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Apixaban After Anticoagulation-associated Intracerebral Haemorrhage in Patients With Atrial Fibrillation (APACHE-AF)

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ClinicalTrials.gov Identifier: NCT02565693
Recruitment Status : Recruiting
First Posted : October 1, 2015
Last Update Posted : December 5, 2018
Sponsor:
Collaborators:
Dutch Heart Foundation
ZonMw: The Netherlands Organisation for Health Research and Development
Information provided by (Responsible Party):
H. Bart van der Worp, UMC Utrecht

Brief Summary:

There is a marked lack of evidence on the optimal prevention of ischaemic stroke in patients with atrial fibrillation and a recent intracerebral haemorrhage (ICH) during treatment with oral anticoagulation. These patients are currently treated with vitamin K antagonists, DOACs, antiplatelet drugs, or no antithrombotic treatment, depending on personal and institutional preferences. Treatment with a direct oral anticoagulant like apixaban might be an attractive alternative in terms of a low risk of recurrent ICH, while at the same time being effective for the prevention of ischaemic stroke. This study aims to obtain reliable estimates of the rates of vascular death or non-fatal stroke in patients with atrial fibrillation and a recent anticoagulation-associated intracerebral haemorrhage who are treated with apixaban versus those who are treated with antiplatelet drugs or no antithrombotic drug at all.

This study has a multi-centre, phase II, randomised, open-label clinical trial with blinded outcome assessment design.


Condition or disease Intervention/treatment Phase
Cerebral Hemorrhage Atrial Fibrillation Drug: Apixaban Drug: Aspirin Drug: Carbasalate calcium Drug: Clopidogrel Drug: Dipyridamole Other: No antithrombotic treatment Phase 2

Detailed Description:

Rationale: There is a marked lack of evidence on the optimal prevention of ischaemic stroke and other thrombo-embolic events in patients with non-valvular atrial fibrillation (AF) and a recent intracerebral haemorrhage (ICH) during treatment with oral anticoagulation. These patients are currently treated with oral anticoagulants, antiplatelet drugs, or no antithrombotic treatment, depending on personal and institutional preferences. Randomised trials in patients with AF but without ICH have convincingly shown that vitamin K antagonists (VKAs, such as warfarin) reduce the risk of ischaemic stroke and other thrombo-embolic events, but increase the risk of bleeding as compared to no anticoagulant therapy. In the ARISTOTLE trial, the direct oral anticoagulant (DOAC) apixaban was superior to warfarin in preventing stroke or systemic embolism, caused less bleeding, and resulted in lower mortality. In other trials, the other DOACs, rivaroxaban, edoxaban, and dabigatran had a similar benefit as compared with warfarin. DOACs have not been tested in patients with AF and a recent ICH. Apixaban is the only DOAC tested against aspirin in a large randomised trial, in which patients with AF who were treated with apixaban had a lower risk of stroke or systemic embolism than those treated with aspirin, whereas ICH rates were similar in both treatment groups. We hypothesize that in patients with AF who survived an anticoagulation-associated ICH, apixaban is an attractive alternative to antiplatelet drugs or no antithrombotic treatment at all in terms of a low risk of recurrent ICH, while at the same time being more effective for the prevention of ischaemic stroke.

Objective: 1) To obtain reliable estimates of the rates of vascular death or non-fatal stroke in patients with atrial fibrillation and a recent anticoagulation-associated intracerebral haemorrhage who are treated with apixaban versus those who are treated with an antiplatelet drug or no antithrombotic drugs. 2) To compare the rates of all-cause death, stroke, ischaemic stroke, ICH, other major haemorrhage, systemic embolism, and functional outcome between patients treated with apixaban and those who are treated with an antiplatelet drug or no antithrombotic drugs.

Study design: A randomised, open, multi-center clinical trial with masked outcome assessment.

Study population: 100 adults with a history of atrial fibrillation and a recent intracerebral haemorrhage during treatment with anticoagulation in whom clinical equipoise exists on the optimal stroke prevention therapy.

Intervention: Apixaban 5 mg twice daily versus antiplatelet therapy or no antithrombotic drugs.

Primary outcome: Vascular death or non-fatal stroke during follow-up. Time frame: We aim to include 100 patients in six years. All patients will be followed up for the duration of the study, but at least for one year.


Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 100 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Apixaban Versus Antiplatelet Drugs or no Antithrombotic Drugs After Anticoagulation-associated Intracerebral Haemorrhage in Patients With Atrial Fibrillation: A Randomised Phase II Clinical Trial
Actual Study Start Date : September 2014
Estimated Primary Completion Date : January 31, 2021
Estimated Study Completion Date : January 31, 2021


Arm Intervention/treatment
Experimental: Apixaban

Apixaban: oral, 5 mg twice daily. If two of the three following criteria are met, the dose will be reduced to 2.5 mg twice daily:

  • Age ≥ 80 years
  • Body weight ≤ 60 kg
  • Serum creatinine ≥ 133 μmol. Additionally, if the creatinin clearance is below 30 ml per minute, the dose will be reduced to 2.5 mg twice daily.
Drug: Apixaban
Other Name: Eliquis

Avoiding oral anticoagulants

The following treatment regimens are allowed in the comparator arm:

- No antithrombotic treatment

or:

  • Acetylsalicylic acid 80 mg once daily
  • Carbasalate calcium 100 mg once daily
  • Clopidogrel 75 mg once daily
  • Acetylsalicylic acid 80 mg once daily and dipyridamole 200 mg twice daily
  • Carbasalate calcium 100 mg once daily and dipyridamole 200 mg twice daily
Drug: Aspirin
Other Name: Acetylsalicylic acid

Drug: Carbasalate calcium
Drug: Clopidogrel
Drug: Dipyridamole
Other: No antithrombotic treatment



Primary Outcome Measures :
  1. Number of patients who experience the combination of vascular death or non-fatal stroke (cerebral infarction, intracerebral haemorrhage, or subarachnoid haemorrhage) [ Time Frame: Throughout the study. Patients will be followed up between 12 (minimum) and 72 (maximum) months. ]

    Ischaemic stroke Clinical evidence of the sudden onset of an new neurological deficit, or an increase in an existing deficit, persisting for more than 24 hours, without evidence of a intracerebral haemorrhage on a CT or MRI scan or at post-mortem investigation.

    Intracerebral haemorrhage Clinical evidence of the sudden onset of a new neurological deficit, or an increase in an existing deficit, persisting for more than 24 hours, with a corresponding intracerebral haemorrhage on a CT or MR scan or at post-mortem investigation.

    Unclassified stroke Clinical evidence of the sudden onset of a new neurological deficit, or an increase in an existing deficit, persisting for more than 24 hours, without imaging or post-mortem investigations performed.

    Subarachnoid haemorrhage Subarachnoid haemorrhage (SAH) demonstrated by CT, lumbar puncture, or at post-mortem investigation.

    Vascular death See Outcome 2, Vascular death



Secondary Outcome Measures :
  1. Number of patients who experience vascular death [ Time Frame: Throughout the study. Patients will be followed up between 12 (minimum) and 72 (maximum) months. ]
  2. Number of patients who experience death from any cause. [ Time Frame: Throughout the study. Patients will be followed up between 12 (minimum) and 72 (maximum) months. ]
    Vascular death Death from cerebral infarction; intracerebral, subarachnoid, epidural, or subdural haemorrhage; unclassified stroke; myocardial infarction; extracranial haemorrhage; or systemic embolism. Death should have been unlikely without the events mentioned above. Other events classifying as vascular death: fatal arterial or gastric bleeding, terminal heart failure, fatal pulmonary embolism, and sudden death, defined as death within one hour after onset of symptoms.

  3. Number of patients who experience all stroke. [ Time Frame: Throughout the study. Patients will be followed up between 12 (minimum) and 72 (maximum) months. ]

    Ischaemic stroke Clinical evidence of the sudden onset of an new neurological deficit, or an increase in an existing deficit, persisting for more than 24 hours, without evidence of a intracerebral haemorrhage on a CT or MRI scan or at post-mortem investigation.

    Intracerebral haemorrhage Clinical evidence of the sudden onset of a new neurological deficit, or an increase in an existing deficit, persisting for more than 24 hours, with a corresponding intracerebral haemorrhage on a CT or MR scan or at post-mortem investigation.

    Unclassified stroke Clinical evidence of the sudden onset of a new neurological deficit, or an increase in an existing deficit, persisting for more than 24 hours, without imaging or post-mortem investigations performed.

    Subarachnoid haemorrhage Subarachnoid haemorrhage (SAH) demonstrated by CT, lumbar puncture, or at post-mortem investigation.


  4. Number of patients who experience ischaemic stroke. [ Time Frame: Throughout the study. Patients will be followed up between 12 (minimum) and 72 (maximum) months. ]
    Clinical evidence of the sudden onset of an new neurological deficit, or an increase in an existing deficit, persisting for more than 24 hours, without evidence of a intracerebral haemorrhage on a CT or MRI scan or at post-mortem investigation.

  5. Number of patients who experience intracerebral haemorrhage. [ Time Frame: Throughout the study. Patients will be followed up between 12 (minimum) and 72 (maximum) months. ]
    Clinical evidence of the sudden onset of a new neurological deficit, or an increase in an existing deficit, persisting for more than 24 hours, with a corresponding intracerebral haemorrhage on a CT or MR scan or at post-mortem investigation.

  6. Number of patients who experience other major extracranial haemorrhage [ Time Frame: Throughout the study. Patients will be followed up between 12 (minimum) and 72 (maximum) months. ]

    Major extracranial bleeding will be defined using the ISTH criteria.55 1) Fatal bleeding, and/or 2) Symptomatic bleeding in a critical area or organ, such as intraspinal, intraocular, retroperitoneal, intra-articular or pericardial, or intramuscular with compartment syndrome, and/or 3) Bleeding causing a fall in haemoglobin level of 1.24 mmol L-1 or more, or leading to transfusion of two or more units of whole blood or red cells.

    


  7. Number of patients who experience any intracranial haemorrhage other than ICH. [ Time Frame: Throughout the study. Patients will be followed up between 12 (minimum) and 72 (maximum) months. ]
    subdural haemorrhage: evidence of a subdural haematoma on a CT or MRI scan or at post-mortem investigations; epidural hematoma: evidence of an epidural haematoma on a CT or MRI scan or at post-mortem investigations.

  8. Number of patients who experience systemic embolism. [ Time Frame: Throughout the study. Patients will be followed up between 12 (minimum) and 72 (maximum) months. ]
    The diagnosis of systemic embolism requires a clinical history consistent with an acute loss of blood flow to a peripheral artery (or arteries) supported by evidence of embolism from surgical specimens, post-mortem investigations, angiography, vascular imaging, or other objective testing.

  9. Number of patients who experience myocardial infarction. [ Time Frame: Throughout the study. Patients will be followed up between 12 (minimum) and 72 (maximum) months. ]

    Detection of a rise and/or fall of cardiac biomarker values [preferably cardiac troponin] with at least 1 value above the 99th percentile upper reference limit and with at least 1 of the following:

    Symptoms of ischemia. New or presumed new significant ST-segment-T wave changes or new left bundle branch block. Development of pathological Q waves in the ECG. Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality. Identification of intracoronary thrombus by angiography or autopsy.

    Cardiac death with symptoms suggestive of myocardial ischemia and presumed new ischemic ECG changes or new LBBB, but death occurred before cardiac biomarkers were obtained, or before cardiac biomarker values would be increased.


  10. Number of patients who experience who experience a good functional outcome as assessed with the score on the modified Rankin Scale [ Time Frame: Throughout the study. Patients will be followed up between 12 (minimum) and 72 (maximum) months. ]
    Van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1988 May;19(5):604-7.



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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Intracerebral haemorrhage (including including isolated spontaneous intraventricular haemorrhage), documented with CT or MRI, during treatment with anticoagulation (VKA, any direct thrombin inhibitor, any factor Xa inhibitor, or (low molecular weight) heparin at a therapeutic dose).
  • The haemorrhage has occurred between 7 and 90 days before randomization.
  • Diagnosis of (paroxysmal) non-valvular AF, documented on electrocardiography.
  • A CHA2DS2-VASc score ≥ 2.
  • Score on the modified Rankin scale (mRS)≤4.
  • Equipoise regarding the optimal medical treatment for the prevention of stroke.
  • Age ≥ 18 years.
  • Written informed consent by the patient or by a legal representative

Exclusion Criteria:

  • Conditions other than atrial fibrillation for which the patient requires long-term anticoagulation
  • A different clinical indication for the use of an antiplatelet drug even if treated with apixaban, such as clopidogrel for recent coronary stenting.
  • Mechanical prosthetic heart valve (biological prosthetic heart valves are allowed) or rheumatic mitral valve disease.
  • Serious bleeding event in the previous 6 months, except for intracerebral haemorrhage.
  • High risk of bleeding (e.g., active peptic ulcer disease, a platelet count of <100,000.mL-1 or haemoglobin level of <6.2 mMol.L-1, ischaemic stroke in the previous 7 days (patients are eligible thereafter), documented haemorrhagic tendencies, or blood dyscrasias).
  • Current alcohol or drug abuse.
  • Life expectancy of less than 1 year.
  • Severe renal insufficiency (a serum creatinine level of more than 221 μmol per liter or a calculated creatinine clearance of <15 ml per minute).
  • Alanine aminotransferase or aspartate aminotransferase level greater than 2 times the upper limit of the normal range or a total bilirubin more than 1.5 times the upper limit of the normal range, unless a benign causative factor (e.g. Gilbert's syndrome) is known or identified.
  • Allergy to apixaban.
  • Use of strong cytochrome P450 3A4 (CYP3A4) and P-glycoprotein (P-gp) inhibitors (e.g. systemic azole-antimycotics as ketoconazole or HIV protease inhibitors such as ritonavir).
  • Pregnancy or breastfeeding.
  • Women of childbearing potential: any woman who has begun menstruation and is not postmenopausal or otherwise permanently unable to conceive. A postmenopausal woman is defined as a woman who is over the age of 45 and has not had a menstrual period for at least 12 months.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT02565693


Contacts
Contact: Floris H.B.M. Schreuder, MD +31243610245 Floris.Schreuder@radboudumc.nl
Contact: H Bart van der Worp, MD PhD + 31 88 755 7975 h.b.vanderworp@umcutrecht.nl

Locations
Netherlands
Amsterdam UMC Recruiting
Amsterdam, Netherlands
Principal Investigator: Jonathan Coutinho, MD PhD         
OLVG Recruiting
Amsterdam, Netherlands
Principal Investigator: Vincent IH Kwa, MD PhD         
Gelre Ziekenhuizen Recruiting
Apeldoorn, Netherlands
Principal Investigator: Henri P Bienfait, MD         
Rijnstate Recruiting
Arnhem, Netherlands
Principal Investigator: Jeannette Hofmeijer, MD PhD         
Amphia Ziekenhuis Recruiting
Breda, Netherlands
Principal Investigator: Michel JM Remmers, MD         
Haaglanden MC Recruiting
Den Haag, Netherlands
Contact: Ido R van den Wijngaard    +31 88 979 2508    i.van.den.wijngaard@haaglandenmc.nl   
Albert Schweitzer Ziekenhuis Recruiting
Dordrecht, Netherlands
Principal Investigator: Henk Kerkhoff, MD PhD         
Medisch Spectrum Twente Recruiting
Enschede, Netherlands
Principal Investigator: Heleen M den Hertog, MD PhD         
University Medical Center Groningen Recruiting
Groningen, Netherlands
Principal Investigator: Gert-Jan Luijckx, MD PhD         
Zuyderland Ziekenhuis Recruiting
Heerlen, Netherlands
Principal Investigator: Antonia CH Schreuder, MD         
Leiden University Medical Center Recruiting
Leiden, Netherlands
Principal Investigator: Marieke JH Wermer, MD PhD         
Maastricht University Medical Center Recruiting
Maastricht, Netherlands
Principal Investigator: Julie Staals, MD PhD         
Radboud University Medical Center Recruiting
Nijmegen, Netherlands
Principal Investigator: Catherina JM Klijn, MD PhD         
Erasmus MC Recruiting
Rotterdam, Netherlands
Principal Investigator: Diederik WJ Dippel, MD PhD         
Elisabeth-Tweesteden Ziekenhuis Recruiting
Tilburg, Netherlands
Principal Investigator: Julia H van Tuijl, MD PhD         
UMC Utrecht Recruiting
Utrecht, Netherlands, 3584CX
Contact: Bart M van der Worp, MD, PhD    +31887577975    h.b.vanderworp@umcutrecht.nl   
Principal Investigator: H Bart van der Worp, MD PhD         
Sub-Investigator: Koen M van Nieuwenhuizen, MD         
Sponsors and Collaborators
UMC Utrecht
Dutch Heart Foundation
ZonMw: The Netherlands Organisation for Health Research and Development
Investigators
Study Chair: Catharina JM Klijn, MD PhD Radboud University
Study Chair: H Bart van der Worp, MD PhD UMC Utrecht

Additional Information:
Responsible Party: H. Bart van der Worp, Co-Coordinating Investigator, UMC Utrecht
ClinicalTrials.gov Identifier: NCT02565693     History of Changes
Other Study ID Numbers: NL47761.041.14
2014-000112-33 ( EudraCT Number )
NTR4526 ( Registry Identifier: Nederlands Trialregister )
U1111-1154-5474 ( Registry Identifier: WHO Universal Trial Number )
First Posted: October 1, 2015    Key Record Dates
Last Update Posted: December 5, 2018
Last Verified: December 2018

Additional relevant MeSH terms:
Atrial Fibrillation
Hemorrhage
Cerebral Hemorrhage
Arrhythmias, Cardiac
Heart Diseases
Cardiovascular Diseases
Pathologic Processes
Intracranial Hemorrhages
Cerebrovascular Disorders
Brain Diseases
Central Nervous System Diseases
Nervous System Diseases
Vascular Diseases
Clopidogrel
Aspirin
Dipyridamole
Apixaban
Carbaspirin calcium
Platelet Aggregation Inhibitors
Purinergic P2Y Receptor Antagonists
Purinergic P2 Receptor Antagonists
Purinergic Antagonists
Purinergic Agents
Neurotransmitter Agents
Molecular Mechanisms of Pharmacological Action
Physiological Effects of Drugs
Factor Xa Inhibitors
Antithrombins
Serine Proteinase Inhibitors
Protease Inhibitors