- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT04157881
A Study on the Impact of Rabeprazole-induced Elevated Stomach pH on APO-Dabigatran Exposure in Healthy Volunteers (TADA)
Impact of Rabeprazole-induced Elevated Gastric pH on APO-Dabigatran Exposure in Healthy Volunteers
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Non-valvular atrial fibrillation (AF) and venous thromboembolism (VTE) affect hundreds of thousands of Canadians and many millions worldwide. Affected patients are routinely treated with oral anticoagulants. Vitamin K antagonists (VKAs) were the only orally available anticoagulants for more than 60 years. Over the past decade, Direct Acting Oral Anticoagulants (DOACs) have increasingly replaced VKAs for treatment of patients with AF or VTE because of similar or superior efficacy and safety, and greater convenience. One of these new agents, dabigatran etexilate, has now come off patent in Canada, and at least one generic made by Apotex has been approved by Health Canada.
Prior to their introduction into clinical use, the development of an orally active direct thrombin inhibitors (DTIs) proved technically difficult because it required the conversion of a small, water soluble, poorly absorbable, active site-directed molecule into a fat-soluble prodrug that is transformed back to the active drug after intestinal absorption. In the case of dabigatran, this was achieved by administering it as an oral prodrug, dabigatran etexilate. When administered as the pro-drug, the bioavailability of dabigatran is pH-dependent and is optimal at low pH. To overcome the issue with pH-dependency of drug absorption, dabigatran capsules contain drug pellets, which are made up of a tartaric acid core coated with dabigatran etexilate, thereby maintaining an acid micro-environment (1, 2). After absorption the prodrug is metabolized to the active form dabigatran through esterases that are ubiquitous in the body.
Many patients taking oral anticoagulants are elderly and have an increased gastric pH (3), often as a result of commonly prescribed co-medications such as proton pump inhibitors (PPIs). Optimization of the formulation of originator Pradaxa® (dabigatran etexilate) provides consistent absorption in elderly patients, independent of gastric pH (1, 4), as was demonstrated in phase III trials where consistent outcomes were achieved in the young and elderly, and in the presence and absence of PPI therapy(5).
Generic formulations of dabigatran etexilate are required to demonstrate bioequivalence to the originator in healthy volunteers in order to receive regulatory approval in Canada. According to Canadian regulations and Health Canada, bioequivalence trials do not usually require testing in older patients with an altered gastric pH or in patients taking a PPI (6). The sophisticated pharmaceutical formulation of Pradaxa® ensures stable and reliable absorption despite its low solubility under elevated pH. Pradaxa® has a bioavailability of 6.5% (4, 7) and even any seemingly small alteration in absorption resulting from a change in formulation may significantly affect drug levels. Lower drug levels could lead to an increase in thrombotic events, and higher drug levels could increase bleeding. The European Union (EU) product specific guideline for dabigatran etexilate, however, does require additional bioequivalence studies with elevated gastric pH by means of PPI pre-treatment(8).
APO-Dabigatran is one of the first generic formulations of dabigatran etexilate to be introduced into the Canadian market. APO-Dabigatran compared with Pradaxa® demonstrated similar bioavailability in healthy volunteers, fulfilling the requirements as a generic alternative to the original compound. Unlike Pradaxa®, APO-Dabigatran is formulated using fumaric acid and it is unclear whether this produces a similar pharmacokinetic profile to that of Pradaxa in patients with altered gastric pH, for example in the elderly or those taking a PPI.
This study objective is to determine in healthy volunteers whether concomitant PPI therapy impairs absorption of APO-dabigatran 150 mg and thereby reduces drug blood levels.
Study Type
Enrollment (Actual)
Phase
- Phase 4
Contacts and Locations
Study Locations
-
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Ontario
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Hamilton, Ontario, Canada, L8L 2X2
- The Population Health Research Institute
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Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- 20 to 40 years old
- Body mass index 18-30 kg/m2
- Male. Those able to father a child must be ready and able to use highly effective methods of birth control per ICH M3 (R2) that result in a low failure rate of less than 1% per year when used consistently and correctly. A list of contraception methods meeting these criteria is provided in the patient information sheet.
Exclusion Criteria:
- Any documented history of heart, lung, liver, kidney, gastrointestinal, genitourinary, musculoskeletal or endocrine disorders or other systemic illness not specifically listed.
- Regular use of any medications or herbal supplements/remedies (e.g. St. John's wort).
- Laboratory values outside of reference range that may compromise safety or validity of the trial.
- Smoking or alcohol consumption such that the investigators feel that they will not be able to comply with the trial protocol.
- Measures at screening outside of the reference ranges for systolic and diastolic blood pressure (>140/90) and pulse rate (>90/min).
- Patients who are not expected to comply with the protocol requirements or not expected to complete the trial as scheduled (includes any condition that, in the investigator's opinion, makes the patient an unreliable trial participant).
- Previous enrollment in this trial.
- Currently enrolled in another investigational device or drug trial, or less than 30 days since ending another investigational device or drug trial(s), or receiving other investigational treatment(s)
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Prevention
- Allocation: Non-Randomized
- Interventional Model: Crossover Assignment
- Masking: None (Open Label)
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Other: APO-Dabigatran
Single dose 150mg APO-Dabigatran given with 24 hours of Pharmacokinetic (PK) testing post dose
|
Absorption of APO-Dabigatran post single dose
|
Other: APO-Dabigatran and Rabeprazole
4-7 doses of rabeprazole followed by single dose 150mg APO-Dabigatran given with 24 hours of Pharmacokinetic (PK) testing post dose
|
Absorption of APO-Dabigatran post single dose
Absorption of APO-Dabigatran measured with and without influence of rabeprazole
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What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
24-hour APO-Dabigatran exposure by peak concentration
Time Frame: 24 Hours
|
As measured by peak concentration (Cmax)
|
24 Hours
|
24-hour APO-Dabigatran exposure
Time Frame: 24 Hours
|
As measured by area under the curve (AUC)
|
24 Hours
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Area under the curve Dilute Thrombin time (dTT)
Time Frame: 24 hours
|
dilute thrombin time measured at 0 minutes, 30 minutes, 60 minutes, 90 minutes, 2 hours, 3 hours, 4 hours, 6 hours, 8 hours, 24 hours to calculate AUC and maximum
|
24 hours
|
Maximum Dilute Thrombin time (dTT)
Time Frame: 24 hours
|
dilute thrombin time measured at 0 minutes, 30 minutes, 60 minutes, 90 minutes, 2 hours, 3 hours, 4 hours, 6 hours, 8 hours, 24 hours to calculate AUC and maximum
|
24 hours
|
Area under the curve activated partial thromboplastin time (aPTT)
Time Frame: 24 hours
|
activated partial thromboplastin time measured at 0 minutes, 30 minutes, 60 minutes, 90 minutes, 2 hours, 3 hours, 4 hours, 6 hours, 8 hours, 24 hours to calculate AUC and maximum
|
24 hours
|
Maximum activated partial thromboplastin time (aPTT)
Time Frame: 24 hours
|
activated partial thromboplastin time measured at 0 minutes, 30 minutes, 60 minutes, 90 minutes, 2 hours, 3 hours, 4 hours, 6 hours, 8 hours, 24 hours to calculate AUC and maximum
|
24 hours
|
Collaborators and Investigators
Collaborators
Investigators
- Principal Investigator: John Eikelboom, MBBS, MSc, Population Health Research Institute
Publications and helpful links
General Publications
- Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, Pogue J, Reilly PA, Themeles E, Varrone J, Wang S, Alings M, Xavier D, Zhu J, Diaz R, Lewis BS, Darius H, Diener HC, Joyner CD, Wallentin L; RE-LY Steering Committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009 Sep 17;361(12):1139-51. doi: 10.1056/NEJMoa0905561. Epub 2009 Aug 30. Erratum In: N Engl J Med. 2010 Nov 4;363(19):1877.
- Stangier J. Clinical pharmacokinetics and pharmacodynamics of the oral direct thrombin inhibitor dabigatran etexilate. Clin Pharmacokinet. 2008;47(5):285-95. doi: 10.2165/00003088-200847050-00001.
- Coppens M, Eikelboom JW, Gustafsson D, Weitz JI, Hirsh J. Translational success stories: development of direct thrombin inhibitors. Circ Res. 2012 Sep 14;111(7):920-9. doi: 10.1161/CIRCRESAHA.112.264903.
- Hurwitz A, Brady DA, Schaal SE, Samloff IM, Dedon J, Ruhl CE. Gastric acidity in older adults. JAMA. 1997 Aug 27;278(8):659-62.
- Sarah S. The pharmacology and therapeutic use of dabigatran etexilate. J Clin Pharmacol. 2013 Jan;53(1):1-13. doi: 10.1177/0091270011432169. Epub 2013 Jan 24.
- Weitz JI, Earl KM, Leblanc K, Semchuk W, Jamali F. Establishing Therapeutic Equivalence of Complex Pharmaceuticals: The Case of Dabigatran. Can J Cardiol. 2018 Sep;34(9):1116-1119. doi: 10.1016/j.cjca.2018.05.023. Epub 2018 Jun 5.
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 (Actual)
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
- Pathologic Processes
- Heart Diseases
- Cardiovascular Diseases
- Vascular Diseases
- Embolism and Thrombosis
- Arrhythmias, Cardiac
- Atrial Fibrillation
- Thromboembolism
- Venous Thromboembolism
- Molecular Mechanisms of Pharmacological Action
- Enzyme Inhibitors
- Gastrointestinal Agents
- Protease Inhibitors
- Antithrombins
- Serine Proteinase Inhibitors
- Anticoagulants
- Anti-Ulcer Agents
- Proton Pump Inhibitors
- Dabigatran
- Rabeprazole
Other Study ID Numbers
- TADA_1910_V1.9
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
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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