STAT-STatin and Aspirin in Trauma (STAT)

• ClinicalTrials.gov Identifier: NCT02901067
• Recruitment Status: Recruiting
• First Posted: September 15, 2016
• Last Update Posted: June 19, 2020
• Sponsor: Denver Health and Hospital Authority
• Information provided by (Responsible Party): Ernest E. Moore, MD, Denver Health and Hospital Authority

Study Description

Brief Summary:

This is a phase II, pragmatic, prospective, randomized, double-blind, adaptive clinical trial examining the efficacy of statins and aspirin in the reduction of acute lung injury and venous thromboembolism in patients with fibrinolysis shutdown.

Condition or disease	Intervention/treatment	Phase
Wounds and Injuries; Venous Thromboembolism	Drug: Aspirin and Rosuvastatin; Drug: Placebo (for Aspirin and Rosuvastatin)	Phase 2

Detailed Description:

This protocol describes a Phase II, pragmatic, prospective, randomized, double-blind, adaptive clinical trial comparing combination rosuvastatin and aspirin therapy to placebo. Currently, there is no treatment for fibrinolysis shutdown or effective measures to prevent macro- and micro-thrombosis post-injury, thus, placebos are acceptable as the control group. Treatment for both groups would otherwise be by standard of care, which includes pharmacologic thromboembolism prophylaxis. The safety of concomitant use of VTE pharmacological prophylaxis with statins and aspirin is well documented in cardiac surgery patients.

Eligible adult patients with anticipated ICU admission will be screened for eligibility in the STAT trial (see inclusion/exclusion criteria) based on history, physical exam and clinical data obtained during their initial treatment. If deemed eligible for enrollment in the STAT trial, the patient, their legally authorized representative (LAR), or their proxy decision-maker will be contacted by our on-site professional research assistants (PRAs) for consent to enroll in the study. Only patients for whom consent is obtained within 24 hours post-injury will be eligible for randomization into the treatment phase of the study.

Upon consent, blood samples will be obtained immediately after consent at 6, 12, 24, 48, 72, 120 and 168 hours after injury. Traditional and tPA-Challenge TEG will be performed on these samples to evaluate the development of the three fibrinolysis phenotypes. Upon receiving an order for prophylactic anticoagulation, the DHMC pharmacy will randomize the patient to the control or intervention arms of the study. Randomization will occur using a computer-generated block (groups of 20 patients) random number sequence in sealed, opaque envelopes maintained at the DHMC pharmacy. Patients assigned to the intervention arm will receive the standard of care anticoagulation plus the combination experimental drugs (20mg of rosuvastatin daily and 325mg of aspirin) daily either orally or crushed via feeding tube. These doses are consistent with those currently recommended in the postoperative period following cardiac surgery. Patients assigned to the control group will receive identical-looking placebos at the same time points as the experimental group either orally or crushed via feeding tube.

Healthcare providers, PRAs and patients will be blinded to study allocation standard of care anticoagulation plus the combination placebos (produced to look and group assignment (double-blind design).

The DHMC pharmacist will be aware of the patient's treatment arm so that rapid un-blinding will be possible in the event of an adverse event possibly related to a study medication. The blood samples will be used to monitor for the type of fibrinolysis, the function of the biochemical mediators of coagulation and potential side effects of these medications, as explained in more detail below.

Study medications or placebo will be administered during ICU admission while patients are receiving the standard of care dosing of prophylactic anticoagulation (i.e. heparin or heparin-derivatives) and will be interrupted concomitantly with interruption of pharmacological VTE prophylaxis. Patients diagnosed with VTE will be withdrawn from the study drugs and will receive the appropriate VTE treatment per current ICU protocols.

The investigators will monitor function/damage of liver, renal and muscle before initiation of therapy (if the patient already has a recent test of these functions up to 12 hours prior to the initiation of therapy, the result of this test will be used to avoid unnecessary sampling), and upon the end of the therapy or as clinically necessary (i.e., any clinical indications of organ dysfunction). Stopping rules are:

1. Bleeding: Any ongoing bleeding requiring blood transfusion or operative procedure to stop bleeding. Bleeding will be monitored via monitoring of the daily measurements of hemoglobin levels, which are an integral part of the ICU protocols for trauma patients. Study medications will be unblinded and stopped if there is an unexplained drop in hemoglobin level greater than 2g/dl within 24 hours after enrollment leading to discontinuation of VTE Prophylaxis OR a drop in hemoglobin level greater than 1g/dl daily for three consecutive days leading to discontinuation of VTE Prophylaxis.

2. Liver dysfunction: Alteration in liver chemistry is a rare sequela of statin therapy. A meta-analysis of 13 placebo-controlled trials incorporating nearly 50,000 patients examined the incidence of liver toxicity (defined as elevation of hepatic transaminases greater than 3 times the upper limit of normal) in patients receiving statin therapy. 77 This study reported the incidence of elevated AST or ALT in statin-treated patients vs placebo controls as 1.14% and 1.05%, respectively (OR 1.25; 95% CI 0.99

   - 1.62). Further, the only individual drug associated with a statistically significant elevation in transaminases over a follow-up interval exceeding 3 years was fluvastatin. These and more recent data have informed expert opinion, 78 which ultimately prompted the FDA in 2012 to revoke the recommendation that liver function tests be monitored in patients taking statins. That said, given our at-risk patient population, the investigators will use the accepted definition of 3 times the baseline of the AST test as the criterion for interruption of therapy;

3. Renal dysfunction: While transient proteinuria has been observed in patients undergoing statin therapy, acute kidney injury (AKI) is a rare complication. The JUPITER randomized controlled trial incorporating approximately 17,000 patients and comparing rosuvastatin to placebo found no difference in AKI (6.0% v 5.4%; p = 0.08) between the groups. 79 In a randomized trial comparing rosuvastatin to atorvastatin, simvastatin, and pravastatin, acute renal failure was observed in 2 of 420 patients receiving high-dose rosuvastatin. 80 The AKI as serum creatinine increase greater than 2x of baseline (>Grade 1, based on AKIN criteria) as the criterion to interrupt therapy.
4. Muscle injury: Myositis and rhabdomyolysis are rare sequelae of statin therapy. A meta-analysis of 26 studies incorporating nearly 130,000 patients identified an incidence of between 1 and 4 per 10,000 patients developing rhabdomyolysis following statin therapy. 81 This meta-analysis includes a study of 12,000 patients comparing the efficacy of simvastatin 80mg with 20mg doses. In this study, the overall incidence of myolysis and rhabdomyolysis were 0.5 and 0.1 per 1000 person-years, respectively, wherein all cases of rhabdomyolysis occurred in the high dose cohort. 82 The accepted definition of myositis is muscle pain in the setting of a serum creatine kinase concentration greater than 10 times the patient's baseline.46 The investigators will use this threshold to clinically quantify myositis, preceding potential development of rhabdomyolysis, as well as the criterion to interrupt therapy.
5. If the study patient receives aspirin, as prescribed by their SICU attending, administration of the study drug will be stopped.
6. Thrombocytopenia: If the study patient's platelet count decreases below 50,000 uL requiring transfusion of platelets while receiving the study drug, administration of the study drug will be stopped. This will be monitored and recorded in our twice daily safety monitoring log.

Any of the above-mentioned stopping rules will be reported as an SAE and will trigger an immediate review by the DSMB.

Study Design

• Study Type: Interventional (Clinical Trial)
• Estimated Enrollment: 440 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
• Primary Purpose: Treatment
• Official Title: STAT (STatins and Aspirin in Trauma) Trial: A Phase II, Pragmatic, Prospective, Randomized, Double-blind, Adaptive Clinical Trial Examining the Efficacy of Statins and Aspirin in the Reduction of Acute Lung Injury and Venous Thromboembolism in Patients With Fibrinolysis Shutdown
• Actual Study Start Date: February 3, 2017
• Estimated Primary Completion Date: December 2021
• Estimated Study Completion Date: December 2021

Arms and Interventions

Arm	Intervention/treatment
Experimental: Experimental; Administration of 325mg Aspirin and 20mg of Rosuvastatin mixture in a single capsule daily either orally or via a feeding tube for the duration of the patient's stay in the ICU.	Drug: Aspirin and Rosuvastatin; Patients assigned to the intervention arm will receive the standard of care anti-coagulation plus the combination experimental drugs (20mg of rosuvastatin daily and 325mg of aspirin) daily either orally or via feeding tube.
Placebo Comparator: Control; Administration of the placebo, which is identical-looking to the Aspirin and Rosuvastatin single capsule mixture, daily either orally or via a feeding tube for the duration of the patient's stay in the ICU.	Drug: Placebo (for Aspirin and Rosuvastatin); Patients assigned to the control group will receive the standard of care anti-coagulation plus identical-looking placebos either orally or via feeding tube.

Outcome Measures

Primary Outcome Measures :

1. Incidence of VTE [ Time Frame: Day 5 or ICU discharge or upon symptoms of VTE (whichever comes first) ]
   Based on screening duplex ultrasound (US) of legs and central line on day 5 or upon ICU discharge or upon symptoms of VTE (whichever comes first).

Secondary Outcome Measures :

1. Fibrinolysis phenotypes [ Time Frame: During ICU stay at the following timepoints - 6, 12, 24, 48, 72, 120 and 168 hours ]
   Measured by traditional and tissue plasminogen activator (tPA) - Challenge thrombelastography (TEG) lysis at 30 minutes (LY30).
2. Plasminogen activator inhibitor (PAI) - 1 and tissue plasminogen activator (tPA) levels in plasma [ Time Frame: During ICU stay at the following timepoints - 6, 12, 24, 48, 72, 120 and 168 hours ]
   To be measured in platelet poor plasma (PPP)
3. Incidence of acute lung injury (ALI) [ Time Frame: Within two weeks post-injury ]
   Based on Berlin Criteria
4. Ventilator days [ Time Frame: Up to 28 days ]
   As measured by ventilator-free days
5. Incidence of arterial thrombotic complications: myocardial infarction (MI) and cerebrovascular accident (CVA). [ Time Frame: Up to 28 days ]
6. All-cause mortality [ Time Frame: 30 days ]
7. Intensive care unit (ICU) days [ Time Frame: Up to 28 days ]
   As measured by ICU-free days
8. Incidence of multiple organ failure (MOF) [ Time Frame: Up to 28 days ]
   As measured by Denver MOF score

Eligibility Criteria

• Ages Eligible for Study: 18 Years to 65 Years (Adult, Older Adult)
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Criteria

Inclusion Criteria: all adult trauma patients requiring admission to the surgical intensive care unit (SICU) and expected hospital stay for at least 3 days. Outside hospital transfer patients that require SICU admission less than 24 hours after their injury are also eligible for enrollment.

Exclusion criteria for prophylactic anticoagulation and for the study are:

• Known inherited bleeding disorder or coagulopathy
• Known contraindication to pharmacologic anticoagulation
• Spinal column fracture with epidural hematoma

• Head trauma/central nervous system injury

  • Severe TBI; defined as AIS Head >3
  • Intracranial hemorrhage; subdural or epidural hematoma
  • Neurosurgery service objection; neurosurgical contra-indications will be documented
• Ongoing hemorrhage requiring blood product transfusion
• Thrombocytopenia (platelet count < 50,000)
• Non-operatively managed liver or spleen injuries Grade III or above
• Known chronic kidney disease (GFR < 15ml/min)
• Rising creatinine (Cr > 1.5x baseline) at the time of enrollment
• Inclusion in any other clinical trial
• Documented previous ischemic strokes

In addition, the following exclusion criteria apply:

• Receiving statin or aspirin therapy pre-injury, as potentially being assigned for Control would increase patient's risks
• Known allergy or other contraindication to statins or aspirin
• Pregnant patients
• Prisoners, as their ability to freely consent is impaired
• Inability to obtain consent from patient or proxy prior to 48 hours post-injury
• VTE event (DVT or PE) diagnosed during current hospitalization prior to obtaining informed consent

Contacts and Locations

Contacts

Contact: Arsen Ghasabyan, MPH; 3036023795; arsen.ghasabyan@dhha.org

Contact: James Chandler; james.chandler@dhha.org

Locations

United States, Colorado

Denver Health Medical Center; Recruiting

Denver, Colorado, United States, 80204

Principal Investigator: Ernest E. Moore, M.D.

Sponsors and Collaborators

Denver Health and Hospital Authority

Investigators

• Principal Investigator: Ernest E Moore, MD; Denver Health Medical Center

  Study Documents (Full-Text)

Documents provided by Ernest E. Moore, MD, Denver Health and Hospital Authority:

Informed Consent Form  [PDF] February 22, 2019

Study Protocol and Statistical Analysis Plan  [PDF] February 22, 2019

More Information

• Responsible Party: Ernest E. Moore, MD, Professor of Surgery, Denver Health and Hospital Authority
• ClinicalTrials.gov Identifier: NCT02901067
• Other Study ID Numbers: COMIRB 16-0391
• First Posted: September 15, 2016
• Last Update Posted: June 19, 2020
• Last Verified: June 2020

• Studies a U.S. FDA-regulated Drug Product: Yes
• Studies a U.S. FDA-regulated Device Product: No

Keywords provided by Ernest E. Moore, MD, Denver Health and Hospital Authority:

Fibrinolysis

Additional relevant MeSH terms:

Thromboembolism; Venous Thromboembolism; Wounds and Injuries; Embolism and Thrombosis; Vascular Diseases; Cardiovascular Diseases; Aspirin; Rosuvastatin Calcium; Anti-Inflammatory Agents, Non-Steroidal; Analgesics, Non-Narcotic; Analgesics; Sensory System Agents; Peripheral Nervous System Agents; Physiological Effects of Drugs; Anti-Inflammatory Agents; Antirheumatic Agents; Fibrinolytic Agents; Fibrin Modulating Agents; Molecular Mechanisms of Pharmacological Action; Platelet Aggregation Inhibitors; Cyclooxygenase Inhibitors; Enzyme Inhibitors; Antipyretics; Anticholesteremic Agents; Hypolipidemic Agents; Antimetabolites; Lipid Regulating Agents; Hydroxymethylglutaryl-CoA Reductase Inhibitors