- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT03364075
Genetic Variants Associated With Low Back Pain and Their Response to Treatment With Duloxetine or Propranolol
Genetic Variants Associated With the Occurrence of Localized Low Back Pain or Low Back Pain With Widespread Pain Symptoms, and Their Response to Treatment With Duloxetine or Propranolol
Study Overview
Status
Conditions
Detailed Description
Low back pain disorders are reported in 19-21% of the North American population, with the majority of them associating pain and physical impairment. Patients with this illness have an increased utilization of medical services, higher incidence of lost work days and long-term disability, representing a significant burden to the healthcare system and the economy.
Within the population of CLBP patients, two broad subgroups can easily be identified in the clinical setting: the patients who present with CLBP as their only pain symptom, and patients that present with CLBP and also associate widespread painful symptoms. The presence of widespread painful symptoms in the setting of low back pain has been recognized as a strong predictor of chronicity, apart from this, patients in this subgroup are more commonly middle aged females, report higher intensity of pain, more emotional problems and sleep disorders amongst others.
A recent publication by Slate et al has described genetic differences in patients with Temporal Mandibular Disorder (TMD) that present with either localized or widespread painful symptoms. This study established a link between Single Nucleotide Polymorphisms (SNPs) associated to the Serotonin Receptor and patients with localized TDM, and the presence of SNPs associated to the T cell receptor with patients with TMD and widespread symptoms. CLBP and TMD are two chronic pain conditions that are commonly present together. Given the connection between these two chronic pain disorders, it is highly likely that the genetic association findings from Slate et al could also be present in the CLPB population.
The main purpose of this study is to determine if CLBP patients presenting with either localized or widespread painful symptoms respond differently to treatment with Duloxetine, a Serotonin and Norepinephrine Reuptake Inhibitor (SNRI), and if the effectiveness of treatment with this drug can determined by the presence or absence of SNPs associated with the Serotonin receptor.
Another novel treatment alternative for patients with CLBP is Propranolol. This drug is a non-selective beta blocker that has also been shown to have analgesic effects on TMD. These effects though, are only present in patients carrying haplotypes associated with low activity of catechol-O-methyltransferase (COMT). The effect of beta blockers as analgesics has not yet been fully characterized, in animal models, catecholamine stimulation of beta 2 and beta 3 adrenoreceptors has shown to produce hyperalgesia and allodynia, on the other hand, in the clinical setting, the beta 1 selective blocker Esmolol has also been shown to have an analgesic effect in postoperative acute pain management. The inclusion of Propranolol as one of the treatment arms of this study will help elucidate Propranolol's possible role in chronic pain management; the expectation being that a more prominent analgesic effect will be found in patients displaying low activity COMT haplotypes.
Patients will be recruited from the Montreal General Hospital (MGH) Pain Centre and from the Quebec Pain Registry.
This study is a randomized, double-blind, placebo controlled, three period crossover clinical study. Each treatment period will be of two weeks duration with a 1 week washout phase between treatment periods. Following a Latin square design, patients will be randomly assigned to one of six different treatment groups, starting their first treatment cycle with either Duloxetine, Propranolol or Placebo and rotating through the other treatments in the subsequent cycles. The trial has a duration of 56 days total, and involves 6 clinic visits per participant, one at the beginning and at the end of each treatment cycle.
Randomization will be performed by a member of our research group that is not involved in the study using the online software (http//:www.randomization.com). The software's first generator will be used which randomizes each subject to a single treatment group by using the method of randomly permuted blocks. The randomization log will be provided to the pharmacy which will be in charge of dispensing the treatment.
All clinicians and researchers involved in the study data collection and experimental procedures will remain blinded to study group allocation for the duration of the study. Blinding will be maintained until the end for statistical analysis.
In case of serious adverse effects interfering with the patient safety, the blind responsible (pharmacy) will disclose the treatment to the MD of the MGH Pain Centre and that subject will be dropped out of the study.
Study Type
Enrollment (Actual)
Phase
- Phase 2
Contacts and Locations
Study Locations
-
-
Quebec
-
Montréal, Quebec, Canada, H4A 3J1
- Centre for Innovative Medicine - McGill University Health Centre
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
- Male or Female patients aged 18 or above.
- Chronic Low Back Pain as the primary painful condition. CLBP diagnose based on medical history and physical examination, with pain restricted to the low back (T6 or below), with or without radiation to the lower limbs but no neurologic signs defined as per the Quebec Task Force on Spinal Disorders Class 1 to 3. This pain must be persistent in the lower back ≥4 days/week for the past 6 months or longer.
- Average pain score of ≥4 at the time of recruitment.
- Women of childbearing potential must agree not to become pregnant during the time of the study and to use adequate contraception during this time. Adequate contraception will be defined as the use of highly effective or double barrier methods. When used consistently and correctly, "double barrier" methods of contraception (e.g. male condom with diaphragm, male condom with cervical cap) can be used as an effective alternative to the highly effective contraception methods such as combined oral contraceptives, injectables or intrauterine devices. Both options will be discussed during the informed consent process.
- Stable drug regimen for 1 month prior to entering the study and throughout the study. Patients will not be taken off their current pain medication to participate in the study, but they will be asked to keep a stable regimen (not change any doses, add or remove other medication) during the study.
- Ability to follow study protocol (cognitive and situational).
- Ability to write and speak in English and/or French.
- Agrees to provide signed and dated informed consent form and biobanking consent form.
- Willing to comply with all study procedures, including the biobanking aspect of the project and to be available for the duration of the study.
Exclusion Criteria:
- Uncontrolled medical or psychiatric conditions.
- History of major depressive disorder, psychotic disorder or schizophrenia, and/or manic episodes within the past year.
- Pregnancy and/or breast-feeding. Patients who are unsure of their status will also be excluded from participating
- Pain due to cancer.
- Disability compensation or litigation.
- Neurologic signs of lumbosacral radiculopathy within the past 6 months: lower extremity muscle weakness/sensory loss in a dermatomal distribution, abnormal deep tendon reflexes.
- Radiographic and/or electrophysiology evidence of radicular compression in the past 6 months.
- Clinical signs of lumbar stenosis within the past 6 months: numbness, weakness, and/or discomfort radiating from the spine down to the buttocks and legs while walking or in prolonged standing and relieved with sitting or lying.
- Clinical signs of back pain that requires an urgent/alternative intervention: new onset bowel/bladder incontinence, saddle anaesthesia, foot drop, unexplained weight loss, fever.
- Radiographic evidence of spinal stenosis, high-grade spondylolisthesis (grade 3 or 4), acute spinal fracture, tumour, abscess or acute pathology in the low back/abdominal area in the past 6 months.
- Low back surgery (lumbosacral spine) within the past 12 months, or history of more than 1 low back surgery.
- Minimally invasive procedures aimed to reduce pain in the lumbosacral area within the past month (Medial Branch Blocks/Ablations, Epidural Steroid Injections, Trigger point injections, Sacroiliac Joint Injections, Greater Trochanteric/Acetabulofemoral Joint Injections).
- Known hypersensitivity to Beta Blockers or SNRIs.
- Currently taking SNRIs, Beta Blockers, Opioids at a daily dose superior to 30mg of Morphine Oral Equivalent, Tricyclic Antidepressants, Methylene Blue, Linezolid, Monoamine Oxidase Inhibitors (such as Selegiline, Isoniazid, Procarbazine), Thioridazine, CYP1A2 inhibitors (Fluvoxamine, Verapamil, Cimetidine, Fluoroquinolone antibiotics such as Ciprofloxacin).
- Active alcoholism within the past 6 months.
- Psychoactive recreational drug abuse within the past 6 months including MDMA, Ketamine, hallucinogens such as LSD and/or sympathomimetics such as Cocaine.
- Patients with asthma, cardiac arrhythmias such as Wolff-Parkinson-White syndrome, coronary artery disease, congestive heart failure, renal failure or dialysis, liver insufficiency, diabetes mellitus, hyperthyroidism.
- Heart rate less than 60 bpm or systolic/diastolic blood pressure less than 105/60 mmHg during the initial visit.
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Crossover Assignment
- Masking: Triple
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Active Comparator: Duloxetine Treatment
patients treated with Duloxetine
|
30 mg for seven days, then increased to 60 mg for seven days
Other Names:
DNA and RNA extraction from blood samples to identify genetic variants associated to pain pathways
1 capsule BID for two weeks
|
Active Comparator: Propranolol Treatment
patients treated with Propranolol
|
DNA and RNA extraction from blood samples to identify genetic variants associated to pain pathways
1 capsule BID for two weeks
40 mg for seven days, then increase to 60 mg for seven days
Other Names:
|
Placebo Comparator: Placebo Treatment
patients treated with placebo
|
30 mg for seven days, then increased to 60 mg for seven days
Other Names:
40 mg for seven days, then increase to 60 mg for seven days
Other Names:
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
pain index
Time Frame: Difference between the average pain index on the first three days of treatment compared to the last three days of the 14 day treatment cycle
|
Average pain intensity multiplied by percentage of time in pain in the waking day.
|
Difference between the average pain index on the first three days of treatment compared to the last three days of the 14 day treatment cycle
|
Collaborators and Investigators
Sponsor
Investigators
- Principal Investigator: Mark Ware, MBBS MRCP, Director of Clinical Research Alan Edwards Pain Management Unit
Publications and helpful links
General Publications
- Tchivileva IE, Lim PF, Smith SB, Slade GD, Diatchenko L, McLean SA, Maixner W. Effect of catechol-O-methyltransferase polymorphism on response to propranolol therapy in chronic musculoskeletal pain: a randomized, double-blind, placebo-controlled, crossover pilot study. Pharmacogenet Genomics. 2010 Apr;20(4):239-48. doi: 10.1097/FPC.0b013e328337f9ab.
- Thomas E, Silman AJ, Croft PR, Papageorgiou AC, Jayson MI, Macfarlane GJ. Predicting who develops chronic low back pain in primary care: a prospective study. BMJ. 1999 Jun 19;318(7199):1662-7. doi: 10.1136/bmj.318.7199.1662.
- Lim KL, Jacobs P, Klarenbach S. A population-based analysis of healthcare utilization of persons with back disorders: results from the Canadian Community Health Survey 2000-2001. Spine (Phila Pa 1976). 2006 Jan 15;31(2):212-8. doi: 10.1097/01.brs.0000194773.10461.9f.
- Von Korff M, Crane P, Lane M, Miglioretti DL, Simon G, Saunders K, Stang P, Brandenburg N, Kessler R. Chronic spinal pain and physical-mental comorbidity in the United States: results from the national comorbidity survey replication. Pain. 2005 Feb;113(3):331-339. doi: 10.1016/j.pain.2004.11.010.
- Coyte PC, Asche CV, Croxford R, Chan B. The economic cost of musculoskeletal disorders in Canada. Arthritis Care Res. 1998 Oct;11(5):315-25. doi: 10.1002/art.1790110503.
- Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010 Dec;19(12):2075-94. doi: 10.1007/s00586-010-1502-y. Epub 2010 Jul 3.
- Fairbank J, Gwilym SE, France JC, Daffner SD, Dettori J, Hermsmeyer J, Andersson G. The role of classification of chronic low back pain. Spine (Phila Pa 1976). 2011 Oct 1;36(21 Suppl):S19-42. doi: 10.1097/BRS.0b013e31822ef72c.
- Natvig B, Bruusgaard D, Eriksen W. Localized low back pain and low back pain as part of widespread musculoskeletal pain: two different disorders? A cross-sectional population study. J Rehabil Med. 2001 Jan;33(1):21-5. doi: 10.1080/165019701300006498.
- Slade GD, Smith SB, Zaykin DV, Tchivileva IE, Gibson DG, Yuryev A, Mazo I, Bair E, Fillingim R, Ohrbach R, Greenspan J, Maixner W, Diatchenko L. Facial pain with localized and widespread manifestations: separate pathways of vulnerability. Pain. 2013 Nov;154(11):2335-2343. doi: 10.1016/j.pain.2013.07.009. Epub 2013 Jul 16.
- Wiesinger B, Malker H, Englund E, Wanman A. Back pain in relation to musculoskeletal disorders in the jaw-face: a matched case-control study. Pain. 2007 Oct;131(3):311-319. doi: 10.1016/j.pain.2007.03.018. Epub 2007 Apr 24.
- Millan MJ. Descending control of pain. Prog Neurobiol. 2002 Apr;66(6):355-474. doi: 10.1016/s0301-0082(02)00009-6.
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
- Pain
- Neurologic Manifestations
- Back Pain
- Low Back Pain
- Physiological Effects of Drugs
- Adrenergic beta-Antagonists
- Adrenergic Antagonists
- Adrenergic Agents
- Neurotransmitter Agents
- Molecular Mechanisms of Pharmacological Action
- Anti-Arrhythmia Agents
- Antihypertensive Agents
- Vasodilator Agents
- Peripheral Nervous System Agents
- Analgesics
- Sensory System Agents
- Psychotropic Drugs
- Neurotransmitter Uptake Inhibitors
- Membrane Transport Modulators
- Serotonin Agents
- Antidepressive Agents
- Dopamine Agents
- Serotonin Receptor Agonists
- Serotonin and Noradrenaline Reuptake Inhibitors
- Propranolol
- Duloxetine Hydrochloride
- Serotonin
Other Study ID Numbers
- MUHC15046
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
product manufactured in and exported from the U.S.
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
Clinical Trials on Low Back Pain
-
Dow University of Health SciencesRecruitingLow Back Pain | Chronic Low-back Pain | Low Back Pain, Mechanical | Mechanical Low Back Pain | Pain, Chronic | Pain, Back | Lower Back Pain Chronic | CLBP - Chronic Low Back PainPakistan
-
Faculdade de Ciências Médicas da Santa Casa de...CompletedLow Back Pain, Mechanical | Low Back Pain, Postural | Lower Back Pain Chronic | Low Back Pain, Posterior CompartmentBrazil
-
University School of Physical Education in WroclawCompletedLow Back Pain | Low Back Pain, Mechanical | Low Back Pain, PosturalPoland
-
Texas Woman's UniversityTexas Physical Therapy AssociationCompletedLow Back Pain | Chronic Low Back Pain | Subacute Low Back PainUnited States
-
University of ParmaKing's College London; Helmholtz Zentrum München; GENOS; Ip Research Consulting... and other collaboratorsUnknownChronic Low Back Pain | Acute Low Back PainUnited States, Australia, Belgium, Croatia, Italy, United Kingdom
-
Apsen Farmaceutica S.A.CompletedLow Back Pain | Low Back Pain, Mechanical | Acute Low Back PainBrazil
-
Universidade Federal do PiauíFoundation for Research Support of the State of PiauíCompletedLow Back Pain, Recurrent | Chronic Low Back PainBrazil
-
Washington University School of MedicineEunice Kennedy Shriver National Institute of Child Health and Human Development...CompletedChronic Low Back Pain | Mechanical Low Back PainUnited States
-
University of ExtremaduraCompletedChronic Low Back Pain | Postural Low Back PainSpain
-
Université du Québec à Trois-RivièresCompletedChronic Low Back Pain | Mechanical Low Back PainCanada
Clinical Trials on Duloxetine
-
Shanghai Mental Health CenterJiangsu Nhwa Pharmaceutical Co., Ltd.Completed
-
Boehringer IngelheimCompletedDiabetic Neuropathies | Depressive Disorder, MajorGermany
-
CSPC ZhongQi Pharmaceutical Technology Co., Ltd.RecruitingMajor Depressive Disorder (MDD)China
-
CSPC ZhongQi Pharmaceutical Technology Co., Ltd.Completed
-
University of MinnesotaHoffmann-La Roche; Minnesota Medical FoundationCompleted
-
University of PittsburghEli Lilly and Company; National Institutes of Health (NIH)CompletedBack Pain | Major Depressive Disorder | AgedUnited States
-
Hamilton Health Sciences CorporationSt. Joseph's Healthcare Hamilton; Eli Lilly and Company; McMaster UniversityUnknown
-
New York State Psychiatric InstituteEli Lilly and CompanyCompletedDysthymic Disorder | Depressive Disorder NOSUnited States
-
Boehringer IngelheimCompleted
-
Eli Lilly and CompanyShionogiCompleted