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 Table of Contents  
STUDY PROTOCOL
Year : 2016  |  Volume : 1  |  Issue : 2  |  Page : 50-61

Role of DLBS1033 in the management of acute ischemic stroke patients: study protocol for a randomized controlled study


1 Division of Educational Coordination Committee, R. Syamsudin, SH Hospital, Sukabumi, West Java, Indonesia
2 Division of Pathology Clinic, R. Syamsudin, SH Hospital, Sukabumi, West Java, Indonesia
3 Dexa Laboratories of Biomolecular Science, Dexa Medica Group, Cikarang, Indonesia

Date of Web Publication29-Apr-2016

Correspondence Address:
Maruli Simangunsong
Division of Educational Coordination Committee, R. Syamsudin, SH Hospital, Sukabumi, West Java
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2468-5577.181235

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  Abstract 

Background: In Indonesia, the incidence of stroke is growing rapidly every year and it becomes a burden to the government. Medications improving neurological function are required, in order to increase patient's quality of life. There were an enzyme (lumbrokinase) secreted from the alimentary tract of earthworm and it has anti-thrombotic and thrombolytic effect so that it can be beneficial in the management and prevention of stroke. DLBS1033 is a standardized bioactive protein fraction derived from Lumbricus rubellus through a patented technology of extraction. DLBS1033 has been shown to have antithrombosis and thrombolytic activities. The safety profile of DLBS1033 was also demonstrated in toxicology studies, animal studies, and in healthy adult subjects. Based on its mechanism of action and safety profile, DLBS1033 can be considered beneficial on acute ischemic stroke patients. Through this clinical study, we will evaluate the efficacy and safety of the product in acute ischemic stroke management.
Methods/Design: This is a prospective, randomized, double-blind, and controlled clinical study to investigate the effects of DLBS1033 in conjunction with standard therapy compared to standard therapy alone in the management of acute ischemic stroke. Patients included into the study will be randomized into two groups and receive either standard therapy alone (as control group) or standard therapy plus DLBS1033 (as DLBS1033 group). Functional outcomes will be measured using the Modified Rankin Scale (MRS) and The Modified National Institutes of Health Stroke (mNIHSS).
Discussion: The study is expected to be a medical breakthrough in acute ischemic stroke management. Therefore, the morbidity and mortality of this disease can be lowered.
Trial registration: ClinicalTrials.gov identifier: NCT02362984; registered on 3 February 2015.

Keywords: DLBS1033; acute ischemic stroke; MRS; mNIHSS; nervous system diseases


How to cite this article:
Simangunsong M, Bihantoro, Wijayanti Z, Aisyah E, Mustikawati N, Tjandrawinata RR, Hendri P, Hidayah N, Susantos LW, Fenny, Purnama D. Role of DLBS1033 in the management of acute ischemic stroke patients: study protocol for a randomized controlled study. Asia Pac J Clin Trials Nerv Syst Dis 2016;1:50-61

How to cite this URL:
Simangunsong M, Bihantoro, Wijayanti Z, Aisyah E, Mustikawati N, Tjandrawinata RR, Hendri P, Hidayah N, Susantos LW, Fenny, Purnama D. Role of DLBS1033 in the management of acute ischemic stroke patients: study protocol for a randomized controlled study. Asia Pac J Clin Trials Nerv Syst Dis [serial online] 2016 [cited 2018 Dec 19];1:50-61. Available from: http://www.actnjournal.com/text.asp?2016/1/2/50/181235


  Background Top


The clinical manifestation of losing neurological function due to an acute attack is mostly associated with vascular abnormality. That vascular abnormality causing such a neurological deficiency is the so-called stroke. According to its pathology, stroke condition is divided into two groups. Ischemic stroke occurs when the blood supply to part(s) or whole part of the brain is suddenly interrupted due to the presence of blood clots, leading to lacking of nutrient and energy (like oxygen and glucose) delivered to the brain. The other type is hemorrhagic stroke, which occurs when a blood vessel in the brain bursts, spilling blood around the brain or into the space of cerebrospinal fluid (Caplan, 2009a).

The incidence of ischemic stroke is higher than hemorrhagic stroke (85% versus 15%). In Indonesia, stroke is the first leading cause of death and disability condition (Hankey, 2002; the National Institute of Health Research and Development, 2008; Caplan, 2009b). In the future, the stroke incidence is even predicted to increase because of the unhealthy lifestyle.

Ischemic stroke can be induced by circulation failure, general hemodinamic disturbance, increasing number of viscosity, increasing number of coagulation, blood clot formation (thrombus), emboli, and vessel damage underlying the atherosclerosis. In case of subarachnoid hemorrhage, the disturbance of energy delivery to the brain area due to vasospasm will result in an ischemic area of the brain, followed by clinical function damage. This damage is reversible when the circulation is timely repaired, otherwise it will become permanent. Some people suffer from transient ischemic attacks (TIAs), which can be called as mini-strokes that last only 5 to 20 minutes. In almost all TIAs, the symptoms disappear within an hour (Caplan, 2009a).

Based on The Report of Ministry of Health (RISKESDAS 2007) and hospital data on hospitalization period of stroke patients in Indonesia, stroke becomes a serious problem not only because there is a short golden (or window) period of initiating medication, but also the complexity of handling the disease (the National Institute of Health Research and Development, 2008; Prasetyo et al., 2011). The medication target area of ischemic stroke is called penumbra. That is the area of surviving cells that does not have any function (Caplan, 2009c). In stroke, besides the cerebral blood flow reduction, an inflammation and hyperproduction of peroxides will worsen the survival of penumbra (Warlow et al., 2008).

No standard therapy has currently been established for the treatment of ischemic stroke. Several therapies that have been frequently being used in the hope that they will improve the outcome after an ischemic stroke attack include thrombolytic therapy (rtPA), antiplatelet agents (aspirin, clopidogrel, cilostazol), anticoagulants (heparin, enoxaparin), as well as neuro-protective agents (citicoline, piracetam) (Adams et al., 2003). In clinical practice, there are several medications to prevent membrane cells damage induced by proteolytic enzyme or to prevent apoptosis. In case of secondary prevention, antiplatelet aggregation as a standard treatment can be used (collaboration study with aspirin). Several other studies related to medication of stroke are CAPRIE study (clopidogrel) (CAPRIE Steering Committee, 1996), CSPS study (cilostazol) (Shinohara et al., 2010), and RELY study (Dabigatran) (Ezekowitz, et al., 2009).

In hyperacute condition, thrombolytic agent such as rtPA can be used. It can lyse the thrombus around the ischemic stroke area (Warlow et al., 2008; Caplan, 2009c). However, the use of thrombolytic drugs carries the real risk of major bleeding. The risks and potential benefits of rtPA should be discussed whenever possible with the patient and family before treatment is initiated. Besides, the medication with rtPA has a limitation of time. It should be used not more than 3 hours after stroke (Caplan, 2009c). Meanwhile, in Indonesia stroke patients usually come to the hospital in more than 24 hours after stroke attack.

For several thousand years earthworms have widely been used in Indonesia, China, Japan, and the Far East to treat various chronic diseases. It was reported long time ago in 1899 that an enzyme secreted from the alimentary tract of the earthworm could dissolve fibrin (Willem and Minne, 1899). Mihara et al. (1991) found that the extract of earthworm from Lumbricidae family could directly dissolve fibrin and activate plasminogen. In 1991, Japanese researchers have purified and characterized group of serine protease enzyme found in Lumbricus rubellus and named collectively as lumbrokinase. Lumbrokinase has potent fibrinolytic and fibrinogenolytic activities, lowering blood viscosity, and markedly reducing platelet aggregation (Mihara et al., 1991).

Lumbrokinase has been investigated in some clinical studies. A study was also done on hyperfibrinogenemia patients, and the result indicated that lumbrokinase could relieve hyperfibrinogenemia, therefore the formation of thrombin would be decreased (Gao and Qin, 1999). Studies from Jin et al. (2000, 2001) suggest that the decrease of fibrinogen content after administration of lumbrokinase is beneficial to the prevention and treatment of stroke.

DLBS1033 is a standardized bioactive protein fraction derived from Lumbricus rubellus through a patented technology of extraction. DLBS1033 has been shown to have antithrombosis activities due to its fibrinogen degradation assay, antiplatelet aggregation, and ex vivo antithrombosis assay; and thrombolytic activities demonstrated by fibrin plate assay and clot lysis assay (Trisina et al., 2011).

In vitro studies demonstrated reduced expression of several genes involved in inflammatory and atherogenic reaction by DLBS1033, such as nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), tumor necrosis factor α (TNF-α), vascular cell adhesion molecule 1 (VCAM-1), and P-selectin. The down-regulation of NF-κB has a link to the inhibition of atheroma formation, suggesting that DLBS1033 can be used as an antiatherogenesis agent. DLBS1033 can inhibit the progression of other cytokines that are activated by TNF-α and adherence of leukocytes to endothelium. Activity of DLBS1033 in decreasing the expression of P-selectin may be related to the suppression of de novo synthesis of P-selectin mediated by cytokine. DLBS1033 suppressed the expression of VCAM-1, a member of the immunoglobulin gene superfamily that mediates leukocyte binding to the endothelial cell (Kurnia and Tjandrawinata, 2011). In the same study, it was shown that DLBS1033 suppressed the expression of MMP-9 gene, a marker of plaque instability, suggesting that this bioactive protein fraction has the ability to control plaque stabilization. MMP-9 is a protease that degrades extracellular matrix proteins including gelatin, collagen, elastin, and laminin that are important in tissue destruction; and also in tissue remodeling and inflammation. This study indicated that DLBS1033 could regulate the uncontrolled event of plaque rupture by inhibiting the expression of MMP-9. Besides, DLBS1033 also down-regulated JAK/STAT1 system which is responsible for vascular smooth muscle cell proliferation (Kurnia and Tjandrawinata, 2011).

The toxicology studies, in vitro in cell cultures (Sunardi, et al., 2008), preclinical acute toxicology (Sukandar, et al., 2009), subchronic toxicology (Sajuthi and Suhartono, 2008), and teratogenic toxicology (Sukandar, 2009) studies in rats also have confirmed the safety profile of DLBS1033. The safety profile of DLBS1033 was also demonstrated in an animal study using healthy Macaca fascicularis (Sajuthi, et al., 2008), in which DLBS1033 did not affect the number of thrombocytes, blood glucose level, triglyceride level, and body weight. In a different study which was also conducted in rats, addition of DLBS1033 treatment to aspirin or clopidogrel (dual antiplatelet agents) for 28 days did not increase the risk of bleeding. However, concomitant use of triple agents (DLBS, aspirin, and clopidogrel) led to a linear progression of petechiae in the gastric mucosa (Sukandar et al., 2014).

Safety profile of DLBS1033 has also been demonstrated in healthy adult subjects (Gayatri, 2012; Yunaidi, et al., 2011). Based on the evaluation of safety parameters, which included hematology parameters, blood chemistry, urine and stool occult blood evaluation, and ECG interpretation, DLBS1033 was proven safe in healthy subjects. To date, DLBS1033 has been approved by National Agency of Drug and Food Control (NADFC), Republic of Indonesia, to be marketed as Indonesian traditional medicine (with brand name of Degrade®, POM TR 111 527 331). Since then, no clinically significant adverse drug reactions have been reported.

Based on its mechanism of action and safety profile, DLBS1033 benefits acute ischemic stroke patients. Therefore, through the current clinical study, we will evaluate the efficacy and safety of the product in acute ischemic stroke.

In this study we use standard therapy recommended by American Heart Association/American Stroke Association Guidelines for acute ischemic stroke (Adams et al., 2007). The standard therapy used in this study includes aspirin, statin, and vitamin B complex.

Objectives

To investigate the efficacy of bioactive protein fraction DLBS1033 combined with standard therapy compared to standard therapy alone in improving functional outcomes in acute ischemic stroke patients, as measured by Modified Rankin Scale (MRS) and The Modified National Institutes of Health Stroke Scale (NIHSS).

To investigate the efficacy of bioactive protein fraction DLBS1033 combined with standard therapy compared to standard therapy alone in improving hemostatic parameters in acute ischemic stroke patients, as measured by fibrinogen and D-dimer level.

To evaluate the safety of bioactive protein fraction DLBS1033 combined with standard therapy in acute ischemic stroke patients.

Hypothesis

Treatment with DLBS1033 at the dose of 3 × 490 mg daily in addition to the standard therapy of acute ischemic stroke is more effective than the standard therapy alone in improving neurologic function measured by Modified Rankin Scale (MRS) and The Modified National Institutes of Health Stroke Scale (NIHSS).

Treatment with DLBS1033 at the dose of 3 × 490 mg daily in addition to the standard therapy of acute ischemic stroke is more effective than the standard therapy alone in improving hemostatic parameters measured by fibrinogen and D-dimer level.

Treatment with DLBS1033 at the dose of 3 × 490 mg daily in addition to the standard therapy is considered safe in the management of ischemic stroke patients.


  Methods/Design Top


Study design

This is a prospective, randomized, double blind, and controlled clinical study to investigate the effects of DLBS1033 in conjunction with standard therapy compared to standard therapy alone. Patients included into the study will be randomized into two groups and receive either standard therapy alone (as control group) or standard therapy plus DLBS1033 (as DLBS1033 group) administered orally for 8 days.

Study setting/location

This research will be held in neurological ward (Melati ward) in RSUD R. Syamsudin, SH hospital, Indonesia. It will begin in October 2014 and expected to be completed in June 2015. Laboratory and serum biochemistry will be processed in Laboratory Unit in RSUD R. Syamsudin, SH and Praditha Laboratory in Sukabumi.

Study population

Study population is acute ischemic stroke patients with Partial Anterior Circulation Infarct (PACI) and Lacunar Anterior Circulation Infarct (LACI) as classified by Bamford criteria according to the symptoms and signs with which region of the brain has been affected. There will be 116 subjects (58 subjects in each group) planned to be enrolled in the study.

Inclusion criteria

  1. Signed informed consent from the patients or patients' legally acceptable representatives (must be obtained before any trial related activities)
  2. Male or female subjects with age of 18-65 years at screening
  3. Has been diagnosed having first acute ischemic stroke clinically confirmed by CT scan. The type of ischemic stroke that included in this study is Partial Anterior Circulation Infarct (PACI) and Lacunar Anterior Circulation Infarct (LACI) as classified by Bamford criteria
  4. Patients with moderate to severe condition based on the Modified Rankin Scale (MRS) score > 2
  5. Patients with moderate condition based on The Modified National Institutes of Health Stroke Scale (mNIHSS) score of 5-15
  6. Patients present at hospital and receiving first dose of study medication within 72 hours after the onset of the stroke symptoms
  7. Able to take oral medication
  8. Patients or patients' legally acceptable representatives are able and willing to record adverse events in a diary
  9. Patients or patients' legally acceptable representatives have the ability to comply with the trial protocol


Exclusion criteria

  1. For females of childbearing potential: pregnancy and lactation period. Patients must accept pregnancy tests during the trial if menstrual cycle is missed. Fertile patients must use effective contraception
  2. History of or current hemorrhagic stroke (within the last 3 months)
  3. Transient ischemic stroke (TIA)
  4. Patients with seizure at the onset of stroke
  5. History of serious head injury within the last 3 months.
  6. History of major surgery within the last 3 months
  7. Recent (within the last 6 months) serious cardiovascular conditions, such as myocardial infarction, congestive heart failure, aortic dissection, and heart atrial fibrillation
  8. Presence of severe renal dysfunction, defined as serum creatinine level > 3 × upper limit of normal (ULN)
  9. Presence of severe hepatic dysfunction, defined as any of serum alanine aminotransferase (ALT), aspartate transaminase (AST), gamma glutamyl transferase (γ-GT) level of > 3 × ULN
  10. Presence of acute systemic inflammatory response syndrome (SIRS). The term SIRS describes a clinical state arising from a non-specific cause, infective, or otherwise. It is defined as the presence of more than one of the following clinical manifestations:
    • Body temperature > 38°C or < 36°C
    • eart rate > 90 beats per minute
    • Tachypnea, manifested by a respiratory rate > 20 breaths per minute
    • An alteration in the white blood cell count, such as a count > 12,000/mm 3 , a count < 4,000/mm 3, or the presence of > 10% immature neutrophils (bands)
  11. Presence of chronic infections
  12. Patients with thrombocytopenia (when thrombocytes level < 150.000/μL)
  13. Patients with higher risks of bleeding:
    • Subjects with history of acquired or congenital bleeding disorder, coagulopathy, platelet disorder, severe anaemia (defined as hemoglobin < 8.0 g/dL), gastrointestinal or urinary bleeding within the past 3 weeks
    • Subjects with malignancy
  14. Subjects with uncontrolled hypertension (systolic blood pressure > 185 mmHg or diastolic blood pressure > 110 mmHg)
  15. Subjects with random plasma glucose ≥ 200 mg/dL at screening
  16. Current or regular use of oral anticoagulants, antiplatelets other than study medication, and herbal medicines.
  17. Known or suspected hypersensitivity to the trial product or related products
  18. Participation in any other clinical studies within 30 days prior to screening


Withdrawal criteria

The patient may be withdrawn from the trial at the discretion of the investigator or the sponsor if judged non-compliant with trial procedures or due to safety concerns. A patient must be withdrawn if any of the following applies:

  1. Any event including allergic reaction or severe adverse events that might jeopardize the health of the patient
  2. Having any condition necessitating therapy with any anticoagulants, or antiplatelets other than study medication
  3. Participation in any other clinical trial during the course of the trial
  4. Not complying with study medication and/or study protocol
  5. Subject's own discretion to withdraw from the study


Outcome measures

Primary outcome


Improvement rate on days 4 and 8 (end of study) as defined by proportion of subjects with category of Modified Rankin Scale (MRS) of 0-2. The 6-point Modified Rankin Scale (MRS) assesses the extent of disability after stroke attack (supplementary Table 1 online). Patients with no impairment or symptoms receive the best score of 0; while patients with severe disability, who are bedridden, incontinent, and require constant nursing care and attention are rated the worst score of 5; death is scored 6 in MRS (Bonita and Beaglehole, 1998).

Modified Rankin Scale (MRS) has moderate to excellent inter-rater reliability (Van Swieten et al., 1988). The scale has also been shown to be valid and is considered more powerful than the Barthel Index as a primary endpoint in a clinical trial of stroke therapy (Wilson et al., 2002; Weir, et al., 2004; Young et al., 2005; Jensen and Lyden, 2006).

Secondary outcomes

  • Improvement (change) in functional outcomes from baseline to days 4 and 8 of treatment as measured by the modified National Institute of Health Stroke Scale (mNIHSS). The National Institute of Health Stroke Scale (NIHSS), a standardized measure of neurological function, has been used in clinical trials to assess neurological outcome after investigational therapy for acute stroke (Wityk et al., 1994). NIHSS is used to study the degree and time course of recovery in patients with acute stroke who were treated with conventional therapy. The NIHSS is a convenient, rapidly applied scale for neurological assessment that correlates with other measures of stroke outcome, such as infarct size on clinical trial. It takes only less than 10 minutes to complete NIHSS. Because of its simplicity and higher inter-rater reliability, it is well suited for clinical treatment trials of acute stroke, in which serial assessments may be performed by different persons (Brott et al., 1989a, b; Goldstein et al., 1989).


The NIHSS is an 11-item assessment of neurological function modified from Brott et al. (1989a) (supplementary Table 2 online). Several simpler versions have been proposed, but the most validated is the Modified or mNIHSS (Meyer et al., 2002; Lyden et al., 2006). Previous studies used an increase or decrease in the stroke score by 4 points or more in NIHSS as a marker for clinically important change (Brott et al., 1992). While in mNIHSS early changes (i.e. improvement by 2 points or more) in the total score were also strongly predictive of a favorable outcome following treatment with thrombolytic agents (Meyer et al., 2002; Hacke et al., 2004). Baseline severity as measured by the NIHSS is the most important predictor of ultimate outcome (Schlegel et al., 2003, 2004; Derex et al., 2004).

  • Improvement (change) in haemostatic parameters from baseline to day 8 of treatment as measured by:

    ○ Fibrinogen level

    ○ D-dimer level


The dynamic observation of plasma fibrinogen and D-dimer of acute ischemic stroke may has an early prognostic value on progressive ischemic stroke. There is a more significant hypercoagulabale state in progressive ischemic stroke.

Safety outcome

Safety parameters other than vital signs and adverse event will be measured at baseline and end of study. Vital signs and adverse event will be measured at baseline and every follow-up visit including end of study.

The safety parameters include:

  • Vital signs (body temperature, blood pressure, heart rate, respiration rate)
  • Liver function: serum AST, Alanine transaminase (ALT), γ-glutamyl transferase (γ-GT), total bilirubin
  • Renal function: serum creatinine
  • Hemostasis parameters: prothrombin time (PT), activated partial thromboplastin time (aPTT)
  • Adverse events: (1) Bleeding events / tendency, such as hematuria, gastric bleeding, decrease of hemoglobin level of > 2 g/dL or any major bleeding events necessitating hospitalization. Tendency of bleeding will therefore be carefully evaluated through routine hematology. (2) Other adverse events.


Any adverse event will be observed and carefully evaluated along the course of the study.

Study procedures

Recruitment of participants


Patients hospitalized in neurological ward (Melati ward) R. Syamsudin, SH hospital and diagnosed with acute ischemic stroke (confirmed by CT Scan) will be screened based on inclusion criteria. If patients were eligible to be enrolled in this study, patients would be handled as per acute ischemic stroke management and the treatment(s) will be switched immediately into the study's regimens.

Randomization, blinding procedure, and packaging of the trial products

Patients included into the study will be randomized into two groups and receive either standard therapy alone (as control group) or standard therapy plus DLBS1033 (as DLBS1033 group). Randomization and blinding code preparation will be performed by Ferron Par Pharmaceuticals (FPP) using the permuted block-allocation and Table of Random numbers. The blinding codes will be prepared by the Management of FPP who is not directly involved in both the study preparation and conduct, so as that even the Monitor(s) and Data Management will also be blind of the codes till the unblinding procedures apply.

All packaging and labeling of the study products will be prepared by FPP according to the current Good Manufacturing Practice (cGMP). The study products will be prepared in such packages which will be recognized as products for clinical trial only. In order to keep the blinding procedures, the study drugs will all be provided by FPP in a double-blind double-dummy preparation. Dummy tablets (as placebo of DLBS1033) will also be prepared by FPP and made identical in appearance with the active tablets. Each subject will receive two kinds of medication, i.e. either DLBS1033 tablets or its dummy and standard therapies, in sufficient numbers to be taken over 8 days of study period. By that way, each subject in both groups will receive apparently identical study medication, disabling them as well as the Investigator to identify which of the study treatments received by each individual subject.

Study product

Investigational drug:

  • Bioactive protein fraction DLBS1033 enteric coated tablet @ 490 mg.
Investigational drug will be administered orally, one tablet three times daily for 8 days of study period.

Control:

  • Placebo DLBS1033
Placebo will be administered orally, one tablet three times daily for 8 days of study period.

Standard therapy used in this study

During hospitalization study period:

  • Aspirin enteric-coated tablet @ 80 mg (Thrombo Aspilet®, Medifarma), will be given orally, one tablet once daily for 8 days of study period
  • Simvastatin film-coated tablet @ 20 mg (Esvat®, PT Dexa Medica), will be given orally, one tablet once daily for 8 days of study period.
  • Vitamin B complex film-coated tablet (Neurodex®, PT Dexa Medica), consisted of vitamin B 1 mononitrate 100 mg, vitamin B 6 HCl 200 mg, and vitamin B 12 200 mcg, will be given orally, one tablet once daily for 8 days of study period.
  • Citicoline injection in ampule @ 250 mg/2 mL (Neulin®, PT Ferron Par Pharmaceuticals), will be given as IV drip, 250 mg twice daily for 8 days of study period.


Concomitant medication

During participation in the study, depending on his/her concomitant illnesses, subjects shall take concomitant medication, such as:

  • Antihypertension drugs: Calcium Channel Blockers, Angiotensin-converting enzyme (ACE) inhibitors, β-blockers, and/or diuretics
  • Subjects, whose blood pressures have been well-controlled (less than 140/90 mmHg or 130/80 mmHg in diabetics) with currently used agents, can continue their therapy. Otherwise, they will receive ramipril, amlodipine, bisoprolol, and/or HCT tablets, as ACE inhibitor, calcium channel blocker, β-blocker, and diuretic, respectively.
  • Insulin and/or any oral antidiabetic agents
  • Subjects with diabetes should continue their diabetes therapy. Those with newly-diagnosed diabetes mellitus should also be treated in accordance with the proper diabetes management. Subjects with random plasma glucose more than 200 mg/dL at screening will be excluded from the study. Otherwise, they should be given a short-acting insulin therapy until the plasma glucose is controlled prior to enrollment (72 hours after the onset of stroke). After insulin therapy, if random blood sugar < 200 mg/dL, then subjects will be included in this study.


Treatment allocation and regimens

There will be 2 groups of treatment; each will consist of 58 subjects. A total of 116 subjects will be randomized into two groups ([Table 1]).
Table 1: Treatment allocation


Click here to view


All subjects will be instructed to have the examination for efficacy and safety evaluation 3 and 7 days after medication initiation. Physiotherapy will be given to each study subject every day during hospitalization. All subjects will be under direct supervision of a medical doctor during the study period.

Further details of visit schedule are shown in [Table 2].
Table 2: Examinations and evaluation during the study conduct


Click here to view


Study conduct

Before its commencement, the study protocol must obtain approval from the Independent Ethics Committee situated in the country where the clinical study will be conducted. Informed consent will be obtained from each clinical trial subject or his/her legal guardian.

Subjects will be screened consecutively and eligible subjects will be randomized into two groups and receive the investigational drug, DLBS1033 at a dose of 490 mg three times daily or its placebo in addition to standard therapy for 8-day course of therapy. Standard therapy used in this study will consist of:

  • Aspirin enteric-coated tablet 80 mg, orally, one tablet once daily
  • Simvastatin film-coated tablet 20 mg, orally, one tablet once daily
  • Vitamin B complex film-coated tablet, consisted of vitamin B 1 mononitrate 100 mg, vitamin 
B 6 HCl 200 mg, and vitamin B 12 200 mcg, orally, one tablet once daily
  • Citicoline injection, 250 mg i.v drip, twice daily


After hospital admission and diagnosis, patient will be handled as per acute ischemic stroke management in study site. Right after the patient is confirmed eligible to the study, the treatment(s) will be switched immediately into the study treatments. Clinical and laboratory examinations to evaluate the investigational drug's efficacy will be performed at baseline and days 4 and 8 of treatment (end of study); while safety examinations will be performed at baseline and end of study. Eligible subjects will be closely monitored by an investigator during their participation in the study to evaluate the outcome.

The schematic design of the study is shown in [Figure 1].
Figure 1: Study design of DLBS1033.
Note: MRS: Modified Rankin Scale; mNIHSS: Modified National Institutes of Health Stroke Scale; TIA: transient ischemic attack; MI: myocardial infarction; CHF: congestive heart failure; AF: atrial fibrillation; ALT: Alanine Aminotransferase; AST: Aspartate Transaminase; GGT: gamma glutamyl transferase; SIRS: systemic inflammatory response syndrome; SBP: systolic blood pressure; DBP: diastolic blood pressure. PT: prothrombin time; aPTT: activated partial thromboplastin time.


Click here to view


Measurement tools used

  1. Research explanation manuscript for subjects/subject's relatives
  2. Informed consent
  3. Patient screening form, to obtain data about inclusion criteria, exclusion criteria, withdrawal criteria, and Bamford criteria
  4. Patient history form, to obtain data about demographics, history of the disease, family history, and habitual history
  5. Patient physical examination form, to obtain data about weight, height, vital sign, general examination, neurological examination, Modified Rankin Scale (MRS), and The Modified National Institutes of Health Stroke Scale (mNIHSS)
  6. Physiotherapy form
  7. A form to record any adverse event and concomitant drugs
  8. Radiological examinations
    • Chest X-ray

      Chest X-ray examination will be done in anterior posterior position. Radiography evaluation consists on physiology and pathology description of heart and lungs. Chest X-ray examination will be performed using Siemens ® Digital X-Ray (last calibrated in 2014). Evaluation will be done by radiologists and neurologists.
    • Head CT scan

      Head CT scan examination will be done toward patients with suspect acute ischemic stroke. The goal from this examination is to diagnose ischemic stroke correctly. CT scan will be performed using Philips ® (last calibrated in 2014). Evaluation will be done by radiologists and neurologists.
  9. Electrocardiography
    • Electrocardiography examination will be done using Fukuda ® (last calibrated in 2014). Evaluation will be done by neurologist.
  10. Laboratory examinations
    • Pregnancy test Pregnancy test will be performed using Focus Diagnostics ® HCG rapid test strip method. Morning urine will be used as sample. Positive indicators marked by two red lines (=).
    • Complete blood count Complete blood count consists of hemoglobin, hematocrit, leukocytes, and platelets. Complete blood count will be performed using Mindray ® by independent method. Dilven ST and Lyse BC3 will be used as reagen. Instrument was last calibrated in 2014.
    • Random blood glucose


Random blood glucose will be performed using ABX Pentra by enzymatic (hexokinase) method. The ABX Pentra Glucose HK CP will be used as reagen. Catalog number is A11A01667. Normal range is 74-10 6 mg/dL. Instrument was last calibrated in 2014.

  • Lipid profile

    ○ Total cholesterol

    Total cholesterol will be performed using ABX Pentra by CHOD_PAP enzymatic polymetric method. The ABX Pentra Cholesterol CP will be used as reagen. Catalog number is A11A01634. Normal value is < 200 mg/dL. Instrument was last calibrated in 2014. ○ Tryglyceride

    Tryglyceride will be performed using ABX Pentra by enzymatic DHAP method. The ABX Pentra Tryglycerides CP will be used as reagen. Catalog number is A11A01640. Normal value is < 200 mg/dL. Instrument was last calibrated in 2014. ○ High Density Lipoprotein (HDL)

    HDL examination will be performed using ABX Pentra by HDL direct CP method. The ABX Pentra HDL direct CP will be used as reagen. Catalog number is A11A01636. Normal value is > 35 mg/dL. Instrument was last calibrated in 2014. ○ Low Density Lipoprotein (LDL)

    LDL examination will be performed using ABX Pentra by LDL direct CP method. The ABX Pentra LDL direct CP will be used as reagen. Catalog number is A11A01638. Normal value is < 150 mg/dL. Instrument was last calibrated in 2014.
  • Serum Glutamic Oxaloacetic Transaminase (SGOT) or Aspartate Transaminase (AST)

    Serum Glutamic Oxaloacetic Transaminase (SGOT) will be performed using ABX Pentra by IFCC (modified method without pyridoxal phosphate). The ABX Pentra ALT CP will be used as reagen. Catalog number is A11A01627. Normal value for male is < 34 U/L; for female is < 31 U/L. Instrument was last calibrated in 2014.
  • Serum Glutamic Pyruvic Transaminase (SGPT) or Alanine Aminotransferase (ALT) Serum Glutamic Pyruvic Transaminase (SGPT) will be performed using ABX Pentra by kynetic photometric method. The ABX Pentra ALP CP will be used as reagen. Catalog number is A11A01639. Normal value for male is < 46 U/L; for female is < 36 U/L. Instrument was last calibrated in 2014.
  • Serum creatinine

    Serum creatinine will be performed using ABX Pentra by Jaffe developed method. The ABX Pentra Creatinine 120 CP will be used as reagen. Catalog number is A11A01933. Normal value for male is < 1.1 mg/dL; for female is < 0.9 mg/dL. Instrument was last calibrated in 2014.
  • Total bilirubin

    Total bilirubin will be performed using ABX Pentra by photometric test using 2,4-dichloroaniline method. The ABX Pentra Bilirubin Total CP will be used as reagen. Catalog number is A11A01639. Normal range is 6.7-8.7 mg/dL. Instrument was last calibrated in 2014.
  • D-dimer level

    D-dimer level will be performed by immunology mechanic method.
  • Fibrinogen level

    Fibrinogen level will be performed by coagulation mechanic (Clauss) method.
  • Prothrombin Time (PT)

    Prothrombin level will be performed by coagulation mechanic method.
  • Activated Partial Thromboplastin Time (aPTT)

    Activated Partial Thromboplastin Time level will be performed by coagulation mechanic method.


Safety considerations

Subjects will receive standard therapy recommended by American Heart Association/American Stroke Association Guidelines. In addition to standard therapy, patients will receive either DLBS1033 or placebo. A sheet of paper will be given to each subject so that any adverse events that occur in every subject can be recorded. There are many things to record, such as frequency, severity, relationships with drug research, and others.

Bleeding events/tendency, such as hematuria, gastric bleeding, decrease of hemoglobin level of > 2 g/dL, or any major bleeding events necessitating hospitalization should be recorded. Tendency of bleeding will therefore be carefully evaluated through routine hematology measured on Day 1 (baseline) and 8th. If massive bleeding occurs, it will be recorded, and subject will be excluded from this study. Subjects will be consulted to related specialist and will be treated based on clinical pathway.

Statistical considerations and data analysis

Sample size and statistical power


Sample size estimation was based on the primary efficacy endpoints: the improvement rate in terms of MRS category of 0-2 at the end of study.

The primary hypothesis of interest of this study is that treatment with DLBS1033 in addition to the standard therapy of acute ischemic stroke is more effective than the standard therapy alone in improving motoric function measured by Modified Rankin Scale (MRS).

The improvement rate of 75% in terms of MRS category 0-2 have been reported in a study using low-dose aspirin treatment (for 3 months) in subjects with ischemic stroke (Fujita et al., 2011). Using Formula 1, a significance level 0.05, and a statistical power of at least 80% to detect the minimum clinically significant difference of improvement rate between groups of 20%, 58 patients per arm are required to complete the trial. Thus, a total of 116 patients (58 patients per arm) will be enrolled to accommodate a drop-out rate of about 15%.



Statistical methods

Demography and baseline characteristics of the study population will be tabulated and summarized by descriptive statistics. Characteristic comparability between groups at baseline will be assessed by independent t-test, for continuous data; or by chi-square test, for categorical data.

Primary efficacy endpoints will be analyzed between groups by chi-square test. Secondary efficacy endpoints will be analyzed between groups by independent t-test, while within group by repeated measures (related ANOVA).

Safety assessment will be based on laboratory examination (haematological examination, liver function, and renal function) and adverse events. All laboratory examinations, such as hemoglobin, hematocrit, RBC, WBC, platelet count, AST, ALT, γ-GT, total bilirubin, and serum creatinine, as well as vital signs at each visit will be descriptively summarized in the tables of means. Those parameters will be statistically analysed within group to compare the values between baseline and end of study by paired t-test.

Throughout the analysis, variables may be log-transformed in order to meet the underlying distributional assumptions of the statistical models; or the corresponding nonparametric test will be used. All statistical tests will be at 5% significance level.

Adverse events will be summarized by system organ class and WHO ARD preferred term. The summary on number of subjects with event, percentage of exposed with event, and number of events will be tabulated.


Ethical considerations

In conducting this study, the researcher will ask an ethic recommendation from Faculty of Medicine, University of Indonesia and hospital's director as an approval for conducting the biomedical research on human as a study subject. In this study, all procedures will be done based on the subject approcal through written informed consent.


  DiscussioN Top


This study was performed to evaluate the efficacy and safety of DLBS1033 in acute ischemic stroke management. The outcomes of this study are expected to be a breakthrough in medical science. In Indonesia, stroke is one of the most common vascular diseases. This condition happens due to lack of public awareness about the importance of health. Since the preventive effort is still minimal, stroke management is now leaning towards curative instead of preventive effort. Many previous studies proved that treatment with DLBS1033 in addition to the standard therapy is effective in improving motoric function of acute ischemic stroke patients. Through this study, DLBS1033 is expected to lower the level of morbidity and mortality in acute ischemic stroke cases. Thus, people with acute ischemic stroke will have a better quality of life.

Trial status

Recruitment of participants at the time of submission.

Supplementary files

Supplementary Table 1 [Additional file 1] : Modified Rankin Scale

Supplementary Table 2 [Additional file 2] : The Modified National Institutes of Health Stroke Scale (mNIHSS).

Conflicts of interest

None declared.

Author contributions


MS designed the trial protocol, B, ZW, and EA collected and analyzed statistical data. MS served as a principle investigator and wrote the paper. NM, RRT, PH, NH, LWS, F and DP participated in trial design and conduction. All authors approved the final version of the paper.

Plagiarism check

This paper was screened twice using CrossCheck to verify originality before publication.

Peer review

This paper was double-blinded and stringently reviewed by international expert reviewers.[45]

 
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    Tables

  [Table 1], [Table 2]



 

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