Multiple N-of-1 Trials of (Intermittent) Hypoxia Therapy in Parkinson's Disease
- Conditions
- Parkinson DiseaseEffect of Drug
- Interventions
- Drug: Hypoxic Gas Mixture
- Registration Number
- NCT05214287
- Lead Sponsor
- Radboud University Medical Center
- Brief Summary
In recent years, mitochondrial dysfunction and oxidative stress have been implicated in PD pathophysiology. Intermittent hypoxia therapy (IHT) is an upcoming treatment used by elite athletes as well as fragile individuals in clinical settings that works by improving exercise tolerance, neuroplasticity and inducing hypoxic preconditioning (HPC). HPC might improve the oxidative stress response in PD on the long-term. In addition, preclinical evidence suggests beneficial short-term effects such as influence on dopamine and noradrenalin release. Anecdotal evidence indeed suggests that visiting high-altitude areas improves PD symptoms and it is hypothesized that this effect results from decreased oxygen pressure at high altitudes. The safety and feasibility of (intermittent) hypoxia therapy on PD symptoms will be assessed in an exploratory phase I randomized-controlled trial.
- Detailed Description
Parkinson's disease (PD) currently affects 10 million people worldwide and its prevalence is projected to exponentially rise further in the absence of disease-modifying therapies. A scarcity of symptomatic treatments is available and the mainstay of therapy has been levodopa for over half a century. Although this treatment suffices for many patients in early phases of PD, treatment burden is significant, as are the adverse effects, wearing-off and dyskinesia that develop with disease progression. Therefore, additional treatment modalities are needed.
Preclinical studies have suggested that moderate hypoxia provokes release of survival-enhancing neurotransmitters, such as dopamine release from the substantia nigra. Clinical and preclinical evidence suggests the effects of hypoxia seem especially robust when applied using intermittent hypoxia therapy (IHT) compared to continuous hypoxia. IHT means that hypoxia is present for relatively short periods (i.e. minutes), interspersed with short periods of recovery at normoxia (i.e. sea-level). The precise working mechanism of IHT on the short term remains unclear, but the immediate clinical effects appear to be related to augmented dopamine release from the substantia nigra. Specifically, IHT may improve parkinsonian symptoms via activation of the Hypoxia Inducible Factor 1 (HIF-1) pathway, which in turn activates tyrosine hydroxylase (TH), which is the main rate-limiting enzyme in the production of dopamine. Several studies have demonstrated that HIF-1 stabilization leads to an increase in TH production, and consequently a rise in cellular dopamine content. IHT is a therapy proven safe and effective in a variety of disciplines, including fragile populations such as individuals with chronic obstructive pulmonary disorder (COPD), cardiac morbidity and spinal cord injury. Long-term application of IHT protocols was associated with improved oxidative stress response and adaptive plasticity in the dopaminergic system of rodents, suggesting that in addition to the acute symptomatic effects, repeated exposure to (intermittent) hypoxia might also exert some long-term neuroprotective effects. The general concept behind a possible (long-term) neuroprotective effect of IHT is the phenomenon of hypoxic conditioning: induction of a sub-toxic hypoxic stimulus to improve the (systemic) tolerance of cells and tissues to subsequent more severe stimuli, either in dose or duration. In this way, key adaptive mechanisms are induced that allow maintenance of cellular homeostasis under low-oxygen conditions. Among these adaptive mechanisms, activation of HIF-1 is the most prominent and most extensively described mechanism. Interestingly, IHT protocols also blocked the neurotoxic effect of agents that induce PD in rodents, preventing development of locomotor deficits, again suggesting some neuroprotective effects. Furthermore, circumstantial anecdotal evidence from individuals with PD suggests that ascending to high-altitude areas (e.g. on holidays) improves motor symptoms of PD, which the investigators recently confirmed in a survey conducted in the holiday context (https://doi.org/10.1002/mdc3.13597). The investigators hypothesize that the positive effect of altitude on the symptoms of PD result from decreased oxygen pressure at high altitude, which serves as an acute bodily stressor that releases survival-enhancing neurotransmitters such as dopamine and noradrenaline and might induce neuroprotective mechanisms.
The investigators will assess the potential of IHT in PD by assessing symptomatic effects of intermittent hypoxia therapy in an exploratory phase I trial. Primary objectives are the safety and feasibility of intermittent hypoxia in PD and assessing the responsiveness of subjective and standardized symptom scales to this intervention. This trial will exploit an aggregated N-of-1 approach, which allows testing multiple high-altitude simulation protocols and outcome measures, analysis of the treatment effect in individuals as it can account for random variation for treatment effects in the individual and enhances methodological power due to repeated treatment pairs.
During a screening procedure, participants undergo pulmonary function testing, carbon monoxide diffusion capacity testing and electrocardiography. If no cardiorespiratory abnormalities are demonstrated, individuals undergo a hypoxic intervention with gradually decreasing FiO2 levels from room air to either FiO2 0.127 or an arterial oxygen saturation (SaO2) of 80%, under vital parameter and blood gas monitoring. If a participant reaches FiO2 0.127 without SaO2 \<80%, the most intense active interventions will contain that FiO2. If a participant has an SaO2 \<80% before FiO2 0.127 is reached but still has an SaO2 of 80% or higher at FiO2 0.133, the most intense active intervention will be FiO2 0.133 instead of 0.127 (see Interventions)
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 29
Not provided
Not provided
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- CROSSOVER
- Arm && Interventions
Group Intervention Description Intermittent with 5x5-minutes, FiO2 0.127 or 0.133 Hypoxic Gas Mixture Delivered intermittently, with FiO2 0.127 or 0.133 (depending on SaO2 during screening procedure at FiO2 0.127, see study procedures) and room-air, each 5 minutes, for 5 cycles/session Continuous for 45 minutes, FiO2 0.163 Hypoxic Gas Mixture Delivered via the hypoxicator Intermittent with 5x5-minutes, FiO2 0.163 Hypoxic Gas Mixture Delivered intermittently, with FiO2 0.163 and room-air, each 5 minutes, for 5 cycles/session Continuous for 45 minutes, FiO2 0.127 or 0.133 Hypoxic Gas Mixture FiO2 0.127 or 0.133 (depending on SaO2 during screening procedure at FiO2 0.127, see study procedures) Continuous for 45 minutes, FiO2 0.209 Hypoxic Gas Mixture Delivered via an open three-way valve in the circuitry from hypoxicator to the participant
- Primary Outcome Measures
Name Time Method Heartrate Baseline and every 5 mins until 30 mins post-intervention Beats/min
Nature and number of adverse events Until 3 days post-intervention Actively reported during intervention and passively for up to 3 days after the intervention, adverse events will be collected.
Oxygen saturation Baseline and every 5 mins until 30 mins post-intervention Percentage
Self-reported dizziness, discomfort and stress on a ten-point scale Until 3 days post-intervention Every 10 minutes up to one hour post-intervention, one time next morning post-intervention, 10-point Likert scale, lower is better.
Blood pressure Baseline and every 5 mins until 30 mins post-intervention Systolic and diastolic blood pressure
Respiratory rate Baseline and every 5 mins until 30 mins post-intervention Breaths/min
Feasibility questionnaire After 1st, 5th, 10th post-intervention test 17-item scale, scored 1-10, lower is better. Subscores and total score
- Secondary Outcome Measures
Name Time Method Participant-selected motor symptom Directly after, as well as 30 and 60 minutes after the intervention and four times once every hour after that. In addition, these will be measured once every morning (i.e. in OFF) for the next three mornings after the intervention. Change from (pre-treatment) baseline in the symptom that improved most during previous positive altitude effect (if applicable), or other symptom of choice. Self-reported severity scores on a Likert-scale. 10-point Likert scale allowing half points. Lower is better.
Accelerometry during MDS-UPDRS part III, items on pronation-supination and tremor 30 minutes During the MDS-UPDRS part III, accelerometry allows for quantification of therapeutic effects in addition to the MDS-UPDRS part III. Lower amplitude is better in tremor, higher frequency and rotational power is better in pronation-supination. Change from (pre-treatment) baseline.
Modified Purdue pegboard test 30 minutes Change from (pre-treatment) baseline in number of pins per side. The Purdue pegboard test is primarily a measure of bradykinesia, hypokinesia and fine motor skills. Higher is better.
General impression of PD symptoms Directly after, as well as 30 and 60 minutes after the intervention and four times once every hour after that. In addition, these will be measured once every morning (i.e. in OFF) for the next three mornings after the intervention. Change from (pre-treatment) baseline on 10-point Likert scale allowing half points. Lower is better.
Heart Rate Variability (HRV) 30 minutes Average HRV during intervention and post intervention. HRV is a marker of cardiovascular stress. Change form (pre-treatment) baseline. Lower equals more stress.
Urge to take dopaminergic medication Directly after, as well as 30 and 60 minutes after the intervention and four times once every hour after that. In addition, these will be measured once every morning (i.e. in OFF) for the next three mornings after the intervention. Change from (pre-treatment) baseline on 10-point Likert scale allowing half points. Lower is better.
Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS) part III 30 minutes The MDS-UPDRS part III is the gold standard for motor assessment in Parkinson's disease. Change form (pre-treatment) baseline in item subscores and total scores. Lower is better.
Finger tapping 30 minutes Change from (pre-treatment) baseline in number of taps during 10-second trials on both hands, one session each. Finger tapping is considered a measure of bradykinesia. Higher is better.
MDS Non-Motor Symptoms Scale (only items related to stress, fatigue, mood, anxiety, pain) 30 minutes The most important potentially adaptive non-motor symptoms mentioned in this gold standard for non-motor symptom screening are selected. Likert scale 1-10 (allowing half points). Change from (pre-treatment) baseline. Lower is better.
Timed Up & Go Test 30 minutes Change from (pre-treatment) baseline in total time and steps. The Timed Up \& Go Test is a test that evaluates primarily gait functioning. Lower is better.
MiniBESTest 30 minutes Change from (pre-treatment) baseline in item subscores and total score. The MiniBESTest is a concise balance test. Higher is better.
Trial Locations
- Locations (1)
Dpt. of Physiology, Radboud University Medical Center
🇳🇱Nijmegen, Netherlands