FREEDOM COVID-19 Anticoagulation Strategy (FREEDOM COVID)

• ClinicalTrials.gov Identifier: NCT04512079
• Recruitment Status: Recruiting
• First Posted: August 13, 2020
• Last Update Posted: January 20, 2022
• Sponsor: Valentin Fuster
• Information provided by (Responsible Party): Valentin Fuster, Icahn School of Medicine at Mount Sinai

Study Description

Brief Summary:

Coronavirus Disease (COVID-19), caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has led to unprecedented morbidity and mortality in the modern era. To date, nearly 13 million people have contracted COVID-19, leading to more than 550,000 deaths worldwide. As the number of affected individuals continues to climb, effective strategies for treatment and prevention of the disease are of paramount importance. SARS-CoV-2 is understood to directly invade cells via the human angiotensin-converting enzyme 2 (ACE2) receptor, which is expressed predominantly in the lungs but also throughout the cardiovascular system. Thus, while acute respiratory distress syndrome remains a feared complication, new thromboembolic disease has emerged as a common and potentially catastrophic manifestation of COVID-19.

Condition or disease	Intervention/treatment	Phase
COVID-19; SARS-CoV-2	Drug: Enoxaparin; Drug: Apixaban	Phase 4

Detailed Description:

This is a Prospective, multi-center, open label, randomized controlled comparative safety and effectiveness trial with objectives: 1. To determine the effectiveness of enoxaparin and apixaban in patients hospitalized (but not yet intubated) with confirmed COVID-19 and 2. To determine the safety of enoxaparin and apixaban in patients hospitalized (but not yet intubated) with confirmed COVID-19. Observational analyses have suggested potential benefit for in-hospital use of anticoagulation. Yet, due to a lack of rigorous evidence for optimal anticoagulation regimens, practice patterns among hospitalized patients with COVID-19 vary significantly. Specifically, the choice of anticoagulant, dosing, and duration of treatment are not well understood. A preliminary analysis of approximately 2700 patients admitted to the Mount Sinai Health System (MSHS) in New York, demonstrated an association between in-hospital administration of therapeutic Anticoagulation (AC) and improved survival compared to no or prophylactic dose AC. A subsequent analysis under review of a larger 4400 patient cohort with longer follow up demonstrated similar associations with reduction in the risk of mortality and risk of intubation. Further analyses suggest more pronounced benefit with therapeutic as opposed to prophylactic doses. Bleeding rates were generally low overall, but higher among patients on therapeutic anticoagulation. Finally, though exploratory in nature, a potential signal for benefit was observed for patients on novel oral anticoagulant therapy (primarily apixaban) at therapeutic doses compared to low molecular weight heparin. Ultimately, randomized controlled trials are needed to elucidate the optimal anticoagulation regimen to improve outcomes in patients hospitalized with COVID-19.

Study Design

• Study Type: Interventional (Clinical Trial)
• Estimated Enrollment: 3600 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment

Intervention Model Description

Study participants will be randomized in a 1:1:1 fashion to 1 of 3 arms:

1. Prophylactic enoxaparin (40 mg SC QD; 30 mg SC QD for CrCl <30 mL/min)
2. Full-dose enoxaparin (1 mg/kg SC Q12h; 1 mg/kg SC QD for CrCl <30 mL/min)
3. Apixaban (5 mg Q12h; 2.5 mg Q12h for patients with at least two of three of age ≥80 years, weight ≤60 kg or serum creatinine ≥1.5 mg/dL)

• Masking: None (Open Label)
• Primary Purpose: Treatment
• Official Title: FREEDOM COVID Anticoagulation Strategy Randomized Trial
• Actual Study Start Date: September 8, 2020
• Estimated Primary Completion Date: July 2022
• Estimated Study Completion Date: July 2022

Arms and Interventions

Arm	Intervention/treatment
Active Comparator: Prophylactic Enoxaparin; Prophylactic enoxaparin (40 mg SC QD; 30 mg SC QD for CrCl <30 mL/min)	Drug: Enoxaparin; Prophylactic enoxaparin (40 mg SC QD; 30 mg SC QD for CrCl <30 mL/min) Full-dose enoxaparin (1 mg/kg SC Q12h; 1 mg/kg SC QD for CrCl <30 mL/min)
Active Comparator: Full Dose Enoxaparin; Full-dose enoxaparin (1 mg/kg SC Q12h; 1 mg/kg SC QD for CrCl <30 mL/min)	Drug: Enoxaparin; Prophylactic enoxaparin (40 mg SC QD; 30 mg SC QD for CrCl <30 mL/min) Full-dose enoxaparin (1 mg/kg SC Q12h; 1 mg/kg SC QD for CrCl <30 mL/min)
Experimental: Apixaban; Apixaban (5 mg Q12h; 2.5 mg Q12h for patients with at least two of three of age ≥80 years, weight ≤60 kg or serum creatinine ≥1.5 mg/dL)	Drug: Apixaban; (5 mg Q12h; 2.5 mg Q12h for patients with at least two of three of age ≥80 years, weight ≤60 kg or serum creatinine ≥1.5 mg/dL)

Outcome Measures

Primary Outcome Measures :

1. Time to first event [ Time Frame: 30 days ]
   The time to first event rate within 30 days of randomization of the composite of all-cause mortality, intubation requiring mechanical ventilation, systemic thromboembolism (including pulmonary emboli) confirmed by imaging or requiring surgical intervention OR ischemic stroke confirmed by imaging.
2. Number of in-hospital rate of BARC 3 or 5 [ Time Frame: 30 days ]

   Number of in-hospital rate of BARC 3 or 5 bleeding (binary). BARC Type 3: a. Overt bleeding plus hemoglobin drop of 3 to < 5 g/dL (provided hemoglobin drop is related to bleed); transfusion with overt bleeding

   b. Overt bleeding plus hemoglobin drop < 5 g/dL (provided hemoglobin drop is related to bleed); cardiac tamponade; bleeding requiring surgical intervention for control; bleeding requiring IV vasoactive agents

   c. Intracranial hemorrhage confirmed by autopsy, imaging, or lumbar puncture; intraocular bleed compromising vision. BARC Type 5:

   1. Probable fatal bleeding
   2. Definite fatal bleeding (overt or autopsy or imaging confirmation)

Secondary Outcome Measures :

1. Number of participants with Myocardial infarction [ Time Frame: 30 days after randomization ]
   Myocardial infarction (according to the 4th universal definition, types 1,2, and 3)
2. Number of participants with Myocardial infarction [ Time Frame: 90 days after randomization ]
   Myocardial infarction (according to the 4th universal definition, types 1,2, and 3)
3. Number of participants with Deep Vein Thrombosis [ Time Frame: 30 days after randomization ]
   Deep vein thrombosis with confirmation on imaging
4. Number of participants with Deep Vein Thrombosis [ Time Frame: 90 days after randomization ]
   Deep vein thrombosis with confirmation on imaging
5. Number of participants requiring Ventilation [ Time Frame: 30 after randomization ]
   Intubation and mechanical ventilation
6. Number of participants requiring Ventilation [ Time Frame: 90 days after randomization ]
   Intubation and mechanical ventilation
7. Number of All Death [ Time Frame: 30 days after randomization ]
   All-cause death
8. Number of All Death [ Time Frame: 90 days after randomization ]
   All-cause death
9. Cause of Death [ Time Frame: 30 days after randomization ]
   Cause of Death
10. Cause of Death [ Time Frame: 90 days after randomization ]
    Cause of Death
11. Number of participants with Stroke [ Time Frame: 30 days after randomization ]
    Stroke confirmed by imaging or autopsy (all, ischemic and hemorrhagic)
12. Number of participants with Stroke [ Time Frame: 90 days after randomization ]
    Stroke confirmed by imaging or autopsy (all, ischemic and hemorrhagic)
13. Number of participants with Pulmonary Emboli [ Time Frame: 30 days after randomization ]
    Pulmonary emboli confirmed by imaging or autopsy
14. Number of participants with Pulmonary Emboli [ Time Frame: 90 days after randomization ]
    Pulmonary emboli confirmed by imaging or autopsy
15. Number of participants with Systemic Thromboembolism [ Time Frame: 30 days after randomization ]
    Systemic thromboembolism confirmed by imaging or requiring surgical intervention
16. Number of participants with Systemic Thromboembolism [ Time Frame: 90 days after randomization ]
    Systemic thromboembolism confirmed by imaging or requiring surgical intervention

Eligibility Criteria

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

Criteria

Inclusion Criteria:

• Hospitalization within the prior 24 hours for either confirmed (based on PCR or antigen positive test for SARS-CoV-2) or suspected COVID-19 based on 3 criteria (all 3 must be present for suspected cases):

  1. Fever >38 degrees Celsius
  2. O2 saturation ≤94
  3. Abnormal laboratory marker (at least 1):

  i. d-dimer ≥1.0 μg /mL ii. CRP >2 mg/L iii. Ferritin >300 μg /L iv. Lymphopenia <1500 cells /m3

• Patient or legal guardian provides written informed consent

Exclusion Criteria:

• Age <18 years
• Mechanical ventilation on admission or high likelihood for the need for invasive mechanical ventilation within 24 hours of admission
• Anticipated duration of hospital stay <72 hours
• Treatment with therapeutic dose UFH or LMWH, vitamin K antagonists, or NOACs within seven days
• Active bleeding

• Risk factors for bleeding, including:

  1. intracranial surgery or stroke within 3 months
  2. history of intracerebral arteriovenous malformation
  3. cerebral aneurysm or mass lesions of the central nervous system
  4. intracranial malignancy
  5. history of intracranial bleeding
  6. history of bleeding diatheses (e.g., hemophilia)
  7. history of gastrointestinal bleeding within previous 3 months
  8. thrombolysis within the previous 7 days
  9. presence of an epidural or spinal catheter
  10. recent major surgery <14 days
  11. uncontrolled hypertension (sBP > 200 mmHg or dBP > 120 mmHg)
  12. other physician-perceived contraindications to anticoagulation
  13. Platelet count <50 x109/L, INR >2.0, or baseline aPTT >50 seconds
  14. Hemoglobin <80 g/L (to minimize the likelihood of requiring red blood cell transfusion if potential bleeding were to occur)
  15. current treatment with antithrombotics or antiplatelet agents including but not limited to ticagrelor, prasugrel, and aspirin> 100mg, or non-steroidal anti-inflammatory drugs (e.g. ibuprofen, naproxen, etc.) due to increased risk of bleeding, unless such agents can be permanently discontinued (aspirin <= 100mg and clopidogrel <=75mg is permitted)
• Acute or subacute bacterial endocarditis
• History of heparin induced thrombocytopenia (HIT) or other heparin allergy including hypersensitivity
• Patients with non-COVID-19 related clinical condition for which life expectancy is <6 months
• Pregnancy (women of childbearing potential are required to have a negative pregnancy test prior to enrollment)
• Active enrollment in other trials related to anticoagulation
• Patients has end stage kidney disease (ESKD) on chronic dialysis
• Patient is a member of a vulnerable population: In the judgment of the investigator the patient is unable to give Informed Consent for reasons of incapacity, immaturity, adverse personal circumstances or lack of autonomy. This may include: Individuals with mental disability, persons in nursing homes, children, impoverished persons, persons in emergency situations, homeless persons, nomads, refugees, and those incapable of giving informed consent. Vulnerable populations also may include members of a group with a hierarchical structure such as university students, subordinate hospital and laboratory personnel, employees of the Sponsor, members of the armed forces, and persons kept in detention.

Contacts and Locations

Contacts

Contact: Debra Fitzpatrick, MS; 212-659-9151; debra.fitzpatrick@mssm.edu

Locations

United States, New York

Icahn School of Medicine at Mount Sinai; Recruiting

New York, New York, United States, 10029

Contact: Debra Fitzpatrick, MS 212-659-9151 debra.fitzpatrick@mssm.edu

Principal Investigator: Valentin Fuster, MD, PhD

Brazil

Instituto do Coração - INCOR; Recruiting

São Paulo, Brazil

Principal Investigator: Ludhmila Abrahao Hajjar, MD

Instituto Prevent Senior - IPS; Recruiting

São Paulo, Brazil

Principal Investigator: Rodrigo Esper, MD

Colombia

Clínica de la Costa; Recruiting

Barranquilla, Colombia

Principal Investigator: Eduardo Antonio Martinez, MD

Clínica Shaio; Recruiting

Bogotá, Colombia

Principal Investigator: Fernan Mendoza, MD

Fundación Cardioinfantil; Recruiting

Bogotá, Colombia

Principal Investigator: Dario Echeverri, MD

Fundacion Oftalmológica de Santander - Foscal; Recruiting

Bucaramanga, Colombia

Principal Investigator: Hector Julio Melendez, MD

Centro Médico Imbanaco; Recruiting

Cali, Colombia

Principal Investigator: Angela María Fernández, MD

CardioVid; Recruiting

Medellín, Colombia

Principal Investigator: Clara Ines Saldarriaga, MD

India

Eternal Heart Care Centre and Research Ins Pvt Ltd.; Recruiting

Jaipur, India

Principal Investigator: Jugal Bihari Gupta, MD

Jaipur National University; Recruiting

Jaipur, India

Principal Investigator: Madhumati Varma, MD

Sawai Mann Singh Hospital; Recruiting

Jaipur, India

Principal Investigator: Sudhir Bhandari, MD

Jaslok Hospital & Research Center; Recruiting

Mumbai, India

Principal Investigator: Nihar Mehta, MD

Saifee Hospital; Recruiting

Mumbai, India

Principal Investigator: Deepesh Aggarwal, MD

Sengupta Hospital & Research Institute; Recruiting

Nagpur, India

Principal Investigator: Shantanu Sengupta, MD

D Y Patil University School of Medicine & D Y Patil Hospital; Recruiting

Navi Mumbai, India

Principal Investigator: Abhay Uppe, MD

Mexico

Hospital Cardiológica Aguascalientes; Recruiting

Aguascalientes, Mexico

Principal Investigator: Guillermo Antonio Llamas Esperón, MD

Centro Médico Nacional 20 de Noviembre; Recruiting

Mexico City, Mexico

Principal Investigator: Julieta Moralos Portano, MD

Christus Muguerza Hospital Alta Especialidad; Recruiting

Monterrey, Mexico

Principal Investigator: Jose Ramon Azpiri, MD

Centro de Estudios Clinicos de Querétaro S.C.; Recruiting

Santiago de Querétaro, Mexico

Principal Investigator: Marco Antonio Alcocer Gamba, MD

Centro Medico Hospital del Prado; Recruiting

Tijuana, Mexico

Principal Investigator: Patricia Aubanel Riedel, MD

Sponsors and Collaborators

Valentin Fuster

Investigators

• Principal Investigator: Valentin Fuster, MD,PhD; Icahn School of Medicine at Mount Sinai
• Principal Investigator: Anu Lala, MD; Icahn School of Medicine at Mount Sinai

More Information

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):

Farkouh ME, Stone GW, Lala A, Bagiella E, Moreno PR, Nadkarni GN, Ben-Yehuda O, Granada JF, Dressler O, Tinuoye EO, Granada C, Bustamante J, Peyra C, Godoy LC, Palacios IF, Fuster V. Anticoagulation in Patients With COVID-19: JACC Review Topic of the Week. J Am Coll Cardiol. 2022 Mar 8;79(9):917-928. doi: 10.1016/j.jacc.2021.12.023.

• Responsible Party: Valentin Fuster, Principal Investigator, Icahn School of Medicine at Mount Sinai
• ClinicalTrials.gov Identifier: NCT04512079
• Other Study ID Numbers: GCO 20-2115
• First Posted: August 13, 2020
• Last Update Posted: January 20, 2022
• Last Verified: January 2022

Individual Participant Data (IPD) Sharing Statement:

• Plan to Share IPD: Yes
• Plan Description: Individual participant data that underlie the results reported in this article, after de-identification (text, tables, figures, and appendices).
• Supporting Materials: Study Protocol
• Time Frame: Beginning 9 months and ending 36 months following article publication.
• Access Criteria: Investigators whose proposed use of the data has been approved by an independent review committee ("learned intermediary") identified for this purpose. The type of analysis that will be conducted is for individual participant data meta-analysis. Proposals may be submitted up to 36 months following article publication. After 36 months the data will be available in our University's data warehouse but without investigator support other than deposited metadata.

• Studies a U.S. FDA-regulated Drug Product: Yes
• Studies a U.S. FDA-regulated Device Product: No

Keywords provided by Valentin Fuster, Icahn School of Medicine at Mount Sinai:

Randomization; Hospitalization; PCR or Antigen Positive Test; Abnormal Laboratory Maker; Anticoagulation; Apixaban

Additional relevant MeSH terms:

COVID-19; Respiratory Tract Infections; Infections; Pneumonia, Viral; Pneumonia; Virus Diseases; Coronavirus Infections; Coronaviridae Infections; Nidovirales Infections; RNA Virus Infections; Lung Diseases; Respiratory Tract Diseases; Enoxaparin; Apixaban; Anticoagulants; Fibrinolytic Agents; Fibrin Modulating Agents; Molecular Mechanisms of Pharmacological Action; Factor Xa Inhibitors; Antithrombins; Serine Proteinase Inhibitors; Protease Inhibitors; Enzyme Inhibitors