A Randomized Phase II Open Label Study to Compare the Safety and Efficacy of Subcutaneous Dalteparin Versus Direct Oral Anticoagulants for Cancer-associated Venous Thromboembolism

Study Overview
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Brief Summary
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This is an open label, multi-center, and randomized phase II trial designed to compare the safety and efficacy of direct oral anticoagulants and subcutaneous dalteparin in patients with acute venous thromboembolism and upper gastrointestinal, hepatobiliary, or pancreatic cancer, based on a group sequential design. Enrolled patients will be randomized in a 1:1 ratio. Patients will be stratified by performance status, type of cancer, chemotherapy and medical centers.

Detailed Description
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This randomized II clinical trial will enrol patients with advanced upper gastrointestinal, hepatobiliary and pancreatic cancer who have venous thromboembolism (VTE), including pulmonary embolism and deep vein thrombosis. Patients will be randomized in a 1:1 ratio and stratified by performance status, type of cancer and medical centers. The enrolled patients will receive either subcutaneous dalteparin or DOAC(rivaroxaban, apixavan) according to randomization until the end of planned treatment schedules (six months), recurrence of VTE, clinical relevant bleeding, major bleeding, death or discontinuation of study treatment for any other reason (e.g. withdrawal of consent or discretion of the investigator). The primary end-point is the rate of clinical relevant bleeding event as defined as overt bleeding which was associated with medical intervention. In addition to time to clinical relevant bleeding event, time to event of major bleeding, total bleeding including minor event, time to recurrent VTE, overall bleeding rate and overall VTE recurrent rate will be analyzed to compare safety and efficacy of both anticoagulants. The final analysis will be conducted when the last enrolled patient has an event or has completed as least six months follow up in the study. Patients without bleeding and recurrent VTE events at data cut-off are censored at the last date the patient is known to be free of events. Planned interim analysis will be conducted in the intentions to treatment analysis set. The interim analysis for the randomized portion of the study will be performed when at least 40% of estimated bleeding events have been observed. The purpose of interim analysis is for early stopping of the study for safety. This study will use a Data Monitoring Committee.

Official Title
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A Randomized Phase II Open Label Study to Compare the Safety and Efficacy of Subcutaneous Dalteparin Versus Direct Oral Anticoagulants for Cancer-associated Venous Thromboembolism in Patients With Advanced Upper Gastrointestinal, Hepatobiliary and Pancreatic Cancer: PRIORITY

Conditions
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Cancer-associated Thrombosis, Esophageal Cancer, Stomach Cancer, Hepatocellular Carcinoma, Pancreatic Cancer, Duodenal Cancer, Esophagogastric Junction Cancer, Malignant Gastrointestinal Stromal Tumor, Ampulla of Vater Cancer, Biliary Cancer (Cholangiocarcinoma, Gall Bladder Cancer)

Intervention / Treatment
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* Drug: Rivaroxaban
* Drug: Dalteparin
* Drug: apixaban


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Histologically or cytologically confirmed locally advanced or metastatic active cancer including Esophageal cancer, Esophagogastric junction cancer, Stomach cancer, Gastrointestinal stromal disease, Ampulla of Vater cancer, Duodenal cancer, Hepatocelluar carcinoma, Biliary cancer (cholangiocarcinoma, gall bladder cancer), Pancreatic cancer Newly diagnosed deep vein thrombosis in any site and/or pulmonary thromboembolism on the basis of CT or doppler ultrasound image with or without symptoms Male or female ≥ 18 years, < 80 years old age Adequate major organ function including the following: Hematopoietic function: Platelet ≥ 75,000/mm3, Hepatic function: alanine aminotransferase levels 3 x upper limit of normal (if, with liver metastasis, alanine aminotransferase levels 5 x upper limit of normal), Aspartate Transaminase levels 3 x upper limit of normal (if, with liver metastasis, Aspartate Transaminase levels 5 x upper limit of normal), Renal function: estimated glomerular filtration rate ≥ 30 ml/min, Adequate coagulation time: prothrombin time ≤ 2 international normalized ratio, activated partial thromboplastin time 1.5 x upper limit of normal Able to understand and comply with the requirement of the study and to provide written informed consent Exclusion Criteria: Patients will be excluded from the study for any of the following reasons: Hemodynamically unstable pulmonary thromboembolism Use with P-gp and strong CYP3A4 Inhibitors (e.g., ketoconazole, itraconazole, lopinavir/ritonavir, ritonavir, indinavir/ritonavir, and conivaptan) or inducers (e.g., carbamazepine, phenytoin, rifampin, St. John's wort) Lack of physical integrity of the upper gastrointestinal tract or malabsorption syndrome (e.g. patients with partial or total gastrectomy can enter the study, but not those with a jejunostomy probe), or inability to take oral medication Patients with current bleeding Recent history of major or uncontrolled bleeding within the previous 4 weeks Severe malnutrition, BMI < 16 Patients who are receiving a therapeutic dose of rivaroxaban, low molecular weight heparin, fondaparinux, or unfractionated heparin for more than 72 hours before enrollment Administration of a fibrinolytic agent for treatment of the current episode Uncontrolled systolic blood pressure ≥ 180 mmHg or diastolic blood pressure ≥ 110 mmHg Patients who have to keep concurrent antiplatelet agent (e.g. aspirin, clopidogrel) Patients who have clinical significant liver cirrhosis (Child Pugh score ≥ 7) Inadequate cardiovascular function: New York Heart Association class III or IV heart disease, Unstable angina or myocardial infarction within the past 6 months, History of significant ventricular arrhythmia requiring medication with antiarrhythmics or significant conduction system abnormality Serious concurrent infection or nonmalignant illness that is uncontrolled or whose control may be jeopardized by complications of study therapy, including infective endocarditis History of or current brain metastases Life expectancy less than 3 months

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 80 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Low molecular weight heparin<br>Dalteparin, 200 IU/kg subcutaneously once daily for 4 weeks followed by 150 IU/kg once daily for 20 weeks | Drug: Dalteparin<br>* 200 IU/kg q24 hours for 4 weeks followed by 150 IU/kg q24 hours for 20 weeks<br>* Other names: Fragmin;|
| Experimental: Direct oral anticoagulant<br>Rivaroxaban, 15 mg orally twice daily for 3 weeks followed by 20mg once daily for 21 weeks Apixaban, 10 mg orally twice daily for 7days followed by 5mg twice daily for 21 weeks | Drug: Rivaroxaban<br>* 15 mg q12 hours for 3 weeks followed by 20mg q24 hours for 21 weeks<br>* Other names: Xarelto;Drug: apixaban<br>* 10 mg q12 hours for 7days followed by 5mg q12 hours for 21 weeks<br>* Other names: eliquis;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of clinical relevant bleeding | Clinically relevant bleeding: overt bleeding which was associated with medical intervention, unscheduled contact with a physician, interruption or discontinuation of anticoagulation, or associated with any other discomfort such as pain or impairment of activities of daily life, including major bleeding | 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of major bleeding | Major bleeding: Contributing to death, associated with a fall in hemoglobin ≧ 2 g/dL, or leading to transfusion of ≧ 2 units of red cells or if bleeding is intracranial, retroperitoneal, or another critical site. | 6 months | 
| Rate of total event of bleeding |  | 6 months | 
| Time to major bleeding event |  | 6 months | 
| Time to clinical relevant bleeding event |  | 6 months | 
| Time to total event of bleeding |  | 6 months | 
| Rate of recurrent or aggravated venous thromboembolism |  | 6 months | 
| Time to recurrent or aggravated venous thromboembolism |  | 6 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Anticoagulant Adverse Reaction, Cancer-associated Thrombosis, Low molecular weight heparin, Direct oral anticoagulant