Effects of Erythropoietin for Cognitive Side-effects of ECT (EPO-T)

Erythropoietin as an add-on Treatment for Cognitive Side-effects of Electroconvulsive Therapy

EPO-T aims to investigate (i) whether short-term add-on treatment with erythropoietin (EPO) can reduce cognitive side-effects of ECT and (ii) whether such effects are long-lasting. Further, structural and functional magnetic resonance imaging (MRI) will be used to explore the neural underpinnings of such beneficial effects of EPO. Finally, the trial examines whether potential protective effects of EPO on cognition are accompanied by changes in markers of oxidative stress, inflammation, and neuroplasticity.

It is hypothesized that EPO treatment will (i) counteract ECT-induced cognitive decline, accompanied by (ii) increased sub-regional hippocampal volume, (iii) greater memory-related hippocampal activation and reinforcement of dorsolateral prefrontal activity during memory encoding and working memory, and (iv) changes in peripheral markers of inflammation, oxidative stress and neuroplasticity. Furthermore, we hypothesize that add-on EPO-treatment will produce greater, more sustained mood improvement than ECT treatment alone.

Study Overview

• Status: Completed
• Conditions: Cognitive Impairment; Bipolar Depression; Unipolar Depression; ECT
• Intervention / Treatment: Drug: Erythropoietin; Drug: Saline

Detailed Description

The trial will include patients with a diagnosis of major depression (MDD) unipolar disorder (UD) or bipolar disorder (BD) with a current moderate to severe depressive episode symptoms (a score of >17 on the Hamilton Depression Rating Scale 17-items (HRDS-17) scheduled for ECT treatment. Patients will be recruited from Psychiatric Centres in The Mental Health Services in the Capital Region of Denmark and will undergo an eligibility assessment prior to randomization to 4 intravenous infusions of either recombinant human EPO (40.000 IU/ml; Epoetin alpha; Eprex, Janssen-Cilag) or placebo (1 ml NaCl) diluted with 100 ml saline (0.9% NaCl).

Cognitive functions, mood symptoms, and blood- and urine markers of inflammation, oxidative stress, and neuroplasticity will be assessed 3 times during the trial. First time at baseline, second time 3 days after ECT session 8 (patients skip one ECT session day after 8 ECTs to minimise the confounding effects of acute side-effects of ECT due to anaesthesia etc.), and the third time at a 3 month follow-up after ECT completion. In addition, the neuronal substrates for potential effects of EPO on cognition are investigated with structural and functional MRI after 8 ECT sessions (after 3 weekly EPO or saline infusions).

Block randomization and power calculations have been conducted by the independent Pharma Consulting Group AB (www.pharmaconsultinggroup.com). Treatment groups are stratified for age (>40 or <40) and gender.

The difference in cognitive change between EPO and saline-treated groups from baseline to post-treatment in our previous trial was 0.5 SD. Based on these findings, the sample size of N=52 (n=26 per group) in the current trial will reach a >0.8 power to detect a clinically relevant difference in the primary outcome measure (the cognitive composite score) between the 2 groups at an alpha level of 5% (two-sided test). The study is also powered to investigate differences in functional magnetic resonance imaging (fMRI) blood-oxygen dependent level (BOLD) response in key neural networks based on previous fMRI studies from our group in which sample sizes of 30 age and gender matched participants (n=15 per group) had the power of >0.8 to show drug-related effects on task-related neural response at an alpha level of p<0.05. In the current trial, inclusion of 52 participants (n=26 per treatment group) therefore ensures sufficient statistical power to detect EPO-related effects on neural activity.

Behavioural, mood, and biomarker data will be analysed using Mixed Models Design and Intention to Treat (ITT) approaches. Resting state and task-related fMRI data will be pre-processed and analyzed using FMRIB Expert Analysis Tool (FEAT) and the 'randomize' algorithm integrated in FSL, FMRIB Software Library (www.fmrib.ox.ac.uk/fsl).

• Study Type: Interventional
• Enrollment (Actual): 60
• Phase: Phase 2

Contacts and Locations

Study Locations

• Denmark
  • Copenhagen O
    • Copenhagen, Copenhagen O, Denmark, 2100
      • Mental Health Services, Capital Region of Denmark, Copenhagen University Hospital, Rigshospitalet

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 65 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• ICD-10 diagnosis of major depressive disorder/unipolar disorder or bipolar disorder (confirmed using the Mini International Neuropsychiatric Interview; M.I.N.I.) with current moderate to severe depressive episode symptoms
• Hamilton Depression Rating Scale 17-items score ≥17
• Fluent Danish skills

Exclusion Criteria:

• Treatment under involuntary measures
• Other neuropsychiatric conditions
• Alcohol or substance misuse disorder
• Recent suicide attempts
• Diabetes
• Kidney disease
• Renal failure
• Untreated/insufficiently treated arterial hypertension
• Heart diseases (previously diagnosed or abnormal ECG findings during screening)
• Previous or current epilepsy in patient or first degree family
• Malignancies or thromboses
• Known allergy or antibodies against erythropoietin
• Initial hematocrit > 50% (males) or > 48% (females)
• Initial thrombocyte numbers over normal (>400 billions/L)
• Initial reticulocyte numbers <1‰
• Contraindications against prophylactic thrombosis treatment
• Myeloproliferative disorder, polycythemia
• Pregnancy or breast feeding
• Use of contraceptive medication or other hormonal contraceptives
• Sexually active women in the fertile age, who do not or do not want to use double barrier anticontraceptive methods
• Previous or current history of thromboembolic events or thromboses in patient or first degree family (increased risk of thromboembolic events)
• Overweight (BMI>30) or body weight <45 or >95 kg.
• Previous electroconvulsive therapy (ECT) treatment within last 3 months
• Reluctance or inability to comply with the protocol requirements

Study Plan

How is the study designed?

Design Details

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

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Erythropoietin; 4 intravenous infusions of recombinant human erythropoietin (EPO)	Drug: Erythropoietin; 40.000 IU/ml Erythropoietin (Epoetin alpha; Eprex) diluted with 100 ml saline (0.9% NaCl) is administered 4 times as intravenous infusions over 15 minutes.; Other Names: EPO; Eprex
Placebo Comparator: Saline; 4 intravenous infusions of saline (1 ml NaCl)	Drug: Saline; 1 ml NaCl is administered 4 times as intravenous infusions over 15 minutes; Other Names: Placebo

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Cognitive composite score	A cognitive composite score based on an average of the Rey Auditory Verbal Learning Test (RAVLT), The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) Coding, Verbal Fluency with the letter "D", Wechsler Adult Intelligence Scale (WAIS)-III Letter-Number Sequencing, Trail Making Test Part B, and Rapid Visual Information Processing (RVP) from the Cambridge Neuropsychological Test Automated Battery (CANTAB Cognition Ltd.).	Change from baseline to week 4 (i.e., after the last EPO injection and 8th ECT session)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Autobiographical Memory Interview-Short Form (AMI-SF)	Neuropsychological test assessing retrograde autobiographical memory	Baseline, week 4 (i.e., after the last EPO injection and 8th ECT session), and 3 months after ECT treatment completion
Rey Auditory Verbal Learning Test (RAVLT)	Neuropsychological test assessing verbal learning and memory	Baseline, week 4 (i.e., after the last EPO injection and 8th ECT session), and 3 months after ECT treatment completion

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Rey Auditory Verbal Learning Test (RAVLT)	Neuropsychological test assessing verbal learning and memory	Baseline, week 4 (i.e., after the last EPO injection and 8th ECT session), and 3 months after ECT treatment completion
The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) Coding	Neuropsychological test assessing attention	Baseline, week 4 (i.e., after the last EPO injection and 8th ECT session), and 3 months after ECT treatment completion
Verbal Fluency with the letter "D"	Neuropsychological test assessing executive functions	Baseline, week 4 (i.e., after the last EPO injection and 8th ECT session), and 3 months after ECT treatment completion
Wechsler Adult Intelligence Scale (WAIS)-III Letter-Number Sequencing	Neuropsychological test assessing executive functions	Baseline, week 4 (i.e., after the last EPO injection and 8th ECT session), and 3 months after ECT treatment completion
Trail Making Test Part B	Neuropsychological test assessing executive functions	Baseline, week 4 (i.e., after the last EPO injection and 8th ECT session), and 3 months after ECT treatment completion
Rapid Visual Information Processing (RVP) from the Cambridge Neuropsychological Test Automated Battery (CANTAB Cognition Ltd.)	Neuropsychological test assessing sustained attention	Baseline, week 4 (i.e., after the last EPO injection and 8th ECT session), and 3 months after ECT treatment completion
Hamilton Depression Rating Scale 17-items Version	Clinician-based interview assessing depression severity	Baseline, week 4 (i.e., after the last EPO injection and 8th ECT session), and 3 months after ECT treatment completion
Beck Depression Inventory 21-items	Questionnaire assessing subjectively-rated depression severity	Baseline, week 4 (i.e., after the last EPO injection and 8th ECT session), and 3 months after ECT treatment completion
Cognitive Complaints in Bipolar Disorder Rating Assessment	Questionnaire assessing subjectively-rated cognitive complaints	Baseline, week 4 (i.e., after the last EPO injection and 8th ECT session), and 3 months after ECT treatment completion

Collaborators and Investigators

• Sponsor: Martin Balslev Jørgensen
• Collaborators: Mental Health Services in the Capital Region, Denmark; The Augustinus Foundation, Denmark.
• Investigators: Principal Investigator: Martin B. Jørgensen, Prof., Psychiatric Centre Copenhagen, Rigshospitalet; Study Director: Kamilla W. Miskowiak, Prof., Psychiatric Centre Copenhagen, Rigshospitalet

Publications and helpful links

General Publications

• Schmidt LS, Petersen JZ, Vinberg M, Hageman I, Olsen NV, Kessing LV, Jorgensen MB, Miskowiak KW. Erythropoietin as an add-on treatment for cognitive side effects of electroconvulsive therapy: a study protocol for a randomized controlled trial. Trials. 2018 Apr 19;19(1):234. doi: 10.1186/s13063-018-2627-2.

Study record dates

Study Major Dates

• Study Start (Actual): June 26, 2017
• Primary Completion (Actual): January 10, 2023
• Study Completion (Actual): February 10, 2023

Study Registration Dates

• First Submitted: October 24, 2017
• First Submitted That Met QC Criteria: November 9, 2017
• First Posted (Actual): November 13, 2017

Study Record Updates

• Last Update Posted (Actual): September 21, 2023
• Last Update Submitted That Met QC Criteria: September 18, 2023
• Last Verified: September 1, 2023

More Information

Terms related to this study

• Keywords: functional magnetic resonance imaging; depression; cognition; erythropoietin; electroconvulsive therapy; cognitive side-effects
• Additional Relevant MeSH Terms: Behavioral Symptoms; Mental Disorders; Mood Disorders; Bipolar and Related Disorders; Depression; Depressive Disorder; Bipolar Disorder; Hematinics; Epoetin Alfa
• Other Study ID Numbers: H-16038506; RHP-2017-023 (Other Identifier: The Danish Data Protection Agency Capital Region of Denmark); 2016-002326-36 (EudraCT Number)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No