HIP Fracture Oral ThromboPROphylaxis: a Pilot Randomized Controlled Trial (Hip PRO Pilot)
试验速览
- 阶段
- 2 期
- 状态
- 招募中
- 入组人数
- 250
- 试验地点
- 3
- 主要终点
- Recruitment Rate
研究概览
简要总结
As our Canadian population ages, hip fractures in these older adults are becoming very common. The best treatment for the majority of these injuries is urgent treatment with surgery. However, the hip fracture itself, the surgery required, and the immobility following these injuries are all risk factors for developing blood clots in the legs (deep vein thrombosis or DVT) and blood clots in the lungs (pulmonary embolism or PE). These complications are a common cause of death in patients with hip fractures and often result in prolonged medical treatment and hospital stays.
Patients with hip fractures who require surgery are traditionally given injectable blood thinners to help prevent blood clots; however, these medications are costly, may not be tolerated well, and can be difficult to take, as prescribed. Oral blood thinning medications are being used more commonly, but it is unknown which of these medications is the most effective in preventing blood clots in patients after a hip fracture.
Thrombelastography (TEG) technology uses a small sample of blood to evaluate a person's clotting ability. Our research has used TEG technology to evaluate blood clotting risk after hip fracture surgery and the investigators have found that platelets may play an important role in abnormal blood clotting after a hip fracture. The investigators have also shown that acetylsalicylic acid (ASA or Aspirin) may help reduce the abnormal platelet hyperactivity associated with blood clotting. This medication warrants investigation for blood clot prevention after hip fracture.
The investigators propose to directly compare different oral medication regimens after hip fracture surgery, in order to determine which is safest and most effective in preventing blood clots. Our multi-disciplinary research team includes physicians, surgeons, and scientists with experience evaluating different medications for blood clot prevention. Our results will help determine the best medical treatment for preventing DVT and PE, which will benefit patients with hip fractures worldwide.
详细描述
- Background:
With over 30,000 hip fractures in Canada annually, these injuries are an epidemic. Venous thromboembolism (VTE) events are common following hip fracture surgery (HFS) and include life-threatening pulmonary embolism (PE; a leading cause of preventable mortality) and debilitating deep vein thromboses (DVTs; second most common complication). Thromboprophylaxis reduces VTE, but the optimal medication remains unknown.
Low molecular weight heparin (LMWH) has been the mainstay, but adherence is poor: only 1 in 5 patients adhere after HFS, limiting its effectiveness. Meta-analyses support that direct oral anticoagulants (DOACs) are as effective as LMWH in prevention of VTE, but the data are limited by borderline effect sizes, small sample sizes, and inconsistent outcomes. Our survey found that surgeons report safety concerns and are reluctant to use DOACs due to post-operative bleeding risk.
Our research demonstrates platelet-dominant hypercoagulability using serial thrombelastography (TEG), reduced platelet activity with aspirin (ASA) use, and maybe increasing comfort with prescribing ASA post-HFS. Randomized controlled trials (RCTs) comparing LMWH and ASA post-injury are limited by non-standardized therapy duration, asymptomatic DVT inclusion, and patient heterogeneity. ASA has been favourably compared to DOACs and LMWH in arthroplasty RCTs examining oral thromboprophylaxis following total hip and total knee arthroplasty. Continued morbidity and mortality, patient and surgeon preference, and our network meta-analysis support the need for comparison between DOAC and ASA for VTE prevention after HFS. Based on our research, our resent network meta-analysis supporting oral thromboprophylaxis, along with patient preference for oral medications, there is a need for comparison between DOAC and ASA for prevention of VTE to reduce the continued morbidity and mortality that ensues following HFS. 2. Objectives:
Specific Aims:
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Treatment
- 盲法
- Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
入排标准
- 年龄范围
- 50 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •Patients aged 50 years or older with an acute hip fracture (presentation to hospital within 24 hours of injury) that requires surgical treatment will be approached for inclusion in the study:
- •Age ≥ 50 years with a hip fracture (AO-OTA classification 31-A1-A3 and 31-B1-B3) amenable to surgical treatment (presentation to hospital within 24 hours of injury). Patients with additional injuries will be included and any additional injuries will be documented.
- •Both open and closed fractures will be included, and open fractures will be documented.
- •Patients on single agent anti-platelet therapy (i.e., acetylsalicylic acid or clopidogrel) will be included.
- •Signed informed consent or surrogate consent to participate in study.
排除标准
- •Delayed presentation (over 24 hours between hip fracture and presentation to hospital).
- •Pathological fractures secondary to primary cancer or metastatic bone disease.
- •Peri-prosthetic femur fractures.
- •Received more than two doses of any thromboprophylaxis agent post-operatively, prior to randomization.
- •Pre-hospital therapeutic intensity antithrombotic therapy, including LMWH, Warfarin, DOACs, clopidogrel/ticagrelor, or chronic ASA use of any dose in the three months prior to hip fracture.
- •Known inherited bleeding or clotting disorder (factor V Leiden gene mutation, prothrombin gene mutation, protein C or protein S deficiency, antithrombin deficiency).
- •Intracranial hemorrhage requiring serial CT scans of the brain and/or surgical intervention.
- •Contraindication to ASA use (allergy, documented gastrointestinal ulcer within the past year, severe thrombocytopenia [platelet count <50 x109/L at the time of hospital admission]).
- •Contraindication to rivaroxaban use (allergy, acute renal failure [CrCl <30 mL/min]).
- •Participant or surrogate unable to or unwilling to provide consent or complete follow-up. Or surrogate consent not available.
- •Under age 50 years (more likely high energy, multiple injuries).
- •Multiply injured patients who require prolonged thromboprophylaxis or delayed thromboprophylaxis initiation.
- •Patient unable to attend follow-up visits.
- •Currently incarcerated, at a correctional facility.
研究组 & 干预措施
Rivaroxaban 10mg
Rivaroxaban 10mg daily for 35 days post hip fracture surgery
干预措施: Rivaroxaban 10mg (Drug)
acetylsalicylic acid (ASA) 81mg daily
acetylsalicylic acid (ASA) 81mg daily for 35 days post hip fracture surgery
干预措施: acetylsalicylic acid (ASA) 81mg Oral Tablet (Drug)
结局指标
主要结局
Recruitment Rate
时间窗: 12 months
Mean number of participants recruited per centre per month, calculated based on the total recruitment
次要结局
- Retention rate(12 months)
- Frailty(Baseline)
- Partial thromboplastin time(Baseline, Post-operative day 1, Post-operative day 2, Post-operative day 3, Post-operative day 4, Post-operative day 5, Post-operative day 6, or until hospital discharge)
- Bleeding complications(Baseline, Post-operative day 1, Post-operative day 2, Post-operative day 3, Post-operative day 4, Post-operative day 5, Post-operative day 6, or until hospital discharge, 2-week, 4-week, 6-week, 12-week)
- Treatment fidelity(12 months)
- Trial implementation barriers Questionnaire(12 months)
- Consent rates(12 months)
- Healthcare cost(12 months)
- Arterial thromboembolism events(Baseline, Post-operative day 1, Post-operative day 2, Post-operative day 3, Post-operative day 4, Post-operative day 5, Post-operative day 6, or until hospital discharge, 2-week, 4-week, 6-week, 12-week)
- Mortality(90 days)
- Complete Blood Counts(Baseline, Post-operative day 1, Post-operative day 2, Post-operative day 3, Post-operative day 4, Post-operative day 5, Post-operative day 6, or until hospital discharge)
- Cumulated Ambulation Score(Baseline and 2 weeks follow up)
- Venous thromboembolism events(Baseline, Post-operative day 1, Post-operative day 2, Post-operative day 3, Post-operative day 4, Post-operative day 5, Post-operative day 6, or until hospital discharge, 2-week, 4-week, 6-week, 12-week)
- activated partial thromboplastin time(Baseline, Post-operative day 1, Post-operative day 2, Post-operative day 3, Post-operative day 4, Post-operative day 5, Post-operative day 6, or until hospital discharge)
- Study Medication Adherence(Baseline, Post-operative day 1, Post-operative day 2, Post-operative day 3, Post-operative day 4, Post-operative day 5, Post-operative day 6, or until hospital discharge, 2-week, 4-week, 6-week, 12-week)