The Role of Endothelin-1 in Sickle Cell Disease
Condition: Sickle Cell Anemia
MeSH terms: Anemia, Sickle Cell
Study type: Interventional
Phase: Phase 1

Summary: 
      The primary goal of the study is to determine the safety and tolerability of ambrisentan. It
      is also expected that ambrisentan will improve blood flow in the lungs, decrease
      inflammation, and reduce pain in sickle cell patients. An additional goal is to evaluate the
      use of select biomarkers in evaluating sickle nephropathy.
    

Detailed description: 
      The purpose of this study is to test the hypothesis that endothelin antagonist (ETA) receptor
      blockade using ambrisentan is safe, tolerable, and improves kidney function/albuminuria in
      patients with sickle cell disease (SCD). The investigators anticipate a reduction in
      proteinuria, a decrease in tricuspid regurgitation jet (TRJ) velocity, reduction in
      inflammatory markers, improvement in forearm blood flow, and improvement in nociception/pain.

      The primary efficacy endpoint was chosen as the effect of ETA receptor blockade on the
      reduction of microalbuminuria based upon findings in diabetic nephropathy, which has a
      similar pathogenesis to sickle nephropathy. A 30% reduction in proteinuria is rather
      conservative and realistic based upon the results of studies of ETA receptor blockade in
      diabetic nephropathy that consistently resulted in 40-45% reduction in proteinuria.
      Pre-clinical data has shown that changes can be detected in urinary nephrin excretion before
      overt proteinuria is observed in a model of chronic ET-1 elevation. Furthermore, tubular
      injury that can occur as a result of an intrarenal vaso-occlusive crisis (VOC) should be
      expected to increase the level of renal tubular injury markers, neutrophil
      gelantinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), and netrin.
      Treatment with ambrisentan would be expected to attenuate these changes. Dr. Jennifer
      Pollock, has extensive experience with all of the biomarker assays including ET-1. Dr.
      Pollock runs bio-analytical core labs for two PO1s and has published extensively on these and
      similar methods in human and animal samples.

      Additional rationale for this project is based on recent 24-hour urine results for creatinine
      clearance and total protein excretion from 97 patients with sickle cell anemia (Hb SS) and
      sickle beta zero thalassemia (SB0-thalassemia) followed in the Augusta Sickle Cell Clinic.
      These patients ranged in age from 19-63 years (52 females, 45 males). Of these, 17 (18%) had
      microalbuminuria as defined by a 24-hour albumin excretion of 150-300 mg, 34 (36%) had
      macroalbuminuria (>300 mg albumin excretion/24-hours), thus 54% of the patients had
      microalbuminuria or macroalbuminuria and only 46% were normo albuminuric. 58 patients (58%)
      were on chronic hydroxyurea therapy. 9 patients were on angiotensin converting enzyme
      inhibitors (ACEi) and 20 were on angiotensin receptor blockers (ARBs) (total 30%). 55
      patients (57%) had glomerular hyperfiltration (creatinine clearance of >120 ml/min). There
      was an age related decline in the glomerular filtration rate (GFR) observed. The number of
      patients with normo albuminuria shows a sharp decline by age indicative of the progression of
      sickle nephropathy. Recent studies of pain in SCD have led to a change in perception.
      Approximately 50% of the patients reported experiencing daily, chronic pain. In addition,
      issues related to centralization and neuropathic pain in this patient population has begun to
      gain increasing attention. A large body of evidence suggests that endothelin-1 plays an
      important role in enhancing pain stimuli and nociception in various conditions. This is
      mediated by ETA receptor. Berkeley SCD transgenic mice do have hyperalgesia as shown in the
      rationale preliminary data section of Aim 2 and ETA receptor blockade reverses this
      hyperalgesia towards normal. As part of an ongoing National Institute on Minority Health and
      Health Disparities (NIMHD) funded study of pain and its genetic correlates (study reference:
      1 P20 MD003383-01), the investigators have found that SCD patients display significant
      hyperalgesia as measured by pressure pain algometer testing. The testing was done at three
      different anatomic sites in patients (n=38) and controls (n=20) and showed that SCD patients
      perceived pain at significantly lower pressures compared to controls (masseter: 157.7
      kilopascal (kPa) for patients, 214.4 kPa for controls, p=0.017; ulna: 299.1 kPa for patients,
      477.5 kPa for controls, p=0.0018; and trapezius: 290.1 kPa for patients, 462.8 kPa for
      controls, p=0.02). These data suggest that hyperalgesia is present in the vast majority of
      SCD patients and will constitute an objective parameter to monitor during the study.

      Protocol-required assessments performed at every study visit include: physical exam, vital
      signs, con medication review, study drug accountability, adverse events review, pain diary
      completion, and pregnancy testing if applicable.

      Protocol-required assessments performed at specified study visits include: collection of
      blood and urine for safety and efficacy testing; electrocardiogram (ECG); echocardiogram
      (echo); Quantitative Sensory Testing (pressure pain threshold via algometer, cutaneous
      mechanical pain via monofilament, and thermal testing via Q-Sense Small Fiber Test);
      transcranial Doppler (TCD); forearm blood flow measurement; skin blood flow measurement; and
      completion of quality of life questionnaires.

      Description of Procedures:

      Sensory Testing: Patients will also undergo sensory testing at baseline and at the end of the
      study period. Sensory testing will include: 1) Pressure pain threshold will be measured by a
      hand-held, digital algometer as described by Fillingim et al at three different anatomical
      sites: center of right upper trapezius, right masseter, and the right ulna; 2) Cutaneous
      mechanical pain testing- Assessment of temporal summation of mechanical pain will be done
      using nylon monofilaments tested on the dorsum of the hand.; and 3) Thermal sensory testing
      will be performed using Q-Sense Small Fiber Test, which offers a scientifically validated
      measure of warm, cool and heat-pain thermal sensory thresholds.

      Pain Diaries/Questionnaires: Patients will be asked to complete a daily pain diary as
      described in the PISCES study. The evaluation of pain diaries will be performed by Dr. Robert
      Gibson and the research staff. In addition, investigators will also incorporate two pre/post
      measures that will examine the effects of pain on functional performance and quality of life.
      The Assessment of Motor and Process Skills (AMPS) is a well-established functional
      assessment. This assessment has demonstrated the ability to discriminate between healthy
      controls and those with wide spread chronic pain. It also demonstrates the ability to measure
      change following intervention. The investigators will also measure patient's quality of life
      with the Adult Sickle Cell Quality of Life Measurement Information System (ASCQ-Me). This
      quality of life assessment has been specifically developed for sickle cell populations. Dr.
      Robert Gibson has training and experience with the ASCQ-Me and is certified to administer the
      AMPS.

      Echocardiogram for tricuspid regurgitation jet (TRJ) Velocity Measurement: A transthoracic
      echocardiogram for the measurement of TRJ velocity and pulmonary artery systolic pressure
      will be performed at baseline (unless obtained clinically within 6 months of Day 1) and at
      the end of the study.

      Electrocardiogram: An electrocardiogram (ECG) is a test that measures the electrical activity
      of the heart. An ECG will be done as a safety measure at baseline, Day 8 visit, and end of
      study, although ambrisentan is not known to prolong corrected QT interval (QTc).

      Forearm Blood Flow Measurement: Brachial artery flow-mediated dilation (FMD) will be
      performed in accordance to the recent tutorial for ultrasound assessment of FMD. Patients
      will be tested under fasting conditions in a controlled environment at baseline and at the
      end of the study period.

      Skin Blood Flow Measurement: Skin blood flow will be measured non-invasively using a low
      frequency laser imaging camera and/or a small skin probe. Ring-shaped probes that are about
      1.5 inches wide will be placed on the forearm with sticky tape. One ring will be filled with
      approximately 2 ml (about 1/2 teaspoon) of water for local heat and the others will be used
      for iontophoresis. For local heat, investigators will heat the water in the ring to between
      42°C (107°F) and 44°C (111°F) and wait approximately 30 minutes for the increase in skin
      blood flow to become stable. Iontophoresis is a technique that delivers a vasoactive drug
      about 1 mm deep into the skin using a low level electrical current. The advantage of this
      technique is that it is non-invasive and the drug does not go into the body, it just remains
      at the surface of the skin. We will use a 1-2% solution of either acetylcholine, sodium
      nitroprusside, or N-nitro-L-arginine methyl ester (L-NAME) (vasoactive substances) to
      increase or decrease skin blood flow. Multiple short currents (10-180 seconds) will be
      performed approximately 1 minute apart. Investigators will monitor skin blood flow through
      the ring during the forearm arterial blood flow test described above as well as during local
      heat and iontophoresis.

      Blood and Urine Measurement: Lab tests to be performed for safety/ efficacy assessments at
      specified study visits include complete blood count (CBC), complete metabolic panel (CMP),
      spot urine for albumin-creatinine ratio, 24-hour urine, pregnancy testing, biomarkers, and
      inflammatory markers.

      Transcranial Doppler (TCD): Pre- and post-treatment TCD will be performed to assess velocity
      of cerebral blood flow. This non-invasive test is performed while the subject is lying down
      and involves use of sound waves to assess macro-circulation in the head. A transducer is used
      to hear and record the results.
    

Intervention name(s): Ambrisentan; Placebo
Intervention type(s): Drug; Drug
Intervention description(s): Ambrisentan 5 milligrams a day or a placebo (sugar pill) for twelve weeks; One inactive pill daily for twelve weeks
Other intervention name(s): Letairis; "Sugar Pill"
Intervention MeSH terms: Ambrisentan
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Care Provider, Investigator)
Primary purpose: Treatment
Keywords: Sickle Cell Anemia; Sickle Cell Thalassemia; Sickle Beta Thalassemia; Proteinuria; Sickle nephropathy