Clinical trial NCT01936831
Conditions: Tuberculosis
Sponsor: Advancing Clinical Therapeutics Globally for HIV/AIDS and Other Infections
Start date: 2014-08-13; Completion date: 2021-10-06
Enrollment: 282 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
Isoniazid (INH) is a drug commonly used to treat tuberculosis (TB) worldwide. Sometimes, the bacteria that cause TB can become resistant to INH. Resistance means that bacteria have adapted to a drug and are able to live in the presence of the drug. When TB becomes resistant to INH, INH does not work as well at fighting the bacteria. This study treated people with INH-resistant TB with different doses of INH to see if INH can still fight the bacteria if the dose is increased. We evaluated how well the drug works at higher doses for participants who have resistant TB as well as how well the drug works at regular doses for participants who have TB that is not resistant. The study also evaluated the safety and tolerability of the different doses of INH. Tolerability is how well people can put up with the side effects of a drug. Using increased doses of INH to treat TB that is resistant to INH is experimental and has not been approved by regulatory authorities. While there is some evidence that this approach will work, this has not yet been proven.

Detailed description:
A5312 was a two-stage, two-step, phase IIa, open-label, randomized clinical trial among adult participants with sputum smear positive pulmonary TB evaluating the early bacterial activity (EBA).

No study drug was administered under Step 1. Data collected in Step 1: (a) determined eligibility to Step 2, and (b) allowed characterization of INH MICs in three groups. Groups 1, 2, and 3 consist of participants infected with TB with inhA mutations, with drug susceptible TB (DS-TB), and with TB with katG resistance-conferring mutations, respectively.

Participants enrolled to Step 2 received the study drug, INH, which was given with vitamin B6 \>=25 mg daily, by mouth. During both stages, participants in Group 1 who met Step 2 entry criteria were randomized to receive 5, 10, or 15 mg/kg of INH daily for 7 days. During Stage 2, participants in Group 2 who met Step 2 entry criteria received 5 mg/kg of INH daily for 7 days. Under protocol version 3.0 during Stage 2, participants in Group 3 who met Step 2 entry criteria were randomized to receive 15 or 20 mg/kg of INH daily for 7 days. After completion of 7 days of INH alone, participants were referred to begin standard anti-TB chemotherapy according to local guidelines.

In Step 2, prior to initiation of treatment, sputum was collected for quantitative culture on solid medium (for colony forming units (CFU) for Groups 1 and 2 only) and liquid medium (for determination of time to positivity (TTP) for all groups). Sixteen-hour sputum collections were performed daily during INH treatment, as per standard early bacterial activity (EBA) methodology. Sampling for PK analysis was performed at steady state on Day 6 (±1). Safety and tolerability were monitored via clinical evaluations throughout the study and through scheduled laboratory evaluations.

The study consisted of two stages, as follows:

Stage 1-Pilot study to ensure feasibility:

The goal of Stage 1 was to demonstrate feasibility, not treatment efficacy.

Participants were recruited at a single clinical site. All eligible participants entered Step 1 of the study (determination of INH resistance, measurement of INH minimum inhibitory concentrations (MIC)). Among Group 1 participants who met the Step 2 entry criteria, 15 participants were randomized 1:1:1 to receive 5, 10, or 15 mg/kg daily of INH for 7 days with evaluations performed as described above.

Stage 1 completed March 26, 2015. A total of 15 Group 1, 44 Group 2, and 12 Group 3 participants were enrolled in Step 1 only during Stage 1. These participants did not receive study treatment. They provided sputum samples for MIC determination.

Stage 2-Main study:

During Stage 2, Group 1 participants who met Step 2 entry criteria were randomized 1:1:1 to receive 5, 10, or 15 mg/kg of INH daily for 7 days. Group 2 participants who met Step 2 entry criteria were enrolled and received INH at a dose of 5 mg/kg daily. Group 3 participants who met Step 2 entry criteria were enrolled and randomized 1:1 to receive INH at a dose of 15 or 20 mg/kg daily.

In Stage 1, Group 1 participants who did not meet Step 2 entry criteria, all Group 2 participants and all Group 3 participants were referred to a local TB program for treatment. In Stage 2, Group 1, 2 and 3 participants who did not meet Step 2 entry criteria, were referred to a local TB program for treatment.

Protocol Versions:

Key differences in protocol versions include the following:

* Study entry criteria were changed from protocol versions 1.0 to 2.0

  * No longer excluded individuals for antiretroviral therapy use
  * Exclusion of individuals with any MDR-TB treatment with second-line anti-TB drugs was relaxed to exclude only those with more than 7 cumulative days of use.
* Protocol version 2.0 allowed additional sites to enroll participants.
* Under protocol versions 1.0 and 2.0, eligible individuals in Group 1 and Group 2 could enroll in Step 1 and Step 2, and eligible individuals in Group 3 could be enrolled in Step 1 only. Under protocol version 3.0, eligible individuals in Group 3 could enroll in Step 1 and Step 2.
* Early bactericidal activity was described using both solid culture CFU and liquid culture TTP under protocol versions 1.0 and 2.0. Under protocol version 3.0, early bactericidal activity was measured by liquid culture TTP only.
* There were technical difficulties with measuring the isoniazid minimum inhibitory concentration using 1% agar solution for participants enrolled under protocols versions 1.0 and 2.0. For protocol version 3.0, the Thermo Fisher MYCOTB Sensititre plate was substituted to overcome the technical difficulties.

Arms: arm 1: Group 1 participants had an M. tuberculosis strain with an inhA mutation only. 5 mg cohort received Isoniazid 5 mg/kg daily plus vitamin B6 \>=25 mg daily for 7 days arm 2: Group 1 participants had an M. tuberculosis strain with an inhA mutation only. 10 mg cohort received Isoniazid 10 mg/kg daily plus vitamin B6 \>=25 mg daily for 7 days arm 3: Group 1 participants had an M. tuberculosis strain with an inhA mutation only. 15 mg cohort received Isoniazid 15 mg/kg daily plus vitamin B6 \>=25 mg daily for 7 days arm 4: Group 2 participants had an M. tuberculosis strain with neither inhA nor katG mutations. All Group 2 participants received Isoniazid 5 mg/kg daily plus vitamin B6 \>=25 mg daily for 7 days arm 5: Group 3 participants had an M. tuberculosis strain with a katG mutation with or without an inhA mutation. 15mg cohort received Isoniazid 15 mg/kg daily plus vitamin B6 \>=25 mg daily for 7 days arm 6: Group 3 participants had an M. tuberculosis strain with a katG mutation with or without an inhA mutation. 20mg cohort received Isoniazid 20 mg/kg daily plus vitamin B6 \>=25 mg daily for 7 days
Interventions: intervention 1: Isoniazid intervention 2: Vitamin B6
Intervention descriptions: intervention 1: INH was available in 100 mg tablets. INH was administered orally daily in the morning on an empty stomach. Doses of INH were given according to the weight bands and by cohort. intervention 2: Vitamin B6 was administered at \>= 25 mg daily and was obtained locally for use by study participants.

Protocol documents:
Prot_ICF_000.pdf: 
 
 
A5312 
 
The Early Bactericidal Activity of High-Dose or Standard-
Dose Isoniazid among Adult Participants with Isoniazid-
Resistant or Drug-Sensitive Tuberculosis 
 
 
NIAID CRMS # 11872 
 
 
 
 
 
 
 
 
 
This file contains the current ACTG A5312 protocol:  
 
• Letter of Amendment #1, dated 03 August 2020 
• Clarification Memorandum #2, dated 25 February 2020 
• Clarification Memorandum #1, dated 12 December 2019 
• Protocol Version 3.0, dated 21 August 2018  


Letter of Amendment #1 
  Page 1 of 3 
03 August 2020 
ACTG A5312 Protocol Version 3.0 
Letter of Amendment #1 for: 
A5312 
The Early Bactericidal Activity of High-Dose or Standard-Dose Isoniazid among 
Adult Participants with Isoniazid-Resistant or Drug-Sensitive Tuberculosis 
NIAID CRMS # 11872 
Letter of Amendment Date: 03 August 2020 
ACTG NETWORK COORDINATING CENTER 
Social & Scientific Systems 
 
8757 Georgia Avenue, 12th Floor 
Silver Spring, MD  20910-3714  
Phone: 301-628-3000 
Fax: 301-628-3302 
LETTER OF AMENDMENT 
DATE: 
August 3, 2020 
TO: 
ACTG CTU Principal Investigators, CRS Leaders, and CTU/CRS Coordinators 
FROM: 
A5312 Protocol Team  
SUBJECT: 
Letter of Amendment #1 for Protocol A5312, Version 3.0 
The following information affects the A5312 study and must be forwarded to your institutional review 
board (IRB)/ethics committee (EC) as soon as possible for their information and review. This Letter 
of Amendment (LOA) must be approved by your IRB/EC before implementation.  
The following information may also affect the Sample Informed Consent. Your IRB/EC is responsible 
for determining the process of informing participants of the contents of this LOA. 
Upon receiving final IRB/EC and any other applicable regulatory entity approvals for this LOA, sites 
should implement the LOA immediately. Sites are still required to submit an LOA registration packet 
to the DAIDS Protocol Registration Office (PRO) at the Regulatory Support Center. Sites will receive 
a registration notification for the LOA once the DAIDS PRO verifies that all required LOA registration 
documents have been received and are complete. An LOA registration notification from the DAIDS 
PRO is not required prior to implementing the LOA. A copy of the LOA registration notification, along 
with this letter and any IRB/EC correspondence, should be retained in the site’s regulatory file. 
This LOA is being implemented to reopen the study to screening and accrual following closure due to 
COVID-19. 
The following is a change to A5312, Version 3.0, 08/21/18, titled "The Early Bactericidal Activity of High-
Dose or Standard-Dose Isoniazid among Adult Participants with Isoniazid-Resistant or Drug-Sensitive 


Letter of Amendment #1 
  Page 2 of 3 
03 August 2020 
ACTG A5312 Protocol Version 3.0 
Tuberculosis.” This change will be included in the next version of the A5312 protocol if it is amended at a 
future date.  
1.
A Protocol Signature Page (PSP) is appended for submission to DAIDS Protocol Registration System
(DPRS) as part of the LOA registration packet.
2.
The study temporarily closed to screening and accrual on March 27, 2020 due to COVID-19. The
study is now being reopened to screening and accrual.


Letter of Amendment #1 
  Page 3 of 3 
03 August 2020 
ACTG A5312 Protocol Version 3.0 
The Early Bactericidal Activity of High-Dose or Standard-Dose Isoniazid among Adult Participants with 
Isoniazid-Resistant or Drug-Sensitive Tuberculosis 
SIGNATURE PAGE 
I will conduct the study in accordance with the provisions of this protocol and all applicable protocol-related 
documents. I agree to conduct this study in compliance with United States (US) Health and Human Service 
regulations (45 CFR 46); applicable US Food and Drug Administration regulations; standards of the 
International Conference on Harmonization Guideline for Good Clinical Practice (E6); Institutional Review 
Board/Ethics Committee determinations; all applicable in-country, state, and local laws and regulations; and 
other applicable requirements (e.g., US National Institutes of Health, Division of AIDS) and institutional 
policies. 
Principal Investigator: _____________________________________________________ 
Print/Type 
Signed: _______________________________________________Date: _____________ 
Name/Title 


Clarification Memo #2 
  Page 1 of 2 
25 February 2020 
ACTG A5312 Protocol Version 3.0 
Clarification Memo #2 for: 
A5312 
The Early Bactericidal Activity of High-Dose or Standard-Dose Isoniazid among 
Adult Participants with Isoniazid-Resistant or Drug-Sensitive Tuberculosis 
NIAID CRMS # 11872 
Clarification Memo Date: 25 February 2020 
ACTG NETWORK COORDINATING CENTER 
Social & Scientific Systems 
8757 Georgia Avenue, 12th Floor 
Silver Spring, MD  20910-3714 
Phone: 301-628-3000 
Fax: 301-628-3302 
CLARIFICATION MEMO 
DATE: 
February 25, 2020 
TO: 
ACTG CTU Principal Investigators, CRS Leaders, and CTU/CRS Coordinators 
FROM: 
A5312 Protocol Team  
SUBJECT: 
Clarification Memo #2 for Protocol A5312, Version 3.0 
This clarification memo (CM) does not result in a change in the protocol informed consent 
document. The Division of AIDS does not require you to forward it to your institutional 
review board (IRB); however, you must follow your IRB's policies and procedures. If IRB 
review of clarification memos is required at your site, please submit this document for 
review. 
Each site should file a copy of this CM with the protocol for reference. 
The protocol clarification contained in this memo should be implemented immediately. 
The reason for this CM is to clarify the washout period for drugs with anti-TB activity.  
The following is a clarification to Protocol A5312, Version 3.0, 08/21/18, titled "The Early 
Bactericidal Activity of High-Dose or Standard-Dose Isoniazid among Adult Participants with 


Clarification Memo #2 
  Page 2 of 2 
25 February 2020 
ACTG A5312 Protocol Version 3.0 
Isoniazid-Resistant or Drug-Sensitive Tuberculosis.” This clarification will be included in the next 
version of the A5312 protocol if it is amended at a future date. 
•
Section 4.4.2 (Exclusion Criterion for Step 2) has been revised to read:
Receipt of more than 7 cumulative days of second-line anti-TB drugs (including all drugs with
anti-TB activity, except INH, RIF, ethambutol, pyrazinamide, and streptomycin) and/or
antibiotics intended for bacterial treatment that may have anti-TB activity, including
amoxicillin/clavulanate (Augmentin), linezolid, metronidazole, or drugs from the quinolone
class, within the 14 days prior to Step 1 screening sputum collection.
NOTE: In participants who have received 7 days or less of these drugs, the minimum
washout period for these drugs is 7 days prior to Step 2 pre-entry sputum collection,
regardless of how many cumulative days, up to a maximum of 7 days, the drugs have
been taken.


Clarification Memo #1 
  Page 1 of 2 
12 December 2019 
ACTG A5312 Protocol Version 3.0 
Clarification Memo #1 for: 
A5312 
The Early Bactericidal Activity of High-Dose or Standard-Dose Isoniazid among 
Adult Participants with Isoniazid-Resistant or Drug-Sensitive Tuberculosis 
NIAID CRMS # 11872 
Clarification Memo Date: 12 December 2019 
ACTG NETWORK COORDINATING CENTER 
Social & Scientific Systems 
8757 Georgia Avenue, 12th Floor 
Silver Spring, MD  20910-3714 
Phone: 301-628-3000 
Fax: 301-628-3302 
CLARIFICATION MEMO 
DATE: 
December 12, 2019 
TO: 
ACTG CTU Principal Investigators, CRS Leaders, and CTU/CRS Coordinators 
FROM: 
A5312 Protocol Team  
SUBJECT: 
Clarification Memo #1 for Protocol A5312, Version 3.0 
This clarification memo (CM) does not result in a change in the protocol informed consent 
document. The Division of AIDS does not require you to forward it to your institutional 
review board (IRB); however, you must follow your IRB's policies and procedures. If IRB 
review of clarification memos is required at your site, please submit this document for 
review. 
Each site should file a copy of this CM with the protocol for reference. 
The protocol clarifications contained in this memo should be implemented immediately. 
The main reason for this CM is to clarify the target accrual for the study. In addition, the ACTG 
Web site address has been updated, and the laboratory requirement for CD4+ count testing has 
been updated to comply with the DAIDS policy on Requirements for DAIDS Funded and/or 
Sponsored Laboratories in Clinical Trials.  


Clarification Memo #1 
  Page 2 of 2 
12 December 2019 
ACTG A5312 Protocol Version 3.0 
The following are clarifications to Protocol A5312, Version 3.0, 08/21/18, titled "The Early 
Bactericidal Activity of High-Dose or Standard-Dose Isoniazid among Adult Participants with 
Isoniazid-Resistant or Drug-Sensitive Tuberculosis.” These clarifications will be included in the 
next version of the A5312 protocol if it is amended at a future date. 
1. There were 259 total participants enrolled in A5312 prior to the implementation of Version 3.0;
this includes 64 participants who were enrolled in Group 3, Step 1. Under Version 3.0, the
target accrual for Group 3, Step 2, is 20 participants. Since some participants who screen for
the study will qualify for Step 1 and not for Step 2, it is expected that 20 additional participants
will enroll in Group 3, Step 1 only. Thus, the total accrual for the study is 299 participants (259
under Version 2.0, and 40 participants under Version 3.0). Participants in Group 3, Step 2,
who discontinue before the day 7 sample collection will be replaced and are not included in the
calculation for target accrual. Below is the breakdown of enrollment by group and step:
Group 
Step 
Actual Accrual 
prior to Version 
3.0 
Expected Accrual 
under Version 3.0 
Target Accrual 
(Actual + 
Expected) 
1 
1 only 
66 
66 
1 + 2 
44 
44 
2 
1 only 
69 
69 
1 + 2 
16 
16 
3 
1 only 
64 
20 
84 
1 + 2 
20 
20 
Total: 299 
2. Study Management, Copies of the Protocol: The text has been revised to read:
To request hard copies of the protocol, send a message to ACTGNCC@s-3.com via e-mail.
Electronic copies can be downloaded from the ACTG Web site (https://actgnetwork.org).
3. Section 4.3, Inclusion Criteria for Step 2, Criterion 4.3.6:
For HIV-positive candidates only: CD4+ count of ≥50 cells/mm3, performed within 7 days prior
to entry at any network-approved laboratory that is IQA-certified.
4. Section 6.3, Instructions for Evaluations. The following language has been added as the first
paragraph in this section:
Each study site and laboratory involved in this study will comply with the DAIDS policy
on Requirements for DAIDS Funded and/or Sponsored Laboratories in Clinical Trials
Policy, which is available at
https://www.niaid.nih.gov/sites/default/files/laboratorypolicy1.pdf.
5. Section 6.3.7, Laboratory Evaluations, CD4+ Count (HIV-infected participants):
For participants who are HIV-infected, a CD4+ count determination performed within 7 days
prior to entry at a network-approved laboratory that possesses IQA certification must be
recorded.


A5312 
The Early Bactericidal Activity of High-Dose or Standard-Dose Isoniazid among 
Adult Participants with Isoniazid-Resistant or Drug-Sensitive Tuberculosis 
A Limited Center Trial of the AIDS Clinical Trials Group (ACTG) 
Sponsored by: 
The National Institute of Allergy 
and Infectious Diseases 
Non-IND 
The ACTG Tuberculosis  
Transformative Science Group: 
Gavin Churchyard, MBBCh, MMED, FCP, PhD, 
Chair 
Protocol Co-Chairs: 
Kelly Dooley, MD, PhD 
Andreas Diacon, MD 
Protocol Vice Chair: 
Susan Swindells, MBBS 
DAIDS Clinical Representative: 
Richard Hafner, MD 
Clinical Trials Specialist: 
Laura Moran, MPH 
FINAL Version 3.0 
August 21, 2018 


A5312 
 
 
FINAL Version 3.0 
 
  
 08/21/18 
 
The Early Bactericidal Activity of High-Dose or Standard-Dose Isoniazid among Adult 
Participants with Isoniazid-Resistant or Drug-Sensitive Tuberculosis 
 
SIGNATURE PAGE 
 
 
I will conduct the study in accordance with the provisions of this protocol and all 
applicable protocol-related documents. I agree to conduct this study in compliance with 
United States (US) Health and Human Service regulations (45 CFR 46); applicable U.S. 
Food and Drug Administration regulations; standards of the International Conference on 
Harmonization Guideline for Good Clinical Practice (E6); Institutional Review 
Board/Ethics Committee determinations; all applicable in-country, state, and local laws 
and regulations; and other applicable requirements (e.g., US National Institutes of Health, 
Division of AIDS) and institutional policies. 
 
 
 
 
 
Principal Investigator: _______________________________________________ 
   Print/Type 
 
 
 
 
 
Signed: ___________________________________ Date: ___________________ 
  Name/Title 
 
 
 


 
 
A5312 
 
 
FINAL Version 3.0 
 
  
 08/21/18 
 
 
TABLE OF CONTENTS 
Page 
 
SIGNATURE PAGE .................................................................................................................... 2 
SITES PARTICIPATING IN THE STUDY .................................................................................... 5 
PROTOCOL TEAM ROSTER ..................................................................................................... 6 
STUDY MANAGEMENT ............................................................................................................. 9 
PROTOCOL-SPECIFIC GLOSSARY OF TERMS ..................................................................... 11 
SCHEMA .................................................................................................................................. 12 
1.0 
HYPOTHESES AND STUDY OBJECTIVES.................................................................. 16 
1.1 
Hypotheses ........................................................................................................ 16 
1.2 
Primary Objectives ............................................................................................. 16 
1.3 
Secondary Objectives ........................................................................................ 16 
1.4 
Exploratory Objectives ....................................................................................... 17 
2.0 
INTRODUCTION ........................................................................................................... 17 
2.1 
Background ........................................................................................................ 17 
2.2 
Rationale ........................................................................................................... 21 
3.0 
STUDY DESIGN ........................................................................................................... 22 
4.0 
SELECTION AND ENROLLMENT OF PARTICIPANTS ................................................ 26 
4.1 
Inclusion Criteria for Step 1 ............................................................................... 26 
4.2 
Exclusion Criteria for Step 1 ............................................................................... 27 
4.3 
Inclusion Criteria for Step 2 ................................................................................ 27 
4.4 
Exclusion Criteria for Step 2 ............................................................................... 29 
4.5 
Study Enrollment Procedures............................................................................. 30 
4.6 
Coenrollment Guidelines .................................................................................... 31 
5.0 
STUDY TREATMENT ................................................................................................... 31 
5.1 
Regimens, Administration, and Duration ............................................................ 32 
5.2 
Study Product Formulation and Preparation ....................................................... 34 
5.3 
Pharmacy: Product Supply, Distribution, and Accountability .............................. 34 
5.4 
Concomitant Medications ................................................................................... 35 
5.5 
Adherence Assessment ..................................................................................... 35 
6.0 
CLINICAL AND LABORATORY EVALUATIONS ........................................................... 36 
6.1 
Schedule of Events ............................................................................................ 36 
6.2 
Timing of Evaluations ......................................................................................... 39 
6.3 
Instructions for Evaluations ................................................................................ 41 
7.0 
CLINICAL MANAGEMENT ISSUES .............................................................................. 46 
7.1 
Toxicity .............................................................................................................. 46 
7.2 
Other Diseases .................................................................................................. 47 
7.3 
Pregnancy.......................................................................................................... 47 
8.0 
CRITERIA FOR DISCONTINUATION ........................................................................... 47 
8.1 
Premature Study Discontinuation ....................................................................... 47 


 
 
A5312 
FINAL Version 3.0 
 
CONTENTS (Cont'd) 
08/21/18 
 
Page 
 
9.0 
STATISTICAL CONSIDERATIONS ............................................................................... 48 
9.1 
General Design Issues ....................................................................................... 48 
9.2 
Endpoints ........................................................................................................... 49 
9.3 
Randomization and Stratification ........................................................................ 50 
9.4 
Sample Size and Accrual ................................................................................... 51 
9.5 
Monitoring .......................................................................................................... 54 
9.6 
Analyses ............................................................................................................ 54 
10.0 
PHARMACOLOGY PLAN .............................................................................................. 56 
10.1 
Pharmacology Objectives .................................................................................. 56 
10.2 
Pharmacology Study Design .............................................................................. 56 
10.3 
Primary and Secondary Data, Modeling, and Data Analysis .............................. 58 
10.4 
Anticipated Outcomes ........................................................................................ 58 
11.0 
DATA COLLECTION AND MONITORING AND ADVERSE EVENT REPORTING ........ 58 
11.1 
Records to Be Kept ............................................................................................ 58 
11.2 
Role of Data Management ................................................................................. 58 
11.3 
Clinical Site Monitoring and Record Availability .................................................. 58 
11.4 
Expedited Adverse Event Reporting to DAIDS ................................................... 59 
12.0 
PARTICIPANTS ............................................................................................................ 60 
12.1 
Institutional Review Board (IRB) Review and Informed Consent ........................ 60 
12.2 
Participant Confidentiality ................................................................................... 60 
12.3 
Study Discontinuation ........................................................................................ 60 
13.0 
PUBLICATION OF RESEARCH FINDINGS .................................................................. 60 
14.0 
BIOHAZARD CONTAINMENT ...................................................................................... 61 
15.0 
REFERENCES .............................................................................................................. 62 
APPENDIX I: SAMPLE INFORMED CONSENT FOR PROTOCOL A5312, STAGE 1 .............. 65 
APPENDIX II:  SAMPLE INFORMED CONSENT FOR PROTOCOL A5312, STAGE 2, 
STEP 1 .......................................................................................................................... 78 
APPENDIX III: SAMPLE INFORMED CONSENT FOR A5312: STAGE 2, STEP 2 ................... 85 
 
 


 
5 
A5312 
FINAL Version 3.0 
 
 
08/21/18 
 
SITES PARTICIPATING IN THE STUDY 
 
Task Applied Science and Brooklyn Chest Hospital, Cape Town, South Africa, will serve as 
clinical sites for Stage 1 and Stage 2.  
 
Additional sites may be added for Stage 1 or Stage 2. Please see the A5312 protocol-specific 
web page (PSWP) for a list of participating sites.  
  
 
 
 
 


 
6 
A5312 
FINAL Version 3.0 
 
 
08/21/18 
 
PROTOCOL TEAM ROSTER 
 
Co-Chairs 
Andreas Diacon, MD 
Stellenbosch University 
PO Box 19063 
Tygerberg, 7505 
SOUTH AFRICA 
Phone: +27-21-938-9392  
FAX: +27-21-938-9476 
E-Mail: ahd@sun.ac.za 
 
Kelly E. Dooley, MD, PhD 
Johns Hopkins University  
School of Medicine 
600 N. Wolfe Street, Osler 527 
Baltimore, MD 21287 
Phone: 443-287-0517  
FAX: 410-614-9978 
E-Mail: kdooley1@jhmi.edu 
 
Vice Chair 
Susan Swindells, MBBS 
University of Nebraska Medical Center 
988106 Nebraska Medical Center 
Omaha, NE 68198-8106 
Phone: 402-559-5392 
FAX: 402-553-5527 
E-Mail: sswindells@unmc.edu 
 
DAIDS Clinical Representative  
Richard Hafner, MD 
DIADS/NIAID/NIH/TBCB 
5601 Fishers Lane 
Room 9E30 
Rockville MD 20852 
Phone: 301-435-3766  
E-Mail: rhafner@niaid.nih.gov 
 
Clinical Trials Specialist 
Laura Moran, MPH 
ACTG Network Coordinating Center 
Social & Scientific Systems, Inc. 
8757 Georgia Avenue, 12th Floor 
Silver Spring, MD 20910-3714 
Phone: 301-628-3373 
FAX: 301-628-3302 
E-Mail: lmoran@s-3.com 
Statisticians 
Sachiko Miyahara, PhD 
Statistical & Data Analysis Center 
651 Huntington Avenue 
FXB 549A 
Boston, MA 02115 
Phone: 617-432-2837 
FAX: 617-432-3163 
E-Mail: miyahara@sdac.harvard.edu 
 
Susan Rosenkranz, PhD 
Statistical & Data Analysis Center 
900 Commonwealth Avenue, 2nd floor 
Boston, MA 02215 
Phone: 617-632-5915 
FAX: 617-632-2001 
E-Mail: sue@sdac.harvard.edu 
 
Xin Sun, MS 
Statistical & Data Analysis Center 
651 Huntington Avenue 
FXB 506 
Boston, MA 02115 
Phone: 617-432-4456 
FAX: 617-432-3163 
E-Mail: xsun@sdac.harvard.edu 
 
Site Support Specialist 
Akbar Shahkolahi, PhD 
ACTG Network Coordinating Center 
Social & Scientific Systems, Inc. 
8757 Georgia Avenue, 12th Floor 
Silver Spring, MD 20910 
Phone: 301-628-3318 
Fax: 301-628-3302 
E-mail: ashahkolahi@s-3.com 
 


 
7 
A5312 
FINAL Version 3.0 
 
PROTOCOL TEAM ROSTER (Cont'd) 
08/21/18 
 
Data Manager 
Kathleen Donahue, BS, MA 
Frontier Science and Technology Research 
Foundation 
4033 Maple Road 
Amherst, NY 14226 
Phone: 716-834-0900 X7329 
FAX: 716-834-8432 
E-Mail: donahue@fstrf.org 
 
DAIDS Pharmacist 
Lynette Purdue, PharmD 
Pharmaceutical Affairs Branch 
DAIDS, NIAID, NIH 
5601 Fisher’s Lane, Room 9E28 
Rockville, MD 20852 
Phone: 240-627-3061 
Fax: 240-627-3112 
E-Mail: lpurdue@niaid.nih.gov 
 
Pharmacologist 
Helen M. McIlleron, MB, ChB, PhD 
University of Cape Town 
K45 Old Main Building 
Groote Schuur Hospital 
Observatory, Cape Town 7925 
SOUTH AFRICA 
Phone: 021-788-2985 
E-Mail: helen.mcilleron@uct.ac.za 
 
Investigators  
Karla Mellet, MB ChB 
Helen Joseph Hospital 
Perth Road, Westdene 
Johannesburg  
SOUTH AFRICA 
Phone: 27-11-276-8968 
FAX: 27-11-482-2130 
E-Mail: kmellet@witshealth.co.za 
 
Eric Nuermberger, MD 
Johns Hopkins University  
1550 Orleans Street, Room 107 
Baltimore, MD 21231 
Phone: 410-502-0580 
FAX: 410-614-8173 
E-Mail: enuermb1@jhmi.edu 
Investigators (Cont'd) 
Alexander Pym, MD, PhD 
Medical Research Council 
491 Ridge Road 
Morningside 
Durban  
SOUTH AFRICA 
Phone: +27 (0)31-203-4771  
E-mail: Alexander.Pym@mrc.ac.za 
 
Florian von Groote-Bidlingmaier, MD 
TASK Applied Science, M2 
Karl Bremer Hospital 
Bellville 7530 
Cape Town 
SOUTH AFRICA 
Phone: +27-21-9497751  
FAX: +27-21-9181378 
E-Mail: florianv@sun.ac.za 
 
Field Representatives 
David N. Currin, RN, ACRN, CCRC 
University of North Carolina at Chapel Hill 
Bioinformatics Building, Room 2109D 
Campus Box 7215 
130 Mason Farm Road 
Chapel Hill NC 27599-7215 
Phone: 919-966-2624 
FAX: 919-966-8928 
E-Mail: dcurrin@med.unc.edu 
 
Rachel Mahachi, MNS, BN 
University of Zimbabwe 
Parirenyatwa Annex 
Cnr Josiah Tongogara/Marowe Street 
Harare  
ZIMBABWE 
Phone: 011-263-772-211-489  
FAX: 011-263-4-704897 
E-Mail: rmahachi@uzcrc.co.zw 
 


 
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Laboratory Technologist 
Christopher Lane, AAS 
University of Rochester 
601 Elmwood Avenue, Box 689 
Rochester, NY 14642 
Phone: 585-276-5574 
FAX: 585-442 9328 
E-Mail: christopher_lane@urmc.rochester.edu  
 
Community Scientific Subcommittee (CSS) 
Representative 
Ronald Ssenyonga 
PO Box 10005 
Ring Road, Butikiiro House 
Kampala  
UGANDA 
Phone: 256-712663189 
E-Mail: senyoronnie@yahoo.com 
 
Laboratory Data Coordinator 
Mark Lojacono, MA, MSc 
Frontier Science & Technology Research 
Foundation 
4033 Maple Rd. 
Amherst, NY 14226 
Phone: 716-834-0900 X7346 
E-Mail: lojacono@fstrf.org 
 
 
 


 
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STUDY MANAGEMENT 
 
All general questions concerning this protocol should be sent to actg.teamA5312@fstrf.org via 
e-mail. The appropriate team member will respond with a "cc" to actg.teamA5312@fstrf.org. A 
response should generally be received within 24 hours (Monday-Friday). 
 
Protocol E-mail Group 
Sites registering to this study should contact the Computer Support Group at the Data 
Management Center (DMC) as soon as possible to have the relevant personnel at the site 
added to the actg.protA5312 e-mail group. Include the protocol number in the e-mail subject 
line.  
• 
Send an e-mail message to actg.user.support@fstrf.org. 
 
Clinical Management  
For questions concerning entry criteria, toxicity management, concomitant medications, and 
coenrollment, contact the protocol co-chairs. Send an e-mail message to 
actg.cmcA5312@fstrf.org (ATTN: Kelly Dooley, MD, PhD, or Andreas Diacon, MD). Include the 
protocol number, patient identification number (PID), and a brief relevant history. 
 
Laboratory 
For questions specifically related to pharmacologic laboratory tests, contact the protocol 
pharmacologist. Send an e-mail message to actg.teamA5312@fstrf.org (ATTN: Helen M. 
McIlleron, MB ChB, PhD). 
 
Data Management 
For nonclinical questions about transfers, inclusion/exclusion criteria, case report forms (CRFs), 
the CRF schedule of events, randomization/registration, delinquencies, and other data 
management issues, contact the data manager.  
• 
For transfers, reference the Patient Transfer from Site to Site SOP 119, and contact 
Kathleen Donahue, BS, MA (donahue@fstrf.org) directly.  
• 
For other questions, send an e-mail message to actg.teamA5312@fstrf.org (ATTN: Kathleen 
Donahue, BS, MA). Include the protocol number, PID, and a detailed question. 
 
Randomization 
For randomization questions or problems and study identification number (SID) lists.  
• 
Send an e-mail message to rando.support@fstrf.org or 
• 
Call the Statistical and Data Analysis Center (SDAC)/DMC Randomization Desk at (716) 
834-0900 x7301.   
 
Computer and Screen Problems  
Contact the SDAC/DMC programmers. 
• 
Send an e-mail message to actg.support@fstrf.org or call (716) 834-0900 x7302. 
 
Protocol Document Questions 
For questions concerning the protocol document, contact the clinical trials specialist. Send an e-
mail message to actg.teamA5312@fstrf.org (ATTN: Laura Moran, MPH). 


 
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Copies of the Protocol 
To request hard copies of the protocol, send a message to ACTGNCC@s-3.com (ATTN: Diane 
Delgado) via e-mail. Electronic copies can be downloaded from the ACTG Web site 
(https://www.actgnetwork.org). 
 
Product Package Inserts or Investigator Brochures 
To request copies of product package inserts or investigator brochures, contact the DAIDS 
Regulatory Support Center (RSC) at RIC@tech-res.com or call (301) 897-1708. 
 
Protocol Registration 
For protocol registration questions: 
• 
Send an e-mail message to Protocol@tech-res.com or call (301) 897-1707.  
 
Study Product 
For questions or problems regarding study product, dose, or supplies, call Lynette Purdue, 
protocol pharmacist, at 240-627-3061.  
 
Expedited Adverse Event (EAE) Reporting/Questions  
Contact DAIDS through the RSC Safety Office at DAIDSRSCSafetyOffice@tech-res.com or call 
1-800-537-9979 or 301-897-1709; or fax 1-800-275-7619 or 301-897-1710.  
 
Phone Calls 
Sites are responsible for documenting any phone calls made to A5312 protocol team members. 
Send an e-mail to actg.teamA5312@fstrf.org. 
 
Protocol-Specific Web Page 
Additional information about the study may be found on the A5312 protocol-specific web page 
(PSWP).


 
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PROTOCOL-SPECIFIC GLOSSARY OF TERMS 
 
CFU 
 
Colony-forming unit 
 
DR-TB  
Drug-resistant tuberculosis 
 
DS-TB  
Drug-sensitive tuberculosis 
 
DST 
 
Drug susceptibility testing 
 
EBA 
 
Early bactericidal activity 
 
EBA0-7 (CFU) Early bactericidal activity over 7 days measured by the daily fall of log10CFU/mL 
sputum 
 
EBA0-7 (TTD) Early bactericidal activity measured by prolongation of TTD/day 
 
MDR-TB 
Multidrug-resistant tuberculosis 
 
MGIT  
Mycobacterium growth indicator tube 
 
MIC 
 
Minimum inhibitory concentration 
 
NAT2  
N-acetyltransferase 2  
 
TTD 
 
Time to detection 
 
XDR-TB  
Extensively drug-resistant tuberculosis


 
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SCHEMA 
 
A5312 
 
The Early Bactericidal Activity of High-Dose or Standard-Dose Isoniazid among Adult 
Participants with Isoniazid-Resistant or Drug-Sensitive Tuberculosis 
 
DESIGN 
A two-stage, two-step, phase IIa, open-label, randomized clinical trial 
examining the bactericidal activity of (1) isoniazid (INH) at three different 
doses for treatment of isolates with inhA mutations; (2) INH at two different 
doses for treatment of isolates with katG mutations; and (3) INH at 
standard dosing for isolates without either inhA or katG mutations. In addition, 
the association between the early bactericidal activity (EBA) and 
pharmacokinetic (PK) parameters, such as area under the curve 
(AUC)/minimum inhibitory concentration (MIC) of INH, will be examined 
among participants with drug-resistant TB (DR-TB), and drug-sensitive TB 
(DS-TB) (when Stage 2 opens).  
 
The study will be conducted in two stages. Stage 1 will be a pilot for 
determination of feasibility and sample size verification, and Stage 2 will be 
the main study. These stages will be conducted sequentially, and a 
participant may enroll in only one of the stages.  
 
Each stage consists of two steps. The goal of Step 1 is to determine the MIC 
distribution of M. tuberculosis strains among participants with DR-TB or DS-
TB. The goal of Step 2 is to examine the treatment effect of INH at different 
doses among participants with DR-TB (both stages) or DS-TB (in Stage 2 
only). 
 
In Step 1, a spot sputum sample will be collected from all eligible participants 
for acid fast bacilli (AFB) microscopy, for genotypic determination of INH 
resistance (inhA or katG mutations), and for phenotypic determination of INH 
MIC.  
 
In Step 2, eligible participants will be administered INH daily for 7 days, and 
have serial overnight sputum sampling for estimation of participant-specific 
EBA (both quantitative and liquid cultures). Intensive PK samples for INH 
quantification, and blood and saliva samples for NAT2 determination, will also 
be collected in Step 2. 
 
Eligible participants will enroll into one of three groups: 
 
Group 1: Participants with AFB smear-positive pulmonary TB with an M. 
tuberculosis isolate with an inhA mutation only, which generally confers low-
level INH resistance. During Stage 1 and Stage 2, participants who meet  


 
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Step 1 and Step 2 entry criteria will be randomized to receive INH at 5, 10, or 
15 mg/kg daily for 7 days. Participants who do not meet Step 2 criteria will be 
enrolled in Step 1 only. 
 
Group 2: Participants with M. tuberculosis harboring neither inhA nor katG 
resistance mutations. During Stage 1, eligible participants will be enrolled in 
Step 1 only. During Stage 2, participants who meet Step 1 and Step 2 entry 
criteria will be enrolled as positive controls. Also during Stage 2, participants 
not eligible to enter Step 2 and participants recruited after Step 2 accrual 
targets have been met may be enrolled in Step 1. 
 
Group 3: Participants with an M. tuberculosis isolate with a katG mutation 
(with or without an inhA mutation), associated with high-level resistance. 
During Stage 2, participants who meet Step 1 and Step 2 entry criteria 
will be randomized 1:1 to receive either INH 15 mg/kg or 20 mg/kg daily 
for 7 days. Participants who do not meet Step 2 criteria will be enrolled 
in Step 1 only. 
  
Participants who are screened for the study, but are not eligible to receive 
study treatment will be referred without delay for appropriate treatment. 
Those who are registered or randomized to receive treatment will be referred 
without delay to appropriate treatment after completing study treatment (no 
later than Day 10).  
 
DURATION 
Approximately 23 days 
 
SAMPLE SIZE 
Among participants eligible to participate in Step 1 only, accrual targets are 
as follows: 
 
Group 1: Minimum of 16 to a maximum of 70 
Group 2: Minimum of 48 to a maximum of 64 
Group 3: Minimum of 64 to a maximum of 84 
 
These participants may be enrolled during Stages 1 or 2. 
 
Among participants eligible to enroll in Step 1 and Step 2, accrual targets are 
as follows: 
 
Group 1: 48 evaluable participants (16 completing treatment in each 
dosing cohort). During Stage 1, 15 Group 1 participants will be enrolled (5 
per dosing cohort). Once it is determined that the study is feasible, Stage 
2 will begin and an additional 33 Group 1 participants will be randomized 
(11 participants added to each cohort, for a total of 16 participants per 
cohort). 
 


 
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Group 2: 16 evaluable participants will be followed as a fourth Step 2 
cohort, enrolled during Stage 2.  
 
Group 3: 20 evaluable participants (10 completing treatment in each 
dosing cohort) will be randomized. 
 
At the end of Stage 1, the sample size for enrollment in the treatment cohorts 
may be increased up to 88 evaluable participants (22 in each treatment 
cohort) if the standard deviations of the primary endpoint from Group 1 are 
larger than expected. 
 
Schema Table 1: A5312 Accrual Targets 
 
Resistance  
Mutation 
Participants 
Completing Step 1 
Only1 
Participants Completing  
Step 1 and Step 22 
Total Participants 
 
Stage 1 & Stage 2 
Combined 
Stage 1 
Stage 2 
Group 
1 
inhA 
Minimum of 16 to a 
maximum of 703 
15 
(5 per dosing 
cohort) 
33 (11 
per dosing 
cohort) 
Step 1 only: maximum 
of 703 
Steps 1 and 2: 48 
Group 
2 
Neither inhA 
nor katG 
Minimum of 48 to a 
maximum of 644 
- 
16 
Step 1 only: maximum 
of 644 
Steps 1 and 2: 16 
Group 
3 
katG with or 
without inhA  
Minimum of 64 to a 
maximum of 84 
- 
20 (10 per 
dosing 
cohort) 
Step 1 only: maximum 
of 845 
Steps 1 and 2: 20 
1 Participants completing Step 1 only (participants who were considered for Step 2 but could not 
enter Step 2, or participants who were considered for Step 1 only) will provide sputum for 
determination of MIC distribution, and then be discontinued from the study. 
2 Participants completing Step 1 and Step 2 will provide sputum for determination of MIC  
   distribution and participate in the treatment part of the study. 
3 Once the Group 1 accrual target is reached for participants completing Steps 1 and 2, accrual 
beyond the minimum for those completing Step 1 only will stop.  
4 Once the Group 2 accrual target is reached for participants completing Steps 1 and 2, accrual 
beyond the minimum for those completing Step 1 only will stop.  
5 Once the Group 3 accrual target is reached for participants completing Steps 1 and 2, 
accrual beyond the minimum for those completing Step 1 only will stop.   
 
 
POPULATION 
Patients between 18 and 65 years old with sputum smear-positive pulmonary 
TB (new or retreatment cases) 
 


 
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REGIMEN 
Participants enrolled in Step 1 only will not receive study drug.  
 
Participants enrolled in Step 2 will receive study drug as follows: 
 
Group 1: Participants with M. tuberculosis with an inhA mutation only who 
meet Step 2 entry criteria will be randomized 1:1:1 to receive the following 
treatments for 7 days: 
 
5 mg cohort: INH 5 mg/kg daily plus vitamin B6 ≥25 mg daily 
10 mg cohort: INH 10 mg/kg daily plus vitamin B6 ≥25 mg daily  
15 mg cohort: INH 15 mg/kg daily plus vitamin B6 ≥25 mg daily 
 
Group 2: Participants with M. tuberculosis with neither katG nor inhA 
mutations who meet Step 2 entry criteria will receive INH 5 mg/kg daily plus 
vitamin B6 ≥25 mg daily for 7 days. 
 
Group 3: Participants with an M. tuberculosis isolate with a katG mutation 
with or without an inhA mutation who meet Step 2 entry criteria will be 
randomized to receive either INH 15 mg/kg or 20 mg/kg daily, plus 
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1.0 
HYPOTHESES AND STUDY OBJECTIVES 
 
1.1 
Hypotheses 
 
1.1.1 In the majority of participants infected with TB with inhA mutations, drug 
concentrations can be achieved that will result in an early bactericidal activity 
(EBA) measured as the daily fall of log10 colony-forming unit (CFU)/mL sputum 
over 7 days (EBA0-7 (CFU)) that is at least 50% the EBA0-7 (CFU) of standard-
dose isoniazid (INH) when given to participants with drug-sensitive TB (DS-TB).  
 
1.1.2 High-dose INH will be well tolerated in a majority of participants. 
 
1.1.3 Among participants infected with TB with katG mutations (Group 3), the 
distribution of minimum inhibitory concentrations (MICs) will be wide, but, 
nevertheless, INH at a dose of 15 or 20 mg/kg daily will have measurable 
activity. 
 
1.2 
Primary Objectives 
 
1.2.1 Estimate the 7-day EBA, based on CFU counts, of INH among participants 
infected with TB with inhA mutations taking one of three doses of INH (5, 10, or 
15 mg/kg daily), and participants infected with DS-TB taking standard-dose INH 
(5 mg/kg daily). 
 
1.2.2 Estimate the 7-day EBA, based on TTD, of INH among participants infected with 
TB with inhA mutations taking one of three doses of INH (5, 10, or 15 mg/kg), 
participants infected with TB with katG mutations taking 15 or 20 mg/kg 
daily, and participants infected with DS-TB taking standard-dose INH (5 mg/kg 
daily). 
 
1.2.3 Determine the association between the area under the curve (AUC)/MIC of INH 
and the EBA of INH among participants with smear-positive pulmonary TB.  
 
1.2.4 Describe the safety and tolerability of doses of 5, 10, and 15 mg/kg of INH 
administered daily among participants with sputum smear-positive pulmonary TB. 
 
1.3 
Secondary Objectives 
 
1.3.1 Determine the steady-state pharmacokinetics (PK) of INH among participants 
with sputum smear-positive pulmonary TB taking 5, 10, or 15 mg/kg daily, taking 
into account INH acetylator status (N-acetyltransferase 2 [NAT2] genotype). 
 
1.3.2 Determine and describe the distribution of MICs of M. tuberculosis isolates with 
genotypic evidence of low-level INH resistance (inhA mutations), high-level INH 
resistance (katG mutations), or neither of these mutations among participants 
with smear-positive pulmonary TB. 
 


 
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1.3.3 Estimate the proportion of participants infected with a TB strain that has an inhA 
mutation that will achieve a target AUC/MIC that is associated with clinically 
relevant reductions in mycobacterial burden defined as at least 50% the EBA0-7 of 
standard-dose INH when given to participants with DS-TB, by dose.  
 
1.3.4 Estimate linear or nonlinear model parameters based on EBA measured 
separately by CFU counts and time to detection (TTD) for INH among 
participants infected with TB with inhA mutations taking one of three doses of 
INH (5, 10, or 15 mg/kg daily), participants infected with TB with katG 
mutations taking 15 or 20 mg/kg daily, and participants infected with DS-TB 
taking standard-dose INH (5 mg/kg daily). 
 
1.4 
Exploratory Objectives 
 
1.4.1 Evaluate the correlation between EBA0-7 (TTD) and EBA0-7 (CFU) among 
participants with smear-positive pulmonary TB. 
 
1.4.2 Evaluate the ability of a new PCR method that uses salivary samples to correctly 
characterize NAT2 genotype compared to standard NAT2 genotyping methods 
using blood samples and sequencing methodology. 
 
1.4.3 Estimate the prevalence of quinolone and aminoglycoside resistance among 
study participants with MDR-TB receiving study treatment. 
 
2.0 
INTRODUCTION 
 
2.1 
Background 
 
Drug-resistant tuberculosis (DR-TB), including multidrug-resistant (MDR-) and 
extensively drug-resistant (XDR-) TB, is increasingly a global health threat [1]. MDR-TB 
is resistant to isoniazid (INH) and rifampin (RIF), while XDR-TB is resistant to INH, RIF, 
fluoroquinolones, and injectable anti-TB drugs. Therapeutic options are few, and current 
treatment requires 18-24 months of highly toxic, poorly efficacious multidrug therapy. 
There are new drugs in the pipeline, but these compounds must be combined with an 
optimized background regimen that includes partner drugs that can rapidly reduce 
mycobacterial burden, thus protecting the new drug against the development of clinical 
resistance [2, 3]. Having a potent combination of 3-4 drugs with good activity against M. 
tuberculosis in a regimen is essential to prevent acceleration of resistance and 
progression from MDR-TB to XDR-TB. The World Health Organization (WHO) 
recommends that regimens for MDR-TB or XDR-TB contain at least four drugs to which 
the organism is likely to be sensitive [4]. A common standard regimen, for example, may 
include kanamycin (ototoxicity, poor bactericidal activity), ofloxacin (not the most active 
fluoroquinolone but gatifloxacin [hypoglycemia] and moxifloxacin [QT prolongation] carry 
safety risks), ethionamide (dose-limiting GI toxicity), PZA (risk of resistance, as this drug 
is a standard part of first-line regimens), cycloserine (severe CNS toxicity), and 
ethambutol (ophthalmologic toxicity risk and risk of resistance, as this drug is a standard 
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therapy, but results can take 1-2 months and are only available if a culture can be 
grown. Clearly, we must do a better job of identifying drugs to which a participant’s TB 
isolate is likely to be susceptible at the time of MDR-TB diagnosis.  
 
For INH, different resistance mechanisms confer high- or low-level resistance. Low-level 
“resistance” may be overcome by increasing the INH dosage. Pharmacodynamic (PD) 
studies in a variety of experimental models and in humans, coupled with data on the 
range of INH MIC values against INH-resistant clinical isolates, suggest that high-dose 
INH may produce drug exposures capable of significant bactericidal activity in 
participants with TB with low-level INH resistance [5-12]. 
 
INH is cheap, widely used, orally bioavailable, safe, and generally free of drug-drug 
interactions. It has potent EBA and plays an important role in rapidly reducing the 
bacterial burden and preventing the selection of drug-resistant mutants [7, 13]. Against 
drug-susceptible strains, INH alone is able to decrease the bacterial burden by 90-95% 
in the first two days of treatment. Although INH exposures are influenced by the patient’s 
acetylator status, near maximal activity against drug-susceptible strains is observed at 
the commonly prescribed dose, even in rapid acetylators. INH is a prodrug that is 
activated by the M. tuberculosis catalase-peroxidase encoded by katG [6]. The activated 
drug inhibits the activity of the enoyl-acyl carrier protein reductase (inhA) and thereby 
blocks mycolic acid synthesis [14]. Against susceptible strains of M. tuberculosis, the 
MIC is 0.03-0.06 mcg/mL. Mutations in the katG gene may result in partial loss of KatG 
function, resulting in reduced INH activation and INH MICs of 2 to 8 mcg/mL or, 
alternatively, complete loss of KatG function, no INH activation, and INH MICs ≥16 
mcg/mL. On the other hand, mutations in inhA and the inhA promoter region are 
associated with low-level resistance (MIC 0.2-1 mcg/mL) and cross-resistance with 
ethionamide. Data on the distribution of INH MICs against clinical DR-TB isolates are 
sparse [15], but reports suggest inhA mutations account for 30-40% of INH-R strains, 
and as many as 43-75% of MDR-TB strains are susceptible to INH concentrations <5 
mcg/mL [16]. Since INH concentrations well above this level are achievable in patients 
receiving INH in moderately elevated dosages (higher-dose INH), patients infected with 
low-level-resistant strains may represent a substantial sub-population of DR-TB in which 
high-dose INH may be effective. 
 
In experimental TB models, AUC/MIC is the PD parameter most closely correlated with 
INH activity [10, 11]. AUC/MIC values of ~60 and 100-200 mcg-h/mL produced 50% and 
100%, respectively, of the maximal INH effect in vitro as well as in mice. A similar 
relationship is evident in human EBA studies (vide infra) [13]. Assuming INH AUC/MIC 
values approaching 60 mcg-h/mL could be achieved, significant bactericidal activity 
against “resistant” strains would be expected. This concept is supported by experiments 
in mice, in which INH at 10 mg/kg/day produced an AUC/MIC of approximately 40 mcg-
h/mL and exhibited bactericidal activity against an inhA promoter mutant (MIC 0.25 
mcg/mL), but was ineffective against a katG mutant (MIC 4-8 mcg/mL) against which the 
AUC/MIC was ≤2 (Nuermberger, unpublished data). Similarly, bactericidal activity was 
observed with INH 25 mg/kg/day in mice infected with a katG mutant with an INH MIC of 
2 mcg/mL, where the predicted AUC/MIC would be ~15 [12].  
 


 
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In humans, INH exposures are variable and determined largely by the patient’s NAT2 
genotype [9, 17]. Fast acetylators have lower INH concentrations than slow or 
intermediate acetylators taking the same dose, and the distribution of fast acetylators 
varies by geographical region (33% in the United States and 88% in China, for example) 
[10]. Attainment of an AUC greater than 10.5 mcg-h/mL, which generally occurs in slow 
acetylators at a 3 mg/kg dosage and for most rapid acetylators at a 6 mg/kg dosage, 
was associated with 90% of maximal EBA, and this is consistent with the AUC/MIC >100 
mcg-h/mL necessary for maximal INH activity in pre-clinical models [13]. Assuming the 
INH AUC/MIC necessary to achieve 50% of the maximum kill is similar among patients 
with DS-TB and DR-TB, significant bactericidal activity against low-level resistant strains 
(MIC ≤0.5 mcg/mL) can be expected with AUC values of approximately 25 (AUC/MIC 
≥50). Such exposures should be achievable with 300 mg of INH (5 mg/kg, standard-
dose INH) in slow acetylators and 600 mg of INH (10 mg/kg, high-dose INH) in fast 
acetylators. Higher INH doses may produce activity against strains for which the INH 
MIC is 1, or even 2, mcg/mL, depending on acetylator status. For example, in one PK 
study in healthy Japanese participants who were fast acetylators, a 900 mg (15 mg/kg) 
dose produced a mean AUC of 48.2 mcg-h/mL, which would produce AUC/MIC values 
of ~50 and ~25 against isolates for which INH MICs are 1 and 2 mcg/mL, respectively 
[18]. 
 
In addition to such arguments based on PDs, indirect clinical evidence that high-dose 
INH inhibits or kills low-level INH-resistant organisms comes from a randomized trial in 
which low-level INH resistance (MIC <5 mcg/mL) was less likely to emerge in slow 
acetylators receiving 8-9 mg/kg of INH as monotherapy, compared to slow acetylators 
receiving 4-5 mg/kg or rapid acetylators receiving either dose, whereas high-level INH 
resistance was more common among slow acetylators receiving the higher dose [19]. 
Three recent observational trials that demonstrated high success rates of “short-course” 
MDR-TB treatment (9-12 months) used multidrug treatment regimens that included high-
dose INH. In the first study in Bangladesh [20], the most effective regimen involved an 
intensive phase of at least 4 months during which participants received high-dose INH 
(10-12 mg/kg). Notably, the investigators from the Bangladesh study indicated that 
the majority of patients in the study had TB with INH resistance mediated by katG 
mutations. They observed that the most frequent katG mutation (315) confers a 
range of MIC values but that the majority of strains have resistance levels around 
the peak serum concentration of standard-dose INH (5 mg/kg); they further stated 
that high-dose isoniazid would, thus, be active against the majority of strains with 
katG mutations [21]. To wit, in prospective observational studies in Cameroon and 
Niger that followed the work in Bangladesh [22, 23], the efficacy of a ‘Bangladesh-
type regimen’ that included standard- or high-dose INH among patients with MDR-
TB was similarly impressive, even among those patients with medium- to high-level 
INH resistance. In a randomized controlled trial in India, participants with MDR-TB (no 
information about mechanism of INH resistance) were randomized to high-dose INH 
(16-18 mg/kg), standard dose INH (5 mg/kg), or placebo, each together with a 
standardized background regimen [24]. Six-month culture conversion rates were 74%, 
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INH (3.4 vs. 6.4 vs. 6.6 months). The relationship between INH MIC and/or acetylator 
status and treatment outcomes was not explored in this study. Of note, peripheral 
neuropathy was more common among those receiving high-dose INH. However, vitamin 
B6 supplementation was not given [25]. Hepatotoxicity rates were not different among 
groups, with relative risk of hepatotoxicity comparing high-dose INH to standard-dose 
INH and placebo groups of 0.96 (95% CI 0.54-1.74). Other trials have shown no benefit 
of adding standard dose INH, but improved outcomes when adding high-dose INH to 
retreatment regimens [26, 27]. Of note, doses of INH up to 20 mg/kg have been 
studied and are well-tolerated, but there is limited safety information for doses 
higher than that [24, 28-30]. 
 
INH Drug Information 
INH is the hydrazide of isonicotinic acid and is one of the primary drugs for TB treatment. 
The activity of INH is limited to the mycobacteria of the M. tuberculosis complex. The 
probable mechanism of action is the inhibition of the biosynthesis of mycolic acids, a 
component of the mycobacterial cell wall.  
 
Dose and indications 
INH is U.S. Food and Drug Administration (FDA)-approved for the treatment of active TB 
in combination with other appropriate anti-TB medications, and as a single agent for TB 
preventive therapy (treatment of latent TB infection). The approved dose is 5 mg/kg up 
to 300 mg daily or 15 mg/kg up to 900 mg twice or thrice weekly, given for 6-9 months. 
In the Companion Handbook of the WHO Guidelines for the Programmatic 
Management of Drug-Resistant Tuberculosis, the dose recommended for high-
dose INH for patients with drug-resistant TB is for 16-20 mg/kg once daily. The 
WHO recently produced guidelines for treatment of INH-resistant TB in which they 
suggested a dose of up to 15 mg/kg daily [31]. In this study, participants will receive 
5, 10, 15, or 20 mg/kg daily for 7 days to evaluate the activity of INH against M. 
tuberculosis organisms that harbor resistance mutations to INH.  
 
Pharmacokinetics  
INH is generally well absorbed; food and antacids decrease the rate, but not the extent 
of absorption. The peak blood levels of INH, 3 to 5 mcg/mL, are obtained 30 minutes to 
2 hours after ingestion of routine doses [32]. It diffuses into all body fluids and cells and 
penetrates into the caseous material of a tuberculoma or pulmonary cavity. In the liver, it 
is acetylated to inactive metabolites, and 75% to 95% of the dose is excreted as inactive 
metabolites in the urine within 24 hours. INH clearance rates depend on NAT2 
metabolizer genotype, which is associated with race but not gender [33]. The INH AUC 
among “fast acetylators” is 30% to 50% of that among “slow acetylators.” Because INH 
is well tolerated over a wide range of therapeutic doses, a single dose is recommended, 
regardless of weight or acetylator status. Persons who have rapid acetylation achieve 
effective concentrations, while persons who have slow acetylation do not experience 
increased toxicity. Half-life (T1/2) may vary from 1 hour in fast acetylators (T1/2 < 90 min) 
to 3 hours in slow acetylators (T1/2 >90 min).  
 


 
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Drug-drug interactions  
INH decreases the clearance of some medications that are metabolized in the liver 
(particularly carbamazepine, phenytoin, and diazepam) [34]. However, in the context of 
multidrug therapy including RIF, these potential drug-drug interactions are of little 
significance because the effect of INH is counteracted by the more potent opposing 
effect of RIF [35]. 
 
Toxicity  
The total incidence of all adverse effects from INH at standard doses given for full 
treatment duration is approximately 5%, many of which do not require discontinuation 
of the drug. Peripheral neurotoxicity is dose and duration dependent, and it is 
uncommon (<0.2%) at conventional doses. The risk of peripheral neuritis increases for 
persons who are malnourished or predisposed to neuritis by other illnesses. 
Concomitant administration of pyridoxine (vitamin B6) is recommended for these 
persons, and will be given to all participants receiving concomitant INH in this trial. Other 
nervous system reactions are rare at normal doses, and they include convulsions, 
encephalopathy, optic neuritis, memory impairment, and psychosis. Gastrointestinal 
adverse effects include nausea, vomiting, and epigastric distress. Asymptomatic 
elevation of aminotransferases is common and occurs in 10-20% of persons receiving 
INH. However, idiosyncratic severe hepatic reactions are uncommon, but are more likely 
in older persons (up to 2.3% hepatitis incidence in persons over 50 years old) and may 
be life threatening. Daily consumption of alcohol increases the risk of INH-associated 
hepatotoxicity by approximately four-fold. The risk of INH-induced hepatotoxicity may 
also be increased in the postpartum period. The prodromal symptoms of hepatotoxicity 
are anorexia, nausea, vomiting, fatigue, malaise, and weakness; persons who take INH 
and have these symptoms should stop therapy and be evaluated immediately. Doses of 
16-18 mg/kg given for a full treatment course together with second-line drugs for 
MDR-TB in a randomized clinical trial were safer and did not have higher risk of 
hepatotoxicity than standard-dose (5 mg/kg) INH [24]. In patients enrolled in the 
inhA arms in this trial (A5312), there have been no Grade 3 or higher treatment-
related adverse events (AEs). No peripheral neuropathy has been detected. 
 
2.2 
Rationale 
 
In summary, high-dose INH may be useful in the treatment of TB infection commonly 
considered INH resistant, but its efficacy will likely depend on the dosage and the degree 
of resistance. In participants infected with TB with isolated inhA mutations, moderate to 
high-dose INH is likely to be effective. Participants infected with TB with katG mutations 
may derive a therapeutic benefit, provided the dose of INH is sufficiently high. 
Genotypic tests that can detect the most common inhA and katG mutations conferring 
INH resistance with a short turnaround time directly from sputum have been developed 
(Hain MTBDRplus), and their use is endorsed by the World Health Organization (WHO) 
[36, 37]. These tests can quickly identify participants who are likely to benefit from high-
dose INH. Hain MTBDRplus also detects mutations associated with RIF resistance. 
Another rapid test, Gene Xpert, detects RIF resistance and has become an important 
tool for diagnosis of MDR-TB. In South Africa and in other settings, sputum of patients is 
tested first with Gene Xpert; if RIF resistance is detected, then the Hain test is used to 


 
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see if there is also INH resistance and confirm MDR-TB. Once MDR-TB is identified, 
patient sputum is sent for phenotypic drug sensitivity tests for first-line and second-line 
TB drugs. For those patients who are very ill and require immediate treatment, an 
empiric MDR regimen is given; for others, therapy is held until Hain results are available, 
treatment history can be reviewed, and the appropriate treatment can be chosen and 
made available to the clinic serving the patient (a process that takes at least 1-2 weeks). 
Gene Xpert testing that will test for both RIF and INH resistance at the time of 
diagnosis (and includes testing for inhA and katG mutations) is currently under 
development. Thus, information about the type of INH resistance will soon be 
available at the start of MDR-TB treatment. We believe that patients with MDR-TB 
with inhA mutations can benefit from moderate- to high-dose INH. It is also likely that 
many patients with MDR-TB with katG mutations can benefit from high-dose INH. 
Whether and at which dosage high-dose INH can overcome INH resistance conferred 
by inhA or katG mutations can be assessed using an EBA study, in which daily 
quantitative sputum cultures are collected from patients with sputum smear-positive 
pulmonary TB [38-41]. 
 
In this phase IIa EBA study including participants with INH monoresistant-TB and MDR-
TB, we propose combining genotypic and phenotypic INH susceptibility testing, 
population PK, and PDs to determine the relationship between INH AUC/MIC and 
bactericidal activity. The study will determine whether or not higher-dose INH has a role 
in the treatment of TB infection with a bacterium resistant to INH, and if it can be used, 
the study will enable an optimized dosing strategy based on rapid genotypic tests 
available at the initiation of TB therapy, a novel approach.  
 
3.0 
STUDY DESIGN 
 
This is a two-stage, two-step, phase IIa, open-label, randomized clinical trial among 
adult participants with sputum smear positive pulmonary TB evaluating the EBA of three 
different doses of INH among participants infected with M. tuberculosis with inhA 
mutations (Group 1). In addition, the EBA of INH among participants with M. tuberculosis 
with no genotypic evidence of INH resistance (Group 2) will be determined. Among 
participants infected with an M. tuberculosis strain with katG mutations (Group 3), the 
EBA of INH at a dose of 15 or 20 mg/kg will be determined. These doses are 
selected because doses of up to 15-20 mg/kg appear to be safe (in other studies, 
as well as in the 15 mg/kg dosing cohort in Group 1 in the current trial) and the 
safety of doses higher than 20 mg/kg has not been established. In addition, upon 
preliminary assessment of the EBA data in the inhA arms, INH demonstrated 
activity, and this activity appeared to be dose-related. 
 
No study drug is administered under Step 1. Data collected in Step 1: (a) determine 
eligibility to Step 2, and (b) allow characterization of INH MICs in three groups 
(secondary objective). Groups 1, 2, and 3 consist of participants infected with TB with 
inhA mutations, with DS-TB and with TB with katG resistance-conferring mutations, 
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The study’s primary objectives are addressed via Step 2 evaluations. Participants 
enrolling to Step 2 receive the study drug, INH, which will be given with vitamin B6 ≥25 
mg daily, by mouth. During both stages, participants in Group 1 who meet Step 2 entry 
criteria will be randomized to receive 5, 10, or 15 mg/kg of INH daily for 7 days. During 
Stage 2, participants in Group 2 who meet Step 2 entry criteria will receive 5 mg/kg of 
INH daily for 7 days. During Stage 2, participants in Group 3 who meet Step 2 entry 
criteria will be randomized 1:1 to receive 15 or 20 mg/kg of INH daily for 7 days. 
After completion of 7 days of INH alone, participants will be referred to begin standard 
anti-TB chemotherapy according to South African TB Control Programme Guidelines.  
 
In Stage 1, Group 1 participants who do not meet Step 2 entry criteria, all Group 2 
participants and all Group 3 participants will be referred to the South African TB Control 
Programme for treatment. In Stage 2, Group 1 participants who do not meet Step 2 entry 
criteria, Group 2 participants who do not meet Step 2 entry criteria, and Group 3 
participants who do not meet Step 2 entry criteria will be referred to the South 
African TB Control Programme for treatment. 
 
In Step 2, prior to initiation of treatment, sputum will be collected for quantitative culture 
on solid medium (for CFU for Groups 1 and 2 only) and liquid medium (for 
determination of TTD for all groups) and for MIC determination and phenotypic DST. In 
addition to GenoType MTBDRplus, GenoType MTBDRsl, which identifies additional 
mutations associated with resistance to fluoroquinolones and injectable TB medicines, 
will be performed on sputum of participants with MDR-TB (but not INH-monoresistant 
TB) who are enrolled in the study. Sixteen-hour sputum collections will be performed 
daily during INH treatment, as per standard EBA methodology [42]. Sampling for PK 
analysis will be performed at steady state on Day 6 (±1). NAT2 genotyping will be 
performed on a blood sample to help explain variability in INH PK parameters, and a 
saliva sample will be collected for evaluation of a new rapid NAT2 genotyping test. 
Safety and tolerability will be monitored via clinical evaluations throughout the study and 
through scheduled laboratory evaluations. 
 
To avoid unnecessary delay in initiating TB treatment, screening evaluations for Step 1 
and Step 2 may occur on the same day.  
 
To minimize risk to study staff and study participants, participants with MDR-TB will be 
hospitalized on a different ward from participants with DS-TB or INH-monoresistant TB. 
Strict infection control practices will be followed, including the wearing of N95 masks 
where appropriate and hospitalization on wards with negative pressure ventilation. In 
addition, persons with a previous known exposure to XDR-TB or those who have been 
treated previously for MDR-TB, and thus have a higher risk of XDR-TB, will not be 
included in this study. 
 


 
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The study will proceed in two stages, as follows: 
 
Stage 1—Pilot study to ensure feasibility: 
Participants will be recruited at a single clinical site, Task Applied Science at Brooklyn 
Chest Hospital, affiliated with Stellenbosch University, in Cape Town, South Africa. All 
eligible participants will enter Step 1 of the study (determination of INH resistance, 
measurement of INH MIC). Among Group 1 participants who meet the Step 2 entry 
criteria, 15 participants will be randomized 1:1:1 to receive 5, 10, or 15 mg/kg daily of 
INH for 7 days with evaluations performed as described above.  
 
As of March 26, 2015, Stage 1 is complete. A total of 15 Group 1, 44 Group 2, and 12 
Group 3 participants were enrolled in Step 1 only during Stage 1. These participants did 
not receive study treatment. They provided sputum samples for MIC determination. 
 
The goal of Stage 1 will be to demonstrate feasibility, not treatment efficacy. The rate at 
which the study accrues Group 1 participants at a single site will be assessed after 6 
months to determine the advisability of proceeding with Stage 2 and advisability of 
including additional sites. In addition, the standard deviations (SDs) of the primary 
endpoint will be reviewed for a possible sample size increase if the SDs in Group 1 are 
larger than expected. 
 
Stage 2:  
During Stage 2, to be conducted at Task Applied Science and other approved sites, 
Group 1 participants who meet Step 2 entry criteria will be randomized 1:1:1 to receive 
5, 10, or 15 mg/kg of INH daily for 7 days until the accrual target (taking together 
participants who enrolled during Stage 1 and Stage 2) is met. Study drug administration 
and study procedures will be as described above. In addition, 16 Group 2 participants 
who meet Step 2 entry criteria will be enrolled and will receive INH at a dose of 5 mg/kg 
daily, and undergo study procedures as described above. Also, 20 Group 3 
participants who meet Step 2 entry criteria will be enrolled and randomized 1:1 to 
receive INH at a dose of 15 or 20 mg/kg daily, and undergo study procedures as 
described above. 
 
A minimum of 16 to a maximum of 70 Group 1 participants, a minimum of 48 to a 
maximum of 64 Group 2 participants, and a minimum of 64 to a maximum of 84 Group 
3 participants will be enrolled in Step 1 only during Stages 1 and 2 combined. 
Participants enrolling to Step 1 only will not receive study drug. They will provide sputum 
samples for MIC determination. 
 


 
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Figure 3.0-1:  Study Design Schematic: 
 
Stage 1: 
 
 
 
 


 
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Figure 3.0-2:  Stage 2: 
 
 
 
 
 
4.0 
SELECTION AND ENROLLMENT OF PARTICIPANTS 
 
4.1 
Inclusion Criteria for Step 1 
 
4.1.1 New or recurrent pulmonary TB with sputum positive for acid-fast bacilli on direct 
microscopy of at least grade 1+ (International Union Against Tuberculosis and 
Lung Disease [IUATLD] scale) at the study laboratory on at least one pre-
treatment sputum sample within 14 days prior to entry. 
 
4.1.2 Age ≥18 and ≤65 years at study entry. 
 


 
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4.1.3 Infected with an M. tuberculosis strain for which Hain GenoType MTBDRplus 
genotype, performed at the study laboratory within 14 days prior to study entry, 
reveals one of the following results for INH susceptibility testing: 
 
• 
inhA promoter or functional mutation only (Group 1 participants, eligible for 
Steps 1 and 2) 
• 
No mutations in the inhA or katG genes (Group 2 participants, eligible for 
Step 1 and, during Stage 2 of the study, also eligible for Step 2) 
• 
katG mutation with or without an inhA mutation (Group 3 participants, eligible 
for Step 1 and, during Stage 2 of the study, also eligible for Step 2) 
 
4.1.4 Ability and willingness of the participant or legal guardian/representative to 
provide informed consent. 
 
4.2 
Exclusion Criteria for Step 1  
 
 
There are no exclusion criteria for Step 1.  
 
4.3 
Inclusion Criteria for Step 2 
 
4.3.1 Entry into Step 1. 
 
4.3.2 During Stage 1 of the protocol: inhA promoter or functional mutation only (Group 
1). 
 
During Stage 2 of the protocol: inhA promoter or functional mutation only (Group 
1) OR mutations in neither inhA nor katG genes (Group 2) or mutation in the 
katG gene, with or without mutations in inhA promoter or functional genes 
(Group 3). 
 
4.3.3 Body weight: 40 kg to 90 kg, inclusive. 
 
4.3.4 Laboratory values obtained within 30 days prior to entry: 
• 
Absolute neutrophil count (ANC) ≥750 cells/mm3 
• 
Hemoglobin ≥7.4 g/dL 
• 
Platelet count ≥50,000/mm3 
• 
Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) 
≤3 X upper limit of normal (ULN) 
• 
Total bilirubin ≤2.5 X ULN 
 
4.3.5 HIV infection status must be documented as either absent or present, as defined 
below: 
 
Absence of HIV-1 infection, as documented by any licensed rapid HIV test or HIV 
enzyme or chemiluminescence immunoassay (E/CIA) test kit, within 30 days 
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OR 
 
HIV-1 infection, documented by any licensed rapid HIV test or HIV enzyme or 
chemiluminescence immunoassay (E/CIA) test kit at any time prior to Step 2 
entry and confirmed by a licensed Western blot or a second antibody test by a 
method other than the initial rapid HIV and/or E/CIA, or by HIV-1 antigen or 
plasma HIV-1 RNA viral load. 
 
NOTE: The term “licensed” refers to a US FDA-approved kit, which is 
recommended. For sites that are unable to obtain an FDA-approved kit, a kit that 
has been certified or licensed by an oversight body within the country and 
validated internally is acceptable.  
 
WHO and Centers for Disease Control and Prevention (CDC) guidelines 
mandate that confirmation of the initial test result must use a test that is different 
from the one used for the initial assessment. A reactive initial rapid test should be 
confirmed by either another type of rapid assay or an E/CIA that is based on a 
different antigen preparation and/or different test principle (e.g., indirect versus 
competitive), or a Western blot or a plasma HIV-1 RNA viral load. 
 
4.3.6 For HIV-positive candidates only: CD4+ cell count of ≥50 cells/mm3, performed 
within 7 days prior to entry at a DAIDS-approved laboratory. 
 
4.3.7 For females of reproductive potential, negative serum or urine pregnancy test 
within 7 days prior to entry. Female participants who are participating in sexual 
activity that could lead to pregnancy must agree to use one reliable non-
hormonal method of contraception (condoms or an IUD), or another method 
(diaphragm or cervical cap) if it is approved by the national regulatory authority 
and used according to package insert, while receiving study medications.   
 
NOTE: Female participants who are not of reproductive potential or whose male 
partner/s has/have undergone successful vasectomy with documented 
azoospermia or has/have documented azoospermia for any other reason, are 
eligible without requiring the use of contraceptives. Participant-reported history is 
acceptable documentation of menopause (i.e., at least 1 year amenorrheic), 
hysterectomy, or bilateral oophorectomy or bilateral tubal ligation; these 
participants are all considered not of reproductive potential. 
 
4.3.8 Willingness to be hospitalized for a minimum of 9 consecutive days.  
 
4.3.9 Ability to produce an overnight sputum sample of sufficient quality and quantity. 
As a guideline, this should be 10 mL or more during a 16-hour collection period.  
 
NOTE: If a participant’s failure to produce sufficient sputum appears to be due to 
poor technique rather than low volume of sputum production, this evaluation may 
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4.4 
Exclusion Criteria for Step 2 
 
4.4.1 Current treatment with INH or receipt of INH during the 7 days prior to Step 2 
entry. 
 
NOTE: Participants who have been started on INH-containing anti-TB treatment 
and have received this treatment for less than or equal to 2 weeks, but for whom 
TB drugs have been discontinued because of resistance to INH (with or without 
resistance to RIF), can participate in the study, but may need to be hospitalized, 
at the discretion of the investigator, while these drugs wash out; the minimum 
washout period for these drugs is 7 days.   
 
4.4.2 Receipt of more than 7 cumulative days of second-line anti-TB drugs 
(including all drugs with anti-TB activity, except INH, RIF, ethambutol, 
pyrazinamide, and streptomycin) and/or antibiotics intended for bacterial 
treatment that may have anti-TB activity, including amoxicillin/clavulanate 
(Augmentin), linezolid, metronidazole, or drugs from the quinolone class, 
within the 14 days prior to Step 1 screening sputum collection. The 
minimum washout period for these drugs is 7 days prior to Step 2 pre-
entry sputum collection. 
 
4.4.3 Known exposure to a person diagnosed with XDR-TB or known personal 
diagnosis of XDR-TB in the past. 
 
4.4.4 Breastfeeding. 
 
4.4.5 Known allergy/sensitivity to INH. 
 
4.4.6 Karnofsky score <60 or poor general condition where any delay in full TB 
treatment cannot be tolerated in the opinion of the investigator (at screening). 
 
4.4.7 Any of the following co-morbidities, complications, or underlying medical 
conditions: 
 
• 
Known current neurological TB (e.g., TB of the spine, TB meningitis) 
• 
Peripheral neuropathy ≥Grade 2, according to the December 2004 
(Clarification, August 2009) Division of AIDS (DAIDS) Toxicity Table, within 
14 days prior to entry 
• 
Current or history of epilepsy, defined as seizure disorder requiring current 
treatment with an antiepileptic medicine or history of any seizures within the 
prior year 
 
4.4.8 Any condition as determined by physical examination, medical history, laboratory 
data, or chest x-ray which, in the opinion of the investigator, would interfere with 
participation in the study. 
 


 
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4.5 
Study Enrollment Procedures 
 
4.5.1 Prior to implementation of this protocol, and any subsequent full version 
amendments, each site must have the protocol and the protocol consent form(s) 
approved, as appropriate, by their local institutional review board (IRB)/ethics 
committee (EC) and any other applicable regulatory entity (RE). Upon receiving 
final approval, sites will submit all required protocol registration documents to the 
DAIDS Protocol Registration Office (DAIDS PRO) at the Regulatory Support 
Center (RSC). The DAIDS PRO will review the submitted protocol registration 
packet to ensure that all of the required documents have been received.  
Site-specific informed consent forms (ICFs) will be reviewed and approved by the 
DAIDS PRO and sites will receive an Initial Registration Notification from the 
DAIDS PRO that indicates successful completion of the protocol registration 
process. A copy of the Initial Registration Notification should be retained in the 
site's regulatory files.  
 
Upon receiving final IRB/EC and any other applicable RE approvals for an 
amendment, sites should implement the amendment immediately. Sites are 
required to submit an amendment registration packet to the DAIDS PRO at the 
RSC. The DAIDS PRO will review the submitted protocol registration packet to 
ensure that all the required documents have been received. Site-specific ICFs 
will not be reviewed and approved by the DAIDS PRO, and sites will receive an 
Amendment Registration Notification when the DAIDS PRO receives a complete 
registration packet. A copy of the Amendment Registration Notification should be 
retained in the site's regulatory files. 
 
For additional information on the protocol registration process and specific 
documents required for initial and amendment registrations, refer to the current 
version of the DAIDS Protocol Registration Manual. 
 
Protocol activation is required prior to enrolling participants into the study. The 
Network Coordinating Center will provide notification of activation.  
 
Once a candidate for study entry has been identified, details will be carefully 
discussed with the participant. The participant will be asked to read and sign the 
approved protocol consent form.  
 
For participants from whom a signed informed consent has been obtained, an 
ACTG Screening Checklist must be entered through the Data Management 
Center (DMC) Subject Enrollment System.  
 
4.5.2 Registration/Randomization 
 
For participants from whom informed consent has been obtained, but who are 
deemed ineligible or who do not enroll into the initial protocol step, an ACTG 
Screening Failure Results form must be completed and keyed into the database.  
 


 
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Patients who are eligible for participation in the study based on screening results 
will be registered to the protocol at the time of enrollment.  
 
During Stage 1, Group 1 participants who meet Step 2 entry criteria will be 
randomized 1:1:1 to one of three doses of INH (5, 10, or 15 mg/kg). Group 1 
participants who do not meet Step 2 entry criteria, as well as Group 2 and 3 
participants will be enrolled in Step 1, but will not receive study drug. They will be 
discontinued from the study after their Step 1, Day 0 visit and referred for 
standard local TB treatment.  
 
During Stage 2, Group 1 participants who meet Step 2 entry criteria will be 
randomized as during Stage 1. Group 2 participants who meet Step 2 entry 
criteria will be registered and assigned to receive 5 mg/kg study drug daily. 
Group 3 participants who meet Step 2 entry criteria will be randomized 1:1 
to receive 15 mg/kg or 20 mg/kg study drug daily. Group 1, 2, or 3 
participants who do not meet Step 2 entry criteria will be enrolled in Step 1, but 
will not receive study drug. They will be discontinued from the study after their 
Step 1 Day 0 visit and referred for standard local TB treatment.  
 
During Stage 2, enrollment of Group 2 participants will proceed so that, on 
average, for every two Group 1 participants enrolled in Step 2 per month, one 
Group 2 participant will be enrolled. The enrollment for Group 2 will be controlled 
by setting a recruitment limit, and it will be manually adjusted by the data 
manager and statisticians routinely (e.g., every month or twice per month). 
 
4.6 
Coenrollment Guidelines  
 
Sites are encouraged to coenroll participants in A5243, “Plan for Obtaining Human 
Biological Samples at Non-US Clinical Research Sites for Currently Unspecified Genetic 
Analyses.” Coenrollment in A5243 does not require permission from the A5312 protocol 
chairs. For specific questions and approval for coenrollment in other studies, sites must 
contact the protocol chairs via e-mail as described in the Study Management section. 
 
5.0 
STUDY TREATMENT  
 
INH is approved for use by the US FDA for the treatment of DS-TB. The recommended 
dose of INH is 5 mg/kg (up to 300 mg daily) once daily for active TB. For the treatment of 
latent TB infection, the recommended dose is 10-15 mg/kg (up to 900 mg) twice- or 
thrice-weekly. In this study, INH will be given at 5 mg/kg daily to participants with DS-TB 
and at 5, 10, or 15 mg/kg once daily, for a total of seven daily doses, to participants 
infected with M. tuberculosis that has an inhA resistance mutation or at a dose of 15 or 
20 mg/kg to participants infected with M. tuberculosis that has a katG mutation. 
The rationale for the higher doses is to try to overcome INH resistance by increasing the 
dose. In addition, participants will receive vitamin B6 ≥25 mg daily. 
 


 
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5.1 
Regimens, Administration, and Duration 
 
Stage 1 
 
Step 1:  
Group 1: Participants in Group 1 who do not meet Step 2 entry criteria but are 
enrolled for determination of MIC only will not receive study drug. 
 
Groups 2 and 3: In Stage 1, participants infected with M. tuberculosis with neither 
katG nor inhA mutations (Group 2) and those infected with M. tuberculosis with a 
katG mutation with or without an inhA mutation (Group 3) will not receive study 
drugs. 
 
Step 2: 
Group 1 (n=15): Participants infected with M. tuberculosis with an isolated inhA 
mutation will be randomized 1:1:1 to receive the following treatments for 7 days: 
 
5 mg 
cohort     
INH 5 mg/kg by mouth once daily on Days 
1-7 plus vitamin B6 ≥25 mg daily 
10 mg 
cohort    
INH 10 mg/kg by mouth once daily on 
Days 1-7 plus vitamin B6 ≥25 mg daily 
15 mg 
cohort    
INH 15 mg/kg by mouth once daily on 
Days 1-7 plus vitamin B6 ≥25 mg daily 
 
Stage 2 
 
Step 1:  
Participants who do not meet Step 2 entry criteria but are enrolled only for 
determination of MIC will not receive study drug. 
 
Step 2: 
Group 1 (n=33): Participants infected with M. tuberculosis with an isolated inhA 
mutation will be randomized 1:1:1 to receive the following treatments for 7 days: 
 
5 mg 
cohort     
INH 5 mg/kg by mouth once daily on Days 
1-7 plus vitamin B6 ≥25 mg daily 
10 mg 
cohort    
INH 10 mg/kg by mouth once daily on 
Days 1-7 plus vitamin B6 ≥25 mg daily 
15 mg 
cohort    
INH 15 mg/kg by mouth once daily on 
Days 1-7 plus vitamin B6 ≥25 mg daily 
 


 
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Group 2 (n=16): Participants infected with M. tuberculosis with neither katG nor inhA 
mutations who meet the Step 2 entry criteria will receive the following treatment for 7 
days: 
 
Control 
INH 5 mg/kg by mouth once daily on Days 
1-7 plus vitamin B6 ≥25 mg daily 
 
Group 3 (n=20): Participants infected with M. tuberculosis with a katG 
mutation, with or without an inhA mutation, who meet the Step 2 entry criteria 
will receive the following treatment for 7 days: 
 
katG 15 
mg 
cohort 
INH 15 mg/kg by mouth once daily on 
Days 1-7 plus vitamin B6 ≥25 mg daily 
katG 20 
mg 
cohort 
INH 20 mg/kg by mouth once daily on 
Days 1-7 plus vitamin B6 ≥25 mg daily 
 
INH is available in 100 mg tablets. INH will be administered orally daily in the 
morning on an empty stomach. Doses of INH will be given according to the weight 
bands outlined below: 
 
Dose cohort 
Weight 
Dose 
5 mg/kg 
≥40 kg and ≤70 kg 
300 mg 
5 mg/kg 
>70 kg and ≤90 kg 
400 mg 
10 mg/kg 
≥40 kg and ≤55 kg 
500 mg 
10 mg/kg 
>55 kg and ≤65 kg 
600 mg 
10 mg/kg 
>65 kg and ≤75 kg 
700 mg 
10 mg/kg 
>75 kg and ≤85 kg 
800 mg 
10 mg/kg 
>85 kg and ≤90 kg 
900 mg 
15 mg/kg 
≥40 kg and ≤43 kg 
600 mg 
15 mg/kg 
>43 kg and ≤50 kg 
700 mg 
15 mg/kg 
>50 kg and ≤57 kg 
800 mg 
15 mg/kg 
>57 kg and ≤63 kg 
900 mg 
15 mg/kg 
>63 kg and ≤70 kg 
1000 mg 
15 mg/kg 
>70 kg and ≤76 kg 
1100 mg 
15 mg/kg 
>76 kg and ≤83 kg 
1200 mg 
15 mg/kg 
>83 kg and ≤90 kg 
1300 mg 
20 mg/kg 
≥40 kg and ≤43 kg 
800 mg 
20 mg/kg 
>43 kg and ≤48 kg 
900 mg 
20 mg/kg 
>48 kg and ≤53 kg 
1000 mg 
20 mg/kg 
>53 kg and ≤58 kg 
1100 mg 
20 mg/kg 
>58 kg and ≤63 kg 
1200 mg 
20 mg/kg 
>63 kg and ≤68 kg 
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Dose cohort 
Weight 
Dose 
20 mg/kg 
>68 kg and ≤73 kg 
1400 mg 
20 mg/kg 
>73 kg and ≤78 kg 
1500 mg 
20 mg/kg 
>78 kg and ≤83 kg 
1600 mg 
20 mg/kg 
>83 kg and ≤88 kg 
1700 mg 
20 mg/kg 
>88 kg and ≤93 kg 
1800 mg 
 
Participants will receive INH at the assigned dose for 7 days and then will be referred 
to the local/national TB program for TB treatment by Day 10 (or earlier if study 
treatment is prematurely discontinued). Results of study-related DST will be provided 
to the treatment program for their use, as appropriate. 
 
5.2 
Study Product Formulation and Preparation 
 
INH tablets locally procured by the sites must be stored in accordance with the 
manufacturer’s instructions and be the same strength and formulation for the duration of 
the study. 
 
5.3 
Pharmacy: Product Supply, Distribution, and Accountability 
 
5.3.1 Study Product Acquisition/Distribution 
 
INH and vitamin B6 will be obtained locally for use by study participants. 
 
INH will be obtained from a source matching at least one of the following 
qualifications: 
• 
Approved by the U.S. FDA 
• 
Approved by a country listed under the Federal Food, Drug, and Cosmetic 
Act Chapter VIII, Section 802(b) (1) (A) (These countries are Australia, 
Canada, Israel, Japan, New Zealand, Switzerland, South Africa, or the 
countries of the European Union or country in the European Economic Area) 
• 
Approved by and listed under the WHO Prequalification Programme 
(http://extranet.who.int/prequal/) 
 
Each CRS conducting A5312 must obtain the approval for use of locally procured 
INH tablets from the protocol team prior to administration to A5312 participants 
and keep a detailed log of the manufacturer information (name and location), 
strength and dosage form, each lot number, expiration date, and start and stop 
dates for usage of that lot number. This is in addition to the accountability records 
required in section 5.3.2. 
 
The source of vitamin B6 must also meet the requirements of this policy. 
 


 
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5.3.2 Study Product Accountability 
 
The Clinical Research Site Pharmacist of Record is required to maintain records 
of all study products received and dispensed to study participants, and final 
disposition of all study products.  
 
5.4 
Concomitant Medications 
 
Below are lists of selected concomitant medications. These lists are only current as of 
the date of this protocol. Whenever a concomitant medication or study agent is initiated 
or a dose changed, investigators must review the concomitant medications’ and study 
agents' most recent package inserts, Investigator’s Brochures, or updated information 
from DAIDS to obtain the most current information on drug interactions, 
contraindications, and precautions. 
 
Additional drug information may be found on the ACTG Drug Interactions Database, 
located at: http://tprc.pharm.buffalo.edu/home/di_search/. 
 
5.4.1 Required Medications 
 
TB-Drug-Induced Peripheral Neuropathy Prophylaxis 
Vitamin B6 (pyridoxine) once daily while participant is receiving INH; vitamin B6 
will be required and provided by the site. A dose of 25 mg is recommended but 
may be higher based on the current local, national, or international dosing 
guidelines. 
 
5.4.2 Prohibited Medications 
 
Use of other anti-TB medications is prohibited from screening until after the final 
dose of study medications. Antacids must not be given together with the study 
drug. 
 
5.4.3 Precautionary Medications 
 
For a list of precautionary medications, refer to the ACTG Drug Interactions 
Database (see link above). 
 
5.5 
Adherence Assessment  
 
Study doses of INH will be observed during hospitalization, and adherence will be 
documented by study staff using hospital records. 


 
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6.0 
CLINICAL AND LABORATORY EVALUATIONS 
 
6.1 
Schedule of Events  
 
6.1.1 Table 6.1-1:  Step 1  
 
 
 
 
 
 
 
 
 
 
 
 
 
1At the discretion of the investigator, some participants may be hospitalized during the screening evaluations, but this 
is not a requirement. 
2The screening and Step 1 Day 0 visits may be combined for these participants. 
3Step 1 Day 0 spot sputum collection is only required if the screening spot sputum is insufficient or inadequate for Step 
1 entry evaluations. 
 
 
Evaluation 
Screening 
Step 1 
Day 02 
Spot Sputum Collection 
X 
X3 
AFB Microscopy 
X 
 
Genotypic DST with HAIN 
MTBDRplus  
X 
 
Culture and Phenotypic DST 
Determination with MIC 
 
X 
Hospitalization1 
X 
 


 
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6.1.2 Table 6.1-2:  Step 2 
 
Evaluation 
Screening 
Pre-entry 
Entry: 
Registration/ 
Randomization 
Study Treatment (Days) 
Discharge 
Final 
Visit 
Premature 
Discontin-
uation 
Step 2 
Day 0 
1 
2 
3 
4 
5 
6 
7 
Day 8 
Day 
21 
+/-3 
Documentation of HIV 
status 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Medical/Medication 
History 
  
 
X 
 
 
 
 
 
 
 
 
 
 
Complete Physical 
Examination 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Targeted Physical 
Examination 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Karnofsky Score 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Height 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Weight 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Signs/Symptoms/ 
Diagnoses 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Concomitant/TB/ 
ARV Medications 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Complete Blood Count 
with Differential 
X 
 
X 
 
 
 
 
 
 
X 
 
X 
X 
Complete Blood 
Chemistry Profile 
X 
 
X 
 
 
 
 
 
 
X 
 
X 
X 
CD4+ Count (HIV-infected 
participants) 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy Test 
X1 
 
X 
 
 
 
 
 
 
 
 
 
 


 
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Evaluation 
Screening 
Pre-entry 
Entry: 
Registration/ 
Randomization 
Study Treatment (Days) 
Discharge 
Final 
Visit 
Premature 
Discontin-
uation 
Step 2 
Day 0 
1 
2 
3 
4 
5 
6 
7 
Day 8 
Day 
21 
+/-3 
NAT2 genotype (blood 
and saliva) 
 
 
X 
 
 
 
 
 
 
 
 
 
 
Chest X-ray 
X2 
 
 
 
 
 
 
 
 
 
 
 
 
Spot Sputum Collection 
 
 
X3 
 
 
 
 
 
 
 
 
 
 
Genotypic DST 
(MTBDRsl)4 
 
 
X 
 
 
 
 
 
 
 
 
 
 
Overnight Sputum 
Collection 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
EBA Analysis by Solid 
Culture CFU (Groups 1 
and 2 only) 
Determination and Liquid 
MGIT Culture for TTD5 (all 
groups) 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
Pharmacokinetic 
Sampling 
 
 
 
 
 
 
 
 
X 
 
 
 
 
Hospitalization 
X6 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
1Participants must have a negative serum or urine pregnancy test within 7 days prior to entry. 
2A chest x-ray is not required at screening if results of a chest x-ray performed within 14 days prior to screening are available. 
3Sputum from Step 1 (Screening or Day 0) may be used if there is an adequate amount for genotypic DST.  
4For those participants who have MDR-TB identified by MTBDRplus. 
5X’s here refer to the date that the overnight sputum collection was begun. Assay will be conducted the next morning. 
6At the discretion of the investigator, some participants may be hospitalized during the screening evaluations, but this is not a 
requirement. 


 
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6.2 
Timing of Evaluations 
 
6.2.1 Screening and Pre-Entry Evaluations  
 
Screening 
Screening procedures will be performed within the 2 weeks prior to entry unless 
otherwise noted to minimize participants’ waiting time for a decision about 
whether or not they can be enrolled. In addition to data being collected on 
participants who enroll into the study, demographic, clinical, and laboratory data 
on screening failures will be captured in a Screening Failure Results form and 
entered into the ACTG database.  
 
To avoid unnecessary delay in initiating TB treatment, screening evaluations for 
Step 1 and Step 2 may occur on the same day.  
 
Recruitment will occur through the study site(s) and may include referrals of TB 
participants from outlying TB clinics and local or regional mycobacteriology 
laboratories. Participants with a presumptive diagnosis of sputum smear positive 
or GeneXpert-positive pulmonary TB will be invited to screen for the study.  
 
NOTE: Some participants may be hospitalized during the screening period, at the 
discretion of the investigator, for the safety of the participant or to decrease risk 
of transmission to others.  
 
Pre-entry  
Only those participants who are expected to be enrolled in a treatment group will 
have this visit. At least 48 hours prior to the first dose of study medication, 
participants who will be enrolled in a treatment group will be admitted to the 
inpatient EBA unit at the study site to complete the pre-entry requirements. Two 
days prior to scheduled drug dosing, beginning at around 4pm ±1 hour, a 16-hour 
quantitative sputum collection will be performed. Participants who do not produce 
an overnight sputum sample of sufficient quality and quantity will be considered 
screen failures. However, if a participant’s failure to produce sufficient sputum 
appears to be due to poor technique rather than low volume of sputum 
production, this evaluation may be repeated. 
 
6.2.2 Entry Evaluations (Day 0) 
 
6.2.2.1 Step 1, Day 0 
 
Those participants registered to the study but not enrolled in a treatment 
group (i.e., Stages 1 or 2, Group 1 who do not meet Step 2 entry 
criteria; Stage 1, Groups 2 and 3; or Stage 2, Group 2 or 3 who do not 
meet Step 2 entry criteria) will only have sputum for phenotypic DST 
determination with MIC at this visit. This evaluation may be performed 
on sputum collected at Step 1 Day 0 or sputum collected at screening. 
Thus, the screening and Step 1 Day 0 visits may be combined for these 


 
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participants. After this evaluation is performed, the participant will be 
discontinued from the study. 
 
6.2.2.2 Step 2, Day 0 
 
Those participants enrolled in a treatment group will remain in the 
hospital until Day 8. Registration/randomization will occur on the day of 
study entry. A 16-hour quantitative sputum collection will be performed. 
Participants who do not produce an overnight sputum sample of 
sufficient quality and quantity on Step 2 Day 0 will be discontinued from 
the study (see section 8.1). However, if a participant’s failure to produce 
sufficient sputum appears to be due to poor technique rather than low 
volume of sputum production, this evaluation may be repeated. 
 
6.2.3 Post-Entry Evaluations (for participants who meet Step 2 entry criteria) 
 
Days 1-7 (Treatment) 
Participants must begin treatment within 24 hours after 
registration/randomization. Participants will receive their assigned dose of INH in 
the morning on an empty stomach, defined as nothing by mouth except water 
and study medications 2 hours pre-dose and 1 hour post-dose. 
 
Day 8 (Discharge) 
Those participants enrolled in a treatment group will be discharged from the 
hospital on Day 8. Upon discharge from the hospital and no later than Day 10, 
participants will be referred to the standard local TB treatment. 
 
Final Visit 
This visit will occur 14 (±3) days after the final dose of study medications to 
evaluate for evidence of delayed toxicity and to follow up on any adverse events 
(AEs) that occurred during the study.  
 
6.2.4 Discontinuation Evaluations 
 
Evaluations for Randomized or Registered Participants Enrolled to Step 2 Who 
Do Not Start Study Treatment 
All case report forms (CRFs) must be completed and keyed for the period up to 
and including Step 2 Day 0. 
 
Evaluations for Registered Participants Not Enrolled to Step 2  
All CRFs must be completed and keyed for the period up to and including Step 1 
Day 0. An off-study form will be completed for these participants at Step 1 Day 0. 
No premature discontinuation evaluations are needed.  
 


 
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Premature Study Discontinuation Evaluations  
If study withdrawal occurs, the participant will be asked to complete a premature 
discontinuation visit. Assessments to be performed at the premature 
discontinuation visit are listed in section 6.1. Participants who prematurely 
discontinue treatment will be prematurely discontinued from the study. 
 
6.3 
Instructions for Evaluations 
 
All clinical and laboratory information required by this protocol is to be present in the 
source documents. Sites must refer to the Source Document Guidelines on the DAIDS 
Web site for information about what must be included in the source document: 
https://www.niaid.nih.gov/sites/default/files/sourcedocappndx.pdf. 
 
All stated evaluations are to be recorded on the CRF and keyed into the database 
unless otherwise specified. This includes events that meet the International Conference 
on Harmonisation (ICH) definitions for a serious AE: 
 
• 
Results in death 
• 
Life-threatening 
• 
Requires inpatient hospitalization or prolongation of existing hospitalization 
• 
Results in persistent or significant disability/incapacity  
• 
Congenital anomaly/birth defect 
• 
Other important medical event (may not be immediately life-threatening or result in 
death or hospitalization but may jeopardize the participant or may require 
intervention to prevent one of the events listed above.  
 
To grade diagnoses, signs and symptoms, and laboratory results, sites must refer to the 
DAIDS Table for Grading the Severity of Adult and Pediatric Adverse Events (DAIDS AE 
Grading Table), Version 1.0, December 2004 (Clarification, August 2009), which can be 
found on the DAIDS RSC Web site: http://rsc.tech-res.com/clinical-research-
sites/safety-reporting/daids-grading-tables.  
 
Step 1 
 
6.3.1 Sputum Samples 
 
Spot Sputum Collection 
Spot sputum will be collected for the following: 
 
 
AFB Microscopy  
Direct microscopy for acid-fact bacilli will be performed and reported as negative, 
or as scanty, 1+, 2+, or 3+ positive, according to IUATLD scale. 
 
Genotypic DST with HAIN MTBDRplus 
Hain MTBDRplus testing for detection of INH resistance (inhA or katG mutations) 
and RIF resistance (rpoB mutations) will be performed. 


 
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Culture and Phenotypic DST Determination with MIC 
Phenotypic DST for INH and RIF using the proportion method. The MIC for INH 
will be determined. 
 
6.3.2 Hospitalization 
 
At the discretion of the investigator, a participant may be hospitalized during the 
screening period if necessary for the safety of the participant or to decrease risk 
of transmission to others. 
 
Step 2 
 
6.3.3 Documentation of HIV Status 
 
Section 4.3.5 provides assay requirements for HIV-1 status documentation. HIV 
status will not be reported on a CRF. 
 
6.3.4 Medical History 
 
The medical history must include all diagnoses identified by the ACTG criteria for 
clinical events and other diagnoses. For current criteria, refer to the appendix 
identified in the study CRF. Allergies to any medications and their formulations 
must be documented.  
 
6.3.5 Medication History 
 
A medication history must be present, including start and stop dates. The table 
below lists the medications that must be included in the history.  
 
Table 6.3.5-1: Medication History 
Category 
Timeframe 
Location 
TB treatment 
Complete history, 
including doses 
TB Medication History 
CRF 
ART 
Within 30 days prior to 
entry, including doses 
Antiretroviral Medication 
History CRF 
Prescription drugs for 
treatment of opportunistic 
infections 
Within 30 days prior to 
entry 
CRF 
Prescription drugs for 
prophylaxis of opportunistic 
infections 
Within 30 days prior to 
entry 
 
CRF 
Prescription drugs (other) 
Within 30 days prior to 
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CRF 


 
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Category 
Timeframe 
Location 
Alternative therapies 
Within 30 days prior to 
entry 
Record as yes/no on CRF; 
if yes, record details in 
source document 
Dietary supplements 
Within 30 days prior to 
entry 
CRF 
 
 
6.3.6  Clinical Assessments 
 
Complete Physical Examination 
A complete physical examination will include at a minimum an examination of the 
skin, head, mouth, neck and lymph nodes; auscultation of the chest; cardiac 
exam; abdominal exam; examination of the lower extremities for edema. The 
complete physical exam will also include signs and symptoms, diagnoses, and 
vital signs (temperature, pulse, respiration rate, and blood pressure). Neurologic 
examination to evaluate for peripheral neuropathy will be performed. 
 
Targeted Physical Examination 
A targeted physical examination will include vital signs (temperature, pulse, 
respiration rate, and blood pressure). The targeted physical examination is to be 
driven by any previously identified or new signs or symptoms, including 
diagnoses that the participant has experienced since the last visit. Neurologic 
examination to evaluate for peripheral neuropathy will be performed at the final 
study visit or, for those who discontinue the study early, at the discontinuation 
visit. 
 
Karnofsky Score 
This will be recorded at screening. 
 
Height 
Height will be recorded at screening only.  
 
Weight 
Weight will be recorded at all visits, except pre-entry. 
 
Signs and Symptoms 
At entry, all grades that occurred within 7 days prior to entry must be recorded; 
post-entry, only signs and symptoms Grade ≥2 must be recorded. In addition, all 
signs and symptoms that lead to a change in treatment must be recorded, 
regardless of grade. 
 
Diagnoses 
Record all diagnoses identified by the ACTG criteria for clinical events and other 
diseases.  
 


 
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Concomitant Medications 
All concomitant medications (as per section 5.4) started or stopped since the last 
visit must be recorded on the CRF. Alternative therapies will be recorded as a 
yes/no on the CRF. If yes, the details will be recorded in the source documents 
only. 
 
TB Medications 
On-study TB treatment: INH will be administered on Days 1-7. At each visit, 
record all modifications, including start/stop dates, initial doses, and participant-
initiated and/or health care provider-mandated modifications, and any permanent 
discontinuation of study TB treatment.  
 
Standard local TB treatment: Standard local TB treatment will start on Day 8 and 
no later than Day 10. Record all modifications, including start/stop dates, initial 
doses, participant-initiated and/or health care provider-mandated modifications, 
and any permanent discontinuation of TB medications. 
 
Antiretroviral Medications 
Record all modifications, including start/stop dates, initial doses, participant-
initiated and/or health care provider-mandated modifications, and any temporary 
holds or permanent discontinuations.  
 
6.3.7 Laboratory Evaluations 
 
Complete Blood Count with Differential 
Record all values regardless of grade for: hemoglobin, platelet count, white blood 
cell count, absolute neutrophil count.   
 
Complete Blood Chemistry Profile  
Record all values regardless of grade for: AST, ALT, alkaline phosphatase, total 
bilirubin, creatinine, potassium, and albumin.  
 
CD4+ Count (HIV-infected participants) 
For participants who are HIV-infected, a CD4+ count determination performed 
within 7 days prior to entry at a DAIDS-approved laboratory must be recorded. 
 
Pregnancy Test 
For women with reproductive potential: Serum or urine β-HCG. (Urine test must 
have a sensitivity of 15-25 mIU/mL.) 
 
NAT2 Genotype 
Both whole blood and saliva will be collected for this testing. The sample of saliva 
will be collected using an Oragene kit. 
 


 
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6.3.8 Chest X-ray 
 
A chest x-ray will be performed at screening, unless the results of a chest x-ray 
performed within 14 days prior to screening are available. 
 
6.3.9 Sputum Samples 
 
Spot Sputum Collection 
Spot sputum will be collected for the following: 
 
 
Genotypic DST (MTBDRsl)  
Among those participants with MDR-TB, Hain MTBDRsl testing for detection of 
fluoroquinolone and injectable TB drug resistance will be performed. 
 
Overnight Sputum Collection  
Sputum will be collected over 16 hours each night beginning at around 4pm ±1 
hour, and each participant’s overnight sputum samples will be pooled in an 
appropriate, clean container. This sputum will be used for the following: 
 
EBA Analysis by Solid Culture CFU Determination and Liquid MGIT Culture for 
TTD  
Sputum will be cultured on solid media, and CFU count will be determined for 
Groups 1 and 2 only. For all groups daily TTD determination will be done, and 
measured in hours.  
 
Start and stop times, total volume collected, and any interruptions in collection or 
temperature control problems will be recorded. 
 
6.3.10 Pharmacokinetic Sampling 
 
See section 10.0, Pharmacology Plan. Blood samples for study drug 
concentrations may be collected from an indwelling catheter, or if a catheter 
cannot be placed or maintained successfully, by direct venipuncture. 
 
6.3.11 Hospitalization 
 
At the discretion of the investigator, a participant may be hospitalized during the 
screening period if necessary for the safety of the participant or to decrease risk 
of transmission to others. 
 
All participants will be hospitalized for pre-entry and entry visits. Those 
participants who are randomized to receive treatment will be hospitalized during 
Days 1-7 to receive treatment and will be discharged from the hospital on Day 8. 
 


 
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7.0 
CLINICAL MANAGEMENT ISSUES 
 
7.1 
Toxicity  
 
Only toxicities related to study medications will be considered in the toxicity 
management section. The grading system for drug toxicities is located in the DAIDS AE 
Grading Table, Version 1.0, December 2004 (Clarification, August 2009), located at the 
DAIDS RSC web site: http://rsc.tech-res.com/clinical-research-sites/safety-
reporting/daids-grading-tables.  
 
7.1.1 Grade 1 
 
Study participants who develop a Grade 1 AE or toxicity may continue study 
medications at the discretion of the site investigator.  
 
If participants choose to discontinue study drug, the A5312 Clinical Management 
Committee (actg.cmcA5312@fstrf.org) should be notified within 48 hours. The 
site should complete the premature discontinuation evaluations, as per section 
6.1.2, within 7 days after stopping study medications.  
 
7.1.2 Grade 2 
 
Participants who develop a Grade 2 AE or toxicity may continue study drugs, at 
the discretion of the site investigator, and will be followed carefully.  
 
If participants choose to discontinue study drug, the A5312 Clinical Management 
Committee should be notified within 48 hours. The site should complete the 
premature discontinuation evaluations, as per section 6.1.2, within 7 days after 
stopping study medications.  
 
Grade 2 clinical or laboratory abnormalities that are deemed likely related to 
study drug will be followed to stabilization or resolution to Grade ≤1. Evaluations 
and the frequency of follow-up visits are at the discretion of the site investigator. 
The A5312 Clinical Management Committee should be notified of any 
requirements for continuing follow-up of toxicities beyond 7 days after stopping 
study medications. 
 
7.1.3 Grade 3  
 
Unless the site investigator has compelling evidence that the Grade 3 AE or 
toxicity is not related to the study drug, the participant must permanently 
discontinue the study drug. The A5312 Clinical Management Committee should 
be notified within 48 hours. The site should complete the premature 
discontinuation evaluations, as per section 6.1.2, within 7 days after stopping 
study medications.  
 


 
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Clinical or laboratory abnormalities of Grade 3 that are deemed likely related to 
study medication will be followed to stabilization, resolution to Grade ≤1, or return 
to baseline. Evaluations and the frequency of follow-up visits are at the discretion 
of the site investigator. The A5312 Clinical Management Committee should be 
notified of any requirements for continuing follow-up of toxicities beyond 7 days 
after stopping study medications. 
 
7.1.4 Grade 4 
 
Any participant with Grade 4 toxicity will be immediately and permanently 
discontinued from the study. The site should complete the premature 
discontinuation evaluations, as per section 6.1.2, within 7 days after stopping 
study medications.  
 
Clinical or laboratory abnormalities of Grade 4 that are deemed likely related to 
study medication will be followed to stabilization, resolution to Grade ≤1, or return 
to baseline. Evaluations and the frequency of follow-up visits are at the discretion 
of the site investigator. The A5312 Clinical Management Committee should be 
notified of any requirements for continuing follow-up of toxicities beyond 7 days 
after stopping study medications. 
 
7.2 
Other Diseases 
 
Participants who develop new medical diagnoses during the study will be counseled and 
given recommendations for referrals to medical providers, as necessary. 
 
7.3 
Pregnancy  
 
After study entry, female participants who become pregnant must immediately 
discontinue study treatment and complete the premature study discontinuation 
evaluations. They will be referred to their local clinic for standard TB care and prenatal 
care. Site personnel must notify the A5312 Clinical Management Committee 
(actg.cmca5312@fstrf.org) within 48 hours after receiving this information. Pregnancy 
outcomes will not be recorded.  
 
8.0 
CRITERIA FOR DISCONTINUATION 
 
8.1 
Premature Study Discontinuation 
 
• 
Inability to produce an overnight sputum sample of sufficient quality and quantity 
over a 16-hour collection period on Step 2 Day 0 
• 
Grade ≥3 drug-related AE or toxicity or any Grade 4 AE or toxicity (see section 7.1 
Toxicity) 
• 
Requirement for prohibited concomitant medications (see section 5.4) 
• 
Failure by the participant to comply with inpatient hospital stay 
• 
Pregnancy 


 
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• 
Nonadherence with one or more doses of study treatment 
• 
Development of another medical condition that makes the administration of one or 
more planned doses of study drug inadvisable 
• 
Inability to provide a study-required sputum sample at any time through day 8 
• 
Request by the participant to stop study treatment or withdraw 
• 
It is the investigator's judgment that it is no longer in the best interest of the 
participant to continue study participation. 
• 
At the discretion of the ACTG, IRB/EC, NIAID, Office for Human Research 
Protections (OHRP), or other government agencies as part of their duties, or the 
investigator.  
 
9.0 
STATISTICAL CONSIDERATIONS 
 
9.1 
General Design Issues 
 
This is a two-stage, two-step, phase IIa, open-label EBA and PK study in participants 
with sputum smear-positive pulmonary TB.  
 
No study drug is administered under Step 1. Data collected in Step 1: (a) determine 
eligibility to Step 2, and (b) allow characterization of INH MICs in 3 groups (secondary 
objective). Groups 1, 2, and 3 consist of participants infected with TB with inhA 
mutations, with DS-TB, and with TB with katG (with or without an inhA mutation) 
resistance-conferring mutations, respectively. 
  
The study’s primary objectives are addressed via Step 2 evaluations, through which the 
study estimates the 7-day EBA of INH among participants infected with TB with inhA 
mutations (Group 1) taking one of three doses of INH (5, 10, or 15 mg/kg), participants 
infected with TB with katG with or without inhA mutations (Group 3) taking 15 or 
20 mg/kg of INH (TTP only), and participants infected with DS-TB (Group 2) taking 
standard-dose INH (5 mg/kg daily). In addition, the association between PK parameters, 
such as AUC/MIC, and the EBA of INH will be examined. The total sample size for 
determination of participant-specific EBAs is set to 84 evaluable participants at 
minimum.  
 
The study will be conducted in two stages: Stage 1 is a feasibility pilot to ensure that 
recruitment can proceed at a reasonable pace and also to examine whether the estimate 
of SDs for the sample size calculations are reasonable. During Stage 1, 15 Group 1 
participants will be enrolled to Step 2, and they will be randomized 1:1:1 to a dose of 5, 
10, or 15 mg/kg of INH daily. During Stage 2, 33 additional participants in Group 1 will be 
randomized 1:1:1 to 5, 10, or 15 mg/kg until the accrual target of evaluable participants 
is reached.  
 
During Stage 1, which closed to accrual on March 26, 2015, 44 Group 2 participants 
enrolled to Step 1 only; these participants did not receive any study drug, but had 
sputum collected for MIC determination. During Stage 2, 16 participants in Group 2 who 
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daily (positive control). In addition, if the accrual target for Group 2, “Step 1 only” has not 
yet been met and the Group 2 participant does not meet Step 2 eligibility criteria, they 
may also enroll to Step 1. During Stage 2, 20 participants in Group 3 who meet the 
Step 2 entry criteria will enter Step 2 and will be randomized 1:1 to receive 15 or 20 
mg/kg of INH daily. In addition, if the accrual target for Group 3 “Step 1 only” has 
not yet been met and Group 3 participants do not meet Step 2 eligibility criteria, 
they may also enroll to Step 1. 
 
During Stages 1 and 2 combined, the maximum number of participants in Groups 1, 2, 
and 3 enrolling to Step 1 only are 70, 64, and 84, respectively. 
 
9.2 
Endpoints 
 
9.2.1 Primary Endpoints  
 
9.2.1.1 Daily decline in log10 CFU per mL sputum from baseline to Day 7 of 
study treatment, defined as EBA0-7 (CFU)  = [baseline log10 CFU per mL 
(mean of the pre-entry visit and entry visit sputum colony counts) – Day 
7 log10 CFU per mL]/7 (Groups 1 and 2) 
 
9.2.1.2 Daily decline in TTD from baseline to Day 7 of study treatment, defined 
as EBA0-7 (TTD) = [baseline TTD (mean of the pre-entry visit and entry 
visit TTDs) – Day 7 TTD]/7 (all groups). 
 
9.2.1.3 Daily log10 CFU per mL sputum and TTD from baseline to Day 7 of study 
treatment; area under the time-concentration curve (AUC) for INH; MIC 
of M. tuberculosis isolates against INH (Group 1 for CFU and TTD and 
Group 3 for TTD only) 
 
9.2.1.4 Grade 2 or higher drug-related adverse clinical or laboratory events (all 
groups) 
 
9.2.2 Secondary Endpoints  
 
9.2.2.1 Steady state PK parameters, including maximum concentration (Cmax), 
AUC0-24, and T1/2; NAT2 acetylator status (See Section 10.0) (all 
groups). All PK parameters will be measured from the PK sampling at 
Day 6 and NAT2 acetylator status will be determined based on 
specimens collected at Step 2 Day 0. 
 
9.2.2.2 INH MIC against M. tuberculosis isolates as determined by phenotypic 
DST (all groups). INH MIC will be determined from spot sputum 
collected at Step 1 Day 0. 
 
9.2.2.3 AUC/MICs which reach 50% of the mean EBA0-7 (CFU) and EBA0-7 
(TTD) among Group 2 participants (Group 1 for CFU and TTD and 
Group 3 for TTD only). INH MIC will be determined from spot sputum 


 
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collected at Step 1 Day 0 and AUC will be measured from the PK 
sampling at Day 6. 
 
9.2.2.4 The endpoints below are created separately based on log10 CFU and 
TTD. 
 
If the number of phases is the same for every dosing cohort:  
• 
EBA measured by early- and late-phase individual-based parameter 
estimates from nonlinear mixed effect models. The early- and late-
phase slopes are denoted as EBA0-2 and EBA2-7, respectively. 
Before fitting the model, both TTDs and log10 CFU from the pre-
evaluation and entry visits will be averaged and treated as the 
baseline TTD and log10 CFU (all groups). 
 
If the number of phases differs between every dosing cohort:  
• 
EBA measured by individual-based parameter estimates from linear 
or nonlinear mixed effect models. Before fitting the model, both 
TTDs and log10 CFU from the pre-evaluation and entry visits will be 
averaged and treated as the baseline TTD and log10 CFU. 
• 
(log10 CFU only) EBA measured by ratio of the following areas: 
numerator = AUC of observed log10 CFU over 7 days and 
denominator = baseline log10 CFU for each participant.  
 
9.2.3 Exploratory Endpoints 
 
9.2.3.1 Daily TTD and log10 CFU per mL sputum between baseline and Day 7. 
Both TTDs and log10 CFU from the pre-evaluation and entry visits will be 
averaged and treated as the baseline TTD and log10 CFU. 
 
9.2.3.2 NAT2 genotype results from the new PCR method using saliva sample; 
NAT2 genotype results from standard methods that use sequencing 
using whole blood sample. NAT2 acetylator status will be determined 
based on specimens collected at Step 2 Day 0. 
 
9.2.3.3 MTBDRsl result (i.e., binary resistance status of quinolone and 
aminoglycoside) based on sputum collected at Step 2 Day 0. 
 
9.3 
Randomization and Stratification 
 
No randomization takes place under Step 1. Participants in Groups 1 and 3 who are 
eligible for Step 2 will be randomized equally to the three and two doses, respectively. 
During Stage 2, participants in Group 2 who are eligible for Step 2 will be enrolled at a 
pace to try to keep enrollments into each dosing cohort about equal (on average enroll 
two Group 1 participants into Step 2, then one Group 2 participant into Step 2, etc.) by 
setting a recruitment limit for Group 2. The data manager and statisticians will manually 
adjust the limit routinely (e.g., every month or twice per month). Randomization will not 
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9.4 
Sample Size and Accrual 
 
Primary Objectives: 
 
One of the primary objectives is to estimate the distribution of the EBA0-7 (CFU) from 
each cohort in Group 1 (5, 10, and 15 mg/kg of INH for participants with an inhA 
mutation) and the EBA0-7 (CFU) from Group 2 (5 mg/kg of INH for participants without 
katG or inhA mutations). Another primary objective is to estimate the distribution of 
the EBA0-7 (TTP) from each cohort in Group 1, Group 2, and each cohort in Group 
3. The aim is to establish proof-of-concept for the higher doses of INH.  
 
Sample Size: 
 
The planned sample size is 16 participants per treatment cohort in Group 1 and Group 
2; participants discontinuing before the day 7 sample collection will be replaced.  This 
sample size is similar to that of other recent exploratory EBA studies.   
 
Here is some information about the likely precision of estimates that can be achieved 
with the planned sample size of 16 participants in this proof-of-concept study.  Among 
participants with DS-TB who were taking 300 mg doses of INH, the estimated mean 
EBA0-5 was 0.21 log10CFU/mL/day (n=16, SE 0.03, between-participant SD 0.12, 
coefficient of variation [CV] 57%) [41]. We assume the mean EBA0-7 (CFU) from Group 1 
is approximately half of EBA0-7 (CFU) from Group 2.  Further assuming constant CV, the 
table below gives the anticipated precisions (half-widths) of 95% confidence intervals 
(CIs) around estimates of log10CFU/mL/day for any one Group 1 cohort and for the 
Group 2 cohort, for sample sizes of 10, 16, and 20.  Because the MIC distribution may 
be more variable for Group 1, the table also shows anticipated CI widths for a Group 1 
cohort if the CV and SD are larger (114% and 0.120, respectively). 


 
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Table 9.4-1: Sample Size per Arm and Expected Half-width of 95% CI for the 
Hypothesized Mean Log10 CFU/mL Decrease per Day with a Range of Estimated 
CV and SD  
 
For Group 1 cohorts, the sample size of 16 is required for a two-sided 95% CI with a 
precision (half-width) of less than or equal to 0.064 with SDs between 0.060 and 0.120. 
This means that, for example, if the mean of EBA0-7 (CFU) from the 15 mg/kg of INH for 
participants with an inhA mutation is 0.1 and the SD is 0.12, there is 95% probability that 
the CI of 0.04 and 0.17 covers the true mean. 
 
Similarly, if the mean of EBA0-7 (CFU) from Group 2 is 0.2 and the SD is 0.12, there is 
95% probability that the CI of 0.14 and 0.26 covers the true mean. 
 
This sample size should allow for evaluation of the association between AUC/MIC and 
EBA0-7, one of the other primary analyses, with high precision, as the data from all 
experimental dosing cohorts will be pooled for this PK/PD analysis [9, 13, 15, 42]. 
 
For Group 3, the sample size of 10 per dosing cohort was selected since the 
analysis of EBA0-7 (TTP) per dosing cohort will be exploratory. Assuming the SD 
for Group 3 cohorts will be 6, which is the overall SD of EBA0-14 (TTP) from the 
previous ACTG EBA study (A5307, unpublished), a half-width of a 95% CI is 0.086 
with the sample size of 10. This means, for example, if the mean of EBA0-7 (TTP) 
from a dosing cohort in Group 3 is 13, there is 95% probability that the CI of 9.28 
and 16.7 covers the true mean. A possible dosing effect for this group will be 
examined through visual displays.  
 
Group 
Sample 
Size per 
Group 
Hypothesized Mean 
log10CFU/mL/day 
CV 
SD 
Expected 
Half-width
of 95% CI 
Any one Group 1 cohort 
10 
0.105 
57% 
0.060 
0.043 
16 
0.105 
57% 
0.060 
0.032 
20 
0.105 
57% 
0.060 
0.028 
Any one Group 1 cohort 
10 
0.105 
114% 
0.120 
0.086 
16 
0.105 
114% 
0.120 
0.064 
20 
0.105 
114% 
0.120 
0.056 
Group 2 
10 
0.210 
57% 
0.120 
0.086 
16 
0.210 
57% 
0.120 
0.064 
20 
0.210 
57% 
0.120 
0.056 


 
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Accrual: 
During Stage 1, five participants were recruited to each cohort in Group 1. During Stage 
2, 11 additional participants will be recruited to each cohort in Group 1, 20 participants 
in Group 3, and 16 participants in Group 2 will be recruited. In the final analyses, the 
data from both stages will be combined. The time to accrual for this study (Stage 1 and 2 
combined) is approximately 4 years. 
 
To maintain desired precision of estimation (primary analyses), participants who 
discontinue the study prior to the Day 7 evaluations will be replaced. All data from every 
randomized participant will be stored in the study database, and will be examined for the 
final analyses. 
 
Participants enrolling to Step 1 only will be considered evaluable if all data that are 
required are available at screening and/or entry regardless of subsequent known or 
unknown loss to follow up. 
 
Table 9.4-2:  A5312 Accrual Targets 
 
Resistance  
Mutation 
Participants 
Completing Step 1 
Only1 
Participants Completing  
Step 1 and Step 22 
Total Participants 
 
Stage 1 & Stage 2 
Combined 
Stage 1 
Stage 2 
Group 
1 
inhA 
Minimum of 16 to a 
maximum of 703 
15 
(5 per dosing 
cohort) 
33 (11 
per dosing 
cohort) 
Step 1 only: maximum 
of 703 
Steps 1 and 2: 48 
Group 
2 
Neither inhA 
nor katG 
Minimum of 48 to a 
maximum of 644 
- 
16 
Step 1 only: maximum 
of 644 
Steps 1 and 2: 16 
Group 
3 
katG with or 
without inhA  
Minimum of 64 to 
maximum of 84 
- 
20 (10 per 
dosing 
cohort) 
Step 1 only: maximum 
of 845 
Steps 1 and 2: 20 
1 Participants completing Step 1 only (participants who were considered for Step 2 but could not 
enter Step 2, or participants who were considered for Step 1 only) will provide sputum for 
determination of MIC distribution, and then be discontinued from the study. 
2 Participants completing Step 1 and Step 2 will provide sputum for determination of MIC  
   distribution and participate in the treatment part of the study. 
3 Once the Group 1 accrual target is reached for participants completing Steps 1 and 2, accrual 
beyond the minimum for those completing Step 1 only will stop.  
4 Once the Group 2 accrual target is reached for participants completing Steps 1 and 2, accrual 
beyond the minimum for those completing Step 1 only will stop. 
 5 Once the Group 3 accrual target is reached for participants completing Steps 1 and 2, 
accrual beyond the minimum for those completing Step 1 only will stop.  


 
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9.5 
Monitoring 
 
Accrual reports will be created and distributed to the protocol team periodically (e.g., 
once a month) to ensure that the total target number of evaluable participants is 
enrolled. The report will include information such as screening, accrual, and retention. 
The first Tuberculosis Transformative Science Group (TB TSG) Study Monitoring 
Committee (SMC) review took place 6 months after the study opening, and 
feasibility of this study was reviewed. 
 
At the second SMC review, the TB TSG SMC reviewed the SDs of the EBA0-7 (CFU) 
among participants in Group 1 to evaluate if the estimates of SDs used for the sample 
size calculations were reasonable (i.e., the SD of the EBA0-7 (CFU) from Group 1 varies 
between 0.06 and 0.12). If the SD from each cohort in Group 1 was larger than 
expected, the sample size could have been increased up to 22 per cohort, to improve 
the precision of 95% CIs around mean EBA0-7 (CFU) for Group 1 cohorts. With the 
increased sample size of 22, a half-width will be reduced to less than or equal to 0.053 
with SDs between 0.060 and 0.120. However, the SMC determined the sample size 
increase from 16 to 22 in Group 1 cohorts was not necessary. 
 
During the study, the safety and tolerability of the study medication will be monitored by 
means of adverse event reports (AER) and toxicity reports presenting laboratory and 
clinical data. The report will be stratified by group, and within Group 1, by dose. It is 
required that these data be entered into the database within two business days of the 
time at which the results of the laboratory tests or clinical examinations become 
available. The study team will discuss these reports on regularly scheduled conference 
calls or by e-mail and any concerns will be presented to the TB TSG SMC. The TB TSG 
SMC will also review the DAIDS Safety Monitoring Report every 3 months. 
 
9.6 
Analyses 
 
9.6.1 Analyses of Primary Endpoints 
 
9.6.1.1 Descriptive statistics of EBA0-7 (CFU) for each of the cohorts in 
Groups 1 and 2 will be reported in a table. Box plots and a plot with 
four CIs will be created. 
 
9.6.1.2 Descriptive statistics of EBA0-7 (TTD) for each of the cohorts will be 
reported in a table. Box plots and a plot with six CIs will be created. 
 
9.6.1.3 The relationship between the AUC/MIC and the EBA will be evaluated 
with linear or nonlinear models, adjusting for other covariates, such as 
baseline log10 CFU per mL. PK/PD modeling will be performed to 
evaluate the relationship between drug concentrations and rate or 
magnitude of bacterial decline. The distributions of PK/PD parameters 
will be examined first and appropriate transformations will be applied if 
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9.6.1.4 Grade 2 or higher AEs will be reported in a tabular form by cohorts.  
 
9.6.2 Analyses of Secondary Endpoints 
 
9.6.2.1 INH PK parameters will be estimated using noncompartmental analysis 
and the descriptive statistics will be reported by NAT2 genotype status 
(See section 10.0). 
 
9.6.2.2 The distribution of INH MIC against M. tuberculosis isolates with inhA 
mutation, katG mutation, or neither of these mutations will be reported. 
 
9.6.2.3 The AUC/MIC that achieves 50% of the mean EBA in Group 2 will be 
estimated and designated the “Target AUC/MIC”. A Monte Carlo 
simulation will be performed using the MIC distribution (Group 1), NAT2 
genotype distribution (Groups 1 and 2), and distribution of AUC values 
(Groups 1 and 2) associated with each dose and put to estimate the 
proportion of participants who have TB with an inhA mutation in a 
population would be expected to achieve the target AUC/MIC with 5, 10, 
or 15 mg/kg daily. As exploratory analysis, the same analysis will be 
performed for Group 3 to determine which proportion of 
individuals with TB with a katG mutation would be expected to 
achieve the target AUC/MIC with a dose of 15 or 20 mg/kg daily. 
 
9.6.2.4 The same analysis below will be conducted separately based on log10 
CFU and TTD. If the number of phases is the same for every dosing 
cohort:  
 
• 
Six bi-exponential models for log10 CFU and four bi-exponential 
models will be fit in order to estimate the “early” and “late” phase 
slopes for each cohort. Since this is an INH mono-therapy study, 
there may be an inflection point at Day 2 after the initiation of INH 
treatment.  
 
If the number of phases is not the same for every dosing cohort:  
• 
Six linear or nonlinear mixed effect models for log10 CFU and four 
linear or nonlinear mixed effect models for TTD will be fit in order 
to estimate treatment effect for each cohort.  
• 
(For log10 CFU only): Another approach will be taken to utilize the 
area between baseline CFU per mL and the CFU curve (ABBCC) for 
each participant, as measured using the trapezoidal rule. Since 
baseline CFU per mL may differ substantially between groups, the 
ABBCC will be expressed as a proportion of the total area under the 
baseline CFU per mL. The descriptive statistics will be reported for 
each cohort. 
 


 
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9.6.3 Analyses of Exploratory Endpoints 
 
9.6.3.1 Daily log10 CFU will be plotted against daily TTD and the correlation 
between these outcomes will be evaluated. 
 
9.6.3.2 The ability of the saliva test to accurately characterize acetylator status 
(fast, intermediate, or slow) as determined by sequencing (gold 
standard) will be evaluated. 
 
9.6.3.3 Prevalence of quinolone and aminoglycoside resistance will be 
reported in a table. 
 
10.0 
PHARMACOLOGY PLAN 
 
10.1 
Pharmacology Objectives 
 
See sections 1.2.2 and 1.3.1. 
 
10.2 
Pharmacology Study Design 
 
10.2.1 Methods and Timing for Assessing, Recording, and Analyzing PK Outcome 
Measures 
 
Intensive PK sampling will be performed on Day 6 of Step 2 when INH is at 
steady state, with blood collected pre-dose and at 0.5, 1, 2, 4, 6, 8, 12, and 24 
hours post-dose. PK samples are to be collected at the specified time points 
within the allowed applicable window periods as follows—pre‐dose: 0‐10 
minutes before dose; 0.5 hours to 8 hours post‐dose: ±10 minutes of 
dosing time; 12 hours and 24 hours post‐dose: ±15 minutes of dosing time 
and prior to next dose. The INH MIC for M. tuberculosis for each individual will 
be determined and AUC/MIC for each study participant will be estimated, as this 
is the PD parameter that correlates best with efficacy for this drug against M. 
tuberculosis.   
 
10.2.2 PK Evaluations 
 
PK parameters for INH will be derived from plasma concentration versus time 
data. Samples will be drawn on a specified study day at optimized sampling 
times, as per section 10.2.1. The PK parameters to be assessed include: 
 
• 
AUC0-24 – area under the plasma concentration-time curve in one dosing 
interval over 24 hours;  
• 
Cmax – maximum observed plasma concentration; 
• 
Cmin – minimum observed plasma concentration; 
• 
Tmax – time of maximum observed plasma concentration; 
• 
T1/2 – elimination half-life; and 
• 
CL/F – oral clearance. 


 
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Individual participant PK parameter values will be derived by noncompartmental 
methods using a validated PK program. In addition, PK/PD modeling will be 
performed to evaluate the relationship between drug concentrations and rate or 
magnitude of bacterial decline. Dates, times, amounts, and fasted/fed status for 
the last three INH doses will be collected on CRFs. Fasted is defined as nothing 
by mouth except water and study medications 2 hours pre-dose and 1 hour post-
dose. In addition, information that could explain unusual PK values (e.g., 
vomiting after the dose, not fasting when taken) or reasons for a missed sample 
(e.g., dropped tube, IV stopped working) are to be reported. 
 
10.2.3 Pharmacogenomics: Host Genetic Analysis 
 
NAT2 genotyping will be performed to determine acetylator status (fast, medium, 
or slow) and will be used as an explanatory variable in PK analyses. 
 
10.2.4 Pharmacokinetics: Blood Collection and Processing 
 
Blood samples for study drug concentrations will be collected from an indwelling 
catheter, or, if a catheter cannot be placed successfully, by direct venipuncture. If 
a catheter is used for blood collection, then prior to blood sampling, the fluid in 
the catheter will be completely withdrawn at each sampling time and discarded.  
Each sample will require approximately 4 mL of blood be drawn into one 
Vacutainer tube.  
 
10.2.5 Sample Processing and Storage 
 
Detailed blood processing, handling, and storage procedures can be found in the 
A5312 Laboratory Processing Chart (LPC).  
 
Plasma samples will be processed and frozen immediately in an upright position 
at -70ºC or colder, in storage boxes. These samples will be used only for PK 
studies. They will be stored frozen until study completion. During frozen storage,  
samples will be labeled with coded sample and volunteer identifiers, and not with 
name.  
 
10.2.6 Laboratory Performing the Assays 
 
Plasma INH concentrations will be determined by a validated high-performance 
liquid chromatography procedure performed according to written standard 
operating procedures. The intraday accuracy and intraday precision will be 
obtained with quality control samples, which will be analyzed concurrently with 
each set of volunteer samples. Quality control procedures will be in place to 
ensure stability of sample materials. 
 


 
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10.3 
Primary and Secondary Data, Modeling, and Data Analysis 
 
Refer to section 10.2.2 for definitions of AUC, Cmax, CL/F, Tmax, and T1/2 for this analysis. 
 
Data will initially be analyzed using noncompartmental methods. The Cmax, Tmax, and Cmin 
will be determined for each participant by inspection of the serum concentration-versus-
time graphs. The AUC from time zero to the time of the last quantifiable concentration 
(AUC0-t) will be determined by the linear trapezoidal rule.  
 
PK/PD modeling will be performed to evaluate the relationship between drug 
concentrations and rate or magnitude of bacterial decline. A detailed plan of PK and 
PK/PD data analysis is included in the Statistical Analysis Plan. 
 
10.4 
Anticipated Outcomes 
 
See Hypothesis 1.1.1. 
 
NAT2 acetylator status will explain a large proportion of the variability in INH PK 
estimates. 
 
11.0 
DATA COLLECTION AND MONITORING AND ADVERSE EVENT REPORTING 
 
11.1 
Records to Be Kept 
 
CRFs will be provided for each participant. Participants must not be identified by name 
on any CRFs. Participants will be identified by the patient identification number (PID) 
and study identification number (SID) provided by the ACTG DMC upon randomization.  
 
11.2 
Role of Data Management 
 
11.2.1 Instructions concerning the recording of study data on CRFs will be provided by 
the ACTG DMC. Each clinical research site is responsible for keying the data in a 
timely fashion. 
 
11.2.2 It is the responsibility of the ACTG DMC to assure the quality of computerized 
data for each ACTG study. This role extends from protocol development to 
generation of the final study databases. 
 
11.3 
Clinical Site Monitoring and Record Availability 
 
11.3.1 Site monitors under contract to the NIAID will visit participating clinical research 
sites to review the individual participant records, including consent forms, CRFs, 
supporting data, laboratory specimen records, and medical records (physicians’ 
progress notes, nurses’ notes, individuals’ hospital charts), to ensure protection 
of study participants, compliance with the protocol, and accuracy and 
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ensure that regulatory requirements are being followed and sites’ pharmacies to 
review product storage and management. 
 
11.3.2 The site investigator will make study documents (e.g., consent forms, drug 
distribution forms, CRFs) and pertinent hospital or clinic records readily available 
for inspection by the local IRB/EC, the site monitors, the NIAID, the OHRP, and 
other local, U.S., and international regulatory entities for confirmation of the 
study data.  
 
11.4 
Expedited Adverse Event Reporting to DAIDS 
  
11.4.1 
Adverse Event Reporting to DAIDS 
 
Requirements, definitions and methods for expedited reporting of AEs are 
outlined in Version 2.0 of the DAIDS EAE Manual, which is available on the 
RSC website at http://rsc.tech-res.com/clinical-research-sites/safety-
reporting/manual. 
 
The DAIDS Adverse Events Reporting System (DAERS), an internet-based 
reporting system, must be used for expedited AE reporting to DAIDS. In the 
event of system outages or technical difficulties, expedited AEs may be 
submitted via the DAIDS EAE Form. For questions about DAERS, please 
contact DAIDS-ES (now part of the NIAID Clinical Research Management 
System) at CRMSsupport@niaid.nih.gov. Site queries may also be sent from 
within the DAERS application itself. 
 
Sites where DAERS has not been implemented will submit expedited AEs by 
documenting the information on the current DAIDS EAE Form. This form is 
available on the RSC website at http://rsc.tech-res.com/clinical-research-
sites/safety-reporting/daids/paper-eae-reporting. For questions about EAE 
reporting, please contact the RSC (DAIDSRSCSafetyOffice@tech-res.com). 
 
11.4.2 
Reporting Requirements for this Study 
 
The SAE Reporting Category, as defined in Version 2.0 of the DAIDS EAE 
Manual, will be used for this study. 
 
The study agent for which expedited reporting is required is isoniazid.  
In addition to the EAE Reporting Category identified above, other AEs that must 
be reported in an expedited manner are all hepatic failures.  
 
11.4.3 
Grading Severity of Events 
The DAIDS Table for Grading the Severity of Adult and Pediatric Adverse 
Events (DAIDS AE Grading Table) Version 1.0 - December 2004 (Clarification 
dated August 2009) is used for this study and is available on the RSC website 
at http://rsc.tech-res.com/clinical-research-sites/safety-reporting/daids-
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11.4.4 
Expedited AE Reporting Period 
 
The expedited AE reporting period for this study is as per the EAE manual.  
 
After the protocol-defined AE reporting period, unless otherwise noted, only 
suspected, unexpected serious adverse reactions (SUSARs), as defined in 
Version 2.0 of the EAE Manual, will be reported to DAIDS if the study staff 
become aware of the events on a passive basis (from publicly available 
information). 
 
12.0 
PARTICIPANTS 
 
12.1 
Institutional Review Board (IRB) Review and Informed Consent 
 
This protocol and the informed consent documents (Appendix I, Appendix II, Appendix 
III) and any subsequent modifications will be reviewed and approved by the IRB or EC 
responsible for oversight of the study. A signed consent form will be obtained from the 
participant. The consent form will describe the purpose of the study, the procedures to 
be followed, and the risks and benefits of participation. A copy of the consent form will 
be given to the participant, and this fact will be documented in the participant’s record. 
 
12.2 
Participant Confidentiality 
 
All laboratory specimens, evaluation forms, reports, and other records that leave the site 
will be identified by coded number only to maintain participant confidentiality. All records 
will be kept locked. All computer entry and networking programs will be done with coded 
numbers only. Clinical information will not be released without written permission of the 
participant, except as necessary for monitoring by ACTG, IRB/EC, the NIAID, the OHRP, 
or other local, U.S., and international regulatory entities as part of their duties. 
 
12.3 
Study Discontinuation 
 
The study may be discontinued at any time by the ACTG, IRB/EC, the NIAID, the OHRP, 
or other government agencies as part of their duties to ensure that research participants 
are protected.  
 
13.0 
PUBLICATION OF RESEARCH FINDINGS 
 
Publication of the results of this trial will be governed by ACTG policies.  
 


 
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14.0 
BIOHAZARD CONTAINMENT 
 
Transmission of HIV and other blood borne pathogens can occur through contact with 
contaminated needles, blood, and blood products. Respiratory pathogens such as 
Mycobacterium tuberculosis (MTB) are transmitted by inhalation of droplet nuclei. 
Appropriate blood, secretion, and respiratory precautions will be employed by all 
personnel in the collection of clinical samples and the shipping and handling of all clinical 
samples and isolates for this study, as currently recommended by the Centers for 
Disease Control and Prevention (CDC) in the United States and the World Health 
Organization (WHO) internationally.  
 
All protocol specimens will be shipped using packaging that meets requirements 
specified by the International Air Transport Association Dangerous Goods Regulations 
for UN 3373, Biological Substance, Category B, and Packing Instruction 650. Culture 
isolates, if obtained in this study, are to be shipped as specified for UN 2814 Category A 
Infectious Substances.  
 
Refer to individual carrier guidelines (e.g., Federal Express or Airborne) for specific 
instructions and to the ACTG/IMPAACT Laboratory Technologists Committee Guidelines 
for Shipment and Receipt of Category A Infectious Substances and Category B 
Biological Substances Shipments and Instructions for Overnight Shipments documents 
at: http://www.hanc.info/labs/labresources/procedures/Pages/actnShippingDemo.aspx  
 
Infection control for active TB cases and good laboratory practices for MTB isolation and 
storage of Mycobacterium isolates will be according to ACTG/IMPAACT policies and 
procedures, CDC/WHO guidance, and local policies and practices to minimize TB 
transmission. 
 
 


 
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15.0 
REFERENCES 
 
1. World Health Organization. Multidrug and extensively drug-resistant TB (M/XDR-TB): 
2010 global report on surveillance and response. WHO/HTM/TB/2010.3.  
2. Mitnick CD, Castro KG, Harrington M, Sacks LV, Burman W. Randomized trials to 
optimize treatment of multidrug-resistant tuberculosis. PLoS Med 2007;4(11):e292.  
3. Diacon AH, Pym A, Grobusch M, et al. The diarylquinoline TMC207 for multidrug-
resistant tuberculosis. N Engl J Med 2009;360(23):2397-405.  
4. World Health Organization. Treatment of tuberculosis guidelines. 4th edition. 
WHO/HTM/TB/2009.420.  
5. Nolan CM, Goldberg SV. Treatment of isoniazid-resistant tuberculosis with isoniazid, 
rifampin, ethambutol, and pyrazinamide for 6 months. Int J Tuberc Lung Dis 
2002;6(11):952-8.  
6. Warren RM, Streicher EM, Gey van Pittius NC, et al. The clinical relevance of 
Mycobacterial pharmacogenetics. Tuberculosis (Edinb) 2009;89(3):199-202.  
7. Donald PR, Sirgel FA, Botha FJ, et al. The early bactericidal activity of isoniazid 
related to its dose size in pulmonary tuberculosis. Am J Respir Crit Care Med 
1997;156(3 Pt 1):895-900.  
8. Schaaf HS, Marais BJ, Hesseling AC, Gie RP, Beyers N, Donald PR. Childhood 
drug-resistant tuberculosis in the Western Cape Province of South Africa. Acta 
Paediatr 2006;95(5):523-8.  
9. Wilkins JJ, Langdon G, McIlleron H, Pillai GC, Smith PJ, Simonsson US. Variability 
in the population pharmacokinetics of isoniazid in South African tuberculosis 
patients. Br J Clin Pharmacol 2011;72(1):51-62.  
10. Gumbo T, Louie A, Liu W, et al. Isoniazid bactericidal activity and resistance 
emergence: integrating pharmacodynamics and pharmacogenomics to predict 
efficacy in different ethnic populations. Antimicrob Agents Chemother 
2007;51(7):2329-36.  
11. Jayaram R, Shandil RK, Gaonkar S, et al. Isoniazid pharmacokinetics-
pharmacodynamics in an aerosol infection model of tuberculosis. Antimicrob Agents 
Chemother 2004;48(8):2951-7.  
12. Cynamon MH, Zhang Y, Harpster T, Cheng S, DeStefano MS. High-dose isoniazid 
therapy for isoniazid-resistant murine Mycobacterium tuberculosis infection. 
Antimicrob Agents Chemother 1999;43(12):2922-4.  
13. Donald PR, Parkin DP, Seifart HI, et al. The influence of dose and N-
acetyltransferase-2 (NAT2) genotype and phenotype on the pharmacokinetics and 
pharmacodynamics of isoniazid. Eur J Clin Pharmacol 2007;63(7):633-9.  
14. Vilcheze C, Jacobs WR,Jr. The mechanism of isoniazid killing: clarity through the 
scope of genetics. Annu Rev Microbiol 2007;61:35-50.  


 
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15. Schaaf HS, Victor TC, Engelke E, et al. Minimal inhibitory concentration of isoniazid 
in isoniazid-resistant Mycobacterium tuberculosis isolates from children. Eur J Clin 
Microbiol Infect Dis 2007;26(3):203-5.  
16. Abate G, Hoffner SE, Thomsen VO, Miorner H. Characterization of isoniazid-
resistant strains of Mycobacterium tuberculosis on the basis of phenotypic properties 
and mutations in katG. Eur J Clin Microbiol Infect Dis 2001;20(5):329-33.  
17. Kinzig-Schippers M, Tomalik-Scharte D, Jetter A, et al. Should we use N-
acetyltransferase type 2 genotyping to personalize isoniazid doses? Antimicrob 
Agents Chemother 2005;49(5):1733-8.  
18. Kubota R, Ohno M, Hasunuma T, Iijima H, Azuma J. Dose-escalation study of 
isoniazid in healthy volunteers with the rapid acetylator genotype of arylamine N-
acetyltransferase 2. Eur J Clin Pharmacol 2007;63(10):927-33.  
19. Selkon JB, Devadatta S, Kulkarni KG, et al. The emergence of isoniazid-resistant 
cultures in patients with pulmonary tuberculosis during treatment with isoniazid alone 
or isoniazid plus pas. Bull World Health Organ 1964;31:273-94.  
20. Van Deun A, Maug AK, Salim MA, et al. Short, Highly Effective and Inexpensive 
Standardized Treatment of Multidrug-resistant Tuberculosis. Am J Respir Crit Care 
Med 2010;182(5):684-92. 
21. Reider HL, Van Deun A. Rationale for high-dose isoniazid in the treatment of 
multidrug-resistant tuberculosis. Int J Tuberc Lung Dis 2017;21:123-4. 
22. Kuaban C, Noeske J, Rieder HL, Ait-Khaled N, Abena Foe JL, Trebucq A. High 
effectiveness of a 12-month regimen for MDR-TB patients in Cameroon. Int J 
Tuberc Lung Dis 2015;19:517-24.  
23. Piubello A, Harouna SH, Souleymane MB. High cure rate with standardised 
short-course multidrug-resistant tuberculosis treatment in Niger: no relapses. 
Int J Tuberc Lung Dis 2014;18:1188-94. 
24. Katiyar SK, Bihari S, Prakash S, Mamtani M, Kulkarni H. A randomised controlled 
trial of high-dose isoniazid adjuvant therapy for multidrug-resistant tuberculosis. Int J 
Tuberc Lung Dis 2008;12(2):139-45.  
25. van der Watt JJ, Harrison TB, Benatar M, Heckmann JM. Polyneuropathy, anti-
tuberculosis treatment and the role of pyridoxine in the HIV/AIDS era: a systematic 
review. Int J Tuberc Lung Dis 2011;15(6):722-8.  
26. Petty TL, Mitchell RS. Successful treatment of advanced isonizid- and streptomycin-
resistant pulmonary tuberculosis with ethionamide, pyrazinamide, and isoniazid. Am 
Rev Respir Dis 1962;86:503-12.  
27. The results from twelve to thirty-six months in patients submitted to two studies of 
primary chemotherapy for pulmonary tuberculosis in East Africa. Tubercle 
1969;50(3):233-56.  
28. Donald PR, Schoeman JF, Van Zyl LE, et al. Intensive short course 
chemotherapy in the management of tuberculous meningitis. Int J Tuberc 
Lung Dis. 1998;2(9):704-11. 


 
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29. Girling DJ, The hepatic toxicity of antituberculosis regimens containing 
isoniazid, rifampicin and pyrazinamide. Tubercle. 1978;59(1):13-32. 
30. Trébucq A, Schweobel V, Kashongwe Z, et al. Treatment outcome with a short 
multidrug-resistant tuberculosis regimen in nine African countries. Int J 
Tuberc Lung Dis 2018;22:17-25. 
31. World Health Organization. WHO treatment guidelines for isoniazid-resistant 
tuberculosis: Supplement to the WHO treatment guidelines for drug-resistant 
tuberculosis. WHO/CDS/TB/2018.7. 
32. Peloquin CA, Namdar R, Dodge AA, Nix DE. Pharmacokinetics of isoniazid under 
fasting conditions, with food, and with antacids. Int J Tuberc Lung Dis. 
1999;3(8):703-10. 
33. Ellard GA. The potential clinical significance of the isoniazid acetylator phenotype in 
the treatment of pulmonary tuberculosis. Tubercle 1984;65(3):211-27. 
34. Baciewicz AM, Self TH. Isoniazid interactions. South Med J. 1985;78(6):714-8. 
35. Kay L, Kampmann JP, Svendsen TL, et al. Influence of rifampicin and isoniazid on 
the kinetics of phenytoin. Br J Clin Pharmacol. 1985;20(4):323-6. 
36. Ling DI, Zwerling AA, Pai M. Rapid diagnosis of drug-resistant TB using line probe 
assays: from evidence to policy. Expert Rev Respir Med 2008;2(5):583-8.  
37. World Health Organization. Molecular line probe assays for rapid screening of 
patients at risk of multidrug-resistant tuberculosis (MDR-TB). Policy statement. 2008.  
38. Diacon AH, Dawson R, Hanekom M, et al. Early bactericidal activity and 
pharmacokinetics of PA-824 in smear-positive tuberculosis patients. Antimicrob 
Agents Chemother 2010;54(8):3402-7.  
39. Diacon AH, Patientia RF, Venter A, et al. Early bactericidal activity of high-dose 
rifampin in patients with pulmonary tuberculosis evidenced by positive sputum 
smears. Antimicrob Agents Chemother 2007;51(8):2994-6.  
40. Rustomjee R, Diacon AH, Allen J, et al. Early bactericidal activity and 
pharmacokinetics of the diarylquinoline TMC207 in treatment of pulmonary 
tuberculosis. Antimicrob Agents Chemother 2008;52(8):2831-5.  
41. Hafner R, Cohn JA, Wright DJ, et al. Early bactericidal activity of isoniazid in 
pulmonary tuberculosis. Optimization of methodology. The DATRI 008 Study Group. 
Am J Respir Crit Care Med 1997;156(3 Pt 1):918-23.  
42. Donald PR, Diacon AH. The early bactericidal activity of anti-tuberculosis drugs: a 
literature review. Tuberculosis (Edinb) 2008;88 Suppl 1:S75-83.  
 
 
 


 
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APPENDIX I: SAMPLE INFORMED CONSENT FOR PROTOCOL A5312, STAGE 1 
 
DIVISION OF AIDS  
AIDS CLINICAL TRIALS GROUP (ACTG) 
 
The Early Bactericidal Activity of High-Dose or Standard-Dose Isoniazid among Adult 
Participants with Isoniazid-Resistant or Drug-Sensitive Tuberculosis 
 
 
INTRODUCTION 
 
You are being asked to take part in this research study because you have pulmonary 
tuberculosis (TB), a bacterial infection in your lungs. This research study is conducted by the 
AIDS Clinical Trials Group (ACTG), which is a research organization based in the United States. 
Although the name contains the word “AIDS”, this study is not about research on AIDS or HIV. 
This study is sponsored by the United States National Institutes of Health (NIH). The doctor in 
charge of this study at this site is: (insert name of Principal Investigator). Before you decide if 
you want to be a part of this study, we want you to know about the study.  
 
This is a consent form. It gives you information about this study. The study staff will talk with you 
about this information. You are free to ask questions about this study at any time. If you agree to 
take part in this study, you will be asked to sign this consent form. You will get a copy to keep. 
 
 
WHY IS THIS STUDY BEING DONE? 
 
Isoniazid (INH) is a drug commonly used to treat TB worldwide. Sometimes, the bacteria that 
cause TB can become resistant to INH. Resistance means that bacteria have adapted to a drug 
and are able to live in the presence of the drug. When TB becomes resistant to INH, INH does 
not work as well at fighting the bacteria. This study will treat people with INH-resistant TB with 
different doses of INH to see if INH can still fight the bacteria if we just increase the dose. We 
will compare how well the drug works at higher doses for participants who have resistant TB to 
how well the drug works at regular doses for participants who have TB that is not resistant. The 
study will also compare the safety and tolerability of the different doses of INH. Tolerability is 
how well people can put up with the side effects of a drug. Using increased doses of INH to treat 
TB that is resistant to INH is experimental and has not been approved by regulatory authorities. 
While there is some evidence that this approach will work, this has not yet been proven. 
 
This study will be done in two stages. Stage 1 is a pilot study. A pilot study is a small study that 
is done before a larger study, to help determine if a larger study will be possible.  This pilot 
study is a small study that will help us determine if it will be possible to enroll enough 
participants into Stage 2, which is the larger stage of this study. You will be enrolled in Stage 1. 
If Stage 1 is successful, then Stage 2 will begin. 
 
 


 
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WHAT DO I HAVE TO DO IF I AM IN THIS STUDY? 
 
After you have signed this consent form, you will have a screening visit. For this screening visit, 
your study doctor may decide you need to be admitted to the hospital. If you have stopped 
taking INH recently, you may need to be admitted to the hospital for up to 7 days before 
screening so that there is time for the INH to wash out of your body. During the screening, you 
will be asked to provide sputum (cough up phlegm). That sputum will be checked for the 
bacteria that cause TB. If they are found, your sputum will be tested to see if the TB bacteria in 
your body are resistant to INH and if it is low-level or high-level resistance. (With low-level 
resistance, the bacteria are not as resistant to INH as they are with high-level resistance.) 
Depending on the result of this test, you will be assigned to a group as follows:  
 
• 
Group 1: Low Level INH Resistance 
 
If you have low-level INH resistance but you do not meet all eligibility criteria, and you 
are one of the first 16 to 70 participants in this group, you will be enrolled in the study for 
one day only and you will be asked to provide a sputum sample. The sample you 
provide will help us see how much INH is needed to prevent your TB from growing in a 
test tube. After you provide this sputum sample, you will be finished with the study. You 
will not receive INH treatment. Instead, you will be referred to receive standard TB 
treatment outside the study. (See Attachment A, Study Schedule for Participants 
Providing a Sputum Sample Only.) 
 
If you have low-level INH resistance and you meet all eligibility criteria, and you are one 
of the first 15 participants, you will be enrolled into the study and you will receive study 
treatment. You will be randomized to receive 5, 10, or 15 mg/kg INH once a day for 7 
days. Randomized means that you have an equal chance of being assigned to any of 
the three doses. (Mg/kg, or milligrams per kilogram, means the amount of INH in 
milligrams you will receive for each kilogram you weigh). INH will be provided for you. In 
addition, you must take vitamin B6 once a day while taking INH, to help prevent possible 
side effects of INH. Vitamin B6 will also be provided to you. You may need to take up to 
13 tablets of INH and an additional tablet of vitamin B6 daily. While you are receiving 
study treatment, you will be hospitalized. Attachment A, Study Schedule for Participants 
Receiving Study Treatment, explains what evaluations you will have. 
 
You will be referred to appropriate treatment for your TB after you complete study 
treatment, no later than Day 10 of the study. 
 
• 
Group 2: No INH Resistance 
 
If you have no INH resistance and you are one of the first 48 to 64 participants in this 
group, you will be enrolled in the study for one day only and you will be asked to provide 
a sputum sample. The sample you provide will help us see how much INH is needed to 
prevent your TB from growing in a test tube. After you provide this sputum sample, you 
will be finished with the study. You will not receive INH treatment. Instead, you will be 
referred to receive standard TB treatment outside the study. (See Attachment A, Study 
Schedule for Participants Providing a Sputum Sample Only.) 


 
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• 
Group 3: High-level INH Resistance  
 
If you have high-level INH resistance, and you are one of the first 64 participants in this 
group, you will be enrolled in the study for one day only and you will be asked to provide 
a sputum sample. The sample you provide will help us see how resistant your TB 
infection is to INH. After you provide this sputum sample, you will be finished with the 
study. You will not receive INH treatment. Instead, you will be referred to receive 
standard TB treatment outside the study. (See Attachment A, Study Schedule for 
Participants Providing a Sputum Sample Only.) 
 
If you do not enroll into the study 
If you decide not to take part in this study or if you do not meet the eligibility requirements, you 
will be referred without delay to appropriate treatment for your TB. We will still use some of your 
information. As part of this screening visit, some demographic (e.g., age, gender, race), clinical 
(e.g., disease condition, diagnosis), and laboratory information is being collected from you so 
that researchers may help determine whether there are patterns or common reasons why 
people do not join a study.  
 
What if I have to permanently stop taking study-provided INH after I start taking it? 
During the study: 
 
If you must permanently stop taking study-provided INH, you will be taken off the study. The 
study staff will discuss other options that may be available to you. 
 
After the study: 
 
After you have completed your study participation, the study will not continue to provide you with 
INH you received on the study. You will be referred for full TB treatment which always requires 
more than one drug and may or may not include INH. 
 
Other 
If you agree, some of your blood that is left over after all required study testing is done may be 
stored (with usual protections of your identity) and used for future ACTG-approved research that 
is separate from this study. Genetic testing will not be done on these blood samples. Samples 
collected from you will be stored in a laboratory called the Biomedical Research Institute in 
Rockville, Maryland, United States. These samples may be stored for an unknown period of 
time. Results of testing performed on these samples will not be given to you. You may withdraw 
your consent for research on stored specimens at any time, and the specimens will be 
discarded. No matter what you decide, it will not affect your participation in the study. 
 
________ YES, I agree to have my leftover blood stored.  
 
________ NO, I do not agree. 
 


 
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HOW MANY PEOPLE WILL TAKE PART IN THIS STUDY? 
 
Stage 1 of the study closed to accrual on March 26, 2015. A total of 71 participants provided a 
sputum sample only, and 15 participants received study treatment. 
 
 
HOW LONG WILL I BE IN THIS STUDY? 
 
Participants who receive study treatment will be in the study for 20-25 days after enrollment. 
Participants who will provide a sputum sample only will participate in a single study visit and 
then be discontinued from the study.  
 
 
WHY WOULD THE DOCTOR TAKE ME OFF THIS STUDY EARLY? 
 
The study doctor may need to take you off the study early without your permission if: 
 
• 
the study is stopped or cancelled  
• 
you are not able to cough up enough phlegm during the study  
• 
you are unable to complete the hospital stay  
• 
you do not take one or more doses of the study drug 
• 
continuing the study drugs may be harmful to you 
• 
you need a treatment that you may not take while taking the study drugs 
• 
you become pregnant  
 
 
WHAT ARE THE RISKS OF THE STUDY? 
 
The INH used in this study may have side effects, some of which are listed below. Please note 
that the list below does not include all the side effects seen with this drug. This list includes the 
more serious or common side effects with a known or possible relationship. If you have 
questions concerning the additional study drug side effects, please ask the medical staff at your 
site. 
 
The INH treatment you receive in this study is not the standard TB treatment. Treatment with 
just INH may have little to no effect on the bacteria that are causing your TB, depending on how 
resistant these bacteria are to INH. After you leave the study, you will be referred for TB 
treatment that will include a full course of effective TB treatment, which will include more than 
one anti-TB drug. It is very important that you complete this full TB treatment as prescribed. If 
you do not complete treatment, the bacteria in your body could become resistant to anti-TB 
drugs. 
 
Risks of Antibacterial Drugs 
Some medications used to treat TB may be associated with diarrhea/loose or watery bowels) 
including bloody diarrhea, which may be serious. 
 


 
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Isoniazid (INH) 
The following side effects have been associated with the use of INH: 
 
Serious and sometimes life-threatening liver damage may develop even after many months of 
treatment. Older age, already having some liver disease, drinking alcohol regularly, and using 
injection drugs are all associated with an increased risk of developing liver damage. Women, 
particularly black and Hispanic women, or if they are pregnant or recently gave birth to a baby, 
may also be at increased risk of life-threatening liver damage. If you develop any of the 
following symptoms, you should call your doctor right away: 
• 
unexplained loss of appetite 
• 
nausea and/or vomiting 
• 
pale colored stools 
• 
yellowing of the eyes or skin 
• 
pain in the upper abdomen 
• 
dark urine 
 
Additional side effects may include: 
• 
tingling and numbness in the hands and feet 
• 
memory loss, confusion, trouble sleeping, changes in behavior or mood 
• 
unsteadiness or dizziness 
• 
seizures 
• 
low blood counts 
• 
rash and itching 
• 
high blood sugar 
• 
joint pain 
• 
reduced vitamin B6 levels (a vitamin that helps with many functions in your body) 
 
Non-Study Medications 
There is a risk of serious and/or life-threatening side effects when non-study medications are 
taken with the study drug. For your safety, you must tell the study doctor or nurse about all 
medications you are taking before you start the study and also before starting any new 
medications while on the study. In addition, you must tell the study doctor or nurse before 
enrolling in any other clinical trials while on this study. 
 
Risks of Drawing Blood and Having an Indwelling Catheter 
Taking blood may cause some discomfort, bleeding, bruising, and/or swelling where the needle 
enters the body, lightheadedness, and in rare cases, fainting or infection. There is a very small 
risk of infection or a blood clot from the indwelling catheter. 
 
Risks of Chest X-ray 
The amount of high-energy radiation used in a chest x-ray is relatively small and does not pose 
any significant risk to you. 
 


 
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Risk of Hospitalization 
While you are in the hospital, you may be exposed to other patients who have TB that is more 
resistant to drug treatment (multidrug-resistant TB [MDR-TB] or extensively drug-resistant TB 
[XDR-TB]). You will be separated from these patients; they will be hospitalized on a different 
ward and safety precautions will be taken to prevent transmission of disease. Patients who have 
been treated for MDR-TB or who have been exposed to XDR-TB will not be included in this 
study.  
 
Risks of Social Harm 
It is possible that participating in this study will make it difficult for you to keep your TB status 
secret from people close to you. If you are infected with HIV, the virus that causes AIDS, it may 
also be difficult to keep this secret from people close to you. This may lead to unwelcome 
discussions about or reactions to your HIV or TB status. Please talk with the study staff if you 
have any concerns about this. 
 
 
ARE THERE RISKS RELATED TO PREGNANCY? 
 
INH may be unsafe for unborn babies. If you are having sex that could lead to pregnancy, you 
must agree not to become pregnant while you are participating in this study. You must use one 
of the following barrier methods of birth control that you discuss with the study staff: 
 
• 
male or female condoms 
• 
intrauterine device (IUD) 
• 
diaphragm or cervical cap [Remove if not approved by your country’s national regulatory 
authority.] 
 
 
ARE THERE BENEFITS TO TAKING PART IN THIS STUDY? 
 
If you are in the study and you receive study treatment, there may be a direct benefit to you, but 
no guarantee can be made. It is also possible that you may receive no benefit from being in this 
study. Information learned from this study may help future patients who have TB. 
 
If you are in the study and asked to provide a sputum sample only, there is no direct benefit to 
you for participating in this study. Collecting your sputum will help us learn about how likely it is 
that INH will work to treat patients like you in the future. 
 
 
WHAT OTHER CHOICES DO I HAVE BESIDES THIS STUDY? 
 
The study-provided drug, laboratory tests to monitor how well this drug is working, and quality 
medical care may or may not be available to you outside the study. The clinic staff will discuss 
with you other treatment choices in your area and the risks and the benefits of all the choices. 
 
 


 
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WHAT ABOUT CONFIDENTIALITY? 
 
Efforts will be made to keep your personal information confidential. We cannot guarantee 
absolute confidentiality. Your personal information may be disclosed if required by law. [Insert 
language about any local disclosure requirements for HIV status.] Any publication of this study 
will not use your name or identify you personally. 
 
Your records may be reviewed by the ACTG, Office for Human Research Protections (OHRP), 
your country’s national health agency, (insert name of site) institutional review board 
(IRB)/ethics committee (EC), National Institutes of Health (NIH), other local, US, and 
international regulatory entities, study staff, and study monitors. (An IRB or EC is a 
committee that watches over the safety and rights of research participants.) 
 
A description of this clinical trial will be available on www.ClinicalTrials.gov, as required by US 
law. This Web site will not include information that can identify you. At most, the Web site will 
include a summary of the results. You can search this Web site at any time.  
 
 
WHAT ARE THE COSTS TO ME? 
 
There will be no cost to you for study-related visits, physical examinations, laboratory tests or 
other procedures. Taking part in this study may lead to added costs to you and your medical 
insurance company. In some cases, it is possible that your insurance company will not pay for 
these costs because you are taking part in a research study.  
 
 
WHAT HAPPENS IF I AM INJURED OR, IF I BECOME PREGNANT, MY BABY IS INJURED? 
 
If you or your baby is injured as a result of your being in this study, you or your baby will be 
given immediate treatment for injuries and be referred for further treatment, if necessary. 
However, you may/may not (per site/country policy) have to pay for this care. There is no 
program for compensation either through (this institution) or the NIH. You will not be giving up 
any of your legal rights by signing this consent form. 
 
 
WHAT ARE MY RIGHTS AS A RESEARCH PARTICIPANT? 
 
Taking part in this study is completely voluntary. You may choose not to take part in this study 
or you may leave this study at any time. The care that you would normally receive will not be 
affected if you decide not to take part. Your decision will not have any impact on your 
participation in other studies conducted by NIH and will not result in any penalty or loss of 
benefits to which you are otherwise entitled.  
 
We will tell you about new information from this or other studies that may affect your health, 
welfare, or willingness to stay in this study. If you want the results of the study, let the study staff 
know. 
 


 
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WHAT DO I DO IF I HAVE QUESTIONS OR PROBLEMS? 
 
For questions about this study or a research-related injury, contact: 
 
• 
name of the investigator or other study staff 
• 
telephone number of above  
 
For questions about your rights as a research participant, contact: 
 
• 
name or title of person on the IRB or EC or other organization appropriate for the site 
• 
telephone number of above 


 
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SIGNATURE PAGE ACTG Study A5312 
 
If you have read this consent form (or had it explained to you), all your questions have been 
answered, and you agree to take part in this study, please sign your name below. 
 
 
 
____________________________ 
_________________________________________ 
Participant’s Name (print) 
Participant’s Signature and Date 
 
 
____________________________ 
_________________________________________ 
Participant’s Legal Representative (print) 
Legal Representative’s Signature and Date 
(As appropriate) 
 
 
____________________________ 
_________________________________________ 
Study Staff Conducting 
Study Staff’s Signature and Date 
Consent Discussion (print)  
 
 
____________________________ 
_________________________________________ 
Witness’s Name (print) 
Witness’s Signature and Date 
(As appropriate) 
 
 
 


 
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ATTACHMENT A 
A5312 Stage 1 Study Visits 
 
The study staff can answer any questions you have about individual study visits, the evaluations 
that will occur, or how long each visit will be. The table below can be used as a quick reference 
for you, along with the explanations that follow. 
 
I. Appendix I, Table 1:   Study Schedule for Participants Providing a Sputum Sample Only 
(some Group 1 participants, and all Group 2 and 3 participants) 
 
Evaluation or 
Procedure 
Screening1 
Entry2 
Consent & contact 
information collected 
√ 
 
 
Sputum collected 
 
√ 
√ 
 
1Screening: If your doctor thinks it is best, you may be admitted to the hospital during screening. 
 
2Entry: If you are enrolled, you will have a sputum sample collected and then be discontinued 
from the study and referred for standard local TB treatment.  
 
 
II. Explanation of Evaluations for Participants Providing a Sputum Sample Only 
 
Below are descriptions of the evaluations for participants who do not receive study treatment. 
You will be told the results of all tests performed. 
 
Consent and contact information collected: After you read the consent and have had a chance 
to ask questions about the study, you will sign the consent form if you want to continue and join 
the study. You will also be asked how to be contacted, and whether you give the study team 
permission to contact you. 
 
Sputum collected: You will be asked to provide sputum samples. To provide this sample, you 
will be asked to cough deeply and then spit into a cup. If you need help to cough deeply, the 
clinic staff may ask you to briefly breathe a mist of saltwater through a tube or a mask. This 
sputum will be checked for the bacteria that causes TB and to see if these bacteria are resistant 
to INH. 
 
 
 
 


 
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III. Appendix I, Table 2:  Study Schedule for Participants Receiving Study Treatment (some 
Group 1 participants) 
 
Evaluation 
or 
Procedure 
Screening
1 
Pre-
entry2 
Entry3 
Study 
Treatmen
t4 
Discharge
5 
Final 
Visit6 
Early  
Discontinuation7 
Consent & 
contact 
information 
collected 
√ 
 
 
 
 
 
 
HIV status 
 
√ 
 
 
 
 
 
 
Chest x-ray 
 
√ 
 
 
 
 
 
 
Physical 
exam 
√ 
 
√ 
√ 
√ 
√ 
√ 
Blood 
collected 
√ 
 
√ 
Days 6  
and 7 
only 
 
√ 
√ 
Pregnancy 
test 
√ 
 
√ 
 
 
 
√ 
Saliva 
collected 
 
 
√ 
 
 
 
 
Sputum 
collected 
√ 
√ 
√ 
√ 
 
 
 
 
1Screening: After you have read and signed the consent form, you will have a physical exam 
and several tests done to make sure that you meet the requirements for joining the study. If your 
doctor thinks it is best, you may be admitted to the hospital during screening.  
 
2Pre-entry: If you qualify for the study based on your screening tests, you will be admitted to the 
hospital, if you were not during screening. 
 
3Entry: If you are enrolled, you will remain in the hospital. At this visit, you will receive your 
treatment assignment.  
 
4Study Treatment: You will receive daily INH treatment while in the hospital.  
 
5Discharge: On Day 8, you will be released from the hospital  
 
6Final Visit: You will come to the clinic for a final visit about 14 days after you are released from 
the hospital.  
 
7Early Discontinuation: If you stop the study early, you will be asked to come in for a final visit. 


 
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IV. Explanation of Evaluations for Participants Receiving Study Treatment (some Group 1 
participants)  
 
Below are descriptions of the evaluations for participants who receive study treatment. You will 
be told the results of all tests performed. 
 
Consent and contact information collected: After you read the consent and have had a chance 
to ask questions about the study, you will sign the consent form if you want to be screened for 
the study. You will also be asked how to be contacted, and whether you give the study team 
permission to contact you. 
 
HIV status: If there is no record available, another HIV test will be done. If an HIV test has to be 
done, you may have to sign a separate consent form before this is done. You will be told the 
results of the HIV test as soon as it is available. You may experience stress while waiting for the 
results of the HIV test. 
 
Chest x-ray: You will have a chest x-ray at screening, if you have not had one done within 14 
days before screening. 
 
Physical examination: You will have a physical exam and will be asked questions about your 
health and about any medications you have taken or are taking now. 
 
Blood collected: Blood will be collected from you for various tests during the study. These 
include routine blood tests for safety. If you have HIV, you will also have a CD4+ count (a test 
that shows how many infection-fighting cells you have in your blood).  
 
At entry, blood will be collected for a NAT2 genetic test, which looks at changes in a single 
human gene that may affect how quickly your body breaks down INH. A gene is a small unit in 
your body that carries instructions for how your body works. This test will not look at any other 
genes.  
 
At Day 6 during study treatment, blood will be collected to look at the level of INH. Blood will be 
collected 9 times over a 24-hour period. An indwelling catheter (a small, thin tube) may be put 
into an arm vein and left in place. This will allow the blood samples to be drawn without any 
additional needle sticks. If a catheter cannot be placed or kept in your arm vein, the blood draw 
will be done by putting a needle in your vein and drawing blood 9 different times.  
 
Blood volume by visit is as follows: 
Screening visit: 10 mL (about 2 teaspoons) 
Pre-entry visit: 10 mL (about 2 teaspoons) 
Study treatment, Day 6 visit: 32 mL (about 8 teaspoons) 
Study treatment, Day 7 visit: 6 mL (about 1 teaspoon) 
Final visit or early discontinuation visit: 6 mL (about 1 teaspoon) 
 
Pregnancy test: If you are a woman who is able to become pregnant, you will be asked to give a 
small urine or blood sample (about 5 mL or 1 teaspoon) for a pregnancy test. 
 


 
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Saliva collected: Saliva will be collected for the NAT2 genetic test, which looks at changes in a 
single human gene that may affect how quickly your body breaks down INH. This test will not 
look at any other genes.  
 
Sputum collected: You will be asked to provide sputum samples. To provide this sample, you 
will be asked to cough deeply and then spit into a cup. If you need help to cough deeply, the 
clinic staff may ask you to briefly breathe a mist of saltwater through a tube or a mask. At pre-
entry, entry, and days 1 through 7, sputum will be collected each night (starting around 4 PM) 
for 16 hours. This sputum will be checked for the bacteria that causes TB and to see if these 
bacteria are resistant to INH. 
 
 
 


 
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APPENDIX II:  SAMPLE INFORMED CONSENT FOR PROTOCOL A5312, STAGE 2, STEP 1 
 
DIVISION OF AIDS  
AIDS CLINICAL TRIALS GROUP (ACTG) 
 
The Early Bactericidal Activity of High-Dose or Standard-Dose Isoniazid among Adult 
Participants with Isoniazid-Resistant or Drug-Sensitive Tuberculosis 
FINAL Version 3.0, August 21, 2018 
 
 
INTRODUCTION 
 
You are being asked to take part in this research study because you have pulmonary 
tuberculosis (TB), a bacterial infection in your lungs. This research study is conducted by the 
AIDS Clinical Trials Group (ACTG), which is a research organization based in the United States. 
Although the name contains the word “AIDS”, this study is not about research on AIDS or HIV. 
This study is sponsored by the United States National Institutes of Health (NIH). The doctor in 
charge of this study at this site is: (insert name of Principal Investigator). Before you decide if 
you want to be a part of this study, we want you to know about the study.  
 
This is a consent form. It gives you information about this study. The study staff will talk with you 
about this information. You are free to ask questions about this study at any time. If you agree to 
take part in this study, you will be asked to sign this consent form. You will get a copy to keep. 
 
 
WHY IS THIS STUDY BEING DONE? 
 
Isoniazid (INH) is a drug commonly used to treat TB worldwide. Sometimes, the bacteria that 
cause TB can become resistant to INH. Resistance means that bacteria have adapted to a drug 
and are able to live in the presence of the drug. When TB becomes resistant to INH, INH does 
not work as well at fighting the bacteria. This study will treat people with INH-resistant TB with 
different doses of INH to see if INH can still fight the bacteria if we just increase the dose. We 
will compare how well the drug works at higher doses for participants who have resistant TB to 
how well the drug works at regular doses for participants who have TB that is not resistant. The 
study will also compare the safety and tolerability of the different doses of INH. Tolerability is 
how well people can put up with the side effects of a drug. Using increased doses of INH to treat 
TB that is resistant to INH is experimental and has not been approved by regulatory authorities. 
While there is some evidence that this approach will work, this has not yet been proven. 
 
 
WHAT DO I HAVE TO DO IF I AM IN THIS STUDY? 
 
After you have signed this consent form, you will have a screening visit. During the screening, 
you will be asked to provide sputum (cough up phlegm). That sputum will be checked for the 
bacteria that cause TB. If they are found, your sputum will be tested to see if the TB bacteria in 
your body are resistant to INH and if it is low-level or high-level resistance. (With low-level 


 
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resistance, the bacteria are not as resistant to INH as they are with high-level resistance.) 
Depending on the result of this test, you will be assigned to a group as follows:  
• 
Group 1: Low-Level INH Resistance 
 
If you have low-level INH resistance but you do not meet all eligibility criteria, and you 
are one of the first 16 to 70 participants in this group, you will be enrolled in the study for 
one day only and you will be asked to provide a sputum sample. The sample you 
provide will help us see how much INH is needed to prevent your TB from growing in a 
test tube. After you provide this sputum sample, you will be finished with the study. You 
will not receive INH treatment. Instead, you will be referred to receive standard TB 
treatment outside the study. (See Attachment A, Study Schedule for Participants 
Providing a Sputum Sample Only.) 
 
• 
Group 2: No INH Resistance 
 
If you have no INH resistance but you do not meet all eligibility criteria and you are one 
of the first 64 to 84 participants in this group, you will be enrolled in the study for one day 
only and you will be asked to provide a sputum sample. The sample you provide will 
help us see how much INH is needed to prevent your TB from growing in a test tube. 
After you provide this sputum sample, you will be finished with the study. You will not 
receive INH treatment. Instead, you will be referred to receive standard TB treatment 
outside the study. (See Attachment A, Study Schedule for Participants Providing a 
Sputum Sample Only.) 
 
• 
Group 3: High-Level INH Resistance  
 
If you have high-level INH resistance, you will be enrolled in the study for one day only 
and you will be asked to provide a sputum sample. The sample you provide will help us 
see how resistant your TB infection is to INH. After you provide this sputum sample, you 
will be finished with the study. You will not receive INH treatment. Instead, you will be 
referred to receive standard TB treatment outside the study. (See Attachment A, Study 
Schedule for Participants Providing a Sputum Sample Only.) There will be 64 to 84 
people enrolled in Group 3.  
 
After you provide a sputum sample, you will be invited to participate in Step 2 of the study. 
Step 2 is the TB treatment part of the study. For this, you will have another screening visit and if 
you meet all the eligibility criteria, you will be admitted to hospital and receive study medication.  
 
If you do not enroll into the study 
If you decide not to take part in this study or if you do not meet the eligibility requirements, you 
will be referred without delay to appropriate treatment for your TB. We will still use some of your 
information. As part of this screening visit, some demographic (e.g., age, gender, race), clinical 
(e.g., disease condition, diagnosis), and laboratory information is being collected from you so 
that researchers may help determine whether there are patterns or common reasons why 
people do not join a study.  


 
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HOW MANY PEOPLE WILL TAKE PART IN THIS STUDY? 
 
Up to 218 participants will provide a sputum sample only.  
 
 
HOW LONG WILL I BE IN THIS STUDY? 
 
Participants who will provide a sputum sample only will participate in a single study visit and 
then be discontinued from the study.  
 
 
WHY WOULD THE DOCTOR TAKE ME OFF THIS STUDY EARLY? 
 
The study doctor may need to take you off the study early without your permission if: 
 
• 
the study is stopped or cancelled  
• 
you are not able to cough up enough phlegm during the study  
 
 
WHAT ARE THE RISKS OF THE STUDY? 
 
Risks of Social Harm 
It is possible that participating in this study will make it difficult for you to keep your TB status 
secret from people close to you. If you are infected with HIV, the virus that causes AIDS, it may 
also be difficult to keep this secret from people close to you. This may lead to unwelcome 
discussions about or reactions to your HIV or TB status. Please talk with the study staff if you 
have any concerns about this. 
 
 
ARE THERE RISKS RELATED TO PREGNANCY? 
 
As you are only giving a sputum sample and you are taking no study-provided medicine, there is 
no risk for unborn babies. 
 
 
ARE THERE BENEFITS TO TAKING PART IN THIS STUDY? 
 
There is no direct benefit to you for participating in this study. Collecting your sputum will help 
us learn about how likely it is that INH will work to treat patients like you in the future. 
 
 
WHAT OTHER CHOICES DO I HAVE BESIDES THIS STUDY? 
 
Quality medical care may or may not be available to you outside the study. The clinic staff will 
discuss with you other choices in your area and the risks and the benefits of all the choices. 
 


 
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WHAT ABOUT CONFIDENTIALITY? 
 
Efforts will be made to keep your personal information confidential. We cannot guarantee 
absolute confidentiality. Your personal information may be disclosed if required by law. [Insert 
language about any local disclosure requirements for HIV status.] Any publication of this study 
will not use your name or identify you personally. 
 
Your records may be reviewed by the ACTG, Office for Human Research Protections (OHRP), 
your country’s national health agency, (insert name of site) institutional review board 
(IRB)/ethics committee (EC), National Institutes of Health (NIH), other local, US, and 
international regulatory entities, study staff, and study monitors. (An IRB or EC is a 
committee that watches over the safety and rights of research participants.) 
 
A description of this clinical trial will be available on www.ClinicalTrials.gov, as required by US 
law. This Web site will not include information that can identify you. At most, the Web site will 
include a summary of the results. You can search this Web site at any time.  
 
 
WHAT ARE THE COSTS TO ME? 
 
There will be no cost to you for study-related visits, physical examinations, laboratory tests or 
other procedures. Taking part in this study may lead to added costs to you and your medical 
insurance company. In some cases, it is possible that your insurance company will not pay for 
these costs because you are taking part in a research study.  
 
 
WHAT HAPPENS IF I AM INJURED? 
 
If you are injured as a result of your being in this study, you will be given immediate treatment 
for injuries and be referred for further treatment, if necessary. However, you may/may not (per 
site/country policy) have to pay for this care. There is no program for compensation either 
through (this institution) or the NIH. You will not be giving up any of your legal rights by signing 
this consent form. 
 
 
WHAT ARE MY RIGHTS AS A RESEARCH PARTICIPANT? 
 
Taking part in this study is completely voluntary. You may choose not to take part in this study 
or you may leave this study at any time. The care that you would normally receive will not be 
affected if you decide not to take part. Your decision will not have any impact on your 
participation in other studies conducted by NIH and will not result in any penalty or loss of 
benefits to which you are otherwise entitled.  
 
We will tell you about new information from this or other studies that may affect your health, 
welfare, or willingness to stay in this study. If you want the results of the study, let the study staff 
know. 


 
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WHAT DO I DO IF I HAVE QUESTIONS OR PROBLEMS? 
 
For questions about this study or a research-related injury, contact: 
 
• 
name of the investigator or other study staff 
• 
telephone number of above  
 
For questions about your rights as a research participant, contact: 
 
• 
name or title of person on the IRB or EC or other organization appropriate for the site 
• 
telephone number of above 
 
 


 
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SIGNATURE PAGE ACTG Study A5312 
 
If you have read this consent form (or had it explained to you), all your questions have been 
answered, and you agree to take part in this study, please sign your name below. 
 
 
____________________________ 
_________________________________________ 
Participant’s Name (print) 
Participant’s Signature and Date 
 
 
____________________________ 
_________________________________________ 
Participant’s Legal Representative (print) 
Legal Representative’s Signature and Date 
(As appropriate) 
 
 
____________________________ 
_________________________________________ 
Study Staff Conducting 
Study Staff’s Signature and Date 
Consent Discussion (print)  
 
 
____________________________ 
_________________________________________ 
Witness’s Name (print) 
Witness’s Signature and Date 
(As appropriate) 
 
 
 


 
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ATTACHMENT A 
A5312 Stage 2, Step 1 Study Visits 
 
The study staff can answer any questions you have about individual study visits, the evaluations 
that will occur, or how long each visit will be. The table below can be used as a quick reference 
for you, along with the explanations that follow. 
 
I. Appendix II Table 1:   Study Schedule for Participants Providing a Sputum Sample Only 
(some Group 1, 2, and 3 participants) 
 
Evaluation or 
Procedure 
Screening1 
Entry2 
Consent & contact 
information collected 
√ 
 
 
Sputum collected 
 
√ 
√ 
 
1Screening: If your doctor thinks it is best, you may be admitted to the hospital during screening. 
 
2Entry: If you are enrolled, you will have a sputum sample collected and then be discontinued 
from the study and referred for standard local TB treatment.  
 
 
II. Explanation of Evaluations for Participants Providing a Sputum Sample Only 
 
Below are descriptions of the evaluations for participants who do not receive study treatment. 
You will be told the results of all tests performed. 
 
Consent and contact information collected: After you read the consent and have had a chance 
to ask questions about the study, you will sign the consent form if you want to continue and join 
the study. You will also be asked how to be contacted, and whether you give the study team 
permission to contact you. 
 
Sputum collected: You will be asked to provide a sputum sample. To provide this sample, you 
will be asked to cough deeply and then spit into a cup. If you need help to cough deeply, the 
clinic staff may ask you to briefly breathe a mist of saltwater through a tube or a mask. This 
sputum will be checked for the bacteria that causes TB and to see if these bacteria are resistant 
to INH. 
 
 


 
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APPENDIX III: SAMPLE INFORMED CONSENT FOR A5312: STAGE 2, STEP 2 
 
DIVISION OF AIDS  
AIDS CLINICAL TRIALS GROUP (ACTG) 
 
The Early Bactericidal Activity of High-Dose or Standard-Dose Isoniazid among Adult 
Participants with Isoniazid-Resistant or Drug-Sensitive Tuberculosis 
FINAL Version 3.0, August 21, 2018 
 
INTRODUCTION 
 
You are being asked to take part in this research study because you have pulmonary 
tuberculosis (TB), a bacterial infection in your lungs. You participated in the Stage 2, Step 1 part 
of this study. You have given a sputum sample which has been tested, and the bacteria causing 
TB has been found in your sputum. The TB bacteria in your body are either not resistant to INH, 
have a low level of INH resistance (the TB bacteria are not that resistant to INH), or have a 
high level of INH resistance (the TB bacteria are more resistant to INH). This is why you 
have been asked to take part in Step 2 of the study. 
 
This research study is conducted by the AIDS Clinical Trials Group (ACTG), which is a research 
organization based in the United States. Although the name contains the word “AIDS”, this 
study is not about research on AIDS or HIV. This study is sponsored by the United States 
National Institutes of Health (NIH). The doctor in charge of this study at this site is: (insert name 
of Principal Investigator). Before you decide if you want to be a part of this study, we want you 
to know about the study.  
 
This is a consent form. It gives you information about this study. The study staff will talk with you 
about this information. You are free to ask questions about this study at any time. If you agree to 
take part in this study, you will be asked to sign this consent form. You will get a copy to keep. 
 
 
WHY IS THIS STUDY BEING DONE? 
 
Isoniazid (INH) is a drug commonly used to treat TB worldwide. Sometimes, the bacteria that 
cause TB can become resistant to INH. Resistance means that bacteria have adapted to a drug 
and are able to live in the presence of the drug. When TB becomes resistant to INH, INH does 
not work as well at fighting the bacteria. This study will treat people with INH-resistant TB with 
different doses of INH to see if INH can still fight the bacteria if we just increase the dose. We 
will compare how well the drug works at higher doses for participants who have resistant TB to 
how well the drug works at regular doses for participants who have TB that is not resistant. The 
study will also compare the safety and tolerability of the different doses of INH. Tolerability is 
how well people can put up with the side effects of a drug. Using increased doses of INH to treat 
TB that is resistant to INH is experimental and has not been approved by regulatory authorities. 
While there is some evidence that this approach will work, this has not yet been proven. 
 
 


 
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WHAT DO I HAVE TO DO IF I AM IN THIS STUDY? 
 
After you have signed this consent form, you will have a screening visit. For this screening visit, 
your study doctor may decide you need to be admitted to the hospital. If you have stopped 
taking INH recently, you may need to be admitted to the hospital for up to 7 days before 
screening so that there is time for the INH to wash out of your body. During Stage 2, Step 1 
screening, you were asked to provide sputum (cough up phlegm). That sputum was checked for 
the bacteria that cause TB, if the TB bacteria in your body are resistant to INH, and if it is low-
level or high-level resistance. (With low-level resistance, the bacteria are not as resistant to INH 
as they are with high-level resistance.) Depending on the result of this test, you will be assigned 
to a group as follows:  
 
• 
Group 1: Low-Level INH Resistance 
 
If you have low-level INH resistance and you meet all eligibility criteria, you will be 
enrolled into the study and you will receive study treatment. You will be randomized to 
receive 5, 10, or 15 mg/kg INH once a day for 7 days. Randomized means that you have 
an equal chance of being assigned to any of the three doses. (Mg/kg, or milligrams per 
kilogram, means the amount of INH in milligrams you will receive for each kilogram you 
weigh). Attachment A, Study Schedule for Participants Receiving Study Treatment, 
explains what evaluations you will have. 
 
• 
Group 2: No INH Resistance 
 
If you have no INH resistance and you meet all eligibility criteria, you will be enrolled 
into the study and you will receive study treatment of 5 mg/kg INH once a day for 7 
days. Attachment A, Study Schedule for Participants Receiving Study Treatment, 
explains what evaluations you will have. 
 
• 
Group 3: High-Level INH Resistance 
 
If you have high-level INH resistance and you meet all eligibility criteria, you will 
be enrolled into the study and you will receive study treatment of 15 or 20 mg/kg 
INH once a day for 7 days. Attachment A, Study Schedule for Participants 
Receiving Study Treatment, explains what evaluations you will have. 
 
INH will be provided for you. In addition, you must also take vitamin B6 once a day while taking 
INH, to help prevent possible side effects of INH. Vitamin B6 will also be provided to you. You 
may need to take up to 13 tablets of INH and an additional tablet of vitamin B6 daily. While you 
are receiving study treatment, you will be hospitalized. 
 
You will be referred to appropriate treatment for your TB after you complete study treatment, no 
later than Day 10 of the study.  
 
If you do not enroll into the study 
If you decide not to take part in this study or if you do not meet the eligibility requirements, you 
will be referred without delay to appropriate treatment for your TB. We will still use some of your 


 
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information. As part of this screening visit, some demographic (e.g., age, gender, race), clinical 
(e.g., disease condition, diagnosis), and laboratory information is being collected from you so 
that researchers may help determine whether there are patterns or common reasons why 
people do not join a study.  
 
What if I have to permanently stop taking study-provided INH after I start taking it? 
 
During the study: 
 
If you must permanently stop taking study-provided INH, you will be taken off the study. The 
study staff will discuss other options that may be available to you. 
 
After the study: 
 
After you have completed your study participation, the study will not continue to provide you with 
INH you received on the study. You will be referred for full TB treatment which always requires 
more than one drug and may or may not include INH. 
 
Other 
 
If you agree, some of your blood that is left over after all required study testing is done may be 
stored (with usual protections of your identity) and used for future ACTG-approved research that 
is separate from this study. Genetic testing will not be done on these blood samples. Samples 
collected from you will be stored in a laboratory called the Biomedical Research Institute in 
Rockville, Maryland, United States. These samples may be stored for an unknown period of 
time. Results of testing performed on these samples will not be given to you. You may withdraw 
your consent for research on stored specimens at any time, and the specimens will be 
discarded. No matter what you decide, it will not affect your participation in the study. 
 
________ YES, I agree to have my leftover blood stored.  
 
________ NO, I do not agree. 
 
 
HOW MANY PEOPLE WILL TAKE PART IN THIS STUDY? 
 
Between 64 and 84 participants will take part in this study.  
 
 
HOW LONG WILL I BE IN THIS STUDY? 
 
Participants will be in the study for 20-25 days after enrollment.  
 


 
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WHY WOULD THE DOCTOR TAKE ME OFF THIS STUDY EARLY? 
 
The study doctor may need to take you off the study early without your permission if: 
 
• 
the study is stopped or cancelled  
• 
you are not able to cough up enough phlegm during the study  
• 
you are unable to complete the hospital stay  
• 
you do not take one or more doses of the study drug 
• 
continuing the study drugs may be harmful to you 
• 
you need a treatment that you may not take while taking the study drugs 
• 
you become pregnant  
 
 
WHAT ARE THE RISKS OF THE STUDY? 
 
The INH used in this study may have side effects, some of which are listed below. Please note 
that the list below does not include all the side effects seen with this drug. This list includes the 
more serious or common side effects with a known or possible relationship. If you have 
questions concerning the additional study drug side effects, please ask the medical staff at your 
site. 
 
The INH treatment you receive in this study is not the standard TB treatment. Treatment with 
just INH may have little to no effect on the bacteria that are causing your TB, depending on how 
resistant these bacteria are to INH. After you leave the study, you will be referred for TB 
treatment that will include a full course of effective TB treatment, which will include more than 
one anti-TB drug. It is very important that you complete this full TB treatment as prescribed. If 
you do not complete treatment, the bacteria in your body could become resistant to anti-TB 
drugs. 
 
Risks of Antibacterials 
Some medications used to treat TB may be associated with diarrhea/loose or watery bowels) 
including bloody diarrhea, which may be serious. 
 
Isoniazid (INH) 
The following side effects have been associated with the use of INH: 
 
Serious and sometimes life-threatening liver damage may develop even after many months of 
treatment. Older age, already having some liver disease, drinking alcohol regularly, and using 
injection drugs are all associated with an increased risk of developing liver damage. Women, 
particularly black and Hispanic women, or if they are pregnant or recently gave birth to a baby, 
may also be at increased risk of life-threatening liver damage. If you develop any of the 
following symptoms, you should call your doctor right away: 
• 
unexplained loss of appetite 
• 
nausea and/or vomiting 
• 
pale colored stools 
• 
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• 
pain in the upper abdomen 
• 
dark urine 
 
Additional side effects may include: 
• 
tingling and numbness in the hands and feet 
memory loss, confusion, trouble sleeping, changes in behavior or mood 
• 
unsteadiness or dizziness 
• 
seizures 
• 
low blood counts 
• 
rash and itching 
• 
high blood sugar 
• 
joint pain 
• 
reduced vitamin B6 levels (a vitamin that helps with many functions in your body) 
 
The available data from research studies that gave high doses of INH (15–20 mg/kg, as in 
Group 3) show that high doses of INH are usually well tolerated. More participants in 
these studies had numbness and tingling in their hands and feet when they took higher 
doses. Malnourished participants who took higher doses had a higher occurrence of 
numbness and tingling. Usually, this occurred when high doses of INH were taken for 
much longer than 7 days. Up to now, in this study (A5312) there have been no serious 
side effects from the treatment, and there have been no reported episodes of numbness 
or tingling. To ensure your safety, you will be given vitamin B6 to take once a day; this 
should help decrease the occurrence of numbness and tingling. 
 
Non-Study Medications 
There is a risk of serious and/or life-threatening side effects when non-study medications are 
taken with the study drug. For your safety, you must tell the study doctor or nurse about all 
medications you are taking before you start the study and also before starting any new 
medications while on the study. In addition, you must tell the study doctor or nurse before 
enrolling in any other clinical trials while on this study. 
 
Risks of Drawing Blood and Having an Indwelling Catheter 
Taking blood may cause some discomfort, bleeding, bruising, and/or swelling where the needle 
enters the body, lightheadedness, and in rare cases, fainting or infection. There is a very small 
risk of infection or a blood clot from the indwelling catheter. 
 
Risks of Chest X-ray 
The amount of high-energy radiation used in a chest x-ray is relatively small and does not pose 
any significant risk to you. 
 
Risk of Hospitalization 
While you are in the hospital, you may be exposed to other patients who have TB that is more 
resistant to drug treatment (multidrug-resistant TB [MDR-TB] or extensively drug-resistant TB 
[XDR-TB]). You will be separated from these patients; they will be hospitalized on a different  


 
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ward and safety precautions will be taken to prevent transmission of disease. Patients who have 
been treated for MDR-TB or who have been exposed to XDR-TB will not be included in this 
study.  
 
Risks of Social Harm 
It is possible that participating in this study will make it difficult for you to keep your TB status 
secret from people close to you. If you are infected with HIV, the virus that causes AIDS, it may 
also be difficult to keep this secret from people close to you. This may lead to unwelcome 
discussions about or reactions to your HIV or TB status. Please talk with the study staff if you 
have any concerns about this. 
 
 
ARE THERE RISKS RELATED TO PREGNANCY? 
 
INH may be unsafe for unborn babies. If you are having sex that could lead to pregnancy, you 
must agree not to become pregnant while you are participating in this study. You must use one 
of the following barrier methods of birth control that you discuss with the study staff: 
 
• 
male or female condoms 
• 
intrauterine device (IUD) 
• 
diaphragm or cervical cap [Remove if not approved by your country’s national regulatory 
authority.] 
 
 
ARE THERE BENEFITS TO TAKING PART IN THIS STUDY? 
 
If you are receiving study treatment and you are in Group 1 or Group 3, there may be a direct 
benefit to you, but no guarantee can be made. It is also possible that you may receive no benefit 
from being in this study. Information learned from this study may help future patients who have 
TB. 
 
If you are receiving study treatment and you are in Group 2, you have been asked to participate 
in this study to serve as a control, a group with which the experimental group can be compared 
to determine how well the experimental treatment is working. There may be no direct benefit to 
you for participating in this study.  
 
 
WHAT OTHER CHOICES DO I HAVE BESIDES THIS STUDY? 
 
The study-provided drug, laboratory tests to monitor how well this drug is working, and quality 
medical care may or may not be available to you outside the study. The clinic staff will discuss 
with you other treatment choices in your area and the risks and the benefits of all the choices. 
 
 


 
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WHAT ABOUT CONFIDENTIALITY? 
 
Efforts will be made to keep your personal information confidential. We cannot guarantee 
absolute confidentiality. Your personal information may be disclosed if required by law. [Insert 
language about any local disclosure requirements for HIV status.] Any publication of this study 
will not use your name or identify you personally. 
 
Your records may be reviewed by the ACTG, Office for Human Research Protections (OHRP), 
your country’s national health agency, (insert name of site) institutional review board 
(IRB)/ethics committee (EC), National Institutes of Health (NIH), other local, US, and 
international regulatory entities, study staff, and study monitors. (An IRB or EC is a 
committee that watches over the safety and rights of research participants.) 
 
A description of this clinical trial will be available on www.ClinicalTrials.gov, as required by US 
law. This Web site will not include information that can identify you. At most, the Web site will 
include a summary of the results. You can search this Web site at any time.  
 
 
WHAT ARE THE COSTS TO ME? 
 
There will be no cost to you for study-related visits, physical examinations, laboratory tests or 
other procedures. Taking part in this study may lead to added costs to you and your medical 
insurance company. In some cases, it is possible that your insurance company will not pay for 
these costs because you are taking part in a research study.  
 
 
WHAT HAPPENS IF I AM INJURED OR, IF I BECOME PREGNANT, MY BABY IS INJURED? 
 
If you or your baby is injured as a result of your being in this study, you or your baby will be 
given immediate treatment for injuries and be referred for further treatment, if necessary. 
However, you may/may not (per site/country policy) have to pay for this care. There is no 
program for compensation either through (this institution) or the NIH. You will not be giving up 
any of your legal rights by signing this consent form. 
 
 
WHAT ARE MY RIGHTS AS A RESEARCH PARTICIPANT? 
 
Taking part in this study is completely voluntary. You may choose not to take part in this study 
or you may leave this study at any time. The care that you would normally receive will not be 
affected if you decide not to take part. Your decision will not have any impact on your 
participation in other studies conducted by NIH and will not result in any penalty or loss of 
benefits to which you are otherwise entitled.  
 
We will tell you about new information from this or other studies that may affect your health, 
welfare, or willingness to stay in this study. If you want the results of the study, let the study staff 
know. 
 


 
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WHAT DO I DO IF I HAVE QUESTIONS OR PROBLEMS? 
 
For questions about this study or a research-related injury, contact: 
 
• 
name of the investigator or other study staff 
• 
telephone number of above  
 
For questions about your rights as a research participant, contact: 
 
• 
name or title of person on the IRB or EC or other organization appropriate for the site 
• 
telephone number of above 
 


 
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SIGNATURE PAGE ACTG Study A5312 
 
If you have read this consent form (or had it explained to you), all your questions have been 
answered, and you agree to take part in this study, please sign your name below. 
 
 
 
____________________________ 
_________________________________________ 
Participant’s Name (print) 
Participant’s Signature and Date 
 
 
________________________________ 
 
 
 
 
 
 
 
 
Participant’s Legal Representative (print) 
Legal Representative’s Signature and Date 
(As appropriate) 
 
 
____________________________ 
_________________________________________ 
Study Staff Conducting 
Study Staff’s Signature and Date 
Consent Discussion (print)  
 
 
____________________________ 
_________________________________________ 
Witness’s Name (print) 
Witness’s Signature and Date 
(As appropriate) 
 
 
 
 
 


 
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ATTACHMENT A 
A5312 Stage 2, Step 2 Study Visits 
 
The study staff can answer any questions you have about individual study visits, the evaluations 
that will occur, or how long each visit will be. The table below can be used as a quick reference 
for you, along with the explanations that follow. 
 
I. Appendix III, Table 1:  Study Schedule for Participants Receiving Study Treatment (some 
Group 1, 2, and 3 participants) 
 
Evaluation 
or 
Procedure 
Screening
1 
Pre-
entry2 
Entry3 
Study 
Treatment
4 
Discharg
e5 
Final 
Visit6 
Early  
Discontinuation
7 
Consent & 
contact 
information 
collected 
√ 
 
 
 
 
 
 
HIV status 
 
√ 
 
 
 
 
 
 
Chest x-ray 
 
√ 
 
 
 
 
 
 
Physical 
exam 
√ 
 
√ 
√ 
√ 
√ 
√ 
Blood 
collected 
√ 
 
√ 
Days 6  
and 7 only 
 
√ 
√ 
Pregnancy 
test 
√ 
 
√ 
 
 
 
√ 
Saliva 
collected 
 
 
√ 
 
 
 
 
Sputum 
collected 
√ 
√ 
√ 
√ 
 
 
 
1Screening: After you have read and signed the consent form, you will have a physical exam 
and several tests done to make sure that you meet the requirements for joining the study. If your 
doctor thinks it is best, you may be admitted to the hospital during screening.  
2Pre-entry: If you qualify for the study based on your screening tests, you will be admitted to the 
hospital, if you were not during screening. 
3Entry: If you are enrolled, you will remain in the hospital. At this visit, you will receive your 
treatment assignment.  
4Study Treatment: You will receive daily INH treatment while in the hospital.  
5Discharge: On Day 8, you will be released from the hospital  
6Final Visit: You will come to the clinic for a final visit about 14 days after you are released from 
the hospital.  
7Early Discontinuation: If you stop the study early, you will be asked to come in for a final visit. 


 
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II. Explanation of Evaluations for Participants Receiving Study Treatment (some Group 1, 2, 
and 3 participants)  
 
Below are descriptions of the evaluations for participants who receive study treatment. You will 
be told the results of all tests performed. 
 
Consent and contact information collected: After you read the consent and have had a chance 
to ask questions about the study, you will sign the consent form if you want to be screened for 
the study. You will also be asked how to be contacted, and whether you give the study team 
permission to contact you. 
 
HIV status: If there is no record available, another HIV test will be done. If an HIV test has to be 
done, you may have to sign a separate consent form before this is done. You will be told the 
results of the HIV test as soon as it is available. You may experience stress while waiting for the 
results of the HIV test. 
 
Chest x-ray: You will have a chest x-ray at screening, if you have not had one done within 14 
days before screening. 
 
Physical examination: You will have a physical exam and will be asked questions about your 
health and about any medications you have taken or are taking now. 
 
Blood collected: Blood will be collected from you for various tests during the study. These 
include routine blood tests for safety. If you have HIV, you will also have a CD4+ count (a test 
that shows how many infection-fighting cells you have in your blood).  
 
At entry, blood will be collected for a NAT2 genetic test, which looks at changes in a single 
human gene that may affect how quickly your body breaks down INH. A gene is a small unit in 
your body that carries instructions for how your body works. This test will not look at any other 
genes.  
 
At Day 6 during study treatment, blood will be collected to look at the level of INH. Blood will be 
collected 9 times over a 24-hour period. An indwelling catheter (a small, thin tube) may be put 
into an arm vein and left in place. This will allow the blood samples to be drawn without any 
additional needle sticks. If a catheter cannot be placed or kept in your arm vein, the blood draw 
will be done by putting a needle in your vein and drawing blood 9 different times.  
 
Blood volume by visit is as follows: 
Screening visit: 10 mL (about 2 teaspoons) 
Pre-entry visit: 10 mL (about 2 teaspoons) 
Study treatment, Day 6 visit: 32 mL (about 8 teaspoons) 
Study treatment, Day 7 visit: 6 mL (about 1 teaspoon) 
Final visit or early discontinuation visit: 6 mL (about 1 teaspoon) 
 
Pregnancy test: If you are a woman who is able to become pregnant, you will be asked to give a 
small urine or blood sample (about 5 mL or 1 teaspoon) for a pregnancy test. 
 


 
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Saliva collected: Saliva will be collected for the NAT2 genetic test, which looks at changes in a 
single human gene that may affect how quickly your body breaks down INH. This test will not 
look at any other genes.  
 
Sputum collected: You will be asked to provide sputum samples. To provide this sample, you 
will be asked to cough deeply and then spit into a cup. If you need help to cough deeply, the 
clinic staff may ask you to briefly breathe a mist of saltwater through a tube or a mask. At pre-
entry, entry, and days 1 through 7, sputum will be collected each night (starting around 4 PM) 
for 16 hours. This sputum will be checked for the bacteria that causes TB and to see if these 
bacteria are resistant to INH.  
 

SAP_002.pdf: 
 
 
 
 
ACTG A5312 
 
Statistical Analysis Plan for Pharmacology Objectives 
Version 1.0 
 
This is the ACTG A5312 Pharmacology SAP Version 1.0 with names of authors, names 
of publication writing team members, and analysis timeline redacted. 
 
 
 
The Early Bactericidal Activity of High-Dose or Standard-Dose 
Isoniazid among Adult Participants with Isoniazid-Resistant or Drug-
Sensitive Tuberculosis  
 
 
ClinicalTrials.gov Identifier: NCT01936831 
 
November 21, 2022 
 
 
 
 
 


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November 21, 2022 
Page 2 of 10 
 
2 
Table of Contents 
1 
Introduction ............................................................................................................................................ 3 
1.1 
Purpose .......................................................................................................................................... 3 
1.2 
Key Updates to the SAP ................................................................................................................ 3 
2 
Protocol Overview .................................................................................................................................. 3 
2.1 
Study Design (Protocol Version 3.0) .............................................................................................. 3 
2.2 
Major Protocol Revisions ............................................................................................................... 5 
2.3 
Primary Pharmacology Objective ............................................................................................... 6 
2.3.1 
Determine the association between the area under the curve (AUC)/MIC of INH and the EBA of 
INH among participants with smear-positive pulmonary TB. ..................................................................... 6 
2.4 
Secondary Pharmacology Objectives ........................................................................................ 7 
2.4.1 
Determine the steady state pharmacokinetics (PK) of INH among participants with sputum 
smear-positive pulmonary TB taking 5, 10, 15, or 20 mg/kg daily, taking into account INH acetylator 
status (N-acetyltransferase 2 [NAT2] genotype). ....................................................................................... 7 
2.4.2 
Determine and describe the distribution of MICs of M. tuberculosis isolates with genotypic 
evidence of low-level INH resistance (inhA mutations), high-level INH resistance (katG mutations), or 
neither of these mutations among participants with smear-positive pulmonary TB. .................................. 7 
2.4.3 
Estimate the proportion of participants infected with a TB strain that has an inhA or katG 
mutation that will achieve a target AUC/MIC that is associated with clinically relevant reductions in 
mycobacterial burden defined as at least 50% the EBA0-7 of standard-dose INH when given to 
participants with DS-TB, by dose. .............................................................................................................. 7 
2.5 
Exploratory Pharmacology Objectives ...................................................................................... 7 
2.5.1 
Evaluate the ability of a new PCR method that uses salivary samples to correctly characterize 
NAT2 genotype compared to standard NAT2 genotyping methods using blood samples and sequencing 
methodology. .............................................................................................................................................. 7 
This objective will be addressed in a separate SAP. ............................................................................ 7 
3 
Definitions ............................................................................................................................................... 7 
3.1 
Endpoint Definitions .................................................................................................................... 7 
3.2 
Analysis Populations ................................................................................................................... 8 
4 
Statistical Methods ................................................................................................................................. 8 
4.1 
General Considerations ................................................................................................................. 8 
4.2 
Analyses to address the primary pharmacology objective ............................................................. 8 
4.3 
Analyses to address secondary pharmacology objective 1 ........................................................... 9 
4.4 
Analyses to address secondary pharmacology objective 2 ........................................................... 9 
 
 
 


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1 Introduction 
1.1 Purpose 
This Pharmacology Statistical Analysis Plan (SAP) describes the pharmacology-related primary and 
secondary outcomes measures of ACTG A5312 that will be included in the primary manuscript, and that 
address the pharmacology-related primary and secondary objectives of the study. The Pharmacology SAP 
outlines the general statistical approaches that will be used in the analyses to address these objectives. It 
has been developed to facilitate discussion of the statistical analysis components among the study team, 
and to provide agreement between the study team, pharmacometricians, and statisticians regarding the 
statistical analyses to be performed and presented in the pharmacology statistical analysis report. It also 
describes the results for the primary and secondary outcome measures that will be posted on 
ClinicalTrials.gov. 
 
An original component of the EBA study, which had participants infected with TB with inhA mutations take 
one of three doses of INH (5, 10, or 15 mg/kg daily) and participants infected with DS-TB take standard-
dose INH (5 mg/kg daily), was terminated early by the TB TSG on May 4, 2018. With protocol version 3.0, 
dated August 21, 2018, participants infected with TB with katG mutations are also included in the EBA part 
of the study (Step 2), and randomized to one of the two treatment groups (15 or 20 mg/kg daily INH). This 
statistical analysis plan is based on protocol version 3.0.  
 
Regarding including participants infected with TB with katG mutations taking 15 or 20 mg/kg daily into Step 
2 of the study (protocol version 3.0): Analysis of these data the will be conducted after 20 eligible participants 
in this group complete the 7-day treatment period, and data become available. Analysis will be similar to 
what is described here for Groups 1 (participants infected with TB with inhA mutations) and 2 (participants 
infected with drug-sensitive TB, with neither inhA nor katG mutations).   
 
Version 1.0 of this Pharmacology Statistical Analysis plan will be used for submission of results to 
ClinicalTrials.gov. Results are required to be submitted within one year of the primary completion date 
(PCD), which is the date the last participant with katG mutations is examined for the purposes of data 
collection for the primary outcome measure.    
1.2 Key Updates to the SAP 
Version  
Changes Made 
Rationale 
Effective Date 
1.0 
(Original version) 
(Original version) 
November 21, 2022 
 
2 Protocol Overview 
2.1 Study Design (Protocol Version 3.0) 
This is a two-stage, two-step, phase IIa, open-label, randomized clinical trial examining the bactericidal 
activity (EBA) of (1) isoniazid (INH) at three different doses for treatment of isolates with inhA mutations; (2) 
INH at two different doses for treatment of isolates with katG mutations; and (3) INH at standard dosing 


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November 21, 2022 
Page 4 of 10 
 
among patients with drug-sensitive TB (DS-TB). In addition, the association between the EBA among 
patients with DR-TB and pharmacokinetic (PK) parameters will be examined. 
 
The study will be conducted in 2 stages. Stage 1 will be a pilot for determination of feasibility (accrual and 
speed) and sample size verification, and Stage 2 will be the main study. During Stage 2, participants with 
acid fast bacilli (AFB) smear-positive pulmonary TB with a Mycobacterium tuberculosis isolate with an inhA 
mutation, which generally confers low-level INH resistance, will be randomized to receive INH at 5, 10, or 
15 mg/kg daily for 7 days (Group 1). Participants with an M. tuberculosis isolate with a katG mutation (with 
or without an inhA mutation), which associated with high-level resistance, will be randomized 1:1 to receive 
either INH 15 mg/kg or 20 mg/kg daily for 7 days (Group 3). During Stage 1, participants with M. tuberculosis 
harboring neither inhA nor katG INH resistance mutations (Group 2) will not receive study treatment, but a 
maximum of 64 in this group will have a sputum sample collected for MIC determination. During Stage 2, 
Group 2 participants will be enrolled as a positive control group and receive INH at 5 mg/kg daily for 7 days. 
Among patients receiving study treatment, serial sputum samples, including quantitative cultures and liquid 
cultures, will be collected daily between pre-entry and Day 7 to determine EBA of the study treatment over 
the treatment period. 
 
Each stage consists of two steps. The goal of Step 1 is to determine the MIC distribution of M. tuberculosis 
strains among participants with DR-TB or DS-TB. The goal of Step 2 is to examine the treatment effect of 
INH at different doses among participants with an inhA mutation (in both stages), a katG mutation (in Stage 
2 only) or DS-TB (in Stage 2 only). In Step 1, a spot sputum sample will be collected from all eligible 
participants for acid fast bacilli (AFB) microscopy, for genotypic determination of INH resistance (inhA or 
katG mutations), and for phenotypic determination of INH MIC. In Step 2, eligible participants will be 
administered INH daily for 7 days and have serial overnight sputum sampling for estimation of participant-
specific EBA (both quantitative and liquid cultures). Intensive PK samples for INH quantification, and blood 
and saliva samples for NAT2 determination, will also be collected in Step 2. 
 
Participants who are screened for the study, but are not eligible to receive study treatment will be referred 
without delay for appropriate treatment. Those who are registered or randomized to receive treatment will 
be referred without delay to appropriate treatment after completing study treatment (no later than Day 10). 
 
SAMPLE SIZE: Among participants eligible to participate in Step 1 only, accrual targets are 70, 64, and 
84 participants from Groups 1, 2, and 3, respectively. These participants may be enrolled during Stages 1 
or 2. 
Among participants eligible to enroll in Step 1 and Step 2, accrual targets are as follows: 
• 
Group 1: 48 evaluable participants (16 completing treatment in each dosing cohort) from Stage 1 
and Stage 2 combined. During Stage 1, 15 Group 1 participants were enrolled (5 per dosing 
cohort) as of March 26, 2015. Stage 2 opened and an additional 33 Group 1 participants will be 
randomized (11 participants added to each cohort, for a total of 16 participants per cohort)  
• 
Group 2: 16 evaluable participants will be followed as a fourth Step 2 cohort, enrolled during 
Stage 2.  
• 
Group 3: 20 evaluable participants (10 completing treatment in each dosing cohort) will be 
randomized. 
 


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2.2 Major Protocol Revisions  
Participants enrolled under three versions of the protocol.  Here we summarize the main purposes of the 
protocol version changes and the LOAs. 
• 
Protocol Version 1.0 (dated October 25, 2015) 
• 
Protocol Version 1.0 LOA#1 (dated May 4, 2013) – approved on September 17, 2015 
The main purpose was to modify the protocol to reflect the decision to conduct A5312 as a non-
IND study.  
• 
Protocol Version 1.0 LOA #2 (dated January 16, 2015) – approved on September 17, 2015 
The main purpose was to relax the Step 2 entry criteria to improve recruitment. The changes 
included, 1) HIV-positive candidates with CD4+ cell count of ≥50 cells/mm3 (instead the original 
cut off of 200 cells/mm3) are eligible for the study, and 2) The exclusion of current treatment, or 
treatment within 30 days prior to entry, with antiretroviral therapy (ART) or expected to initiate 
ART within 8 days after Step 2 entry has been removed. 
• 
Protocol Version 1.0 LOA #3 (dated April 10, 2015) 
The main purpose was to to increase the target accrual for Groups 1 and 2 during Step 1. 
• 
Protocol Version 2.0 (dated August 18, 2015) – approved on February 4, 2016 
The main changes were to increase the target accrual for Groups 1 and 2 during Step 1 (the 
target accrual for Groups 1 and 2 during Step 2 remains the same), to change the consent forms, 
to change the inclusion criteria for Group 3 to allow participants who have a katG mutation with or 
without an inhA mutation to enter study, and update protocol for the completion of Stage 1.   
• 
LOA #1 after Protocol Version 2.0 (dated October  2016) – approved by the TB TSG Steering on 
September 28, 2016 
The main changes were to relax the exclusion criteria on usage of second-line anti-TB drugs 
and/or antibiotics intended for bacterial treatment prior to Step 1 screening (relaxed Section 4.4.2 
and removed Section 4.4.3 of the protocol).   
• 
Protocol Version 3.0 (dated August 21, 2018) 
The main change was to enroll participants with an M. tuberculosis isolate with a katG mutation 
(with or without an inhA mutation), associated with high-level resistance for Step 2 for the 
bactericidal activity analysis. During Stage 2, participants with an M. tuberculosis isolate with a 
katG mutation who meet Step 1 and Step 2 entry criteria are to be randomized 1:1 to receive 
either INH 15 mg/kg or 20 mg/kg daily for 7 days. Participants who do not meet Step 2 criteria will 
be enrolled in Step 1 only. 
 
• 
LOA #1 after Protocol Version 3.0 (dated August 3, 2020) 


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This amendment was implemented to reopen the study to screening and accrual following closure 
due to COVID-19 on March 27, 2020 by the ACTG Network. 
 
In addition to the LOA, five Clarification Memos (CMs) were issued after protocol version 1.0 was 
released, three CMs were issued after protocol version 2.0 was released, and two CMs were issued after 
protocol version 3.0 was released. The list below summarizes the main purpose of each CM.  
• 
CM#1 on Protocol Version 1.0 (dated July 25, 2013) 
The main purpose was to clarify the sample size descriptions in Section 9.4 and 9.6.2.5. 
 
• 
CM#2 on Protocol Version 1.0 (dated September 24, 2013) 
The main purpose was to remove language regarding non-inferiority testing from the protocol.   
 
• 
CM#3 on Protocol Version 1.0 (dated November 13, 2013) 
The main purpose was to remove secondary objective 1.3.5 and the corresponding endpoint 
(9.2.2.5) and analysis (9.6.2.5). 
 
• 
CM#4 on Protocol Version 1.0 (dated January 13, 2014) 
The main purpose was to clarify that Brooklyn Chest Hospital will participate in Stage 1 of the 
protocol.   
 
• 
CM#5 on Protocol Version 1.0 (dated February 4, 2014) 
The main purpose was to update the biohazard containment section to include instructions on the 
transport of Mycobacterium tuberculosis material. 
 
• 
CM#1 on Protocol Version 2.0 (dated September 14, 2015) 
The main purpose of this memo was to remove ethambutol (EMB) resistance testing from the 
study. 
 
• 
CM #2 on Protocol Version 2.0 (dated November 17, 2015) 
The main purpose of this memo was to add PK sampling windows to the study. 
 
• 
CM #3 on Protocol Version 2.0 (dated January 6, 2016) 
The purpose of this memo was to clarify that antiretroviral medications were no longer prohibited 
as per the eligibility criterion change made with A5312 Version 1.0, Letter of Amendment #2. 
 
• 
CM #1 on Protocol Version 3.0 (dated December 12, 2019) 
The main reason for this memo was to clarify the target accrual for the study. 
 
• 
CM #2 for protocol Version 3.0 (dated February 25, 2020) 
The reason for this memo was to clarify the washout period for drugs with anti-TB activity. 
 
2.3 Primary Pharmacology Objective 
 
2.3.1 
Determine the association between the area under the curve (AUC)/MIC of INH and the EBA 


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of INH among participants with smear-positive pulmonary TB. 
 
2.4 Secondary Pharmacology Objectives 
 
2.4.1 
Determine the steady state pharmacokinetics (PK) of INH among participants with sputum 
smear-positive pulmonary TB taking 5, 10, 15, or 20 mg/kg daily, taking into account INH 
acetylator status (N-acetyltransferase 2 [NAT2] genotype). 
 
2.4.2 
Determine and describe the distribution of MICs of M. tuberculosis isolates with genotypic 
evidence of low-level INH resistance (inhA mutations), high-level INH resistance (katG 
mutations), or neither of these mutations among participants with smear-positive pulmonary 
TB.  
 
2.4.3 
Estimate the proportion of participants infected with a TB strain that has an inhA or katG 
mutation that will achieve a target AUC/MIC that is associated with clinically relevant 
reductions in mycobacterial burden defined as at least 50% the EBA0-7 of standard-dose INH 
when given to participants with DS-TB, by dose.  
 
2.5 Exploratory Pharmacology Objectives 
 
2.5.1 
Evaluate the ability of a new PCR method that uses salivary samples to correctly characterize 
NAT2 genotype compared to standard NAT2 genotyping methods using blood samples and 
sequencing methodology. 
 
This objective will be addressed in a separate SAP. 
3 Definitions 
 
3.1 Endpoint Definitions  
 
Intensive PK sampling was conducted on study day 6, when the participant will have reached steady-
state. Sample times were pre-dose, and 0.5, 1, 2, 4, 6, 8, 12 and 24 hours after the dose taken in the 
clinic. Concentrations from intensive sampling are used to estimate participant specific steady-state INH 
PK parameters, using noncompartmental analysis. Details are as follows: 
• 
Minimum concentration, Cmin:  the minimum plasma concentration observed in the 24-hour dosing 
interval.  
• 
Maximum concentration, Cmax:  the maximum plasma concentration observed in the 24-hour 
dosing interval. 
• 
Time of maximum concentration, Tmax:  the time at which Cmax occurred. If there is a tie for 
maximum concentration, Tmax is assigned the earliest such sample time. 
• 
Area under the concentration-time curve from 0-24 hours, AUC0-24:  the AUC will be calculated 
using the linear trapezoidal rule (the sum of adjacent trapezoids in the concentration-time curve). 
In calculation of AUC, the estimated concentration at precisely 24 hours (𝐶̂24) will be used, where 
𝐶̂24 is estimated using the observed concentrations and times for the samples scheduled to be 
collected at 12 and 24 hours after the in-clinic dose. A simple linear regression model is fit to 
these two points. The concentration at exactly 24 hours is estimated from the intercept and slope 
estimates. (This approach guards against a upward/downward bias in AUC when the final sample 
was collected before/after 24 hours.  In the case where the sample time was exactly 24 hours, the 
observed and estimated concentrations at 24 hours are identical.) 
• 
Elimination half-life, T½: assuming exponential decay, participant-specific half-life will be estimated 
by first fitting a log-linear regression (log base e) to the 3 or more observed concentrations (in the 


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participant’s concentration-time data) that occur after (ie, not including) Cmax, provided all such 
concentrations are monotonically decreasing; if 3 such terminal concentrations are not available, 
half-life will not be calculated. The value of half-life is given by ln(2)/ke, where ke, is the participant-
specific estimated slope with the sign reversed (ie, expressed as a positive number). The values 
below limit of quantification (BLQ) will be removed when calculating half-life. 
• 
Apparent oral clearance, CL/F: estimated as the (daily) dose amount divided by the AUC (after 
converting numerator and denominator to like units). 
 
Activity parameters EBA0-7(CFU) and EBA0-7(TTD) are defined in the Primary Statistical Analysis Plan, 
version 1.0. 
 
3.2 Analysis Populations 
 
Pharmacology population: The pharmacology population is defined as those participants: (1) whose 
intensive PK sampling began on study day 6, (2) who were fasted (nothing by mouth except water and 
study medications from 2 hours pre-dose to 1 hour post-dose) at the time of the pre-dose sample, (3) who 
had taken at least 2 INH doses within the 52-hour period prior to the pre-dose sample, and (4) for whom 
concentrations are available for both the 1- and 2-hour sample (so as not to miss Tmax). 
 
Efficacy population: The efficacy population is limited to participants in the pharmacology population for 
whom INH AUC or INH MIC is available, and for whom EBA0-7(CFU) and/or EBA0-7(TTD) are available. 
4 
Statistical Methods 
4.1 General Considerations 
For visit schedule and analysis windows, see the “A5312_final_analysis_SAP_v1.0.docx.”  
 
Categorical data will be summarized using N (%).  PK parameters and MIC will be summarized using N, 
min, Q1, median, Q3, max.  Other continuous data will be summarized using N, min, Q1, median, Q3, 
max, mean and standard deviation (SD).  
4.2 Analyses to address the primary pharmacology objective  
Determine the association between the area under the curve AUC of INH and the EBA of INH among 
participants with smear-positive pulmonary TB (post hoc change from AUC/MIC to AUC1).   
 
Pharmacometricians will address this objective as follows: 
 
The drug-induced bacterial killing for sputum solid culture colony-forming unit (CFU) and growth of 
bacteria in Mycobacteria Growth Indicator Tube (MGIT) for time to positivity (TTP) will be jointly modelled 
using nonlinear mixed-effects modelling. A mono-exponential model will be used to describe the bacterial 
load decline in CFU, while an exponential growth model will be used to describe the TTP in MGIT. The 
two models will be joined by using the predicted CFU bacterial load in the sputum to initialize the MGIT 
inoculum. An Emax model will be used to relate isoniazid AUC to the kill rate of the bacteria in the CFU. If 
the unavailable CFU data in Group 3 participants results in the underperformance of the above-described 
 
1 Regarding the post hoc change from AUC/MIC to AUC as the explanatory variable, in the time since the 
protocol was written, the team has reconsidered the interpretability of MIC testing using the 1% agar method (which 
was used in protocol versions 1.0 and 2.0), and is reporting only MICs obtained using Thermo Fisher Sensitre 
MYCOTB plates (which was used in protocol version 3.0).  Only participants with a katG mutation were treated with 
INH and had MIC testing using this method.  In addition, the low data availability for MICs limits its usefulness in 
modeling.  


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model, a linear mixed-effects model will be used to evaluate the entire TTP profile, exploring the effect of 
isoniazid area under concentration curve (AUC0-24) covariation with longitudinal changes in TTP. 
 
For clinicaltrials.gov, the outcomes measures (INH AUC, EBA0-7(CFU) and EBA0-7(TTP)) will be 
summarized. 
4.3 Analyses to address secondary pharmacology objective 1  
Determine the steady state pharmacokinetics (PK) of INH among participants with sputum smear-
positive pulmonary TB taking 5, 10, 15, or 20 mg/kg daily, taking into account INH acetylator status 
(N-acetyltransferase 2 [NAT2] genotype). 
 
Pharmacologists will address this objective for the submission of study results to clinicaltrials.gov as 
follows: 
 
Participant-specific PK parameters will be estimated using noncompartmental methods. 
 
For the PK parameters Cmin, Cmax, and AUC0-24h:  N, min, max, median, and the 25% and 75% percentiles 
will be tabulated for the following categories listed below. Additional parameters (Tmax, CL/F, T½) and 
statistics (min, Q1, median, Q3, max) will also be summarized but are not required for clinicaltrials.gov 
submission. 
 
Resistance/dose groups 
1. Group 1:  inhA resistance mutation 
a) 5 mg/kg/day 
b) 10 mg/kg/day 
c) 15 mg/kg/day 
2. Group 2:  neither inhA nor katG resistance mutation 
a)  5 mg/kg/day 
3. Group 3: katG resistance mutation 
a) 15 mg/kg/day 
b) 20 mg/kg/day 
Additional analysis stratified by NAT2 acetylator status will be done, but will not be included in 
clinicialtrials.gov. 
 
4.4 Analyses to address secondary pharmacology objective 2  
Determine and describe the distribution of MICs of M. tuberculosis isolates with genotypic evidence of 
low-level INH resistance (inhA mutations), high-level INH resistance (katG mutations), or neither of 
these mutations among participants with smear-positive pulmonary TB. 
 
Statisticians will address this objective for the submission of study results to clinicaltrials.gov as 
follows: 
 
Descriptive statistics of MICs with N missing, N, median (IQR), min, and max will be summarized by 
mutation group (inhA mutation, katG mutation, or neither of these mutations).  
 
Analyses to address secondary pharmacology objective 3  
Estimate the proportion of participants infected with a TB strain that has an inhA or katG mutation that 
will achieve a target AUC/MIC that is associated with clinically relevant reductions in mycobacterial 


A5312 Pharmacology Statistical Analysis Plan, v1.0   
 
 
 
November 21, 2022 
Page 10 of 10 
 
burden defined as at least 50% the EBA0-7 of standard-dose INH when given to participants with DS-
TB, by dose. 
 
Post hoc change:  Given the complexity of the EBA PK-PD model and the associated variability, technical 
issues with MIC determination using the 1% agar solution method used for participants with inhA mutated 
or DS-TB (Groups 1 and 2) and non-comparability of those results to MIC determination using Thermo 
Fisher Sensititre MYCOTB plates (used for Group 3), the analysis team decided that establishing a target 
based on AUC or AUC/MIC would be problematic.  Instead, the median drop in log10 CFU in participants 
with DS-TB (Group 2) on day 7 of treatment was identified and divided by two, to arrive at a target EBA.  
Analysis will focus on estimating the proportions of participants in each group/dose who achieve that 
target. 
 
 
Pharmacometricians will address this objective for the submission of study results to clinicaltrials.gov 
as follows: 
 
The DS-TB arm day 7 drop per mL in log10 CFU was 1.3 log10 CFU; half of this drop is 0.65 log10 CFU 
which will be the target change in EBA from day 0 to day 7.  Analysis will focus on reporting the proportion 
of participants in each group/dose whose estimated EBA was 0.65 log10 CFU/mL or larger (median of 
bootstrap simulations) along with a bootstrap 95% confidence interval (5th and 95th percentiles of 
bootstrap simulations). In the simulations, a distribution of NAT2 genotypes will be assumed which 
matches the distribution observed in Group 1 and 2 participants (14% rapid, 58% intermediate, and 28% 
slow acetylators2). 
 
 
 
2 Gausi K, Ignatius EH, Sun X, Kim S, Moran L, Wiesner L, et al. A Semimechanistic Model of the Bactericidal Activity 
of High-Dose Isoniazid against Multidrug-Resistant Tuberculosis: Results from a Randomized Clinical Trial. Am J 
Respir Crit Care Med [Internet]. 2021 Dec 1 [cited 2021 Sep 15];204(11):1327–35. Available from: 
www.atsjournals.org. 

SAP_001.pdf: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Approvals 
 


A5312 Primary Statistical Analysis Plan  
 
 
 
 
 
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Page 1 of 13 
 
 
 
 
 
 
ACTG A5312 
 
Statistical Analysis Plan for Primary Analysis 
 
Version 3.0 
 
This is ACTG A5312 SAP Version 3.0 with names of authors, names of publication 
writing team members and analysis timeline redacted. 
 
 
 
The Early Bactericidal Activity of High-Dose or Standard-Dose 
Isoniazid among Adult Participants with Isoniazid-Resistant or Drug-
Sensitive Tuberculosis 
Protocol Version 3.0 
 
 
 
 
ClinicalTrials.gov Identifier: NCT01936831 
 
May 5, 2022 
 
 
 
 
 
 
 
 


A5312 Primary Statistical Analysis Plan  
 
 
 
 
 
May 5, 2022 
 
Page 2 of 13 
 
 
Table of Contents 
 
1 
Introduction ............................................................................................................................................ 3 
1.1 
Purpose .......................................................................................................................................... 3 
1.2 
Key Updates to the SAP ................................................................................................................ 3 
2 
Protocol Overview .................................................................................................................................. 4 
2.1 
Study Design (Protocol Version 3.0) .............................................................................................. 4 
2.2 
Major Protocol Revisions ............................................................................................................... 5 
2.3 
Hypotheses ................................................................................................................................... 7 
2.4 
Primary Objectives ....................................................................................................................... 7 
2.5 
Secondary Objectives.................................................................................................................. 7 
2.6 
Exploratory Objectives ................................................................................................................ 8 
3 
Definitions ............................................................................................................................................... 8 
3.1 
Analysis Population ..................................................................................................................... 8 
3.2 
Endpoint Definitions .................................................................................................................... 8 
4 
Statistical Methods ................................................................................................................................. 9 
4.1 
General Considerations ................................................................................................................. 9 
4.2 
Visit Schedule and Analysis Windows ........................................................................................... 9 
4.3 
Analyses of Outcomes Measures ............................................................................................. 12 
4.3.1 
Primary outcomes .................................................................................................................... 12 
4.3.2 
Secondary outcomes ............................................................................................................... 12 
5 
Report components .............................................................................................................................. 13 
1. 
Recruitment/Accrual ................................................................................................................. 13 
 
 
 


A5312 Primary Statistical Analysis Plan  
 
 
 
 
 
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1 Introduction 
1.1 Purpose 
This Primary Statistical Analysis Plan (SAP) describes the primary and secondary outcomes measures of 
ACTG A5312 that will be included in the primary manuscripts, and which address the primary and secondary 
objectives of the study.  The Primary SAP outlines the general statistical approaches that will be used in the 
analysis of the study.  It has been developed to facilitate discussion of the statistical analysis components 
among the study team, and to provide agreement between the study team and statisticians regarding the 
statistical analyses to be performed and presented in the primary statistical analysis report.  It also describes 
the results for the primary and secondary outcome measures that will be posted on ClinicalTrials.gov.  
Outlines of analyses for the other objectives will be presented in the SAP for Other Objectives.  Detailed 
outlines of tables, figures, and coding descriptions that will be included in the Primary Analysis Report are 
included in the Analysis Implementation Plan (AIP). 
 
An original component of the EBA study, which would have participants infected with TB with inhA mutations 
take one of three doses of INH (5, 10, or 15 mg/kg daily) and participants infected with DS-TB take standard-
dose INH (5 mg/kg daily), was terminated early by the TB TSG on May 4, 2018. Protocol version 3.0 allows 
enrollment of participants infected with TB with katG mutations into the EBA part of the study (Step 2) and 
randomizes them to one of the two treatment groups (15 or 20 mg/kg daily INH). This statistical analysis 
plan is based on version 3.0. Analysis for the participants infected with TB with katG mutations taking 15 or 
20 mg/kg daily will be conducted after approximately 20 eligible participants in this group complete the 7-
day treatment period, and data become available.  
 
The two final statistical reports will be used for submission of results to ClinicalTrials.gov. Results are 
required to be submitted within one year of the primary completion date (PCD), which is the date the last 
participant with katG mutations is examined for the purposes of data collection for the primary outcome 
measure.    
1.2 Key Updates to the SAP 
Version 
Changes Made 
Date finalized 
1 
Original Version 
7/2/2018 
1 
Protocol amendment review (Version 3.0) by Sachiko 
Miyahara and Xin Sun 
3/28/2019 
2 
Review after LOA #1. Updated the protocol overview to 
describe the LOA and CMs and personnel changes.  
The plans for analysis are unchanged. 
1/21/2021 
3 
A new lab, BARC, did culture for TASK participants 
enrolled in protocol Version 3.0 and reported re-
cultured results after additional decontamination. 
These results were not supposed to be reported (were 
not reported previously) and will be excluded from 
analysis.  Under protocol Version 3.0 TTP is not done 
in duplicate for each sample so this has been clarified.  
Clarified that a separate statistical report will be 
prepared for participants enrolled under protocol 
Version 3.0.  Added Ryan Wu to statistical team. 
5/5/2022 


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2 Protocol Overview 
2.1 Study Design (Protocol Version 3.0) 
This is a two-stage, two-step, phase IIa, open-label, randomized clinical trial examining the bactericidal 
activity (EBA) of (1) isoniazid (INH) at three different doses among patients with drug-resistant tuberculosis 
(DR-TB) and (2) INH at standard dosing among patients with drug-sensitive TB (DS-TB). In addition, the 
association between the EBA among patients with DR-TB and pharmacokinetic (PK) parameters, such as 
area under the curve (AUC)/minimum inhibitory concentration (MIC) of INH, will be examined. 
 
The study will be conducted in 2 stages. Stage 1 will be a pilot for determination of feasibility (accrual and 
speed) and sample size verification, and Stage 2 will be the main study. During Stage 2, participants with 
acid fast bacilli (AFB) smear-positive pulmonary TB with a Mycobacterium tuberculosis isolate with an inhA 
mutation, which generally confers low-level INH resistance, will be randomized to receive INH at 5, 10, or 
15 mg/kg daily for 7 days (Group 1). Participants with an M. tuberculosis isolate with a katG mutation (with 
or without an inhA mutation), which is associated with high-level resistance, will be randomized 1:1 to 
receive either INH 15 mg/kg or 20 mg/kg daily for 7 days (Group 3). During Stage 1, participants with M. 
tuberculosis harboring neither inhA nor katG INH resistance mutations (Group 2) will not receive study 
treatment, but a maximum of 48 in this group will have a sputum sample collected for MIC determination. 
During Stage 2, Group 2 participants will be enrolled as a positive control group and receive INH at 5 mg/kg 
daily for 7 days. Among patients receiving study treatment, serial sputum samples, including quantitative 
cultures and liquid cultures, will be collected daily between pre-entry and Day 7 to determine EBA of the 
study treatment over the treatment period. 
 
Each stage consists of two steps. The goal of Step 1 is to determine the MIC distribution of M. tuberculosis 
strains among participants with DR-TB or DS-TB. The goal of Step 2 is to examine the treatment effect of 
INH at different doses among participants with an inhA mutation (in both stages), a katG mutation (in Stage 
2 only) or DS-TB (in Stage 2 only). In Step 1, a spot sputum sample will be collected from all eligible 
participants for acid fast bacilli (AFB) microscopy, for genotypic determination of INH resistance (inhA or 
katG mutations), and for phenotypic determination of INH MIC. In Step 2, eligible participants will be 
administered INH daily for 7 days and have serial overnight sputum sampling for estimation of participant-
specific EBA (both quantitative and liquid cultures). Intensive PK samples for INH quantification, and blood 
and saliva samples for NAT2 determination, will also be collected in Step 2. 
 
Participants who are screened for the study, but are not eligible to receive study treatment will be referred 
without delay for appropriate treatment. Those who are registered or randomized to receive treatment will 
be referred without delay to appropriate treatment after completing study treatment (no later than Day 10). 
 
SAMPLE SIZE: Among participants eligible to participate in Step 1 only, accrual targets are 70, 64, and 
64 participants from Groups 1, 2, and 3, respectively. These participants may be enrolled during Stages 1 
or 2. 
Among participants eligible to enroll in Step 1 and Step 2, accrual targets are as follows: 


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• 
Group 1: 48 evaluable participants (16 completing treatment in each dosing cohort) from Stage 1 
and Stage 2 combined. During Stage 1, 15 Group 1 participants were enrolled (5 per dosing 
cohort) as of March 26, 2015. Stage 2 opened and an additional 33 Group 1 participants will be 
randomized (11 participants added to each cohort, for a total of 16 participants per cohort)  
• 
Group 2: 16 evaluable participants will be followed as a fourth Step 2 cohort, enrolled during 
Stage 2.  
• 
Group 3: No participants in Group 3 will enter Step 2 during original component (i.e. Protocol 
Version 2.0).  Protocol Version 3.0 will enrolled 20 participants in Group 3 Step 2, randomized 1:1 
to either INH 15 mg/kg (n=10) or INH 20 mg/kg (n=10) daily, plus vitamin B6 ≥25 mg daily for 7 
days. 
2.2 Major Protocol Revisions  
Version 2.0 of the study protocol had two Letters of Amendments (LOA).  One additional LOA was 
approved by the TB TSG Steering Committee in September 2016 to improve accrual. Version 3.0 of the 
protocol was finalized on March 15, 2018.  The list below summarizes the main purposes of the LOAs and 
the changes in Version 2.0 from Version 1.0 and in Version 3.0 from Version 2.0. 
• 
LOA#1 (dated May 4, 2013) – approved on September 17, 2015 
The main purpose was to modify the protocol to reflect the decision to conduct A5312 as a non-
IND study.  
• 
LOA #2 (dated January 16, 2015) – approved on September 17, 2015 
The main purpose was to relax the Step 2 entry criteria to improve recruitment. The changes 
included, 1) HIV-positive candidates with CD4+ cell count of ≥50 cells/mm3 (instead the original 
cut off of 200 cells/mm3) are eligible for the study, and 2) The exclusion of current treatment, or 
treatment within 30 days prior to entry, with antiretroviral therapy (ART) or expected to initiate 
ART within 8 days after Step 2 entry has been removed. 
• 
Protocol Version 2.0 (dated August 18, 2015)  
The main changes were to increase the target accrual for Groups 1 and 2 during Step 1 (the 
target accrual for Groups 1 and 2 during Step 2 remains the same), to change the consent forms, 
to change the inclusion criteria for Group 3 to allow participants who have a katG mutation with or 
without an inhA mutation to enter study, and update protocol for the completion of Stage 1.   
• 
LOA #1 after Protocol Version 2.0 (dated October  2016) – approved by the TB TSG Steering on 
September 28, 2016 
The main changes were to relax the exclusion criteria on usage of second-line anti-TB drugs 
and/or antibiotics intended for bacterial treatment prior to Step 1 screening (relaxed Section 4.4.2 
and removed Section 4.4.3 of the protocol).   


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• 
Protocol Version 3.0 (dated August 21, 2018)  
The main purpose of this amendment was to add a treatment cohort for participants with katG 
mutation (Group 3) randomizing them 1:1 to receive either INH 15 mg/kg (n=10) or INH 20 mg/kg 
(n=10) daily, plus vitamin B6 ≥25 mg daily for 7 days.  Accrual targets were increased for Group 3 
to recruit eligible participants. 
• 
LOA #1 for Protocol Version 3.0 (dated August 3, 2020)  
On March 18, 2020 the ACTG Network Leadership issued guidance designed to protect the 
health of ACTG study participants and the ACTG research community and support the best 
outcomes for our research program.  For A5312 this guidance closed recruiting of new study 
participants but allowed those in screening at that date to be enrolled.  The LOA was implemented 
to reopen the study to screening and accrual. 
In addition to the LOAs, five Clarification Memos (CMs) were issued after protocol version 1.0 was 
released, one CM was issues after protocol version 2.0 was released, and two CMs were issued after 
protocol version 3.0 was released. The list below summarizes the main purpose of each CM.  
• 
CM#1 (dated July 25, 2013) 
The main purpose was to clarify the sample size descriptions in Section 9.4 and 9.6.2.5. 
 
• 
CM#2 (dated June 27, 2013) 
The main purpose was to remove language regarding non-inferiority testing from the protocol.   
 
• 
CM#3 (dated November 13, 2013) 
The main purpose was to remove secondary objective 1.3.5 and the corresponding endpoint 
(9.2.2.5) and analysis (9.6.2.5). 
 
• 
CM#4 (dated January 13, 2014) 
The main purpose was to clarify that Brooklyn Chest Hospital will participate in Stage 1 of the 
protocol.   
 
• 
CM#5 (dated February 4, 2014) 
The main purpose was to update the biohazard containment section to include instructions on the 
transport of Mycobacterium tuberculosis material.   
 
• 
CM#1 on Protocol Version 2.0 (dated February 4, 2014) 
The main purpose of this memo was to remove ethambutol (EMB) resistance testing from the 
study. 
• 
CM #1 on Protocol Version 3.0 (dated December 12, 2019) 
The main purpose of this memo was to clarify the sample size under Version 3.0, a total of 40 
Group 3 participants, 20 in Step 1 only and 20 in both Step 1 and Step 2.  It also clarified that CD4 
results from any network-approved lab with IQA certification was acceptable, including that used 
in inclusion criteria. 
 
• 
CM #2 on Protocol Version 3.0 (dated February 25, 2020) 


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This purpose of this memo was to clarify that participants who received 7 days or less of second-
line anti-TB drugs in the 14 days prior to Step 1 screening needed to have a washout period of at 
least 7 days prior to Step 2 pre-entry sputum collection. 
 
This statistical analysis plan is based on protocol version 3.0. 
 
 
2.3 Hypotheses 
 
1. In the majority of participants infected with TB with inhA mutations, drug concentrations can be 
achieved that will result in an early bactericidal activity (EBA) measured as the daily fall of log10 
colony-forming unit (CFU)/mL sputum over 7 days (EBA0-7(CFU)) that is at least 50% the EBA0-
7(CFU) of standard-dose isoniazid (INH) when given to participants with drug-sensitive TB (DS-
TB).  
 
2. High-dose INH will be well-tolerated in a majority of participants. 
 
3. Among participants infected with TB with katG mutations (Group 3), the distribution of minimum 
inhibitory concentrations (MICs) will be wide, but nevertheless, INH at a dose of 15 or 20 mg/kg 
daily will have measurable activity. 
 
2.4 Primary Objectives 
 
1. Estimate the 7-day EBA, based on CFU counts, of INH among participants infected with TB with 
inhA mutations taking one of three doses of INH (5, 10, or 15 mg/kg daily), and participants 
infected with DS-TB taking standard-dose INH (5 mg/kg daily). 
 
2. Estimate the 7-day EBA, based on time-to-detection (TTD), of INH among participants infected 
with TB with inhA mutations taking one of three doses of INH (5, 10, or 15 mg/kg), participants 
infected with TB with katG mutations taking 15 or 20 mg/kg daily, and participants infected with 
DS-TB taking standard-dose INH (5 mg/kg daily). 
 
3. Determine the association between the area under the curve (AUC)/MIC of INH and the EBA of 
INH among participants with smear-positive pulmonary TB. 
 
4. Describe the safety and tolerability of doses of 5, 10, and 15 mg/kg of INH administered daily 
among participants with sputum smear-positive pulmonary TB. 
 
2.5 Secondary Objectives 
 
1. Determine the steady state pharmacokinetics (PK) of INH among participants with sputum smear-
positive pulmonary TB taking 5, 10, or 15 mg/kg daily, taking into account INH acetylator status 
(N-acetyltransferase 2 [NAT2] genotype). 
 
2. Determine and describe the distribution of MICs of M. tuberculosis isolates with genotypic 
evidence of low-level INH resistance (inhA mutations), high-level INH resistance (katG mutations), 
or neither of these mutations among participants with smear-positive pulmonary TB. 


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Page 8 of 13 
 
 
 
3. Estimate the proportion of participants infected with a TB strain that has an inhA mutation that will 
achieve a target AUC/MIC that is associated with clinically-relevant reductions in mycobacterial 
burden defined as at least 50% the EBA0-7 of standard-dose INH when given to participants with 
DS-TB, by dose. 
 
4. Estimate linear or nonlinear model parameters based on EBA measured separately by CFU 
counts and time to detection (TTD) for INH among participants infected with TB with inhA 
mutations taking one of three doses of INH (5, 10, or 15 mg/kg daily),  participants infected with 
TB with katG mutations taking 15 or 20 mg/kg daily (if CFU data are available), and participants 
infected with DS-TB taking standard-dose INH (5 mg/kg daily). 
 
 
2.6 Exploratory Objectives 
 
1. Evaluate the correlation between EBA0-7 (TTD) and EBA0-7(CFU) among participants with 
smear-positive pulmonary TB. 
 
2. Evaluate the ability of a new PCR method that uses salivary samples to correctly characterize 
NAT2 genotype compared to standard NAT2 genotyping methods using blood samples and 
sequencing methodology. 
 
3. Estimate the prevalence of quinolone, and aminoglycoside resistance among study participants 
with MDR-TB receiving study treatment. 
3 Definitions 
 
3.1 Analysis Population 
 
Safety population: Safety analyses will be intent-to-treat and include all eligible participants who took at 
least one dose of study drugs.  
 
Efficacy population: The primary analyses will use a per-protocol approach, limited to participants who 
provide CFU and TTD data at both study entry and Day 7. For the model based analysis, all randomized 
participants who had at least one CFU count or TTD will be included.   
 
3.2 Endpoint Definitions 
The following is the calculation of log 10 transformed CFU/mL sputum at each time point. 
• 
log10 CFU/mL = log10[(average of CFU/mLA and CFU/mLB) x (dilution factor) x 10(Dilution)] where 
the dilution factor is set to 20. CFU/mLA and CFU/mLB are measured from the same sputum 
sample at a time point. 
 
Example: If CFU/mLA = 150, CFU/mLB = 185, and dilution = 4, then log10 CFU/mL = 7.53 
When multiple TTD results were obtained for a specimen (per Protocol Version 2.0 but not Protocol 
Version 3.0), the folllowing is the calculation of total TTD. 
• 
The final TTD is the mean of TTDA and TTDB. TTDA and TTDB are measured from the same 


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Page 9 of 13 
 
 
sputum sample at a time point. If one of the TTD is missing, the other TTD will be used as the 
final TTD.  In a rare case of observing TTD = 42 days, the sites will determine if the value should 
be used as is or treated as missing. 
The following are definitions from Section 9.2 of  the protocol document.   
 
• 
EBA0-7(CFU)= [baseline log10 CFU/mL sputum (mean of log10 CFU/mL at pre-entry and day 0) 
– log10 CFU/mL at day 7]/7. For a CFU/ml count of 0, the log10 CFU/mL will be set to 0 
 
• 
EBA0-7(TTD)= [baseline TTD (mean of TTD at pre-entry and day 0) – TTD at day 7]/7  
 
• 
EBA0-2(CFU)= [baseline log10 CFU/mL sputum (mean of log10 CFU/mL at pre-entry and day 0) 
– log10 CFU/mL at day 2]/2. For a CFU/ml count of 0, the log10 CFU/mL will be set to 0 
 
• 
EBA0-2 (TTD)= [baseline TTD (mean of TTD at pre-entry and day 0) – TTD at day 2]/2.  
 
• 
EBA2-7(CFU)= (log10 CFU/mL sputum at day 2 – log10 CFU/mL at day 7)/5. For a CFU/ml count 
of 0, the log10 CFU/mL will be set to 0 
 
• 
EBA2-7 (TTD)= [TTD at day 2 – TTD at day 7]/5   
 
For Group 3, TTP results from contaminated samples and from TTP from re-culture results after an 
additional decontamination step will be excluded from analysis. 
 
4 
Statistical Methods 
4.1 General Considerations 
Baseline characteristics will be summarized by cohorts (by Group and treatment arm) but with no 
statistical comparisons comparing cohorts.   
 
Categorical data will be summarized using N (%), and continuous data using N, min, Q1, median, Q3, 
max, and mean (STD) (when appropriate). Nonlinear mixed model using SAS procedure NLMIXED will be 
used to estimate the decrease of log10 CFU counts per day for the ‘early’ and ‘terminal’ phase as well as 
the increase of TTD per day. If there is no clear bi-phase pattern, linear mixed model using SAS 
procedure MIXED will be used. For TTD, log10 transformation may be applied if appropriate. Any 
modifications to outcome measures after the team has seen data collected after entry will be considered 
as post hoc. 
 
The primary endpoint analysis is defined in Section 4.3.1; however, the secondary modeling approach, 
which is described in Section 4.3.2, might be more appropriate in case of missing CFU or TTP outcomes 
at baseline and Day 7.   
4.2 Visit Schedule and Analysis Windows 
• 
Screening visit window =  within 2 weeks (14 days) prior to Step 1 entry 
 


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• 
Pre-entry visit window = approximately 2 days prior to Step 2 entry 
• 
Step 2 entry visit = Day 0 in Step 2 
• 
On-Treatment evaluations: conducted between Day 1 and Day 7. Participants will be discharged 
on Day 8. 
 
• 
Post-Treatment evaluations: completed in a period of plus or minus 3 days from Day 21. 
 
Note: Participants who do not complete 7 days of study treatment or who cannot provide at least 1 mL for 
all required overnight sputum samples through Day 7 will be discontinued from the study, and replaced.   
 
• 
Schedule of Events 
 
Evaluation 
Screening 
Pre-
entry 
Entry: 
Registration/ 
Randomization 
Study Treatment 
(Days) 
Discharge 
Final 
Visit 
Premature 
Discontin-
uation 
Step 2 
Day 0 
1 2 3 4 5 6 
7 
Day 8 
Day 
21 
+/-3 
Documentation of 
HIV status 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Medical/Medicatio
n History 
  
 
X 
 
 
 
 
 
 
 
 
 
 
Complete 
Physical 
Examination 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Targeted Physical 
Examination 
 
 
X 
X X X X X X X 
X 
X 
X 
Karnofsky Score 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Height 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Weight 
X 
 
X 
X X X X X X X 
X 
X 
X 
Signs/Symptoms/ 
Diagnoses 
 
 
X 
X X X X X X X 
X 
X 
X 
Concomitant/TB/ 
ARV Medications 
 
 
X 
X X X X X X X 
X 
X 
X 
Complete Blood 
Count with 
Differential 
X 
 
X 
 
 
 
 
 
 
X 
 
X 
X 
Complete Blood 
Chemistry Profile 
X 
 
X 
 
 
 
 
 
 
X 
 
X 
X 
CD4+ Count (HIV-
infected 
participants) 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy Test 
X1 
 
X 
 
 
 
 
 
 
 
 
 
 
NAT2 genotype 
(blood and saliva) 
 
 
X 
 
 
 
 
 
 
 
 
 
 
Chest X-ray 
X2 
 
 
 
 
 
 
 
 
 
 
 
 
Spot Sputum 
Collection 
 
 
X3 
 
 
 
 
 
 
 
 
 
 
Genotypic DST 
 
 
X 
 
 
 
 
 
 
 
 
 
 


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Page 11 of 13 
 
 
Evaluation 
Screening 
Pre-
entry 
Entry: 
Registration/ 
Randomization 
Study Treatment 
(Days) 
Discharge 
Final 
Visit 
Premature 
Discontin-
uation 
Step 2 
Day 0 
1 2 3 4 5 6 
7 
Day 8 
Day 
21 
+/-3 
(MTBDRsl)4 
Overnight Sputum 
Collection 
 
X 
X 
X X X X X X X 
 
 
 
EBA Analysis by 
Solid Culture CFU 
Determination and 
Liquid MGIT 
Culture for TTD5 
 
X 
X 
X X X X X X X 
 
 
 
Pharmacokinetic 
Sampling 
 
 
 
 
 
 
 
 
X 
 
 
 
 
Hospitalization 
X6 
X 
X 
X X X X X X X 
 
 
 
 
1Participants must have a negative serum or urine pregnancy test within 7 days prior to entry. 
2A chest x-ray is not required at screening if results of a chest x-ray performed within 14 days prior to 
screening are available. 
3Sputum from Step 1 (Screening or Day 0) may be used if there is an adequate amount for genotypic 
DST.  
4For those participants who have MDR-TB identified by MTBDRplus. 
5X’s here refer to the date that the overnight sputum collection was begun. Assay will be conducted the 
next morning. 
6At the discretion of the investigator, some participants may be hospitalized during the screening 
evaluations, but this is not a requirement. 
 
 


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4.3 Analyses of Outcomes Measures 
4.3.1 
Primary outcomes 
 
This is a per-protocol analysis in the efficacy population defined in Section 3.1. The primary endpoint is 
EBA0-7(CFU), which is defined in Section 3.2. Descriptive statistics of EBA0-7(CFU) with N, mean (s.d.), 
median (IQR), min, and max for each of the cohorts will be reported. Box plot of EBA0-7(CFU) with Q1, 
median, mean, and Q3 and plot with 95% confidence intervals for the mean EBA0-7(CFU) will be created 
for each cohort. Note: The analysis for this outcome will be performed for Group 1 and Group 2.  
 
Another primary endpoint is EBA0-7(TTD), which is defined in Section 3.2. Descriptive statistics of EBA0-
7(TTD) with N, mean (s.d.), median (IQR), min, and max will be reported by each cohort. Box plot of 
EBA0-7(TTD) with Q1, median, mean, and Q3 and plot of 95% confidence interval for the mean EBA0-
7(TTD) will be created for each cohort. 
 
New grade 2 or higher signs and symptoms, as well as laboratory events will be summarized in a table 
using SMR. In addition, all new grade 2 or higher signs/ symptoms and laboratory events with relatedness 
of treatment and most related drugs. 
 
The PK analysis to examine the relationship between the AUC/MIC and the EBA as described in the 
protocol Section 9.2.1.2 will be provided in a separate PK analysis plan. 
 
4.3.2 
Secondary outcomes 
 
Descriptive statistics of MICs with N, mean (s.d.), median (IQR), min, and max will be summarized by 
mutation Group (inhA mutation, katG mutation, or neither of these mutations). Box plot of MICs by 
mutation Group with Q1, median, mean, and Q3, histogram to examine possible bimodal distributions, and 
plot of 95% confidence interval for the mean MICs by mutation Group will be created. 
 
Nonlinear mixed model using SAS procedure NLMIXED will be fit to estimate the decrease of log10 CFU 
counts per day for the ‘early’ and ‘terminal’ phase. If there is no clear bi-phase pattern, linear mixed model 
using SAS procedure MIXED will be used. All available log10 transformed CFU counts at all time points 
will be included as a dependent variable, and day of the samples will be included as the primary 
exploratory variable in the model for each cohort.  Note: The analysis for this outcome will be performed 
for Group 1 and Group 2.  
 
Nonlinear mixed model using SAS procedure NLMIXED will be used to estimate the increase of TTD per 
day for the ‘early’ and ‘terminal’ phase. If there is no clear bi-phase pattern, linear mixed model using SAS 
procedure MIXED will be used. Log10 transformation may be applied if appropriate. TTD from all time 
points (excluding results from contaminated samples or re-culture of contaminated samples after addition 
decontamination)  will be included as a dependent variable, and day of the sample will be included as 
exploratory variable in the model for each cohort.   
 
Additional analyses will be conducted: 
 
• 
Descriptive statistics of EBA0-2(CFU) with N, mean (s.d.), median (IQR), min, and max for each 
of the cohorts will be reported. Box plot of EBA0-2(CFU) with Q1, median, mean, and Q3 and plot 


A5312 Primary Statistical Analysis Plan  
 
 
 
 
 
May 5, 2022 
 
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with 95% confidence intervals for the mean EBA0-2(CFU) will be created for each cohort. Note: 
Note: The analysis for this outcome will be performed for Group 1 and Group 2.  
 
• 
Descriptive statistics of EBA2-7(CFU) with N, mean (s.d.), median (IQR), min, and max for each 
of the cohorts will be reported. Box plot of EBA2-7(CFU) with Q1, median, mean, and Q3 and plot 
with 95% confidence intervals for the mean EBA2-7(CFU) will be created for each cohort. Note: 
The analysis for this outcome will be performed for Group 1 and Group 2.  
 
• 
Descriptive statistics of EBA0-2(TTD) with N, mean (s.d.), median (IQR), min, and max will be 
reported by each cohort. Box plot of EBA0-2(TTD) with Q1, median, mean, and Q3 and plot of 
95% confidence interval for the mean EBA0-2(TTD) will be created for each cohort. 
 
• 
Descriptive statistics of EBA2-7(TTD) with N, mean (s.d.), median (IQR), min, and max will be 
reported by each cohort. Box plot of EBA2-7(TTD) with Q1, median, mean, and Q3 and plot of 
95% confidence interval for the mean EBA2-7(TTD) will be created for each cohort. 
 
Note: The analysis of secondary PK endpoints as described in the protocol Section 9.2.2.1 and 9.2.2.3 will 
be provided in a separate PK analysis plan. 
 
5 
Report components 
 
Detailed descriptions of the content of each of the following sections are given in the AIP.   
 
1. Recruitment/Accrual 
2. Participants and Data Ineligible for Analysis 
3. Baseline Characteristics 
4. Completeness of Database 
5. Study Status 
6. Treatment Status 
7. Safety 
• 
Signs and Symptoms and Laborary Abnormalities 
• 
Diagnoses 
8. Primary Outcomes 
9. Secondary Outcomes 
 
Analyses of Group 1 and Group 2 Step 1 and Step 2 and Group 3 Step 1 participants enrolled under 
Protocol Version 2.0 were complete in 2018. Protocol Version 2.0 did not randomize Group 3 participants 
to receive any study treatment.  Protocol Version 3.0 randomized Group 3 participants who met Step 1 
and Step 2 entry criteria to receive 7 days of INH randomized 1:1 to one of two doses: 15 mg/kg or 20 
mg/kg. As a result, there will be two separate primary statistical reports for this study: 
1.  A report Groups 1 and 2 Steps 1 and 2 and Group 3 Step 1 enrolled under Protocol Version 2.0 
(complete and dated Septemember 17, 2018) 
 
2. A report covering Group 3 participants enrolled under Protocol version 3.0. 
 
Note: some basic summaries from participants enrolled under Protocol Version 2.0 may also be 
included in the second report to provide context.