A Trial for Prevention of Recurrent Ischemic Priapism in Men With Sickle Cell Disease: A Pilot Study (PIN)

  • STATUS
    Recruiting
  • End date
    Jan 1, 2027
  • participants needed
    200
  • sponsor
    Vanderbilt University Medical Center
Updated on 29 April 2022

Summary

To conduct a randomized controlled internal pilot feasibility trial for the prevention of recurrent ischemic priapism referred to as the Priapism in Nigeria (PIN) trial. The study team will enroll a minimum of 30 participants and a maximum of 200 participants. Study investigators hypothesize that hydroxyurea therapy combined with tadalafil is superior to a combination of hydroxyurea and placebo in the prevention of recurrent ischemic priapism.

Description

Sickle cell disease (SCD) is one of the commonest genetic diseases in the world. Approximately 300,000 newborns are born with SCD every year, with 50% of the birth being in Nigeria alone. This huge burden makes Nigeria critical to any intervention that seeks to address the challenges of individuals with SCD. Men with SCD experience many complications, which can even affect their sexuality and reproductive health. One of the most common, but often neglected complications of SCD in men is priapism. Priapism is defined as a painful, purposeless, and sustained erection. In men with SCD, priapism tends to be recurrent and devastating. The prevalence of priapism was 42% in Jamaican men with SCD. Researchers reported the incidence of priapism in SCD to be very low before the age of 10 years, but the cumulative incidence rose to 32.7% by the age of 20 years. Researchers reported the prevalence of priapism in SCD to be 35%, out of which 72% was recurrent ischemic priapism (lasting <4 hours). The majority of the individuals with SCD experienced their first episode of priapism before the age of 20 years, with a mean age of onset being 15 years. In a cross-sectional study of 353 men with SCD, conducted by our team in Kano, Nigeria, the prevalence of priapism was approximately 32%; out of which 74% was recurrent ischemic priapism. In the same study, the prevalence of priapism in men without SCD (n=250) was 2%. The results from focus groups (3 in Nigeria and 3 in the U.S.) our team conducted revealed men with SCD who experienced recurrent ischemic priapism struggled with embarrassment, shame, anxiety and depression, and declining sexual function.

The prevention and treatment of ischemic priapism in SCD is still inadequate. Researchers used a combination of preventive oral etilefrine and self-administered intracavernosal injection of etilefrine for breakthrough priapism lasting >1 hour. Sixty-six percent (4 of 6) had no recurrence of priapism while the remaining two used intracavernosal injection of etilefrine. In a non-RCT study, Researchers reported a good response to oral etilefrine; which was shown to have reduced the frequency of recurrent ischemic priapism in SCD (mean difference 5.78); P < 0.0001.(21) However, in the only RCT for this drug, etilefrine was found to have no efficacy over placebo. Researchers showed that in 35 patients on graded doses of finasteride (5-alpha reductase inhibitor), priapism recurrences were reduced from an average of 22.7 to 2.1 at the end of the 120-day follow-up. A combination of oral ketoconazole with prednisolone showed a promising result in case-series reported by researchers. However, an RCT (n=40) showed no efficacy of ketoconazole (81.25% and 83% in both arms still having post-operative painful erections). In another study, hydroxyurea was shown to have decreased priapism recurrences in 4 of 5 men treated with a high dose. Nonetheless, stopping hydroxyurea heralded relapse of priapism. Researchers reported that sildenafil has controlled priapism experiences in 6 of 7 men observed. Non-RCT designs, small sample sizes, or adverse effects of the trial medications limit most of these studies.

This conceptual framework is based on the synergistic effect of tadalafil (PDE-5 inhibitor, which increases the bioavailability of cGMP), and hydroxyurea (NO donor). In SCD there is chronic hemolysis causing depletion of NO and dysregulation of PDE-5, which underpin the molecular basis of priapism. Chronic dosing of low-dose tadalafil inhibits PDE-5 to paradoxically restore the normal homeostatic mechanism of the NO-cGMP-PDE-5 pathway. Restored PDE-5 function helps prevent recurrent ischemic priapism. Despite the need, all prior priapism studies did not provide sufficient evidence for practice-based outcomes. Several reasons exist for the lack of any substantial progress for secondary prevention of ischemic priapism, the foremost of which is that SCD is a rare disease in high-income settings where most of the studies have been conducted. To overcome these limitations, the investigators propose an internal pilot trial to assess the feasibility trial in a setting where there are over 5000 men available to be enrolled in one city, Kano Nigeria. The trial will also build on the infrastructures and workflow established by NIH-funded pre-existing SCD stroke prevention trials conducted at the same hospitals in Kano.

The aims are 1) To conduct a randomized internal pilot trial and possible complete a phase III trial for the prevention of recurrent ischemic priapism (hydroxyurea + tadalafil vs hydroxyurea + placebo), referred to as the Priapism in Nigeria (PIN) trial, and 2) To assess the tolerability of moderate-dose hydroxyurea and its effect on spermatogenesis.

Trained study personnel will approach the eligible participants for consenting. After obtaining signed informed consent and ensuring they have fulfilled inclusion criteria, the participants will be randomized 1:1 to the treatment and placebo arms. The primary study statistician will be supported by a local statistician in Nigeria to perform the randomization process. After the random allocation, all study personnel and participants will be blinded to the treatment. The treatment arm will include tadalafil, given orally initially at a low-dose of 2.5 mg daily for four weeks. If tolerated very well during the four weeks, the dose will be increased to 5.0 mg daily as the final dose. Tadalafil and the identical placebo will be purchased from a local pharmaceutical company, Bond Chemical Nigerian Limited, which is licensed to produce tadalafil and hydroxyurea in Nigeria. Participants will be instructed to take tadalafil or placebo in the morning for this trial. Chronic morning dosing with tadalafil will allow the drug to be metabolized and is unlikely to be associated with sleep-related erections. Both treatment and placebo arms will be on hydroxyurea as standard care. Hydroxyurea will be given orally at a moderate-dose of 20mg/kg/day and is also produced by the Bond Chemical Nigerian Limited. The moderate-dose of hydroxyurea is found to be effective, with minimal adverse effects, in the preliminary data of stroke prevention in Nigeria (1R01NS094041) trial just recently completed in Kano, Nigeria. Both arms of the trial will be followed for one year; afterward, the trial will go into the open-label phase. The participant can select whether they want to continue either therapy or start a new treatment. At the baseline, demographic and clinical data from medical records of the participants will be collected. The data will include but are not limited to: co-morbidities (hypertension, diabetes, etc.), drug history (antihypertensives, aphrodisiacs, hormonal shots, alpha receptor agonists, antipsychotics, etc.), pain history, and blood transfusions history. The investigators will use internationally validated questionnaires (International Index of Erectile Function [IIEF],(24) PROMIS Erectile function,(25) sexual activity, and satisfaction with sex life) to evaluate erectile and sexual functions of the participants at baseline and subsequent follow-ups.

Details
Condition Priapism Due to Sickle Cell Disease
Treatment hydroxyurea, Placebo, Tadalafil
Clinical Study IdentifierNCT05142254
SponsorVanderbilt University Medical Center
Last Modified on29 April 2022

Eligibility

Yes No Not Sure

Inclusion Criteria

Men with confirmed diagnosis of HbSS or Hb beta zero thalassemia
Ages between 18 to 40 years
Eligible study participants must receive care in an SCD clinic at AKTH and MMSH at the time of the recruitment
Participants must commit to long-term follow-up and taking the trial medications
At least 3 episodes of priapism, each lasting for no less than an hour in the past 6 months
Adequate renal and hepatic function (baseline liver enzymes and synthetic activities should be no more than four-fold above the reference ranges for Aminu Kano Teaching Hospital (AKTH). These are the ranges obtained in AKTH: Alkaline phosphatase: 42-110 U/L, Alanine transaminase: 4-34 U/L, Aspartate transaminase: 7-45 U/L, Albumin: 32-52 g/L, and Globulin: 32-43 g/L

Exclusion Criteria

Individuals already enrolled in another clinical trial
eGFR <50ml/min
Liver cirrhosis based on clinical history, laboratory data or both
Previously known pulmonary hypertension based on TRJV greater than 3.0 m/sec
Contraindications to tadalafil (arrhythmia, severe liver disease, concurrent use of nitrates, etc.) or hydroxyurea (leg ulcer, hypersensitivity, etc.)
Patients who have penile prosthetic implants or shunts or any other surgical procedure on the penis
Patients who have taken drugs/medications that may induce priapism over the 14 weeks before trial
Medications injected directly into the penis to treat erectile dysfunction, such as alprostadil, papaverine, phentolamine, and others
Antidepressants, such as fluoxetine, bupropion, and sertraline
Alpha blockers including prazosin, terazosin, doxazosin, and tamsulosin
Medications used to treat anxiety or psychotic disorders, such as hydroxyzine, risperidone, olanzapine, lithium, clozapine, chlorpromazine, and thioridazine
Blood thinners, such as warfarin and heparin
Hormones such as testosterone or gonadotropin-releasing hormone
Medications used to treat attention-deficit/hyperactivity disorder (ADHD), such as atomoxetine (Strattera)
Alcohol, marijuana, cocaine and other illicit drug abuse can cause priapism
Not able to understand or comply with study instructions and requirements
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