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Linezolid to Treat Extensively-Drug Resistant Tuberculosis

Primary Purpose

Pulmonary Tuberculosis, Multidrug Resistant Tuberculosis, Extensively Drug Resistant Tuberculosis

Status
Completed
Phase
Phase 2
Locations
Korea, Republic of
Study Type
Interventional
Intervention
Immediate Start Linezolid
Delayed Start Linezolid
Sponsored by
National Institute of Allergy and Infectious Diseases (NIAID)
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Pulmonary Tuberculosis focused on measuring XDR-TB, Linezolid, Drug Resistance, Computed Tomography, Pharmacokinetics, Tuberculosis, Drug Resistance Tuberculosis, MDR-TB

Eligibility Criteria

20 Years - undefined (Adult, Older Adult)All SexesDoes not accept healthy volunteers
  • INCLUSION CRITERIA:

Males and females age 20 and above

Documented pulmonary tuberculosis at screening

Radiographic evidence of tuberculous disease of the lung(s)

History of chronic, AFB positive sputum smears and culture positive TB

Mycobacterium species identification as Mycobacterium tuberculosis

Confirmed resistance to INH, RIF, kanamycin, ofloxacin, and moxifloxacin by genotypic or phenotypic testing OR subjects with documented failure to respond to treatment despite DST susceptibility

Failure to respond (after at least 6 months) to a anti-TB drug regimen including any known active agents

Willingness to be an inpatient until 2 consecutive AFB-negative sputum smears

When an outpatient, willing to come back for weekly tests and scheduled follow-up visits

Willingness to have samples stored

Ability and willingness to give written or oral informed consent

EXCLUSION CRITERIA:

Subjects below 20 years of age

Subjects who have previously been on LZD

Women of childbearing potential, who are pregnant, breast feeding, or unwilling to avoid pregnancy (i.e., the use of appropriate contraception including oral and subcutaneous implantable hormonal contraceptives, condoms, diaphragm, intrauterine device (IUD), or abstinence from sexual intercourse). [Note: Prospective female participants of childbearing potential must have negative pregnancy test (urine) within 48 hours prior to study entry.]

Men who are unwilling to use contraceptives or practice abstinence

People with any of the following in their current medical assessments:

Absolute neutrophil count less than 1000 cells/mL

White blood cell count (WBC) less than 3.0 X 10(3)/microL

Hemoglobin less than 7.0 g/dL

Platelet count less than 75,000 cells/mm(3)

Serum creatinine greater than 2.0 mg/dL

Aspartate aminotransferase (AST or SGOT) greater than 100 IU/L

Alanine aminotransferase (ALT or SGPT) greater than 100 IU/L

Total bilirubin greater than 2.0 mg/dL

Moderate or severe peripheral or optical neuropathy (or a history of)

HIV-1 or HIV-2 infection

Systemic lupus erythematosus, rheumatoid arthritis, or other connective tissue disease

Patients who, in the investigator's judgment, are too ill to participate in the study

History of allergy or serious adverse reaction to the LZD formulation used in this study

Patients with anticipated surgical intervention

The use of any of the following drugs within 30 days prior to study or anticipated use of these drugs within the next 60 days: (Please not, bronchodilators and cough syrup (or similar cough medicines) are allowed before and during the study if blood pressure is monitored regularly, per Contraindications, p.12, of the Zyvox Package Insert.)

Selective serotonin reuptake inhibitors (SSRIs)

Monoamine oxidase inhibitors (MAOIs)

Systemic cancer chemotherapy

Systemic corticosteroids

Systemic investigational agents

Antiretroviral medications

Growth factors

HIV vaccines

Immune globulin

Interleukins

Interferons

The need for ongoing therapy with antidepressants (SSRI, MAOI), hydroxyzine, dopaminergic agents (such as Sinemet, dopamine, and dobutamine), lithium, cyclosporine, tacrolimus, sirolimus, and levodopa (such as sinemet) while on study drug

Any other serious systemic illness requiring treatment and/or hospitalization until subject either completes therapy or is clinically stable on therapy for at least 14 days prior to study entry

Patients who the physician has reason to believe may have been non-compliant in the previous 12 months of treatment

SUBSTUDY ELIGIBILITY CRITERIA

INCLUSION CRITERIA:

Subjects who meet the inclusion criteria for main study are eligible for the substudy.

EXCLUSION CRITERIA:

Exclusion criteria for main study apply to the substudy with the exception that subjects with uncontrolled diabetes mellitus will be excluded from the substudy. The study physician may decide that a patient is healthy enough to participate in the main study but not the sub-study.

Sites / Locations

  • National Masan Tuberculosis Hospital
  • National Medical Center

Arms of the Study

Arm 1

Arm 2

Arm Type

Experimental

Experimental

Arm Label

Delayed Start Linezolid

Immediate Start Linezolid

Arm Description

Subjects continued their existing regimen for 2 months after which LZD (600 mg once daily) was added. After 2 consecutive AFB negative sputum smears (not to exceed 4 months of LZD therapy), subjects were randomized to continue on 600 mg LZD once daily or to de-escalate to 300 mg once daily. Regardless of the dosage, subjects remained on LZD treatment for 18 months after sputum culture conversion or until they could no longer tolerate therapy.

Upon completion of entry criteria, subjects had LZD (600 mg once daily) added to their regimen. After 2 consecutive AFB negative sputum smears (or at 4 months) subjects were randomized to continue on 600 mg LZD once daily or to de-escalate to 300 mg once daily. Regardless of the dosage, subjects remained on LZD treatment for 18 months after sputum culture conversion or until they could no longer tolerate therapy.

Outcomes

Primary Outcome Measures

Number of Patients Converted to Sputum Culture Negative in Each Arm, With Data Censored at 4 Months.

Secondary Outcome Measures

Full Information

First Posted
August 1, 2008
Last Updated
February 12, 2016
Sponsor
National Institute of Allergy and Infectious Diseases (NIAID)
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1. Study Identification

Unique Protocol Identification Number
NCT00727844
Brief Title
Linezolid to Treat Extensively-Drug Resistant Tuberculosis
Official Title
A Phase 2a, Randomized, 2-Arm, Open-Label, Clinical Trial of the Efficacy of Linezolid Combined With Antituberculous Therapy in Subjects With Extensively Drug-Resistant (XDR) Pulmonary Tuberculosis
Study Type
Interventional

2. Study Status

Record Verification Date
May 2014
Overall Recruitment Status
Completed
Study Start Date
July 2008 (undefined)
Primary Completion Date
October 2012 (Actual)
Study Completion Date
November 2014 (Actual)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Principal Investigator
Name of the Sponsor
National Institute of Allergy and Infectious Diseases (NIAID)

4. Oversight

Data Monitoring Committee
Yes

5. Study Description

Brief Summary
This study, conducted in Masan and Seoul, South Korea, investigated the effectiveness of linezolid (LZD) in treating patients with extensively drug resistant tuberculosis (XDR TB). Because regular medicines do not work well against XDR TB, many more people die from it than from regular TB, which can be successfully treated by taking TB medication for 6 months. Linezolid has been used to treat other kinds of infections, but has not been well studied for TB. This study examined the side effects and effectiveness of prolonged treatment with linezolid at two different doses. People 20 years of age and older who have XDR TB were eligible for this 3-year study. Participants underwent the following tests and procedures: LZD treatment: Patients were randomly assigned to one of two study groups. Group 1 patients were observed for 2 months before starting LZD, while group 2 patients begin taking LZD right away. Both groups began with a 600 mg daily dose of LZD. After patients stopped coughing up TB germs (or after 4 months on LZD) they were randomly assigned either to continue taking 600 mg of LZD for the rest of the study or to take a decreased dose of 300 mg. In addition to LZD, patients continued to take their currently prescribed TB medications. Medical history. Physical examinations each month during treatment. Sputum collections once a week or more until 3 weeks after the patient was no longer contagious. Blood draws every week for 16 to 24 weeks and then once a month. Urine collections at several time points. Nerve and eye examinations before starting treatment and then monthly to look for possible LZD side effects. CT scans of the lungs three to four times the first year and once more later in the study. For this test the patient lay on a table within the doughnut-shaped CT scanner while special X-ray pictures are taken. Patients who participated in a substudy had PET scans instead of the CT scans. For this test, the patient was given an injection into a vein of a radioactive chemical that can be detected by a special camera and viewed on a screen. The patient lay on a table within the doughnut-shaped scanner while pictures were taken.
Detailed Description
World-wide, there is an increasing incidence of multi-drug resistant tuberculosis (MDR-TB) and extensively drug-resistant TB (XDR-TB). For patients diagnosed with either of these deadly diseases, effective drug treatment options are sub-optimal or non-existent. In South Korea, there are a growing number of patients not responding to any therapy who have little hope for survival without new drugs. Linezolid (LZD), an antimicrobial approved for gram positive bacterial infections, has been used off-label for drug resistant TB and is quickly becoming a sought after drug for this population, despite lack of clinical evidence of efficacy. At the present time the prohibitive cost of LZD limits widespread use; however, when patent exclusivity expires in May of 2015 it will be imperative to have examined the benefits versus risks of LZD for TB in a controlled setting. The National Masan Tuberculosis Hospital (NMTH) in Masan, South Korea and the National Medical Center in Seoul, South Korea provide us with an opportunity to systematically address questions about LZD in a highly drug-resistant population. This is a Phase 2a, randomized, 2-arm study of LZD, which evaluated the efficacy, safety, and tolerability of LZD in subjects whose isolates have shown resistance to all known active TB drugs or who have failed to respond to any active drugs to which they are susceptible. Subjects were required to have been on a failing regimen for at least 6 months prior to study entry, with persistent sputum smear positivity, culture positivity and no significant clinical sign of response to therapy. To be considered for the study, a subject's treatment plan must have been stable without the addition of drugs to which the subjects isolate was suspected to be sensitive: however drugs may have been discontinued during this time. Subjects were stratified based upon a diagnosis of diabetes mellitus (type I and II included) using block randomization. At the primary randomization, subjects were randomly assigned either to immediately add 600 mg LZD once daily to their existing regimen or to a delay of 2 months before adding 600 mg LZD once daily to their existing regimen. A second randomization occurred after 2 consecutive negative sputum smears or at 4 months after the start of LZD therapy (whichever came first), when subjects either stayed with their current 600 mg LZD once daily or de-escalated to 300 mg LZD once daily (see Section 4.1.4 Study Schema). The second randomization was stratified on diabetes. The primary objective of this study was to evaluate the efficacy of LZD therapy, as measured by sputum culture conversion. Secondary aims of this study included: investigation of the pharmacokinetic and pharmacodynamic profiles of LZD in blood; tolerability and toxicity of prolonged LZD administration at doses of 300 mg and 600 mg daily; the rate of change of radiological findings by computed tomography (CT); the rate of relapse 12 months after discontinuation of therapy; the rate of development of drug resistance to LZD; changes in immunologic and bacterial lipid markers during LZD therapy; the correlation of whole-blood killing assays with response to LZD therapy; and effects of LZD on mitochondrial function, a potential early indicator of LZD toxicity. In a substudy, we aimed to investigate the changes in lung architecture and cellular activity during treatment using F-fluoro-2-deoxy-D-glucose - positron emission tomography-computed tomography (FDG-PET-CT) of 20 subjects on LZD therapy. Estimated total study duration for each subject was approximately 3 years.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Pulmonary Tuberculosis, Multidrug Resistant Tuberculosis, Extensively Drug Resistant Tuberculosis
Keywords
XDR-TB, Linezolid, Drug Resistance, Computed Tomography, Pharmacokinetics, Tuberculosis, Drug Resistance Tuberculosis, MDR-TB

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 2
Interventional Study Model
Parallel Assignment
Masking
None (Open Label)
Allocation
Randomized
Enrollment
41 (Actual)

8. Arms, Groups, and Interventions

Arm Title
Delayed Start Linezolid
Arm Type
Experimental
Arm Description
Subjects continued their existing regimen for 2 months after which LZD (600 mg once daily) was added. After 2 consecutive AFB negative sputum smears (not to exceed 4 months of LZD therapy), subjects were randomized to continue on 600 mg LZD once daily or to de-escalate to 300 mg once daily. Regardless of the dosage, subjects remained on LZD treatment for 18 months after sputum culture conversion or until they could no longer tolerate therapy.
Arm Title
Immediate Start Linezolid
Arm Type
Experimental
Arm Description
Upon completion of entry criteria, subjects had LZD (600 mg once daily) added to their regimen. After 2 consecutive AFB negative sputum smears (or at 4 months) subjects were randomized to continue on 600 mg LZD once daily or to de-escalate to 300 mg once daily. Regardless of the dosage, subjects remained on LZD treatment for 18 months after sputum culture conversion or until they could no longer tolerate therapy.
Intervention Type
Drug
Intervention Name(s)
Immediate Start Linezolid
Other Intervention Name(s)
Zyvox
Intervention Type
Drug
Intervention Name(s)
Delayed Start Linezolid
Other Intervention Name(s)
Zyvox
Primary Outcome Measure Information:
Title
Number of Patients Converted to Sputum Culture Negative in Each Arm, With Data Censored at 4 Months.
Time Frame
Sputum smear conversion or max 4 months after the start of Linezolid therapy.

10. Eligibility

Sex
All
Minimum Age & Unit of Time
20 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
INCLUSION CRITERIA: Males and females age 20 and above Documented pulmonary tuberculosis at screening Radiographic evidence of tuberculous disease of the lung(s) History of chronic, AFB positive sputum smears and culture positive TB Mycobacterium species identification as Mycobacterium tuberculosis Confirmed resistance to INH, RIF, kanamycin, ofloxacin, and moxifloxacin by genotypic or phenotypic testing OR subjects with documented failure to respond to treatment despite DST susceptibility Failure to respond (after at least 6 months) to a anti-TB drug regimen including any known active agents Willingness to be an inpatient until 2 consecutive AFB-negative sputum smears When an outpatient, willing to come back for weekly tests and scheduled follow-up visits Willingness to have samples stored Ability and willingness to give written or oral informed consent EXCLUSION CRITERIA: Subjects below 20 years of age Subjects who have previously been on LZD Women of childbearing potential, who are pregnant, breast feeding, or unwilling to avoid pregnancy (i.e., the use of appropriate contraception including oral and subcutaneous implantable hormonal contraceptives, condoms, diaphragm, intrauterine device (IUD), or abstinence from sexual intercourse). [Note: Prospective female participants of childbearing potential must have negative pregnancy test (urine) within 48 hours prior to study entry.] Men who are unwilling to use contraceptives or practice abstinence People with any of the following in their current medical assessments: Absolute neutrophil count less than 1000 cells/mL White blood cell count (WBC) less than 3.0 X 10(3)/microL Hemoglobin less than 7.0 g/dL Platelet count less than 75,000 cells/mm(3) Serum creatinine greater than 2.0 mg/dL Aspartate aminotransferase (AST or SGOT) greater than 100 IU/L Alanine aminotransferase (ALT or SGPT) greater than 100 IU/L Total bilirubin greater than 2.0 mg/dL Moderate or severe peripheral or optical neuropathy (or a history of) HIV-1 or HIV-2 infection Systemic lupus erythematosus, rheumatoid arthritis, or other connective tissue disease Patients who, in the investigator's judgment, are too ill to participate in the study History of allergy or serious adverse reaction to the LZD formulation used in this study Patients with anticipated surgical intervention The use of any of the following drugs within 30 days prior to study or anticipated use of these drugs within the next 60 days: (Please not, bronchodilators and cough syrup (or similar cough medicines) are allowed before and during the study if blood pressure is monitored regularly, per Contraindications, p.12, of the Zyvox Package Insert.) Selective serotonin reuptake inhibitors (SSRIs) Monoamine oxidase inhibitors (MAOIs) Systemic cancer chemotherapy Systemic corticosteroids Systemic investigational agents Antiretroviral medications Growth factors HIV vaccines Immune globulin Interleukins Interferons The need for ongoing therapy with antidepressants (SSRI, MAOI), hydroxyzine, dopaminergic agents (such as Sinemet, dopamine, and dobutamine), lithium, cyclosporine, tacrolimus, sirolimus, and levodopa (such as sinemet) while on study drug Any other serious systemic illness requiring treatment and/or hospitalization until subject either completes therapy or is clinically stable on therapy for at least 14 days prior to study entry Patients who the physician has reason to believe may have been non-compliant in the previous 12 months of treatment SUBSTUDY ELIGIBILITY CRITERIA INCLUSION CRITERIA: Subjects who meet the inclusion criteria for main study are eligible for the substudy. EXCLUSION CRITERIA: Exclusion criteria for main study apply to the substudy with the exception that subjects with uncontrolled diabetes mellitus will be excluded from the substudy. The study physician may decide that a patient is healthy enough to participate in the main study but not the sub-study.
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Clifton Barry, Ph.D.
Organizational Affiliation
National Institute of Allergy and Infectious Diseases (NIAID)
Official's Role
Principal Investigator
Facility Information:
Facility Name
National Masan Tuberculosis Hospital
City
Changwon
Country
Korea, Republic of
Facility Name
National Medical Center
City
Seoul
Country
Korea, Republic of

12. IPD Sharing Statement

Citations:
PubMed Identifier
17242139
Citation
Richter E, Rusch-Gerdes S, Hillemann D. First linezolid-resistant clinical isolates of Mycobacterium tuberculosis. Antimicrob Agents Chemother. 2007 Apr;51(4):1534-6. doi: 10.1128/AAC.01113-06. Epub 2007 Jan 22.
Results Reference
background
PubMed Identifier
18070973
Citation
Hillemann D, Rusch-Gerdes S, Richter E. In vitro-selected linezolid-resistant Mycobacterium tuberculosis mutants. Antimicrob Agents Chemother. 2008 Feb;52(2):800-1. doi: 10.1128/AAC.01189-07. Epub 2007 Dec 10. No abstract available.
Results Reference
background
PubMed Identifier
15451500
Citation
Duncan K, Barry CE 3rd. Prospects for new antitubercular drugs. Curr Opin Microbiol. 2004 Oct;7(5):460-5. doi: 10.1016/j.mib.2004.08.011.
Results Reference
background
PubMed Identifier
23075177
Citation
Lee M, Lee J, Carroll MW, Choi H, Min S, Song T, Via LE, Goldfeder LC, Kang E, Jin B, Park H, Kwak H, Kim H, Jeon HS, Jeong I, Joh JS, Chen RY, Olivier KN, Shaw PA, Follmann D, Song SD, Lee JK, Lee D, Kim CT, Dartois V, Park SK, Cho SN, Barry CE 3rd. Linezolid for treatment of chronic extensively drug-resistant tuberculosis. N Engl J Med. 2012 Oct 18;367(16):1508-18. doi: 10.1056/NEJMoa1201964.
Results Reference
result

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Linezolid to Treat Extensively-Drug Resistant Tuberculosis

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