Nebulised BromAc in Healthy Volunteers
Condition: COVID-19 Pneumonia; Bromelains Adverse Reaction; Acetylcysteine Adverse Reaction; Mucus; Plug; COVID-19 Acute Respiratory Distress Syndrome
MeSH terms: COVID-19; Pneumonia; Respiratory Distress Syndrome; Respiratory Distress Syndrome, Newborn; Acute Lung Injury
Study type: Interventional
Phase: Phase 1

Summary: 
      COVID-19 is a disease that has multiple facets including an inflammatory storm, it promotes
      blood clotting and causes kidney damage, mucinous secretions in the lung are of great
      importance to outcome. Increasingly sticky sputum is associated with critical illness, with
      considerably raised levels of a specific type of mucous protein (MUC5AC) in sputum in
      COVID-19 patients. There is a strong link between viral infection and mucus production via
      multiple inter-cellular signalling pathways including Interleukin (IL)6, IL10 and Tumour
      Necrosis Factor (TNF) whereby the inflammatory storm causes sudden secretion of high volumes
      of dense mucus.

      An Australian pharmaceutical company has developed BromAc (Bromelain & Acetylcysteine) for
      the palliative treatment of highly mucinous tumors of the appendix and lung. During
      pre-clinical development, they found that BromAc® rapidly dissolved and removed tumour mucin,
      making it a potent mucolytic. In combination, bromelain and acetylcysteine disrupt the
      architecture of the SARS-COV-2 virus in a way that renders it non-infective, reduced
      cytokines and chemokines in COVID-19 sputum and is a highly effective respiratory mucolytic.

      The aim of this study is to assess whether BromAc delivered into the respiratory tract as a
      nebulised aerosol is tolerated and safe at three specific concentrations in healthy volunteer
      participants. The investigators will further assess the safety of nebulised BromAc and
      efficacy of the drug product as a mucolytic and anti-inflammatory, and whether this improves
      clinical outcome in participants with COVID-19. The hypothesis is that BromAc will be
      tolerated by patients and will result in mucus clearance, improving oxygenation and
      compliance in those that are ventilated.

      This is a phase I study on the safety of BromAc, where 12 healthy volunteers will receive
      BromAc as a nebulised aerosol into the respiratory tract. BromAc is a product that combines
      two existing products to be delivered into the respiratory tract via nebulised aerosol
      delivery through a mask. The participant will be assessed for symptoms and side effects. The
      participant will receive nebulised BromAc at the allocated dose level for a total of 3 days.
      The hypothesis is that nebulised airway delivery of BromAc will be safe at the concentrations
      assessed.
    

Detailed description: 
      The SARS-CoV-2 virus, with its clinical syndrome known as COVID-19, has a spike protein (S),
      nucleocapsid protein (N) that contains the RNA, membrane protein (M) and the envelope protein
      (E). The spike protein is responsible for initiating internalisation of the virus genome into
      human lung cells via ACE2 receptors in the nasopharyngeal and lung tissue, it protrudes on
      the outer surface and is made up of number of amino acids and glycoproteins. The integrity of
      the proteins (S, N, M & E) is vital for viral functions, and formation of disulfide bonds
      between these have been suggested to play a vital role in the performance of the protein. The
      cleavage site after binding has been reported to split the spike glycoprotein, which is then
      reported to be supported with disulphide bonds. Binding then triggers proteolysis processed
      by transmembrane protease, serine 2 (TMPRSS2), furin, and perhaps other proteases, leading to
      fusion of viral and cellular membranes and thus target cells penetration. Hijacking of the
      cellular machinery then allows viral multiplication.

      COVID-19 is a disease that has multiple facets including cytokine storm, thromboembolism and
      renal impairment, but the investigators believe mucinous secretions in the lung are of great
      importance to outcome. Early reports of lung pathology included cellular fibromyxoid exudate,
      proteinaceous exudate, massive luminal fibrous exudate and severe mucoid tracheal bronchitis.
      Autopsies in a cohort of fatal cases from northern Italy showed 'lumina often contained dense
      mucoid material. There are many pathological changes in the lungs, and these evolve over
      time. Early disease is characterised by neutrophilic exudative capillaritis with thrombosis.
      Late changes occurring on average from day 10 include diffuse alveolar damage, intravascular
      thrombosis, infection, disseminated intravascular coagulopathy (DIC) and later intra-alveolar
      fibroblast proliferation. Bronchoscopy was performed for acute hypoxia due to lung collapse
      in a COVID-19 patient, revealing a thick mucus plug. Multiple other reports of similar
      findings in bronchoscopies have been described where mucolytic therapy and suctioning have
      been advocated. Sputum characteristics in patients with severe COVID-19 correlate with
      outcome. Increasingly sticky sputum was associated with critical illness and considerably
      raised levels of MUC5AC in sputum in COVID-19 patients. There is a strong link between viral
      infection and mucus production via multiple signalling pathways including Interleukin (IL)6,
      IL10 and Tumour Necrosis Factor (TNF) whereby the cytokine storm causes sudden mucus
      hypersecretion.

      Currently, there are few therapeutic agents of limited efficacy to treat or avoid the
      complications of COVID-19. An Australian pharmaceutical company has developed BromAc for the
      palliative treatment of highly mucinous tumors of the appendix and lung. This drug is
      composed of bromelain and acetylcysteine. During pre-clinical development, the sponsor found
      that BromAc® rapidly dissolved and removed tumour mucin, making it a potent mucolytic.
      BromAc® in combination have the ability, as shown in pre-clinical studies, to remove the
      mucin protective framework expressed by cancer including mucins MUC1, MUC2, MUC4, MUC5AC and
      MUC16. The sponsor has that BromAc breaks peptide and glycosidic linkages and disulphide
      bonds in tumour produced and respiratory mucin. It also combines synergistically with a
      variety of anticancer and antibacterial drugs.

      In an in vitro study with Vero and CALU-3 cells infected by SARS-CoV-2 (MOI 1 to -4) and
      treated with BromAc, it was found that the drug was able to reduce the virus' ability to
      infect cells, demonstrating an antiviral potential against SARS-CoV-2. In addition to the
      anti-viral effect, BromAc is a potent mucolytic. In laboratory studies conducted in Brazil,
      BromAc (125ug or 250ug/ml plus 20mg/ml Acetylcysteine) resulted in complete dissolution of
      severe COVID-19 sputum within 30 minutes. BromAc was also shown to significantly
      down-regulate cytokines and chemokines in comparison to Acetylcysteine alone or control,
      specifically those important to COVID-19 cytokine storm CCL2, CCL3, IL-6, CXCL10. In vitro
      safety models have received nebulised and intranasal BromAc up to 500ug/20mg/ml three times
      daily for five days, with no evidence of toxicity.

      In oncology, BromAc interferes with the effect of mucin, reduces cancer cell viability and
      profoundly enhances the effects of certain chemotherapy agents. MUC1, MUC2 and MUC5AC are
      highly expressed in gastrointestinal tumours. In brief, when investigating the effects of
      BromAc treatment on specific mucin isoforms in gastrointestinal carcinoma cells, the sponsor
      observed a significant decrease in the expression of MUC2 and MUC5AC in gastrointestinal
      LS174T cell lines. MUC1 and MUC5 are overexpressed and aberrantly glycosylated in most
      carcinomas, exploited by malignant cells to induce transformation and tumorigenicity. The
      sponsor's team have performed dose escalation animal safety studies with repeat injection in
      three different animal species into the peritoneum with doses of Bromelain up to 10mg/kg and
      Acetylcysteine 500mg/kg. There was no toxicity seen. BromAc was shown to remove mucin from
      the a range of human tumours in vivo, while none of the drugs worked alone. BromAc has the
      ability, as demonstrated in preclinical studies, to remove the protective structure of mucin
      expressed by cancer, including MUC1, MUC2, MUC4, MUC5B, MUC5AC and MUC16. BromAc's mechanism
      of action in removing peptide and glycoside bonds and disulfide bonds in mucin has also been
      shown. In addition, secondary infection in patients with COVID-19 might also be prevented or
      treated because of the effect of BromAc on biofilm. The sponsor has described efficacy in
      used endotracheal tubes at dissolving biofilm via nebulisation of BromAc, in addition to
      extensive laboratory work on pseudomonas aeruginosa and staphylococcus aureus established
      biofilms.

      It is known that oxygen exchange is the main problem in patients with COVID-19 and hypoxia is
      one of the most serious effects, in which patients succumb to acute respiratory distress
      syndrome (ARDS). The development of mucinous sputum plugs in individuals infected with
      SARS-CoV-2 is variable in the early stages of the disease. In addition, 30-40% of patients
      who are in hospital have expectoration production, and in a recent study on pulmonary
      pathology in patients with COVID-19, subsequent tests revealed markedly increased levels of
      MUC1 and MUC5AC in sputum and trachea aspirate.

      This study aims to examine the safety and efficacy of nebulised BromAc in a dose escalation
      phase I component. A phase I study applying the safe and effective dose in patients with
      moderate to severe COVID-19 will also be conducted. The primary endpoint in the phase I
      studies is the safety and tolerability of the planned doses. The hypothesis is that BromAc
      will be tolerated by patients and will result in mucus clearance, improving oxygenation and
      compliance in those that are ventilated.

      This is a phase I study on the safety of BromAc, where 12 healthy volunteers who are
      otherwise well and remain in the outpatient setting will receive BromAc as a nebulised
      aerosol into the respiratory tract. BromAc is a product that combines two existing products
      (Bromelain and Acetylcysteine), along with 0.9% normal saline to be delivered into the
      respiratory tract via nebulised aerosol delivery through a mask. The participant will be
      assessed for symptoms and side effects.
    

Intervention name(s): BromAc
Intervention type(s): Drug
Intervention description(s): Bromelain and acetylcysteine are combined in various concentrations (either 100ug, 150ug or 200ug of bromelain, with 20mg of acetylcysteine). This is then delivered by a nebuliser to up to 12 healthy volunteers. The primary aim is determining safety.
Allocation: Non-Randomized
Intervention model: Sequential Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: bromelain; BromAc; acetylcysteine; SARS-CoV-2; mucin; mucus plug; COVID-19 pneumonia; ventilator associated pneumonia; secondary bacterial infection