Neurocysticercosis: Combined Treatment With Praziquantel (PZQ) and Albendazole (ABZ)

Antiparasitic Therapy for Neurocysticercosis: Phase II/III Study on Safety and Efficacy of Combined Treatment With Praziquantel and Albendazole

The purpose of this study is to determine if combination drug therapy of praziquantel and albendazole is safe and effective to cure neurocysticercosis.

Study Overview

• Status: Completed
• Conditions: Epilepsy; Neurocysticercosis
• Intervention / Treatment: Drug: Praziquantel; Drug: Albendazole; Drug: ABZ Placebo; Drug: PZQ Placebo

Detailed Description

Neurocysticercosis is the single major cause of acquired or late-onset epilepsy in the world, and a common diagnosis in immigrant populations in the United States and other industrialized countries. An estimated 50 million humans are affected by Neurocysticercosis. The disease occurs when a parasite called Taenia solium, or the pig tapeworm, infects the brain, forming cysts. Neurocysticercosis is generally treated with 1 of 2 drugs, praziquantel or albendazole. However, current treatment with either of these drugs alone is not totally effective.

The goal of this trial is to determine if combination drug therapy of praziquantel and albendazole is safe and more effective to cure Neurocysticercosis than either drug administered alone. This trial will consist of two sub-studies and a parent study.

In the first substudy which was performed and completed as the initial part and guide to the design of the parent study, a series of 32 patients with viable cystic intraparenchymal Neurocysticercosis were treated with either albendazole ( 15 mg / kg /d ) + praziquantel ( 50 mg / kg/ d ) or albendazole+Placebo in a double blind randomized study. Half of patients in each group had their seizure disorder treated with phenytoin and the other half with carbamazepine (not assigned by the study). The study was designed and powered for pharmacokinetic evaluation and exploratory safety so comparative cysticidal efficacy has not yet been analyzed. There were no safety concerns. Pharmacokinetics of ABZ and PZQ were obtained and described.

In the parent study, a total of 240 participants ( including the 32 participants from the first substudy ) will be randomly chosen to receive albendazole + praziquantel, albendazole + placebo or albendazole at an increased dose + placebo for 10 days. These groups will also receive other standard medications to manage the disease including appropriate anti-epileptic drug therapy. Participants will stay in the hospital for at least 2 weeks after treatment begins, which includes 5 days after the end of anti-parasitic treatment. After discharge from the hospital, follow-up visits will be on days 21 and 30 after treatment begins, then monthly until day 90, and finally every 3 months until completing 18 months. Brain images will be taken at 6 and 12 months after treatment begins. For participants, duration of the trial is 1 year and a half.

• Study Type: Interventional
• Enrollment (Actual): 156
• Phase: Phase 2; Phase 3

Contacts and Locations

Study Locations

• Peru
  • Lima, Peru, LIMA 31
    • Hospital Nacional Cayetano Heredia
  • Lima, Peru
    • Universidad Peruana Cayetano Heredia
  • Lima, Peru, Lima 11
    • Hospital Nacional Edgardo Rebagliati
  • Lima, Peru, Lima 5
    • Hospital Nacional Guillermo Almenara
  • Lima, Peru
    • Instituto Nacional de Ciencias Neurologicas

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 14 years to 63 years (Child, Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

For parent study:

Inclusion Criteria:

• Male or female individuals between 16 to 65 years of age, with a diagnosis of Neurocysticercosis and 20 or less viable cysts.
• Patients with a diagnosis of epilepsy secondary to Neurocysticercosis and a history of one or more spontaneous seizures within the previous year but not longer than 10 years.
• Willingness to complete a minimum of two weeks of hospitalization.
• If female of child bearing potential, negative urine pregnancy testing and willingness to use an adequate method of contraception while on study medications and for at least 3 months following Albendazole therapy.
• Normal laboratory values for hematocrit, platelets, white blood cells and glucose and normal or decreased values for Alanine transaminase, Aspartate transaminase and creatinine.
• Negative PPD measurement and if positive ( > 9mm induration in the absence of other findings or immunosuppression ) , negative smears for TB.
• Negative fecal exam for Taenia eggs or Strongyloides larvae.

Exclusion Criteria:

• Primary generalized seizures ( e.g., not caused by Neurocysticercosis )
• A history of generalized epileptic status .
• A type of Neurocysticercosis which can expose the patient to increased risk during the study.
• Patients with persistent or progressive symptomatic intracranial hypertension or intracranial hypertension.
• Previous therapy with Albendazole or Praziquantel in the previous year.
• Pulmonary tuberculosis, or symptoms compatible with tuberculosis not otherwise explained.
• Active hepatitis
• Systemic disease that may affect short term prognosis.
• Patients in unstable condition ( consistently abnormal vital signs: body temperature, heart rate, respiratory rate, and blood pressure )
• Pregnancy during antiparasitic treatment
• History of hypersensitivity to Albendazole or Praziquantel
• Concurrent treatment with Cimetidine or Theophylline
• Chronic alcohol or drug abuse
• Unwilling or unable to provide a Computed tomography initially or an Magnetic resonance imaging at 6 months ( as patients with ferromagnetic implants ) , Computed tomography at the end of therapy.
• Unwillingness of subject or legal representative to give written informed consent.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: I. ABZ + ABZ Placebo + PZQ; Albendazole 15 mg / kg / d (until 800 mg / d) + Placebo of Albendazole ( 7.5 mg / Kg / d )+ Praziquantel 50 mg / kg / d (until 3600 mg / d)	Drug: Praziquantel; - Praziquantel 50 mg / kg / d (up to 3600 mg / d ) for 10 days.; Other Names: PZQ; Drug: Albendazole; Albendazole 15 mg / kg / d ( up to 800 mg /d ) in Arm I for 10 days.; Albendazole at an increased dose, 22.5 mg / kg / d (up to 1200 mg / d ), in Arm II for 10 days.; Other Names: ABZ; Drug: ABZ Placebo; - Placebo (of Albendazole ) 7.5 mg / kg / d in Arm I and II for 10 days.; Other Names: Placebo of Albendazole
Active Comparator: II.- ABZ + ABZ Placebo + PZQ Placebo; Albendazole 15 mg / kg / d ( until 800 mg / d ) + Placebo of Albendazole ( 7.5 mg / Kg / d ) + Placebo of Praziquantel ( 50 mg / kg / d )	Drug: Albendazole; Albendazole 15 mg / kg / d ( up to 800 mg /d ) in Arm I for 10 days.; Albendazole at an increased dose, 22.5 mg / kg / d (up to 1200 mg / d ), in Arm II for 10 days.; Other Names: ABZ; Drug: ABZ Placebo; - Placebo (of Albendazole ) 7.5 mg / kg / d in Arm I and II for 10 days.; Other Names: Placebo of Albendazole; Drug: PZQ Placebo; - Placebo (of Praziquantel) 50 mg / kg / d in Arm II and III for 10 days.; Other Names: Placebo of PZQ
Active Comparator: III .- Albendazole + PZQ Placebo; Albendazole 22.5 mg / kg / d (until 1200 mg / d) + Placebo of Praziquantel ( 50 mg / kg / d ) This arm was not used in the first substudy ( initial part and guide to the design of the parent study ) however it will be used henceforward.	Drug: Albendazole; Albendazole 15 mg / kg / d ( up to 800 mg /d ) in Arm I for 10 days.; Albendazole at an increased dose, 22.5 mg / kg / d (up to 1200 mg / d ), in Arm II for 10 days.; Other Names: ABZ; Drug: PZQ Placebo; - Placebo (of Praziquantel) 50 mg / kg / d in Arm II and III for 10 days.; Other Names: Placebo of PZQ

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
PK Substudy - Area Under the Curve of Albendazole in Treatment in Day 1	- To evaluate kinetic disposition of Albendazole we calculated the Area under the curve of the active metabolite of Albendazole (Albendazole Sulphoxide) with Praziquantel or Placebo (of Praziquantel).	0, 0.5, 1, 1.5, 2, 3, 4, 8, 10 and 12 hours post dose on Treatment day 1
PK Substudy - Area Under the Curve of Albendazole in Treatment Days 10 and 11	- To evaluate kinetic disposition of Albendazole we calculated the Area under the curve of the active metabolite of Albendazole (Albendazole Sulphoxide) with Praziquantel or Placebo (of Praziquantel).	0.5, 1, 1.5, 2, 3, 4, 8, 10, 12, 24 and 36 hours post dose on Treatment days 10-11
PK Substudy - Maximum Concentration of Albendazole	Highest serum level of Albendazole measured from all level assessments in the curve.	Treatment day 1 and Treatment days 10-11
Phase III Trial - Proportion of Patients Without Remaining Live Cysts	Proportion of patients whose 6 month MR does not show viable parasites anymore	Day 180

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
PK Substudy - Area Under the Curve of Praziquantel by Antiepileptic Drug in Treatment Day 1	- To evaluate the kinetic disposition of Praziquantel by antiepileptic drug after the last praziquantel dose, we calculated the Area Under the Curve of Praziquantel with Carbamazepine or Phenytoin	0, 0.5, 1, 1.5, 2, 3, 4, 8, 10 and 12 hours post dose in treatment day 1
PK Substudy - Area Under the Curve of Praziquantel by Antiepileptic Drug in Treatment Days 10 and 11	- To evaluate the kinetic disposition of Praziquantel by antiepileptic drug after the last praziquantel dose, we calculated the Area Under the Curve of Praziquantel with Carbamazepine or Phenytoin	0.5, 1, 1.5, 2, 3, 4, 8, 10, 12, 24 and 36 hours post dose on treatment days 10-11
PK Substudy - Safety of Combined Albendazole Plus Praziquantel Therapy	- Describe if some Serious Adverse Event was associated to combined Albendazole plus Praziquantel therapy.	90 days post tx
Phase III Trial - Proportion of Cysts Which Resolved	Proportion of Viable Brain Parasites which Are not Alive Anymore at 6 Months MRI	Day 180
Phase III Trial - Seizure Frequency	Seizure frequency by treatment group	Day 1 - 540

Collaborators and Investigators

• Sponsor: Universidad Peruana Cayetano Heredia
• Collaborators: National Institute of Neurological Disorders and Stroke (NINDS)
• Investigators: Principal Investigator: Hector H. Garcia, MD, Universidad Peruana Cayetano Heredia; Principal Investigator: E. Javier Pretell, MD, Hospital Alberto; Principal Investigator: Javier A. Bustos, MD, Universidad Peruana Cayetano Heredia

Publications and helpful links

General Publications

• Garcia HH, Lescano AG, Lanchote VL, Pretell EJ, Gonzales I, Bustos JA, Takayanagui OM, Bonato PS, Horton J, Saavedra H, Gonzalez AE, Gilman RH; Cysticercosis Working Group in Peru. Pharmacokinetics of combined treatment with praziquantel and albendazole in neurocysticercosis. Br J Clin Pharmacol. 2011 Jul;72(1):77-84. doi: 10.1111/j.1365-2125.2011.03945.x.
• Garcia HH, Gonzales I, Lescano AG, Bustos JA, Zimic M, Escalante D, Saavedra H, Gavidia M, Rodriguez L, Najar E, Umeres H, Pretell EJ; Cysticercosis Working Group in Peru. Efficacy of combined antiparasitic therapy with praziquantel and albendazole for neurocysticercosis: a double-blind, randomised controlled trial. Lancet Infect Dis. 2014 Aug;14(8):687-695. doi: 10.1016/S1473-3099(14)70779-0. Epub 2014 Jul 3.
• Garcia HH, Lescano AG, Gonzales I, Bustos JA, Pretell EJ, Horton J, Saavedra H, Gonzalez AE, Gilman RH; Cysticercosis Working Group in Peru. Cysticidal Efficacy of Combined Treatment With Praziquantel and Albendazole for Parenchymal Brain Cysticercosis. Clin Infect Dis. 2016 Jun 1;62(11):1375-9. doi: 10.1093/cid/ciw134. Epub 2016 Mar 16.

Study record dates

Study Major Dates

• Study Start: January 1, 2010
• Primary Completion (Actual): December 1, 2012
• Study Completion (Actual): September 1, 2013

Study Registration Dates

• First Submitted: February 27, 2007
• First Submitted That Met QC Criteria: February 27, 2007
• First Posted (Estimate): February 28, 2007

Study Record Updates

• Last Update Posted (Estimate): June 11, 2015
• Last Update Submitted That Met QC Criteria: May 15, 2015
• Last Verified: May 1, 2015

More Information

Terms related to this study

• Keywords: epilepsy; albendazole; parasite; PZQ; neurocysticercosis; NCC; praziquantel; ABZ; pig tapeworm; Taenia solium; late-onset epilepsy; acquired epilepsy
• Additional Relevant MeSH Terms: Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Infections; Central Nervous System Infections; Parasitic Diseases; Helminthiasis; Cestode Infections; Central Nervous System Helminthiasis; Central Nervous System Parasitic Infections; Epilepsy; Cysticercosis; Taeniasis; Neurocysticercosis; Molecular Mechanisms of Pharmacological Action; Anti-Infective Agents; Antineoplastic Agents; Tubulin Modulators; Antimitotic Agents; Mitosis Modulators; Antiprotozoal Agents; Antiparasitic Agents; Anthelmintics; Antiplatyhelmintic Agents; Anticestodal Agents; Albendazole; Praziquantel
• Other Study ID Numbers: R01NS054805 (U.S. NIH Grant/Contract)