The design and development of a multicentric protocol to investigate the impact of adjunctive doxycycline on the management of peripheral lymphoedema caused by lymphatic filariasis and podoconiosis

John Horton, Ute Klarmann-Schulz, Mariana Stephens, Philip J Budge, Yaya Coulibaly, Alex Debrah, Linda Batsa Debrah, Suma Krishnasastry, Upendo Mwingira, Abdallah Ngenya, Samuel Wanji, Mirani Weerasooriya, Channa Yahathugoda, Inge Kroidl, Drew Deathe, Andrew Majewski, Sarah Sullivan, Charles Mackenzie, Thomas B Nutman, Joseph P Shott, Gary Weil, Eric Ottesen, Achim Hoerauf, John Horton, Ute Klarmann-Schulz, Mariana Stephens, Philip J Budge, Yaya Coulibaly, Alex Debrah, Linda Batsa Debrah, Suma Krishnasastry, Upendo Mwingira, Abdallah Ngenya, Samuel Wanji, Mirani Weerasooriya, Channa Yahathugoda, Inge Kroidl, Drew Deathe, Andrew Majewski, Sarah Sullivan, Charles Mackenzie, Thomas B Nutman, Joseph P Shott, Gary Weil, Eric Ottesen, Achim Hoerauf

Abstract

Background: As new lymphatic filariasis infections are eliminated through mass chemotherapy, previously affected individuals are left with the sequellae, especially chronic progressive lymphoedema. Currently this is managed by careful attention to limb hygiene to prevent infection. Studies over the past 15 years have suggested that the incorporation of doxycycline treatment may arrest or even reverse progression of lymphoedema. Most of this work has been observational or based on small studies, and if this intervention is effective, studies need to be conducted on a larger scale and under diverse geographical and social conditions before it can be incorporated into treatment policy.

Methods/design: The double-blind, placebo-controlled study was designed to investigate the impact of six weeks treatment with doxycycline added to standard limb hygiene on early stage filarial lymphoedema in five sites in Africa and the Indian subcontinent. One site in Cameroon is selected for studying lymphoedema in podoconiosis. Each site was individually powered with the potential to undertake a meta-analysis on completion. Evaluation methods followed those used in Ghana in 2012 with additions resulting from advances in technology. The details of the core protocol and how it was varied to take account of differing situations at each of the sites are provided. The study will enrol up to 1800 patients and will complete in mid-2021.

Conclusions: This paper provides details of what challenges were faced during its development and discusses the issues and how they were resolved. In particular, the reasons for inclusion of new technology and the problems encountered with the supply of drugs for the studies are described in detail. By making these details available, it is hoped that the study protocol will help others interested in improving treatment for filarial lymphoedema in the design of future studies. Trial registration India: Clintrials.gov. NCT02929121 registered 10 Oct 2016: https://ichgcp.net/clinical-trials-registry/NCT02929121 Mali: Clintrials.gov. NCT02927496 registered 7 Oct 2016: https://ichgcp.net/clinical-trials-registry/NCT0292749 Sri Lanka: Clintrials.gov. NCT02929134 registered 10 Oct 2016: https://ichgcp.net/clinical-trials-registry/NCT02929134 Ghana: ISRCTN. 14042737 registered 10 July 2017: https://doi.org/10.1186/ISRCTN14042737 Tanzania: ISRCTN. 65756724 registered 21 July 2017: https://doi.org/10.1186/ISRCTN65756724 Cameroon: ISRCTN. 1181662 registered 25 July 2017: https://doi.org/10.1186/ISRCTN11881662.

Keywords: Clinical trial; Doxycycline; Hygiene; Lymphatic filariasis; Lymphoedema; Morbidity management; Podoconiosis.

Conflict of interest statement

JPS is an employee of the United States Agency for International Development. All other authors declare that they have no competing interests.

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