Amantadine to Speed Awakening After Cardiac Arrest
Phase: PHASE2
Conditions: Coma, Heart Arrest, Anoxia
Sponsor: Jon Rittenberger, MD

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Amantadine to Speed Awakening After Cardiac Arrest (AWAKE) 
 
NCT02486211 
 
June 28, 2019 

4. RESEARCH DESIGN AND METHODS 
4.1 Design 
We will conduct a single-center randomized, controlled, double-blinded trial to determine the effect of 
amantadine administration in patients resuscitated from cardiac arrest who remain comatose at 
hospital day 3.  The primary outcome will be the rate of awakening (defined as following commands) 
during hospitalization.   
 
4.2 Recruitment and Informed Consent:  
The Post-Cardiac Arrest Service treats over 90% of patients successfully resuscitated from cardiac 
arrest at UPMC Presbyterian Hospital, ensuring that the PI will care for all potential candidates as 
part of his clinical duties.  Potential subjects who remain comatose for 48 hours will be unable to 
provide informed consent.  Therefore, the investigators will approach family or legally authorized 
representatives to provide consent as a proxy for the subject.  The investigators will already have a 
relationship with these proxies, and we have previously recruited 50% of potentially eligible subjects 
into studies in this setting. [30, 31]   
 
4.3 Inclusion and Exclusion Criteria are listed in Table 2.   
 
4.4 Randomization 
After informed consent, subjects will 
be randomly assigned to either 
amantadine or placebo.  For 
intention-to-treat analysis, subjects 
will be considered to be randomized 
as soon as an assignment in made.  
For per-protocol analyses, subjects 
will be considered to be randomized 
after receiving the first dose of study 
medication.  The Investigational 
Drug Service (IDS) at the University 
of Pittsburgh will prepare and 
dispense study drug and maintain the block randomization list.  At randomization, subjects will be 
stratified by PCAC strata and presence of early malignant patterns on EEG recording (these EEG 
patterns must have stopped by time of randomization, because continued malignant EEG is an 
exclusion). Both of these have been associated with outcome. [2, 16, 32, 3.C.1.b]  
4.5 Intervention 
Subjects assigned to the intervention arm will receive a dose of 100mg of amantadine, 
administered twice daily (at 6 am and 12 noon) for up to 7 days. The timing selected reflects the 
standard times used in our neurologic intensive care unit for this medication.  Subjects assigned to 
the placebo arm will receive a dose of placebo that will appear identical to the amantadine. The 
amantadine and placebo will be made by the University of Pittsburgh IDS.   
4.6 Allocation Concealment 
Amantadine and placebo will appear identical.  Drugs will be only have numerical identifiers when 
handled by the treating nurse and team.  Unblinding can be provided to the treating team by the IDS 
only after consultation with the principle investigator or in predefined emergency situations.  These 
Table 2. Inclusion and Exclusion Criteria 
Inclusion Criteria 
Exclusion Criteria 
Non-traumatic cardiac arrest 
Written do not attempt resuscitation (DNAR) 
reported to providers before randomization 
Age 18 years or more 
Known prisoner or pregnancy 
Defibrillation and/or chest 
compressions by healthcare 
providers 
Lack of motor response to pain and absent 
N20 response on SSEP prior to 
randomization. 
Return of spontaneous circulation 
Initial CT demonstrating brain edema 
(defined as grey white ratio <1.2) 
 
Presence of malignant pattern on EEG at 
time of randomization. 
 
Next of kin unwilling to provide supportive 
care for at least one week after enrollment. 
 
Creatinine clearance <50mL/min 
 
Presently using other dopaminergic agent 

situations include severe allergic reactions not attributable to any other drug or unexplained 
tachydysrhythmia requiring cardioversion. 
4.7 Justification for Timing of Intervention 
One side effect of temperature management is a decrease in gastrointestinal motility.  This returns to 
normal in the majority of patients after rewarming is completed.  This will occur by 72 hours.  As 
amantadine is only available in an oral form, decreased gastrointestinal motility could affect 
absorption.  As noted in the preliminary data above, development and persistence of malignant EEG 
patterns is associated with poor neurologic outcome independent of initial illness severity. [Section 
3.C.1.b]  This design will allow these patients to be diagnosed with persistent malignant EEG patterns 
and excluded from the study. 
4.8 Pharmacokinetic Measurements 
Plasma concentrations of amantadine will be determined using solid phase extraction and a validated 
ultra-high performance liquid chromatography tandem mass spectrometry adapted from Arndt et al. 
[33] A 5 ml sample of blood will be obtained in citrated tubes, centrifuged (1000g x 15 minutes), 
decanted, and plasma frozen at -80ºC until assay. Sampling will occur at 8 time points; daily “peak” 
levels 1-2 h following the afternoon dose on days 1-4 and “trough” levels immediately prior to 6 AM 
dose on days 2-5. This sampling strategy is designed to both confirm enteral absorption and to permit 
post-hoc analyses of any differential effect of amantadine based on plasma levels achieved in the 
study. The 4 days of sampling will capture steady-state levels (amantadine half-live is ~17 h) and also 
spans the period of greatest vulnerability for hypothermia-induced changes in drug pharmacokinetics 
if they should occur. 
4.9 Monitoring of Compliance:  
Dr. Rittenberger leads a unique 
Post-Cardiac Arrest Service that 
has cared for this population 
since 2007.  This ensures 
standardization of prognostic 
workup and clinical care outside 
of the care delineated in this 
study protocol.  At enrollment, a 
trained research assistant will 
prospectively record pertinent 
information on the subject.  The 
research assistant will also 
facilitate obtaining study drug 
from IDS to ensure drug 
administration in a timely 
fashion.  The PI will perform 
random data spot checks, audits 
and will oversee the database 
and maintain quality. 
4.10 Ancillary Care  
It is critical to control for potential 
effect modifiers that occur when a patient is hospitalized after resuscitation from cardiac arrest. 
Table 3.  EEG and seizure definitions. MSE- myoclonic status epilepticus, 
GPEDs- generalized periodic epileptiform discharges, NCSE- nonconvulsive 
status epilepticus, EDs- epileptiform discharges. 
Interpretation 
Definition 
Electrographic 
seizure 
Repetitive generalized or focal spikes, sharp waves, 
spike-and-wave or sharp-slow wave complexes at ≥ 3Hz 
or sequential rhythmic, periodic or quasi-periodic waves at 
≥ 1Hz with unequivocal evolution in frequency, 
morphology, or location lasting at least 10 seconds. 
NCSE 
Impaired consciousness with: 
1. A continuous single electrographic seizure lasting 
30 minutes or greater or recurrent electrographic 
seizures lasting for over 30 minutes. 
2. Presence of GPEDs lasting at least 30 minutes at 
a rate ≥2.5 Hz. 
3. Presence of GPEDs lasting at least 30 minutes at 
a rate of ≥1 Hz with unequivocal evolution in 
frequency, morphology, or location over time. 
MSE 
More than 30-minute period of myoclonic jerks or subtle 
facial movements locked in with bursts in a burst-
suppression pattern or associated with GPEDs.  
Interictal GPEDs 
GPEDs at a rate of < 2.5 Hz not satisfying criteria 3 
EDs 
Spikes, polyspikes, sharp waves, spike-and wave or 
sharp-slow waves occurring independently, periodically 
(GPEDs) or during burst-suppression. 

Experts have recommended a standardized approach that includes targeted temperature 
management to optimize outcomes following cardiac arrest. [4, 8, 17]  Our prior work has 
demonstrated that initial critical care management of the post-cardiac arrest patient has a large 
influence on neurological recovery and survival. [5, 26]  Case control studies have reported improved 
outcomes in patients receiving combinations of hospital-based treatments compared to historical 
controls. [5, 24]  We have shown that early use of coronary angiography and primary PCI is 
associated with good neurologic prognosis. [6, 8, 34]  Our work through the ROC cardiac arrest 
registry has demonstrated that patients who were treated to a receiving hospital that had a coronary 
catheterization laboratory had better outcomes compared to those who were not. [8]  Collectively, 
these studies demonstrate that hospital-based care of those resuscitated from cardiac arrest impacts 
patient outcomes and may modify the effect of interventions for cardiac arrest. We have addressed 
this issue for all subjects will be cared for by the Post Cardiac Arrest Service at UPMC-Presbyterian 
and receive standardized post arrest care delivered by the Post Cardiac Arrest Service.   
4.11 EEG Protocol  
We obtain a 22-channel digital EEG with simultaneous video recording on all patients resuscitated 
from cardiac arrest in our facility. This permits correlation of motor activity with electrographic findings 
and allows for accurate diagnosis of malignant EEG patterns.  Contemporaneous interpretation is 
provided by the Department of Neurology.  Subjects will be classified as demonstrating a malignant 
pattern or not using standard definitions. [Table 3]  Locally, the PCAC II illness severity phenotype 
with malignant EEG patterns has a 
markedly reduced survival when 
compared to PCAC II illness severity 
without malignant EEG patterns. 
Thus, subjects will be stratified on 
PCAC and (in the PCAC II illness 
severity subjects) presence of 
malignant EEG pattern prior to 
randomization.  If malignant patterns 
do develop, we will provide therapy to 
suppress the EEG and any clinical 
evidence of seizures. [Figure 3] This 
ensures a standard approach to all 
subjects in the study.  Importantly, 
subjects with malignant EEG patterns 
that persist beyond 48 hours are 
excluded from the study and will not 
be enrolled.  
4.12 Justification for Outcome Measures  
We have chosen the rate of awakening as the primary outcome in this study.  This short-term 
outcome is appropriate to determine if a potential for benefit exists. [35]  Awakening is a prerequisite 
for a good neurologic outcome. [17]  Persistent coma is the most common reason for withdrawal of 
care (56%) while multiple organ failure is the etiology of death in a minority (17%) of patients. [2].  
Prior literature is hindered by withdrawal of support in patients who remain comatose.  Achievement 
of awakening will likely increase the family’s interest in continuing supportive care for this population. 
Consequently it is critical to evaluate rate of awakening and time to awakening in both an 
intervention and placebo group as delaying time to withdrawal may independently increase the rate of 
awakening. 

Awakening is an appropriate short-term outcome as subjects who awaken survive and comprise all 
good outcomes by definition of CPC or mRS.  Most tend to improve in functional status over the year 
after hospitalization. [19]  Two-thirds of patients who awaken but do not survive to discharge die from 
multiple organ failure.  This investigation proposes an early neurologic intervention that is unlikely to 
improve other organ failure.  Thus, we 
have chosen a short-term neurologic 
outcome to maximize detection of a 
neurologic benefit to this intervention.  
If the rate of awakening is higher in 
the treatment arm, the face value of 
awakening would probably prompt 
clinicians to adopt the treatment. 
Furthermore, a larger trial powered to 
evaluate a treatment effect on long-
term functional outcomes might be 
justified. 
4.13 Daily Examinations 
A study physician will complete a 
neurologic examination upon hospital 
arrival and again once the subject has rewarmed to a core temperature of >36°C.  [Table 4]  The 
initial examination is used to determine the category of initial illness severity. [2]  Daily examinations 
will not be performed until sedative medications have been discontinued for at least 40 minutes. [36] 
Our facility uses propofol for the majority of patients.   In subjects receiving continuous infusion of 
midazolam, the midazolam will be discontinued for 60 minutes before examination. In the rare 
instance of neuromuscular blockade use, examinations will not be completed until the train of four 
monitor reads 4/4.  Following rewarming, this examination will be completed daily.  Prior literature has 
demonstrated that individual findings are less predictive for outcome in the modern era, thus, no one 
finding will result in cessation of support. [7, 37, 38]  
4.14 Prognostic Evaluation  
Prior literature has demonstrated that 
individual physical exam or test 
findings are insufficient to preclude a 
good outcome. Therefore, no single 
finding will result in cessation of 
support. [7, 37, 38] A multimodal 
workup will be employed to predict 
neurologic outcome.  This includes 
clinical examination, continuous EEG 
monitoring, computerized tomography, 
somatosensory evoked potentials, and 
magnetic resonance imaging. [Figure 4]  The clinical examination is described in Table 4.  
Continuous EEG monitoring is described above. 
4.14.a Computerized tomography of the brain- Loss of grey-white differentiation (gray-white ratio of 
Hounsfeld Units <1.2) on initial CT of the brain predicts survival and neurologic outcome following 
cardiac arrest. [39-41] Subjects with a grey-white ratio <1.2 will be excluded from the study. 

4.14.b Somatosensory evoked potentials- Subjects without a motor response to painful stimuli (GCS 
Motor=1) at 72 hours following cardiac arrest will have SSEP’s obtained as part of the standard 
protocol.  A lack of N20 response bilaterally remains predictive for a poor neurologic outcome 
following cardiac arrest. [42] 
4.14.c Magnetic Resonance Imaging- Subjects who remain unconscious for >72 hours after cardiac 
arrest may receive MRI of the brain.  Whole brain ADC mapping <750 x10-6 mm2/sec has been 
associated with a mRS of >3 in prior work. [43] 
4.14.d Neuronal Specific Enolase/S100B- These are not available clinically in our local facilities and 
have varying associations with neurologic outcome. [7, 42, 44]   
4.15 Statistical Analysis 
4.15.a Random Assignment 
Those eligible for the study will be randomly assigned with equal probability to the experimental 
condition (amantadine) or the control condition (placebo).  Random assignment will be stratified by 
cardiac arrest category (PCAC) and presence of malignant EEG patters (only in those with PCAC II), 
resulting in four strata:  PCAC IV, PCAC III, PCAC II with malignant EEG patterns, and PCAC II 
without malignant EEG patterns. Survival markedly differs between these strata. [Section 3.C.1.b]  
To maximize the probability of a balanced design, assignments will occur in block of two and four 
within each stratum.  To ensure that the research team will be masked to the next treatment 
assignment, the size of the block will be randomly generated. 
Random assignment will occur through the University of Pittsburgh Investigational Drug Service 
(IDS).  Study staff will contact the IDS pharmacist, provide the necessary information (e.g., stratum) 
and the random assignment will be delivered.  Given the volume of clinical studies at the University of 
Pittsburgh, IDS pharmacy medications and randomization are available 24/7. 
4.15.b Data Analysis 
The data analysis will begin by describing the baseline characteristics of the population.  Summary 
statistics, such as means, standard deviations and frequencies will be generated.  Graphical 
techniques, such as scatter plots and box plots will be used to evaluate the distribution of the baseline 
characteristics.   
The balance of the baseline characteristics across treatment group will be compared.  For discrete 
characteristics a chi-square tests or Fisher’s exact test will be used to compare the proportions 
across treatment group.  For continuous measures, either t-tests or Wilcoxon tests will be used to 
compare the characteristics across treatment group.  
Aim 1, Hypothesis 1: Administration of amantadine after cardiac arrest will decrease time to 
awakening when compared to placebo during the 7 days of treatment. 
Kaplan-Meier curves will be generated for time-to-awakening for each treatment group and a log-rank 
statistic will be used to compare the cumulative probability of awakening across treatment groups.   
Those participants who are not awake by treatment day 7 will be considered censored observations.  
A Cox proportional hazards regression model will be used to compare time-to-awakening by 
treatment group controlling for baseline characteristics that are not balanced through random 
assignment and stratification variables.  The assumptions of the Cox proportional hazards model will 
be evaluated (proportionality of the hazards model) and if violated, a split analysis will be conducted. 

Aim 1, Hypothesis 2: A larger proportion of subjects will awaken during the first 7 days of treatment 
after administration of amantadine when compared to placebo. 
A chi-square test will be used to compare the proportion of participants that are awake at day 7 
between the two treatment groups.  Logistic regression model will be used to compare the 
proportions by treatment group controlling for baseline characteristics that are not balanced through 
random assignment and stratification variables. 
Aim 2: Determine if the number of serious adverse events differ between subjects randomized to 
amantadine and subjects randomized to placebo.   
It is anticipated that given the severe critical state of those enrolled in the study, each study 
participant will have multiple serious adverse events.  A t-test (or Wilcoxon test) will be used to 
compare the means number of serious adverse events that occurred during the 7 days after 
treatment initiation.  A regression model will be used to compare the means after controlling for 
baseline characteristics that are not balanced through random assignment and stratification variables.  
The type of regression model will depend in the distribution of the number of serious adverse events 
and could be a linear regression model, negative binomial model, or Poisson model. 
4.15.c Sample Size 
The sample size calculations are based on the analysis approach for the primary hypothesis (Aim 1, 
Hypothesis 1) with a type I error rate of 0.05, a two-sided alternative hypothesis, and 80% power.  
Based on these assumptions, a sample of 120 (60 per treatment group) will be sufficient to detect a 
difference of awakening of 30% in the control group and 50% in the active treatment group.