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Iroh Tam P, Arnold SLM, Barrett LK, Chen CR, Conrad TM, Douglas E, Gordon MA, Hebert D, Henrion M, Hermann D, Hollingsworth B, Houpt E, Jere KC, Lindblad R, Love MS, Makhaza L, McNamara CW, Nedi W, Nyirenda J, Operario DJ, Phulusa J, Quinnan GV, Sawyer LA, Thole H, Toto N, Winter A, Van Voorhis WC. Clofazimine for Treatment of Cryptosporidiosis in Human Immunodeficiency Virus Infected Adults: An Experimental Medicine, Randomized, Double-blind, Placebo-controlled Phase 2a Trial. Clin Infect Dis 2021; 73:183-191. [PMID: 32277809 PMCID: PMC8282326 DOI: 10.1093/cid/ciaa421] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [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: 12/29/2019] [Accepted: 04/09/2020] [Indexed: 01/01/2023] Open
Abstract
Background We evaluated the efficacy, pharmacokinetics (PK), and safety of clofazimine (CFZ) in patients living with human immunodeficiency virus (HIV) with cryptosporidiosis. Methods We performed a randomized, double-blind, placebo-controlled study. Primary outcomes in part A were reduction in Cryptosporidium shedding, safety, and PK. Primary analysis was according to protocol (ATP). Part B of the study compared CFZ PK in matched individuals living with HIV without cryptosporidiosis. Results Twenty part A and 10 part B participants completed the study ATP. Almost all part A participants had high viral loads and low CD4 counts, consistent with failure of antiretroviral (ARV) therapy. At study entry, the part A CFZ group had higher Cryptosporidium shedding, total stool weight, and more diarrheal episodes compared with the placebo group. Over the inpatient period, compared with those who received placebo, the CFZ group Cryptosporidium shedding increased by 2.17 log2 Cryptosporidium per gram stool (95% upper confidence limit, 3.82), total stool weight decreased by 45.3 g (P = .37), and number of diarrheal episodes increased by 2.32 (P = .87). The most frequent solicited adverse effects were diarrhea, abdominal pain, and malaise. One placebo and 3 CFZ participants died during the study. Plasma levels of CFZ in participants with cryptosporidiosis were 2-fold lower than in part B controls. Conclusions Our findings do not support the efficacy of CFZ for the treatment of cryptosporidiosis in a severely immunocompromised HIV population. However, this trial demonstrates a pathway to assess the therapeutic potential of drugs for cryptosporidiosis treatment. Screening persons living with HIV for diarrhea, and especially Cryptosporidium infection, may identify those failing ARV therapy. Clinical Trials Registration NCT03341767.
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Affiliation(s)
- Py Iroh Tam
- Paediatrics and Child Health Research Group, Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - S L M Arnold
- Center for Emerging and Re-emerging Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - L K Barrett
- Center for Emerging and Re-emerging Infectious Diseases, University of Washington, Seattle, Washington, USA
| | | | | | - E Douglas
- Center for Emerging and Re-emerging Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - M A Gordon
- Paediatrics and Child Health Research Group, Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | | | - M Henrion
- Paediatrics and Child Health Research Group, Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - D Hermann
- Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | | | - E Houpt
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - K C Jere
- Paediatrics and Child Health Research Group, Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | | | - M S Love
- Calibr, La Jolla, California, USA
| | - L Makhaza
- Paediatrics and Child Health Research Group, Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - W Nedi
- Paediatrics and Child Health Research Group, Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - J Nyirenda
- Paediatrics and Child Health Research Group, Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - D J Operario
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - J Phulusa
- Paediatrics and Child Health Research Group, Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | | | - H Thole
- Paediatrics and Child Health Research Group, Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - N Toto
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | - W C Van Voorhis
- Center for Emerging and Re-emerging Infectious Diseases, University of Washington, Seattle, Washington, USA
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Jumani RS, Bessoff K, Love MS, Miller P, Stebbins EE, Teixeira JE, Campbell MA, Meyers MJ, Zambriski JA, Nunez V, Woods AK, McNamara CW, Huston CD. A Novel Piperazine-Based Drug Lead for Cryptosporidiosis from the Medicines for Malaria Venture Open-Access Malaria Box. Antimicrob Agents Chemother 2018; 62:e01505-17. [PMID: 29339392 PMCID: PMC5913971 DOI: 10.1128/aac.01505-17] [Citation(s) in RCA: 38] [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: 07/24/2017] [Accepted: 01/05/2018] [Indexed: 12/21/2022] Open
Abstract
Cryptosporidiosis causes life-threatening diarrhea in children under the age of 5 years and prolonged diarrhea in immunodeficient people, especially AIDS patients. The standard of care, nitazoxanide, is modestly effective in children and ineffective in immunocompromised individuals. In addition to the need for new drugs, better knowledge of drug properties that drive in vivo efficacy is needed to facilitate drug development. We report the identification of a piperazine-based lead compound for Cryptosporidium drug development, MMV665917, and a new pharmacodynamic method used for its characterization. The identification of MMV665917 from the Medicines for Malaria Venture Malaria Box was followed by dose-response studies, in vitro toxicity studies, and structure-activity relationship studies using commercial analogues. The potency of this compound against Cryptosporidium parvum Iowa and field isolates was comparable to that against Cryptosporidium hominis Furthermore, unlike nitazoxanide, clofazimine, and paromomycin, MMV665917 appeared to be curative in a NOD SCID gamma mouse model of chronic cryptosporidiosis. MMV665917 was also efficacious in a gamma interferon knockout mouse model of acute cryptosporidiosis. To determine if efficacy in this mouse model of chronic infection might relate to whether compounds are parasiticidal or parasitistatic for C. parvum, we developed a novel in vitro parasite persistence assay. This assay suggested that MMV665917 was parasiticidal, unlike nitazoxanide, clofazimine, and paromomycin. The assay also enabled determination of the concentration of the compound required to maximize the rate of parasite elimination. This time-kill assay can be used to prioritize early-stage Cryptosporidium drug leads and may aid in planning in vivo efficacy experiments. Collectively, these results identify MMV665917 as a promising lead and establish a new method for characterizing potential anticryptosporidial agents.
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Affiliation(s)
- R S Jumani
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
- Cellular, Molecular and Biomedical Sciences Graduate Program, University of Vermont, Burlington, Vermont, USA
| | - K Bessoff
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - M S Love
- California Institute for Biomedical Research, La Jolla, California, USA
| | - P Miller
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - E E Stebbins
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - J E Teixeira
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - M A Campbell
- Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - M J Meyers
- Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - J A Zambriski
- Paul G. Allen School for Global Animal Health, College of Veterinary Medicine, Washington State University, Pullman, Washington, USA
| | - V Nunez
- California Institute for Biomedical Research, La Jolla, California, USA
| | - A K Woods
- California Institute for Biomedical Research, La Jolla, California, USA
| | - C W McNamara
- California Institute for Biomedical Research, La Jolla, California, USA
| | - C D Huston
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
- Cellular, Molecular and Biomedical Sciences Graduate Program, University of Vermont, Burlington, Vermont, USA
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