ARTEMIDA Trial (A Randomized Trial of Efficacy, 12

Months International Double-Blind Actovegin)

A Randomized Controlled Trial to Assess the Efficacy of Actovegin
in Poststroke Cognitive Impairment
Alla Guekht, MD; Ingmar Skoog, MD; Sally Edmundson, MSc; Vladimir Zakharov, MD;
Amos D. Korczyn, MD, MSc

Background and Purpose—Poststroke cognitive impairment is a debilitating consequence of stroke. The aim of this study
was to assess whether Actovegin confers cognitive benefit in patients who have had an ischemic stroke.
Methods—This was a 12-month, parallel-group, randomized, multicenter, double-blind, placebo-controlled study. Eligible
patients were ≥60 years of age with a Montreal Cognitive Assessment test score of ≤25 points. Patients were randomized
into 2 groups within 1 week of acute supratentorial ischemic stroke in a 1:1 ratio: Actovegin (a deproteinized hemoderivative
of calf blood, 2000 mg/d for ≤20 intravenous infusions followed by 1200 mg/d orally) or placebo for 6 months. Patients
Downloaded from http://stroke.ahajournals.org/ by guest on May 28, 2017

were treated in accordance with standard clinical practice for a further 6 months. The primary end point was the change
from baseline in Alzheimer’s Disease Assessment Scale, cognitive subscale, extended version at 6 months.
Results—Two-hundred forty-eight patients were randomized to Actovegin and 255 patients to placebo. At month 6, the least
squares mean change from baseline in Alzheimer’s Disease Assessment Scale, cognitive subscale, extended version was
−6.8 for Actovegin and −4.6 for placebo; the estimated treatment difference was −2.3 (95% confidence interval, −3.9,
−0.7; P=0.005). Recurrent ischemic stroke was the most frequently reported serious adverse event, with a nonsignificantly
higher number for Actovegin versus placebo.
Conclusions—Actovegin had a beneficial effect on cognitive outcomes in patients with poststroke cognitive impairment.
The safety experience was consistent with the known safety and tolerability profile of the drug. These results warrant
confirmation in additional robustly designed studies.
Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01582854.   
(Stroke. 2017;48:00-00. DOI: 10.1161/STROKEAHA.116.014321.)
Key Words: Actovegin ◼ post-stroke cognitive impairment ◼ stroke ◼ vascular dementia

A lthough the standard of stroke care has improved sub-

stantially and rates of stroke mortality have decreased in
the past 2 decades, stroke remains one of the most common
causes of death worldwide and the third leading cause of loss of
disability-adjusted life years.1–3 Stroke significantly increases
cognitive decline among stroke survivors.4 Poststroke cogni-
tive impairment (PSCI) is associated with significant morbid-
ity with ≤41% of patients becoming clinically demented in the
first year after a stroke.5
Targets critical to the prevention of PSCI focus on acute
treatment and the prevention of recurrence. However, there are
no established therapeutic strategies, and candidate pharmaco-
logical therapies have yet to demonstrate efficacy in reducing
or preventing cognitive decline after stroke, using randomized
controlled trials in the acute stroke setting.6,7
Randomized controlled trials examining the use of
Alzheimer’s disease (AD) symptomatic therapies such as ace-
tylcholinesterase inhibitors (AChEIs) and memantine have
shown some clinical benefits in vascular dementia (VaD)
but have not been granted U.S. Food & Drug Administration
approval for use in VaD primarily because of inconsistent
efficacy with respect to activities of daily living and global
function.8 Approaches targeting multiple pathogenetic mecha-
nisms, such as biological therapies, have hinted at a break-
through, but the available evidence has also been limited to
date.9

Received July 7, 2016; final revision received February 8, 2017; accepted February 10, 2017.
From the Department of Neurology, Neurosurgery and Genetics, Russian National Research Medical University Moscow and Clinical Center for
Neuropsychiatry, Russia (A.G.); Sahlgrenska Academy, University of Gothenburg, Sweden (I.S.); Takeda Development Centre Europe, London, United
Kingdom (S.E.); Department of Neurology, First Moscow State Medical University, Russia (V.Z.); and Department of Neurology, Tel Aviv University,
Israel (A.D.K.).
The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.
116.014321/-/DC1.
Correspondence to Alla Guekht, MD, Department of Neurology, Neurosurgery and Genetics, Russian National Research Medical University Moscow
and Moscow Research and Clinical Center for Neuropsychiatry, Donskaya St, 43, Moscow 115419, Russia. E-mail guekht@mail.ru
© 2017 The Authors. Stroke is published on behalf of the American Heart Association, Inc., by Wolters Kluwer Health, Inc. This is an open access
article under the terms of the Creative Commons Attribution Non-Commercial-NoDerivs License, which permits use, distribution, and reproduction in any
medium, provided that the original work is properly cited, the use is noncommercial, and no modifications or adaptations are made.
Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STROKEAHA.116.014321

1
 2  Stroke  May 2017
Actovegin is a deproteinized pyrogen- and antigen-free
hemodialysate manufactured from calf blood by ultrafiltra-
tion. It contains >200 bioactive constituents (with molecular
weight <5 kDa) and exhibits a range of pleiotropic effects.10
Actovegin improves oxygen utilization and uptake, as well
as energy metabolism and glucose uptake in mitochon-
dria, thereby enhancing oxidative metabolism in the brain.11
Actovegin has been shown to possess neuroprotective poten-
tial; it ameliorated Aβ25–35-induced neuronal apoptosis by
reducing caspase-3 levels in a dose-dependent manner and
decreasing reactive oxygen species content in hippocampal
neurons.12 The effects of Actovegin on cerebral metabolism,
mortality, and cognitive performance have also been assessed
in animal models of cerebral ischemia.13–15 Actovegin facili-
tated [14C] glucose uptake into the brain under hypoxic condi-
tions and normalized metabolic parameters, measured as the
concentrations of glucose, lactate, creatine phosphate, and
adenosine triphosphate normalized in 2-year-old rats. Most
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recently, a study in a rat model of transient global cerebral
ischemia found that Actovegin significantly decreased hip-
pocampal CA1 cell death and improved spatial learning and
memory.16
Actovegin received its market authorization in 1976
in Germany; in 1995, production was transferred from
Germany to Linz, Austria. Actovegin is registered for clini-
cal use in Austria, Russia, countries of The Commonwealth
of Independent States, some Eastern European, and Asian
countries. Actovegin was never introduced to the U.S. Food
& Drug Administration; therefore, it is not marketed in North
America. In the clinical setting, Actovegin has been used for
around 40 years for the treatment of various neurological dis-
orders, including cerebrovascular disease and cognitive decline
of various origins. It is also prescribed for the treatment of
peripheral arterial disease and diabetic polyneuropathy. In
randomized, placebo-controlled trials, Actovegin has been
shown to improve cognitive performance in patients with age-
associated memory impairment.17,18 Two pilot studies in stroke
patients have shown treatment benefits with Actovegin based
on many cognitive and neurological deficit measures. It has
provided some evidence on the effects of Actovegin in acute
ischemic stroke, but these have never been tested in a multi-
center randomized study.19,20 Apart from its clinical properties,
it has been suggested that Actovegin also has ergogenic effects.
This is, however, not based on scientific evidence; the specula-
tion emerged because Actovegin has repeatedly been used as a
performance-enhancing drug by professional cyclists and by
Olympic athletes, possibly to accelerate muscle injury repair
and improve endurance. Late in 2000, Actovegin was included
on the World Anti-Doping Agency active list, but it was
removed again after 2 months because of insufficient direct
evidence demonstrating an ergogenic effect of Actovegin.21
The overall safety profile of Actovegin seems favorable, and its
clinical use for >35 years has not identified any unacceptable
safety concerns. Indeed, the Actovegin summary of product
characteristics22 states that only in rare cases, patients prone
to hypersensitivity may develop allergic reactions (medication
fever and anaphylactic shock), urticaria, flush, and myalgia. In
contrast, AChEIs and memantine have side effects which occur
commonly in patients, including gastrointestinal effects (diar-
rhea or constipation), headache, and dizziness.23,24
The ARTEMIDA study (A Randomized Trial of Efficacy,
12 Months International Double-Blind Actovegin) was
designed to test the hypothesis that Actovegin would confer
cognitive benefits in patients with acute ischemic stroke.25 In
addition, we wanted to explore whether the therapeutic effects
are sustained after treatment cessation and provide evidence
of efficacy and safety tolerability of Actovegin for the symp-
tomatic effect on PSCI.
Methods
Study Design, Treatment Regimen, and Procedures
ARTEMIDA was a multicenter, randomized, double-blind, placebo-
controlled, parallel-group study assessing the effects of Actovegin on
cognitive functioning in patients with PSCI. Patients were recruited
from 33 tertiary hospitals in Russia, Belarus, and Kazakhstan (Table I
in the online-only Data Supplement). The study consisted of a screen-
ing and randomization period (≤7 days post-stroke), a 6-month dou-
ble-blind treatment period and a 6-month follow-up period (Figure I
in the online-only Data Supplement). During double-blind treatment,
patients were randomized to receive either intravenous Actovegin
(0.9% sodium chloride; 2000 mg/250 mL daily for ≤20 infusions
followed by 1200 mg/d orally [two 200 mg tablets 3× daily]) or pla-
cebo for 6 months. Actovegin and placebo were then discontinued,
and patients were followed up for a subsequent 6 months. Patients
were hospitalized in stroke units for first or recurrent stroke and
received standard stroke care in accordance with local guidelines
which included general supportive care, treatment of acute com-
plications, rehabilitation, and antiplatelet therapy; nootropic agents
were excluded. Visits were scheduled at baseline, at the end of the
infusion period, then every 4 weeks until the end of 6 months treat-
ment, and a single visit 6 months after the end of treatment. Adverse
events (AEs), treatment compliance, and concomitant medication use
were reported during each visit. The study protocol was approved by
each respective institutional review board or ethics committee and
followed established Good Clinical Practice guidelines. All patients
gave written informed consent to participate in the study. An indepen-
dent contract research organization, Pharm-Olam International Ltd
(Houston), managed the administration, coordination, and monitor-
ing of the study, including data management, statistical analysis, and
the Interactive Voice Response System–Interactive Web Response
System, with oversight by Takeda.
Inclusion and Exclusion Criteria
Patients were eligible for enrolment if they were ≥60 years of age, had
a clinical diagnosis of acute supratentorial ischemic stroke (National
Institutes of Health Stroke Scale [NIHSS] score of 3–18) confirmed
by computed tomography or magnetic resonance imaging. Patients
must have been conscious, able to complete the Montreal Cognitive
Assessment (MoCA; score of ≤25 points with adjustment for level
of education) and extended version of the Alzheimer’s Disease
Assessment Scale-cognitive subscale (ADAS-cog+), and without
evidence of dementia documented in medical records or according
to concern of a knowledgeable informant. A detailed patient history
was performed. Full lists of study inclusion and exclusion criteria and
prohibited medications during double-blind treatment are provided in
Tables II through IV in the online-only Data Supplement.
Randomization and Masking
Patients were randomized to receive either Actovegin or placebo
in a 1:1 ratio, without stratification and using a block size of 4, by
means of a computerized central randomization system, Interactive
Voice Response System–Interactive Web Response System. During
double-blind treatment and until end of follow-up, all investigators
 Guekht et al   Effect of Actovegin After Acute Ischemic Stroke   3
and patients were masked to treatment assignment (Randomization
and Masking Full Methods in the online-only Data Supplement).
Efficacy and Safety Criteria
The primary end point, the ADAS-cog+ change from baseline, was
performed at 6 months. The same measure was performed at 3 and
12 months as a secondary end point. Other secondary end points
were performed as follows: the change from baseline in MoCA
and the NIHSS during screening, 3, 6, 12 months, and at the end
of the infusion period; the Beck Depression Inventory (BDI-II) at
3, 6, and 12 months; the Barthel Index at 6 months; the EuroQoL
EQ-5D questionnaire at 6 and 12 months; and the International
Statistical Classification and Related Health Problems, version 10
diagnosis of dementia at 6 and 12 months. A full list of all primary,
secondary, and safety end points is given in Table V in the online-
only Data Supplement. The presentation of safety data focused on
treatment-emergent AEs (TEAEs). TEAEs were defined as AEs that
first occurred or worsened (increase in severity) after the first dose
of study drug. There were no prespecified safety end points. TEAEs
were reported spontaneously by the patient in response to an open-
ended question by the contact at each visit; abnormal laboratory
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values that constituted a serious adverse event or led to the discon-
tinuation of Actovegin were reported as a TEAE.
Statistical Analysis
All reported efficacy analyses were predefined and based on the
intent-to-treat (ITT) population (randomized and received any study
medication). In addition, supportive analyses were performed in a
predefined per protocol population which includes those ITT patients
who did not have any key protocol deviations, including violation of
inclusion and exclusion criteria (Per Protocol Analyses in the online-
only Data Supplement).
For the analyses of change from baseline in ADAS-cog+, partially
complete ADAS-cog+ assessments with missing individual item
scores were imputed with the worst score on the test. Completely
missing ADAS-cog+ scores at 6 months were imputed by last obser-
vation carried forward from 3 months, considered conservative as the
condition under study was expected to improve spontaneously over
this period.26 Change from baseline in ADAS-cog+ at 3, 6 (primary
end point), and 12 months was analyzed using an ANCOVA model,
including treatment, grouped center, baseline score, and the treat-
ment by grouped center interaction (included as significant at the
10% significance level). The grouping of centers into 8 geographi-
cal groups was determined before unblinding. Changes in MoCA
and NIHSS score were analyzed using ANCOVA models, including
treatment, grouped center, baseline score, and in addition for MoCA,
number of years of education. The least squares (LS [population
margin mean]) means, mean differences between treatments, and
associated 95% confidence intervals (CIs) were estimated from the
ANCOVA models.
The ADAS-cog has been widely used as the primary efficacy
outcome in AD clinical trials and has been used to assess cognitive
impairment in stroke trials along with other instruments.27,28 The
ADAS-cog+ is an expanded version of the ADAS-cog, which has
increased sensitivity in detecting patients with mild cognitive impair-
ment and may be particularly useful in vascular cognitive impair-
ment29; however, it has never been used in clinical trials to assess
the effects of treatments on cognition in stroke patients. Generally,
in clinical trials, outcomes may be measured in different ways. We
defined responders as having a ≥4-point improvement on the ADAS-
cog+ as this is accepted to represent a clinically relevant change on an
individual basis in patients with mild-to-moderate AD.30,31
The proportions of ADAS-cog+ responders at 3, 6, and 12
months were compared between treatments using a χ2 test, and the
proportions of patients with a diagnosis of dementia (according to
International Statistical Classification and Related Health Problems,
version 10 criteria) by 6 and 12 months were compared using a Fisher
exact test; 95% CI was calculated using the Normal approximation to
the Binomial distribution with a continuity correction. The Barthel
Index, BDI-II, and EuroQoL EQ-5D were summarized using descrip-
tive statistics.
The sample size, based on a 2-sample t test with 5% 2-sided sig-
nificance level, estimated that 200 patients per treatment arm would
provide 90% power to detect a difference of at least 2.6 in the mean
change from baseline to 6 months in ADAS-cog+ score between the
groups, assuming a common SD of 8.0. After allowing for an esti-
mated dropout rate of 20%, a total of 500 patients were planned to
be randomized.
A more accurate power calculation would have been obtained if
it had been based on the ANCOVA model, but at the time of plan-
ning the study, the information about correlation between outcome
and covariate was not available. Therefore, a preexisting estimate of
the SD from an ANOVA analysis was used as a suitable alternative.
No multiplicity adjustments were made to the primary and second-
ary end point results. SAS version 9.1.3 was used for all statistical
analyses.
Results
Study Population
Patient recruitment began in June 2012, and the study ended
in November 2014. Of 522 patients recruited, 503 patients
were randomized (248 to Actovegin and 255 to placebo),
received ≥1 dose of study medication, and were included in
the ITT and safety analysis set (see Figure 1 for patient flow
diagram). However, there were 2 patients who were random-
ized to the placebo group but received an incorrect kit, which
after unblinding was determined to have contained Actovegin.
Those patients were included as randomized for the ITT anal-
yses (placebo group) and as treated for the safety analyses.
Patients who had not prematurely discontinued the study were
considered to have completed the study. Study discontinua-
tion was similar in both groups, 36 (14.5%) in the Actovegin
group and 34 (13.3%) in the placebo group. Key protocol
deviations (eg, disallowed concomitant medication, ADAS-
cog+ performed incorrectly; Table VI in the online-only Data
Supplement) were similar between groups (placebo: n=35
[13.7%], Actovegin: n=36 [14.5%]). In total, 71 (14.1%) of
503 patients had at least 1 key protocol deviation. In terms
of stroke care, overall, 81.1% of patients had received ≥1 of
the following rehabilitation therapies: physiotherapy (86.3%),
other rehabilitation therapy (40.0%), speech therapy (21.7%),
cognitive rehabilitation therapy (18.9%), and occupational
therapy (16.5%). The incidences of rehabilitation therapy
were similar between the treatment groups.
All of the patients reported medical history and concomi-
tant disease. The incidences of reported medical history and
concomitant disease were similar between the treatment
groups Table 1). Overall, the following were reported in
≥20.0% of patients: hypertension (87.1%), myocardial isch-
emia (28.8%), cerebral arteriosclerosis (23.5%), coronary
artery disease (21.3%), and arteriosclerosis (24.1%). Table 1
shows the demographic and baseline characteristics of the ITT
analysis set. Overall, there were no meaningful differences in
demographic and baseline characteristics between the study
groups. The mean (SD) NIHSS score at baseline was similar
in both Actovegin and placebo groups (5.3 [2.24] versus 5.6
[2.37]). The mean total number of intravenous infusions was
12.2 (median of 12.0) in both groups. Adherence to treatment
was high (a mean of 99.6% for the infusions and 93.3% for
the tablets).
 4  Stroke  May 2017
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Figure 1. Patient flow diagram. The numbers presented are as treated. There were 2 patients who were randomized to the placebo group
but received an incorrect kit, which after unblinding was determined to have contained Actovegin. Those patients are included as ran-
domized for the intent-to-treat (ITT) analyses (placebo group) and as treated for the safety analyses (Actovegin group). More than 1 reason
for discontinuation could have been selected.
Clinically significant laboratory values (cholesterol and
low-density lipoprotein cholesterol) were observed at screen-
ing (Table 1). These values remained significant at month 6
for cholesterol (14/253 patients [5.5%] in the placebo group
and 12/250 patients (4.8%) in the Actovegin group) and low-
density lipoprotein cholesterol (15/253 patients [5.9%] in the
placebo group and 11/250 patients [4.4%] in the Actovegin
group).
Efficacy
Primary End Point
Figure 2A illustrates and Table 2 enumerates the effect of
Actovegin and placebo on the change in ADAS-cog+ from
baseline to months 3, 6 (primary end point), and 12. At base-
line, the mean (SD) ADAS-cog+ score was similar between
Actovegin and placebo groups (29.4 [12.45] and 29.9 [12.49],
respectively). The LS mean change (SE) from baseline in
ADAS-cog+ at month 6 was greater for Actovegin (−6.8
[0.58]) than for placebo (−4.6 [0.58]), and the estimated LS
mean treatment difference from the model was statistically
significant (−2.3; 95% CI, −3.9, −0.7; P=0.005). The results
of the ANCOVA for the per protocol analysis set (196 and 202
patients in the Actovegin and placebo groups, respectively, at 6
months) were supportive of the results of the primary analysis
on the ITT set described (Per Protocol Analyses in the online-
only Data Supplement). Table 2 illustrates that missing scores
at month 6 were imputed using the month 3 scores (therefore,
the number of observations is the same for these 2 measure-
ments), whereas imputation for months 3 and 12 missing
scores was not planned because these were secondary end
points. The reasons for differing patient numbers with scores
between randomization, baseline, and each visit is because of
patients dropping out of the study (Figure 1), patients not turn-
ing up for a visit, or incorrectly completing the ADAS-cog+
(Table VI in the online-only Data Supplement), including 3
patients who completed the study but did not have the neces-
sary ADAS-cog+ data from which to calculate a change from
baseline required in Table 2.
Secondary End Points
At month 3, the mean ADAS-cog+ score had improved in
both groups (−5.4 [0.53] for Actovegin and −4.3 [0.52] for
placebo), but the LS mean treatment difference did not reach
statistical significance (−1.1; 95% CI, −2.6, 0.3; P=0.12). By
month 12 (6 months after treatment cessation), the LS mean
change had increased further for Actovegin (−8.2 [0.66]) than
for placebo (−4.5 [0.66]), and the estimated LS mean treat-
ment difference had increased to −3.7 (95% CI, −5.5, −1.9;
P<0.001).
A summary of the ADAS-cog+ responder analysis is pre-
sented in Figure 2B and Supplemental Table VII in the online-
only Data Supplement. At months 3, 6, and 12, statistically
 Guekht et al   Effect of Actovegin After Acute Ischemic Stroke   5

Table 1.  Baseline Characteristics of the Intent-to-Treat month 3, the LS mean difference between groups was 0.7 (95%
Population CI, 0.1, 1.2; P=0.016), at month 6, the LS mean difference was
Actovegin; Placebo; 0.7 (95% CI, 0.2, 1.3; P=0.013), and at month 12, the LS mean
n=248 n=255 difference increased to 1.0 (95% CI, 0.3, 1.7; P=0.003).
At month 6, 10.5% of patients in the placebo group and
Age, y 70.3 (6.7) 69.6 (7.2)
7.3% of patients in the Actovegin group had a diagnosis of
≤65 y
  78 (31.5) 97 (38.0) dementia (according to International Statistical Classification
Education (years) 12.2 (3.4) 12.3 (3.4) and Related Health Problems, version 10 criteria). By month
Male sex 128 (51.6) 113 (44.3) 12, the number of patients with a diagnosis of dementia had
increased to 12.7% in the placebo group and 8.7% in the
Diagnosis of diabetes mellitus 40 (16.1) 57 (22.4)
Actovegin group. Although the between-group differences
Previous ischemic stroke 40 (16.1) 38 (14.9) were not statistically significant, the numeric differences
Smoking status showed fewer dementia diagnoses in the Actovegin group ver-
sus placebo at month 6 (−3.2; 95% CI, −8.5, 2.1; P=0.25) and
 Never 172 (69.4) 195 (75.6)
month 12 (−4.0; 95% CI, −9.7, 1.7; P=0.22; Table VII in the
 Current 53 (21.4) 37 (14.5) online-only Data Supplement).
 Former 23 (9.3) 23 (9.0) Both treatment groups showed similar results in NIHSS
Medical history score with no statistically significant differences in scores
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between Actovegin and placebo at month 3 (−0.2; 95% CI,

 Hypertension 218 (87.9) 220 (86.3)
−0.5, 0.1; P=0.14), month 6 (0.0; 95% CI, −0.3, 0.2; P=0.89),
 Myocardial ischemia 71 (28.6) 74 (29.0) and month 12 (−0.1; 95% CI, −0.4, 0.2; P=0.46; Table VII in
 Cerebral arteriosclerosis 55 (22.2) 63 (24.7) the online-only Data Supplement).
 Coronary artery disease 52 (21.0) 55 (21.6)
Baseline scores for the Barthel Index, BDI-II, and EQ-5D
were not collected; these parameters were only summa-
NIHSS score at baseline mean (SD) 5.3 (2.24) 5.6 (2.37)
rized using descriptive statistics. Health scores were similar
MoCA score at baseline mean (SD) 2.2 (2.46) 1.9 (2.24) between groups. At months 3 and 6, the median Barthel Index
Total number of completed IV infusions mean score was 100.0 for both groups. However, more patients
12.2 (3.82) 12.1 (3.83)
(SD) in the Actovegin group had a score of ≥95 points compared
Concomitant medication with placebo at both months 3 (83.9% versus 76.6%) and 6
(84.0% versus 78.5%). At months 6 and 12, EuroQoL EQ-5D
 Platelet aggregation inhibitors excluding
230 (92.0) 243 (96.0) results were also similar between groups (Table VII in the
heparin (anticoagulant)
online-only Data Supplement). In both treatment groups, most
 ACE inhibitors 192 (76.8) 201 (79.4) patients had no problem or slight problems with mobility, self-
 Other antihypertensives 192 (76.8) 194 (76.7) care, and usual activities; no pain or slight pain; and were not
 Electrolyte solutions 122 (48.8) 126 (49.8) anxious or only slightly anxious. The mean general health
scores were also similar between the treatment groups (Table
 Amino acids and derivatives 116 (46.4) 129 (51.0)
VIII in the online-only Data Supplement). The majority of
 Statins (HMG COA reductase inhibitors) 108 (43.2) 113 (44.7) patients in both treatment groups had BDI-II scores between
Clinically significant laboratory values at screening (% of patients) 0 and 13 (indicating minimal depression) at months 3, 6, and
12 (Actovegin: 59.7%, 60.9%, and 62.1%; placebo: 61.2%,
 Cholesterol 17 (6.8) 17 (6.7)
59.5%, and 55.3% respectively).
 Triglycerides 11 (4.4) 10 (4.0)
Data are n (%) or mean (SD). ACE indicates angiotensin-converting enzyme; HMG Safety
CoA, 3-hydroxy-3-methyl-glutaryl-co-enzyme A; IV, intravenous; MoCA, Montreal
The safety analysis set includes all patients who received at
Cognitive Assessment; and NIHSS, National Institutes of Health Stroke Scale.
least 1 dose of medication, 250 in the Actovegin group and
253 in the placebo group. The incidence of TEAE was simi-
significantly more patients in the Actovegin group met the lar between the 2 study groups. TEAEs were reported by 96
definition of responder (≥4-point improvement in ADAS- (37.9%) of 253 patients receiving placebo and by 89 (35.6%)
cog+ score from baseline, defined a priori in the protocol and of 250 patients receiving Actovegin.
an established measure30) than in the placebo group. By month Overall, 33 of 503 patients (6.6%) discontinued treatment
6, 62.5% of patients in the Actovegin group were considered because of a TEAE (12/253 [4.7%] in the placebo group and
responders versus 52.3% in placebo. The difference in rates 21/250 patients [8.4%] in the Actovegin group). A total of 18
for Actovegin–placebo was 10.2%, with an associated 95% CI of 503 patients (3.6%) reported a TEAE that was considered
(0.8%, 19.5%), which was statistically significant in favor of related to the study medication, 9 (3.6%) in each treatment
Actovegin (P=0.034). group. A summary of patients with clinically significant labo-
Compared with placebo, Actovegin was also associated ratory test results and a summary of TEAEs related to chem-
with statistically significant improvements in MoCA scores istry laboratory results are provided in Tables IX and X in the
(Figure 3; Table VII in the online-only Data Supplement). At online-only Data Supplement, respectively.
 6  Stroke  May 2017

Figure 2. Analysis of the effect of

Actovegin and placebo on Alzheimer’s
Disease Assessment Scale, cognitive
subscale, extended version (ADAS-cog+).
A, Change in ADAS-cog+ score from
baseline over the course of the study in
the intent-to-treat (ITT) population. B,
Analysis of ADAS-cog+ responders in the
ITT population. A responder was defined
as demonstrating an improvement of ≥4
points on the ADAS-cog+ scale using
observed case data. *P=0.005; †P<0.001;
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‡P<0.05 vs placebo. CI indicates confi-

dence interval; LS, least squares; and tx,
treatment.

The most frequently reported TEAE was recurrent ischemic Discussion

stroke, followed by headache (Table 3). During double-blind
treatment, 21 patients (14 in the Actovegin group and 7 in
the placebo group) experienced cerebrovascular events (isch-
emic stroke, intracerebral hemorrhage, and transient ischemic
attack). The odds ratio (95% CI) for cerebrovascular events
for patients on Actovegin compared with placebo was 2.09
(0.83, 5.26), suggesting this was not statistically significant
(post hoc analysis). During the 6-month follow-up, 3 patients
in the placebo group and 2 patients in the Actovegin group dis-
continued because of recurrent ischemic stroke. Further safety
results and an overview of TEAEs (Table XI in the online-
only Data Supplement) and cerebrovascular events related
to TEAEs are provided in Table XII in the online-only Data
Supplement.
In this study, Actovegin improved cognitive outcomes in
patients with PSCI, compared with placebo. This is the first
prospective randomized controlled trial to assess the effect
of Actovegin on cognition in patients who had experienced a
recent mild-to-moderate ischemic stroke.
Actovegin treatment was commenced 5 to 7 days after
stroke onset to obtain credible cognitive function data at start-
ing point, and PSCI diagnosed by MoCA32,33 was similar in
the placebo and Actovegin groups at baseline. Patients with
previously diagnosed dementia were excluded; however, it
cannot be ruled out that patients may have had prestroke mild
AD or vascular cognitive impairment-not dementia.34 PSCI
represents vascular cognitive impairment by definition, but

Table 2.  Summary of Primary and Key Secondary Outcomes in the Intent-to-Treat Population
ADAS-cog+ Actovegin; n=248 Placebo; n=255 Actovegin vs Placebo (95% CI)
Baseline (mean, SD) 29.4 (12.5); n=241 29.9 (12.5); n=246 …
Change from baseline at mo 3* −5.4 (0.5); n=224 −4.3 (0.5); n=234 −1.1 (−2.6, 0.3); P=0.12
Change from baseline at mo 6† −6.8 (0.6); n=224 −4.6 (0.6); n=234 −2.3 (−3.9, −0.7); P=0.005
Change from baseline at mo 12* −8.2 (0.7); n=211 −4.5 (0.7); n=219 −3.7 (−5.5, −1.9); P<0.001
Data are LS mean (SE). ADAS-cog+ indicates Alzheimer’s Disease Assessment Scale, cognitive subscale, extended version;
CI, confidence interval; LOCF, last observation carried forward; and LS, least squares.
*Change from baseline (Imputed data) results based on data which include imputation of missing values. Partially missing
ADAS-cog+ scores, with some missing individual question scores, were imputed with the worst scenario score.
†Completely missing ADAS-cog+ scores were imputed by LOCF from Month 3.
 Guekht et al   Effect of Actovegin After Acute Ischemic Stroke   7
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vascular and degenerative components often overlap and con-
tribute to cognitive decline over the long term.35
Most patients in this study had multiple vascular risk fac-
tors, which could have triggered covert cerebrovascular
disease. However, neither AD biomarker assessments nor
specific magnetic resonance imaging protocols for detecting
white matter abnormalities were included in the study design.
This is a potential limitation of this study because patients
with white matter lesions or AD changes could have been less
susceptible to treatment or had a worse trajectory of cognitive
decline after stroke.
The dosing regimen of Actovegin for this trial reflected cur-
rent labeling, although oral treatment was for a longer period,
thus the dosing regimen in the current study was exploratory
to some extent. Our assumption that a 6-month treatment
period would be sufficient to show benefits was based on data
obtained in large-scale clinical trials on AChEIs for the treat-
ment of vascular cognitive impairment.8
The primary efficacy outcome in our study was the change
from baseline in ADAS-cog+ at 6 months using the last obser-
vation carried forward approach. A statistically significant
LS mean treatment difference of 2.3 points in ADAS-cog+
score was achieved in the Actovegin group at 6 months and
increased to 3.7 points at 12 months. The mean total ADAS-
cog+ scores improved in both groups over 12 months; how-
ever, the change was more prominent in the Actovegin group
at 3, 6, and 12 months and was supported by the secondary
efficacy end point. It is noteworthy that a statistically signifi-
cant improvement in Actovegin was sustained over 6 months
after treatment withdrawal. Significantly more patients receiv-
ing Actovegin met the definition of responder comparing to
placebo. The proportion of responders increased over time in
both treatment groups, which can be partially explained by the
spontaneous recovery observed in mild stroke survivors in the
placebo group. However, the difference between treatments
remained similar at all time points in favor of Actovegin.
It is debatable whether a statistically significant difference
of 2.3 points achieved in ADAS-cog+ score reflects clinically
meaningful change. In phase III trials, AChEIs have produced
modest cognitive improvements (1–2 points on ADAS-cog), but
Figure 3.  Change in Montreal Cogni-
tive Assessment (MoCA) scores over the
course of the study in the intent-to-treat
(ITT) population. *P<0.05; **P<0.005 vs
placebo. CI indicates confidence interval;
LS, least squares; and tx, treatment.
AChEIs have not been granted U.S. Food & Drug Administration
approval for use in VaD primarily because of inconsistent effi-
cacy with respect to activities of daily living and global func-
tion.8 According to The European Medicines Agency guidelines,
when choosing efficacy end points in clinical trials in patients
with mild cognitive impairment and dementia, it is necessary
to demonstrate the clinical relevance of results.36 However, it
is also recognized that the inclusion of 2 coprimary end points
addressing cognition and functional activities of daily living
might be difficult. Currently used cognitive scales have demon-
strated a ceiling effect which means that they are not sensitive
enough to detect small changes in cognition, whereas complex
neuropsychological batteries may be difficult to implement
in large clinical trials. Also it is noteworthy that the VaD tri-
als evaluated functional efficacy with the same measures used
in AD trials. Stroke patients with cognitive impairment may
have noticeable impairments in their daily functioning, not only
because of affected cognitive domains, such as executive func-
tions, but also because of motor or language deficits. It explains
the fact that in VaD populations, demonstration of functional
benefit is more difficult to achieve given the high prevalence of
physical disability because of stroke.37 In addition, the extent
to which individuals are capable to compensate for this deficit
and adjust daily activities is highly variable. Therefore, clinical
relevance, assessed by instrumental activities or health-related
quality of life, may also be greatly confounded by differences in
social status and occupational environment.
Table 3.  Summary of TEAEs (Occurring in ≥2% of Patients;
Safety Analysis Set)
Actovegin; n=250 Placebo; n=253
No. of patients with at least 1 TEAE 89 (35.6) 96 (37.9)
No. of TEAEs 206 215
Ischemic stroke 13 (5.2) 5 (2.0)
Headache 7 (2.8) 7 (2.8)
Respiratory tract infection viral 5 (2.0) 8 (3.2)
Adverse events are coded with MedDRA Version 17.1. Data are n (%). TEAE
indicates treatment-emergent adverse event.
 8  Stroke  May 2017
The MoCA was chosen as the other secondary supportive
cognitive end point. Although the MoCA is considered a sen-
sitive screening instrument to detect PSCI in clinical prac-
tice,33,38 further research is needed to validate its use as a tool to
detect treatment effects and clinically meaningful longitudinal
changes in cognitive function.39 The thresholds used to define
test positivity on scales such as MoCA have been derived from
community-dwelling older adults and are not well established
in stroke survivor cohorts; it was also not prespecified in this
study.33 Nevertheless, our results showed a similarity in cogni-
tion changes assessed by MoCA and ADAS-cog+ with statis-
tically significant differences in favor of Actovegin sustained
during the whole study, which was detected on MoCA scores
with Actovegin treatment at month 3 onwards. However, the use
of the MoCA as a secondary efficacy end point in our study and
the related findings were exploratory, and its validity in testing
cognitive changes over time should be tested in further trials.
A trend toward a reduction in the incidence of dementia
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was detected with Actovegin versus placebo, but this study
was designed to determine symptomatic efficacy rather than
dementia prevention, which requires large samples and long
follow-up, and this study did not provide an opportunity to
detect a clinical transformation from vascular mild cognitive
impairment to overt dementia.
Other secondary end points assessed neurological deficits
and functional recovery after stroke. The LS mean differences
in NIHSS between groups did not reach statistical significance
at any time point. At months 3 and 6, the median Barthel Index
score was 100.0 for both groups, but more patients in the
Actovegin group had a score of ≥95 points compared with the
placebo group. Actovegin treatment was started ≤7 days after
stroke onset, whereas an acute stroke management within the
first 12 to 24 hours after the onset of symptoms is generally
recommended. In addition, the study population consisted of
patients with mild-to-moderate stroke; therefore, a high rate
of spontaneous recovery under placebo might be expected and
a ceiling effect cannot be ruled out. The aforementioned rea-
sons might partially explain the similar neurological outcomes
observed in both groups after 6 months of treatment. The study
was also not primarily designed to assess stroke outcomes.
Summary results from the EuroQoL EQ-5D and the BDI-II
also showed similar responses in both groups. However, it is
important to note that baseline scores for quality of life and
depression were not collected because they were not easily
accessible in the immediate poststroke state.
The incidence of TEAEs and deaths was similar between
treatment groups. Although ischemic strokes occurred more
frequently in the Actovegin group, the difference was not
statistically significant (post hoc analysis) and they were not
likely to occur at any given time point (eg, during infusion).
The rate of recurrent ischemic stroke is not unexpected in this
population; the risk of recurrence is higher within the first year
(4.7%–15%) and is even higher in the first 3 months (9.5%–
20%).40 It is noteworthy that the number of male patients with
recurrent ischemic stroke was 73.3% in the Actovegin group
and 40.0% in the placebo group; the same misbalance was
found with regards to smokers: 53.3% in the Actovegin and
30.0% in the placebo group. The clinical use of Actovegin for
4 decades is supported by a favorable safety profile with a low
incidence of AEs, and there have been no reports from previous
studies or spontaneous reports of AEs associated with stroke.41
Therefore, a specific reason for this isolated finding, which we
consider to be coincidental, has not yet been identified.
Limitations of this trial include missing data for the pri-
mary measure, ADAS-cog+ score, which consists of indi-
vidual questionnaires that make up the primary efficacy end
point. Missing data were recognized as a potential source of
bias; however, this was addressed using a combination of 2
potentially conservative approaches (worst score imputa-
tion for partially complete ADAS-cog+ assessments, and last
observation carried forward for completely missing ADAS-
cog+ assessments). For data missing at baseline and month
3, it was not feasible to account for patients who did not have
any baseline assessment or undertake imputation of miss-
ing month 3 ADAS-cog+ score based on baseline score as
part of the planned analyses. As above, missing data for the
individual questionnaire items were imputed using the worst
score rather than the last nonmissing item score from the pre-
vious visit because this approach was considered to be a more
conservative strategy, similar to that commonly adopted for
binary end points where missing data are imputed as failure.
The study showed an overall missing rate for the primary out-
come in ≈9% of randomized patients, a rate that is comparable
between treatment groups at baseline and month 3.
In conclusion, Actovegin has been shown to be effective
in improving cognitive outcomes in a prospective random-
ized controlled trial which, to some extent, had an exploratory
design and several limitations. Further studies with robust
designs may help to establish the optimal dosing regimen and
treatment duration for Actovegin in PSCI, and whether or not
Actovegin improves neurological deficits and has an effect on
activities of daily living and QoL in parallel with its effects on
cognitive outcomes and disease progression.
Acknowledgments
We thank the participating centers’ staff and patients for their efforts and
commitment during the trial; Ulf Vigonius, Martin Eeg, and Gediminas
Puras for their contribution to the design of the study; Alexander
Knyazev for scientific advice; and Alexander Kroll and Ella Palmer of
Synergy Vision, London, United Kingdom for technical and medical
writing assistance with the preparation of this report. See online-only
Data Supplement for authors’ contributions and competing interests.
Sources of Funding
This study was organized and funded by Takeda Pharmaceuticals.
Disclosures
Drs Guekht, Skoog, and Zakharov were consultants for Takeda
and have received honoraria for scientific clinical trial advice from
Takeda. S. Edmundson is an employee of Takeda. The other author
reports no conflicts.
References
1. Feigin VL, Forouzanfar MH, Krishnamurthi R, Mensah GA, Connor
M, Bennett DA, et al; Global Burden of Diseases, Injuries, and Risk
Factors Study 2010 (GBD 2010) and the GBD Stroke Experts Group.
Global and regional burden of stroke during 1990-2010: findings from
the Global Burden of Disease Study 2010. Lancet. 2014;383:245–254.
doi: 10.1016/S0140-6736(13)61953-4.
 Guekht et al   Effect of Actovegin After Acute Ischemic Stroke   9
2. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et
al. Global and regional mortality from 235 causes of death for 20 age
groups in 1990 and 2010: a systematic analysis for the Global Burden
of Disease Study 2010. Lancet. 2012;380:2095–2128. doi: 10.1016/
S0140-6736(12)61728-0.
3. Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et
al. Disability-adjusted life years (DALYs) for 291 diseases and injuries
in 21 regions, 1990-2010: a systematic analysis for the Global Burden
of Disease Study 2010. Lancet. 2012;380:2197–2223. doi: 10.1016/
S0140-6736(12)61689-4.
4. Rajan KB, Aggarwal NT, Wilson RS, Everson-Rose SA, Evans DA.
Association of cognitive functioning, incident stroke, and mor-
tality in older adults. Stroke. 2014;45:2563–2567. doi: 10.1161/
STROKEAHA.114.005143.
5. Pendlebury ST, Rothwell PM. Prevalence, incidence, and factors asso-
ciated with pre-stroke and post-stroke dementia: a systematic review
and meta-analysis. Lancet Neurol. 2009;8:1006–1018. doi: 10.1016/
S1474-4422(09)70236-4.
6. Brainin M, Tuomilehto J, Heiss WD, Bornstein NM, Bath PM, Teuschl
Y, et al; Post Stroke Cognition Study Group. Post-stroke cognitive
decline: an update and perspectives for clinical research. Eur J Neurol.
2015;22:229–238, e13. doi: 10.1111/ene.12626.
7. Lakhan SE, Kirchgessner A, Hofer M. Inflammatory mechanisms in
ischemic stroke: therapeutic approaches. J Transl Med. 2009;7:97. doi:
Downloaded from http://stroke.ahajournals.org/ by guest on May 28, 2017
10.1186/1479-5876-7-97.
8. Ritter A, Pillai JA. Treatment of vascular cognitive impairment. Curr
Treat Options Neurol. 2015;17:367. doi: 10.1007/s11940-015-0367-0.
9. Guekht AB, Moessler H, Novak PH, Gusev EI; Cerebrolysin
Investigators. Cerebrolysin in vascular dementia: improvement of clini-
cal outcome in a randomized, double-blind, placebo-controlled multi-
center trial. J Stroke Cerebrovasc Dis. 2011;20:310–318. doi: 10.1016/j.
jstrokecerebrovasdis.2010.01.012.
10. Machicao F, Muresanu DF, Hundsberger H, Pflüger M, Guekht A.
Pleiotropic neuroprotective and metabolic effects of Actovegin’s mode of
action. J Neurol Sci. 2012;322:222–227. doi: 10.1016/j.jns.2012.07.069.
11. Kuninaka T, Senga Y, Senga H, Weiner M. Nature of enhanced mito-
chondrial oxidative metabolism by a calf blood extract. J Cell Physiol.
1991;146:148–155. doi: 10.1002/jcp.1041460119.
12. Elmlinger MW, Kriebel M, Ziegler D. Neuroprotective and anti-oxidative
effects of the hemodialysate Actovegin on primary rat neurons in vitro.
Neuromolecular Med. 2011;13:266–274. doi: 10.1007/s12017-011-8157-7.
13. Hoyer S, Betz K. Elimination of the delayed postischemic energy deficit
in cerebral cortex and hippocampus of aged rats with a dried, deprotein-
ized blood extract (Actovegin). Arch Gerontol Geriatr. 1989;9:181–192.
14. Krüger G, Quadbeck G. [The electroencephalogram of the rat in oxy-
gen deficiency as an indicator of drug effects on cerebral metabolism].
Arzneimittelforschung. 1972;22:451–456.
15. Lanner G, Argyropoulos. [Pharmacological effect of Solcoseryl on the
metabolism of the brain. Animal experiments and clinical research].
Wien Med Wochenschr. 1975;125:681–685.
16. Meilin S, Machicao F, Elmlinger M. Treatment with Actovegin improves
spatial learning and memory in rats following transient forebrain isch-
aemia. J Cell Mol Med. 2014;18:1623–1630. doi: 10.1111/jcmm.12297.
17. Saletu B, Küfferle B, Anderer P, Grünberger J, Steinberger K. EEG-
brain mapping in schizophrenics with predominantly positive and nega-
tive symptoms. Comparative studies with remoxipride/haloperidol. Eur
Neuropsychopharmacol. 1990;1:27–36.
18. Semlitsch HV, Anderer P, Saletu B, Hochmayer I. Topographic map-
ping of cognitive event-related potentials in a double-blind, placebo-
controlled study with the hemoderivative Actovegin in age-associated
memory impairment. Neuropsychobiology. 1990;24:49–56.
19. Derev’yannykh EA, Bel’skaya GN, Knoll EA, Krylova LG, Popov DV.
Experience in the use of Actovegin in the treatment of patients with cog-
nitive disorders in the acute period of stroke. Neurosci Behav Physiol.
2008;38:873–875. doi: 10.1007/s11055-008-9051-0.
20. Shamalov NA, Stakhovskaia LV, Shetova IM, Efremova NM, Anisimov
KV. [Efficacy and safety of the combined therapy with citicholine and
actovegin in the acute period of ischemic stroke]. Zh Nevrol Psikhiatr Im
S S Korsakova. 2010;110(9 pt 2):13–17.
21. Søndergård SD, Dela F, Helge JW, Larsen S. Actovegin, a non-prohibited
drug increases oxidative capacity in human skeletal muscle. Eur J Sport
Sci. 2016;16:801–807. doi: 10.1080/17461391.2015.1130750.
22. Actovegin 80 mg Injection Solution - Summary of Product Characteristics
(SPC). Http://www.Pharmazie.Com/graphic/a/17/2-00017.Pdf. Accessed
November 15, 2016.
23. Ramipril 1.25 mg Capsules - Summary of Product Characteristics
(SPC). Https://www.Medicines.Org.Uk/emc/medicine/24132. Accessed
November 15, 2016.
24. Memantine Accord 20 mg Film-Coated Tablets - Summary of Product
Characteristics (SPC). Https://www.Medicines.Org.Uk/emc/medicine/
28669. Accessed November 15, 2016.
25. Guekht A, Skoog I, Korczyn AD, Zakharov V, Eeg M, Vigonius U. A
randomised, double-blind, placebo-controlled trial of Actovegin in
patients with post-stroke cognitive impairment: ARTEMIDA Study
Design. Dement Geriatr Cogn Dis Extra. 2013;3:459–467. doi:
10.1159/000357122.
26. European Medicines Agency. Guideline on Missing Data in
Confirmatory Clinical Trials. http://www.ema.europa.eu/docs/en_GB/
document_library/Scientific_guideline/2010/09/WC500096793.pdf.
Accessed April 11, 2017.
27. Ankolekar S, Geeganage C, Anderton P, Hogg C, Bath PM. Clinical
trials for preventing post stroke cognitive impairment. J Neurol Sci.
2010;299:168–174. doi: 10.1016/j.jns.2010.08.052.
28. Cano SJ, Posner HB, Moline ML, Hurt SW, Swartz J, Hsu T, et al.
The ADAS-cog in Alzheimer’s disease clinical trials: psychometric
evaluation of the sum and its parts. J Neurol Neurosurg Psychiatry.
2010;81:1363–1368. doi: 10.1136/jnnp.2009.204008.
29. Skinner J, Carvalho JO, Potter GG, Thames A, Zelinski E, Crane PK,
et al; Alzheimer’s Disease Neuroimaging Initiative. The Alzheimer’s
Disease Assessment Scale-Cognitive-Plus (ADAS-Cog-Plus): an expan-
sion of the ADAS-Cog to improve responsiveness in MCI. Brain Imaging
Behav. 2012;6:489–501. doi: 10.1007/s11682-012-9166-3.
30. Raina P, Santaguida P, Ismaila A, Patterson C, Cowan D, Levine M, et
al. Effectiveness of cholinesterase inhibitors and memantine for treating
dementia: evidence review for a clinical practice guideline. Ann Intern
Med. 2008;148:379–397.
31. Winblad B, Brodaty H, Gauthier S, Morris JC, Orgogozo JM, Rockwood
K, et al. Pharmacotherapy of Alzheimer’s disease: is there a need to rede-
fine treatment success? Int J Geriatr Psychiatry. 2001;16:653–666.
32. Burton L, Tyson SF. Screening for cognitive impairment after stroke:
a systematic review of psychometric properties and clinical utility. J
Rehabil Med. 2015;47:193–203. doi: 10.2340/16501977-1930.
33. Pendlebury ST, Mariz J, Bull L, Mehta Z, Rothwell PM. MoCA,
ACE-R, and MMSE versus the National Institute of Neurological
Disorders and Stroke-Canadian Stroke Network Vascular Cognitive
Impairment Harmonization Standards Neuropsychological Battery
after TIA and stroke. Stroke. 2012;43:464–469. doi: 10.1161/
STROKEAHA.111.633586.
34. Black SE. Vascular cognitive impairment: epidemiology, subtypes, diag-
nosis and management. J R Coll Physicians Edinb. 2011;41:49–56. doi:
10.4997/JRCPE.2011.121.
35. Korczyn AD. Mixed dementia–the most common cause of dementia.
Ann N Y Acad Sci. 2002;977:129–134.
36. European Medicines Agency. Guideline on Medicinal Products for the
Treatment of Alzheimer’s Disease and Other Dementias. http://www.ema.
europa.eu/docs/en_GB/document_library/Scientific_guideline/2009/09/
WC500003562.pdf. Accessed April 11, 2017.
37. Gorelick PB, Scuteri A, Black SE, Decarli C, Greenberg SM, Iadecola
C, et al; American Heart Association Stroke Council, Council on
Epidemiology and Prevention, Council on Cardiovascular Nursing,
Council on Cardiovascular Radiology and Intervention, and Council
on Cardiovascular Surgery and Anesthesia. Vascular contribu-
tions to cognitive impairment and dementia: a statement for health-
care professionals from the American Heart Association/American
Stroke Association. Stroke. 2011;42:2672–2713. doi: 10.1161/
STR.0b013e3182299496.
38. Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead
V, Collin I, et al. The Montreal Cognitive Assessment, MoCA: a
brief screening tool for mild cognitive impairment. J Am Geriatr Soc.
2005;53:695–699. doi: 10.1111/j.1532-5415.2005.53221.x.
39. Koski L. Validity and applications of the Montreal cognitive assessment
for the assessment of vascular cognitive impairment. Cerebrovasc Dis.
2013;36:6–18. doi: 10.1159/000352051.
40. Burn J, Dennis M, Bamford J, Sandercock P, Wade D, Warlow C. Long-
term risk of recurrent stroke after a first-ever stroke. The Oxfordshire
Community Stroke Project. Stroke. 1994;25:333–337.
41. Buchmayer F, Pleiner J, Elmlinger MW, Lauer G, Nell G, Sitte HH.
Actovegin®: a biological drug for more than 5 decades. Wien Med
Wochenschr. 2011;161:80–88. doi: 10.1007/s10354-011-0865-y.
 ARTEMIDA Trial (A Randomized Trial of Efficacy, 12 Months International
Double-Blind Actovegin): A Randomized Controlled Trial to Assess the Efficacy of
Actovegin in Poststroke Cognitive Impairment
Alla Guekht, Ingmar Skoog, Sally Edmundson, Vladimir Zakharov and Amos D. Korczyn
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SUPPLEMENTAL MATERIAL

ARTEMIDA: a randomized controlled trial to assess the efficacy and safety of

Actovegin in post-stroke cognitive impairment

Alla Guekht,1* Ingmar Skoog,2 Sally Edmundson,3 Vladimir Zakharov,4 Amos D Korczyn,5

1
Department of Neurology, Neurosurgery and Genetics, Russian National Research Medical

University, Moscow; Moscow Research and Clinical Center for Neuropsychiatry, Russia

2
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

3
Takeda Development Centre Europe, London, UK

4
Department of Neurology, 1st Moscow State Medical University, Moscow, Russia

5
Department of Neurology, Tel Aviv University, Tel Aviv, Israel

*Corresponding author:

Prof. Alla Guekht, Department of Neurology, Neurosurgery and Genetics

Russian National Research Medical University

Moscow; Moscow Research and Clinical Center for Neuropsychiatry

Donskaya Street 43, Moscow 115419, Russia

Email: guekht@mail.ru

Page 1 of 24
Contents
Supplemental Figure I: Study design ...................................................................................................... 3
Supplemental Table I: Full list of investigators and study centers ......................................................... 4
Supplemental Table II: Full list of inclusion criteria ............................................................................ 10
Supplemental Table III: Full list of exclusion criteria .......................................................................... 11
Supplemental Table IV: Full list of medications prohibited during double-blind treatment ................ 13
Supplemental Table V: All primary, secondary and safety endpoints .................................................. 14
Supplemental Table VI: Key protocol deviations occurring in more than one patient ......................... 15
Supplemental Table VII. Summary of primary and key secondary outcomes in the ITT population. . 16
Supplemental Table VIII: Summary of EuroQol EQ-5D at 6 Months and 12 Months ........................ 17
Supplemental Table IX: Summary of patients with clinically significant chemistry laboratory values
by visit (safety analysis set) .................................................................................................................. 19
Supplemental Table X: Summary of TEAEs related to chemistry laboratory results (safety analysis
set) ......................................................................................................................................................... 20
Supplemental Table XI: Overview of TEAEs (safety analysis set) ...................................................... 21
Supplemental Table XII: Overview of TEAEs related to recurrent cerebrovascular events (safety
analysis set). .......................................................................................................................................... 22
Randomization and masking Full Methods .......................................................................................... 23
Per protocol (PP) analyses .................................................................................................................... 23
Further Safety Results ........................................................................................................................... 23
Authors’ contributions .......................................................................................................................... 24

Page 2 of 24
Supplemental Figure I: Study design

Actovegin i.v. followed by

Actovegin tablets
Screening and
Efficacy follow-up
Randomization
Placebo i.v. followed by
placebo tablets

≤7 days post stroke 6 months 6 months

Subjects who had suffered ischemic stroke were randomized to receive either Actovegin or

placebo in a 1:1 ratio within 5 to 7 days following the stroke onset. The trial consisted of a

screening period (up to 6 days), followed by a randomized treatment period (up to

20 intravenous [i.v.] daily infusions, then tablets for the remainder of the 6-month treatment

period), ending with a 6-month efficacy follow-up period (where subjects were allowed to

undergo treatment in accordance with standard clinical practice).

Page 3 of 24
Supplemental Table I: Full list of investigators and study centers

Number of
Investigator Centre number, address patients
randomized

Russia
St. Petersburg State Budgeted Healthcare
Dr. Larisa
Institution “City Hospital#26”, 2
Voronkova 41
Kostyushko str., 196247, St. Petersburg,
Russia
St. Petersburg State Budgeted Healthcare
Institution of Resort District City Hospital
Dr. Alina Agafyina #40 37
9 Borisova str., 191014, St. Petersburg,
Russia
St. Petersburg State Budgeted Healthcare
Dr. Lyudmila Institution Nikolaevskaya Hospital
24
Roshkovskaya 1 Konstantinovskaya str., Petrodvorets,
198510, Saint-Petersburg, Russia
Saint Petersburg State Budgetary
Dr. Konstantin V. Healthcare Institution "City Multifield
23
Golikov Hospital #2", 5, Uchebny per., St.
Petersburg, 194354, Russia
Scientific research medical complex “Your
Health” LLC, 7, Zinina str., Kazan, 420097,
Russia
Prof. Eduard Z. Clinical base: Municipal Healthcare
23
Yakupov Institution “City Emergency Hospital #2”,
therapy and neurology department, 31,
Lieutenant Shmidt str., Kazan, 420097,
Russia
State Budgetary Healthcare Institution
“Samara Region Clinical Hospital named
Prof. Irina
after M.I. Kalinin” 23
Poverennova
159, Tashkentskaya str, Samara, 443095,
Russia
Municipal Budgetary Healthcare Institution
Dr. Elena of Novosibirsk “City Clinical Hospital#34”,
22
Vostrikova 18, Titova str., Novosibirsk, Novosibirsk
region, 630054, Russia

Page 4 of 24
 State Autonomous Healthcare Institution
Prof. Dina R.
Interregional Clinical Diagnostic Centre 19
Khasanova
12a Karbysheva str., Kazan, 420101, Russia
State Budgetary Educational Institution of
Higher Professional Education Kazan State
Medical University of the Ministry of
Healthcare and Social Development of the
Russian Federation, 49 Butlerova str.,
Prof. Enver I.
Kazan, 420012, Tatarstan Republic, Russia 16
Bogdanov
Clinical base: State Healthcare Institution
Republican Clinical Hospital of the
Ministry of Healthcare of Tatarstan
Republic, 138 Orenburgsky tract, Kazan,
420064, Tatarstan Republic, Russia
State Budgetary Healthcare Institution of
Dr. Svetlana Irkutsk “Mark of Honour” Order Clinical
16
Sayutina Regional Hospital, 100 Yubileinii
microdistrict, Irkutsk, 664079, Russia
Municipal Budgetary Healthcare Institution
Vsevolozhskaya Clinical Central District
Hospital
Dr. Liya Lukinykh 16
20 Koltushskoye shosse, Leningrad Region,
Vsevolozhsk district, Vsevolozhsk, 188640,
Russia
State Budgetary Healthcare Institution of
Novosibirsk region “City Clinical
Dr. Liubov
Hospital#2”, 16
Shpagina
21, Polsunova str., Novosibirsk,
Novosibirsk Region, 630051, Russia
State Budgetary Healthcare Institution of
Novosibirsk region “City Clinical Hospital
Dr. Olga A.
#1”, 14
Dinisova
6 bld, Zalesskogo str, Novosibirsk,
Novosibirsk Region, 630047, Russia
State Healthcare Institution of Yaroslavl
Dr. Alexander region Clinical Hospital #8;
14
Malygin 39, Suzdalskoe shosse, Yaroslavl, 150030,
Russia
State Budgetary Educational Institution of
Prof. Ludmila
High Professional Education “Russian 13
Stakhovskaya
National Research Medical University

Page 5 of 24
 named after N.I. Pirogov” of Ministry of
Healthcare and Social Development of
Russian Federation based on State
Budgetary Healthcare Institution of
Moscow city “City Clinical Hospital #31 of
Moscow Healthcare Department”
42, Lobachevskogo str., Moscow, 119415,
Russia
Saint-Petersburg State Budgetary Institution
Dr. Vasily of Healthcare “City Hospital #15”
11
Vasilyuk 4, Avangardnaya str.,
Saint-Petersburg, 198204, Russia
Saint Petersburg State Budgeted Healthcare
Dr. Nikolay Institution "City Alexandrovskaya
10
Gaiduk Hospital", 4, Solidarnosti pr., St.
Petersburg, 193312, Russia
State Budgetary Healthcare Institution of
Kemerovo Regional "Kemerovo Regional
Dr. Nadezhda
Clinical Hospital", 8
Korotkevich
22, Oktyabrsky prospect str., Kemerovo,
Kemerovo region, 650066, Russia
State Budgetary Healthcare Institution of
Dr. Natalia Moscow city “City Clinical Hospital #61 of
6
Vakhnina Moscow Healthcare Department”
15, Dovatora str., Moscow, 119048, Russia
Federal State Budgetary Institution
“Scientific Research Centre of Neurology
Prof. Marina
of RAMS” 6
Maximova
80, Volokolamskoye shosse, Moscow,
125367, Russia
State Budgetary Healthcare Institution of
Moscow city “City Clinical Hospital named
after S.P. Botkin” of Moscow Healthcare
Prof. Oleg Levin 5
Department
5, bld. 2, 2nd Botkinsky proezd, Moscow,
125284, Russia
State Budgetary Healthcare Institution of
Prof. Larisa Sverdlovsk region “Sverdlovsk Regional
Volkova Clinical Hospital #1” 5
185, Volgogradskaya str., Ekaterinburg,
620102, Russia

Page 6 of 24
 State Budgetary Healthcare Institution of
Moscow city “City Clinical Hospital #12 of
Prof. Alla Guekht Moscow Healthcare Department” 4
26, Bakinskaya str, Moscow, 115516,
Russia
St. Petersburg State Budgeted Healthcare
Institution City Mariinskaya Hospital
Dr. Ivan Sardaryan 4
56 Liteyny pr., 191014, St. Petersburg,
Russia
Federal State Budgetary Military
Educational Institution of Higher
Professional Education "Military Medical
Academy n.a. S.M. Kirov" of Ministry of
Prof. Miroslav M.
Defense of the Russian Federation, Legal 3
Odinak
address: 6, lit. Z, Academician Lebedev str.,
St. Petersburg, 194044, Russia, Actual
address: 2 Lesnoy pr., St. Petersburg,
194044, Russia
Federal State Budgetary Institution
Research Institute for Complex Issues of
Cardiovascular Diseases under the Siberian
Prof. Andrey
Branch of The Russian Academy of 3
Kovalenko
Medical Sciences,
6, Sosnovy blvd., Kemerovo, Kemerovo
region, 650002, Russia
State Budgetary Educational Institution of
Higher Professional Education “Ural State
Medical Academy” of Ministry of Health
and Social Development of Russian
Dr. Vadim Gusev Federation (3, Repin str., Ekaterinburg, 3
620028, Russia) based on Municipal
Healthcare Institution “Central City Clinical
Hospital # 23” 9, Starykh Bolshevikov str.,
Ekaterinburg, Russia, 620017, Russia
State Budgetary Educational Institution of
High Professional Education “Russian
National Research Medical University
Prof. Eugene named after N.I. Pirogov” of Ministry of
0
Gusev Healthcare and Social Development of
Russian Federation based on State
Budgetary Healthcare Institution of
Moscow city “City Clinical Hospital # 1

Page 7 of 24
 named after N.I. Pirogov of Moscow
Healthcare Department”
8, Leninsky prospect, Moscow, 119049,
Russia
State Budgetary Educational Institution of
Higher Professional Education “Siberia
State Medical University” Ministry of
Health and Social Development of Russian
Prof. Valentina M. Federation,
0
Alifirova 2 Moskovsky trakt, Tomsk,Tomsk Region,
634050, Russia
Clinical base: Regional State Budgetary
Healthcare Institution Tomsk Regional
Clinical Hospital
State Education Institution of Higher
Profession Education “Krasnoyarsk State
Medical University named professor
V.F.Voyno-Yasenetsky Department of
Health and Social Development of Russian
Federation”, 1, Partizana Zheleznijaka str,,
Krasnoyarsk, Krasnoyrsk Region, 660049,
Prof. Semen V. Russia 0
Prokopenko
Сlinical base: 1-Federal State Budgetary
Institution of Healthcare “Siberian Clinical
Centre of Federal Medico-Biological
Agency”;
2- Municipal Budgetary Institution of
Healthcare “City Clinical Hospital #6
named Karpovicha N.S.
St. Petersburg State Budgeted Healthcare
Dr. Alexander
Institution City Elizavetinskaya Hospital
Nazarov 0
14 Vavilovykh str., 195257, St. Petersburg,
Russia
Kazakhstan
State public institution under economic
jurisdiction “City Clinical Hospital №7” of
Dr. Erkyn
Almaty Health Administration 4
Nurguzhayev
microdistrict «Kalkaman», Almaty, 050006,
Kazakhstan
Belarus

Page 8 of 24
 Healthcare Institution "Vitebsk Regional
Dr. Mikalai M. Clinical Hospital"
38
Bialauski 37 Voinov Internationalistov str., 210037,
Vitebsk, Belarus
Institution "Gomel Regional Clinical
Prof. Alena I. Hospital"
26
Mikhailava 5 Brat’ev Lizukovyh str., 246029 Gomel,
Belarus
Healthcare institution "City Clinical
Prof. Natalya P.
Emergency Hospital" 20
Mitkovskaya
58 Kizhevatova str., 220024 Minsk, Belarus
Healthcare Institution "Grodno Regional
Dr. Sergey D. Clinical Hospital"
16
Kulesh Leninskogo komsomola bulv., 52 230017
Grodno, Belarus
Healthcare Institution "City Clinical
Prof. Aliaksandr S.
Hospital #9" 14
Fedulau
8 Semashko str., 220116 Minsk, Belarus

Page 9 of 24
Supplemental Table II: Full list of inclusion criteria

On study entry
1. Had suffered a supra-tentorial ischemic stroke supported by computed
tomography (CT) scan or magnetic resonance imaging (MRI) findings (in
accordance with local practice)
2. Had provided written informed consent
3. Were male or female, aged 60 years or above
4. Were conscious and considered legally competent, but had symptoms or signs
indicating cognitive impairment according to the investigator’s opinion
5. Had a score on the NIHSS between 3 and 18 (inclusive)
6. Were capable of completing the MoCA scale and had a score of ≤ 25 points with
adjustment for level of education (4 to 9 school years ≤ 23 points, 10 to 12 years
≤ 24 points, 12 years ≤ 25 points)
7. If female, was post-menopausal or had been surgically sterilized/hysterectomized
and did not intend to become pregnant during the course of the trial (e.g., oocyte
implantation)
8. If male, did not intend to induce pregnancy (parenthood was not desired) during
clinical trial conduct or within 3 months after the last planned dose of IMP
At randomization
9. Were fully conscious
10. Were still capable of completing the MoCA scale and had a score of ≤ 25 points
with adjustment for level of education (4 to 9 school years ≤ 23 points, 10 to 12
years ≤ 24 points, 12 years ≤ 25 points)
11. Were able to perform the ADAS-cog+

Page 10 of 24
Supplemental Table III: Full list of exclusion criteria

On study entry
1. A known medical history of dementia
2. A known medical history of or presence of major depression or psychotic
disorder
3. A known medical history or presence of malignancies or other
serious/life-threatening diseases that were likely to cause the subject’s death
within 12 months
4. Concomitant acute coronary syndrome (e.g. acute myocardial infarction or
unstable angina)
5. Suspected or diagnosed endocarditis
6. Thought to have had a cardioembolic stroke (e.g., atrial fibrillation, prosthetic
valve) despite adequate treatment with anticoagulants
7. A suspicion of cerebral vasculitis as judged by the investigator
8. Stroke due to a complication of cerebral angiography, a revascularization
procedure, or trauma
9. Evidence from imaging or pre-enrolment investigation of any diagnosis other
than ischemic stroke likely to cause the presenting symptoms and signs (e.g.,
malignancy, hemorrhage)
10. Treatment with thrombolytics, carotid surgery or neurosurgery during this index
stroke or was indicated for such treatment
11. Indicated for investigation with carotid angiogram
12. Abnormal clinically relevant screening laboratory values suggesting an
undiagnosed disease requiring further clinical evaluation as assessed by the
investigator
13. Neurological deficits deemed to interfere with the ability to adhere to the protocol
(e.g. pronounced dysphasia)
14. Current known alcohol or illicit drug abuse or dependence
15. A known medical history of Parkinson’s disease, multiple sclerosis, uncontrolled
epilepsy, or other neurological disorders severely affecting motor or cognitive
function, in the opinion of the investigator
16. A history of clinically significant allergies or idiosyncrasies to Actovegin
17. In a dependency situation (e.g. kept in detention, investigator in the current trial, a
first-degree relative of a clinical trial investigator, an employee at the clinical trial
site, minor, or had a legal guardian), or were unable to understand and give
written informed consent

Page 11 of 24
18. Participation in another clinical trial with an investigational medicinal product
(IMP) or device within 30 days of signing informed consent
At randomization
19. A suspicion of progressive stroke
20. Eligibility for carotid angiogram, endarterectomy, or any neurosurgical
intervention
21. A planned surgery or another procedure requiring general anesthesia
22. A blood pressure at baseline of >220 mmHg (systolic) or 140 mmHg (diastolic)
23. Taking any of the disallowed drugs following signing of the informed consent
form (ICF)

Page 12 of 24
Supplemental Table IV: Full list of medications prohibited during double-blind
treatment

Peripheral vasodilators

Amantadine derivatives

Psychoanaleptics in entirety, with the exception of antidepressants, including:

 Centrally-acting sympathomimetics
 Bicyclic compounds
 Xanthine derivatives
 Tricyclic units (this does not refer to tricyclic antidepressants but to tricyclic
psychostimulants and nootropic compounds)
 Other psychostimulants and nootropics (glycine exempted)
 Antidepressants combined with psycholeptics
 Psychostimulants combined with neuroleptics
 Compounds for the treatment of dementia diseases, acetylcholinesterase inhibitors
 Other compounds for the treatment of dementia diseases

Parasympathomimetics, cholinesterase inhibitors

Cholinesters

Other parasympathomimetics

Other compounds with effect on the nervous system

Gangliosides and ganglioside derivatives

Remaining compounds with effect on the nervous system

Cerebrolysin

Page 13 of 24
Supplemental Table V: All primary, secondary and safety endpoints

Primary

Change from baseline in ADAS-cog+ at 6 months

Secondary

Change from baseline in ADAS-cog+ at 3 and 12 months

Change from baseline in MoCA at end of infusion period, 3, 6, and 12 months

Proportion of ADAS-cog+ responders at 3, 6, and 12 months

Diagnosis of dementia evaluated after 6 and 12 months classified according to International

Statistical Classification and Related Health Problems, version 10 (ICD-10)

Change from baseline in NIHSS at end of infusion period, 3, 6, and 12 months

Barthel Index at 6 months

EuroQoL EQ-5D at 6 and 12 months

BDI-II at 3, 6, and 12 months

Safety
Adverse events
Safety laboratory parameters
Standard 12-lead ECG assessments
Physical examination
Vital signs including blood pressure and heart rate

ADAS-cog+: Alzheimer’s Disease Assessment Scale-cognitive subscale+; MoCA: Montreal

Cognitive Assessment; NIHSS: National Institutes of Health Stroke Scale; ICD: International

Classification of Diseases; BDI-II: Beck Depression Inventory version II; ECG:

electrocardiogram.

Page 14 of 24
Supplemental Table VI: Key protocol deviations occurring in more than one patient

Actovegin Placebo
N=248 N=255
Key deviation n (%) n (%)
Any key deviation 36 (14.5) 35 (13.7)

ADAS-Cog+ Visit 1, Task 7 was performed incorrectly.

Correct ‘yes’ answers only were indicated on page 1 5 (2.0) 5 (2.0)
Disallowed concomitant medication 3 (1.2) 2 (0.8)
Were taking any of the disallowed drugs following
signing of the ICF 0 2 (0.8)
Visit 1 – Task 7 was performed incorrectly. Correct ‘yes’
answers only indicated on page 1 7 (2.8) 8 (3.2)
‘Number cancellation’ test of the ADAS-Cog+ test on
Visit 9 was conducted incorrectly. Duration of this test
wasn’t limited 1 (0.4) 3 (1.2)
‘Number cancellation’ test of the ADAS-Cog+ test on
Visit 1 was done by patients to the end, without time
limitation. Investigators didn’t calculate correct number
that subject forgotten to strike out as ‘wrong’ 5 (2.0) 5 (2.0)
‘Number cancellation’ test of the ADAS-Cog+ test on
Visit 9 was done by patients to the end, without time
limitation. Investigators didn’t calculate correct number
that subject forgotten to strike out as ‘wrong’ 5 (2.0) 5 (2.0)
ADAS-cog+: Alzheimer’s Disease Assessment Scale-cognitive subscale+; ICF: informed

consent form.

Page 15 of 24
Supplemental Table VII. Summary of primary and key secondary outcomes in the ITT
population.
Actovegin Placebo Actovegin versus
N=248 N=255 placebo (95% CI)
ADAS-cog+ responders*
10.2 (0.9, 19.5);
Month 3 (n, %) 127/215 (59.1%) 109/223 (48.9%)
p=0.032
10.2 (0.8, 19.5);
Month 6 (n, %) 130/208 (62.5%) 113/216 (52.3%)
p=0.034
10.1 (0.8, 19.3);
Month 12 (n, %) 138/200 (69.0%) 122/207 (58.9%)
p=0.035
MoCA score
Baseline (mean, SD) 18.8 (3.83) 18.6 (4.20)
-
n=248 n=255
Change from baseline 3.4 (0.20) 2.7 (0.20) 0.7 (0.1, 1.2);
at Month 3 n=224 n=234 p=0.016
Change from baseline 3.8 (0.21) 3.1 (0.21) 0.7 (0.2, 1.3);
at Month 6 n=217 n=228 p=0.013
Change from baseline 3.9 (0.25) 2.9 (0.24) 1.0 (0.3, 1.7);
at Month 12 n=211 n=220 p=0.003
NIHSS
5.3 (2.24) 5.6 (2.37)
Baseline (mean, SD) -
n=248 n=255
Change from baseline -2.9 (0.10) -2.7 (0.10) -0.2 (-0.5, 0.1);
at Month 3 n=224 n=235 p=0.136
Change from baseline -3.2 (0.10) -3.2 (0.10) 0.0 (-0.3, 0.2);
at Month 6 n=219 n=228 p=0.890
Change from baseline -3.5 (0.10) -3.4 (0.10) -0.1 (-0.4, 0.2);
at Month 12 n=211 n=220 p=0.455
Dementia diagnosis (according to ICD-10 criteria)
16/218 24/228 -3.2 (-8.5, 2.1);
Month 6 (n, %)
(7.3%) (10.5%) p=0.251
19/218 29/228 -4.0 (-9.7, 1.7);
Month 12 (n, %)
(8.7%) (12.7%) p=0.221
Data are LS mean (SE) unless otherwise indicated.

*A responder was defined as an improvement of 4 points or more on the ADAS-cog+ scale

using Observed Case data.

Page 16 of 24
Supplemental Table VIII: Summary of EuroQol EQ-5D at 6 Months and 12 Months

Month 6 Month 12

Actovegin Placebo Actovegin Placebo

EuroQol Category N=248 N=255 N=248 N=255

Mobility, n (%)

No problem 103 (41.5) 82 (32.2) 94 (37.9) 93 (36.5)

Slight problem 74 (29.8) 81 (31.8) 77 (31.0) 75 (29.4)

Moderate problem 31 (12.5) 42 (16.5) 31 (12.5) 30 (11.8)

Severe problem 10 (4.0) 18 (7.1) 8 (3.2) 19 (7.5)

Unable 1 (0.4) 1 (0.4) 2 (0.8) 2 (0.8)

Self-care, n (%)

No problem 145 (58.5) 124 (48.6) 137 (55.2) 123 (48.2)

Slight problem 49 (19.8) 65 (25.5) 55 (22.2) 60 (23.5)

Moderate problem 19 (7.7) 25 (9.8) 15 (6.0) 24 (9.4)

Severe problem 5 (2.0) 9 (3.5) 4 (1.6) 10 (3.9)

Unable 1 (0.4) 1 (0.4) 1 (0.4) 2 (0.8)

Usual activities, n (%)

No problem 81 (32.7) 84 (32.9) 81 (32.7) 79 (31.0)

Slight problem 101 (40.7) 88 (34.5) 97 (39.1) 86 (33.7)

Moderate problem 22 (8.9) 44 (17.3) 24 (9.7) 40 (15.7)

Severe problem 10 (4.0) 6 (2.5) 7 (2.8) 11 (4.3)

Unable 5 (2.0) 2 (0.8) 3 (1.2) 3 (1.2)

Pain or discomfort, n (%)

No pain 124 (50.0) 118 (46.3) 116 (46.8) 119 (46.7)

Slight pain 76 (30.6) 65 (25.5) 71 (28.6) 67 (26.3)

Moderate pain 15 (6.0) 39 (15.3) 21 (8.5) 29 (11.4)

Page 17 of 24
 Month 6 Month 12

Actovegin Placebo Actovegin Placebo

EuroQol Category N=248 N=255 N=248 N=255

Severe pain 2 (0.8) 2 (0.8) 4 (1.6) 3 (1.2)

Extreme pain 1 (0.4) 0 0 1 (0.4)

Anxiety or depression, n
(%)

Not anxious 124 (50.0) 123 (48.2) 120 (48.4) 120 (47.1)

Slightly anxious 77 (31.0) 75 (29.4) 78 (31.5) 69 (27.1)

Moderately anxious 15 (6.0) 24 (9.4) 12 (4.8) 27 (10.6)

Severely anxious 2 (0.8) 2 (0.8) 2 (0.8) 2 (0.8)

Extremely anxious 1 (0.4) 0 0 1 (0.4)

General health
(on a scale of 0–100)

n 219 224 212 220

Mean (SD) 67.3 (16.04) 65 (16.82) 67.8 (15.87) 65.6 (17.51)

Median 70.0 65.0 70.0 70.0

Min, max 30.0, 100.0 25.0, 100.0 20.0, 100.0 20.0, 100.0

Page 18 of 24
Supplemental Table IX: Summary of patients with clinically significant chemistry
laboratory values by visit (safety analysis set)

Actovegin Placebo
Visit Analyte N=250 N=253
n (%) n (%)
Alanine aminotransferase 2 (0.8) 0 (0.0)
Alkaline phosphatase 0 (0.0) 1 (0.4)
Aspartate aminotransferase 1 (0.4) 0 (0.0)
Bilirubin 0 (0.0) 1 (0.4)
Cholesterol 17 (6.8) 17 (6.7)
Screening Creatine kinase 2 (0.8) 4 (1.6)
Creatinine 2 (0.8) 1 (0.4)
Gamma-glutamyl-transpeptidase 2 (0.8) 8 (3.2)
HDL cholesterol 6 (2.4) 7 (2.8)
LDL cholesterol 14 (5.6) 17 (6.7)
Triglycerides 11 (4.4) 10 (4.0)
Alanine aminotransferase 1 (0.4) 1 (0.4)
Alkaline phosphatase 1 (0.4) 0 (0.0)
Aspartate aminotransferase 0 (0.0) 1 (0.4)
Cholesterol 12 (4.8) 14 (5.5)
Creatine kinase 1 (0.4) 0 (0.0)
Month 6 Creatinine 0 (0.0) 1 (0.4)
Gamma-glutamyl-transpeptidase 2 (0.8) 3 (1.2)
HDL cholesterol 5 (2.0) 3 (1.2)
LDL cholesterol 11 (4.4) 15 (5.9)
Potassium 2 (0.8) 1 (0.4)
Triglycerides 6 (2.4) 8 (3.2)

Page 19 of 24
Supplemental Table X: Summary of TEAEs related to chemistry laboratory results
(safety analysis set)

Actovegin Placebo Total

Preferred Term N=250 N=253 N=503
n (%) n (%) n (%)

Metabolism and nutrition disorders

Dyslipidaemia 8 (3.2) 2 (0.8) 10 (2.0)
Hyperkalaemia 2 (0.8) 1 (0.4) 3 (0.6)
Hypercholesterolaemia 0 (0.0) 2 (0.8) 2 (0.4)
Type 2 diabetes mellitus 0 (0.0) 1 (0.4) 1 (0.2)
Investigations
Gamma glutamyltransferase increased 1 (0.4) 2 (0.8) 3 (0.6)
Alanine aminotransferase increased 0 (0.0) 1 (0.4) 1 (0.2)
Aspartate aminotransferase increased 0 (0.0) 1 (0.4) 1 (0.2)
Blood creatine phosphokinase increased 1 (0.4) 0 (0.0) 1 (0.2)
Blood homocysteine increased 1 (0.4) 0 (0.0) 1 (0.2)

Page 20 of 24
Supplemental Table XI: Overview of TEAEs (safety analysis set)

Actovegin Placebo Total

Number of patients with: N=250 N=253 N=503
n (%) n (%) n (%)

TEAEs 89 (35.6) 96 (37.9) 185 (36.8)

Number of TEAEs 206 215 421

Severe TEAEs 11 (4.4) 13 (5.1) 24 (4.8)

SAEs 22 (8.8) 17 (6.7) 39 (7.8)

TEAEs leading to IMP

21 (8.4) 12 (4.7) 33 (6.6)
discontinuation

TEAEs considered related to IMP 9 (3.6) 9 (3.6) 18 (3.6)

SAE deaths 7 (2.8) 6 (2.4) 13 (2.6)

Page 21 of 24
Supplemental Table XII: Overview of TEAEs related to recurrent cerebrovascular
events (safety analysis set).

Actovegin Placebo Total

Study phase Preferred term
N=250 N=253 N=503

Ischemic stroke/TIA 13 (5.2%) 7 (2.8%) 20 (4.0%)

Treatment phase Intracerebral

1 (0.4%) 0 1 (0.2%)
hemorrhage
14
Subtotal 7 (2.8%) 21 (4.2%)
(5.6%)*

Follow-up phase Ischemic stroke 2 (0.8%) 3 (1.2%) 5 (1.0%)

Total 16 (6.4%) 10 (4.0%) 26 (5.2%)

Data are n (%).

*The odds ratio (95% CI) for cerebrovascular events on Actovegin compared to placebo was

2.09 (0.83, 5.26); р=0,124 suggesting this was not statistically significant (post-hoc analysis).

Page 22 of 24
Randomization and masking Full Methods
Patients were randomized to receive either Actovegin or placebo in a 1:1 ratio, without

stratification and using a block size of four, by means of a computerized central

randomization system, IVRS/IWRS. Before dispensing treatment, investigators reviewed all

eligibility criteria and provided the IVRS/IWRS with the patient number, date of birth, and

gender. Based on this information, patients were assigned to a kit number determined by the

program. The infusion and tablet bottles were labelled and masked with a kit number

generated by the randomization. During double-blind treatment and until end of follow-up, all

investigators and patients were masked to treatment assignment.

Per protocol (PP) analyses

The demographic and baseline characteristics for the PP analysis set were similar to those for

the ITT set. The results of the ANCOVA for the PP analysis set (212 and 220 patients in the

Actovegin and placebo groups respectively [196 and 202 respectively at 6 months) were

supportive of the results of the primary analysis on the ITT set described: the LS mean (SE)

change from baseline was -4.2 (0.60) for placebo and -6.4 (0.60) for Actovegin. The LS mean

difference for Actovegin – placebo was -2.2, with an associated 95% CI (-3.9, -0.5), which

was statistically significant in favour of Actovegin (p = 0.010).

Further Safety Results

Dyslipidemia was reported more frequently with Actovegin, compared with placebo during

the study. All of these events were non-serious and did not lead to discontinuation from the

study. Of note, the number of clinically significant chemistry laboratory values associated

with cholesterol (low density lipoproteins) and triglycerides at month 6 was higher in the

placebo group compared to Actovegin. Six (2.4%) deaths occurred in the placebo group and

seven (2.8%) in the Actovegin group. All of the deaths were considered not related to the

study medication. An overview of TEAEs is presented in Supplemental Table XI.

Page 23 of 24
The noticeable difference in AEs leading to discontinuation from the study was due to

recurrent stroke. However, during double-blind treatment, 21 patients (14 in the Actovegin

group and seven in the placebo group) experienced cerebrovascular events (ischemic stroke,

intracerebral hemorrhage and transient ischemic attack [TIA]). The odds ratio (95% CI) for

cerebrovascular events on Actovegin compared to placebo was 2.09 (0.83, 5.26), suggesting

this was not statistically significant (post-hoc analysis). Of these 21 patients, seven patients

(2.8%) in the placebo group and 13 patients (5.2%) in the Actovegin group experienced

recurrent ischemic stroke. Two patients in the placebo group and one patient in the Actovegin

group had a fatal outcome as a result of this event; one patient in the Actovegin group

experienced a fatal event of cerebral hemorrhage. Of seven patients in the placebo group, one

patient experienced a non-serious cerebrovascular event, which was interpreted by the

investigator as a transient ischemic attack. During the 6-month follow up, three patients in the

placebo group and two patients in the Actovegin group discontinued due to recurrent

ischemic stroke. Overall, 10 (4.0%) of 253 patients receiving placebo and 16 (6.4%) of 250

patients in the Actovegin group experienced cerebrovascular events. All cases of recurrent

strokes were not related to the study medication (reported by investigators). A summary of

TEAEs related to cerebrovascular events is presented in Supplemental Table XII.

Authors’ contributions
A.G., I.S., V.Z., and A.D.K were members of the steering committee that developed the

concept and design of the study, approved the statistical plans, had full access to and

interpreted the data, critically reviewed the report, and were responsible for the decision to

submit for publication. S.E. oversaw the statistical analysis and critically reviewed the report.

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