Maximizing trEatment of Neurological Dysfunction Using INtravenous Guanfacine Study

NCT ID: NCT04742673

Last Updated: 2026-02-05

Basic Information

• Recruitment Status: COMPLETED
• Clinical Phase: PHASE2
• Total Enrollment: 46 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2021-05-04
• Study Completion Date: 2025-11-30

Brief Summary

This proof-of-concept study examines whether the acute brain dysfunction that occurs in critically ill patients is improved by administration of intravenous guanfacine.

Detailed Description

Delirium during critical illness is, to date, the primary potentially modifiable risk factor for acquired dementia after critical illness (ADRD). There are, however, no Food and Drug Administration (FDA) approved medications to mitigate delirium. Benzodiazepines are ineffective at reducing the incidence or duration of delirium, and on the contrary, increase the risk. Furthermore, large randomized controlled studies have shown that antipsychotic agents have no effect (vs. placebo) on delirium duration, mechanical ventilation, hospital length of stay, or death. Therefore, current clinical practice guidelines no longer recommend routine use of benzodiazepines or antipsychotics for treatment of delirium. Despite these recommendations, benzodiazepine, antipsychotics, and other drugs are routinely prescribed to critically ill patients due to the urgent clinical need to control delirium symptoms. The alpha-2 agonist dexmedetomidine is the most successful agent for delirium identified to date. However, it is typically administered as a continuous infusion and requires ICU-level monitoring due to hypotension and bradycardia risks. The delirium sparing benefits of dexmedetomidine have been postulated to result from alpha-2 agonist mediated modulation of CNS inflammation, microcirculatory blood flow, and biomimetic sleep.

The alpha-2 agonist guanfacine, an FDA-approved medication for use in hypertension and attention deficit hyperactivity disorder, has a higher selectivity for the alpha-2A receptor in the central nervous system. Thus, delirium sparing benefits may be improved with guanfacine while reducing systemic effects. Further, instead of a continuous infusion, the pharmacokinetic and pharmacodynamic properties of guanfacine favor a twice a day bolus dosing schedule. This Maximizing trEatment of Neurological Dysfunction using INtravenous Guanfacine (MENDING) study will investigate the benefits of intravenous (IV) guanfacine. In this phase II proof-of-concept trial of IV guanfacine vs. placebo for the treatment of critical illness delirium, the following specific aims will be tested in critically ill patients with delirium:

Aim 1: To determine whether IV guanfacine will increase the number of days alive without delirium and coma (DCFDs) over 14 days relative to placebo.

Aim 2: To evaluate whether IV guanfacine twice a day will increase days alive and free of mechanical ventilation (VFDs) and days alive and free of the ICU (IFDs) over 28 days relative to placebo.

Aim 3: To assess whether IV guanfacine can reduce the development of ADRD after critical illness.

Identifying a safe and effective treatment for delirium would have exponential benefits to patients, families, healthcare, and society. This first study of IV guanfacine builds upon extensive research regarding the benefits of alpha-2 agonists for brain dysfunction.

Conditions

Critical Illness; Delirium; Cognitive Impairment

Study Design

• Allocation Method: RANDOMIZED
• Intervention Model: PARALLEL
• Primary Study Purpose: TREATMENT
• Blinding Strategy: QUADRUPLE

Study Groups

Placebo

Participants will flow through the trial in the following manner:

1. Consent in ICU: perform required inclusion/exclusion assessments; discuss study goals, activities, and requirements; obtain informed consent

2. Pre-randomization phase: twice daily assessments of mental status

3. Randomize delirious patients: IV guanfacine or placebo

4. Interventional Trial phase: study drug administration, mental status assessments, safety monitoring

5. Blood draws: collect blood samples on Interventional Trial Phase days 1 and 2

6. Follow-up assessments: telephone and online questionnaires at 30, 90, and 180 days after hospital discharge.

Group Type: PLACEBO_COMPARATOR

Placebo

Intervention Type: DRUG

Patients randomized to the placebo arm will receive intravenous normal saline when they exhibit ICU delirium.

IV Guanfacine

Participants will flow through the trial in the following manner:

1. Consent in ICU: perform required inclusion/exclusion assessments; discuss study goals, activities, and requirements; obtain informed consent

2. Pre-randomization phase: twice daily assessments of mental status

3. Randomize delirious patients: IV guanfacine or placebo

4. Interventional Trial phase: study drug administration, mental status assessments, safety monitoring

5. Blood draws: collect blood samples on Interventional Trial Phase days 1 and 2

6. Follow-up assessments: telephone and online questionnaires at 30, 90, and 180 days after hospital discharge.

Group Type: EXPERIMENTAL

Guanfacine

Intervention Type: DRUG

Patients randomized to the IV Guanfacine arm will receive intravenous guanfacine when they exhibit ICU delirium.

Interventions

Guanfacine

Patients randomized to the IV Guanfacine arm will receive intravenous guanfacine when they exhibit ICU delirium.

Intervention Type: DRUG

Placebo

Patients randomized to the placebo arm will receive intravenous normal saline when they exhibit ICU delirium.

Intervention Type: DRUG

Eligibility Criteria

Inclusion Criteria

1. adult patients (≥ 18 years old)

2. requiring admission to an ICU

3. for treatment of respiratory failure (e.g., mechanical ventilation, non-invasive positive pressure ventilation [NIPPV], Extracorporeal Membrane Oxygenation [ECMO], optiflow) and/or for treatment of shock (e.g., vasopressors, ECMO, intra-aortic balloon pump [IABP]).

13. Cardiac surgery within the current hospitalization.

Exclusion Criteria

1. allergic to guanfacine, clonidine, or dexmedetomidine

2. on home antipsychotics who, therefore, require continuing antipsychotic administration in the hospital

3. present history of 2nd or 3rd degree heart block, or persistent bradycardia < 50 beats/minute that requires intervention (e.g., atropine, glycopyrrolate). If patient has a pacemaker for bradyarrythmias, then patient does not meet this exclusion criterion and may be enrolled.

4. co-enrolled in another interventional trial examining similar outcomes or in a study that does not allow co-enrollment

5. expected death within 24 hours of enrollment or lack of commitment to aggressive treatment by family or the medical team (e.g., likely withdrawal of life support measures within 24 hours of screening)

6. acute or subacute neurologic deficit that is expected to make the patient incapable of living independently after hospital discharge due to cognitive deficits (e.g., stroke, intracranial hemorrhage, cranial trauma, intracranial malignancy, anoxic brain injury, cerebral edema).

7. dementia or other chronic neurologic disease or disorder that makes the patient incapable of living independently at baseline

8. active substance abuse, psychotic disorder, or homelessness without a secondary contact person (which would make long-term follow-up difficult)

9. blindness or deafness (which would prevent assessment of the study's outcomes)

10. pregnancy or breastfeeding

11. prisoner

• Minimum Eligible Age: 18 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

Massachusetts General Hospital

OTHER

Sponsor Role: collaborator

National Institute on Aging (NIA)

NIH

Sponsor Role: collaborator

Vanderbilt University Medical Center

OTHER

Sponsor Role: lead

Responsible Party

Christopher G Hughes

Professor of Anesthesiology

Responsibility Role: PRINCIPAL_INVESTIGATOR

Principal Investigators

Christopher Hughes, MD

Role: PRINCIPAL_INVESTIGATOR

Vanderbilt University Medical Center

Locations

Vanderbilt University Medical Center

Nashville, Tennessee, United States

Countries

United States

References

Arnsten AFT, Ishizawa Y, Xie Z. Scientific rationale for the use of alpha2A-adrenoceptor agonists in treating neuroinflammatory cognitive disorders. Mol Psychiatry. 2023 Nov;28(11):4540-4552. doi: 10.1038/s41380-023-02057-4. Epub 2023 Apr 7.

Reference Type: DERIVED

PMID: 37029295 (View on PubMed)

Provided Documents

Document Type: Study Protocol and Statistical Analysis Plan

View Document

Other Identifiers

3R01AG053582-05S1

Identifier Type: NIH

Identifier Source: secondary_id

View Link

U11543

Identifier Type: -

Identifier Source: org_study_id