Delirium
Conditions
Keywords
delirium, melatonin, pharmacokinetics, feasibility, prevention
Brief summary
The purpose of this study is to determine the feasibility of conducting a randomized controlled trial (RCT) with melatonin for prevention of delirium in critically ill adult patients. The investigators hypothesize that melatonin, administered on a scheduled nightly basis during ICU admission, will be efficacious and safe for the prevention of delirium in critically ill adults.
Detailed description
The available evidence indicates melatonin may decrease the incidence of delirium in non-critically ill patient populations; however, trials in the critically ill are lacking. The investigators hypothesize that melatonin, administered on a scheduled nightly basis during ICU admission, will be efficacious and safe for the prevention of delirium in critically ill adults. The null hypothesis is that there is no difference in delirium incidence between placebo and melatonin. Prior to conducting an adequately powered multi-centre, blinded randomized, placebo-controlled trial in critically ill patients, there is a need for a better understanding of melatonin pharmacokinetics (PK) in critically ill patients. This will help to determine appropriate dosing, drug administration issues (specifically protocol adherence), adverse drug effects, and recruitment rates based on inclusion and exclusion criteria. The specific aim is to conduct a phase II triple blind, placebo-controlled randomized trial comparing two doses of melatonin (low dose = 0.5 mg and high dose = 2.0 mg) to assess the feasibility of a future full-scale RCT. Feasibility of the larger trial will be based on protocol adherence and participant recruitment rates. Data on PK properties of melatonin will be assessed to determine dosing for future studies of melatonin for delirium prevention in the critically ill.
Interventions
DRUGMelatonin
Study drug will be given at 21:00 - 23:59 daily, starting on the day of enrolment until ICU discharge, death, or up to 14 days, as most critically ill patients are at greatest risk of delirium in the first two weeks of admission. The study medication will be given by mouth (PO or per os) or if needed, via the feeding tube followed by a flush with 20mL water. Doses can be given up to midnight if administration needs to be delayed for procedures or investigations.
DRUGPlacebo
Study drug will be given at 21:00 - 23:59 daily, starting on the day of enrolment until ICU discharge, death, or up to 14 days, as most critically ill patients are at greatest risk of delirium in the first two weeks of admission. The study medication will be given by mouth (PO or per os) or if needed, via the feeding tube followed by a flush with 20mL water. Doses can be given up to midnight if administration needs to be delayed for procedures or investigations.
Sponsors
Sunnybrook Health Sciences Centre
Centre Integre Universitaire de Sante et Services Sociaux du Nord de l'ile de Montreal
Mount Sinai Hospital, Canada
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
PREVENTION
Masking
QUADRUPLE (Subject, Caregiver, Investigator, Outcomes Assessor)
Masking description
All study personnel, patients, and their families will remain blinded. Treatment allocation will only be known to the clinical trials pharmacist, who will perform subject randomization.
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1. Critically ill patients ≥18 years of age 2. Anticipated ICU stay of \>48 hours 3. Able to receive enteral administration of study drug (i.e. by mouth or any feeding tube = naso- or oro- or percutaneous gastric or post-pyloric feeding tube) 4. Consent to participate.
Exclusion criteria
1. ICU admission of \>48 hours prior to screening 2. Unable to assess for delirium (e.g. comatose defined as SAS 1 or 2 or either 'No Response' Score A or B on ICDSC, chemically paralyzed with neuromuscular blocking drugs) 3. Screened delirium positive prior to randomization (ICDSC score ≥4 out of 8) 4. Anticipated withdrawal in next 48 hours 5. Known history of severe cognitive or neurodegenerative disease (e.g. dementia, Parkinson's disease) or severe structural brain injury (e.g. traumatic brain injury, intracranial hemorrhage) as the ICDSC assessment tool has not been validated in these patient populations 6. Unable to communicate in English or French (Montreal site) 7. Contraindications to receiving any enteral medication (defined as absolute contraindication to enteral nutrition such as gastrointestinal obstruction, perforation, recent upper GI surgery, no enteral access) 8. Active seizures 9. Known pregnancy 10. Legal blindness 11. Known allergy to melatonin
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Feasibility: Study adherence | 1 year | Investigators will calculate protocol adherence as the overall proportion of administered doses in the prescribed dose administration window (between 21:00 and to 23:59 hours) divided by total number of eligible study days. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Feasibility: Time in motion (minutes) | 1 year | Research coordinators at each site will capture the amount of time (minutes) taken to screen, consent, and enrol patients, complete study procedures, and collect data. |
| Pharmacokinetic: Peak melatonin concentration (Cmax) | 24 hours | Peak melatonin concentration. Plasma melatonin concentrations measured by mass spectrometry. N=5 from each study arm of Mount Sinai Hospital site. On study day 1, eight blood samples (4 mL each) will be collected at the following intervals, from the time of first study drug dose to the following morning (time 0, 0.5, 1, 2, 4, 6, 8, 12 hours). |
| Pharmacokinetic: Time of peak melatonin concentration (Tmax) | 24 hours | Time of peak melatonin concentration (Tmax). Plasma melatonin concentrations measured by mass spectrometry. N=5 from each study arm of Mount Sinai Hospital site. On study day 1, eight blood samples (4 mL each) will be collected at the following intervals, from the time of first study drug dose to the following morning (time 0, 0.5, 1, 2, 4, 6, 8, 12 hours). |
| Pharmacokinetic: Morning melatonin concentration (C9AM) | 24 hours | Morning melatonin concentration (C9AM). Plasma melatonin concentrations measured by mass spectrometry. N=5 from each study arm of Mount Sinai Hospital site. On study day 1, eight blood samples (4 mL each) will be collected at the following intervals, from the time of first study drug dose to the following morning (time 0, 0.5, 1, 2, 4, 6, 8, 12 hours). |
| Pharmacokinetic: Melatonin half-life (T½) | 24 hours | Melatonin half-life (T½). Plasma melatonin concentrations measured by mass spectrometry. N=5 from each study arm of Mount Sinai Hospital site. On study day 1, eight blood samples (4 mL each) will be collected at the following intervals, from the time of first study drug dose to the following morning (time 0, 0.5, 1, 2, 4, 6, 8, 12 hours). |
| Pharmacokinetic: Mean apparent clearance (CL/F) | 24 hours | Mean apparent clearance (CL/F). Plasma melatonin concentrations measured by mass spectrometry. N=5 from each study arm of Mount Sinai Hospital site. On study day 1, eight blood samples (4 mL each) will be collected at the following intervals, from the time of first study drug dose to the following morning (time 0, 0.5, 1, 2, 4, 6, 8, 12 hours). |
| Pharmacokinetic: Mean apparent volume distribution (V/F) | 24 hours | Mean apparent volume distribution (V/F). Plasma melatonin concentrations measured by mass spectrometry. N=5 from each study arm of Mount Sinai Hospital site. On study day 1, eight blood samples (4 mL each) will be collected at the following intervals, from the time of first study drug dose to the following morning (time 0, 0.5, 1, 2, 4, 6, 8, 12 hours). |
| Pharmacokinetic: Area under the concentration-time curve (AUC) | 24 hours | Area under the concentration-time curve (AUC). Plasma melatonin concentrations measured by mass spectrometry. N=5 from each study arm of Mount Sinai Hospital site. On study day 1, eight blood samples (4 mL each) will be collected at the following intervals, from the time of first study drug dose to the following morning (time 0, 0.5, 1, 2, 4, 6, 8, 12 hours). |
| Feasibility: Trial recruitment | 1 year | Proportion of ICU patients screened that meet study inclusion criteria, the number of patients excluded and reasons for exclusion, and the consent rate of eligible participants. |
| Clinical: Delirium incidence | 14 days | Intensive Care Delirium Screening Checklist (ICDSC) administered daily. Delirium defined as an ICDSC score ≥4. |
| Clinical: Delirium time to onset and duration (days) | 14 days | Time to onset of first ICDSC score ≥4, and number of days with ICDSC score ≥4. |
| Clinical: Sleep | 14 days | Richards Campbell Sleep Questionnaire (RCSQ) administered daily, where possible. Patients with or without the assistance of their nurse will be asked to complete the questions of the RCSQ each morning. Nurses will not complete the RCSQ if the patient is unable to verbalize, as poor correlation has been shown between patient and nursing scores. |
| Clinical: Duration of mechanical ventilation | ICU admission | Duration of mechanical ventilation (days) |
| Clinical: ICU length of stay | ICU admission | Duration of stay for index ICU admission (days) |
| Clinical: Hospital length of stay | 1 year | Duration of stay for admission involving trial enrolment (days) |
| Clinical: ICU mortality | 1 year | Number of deaths during index ICU admission |
| Clinical: Hospital mortality | 1 year | Number of deaths during hospital admission |
| Clinical: Adverse events | 14 days | Adverse events reported by the participant, family, or treating team. The following potential adverse effects will be collected: morning drowsiness (Sedation Agitation Scale (SAS) score \<3 or patient's self report of drowsiness between 07:00h and 12:00h), headache, and vivid dreams. |
Countries
Canada
Contacts
Primary ContactLisa Burry, PharmD
Backup ContactLouise Rose
Outcome results
None listed