Azacytidine During Anti-tuberculosis Therapy

Tuberculosis has been shown to make immune genes inaccessible and slows immune response The purpose of this research is to see if if azacitidine is safe and can return the ability of the body to resist tuberculosis (TB), a contagious infection that attacks the lungs. Individuals with tuberculosis are being asked to participate. Some will receive a drug to restore a host immunity while others can choose to receive standard of care. All patients will continue to receive standard of care tuberculosis therapy regardless of whether they chose to participate in the study.

This study is a Phase Ib/IIa single-institution, open-label, non-randomized clinical trial of sub-cutaneous azacitidine in pulmonary TB patients during the continuation phase of ATT.

All study participants will have drug-sensitive TB and successfully complete 2 months of standard intensive phase 4-drug RHZE (rifampin, isoniazid, pyrazinamide, ethambutol). By definition, to have uncomplicated TB, participants will have become asymptomatic and smear-negative by the end of intense phase anti-Tb therapy and be ready to transition from standard 4-drug (INH, RIF, ETH, PZA) intense phase to the 2-drug continuation phase (INH and RIF). All participants will have 1 and 2-month cultures "no growth to date" at the time of AZA administration (1-month cultures will therefore be no growth at \~6 weeks and 2-month cultures will be no growth at \~2 weeks).

Eligible study participants will be allocated to the AZA in sequential blocks of 8 study participants.

The following will be performed during screening and work up. These procedures will be performed within 4 weeks prior to administration of study drug. A signed and dated IRB approved consent form will be obtained before study specific procedures are performed. Procedures part of routine care are not considered study specific. All subjects will be screened for eligibility before enrollment.

1. Informed consent
2. Full History and Exam

   1. Concomitant medications
   2. Allergies
   3. Alcohol and substance use
   4. Vital signs and physical exam
3. Review of baseline laboratory results including complete blood count (CBC) with differential, liver function, renal function and microbiology studies

   a. After consent, CBC, coagulation and Renal and liver function studies will occur within 14-days prior to study drug.

   i. CBC: WBC, Hemoglobin, Hematocrit, Platelet count ii. Coagulation studies: PT and PTT iii. Sodium, potassium, blood urea nitrogen, creatinine, glucose, AST, ALT, alkaline phosphatase, total bilirubin b. After screening labs, participants with cytopenias or inappropriate coagulation, renal or liver function (see inclusion and exclusion criteria), will not receive study drug
4. Pregnancy test (within 24 hours prior to AZA dosing)

PHASE IB: AZACITIDINE AFTER 10 WEEKS OF ATT; PRE-TREATMENT EVALUATION

1-Month pre-study drug: Recruitment, consent and completion of the Case Report Form (CRF) including baseline history and physical exam will occur between week 4-10 of Anti-TB therapy.

0-2 weeks pre-study drug: Blood draw for baseline immune correlates and to screen for eligibility criteria (CBC, CMP and coagulation) will occur 1-14 days prior to azacitidine dosing. A pregnancy test will occur within 24 hours prior to AZA dosing. (A CMP will include measurement of alanine aminotransferase, alkaline phosphatase, aspartate aminotransferase, total bilirubin, creatinine, chloride, carbon dioxide/bicarbonate, sodium, potassium and glucose. A CBC will include a differential and includes red blood cell count, white blood cell count, hemoglobin, hematocrit, platelet count, percent and absolute neutrophil count, percent and absolute lymphocyte count, percent and absolute monocyte count, and percent and absolute eosinophil count.)

CYCLE 1 DAYS 1-21 AZA dosing will occur during weeks 10-13 of ATT (+/- 1 week). Pretreatment enrollment labs will be reviewed, and a symptom screen and a focused exam will occur before each sub-cutaneous dosing of azacitidine. Administration includes inverting 2-3 times to homogenize contents, rolling the syringe in the palms for 30 seconds and then administering subcutaneously at a maximum of 4mL. (On subsequent days, injection sites will be \> 1 inch from a previous site and only at intact and healthy skin). Subjects will come to the clinic each day (10 minute visit) for 5 days to receive the injection. A weekly telephone call will screen for symptoms with clinically relevant symptoms triggering a clinical visit and in-person evaluation.

POST DOSE FOLLOW UP Additional screenings for cytopenias, renal and liver function will occur weekly (between days 4-11, 10-18, 17-25, and 24-32). Two mL of plasma will be collected at the same time for pharmacokinetic analysis (between days 4-11, 10-18, 17-25, and 24-32). Follow up study visits and clinical evaluation will occur monthly for the last 4 months of anti-TB therapy as standard of care. Additional blood draws for PBMCs, and immune correlates will occur at week 16 of ATT (week 6 post commencing AZA).

PHASE II: AZACITIDINE AFTER 10 WEEKS OF ATT; PRE-TREATMENT EVALUATION

1-Month pre-study drug: Recruitment, consent and completion of the CRF including baseline history and physical exam will occur between week 4-10 of Anti-TB therapy.

0-2 weeks pre-study drug: Blood draw for baseline immune correlates and to screen for eligibility criteria (CBC, CMP and coagulation) will occur within 1-14 days prior to azacitidine dosing. A pregnancy test will occur within 24 hours prior to AZA dosing.

CYCLE 1 DAYS 1-21 AZA dosing will occur during weeks 10-13 of ATT (+/- 1 week). Pretreatment enrollment labs will be reviewed, and a symptom screen and a focused exam will occur before administering AZA. Subjects will come to the clinic each day (10 minute visit) for 5 days to receive the injection. A weekly telephone call will screen for symptoms with clinically relevant symptoms triggering a clinical visit and in-person evaluation.

POST DOSE FOLLOW UP Additional screenings for cytopenias, renal and liver function will occur weekly (between days 4-11, 10-18, 17-25 and 24-32). Follow up study visits and clinical evaluation will occur at week 12 (at the peak of AZA induced toxicity), 16, 20 and 24. Additional blood draws for PBMCs and immune correlates will occur at week 16 of ATT (week 6 post commencing AZA).

Eligibility Criteria:
Inclusion Criteria:

1. Age 18 years or older
2. Microbiologically confirmed pulmonary Tuberculosis, including cavitary, lymph node or military pulmonary TB
3. Asymptomatic by the end of intense phase ATT (8 weeks) and remains asymptomatic until AZA dosing.
4. Acid-Fast Bacilli (AFB)-smear negative at the end of intensive phase.
5. 1-month sputum culture negative and 2-month sputum with no growth at time of study entry.
6. HIV-negative.
7. Adequate hepatic function (direct bilirubin 1.5 x upper limit of normal (ULN) or less, alanine aminotransferase (ALT) and/or aspartate aminotransferase (AST) 1.5 x ULN or less) at the end of ATT intensive phase.
8. Adequate renal function (creatinine 2 mg/dl or less and glomular filtration rate (GFR) 60 or greater).
9. Written informed consent obtained
10. Women and men of childbearing potential must agree to use 2 clinically effective methods of contraception (e.g., oral, intrauterine device \[IUD\], diaphragm plus spermicide, injectable, transdermal or implantable contraception) during the study and at least 3 months after the last treatment.

Exclusion Criteria:

1. HIV-infection
2. Pre-existing liver disease as defined by imaging or pathology consistent with moderate or worse firbrosis or cirrhosis (Metavir scoring system F2)
3. Smear-positive at 2 months
4. 1-month or 2 month sputum culture positive at time of study entry.
5. Participants with extrapulmonary TB.
6. History or current drug-resistant tuberculosis
7. After consent and within two weeks before Investigational Product (IP), a study complete blood count (CBC) will be performed and individuals with cytopenias (Hemoglobin \<12 g/dL, WBC \< 3 cells/ mm3, Absolute Neutrophil Count (ANC) \< 2,000 cells/mm3, or platelets \< 110,000 platelets/mm3) will be excluded.
8. Any concurrent uncontrolled medical condition, laboratory abnormality, or psychiatric illness which could place the patient at unacceptable risk of study treatment.
9. Pregnant or breast feeding females.
10. Uncontrolled systemic fungal, bacterial or viral infection (defined as ongoing signs/symptoms related the infection without improvement despite appropriate antibiotics, antiviral therapy and/or other treatment)
11. History of inflammatory bowel disease (eg, Crohn's disease, ulcerative colitis), celiac disease (ie. sprue), prior gastrectomy or upper bowel removal, or any other gastrointestinal disorder or defect that would interfere with the absorption, distribution, metabolism or excretion of the study drug and/or predispose the subject to an increased risk of gastrointestinal toxicity
12. Cancer (excluding surgically treated skin cancer) or hematologic malignancy currently active or active in the past three years.
13. Abnormal coagulation parameters (Prothrombin Time (PT) \>15 seconds, Partial Thromboplastin (PTT) \>40 seconds, and/or international normalized ratio (INR) \>1.5)
14. Significant active cardiac disease within the previous 6 months including:

    1. New York Heart Association (NYHA) class 4 congestive heart failure (CHF)
    2. Unstable angina
    3. Myocardial infarction
15. Active viral infection with HIV or hepatitis type B or C
16. Known or suspected hypersensitivity to azacytidine or mannitol
17. Inability to give informed consent.