Supplementary Appendix

Transcription

1 Supplementary Appendix This appendix has been provided by the authors to give readers additional information about their work. Supplement to: Eikelboom JW, Connolly SJ, Brueckmann M, et al. versus warfarin in patients with mechanical heart valves. N Engl J Med 2013;369: DOI: /NEJMoa

2 Supplementary Appendix Table of contents: List of Investigators and Committees Page 2 Exclusion Criteria of the RE-ALIGN Trial Page 3 Study Drug Initiation, Monitoring, and Dose Adjustment Page 4 Details on Fatal Cases Page 6 Supplementary Figure S1: Comparison of observed trough dabigatran levels with those predicted by dose-modeling Page 7 Supplementary appendix Table S1: Efficacy and safety outcomes in the RE-ALIGN and RE-ALIGN extension trial, comparison of intention-to-treat (ITT) vs. on treatment analysis set Page 9 Supplementary appendix Table S2: Efficacy and safety outcomes, separated into RE-ALIGN trial (12 weeks of treatment) and the RE-ALIGN extension trial (treatment beyond 12 weeks) Page 10 Supplementary appendix Table S3: Listing of thromboembolic events and death in the RE-ALIGN and RE-ALIGN extension trial (ITT analysis set) Page 11 Supplementary appendix Table S4: Listing of major bleeding events in the RE-ALIGN trial (ITT analysis set) Page 14 References to Supplementary appendix Page 16 1

3 List of Investigators and Committees in the RE-ALIGN and RE-ALIGN Extension Trial Steering Committee: J.Eikelboom (co-chair), F.Van de Werf (co-chair), S.Connolly, C.Granger, P.Kappetein, M. Brueckmann, and M.Mack. Data Safety Monitoring Board: M.L.Simoons (chair), D.Lindblom, M.Prins and J.G.P Tijssen. List of principal investigators in the RE-ALIGN trial (at least one patient screened): Belgium: M.De Pauw, M-C.Herregods, D.Schoors, J-L.Vanoverschelde, M.Vrolix, Canada: C.Brown, S.Meyer, M.Quantz, R.Singal, K.H.T.Teoh, S.Verma, R.Whitlock, Czech Republic: H.Bedanova, R.Brat, P.Marcian, M.Setina, J.Vojacek, Denmark: S.U.A.Gill, P.Skov Olsen, France: L.Barandon, B.Iung, A.Leguerrier, J-F.Obadia, Germany:, T.Horacek, S.Schellong, M.R. Siepe, G.Szabó, M.Thielmann, Netherlands: A.M.W.Alings, R.Riezebos, R.J.Winter de, Norway: D.Atar, R. Haaverstad, S.Halvorsen, Poland: T.Hryniewiecki, P.Ponikowski, J.Rogowski, Sweden: C.Christersson, A.Jeppsson, and J.Sjögren. List of principal investigators in the RE-ALIGN extension trial (at least one patient screened): Belgium: M-C.Herregods, J-L.Vanoverschelde, M.Vrolix, Canada: C.Brown, M.Quantz, K.H.T.Teoh, S.Verma,, R.Whitlock, Czech Republic: H.Bedanova, R.Brat, P.Marcian, M.Setina, Denmark: S.U.A.Gill, P.Skov Olsen, France: L.Barandon, B.Iung, A.Leguerrier, J- F.Obadia, Germany: T.Horacek, S.Schellong, M.R. Siepe, G.Szabó, M.Thielmann, Netherlands: A.M.W.Alings, R.Riezebos, Norway: D.Atar, R. Haaverstad, S.Halvorsen, Poland: T.Hryniewiecki, P.Ponikowski, and J.Rogowski. 2

4 Exclusion Criteria of the RE-ALIGN Trial Patients were not eligible for inclusion if they met any one of the following criteria: previous prosthetic heart valve replacement; aortic root replacement, replacement of ascending aorta, concomitant bioprosthetic valve replacement or mechanical tricuspid or pulmonary valve replacement at the time of the index valve replacement surgery (defined as the surgery that had been conducted within 7 days of randomization for population A or at least three months ago for population B); clinically relevant paravalvular leaks, endocarditis, complex congenital heart abnormality, acute coronary syndrome within one month, uncontrolled hypertension, recent emergency surgery, planned surgery or intervention within one month after randomization, any history of hemorrhagic stroke, at high risk for bleeding, active hepatitis or abnormal liver function with persistently elevated ALT, AST or alkaline phosphatase more than 3x the upper limit of normal, creatinine clearance <40 ml/min, patients with a clear indication for long-term dual antiplatelet or oral anticoagulant for other indications for which dabigatran is not approved, recent malignancy or radiation, treatment with selected drugs that may interact with dabigatran, at risk of pregnancy or with known allergy to dabigatran or warfarin. 3

5 Study Drug Initiation, Monitoring, and Dose Adjustment A. Population A patients randomised to dabigatran started treatment on day 3 to 7 post surgery, with the actual timing at the discretion of the local investigator. Bridging with intravenous heparin or subcutaneous low molecular weight heparin was permitted. If bridging was used, the protocol indicated that the first dose of dabigatran was to be given at the time of stopping the infusion or within two hours prior to the next subcutaneous injection. Population B patients started dabigatran when the INR was less than 2.5. The starting dose of dabigatran was based on renal function: the initial dose was 150 mg twice daily in patients with a creatinine clearance less than 70 ml/min, 220 mg twice daily in those with a creatinine clearance of 70 to 109 ml/min and 300 mg twice daily in those with a clearance of 110 ml/min or greater. Trough plasma concentrations of dabigatran were measured using the Hemoclot assay (Hyphen Biomed, France) at 1, 2, 4 and 12 weeks and thereafter at 6-monthly intervals. If a patient was found to have a level <50ng/mL during the first 1 to 2 weeks of treatment the dose of dabigatran was increased to the next higher dose. If a patient had a plasma level <50ng/mL (confirmed on repeat testing) despite receiving dabigatran at the highest dose of 300mg twice daily or a plasma level of 250ng/mL or higher despite receiving 150mg twice daily, the patient was switched to warfarin. Dosing was based on trough dabigatran concentrations because of close correlation between trough and peak levels in RE-LY and evidence suggesting that trough and peak levels were similarly predictive of thrombotic and bleeding events (1). Plasma 4

6 concentrations of dabigatran were also determined by a validated high performance liquid chromatography tandem mass spectrometry method (HPLC-MS/MS). Assay accuracy and precision were within 9.1 % and 13.8 % respectively, and the lower limit of quantification was 1ng/mL. B. Warfarin The target INR range in patients randomized to receive warfarin was 2 to 3 in those deemed to be at low thromboembolic risk (patients with a mechanical aortic valve with no additional risk factors) and 2.5 to 3.5 in those deemed to be at intermediate to high risk (patients with a mechanical aortic valve with additional risk factors or a mechanical mitral valve) (2), according to local practice. Population A patients randomized to receive warfarin started treatment up to day 7 post surgery, with the actual timing at the discretion of the local investigator. Use of anticoagulant bridging with intravenous heparin or subcutaneous low molecular weight heparin was also at the discretion of the investigator. The protocol required the INR to be measured daily for the first few days and thereafter at least once every 2 weeks for the first 12 weeks, and once every 4 weeks thereafter. Patients who had received a mechanical valve more than 3 months prior to randomisation and were currently taking a vitamin K antagonist (population B) switched to study warfarin with dose adjustment as necessary. These patients continued to have their INR monitored at least once every 4 weeks. 5

7 Details on Fatal Cases One death in the warfarin arm (main trial) was un-witnessed and we were unable to obtain additional information. It was adjudicated as cardiovascular death (sudden or arrhythmic death). The second death in a warfarin patient in the extension trial met the VARC definition for cardiovascular mortality with high likelihood of arrhythmia. The death that happened in a dabigatran patient (main trial) met the VARC definition for cardiovascular mortality. The patient presented with syncope and was consecutively resuscitated. The death was associated with and was potentially triggered by hemopericardium and cardiac tamponade. It is not clear if the hemopericardium was secondary to resuscitation or was already present before the resuscitation efforts began. 6

8 Suppl. Figure S1. Comparison of observed trough dabigatran levels with those predicted by dose-modeling Expected (predicted) values were obtained by 1) simulating 5000 trial replicates using the pharmacokinetic model (reference 3), 2) calculating the median concentrations for each replicate and 3) summarizing the distribution of medians across replicates in terms of median and 5 th and 95 th percentiles. A) Study population A by visit and dose group At 1 week of treatment, medians of observed concentrations were lower than predicted in dose groups 220 and 300mg bid, and at the lower end of the expected range for dose group 150mg bid. At 4 weeks of treatment, observed concentrations were within the expected range. Black dots represent medians of predicted concentrations with 90% confidence interval.red dots represent medians of observed concentrations. 7

9 B) Study population B by visit and dose group Patient B population is not underexposed compared to prediction at 1 week and at 4 weeks of treatment. Large variability due to small number of patients. Black dots represent medians of predicted concentrations with 90% confidence interval. Red dots represent medians of observed concentrations. 8

10 Suppl. Table S1. Efficacy and safety outcomes in the RE-ALIGN and RE-ALIGN extension trial, comparison of intention-totreat (ITT) vs. on treatment analysis set Intention-to-treat, n=252 from randomization until date of trial termination (28Nov) On Treatment, n=243 from first drug intake until last drug intake +6 days n=168 Warfarin n=84 n=162 Warfarin n=81 Death Stroke SEE TIA Myocardial infarction Death/Stroke/SEE/MI Death/Stroke/SEE/TIA/MI Major Bleeding (MBE) MBE with pericardial location Any Bleeding Number of pts. (%) Number of pts. (%) Number of pts. (%) Number of pts. (%) 1 (0.6) 2 (2.4) 1 (0.6) 2 (2.5) 9 (5.4) 0 8 (4.9) (1.8) 2 (2.4) 2 (1.2) 1 (1.2) 3 (1.8) 0 3 (1.9) 0 13 (7.7) 2 (2.4) 12 (7.4) 2 (2.5) 15 (8.9) 4 (4.8) 14 (8.6) 3 (3.7) 7 (4.2) 2 (2.4) 7 (4.3) 1 (1.2) 7 (4.2) 2 (2.4) 7 (4.3) 1 (1.2) 45 (26.8) 10 (11.9) 37 (22.8) 9 (11.1) Abbreviations: SEE = systemic embolism, TIA = transient ischemic attack, MI = myocardial infarction, MBE = major bleeding event. 9

11 Suppl. Table S2. Efficacy and safety outcomes, separated into RE-ALIGN trial (12 weeks of treatment) and the RE-ALIGN extension trial (treatment beyond 12 weeks) REALIGN, n=252 REALIGN extension, n=158 n=168 Warfarin n=84 n=99 Warfarin n=59 Number of pts. (%) Number of pts. (%) Number of pts. (%) Number of pts. (%) Death Stroke SEE TIA Myocardial infarction Death/Stroke/SEE/MI Death/Stroke/SEE/TIA/MI Major Bleeding (MBE) MBE with pericardial location Any Bleeding 1 (0.6) 1 (1.2) 0 1 (1.7) 6 (3.6) 0 3 (3.0) (1.2) 2 (2.4) 1 (1.0) 0 2 (1.2) 0 1 (1.0) 0 9 (5.4) 1 (1.2) ) 4 (4.0) 1 (1.7) 10 (6.0) 3 (3.6) 5 (5.1) 1 (1.7) 7 (4.2) 2 (2.4) (4.2) 2 (2.4) (24.4) 10 (11.9) 6 (6.1) 1 (1.7) Abbreviations: SEE = systemic embolism, TIA = transient ischemic attack, MI = myocardial infarction, MBE = major bleeding event. 10

12 Suppl. Table S3. Listing of thromboembolic events and death in the RE-ALIGN and RE-ALIGN extension trial (ITT) RE-ALIGN (treatment over the first 12 weeks) Patient number Outcome event Treatment at event onset Event onset date Last dabigatran trough plasma concentration [ng/ml] or INR preceding the event Date of blood sampling Population A or B Valve type Echocardiography related to outcome event (TTE and/or TEE) Time from surgery (days) Time from transition to study drug in Pop. B patients (days) Use of bridging while transitioning to study drug Stroke 30 Apr Apr A AO No thrombus visible on TTE and TEE, ( 01 May ) 45 enoxaparin 17Mar to 20Mar MI MI Valve thrombosis Stroke Death 150 mg bid 12 Sept 24 Jul 26 Jul 12 Feb 21 Sept 84.4 no plasma concentration obtained within time window no plasma concentration obtained within time window Aug 21 Dec 20 Sep B MI No imaging available B B MI MI No Thrombus visible on TTE (low image quality), (24 Jul ) Thrombus visible on TEE, (26 Jul ) A AO No thrombus visible 82 A AO No imaging available Nov2011to 24Nov Aug to 30Aug Valve thrombosis 21 Nov Oct B MI Thrombus visible

13 Stroke 03 Jun Apr A AO No thrombus visible Stroke TIA Stroke 300mg bid Death Warfarin 02 Jun May 21 Mar 31 Jan 11 Oct INR 2.08 A AO + MI 12 Mar A AO 30 Jan A AO 04Sep Thrombus (uncertain) in TEE (06Jun); valve thrombosis ruled out by adjudication No imaging available No thrombus visible (21 Nov ) A MI No imaging available enoxaparin 03Mar to 05Mar enoxaparin 23Jan to 25Jan heparin 21Aug to 28Aug Valve thrombosis (before 1 st drug intake) 220mg bid 16 Apr BLQ (sample before first drug administration) TIA Warfarin 01 May INR Stroke (before 1 st drug intake) TIA (before 1 st drug intake) TIA Warfarin BLQ (sample before 29 Sept first drug administration) BLQ (sample before 09 Oct first drug administration) 27 Nov INR Apr A MI Thrombus visible on TEE (16 Apr ) 30 APR A AO No imaging available 27 Sept A AO No imaging available 27 Sept A AO No imaging available 21 Sept A MI No thrombus visible on TTE(13 Feb 2013) heparin 10Apr to 29Apr heparin 05Mar to 15Mar enoxaparin 28Sep - ongoing enoxaparin 28Sep - ongoing 12

14 RE-ALIGN extension (Treatment from week 12 onwards) Patient number Outcome event Treatment at event onset Event onset date Last dabigatran trough plasma concentration [ng/ml] or INR preceding the event Date of blood sampling Population A or B Valve type Echocardiography related to outcome event (TTE and/or TEE) Time from surgery (days) Time from transition to study drug in Pop. B patients (days) Use of bridging while transitioning to study drug TIA Valve Thrombosis 150 mg bid 10 Nov 26 Nov Sep B MI Insufficient imaging data May B MI Thrombus visible to 22 Feb Valve Thrombosis MI Stroke Stroke Stroke 220mg bid 300mg bid Death Warfarin 27 Jun 27 Jun 26 Sept 23 Sept 07 Oct Jul INR May A AO 22 May A AO No thrombus visible on TTE (27Jun ) 119 Thrombus visible on TEE (29 Jun ) Jul A AO No thrombus visible Sept A AO No thrombus visible May A AO 19 Jun A AO No thrombus visible on TEE (10 Oct ) No imaging available Mar to 02Mar 01Mar to 02Mar 07Feb to 10Feb 04Apr to 05Apr 26Apr to 27Apr 01Feb to 05Feb TTE= transthoracic echo; TEE= transesophageal echo; BLQ=Below limit of quantification; ITT = intention to treat analysis, AO = aortic; MI = mitral. The lower limit of quantitation for the assay was 1.0 ng/ml. Assay accuracy and precision were within 9.1 % and 13.8 % respectively. 13

15 Suppl. Table S4. Listing of major bleeding events in the RE-ALIGN trial* (ITT) Patient number Site of major bleeding event Treatment at event onset Event onset date Last dabigatran trough plasma concentration [ng/ml] or INR preceding the event Date of blood sampling Population A or B Valve type Time from surgery (days) Use of bridging while transitioning to study drug Bleeding from hemorrhoids Pericardial Pericardial Pericardial Pericardial Pericardial Pericardial Pericardial 300mg bid 300mg bid 10 Feb BLQ (before first drug administration) 23 Feb Mar BLQ (before first drug administration) 02 Apr Mar BLQ (before first drug administration) 13 Apr May 25 Jun BLQ (before first drug administration) no plasma concentration obtained within time window 07 Feb A AO 4 14 Feb A AO Mar A AO 5 27 Mar A AO Mar A AO 9 11 Apr A AO 9 28 Apr A AO 5 A AO 13 enoxaparin 06Feb to 07Feb enoxaparin 06Feb to 07Feb heparin 04 Apr ; 05Apr to 06Apr heparin 19Apr 14

16 Pericardial 21 Sep Sep 300mg bid A AO May Pericardial Warfarin 20 May INR 2.3 A AO Pericardial Warfarin study drug not yet started 23 Aug INR Aug A AO 6 28Aug to 30Aug enoxaparin 09May to 12May 17Aug to 08Sep BLQ=Below limit of quantification; ITT = intention to treat analysis; AO = aortic; MI = mitral. *There were no major bleeding events observed in the extension trial. All major bleeding events occurred in Population A patients. The lower limit of quantitation for the assay was 1.0 ng/ml. Assay accuracy and precision were within 9.1 % and 13.8 % respectively. 15

17 References to Supplementary appendix 1) Reilly PA, Lehr T, Haertter S, et al. The Effect of Plasma Concentrations and Patient Characteristics on the Frequency of Ischemic Stroke and Major Bleeding in Atrial Fibrillation Patients in the RE-LY Trial. JACC 2013, in press. 2) Vahanian A, Alfieri O, Andreotti F, et al. Guidelines of the management of valvular heart disease (version ). The joint task force of the management of valvular heart disease of the Eureopean Society of Cardiology (ESC) and the European Association for Cardio-thoracic Surgery (EACTS). Eur Heart J ;33: ) Liesenfeld KH, Lehr T, Dansirikul C, et al. Population pharmacokinetic analysis of the oral thrombin inhibitor dabigatran etexilate in patients with non-valvular atrial fibrillation from the RE-LY trial. J Thromb Haemost. 2011;9: