The Effect of NK1R Antagonism on Alcohol Craving and PTSD Symptoms in Alcohol Dependent Patients With PTSD

This study has been completed.
Sponsor:
Information provided by (Responsible Party):
National Institutes of Health Clinical Center (CC) ( National Institute on Alcohol Abuse and Alcoholism (NIAAA) )
ClinicalTrials.gov Identifier:
NCT00896038
First received: May 8, 2009
Last updated: August 15, 2014
Last verified: August 2014
  Purpose

Objective:

Alcoholism is highly co-morbid with post traumatic stress disorder (PTSD). Since stress and negative affective states are major relapse triggering factors for alcohol use, the negative symptoms associated with PTSD are thought to promote alcohol dependence. Substance P, which is released in the amygdala in response to stress, acts at NK1 receptors (NK1Rs) to mediate behavioral stress responses. Blockade of the NK1R represents a novel approach for anti-stress actions. In a recent double blind, placebo controlled study involving detoxified anxious alcoholics, we found that NK1R antagonism decreased alcohol cravings, attenuated cortisol response to stress, and significantly decreased insula activation in response to negative sensory input. The present study is intended to expand the findings and determine whether the NK1R is a candidate target for treating alcohol dependent patients with PTSD.

Study Population:

On hundred twenty participants with PTSD and co-morbid alcohol dependence will be recruited and stratified by PTSD etiology (60 participants each with civilian and combat PTSD, resp). Within each stratum, the treatment groups will be balanced for sex using urn randomization. Stratification is indicated since civilian and combat-related PTSD can theoretically have a different pathophysiology. Civilians typically experience a single trauma exposure of invariably high magnitude, resulting in symptoms immediately. Combat-related PTSD typically results from multiple traumatic exposures over a prolonged period of time, of variable magnitude, and frequently with delayed emergence of symptoms.

Design:

Participants will be admitted to the NIAAA research inpatient unit at the NIH Clinical Research Center (CRC) under protocol number 05-AA-0121 for assessment and treatment of people with alcohol drinking problems, which provides diagnostic assessments and standard withdrawal treatment if needed. Participants will enter into the present protocol once such treatment, if needed is completed. Following inclusion, all participants will receive 1 week of single blind placebo, and will then be randomized to double blind treatment with aprepitant or placebo. Randomized treatment will be for 3 weeks. Spontaneous cravings for alcohol, and ratings of psychopathology will be obtained twice weekly on the inpatient unit throughout the study. Cravings as well as endocrine and immune responses will also be assessed in a challenge session that combines a social stressor and exposure to physical alcohol cues. During the final week, three sessions utilizing scripts will be carried out, on separate days in counter-balanced order, exposing the participant to personalized trauma, alcohol-associated or neutral stimuli. Cravings as well as endocrine and immune responses will also be assessed during the script presentations. An fMRI session will be carried out last to assess responses to affective stimuli. Participants will remain hospitalized throughout the study, and will remain on the unit for a three day post-medication monitoring period.

Outcome Measures:

The primary outcome will be craving alcohol and changes in PTSD symptoms resulting from the script sessions. Secondary outcomes will include cravings and changes in PTSD symptoms resulting from the combined social stress-alcohol cure challenge session, spontaneous craving and PTSD symptoms during hospitalization, and brain responses on the fMRI session. Changes in PTSD symptoms and cravings for alcohol are intended to be surrogate markers for the overall effect of the drug treatment and are not intended to represent global improvement for either PTSD or alcoholism.


Condition Intervention Phase
Alcoholism
Alcohol Dependence
Post-Tramatic Stress Disorder
fMRI
Drug: Aprepitant
Phase 2

Study Type: Interventional
Study Design: Allocation: Randomized
Endpoint Classification: Efficacy Study
Intervention Model: Parallel Assignment
Masking: Double Blind (Subject, Investigator)
Primary Purpose: Treatment
Official Title: The Effect of NK1R Antagonism on Alcohol Craving and PTSD Symptoms in Alcohol Dependent Patients With PTSD

Resource links provided by NLM:


Further study details as provided by National Institutes of Health Clinical Center (CC):

Primary Outcome Measures:
  • The primary outcome will be craving for alcohol and changes in PTSD symptoms resulting from guided imagery challenge sessions. [ Time Frame: 3 weeks ] [ Designated as safety issue: No ]

Secondary Outcome Measures:
  • Secondary outcomes will include cravings and changes in PTSD symptoms resulting from the combined social stress, alcohol cue challenge session, spontaneous craving and PTSD symptoms during hospitalization, and brain responses on the fMRI session...

Enrollment: 58
Study Start Date: May 2009
Study Completion Date: August 2014
Primary Completion Date: May 2014 (Final data collection date for primary outcome measure)
Intervention Details:
    Drug: Aprepitant
    N/A
Detailed Description:

Objective:

Alcoholism is highly co-morbid with post traumatic stress disorder (PTSD). Since stress and negative affective states are major relapse triggering factors for alcohol use, the negative symptoms associated with PTSD are thought to promote alcohol dependence. Substance P, which is released in the amygdala in response to stress, acts at NK1 receptors (NK1Rs) to mediate behavioral stress responses. Blockade of the NK1R represents a novel approach for anti-stress actions. In a recent double blind, placebo controlled study involving detoxified anxious alcoholics, we found that NK1R antagonism decreased alcohol cravings, attenuated cortisol response to stress, and significantly decreased insula activation in response to negative sensory input. The present study is intended to expand the findings and determine whether the NK1R is a candidate target for treating alcohol dependent patients with PTSD.

Study Population:

On hundred twenty participants with PTSD and co-morbid alcohol dependence will be recruited and stratified by PTSD etiology (60 participants each with civilian and combat PTSD, resp). Within each stratum, the treatment groups will be balanced for sex using urn randomization. Stratification is indicated since civilian and combat-related PTSD can theoretically have a different pathophysiology. Civilians typically experience a single trauma exposure of invariably high magnitude, resulting in symptoms immediately. Combat-related PTSD typically results from multiple traumatic exposures over a prolonged period of time, of variable magnitude, and frequently with delayed emergence of symptoms.

Design:

Participants will be admitted to the NlAAA research inpatient unit at the NIH Clinical Research Center (CRC) under protocol number 05-AA-0121 for assessment and treatment of people with alcohol drinking problems, which provides diagnostic assessments and standard withdrawal treatment if needed. Participants will enter into the present protocol once such treatment, if needed, is completed. Following inclusion, all participants will receive 1 week of single blind placebo, and will then be randomized to double blind treatment with aprepitant or placebo. Randomized treatment will be for approximately 3 weeks. Spontaneous cravings for alcohol, and ratings of psychopathology will be obtained twice weekly on the inpatient unit throughout the study. Cravings as well as endocrine and immune responses will also be assessed in a challenge session that combines a social stressor and exposure to physical alcohol cues. During the final week, three sessions utilizing scripts will be carried out, on separate days in counter-balanced order, exposing the participant to personalized trauma, alcohol associated or neutral stimuli. Cravings as well as endocrine and immune responses will also be assessed during the script presentations. An fMRI session will be carried out during week 4 to assess responses to affective stimuli. Participants will remain hospitalized throughout the study, and will remain on the unit for a three day post-medication monitoring period.

Outcome Measures:

The primary outcome will be change in craving for alcohol and changes in PTSD symptoms resulting from the script sessions. Secondary outcomes will include cravings and changes in PTSD symptoms resulting from the combined social stress-alcohol cue challenge session, spontaneous craving and PTSD symptoms during hospitalization, and brain responses on the fMRI session. Changes in PTSD symptoms and change in craving for alcohol are intended to be surrogate markers for the overall effect of the drug treatment and are not intended to represent global improvement for either PTSD or alcoholism.

  Eligibility

Ages Eligible for Study:   21 Years to 50 Years
Genders Eligible for Study:   Both
Accepts Healthy Volunteers:   No
Criteria
  • INCLUSION CRITERIA:
  • Alcohol-dependent patients with a diagnosis of PTSD.
  • Ages 21 - 50.
  • Right-handed.
  • Meet the DSM-IV diagnostic criteria for alcohol dependence (poly-substance abuse is common in younger alcohol-dependent patients and will not be exclusionary) and PTSD.
  • Alcohol use within the last month.
  • Females of childbearing potential must agree to use a reliable method of birth control during the study. Reliable methods of birth control include barrier methods such as diaphragms with contraceptive jelly, cervical caps with contraceptive jelly, condoms with contraceptive foam, or intrauterine devices; a partner with a vasectomy; or abstinence from intercourse. Hormonal contraceptives are not adequate in this study, because the study drug can render them less effective.

EXCLUSION CRITERIA:

  • Individuals who present with complicated medical problems requiring intensive medical or diagnostic management.
  • Individuals who are infected with the Human Immunodeficiency Virus (HIV).
  • Individuals with serious neuro-psychiatric conditions which impair judgment or cognitive function to an extent that precludes them from providing informed consent or complying with treatment, such as psychotic illness or severe dementia (incompetent individuals).
  • Individuals who are evaluated and judged by a board certified psychiatrist to be either severely depressed or an imminent risk for suicide, violence, or impulsive behavior, such as self-purging.
  • Individuals who are unlikely or unable to complete the treatment program because they are likely to be incarcerated while on the protocol.
  • Individuals who are required to receive treatment by a court of law or who are involuntarily committed to treatment.
  • Pregnancy or lactation (negative pregnancy test required).
  • A history of seizures, other than documented febrile seizures.
  • Individuals currently using psychotropic medications will not be eligible for participation in the protocol if they are either unwilling or unable, for medical reasons, to be removed from their medication during hospitalization.
  • Individuals in whom aprepitant is contraindicated because they take medications that can interact with this drug. Specifically, aprepitant should not be used concurrently with pimozide, terfenadine, astemizole, or cisapride. Dose-dependent inhibition of cytochrome P450 isoenzyme 3A4 (CYP3A4) by aprepitant could result in elevated plasma concentrations of these drugs, potentially causing serious or life-threatening reactions
  • Inability or unwillingness to participate in an fMRI scan, including presence of metallic objects in the body that would interfere with the scan or pronounced claustrophobia.
  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT00896038

Locations
United States, Maryland
National Institutes of Health Clinical Center, 9000 Rockville Pike
Bethesda, Maryland, United States, 20892
Sponsors and Collaborators
Investigators
Principal Investigator: David T George, M.D. National Institute on Alcohol Abuse and Alcoholism (NIAAA)
  More Information

Publications:
Responsible Party: National Institutes of Health Clinical Center (CC) ( National Institute on Alcohol Abuse and Alcoholism (NIAAA) )
ClinicalTrials.gov Identifier: NCT00896038     History of Changes
Other Study ID Numbers: 090136, 09-AA-0136
Study First Received: May 8, 2009
Last Updated: August 15, 2014
Health Authority: United States: Federal Government

Keywords provided by National Institutes of Health Clinical Center (CC):
Alcohol Dependence
Alcohol Treatment
Alcoholics
Alcoholism
Post-Traumatic Stress Disorder (PTSD)
Post Traumatic Stress Disorder
PTSD

Additional relevant MeSH terms:
Alcoholism
Stress Disorders, Post-Traumatic
Stress Disorders, Traumatic
Alcohol-Related Disorders
Substance-Related Disorders
Chemically-Induced Disorders
Mental Disorders
Anxiety Disorders
Ethanol
Aprepitant
Fosaprepitant
Anti-Infective Agents, Local
Anti-Infective Agents
Therapeutic Uses
Pharmacologic Actions
Central Nervous System Depressants
Physiological Effects of Drugs
Central Nervous System Agents
Antiemetics
Autonomic Agents
Peripheral Nervous System Agents
Gastrointestinal Agents
Neurokinin-1 Receptor Antagonists
Neurotransmitter Agents
Molecular Mechanisms of Pharmacological Action

ClinicalTrials.gov processed this record on August 26, 2014