1
|
Walker LE, FitzGerald R, Saunders G, Lyon R, Fisher M, Martin K, Eberhart I, Woods C, Ewings S, Hale C, Rajoli RKR, Else L, Dilly‐Penchala S, Amara A, Lalloo DG, Jacobs M, Pertinez H, Hatchard P, Waugh R, Lawrence M, Johnson L, Fines K, Reynolds H, Rowland T, Crook R, Okenyi E, Byrne K, Mozgunov P, Jaki T, Khoo S, Owen A, Griffiths G, Fletcher TE. An Open Label, Adaptive, Phase 1 Trial of High-Dose Oral Nitazoxanide in Healthy Volunteers: An Antiviral Candidate for SARS-CoV-2. Clin Pharmacol Ther 2022; 111:585-594. [PMID: 34699618 PMCID: PMC8653087 DOI: 10.1002/cpt.2463] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/16/2021] [Indexed: 12/18/2022]
Abstract
Repurposing approved drugs may rapidly establish effective interventions during a public health crisis. This has yielded immunomodulatory treatments for severe coronavirus disease 2019 (COVID-19), but repurposed antivirals have not been successful to date because of redundancy of the target in vivo or suboptimal exposures at studied doses. Nitazoxanide is a US Food and Drug Administration (FDA) approved antiparasitic medicine, that physiologically-based pharmacokinetic (PBPK) modeling has indicated may provide antiviral concentrations across the dosing interval, when repurposed at higher than approved doses. Within the AGILE trial platform (NCT04746183) an open label, adaptive, phase I trial in healthy adult participants was undertaken with high-dose nitazoxanide. Participants received 1,500 mg nitazoxanide orally twice-daily with food for 7 days. Primary outcomes were safety, tolerability, optimum dose, and schedule. Intensive pharmacokinetic (PK) sampling was undertaken day 1 and 5 with minimum concentration (Cmin ) sampling on days 3 and 7. Fourteen healthy participants were enrolled between February 18 and May 11, 2021. All 14 doses were completed by 10 of 14 participants. Nitazoxanide was safe and with no significant adverse events. Moderate gastrointestinal disturbance (loose stools or diarrhea) occurred in 8 participants (57.1%), with urine and sclera discoloration in 12 (85.7%) and 9 (64.3%) participants, respectively, without clinically significant bilirubin elevation. This was self-limiting and resolved upon drug discontinuation. PBPK predictions were confirmed on day 1 but with underprediction at day 5. Median Cmin was above the in vitro target concentration on the first dose and maintained throughout. Nitazoxanide administered at 1,500 mg b.i.d. with food was safe with acceptable tolerability a phase Ib/IIa study is now being initiated in patients with COVID-19.
Collapse
Affiliation(s)
- Lauren E. Walker
- University of LiverpoolLiverpoolUK
- Liverpool University Hospitals NHS Foundation TrustLiverpoolUK
| | | | - Geoffrey Saunders
- Southampton Clinical Trials UnitUniversity of SouthamptonSouthamptonUK
| | - Rebecca Lyon
- Liverpool University Hospitals NHS Foundation TrustLiverpoolUK
| | - Michael Fisher
- University of LiverpoolLiverpoolUK
- Liverpool University Hospitals NHS Foundation TrustLiverpoolUK
| | - Karen Martin
- Southampton Clinical Trials UnitUniversity of SouthamptonSouthamptonUK
| | - Izabela Eberhart
- Southampton Clinical Trials UnitUniversity of SouthamptonSouthamptonUK
| | - Christie Woods
- Liverpool University Hospitals NHS Foundation TrustLiverpoolUK
| | - Sean Ewings
- Southampton Clinical Trials UnitUniversity of SouthamptonSouthamptonUK
| | - Colin Hale
- Liverpool University Hospitals NHS Foundation TrustLiverpoolUK
| | | | | | | | | | | | | | | | - Parys Hatchard
- Southampton Clinical Trials UnitUniversity of SouthamptonSouthamptonUK
| | - Robert Waugh
- Southampton Clinical Trials UnitUniversity of SouthamptonSouthamptonUK
| | - Megan Lawrence
- Southampton Clinical Trials UnitUniversity of SouthamptonSouthamptonUK
| | - Lucy Johnson
- Southampton Clinical Trials UnitUniversity of SouthamptonSouthamptonUK
| | - Keira Fines
- Southampton Clinical Trials UnitUniversity of SouthamptonSouthamptonUK
| | | | - Timothy Rowland
- Liverpool University Hospitals NHS Foundation TrustLiverpoolUK
| | - Rebecca Crook
- Liverpool University Hospitals NHS Foundation TrustLiverpoolUK
| | - Emmanuel Okenyi
- Liverpool University Hospitals NHS Foundation TrustLiverpoolUK
| | - Kelly Byrne
- Liverpool School of Tropical MedicineLiverpoolUK
| | - Pavel Mozgunov
- MRC Biostatistics UnitUniversity of CambridgeCambridgeUK
| | - Thomas Jaki
- MRC Biostatistics UnitUniversity of CambridgeCambridgeUK
| | | | | | - Gareth Griffiths
- Southampton Clinical Trials UnitUniversity of SouthamptonSouthamptonUK
| | - Thomas E. Fletcher
- Liverpool University Hospitals NHS Foundation TrustLiverpoolUK
- Liverpool School of Tropical MedicineLiverpoolUK
| | | |
Collapse
|
2
|
Griffiths GO, FitzGerald R, Jaki T, Corkhill A, Reynolds H, Ewings S, Condie S, Tilt E, Johnson L, Radford M, Simpson C, Saunders G, Yeats S, Mozgunov P, Tansley-Hancock O, Martin K, Downs N, Eberhart I, Martin JWB, Goncalves C, Song A, Fletcher T, Byrne K, Lalloo DG, Owen A, Jacobs M, Walker L, Lyon R, Woods C, Gibney J, Chiong J, Chandiwana N, Jacob S, Lamorde M, Orrell C, Pirmohamed M, Khoo S. AGILE: a seamless phase I/IIa platform for the rapid evaluation of candidates for COVID-19 treatment: an update to the structured summary of a study protocol for a randomised platform trial letter. Trials 2021; 22:487. [PMID: 34311777 PMCID: PMC8311065 DOI: 10.1186/s13063-021-05458-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/14/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND There is an urgent unmet clinical need for the identification of novel therapeutics for the treatment of COVID-19. A number of COVID-19 late phase trial platforms have been developed to investigate (often repurposed) drugs both in the UK and globally (e.g. RECOVERY led by the University of Oxford and SOLIDARITY led by WHO). There is a pressing need to investigate novel candidates within early phase trial platforms, from which promising candidates can feed into established later phase platforms. AGILE grew from a UK-wide collaboration to undertake early stage clinical evaluation of candidates for SARS-CoV-2 infection to accelerate national and global healthcare interventions. METHODS/DESIGN AGILE is a seamless phase I/IIa platform study to establish the optimum dose, determine the activity and safety of each candidate and recommend whether it should be evaluated further. Each candidate is evaluated in its own trial, either as an open label single arm healthy volunteer study or in patients, randomising between candidate and control usually in a 2:1 allocation in favour of the candidate. Each dose is assessed sequentially for safety usually in cohorts of 6 patients. Once a phase II dose has been identified, efficacy is assessed by seamlessly expanding into a larger cohort. AGILE is completely flexible in that the core design in the master protocol can be adapted for each candidate based on prior knowledge of the candidate (i.e. population, primary endpoint and sample size can be amended). This information is detailed in each candidate specific trial protocol of the master protocol. DISCUSSION Few approved treatments for COVID-19 are available such as dexamethasone, remdesivir and tocilizumab in hospitalised patients. The AGILE platform aims to rapidly identify new efficacious and safe treatments to help end the current global COVID-19 pandemic. We currently have three candidate specific trials within this platform study that are open to recruitment. TRIAL REGISTRATION EudraCT Number: 2020-001860-27 14 March 2020 ClinicalTrials.gov Identifier: NCT04746183 19 February 2021 ISRCTN reference: 27106947.
Collapse
Affiliation(s)
- Gareth O. Griffiths
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Richard FitzGerald
- NIHR Royal Liverpool and Broadgreen CRF, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Thomas Jaki
- Lancaster University, Lancaster UK and MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Andrea Corkhill
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | | | - Sean Ewings
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Susannah Condie
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Emma Tilt
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Lucy Johnson
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Mike Radford
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Catherine Simpson
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Geoffrey Saunders
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Sara Yeats
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Pavel Mozgunov
- Lancaster University, Lancaster UK and MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Olana Tansley-Hancock
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Karen Martin
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Nichola Downs
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Izabela Eberhart
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Jonathan W. B. Martin
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Cristiana Goncalves
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Anna Song
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Tom Fletcher
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kelly Byrne
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | | | - Lauren Walker
- NIHR Royal Liverpool and Broadgreen CRF, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Rebecca Lyon
- NIHR Royal Liverpool and Broadgreen CRF, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Christie Woods
- NIHR Royal Liverpool and Broadgreen CRF, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Jennifer Gibney
- NIHR Royal Liverpool and Broadgreen CRF, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Justin Chiong
- NIHR Royal Liverpool and Broadgreen CRF, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- University of Liverpool, Liverpool, UK
| | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Catherine Orrell
- Desmond Tutu Health Foundation, University of Cape Town, Cape Town, South Africa
| | - Munir Pirmohamed
- NIHR Royal Liverpool and Broadgreen CRF, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- University of Liverpool, Liverpool, UK
| | - Saye Khoo
- NIHR Royal Liverpool and Broadgreen CRF, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- University of Liverpool, Liverpool, UK
| | - on behalf of the AGILE investigators
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
- NIHR Royal Liverpool and Broadgreen CRF, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Lancaster University, Lancaster UK and MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- University of Liverpool, Liverpool, UK
- Liverpool School of Tropical Medicine, Liverpool, UK
- Royal Free London NHS Foundation Trust, London, UK
- University of the Witwatersrand, Johannesburg, South Africa
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Desmond Tutu Health Foundation, University of Cape Town, Cape Town, South Africa
| |
Collapse
|