Ignite Creation Date:
2024-05-05 @ 11:14 PM
Last Modification Date:
2024-10-26 @ 10:30 AM
Study NCT ID:
NCT01283009
Status:
COMPLETED
Last Update Posted:
2020-10-08
First Post:
2011-01-21
Brief Title:
Extended Steroid in Use in Community Acquired Pneumonia CAPe
Sponsor:
VA Office of Research and Development
Organization:
VA Office of Research and Development
Study Overview
Official Title:
CSP 574 - Evaluate the Safety and Efficacy of Methylprednisolone in Hospitalized Veterans With Severe Community-Acquired Pneumonia
Status:
COMPLETED
Status Verified Date:
2020-09
Last Known Status:
None
Delayed Posting:
No
If Stopped, Why?:
Not Stopped
Has Expanded Access:
False
If Expanded Access, NCT#:
N/A
Has Expanded Access, NCT# Status:
N/A
Acronym:
ESCAPe
Brief Summary:
The goal of the study is to determine whether providing early treatment with a glucocorticoid drug called methylprednisolone will improve survival in critically ill patients with severe community-acquired pneumonia CAP Pneumonia develops when bacteria and other agents invade the lungs The bodys immune system creates a response to produce inflammation to kill the bacteria A moderate amount of inflammation is beneficial But in patients sick enough to be admitted to the ICU inflammation is frequently out of control When the body cannot regulate inflammation vital organs brain heart lung kidney liver may be damaged contributing to death or residual organ damage for those who survive Glucocorticoids help reduce inflammation Recent studies have shown that when the body is unable to produce sufficient amounts of glucocorticoids inflammation can get out of control Under these circumstances glucocorticoids given in small doses may help aid the bodys ability to reduce inflammation and improve recovery In a small preliminary trial glucocorticoid treatment in addition to standard antibiotic treatment sped up recovery from pneumonia It also decreased the length of hospital stay and increased survival This Cooperative Studies Program CSP study will be the first large-scale prospective randomized clinical trial evaluating whether or not this treatment improves recovery
In this study at each site patients with severe CAP will be assigned to one of two treatment groups One group will receive methylprednisolone and the other will receive a placebo an inert substance that will look like the drug The investigators have chosen a total duration of treatment of 20 days 7 days full dose followed by slow reduction over 13 days to prevent relapse of inflammation and allow the body to recover its own ability to produce glucocorticoid All patients will also receive standardized management of CAP in accordance with current practice guidelines The study will take into consideration when assigning the treatment each participating site and whether or not the patient requires mechanical ventilation at the time of assignment Patients will be followed clinically for 180 days The primary outcome is all cause 60-day mortality Secondary outcomes are 1 in-hospital morbidity-mortality including ventilator-free days multiorgan dysfunction syndrome MODS-free days duration of ICU and hospital stay and hospital discharge and 2 posthospital discharge morbidity-mortality including cardiovascular complications functional and general health status in the first 180 days rehospitalization and mortality at 1 year Serial blood samples will also be collected and stored for future translational research relating longitudinal inflammation markers to clinical outcomes
This study will advance knowledge on the relationship between inflammation and long-term outcome in severe CAP
In this study at each site patients with severe CAP will be assigned to one of two treatment groups One group will receive methylprednisolone and the other will receive a placebo an inert substance that will look like the drug The investigators have chosen a total duration of treatment of 20 days 7 days full dose followed by slow reduction over 13 days to prevent relapse of inflammation and allow the body to recover its own ability to produce glucocorticoid All patients will also receive standardized management of CAP in accordance with current practice guidelines The study will take into consideration when assigning the treatment each participating site and whether or not the patient requires mechanical ventilation at the time of assignment Patients will be followed clinically for 180 days The primary outcome is all cause 60-day mortality Secondary outcomes are 1 in-hospital morbidity-mortality including ventilator-free days multiorgan dysfunction syndrome MODS-free days duration of ICU and hospital stay and hospital discharge and 2 posthospital discharge morbidity-mortality including cardiovascular complications functional and general health status in the first 180 days rehospitalization and mortality at 1 year Serial blood samples will also be collected and stored for future translational research relating longitudinal inflammation markers to clinical outcomes
This study will advance knowledge on the relationship between inflammation and long-term outcome in severe CAP
Detailed Description:
VA Cooperative Study 574 is designed to prospectively evaluate the efficacy of prolonged glucocorticoid methylprednisolone treatment on short- in hospital and long-term after hospital discharge morbidity and mortality in Veteran patients admitted to the Intensive Care Unit ICU including intermediate care unit with severe community-acquired pneumonia CAP
CAP is the sixth most common cause of death acute mortality in the United States and the leading cause of community-acquired infection requiring intensive care unit ICU admission Despite significant advancements in medical care there has been little change in crude mortality from respiratory tract infection for more than 5 decades 1950-2000 In the United States alone over 13 million people were admitted to the hospital in 2002 with severe CAP 262 per 10000 population with an estimated inpatient cost of approximately 44 billion In addition severe CAP patients surviving hospitalization experience a significant increase in long-term morbidity cardiovascular complications impaired functional status and recurrent hospitalizations and a sizable mortality up to 1 year up to 25 that is independent of patients chronic health condition
Dysregulated systemic inflammation characterized by persistent elevation in circulating inflammatory cytokine levels over time is the central pathogenetic process contributing to short- and long-term morbidity and mortality in patients with severe CAP Even when patients survive ICU and hospital admission elevation in inflammatory cytokine lasts for greater than 3 weeks and interleukin IL-6 levels at hospital discharge predict subsequent mortality Endogenous and exogenous glucocorticoids are the most important physiologic inhibitors of inflammation In a meta-analysis of four small published studies that included a total of 198 patients with severe CAP prolonged glucocorticoid treatment was associated with a significant reduction in short-term mortality RR 040 95CI 018-089 p 003 I2 12 This Cooperative Studies Program CSP study will be the first large-scale prospective randomized clinical trial evaluating the efficacy of prolonged methylprednisolone in the treatment of severe CAP
In this study at each site patients with severe CAP will be randomized in a 11 ratio to receive methylprednisolone or placebo in a double-blind fashion The investigators have chosen a total duration of treatment of 20 days 7 days full dose followed by slow reduction over 13 days to forestall relapse of systemic inflammation and allow recovery of the suppressed hypothalamic-pituitary-adrenal HPA axis All patients will also receive standardized management of CAP in accordance with current practice guidelines Randomization will be stratified separately within each participating site by whether or not the patient requires mechanical ventilation at the time of randomization Patients will be followed clinically for 180 days The primary outcome is all cause 60-day mortality Secondary outcomes are 1 in-hospital morbidity-mortality including ventilator-free days multiorgan dysfunction syndrome MODS-free days duration of ICU and hospital stay and hospital discharge and 2 posthospital discharge morbidity-mortality including cardiovascular complications functional and general health status in the first 180 days rehospitalization and mortality at 1 year Serial blood samples will also be collected and stored for future translational research relating longitudinal inflammation markers to clinical outcomes
Based on published studies and VA Decision Support System the investigators estimate the all cause 60-day mortality in severe CAP patients admitted to ICU is 28 The investigators hypothesize that prolonged methylprednisolone treatment will reduce the 60-day mortality from 28 to 21 a 25 relative reduction A total of 1406 patients 703 per group will be required to give 85 power to detect this hypothesized improvement using a two-sided 5 significance level test Adjusting for 1 attrition the target sample size is 1420 Assuming 5 years of accrual and an intake rate of 8 patients per year per Veterans Affairs Medical Center VAMC the investigators will need 36 participating VAMCs
Treatment of severe CAP is of particular importance to the VA health care system because of the large patient population and because a single episode of severe CAP is associated with significant short- and long-term morbidity and mortality In fiscal year 2006 17890 patients were admitted to the VA hospital system with a diagnosis of CAP Of these 3727 21 required ICU admission during their hospital stay For ICU-admitted patients mortality rates in the hospital at 60 90 180 and 365 days were 26 34 37 44 and 51 respectively They had on average a hospital stay of 177 days with hospital costs of 49936 and 48 of them were readmitted within 12 months of hospital discharge This study will investigate the effects of an off-patent inexpensive treatment that based on strong experimental and translational evidence and the encouraging findings of preliminary trials has the potential of significantly decreasing mortality and morbidity Equally important this study will advance knowledge on the relationship between inflammation and long-term outcome in severe CAP Given that methylprednisolone is off-patent there is little incentive for the pharmaceutical industry to fund this study The VA system with its Cooperative Studies Program is uniquely suited to conduct the study
CAP is the sixth most common cause of death acute mortality in the United States and the leading cause of community-acquired infection requiring intensive care unit ICU admission Despite significant advancements in medical care there has been little change in crude mortality from respiratory tract infection for more than 5 decades 1950-2000 In the United States alone over 13 million people were admitted to the hospital in 2002 with severe CAP 262 per 10000 population with an estimated inpatient cost of approximately 44 billion In addition severe CAP patients surviving hospitalization experience a significant increase in long-term morbidity cardiovascular complications impaired functional status and recurrent hospitalizations and a sizable mortality up to 1 year up to 25 that is independent of patients chronic health condition
Dysregulated systemic inflammation characterized by persistent elevation in circulating inflammatory cytokine levels over time is the central pathogenetic process contributing to short- and long-term morbidity and mortality in patients with severe CAP Even when patients survive ICU and hospital admission elevation in inflammatory cytokine lasts for greater than 3 weeks and interleukin IL-6 levels at hospital discharge predict subsequent mortality Endogenous and exogenous glucocorticoids are the most important physiologic inhibitors of inflammation In a meta-analysis of four small published studies that included a total of 198 patients with severe CAP prolonged glucocorticoid treatment was associated with a significant reduction in short-term mortality RR 040 95CI 018-089 p 003 I2 12 This Cooperative Studies Program CSP study will be the first large-scale prospective randomized clinical trial evaluating the efficacy of prolonged methylprednisolone in the treatment of severe CAP
In this study at each site patients with severe CAP will be randomized in a 11 ratio to receive methylprednisolone or placebo in a double-blind fashion The investigators have chosen a total duration of treatment of 20 days 7 days full dose followed by slow reduction over 13 days to forestall relapse of systemic inflammation and allow recovery of the suppressed hypothalamic-pituitary-adrenal HPA axis All patients will also receive standardized management of CAP in accordance with current practice guidelines Randomization will be stratified separately within each participating site by whether or not the patient requires mechanical ventilation at the time of randomization Patients will be followed clinically for 180 days The primary outcome is all cause 60-day mortality Secondary outcomes are 1 in-hospital morbidity-mortality including ventilator-free days multiorgan dysfunction syndrome MODS-free days duration of ICU and hospital stay and hospital discharge and 2 posthospital discharge morbidity-mortality including cardiovascular complications functional and general health status in the first 180 days rehospitalization and mortality at 1 year Serial blood samples will also be collected and stored for future translational research relating longitudinal inflammation markers to clinical outcomes
Based on published studies and VA Decision Support System the investigators estimate the all cause 60-day mortality in severe CAP patients admitted to ICU is 28 The investigators hypothesize that prolonged methylprednisolone treatment will reduce the 60-day mortality from 28 to 21 a 25 relative reduction A total of 1406 patients 703 per group will be required to give 85 power to detect this hypothesized improvement using a two-sided 5 significance level test Adjusting for 1 attrition the target sample size is 1420 Assuming 5 years of accrual and an intake rate of 8 patients per year per Veterans Affairs Medical Center VAMC the investigators will need 36 participating VAMCs
Treatment of severe CAP is of particular importance to the VA health care system because of the large patient population and because a single episode of severe CAP is associated with significant short- and long-term morbidity and mortality In fiscal year 2006 17890 patients were admitted to the VA hospital system with a diagnosis of CAP Of these 3727 21 required ICU admission during their hospital stay For ICU-admitted patients mortality rates in the hospital at 60 90 180 and 365 days were 26 34 37 44 and 51 respectively They had on average a hospital stay of 177 days with hospital costs of 49936 and 48 of them were readmitted within 12 months of hospital discharge This study will investigate the effects of an off-patent inexpensive treatment that based on strong experimental and translational evidence and the encouraging findings of preliminary trials has the potential of significantly decreasing mortality and morbidity Equally important this study will advance knowledge on the relationship between inflammation and long-term outcome in severe CAP Given that methylprednisolone is off-patent there is little incentive for the pharmaceutical industry to fund this study The VA system with its Cooperative Studies Program is uniquely suited to conduct the study
Study Oversight
Has Oversight DMC:
None
Is a FDA Regulated Drug?:
None
Is a FDA Regulated Device?:
None
Is an Unapproved Device?:
None
Is a PPSD?:
None
Is a US Export?:
None
Is an FDA AA801 Violation?:
None