Protocols

The URICO-ICTUS study, a phase 3 study of combined

treatment with uric acid and rtPA administered
intravenously in acute ischaemic stroke patients within
the first 4
5 h of onset of symptoms
Sergio Amaro1, David Cánovas2, Mar Castellanos3, Jaime Gállego4, Joan Martı́-Fàbregas5,
Tomás Segura6, and Ángel Chamorro1

clinical onset and with a baseline National Institute of Health

Rationale Oxidative stress is a major contributor to brain
Stroke Scale score 46 and o25 and a modified Rankin Scale
damage in patients with ischaemic stroke. Uric acid (UA) is a
score r2 before the ischaemic event. Patients with renal
potent endogenous antioxidant molecule. In experimental
insufficiency, gout or asymptomatic hiperuricaemia treated
ischaemia in rats, the exogenous administration of uric acid is
with allopurinol will be excluded.
neuroprotective and enhances the effect of rtPA. Moreover, in
Study outcomes The primary outcome measure is the propor-
acute stroke patients receiving rtPA within 3 h of stroke onset,
tion of patients achieving an modified Rankin Scale of 0 to 1 at
the intravenous administration of uric acid is safe, prevents an
3 months after treatment or two in those patients with a prior
early decline in uric acid levels and reduces an early increase in
qualifying modified Rankin Scale of 2. Secondary outcome
oxidative stress markers and in active matrix metalloprotei-
measures include the final infarction volume measured at 72 h
nase nine levels.
and the proportion of patients with symptomatic intracranial
Aim To determine whether the combined treatment with uric
haemorrhage (Z4 points of increase in the National Institute
acid and rtPA is superior to rtPA alone in terms of clinical
of Health Stroke Scale score).
efficacy in acute ischaemic stroke patients treated within the
first 4.5 h of onset of symptoms. Key words: acute stroke therapy, cerebral infarction, clinical
Study design Multicentre, interventional, randomised, dou- trial, neuroprotection, protocols, rtPA
ble-blind and vehicle-controlled efficacy study with parallel
assignment (1 : 1). Estimated enrolment: 420 patients over 3
years, starting in January 2010. Treatment arms included
Introduction and rationale
patients will receive a single intravenous infusion of 1 g of
UA dissolved in a vehicle (500 ml of 0.1% lithium carbonate Currently, rtPA is the only approved therapy for stroke patients
and 5% mannitol) (n 5 210) or vehicle alone (n 5 210). Inclu- within the first hours of clinical onset (1). Oxidative stress is a
sion and exclusion criteria: the study will include patients major contributor to brain damage in patients with ischaemic
older than 18 years, treated with rtPA within the first 4.5 h of stroke, particularly when ischaemia is followed by reperfusion
(2). Uric acid (UA) is an endogenous product derived from the
metabolism of purines, which, in humans, is responsible for
Correspondence: Ángel Chamorro, Hospital Clı́nic Barcelona, Villarroel, 60% of the total antioxidant capacity of the organism (3).
170, 08036 Barcelona, Spain.
E-mail: achamorro@ub.edu Previously, we had reported an observational study indicating
1
Comprehensive Stroke Center, Institute of Neurosciences, Hospital that higher levels of UA at stroke admission predicted a better
Clı́nic, Institute Investigacions Biomèdicas August Pi I Sunyer (IDIBAPS), outcome at follow-up (4). Recent experimental evidences have
University of Barcelona, Barcelona, Spain shown that the exogenous administration of UA is neuropro-
2
Neurology Service Corporació Sanitària Parc Taulı́, Parc Taulı́, Sabadell,
tective both in cortical and in subcortical brain areas as a result
Spain
3
Neurology Service Hospital Univesitario Josep Trueta de Girona, of its antioxidant properties. In these studies, animals treated
Av. de França, Girona, Spain with UA showed smaller brain infarction after transient focal
4
Neurology Service Hospital de Navarra, Pamplona, Spain ischaemia, both using the intraluminal model and after the
5
Neurology Service Hospital Hospital de la Santa Creu i Sant Pau, injection of autologous clots (5, 6). Moreover, in the throm-
Barcelona, Spain boembolic model, the protective effects of the exogenous
6
Neurology Service Hospital Universitario de Albacete, Albacete, Spain
infusion of UA were additive to the effects of rtPA (alteplase)
DOI: 10.1111/j.1747-4949.2010.00448.x (6). Likewise, a recently published pilot trial showed that the

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Journal compilation & 2010 World Stroke Organization International Journal of Stroke Vol 5, August 2010, 325–328 325
 Protocols
administration of UA was free from serious adverse effects in
stroke patients receiving rtPA within 3 h of stroke onset (7). In
that trial, the infusion of UA (1 g) avoided an early decay in UA
levels and reduced lipid peroxidation markers (malondialde-
hyde) and the activation of matrix metalloproteinase-9, a
molecule related to poor clinical outcomes (7, 8). Based on
these data, we aim to conduct a phase 3, randomised, double-
blind and controlled trial assessing the clinical efficacy of UA
administration in acute ischaemic stroke patients treated with
rtPA within the 4
5-h window.
Methods
Design
The URIC-ICTUS trial is a multicentre, interventional,
randomised, double-blind, vehicle-controlled and efficacy
study with a parallel assignment (1 : 1) including acute
stroke patients receiving intravenous (i.v.) rtPA within the
first 4
5 h of the onset of symptoms. The study will be
conducted according to ICH/GCP guidelines. All participating
institutions have obtained Local Ethics Committee
approval before trial initiation. The URIC-ICTUS Study is
registered at http://www.clinicaltrials.gov/ (registration num-
ber NCT00860366).
Patient population – inclusion and exclusion criteria
Patients fulfilling all the following criteria will be included in
the study:
 age older than 18 years
 acute ischaemic stroke treated with rtPAwithin the first 4
5 h
of clinical onset
 baseline National Institute of Health Stroke Scale (NIHSS)
46 and o25, and modified Rankin Scale (mRS) r2 before
the stroke
 absence of blood in the CNS in the initial cranial CT
 signed informed consent.
Otherwise, patients will be excluded if they disclose one or
more of the following exclusion criteria:
 presence of any of the current exclusion criteria for the
administration of rtPA in the clinical practice
 a history of gout with or without a history of gouty
nephropathy, or uric lithiasis
 asymptomatic hyperuricaemia under chronic treatment
with allopurinol or chronic treatment with lithium
 chronic renal insufficiency (baseline creatinine 41
5 mg/dl
or 132
6 mmol/l).
Randomisation
A block randomisation list will be generated by means of the
PROC PLAN module of SAS (version 9). Randomisation will
be stratified by centre and baseline NIHSS (NIHSS score of 10
as a cut point) with a probability of assignment to each
326 Journal compilation & 2010 World Stroke Organization International Journal of Stroke Vol 5, August 2010, 325–328
S. Amaro et al.
treatment arm of 1 : 1. The randomisation will be performed
in a web-based system provided by Onmedic Networks S. L.
(Barcelona, Spain), under the supervision of the Clinical Trials
Unit of Hospital Clı́nic of Barcelona.
Treatments
Patients will be randomised into two treatment arms. Patients
allocated to the active arm will receive an i.v. infusion of 1 g of
UA dissolved in a vehicle containing 500 ml of 0
1% lithium
carbonate and 5% mannitol over 90 min. Patients allocated to
the control arm will receive a single intravenous infusion of
500 ml of a vehicle containing 0
1% lithium carbonate and 5%
mannitol over 90 min.
The selected dose of UA is based on previous clinical studies
including healthy volunteers (9, 10), and acute stroke patients
receiving rtPA (7). The intravenous infusion of doses up to 1 g
of UA has been shown to be safe and to reduce several
parameters of oxidative stress. In acute stroke patients receiv-
ing rtPA, UA infusion in the early phase prevents an early decay
in UA levels and reduces markers of lipid peroxidation and the
activation of matrix metalloproteinase-9, a molecule related to
poor clinical outcomes (7, 8).
Uric acid will be obtained from Sigma (Ultra pure prepara-
tions; Sigma Chemical Co., Poole, UK). Both UA and vehicle
solutions will be manufactured by Laboratorios Grifols
(Barcelona, Spain) following Good Manufacturing Practices
regulations. The use of UA as an investigational medicinal
product in human clinical trials received recently the approval
of the Spanish Medicines and Healthcare Products Agency
(eudraCT 2004-002937-37).
A schematic outline of the study including the timing of
treatments is shown in Fig. 1. Intravenous rtPA treatment will
be initiated at a standard dose and regimen (0
9 mg/kg, initial
bolus of 10% of the final dose and the remaining dose as an
intravenous infusion lasting 60 min) following current clinical
guidelines. When a patient meets all the inclusion/exclusion
criteria and signs the informed consent, UA/vehicle infusion
will be initiated as soon as possible after starting the infusion of
rtPA treatment. The 90-min intravenous infusion of the
Fig. 1 URICO-ICTUS study design. Schematic outline of the study including
the timing of treatments and ancillary studies.
& 2010 The Authors.
 S. Amaro et al.
experimental treatment (UA/vehicle) will be performed
through a peripheral venous line in an extremity different
from that used for rtPA infusion. Antithrombotic treatments
will be avoided during the first 24 h after rtPA treatment, except
for special circumstances (e.g. pulmonary embolism).
Primary outcome
The primary outcome measure of the study is the proportion
of patients with a favourable clinical outcome at 3 months,
defined as achieving an mRS score of 0–1 at 3 months after
treatment, or 2 in those patients showing an mRS of 2 before
the inclusion in the study. The evaluators of the functional
outcome at day 90 will be certified in the use of neurological
scales (NIHSS, mRS) and will use a structured interview
questionnaire to homogenise the evaluation in all participat-
ing centres.
Secondary outcomes
Secondary outcome measures include the following efficacy
and safety variables:
 proportion of patients with NIHSS o2 at 2 h after finishing
the experimental treatment
 proportion of patients with NIHSS o1 at day 90
 proportion of patients achieving a Barthel scale of 95 to 100
at day 90
 all-cause mortality within the first 90 days
 final infarction volume measured by means of MRI or
multimodal CT at 72 h of onset (in selected centres)
 proportion of patients with an intracranial haemorrhage
associated with a worsening of at least 4 points in the NIHSS
within the first 36 h of treatment.
Ancillary studies
Neuroimaging substudy
All patients will receive a baseline CT scan before the inclusion
in the study to discard the presence of any intracranial
haemorrhage and to evaluate the extension of early signs of
ischaemia (ASPECT score) and the presence of the hyperdense
middle cerebral artery sign. In selected centres, a multimodal
CT (angio-CT and CT-perfusion) or MRI (including DWI,
PWI, T2, T1, T2 and FLAIR sequences and angio-MRI) will
be performed at the end of rtPA infusion (40–120 min after the
start of the infusion) and at 72 h. The variables that will be
evaluated in the multimodal imaging include arterial status
(early vs. late recanalisation and TICI score), the presence and
volume of mismatch, the volume of established infarction
and the presence of intracranial haemorrhages. An additional
mandatory CT scan will be performed 24 h after rtPA in-
fusion to evaluate the presence of intracranial bleeding. The
neuroimaging studies will be evaluated in a single centre by
& 2010 The Authors.
Journal compilation & 2010 World Stroke Organization International Journal of Stroke Vol 5, August 2010, 325–328
Protocols
neuroradiologists blinded to treatments and to the clinical
course of patients.
Blood biomarkers’ substudy
Following the recommendations of the Stroke Academy In-
dustry Roundtable (STAIR) (11), a longitudinal blood bio-
marker study will be executed to evaluate the biological activity
of the investigational drug. In selected centres, serial blood
extractions will be performed at baseline, at 6–12 h, and at 48 h
after the start of the experimental treatment (Fig. 1). After
appropriate processing of the blood, serum and plasma
samples will be stored at 801C until their analysis, which
will include biochemical markers of parenchymal damage
(S100B), markers of blood–brain barrier damage (matrix
metalloproteinase-9, fibronectin) and oxidative stress markers
(malondialdehyde, F2-isoprostanes).
Data-safety monitoring board (DSMB)
The study will be monitored by the Clinical Trials Unit of
Hospital Clinic of Barcelona. A DSMB will be composed by
three independent members (one neurologist, one biostatisti-
cian and one clinical pharmacologist), who will evaluate
periodically the frequency and type of fatal or serious adverse
events, including the rate of death of any cause, the incidence of
symptomatic intracerebral haemorrhages (increase in at least 4
points in the NIHSS) and all the adverse events considered to
be related to the investigational drug.
Sample size
The primary outcome of this trial is a favourable clinical
outcome at 90 days defined as an mRS score of 0–1 at 90 day or
an mRS of 2 in patients with a qualifying mRS of 2 at entry in
the study. Based on an expected response rate of 40% in the
primary outcome variable in the control group and assuming a
loss to follow-up of 5%, a total of 210 patients per group will be
required to detect a significant difference not inferior to 14%
between treatment groups (a 5%, b 80%). These estimations
are based on the recently published results of the ECASS3 trial
(12), on the results of a pilot trial of UA infusion in acute
ischaemic stroke patients receiving rtPA (n 5 24) (7) and on
data from the prospective registry of patients treated with rtPA
in the co-ordinating centre (Hospital Clı́nic of Barcelona;
n 5 120 at the time of sample size calculation). Patients will
be included over a period of 3 years and the analysis of results is
planned at the end of 2012.
Statistical analyses
The primary outcome variable will be analysed in the ‘inten-
tion-to-treat’ population using a binary logistic regression
model adjusted by centre and baseline NIHSS. Additionally, an
exploratory unadjusted analysis will also be performed. As a
proof of sensitivity and consistency of the results, the ‘per
protocol’ analysis will be provided as well. Mortality will be
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evaluated using a Cox regression model and adjusting by the
same variables used in the analysis of the primary outcome
variable. The rest of the secondary outcome variables will
be analysed using the appropriate hypothesis test (exact
Fisher’s test for categorical variables, Student’s t-test for
continuous variables and the Mann–Whitney U-test for
ordinal variables). The statistical analysis will performed using
SPSS software version 16
0 (SPSS Inc., Chicago, IL), and
significance will be established at the Po0
05 level (two sided).
Study organisation and funding
The URICO-ICTUS trial is funded by the Institute of Health
Carlos III of the Spanish Ministry of Health (grant number
EC07/90276) and by a private grant from Fundación Doctor
Melchor Colet. A total of six Spanish tertiary hospitals will
participate in the study. The study will be co-ordinated in the
Hospital Clinic of Barcelona by the Fundació Clı́nic per a la
Recerca Biomèdica and the Clinic Trials Unit of Hospital Clı́nic
de Barcelona. The Executive Committee (seven members,
principal investigator Ángel Chamorro) is responsible for the
development of the study protocol and its amendments.
The independent DSMB (three members) is responsible for
reviewing safety and efficacy data on an ongoing basis. It will
also perform interim analyses (group sequential procedure) on
the primary end-point at scheduled time-points during the
study according to a prespecified plan.
Summary and conclusions
Growing experimental and clinical evidence prove UA as a
promising neuroprotective agent in brain ischaemia. In ex-
perimental ischaemia, the benefits yielded by the exogenous
infusion of UA are in addition to those provided by rtPA. In
both healthy volunteers and patients suffering an acute ischae-
mic stroke, the i.v. infusion of UA is feasible and safe. In stroke
patients treated with intravenous rtPA, the addition of UA is
able to reduce the parameters of oxidative stress and prevent
the activation of matrix metalloproteinase-9. Based on this
knowledge, the URICO-ICTUS trial will evaluate the clinical
328 Journal compilation & 2010 World Stroke Organization International Journal of Stroke Vol 5, August 2010, 325–328
S. Amaro et al.
efficacy of the intravenous infusion of UA in acute ischaemic
stroke patients receiving rtPA within the first 4
5 h. Moreover,
the preplanned neuroimaging and blood biomarker substudies
will quantify signs of the biological activity of UA infusion
using several validated surrogate outcomes.
References
1 The National Institute of Neurological Disorders and Stroke rt-PA
Stroke Study Group. Tissue plasminogen activator for acute ischemic
stroke. N Engl J Med 1995; 333:1581–7.
2 McCord JM. Oxygen-derived free radicals in postischemic tissue
injury. N Engl J Med 1985; 312:159–63.
3 Ames BN, Cathcart R, Schwiers E, Hochstein P. Uric acid provides an
antioxidant defense in humans against oxidant- and radical-caused
aging and cancer: a hypothesis. Proc Natl Acad Sci USA 1981; 78:
6858–62.
4 Chamorro A, Obach V, Cervera A, Revilla M, Deulofeu R, Aponte JH.
Prognostic significance of uric acid serum concentration in patients
with acute ischemic stroke. Stroke 2002; 33:1048–52.
5 Yu ZF, Bruce-Keller AJ, Goodman Y, Mattson MP. Uric acid protects
neurons against excitotoxic and metabolic insults in cell culture, and
against focal ischemic brain injury in vivo. J Neurosci Res 1998; 53:
613–25.
6 Romanos E, Planas AM, Amaro S, Chamorro A. Uric acid reduces brain
damage and improves the benefits of rt-PA in a rat model of
thromboembolic stroke. J Cereb Blood Flow Metab 2007; 27:14–20.
7 Amaro S, Soy D, Obach V, Cervera A, Planas AM, Chamorro A. A pilot
study of dual treatment with recombinant tissue plasminogen activator
and uric acid in acute ischemic stroke. Stroke 2007; 38:2173–5.
8 Amaro S, Obach V, Cervera A et al. Course of matrix metalloprotei-
nase-9 isoforms after the administration of uric acid in patients with
acute stroke: a proof-of-concept study. J Neurol 2009; 256:651–6.
9 Waring WS, Convery A, Mishra V, Shenkin A, Webb DJ, Maxwell SR.
Uric acid reduces exercise-induced oxidative stress in healthy adults.
Clin Sci 2003; 105:425–30.
10 Waring WS, Webb DJ, Maxwell SR. Systemic uric acid administration
increases serum antioxidant capacity in healthy volunteers. J Cardio-
vasc Pharmacol 2001; 38:365–71.
11 Stroke Therapy Academic Industry Roundtable II. Recommendations
for clinical trial evaluations of acute stroke therapies. Stroke 2001;
32:1598–606.
12 Hacke W, Kaste M, Bluhmki E et al. ECASS Investigators. Thrombolysis
with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med
2008; 359:1317–29.
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