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    Clinical Trial Results:
    Hellenic Anglo Research into Morning Or Night antihypertensive drug deliverY trial.

    Summary
    EudraCT number
    2011-004192-37
    Trial protocol
    GB  
    Global end of trial date
    31 Oct 2016

    Results information
    Results version number
    v1(current)
    This version publication date
    14 May 2017
    First version publication date
    14 May 2017
    Other versions

    Trial information

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    Trial identification
    Sponsor protocol code
    CRO1749
    Additional study identifiers
    ISRCTN number
    -
    US NCT number
    NCT01669928
    WHO universal trial number (UTN)
    -
    Sponsors
    Sponsor organisation name
    Joint Research Compliance Office, Imperial College London
    Sponsor organisation address
    Room 221, Medical school Building, St Mary's Campus, Norfolk Place, London, United Kingdom, W2 1PG
    Public contact
    Professor Neil Poulter, Imperial College London, +44 20 7594 3446, n.poulter@imperial.ac.uk
    Scientific contact
    Professor Neil Poulter, Imperial College London, +44 20 7594 3446, n.poulter@imperial.ac.uk
    Paediatric regulatory details
    Is trial part of an agreed paediatric investigation plan (PIP)
    No
    Does article 45 of REGULATION (EC) No 1901/2006 apply to this trial?
    No
    Does article 46 of REGULATION (EC) No 1901/2006 apply to this trial?
    No
    Results analysis stage
    Analysis stage
    Final
    Date of interim/final analysis
    11 Apr 2016
    Is this the analysis of the primary completion data?
    Yes
    Primary completion date
    11 Apr 2016
    Global end of trial reached?
    Yes
    Global end of trial date
    31 Oct 2016
    Was the trial ended prematurely?
    No
    General information about the trial
    Main objective of the trial
    To detect if there is a 3mm Hg difference in average 24 hour systolic blood pressure when blood pressure lowering medications are taken in the evening compared with same medications taken in the morning.
    Protection of trial subjects
    No measures were required to be put into place as patients were on their usual blood pressure medications with the only change being the time of day (morning or evening) the medication should be taken.
    Background therapy
    All study recruits continued on whatever drug therapy and lifestyle manoeuvres were in place before recruitment into the trial. Recruits were advised to make no changes to these interventions at any stage in the trial other than the timing of drug administration (morning or evening).
    Evidence for comparator
    In order to detect a 3 mm Hg difference in mean 24 hour systolic BP (SBP) (between periods when antihypertensive medications are taken in the morning and when taken at night) with 80% power (2-sided), p < 0.05 and an estimated standard deviation (SD) in mean 24 hour SBP of 10 mmHg, 90 patients were needed to complete the trial. Assuming a dropout rate of approximately 10%, 100 patients in total were required to be randomized between the two centres, with 45 patients in each treatment group.
    Actual start date of recruitment
    23 Jul 2013
    Long term follow-up planned
    No
    Independent data monitoring committee (IDMC) involvement?
    Yes
    Population of trial subjects
    Number of subjects enrolled per country
    Country: Number of subjects enrolled
    United Kingdom: 53
    Country: Number of subjects enrolled
    Greece: 50
    Worldwide total number of subjects
    103
    EEA total number of subjects
    103
    Number of subjects enrolled per age group
    In utero
    0
    Preterm newborn - gestational age < 37 wk
    0
    Newborns (0-27 days)
    0
    Infants and toddlers (28 days-23 months)
    0
    Children (2-11 years)
    0
    Adolescents (12-17 years)
    0
    Adults (18-64 years)
    51
    From 65 to 84 years
    52
    85 years and over
    0

    Subject disposition

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    Recruitment
    Recruitment details
    103 patients were recruited to the trial between July 2013 and Jan 2015, across two sites: Peart-Rose Research Unit, Imperial College London, UK and the Outpatient Clinic of 1st Medical Propedeutic Dept. of Internal Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Greece. The the last patient last visit occurred in July 2015.

    Pre-assignment
    Screening details
    Suitable participants were identified at treating hospitals, research departments or the general practices by the study team. Patients were screened if they were on 2 or more stable hypertensive medications for at least 3 months prior to the study and were aged between 18-80 years.

    Period 1
    Period 1 title
    Baseline to Crossover
    Is this the baseline period?
    Yes
    Allocation method
    Not applicable
    Blinding used
    Not blinded

    Arms
    Are arms mutually exclusive
    Yes

    Arm title
    Morning/Evening
    Arm description
    Patients who took their BP medication in the morning (between 06:00 and 11:00) in the first period for 12 weeks and in the evening (between 18:00 and 23:00) in the second period for another 12 weeks.
    Arm type
    Sequence

    Investigational medicinal product name
    Usual BP medication
    Investigational medicinal product code
    Other name
    Pharmaceutical forms
    Tablet, Capsule
    Routes of administration
    Oral use
    Dosage and administration details
    Usual BP medication

    Arm title
    Evening/Morning
    Arm description
    Patients who took their BP medication in the evening (between 18:00 and 23:00) in the first period for 12 weeks and in the morning (between 06:00 and 11:00) in the second period for another 12 weeks.
    Arm type
    Sequence

    Investigational medicinal product name
    No investigational medicinal product assigned in this arm
    Number of subjects in period 1
    Morning/Evening Evening/Morning
    Started
    51
    52
    Crossover
    48
    49
    Completed
    48
    49
    Not completed
    3
    3
         Consent withdrawn by subject
    2
    1
         Physician decision
    -
    1
         Dropped out and rescreened
    -
    1
         Randomised in error
    1
    -
    Period 2
    Period 2 title
    Crossover to Final Visit
    Is this the baseline period?
    No
    Allocation method
    Not applicable
    Blinding used
    Not blinded

    Arms
    Are arms mutually exclusive
    Yes

    Arm title
    Morning/Evening
    Arm description
    Patients who took their BP medication in the morning (between 06:00 and 11:00) in the first period for 12 weeks and in the evening (between 18:00 and 23:00) in the second period for another 12 weeks.
    Arm type
    Sequence

    Investigational medicinal product name
    No investigational medicinal product assigned in this arm
    Arm title
    Evening/Morning
    Arm description
    Patients who took their BP medication in the evening (between 18:00 and 23:00) in the first period for 12 weeks and in the morning (between 06:00 and 11:00) in the second period for another 12 weeks.
    Arm type
    Sequence

    Investigational medicinal product name
    No investigational medicinal product assigned in this arm
    Number of subjects in period 2
    Morning/Evening Evening/Morning
    Started
    48
    49
    Completed
    48
    47
    Not completed
    0
    2
         Consent withdrawn by subject
    -
    1
         Adverse event, non-fatal
    -
    1
    Period 3
    Period 3 title
    At Final visit
    Is this the baseline period?
    No
    Allocation method
    Not applicable
    Blinding used
    Not blinded

    Arms
    Are arms mutually exclusive
    No

    Arm title
    Morning
    Arm description
    Result for the morning admission.
    Arm type
    Morning

    Investigational medicinal product name
    No investigational medicinal product assigned in this arm
    Arm title
    Evening
    Arm description
    Results for evening admission
    Arm type
    Evening

    Investigational medicinal product name
    No investigational medicinal product assigned in this arm
    Number of subjects in period 3
    Morning Evening
    Started
    103
    103
    Completed
    98
    100
    Not completed
    5
    3
         Consent withdrawn by subject
    3
    1
         Physician decision
    -
    1
         Adverse event, non-fatal
    1
    -
         Dropped out and rescreened
    -
    1
         Error randomisation
    1
    -

    Baseline characteristics

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    Baseline characteristics reporting groups
    Reporting group title
    Morning/Evening
    Reporting group description
    Patients who took their BP medication in the morning (between 06:00 and 11:00) in the first period for 12 weeks and in the evening (between 18:00 and 23:00) in the second period for another 12 weeks.

    Reporting group title
    Evening/Morning
    Reporting group description
    Patients who took their BP medication in the evening (between 18:00 and 23:00) in the first period for 12 weeks and in the morning (between 06:00 and 11:00) in the second period for another 12 weeks.

    Reporting group values
    Morning/Evening Evening/Morning Total
    Number of subjects
    51 52 103
    Age categorical
    Units: Subjects
        In utero
    0
        Preterm newborn infants (gestational age < 37 wks)
    0
        Newborns (0-27 days)
    0
        Infants and toddlers (28 days-23 months)
    0
        Children (2-11 years)
    0
        Adolescents (12-17 years)
    0
        Adults (18-64 years)
    0
        From 65-84 years
    0
        85 years and over
    0
    Age continuous
    Units: years
        arithmetic mean (standard deviation)
    61.8 ± 11 61.8 ± 9.7 -
    Gender categorical
    Units: Subjects
        Female
    24 21 45
        Male
    27 31 58

    End points

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    End points reporting groups
    Reporting group title
    Morning/Evening
    Reporting group description
    Patients who took their BP medication in the morning (between 06:00 and 11:00) in the first period for 12 weeks and in the evening (between 18:00 and 23:00) in the second period for another 12 weeks.

    Reporting group title
    Evening/Morning
    Reporting group description
    Patients who took their BP medication in the evening (between 18:00 and 23:00) in the first period for 12 weeks and in the morning (between 06:00 and 11:00) in the second period for another 12 weeks.
    Reporting group title
    Morning/Evening
    Reporting group description
    Patients who took their BP medication in the morning (between 06:00 and 11:00) in the first period for 12 weeks and in the evening (between 18:00 and 23:00) in the second period for another 12 weeks.

    Reporting group title
    Evening/Morning
    Reporting group description
    Patients who took their BP medication in the evening (between 18:00 and 23:00) in the first period for 12 weeks and in the morning (between 06:00 and 11:00) in the second period for another 12 weeks.
    Reporting group title
    Morning
    Reporting group description
    Result for the morning admission.

    Reporting group title
    Evening
    Reporting group description
    Results for evening admission

    Primary: 24 hour ABPM - mean systolic BP

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    End point title
    24 hour ABPM - mean systolic BP
    End point description
    24 hour ABPM - mean systolic BP
    End point type
    Primary
    End point timeframe
    24 hours
    End point values
    Morning Evening
    Number of subjects analysed
    95
    95
    Units: mmHg
    130
    130
    Statistical analysis title
    Regression adjusted
    Statistical analysis description
    Includes 95 patients who had ABPMs at baseline, crossover and final visits.
    Comparison groups
    Morning v Evening
    Number of subjects included in analysis
    190
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    Method
    Parameter type
    Mean difference (final values)
    Point estimate
    0.11
    Confidence interval
         level
    95%
         sides
    2-sided
         lower limit
    -3.2
         upper limit
    3.42
    Statistical analysis title
    Observed difference [1]
    Statistical analysis description
    95 patients who completed ABPMs at baseline, crossover and final visits were included in this analysis.
    Comparison groups
    Morning v Evening
    Number of subjects included in analysis
    190
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    Method
    Parameter type
    Mean difference (final values)
    Point estimate
    0.1
    Confidence interval
         level
    95%
         sides
    2-sided
         lower limit
    0
         upper limit
    -
    Notes
    [1] - A low or upper value for the confidence interval may be missing. Values for both the lower and upper limit are expected to be provided with a 2-sided confidence interval.
    Justification: The outcome is a difference and it is not specific to one group or the other but it makes sense to enter the observed values for the two groups. These are not estimates but exact numbers so there is no related confidence interval.

    Primary: 24 hour ABPM - mean diastolic BP

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    End point title
    24 hour ABPM - mean diastolic BP
    End point description
    24 hour ABPM - mean diastolic BP
    End point type
    Primary
    End point timeframe
    24 hours
    End point values
    Morning Evening
    Number of subjects analysed
    95
    95
    Units: mmHg
    77
    78
    Statistical analysis title
    Regression adjusted
    Statistical analysis description
    Includes 95 patients who had ABPMs at baseline, crossover and final visits.
    Comparison groups
    Morning v Evening
    Number of subjects included in analysis
    190
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    Method
    Parameter type
    Mean difference (final values)
    Point estimate
    0.77
    Confidence interval
         level
    95%
         sides
    2-sided
         lower limit
    -1.38
         upper limit
    2.91

    Adverse events

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    Adverse events information [1]
    Timeframe for reporting adverse events
    23rd July 2013 (date first patient enrolled) to 15th July 2015 (28 days after last patient, last visit).
    Assessment type
    Systematic
    Dictionary used for adverse event reporting
    Dictionary name
    MedDRA
    Dictionary version
    19.0
    Reporting groups
    Reporting group title
    Morning/Evening
    Reporting group description
    -

    Reporting group title
    Evening/Morning
    Reporting group description
    -

    Notes
    [1] - There are no non-serious adverse events recorded for these results. It is expected that there will be at least one non-serious adverse event reported.
    Justification: No non-serious adverse events were reported, only one three serious adverse events were reported in the trial.
    Serious adverse events
    Morning/Evening Evening/Morning
    Total subjects affected by serious adverse events
         subjects affected / exposed
    0 / 51 (0.00%)
    2 / 52 (3.85%)
         number of deaths (all causes)
    0
    0
         number of deaths resulting from adverse events
    0
    0
    Investigations
    Endoscopic retrograde cholangiopancreatography
    Additional description: Planned admission for ERCP with stent.
         subjects affected / exposed
    0 / 51 (0.00%)
    1 / 52 (1.92%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Cardiac disorders
    Syncope
    Additional description: Syncope episode leading to angiogram, showing 3 vessel disease. Patient underwent cardiac bypass surgery and pacemaker insertion.
         subjects affected / exposed
    0 / 51 (0.00%)
    1 / 52 (1.92%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    General disorders and administration site conditions
    Chest pain
    Additional description: Pain in chest radiating through back. Troponin negative, angiogram showed no aortic dissection but showed gallstone. Chest X-ray clear.
         subjects affected / exposed
    0 / 51 (0.00%)
    1 / 52 (1.92%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Frequency threshold for reporting non-serious adverse events: 0.05%
    Non-serious adverse events
    Morning/Evening Evening/Morning
    Total subjects affected by non serious adverse events
         subjects affected / exposed
    0 / 51 (0.00%)
    0 / 52 (0.00%)

    More information

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    Substantial protocol amendments (globally)

    Were there any global substantial amendments to the protocol? Yes
    Date
    Amendment
    18 Jul 2012
    Substantial amendment. Minor administrative changes to the trial protocol and patient information sheet. Submission of letter of invitation to participant and patient diary card for Ethics approval.
    25 Sep 2012
    Minor amendment. Administrative changes made to the GP letter regarding patient participation to provide information on which randomisation arm the patient has been allocated and to provide further detail of the current medication the patient is taking.
    19 Oct 2012
    Minor amendment. Administrative changes to the trial protocol, patient information sheet and consent form to clarify inconsistencies regarding ABPM measurement timings.
    02 Jul 2013
    Substantial amendment. Following sections of the protocol changed: 1) Secondary outcome Clarification that occurrence of side effects is based self reported serious adverse events to maintain consistency with the adverse events reporting section which already states this. 2) and 3) Inclusion and Exclusion Criteria Reduction of the lower accepted Diastolic Blood Pressure to 65 mmHg (instead of 75) to enhance the generalisability of the findings as our clinic database has shown this better reflects the current patient population in the clinic and therefore the population under study. 4) Treatment Schedule Further details added to the protocol and patient information sheet to clarify the questions asked and data that will be collected. 5) Sponsor Sponsor contact change from Lucy Parker to Nabila Youssouf. NB the Sponsor did not change.
    23 Apr 2014
    Minor and substantial amendments. SUBSTANTIAL AMENDMENT TO MHRA AND ETHICS Change in the inclusion criteria that previously included 'Caucasian patients [white and of European origin] aged 18-80 years' to now state 'Any patients aged 18-80 years'. This was to enhance the generalisability of the findings as the clinic database has shown this better reflects the current patient population in the clinic and therefore the population under study. MINOR AMENDMENT TO MHRA AND ETHICS In the previous amendment we informed of a change in Sponsor contact details but the details were not changed on the protocol in error, so this was been corrected in version 5 of the protocol. SUBSTANTIAL AMENDMENT TO ETHICS ONLY 1) Questionnaire designed to be given to patients at the end of the study to gain their feedback on preference for time of day for taking medication. We have attached the questionnaire for review (to ethics only) 2) Intended to contact patients who have taken part in other studies and consented to being contacted for future studies. Drafted letter and questionnaire for review (to ethics only)
    19 Dec 2014
    Minor amendments: 1) Sponsor contact details The contact person for the Sponsor changed and updated on version 6 of the protocol 2) Correction of typo On page 9, section 4.1 of the protocol which still referred to patients recruited being Caucasian. This was changed in the last substantial amendment in the inclusion/exclusion criteria on the protocol but was missed from this section in error so was now deleted 3) Change in distribution of patient recruitment. The previous version of the protocol stated that an equal number of patients will be recruited at each of the two sites for the study. As recruitment was slower at one site, recruitment would not be equal between sites and this was changed in the protocol accordingly. NB was NOT a change to the number of patients to be recruited.
    11 Feb 2015
    Minor amendment. Updated sponsor details on the protocol version 7.

    Interruptions (globally)

    Were there any global interruptions to the trial? No

    Limitations and caveats

    Limitations of the trial such as small numbers of subjects analysed or technical problems leading to unreliable data.
    None reported
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