Desmopressin for Reversal of Antiplatelet Drugs in Stroke Due to Haemorrhage

Study Overview
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Brief Summary
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Haemorrhagic stroke, an emergency caused by bleeding in the brain, often leads to death or long-term disability. A quarter of these patients are taking blood-thinning drugs (antiplatelet drugs, such as aspirin) because they are at risk of a heart attack or ischaemic stroke. Patients taking these drugs are more likely to die or be disabled if they have a haemorrhagic stroke. At present, there is no effective treatment for reversing their effects. Desmopressin is a drug which may reverse the effects of antiplatelet drugs and stop bleeding. The investigators would like to run a large randomised trial to see if Desmopressin can reduce the number of people who die or are disabled after haemorrhagic stroke.

Detailed Description
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Intracerebral haemorrhage is a medical emergency, caused by a blood vessel bleeding directly into the brain. Outcome is directly related to the amount of bleeding that occurs. Many patients die early and others are left with significant disability. A quarter of all people with intracerebral haemorrhage are taking an antiplatelet drug, which is associated with larger volumes of brain haemorrhage and significantly worse outcomes. Four to five million people are taking antiplatelet drugs in the UK and use continues to rise in an ageing population. Despite advances in treatment of ischaemic stroke, there is no effective drug treatment for intracerebral haemorrhage. Treatment for intracerebral haemorrhage has been identified as a priority area by Stroke Association and stroke survivors. Desmopressin is a drug that reverses blood thinning effects of antiplatelet drugs, by indirectly increasing platelet adhesion, which the investigators hypothesise will minimise the devastating consequences of intracerebral haemorrhage associated with antiplatelet drugs. Desmopressin is commonly used in patients with inherited platelet dysfunction disorders and is an appealing treatment for antiplatelet-associated intracerebral haemorrhage. A recent systematic review did not find any randomised controlled trials evaluating desmopressin for antiplatelet-associated intracerebral haemorrhage. Desmopressin is affordable, available and could be implemented clinically across the UK and worldwide in the next five years with immediate benefit for stroke patients, their families and society.

Official Title
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Desmopressin for Reversal of Antiplatelet Drugs in Stroke Due to Haemorrhage (DASH)

Conditions
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Stroke, Acute

Intervention / Treatment
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* Drug: Desmopressin Injection
* Drug: Normal saline


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Adults (≥18 years) Confirmed intracerebral haemorrhage on imaging Less than 24 hours from onset of symptoms [or from when last seen free of stroke symptoms] Prescribed and thought to be taking a daily oral antiplatelet drug in the preceding seven days (cyclooxygenase inhibitors, phosphodiesterase inhibitors or P2Y12 inhibitors) Signed consent (or waiver of consent). Exclusion Criteria: Aneurysmal subarachnoid haemorrhage known at time of enrolment Haemorrhage suspected to be due to transformation of ischaemic stroke Haemorrhage known to be due to thrombolytic drug Haemorrhage known to be due to venous thrombosis Risk/s of fluid retention associated with desmopressin judged clinically significant by the attending physician (for example patients with pulmonary oedema and/or cardiac failure) - - Significant hypotension (systolic blood pressure <90mmHg) Known drug-eluting coronary artery stent in previous three months Allergy to desmopressin Pregnant or breast-feeding Life expectancy less than four hours, or planned for palliative care only Glasgow coma scale less than 5, mRS >4.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 110 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: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Intervention<br>Desmopressin injection | Drug: Desmopressin Injection<br>* Single dose 20 micrograms in 50ml Normal Saline as intravenous injection infused over 20 minutes<br>|
| Placebo Comparator: Control<br>Normal Saline | Drug: Normal saline<br>* Single dose 50ml Normal Saline as intravenous injection infused over 20 minutes<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of eligible patients who received allocated treatment | Number - higher number indicates feasibility of trial | 90 days | 
| Rate of eligible patients randomised | Shorter period of time to recruit number of patients indicates trial is feasibility;e | 18 months | 
| Proportion of eligible patients and randomised | Are there sufficient numbers of patients to justify a larger trial | 18 months | 
| Proportion of participants followed up at 90 days | Higher number indicates feasibility | 90 days | 
| Proportion of patients with full outcome data available, and reasons for non-availability | Higher number indicates feasibility | 90 days | 
| Proportion of eligible patients approached | Higher number indicates feasibility | 18 months | 
| Adherence to intervention | Higher number indicates feasibility | 18 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Death or dependency at 90 days | Lower number indicates positive outcome | 18 months | 
| Number of patients dead or suffered serious adverse events | Number - higher number indicates worse outcome | Day 28 and 90 | 
| Change in intracerebral haemorrhage volume at 24 hours | Higher volume indicates worse outcome | 24 hours | 
| Disability - Barthel index | Scores range from 0 - 100, with lower scores indicating increased disability. | Day 90 | 
| Quality of life - EuroQol | Consists of two parts: a descriptive system (Part I) and a visual analogue scale (VAS) (Part II). Part 1 consists of 5 single-item dimensions. Scores range from 5 - 15 with lower scores indicating no problems to higher scores indicating extreme problems. Part II uses a vertical graduated VAS (thermometer) to measure health status, ranging from worst imaginable health state (0) to best imaginable health state (100). | Day 90 | 
| Cognition - telephone MMSE | Scores are out of 22, with lower scores indicating cognitive impairment | Day 90 | 
| Length of hospital stay | Number of days - higher number indicates longer length of stay | Day 90 | 
| Discharge destination | Destination of participant following discharge from hospital | 18 months | 
| Health Economic assessment (EQ5D) | Range 0-100, Higher score indicates better health | 90 Days | 
| Serious adverse events (including thromboembolic events) | Higher volume indicates worse outcome | Day 90 | 
| Change in factor vIII, Von Willebrand Factor antigen and Von Willebrand Factor activity will be assessed |  | One hour post administration of Desmopressin | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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intracerebral haemorrhage