Safety Study of Fluconazole in Combination With Flucytosine for the Treatment of Early Cryptococcal Infection (SToP-Crypto)

• ClinicalTrials.gov Identifier: NCT01562132
• Recruitment Status: Terminated
• First Posted: March 23, 2012
• Results First Posted: August 31, 2015
• Last Update Posted: August 31, 2015
• Sponsor: Yale University
• Collaborators: National Institute of Neurological Disorders and Stroke (NINDS); Kenya Medical Research Institute; Bausch Health Americas, Inc.; University of Nairobi
• Information provided by (Responsible Party): Ana-Claire Meyer, Yale University

Study Description

Brief Summary:

The purpose of this study is to determine if treatment with two medicines in combination (fluconazole and flucytosine) is safe as compared with one medicine alone (fluconazole) for the treatment of an early infection with a fungus called cryptococcus.

Condition or disease	Intervention/treatment	Phase
Cryptococcal Infection Disseminated	Drug: Flucytosine and fluconazole; Drug: Fluconazole	Phase 2

Detailed Description:

Currently there is wide variation in practice and little evidence to guide the treatment of early cryptococcal infection in HIV-infected individuals with advanced immunosuppression. However, epidemiologic studies suggest that this may be a promising novel approach to decrease the mortality due to cryptococcal meningitis (CM), the second leading cause of death among HIV-infected individuals in many resource-limited settings. Screening asymptomatic HIV-infected individuals with advanced immunosuppression for serum cryptococcal antigen (CrAg) clearly identifies a population at high risk of CM and death and is a feasible screening method for resource-limited settings. However, screening with serum CrAg alone without additional diagnostic studies identifies a heterogeneous clinical population with early cryptococcal infection, many of whom already have sub-clinical meningeal infection or fungemia. The mainstay of anti-cryptococcal therapy in resource-limited settings is oral fluconazole though preliminary evidence suggests this is not an effective treatment. Thus, there is a critical need for potent therapies that (1) can be safely administered in resource-limited settings and (2) are effective in a heterogeneous population of HIV-infected individuals with advanced immunosuppression and early cryptococcal infection who are initiating anti-retroviral therapy (ART).

This single center, open-label, randomized Phase IIb study is being conducted to assess the safety and estimate the efficacy of oral fluconazole in combination with flucytosine for the treatment of early cryptococcal infection. The study will be based at two sites supported by Family AIDS Care and Education Services (FACES) in Western Kenya. A consecutive sample of 100 HIV-infected adults with CD4 cell count ≤100 cells/µl and serum CrAg titer ≥1:2 who have no signs or symptoms of severe, systemic cryptococcal infection will be enrolled. At enrollment, specimens from participants will be cultured for evidence of Cryptococcus neoformans. Individuals who meet inclusion and exclusion criteria and consent to participate in the study will be randomized to combination therapy with oral fluconazole (1200mg/day) plus flucytosine (100mg/kg/day) or fluconazole alone for the fourteen days of therapy. Subsequently both groups will receive anti-retroviral therapy as well as fluconazole 800mg/day for 8 weeks followed by 200mg/day. The primary safety endpoint will be the incidence of treatment-related adverse events and serious adverse events. The primary efficacy endpoint will be survival at 12 weeks.

In addition, we will offer additional diagnostic testing and aim for 50% participation, approximately 25 individuals from each arm. We will perform a battery of diagnostic tests including chest radiography, fungal cultures in blood, sputum, urine, stool and cerebrospinal fluid (CSF), cryptococcal antigen testing in the CSF, and gram stain, Ziehls-Nielsen stain and India Ink staining of CSF sediment. Anti-fungal susceptibility testing via broth microdilution and polymerase chain reaction serotyping and mating type analysis will be performed on clinical isolates.

Study Design

• Study Type: Interventional (Clinical Trial)
• Actual Enrollment: 6 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Masking: None (Open Label)
• Primary Purpose: Treatment
• Official Title: An Open Label Randomized Controlled Phase IIb Trial to Determine the Safety of Oral Fluconazole in Combination With Flucytosine as Compared to Fluconazole Alone
• Study Start Date: September 2013
• Actual Primary Completion Date: July 2014
• Actual Study Completion Date: July 2014

Arms and Interventions

Arm	Intervention/treatment
Experimental: 5FC plus fluconazole; Combination therapy with oral fluconazole and flucytosine	Drug: Flucytosine and fluconazole; Flucytosine 100mg/kg/day in 4 divided doses orally for 14 days given in combination with fluconazole 1200mg orally once daily for 14 days, followed by 800mg orally once daily for 8 weeks, followed by 200mg orally once daily; Other Names: Ancobon; Diflucan
Active Comparator: fluconazole alone; Fluconazole monotherapy	Drug: Fluconazole; fluconazole 1200mg orally once daily for 14 days, followed by 800mg orally once daily for 8 weeks, followed by 200mg orally once daily; Other Name: Diflucan

Outcome Measures

Primary Outcome Measures :

1. Survival at 12 Weeks [ Time Frame: 12 weeks ]

Secondary Outcome Measures :

1. Survival at 2 Weeks [ Time Frame: 2 weeks ]
2. Survival at 24 Weeks [ Time Frame: 24 weeks ]
3. Number of Individuals Who Develop Cryptococcal Meningitis [ Time Frame: 24 weeks ]

   Clinical meningitis AND at least one of the following: cryptococcal antigen in the cerebrospinal fluid (CSF), cryptococcal organisms on India Ink stain, or fungal culture of CSF.

   Clinical meningitis will be defined as:

   • fever>39.0°C, AND
   • severe headache, AND

   At least one of the following:

   • meningismus,
   • photophobia,
   • new onset seizure,
   • focal neurological deficit localizable to the central nervous system
   • papilledema
   • confusion, delirium, or decreased level of consciousness.
4. Number of Individuals Who Develop Immune Reconstitution Inflammatory Syndrome Due to Cryptococcus [ Time Frame: 24 weeks ]

   Individuals who develop clinical meningitis without evidence of fungal, bacterial, or parasitic (e.g. malaria) organisms in the cerebrospinal fluid. Clinical meningitis will be defined as:

   • fever>39.0°C, AND
   • severe headache, AND
   • At least one of the following:
   • meningismus,
   • photophobia,
   • new onset seizure,
   • focal neurological deficit localizable to the central nervous system
   • papilledema
   • confusion, delirium, or decreased level of consciousness.
5. Achieve Targeted Recruitment, Retention and Adherence Rates [ Time Frame: 24 weeks ]
6. Proportion of Individuals Requiring Treatment Discontinuation [ Time Frame: 4 weeks ]
7. Proportion of Individuals Requiring Dose Reduction [ Time Frame: 24 weeks ]
8. Number of Individuals With Treatment Related Adverse Events [ Time Frame: 24 weeks ]
9. Number of Individuals With Treatment Related Serious Adverse Events [ Time Frame: 24 weeks ]
10. Cryptococcal Meningitis-free Survival at 24 Weeks [ Time Frame: 24 weeks ]

    Clinical meningitis AND at least one of the following: cryptococcal antigen in the cerebrospinal fluid (CSF), cryptococcal organisms on India Ink stain, or fungal culture of CSF.

    Clinical meningitis will be defined as:

    • fever>39.0°C, AND
    • severe headache, AND

    At least one of the following:

    • meningismus,
    • photophobia,
    • new onset seizure,
    • focal neurological deficit localizable to the central nervous system
    • papilledema
    • confusion, delirium, or decreased level of consciousness.

Eligibility Criteria

• Ages Eligible for Study: 18 Years and older (Adult, Older Adult)
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Criteria

Inclusion Criteria:

• Able and willing to give informed consent
• Age > 18 years
• HIV infection as confirmed by HIV-antibody test as per Kenyan guidelines
• CD4+ T-cell count ≤100 cells/µl
• Serum CrAg titer≥1:2
• Able to travel to district hubs (Sindo District Hospital, Lumumba Health Centre) for regular study visits

Exclusion Criteria:

• clinical meningitis:
• clinical sepsis:
• hemiparesis, aphasia, visual field deficit or other finding on neurological examination localizable to the central nervous system
• a history of culture proven or suspected (cryptococcal antigen present) cryptococcal meningitis
• a history of stroke or other infection of the central nervous system
• a seizure within the last 2 months
• currently taking or ever taken antiretroviral therapy
• currently taking anti-tuberculous therapy
• currently or recently (<2 months) prescribed fluconazole, itraconazole, clotrimazole troches, amphotericin or other oral anti-fungal medications
• pregnant or breast-feeding
• alanine aminotransferase concentration more than 3 times the upper limit of normal
• neutrophil count <1000x103 cells/mL
• hemoglobin <8g/dL
• platelet count <100,000x 103 platelets/mL
• creatinine clearance ≤50 ml/min
• individuals with active heavy alcohol use or active recreational drug use

Contacts and Locations

Locations

Kenya

Family AIDS Care and Education Services

Kisumu, Nyanza, Kenya

Family AIDS Care and Education Services

Sindo, Nyanza, Kenya

Sponsors and Collaborators

Yale University

National Institute of Neurological Disorders and Stroke (NINDS)

Kenya Medical Research Institute

Bausch Health Americas, Inc.

University of Nairobi

Investigators

• Principal Investigator: Ana-Claire L Meyer, MD, MSHS; University of California, San Francisco
• Principal Investigator: Mark A Jacobson, MD; University of California, San Francisco
• Principal Investigator: Judith K Kwasa, MBChB MMed; University of Nairobi

More Information

• Responsible Party: Ana-Claire Meyer, Principal Investigator, Yale University
• ClinicalTrials.gov Identifier: NCT01562132
• Other Study ID Numbers: R21NS077858-01 ( U.S. NIH Grant/Contract ); R21NS077858-01 ( U.S. NIH Grant/Contract )
• First Posted: March 23, 2012
• Results First Posted: August 31, 2015
• Last Update Posted: August 31, 2015
• Last Verified: July 2015

Keywords provided by Ana-Claire Meyer, Yale University:

cryptococcus; HIV

Additional relevant MeSH terms:

Infection; Fluconazole; Flucytosine; Antifungal Agents; Anti-Infective Agents; 14-alpha Demethylase Inhibitors; Cytochrome P-450 Enzyme Inhibitors; Enzyme Inhibitors; Molecular Mechanisms of Pharmacological Action; Steroid Synthesis Inhibitors; Hormone Antagonists; Hormones, Hormone Substitutes, and Hormone Antagonists; Physiological Effects of Drugs; Cytochrome P-450 CYP2C9 Inhibitors; Cytochrome P-450 CYP2C19 Inhibitors; Antimetabolites