Emetine for Viral Outbreaks (a.k.a. EVOLVE Antiviral Initiative)

Official title

Emetine for Viral Outbreaks: A Phase 2/3 Randomized, Double-Blinded, Placebo-Controlled Trial to Evaluate the Efficacy and Safety of Emetine for Dengue Fever (a.k.a. EVOLVE Antiviral Initiative)

Overview

The goal of this study is to evaluate the efficacy and safety of emetine administered orally for symptomatic patients aged 18-65 years infected with the dengue virus. The main questions it aims to answer are: 1. Does emetine reduce 28-day mortality or progression to severe dengue (severe plasma leakage, severe bleeding, or severe organ involvement)? 2. What are the safety outcomes of emetine, including serious adverse events and toxicities? Participants will be asked to: 1. Take either 6mg emetine, 12mg emetine, or a placebo pill for 7 consecutive days as part of the treatment regimen. 2. Have blood samples taken for at least 5 days to monitor viral load, inflammatory markers, and safety parameters. 3. Be monitored by healthcare staff for daily vital signs and symptoms for clinical assessments for 28 days.

Detailed description

Dengue fever is a mosquito-borne viral infection caused by the dengue virus (DENV), which belongs to the Flaviviridae family. It is transmitted primarily by Aedes aegypti and Aedes albopictus mosquitoes. Dengue is recognized as one of the top ten global public health threats, affecting an estimated 390 million people annually, with approximately 96 million cases manifesting clinically. Globally, dengue has seen a significant rise in incidence, with a 30-fold increase in the past 50 years. There is currently no antiviral agent proven to work against it. Dengue fever is endemic in Nepal with cyclical outbreaks. The country relies on supportive treatment. This often includes intravenous fluids and, in rare cases, steroids and organ support. Effective antiviral agents could significantly reduce the burden of dengue by preventing disease progression and reducing transmission.

In vitro and in vivo studies have suggested strong antiviral activity of emetine against SARS-CoV-2, dengue, Ebola, cytomegalovirus, and several other viruses. Low et al. had carefully demonstrated that emetine inhibited all four serotypes of DENV infection in cell lines by inhibiting the viral RNA synthesis or the viral protein translation pathway. In the past, emetine, an alkaloid extracted from ipecacuanha roots, has been widely used in the human treatment of amoebic dysentery, amoebic liver abscess, and several viruses such as herpes simplex, herpes zoster, influenza, hepatitis, and mumps. Because of cardiotoxicity (cardiac dysrhythmias), emetine was replaced by metronidazole. The toxicity was unequivocally associated with high-dose emetine (60 mg/day for 10 days to achieve an minimum inhibitory concentration (MIC) of 25 micromol (µM) against Entamoeba histolytica; however, the cardiovascular side-effects were minimal or none when emetine was used for various indications in low dose (\<20 mg/day). The investigators have recently shown that by lowering the standard amoebicidal dose by a factor of 10, emetine can inhibit viral replication while avoiding cardiovascular toxicity.

Phase 1 and 2 studies have been previously carried out. The investigators' clinical trial to evaluate emetine against SARS-CoV-2 is currently approved by Johns Hopkins Medicine (JHM) Institutional Review Board (IRB) (IRB00283778) and is ongoing in Nepal. The investigators have enrolled a few patients in this trial and have not encountered any toxicity. Given the broad-spectrum antiviral activity of emetine, the investigators now plan to evaluate emetine's efficacy and safety in the treatment of symptomatic dengue fever in a clinical trial. The investigators hypothesize that emetine will be efficacious against dengue at low doses. By evaluating its efficacy against dengue, this research can directly inform treatment strategies for patients in over 100 countries, since about 50% of the global population is at risk of dengue fever. In the past, emetine was an essential World Health Organization (WHO)- and FDA-approved drug.

Interventions

• Drug Emetine Hydrochloride 6mg
  To administer Emetine Hydrochloride 6mg orally for 10 consecutive days to evaluate the efficacy and safety of emetine for symptomatic dengue patients.
• Drug Placebo
  Participant take a placebo for 10 consecutive days.
• Drug Emetine Hydrochloride 12mg
  To administer Emetine Hydrochloride 12mg orally for 10 consecutive days to evaluate the efficacy and safety of emetine for symptomatic dengue patients.

Primary outcome measures

• Evaluate effectiveness of emetine in dengue patients assessed by 28-day mortality or progression [Time frame: 28 days]
• Safety of emetine assessed by number of adverse events [Time frame: Up to 28 days]
• Safety of emetine assessed by rate of drug discontinuation [Time frame: Up to 28 days]

Secondary outcome measures (12)

• Recovery (≥ 3 days without symptoms) [Time frame: Up to 14 days]
• Time to Virologic Clearance of Dengue Virus by Qualitative RT-PCR [Time frame: Pre-dose (day 0), day 3, and day 5]
• Quantitative Viral Load Assessment by RT-PCR Cycle Threshold (Ct) Values [Time frame: Days 0,3, 5]
• Changes in inflammatory marker measured by hematocrit [Time frame: Days 0 to 5]
• Changes in inflammatory marker measured by white blood count [Time frame: Day 0-5]
• Changes in inflammatory marker measured by reticulocyte count [Time frame: Day 0-5]
• Changes in inflammatory marker measured by platelet count [Time frame: Day 0-5]
• Changes in inflammatory marker measured by alanine aminotransferase [Time frame: Day 0-5]
• Changes in inflammatory marker measured by serum bilirubin [Time frame: Day 0-5]
• Changes in inflammatory marker measured by serum albumin [Time frame: Day 0-5]
• Changes in inflammatory marker measured by C-reactive protein [Time frame: Day 0-5]
• Post infection fatigue measured by Fatigue Questionnaire [Time frame: On Day 28]

Eligibility criteria

Inclusion criteria

• Age 18 to 65 years
• Admitted to the hospital
• Laboratory-confirmed infection with dengue virus within the last 5 days and preferably within the last 3 days. Testing for dengue virus using positive Nonstructural protein 1(NS1) strip assay or reverse-transcriptase polymerase chain reaction (RT-PCR)
• Having two or more clinical symptoms (fever, headache, retro-orbital pain, myalgia, arthralgia, rash, hemorrhagic manifestations, or leucopenia, gastrointestinal symptoms) with the onset of fever within 72 hours of presentation, and
• Able to provide voluntary informed consent and comply with all study procedures and visits.

Exclusion criteria

• Age ≥65 years
• Pregnant or breastfeeding
• Current or recent use of the study drug
• Known allergy to study drug
• Current or planned participation in another pharmacological interventional trial in the next 10 days
• Participants with known past history of dengue infection
• Participants on aspirin, anticoagulants, or with other conditions that might increase the risk of bleeding
• Participants on immunosuppressive agents, including long-term steroids
• Severe dengue as defined by the WHO 2009 revised case classification.
• Individuals with long-term immunosuppressive agents such as anti-cancer chemotherapy or radiation therapy within the past 6 months, or those on systemic corticosteroid therapy
• History of prior vaccination against dengue fever within one year.
• Patients who have recently used ayurvedic or herbal medications for dengue or any other conditions in the last 7 days (eg, Papaya leaf extract)

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

Quadruple blind

Primary purpose

Treatment

Study locations

United States · 1 center

• Johns Hopkins University, Division of Infectious Disease — Baltimore

Nepal · 1 center

• Bharatpur Hospital — Bharatpur-10

Publications

• Choy KT, Wong AY, Kaewpreedee P, Sia SF, Chen D, Hui KPY, Chu DKW, Chan MCW, Cheung PP, Huang X, Peiris M, Yen HL. Remdesivir, lopinavir, emetine, and homoharringtonine inhibit SARS-CoV-2 replication in vitro. Antiviral Res. 2020 Jun;178:104786. doi: 10.1016/j.antiviral.2020.104786. Epub 2020 Apr 3. PMID 32251767
• Ooi EE. Repurposing Ivermectin as an Anti-dengue Drug. Clin Infect Dis. 2021 May 18;72(10):e594-e595. doi: 10.1093/cid/ciaa1341. No abstract available. PMID 33124646
• Bhat CS, Shetty R, Sundaram B, Ramanan AV. Immunomodulatory therapy in dengue: need for clinical trials and evidence base. Arch Dis Child. 2023 Jun;108(6):451-452. doi: 10.1136/archdischild-2022-324100. Epub 2022 Jun 9. No abstract available. PMID 35680407
• Guzman MG, Gubler DJ, Izquierdo A, Martinez E, Halstead SB. Dengue infection. Nat Rev Dis Primers. 2016 Aug 18;2:16055. doi: 10.1038/nrdp.2016.55. PMID 27534439
• Beesetti H, Khanna N, Swaminathan S. Investigational drugs in early development for treating dengue infection. Expert Opin Investig Drugs. 2016 Sep;25(9):1059-69. doi: 10.1080/13543784.2016.1201063. Epub 2016 Jun 24. PMID 27322111
• Entner N, Grollman AP. Inhibition of protein synthesis: a mechanism of amebicide action of emetine and other structurally related compounds. J Protozool. 1973 Feb;20(1):160-3. doi: 10.1111/j.1550-7408.1973.tb06025.x. No abstract available. PMID 4347870
• Bleasel MD, Peterson GM. Emetine Is Not Ipecac: Considerations for Its Use as Treatment for SARS-CoV2. Pharmaceuticals (Basel). 2020 Nov 27;13(12):428. doi: 10.3390/ph13120428. PMID 33261173
• Grollman AP. Structural basis for inhibition of protein synthesis by emetine and cycloheximide based on an analogy between ipecac alkaloids and glutarimide antibiotics. Proc Natl Acad Sci U S A. 1966 Dec;56(6):1867-74. doi: 10.1073/pnas.56.6.1867. No abstract available. PMID 16591432

Identifiers

NCT: NCT07016321 · IRB00486563

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗