Intermediate or Prophylactic-Dose Anticoagulation for Venous or Arterial Thromboembolism in Severe COVID-19: A Cluster Based Randomized Selection Trial (IMPROVE-COVID)
Overview
- Phase
- Phase 4
- Status
- Completed
- Sponsor
- Columbia University
- Enrollment
- 94
- Locations
- 1
- Primary Endpoint
- Total Number of Patients Who Were Alive and Without Venous/Thrombotic Events in ICU
Overview
Brief Summary
This study is being conducted to assess the effectiveness of intermediate versus prophylactic doses of anticoagulation (blood thinners) in patients critically ill with COVID-19 in the intensive care units (ICUs) throughout the hospital. Anticoagulation is part of the patient's usual standard of care but determining the dose of anticoagulation is based on physician preference. The investigators are conducting this study (a randomized trial with adaptive design employing cluster randomization) with the support of all of the ICUs to collect data in order to determine what should be the standard of care in terms of anticoagulation in these critically ill patients. The patients care will not be altered other than the choice of anticoagulation (both approved and used throughout the hospital as standard of care) based on the ICU bed they are assigned. Patient data will be collected until discharge.
Detailed Description
Hemostatic, biomarker, and inflammatory changes are common in severe manifestations of coronavirus disease 2019 (COVID-19).Such factors, as well as the bedridden status and critical illness may constitute a prothrombotic milieu, predisposing to venous and arterial thrombosis. However, the optimal antithrombotic regimen for patients with COVID-19, especially those with severe disease, remains uncertain and is currently an area of active clinical interest. Prophylactic-dose anticoagulation is generally recommended for acutely ill hospitalized patients. However, given the hemostatic abnormalities of severe COVID-19 illness, it is unknown whether more intensive anticoagulation is preferred to reduce the risk of thrombotic events, potentially mitigating microvascular and macrovascular thrombi and even disseminated intravascular coagulation (DIC). Further, the risks of therapeutic dose anticoagulation must be weighed against the bleeding risks inherent to this approach. To address this critical gap in knowledge in an area of clinical equipoise, the investigators plan to conduct a cluster-randomized trial in patients admitted to intensive care units (ICUs) in a large volume academic medical center to select the best anticoagulation intervention.
Study Design
- Study Type
- Interventional
- Allocation
- Randomized
- Intervention Model
- Parallel
- Primary Purpose
- Treatment
- Masking
- Single (Outcomes Assessor)
Eligibility Criteria
- Ages
- 18 Years to 80 Years (Adult, Older Adult)
- Sex
- All
- Accepts Healthy Volunteers
- No
Inclusion Criteria
- •Confirmed diagnosis of COVID-19 by reverse transcription polymerase chain reaction (RT-PCR)
- •New admission to eligible CUIMC ICUs within 5 days
- •Transfer from nonparticipating to participating ICU is eligible if otherwise meets eligibility criteria.
- •Patients transferred between participating ICUs will maintain initial treatment assignment.
- •Patients not on therapeutic anticoagulation and who were already admitted to participating ICU within 5 days of trial initiation are additionally eligible.
Exclusion Criteria
- •Weight under 50kg
- •Contraindication to anticoagulation in the opinion of the treating clinician including
- •overt bleeding
- •platelet count \<50,000
- •Bleeding Academic Research Consortium (BARC) major bleeding in the past 30 days
- •Gastrointestinal (GI) bleeding within 3 months
- •history of intracranial hemorrhage
- •Ischemic stroke within the past 2 weeks
- •craniotomy/major neurosurgery within the past 30 days
- •cardiothoracic surgery within the past 30 days
Arms & Interventions
Intervention arm: intermediate-dose anticoagulation
If estimated glomerular filtration rate (eGFR) ≥ 30 mL/min: enoxaparin 1mg/kg subcutaneous (SC) daily or unfractionated heparin infusion at 10 units/kg/hour with goal anti-Xa 0.1-0.3 U/mL.
If eGFR <30 mL/min or acute kidney injury or CRRT: Unfractionated heparin infusion at 10 units/kg/hour (minimum 500 units/hour if CRRT) with goal anti-Xa 0.1-0.3 U/mL
Intervention: Heparin Infusion (Drug)
Intervention arm: intermediate-dose anticoagulation
If estimated glomerular filtration rate (eGFR) ≥ 30 mL/min: enoxaparin 1mg/kg subcutaneous (SC) daily or unfractionated heparin infusion at 10 units/kg/hour with goal anti-Xa 0.1-0.3 U/mL.
If eGFR <30 mL/min or acute kidney injury or CRRT: Unfractionated heparin infusion at 10 units/kg/hour (minimum 500 units/hour if CRRT) with goal anti-Xa 0.1-0.3 U/mL
Intervention: Enoxaparin/Lovenox Intermediate Dose (Drug)
Control arm: prophylaxis
Prophylactic dose anticoagulation (per Columbia University Irving Medical Center (CUIMC) Guidelines):
If eGFR ≥30 mL/min (stable kidney function):
- BMI < 40 kg/m2: Enoxaparin 40 mg SC daily
- BMI 40 - 50 kg/m2: Enoxaparin 40 mg SC q12h
- BMI > 50 kg/m2: Enoxaparin 60 mg SC q12h
If eGFR < 30 mL/min or acute kidney injury:
- 50-120 kg: Unfractionated heparin 5000 units SC q8h
- >120 kg: Unfractionated heparin 7500 units SC q8h
If CRRT: Unfractionated heparin infusion pre-filter at 500 units/hour
Intervention: Enoxaparin Prophylactic Dose (Drug)
Control arm: prophylaxis
Prophylactic dose anticoagulation (per Columbia University Irving Medical Center (CUIMC) Guidelines):
If eGFR ≥30 mL/min (stable kidney function):
- BMI < 40 kg/m2: Enoxaparin 40 mg SC daily
- BMI 40 - 50 kg/m2: Enoxaparin 40 mg SC q12h
- BMI > 50 kg/m2: Enoxaparin 60 mg SC q12h
If eGFR < 30 mL/min or acute kidney injury:
- 50-120 kg: Unfractionated heparin 5000 units SC q8h
- >120 kg: Unfractionated heparin 7500 units SC q8h
If CRRT: Unfractionated heparin infusion pre-filter at 500 units/hour
Intervention: Heparin SC (Drug)
Outcomes
Primary Outcomes
Total Number of Patients Who Were Alive and Without Venous/Thrombotic Events in ICU
Time Frame: Discharge from ICU or 30 days
Composite of being alive and without clinically-relevant venous or arterial thrombotic events at discharge from ICU (without transfer to another ICU or palliative care unit/hospice) or at 30 days (if ICU duration lasted 30 days or longer).
Secondary Outcomes
- Total Number of Patients With Clinically Relevant Venous or Arterial Thrombotic Events in ICU(Discharge from hospital or 30 days)
- ICU Length of Stay(Discharge from ICU, up to 36 days)
- Total Number of Patients With the Need for Renal Replacement Therapy in the ICU(Discharge from ICU or 30 days)
- Total Number of Patients With Major Bleeding in the ICU(Discharge from ICU or 30 days)
- Hospital Length of Stay(Discharge from ICU, up to 36 days)
Investigators
Sahil A. Parikh
Associate Professor of Medicine
Columbia University