The design of a Bayesian adaptive clinical trial of tranexamic acid in severely injured children.

Publisher: BioMed Central Country of Publication: England NLM ID: 101263253 Publication Model: Electronic Cited Medium: Internet ISSN: 1745-6215 (Electronic) Linking ISSN: 17456215 NLM ISO Abbreviation: Trials Subsets: MEDLINE

Original Publication: [London] : BioMed Central, 2006-

Antifibrinolytic Agents*/therapeutic use ; Tranexamic Acid*/therapeutic use ; Wounds and Injuries*/drug therapy; Bayes Theorem ; Child ; Double-Blind Method ; Hemorrhage/drug therapy ; Humans ; Trauma Severity Indices

Background: Trauma is the leading cause of death and disability in children in the USA. Tranexamic acid (TXA) reduces the blood transfusion requirements in adults and children during surgery. Several studies have evaluated TXA in adults with hemorrhagic trauma, but no randomized controlled trials have occurred in children with trauma. We propose a Bayesian adaptive clinical trial to investigate TXA in children with brain and/or torso hemorrhagic trauma.
Methods/design: We designed a double-blind, Bayesian adaptive clinical trial that will enroll up to 2000 patients. We extend the traditional E max dose-response model to incorporate a hierarchical structure so multiple doses of TXA can be evaluated in different injury populations (isolated head injury, isolated torso injury, or both head and torso injury). Up to 3 doses of TXA (15 mg/kg, 30 mg/kg, and 45 mg/kg bolus doses) will be compared to placebo. Equal allocation between placebo, 15 mg/kg, and 30 mg/kg will be used for an initial period within each injury group. Depending on the dose-response curve, the 45 mg/kg arm may open in an injury group if there is a trend towards increasing efficacy based on the observed relationship using the data from the lower doses. Response-adaptive randomization allows each injury group to differ in allocation proportions of TXA so an optimal dose can be identified for each injury group. Frequent interim stopping periods are included to evaluate efficacy and futility. The statistical design is evaluated through extensive simulations to determine the operating characteristics in several plausible scenarios. This trial achieves adequate power in each injury group.
Discussion: This trial design evaluating TXA in pediatric hemorrhagic trauma allows for three separate injury populations to be analyzed and compared within a single study framework. Individual conclusions regarding optimal dosing of TXA can be made within each injury group. Identifying the optimal dose of TXA, if any, for various injury types in childhood may reduce death and disability.
(© 2021. The Author(s).)

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U24TR001597 United States TR NCATS NIH HHS; R25 NS088248 United States NS NINDS NIH HHS; R34 HL135214 United States HL NHLBI NIH HHS; R34HL135214 United States HL NHLBI NIH HHS; U24 TR001597 United States TR NCATS NIH HHS

Keywords: Adaptive clinical trial design; Bayesian statistics; Dose-response; Pediatrics; Response-adaptive randomization; Tranexamic acid; Trauma

0 (Antifibrinolytic Agents)
6T84R30KC1 (Tranexamic Acid)

Date Created: 20211105 Date Completed: 20211108 Latest Revision: 20240404

20240404

PMC8567588

10.1186/s13063-021-05737-0

34736498