FREEDOM COVID-19 Anticoagulation Strategy

FREEDOM COVID Anticoagulation Strategy Randomized Trial

Sponsors

Lead Sponsor: Valentin Fuster

Source Icahn School of Medicine at Mount Sinai
Brief Summary

Coronavirus Disease (COVID-19), caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has led to unprecedented morbidity and mortality in the modern era. To date, nearly 13 million people have contracted COVID-19, leading to more than 550,000 deaths worldwide. As the number of affected individuals continues to climb, effective strategies for treatment and prevention of the disease are of paramount importance. SARS-CoV-2 is understood to directly invade cells via the human angiotensin-converting enzyme 2 (ACE2) receptor, which is expressed predominantly in the lungs but also throughout the cardiovascular system. Thus, while acute respiratory distress syndrome remains a feared complication, new thromboembolic disease has emerged as a common and potentially catastrophic manifestation of COVID-19.

Detailed Description

This is a Prospective, multi-center, open label, randomized controlled comparative safety and effectiveness trial with objectives: 1. To determine the effectiveness of enoxaparin and apixaban in patients hospitalized (but not yet intubated) with confirmed COVID-19 and 2. To determine the safety of enoxaparin and apixaban in patients hospitalized (but not yet intubated) with confirmed COVID-19. Observational analyses have suggested potential benefit for in-hospital use of anticoagulation. Yet, due to a lack of rigorous evidence for optimal anticoagulation regimens, practice patterns among hospitalized patients with COVID-19 vary significantly. Specifically, the choice of anticoagulant, dosing, and duration of treatment are not well understood. A preliminary analysis of approximately 2700 patients admitted to the Mount Sinai Health System (MSHS) in New York, demonstrated an association between in-hospital administration of therapeutic Anticoagulation (AC) and improved survival compared to no or prophylactic dose AC. A subsequent analysis under review of a larger 4400 patient cohort with longer follow up demonstrated similar associations with reduction in the risk of mortality and risk of intubation. Further analyses suggest more pronounced benefit with therapeutic as opposed to prophylactic doses. Bleeding rates were generally low overall, but higher among patients on therapeutic anticoagulation. Finally, though exploratory in nature, a potential signal for benefit was observed for patients on novel oral anticoagulant therapy (primarily apixaban) at therapeutic doses compared to low molecular weight heparin. Ultimately, randomized controlled trials are needed to elucidate the optimal anticoagulation regimen to improve outcomes in patients hospitalized with COVID-19.

Overall Status Recruiting
Start Date September 8, 2020
Completion Date June 2021
Primary Completion Date March 2021
Phase Phase 4
Study Type Interventional
Primary Outcome
Measure Time Frame
Time to first event 30 days
Number of in-hospital rate of BARC 3 or 5 30 days
Secondary Outcome
Measure Time Frame
Number of participants with Myocardial infarction 30 days after randomization
Number of participants with Myocardial infarction 90 days after randomization
Number of participants with Deep Vein Thrombosis 30 days after randomization
Number of participants with Deep Vein Thrombosis 90 days after randomization
Number of participants requiring Ventilation 30 after randomization
Number of participants requiring Ventilation 90 days after randomization
Number of All Death 30 days after randomization
Number of All Death 90 days after randomization
Cause of Death 30 days after randomization
Cause of Death 90 days after randomization
Number of participants with Stroke 30 days after randomization
Number of participants with Stroke 90 days after randomization
Number of participants with Pulmonary Emboli 30 days after randomization
Number of participants with Pulmonary Emboli 90 days after randomization
Number of participants with Systemic Thromboembolism 30 days after randomization
Number of participants with Systemic Thromboembolism 90 days after randomization
Enrollment 3600
Condition
Intervention

Intervention Type: Drug

Intervention Name: Enoxaparin

Description: Prophylactic enoxaparin (40 mg SC QD; 30 mg SC QD for CrCl <30 mL/min) Full-dose enoxaparin (1 mg/kg SC Q12h; 1 mg/kg SC QD for CrCl <30 mL/min)

Intervention Type: Drug

Intervention Name: Apixaban

Description: (5 mg Q12h; 2.5 mg Q12h for patients with at least two of three of age ≥80 years, weight ≤60 kg or serum creatinine ≥1.5 mg/dL)

Arm Group Label: Apixaban

Eligibility

Criteria:

Inclusion Criteria:

- Hospitalization within the prior 24 hours for either confirmed (based on PCR or antigen positive test for SARS-CoV-2) or suspected COVID-19 based on 3 criteria (all 3 must be present for suspected cases):

1. Fever >38 degrees Celsius

2. O2 saturation ≤94

3. Abnormal laboratory marker (at least 1):

i. d-dimer ≥1.0 μg /mL ii. CRP >2 mg/L iii. Ferritin >300 μg /L iv. Lymphopenia <1500 cells /m3

- Patient or legal guardian provides written informed consent

Exclusion Criteria:

- Age <18 years

- Mechanical ventilation on admission or high likelihood for the need for invasive mechanical ventilation within 24 hours of admission

- Anticipated duration of hospital stay <72 hours

- Treatment with therapeutic dose UFH or LMWH, vitamin K antagonists, or NOACs within seven days

- Active bleeding

- Risk factors for bleeding, including:

1. intracranial surgery or stroke within 3 months

2. history of intracerebral arteriovenous malformation

3. cerebral aneurysm or mass lesions of the central nervous system

4. intracranial malignancy

5. history of intracranial bleeding

6. history of bleeding diatheses (e.g., hemophilia)

7. history of gastrointestinal bleeding within previous 3 months

8. thrombolysis within the previous 7 days

9. presence of an epidural or spinal catheter

10. recent major surgery <14 days

11. uncontrolled hypertension (sBP > 200 mmHg or dBP > 120 mmHg)

12. other physician-perceived contraindications to anticoagulation

13. Platelet count <50 x109/L, INR >2.0, or baseline aPTT >50 seconds

14. Hemoglobin <80 g/L (to minimize the likelihood of requiring red blood cell transfusion if potential bleeding were to occur)

15. current treatment with antithrombotics or antiplatelet agents including but not limited to ticagrelor, prasugrel, and aspirin> 100mg, or non-steroidal anti-inflammatory drugs (e.g. ibuprofen, naproxen, etc.) due to increased risk of bleeding, unless such agents can be permanently discontinued (aspirin <= 100mg and clopidogrel <=75mg is permitted)

- Acute or subacute bacterial endocarditis

- History of heparin induced thrombocytopenia (HIT) or other heparin allergy including hypersensitivity

- Patients with non-COVID-19 related clinical condition for which life expectancy is <6 months

- Pregnancy (women of childbearing potential are required to have a negative pregnancy test prior to enrollment)

- Active enrollment in other trials related to anticoagulation

- Patients has end stage kidney disease (ESKD) on chronic dialysis

- Patient is a member of a vulnerable population: In the judgment of the investigator the patient is unable to give Informed Consent for reasons of incapacity, immaturity, adverse personal circumstances or lack of autonomy. This may include: Individuals with mental disability, persons in nursing homes, children, impoverished persons, persons in emergency situations, homeless persons, nomads, refugees, and those incapable of giving informed consent. Vulnerable populations also may include members of a group with a hierarchical structure such as university students, subordinate hospital and laboratory personnel, employees of the Sponsor, members of the armed forces, and persons kept in detention.

Gender: All

Minimum Age: 18 Years

Maximum Age: N/A

Healthy Volunteers: No

Overall Official
Overall Contact

Last Name: Debra Fitzpatrick, MS

Phone: 212-659-9151

Email: [email protected]

Location
Facility: Status: Contact: Investigator: Icahn School of Medicine at Mount Sinai Debra Fitzpatrick, MS 212-659-9151 [email protected] Valentin Fuster, MD, PhD Principal Investigator
Location Countries

United States

Verification Date

October 2020

Responsible Party

Type: Sponsor-Investigator

Investigator Affiliation: Icahn School of Medicine at Mount Sinai

Investigator Full Name: Valentin Fuster

Investigator Title: Principal Investigator

Keywords
Number Of Arms 3
Arm Group

Label: Prophylactic Enoxaparin

Type: Active Comparator

Description: Prophylactic enoxaparin (40 mg SC QD; 30 mg SC QD for CrCl <30 mL/min)

Label: Full Dose Enoxaparin

Type: Active Comparator

Description: Full-dose enoxaparin (1 mg/kg SC Q12h; 1 mg/kg SC QD for CrCl <30 mL/min)

Label: Apixaban

Type: Experimental

Description: Apixaban (5 mg Q12h; 2.5 mg Q12h for patients with at least two of three of age ≥80 years, weight ≤60 kg or serum creatinine ≥1.5 mg/dL)

Acronym FREEDOM COVID
Patient Data Yes
Study Design Info

Allocation: Randomized

Intervention Model: Parallel Assignment

Intervention Model Description: Study participants will be randomized in a 1:1:1 fashion to 1 of 3 arms: Prophylactic enoxaparin (40 mg SC QD; 30 mg SC QD for CrCl <30 mL/min) Full-dose enoxaparin (1 mg/kg SC Q12h; 1 mg/kg SC QD for CrCl <30 mL/min) Apixaban (5 mg Q12h; 2.5 mg Q12h for patients with at least two of three of age ≥80 years, weight ≤60 kg or serum creatinine ≥1.5 mg/dL)

Primary Purpose: Treatment

Masking: None (Open Label)

Source: ClinicalTrials.gov