mulTi-Arm Therapeutic Study in Pre-ICu Patients Admitted With Covid-19 - Repurposed Drugs (TACTIC-R) (TACTIC-R)

• ClinicalTrials.gov Identifier: NCT04390464
• Recruitment Status: Unknown
• First Posted: May 15, 2020
• Last Update Posted: May 18, 2020
• Sponsor: Cambridge University Hospitals NHS Foundation Trust
• Information provided by (Responsible Party): Frances Hall, Cambridge University Hospitals NHS Foundation Trust

Study Description

Brief Summary:

TACTIC-R is a randomised, parallel arm, open-label platform trial for investigating potential treatment for COVID-19 disease. While SARS-CoV infection evades detection by the immune system in the first 24 hours of infection, it ultimately produces a massive immune system response in the subgroup of people who develop severe complications. Most tissue damage following infection with COVID19 appears to be due to a later, exaggerated, host immune response. This leads to lung and sometimes multi-organ damage.

Most people who develop these severe complications still have virus present in their respiratory tract at the time-point when the disease starts to evolve. Immune modulation in the presence of active infection has potential to cause more harm than benefit. Safety considerations when studying immune modulation strategies are paramount. Therefore, this study proposes to assess the efficacy of immunomodulatory agents that target dysregulated immune response that drive the severe lung, and other organ, damage. The medications investigated for efficacy in this trial are Baricitinib and Ravulizumab.

Condition or disease	Intervention/treatment	Phase
COVID19	Drug: Ravulizumab; Drug: Baricitinib; Other: Standard of care	Phase 4

Detailed Description:

TACTIC-R will assess the efficacy of the immunomodulatory agents Baricitinib and Ravulizumab as potential treatments for COVID-19 disease against Standard of Care alone. These agents target the dysregulated immune response that drives the severe lung, and other organ, damage frequently seen during COVID-19 infection. This trial will compare these immunomodulatory agents to Standard of Care over a 14-day treatment period, with follow-up at 28 and 90 days. Patients will be randomised in a 1:1:1 ratio across treatments.

TACTIC-R will use a platform design with interim analysis to make efficient decisions about efficacy and futility (e.g. lack of efficacy and risk of harm) of the trial treatments. This enables the trial to stop recruiting to arms early where a clear efficacy decision can be made. It also allows for the addition of further arms.

TACTIC-R will also iterate an algorithm for use of clinical and biochemical phenotyping to:

1. Stratify patients to therapeutic arms according to probability of efficacy
2. Identify early indicators of failure of therapeutic strategy.

By collecting samples for genomics, transcriptomics, proteomics and immunological phenotyping, parallel studies associated with TACTIC-R will investigate host susceptibility factors for development of severe COVID-19-related disease and predictive biomarkers of response to therapeutic strategy.

Study Design

• Study Type: Interventional (Clinical Trial)
• Estimated Enrollment: 1167 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Intervention Model Description: TACTIC-R is a randomised, parallel arm, open-label platform trial.
• Masking: None (Open Label)
• Primary Purpose: Treatment
• Official Title: mulTi-Arm Therapeutic Study in Pre-ICu Patients Admitted With Covid-19 - Repurposed Drugs (TACTIC-R)
• Actual Study Start Date: May 8, 2020
• Estimated Primary Completion Date: May 7, 2021
• Estimated Study Completion Date: May 1, 2022

Arms and Interventions

Arm	Intervention/treatment
Active Comparator: Standard of care; Standard of care	Other: Standard of care; Regular standard of care for COVID-19 patients
Experimental: Ravulizumab + Standard of care; Ravulizumab IV (adjusted to weight, Day 1 only)	Drug: Ravulizumab; Ravulizumab (Ultomiris, Alexion Pharmaceuticals) is a monoclonal antibody that binds to terminal complement protein C5 and prevents the complement-mediated destruction of cells. It is administered by intravenous infusion. Ravulizumab has a marketing authorisation in the UK for treating Paroxysmal Nocturnal Haemoglobinuria in adults.; Other Name: Ultomiris
Experimental: Baricitinib + Standard of care; Baricitinib PO OD (4mg, Days 1-14)	Drug: Baricitinib; Baricitinib is administered orally once daily. It is licensed for treatment of rheumatoid arthritis, it is a relatively fast acting disease modifying anti-rheumatic drug and has the potential to be scaled up for use for a pandemic.; Other Name: Olumiant

Outcome Measures

Primary Outcome Measures :

1. Time to incidence of the composite endpoint of: Death, Mechanical ventilation, ECMO, Cardiovascular organ support, or Renal failure [ Time Frame: up to Day 14 ]
   Number of days taken for occurrence of one of the following events: 1. Death 2. Mechanical ventilation 3. Extracorporeal membrane oxygenation (ECMO) 4. Cardiovascular organ support (balloon pump or inotropes) 5. Renal failure (estimated creatinine clearance (by Cockcroft-Gault formula) <15 ml /min/1.73m^2), haemofiltration or dialysis

Secondary Outcome Measures :

1. Change in clinical status as assessed on 7-point ordinal scale compared to baseline [ Time Frame: 14 days ]
   The clinical status of the patients is assessed using 7-point ordinal scale as follows: 1 = Death, 2 = Mechanical ventilation, 3 = Non-invasive or high flow oxygen, 4 = Low flow oxygen, 5 = Hospitalised - no oxygen, 6 = Discharged - normal activities not resumed, 7 = Discharged - normal activities resumed
2. Proportion of patients with adverse events of special interest in each treatment arm [ Time Frame: 14 days ]
   The proportion of patients in each treatment arm that experience adverse events of special interest, defined as: venous thromboembolism, new infections requiring antimicrobials
3. Time to Sp02 >94% on room air [ Time Frame: 14 days ]
   The time taken to achieve blood oxygen saturation levels above 94% in patients on room air, measured in hours/days
4. Time to first negative SARS-CoV2 PCR [ Time Frame: 14 days ]
   The amount of time between a patient's first positive SARS-CoV2 PCR test and a patient's first negative SARS-CoV2 PCR test, measured in days
5. Duration of oxygen therapy [ Time Frame: 14 days ]
   The duration of oxygen therapy given to a patient, measured in days
6. Duration of hospitalisation [ Time Frame: 14 days ]
   The duration of hospitalisation of a patient, measured in days
7. All cause mortality at day 28 [ Time Frame: 28 Days ]
   The number of deaths recorded at 28 days irrespective of the cause
8. Time to clinical improvement [ Time Frame: 14 days ]
   The time to clinical improvement for a patient, defined as: >2 point improvement from Day 1 on the 7-point ordinal scale, measured in days

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

To be included in the trial the participant must:

1. Be aged 18 and over

2. Have clinical picture strongly suggestive of COVID-19-related (with/without positive COVID-19 test) AND

   • Risk count (as defined below) >3 OR
   • ≥ 3 if risk count includes "Radiographic severity score >3"
3. Be considered an appropriate subject for intervention with immunomodulatory in the opinion of the supervising clinician
4. Be able to be maintained on venous thromboembolism prophylaxis or current maintenance therapy during inpatient dosing period, according to local guidelines

Exclusion Criteria

The presence of any of the following will preclude participant inclusion:

1. Inability to supply direct informed consent or assent from Next of Kin or Independent Healthcare Provider on behalf of patient
2. Mechanical ventilation at time of prior to dosing
3. Contraindications to study drugs, including hypersensitivity to the active substances or any of the excipients
4. Currently on any of the study investigational medicinal products
5. Known unresolved Neisseria meningitidis infection
6. Unwilling to be vaccinated against Neisseria meningitidis or receive prophylactic antibiotic cover until 2 weeks after vaccination
7. Known active tuberculosis (no blood screening required)
8. Known active Hepatitis B or C (no blood screening required); active varicella zoster
9. Concurrent participation in any interventional clinical trial including COVID-19-related disease trials (observational studies allowed)
10. Patient moribund at presentation or screening
11. Pregnancy at screening (or unwillingness to adhere to pregnancy advice in protocol)
12. Unwillingness to adhere to breastfeeding advice in protocol
13. Either alanine transaminase or aspartate transaminase (ALT or AST) > 5 times the upper limit of normal
14. Stage 4 severe chronic kidney disease or requiring dialysis (i.e. Cockcroft Gault estimated creatinine clearance < 30 ml /min/1.73 m^2)
15. Currently receiving probenecid or chronic IVIG treatment
16. Any medical history or clinically relevant abnormality that is deemed by the principal investigator and/or medical monitor to make the patient ineligible for inclusion because of a safety concern.

Risk Count

Patients will be given a Risk Count equal to the cumulative points received for the following criteria (no = 0 points, yes = 1 point):

Male gender, Age > 40 years, Non-white ethnicity, Diabetes, Hypertension, Neutrophils > 8.0x10^9/L, CRP > 40mg/L, Radiographic severity score >3

Contacts and Locations

Contacts

Contact: Elena Hernan-Sancho; 01223 349132 ext 349132; elena.hernansancho@addenbrookes.nhs.uk

Locations

United Kingdom

Cambridge University Hospitals NHS Foundation Trust; Recruiting

Cambridge, Cambridgeshire, United Kingdom, CB2 0QQ

Contact: Elena Hernan Sanch0 01223369824 elena.hernansancho@addenbrookes.nhs.uk

Contact: Maria King 07792173955 maria.king@addenbrookes.nhs.uk

Sponsors and Collaborators

Cambridge University Hospitals NHS Foundation Trust

Investigators

• Principal Investigator: Frances Hall Hall, FRCP (UK), D.Phil; Cambridge University Hospitals NHS Foundation Trust

More Information

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):

Kreuzberger N, Hirsch C, Chai KL, Tomlinson E, Khosravi Z, Popp M, Neidhardt M, Piechotta V, Salomon S, Valk SJ, Monsef I, Schmaderer C, Wood EM, So-Osman C, Roberts DJ, McQuilten Z, Estcourt LJ, Skoetz N. SARS-CoV-2-neutralising monoclonal antibodies for treatment of COVID-19. Cochrane Database Syst Rev. 2021 Sep 2;9:CD013825. doi: 10.1002/14651858.CD013825.pub2. Review.

Kulkarni S, Fisk M, Kostapanos M, Banham-Hall E, Bond S, Hernan-Sancho E, Norton S, Cheriyan J, Cope A, Galloway J, Hall F, Jayne D, Wilkinson IB. Repurposed immunomodulatory drugs for Covid-19 in pre-ICu patients - mulTi-Arm Therapeutic study in pre-ICu patients admitted with Covid-19 - Repurposed Drugs (TACTIC-R): A structured summary of a study protocol for a randomised controlled trial. Trials. 2020 Jul 8;21(1):626. doi: 10.1186/s13063-020-04535-4.

• Responsible Party: Frances Hall, Consultant Rheumatologist, Cambridge University Hospitals NHS Foundation Trust
• ClinicalTrials.gov Identifier: NCT04390464
• Other Study ID Numbers: TACTIC-R
• First Posted: May 15, 2020
• Last Update Posted: May 18, 2020
• Last Verified: May 2020

• Studies a U.S. FDA-regulated Drug Product: No
• Studies a U.S. FDA-regulated Device Product: No

Additional relevant MeSH terms:

COVID-19; Respiratory Tract Infections; Infections; Pneumonia, Viral; Pneumonia; Virus Diseases; Coronavirus Infections; Coronaviridae Infections; Nidovirales Infections; RNA Virus Infections; Lung Diseases; Respiratory Tract Diseases; Ravulizumab; Complement Inactivating Agents; Immunosuppressive Agents; Immunologic Factors; Physiological Effects of Drugs