Administration of Intranasal Midazolam for Anxiety in Palliative Care

Phase 2RecruitingNCT06330584

Insel Gruppe AG, University Hospital Bern36 enrolled

Overview

The goal of this double-blind, randomized, placebo-controlled parallel-group multicenter exploratory pilot study (three study arms) is to describe effects and safety of different doses of intranasal midazolam to treat acute anxiety in palliative care patients, while providing pharmacokinetic and pharmacodynamic data.

36 patients (12 per study arm) will be enrolled. All patients hospitalized at the four study sites, which are prescribed intranasal midazolam in their as-needed drug regimen and who meet inclusion criteria, are eligible. Patients will be asked for consent at the time of prescription of midazolam by the attending physician. Patients who have provided consent and have been randomized to one of the arms will be included (block randomization). In a nested analysis, pharmacokinetic properties of all three doses will be analyzed in participants with available venous access. The primary outcome is the change in patient-reported levels of anxiety from baseline. Secondary outcomes include time until first requested additional dose, cumulative number of doses including time points of administration after the first application, oxygen saturation, heart rate, cortisol levels in oral fluid, levels of sedation on the Richmond Agitation Sedation Scale Palliative Version (RASS-PAL), and occurrence of (serious) adverse events. The primary and secondary outcomes will be assessed at baseline, i.e., immediately before the intervention (0 minutes) and 30 minutes after the intervention. The secondary outcomes 'Time to first requested additional dose' and 'Cumulative number of doses over 24 hours' as well as (serious) adverse events will be assessed starting 30 minutes after the intervention up to 24 hours after the intervention. In patients included in the nested pharmacokinetic analysis, basic pharmacokinetic parameters will additionally be assessed at 10 time points, starting at baseline (0 minutes) up to 240 minutes after the intervention.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

TREATMENT

Masking

QUADRUPLE

Enrollment

Conditions

Anxiety Acute Anxiety Palliative Care

Interventions

Placebo Nasal Spray 0 mg/sprayDRUG

A unit-dose nasal spray will be used for the intervention. 1 spray (= 0.1 μl = 0 mg midazolam/spray) in each nostril, i.e., no active compound

Midazolam Nasal Spray 0.45 mg/sprayDRUG

A unit-dose nasal spray will be used for the intervention. 1 spray (= 0.1 μl = 0.45 mg midazolam/spray) in each nostril, i.e., total dose of midazolam 0.9 mg

Midazolam Nasal Spray 0.9 mg/sprayDRUG

A unit-dose nasal spray will be used for the intervention. 1 spray (= 0.1 μl = 0.9 mg midazolam/spray) in each nostril, i.e., total dose of midazolam 1.8 mg

Eligibility

Sex: ALLMin age: 18 Years

Medical Language ↔ Plain English

Inclusion Criteria: * Adult palliative care patients (≥ 18 years) hospitalized at one of the study sites * Self-reported acute anxiety with clinical indication for intranasal midazolam administration according to attending physician * Patient willing and able to provide written informed consent * Informed consent as documented by signature * Patient willing and able to complete anxiety assessment * Additionally for nested pharmacokinetic analysis: Patients with available central or peripheral venous access, i.e., peripheral venous catheter (PVC), central venous catheter (CVC), peripherally inserted central venous catheter (PICC) line, midline catheter, or PORT-A-CATH® (PAC), and patient willing and able to provide blood samples Exclusion Criteria: * Intranasal midazolam prescribed for seizures * Midazolam (any route of administration) prescribed and administered for continuous sedation * History of allergy or hypersensitivity to midazolam * History of benzodiazepine-related paradoxical reaction to midazolam * Acute narrow-angle glaucoma * Impaired nasal absorption (e.g., nasogastric tube, nasal obstruction, nasal polyps, etc.) * Intranasal midazolam within 24 h before study enrollment * Time between informed general consent for study participation through investigators and planned midazolam administration \< 24 h * Co-medication with strong CYP3A4 inducers or inhibitors according to pre-defined list (FDA) * Recently initiated therapy with strong opioids (i.e., within past 5 days) * Co-medication with other CNS depressants causing clinically relevant degree of sedation * Inability to follow the procedures of the study (i.e., provision of Informed Consent, completion of assessment tool, e.g., due to language problems or dementia)

Locations (5)

Palliativzentrum Bethesda Spital

Basel, Canton of Basel-City, Switzerland

RECRUITING

Inselspital, Universitätsspital Bern

Bern, Switzerland

NOT_YET_RECRUITING

Universitäres Zentrum für Palliative Care (UZP)

Bern, Switzerland

Outcomes

Primary Outcomes

Change from baseline in anxiety levels, measured by Visual Analogue Scale (VAS) and quantified by Numerical Rating Scale (NRS)

Patient-reported levels of anxiety, measured by VAS (0-100 mm, from left 'no anxiety at all' to right 'worst possible anxiety') at baseline (0 minutes) and 30 minutes after study drug or placebo administration. The VAS response will be quantified measuring the distance in mm from zero to the position of the VAS response on a ruler (=100 mm, separated by 1 mm intervals), with 0 mm representing absence of anxiety, and 100 mm representing maximal possible anxiety.