Safety Study of Fluconazole in Combination With Flucytosine for the Treatment of Early Cryptococcal Infection (SToP-Crypto)

An Open Label Randomized Controlled Phase IIb Trial to Determine the Safety of Oral Fluconazole in Combination With Flucytosine as Compared to Fluconazole Alone

The purpose of this study is to determine if treatment with two medicines in combination (fluconazole and flucytosine) is safe as compared with one medicine alone (fluconazole) for the treatment of an early infection with a fungus called cryptococcus.

Study Overview

• Status: Terminated
• Conditions: Cryptococcal Infection Disseminated
• Intervention / Treatment: Drug: Flucytosine and fluconazole; Drug: Fluconazole

Detailed Description

Currently there is wide variation in practice and little evidence to guide the treatment of early cryptococcal infection in HIV-infected individuals with advanced immunosuppression. However, epidemiologic studies suggest that this may be a promising novel approach to decrease the mortality due to cryptococcal meningitis (CM), the second leading cause of death among HIV-infected individuals in many resource-limited settings. Screening asymptomatic HIV-infected individuals with advanced immunosuppression for serum cryptococcal antigen (CrAg) clearly identifies a population at high risk of CM and death and is a feasible screening method for resource-limited settings. However, screening with serum CrAg alone without additional diagnostic studies identifies a heterogeneous clinical population with early cryptococcal infection, many of whom already have sub-clinical meningeal infection or fungemia. The mainstay of anti-cryptococcal therapy in resource-limited settings is oral fluconazole though preliminary evidence suggests this is not an effective treatment. Thus, there is a critical need for potent therapies that (1) can be safely administered in resource-limited settings and (2) are effective in a heterogeneous population of HIV-infected individuals with advanced immunosuppression and early cryptococcal infection who are initiating anti-retroviral therapy (ART).

This single center, open-label, randomized Phase IIb study is being conducted to assess the safety and estimate the efficacy of oral fluconazole in combination with flucytosine for the treatment of early cryptococcal infection. The study will be based at two sites supported by Family AIDS Care and Education Services (FACES) in Western Kenya. A consecutive sample of 100 HIV-infected adults with CD4 cell count ≤100 cells/µl and serum CrAg titer ≥1:2 who have no signs or symptoms of severe, systemic cryptococcal infection will be enrolled. At enrollment, specimens from participants will be cultured for evidence of Cryptococcus neoformans. Individuals who meet inclusion and exclusion criteria and consent to participate in the study will be randomized to combination therapy with oral fluconazole (1200mg/day) plus flucytosine (100mg/kg/day) or fluconazole alone for the fourteen days of therapy. Subsequently both groups will receive anti-retroviral therapy as well as fluconazole 800mg/day for 8 weeks followed by 200mg/day. The primary safety endpoint will be the incidence of treatment-related adverse events and serious adverse events. The primary efficacy endpoint will be survival at 12 weeks.

In addition, we will offer additional diagnostic testing and aim for 50% participation, approximately 25 individuals from each arm. We will perform a battery of diagnostic tests including chest radiography, fungal cultures in blood, sputum, urine, stool and cerebrospinal fluid (CSF), cryptococcal antigen testing in the CSF, and gram stain, Ziehls-Nielsen stain and India Ink staining of CSF sediment. Anti-fungal susceptibility testing via broth microdilution and polymerase chain reaction serotyping and mating type analysis will be performed on clinical isolates.

• Study Type: Interventional
• Enrollment (Actual): 6
• Phase: Phase 2

Contacts and Locations

Study Locations

• Kenya
  • Nyanza
    • Kisumu, Nyanza, Kenya
      • Family AIDS Care and Education Services
    • Sindo, Nyanza, Kenya
      • Family AIDS Care and Education Services

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:

• Able and willing to give informed consent
• Age > 18 years
• HIV infection as confirmed by HIV-antibody test as per Kenyan guidelines
• CD4+ T-cell count ≤100 cells/µl
• Serum CrAg titer≥1:2
• Able to travel to district hubs (Sindo District Hospital, Lumumba Health Centre) for regular study visits

Exclusion Criteria:

• clinical meningitis:
• clinical sepsis:
• hemiparesis, aphasia, visual field deficit or other finding on neurological examination localizable to the central nervous system
• a history of culture proven or suspected (cryptococcal antigen present) cryptococcal meningitis
• a history of stroke or other infection of the central nervous system
• a seizure within the last 2 months
• currently taking or ever taken antiretroviral therapy
• currently taking anti-tuberculous therapy
• currently or recently (<2 months) prescribed fluconazole, itraconazole, clotrimazole troches, amphotericin or other oral anti-fungal medications
• pregnant or breast-feeding
• alanine aminotransferase concentration more than 3 times the upper limit of normal
• neutrophil count <1000x103 cells/mL
• hemoglobin <8g/dL
• platelet count <100,000x 103 platelets/mL
• creatinine clearance ≤50 ml/min
• individuals with active heavy alcohol use or active recreational drug use

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: RANDOMIZED
• Interventional Model: PARALLEL
• Masking: NONE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
EXPERIMENTAL: 5FC plus fluconazole; Combination therapy with oral fluconazole and flucytosine	Drug: Flucytosine and fluconazole; Flucytosine 100mg/kg/day in 4 divided doses orally for 14 days given in combination with fluconazole 1200mg orally once daily for 14 days, followed by 800mg orally once daily for 8 weeks, followed by 200mg orally once daily; Other Names: Diflucan; Ancobon
ACTIVE_COMPARATOR: fluconazole alone; Fluconazole monotherapy	Drug: Fluconazole; fluconazole 1200mg orally once daily for 14 days, followed by 800mg orally once daily for 8 weeks, followed by 200mg orally once daily; Other Names: Diflucan

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Number of Participants Alive at 12 Weeks	12 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Participants Alive at 2 Weeks		2 weeks
Survival at 24 Weeks		24 weeks
Number of Individuals Who Develop Cryptococcal Meningitis	Clinical meningitis AND at least one of the following: cryptococcal antigen in the cerebrospinal fluid (CSF), cryptococcal organisms on India Ink stain, or fungal culture of CSF. Clinical meningitis will be defined as: fever>39.0°C, AND; severe headache, AND At least one of the following: meningismus,; photophobia,; new onset seizure,; focal neurological deficit localizable to the central nervous system; papilledema; confusion, delirium, or decreased level of consciousness.	24 weeks
Number of Individuals Who Develop Immune Reconstitution Inflammatory Syndrome Due to Cryptococcus	Individuals who develop clinical meningitis without evidence of fungal, bacterial, or parasitic (e.g. malaria) organisms in the cerebrospinal fluid. Clinical meningitis will be defined as: fever>39.0°C, AND; severe headache, AND; At least one of the following:; meningismus,; photophobia,; new onset seizure,; focal neurological deficit localizable to the central nervous system; papilledema; confusion, delirium, or decreased level of consciousness.	24 weeks
Achieve Targeted Recruitment, Retention and Adherence Rates		24 weeks
Proportion of Individuals Requiring Treatment Discontinuation		4 weeks
Proportion of Individuals Requiring Dose Reduction		24 weeks
Number of Individuals With Treatment Related Adverse Events		24 weeks
Number of Individuals With Treatment Related Serious Adverse Events		24 weeks
Cryptococcal Meningitis-free Survival at 24 Weeks	Clinical meningitis AND at least one of the following: cryptococcal antigen in the cerebrospinal fluid (CSF), cryptococcal organisms on India Ink stain, or fungal culture of CSF. Clinical meningitis will be defined as: fever>39.0°C, AND; severe headache, AND At least one of the following: meningismus,; photophobia,; new onset seizure,; focal neurological deficit localizable to the central nervous system; papilledema; confusion, delirium, or decreased level of consciousness.	24 weeks

Collaborators and Investigators

• Sponsor: Yale University
• Collaborators: National Institute of Neurological Disorders and Stroke (NINDS); University of Nairobi; Bausch Health Americas, Inc.; Kenya Medical Research Institute
• Investigators: Principal Investigator: Ana-Claire L Meyer, MD, MSHS, University of California, San Francisco; Principal Investigator: Judith K Kwasa, MBChB MMed, University of Nairobi

Study record dates

Study Major Dates

• Study Start: September 1, 2013
• Primary Completion (ACTUAL): July 1, 2014
• Study Completion (ACTUAL): July 1, 2014

Study Registration Dates

• First Submitted: March 21, 2012
• First Submitted That Met QC Criteria: March 21, 2012
• First Posted (ESTIMATE): March 23, 2012

Study Record Updates

• Last Update Posted (ACTUAL): September 29, 2021
• Last Update Submitted That Met QC Criteria: September 1, 2021
• Last Verified: September 1, 2021

More Information

Terms related to this study

• Keywords: HIV; cryptococcus
• Additional Relevant MeSH Terms: Infections; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Anti-Infective Agents; Enzyme Inhibitors; Antimetabolites; Hormones, Hormone Substitutes, and Hormone Antagonists; Cytochrome P-450 Enzyme Inhibitors; Hormone Antagonists; Antifungal Agents; Steroid Synthesis Inhibitors; 14-alpha Demethylase Inhibitors; Cytochrome P-450 CYP2C9 Inhibitors; Cytochrome P-450 CYP2C19 Inhibitors; Fluconazole; Flucytosine
• Other Study ID Numbers: 1307012426; R21NS077858-01 (NIH)

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No