Safety of Darbepoetin Alfa Treatment in Patients With Severe Traumatic Brain Injury

Study Description

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Brief Summary:

The purpose of this study is to see if the treatment of severely brain injured patients with darbepoetin (a long acting form of erythropoietin) will be safe, and will reduce brain damage by decreasing harmful levels of chemicals in the brain.

Condition or disease	Intervention/treatment	Phase
Traumatic Brain Injury	Drug: Darbeopoetin; Drug: Normal Saline (Placebo)	Phase 2

Detailed Description:

Traumatic brain injury (TBI) is a common neurosurgical problem with a high morbidity and mortality. Studies interested in defining possible therapeutic targets in TBI have led to an appreciation of two phases of injury. These phases are referred to as primary and secondary TBI. The primary injury encompasses the immediate insult, diffuse axonal injury, hemorrhage, contusion, and primary ischemia. The secondary injury evolves over the post-traumatic period and is due to a combination of vasogenic and cytotoxic edema resulting from several processes including; glutamate excitotoxicity, disturbance of ionic homeostasis, lipid peroxidation, generation of nitric oxide (NO) and free radicals, and release of inflammatory regulators such as bradykinin and eicosanoids. It has long been recognized that one of the most important factors in the secondary injury process is the indiscriminate release of the excitatory neurotransmitter glutamate from neurons and glia. Glutamate excitotoxicity leads to substantial intraneuronal release of calcium which in turn mediates the activation of phospholipases which generate arachadonic acid, the activation of proteases, and the activation of NO, all of which cause neuronal membrane disruption and loss of ionic equilibrium. Receptors for erythropoietin (EPOr) are distributed throughout the brain and studies have demonstrated that these receptors are not only important in the process of development but also in neuroprotection. Treatment with erythropoietin (EPO) protects neurons in models of ischemic and traumatic degenerative damage due to exocitotoxins and consequent generation of free radicals including NO. EPOr activation also prevents the indiscriminate exocytosis of glutamate in a model of chemically induced ischemia on neurons of rat hippocampus.

The hypothesis of this study is that treatment of severely brain injured patients with darbepoetin alfa (Aranesp®) will be safe and reduce the cerebrospinal fluid (CSF) levels of glutamate within a 96 hour period after traumatic brain injury. This effect is potentially mediated through the activation of EPO receptors whose activation prevents the exocytosis of glutamate, a known neurocytotoxin, into CSF.

Study Design

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Study Type :	Interventional (Clinical Trial)
Actual Enrollment :	10 participants
Allocation:	Randomized
Intervention Model:	Crossover Assignment
Masking:	Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary Purpose:	Treatment
Official Title:	A Prospective Randomized Placebo Controlled Study of the Efficacy and Safety of Darbepoetin Alfa Treatment in Patients With Severe Traumatic Brain Injury
Study Start Date :	November 2006
Actual Primary Completion Date :	December 2009
Actual Study Completion Date :	December 2009

Arms and Interventions

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Arm	Intervention/treatment
Active Comparator: Darbopoeitin; The treatment group, comprised of ten patients, will receive an intravenous dose of 200 mcg (1 ml) of darbepoetin (Aranesp®). Patients will be randomly assigned to either the treatment group, or the control group in a 2:1 ratio. The treatment group will be given 200 mcg of darbepoetin intravenously. The control group will be given a matching placebo of 1 mL of normal saline.	Drug: Darbeopoetin; The treatment group, comprised of ten patients, will receive an intravenous dose of 200 mcg (1 ml) of darbepoetin (Aranesp®). Patients will be randomly assigned to either the treatment group, or the control group in a 2:1 ratio. The treatment group will be given 200 mcg of darbepoetin intravenously. The control group will be given a matching placebo of 1 mL of normal saline.; Other Name: ARANESP
Placebo Comparator: Normal Saline (Placebo); The treatment group, comprised of ten patients, will receive an intravenous dose of 200 mcg (1 ml) of darbepoetin (Aranesp®). Patients will be randomly assigned to either the treatment group, or the control group in a 2:1 ratio. The treatment group will be given 200 mcg of darbepoetin intravenously. The control group will be given a matching placebo of 1 mL of normal saline.	Drug: Normal Saline (Placebo); The treatment group, comprised of ten patients, will receive an intravenous dose of 200 mcg (1 ml) of darbepoetin (Aranesp®). Patients will be randomly assigned to either the treatment group, or the control group in a 2:1 ratio. The treatment group will be given 200 mcg of darbepoetin intravenously. The control group will be given a matching placebo of 1 mL of normal saline.; Other Name: Placebo

Outcome Measures

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Primary Outcome Measures :

1. Neuron-specific serum enolase, CSF glutamate and CSF S100B levels in patients receiving darbepoetin compared to placebo [ Time Frame: over 96 hours ]
   The primary outcome measures include Neuron-specific serum enolase, CSF glutamate and CSF S100B levels in patients receiving darbepoetin compared to placebo over a 96 hour period and ICP levels in patients receiving darbepoetin compared to placebo over a 96 hour period

Secondary Outcome Measures :

1. Secondary outcome measures include ICU and hospital length of stay, GCS at ICU discharge, survival status, location after ICU and hospital discharge. GCS will be evaluated at day 28 and 1 year. [ Time Frame: day 28 and 1 year ]

Eligibility Criteria

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Ages Eligible for Study:	18 Years to 70 Years (Adult, Older Adult)
Sexes Eligible for Study:	All
Accepts Healthy Volunteers:	No

Criteria

Inclusion Criteria:

• Age 18-70 inclusive.
• Admitted to ICU with a TBI and a GCS ≤ 8 with a motor score < 6.
• Patient must have a functioning external ventricular drain in place for intracranial pressure (ICP) monitoring.
• Completion of informed consent by the next-of-kin or legal guardian.
• Randomization within 12 hours of initial triage by medical or paramedical staff.
• Abnormal CT of the brain.

Exclusion Criteria:

• Pregnancy
• Cardiac arrest during the current hospital admission.
• Bilateral non-reactive dilated pupils at the time of randomization.
• A history of renal failure, NYHA class IV congestive heart failure, or recent myocardial infarction (within 6 months).
• A history of primary or secondary polycythemia.
• Previous adverse reactions to rhEPO or darbepoetin.
• Previous history of seizure disorder.
• Recent history (within the past 3 months) of significant uncontrolled hypertension defined as SBP > 200 mm Hg or DBP > 110 mmHg.
• Patients involved in other clinical investigations involving therapeutic interventions
• Hemoglobin ≥150 g/L in females
• Hemoglobin ≥160g/L in males
• Past history of thrombotic events

Contacts and Locations

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Locations

Canada, Alberta
Royal Alexandra Hospital
Edmonton, Alberta, Canada, T5H 3V9
University of Alberta Hospital
Edmonton, Alberta, Canada, T6G 2B7

Sponsors and Collaborators

Royal Alexandra Hospital

University of Alberta

Investigators

Principal Investigator:	Demetrios J. Kutsogiannis, MD MHS FRCPC	Division of Critical Care Medicine

More Information

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Responsible Party:	Demetrios J. Kutsogiannis, MD, MHS, FRCPC, Royal Alexandra Hospital
ClinicalTrials.gov Identifier:	NCT00375869 History of Changes
Other Study ID Numbers:	TBI2006
First Posted:	September 13, 2006
Last Update Posted:	March 5, 2012
Last Verified:	March 2012

Keywords provided by Demetrios J. Kutsogiannis, Royal Alexandra Hospital:

Neuroprotection; neuron specific enolase; CSF glutamate levels; Darbepoetin Alfa

Additional relevant MeSH terms:

Wounds and Injuries; Brain Injuries; Brain Injuries, Traumatic; Brain Diseases; Central Nervous System Diseases	Nervous System Diseases; Craniocerebral Trauma; Trauma, Nervous System; Darbepoetin alfa; Hematinics