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Clinical Investigations in Critical Care |

Extended Evaluation of Recombinant Human Activated Protein C United States Trial (ENHANCE US)*: A Single-Arm, Phase 3B, Multicenter Study of Drotrecogin Alfa (Activated) in Severe Sepsis

Gordon R. Bernard, MD, FCCP; Benjamin D. Margolis, MD, FCCP; Harvey M. Shanies, MD, PhD, FCCP; E. Wesley Ely, MD, MPH, FCCP; Arthur P. Wheeler, MD, FCCP; Howard Levy, MB,BCh, PhD, FCCP; Kar Wong, PhD; Theressa J. Wright, MD; for the Extended Evaluation of Recombinant Human Activated Protein C United States Investigators
Author and Funding Information

Affiliations: *From the Division of Allergy, Pulmonary, and Critical Care Medicine (Drs. Bernard, Ely, and Wheeler), Vanderbilt University School of Medicine, Nashville, TN; Section of Pulmonary and Critical Care Medicine (Dr. Margolis), West Suburban Hospital, Oak Park, IL; Division of Pulmonary and Critical Care Medicine (Dr. Shanies), Mount Sinai School of Medicine, New York, NY; and Lilly Research Laboratories (Drs. Levy, Wong, and Wright), Eli Lilly and Company, Indianapolis, IN.,  A list of the ENHANCE US investigators in located in the Appendix.

Correspondence to: Gordon R. Bernard, MD, FCCP, Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, T-1218 Medical Center North, Vanderbilt University School of Medicine, Nashville, TN 37232; e-mail: Gordon.Bernard@vanderbilt.edu



Chest. 2004;125(6):2206-2216. doi:10.1378/chest.125.6.2206
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Study objective: To gather additional 28-day all-cause mortality and safety data among adult patients with severe sepsis who were treated with drotrecogin alfa (activated).

Design: Prospective, single-arm, multicenter clinical trial.

Setting: Eighty-five study sites in the United States and two in Puerto Rico.

Participants: Adult patients (273 patients) with a diagnosis of severe sepsis, which was defined as a systemic inflammatory response due to acute infection and one or more sepsis-induced organ dysfunctions present for ≤ 48 h, as in the recombinant human activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) trial.

Interventions: Drotrecogin alfa (activated) [Xigris; Eli Lilly and Company; Indianapolis, IN], 24 μg/kg/h, as a continuous IV infusion for a duration of 96 ± 1 h.

Measurements and results: The primary end point was all-cause mortality, which was assessed 28 days after the start of the infusion of drotrecogin alfa (activated). Serious bleeding was monitored to day 28. Comparisons of mortality were made to treatment groups from two double-blind, placebo-controlled clinical trials (PROWESS United States and the Secretory Phospholipase A2 Inhibitor [sPLA2I] in Severe Sepsis trial) that used similarly defined patient populations from the United States. For the 273 adult patients enrolled in this study, the 28-day all-cause mortality rate was 26.4%. This mortality rate was 6% lower than that observed in the placebo groups in the PROWESS US trial (32.9%) and the sPLA2I trial (33.2%), and was similar to that of the group treated with drotrecogin alfa (activated) in the PROWESS US trial (24.4%). One nonfatal intracranial hemorrhage was reported in the Extended Evaluation of Recombinant Human Activated Protein C United States trial (ENHANCE US) [0.35%]. Serious bleeding events during the infusion period occurred in 11 patients (4.0%) compared to 10 patients (2.8%) in the PROWESS US drotrecogin alfa (activated) treatment group.

Conclusions: Despite the limitations associated with comparisons across trials, this study provides confirmatory evidence of the efficacy and safety of drotrecogin alfa (activated) documented in the PROWESS trial.

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