Our study aims to assess the clinical effect of SQG on vascular endothelial dysfunction in patients with stage I or Ⅱ hypertension, to provide a reliable experimental basis for the early prevention and treatment of target organ damage in hypertension, and to observe whether TCM plus western medicine can obtain better curative effect than western medicine alone.
This study is a randomized, double-blind, double-simulation controlled trial, and participants will be recruited from China-Japan Friendship Hospital by using notices at the hospital and newspaper advertisements.
In this clinical trial, patients with stage I or Ⅱ hypertension will be analyzed to determine the efficacy and safety of SQG, and basic analysis will be conducted in terms of the examination results. The study participants will voluntarily sign an informed consent and all examinations and tests will be carried out based on the clinical trial plan. Eligible subjects will be chosen based on specific inclusion and exclusion criteria. Participants will be randomized before the first treatment. Three hundred subjects with stage I or II hypertension will be randomly assigned to three groups (in a 1:1:1 ratio): group A(treatment with SQG and placebo of Cozaar), group B (treatment with Cozaar and SQG placebo), and group C (treatment with SQG and Cozaar). Recruited patients will receive an 8-week treatment (SQG and placebo of SQG will be given twice a day in the morning and evening, 10g every time, and the Cozaar and placebo of Cozaar will be administrated at 50mg every morning). The SQG and its placebo produced in China in accordance with the China Pharmacopoeia standard of quality control, will be used in this study. Upon completion of the 8-week treatment, follow-up tests will be conducted at weeks 2, 4, 6 and 8 after randomization (Fig. 2). This study was registered at the institute ‘Chinese Clinical Trial Registry’, which is a registry in the WHO Registry Network (ChiCTR1800016427).
Patients with hypertension, recruited at clinic and ward of China-Japan friendship hospital through advertisements and referrals, will be screened. The principle investigator (PI), together with a well-trained attending physician, will identify potentially eligible patients based on the eligibility criteria. Then, a researcher will inform the patient face to face of the whole schedule, including the aim, procedures, possible side effects and benefits of the study SQG in detail. If the patient agrees to take part in the study, he must sign an informed consent before randomization.
The inclusion, exclusion and withdraw criteria will be seen in Fig.3.
Our protocol (version identifier: V1.0 (2018.3.30)) was approved by the clinical research ethics committee of China-Japanese Friendship Hospital (Approval No.2018-59-K43). And we also registered our trial at Chinese Clinical Trial Registry (ChiCTR1800016427), complies with the principles of the Declaration of Helsinki and the principles of Good Clinical Practice[11-12]. Every participant will sign an informed consent before enrollment and they will have right to withdraw from the trial at any time.
Randomization and blinding
One sealed opaque envelope with random series was prepared. The random series was generated by Statistical Analysis System(SAS, Version 9.4)by statisticians in the Scientific Research Department of China-Japanese Friendship Hospital. Three hundred participants will be randomly assigned to three groups to obtain the clinical trial plan corresponding to the random number.
There are three hundred sealed opaque envelopes, each of which contains information of one participant: group number, treatment, possible adverse events and emergency measures. The envelopes are kept by a special person, rather than the researchers, participants, clinical trial pharmacists, data managers or statisticians, and neither of whom knows the location nor the treatment plan. The drug is similar to its placebo in each group. The manufacturer labeled the random codes on the package according to the principles of GCP.
Eligible participants will be randomly assigned to three groups to obtain the clinical trial plan corresponding to the random number. Group A will be given SQG and placebo of Cozaar, group B will be given Cozaar and placebo of SQG and group C will be given SQG and Cozaar. SQG (or its placebo) will be administrated twice a day at the doze of 10g each time, and 50mg Cozaar (or its placebo) will be administrated once in the morning. SQG (production batch number: 181201), placebo of SQG (production batch number: 181201), and placebo of Cozaar (production batch number: 181001) were produced and packed in a single batch by Jiangxi Puzheng Pharmaceutical Co., Ltd. (Social unified code: 91360823744294486X). The test results of drug quality are consistent with the Chinese Medicine Standards of the State Food and Drug Administration (SFDA). SQG is composed of original drug flow paste 200 kg and dextrin 180 kg. The placebo of SQG is composed of caramel 5 kg, dextrin 120 kg and original drug flow paste 25 kg. The main component of Cozaar placebo is dextrin. Cozaar was bought from Pharmaceutical Branch of China Pharmaceutical Holdings Beijing Co., Ltd. (Social unified code：91110101101297579G).
Comparison of drug efficiency between the three groups
(Efficiency needs to meet the following two points).
(1) Blood pressure: The change of blood pressure needs to reach a valid standard according to Guiding Principles for Clinical Research of New Chinese Medicines.
(2) Flow-mediated dilation (FMD): Its value needs to increase by at least 2%.
1. The change of average systolic and diastolic blood pressure during the day and the night, the change of blood pressure drop rate at night: Above indicators will be assessed by 24-hour blood pressure monitoring.
2. Target organ damage assessment:
(1) Heart rate variability (HRV): Analysis of HRV based on routine 24-hour Holter recordings provides a sensitive, noninvasive measurement of autonomic input to the heart.
(2) Ankle-brachial index(ABI) and pulse wave velocity (PWV): The ABI is the ratio of the systolic blood pressure which measures the brachial arteryat the ankle. The PWV is defined and calculated as the distance between the two arterial sites divided by the time delay between the two arterial point sites .
3. Symptom improvement assessment：
(1) Hypertension symptom scale：Hypertension symptoms of all patients will be assessed through hypertension symptom scale (Additional file 2).
(2) TCM syndrome integral scale：TCM syndrome of all patients will be assessed through TCM syndrome intergral scale (Additional file 3).
(3) Pittsburgh sleep quality index scale: Sleep quality of all patients will be assessed through Pittsburgh sleep quality index scale[18-19].
(4) Self-Rating Anxiety Scale (SAS): Patients’ anxiety condition will be assessed through Self-Rating Anxiety Scale .
(5) Self-rating depression scale (SDS): Patients’ depression condition will be assessed through Self-Rating Depression Scale .
(6) The Short Form-36 Health Survey (SF-36): Changes in patients’ health-related quality of life will be assessed through SF-36 [22-23].
4. Blood lipids: Changes of total cholesterol, triglyceride, low density lipoprotein and high density lipoprotei will be assessed at baseline and treatment endpoint..
5. Serum indicators of vascular function: Changes of serum ET-1, TXA2, NO, PGI2 values will be assessed at baseline and treatment endpoint.
6. Safety indicators: Creatinine, blood glucose, homocysteine, uric acid (UA), blood routine, urine routine will be tested at baseline and treatment endpoint.
1. Creatinine, blood glucose, blood lipids, homocysteine, uric acid (UA), blood routine, urine routine will be tested at the Clinical Laboratory, China-Japanese Friendship Hospital Beijing, China. Creatinine, blood glucose, blood lipids, homocysteine, uric acid (UA), Ang-II, hs-CRP will be tested by Chemistry Analyzer(Instrument name and model: BECKMAN COULTER Chemistry Analyzer AU5800, Beckman Kurt Co., Ltd, US). Blood routine will be tested by Blood Routine Analyzer (Instrument name and model: Sysmex blood routine analyzer Xn90, SYSMEX Co., Ltd., Japan) and urine routine will be tested by Urine Analyzer(Instrument name and model: Fully Automated Urine Analyzer AUTION MAX AX-4030, Aikolai Co., Ltd.,Japen).
2. ET-1, TXA2, NO, PGI2 will be sent to the Clinical Research Center of China-Japan Friendship Hospital (2~6°C transportation) within 10 min. After the blood is centrifuged, the supernatant fluid will be pipetted and stored in a cryotube, and stored in a -80℃ refrigerator.
3. The cryopreserved supernatant fluid will be tested by using an ELISA kit or chemical kit within six months. Serum ET-1, TXA2 and PGI2 levels will be tested by enzyme-linked immunosorbent assay (ELISA) using Human ET-1, TXA2 and PGI2 ELISA kit. Serum NO levels will be measured by Nitrate reductase method using the Nitric Oxide (NO) assay kit. The experimental procedure, referring to the instructions of the kit, will be carried out by a professional technician. Instruments will be used during the experiment: electronic balance (Model: YP30001, Shanghai Guangzheng Medical Instruments Co., Ltd, China), minishaker (Typ: MS1 Minishaker, IKA (Guangzhou) Instruments and Equipment Co., Ltd, China), Desktop low-speed automatic balancing centrifug (Model: LDZ5-2, Beijing Jingli Centrifuge Co., Ltd, China), Electric constant temperature water tank (Model: HW. W21.600, Beijing Changfeng Instrument and Meter Company, China), and Multi-function microplate reader (Model: SpectraMax M2, Meigu Molecular(Shanghai) Instruments Co., Ltd, China).
Data collection and management
Each participant will get CRF for collecting relevant data. There will be an evaluation for every participant every 14 days during the trial (day -17 ± 0, day 14 ± 2 days, day 28 ± 5days, day 42 ± 5 days and day 56 ± 5days). Every evaluation will include physical examination, symptom improvement record, the use and recovery and distribution of the test drugs, combined medication record, adverse events record. Blood samples, 24-hour blood pressure monitoring will be collected only at the first and last time. Trials (SPIRIT) flow-chart of the trail can be found in Fig.4.
Data will be input into clinical data management system (CDMS) with the website (http:// www.cardiar.com/zryygxy) by two research staff. The CDMS will be managed by Beijing Cardiar Technology Co., Ltd.(Social unified code: 91110 10655 68170 240). All data supporting the conclusion of this trail will be available in this system. There will be a password to control access. To ensure the data integrity and easiness of storage, we will use data rules, valid values and scope checks. Missing data and specific errors will be found by our system. The changes of document will be available but the changes trails will be audited. Auditing trial conduct will be carried out by Beijing Inruida Pharmaceutical Technology Co., Ltd.(Social unified code: 91110105MA00H1U54L), the procedures mentioned above will be kept completely independent from investigators and the sponsor. All personnel involved in data entry and management will sign a confidentiality agreement to prevent data leakage and the participant’s personal information will be fully protected. Original CRF will be kept for 5 years after the end of this trial.
Adverse events (AEs)
Adverse events are defined as accidents or any signs of discomfort, symptoms or diseases. These adverse events include hypertensive emergencies, bleeding, hematoma, syncope, severe pain and local infection. If any adverse event occurs during the observation period, all details should be written down on the CRF, and the clinical research must report the adverse events to the research leader, sponsor, the ethics committee within 24 hours. Ethics committee needs to give treatment advices according to the corresponding adverse events.
Sample size calculation
There will be an superiority trial between group B(treatment with Cozaar and placebo of SQG) and group C(treatment with SQG and Cozaar), and there will be an non-inferiority trial between the group A(treatment with SQG and placebo of Cozaar) and group B(treatment with Cozaar and placebo of SQG).
The sample size was estimated based on clinical research literature and preliminary clinical basis of blood pressure and FMD of hypertensive subjects. Given a type-Ⅰ error rate of α=0.05 and a type-Ⅱ error rate of β=0.2. The efficiency of the group C was estimated at 90%, and the group B at 70%. The calculation result was 78 patients each group by PASS 11 software, 156 patients for three groups. After considering the expulsion rate and the requirement of minimum case number of the GCP(A randomized controlled clinical trial requires at least 100 patients each group). We estimated 100 patients in group B and group C. Group A was an exploratory trail with the above two groups, 100 patients initially identified. Above all, we decided to recruit 300 patients during the trail.
Data entry and management will be completed by an independent data administrator to ensure data accuracy. A professional statistician will perform the data analysis for the results. We will use the intent-to-treat principle to analyze the efficacy and safety of SQG. For continuous variables, the independent two-sample Student’s t test will be used for comparisons between the two study groups, and the paired test will be used for intra-group comparisons. The χ2 test will be used for categorical variables. When continuous data distribution is not normal, the Wilcoxon test will be used. P < 0.05 is considered to be statistically significant, and all tests are two-tailed.