Phenoxybenzamine Versus Doxazosin in PCC Patients

Study Overview
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Brief Summary
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Rationale: The optimal preoperative medical management for patients with a pheochromocytoma is currently unknown. In particular, there is no agreement with respect to whether phenoxybenzamine or doxazosin is the optimal alfa-adrenoreceptor antagonist to be administered before surgical resection of a pheochromocytoma. We hypothesized that the competitive alfa1-antagonist doxazosin is superior to the non-competitive alfa1- and alfa2-antagonist phenoxybenzamine. Objective: comparing effects of preoperative treatment with either phenoxybenzamine or doxazosin on intraoperative hemodynamic control in patients undergoing surgical resection of a pheochromocytoma. Study design: Randomised controlled open-label trial. Study population: 18 - 55 yr old. Adult patients with a recently diagnosed benign pheochromocytoma. Intervention: Patients are randomised to receive oral treatment with either phenoxybenzamine or doxazosin preoperatively. Main study parameters/endpoints: The main study parameter is defined as the percentage of intraoperative time that blood pressure is outside the predefined target range after pretreatment with either phenoxybenzamine or doxazosin. In this multicenter trial, we compare the effects of two commonly used drugs in patients being medically prepared for resection of a benign pheochromocytoma. Participants are not subjected to an experimental treatment of any kind, as we merely aim to describe in detail the perioperative course in general and, in particular, the intraoperative hemodynamic control in patients treated preoperatively with either phenoxybenzamine or doxazosin. A routine diagnostic work-up for pheochromocytoma will be performed in all participants. One extra blood sample (volume: 48,5 mL) is drawn before start of the study medication, and participants need to record their symptoms in a diary. In addition, patients who are pretreated in the outpatient clinic monitor their blood pressure and pulse rate at home with an automated device. Treatment with an alfa-adrenoreceptor antagonist is initiated at least 2 - 3 weeks prior to surgery. Patients who are admitted to the hospital for pretreatment with an alfa-adrenoreceptor antagonist have their blood pressure and pulse rate measured by the nursing staff. The final site visit is planned at 30 days after surgery, in line with current practice.

Detailed Description
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INTRODUCTION AND RATIONALE Pheochromocytoma (PCC) is a rare but clinically important catecholamine secreting neuro-endocrine tumour that typically arises from the adrenal gland. In addition, this neuro-endocrine tumour can also originate from chromaffin cells in sympathetic ganglia(1)(2). In this protocol, PCC refers to both adrenal and extra-adrenal chromaffin tumours with hypersecretion of catecholamines (i.e. norepinephrine and/or epinephrine). The annual incidence rate in the US population has been estimated to be 1-2 cases per 100,000 adult individuals (3). Data on the incidence and prevalence of PCC in the Netherlands have not been published. Based on the Dutch registry of pathology diagnoses (PALGA), we found an incidence of 117 cases of PCC in the year 2007 (unpublished observation). PCCs may occur as part of an autosomal dominant inherited tumor syndrome, caused by germline mutations in the RET proto-oncogene (Multiple Endocrine Neoplasia type 2 syndrome), VHL gene (von Hippel-Lindau disease), NF1 gene (Neurofibromatosis type 1), or in one of the genes encoding the subunits of mitochondrial complex II, also called succinate dehydrogenase (SDHB, SDHC, SDHD)(4). PCCs are termed 'sporadic' when the family history for PCC is negative. Overall, about 25% of all PCC patients harbour a germline mutation. Notably, germline mutations in one of the PCC susceptibility genes may also be present in a significant number of patients with a sporadic PCC, with mutation rates varying between 7.5 - 14.6% in the populations studied(5-7). Therefore, genetic testing is recommended in all patients with PCC(7). Very recently, a new PCC susceptibility gene has been described, and it seems likely that future research will result in the discovery of other genetic mutations associated with PCC(8). PCC constitutes a surgically curable cause of hypertension. Hypertension in patients with PCC can be either persistent or paroxysmal, but is absent in a minority of patients. It is a potentially life-threatening disease with a high risk for cardiovascular complications such as myocardial infarction, arrhythmias, cardiomyopathy, stroke and pulmonary edema(1). The clinical picture results from release of catecholamines by the tumour. This release can be evoked by stimuli that would normally not pose a hazard, such as surgery or general anaesthesia. Thus, preoperative treatment with alpha-adrenoceptor antagonists is usually recommended for prevention of these serious and potentially fatal complications(9). In one of the largest surgical series reported so far, perioperative mortality and morbidity were 2.4% and 23.6%, respectively(10). According to the literature, about 10% of the patients with PCC are normotensive(1). A normal blood pressure at diagnosis is relatively frequent among carriers of one the aforementioned germline mutations, as these individuals are subjected to periodic biochemical screening for the presence of PCC. It has been demonstrated that intraoperative hemodynamic instability during adrenalectomy for PCC occurred to the same extent in MEN2a patients (most of whom were normotensive) as in patients without MEN2a (most of whom were hypertensive)(11). Thus, preoperative treatment with alpha -adrenoceptor antagonists is also recommended for normotensive patients with PCC (9,11), Historically, the noncompetitive and nonselective alpha -adrenoceptor antagonist phenoxybenzamine has been the drug of choice(12). Alternatively, doxazosin - a competitive and selective alpha 1-adrenoceptor antagonist - might be at least as effective asphenoxybenzamine with fewer side effects. Notably, it has been suggested that doxazosin results in a significant and clinically relevant reduction of postoperative hypotension(13). Severe postoperative hypotension necessitates admission to the intensive care unit (ICU), where volume resuscitation and norepinephrine are administered under strict monitoring of hemodynamics. Data on the optimal preoperative pharmacological management of patients with PCC are conflicting. For example, a recent study reported comparable effects of phenoxybenzamine and doxazosin on intraoperative hemodynamic control(14).This study, however, was retrospective in design and therefore affected by several confounding factors such as lack of randomisation, non-standardised intraoperative care, and use of historical controls. Until now, prospective randomised controlled trials comparing phenoxybenzamine and doxazosin have not been conducted. Thus, the preoperative drug therapy of choice remains an unresolved issue, and at a recent international PCC symposium it was concluded that no specific recommendations can be made on this subject(9). We performed a survey among all university medical centers in the Netherlands, showing that almost half of the centers prescribed phenoxybenzamine, whereas the other centers used doxazosine as the preoperative drug of choice for patients with PCC(15). Usually, these drugs are administered during 2-3 weeks before surgery. This preoperative medical preparation takes place either in the outpatient or inpatient clinic, depending on patient-related factors (e.g. disease severity, geographical considerations) and local experience. Preoperative volume expansion is recommended in all patients with PCC(9). The rationale behind this recommendation is based on the notion that PCC is associated with a decreased intravascular volume, which is restored under influence of treatment with alpha -adrenoceptor antagonists. Without administration of volume expansion severe hypotension might ensue. Therefore, it is common practice to advise a liberal salt intake during alpha -adrenoceptor antagonist therapy and to administer a saline infusion (e.g. 2L NaCL 0.9% in 24 hours) shortly before surgery(9,15). Several drugs, including certain anaesthetics, may evoke an uncontrolled catecholamine release with resulting severe hemodynamic instability(16). Patients are advised to carry a document enlisting all medications which are contra-indicated in case of a PCC. There is no consensus on the optimal anaesthetic management during resection of a PCC, as randomised controlled trials on this subject are not available(16,17). In a survey on the anaesthetic management of PCC in the Netherlands, we found as many different protocols as the number of hospitals (=10) which had responded (including all university medical centers; unpublished observation). PRESCRIPT represents the first randomised controlled trial comparing the effects of pretreatment with either phenoxybenzamine or doxazosin on the intraoperative hemodynamic control in patients with PCC. The relevance of conducting a trial as described in this study protocol was recently expressed again by experts in the field of PCC research(18). In addition, PRESCRIPT provides a unique opportunity to prospectively collect data containing detailed information on items such as presenting symptoms and signs, perioperative outcome and results of biochemical, imaging and genetic studies in patients with PCC. Of interest, results of this study are expected to have a direct impact on national and international guidelines regarding the perioperative care of patients with PCC. OBJECTIVES Primary Objective: The primary objective is to determine which of two commonly used drugs for preoperative management provides the best intraoperative hemodynamic control in patients undergoing resection of a PCC. Secondary Objective(s): to identify other determinants of intraoperative hemodynamic control. Potential determinants are: gender or age of the patient, clinical setting for preoperative management (i.e. outpatient or inpatient clinic), preoperative levels, of catecholamines or N-terminal pro-brain-type natriuretic peptide (NT-proBNP) PCC size, sporadic or hereditary PCC, to describe prospectively symptoms and signs of PCC in a large cohort of patients. Note: until now, data on symptoms and signs have been described retrospectively to describe prospectively the results of several diagnostic techniques to assess prospectively the distribution of sporadic and hereditary PCC in a large cohort of Dutch patients to build a biobank with blood and tissue samples for future studies on PCC STUDY DESIGN Randomised open-label controlled trial.

Official Title
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Pheochromocytoma Randomised Study Comparing Adrenoreceptor Inhibiting Agents for Preoperative Treatment

Conditions
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Pheochromocytoma

Intervention / Treatment
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* Drug: Phenoxybenzamine
* Drug: Doxazosin


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: age > 18 years diagnosis of benign Pheochromocytoma (adrenal or extra-adrenal, sporadic or hereditary: hypertension elevated plasma and/or urinary (nor)metanephrines. From each patient, a blood sample is collected for measurement of plasma (nor)metanephrines with the reference laboratory assay (i.e. XLC-MS/MS) at the Department of Laboratory Medicine of the UMCG. localisation of PCC by anatomical (MRI/CT) and functional imaging (I123-MIBG scintigraphy or 18F-DOPA PET) planned for surgical removal of the PCC Exclusion Criteria: age < 18 years malignant PCC, i.e. presence of lesions on imaging studies suggestive of distant metastases severe hemodynamic instability before surgery necessitating admission to intensive care unit pregnancy incapability to adhere to the study protocol

Ages Eligible for Study
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Minimum Age: 18 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: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Phenoxybezamine<br>Phenoxybenzamine (capsules 10 mg, once to twice daily) is administered orally, starting 2-3 weeks before planned resection of PCC. | Drug: Phenoxybenzamine<br>* Starting dosage of phenoxybenzamine in hypertensive subjects:20 mg q.d. (=10 mg b.i.d.) and in normotensive subjects 10 mg q.d. (in the evening). Dose escalation until blood pressure targets are reached, with a maximum dose of 140 mg q.d. (=70 mg b.i.d.)<br>* Other names: Dibenzyran;|
| Active Comparator: Doxazosin<br>Phenoxybenzamine (slow release tablets 4 or 8 mg, once to twice daily) is administered orally, starting 2-3 weeks before planned resection of PCC. | Drug: Doxazosin<br>* Starting dosage of doxazosine in hypertensive subjects:8 mg q.d. (=4 mg b.i.d.)and in normotensive subjects starting dose 4 mg q.d. (in the evening). Dose escalation until blood pressure targets are reached, with a maximum dose of 48 mg q.d. .(=24 mg b.i.d.)<br>* Other names: Cardura;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The main study parameter is defined as the percentage of intraoperative time that blood pressure is outside the predefined target range after pretreatment with either phenoxybenzamine or doxazosin. | Blood pressure and heart rate will be monitored continuesly during surgery. | Duration of surgery, i.e. on average 3 hours | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| To attain preoperative blood pressure target values without co-medication | success rate of doxazosin and phenoxybenzamine to attain preoperative blood pressure target values without co-medication | an expected average of 2 to 6 weeks before surgery | 
| Resolution of (paroxysmal) symptoms and signs of pheochromocytoma. | Resulution of headache, palpitations, sweeting, paleness, nausea, flushes, fatigue and anxiety. | an expected average of 2-6 weeks before surgery | 
| Need for additional antihypertensive agents | Assessment of the number of patients who need additional antihypertensive drugs on top of the study drugs | an expected average of 2-6 weeks before surgery | 
| Adverse effects of study medication | Adverse effects of doxazosin or phenoxybenzamine | an expected average of 2-6 weeks before surgery | 
| Length of preoperative treatment in either outpatient or inpatient clinic. | Comparing duration of preoperative treatment in either outpatient or inpatient clinic | an expected average of 2-6 weeks before surgery | 
| Control of blood pressure and heart rate. | number of episodes with systolic blood pressure (SBP) > 160 mmHg number of episodes with mean arterial blood pressure (MAP) < 60 mmHg duration (in minutes) of SBP > 160 mmHg duration (in minutes) of MAP < 60 mmHg number of episodes with heart rate > 100/min duration (in minutes) of heart rate > 100/min amount and type of vasoactive agents needed during surgery for adequate blood pressure control. cumulative amount and type of intravenous fluids administered | Duration of surgery, i.e. on average 3 hours | 
| Length of hospital stay. | Number of days the patient is staying in the hospital before and after surgery | Participants will be followed for the duration of hospital stay an expected average of 2-5 weeks. | 
| Composite semi-quantitative score of intra- and postoperative hemodynamic control. | Composite semi-quantitative score of intra- and postoperative hemodynamic control based on the following parameters: blood pressure and heart rate outside target range need for administration of vasoactive agents need for administration of intravenous fluids | During surgery and the first 24 hours after surgery at the intensive/ medium care unit | 
| Postoperative hypoglycaemia | Frequency and severity (in mmol/L)of hypoglycaemia during first 24 hours after surgery. | First 24 hours postoperative | 
| Perioperative mortality. | Death from any cause occurring during period from first administration of study medication until 30 days after surgery. | From first administration of study medication until 30 days after surgery. | 
| Perioperative cardiovascular morbidity. | Cardiovascular events occurring during period from first administration of study medication until 30 days after surgery. Cardiovascular events are: myocardial infarction, cardiac arrhythmia requiring medical intervention, heart failure, cerebrovascular ischemia, cerebrovascular haemorrhage. | From first administation of study medicaion until 30 days after surgery. | 
| Composite endpoint of perioperative mortality and perioperative cardiovascular morbidity. | Death from any cause occurring or cardiovascular events occurring during period from first administration of study medication until 30 days after surgery. | From first administration of study medication until 30 days after surgery. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Pheochromocytoma, Doxazosin, Phenoxybenzamine