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Health Technol Assess. 2019 Jul;23(35):1-48. doi: 10.3310/hta23350.

Tranexamic acid to improve functional status in adults with spontaneous intracerebral haemorrhage: the TICH-2 RCT.

Author information

1
Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.
2
Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK.
3
Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
4
Department of Neurology, Semmelweis University, Budapest, Hungary.
5
The First University Clinic of Tbilisi State Medical University, Tbilisi, Georgia.
6
Neurology Unit, Azienda Socio Sanitaria Territoriale di Mantova, Mantua, Italy.
7
Stroke Service, Adelaide and Meath Hospital, Tallaght, Ireland.
8
Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.
9
NIHR Nottingham Biomedical Research Centre, Nottingham, UK.
10
Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK.
11
UGC de Medicina Intensiva, Hospital Universitario Virgen del Rocío, IBiS/CSIC/Universidad de Sevilla, Seville, Spain.
12
Vascular Medicine, Division of Medical Sciences & GEM, University of Nottingham, Derby, UK.
13
Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland.
14
Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
15
Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia.
16
Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Department of Neurology, Copenhagen, Denmark.
17
Department of Neurology, Selcuk University Medical Faculty, Konya, Turkey.
18
Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK.
19
Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK.
20
Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK.
21
Stroke Research, Faculty of Medicine and Health Sciences, Keele University, Keele, UK.
22
Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland.
23
Division of Neurosurgery, Department of Surgery, National University of Malaysia, Kuala Lumpur, Malaysia.
24
Stroke Research Centre, University College London Queen Square Institute of Neurology, Faculty of Brain Sciences of University College London, University College London, London, UK.
25
National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK.
26
School of Economics, University of Nottingham, Nottingham, UK.

Abstract

BACKGROUND:

Tranexamic acid reduces death due to bleeding after trauma and postpartum haemorrhage.

OBJECTIVE:

The aim of the study was to assess if tranexamic acid is safe, reduces haematoma expansion and improves outcomes in adults with spontaneous intracerebral haemorrhage (ICH).

DESIGN:

The TICH-2 (Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage) study was a pragmatic, Phase III, prospective, double-blind, randomised placebo-controlled trial.

SETTING:

Acute stroke services at 124 hospitals in 12 countries (Denmark, Georgia, Hungary, Ireland, Italy, Malaysia, Poland, Spain, Sweden, Switzerland, Turkey and the UK).

PARTICIPANTS:

Adult patients (aged ≥ 18 years) with ICH within 8 hours of onset.

EXCLUSION CRITERIA:

Exclusion criteria were ICH secondary to anticoagulation, thrombolysis, trauma or a known underlying structural abnormality; patients for whom tranexamic acid was thought to be contraindicated; prestroke dependence (i.e. patients with a modified Rankin Scale [mRS] score > 4); life expectancy < 3 months; and a Glasgow Coma Scale score of < 5.

INTERVENTIONS:

Participants, allocated by randomisation, received 1 g of an intravenous tranexamic acid bolus followed by an 8-hour 1-g infusion or matching placebo (i.e. 0.9% saline).

MAIN OUTCOME MEASURE:

The primary outcome was functional status (death or dependency) at day 90, which was measured by the shift in the mRS score, using ordinal logistic regression, with adjustment for stratification and minimisation criteria.

RESULTS:

A total of 2325 participants (tranexamic acid, n = 1161; placebo, n = 1164) were recruited from 124 hospitals in 12 countries between 2013 and 2017. Treatment groups were well balanced at baseline. The primary outcome was determined for 2307 participants (tranexamic acid, n = 1152; placebo, n = 1155). There was no statistically significant difference between the treatment groups for the primary outcome of functional status at day 90 [adjusted odds ratio (aOR) 0.88, 95% confidence interval (CI) 0.76 to 1.03; p = 0.11]. Although there were fewer deaths by day 7 in the tranexamic acid group (aOR 0.73, 95% CI 0.53 to 0.99; p = 0.041), there was no difference in case fatality at 90 days (adjusted hazard ratio 0.92, 95% CI 0.77 to 1.10; p = 0.37). Fewer patients experienced serious adverse events (SAEs) after treatment with tranexamic acid than with placebo by days 2 (p = 0.027), 7 (p = 0.020) and 90 (p = 0.039). There was no increase in thromboembolic events or seizures.

LIMITATIONS:

Despite attempts to enrol patients rapidly, the majority of participants were enrolled and treated > 4.5 hours after stroke onset. Pragmatic inclusion criteria led to a heterogeneous population of participants, some of whom had very large strokes. Although 12 countries enrolled participants, the majority (82.1%) were from the UK.

CONCLUSIONS:

Tranexamic acid did not affect a patient's functional status at 90 days after ICH, despite there being significant modest reductions in early death (by 7 days), haematoma expansion and SAEs, which is consistent with an antifibrinolytic effect. Tranexamic acid was safe, with no increase in thromboembolic events.

FUTURE WORK:

Future work should focus on enrolling and treating patients early after stroke and identify which participants are most likely to benefit from haemostatic therapy. Large randomised trials are needed.

TRIAL REGISTRATION:

Current Controlled Trials ISRCTN93732214.

FUNDING:

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 35. See the NIHR Journals Library website for further project information. The project was also funded by the Pragmatic Trials, UK, funding call and the Swiss Heart Foundation in Switzerland.

plain-language-summary:

Stroke caused by bleeding in the brain [i.e. an intracerebral haemorrhage (ICH)] is a medical emergency. Around one-third of such strokes are complicated by continuing bleeding, which usually occurs within the first few hours after trauma and childbirth, and is associated with death or severe disability. Tranexamic acid is a drug that is seen to reduce death from bleeding after trauma and childbirth.The study enrolled adults within 8 hours of an ICH into this large randomised trial. Half of the participants were given an injection of tranexamic acid and the other half placebo (in the form of salt water). The main aim of the trial was to measure changes in recovery by a telephone questionnaire on how much the person was able to do or needed help with 90 days after the stroke (i.e. functional status). Other measures included amount of brain bleeding, complications after stroke (serious adverse events), drug side effects and death within 7 days of stroke.A total of 2325 participants from 124 hospitals in 12 countries were enrolled between 2013 and 2017. Participants treated with tranexamic acid had no significant difference in functional status 90 days after stroke. There were small but significant reductions in brain bleeding, death in the first 7 days and complications after stroke, and tranexamic acid was safe with no increased side effects.Treatment with tranexamic acid did not result in a significant improvement in recovery at 90 days (i.e. functional status), despite small reductions in the number of early deaths, amount of brain bleeding and the number of complications. Larger trials are needed to confirm if these small benefits observed after treatment with tranexamic acid can significantly improve functional status after stroke due to bleeding in the brain (ICH).

KEYWORDS:

INTRACEREBRAL HAEMORRHAGE; RANDOMISED CONTROLLED TRIAL; TRANEXAMIC ACID

PMID:
31322116
PMCID:
PMC6680370
DOI:
10.3310/hta23350
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Conflict of interest statement

Rustam Al-Shahi Salman is a member of the Efficacy and Mechanism Evaluation Funding Board panel. Lelia Duley reports grants from the Nottingham Clinical Trials Unit during the conduct of the study. Christian Ovesen reports grants from the Velux Foundation (Søborg, Denmark), the Hojmosegaard Grant/Danish Medical Association (Copenhagen, Denmark), the Axel Muusfeldt’s Foundation (Albertslund, Denmark), the University of Copenhagen (Copenhagen Denmark) and non-financial support from Merck Sharp & Dohme (MSD; Kenilworth, NJ, USA) outside the submitted work. Robert A Dineen reports grants from the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme (project number 11/129/109) during the conduct of the study. Timothy J England reports grants from the NIHR HTA programme during the conduct of the study. Thompson G Robinson reports grants from the University of Leicester. Christine Roffe has been a member of the HTA General Board since 2017. David Werring reports personal fees from Bayer AG (Leverkusen, Germany) outside the submitted work. Philip M Bath reports grants from the British Heart Foundation and the NIHR HTA programme during the conduct of the study, others from Platelet Solutions Ltd (Nottingham, UK) and personal fees from Diamedica (UK) Ltd (Bratton Fleming, UK), Nestlé SA (Vevey, Switzerland), Phagenesis Ltd (Manchester, UK), ReNeuron Group plc (Bridgend, UK), Athersys Inc. (Cleveland, OH, USA) and Covidien (Dublin, Ireland) outside the submitted work.

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