Sevelamer for Reducing Endotoxemia and Immune Activation

Sevelamer Carbonate for Reducing Endotoxemia and Immune Activation: A Proof of Concept Study

HIV-infected people can have an increase in inflammation in their body organs, even after taking anti-HIV medicines.

Sevelamer carbonate is used to bind phosphate in dialysis patients. It can also bind endotoxin in the gut and lowers endotoxin levels in the blood of dialysis patients. Sevelamer carbonate decreases the inflammation endotoxin causes in dialysis patients.

A5296 is a phase II, single-arm study to evaluate the effect of 8 weeks of sevelamer carbonate administration on markers of microbial translocation and T-cell activation in the blood in chronically HIV-infected subjects not receiving ART.

Study Overview

• Status: Completed
• Conditions: HIV-1 Infection
• Intervention / Treatment: Drug: Sevelamer carbonate; Device: Sevelamer carbonate

Detailed Description

HIV-infected people can have an increase in inflammation in their body organs, even after taking anti-HIV medicines. Inflammation is a normal body reaction to any infection. However, if inflammation lasts a long time like in HIV infection, it may lead to complications, such as heart disease, cancer, liver disease, and problems with thinking. Also, HIV-infected people with high inflammation have lower CD4+ T-cell counts (cells that fight infection). Many HIV researchers are studying the harmful effects of this prolonged inflammation and possible ways to prevent these complications.

The increase in inflammation in HIV-infected people may be caused by HIV or by other factors such as parts of bacteria. These bacterial pieces, called endotoxins, do not cause harm in the intestine (gut). However, in HIV infection, there is damage to the gut that allows endotoxins to cross from the gut into the blood. These endotoxins then cause inflammation in the body. New research is focusing on strategies to reduce the levels of endotoxin as a way to decrease inflammation.

A drug called sevelamer carbonate is used to bind phosphate in dialysis patients. However, sevelamer carbonate also binds endotoxin in the gut and lowers endotoxin levels in the blood of dialysis patients. Sevelamer carbonate also decreases the inflammation endotoxin causes in dialysis patients. This study will see if sevelamer carbonate can have the same effects in HIV-infected patients.

A5296 is a phase II, single-arm study to evaluate the effect of 8 weeks of sevelamer carbonate administration on markers of microbial translocation as well as monocyte and T-cell activation in the blood in chronically HIV-infected subjects with CD4+ T-cell count ≥ 400 cells/mm3 not receiving ART. This study enrolled 40 subjects. To assess whether there is a persistent effect of study drug, subjects were observed for an additional 8 weeks off sevelamer carbonate and changes in biomarkers were monitored.

As A5296 is a phase II study of biologic activity, the primary and secondary analyses are as-treated, limited to subjects who have data for baseline and week 8 and who remain on study treatment through week 8. For any subject who initiated antiretroviral treatment (ART), analyses only included data collected prior to the time ART was started.

• Study Type: Interventional
• Enrollment (Actual): 40
• Phase: Phase 2

Contacts and Locations

Study Locations

• United States
  • Alabama
    • Birmingham, Alabama, United States, 35294
      • Alabama Therapeutics CRS (5801)
  • California
    • Los Angeles, California, United States, 90095
      • UCLA CARE Center CRS (601)
    • San Francisco, California, United States, 94110
      • Ucsf Aids Crs (801)
    • Torrance, California, United States, 90502
      • Harbor-UCLA Med. Ctr. CRS (603)
  • Colorado
    • Aurora, Colorado, United States, 80045
      • University of Colorado Hospital CRS (6101)
  • Florida
    • Miami, Florida, United States, 33136
      • Univ. of Miami AIDS CRS (901)
  • Illinois
    • Chicago, Illinois, United States, 60611
      • Northwestern University CRS (2701)
  • Massachusetts
    • Boston, Massachusetts, United States, 02114
      • Massachusetts General Hospital ACTG CRS (101)
  • Missouri
    • Saint Louis, Missouri, United States, 63110
      • Washington University CRS (2101)
  • New York
    • Rochester, New York, United States, 14642
      • AIDS Care CRS (1108)
    • Rochester, New York, United States, 14642
      • Univ. of Rochester ACTG CRS (1101)
  • Ohio
    • Cincinnati, Ohio, United States, 45267
      • Univ. of Cincinnati CRS (2401)
    • Cleveland, Ohio, United States, 44106
      • Case CRS (2501)
    • Cleveland, Ohio, United States, 44109
      • Metro Health CRS (2503)
  • Pennsylvania
    • Philadelphia, Pennsylvania, United States, 19104
      • Hosp. of the Univ. of Pennsylvania CRS (6201)

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• HIV-1 infection
• No plans to initiate ART during the course of the proposed study.
• Screening CD4+ T-cell count ≥ 400 cells/mm3 performed in a laboratory that has a Clinical Laboratory Improvement Amendments (CLIA) certification or its equivalent.
• HIV-1 RNA >50 copies/mL within the last 180 days prior to entry.
• Screening serum phosphate > 2.6 mg/dL within 60 days prior to entry.
• Certain laboratory values, as detailed in section 4.1.6 of the protocol, obtained within 30 days prior to entry
• Female subjects of reproductive potential must have a negative serum or urine pregnancy test performed within 30 days prior to entry.

• Female subjects participating in sexual activity that could lead to pregnancy must agree to use at least one of the following forms of birth control for at least 30 days prior to study entry until the final study visit:

  • Condoms (male or female) with or without a spermicidal agent
  • Diaphragm or cervical cap with spermicide
  • Intrauterine device (IUD)
  • Hormone-based contraceptive
• Female subjects who are not of reproductive potential are eligible without requiring the use of a contraceptive.
• Confirmation of the availability of the stored pre-entry plasma and peripheral blood mononuclear cell (PBMC) samples for endotoxin, sCD14, and immune activation determinations, obtained from a fasting sample.
• Ability and willingness of subject to provide informed consent.
• No plans to use probiotics (defined as products that contain significant amounts of live microorganisms and are ingested for specific health benefits, e.g., yogurt with live and active cultures, Lactobacillus GG, Saccharomyces boulardii) during the study.

Exclusion Criteria:

• Known diagnosis of acute HIV infection within 180 days prior to study entry.
• Pregnant or breastfeeding.
• Use of any antiretroviral agent within 24 weeks prior to study entry.
• Use of systemic cancer chemotherapy or radiation therapy, immunosuppressive or immunomodulatory therapy (e.g., interferons, tumor necrosis factor antagonists, interleukins, systemic corticosteroids) within 24 weeks prior to study entry.

NOTE A: Use of inhaled steroids, nasal steroids, topical steroids, or the equivalent of 10 mg of prednisone or less per day or a less than 2-week course of oral steroids is not exclusionary.

NOTE B: A single course of 1% hydrocortisone cream applied up to 3 times a day to <10 square inches area for <2 weeks is permitted while on study. Use of all other topical steroids is excluded.

• Known allergy/sensitivity or any hypersensitivity to components of the study drug or its formulation.
• Active drug or alcohol use or dependence that, in the opinion of the site investigator, would interfere with adherence to study requirements.
• Serious illness requiring systemic treatment and/or hospitalization within 60 days prior to study entry.
• Known cirrhosis or severe liver disease (e.g., ascites, encephalopathy, history of variceal bleeding).

NOTE: Potential subjects with chronic hepatitis B or C virus infection who do not have known cirrhosis or severe liver disease may participate in the study.

• Severe kidney disease (defined as estimated glomerular filtration rate [GFR] <30 mL/min/1.73m2) at screening.
• History of bowel obstruction or severe GI motility disorders including severe constipation.
• Severe dysphagia or swallowing disorders.
• Major GI tract surgery within 60 days prior to study entry.
• Intent to initiate or change the dose of lipid-lowering drugs during study. NOTE: Potential subjects on stable doses of lipid-lowering agents (defined as no change in preparation or dose within 90 days prior to study entry) are permitted and may be enrolled.
• Use of investigational therapies within 90 days prior to study entry unless permission was granted by the A5296 protocol chairs (see Study Management page).
• Currently receiving hepatitis C therapy or anticipation that such therapy will be started during the study.
• Use of probiotics, for more than 3 consecutive days within the 60 days prior to study entry.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: NA
• Interventional Model: SINGLE_GROUP
• Masking: NONE

Number of Arms

1

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
EXPERIMENTAL: Sevelamer carbonate; Patients will be administered two 800 mg tablets of Sevelamer carbonate orally three times a day for 8 weeks.	Drug: Sevelamer carbonate; Patients will be administered two 800 mg tablets of Sevelamer carbonate orally three times a day for 8 weeks.; Other Names: Renvela; Device: Sevelamer carbonate; Other Names: Renvela

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Endotoxin	Change in LPS from baseline to week 8, where baseline value is the average of pre-entry and entry values.	baseline and Week 8
Change in Soluble CD14 (sCD14)	Change in soluble CD14 (sCD14) from baseline to week 8, where baseline value is the average of pre-entry and entry	baseline and week 8

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Endotoxin	Change in endotoxin from baseline to week 4, where baseline value is the average of pre-entry and entry	baseline and week 4
Change in Endotoxin	Change in endotoxin from week 8 to week 16	week 8 and week 16
Change in sCD14	Change in sCD14 from baseline to week 4, where baseline value is the average of pre-entry and entry	baseline and week 4
Change in sCD14	Change in sCD14 from week 8 to week 16	week 8 and week 16
Change in CD4+ T-cell Activation	Change from baseline to week 8 in CD4+ T-cell activation, defined as the %CD38+/HLA-DR+, where baseline value is the average of pre-entry and entry	baseline and week 8
Change in CD4+ T-cell Activation	Change from baseline to week 4 in CD4+ T-cell activation, defined as the %CD38+/HLA-DR+, where baseline value is the average of pre-entry and entry	baseline and week 4
Change in CD4+ T-cell Activation	Change from week 8 to week 16 in CD4+ T-cell activation, defined as the %CD38+/HLA-DR+	week 8 and week 16
Change in CD8+ T-cell Activation	Change from baseline to week 4 in CD8+ T-cell activation, defined as the %CD38+/HLA-DR+, where baseline value is the average of pre-entry and entry	baseline and week 4
Change in CD8+ T-cell Activation	Change in CD8+ T-cell activation defined as the %CD38+/HLA-DR+ from baseline to week 8, where baseline is the average of pre-entry and entry	Baseline and Week 8
Change in CD8+ T-cell Activation	Change in CD8+ T-cell activation defined as the %CD38+/HLA-DR+ from week 8 to week 16	week 8 and week 16
Change in Proportion of Cycling CD8+	Change from baseline to week 4 in cycling CD8+ , defined as the %Ki67+, where baseline value is the average of pre-entry and entry	baseline and week 4
Change in Proportion of Cycling CD8+	Change from baseline to week 8 in cycling CD8+ , defined as the %Ki67+, where baseline value is the average of pre-entry and entry	baseline and week 8
Change in Proportion of Cycling CD8+	Change from week 8 to week 16 in cycling CD8+ , defined as the %Ki67+	from week 8 to week 16
Change in Proportion of Cycling CD4+	Change from baseline to week 4 in cycling CD4+ , defined as the %Ki67+, where baseline value is the average of pre-entry and entry	baseline and week 4
Change in Proportion of Cycling CD4+	Change from baseline to week 8 in cycling CD4+ , defined as the %Ki67+, where baseline value is the average of pre-entry and entry	baseline and week 8
Change in Proportion of Cycling CD4+	Change from week 8 to week 16 in cycling CD4+ , defined as the %Ki67+	week 8 and week 16
Change in Blood Phosphate Levels	Change in blood phosphate levels from baseline to week 4, where baseline value is the average of pre-entry and entry	from baseline to week 4
Change in Blood Phosphate Levels	Change in blood phosphate levels from baseline to week 8	Baseline to Week 8
Change in Blood Phosphate Levels	Change in blood phosphate levels from week 8 to week 16	from week 8 to week 16
Change in log10 HIV RNA Levels	Change in log10 HIV RNA levels from baseline to week 4, where baseline value is the average of pre-entry and entry	baseline and week 4
Change in log10 HIV RNA Levels	Change in log10 HIV RNA levels from baseline to week 8, where baseline value is the average of pre-entry and entry	baseline and week 8
Change in log10 HIV RNA Levels	Change in log10 HIV RNA levels from week 8 to week 16	week 8 and week 16
Change in CD4+ T-cell Counts	Change in CD4+ T-cell counts from baseline to week 4, where baseline is the average of pre-entry and entry	baseline and week 4
Change in CD4+ T-cell Counts	Change in CD4+ T-cell counts from baseline to week 8, where baseline is the average of pre-entry and entry	baseline and week 8
Change in CD4+ T-cell Counts	Change in CD4+ T-cell counts from week 8 to week 16	week 8 and week 16
Change in IL-6	Changes in levels of systemic inflammation marker IL-6 from baseline to week 4, where baseline is the average of pre-entry and entry	baseline and week 4
Change in IL-6	Changes in levels of systemic inflammation marker IL-6 from baseline to week 8, where baseline is the average of pre-entry and entry	baseline and week 8
Change in IL-6	Changes in levels of systemic inflammation marker IL-6 from week 8 to week 16	week 8 and week 16
Change in C-reactive Protein (CRP)	Changes in levels of systemic inflammation marker CRP from baseline to week 4, where baseline is the average of pre-entry and entry	baseline and week 4
Change in CRP	Changes in levels of systemic inflammation marker CRP from baseline to week 8, where baseline is the average of pre-entry and entry	Baseline and Week 8
Change in CRP	Changes in levels of systemic inflammation marker CRP from week 8 to week 16, where baseline is the average of pre-entry and entry	week 8 and week 16
Change in D-dimer	Change in levels of coagulation biomarker d-dimer from baseline to week 4, where baseline value is the average of pre-entry and entry	baseline and week 4
Change in D-dimer	Change in levels of coagulation biomarker d-dimer from baseline to week 8, where baseline value is the average of pre-entry and entry	baseline and week 8
Change in D-dimer	Change in levels of coagulation biomarker d-dimer from week 8 to week 16	week 8 and week 16
Change in Tissue Factor	Change in levels of coagulation biomarker tissue factor from baseline to week 4, where baseline value is the average of pre-entry and entry	baseline and week 4
Change in Tissue Factor	Change in levels of coagulation biomarker tissue factor from baseline to week 8, where baseline value is the average of pre-entry and entry	baseline and week 8
Change in Tissue Factor	Change in levels of coagulation biomarker tissue factor from week 8 to week 16	week 8 and week 16
Change in Total Cholesterol	Change in total cholesterol from baseline to week 8, where baseline value is the average of pre-entry and entry	baseline and week 8
Change in Total Cholesterol	Change in total cholesterol from week 8 to week 16	week 8 and week 16
Change in LDL Cholesterol	Change in fasting LDL cholesterol from baseline to week 8, where baseline value is the average of pre-entry and entry	baseline and week 8
Change in LDL Cholesterol	Change in fasting LDL cholesterol from week 8 to week 16	week 8 and week 16
Change in HDL Cholesterol	Change in fasting HDL cholesterol from baseline to week 8, where baseline value is the average of pre-entry and entry	baseline and week 8
Change in HDL Cholesterol	Change in fasting HDL cholesterol from week 8 to week 16	from week 8 to week 16
Change in Non-HDL Cholesterol	Change in non-HDL cholesterol from baseline to week 8, where baseline value is the average of pre-entry and entry	baseline and week 8
Change in Non-HDL Cholesterol	Change in non-HDL cholesterol from week 8 to week 16	week 8 and week 16
Change in Fasting Glucose	Change in fasting glucose from baseline to week 8, where baseline value is the average of pre-entry and entry	baseline and week 8
Change in Fasting Glucose	Change in fasting glucose from week 8 to week 16	week 8 and week 16
Primary Adverse Events	Number of subjects experiencing primary adverse events, defined as all reported Grade ≥ 2 signs and symptoms, Grade ≥ 2 laboratory abnormalities and other serious adverse events (SAEs)	baseline and week 16

Collaborators and Investigators

• Sponsor: AIDS Clinical Trials Group
• Collaborators: National Institute of Allergy and Infectious Diseases (NIAID)
• Investigators: Study Chair: Rajesh Gandhi, MD, Massachusetts General Hospital ACTG CRS; Study Chair: Netanya Sandler, MD, National Institutes of Health (NIH)

Publications and helpful links

General Publications

• Sandler NG, Zhang X, Bosch RJ, Funderburg NT, Choi AI, Robinson JK, Fine DM, Coombs RW, Jacobson JM, Landay AL, Douek DC, Tressler R, Read SW, Wilson CC, Deeks SG, Lederman MM, Gandhi RT; AIDS Clinical Trials Group A5296 Team. Sevelamer does not decrease lipopolysaccharide or soluble CD14 levels but decreases soluble tissue factor, low-density lipoprotein (LDL) cholesterol, and oxidized LDL cholesterol levels in individuals with untreated HIV infection. J Infect Dis. 2014 Nov 15;210(10):1549-54. doi: 10.1093/infdis/jiu305. Epub 2014 May 26.

Study record dates

Study Major Dates

• Study Start: November 1, 2011
• Primary Completion (ACTUAL): September 1, 2012
• Study Completion (ACTUAL): November 1, 2012

Study Registration Dates

• First Submitted: February 29, 2012
• First Submitted That Met QC Criteria: February 29, 2012
• First Posted (ESTIMATE): March 5, 2012

Study Record Updates

• Last Update Posted (ACTUAL): October 11, 2018
• Last Update Submitted That Met QC Criteria: September 11, 2018
• Last Verified: September 1, 2018

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Pathologic Processes; Infections; Systemic Inflammatory Response Syndrome; Inflammation; Sepsis; Bacteremia; Toxemia; Endotoxemia; Molecular Mechanisms of Pharmacological Action; Chelating Agents; Sequestering Agents; Sevelamer
• Other Study ID Numbers: ACTG A5296; 1U01AI068636 (U.S. NIH Grant/Contract)