Recombinant Human Soluble Thrombomodulin in Sepsis-Induced Coagulopathy: An Updated Systematic Review and Meta-Analysis

Abstract

Background Clinical effectiveness of recombinant human soluble thrombomodulin (rhTM) in sepsis or sepsis-induced coagulopathy remains a matter of dispute. Recently, the Sepsis Coagulopathy Asahi Recombinant LE Thrombomodulin (SCARLET) trial, the latest multinational multi-centre phase III randomized controlled trial, was completed. Objective This article assesses the benefits and harms of rhTM therapy in sepsis-induced coagulopathy by updating our previous systematic review. Methods We performed a systematic review and meta-analysis of rhTM therapy for sepsis-induced coagulopathy in randomized controlled trials. All-cause 28-day mortality as efficacy and serious bleeding complications as the adverse effect were measured as primary outcomes. We assessed the certainty of a body of evidence at the outcome level using the Grading of Recommendations Assessment, Development and Evaluation approach. Results We analysed five trials enrolling 1,762 patients. Approximately 13% reduction in the risk of mortality was observed in the rhTM group, but the difference was not significant (relative risk, 0.87; 95% confidence interval, 0.74–1.03; p = 0.10; I 2 = 0%). Risk of serious bleeding complications did not increase with rhTM administration. We judged the certainty of evidence as moderate for mortality and low for serious bleeding. Trial sequential analysis indicated that only 42.0% of the required information size is actually available at this stage to reject or accept low risk-of-bias trials examining the anticipated effect for all-cause mortality. Conclusion Even in this updated review including the latest SCARLET trial, we currently cannot make any declarative judgments about the beneficial effects of rhTM in sepsis-induced coagulopathy, although some favourable effects were suggested.

The efficacy of recombinant human soluble thrombomodulin (rhsTM) treatment for acute exacerbation of idiopathic pulmonary fibrosis: a systematic review and meta-analysis

“…However, a similar efficacy of rhsTM treatment for sepsis-associated coagulopathy was not confirmed in a recent RCT that was conducted by international multi-institutions [53]. In addition, the latest systematic review and metaanalysis did not reveal the advantage of rhsTM treatment for sepsis-induced DIC [54]. Conversely, only a small number of studies reported the effect of rhsTM treatment on DIC complicated with ARDS.…”

Extracellular HMGB1: a therapeutic target in severe pulmonary inflammation including COVID-19?

“…There is a great number of clinical and preclinical reports of successful thrombomodulin treatment in inflammatory conditions (Ito et al 2016). Recombinant thrombomodulin is efficaciously used in Japan to treat patients with disseminated intravascular coagulation in sepsis (Yamakawa et al 2019).…”

A question is “what are the optimal targets for anticoagulant therapies?”

“…Another reason is concomitant uses of heparin that counter a benefit of rTM. Although a recent meta-analysis including SCARLET trial found trend toward improved survival, this effect was not statistically significant [11]. Therefore, further rTM trials for septic DIC patients are desirable.…”