- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT02534571
To Compare a Hemostatic Powder TC-325 and Standard Treatment in the Control of Acute Upper Gastrointestinal Bleeding From Nonvariceal Causes (TC325)
Endoscopic Application of a Hemostatic Powder TC-325 Versus Standard Treatment in the Control of Acute Upper Gastrointestinal Bleeding From Nonvariceal Causes; A Non-inferiority Randomized Trial
Study Overview
Status
Conditions
Detailed Description
Impact and Objectives Long-term impact :Acute upper gastrointestinal bleeding is a common medical emergency. The majority of causes are non-variceal in etiology and are mostly peptic ulcers. Endoscopic treatment reduces further bleeding, surgery and deaths from the condition. The current endoscopic treatment to non-variceal causes includes.the use of hemo-clips and thermo-coagulation. Endoscopic treatment is skill demanding and can be challenging in difficult access areas in the gastroduodenal tract e.g. posterior bulbar duodenum. Endoscopic application of hemostatic powder (labeled TC-325) is technically easy. The proposed randomized trial is the first to compare TC-325 to standard treatment. An non-inferior treatment of hemostatic powder TC-325 would mean wider application of endoscopic treatment as most endoscopists are able to use it. It can at least be used for acute control of bleeding allowing time for more definitive treatment.
Objectives :
- To compare clinical efficacy of the hemostatic powder TC-325 to standard treatment in overall rate of hemostasis in patients with active bleeding from a non-variceal source in the upper gastrointestinal tract. Investigators aim to determine the initial rate of hemostasis and the rate of further bleeding after initial control in both groups. Investigators would like to define role of TC-325 as a mono-therapy when compared to standard treatment. The rate of further bleeding after initial control would also inform us if endoscopic application of TC-325 should be followed by a second look endoscopy with targeted treatment to the bleeding artery.
- To compare ease of application of hemostatic powder TC-325 to standard treatment.
Background of Research, Research Plan and Methodology :
a. Background of research Acute upper gastrointestinal bleeding (AUGIB) is one of the commonest medical emergencies. Mortality in patients with AUGIB remains high. In the National United Kingdom Audit of 2007, the crude overall in patient mortality was 10%. Mortality increases in patients with advanced age and significant comorbid illnesses. Endoscopic therapy greatly improves outcomes in patients with AUGIB. In pooled analyses of randomized controlled trials on endoscopic therapy in patients with nonvariceal upper gastrointestinal bleeding, endoscopic therapy significantly reduces not only further bleeding but also surgery and deaths.
The National United Kingdom audit in 2007 found continuing delays in endoscopy and treatment in patients admitted with AUGIB. Only 55% of patients judged to belong to the high risk group underwent endoscopy within 24 hours of their admissions, and only 74% of high risk lesions were offered endoscopic treatment. The gap in service provision may be an organization issue. The lack of skills in endoscopic therapy may also contribute to this shortfall. An easy-to-use endoscopic treatment is likely to help generalize endoscopic hemostasis.
The current standard of endoscopic therapy consists of the use of hemoclips or thermo-coagulation with or without pre-injection with diluted epinephrine. TC-325 is a proprietary, inert inorganic mineral blend powder approved by FDA for the purpose of hemostasis. In the United States the powder is used for compression treatment of bleeding from external injuries in both civilian and combat casualties. The powder is highly absorbent. When in contact with fluid or blood the powder rapidly concentrates clotting factors at the bleeding site and forms an adherent coagulum. In 2011, Investigators reported the first endoscopic human application of the hemostatic powder TC-325. In 20 patients with Forrest type I bleeding from their gastro-duodenal ulcers, Investigators were able to control bleeding in 19 of them. The single patient with refractory bleeding from an angular gastric ulcer underwent angiography to his left gastric artery and a pseudo-aneurysm was found arising from the article. The aneurysm was successfully embolized with coils by angiographic methods. None of these patients needed surgery or died when followed up for 30 days. These initial results were encouraging. In gastroduodenal ulcers with Forrest I bleeding, rate of further bleeding would be around 55% if untreated by endoscopy.
Subsequent to this pilot study, several series were published on the endoscopic use of TC-325. The pooled rate in the initial control of bleeding with the use of TC-325 was 89.6%. Rate of further bleeding after hemostasis was 19.2%. The reported series consisted of patients with different case-mix but exclusively non-variceal in etiologies. Indications for use of TC-325 also varied in these series. The powder was used as mono-therapy, in combination to other endoscopic therapies or as a rescue therapy when conventional endoscopic treatment failed. In the absence of comparative studies, the role of TC-325 remains undefined.
Herein Investigators propose a randomized controlled study to compare endoscopic use of TC-325 as a mono-therapy to current standards of hemostasis using either hemo-clips or contact thermo-coagulation with or without diluted epinephrine in patients with active bleeding (Forrest type I) from non-variceal upper GI causes. Investigators hypothesize that endoscopic application of TC-325 would not be inferior in the control of bleeding from non-variceal sources when compared to standard treatment. If such is the case, endoscopic use of TC-325 may be preferred over existing techniques because of simplicity in TC-325 application. It appeals especially to endoscopists with less experience in endoscopic hemostasis. In lesions of challenging anatomical positions e.g. posterior bulbar duodenum, TC-325 may prove superior.
Study Type
Enrollment (Actual)
Phase
- Phase 3
Contacts and Locations
Study Locations
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Hong Kong
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Hong Kong, Hong Kong, China
- Endoscopy centre
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Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- patients with overt signs of upper gastrointestinal bleeding (hematemesis, melena and/or circulatory instability)
- documented bleeding (Forrest I) from a non-variceal upper gastrointestinal source (gastro-duodenal ulcers, Mallory Weiss tear, cancers, Dieulafoy's and other vascular lesions) at endoscopy.
Exclusion Criteria:
- without a full informed consent from the patient or his next of kin
- Age <18 years
- Pregnant
- Lactating women
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: None (Open Label)
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: TC-325
Endoscopic Application of a Hemostatic Powder TC-325, <=150gm , once
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Endoscopic Application of a Hemostatic Powder TC-325 <=150g once
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Active Comparator: standard treatment
standard treatment of either hemo-clipping or thermo-coagulation with or without pre injection with diluted epinephrine <=20 clip or4 pulse , once only
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Hemo-clipping <=20 clips
Other Names:
epinephrine injection endoscopically <20 mls
Other Names:
contact thermo-coagulation < = 4 pulses
Other Names:
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What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
number of participants who presents and confirmed endoscopically as recurrent upper gastro-intestinal bleeding
Time Frame: 30 days
|
( Further bleeding is defined by failure to control bleeding at index endoscopy, renewed hematemesis, fresh melena with circulatory instability after initial control of bleeding (systolic blood pressure of 90 mmHg or less or pulse rate of 110 per minute or more) and/or a drop in haemoglobin by 2 g/dl and haematocrit by 10% over 24 hours despite adequate transfusion.
Further bleeding after initial endoscopic hemostasis requires documentation with immediate endoscopy which finds fresh blood and active bleeding from a previously treated upper GIB source.
Patients with further bleeding after initial endoscopic control are considered to have reached an outcome endpoint.
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30 days
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Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
number of participants who required subsequent endoscopic treatment upon recurrent bleeding
Time Frame: 30 days
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number of participants who required subsequent endoscopic treatment upon recurrent bleeding
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30 days
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number of participants who required subsequent surgical treatment upon recurrent bleeding
Time Frame: 30 days
|
number of participants who required subsequent surgical treatment upon recurrent bleeding
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30 days
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number of participants who required further blood transfusion post randomization
Time Frame: 30 days
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number of participants who required further blood transfusion post randomization
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30 days
|
Days of hospitalization post randomization
Time Frame: 60 days
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Days of hospitalization post randomization
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60 days
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number of days which participant required caring in Intensive care unit post randomization
Time Frame: 60 days
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number of days which participant required caring in Intensive care unit post randomization
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60 days
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number of participants with adverse events as a Measure of Safety and Tolerability (related or unrelated to endoscopic treatment)
Time Frame: 30 days
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number of participants with adverse events as a Measure of Safety and Tolerability (related or unrelated to endoscopic treatment
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30 days
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number of participants with mortality from all causes within 30 days randomization.
Time Frame: 30 days
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number of participants with mortality from all causes within 30 days randomization
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30 days
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Ease of endoscopic treatment as measured by Visual Analog Scale reported by Endoscopist
Time Frame: 3 days
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self reported VAS scale: 0 cm to 10 cm
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3 days
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procedure time of endoscopic treatment
Time Frame: 3 days
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procedure time of endoscopic treatment
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3 days
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number of participant who need extra assistant to accomplish the endoscopic treatment
Time Frame: 3 days
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number of participant who need extra assistant eg advanced endoscopist to accomplish the endoscopic treatment other than the main endoscopist
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3 days
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Collaborators and Investigators
Sponsor
Investigators
- Principal Investigator: James YW LAU, MD, CUHK
Publications and helpful links
General Publications
- Lau JYW, Pittayanon R, Kwek A, Tang RS, Chan H, Rerknimitr R, Lee J, Ang TL, Suen BY, Yu YY, Chan FKL, Sung JJY. Comparison of a Hemostatic Powder and Standard Treatment in the Control of Active Bleeding From Upper Nonvariceal Lesions : A Multicenter, Noninferiority, Randomized Trial. Ann Intern Med. 2022 Feb;175(2):171-178. doi: 10.7326/M21-0975. Epub 2021 Dec 7.
- Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol. 2021 May 1;116(5):899-917. doi: 10.14309/ajg.0000000000001245. Erratum In: Am J Gastroenterol. 2021 Nov 1;116(11):2309.
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Estimate)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
- Digestive System Diseases
- Pathologic Processes
- Gastrointestinal Diseases
- Hemorrhage
- Gastrointestinal Hemorrhage
- Physiological Effects of Drugs
- Adrenergic Agents
- Neurotransmitter Agents
- Molecular Mechanisms of Pharmacological Action
- Autonomic Agents
- Peripheral Nervous System Agents
- Adrenergic alpha-Agonists
- Adrenergic Agonists
- Bronchodilator Agents
- Anti-Asthmatic Agents
- Respiratory System Agents
- Coagulants
- Adrenergic beta-Agonists
- Sympathomimetics
- Vasoconstrictor Agents
- Mydriatics
- Hemostatics
- Epinephrine
Other Study ID Numbers
- TC325 Study
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
product manufactured in and exported from the U.S.
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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