Efavirenz (EFV) in HIV-Infected and HIV/Tuberculosis (TB) Coinfected Children

This study is currently recruiting participants. (see Contacts and Locations)
Verified December 2013 by National Institute of Allergy and Infectious Diseases (NIAID)
Sponsor:
Collaborator:
Information provided by (Responsible Party):
National Institute of Allergy and Infectious Diseases (NIAID)
ClinicalTrials.gov Identifier:
NCT00802802
First received: December 4, 2008
Last updated: December 2, 2013
Last verified: December 2013
  Purpose

Efavirenz (EFV) is an anti-HIV medicine that is commonly used to treat HIV infection in adults and children older than 3 years of age. This study is being conducted to look at the safety of EFV, blood levels of EFV, genetic factors that may affect blood levels of EFV, and how easy it is for infants and young children to take and tolerate EFV. This information will help recommend the best doses of EFV for children younger than 3 years of age.


Condition Intervention Phase
HIV Infections
Tuberculosis
Drug: Efavirenz (EFV)
Drug: Rifampin-containing anti-TB therapy
Phase 1

Study Type: Interventional
Study Design: Allocation: Randomized
Endpoint Classification: Safety/Efficacy Study
Intervention Model: Parallel Assignment
Masking: Open Label
Primary Purpose: Treatment
Official Title: Dose-Finding and Pharmacogenetic Study of Efavirenz in HIV-infected and HIV/TB Co-infected Infants and Children 3 Months to Less Than 36 Months of Age

Resource links provided by NLM:


Further study details as provided by National Institute of Allergy and Infectious Diseases (NIAID):

Primary Outcome Measures:
  • Any treatment-related Grade 2B rash or Grade 3 or 4 toxicity requiring permanent discontinuation of efavirenz (EFV) [ Time Frame: Measured through Week 24 ] [ Designated as safety issue: Yes ]
  • Death [ Time Frame: Measured through Week 24 ] [ Designated as safety issue: Yes ]
  • A safety event as defined as a Grade 4 life-threatening toxicity or Grade 4 toxicity accompanying a serious adverse event (SAE) (e.g., hospitalization) or death that is judged to be at least possibly related to EFV [ Time Frame: Measured through Week 24 ] [ Designated as safety issue: Yes ]
  • Failure to achieve the area under the curve (AUC) target range despite dose adjustment [ Time Frame: Measured through Week 24 ] [ Designated as safety issue: No ]

Secondary Outcome Measures:
  • A confirmed decrease (less than 1 log) from entry quantitative HIV RNA and RNA greater than 400 copies/mL [ Time Frame: Measured at Week 8 ] [ Designated as safety issue: No ]

Estimated Enrollment: 155
Study Start Date: October 2009
Estimated Primary Completion Date: September 2014 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Experimental: Cohort I, Step 1
HIV-infected children 3 months to 36 months of age, receiving EFV and two NRTIs
Drug: Efavirenz (EFV)
Participants will be administered oral EFV at a dose ranging from 50 mg to 800 mg once daily, based on weight and CYP 2B6 genotype. EFV capsules will be opened into a small amount of a compatible food or liquid vehicle; the smallest amount of food or liquid that will enable the child to swallow the capsule contents should be used (i.e., EFV should not be taken with a meal).
Other Name: EFV
Experimental: Cohort II
HIV/TB-coinfected children 3 months to 36 months of age, receiving EFV, two NRTIs, and rifampin-containing anti-tuberculosis (anti-TB) therapy
Drug: Efavirenz (EFV)
Participants will be administered oral EFV at a dose ranging from 50 mg to 800 mg once daily, based on weight and CYP 2B6 genotype. EFV capsules will be opened into a small amount of a compatible food or liquid vehicle; the smallest amount of food or liquid that will enable the child to swallow the capsule contents should be used (i.e., EFV should not be taken with a meal).
Other Name: EFV
Drug: Rifampin-containing anti-TB therapy
Treatment with rifampin-containing anti-TB treatment regimen. Treatment will last at least 24 weeks and up to 36 weeks.
Experimental: Cohort I, Step 2
HIV-infected children from Cohort I who become coinfected with TB during the study. They will receive EFV, two NRTIs, and rifampin-containing anti-TB therapy
Drug: Efavirenz (EFV)
Participants will be administered oral EFV at a dose ranging from 50 mg to 800 mg once daily, based on weight and CYP 2B6 genotype. EFV capsules will be opened into a small amount of a compatible food or liquid vehicle; the smallest amount of food or liquid that will enable the child to swallow the capsule contents should be used (i.e., EFV should not be taken with a meal).
Other Name: EFV
Drug: Rifampin-containing anti-TB therapy
Treatment with rifampin-containing anti-TB treatment regimen. Treatment will last at least 24 weeks and up to 36 weeks.

  Hide Detailed Description

Detailed Description:

An increasing number of children in resource-limited countries require treatment for both HIV and tuberculosis (TB); however, the options for antiretroviral therapy (ART) that is compatible with concurrent rifampin-containing anti-TB therapy are limited. As a result, treatment of HIV/TB-coinfected patients remains difficult with multiple drug interactions, very high pill burdens, overlapping toxicities, and possible immune reconstitution affecting treatment outcomes.

The use of EFV in adults and older children has allowed them to maintain their non-nucleoside reverse transcriptase inhibitor (NNRTI) backbone while receiving TB therapy including rifampin. In younger children with TB/HIV coinfection, the first-line treatment recommendation has been the triple-nucleoside reverse transcriptase inhibitor (NRTI) regimen. However, this regimen has been shown to be less effective than an EFV plus NNRTI-based regimen. In addition, triple-NRTI regimens in resource-limited settings are costly and have limited data in patients with TB, and monitoring for drug-related hypersensitivity reactions is difficult. All of these factors make EFV an attractive agent for use in HIV-infected pediatric patients with and without TB coinfection. This study will evaluate the safety, tolerance, and pharmacokinetics (PKs) of EFV when administered as opened capsules to pediatric patients younger than 3 years of age, with and without concomitant rifampin-containing anti-TB therapy. This study will also investigate genetic polymorphisms, including CYP 2B6, to help establish dosing guidelines.

This study will have two cohorts that will enroll at the same time. Cohort I, Step 1 will enroll HIV-infected infants without TB coinfection who are eligible for initiation of ART. Cohort I, Step 1 will be administered EFV for up to 24 weeks. EFV dosage, in Cohort I, Step 1, will range from 50 mg to 600 mg once daily, based on weight and CYP 2B6 genotype.

Participants in Cohort I Step 1 who develop TB or TB immune reconstitution inflammatory syndrome (IRIS) and require anti-TB medications will be allowed to enroll into Cohort I, Step 2, in which they will receive rifampin-containing anti-TB therapy and a higher dose of EFV (50 mg to 800 mg) to account for the anticipated impact of rifampin on EFV PKs. If participants in Cohort I, Step 2 require more than 24 weeks of anti-TB therapy and are unable to obtain EFV capsules from in-country sources, they may remain on the study longer than 24 weeks until discontinuing anti-TB therapy, up to 36 weeks study duration.

Participants in Cohort II will be HIV/TB coinfected infants who are eligible for ART and have been treated with and tolerated a rifampin-containing anti-TB treatment regimen for at least 1 week prior to enrollment. Participants in Cohort II will be followed while taking both rifampin-containing anti-TB and EFV therapy for 24 weeks; participants unable to obtain EFV capsules from in-country sources at the conclusion of the study may remain on the study until discontinuing anti-TB therapy, up to 36 weeks study duration. An estimated 10 to 20 of these participants from Cohort II will be followed every 4 weeks on study and provided EFV until completion of TB treatment (for up to 36 weeks study duration).

Participants in both cohorts will be stratified based on age. One stratification will include children 3 months to younger than 24 months of age, and the second stratification will include children 24 months to younger than 36 months of age. Participants will then be further stratified by cytochrome P450 genotype polymorphisms, including CYP 2B6. All participants will receive an EFV-based ART regimen using the capsule formulation of EFV and two NRTIs (chosen by site investigator). EFV capsules will be opened into a small amount of compatible, familiar, and locally available food or liquid (e.g., formula, expressed breast milk, mashed banana).

Study visits will occur at screening, entry, and at Weeks 2, 4, 6, 8, 12, 16, 20, and 24; some participants may continue to have a visit every 4 weeks after Week 24 until Week 36. At most visits, participants will undergo a physical exam, give a medical history, and have blood and urine collected. At some visits, dried blood spots (DBS) will be prepared and plasma samples will be stored. The Week 2 visit will also consist of intensive PK samplings where blood will be collected prior to taking the EFV dose and at 2, 4, 8, 12, and 24 hours post-dose. Individual dose adjustments may be made based on the results from the Week 2 visit.

  Eligibility

Ages Eligible for Study:   3 Months to 35 Months
Genders Eligible for Study:   Both
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria (Cohort I, Step 1 and Cohort II)

  • Older than 3 months but younger than 36 months of age (up to but not including the 3rd birthday) at the time of enrollment
  • Documentation of HIV-1 infection defined as positive results from two samples collected at different time points. More details on this criterion can be found in the protocol.
  • Treatment-eligible as defined by country-specific guidelines, World Health Organization (WHO) treatment algorithm, or by clinician's determination that the participant should be treated on other clinical grounds and will initiate antiretroviral (ARV) therapy (ART) AND has determined that in-country access to ART will be available at study conclusion
  • Able to swallow the contents of efavirenz (EFV) as opened capsules in food or liquid vehicle
  • Parent, legal guardian, or designated guardian according to country-specific guidelines able and willing to provide signed informed consent and to have the participant followed at the clinical site

Inclusion Criteria (Cohort I, Step 2 ONLY)

  • Currently enrolled in Cohort I, Step 1
  • Clinically diagnosed with HIV/TB co-infection and requires rifampin-containing therapy, in the clinical judgment of the site investigator
  • Chemistry and hematology laboratory values drawn during Cohort I, Step 1 are all Grade 3 or lower, except for aspartate aminotransferase/alanine aminotransferase (AST/ALT), which must be Grade 2 or lower within 4 weeks of entry into Cohort I, Step 2

Inclusion Criteria (Cohort II ONLY)

  • Clinically diagnosed with HIV/TB coinfection and requires rifampin-containing therapy, in the clinical judgment of the site investigator
  • Participant is tolerating a rifampin-containing anti-TB drug regimen for at least 1 week prior to study entry
  • Participant plans to continue anti-TB and study treatment for at least 16 weeks from initiation of study treatment

Exclusion Criteria (Cohort I, Step 1 and Cohort II)

  • Known hypersensitivity to any component of EFV capsule formulation.
  • Participants with severe malnutrition defined in the protocol
  • Infants/children who have previously been treated with EFV-based ART
  • Infants/children younger than 24 months of age with documented receipt of nevirapine (NVP) therapy, including single dose NVP for prevention of mother-to-child transmission (PMTCT). More information on this criterion can be found in the protocol.
  • Infants/children younger than 24 months of age whose mothers have documentation of receiving NVP as part of PMTCT unless they meet criteria under the exception detailed in the protocol. More information on this criterion can be found in the protocol.
  • Grade 2 or higher AST or ALT at screening
  • Any Grade 3 or higher laboratory toxicity at screening
  • Higher than Grade 3 clinical toxicity at screening
  • Participants with acute, serious infections requiring active treatment (e.g. pneumocystis pneumonia [PCP], etc.) may not enroll until judged to be clinically stable by the site investigator. Participants may enroll while completing active opportunistic infection treatment. Prophylaxis against opportunistic infections, including isoniazid, will be allowed.
  • Chemotherapy for active malignancy
  • Active central nervous system (CNS) infection, such as TB meningitis or cryptococcal meningitis, receiving primary therapy
  • Breastfeeding infants whose mothers are receiving or plan to initiate EFV-based highly active antiretroviral therapy (HAART) before the results of the intensive pharmacokinetic (PK) studies are available will be excluded from enrollment in this study due to the potential effect on the infant's EFV PK levels that will be evaluated in the study. More information on this criterion can be found in the protocol.
  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT00802802

Locations
Botswana
Gaborone Prevention/Treatment Trials CRS Withdrawn
Gaborone, Botswana
Molepolole Prevention/Treatment Trials CRS (Molepolole PTT CRS) Withdrawn
Molepolole, Botswana
India
BJ Medical College CRS Recruiting
Pune, Maharashtra, India, 411001
Contact: Nishi Suryavanshi, PhD    91-20-26052419    nishi@jhumitpune.com   
South Africa
Soweto IMPAACT CRS Recruiting
Johannesburg, Gauteng, South Africa, 2001
Contact: Nasreen Abrahams    27-11-9899742    abrahamsn@phru.co.za   
Shandukani Research CRS Recruiting
Johannesburg, Gauteng, South Africa, 2001
Contact: Hermien Gous, PharmD    27-11-3585502    hgous@wrhi.ac.za   
Principal Investigator: Harry Moultrie         
Durban Paediatric HIV CRS Recruiting
Durban, KwaZulu-Natal, South Africa, 4001
Contact: Rosie Mngqibisa, MBBS    27-31-2604669    mngqibisa@ukzn.ac.za   
Principal Investigator: Raziya Bobat, MD         
Stellenbosch Univ. CRS Recruiting
Cape Town, South Africa, 7505
Contact: Joan Coetzee    27-21-9384157    joan@sun.ac.za   
Principal Investigator: Mark F. Cotton, MD         
Uganda
Makerere University- JHU Research Collaboration {MUJHU CARE LTD} CRS Not yet recruiting
Kampala, Uganda
Contact: Carolyne Onyango, MD    256-414-541044    carolonyango@mujhu.org   
Zambia
George Clinic CRS Not yet recruiting
Lusaka, Zambia, 10101
Contact: Felistas Mbewe    260-966828341    felistas.mbewe@cidrz.org   
Zimbabwe
UZ-Parirenyatwa CRS Recruiting
Harare, Zimbabwe
Contact: Rachel Mahachi    263-4-701356    rmahachi@uzcrc.co.zw   
Principal Investigator: James G. Hakim, MScClinEpi, FRCP         
Sponsors and Collaborators
Investigators
Study Chair: Carolyn Bolton, MBBCh UAB, CIDRZ
Study Chair: Mutsawashe Bwakura-Dangarembizi, MD Univ. of Zimbabwe, AIDS Research Unit
Study Chair: Ellen Gould Chadwick, MD Northwestern Univ. Feinberg School of Medicine - Dept. of Peds, Children's Memorial Hosp.
  More Information

Additional Information:
Publications:
Responsible Party: National Institute of Allergy and Infectious Diseases (NIAID)
ClinicalTrials.gov Identifier: NCT00802802     History of Changes
Other Study ID Numbers: P1070, 10633, IMPAACT P1070
Study First Received: December 4, 2008
Last Updated: December 2, 2013
Health Authority: United States: Food and Drug Administration

Additional relevant MeSH terms:
HIV Infections
Acquired Immunodeficiency Syndrome
Tuberculosis
Lentivirus Infections
Retroviridae Infections
RNA Virus Infections
Virus Diseases
Sexually Transmitted Diseases, Viral
Sexually Transmitted Diseases
Immunologic Deficiency Syndromes
Immune System Diseases
Slow Virus Diseases
Mycobacterium Infections
Actinomycetales Infections
Gram-Positive Bacterial Infections
Bacterial Infections
Rifampin
Efavirenz
Antibiotics, Antitubercular
Anti-Bacterial Agents
Anti-Infective Agents
Therapeutic Uses
Pharmacologic Actions
Antitubercular Agents
Enzyme Inhibitors
Molecular Mechanisms of Pharmacological Action
Leprostatic Agents
Nucleic Acid Synthesis Inhibitors
Reverse Transcriptase Inhibitors
Anti-Retroviral Agents

ClinicalTrials.gov processed this record on August 28, 2014