Minocycline for the Treatment of Decreased Mental Function in HIV-Infected Adults

• Sponsor: AIDS Clinical Trials Group
• Collaborators: National Institute of Allergy and Infectious Diseases (NIAID); Neurologic AIDS Research Consortium (NARC)
• Information provided by (Responsible Party): AIDS Clinical Trials Group

Study Description

Brief Summary:

The purpose of this study is to determine the effectiveness of minocycline, an antibiotic, in lessening the decreased mental function sometimes caused by anti-HIV drugs.

Condition or disease	Intervention/treatment	Phase
HIV Infections	Drug: Minocycline; Drug: Placebo (Tetracycline)	Phase 2

Detailed Description:

Cognitive impairment, including disabling cognitive, behavioral, and social dysfunction, continues to be a major problem faced by HIV-infected people taking antiretroviral therapy (ART). Research is needed to develop treatment that can be given alongside ART to prevent or lessen cognitive impairment caused by ART. Minocycline, an antibiotic commonly used for the treatment of acne and rheumatoid arthritis, has demonstrated anti-inflammatory and neuroprotective properties in previous studies. This study will evaluate the effectiveness of 24-week therapy with minocycline in lessening the cognitive impairment of HIV infected adults taking ART.

This study will last at least 24 weeks and has two steps. Patients will be stratified by HIV viral load and their neurocognitive state at study screening. In Step I, patients will be randomly assigned to one of two groups. Group 1 participants will receive twice-daily minocycline for 24 weeks; Group 2 participants will receive placebo. At the end of Phase I, study participants will be offered to enter Step II; all participants in Step II will receive twice-daily minocycline for an additional 24 weeks.

There will be a total of 8 study visits: 5 visits for Step I (including the entry visit) and 3 visits for Step II. Medical history will occur at all visits. Blood collection will occur at all visits. Participants who have positive nonreactive rapid plasma regain (RPR) values at screening will have mandatory lumbar punctures; for those with negative serum RPR results lumbar punctures are optional. Participants who test positive for syphilis will also have a lumbar puncture at their discretion to determine if syphilis has affected the brain. A neurological exam, other neuropsychological, dementia, and depression scale assessments, and urine collection will occur at most visits. Patients will be asked to complete a questionnaire on daily living at study entry and Weeks 12 and 24. Patients who have a lumbar puncture at Week 24 will receive a phone call 2 to 5 days after the procedure to report any adverse effects. Some participants may also have an electrocardiogram (ECG) during the study. For participants not on atazanavir some procedures and sample collections are optional.

Study Design

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Study Type :	Interventional (Clinical Trial)
Actual Enrollment :	107 participants
Allocation:	Randomized
Intervention Model:	Parallel Assignment
Masking:	Double (Participant, Care Provider)
Primary Purpose:	Treatment
Official Title:	Phase II, Randomized, Placebo-Controlled, Double-Blind Study of Minocycline in the Treatment of HIV-Associated Cognitive Impairment
Study Start Date :	March 2007
Actual Primary Completion Date :	January 2010
Actual Study Completion Date :	January 2010

Arms and Interventions

Arm	Intervention/treatment
Experimental: Arm 1: Minocycline; 100 mg orally every 12 hours	Drug: Minocycline; Tetracycline antibiotic, 100 mg taken orally every 12 hours
Placebo Comparator: Arm 2: Matching placebo; orally every 12 hours	Drug: Placebo (Tetracycline); Tetracycline antibiotic placebo, orally every 12 hours

Outcome Measures

Primary Outcome Measures :

1. Change in Cognitive Performance Compared to Baseline [ Time Frame: At baseline and week 24 ]

   Th cognitive performance is measured by NPZ-8. NPZ-8 is defined as the average of age and education adjusted z-scores of eight neuropsychological tests subcomponents in the neuropsychological test battery. These eight tests are:

   1. Grooved Pegboard Dominant Hand (GPD)
   2. Grooved Pegboard Non-dominant hand (GPN)
   3. Choice Reaction Time (CRT)
   4. Sequential Reaction Time (QRT)
   5. Timed Gait (TIG)
   6. Trail Making Part A (TMA)
   7. Trail Making Part B (TMB)
   8. Symbol Digit (SYD) The primary outcome is NPZ-8 score at week24 - NPZ-8 score at baseline.

Secondary Outcome Measures :

1. Change in Global Deficit Z-Score (GDS) [ Time Frame: At baseline and week 24 ]
   GDS on the test battery is the simple average of all 14 individual deficit scores in the test battery, including Time Gait, Grooved Pegboard Test for the dominant and non-dominant hands, Trail Making Test parts A and B, Symbol Digit Test, simple and sequential reaction time - CalCAP, Hopkins Verbal Learning Test (Revised)- Learning, Delayed Recall and Recognition trials, and Stroop Color Interference Test-color, word, and interference tasks. The outcome is the 24 week change of GDS Z-score (24 week-baseline).
2. Change in Investigator's Clinical Global Impression Score (ICGIS) [ Time Frame: At week 24 ]

   Clinicians were asked to rate their overall impression about the clinical improvement or worsening of his/her study participants. They can choose from the following 7 levels: (0) No Change, (1) Mild Improvement, (2) Moderate Improvement, (3) Marked Improvement, (4) Mild Worsening, (5) Moderate Worsening, and (6) Marked Worsening.

   For the analysis, we simplified the outcome into the following 3 levels: (0) worsened, (1) No Change, and (2) Improved.

3. Change in Cognitive Gross Motor Function Domain Z-Score [ Time Frame: At baseline and week 24 ]
   The cognitive gross motor function is a age and education adjusted z score of Timed Gait (TIG). The outcome is the 24 week change of cognitive gross motor function domain z-scores (week 24-baseline).
4. Change in Fine Motor Function Domain Z-Score [ Time Frame: At baseline and week 24 ]
   The fine motor function domain score is an average of age, sex, education, and African-American ethnicity adjusted z scores of Grooved Pegboard Dominant Hand (GPD) and Grooved Pegboard Non-dominant hand (GPN). The outcome is a 24 week change of the fine motor function domain z-score (week 24-baseline).
5. Change in Psychomotor Function Domain Z-Score [ Time Frame: At baseline and week 24 ]
   The psychomotor function domain score us the average of age, sex, education, and African-American ethnicity adjusted z scores of Trail Making Part A (TMA) and Trail Making Part B (TMB). The outcome is the 24 week change of psychomotor function domain z-scores (week24-baseline).
6. Change in Fine Motor/Nonverbal Function Domain Z-Score [ Time Frame: At baseline and week 24 ]
   The fine motor/nonverbal function domain score is a age and education adjusted z score of Symbol Digit Test (SYD) The outcome is the 24 change of fine motor/nonverbal function domain z-score (week 24-baseline).
7. Change in Information Processing Function Domain Z-Score [ Time Frame: At baseline and week 24 ]
   The information processing function domain score is the average of age and education adjusted z scores of simple and sequential reaction time - CalCAP. The outcome is the 24 week change of information processing function domain z-scores (week 24-baseline).
8. Change in Verbal Memory Domain Z-Score [ Time Frame: At baseline and week 24 ]
   The verbal memory domain score is the average of age and education adjusted z scores of Hopkins Verbal Learning Test- Revised, Learning and Delayed Recall. The outcome is the 24 week change of verbal memory domain z-scores (week 24-baseline).
9. Change in Frontal Systems Function Domain Z-Score [ Time Frame: At baseline and week 24 ]
   The frontal systems function domain score is the average of age and education adjusted z scores of Stroop Color Interference Test (CTP) and interference task (STP). The outcome is the 24 week change of frontal systems function domain z-score (week 24-baseline).
10. Change in Karnofsky Performance Score [ Time Frame: At baseline and week 24 ]

    The original Karnofsky performance score is 11 level score which ranges between 0 to 100. The score 100 means normal and 0 means death; therefore, higher score means higher ability to perform daily tasks.

    For the analysis, a new dichotomous variable (no change/worse vs. better at 24 weeks compared to baseline) was created.

11. Changes in Cluster of Differentiation 4 (CD4) Cell Counts (24 Weeks) [ Time Frame: At baseline and weeks 24 ]
    The outcome was the 24 week change in CD4 cell count (week 24-baseline).
12. Changes in Cluster of Differentiation 8 (CD8) Cell Counts (24 Weeks) [ Time Frame: At baseline and week 24 ]
    The outcome was the 24 week change of CD8 cell counts (week 24-baseline).
13. Number of Participants With Grade 2 or Higher Toxicity and/or Signs and Symptoms [ Time Frame: Throughout study up to week 48 ]
    Grade or higher means that adverse events were moderate, severe, or life-threatening, or death. Grade 2 or higher adverse events are lised in the Adverse Event section.
14. Change of HIV Plasma RiboNucleic Acid (RNA) Viral Load [ Time Frame: At baseline and week 24 ]
    The original scale of HIV RNA viral load is between 30 copies/mL to infinitive. The minimum score of 30 is the lowest detectable value. The summary table categorized this continuous value to a dichotomous variable (<30 copies/mL and >= 30 copies/mL).
15. Changes in Instrumental Activities of Daily Living Questionnaire [ Time Frame: At baseline and week 24 ]
    The Instrumental Activities of Daily Living (IADL) questionnaire is designed to learn more about how subjects are able to perform common tasks. There are 16 common tasks. For each task, if the score at the time of evaluation is worse than the best in the past, an indicator of 1 is given. Otherwise, the indicator is 0. The overall IADL score is a sum of 16 indicators divided by 16; therefore, the range is between 0 and 1 and the lower score is better. The 24-week change of IADL score was changed into a categorical variable (no change/worse vs. better) at week 24 compare to baseline.
16. Changes in Medication Management Test (Modified) [ Time Frame: At baseline and weeks 24 ]
    The medication management test (modified) is designed to assess participants' medication management ability and their own medications and management. It's the number of how many times participants correctly answered 16 questions. The score ranges between 0 and 16, and higher score indicates better medication management.
17. Changes in Protein Markers of Oxidative Stress (Unit = Counts Per Second Only) [ Time Frame: At pre-entry and Week 24 ]
    Protein marker of oxidative stress (Ceramides, Monohexosylceramides, Dihydro Glycosyl Galceramides, and Dihexosylceramides). For all markers, the outcome is the 24 week change (week 24-baseline).
18. Changes in Markers of Oxidative Stress and Immune Activation (Unit=pg/mL Only) [ Time Frame: At pre-entry and Week 24 ]
    Protein markers of oxidative stress (Protein carbonyls) and markers of immune activation (TNF-a, IL-6,CXCL8, Hepatocyte growth factor, Osteopontin, sFAS, sFAS ligand, and CXCL12). For all markers, the outcome is the 24 week change (week 24-baseline).
19. Changes in Markers of Oxidative Stress (Unit = Pixels/mm2 Only) [ Time Frame: At pre-entry and Week 24 ]
    Protein marker of oxidative stress (Neurofilament heavy polypeptide). The outcome is the 24 week change (week 24-baseline).
20. Changes in Neurotransmitter Levels (Unit = uM Only) [ Time Frame: At pre-entry and Week 24 ]
    Neurotransmitter levels (Glutamate, Tryptophan, Anthranilic Acid, Quinolinic Acid, Kynurenin, and 3-Hydroxykynurenine). The outcome is the 24 week change (week 24-baseline).
21. Changes in Alternate Psychomotor Function Z-Score [ Time Frame: At baseline and week 24 ]
    The alternate psychomotor function is defined as the mean of age, sex, education, and African-American ethnicity adjusted z scores of Trail Making Part A (TMA), and age and education adjusted z score of Symbol Digit (SYD). The outcome is the 24 week change in alternate psychomotor function z-score (week 24-baseline).
22. Changes in Alternate Verbal Memory Z-Score [ Time Frame: At baseline and week 24 ]
    The alternate verbal memory was defined as a mean of age and education adjusted z score of trials 1 to 3 and delayed recall tests. The outcome is the 24 week change in alternate verbal memory z-score (week 24-baseline).
23. Changes in Alternate Frontal Systems Z-Score [ Time Frame: At baseline and week 24 ]
    The alternate frontal systems was defined as a mean of age and education adjusted z score of Interference task, and age, sex, education, and African-American ethnicity adjusted z score of Trail Making Part B. The outcome was the 24 week change in alternate frontal systems z-score (week 24-baseline).

Eligibility Criteria

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Ages Eligible for Study:	18 Years to 65 Years (Adult, Older Adult)
Sexes Eligible for Study:	All
Accepts Healthy Volunteers:	No

Criteria

Inclusion Criteria:

• HIV infected
• Currently on a stable ART regimen for at least 16 consecutive weeks prior to study entry. Participants whose regimens have changed with respect to dose or formulation are eligible, but patients who have changed to different drugs in the same class are not eligible. Participants taking atazanavir must also be taking ritonavir or a ritonavir-boosted drug to be eligible for this study. More information on this criterion can be found in the protocol.
• Plan to stay on current ART regimen between study screening and Week 24
• AIDS Dementia Scale (ADC) Stage greater than 0
• Cognitive impairment, as evidenced by neuropsychological tests administered at screening
• Progressive neurocognitive decline. More information on this criterion can be found in the protocol.
• Estimated premorbid IQ of 70 or higher indicated by an age-corrected scaled score of 5 or higher on the vocabulary section of the Wechsler Adult Intelligence Scale Revised (WAIS-R) administered at study screening
• Karnofsky performance score of 60 or higher
• Ability to sit and stand for at least 2 hours and swallow medications with an 8-ounce glass of water
• Willing to use acceptable methods of contraception
• Willing to adhere to study schedule

Exclusion Criteria:

• Current cancers. Patients with basal cell carcinoma, in situ carcinoma of the cervix, or Kaposi's sarcoma without evidence of visceral involvement or cancer not requiring systemic chemotherapy are not excluded.
• Severe premorbid psychiatric illness, including schizophrenia and major depression, which, in the opinion of the investigator, may interfere with the study
• Active symptomatic AIDS-defining opportunistic infection within 45 days prior to study entry
• Previous or current confounding neurological disorders. More information on this criterion can be found in the protocol.
• Central nervous system infections or cancers. More information on this criterion can be found in the protocol.
• Systemic lupus
• Thyroid disease diagnosed within 24 weeks of study entry
• Active drug or alcohol abuse that, in the opinion of the investigator, may interfere with the study
• Serious illness requiring systemic treatment or hospitalization. Patients who complete therapy or are clinically stable on therapy are not excluded.
• Investigational agents within 45 days prior to study entry. Patients taking expanded access drugs or drugs used in an ACTG protocol for HIV treatment or for HIV-associated complications that are not prohibited by this protocol are not excluded.
• History of allergy/sensitivity to minocycline or other tetracyclines and their formulations
• Any esophageal or other condition that would interfere with a patient's ability to swallow study medication
• Participation in a previous clinical drug research trial of HIV-associated cognitive impairment. Patients who have had an objective decline in performance as defined by the protocol are not excluded.
• Any other clinically significant condition or laboratory abnormality that, in the opinion of the investigator, would interfere with the study
• Certain medications
• Certain abnormal laboratory values. Patients who test positive on nonreactive rapid plasma reagin tests (RPR)are not excluded.
• Inability to undergo lumbar punctures
• Breastfeeding

Contacts and Locations

Locations

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United States, California
UCLA-David Geffen School of Medicine
Los Angeles, California, United States, 90035
University of California
San Diego, California, United States, 92103
United States, Colorado
University of Colorado Health Science Center
Denver, Colorado, United States, 80262-3706
United States, Georgia
The Ponce de Leon Ctr. CRS
Atlanta, Georgia, United States, 30308
United States, Illinois
Northwestern University CRS
Chicago, Illinois, United States, 60611
United States, Maryland
Johns Hopkins School of Medicine
Baltimore, Maryland, United States, 21287-8106
United States, Massachusetts
Massachusetts General Hospital, Division of Infectious Diseases
Boston, Massachusetts, United States, 02114
United States, Michigan
Henry Ford Hosp. CRS
Detroit, Michigan, United States, 48202
United States, Missouri
Washington University
St. Louis, Missouri, United States, 63108-2138
United States, New York
NYU Med Ctr, Dept of Medicine
New York, New York, United States, 10016
1101 University of Rochester Medical Center, Division of Infectious Diseases
Rochester, New York, United States, 14642
United States, North Carolina
University of North Carolina, AIDS Clinical Trials Unit
Chapel Hill, North Carolina, United States, 27514
United States, Oregon
The Research and Education Group - Portland CRS
Portland, Oregon, United States, 97209
United States, Pennsylvania
University of Pennsylvania, ACTU
Philadelphia, Pennsylvania, United States, 19104
United States, Virginia
Virginia Commonwealth Univ. Medical Ctr. CRS
Richmond, Virginia, United States, 23219
United States, Washington
Univ of Washington, Harborview Medical Ctr
Seattle, Washington, United States, 98104

Sponsors and Collaborators

AIDS Clinical Trials Group

National Institute of Allergy and Infectious Diseases (NIAID)

Neurologic AIDS Research Consortium (NARC)

Investigators

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Study Chair:	Ned Sacktor, MD	Department of Neurology, Johns Hopkins Bayview Medical Center

More Information

Publications of Results:

Sacktor N, Miyahara S, Deng L, Evans S, Schifitto G, Cohen BA, Paul R, Robertson K, Jarocki B, Scarsi K, Coombs RW, Zink MC, Nath A, Smith E, Ellis RJ, Singer E, Weihe J, McCarthy S, Hosey L, Clifford DB; ACTG A5235 team. Minocycline treatment for HIV-associated cognitive impairment: results from a randomized trial. Neurology. 2011 Sep 20;77(12):1135-42. doi: 10.1212/WNL.0b013e31822f0412. Epub 2011 Sep 7.

Sacktor N, Miyahara S, Evans S, Schifitto G, Cohen B, Haughey N, Drewes JL, Graham D, Zink MC, Anderson C, Nath A, Pardo CA, McCarthy S, Hosey L, Clifford D; ACTG A5235 team. Impact of minocycline on cerebrospinal fluid markers of oxidative stress, neuronal injury, and inflammation in HIV-seropositive individuals with cognitive impairment. J Neurovirol. 2014 Dec;20(6):620-6. doi: 10.1007/s13365-014-0292-0. Epub 2014 Nov 7.

Other Publications:

Bell JE. An update on the neuropathology of HIV in the HAART era. Histopathology. 2004 Dec;45(6):549-59. Review.

Ferrari S, Vento S, Monaco S, Cavallaro T, Cainelli F, Rizzuto N, Temesgen Z. Human immunodeficiency virus-associated peripheral neuropathies. Mayo Clin Proc. 2006 Feb;81(2):213-9. Review.

Zink MC, Uhrlaub J, DeWitt J, Voelker T, Bullock B, Mankowski J, Tarwater P, Clements J, Barber S. Neuroprotective and anti-human immunodeficiency virus activity of minocycline. JAMA. 2005 Apr 27;293(16):2003-11.

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Responsible Party:	AIDS Clinical Trials Group
ClinicalTrials.gov Identifier:	NCT00361257 History of Changes
Other Study ID Numbers:	ACTG A5235; 1U01AI068636 ( U.S. NIH Grant/Contract )
First Posted:	August 8, 2006
Results First Posted:	July 26, 2011
Last Update Posted:	February 5, 2016
Last Verified:	January 2016

Keywords provided by AIDS Clinical Trials Group:

Treatment Experienced

Additional relevant MeSH terms:

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HIV Infections; Lentivirus Infections; Retroviridae Infections; RNA Virus Infections; Virus Diseases; Sexually Transmitted Diseases, Viral; Sexually Transmitted Diseases; Immunologic Deficiency Syndromes	Immune System Diseases; Minocycline; Tetracycline; Anti-Bacterial Agents; Anti-Infective Agents; Protein Synthesis Inhibitors; Enzyme Inhibitors; Molecular Mechanisms of Pharmacological Action