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Sharma M, Molina CA, Toyoda K, Bereczki D, Bangdiwala SI, Kasner SE, Lutsep HL, Tsivgoulis G, Ntaios G, Czlonkowska A, Shuaib A, Amarenco P, Endres M, Yoon BW, Tanne D, Toni D, Yperzeele L, von Weitzel-Mudersbach P, Sampaio Silva G, Avezum A, Dawson J, Strbian D, Tatlisumak T, Eckstein J, Ameriso SF, Weber JR, Sandset EC, Goar Pogosova N, Lavados PM, Arauz A, Gailani D, Diener HC, Bernstein RA, Cordonnier C, Kahl A, Abelian G, Donovan M, Pachai C, Li D, Hankey GJ. Safety and efficacy of factor XIa inhibition with milvexian for secondary stroke prevention (AXIOMATIC-SSP): a phase 2, international, randomised, double-blind, placebo-controlled, dose-finding trial. Lancet Neurol 2024; 23:46-59. [PMID: 38101902 PMCID: PMC10822143 DOI: 10.1016/s1474-4422(23)00403-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 10/02/2023] [Accepted: 10/06/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND People with factor XI deficiency have lower rates of ischaemic stroke than the general population and infrequent spontaneous bleeding, suggesting that factor XI has a more important role in thrombosis than in haemostasis. Milvexian, an oral small-molecule inhibitor of activated factor XI, added to standard antiplatelet therapy, might reduce the risk of non-cardioembolic ischaemic stroke without increasing the risk of bleeding. We aimed to estimate the dose-response of milvexian for recurrent ischaemic cerebral events and major bleeding in patients with recent ischaemic stroke or transient ischaemic attack (TIA). METHODS AXIOMATIC-SSP was a phase 2, randomised, double-blind, placebo-controlled, dose-finding trial done at 367 hospitals in 27 countries. Eligible participants aged 40 years or older, with acute (<48 h) ischaemic stroke or high-risk TIA, were randomly assigned by a web-based interactive response system in a 1:1:1:1:1:2 ratio to receive one of five doses of milvexian (25 mg once daily, 25 mg twice daily, 50 mg twice daily, 100 mg twice daily, or 200 mg twice daily) or matching placebo twice daily for 90 days. All participants received clopidogrel 75 mg daily for the first 21 days and aspirin 100 mg daily for the first 90 days. Investigators, site staff, and participants were masked to treatment assignment. The primary efficacy endpoint was the composite of ischaemic stroke or incident covert brain infarct on MRI at 90 days, assessed in all participants allocated to treatment who completed a follow-up MRI brain scan, and the primary analysis assessed the dose-response relationship with Multiple Comparison Procedure-Modelling (MCP-MOD). The main safety outcome was major bleeding at 90 days, assessed in all participants who received at least one dose of the study drug. This trial is registered with ClinicalTrials.gov (NCT03766581) and the EU Clinical Trials Register (2017-005029-19). FINDINGS Between Jan 27, 2019, and Dec 24, 2021, 2366 participants were randomly allocated to placebo (n=691); milvexian 25 mg once daily (n=328); or twice-daily doses of milvexian 25 mg (n=318), 50 mg (n=328), 100 mg (n=310), or 200 mg (n=351). The median age of participants was 71 (IQR 62-77) years and 859 (36%) were female. At 90 days, the estimates of the percentage of participants with either symptomatic ischaemic stroke or covert brain infarcts were 16·8 (90·2% CI 14·5-19·1) for placebo, 16·7 (14·8-18·6) for 25 mg milvexian once daily, 16·6 (14·8-18·3) for 25 mg twice daily, 15·6 (13·9-17·5) for 50 mg twice daily, 15·4 (13·4-17·6) for 100 mg twice daily, and 15·3 (12·8-19·7) for 200 mg twice daily. No significant dose-response was observed among the five milvexian doses for the primary composite efficacy outcome. Model-based estimates of the relative risk with milvexian compared with placebo were 0·99 (90·2% CI 0·91-1·05) for 25 mg once daily, 0·99 (0·87-1·11) for 25 mg twice daily, 0·93 (0·78-1·11) for 50 mg twice daily, 0·92 (0·75-1·13) for 100 mg twice daily, and 0·91 (0·72-1·26) for 200 mg twice daily. No apparent dose-response was observed for major bleeding (four [1%] of 682 participants with placebo, two [1%] of 325 with milvexian 25 mg once daily, two [1%] of 313 with 25 mg twice daily, five [2%] of 325 with 50 mg twice daily, five [2%] of 306 with 100 mg twice daily, and five [1%] of 344 with 200 mg twice daily). Five treatment-emergent deaths occurred, four of which were considered unrelated to the study drug by the investigator. INTERPRETATION Factor XIa inhibition with milvexian, added to dual antiplatelet therapy, did not substantially reduce the composite outcome of symptomatic ischaemic stroke or covert brain infarction and did not meaningfully increase the risk of major bleeding. Findings from our study have informed the design of a phase 3 trial of milvexian for the prevention of ischaemic stroke in patients with acute ischaemic stroke or TIA. FUNDING Bristol Myers Squibb and Janssen Research & Development.
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Affiliation(s)
- Mukul Sharma
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
| | | | - Kazunori Toyoda
- National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | | | - Shrikant I Bangdiwala
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Helmi L Lutsep
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - Georgios Tsivgoulis
- Second Department of Neurology, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - George Ntaios
- Department of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Anna Czlonkowska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Ashfaq Shuaib
- Division of Neurology, Department of Medicine, University of Alberta Hospital, Edmonton, AB, Canada
| | - Pierre Amarenco
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Department of Neurology and Stroke Center, University of Paris, Bichat Hospital, Paris, France
| | - Matthias Endres
- Department of Neurology and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Byung-Woo Yoon
- Uijeongbu Eulji Medical Center, Eulji University, Gyeonggi-do, South Korea
| | - David Tanne
- Stroke and Cognition Institute, Rambam Health Care Campus, Haifa, Technion, Israel
| | - Danilo Toni
- Emergency Department Stroke Unit, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Laetitia Yperzeele
- Stroke Unit and Neurovascular Center Antwerp, Department of Neurology, Antwerp University Hospital, Antwerp (Edegem), Belgium
| | | | - Gisele Sampaio Silva
- Universidade Federal de São Paulo/UNIFESP and Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Alvaro Avezum
- Centro Internacional de Pesquisa, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Jesse Dawson
- School of Cardiovascular and Metabolic Health, College of Medical, Veterinary & Life Sciences, Queen Elizabeth University Hospital, Glasgow, UK
| | - Daniel Strbian
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Clinical Neuroscience/Neurology, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jens Eckstein
- Department of Internal Medicine and Department of Digitalization & ICT, University Hospital Basel, Basel, Switzerland
| | - Sebastián F Ameriso
- Servicio de Neurología Vascular, Departamento de Neurología, FLENI, Buenos Aires, Argentina
| | - Joerg R Weber
- Department of Neurology, Klinikum Klagenfurt, Austria
| | - Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital and The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Nana Goar Pogosova
- National Medical Research Center of Cardiology after E Chazov, Moscow, Russia
| | - Pablo M Lavados
- Departamento de Neurología y Psiquiatría, Unidad de Investigación y Ensayos Clínicos, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Antonio Arauz
- Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, México City, México
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hans-Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), University Duisburg-Essen, Essen, Germany
| | - Richard A Bernstein
- Davee Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Charlotte Cordonnier
- University of Lille, Lille, Inserm, CHU Lille, U1172 - LiINCog - Lille Neuroscience & Cognition, F-59000, Lille, France
| | - Anja Kahl
- Bristol Myers Squibb, Princeton, NJ, USA
| | | | | | | | - Danshi Li
- Bristol Myers Squibb, Princeton, NJ, USA
| | - Graeme J Hankey
- Medical School, Centre for Neuromuscular and Neurological Disorders, The University of Western Australia, Perth, WA, Australia; Perron Institute for Neurological and Translational Science, Perth, Australia
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Strilciuc S, Radu C, Grad DA, Stan AD, Vladescu C, Buzoianu AD, Muresanu D. Cost-Effectiveness of Cerebrolysin after Ischemic Stroke: Secondary Analysis of the CARS Study. Healthcare (Basel) 2023; 11:healthcare11101497. [PMID: 37239783 DOI: 10.3390/healthcare11101497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/08/2023] [Accepted: 05/18/2023] [Indexed: 05/28/2023] Open
Abstract
The cost-effectiveness of Cerebrolysin as an add-on therapy for moderate-severe acute ischemic stroke is a topic that remains understudied. This study aims to address this gap by performing a comprehensive cost-utility analysis using both deterministic and probabilistic methods from a payer perspective and within the Romanian inpatient care setting. Quality-adjusted life years (QALYs) were calculated using partial individual patient data from the 2016 Cerebrolysin and Recovery After Stroke (CARS) trial, utilizing three different health state valuation models. Cost data was extracted from actual acute care costs reported by Romanian public hospitals for reimbursement purposes for patients included in the CARS study. Incremental cost-effectiveness ratios were calculated for each treatment arm for the duration of the clinical trial. Deterministic analysis based on sample mean values indicates Cerebrolysin would be cost-effective at a threshold between roughly 18.8 and 29.9 thousand EUR, depending on valuation techniques. Probabilistic sensitivity analysis results indicate an 80% chance probability of cost-effectiveness of Cerebrolysin as an add-on therapy for acute ischemic stroke, considering a willingness-to-pay threshold of 50,000 EUR in a 90-day timeframe after stroke. Further economic evaluations of Cerebrolysin are needed to strengthen these findings, covering a timeframe of at least 12 months after the acute incident, which would account for treatment effects spanning beyond the first 90 days after ischemic stroke. These should be conducted to determine its cost-effectiveness under various care settings and patient pathways. Most importantly, modelling techniques are needed to answer important questions such as the estimates of population gain in QALYs after acute administration of Cerebrolysin and the potential offsetting of direct medical costs as a result of administering the intervention.
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Affiliation(s)
- Stefan Strilciuc
- Department of Neuroscience, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, 400364 Cluj-Napoca, Romania
- Department of Public Health, Faculty of Political, Administrative and Communication Sciences, Babes-Bolyai University, 400084 Cluj-Napoca, Romania
| | - Constantin Radu
- Yale School of Public Health, Yale University, New Haven, CT 06520, USA
| | - Diana-Alecsandra Grad
- RoNeuro Institute for Neurological Research and Diagnostic, 400364 Cluj-Napoca, Romania
- Department of Public Health, Faculty of Political, Administrative and Communication Sciences, Babes-Bolyai University, 400084 Cluj-Napoca, Romania
| | - Adina Dora Stan
- Department of Neuroscience, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, 400364 Cluj-Napoca, Romania
| | - Cristian Vladescu
- National Institute for Management of Health Services, 021254 București, Romania
- Faculty of Medicine, Titu Maiorescu University, 031595 București, Romania
| | - Anca Dana Buzoianu
- Department of Clinical Pharmacology, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Dafin Muresanu
- Department of Neuroscience, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, 400364 Cluj-Napoca, Romania
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