Dapagliflozin for Cardio-renal Protection After ICU Discharge

Официальное название

Dapagliflozin for Cardio-renal Protection After ICU Discharge: A Prospective, Randomized, Double Blinded, Multicenter Study: "DAPA-ICU Trial"

Обзор

Several millions of patients are admitted to ICUs in Europe or USA each year. We and others, have shown that patients discharged from intensive care units (ICU) have a high incidence of cardiovascular and/or renal events and high mortality rate (22%) during the year following ICU discharge. Furthermore, a very recent meta-analysis found an excess hazard of late cardiovascular events which persists for at least 5 years following hospital discharge in sepsis survivors. Hence, many international ICU societies recommended investigating and improving post-ICU outcome with scarce guidance. We demonstrated that the proportion of ICU patients dying or presenting cardiovascular events within the year following ICU discharge is reported \~25% \[2\], reaching \~40% in some studies when considering patients with acute kidney injury (AKI). Plasma biomarkers at ICU discharge have good predictive value and patients with increased kidney or cardiovascular biomarkers display high risk of such events. In addition, we and others demonstrated that AKI or sub-AKI (patient not meeting the AKI definition but with an increased kidney related biomarker) could induce remote cardio-vascular injury and fibrosis, which may be involved in the poor long-term prognosis of ICU-acquired AKI. We hypothesize that strategy that prevent worsening in cardiovascular and/or renal injuries and/or in cardiovascular consequences of sub-AKI and AKI after ICU discharge improve long-term outcomes in ICU survivors. SGLT2 inhibitors are widely recognized as key drugs to protect the kidney and/or the myocardium in chronic diseases such as diabetes or heart failure. Cardio protective effect of SGLT2 inhibitors is optimal in patients with higher cardiac biomarker.

Подробное описание

Phase III study Prospective, multicenter, superiority, double-blind, randomized controlled study with two arms (1:1).

Every patient will be screened in the 48h before ICU discharge for trial inclusion and non-inclusion criteria until 72h hours after ICU discharge. After providing written informed consent, patients will be randomly assigned to receive either dapagliflozin (at a dose of 10 mg once daily) or matching placebo, in accordance with the sequestered, fixed-randomization schedule, with the use of balanced blocks to ensure an approximate 1:1 ratio of the two regimens for one year.

Four visits are planned, one at inclusion (V0), one at 6 months (V1), one at the end of the treatment (V2 at one year), one 6 weeks after the end of the treatment (V3, end of the study) and two phone calls at 3 (Phone call 1) and 9 months (phone call 2).

At 6 months (V1) and at 12 months (V2) visits, a clinical exam and biological analysis will be performed at hospital (i.e., HbA1c, glucose level, ionogram, NT-proBNP or BNP, serum creatinine, hematocrit and pregnancy urinary test) by anesthesiologists, cardiologists or nephrologists, to assess primary and secondary endpoints, including eGFR.

At 12 months + 6 weeks (V3) visit, a clinical exam and biological analysis will be performed at hospital (i.e., glucose level, NT-proBNP or BNP, serum creatinine) by anesthesiologists, cardiologists or nephrologists, to assess primary and secondary endpoints, including eGFR.

The phone calls, at 3 and 9 months, will be made by the designated persons and respecting the confidentiality and security of the data collected.

At inclusion (V0) and at 6 months (V1) the treatment will be deliver for the next 6 months. At 6 months (V1), the patient will pick up his treatment at the hospital.

Primary endpoints will be assessed at 6 and 12 months visit and phone calls (3 and 9 months).

Secondary endpoints will be assessed at each visit and phone calls (3, 6, 9, 12 and 12 + 6 weeks).

eGFR (glomerular filtration rate) will be assessed only at 6, 12 months and 12 + 6 weeks. The eGFR (glomerular filtration rate) will not be assessed at phone calls.

At each visit and phone calls, adverse events and severe adverse events will also be assessed.

Вмешательства

• Препарат Dapagliflozin 10 MG Oral Tablet [Farxiga]
  One tablet of dapagliflozin 10 mg will be administered once daily from randomization and for 12 months period +/- 15 days..
• Препарат One tablet of placebo of dapagliflozin 10 mg
  One tablet of placebo of dapagliflozin 10 mg will be administered, per os, once daily from randomization and for 12 months period ± 15 days.

Первичные конечные точки

• All-cause mortality [Срок оценки: Within the year after randomization]
• Unscheduled hospital hospitalization for heart failure [Срок оценки: Within the year after randomization]
• Decrease of eGFR by more than 50% from ICU discharge and/or end stage kidney disease defined as an eGFR<15ml/min/1.73m² and/or initiation of renal replacement therapy and/or kidney transplantation [Срок оценки: Within the year after randomization]

Вторичные конечные точки (12)

• Unscheduled hospital hospitalization for acute heart failure [Срок оценки: Within the year after randomization]
• Unscheduled hospital hospitalization for stroke [Срок оценки: Within the year after randomization]
• Unscheduled hospital hospitalization for acute coronary syndrome [Срок оценки: Within the year after randomization]
• Occurrence of severe chronic kidney disease [Срок оценки: Within the year after randomization]
• • Decrease of estimated glomerular filtration rate of more than 50% from baseline [Срок оценки: Within the year after randomization]
• New episode of acute kidney injury (according to the KDIGO criteria) requiring hospitalization [Срок оценки: Within the year after randomization]
• Occurrence of end stage kidney disease defined (eGFR<15ml/min/1.73m2) and/or initiation of renal replacement therapy and/or kidney transplantation [Срок оценки: Within the year after randomization]
• Change in NT-proBNP (pg/mL) from baseline to end of study [Срок оценки: Between 12 months (end of treatment) and 12 months + 6 weeks (end of study)]
• Occurrence of cardiovascular events [Срок оценки: Within the year after randomization]
• Occurrence of renal events [Срок оценки: Within the year of treatment]
• Urinary tract infection [Срок оценки: Within the year after randomization]
• Necrotizing fasciitis [Срок оценки: Within the year after randomization]

Критерии участия

Критерии включения

• Age >or= 18 years
• Mechanical ventilation and/or vasopressors/inotropes for more than 24h during ICU stay
• Patients ready to be discharged from ICU according to physician in charge
• Inform consent form signed by the patient
• NT-proBNP greater than 800 ng/L or BNP > 90 ng/L and/or Estimated glomerular filtration rate (eGFR) between 25ml/min/1.73m² and 90ml/min/1.73m² of body-surface area (CKD-EPI formula) at inclusion.

Критерии исключения

• Pregnancy
• Ability to become pregnant and refusal to use effective contraception during all study treatment Women of childbearing potential (WOCBP)\*\* must agree to use adequate contraception according to Recommendations related to contraception and pregnancy testing in clinical trials, by Clinical Trial Facilitation Group (CTFG).

The inclusion of WOCBP requires use of a highly effective contraceptive measure :

• combined (estrogen and progestogen containing) hormonal contraception associated with inhibition of ovulation

• oral
• intravaginal
• transdermal
• progestogen-only hormonal contraception associated with inhibition of ovulation

• oral
• injectable
• implantable
• intrauterine device (IUD)
• intrauterine hormone-releasing system ( IUS)
• bilateral tubal occlusion
• vasectomised partner
• sexual abstinence

The above mentioned risk mitigation measures (contraception) should be maintained during treatment and until the end of relevant systemic exposure.

\*\* a woman is considered of childbearing potential (WOCBP), i.e. fertile, following menarche and until becoming post-menopausal unless permanently sterile. Permanent sterilisation methods include hysterectomy, bilateral salpingectomy and bilateral oophorectomy.

A postmenopausal state is defined as no menses for 12 months without an alternative medical cause.

A high follicle stimulating hormone (FSH) level in the postmenopausal range may be used to confirm a post-menopausal state in women not using hormonal contraception or hormonal replacement therapy. However in the absence of 12 months of amenorrhea, a single FSH measurement is insufficient.

• Breast feeding
• Known hypersensitivity to dapagliflozin or any of the excipients
• Patients treated with dapagliflozin before ICU admission
• Patients with severe cirrhosis (Child-Pugh C)
• Patients who admitted or who developed during their ICU stay a urinary tract infection or a perineal infection and patients at risk of skin infection near the perineum (e.g., a sacral pressure ulcer)
• Estimated glomerular filtration rate (eGFR) below 25 ml per minute per 1.73 m2 of body-surface area (CKD -EPI formula).
• Patient for whom treatment with Dapagliflozine is strongly recommended according to recent international guidelines:

• patients with type 2 diabetes mellitus adults for whom the treatment is inadequately controlled as an adjunct to diet and exercise: either as monotherapy when metformin is considered inappropriate due to inadequate tolerance, or in addition to other medications for the treatment of type 2 diabetes,
• symptomatic chronic heart failure with reduced or preserved left ventricular ejection fraction,
• chronic kidney disease, in addition to standard therapy with a glomerular filtration rate (GFR) between 25 and 75 mL/min/1.73m² and a urinary albumin-to-creatinine ratio (ACR) between 200 and 5000 mg/g and treated for at least 4 weeks with an ACE inhibitor or angiotensin 2 receptor blocker (ARB II or sartan).
• Patient without national health insurance, and patient on AME (state medical aid)
• Persons deprived of liberty by a judicial or administrative decision
• Participation in other interventional study

Критерии приведены из реестра в оригинале (на английском). Окончательную оценку соответствия проводит исследовательский центр.

Здоровые добровольцы: Нет

Дизайн исследования

Распределение

Рандомизированное

Модель

Параллельные группы

Маскирование

Двойное слепое

Основная цель

Лечение

Центры проведения

Франция · 2 центра

• Hospital Saint Louis — Paris
• Saint Louis Hospital — Paris

Публикации

• Sano M, Goto S. Possible Mechanism of Hematocrit Elevation by Sodium Glucose Cotransporter 2 Inhibitors and Associated Beneficial Renal and Cardiovascular Effects. Circulation. 2019 Apr 23;139(17):1985-1987. doi: 10.1161/CIRCULATIONAHA.118.038881. No abstract available. PMID 31009585
• Chang YK, Choi H, Jeong JY, Na KR, Lee KW, Lim BJ, Choi DE. Dapagliflozin, SGLT2 Inhibitor, Attenuates Renal Ischemia-Reperfusion Injury. PLoS One. 2016 Jul 8;11(7):e0158810. doi: 10.1371/journal.pone.0158810. eCollection 2016. PMID 27391020
• Zelniker TA, Wiviott SD, Raz I, Im K, Goodrich EL, Bonaca MP, Mosenzon O, Kato ET, Cahn A, Furtado RHM, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Sabatine MS. SGLT2 inhibitors for primary and secondary prevention of cardiovascular and renal outcomes in type 2 diabetes: a systematic review and meta-analysis of cardiovascular outcome trials. Lancet. 2019 Jan 5;393(10166):31-39. doi: 10.1016/S014 PMID 30424892
• Zannad F, Ferreira JP, Pocock SJ, Anker SD, Butler J, Filippatos G, Brueckmann M, Ofstad AP, Pfarr E, Jamal W, Packer M. SGLT2 inhibitors in patients with heart failure with reduced ejection fraction: a meta-analysis of the EMPEROR-Reduced and DAPA-HF trials. Lancet. 2020 Sep 19;396(10254):819-829. doi: 10.1016/S0140-6736(20)31824-9. Epub 2020 Aug 30. PMID 32877652
• Depret F, Hollinger A, Cariou A, Deye N, Vieillard-Baron A, Fournier MC, Jaber S, Damoisel C, Lu Q, Monnet X, Rennuit I, Darmon M, Leone M, Guidet B, Sonneville R, Montravers P, Pili-Floury S, Lefrant JY, Duranteau J, Laterre PF, Brechot N, Oueslati H, Cholley B, Struck J, Hartmann O, Mebazaa A, Gayat E, Legrand M. Incidence and Outcome of Subclinical Acute Kidney Injury Using penKid in Critically PMID 32516543
• Legrand M, Rossignol P. Cardiovascular Consequences of Acute Kidney Injury. N Engl J Med. 2020 Jun 4;382(23):2238-2247. doi: 10.1056/NEJMra1916393. No abstract available. PMID 32492305
• Gayat E, Cariou A, Deye N, Vieillard-Baron A, Jaber S, Damoisel C, Lu Q, Monnet X, Rennuit I, Azoulay E, Leone M, Oueslati H, Guidet B, Friedman D, Tesniere A, Sonneville R, Montravers P, Pili-Floury S, Lefrant JY, Duranteau J, Laterre PF, Brechot N, Chevreul K, Michel M, Cholley B, Legrand M, Launay JM, Vicaut E, Singer M, Resche-Rigon M, Mebazaa A. Determinants of long-term outcome in ICU surviv PMID 29347987
• Arrigo M, Feliot E, Gayat E, Mebazaa A. Cardiovascular events after ICU discharge in patients with new-onset atrial fibrillation: A report from the FROG-ICU study. Int J Cardiol. 2018 Nov 1;270:203. doi: 10.1016/j.ijcard.2018.07.080. Epub 2018 Jul 20. No abstract available. PMID 30045823

Идентификаторы

NCT: NCT07025629 · APHP220826

Первоисточники (государственные реестры)

• ClinicalTrials.gov (NIH, США)

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