BALTIMORE—The death of a healthy volunteer during a study of normal airway relaxation prompted the Office for Human Research Protections (OHRP) of the US Department of Health and Human Services (DHHS) to temporarily suspend all federally funded research at Johns Hopkins Medical Institutions on July 19. Besides raising awareness of gaps in institutional protections for human subjects in experimental research, the suspension, which was lifted with restrictions three days later, has highlighted confusion regarding federal rules that govern the nontherapeutic use of drugs in human research.

Ellen Roche, the 24-year-old lab technician who had volunteered for the study at the Johns Hopkins Bayview Medical Center (JHBMC), died of respiratory and renal failure on June 2, almost one month after inhaling hexamethonium. Within a day of receiving the drug via a nebulizer on May 4, “she developed a dry cough and dyspnea on exertion,” the Johns Hopkins Internal Investigative Committee (JHIIC) reported.[1] Her symptoms worsened, and on May 9, she was admitted to the JHBMC. “Her chest x-ray demonstrated streaky densities in the perihilar region,” the committee stated. After she received supplementary oxygen and empiric antibiotics for possible pneumonia, her condition worsened. Computed tomography on May 12 revealed “a ground glass appearance of the lungs, worse at the lung bases.” Despite an “extensive, thorough, and comprehensive search for infectious pathogens,” none were found.

The patient’s condition continued to decline despite extensive intensive care.

After the patient’s death following withdrawal from life support, autopsy revealed no evidence of infection, just “widespread and extensive damage to the lungs,” the committee reported. “There were diffuse areas of hemorrhagic patches in both lungs. … Overall the gross picture was consistent with that of an acute and diffuse injury to the lungs … [including] diffuse loss of alveolar space with marked fibrosis and fibrin thrombi involving all lobes, … evidence of alveolar cell hyperplasia, as well as chronic inflammation compatible with an organizing stage of diffuse alveolar damage.”

DEATH ATTRIBUTED TO INHALED HEXAMETHONIUM

The committee concluded that “inhaled hexamethonium … was either solely responsible for the subject’s illness or played an important contributory role.” In a June 15 letter to other researchers, Solbert Permutt, MD, the Hopkins Professor and principal investigator who was awarded the grant that funded the study, wrote, “[W]e feel compelled to warn our colleagues … using or thinking of using hexamethonium of the death of the volunteer.” The same day, the OHRP posted a similar warning on their Web site, advising institutional review boards (IRBs) to reassess protocols involving inhalation of hexamethonium and, “if necessary, consider temporarily suspending the research in light of this event.”[2]

In its July 19 letter to senior Hopkins officials, the OHRP cited both substantive and procedural lapses regarding the research protocol in question, titled “Mechanisms of Deep Inspiration-Induced Airway Relaxation.” Although the university has accepted full responsibility for Ms. Roche’s death and is now working with the OHRP to address its concerns, it has questioned some of the federal agency’s allegations.

HEXAMETHONIUM’S TOXICITY

Most important, the OHRP faulted the investigators and the JHBMC IRB for ignoring published information regarding hexamethonium-associated lung toxicity. “Such data was readily available via routine MEDLINE and Internet database searches, as well as recent textbooks on pathology of the lung,” the OHRP asserted. Further, “hexamethonium is not currently approved by the FDA [Food and Drug Administration], and has never been approved by the FDA for administration via inhalation.” (See “A Brief History of Hexamethonium” at the end of this document.)

Failure to recognize the drug’s toxicity led to two citations by the OHRP: First, the IRB and investigators “failed to ensure that risks to subjects were minimized and reasonable, as required by DHHS regulations.” Second, they “failed to provide a description of the possible pulmonary toxicity of hexamethonium” in the required signed consent form, which listed only hypotension, dizziness, and a mild asthma attack as possible effects, and which referred to the drug as a “medication,” despite its unapproved status. The researchers were also cited for failing “to promptly report the cough, shortness of breath, and a decrease in pulmonary function” experienced by the first study subject. (Ms. Roche was the third subject to receive the drug in the JHBMC study.)

JHIIC: GOOD FAITH EFFORT MADE

According to the JHIIC, however, “a good faith effort was made to review the literature,” yet neither the investigators nor the IRB were aware of hexamethonium-associated risks to the lungs. In his June 15 letter, Dr. Permutt argued, “Several cases of respiratory failure attributable to a ‘fibrinous pneumonitis’ syndrome were reported in the ‘50s in patients receiving hexamethonium. These events, however, occurred in patients who were receiving large doses of hexamethonium for periods of months. We are unaware of any report of the lungs being affected by a single dose of hexamethonium.”

ADVERSE REACTIONS NOT NOTED IN PREVIOUS STUDIES?

Further, Dr. Permutt wrote, “We are aware [of] five published reports in the 1980s and 1990s in which hexamethonium was delivered to humans by inhalation as part of experimental protocols … with no adverse effects other than the expected reduction in blood pressure.”

Omission of adverse reactions from reports of previous human studies might have contributed to the researchers’ ignorance—and the protocol’s approval. For example, only after the death at Johns Hopkins did a report of respiratory problems following hexamethonium inhalation in an earlier human study at the University of California, San Francisco surface—and then only in the lay media, not in a scientific publication. According to an article in the New York Times,[3] two human subjects became ill after each inhaled a gram of hexamethonium in 1978[4]; one presented to the emergency room with dyspnea and chest pains. Convinced that the respiratory symptoms were due to other causes, the researchers declined to describe them when they published the research.

How can oversights such as the one that led to Ms. Roche’s death be avoided in the future? “For its part, Hopkins has pledged to do ‘whatever it takes’ to protect human subjects,” said spokesperson Joann Rodgers. According to a July 21 response to the OHRP, Hopkins plans “the development [by September 15] of a standard that both an investigator and the IRB can apply to determine that a literature search conducted in support of an application for human subjects research is both adequate and comprehensive.” They add, “We are hopeful that this work may prove useful to researchers at other institutions.”

CONFUSION OVER IND APPLICATIONS

A June 28 FDA inspectional observation cited a principal investigator, Alkis Togias, MD, Associate Professor of Medicine at Hopkins, for failure to submit the an investigational new drug (IND) application for hexamethonium, required for the administration of any unapproved drug to humans.

In his defense, the JHIIC claimed that the decision not to pursue an IND application was made in the context of “a long background of uncertainty regarding FDA guidelines for non–FDA-approved drugs in physiologic (nontherapeutic) studies of lung function.”

Said Ms. Rodgers, “The rules regarding requirement for an IND are sometimes unclear.” This uncertainty had persisted despite repeated queries to the agency to clarify this issue, although, according to the FDA, these requests had pertained solely to use of approved drugs or endogenous products, and not to inhalation of unapproved drugs or shelf chemicals such as hexamethonium.

IRB’S RESPONSIBILITY FOR OVERSIGHT?

A major question raised by Ms. Roche’s death is how much responsibility Hopkins’ IRB must bear. “The IRB process is the infrastructure for oversight of human research in this country—this is what we rely upon,” said DHHS spokesman Bill Hall. Beyond its failure to recognize hexamethonium’s toxic potential, other aspects of IRB procedure were cited in the OHRP’s July 19 letter. “The IRB process in place at Hopkins was not in compliance with the procedures outlined in the federal regulations for human subjects protections,” according to Mr. Hall. For example, study protocols were not routinely being “discussed and voted upon on an individual basis by the entire IRB, as called for in the regulations; they were reviewed by select subcommittees without being discussed, one by one, by the full IRB.”

In response, Johns Hopkins noted in a July 21 statement that: “[T]he process involves a ‘triple review’: First, the protocol is circulated to all IRB members…. Second, the protocol is re-reviewed…. Third, the protocol is recirculated to all IRB members … before final approval at a convened meeting.” While it remains unclear whether following OHRP guidelines for IRB procedure would have prevented approval of a protocol involving inhaled hexamethonium, Mr. Hall remarked, “I think following correct procedure would ensure that Hopkins had the greatest level of protections possible for volunteers.”

Would OHRP intervene in other cases in which a similar protocol involving inhaled hexamethonium had been instituted? “The fact that this happened doesn’t mean the OHRP would automatically investigate other institutions where hexamethonium inhalation studies were being done,” remarked Mr. Hall.

“In general,” Mr. Hall continued, “when OHRP receives an incident report, or an allegation of problems regarding a human research study, the office reviews the substance of those allegations, determines whether there is the need to open a case, and, if so, will send a letter to the institution requesting information.” But, he said, “if no one comes forth to report a potential problem, the OHRP would have no reason to investigate an institution.”

—Mimi Zucker, PhD

A Brief History of Hexamethonium

Washington, DC—Hexamethonium, a ganglionic nicotinic cholinergic blocker, was approved by the FDA in the 1950s. “Hexamethonium chloride tablets were approved as antihypertensives … and, like all drugs reviewed by the FDA prior to 1961, were approved only for safety and not for efficacy,” said Crystal Rice, a spokesperson for the FDA. “In 1950, the only effective oral treatment for malignant hypertension was the combination of hexamethonium and hydralazine,” emphasized H. Mitchell Perry, MD, who added, “It could control blood pressure in seriously hypertensive patients who could tolerate side effects of autonomic blockade and who didn’t have uremia.” As better antihypertensives became available, hexamethonium use decreased, and in 1972, the FDA withdrew approval of the drug, based on a lack of substantial evidence for hexamethonium’s efficacy. Adverse effects of hexamethonium use, including lung toxicity, were reported more than 40 years ago.[1] Dr. Perry documented cases of toxicity while using oral hexamethonium as an antihypertensive agent in the 1950s. In a 1957 study, Dr. Perry and colleagues had noted “nine patients who were autopsied after an unusual fatal syndrome—they had extreme tachypnea, they were pyrexic, and they had a high white cell count.[2] These patients had received a normal dose of oral hexamethonium (4 to 6 g per day), for at least a month. However, it must be emphasized that adsorption from the GI tract is poor.” The generalized lung damage in these patients resembled the histopathology seen in lungs of patients with frank uremia, “but they didn’t have renal failure,” Dr. Perry noted. “We called this condition fibrinous pneumonitis.” Yet protocols involving inhaled hexamethonium were used in human studies at several institutions well into the 1990s, suggesting widespread ignorance of hexamethonium’s potential toxicity.[3-7] Said Dr. Perry, “It’s surprising that ethics committees missed this information on the drug. It should stand out in the older literature, given that that was the only time when the drug was clinically used with some frequency.” —Mimi Zucker, PhD

References 1. Pneumotox on line. Hexamethonium. Available at: http://www.pneumotox.com/pneumotox/hexamethonium.html. Accessed July 20, 2001. 2. Perry HM Jr, O’Neal RM, Thomas WA. Pulmonary disease following chronic chemical ganglionic blockade. Am J Med. 1957;22:37-50. 3. Lee LY, Gerhardstein DC, Wang AL, Burki NK. Nicotine is responsible for airway irritation evoked by cigarette smoke inhalation in men. J Appl Physiol. 1993;75:1955-1961. 4. Sterk PJ, Daniel EE, Zamel N, Hargreave FE. Limited maximal airway narrowing in nonasthmatic subjects: role of neural control and prostaglandin release. Am Rev Respir Dis. 1985;132:865-870. 5. O’Byrne PM, Thomson NC, Latimer KM, et al. The effect of inhaled hexamethonium bromide and atropine sulphate on airway responsiveness to histamine. J Allergy Clin Immunol. 1985;76:97-103. 6. Boushey HA. The role of the parasympathetic system in the regulation of bronchial smooth muscle. Eur J Respir Dis. 1984;135(suppl):80-90. 7. Holtzman MJ, Sheller JR, Dimeo M, et al. Effect of ganglionic blockade on bronchial reactivity in atopic subjects. Am Rev Respir Dis. 1980;122:17-25.

References
1. Hopkins Internal Investigative Committee. Report of internal investigation into the death of a volunteer research subject. Available at: http://www.hopkinsmedicine.org/press/2001/JULY/report_of_internal_investigation.htm. Accessed July 23, 2001.
2. US Department of Health and Human Services Office for Human Research Protections. (June 15, 2001) Alert for IRBs that review biomedical research. Available at: http://ohrp.osophs.dhhs.gov/whatsnew.htm. Accessed July 22, 2001.
3. Glanz J. 1978 study had troubles like fatal Hopkins test. The New York Times. July 26, 2001:1.
4. Holtzman MJ, Sheller JR, Dimeo M, et al. Effect of ganglionic blockade on bronchial reactivity in atopic subjects. Am Rev Respir Dis. 1980;122:17-25.