1
|
Davis AG, Wasserman S, Stek C, Maxebengula M, Liang CJ, Stegmann S, Koekemoer S, Jackson A, Kadernani Y, Bremer M, Daroowala R, Aziz S, Goliath R, Sai LL, Sihoyiya T, Denti P, Lai RP, Crede T, Naude J, Szymanski P, Vallie Y, Banderker IA, Moosa MS, Raubenheimer P, Candy S, Offiah C, Wahl G, Vorster I, Maartens G, Black J, Meintjes G, Wilkinson RJ. A phase 2A trial of the safety and tolerability of increased dose rifampicin and adjunctive linezolid, with or without aspirin, for HIV-associated tuberculous meningitis (The LASER-TBM Trial). Clin Infect Dis 2022; 76:1412-1422. [PMID: 36482216 PMCID: PMC10110270 DOI: 10.1093/cid/ciac932] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/12/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Drug regimens which include intensified antibiotics alongside effective anti-inflammatory therapies may improve outcomes in Tuberculous Meningitis (TBM). Safety data on their use in combination and in the context of HIV is needed to inform clinical trial design. METHODS We conducted a phase 2 open-label parallel-design RCT to assess safety of high-dose rifampicin, linezolid and high-dose aspirin in HIV-associated TBM. Participants were randomised (1.4:1:1) to three treatment arms (arm 1, standard of care (SOC); arm 2 SOC + additional rifampicin (up to 35mg/kg/day)) + linezolid 1200mg/day reducing after 28/7 to 600mg/day; arm 3, as per arm 2 + aspirin 1000mg/day) for 56 days, when the primary outcome of adverse events of special interest (AESI) or death was assessed. RESULTS 52 participants with HIV-associated TBM were randomised. 59% had mild disease (MRC Grade 1) vs 39% (Grade 2) vs 2% (Grade 3). 33% had microbiologically-confirmed TBM; 41% 'possible', 25% 'probable'. AESI or death occurred in 10/16 (63%) (arm 3) vs 4/14 (29%) (arm 2) vs 6/20 (30%) (arm 1) (p = 0.083). The cumulative proportion of AESI or death (Kaplan-Meier) demonstrated worse outcomes in arm 3 vs arm 1 (p = 0.04), however only one event in arm 3 was attributable to aspirin and was mild. There was no difference in efficacy (modified Rankin scale) at day 56 between arms. CONCLUSIONS High-dose rifampicin and adjunctive linezolid can safely be added to SOC in HIV-associated TBM. Larger studies are required to evaluate whether potential toxicity associated with these interventions, particularly high-dose aspirin, is outweighed by mortality or morbidity benefit.
Collapse
Affiliation(s)
- Angharad G Davis
- The Francis Crick Institute, Midland Road, London, NW1 1AT, United Kingdom.,Faculty of Life Sciences, University College London, WC1E 6BT, United Kingdom.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa.,Department of Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Cari Stek
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa.,Department of Infectious Diseases, Imperial College London, W12 0NN, United Kingdom
| | - Mpumi Maxebengula
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - C Jason Liang
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Maryland, USA
| | - Stephani Stegmann
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Sonya Koekemoer
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Amanda Jackson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Yakub Kadernani
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Marise Bremer
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Remy Daroowala
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa.,Department of Infectious Diseases, Imperial College London, W12 0NN, United Kingdom
| | - Saalikha Aziz
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Rene Goliath
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Louise Lai Sai
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Thandi Sihoyiya
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Paolo Denti
- The Francis Crick Institute, Midland Road, London, NW1 1AT, United Kingdom.,Department of Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Rachel Pj Lai
- The Francis Crick Institute, Midland Road, London, NW1 1AT, United Kingdom.,Department of Infectious Diseases, Imperial College London, W12 0NN, United Kingdom
| | - Thomas Crede
- Mitchells Plain Hospital, 8 A Z Berman Drive, Lentegeur, Cape Town, 7785, South Africa
| | - Jonathan Naude
- Mitchells Plain Hospital, 8 A Z Berman Drive, Lentegeur, Cape Town, 7785, South Africa
| | - Patryk Szymanski
- Mitchells Plain Hospital, 8 A Z Berman Drive, Lentegeur, Cape Town, 7785, South Africa
| | - Yakoob Vallie
- New Somerset Hospital, Portswood Rd, Green Point, Cape Town, 8051, South Africa
| | | | - Muhammed S Moosa
- New Somerset Hospital, Portswood Rd, Green Point, Cape Town, 8051, South Africa
| | - Peter Raubenheimer
- Department of Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Sally Candy
- Division of Diagnostic Radiology, University of Cape Town, Groote Schuur Hospital, Observatory 7925, Republic of South Africa
| | - Curtis Offiah
- Department of Neuroradiology, Imaging Department, Royal London Hospital, Barts Health NHS Trust, Whitechapel, London, E1 1BB, United Kingdom
| | - Gerda Wahl
- Department of Medicine, Walter Sisulu University, Mthatha 5117, Republic of South Africa
| | - Isak Vorster
- Division of Diagnostic Radiology, University of Cape Town, Groote Schuur Hospital, Observatory 7925, Republic of South Africa
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa.,Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - John Black
- Department of Medicine, Walter Sisulu University, Mthatha 5117, Republic of South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa.,Department of Medicine, University of Cape Town, Observatory 7925, Republic of South Africa
| | - Robert J Wilkinson
- The Francis Crick Institute, Midland Road, London, NW1 1AT, United Kingdom.,Faculty of Life Sciences, University College London, WC1E 6BT, United Kingdom.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa.,Department of Medicine, University of Cape Town, Observatory 7925, Republic of South Africa.,Department of Infectious Diseases, Imperial College London, W12 0NN, United Kingdom
| |
Collapse
|
3
|
Davis AG, Wasserman S, Maxebengula M, Stek C, Bremer M, Daroowala R, Aziz S, Goliath R, Stegmann S, Koekemoer S, Jackson A, Lai Sai L, Kadernani Y, Sihoyiya T, Liang CJ, Dodd L, Denti P, Crede T, Naude J, Szymanski P, Vallie Y, Banderker I, Moosa S, Raubenheimer P, Lai RPJ, Joska J, Nightingale S, Dreyer A, Wahl G, Offiah C, Vorster I, Candy S, Robertson F, Meintjes E, Maartens G, Black J, Meintjes G, Wilkinson RJ. Study protocol for a phase 2A trial of the safety and tolerability of increased dose rifampicin and adjunctive linezolid, with or without aspirin, for HIV-associated tuberculous meningitis [LASER-TBM]. Wellcome Open Res 2021; 6:136. [PMID: 34286103 PMCID: PMC8283551 DOI: 10.12688/wellcomeopenres.16783.1] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Tuberculous meningitis (TBM) is the most lethal form of tuberculosis with a mortality of ~50% in those co-infected with HIV-1. Current antibiotic regimens are based on those known to be effective in pulmonary TB and do not account for the differing ability of the drugs to penetrate the central nervous system (CNS). The host immune response drives pathology in TBM, yet effective host-directed therapies are scarce. There is sufficient data to suggest that higher doses of rifampicin (RIF), additional linezolid (LZD) and adjunctive aspirin (ASA) will be beneficial in TBM yet rigorous investigation of the safety of these interventions in the context of HIV associated TBM is required. We hypothesise that increased dose RIF, LZD and ASA used in combination and in addition to standard of care for the first 56 days of treatment with be safe and tolerated in HIV-1 infected people with TBM. Methods: In an open-label randomised parallel study, up to 100 participants will receive either; i) standard of care (n=40, control arm), ii) standard of care plus increased dose RIF (35mg/kg) and LZD (1200mg OD for 28 days, 600mg OD for 28 days) (n=30, experimental arm 1), or iii) as per experimental arm 1 plus additional ASA 1000mg OD (n=30, experimental arm 2). After 56 days participants will continue standard treatment as per national guidelines. The primary endpoint is death and the occurrence of solicited treatment-related adverse events at 56 days. In a planned pharmacokinetic (PK) sub-study we aim to assess PK/pharmacodynamic (PD) of oral vs IV rifampicin, describe LZD and RIF PK and cerebrospinal fluid concentrations, explore PK/PD relationships, and investigate drug-drug interactions between LZD and RIF. Safety and pharmacokinetic data from this study will inform a planned phase III study of intensified therapy in TBM. Clinicaltrials.gov registration: NCT03927313 (25/04/2019)
Collapse
Affiliation(s)
- Angharad G Davis
- The Francis Crick Institute, Midland Rd, London, NW1 1AT, UK.,Faculty of Life Sciences, University College London, London, WC1E 6BT, UK.,Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa.,Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Mpumi Maxebengula
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Cari Stek
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa.,Department of Infectious Diseases, Imperial College London, London, W12 0NN, UK
| | - Marise Bremer
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Remy Daroowala
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa.,Department of Infectious Diseases, Imperial College London, London, W12 0NN, UK
| | - Saalikha Aziz
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Rene Goliath
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Stephani Stegmann
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Sonya Koekemoer
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Amanda Jackson
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Louise Lai Sai
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Yakub Kadernani
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Thandi Sihoyiya
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - C Jason Liang
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Maryland, USA
| | - Lori Dodd
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Maryland, USA
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Thomas Crede
- Mitchells Plain Hospital, 8 A Z Berman Drive, Lentegeur, Cape Town, 7785, South Africa
| | - Jonathan Naude
- Mitchells Plain Hospital, 8 A Z Berman Drive, Lentegeur, Cape Town, 7785, South Africa
| | - Patryk Szymanski
- Mitchells Plain Hospital, 8 A Z Berman Drive, Lentegeur, Cape Town, 7785, South Africa
| | - Yakoob Vallie
- New Somerset Hospital, Portswood Rd, Green Point, Cape Town, 8051, South Africa
| | - Ismail Banderker
- New Somerset Hospital, Portswood Rd, Green Point, Cape Town, 8051, South Africa
| | - Shiraz Moosa
- New Somerset Hospital, Portswood Rd, Green Point, Cape Town, 8051, South Africa
| | - Peter Raubenheimer
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Rachel P J Lai
- The Francis Crick Institute, Midland Rd, London, NW1 1AT, UK.,Department of Infectious Diseases, Imperial College London, London, W12 0NN, UK
| | - John Joska
- Department of Psychiatry and Mental Health, HIV Mental Health Research Unit, Neuroscience Institute, University of Cape Town, Observatory, 7925, South Africa
| | - Sam Nightingale
- Department of Psychiatry and Mental Health, HIV Mental Health Research Unit, Neuroscience Institute, University of Cape Town, Observatory, 7925, South Africa
| | - Anna Dreyer
- Department of Psychiatry and Mental Health, HIV Mental Health Research Unit, Neuroscience Institute, University of Cape Town, Observatory, 7925, South Africa
| | - Gerda Wahl
- Department of Medicine, Water Sisulu University, Mthatha, 5117, South Africa
| | - Curtis Offiah
- Department of Neuroradiology, Imaging Department, Royal London Hospital, Barts Health NHS Trust, London, E1 1BB, UK
| | - Isak Vorster
- Division of Diagnostic Radiology, University of Cape Town, Groote Schuur Hospital, Observatory, 7925, South Africa
| | - Sally Candy
- Division of Diagnostic Radiology, University of Cape Town, Groote Schuur Hospital, Observatory, 7925, South Africa
| | - Frances Robertson
- MRC/UCT Medical Imaging Research Unit Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Observatory, 7925, South Africa
| | - Ernesta Meintjes
- MRC/UCT Medical Imaging Research Unit Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Observatory, 7925, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - John Black
- Department of Medicine, Water Sisulu University, Mthatha, 5117, South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa.,Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Robert J Wilkinson
- The Francis Crick Institute, Midland Rd, London, NW1 1AT, UK.,Faculty of Life Sciences, University College London, London, WC1E 6BT, UK.,Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa.,Department of Medicine, University of Cape Town, Observatory, 7925, South Africa.,Department of Infectious Diseases, Imperial College London, London, W12 0NN, UK
| |
Collapse
|