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Keywords:

  • anticoagulants;
  • disseminated intravascular coagulation;
  • protein C;
  • thrombomodulin

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Addendum
  8. Acknowledgements
  9. Disclosure of Conflict of Interests
  10. References
  11. Appendix

Summary. Background: Soluble thrombomodulin is a promising therapeutic natural anticoagulant that is comparable to antithrombin, tissue factor pathway inhibitor and activated protein C. Objectives: We conducted a multicenter, double-blind, randomized, parallel-group trial to compare the efficacy and safety of recombinant human soluble thrombomodulin (ART-123) to those of low-dose heparin for the treatment of disseminated intravascular coagulation (DIC) associated with hematologic malignancy or infection. Methods: DIC patients (n = 234) were assigned to receive ART-123 (0.06 mg kg−1 for 30 min, once daily) or heparin sodium (8 U kg−1  h−1 for 24 h) for 6 days, using a double-dummy method. The primary efficacy endpoint was DIC resolution rate. The secondary endpoints included clinical course of bleeding symptoms and mortality rate at 28 days. Results: DIC was resolved in 66.1% of the ART-123 group, as compared with 49.9% of the heparin group [difference 16.2%; 95% confidence interval (CI) 3.3–29.1]. Patients in the ART-123 group also showed more marked improvement in clinical course of bleeding symptoms (P = 0.0271). The incidence of bleeding-related adverse events up to 7 days after the start of infusion was lower in the ART-123 group than in the heparin group (43.1% vs. 56.5%, P = 0.0487). Conclusions: When compared with heparin therapy, ART-123 therapy more significantly improves DIC and alleviates bleeding symptoms in DIC patients.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Addendum
  8. Acknowledgements
  9. Disclosure of Conflict of Interests
  10. References
  11. Appendix

Disseminated intravascular coagulation (DIC) frequently complicates hematologic malignancy and infections such as sepsis [1–3]. In such patients, coagulation activation, inhibition of fibrinolysis and consumption of coagulation inhibitors lead to a hypercoagulable state resulting in fibrin deposition in microvessels and inflammatory reactions. Furthermore, cross-talk between the coagulation system and inflammatory reactions causes organ damage, followed by multiple organ dysfunction syndrome (MODS), or even death [1,3–5]. Consumption of platelets and coagulation factors causes bleeding symptoms, which interfere with therapy and may lead to hemorrhagic death.

It is important to treat aggressively the underlying disease associated with DIC. Sometimes, however, it is impossible to remove or blunt the triggering event for DIC swiftly. Because DIC is involved in the pathophysiology of sepsis, progression of MODS, and bleeding in patients with hematologic malignancy, inhibition of coagulation activation is also vital for effective therapy [1,6]. Anticoagulant therapy in animal models of DIC has been shown to improve organ damage and to lower mortality rate [7,8].

Heparin has been widely used for anticoagulant therapy in DIC in the absence of better alternatives, although it has not been shown to offer any survival benefit in controlled trials [1,6,9,10]. Also, the safety of heparin in patients with DIC complicated by profuse bleeding symptoms is the subject of debate. Furthermore, there have been no prospective comparative studies clearly confirming the efficacy of any drugs over heparin in the treatment of DIC [11,12,13]. Therefore, novel therapeutic anticoagulants for DIC are required to replace heparin.

Thrombomodulin is a thrombin receptor on the endothelial cell surface that plays an important role in the regulation of intravascular coagulation [5]. Recombinant human soluble thrombomodulin (ART-123) is composed of the active, extracellular domain of thrombomodulin. Like membrane-bound thrombomodulin, ART-123 binds to thrombin to inactivate coagulation, and the thrombin–ART-123 complex activates protein C to produce activated protein C (APC), which in the presence of protein S inactivates factors VIIIa and Va, thereby inhibiting further thrombin formation. ART-123 has a long half-life (about 20 h), and has been shown to have a wider safety margin than other anticoagulants and to have a favorable antithrombotic profile with less bleeding in animal and in vitro experiments [14–17]. Therefore, we postulated that ART-123 may be effective in DIC patients with frequent bleeding complications.

In a phase II clinical assessment of ART-123, we obtained good dose–response effects in patients with DIC associated with a wide variety of underlying diseases (hematologic malignancy, solid tumor, infection, etc.) [18]. We therefore conducted a multicenter, double-blind, randomized, parallel-group trial in order to compare the efficacy and safety of ART-123 to those of low-dose heparin for the treatment of DIC associated with hematologic malignancy or infection.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Addendum
  8. Acknowledgements
  9. Disclosure of Conflict of Interests
  10. References
  11. Appendix

Patients and selection criteria

Patients with DIC associated with hematologic malignancy or infection were recruited. DIC was diagnosed according to the diagnostic criteria established by the Japanese Ministry of Health and Welfare (JMHW DIC criteria; Table 1) [19]. Inclusion criteria were as follows: (i) when a DIC score of more than 7 points, or more than 4 points in the presence of severe thrombocytopenia because of bone marrow failure is present, DIC is diagnosed. When a DIC score of 6 points or 3 points in the presence of severe thrombocytopenia because of bone marrow failure is present, two or more positive findings of supplementary tests are needed to make a diagnosis of DIC; (ii) negative ART-123 skin test; (iii) 15 years old or older; (iv) bodyweight ≤ 100 kg; and (v) inpatient status.

Table 1.   Diagnostic criteria for disseminated intravascular coagulation (DIC) by the Japanese Ministry of Health and Welfare (JMHW)
 DIC criteria (point)
Without severe thrombocytopeniaWith severe thrombocytopenia*
  1. *If severe thrombocytopenia with markedly decreased megakaryocytes because of leukemia or a related disorder, aplastic anemia, use of antineoplastic agents, or other such cause is observed, score Platelet count and Bleeding symptoms as 0 points and make the assessment.

  2. **If DIC is suspected and 2 or more of 6 findings in ‘V. Findings of Supplementary Tests for Diagnosis’ are present, assess the condition as DIC.

  3. FDP, fibrin and fibrinogen degradation products; PT, prothrombin time.

I. Underlying disease
  Yes11
II. Clinical symptoms
 Bleeding symptoms  
  Yes1
  No0
 Organ symptoms  
  Yes11
  No00
III. Laboratory tests
 Platelet count (×103μL−1)  
  ≤ 1201
  ≤ 802
  ≤ 503
 FDP (μg mL−1)  
  ≥ 1011
  ≥ 2022
  ≥ 4033
 Fibrinogen (g L−1)  
  ≤ 1.511
  ≤ 122
 PT ratio  
  ≥ 1.2511
  ≥ 1.6722
IV. Diagnosis of DIC
  DIC≥ 7≥ 4
  DIC suspected**63
  no DIC≤ 5≤ 2
V. Findings of Supplementary Tests for Diagnosis
(1) Positive for soluble fibrin monomers
(2) High value for D dimer
(3) High value for thrombin-antithrombin complex
(4) High value for plasmin-alpha2-plasmin inhibitor complex
(5) Appearance of tendency for score to increase as disease develops. In particular, within several days, appearance of a tendency for the platelet count or fibrinogen to decrease suddenly, or a tendency for FDP to increase suddenly
(6) Response to anticoagulant therapy

Exclusion criteria were as follows: fatal or life-threatening bleeding (intracranial, gastrointestinal or pulmonary bleeding); high probability of developing fatal or life-threatening bleeding; history (within 1 year) of cerebrovascular disorder (cerebral bleeding, cerebral infarction); recent central nervous system surgery or trauma; history of hypersensitivity to protein preparations or unfractionated heparin; pregnancy, nursing or potential pregnancy; positive ART-123 skin test; dialysis therapy or severely impaired drug excretion because of kidney disorder; fulminant hepatitis, decompensated liver cirrhosis, or other serious liver disorder; expected difficulty in ensuring an adequate study drug infusion, or obtaining efficacy and safety data; administration of another study drug within 6 months prior to the current study; participation in previous clinical studies on ART-123; administration of unfractionated heparin (within 3 months prior to the start of study drug infusion); patients judged as inappropriate at the discretion of investigators.

This study was conducted in compliance with good clinical practice and the ethical principles of the Declaration of Helsinki. Prior approval was obtained from the ethics review boards of all participating institutions. Written informed consent was obtained from all patients (or acceptable representatives) before the ART-123 skin test was performed.

Treatment assignments

This study was a randomized, parallel-group comparison trial using the double-blind method. Patients were randomly allocated to either of two groups (ART-123 and heparin groups) by the patient registration center. Allocation was separately performed on the basis of primary underlying disease for DIC (hematologic malignancy or infection), using the dynamic balancing method, including factors for preregistration DIC scores and preregistration bleeding symptoms. Randomization code lists were computer generated by the medical statistics advisor, and were concealed from the investigators, patients and sponsor.

With the double-dummy method, patients in the ART-123 group received ART-123 and heparin placebo, and patients in the heparin group received heparin sodium and ART-123 placebo. ART-123 was administered for 6 consecutive days; 0.06 mg kg−1 was drip infused for 30 min once daily. Heparin sodium (Fuso Pharmaceutical Industries, Ltd, Osaka, Japan) was administered for 6 consecutive days; 8 U kg−1 h−1 was drip infused 24 h a day.

During the infusion of study drug, the use of drugs that may have influenced drug efficacy assessment, such as anticoagulants (including synthetic protease inhibitors), antiplatelet agents and fibrinolytic agents, was contraindicated. However, use of the following drugs was allowed: blood preparations (excluding antithrombin); heparin (≤ 1000 U day−1) or urokinase (≤ 10 000 U per infusion) to prevent catheter coagulation; and drugs used to treat other conditions. During the infusion of study drug, dialysis therapy for renal failure or extracorporeal circulation for blood purification was contraindicated. Patients were followed until day 28 after the start of infusion.

Evaluation of patients

The prospectively defined primary efficacy endpoint was DIC resolution rate (rate of recovery from DIC) as assessed at 7 days after the start of infusion (or withdrawal). In accordance with JMHW DIC criteria (Table 1), DIC scores were determined before and after study drug infusion, and DIC resolution rate was assessed. Resolved DIC status (no DIC) was defined on the basis of DIC scores (patients without severe thrombocytopenia because of bone marrow failure: ≤ 5 points; patients with severe thrombocytopenia because of bone marrow failure: ≤ 2 points; Table 1). Secondary endpoints included clinical course of bleeding symptoms and mortality at 28 days after the start of infusion.

Coagulation tests were conducted on the day of registration, at baseline and at the end of study drug infusion (or withdrawal) to measure the following: fibrin and fibrinogen degradation products; fibrinogen; prothrombin time ratio; activated partial thromboplastin time; platelet count; antithrombin; thrombin–antithrombin complex (TAT); plasmin–plasmin inhibitor complex (PPIC); D-dimer; α2 plasmin inhibitor (α2-PI); protein C; plasminogen activator inhibitor-1 (PAI-1); and fibrin monomer. Antithrombin, TAT, PPIC, D-dimer, α2-PI, protein C, PAI-1 and fibrin monomer were measured by an independent analysis institution (SRL Medisearch Inc., Tokyo, Japan). Serum samples collected at baseline and at 28 days (or withdrawal) were tested by ELISA for antibodies against ART-123.

All adverse events observed until 14 days after the start of infusion, including new or exacerbated bleeding and organ symptoms, and abnormal changes in clinical laboratory test findings, were recorded by the investigators. Serious adverse events, including death, life-threatening events, prolonged hospitalization, permanent or significant disorder or dysfunction, or other severe medical events, were recorded throughout the study period.

Statistical analysis

As representative underlying diseases for DIC, we selected hematologic malignancy and infection. The sample size necessary to ascertain non-inferiority to heparin, without qualitative interaction between underlying disease and drug, was calculated for each underlying disease, and one verification study was conducted. All analyses were performed in accordance with a predefined analysis plan. The primary endpoint, DIC resolution rate, was analyzed among the full analysis set (FAS). Safety was analyzed among patients in whom study drug was infused at least once.

To examine efficacy, the DIC resolution rate of the ART-123 group was compared with that of the heparin group using non-inferiority analysis. The results for two underlying diseases were combined as prospectively defined in the protocol, and two adjusted rates for each group and the two-tailed 95% confidence interval (CI) of the difference were calculated. Non-inferiority was defined as the lower limit of the 95% CI of the difference exceeding the predetermined margin (−5%), and superiority was defined as the lower limit of the 95% CI exceeding 0% in the protocol. This definition of ‘superiority’ has subsequently been approved by a guideline released by the Committee for Proprietary Medicinal Products [20].

With regard to secondary endpoints, the results were tabulated for each underlying disease. In addition, multiplicity was not taken into account for analyses other than the primary endpoint. Furthermore, with factors that were specified as covariates beforehand, a generalized linear model was used to adjust factor influence. With regard to safety, intergroup comparisons were carried out using Fisher's exact test. The level of significance was set at 5% (two-sided).

On the assumption that the DIC resolution rates for two underlying diseases would be about 55% for the ART-123 group and about 40% for the heparin group, investigating a one-sided 2.5% non-inferiority verification using a non-inferiority margin of −5% with a power of 80% would require about 110 patients for each treatment group. We also decided to enroll at least 50 patients per group for each underlying disease.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Addendum
  8. Acknowledgements
  9. Disclosure of Conflict of Interests
  10. References
  11. Appendix

Patients

Between June 2000 and September 2005, 113 investigative sites in Japan (see Appendix 1) screened 241 patients for this study, and 234 patients were randomized (Fig. 1). Of these, two were withdrawn before study drug infusion, and 232 were treated with study drug. One patient was excluded because of double registration, and the remaining 231 patients were evaluated for safety analyses. Four additional patients, who failed to meet the inclusion criteria for the studied indication, were also excluded from the FAS. The primary efficacy endpoint was assessed in 224 of the 227 FAS population (Fig. 1).

image

Figure 1.  Trial profile. ART-123, recombinant human soluble thrombomodulin; DIC, disseminated intravascular coagulation; FAS, full analysis set.

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Baseline characteristics, including severity of underlying disease, DIC scores, and bleeding symptoms, were similar between the ART-123 and heparin groups, except for age (Table 2). The results of subpopulation analysis and bias adjustment confirmed that this bias (age) did not affect the primary endpoint results. The patient characteristics of the FAS population during study drug infusion are shown in Table 3. The requirement for platelet concentrate was larger for the heparin group in patients with DIC associated with hematologic malignancy. Other characteristics were similar between the groups. An ART-123 skin test was conducted in all patients prior to starting study drug, but none of the patients tested positive.

Table 2.   Baseline demographics and disease characteristics
 ART-123 (n = 114)Heparin (n = 113)
  1. *For patients with severe thrombocytopenia, category 1: 3 points, category 2: 4–5 points, category 3: 6–9 points; for patients without severe thrombocytopenia, category 1: 6 points, category 2: 7–8 points, category 3: 9–13 points. The values are given in (%).

  2. ART-123, recombinant human soluble thrombomodulin; AML, acute myelogenous leukemia; ALL, acute lymphocytic leukemia; CML, chronic myelogenous leukemia; ATL, adult T-cell leukemia; MDS, myelodysplastic syndrome; FDP, fibrin and fibrinogen degradation products; PT, prothrombin time.

Men68 (59.6)65 (57.5)
Age (years)
 < 5026 (22.8)9 (8.0)
 50≤ ≤ 6944 (38.6)41 (36.3)
 70 ≤44 (38.6)63 (55.8)
Weight (kg)
 < 5036 (31.6)43 (38.1)
 50 ≤ < 6039 (34.2)29 (25.7)
 60 ≤39 (34.2)41 (36.3)
Severity of underlying diseases
 Moderate17 (14.9)15 (13.3)
 Severe97 (85.1)98 (86.7)
Underlying disease
 AML (M3)3 (2.6)1 (0.9)
 AML (except for M3)36 (31.6)35 (31.0)
 ALL14 (12.3)9 (8.0)
 CML1 (0.9)5 (4.4)
 ATL0 (0.0)1 (0.9)
 MDS0 (0.0)4 (3.5)
 Malignant lymphoma8 (7.0)6 (5.3)
 Multiple myeloma1 (0.9)0 (0.0)
 Malignant reticulosis1 (0.9)0 (0.0)
 Sepsis28 (24.6)22 (19.5)
 Pneumonia10 (8.8)10 (8.8)
 Biliary tract infection0 (0.0)2 (1.8)
 Peritonitis1 (0.9)1 (0.9)
 Abscess1 (0.9)4 (3.5)
 Viremia3 (2.6)3 (2.7)
 Meningitis2 (1.8)0 (0.0)
 Cholangitis1 (0.9)2 (1.8)
 Enterocolitis1 (0.9)1 (0.9)
 Other infections3 (2.6)7 (6.2)
DIC score at baseline*
 Category 112 (10.5)20 (17.7)
 Category 280 (70.2)71 (62.8)
 Category 322 (19.3)22 (19.5)
Bleeding symptoms at baseline
 Absent31 (27.2)31 (27.4)
 Present83 (72.8)82 (72.6)
Organ symptoms at baseline
 Absent68 (59.6)73 (64.6)
 Present46 (40.4)40 (35.4)
FDP (μg mL−1) at baseline
 20 >19 (16.7)16 (14.2)
 20 ≤ < 4037 (32.5)39 (34.5)
 40 ≤ < 10044 (38.6)36 (31.9)
 100 ≤14 (12.3)22 (19.5)
Platelet count (×103μ L−1) at baseline
 50 ≥74 (64.9)72 (63.7)
 50< ≤ 8020 (17.5)27 (23.9)
 80< ≤ 12012 (10.5)12 (10.6)
 120 <8 (7.0)2 (1.8)
Fibrinogen (g L−1) at baseline
 1 ≥9 (7.9)12 (10.6)
 1< ≤ 1.58 (7.0)14 (12.4)
 1.5< ≤ 3.542 (36.8)39 (34.5)
 3.5 <55 (48.2)48 (42.5)
PT ratio at baseline
 1.25 >72 (63.2)70 (61.9)
 1.25 ≤ < 1.6733 (28.9)36 (31.9)
 1.67 ≤9 (7.9)7 (6.2)
Thrombin–antithrombin complex (ng mL−1) at baseline
 10 >20 (17.5)20 (17.7)
 10 ≤ < 2032 (28.1)27 (23.9)
 20 ≤ < 4034 (29.8)30 (26.5)
 40 ≤28 (24.6)36 (31.9)
Antithrombin (%) at baseline
 50 >13 (11.4)17 (15.0)
 50 ≤ < 7028 (24.6)30 (26.5)
 70 ≤73 (64.0)66 (58.4)
Protein C (%) at baseline
 20 >11 (9.6)9 (8.0)
 20 ≤ < 5054 (47.4)62 (54.9)
 50 ≤49 (43.0)42 (37.2)
Concurrent illness
 Hepato-biliary disease24 (21.1)25 (22.1)
 Kidney disease28 (24.6)19 (16.8)
DIC treatment before the study drug
 Present46 (40.4)50 (44.2)
Antithrombin used before the study drug
 Present10 (8.8)20 (17.7)
Table 3.   Patient characteristics of full analysis set population during study drug infusion
 Hematologic malignancyInfection
ART-123 (n = 64)Heparin (n = 61)ART-123 (n = 50)Heparin (n = 52)
  1. The values are given in (%).

Transfusion requirements
 Platelet concentrate42 (65.6)51 (83.6)22 (44.0)22 (42.3)
 Fresh frozen plasma11 (17.2)12 (19.7)13 (26.0)17 (32.7)
Co-medication
 Chemotherapeutic agents administration
  Present55 (85.9)46 (75.4)--
 Radiotherapy
  Present0 (0.0)0 (0.0)--
 Antibiotics administration
  Present--48 (96.0)52 (100.0)
 Surgical measures
  Present--7 (14.0)11 (21.2)
 G-CSF administration
  Present--3 (6.0)5 (9.6)
The use of agents to prevent catheter coagulation
 Heparin28 (43.8)23 (37.7)20 (40.0)14 (26.9)
 Urokinase0 (0.0)0 (0.0)0 (0.0)0 (0.0)

Efficacy

The DIC resolution rates for the ART-123 and heparin groups were 65.6% and 45.9% (difference 19.7%; 95% CI 2.6–36.8) respectively in patients with DIC associated with hematologic malignancy, and were 66.7% and 54.9% (difference 11.8%; 95% CI −7.3 to 30.9) respectively in patients with DIC associated with infection (Table 4). Because no interaction was evident between underlying disease and drug (P = 0.571) with the Breslow–Day test, data from two underlying diseases were combined as prospectively defined in the protocol. The DIC resolution rates were 66.1% for the ART-123 group and 49.9% for the heparin group (difference 16.2%; 95% CI 3.3–29.1; Table 4). As the lower limit of the 95% CI exceeded 0%, it appears that ART-123 is significantly superior to heparin for the improvement of DIC.

Table 4.   Efficacy outcomes
 Underlying disease
Hematologic malignancyInfection
  1. *DIC resolution rate was calculated for each underlying disease, and the absence of qualitative interaction between underlying disease and drug was confirmed using descriptive analysis and the Breslow-Day test. Based on the Woolson-Bean method, the results for the two underlying diseases were combined, and two adjusted rates for each group and two-tailed 95% CI of the difference were calculated. The DIC resolution rate was 66.1% for the ART-123 group and 49.9% for the heparin group (difference 16.2%; 95% CI 3.3–29.1).

  2. The values are given in (%).

DIC resolution rate*
 ART-123 group42/64 patients (65.6)32/48 patients (66.7)
 Heparin group28/61 patients (45.9)28/51 patients (54.9)
 Difference (95% CI)19.7% (2.6 to 36.8)11.8% (−7.3 to 30.9)
The disappearance rate of bleeding symptoms at day 7
 ART-123 group14/43 patients (32.6)17/45 patients (37.8)
 Heparin group6/45 patients (13.3)13/46 patients (28.3)
 Difference (95% CI)19.2% (2.1 to 36.4)9.5% (−9.7 to 28.8)
The mortality rate at day 28
 ART-123 group11/64 patients (17.2)14/50 patients (28.0)
 Heparin group11/61 patients (18.0)18/52 patients (34.6)
 Difference (95% CI)−0.8% (−14.2 to 12.5)−6.6% (−24.6 to 11.3)

In the heparin group, the DIC resolution rates were 43.8% (7/16 patients), 56.7% (17/30 patients) and 48.5% (32/66 patients) for the subgroups of the antithrombin levels at baseline of < 50%, ≤ 50% < 70%, and ≤ 70%, respectively. A consistent effect of treatment with heparin was seen regardless of the antithrombin levels at baseline, suggesting that the therapeutic effect of heparin was not influenced by the antithrombin levels in this study.

The mortality rates for the ART-123 and heparin groups were 17.2% and 18.0% (difference −0.8%; 95% CI −14.2 to 12.5) respectively in patients with DIC associated with hematologic malignancy, and were 28.0% and 34.6% (difference −6.6%; 95% CI −24.6 to 11.3) respectively in patients with DIC associated with infection (Table 4).

The disappearance rates for bleeding symptoms at day 7 for the ART-123 and heparin groups were 32.6% and 13.3% (difference 19.2%; 95% CI 2.1–36.4) respectively in patients with DIC associated with hematologic malignancy, and were 37.8% and 28.3% (difference 9.5%; 95% CI −9.7 to 28.8) respectively in patients with DIC associated with infection (Table 4). The clinical course of bleeding symptoms in the ART-123 group at day 7 was significantly improved when compared with the heparin group (P = 0.0271; Table 5).

Table 5.   Clinical course of bleeding symptoms at day 7
Underlying diseaseDrugsGrade for bleeding symptomsExpanded Mantel Test (two-sided)
DisappearedImprovedUnchangedExacerbatedNo symptomsχ2 valueP-value
  1. Bleeding symptoms were observed during registration, every day during study drug infusion and at the end of study drug infusion (or withdrawal), and severity of symptoms was evaluated in 4 grades (no symptoms, mild, moderate and severe) based on the evaluation criteria established for each symptom. Changes in the grade of each symptom from the start of infusion to day 7 (or withdrawal) were collectively evaluated by the investigator on a scale of 1 to 6: 1, disappeared (all symptoms dissipated); 2, improved (total number of improved symptoms was higher than that of exacerbated or new symptoms); 3, unchanged (the only confirmed symptom remained unchanged, or total number of improved symptoms was comparable to that of exacerbated or new symptoms); 4, exacerbated (total number of improved symptoms was lower than that of exacerbated or new symptoms); 5, no symptoms (no symptoms were seen from the beginning); and 6, unassessable.

Hematologic malignancyART-123 group1491010214.88480.0271
Heparin group612101716
InfectionART-123 group17101085
Heparin group131010136

In the ART-123 group, almost all coagulation test findings tended to normalize, and, for instance, the rate of change in D-dimer, TAT and PAI-1 in the ART-123 group was significantly higher than that in the heparin group (Fig. 2), suggesting that ART-123 is superior to heparin in the attenuation of hypercoagulable states.

image

Figure 2.  Box-and-whisker plots and changes in coagulation test findings during treatment. Box-and-whisker plots for D-dimer (A), thrombin–antithrombin complex (TAT) (B), and plasminogen activator inhibitor-1 (PAI-1) (C) are shown. Rectangles represent the lower and upper limits of the interquartile range, and median values are demarcated inside the rectangles. The vertical lines (or ‘whiskers’) represent the spread of the data. The upper line represents the upper, or third quartile, plus 1.5 (interquartile range), and the lower line represents the lower, or first quartile, minus 1.5 (interquartile range). Outlying values are not indicated. Rate of change: value at the end of study drug infusion (or withdrawal) divided by value at baseline. *Median of difference between the groups is based on Mann–Whitney–Wilcoxon statistics. Medians of difference between the groups (95% CI) are −14.6 (−28.4 to −4.2), −15.9 (−27.1 to −5.5) and −29.2 (−47.9 to −11.3) for D-dimer, TAT and PAI-1, respectively.

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Safety

The incidence of bleeding-related adverse events up to 7 days after the start of infusion was lower in the ART-123 group than in the heparin group [50/116 patients (43.1%) vs. 65/115 patients (56.5%); P = 0.0487]. The incidences of bleeding-related adverse events up to 14 days after the start of infusion for the ART-123 and heparin groups were 55.2% (64/116 patients) and 65.2% (75/115 patients), respectively (P = 0.1397). The number of serious adverse events related to bleeding during the 28 days is shown in Table 6. The number of serious bleeding-related adverse events during infusion of study drug for the ART-123 group was two (2/116 patients), and that for the heparin group was four (3/115 patients). The incidence of bleeding-related adverse events leading to discontinuation for the heparin group was higher than that for the ART-123 group [7/115 patients (6.1%) vs. 2/116 patients (1.7%)].

Table 6.   Serious adverse events related to bleeding during the 28-day period
VariableNo. of event
Heparin groupART-123 group
  1. Serious adverse events related to bleeding were defined as any bleeding event classified as serious by the investigator, including death, life-threatening events, prolonged hospitalization, permanent or significant disorder or dysfunction, or other severe medical events.

Gastrointestinal21
Melenic01
Hemoptysis01
Respiratory tract01
Lung11
Lung or respiratory tract10
Cerebral21
Intracranial10
Hemothorax01
Catheter site10
Bone marrow aspiration site10
Postbiopsy01

For all other adverse events, there were no significant differences in incidence between the groups. There were no significant differences in the incidence of serious adverse events during the 28 days between the groups [37/116 patients (31.9%) for the ART-123 group, and 41/115 patients (35.7%) for the heparin group]. The incidence of adverse events leading to discontinuation for the ART-123 group was 8.6% (10/116 patients), and that for the heparin group was 15.7% (18/115 patients). No patients were found to possess antibodies that neutralized ART-123 activity.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Addendum
  8. Acknowledgements
  9. Disclosure of Conflict of Interests
  10. References
  11. Appendix

In this phase III study, we demonstrated that ART-123 significantly improves DIC and alleviates bleeding symptoms, as compared with heparin, and that the incidence of bleeding-related adverse events during the 7-day treatment period is significantly lower with ART-123 than with heparin. ART-123 improved almost all coagulation test findings, and improved or eliminated bleeding symptoms; thus, ART-123 appears to be very useful in improving the hypercoagulable state in DIC patients, in whom coagulation test findings are markedly abnormal and bleeding risks are high [1].

ART-123 appears to possess a unique mechanism of action in which thrombin generation is suppressed via APC without direct inhibition of thrombin activity at clinical blood concentrations. ART-123 has a wider safety margin than other anticoagulants [14,15], and the dosage of ART-123 can be set to provide potent anticoagulant activity while minimizing bleeding, thus allowing stable outcomes to be achieved. It is also noted that ART-123 does not require antithrombin, which is often reduced in DIC patients, for activity.

This study was not a placebo-controlled trial, because of ethical constraints in Japan, where six anticoagulants, including unfractionated heparin, low molecular weight heparin (LMWH) and heparinoid have been approved for DIC treatment. We used low-dose unfractionated heparin as a comparator, because heparin is typically used in anticoagulant therapy for DIC [1,6,9,21]. Although no randomized trial has proven the efficacy of heparin, three clinical trials on sepsis using natural anticoagulants suggested that the mortality rate was lower among patients who received low-dose heparin for prevention of deep vein thrombosis than among those who did not receive heparin [22–24]. There is, at least, no evidence that administration of low-dose heparin aggravates DIC. The efficacies and safeties of three anticoagulants, LMWH, heparinoid and plasma-derived APC, for DIC have been compared with those of heparin (7–10 U kg−1 h−1 for 24 h) in Japan [11–13]. None of these three anticoagulants has been shown to be superior to heparin in terms of efficacy. Therefore, this study is the first prospective study to confirm the superiority of the low-dose heparin alternative in the treatment of DIC.

Non-significant trends in favor of ART-123, as compared with heparin, were observed for mortality in patients with DIC associated with infection. The mortality rate for the ART-123 group was 6.6% lower than that for the heparin group [reduction in relative risk of death (rrr) = 19.1%]. In the PROWESS trial on severe sepsis, recombinant APC was shown to reduce the mortality rate by 6.1% as compared with placebo (P = 0.005, rrr = 19.4%) [25]. In fact, APC is the only drug for which an effect on mortality in sepsis has been demonstrated against placebo, in spite of many methodological concerns [26]. In contrast to the very short in vivo half-life of recombinant APC, ART-123 has a long in vivo half-life, and also has a unique N-terminal structure that exhibits anti-inflammatory activity [27]. ART-123 might be appropriate for septic patients with reduced endothelial thrombomodulin [28]. It would be interesting to investigate whether ART-123 would significantly reduce the mortality rate in a large-scale clinical study, as compared with placebo, in patients with DIC secondary to infection or sepsis.

Like numerous previous studies [29–32], we found that DIC is a strong predictor of mortality in patients with DIC associated with infection. For patients with resolved DIC (no DIC), 28-day mortality for the ART-123 and heparin groups was 3.1% (1/32 patients) and 17.9% (5/28 patients). For patients without resolved DIC, 28-day mortality for the ART-123 and heparin groups was 68.8% (11/16 patients) and 52.2% (12/23 patients). For both drug groups, patients with resolved DIC had a lower mortality rate.

Because the diagnostic criteria for overt DIC recently proposed by the International Society on Thrombosis and Haemostasis (ISTH DIC criteria) [33] were not yet available at the start of this study, we utilized the JMHW DIC criteria [19], which have been widely used in clinical settings in Japan. The ISTH DIC criteria are based, in principle, on the JMHW DIC criteria for patients without blood disease, and both criteria are reported to be similarly effective in identifying DIC patients [34,35]. The validity of the ISTH scoring system in critical care settings excluding ‘hematologic malignancy’ has been proved against ‘expert opinion’ [36]. By using the same approach, the sensitivity and specificity of the JMHW scoring system for patients with severe thrombocytopenia have been validated in leukemia-associated DIC [37]. It was shown that the JMHW scoring system is superior to the ISTH scoring system in terms of sensitivity and negative predictive value for leukemia-associated DIC. Thus, it appears that both JMHW scoring systems with or without severe thrombocytopenia are comparable in the diagnosis of DIC. In the protocol of this study, we prospectively defined a combined analysis of DIC resolution rate. Therefore, a combined analysis of data from hematologic malignancy and infection may be justified.

Here, we have demonstrated the superiority of ART-123 as a drug for the treatment of DIC over low-dose heparin. Because of its safety and efficacy, ART-123 appears to be a promising agent in the treatment of DIC associated with hematologic malignancy or infection and in the prevention of venous thromboembolism [38]. It is likely that ART-123 may be efficacious for the treatment of patients with DIC associated with solid tumor, pediatric DIC patients or obstetric DIC patients. In addition, previous studies have shown that thrombomodulin plays a central role in regulating not only hemostasis but also inflammation, and that ART-123 also possesses both antithrombotic and anti-inflammatory activities [27,39,40]. Therefore, ART-123 may be useful in the management of various diseases that are exacerbated by inflammation–coagulation interactions, such as sepsis, acute respiratory distress syndrome and inflammatory bowel disease. Further clinical investigations are necessary to clarify this point.

Addendum

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Addendum
  8. Acknowledgements
  9. Disclosure of Conflict of Interests
  10. References
  11. Appendix

H. Saito, I. Maruyama, S. Shimazaki, Y. Yamamoto, N. Aikawa, R. Ohno, A. Hirayama, T. Matsuda, H. Asakura, M. Nakashima and N. Aoki all participated in the study design and interpretation of data. H. Asakura and N. Aoki contributed to data assessment and interpretation. M. Nakashima was the medical statistics advisor. N. Aoki was the medical expert. H. Saito prepared the draft manuscript. I. Maruyama, S. Shimazaki, Y. Yamamoto, N. Aikawa, R. Ohno, A. Hirayama, T. Matsuda, H. Asakura, M. Nakashima and N. Aoki critically reviewed multiple drafts of the manuscript.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Addendum
  8. Acknowledgements
  9. Disclosure of Conflict of Interests
  10. References
  11. Appendix

We thank N. Nara for interpretation of data and the late K. Osato for assisting with study design. This study was funded by Asahi Kasei Pharma.

Disclosure of Conflict of Interests

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Addendum
  8. Acknowledgements
  9. Disclosure of Conflict of Interests
  10. References
  11. Appendix

H. Asakura, M. Nakashima and N. Aoki have received consultancy funding from Asahi Kasei Pharma. Although it was not directly related to the current study, I. Maruyama has received research funding support from Asahi Kasei Pharma.

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  4. Methods
  5. Results
  6. Discussion
  7. Addendum
  8. Acknowledgements
  9. Disclosure of Conflict of Interests
  10. References
  11. Appendix
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Appendix

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Addendum
  8. Acknowledgements
  9. Disclosure of Conflict of Interests
  10. References
  11. Appendix

Appendix 1

ART-123 Trial Group

In addition to the authors, the following institutions and investigators participated in this study: Y. Torimoto and K. Sato (Asahikawa Medical College Hospital, Hokkaido); T. Miyake, T. Fukuhara, and K. Chiba (Asahikawa City Hospital, Hokkaido); S. Sumita and I. Kobayashi (Asahikawa Red Cross Hospital, Hokkaido); T. Kawamura (Hakodate Central General Hospital, Hokkaido); Y. Kunieda and K. Hatanaka (Wakkanai City Hospital, Hokkaido); M. Musashi (Hokkaido University Hospital, Hokkaido); T. Ogawa, M. Nakata, K. Yoshida and K. Aikawa (National Hospital Organization Hokkaido Cancer Center, Hokkaido); Y. Asai and K. Mori (Sapporo Medical University Hospital, Hokkaido); Y. Murata (Aomori Prefectural Central Hospital, Aomori); Y. Ishida, S. Ito, and K. Murai (Iwate Medical University Hospital, Iwate); S. Endo (Iwate Medical University Hospital, Iwate); K. Endo and T. Sasaki (Sendai City Hospital, Miyagi); Y. Shinozawa (Tohoku University Hospital, Miyagi); T. Hayashi (Yamagata University Hospital, Yamagata); T. Nagasawa and H. Kojima (Tsukuba University Hospital, Ibaraki); Y. Sakata and S. Madoiwa (Jichi Medical School Hospital, Tochigi); M. Sawamura (Nishigunma Hospital, Gunma); Y. Okada (National Defence Medical College Hospital, Saitama); J. Uehara and A. Yamaguchi (Saitama Medical Center, Saitama); J. Nishida (Jichi Medical School Omiya Medical Center, Saitama); C. Sakai (Chiba Cancer Center, Chiba); M. Shibuya and S. Kimura (Matsudo City Hospital, Chiba); K. Matsue, K. Yamada, and M. Takeuchi (Kameda Medical Center, Chiba); A. Kidokoro and T. Iba (Juntendo University Urayasu Hospital, Chiba); K. Mashiko, K. Abe, and Y. Ueno (Nippon Medical School Chiba Hokusoh Hospital, Chiba); K. Kato (Nihon University Itabashi Hospital, Tokyo); K. Kawasugi (Teikyo University Hospital, Tokyo); M. Ohta (Tokyo Metropolitan Geriatric Hospital, Tokyo); A. Urabe and S. Iki (Kanto Medical Center NTT EC); S. Fujishima, K. Aoki, and S. Miyatake (Keio University Hospital, Tokyo); T. Yukioka and M. Kanai (Tokyo Medical University Hospital, Tokyo); H. Osawa (Shirahigebashi Hospital Seiwakai Medical Corporation, Tokyo); S. Kushimoto (Nippon Medical School, Tokyo); A. Murata, Y. Yamaguchi, T. Tarui, and H. Goto (Kyorin University Hospital, Tokyo); H. Hamaguchi, K. Nagata, and N. Amemiya (Musashino Red Cross Hospital, Tokyo); S. Suzaki (Musashino Red Cross Hospital, Tokyo); F. Mizorogi, T. Shimada, and S. Fukumi (Daisan Hospital Jikei University School of Medicine, Tokyo); N. Ninomiya and Y. Nakanowatari (Nippon Medical School, Tama Nagayama Hospital, Tokyo); Y. Murai and S. Motomura (Tama-Hokubu Medical Center, Tokyo); M. Honma (Tokyo Disaster Medical Center, Tokyo); M. Aosaki (Yokohama Medical Center, Kanagawa); H. Tsukada (Niigata University Medical & Dental Hospital, Niigata); T. Chou, Y. Imai, and T. Hirose (Niigata Cancer Center Hospital, Niigata); Y. Seki (Niigata Prefectural Shibata Hospital, Niigata); S. Minami, M. Kuriyama, and Y. Ontachi (Nanto Municipal Hospital, Toyama); M. Saito (NTT West Kanazawa Hospital, Ishikawa); M. Ueda and M. Maekawa (Ishikawa Prefectural Central Hospital, Ishikawa); Y. Ontachi (Kanazawa Wakamatsu National Hospital, Ishikawa); Y. Urasaki and Y. Kawai (University of Fukui Hospital, Fukui); M. Yanagi (University of Yamanashi Hospital, Yamanashi); T. Matsushita (Nagoya University Hospital, Aichi); M. Hamaguchi (Nagoya Medical Center, Aichi); Y. Kuwabara, S. Ito, and H. Ito (Nagoya City University Hospital, Aichi); M. Ueyama (Chukyo Hospital, Aichi); H. Noguchi (Aichi Medical University Hospital, Aichi); M. Watanabe and K. Nakase (Mie University Hospital, Mie); K. Maruyama and J. Masuda (Mie University Hospital, Mie); I. Tanaka (Suzuka Kaisei Hospital, Mie); T. Inoue (Shiga University of Medical Science Hospital, Shiga); T. Tani and K. Hanasawa (Shiga University of Medical Science Hospital, Shiga); Y. Eguchi (Shiga University of Medical Science Hospital, Shiga); T. Suzuki, M. Matsui, and T. Utumi (Shiga Medical Center for Adults, Shiga); M. Hino (Osaka City University Hospital, Osaka); D. Sadamitsu, Hong Cheng Bai and F. Kimbara (Osaka National Hospital, Osaka); N. Awata (Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka); H. Tanaka (Osaka University Hospital, Osaka); K. Tabuse and T. Tsuji (Osaka Minami Medical Center, Osaka); M. Tsukaguchi and Y. Furukawa (Sakai Municipal Hospital, Osaka); K. Tsubaki and M. Sugiyama (Nara Hospital, Kinki University School of Medicine, Nara); S. Koga (Wakayama Medical University Hospital, Wakayama); M. Shinozaki, H. Nasu, and T. Naka (Wakayama Medical University Hospital, Wakayama); K. Imajo, Y. Hara, K. Fujii, and M. Niiya (Okayama Citizens’ Hospital, Okayama); C. Fujii M. Fukuda and K. Kumada (Kawasaki Medical School Hospital, Okayama); M. Ohtani and T. Yamanoue (Hiroshima University Hospital, Hiroshima); T. Shigekiyo (Tokushima Prefectural Central Hospital, Tokushima); H. Azuma (Tokushima University Hospital, Tokushima); T. Goto and M. Ichimiya (Tokushima Red Cross Hospital, Tokushima); T. Fujisaki and Y. Minamoto (Matsuyama Red Cross Hospital, Ehime); Y. Shirakawa (Ehime University Hospital, Ehime); T. Ikezoe and K. Togitani (Kochi Medical School Hospital, Kochi); Y. Izumi (Kokura Memorial Hospital, Fukuoka); Y. Ohno (Kitakyushu Municipal Medical Center, Fukuoka); Y. Abe (Kitakyushu Municipal Medical Center, Fukuoka); N. Hirase (Kokura National Hospital, Fukuoka); S. Takeda (Kokura National Hospital, Fukuoka); K. Okamoto (University of Occupational and Environmental Health Hospital, Fukuoka); T. Kawashima, K. Tanaka, and S. Fukahori (Kurume University Hospital, Fukuoka); I. Ichinose (Fukuoka University Hospital, Fukuoka); T. Kamimura (Harasanshin General Hospital, Fukuoka); K. Shimoda (Kyushu University Hospital, Fukuoka); N. Uike, Y. Yufu, and A. Maekawa (National Kyushu Cancer Center, Fukuoka); S. Okamura, A. Kubota, and T. Yokoyama (Kyushu Medical Center, Fukuoka); K. Tanimoto (Shinkoga Hospital, Fukuoka); E. Sueoka, M. Sano, N. Funai, and T. Hisatomi (Saga Medical School Hospital, Saga); E. Matsuishi (Saga Prefectural Hospital KOSEIKAN, Saga); S. Kawano, H. Suzushima and T. Shimomura (NTT West Japan Kyushu Hospital, Kumamoto); F. Kawano, M. Hidaka, and I. Sanada (Kumamoto Medical Center, Kumamoto); K. Horikawa (Kumamoto University Hospital, Kumamoto); H. Tsuda and H. Yamasaki (Kumamoto City Hospital, Kumamoto); S. Koga and T. Takeguchi (Amakusa Chuo General Hospital, Kumamoto); S. Nishimura (Yatsushiro General Hospital, Kumamoto); Y. Saburi, T. Imamura, E. Ohno, K. Kohno, E. Ohtsuka, and T. Ando (Oita Prefectural Hospital, Oita); S. Makino (Miyazaki Prefectural Miyazaki Hospital, Miyazaki); K. Maeda and S. Sato (Miyakonojo Hospital, Miyazaki); Y. Kubuki (University of Miyazaki Hospital, Miyazaki); H. Miyahara (Kagoshima Prefectural Hokusatsu Hospital, Kagoshima); M. Ojiro, M. Furuzono, and S. Yoshimi (Kagoshima Prefectural Oshima Hospital, Kagoshima); M. Masuda, N. Taira, and T. Tomoyose (University of the Ryukyus Hospital, Okinama).