Modulation of GABA-A Receptors in Parkinson Disease-Flumazenil Arm

Study Overview
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Brief Summary
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This arm is a positron emission tomography (PET) biomechanistic GABA-A receptor target engagement study that includes detailed clinical and motor assessments before and after the i.v. administration of 1 mg flumazenil or placebo in Parkinson disease subjects. Each subject will receive 1mg flumazenil or placebo at two visits.

Detailed Description
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This biomechanistic GABA-A receptor target engagement study includes clinical and motor assessments before and at various time points up to approximately 90 minutes after the i.v. administration of 1 mg flumazenil and placebo in Parkinson disease subjects. Thirty Parkinson disease subjects with disease severity (Hoehn and Yahr) stages 2-4 will be recruited. Baseline [11C]FMZ and vesicular monoamine transporter type 2 (VMAT2) [11C]DTBZ brain PET imaging will be performed prior to drug administration to assess for GABA-A receptor availability and the integrity of nigrostriatal dopaminergic nerve terminals, respectively.

Official Title
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Modulation of GABA-A Receptors and Axial Motor Impairments in Parkinson Disease-Flumazenil Arm

Conditions
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Parkinson Disease

Intervention / Treatment
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* Drug: Flumazenil
* Drug: Placebo


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Parkinson's disease (PD): PD diagnosis will follow the UK Parkinson's Disease Society Brain Bank Research Center (UKPDSBRC) clinical diagnostic criteria for PD. Hoehn and Yahr stages 2-4 Absence of dementia confirmed by cognitive testing. Abnormal 11C-Dihydrotetrabenazine ([11C]-DTBZ) PET study to demonstrate nigrostriatal dopaminergic denervation. Exclusion Criteria: PD with Dementia (PDD) or dementia with Lewy bodies (DLB). Other disorders which may resemble PD, such as vascular dementia, normal pressure hydrocephalus, multiple system atrophy, corticobasal ganglionic degeneration, or toxic causes of parkinsonism. Prototypical cases have distinctive clinical profiles, like early and severe dysautonomia or appendicular apraxia, which may differentiate them from idiopathic PD. The use of the UKPDSBRC clinical diagnostic criteria for PD will mitigate the inclusion of subjects with atypical parkinsonism. Subjects on benzodiazepine, GABA-ergic medications (baclofen, tizanidine), neuroleptic, anticholinergic (trihexyphenidyl, benztropine), or cholinesterase inhibitor drugs. Evidence of a mass lesion on structural brain imaging (MRI). Participants in whom MRI is contraindicated including, but not limited to, those with a pacemaker, presence of metallic fragments near the eyes or spinal cord, chest, or cochlear implant. Severe claustrophobia precluding MR or PET imaging. Subjects limited by participation in research procedures involving ionizing radiation. Pregnancy (urine or serum pregnancy test within 48 hours of each PET session) or breastfeeding. History of seizures Significant anxiety or history of panic disorder. History of recent suicide attempt or overdose of tricyclic antidepressants or other medications Any other medical history determined by investigators to preclude safe participation. Allergy to flumazenil Significant liver disease History of alcohol or other substance abuse within past two years. History of regular benzodiazepine use within past year

Ages Eligible for Study
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Minimum Age: 50 Years
Maximum Age: 99 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: Other
Allocation: Randomized
Intervention Model: Crossover Assignment
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Sequence A - (Flumazenil at Visit 1)<br>A detailed 90 minute clinical assessment was conducted before and after treatment administration for each visit. Flumazenil 1mg in 10cc normal saline was given intravenously (iv) over 5-10 minutes on the first visit as treatment. 10 cc of normal saline placebo was given intravenously (iv) over 5-10 minutes on the second visit as treatment. | Drug: Flumazenil<br>* 1mg in 10cc normal saline<br>Drug: Placebo<br>* 10 cc normal saline<br>|
| Experimental: Sequence B - (Placebo at Visit 1)<br>A detailed 90 minute clinical assessment was conducted before and after treatment administration for each visit. 10 cc of normal saline placebo was given intravenously (iv) over 5-10 minutes on the first visit as treatment. Flumazenil 1mg in 10cc normal saline was given intravenously (iv) over 5-10 minutes on the second visit as treatment. | Drug: Flumazenil<br>* 1mg in 10cc normal saline<br>Drug: Placebo<br>* 10 cc normal saline<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Postural Instability and Gait Disorder (PIGD) Score | Postural Instability and Gait Disorder (PIGD) score is a subscale score of MDS-UPDRS scale. It is computed as a sum of following MDS-UPDRS items: 3.10 Gait 3.11 Freezing of gait 3.12 Postural stability 3.13 Posture Minimal possible score is 0, maximal possible score is 16. Higher scores indicate greater severity of PIGD symptoms (worse outcome). | up to 3 hours (including pre and post infusion motor evaluation) | 
| PIGD Score Change | Difference in PIGD score from pre-infusion to post-infusion. Only observations where PIGD score change is less than 0 (decrease) are retained, as the hypothesis we are interested is whether the effect magnitude of flumazenil on PIGD score depends on baseline GABA-A receptor binding as assesed by FMZ PET. | up to 3 hours (including pre and post infusion motor evaluation) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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MRI, Gait, Balance, Flumazenil, PET Imaging, Mobility, Intravenous