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Clinical Trial Details — Status: Completed

Administrative data

NCT number NCT01003639
Other study ID # NORDIC01
Secondary ID 1U10EY017281-01A
Status Completed
Phase Phase 2/Phase 3
First received
Last updated
Start date January 2010
Est. completion date January 2014

Study information

Verified date November 2018
Source St. Luke's-Roosevelt Hospital Center
Contact n/a
Is FDA regulated No
Health authority
Study type Interventional

Clinical Trial Summary

Idiopathic intracranial hypertension (IIH), also called pseudotumor cerebri, is a disorder of elevated intracranial pressure of unknown cause [Corbett, et al., 1982; Wall, et al., 1991]. Its incidence is 22.5 new cases each year per 100,000 overweight women of childbearing age, and is rising [Garrett, et al., 2004] in parallel with the obesity epidemic. It affects about 100,000 Americans. Most patients suffer debilitating headaches. Because of pressure on the optic nerve (papilledema), 86% have some degree of permanent visual loss and 10% develop severe visual loss [Wall, et al., 1991]. Interventions to prevent loss of sight, all with unproven efficacy, include diet, diuretics such as acetazolamide, repeated spinal taps, optic nerve sheath fenestration surgery, and cerebrospinal fluid (CSF) shunting procedures. The purported goal of these therapies is to lower intracranial pressure; however, it is unclear which treatments work and by what mechanism. None of these strategies has been verified by properly designed clinical trials. Thus, there is confusion, uncertainty, and weak scientific rationales to guide treatment decisions. This trial will study subjects who have mild visual loss from IIH to (1) establish convincing, evidence-based treatment strategies for IIH to restore and protect vision, (2) follow subjects up to 4 years to observe the long-term treatment outcomes and (3) determine the cause of IIH. To meet those aims, the trial will be divided into a 12-month intervention phase and a 3-year observational phase. Subjects are not required to complete the observational phase of the study, but will be asked to do so and consented for the observational phase of the study at the conclusion of the intervention phase (12 months).


Description:

Clinical Phase: Phase II Investigators: NORDIC Network sites Study Centers: 38 study centers Coordinating Center - University of Rochester Statistical Center - University of Rochester Study Period Planned enrollment duration: 2 years Planned duration of treatment: 6 months followed by open-label treatment Planned duration of follow-up: 4.5 years Study Objectives: The primary objective is determining the efficacy of diet plus acetazolamide vs diet alone in reducing or reversing visual loss in subjects with mild visual loss.

The secondary objective is to identify proteomic and genetic risk factors for IIH by screening a large cohort of IIH patients and controls.

Study Population This project will enroll 166 individuals with IIH who are 18-60 years of age. We anticipate that the population will be primarily composed of women in the childbearing years that are overweight. 154 control subjects will also be enrolled. Control subjects will be matched as closely as possibly by age, sex, race, ethnicity and weight to subjects enrolled at the site.

Study Design: Multi-center, double-blind randomized intervention study followed by a 4-year observation period. Subjects will be randomized to diet and acetazolamide or diet and placebo. The study will use 250 mg acetazolamide or matching placebo tablets taken with food at meals and at bedtime. The subject will begin with one tablet four times daily, at meals and at bedtime for the first week. Beginning on Day 7, subjects will increase the dosage by 1 tablet every 4 days until a final dosage of 4 tablets four times daily (4 grams) is reached or side effects prohibit increasing the dosage further. If the study drug is not tolerated at a dose of 250 mg, then 125 mg (1/2 tablet) will be tried. If this is not tolerated, no pharmacologic treatment will be given.

After the 6 month visit, all subjects will transition from study medication to acetazolamide (open label) by replacing one tablet of study drug with 250 mg of acetazolamide every four days. The acetazolamide dose will be titrated in a manner similar to the initial study drug schedule to the maximum tolerated dose of acetazolamide. To avoid treating subjects (who may have initially been assigned to placebo) unnecessarily, any subject with grade 0-1 papilledema will be tapered off study drug but not placed on acetazolamide unless they have persisting headaches or pulse-synchronous tinnitus. If so, they will be placed on acetazolamide regardless of the low papilledema grade. At the 9-month follow-up visit, we will make sure that the subjects' vision is stable after the transition off of study medication. After the 9 month visit, medication will be prescribed by the subject's treating physician. The intervention phase of the study will end at the subject's 12 month visit and subjects will be invited to participate in the observational phase of the study and consented to do so if willing.

Number of Subjects: 166 subjects with IIH and 154 control subjects Main Inclusion Criteria

1. Diagnosis of IIH by modified Dandy criteria

2. Diagnosis of IIH for 6 weeks or less

3. Age 18 to 60 years at time of diagnosis

4. Reproducible visual loss present on automated perimetry (in eye with greatest loss)*

5. perimetric mean deviation (PMD) -2 decibel (dB) up to -5 dB in the worst eye

6. Presence of bilateral papilledema

7. Able to provide informed consent or parental permission with appropriate assent

Main Exclusion Criteria

1. Total treatment of IIH of more than one week in the past six weeks

2. Corticosteroids or surgery used for IIH treatment within the past two months

3. Abnormalities on neurologic examination aside from papilledema and its related visual loss or VI nerve paresis (unless pre-existing and unrelated to IIH)

4. Abnormal CT or MRI scan (intracranial mass, hydrocephalus, dural sinus thrombus or arteriovenous malformation) other than empty sella, dilated optic nerve sheath, flattened sclera, or secondary Chiari

5. CSF pressure less than 200 mm water (patients may have repeat CSF pressure measurements if the first is normal or no opening pressure obtained)

6. Abnormal CSF contents (increased cells, elevated protein, low glucose)

7. Intraocular pressure currently > 28 mm Hg or > 30 mm Hg at any time in the past

8. Refractive error > +/- 6.00 sphere or > +/- 3.00 cylinder in either eye

9. Other disorders causing visual loss except for refractive error and amblyopia including cells in the vitreous or iritis

10. Inability to provide reliable and reproducible visual field examination (failure to maintain fixation using an eye monitoring device, more than 15% false positive errors

11. Abnormal blood work-up indicating a medical or systemic condition associated with raised intracranial pressure (ICP)

12. Exposure to a drug, substance or disorder that has been associated with elevation of intracranial pressure within 2 months of diagnosis such as lithium, vitamin A, tetracycline, steroid withdrawal (see table in Manual of Procedures (MOP) for conditions and drugs)

13. Other condition requiring diuretics, steroids or other pressure lowering agents including topiramate

14. Presence of a medical condition such as renal stones that would contraindicate use of the study drugs (acetazolamide)

15. Pregnancy or unwillingness for subject with childbearing potential to use contraception during the first year of the study

16. Presence of a physical, mental, or social condition likely to affect follow-up (drug addiction, terminal illness, no telephone, homeless)

17. Anticipation of a move from the site area within six months and unwillingness to return for follow-up.

Route and Dosage Form: 250 mg acetazolamide tablets or matching placebo taken with food 4 times daily. Subjects will titrate to a maximum dose of 4 tablets 4 times daily (4 grams) as tolerated. If a subject is not able to tolerate a dose of 250 mg, 125 mg (1/2 tablet) may be tried. If this is not tolerated, no pharmacologic treatment will be given.

Duration of Treatment: 6 months of randomized treatment followed by open label acetazolamide treatment. After the 9-month visit medication will be prescribed by the subject's treating physician. The intervention phase of the study will end at Month 12 and the subject invited to continue in the observational phase.

Primary Outcome Measure(s): The primary outcome measure is the change from baseline to Month 6 in PMD (perimetric mean deviation) in the eye with the most severe initial visual loss.

Secondary Outcome Measure: CSF pressure measurement by lumbar puncture Number of abnormal perimetry test locations Visual field examination ratings (improved, remained the same, or worsened) Papilledema grade QOL assessments Dietary Outcomes (BMI, Waist circumference, urinary sodium) Safety Outcomes: Adverse events will be tabulated by treatment group, severity, and perceived relationship to the study intervention Sample Size Considerations


Recruitment information / eligibility

Status Completed
Enrollment 165
Est. completion date January 2014
Est. primary completion date June 2013
Accepts healthy volunteers Accepts Healthy Volunteers
Gender All
Age group 18 Years to 60 Years
Eligibility Inclusion Criteria:

1. Diagnosis of IIH by modified Dandy criteria Signs and symptoms of increased intracranial pressure Absence of localizing findings on neurologic examination Absence of deformity, displacement, or obstruction of the ventricular system and otherwise normal neurodiagnostic studies, except for evidence of increased cerebrospinal fluid pressure (>200 mm water). Abnormal neuroimaging except for empty sella turcica, optic nerve sheath enlargement, and smooth-walled non flow-related venous sinus stenosis or collapse106 should lead to another diagnosis Awake and alert No other cause of increased intracranial pressure present

2. Diagnosis of IIH for 6 weeks or less

3. Age 18 to 60 years at time of diagnosis

4. Reproducible visual loss present on automated perimetry (in eye with greatest loss)

5. Average PMD -2 dB up to -5 dB in the worst eye

6. Presence of bilateral papilledema

7. Able to provide informed consent

8. Women of child-bearing potential must use an acceptable form of birth control during the intervention phase of the study. Acceptable forms include oral contraceptives, transdermal contraceptives,

Exclusion Criteria:

1. Total treatment of IIH of more than two weeks (except for acetazolamide which is limited to 1 week). For every day on treatment there must be a one-day washout period.

2. Previous surgery for IIH including optic nerve sheath fenestration, CSF shunting procedures, subtemporal decompression and venous stenting

3. Previous gastric bypass surgery

4. Abnormalities on neurologic examination aside from papilledema and its related visual loss or VI nerve paresis

5. Abnormal CT or MRI scan (intracranial mass, hydrocephalus, dural sinus thrombus or arteriovenous malformation) other than empty sella, unfolded optic nerve sheaths, flattened sclera, or smooth- walled venous stenosis

6. CSF pressure less than 200 mm water (patients may have repeat CSF pressure measurements if the first is normal or no opening pressure obtained)

7. Abnormal CSF contents: increased cells: > 5 cells, elevated protein:

> 45 mg%, low glucose: < 30 mg% (If the lumbar puncture produces a cell count compatible with a traumatic needle insertion, the patient does not need to be excluded if the CSF WBC after correction is 5 wbc/mm3 or less- see Operations Manual for calculation) 8. Intraocular pressure currently > 28 mm Hg or > 30 mm Hg at any time in the past 9. Refractive error > +/- 6.00 sphere or > +/- 3.00 cylinder in either eye with the following exceptions: Subjects with myopia of >-6.00 D sphere but less than or equal to - 8.00 D sphere are eligible if 1)there are no abnormalities on ophthalmoscopy or fundus photos related to myopia that are associated with visual loss (such as staphyloma, retinal thinning in the posterior pole or more than mild optic disc tilt), and 2) the subject wears a contact lens for all perimetry examinations with the appropriate correction. If either the Site Investigator or the PRC director (or his designate) decides there are optic fundus abnormalities of myopia that are associated with visual loss, then 9. Subjects with hyperopia of > +6.00 D but less than or equal to

- 8.00 D sphere are eligible if 1) there is an unambiguous characteristic halo of peripapillary edema as opposed to features of a small crowded disc or other hyperopic change related to visual loss determined by the site investigator or the PRC director (or his designate) and 2) the subject wears a contact le 10. Other disorders causing visual loss except for refractive error and amblyopia including cells in the vitreous or iritis 11. Optic disc drusen on exam or in previous history 12. Presence of diagnosed untreated obstructive sleep apnea 13. Inability to provide reliable and reproducible visual field examination (failure to maintain fixation using an eye monitoring device, more than 15% false positive errors) 14. Abnormal blood work-up indicating a medical or systemic condition associated with raised ICP 15. Study blood results showing severe anemia, leukopenia or thrombocytopenia, renal failure, or hepatic disease, based on the Site Investigator's judgment 16. Type I diabetes or the presence of diabetic retinopathy 17. Exposure to a drug, substance or disorder that has been associated with elevation of intracranial pressure within 2 months of diagnosis such as lithium, vitamin A, various cyclines (see table in Operations Manual for conditions and drugs) 18. Other condition requiring diuretics, oral, I.V. or injectable steroids or other pressure lowering agents including topiramate (nasal, inhaled, or topical steroids are allowed since the systemic effects are small) 19. Presence of a medical condition such as renal stones that would contraindicate use of the study drug (acetazolamide) 20. Pregnancy or unwillingness for subject of childbearing potential to use contraception during the first year of the study 21. Breastfeeding mothers are excluded from participation unless willing to discontinue breastfeeding by the baseline visit 22. Presence of a physical, mental, or social condition likely to affect follow-up (drug addiction, terminal illness, no telephone, homeless) 23. Anticipation of a move from the site area within six months and unwillingness to return for follow-up at an IIHTT study site 24. Allergy to pupil dilating drops or narrow angles precluding safe dilation

Study Design


Related Conditions & MeSH terms


Intervention

Drug:
Acetazolamide
Subjects will begin with four 250 mg tablets daily. Tablets will be divided among two doses, taken with meals. Beginning on day 7, subjects will increase the dose by 1 pill every week until 16 tablets daily is reached (4 grams acetazolamide or placebo) or side effects prohibit increasing the dosage further. Thus, subjects who are able to tolerate the study medication will reach the maximum dose by day 84.
Placebo
Subjects will begin with four tablets daily. Tablets will be divided among two doses, taken with meals. Beginning on day 7, subjects will increase the dose by 1 pill every week until 16 tablets daily is reached (4 grams acetazolamide or placebo) or side effects prohibit increasing the dosage further. Thus, subjects who are able to tolerate the study medication will reach the maximum dose by day 84.
Behavioral:
Formal weight loss counselling program
Teleconference, web-based from central location, using site visits and subject self-assessment tools

Locations

Country Name City State
Canada University of Calgary: Rockyview General Hospital Calgary Alberta
Canada Queen's University - Hotel Dieu Hospital Kingston Ontario
United States Emory University Atlanta Georgia
United States Greater Baltimore Medical Center Department Of Ophthamology Baltimore Maryland
United States Johns Hopkins Universtiy - Wilmer Ophthamological Institute Baltimore Maryland
United States Louisiana State University Health Sciences Center - Earl K. Long Medical Center Baton Rouge Louisiana
United States Bethesda Neurology, LLC Bethesda Maryland
United States University of Alabama Birmingham Birmingham Alabama
United States Massachusetts Eye and Ear Infirmary - Neuro-Ophthamology Service Boston Massachusetts
United States University of Virginia - Department of Ophthalmology Charlottesville Virginia
United States Ohio State University Columbus Ohio
United States Duke Eye Center Durham North Carolina
United States Michigan State University Department of Neurology East Lansing Michigan
United States The Methodist Hospital: Methodist Eye Associates Houston Texas
United States Universtiy of Houston - University Eye Institute Houston Texas
United States Department of Ophthamology and Visual Sciences, University of Iowa Iowa City Iowa
United States University of Kentucky Lexington Kentucky
United States Doheny Eye Center, University of Southern California Los Angeles California
United States Bascom Palmer Eye Institute, University of Miami Miami Florida
United States University of Minnesota Minneapolis Minnesota
United States New York Eye and Ear Infirmary New York New York
United States The Mount Sinai Medical Center New York New York
United States Weill Cornell Medical College New York New York
United States New Jersey Medical School/University Physicians Associates of New Jersey Newark New Jersey
United States Dean A. McGee Eye Institute Oklahoma City Oklahoma
United States University of Illinois Peoria Illinois
United States University of Pennsylvania, Department of Ophthamology Philadelphia Pennsylvania
United States Oregon Health & Science University - Casey Eye Institute Portland Oregon
United States Raleigh Neurology Associates, PA Raleigh North Carolina
United States University of Rochester - Flaum Eye Institute Rochester New York
United States William Beaumont Hosptial Research Institute Royal Oak Michigan
United States Saint Louis University Eye Institute Saint Louis Missouri
United States University of St. Louis Saint Louis Missouri
United States University of Utah, John A. Moran Eye Center Salt Lake City Utah
United States University of Texas Science Center San Antonio Texas
United States Swedish Medical Center Seattle Washington
United States Stony Brook University Stony Brook New York
United States SUNY Upstate Medical University, Neurology Medical Service Group Syracuse New York
United States Neuro-Ophthamology & Balance Disorders Clinic Tallahassee Florida
United States The Eye Care Group, PC Waterbury Connecticut
United States Wake Forrest University Eye Center Winston-Salem North Carolina

Sponsors (5)

Lead Sponsor Collaborator
St. Luke's-Roosevelt Hospital Center National Eye Institute (NEI), University of California, Davis, University of Iowa, University of Rochester

Countries where clinical trial is conducted

United States,  Canada, 

References & Publications (1)

NORDIC Idiopathic Intracranial Hypertension Study Group Writing Committee, Wall M, McDermott MP, Kieburtz KD, Corbett JJ, Feldon SE, Friedman DI, Katz DM, Keltner JL, Schron EB, Kupersmith MJ. Effect of acetazolamide on visual function in patients with id — View Citation

Outcome

Type Measure Description Time frame Safety issue
Primary Mean Change in Perimetric Mean Deviation Treatment Effects on the Primary Outcome Variable, Mean change From Baseline to Month 6 in Perimetric Mean Deviation (PMD) in the Study Eye. Perimetric mean deviation is a measure of global visual field loss (mean deviation from age-corrected normal values), with a range of 2 to -32 dB; larger negative values indicate greater vision loss. base line and 6 months
Secondary Mean Change of Papilledema Grade on Fundus Photography Mean change at month 6 as compared to baseline. Frisén papilledema grade is an ordinal scale that uses ocular fundus features to rate the severity of papilledema; grade 0 indicates no features of papilledema and grade 5 indicates severe papilledema. Baseline and 6 Months
Secondary Visual Function Questionnaire (VFQ-25) Visual Function Questionnaire (VFQ-25) total score, VFQ-25 10-item neuro-ophthalmic supplement total score: 0-100 (higher scores indicate better quality of life) baseline
Secondary Visual Acuity (No. of Correct Letters) Baseline
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