Coagulopathy of COVID-19: A Pragmatic Randomized Controlled Trial of Therapeutic Anticoagulation Versus Standard Care

• ClinicalTrials.gov Identifier: NCT04362085
• Recruitment Status: Completed
• First Posted: April 24, 2020
• Last Update Posted: October 26, 2021
• Sponsor: Unity Health Toronto
• Collaborators: University of Vermont Medical Center; University of Sao Paulo; Hôpital Charles Lemoyne; William Osler Health System; MOUNT SINAI HOSPITAL; Trillium Health Partners; St. Joseph's Health Centre; The Ottawa Hospital; Hopital du Sacre-Coeur de Montreal; Michael Garron Hospital; University of Alberta; Southlake Regional Health Centre; Maisonneuve-Rosemont Hospital; Queen Elizabeth II Health Sciences Centre; Foothills Medical Centre; Rockyview General Hospital; Peter Lougheed Centre; Mater Misericordiae University Hospital; King Saud University Medical City; King Fahad Medical City; King Faisal Specialist Hospital; Versiti; Barnes-Jewish Hospital; Al Ain Hospital
• Information provided by (Responsible Party): Unity Health Toronto

Study Description

Brief Summary:

Coagulopathy of COVID-19 afflicts approximately 20% of patients with severe COVID-19 and is associated with need for critical care and death. COVID-19 coagulopathy is characterized by elevated D-dimer, an indicator of fibrin formation and clot lysis, and a mildly prolonged prothrombin time, suggestive of coagulation consumption. To date, it seems that COVID-19 coagulopathy manifests with thromboembolism, thus anticoagulation may be of benefit. We propose to conduct a parallel pragmatic multi-centre open-label randomized controlled trial to determine the effect of therapeutic anticoagulation compared to standard care in hospitalized patients admitted for COVID-19 with an elevated D-dimer.

Condition or disease	Intervention/treatment	Phase
COVID-19	Drug: Therapeutic Anticoagulation	Phase 3

Detailed Description:

2-arm, parallel, pragmatic, multi-centre, open-label randomized controlled trial to determine the effect of therapeutic anticoagulation, with low molecular weight heparin or unfractionated heparin (high dose nomogram), compared to standard care in hospitalized patients with COVID-19 and an elevated D-dimer on the composite outcome of intensive care unit (ICU) admission, non-invasive positive pressure ventilation, invasive mechanical ventilation or death at 28 days. Eligible participants will be randomized to one of two treatment regimens, receiving either therapeutic anticoagulation or standard care until discharged from hospital, death or day 28.

The primary composite outcome of ICU admission, non-invasive positive pressure ventilation, invasive mechanical ventilation, or all-cause death up to 28 days.

Key secondary outcomes between study arms up to day 28 include:

1. All-cause death
2. Composite outcome of ICU admission or all-cause death
3. Composite outcome of mechanical ventilation or all-cause death
4. Major bleeding as defined by the ISTH Scientific and Standardization Committee (ISTH-SSC) recommendation
5. Number of participants who received red blood cell transfusion (≥1 unit)
6. Number of participants with transfusion of platelets, frozen plasma, prothrombin complex concentrate, cryoprecipitate and/or fibrinogen concentrate
7. Renal replacement therapy;
8. Number of hospital-free days alive
9. Number of ICU-free days alive
10. Number of ventilator-free days alive
11. Number of organ support-free days alive
12. Number of participants with venous thromboembolism
13. Number of participants with arterial thromboembolism
14. Number of participants with heparin induced thrombocytopenia
15. Changes in D-dimer up to day 3

The treatment arm is therapeutic anticoagulation with low molecular weight heparin (LMWH) or unfractionated heparin (UFH, high dose nomogram). The choice of LMWH versus UFH will be at the clinician's discretion. LMWH options include: Tinzaparin, Enoxaparin, or Dalteparin. UFH will be administered using a weight-based nomogram with titration according to the center-specific protocol. Therapeutic anticoagulation will be administered until discharged from hospital, 28 days or death. If the patient is admitted to the ICU or requiring ventilatory support, we recommend continuation of the allocated treatment as long as the treating physician is in agreement. The standard care arm is the administration of LMWH, UFH or fondaparinux at thromboprophylactic doses in the absence of contraindication.

No study specific bloodwork will be ordered aside from a single D-dimer test (if not collected through standard of care) up to and including day 3 after randomization for all participants in both study arms. In those on the active treatment arm who are receiving UFH, the aPTT or UFH anti-Xa will be drawn according to local institutional UFH nomogram protocol guidance. All laboratory results will be collected from standard of care from admission to hospital discharge, death or 28 days, where available. An optional biobanking component will collect blood at baseline and 2 follow up time points.

This study will immediately impact the clinical care of patients with severe COVID-19 internationally, whether the findings are positive or negative, as COVID-19 coagulopathy is a highly prevalent complication of severe COVID-19 and may precede the respiratory manifestations that characterize it.

Study Design

• Study Type: Interventional (Clinical Trial)
• Actual Enrollment: 465 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Intervention Model Description: This study is a 2-arm, parallel, pragmatic, multi-centre, open-label randomized controlled trial to determine the effect of therapeutic anticoagulation on the composite outcome of ICU admission, mechanical ventilation and/or death in hospitalized patients with COVID-19.
• Masking: None (Open Label)
• Masking Description: Blinding of participants, clinical research staff, and clinicians is not possible due to the nature of the intervention. However, the biostatisticians will be blinded at the data analysis phase.
• Primary Purpose: Treatment
• Official Title: Coagulopathy of COVID-19: A Pragmatic Randomized Controlled Trial of Therapeutic Anticoagulation Versus Standard Care as a Rapid Response to the COVID-19 Pandemic (RAPID COVID COAG)
• Actual Study Start Date: May 11, 2020
• Actual Primary Completion Date: May 10, 2021
• Actual Study Completion Date: October 14, 2021

Arms and Interventions

Arm	Intervention/treatment
Experimental: Therapeutic Anticoagulation; Therapeutic anticoagulation with LMWH or UFH (high dose nomogram). The choice of LMWH versus UFH will be at the clinician's discretion and dependent on local institutional supply. Therapeutic anticoagulation will be administered until discharged from hospital, 28 days or death. If the patient is admitted to the ICU or requiring ventilatory support, we recommend continuation of the allocated treatment as long as the treating physician is in agreement.	Drug: Therapeutic Anticoagulation; The choice of low molecular weight heparin (LMWH) versus unfractionated heparin (UFH) will be at the clinician's discretion. LMWH options include: Tinzaparin, Enoxaparin or Dalteparin. UFH will be administered using a weight-based nomogram with titration according to center-specific institutional protocol.
No Intervention: Standard Care; Administration of LMWH, UFH or fondaparinux at thromboprophylactic doses for acutely ill hospitalized medical patients, in the absence of contraindication, is considered standard care.

Outcome Measures

Primary Outcome Measures :

1. Composite outcome of ICU admission (yes/no), non-invasive positive pressure ventilation (yes/no), invasive mechanical ventilation (yes/no), or all-cause death (yes/no) up to 28 days. [ Time Frame: Up to 28 days ]
   Composite outcome of ICU admission (yes/no), non-invasive positive pressure ventilation (yes/no), invasive mechanical ventilation (yes/no), or all-cause death (yes/no) up to 28 days.

Secondary Outcome Measures :

1. All-cause death [ Time Frame: Up to 28 days ]
   All-cause death
2. Composite outcome of ICU admission or all-cause death [ Time Frame: Up to 28 days ]
   Composite outcome of ICU admission or all-cause death
3. Composite outcome of mechanical ventilation or all-cause death [ Time Frame: Up to 28 days ]
   Composite outcome of mechanical ventilation or all-cause death
4. Major bleeding [ Time Frame: Up to 28 days ]
   Major bleeding as defined by the ISTH Scientific and Standardization Committee (ISTH-SSC) recommendation
5. Red blood cell transfusion [ Time Frame: Up to 28 days ]
   Red Blood Cell transfusion (greater than or equal to 1 unit)
6. Transfusion of platelets, frozen plasma, prothrombin complex concentrate, cryoprecipiate and/or fibrinogen concentrate [ Time Frame: Up to 28 days ]
   Transfusion of platelets, frozen plasma, prothrombin complex concentrate, cryoprecipiate and/or fibrinogen concentrate
7. Renal replacement therapy [ Time Frame: Up to 28 days ]
   Renal replacement therapy defined as continuous renal replacement therapy or intermittent hemodialysis
8. Hospital-free days alive up to day 28 [ Time Frame: Up to 28 days ]
   Hospital-free days alive up to day 28
9. ICU-free days alive up to day 28 [ Time Frame: Up to 28 days ]
   ICU-free days alive up to day 28
10. Ventilator-free days alive up to day 28 [ Time Frame: Up to 28 days ]
    Ventilator-free days alive up to day 28
11. Organ support-free days alive up to day 28 [ Time Frame: Up to 28 days ]
    Organ support-free days alive up to day 28
12. Venous thromboembolism [ Time Frame: Up to 28 days ]
    Venous thromboembolism
13. Arterial thromboembolism [ Time Frame: Up to 28 days ]
    Arterial thromboembolism
14. Heparin induced thrombocytopenia [ Time Frame: Up to 28 days ]
    Heparin induced thrombocytopenia
15. Changes in D-dimer up to day 3 [ Time Frame: Up to day 3 ]
    D-dimer

Eligibility Criteria

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

Criteria

The inclusion criteria are:

1. laboratory confirmed diagnosis of SARS-CoV-2 via reverse transcriptase polymerase chain reaction as per the World Health Organization protocol or by nucleic acid based isothermal amplification.Positive test prior to hospital admission OR within first 5 days (i.e. 120 hours) after hospital admission;
2. admitted to hospital for COVID-19;
3. one D-dimer value above ULN (5 days (i.e. 120 hours) of hospital admission) and either: a) D-Dimer ≥2 times ULN; or b) D-dimer above ULN and oxygen saturation ≤ 93% on room air;
4. ≥18 years of age;
5. informed consent from the patient (or legally authorized substitute decision maker).

The exclusion criteria are:

1. pregnancy;
2. hemoglobin <80 g/L in the last 72 hours;
3. platelet count <50 x 10^9/L in the last 72 hours;
4. known fibrinogen <1.5 g/L (if testing deemed clinically indicated by the treating physician prior to the initiation of anticoagulation);
5. known INR >1.8 (if testing deemed clinically indicated by the treating physician prior to the initiation of anticoagulation);
6. patient already on intermediate dosing of LMWH that cannot be changed (determination of what constitutes an intermediate dose is to be at the discretion of the treating clinician taking the local institutional thromboprophylaxis protocol for high risk patients into consideration);
7. patient already on therapeutic anticoagulation at the time of screening (low or high dose nomogram UFH, LMWH, warfarin, direct oral anticoagulant (any dose of dabigatran, apixaban, rivaroxaban, edoxaban);
8. patient on dual antiplatelet therapy, when one of the agents cannot be stopped safely;
9. known bleeding within the last 30 days requiring emergency room presentation or hospitalization;
10. known history of a bleeding disorder of an inherited or active acquired bleeding disorder;
11. known history of heparin-induced thrombocytopenia;
12. known allergy to UFH or LMWH;
13. admitted to the intensive care unit at the time of screening;
14. treated with non-invasive positive pressure ventilation or invasive mechanical ventilation at the time of screening (of note: high flow oxygen delivery via nasal cannula is acceptable and is not an exclusion criterion).
15. imminent death according to the judgement of the most responsible physician
16. enrollment in another clinical trial of antithrombotic therapy involving pre-intensive care unit hospitalized patients

Contacts and Locations

Locations

Canada, Ontario

St. Michael's Hospital

Toronto, Ontario, Canada

Sponsors and Collaborators

Unity Health Toronto

University of Vermont Medical Center

University of Sao Paulo

Hôpital Charles Lemoyne

William Osler Health System

MOUNT SINAI HOSPITAL

Trillium Health Partners

St. Joseph's Health Centre

The Ottawa Hospital

Hopital du Sacre-Coeur de Montreal

Michael Garron Hospital

University of Alberta

Southlake Regional Health Centre

Maisonneuve-Rosemont Hospital

Queen Elizabeth II Health Sciences Centre

Foothills Medical Centre

Rockyview General Hospital

Peter Lougheed Centre

Mater Misericordiae University Hospital

King Saud University Medical City

King Fahad Medical City

King Faisal Specialist Hospital

Versiti

Barnes-Jewish Hospital

Al Ain Hospital

Investigators

• Principal Investigator: Michelle Sholzberg, MD, FRCPC; Unity Health Toronto
• Principal Investigator: Peter Jüni, MD, FESC; Unity Health Toronto
• Principal Investigator: Mary Cushman, MD; University of Vermont Medical Center, Vermont

More Information

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):

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.

Sholzberg M, Tang GH, Rahhal H, AlHamzah M, Kreuziger LB, Ainle FN, Alomran F, Alayed K, Alsheef M, AlSumait F, Pompilio CE, Sperlich C, Tangri S, Tang T, Jaksa P, Suryanarayan D, Almarshoodi M, Castellucci LA, James PD, Lillicrap D, Carrier M, Beckett A, Colovos C, Jayakar J, Arsenault MP, Wu C, Doyon K, Andreou ER, Dounaevskaia V, Tseng EK, Lim G, Fralick M, Middeldorp S, Lee AYY, Zuo F, da Costa BR, Thorpe KE, Negri EM, Cushman M, Juni P; RAPID trial investigators. Effectiveness of therapeutic heparin versus prophylactic heparin on death, mechanical ventilation, or intensive care unit admission in moderately ill patients with covid-19 admitted to hospital: RAPID randomised clinical trial. BMJ. 2021 Oct 14;375:n2400. doi: 10.1136/bmj.n2400.

Sholzberg M, Tang GH, Rahhal H, AlHamzah M, Kreuziger LB, Ni Ainle F, Alomran F, Alayed K, Alsheef M, AlSumait F, Pompilio CE, Sperlich C, Tangri S, Tang T, Jaksa P, Suryanarayan D, Almarshoodi M, Castellucci L, James PD, Lillicrap D, Carrier M, Beckett A, Colovos C, Jayakar J, Arsenault MP, Wu C, Doyon K, Andreou ER, Dounaevskaia V, Tseng EK, Lim G, Fralick M, Middeldorp S, Lee AYY, Zuo F, da Costa BR, Thorpe KE, Negri EM, Cushman M, Juni P; RAPID Trial investigators. Heparin for Moderately Ill Patients with Covid-19. medRxiv. 2021 Jul 12:2021.07.08.21259351. doi: 10.1101/2021.07.08.21259351. Preprint.

Sholzberg M, Tang GH, Negri E, Rahhal H, Kreuziger LB, Pompilio CE, James P, Fralick M, AlHamzah M, Alomran F, Tseng E, Lim G, Lillicrap D, Carrier M, Ainle FN, Beckett A, da Costa BR, Thorpe K, Middeldorp S, Lee A, Cushman M, Juni P. Coagulopathy of hospitalised COVID-19: A Pragmatic Randomised Controlled Trial of Therapeutic Anticoagulation versus Standard Care as a Rapid Response to the COVID-19 Pandemic (RAPID COVID COAG - RAPID Trial): A structured summary of a study protocol for a randomised controlled trial. Trials. 2021 Mar 10;22(1):202. doi: 10.1186/s13063-021-05076-0.

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.

• Responsible Party: Unity Health Toronto
• ClinicalTrials.gov Identifier: NCT04362085
• Other Study ID Numbers: RAPID COVID-COAG
• First Posted: April 24, 2020
• Last Update Posted: October 26, 2021
• Last Verified: October 2021

Individual Participant Data (IPD) Sharing Statement:

• Plan to Share IPD: No

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

Keywords provided by Unity Health Toronto:

coagulopathy; anticoagulation

Additional relevant MeSH terms:

COVID-19; Hemostatic Disorders; Blood Coagulation Disorders; Pneumonia, Viral; Pneumonia; Respiratory Tract Infections; Infections; Virus Diseases; Coronavirus Infections; Coronaviridae Infections; Nidovirales Infections; RNA Virus Infections; Lung Diseases; Respiratory Tract Diseases; Hematologic Diseases; Vascular Diseases; Cardiovascular Diseases; Hemorrhagic Disorders