Diuretic Versus Placebo in Pulmonary Embolism (DiPER)

Assistance Publique - Hôpitaux de Paris

Status and phase: Unknown; Phase 3

Conditions: Pulmonary Embolism With Right Ventricle Enlargement

Treatments: Drug: Diuretics : Furosemide; Drug: Placebo

Study type: Interventional

Funder types: Other

Identifiers

NCT02268903

AOM 130519

Details and patient eligibility

About

Pulmonary Embolism (PE) is a frequent and severe disease with an annual incidence of about 75000 cases in France and a short-term mortality rate of about 10%. Death is usually related to an acute right ventricular (RV) failure due to the increase in right ventricular afterload. Treatment of PE with RV failure consists in fluid expansion and thrombolysis in case of shock. However several studies suggest that fluid expansion may worsen acute RV failure by increasing RV dilatation and ischemia and left ventricular compression by RV dilatation. Thus, current guidelines regarding PE treatment remain unclear about the use of fluid expansion. In a preliminary study published by our group, we showed that diuretic treatment in the setting of PE with RV dilatation is safe and is associated with an increase in urine output, a decrease in heart rate and an increase in SpO2 in normotensive patients with oliguria. This may be related to the decrease of ventricular interdependence and enhancement of both LV and RV function.

The main objective of the study is to evaluate the 24-hours clinical benefit of furosemide in patients referred for acute PE with RV dilatation compared to placebo. The combination of urine output and sPESI clinical parameters reflects hemodynamic status. It is relevant as it indicates the disappearance of pre-shock symptoms and is therefore associated with a lower event risk. Thus, it allows early discharge of the patients from the intensive care unit.

Enrollment: 270 estimated patients

Sex: All

Ages: 18+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

Patients aged 18 years and over with

1. Symptomatic acute pulmonary embolism with first clinical symptoms within 15 days, and objectively confirmed by CT scan

2. RV dysfunction (≥1 criterion) confirmed by elevated BNP value or echocardiography or spiral computed tomography of the chest:

   • Echocardiography

     o Right/Left ventricular end diastolic diameter > 1(apical or subcostal 4-chamber view)

   • Computed tomography

     o Right/Left short-axis diameter ratio>0.9 (transverse plane)

   • Positive Nt-proBNP (>600) or BNP>200 pg/mL

3. One abnormal following PESI criteria

   • Heart Rate>110/min
   • Systolic blood pressure<100mmHg
   • Arterial oxyhemoglobin level<90% on room air or after 5 minutes of oxygen withdrawal.

Exclusion criteria

• Cardiogenic shock requiring thrombolysis
• Previous significant left ventricular insufficiency (LVEF<45%)
• Systolic blood pressure<90mmHg at admission
• Age ≤ 18 years
• Pregnancy
• No health insurance
• Patients deprived of liberty or under legal protection
• Creatinin clearance <30mL/min/m²
• hypersensibility to furosemide or its excipients
• functional renal insufficiency
• Hepatic encephalopathy
• Urinary tracks obstruction
• Hypovolemia or dehydration.
• Sever hypokalemia (K+ < 3mmol/L)
• Severe hyponatremia (Na+ < 125mmol/L)
• Ongoing hepatitis and hepatic insufficiency severe in patients with renal insufficiency or dialysis

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Quadruple Blind

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270 participants in 2 patient groups, including a placebo group

Diuretics

Active Comparator group

Treatment:

Drug: Diuretics : Furosemide

Placebo

Placebo Comparator group

Treatment:

Drug: Placebo