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Prophylaxis With Apixaban in Transplant Eligible Patients With Multiple Myeloma Receiving Induction Therapy With IMiDs

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details.
 
ClinicalTrials.gov Identifier: NCT04106700
Recruitment Status : Suspended (Low recruitment)
First Posted : September 27, 2019
Last Update Posted : June 11, 2020
Sponsor:
Collaborator:
Bristol-Myers Squibb
Information provided by (Responsible Party):
Instituto de Investigacion Sanitaria La Fe

Brief Summary:
Interventional, no-randomized, open-label, and single arm multicentre study of apixaban for the prevention of thromboembolic events during induction therapy in transplant-eligible patients with newly diagnosed multiple myeloma who receive bortezomib, thalidomide, and dexamethasone (VTD) during the induction phase of therapy prior to autologous stem cell transplantation (ASCT). The current study is designed to evaluate the efficacy and safety of apixaban during the induction period. Efficacy will be defined as a composite endpoint of acute symptomatic proximal and distal deep venous thrombosis, pulmonary embolism, VTE related deaths, and acute ischemic stroke.

Condition or disease Intervention/treatment Phase
Venous Thromboembolism Drug: Apixaban 2.5 MG Phase 2

Detailed Description:

This study is designed to test the efficacy and safety of the oral anti factor Xa apixaban 2.5 mg given twice daily as a prophylaxis of VTE in transplant-eligible patients with multiple myeloma during the induction therapy with VTD.

Induction therapy prior to ASCT will consist in no less than 4 and no more than 6 cycles of VTD, depending on treatment response. Duration of each cycle is 4 weeks if there is not any disease or treatment-related complication; therefore, treatment duration will be around 4-6 months. Daily Prophylaxis with apixaban will continue up to a maximum of 14 days after the last dose of thalidomide. In addition, there will be an additional observation period of 14 (± 7) days, starting the day after the last dose of study medication (until 28 days after the end of the last cycle of VTD).

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 60 participants
Allocation: N/A
Intervention Model: Single Group Assignment
Intervention Model Description: Clinical trial with a single arm
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Venous Thromboembolism Prophylaxis With Apixaban in Transplant Eligible Patients With Newly Diagnosed Multiple Myeloma Receiving Induction Therapy With an Immunomodulatory-based Regimen
Actual Study Start Date : April 12, 2019
Estimated Primary Completion Date : July 31, 2020
Estimated Study Completion Date : July 31, 2020

Resource links provided by the National Library of Medicine

MedlinePlus related topics: Multiple Myeloma
Drug Information available for: Apixaban

Arm Intervention/treatment
Experimental: Apixaban (single arm) Drug: Apixaban 2.5 MG
Apixaban will be started simultaneously with anti myeloma treatment on day 1 of cycle 1 of VTD, and continues for 4 to 6 months depending on the number of induction cycles administered to the patient




Primary Outcome Measures :
  1. Venous thromboembolism (VTE)- related death [ Time Frame: Cycle 1 Day 1 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    i.e. death for which VTE can not be excluded as a cause

  2. Venous thromboembolism (VTE)- related death [ Time Frame: Cycle 2 Day 1 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    i.e. death for which VTE can not be excluded as a cause

  3. Venous thromboembolism (VTE)- related death [ Time Frame: Cycle 3 Day 1 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    i.e. death for which VTE can not be excluded as a cause

  4. Venous thromboembolism (VTE)- related death [ Time Frame: Cycle 4 Day 1 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    i.e. death for which VTE can not be excluded as a cause

  5. Venous thromboembolism (VTE)- related death [ Time Frame: Cycle 5 Day 1(each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    i.e. death for which VTE can not be excluded as a cause

  6. Venous thromboembolism (VTE)- related death [ Time Frame: Cycle 6 Day 1 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    i.e. death for which VTE can not be excluded as a cause

  7. Venous thromboembolism (VTE)- related death [ Time Frame: Cycle 4 Day 29 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    i.e. death for which VTE can not be excluded as a cause

  8. Venous thromboembolism (VTE)- related death [ Time Frame: Cycle 6 Day 29 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    i.e. death for which VTE can not be excluded as a cause

  9. Venous thromboembolism (VTE)- related death [ Time Frame: Cycle 4 Day 43 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    i.e. death for which VTE can not be excluded as a cause

  10. Venous thromboembolism (VTE)- related death [ Time Frame: Cycle 6 Day 43 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    i.e. death for which VTE can not be excluded as a cause

  11. Venous thromboembolism (VTE)- related death [ Time Frame: 14 days after last dose of apixaban ]
    i.e. death for which VTE can not be excluded as a cause

  12. Symptomatic deep-vein thrombosis (DVT) [ Time Frame: Cycle 1 Day 1 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    Lower extremity DVT: erythema (redness of the skin), warmth, pain, swelling, tenderness

  13. Symptomatic deep-vein thrombosis (DVT) [ Time Frame: Cycle 2 Day 1 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    Lower extremity DVT: erythema (redness of the skin), warmth, pain, swelling, tenderness

  14. Symptomatic deep-vein thrombosis (DVT) [ Time Frame: Cycle 3 Day 1 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    Lower extremity DVT: erythema (redness of the skin), warmth, pain, swelling, tenderness

  15. Symptomatic deep-vein thrombosis (DVT) [ Time Frame: Cycle 4 Day 1 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    Lower extremity DVT: erythema (redness of the skin), warmth, pain, swelling, tenderness

  16. Symptomatic deep-vein thrombosis (DVT) [ Time Frame: Cycle 5 Day 1 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    Lower extremity DVT: erythema (redness of the skin), warmth, pain, swelling, tenderness

  17. Symptomatic deep-vein thrombosis (DVT) [ Time Frame: Cycle 6 Day 1 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    Lower extremity DVT: erythema (redness of the skin), warmth, pain, swelling, tenderness

  18. Symptomatic deep-vein thrombosis (DVT) [ Time Frame: Cycle 4 Day 29 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    Lower extremity DVT: erythema (redness of the skin), warmth, pain, swelling, tenderness

  19. Symptomatic deep-vein thrombosis (DVT) [ Time Frame: Cycle 6 Day 29 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    Lower extremity DVT: erythema (redness of the skin), warmth, pain, swelling, tenderness

  20. Symptomatic deep-vein thrombosis (DVT) [ Time Frame: Cycle 4 Day 43 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    Lower extremity DVT: erythema (redness of the skin), warmth, pain, swelling, tenderness

  21. Symptomatic deep-vein thrombosis (DVT) [ Time Frame: Cycle 6 Day 43 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    Lower extremity DVT: erythema (redness of the skin), warmth, pain, swelling, tenderness

  22. Symptomatic deep-vein thrombosis (DVT) [ Time Frame: 14 days after last dose of apixaban ]
    Lower extremity DVT: erythema (redness of the skin), warmth, pain, swelling, tenderness

  23. Pulmonary embolism (PE) [ Time Frame: Cycle 1 Day 1 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    Pleuritic chest pain, dyspnea (shortness of breath), cough, hemoptysis (expectoration of blood or blood-stained sputum), syncope (fainting), lightheadedness/dizziness, tachypnea (rapid breathing), tachycardia (fast heart rate).

  24. Pulmonary embolism (PE) [ Time Frame: Cycle 2 Day 1 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    Pleuritic chest pain, dyspnea (shortness of breath), cough, hemoptysis (expectoration of blood or blood-stained sputum), syncope (fainting), lightheadedness/dizziness, tachypnea (rapid breathing), tachycardia (fast heart rate).

  25. Pulmonary embolism (PE) [ Time Frame: Cycle 3 Day 1 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    Pleuritic chest pain, dyspnea (shortness of breath), cough, hemoptysis (expectoration of blood or blood-stained sputum), syncope (fainting), lightheadedness/dizziness, tachypnea (rapid breathing), tachycardia (fast heart rate).

  26. Pulmonary embolism (PE) [ Time Frame: Cycle 4 Day 1 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    Pleuritic chest pain, dyspnea (shortness of breath), cough, hemoptysis (expectoration of blood or blood-stained sputum), syncope (fainting), lightheadedness/dizziness, tachypnea (rapid breathing), tachycardia (fast heart rate).

  27. Pulmonary embolism (PE) [ Time Frame: Cycle 5 Day 1 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    Pleuritic chest pain, dyspnea (shortness of breath), cough, hemoptysis (expectoration of blood or blood-stained sputum), syncope (fainting), lightheadedness/dizziness, tachypnea (rapid breathing), tachycardia (fast heart rate).

  28. Pulmonary embolism (PE) [ Time Frame: Cycle 6 Day 1 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    Pleuritic chest pain, dyspnea (shortness of breath), cough, hemoptysis (expectoration of blood or blood-stained sputum), syncope (fainting), lightheadedness/dizziness, tachypnea (rapid breathing), tachycardia (fast heart rate).

  29. Pulmonary embolism (PE) [ Time Frame: Cycle 4 Day 29 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    Pleuritic chest pain, dyspnea (shortness of breath), cough, hemoptysis (expectoration of blood or blood-stained sputum), syncope (fainting), lightheadedness/dizziness, tachypnea (rapid breathing), tachycardia (fast heart rate).

  30. Pulmonary embolism (PE) [ Time Frame: Cycle 6 Day 29 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    Pleuritic chest pain, dyspnea (shortness of breath), cough, hemoptysis (expectoration of blood or blood-stained sputum), syncope (fainting), lightheadedness/dizziness, tachypnea (rapid breathing), tachycardia (fast heart rate).

  31. Pulmonary embolism (PE) [ Time Frame: Cycle 4 Day 43 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    Pleuritic chest pain, dyspnea (shortness of breath), cough, hemoptysis (expectoration of blood or blood-stained sputum), syncope (fainting), lightheadedness/dizziness, tachypnea (rapid breathing), tachycardia (fast heart rate).

  32. Pulmonary embolism (PE) [ Time Frame: Cycle 6 Day 43 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]
    Pleuritic chest pain, dyspnea (shortness of breath), cough, hemoptysis (expectoration of blood or blood-stained sputum), syncope (fainting), lightheadedness/dizziness, tachypnea (rapid breathing), tachycardia (fast heart rate).

  33. Pulmonary embolism (PE) [ Time Frame: 14 days after last dose of apixaban ]
    Pleuritic chest pain, dyspnea (shortness of breath), cough, hemoptysis (expectoration of blood or blood-stained sputum), syncope (fainting), lightheadedness/dizziness, tachypnea (rapid breathing), tachycardia (fast heart rate).

  34. Asymptomatic proximal DVT as detected by systematic compression ultrasound [ Time Frame: Cycle 4 Day 43 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]

    Diagnostic assessment of DVT. Presence of any one of the following will be considered diagnostic for the presence of DVT:

    1. New or previously undocumented non-compressibility of one or more proximal venous segments (popliteal vein or higher) of the legs on compression ultrasound.
    2. Constant intraluminal filing defect(s) in two or more views on contrast venography in one or more venous segments in the legs or pelvis, or involving the inferior vena cava.

  35. Asymptomatic proximal DVT as detected by systematic compression ultrasound [ Time Frame: Cycle 6 Day 43 (each cycle is 28 days. Treatment will finish on cycle 4 or 6. Treatment with Apixaban will continue until 14 days after cycle 4/6) ]

    Diagnostic assessment of DVT. Presence of any one of the following will be considered diagnostic for the presence of DVT:

    1. New or previously undocumented non-compressibility of one or more proximal venous segments (popliteal vein or higher) of the legs on compression ultrasound.
    2. Constant intraluminal filing defect(s) in two or more views on contrast venography in one or more venous segments in the legs or pelvis, or involving the inferior vena cava.


Secondary Outcome Measures :
  1. Major bleeding event [ Time Frame: Cycle 1 Day 1, Cycle 2 Day 1, Cycle 3 Day 1, Cycle 4 Day 1, Cycle 5 Day 1, Cycle 6 Day 1, Cycle 4/ 6 Day 29, Cycle 4/6 Day 43, Day 14 after end of treatment (each cycle is 28 days. Treatment with Apixaban will continue until 14 days after cycle 4 or 6) ]

    Defined as a bleeding event that is acute clinically overt bleeding accompanied by one or more of the following:

    • A decrease in hemoglobin (Hb) of 2 g/dL or more over a 24-hour period.
    • A transfusion of 2 or more units of packed red blood cells.
    • Bleeding that occurs in at least one of the following critical sites: intracranial, intra-spinal, intraocular (within the corpus of the eye; thus, a conjunctival bleed is not an intraocular bleed), pericardial, an operated joint and requires re-operation or intervention, intramuscular with compartment syndrome, retroperitoneal.
    • Bleeding that is fatal.

  2. Clinically relevant non-major bleeding event [ Time Frame: Cycle 1 Day 1, Cycle 2 Day 1, Cycle 3 Day 1, Cycle 4 Day 1, Cycle 5 Day 1, Cycle 6 Day 1, Cycle 4/ 6 Day 29, Cycle 4/6 Day 43, Day 14 after end of treatment (each cycle is 28 days. Treatment with Apixaban will continue until 14 days after cycle 4 or 6) ]

    Defined as a bleeding event that is:

    • Acute clinically overt bleeding.
    • Does not satisfy additional criteria required for the bleeding event to be defined as a major bleeding event and meets at least one of the following criteria:
    • Epistaxis: need to medical attention from a physician or visits an emergency room, requires an intervention, persists for 5 minutes or more.
    • Gastrointestinal bleed: vomit containing frank blood or coffee ground material which tests positive for blood, endoscopically confirmed bleeding, frank blood per rectum or melena stools.
    • Hematuria: overt spontaneous bleeding, bleeding persists for 24 hours or more after instrumentation.
    • Bruising/ecchymosis: any bruise, which is assessed as "unusual".
    • Hematoma: presence of a hematoma is demonstrated radiographically, and a drop-in hemoglobin is present with no external evidence of bleeding.
    • Hemoptysis: expectoration of blood or blood-stained sputum.

  3. Fatal Bleeding Event [ Time Frame: Cycle 1 Day 1, Cycle 2 Day 1, Cycle 3 Day 1, Cycle 4 Day 1, Cycle 5 Day 1, Cycle 6 Day 1, Cycle 4/ 6 Day 29, Cycle 4/6 Day 43, Day 14 after end of treatment (each cycle is 28 days. Treatment with Apixaban will continue until 14 days after cycle 4 or 6) ]
    Defined as a bleeding event that determines is the primary cause of death or contributes directly to death.

  4. Liver injury event [ Time Frame: Cycle 1 Day 1, Cycle 2 Day 1, Cycle 3 Day 1, Cycle 4 Day 1, Cycle 5 Day 1, Cycle 6 Day 1, Cycle 4/ 6 Day 29, Cycle 4/6 Day 43, Day 14 after end of treatment (each cycle is 28 days. Treatment with Apixaban will continue until 14 days after cycle 4 or 6) ]
    Potential or suspected cases of liver injury including but not limited to liver test abnormalities (elevation of ALT, AST, GGT, alkaline phosphatase and total bilirrubin), jaundice, hepatitis or cholestasis events.

  5. Serious adverse events [ Time Frame: Cycle 1 Day 1, Cycle 2 Day 1, Cycle 3 Day 1, Cycle 4 Day 1, Cycle 5 Day 1, Cycle 6 Day 1, Cycle 4/ 6 Day 29, Cycle 4/6 Day 43, Day 14 after end of treatment (each cycle is 28 days. Treatment with Apixaban will continue until 14 days after cycle 4 or 6) ]

    A Serious Adverse Event is any untoward medical occurrence that:

    • Results in death.
    • Is life-threatening (defined as an event in which the subject was at risk of death at the time of the event; it does not refer to an event which hypothetically might have caused death if it were more severe).
    • Requires inpatient hospitalization or prolongation of existing hospitalization
    • Results in persistent or significant disability/incapacity.
    • Is a congenital anomaly/birth defect.
    • Is an important medical event (defined as a medical event(s) that may require medical intervention to prevent one of a serious outcome listed above).
    • Overdose.
    • Second primary malignancies.

  6. Symptomatic DVT or PE occurring during the 90 days of follow-up period [ Time Frame: Day +90 follow-up ]
    Symptomatic DTV or PE as defined aforementioned, assessed 90 days after the last dose of the study drug.

  7. Death occurring during the 90 days of follow-up period [ Time Frame: Day +90 follow-up ]
    All cause of mortality occurring during the 90 days after the last dose of the study drug.



Information from the National Library of Medicine

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. For general information, Learn About Clinical Studies.


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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:

  • Signed written informed consent
  • Subjects must have documented newly diagnosed symptomatic multiple myeloma requiring front-line treatment.
  • Patients should be considered transplant-eligible
  • Subjects will receive front-line induction therapy with a triplet regimen consisting of bortezomib, thalidomide and dexamethasone (VTD).
  • To enter to the study at the same time of start anti myeloma induction therapy.
  • Ages eligible for study: 18 to 70 years.
  • Subjects must have an Eastern Cooperative Oncology Group (ECOG) performance status score ≤2.

Exclusion Criteria:

  • Patients with the diagnosis of plasma cell leukemia, Waldenström macroglobulinemia, POEMS syndrome or amyloidosis of light chain.
  • Patients with smouldering multiple myeloma or monoclonal gammopathy of undeterminated significance.
  • Patients considered non-transplant-eligible.
  • Grade ≥2 of peripheral neuropathy.
  • Prior history of documented any venous thromboembolism and arterial thrombosis event
  • Active or high risk of bleeding.
  • Need for on-going anticoagulant or antiplatelet treatment.
  • Contraindication of anticoagulant prophylaxis
  • Uncontrolled hypertension: systolic blood pressure >200 mmHg and/or diastolic blood pressure >100 mmHg.
  • HIV, HBV or HCV-positive active.
  • Expected survival <6 months.
  • Weight <40 Kg.
  • Low platelet count (<50 x109/L).
  • ALT >3x UNL, bilirubin >2x ULN.
  • Creatinine clearance <30 mL/min.
  • Women of childbearing potential who are unwilling to use an acceptable method of contraception.
  • Women of childbearing potential who are pregnant or breastfeeding.
  • Women with a positive pregnancy test on enrollment, prior to investigational product administration.
  • Administration of any investigational drug currently or within 30 days prior to planned enrollment into this study.
  • Subjects unwilling or unable to comply with study medication instructions or study procedures (e.g. bilateral lower extremity venous ultrasonography).
  • Known allergies to ingredients contained in apixaban.
  • Use of any contraindicated medications with apixaban (see section 5.4.1).

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): NCT04106700


Locations
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Spain
Hospital Clinico Universitario
Valencia, Spain, 46010
Hospital Universitario Doctor Peset
Valencia, Spain, 46017
Hospital Universitario y Politécnico La Fe
Valencia, Spain, 46026
Hospital General Universitario
Valencia, Spain
Sponsors and Collaborators
Instituto de Investigacion Sanitaria La Fe
Bristol-Myers Squibb
Investigators
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Study Director: Javier de la Rubia Hospital Doctor Peset
Principal Investigator: Samuel Romero Hospital Universitario y Politecnico La Fe
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Responsible Party: Instituto de Investigacion Sanitaria La Fe
ClinicalTrials.gov Identifier: NCT04106700    
Other Study ID Numbers: APIXABAN
First Posted: September 27, 2019    Key Record Dates
Last Update Posted: June 11, 2020
Last Verified: June 2020
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: No

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Studies a U.S. FDA-regulated Drug Product: Yes
Studies a U.S. FDA-regulated Device Product: No
Product Manufactured in and Exported from the U.S.: Yes
Keywords provided by Instituto de Investigacion Sanitaria La Fe:
Multiple Myeloma
Venous Thromboembolism
Additional relevant MeSH terms:
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Multiple Myeloma
Neoplasms, Plasma Cell
Thromboembolism
Venous Thromboembolism
Neoplasms by Histologic Type
Neoplasms
Hemostatic Disorders
Vascular Diseases
Cardiovascular Diseases
Paraproteinemias
Blood Protein Disorders
Hematologic Diseases
Hemorrhagic Disorders
Lymphoproliferative Disorders
Immunoproliferative Disorders
Immune System Diseases
Embolism and Thrombosis
Apixaban
Factor Xa Inhibitors
Antithrombins
Serine Proteinase Inhibitors
Protease Inhibitors
Enzyme Inhibitors
Molecular Mechanisms of Pharmacological Action
Anticoagulants