Safety of Early High-Dose Recombinant Erythropoietin for Neuroprotection in Very Preterm Infants Jean-Claude Fauchere, MD1, Brigitte M. Koller, RN1, Alois Tschopp, PhD2, Christof Dame, MD3, Christoph Ruegger, MD1, and Hans Ulrich Bucher, MD1, on behalf of the Swiss Erythropoietin Neuroprotection Trial Group* Objective To investigate the safety and short term outcome of high dose recombinant human erythropoietin (rhEpo) given shortly after birth and subsequently over the first 2 days for neuroprotection to very preterm infants. Study design Randomized, double masked phase II trial. Preterm infants (gestational age 26 0/7-31 6/7 weeks) were given rhEpo (nt = 229; 3000 U/kg body weight) or NaCl 0.9% (nc = 214) intravenously at 3, 12-18, and 3642 hours after birth. Results There were no relevant differences between the groups for short-term outcomes such as mortality, retinopathy of prematurity, intraventricular hemorrhage, sepsis, necrotizing enterocolitis, and bronchopulmonary dysplasia. At day 7-10, we found significantly higher hematocrit values, reticulocyte, and white blood cell counts, and a lower platelet count in the rhEpo group. Conclusions Early high-dose rhEpo administration to very premature infants is safe and causes no excess in mortality or major adverse events. (J Pediatr 2015;167:52-7) Trial registration ClinicalTrials.gov: NCT00413946. See editorial, p 10
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remature birth, intraventricular hemorrhage (IVH), and hypoxic ischemic encephalopathy remain major risk factors for delayed psychomotor development, cognitive deficits, and cerebral palsy in newborn infants.1-7 The most critical period centers around birth when oxygenation, especially of the brain, may be impaired because of insufficient placento-fetal perfusion, or after birth because of respiratory and circulatory disorders. Additional factors such as inflammation, excitotoxicity, or oxidative stress can alter brain development, which remains particularly vulnerable during the phase of oligodendrocyte development.8-10 Although therapeutic hypothermia improves long-term neurodevelopmental outcome in term neonates with hypoxic-ischemic encephalopathy,11 there is still urgent need for alternative or additional treatment options for proven and safe neuroprotection in infants born prematurely. Although there are some drugs which show promise for ante- and postnatal neuroprotection in preclinical studies, their specific interactions in developing organ systems, their dosing, and their timing are still insufficiently known. Recombinant human erythropoietin (rhEpo), the primary regulator of erythropoiesis, has been evaluated for postnatal neuroprotection in newborn infants.12 Several reasons explain the high potential of rhEpo for neuroprotective treatment: (1) the endogenous erythropoietin (Epo)/Epo receptor system is essential for proper development of the central nervous system as shown in mutant mice with conditional ablation of one of these genes13; (2) the Epo/Epo receptor system in the brain is stimulated in response to hypoxic-ischemic injury and subsequently induces receptor-mediated, cell-specific effects of early and late tissue healing14-16; (3) in vitro and in vivo experiments demonstrate the anti-inflammatory, anti-excitotoxic, anti-oxidant, and antiapoptotic effects of Epo on neurons and oligodendroglia and characterize the molecular mechanisms of these processes17,18; (4) rhEpo promotes neurogenesis and angiogenesis, which are essential for repair processes after brain injury and the development of compensatory mechanisms for proper neurodevelopment17,19-22; and (5) retrospectively performed analysis of clinical data from preterm infants treated with
DOL ELBW Epo GA IVH MDI PMA PVL rhEpo ROP WBC
Day of life Extremely low birth weight Erythropoietin Gestational age Intraventricular hemorrhage Mental developmental index Postmenstrual age Periventricular leukomalacia Recombinant human erythropoietin Retinopathy of prematurity White blood cell
From the 1Division of Neonatology, University Hospital Zurich, University of Zurich; 2Division of Biostatistics, Institute of Social and Preventive Medicine, University of Zurich, Zurich, Switzerland; and 3Department of –Universita €tsmedizin, Berlin, Neonatology, Charite Germany *List of members of the Swiss Epo Neuroprotection Trial Group is available at www.jpeds.com (Appendix). Supported by the Swiss National Science Foundation (3200B0-108176/1) and the Roche Foundation for Anemia Research. The authors declare no conflicts of interest. Portions of the study were presented at the European Society for Paediatric Research meeting, Porto, Portugal, October 10-14, 2013. 0022-3476/$ - see front matter. Copyright ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2015.02.052
52
Vol. 167, No. 1 July 2015 rhEpo for the anemia of prematurity demonstrated a robust improvement of neurodevelopmental outcome.23-26 Several interventional clinical trials on the neuroprotective effect of rhEpo or of its highly glycosylated derivate darbepoetin have been completed in neonates, including infants at high risk for long-term neurodevelopmental disorders because of extreme prematurity,27-30 (near-) term neonates with asphyxia (with or without therapeutic hypothermia),31-33 neonates with stroke,34 neonates undergoing cardiac surgery,35 infants suffering from cerebral palsy,36 and in adults with arterial ischemic stroke, subarachnoidal hemorrhage, chronic schizophrenia, progressive multiple sclerosis, or cardiac surgery.37,38 Some clinical trials initiated for neuroprotection in very premature neonates were either placed on hold by the Food and Drug Administration because of safety concerns and later restarted with or without modified doses and dosing schedules, or never started recruitment for various reasons (NCT00451698, NCT00491413, and NCT00589953). The primary objective of our phase II trial was to investigate the neuroprotective effect of rhEpo in very premature infants with the goal to improve their long-term neurodevelopmental outcome. The primary hypothesis of this trial is that high-dose rhEpo improves the Bayley mental developmental index (MDI) of infants born very preterm at 24 months of age compared with placebo. Herein, we report the short-term safety of early high-dose rhEpo administered immediately after birth and subsequently over the first 2 days of life to very preterm infants.
Methods This phase II clinical trial was a randomized, double-masked, placebo-controlled multicenter trial (ClinicalTrials.gov: NCT00413946). The full study protocol has been reported.27 Briefly, very preterm infants born between 26 0/7 and 31 6 /7 weeks of gestation were eligible for enrollment. The exclusion criteria were genetically defined syndromes, congenital malformations adversely affecting neurodevelopment, or severe IVH $III before randomization. The patients were randomized within the first 3 hours after birth. The study medication (rhEpo or NaCl 0.9%) was randomly assigned to each patient number in advance, using a computerbased random number generator. Epoetin beta (3000 U rhEpo/kg body weight at birth, equal to 1 mL solution/kg birth weight; Roche, Basel Switzerland), or an equivalent volume of saline placebo was given intravenously at 7 d) Cystic PVL ROP grade 1-4 vs no ROP ROP grade 1 vs no ROP ROP grade 2 vs no ROP ROP grade 3 vs no ROP ROP grade 4 ROP plus disease vs no ROP ROP exam not assessed (death or no supplemental oxygen) Sepsis NEC PDA (treatment needed) PDA surgical ligation BPD (oxygen dependence at 36 0/7 wk PMA) vs no BPD BPD mild vs no BPD BPD moderate vs no BPD BPD severe vs no BPD Survivors without severe IVH, PVL, ROP Hemangioma Hematologic parameters Hematocrit at day 7-10 (%) Reticulocytes at day 7-10 (G/L) Platelet count at day 7-10 (G/L) WBC count at day 7-10 (G/L)
rhEpo
(nc = 214)
%
(nt = 229)
%
Difference, OR (CI 95%)
12 202 41/214 4/214 6/214 72/214 3/214 19/191 8/191 6/191 5/191 0/191 2/191 23/214 29/214 10/214 65/214 10/214 67/214 40/214 21/214 6/214 183/214 21/214
5.6 94.4 21.1 1.9 2.8 33.6 1.4 9.9 4.2 3.1 2.6 0 1.0 10.7 13.6 4.7 30.4 4.7 31.3 18.7 9.8 2.8 85.5 9.8
12 217 43/229 3/229 10/229 78/229 4/229 20/212 6/212 12/212 2/212 0/212 2/212 17/229 31/229 6/229 65/229 4/229 71/229 43/229 18/229 10/229 196/229 30/229
5.2 94.8 18.8 1.3 4.4 34.1 1.7 9.4 2.8 5.7 0.9 0 0.9 7.4 13.5 2.6 28.4 1.7 31.0 18.8 7.9 4.4 85.6 13.1
OR 1.1 (0.5-2.5) OR 1.1 (0.5-2.5) OR 1.0 (0.6-1.6) OR 0.7 (0.2-3.2) OR 1.6 (0.6-4.4) OR 1.0 (0.7-1.5) OR 1.3 (0.3-5.7) OR 0.9 (0.5-1.8) OR 0.7 (0.2-2.0) OR 1.8 (0.7-4.9) OR 0.4 (0.1-1.9) OR 0.9 (0.1-6.4)
44.7 80.4 274.4 13.4
47.3 372.5 205.1 19.4
OR 1.0 (0.6-1.7) OR 0.6 (0.2-1.5) OR 0.9 (0.6-1.4) OR 0.4 (0.1-1.2) OR 1.0 (0.7-1.5) OR 1.0 (0.6-1.6) OR 0.8 (0.4-1.6) OR 1.6 (0.6-4.4) OR 1.0 (0.6-1.7) OR 1.4 (0.8-2.5) Diff
Diff 2.6 ( 4.3 to 1.0) 292.2 ( 334.6 to 249.6) Diff 69.3 (41.2-97.5) Diff 6.0 ( 8.1 to 3.9)
BPD, bronchopulmonary dysplasia; NEC, necrotizing enterocolitis; PDA, persistent ductus arteriosus. The differences regarding the denominators for different variables are due to missing values.
Epo therapy was an independent risk factor for the development of infantile hemangioma.47 From a total of 2563 infants born between 23 and 36 weeks GA, 110 infants had hemangiomas (4.3%). In premature infants born
P
remature birth, intraventricular hemorrhage (IVH), and hypoxic ischemic encephalopathy remain major risk factors for delayed psychomotor development, cognitive deficits, and cerebral palsy in newborn infants.1-7 The most critical period centers around birth when oxygenation, especially of the brain, may be impaired because of insufficient placento-fetal perfusion, or after birth because of respiratory and circulatory disorders. Additional factors such as inflammation, excitotoxicity, or oxidative stress can alter brain development, which remains particularly vulnerable during the phase of oligodendrocyte development.8-10 Although therapeutic hypothermia improves long-term neurodevelopmental outcome in term neonates with hypoxic-ischemic encephalopathy,11 there is still urgent need for alternative or additional treatment options for proven and safe neuroprotection in infants born prematurely. Although there are some drugs which show promise for ante- and postnatal neuroprotection in preclinical studies, their specific interactions in developing organ systems, their dosing, and their timing are still insufficiently known. Recombinant human erythropoietin (rhEpo), the primary regulator of erythropoiesis, has been evaluated for postnatal neuroprotection in newborn infants.12 Several reasons explain the high potential of rhEpo for neuroprotective treatment: (1) the endogenous erythropoietin (Epo)/Epo receptor system is essential for proper development of the central nervous system as shown in mutant mice with conditional ablation of one of these genes13; (2) the Epo/Epo receptor system in the brain is stimulated in response to hypoxic-ischemic injury and subsequently induces receptor-mediated, cell-specific effects of early and late tissue healing14-16; (3) in vitro and in vivo experiments demonstrate the anti-inflammatory, anti-excitotoxic, anti-oxidant, and antiapoptotic effects of Epo on neurons and oligodendroglia and characterize the molecular mechanisms of these processes17,18; (4) rhEpo promotes neurogenesis and angiogenesis, which are essential for repair processes after brain injury and the development of compensatory mechanisms for proper neurodevelopment17,19-22; and (5) retrospectively performed analysis of clinical data from preterm infants treated with
DOL ELBW Epo GA IVH MDI PMA PVL rhEpo ROP WBC
Day of life Extremely low birth weight Erythropoietin Gestational age Intraventricular hemorrhage Mental developmental index Postmenstrual age Periventricular leukomalacia Recombinant human erythropoietin Retinopathy of prematurity White blood cell
From the 1Division of Neonatology, University Hospital Zurich, University of Zurich; 2Division of Biostatistics, Institute of Social and Preventive Medicine, University of Zurich, Zurich, Switzerland; and 3Department of –Universita €tsmedizin, Berlin, Neonatology, Charite Germany *List of members of the Swiss Epo Neuroprotection Trial Group is available at www.jpeds.com (Appendix). Supported by the Swiss National Science Foundation (3200B0-108176/1) and the Roche Foundation for Anemia Research. The authors declare no conflicts of interest. Portions of the study were presented at the European Society for Paediatric Research meeting, Porto, Portugal, October 10-14, 2013. 0022-3476/$ - see front matter. Copyright ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2015.02.052
52
Vol. 167, No. 1 July 2015 rhEpo for the anemia of prematurity demonstrated a robust improvement of neurodevelopmental outcome.23-26 Several interventional clinical trials on the neuroprotective effect of rhEpo or of its highly glycosylated derivate darbepoetin have been completed in neonates, including infants at high risk for long-term neurodevelopmental disorders because of extreme prematurity,27-30 (near-) term neonates with asphyxia (with or without therapeutic hypothermia),31-33 neonates with stroke,34 neonates undergoing cardiac surgery,35 infants suffering from cerebral palsy,36 and in adults with arterial ischemic stroke, subarachnoidal hemorrhage, chronic schizophrenia, progressive multiple sclerosis, or cardiac surgery.37,38 Some clinical trials initiated for neuroprotection in very premature neonates were either placed on hold by the Food and Drug Administration because of safety concerns and later restarted with or without modified doses and dosing schedules, or never started recruitment for various reasons (NCT00451698, NCT00491413, and NCT00589953). The primary objective of our phase II trial was to investigate the neuroprotective effect of rhEpo in very premature infants with the goal to improve their long-term neurodevelopmental outcome. The primary hypothesis of this trial is that high-dose rhEpo improves the Bayley mental developmental index (MDI) of infants born very preterm at 24 months of age compared with placebo. Herein, we report the short-term safety of early high-dose rhEpo administered immediately after birth and subsequently over the first 2 days of life to very preterm infants.
Methods This phase II clinical trial was a randomized, double-masked, placebo-controlled multicenter trial (ClinicalTrials.gov: NCT00413946). The full study protocol has been reported.27 Briefly, very preterm infants born between 26 0/7 and 31 6 /7 weeks of gestation were eligible for enrollment. The exclusion criteria were genetically defined syndromes, congenital malformations adversely affecting neurodevelopment, or severe IVH $III before randomization. The patients were randomized within the first 3 hours after birth. The study medication (rhEpo or NaCl 0.9%) was randomly assigned to each patient number in advance, using a computerbased random number generator. Epoetin beta (3000 U rhEpo/kg body weight at birth, equal to 1 mL solution/kg birth weight; Roche, Basel Switzerland), or an equivalent volume of saline placebo was given intravenously at 7 d) Cystic PVL ROP grade 1-4 vs no ROP ROP grade 1 vs no ROP ROP grade 2 vs no ROP ROP grade 3 vs no ROP ROP grade 4 ROP plus disease vs no ROP ROP exam not assessed (death or no supplemental oxygen) Sepsis NEC PDA (treatment needed) PDA surgical ligation BPD (oxygen dependence at 36 0/7 wk PMA) vs no BPD BPD mild vs no BPD BPD moderate vs no BPD BPD severe vs no BPD Survivors without severe IVH, PVL, ROP Hemangioma Hematologic parameters Hematocrit at day 7-10 (%) Reticulocytes at day 7-10 (G/L) Platelet count at day 7-10 (G/L) WBC count at day 7-10 (G/L)
rhEpo
(nc = 214)
%
(nt = 229)
%
Difference, OR (CI 95%)
12 202 41/214 4/214 6/214 72/214 3/214 19/191 8/191 6/191 5/191 0/191 2/191 23/214 29/214 10/214 65/214 10/214 67/214 40/214 21/214 6/214 183/214 21/214
5.6 94.4 21.1 1.9 2.8 33.6 1.4 9.9 4.2 3.1 2.6 0 1.0 10.7 13.6 4.7 30.4 4.7 31.3 18.7 9.8 2.8 85.5 9.8
12 217 43/229 3/229 10/229 78/229 4/229 20/212 6/212 12/212 2/212 0/212 2/212 17/229 31/229 6/229 65/229 4/229 71/229 43/229 18/229 10/229 196/229 30/229
5.2 94.8 18.8 1.3 4.4 34.1 1.7 9.4 2.8 5.7 0.9 0 0.9 7.4 13.5 2.6 28.4 1.7 31.0 18.8 7.9 4.4 85.6 13.1
OR 1.1 (0.5-2.5) OR 1.1 (0.5-2.5) OR 1.0 (0.6-1.6) OR 0.7 (0.2-3.2) OR 1.6 (0.6-4.4) OR 1.0 (0.7-1.5) OR 1.3 (0.3-5.7) OR 0.9 (0.5-1.8) OR 0.7 (0.2-2.0) OR 1.8 (0.7-4.9) OR 0.4 (0.1-1.9) OR 0.9 (0.1-6.4)
44.7 80.4 274.4 13.4
47.3 372.5 205.1 19.4
OR 1.0 (0.6-1.7) OR 0.6 (0.2-1.5) OR 0.9 (0.6-1.4) OR 0.4 (0.1-1.2) OR 1.0 (0.7-1.5) OR 1.0 (0.6-1.6) OR 0.8 (0.4-1.6) OR 1.6 (0.6-4.4) OR 1.0 (0.6-1.7) OR 1.4 (0.8-2.5) Diff
Diff 2.6 ( 4.3 to 1.0) 292.2 ( 334.6 to 249.6) Diff 69.3 (41.2-97.5) Diff 6.0 ( 8.1 to 3.9)
BPD, bronchopulmonary dysplasia; NEC, necrotizing enterocolitis; PDA, persistent ductus arteriosus. The differences regarding the denominators for different variables are due to missing values.
Epo therapy was an independent risk factor for the development of infantile hemangioma.47 From a total of 2563 infants born between 23 and 36 weeks GA, 110 infants had hemangiomas (4.3%). In premature infants born
