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Gladwin MT, Gordeuk VR, Desai PC, Minniti C, Novelli EM, Morris CR, Ataga KI, De Castro L, Curtis SA, El Rassi F, Ford HJ, Harrington T, Klings ES, Lanzkron S, Liles D, Little J, Nero A, Smith W, Taylor JG, Baptiste A, Hagar W, Kanter J, Kinzie A, Martin T, Rafique A, Telen MJ, Lalama CM, Kato GJ, Abebe KZ. Riociguat in patients with sickle cell disease and hypertension or proteinuria (STERIO-SCD): a randomised, double-blind, placebo controlled, phase 1-2 trial. Lancet Haematol 2024; 11:e345-e357. [PMID: 38554715 DOI: 10.1016/s2352-3026(24)00045-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Although nitric oxide based therapeutics have been shown in preclinical models to reduce vaso-occlusive events and improve cardiovascular function, a clinical trial of a phosphodiesterase 5 inhibitor increased rates of admission to hospital for pain. We aimed to examine if riociguat, a direct stimulator of the nitric oxide receptor soluble guanylate cyclase, causes similar increases in vaso-occlusive events. METHODS This was a phase 1-2, randomised, double blind, placebo-controlled trial. Eligible patients were 18 years or older, had confirmed sickle cell disease documented by haemoglobin electrophoresis or HPLC fractionation (haemoglobin SS, SC, Sβ-thalassemia, SD, or SO-Arab), and stage 1 hypertension or proteinuria. Participants were randomly assigned 1:1 to receive either riociguat or matching placebo via a web-based system to maintain allocation concealment. Both treatments were administered orally starting at 1·0 mg three times a day up to 2·5 mg three times a day (highest tolerated dose) for 12 weeks. Dose escalation by 0·5 mg was considered every 2 weeks if systolic blood pressure was greater than 95 mm Hg and the participant had no signs of hypotension; otherwise, the last dose was maintained. The primary outcome was the proportion of participants who had at least one adjudicated treatment-emergent serious adverse event. The analysis was performed by the intention-to-treat. This trial is registered with ClinicalTrials.gov (NCT02633397) and was completed. FINDINGS Between April 11, 2017, and Dec 31, 2021, 165 participants were screened and consented to be enrolled into the study. Of these, 130 participants were randomly assigned to either riociguat (n=66) or placebo (n=64). The proportion of participants with at least one treatment-emergent serious adverse event was 22·7% (n=15) in the riociguat group and 31·3% (n=20) in the placebo group (difference -8·5% [90% CI -21·4 to 4·5]; p=0·19). A similar pattern emerged in other key safety outcomes, sickle cell related vaso-occlusive events (16·7 [n=11] vs 21·9% [n=14]; difference -5·2% [-17·2 to 6·5]; p=0·42), mean pain severity (3·18 vs 3·32; adjusted mean difference -0·14 [-0·70 to 0·42]; p=0·69), and pain interference (3·15 vs 3·12; 0·04 [-0·62 to 0·69]; p=0·93) at 12 weeks were similar between groups. Regarding the key clinical efficacy endpoints, participants taking riociguat had a blood pressure of -8·20 mm Hg (-10·48 to -5·91) compared with -1·24 (-3·58 to 1·10) in those taking placebo (-6·96 mm Hg (90% CI -10·22 to -3·69; p<0·001). INTERPRETATION Riociguat was safe and had a significant haemodynamic effect on systemic blood pressure. The results of this study provide measures of effect and variability that will inform power calculations for future trials. FUNDING Bayer Pharmaceuticals.
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Affiliation(s)
- Mark T Gladwin
- University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Victor R Gordeuk
- Division of Hematology and Oncology, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Payal C Desai
- Levine Cancer Institute, Atrium Health, Wake Forest School of Medicine, Charlotte, NC, USA
| | | | - Enrico M Novelli
- Department of Medicine, Division of Hematology and Oncology, and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Claudia R Morris
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatric Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kenneth I Ataga
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Laura De Castro
- Department of Medicine, Division of Hematology and Oncology, and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Fuad El Rassi
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA; Georgia Comprehensive Sickle Cell Clinic at Grady Health System, Atlanta, GA, USA
| | - Hubert James Ford
- Pulmonary Hypertension Program, Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Thomas Harrington
- Division of Hematology, Department of Medicine, University of Miami, Miami, FL, USA
| | - Elizabeth S Klings
- The Pulmonary Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Sophie Lanzkron
- Sickle Cell Center for Adults, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Darla Liles
- Brody School of Medicine East Carolina University, Greenville, NC, USA
| | - Jane Little
- University of North Carolina Comprehensive Sickle Cell Disease Program and Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alecia Nero
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Wally Smith
- Division of General Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - James G Taylor
- Center for Sickle Cell Disease, Departments of Medicine (Hematology and Oncology) and Microbiology and Immunology, Howard University College of Medicine, Washington, DC, USA; Department of Food and Human Nutrition Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Ayanna Baptiste
- Department of Medicine, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Ward Hagar
- Internal Medicine, Department of Pediatrics, University of California San Francisco, Benioff Children's Hospital Oakland, Oakland, CA, USA
| | - Julie Kanter
- Hematology Oncology, Department of Internal Medicine, University of Alabama Birmingham, Birmingham, AL, USA
| | - Amy Kinzie
- Sickle Cell Center of Southern Louisiana, Tulane University School of Medicine, New Orleans, LA, USA
| | - Temeia Martin
- Medical University of South Carolina, Charleston, SC, USA
| | - Amina Rafique
- Sickle Cell Center of Southern Louisiana, Tulane University School of Medicine, New Orleans, LA, USA
| | - Marilyn J Telen
- Division of Hematology, Department of Medicine, Duke University School of Medicine, and Duke Comprehensive Sickle Cell Center, Durham, NC, USA
| | - Christina M Lalama
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Center for Clinical Trials & Data Coordination, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gregory J Kato
- Department of Medicine, Division of Hematology and Oncology, and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kaleab Z Abebe
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Center for Clinical Trials & Data Coordination, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Seeman T, Šuláková T, Stabouli S. Masked Hypertension in Healthy Children and Adolescents: Who Should Be Screened? Curr Hypertens Rep 2023; 25:231-242. [PMID: 37639176 PMCID: PMC10491704 DOI: 10.1007/s11906-023-01260-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 08/29/2023]
Abstract
PURPOSE OF REVIEW The goal is to review masked hypertension (MH) as a relatively new phenomenon when patients have normal office BP but elevated out-of-office BP. Firstly, it was described in children in 2004. It has received increased attention in the past decade. RECENT FINDINGS The prevalence of MH in different pediatric populations differs widely between 0 and 60% based on the population studied, definition of MH, or method of out-of-office BP measurement. The highest prevalence of MH has been demonstrated in children with chronic kidney disease (CKD), obesity, diabetes, and after heart transplantation. In healthy children but with risk factors for hypertension such as prematurity, overweight/obesity, diabetes, chronic kidney disease, or positive family history of hypertension, the prevalence of MH is 9%. In healthy children without risk factors for hypertension, the prevalence of MH is very low ranging 0-3%. In healthy children, only patients with the following clinical conditions should be screened for MH: high-normal/elevated office BP, positive family history of hypertension, and those referred for suspected hypertension who have normal office BP in the secondary/tertiary center.
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Affiliation(s)
- Tomáš Seeman
- Department of Pediatrics, Charles University Prague, 2nd Medical Faculty, V Úvalu 84, 15006, Prague, Czech Republic.
- Department of Pediatrics, University Hospital Ostrava, Ostrava, Czech Republic.
| | - Terezie Šuláková
- Department of Pediatrics, University Hospital Ostrava, Ostrava, Czech Republic
- Department of Pediatrics, Medical Faculty, University of Ostrava, Ostrava, Czech Republic
| | - Stella Stabouli
- 1st Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University Thessaloniki, Hippokratio Hospital, Thessaloniki, Greece
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