Shortening Treatment by Advancing Novel Drugs (STAND)

A Phase 3 Open-Label Partially Randomized Trial to Evaluate the Efficacy, Safety and Tolerability of the Combination of Moxifloxacin Plus PA-824 Plus Pyrazinamide After 4 and 6 Months of Treatment in Adult Subjects With Drug-Sensitive Smear-Positive Pulmonary Tuberculosis and After 6 Months of Treatment in Adult Subjects With Multi-Drug Resistant, Smear-Positive Pulmonary Tuberculosis.

The purpose of this study is to assess the efficacy, safety and tolerability of a combination of moxifloxacin, PA-824, and pyrazinamide treatments with varying doses and treatment lengths from 4 to 6 months in subjects with drug-sensitive (DS) pulmonary TB compared to standard HRZE treatment.

This study will also assess the efficacy, safety and tolerability of a combination of moxifloxacin, PA-824, and pyrazinamide treatments after 6 months of treatment in subjects with multi drug-resistant (MDR) pulmonary TB compared to a combination of moxifloxacin, PA-824, and pyrazinamide treatments in DS-TB subjects.

Study Overview

• Status: Completed
• Conditions: Tuberculosis, Pulmonary, Drug Sensitive; Tuberculosis, Pulmonary, Multi Drug-resistant
• Intervention / Treatment: Drug: Moxifloxacin; Drug: PA-824; Drug: Pyrazinamide; Drug: HRZE (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol combination); Drug: HR (rifampicin plus isoniazid combination tablets)

• Study Type: Interventional
• Enrollment (Actual): 284
• Phase: Phase 3

Contacts and Locations

Study Locations

• Georgia
  • Tbilisi, Georgia, 0101
    • National Center for Tuberculosis and Lung Diseases
• Kenya
  • Nairobi, Kenya
    • Centre for Respiratory Disease Research (CRDR) Keny Medical Research Institute (KEMRI)
  • Nairobi, Kenya
    • Centre for Respiratory Disease Research (CRDR) Kenya Medical Research Institute (KEMRI)
• Malaysia
  • Kuala Lumpur, Malaysia, 53000
    • Institute of Respiratory Medicine (IPR)
  • Kuala Lumpur
    • Cheras, Kuala Lumpur, Malaysia
      • Pusat Perubatan Universiti Kebangsaan
  • Selangor
    • Batu Caves, Selangor, Malaysia
      • Universiti Teknologi Mara
• Philippines
  • Manila, Philippines, 1104
    • Lung Center of Philippines
  • Manila
    • Ermita, Manila, Philippines, 1000
      • Philippine General Hospital
    • Pio del Pilar, Manila, Philippines, 1230
      • Vincent Balang
• South Africa
  • Brits, South Africa, 0250
    • Madibeng Centre for Research (MCR)
  • Durban, South Africa, 4001
    • THINK: Tuberculosis & HIV Investigative Network of Kwazulu Natal
  • Klerksdorp, South Africa
    • The Aurum Institute
  • Rustenburg, South Africa
    • The Aurum Institute: Rustenberg
  • Cape Town
    • Bellville, Cape Town, South Africa, 7531
      • TASK
    • Mowbray, Cape Town, South Africa, 7700
      • University of Cape Town Lung Institute
  • Gauteng
    • Pretoria, Gauteng, South Africa
      • Setshaba Research Centre
    • Tembisa, Gauteng, South Africa, 1632
      • The Aurum Institute: Tembisa Hospital Cnr
  • Johannesburg
    • Westdene, Johannesburg, South Africa
      • CHRU Themba Lethu Clinic
  • KwaZulu-Natal
    • Durban, KwaZulu-Natal, South Africa, 4001
      • Durban International Clinical Trials Unit (DbnlCTU)
  • North West Province
    • Klerksdorp, North West Province, South Africa, 2571
      • Klerksdorp Tshepong Hospital
  • Pretoria
    • Mamelodi East, Pretoria, South Africa
      • Synexus SA
• Tanzania
  • Dar es Salaam, Tanzania
    • Ifakara Health Institute (IHI)
  • Mbeya, Tanzania
    • NIMR - Mbeya Medical Research Programme (MMRP)
  • Mwanza, Tanzania
    • Kilimanjaro National Institute for Medical Research
• Uganda
  • Kampala, Uganda
    • Uganda CWRU Research Collaboration
• Zambia
  • Lusaka, Zambia
    • Centre for Infectious Disease Research in Zambia (CIDRZ)

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:

1. Signed written consent or witnessed oral consent in the case of illiteracy, prior to undertaking any trial-related procedures.
2. Male or female, aged 18 years or over.
3. Body weight (in light clothing and no shoes) ≥ 30 kg.
4. Sputum positive for tubercule bacilli (at least 1+ on the International Union Against Tuberculosis and Lung Disease (IUATLD) and World Health Organization (WHO) scale on smear microscopy at the trial laboratory.

5. Drug-Sensitive TB treatment arms subjects should be:

   • sensitive to rifampicin by rapid sputum based test (may be sensitive or resistant to isoniazid) AND
   • either newly diagnosed for TB or have a patient history of being untreated for at least 3 years after cure from a previous episode of TB. If they are entered into the trial due to being sensitive to rifampicin by rapid sputum based test, however on receipt of the rifampicin resistance testing using an indirect susceptibility test in liquid culture this shows they are rifampicin resistant, they will be:
   • Excluded as late exclusions;
   • Possibly replaced as determined by the sponsor.
6. MDR-TB treatment arm subjects should be resistant to rifampicin by rapid sputum based test (may be sensitive or resistant to isoniazid).
7. A chest x-ray which in the opinion of the investigator is compatible with pulmonary TB.
8. Be of non-childbearing potential or using effective methods of birth control, as defined below:

Non-childbearing potential:

• Subject - not heterosexually active or practice sexual abstinence; or
• Female subject or male subjects female sexual partner - bilateral oophorectomy, bilateral tubal ligation and/or hysterectomy or has been postmenopausal with a history of no menses for at least 12 consecutive months; or
• Male subject or female subjects male sexual partner - vasectomised or has had a bilateral orchidectomy minimally three months prior to screening;

Effective birth control methods:

• Double barrier method which can include a male condom, diaphragm, cervical cap, or female condom; or
• Female subject: Barrier method combined with hormone-based contraceptives or an intra-uterine device for the female patient.
• Male subjects' female sexual partner: Double barrier method or hormone-based contraceptives or an intra-uterine device for the female partner.

and are willing to continue practising birth control methods and are not planning to conceive throughout treatment and for 12 weeks (male subjects) or 1 week (female subjects) after the last dose of trial medication or discontinuation from trial medication in case of premature discontinuation.

(Note: Hormone-based contraception alone may not be reliable when taking IMP; therefore,

Exclusion Criteria:

1. Any non TB related condition (including myasthenia gravis) where participation in the trial, as judged by the investigator, could compromise the well-being of the subject or prevent, limit or confound protocol specified assessments.
2. Being or about to be treated for Malaria.
3. Is critically ill and, in the judgment of the investigator, has a diagnosis likely to result in death during the trial or the follow-up period.
4. TB meningitis or other forms of extrapulmonary tuberculosis with high risk of a poor outcome, or likely to require a longer course of therapy (such as TB of the bone or joint), as judged by the investigator.
5. History of allergy or hypersensitivity to any of the trial IMP or related substances, including known allergy to any fluoroquinolone antibiotic, history of tendinopathy associated with quinolones or suspected hypersensitivity to any rifampicin antibiotics.

6. For HIV infected subjects any of the following:

   • CD4+ count <100 cells/µL;
   • Karnofsky score <60%;
   • Received intravenous antifungal medication within the last 90 days;
   • WHO Clinical Stage 4 HIV disease.

7. Resistant to fluoroquinolones (rapid, sputum - based molecular screening tests). If they are entered into the trial due to being sensitive to fluoroquinolones by rapid sputum based test, however on receipt of the fluoroquinolones resistance testing using an indirect susceptibility test in liquid culture this shows they are fluoroquinolones resistant, they will be:

   • Excluded as late exclusions;
   • Possibly replaced as determined by the sponsor.

8. Resistant to pyrazinamide (rapid, sputum - based molecular screening tests).

   Drug-Sensitive TB treatment arms subjects may be entered prior to receipt of the rapid, sputum - based molecular pyrazinamide resistance screening test result. On receipt of the result, if they are resistant, they will be:

   • Excluded as late exclusions;
   • Possibly replaced as determined by the sponsor. MDR-TB treatment arm subjects may not be entered prior to receipt of the rapid, sputum - based molecular pyrazinamide resistance screening test result showing they are sensitive to pyrazinamide.
9. Having participated in other clinical trials with investigational agents within 8 weeks prior to trial start or currently enrolled in an investigational trial.

10. Subjects with any of the following at screening (per measurements and reading done by Central Electrocardiogram (ECG) where applicable):

    • Cardiac arrhythmia requiring medication;
    • Prolongation of QT/QTc interval with QTcF (Fridericia correction) >450 ms;
    • History of additional risk factors for Torsade de Pointes, (e.g., heart failure, hypokalemia, family history of Long QT Syndrome);
    • Any clinically significant ECG abnormality, in the opinion of the investigator.

11. Unstable Diabetes Mellitus which required hospitalization for hyper- or hypo-glycaemia within the past year prior to start of screening.

    Specific Treatments

12. Previous treatment with PA-824 as part of a clinical trial.

13. For DS-TB treatment arms: Previous treatment for tuberculosis within 3 years prior to Day (-9 to -1)(Screening). Subjects who have previously received isoniazid prophylactically may be included in the trial as long as that treatment is/was discontinued at least 7 days prior to randomization into this trial.

    For the MDR-TB Subjects: Previous treatment for MDR-TB, although may have been on a MDR TB treatment regimen for no longer than 7 days at start of screening.

    Previous treatment for TB includes, but is not limited to, gatifloxacin, amikacin, cycloserine, rifabutin, kanamycin, para-aminosalicylic acid, rifapentine, thioacetazone, capreomycin, quinolones, thioamides, and metronidazole.

14. Any diseases or conditions in which the use of the standard TB drugs or any of their components is contra-indicated, including but not limited to allergy to any TB drug, their component or to the IMP.
15. Use of any drug within 30 days prior to randomisation known to prolong QTc interval (including, but not limited to, amiodarone, amitriptyline, bepridil, chloroquine, chlorpromazine, cisapride, clarithromycin, disopyramide dofetilide, domperidone, droperidol, erythromycin, halofantrine, haloperidol, ibutilide, levomethadyl, mesoridazine, methadone, pentamidine, pimozide, procainamide, quinacrine, quinidine, sotalol, sparfloxacin, thioridazine).
16. Use of systemic glucocorticoids within one year of start of screening (inhaled or intranasal glucocorticoids are allowed).

17. Subjects recently started or expected to need to start anti-retroviral therapy (ART) within 1 month after randomization. Subjects may be included who have been on ARTs for greater than 30 days prior to start of screening, or who are expected to start ART greater than 30 days after randomization.

    Laboratory Abnormalities

18. Subjects with the following toxicities at screening as defined by the enhanced Division of Microbiology and Infectious Disease (DMID) adult toxicity table (November 2007), where applicable:

    • creatinine grade 2 or greater (>1.5 times upper limit of normal [ULN]);
    • creatinine clearance (CrCl) level less than 30 mLs/min according to the Cockcroft-Gault Formula;
    • haemoglobin grade 4 (<6.5 g/dL);
    • platelets grade 3 or greater (under 50x109 cells/L/ 50 000/mm3);
    • serum potassium less than the lower limit of normal for the laboratory. This may be repeated once;
    • aspartate aminotransferase (AST) grade 3 or greater (≥3.0 x ULN) ;
    • alanine aminotransferase (ALT) grade 3 or greater (≥3.0 x ULN);

    • alkaline phosphatase (ALP):

      • grade 4 (>8.0 x ULN) to be excluded;
      • grade 3 (≥3.0 - 8.0 x ULN) must be discussed with and approved by the sponsor Medical Monitor;

    • total bilirubin:

      • 2.0 x ULN, when other liver functions are in the normal range
      • 1.50 x ULN when accompanied by any increase in other liver function tests subjects with total bilirubin > 1.25 x ULN and accompanied by any increase in other liver function tests must be discussed with the sponsor medical monitor before enrollment

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

5

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: MDR-TB; moxifloxacin 400 mg + PA-824 200 mg + pyrazinamide 1500 mg for 26 weeks.	Drug: Moxifloxacin; Oral; Other Names: Avelox; BAY 12-8039; Avalon; Avelon; Drug: PA-824; Oral; Drug: Pyrazinamide; Oral
Active Comparator: DS-TB (HRZE), HR; 26 consecutive weeks to DS-TB subjects only, as follows: HRZE (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol combination) Weeks 1-8 with daily dose per the subjects weight HR (Rifampicin plus isoniazid combination tablets) Weeks 9 - 26 with daily dose per the subjects weight Daily dose per the subjects weight as follows: 30-39kg: 2 tablets; 40-54kg: 3 tablets; 55 - 70kg: 4 tablets; 71kg and over: 5 tablets.	Drug: HRZE (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol combination); Oral; Other Names: Rifafour e-275; Drug: HR (rifampicin plus isoniazid combination tablets); Oral
Experimental: DS-TB PA-824 200mg 26 weeks; moxifloxacin 400 mg + PA-824 200 mg + pyrazinamide 1500 mg orally once daily for 26 weeks	Drug: Moxifloxacin; Oral; Other Names: Avelox; BAY 12-8039; Avalon; Avelon; Drug: PA-824; Oral; Drug: Pyrazinamide; Oral
Experimental: DS-TB PA-824 200mg 17 weeks; moxifloxacin 400 mg + PA-824 200 mg + pyrazinamide 1500 mg orally once a day for 17 weeks	Drug: Moxifloxacin; Oral; Other Names: Avelox; BAY 12-8039; Avalon; Avelon; Drug: PA-824; Oral; Drug: Pyrazinamide; Oral
Experimental: DS-TB PA-824 100mg 17 weeks; moxifloxacin 400 mg + PA-824 100 mg + pyrazinamide 1500 mg orally once daily for 17 weeks	Drug: Moxifloxacin; Oral; Other Names: Avelox; BAY 12-8039; Avalon; Avelon; Drug: PA-824; Oral; Drug: Pyrazinamide; Oral

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Incidence of Combined Bacteriologic Failure or Relapse or Clinical Failure at Month 12 From Start of Therapy (Day 1) (Modified Intent to Treat [MITT] Population)	Patients were classified as having a favorable, unfavorable or unassessable status at 12 months from the start of therapy. A favourable status was a negative culture status at 12 months from start of therapy in patients who had not already been classified as having an unfavorable outcome, and whose last positive culture result was followed by at least 2 negative culture results. Patients with an unfavorable status did not achieve/maintain culture negative status, or previously had culture negative status who following end of treatment (EOT), had 2 positive cultures, or had a positive culture not followed by 2 negative cultures, or were dying from any cause during treatment (except accidental cause not including suicide), or were dying from TB related causes during follow-up, or required an extension, restart or change of treatment except for reinfection/pregnancy, or failed to complete adequate treatment who were unassessable at 12 months or lost to follow-up/withdrawn before EOT.	From Day 1 to Month 12.
Incidence of Combined Bacteriologic Failure or Relapse or Clinical Failure at Month 12 From Start of Therapy (Day 1) (Per Protocol [PP] Population)	Patients were classified as having a favorable, unfavorable or unassessable status at 12 months from the start of therapy. A favourable status was a negative culture status at 12 months from start of therapy in patients who had not already been classified as having an unfavorable outcome, and whose last positive culture result was followed by at least 2 negative culture results. Patients with an unfavorable status did not achieve/maintain culture negative status, or previously had culture negative status who following EOT, had 2 positive cultures, or had a positive culture not followed by 2 negative cultures, or died from any cause during treatment (except accidental cause not including suicide), or were dying from TB related causes during follow-up, or required a restart or change of treatment because of an unfavorable outcome with or without bacteriological confirmation, ie, on bacteriological, radiographic or clinical grounds.	From Day 1 to Month 12.

Collaborators and Investigators

• Sponsor: Global Alliance for TB Drug Development
• Investigators: Principal Investigator: Stephen H Gillespie, MD, University of St Andrews

Study record dates

Study Major Dates

• Study Start (Actual): February 1, 2015
• Primary Completion (Actual): January 1, 2018
• Study Completion (Actual): May 1, 2018

Study Registration Dates

• First Submitted: October 14, 2014
• First Submitted That Met QC Criteria: January 15, 2015
• First Posted (Estimate): January 21, 2015

Study Record Updates

• Last Update Posted (Actual): March 26, 2019
• Last Update Submitted That Met QC Criteria: March 1, 2019
• Last Verified: March 1, 2019

More Information

Terms related to this study

• Keywords: Tuberculosis; PA-824; Ethambutol; Isoniazid; Moxifloxacin; Pretomanid; Rifampicin; Multi Drug-Resistant Tuberculosis; HR; HRZE; Pyrazinamide; Drug-sensitive Tuberculosis; NC-006; STAND
• Additional Relevant MeSH Terms: Infections; Respiratory Tract Infections; Respiratory Tract Diseases; Immune System Diseases; Lung Diseases; Bacterial Infections; Bacterial Infections and Mycoses; Gram-Positive Bacterial Infections; Actinomycetales Infections; Mycobacterium Infections; Hypersensitivity; Tuberculosis; Tuberculosis, Pulmonary; Molecular Mechanisms of Pharmacological Action; Anti-Infective Agents; Nucleic Acid Synthesis Inhibitors; Enzyme Inhibitors; Antimetabolites; Antineoplastic Agents; Topoisomerase II Inhibitors; Topoisomerase Inhibitors; Hypolipidemic Agents; Lipid Regulating Agents; Anti-Bacterial Agents; Leprostatic Agents; Cytochrome P-450 Enzyme Inducers; Cytochrome P-450 CYP3A Inducers; Antitubercular Agents; Antibiotics, Antitubercular; Cytochrome P-450 CYP2B6 Inducers; Cytochrome P-450 CYP2C8 Inducers; Cytochrome P-450 CYP2C19 Inducers; Cytochrome P-450 CYP2C9 Inducers; Fatty Acid Synthesis Inhibitors; Moxifloxacin; Rifampin; Isoniazid; Pyrazinamide; Ethambutol
• Other Study ID Numbers: NC-006-(M-PA-Z)