High Versus Low LMWH Dosages in Hospitalized Patients With Severe COVID-19 Pneumonia and Coagulopathy
NCT ID: NCT04408235
Last Updated: 2020-05-29
Study Results
The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.
Basic Information
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UNKNOWN
PHASE3
300 participants
INTERVENTIONAL
2020-06-30
2021-06-30
Brief Summary
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Aim of this study is to assess whether high doses of Low Molecular Weight Heparin (LMWH) (ie. Enoxaparin 70 IU/kg twice daily) compared to standard prophylactic dose (ie, Enoxaparin 4000 IU once day) are:
1. More effective to prevent clinical worsening, defined as the occurrence of at least one of the following events, whichever comes first, during hospital stay:
1. Death
2. Acute Myocardial Infarction \[AMI\]
3. Objectively confirmed, symptomatic arterial or venous thromboembolism \[TE\]
4. Need for either non-invasive - Continuous Positive Airway Pressure (Cpap) or Non-Invasive Ventilation (NIV) - or invasive mechanical ventilation for patients who are in standard oxygen therapy by delivery interfaces at randomisation
5. Need for invasive mechanical ventilation for patients who are in non-invasive mechanical ventilation at randomisation
2. Similar in terms of major bleeding risk during hospital stay
Detailed Description
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The study will involve 7 Italian Academic and non-Academic Internal Medicine Units, 2 Infectious Diseases Units, 1 Respiratory Diseases Unit.
Patients who satisfy all inclusion criteria and do not have any exclusion criteria and have signed written informed consent, will be randomly assigned to a Low-Dose LMWH group (Control Group) or High-Dose LMWH group (Intervention Group) in a 1:1 ratio.
Control Group (Low-Dose LMWH): patients in this group will be administered Enoxaparin (Inhixa®) at standard prophylactic dose (i.e., 4000 IU subcutaneously once day).
Intervention Group (High-Dose LMWH): patients in this group will be administered Enoxaparin (Inhixa®) at dose of 70 IU/kg every 12 hours, as reported in the following table.
The study is conceived as open-label: patients and all health-care personnel involved in the study will be aware of the assigned group.
The treatments will be initiated as soon as possible after randomization (maximum allowed starting time 12h after randomization).
Patients allocated to the two arms will maintain the doses of Enoxaparin, as stated in the protocol, until:
1. hospital discharge or
2. when at least one of the following events occurs:
1. Acute Myocardial Infarction \[AMI\]
2. Objectively confirmed, symptomatic arterial or venous thromboembolism \[TE\]
3. Need for either non-invasive - Continuous Positive Airway Pressure (Cpap) or Non-Invasive Ventilation (NIV) - or invasive mechanical ventilation for patients, who are in standard oxygen therapy by delivery interfaces at randomisation
4. Need for invasive mechanical ventilation for patients, who are in non-invasive mechanical ventilation at randomisation
5. Major bleeding
6. Any adverse events and clinical condition requiring interruption of the scheduled intervention according to the judgement of the physician in charge
7. Death
The decision about what type and dose of antithrombotic treatment to administer, after the interruption of assigned dose of Enoxaparin, will be left to clinical judgement of the physicians in charge.
Any information about the type and dose of antithrombotic treatments administered after the interruption of the assigned dose of Enoxaparin will be collected until the hospital discharge or death.
Each patient will be followed-up until hospital discharge. Information about the status (dead/alive) of patients who are discharged from hospital before 30 days will be sought on Day 30 from randomisation.
Conditions
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Keywords
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Study Design
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RANDOMIZED
PARALLEL
TREATMENT
SINGLE
Study Groups
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Low-Dose LMWH
Enoxaparin 4000 IU daily
Enoxaparin
Low-Dose LMWH: enoxaparin 4000 IU daily; High dose LMWH: 70 IU/kg twice daily
High-Dose LMWH
Enoxaparin 70 IU/kg twice daily
Enoxaparin
Low-Dose LMWH: enoxaparin 4000 IU daily; High dose LMWH: 70 IU/kg twice daily
Interventions
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Enoxaparin
Low-Dose LMWH: enoxaparin 4000 IU daily; High dose LMWH: 70 IU/kg twice daily
Other Intervention Names
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Eligibility Criteria
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Inclusion Criteria
* Severe pneumonia defined by the presence of at least one of the following criteria:
1. Respiratory Rate ≥25 breaths /min
2. Arterial oxygen saturation≤93% at rest on ambient air
3. PaO2/FiO2 ≤300 mmHg
* Coagulopathy, defined by the presence of at least one of the following criteria:
1. D-dimer \>4 times the upper level of normal reference range
2. Sepsis-Induced Coagulopathy (SIC) score \>4
* No need for invasive mechanical ventilation
Exclusion Criteria
* Thrombocytopenia (platelet count \< 80.000 mm3)
* Coagulopathy: INR \>1.5, aPTT ratio \> 1.4
* Impaired renal function (eGFR calculated by CKD-EPI Creatinine equation \< 30 ml/min)
* Known hypersensitivity to enoxaparin
* History of heparin induced thrombocytopenia
* Presence of an active bleeding or a pathology susceptible of bleeding in presence of anticoagulation (e.g. recent haemorrhagic stroke, peptic ulcer, malignant cancer at high risk of haemorrhage, recent neurosurgery or ophthalmic surgery, vascular aneurysms, arteriovenous malformations)
* Concomitant anticoagulant treatment for other indications (e.g. atrial fibrillation, venous thromboembolism, prosthetic heart valves).
* Concomitant double antiplatelet therapy
* Administration of therapeutic doses of LMWH, fondaparinux, or unfractionated heparin (UFH) for more than 72 hours before randomization; prophylactic doses are allowed
* Pregnancy or breastfeeding or positive pregnancy test
* Presence of other severe diseases impairing life expectancy (e.g. patients are not expected to survive 28 days given their pre-existing medical condition)
* Lack or withdrawal of informed consent
18 Years
80 Years
ALL
No
Sponsors
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Azienda Ospedaliero-Universitaria di Modena
OTHER
Responsible Party
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Marco Marietta
Head, Hemostasis and Thrombosis Unit
Principal Investigators
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Marco Marietta, MD
Role: PRINCIPAL_INVESTIGATOR
Azienda Ospedaliero-Universitaria di Modena
Locations
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Azienda Ospedaliero-Universitaria
Modena, , Italy
Countries
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Central Contacts
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Facility Contacts
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Pasquale Mighali
Role: primary
References
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Wu C, Chen X, Cai Y, Xia J, Zhou X, Xu S, Huang H, Zhang L, Zhou X, Du C, Zhang Y, Song J, Wang S, Chao Y, Yang Z, Xu J, Zhou X, Chen D, Xiong W, Xu L, Zhou F, Jiang J, Bai C, Zheng J, Song Y. Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China. JAMA Intern Med. 2020 Jul 1;180(7):934-943. doi: 10.1001/jamainternmed.2020.0994.
Leisman DE, Deutschman CS, Legrand M. Facing COVID-19 in the ICU: vascular dysfunction, thrombosis, and dysregulated inflammation. Intensive Care Med. 2020 Jun;46(6):1105-1108. doi: 10.1007/s00134-020-06059-6. Epub 2020 Apr 28. No abstract available.
Tang N, Bai H, Chen X, Gong J, Li D, Sun Z. Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy. J Thromb Haemost. 2020 May;18(5):1094-1099. doi: 10.1111/jth.14817. Epub 2020 Apr 27.
Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost. 2020 Apr;18(4):844-847. doi: 10.1111/jth.14768. Epub 2020 Mar 13.
Marietta M, Ageno W, Artoni A, De Candia E, Gresele P, Marchetti M, Marcucci R, Tripodi A. COVID-19 and haemostasis: a position paper from Italian Society on Thrombosis and Haemostasis (SISET). Blood Transfus. 2020 May;18(3):167-169. doi: 10.2450/2020.0083-20. Epub 2020 Apr 8. No abstract available.
Thachil J, Tang N, Gando S, Falanga A, Cattaneo M, Levi M, Clark C, Iba T. ISTH interim guidance on recognition and management of coagulopathy in COVID-19. J Thromb Haemost. 2020 May;18(5):1023-1026. doi: 10.1111/jth.14810. Epub 2020 Apr 27. No abstract available.
Thachil J. The versatile heparin in COVID-19. J Thromb Haemost. 2020 May;18(5):1020-1022. doi: 10.1111/jth.14821. Epub 2020 Apr 27. No abstract available.
Flumignan RL, Civile VT, Tinoco JDS, Pascoal PI, Areias LL, Matar CF, Tendal B, Trevisani VF, Atallah AN, Nakano LC. Anticoagulants for people hospitalised with COVID-19. Cochrane Database Syst Rev. 2022 Mar 4;3(3):CD013739. doi: 10.1002/14651858.CD013739.pub2.
Flumignan RL, Tinoco JDS, Pascoal PI, Areias LL, Cossi MS, Fernandes MI, Costa IK, Souza L, Matar CF, Tendal B, Trevisani VF, Atallah AN, Nakano LC. Prophylactic anticoagulants for people hospitalised with COVID-19. Cochrane Database Syst Rev. 2020 Oct 2;10(10):CD013739. doi: 10.1002/14651858.CD013739.
Other Identifiers
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EudraCT N°: 2020-001972-13
Identifier Type: -
Identifier Source: org_study_id