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Effect of Recombinant Erythropoietin on Numbers of Circulating Endothelial Progenitor Cells in Subacute TBI

Information source: Uniformed Services University of the Health Sciences
ClinicalTrials.gov processed this data on August 23, 2015
Link to the current ClinicalTrials.gov record.

Condition(s) targeted: Traumatic Brain Injury

Intervention: Erythropoietin (Drug)

Phase: Phase 2

Status: Not yet recruiting

Sponsored by: Uniformed Services University of the Health Sciences

Official(s) and/or principal investigator(s):
Ramon Diaz-Arrastia, MD, PhD, Principal Investigator, Affiliation: Uniformed Services University of the Health Sciences
Eric Wassermann, MD, Principal Investigator, Affiliation: National Institutes of Health (NIH)

Overall contact:
Carol Moore, MA, Phone: 301-295-6439, Email: Carol.Moore.CTR@usuhs.edu

Summary

- Traumatic brain injury (TBI) is the leading cause of death and disability in people

under age 45 in industrialized countries. Significant numbers of US veterans from the wars in Iraq and Afghanistan return with TBI. However, to date, there are no specific neuroprotective treatment options with proven clinical efficacy.

- Erythropoietin (EPO) is approved by the FDA to treat anemia and has comprehensive

preclinical data supporting its neuroprotective and neuroregenerative efficacy following traumatic (TBI) and a wide range of other acquired brain insults. Injury to small and medium-sized cerebral blood vessels is a well recognized consequence of TBI. EPO increases production of endothelial progenitor cells (EPCs) and promotes angiogenesis and neovascularization after TBI. EPO also promotes neurogenesis and improves functional recovery in animals after experimental stroke and TBI. Neovascularization is coupled with neurogenesis, and augmentation of both processes by EPO may result in lessened cognitive deficits. Neovascularization by EPO may prevent post-traumatic deficits in cerebrovascular reactivity (CVR), which can be measured noninvasively using magnetic resonance imaging (MRI).

- This proposal is for a randomized, placebo-controlled pilot clinical trial designed to

obtain data on the effects of EPO in humans with persistent post-concussive symptoms after TBI. The primary objective is to evaluate effect of 4 week administration of recombinant erythropoietin on numbers of circulating endothelial progenitor cells in patients with persistent symptoms during the subacute period after TBI. This information will guide the design of a future definitive study.

Clinical Details

Official title: Effect of Administration of Recombinant Erythropoietin on Numbers of Circulating Endothelial Progenitor Cells in Patients With Persistent Symptoms During the Subacute Period After TBI

Study design: Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Double Blind (Subject, Investigator), Primary Purpose: Prevention

Primary outcome: Effect of 4 weeks of EPO administration on numbers of circulating EPCs in patients with persistent symptoms during the subacute period after TBI (within subject comparison).

Secondary outcome:

Comparison of the change of numbers of circulating EPC's between EPO and placebo groups.

Effect of 4 weeks of EPO administration on plasma biomarkers of angiogenesis and inflammation, such as stem cell factor (SCF), vascular endothelial growth factor (VEGF), stromal-derived factor (SDF-1α); and matrix metalloproteinase-9 (MMP-9)

Effect of 4 weeks of placebo administration on numbers of circulating EPCs in patients with persistent symptoms during the subacute period after TBI.

Detailed description:

- The study population will include 30 males and females with persistent post-concussive

symptoms continuing up to 7 days after TBI. Participants will be military service members or civilians presenting as outpatients for clinical management of TBI or post-concussive symptoms at the Center for Neuroscience and Regenerative Medicine (CNRM)-affiliated hospitals. These include the Walter Reed National Military Medical Center (WRNMMC), Suburban Hospital (SH), and Washington Hospital Center (WHC).

- Design: Participants will be referred to the NIH Clinical Center (CC) from

participating hospitals or will be recruited by advertisements through CNRM Recruitment core to receive EPO or placebo. Telephone screening will be carried out to determine tentative eligibility. At the baseline visit, participants will be screened, consented and randomized 2: 1 to receive either EPO or placebo with a dose of 40,000 IU EPO subcutaneously (s. c.) (n=20) once weekly for 4 weeks or placebo (n=10). Each participant will have 6 outpatient visits (visits 1-6) performed at the NIH CC. Placebo or active drug will be administered s. c. based on the randomization at visits 1-4; blood will be collected for EPC assays and safety laboratory measurements during each visit. Brain MRI and neuropsychological tests will be performed during visit 1 (before administering EPO or placebo), and visit 5 (one week after final drug administration) and visit 6 (6 months after study enrollment).

- Outcome Measures:

- Primary outcome:

(1). Effect of 4 weeks of EPO administration on numbers of circulating EPCs in patients with persistent symptoms during the subacute period after TBI (within subject comparison).

- Secondary outcomes:

(2). Comparison of the change of numbers of circulating EPC's between EPO and placebo groups. (3). Effect of 4 weeks of EPO administration on MRI biomarkers of TBI recovery (such as CVR on hypercapnia and global and regional brain volumes by MRI). (4). Effect of 4 weeks of EPO administration on plasma biomarkers of angiogenesis and inflammation, such as stem cell factor (SCF), vascular endothelial growth factor (VEGF), stromal-derived factor (SDF-1α); and matrix metalloproteinase-9 (MMP-9). (5). Effect of 4 weeks of placebo administration on numbers of circulating EPCs in patients with persistent symptoms during the subacute period after TBI.

- Tertiary outcome:

(6). Relationship between EPC levels at baseline and after 4 weeks and neuropsychological performance following TBI.

Eligibility

Minimum age: 18 Years. Maximum age: 70 Years. Gender(s): Both.

Criteria:

Inclusion Criteria:

- Age 18 - 70 years, inclusive

- History of having sustained a TBI > 3 days and < 7 days prior to enrollment. This

evidence will be any one of the following:

1. GCS 3 - 12 on first presentation to medical attention

2. Post-traumatic amnesia > 24 hours 3. TBI-related abnormality on neuroimaging

- Persistent post-concussive symptoms

1. Three of more of the following symptoms, which started shortly after the trauma and persist for at least up to the time of enrollment:

- Fatigueability

- Disordered sleep

- Headache

- Vertigo or dizziness

- Irritability or aggression

- Anxiety, depression, or affective instability

- Changes in personality (e. g., social or sexual inappropriateness)

- Apathy or lack of spontaneity

2. Symptoms had their onset after trauma, or there is a significant worsening or pre-existing symptoms after trauma.

- Ability to give consent by the participant himself

- Willingness of women of childbearing potential to use effective contraception during

this Exclusion Criteria:

- Contraindication to EPO therapy:

1. Known allergy to EPO, hypersensitivity to mammalian cell-derived products, or hypersensitivity to albumin 2. Serum hemoglobin > 16 g/dL in a male patient or > 14 g/dL in a female patient; or a platelet count > 400,000/mm3 or serum hemoglobin < 10 g/dL in either a male or female patient 3. liver or kidney disease; the former will be operationally defined as a serum bilirubin > 4 mg/dL, alkaline phosphatase (AP) > 250 U/L, aspartate aminotransferase (SGOT, AST) > 150 U/L, alanine aminotransferase (SGPT, ALT) >150 U/L, or Moderately decreased GFR 30-59 ml/min/1. 73m2 4. Pregnancy or lactating; note that a negative pregnancy test will be required if the patient is a female of childbearing potential

- Use of EPO one month prior to the randomization

- Suspicion of a coagulation disorder associated with bleeding (PTT>45 or INR>1. 7,

spontaneously out of normal range)

- Pre-existing and active major disabling psychiatric disorder (e. g., schizophrenia or

bipolar disorder), or other neurological disease (epilepsy, multiple sclerosis, developmental disorder) not related to TBI

- History of heart disease or heart attack, congestive heart failure, stroke, venous

thromboembolism.

- History of disorders that predispose to coagulation (e. g. polycythemia vera,

essential thrombocytosis, or thrombotic thrombocytopenic purpura).

- Uncontrolled hypertension, defined as above 140/90 mm Hg in three measurements in two

separate visits despite antihypertensive therapy.

- Known malignant conditions, e. g., melanoma, breast, brain, lung tumor or prostate

cancer

- Terminal medical diagnosis consistent with survival < 1 year

- Planned surgical procedure during duration of the study

- Current use of Coumadin or other blood thinners (e. g. Pradaxa, Heparin, Lovenox).

- Any history of previous deep venous thrombosis (DVT), pulmonary embolization (PE), or

other thromboembolic event

- Current participation in other interventional clinical trial

- Current use of iron supplements

- Evidence of penetrating brain injury

- Contraindication to MRI scanning

- No adherence to use of effective method of contraception for females of childbearing

potential for time from enrollment to the study until 2 weeks after completion of the study drug

Locations and Contacts

Carol Moore, MA, Phone: 301-295-6439, Email: Carol.Moore.CTR@usuhs.edu

National Institutes of Health, Clinical Center., Bethesda, Maryland 20814, United States; Not yet recruiting
Tanya Bogoslovsky, MD, PhD, Sub-Investigator
Dzung Pham, PhD, Sub-Investigator
John Butman, MD, Sub-Investigator
John Dsurney, PhD, Sub-Investigator
Kimbra Kenney, MD, Sub-Investigator
Carol Moore, MA, CCRC, Sub-Investigator
Bao-Xi Qu, MD, Sub-Investigator
Yunhua Gong, MD, Sub-Investigator
Christian Shenouda, MD, Sub-Investigator
Franck Amyot, PhD, Sub-Investigator
Additional Information

Related publications:

Bahlmann FH, De Groot K, Spandau JM, Landry AL, Hertel B, Duckert T, Boehm SM, Menne J, Haller H, Fliser D. Erythropoietin regulates endothelial progenitor cells. Blood. 2004 Feb 1;103(3):921-6. Epub 2003 Oct 2.

Guo X, Liu L, Zhang M, Bergeron A, Cui Z, Dong JF, Zhang J. Correlation of CD34+ cells with tissue angiogenesis after traumatic brain injury in a rat model. J Neurotrauma. 2009 Aug;26(8):1337-44. doi: 10.1089/neu.2008-0733.

Bogoslovsky T, Chaudhry A, Latour L, Maric D, Luby M, Spatz M, Frank J, Warach S. Endothelial progenitor cells correlate with lesion volume and growth in acute stroke. Neurology. 2010 Dec 7;75(23):2059-62. doi: 10.1212/WNL.0b013e318200d741.

Starting date: September 2014
Last updated: May 28, 2014

Page last updated: August 23, 2015

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