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

Abstract 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 t...

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Autores principales:	John M. VanBuren, T. Charles Casper, Daniel K. Nishijima, Nathan Kuppermann, Roger J. Lewis, J. Michael Dean, Anna McGlothlin, For the TIC-TOC Collaborators of the Pediatric Emergency Care Applied Research Network (PECARN)
Formato:	article
Lenguaje:	EN
Publicado:	BMC 2021
Materias:	Bayesian statistics Tranexamic acid Pediatrics Adaptive clinical trial design Response-adaptive randomization Dose-response Medicine (General) R5-920
Acceso en línea:	https://doaj.org/article/1cc18e06b8e348a38442702dd6d5bb1c
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spelling	oai:doaj.org-article:1cc18e06b8e348a38442702dd6d5bb1c2021-11-08T11:02:56ZThe design of a Bayesian adaptive clinical trial of tranexamic acid in severely injured children10.1186/s13063-021-05737-01745-6215https://doaj.org/article/1cc18e06b8e348a38442702dd6d5bb1c2021-11-01T00:00:00Zhttps://doi.org/10.1186/s13063-021-05737-0https://doaj.org/toc/1745-6215Abstract 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.John M. VanBurenT. Charles CasperDaniel K. NishijimaNathan KuppermannRoger J. LewisJ. Michael DeanAnna McGlothlinFor the TIC-TOC Collaborators of the Pediatric Emergency Care Applied Research Network (PECARN)BMCarticleBayesian statisticsTranexamic acidPediatricsAdaptive clinical trial designResponse-adaptive randomizationDose-responseMedicine (General)R5-920ENTrials, Vol 22, Iss 1, Pp 1-11 (2021)
institution	DOAJ
collection	DOAJ
language	EN
topic	Bayesian statistics Tranexamic acid Pediatrics Adaptive clinical trial design Response-adaptive randomization Dose-response Medicine (General) R5-920
spellingShingle	Bayesian statistics Tranexamic acid Pediatrics Adaptive clinical trial design Response-adaptive randomization Dose-response Medicine (General) R5-920 John M. VanBuren T. Charles Casper Daniel K. Nishijima Nathan Kuppermann Roger J. Lewis J. Michael Dean Anna McGlothlin For the TIC-TOC Collaborators of the Pediatric Emergency Care Applied Research Network (PECARN) The design of a Bayesian adaptive clinical trial of tranexamic acid in severely injured children
description	Abstract 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.
format	article
author	John M. VanBuren T. Charles Casper Daniel K. Nishijima Nathan Kuppermann Roger J. Lewis J. Michael Dean Anna McGlothlin For the TIC-TOC Collaborators of the Pediatric Emergency Care Applied Research Network (PECARN)
author_facet	John M. VanBuren T. Charles Casper Daniel K. Nishijima Nathan Kuppermann Roger J. Lewis J. Michael Dean Anna McGlothlin For the TIC-TOC Collaborators of the Pediatric Emergency Care Applied Research Network (PECARN)
author_sort	John M. VanBuren
title	The design of a Bayesian adaptive clinical trial of tranexamic acid in severely injured children
title_short	The design of a Bayesian adaptive clinical trial of tranexamic acid in severely injured children
title_full	The design of a Bayesian adaptive clinical trial of tranexamic acid in severely injured children
title_fullStr	The design of a Bayesian adaptive clinical trial of tranexamic acid in severely injured children
title_full_unstemmed	The design of a Bayesian adaptive clinical trial of tranexamic acid in severely injured children
title_sort	design of a bayesian adaptive clinical trial of tranexamic acid in severely injured children
publisher	BMC
publishDate	2021
url	https://doaj.org/article/1cc18e06b8e348a38442702dd6d5bb1c
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The design of a Bayesian adaptive clinical trial of tranexamic acid in severely injured children

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