Dose-finding Study of Intrathecal Paracetamol Administered Immediately Before Spinal Anaesthesia

Study Overview
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Brief Summary
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Two-part study of intrathecal paracetamol administered immediately before spinal anaesthesia in patients scheduled for hip replacement surgery

Detailed Description
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This is a prospective, single centre, two-part, three doses study. Part 1 is a Phase I, three cohorts, dose-ascending, open-label, safety study. Part 2 is a Phase II, randomised, parallel-group, double-blind, placebo-controlled, exploratory efficacy and safety study The objective of the study is to investigate the efficacy and safety of a single intrathecal injection of paracetamol, administered at 3 doses to 3 active treatment groups, as compared to placebo solution, for post-operative analgesia of hip replacement surgery performed under spinal anaesthesia. Patients scheduled for hip replacement surgery will be randomised into 4 treatment groups (15 patients per group) to receive either one of the 3 single doses of paracetamol 3% (D1: 60 mg, D2: 90 mg, D3: 120 mg) or placebo solution (P: saline solution) by intrathecal (IT) injection. Immediately after paracetamol or placebo IT administration, all patients will receive a single IT dose of Hyperbaric Bupivacaine HCl 0.5% (12.5 mg for ≤ 160 cm-tall patients and 15 mg for > 160 cm-tall patients). The time interval between paracetamol IT and bupivacaine IT administrations should not exceed 2 min. The study will include a screening phase (Visit 1, Days -21/1), a treatment phase (paracetamol IT administration, anaesthesia and surgical procedure: Visit 2, Day 1) and a follow-up phase including an observation period (Visit 3, from Day 1 after surgery until discharge, a final visit (at discharge) and a follow-up (day 6±1). Pain at rest will be assessed at screening and on visit 2 at baseline (0 h), 1, 2, 3, 6, 9, 12, 15, 18, 21, 24, 27, 30, 33, 36, 39, 42, 45 and 48 h after anaesthetic IT injection and at discharge, using a 0-100 mm VAS.

Official Title
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Two-part Study of Intrathecal Paracetamol Administered Immediately Before Spinal Anaesthesia in Patients Scheduled for Hip Replacement Surgery

Conditions
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Phase 1: Pain Management, Phase 2: Pain Management

Intervention / Treatment
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* Drug: Paracetamol 3%
* Drug: Placebo injection containing Saline solution 0.9%
* Drug: Hyperbaric Bupivacaine HCl 0.5%


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria Phase 1 and Phase 2: Informed consent: signed written informed consent before inclusion in the study Sex, age and surgery: male/female 18-80 years (inclusive) old patients, scheduled for hip replacement surgery, with anticipated need for post-operative narcotic analgesia, adequate i.v. access and anticipated hospital stay > 48 hours. Body Mass Index (BMI): 18 - 34 kg/m2 inclusive ASA physical status: I-III Full comprehension: ability to comprehend the full nature and purpose of the study, including possible risks and side effects; ability to co-operate with the investigator and to comply with the requirements of the entire study Inclusion criteria - Phase 1 only : Age: 18-70 (inclusive) old patients Inclusion criteria - Phase 2 only : Age: 18-80 (inclusive) old patients Hospital stay: Patients with anticipated hospital stay > 48 hours Exclusion Criteria Phase 1 and Phase 2: Physical findings: clinically significant abnormal physical findings which could interfere with the objectives of the study. Contraindications to spinal anaesthesia. History of neuromuscular diseases to the lower extremities ASA physical status: IV-V Further anaesthesia: patients expected to require further anaesthesia Pain assessment: anticipated to be unable to make a reliable self-report of pain intensity Allergy: ascertained or presumptive hypersensitivity to the active principles (paracetamol and/or amide type anaesthetics) and/or formulations' ingredients or related drugs, opioids, non-steroidal anti-inflammatory drugs; history of anaphylaxis to drugs or allergic reactions in general, which the investigator considers could affect the outcome of the study Diseases: significant history of renal, hepatic, gastrointestinal, cardiovascular, respiratory, skin, haematological, endocrine or neurological diseases that may interfere with the aim of the study; ascertained psychiatric and neurological diseases, sepsis, blood coagulation disorders, severe cardiopulmonary disease, thyroid disease, diabetes, other neuropathies, history or evidence of asthma or heart failure. History of severe head trauma that required hospitalisation, intracranial surgery or stroke within the previous 30 days, or any history of intracerebral arteriovenous malformation, cerebral aneurism or CNS mass lesion. Liver function: Impaired liver function (transaminases > twice upper limit) Renal function: Renal dysfunction (creatinine > 2.0 mg/dL) Investigative drug studies: participation in the evaluation of any investigational product for 3 months before this study, calculated from the first day of the month following the last visit of the previous study Drug, alcohol: history of drug or alcohol abuse. Pre-existing dependence on narcotics or known tolerance to opioids Pregnancy and lactation: positive pregnancy test at screening (if applicable), pregnant or lactating women [The pregnancy test will be performed to all fertile women and to all women up to 55 years old, if not in proven menopause (available laboratory test confirming menopause or surgically sterilised)] Chronic pain syndromes: patients with chronic pain syndromes (taking opioids, anticonvulsant agents or chronic analgesic therapy). Medications: medication known to interfere with the extent of spinal blocks for 2 weeks before the start of the study. Paracetamol formulations, other than the investigational product, for 1 week before the start of the study and during the study. Hormonal contraceptives for females are allowed. Phase 2 only - Exclusion criteria Pain assessment: anticipated to be unable to make a reliable self-report of pain intensity

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 80 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: Supportive Care
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: 4 arms for Phase II only
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: 60 mg Paracetamol 3% (2 mL)<br>60 mg Paracetamol 3%. Solution for injection, single administration by Intrathecal route. | Drug: Paracetamol 3%<br>* Investigate the efficacy and safety of a single intrathecal injection of paracetamol,for post-operative analgesia of hip replacement surgery<br>Drug: Hyperbaric Bupivacaine HCl 0.5%<br>* NIMP, spinal anaesthetic before the surgical procedure<br>|
| Experimental: 90 mg Paracetamol 3% (3 mL)<br>90 mg Paracetamol 3%. Solution for injection, single administration by Intrathecal route. | Drug: Paracetamol 3%<br>* Investigate the efficacy and safety of a single intrathecal injection of paracetamol,for post-operative analgesia of hip replacement surgery<br>Drug: Hyperbaric Bupivacaine HCl 0.5%<br>* NIMP, spinal anaesthetic before the surgical procedure<br>|
| Experimental: 120 mg Paracetamol 3% (4mL)<br>120 mg Paracetamol 3%. Solution for injection, single administration by Intrathecal route. | Drug: Paracetamol 3%<br>* Investigate the efficacy and safety of a single intrathecal injection of paracetamol,for post-operative analgesia of hip replacement surgery<br>Drug: Hyperbaric Bupivacaine HCl 0.5%<br>* NIMP, spinal anaesthetic before the surgical procedure<br>|
| Placebo Comparator: Phase II Only: Saline solution 0.9%<br>Placebo, 0.9%. Solution for injection , single administration by route Intrathecal (2 mL, 3 mL and 4 mL) Study part 2 will be placebo-controlled. Each patient will be allocated to a treatment arm (one of the three paracetamol doses or placebo) according to a computer-generated randomisation list. | Drug: Placebo injection containing Saline solution 0.9%<br>* Injection containing sterile solution of Saline Solution 0.9 %. Study part 2 will be placebo-controlled. Each patient will be allocated to a treatment arm (one of the three paracetamol doses or placebo) according to a computer-generated randomisation list.<br>Drug: Hyperbaric Bupivacaine HCl 0.5%<br>* NIMP, spinal anaesthetic before the surgical procedure<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Phase 1: Number of Participants With Adverse Events Related, Not Related and Serious Events Related to Paracetamol | Phase 1: Number of participants with treatment evaluation and confirmation of the safety of the three doses of paracetamol 3% solution administered in the total number of patients enrolled | In the first 24 hours, in the first 48 hours and at day 7±1 | 
| Phase 2: Pain Intensity | Phase 2: Pain intensity at rest evaluated as VAS scores ( 0-100 mm visual analogue scale : 0 is the absence pain and 100 is the maximum pain sensation) | baseline (0 h), 1, 6, 9, 12, 15, 24, and 48 h after anaesthetic IT injection and at discharge | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Phase 2: Morphine | Phase 2: Total morphine use | At 24 and 48 h after anaesthetic IT injection and entire study period, up to 7 days | 
| Phase 2: Time to First Morphine Use | Phase 2: Time to first morphine use (minutes) | Postoperative, up to 48 hours after end of surgery | 
| Phase 2: Number of Participants With Need for Supplemental Analgesia | Phase 2: Need for supplementary analgesia, other than the planned morphine PCA | Postoperative, up to 48 hours after end of surgery | 
| Phase 2: Morphine-related Adverse Events | Percentage of subjects experiencing during the study the morphine-related adverse events pre-specified in the protocol | up to 24 hours after surgery, up to 48 hours | 
| Phase 2: Time to Readiness for Surgery | Time period from completion of spinal injection (time 0 h) to achievement of sensory and motor block adequate for surgery. | Intraoperative | 
| Phase 2:Maximum Level of Sensory Block | Sensorial block will be verified by bilateral Pinprick test using a 20-G hypodermic needle and will be recorded. Pinprick sensation will be scored as being present (score 1) or absent (score 0). Onset of sensory block is defined as an absent touch sensation (score 0) | Intraoperative | 
| Phase 2: Time to Sensory Block | Time to maximum level of sensory block | Intraoperative | 
| Phase 2: Time to Regression of Spinal Block | Time period from spinal injection (time 0 h) to the time when the Bromage score returns to 0 and sensitive perception returns to S1. Bromage scale: I - Free movement of legs and feet II - Just able to flex knees with free movement of feet III - Unable to flex knees, but with free movement of feet IV - Unable to move legs or feet | from readiness for surgery,then every 10 min until the maximum level is reached (two consecutive observations with the same level of sensory block) and then every 30 min until regression of spinal block | 
| Phase 2: Vital Signs | Systolic and Diastolic Blood Pressure (mmHg) | at screening, at baseline (before the spinal injection) and at end of the study (Day 6). | 
| Phase2: Concomitant Medications | record the concomitant medications intaked during the study | at screening, at baseline until the end of the study (Day 6) | 
| Phase 2: SpO2 | Oxygen saturation is the fraction of oxygen-saturated hemoglobin relative to total hemoglobin (unsaturated + saturated) in the blood. | at screening, at baseline (before the spinal injection) and at the end of the study (day 6) | 
| Phase 2: ECG | Electrocardiography is the process of producing an electrocardiogram (ECG), it is a graph of voltage versus time of the electrical activity of the heart using electrodes placed on the skin. | screening, baseline and end of study (Day 6±1) |