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XENITH: Rivaroxaban for Pulmonary Embolism Managed With Catheter Directed Thrombolysis (XENITH)

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ClinicalTrials.gov Identifier: NCT02506985
Recruitment Status : Terminated
First Posted : July 23, 2015
Results First Posted : September 27, 2018
Last Update Posted : September 27, 2018
Sponsor:
Collaborator:
Janssen Scientific Affairs, LLC
Information provided by (Responsible Party):
Susan Smyth, University of Kentucky

Brief Summary:
The trial is an open-label, randomized, trial examining novel biomarkers of thrombosis in patients managed with rivaroxaban vs. standard care following treatment of pulmonary embolism (PE) with catheter-guided alteplase. Patients >18 years old who present with PE and are managed with catheter-guided alteplase will be screened for study inclusion. Patient's meeting inclusion/exclusion criteria will undergo informed consent. Immediately following completion of alteplase infusion, patients will be randomized to receipt of rivaroxaban 15 mg oral bid for 21 days followed by 20mg oral daily or continuation on unfractioned heparin or low-molecular weight heparin with initiation of warfarin adjusted to INR of 2-3. Blood samples will be taken within 2 hours of CDT completion prior to receipt of study treatment (study day 1), at 8h-12h, 24h, 48h, 5d (or prior to hospital discharge), and at 30 day follow-up. Clinical endpoints, including bleeding, evidence of thrombosis progression, and death will be tracked during index hospitalization and at follow-up 30 days post-discharge.

Condition or disease Intervention/treatment Phase
Pulmonary Embolism Venous Thrombosis Drug: rivaroxaban Drug: warfarin Phase 4

Detailed Description:
Catheter-guided alteplase has a growing role in the management of acute pulmonary embolism (PE). Following a 12-24 hour alteplase infusion (for bilateral or unilateral PE, respectively) patients are routinely managed with therapeutic unfractionated heparin (UFH) as a bridge to chronic warfarin therapy. It is our desire to study the effects of rivaroxaban vs. standard care following catheter-guided alteplase thrombolytic therapy (CDT) in patients with acute pulmonary embolism. Use of rivaroxaban may offer several important advantages compared to standard therapy in this setting. Among these is the potential for rivaroxaban to improve novel biomarkers of thrombosis including inhibition neutrophil extracellular traps (NETs), tissue factor-positive microparticles, and markers of inflammation. Neutrophil release of extracellular DNA may provide a scaffold upon which venous thrombosis propagates. NETs are associated with thrombus organization. Their dissolution may facilitate thrombolysis. Circulating DNA, a surrogate marker for NETs, is elevated 2-3 fold in patients with venous thromboembolism (VTE) and correlates strongly with plasma myeloperoxidase (MPO), an inflammatory marker of neutrophil and monocyte activation. The investigators have previously demonstrated that heparin can trigger MPO release from leukocytes. Thus, it is resonable to speculate that anti-Xa therapy may reduce inflammation, MPO, and NET levels in circulation. Further, the investigators have observed that catheter-directed thrombolysis may increase length of stay (time frame = 8 hours to 30 days following administration of study drugs) and the investigators would also propose treatment with rivaroxaban may balance this by eliminating a "bridging" period.

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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 10 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: XENITH: Rivaroxaban for Pulmonary Embolism Managed With Catheter Directed Thrombolysis
Study Start Date : July 2015
Actual Primary Completion Date : June 29, 2016
Actual Study Completion Date : June 29, 2016

Resource links provided by the National Library of Medicine


Arm Intervention/treatment
Experimental: rivaroxaban
For the first 3 weeks, patients will receive rivaroxaban 15mg twice-daily; thereafter they will take rivaroxaban 20mg once-daily as per the drug label. Rivaroxaban will be initiated immediately following completion of alterplase infusion, and heparin will be discontinued at the time of rivaroxaban administration.
Drug: rivaroxaban
Immediately following completion of alteplase infusion, patients will receive rivaroxaban 15 mg oral bid for 21 days followed by 20 mg oral daily.
Other Name: Xarelto

Experimental: heparin-warfarin
Unfractioned heparin (UFH), following hospital protocol to achieve a target PTT or enoxaparin, 1.0mg/kg twice-daily, for a minimal duration of treatment of 5 days. Warfarin may be started on the night after CDT. UFH or enoxaparin should continue until the INR is >= 2.0 on two consecutive measurements at least 24 hours apart with an advised overlap with VKA for 4 to 5 days. VKA dosages will be adjusted to maintain the INR within the therapeutic range (target 2.5, range 2.0 - 3.0).
Drug: warfarin
Immediately following completion of alteplase infusion, patients will continue on unfractionated heparin or low-molecular weight heparin with initiation of warfarin adjusted to INR of 2-3.
Other Name: Coumadin




Primary Outcome Measures :
  1. Change in Markers of NETosis at 12h Compared to Baseline [ Time Frame: 12h ]
    Change in Markers of NETosis at 12h Compared to Baseline

  2. Change in Markers of NETosis at 24h Compared to Baseline [ Time Frame: 24h ]
    Values will be reported in comparison to baseline in the two treatment groups.

  3. Change in Markers of NETosis at 48h Compared to Baseline [ Time Frame: 48h ]
    Values will be reported in comparison to baseline in the two treatment groups.

  4. Change in Markers of NETosis at 5 Days (or Day of Hospital Discharge) Compared to Baseline [ Time Frame: 5 days (or day of hospital discharge) ]
    Change in Markers of NETosis at 5 days (or day of hospital discharge) Compared to Baseline. Values will be reported in comparison to baseline in the two treatment groups.

  5. Change in Markers of NETosis at 30 Days Compared to Baseline [ Time Frame: 30 days ]
    Values will be reported in comparison to baseline in the two treatment groups.



Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Provisions of informed consent prior to any study specific procedure
  • Diagnosis of acute PE
  • Evidence of RV strain as defined by one of the following:
  • 1. an RV-to-LV diameter ratio>0.9
  • 2. elevated troponin
  • 3. elevated BNP
  • Plan for CDT for PE.

Exclusion Criteria:

  • Arterial hypotension and cardiogenic shock at the time of enrollment. Arterial hypotension defined as a systolic arterial pressure <90mm Hg or a drop in systolic arterial pressure of at least 40 mm Hg for at least 15 minutes with tissue hypoperfusion and/or hypoxia)
  • Hypersensitivity or other reaction to rivaroxaban
  • Other indication for VKA than PE
  • Creatinine clearance <30 ml/min
  • Significant liver disease (e.g. acute hepatitis, chronic active hepatitis, cirrhosis) or ALT > 3 x ULN
  • Life expectancy <3 months

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT02506985


Sponsors and Collaborators
Susan Smyth
Janssen Scientific Affairs, LLC
Investigators
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Principal Investigator: Susan S Smyth, MD PhD University of Kentucky

Publications:

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Responsible Party: Susan Smyth, Principle Investigator, University of Kentucky
ClinicalTrials.gov Identifier: NCT02506985     History of Changes
Other Study ID Numbers: 15-0275-F6A
First Posted: July 23, 2015    Key Record Dates
Results First Posted: September 27, 2018
Last Update Posted: September 27, 2018
Last Verified: August 2018
Keywords provided by Susan Smyth, University of Kentucky:
Rivaroxaban
CDT (Catheter directed thrombolysis)
PE (pulmonary embolism)
NETs
factor Xa
Additional relevant MeSH terms:
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Warfarin
Pulmonary Embolism
Thrombosis
Embolism
Venous Thrombosis
Embolism and Thrombosis
Vascular Diseases
Cardiovascular Diseases
Lung Diseases
Respiratory Tract Diseases
Heparin
Calcium heparin
Rivaroxaban
Anticoagulants
Fibrinolytic Agents
Fibrin Modulating Agents
Molecular Mechanisms of Pharmacological Action
Factor Xa Inhibitors
Antithrombins
Serine Proteinase Inhibitors
Protease Inhibitors
Enzyme Inhibitors