Pilot Clinical Trial of PRS TB Regimen I - Phase II
Condition: Pulmonary Tuberculosis TB in Sputum: (+) Microscopy
MeSH terms: Tuberculosis; Tuberculosis, Pulmonary
Study type: Interventional
Phase: Phase 4

Summary: 
      Tuberculosis is the current leading cause of death due to an identifiable infectious agent
      worldwide. The current standard regimen for tuberculosis requires a patient to take drug
      combination (isoniazid, rifampicin, ethambutol, and pyrazinamide) for six to eight month
      periods. The purpose of this study is to compare tuberculosis treatment therapy between the
      current standard regimen and PRS derived combinatorial regimen. PRS derived regimen may
      potentially allow for a shorter course of treatment, which may reduce problems associated
      with adherence, toxicity, and development of drug resistance.
    

Detailed description: 
      Tuberculosis (TB) is a major health problem of global proportions. Although drug sensitive TB
      is a treatable disease, the current standard treatment requires 6 - 8 months of a multi-drug
      regimen to achieve relapse-free cure. This long course of treatment is often associated with
      toxicity, poor compliance, and development of drug resistance. A more effective drug
      combination that provides more rapid sterilization of tissues has the potential to ameliorate
      these critical problems.

      The current drug regimen for treating tuberculosis is lengthy and onerous, and hence
      complicated by poor compliance leading to drug resistance and disease relapse. Previously,
      using an output-driven optimization platform, parabolic response surface (PRS, previously
      called Feedback System control or FSC), and an in vitro macrophage model of Mycobacterium
      tuberculosis infection, we identified several new experimental drug regimens among billions
      of possible drug-dose combinations that outperform the current Standard Regimen. We used the
      PRS platform to optimize the in vivo drug doses of novel regimens (designated PRS regimen) in
      a mouse model of pulmonary tuberculosis and then showed that the regimens sterilized much
      more rapidly than the Standard Regimen and substantially reduced treatment time to
      relapse-free cure by 25% for PRS regimen, which consists of Clofazimine (Cfz), Ethambutol
      (E), high dose Pyrazinamide (Z, high), and Prothionamide (Pto). The regimen have the
      potential to provide a markedly shorter course of treatment for tuberculosis in humans. As
      PRS regimen omit isoniazid, rifampicin, fluoroquinolones, and injectable aminoglycosides,
      they are suitable for treating many cases of multidrug and extensively drug-resistant
      tuberculosis.

      1 Significance of the study Based on results in cell culture in macrophages and in mice we
      anticipate that PRS regimen will prove to be more effective and will allow a shorter course
      of treatment than the standard regimen. By allowing a shorter course of treatment, problems
      with adherence, toxicity, and development of drug resistance can be reduced. Moreover,
      because the regimen does not include INH or RIF, it can be used in cases of TB that are
      resistant to those drugs.

      2 Methods

        1. Summary of Experimental Design This is a randomized, controlled, open-label pilot
           clinical trial. Previously untreated, smear positive tuberculosis patients (aged 18 - 65
           years) with radiographic evidence of TB and whose bacteria are sensitive to first-line
           drugs will be randomly distributed to group A (standard regimen) and B (new short course
           PRS regimen). The study will compare sputum conversion rate at the end of treatment
           between treatment regimens and will evaluate objective indicators of treatment success
           rate and incidence of adverse events.

        2. Identification of Subjects: Potentially eligible subjects will be identified from among
           subjects seen at or referred to the Shanghai Pulmonary Hospital for treatment of
           tuberculosis. Subjects will be informed about the study and those who express interest
           in participation will be provided a written consent form.

        3. Consent Process: As described in detail below, Subjects will be informed that
           participation is voluntary and that they will receive appropriate care for their
           condition regardless of whether or not they participate in the study. Because subjects
           have active TB, they will be in isolation in the Shanghai Pulmonary Hospital. The
           investigator will review the consent form with the subject and ensure that the subject
           understands the consent form and that all of the subject's questions have been answered.
           Because timely initiation of treatment is important, subjects will be allowed up to two
           days to decide whether to participate in the study or to receive standard care.

        4. Screening for Eligibility: Screening tests indicated in the Table of Study Procedures
           (located at the end of this document) and required for assessment of eligibility per
           inclusion/exclusion criteria will be completed within 14 days prior to study enrollment.

        5. Randomization: Eligible subjects will be randomized 1:1 by using a random number
           generator either to Group A (standard care) or to Group B (the investigational PRS
           regimen).

        6. Study Treatment: Subjects are treated according to their assignment to Group A or Group
           B as indicated below.

           Group A, Standard Regimen (2EHRZ/4HR): The standard six-month regimen is eight weeks of
           daily treatment with isoniazid, rifampin, ethambutol, and pyrazinamide followed by
           sixteen weeks of isoniazid and rifampin.

           All drugs are administered orally, seven days/week. Study drugs are dosed by weight as
           shown in the below. Group B, PRS Regimen (4EZ [high dose] Cfz Pto): The PRS regimen is 4
           months of daily Cfz, Emb, Pto, and high dose pyrazinamide, dosed by weight according to
           below.

           The drug dosing for both Group A and Group B are summarized in the below:

           ………………………………………………………………………………………………………………………… Isoniazid (H):daily dose (gm)0.3(weight
           <50kg);0.3(weight≥50kg),use method: 1 times/day.

           Rifampin (R):daily dose (gm)0.45(weight <50kg);0.6(weight≥50kg),use method: 1
           times/day（Fasting medication）.

           ethambutol (E):daily dose (gm)0.75(weight <50kg);1.0(weight≥50kg),use method: 1～2
           times/day.

           pyrazinamide (Z):daily dose (gm)1.5(weight <50kg);1.5(weight≥50kg),use method:1～3
           times/day.

           Pyrazinamide (High dose):daily dose (gm)1.75(weight <50kg);2.0(weight≥50kg),use
           method:1～2 times/day.

           clofazimine（Cfz）:daily dose (gm)0.15(weight <50kg);0.15(weight≥50kg),use
           method:1～3times/day.

           prothionamide（Pto）:daily dose (gm)0.6(weight <50kg);0.6(weight≥50kg),use method: 3
           times/day.

           ……………………………………………………………………………………………………………

        7. Patient follow up After 6-months standard treatment or 4-months short term PRS regimen
           treatment, subjects will have long term follow up to evaluate efficacy and ensure
           absence of relapse. The checkup times are at 1 month, 3 months, 6 months, 12 months and
           24 months.

      Evaluation of Efficacy i Bacteriology: sputum smear microscopy, culture using the Becton
      Dickinson Company mycobacterial growth indicator tube (MGIT) system and Lowenstein-Jensen
      (LJ) slant culture. MGIT testing will be used to evaluate drug susceptibility .

      ii Radiology: All patients undergo chest X-ray and CT scan before treatment. X-ray will be
      reviewed after 8 weeks of treatment and at end of treatment and during the follow-up period.
      CT scan will be reviewed at end of treatment.

      iii Bacterial load of sputum samples will be evaluated within two weeks after the start of
      treatment.

      iv Time to culture positivity: Time to culture positivity will be performed by MGIT culture
      within two months after the start of treatment.

      v Evaluation of results: We shall employ the World Health Organization (WHO) uniform
      standards in evaluating cure rate and treatment success rate, the sputum negative conversion
      rate, incidence of adverse events and patient compliance and other indicators. We shall
      compare these outcomes between the experimental group and the standard group to analyze the
      effect of each treatment regime.
    

Intervention name(s): Group A (the standard 2HRZE/4HR regimen）; Group B (New short course PRS regimen, 4EZ(high dose)PtoCfz)
Intervention type(s): Drug; Drug
Intervention description(s): The standard six-month regimen is eight weeks of daily treatment with isoniazid, rifampin, ethambutol, and pyrazinamide followed by sixteen weeks of isoniazid and rifampin. The six-month regimen is the standard regimen for the treatment of drug-susceptible tuberculosis recommended by WHO.; The PRS regimen I（new short course PRS regimen） is 4 months of daily Cfz, Emb, Pto, and high dose pyrazinamide, dosed by weight.Comparison of Standard Regimen：The standard six-month regimen is eight weeks of daily treatment with isoniazid, rifampin, ethambutol, and pyrazinamide followed by sixteen weeks of isoniazid and rifampin.
Other intervention name(s): The control group; The experimental group
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Tuberculosis