metoprolol tartrate
Other Intervention Name(s)
lopressor
Intervention Description
25-100 mg PO. Single dose.
Intervention Type
Drug
Intervention Name(s)
nebivolol hydrochloride
Other Intervention Name(s)
Bystolic
Intervention Description
2.5-40 mg PO. Single dose.
Intervention Type
Drug
Intervention Name(s)
prazosin hydrochloride
Other Intervention Name(s)
Minipress
Intervention Description
0.5-1 mg PO. Single dose.
Intervention Type
Drug
Intervention Name(s)
tamsulosin hydrochloride
Other Intervention Name(s)
Flomax
Intervention Description
0.4-0.8 mg PO. Single dose.
Intervention Type
Other
Intervention Name(s)
Head-up tilt.
Other Intervention Name(s)
HUT
Intervention Description
Head of the bed elevated 10 degrees (7 inch) or whole bed tilted head-up 5 degrees in reverse trendelenburg (head of the bed elevated 7 inches)
Intervention Type
Drug
Intervention Name(s)
aliskiren
Other Intervention Name(s)
Tekturna
Intervention Description
aliskiren (Tekturna) 150-300mg po single dose
Intervention Type
Other
Intervention Name(s)
Local heat stress
Other Intervention Name(s)
heating pad
Intervention Description
Passive heat-stress using a commercial heating pad applied over the abdomen and part of the torso
Primary Outcome Measure Information:
Title
Decrease in supine systolic blood pressure
Time Frame
12 hours
Secondary Outcome Measure Information:
Title
Decrease in pressure natriuresis
Time Frame
12 hours

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Maximum Age & Unit of Time
80 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Patients with autonomic failure and with supine hypertension from all races Exclusion Criteria: All medical students Pregnant women High-risk patients (e.g. heart failure, symptomatic coronary artery disease, liver impairment, history of stroke or myocardial infarction) History of serious allergies or asthma.
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Italo Biaggioni, MD
Organizational Affiliation
Vanderbilt University
Official's Role
Principal Investigator
Facility Information:
Facility Name
Vanderbilt University
City
Nashville
State/Province
Tennessee
ZIP/Postal Code
37232
Country
United States

12. IPD Sharing Statement

Citations:
PubMed Identifier
21664375
Citation
Shibao C, Okamoto L, Biaggioni I. Pharmacotherapy of autonomic failure. Pharmacol Ther. 2012 Jun;134(3):279-86. doi: 10.1016/j.pharmthera.2011.05.009. Epub 2011 Jun 12.
Results Reference
background
PubMed Identifier
16533484
Citation
Shibao C, Gamboa A, Diedrich A, Biaggioni I. Management of hypertension in the setting of autonomic dysfunction. Curr Treat Options Cardiovasc Med. 2006 Apr;8(2):105-9. doi: 10.1007/s11936-006-0002-1.
Results Reference
result
PubMed Identifier
16391172
Citation
Shibao C, Gamboa A, Abraham R, Raj SR, Diedrich A, Black B, Robertson D, Biaggioni I. Clonidine for the treatment of supine hypertension and pressure natriuresis in autonomic failure. Hypertension. 2006 Mar;47(3):522-6. doi: 10.1161/01.HYP.0000199982.71858.11. Epub 2006 Jan 3.
Results Reference
result
PubMed Identifier
15738343
Citation
Shibao C, Gamboa A, Diedrich A, Biaggioni I. Management of hypertension in the setting of autonomic failure: a pathophysiological approach. Hypertension. 2005 Apr;45(4):469-76. doi: 10.1161/01.HYP.0000158835.94916.0c. Epub 2005 Feb 28.
Results Reference
result
PubMed Identifier
12923400
Citation
Diedrich A, Jordan J, Tank J, Shannon JR, Robertson R, Luft FC, Robertson D, Biaggioni I. The sympathetic nervous system in hypertension: assessment by blood pressure variability and ganglionic blockade. J Hypertens. 2003 Sep;21(9):1677-86. doi: 10.1097/00004872-200309000-00017. Erratum In: J Hypertens. 2003 Nov;21(11):2204-5.
Results Reference
result
PubMed Identifier
12119802
Citation
Biaggioni I, Robertson RM. Hypertension in orthostatic hypotension and autonomic dysfunction. Cardiol Clin. 2002 May;20(2):291-301, vii. doi: 10.1016/s0733-8651(01)00005-4.
Results Reference
result
PubMed Identifier
11927799
Citation
Jordan J, Biaggioni I. Diagnosis and treatment of supine hypertension in autonomic failure patients with orthostatic hypotension. J Clin Hypertens (Greenwich). 2002 Mar-Apr;4(2):139-45. doi: 10.1111/j.1524-6175.2001.00516.x.
Results Reference
result
PubMed Identifier
10851208
Citation
Shannon JR, Jordan J, Diedrich A, Pohar B, Black BK, Robertson D, Biaggioni I. Sympathetically mediated hypertension in autonomic failure. Circulation. 2000 Jun 13;101(23):2710-5. doi: 10.1161/01.cir.101.23.2710.
Results Reference
result
PubMed Identifier
9890307
Citation
Jordan J, Shannon JR, Pohar B, Paranjape SY, Robertson D, Robertson RM, Biaggioni I. Contrasting effects of vasodilators on blood pressure and sodium balance in the hypertension of autonomic failure. J Am Soc Nephrol. 1999 Jan;10(1):35-42. doi: 10.1681/ASN.V10135.
Results Reference
result
PubMed Identifier
9369256
Citation
Shannon J, Jordan J, Costa F, Robertson RM, Biaggioni I. The hypertension of autonomic failure and its treatment. Hypertension. 1997 Nov;30(5):1062-7. doi: 10.1161/01.hyp.30.5.1062.
Results Reference
result
PubMed Identifier
19047577
Citation
Okamoto LE, Gamboa A, Shibao C, Black BK, Diedrich A, Raj SR, Robertson D, Biaggioni I. Nocturnal blood pressure dipping in the hypertension of autonomic failure. Hypertension. 2009 Feb;53(2):363-9. doi: 10.1161/HYPERTENSIONAHA.108.124552. Epub 2008 Dec 1.
Results Reference
result
PubMed Identifier
18426998
Citation
Gamboa A, Shibao C, Diedrich A, Paranjape SY, Farley G, Christman B, Raj SR, Robertson D, Biaggioni I. Excessive nitric oxide function and blood pressure regulation in patients with autonomic failure. Hypertension. 2008 Jun;51(6):1531-6. doi: 10.1161/HYPERTENSIONAHA.107.105171. Epub 2008 Apr 21.
Results Reference
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PubMed Identifier
23266540
Citation
Arnold AC, Okamoto LE, Gamboa A, Shibao C, Raj SR, Robertson D, Biaggioni I. Angiotensin II, independent of plasma renin activity, contributes to the hypertension of autonomic failure. Hypertension. 2013 Mar;61(3):701-6. doi: 10.1161/HYPERTENSIONAHA.111.00377. Epub 2012 Dec 24.
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PubMed Identifier
22801444
Citation
Arnold AC, Biaggioni I. Management approaches to hypertension in autonomic failure. Curr Opin Nephrol Hypertens. 2012 Sep;21(5):481-5. doi: 10.1097/MNH.0b013e328356c52f.
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PubMed Identifier
19738158
Citation
Garland EM, Gamboa A, Okamoto L, Raj SR, Black BK, Davis TL, Biaggioni I, Robertson D. Renal impairment of pure autonomic failure. Hypertension. 2009 Nov;54(5):1057-61. doi: 10.1161/HYPERTENSIONAHA.109.136853. Epub 2009 Sep 8.
Results Reference
result

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Treatment of Supine Hypertension in Autonomic Failure

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