Prevention of Hypertensive Injury to the Brain by Intensive Treatment in IntraCerebral Haemorrhage (PROHIBIT-ICH)

Intracerebral Hemorrhage Clinical Trial

— PROHIBIT-ICH  

Official title:

Prevention of Hypertensive Injury to the Brain by Intensive Treatment in IntraCerebral Haemorrhage

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT03863665
• Other study ID #: PROHIBIT-ICH01
• Status: Recruiting
• Phase: N/A
• Start date: March 11, 2019
• Est. completion date: February 28, 2023

Study information

• Verified date: September 2021
• Source: University College, London
• Contact: Jo Hornby
• Phone: 020 7670 5718
• Email: prohibit-ich[@]ucl.ac.uk
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

PROHIBIT-ICH will randomise participants to compare a strategy of intensive BP treatment (target <120/80 mm Hg) guided by telemetric home monitoring, versus standard primary care (current RCP guideline is 130/80 mm Hg), in 112 adult survivors of hypertension-related ICH. The investigators will establish the feasibility and safety of the intervention, the efficacy of BP reduction, and explore whether it reduces the progression of SVD-related injury on brain MRI.

Description:

About 112 eligible participants will be identified from primary care by a member of the research practitioner or member of research/clinical teams (patient identification sites) outpatient clinics (stroke clinics, neurology clinics, geriatric clinics, neurosurgical clinics) and from acute stroke units or high dependency units at participating hospitals. Patients may be under the care of stroke physicians, geriatricians, neurologists, or neurosurgeons. The Bluetooth telemetric home monitoring equipment will be provided either at hospital discharge or after hospital discharge and the equipment will be set up in the participant's home. Patients will be handed or sent a participant information leaflet. An opportunity to meet a member of the research team will be arranged in person by a member of the clinical care team or subsequently by phone by a member of the research team. All interested participants will have an opportunity to ask questions about the study and these will be answered by a member of the research team prior to enrolment. Consent: Participants will be asked to give written consent prior to participation, after a meeting with a researcher when any questions about the study will be answered. Baseline: At baseline, the following trial specific procedures will be carried out after consent as a requirement for the study to commence: - Medical History recorded - Blood pressure medication and dose recorded - Blood pressure (BP) - Blood test (Venepuncture) - MRI Scan - Cognitive functional change Assessment (Montreal Cognitive Assessment) - Completion of the EQ-5D questionnaire - 24 hour ABPM When a person agrees to participate demographic, contact and medical history information necessary to conduct the study will be recorded. Each participant will be allocated a unique trial number. Relevant sections of medical notes and data collected during the study may be looked at by the researchers from regulatory authorities or from the NHS Trust, where it is relevant to the subject's participation in the trial. Randomisation: Patients will be randomized in a 1:1 group assignment ratio to intensive BP lowering (intervention group) or standard care (control group) using an on line randomization service (Sealed Envelope), available 24 hours a day. Intervention: The Telemetric Bluetooth home Blood Pressure-monitoring device will monitor participant's BP to keep the target of 120/80mm Hg, if this is not achievable then the BP medication will be adjusted accordingly in order to achieve a target of 120/80mm Hg at 3 months follow-up. BP readings (3 readings over 10-minutes in the seated position in the non dominant arm, unless hemiparesis) will be taken 3 times daily (early morning, early afternoon and evening). All BP data will be automatically transmitted centrally in real time to the device co-ordination site in Oxford. A dedicated research member will be responsible for checking all BP data daily on patients in the study, and will advise on adjusting medication according to a standard protocol based on the latest BHS guideline, to ensure that BP is lowered to the intervention arm target. The local study centre will send new prescriptions directly to patients (with communication simultaneously with the GP). For dose changes, advice will be given to participants by phone by the central study team. All medication changes will be notified to the local research team and GP; responsibility for BP treatment will be by the local PI. Follow up: 3 month Follow-up (Visit two): Completion of 3 month CRF, blood pressure recorded and completion of Modified Cognitive assessment, EQ-5D questionnaire and home blood pressure acceptability questionnaire. 24-hour ABPM to be performed at the time of the 3 month follow-up visit. 12 month follow-up (Final visit): Completion of 12 month CRF, blood pressure recorded, and completion of Cognitive assessment and EQ-5D questionnaire. 24-hour ABPM to be performed at the time of the 12 month follow-up visit. An MRI scan will be performed at baseline and the 12 month follow-up visit on all participants to identify markers of cerebral small vessel disease including: - change in white matter hyperintensity volume - change in white matter microstructure (DTI) - change in the number of CMBs - change in cerebral atrophy Primary outcomes: (a) BP study (i) Efficacy: the magnitude of difference in BP at 3 months in the intervention arm versus control arm compared with baseline measures (ii) Feasibility: consent rate; dropout rate from the intervention prior to 1 month; patient approval of the monitoring process (iii) Safety: serious adverse event related to reducing BP in intervention arm (b) Imaging study (i) Efficacy: the progression in MRI white matter hyperintensity (WMH) volume over 1 year Secondary outcomes: 1. BP study: clinical outcomes including recurrent vascular events and cognition; number of BP lowering drugs at 3 months and at 1 year follow-up visits; mean daytime BP at 1 year on 24-hour ABPM 2. Imaging study: neuroimaging outcomes including (but not limited to) the proportion of patients who develop new cerebral microbleeds (CMBs) over 1 year; number of new CMBs at 1 year; new infarcts or intracerebral haemorrhages at 1 year; change in mean diffusivity (MD), fractional anisotropy (FA) and other 3T DTI metrics; change in cerebral blood flow (CBF) on 3T PCASL; change in total brain volume, white matter volume and grey matter volume on 3T T1 volumetric images; composite neuroimaging measures (e.g summary SVD scores)

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 112
• Est. completion date: February 28, 2023
• Est. primary completion date: December 31, 2022
• Accepts healthy volunteers: No
• Gender: All
• Age group: 30 Years and older

Eligibility

Inclusion Criteria:

1. Adults (=40 years) with spontaneous primary ICH (i.e. without known underlying structural, macrovascular or other cause (e.g. arteriovenous malformation, tumour) after adequate investigation at the discretion of the local investigator). This will include participants presumed to have cerebral SVD (both hypertensive arteriopathy and cerebral amyloid angiopathy)

2. Clinical team opinion that BP control since the ICH is not adequate AND the measured SBP prior to randomisation is =130 mm Hg

3. Recruitment soon after ICH, ideally at hospital discharge or within weeks, is encouraged; recruitment at a later stage after ICH is also exceptionally allowed if there is evidence of inadequate BP control AND SBP at randomisation is =130 mm Hg

4. For patients recruited in hospital there should be a plan for home discharge (not to a nursing or care home) after their inpatient stay, or living at home at the time of recruitment

5. Willingness and demonstration of ability to undertake home BP measurements, either unassisted or with the help of a relative, friend or carer

6. Ability and willingness to complete an MRI scan

7. Ability and willingness to attend and complete the study assessments including cognitive screen

8. Ability and willingness to provide informed consent, or with a suitable consultee available and able to participate in the intervention (e.g. with a motivated carer)

Exclusion Criteria:

1. Inability to provide informed consent or lack of suitable consultee (if unable to provide personal consent, lack of suitable consultee)

2. Evidence of a macrovascular or structural cause for ICH (e.g. AVM or tumour)

3. Diagnosis of dementia (DSM IV criteria, or self-reported or documented in medical records)

4. Low Functional status (MRS =4) before or after ICH or frailty likely to make participation in 1-year follow-up difficult for the participant

5. Life expectancy <2 years

6. Taking more than 2 BP-lowering medications (i.e. 3 or more) at the time of consent

7. Consistently good BP control (below 130/80 mm Hg on measures taken as part of routine clinical care) prior to planned recruitment, judged not to require more intensive treatment

8. Known flow-restricting intracranial/extracranial large arterial stenosis

9. Known contraindication to MRI

10. Known absence of mobile phone coverage from all network operators and home internet at the participant's home

11. Known sensitivity or contra-indication to BP treatments (e.g. symptomatic postural hypotension) is not an absolute exclusion criterion, but more information must be provided

12. Note that participation in other CTIMP or device trial is NOT an automatic exclusion criterion

Related Conditions & MeSH terms

• Cerebral Hemorrhage
• Hemorrhage
• Intracerebral Hemorrhage

Intervention

Device:
• A&D BP Digital Blood Pressure Monitor (UA-767PBT-Ci) CE Declaration UA-767PBT-Ci
Telemetric home monitoring is a promising strategy to facilitate home BP monitoring after stroke, which should improve adherence and optimize medication to better control BP. Telemetry allows patients with hypertension to monitor their own BP and automatically send the information to a secure website, available to their clinicians to monitor and adjust their treatment.

Locations

Country	Name	City	State
United Kingdom	Royal United Hospitals Bath	Bath
United Kingdom	West Suffolk Hospital	Bury St Edmunds
United Kingdom	Cambridge	Cambridge
United Kingdom	Edinburgh	Edinburgh
United Kingdom	Glasgow	Glasgow
United Kingdom	Croydon University Hospital	London
United Kingdom	Imperial	London
United Kingdom	King's	London
United Kingdom	St George's	London
United Kingdom	UCLH	London
United Kingdom	Luton & Dunstable Hospital	Luton
United Kingdom	Nottingham	Nottingham
United Kingdom	Oxford	Oxford
United Kingdom	Royal Preston	Preston
United Kingdom	Salford	Salford
United Kingdom	Sheffield	Sheffield

Sponsors (1)

Lead Sponsor	Collaborator
University College, London

Country where clinical trial is conducted

United Kingdom, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	The efficacy of telemetric BP monitoring to guide intensive BP treatment in ICH survivors by detecting a statistically significant reduction in BP in the intervention compared to the control arm at 3 months.	Difference in systolic BP between the intervention and control arms at 3 months	3 months from randomisation
Primary	The feasibility of telemetric BP lowering in ICH survivors by detection of how many eligible participants agree	Feasibility criteria are at least =50% of eligible participants agree to participate	3 months from randomisation
Primary	The feasibility of telemetric BP lowering in ICH survivors by detection of how many drop out in the intervention arm	<30% dropout from the intervention arm (discontinuation of home BP monitoring against the advice of the BP monitoring centre) prior to 1 month	3 months from randomisation
Primary	The feasibility of telemetric BP lowering in ICH survivors by detecting patient approval of the device detected by the acceptability questionnaire	Patient approval of the monitoring process in =70% of those randomised to the intervention arm.	3 months from randomisation
Primary	Efficacy of brain imaging by detecting the progression in MRI white matter hyperintensity (WMH) volume over 1 year	This will detected in both arms and compared	12 months from randomisation
Primary	The safety of telemetric BP lowering in ICH survivors measured by serious adverse events	Safety is measured by serious adverse events related to reducing BP in the intervention arm	12 months from randomisation
Secondary	Incidence of recurrent vascular events	Any incidence of vascular events reported in both arms	12 months from randomisation
Secondary	Cognitive ability assessed by the Cognitive Assessment (MoCA) questionnaire in both arms	The Cognitive Assessment is a questionnaire widely used as a screening assessment for detecting cognitive impairment. It assesses different cognitive domains: attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation. An abbreviated version of the assessment assessing attention, verbal learning, memory, executive functions/language and orientation can be performed over the phone.	12 months from randomisation
Secondary	The number of BP lowering drugs at 3 months and at 1 year follow-up visits	This will detected in both arms and compared	12 months from randomisation
Secondary	mean daytime BP at 1 year on 24-hour ABPM	The blood pressure measured in both groups	12 months from randomisation
Secondary	Neuroimaging outcomes: the proportion of patients who develop new cerebral microbleeds (CMBs) over 1 year	neuroimaging outcomes will be measured in both arms	12 months from randomisation
Secondary	Neuroimaging outcomes: the proportion of patients who develop new infarcts or intracerebral haemorrhages at 1 year	neuroimaging outcomes will be measured in both arms	12 months from randomisation
Secondary	Neuroimaging outcomes: measure change in mean diffusivity (MD)	neuroimaging outcomes will be measured in both arms	12 months from randomisation
Secondary	Neuroimaging outcomes: measure fractional anisotropy (FA)	neuroimaging outcomes including (but not limited to) ; ; change in mean diffusivity (MD), fractional anisotropy (FA) and other 3T DTI metrics; change in cerebral blood flow (CBF) on 3T PCASL; change in total brain volume, white matter volume and grey matter volume on 3T T1 volumetric images; composite neuroimaging measures (e.g summary SVD scores)	12 months from randomisation
Secondary	Neuroimaging outcomes: measure change in brain volume	neuroimaging outcomes including (but not limited to) : change in cerebral blood flow (CBF) on 3T PCASL; change in total brain volume, white matter volume and grey matter volume on 3T T1 volumetric images; composite neuroimaging measures (e.g summary SVD scores)	12 months from randomisation