Journal
ANNALS OF NEUROLOGY
Volume 85, Issue 1, Pages 125-136Publisher
WILEY
DOI: 10.1002/ana.25383
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Funding
- National Institute of Neurological Disorders and Stroke (NINDS) [U01NS088312]
- National Institute of Neurological Disorders and Stroke [U01NS077179, U01NS077352]
- Vanderbilt University [ULTR002243]
- Washington University at St. Louis [UL1TR000448]
- Columbia University Medical Center [UL1TR000040]
- University at Buffalo/SUNY [UL1TR001412]
- NATIONAL CENTER FOR ADVANCING TRANSLATIONAL SCIENCES [UL1TR002345, UL1TR000448, UL1TR001412] Funding Source: NIH RePORTER
- NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE [U01NS077352, U24NS107165, U01NS088312, U24NS107128, R01NS075930, U10NS077265, U01NS077179] Funding Source: NIH RePORTER
- NATIONAL INSTITUTE ON AGING [P01AG052350] Funding Source: NIH RePORTER
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Objective Agonism of protease-activated receptor (PAR) 1 by activated protein C (APC) provides neuro- and vasculoprotection in experimental neuroinjury models. The pleiotropic PAR1 agonist, 3K3A-APC, reduces neurological injury and promotes vascular integrity; 3K3A-APC proved safe in human volunteers. We performed a randomized, controlled, blinded trial to determine the maximally tolerated dose (MTD) of 3K3A-APC in ischemic stroke patients. Methods The NeuroNEXT trial, RHAPSODY, used a novel continual reassessment method to determine the MTD using tiers of 120, 240, 360, and 540 mu g/kg of 3K3A-APC. After intravenous tissue plasminogen activator, intra-arterial mechanical thrombectomy, or both, patients were randomized to 1 of the 4 doses or placebo. Vasculoprotection was assessed as microbleed and intracranial hemorrhage (ICH) rates. Results Between January 2015 and July 2017, we treated 110 patients. Demographics resembled a typical stroke population. The MTD was the highest-dose 3K3A-APC tested, 540 mu g/kg, with an estimated toxicity rate of 7%. There was no difference in prespecified ICH rates. In exploratory analyses, 3K3A-APC reduced ICH rates compared to placebo from 86.5% to 67.4% in the combined treatment arms (p = 0.046) and total hemorrhage volume from an average of 2.1 +/- 5.8 ml in placebo to 0.8 +/- 2.1 ml in the combined treatment arms (p = 0.066). Interpretation RHAPSODY is the first trial of a neuroprotectant for acute ischemic stroke in a trial design allowing thrombectomy, thrombolysis, or both. The MTD was 540 mu g/kg for the PAR1 active cytoprotectant, 3K3A-APC. A trend toward lower hemorrhage rate in an exploratory analysis requires confir
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