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The Exercise Response to Pharmacologic Cholinergic Stimulation in Myalgic Encephalomyelitis / Chronic Fatigue Syndrome

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. Identifier: NCT03674541
Recruitment Status : Enrolling by invitation
First Posted : September 17, 2018
Last Update Posted : July 15, 2020
Information provided by (Responsible Party):
David Systrom, Brigham and Women's Hospital

Brief Summary:

Myalgic encephalomyelitis/Chronic fatigue syndrome (ME/CFS), otherwise known as Chronic fatigue syndrome (CFS) or myalgic encephalomyelitis (ME), is an under-recognized disorder whose cause is not yet understood. Suggested theories behind the pathophysiology of this condition include autoimmune causes, an inciting viral illness, and a dysfunctional autonomic nervous system caused by a small fiber polyneuropathy. Symptoms include fatigue, cognitive impairments, gastrointestinal changes, exertional dyspnea, and post-exertional malaise. The latter two symptoms are caused in part by abnormal cardiopulmonary hemodynamics during exercise thought to be due to a small fiber polyneuropathy. This manifests as low biventricular filling pressures throughout exercise seen in patients undergoing a level 3 CPET along with small nerve fiber atrophy seen on skin biopsy.

After diagnosis, patients are often treated with pyridostigmine (off-label use of this medication) to enhance cholinergic stimulation of norepinephrine release at the post-ganglionic synapse. This is thought to improve venoconstriction at the site of exercising muscles, leading to improved return of blood to the heart and increasing filling of the heart to more appropriate levels during peak exercise. Retrospective studies have shown that noninvasive measurements of exercise capacity, such as oxygen uptake, end-tidal carbon dioxide, and ventilatory efficiency, improve after treatment with pyridostigmine. To date, there are no studies that assess invasive hemodynamics after pyridostigmine administration.

It is estimated that four million people suffer from ME/CFS worldwide, a number that is thought to be a gross underestimate of disease prevalence. However, despite its potential for debilitating symptoms, loss of productivity, and worldwide burden, the pathophysiology behind ME/CFS remains unknown and its treatment unclear. By evaluating the exercise response to cholinergic stimulation, this study will shed further light on the link between the autonomic nervous system and cardiopulmonary hemodynamics, potentially leading to new therapeutic targets.

Condition or disease Intervention/treatment Phase
Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Chronic Fatigue Syndrome Myalgic Encephalomyelitis Exercise Intolerance Dysautonomia Low Ventricular Filling Pressures (Preload Failure) Postural Orthostatic Tachycardia Syndrome Orthostatic Hypotension Fibromyalgia Drug: Pyridostigmine Bromide Drug: Placebo Phase 2

Detailed Description:

The hypothesis of our study is that hemodynamic, ventilatory and oxygen exchange variables such biventricular filling pressures and systemic oxygen extraction can be improved by cholinergic stimulation in patients with ME/CFS.

The objective of this study is to examine the exercise response to pharmacologic cholinergic stimulation in ME/CFS patients already undergoing a clinically indicated level 3 cardiopulmonary exercise test (CPET). This will be achieved by inhibiting acetylcholinesterase with pyridostigmine, thus increasing acetylcholine levels, downstream levels of norepinephrine, and enhancing vascular regulation.

To test our hypothesis, we propose the following specific aims:

Define the response of peak oxygen uptake (VO2) to pyridostigmine. Define the gas exchange responses, such as end-tidal CO2 and ventilatory efficiency to pyridostigmine.

Define the hemodynamic responses, such as right atrial pressures, pulmonary artery pressure, pulmonary capillary wedge pressures, cardiac output, heart rate, stroke volume, pulmonary vascular resistance and systemic vascular resistance to pyridostigmine.

Evaluate the response of skeletal muscle oxygen extraction and lactate to pyridostigmine.

These determinations will occur during a clinically indicated level 3 CPET, which includes exercising on a stationary cycle with a right heart catheter (RHC) and a radial arterial line in place. To stimulate the cholinergic response, a single dose of an oral acetylcholinesterase inhibitor, pyridostigmine, versus placebo will be given after the level 3 CPET. Recovery cycling will be performed after a rest period of 50 minutes. This will be administered in a randomized, double-blind, placebo-controlled trial.

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 50 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Intervention Model Description: Subjects will be assigned ramsomly to receive either pyridostigmine or placebo, both study participants and investigators will be blinded.
Masking: Triple (Participant, Care Provider, Investigator)
Primary Purpose: Treatment
Official Title: The Exercise Response to Pharmacologic Cholinergic Stimulation in Myalgic Encephalomyelitis / Chronic Fatigue Syndrome
Actual Study Start Date : January 14, 2020
Estimated Primary Completion Date : June 1, 2021
Estimated Study Completion Date : June 1, 2021

Resource links provided by the National Library of Medicine

Arm Intervention/treatment
Active Comparator: Study Drug - Pyridostigmine
Pyridostigmine 60 mg by mouth as a one time dose
Drug: Pyridostigmine Bromide
Pyridostigmine Bromide 60 mg capsule by mouth as a one time dose
Other Name: Mestinon

Placebo Comparator: Placebo
Placebo by mouth as a one time dose
Drug: Placebo
Placebo (Cellulose microcrystalline) capsule by mouth as a one time dose

Primary Outcome Measures :
  1. Maximal Oxygen Uptake (VO2max) [ Time Frame: 1 hour ]
    Define the response of oxygen uptake to pyridostigmine

Secondary Outcome Measures :
  1. End-tidal Carbon Dioxide (CO2) [ Time Frame: 1 hour ]
    Define the response of carbon dioxide production to pyridostigmine

  2. Ventilatory Efficiency (VE/VCO2) [ Time Frame: 1 hour ]
    Define the ventilatory efficiency response to pyridostigmine

  3. Right atrial pressure (RAP) [ Time Frame: 1 hour ]
    Define the right atrial pressure response to pyridostigmine

  4. Pulmonary artery pressure (PAP) [ Time Frame: 1 hour ]
    Define the pulmonary artery pressure response to pyridostigmine

  5. Pulmonary capillary wedge pressure (PCWP) [ Time Frame: 1 hour ]
    Define the pulmonary capillary wedge pressure response to pyridostigmine

  6. Cardiac output (CO) [ Time Frame: 1 hour ]
    Define the cardiac output response to pyridostigmine

  7. Heart rate (HR) [ Time Frame: 1 hour ]
    Define the heart rate response to pyridostigmine

  8. stroke Volume (SV) [ Time Frame: 1 hour ]
    Define the stroke volume response to pyridostigmine

  9. Pulmonary vascular resistance (PVR) [ Time Frame: 1 hour ]
    Define the pulmonary vascular resistance response to pyridostigmine

  10. Systemic vascular resistance (SVR) [ Time Frame: 1 hour ]
    Define the systemic vascular resistance response to pyridostigmine

  11. Arterial venous content difference (Ca-v O2 Difference) [ Time Frame: 1 hour ]
    Evaluate skeletal muscle oxygen extraction response to pyridostigmine

  12. Lactate [ Time Frame: 1 hour ]
    Evaluate the lactate response to pyridostigmine

Information from the National Library of Medicine

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, Learn About Clinical Studies.

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Ages Eligible for Study:   18 Years to 80 Years   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  • Meets the Institute of Medicine (IOM) criteria for ME/CFS
  • Completing the clinically indicated iCPET

Exclusion Criteria:

  • Obesity (BMI > 30 kg/m2)
  • Non-controlled asthma
  • Anemia (Hb < 10 g/dl)
  • Active or treated cancer
  • History of interstitial lung disease (ILD)
  • Chronic obstructive pulmonary disease (COPD)
  • Pulmonary hypertension (PH)
  • Congestive heart failure (CHF)
  • Active arrhythmias
  • Valvular heart disease
  • Coronary artery disease (CAD)
  • Other conditions that could predict a limitation or not completion of the study.
  • Pregnancy
  • Submaximal testing in clinically indicated iCPET
  • Pulmonary mechanical limitation to exercise in clinically indicated iCPET.
  • Pulmonary arterial hypertension in clinically indicated iCPET.
  • Pulmonary venous hypertension in clinically indicated iCPET.
  • Exercise induced pulmonary arterial hypertension in clinically indicated iCPET.
  • Exercise induced pulmonary venous hypertension in clinically indicated iCPET.
  • Persistent hypotension during or after the clinically indicated iCPET.
  • Refractory arrhythmia during or after the clinically indicated level 3 CPET.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its identifier (NCT number): NCT03674541

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United States, Massachusetts
Brigham and Women's Hospital
Boston, Massachusetts, United States, 02215
Sponsors and Collaborators
Brigham and Women's Hospital
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Principal Investigator: David Systrom, MD Brigham and Women's Hospital
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Responsible Party: David Systrom, Principal Investigator; Director, Dyspnea Center; Associate Professor of Medicine, Brigham and Women's Hospital Identifier: NCT03674541    
Other Study ID Numbers: 2018P001871
First Posted: September 17, 2018    Key Record Dates
Last Update Posted: July 15, 2020
Last Verified: July 2020
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: Undecided

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Studies a U.S. FDA-regulated Drug Product: Yes
Studies a U.S. FDA-regulated Device Product: No
Product Manufactured in and Exported from the U.S.: Yes
Keywords provided by David Systrom, Brigham and Women's Hospital:
Myalgic encephalomyelitis/Chronic fatigue syndrome
Myalgic encephalomyelitis
Chronic fatigue syndrome
Exercise Intolerance
Invasive Cardiopulmonary Exercise Test
Additional relevant MeSH terms:
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Fatigue Syndrome, Chronic
Hypotension, Orthostatic
Primary Dysautonomias
Postural Orthostatic Tachycardia Syndrome
Pathologic Processes
Muscular Diseases
Musculoskeletal Diseases
Rheumatic Diseases
Neuromuscular Diseases
Nervous System Diseases
Vascular Diseases
Cardiovascular Diseases
Arrhythmias, Cardiac
Heart Diseases
Cardiac Conduction System Disease
Virus Diseases
Central Nervous System Diseases
Orthostatic Intolerance
Autonomic Nervous System Diseases
Central Nervous System Infections
Musculoskeletal Pain