AGILE (Early Phase Platform Trial for COVID-19)

University of Liverpool

Status and phase: Enrolling; Phase 2; Phase 1

Conditions: Covid19

Treatments: Drug: Nitazoxanide; Drug: CST-2: Placebo; Drug: Paxlovid; Drug: Molnupiravir; Drug: Placebo; Drug: VIR-7832; Drug: ALG-097558; Drug: Favipiravir; Drug: VIR-7831; Drug: NHS standard of care as per COVID-19 treatment guidelines; Drug: CST-2: EIDD-2801; Drug: CST-5: Placebo; Drug: ALG-097558 and Remdesivir

Study type: Interventional

Funder types: Other

Identifiers

NCT04746183

UoL001542i, UoL001542j

Details and patient eligibility

About

The AGILE platform master protocol allows incorporation of a range of identified and yet-to-be-identified candidates as potential treatments for adults with COVID-19 into the trial. Candidates will be added into the trial via candidate-specific trial (CST) protocols of this master protocol as appendices. Having one master protocol ensures different candidates are evaluated in the same consistent manor and opening up new trials for new candidates is more efficient. Inclusion of new candidates will be based on pre-clinical data, evidence in the clinical setting and GMP capabilities.

Full description

AGILE is a multicentre, multi-arm, multi-dose, multi-stage open-label, adaptive, seamless phase I/II Bayesian randomised platform trial to determine the optimal dose, activity and safety of multiple candidate agents for the treatment of COVID-19.

This study allows for the assessment of many candidates at different doses, with the ability to add candidates as they are identified or drop them as their evaluation is completed. Promising candidates will move to an external trial for further evaluation in the phase II/III setting.

Each candidate will be evaluated in its own trial, randomising between candidate and control with 2:1 allocation in favour of the candidate. Each dose will be assessed for safety sequentially in cohorts of 6 patients. Once a phase II dose has been identified we will assess efficacy by seamlessly expanding into a larger cohort.

AGILE is completely flexible in that the core design in the master protocol (as has been explained above) can be adapted for each candidate based on prior knowledge of the candidate - i.e. population, primary endpoint and sample size can be amended. This will be detailed in each candidate-specific trial protocol of the master protocol.

Candidate-Specific Trial 2 (CST-2): Open-label 2:1 randomised controlled phase I of EIDD-2801 versus standard of care followed by a 1:1 blinded controlled parallel group Phase II trial of EIDD-2801 versus placebo. A phase I will be carried out to confirm the optimal dose in this group. Following a safety review, EIDD-2801 will be tested for efficacy in a blinded placebo controlled randomised phase II trial.

Candidate-Specific Trial 3 (CST-3A): Multicentre, Adaptive, Phase I trial to Determine the optimal dose, Safety and Efficacy of Nitazoxanide for the Treatment of COVID-19

Candidate-Specific Trial 3 (CST-3B): A Randomized, Multicentre, Seamless, Adaptive, Phase I/II trial to Determine the optimal dose, Safety and Efficacy of Nitazoxanide for the Treatment of COVID-19

Candidate-Specific Trial 5 (CST-5): Randomized, Multicentre, Seamless, Adaptive, Phase I/II Platform Study to Determine the Phase II dose of VIR-7832, and Evaluate the Safety and Efficacy of VIR-7831 and VIR-7832 for the Treatment of COVID-19

Candidate-Specific Trial 6 (CST-6): A Randomized, Multicentre, Seamless, Adaptive, Phase I/II Platform Study to Determine the Phase II dose and to Evaluate the Safety and Efficacy of intravenous Favipiravir for the Treatment of COVID-19

Candidate-Specific Trial 8 (CST-8): A Randomised, Multicentre, Seamless, Adaptive, Phase I Platform Study to Determine the recommended Phase II dose and Evaluate the Safety and Efficacy of antiviral combination of Molnupiravir and Paxlovid® for the Treatment of COVID-19

Candidate-Specific Trial 9 (CST-9a): A multicentre, adaptive Phase II Platform trial to evaluate the safety, efficacy and virological response of ALG-097558 as monotherapy and in combination with Remdesivir in high-risk population for the treatment of COVID-19 disease.

Candidate-Specific Trial 9 (CST-9b): A Multicentre, Adaptive Phase II Randomised Double-Blind Placebo Controlled Trial to Evaluate the Safety, Efficacy and Virological response of ALG-097558 for the Treatment of COVID-19 disease.

Enrollment: 600 estimated patients

Sex: All

Ages: 18+ years old

Volunteers: No Healthy Volunteers

Inclusion and exclusion criteria

Master Protocol Inclusion Criteria:

1. Adults (≥18 years) with laboratory-confirmed* SARS-CoV-2 infection (PCR)

2. Ability to provide informed consent signed by study patient or legally acceptable representative

3. Women of childbearing potential (WOCBP) and male patients who are sexually active with WOCBP must agree to use a highly effective method of contraception (as outlined in the protocol) from the first administration of trial treatment, throughout trial treatment and for the duration outlined in the candidate-specific trial protocol after the last dose of trial treatment

   • If any CSTs are included in the community setting, the CST protocol will clarify whether patients with suspected SARS-CoV-2 infection are also eligible.

Standard additional criteria that may be applied per CST protocol:

Group A (severe disease) 4a. Patients with clinical status of Grades 4 (hospitalised, oxygen by mask or nasal prongs), 5 (hospitalised, on non-invasive ventilation, or high flow oxygen), 6 (hospitalised, intubation and mechanical ventilation) or 7 (ventilation and additional organ support - pressors, renal replacement therapy (RRT), extracorporeal membrane oxygenation (ECMO)), as defined by the WHO clinical severity score, 9-point ordinal scale.

Group B (mild-moderate disease) 4b. Ambulant or hospitalised patients with the following characteristics peripheral capillary oxygen saturation (SpO2) >94% RA N.B. The CST protocol inclusion criteria will take precedence over the master protocol inclusion criteria.

CST-2 Inclusion Criteria:

For the purpose of the EIDD-2801 candidate-specific trial the following inclusion criteria have been amended from the Master protocol to:

1. Male or female ≥ 60 years old or ≥50 years old with at least one well controlled comorbidity: cardiovascular disease, chronic lung disease (e.g. COPD, or pulmonary hypertension), immune deficiency (taking the equivalent of 20 mg prednisone daily, chemotherapy, or immune modulating biologic therapies), diabetes (treated with insulin or oral medications), BMI≥30, or hypertension requiring medication with laboratory confirmed SARS-CoV-2 infection (PCR) .

3. Women of childbearing potential (WOCBP) and male patients who are sexually active with WOCBP must agree to use two effective methods of contraception, one of which should be highly effective (as outlined in the protocol). For women, from the first administration of trial treatment, throughout trial and up to 50 days after the last follow up visit (50 days after day 29) and for men with female partners of child bearing potential, from the first administration until 100 days after last follow up visit (100 days after day 29).

4. Group B (mild-moderate disease): Ambulant with the following characteristics peripheral capillary oxygen saturation (SpO2) >94% RA (NB this differs to the Master Protocol which also includes hospitalised patients in this group).

Additional criteria specific to this candidate are:

5. Has signs or symptoms of COVID-19 that began within 5 days of the planned first dose of study drug.

6. Is in generally good health (except for current respiratory infection) and is free of uncontrolled chronic conditions.

7. Is willing and able to comply with all study procedures and attending clinic visits through the 4th week.

8. Has someone, aged ≥ 16 living in the same household during the dosing period.

CST-6 Additional inclusion criteria:

1. Group A (severe disease). Patients with clinical status of Grades 5 (hospitalised, oxygen by mask or nasal prongs), 6 (hospitalised, on non-invasive ventilation, or high flow oxygen as defined by the WHO Clinical Progression Scale (WHO, 2020)).
2. Less than or equal to 14 days from onset of COVID-19 symptoms

CST-8 Inclusion Criteria:

1. For the purpose of CST-8, criteria 1 has been amended from the Master Protocol to:

   Adults (≥18 years) outpatients positive lateral flow test at screening or baseline Day 1, who are within 5 days of symptom onset prior to the planned first dose of study drug.

2. Criteria 3 has been amended from the Master Protocol to:

Women of childbearing potential (WOCBP) and male participants who are sexually active with WOCBP must agree to use a highly effective method of contraception (as outlined in section 5.5 of the Master Protocol) for the duration of the treatment and for six weeks following the last dose.

Additional criteria specific to CST-8 are:

• Initial onset of COVID-19 signs/symptoms within 5 days prior to the day of randomisation and at least 1 of the current specified COVID-19 signs/symptoms (listed on the NHS website) present on the day of randomisation
• Is willing and able to comply with all study procedures and attending clinic visits

CST-9a Inclusion Criteria:

For the purpose of CST-9a, criteria 1 has been amended from the Master Protocol to:

1. Adults (>/= 18 years of age) with a positive SARS-CoV-2 lateral flow test on screening or Day 1, who are at high risk (as defined in UK DHSC criteria) of progressing to severe COVID-19 disease, within 3 days of symptom onset, with at least one symptom of COVID-19 infection present on the day of randomization and are with mild- moderate disease severity at enrolment.

   Criterion 2 has been amended from the Master Protocol to:

2. Ability to provide informed consent signed by trial participant or legally acceptable representative and are willing and able to comply with all trial procedures and attending clinic visits

   Criterion 3 has been amended from the Master Protocol to:

3. Women of childbearing potential (WOCBP) and male participants who are sexually active with WOCBP must agree to use two effective methods of contraception, one of which must be highly effective for the duration of the treatment and for 90 Days following the last dose

Master Protocol Exclusion Criteria:

1. Alanine aminotransferase (ALT) and/or aspartate aminotransferase (AST) >5 times the upper limit of normal (ULN)
2. Stage 4 severe chronic kidney disease or requiring dialysis (i.e., estimated glomerular filtration rate <30 mL/min/1.73 m^2)
3. Pregnant or breast feeding
4. Anticipated transfer to another hospital which is not a study site within 72 hours
5. Allergy to any study medication
6. Patients taking other prohibited drugs (as outline in CST protocol) within 30 days or 5 times the half-life (whichever is longer) of enrolment
7. Patients participating in another CTIMP trial

N.B. The CST protocol exclusion criteria will take precedence over the master protocol exclusion criteria.

CST-9a Exclusion Criteria:

Exclusion criteria has been amended from master protocol as:

1. Prior SARS-CoV-2 infection <90 days before enrolment and/or received any COVID-19 vaccine dose <90 days before enrolment
2. Alanine aminotransferase (ALT) >3 times the upper limit of normal (ULN) or Active Liver disease
3. History or current evidence of cirrhosis
4. Receiving dialysis or have known moderate to severe renal impairment (defined as CKD stage 4 or 5) or current acute kidney injury on most recent eGFR in the past 6 months
5. Pregnant or breast feeding
6. Anticipated transfer to another hospital which is not a trial site within 72 hours
7. Known allergy to any trial medication
8. Swallowing difficulties
9. Currently receiving ALG-097558, Paxlovid, molnupiravir or remdesivir or any SoC therapy for COVID-19 at the time of screening
10. Received sotrovimab at any point during the current SARS-CoV-2 infection
11. Oxygen saturations <94% on room air
12. Urgent or expected need for nasal high-flow oxygen therapy or positive pressure ventilation, invasive mechanical ventilation or ECMO.
13. Participants who have taken or require treatment with a comedication that is a strong CYP450 3A4 inhibitor (atazanavir, clarithromycin, itraconazole, posaconazole, voriconazole, nefazodone, nelfinavir, grapefruit juice, HIV protease inhibitors), strong CYP450 3A4 inducers (rifampin, phenytoin, carbamazepine, St. John's Wort) or sensitive substrates of CYP450 2C8 and 2B6 (repaglinide, rosiglitazone, paclitaxel, bupropion) within at least 2 weeks or 5 half-lives (whichever is longer) before the planned first dose of study drug.
14. Participating in another CTIMP trial

CST-9b Exclusion criteria:

1. Prior SARS-CoV-2 infection diagnosed <90 days before enrolment and/or received any COVID-19 vaccine dose <90 days before enrolment
2. Alanine aminotransferase (ALT) >3 times the upper limit of normal (ULN) or Active Liver disease
3. History or current evidence of cirrhosis
4. Receiving dialysis or have known severe renal impairment defined as CKD stage 5 (an eGFR <15 mL/min/1.73 m2 at screening, or current acute kidney injury in most recent eGFR in past 6 months.
5. Pregnant or breast feeding
6. Anticipated transfer to another hospital which is not a trial site within 72 hours
7. Known allergy to any trial medication
8. Swallowing difficulties
9. Currently receiving ALG-097558, Paxlovid, molnupiravir or remdesivir or any standard of care antiviral therapy for COVID-19 at the time of screening
10. Received sotrovimab at any point during the current SARS-CoV-2 infection prior to enrolment
11. Oxygen saturations <94% on room air. NOTE: Participants on stable oxygen therapy, including use of NIPPV (non-invasive positive pressure ventilation), for a pre-existing medical condition (e.g., COPD) may be included with oxygen saturation of <94% on room air, provided there is no new increased oxygen requirement.
12. Urgent or expected need for nasal high-flow oxygen therapy or positive pressure ventilation, invasive mechanical ventilation or ECMO.
13. Participants who have taken or require treatment with a comedication that is a strong CYP450 3A4 inhibitor (atazanavir, clarithromycin, itraconazole, posaconazole, voriconazole, nefazodone, nelfinavir, grapefruit juice, HIV protease inhibitors), strong CYP450 3A4 inducers (rifampin, phenytoin, carbamazepine, St. John's Wort) or sensitive substrates of CYP450 2C8 and 2B6 (repaglinide, rosiglitazone, paclitaxel, bupropion) within at least 2 weeks or 5 half-lives (whichever is longer) before the planned first dose of study drug.
14. Participating in another CTIMP trial within 5 half-lives of the last administered dose of an investigational medicinal product.
15. Participants eligible for other antiviral treatment according to DHSC criteria, or those otherwise eligible for CST9a.

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Sequential Assignment

Masking: Quadruple Blind

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600 participants in 21 patient groups, including a placebo group

CST-2 EIDD-2801 Phase Ib

Experimental group

Description:

EIDD-2801 (also known as MK-4482, molnupiravir). Phase Ib: EIDD-2801 will be administered orally, twice daily (BID) for 10 doses (5 or 6 days). The starting dose will be established based on safety and pharmacokinetics from the EIDD-2801-1001-US/UK study, and dose escalations may occur as described in this CST.

Treatment:

Drug: CST-2: EIDD-2801

CST-2 Control

No Intervention group

Description:

Phase 1b only (standard of care)

CST-2 Placebo

Placebo Comparator group

Description:

Phase II placebo blinded controlled

Treatment:

Drug: CST-2: Placebo

CST-3A Nitazoxanide

Experimental group

Description:

Phase Ia Nitazoxanide will be administered orally, initially twice daily (BID) for 14 doses (7 days). The starting dose will be 1500mg BID based on existing dose information, but dose adaptations may occur

Treatment:

Drug: Nitazoxanide

CST-5 VIR-7832 Phase I

Experimental group

Description:

Phase I: Single doses of VIR-7832 will be administered by intravenous (IV) infusion. The starting dose will be 50 mg, and dose escalations of 150 and 500 mg are anticipated.

Treatment:

Drug: VIR-7832

CST-5 VIR-7831 Phase II

Active Comparator group

Description:

Phase II: 500 mg dose of VIR-7831 will be given by IV infusion.

Treatment:

Drug: VIR-7831

CST-5 Placebo Phase I

Placebo Comparator group

Description:

Phase I: placebo blinded controlled

Treatment:

Drug: CST-5: Placebo

CST3B Nitazoxanide

Experimental group

Description:

Phase II experimental arm.

Treatment:

Drug: Nitazoxanide

CST3B Control

No Intervention group

Description:

Standard of care

CST6 IV Favipiravir

Experimental group

Description:

IV Favipiravir twice daily for 7 days. Starting dose 600 mg twice daily. Dose escalation to 1200 mg twice daily, 1800 twice daily, 2400 twice daily.

Treatment:

Drug: Favipiravir

CST6 Control

No Intervention group

Description:

Standard of care

CST-2 EIDD-2801 Phase II

Experimental group

Description:

EIDD-2801 (also known as MK-4482, molnupiravir). Phase II: As per Phase Ib, with the dose determined by the recommended phase II dose.

Treatment:

Drug: CST-2: EIDD-2801

CST-8 Phase I Molnupiravir + Paxlovid®

Experimental group

Description:

Molnupiravir 800mg Twice a day (BD) in combination with Paxlovid® (300mg nirmatrelvir + ritonavir 100mg) twice a day (BD) for 5 days as starting dose, with a de-escalation protocol reducing in increments of molnupiravir to 600mg BD, then 400mg BD if required. The dose of Paxlovid® will be fixed for all cohorts.

Treatment:

Drug: Molnupiravir

Drug: Paxlovid

CST-8 Phase I Molnupiravir + Paxlovid® Control

No Intervention group

Description:

Standard of care

CST-5 VIR-7832

Active Comparator group

Description:

Phase II: 500 mg dose of VIR-7832 will be given by IV infusion.

Treatment:

Drug: VIR-7832

CST-5 Placebo Phase II

Placebo Comparator group

Description:

Phase II: placebo blinded controlled

Treatment:

Drug: CST-5: Placebo

CST-9a Monotherapy

Experimental group

Description:

Phase II: ALG-097558 600 mg twice a day orally for 5 days

Treatment:

Drug: ALG-097558

Drug: ALG-097558

CST-9a Combination

Experimental group

Description:

Phase II: ALG-097558 600 mg twice a day orally for 5 days in combination with IV remdesivir for 3 days (200 mg day 1, 100 mg day 2 and 3)

Treatment:

Drug: ALG-097558 and Remdesivir

Drug: ALG-097558

Drug: ALG-097558

CST-9a Control

Active Comparator group

Description:

Phase II : standard of care

Treatment:

Drug: NHS standard of care as per COVID-19 treatment guidelines

CST-9b: ALG-097558

Experimental group

Description:

twice daily dose for 5 days

Treatment:

Drug: ALG-097558

Drug: ALG-097558

CST-9b: placebo for ALG097558

Placebo Comparator group

Treatment:

Drug: Placebo