Open Label Study Comparing Efficacy and Safety of Dabigatran Etexilate to Standard of Care in Paediatric Patients With Venous Thromboembolism (VTE)

Open-label, Randomized, Parallel-group, Active-controlled, Multi-centre Non-inferiority Study of Dabigatran Etexilate Versus Standard of Care for Venous Thromboembolism Treatment in Children From Birth to Less Than 18 Years of Age

The main objectives of this large phase IIb/III paediatric study are to assess the efficacy and safety of dabigatran etexilate relative to standard of care and to document the appropriateness of the proposed dabigatran etexilate dosing algorithm for use in patients from birth to less than 18 years of age.

Study Overview

• Status: Completed
• Conditions: Venous Thromboembolism
• Intervention / Treatment: Drug: dabigatran etexilate; Drug: standard of care

• Study Type: Interventional
• Enrollment (Actual): 267
• Phase: Phase 3

Contacts and Locations

Study Locations

• Argentina
  • Caba, Argentina, C1270AAN
    • Hospital General de Niños Pedro de Elizalde
• Austria
  • Innsbruck, Austria, 6020
    • Medical University of Innsbruck
  • Wien, Austria, 1090
    • AKH - Medical University of Vienna
• Belgium
  • Bruxelles, Belgium, 1200
    • Brussels - UNIV Saint-Luc
  • Gent, Belgium, 9000
    • UNIV UZ Gent
  • Leuven, Belgium, 3000
    • UZ Leuven
• Brazil
  • Campinas, Brazil, 13059-740
    • HMCP - Hospital e Maternidade Celso Pierro - PUC-Campinas
  • Campinas, Brazil, 13083-970
    • Faculdade de Ciencias Medicas da UNICAMP
  • Sao Paulo, Brazil, 01227-200
    • PenSI - Pesquisa e Ensino em Saude Infantil
  • Sao Paulo, Brazil, 05403-000
    • Instituto de Crianca / Hospital das Clínicas-FMUSP
• Canada
  • Ontario
    • Ottawa, Ontario, Canada, K1H 8L1
      • Children's Hospital of Eastern Ontario
    • Toronto, Ontario, Canada, M5G 1X8
      • The Hospital for Sick Children
  • Quebec
    • Montreal, Quebec, Canada, H3T 1C5
      • CHU Sainte-Justine
• Czechia
  • Brno, Czechia, 61300
    • University Hospital Brno
  • Hradec Kralove, Czechia, 500 05
    • General Univ.hosp Hradec Kralove
  • Olomouc, Czechia, 77900
    • University Hospital Olomouc
  • Ostrava, Czechia, 70852
    • University Hospital Ostrava
  • Plzen-Lochotin, Czechia, 304 60
    • University Hospital Plzen, Plzen-Lochotin
  • Prague, Czechia, 15006
    • University Hospital Motol
• Denmark
  • Copenhagen, Denmark, 2100
    • Rigshospitalet, København, Børneonkologisk Afsnit 5002
• Finland
  • Tampere, Finland, 33520
    • TaUH, Pediatric Early Phase Trial Unit
• France
  • Brest cedex, France, 29609
    • HOP de la Cavale Blanche
• Germany
  • Essen, Germany, 45147
    • Universitätsklinikum Essen AöR
  • Münster, Germany, 48149
    • Universitätsklinikum Münster
• Greece
  • Athens, Greece, 11527
    • "Aghia Sophia" Children's Hospital
• Hungary
  • Debrecen, Hungary, 4032
    • University Debrecen Hospital
• Israel
  • Jerusalem, Israel, 9103102
    • Shaare Zedek Medical Center, Jerusalem 91031
• Italy
  • Roma, Italy, 00161
    • Università degli Studi "La Sapienza"
  • Torino, Italy, 10126
    • Ospedale Infantile Regina Margherita
• Lithuania
  • Vilnius, Lithuania, 08406
    • Children Intensive Care Hosp,Anaesthesiology Dept,Vilnius
• Mexico
  • México D.F, Mexico, 04530
    • Instituto Nacional de Pediatria
  • Nuevo León, Mexico, 64460
    • Hospital Universitario Dr Jose Eleuterio Gonzalez
• Norway
  • Bergen, Norway, N-5021
    • Haukeland Universitetssykehus
  • Oslo, Norway, N-0372
    • Oslo Universitetssykehus HF, Rikshospitalet
• Russian Federation
  • Kazan, Russian Federation, 420138
    • Children Rep.Clin.Hosp of MoH,Cardio Vas.surgery Dept, Kazan
  • Kemerovo, Russian Federation, 650002
    • Science Res.Instit.CV Diseases,Scientific Res.Dept,Kemerovo
  • Moscow, Russian Federation, 125373
    • Child.CityClin.Hos.na.ZA Bashlyaeva MoscowHealth Dep,Cardiol
  • Moscow, Russian Federation, 105077
    • Izmilovskaya Child City ClinHosp,Haematological Dept, Moscow
  • St. Petersburg, Russian Federation, 194100
    • St.Petersburg State Pediatric Univ.Ministry of Healthcare RF
  • Tyument, Russian Federation, 625023
    • Reg Clin.Hosp.#1,Healthcare Tyumen Region,Cardiovas.Surgery
  • Yekaterinburg, Russian Federation, 620134
    • Childr.CityClin.Hos#9,pediatric&Neonatal Neurol.Ekaterinburg
• Spain
  • Madrid, Spain, 28009
    • Hospital Infantil Universitario Nino Jesus
• Sweden
  • Göteborg, Sweden, 41345
    • Sahlgrenska US, Göteborg
  • Solna, Sweden, 171 65
    • Karolinska Univ. sjukhuset
• Switzerland
  • Zürich, Switzerland, 8032
    • Universitäts-Kinderspital
• Taiwan
  • Taichung, Taiwan, 407
    • Taichung Veterans General Hospital
• Thailand
  • Bangkok, Thailand, 10330
    • King Chulalongkorn Memorial Hospital
• Turkey
  • Adana, Turkey, 1330
    • Cukurova Universitesi Tip Fakultesi Cocuk Sagligi
  • Ankara, Turkey, 06100
    • Hacettepe Universitesi Tip Fakultesi
  • Antalya, Turkey, 7058
    • Akdeniz Universitesi Tip Fakultesi
  • Istanbul, Turkey, 34098
    • Istanbul Universitesi Cerrahpasa Tip Fakultesi
  • Istanbul, Turkey, 34303
    • Istanbul Saglik Bilimleri Uni. Kanuni Sultan Suleyman EAH
  • Izmir, Turkey, 35040
    • Ege Universitesi Tip Fakultesi Cocuk Hematolojisi Bilim Dali
  • Konya, Turkey, 42080
    • Necmettin Erbakan Universitesi Meram Tip Fakultesi
• Ukraine
  • Dnipropetrovsk, Ukraine, 49100
    • Reg.Children Hosp.Dnipropetrovsk
  • Vinnytsya, Ukraine, 21029
    • Reg.Children Hosp,Vinnytsia
• United States
  • California
    • Sacramento, California, United States, 95817
      • University of California Davis
  • Florida
    • Miami, Florida, United States, 33136
      • University of Miami
    • Tampa, Florida, United States, 33607
      • St. Joseph's Children's Hospital
  • Iowa
    • Des Moines, Iowa, United States, 50309
      • Blank Children's Hospital
    • Iowa City, Iowa, United States, 52242
      • University of Iowa Hospitals and Clinics
  • Massachusetts
    • Boston, Massachusetts, United States, 02115
      • Boston Children's Hospital
  • North Carolina
    • Winston-Salem, North Carolina, United States, 27157
      • Wake Forest University Health Sciences
  • Virginia
    • Charlottesville, Virginia, United States, 22908
      • University of Virginia Health System
  • Washington
    • Spokane, Washington, United States, 99204
      • Providence Sacred Heart Medical Center and Children's Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: No older than 17 years (Child)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion criteria:

• Male or female subjects 0 to less than 18 years of age at the time of informed consent / assent
• Documented diagnosis of clinically stable VTE (e.g. DVT, PE, central line thrombosis, sinus vein thrombosis) per investigator judgment, initially treated (minimum of 5 to 7 days, but not longer than 21 days) with parenteral anticoagulation therapy, such as unfractionated heparin (UFH) or a low molecular weight heparin (LMWH).
• Clinical indication for at least 3 month of treatment with anticoagulants for the VTE episode defined under the above inclusion criterion.
• Written informed consent provided by the patient's parent or legal guardian and assent provided by the patient (if applicable) at the time of informed consent form (ICF) signature according to local regulations.

Exclusion criteria:

• Conditions associated with an increased risk of bleeding
• Renal dysfunction (eGFR < 50 mL/min/1.73m^2 using the Schwartz formula) or requirement for dialysis. eGFR retesting during the screening period is allowed (once).
• Active infective endocarditis
• Subjects with a heart valve prosthesis requiring anticoagulation.
• Hepatic disease:

Active liver disease, including known active hepatitis A, B or C or, Persistent alanine aminotransferase (ALT) or aspartate transaminase (AST) or alkaline phosphatase (AP) > 3 × upper limit of normal (ULN) within 3 months of screening

• Pregnant or breast feeding females. Females who have reached menarche and are not using a medically accepted contraceptive method per local guidelines. Acceptable methods of birth control must be used in a correct and consistent manner
• Patients in stratum 3 (0 to < 2 years) with gestational age at birth < 37 weeks or with body weight lower than the 3rd percentile
• Anemia (hemoglobin < 80g/L) or thrombocytopenia (platelet count < 80 x 109/L) at screening. Transfusions during the screening period are allowed, provided that a satisfactory hemoglobin or platelet level is attained prior to visit 2
• Patients who have taken prohibited or restricted medication within one week of the first dose of study medication other than medication for prior VTE treatment and P-glycoprotein inhibitors..
• Patients who have received an investigational drug in the past 30 days prior to screening
• Patients who are allergic/sensitive to any component of the study medication including solvent
• Patients or parents/legal guardians considered unreliable to participate in the trial per investigator judgment or any condition which would present a safety hazard to the patient based on investigator judgment
• Patients or parents/legal guardians who are unwilling or unable to undergo or permit repeat of the baseline imaging tests required to confirm thrombus resolution at study day 84 (or eEOT, whichever comes first) or in whom repeating such imaging tests at these pre-specified time points may not be medically in the patient's best interest. Examples may include unwarranted radiation exposure as a result of a repeat CT scan at day 84 for a patient with an isolated case of pulmonary embolism evaluated at baseline solely by a CT scan. In such cases, the baseline radiological assessment (e.g. CT) may be supplemented with an acceptable non-radiological assessment at baseline (e.g. MRI) which could then be repeated at day 84 hence alleviating any potential unwarranted radiation exposure.
• Further exclusion criteria apply

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: dabigatran etexilate; Dabigatran etexilate capsules, pellets or liquid formulation given BID in an open label fashion for 3 months	Drug: dabigatran etexilate; Age and weight appropriate capsule dose (combination of 50 mg, 75 mg and 110 mg capsules) or pellets or oral liquid formulation
Active Comparator: standard of care; Low molecular weight heparin, vitamin K antagonist or fondaparinux prescribed in an open label fashion for 3 months (these medications will not supplied in this study as IMP)	Drug: standard of care; Low molecular weight heparin, vitamin K antagonist or fondaparinux prescribed in an open label fashion for 3 months (these medications will not supplied in this study as IMP)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Composite Primary Endpoint	The primary endpoint was the combined endpoint of the proportions of patients with: Complete thrombus resolution; Freedom from recurrent VTE; Freedom from mortality related to VTE. The events outlined in the above combined primary endpoint were assessed by radiologists or other such qualified clinicians using an appropriate method such as ultrasound, echocardiography, venography, or CT scan, based on the location of the thrombus and the test used to perform the baseline assessment. The primary efficacy endpoint contained 3 components. Each component was evaluated separately, and only if the criteria for all 3 components were satisfied, the primary endpoint was considered achieved.	From the time of randomisation until Week 12, 84 days after randomisation including a visit window of 7 days.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Freedom From Major Bleeding Events (MBEs)	Freedom from major bleeding events (MBEs), defined as either fatal bleeding, clinically overt bleeding associated with a decrease in haemoglobin of at least 20 g/L in a 24-hour period, bleeding that is retroperitoneal, pulmonary, intracranial or otherwise involves the central nervous system, or bleeding that requires intervention in an operating suite.	From first administration of trial medication until last administration of trial medication +6 days (residual effect period). Up to 97 days.
Steady State Plasma Concentrations of Total Dabigatran at Visit 3	Descriptive statistics for steady state plasma concentrations of total dabigatran etexilate at visit 3	From the time of randomisation until visit 3
Steady State Plasma Concentrations After at Least 3 Days Following Any Dabigatran Etexilate Dose Adjustment	Descriptive statistics for steady state plasma concentrations of total dabigatran etexilate after at least 3 days following any dabigatran etexilate dose adjustment	From the time of randomisation until Week 12, 84 days after randomisation including a visit window of 7 days.
Frequency of Dose Adjustment During the Treatment Phase	Frequency of dose adjustments (i.e. number of patients with dose adjustment), temporary and permanent discontinuation from therapy, and number of patients with laboratory monitoring requirements for dose	From first administration of trial medication until last administration of trial medication +6 days (residual effect period).
Frequency of Patients Switching the Type of Anti-coagulation Therapy Including Dabigatran Etexilate to Standard of Care Treatment and Switching From One Standard of Care Treatment to Another	Frequency of patients switching the type of anti-coagulation therapy including Dabigatran etexilate (DE) to standard of care (SoC) treatment and switching from one standard of care treatment to another. For DE arm, only the switch from DE to SoC was counted, while for the SoC arm, all switches among SoC treatments were counted.	From first administration of trial medication until last administration of trial medication +6 days (residual effect period).
Freedom From Thrombus Progression at End of Therapy Compared With Baseline	Freedom from thrombus progression at end of therapy compared with baseline, based on adjudication-confirmed data.	From the time of randomisation until Week 12, 84 days after randomisation including a visit window of 7 days.
All Bleeding Events	The number of participants with bleeding events includes major bleeding events (MBEs), clinically relevant non-major (CRNM) bleeding, minor bleeding events, any bleeding events, and the numbers of the combined endpoint of major and CRNM bleeding events was presented, based on adjudication-confirmed data.	From first administration of trial medication until last adminstration of trial medication +6 days (residual effect period). Up to 97 days.
All-cause Mortality	Patients being alive at the end of observational period will be censored for all-cause mortality at the date of patients' last date known to be alive, or the date of data cut-off whichever comes first.	From first administration of trial medication until last administration of trial medication +6 days (residual effect period). Up to 97 days.
All Components of the Primary Efficacy Endpoint	Patients with VTE-related death occurring between randomisation to Day 84 + 7 days were considered as not meeting the endpoint. The presence of recurrent VTE(s) was examined throughout the trial, and only the date of first occurrence was used for analysis. Assessment of index VTE status (best overall response) was scheduled on Day 84 ± 7 days (Visit 8) for patients who were alive without an early consent withdraw. In the case a Patient discontinued trial medication prematurely due to any reason the index VTE assessment took place at the early end of treatment visit.	From the time of randomisation until Week 12, 84 days after randomisation including a visit window of 7 days.
Assessment of the Acceptability of an Age-appropriate Formulation at End of Therapy (Capsules)	Acceptability was defined as the overall ability and willingness of the patient to use the medicinal product. Questions regarding acceptability were to be answered by the patient and/or parent/caregiver (as applicable) and by the investigator/site staff. Investigator questionnaire capsules: What is your impression about the patient's acceptability of DE intake? The score is 1 (good), 2 (satisfactory), 3 (not satisfactory) and 4 (bad). Parents questionnaire capsules: How acceptable was the DE treatment for the child? The score is 1 (good), 2 (satisfactory), 3 (not satisfactory) and 4 (bad). Patients questionnaire capsules: Was taking the study capsules easy or difficult? The score is 1 (Very easy), 2 (easy), 3 (neither easy nor difficult), 4 (difficult) and 5 (very difficult). Scores refers to the end of treatment.	Assessment at the last study visit at day 84 (+- 7 days), or at day of early termination.
Assessment of the Acceptability of an Age-appropriate Formulation at End of Therapy (Pellets)	Acceptability was defined as the overall ability and willingness of the patient to use the medicinal product. Questions regarding acceptability were to be answered by the patient and/or parent/caregiver (as applicable) and by the investigator/site staff. Investigator questionnaire pellets: What is your impression about the patient's acceptability of DE intake? The score is 1 (good), 2 (satisfactory), 3 (not satisfactory) and 4 (bad). Parents questionnaire pellets: Do you think that spitting occurs? The score is 1 (Never), 2 (sometimes) and 3 (often). Scores refers to the end of treatment.	Assessment at the last study visit at day 84 (+- 7 days), or at day of early termination.
Assessment of the Acceptability of an Age-appropriate Formulation at End of Therapy (Oral Liquid Formulation - OLF)	Acceptability was defined as the overall ability and willingness of the patient to use the medicinal product. Questions regarding acceptability were to be answered by the patient and/or parent/caregiver (as applicable) and by the investigator/site staff. Investigator questionnaire flavoured OLF: What is your impression about the patient's acceptability of DE intake? The score is 1 (good), 2 (satisfactory), 3 (not satisfactory) and 4 (bad). Investigator questionnaire unflavoured OLF: What is your impression about the patient's acceptability of DE intake? The score is 1 (good), 2 (satisfactory), 3 (not satisfactory) and 4 (bad). Parents questionnaire flavoured OLF.: Do you think spitting occurs? The score ranges form 1 (never), 2 ( sometimes) to 3 (often). Parents questionnaire unflavoured OLF:Do you think spitting occurs? The score ranges form 1 (never), 2 ( sometimes) to 3 (often). Scores refers to the end of treatment.	Assessment at the last study visit at day 84 (+- 7 days), or at day of early termination.

Collaborators and Investigators

• Sponsor: Boehringer Ingelheim

Publications and helpful links

General Publications

• Brandao LR, Tartakovsky I, Albisetti M, Halton J, Bomgaars L, Chalmers E, Luciani M, Saracco P, Felgenhauer J, Lvova O, Simetzberger M, Sun Z, Mitchell LG. Dabigatran in the treatment and secondary prophylaxis of venous thromboembolism in children with thrombophilia. Blood Adv. 2022 Nov 22;6(22):5908-5923. doi: 10.1182/bloodadvances.2021005681.
• Halton J, Brandao LR, Luciani M, Bomgaars L, Chalmers E, Mitchell LG, Nurmeev I, Sharathkumar A, Svirin P, Gorbatikov K, Tartakovsky I, Simetzberger M, Huang F, Sun Z, Kreuzer J, Gropper S, Reilly P, Brueckmann M, Albisetti M; DIVERSITY Trial Investigators. Dabigatran etexilate for the treatment of acute venous thromboembolism in children (DIVERSITY): a randomised, controlled, open-label, phase 2b/3, non-inferiority trial. Lancet Haematol. 2021 Jan;8(1):e22-e33. doi: 10.1016/S2352-3026(20)30368-9. Epub 2020 Dec 5.
• Albisetti M, Biss B, Bomgaars L, Brandao LR, Brueckmann M, Chalmers E, Gropper S, Harper R, Huang F, Luciani M, Manastirski I, Mitchell LG, Tartakovsky I, Wang B, Halton JML. Design and rationale for the DIVERSITY study: An open-label, randomized study of dabigatran etexilate for pediatric venous thromboembolism. Res Pract Thromb Haemost. 2018 Mar 25;2(2):347-356. doi: 10.1002/rth2.12086. eCollection 2018 Apr.

Helpful Links

• Related Info

Study record dates

Study Major Dates

• Study Start (Actual): September 25, 2013
• Primary Completion (Actual): October 16, 2019
• Study Completion (Actual): November 14, 2019

Study Registration Dates

• First Submitted: July 4, 2013
• First Submitted That Met QC Criteria: July 10, 2013
• First Posted (Estimate): July 11, 2013

Study Record Updates

• Last Update Posted (Actual): July 7, 2020
• Last Update Submitted That Met QC Criteria: June 22, 2020
• Last Verified: June 1, 2020

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Cardiovascular Diseases; Vascular Diseases; Embolism and Thrombosis; Thromboembolism; Venous Thromboembolism; Molecular Mechanisms of Pharmacological Action; Enzyme Inhibitors; Protease Inhibitors; Antithrombins; Serine Proteinase Inhibitors; Anticoagulants; Dabigatran
• Other Study ID Numbers: 1160.106; 2013-002114-12 (EudraCT Number)