Clinical trial NCT05889793: Evaluating Emetine for Viral Outbreaks (EVOLVE)
Official title: Emetine for Viral Outbreaks: Randomized, Double-Blind, Placebo-Controlled, Clinical Trial to Evaluate Oral Emetine Against Covid-19 (EVOLVE)
Study type: INTERVENTIONAL
Overall status: RECRUITING
Phase: PHASE2
PHASE3
Conditions: COVID-19
Lead sponsor: Johns Hopkins University
Sponsor class: OTHER
Collaborators: name: Nepal Health Research Council
name: Bharatpur Hospital Chitwan
name: Stony Brook University
name: Rutgers University
First posted: 2023-06-05
Enrollment: 600
Sex: ALL
Minimum age (years): 30
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Intervention model description: Double-blinded randomized controlled clinical trial (RCT) with placebo and intervention group
Primary purpose: TREATMENT

Brief summary: The goal of this clinical trial (phase 2/phase 3) is to evaluate the efficacy and safety of emetine administered orally for symptomatic Covid-19 patients in patients ages 30 years and above. Participants will be asked to:

* Take Emetine 6mg orally for 10 consecutive days
* Be monitored by healthcare staff or self-monitor for daily vital signs and symptoms
* Undergo blood draws

Researchers will compare the control group given placebo medicine to assess if emetine improved the symptoms of Covid-19.

Detailed description: More than 675 million cases of coronavirus disease-19 (COVID-19) have occurred in this ongoing pandemic caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). More than 6.8 million people have died so far, with case count and deaths cumulating every day. Despite the scale of the damage, there exists extremely limited antiviral treatment options for Covid-19. Emetine exhibits broad spectrum antiviral activity including inhibition of SARS-CoV-2 by inhibiting viral replication and protein biosynthesis. It has been have recently shown that by lowering the standard amoebicidal dose by a factor of 10, emetine can inhibit viral replication while avoiding cardiovascular toxicity. Therefore, the investigators plan to evaluate emetine's efficacy and safety for treatment of symptomatic Covid-19 in a randomized, clinical trial. Emetine, an alkaloid extracted from ipecacuanha roots, was widely used for the treatment of amoebic dysentery. Because of cardiotoxicity (cardiac dysrhythmias), emetine was replaced by metronidazole. The toxicity was unequivocally associated with high-dose emetine (60 mg/day for 10 days to achieve a minimum inhibitory concentration (MIC) of 25 µM against Entamoeba hystolytica); however, the cardiovascular side-effects were minimal or none when emetine was used for various indications in low dose (\<20 mg/day). In a screening of 3000 potential compounds against SARS-CoV-2, emetine was found to have the lowest half maximal inhibitory concentration (IC50) of 4.0e-4 µM and a half maximum cytotoxicity concentration (CC50) \>10 µM in Vero E6 cells providing it a high therapeutic index. Likewise, several in-vitro studies have demonstrated very low IC50 (\~0.05µM) against SARS-CoV-2 for emetine. Based on this, a lower dose of emetine (6 mg/day for 10 days) has been calculated for the treatment of SARS-CoV-2. The investigators hypothesize that low dose emetine will be effective and safe in the treatment of Covid-19. Extensive use of the drug in the past has documented that low dose usage avoids the cardiovascular side-effects there were present at higher doses (\>20 mg per day); however, the safety has not been systematically documented in a clinical trial, a key objective of this study. The primary objective of the trial would be to evaluate the safety and efficacy of oral formulation of emetine for patients diagnosed with Covid-19 in a phase 2 study to be followed up by a multicenter phase 3 study based on the preliminary results. Proven beneficial, this study has the potential to save millions of lives by providing a viable, convenient option for treatment of Covid-19. Preliminary results can provide the basis for additional research to evaluate added benefit to patients by combining emetine with other drugs. Emetine has also been shown in-vitro to have activity against Middle East Respiratory Syndrome (MERS), Zika, Cytomegalovirus and Ebola virus infections-this highlights a broader application for emetine beyond coronavirus infections.

Eligibility criteria: Inclusion Criteria:

* 30 years of age or older at time of randomization
* RT-PCR positive for SARS-CoV-2 infection within ≤ 10 days of the screening visit.
* In addition to confirmed RT-PCR, symptomatic Covid-19 patients with at least two or more symptoms within 7 days of the screening visit: Cough, shortness of breath, fever/chills, sore throat, nausea, vomiting, diarrhea, fatigue, body aches, headache
* Ability to give informed consent (administered in local language)

Exclusion Criteria

* Asymptomatic Covid-19 patients
* Pregnant or breastfeeding woman
* Current or recent use of the study drug
* Known allergy to study drug
* Current or planned participation in another interventional trial in next 10 days.
* Critical Covid-19 patients (ARDS) at the time of screening.
* Patients needing intubation, mechanical ventilation, or ICU care at screening
* Patients with prior cardiac disease including cardiac dysrhythmias, heart failure, ischemic heart disease or cardiomyopathies.

Primary outcomes:
measure: Evaluate effectiveness of emetine in symptomatic Covid-19 patients
timeFrame: After medication administration up to 30 days
measure: Evaluate effectiveness of emetine in symptomatic Covid-19 patients
timeFrame: After medication administration up to 30 days
measure: Evaluate safety of emetine in symptomatic Covid-19 patients
timeFrame: Duration of the intervention and for up to 30 days post intervention
measure: Evaluate safety of emetine in symptomatic Covid-19 patients
timeFrame: Duration of intervention up to 10 days
Secondary outcomes:
measure: Virologic conversion as assessed by SARS-CoV-2 real time polymerase chain reaction (RT-PCR)
timeFrame: Day 0 and then at days 3, 5 and 10
measure: Anti-inflammatory effect of emetine
timeFrame: Days 0 (baseline), 3 and 7 for up to 10 days after intervention
measure: Anti-inflammatory effect of emetine
timeFrame: Days 0 (baseline), 3 and 7 for up to 10 days after intervention
measure: Anti-inflammatory effect of emetine
timeFrame: Days 0 (baseline), 3 and 7 for up to 10 days after intervention
measure: Anti-inflammatory effect of emetine
timeFrame: Days 0 (baseline) 3 and 7 for up to 10 days after intervention.
measure: Anti-inflammatory effect of emetine
timeFrame: Days 0 (baseline), 3 and 7 for up to 10 days after intervention.
measure: Anti-inflammatory effect of emetine
timeFrame: Days 0 (baseline), 3 and 7 for up to 10 days after intervention.
Other outcomes:
measure: Determine longer term impact of Covid-19 as assessed by the Health-related quality of life assessment (HR-QOL-14)
timeFrame: Days 30, 90 and 180 after medication administration up to day 180.
Locations:
city: Baltimore
country: United States
facility: Johns Hopkins University, Division of Infectious Diseases
state: Maryland
city: Bharatpur
country: Nepal
facility: Bharatpur Hospital
state: Chitwan
Study officials:
affiliation: Johns Hopkins School of Medicine
name: Kunchok Dorjee, MBBS, PhD, MPH
role: PRINCIPAL_INVESTIGATOR
References:
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citation: Bleasel MD, Peterson GM. Emetine, Ipecac, Ipecac Alkaloids and Analogues as Potential Antiviral Agents for Coronaviruses. Pharmaceuticals (Basel). 2020 Mar 21;13(3):51. doi: 10.3390/ph13030051.
citation: Jan JT, Cheng TR, Juang YP, Ma HH, Wu YT, Yang WB, Cheng CW, Chen X, Chou TH, Shie JJ, Cheng WC, Chein RJ, Mao SS, Liang PH, Ma C, Hung SC, Wong CH. Identification of existing pharmaceuticals and herbal medicines as inhibitors of SARS-CoV-2 infection. Proc Natl Acad Sci U S A. 2021 Feb 2;118(5):e2021579118. doi: 10.1073/pnas.2021579118.
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