- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT01628055
IVIG in Acute Ischemic Stroke: A Pilot Study (IVIG/AIS)
The purpose of the study is to evaluate the ability of IVIG to affect the rate of progression of brain ischemia, as evidenced by neuroimaging.
The results of an ongoing epidemiological study indicate that patients with primary immunodeficiency (PID) on IVIG replacement therapy have an overall prevalence of stroke that is 5 times less than in the general population. Even more striking is the absence of stroke in IVIG-treated PID patients over 65, while in the same general population age group the stroke prevalence goes up to 8.1%. This suggests that the degree of stroke protection correlates with the length of IVIG treatment, since older PID patients have been treated with IVIG significantly longer than younger ones.
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Study Type
Phase
- Phase 1
Contacts and Locations
Study Locations
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Virginia
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Falls Church, Virginia, United States, 22042
- Inova Health Systems; Inova Fairfax Hospital
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Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- Onset of neurological symptoms between 4.5 and 8 hours
- Male or Female age 45 -75 years old
- Score of 10-15 points on the National Institutes of Health Stroke Scale (NIHSS) with clinical signs suggestive of ischemic stroke
- Acute brain ischemia with a distinct penumbra (at least 20%), measured by magnetic resonance perfusion imaging (PI) and diffusion-weighted imaging (DWI), in the territory of the middle cerebral artery, anterior cerebral artery, or posterior cerebral artery with a hemispheric distribution
- Ability and willingness to provide informed consent and comply with study requirements and procedures
Exclusion Criteria:
- Eligibility for acute thrombolytic (rtPA) treatment
- Normal brain MRI
- Transient ischemic attack or rapidly improving neurological symptoms
- Previous disability
- Hemorrhagic stroke on brain MRI (T2*/SWI)
- Ongoing infection defined by clinical and laboratory signs: an evidence-based guideline will be followed to detect infectious complications (in short, physical and laboratory measures including WBC, ESR, hsCRP, PCT, fever, abnormal urine, chest X-ray or positive cultures)
- Diagnosis of malignancy
- Known sensitivity to any ingredients in the study drug or radiological contrast material
- Participation in another clinical trial within the past 30 days
- Stroke in the previous 3 months
- Chronic liver, kidney or hematological disease
- Contraindications to MRI -Brain aneurysm clip, implanted neural stimulator, implanted cardiac pacemaker or defibrillator, cochlear implant, ocular foreign body e.g. metal shavings, other implanted medical devices: (e.g. Swan Ganz catheter) insulin pump, metal shrapnel or bullet.
- Diabetes
- Hypertension
- Females who are pregnant or breastfeeding
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Quadruple
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: Privigen
The IVIG preparation to be used is 10% liquid (Privigen).
IVIG will be applied at a dose of 1.0g/kg, which is approximately 1/2 of the optimal dose used for other immuno/inflammatory indications.
The infusion will start at 0.5 ml/kg/hr for the first 30 minutes, to watch for the signs of hypersensitivity to immunoglobulins, and then increased to 2.5 ml/kg/hr, two times slower than the recommended rate indicated in the product package insert (5 ml/kg/hr).
Such a low, single dose has not been associated with hyperviscosity and together with a slow infusion will safeguard against occurrence of adverse events related to IVIG infusions.
They will receive a total of 1g/kg and depending on patient's weight, it will take between 3.5 to 4+ hours to infuse that amount.
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10% liquid intravenous immunoglobulin at a single dose of 1.0g/kg, run at 0.5ml/kg/hr for the first 30 minutes, then increased to 2.5ml/kg/hr until complete (~3-4 hours depending on weight).
Other Names:
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Placebo Comparator: Normal Saline
The placebo is the normal saline.
Since saline solution will be infused at the volume equivalent to that in which the intended dose of immunoglobulin molecules will be delivered, the placebo (comparator) arm will also serve as a control for the volume of fluid infused to the treatment arm participants.
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Normal Saline is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment. It contains no antimicrobial agents. The pH is 5.0 (4.5 to 7.0). It contains 9 g/L Sodium Chloride with an osmolarity of 308 mOsmol/L and 154 mEq/L Sodium and Chloride. The infusion will start at 0.5 ml/kg/hr for the first 30 minutes and then increased to 2.5 ml/kg/hr for 3-4 hours.
Other Names:
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What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Post-IVIG DWI/PI mismatch measurement
Time Frame: 3 days
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Decrease in the size of post IVIG necrotic area relative to baseline values and percent of penumbra saved, defined by neuroimaging as DWI/PI mismatch.
|
3 days
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Favorable clinical outcome
Time Frame: 90 days
|
Favorable clinical outcome at Day 90, which requires fulfillment of all three of the following criteria: improvement in NIHSS of 8 points or more from baseline; modified Rankin scale (mRS) score of 0-2 points; and Barthel index (BI) of 75-100
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90 days
|
Clinical outcome measure by NIHSS
Time Frame: 3 days
|
Clinical outcome measured by change in NIHSS scores will be also examined on Day 3
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3 days
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Active complement fragment levels
Time Frame: 90 days
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Levels of active complement fragments, C3a, C5a, C5b-9 and C4d at Day 0 and post-IVIG and Day 90.
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90 days
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Adverse Events
Time Frame: 90 days
|
Incidence in adverse events.
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90 days
|
Collaborators and Investigators
Sponsor
Collaborators
Investigators
- Study Director: Beverly C Walters, MD, Inova Health Systems
- Study Chair: Milan Basta, MD, BioVisions, Inc.
- Principal Investigator: Jack Cochran, MD, Inova Health Systems
Publications and helpful links
General Publications
- Clark WM, Wissman S, Albers GW, Jhamandas JH, Madden KP, Hamilton S. Recombinant tissue-type plasminogen activator (Alteplase) for ischemic stroke 3 to 5 hours after symptom onset. The ATLANTIS Study: a randomized controlled trial. Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke. JAMA. 1999 Dec 1;282(21):2019-26. doi: 10.1001/jama.282.21.2019.
- Darabi K, Abdel-Wahab O, Dzik WH. Current usage of intravenous immune globulin and the rationale behind it: the Massachusetts General Hospital data and a review of the literature. Transfusion. 2006 May;46(5):741-53. doi: 10.1111/j.1537-2995.2006.00792.x.
- D'Ambrosio AL, Pinsky DJ, Connolly ES. The role of the complement cascade in ischemia/reperfusion injury: implications for neuroprotection. Mol Med. 2001 Jun;7(6):367-82.
- Ember JA, Hugli TE. Complement factors and their receptors. Immunopharmacology. 1997 Dec;38(1-2):3-15. doi: 10.1016/s0162-3109(97)00088-x.
- de Boer JP, Wolbink GJ, Thijs LG, Baars JW, Wagstaff J, Hack CE. Interplay of complement and cytokines in the pathogenesis of septic shock. Immunopharmacology. 1992 Sep-Oct;24(2):135-48. doi: 10.1016/0162-3109(92)90019-9.
- Szalai AJ, van Ginkel FW, Wang Y, McGhee JR, Volanakis JE. Complement-dependent acute-phase expression of C-reactive protein and serum amyloid P-component. J Immunol. 2000 Jul 15;165(2):1030-5. doi: 10.4049/jimmunol.165.2.1030.
- Van Beek J, Bernaudin M, Petit E, Gasque P, Nouvelot A, MacKenzie ET, Fontaine M. Expression of receptors for complement anaphylatoxins C3a and C5a following permanent focal cerebral ischemia in the mouse. Exp Neurol. 2000 Jan;161(1):373-82. doi: 10.1006/exnr.1999.7273.
- Lindsberg PJ, Ohman J, Lehto T, Karjalainen-Lindsberg ML, Paetau A, Wuorimaa T, Carpen O, Kaste M, Meri S. Complement activation in the central nervous system following blood-brain barrier damage in man. Ann Neurol. 1996 Oct;40(4):587-96. doi: 10.1002/ana.410400408.
- Nishino H, Czurko A, Fukuda A, Hashitani T, Hida H, Karadi Z, Lenard L. Pathophysiological process after transient ischemia of the middle cerebral artery in the rat. Brain Res Bull. 1994;35(1):51-6. doi: 10.1016/0361-9230(94)90215-1.
- Figueroa E, Gordon LE, Feldhoff PW, Lassiter HA. The administration of cobra venom factor reduces post-ischemic cerebral injury in adult and neonatal rats. Neurosci Lett. 2005 May 20-27;380(1-2):48-53. doi: 10.1016/j.neulet.2005.01.027. Epub 2005 Feb 2.
- Arumugam TV, Tang SC, Lathia JD, Cheng A, Mughal MR, Chigurupati S, Magnus T, Chan SL, Jo DG, Ouyang X, Fairlie DP, Granger DN, Vortmeyer A, Basta M, Mattson MP. Intravenous immunoglobulin (IVIG) protects the brain against experimental stroke by preventing complement-mediated neuronal cell death. Proc Natl Acad Sci U S A. 2007 Aug 28;104(35):14104-9. doi: 10.1073/pnas.0700506104. Epub 2007 Aug 21.
- Szeplaki G, Szegedi R, Hirschberg K, Gombos T, Varga L, Karadi I, Entz L, Szeplaki Z, Garred P, Prohaszka Z, Fust G. Strong complement activation after acute ischemic stroke is associated with unfavorable outcomes. Atherosclerosis. 2009 May;204(1):315-20. doi: 10.1016/j.atherosclerosis.2008.07.044. Epub 2008 Aug 14.
- De Simoni MG, Rossi E, Storini C, Pizzimenti S, Echart C, Bergamaschini L. The powerful neuroprotective action of C1-inhibitor on brain ischemia-reperfusion injury does not require C1q. Am J Pathol. 2004 May;164(5):1857-63. doi: 10.1016/S0002-9440(10)63744-3.
- De Simoni MG, Storini C, Barba M, Catapano L, Arabia AM, Rossi E, Bergamaschini L. Neuroprotection by complement (C1) inhibitor in mouse transient brain ischemia. J Cereb Blood Flow Metab. 2003 Feb;23(2):232-9. doi: 10.1097/01.WCB.0000046146.31247.A1.
- Akita N, Nakase H, Kaido T, Kanemoto Y, Sakaki T. Protective effect of C1 esterase inhibitor on reperfusion injury in the rat middle cerebral artery occlusion model. Neurosurgery. 2003 Feb;52(2):395-400; discussion 400-1. doi: 10.1227/01.neu.0000043710.61233.b4.
- Akita N, Nakase H, Kanemoto Y, Kaido T, Nishioka T, Sakaki T. [The effect of C 1 esterase inhibitor on ischemia: reperfusion injury in the rat brain]. No To Shinkei. 2001 Jul;53(7):641-4. Japanese.
- Basta M, Fries LF, Frank MM. High doses of intravenous Ig inhibit in vitro uptake of C4 fragments onto sensitized erythrocytes. Blood. 1991 Jan 15;77(2):376-80.
- Basta M, Langlois PF, Marques M, Frank MM, Fries LF. High-dose intravenous immunoglobulin modifies complement-mediated in vivo clearance. Blood. 1989 Jul;74(1):326-33.
- Basta M, Kirshbom P, Frank MM, Fries LF. Mechanism of therapeutic effect of high-dose intravenous immunoglobulin. Attenuation of acute, complement-dependent immune damage in a guinea pig model. J Clin Invest. 1989 Dec;84(6):1974-81. doi: 10.1172/JCI114387.
- Basta M. Modulation of complement-mediated immune damage by intravenous immune globulin. Clin Exp Immunol. 1996 May;104 Suppl 1:21-5.
- Basta M, Van Goor F, Luccioli S, Billings EM, Vortmeyer AO, Baranyi L, Szebeni J, Alving CR, Carroll MC, Berkower I, Stojilkovic SS, Metcalfe DD. F(ab)'2-mediated neutralization of C3a and C5a anaphylatoxins: a novel effector function of immunoglobulins. Nat Med. 2003 Apr;9(4):431-8. doi: 10.1038/nm836. Epub 2003 Mar 3.
- Basta M. Ambivalent effect of immunoglobulins on the complement system: activation versus inhibition. Mol Immunol. 2008 Oct;45(16):4073-9. doi: 10.1016/j.molimm.2008.07.012. Epub 2008 Aug 15.
- Spycher M, Matozan K, Minnig K, Zehnder R, Miescher S, Hoefferer L, Rieben R. In vitro comparison of the complement-scavenging capacity of different intravenous immunoglobulin preparations. Vox Sang. 2009 Nov;97(4):348-54. doi: 10.1111/j.1423-0410.2009.01217.x. Epub 2009 Jul 27.
- Al-Buhairi AR, Jan MM. Recombinant tissue plasminogen activator for acute ischemic stroke. Saudi Med J. 2002 Jan;23(1):13-9.
- Bennett WR, Yawn DH, Migliore PJ, Young JB, Pratt CM, Raizner AE, Roberts R, Bolli R. Activation of the complement system by recombinant tissue plasminogen activator. J Am Coll Cardiol. 1987 Sep;10(3):627-32. doi: 10.1016/s0735-1097(87)80206-1.
- Szeplaki G, Varga L, Laki J, Dosa E, Madsen HO, Prohaszka Z, Szabo A, Acsady G, Selmeci L, Garred P, Fust G, Entz L. Elevated complement C3 is associated with early restenosis after eversion carotid endarterectomy. Thromb Haemost. 2006 Oct;96(4):529-34.
- Ahsan N, Palmer BF, Wheeler D, Greenlee RG Jr, Toto RD. Intravenous immunoglobulin-induced osmotic nephrosis. Arch Intern Med. 1994 Sep 12;154(17):1985-7. doi: 10.1001/archinte.154.17.1985.
- Bednarik J, Kadanka Z. [Adverse effects of administration of intravenous human immunoglobulins]. Cas Lek Cesk. 1999 Nov 1;138(21):647-9. Czech.
- Orbach H, Katz U, Sherer Y, Shoenfeld Y. Intravenous immunoglobulin: adverse effects and safe administration. Clin Rev Allergy Immunol. 2005 Dec;29(3):173-84. doi: 10.1385/CRIAI:29:3:173.
- Al-Wahadneh AM, Khriesat IA, Kuda EH. Adverse reactions of intravenous immunoglobulin. Saudi Med J. 2000 Oct;21(10):953-6.
- Katz U, Shoenfeld Y. Review: intravenous immunoglobulin therapy and thromboembolic complications. Lupus. 2005;14(10):802-8. doi: 10.1191/0961203303lu2168rr.
- Reinhart WH, Berchtold PE. Effect of high-dose intravenous immunoglobulin therapy on blood rheology. Lancet. 1992 Mar 14;339(8794):662-4. doi: 10.1016/0140-6736(92)90806-e.
- Fisher M. Characterizing the target of acute stroke therapy. Stroke. 1997 Apr;28(4):866-72. doi: 10.1161/01.str.28.4.866.
- Lansberg MG, O'Brien MW, Tong DC, Moseley ME, Albers GW. Evolution of cerebral infarct volume assessed by diffusion-weighted magnetic resonance imaging. Arch Neurol. 2001 Apr;58(4):613-7. doi: 10.1001/archneur.58.4.613.
Study record dates
Study Major Dates
Study Start
Primary Completion (Anticipated)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Estimate)
Study Record Updates
Last Update Posted (Estimate)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
- Pathologic Processes
- Necrosis
- Cardiovascular Diseases
- Vascular Diseases
- Cerebrovascular Disorders
- Brain Diseases
- Central Nervous System Diseases
- Nervous System Diseases
- Brain Ischemia
- Infarction
- Brain Infarction
- Stroke
- Ischemic Stroke
- Ischemia
- Cerebral Infarction
- Physiological Effects of Drugs
- Immunologic Factors
- Antibodies
- Immunoglobulins
- Immunoglobulins, Intravenous
- gamma-Globulins
- Rho(D) Immune Globulin
- Immunoglobulin G
Other Study ID Numbers
- IVIG/AIS-IFH-MB-CSL
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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