Evaluation of the Safety and Efficacy of Parecoxib in Patients With Subarachnoid Hemorrhage

Spontaneous subarachnoid hemorrhage (SAH) is a specific type of hemorrhagic stroke with a worldwide incidence ranging from 0.5 to 28 per 100,000 population, with large regional variations. Despite improvements in diagnosis, treatment and care, SAH remains a disease with high mortality and morbidity. According to the literature, one third of patients die within the first few days after SAH, and most survivors have cognitive impairment or long-term disability. The overall clinical outcome depends on the severity of early brain injury (EBI), cerebral edema, hydrocephalus, development of delayed ischemic neurological deficit (DIND), epileptic seizures, and other complications. The pathophysiological cascades responsible for the development of these complications remain poorly understood. However, numerous studies support the important role of aseptic cerebrovascular inflammation induced by blood and blood breakdown products in the subarachnoid space after SAH. The increased interest in the development of cerebrovascular inflammation after SAH is confirmed by the increasing number of clinical and experimental studies devoted to this topic. Cerebrovascular aseptic inflammation as a potential treatment target is also mentioned in current guidelines for the management of patients after SAH.

The results of experimental studies formed the basis for the clinical evaluation of the effects of NSAIDs after SAH. The effects of several commonly used NSAIDs, particularly dexketoprofen, ibuprofen, diclofenac, indomethacin, or dipyrone, have been evaluated in prospective and retrospective clinical trials over the past decade. In addition to reducing pro-inflammatory markers such as IL6, lowering body temperature and platelet aggregation, the administration of NSAIDs has been associated with reduced mortality and improved clinical outcomes. Despite the beneficial effects of some NSAIDs, more robust studies are still lacking, except for one study that evaluated the effect of meloxicam in patients after SAH. This study was a randomized, double-blind, placebo-controlled trial. It showed a trend towards a better outcome with a lower incidence of vasospasm or mortality in patients after SAH.

Despite encouraging experimental results, no clinical trials have yet evaluated the anti-inflammatory and other potentially beneficial effects of cyclooxygenase-2 (COX-2) inhibitors. COX-2 inhibitors, or coxibs, belong to the group of NSAIDs that selectively inhibit the COX-2 enzyme, which is responsible for developing inflammation and pain. A planned clinical study will evaluate the effects of parecoxib, a specific COX-2 inhibitor in the NSAIDs group, on overall clinical outcome and development of complications in patients following spontaneous SAH.

• Influence of parecoxib on outcome of patients with SAH [Срок оценки: Discharge from hospital and 90 days ± 7 days after first dose of parecoxib/placebo]
• Occurrence of symptomatic vasospasms (vasospasms confirmed on TCD / CT AG / MR AG / DSA [Срок оценки: Six, eight and ten days after the application of the first dose of the evaluated medicinal product /placebo.]
• Incidence of delayed ischemic neurological deficit (DIND) [Срок оценки: Six, eight and ten days, three and six months after the application of the first dose of the evaluated medicinal product /placebo.]
• Mortality [Срок оценки: During the treatment and post treatment period of hospitalization, 90 days ± 7 days and 180 days ± 14 days]
• Length of hospitalization in ICU [Срок оценки: 3 months]
• Total length of hospitalization [Срок оценки: 3 months]
• Occurrence of acute hydrocephalus [Срок оценки: During the treatment and post treatment period of hospitalization]
• Occurrence of chronic hydrocephalus [Срок оценки: During the treatment and post treatment period of hospitalization, 90 days ± 7 days, 180 days ± 14 days]
• Occurrence of fevers [Срок оценки: During the treatment and post treatment period of hospitalization]
• Occurrence of inflammation [Срок оценки: During the treatment and post treatment period of hospitalization]
• Evaluation of pain according to Visual Analogue Scale [Срок оценки: During the treatment and post treatment period of hospitalization, discharge from hospital, 90 days ± 7 days and 180 days ± 14 days after first dose of parecoxib/placebo]
• Evaluation of prostaglandins and pro-inflammatory cytokines in the cerebrospinal fluid in the case of the below-mentioned external ventricular drainage after 2 days and in the serum [Срок оценки: 0, 2, 4, 6, 8 and 10 days after implantation of drainage]