- ICH GCP
- Amerikanska kliniska prövningsregistret
- Klinisk prövning NCT02042534
Rivaroxaban Versus Warfarin in Acute Ischemic Stroke With Atrial Fibrillation (TripleAXEL)
Rivaroxaban Versus Warfarin in Acute Ischemic Stroke With Atrial Fibrillation: Acute Stroke With Xarelto to Reduce Intracranial Bleeding, Recurrent Embolic Stroke, and Hospital Stay, Phase 2, Conceptual Multicenter Trial
Rationale Acute ischemic stroke due to atrial fibrillation (AF) carries a high risk for early recurrence. In acute stage, guidelines recommend aspirin, but do not recommend anticoagulation due to the increased risk of intracranial bleeding. Since, aspirin has a limited efficacy of preventing recurrent stroke in AF, expert consensus suggests early anticoagulation in non-severe stroke with AF. The current practice for acute ischemic stroke patients with AF is delayed warfarin administration with aspirin use for non-minor stroke or immediate warfarin administration (sometimes with heparin bridging) for minor stroke. However, conventional anticoagulation with warfarin in acute ischemic stroke with AF has the following limitations: 1) risk of intracranial bleeding particularly in acute stage, 2) delayed action and transient paradoxical thrombogenic tendency due to the inhibition of protein C, resulting in the risk of early recurrent embolic stroke, and 3) prolongation of hospitalization waiting for full anticoagulation. In contrast, as compared to warfarin, rivaroxaban is advantageous for reduced risk of intracranial bleeding and immediate anticoagulation efficacy.
Goal The current trial will examine whether early initiation (within 5 days from stroke onset) of rivaroxaban as compared to conventional warfarin would reduce intracranial bleeding, recurrent embolic stroke, and hospital stay in patients with acute ischemic stroke due to AF.
Studieöversikt
Status
Betingelser
Intervention / Behandling
Detaljerad beskrivning
Studietyp
Inskrivning (Faktisk)
Fas
- Fas 2
Kontakter och platser
Studieorter
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Seoul, Korea, Republiken av, 138-736
- Asan Medical Center
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Deltagandekriterier
Urvalskriterier
Åldrar som är berättigade till studier
Tar emot friska volontärer
Kön som är behöriga för studier
Beskrivning
Inclusion Criteria: All of below
- Acute ischemic stroke or TIA presumed to be cardioembolic origin (within 5 days from stroke onset) with mild severity: infarct size on DWI less than 1/3 of MCA territory, 1/2 of ACA territory, 1/2 of PCA territory, and 1/2 of one cerebellar hemisphere
- Atrial fibrillation including paroxysmal atrial fibrillation: atrial fibrillation must be documented by ECG evidence (e.g., 12-lead ECG, rhythm strip, Holter, pacemaker interrogation) within 30 days before randomization. This could be obtained from a notation in the subject's record (e.g., medical chart, hospital discharge summary).
- Age ≥19 years
- Informed consent
Exclusion Criteria: Any of below
- Chronic renal failure (GFR less than 30ml/min) or severe hepatic impairment
- Significant hemorrhagic transformation (parenchymal hematoma type I or II by the ECASS definition)
- Stroke mechanism of presumed small vessel occlusion: single small subcortical infarct in the perforating artery territory
- Large hemispheric or cerebellar infarction; larger than 1/3 of MCA territory, 1/2 of ACA territory, 1/2 of PCA territory, and 1/2 of one cerebellar hemisphere
- Mechanical valve requiring warfarin therapy
- Active internal bleeding
Prior history of symptomatic intracranial bleeding
: patients with asymptomatic bleedings or microbleedings on MRI are eligible for inclusion
- Major surgery or major trauma within 30 days that might be associated with increased bleeding risk
- Clinically significant gastrointestinal bleeding within 6 months
Intravenous tissue plasminogen activator use or mechanical embolectomy within 48 hours plus 'significant hemorrhagic transformation as described above (exclusion criteria 2)' or 'large hemispheric infarction or cerebellar infarction as described above (exclusion criteria 4)'
: patients achieving successful reperfusion without hemorrhage nor large infarction are eligible for enrollment
- Severe anemia: hemoglobin <10 g/dL
- Bleeding diathesis; thrombocytopenia (<90,000/µL, prolonged PT (INR>1.7)
- Sustained uncontrolled hypertension: SBP >180 mmHg or DBP >100 mmHg
- Severe devastating illness, such terminal cancer, hepatic failure; therefore, the participants have a life expectancy less than 6 months.
- Planned invasive procedure with potential for uncontrolled bleeding, including major surgery
Studieplan
Hur är studien utformad?
Designdetaljer
- Primärt syfte: Behandling
- Tilldelning: Randomiserad
- Interventionsmodell: Parallellt uppdrag
- Maskning: Ingen (Open Label)
Vapen och interventioner
Deltagargrupp / Arm |
Intervention / Behandling |
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Experimentell: Rivaroxaban
Rivaroxaban group for 1 month : initial 5 days after randomization rivaroxaban 10mg QD will be administered.
Rivaroxaban 20mg QD, but 15mg in case of Cr CL will be administered for remaining 25 days.
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Rivaroxaban group receive oral rivaroxaban 10 mg once daily for 5 consecutive days, followed by 20 mg or 15 mg in patients with a calculated creatinine clearance of 30-49 ml/min. The dosage of rivaroxaban is leveraged from results of ROCKET-AF trial, where 20 mg of rivaroxaban was shown to offer balanced efficacy and safety.
Andra namn:
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Aktiv komparator: Warfarin
Patients allocated to warfarin receive warfarin plus aspirin 100mg until INR value exceed 1.7 followed by warfarin monotherapy with target INR value of 2.5 [2.0 - 3.0].
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To harmonize the warfarin regimen across the sites, fixed algorithm was used in dose calculation, both loading and maintenance, and age, sex, ethnicity, race, weight, height, smoking history, presence of liver disease, indication, baseline INR, target INR and concomitant medication were considered as cofactors (http://www.warfarindosing.org/Source/InitialDose.aspx).
Investigators will manage anticoagulation with warfarin per routine clinical care.
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Vad mäter studien?
Primära resultatmått
Resultatmått |
Åtgärdsbeskrivning |
Tidsram |
---|---|---|
Number of Participants With Intracranial Bleeding and/or Recurrent Ischemic Lesion as Confirmed by MRI Imaging
Tidsram: 1 month after randomization
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Intracranial bleeding: symptomatic hemorrhage confirmed by CT or MRI or asymptomatic hemorrhage on follow-up GRE or SWI imaging at 1 month Recurrent ischemic lesion: symptomatic ischemic stroke confirmed by relevant neuroimagings or asymptomatic recurrent ischemic lesion on follow-up or FLAIR imaging at 1 month |
1 month after randomization
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Sekundära resultatmått
Resultatmått |
Åtgärdsbeskrivning |
Tidsram |
---|---|---|
The Number of Patients With Intracranial Bleeding
Tidsram: at 1 month
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Intracranial bleeding confirmed by relevant neuroimagings
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at 1 month
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The Number of Patients With Recurrent Ischemic Lesion
Tidsram: at 1 month
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Recurrent ischemic lesion confirmed by relevant neuroimagings
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at 1 month
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Length of Hospitalization
Tidsram: at 1month
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Time to event will be calculated
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at 1month
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Number of Participants With Modified Rankin Score of 0 or 1 at Week 4
Tidsram: at 1 month
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modified Rankin Score 0 : No symptoms at all
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at 1 month
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Samarbetspartners och utredare
Sponsor
Samarbetspartners
Utredare
- Huvudutredare: Sun Uck Kwon, PhD., Asan Medical Center
- Huvudutredare: Keun-Sik Hong, PhD, InjeUniversityIlsanPaikHospital
- Huvudutredare: Young Jae Kim, PhD, EWHA Womans University Mokdong Hospital
- Huvudutredare: Yang Ha Hwang, PhD, Kyungpook National University Hospital
- Huvudutredare: Jaekwan Cha, PhD, Dong-A University Hospital
- Huvudutredare: Woo-Keun Seo, PhD, Korea University Guro Hospital
- Huvudutredare: Eung-Gyu Kim, PhD, InjeUniversityBusanPaikHospital
- Huvudutredare: Byung-Woo Yoon, PhD, Seoul National University Hospital
- Huvudutredare: Kyung-Ho Yu, PhD, Hallym University Medical Center
Publikationer och användbara länkar
Allmänna publikationer
- Hong KS, Kwon SU, Lee SH, Lee JS, Kim YJ, Song TJ, Kim YD, Park MS, Kim EG, Cha JK, Sung SM, Yoon BW, Bang OY, Seo WK, Hwang YH, Ahn SH, Kang DW, Kang HG, Yu KH; Phase 2 Exploratory Clinical Study to Assess the Effects of Xarelto (Rivaroxaban) Versus Warfarin on Ischemia, Bleeding, and Hospital Stay in Acute Cerebral Infarction Patients With Non-valvular Atrial Fibrillation (Triple AXEL) Study Group. Rivaroxaban vs Warfarin Sodium in the Ultra-Early Period After Atrial Fibrillation-Related Mild Ischemic Stroke: A Randomized Clinical Trial. JAMA Neurol. 2017 Oct 1;74(10):1206-1215. doi: 10.1001/jamaneurol.2017.2161.
- Hong KS, Choi YJ, Kwon SU; Triple AXEL Investigators. Rationale and design of Triple AXEL: trial for early anticoagulation in acute ischemic stroke patients with nonvalvular atrial fibrillation. Int J Stroke. 2015 Jan;10(1):128-33. doi: 10.1111/ijs.12386. Epub 2014 Oct 26. Erratum In: Int J Stroke. 2016 Jul;11(5):NP63.
Studieavstämningsdatum
Studera stora datum
Studiestart
Primärt slutförande (Faktisk)
Avslutad studie (Faktisk)
Studieregistreringsdatum
Först inskickad
Först inskickad som uppfyllde QC-kriterierna
Första postat (Uppskatta)
Uppdateringar av studier
Senaste uppdatering publicerad (Uppskatta)
Senaste inskickade uppdateringen som uppfyllde QC-kriterierna
Senast verifierad
Mer information
Termer relaterade till denna studie
Ytterligare relevanta MeSH-villkor
- Patologiska processer
- Nekros
- Hjärtsjukdom
- Hjärt-kärlsjukdomar
- Kärlsjukdomar
- Cerebrovaskulära störningar
- Hjärnsjukdomar
- Sjukdomar i centrala nervsystemet
- Sjukdomar i nervsystemet
- Arytmier, hjärt
- Hjärnischemi
- Infarkt
- Hjärninfarkt
- Stroke
- Ischemisk stroke
- Ischemi
- Ischemisk attack, övergående
- Förmaksflimmer
- Cerebral infarkt
- Molekylära mekanismer för farmakologisk verkan
- Enzyminhibitorer
- Proteashämmare
- Faktor Xa-hämmare
- Antitrombiner
- Serinproteinashämmare
- Antikoagulantia
- Rivaroxaban
- Warfarin
Andra studie-ID-nummer
- LMI-2013-1013
Plan för individuella deltagardata (IPD)
Planerar du att dela individuella deltagardata (IPD)?
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Kliniska prövningar på Ischemisk stroke
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Lawson Health Research InstituteHeart and Stroke Foundation of OntarioAvslutad
-
Uppsala County Council, SwedenOkändAkut stroke | TIA (Transient Ischemic Attack)Sverige
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University of Sao Paulo General HospitalFundação de Amparo à Pesquisa do Estado de São PauloAvslutadKranskärlssjukdom | Cerebral stroke | TIA (Transient Ischemic Attack)Brasilien
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Merck Sharp & Dohme LLCAvslutadKärlsjukdomar | Perifera vaskulära sjukdomar | Migränstörningar | Hjärtsjukdom | Cerebrovaskulär olycka | TIA (Transient Ischemic Attack)
Kliniska prövningar på Rivaroxaban
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Portola PharmaceuticalsAvslutad
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Korea University Anam HospitalRekryteringFörmaksflimmer | Antikoagulerande biverkningKorea, Republiken av
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China National Center for Cardiovascular DiseasesHar inte rekryterat ännuStroke | Förmaksflimmer | Större negativa hjärthändelser | Antikoagulerande biverkning
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BayerAvslutad
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The Affiliated Hospital of Qingdao UniversityAvslutad
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BayerJanssen R&D, L.L.C.Avslutad
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Doasense GmbHAktiv, inte rekryterandeAntikoagulerande terapiTyskland
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BayerAvslutadVenös tromboembolismFörenta staterna, Kanada
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Centre Hospitalier Universitaire de Saint EtienneAvslutad
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University Hospital, GrenobleAvslutad