Role of Midodrine and Tolvaptan in Patients With Cirrhosis With Refractory or Recurrent Ascites

Study Overview
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Brief Summary
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The development of ascites in the natural history of cirrhosis heralds a worsening of the prognosis to 50% survival at 2 years, and this deteriorates to 30-50% at 1 year when the ascites becomes refractory to medical therapy. Hemodynamic alterations and their relation to neurohumoral systems are essential in pathophysiology of ascites formation. The theory that best explain the ascites formation and sodium retention in cirrhotics is portal hypertension leading to splanchnic arterial vasodilatation leading to underfilling of arterial circulation which is sensed by the arterial and the cardiopulmonary receptors leading to sympathetic nervous system activation and activation of the anti-natriuretic factors (RAAS and arginine vasopressin), resulting in sodium and water retention. The therapeutic options available for patients with refractory ascites are serial therapeutic paracentesis, liver transplantation and transjugular intrahepatic portosystemic shunts.Vasopressin V2 receptor antagonists antagonize the antidiuretic effects of vasopressin at the V2 receptor located in the renal collecting duct, they increase free water clearance, and thus may be helpful in mobilizing excess water in conditions associated with water retention including cirrhosis. The use of V2 receptor antagonists in cirrhosis with ascites has been shown to be safe and efficacious. Midodrine, an alpha adreno receptor agonist by causing splanchnic vasoconstriction has been used in hepatorenal syndrome (HRS) and for control of ascites in patients with refractory or recurrent ascites. It is possible that vasoconstrictors and aquaretics (V2 receptor antagonists) by acting at different sites in combination may reverse some of the pathogenic events that results in refractory or recurrent ascites.There are no reports on the use of combination of midodrine and tolvaptan in the patients with cirrhosis with ascites. Therefore, we plan to study the role of midodrine, tolvaptan and their combination on systemic hemodynamics, renal functions and control of ascites in patients with cirrhosis and refractory or recurrent ascites.

Official Title
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Role of Midodrine and Tolvaptan in Patients With Cirrhosis With Refractory or Recurrent Ascites

Conditions
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Cirrhosis, Refractory/Recurrent Ascites

Intervention / Treatment
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* Drug: Standard medical therapy
* Drug: Tolvaptan
* Drug: Midodrine


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria:60 consecutive patients with cirrhosis and refractory or recurrent ascites with stable renal function ( creatinine level <1.5mg/dl for at least 7 days ). Exclusion Criteria: Presence of gastrointestinal bleeding, HRS, hepatic encephalopathy of grade 2 or higher or infection within 1 month preceding the study or during the study, presence of diabetes, intrinsic renal or cardiovascular disease or arterial hypertension on history and physical examination, abnormal urine analysis, chest radiograph or electrocardiogram, presence of hepatocellular carcinoma or portal vein thrombosis or treatment with drugs with known effects on systemic and renal hemodynamics within 7 days of inclusion .

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 70 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Standard medical therapy<br>Standard Medical therapy (n-15) with100 to 400mg spironolactone and/or 40 to 160mg furosemide. | Drug: Standard medical therapy<br> <br> * Other names: Standard Medical therapy (n-15) with100 to 400mg spironolactone and/or 40 to 160mg furosemide.;|
| Active Comparator: Midodrine group<br>Standard medical therapy (n-15) with Midodrine 7.5 mg thrice a day | Drug: Standard medical therapy<br> <br> * Other names: Standard Medical therapy (n-15) with100 to 400mg spironolactone and/or 40 to 160mg furosemide.;Drug: Midodrine<br> <br> * Other names: Midodrine 7.5 mg thrice a day;|
| Active Comparator: Tolvaptan group<br>Standard medical therapy (n-15) with Tolvaptan 15 mg twice a day | Drug: Standard medical therapy<br> <br> * Other names: Standard Medical therapy (n-15) with100 to 400mg spironolactone and/or 40 to 160mg furosemide.;Drug: Tolvaptan<br> <br> * Other names: Tolvaptan 15 mg twice a day;|
| Experimental: Tolvaptan plus midodrine arm<br>Standard medical therapy (n-15) with Tolvaptan 15 mg twice a day and Midodrine 7.5 mg thrice a day | Drug: Standard medical therapy<br> <br> * Other names: Standard Medical therapy (n-15) with100 to 400mg spironolactone and/or 40 to 160mg furosemide.;Drug: Tolvaptan<br> <br> * Other names: Tolvaptan 15 mg twice a day;Drug: Midodrine<br> <br> * Other names: Midodrine 7.5 mg thrice a day;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of patients with control of ascites | Control of ascites will be defined as: Complete: defined as the elimination of ascites Partial: presence of ascites not requiring paracentesis Failure: defined as persistence of ascites requiring paracentesis | 3 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of patients with worsening of encephalopathy |  | 3 months | 
| Number of patients with impairment of liver function |  | 3 months | 
| Number of patients with variceal bleed |  | 3 months | 
| Number of patients developing hepatorenal syndrome |  | 3 months | 
| Number of patients with hypernatremia |  | 3 months |