Treatment for Prevention of Variceal Rebleeding Guided by the Hemodynamic Response
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Purpose
This is a prospective trial of random distribution, open, parallel group, in which patients with esophagic variceal bleeding will be randomized into two treatment groups, after controlling acute bleeding. All patients received standard medical therapy with b-blockers and endoscopic ligation (LEV) of esophageal varices.
The control group will be assigned to receive LEV + Nadolol + MNI. The experimental group will be assigned to receive treatment according to the hemodynamic response.
All patients included in the experimental group received LEV and pharmacological treatment nadolol alone or combined with MNI or Prazosin (PZ)
| Condition | Intervention | Phase |
|---|---|---|
|
Portal Hypertension Complications of Cirrhosis |
Other: Hemodynamic guided therapy |
Phase 4 |
| Study Type: | Interventional |
| Study Design: | Allocation: Randomized Endpoint Classification: Efficacy Study Intervention Model: Parallel Assignment Masking: Open Label Primary Purpose: Prevention |
| Official Title: | Randomized and Controlled Study of Endoscopic Ligation, Nadolol and Isosorbide Mononitrate vs Endoscopic Ligation and Nadolol Alone, or Associated With Isosorbide Mononitrate or Prazosin, Depending of the Hemodinamyc Response |
- Rebleeding [ Time Frame: 1-2 Years ]
- Survival [ Time Frame: 1-2 Years ]
- Adverse effects [ Time Frame: 1-2 Years ]
| Estimated Enrollment: | 140 |
| Study Start Date: | August 2007 |
| Estimated Study Completion Date: | November 2007 |
| Arms | Assigned Interventions |
|---|---|
|
Active Comparator: 2
Standard Therapy: Endoscopic ligation (LEV) + Nadolol + Isosorbide mononitrate (MNI)(drugs carefully titrated until achieve maximum tolerated dose)
|
Other: Hemodynamic guided therapy
To switch two or more different treatments for the prevention of variceal rebleeding according to the hemodynamic response. All patients in the experimental group will begin by: 1) LEV + Nadolol. HVPG measurement: if response, no changes, if not, switch to 2) LEV + Nadolol + MNI. HVPG measurement: if response, no changes, if not, switch to: 3) LEV + Nadolol + Prazosin. (drugs carefully titrated until achieve maximum tolerated dose) |
|
Experimental: 1
Hemodynamic guided therapy: 1) LEV + Nadolol. HVPG measurement: if response, no changes, if not, switch to 2) LEV + Nadolol + MNI. HVPG measurement: if response, no changes, if not, switch to: 3) LEV + Nadolol + Prazosin. (drugs carefully titrated until achieve maximum tolerated dose) |
Other: Hemodynamic guided therapy
To switch two or more different treatments for the prevention of variceal rebleeding according to the hemodynamic response. All patients in the experimental group will begin by: 1) LEV + Nadolol. HVPG measurement: if response, no changes, if not, switch to 2) LEV + Nadolol + MNI. HVPG measurement: if response, no changes, if not, switch to: 3) LEV + Nadolol + Prazosin. (drugs carefully titrated until achieve maximum tolerated dose) |
Detailed Description:
This is a prospective trial of random distribution, open, parallel group, in which patients with esophagic variceal bleeding will be randomized into two treatment groups, after controlling acute bleeding. All patients received standard medical therapy with b-blockers and endoscopic ligation (LEV) of esophageal varices.
The control group will be assigned to receive LEV + Nadolol (N) + Isosorbide Mononitrate (MNI) The experimental group will be assigned to receive treatment according to the hemodynamic response.
All patients included in the experimental group received LEV and pharmacological treatment nadolol alone or combined with MNI or Prazosin (PZ)
A hepatic hemodynamic study will be performed to patients in both groups, at baseline (In which basal values and acute b-blockers response will be assessed), and a second study at the 3 rd -4 th week after the drug therapy start, after the titration of the doses.
In the experimental group, responders to the acute administration of b-blockers will receive LEV + Nadolol alone, and those patients with no response will receive LEV + N + MNI, and another hemodynamic study will be performed 3 rd -4 th week after the drug therapy start, after the titration of the doses, to assess response. The non-responders in this control study will switched to LEV+ N + PZ, and a 3erd hemodynamic study will be performed.
Randomization will be stratified according to the degree of hepatic insufficiency, assessed by the Child-Pugh classification (classes A and B vs C)
Eligibility| Ages Eligible for Study: | 18 Years to 80 Years |
| Genders Eligible for Study: | Both |
| Accepts Healthy Volunteers: | No |
Inclusion Criteria:
- All the patients admitted in emergencies in which 1) with gastrointestinal bleeding due to esophageal varices assessed by endoscopy, will be included.
- We define esophagic variceal bleeding as the endoscopic finding of any the following signs: 1) active variceal bleeding 2) clot or platelet cluster or 3 ) esophageal varices associated to red blood in esophagogastric lumen in the absence of other sources of bleeding.
- Clinical criteria and / or analytical, ultrasound and / or liver biopsy consistent with the diagnosis of liver cirrhosis.
- Written informed consent to participate in the study.
- Patients in fertile age should use barrier methods to prevent pregnancy during the entire study. The pregnancy test prior to the study must be negative
Exclusion Criteria:
- Age <18 or> 80 years.
- Patients not eligible for active treatment due to any underlying morbid condition (terminals). Here are included those patients with advanced liver disfunction (Child-Pugh >) or any patient with life expectancy < 6 mo.
- Refuse to participate in the study.
- Bleeding due to causes other than the esophageal varices.
- Prior inclusion in this study.
- Failure in the control of the acute bleeding (index episode).
- Pretreatment through elective LEV program, sclerotherapy or combined β- blockers plus nitrates, or portosystemic shunt (surgical or percutaneous).
- Contraindication for β- blockers and MNI (not exclude patients with contraindication for one of these drugs) or endoscopic procedures.
- Pregnancy.
- Presence multiple hepatocellular carcinoma or only diameter > 5 cm.
- Portal vein thrombosis.
Contacts and Locations| Contact: Candid Villanueva, MD | +34620955006 | cvillanueva@santpau.es |
| Contact: Jordi Virgili |
| Spain | |
| HospitalSCSP | Recruiting |
| Barcelona, Spain, 08025 | |
| Contact: Candid Villanueva, MD +34620955006 cvillanueva@santpau.es | |
| Principal Investigator: Candid Villanueva, MD | |
| Principal Investigator: | Candid Villanueva, MD | Fundació Institut de Recerca de l'Hospital de la Santa Creu i Sant Pau |
More Information
No publications provided
| ClinicalTrials.gov Identifier: | NCT00563602 History of Changes |
| Other Study ID Numbers: | CONHEMO-2006, EudraCT 2007-002237-37 |
| Study First Received: | November 21, 2007 |
| Last Updated: | November 22, 2007 |
| Health Authority: | Spain: Comité Ético de Investigación Clínica |
Keywords provided by Fundació Institut de Recerca de l'Hospital de la Santa Creu i Sant Pau:
|
Portal hypertension Prevention of rebleeding Complications of cirrhosis Portal hemodynamic |
Prazosine Nadolol isosorbide mononitrate |
Additional relevant MeSH terms:
|
Hypertension Hypertension, Portal Liver Cirrhosis Fibrosis Vascular Diseases Cardiovascular Diseases Liver Diseases Digestive System Diseases Pathologic Processes Isosorbide Isosorbide-5-mononitrate Isosorbide Dinitrate Nadolol Prazosin Diuretics, Osmotic |
Diuretics Natriuretic Agents Physiological Effects of Drugs Pharmacologic Actions Cardiovascular Agents Therapeutic Uses Vasodilator Agents Nitric Oxide Donors Molecular Mechanisms of Pharmacological Action Adrenergic beta-Antagonists Adrenergic Antagonists Adrenergic Agents Neurotransmitter Agents Anti-Arrhythmia Agents Antihypertensive Agents |
ClinicalTrials.gov processed this record on May 19, 2013