Clinical Trial of Dimolegin (DD217) in Prevention of Thrombotic Complications in Patients With COVID-19

Multicenter Randomized Prospective Open-label Clinical Trial of the Safety and Efficacy of Amidine Hydrochloride (DD217) in Prevention of Thrombotic Complications in Hospitalized Patients Diagnosed With COVID-19

Study purpose was to study the safety and efficacy of Dimolegin - DD217 as a drug for prevention of thrombotic complications compared to Clexane (enoxaparin sodium) - the standard therapy currently prescribed to patients hospitalized with COVID-19.

Patients who met all inclusion criteria and no exclusion criteria were randomized into two therapy groups:

• Group 1 - test drug Dimolegin - DD217 (60 mg orally, 1 time per day);
• Group 2 - reference drug Clexane (40 mg subcutaneously, 1 time per day).

The study drugs were taken once a day until:

• the discharge from the hospital due to recovery or positive dynamics;
• or up to 30 days of the patient's stay in the hospital;
• or until the Investigator decides to discontinue the therapy for other reasons. Planned: screening of up to 450 patients, randomization: 430 (215 per group). The required number of patients is 200 per group as a result of the entire study.

Study Overview

• Status: Completed
• Conditions: COVID-19; Venous Thromboembolism
• Intervention / Treatment: Drug: Dimolegin; Drug: Clexane

Detailed Description

Study purpose:

To study the safety and efficacy of Dimolegin - DD217 as a drug for prevention of thrombotic complications compared to Clexane (enoxaparin sodium) - the standard therapy currently prescribed to patients hospitalized with COVID-19.

Study objectives:

• To study the clinical efficacy of Dimolegin - DD217 as a drug for prevention of thrombotic complications in patients hospitalized with COVID-19.
• To assess the proportion of patients with the development of thrombotic complications: deep vein thrombosis (DVT), pulmonary embolism (PE), ischemic stroke, acute mycardial infarction (AMI), arterial thrombotic complications of other localizations (thrombosis of mesenteric arteries, renal arteries, spleen, upper and lower extremities) during the study therapy (maximum - 30 days).
• To evaluate the proportion of patients transferred to the ICU due to complications of COVID-19 and the all-cause mortality rate during the study therapy (maximum - 30 days) and during the study (maximum 90± 2 days); To study the safety of use, the rate of major and clinically significant minor bleeding and possible side effects of Dimolegin - DD217 during the study therapy (maximum - 30 days).

Methodology:

Multicenter randomized prospective open-label clinical study.

Patients who met all inclusion criteria and no exclusion criteria were randomized into two therapy groups:

• Group 1 - test drug Dimolegin - DD217 (60 mg orally, 1 time per day);
• Group 2 - reference drug Clexane (40 mg subcutaneously, 1 time per day). The first dosing (or administration) of the drug was performed on day 1 (D1) (screening/randomization). Further, patients received drugs according to their distribution into groups, preferably in the morning before the end of therapy, i.e. every morning patients received either an injection of Clexane 40 mg subcutaneously once a day, or test drug Dimolegin - DD217 60 mg (6 tablets of 10 mg).

The study drugs were taken once a day until:

• the discharge from the hospital due to recovery or positive dynamics;
• or up to 30 days of the patient's stay in the hospital;
• or until the Investigator decides to discontinue the therapy for other reasons. During the study therapy, 3 face-to-face follow-up visits were envisaged: Visit 2 (D3±1), Visit 3 (D5±1), Visit 4/EOT (D7-D30).

In all groups, specific antithrombotic prophylaxis was carried out only during inpatient treatment under the supervision by Investigator. The study drugs were not dispensed to the patient.

End of therapy (EOT) visit V4 was carried out in connection with the end of therapy and discontinuation of the study drugs. After the end of therapy, patients were included in the follow-up phase. The visit V5 was conducted in the form of a remote survey in 60±2 days after the end of therapy.

Number of subjects:

Planned: screening of up to 450 patients, randomization: 430 (215 per group). The required number of patients is 200 per group as a result of the entire study.

Actually included: 401 patients were screened, 400 patients were randomized (198 to the Dimolegin - DD217 group and 202 to Clexane group), 399 patients received the study drugs (197 in the Dimolegin - DD217 group and 202 in the Clexane group).

Test drug, dose and route of administration, batch number:

Test drug: Amidine hydrochloride (DD217) Dosage form: enteric-coated tablets Active substance: N-(5-chloropyridine-2-yl)-2-[(4- methylaminophenylcarbonyl)-amino]-5-methylbenzamide hydrochloride Active substance: Amidine hydrochloride 10 mg. Dosing regimen: 60 mg (6 x 10 mg tablets) orally, once a day (preferably in the morning)

Duration of treatment and follow-up:

Duration of treatment: maximum 30 days. Duration of follow-up: 60± 2 days after the end of therapy.

Reference drug, dose and route of administration, batch number:

Reference drug: Clexane Dosage form: Solution for injection Active substance: Enoxaparin sodium

Composition (for 4000 anti-Xa IU/0.4 mL, equivalent to 40 mg/0.4 mL):

Active substance: enoxaparin sodium 40 mg Dosing regimen: 40 mg subcutaneously, once a day (preferably in the morning)

Statistical methods:

Concomitant and past diseases (history), as well as adverse events were encoded using the MedDRA classifier in the current version at the time of the analysis (version 24.0). No missing data were imputed.

Analysis of efficacy endpoints:

For the primary efficacy endpoint, the hypothesis of non-inferiority of Dimolegin - DD217 compared to Clexane was evaluated.

This one-sided hypothesis was evaluated with an overall level of statistical significance of α=5 %. Two-sided 90 % confidence intervals (CI) were calculated for the tests. The hypothesis was evaluated by comparing the lower limit of the two-sided 90 % CI with the limit of non-inferiority of Δ = 10 %.

The analysis was carried out in the per protocol set (PPS). The analysis of secondary efficacy endpoints was carried out descriptively, the proportion of patients with the corresponding event is presented. Moreover, 90 % CIs were calculated for differences in proportions in Dimolegin - DD217 Group 1 compared to Clexane Group 2.

Analysis of safety endpoints:

Analysis of the primary safety endpoint (the incidence of cumulative major and clinically significant minor bleedings during the study therapy (maximum - 30 days)) was performed descriptively by presenting the proportion of patients with the corresponding event. Moreover, 90 % CIs were calculated for differences in proportions between the Dimolegin - DD217 group and the Clexane group.

The analysis of secondary safety endpoints was carried out in the same way as described for the primary safety endpoint. All other safety endpoints are analyzed descriptively.

The safety analysis population included all patients who received at least one dose of the study drug.

• Study Type: Interventional
• Enrollment (Actual): 399
• Phase: Phase 3

Contacts and Locations

Study Locations

• Russian Federation
  • Ivanovo, Russian Federation, 153025
    • Regional budgetary healthcare institution Ivanovskaya clinical hospital named after Kuvaevs
  • Krasnodar, Russian Federation, 350086
    • State Budgetary Institution of Healthcare Research Institute - Regional Clinical Hospital No. 1 named after Professor S.V. Ochapov Ministry of Health of the Krasnodar Territory
  • Ryazan', Russian Federation, 390026
    • Federal State Budgetary Educational Institution of Higher Education Ryazan State Medical University named after Academician I.P. Pavlova of the Ministry of Health of the Russian Federation
  • Saratov, Russian Federation, 410028
    • State Healthcare Institution Saratov City Clinical Hospital No. 2 named after IN AND. Razumovsky
  • Sestroretsk, Russian Federation, 197706
    • St. Petersburg State Budgetary Healthcare Institution City Hospital No. 40 of Kurortny District
  • Yaroslavl, Russian Federation, 150047
    • State budgetary institution of health care of the Yaroslavl region Yaroslavl Regional Clinical Hospital of War Veterans - International Center for the Problems of the Elderly Healthy Longevity

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 85 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Patients who have signed a written consent to participate in the study
• Hospitalized patients with a diagnosis: COVID-19 coronavirus disease confirmed by laboratory testing regardless of the severity of clinical signs no later than 72 hours before screening (U07.1 - virus was identified), or COVID-19 coronavirus disease, when the infection is diagnosed clinically or epidemiologically no later than 72 hours before screening, but laboratory tests are inconclusive or unavailable (U07.2 - virus was not identified), moderate form. To be classified as a moderate form, the patient must have at least one of the following criteria: Body temperature > 38 °C; respiratory rate (RR) > 22/min; shortness of breath during physical exertion; CT (radiography) findings typical of viral lesion (minimal or average lesion volume, Grade 1-2 on CT); SpO2<95 %; serum C reactive protein (CRP) > 10 mg/L
• Males and non-pregnant females (negative pregnancy test or human chorionic gonadotropin (HCG) blood test (for females with childbearing potential)) at the age of 18 to 85 years
• Patients who are able to comply with all the requirements of the study protocol;
• Patients who agreed to use adequate methods of contraception during the entire study and for at least 7 days after the end of the study

Exclusion Criteria:

• Patients treated with anticoagulants or fibrinolytics before inclusion in the study (for example, treatment of venous thromboembolism, atrial fibrillation, the presence of a mechanical prosthetic heart valve, etc.)
• The need to prescribe anticoagulants to the patient at therapeutic doses
• Active bleeding currently or within 6 months prior to screening, high risk of bleeding
• Severe anemia
• Severe thrombocytopenia
• Congenital thrombophilia (deficiency of antithrombin III, protein C, protein S, Leiden mutation of coagulation factor V, increased level of coagulation factor VIII, mutation of prothrombin G20210A, etc.)
• Other coagulation disorders and indications when anticoagulants is impossible to use according to the Investigator
• It is necessary to monitor and to treat in the ICU
• Disease with the life expectancy of <3 months
• Surgery on the brain or spinal cord, spine, ophthalmic or major surgery or injury in the last 90 days
• Gastrointestinal tract disorders that can disrupt the absorption of the study drug (Crohn's disease, ulcerative colitis, irritable bowel syndrome, etc.)
• Acute gastric or duodenal ulcer, erosive gastritis with increased risk of bleeding
• Active liver disease (viral hepatitis B or C, cirrhosis of the liver) and biliary tract disease, with the exception of non-alcoholic steatohepatitis with normal levels of hepatic transaminases
• Nephrotic syndrome, significant kidney diseases with the nephrotic syndrome events
• Severe renal failure (creatinine clearance < 30 mL/min)
• Active cancer (excluding non-melanoma skin cancer), defined as cancer without remission or requiring active chemotherapy or additional treatments such as immunotherapy or radiation therapy
• History of HIV, lues
• History of tuberculosis
• Significant drug or alcohol abuse according to the Investigator in the history or currently
• The development of trophic disorders on the lower extremities that do not respond to medical treatment
• The blood level of platelets is below 25•109L
• Body mass index (BMI) less than 18.5 or more than 40 kg/m2. Body weight below 40 kg or above 130 kg
• Systolic blood pressure (SBP) > 180 mmHg and/or diastolic blood pressure (DBP) >110 mmHg and/or SBP < 90 mmHg and/or DBP <60 mmHg
• Hypersensitivity or contraindications to DD217 or enoxaparin sodium
• Women who are pregnant or breastfeeding
• Women planning pregnancy during a clinical trial (including women who received a positive pregnancy test result at screening or before taking the study drug);
• Women of childbearing potential (including non-sterilized surgically and in the postmenopausal period less than 2 years) who do not want or cannot use adequate methods of contraception throughout the study. Adequate methods of contraception include the use of a condom or diaphragm (barrier method) with spermicide
• Participation in another clinical trial currently or within 30 days prior to screening, use of any study drug for 30 days or 5 half-lives (which is longer) prior to screening
• Inability to read or write; unwillingness to understand and follow the procedures of Study Protocol
• Failure to comply with the regimen of treatment or procedures, which, in the opinion of the Investigator, may affect the study results or the safety of the patient and prevent the patient from further participating in the study
• Any other concomitant medical or serious mental conditions that make the patient ineligible for a clinical trial, limit the validity of the informed consent, or may affect the patient's ability to participate in the study

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: Group DD217; Study drug Dimolegin - DD217, 60 mg orally, 1 time per day	Drug: Dimolegin; 60 mg orally, 1 time per day; Other Names: DD217
Active Comparator: Group Clexane; Reference drug Clexane, 40 mg subcutaneously, 1 time per day	Drug: Clexane; 40 mg subcutaneously, 1 time per day; Other Names: Enoxaparin sodium

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
The frequency of DVT	The frequency of DVT during the study therapy (maximum - 30 days)	30 Days
The frequency of PE	The frequency of PE during the study therapy (maximum - 30 days)	30 Days
The frequency of ischemic stroke	The frequency of ischemic stroke during the study therapy (maximum - 30 days)	30 Days
The frequency of AMI	The frequency of AMI during the study therapy (maximum - 30 days)	30 Days
The frequency of arterial thrombotic complication	The frequency of arterial thrombotic complication (thrombosis of mesenteric arteries, renal arteries, spleen, upper and lower extremities) during the study therapy (maximum - 30 days)	30 Days

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
The proportion of patients transferred to the ICU	The proportion of patients transferred to the ICU due to COVID-19 complications (development of acute respiratory failure (ARF), acute respiratory distress syndrome (ARDS), sepsis, etc.) during the study therapy (maximum - 30 days)	30 Days
The all-cause mortality rate	The all-cause mortality rate during the study therapy (maximum - 30 days)	30 Days
The all-cause mortality rate during the study	The all-cause mortality rate during the study (maximum 90±2 days)	90 Days
The proportion of patients who stayed in the hospital more than 30 days	The proportion of patients who stayed in the hospital more than 30 days (the study therapy stops after 30 days)	30 Days
The number of days the patient spent in the hospital before discharge due to recovery or positive dynamics, including outpatient follow-up before 30 days expire	The number of days the patient spent in the hospital before discharge due to recovery or positive dynamics, including outpatient follow-up before 30 days expire	30 Days
Recovery rate	Recovery rate (body temperature < 37.2 °C; oxygen saturation (SpO2) in air > 96 %; negative laboratory tests of biological material for SARS-CoV-2 RNA)	30 Days
Proportion of patients requiring high-flow oxygen therapy or noninvasive ventilation (NIV)	Proportion of patients requiring high-flow oxygen therapy or NIV	30 Days
Changes in the hemostasis system parameters	Changes in the hemostasis system parameters over the time (APTT, international normalized ratio (INR), D-dimer, Fibrinogen)	30 Days
The efficacy of drugs in patients depends on the D-dimer level at screening	The efficacy of drugs in patients depends on the D-dimer level at screening	30 Days

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
The frequency of major and clinically significant minor bleedings	The frequency of major and clinically significant minor bleedings during the study therapy (maximum - 30 days)	30 Days
The total frequency of all hemorrhagic complications	The total frequency of all hemorrhagic complications during the study therapy (maximum - 30 days)	30 Days
The frequency of clinical signs of severe thrombocytopenia	The frequency of clinical signs of severe thrombocytopenia during the study therapy (maximum - 30 days)	30 Days
The frequency of treatment-emergent adverse events	The frequency of treatment-emergent adverse events during the study therapy (maximum - 30 days)	30 Days
The frequency of treatment-emergent serious adverse events	The frequency of treatment-emergent serious adverse events during the study therapy (maximum - 30 days)	30 Days

Collaborators and Investigators

• Sponsor: PharmaDiall Ltd.

Publications and helpful links

General Publications

• Tovbin DG, Tarasov DN, Malakhov DV, Tserkovnikova NA, Aybush AV, Drozd NN. The Development of New Low-Molecular-Weight Factor Xa Inhibitors that are Potential Anticoagulants. Curr Drug Discov Technol. 2022;19(1):e010921191770. doi: 10.2174/1568009621666210224104940.
• Tarasov DN, Tovbin DG, Malakhov DV, Aybush AV, Tserkovnikova NA, Savelyeva MI, Sychev DA, Drozd NN, Savchenko AY. The Development of New Factor Xa Inhibitors Based on Amide Synthesis. Curr Drug Discov Technol. 2018;15(4):335-350. doi: 10.2174/1570163815666180215114732.

Study record dates

Study Major Dates

• Study Start (Actual): February 8, 2021
• Primary Completion (Actual): August 6, 2021
• Study Completion (Actual): October 29, 2021

Study Registration Dates

• First Submitted: December 29, 2021
• First Submitted That Met QC Criteria: January 10, 2022
• First Posted (Actual): January 11, 2022

Study Record Updates

• Last Update Posted (Actual): January 11, 2022
• Last Update Submitted That Met QC Criteria: January 10, 2022
• Last Verified: December 1, 2021

More Information

Terms related to this study

• Keywords: anticoagulant; anticoagulation; venous thromboembolism; pulmonary embolism; deep venous thrombosis; thromboprophylaxis; Dimolegin; Dioxaban; DD217; factor Xa Inhibitor; therapeutic anticoagulation; arterial thromboembolism
• Additional Relevant MeSH Terms: Cardiovascular Diseases; Vascular Diseases; Coronavirus Infections; Coronaviridae Infections; Nidovirales Infections; RNA Virus Infections; Virus Diseases; Infections; Respiratory Tract Infections; Respiratory Tract Diseases; Pneumonia, Viral; Pneumonia; Lung Diseases; Embolism and Thrombosis; COVID-19; Thromboembolism; Venous Thromboembolism; Molecular Mechanisms of Pharmacological Action; Fibrinolytic Agents; Fibrin Modulating Agents; Anticoagulants; Enoxaparin; Enoxaparin sodium
• Other Study ID Numbers: АМ217-03

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No