Trial of Novel Regimens for the Treatment of Pulmonary Tuberculosis (RAD-TB)

National Institute of Allergy and Infectious Diseases (NIAID)

Status and phase: Enrolling; Phase 2

Conditions: Pulmonary Tuberculosis

Treatments: Drug: Pretomanid; Drug: Ethambutol; Drug: TBI-223; Drug: Pyrazinamide; Drug: Bedaquiline; Drug: Isoniazid; Drug: Rifampicin; Drug: Linezolid; Drug: Sutezolid

Study type: Interventional

Funder types: Other; NIH

Identifiers

NCT06192160

A5409

DOH-27-032024-5399 (Other Identifier)

Details and patient eligibility

About

A5409/RAD-TB is an adaptive Phase 2 randomized, controlled, open-label, dose-ranging, platform protocol to evaluate the safety and efficacy of multidrug regimens for the treatment of adults with drug-susceptible pulmonary tuberculosis (TB).

A5409 hypothesizes that novel regimens for the treatment of pulmonary tuberculosis will result in superior early efficacy, as determined by longitudinal mycobacteria growth indicator tube (MGIT) liquid culture time to positivity (TTP) measurements over the first 6 weeks of treatment, and will have acceptable safety and tolerability over 8 weeks of treatment relative to standard of care [(SOC) isoniazid/rifampicin/pyrazinamide/ethambutol (HRZE)].

The study will run for 52 weeks, inclusive of 26 weeks of TB treatment comprised of 8 weeks of experimental or SOC treatment (based on treatment arm assignment) followed by 18 weeks of SOC treatment with 45 participants in each experimental treatment arm and at least 90 participants in the SOC arm.

Enrollment: 315 estimated patients

Sex: All

Ages: 18+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

1. Pulmonary TB (among individuals either without history of prior TB treatment or with history of TB treatment more than 5 years prior to study entry), identified within 7 days prior to study entry by at least one sputum specimen positive for Mtb by Xpert. Semiquantitative Mtb results of "medium" or "high" are required.

2. Pulmonary TB with documented INH susceptibility (by Line Probe Assay (LPA) or Xpert MTB/XDR or other validated molecular test) and with documented RIF susceptibility (by LPA or Xpert MTB/RIF or Xpert MTB/RIF Ultra or other validated molecular test) within 7 days prior to study entry.

3. Documentation of HIV-1 infection status, as below:

   • Presence or Absence of HIV-1 infection, as documented by:

     • Any licensed rapid HIV test or HIV-1 enzyme or chemiluminescence immunoassay (E/CIA) test kit, any time prior to study entry. AND

   • Confirmed by one of the following:

     • A second antibody test from different manufacturers or based on different principles and epitopes (combination antigen-antibody-based rapid tests may be used), or
     • HIV-1 antigen, or
     • Plasma HIV-1 RNA viral load, or
     • A licensed Western blot

4. For individuals with HIV: CD4+ cell count ≥100 cells/mm3 based on testing performed within 30 days prior to study entry.

5. For individuals with HIV: Currently being treated with dolutegravir-based antiretroviral therapy (ART), or plan to initiate dolutegravir-based ART at or before study week 8.

6. Individuals age ≥18 years.

7. The following laboratory values obtained within 7 days prior to study entry at any network-approved non-US laboratory that operates in accordance with Good Clinical Laboratory Practices (GCLP) and participates in appropriate external quality assurance programs:

   • Serum or plasma alanine aminotransferase (ALT) ≤3 times the upper limit of normal (ULN)
   • Serum or plasma total bilirubin ≤2 times ULN
   • Serum or plasma creatinine ≤2 times ULN
   • Serum or plasma potassium ≥3.5 mEq/L
   • Serum or plasma magnesium ≥1.0 mEq/L (≥0.500 mmol/L)
   • Absolute neutrophil count (ANC) ≥1500/mm^3
   • Hemoglobin ≥9.5 g/dL for individuals assigned to female sex at birth and ≥10.0 g/dL for individuals assigned to male sex at birth
   • Platelet count ≥100,000/mm^3
   • Negative for hepatitis B core antibody (HBcAb) total, hepatitis B surface antigen (HBsAg)
   • Negative for hepatitis C virus (HCV) antibody (or if HCV antibody positive, must have a negative HCV PCR)

8. For individuals assigned to female sex at birth and who are of reproductive potential, negative pregnancy test (urine HCG or serum β-HCG) within 3 days (72 hours) prior to entry by any network-approved non-US laboratory or clinic that operates in accordance with GCLP and participates in appropriate external quality assurance programs.

   Individuals assigned to female sex at birth, who are of reproductive potential, and who participate in sexual activity that could lead to pregnancy must agree to use at least two of the following forms of birth control while receiving TB study medications and for 12 months after stopping study medications:

   • Male or female condoms
   • Diaphragm or cervical cap (with spermicide, if available)
   • Intrauterine device (IUD) or intrauterine system (IUS)
   • Hormone-based birth control (e.g., oral contraceptives, Depo-Provera, NuvaRing, implants)

9. For individuals who are assigned male sex at birth who engage in sexual activity that may lead to pregnancy in their partner must agree to either remain abstinent or use male contraceptives. They are also strongly advised to inform their non-pregnant sexual partners of reproductive potential to use effective contraceptives while the individual is on study and for 90 days after experimental treatment discontinuation.

10. For individuals assigned male sex at birth with pregnant partners, willingness to use condoms during vaginal intercourse while on study and for 90 days after experimental treatment discontinuation.

11. For individuals assigned male sex at birth, willingness to refrain from sperm donation while on study and for 90 days after experimental treatment discontinuation.

12. Documentation of Karnofsky performance score ≥60 obtained within 14 days prior to study entry.

13. Chest x-ray obtained within 14 days prior to study entry.

14. A verifiable address or residence readily accessible for visiting, and willingness to inform the study team of any change of address during study treatment and follow-up period.

15. Ability and willingness of individual to provide informed consent.

Exclusion criteria

1. More than cumulative 7 days of treatment directed against active TB for the current TB episode in the 60 days preceding study entry.
2. Current extrapulmonary TB, in the opinion of the investigator.
3. QTcF interval >450 ms within 7 days prior to study entry.
4. History of or ongoing heart failure.
5. Personal or family history of congenital QT prolongation.
6. History of known, untreated, ongoing hypothyroidism.
7. History of or ongoing bradyarrhythmia.
8. History of torsades de pointes.
9. Current Grade 2 or higher peripheral neuropathy.
10. Other medical conditions (e.g., diabetes, liver or kidney disease, blood disorders, chronic diarrhea), in the opinion of the site investigator, in which the current clinical condition of the participant is likely to prejudice the response to, or assessment of, treatment.
11. Pregnant or breastfeeding or planning to become pregnant within the next 12 months.
12. Weight <35 kg.
13. Unable to take oral medications.
14. Taking any of prohibited medications.
15. Known allergy/sensitivity or any hypersensitivity to components of investigational agents or their formulation.
16. Active drug or alcohol use or dependence; or mental illness (e.g., major depression) that, in the opinion of the site investigator, would interfere with adherence to study requirements.
17. Taking an investigational drug or vaccine within 30 or more days prior to study entry.

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: None (Open label)

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315 participants in 6 patient groups

Arm 1: Standard of Care (SOC)

Active Comparator group

Description:

* Weeks 1-8: INH 300 mg, RIF 600 mg, PZA weight-based, EMB weight-based * Weeks 9-26: INH 300 mg, RIF 600 mg

Treatment:

Drug: Rifampicin

Drug: Isoniazid

Drug: Pyrazinamide

Drug: Ethambutol

Arm 2: Bedaquiline (BDQ), Pretomanid (Pa), and Linezolid (LZD)

Experimental group

Description:

* Weeks 1-8: BDQ 400 mg for 2 weeks and then 200 mg for 6 weeks, Pa 200 mg, LZD 600 mg * Weeks 9-26: INH 300 mg, RIF 600 mg

Treatment:

Drug: Linezolid

Drug: Rifampicin

Drug: Isoniazid

Drug: Bedaquiline

Drug: Pretomanid

Arm 3A: BDQ, Pa and TBI-223 (1200 mg)

Experimental group

Description:

* Weeks 1-8: BDQ 400 mg for 2 weeks and then 200 mg for 6 weeks, Pa 200 mg, TBI-223 1200 mg * Weeks 9-26: INH 300 mg, RIF 600 mg

Treatment:

Drug: TBI-223

Drug: Rifampicin

Drug: Isoniazid

Drug: TBI-223

Drug: Bedaquiline

Drug: Pretomanid

Arm 3B: BDQ, Pa and TBI-223 (2400 mg)

Experimental group

Description:

* Weeks 1-8: BDQ 400 mg for 2 weeks and then 200 mg for 6 weeks, Pa 200 mg, TBI-223 2400 mg * Weeks 9-26: INH 300 mg, RIF 600 mg

Treatment:

Drug: TBI-223

Drug: Rifampicin

Drug: Isoniazid

Drug: TBI-223

Drug: Bedaquiline

Drug: Pretomanid

Arm 4A: BDQ, Pa and Sutezolid (SZD) (800 mg)

Experimental group

Description:

* Weeks 1-8: BDQ 400 mg for 2 weeks and then 200 mg for 6 weeks, Pa 200 mg, SZD 800 mg * Weeks 9-26: INH 300 mg, RIF 600 mg

Treatment:

Drug: Sutezolid

Drug: Rifampicin

Drug: Isoniazid

Drug: Bedaquiline

Drug: Sutezolid

Drug: Pretomanid

Arm 4B: BDQ, Pa and SZD (1600 mg)

Experimental group

Description:

* Weeks 1-8: BDQ 400 mg for 2 weeks and then 200 mg for 6 weeks, Pa 200 mg, SZD 1600 mg * Weeks 9-26: INH 300 mg, RIF 600 mg

Treatment:

Drug: Sutezolid

Drug: Rifampicin

Drug: Isoniazid

Drug: Bedaquiline

Drug: Sutezolid

Drug: Pretomanid