Neurobiological Basis of Response to Guanfacine Extended Release in Children and Adolescents With ADHD

Neurobiological Basis of Response to Guanfacine Extended Release in Children and Adolescents With Attention-deficit/Hyperactivity Disorder (ADHD): an Functional Magnetic Resonance Imaging(fMRI) Study of Brain Activation Pre and Post Treatment

This study proposes to evaluate the effects of guanfacine extended release on brain activation during fMRI in children and adolescents with ADHD between the ages 8-15 and ADHD subjects randomized to placebo treatment.

This study also proposes to collect DNA on study participants, to examine the genetic underpinning of the observed fMRI activation profiles at baseline and in response to treatment. The purpose is to examine polymorphisms of the adrenergic 2A gene (and other related targets) for genetic biomarkers in association with the fMRI findings of this study.

Study Overview

• Status: Completed
• Conditions: ADHD; Attention Deficit Hyperactivity Disorder
• Intervention / Treatment: Drug: Guanfacine Hydrochloride XR; Drug: Placebo

Detailed Description

This study proposes to evaluate the effects of guanfacine on brain activation during fMRI in 12 children and adolescents ages 8 - 15 with ADHD treated with once-daily INTUNIV(TM) (guanfacine; GXR) extended release tablets and 12 ADHD subjects randomized to placebo treatment. Children will be comprehensively assessed using a variety of clinical and neuropsychological measures. They will be scanned at baseline while performing both the go/no-go task (a well validated task for measuring inhibitory control (Durston et al., 2002, 2003)) and the Stay Alert task - a new task designed to measure the arousal component of attention, which was used successfully in a recent fMRI study of guanfacine in healthy adults (Clerkin et al., 2009). They will then be treated with GXR or placebo for 6 - 8 weeks in accordance with titration and dosing strategies used in recent Phase III dose optimization trials (e.g., up to 4 mg/day), and re-scanned while performing the same two tasks. The fMRI scans will be conducted using a dedicated research 3.0 T Siemens scanner.

• Study Type: Interventional
• Enrollment (Actual): 27
• Phase: Phase 4

Contacts and Locations

Study Locations

• United States
  • New York
    • New York, New York, United States, 10029
      • Icahn School of Medicine at Mount Sinai

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 8 years to 15 years (Child)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Diagnosis of any subtype of ADHD
• Normal findings on physical exam, laboratory studies, vital signs, and ECG
• Weight = 60 kgs or less
• Able to complete study procedures and swallow capsules;
• Willing to commit to the entire visit schedule
• Off treatment or have been discontinued from their previous medication for two weeks.

Exclusion Criteria:

• Psychiatric comorbidity except Oppositional Defiant Disorder [ODD], Simple Phobia, and dysthymia (unless ongoing medication treatment is required);
• Currently a suicide risk, has previously made a suicide attempt or has a prior history of suicidal behavior;
• Has failed treatment with an adequate trial of an alpha-2 adrenergic agonist;
• Known or suspected allergy, hypersensitivity, or clinically significant intolerance to guanfacine hydrochloride.

Children may not:

• be treated with systemic medication for a medical or psychiatric illness that have CNS effects or affect cognitive function;
• have a known history or presence of structural cardiac abnormalities, exercise-related cardiac events, or clinically significant bradycardia;
• have orthostatic hypotension or a known history of hypertension;
• have an abnormal ECG that is deemed clinically significant;
• have a history of alcohol or other substance abuse or dependence within the last 6 months;
• use any medications that affect BP or heart rate (excluding the subject's current ADHD medication at screening);
• use another investigational medicinal product or participation in a clinical study within 30 days prior to the baseline visit;
• be significantly overweight based on Center for Disease Control and Prevention Body Mass Index (BMI)-for-age gender specific charts;
• have body weight of less than 25kg;
• have a clinically important abnormality on urine drug and alcohol screen (excluding the subject's current ADHD stimulant, if applicable);
• be female and currently pregnant or lactating;
• have symptoms indicative of a primary sleep disorder.
• have braces or other metal permanently placed within their body.
• be too anxious to tolerate the fMRI procedure, or be claustrophobic.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: guanfacine hydrochloride XR; Flexible dose titration of guanfacine extended release (Intuniv; active medication). The medication is titrated in doses from 1 - 4 mg once daily	Drug: Guanfacine Hydrochloride XR; Weekly adjustments based on parent ratings of symptoms, side effects, and health status per vital signs up to 4mg maximum dose; Other Names: GXR; INTUNIV non-stimulant medication
Placebo Comparator: Placebo Group; Flexible dose titration of placebo	Drug: Placebo; Weekly adjustments based on parent ratings of symptoms, side effects, and health status per vital signs up to 4mg maximum dose

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Go/No-go Task Performance Correct Inhibitions	Measures of go/no-go task performance during functional magnetic resonance imaging. Performance on a go-nogo task inside the scanner.	Baseline and 8 weeks
Go/No-go Task Reaction Time	Measures of go/no-go task performance during functional magnetic resonance imaging. Performance on a go-nogo task inside the scanner.	Baseline and 8 weeks
Go/No-go Task Performance Correct Responses	Measures of go/no-go task performance during functional magnetic resonance imaging. Performance on a go-nogo task inside the scanner.	Baseline and 8 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Clinical Global Impressions (CGI-I)	Clinical response was the Clinical Global Impression-Improvement scale (CGI-I). Lower CGI-I scores indicate greater improvement (1=very much improved; 2=much improved; 3=minimally improved; 4=no change; 5=minimally worse; 6= much worse; 7=very much worse.)	up to 8 weeks
Percentage Change in Atomoxetine Stimulant Side Effects Rating Scale (ASSERS)	Side effects rating scale. Assesses side effects known to occur in prior research using stimulant and non stimulant medications for treatment of ADHD. Scores range from 0 (not present) to 9 (severe side effects) and have been reported in aggregate as sum of severity responses on highest dose. This number is the sum of ASSERS, meaning it is the number and severity of side effects experienced. The percentage change in score from baseline.	up to 8 weeks
Finger Windows	Neuropsychological assessment: Finger Windows - a measure of spatial working memory. The participant shows memory of a demonstrated visual pattern. The examiner models a given sequence of windows and ask the participant to imitate the sequence by placing their finger through the same windows in the correct order. The total number of correct sequences achieved determines the level of performance.	Baseline
Digit Span	Neuropsychological assessment - Digit Span. The Digit Span test is either conducted verbally or using a computer program. A sequence of numbers is shown or read out to the participant. The participant is then told to repeat the numbers that were shown or read to them. This process continues until the participant can no longer remember either the full sequence of numbers or the correct order. This sequence is also continued until the participant makes an error. The Digit Span test is scored by the amount of numbers the participant was able to remember in each test. The scorer must add the total number of correct sequences, backwards and forwards. This test is also scored differently for a range of ages.	Baseline
Attention Deficit Hyperactivity Disorder Rating Scale IV (ADHDRS IV)	Norm referenced parent interview to assess severity and frequency of ADHD symptoms. Scores are reported as sums 0 (no symptoms) to 54 (severe).	baseline and 8 weeks
Continuous Performance Test - Commissions	Neuropsychological assessment - Continuous Performance Test - Commissions. CPT is a task-oriented computerized assessment of attention-related problems. Scores are compared with the normative scores for the age, group and gender of the person being tested. A t-score of 50 is equal to the mean, with higher values indicating more problematic behaviors and lower scores indicating less problematic behaviors.	Baseline

Collaborators and Investigators

• Sponsor: Icahn School of Medicine at Mount Sinai

Publications and helpful links

General Publications

• Bedard AC, Schulz KP, Krone B, Pedraza J, Duhoux S, Halperin JM, Newcorn JH. Neural mechanisms underlying the therapeutic actions of guanfacine treatment in youth with ADHD: a pilot fMRI study. Psychiatry Res. 2015 Mar 30;231(3):353-6. doi: 10.1016/j.pscychresns.2015.01.012. Epub 2015 Jan 19.

Study record dates

Study Major Dates

• Study Start: March 1, 2011
• Primary Completion (Actual): December 1, 2013
• Study Completion (Actual): December 1, 2013

Study Registration Dates

• First Submitted: August 30, 2012
• First Submitted That Met QC Criteria: October 16, 2012
• First Posted (Estimate): October 18, 2012

Study Record Updates

• Last Update Posted (Actual): February 14, 2018
• Last Update Submitted That Met QC Criteria: January 17, 2018
• Last Verified: January 1, 2018

More Information

Terms related to this study

• Keywords: Attention Deficit Hyperactivity Disorder; fMRI; Intuniv
• Additional Relevant MeSH Terms: Mental Disorders; Nervous System Diseases; Neurologic Manifestations; Dyskinesias; Attention Deficit and Disruptive Behavior Disorders; Neurodevelopmental Disorders; Attention Deficit Disorder with Hyperactivity; Hyperkinesis; Physiological Effects of Drugs; Adrenergic Agents; Neurotransmitter Agents; Molecular Mechanisms of Pharmacological Action; Antihypertensive Agents; Adrenergic alpha-2 Receptor Agonists; Adrenergic alpha-Agonists; Adrenergic Agonists; Guanfacine
• Other Study ID Numbers: GCO 09-1825; HSM:10-00415