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Casella JF, Barton BA, Kanter J, Black LV, Majumdar S, Inati A, Wali Y, Drachtman RA, Abboud MR, Kilinc Y, Fuh BR, Al-Khabori MK, Takemoto CM, Salman E, Sarnaik SA, Shah N, Morris CR, Keates-Baleeiro J, Raj A, Alvarez OA, Hsu LL, Thompson AA, Sisler IY, Pace BS, Noronha SA, Lasky JL, de Julian EC, Godder K, Thornburg CD, Kamberos NL, Nuss R, Marsh AM, Owen WC, Schaefer A, Tebbi CK, Chantrain CF, Cohen DE, Karakas Z, Piccone CM, George A, Fixler JM, Singleton TC, Moulton T, Quinn CT, de Castro Lobo CL, Almomen AM, Goyal-Khemka M, Maes P, Emanuele M, Gorney RT, Padgett CS, Parsley E, Kronsberg SS, Kato GJ, Gladwin MT. Effect of Poloxamer 188 vs Placebo on Painful Vaso-Occlusive Episodes in Children and Adults With Sickle Cell Disease: A Randomized Clinical Trial. JAMA 2021; 325:1513-1523. [PMID: 33877274 PMCID: PMC8058640 DOI: 10.1001/jama.2021.3414] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Although effective agents are available to prevent painful vaso-occlusive episodes of sickle cell disease (SCD), there are no disease-modifying therapies for ongoing painful vaso-occlusive episodes; treatment remains supportive. A previous phase 3 trial of poloxamer 188 reported shortened duration of painful vaso-occlusive episodes in SCD, particularly in children and participants treated with hydroxyurea. OBJECTIVE To reassess the efficacy of poloxamer 188 for vaso-occlusive episodes. DESIGN, SETTING, AND PARTICIPANTS Phase 3, randomized, double-blind, placebo-controlled, multicenter, international trial conducted from May 2013 to February 2016 that included 66 hospitals in 12 countries and 60 cities; 388 individuals with SCD (hemoglobin SS, SC, S-β0 thalassemia, or S-β+ thalassemia disease) aged 4 to 65 years with acute moderate to severe pain typical of painful vaso-occlusive episodes requiring hospitalization were included. INTERVENTIONS A 1-hour 100-mg/kg loading dose of poloxamer 188 intravenously followed by a 12-hour to 48-hour 30-mg/kg/h continuous infusion (n = 194) or placebo (n = 194). MAIN OUTCOMES AND MEASURES Time in hours from randomization to the last dose of parenteral opioids among all participants and among those younger than 16 years as a separate subgroup. RESULTS Of 437 participants assessed for eligibility, 388 were randomized (mean age, 15.2 years; 176 [45.4%] female), the primary outcome was available for 384 (99.0%), 15-day follow-up contacts were available for 357 (92.0%), and 30-day follow-up contacts were available for 368 (94.8%). There was no significant difference between the groups for the mean time to last dose of parenteral opioids (81.8 h for the poloxamer 188 group vs 77.8 h for the placebo group; difference, 4.0 h [95% CI, -7.8 to 15.7]; geometric mean ratio, 1.2 [95% CI, 1.0-1.5]; P = .09). Based on a significant interaction of age and treatment (P = .01), there was a treatment difference in time from randomization to last administration of parenteral opioids for participants younger than 16 years (88.7 h in the poloxamer 188 group vs 71.9 h in the placebo group; difference, 16.8 h [95% CI, 1.7-32.0]; geometric mean ratio, 1.4 [95% CI, 1.1-1.8]; P = .008). Adverse events that were more common in the poloxamer 188 group than the placebo group included hyperbilirubinemia (12.7% vs 5.2%); those more common in the placebo group included hypoxia (12.0% vs 5.3%). CONCLUSIONS AND RELEVANCE Among children and adults with SCD, poloxamer 188 did not significantly shorten time to last dose of parenteral opioids during vaso-occlusive episodes. These findings do not support the use of poloxamer 188 for vaso-occlusive episodes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01737814.
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Affiliation(s)
- James F. Casella
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Julie Kanter
- Medical University of South Carolina, Charleston
- University of Alabama at Birmingham, Birmingham
| | - L. Vandy Black
- Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana
- University of Florida College of Medicine, Gainesville
| | - Suvankar Majumdar
- University of Mississippi Medical Center, Jackson
- Children’s National Hospital, Washington, DC
| | - Adlette Inati
- Lebanese American University, Byblos and Beirut, Lebanon
- Nini Hospital, Tripoli, Lebanon
| | | | | | | | - Yurdanur Kilinc
- Çukurova University Medical Faculty Balcali Hospital, University of Çukurova, Adana, Turkey
| | - Beng R. Fuh
- East Carolina University, Greenville, North Carolina
| | | | - Clifford M. Takemoto
- Johns Hopkins University School of Medicine, Baltimore, Maryland
- St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Emad Salman
- Golisano Children’s Hospital of Southwest Florida, Ft Myers
| | - Sharada A. Sarnaik
- Wayne State University School of Medicine, Detroit, Michigan
- Children’s Hospital of Michigan, Detroit
| | - Nirmish Shah
- Duke University School of Medicine, Durham, North Carolina
| | - Claudia R. Morris
- Emory University School of Medicine, Atlanta, Georgia
- Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | - Ashok Raj
- University of Louisville/Norton Children’s Hospital, Louisville, Kentucky
| | | | | | - Alexis A. Thompson
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Evanston, Illinois
| | - India Y. Sisler
- Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond
| | | | - Suzie A. Noronha
- University of Rochester School of Medicine and Dentistry, Golisano Children’s Hospital at University of Rochester Medical Center, Rochester, New York
| | - Joseph L. Lasky
- Harbor-UCLA Medical Center, Torrance, California
- Cure 4 The Kids Foundation, Las Vegas, Nevada
| | - Elena Cela de Julian
- Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Courtney Dawn Thornburg
- Rady Children’s Hospital - San Diego, San Diego, California
- UC San Diego School of Medicine, La Jolla, California
| | - Natalie L. Kamberos
- University of Iowa Children’s Hospital, Iowa City
- Loyola University Medical Center, Maywood, Illinois
| | - Rachelle Nuss
- Children’s Hospital Colorado, University of Colorado, Aurora
| | - Anne M. Marsh
- UCSF Benioff Children’s Hospital Oakland (UBCHO), Oakland, California
- University of Wisconsin–Madison, Madison
| | - William C. Owen
- Children’s Hospital of the King’s Daughters, Norfolk, Virginia
| | - Anne Schaefer
- Joe DiMaggio Children’s Hospital, Hollywood, Florida
| | | | | | - Debra E. Cohen
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Studer Family Children’s Hospital Ascension Sacred Heart, University of Florida, Pensacola
| | - Zeynep Karakas
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Connie M. Piccone
- Rainbow Babies and Children’s Hospital, Cleveland, Ohio
- Carle Foundation Hospital, Urbana, Illinois
| | - Alex George
- Baylor College of Medicine, Houston, Texas
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jason M. Fixler
- The Herman and Walter Samuelson Children’s Hospital at Sinai, Baltimore, Maryland
| | - Tammuella C. Singleton
- Tulane University, New Orleans, Louisiana
- Mississippi Center for Advanced Medicine, Slidell, Louisiana
| | - Thomas Moulton
- Bronx-Lebanon Hospital, Bronx, New York City, New York
- Bayer Pharmaceuticals, Whippany, New Jersey
| | | | | | - Abdulkareem M. Almomen
- Blood and Cancer Center, King Khalid University Hospital (KKUH), King Saud University Medical City, Riyadh, Saudi Arabia
| | - Meenakshi Goyal-Khemka
- Phoenix Children’s Hospital, Phoenix, Arizona
- Rutgers Cancer Institute of New Jersey, New Brunswick
| | - Philip Maes
- University Hospital of Antwerp (UZA), Edegem, Belgium
| | - Marty Emanuele
- Visgenx, San Diego, California
- Mast Therapeutics Inc, San Diego, California
| | | | - Claire S. Padgett
- Mast Therapeutics Inc, San Diego, California
- Sanifit Therapeutics, San Diego, California
| | - Ed Parsley
- Mast Therapeutics Inc, San Diego, California
- Biotechnology, San Diego, California
| | | | - Gregory J. Kato
- CSL Behring, King of Prussia, Pennsylvania
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mark T. Gladwin
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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DeBaun MR, Gordon M, McKinstry RC, Noetzel MJ, White DA, Sarnaik SA, Meier ER, Howard TH, Majumdar S, Inusa BPD, Telfer PT, Kirby-Allen M, McCavit TL, Kamdem A, Airewele G, Woods GM, Berman B, Panepinto JA, Fuh BR, Kwiatkowski JL, King AA, Fixler JM, Rhodes MM, Thompson AA, Heiny ME, Redding-Lallinger RC, Kirkham FJ, Dixon N, Gonzalez CE, Kalinyak KA, Quinn CT, Strouse JJ, Miller JP, Lehmann H, Kraut MA, Ball WS, Hirtz D, Casella JF. Controlled trial of transfusions for silent cerebral infarcts in sickle cell anemia. N Engl J Med 2014; 371:699-710. [PMID: 25140956 PMCID: PMC4195437 DOI: 10.1056/nejmoa1401731] [Citation(s) in RCA: 350] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Silent cerebral infarcts are the most common neurologic injury in children with sickle cell anemia and are associated with the recurrence of an infarct (stroke or silent cerebral infarct). We tested the hypothesis that the incidence of the recurrence of an infarct would be lower among children who underwent regular blood-transfusion therapy than among those who received standard care. METHODS In this randomized, single-blind clinical trial, we randomly assigned children with sickle cell anemia to receive regular blood transfusions (transfusion group) or standard care (observation group). Participants were between 5 and 15 years of age, with no history of stroke and with one or more silent cerebral infarcts on magnetic resonance imaging and a neurologic examination showing no abnormalities corresponding to these lesions. The primary end point was the recurrence of an infarct, defined as a stroke or a new or enlarged silent cerebral infarct. RESULTS A total of 196 children (mean age, 10 years) were randomly assigned to the observation or transfusion group and were followed for a median of 3 years. In the transfusion group, 6 of 99 children (6%) had an end-point event (1 had a stroke, and 5 had new or enlarged silent cerebral infarcts). In the observation group, 14 of 97 children (14%) had an end-point event (7 had strokes, and 7 had new or enlarged silent cerebral infarcts). The incidence of the primary end point in the transfusion and observation groups was 2.0 and 4.8 events, respectively, per 100 years at risk, corresponding to an incidence rate ratio of 0.41 (95% confidence interval, 0.12 to 0.99; P=0.04). CONCLUSIONS Regular blood-transfusion therapy significantly reduced the incidence of the recurrence of cerebral infarct in children with sickle cell anemia. (Funded by the National Institute of Neurological Disorders and Stroke and others; Silent Cerebral Infarct Multi-Center Clinical Trial ClinicalTrials.gov number, NCT00072761, and Current Controlled Trials number, ISRCTN52713285.).
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Affiliation(s)
- Michael R DeBaun
- From the Department of Pediatrics, Division of Hematology-Oncology, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University School of Medicine, Nashville (M.R.D.); Department of Ophthalmology and Visual Sciences, Division of Biostatistics (M.G.), Departments of Radiology and Pediatrics (R.C.M.), Neurology and Pediatrics (M.J.N.), and Psychology (D.A.W.), the Program in Occupational Therapy and Department of Pediatrics Hematology-Oncology (A.A.K.), and the Division of Biostatistics and Department of Internal Medicine (J.P.M.), Washington University School of Medicine, St. Louis; Department of Pediatrics, Division of Hematology-Oncology, Wayne State University, Detroit (S.A.S.); Center for Cancer and Blood Disorders, Children's National Medical Center, Department of Pediatrics, George Washington University Medical Center (E.R.M.), and Department of Pediatrics, Division of Hematology-Oncology, Georgetown University Hospital (C.E.G.) - all in Washington, DC; Department of Pediatrics, Division of Hematology-Oncology, University of Alabama at Birmingham, Birmingham (T.H.H.); Department of Pediatrics, Division of Hematology-Oncology, University of Mississippi Medical Center, Jackson (S.M.); Department of Paediatrics, Evelina Children's Hospital, St. Thomas' Hospital NHS Trust (B.P.D.I.), Department of Pediatric Hematology, Royal London Hospital, Barts Health NHS Trust (P.T.T.), and the Neurosciences Unit, Institute of Child Health, University College London (F.J.K.) - all in London; Hospital for Sick Children, Department of Paediatrics, Haematology-Oncology, University of Toronto, Toronto (M.K.-A.); Division of Hematology-Oncology, Department of Pediatrics, UT Southwestern Medical Center, Dallas (T.L.M.C.); Département Pédiatrie, Hôpital Intercommunal de Creteil, Creteil, France (A.K.); Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston (G.A.); Department of Pediatrics, Hematology-Oncology, Univer
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