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Chandiwana N, Kruger C, Richardson N, Nxumalo S, Mashilo N, Dineka Y, Mudau N, Johnstone H, Kim W, Ju C, Arbe-Barnes S, Marrast AC, Flynn J, Venter WDF. Community-based management of a five-arm randomised clinical trial in COVID-19 outpatients in South Africa: challenges and opportunities. Trials 2023; 24:635. [PMID: 37794489 PMCID: PMC10548657 DOI: 10.1186/s13063-023-07577-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 08/04/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Repeated COVID-19 waves and corresponding mitigation measures have impacted health systems globally with exceptional challenges. In response to the pandemic, researchers, regulators, and funders rapidly pivoted to COVID-19 research activities. However, many clinical drug studies were not completed, due to often complex and rapidly evolving research conditions. METHODS We outline our experience of planning and managing a randomised, adaptive, open-label, phase 2 clinical trial to evaluate the safety and efficacy of four repurposed drug regimens versus standard-of-care (SOC) in outpatients with 'mild to moderate' COVID-19 in Johannesburg, South Africa, in the context of a partnership with multiple stakeholders. The study was conducted between 3 September 2020 and 23 August 2021 during changing COVID-19 restrictions, significant morbidity and mortality waves, and allied supply line, economic, and political instability. RESULTS Our clinical study design was pragmatic, including low-risk patients who were treated open label. There was built-in flexibility, including provision for some sample size adjustment and a range of secondary efficacy outcomes. Barriers to recruitment included the timing of waves, staff shortages due to illness, late presentation of patients, COVID-19 misinformation, and political unrest. Mitigations were the use of community health workers, deployment of mobile clinical units, and simplification of screening. Trial management required a radical reorganisation of logistics and processes to accommodate COVID-19 restrictions. These included the delivery of staff training and monitoring remotely, electronic consent, patient training and support to collect samples and report data at home, and the introduction of tele-medicine. These measures were successful for data collection, safe, and well received by patients. CONCLUSION Completing a COVID-19 trial in outpatients during the height of the pandemic required multiple innovations in nearly every aspect of clinical trial management, a high commitment level from study staff and patients, and support from study sponsors. Our experience has generated a more robust clinical research infrastructure, building in efficiencies to clinical trial management beyond the pandemic.
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Affiliation(s)
- Nomathemba Chandiwana
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Building C, 32 Princess of Wales Terrace, Johannesburg, 2001, South Africa.
| | - Chelsea Kruger
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Building C, 32 Princess of Wales Terrace, Johannesburg, 2001, South Africa
| | | | - Sibongiseni Nxumalo
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Building C, 32 Princess of Wales Terrace, Johannesburg, 2001, South Africa
| | - Nkoleleng Mashilo
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Building C, 32 Princess of Wales Terrace, Johannesburg, 2001, South Africa
| | - Yengiwe Dineka
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Building C, 32 Princess of Wales Terrace, Johannesburg, 2001, South Africa
| | - Ntanganedzeni Mudau
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Building C, 32 Princess of Wales Terrace, Johannesburg, 2001, South Africa
| | | | - Wookyung Kim
- Shin Poong Pharm. Co. Ltd, Seoul, Republic of Korea
| | - Chung Ju
- Shin Poong Pharm. Co. Ltd, Seoul, Republic of Korea
- Graduate School of Clinical Pharmacy, CHA University, Pocheon-Si, Gyeonggi-Do, Republic of Korea
| | | | | | - Julia Flynn
- Medicines for Malaria Venture, Geneva, Switzerland
| | - Willem D Francois Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Building C, 32 Princess of Wales Terrace, Johannesburg, 2001, South Africa
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2
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Ogutu B, Yeka A, Kusemererwa S, Thompson R, Tinto H, Toure AO, Uthaisin C, Verma A, Kibuuka A, Lingani M, Lourenço C, Mombo-Ngoma G, Nduba V, N'Guessan TL, Nassa GJW, Nyantaro M, Tina LO, Singh PK, El Gaaloul M, Marrast AC, Chikoto H, Csermak K, Demin I, Mehta D, Pathan R, Risterucci C, Su G, Winnips C, Kaguthi G, Fofana B, Grobusch MP. Ganaplacide (KAF156) plus lumefantrine solid dispersion formulation combination for uncomplicated Plasmodium falciparum malaria: an open-label, multicentre, parallel-group, randomised, controlled, phase 2 trial. Lancet Infect Dis 2023; 23:1051-1061. [PMID: 37327809 DOI: 10.1016/s1473-3099(23)00209-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/01/2023] [Accepted: 03/16/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Emergence of drug resistance demands novel antimalarial drugs with new mechanisms of action. We aimed to identify effective and well tolerated doses of ganaplacide plus lumefantrine solid dispersion formulation (SDF) in patients with uncomplicated Plasmodium falciparum malaria. METHODS This open-label, multicentre, parallel-group, randomised, controlled, phase 2 trial was conducted at 13 research clinics and general hospitals in ten African and Asian countries. Patients had microscopically-confirmed uncomplicated P falciparum malaria (>1000 and <150 000 parasites per μL). Part A identified the optimal dose regimens in adults and adolescents (aged ≥12 years) and in part B, the selected doses were assessed in children (≥2 years and <12 years). In part A, patients were randomly assigned to one of seven groups (once a day ganaplacide 400 mg plus lumefantrine-SDF 960 mg for 1, 2, or 3 days; ganaplacide 800 mg plus lumefantrine-SDF 960 mg as a single dose; once a day ganaplacide 200 mg plus lumefantrine-SDF 480 mg for 3 days; once a day ganaplacide 400 mg plus lumefantrine-SDF 480 mg for 3 days; or twice a day artemether plus lumefantrine for 3 days [control]), with stratification by country (2:2:2:2:2:2:1) using randomisation blocks of 13. In part B, patients were randomly assigned to one of four groups (once a day ganaplacide 400 mg plus lumefantrine-SDF 960 mg for 1, 2, or 3 days, or twice a day artemether plus lumefantrine for 3 days) with stratification by country and age (2 to <6 years and 6 to <12 years; 2:2:2:1) using randomisation blocks of seven. The primary efficacy endpoint was PCR-corrected adequate clinical and parasitological response at day 29, analysed in the per protocol set. The null hypothesis was that the response was 80% or lower, rejected when the lower limit of two-sided 95% CI was higher than 80%. This study is registered with EudraCT (2020-003284-25) and ClinicalTrials.gov (NCT03167242). FINDINGS Between Aug 2, 2017, and May 17, 2021, 1220 patients were screened and of those, 12 were included in the run-in cohort, 337 in part A, and 175 in part B. In part A, 337 adult or adolescent patients were randomly assigned, 326 completed the study, and 305 were included in the per protocol set. The lower limit of the 95% CI for PCR-corrected adequate clinical and parasitological response on day 29 was more than 80% for all treatment regimens in part A (46 of 50 patients [92%, 95% CI 81-98] with 1 day, 47 of 48 [98%, 89-100] with 2 days, and 42 of 43 [98%, 88-100] with 3 days of ganaplacide 400 mg plus lumefantrine-SDF 960 mg; 45 of 48 [94%, 83-99] with ganaplacide 800 mg plus lumefantrine-SDF 960 mg for 1 day; 47 of 47 [100%, 93-100] with ganaplacide 200 mg plus lumefantrine-SDF 480 mg for 3 days; 44 of 44 [100%, 92-100] with ganaplacide 400 mg plus lumefantrine-SDF 480 mg for 3 days; and 25 of 25 [100%, 86-100] with artemether plus lumefantrine). In part B, 351 children were screened, 175 randomly assigned (ganaplacide 400 mg plus lumefantrine-SDF 960 mg once a day for 1, 2, or 3 days), and 171 completed the study. Only the 3-day regimen met the prespecified primary endpoint in paediatric patients (38 of 40 patients [95%, 95% CI 83-99] vs 21 of 22 [96%, 77-100] with artemether plus lumefantrine). The most common adverse events were headache (in seven [14%] of 51 to 15 [28%] of 54 in the ganaplacide plus lumefantrine-SDF groups and five [19%] of 27 in the artemether plus lumefantrine group) in part A, and malaria (in 12 [27%] of 45 to 23 [44%] of 52 in the ganaplacide plus lumefantrine-SDF groups and 12 [50%] of 24 in the artemether plus lumefantrine group) in part B. No patients died during the study. INTERPRETATION Ganaplacide plus lumefantrine-SDF was effective and well tolerated in patients, especially adults and adolescents, with uncomplicated P falciparum malaria. Ganaplacide 400 mg plus lumefantrine-SDF 960 mg once daily for 3 days was identified as the optimal treatment regimen for adults, adolescents, and children. This combination is being evaluated further in a phase 2 trial (NCT04546633). FUNDING Novartis and Medicines for Malaria Venture.
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Affiliation(s)
- Bernhards Ogutu
- Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Adoke Yeka
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Sylvia Kusemererwa
- Medical Research Council, Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Ricardo Thompson
- Chókwè Health Research and Training Center, Centro de Investigação e Treino em Saúde de Chókwè, National Institute of Health, Chókwè, Mozambique
| | - Halidou Tinto
- Institut de Recherche en Science de la Santé, Unité de Recherche Clinique de Nanoro, Nanoro, Burkina Faso
| | - Andre Offianan Toure
- Department of Parasitology and Mycology, Institut Pasteur de Côte d'Ivoire, Abidjan, Côte d'Ivoire
| | | | - Amar Verma
- Department of Paediatrics, Rajendra Institute of Medical Sciences, Jharkhand, India
| | - Afizi Kibuuka
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Moussa Lingani
- Institut de Recherche en Science de la Santé, Unité de Recherche Clinique de Nanoro, Nanoro, Burkina Faso
| | - Carlos Lourenço
- Chókwè Health Research and Training Center, Centro de Investigação e Treino em Saúde de Chókwè, National Institute of Health, Chókwè, Mozambique
| | - Ghyslain Mombo-Ngoma
- Centre de Recherches Médicales de Lambaréné, Lambaréné, Gabon; Department of Implementation Research, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany; Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Videlis Nduba
- Kenya Medical Research Institute, Centre for Respiratory Diseases Research, Nairobi, Kenya
| | - Tiacoh Landry N'Guessan
- Department of Parasitology and Mycology, Institut Pasteur de Côte d'Ivoire, Abidjan, Côte d'Ivoire
| | | | - Mary Nyantaro
- Medical Research Council, Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Lucas Otieno Tina
- Centre for Clinical Research, Kenya Medical Research Institute, US Army Medical Research Directorate, Kisumu, Kenya
| | | | | | | | | | | | | | | | | | | | - Guoqin Su
- Novartis Pharmaceuticals, East Hanover, NJ, USA
| | | | - Grace Kaguthi
- Kenya Medical Research Institute, Centre for Respiratory Diseases Research, Nairobi, Kenya
| | | | - Martin Peter Grobusch
- Centre de Recherches Médicales de Lambaréné, Lambaréné, Gabon; Department of Infectious Diseases, Center of Tropical Medicine and Travel Medicine, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, Netherlands; Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany.
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3
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Gansane A, Lingani M, Yeka A, Nahum A, Bouyou-Akotet M, Mombo-Ngoma G, Kaguthi G, Barceló C, Laurijssens B, Cantalloube C, Macintyre F, Djeriou E, Jessel A, Bejuit R, Demarest H, Marrast AC, Debe S, Tinto H, Kibuuka A, Nahum D, Mawili-Mboumba DP, Zoleko-Manego R, Mugenya I, Olewe F, Duparc S, Ogutu B. Randomized, open-label, phase 2a study to evaluate the contribution of artefenomel to the clinical and parasiticidal activity of artefenomel plus ferroquine in African patients with uncomplicated Plasmodium falciparum malaria. Malar J 2023; 22:2. [PMID: 36597076 PMCID: PMC9809015 DOI: 10.1186/s12936-022-04420-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/16/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The contribution of artefenomel to the clinical and parasiticidal activity of ferroquine and artefenomel in combination in uncomplicated Plasmodium falciparum malaria was investigated. METHODS This Phase 2a, randomized, open-label, parallel-group study was conducted from 11th September 2018 to 6th November 2019 across seven centres in Benin, Burkina Faso, Gabon, Kenya, and Uganda. Patients aged ≥ 14-69 years with microscopically confirmed infection (≥ 3000 to ≤ 50,000 parasites/µL blood) were randomized 1:1:1:1 to 400 mg ferroquine, or 400 mg ferroquine plus artefenomel 300, 600, or 1000 mg, administered as a single oral dose. The primary efficacy analysis was a logistic regression evaluating the contribution of artefenomel exposure to Day 28 PCR-adjusted adequate clinical and parasitological response (ACPR). Safety was also evaluated. RESULTS The randomized population included 140 patients. For the primary analysis in the pharmacokinetic/pharmacodynamic efficacy population (N = 121), the contribution of artefenomel AUC0-∞ to Day 28 PCR-adjusted ACPR was not demonstrated when accounting for ferroquine AUC0-d28, baseline parasitaemia, and other model covariates: odds ratio 1.1 (95% CI 0.98, 1.2; P = 0.245). In the per-protocol population, Day 28 PCR-adjusted ACPR was 80.8% (21/26; 95% CI 60.6, 93.4) with ferroquine alone and 90.3% (28/31; 95% CI 74.2, 98.0), 90.9% (30/33; 95% CI 75.7, 98.1) and 87.1% (27/31; 95% CI 70.2, 96.4) with 300, 600, and 1000 mg artefenomel, respectively. Median time to parasite clearance (Kaplan-Meier) was 56.1 h with ferroquine, more rapid with artefenomel, but similar for all doses (30.0 h). There were no deaths. Adverse events (AEs) of any cause occurred in 51.4% (18/35) of patients with ferroquine 400 mg alone, and 58.3% (21/36), 66.7% (24/36), and 72.7% (24/33) with 300, 600, and 1000 mg artefenomel, respectively. All AEs were of mild-to-moderate severity, and consistent with the known profiles of the compounds. Vomiting was the most reported AE. There were no cases of QTcF prolongation ≥ 500 ms or > 60 ms from baseline. CONCLUSION The contribution of artefenomel exposure to the clinical and parasitological activity of ferroquine/artefenomel could not be demonstrated in this study. Parasite clearance was faster with ferroquine/artefenomel versus ferroquine alone. All treatments were well tolerated. TRIAL REGISTRATION ClinicalTrials.gov, NCT03660839 (7 September, 2018).
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Affiliation(s)
- Adama Gansane
- grid.507461.10000 0004 0413 3193Centre National de Recherche et de Formation sur le Paludisme (CNRFP), 01 BP 220801 BP 2208 Ouagadougou, Burkina Faso
| | - Moussa Lingani
- grid.457337.10000 0004 0564 0509Institut de Recherche en Science de la Santé - Unité de Recherche Clinique de Nanoro (IRSS-URCN), Ouagadougou, Burkina Faso
| | - Adoke Yeka
- grid.463352.50000 0004 8340 3103Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Alain Nahum
- Centre de Recherches Entomologique de Cotonou (CREC), Cotonou, Benin
| | - Marielle Bouyou-Akotet
- grid.502965.dDépartement de Parasitologie-Mycologie-Médecine Tropicale, Faculté de Médecine – Université des Sciences de la Santé, Libreville, Gabon
| | - Ghyslain Mombo-Ngoma
- grid.452268.fCentre de Recherches Médicales de Lambaréné (CERMEL), Lambaréné, Gabon ,Department of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine, and University Medical Center Hamburg-Eppendorf, Hamburg, Germany ,grid.10392.390000 0001 2190 1447Institute for Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - Grace Kaguthi
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute-Centre for Respiratory Diseases Research (KEMRI-CRDR), Nairobi, Kenya
| | - Catalina Barceló
- grid.452605.00000 0004 0432 5267Medicines for Malaria Venture, Geneva, Switzerland
| | | | | | - Fiona Macintyre
- grid.452605.00000 0004 0432 5267Medicines for Malaria Venture, Geneva, Switzerland
| | | | | | | | - Helen Demarest
- grid.452605.00000 0004 0432 5267Medicines for Malaria Venture, Geneva, Switzerland
| | - Anne Claire Marrast
- grid.452605.00000 0004 0432 5267Medicines for Malaria Venture, Geneva, Switzerland
| | - Siaka Debe
- grid.507461.10000 0004 0413 3193Centre National de Recherche et de Formation sur le Paludisme (CNRFP), 01 BP 220801 BP 2208 Ouagadougou, Burkina Faso
| | - Halidou Tinto
- grid.457337.10000 0004 0564 0509Institut de Recherche en Science de la Santé - Unité de Recherche Clinique de Nanoro (IRSS-URCN), Ouagadougou, Burkina Faso
| | - Afizi Kibuuka
- grid.463352.50000 0004 8340 3103Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Diolinda Nahum
- Centre de Recherches Entomologique de Cotonou (CREC), Cotonou, Benin
| | - Denise Patricia Mawili-Mboumba
- grid.502965.dDépartement de Parasitologie-Mycologie-Médecine Tropicale, Faculté de Médecine – Université des Sciences de la Santé, Libreville, Gabon
| | - Rella Zoleko-Manego
- grid.452268.fCentre de Recherches Médicales de Lambaréné (CERMEL), Lambaréné, Gabon ,Department of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine, and University Medical Center Hamburg-Eppendorf, Hamburg, Germany ,grid.10392.390000 0001 2190 1447Institute for Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - Irene Mugenya
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute-Centre for Respiratory Diseases Research (KEMRI-CRDR), Nairobi, Kenya
| | - Frederick Olewe
- grid.33058.3d0000 0001 0155 5938Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya ,grid.442494.b0000 0000 9430 1509Centre for Research in Therapeutic Sciences (CREATES), Strathmore University, Nairobi, Kenya
| | - Stephan Duparc
- grid.452605.00000 0004 0432 5267Medicines for Malaria Venture, Geneva, Switzerland
| | - Bernhards Ogutu
- grid.33058.3d0000 0001 0155 5938Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya ,grid.442494.b0000 0000 9430 1509Centre for Research in Therapeutic Sciences (CREATES), Strathmore University, Nairobi, Kenya
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Mohammed R, Asres MS, Gudina EK, Adissu W, Johnstone H, Marrast AC, Donini C, Duparc S, Yilma D. Efficacy, Safety, Tolerability, and Pharmacokinetics of MMV390048 in Acute Uncomplicated Malaria. Am J Trop Med Hyg 2023; 108:81-84. [PMID: 36509063 PMCID: PMC9833083 DOI: 10.4269/ajtmh.22-0567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/29/2022] [Indexed: 12/12/2022] Open
Abstract
An open label, phase IIa study conducted in Ethiopia evaluated the efficacy, safety, tolerability, and pharmacokinetics of a single 120-mg dose of the phosphatidylinositol 4-kinase inhibitor MMV390048 in Plasmodium vivax malaria. The study was not completed for operational reasons and emerging teratotoxicity data. For the eight adult male patients enrolled, adequate clinical and parasitological response at day 14 (primary endpoint) was 100% (8/8). Asexual parasites and gametocytes were cleared in all patients by 66 and 78 hours postdose, respectively. There were two recurrent P. vivax infections (days 20 and 28) and a new Plasmodium falciparum infection (day 22). MMV390048 exposure in P. vivax patients was lower than previously observed for healthy volunteers. Mild adverse events, mainly headache and gastrointestinal symptoms, were reported by eight patients. Single-dose MMV390048 (120 mg) rapidly cleared asexual parasites and gametocytes in patients with P. vivax malaria and was well tolerated.
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Affiliation(s)
- Rezika Mohammed
- Department of Internal Medicine, University of Gondar Hospital, Gondar, Ethiopia
| | | | - Esayas Kebede Gudina
- Jimma University Clinical Trial Unit, Jimma University Institute of Health, Jimma, Ethiopia;,Department of Internal Medicine, Jimma University Institute of Health, Jimma, Ethiopia
| | - Wondimagegn Adissu
- Jimma University Clinical Trial Unit, Jimma University Institute of Health, Jimma, Ethiopia;,School of Medical Laboratory Sciences, Jimma University Institute of Health, Jimma, Ethiopia
| | | | | | | | - Stephan Duparc
- Medicines for Malaria Venture, Geneva, Switzerland,Address correspondence to Stephan Duparc, Medicines for Malaria Venture, 20 Route de Pré-Bois, 1215 Geneva 15, Switzerland. E-mail:
| | - Daniel Yilma
- Jimma University Clinical Trial Unit, Jimma University Institute of Health, Jimma, Ethiopia;,Department of Internal Medicine, Jimma University Institute of Health, Jimma, Ethiopia
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5
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Chandiwana N, Kruger C, Johnstone H, Chughlay MF, Ju C, Kim B, Dineka Y, Arbe-Barnes S, Miller R, Owen A, Hill A, Windgassen D, Abla N, Marrast AC, Duparc S, Francois Venter WD. Safety and efficacy of four drug regimens versus standard-of-care for the treatment of symptomatic outpatients with COVID-19: A randomised, open-label, multi-arm, phase 2 clinical trial. EBioMedicine 2022; 86:104322. [PMID: 36332361 PMCID: PMC9624152 DOI: 10.1016/j.ebiom.2022.104322] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/09/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022] Open
Abstract
Background This exploratory study investigated four repurposed anti-infective drug regimens in outpatients with COVID-19. Methods This phase 2, single centre, randomised, open-label, clinical trial was conducted in South Africa between 3rd September 2020 and 23rd August 2021. Symptomatic outpatients aged 18–65 years, with RT-PCR confirmed SARS-CoV-2 infection were computer randomised (1:1:1:1:1) to standard-of-care (SOC) with paracetamol, or SOC plus artesunate-amodiaquine (ASAQ), pyronaridine-artesunate (PA), favipiravir plus nitazoxanide (FPV + NTZ), or sofosbuvir-daclatasvir (SOF-DCV). The primary endpoint was the incidence of viral clearance, i.e., the proportion of patients with a negative SARS-CoV-2 RT-PCR on day 7, compared to SOC using a log-binomial model in the modified intention-to-treat (mITT) population. Findings The mITT population included 186 patients: mean age (SD) 34.9 (10.3) years, body weight 78.2 (17.1) kg. Day 7 SARS-CoV-2 clearance rates (n/N; risk ratio [95% CI]) were: SOC 34.2% (13/38), ASAQ 38.5% (15/39; 0.80 [0.44, 1.47]), PA 30.3% (10/33; 0.69 [0.37, 1.29]), FPV + NTZ 27.0% (10/37; 0.60 [0.31, 1.18]) and SOF-DCV 23.5% (8/34; 0.47 [0.22, 1.00]). Three lower respiratory tract infections occurred (PA 6.1% [2/33]; SOF-DCV 2.9% [1/34]); two required hospitalisation (PA, SOF-DCV). There were no deaths. Adverse events occurred in 55.3% (105/190) of patients, including one serious adverse event (pancytopenia; FPV + NTZ). Interpretation There was no statistical difference in viral clearance for any regimen compared to SOC. All treatments were well tolerated. Funding 10.13039/501100004167Medicines for Malaria Venture, with funding from the UK Foreign, Commonwealth and Development Office, within the Covid-19 Therapeutics Accelerator in partnership with 10.13039/100004440Wellcome, the 10.13039/100000865Bill and Melinda Gates Foundation, and Mastercard.
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Affiliation(s)
- Nomathemba Chandiwana
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa,Corresponding author. Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Building C, Sunnyside Office Park, 32 Princess of Wales Terrace, Parktown, Johannesburg, South Africa
| | - Chelsea Kruger
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Chung Ju
- Shin Poong Pharm. Co. Ltd., Seoul, Republic of Korea,Graduate School of Clinical Pharmacy, CHA University, Pocheon-si, Gyeonggi-do, Republic of Korea
| | - Byungsu Kim
- Shin Poong Pharm. Co. Ltd., Seoul, Republic of Korea
| | - Yengiwe Dineka
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Andrew Owen
- Department of Molecular and Clinical Pharmacology, Centre of Excellence in Long-acting Therapeutics (CELT), University of Liverpool, Liverpool, United Kingdom
| | - Andrew Hill
- Department of Molecular and Clinical Pharmacology, Centre of Excellence in Long-acting Therapeutics (CELT), University of Liverpool, Liverpool, United Kingdom
| | | | - Nada Abla
- Medicines for Malaria Venture, Geneva, Switzerland
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6
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Gerding DN, Cornely OA, Grill S, Kracker H, Marrast AC, Nord CE, Talbot GH, Buitrago M, Gheorghe Diaconescu I, Murta de Oliveira C, Preotescu L, Pullman J, Louie TJ, Wilcox MH. Cadazolid for the treatment of Clostridium difficile infection: results of two double-blind, placebo-controlled, non-inferiority, randomised phase 3 trials. Lancet Infect Dis 2019; 19:265-274. [PMID: 30709665 DOI: 10.1016/s1473-3099(18)30614-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 08/06/2018] [Accepted: 10/02/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Cadazolid is a novel quinoxolidinone antibiotic developed for treating Clostridium difficile infection. We aimed to investigate the safety and efficacy of cadazolid compared with vancomycin in patients with C difficile infection. METHODS IMPACT 1 and IMPACT 2 were identically designed, multicentre, double-blind, placebo-controlled, non-inferiority, randomised phase 3 trials. IMPACT 1 was done in Australia, Brazil, Canada, France, Germany, Italy, the Netherlands, Peru, Poland, Romania, Spain, and the USA, and IMPACT 2 was done in Argentina, Belgium, Brazil, Canada, Chile, Croatia, Czech Republic, Greece, Hungary, Israel, Romania, Slovakia, South Korea, the UK, and the USA. Patients (aged 18 years or older) with mild-to-moderate or severe C difficile infection (diarrhoea with positive glutamate dehydrogenase and toxin A or B enzyme immunoassays) were randomly assigned (1:1) with a randomisation list stratified by centre and C difficile infection episode type (block size of four), and allocation was masked to investigators and participants. Patients received either oral cadazolid 250 mg twice daily with vancomycin-matching placebo capsule four times daily or oral vancomycin 125 mg four times a day with cadazolid-matching placebo suspension twice daily for 10 days, with 30 days of follow-up. The primary efficacy outcome was non-inferiority (margin -10%) of cadazolid versus vancomycin for clinical cure in the modified intention-to-treat and per-protocol populations. Clinical cure was defined as resolution of diarrhoea with no additional treatment for C difficile infection. These trials are registered with ClinicalTrials.gov, numbers NCT01987895 (IMPACT 1) and NCT01983683 (IMPACT 2). FINDINGS Between March 28, 2014, and March 24, 2017, for IMPACT 1, and Dec 13, 2013, and May 2, 2017, for IMPACT 2, 1263 participants were randomly assigned to receive cadazolid (306 in IMPACT 1 and 298 in IMPACT 2) or vancomycin (326 in IMPACT 1 and 311 in IMPACT 2). In the modified intention-to-treat population in IMPACT 1, 253 (84%) of 302 had clinical cure in the cadazolid group versus 271 (85%) of 318 in the vancomycin group. In IMPACT 2, 235 (81%) of 290 versus 258 (86%) of 301 had clinical cure. In the per-protocol population, 247 (88%) of 282 versus 264 (92%) of 288 had clinical cure in IMPACT 1 and 214 (87%) of 247 versus 237 (92%) of 259 in IMPACT 2. Non-inferiority for clinical cure to vancomycin was shown in IMPACT 1 but not in IMPACT 2 (IMPACT 1 treatment difference: -1·4 [95% CI -7·2 to 4·3] for modified intention to treat and -4·1 [-9·2 to 1·0] for per protocol; IMPACT 2: -4·7 [-10·7 to 1·3] for modified intention to treat and -4·9 [-10·4 to 0·6] for per protocol). The safety and tolerability profiles of the two antibiotics were similar. INTERPRETATION Cadazolid was safe and well tolerated but did not achieve its primary endpoint of non-inferiority to vancomycin for clinical cure in one of two phase 3 C difficile infection trials. Therefore, further commercial development of cadazolid for C difficile infection is unlikely. FUNDING Actelion Pharmaceuticals.
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Affiliation(s)
- Dale N Gerding
- Edward Hines Jr Veterans Administration Hospital, Hines, IL, USA.
| | - Oliver A Cornely
- Department of Internal Medicine, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, Clinical Trials Centre Cologne, University of Cologne, Cologne, Germany
| | - Simon Grill
- Actelion Pharmaceuticals, Allschwil, Switzerland
| | | | | | - Carl Erik Nord
- Department of Laboratory Medicine, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | | | - Liliana Preotescu
- Matei Bals National Institute of Infectious Diseases, Bucharest, Romania
| | | | - Thomas J Louie
- Foothills Medical Center, Alberta Health Services & University of Calgary, Cumming School of Medicine, Calgary, AB, Canada
| | - Mark H Wilcox
- Microbiology, Old Medical School, Leeds General Infirmary, Leeds, UK
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Lefèvre G, Marrast AC, Grueninger H. Novartis Malaria Initiative: best practice example of pharmaceutical industry's engagement in the fight against malaria. Ann N Y Acad Sci 2011; 1222:19-29. [DOI: 10.1111/j.1749-6632.2011.05973.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Ogutu B, Tiono AB, Makanga M, Premji Z, Gbadoé AD, Ubben D, Marrast AC, Gaye O. Treatment of asymptomatic carriers with artemether-lumefantrine: an opportunity to reduce the burden of malaria? Malar J 2010; 9:30. [PMID: 20096111 PMCID: PMC2824802 DOI: 10.1186/1475-2875-9-30] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2009] [Accepted: 01/22/2010] [Indexed: 11/16/2022] Open
Abstract
Background Increased investment and commitment to malaria prevention and treatment strategies across Africa has produced impressive reductions in the incidence of this disease. Nevertheless, it is clear that further interventions will be necessary to meet the international target of a reversal in the incidence of malaria by 2015. This article discusses the prospective role of an innovative malaria control strategy - the community-based treatment of asymptomatic carriers of Plasmodium falciparum, with artemisinin-based combination therapy (ACT). The potential of this intervention was considered by key scientists in the field at an Advisory Board meeting held in Basel, in April 2009. This article summarizes the discussions that took place among the participants. Presentation of the hypothesis Asymptomatic carriers do not seek treatment for their infection and, therefore, constitute a reservoir of parasites and thus a real public-health risk. The systematic identification and treatment of individuals with asymptomatic P. falciparum as part of a surveillance intervention strategy should reduce the parasite reservoir, and if this pool is greatly reduced, it will impact disease transmission. Testing the hypothesis This article considers the populations that could benefit from such a strategy and examines the ethical issues associated with the treatment of apparently healthy individuals, who represent a neglected public health risk. The potential for the treatment of asymptomatic carriers to impair the development of protective immunity, resulting in a 'rebound' and age escalation of malaria incidence, is also discussed. For policymakers to consider the treatment of asymptomatic carriers with ACT as a new tool in their malaria control programmes, it will be important to demonstrate that such a strategy can produce significant benefits, without having a negative impact on the efficacy of ACT and the health of the target population. Implications of the hypothesis The treatment of asymptomatic carriers with ACT is an innovative and essential tool for breaking the cycle of infection in some transmission settings. Safe and effective medicines can save the lives of children, but the reprieve is only temporary so long as the mosquitoes can become re-infected from the asymptomatic carriers. With improvements in rapid diagnostic tests that allow easier identification of asymptomatic carriers, the elimination of the pool of parasites is within reach.
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Affiliation(s)
- Bernhards Ogutu
- Walter Reed Project/Centre for Clinical Research-Kenya Medical Research Institute, Nairobi, Kenya.
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Budde K, Knoll G, Curtis J, Chan L, Pohanka E, Gentil M, Seifu Y, Marrast AC, Neumayer HH. Long-term safety and efficacy after conversion of maintenance renal transplant recipients from mycophenolate mofetil (MMF) to enteric-coated mycophenolate sodium (EC-MPA, myfortic). Clin Nephrol 2006; 66:103-11. [PMID: 16939066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023] Open
Abstract
AIM A 12-month multicenter, double-blind trial in which maintenance renal transplant patients were randomized to remain on mycophenolate mofetil (MMF) or convert to enteric-coated mycophenolate sodium (EC-MPS, myfortic) has demonstrated that conversion from MMF to EC-MPS is safe. Patients completing the study were invited to enter an open-label extension. Upon entry to the extension, patients who had received MMF during the randomized phase were converted to EC-MPS ("newly-exposed EC-MPS" group) and were monitored separately from those who had been randomized to EC-MPS ("long-term EC-MPS" group). The aim of the extension study was to collect long-term safety and efficacy data on EC-MPS, and to confirm the safety of conversion from MMF to EC-MPS in a larger patient population. METHODS All patients received EC-MPS 720 mg b.i.d. with cyclosporine microemulsion and corticosteroids per local practice. Data derived from the analysis of the first 24 months of the extension phase are presented. RESULTS Of the 297 patients who completed the core study, 260 (88%) entered the extension; 195 (75%) completed the 24-month extension visit. For on-treatment patients > 95% of the planned daily dose of EC-MPS was administered, and < 13% of patients in both groups had discontinued EC-MPS due to adverse events by 24 months. The overall incidence of adverse events during the extension phase, including infections and hematological abnormalities, was comparable to that seen in the core study, with a similar safety profile in the newly-exposed and long-term EC-MPS groups. There were 3 deaths during the first 24 months of the extension, and 2 graft failures in both the "newly-exposed" and "long-term" EC-MPS groups. CONCLUSIONS These data demonstrate that long-term use of EC-MPS is effective and has an acceptable tolerability profile in renal transplant patients, and confirm that conversion of maintenance renal transplant patients from MMF to EC-MPS is a safe therapeutic option.
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Affiliation(s)
- K Budde
- Department of Nephrology, Campus Charité Mitte Charitè, Humboldt University, Berlin, Germany.
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Salvadori M, Holzer H, Civati G, Sollinger H, Lien B, Tomlanovich S, Bertoni E, Seifu Y, Marrast AC. Long-term administration of enteric-coated mycophenolate sodium (EC-MPS; myfortic) is safe in kidney transplant patients. Clin Nephrol 2006; 66:112-9. [PMID: 16939067 DOI: pmid/16939067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND To date, there are no data on long-term use of enteric-coated mycophenolate sodium (EC-MPS; myfortic) from time of renal transplantation. We report the first long-term safety and efficacy data on EC-MPS when administered for up to 3 years post transplant. METHODS De novo renal transplant recipients completing 1 year of treatment in a multicenter, randomized, double-blind trial of EC-MPS versus mycophenolate mofetil (MMF) were invited to take part in an open-label extension during which all patients received EC-MPS 720 mg b.i.d. Results from the period 12 - 36 months post transplant were compared to comparable data from MMF-treated patients taking part in two studies of everolimus versus MMF (RAD 201 and RAD 251). RESULTS Of 367 patients completing the blinded core study, 247(62%) entered the open-label extension phase. During the first 24 months of the extension, the incidence, type and severity of adverse events were comparable between the newly-exposed and long-term EC-MPS patients. There were 2 deaths in the newly-exposed group and 4 among long-term EC-MPS patients, with 1 and 2 graft losses, respectively. Six patients (5%) in the newly-exposed group and 4 (3%) in the long-term EC-MPS group experienced biopsy-proven acute rejection. Cross-study comparisons indicated that the tolerability profile of EC-MPS was similar to MMF, including the incidence of adverse events, infections and malignancies, as was the incidence of efficacy events. CONCLUSION These results demonstrate that EC-MPS with cyclosporine and steroids provides good long-term efficacy and tolerability, and confirm the safety of converting renal transplant patients from MMF to EC-MPS.
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Affiliation(s)
- M Salvadori
- Renal Unit, Careggi University Hospital, Florence, Italy.
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Bererhi L, Bedrossian J, Metivier F, Duboust A, Fornairon S, Marrast AC, Idatte JM. Pregnancy in kidney transplantation: past and present experience. Transplant Proc 1997; 29:2478. [PMID: 9270817 DOI: 10.1016/s0041-1345(97)00456-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- L Bererhi
- Service de Néphrologie, Hôpital Saint Louis, Paris, France
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12
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Cloix P, Marrast AC, Lefrançois N, Garnier JL, Gebührer M, Martin X, Dubernard JM, Touraine JL. Renal transplantation between spouses. Transplant Proc 1996; 28:2802. [PMID: 8908066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- P Cloix
- Department of Renal and Pancreas Transplantation, Hôpital Edouard Herriot, Lyon, France
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13
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Vincent F, Michel M, Marrast AC, Bensousan TA, Glotz D, Duboust A. Management of ovarian cancer in the renal transplant recipient with cyclophosphamide used as an immunosuppressive and antineoplastic agent. Transplant Proc 1995; 27:2432. [PMID: 7652865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- F Vincent
- Intensive Care Unit, Institut Gustave-Roussy, Villejuif, France
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