Erythropoietin in Traumatic Brain Injury (EPO-TBI)

• Probability of an equal or greater Glasgow Coma Scale Extended (GOSE) level at 6 months compared to the probability of a lesser GOSE level, using a proportional odds model [ Time Frame: 6 months ] [ Designated as safety issue: No ]
• Proportion of surviving patients with unfavourable neurological outcome (GOSE 2-4) at 6 months [ Time Frame: 6 months ] [ Designated as safety issue: No ]
• Quality of life assessment (SF-12 and EQ-5D) at 6 months [ Time Frame: 6 months ] [ Designated as safety issue: No ]
• Mortality at 6 months [ Time Frame: 6 months ] [ Designated as safety issue: No ]
• Rate of proximal deep venous thrombosis detected during screening by compression Doppler ultrasound [ Time Frame: up to ICU discharge ] [ Designated as safety issue: Yes ]
• Proportion of patients with composite thrombotic vascular events (DVT, pulmonary embolus, myocardial infarction, cardiac arrest and cerebrovascular events) at 6 months [ Time Frame: 6 months ] [ Designated as safety issue: Yes ]
• Cost effectiveness analysis at 6 months (based on EQ-5D) [ Time Frame: 6 months ] [ Designated as safety issue: No ]

• Probability of an equal or greater GOSE level at 6 months compared to the probability of a lesser GOSE level, using a proportional odds model [ Time Frame: 6 months ] [ Designated as safety issue: No ]
• Proportion of surviving patients with unfavourable neurological outcome (GOSE 2-4) at 6 months [ Time Frame: 6 months ] [ Designated as safety issue: No ]
• Quality of life assessment (SF-12 and EQ-5D) at 6 months [ Time Frame: 6 months ] [ Designated as safety issue: No ]
• Mortality at 6 months [ Time Frame: 6 months ] [ Designated as safety issue: No ]
• Rate of proximal deep venous thrombosis detected during screening by compression Doppler ultrasound [ Time Frame: up to ICU discharge ] [ Designated as safety issue: Yes ]
• Proportion of patients with composite thrombotic vascular events (DVT, PE, myocardial infarction, cardiac arrest and cerebrovascular events) at 6 months [ Time Frame: 6 months ] [ Designated as safety issue: Yes ]
• Duration and incidence of organ failure [ Time Frame: up to ICU discharge ] [ Designated as safety issue: No ]
• Cost effectiveness analysis at 6 months (based on EQ-5D) [ Time Frame: 6 months ] [ Designated as safety issue: No ]

Many people who have a traumatic brain injury (TBI) - usually from a blow to the head such as in a vehicle collision or in a fall do not survive or, if they do, suffer from long-term disability. Previous studies have shown that about 1,000 people in Australia and New Zealand suffer a moderate or severe TBI every year. With current best available treatment and therapies many of these patients sustain loss of brain function and long term disability in varying degrees.

When a patient sustains a traumatic brain injury there are two phases to the injury. First, the head-impact causes immediate damage to the brain. The secondary injury, which can evolve over hours or weeks, is a very complicated process. It involves many, linked, changes to the cells, brain chemistry, tissues or blood vessels that can destroy brain tissue. The treatment of brain injury focuses on trying to minimize the secondary injury and there is much research being done to try to find treatments that will prevent it.

Erythropoietin (EPO) has recently emerged as a drug that may help reduce secondary injury and improve brain function. It has been found to offer some protection to the brain when brain cells are deprived of their normal oxygen supply causing cells to die or be impaired.

The aim of this study is to determine if EPO reduces secondary brain injury and helps patients make a better recovery after traumatic brain injury. The investigators also plan to monitor the effect of EPO on the rate of deep vein thrombosis (DVT - blood clots in the large veins in lower extremity) in patients with moderate or severe TBI in the intensive care unit (ICU).

Study Hypothesis:

In patients with moderate (GCS 9-12) or severe (3-8) TBI, EPO therapy improves long-term neurological function assessed 6 months after injury.

• Drug: Epoetin Alfa
  40,000 IU given as subcutaneous injection weekly up to 3 doses
• Drug: Placebo, Sodium Chloride
  1 ml given as a subcutaneous injection weekly up to 3 doses

• Active Comparator: Erythropoietin
  Intervention: Drug: Epoetin Alfa
• Placebo Comparator: Placebo
  Intervention: Drug: Placebo, Sodium Chloride

Inclusion Criteria:

• Are ≥ 15 to ≤ 65 years of age
• Are < 24 hours since primary traumatic injury
• Are expected to stay ≥ 48 hours
• Have a haemoglobin not exceeding the upper limit of the applicable normal (ULN) reference range in clinical use at the treating institution
• Have written informed consent from legal surrogate

Exclusion Criteria:

• GCS = 3 and fixed dilated pupils
• History of DVT, PE or other thromboembolic event
• A chronic hypercoagulable disorder, including known malignancy
• Treatment with EPO in the last 30 days
• First dose of study drug unable to be given within 24 hours of primary injury
• Pregnancy or lactation or 3 months post partum
• Uncontrolled hypertension (systolic blood pressure of >200 mm Hg or diastolic blood pressure of >110 mm Hg)
• Acute myocardial infarct
• Expected to die imminently (< 24 hours)
• Inability to perform lower limb ultrasounds
• Known sensitivity to mammalian cell derived products
• Hypersensitivity to the active substance or to any of the additives
• Pure red cell aplasia (PRCA)
• End stage renal failure (receives chronic dialysis)
• Severe pre-existing physical or mental disability or severe co-morbidity that may interfere with the assessment of outcome
• Spinal cord injury
• Treatment with any investigational drug within 30 days before enrolment
• The treating physician believes it is not in the best interest of the patient to be randomised to this trial

• National Health and Medical Research Council, Australia
• Transport Accident Commission
• Australian and New Zealand Intensive Care Society Clinical Trials Group
• Monash University