On March 24, 2014, Michael Hoelscher (LMU) presented “Advances in New TB Drug Development”, Tim McHugh (UCL) “Approaches to Monitoring Therapy” and Patrick Phillips (MRC CTU) “Drug Resistance vs. Drug Sensitive Trials “ at the “World TB Day – Reach the 3 Million” in London (www.who.int/campaigns/tb-day/2014/en). This conference, which was a joint venture between University College London (UCL) and the London School of Hygiene and Tropical Medicine (LSHTM), offered a platform to raise the awareness about the pandemic tuberculosis (TB) worldwide and presents the most current research of TB prevention and control efforts.
For a video of the presentations please see http://tb.lshtm.ac.uk/world-tb-day-2014-symposium-slides-and-video.
On March 24 (on World TB Day), the MAMS TB-01 Study has completed enrolment ahead of schedule! We congratulate and thank everybody in achieving this goal prior to the target cut-off date of 31 March 2014. 365 patients have been enrolled in 4 South African and 3 Tanzanian sites.
PanACEA, the Pan-African Consortium for the Evaluation of Antituberculosis Antibiotics aims to develop TB regimens that significantly shorten treatment duration, funded by EDCTP. The consortium’s most recent phase IIb study (MAMS-TB-01) uses an innovative adaptive clinical trial design that allows the efficient evaluation of multiple regimens by incorporating interim analyses that allow for the early exclusion of regimens that show little treatment shortening potential.
Following the first scheduled interim analysis on March 3rd, the Trial Steering Committee (TSC) followed a recommendation of the independent data monitoring committee (IDMC) and has stopped the enrolment into two of the arms in the MAMS-TB trial: HRZQ and HR20ZQ. Patients that have already been enrolled into these arms will continue as laid out in the protocol.
The IDMC reviewed safety and efficacy data extensively including a number of sensitivity analyses and secondary efficacy endpoints. To-date the time at which patients have a negative culture is the best indication of future cure. Only treatment combinations that show a significant improvement in the speed at which they render patients culture negative are likely to shorten treatment. The predefined stopping rules of the MAMS trial were set to allow for early exclusion of regimens that were not likely to reach a hazard ratio of at least 1.8 at the end of the trial. This was based on the results from a study that evaluated a moxifloxacin substitution being studied in the ReMOXTB phase III trial that showed a hazard ratio of 1.68 (the OFLOTUB phase II trial). They recommended that recruitment to arm 2 (HRZQ) and 3 (HR20ZQ; see below) be terminated as there was insufficient evidence that these regimens could shorten treatment. Importantly, there was no evidence that either arm was inferior to standard treatment (the control arm) with regards to efficacy. There was, however, sufficient evidence that the other intervention arms HR35ZE and HR20ZM could shorten treatment to continue enrolling patients.
Since there were no indications of safety or inferiority concerns for SQ109, Sequella and partners will now undertake dose escalation and drug-drug interaction studies to see if a higher dose has potential to make a larger impact on sputum clearance. Analyses of intensive pharmacokinetics of SQ109 in combination with other drugs, especially rifampicin, will be used to determine the relationship between drug levels and bactericidal effects.
This result illustrates the strength of the MAMS approach, as normally the IDMC would not have recommended stopping these arms as there were no safety or inferiority concerns. The pre-specified stopping guidelines allowed the TSC the opportunity to stop these arms early, thereby saving resources and limiting the number of patients allocated to these regimens. This is an important consideration that reduces the number of patients enrolled in studies or arms that are unlikely to result in improved treatments and will speed the development of new TB medicines in the future.
The PanACEA consortium (http://panacea-tb.net/) is a partnership of 11 African and 7 European institutions and is led by three Chief Investigators at University of St. Andrews, Scotland (Prof. Stephen Gillespie), Radboud University Nijmegen / the Netherlands (Prof. Martin Boeree) and Ludwig Maximilians University, Munich / Germany (Prof. Michael Hoelscher). UCL is a major partner with the MRC-CTU at UCL and the Centre for Clinical Microbiology. The MAMS phase IIb trial started in May 2013 and aimed to enroll 372 patients into four intervention and the control arm.
|Control:||HRZE ||isoniazid, rifampicin standard, pyrazinamide, ethambutol
|Arm 1 (R35):||HR35ZE||isoniazid, rifampicin 35 mg/kg, pyrazinamide, ethambutol
|Arm 2 (Q):||HRZQ||isoniazid, rifampicin standard, pyrazinamide, SQ109 300 mg
|Arm 3 (R20Q): ||HR20ZQ||isoniazid, rifampicin 20 mg/kg, pyrazinamide, SQ109 300 mg
|Arm 4 (R20M):||HR20ZM||isoniazid, rifampicin 20 mg/kg, pyrazinamide, moxifloxacin 400 mg
For more information on the study please see: ClinicalTrials.gov – Identifier: NCT01785186
Clinical Ink, in collaboration with PanACEA, received an award for their SureSource platform, a tablet-based system that allows onsite capturing and reporting of clinical trial data in regions remote from city centers. The winners of Clinical Informatics News’ first annual Best Practices Awards were announced at the 2014 Summit for Clinical Ops Executives in Miami. The prize for the category of “Study Startup and Design” was awarded to Clinical Ink for their platform, which mimics the look and feel of paper forms to improve ease of use while providing real-time data validation, and its use in a tuberculosis treatment trial in sites across Tanzania and South Africa, connecting far-flung sites with limited connectivity and clinical trial resources to academic centers where data could be reviewed and interpreted.
For more information please see: http://www.clinicalinformaticsnews.com/2014/2/6/best-practices-awards-recognize-excellence-clinical-it.html.
PanACEA investigators collaborate on comprehensive TB drug development review for Lancet Infectious Diseases special issue for World TB Day. http://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2813%2970328-1/fulltext#
Last fall, the World Health Organization (WHO) published the latest global report on tuberculosis (TB). It provides a comprehensive and up-to-date assessment of the TB epidemic and of the progress made in TB prevention, care and control at global, regional and country level, using data reported by 197 countries and territories that account collectively for over 99% of the TB cases in the world.
On page 92, the MAMTS-TB-01 trial from the PanACEA Consortium is mentioned in the chapter about new regimens in phase II trials.
For more information, please see http://www.who.int/tb/publications/global_report/en/.
PanACEA’s MAMS study continues to enroll patients rapidly. By mid-October more than 200 of the required 372 patients have been enrolled. Recruitment is thus ahead of target.
The 5th Annual PanACEA Meeting has been held on Ile de Gorée / Dakar, Senegal from 19-21 Oct 2013, just preceeding the 7th EDCTP Forum.
Inspite of a couple of logistical challenges with colleagues travelling from all corners of Africa, Europe and the US to Gorée island the meeting has been a great success. PanACEA has geared up for its final year of the current EDCTP grant and has set the framework and a clearly defined vision for PanACEA II. Exciting new ideas for an accelerated pathway to new TB therapies were brought to the table and strategies for a lean, yet inclusive, governance structure permitting rapid decision making have been devised. We are thrilled about the prospects of a more mature and comprehensive PanACEA II at the forefront of TB drug research and will be working hard over the next few months to set the course for the future.