Dose Response to the Norepinephrine Precursor Droxidopa in Hypotensive Individuals With Spinal Cord Injury

June 23, 2023 updated by: Jill M. Wecht, Ed.D., James J. Peters Veterans Affairs Medical Center

The goal of this study is to determine the efficacy of the drug Droxidopa (Northera) in increasing blood pressure in subject with hypotension, low blood pressure, which is classified as blood pressure less than 110/70 in males and 100/70 in females. The first aim is to determine the proportion of subject with Spinal Cord Injury (SCI) who have a normotensive response to Droxidopa. The second is to determine the proportion of subject with SCI who express a hypertensive response to Droxidopa. A Normal blood pressure ranges from 111-139 in males and 101-139 in females and a hypertensive blood pressure is anything higher than 140 in males and females.

The study would take place in James J. Peters VA Medical Center (JJPVAMC) and The Icahn School of Medicine at Mount Sinai (ISMMS) in Manhattan, New York.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

Interruption of sympathetic cardiovascular autonomic regulation following spinal cord injury (SCI) is associated with significantly reduced plasma norepinephrine (NE) levels, hypotension and orthostatic hypotension (OH), particularly in individuals with high cord lesions. Although the incidence of hypotension is reported to be as high as 70% in persons with cervical lesions (i.e., tetraplegia), the vast majority of these individuals remains asymptomatic and, therefore, does not raise clinical concern, or prompt intervention. While it is appreciated that clinicians are faced with substantial challenges in managing blood pressure (BP) in persons with SCI, contrary to the prevailing belief, asymptomatic hypotension and OH are not benign conditions. Reports suggest that asymptomatic hypotensive individuals with SCI may have subclinical cognitive dysfunction affecting memory and attention processing and increased incidence of fatigue and depression compared to normotensive individuals with SCI. It must be appreciated that to date, there are no FDA approved pharmaceutical options proven to be safe and effective for treatment of hypotension and OH in the SCI population. Until 2014, midodrine hydrochloride was the only agent with FDA approval for treatment of symptomatic neurogenic OH (NOH). Midodrine, an alpha-agonist, is the most commonly prescribed agent used to treat symptomatic hypotension in the SCI population despite a lack of convincing evidence of safety or efficacy. In 2014 droxidopa (L-threo-3,4-dihydroxyphenylserine - NORTHERA; Chelsea Therapeutics, Charlotte, NC) was approved by the FDA for treatment of symptomatic NOH based on data collected in conditions of autonomic dysfunction. Droxidopa is a NE precursor that is stored in neuronal and non-neuronal tissue and has been shown to increase standing BP and reduce symptoms of orthostatic intolerance in individuals with symptomatic NOH. We recently reported preliminary evidence of a mean increase in seated BP in individuals with SCI following oral administration of 400 mg of droxidopa; however, this dose was effective in only 5 of the 10 subjects tested and the BP effect waned over a 4-hour observation. Because of its unique pharmacokinetic profile, droxidopa is a highly promising agent to treat hypotension in persons with SCI. As such; there exists a pressing imperative to determine the clinical value and safety of droxidopa in hypotensive individuals with SCI.

Study Type

Interventional

Enrollment (Actual)

22

Phase

  • Phase 4

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Contact Backup

Study Locations

  • United States
    • New York
      • Bronx, New York, United States, 10468
        • James J. Peters Veteran's Affair Medical Center
      • New York, New York, United States, 10029
        • The Icahn School of Medicine at Mount Sinai

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

16 years to 87 years (Adult, Older Adult)

Accepts Healthy Volunteers

Yes

Description

Inclusion Criteria:

Study 1:

  1. Male or Female, age 18 to 89 with traumatic SCI.

  2. SCI Subjects (n=40):

    1. Any level of injury;
    2. Any American Spinal Injury Association Impairment Scale (AIS) grade of SCI;
    3. Non-ventilator dependent
    4. Primarily wheelchair dependent for mobility;
    5. Duration of injury < 1 year

  3. Low Blood Pressure:

    1. Systolic BP less than 110 mmHg and/or diastolic BP less than 70 mmHg for males.
    2. Systolic BP less than 100 mmHg and/or diastolic BP less than 70 mmHg for females.
  4. Primary Language is English.

  5. Able to provide informed consent

    Study 2:

  6. Male or Female, age 18 to 89 with traumatic SCI.

  7. SCI Subjects (n=40):

    1. Any level of injury;
    2. Any AIS grade of SCI;
    3. Non-ventilator dependent
    4. Primarily wheelchair dependent for mobility
    5. Duration of injury < 1 year

  8. Low Blood Pressure:

    1. Systolic BP less than 110 mmHg and/or diastolic BP less than 70 mmHg for males.
    2. Systolic BP less than 100 mmHg and/or diastolic BP less than 70 mmHg for females.
  9. Primary Language is English.
  10. Able to provide informed consent
  11. Showed a normotensive blood pressure in response to Droxidopa during study 1.

Exclusion Criteria:

  • Current illness or infection

  • Individuals with frequent or severe autonomic dysreflexia:

    1. More than 3 symptomatic events per week
    2. BP ≥140/90 mmHg
    3. Significant adverse subjective symptoms reporting
  • Hypertension
  • Any neurological condition other than SCI (Alzheimer's disease, dementia, stroke, multiple sclerosis, Parkinson's disease, etc.)
  • History of epilepsy or other seizure disorder
  • History of traumatic brain injury (TBI)
  • Liver or kidney disease
  • Bladder problems including blockage of the urine and/or weak urine stream.
  • Diagnosis of a psychiatric disorder such as schizophrenia or bipolar disorder
  • Known artery disease, heart failure, Atrio-ventricular block, and irregular heartbeat
  • Any allergies to droxidopa, asprin, polyethylene oxide, polyethylene glycol, hydroxypropyl cellulose, butylated hydroxytoluene, magnesium stearate, hypromellose, yellow ferric oxide, and red ferric oxide
  • Major surgery in the last 30 days
  • Illicit drug abuse in the past 6 months
  • Pregnant

  • Your prescription medications will be reviewed by the study investigators and research staff. If you are currently taking medications to treat any of the following please make the investigators aware:

    d. Depression, Schizophrenia, Attention Deficit Hyperactivity Disorder (ADHD) e. Pain (opioids) f. Infection or illness (antibiotics) g. Erectile dysfunction (Viagra, Cialis, etc.) h. Overactive bladder i. High or low blood pressure j. Migraine headaches k. Malaria l. asthma

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

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

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Study 1: Dose Optimization of Northera
Subjects will be administered oral droxidopa in a dose escalation, open-label manner beginning with 200 mg. The dose will be adjusted upwards by 100 mg on subsequent visits until average Systolic Blood Pressure (SBP) recorded 60-120 minutes after dose administration is 111-139 mmHg in males and 101-139 mmHg in females, sustained elevation (≥ 30 consecutive minutes) in seated SBP ≥ 140/100 mmHg, maximum dose of 800 mg is reached without adequate SBP response. Subjects will visit the testing laboratory on as few as 1 (200 mg) and as many as 7 (800 mg) days. Seated cardiovascular assessments will be monitored and recorded at 15-minute intervals for 4-hours, and the side effects questionnaire will be administered hourly during the 4-hour study. Each study visit will take about 5 hours.
Drug: Northera
Study 1 is a dose optimization, open-label trial of Northera from a dose range of 200mg up to 800mg.
Other Names:
  • Droxidopa
Placebo Comparator: Study 2: Blinded Placebo & Northera
Participants will then be administered either oral optimal dose of Northera (Droxidopa) or matching placebo in a double-blinded manner and will remain in the supine position for 60 minutes. Subjects will remain in their wheelchair for instrumentation, which will include: 1) ECG, 2) brachial BP, 3) finger arteriolar BP and 4) Cerebral Blood Flow velocity (CBFv).
Drug: Northera
Study 1 is a dose optimization, open-label trial of Northera from a dose range of 200mg up to 800mg.
Other Names:
  • Droxidopa
Other: Placebo
Study 2 is blinded placebo controlled trial using the individualized optimal dose of droxidopa determined by study 1.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Proportion of subjects with normotensive systolic blood pressure
Time Frame: 60 to 120 minutes following administration of droxidopa
To determine the proportion (%) of hypotensive participants with SCI who have a normotensive systolic blood pressure (males=111-139 mmHg; females=101-139 mmHg) following administration of droxidopa.
60 to 120 minutes following administration of droxidopa

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Supine systolic blood pressure
Time Frame: within 60 minutes of administration of droxidopa or placebo
To measure supine systolic blood pressure following administration of droxidopa compared to placebo in hypotensive participants with SCI
within 60 minutes of administration of droxidopa or placebo
Orthostatic systolic Blood Pressure
Time Frame: 60-90 minutes following administration of droxidopa or placebo
To document systolic blood pressure responses to head-up tilt to 70 degrees following administration of droxidopa compared to placebo in hypotensive participants with SCI.
60-90 minutes following administration of droxidopa or placebo
Change in cerebral blood flow
Time Frame: 60-90 minutes following administration of droxidopa or placebo
To document change (from supine to 70 degrees head-up tilt) in cerebral blood flow velocity in the middle cerebral artery following administration of droxidopa compared to placebo in hypotensive participants with SCI.
60-90 minutes following administration of droxidopa or placebo

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

James J. Peters Veterans Affairs Medical Center

Collaborators

New York State Department of Health

Investigators

  • Principal Investigator: Jill M Wecht, Ed.D, James J. Peter's VAMC

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

June 1, 2018

Primary Completion (Actual)

December 31, 2021

Study Completion (Actual)

December 31, 2021

Study Registration Dates

First Submitted

February 15, 2018

First Submitted That Met QC Criteria

July 25, 2018

First Posted (Actual)

July 26, 2018

Study Record Updates

Last Update Posted (Actual)

June 26, 2023

Last Update Submitted That Met QC Criteria

June 23, 2023

Last Verified

June 1, 2023

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • WEC-17-042

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

Yes

Studies a U.S. FDA-regulated device product

No

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.

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