DOAC in Chinese Patients With Atrial Fibrillation (DOAC-REAL)
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ClinicalTrials.gov Identifier: NCT05378035 |
Recruitment Status :
Recruiting
First Posted : May 17, 2022
Last Update Posted : January 19, 2024
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Tracking Information | |||||||||
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First Submitted Date | May 12, 2022 | ||||||||
First Posted Date | May 17, 2022 | ||||||||
Last Update Posted Date | January 19, 2024 | ||||||||
Actual Study Start Date | September 28, 2022 | ||||||||
Estimated Primary Completion Date | September 27, 2027 (Final data collection date for primary outcome measure) | ||||||||
Current Primary Outcome Measures |
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Original Primary Outcome Measures | Same as current | ||||||||
Change History | |||||||||
Current Secondary Outcome Measures | Not Provided | ||||||||
Original Secondary Outcome Measures | Not Provided | ||||||||
Current Other Pre-specified Outcome Measures | Not Provided | ||||||||
Original Other Pre-specified Outcome Measures | Not Provided | ||||||||
Descriptive Information | |||||||||
Brief Title | DOAC in Chinese Patients With Atrial Fibrillation | ||||||||
Official Title | Direct Oral Anticoagulant Levels in Chinese Patients With Atrial Fibrillation - A Real- World Pharmacokinetic Study | ||||||||
Brief Summary | Direct oral anticoagulants (DOACs) have emerged as safe and efficacious ischemic stroke prophylaxis for non-valvular atrial fibrillation (NVAF). All four DOACs - apixaban, dabigatran, edoxaban, and rivaroxaban - were shown to reduce the risk of major bleeding compared to warfarin. The predictable pharmacokinetic profiles of DOACs also favour their use over warfarin. Together with increasing AF incidence due to population ageing, increased AF detection, and territory-wide reimbursement schemes, DOAC prescriptions have been surging worldwide. In Hong Kong, more than 78,354 patients received DOAC from January 2009 through April 2021 according to the Hospital Authority registry. The more liberal use of DOACs has led to new issues that require a thorough understanding of ethnic-specific DOAC pharmacokinetic profiles. For instance, 12- 15% of anticoagulated patients annually required interventional procedures that involve temporary discontinuation of DOAC for 48 hours or more. Although guideline-based periprocedural DOAC interruption resulted in a low 30-day thromboembolism rate of 0.16% - 0.6% in a Caucasian cohort, same measures for elective colonoscopies in a local population-based study resulted in a 30-day periprocedural thromboembolism rate of up to 2.2%. Although these studies cannot be compared directly, the remarkable interethnic discrepancy between the two cohorts warrants further pharmacokinetic and pharmacogenomic studies. More importantly, quantifying residual DOAC levels during the interruption periods may imply on duration of periprocedural DOAC interruption, length of hospital-stay, and the risk of thromboembolic and bleeding complications. Mapping inter- and intra-individual variations in DOAC levels may also impact on the management of ischemic stroke among DOAC recipients. Epidemiological studies have shown alarmingly up to 13% of acute ischemic stroke patients were on anticoagulation prior to stroke onset with increasing number of DOAC. These patients received low rates of recanalization therapy due to apprehension of bleeding complications, thus compromised survival and neurological recovery. A prospective study that reveals Asian-specific DOAC pharmacokinetic profiles may inform cross-disciplinary, territory-wide periprocedural care and acute stroke intervention strategy for the rapidly expanding DOAC population. |
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Detailed Description | The investigators aim to determine the DOAC levels at peak, trough, 24, and 48 hours after temporary discontinuation of apixaban, dabigatran, edoxaban, or rivaroxaban before elective interventional procedures in Chinese patients. The investigators hypothesize that DOAC metabolism is ethnically and pharmacogenomically specific. We also hypothesize that discontinuation of DOAC for 24 hours may achieve a coagulation status suitable for most interventional procedures among Asians, as opposed to 48 hours recommended by western guidelines. The investigators shall recruit DOAC patients who require medical procedures that require DOAC interruption for 48 hours, such as colonoscopy, pleural biopsy, cardiac catheterization, digital subtraction angiograph, etc. Eligible subjects shall undergo DOAC level testing at peak, trough, 24, and 48 hours after discontinuation of DOAC for elective medical procedures. The investigators shall also record their baseline demographics, clinical assessments, medical comorbidities, blood parameters, and concurrent medications. Detailed study procedures are as follows:
Definition of peak and trough levels: Peak level is defined as the DOAC level 2-3 hours after intake of apixaban, dabigatran, edoxaban, or rivaroxaban. The investigators shall instruct patients to take their DOAC at 8am and schedule blood tests at 10am to 11am on the date of recruitment (i.e. peak level). Trough level is defined as the DOAC level immediately before the next intended dose of any of the 4 above DOACs. For twice daily apixaban and dabigatran, trough level is defined as 12 hours after the last dose. While for once daily edoxaban and rivaroxaban, trough level is defined as 24 hours after the last dose. Blood Specimen Collection and Processing: Blood samples are required for 1) specific coagulation assays, 2) liquid chromatography-mass spectrometry, and 3) pharmacogenomics studies. 1 bottle of citrated blood sample, 1 bottle of heparin-lithium blood sample, and 3 bottles of EDTA blood samples will be sent to our hematology, pharmacy, and genomics laboratories in Prince of Wales Hospital for storage and processing. Specific coagulation assays: Apixaban, edoxaban, and rivaroxaban binds to Factor Xa (FXa) without the mediation of antithrombin. Once bound, FXa can no longer contribute to the coagulation process, thereby inducing anticoagulation effect. Two levels of lyophilized calibrators prepared from human citrated plasma by means of a dedicated process at two different concentrations of apixaban and rivaroxaban (HemosIL apixaban and rivaroxaban Calibrators, respectively) are used by the ACL TOP® to obtain anti-Xa level. Edoxaban is measured with the Technochrome anti-Xa kit (technoclone). Dabigatran level will be determined by HemosIL Direct Thrombin Inhibitor (DTI) Assay, a modified dilute thrombin time test performed on citrated patient plasma. Citrated patient plasma is diluted in pooled normal plasma (DTI Plasma Diluent - supplied as part of the assay) to reduce interferences from pre-analytical variables. A fixed concentration of reconstituted bovine thrombin is then added to the diluted patient sample, activating the coagulation cascade and converting fibrinogen into fibrin. The presence of Dabigatran in patient samples will have an inhibitory effect on the procoagulant activity of the exogenous thrombin added to the patient sample. The associated clotting time in seconds is measured on the ACL TOP® Hemostasis Testing Systems. Liquid chromatography-mass spectrometry: This study involves the quantitative analysis of direct oral anticoagulants (DOAC) in patients. The plasma concentrations of direct oral anticoagulants (apixaban, dabigatran, edoxaban and rivaroxaban) will be determined by a validated assay using high-performance liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS). The method will be developed and validated with respect to the assay precision, accuracy, specificity, linearity, sensitivity, extraction recovery matrix effect and stability of analyte. Briefly, DOAC in plasma samples will be extracted using protein precipitation, liquid-liquid extraction or solid-phase extraction prior to LC-MS/MS analysis. Calibration standards and quality control samples will be prepared by spiking known amount of DOAC in drug-free plasma, and will be processed in the same manner as patient's samples from the same run. A calibration curve of each DOAC will be constructed using the chromatographic peak area ratio (analyte/internal standard) obtained from the calibration standards, and the concentrations of DOAC in patient's sample will be quantified based on the linear regression model obtained from the calibration curve. Pharmacogenomics: The genotypes of subjects will be determined by DNA microarray. Genomic DNA will be isolated from peripheral blood samples by the DNeasy blood & tissue kit (QIAGEN, Germany). The isolated DNA will be subject to library preparation and Infinium beadchip (Illumina) analysis according to the manufacturer's instructions (Illumina, USA). The beadchips will be scanned using an Illumina iScan System. To optimize the identification of related genotypes (e.g., single-nucleotide polymorphisms), the Infinium Global Diversity Array with Enhanced Pharmacogenomics (PGx) Content-8 v1.0 will be used. Quantifying residual DOAC levels during the interruption periods may imply on duration of periprocedural DOAC interruption, length of hospital-stay, and the risk of thromboembolic and bleeding complications. Mapping inter- and intra-individual variations in DOAC levels may also impact on the management of ischemic stroke among DOAC recipients. A prospective study that reveals Asian-specific DOAC pharmacokinetic profiles may inform cross-disciplinary, territory-wide periprocedural care and acute stroke intervention strategy for the rapidly expanding DOAC population. |
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Study Type | Observational | ||||||||
Study Design | Observational Model: Cohort Time Perspective: Prospective |
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Target Follow-Up Duration | Not Provided | ||||||||
Biospecimen | Retention: Samples With DNA Description: The genotypes of subjects will be determined by DNA microarray. Genomic DNA will be isolated from peripheral blood samples by the DNeasy blood & tissue kit (QIAGEN, Germany). The isolated DNA will be subject to library preparation and Infinium beadchip (Illumina) analysis according to the manufacturer's instructions (Illumina, USA). The beadchips will be scanned using an Illumina iScan System. To optimize the identification of related genotypes (e.g., single-nucleotide polymorphisms), the Infinium Global Diversity Array with Enhanced Pharmacogenomics (PGx) Content-8 v1.0 will be used.The samples will be kept at -80oC freezer for storage after processed.
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Sampling Method | Probability Sample | ||||||||
Study Population | Chinese nonvalvular atrial fibrillation patients on direct oral anticoagulants. | ||||||||
Condition |
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Intervention | Diagnostic Test: Blood Tests
Eligible subjects will receive additional blood tests for determination of DOAC levels and pharmacogenomic studies. Participants shall undergo DOAC level testing at peak, trough, 24, and 48 hours after discontinuation of DOAC for elective medical procedures. We shall also record their baseline demographics, clinical assessments, medical comorbidities, blood parameters, and concurrent medications. We shall minimize the blood taking by combining DOAC levels and blood tests essential for routine medical consultation and pre-procedural workup. Blood taking will only be performed by clinicians or phlebotomists who are experienced in the procedure.
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Study Groups/Cohorts | DOAC Recipients
We shall recruit the DOAC recipients that meet the following inclusion criteria:
Intervention: Diagnostic Test: Blood Tests
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Publications * | Not Provided | ||||||||
* Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline. |
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Recruitment Information | |||||||||
Recruitment Status | Recruiting | ||||||||
Estimated Enrollment |
427 | ||||||||
Original Estimated Enrollment | Same as current | ||||||||
Estimated Study Completion Date | December 31, 2027 | ||||||||
Estimated Primary Completion Date | September 27, 2027 (Final data collection date for primary outcome measure) | ||||||||
Eligibility Criteria | Inclusion Criteria:
Exclusion Criteria:
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Sex/Gender |
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Ages | 18 Years to 80 Years (Adult, Older Adult) | ||||||||
Accepts Healthy Volunteers | No | ||||||||
Contacts |
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Listed Location Countries | Hong Kong | ||||||||
Removed Location Countries | |||||||||
Administrative Information | |||||||||
NCT Number | NCT05378035 | ||||||||
Other Study ID Numbers | CREC 2022.333 | ||||||||
Has Data Monitoring Committee | No | ||||||||
U.S. FDA-regulated Product |
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IPD Sharing Statement |
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Current Responsible Party | Dr. IP Yiu Ming Bonaventure, Chinese University of Hong Kong | ||||||||
Original Responsible Party | Same as current | ||||||||
Current Study Sponsor | Chinese University of Hong Kong | ||||||||
Original Study Sponsor | Same as current | ||||||||
Collaborators | Not Provided | ||||||||
Investigators |
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PRS Account | Chinese University of Hong Kong | ||||||||
Verification Date | January 2024 |