A Trial of Mepolizumab Adjunctive Therapy for the Prevention of Asthma Exacerbations in Urban Children (MUPPITS-2)

Mechanisms Underlying Asthma Exacerbations Prevented and Persistent With Immune-Based Therapy: A Systems Approach Phase 2 (ICAC-30)

The purpose of this study is to see if treatment with a medication called Nucala® (mepolizumab), given along with standard asthma care, makes children less likely to have asthma attacks.

Study Overview

• Status: Completed
• Conditions: Asthma
• Intervention / Treatment: Biological: Mepolizumab; Drug: Placebo

Detailed Description

Asthma is a growing problem, especially in children. It causes frequent wheezing, shortness of breath, chest tightness, and cough. Asthma attacks, or exacerbations, are problems for children with asthma.

The purpose of this study is to see if treatment with a medication called mepolizumab (Nucala®), given along with standard asthma care, makes children less likely to have asthma attacks. Mepolizumab is a new drug that is approved by the Food and Drug Administration (FDA) for use in children with asthma who are aged 12 years and older. Mepolizumab is given by injection. It is being studied by other researchers in children aged 6-11 years.

All participants will be prescribed standard asthma medications by a clinician who is trained in asthma care. Medications will include controller medications, a rescue medication, and a medication for severe asthma attacks (prednisone). The amount of medication that participants receive may be increased or decreased during the study based on their symptoms and breathing test results. Study clinicians will treat all participants according to the same guidelines. These treatment guidelines are based on recommendations from a group of national experts in asthma. This study has been designed this way so that all participants will have safe and effective standard asthma care.

In order to enroll in this study, participants must be willing to have their asthma managed by the study clinician during the entire study period. Participants must also be willing to bring study medications to all study visits.

This study will include up to 20 study visits. Participant involvement in the study will endure for approximately 1 year.

During the treatment period, participants will be placed in one of two treatment groups:

• Mepolizumab injection and guidelines-based asthma care or
• Placebo injection and guidelines-based asthma care.

Participants will not be able to choose which group they are assigned. This assignment is random and by chance, much like flipping a coin. Participants will not know if they are receiving mepolizumab or placebo. Investigators will compare the study results between the participants of each group.

• Study Type: Interventional
• Enrollment (Actual): 335
• Phase: Phase 2

Contacts and Locations

Study Locations

• United States
  • Colorado
    • Aurora, Colorado, United States, 80045
      • Children's Hospital Colorado
  • District of Columbia
    • Washington, District of Columbia, United States, 20010
      • Children's National Medical Center
  • Illinois
    • Chicago, Illinois, United States, 60611
      • Ann and Robert Lurie Children's Hospital of Chicago
  • Massachusetts
    • Boston, Massachusetts, United States, 02118
      • Boston Medical Center
  • Michigan
    • Detroit, Michigan, United States, 48202
      • Henry Ford Health System
  • Missouri
    • Saint Louis, Missouri, United States, 63110
      • St. Louis Children's Hospital
  • New York
    • New York, New York, United States, 10032
      • Columbia University Medical Center
  • Ohio
    • Cincinnati, Ohio, United States, 45229
      • Cincinnati CHildren's Hospital
  • Texas
    • Dallas, Texas, United States, 75390
      • University of Texas Southwestern Medical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 4 years to 15 years (Child)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

Study applicant(s) that fulfill all of the inclusion criteria and none of the exclusion criteria are eligible for the study-

• Participant and/or parent guardian must be able to understand and provide informed consent and age-appropriate assent;
• Must have a primary place of residence in one of the pre-selected recruitment census tracts as outlined in the study's Manual of Procedures (MOP);

• Has had a diagnosis of asthma made >1 year prior to recruitment;

  --Those who received an asthma diagnosis by a clinician ≤1 year prior to recruitment must report that their respiratory symptoms were present for more than 1 year prior to recruitment.

• Has had ≥2 asthma exacerbations in the prior year (defined as a requirement for systemic corticosteroids and/or hospitalization);

• At Visit 0 (Screening), has the following requirement for asthma controller medication:

  • For those ages 6 to 11 years, treatments with at least fluticasone 250 mcg dry powder inhaler (DPI) one puff twice daily or its equivalent and,
  • For those ≥12 years of age, treatment with at least Advair 250/50 mcg dry powder inhaler (DPI), one puff twice daily or its equivalent.
• Has peripheral blood eosinophils ≥150 cells/µl obtained at Visit 0 (Screening) or in another Inner-City Asthma Consortium (ICAC) clinical research study within 6 months;
• Is able to perform spirometry at randomization (Visit for treatment assignment);
• Has documentation of current medical insurance with prescription coverage at randomization; and
• Has had varicella or the varicella vaccination.

Exclusion Criteria:

Individual(s) who meets any of the following criteria are not eligible for enrollment or randomization-

• Is not able or willing to give written informed consent or comply with the study protocol;
• Has concurrent (existing) medical problems that would require systemic corticosteroids or other immunomodulator treatments during the study;
• Is currently receiving immunotherapy;
• Is currently receiving treatment with omalizumab or has had omalizumab treatment within 6 months prior to planned participant randomization to treatment assignment;

• Is currently requiring greater than fluticasone 500 mcg administered twice daily plus a long-acting beta agonist (LABA) one puff twice daily or its equivalent, and/or

  --Individuals using oral corticosteroids daily or every other day for more than 14 days at the time of Visit 0 (Screening).

• Is currently pregnant or lactating, or plans to become pregnant during the time of study participation

  --Note: Females of child-bearing potential (post-menarche) must be abstinent or use a medically acceptable birth control method throughout the study (e.g. oral subcutaneous, mechanical, or surgical contraception).

• Has a known, pre-existing clinically important lung condition other than asthma;
• Has a current malignancy or previous history of cancer in remission for less than 12 months prior to randomization;
• Has known, pre-existing, unstable liver disease;
• Is a current smoker or has a smoking history of 10 or more pack years;
• Has a known immunodeficiency disease;
• Has other conditions that could lead to elevated eosinophils such as hypereosinophilic syndromes, including eosinophilic granulomatosis with polyangiitis;

• Has a known, active pre-existing parasitic infestation or is undergoing treatment for a parasitic infestation

  --Note: Once the individual has been successfully treated, the interested study applicant may be reevaluated for study eligibility.

• Positive for use of investigational drugs within 4 weeks of randomization;

• Has a past or current medical problems or findings from physical examination or laboratory testing that are not listed above, which, in the opinion of the study clinician,

  • May pose additional risks from participation in this study,
  • May interfere with the participant's ability to comply with study requirements, or
  • May impact the quality or interpretation of the data obtained from the study.
• In the event that the study applicant will not allow the study clinician, an asthma specialist, to manage their disease for the duration of the study or who are not willing to change their asthma medications to follow the protocol;
• Has a known history of allergic reaction to previous biologic therapy for asthma; or
• Has had a life threatening asthma exacerbation in the last 2 years requiring intubation, mechanical ventilation or resulting in a hypoxic seizure.

Study Plan

How is the study designed?

Design Details

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

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Mepolizumab; Intervention: Mepolizumab plus guidelines-based standard of care asthma treatment.	Biological: Mepolizumab; Mepolizumab administered every 4 weeks by subcutaneous injection at a dose of: 100 mg for participants ≥12 years of age and; 40 mg for participants ages 6 to 11 years and weighing ≥40 kg. Note: Participants 6 to 11 years of age and weighing ≥40 kg who were enrolled in the study under previous versions of the protocol and were initially assigned a 100 mg dose will have their dose reduced to 40 mg. Participants 11 years of age will increase to the 100 mg dose if they become age 12 years during the study.; Other Names: Nucala®; anti-Interleukin 5 (IL5) antagonist monoclonal antibody
Placebo Comparator: Placebo; Intervention: Placebo for mepolizumab plus guidelines-based standard of care asthma treatment.	Drug: Placebo; Placebo administered every 4 weeks by subcutaneous injection at a dose of: 100 mg for participants ≥12 years of age and; 40 mg for participants ages 6 to 11 years and weighing ≥40 kg. Note: Participants 6 to 11 years of age and weighing ≥40 kg who were enrolled in the study under previous versions of the protocol and were initially assigned a 100 mg dose will have their dose reduced to 40 mg. Participants 11 years of age will increase to the 100 mg dose if they become age 12 years during the study.; Other Names: Placebo for Mepolizumab

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Asthma Exacerbations During the Treatment Period	Exacerbations were defined as a prescription of a course of systemic corticosteroids by a clinician, initiation of a course of systemic corticosteroids by a participant, or as a hospitalization for asthma. If a participant initiated and completed a course of systemic corticosteroids without clinician involvement, this course was counted only if the study clinician agreed the treatment was warranted, and it met the following dosage: the course for prednisone, prednisolone, or methylprednisolone was at least 20 mg daily dose for 3 of 5 consecutive days. The course for dexamethasone was at least a 10 mg single daily dose. If a corticosteroid burst for the treatment of an asthma exacerbation was prescribed by a non-ICAC clinician, it was counted regardless of dose.	Up to 12 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Composite Asthma Severity Index (CASI)	Composite Asthma Severity Index (CASI) scores included 5 domains: day symptoms and albuterol use, night symptoms and albuterol use, controller treatment, lung function measures, and exacerbations. The minimum composite score was 0 while the maximum was 20. The higher the score the more allergy symptoms a subject has.	Week 12, 24, 36, 48, 52 after randomization
Participant Quality of Life Measured Using the Physician Global Assessment Tool	The Physician Global Assessment Tool was used to assess the quality of life of the subjects during treatment. The questionnaire is one question that asks the physician to evaluate how the participant's quality of life changed over the course of treatment. There are seven possible options ranging from significantly worse to significantly improved.	Week 56
Participant Quality of Life Measured Using the Patient Global Assessment, at Visit 14	The Patient Global Assessment Tool was used to assess the quality of life of the subjects during treatment. The questionnaire is one question that asks the participant to evaluate how their quality of life changed over the course of treatment. There are seven possible options ranging from significantly worse to significantly improved.	Week 56
Lung Function as Assessed by Spirometry	A generalized mixed model was used to analyze spirometry parameter at each visit where the lung function was collected. The ratio of the forced expiratory volume to the forced vital capacity of the lungs (FEV1/FVC) is the outcome that measured lung function.	Weeks 12, 24, 36, 48, 52 after randomization
Lung Function as Assessed by Impulse Oscillometry	A generalized mixed model was used to analyze impulse oscillometry parameter at each visit where the lung function was collected. The Percent Predicted FEV1 (%) is the outcome that measured lung function.	Weeks 12, 24, 36, 48, 52 after randomization
Rate of Exacerbations (Mepolizumab vs. Placebo) During the Treatment Period for Participants Who Did Not Fit the FDA-approved Dosing Table for Omalizumab Therapy.	Looking at the rate of exacerbations similarly to the primary endpoint. This outcome measure also took into consideration FDA- approved dosing of omalizumab. The FDA-approved dosing table is based off of age, weight and pre-treatment Serum IGE	Up to 12 months
Rate of Exacerbations (Mepolizumab vs. Placebo) During the Treatment Period for Participants Who Fit the FDA-approved Dosing Table.	Looking at the rate of exacerbations similarly to the primary endpoint. This outcome measure also took into consideration FDA- approved dosing of omalizumab. The FDA-approved dosing table is based off of age, weight and pre-treatment Serum IGE	Up to 12 months
Time to First Asthma Exacerbation	A Cox PH model was also used to model the time to first asthma exacerbation during the treatment period. The Cox PH model included treatment arm as the primary exposure but was also adjusted for study site, number of exacerbations in year prior to study (2 or 3+), peripheral blood eosinophils (above or below 400 cells/μl), BMI (above or below 95th percentile for age) and total serum IgE (above or below 540 kUA/L).	Up to 12 months
Number of Reported Adverse Events (AEs), Including Their Severity	The number of AEs by severity was used to assess safety. Please refer to the Adverse Event tables for specifics.	Week 4 (Treatment Initiation) to Week 56 (Completion of Treatment)
Number of Reported Adverse Events (AEs), Including Their Treatment Relatedness	The number of AEs by relationship to study drug was used to assess safety. Please refer to the Adverse Event tables for specifics.	Week 4 (Treatment Initiation) to Week 56 (Completion of Treatment)
Number of Reported Serious Adverse Events (SAEs) Inclusive of Severity. Please Refer to the Adverse Event Tables for Specifics.	The number of SAEs by severity and relationship to study drug was used to assess safety.	Week 4 (Treatment Initiation) to Week 56 (Completion of Treatment)
Number of Reported Serious Adverse Events (SAEs) Inclusive of Treatment Relatedness. Please Refer to the Adverse Event Tables for Specifics.	The number of SAEs by relationship to study drug was used to assess safety.	Week 4 (Treatment Initiation) to Week 56 (Completion of Treatment)

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
EXPLORATORY: Time to First Respiratory Virus-Induced Exacerbation	As measured by an exacerbation associated with a respiratory virus detected using nasal mucus samples obtained at the time of an exacerbation.	Week 4 (Treatment Initiation) to Week 56 (Completion of Treatment)
EXPLORATORY:Number of Respiratory Virus-Induced Exacerbations	Measured by an exacerbation associated with a respiratory virus detected using nasal mucus samples obtained at the time of an exacerbation.	Week 4 (Treatment Initiation) to Week 56 (Completion of Treatment)
EXPLORATORY:Childhood Asthma Control Test (ACT)/c-ACT	A validated tool to assess overall asthma control (over the last 4 weeks) in participants.	Visits (V) 4 (Week 4 Treatment Initiation) , V4 (Week 16), V7 (Week 28), V10 (Week 40), V13 (Week 52) and V14 (Week 56, Completion of Treatment)
EXPLORATORY:Maximum Number of Asthma Symptom Days	Defined as the highest value among the following variables over a two-week period: number of days with wheezing, tightness in the chest, or cough;; number of nights with disturbed sleep as a result of asthma; and; number of days on which the participant had to slow down or discontinue play/physical activities.	Week 4 (Treatment Initiation) to Week 56 (Completion of Treatment)
EXPLORATORY:Bronchodilator Responsiveness	A measure to determine whether mepolizumab improves pulmonary outcomes.	Baseline (prior to treatment initiation), Week 56 (Completion of Treatment)
EXPLORATORY: Gene Expression in Nasal Lavage Samples	Whole genome transcriptomics of nasal lavage samples to identify inflammatory pathways affected by mepolizumab.	Visits (V) 1 (Week 4 Treatment Initiation) , V3(Week 12), and V14 (Week 56, Completion of Treatment)
EXPLORATORY: Gene Expression in Whole Blood RNA Samples	Whole genome transcriptomics of whole blood RNA samples to identify inflammatory pathways affected by mepolizumab..	Visits (V) 1 (Week 4 Treatment Initiation) , V3(Week 12), and V14 (Week 56, Completion of Treatment)
EXPLORATORY:Levels of Antibody to Mepolizumab	An assay for detection/measurement of levels of antibody to mepolizumab. Analysis will include participants randomized to mepolizumab.	Visit (V) 1 (Week 4, prior to treatment initiation), V3 (Week 12), and Visit 14 (Week 56, Completion of Treatment)
EXPLORATORY:Other Potential Biomarkers Not Specified to Date	Plasma, nasal samples, RNA and DNA will be banked for possible future study of potential biomarkers associated with asthma and asthma exacerbations.	Visit (V) 1 (Week 4, prior to treatment initiation), V3 (Week 12), and Visit 14 (Week 56, Completion of Treatment)

Collaborators and Investigators

• Sponsor: National Institute of Allergy and Infectious Diseases (NIAID)
• Collaborators: GlaxoSmithKline; Rho Federal Systems Division, Inc.; Inner-City Asthma Consortium
• Investigators: Study Chair: Daniel J Jackson, MD, University of Wisconsin, Madison; Study Chair: William W Busse, MD, University of Wisconsin, Madison

Publications and helpful links

General Publications

• Jackson DJ, Bacharier LB, Gergen PJ, Gagalis L, Calatroni A, Wellford S, Gill MA, Stokes J, Liu AH, Gruchalla RS, Cohen RT, Makhija M, Khurana Hershey GK, O'Connor GT, Pongracic JA, Sherenian MG, Rivera-Spoljaric K, Zoratti EM, Teach SJ, Kattan M, Dutmer CM, Kim H, Lamm C, Sheehan WJ, Segnitz RM, Dill-McFarland KA, Visness CM, Becker PM, Gern JE, Sorkness CA, Busse WW, Altman MC; US National Institute of Allergy and Infectious Disease's Inner City Asthma Consortium. Mepolizumab for urban children with exacerbation-prone eosinophilic asthma in the USA (MUPPITS-2): a randomised, double-blind, placebo-controlled, parallel-group trial. Lancet. 2022 Aug 13;400(10351):502-511. doi: 10.1016/S0140-6736(22)01198-9.

Helpful Links

• National Institute of Allergy and Infectious Diseases (NIAID) website
• Division of Allergy, Immunology, and Transplantation (DAIT) website

Study record dates

Study Major Dates

• Study Start (Actual): November 7, 2017
• Primary Completion (Actual): April 20, 2021
• Study Completion (Actual): April 20, 2021

Study Registration Dates

• First Submitted: September 20, 2017
• First Submitted That Met QC Criteria: September 20, 2017
• First Posted (Actual): September 25, 2017

Study Record Updates

• Last Update Posted (Actual): July 20, 2022
• Last Update Submitted That Met QC Criteria: June 23, 2022
• Last Verified: June 1, 2022

More Information

Terms related to this study

• Keywords: children and adolescents; urban setting; double-masked, placebo-controlled randomized trial; asthma exacerbations (attacks); mepolizumab adjunctive therapy; asthma exacerbations prevention; difficult-to-control exacerbation-prone asthma
• Additional Relevant MeSH Terms: Respiratory Tract Diseases; Immune System Diseases; Lung Diseases; Hypersensitivity, Immediate; Bronchial Diseases; Lung Diseases, Obstructive; Respiratory Hypersensitivity; Hypersensitivity; Asthma
• Other Study ID Numbers: DAIT ICAC-30; UM1AI114271 (U.S. NIH Grant/Contract); NIAID CRMS ID#: 38189 (Other Identifier: DAIT NIAID)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Yes
• IPD Plan Description: Participant level data access and additional relevant materials will be made available upon completion of the trial.
• IPD Sharing Time Frame: After completion of the trial, within 24 months status post database lock.

IPD Sharing Access Criteria

Registration is available for the Immunology Database and Analysis Portal (ImmPort) at: https://www.immport.org/registration. Submit a rationale for the purpose of requesting study data access.

ImmPort is a long-term archive of clinical and mechanistic data, a National Institute of Allergy and Infectious Diseases Division of Allergy, Immunology and Transplantation (NIAID DAIT)-funded data repository. This archive is in support of the NIH mission to share data with the public. Data shared through ImmPort is provided by NIH-funded programs, other research organizations and individual scientists, ensuring these discoveries will be the foundation of future research.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: Yes
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No