Assessment of the Safety, Tolerability, and Effectiveness of Rifapentine Given Daily for LTBI

Official title

Six Weeks of Daily Rifapentine vs. a Comparator Arm of 12-16 Week Rifamycin-based Treatment of Latent M. Tuberculosis Infection: Assessment of Safety, Tolerability and Effectiveness

Overview

This study is conducted to compare the safety and effectiveness of a novel short 6-week regimen of daily rifapentine (6wP, experimental arm) with a comparator arm of 12-16 weeks of rifamycin-based treatment (standard of care, control arm) of latent M. tuberculosis infection (LTBI). This trial is conducted among persons who are at increased risk of progression to tuberculosis (TB) and require treatment of LTBI. The study will be conducted in low, medium and high TB incidence settings that have treatment of LTBI as their standard of care and offer 12-16 week rifamycin-based therapy as standard of care. The hypothesis of this study is that the safety and effectiveness of the experimental treatment (6wP arm) is non-inferior to a comparator arm of 12-16 weeks of rifamycin-based treatment of LTBI (control arm). Participants are enrolled and randomly assigned to one of the two study arms: experimental 6wP or control. The comparator (control) arm's treatment regimens include 12 weeks of once-weekly isoniazid (INH) and rifapentine (3HP), 12 weeks of daily INH and rifampin (3HR), and 16 weeks of daily rifampin (4R). A total of 560 participants per arm (1,120 total) for the evaluation of safety and 1,700 participants per arm (3,400 total) for the evaluation of effectiveness will be enrolled, given treatment as per randomization assignment, and followed for 24 months from the date of enrollment. After completion of data collection, statistical analyses will be conducted to compare proportions of drug discontinuation due to adverse drug reaction (ADR) and proportions of newly diagnosed tuberculosis between 6wP and control arm.

Interventions

• Drug Rifapentine daily for 6 weeks
  600 mg of Rifapentine (RPT) given once daily (o.d., omni die) for 6 weeks (6wP).
• Drug Rifapentine and Isoniazid weekly for 12 weeks
  Rifapentine (RPT) 900 mg and isoniazid (INH) 900 mg given once-weekly for 12 weeks (3HP).\* \*Dose adjustments based on patient's weight will be made according to ATS/CDC/IDSA guidelines. RPT 900 mg once-weekly for persons weighing \> 50 kg. For persons weighing \< 50 kg, the following doses will be given: weight \> 25-32 kg - RPT 600 mg; weight \> 32-50 kg - RPT 750 mg; + INH 15 mg/kg (round up to nearest 50 or 100 mg; 900 mg max).
• Drug Rifampin and Isoniazid daily for 12 weeks
  Rifampin (RIF) 600 mg and Isoniazid (INH) 300 mg given once-daily for 12 weeks (3HR)\*. \*Dose adjustments based on patient's weight will be made according to ATS/CDC/IDSA guidelines. RIF 600 mg daily for persons weighing \> 50 kg. For persons weighing \< 50 kg, give 10 mg/kg daily; round up to nearest 50 or 100 mg; + INH 5 mg/kg daily (rounded up to nearest 50 or 100 mg; 300 mg max).
• Drug Rifampin daily for 16 weeks
  Rifampin (RIF) 600 mg given once-daily for 16 weeks (4R).\* \*Dose adjustments based on patient's weight will be made according to ATS/CDC/IDSA guidelines. RIF 600 mg daily for persons weighing \> 50 kg. For persons weighing \< 50 kg, 10 mg/kg daily; round up to nearest 50 or 100 mg.

Primary outcome measures

• Treatment discontinuation due to adverse drug reaction [Time frame: from the date of enrollment to the date of scheduled completion of assigned treatment]
• Culture-confirmed tuberculosis (TB) in participants 18 years old and older and culture-confirmed or clinical TB in participants less then 18 years old. [Time frame: within 24 months from the date of enrollment]

Secondary outcome measures (12)

• Proportion who complete assigned treatment [Time frame: from date of enrollment until the maximum accepted time for treatment completion as follows: 9 weeks for 6wP treatment, 16 weeks for 3HP, 16 weeks for 3HP, and 21 weeks for 4R]
• Proportion of Participants Who Complete Assigned Study Treatment [Time frame: from date of enrollment until the maximum accepted time for treatment completion as follows: 9 weeks for 6wP treatment, 16 weeks for 3HP, 16 weeks for 3HP, and 21 weeks for 4R]
• Proportion with any grade 3, 4, or 5 (i.e., death) adverse event associated with study drug [Time frame: within 6 months from the date of enrollment]
• Proportion of Participants Who Die From Any Cause [Time frame: within 24 months from the date of enrollment]
• Proportion of Participants With Hepatotoxicity or Non-Hepatotoxic Systemic Drug Reactions [Time frame: within 6 months from the date of enrollment]
• Proportion of Participants with Culture-Confirmed or Clinical Tuberculosis (TB) [Time frame: within 24 months from the date of enrollment]
• Proportion of Participants Who Develop Tuberculosis (TB) Among Those Who Complete Assigned Study Treatment [Time frame: within 24 months from the date of enrollment]
• Proportion of Participants With HIV Infection Who Discontinue Study Treatment Due to Adverse Drug Reactions [Time frame: from date of enrollment until the maximum accepted time for treatment completion as follows: 9 weeks for 6wP treatment, 16 weeks for 3HP, 16 weeks for 3HP, and 21 weeks for 4R]
• Safety (defined as treatment discontinuation due to adverse drug reaction) among participants < 18 years old. [Time frame: from date of enrollment until the maximum accepted time for treatment completion as follows: 9 weeks for 6wP treatment, 16 weeks for 3HP, 16 weeks for 3HP, and 21 weeks for 4R]
• Tolerability (defined as proportion of with drug discontinuation for any reason) among participants with human immunodeficiency virus (HIV) infection. [Time frame: from date of enrollment until the maximum accepted time for treatment completion as follows: 9 weeks for 6wP treatment, 16 weeks for 3HP, 16 weeks for 3HP, and 21 weeks for 4R]
• Tolerability (defined as proportion of with drug discontinuation for any reason) among participants < 18 years old. [Time frame: from date of enrollment until the maximum accepted time for treatment completion as follows: 9 weeks for 6wP treatment, 16 weeks for 3HP, 16 weeks for 3HP, and 21 weeks for 4R]
• Effectiveness among participants with human immunodeficiency virus (HIV) infection. [Time frame: within 24 months from the date of enrollment]

Eligibility criteria

Inclusion criteria

• Persons with LTBI who do not have evidence of TB disease (see exclusion criteria) and are at increased risk of progression to TB. LTBI or M. tuberculosis infection may be demonstrated by either a positive tuberculin skin test (TST) or a positive interferon gamma release assay (IGRA; e.g., QuantiFERON or T.SPOT.TB). Details of testing definitions and requirements for each risk factor are further described in the MOOP. Persons with LTBI at increased risk of progression to TB are those with at least one of the following:

• Household and other close contacts (> 4 hours of exposure in a one-week period) within 2 years prior to enrollment, of persons with bacteriologically confirmed TB.

o Acceptable testing approaches for bacteriologic confirmation are 1) culture with rifamycin DST; or, 2) nucleic acid amplification tests (NAATs) that detect M. tuberculosis and detect mutations associated with rifamycin resistance. Additional details on bacteriologic confirmation, including accepted NAATs, will be included in the MOOP.

• Recent M. tuberculosis infection, defined as converting from a documented negative to positive TST or IGRA within 2 years prior to enrollment. Persons without known close contact to someone with active pulmonary TB who have a conversion by IGRA may require additional evaluation to rule out a false conversion. Additional guidance and definitions of conversion are in the MOOP.
• HIV co-infection (with CD4+ T-lymphocyte count > 100 cells/mm3)
• ≥ 2 cm2 of pulmonary parenchymal fibrosis on chest X-ray and no prior history of treatment for TB or LTBI.
• Recent (within 3 years prior to enrollment) immigration to the United States or other country with low to moderate TB incidence, with abnormal chest X-ray, and no evidence of active TB.
• Recent (within 3 years prior to enrollment) immigration to the United States or other country with low to moderate TB incidence, from a country with an estimated incidence rate of TB > 150 per 100,000 (see Appendix D) and either a positive IGRA or a TST ≥15 mm (TST > 15 mm only applicable for those with recent immigration as their only risk factor for progression to TB).
• Recent (within 3 years prior to enrollment) immigration and seeking refugee/asylum status (see MOOP for additional details) to the United States or other country with low to moderate incidence from a country with an estimated incidence rate of TB > 75 per 100,000 (see Appendix E) and either a positive IGRA or a TST ≥15 mm (TST > 15 mm only applicable for those with recent immigration as their only risk factor for progression to TB).
• Individuals with an increased risk of TB due to medical conditions such as end-stage renal disease.
• Individuals currently using immunosuppressive medications such as chronic steroids.
• Individuals with planned use of TNF-α inhibitors.
• Individuals with planned solid organ or hematologic transplantation
• Willing to provide signed informed consent, or parental permission and participant assent.
• For the following special populations, both inclusion criteria above must be met AND the criteria below depending on stage:

• Pregnant women in their second or third trimester (≥14 weeks gestation).

• Stage 1: Include only those who agree to participate in the semi-intensive PK component.
• Stage 2: Include regardless of semi-intensive PK component participation.
• Children aged less than 12 years

• Stage 1: Include only those who agree to participate in the semi-intensive PK component, based on enrollment strategy presented in Appendix I.
• Stage 2: Include regardless of semi-intensive PK component participation, based on PK findings and enrollment strategy described in Appendix I.

Exclusion criteria

• Failure to document positive IGRA or TST
• Current breastfeeding.
• Women who are currently pregnant in their first trimester (<14 weeks gestation) or intend to become pregnant within 120 days of enrollment.
• Non-pregnant women of childbearing potential who refuse to practice an adequate method of contraception (barrier method or non-hormonal intrauterine device) or abstain from activities that could lead to pregnancy.
• Current culture-positive TB, clinical TB, or suspected current TB. (Includes cases in which active TB cannot be excluded with reasonable clinical certainty by the site investigator. If sputum samples have been collected AND site investigators have suspicion of active TB, site investigators must wait to review culture results prior to enrollment.)
• TB resistant to any rifamycin in the source case
• A history of treatment for > 7 consecutive days (if daily dosing) with a rifamycin or >1 week (if weekly dosing) with a rifamycin and INH or > 30 consecutive days with INH within 2 years prior to enrollment.
• A documented history of completing an adequate course of treatment for TB disease or LTBI in a person who is HIV-seronegative.
• History of allergy or intolerance to rifamycins.
• Serum alanine aminotransferase (ALT; SGPT) or serum aspartate aminotransferase (AST; SGOT) > 5x upper limit of normal among persons in whom screening ALT or AST is determined.
• Receiving concomitant medications that are known to be contraindicated with any study drug.
• Weight < 25 kg for participants ≥ 12 years, and weight < 3kg for participants < 12 years

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Randomized

Model

Parallel assignment

Masking

Open label

Primary purpose

Treatment

Study locations

United States · 7 centers

• Denver Health and Hospital Authority — Denver
• George Washington University — Washington D.C.
• Washington DC VA Medical Center — Washington D.C.
• New York Harbor Healthcare System — Manhattan
• New York City Bureau of TB Control — New York
• San Antonio VA — San Antonio
• Seattle King County Health Department — Seattle

Canada · 5 centers

• Calgary TB Clinic — Calgary
• Edmonton TB Clinic — Edmonton
• British Columbia Centre for Disease Control — Vancouver
• Toronto Western Hospital — Toronto
• McGill University Health Centre — Montreal

Australia · 3 centers

• Liverpool Hospital — Sydney
• Paramatta Chest — Sydney
• Royal Prince Alfred Hospital — Sydney

Vietnam · 2 centers

• Ho Chin Minh City-District 6 TB Unit — Ho Chi Minh City
• Ho Chin Minh City-Phoi Viet Resportory Centre — Ho Chi Minh City

Benin · 1 center

• National Referral University Hospital for Pneumo-physiology — Cotonou

Haiti · 1 center

• Les Centres Gheskio (INLR) CRS — Port-au-Prince

South Africa · 1 center

• Desmond Tutu TB Center — Stellenbosch

Uganda · 1 center

• Joint Clinical Research Centre/ Makerere Univ Med Sch — Kampala

Identifiers

NCT: NCT03474029 · CDC-NCHSTP-7024

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗