Treatment of Acute Respiratory Distress Syndrome With Tenecteplase: A Dose Escalation Pilot Study
| Status: | Completed |
|---|---|
| Conditions: | Hospital, Pulmonary |
| Therapuetic Areas: | Pulmonary / Respiratory Diseases, Other |
| Healthy: | No |
| Age Range: | 18 - 75 |
| Updated: | 11/23/2013 |
| Start Date: | February 2007 |
| End Date: | February 2009 |
| Contact: | Dennis W Ashley, MD, FACS |
| Email: | ashley.dennis@mccg.org |
| Phone: | 478-633-1199 |
Treatment of Acute Respiratory Distress Syndrome With Tenecteplase: A Dose Escalation Pilot Study: Phase I
The pathogenesis of ARDS appears to be from damage to the alveolar-capillary barrier, which
is composed of the microvascular endothelium and the alveolar epithelium. This damage may
occur from direct or indirect lung injury. The mechanism of injury to the alveolar capillary
barrier appears to be through neutrophil-mediated injury, pro-inflammatory cytokines,
ventilator-induced lung injury with alveolar over distention and abnormalities of the
coagulation system. This results in blood clot formation in the microcirculation of the
lung. Thrombolytics can dissolve blood clots and result in increased blood flow to the
organs. This treatment may benefit ARDS patients, thus the purpose of this study.
Hardaway, et al.studied the effects of thrombolytics on ARDS in pigs. The experimental group
showed improved oxygenation and survival as compared to controls. There was no bleeding
complications noted with this therapy. Dr. Hardaway followed this animal study with a phase
I clinical trial involving 20 patients with ARDS. The patients were treated with IV
streptokinase or urokinase. Nineteen of the 20 patients showed an increase in PA02 after
thrombolytic therapy. There were no significant bleeding complications in patients that were
critically ill on ventilators.
We propose an additional phase I pilot study to evaluate the effectiveness and safety of
Tenecteplase for the treatment of ARDS. Unlike the other fibrinolytics studied in this
disease state, Tenecteplase, is more fibrin specific and has increased resistance to
plasminogen activator inhibitor (PAI-I) at greater levels than other available
fibrinolytics. We have chosen an experimental dose escalation trial design of tenecteplase
that has demonstrated initial safety trends in a Phase I acute ischemic stroke trial. The
initial dose is 0.1 mg/kg IV and will increase to 0.2 mg/kg, 0.3 mg/kg, with a final cohort
of patients receiving 0.4 mg/kg. Drug administration will be a single dose bolus in each
cohort. Advancement of dose will occur if safety is not in question in the previous cohort.
We hope this will provide an acceptable benefit risk ratio as the mortality of ARDS is
approximately 30 - 60%. All patients will be closely monitored for any change in clotting
parameters and signs of bleeding. Tenecteplase will be administered via a peripheral IV as
described in the package insert.
1. Treatment of acute respiratory distress syndrome with tenecteplase, a dose escalation
pilot study: phase I
2. The study sample size will be 20 patients. The 20 patients will be divided into 4
groups with 5 patients in each group or cohort. The first cohort will received
0.1mg/kg of tenecteplase as a bolus via peripheral IV as described by the package
insert and will be closely monitored for safety and efficacy. If there are no adverse
events associated with tenecteplase, the second cohort of patients will be enrolled and
will receive 0.2 mg/kg of tenecteplase IV bolus. If there are no safety issues, we
will proceed with the next cohort at 0.3 mg/kg with a final cohort of patients
receiving 0.4 mg/kg of tenecteplase IV bolus. Advancement of dose will occur if safety
is not in question in the previous cohort.
3. Tenecteplase will be given as a bolus via peripheral IV as described by package insert.
4. Treatment will be initiated after informed consent is obtained and only >12 hrs after
any subcutaneous Heparin has been stopped and >12 hrs after placement of a pulmonary
artery catheter, central line or arterial line. Only patients meeting criteria for
ARDS (see inclusion criteria) will be considered for the study.
5. Pretreatment assessment: We will obtain informed consent, demographic data, physical
examination and medical history, vital signs, PT, PTT, INR, ABG, hemoglobin hematocrit,
liver enzymes, cardiac enzymes, creatinine, fibrinogen, fibrin split products,
platelets, urine pregnancy test, EKG, chest x-ray, cardiac profile from Swan-Ganz
catheter and ventilator settings before treatment begins.
6. Assessment during treatment: Blood samples will be taken every 6 hours for 24 hours
and analyzes for PT, PTT, INR, fibrinogen, fibrin split products, platelets,
hemoglobin, and hematocrit. Arterial blood gas samples will be taken at hour 1, 2, 3,
and every six hours until 24 hours post-injection. Cardiac profile, vital signs and
ventilator settings will be monitored at hour 1, 2, 3, and every six hours until 24
hours post-infusion. Adverse events will be monitored every hour for 24 hours.
7. Follow-up assessment: 72 hours post treatment physical exam, vital signs, weight,
adverse events, cardiac profile, ventilator settings, PT, PTT, INR, fibrinogen, fibrin
split products, platelets, ABG, hemoglobin and hematocrit, liver enzymes, cardiac
enzymes, creatinine, EKG and chest x-ray will be obtained. Thirty days post treatment
physical exam, vital signs, weight, mortality, adverse events will be followed.
8. Patients will be monitored for signs of clinical bleeding.
Inclusion Criteria:
- Ability to provide written informed consent and comply with study assessments for
full duration of the study by family member.
- Patient-related considerations - See exclusion criteria
- Disease-related considerations - ARDS is indicated by respiratory failure of acute
onset, bilateral lung infiltrates, PaO2/Fi02 <200 mmHg,pulmonary artery wedge
pressure < 18 mmHg, and need for a ventilator. (If the wedge pressure is >18, the
patient is excluded from this study).
- Only acute stage ARDS patients will be enrolled in the study. This is defined by
patients with ARDS for <1 week.
Other considerations
- Satisfactory recruitment and cooperation
- A signed informed consent document
- No participation in another clinical and/or observational trial
- No previous participation in this study
- Not a prisoner or otherwise in custody and not institutionalized for mental
incompetence.
- Patients with major trauma will only be included 5 days after trauma has occurred.
Exclusion Criteria:
- Bleeding - active internal bleeding
- History of cerebrovascular accident
- Intracranial neoplasm, arteriovenous malformation, or aneurysm or acute trauma
- Known bleeding diathesis
- Severe uncontrolled HTN
- Thrombin time over 2 times laboratory normal
- Prothrombin time or partial thromboplastin time > 2 times normal
- Fibrinogen <100
- Platelets <100
- Creatine >2.0
- Liver function tests > 2 times normal
- History of coagulopathy, ulcer, or stroke
- Systolic blood pressure >180, diastolic blood pressure >110
- History of fibrinolytic use within one month prior to treatment
- History of diabetic retinopathy
- Pregnancy, pregnancy will be ruled out in women of childbearing age by urine test.
- Obstetric delivery or intracranial injury within one month prior to treatment
- Major trauma, major surgery, or CPR within 5 days or minor surgery or minor trauma
within 2 days. The classification of major or minor is made by attending physician.
- Patients undergoing non-operative management of liver, spleen, and kidney trauma.
- Aspirin therapy >650mg q day
- Epidural or spinal catheter within 5 days.
- Known risk for embolization, including history of left heart thrombus, mitral
stenosis with atrial fibrillation, acute pericarditis, and subacute bacterial
endocarditis.
- Over the age of 75 years
- Patients on Xigris
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