MUFFIN-PTS trial, Micronized Purified Flavonoid Fraction for the Treatment of Post-Thrombotic Syndrome: protocol of a randomised controlled trial

Jean Philippe Galanaud, Jameel Abdulrehman, A Lazo-Langner, Grégoire Le Gal, Sudeep Shivakumar, Sam Schulman, Susan Kahn, Jean Philippe Galanaud, Jameel Abdulrehman, A Lazo-Langner, Grégoire Le Gal, Sudeep Shivakumar, Sam Schulman, Susan Kahn

Abstract

Introduction: After deep vein thrombosis, up to 50% of patients develop post-thrombotic syndrome (PTS). PTS is a chronic condition that reduces quality of life (QOL). Cornerstones of PTS treatment include the use of elastic compression stockings but this treatment is usually incompletely effective and is burdensome. Venoactive drugs have been reported to be effective to treat chronic venous insufficiency (CVI). However, the level of evidence supporting their use in CVI in general and in PTS in particular is low.

Methods and analysis: The MUFFIN-PTS trial is an academic, publically funded, multicentre randomised placebo-controlled trial assessing the efficacy of micronised purified flavonoid fraction (MPFF, Venixxa), a venoactive drug, to treat PTS. Eighty-six patients with PTS (Villalta score (VS) ≥5) and experiencing at least two of the following PTS manifestations among daily leg heaviness, cramps, pain or oedema will be randomised to receive 1000 mg of oral MPFF or a similar appearing placebo for 6 months, in addition to their usual PTS treatment. Total study follow-up will be 9 months, with visits at inclusion/baseline, 3, 6 and 9 months. Primary outcome is the proportion of patients with improvement in VS in each group, where improvement is defined as a decrease of at least 30% in VS or a VS <5 in the PTS-affected leg. Main secondary outcomes include QOL and patient satisfaction.

Ethics and dissemination: Primary ethics approval was received from Centre intégré universitaire de santé et de services sociaux (CIUSSS) West-Central Montreal Research Ethics Board. Results of the study will be disseminated via peer-reviewed publications and presentations at scientific conferences.

Trial registration number: ClinicalTrials.gov Registry (NCT03833024); Pre-results.

Keywords: clinical trials; thromboembolism; vascular medicine.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
MUFFIN-PTS flow diagram. B, baseline; BID, two times per day; creat cl, creatinine clearance; DVT, deep vein thrombosis; F/U, follow-up; M3, 3-month F/U visit; M6, 6-month F/U visit; M9, 9-month F/U visit; MPFF, micronised purified flavonoid fraction; PTS, post-thrombotic syndrome; QOL, quality of life; RVO, residual venous obstruction; SAE, serious adverse event; US, ultrasound; VS, Villalta score.

References

    1. Rabinovich A, Kahn SR. How I treat the postthrombotic syndrome. Blood 2018;131:2215–22. 10.1182/blood-2018-01-785956
    1. Makedonov I, Kahn SR, Galanaud J-P. Prevention and management of the post-thrombotic syndrome. J Clin Med 2020;9:923. 10.3390/jcm9040923
    1. Galanaud J-P, Monreal M, Kahn SR. Epidemiology of the post-thrombotic syndrome. Thromb Res 2018;164:100–9. 10.1016/j.thromres.2017.07.026
    1. Prandoni P. Healthcare burden associated with the post-thrombotic syndrome and potential impact of the new oral anticoagulants. Eur J Haematol 2012;88:185–94. 10.1111/j.1600-0609.2011.01733.x
    1. Kahn SR, Galanaud J-P, Vedantham S, et al. . Guidance for the prevention and treatment of the post-thrombotic syndrome. J Thromb Thrombolysis 2016;41:144–53. 10.1007/s11239-015-1312-5
    1. Kolbach DN, Sandbrink MWC, Neumann HAM, et al. . Compression therapy for treating stage I and II (Widmer) post-thrombotic syndrome. Cochrane Database Syst Rev 2003:CD004177. 10.1002/14651858.CD004177
    1. Cohen JM, Akl EA, Kahn SR. Pharmacologic and compression therapies for postthrombotic syndrome: a systematic review of randomized controlled trials. Chest 2012;141:308–20. 10.1378/chest.11-1175
    1. Lim CS, Davies AH. Graduated compression stockings. CMAJ 2014;186:E391–8. 10.1503/cmaj.131281
    1. Raju S, Hollis K, Neglen P. Use of compression stockings in chronic venous disease: patient compliance and efficacy. Ann Vasc Surg 2007;21:790–5. 10.1016/j.avsg.2007.07.014
    1. Galanaud J-P, Bertoletti L, Amitrano M, et al. . Predictors of post-thrombotic ulcer after acute DVT: the RIETE registry. Thromb Haemost 2018;118:320–8. 10.1160/TH17-08-0598
    1. Palacios FS, Rathbun SW. Medical treatment for Postthrombotic syndrome. Semin Intervent Radiol 2017;34:61–7. 10.1055/s-0036-1597765
    1. Kearon C, Akl EA, Ornelas J, et al. . Antithrombotic therapy for VTe disease: chest guideline and expert panel report. Chest 2016;149:315–52. 10.1016/j.chest.2015.11.026
    1. ten Cate-Hoek AJ, Weitz JI, Gailani D, et al. . Theme 3: non-invasive management of (recurrent) venous thromboembolism (VTe) and post thrombotic syndrome (PTS). Thromb Res 2015;136 Suppl 1:S13–18. 10.1016/j.thromres.2015.07.036
    1. Martinez-Zapata MJ, Vernooij RWM, Uriona Tuma SM, et al. . Phlebotonics for venous insufficiency. Cochrane Database Syst Rev 2016;4:CD003229. 10.1002/14651858.CD003229.pub3
    1. Wittens C, Davies AH, Bækgaard N, et al. . Editor's Choice - Management of Chronic Venous Disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2015;49:678–737. 10.1016/j.ejvs.2015.02.007
    1. Kahn SR, Comerota AJ, Cushman M, et al. . The postthrombotic syndrome: evidence-based prevention, diagnosis, and treatment strategies: a scientific statement from the American heart association. Circulation 2014;130:1636–61. 10.1161/CIR.0000000000000130
    1. Lyseng-Williamson KA, Perry CM. Micronised purified flavonoid fraction: a review of its use in chronic venous insufficiency, venous ulcers and haemorrhoids. Drugs 2003;63:71–100. 10.2165/00003495-200363010-00005
    1. Bouskela E, Donyo KA. Effects of oral administration of purified micronized flavonoid fraction on increased microvascular permeability induced by various agents and on ischemia/reperfusion in the hamster cheek pouch. Angiology 1997;48:391–9. 10.1177/000331979704800503
    1. Garner RC, Garner JV, Gregory S, et al. . Comparison of the absorption of micronized (Daflon 500 Mg) and nonmicronized 14C-diosmin tablets after oral administration to healthy volunteers by accelerator mass spectrometry and liquid scintillation counting. J Pharm Sci 2002;91:32–40. 10.1002/jps.1168
    1. Kakkos SK, Nicolaides AN. Efficacy of micronized purified flavonoid fraction (Daflon®) on improving individual symptoms, signs and quality of life in patients with chronic venous disease: a systematic review and meta-analysis of randomized double-blind placebo-controlled trials. Int Angiol 2018;37:143–54. 10.23736/S0392-9590.18.03975-5
    1. Rabe E, Agus GB, Roztocil K. Analysis of the effects of micronized purified flavonoid fraction versus placebo on symptoms and quality of life in patients suffering from chronic venous disease: from a prospective randomized trial. Int Angiol 2015;34:428–36.
    1. Son'kin IN, Shaĭdakov EV, Krylov DV, et al. . [Efficacy of Venarus in treatment of patients with post-thrombotic disease of lower limbs]. Angiol Sosud Khir 2014;20:77–83.
    1. Tsukanov YT, Tsukanov AY, Levdanskiy EG. Secondary varicose small pelvic veins and their treatment with micronized purified flavonoid fraction. Int J Angiol 2016;25:121–7. 10.1055/s-0035-1570118
    1. Kahn SR, Partsch H, Vedantham S, et al. . Definition of post-thrombotic syndrome of the leg for use in clinical investigations: a recommendation for standardization. J Thromb Haemost 2009;7:879–83. 10.1111/j.1538-7836.2009.03294.x
    1. Utne KK, Ghanima W, Foyn S, et al. . Development and validation of a tool for patient reporting of symptoms and signs of the post-thrombotic syndrome. Thromb Haemost 2016;115:361–7. 10.1160/th15-04-0318
    1. Prandoni P. Elastic stockings, hydroxyethylrutosides or both for the treatment of post-thrombotic syndrome. Thromb Haemost 2005;93:183–5.
    1. Lamping DL, Schroter S, Kurz X, et al. . Evaluation of outcomes in chronic venous disorders of the leg: development of a scientifically rigorous, patient-reported measure of symptoms and quality of life. J Vasc Surg 2003;37:410–9. 10.1067/mva.2003.152
    1. Kahn SR, Lamping DL, Ducruet T, et al. . VEINES-QOL/Sym questionnaire was a reliable and valid disease-specific quality of life measure for deep venous thrombosis. J Clin Epidemiol 2006;59:1056.e1–1056.e4. 10.1016/j.jclinepi.2005.10.016
    1. Voutilainen A, Pitkäaho T, Kvist T, et al. . How to ask about patient satisfaction? the visual analogue scale is less vulnerable to confounding factors and ceiling effect than a symmetric Likert scale. J Adv Nurs 2016;72:946–57. 10.1111/jan.12875
    1. Overview of the Reporting Adverse Reactions to Marketed Health Products - Guidance Document for Industry. Available:
    1. Ageno W, Squizzato A, Wells PS, et al. . The diagnosis of symptomatic recurrent pulmonary embolism and deep vein thrombosis: guidance from the SSC of the ISTH. J Thromb Haemost 2013;11:1597–602. 10.1111/jth.12301
    1. Cospite M, Dominici A. Double blind study of the pharmacodynamic and clinical activities of 5682 se in venous insufficiency. advantages of the new micronized form. Int Angiol 1989;8:61–5.
    1. Gilly R, Pillion G, Frileux C. Evaluation of a new venoactive micronized flavonoid fraction (S 5682) in symptomatic disturbances of the venolymphatic circulation of the lower limb: a double-blind, placebo-controlled study. Phlebology 1994;9:67–70. 10.1177/026835559400900206
    1. Chassignolle J-F, Amiel M, Lanfranchi G. Activité thérapeutique de Daflon 500 mg dans l’insuffisance veineuse fonctionnelle. J Int Med 1987;99:32–7.
    1. Kahn SR, Shapiro S, Wells PS, et al. . Compression stockings to prevent post-thrombotic syndrome: a randomised placebo-controlled trial. Lancet 2014;383:880–8. 10.1016/S0140-6736(13)61902-9
    1. Piantadosi S. Chapter 7. clinical trials: a methodologic perspective. New York: John Wiley and Sons, 1997.
    1. Ware JE KM, Keller S. SF-36 physical and mental summary measures: A user’s manual. Boston: The Health Institute, New England Medical Center, 1994.
    1. Ware JE SK, Kosinski MA, Gandek B. Sf-36 health survey: manual and interpretation guide. Boston: The Health Institute, New England Medical Center, 1993.
    1. Rabe E, Guex J-J, Morrison N, et al. . Treatment of chronic venous disease with flavonoids: recommendations for treatment and further studies. Phlebology 2013;28:308–19. 10.1177/0268355512471929
    1. Nicolaides A, Kakkos S, Eklof B, et al. . Management of chronic venous disorders of the lower limbs - guidelines according to scientific evidence. Int Angiol 2014;33:87–208.
    1. Martinez-Zapata MJ, Vernooij RW, Simancas-Racines D, et al. . Phlebotonics for venous insufficiency. Cochrane Database Syst Rev 2020;11:CD003229. 10.1002/14651858.CD003229.pub4
    1. Pitsch F. The place of Daflon 500 Mg in recent international guidelines on the management of symptomatic chronic venous disorders. Medicographia 2011;33:306–18.
    1. Rabinovich A, Cohen JM, Cushman M, et al. . Inflammation markers and their trajectories after deep vein thrombosis in relation to risk of post-thrombotic syndrome. J Thromb Haemost 2015;13:398–408. 10.1111/jth.12814
    1. Morling JR, Broderick C, Yeoh SE, et al. . Rutosides for treatment of post-thrombotic syndrome. Cochrane Database Syst Rev 2018;11:CD005625. 10.1002/14651858.CD005625.pub4
    1. Amiel MBR. Etude du délai et de la durée d’action de Daflon 500mg. J Int Med 1987;88:22–4.
    1. Tsouderos Y. Are the phlebotonic properties shown in clinical pharmacology predictive of a therapeutic benefit in chronic venous insufficiency? our experience with Daflon 500 Mg. Int Angiol 1989;8:53–9.
    1. Kirienko A, Radak D. Clinical acceptability study of once-daily versus twice-daily micronized purified flavonoid fraction in patients with symptomatic chronic venous disease: a randomized controlled trial. Int Angiol 2016;35:399–405.
    1. Carpentier P, van Bellen B, Karetova D, et al. . Clinical efficacy and safety of a new 1000-mg suspension versus twice-daily 500-mg tablets of MPFF in patients with symptomatic chronic venous disorders: a randomized controlled trial. Int Angiol 2017;36:402–9. 10.23736/S0392-9590.17.03801-9
    1. Galanaud J-P, Genty-Vermorel C, Rolland C, et al. . Compression stockings to prevent postthrombotic syndrome: literature overview and presentation of the CELEST trial. Res Pract Thromb Haemost 2020;4:1239–50. 10.1002/rth2.12445
    1. Navratilova Z. Efficacy of a 6-month treatment with Daflon 500 mg* in patients with venous edema (efficacy of Daflon 500 mg* in edema treatment EDET). Phlebolymphology 2010;17:137–42.
    1. Lenkovic M, Zgombic ZS, Blazic TM. Benefit of Daflon 500 Mg in the reduction of chronic venous disease-related symptoms. Phlebolymphology 2012;19:79–83.
    1. Yanushko V, SS BAA. Benefits of MPFF on primary chronic venous disease-related symptoms and quality of life: the delta study. Phlebolymphology 2014;21:146–51.

Source: PubMed

3
Abonner