Idiopathic Intracranial Hypertension Treatment Trial
Condition: Idiopathic Intracranial Hypertension
MeSH terms: Intracranial Hypertension; Pseudotumor Cerebri; Hypertension
Study type: Interventional
Phase: Phase 2/Phase 3

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).
    

Detailed 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
    

Intervention name(s): Acetazolamide; Placebo; Formal weight loss counselling program
Intervention type(s): Drug; Drug; Behavioral
Intervention description(s): 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.; 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.; Teleconference, web-based from central location, using site visits and subject self-assessment tools
Other intervention name(s): naproxen; acetaminophen; aspirin; ibuprofen; codein; butalbital; naproxen; acetaminophen; aspirin; ibuprofen; codein; butalbital; naproxen; acetaminophen; aspirin; ibuprofen; codein; butalbital
Intervention MeSH terms: Aspirin; Acetaminophen; Ibuprofen; Naproxen; Acetazolamide; Codeine
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: papilledema; vision loss; headache; obesity; women; diplopia; tinnitus