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Jayk Bernal A, Gomes da Silva MM, Musungaie DB, Kovalchuk E, Gonzalez A, Delos Reyes V, Martín-Quirós A, Caraco Y, Williams-Diaz A, Brown ML, Du J, Pedley A, Assaid C, Strizki J, Grobler JA, Shamsuddin HH, Tipping R, Wan H, Paschke A, Butterton JR, Johnson MG, De Anda C. Molnupiravir for Oral Treatment of Covid-19 in Nonhospitalized Patients. N Engl J Med 2022; 386:509-520. [PMID: 34914868 PMCID: PMC8693688 DOI: 10.1056/nejmoa2116044] [Citation(s) in RCA: 1040] [Impact Index Per Article: 520.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND New treatments are needed to reduce the risk of progression of coronavirus disease 2019 (Covid-19). Molnupiravir is an oral, small-molecule antiviral prodrug that is active against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). METHODS We conducted a phase 3, double-blind, randomized, placebo-controlled trial to evaluate the efficacy and safety of treatment with molnupiravir started within 5 days after the onset of signs or symptoms in nonhospitalized, unvaccinated adults with mild-to-moderate, laboratory-confirmed Covid-19 and at least one risk factor for severe Covid-19 illness. Participants in the trial were randomly assigned to receive 800 mg of molnupiravir or placebo twice daily for 5 days. The primary efficacy end point was the incidence hospitalization or death at day 29; the incidence of adverse events was the primary safety end point. A planned interim analysis was performed when 50% of 1550 participants (target enrollment) had been followed through day 29. RESULTS A total of 1433 participants underwent randomization; 716 were assigned to receive molnupiravir and 717 to receive placebo. With the exception of an imbalance in sex, baseline characteristics were similar in the two groups. The superiority of molnupiravir was demonstrated at the interim analysis; the risk of hospitalization for any cause or death through day 29 was lower with molnupiravir (28 of 385 participants [7.3%]) than with placebo (53 of 377 [14.1%]) (difference, -6.8 percentage points; 95% confidence interval [CI], -11.3 to -2.4; P = 0.001). In the analysis of all participants who had undergone randomization, the percentage of participants who were hospitalized or died through day 29 was lower in the molnupiravir group than in the placebo group (6.8% [48 of 709] vs. 9.7% [68 of 699]; difference, -3.0 percentage points; 95% CI, -5.9 to -0.1). Results of subgroup analyses were largely consistent with these overall results; in some subgroups, such as patients with evidence of previous SARS-CoV-2 infection, those with low baseline viral load, and those with diabetes, the point estimate for the difference favored placebo. One death was reported in the molnupiravir group and 9 were reported in the placebo group through day 29. Adverse events were reported in 216 of 710 participants (30.4%) in the molnupiravir group and 231 of 701 (33.0%) in the placebo group. CONCLUSIONS Early treatment with molnupiravir reduced the risk of hospitalization or death in at-risk, unvaccinated adults with Covid-19. (Funded by Merck Sharp and Dohme; MOVe-OUT ClinicalTrials.gov number, NCT04575597.).
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Affiliation(s)
- Angélica Jayk Bernal
- From IMAT Oncomédica, Monteria, Colombia (A.J.B.); the Department of Public Health, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil (M.M.G.S.); Jongaie Research, Pretoria, South Africa (D.B.M.); Medical Research Institute, St. Petersburg, Russia (E.K.); Advanced Research for Health Improvement, Immokalee, FL (A.G.); Lung Center of the Philippines, Quezon City, Philippines (V.D.R.); Hospital Universitario La Paz, IdiPAZ, Madrid (A.M.-Q.); Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem (Y.C.); and Merck, Kenilworth, NJ (A.W.-D., M.L.B., J.D., A. Pedley, C.A., J.S., J.A.G., H.H.S., R.T., H.W., A. Paschke, J.R.B., M.G.J., C.D.A.)
| | - Monica M Gomes da Silva
- From IMAT Oncomédica, Monteria, Colombia (A.J.B.); the Department of Public Health, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil (M.M.G.S.); Jongaie Research, Pretoria, South Africa (D.B.M.); Medical Research Institute, St. Petersburg, Russia (E.K.); Advanced Research for Health Improvement, Immokalee, FL (A.G.); Lung Center of the Philippines, Quezon City, Philippines (V.D.R.); Hospital Universitario La Paz, IdiPAZ, Madrid (A.M.-Q.); Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem (Y.C.); and Merck, Kenilworth, NJ (A.W.-D., M.L.B., J.D., A. Pedley, C.A., J.S., J.A.G., H.H.S., R.T., H.W., A. Paschke, J.R.B., M.G.J., C.D.A.)
| | - Dany B Musungaie
- From IMAT Oncomédica, Monteria, Colombia (A.J.B.); the Department of Public Health, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil (M.M.G.S.); Jongaie Research, Pretoria, South Africa (D.B.M.); Medical Research Institute, St. Petersburg, Russia (E.K.); Advanced Research for Health Improvement, Immokalee, FL (A.G.); Lung Center of the Philippines, Quezon City, Philippines (V.D.R.); Hospital Universitario La Paz, IdiPAZ, Madrid (A.M.-Q.); Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem (Y.C.); and Merck, Kenilworth, NJ (A.W.-D., M.L.B., J.D., A. Pedley, C.A., J.S., J.A.G., H.H.S., R.T., H.W., A. Paschke, J.R.B., M.G.J., C.D.A.)
| | - Evgeniy Kovalchuk
- From IMAT Oncomédica, Monteria, Colombia (A.J.B.); the Department of Public Health, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil (M.M.G.S.); Jongaie Research, Pretoria, South Africa (D.B.M.); Medical Research Institute, St. Petersburg, Russia (E.K.); Advanced Research for Health Improvement, Immokalee, FL (A.G.); Lung Center of the Philippines, Quezon City, Philippines (V.D.R.); Hospital Universitario La Paz, IdiPAZ, Madrid (A.M.-Q.); Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem (Y.C.); and Merck, Kenilworth, NJ (A.W.-D., M.L.B., J.D., A. Pedley, C.A., J.S., J.A.G., H.H.S., R.T., H.W., A. Paschke, J.R.B., M.G.J., C.D.A.)
| | - Antonio Gonzalez
- From IMAT Oncomédica, Monteria, Colombia (A.J.B.); the Department of Public Health, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil (M.M.G.S.); Jongaie Research, Pretoria, South Africa (D.B.M.); Medical Research Institute, St. Petersburg, Russia (E.K.); Advanced Research for Health Improvement, Immokalee, FL (A.G.); Lung Center of the Philippines, Quezon City, Philippines (V.D.R.); Hospital Universitario La Paz, IdiPAZ, Madrid (A.M.-Q.); Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem (Y.C.); and Merck, Kenilworth, NJ (A.W.-D., M.L.B., J.D., A. Pedley, C.A., J.S., J.A.G., H.H.S., R.T., H.W., A. Paschke, J.R.B., M.G.J., C.D.A.)
| | - Virginia Delos Reyes
- From IMAT Oncomédica, Monteria, Colombia (A.J.B.); the Department of Public Health, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil (M.M.G.S.); Jongaie Research, Pretoria, South Africa (D.B.M.); Medical Research Institute, St. Petersburg, Russia (E.K.); Advanced Research for Health Improvement, Immokalee, FL (A.G.); Lung Center of the Philippines, Quezon City, Philippines (V.D.R.); Hospital Universitario La Paz, IdiPAZ, Madrid (A.M.-Q.); Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem (Y.C.); and Merck, Kenilworth, NJ (A.W.-D., M.L.B., J.D., A. Pedley, C.A., J.S., J.A.G., H.H.S., R.T., H.W., A. Paschke, J.R.B., M.G.J., C.D.A.)
| | - Alejandro Martín-Quirós
- From IMAT Oncomédica, Monteria, Colombia (A.J.B.); the Department of Public Health, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil (M.M.G.S.); Jongaie Research, Pretoria, South Africa (D.B.M.); Medical Research Institute, St. Petersburg, Russia (E.K.); Advanced Research for Health Improvement, Immokalee, FL (A.G.); Lung Center of the Philippines, Quezon City, Philippines (V.D.R.); Hospital Universitario La Paz, IdiPAZ, Madrid (A.M.-Q.); Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem (Y.C.); and Merck, Kenilworth, NJ (A.W.-D., M.L.B., J.D., A. Pedley, C.A., J.S., J.A.G., H.H.S., R.T., H.W., A. Paschke, J.R.B., M.G.J., C.D.A.)
| | - Yoseph Caraco
- From IMAT Oncomédica, Monteria, Colombia (A.J.B.); the Department of Public Health, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil (M.M.G.S.); Jongaie Research, Pretoria, South Africa (D.B.M.); Medical Research Institute, St. Petersburg, Russia (E.K.); Advanced Research for Health Improvement, Immokalee, FL (A.G.); Lung Center of the Philippines, Quezon City, Philippines (V.D.R.); Hospital Universitario La Paz, IdiPAZ, Madrid (A.M.-Q.); Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem (Y.C.); and Merck, Kenilworth, NJ (A.W.-D., M.L.B., J.D., A. Pedley, C.A., J.S., J.A.G., H.H.S., R.T., H.W., A. Paschke, J.R.B., M.G.J., C.D.A.)
| | - Angela Williams-Diaz
- From IMAT Oncomédica, Monteria, Colombia (A.J.B.); the Department of Public Health, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil (M.M.G.S.); Jongaie Research, Pretoria, South Africa (D.B.M.); Medical Research Institute, St. Petersburg, Russia (E.K.); Advanced Research for Health Improvement, Immokalee, FL (A.G.); Lung Center of the Philippines, Quezon City, Philippines (V.D.R.); Hospital Universitario La Paz, IdiPAZ, Madrid (A.M.-Q.); Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem (Y.C.); and Merck, Kenilworth, NJ (A.W.-D., M.L.B., J.D., A. Pedley, C.A., J.S., J.A.G., H.H.S., R.T., H.W., A. Paschke, J.R.B., M.G.J., C.D.A.)
| | - Michelle L Brown
- From IMAT Oncomédica, Monteria, Colombia (A.J.B.); the Department of Public Health, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil (M.M.G.S.); Jongaie Research, Pretoria, South Africa (D.B.M.); Medical Research Institute, St. Petersburg, Russia (E.K.); Advanced Research for Health Improvement, Immokalee, FL (A.G.); Lung Center of the Philippines, Quezon City, Philippines (V.D.R.); Hospital Universitario La Paz, IdiPAZ, Madrid (A.M.-Q.); Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem (Y.C.); and Merck, Kenilworth, NJ (A.W.-D., M.L.B., J.D., A. Pedley, C.A., J.S., J.A.G., H.H.S., R.T., H.W., A. Paschke, J.R.B., M.G.J., C.D.A.)
| | - Jiejun Du
- From IMAT Oncomédica, Monteria, Colombia (A.J.B.); the Department of Public Health, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil (M.M.G.S.); Jongaie Research, Pretoria, South Africa (D.B.M.); Medical Research Institute, St. Petersburg, Russia (E.K.); Advanced Research for Health Improvement, Immokalee, FL (A.G.); Lung Center of the Philippines, Quezon City, Philippines (V.D.R.); Hospital Universitario La Paz, IdiPAZ, Madrid (A.M.-Q.); Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem (Y.C.); and Merck, Kenilworth, NJ (A.W.-D., M.L.B., J.D., A. Pedley, C.A., J.S., J.A.G., H.H.S., R.T., H.W., A. Paschke, J.R.B., M.G.J., C.D.A.)
| | - Alison Pedley
- From IMAT Oncomédica, Monteria, Colombia (A.J.B.); the Department of Public Health, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil (M.M.G.S.); Jongaie Research, Pretoria, South Africa (D.B.M.); Medical Research Institute, St. Petersburg, Russia (E.K.); Advanced Research for Health Improvement, Immokalee, FL (A.G.); Lung Center of the Philippines, Quezon City, Philippines (V.D.R.); Hospital Universitario La Paz, IdiPAZ, Madrid (A.M.-Q.); Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem (Y.C.); and Merck, Kenilworth, NJ (A.W.-D., M.L.B., J.D., A. Pedley, C.A., J.S., J.A.G., H.H.S., R.T., H.W., A. Paschke, J.R.B., M.G.J., C.D.A.)
| | - Christopher Assaid
- From IMAT Oncomédica, Monteria, Colombia (A.J.B.); the Department of Public Health, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil (M.M.G.S.); Jongaie Research, Pretoria, South Africa (D.B.M.); Medical Research Institute, St. Petersburg, Russia (E.K.); Advanced Research for Health Improvement, Immokalee, FL (A.G.); Lung Center of the Philippines, Quezon City, Philippines (V.D.R.); Hospital Universitario La Paz, IdiPAZ, Madrid (A.M.-Q.); Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem (Y.C.); and Merck, Kenilworth, NJ (A.W.-D., M.L.B., J.D., A. Pedley, C.A., J.S., J.A.G., H.H.S., R.T., H.W., A. Paschke, J.R.B., M.G.J., C.D.A.)
| | - Julie Strizki
- From IMAT Oncomédica, Monteria, Colombia (A.J.B.); the Department of Public Health, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil (M.M.G.S.); Jongaie Research, Pretoria, South Africa (D.B.M.); Medical Research Institute, St. Petersburg, Russia (E.K.); Advanced Research for Health Improvement, Immokalee, FL (A.G.); Lung Center of the Philippines, Quezon City, Philippines (V.D.R.); Hospital Universitario La Paz, IdiPAZ, Madrid (A.M.-Q.); Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem (Y.C.); and Merck, Kenilworth, NJ (A.W.-D., M.L.B., J.D., A. Pedley, C.A., J.S., J.A.G., H.H.S., R.T., H.W., A. Paschke, J.R.B., M.G.J., C.D.A.)
| | - Jay A Grobler
- From IMAT Oncomédica, Monteria, Colombia (A.J.B.); the Department of Public Health, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil (M.M.G.S.); Jongaie Research, Pretoria, South Africa (D.B.M.); Medical Research Institute, St. Petersburg, Russia (E.K.); Advanced Research for Health Improvement, Immokalee, FL (A.G.); Lung Center of the Philippines, Quezon City, Philippines (V.D.R.); Hospital Universitario La Paz, IdiPAZ, Madrid (A.M.-Q.); Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem (Y.C.); and Merck, Kenilworth, NJ (A.W.-D., M.L.B., J.D., A. Pedley, C.A., J.S., J.A.G., H.H.S., R.T., H.W., A. Paschke, J.R.B., M.G.J., C.D.A.)
| | - Hala H Shamsuddin
- From IMAT Oncomédica, Monteria, Colombia (A.J.B.); the Department of Public Health, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil (M.M.G.S.); Jongaie Research, Pretoria, South Africa (D.B.M.); Medical Research Institute, St. Petersburg, Russia (E.K.); Advanced Research for Health Improvement, Immokalee, FL (A.G.); Lung Center of the Philippines, Quezon City, Philippines (V.D.R.); Hospital Universitario La Paz, IdiPAZ, Madrid (A.M.-Q.); Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem (Y.C.); and Merck, Kenilworth, NJ (A.W.-D., M.L.B., J.D., A. Pedley, C.A., J.S., J.A.G., H.H.S., R.T., H.W., A. Paschke, J.R.B., M.G.J., C.D.A.)
| | - Robert Tipping
- From IMAT Oncomédica, Monteria, Colombia (A.J.B.); the Department of Public Health, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil (M.M.G.S.); Jongaie Research, Pretoria, South Africa (D.B.M.); Medical Research Institute, St. Petersburg, Russia (E.K.); Advanced Research for Health Improvement, Immokalee, FL (A.G.); Lung Center of the Philippines, Quezon City, Philippines (V.D.R.); Hospital Universitario La Paz, IdiPAZ, Madrid (A.M.-Q.); Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem (Y.C.); and Merck, Kenilworth, NJ (A.W.-D., M.L.B., J.D., A. Pedley, C.A., J.S., J.A.G., H.H.S., R.T., H.W., A. Paschke, J.R.B., M.G.J., C.D.A.)
| | - Hong Wan
- From IMAT Oncomédica, Monteria, Colombia (A.J.B.); the Department of Public Health, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil (M.M.G.S.); Jongaie Research, Pretoria, South Africa (D.B.M.); Medical Research Institute, St. Petersburg, Russia (E.K.); Advanced Research for Health Improvement, Immokalee, FL (A.G.); Lung Center of the Philippines, Quezon City, Philippines (V.D.R.); Hospital Universitario La Paz, IdiPAZ, Madrid (A.M.-Q.); Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem (Y.C.); and Merck, Kenilworth, NJ (A.W.-D., M.L.B., J.D., A. Pedley, C.A., J.S., J.A.G., H.H.S., R.T., H.W., A. Paschke, J.R.B., M.G.J., C.D.A.)
| | - Amanda Paschke
- From IMAT Oncomédica, Monteria, Colombia (A.J.B.); the Department of Public Health, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil (M.M.G.S.); Jongaie Research, Pretoria, South Africa (D.B.M.); Medical Research Institute, St. Petersburg, Russia (E.K.); Advanced Research for Health Improvement, Immokalee, FL (A.G.); Lung Center of the Philippines, Quezon City, Philippines (V.D.R.); Hospital Universitario La Paz, IdiPAZ, Madrid (A.M.-Q.); Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem (Y.C.); and Merck, Kenilworth, NJ (A.W.-D., M.L.B., J.D., A. Pedley, C.A., J.S., J.A.G., H.H.S., R.T., H.W., A. Paschke, J.R.B., M.G.J., C.D.A.)
| | - Joan R Butterton
- From IMAT Oncomédica, Monteria, Colombia (A.J.B.); the Department of Public Health, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil (M.M.G.S.); Jongaie Research, Pretoria, South Africa (D.B.M.); Medical Research Institute, St. Petersburg, Russia (E.K.); Advanced Research for Health Improvement, Immokalee, FL (A.G.); Lung Center of the Philippines, Quezon City, Philippines (V.D.R.); Hospital Universitario La Paz, IdiPAZ, Madrid (A.M.-Q.); Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem (Y.C.); and Merck, Kenilworth, NJ (A.W.-D., M.L.B., J.D., A. Pedley, C.A., J.S., J.A.G., H.H.S., R.T., H.W., A. Paschke, J.R.B., M.G.J., C.D.A.)
| | - Matthew G Johnson
- From IMAT Oncomédica, Monteria, Colombia (A.J.B.); the Department of Public Health, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil (M.M.G.S.); Jongaie Research, Pretoria, South Africa (D.B.M.); Medical Research Institute, St. Petersburg, Russia (E.K.); Advanced Research for Health Improvement, Immokalee, FL (A.G.); Lung Center of the Philippines, Quezon City, Philippines (V.D.R.); Hospital Universitario La Paz, IdiPAZ, Madrid (A.M.-Q.); Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem (Y.C.); and Merck, Kenilworth, NJ (A.W.-D., M.L.B., J.D., A. Pedley, C.A., J.S., J.A.G., H.H.S., R.T., H.W., A. Paschke, J.R.B., M.G.J., C.D.A.)
| | - Carisa De Anda
- From IMAT Oncomédica, Monteria, Colombia (A.J.B.); the Department of Public Health, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil (M.M.G.S.); Jongaie Research, Pretoria, South Africa (D.B.M.); Medical Research Institute, St. Petersburg, Russia (E.K.); Advanced Research for Health Improvement, Immokalee, FL (A.G.); Lung Center of the Philippines, Quezon City, Philippines (V.D.R.); Hospital Universitario La Paz, IdiPAZ, Madrid (A.M.-Q.); Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem (Y.C.); and Merck, Kenilworth, NJ (A.W.-D., M.L.B., J.D., A. Pedley, C.A., J.S., J.A.G., H.H.S., R.T., H.W., A. Paschke, J.R.B., M.G.J., C.D.A.)
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Caraco Y, Crofoot GE, Moncada PA, Galustyan AN, Musungaie DB, Payne B, Kovalchuk E, Gonzalez A, Brown ML, Williams-Diaz A, Gao W, Strizki JM, Grobler J, Du J, Assaid CA, Paschke A, Butterton JR, Johnson MG, De Anda C. Phase 2/3 Trial of Molnupiravir for Treatment of Covid-19 in Nonhospitalized Adults. NEJM Evid 2022; 1:EVIDoa2100043. [PMID: 38319179 DOI: 10.1056/evidoa2100043] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Molnupiravir in Nonhospitalized Patients Molnupiravir induces viral mutations to a threshold beyond which Covid-19 cannot replicate. For nonhospitalized adults with mild-to-moderate Covid-19 symptoms before randomization, molnupiravir did not have dose-related effects on adverse events or laboratory results; 3.1% of patients were hospitalized or died compared with 5.4% treated with placebo.
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Affiliation(s)
- Yoseph Caraco
- Clinical Pharmacology Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - Pablo Andres Moncada
- Department of Internal Medicine, Infectious Disease Service, Fundación Valle del Lili, Cali, Colombia
| | - Anna Nikolaevna Galustyan
- Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russia
- Strategic Medical System LLC, Saint Petersburg, Russia
| | | | - Brendan Payne
- Departments of Infectious Diseases and Medical Virology, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, UK
| | | | | | | | | | - Wei Gao
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Julie M Strizki
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Jay Grobler
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Jiejun Du
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | | | - Amanda Paschke
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | | | | | - Carisa De Anda
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
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Arribas JR, Bhagani S, Lobo SM, Khaertynova I, Mateu L, Fishchuk R, Park WY, Hussein K, Kim SW, Ghosn J, Brown ML, Zhang Y, Gao W, Assaid C, Grobler JA, Strizki J, Vesnesky M, Paschke A, Butterton JR, De Anda C. Randomized Trial of Molnupiravir or Placebo in Patients Hospitalized with Covid-19. NEJM Evid 2022; 1:EVIDoa2100044. [PMID: 38319178 DOI: 10.1056/evidoa2100044] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Molnupiravir or Placebo in Patients with Covid-19 Molnupiravir is an oral agent, a metabolite of which has activity against SARS-CoV-2. In a controlled phase 2 trial in adults hospitalized for Covid-19 who had symptoms for 10 days or less prior to randomization, patients received placebo (n=75) or varying doses of molnupiravir (n=218) administered twice daily for 5 days. There was no impact of treatment on death. Median time to sustained recovery was 9 days in all groups, with day 29 recovery rates ranging from 81.5 to 85.2%. There were no dose-limiting side effects or adverse events.
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Affiliation(s)
- José R Arribas
- Infectious Diseases Unit, Hospital Universitario La Paz-IdiPAZ, Madrid
| | - Sanjay Bhagani
- Department of Infectious Diseases, Royal Free Hospital, London
| | - Suzana M Lobo
- Intensive Care Division, Hospital de Base, Faculdade de Medicina de São José do Rio Preto, Brazil
| | - Ilsiyar Khaertynova
- Republican Clinical Infectious Diseases Hospital n.a. A.F. Agafonov, Kazan, Russian Federation
| | - Lourdes Mateu
- Infectious Diseases Department, Hospital Universitari Germans Trias i Pujol, Barcelona
| | - Roman Fishchuk
- Central City Clinical Hospital of Ivano-Frankivsk City Council, Ivano-Frankivsk, Ukraine
| | - William Y Park
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington/Valley Medical Center, Renton, WA
| | - Khetam Hussein
- Infection Control Unit, Rambam Healthcare Campus, Haifa, Israel
| | - Sei Won Kim
- Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jade Ghosn
- Infectious and Tropical Diseases Department, Assistance Publique-Hôpitaux de Paris Bichat-Claude Bernard Hospital, Paris
- Institut National de la Santé et de la Recherche Médicale, UMR 1137 'Infection, Antimicrobial, Modeling, Evolution', Université de Paris, Paris
| | | | | | - Wei Gao
- Merck & Co., Inc, Kenilworth, NJ
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Martin-Loeches I, Timsit JF, Kollef MH, Wunderink RG, Shime N, Nováček M, Kivistik Ü, Réa-Neto Á, Bruno CJ, Huntington JA, Lin G, Jensen EH, Motyl M, Yu B, Gates D, Butterton JR, Rhee EG. Clinical and microbiological outcomes, by causative pathogen, in the ASPECT-NP randomized, controlled, Phase 3 trial comparing ceftolozane/tazobactam and meropenem for treatment of hospital-acquired/ventilator-associated bacterial pneumonia. J Antimicrob Chemother 2022; 77:1166-1177. [PMID: 35022730 DOI: 10.1093/jac/dkab494] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 12/02/2021] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES In the ASPECT-NP trial, ceftolozane/tazobactam was non-inferior to meropenem for treating nosocomial pneumonia; efficacy outcomes by causative pathogen were to be evaluated. METHODS Mechanically ventilated participants with hospital-acquired/ventilator-associated bacterial pneumonia were randomized to 3 g ceftolozane/tazobactam (2 g ceftolozane/1 g tazobactam) q8h or 1 g meropenem q8h. Lower respiratory tract (LRT) cultures were obtained ≤36 h before first dose; pathogen identification and susceptibility were confirmed at a central laboratory. Prospective secondary per-pathogen endpoints included 28 day all-cause mortality (ACM), and clinical and microbiological response at test of cure (7-14 days after the end of therapy) in the microbiological ITT (mITT) population. RESULTS The mITT population comprised 511 participants (264 ceftolozane/tazobactam, 247 meropenem). Baseline LRT pathogens included Klebsiella pneumoniae (34.6%), Pseudomonas aeruginosa (25.0%) and Escherichia coli (18.2%). Among baseline Enterobacterales isolates, 171/456 (37.5%) were ESBL positive. For Gram-negative baseline LRT pathogens, susceptibility rates were 87.0% for ceftolozane/tazobactam and 93.3% for meropenem. For Gram-negative pathogens, 28 day ACM [52/259 (20.1%) and 62/240 (25.8%)], clinical cure rates [157/259 (60.6%) and 137/240 (57.1%)] and microbiological eradication rates [189/259 (73.0%) and 163/240 (67.9%)] were comparable with ceftolozane/tazobactam and meropenem, respectively. Per-pathogen microbiological eradication for Enterobacterales [145/195 (74.4%) and 129/185 (69.7%); 95% CI: -4.37 to 13.58], ESBL-producing Enterobacterales [56/84 (66.7%) and 52/73 (71.2%); 95% CI: -18.56 to 9.93] and P. aeruginosa [47/63 (74.6%) and 41/65 (63.1%); 95% CI: -4.51 to 19.38], respectively, were also comparable. CONCLUSIONS In mechanically ventilated participants with nosocomial pneumonia owing to Gram-negative pathogens, ceftolozane/tazobactam was comparable with meropenem for per-pathogen 28 day ACM and clinical and microbiological response.
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Affiliation(s)
- Ignacio Martin-Loeches
- St James's Hospital, Trinity College Dublin, James Street, Dublin 8, Ireland.,Universitat de Barcelona, IDIBAPS, CIBERes, Barcelona, Spain
| | | | - Marin H Kollef
- Washington University School of Medicine, 4523 Clayton Ave, Campus Box 8052, St. Louis, MO 63110, USA
| | - Richard G Wunderink
- Northwestern University Feinberg School of Medicine, 303 East Superior St, Simpson Querrey 5th Floor, Suite 5-301, Chicago, IL 60611, USA
| | - Nobuaki Shime
- Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Martin Nováček
- General Hospital of Kolin, Zizkova 146, Kolin 3, 280 00, Czech Republic
| | - Ülo Kivistik
- North Estonia Medical Centre Foundation, Sütiste tee 19, Tallinn, Harjumaa 13419, Estonia
| | - Álvaro Réa-Neto
- Universidade Federal do Paraná, Rua XV de Novembro, 1299 - Centro, Curitiba - PR, 80060-000, Brazil
| | | | | | - Gina Lin
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ 07033, USA
| | - Erin H Jensen
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ 07033, USA
| | - Mary Motyl
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ 07033, USA
| | - Brian Yu
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ 07033, USA
| | - Davis Gates
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ 07033, USA
| | - Joan R Butterton
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ 07033, USA
| | - Elizabeth G Rhee
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ 07033, USA
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Strizki J, Grobler J, Zhang Y, Du J, Zhao S, Levitan D, Therien A, Butterton JR, Murgolo N. 511. Treatment with Molnupiravir in the MOVe-In and MOVe-Out Clinical Trials Results in an Increase in Transition Mutations Across the SARS-CoV-2 Genome. Open Forum Infect Dis 2021. [PMCID: PMC8690616 DOI: 10.1093/ofid/ofab466.710] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Molnupiravir (MOV), (MK-4482, EIDD-2801) is being clinically developed for the treatment of COVID-19 disease caused by SARS-CoV-2. MOV is the orally administered 5′-isobutyrate prodrug of the active, antiviral ribonucleoside analogue, N-hydroxycytidine (NHC, EIDD-1931) which inhibits viral replication by induction of mutations in the viral genome, leading to viral error catastrophe. In 2 clinical studies, hospitalized (MOVe-In) and non-hospitalized (MOVe-Out) participants were treated for 5 days with MOV and followed up to Day 29. Viral RNA isolated from nasal swab samples were sequenced to determine the rate, distribution and type of viral mutations observed after MOV treatment. Methods RNA isolated from nasopharangeal swab samples collected during study conduct was quantified by RT-PCR. Samples containing >22,000 copies/mL of RNA underwent complete genome NGS using the Ion AmpliSeq SARS-CoV-2 research panel and Ion Torrent sequencing. Mutation rates were calculated by determining the number of nucleotide changes observed across the entire genome at Day 3 and/or Day 5 compared to baseline. Results Combined data from both studies showed an increase of ~2-4 fold in the viral mutation rate post-baseline in MOV treated compared with placebo. Mutations were distributed across the entire genome with only a minority being observed in more than one sample. The most frequent mutations were transitions of C to U observed in the highest MOV dose group (800 mg/BID). Conclusion Consistent with the proposed mechanism of action of MOV, an increase in the rate of transition mutations in the virus was observed in post-baseline nasal swab samples from participants treated with MOV compared with placebo. Disclosures Julie Strizki, PhD, Merck & Co., Inc. (Employee, Shareholder) Jay Grobler, PhD, Merck & Co., Inc. (Employee, Shareholder) Ying Zhang, PhD, Merck & Co., Inc. (Employee, Shareholder) Jiejun Du, PhD, Merck & Co., Inc. (Employee, Shareholder) Shunbing Zhao, PhD, Merck & Co., Inc. (Employee, Shareholder) Diane Levitan, PhD, Merck & Co., Inc. (Employee, Shareholder) Alex Therien, PhD, Merck & Co., Inc. (Employee, Shareholder) Joan R. Butterton, MD, Merck Sharp & Dohme Corp. (Employee, Shareholder) Nicholas Murgolo, PhD, Merck & Co., Inc. (Employee, Shareholder)
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Affiliation(s)
| | | | - Ying Zhang
- Merck & Co., Inc., Kenilworth, New Jersey
| | - Jiejun Du
- Merck & Co., Inc., Kenilworth, New Jersey
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6
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Bradley JS, Makieieva N, Tøndel C, Roilides E, Kelly MS, Patel M, Vaddady P, Maniar A, Zhang Y, Paschke A, Butterton JR, Chen LF. 1159. Pharmacokinetics, Safety, and Tolerability of Imipenem/Cilastatin/Relebactam in Pediatric Participants With Confirmed or Suspected Gram-negative Bacterial Infections: A Phase 1b, Open-label, Single-Dose Clinical Trial. Open Forum Infect Dis 2021. [PMCID: PMC8643896 DOI: 10.1093/ofid/ofab466.1352] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Imipenem/cilastatin/relebactam (IMI/REL) is approved for treating hospital-acquired/ventilator-associated bacterial pneumonia, complicated urinary tract infection, and complicated intra-abdominal infection in adults. This study assessed single-dose pharmacokinetics (PK), safety, and tolerability of IMI/REL in neonatal and pediatric participants with confirmed or suspected gram-negative bacterial infections. Methods This was a phase 1, open-label, non-comparative study (NCT03230916). Age- and weight-adjusted dosing is summarized in Table 1. The primary objective was to characterize the PK profiles for imipenem and relebactam after a single intravenous dose of IMI/REL. PK parameters were analyzed using population modeling. The PK target for imipenem was the percent time of the dosing interval that the unbound plasma concentration exceeded the minimum inhibitory concentration (%fT >MIC) of ≥30% (MIC used, 2 µg/mL). The PK target for relebactam was an area under the curve (AUC)/MIC ratio >8 (MIC used, 2 µg/mL), corresponding to AUC0-24h >58.88 μM∙h. Safety and tolerability were assessed for up to 14 days after drug infusion. ![]()
Results Of the 46 participants who received IMI/REL, 42 were included in the PK analysis. The mean plasma concentration-time profiles for imipenem and relebactam were generally comparable across age cohorts (Figure). For imipenem, the geometric mean %ƒT >MIC ranged from 50% to 94% and the mean maximum concentration (Cmax) ranged from 65 μM to 126 μM (Table 2). For relebactam, the geometric Cmax ranged from 33 μM to 87 μM and mean AUC0-6h ranged from 51 μM·h to 159 μM·h across the age cohorts (Table 2). IMI/REL was well tolerated with 8 (17.4%) participants experiencing ≥1 adverse events (AE) and 2 (4.3%) participants experiencing AE that were deemed drug related by the investigator. Drug-related AE were increased alanine aminotransferase, increased aspartate aminotransferase, anemia, and diarrhea, which were non-serious, mild in severity, and resolved within the follow-up period of 14 days. Figure 1 ![]()
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Conclusion Imipenem and relebactam exceeded the pediatric plasma PK targets across pediatric age cohorts in the study; the single doses of IMI/REL were well tolerated. These results will inform IMI/REL dose selection for further pediatric clinical evaluation. Disclosures Camilla Tøndel, MD, PhD, Merck & Co., Inc., (Grant/Research Support) Emmanuel Roilides, MD, PhD, FIDSA, FAAM, FESCMID, FECMM, FISAC, Merck Sharp & Dohme Corp. (Consultant, Grant/Research Support) Matthew S. Kelly, MD, MPH, Merck Sharp & Dohme Corp. (Consultant, Grant/Research Support) Munjal Patel, PhD, Merck Sharp & Dohme Corp. (Employee, Shareholder) Pavan Vaddady, PhD, Merck Sharp & Dohme Corp. (Employee) Alok Maniar, MD, MPH, Merck Sharp & Dohme Corp. (Employee, Shareholder) Ying Zhang, PhD, Merck & Co., Inc. (Employee, Shareholder) Amanda Paschke, MD MSCE, Merck Sharp & Dohme Corp. (Employee, Shareholder) Joan R. Butterton, MD, Merck Sharp & Dohme Corp. (Employee, Shareholder) Luke F. Chen, MBBS MPH MBA FRACP FSHEA FIDSA, Merck (Employee)
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Affiliation(s)
- John S Bradley
- University of California San Diego, San Diego, California
| | - Nataliia Makieieva
- Kharkiv National Medical University, Kharkiv, Kharkivs’ka Oblast’, Ukraine
| | - Camilla Tøndel
- Haukeland University Hospital, Bergen, Hordaland, Norway
| | - Emmanuel Roilides
- Aristotle University and Hippokration General Hospital, Thessaloniki, Thessaloniki, Greece
| | | | | | | | | | - Ying Zhang
- Merck & Co., Inc., Kenilworth, New Jersey
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7
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Timsit JF, Huntington JA, Wunderink RG, Shime N, Kollef MH, Kivistik Ü, Nováček M, Réa-Neto Á, Martin-Loeches I, Yu B, Jensen EH, Butterton JR, Wolf DJ, Rhee EG, Bruno CJ. Ceftolozane/tazobactam versus meropenem in patients with ventilated hospital-acquired bacterial pneumonia: subset analysis of the ASPECT-NP randomized, controlled phase 3 trial. Crit Care 2021; 25:290. [PMID: 34380538 PMCID: PMC8356211 DOI: 10.1186/s13054-021-03694-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 07/18/2021] [Indexed: 11/17/2022]
Abstract
Background Ceftolozane/tazobactam is approved for treatment of hospital-acquired/ventilator-associated bacterial pneumonia (HABP/VABP) at double the dose approved for other infection sites. Among nosocomial pneumonia subtypes, ventilated HABP (vHABP) is associated with the lowest survival. In the ASPECT-NP randomized, controlled trial, participants with vHABP treated with ceftolozane/tazobactam had lower 28-day all-cause mortality (ACM) than those receiving meropenem. We conducted a series of post hoc analyses to explore the clinical significance of this finding. Methods ASPECT-NP was a multinational, phase 3, noninferiority trial comparing ceftolozane/tazobactam with meropenem for treating vHABP and VABP; study design, efficacy, and safety results have been reported previously. The primary endpoint was 28-day ACM. The key secondary endpoint was clinical response at test-of-cure. Participants with vHABP were a prospectively defined subgroup, but subgroup analyses were not powered for noninferiority testing. We compared baseline and treatment factors, efficacy, and safety between ceftolozane/tazobactam and meropenem in participants with vHABP. We also conducted a retrospective multivariable logistic regression analysis in this subgroup to determine the impact of treatment arm on mortality when adjusted for significant prognostic factors. Results Overall, 99 participants in the ceftolozane/tazobactam and 108 in the meropenem arm had vHABP. 28-day ACM was 24.2% and 37.0%, respectively, in the intention-to-treat population (95% confidence interval [CI] for difference: 0.2, 24.8) and 18.2% and 36.6%, respectively, in the microbiologic intention-to-treat population (95% CI 2.5, 32.5). Clinical cure rates in the intention-to-treat population were 50.5% and 44.4%, respectively (95% CI − 7.4, 19.3). Baseline clinical, baseline microbiologic, and treatment factors were comparable between treatment arms. Multivariable regression identified concomitant vasopressor use and baseline bacteremia as significantly impacting ACM in ASPECT-NP; adjusting for these two factors, the odds of dying by day 28 were 2.3-fold greater when participants received meropenem instead of ceftolozane/tazobactam. Conclusions There were no underlying differences between treatment arms expected to have biased the observed survival advantage with ceftolozane/tazobactam in the vHABP subgroup. After adjusting for clinically relevant factors found to impact ACM significantly in this trial, the mortality risk in participants with vHABP was over twice as high when treated with meropenem compared with ceftolozane/tazobactam. Trial registration clinicaltrials.gov, NCT02070757. Registered 25 February, 2014, clinicaltrials.gov/ct2/show/NCT02070757. ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03694-3.
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Affiliation(s)
| | | | - Richard G Wunderink
- Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Hiroshima University, Hiroshima, Japan
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Ülo Kivistik
- Pulmonology Centre, North Estonia Medical Centre, Tallinn, Estonia
| | - Martin Nováček
- Department of Anaesthesia and Intensive Care, General Hospital of Kolin, Kolin, Czech Republic
| | - Álvaro Réa-Neto
- Departamento de Clínica Médica, Universidade Federal do Paraná, Curitiba, Brazil
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James' Hospital, Dublin, Ireland.,Hospital Clinic, Universitat de Barcelona, IDIBAPS, CIBERES, Barcelona, Spain
| | - Brian Yu
- MRL, Merck & Co., Inc., Kenilworth, NJ, USA
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8
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Wunderink RG, Roquilly A, Croce M, Rodriguez Gonzalez D, Fujimi S, Butterton JR, Broyde N, Popejoy MW, Kim JY, De Anda C. A Phase 3, Randomized, Double-Blind Study Comparing Tedizolid Phosphate and Linezolid for Treatment of Ventilated Gram-Positive Hospital-Acquired or Ventilator-Associated Bacterial Pneumonia. Clin Infect Dis 2021; 73:e710-e718. [PMID: 33720350 PMCID: PMC8326538 DOI: 10.1093/cid/ciab032] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Hospital-acquired bacterial pneumonia (HABP) and ventilator-associated bacterial pneumonia (VABP) are associated with high mortality rates. We evaluated the efficacy and safety of tedizolid (administered as tedizolid phosphate) for treatment of gram-positive ventilated HABP/VABP. METHODS In this randomized, noninferiority, double-blind, double-dummy, global phase 3 trial, patients were randomized 1:1 to receive intravenous tedizolid phosphate 200 mg once daily for 7 days or intravenous linezolid 600 mg every 12 hours for 10 days. Treatment was 14 days in patients with concurrent gram-positive bacteremia. The primary efficacy end points were day 28 all-cause mortality (ACM; noninferiority margin, 10%) and investigator-assessed clinical response at test of cure (TOC; noninferiority margin, 12.5%) in the intention-to-treat population. RESULTS Overall, 726 patients were randomized (tedizolid, n = 366; linezolid, n = 360). Baseline characteristics, including incidence of methicillin-resistant Staphylococcus aureus (31.3% overall), were well balanced. Tedizolid was noninferior to linezolid for day 28 ACM rate: 28.1% and 26.4%, respectively (difference, -1.8%; 95% confidence interval [CI]: -8.2 to 4.7). Noninferiority of tedizolid was not demonstrated for investigator-assessed clinical cure at TOC (tedizolid, 56.3% vs linezolid, 63.9%; difference, -7.6%; 97.5% CI: -15.7 to 0.5). In post hoc analyses, no single factor accounted for the difference in clinical response between treatment groups. Drug-related adverse events occurred in 8.1% and 11.9% of patients who received tedizolid and linezolid, respectively. CONCLUSIONS Tedizolid was noninferior to linezolid for day 28 ACM in the treatment of gram-positive ventilated HABP/VABP. Noninferiority of tedizolid for investigator-assessed clinical response at TOC was not demonstrated. Both drugs were well tolerated. CLINICAL TRIALS REGISTRATION NCT02019420.
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Affiliation(s)
- Richard G Wunderink
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Antoine Roquilly
- Université de Nantes, Centre Hospitalier Universitaire de Nantes, EA3826 Thérapeutiques Anti-Infectieuses, Service d’Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, F-44000
| | | | | | - Satoshi Fujimi
- Department of Trauma, Critical Care, and Emergency Medicine, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| | - Joan R Butterton
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey, USA
| | - Natasha Broyde
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey, USA
| | - Myra W Popejoy
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey, USA
| | - Jason Y Kim
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey, USA
| | - Carisa De Anda
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey, USA
- Correspondence: Carisa De Anda, Merck & Co, Inc, 2000 Galloping Hill Rd, Kenilworth, NJ 07033, USA ()
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Wunderink RG, Roquilly A, Croce M, Gonzalez DR, Fujimi S, Butterton JR, Broyde N, Popejoy MW, Kim JY, De Anda C. Reply to Author. Clin Infect Dis 2021; 73:1552-1553. [PMID: 33993256 DOI: 10.1093/cid/ciab391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Richard G Wunderink
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Antoine Roquilly
- Université de Nantes, Centre Hospitalier Universitaire de Nantes, Thérapeutiques Anti-Infectieuses, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes
| | | | | | - Satoshi Fujimi
- Department of Trauma, Critical Care, and Emergency Medicine, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| | | | | | | | - Jason Y Kim
- MRL, Merck & Co., Inc., Kenilworth, New Jersey, USA
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10
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Motsch J, Young K, Brown ML, Butterton JR, Paschke A. Reply to Sfeir. Clin Infect Dis 2021; 72:1485-1486. [PMID: 32634242 DOI: 10.1093/cid/ciaa881] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Johann Motsch
- Universitätsklinikum Heidelberg, Heidelberg, Germany
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11
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Caro L, Prueksaritanont T, Fandozzi CM, Feng HP, Guo Z, Wolford D, Panebianco D, Fraser IP, Levine V, Swearingen D, Butterton JR, Iwamoto M, Yeh WW. Evaluation of Pharmacokinetic Drug Interactions of the Direct-Acting Antiviral Agents Elbasvir and Grazoprevir with Pitavastatin, Rosuvastatin, Pravastatin, and Atorvastatin in Healthy Adults. Clin Drug Investig 2021; 41:133-147. [PMID: 33527237 DOI: 10.1007/s40261-020-00974-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Many people infected with hepatitis C virus have comorbidities, including hypercholesterolemia, that are treated with statins. In this study, we evaluated the drug-drug interaction potential of the hepatitis C virus inhibitors elbasvir (EBR) and grazoprevir (GZR) with statins. Pitavastatin, rosuvastatin, pravastatin, and atorvastatin are substrates of organic anion-transporting polypeptide 1B, whereas rosuvastatin and atorvastatin are also breast cancer resistance protein substrates. METHODS Three open-label, phase I clinical trials in healthy adults were conducted with multiple daily doses of oral GZR or EBR/GZR and single oral doses of statins. Trial 1: GZR 200 mg plus pitavastatin 10 mg. Trial 2: Part 1, GZR 200 mg plus rosuvastatin 10 mg, then EBR 50 mg/GZR 200 mg plus rosuvastatin 10 mg; Part 2, EBR 50 mg/GZR 200 mg plus pravastatin 40 mg. Trial 3: EBR 50 mg/GZR 200 mg plus atorvastatin 10 mg. RESULTS Neither GZR nor EBR pharmacokinetics were meaningfully affected by statins. Coadministration of EBR/GZR did not result in clinically relevant changes in the exposure of pitavastatin or pravastatin. However, EBR/GZR increased exposure to rosuvastatin (126%) and atorvastatin (94%). Coadministration of statins plus GZR or EBR/GZR was generally well tolerated. CONCLUSIONS Although statins do not appreciably affect EBR or GZR pharmacokinetics, EBR/GZR can impact the pharmacokinetics of certain statins, likely via inhibition of breast cancer resistance protein but not organic anion-transporting polypeptide 1B. Coadministration of EBR/GZR with pitavastatin or pravastatin does not require adjustment of either dose of statin, whereas the dose of rosuvastatin and atorvastatin should be decreased when coadministered with EBR/GZR.
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Affiliation(s)
- Luzelena Caro
- Merck & Co., Inc., Kenilworth, NJ, USA.
- Merck & Co., Inc., 770 Sumneytown Pike, WP75B-110, West Point, PA, 19486, USA.
| | - Thomayant Prueksaritanont
- Merck & Co., Inc., Kenilworth, NJ, USA
- Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | | | | | | | | | | | - Iain P Fraser
- Merck & Co., Inc., Kenilworth, NJ, USA
- Abide Therapeutics, San Diego, CA, USA
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12
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Bradley JS, Antadze T, Ninov B, Tayob MS, Broyde N, Butterton JR, Chou MZ, De Anda CS, Kim JY, Sears PS. Safety and Efficacy of Oral and/or Intravenous Tedizolid Phosphate From a Randomized Phase 3 Trial in Adolescents With Acute Bacterial Skin and Skin Structure Infections. Pediatr Infect Dis J 2021; 40:238-244. [PMID: 33395210 DOI: 10.1097/inf.0000000000003010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tedizolid phosphate is an oxazolidinone prodrug approved in 2014 for treatment of adults with acute bacterial skin and skin structure infections (ABSSSIs); however, efficacy has not previously been evaluated in children. This study compared the safety and efficacy of tedizolid (administered as tedizolid phosphate) with active antibacterial comparators for the treatment of ABSSSIs in adolescents. METHODS This was a randomized, assessor-blind, global phase 3 study of tedizolid versus active comparators for the treatment of Gram-positive ABSSSIs in adolescents (12 to <18 years of age; NCT02276482). Enrolled participants were stratified by region and randomized 3:1 to receive tedizolid phosphate 200 mg (oral and/or intravenous) once daily for 6 days or active comparator, selected by investigator from an allowed list per local standard of care, for 10 days. The primary endpoint was safety; blinded investigator's assessment of clinical success at the test-of-cure visit (18-25 days after the first dose) was a secondary efficacy endpoint. Statistical comparisons between treatment groups were not performed. RESULTS Of the 121 participants enrolled, 120 were treated (tedizolid, n = 91; comparator, n = 29). Treatment-emergent adverse events were balanced between treatment groups (tedizolid, 14.3%; comparator, 10.3%). Overall, 3 participants (3.3%) in the tedizolid group and 1 (3.4%) in the comparator group experienced a single drug-related TEAE. Clinical success rates were high in both treatment groups: 96.7% and 93.1% at the test-of-cure visit for the tedizolid and comparator groups, respectively. CONCLUSIONS Tedizolid demonstrated safety and efficacy similar to comparators for the treatment of ABSSSIs in adolescents.
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Affiliation(s)
- John S Bradley
- From the Merck Research Laboratories, Rady Children's Hospital/UCSD, San Diego, CA
| | - Tinatin Antadze
- Merck Research Laboratories, LTD M. Iashvili Children's Central Hospital, Tbilisi, Georgia
| | - Borislav Ninov
- Merck Research Laboratories, UMHAT Dr. Georgi Stranski EAD, Pleven, Bulgaria
| | - Mohammed S Tayob
- Merck Research Laboratories, Mzansi Ethical Research Centre, Middelburg, South Africa
| | - Natasha Broyde
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | | | - Margaret Z Chou
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | | | - Jason Y Kim
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Pamela S Sears
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
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13
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Motsch J, Murta de Oliveira C, Stus V, Köksal I, Lyulko O, Boucher HW, Kaye KS, File TM, Brown ML, Khan I, Du J, Joeng HK, Tipping RW, Aggrey A, Young K, Kartsonis NA, Butterton JR, Paschke A. RESTORE-IMI 1: A Multicenter, Randomized, Double-blind Trial Comparing Efficacy and Safety of Imipenem/Relebactam vs Colistin Plus Imipenem in Patients With Imipenem-nonsusceptible Bacterial Infections. Clin Infect Dis 2021; 70:1799-1808. [PMID: 31400759 PMCID: PMC7156774 DOI: 10.1093/cid/ciz530] [Citation(s) in RCA: 227] [Impact Index Per Article: 75.7] [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: 03/05/2019] [Accepted: 06/24/2019] [Indexed: 12/11/2022] Open
Abstract
Background The β-lactamase inhibitor relebactam can restore imipenem activity against imipenem-nonsusceptible gram-negative pathogens. We evaluated imipenem/relebactam for treating imipenem-nonsusceptible infections. Methods Randomized, controlled, double-blind, phase 3 trial. Hospitalized patients with hospital-acquired/ventilator-associated pneumonia, complicated intraabdominal infection, or complicated urinary tract infection caused by imipenem-nonsusceptible (but colistin- and imipenem/relebactam-susceptible) pathogens were randomized 2:1 to 5–21 days imipenem/relebactam or colistin+imipenem. Primary endpoint: favorable overall response (defined by relevant endpoints for each infection type) in the modified microbiologic intent-to-treat (mMITT) population (qualifying baseline pathogen and ≥1 dose study treatment). Secondary endpoints: clinical response, all-cause mortality, and treatment-emergent nephrotoxicity. Safety analyses included patients with ≥1 dose study treatment. Results Thirty-one patients received imipenem/relebactam and 16 colistin+imipenem. Among mITT patients (n = 21 imipenem/relebactam, n = 10 colistin+imipenem), 29% had Acute Physiology and Chronic Health Evaluation II scores >15, 23% had creatinine clearance <60 mL/min, and 35% were aged ≥65 years. Qualifying baseline pathogens: Pseudomonas aeruginosa (77%), Klebsiella spp. (16%), other Enterobacteriaceae (6%). Favorable overall response was observed in 71% imipenem/relebactam and 70% colistin+imipenem patients (90% confidence interval [CI] for difference, –27.5, 21.4), day 28 favorable clinical response in 71% and 40% (90% CI, 1.3, 51.5), and 28-day mortality in 10% and 30% (90% CI, –46.4, 6.7), respectively. Serious adverse events (AEs) occurred in 10% of imipenem/relebactam and 31% of colistin+imipenem patients, drug-related AEs in 16% and 31% (no drug-related deaths), and treatment-emergent nephrotoxicity in 10% and 56% (P = .002), respectively. Conclusions Imipenem/relebactam is an efficacious and well-tolerated treatment option for carbapenem-nonsusceptible infections. Clinical Trials Registration NCT02452047.
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Affiliation(s)
| | | | - Viktor Stus
- Dnipropetrovsk Medical Academy, Dnipro, Ukraine
| | - Iftihar Köksal
- Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - Olexiy Lyulko
- Department of Urology, Zaporozhye State Medical University, Zaporozhye, Ukraine
| | | | | | | | | | - Ireen Khan
- Merck & Co., Inc., Kenilworth, New Jersey
| | - Jiejun Du
- Merck & Co., Inc., Kenilworth, New Jersey
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14
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Ljungman P, Schmitt M, Marty FM, Maertens J, Chemaly RF, Kartsonis NA, Butterton JR, Wan H, Teal VL, Sarratt K, Murata Y, Leavitt RY, Badshah C. A Mortality Analysis of Letermovir Prophylaxis for Cytomegalovirus (CMV) in CMV-seropositive Recipients of Allogeneic Hematopoietic Cell Transplantation. Clin Infect Dis 2021; 70:1525-1533. [PMID: 31179485 PMCID: PMC7146004 DOI: 10.1093/cid/ciz490] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [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: 02/05/2019] [Accepted: 06/07/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND In a phase 3 trial, letermovir reduced clinically significant cytomegalovirus infections (CS-CMVi) and all-cause mortality at week 24 versus placebo in CMV-seropositive allogeneic hematopoietic cell transplantation (HCT) recipients. This post hoc analysis of phase 3 data further investigated the effects of letermovir on all-cause mortality. METHODS Kaplan-Meier survival curves were generated by treatment group for all-cause mortality. Observations were censored at trial discontinuation for reasons other than death or at trial completion. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox modeling, adjusting for risk factors associated with mortality. RESULTS Of 495 patients with no detectable CMV DNA at randomization, 437 had vital-status data available through week 48 post-HCT at trial completion (101 deaths, 20.4%). Following letermovir prophylaxis, the HR for all-cause mortality was 0.58 (95% CI, 0.35-0.98; P = .04) at week 24 and 0.74 (95% CI, 0.49-1.11; P = .14) at week 48 post-HCT versus placebo. Incidence of all-cause mortality through week 48 post-HCT in the letermovir group was similar in patients with or without CS-CMVi (15.8 vs 19.4%; P = .71). However, in the placebo group, all-cause mortality at week 48 post-HCT was higher in patients with versus those without CS-CMVi (31.0% vs 18.2%; P = .02). The HR for all-cause mortality in patients with CS-CMVi was 0.45 (95% CI, 0.21-1.00; P = .05) at week 48 for letermovir versus placebo. CONCLUSIONS Letermovir may reduce mortality by preventing or delaying CS-CMVi in HCT recipients. CLINICAL TRIALS REGISTRATION clinicaltrials.gov, NCT02137772.
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Affiliation(s)
- Per Ljungman
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | | | - Francisco M Marty
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Roy F Chemaly
- University of Texas, MD Anderson Cancer Center, Houston
| | | | | | - Hong Wan
- Merck & Co., Inc., Kenilworth, New Jersey
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15
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Chen LF, Losada MC, Mahoney KA, Du J, Brown ML, Tipping R, Young K, DeRyke CA, Butterton JR, Paschke A. 1460. Imipenem/Cilastatin (IMI)/Relebactam (REL) in Hospital-Acquired/Ventilator-Associated Bacterial Pneumonia (HABP/VABP): Subgroup Analyses of Critically Ill Patients in the RESTORE-IMI 2 Trial. Open Forum Infect Dis 2020. [PMCID: PMC7777004 DOI: 10.1093/ofid/ofaa439.1641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background HABP/VABP are serious infections associated with high mortality. Critically ill patients (pts) are at particularly high risk of adverse clinical outcomes. In the RESTORE-IMI 2 trial, IMI/REL was non-inferior to PIP/TAZ in primary and key secondary endpoints. We evaluated outcomes specifically in critically ill pts, according to several definitions, from that trial. Methods Randomized, controlled, double-blind, phase 3 trial in adult pts with HABP/VABP. Lower respiratory tract (LRT) specimens were obtained ≤48 hours prior to screening. Pts were randomized 1:1 to IMI/REL 500 mg/250 mg or PIP/TAZ 4 g/500 mg, given IV every 6 h for 7-14 d. The primary endpoint was Day 28 all-cause mortality (ACM) and the key secondary endpoint was clinical response at early follow-up (EFU; 7-14 d after completing therapy) in the modified intent-to-treat (MITT) population (randomized pts with ≥1 dose of study drug, excluding pts with only gram-positive cocci present on baseline Gram stain). This analysis assessed efficacy outcomes specifically in pts in the ICU and in pts with APACHE II score ≥15, both prespecified subgroups. In post-hoc analyses, outcomes were also specifically assessed in the subgroups of pts with moderate/severe renal impairment (creatinine clearance < 60 mL/min) and pts who received vasopressors. Results Of MITT pts (n=531) at baseline, 66.1% (175 IMI/REL, 176 PIP/TAZ) were in the ICU, 47.5% (125 IMI/REL, 127 PIP/TAZ) had APACHE-II score ≥15, and 24.7% (71 IMI/REL, 60 PIP/TAZ) had moderate/severe renal impairment. Further, 20.9% (54 IMI/REL, 57 PIP/TAZ) received vasopressors within 72 h of first dose of study drug and/or during the study. In each subgroup, baseline demographics, clinical characteristics, and causative LRT pathogens (mostly Enterobacterales, P. aeruginosa, and A. calcoaceticus-baumannii complex) were generally comparable between treatment arms. In pts with APACHE-II score ≥15, Day 28 ACM and clinical response rates with IMI/REL were favorable compared to PIP/TAZ (Table). Day 28 ACM was also favorable with IMI/REL in patients receiving vasopressors. Remaining outcomes were similar between treatment arms. Conclusion IMI/REL is an efficacious treatment option for critically ill pts with HABP/VABP. Table. Primary and key secondary efficacy outcomes by subgroup (MITT population) ![]()
Disclosures Luke F. Chen, MBBS MPH MBA FRACP FSHEA FIDSA, Merck & Co., Inc. (Employee, Shareholder)Merck & Co., Inc. (Employee, Shareholder) Maria C. Losada, BA, Merck & Co., Inc. (Employee, Shareholder) Kathryn A. Mahoney, PharmD, Merck (Employee, Shareholder) Jiejun Du, PhD, Merck & Co., Inc. (Employee, Shareholder) Michelle L. Brown, BS, Merck & Co., Inc. (Employee, Shareholder) Robert Tipping, MS, Merck & Co., Inc. (Employee, Shareholder) Katherine Young, MS, Merck & Co., Inc. (Employee, Shareholder)Merck & Co., Inc. (Employee, Shareholder) C. Andrew DeRyke, PharmD, Merck & Co., Inc. (Employee, Shareholder) Joan R. Butterton, MD, Merck & Co., Inc. (Employee, Shareholder) Amanda Paschke, MD MSCE, Merck & Co., Inc. (Employee, Shareholder)
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Affiliation(s)
| | | | | | - Jiejun Du
- Merck & Co., Inc., Kenilworth, New Jersey
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16
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Tipping R, Du J, Losada MC, Brown ML, Young K, Butterton JR, Paschke A, Chen LF. 1574. Multivariate Regression Analysis to Determine Independent Predictors of Treatment Outcomes in the RESTORE-IMI 2 Trial. Open Forum Infect Dis 2020. [PMCID: PMC7777782 DOI: 10.1093/ofid/ofaa439.1754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background In the RESTORE-IMI 2 trial, imipenem/cilastatin/relebactam (IMI/REL) was non-inferior to PIP/TAZ for treating hospital-acquired/ventilator-associated bacterial pneumonia (HABP/VABP) in the primary endpoint of Day 28 all-cause mortality (D28 ACM) and the key secondary endpoint of clinical response (CR) at early follow-up (EFU; 7-14 d after end of therapy). We performed a multivariate regression analysis to determine independent predictors of treatment outcomes in this trial. Methods Randomized, controlled, double-blind, phase 3, non-inferiority trial comparing IMI/REL 500 mg/250 mg vs PIP/TAZ 4 g/500 mg, every 6 h for 7-14 d, in adult patients (pts) with HABP/VABP. Stepwise-selection logistic regression modeling was used to determine independent predictors of D28 ACM and favorable CR at EFU, in the MITT population (randomized pts with ≥1 dose of study drug, except pts with only gram-positive cocci at baseline). Baseline variables (n=19) were pre-selected as candidates for inclusion (Table 1), based on clinical relevance. Variables were added to the model if significant (p < 0.05) and removed if their significance was reduced (p > 0.1) by addition of other variables. Results Baseline variables that met criteria for significant independent predictors of D28 ACM and CR at EFU in the final selected regression model are in Fig 1 and Fig 2, respectively. As expected, APACHE II score, renal impairment, elderly age, and mechanical ventilation were significant predictors for both outcomes. Bacteremia and P. aeruginosa as a causative pathogen were predictors of unfavorable CR, but not of D28 ACM. Geographic region and the hospital service unit a patient was admitted to were found to be significant predictors, likely explained by their collinearity with other variables. Treatment allocation (IMI/REL vs PIP/TAZ) was not a significant predictor for ACM or CR; this was not unexpected, since the trial showed non-inferiority of the two HABP/VABP therapies. No interactions between the significant predictors and treatment arm were observed. Conclusion This analysis validated known predictors for mortality and clinical outcomes in pts with HABP/VABP and supports the main study results by showing no interactions between predictors and treatment arm. Table 1. Candidate baseline variables pre-selected for inclusion ![]()
Figure 1. Independent predictors of greater Day 28 all-cause mortality (MITT population; N=531) ![]()
Figure 2. Independent predictors of favorable clinical response at EFU (MITT population; N=531) ![]()
Disclosures Robert Tipping, MS, Merck & Co., Inc. (Employee, Shareholder) Jiejun Du, PhD, Merck & Co., Inc. (Employee, Shareholder) Maria C. Losada, BA, Merck & Co., Inc. (Employee, Shareholder) Michelle L. Brown, BS, Merck & Co., Inc. (Employee, Shareholder) Katherine Young, MS, Merck & Co., Inc. (Employee, Shareholder)Merck & Co., Inc. (Employee, Shareholder) Joan R. Butterton, MD, Merck & Co., Inc. (Employee, Shareholder) Amanda Paschke, MD MSCE, Merck & Co., Inc. (Employee, Shareholder) Luke F. Chen, MBBS MPH MBA FRACP FSHEA FIDSA, Merck & Co., Inc. (Employee, Shareholder)Merck & Co., Inc. (Employee, Shareholder)
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Affiliation(s)
| | - Jiejun Du
- Merck & Co., Inc., Green Lane, Pennsylvania
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Losada MC, Maniar A, Du J, Brown ML, Young K, Hilbert DW, Tipping R, DeRyke CA, Butterton JR, Paschke A, Chen LF. 1230. Clinical and Microbiologic Outcomes by Causative Pathogen in Hospital-Acquired or Ventilator-Associated Bacterial Pneumonia (HABP/VABP) Treated with Imipenem/Cilastatin (IMI)/Relebactam (REL) Versus Piperacillin/Tazobactam (PIP/TAZ). Open Forum Infect Dis 2020. [PMCID: PMC7776129 DOI: 10.1093/ofid/ofaa439.1415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background IMI/REL is a combination of IMI and the novel class A and class C β-lactamase inhibitor REL. Here we present per-pathogen outcomes from a recent phase 3 clinical trial (RESTORE-IMI 2), in which IMI/REL was shown to be non-inferior to piperacillin/tazobactam (PIP/TAZ) for empiric therapy of HABP/VABP, in both primary and key secondary endpoints. Methods Randomized, controlled, double-blind, multinational, phase 3, non-inferiority trial in adults with HABP/VABP. Lower respiratory tract specimens were obtained ≤48 hours prior to screening. Participants (pts) were randomized 1:1 to IMI/REL 500 mg/250 mg or PIP/TAZ 4 g/500 mg, given intravenously every 6 h for 7-14 d. Pts also received empiric linezolid until baseline cultures confirmed absence of MRSA. This analysis evaluated outcomes by causative LRT pathogen in modified intent to treat (MITT) pts (randomized pts with ≥1 dose of study drug, excluding pts with only gram-positive cocci present on baseline Gram stain) who had ≥1 baseline LRT pathogen susceptible (according to CLSI criteria) to both study drugs. Outcomes assessed were microbiologic response at end of therapy (EOT), clinical response at early follow-up (EFU; 7-14 d after EOT), and Day 28 all-cause mortality (ACM). Results Of 531 MITT pts, 51.4% (130 IMI/REL, 143 PIP/TAZ) had ≥1 baseline LRT pathogen susceptible to both study drugs. The most common causative pathogens in this analysis population were Klebsiella spp (30.4% of patients), Pseudomonas aeruginosa (22.3%), Escherichia coli (22.0%), and Haemophilus influenzae (9.2%), consistent with other recent trials in HABP/VABP and with surveillance data. Outcomes by pathogen were generally comparable between IMI/REL and PIP/TAZ (Table). In a separate subgroup analysis of the microbiologic MITT population, in pts with ≥1 ESBL-positive LRT pathogen (45 IMI/REL, 35 PIP/TAZ), microbiologic response at EOT was 82.2% (IMI/REL) vs 68.6%% (PIP/TAZ), clinical response at EFU was 64.4% vs 60.0%, and Day 28 ACM was 20.0% and 22.9%, respectively. In the IMI/REL arm, 8 pts had ≥1 confirmed KPC-positive baseline LRT pathogen; KPC status was not assessed in the PIP/TAZ arm. Conclusion IMI/REL is an efficacious treatment option for HABP/VABP, regardless of causative pathogen. Table. Primary and secondary efficacy outcomes in patients who were in the MITT population and had at least 1 baseline LRT pathogen susceptible to both study drugs ![]()
Disclosures Maria C. Losada, BA, Merck & Co., Inc. (Employee, Shareholder) Jiejun Du, PhD, Merck & Co., Inc. (Employee, Shareholder) Michelle L. Brown, BS, Merck & Co., Inc. (Employee, Shareholder) Katherine Young, MS, Merck & Co., Inc. (Employee, Shareholder)Merck & Co., Inc. (Employee, Shareholder) Robert Tipping, MS, Merck & Co., Inc. (Employee, Shareholder) C. Andrew DeRyke, PharmD, Merck & Co., Inc. (Employee, Shareholder) Joan R. Butterton, MD, Merck & Co., Inc. (Employee, Shareholder) Amanda Paschke, MD MSCE, Merck & Co., Inc. (Employee, Shareholder) Luke F. Chen, MBBS MPH MBA FRACP FSHEA FIDSA, Merck & Co., Inc. (Employee, Shareholder)Merck & Co., Inc. (Employee, Shareholder)
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Affiliation(s)
| | | | - Jiejun Du
- Merck & Co., Inc., Rahway, New Jersey
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18
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Titov I, Wunderink RG, Roquilly A, Rodríguez Gonzalez D, David-Wang A, Boucher HW, Kaye KS, Losada MC, Du J, Tipping R, Rizk ML, Patel M, Brown ML, Young K, Kartsonis NA, Butterton JR, Paschke A, Chen LF. A Randomized, Double-blind, Multicenter Trial Comparing Efficacy and Safety of Imipenem/Cilastatin/Relebactam Versus Piperacillin/Tazobactam in Adults With Hospital-acquired or Ventilator-associated Bacterial Pneumonia (RESTORE-IMI 2 Study). Clin Infect Dis 2020; 73:e4539-e4548. [PMID: 32785589 PMCID: PMC8662781 DOI: 10.1093/cid/ciaa803] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [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: 12/23/2019] [Accepted: 07/16/2020] [Indexed: 01/20/2023] Open
Abstract
Background Imipenem combined with the β-lactamase inhibitor relebactam has broad antibacterial activity, including against carbapenem-resistant gram-negative pathogens. We evaluated efficacy and safety of imipenem/cilastatin/relebactam in treating hospital-acquired/ventilator-associated bacterial pneumonia (HABP/VABP). Methods This was a randomized, controlled, double-blind phase 3 trial. Adults with HABP/VABP were randomized 1:1 to imipenem/cilastatin/relebactam 500 mg/500 mg/250 mg or piperacillin/tazobactam 4 g/500 mg, intravenously every 6 hours for 7–14 days. The primary endpoint was day 28 all-cause mortality in the modified intent-to-treat (MITT) population (patients who received study therapy, excluding those with only gram-positive cocci at baseline). The key secondary endpoint was clinical response 7–14 days after completing therapy in the MITT population. Results Of 537 randomized patients (from 113 hospitals in 27 countries), the MITT population comprised 264 imipenem/cilastatin/relebactam and 267 piperacillin/tazobactam patients; 48.6% had ventilated HABP/VABP, 47.5% APACHE II score ≥15, 24.7% moderate/severe renal impairment, 42.9% were ≥65 years old, and 66.1% were in the intensive care unit. The most common baseline pathogens were Klebsiella pneumoniae (25.6%) and Pseudomonas aeruginosa (18.9%). Imipenem/cilastatin/relebactam was noninferior (P < .001) to piperacillin/tazobactam for both endpoints: day 28 all-cause mortality was 15.9% with imipenem/cilastatin/relebactam and 21.3% with piperacillin/tazobactam (difference, −5.3% [95% confidence interval {CI}, −11.9% to 1.2%]), and favorable clinical response at early follow-up was 61.0% and 55.8%, respectively (difference, 5.0% [95% CI, −3.2% to 13.2%]). Serious adverse events (AEs) occurred in 26.7% of imipenem/cilastatin/relebactam and 32.0% of piperacillin/tazobactam patients; AEs leading to treatment discontinuation in 5.6% and 8.2%, respectively; and drug-related AEs (none fatal) in 11.7% and 9.7%, respectively. Conclusions Imipenem/cilastatin/relebactam is an appropriate treatment option for gram-negative HABP/VABP, including in critically ill, high-risk patients. Clinical Trials Registration NCT02493764.
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Affiliation(s)
- Ivan Titov
- Department of Anesthesiology and Intensive Care, Ivano-Frankivsk Regional Clinical Hospital, Ivano-Frankivsk, Ukraine
| | - Richard G Wunderink
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Antoine Roquilly
- EA3826 Thérapeutiques Anti-Infectieuses, Institut de Recherche en Santé 2 Nantes Biotech, Université, de Nantes, Nantes, France
| | | | - Aileen David-Wang
- Department of Medicine & Philippine General Hospital, Division of Pulmonary Medicine, University of the Philippines, Manila, Philippines
| | - Helen W Boucher
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, USA
| | - Keith S Kaye
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Maria C Losada
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey, USA
| | - Jiejun Du
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey, USA
| | - Robert Tipping
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey, USA
| | - Matthew L Rizk
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey, USA
| | - Munjal Patel
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey, USA
| | - Michelle L Brown
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey, USA
| | - Katherine Young
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey, USA
| | | | - Joan R Butterton
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey, USA
| | - Amanda Paschke
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey, USA
| | - Luke F Chen
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey, USA
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Feng HP, Guo Z, Ross LL, Fraser I, Panebianco D, Jumes P, Fandozzi C, Caro L, Talaty J, Ma J, Mangin E, Huang X, Marshall WL, Butterton JR, Iwamoto M, Yeh WW. Assessment of drug interaction potential between the HCV direct-acting antiviral agents elbasvir/grazoprevir and the HIV integrase inhibitors raltegravir and dolutegravir. J Antimicrob Chemother 2020; 74:710-717. [PMID: 30541077 DOI: 10.1093/jac/dky465] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 09/14/2018] [Accepted: 10/13/2018] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Elbasvir/grazoprevir is a once-daily fixed-dose combination therapy for the treatment of chronic HCV infection, including HCV/HIV coinfection. OBJECTIVES To evaluate the pharmacokinetic interaction of elbasvir and grazoprevir with raltegravir or dolutegravir. METHODS Three open-label trials in healthy adult participants were conducted. In the raltegravir trials, participants received a single dose of raltegravir 400 mg, a single dose of elbasvir 50 mg or grazoprevir 200 mg, and raltegravir with either elbasvir or grazoprevir. In the dolutegravir trial, participants received a single dose of dolutegravir 50 mg alone or co-administered with once-daily elbasvir 50 mg and grazoprevir 200 mg. RESULTS The raltegravir AUC0-∞ geometric mean ratio (GMR) (90% CI) was 1.02 (0.81-1.27) with elbasvir and 1.43 (0.89-2.30) with grazoprevir. Dolutegravir AUC0-∞ GMR (90% CI) was 1.16 (1.00-1.34) with elbasvir and grazoprevir. The elbasvir AUC0-∞ GMR (90% CI) was 0.81 (0.57-1.17) with raltegravir and 0.98 (0.93-1.04) with dolutegravir. The grazoprevir AUC0-24 GMR (90% CI) was 0.89 (0.72-1.09) with raltegravir and 0.81 (0.67-0.97) with dolutegravir. CONCLUSIONS Elbasvir or grazoprevir co-administered with raltegravir or dolutegravir resulted in no clinically meaningful drug-drug interactions and was generally well tolerated. These results support the assertion that no dose adjustments for elbasvir, grazoprevir, raltegravir or dolutegravir are needed for co-administration in HCV/HIV-coinfected people.
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Affiliation(s)
| | | | - Lisa L Ross
- ViiV Healthcare US, Research Triangle Park, NC, USA
| | | | | | | | | | | | | | - Joanne Ma
- Merck & Co., Inc., Kenilworth, NJ, USA
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20
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Marty FM, Ljungman PT, Chemaly RF, Wan H, Teal VL, Butterton JR, Yeh WW, Leavitt RY, Badshah CS. Outcomes of patients with detectable CMV DNA at randomization in the phase III trial of letermovir for the prevention of CMV infection in allogeneic hematopoietic cell transplantation. Am J Transplant 2020; 20:1703-1711. [PMID: 31883426 DOI: 10.1111/ajt.15764] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 12/13/2019] [Accepted: 12/23/2019] [Indexed: 01/25/2023]
Abstract
Letermovir, a cytomegalovirus (CMV) terminase-complex inhibitor, is indicated for prophylaxis of CMV infection and disease in adult CMV-seropositive recipients of allogeneic hematopoietic cell transplantation (HCT). In a phase III, double-blind, randomized trial, letermovir significantly reduced the risk of clinically significant CMV infection (CS-CMVi) vs placebo through Week 24 post-HCT. This analysis investigated outcomes in participants with detectable CMV DNA at randomization, who were excluded from the primary efficacy analysis. In total, 70 of 565 randomized participants had detectable CMV DNA at randomization (letermovir 48; placebo 22). Study treatment completion rates were greater in letermovir-treated participants compared with placebo (52.1% vs 9.1%). The incidence of CS-CMVi or imputed primary endpoint events through Week 24 were 64.6% and 90.9% in the letermovir and placebo groups, respectively (treatment difference -26.1%; P = .010). Kaplan-Meier event rates for CS-CMVi onset through Week 14 (end-of-treatment period) were 33.1% for letermovir and 86.6% for placebo (P < .001). Median viral loads at the CS-CMVi events was similar in both treatment arms. All-cause mortality through Week 24 posttransplant was 15.0% for letermovir and 18.2% for placebo; through Week 48, mortality rates were 26.5% and 40.9%, respectively (P = .268). Overall, clinical outcomes were similar to those reported for participants with undetectable CMV DNA at randomization.
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Affiliation(s)
- Francisco M Marty
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
| | - Per T Ljungman
- Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Roy F Chemaly
- MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Hong Wan
- Merck & Co., Inc., Kenilworth, New Jersey
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21
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Brown ML, Motsch J, Kaye KS, File TM, Boucher HW, Vendetti N, Aggrey A, Joeng HK, Tipping RW, Du J, DePestel DD, Butterton JR, Paschke A. Evaluation of Renal Safety Between Imipenem/Relebactam and Colistin Plus Imipenem in Patients With Imipenem-Nonsusceptible Bacterial Infections in the Randomized, Phase 3 RESTORE-IMI 1 Study. Open Forum Infect Dis 2020; 7:ofaa054. [PMID: 32154325 PMCID: PMC7052751 DOI: 10.1093/ofid/ofaa054] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 11/21/2019] [Accepted: 02/18/2020] [Indexed: 11/16/2022] Open
Abstract
Background In the randomized controlled RESTORE-IMI 1 clinical trial (NCT02452047), imipenem/cilastatin (IMI) with relebactam (IMI/REL) was as effective as colistin plus IMI for the treatment of imipenem-nonsusceptible gram-negative infections. Differences in nephrotoxicity were observed between treatment arms. As there is no standard definition of nephrotoxicity used in clinical trials, we conducted analyses to further understand the renal safety profile of both treatments. Methods Nephrotoxicity was retrospectively evaluated using 2 acute kidney injury assessment criteria (Kidney Disease Improving Global Outcomes [KDIGO] and Risk, Injury, Failure, Loss, and End-stage Kidney Disease [RIFLE]). Additional outcomes included time to onset of protocol-defined nephrotoxicity and incidence of renal adverse events. Results Of 47 participants receiving treatment, 45 had sufficient data to assess nephrotoxicity (IMI/REL, n = 29; colistin plus IMI, n = 16). By KDIGO criteria, no participants in the IMI/REL but 31.3% in the colistin plus IMI group experienced stage 3 acute kidney injury. No IMI/REL-treated participants experienced renal failure by RIFLE criteria, vs 25.0% for colistin plus IMI. Overall, the time to onset of nephrotoxicity varied considerably (2–22 days). Fewer renal adverse events (12.9% vs 37.5%), including discontinuations due to drug-related renal adverse events (0% vs 12.5%), were observed in the IMI/REL group compared with the colistin plus IMI group, respectively. Conclusions Our analyses confirm the findings of a preplanned end point and provide further evidence that IMI/REL had a more favorable renal safety profile than colistin-based therapy in patients with serious, imipenem-nonsusceptible gram-negative bacterial infections. ClinicalTrials.gov Identifier NCT02452047.
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Affiliation(s)
| | - Johann Motsch
- Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Keith S Kaye
- University of Michigan, Ann Arbor, Michigan, USA
| | | | | | | | | | | | | | - Jiejun Du
- Merck & Co., Inc., Kenilworth, New Jersey, USA
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22
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Bhagunde P, Colon-Gonzalez F, Liu Y, Wu J, Xu SS, Garrett G, Jumes P, Lasseter K, Marbury T, Rizk ML, Lala M, Rhee EG, Butterton JR, Boundy K. Impact of renal impairment and human organic anion transporter inhibition on pharmacokinetics, safety and tolerability of relebactam combined with imipenem and cilastatin. Br J Clin Pharmacol 2020; 86:944-957. [PMID: 31856304 DOI: 10.1111/bcp.14204] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 11/06/2019] [Accepted: 11/17/2019] [Indexed: 01/22/2023] Open
Abstract
AIMS Two phase 1, open-label studies were conducted to investigate the effect of renal impairment (RI) and organic anion transporter (OAT) inhibition on pharmacokinetics (PK) and safety of relebactam (REL) plus imipenem/cilastatin (IMI). METHODS Study PN005 evaluated the PK of REL (125 mg) plus IMI (250 mg) in participants with RI vs healthy controls. Study PN019 evaluated the PK of REL (250 mg) and imipenem (500 mg; dosed as IMI) with/without probenecid (1 g; OAT inhibitor) in healthy adults. RESULTS Geometric mean ratios (RI/healthy matched controls) of area under the concentration-time curve from time 0 to infinity (AUC0-∞ ; 90% confidence interval) for REL, imipenem and cilastatin increased as RI increased from mild (1.6 [1.1, 2.4], 1.4 [1.1, 1.8] and 1.6 [1.0, 2.5], respectively) to severe (4.9 [3.4, 7.0], 2.5 [1.9, 3.3] and 5.6 [3.6, 8.6], respectively). For all 3 analytes, plasma and renal clearance decreased and corresponding plasma apparent terminal half-life increased with increasing RI. Geometric mean ratios ([probenecid+IMI/REL]/[IMI/REL]) of plasma exposure for REL and imipenem were 1.24 (1.19, 1.28) and 1.16 (1.13, 1.20), respectively. The dose fraction excreted (fe) in the urine decreased progressively from mild to severe RI. Probenecid reduced renal clearance of REL and imipenem by 25 and 31%, respectively. Compared with IMI/REL, coadministration of IMI/REL with probenecid yielded lower fe for REL and imipenem. In both studies, treatment was well tolerated; there were no serious adverse events or discontinuations due to adverse events. CONCLUSION RI increased plasma exposure and similarly decreased clearance of REL, imipenem and cilastatin; IMI/REL dose adjustment (fixed-ratio) will be required for patients with RI. Probenecid had no clinically meaningful impact on the PK of REL or imipenem.
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Affiliation(s)
| | | | - Yang Liu
- Merck & Co., Inc., Kenilworth, NJ, USA
| | - Jin Wu
- Merck & Co., Inc., Kenilworth, NJ, USA
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23
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Bradley JS, Antadze T, Mitha IH, Ninov B, Tayob MS, Broyde N, Butterton JR, Chou MZ, De Anda CS, Kim JY, Sears PS. 471. Safety and Efficacy of Oral and/or Intravenous Tedizolid Phosphate (TZD) in Adolescents with Acute Bacterial Skin and Skin Structure Tissue Infections (ABSSSI). Open Forum Infect Dis 2019. [PMCID: PMC6809993 DOI: 10.1093/ofid/ofz360.544] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Tedizolid phosphate has activity against gram-positive pathogens, including methicillin-resistant Staphylococcus aureus, and was approved for the treatment of ABSSSI in adults in 2014. This study compared the safety and efficacy of TZD with protocol-specified, active comparators for the treatment of ABSSSI in adolescents.
Methods
This was a randomized, assessor-blind, global, multicenter, phase 3 study of TZD vs. active comparator for the treatment of gram-positive ABSSSI in adolescents (aged 12 to < 18 years; NCT02276482). Enrolled patients were stratified by region and randomized 3:1 to TZD 200 mg (IV and/or oral) once daily for 6 days or investigator-selected active comparator per local standard of care (IV vancomycin, linezolid, clindamycin, flucloxacillin, or cefazolin, and/or oral linezolid, clindamycin, flucloxacillin, or cephalexin) for 10 days. The primary endpoint was safety. The percentages of patients with treatment-emergent adverse events (TEAEs) were documented; secondary efficacy endpoints included the blinded investigator’s assessment of clinical success at a test of cure visit (18–25 days after start of dosing) and early clinical response (≥20% reduction from baseline lesion area) at 48–72 h. No hypothesis testing was planned for the treatment groups.
Results
Of the 121 patients enrolled, 120 were treated (TZD, N = 91; comparator, N = 29). Median (range) age was 15 (12–17) years. Most patients were male (62.5%), white (86.7%), and enrolled in Europe (78.3%). Infections included major cutaneous abscess (42.5%), cellulitis/erysipelas (40.0%), and infected wound (17.5%). At baseline, the median (range) lesion surface area was 82.1 (14–978) cm2. Of those with gram-positive cultures (n = 64), S. aureus was most frequently isolated (n = 55 [85.9%]) with 3 isolates (4.7%) being methicillin resistant. TZD was well tolerated, and TEAEs were balanced between treatment arms (TZD, 14.3%; comparator, 10.3%). A total of 3 (3.3%) patients in the TZD group and 1 (3.4%) in the comparator group experienced a single-drug-related TEAE. Clinical success rates were high and similar between treatment groups (table).
Conclusion
TZD demonstrated comparable safety and efficacy to comparator in the treatment of ABSSSI in adolescents.
Disclosures
All authors: No reported disclosures.
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Affiliation(s)
- John S Bradley
- University of California San Diego, Dept of Pediatrics, School of Medicine, San Diego, California
| | - Tinatin Antadze
- LTD M. Iashvili Children’s Central Hospital, Tbilisi, Tbilisi, Georgia
| | - Ismail H Mitha
- Worthwhile Clinical Trials, Benoni, Gauteng, South Africa
| | | | - Mohammed S Tayob
- Mzansi Ethical Research Centre, Middelburg, Mpumalanga, South Africa
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Wunderink RG, Roquilly A, Croce M, Rodriguez Gonzalez D, Fujimi S, Butterton JR, Broyde N, Popejoy MW, Kim JY, De Anda CS. 2841. A Phase 3, Randomized, Double-Blind Study Comparing Tedizolid Phosphate (TZD) and Linezolid (LZD) for Treatment of Ventilated Gram-Positive (G+) Nosocomial Pneumonia. Open Forum Infect Dis 2019. [PMCID: PMC6808920 DOI: 10.1093/ofid/ofz359.146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are frequently caused by G+ cocci; TZD has potent in vitro activity against these pathogens, including methicillin-resistant Staphylococcus aureus (MRSA). The VITAL study compared the efficacy and safety of TZD vs. LZD for the treatment of ventilated patients with G+ HAP/VAP. Methods Randomized, double-blind, double-dummy, global, phase 3 study in mechanically ventilated adult patients with presumed G+ HAP/VAP (clinicaltrials.gov NCT02019420). Patients were stratified by region, age, and trauma/nontrauma, then randomized 1:1 to intravenous (IV) TZD 200 mg once daily for 7 days or IV LZD 600 mg every 12 h for 10 d (patients with concurrent G+ bacteremia received 14 d of treatment). The primary efficacy endpoint was day 28 all-cause mortality (ACM) in the intent to treat (ITT) population (all randomized patients; noninferiority [NI] margin, 10%). Secondary endpoints included investigator-assessed clinical response at test of cure (TOC; NI margin, 12.5%). Results In total, 726 patients were randomized (TZD n = 366; LZD n = 360). Baseline characteristics were well balanced between arms. TZD was noninferior to LZD for day 28 ACM in the ITT (table). Noninferiority was not demonstrated for TZD vs. LZD for investigator-assessed clinical success at TOC in the ITT. Stratification factors, analysis population, baseline clinical/laboratory signs of HAP/VAP, G+ only vs. mixed G+/gram-negative (G–) HAP/VAP, adjunctive G– therapy, MRSA vs. methicillin-susceptible S. aureus, and HAP vs. VAP were evaluated, and no single factor accounted for the observed imbalance in clinical response between treatment arms. Greater than 90% of patients experienced treatment-emergent adverse events (TEAEs). Anemia, hypokalemia, and diarrhea were the most frequently reported (TEAEs) in both arms. Types and incidence rates of TEAEs overall, and of drug-related TEAEs specifically, were comparable between TZD and LZD. Conclusion TZD was noninferior to LZD for day 28 ACM in the treatment of ventilated G+ HAP/VAP. However, TZD was not noninferior to LZD based on the investigator-assessed clinical response at TOC. Both drugs were similarly well tolerated and TEAEs were well balanced between groups, with no new safety signals identified. ![]()
Disclosures All Authors: No reported Disclosures.
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Affiliation(s)
- Richard G Wunderink
- Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois
| | | | | | | | - Satoshi Fujimi
- Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
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25
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Wunderink RG, Bruno C, Martin-Loeches I, Kollef M, Timsit JF, Yu B, Huntington JA, Li L, Jensen E, Wolf D, Butterton JR, Rhee EG. 2226. Impact of Prior and Concomitant Antibacterial Therapy on Outcomes in the ASPECT-NP Randomized, Controlled Trial of Ceftolozane/Tazobactam (C/T) vs. Meropenem (MEM) in Patients with Ventilated Nosocomial Pneumonia (NP). Open Forum Infect Dis 2019. [PMCID: PMC6810350 DOI: 10.1093/ofid/ofz360.1904] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background NP is a frequent healthcare-acquired infection associated with high mortality; rising resistance rates among causative Gram-negative pathogens require new treatment options. In the randomized, controlled, double-blind, phase 3 ASPECT-NP trial, C/T (at double the initially approved dose) was noninferior to MEM for ventilated NP in both primary and key secondary endpoints. Here we evaluate the impact of prior and concomitant Gram-negative antibacterial therapy on outcomes in that trial. Methods Mechanically ventilated patients with ventilator-associated or hospital-acquired pneumonia were randomized 1:1 to 3 g C/T or 1 g MEM, both by 1-h IV infusion every 8 hours for 8–14 days. Patients could receive ≤24 hours of active antibacterial therapy within ≤72 hours prior to first dose; longer durations were permitted in case of prior treatment failure (i.e., signs and/or symptoms of the current episode of ventilated NP persisted/worsened despite ≥48 hours of treatment). At sites with MEM-resistant Pseudomonas aeruginosa rates ≥15%, patients could optionally receive up to 72 h of adjunctive empiric aminoglycoside (amikacin was recommended) until study drug susceptibility was confirmed. Primary and key secondary endpoints, respectively, were 28-d all-cause mortality and clinical response at test of cure (TOC; 7–14 days after the end of therapy) in the intent to treat (ITT) population (all randomized patients). Results In the C/T arm, 285/362 (79%) ITT patients received prior systemic Gram-negative therapy and 103/362 (28%) received adjunctive aminoglycoside, compared with 288/364 (79%) and 112/364 (31%) patients, respectively, in the MEM arm. In the microbiologic ITT population, causative pathogens in patients failing prior therapy at the time of enrollment (C/T 15%, MEM 11%) were mainly Klebsiella spp (33%), P. aeruginosa (17%), Escherichia coli (14%), and Acinetobacter baumannii (8%). Mortality and cure rates were comparable between C/T and MEM regardless of receipt of prior systemic or adjunctive Gram-negative therapy (table). Conclusion Prior and adjunctive Gram-negative antibacterial therapy did not affect the relative efficacy of C/T (at the 3-g dose) vs. MEM in these high-risk patients with Gram-negative ventilated NP. ![]()
Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Richard G Wunderink
- Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois
| | | | | | - Marin Kollef
- Washington University School of Medicine, St. Louis, Missouri
| | | | - Brian Yu
- Merck & Co., Inc., Kenilworth, New Jersey
| | | | - Linping Li
- Merck & Co., Inc., Kenilworth, New Jersey
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Kollef MH, Nováček M, Kivistik Ü, Réa-Neto Á, Shime N, Martin-Loeches I, Timsit JF, Wunderink RG, Bruno CJ, Huntington JA, Lin G, Yu B, Butterton JR, Rhee EG. Ceftolozane-tazobactam versus meropenem for treatment of nosocomial pneumonia (ASPECT-NP): a randomised, controlled, double-blind, phase 3, non-inferiority trial. Lancet Infect Dis 2019; 19:1299-1311. [PMID: 31563344 DOI: 10.1016/s1473-3099(19)30403-7] [Citation(s) in RCA: 199] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/04/2019] [Accepted: 07/09/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Nosocomial pneumonia due to antimicrobial-resistant pathogens is associated with high mortality. We assessed the efficacy and safety of the combination antibacterial drug ceftolozane-tazobactam versus meropenem for treatment of Gram-negative nosocomial pneumonia. METHODS We conducted a randomised, controlled, double-blind, non-inferiority trial at 263 hospitals in 34 countries. Eligible patients were aged 18 years or older, were undergoing mechanical ventilation, and had nosocomial pneumonia (either ventilator-associated pneumonia or ventilated hospital-acquired pneumonia). Patients were randomly assigned (1:1) with block randomisation (block size four), stratified by type of nosocomial pneumonia and age (<65 years vs ≥65 years), to receive either 3 g ceftolozane-tazobactam or 1 g meropenem intravenously every 8 h for 8-14 days. The primary endpoint was 28-day all-cause mortality (at a 10% non-inferiority margin). The key secondary endpoint was clinical response at the test-of-cure visit (7-14 days after the end of therapy; 12·5% non-inferiority margin). Both endpoints were assessed in the intention-to-treat population. Investigators, study staff, patients, and patients' representatives were masked to treatment assignment. Safety was assessed in all randomly assigned patients who received study treatment. This trial was registered with ClinicalTrials.gov, NCT02070757. FINDINGS Between Jan 16, 2015, and April 27, 2018, 726 patients were enrolled and randomly assigned, 362 to the ceftolozane-tazobactam group and 364 to the meropenem group. Overall, 519 (71%) patients had ventilator-associated pneumonia, 239 (33%) had Acute Physiology and Chronic Health Evaluation II scores of at least 20, and 668 (92%) were in the intensive care unit. At 28 days, 87 (24·0%) patients in the ceftolozane-tazobactam group and 92 (25·3%) in the meropenem group had died (weighted treatment difference 1·1% [95% CI -5·1 to 7·4]). At the test-of-cure visit 197 (54%) patients in the ceftolozane-tazobactam group and 194 (53%) in the meropenem group were clinically cured (weighted treatment difference 1·1% [95% CI -6·2 to 8·3]). Ceftolozane-tazobactam was thus non-inferior to meropenem in terms of both 28-day all-cause mortality and clinical cure at test of cure. Treatment-related adverse events occurred in 38 (11%) of 361 patients in the ceftolozane-tazobactam group and 27 (8%) of 359 in the meropenem group. Eight (2%) patients in the ceftolozane-tazobactam group and two (1%) in the meropenem group had serious treatment-related adverse events. There were no treatment-related deaths. INTERPRETATION High-dose ceftolozane-tazobactam is an efficacious and well tolerated treatment for Gram-negative nosocomial pneumonia in mechanically ventilated patients, a high-risk, critically ill population. FUNDING Merck & Co.
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Affiliation(s)
- Marin H Kollef
- Washington University School of Medicine, St Louis, MO, USA
| | | | | | | | | | - Ignacio Martin-Loeches
- St James's Hospital, Dublin, Ireland; Universitat de Barcelona, Instituto de Investigaciones Biomédicas August Pi i Sunyer, Centro de Investigación Biomédica en Red Enfermedades Respiratorias, Barcelona, Spain
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27
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Feng HP, Guo Z, Caro L, Talaty JE, Mangin E, Panebianco D, Fandozzi C, Zhu Y, Marshall W, Huang X, Hanley WD, Jumes P, Valesky R, Martinho M, Butterton JR, Iwamoto M, Yeh WW. Assessment of Drug Interaction Potential Between the Hepatitis C Virus Direct-Acting Antiviral Agents Elbasvir/Grazoprevir and the Nucleotide Analog Reverse-Transcriptase Inhibitor Tenofovir Disoproxil Fumarate. Clin Pharmacol Drug Dev 2019; 8:962-970. [PMID: 31173674 DOI: 10.1002/cpdd.701] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 05/07/2019] [Indexed: 11/10/2022]
Abstract
Treatment of individuals coinfected with hepatitis C virus (HCV) and human immunodeficiency virus (HIV) requires careful consideration of potential drug-drug interactions. We evaluated the pharmacokinetic interaction of the direct-acting antiviral agents elbasvir and grazoprevir coadministered with the nucleotide reverse transcriptase inhibitor tenofovir disoproxil fumarate (TDF). Three open-label, multidose studies in healthy adults were conducted. In the first study (N = 10), participants received TDF 300 mg once daily, elbasvir 50 mg once daily, and elbasvir coadministered with TDF. In the second study (N = 12), participants received TDF 300 mg once daily, grazoprevir 200 mg once daily, and grazoprevir coadministered with TDF. In the third study (N = 14), participants received TDF 300 mg once daily and TDF 300 mg coadministered with coformulated elbasvir/grazoprevir 50 mg/100 mg once daily. Pharmacokinetics and safety were evaluated. Following coadministration, the tenofovir area under the plasma concentration-time curve to 24 hours and maximum plasma concentration geometric mean ratios (90% confidence intervals) for tenofovir and coadministered drug(s) versus tenofovir were 1.3 (1.2, 1.5) and 1.5 (1.3, 1.6), respectively, when coadministered with elbasvir; 1.2 (1.1, 1.3) and 1.1 (1.0, 1.2), respectively, when coadministered with grazoprevir; and 1.3 (1.2, 1.4) and 1.1 (1.0, 1.4), respectively, when coadministered with the elbasvir/grazoprevir coformulation. TDF had minimal effect on elbasvir and grazoprevir pharmacokinetics. Elbasvir and/or grazoprevir coadministered with TDF resulted in no clinically meaningful tenofovir exposure increases and was generally well tolerated, with no deaths, serious adverse events (AEs), discontinuations due to AEs, or laboratory AEs reported. No dose adjustments for elbasvir/grazoprevir or TDF are needed for coadministration in HCV/HIV-coinfected people.
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Affiliation(s)
| | | | | | | | | | | | | | - Yali Zhu
- Merck & Co., Inc., Kenilworth, NJ, USA
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28
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Feng H, Guo Z, Caro L, Marshall WL, Liu F, Panebianco D, Vaddady P, Barbour A, Reitmann C, Jumes P, Gilmartin J, Wolford D, Valesky R, Martinho M, Butterton JR, Iwamoto M, Fraser I, Webster L, Yeh WW. No Pharmacokinetic Interactions Between Elbasvir or Grazoprevir and Buprenorphine/Naloxone in Healthy Participants and Participants Receiving Stable Opioid Agonist Therapy. Clin Transl Sci 2018; 11:562-572. [PMID: 30040871 PMCID: PMC6226112 DOI: 10.1111/cts.12565] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 03/14/2018] [Indexed: 01/03/2023] Open
Abstract
The aims of these phase I trials were to evaluate the pharmacokinetic interaction between elbasvir (EBR) or grazoprevir (GZR) and buprenorphine/naloxone (BUP/NAL). Trial 1 was a single-dose trial in healthy participants. Trial 2 was a multiple-dose trial in participants on BUP/NAL maintenance therapy. Coadministration of EBR or GZR with BUP/NAL had minimal effect on the pharmacokinetics of BUP/NAL, EBR, and GZR. The geometric mean ratios (GMRs (90% CI)) for BUP, norbuprenorphine, and NAL AUC0-∞ were 0.98 (0.89-1.08), 0.97 (0.86-1.09), and 0.88 (0.78-1.00) in the presence/absence of EBR; 0.98 (0.81-1.19), 1.13 (0.97-1.32), and 1.10 (0.82-1.47) in the presence/absence of GZR. The GMRs (90% CI) for EBR and GZR AUC0-∞ in the absence/presence of BUP/NAL were 1.22 (0.98-1.52) and 0.86 (0.63-1.18). In conclusion, no dose adjustment for BUP/NAL, EBR, or GZR is required for patients with HCV infection receiving EBR/GZR and BUP/NAL maintenance therapy.
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Affiliation(s)
| | - Zifang Guo
- Merck & Co., Inc.KenilworthNew JerseyUSA
| | | | - William L. Marshall
- Merck & Co., Inc.KenilworthNew JerseyUSA
- Current affiliation: Alexion Pharmaceuticals, Inc.New HavenConnecticutUSA
| | - Fang Liu
- Merck & Co., Inc.KenilworthNew JerseyUSA
| | | | | | | | | | | | | | | | | | | | | | | | - Iain Fraser
- Merck & Co., Inc.KenilworthNew JerseyUSA
- Current affiliation: Abide Therapeutics, Inc.PrincetonNew JerseyUSA
| | - Lynn Webster
- CRI Lifetree Clinical ResearchSalt Lake CityUtahUSA
- Current affiliation: PRA Health SciencesSalt Lake CityUtahUSA
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Marshall WL, Feng HP, Wenning L, Garrett G, Huang X, Liu F, Panebianco D, Caro L, Fandozzi C, Lasseter KC, Preston RA, Marbury T, Butterton JR, Iwamoto M, Yeh WW. Pharmacokinetics, Safety, and Tolerability of Single-Dose Elbasvir in Participants with Hepatic Impairment. Eur J Drug Metab Pharmacokinet 2018; 43:321-329. [PMID: 29247332 DOI: 10.1007/s13318-017-0451-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The combination of elbasvir and grazoprevir is approved for the treatment of hepatitis C virus genotype 1 or 4 infection. OBJECTIVE To evaluate the pharmacokinetics and safety of single-dose elbasvir 50 mg in participants with hepatic impairment. METHODS Participants with mild, moderate, or severe hepatic impairment and age-, sex-, and weight-matched healthy controls were enrolled in a 3-part, open-label, sequential-panel, single-dose pharmacokinetic study. Blood samples were collected to assess pharmacokinetics. Safety and tolerability were assessed throughout the study. RESULTS Thirty-four participants were enrolled: eight with mild hepatic impairment, 11 with moderate hepatic impairment, seven with severe hepatic impairment, and eight healthy matched controls. Participants with mild, moderate, and severe hepatic impairment demonstrated a numeric, but not statistically significant, decrease in elbasvir exposure compared with controls, with a mean 39, 28, and 12% decrease in area under the concentration-time curve from time 0 extrapolated to infinity, as well as a 42, 31, and 42% decrease in maximum plasma concentration (C max), respectively. The observed median time to C max was similar in participants with hepatic impairment and controls. Single-dose administration of elbasvir was well tolerated. CONCLUSIONS The pharmacokinetics of elbasvir after a single, oral 50-mg dose were not clinically meaningfully altered in non-HCV-infected participants with mild, moderate, or severe hepatic dysfunction. However, since elbasvir is currently available only as part of a fixed-dose combination with grazoprevir, the fixed-dose combination should not be administered to patients with moderate or severe hepatic impairment, due to the significantly increased plasma grazoprevir exposures in those populations.
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Affiliation(s)
| | - Hwa-Ping Feng
- Merck & Co., Inc., 8000 Galloping Hill Road, Kenilworth, NJ, 07033, USA.
| | - Larissa Wenning
- Merck & Co., Inc., 8000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Graigory Garrett
- Merck & Co., Inc., 8000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Xiaobi Huang
- Merck & Co., Inc., 8000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Fang Liu
- Merck & Co., Inc., 8000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | | | - Luzelena Caro
- Merck & Co., Inc., 8000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | | | - Kenneth C Lasseter
- Clinical Pharmacology of Miami, 550 West 84th Street, Miami, FL, 33014, USA
| | - Richard A Preston
- Department of Cellular Biology and Pharmacology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, 33199, USA
| | - Thomas Marbury
- Orlando Clinical Research Center, 5055 South Orange Avenue, Orlando, FL, 32809, USA
| | - Joan R Butterton
- Merck & Co., Inc., 8000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Marian Iwamoto
- Merck & Co., Inc., 8000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Wendy W Yeh
- Merck & Co., Inc., 8000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
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Feng HP, Guo Z, Caro L, Marshall WL, Liu F, Panebianco D, Vaddady P, Reitmann C, Jumes P, Wolford D, Fraser I, Valesky R, Martinho M, Butterton JR, Iwamoto M, Webster L, Yeh WW. No Pharmacokinetic Interactions Between Elbasvir or Grazoprevir and Methadone in Participants Receiving Maintenance Opioid Agonist Therapy. Clin Transl Sci 2018; 11:553-561. [PMID: 30040872 PMCID: PMC6226122 DOI: 10.1111/cts.12564] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 08/04/2018] [Indexed: 01/03/2023] Open
Abstract
We conducted two phase I trials to evaluate the pharmacokinetic interactions between elbasvir (EBR), grazoprevir (GZR), and methadone (MK‐8742‐P010 and MK‐5172‐P030) in non‐hepatitis C virus (HCV)‐infected participants on methadone maintenance therapy. Coadministration of EBR or GZR with methadone had no clinically meaningful effect on EBR, GZR, or methadone pharmacokinetics. The geometric mean ratios (GMRs) for R‐ and S‐methadone AUC0‐24 were 1.03 (90% confidence interval (CI), 0.92–1.15) and 1.09 (90% CI, 0.94–1.26) in the presence/absence of EBR; and 1.09 (90% CI, 1.02–1.17) and 1.23 (90% CI, 1.12–1.35) in the presence/absence of GZR. The GMRs for EBR and GZR AUC0‐24 in participants receiving methadone relative to a healthy historical cohort not receiving methadone were 1.20 (90% CI, 0.94–1.53) and 1.03 (90% CI, 0.76–1.41), respectively. These results indicate that no dose adjustment is required for individuals with HCV infection receiving stable methadone therapy and the EBR/GZR fixed‐dose regimen.
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Affiliation(s)
| | - Zifang Guo
- Merck & Co., Inc., Kenilworth, New Jersey, USA
| | | | - William L Marshall
- Merck & Co., Inc., Kenilworth, New Jersey, USA.,Alexion Pharmaceuticals, Inc., New Haven, Connecticut, USA
| | - Fang Liu
- Merck & Co., Inc., Kenilworth, New Jersey, USA
| | | | | | | | | | | | - Iain Fraser
- Merck & Co., Inc., Kenilworth, New Jersey, USA.,Abide Therapeutics, Inc., Princeton, New Jersey, USA
| | | | | | | | | | - Lynn Webster
- CRI Lifetree Clinical Research, Salt Lake City, Utah, USA.,PRA Health Sciences, Salt Lake City, Utah, USA
| | - Wendy W Yeh
- Merck & Co., Inc., Kenilworth, New Jersey, USA
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31
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Sanchez RI, Fillgrove KL, Yee KL, Liang Y, Lu B, Tatavarti A, Liu R, Anderson MS, Behm MO, Fan L, Li Y, Butterton JR, Iwamoto M, Khalilieh SG. Characterisation of the absorption, distribution, metabolism, excretion and mass balance of doravirine, a non-nucleoside reverse transcriptase inhibitor in humans. Xenobiotica 2018; 49:422-432. [PMID: 29557716 DOI: 10.1080/00498254.2018.1451667] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Absorption, distribution, metabolism and elimination of doravirine (MK-1439), a novel non-nucleoside reverse transcriptase inhibitor, were investigated. Two clinical trials were conducted in healthy subjects: an oral single dose [14 C]doravirine (350 mg, ∼200 µCi) trial (n = 6) and an intravenous (IV) single-dose doravirine (100 µg) trial (n = 12). In vitro metabolism, protein binding, apparent permeability and P-glycoprotein (P-gp) transport studies were conducted to complement the clinical trials. Following oral [14 C]doravirine administration, all of the administered dose was recovered. The absorbed dose was eliminated primarily via metabolism. An oxidative metabolite (M9) was the predominant metabolite in excreta and was the primary circulating metabolite (12.9% of circulating radioactivity). Following IV administration, doravirine clearance and volume of distribution were 3.73 L/h (95% confidence intervals (CI) 3.09, 4.49) and 60.5 L (95% CI 53.7, 68.4), respectively. In vitro, doravirine is not highly bound to plasma proteins (unbound fraction 0.24) and has good passive permeability. The metabolite M9 was generated by cytochrome P450 3A (CYP3A)4/5-mediated oxidation. Doravirine was a P-gp substrate but P-gp efflux is not expected to play a significant role in limiting doravirine absorption or to be involved in the elimination of doravirine. In conclusion, doravirine is a low clearance drug, primarily eliminated by CYP3A-mediated metabolism.
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Affiliation(s)
| | | | - Ka Lai Yee
- a Merck & Co., Inc ., Kenilworth , NJ , USA
| | | | - Bing Lu
- a Merck & Co., Inc ., Kenilworth , NJ , USA
| | | | | | | | | | - Li Fan
- a Merck & Co., Inc ., Kenilworth , NJ , USA
| | - Yun Li
- a Merck & Co., Inc ., Kenilworth , NJ , USA
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32
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Marshall WL, McCrea JB, Macha S, Menzel K, Liu F, van Schanke A, de Haes JIU, Hussaini A, Jordan HR, Drexel M, Kantesaria BS, Tsai C, Cho CR, Hulskotte EGJ, Butterton JR, Iwamoto M. Pharmacokinetics and Tolerability of Letermovir Coadministered With Azole Antifungals (Posaconazole or Voriconazole) in Healthy Subjects. J Clin Pharmacol 2018; 58:897-904. [DOI: 10.1002/jcph.1094] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 01/15/2018] [Indexed: 11/10/2022]
Affiliation(s)
| | | | | | | | - Fang Liu
- Merck & Co, Inc; Kenilworth NJ USA
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33
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Anderson MS, Khalilieh S, Yee KL, Liu R, Fan L, Rizk ML, Shah V, Hussaini A, Song I, Ross LL, Butterton JR. A Two-Way Steady-State Pharmacokinetic Interaction Study of Doravirine (MK-1439) and Dolutegravir. Clin Pharmacokinet 2018; 56:661-669. [PMID: 27699622 DOI: 10.1007/s40262-016-0458-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Doravirine, a non-nucleoside reverse-transcriptase inhibitor in development for the treatment of patients with human immunodeficiency virus-1 infection, has potential to be used concomitantly in antiretroviral therapy with dolutegravir, an integrase strand transfer inhibitor. The pharmacokinetic interactions between these drugs were therefore assessed. METHODS Oral formulations of doravirine and dolutegravir were dosed both individually and concomitantly once daily in healthy adults. Twelve subjects (six were male), 23-42 years of age, were enrolled and 11 completed this phase I, open-label, three-period, fixed-sequence study per protocol; one subject was discontinued for a positive cotinine test at admission to period 2. In period 1, dolutegravir 50 mg was administered for 7 days. After a 7-day washout, doravirine 200 mg was dosed for 7 days in period 2, followed (without washout) by both doravirine and dolutegravir simultaneously for 7 days in period 3. Plasma samples were taken to determine dolutegravir and doravirine concentrations. RESULTS The steady-state concentration 24 h post-dose (C24) of dolutegravir was not substantially altered by co-administration of doravirine multiple doses; area under the plasma concentration-time curve from dosing to 24 h post-dose (AUC0-24), maximum concentration (C max), and C24 geometric mean ratios were 1.36, 1.43, and 1.27, respectively. The pharmacokinetics of doravirine was not affected by multiple doses of dolutegravir (geometric mean ratios: 1.00, 0.98, and 1.06 for AUC0-24, C24, and C max, respectively). Both drugs were generally well tolerated. CONCLUSION The results of this study demonstrate that concomitant administration of doravirine and dolutegravir in healthy subjects causes no clinically significant alteration in the pharmacokinetic and safety profiles of the two drugs, thereby supporting further evaluation of co-administration of these agents for human immunodeficiency virus-1 treatment.
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Affiliation(s)
- Matt S Anderson
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ, 07033, USA.
| | | | - Ka Lai Yee
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ, 07033, USA
| | - Rachael Liu
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ, 07033, USA
| | - Li Fan
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ, 07033, USA
| | - Matthew L Rizk
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ, 07033, USA
| | - Vedangi Shah
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ, 07033, USA
| | | | - Ivy Song
- GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Lisa L Ross
- ViiV Healthcare, Research Triangle Park, NC, USA
| | - Joan R Butterton
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ, 07033, USA
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Yee KL, Khalilieh SG, Sanchez RI, Liu R, Anderson MS, Manthos H, Judge T, Brejda J, Butterton JR. The Effect of Single and Multiple Doses of Rifampin on the Pharmacokinetics of Doravirine in Healthy Subjects. Clin Drug Investig 2018; 37:659-667. [PMID: 28353169 DOI: 10.1007/s40261-017-0513-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVE Doravirine is a novel, next-generation, non-nucleoside reverse transcriptase inhibitor in development for the treatment of human immunodeficiency virus-1 infection in combination with other antiretrovirals. Doravirine is a substrate for cytochrome P450 (CYP) 3A and P-glycoprotein. Rifampin (rifampicin) is used for treating tuberculosis in patients who are co-infected with human immunodeficiency virus. Rifampin demonstrates organic anion-transporting polypeptide 1B1 and P-glycoprotein inhibition after single-dose administration and CYP3A and P-glycoprotein induction after multiple-dose administration. The objective of this study was to evaluate the effects of co-administration of single and multiple doses of rifampin on doravirine pharmacokinetics. METHODS In period 1 of this open-label, two-period, fixed-sequence study in healthy adults, subjects received single-dose doravirine 100 mg; blood samples for measuring plasma concentration were collected pre-dose and up to 72 h post-dose. In period 2, following a 7-day washout, subjects received doravirine 100 mg and rifampin 600 mg on day 1, rifampin 600 mg daily on days 4-18, with doravirine 100 mg co-administered on day 17; blood samples were collected pre-dose and up to 72 h post-dose on day 1 and up to 48 h post-dose on day 17. Safety assessments included adverse events, physical examinations, vital signs, and clinical laboratory measurements. RESULTS Ten subjects completed the study. Doravirine area under the concentration-time curve from time zero extrapolated to infinity and plasma concentration at 24 h post-dose were comparable in the presence and absence of single-dose rifampin [geometric mean ratios (90% confidence intervals)] of 0.91 (0.78-1.06) and 0.90 (0.80-1.01), respectively. Doravirine maximum plasma concentration increased when co-administered with single-dose rifampin vs. doravirine alone, geometric mean ratio (90% confidence interval): 1.40 (1.21-1.63). Reductions in doravirine geometric mean ratios (90% confidence interval), area under the concentration-time curve from time zero extrapolated to infinity: 0.12 (0.10-0.15), plasma concentration at 24 h post-dose: 0.03 (0.02-0.04), maximum plasma concentration: 0.43 (0.35-0.52), and apparent terminal half-life were observed when co-administered with multiple-dose rifampin vs. doravirine administered alone. Doravirine was well tolerated. Adverse events were mild and resolved by study completion. CONCLUSIONS Doravirine co-administration with single-dose rifampin indicated that inhibition of organic anion-transporting polypeptide uptake transporters and P-glycoprotein has little impact on doravirine pharmacokinetics. Long-term co-administration of rifampin or other strong CYP3A inducers with doravirine will likely reduce its efficacy.
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Affiliation(s)
- Ka Lai Yee
- Merck & Co., Inc., Kenilworth, NJ, USA.
- , 770 Sumneytown Pike, WP75B-100, West Point, PA, 19486, USA.
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35
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Feng H, Caro L, Fandozzi CM, Guo Z, Talaty J, Wolford D, Panebianco D, Iwamoto M, Butterton JR, Yeh WW. Pharmacokinetic Interactions Between Elbasvir/Grazoprevir and Immunosuppressant Drugs in Healthy Volunteers. J Clin Pharmacol 2018; 58:666-673. [DOI: 10.1002/jcph.1052] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 11/07/2017] [Indexed: 11/10/2022]
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36
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Gane EJ, Pianko S, Roberts SK, Thompson AJ, Zeuzem S, Zuckerman E, Ben-Ari Z, Foster GR, Agarwal K, Laursen AL, Gerstoft J, Gao W, Huang HC, Fitzgerald B, Fernsler D, Li JJ, Grandhi A, Liu H, Su FH, Wan S, Zeng Z, Chen HL, Dutko FJ, Nguyen BYT, Wahl J, Robertson MN, Barr E, Yeh WW, Plank RM, Butterton JR, Esteban R. Safety and efficacy of an 8-week regimen of grazoprevir plus ruzasvir plus uprifosbuvir compared with grazoprevir plus elbasvir plus uprifosbuvir in participants without cirrhosis infected with hepatitis C virus genotypes 1, 2, or 3 (C-CREST-1 and C-CREST-2, part A): two randomised, phase 2, open-label trials. Lancet Gastroenterol Hepatol 2017; 2:805-813. [DOI: 10.1016/s2468-1253(17)30159-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 05/12/2017] [Accepted: 05/18/2017] [Indexed: 01/06/2023]
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37
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Lawitz E, Buti M, Vierling JM, Almasio PL, Bruno S, Ruane PJ, Hassanein TI, Muellhaupt B, Pearlman B, Jancoriene L, Gao W, Huang HC, Shepherd A, Tannenbaum B, Fernsler D, Li JJ, Grandhi A, Liu H, Su FH, Wan S, Dutko FJ, Nguyen BYT, Wahl J, Robertson MN, Barr E, Yeh WW, Plank RM, Butterton JR, Yoshida EM. Safety and efficacy of a fixed-dose combination regimen of grazoprevir, ruzasvir, and uprifosbuvir with or without ribavirin in participants with and without cirrhosis with chronic hepatitis C virus genotype 1, 2, or 3 infection (C-CREST-1 and C-CREST-2, part B): two randomised, phase 2, open-label trials. Lancet Gastroenterol Hepatol 2017; 2:814-823. [PMID: 28802814 DOI: 10.1016/s2468-1253(17)30163-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 05/16/2017] [Accepted: 05/19/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND There is a need for hepatitis C virus (HCV) therapies with excellent efficacy across genotypes and in diverse populations. Part A of the C-CREST-1 and C-CREST-2 trials led to the selection of a three-drug regimen of grazoprevir (MK-5172; an HCV NS3/4A protease inhibitor; 100 mg/day) plus ruzasvir (MK-8408; an NS5A inhibitor; 60 mg/day) plus uprifosbuvir (MK-3682; an HCV NS5B polymerase inhibitor; 450 mg/day). Part B of the studies tested this combination as a single formulation in different treatment durations in a broader population. METHODS Part B of these randomised, phase 2, open-label clinical trials enrolled individuals from 15 countries who were chronically infected with HCV genotypes 1-6 (HCV RNA ≥10 000 IU/mL) with or without compensated cirrhosis. Those with genotype 1, genotype 2, genotype 4, or genotype 6 were treatment-naive; those with genotype 3 could be treatment-naive or treatment-experienced with pegylated interferon and ribavirin. Randomisation occurred centrally using an interactive voice response system and integrated web response system. Participants were randomly assigned to receive treatment for 8, 12, or 16 weeks with a fixed-dose combination of grazoprevir, ruzasvir, and uprifosbuvir with or without ribavirin. The primary endpoint was the proportion of participants achieving sustained virological response 12 weeks after the end of all study therapy (SVR12), defined as HCV RNA less than the lower limit of quantification (either target detected unquantifiable or target not detected [<15 IU/mL]). The trials are registered at ClinicalTrials.gov, numbers NCT02332707 and NCT02332720. FINDINGS 676 participants were randomly assigned between Feb 18, 2015, and Aug 16, 2016. In all 675 participants who received at least one dose of study drug (full analysis set), SVR12 for the 8-week regimen of grazoprevir, ruzasvir, and uprifosbuvir with and without ribavirin was achieved in 39 (93% [95% CI 81-99]) of 42 participants with genotype 1a, 45 (98% [88-100]) of 46 with genotype 1b, 54 (86% [75-93]) of 63 with genotype 2, 98 (95% [89-98]) of 103 with genotype 3, and seven (100% [59-100]) of seven participants with genotype 4. SVR12 for the 12-week regimen with and without ribavirin was achieved in 87 (99% [95% CI 94-100]) of 88 participants with genotype 1, 61 (98% [91-100]) of 62 with genotype 2, and four (100% [40-100]) of four with genotype 6. Among participants with cirrhosis who were infected with genotype 3, SVR12 for the 12-week regimen with and without ribavirin was achieved in 28 (97% [95% CI 82-100]) of 29 of those who were treatment-naive and 29 (100% [88-100]) of 29 who were treatment-experienced. SVR12 for the 16-week regimen with and without ribavirin was achieved in 26 (100% [95% CI 87-100]) of 26 participants with genotype 2 infection and 72 (96% [89-99]) of 75 participants with genotype 3 infection. The most common adverse events were headache (143 [22%] of 664), fatigue (129 [19%] of 664), and nausea (83 [13%] of 664). 16 (2%) of 664 participants had serious adverse events. INTERPRETATION The combined regimen of grazoprevir (100 mg/day), ruzasvir (60 mg/day), and uprifosbuvir (450 mg/day) has the potential to provide a simplified treatment for HCV that is effective and well tolerated in most individuals infected with HCV, as well as a shorter duration of treatment in many individuals. FUNDING Merck & Co, Inc.
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Affiliation(s)
- Eric Lawitz
- Texas Liver Institute, University of Texas Health San Antonio, San Antonio, TX, USA.
| | - Maria Buti
- Hospital Universitari Vall d Hebron and CIBEREHD del Instituto Carlos III, Barcelona, Spain
| | - John M Vierling
- Baylor College of Medicine, Advanced Liver Therapies, Houston, TX, USA
| | - Piero L Almasio
- Biomedical Department of Internal and Specialized Medicine, University of Palermo, Palermo, Italy
| | - Savino Bruno
- IRCCS Istituto Clinico Humanitas and Humanitas University, Rozzano, Italy
| | - Peter J Ruane
- Ruane Medical and Liver Health Institute, Los Angeles, CA, USA
| | | | | | - Brian Pearlman
- Atlanta Medical Center, Atlanta, GA, USA; Emory School of Medicine, Atlanta, GA, USA
| | - Ligita Jancoriene
- Vilnius University Hospital Santariskiu Klinikos, Centre of Infectious Diseases, Vilnius University, Vilnius, Lithuania
| | - Wei Gao
- Merck & Co, Inc, Kenilworth, NJ, USA
| | | | | | | | | | | | | | - Hong Liu
- Merck & Co, Inc, Kenilworth, NJ, USA
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Feng HP, Vaddady P, Guo Z, Liu F, Panebianco D, Levine V, Caro L, Butterton JR, Iwamoto M, Yeh WW. No Pharmacokinetic Interaction Between the Hepatitis C Virus Inhibitors Elbasvir/Grazoprevir and Famotidine or Pantoprazole. Clin Transl Sci 2017. [PMID: 28625018 PMCID: PMC5593162 DOI: 10.1111/cts.12465] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Use of agents to suppress gastric acid secretion is common among patients with hepatitis C virus (HCV) infection. The aims of this open‐label, three‐period, fixed‐sequence study were to evaluate the effect of famotidine and pantoprazole on the pharmacokinetics and safety of elbasvir/grazoprevir fixed‐dose combination (FDC) in 16 healthy subjects. Elbasvir and grazoprevir each exhibited similar pharmacokinetics following single‐dose administration of elbasvir/grazoprevir with or without famotidine or pantoprazole. Geometric mean ratios (GMRs) of grazoprevir AUC(0,∞), Cmax, and C24 (elbasvir/grazoprevir + famotidine or elbasvir/grazoprevir + pantoprazole vs. elbasvir/grazoprevir) ranged from 0.89–1.17. Similarly, GMRs of elbasvir AUC(0,∞), Cmax, and C24 (elbasvir/grazoprevir + famotidine or elbasvir/grazoprevir + pantoprazole vs. elbasvir/grazoprevir) ranged from 1.02–1.11. These results indicate that gastric acid‐reducing agents do not modify the pharmacokinetics of elbasvir or grazoprevir in a clinically relevant manner and may be coadministered with elbasvir/grazoprevir in HCV‐infected patients without restriction.
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Affiliation(s)
- H-P Feng
- Merck & Co., Inc., Kenilworth, NJ, USA
| | - P Vaddady
- Merck & Co., Inc., Kenilworth, NJ, USA
| | - Z Guo
- Merck & Co., Inc., Kenilworth, NJ, USA
| | - F Liu
- Merck & Co., Inc., Kenilworth, NJ, USA
| | | | - V Levine
- Merck & Co., Inc., Kenilworth, NJ, USA
| | - L Caro
- Merck & Co., Inc., Kenilworth, NJ, USA
| | | | - M Iwamoto
- Merck & Co., Inc., Kenilworth, NJ, USA
| | - W W Yeh
- Merck & Co., Inc., Kenilworth, NJ, USA
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Anderson MS, Khalilieh S, Yee KL, Liu R, Fan L, Rizk ML, Shah V, Hussaini A, Song I, Ross LL, Butterton JR. Erratum to: A Two-Way Steady-State Pharmacokinetic Interaction Study of Doravirine (MK-1439) and Dolutegravir. Clin Pharmacokinet 2017; 56:679-681. [PMID: 28185217 DOI: 10.1007/s40262-017-0517-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Matt S Anderson
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ, 07033, USA.
| | | | - Ka Lai Yee
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ, 07033, USA
| | - Rachael Liu
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ, 07033, USA
| | - Li Fan
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ, 07033, USA
| | - Matthew L Rizk
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ, 07033, USA
| | - Vedangi Shah
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ, 07033, USA
| | | | - Ivy Song
- GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Lisa L Ross
- ViiV Healthcare, Research Triangle Park, NC, USA
| | - Joan R Butterton
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ, 07033, USA
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Khalilieh S, Feng HP, Hulskotte EGJ, Wenning LA, Butterton JR. Clinical pharmacology profile of boceprevir, a hepatitis C virus NS3 protease inhibitor: focus on drug-drug interactions. Clin Pharmacokinet 2016; 54:599-614. [PMID: 25787025 DOI: 10.1007/s40262-015-0260-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Boceprevir is a potent, orally administered ketoamide inhibitor that targets the active site of the hepatitis C virus (HCV) non-structural (NS) 3 protease. The addition of boceprevir to peginterferon plus ribavirin resulted in higher rates of sustained virologic response (SVR) than for peginterferon plus ribavirin alone in phase III studies in both previously treated and untreated patients with HCV infection. Because boceprevir is metabolized by metabolic routes common to many other drugs, and is an inhibitor of cytochrome P450 (CYP) 3A4/5, there is a high potential for drug-drug interactions when boceprevir is administered with other therapies, particularly when treating patients with chronic HCV infection who are often receiving other medications concomitantly. Boceprevir is no longer widely used in the US or EU due to the introduction of second-generation treatments for HCV infection. However, in many other geographic regions, first-generation protease inhibitors such as boceprevir continue to form an important treatment option for patients with HCV infection. This review summarizes the interactions between boceprevir and other therapeutic agents commonly used in this patient population, indicating dose adjustment requirements where needed. Most drug interactions do not affect boceprevir plasma concentrations to a clinically meaningful extent, and thus efficacy is likely to be maintained when boceprevir is coadministered with the majority of other therapeutics. Overall, the drug-drug interaction profile of boceprevir suggests that this agent is suitable for use in a wide range of HCV-infected patients receiving concomitant therapies.
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Affiliation(s)
- Sauzanne Khalilieh
- Department of Clinical Pharmacology, Merck & Co., 1 Merck Drive, Kenilworth, NJ, 08889, USA
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Schürmann D, Sobotha C, Gilmartin J, Robberechts M, De Lepeleire I, Yee KL, Guo Y, Liu R, Wagner F, Wagner JA, Butterton JR, Anderson MS. A randomized, double-blind, placebo-controlled, short-term monotherapy study of doravirine in treatment-naive HIV-infected individuals. AIDS 2016; 30:57-63. [PMID: 26372481 DOI: 10.1097/qad.0000000000000876] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the antiviral activity, pharmacokinetics, and safety of doravirine in nonnucleoside reverse transcriptase inhibitor-naïve, HIV-infected men. DESIGN Double-blind, randomized, two-panel, dose-escalation study. METHODS In two sequential panels, 18 individuals received doravirine [25 mg (Panel A) or 200 mg (Panel B)] or matching placebo once daily for 7 days. Plasma samples were collected daily for measurement of HIV-1 RNA levels and doravirine pharmacokinetics. RESULTS For the mean change from baseline in HIV RNA (log10 copies/ml) at 24 h after the day 7 dose, the mean difference (90% confidence interval) between doravirine and placebo was -1.37 (-1.60, -1.14) in the 25-mg group and -1.26 (-1.51, -1.02) in the 200-mg group. None of the participants had viral breakthrough. Increases in mean AUC0-24 h, Cmax, and C24 h were slightly less than dose-proportional, with median Tmax of 1.0-2.0 h. Steady state was achieved after 3-5 days of once-daily dosing. At steady state, accumulation ratios (day 7/day 1) for AUC0-24 h, Cmax, and C24 h were 1.2-1.6. The calculated effective t1/2 (10-16 h) was similar to that in HIV-uninfected individuals. Adverse events were limited in number, transient, and generally mild to moderate in intensity. One participant had a serious adverse event of elevated liver enzymes (judged probably not drug related) in concurrence with a newly acquired hepatitis C infection. CONCLUSION Doravirine monotherapy demonstrated robust antiviral activity at both dose levels, without evidence of viral resistance, and was generally well tolerated. Doravirine pharmacokinetics in HIV-infected individuals were similar to those in uninfected individuals receiving similar doses in prior studies.
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Zeuzem S, Ghalib R, Reddy KR, Pockros PJ, Ari ZB, Zhao Y, Brown DD, Wan S, DiNubile MJ, Nguyen BY, Robertson MN, Wahl J, Barr E, Butterton JR. Grazoprevir-Elbasvir Combination Therapy for Treatment-Naive Cirrhotic and Noncirrhotic Patients With Chronic Hepatitis C Virus Genotype 1, 4, or 6 Infection: A Randomized Trial. Ann Intern Med 2015; 163:1-13. [PMID: 25909356 DOI: 10.7326/m15-0785] [Citation(s) in RCA: 415] [Impact Index Per Article: 46.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Novel interferon- and ribavirin-free regimens are needed to treat hepatitis C virus (HCV) infection. OBJECTIVE To evaluate the safety and efficacy of grazoprevir (NS3/4A protease inhibitor) and elbasvir (NS5A inhibitor) in treatment-naive patients. DESIGN Randomized, blinded, placebo-controlled trial. (ClinicalTrials.gov: NCT02105467). SETTING 60 centers in the United States, Europe, Australia, Scandinavia, and Asia. PATIENTS Cirrhotic and noncirrhotic treatment-naive adults with genotype 1, 4, or 6 infection. INTERVENTION Oral, once-daily, fixed-dose grazoprevir 100 mg/elbasvir 50 mg for 12 weeks, stratified by fibrosis and genotype. Patients were randomly assigned 3:1 to immediate or deferred therapy. MEASUREMENTS Proportion of patients in the immediate-treatment group achieving unquantifiable HCV RNA 12 weeks after treatment (SVR12); adverse events in both groups. RESULTS Among 421 participants, 194 (46%) were women, 157 (37%) were nonwhite, 382 (91%) had genotype 1 infection, and 92 (22%) had cirrhosis. Of 316 patients receiving immediate treatment, 299 of 316 (95% [95% CI, 92% to 97%]) achieved SVR12, including 144 of 157 (92% [CI, 86% to 96%]) with genotype 1a, 129 of 131 (99% [CI, 95% to 100%]) with genotype 1b, 18 of 18 (100% [CI, 82% to 100%]) with genotype 4, 8 of 10 (80% [CI, 44% to 98%]) with genotype 6, 68 of 70 (97% [CI, 90% to 100%]) with cirrhosis, and 231 of 246 (94% [CI, 90% to 97%]) without cirrhosis. Virologic failure occurred in 13 patients (4%), including 1 case of breakthrough infection and 12 relapses, and was associated with baseline NS5A polymorphisms and emergent NS3 or NS5A variants or both. Serious adverse events occurred in 9 (2.8%) and 3 (2.9%) patients in the active and placebo groups, respectively (difference <0.05 percentage point [CI, -5.4 to 3.1 percentage points]); none were considered drug related. The most common adverse events in the active group were headache (17%), fatigue (16%), and nausea (9%). LIMITATION The study lacked an active-comparator control group and included relatively few genotype 4 and 6 infections. CONCLUSION Grazoprevir-elbasvir achieved high SVR12 rates in treatment-naive cirrhotic and noncirrhotic patients with genotype 1, 4, or 6 infection. This once-daily, all-oral, fixed-combination regimen represents a potent new therapeutic option for chronic HCV infection. PRIMARY FUNDING SOURCE Merck & Co.
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Affiliation(s)
- Stefan Zeuzem
- From Goethe University Hospital, Frankfurt, Germany; Texas Clinical Research Institute, Dallas, Texas; University of Pennsylvania, Philadelphia, Pennsylvania; Scripps Translational Science Institute, La Jolla, California; Sheba Medical Center, Ramat Gan, Israel; and Merck & Co., Kenilworth, New Jersey
| | - Reem Ghalib
- From Goethe University Hospital, Frankfurt, Germany; Texas Clinical Research Institute, Dallas, Texas; University of Pennsylvania, Philadelphia, Pennsylvania; Scripps Translational Science Institute, La Jolla, California; Sheba Medical Center, Ramat Gan, Israel; and Merck & Co., Kenilworth, New Jersey
| | - K. Rajender Reddy
- From Goethe University Hospital, Frankfurt, Germany; Texas Clinical Research Institute, Dallas, Texas; University of Pennsylvania, Philadelphia, Pennsylvania; Scripps Translational Science Institute, La Jolla, California; Sheba Medical Center, Ramat Gan, Israel; and Merck & Co., Kenilworth, New Jersey
| | - Paul J. Pockros
- From Goethe University Hospital, Frankfurt, Germany; Texas Clinical Research Institute, Dallas, Texas; University of Pennsylvania, Philadelphia, Pennsylvania; Scripps Translational Science Institute, La Jolla, California; Sheba Medical Center, Ramat Gan, Israel; and Merck & Co., Kenilworth, New Jersey
| | - Ziv Ben Ari
- From Goethe University Hospital, Frankfurt, Germany; Texas Clinical Research Institute, Dallas, Texas; University of Pennsylvania, Philadelphia, Pennsylvania; Scripps Translational Science Institute, La Jolla, California; Sheba Medical Center, Ramat Gan, Israel; and Merck & Co., Kenilworth, New Jersey
| | - Yue Zhao
- From Goethe University Hospital, Frankfurt, Germany; Texas Clinical Research Institute, Dallas, Texas; University of Pennsylvania, Philadelphia, Pennsylvania; Scripps Translational Science Institute, La Jolla, California; Sheba Medical Center, Ramat Gan, Israel; and Merck & Co., Kenilworth, New Jersey
| | - Deborah D. Brown
- From Goethe University Hospital, Frankfurt, Germany; Texas Clinical Research Institute, Dallas, Texas; University of Pennsylvania, Philadelphia, Pennsylvania; Scripps Translational Science Institute, La Jolla, California; Sheba Medical Center, Ramat Gan, Israel; and Merck & Co., Kenilworth, New Jersey
| | - Shuyan Wan
- From Goethe University Hospital, Frankfurt, Germany; Texas Clinical Research Institute, Dallas, Texas; University of Pennsylvania, Philadelphia, Pennsylvania; Scripps Translational Science Institute, La Jolla, California; Sheba Medical Center, Ramat Gan, Israel; and Merck & Co., Kenilworth, New Jersey
| | - Mark J. DiNubile
- From Goethe University Hospital, Frankfurt, Germany; Texas Clinical Research Institute, Dallas, Texas; University of Pennsylvania, Philadelphia, Pennsylvania; Scripps Translational Science Institute, La Jolla, California; Sheba Medical Center, Ramat Gan, Israel; and Merck & Co., Kenilworth, New Jersey
| | - Bach-Yen Nguyen
- From Goethe University Hospital, Frankfurt, Germany; Texas Clinical Research Institute, Dallas, Texas; University of Pennsylvania, Philadelphia, Pennsylvania; Scripps Translational Science Institute, La Jolla, California; Sheba Medical Center, Ramat Gan, Israel; and Merck & Co., Kenilworth, New Jersey
| | - Michael N. Robertson
- From Goethe University Hospital, Frankfurt, Germany; Texas Clinical Research Institute, Dallas, Texas; University of Pennsylvania, Philadelphia, Pennsylvania; Scripps Translational Science Institute, La Jolla, California; Sheba Medical Center, Ramat Gan, Israel; and Merck & Co., Kenilworth, New Jersey
| | - Janice Wahl
- From Goethe University Hospital, Frankfurt, Germany; Texas Clinical Research Institute, Dallas, Texas; University of Pennsylvania, Philadelphia, Pennsylvania; Scripps Translational Science Institute, La Jolla, California; Sheba Medical Center, Ramat Gan, Israel; and Merck & Co., Kenilworth, New Jersey
| | - Eliav Barr
- From Goethe University Hospital, Frankfurt, Germany; Texas Clinical Research Institute, Dallas, Texas; University of Pennsylvania, Philadelphia, Pennsylvania; Scripps Translational Science Institute, La Jolla, California; Sheba Medical Center, Ramat Gan, Israel; and Merck & Co., Kenilworth, New Jersey
| | - Joan R. Butterton
- From Goethe University Hospital, Frankfurt, Germany; Texas Clinical Research Institute, Dallas, Texas; University of Pennsylvania, Philadelphia, Pennsylvania; Scripps Translational Science Institute, La Jolla, California; Sheba Medical Center, Ramat Gan, Israel; and Merck & Co., Kenilworth, New Jersey
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Marshall WL, Badshah C, Liu F, Kraft W, Colon-Gonzalez F, van Schanke A, de Haes JU, Kantesaria B, Hulskotte E, Cho C, Butterton JR, Marcantonio EE. No Evidence of a Drug-Drug Interaction Between Letermovir (MK-8228) and Mycophenolate Mofetil. Biol Blood Marrow Transplant 2015. [DOI: 10.1016/j.bbmt.2014.11.379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Anderson MS, Gilmartin J, Cilissen C, De Lepeleire I, Van Bortel L, Dockendorf MF, Tetteh E, Ancona JK, Liu R, Guo Y, Wagner JA, Butterton JR. Safety, tolerability and pharmacokinetics of doravirine, a novel HIV non-nucleoside reverse transcriptase inhibitor, after single and multiple doses in healthy subjects. Antivir Ther 2014; 20:397-405. [PMID: 25470746 DOI: 10.3851/imp2920] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Doravirine is a novel non-nucleoside inhibitor of HIV-1 reverse transcriptase with potent activity against wild-type virus (95% inhibitory concentration 19 nM, 50% human serum). Doravirine has low potential to cause drug-drug interactions since it is primarily eliminated by oxidative metabolism and does not inhibit or significantly induce drug-metabolizing enzymes. METHODS The pharmacokinetics and safety of doravirine were investigated in two double-blind, dose-escalation studies in healthy males. Thirty-two subjects received single doses of doravirine (6-1,200 mg) or matching placebo tablets; 40 subjects received doravirine (30-750 mg) or matching placebo tablets once daily for 10 days. In addition, the effect of doravirine (120 mg for 14 days) on single-dose pharmacokinetics of the CYP3A substrate midazolam was evaluated (10 subjects). RESULTS The maximum plasma concentration (Cmax) of doravirine was achieved within 1-5 h with an apparent terminal half-life of 12-21 h. Consistent with single-dose pharmacokinetics, steady state was achieved after approximately 7 days of once daily administration, with accumulation ratios (day 10/day 1) of 1.1-1.5 in the area under the plasma concentration-time curve during the dosing interval (AUC0-24 h), Cmax and trough plasma concentration (C24 h). All dose levels produced C24 h>19 nM. Administration of 50 mg doravirine with a high-fat meal was associated with slight elevations in AUC time zero to infinity (AUC0-∞) and C24 h with no change in Cmax. Midazolam AUC0-∞ was slightly reduced by coadministration of doravirine (geometric mean ratio 0.82, 90% CI 0.70, 0.97). There was no apparent relationship between adverse event frequency or intensity and doravirine dose. No rash or significant central nervous system events other than headache were reported. CONCLUSIONS Doravirine is generally well tolerated in single doses up to 1,200 mg and multiple doses up to 750 mg once daily for up to 10 days, with a pharmacokinetic profile supportive of once-daily dosing. Doravirine at steady state slightly reduced the exposure of coadministered midazolam, to a clinically unimportant extent.
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Mallick EM, McBee ME, Vanguri VK, Melton-Celsa AR, Schlieper K, Karalius BJ, O'Brien AD, Butterton JR, Leong JM, Schauer DB. A novel murine infection model for Shiga toxin-producing Escherichia coli. J Clin Invest 2012; 122:4012-24. [PMID: 23041631 DOI: 10.1172/jci62746] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 08/09/2012] [Indexed: 01/10/2023] Open
Abstract
Enterohemorrhagic E. coli (EHEC) is an important subset of Shiga toxin-producing (Stx-producing) E. coli (STEC), pathogens that have been implicated in outbreaks of food-borne illness and can cause intestinal and systemic disease, including severe renal damage. Upon attachment to intestinal epithelium, EHEC generates "attaching and effacing" (AE) lesions characterized by intimate attachment and actin rearrangement upon host cell binding. Stx produced in the gut transverses the intestinal epithelium, causing vascular damage that leads to systemic disease. Models of EHEC infection in conventional mice do not manifest key features of disease, such as AE lesions, intestinal damage, and systemic illness. In order to develop an infection model that better reflects the pathogenesis of this subset of STEC, we constructed an Stx-producing strain of Citrobacter rodentium, a murine AE pathogen that otherwise lacks Stx. Mice infected with Stx-producing C. rodentium developed AE lesions on the intestinal epithelium and Stx-dependent intestinal inflammatory damage. Further, the mice experienced lethal infection characterized by histopathological and functional kidney damage. The development of a murine model that encompasses AE lesion formation and Stx-mediated tissue damage will provide a new platform upon which to identify EHEC alterations of host epithelium that contribute to systemic disease.
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Affiliation(s)
- Emily M Mallick
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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Butterton JR, Collier DS, Romero JM, Zembowicz A. Case records of the Massachusetts General Hospital. Case 14-2007. A 59-year-old man with fever and pain and swelling of both eyes and the right ear. N Engl J Med 2007; 356:1980-8. [PMID: 17494931 DOI: 10.1056/nejmcpc079009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Joan R Butterton
- Infectious Disease Division, Massachusetts General Hospital, USA
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Affiliation(s)
- Reshma Jagsi
- Center for Faculty Development and Partners Office for Women's Careers at Massachusetts General Hospital, 370 Bulfinch, Boston, MA 02114, USA
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Lewis GD, Holmes CB, Holmvang G, Butterton JR. Case records of the Massachusetts General Hospital. Case 8-2007. A 48-year-old man with chest pain followed by cardiac arrest. N Engl J Med 2007; 356:1153-62. [PMID: 17360994 DOI: 10.1056/nejmcpc079002] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Gregory D Lewis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, USA
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Cilmi SA, Karalius BJ, Choy W, Smith RN, Butterton JR. Fabry Disease in Mice Protects against Lethal Disease Caused by Shiga Toxin–Expressing EnterohemorrhagicEscherichia coli. J Infect Dis 2006; 194:1135-40. [PMID: 16991089 DOI: 10.1086/507705] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2005] [Accepted: 05/09/2006] [Indexed: 11/03/2022] Open
Abstract
Fabry disease is an X-linked recessive disorder in which affected persons lack alpha-galactosidase A (alpha -GalA), which leads to excess glycosphingolipids in tissues, mainly globotriaosylceramide (Gb3). Gb3 is the cellular receptor for Shiga toxin (Stx), the primary virulence factor of enterohemorrhagic Escherichia coli. alpha-GalA-knockout mice were significantly protected against lethal intraperitoneal doses of Stx2 or oral doses of Stx2-expressing bacteria, compared with wild-type (wt) control mice. Kidneys of moribund wt mice revealed tubular necrosis, but no histopathologic changes were observed in Gb3-overexpressing mice. Reducing Gb3 levels in alpha-GalA-knockout mice by the intravenous injection of recombinant human alpha-GalA restored the susceptibility of knockout mice to lethal doses of Stx2. These results suggest that excess amounts of Gb3 in alpha-GalA-deficient mice may impair toxin delivery to susceptible tissues.
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Affiliation(s)
- Salvatore A Cilmi
- Infectious Disease Division, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
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Zhu C, Ruiz-Perez F, Yang Z, Mao Y, Hackethal VL, Greco KM, Choy W, Davis K, Butterton JR, Boedeker EC. Delivery of heterologous protein antigens via hemolysin or autotransporter systems by an attenuated ler mutant of rabbit enteropathogenic Escherichia coli. Vaccine 2006; 24:3821-31. [PMID: 16098637 DOI: 10.1016/j.vaccine.2005.07.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In this report, we describe the use of an attenuated regulatory mutant of a rabbit enteropathogenic Escherichia coli (rEPEC) as a live vaccine vector to deliver heterologous protein antigens using two dedicated transport systems, a Salmonella autotransporter and the E. coli hemolysin apparatus. We previously reported that an isogeneic ler (LEE encoded regulator) mutant of rEPEC O103:H2 is attenuated and immunogenic in rabbits. We first evaluated the Salmonella autotransporter MisL containing the immunodominant B-cell epitope of the circumsporozoite protein from Plasmodium falciparum, (NANP)8, fused to the C-terminal translocator domain under the control of the constitutive Tac17 promoter. The rEPEC ler mutant was able to express and to translocate the (NANP)8 passenger peptide to the bacterial surface. We next investigated the delivery of Shiga toxin B subunit (Stx1B) from human enterohemorrhagic E. coli by the rEPEC ler mutant via the MisL autotransporter or the E. coli hemolysin secretion apparatus. The autotransporter and hemolysin plasmids expressed similar levels of Stx1B (30-40 ng/ml/OD600). Only 6% of Stx1B was found in the autotransporter supernatants; the rest was cell-associated, with a small fraction of the Stx1B surface-exposed as determined by immunofluorescence. In contrast, 88% of Stx1B was secreted into culture supernatants by the hemolysin secretion system. In an in vivo study, no significant protection was observed in rabbits inoculated with the ler mutant harboring the Stx1B-autotransporter plasmid following experimental challenge with RDEC-H19A, the prototype rEPEC containing an Stx-converting phage. In contrast, rabbits inoculated with the rEPEC ler mutant containing the Stx1B-hemolysin fusion were partially protected from RDEC-H19A infection as demonstrated by decreased weight loss (p<0.008) when compared to rabbits inoculated with the parent ler mutant. Our results suggest that attenuated rEPEC are capable of serving as vaccine vectors to express heterologous protein antigens from different cellular locations and deliver these antigens to the intestinal mucosa. With this system, secreted proteins may be more effective than cell-associated antigens in generating protection.
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MESH Headings
- Animals
- Bacterial Proteins/genetics
- Bacterial Proteins/immunology
- Bacterial Vaccines/administration & dosage
- Bacterial Vaccines/genetics
- Bacterial Vaccines/immunology
- Cell Membrane/chemistry
- Electrophoresis, Polyacrylamide Gel
- Epitopes, B-Lymphocyte/genetics
- Epitopes, B-Lymphocyte/immunology
- Epitopes, B-Lymphocyte/metabolism
- Escherichia coli/chemistry
- Escherichia coli/genetics
- Escherichia coli/immunology
- Escherichia coli Infections/pathology
- Escherichia coli Infections/prevention & control
- Escherichia coli Proteins/genetics
- Escherichia coli Proteins/immunology
- Escherichia coli Proteins/metabolism
- Escherichia coli Vaccines/administration & dosage
- Escherichia coli Vaccines/genetics
- Escherichia coli Vaccines/immunology
- Feces/microbiology
- Genetic Vectors
- Hemolysin Proteins
- Immunity, Mucosal
- Membrane Transport Proteins/genetics
- Membrane Transport Proteins/immunology
- Plasmids
- Plasmodium falciparum/immunology
- Protein Transport
- Protozoan Proteins/genetics
- Protozoan Proteins/immunology
- Rabbits
- Recombinant Fusion Proteins/genetics
- Recombinant Fusion Proteins/immunology
- Recombinant Fusion Proteins/metabolism
- Shiga Toxin 1/genetics
- Shiga Toxin 1/immunology
- Shiga Toxin 1/metabolism
- Trans-Activators/genetics
- Vaccines, Attenuated/administration & dosage
- Vaccines, Attenuated/genetics
- Vaccines, Attenuated/immunology
- Vaccines, Synthetic/administration & dosage
- Vaccines, Synthetic/immunology
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Affiliation(s)
- Chengru Zhu
- Center for Vaccine Development, University of Maryland School of Medicine, 685 West Baltimore Street, Baltimore, MD 21201, USA
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