COMBISTRAT: AmBisome® in Combination With Caspofungin for the Treatment of Invasive Aspergillosis
Combination therapy of caspofungin and amphotericin B could be a useful treatment option in invasive fungal disease, but before it can be routinely recommended; carefully controlled and well-designed randomized clinical trials are needed.
|Study Design:||Allocation: Randomized
Endpoint Classification: Efficacy Study
Intervention Model: Parallel Assignment
Masking: Open Label
Primary Purpose: Treatment
|Official Title:||AmBisome® in Combination With Caspofungin Versus AmBisome® High Dose Regimen for the Treatment of Invasive Aspergillosis in Immunocompromized Patients: Randomized Pilot Study.|
- To assess efficacy of AmBisome® in combination with caspofungin (Cancidas®) versus AmBisome® high dose regimen in the treatment of Invasive Aspergillosis diagnosed by modified EORTC criteria in immunocompromised patients as probable or proven and deter
- To evaluate and compare the safety and tolerability of the two arms.
- To determine the survival rates and rates of infection relapse at 4 weeks post-treatment for patients treated with each of the two treatment regimens.
- To determine the survival rate at 12 weeks after study entry for patients treated with each of the two treatment regimens.
- To determine and compare the time to favorable response and time to maximal overall response for each of the two treatment regimens.
- To compare the efficacy of each arm versus historical data on conventional amphotericin B and voriconazole for the treatment of Invasive Aspergillosis.
|Study Start Date:||March 2004|
|Estimated Study Completion Date:||May 2006|
Efficacy and toxicity of caspofungin in combination with AmBisome as primary or salvage treatment of invasive aspergillosis has already been assessed in patients with hematologic malignancies. Forty-eight patients with documented (n=23) or possible (n=25) Invasive Aspergillosis (IA). The majority of the patients (65%) received the combination as salvage therapy for progressive IA despite 7 or more days of previous AmBisome monotherapy. The overall response rate was 42%. No significant toxic effects were seen. Factors associated with failure at the end of therapy were documented IA (P=0.03), significant steroid use before the study (P=0.02), and duration of combination therapy for less than 14 days (P=0.01). The response rate in patients with progressive documented IA was low (18%). Authors’ concluded that combination is a promising therapy for IA and was generally well tolerated.35 Furthermore interaction of caspofungin and amphotericin B for clinical isolates of Aspergillus and Fusarium was assessed. Antagonism was not observed for any of the isolates tested. Caspofungin and amphotericin B were synergistic or synergistic to additive for at least half of the isolates studied.36 Gentina et al. evaluated, in refractory IA, i.v. antifungal therapies combining caspofungin (70 mg on D1, followed by 50 mg/d) with Vfend® (200 mg b.i.d) or AmBisome (5 mg/kg/d). Six leukaemia patients with refractory IA received combination including caspofungin with AmBisome (n = 4) or Vfend® (n = 2). Combination therapies were started 8 days after initial IA diagnosis. Duration of neutropenia after initiation of combination therapy ranged 4 to 25 days. IA was classified as definite in 3 cases and probable in 3 cases. All patients had pulmonary IA, including one with disseminated IA (cerebral, thyroid, ocular and pulmonary). In all patients, sequential CT-scans demonstrated improvement with a rapid reduction of the size of lesions. Additional surgery was only required in 2 cases. Improvement allowed administration of consolidation chemotherapy in 3 patients without recurrence of IA. Median duration of combination therapy was 62 days (range 42-107). No toxicity related to this combination antifungal therapy was observed.37 The combination therapy of caspofungin and amphotericin (or liposomal amphotericin) was also assessed by Aliff et al. in a retrospective evaluation of a group of 30 patients with amphotericin-resistant pulmonary aspergillosis and other invasive fungal infections. Twenty-six patients had acute leukemia. Diagnosis was based on clinical, radiographic, and when available, microbiologic data. Response to combination antifungal therapy was graded as either favorable or unfavorable. Favorable responses included improvement of both clinical and radiographic signs of fungal pneumonia. All other responses were graded as unfavorable. Based on the EORTC criteria, the IFIs were classified as proven in 6 patients, probable in 4 patients, and possible in 20 patients. The median duration and dose of amphotericin monotherapy were 12 days (range, 4-65 days) and 7.8 mg/kg (range, 4.2-66.1 mg/kg),respectively. The median duration of combination therapy was 24 days (range, 3-74 days). Eighteen patients (60%) experienced a favorable antifungal response. Twenty patients with acute leukemia received combination therapy for fungal pneumonias arising during intensive chemotherapy treatments. Favorable responses were observed in 15 of these patients (75%), and antifungal response did not depend on the response of the underlying leukemia. Survival to hospital discharge was significantly better (P < 0.001) in patients having a favorable response. Authors concluded that the combination of caspofungin and amphotericin B can be administered safely to high-risk patients with hematologic malignancies.38 Combination therapy could be a useful treatment option in invasive fungal disease, but before it can be routinely recommended; carefully controlled and well-designed randomized clinical trials are needed.