Sequential multiple-assignment randomized trial design of neurobehavioral treatment for patients with metastatic malignant melanoma undergoing high-dose interferon-alpha therapy

S. Freda Auyeung, Qi Long, Erica Bruce Royster, Smitha Murthy, Marcia D. McNutt, David Lawson, Andrew Miller, Amita Manatunga, Dominique Musselman

Research output: Contribution to journalArticle

13 Citations (Scopus)

Abstract

Background: Interferon-alpha therapy, which is used to treat metastatic malignant melanoma, can cause patients to develop two distinct neurobehavioral symptom complexes: a mood syndrome and a neurovegetative syndrome. Interferon-alpha effects on serotonin metabolism appear to contribute to the mood and anxiety syndrome, while the neurovegetative syndrome appears to be related to interferon-alpha effects on dopamine. Purpose: Our goal is to propose a design for utilizing a sequential, multiple assignment, randomized trial design for patients with malignant melanoma to test the relative efficacy of drugs that target serotonin versus dopamine metabolism during 4 weeks of intravenous, then 8 weeks of subcutaneous, interferon-alpha therapy. Methods: Patients will be offered participation in a double-blinded, randomized, controlled, 14-week trial involving two treatment phases. During the first month of intravenous interferon-alpha therapy, we will test the hypotheses that escitalopram will be more effective in reducing depressed mood, anxiety, and irritability, whereas methylphenidate will be more effective in diminishing interferon-alpha-induced neurovegetative symptoms, such as fatigue and psychomotor slowing. During the next 8 weeks of subcutaneous interferon therapy, participants whose symptoms do not improve significantly will be randomized to the alternate agent alone versus escitalopram and methylphenidate together. Results: We present a prototype for a single-center, sequential, multiple assignment, randomized trial, which seeks to determine the efficacy of sequenced and targeted treatment for the two distinct symptom complexes suffered by patients treated with interferon-alpha. Limitations: Because we cannot completely control for external factors, a relevant question is whether or not 'short-term' neuropsychiatric interventions can increase the number of interferon-alpha doses tolerated and improve long-term survival. Conclusions: This sequential, multiple assignment, randomized trial proposes a framework for developing optimal treatment strategies; however, additional studies are needed to determine the best strategy for treating or preventing neurobehavioral symptoms induced by the immunotherapy interferon-alpha.

Original languageEnglish
Pages (from-to)480-490
Number of pages11
JournalClinical Trials
Volume6
Issue number5
DOIs
StatePublished - Nov 16 2009
Externally publishedYes

Fingerprint

Interferon-alpha
Melanoma
Citalopram
Methylphenidate
Therapeutics
Dopamine
Anxiety
Serotonin Agents
Immunotherapy
Interferons
Fatigue
Serotonin
Survival

ASJC Scopus subject areas

  • Medicine(all)
  • Pharmacology

Cite this

Sequential multiple-assignment randomized trial design of neurobehavioral treatment for patients with metastatic malignant melanoma undergoing high-dose interferon-alpha therapy. / Auyeung, S. Freda; Long, Qi; Royster, Erica Bruce; Murthy, Smitha; McNutt, Marcia D.; Lawson, David; Miller, Andrew; Manatunga, Amita; Musselman, Dominique.

In: Clinical Trials, Vol. 6, No. 5, 16.11.2009, p. 480-490.

Research output: Contribution to journalArticle

Auyeung, S. Freda ; Long, Qi ; Royster, Erica Bruce ; Murthy, Smitha ; McNutt, Marcia D. ; Lawson, David ; Miller, Andrew ; Manatunga, Amita ; Musselman, Dominique. / Sequential multiple-assignment randomized trial design of neurobehavioral treatment for patients with metastatic malignant melanoma undergoing high-dose interferon-alpha therapy. In: Clinical Trials. 2009 ; Vol. 6, No. 5. pp. 480-490.
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AU - Auyeung, S. Freda

AU - Long, Qi

AU - Royster, Erica Bruce

AU - Murthy, Smitha

AU - McNutt, Marcia D.

AU - Lawson, David

AU - Miller, Andrew

AU - Manatunga, Amita

AU - Musselman, Dominique

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AB - Background: Interferon-alpha therapy, which is used to treat metastatic malignant melanoma, can cause patients to develop two distinct neurobehavioral symptom complexes: a mood syndrome and a neurovegetative syndrome. Interferon-alpha effects on serotonin metabolism appear to contribute to the mood and anxiety syndrome, while the neurovegetative syndrome appears to be related to interferon-alpha effects on dopamine. Purpose: Our goal is to propose a design for utilizing a sequential, multiple assignment, randomized trial design for patients with malignant melanoma to test the relative efficacy of drugs that target serotonin versus dopamine metabolism during 4 weeks of intravenous, then 8 weeks of subcutaneous, interferon-alpha therapy. Methods: Patients will be offered participation in a double-blinded, randomized, controlled, 14-week trial involving two treatment phases. During the first month of intravenous interferon-alpha therapy, we will test the hypotheses that escitalopram will be more effective in reducing depressed mood, anxiety, and irritability, whereas methylphenidate will be more effective in diminishing interferon-alpha-induced neurovegetative symptoms, such as fatigue and psychomotor slowing. During the next 8 weeks of subcutaneous interferon therapy, participants whose symptoms do not improve significantly will be randomized to the alternate agent alone versus escitalopram and methylphenidate together. Results: We present a prototype for a single-center, sequential, multiple assignment, randomized trial, which seeks to determine the efficacy of sequenced and targeted treatment for the two distinct symptom complexes suffered by patients treated with interferon-alpha. Limitations: Because we cannot completely control for external factors, a relevant question is whether or not 'short-term' neuropsychiatric interventions can increase the number of interferon-alpha doses tolerated and improve long-term survival. Conclusions: This sequential, multiple assignment, randomized trial proposes a framework for developing optimal treatment strategies; however, additional studies are needed to determine the best strategy for treating or preventing neurobehavioral symptoms induced by the immunotherapy interferon-alpha.

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