Anakinra, Anti-inflammatory Agents, Cytokine Storm, Dengue, Dengue With Warning Signs, Hyperinflammatory Syndrome, Immuno-modulation, Macrophage Activation Syndrome, Severe Dengue
Conditions
Keywords
Dengue, Hyperinflammatory syndrome, Anakinra, Vietnam
Brief summary
This study aims to evaluate the effect of anakinra in dengue patients with hyperinflammation as compared to placebo Primary Objective: To evaluate the efficacy of Anakinra in moderate-severe dengue patients with hyperinflammation. Secondary Objectives: * To assess the safety of anakinra therapy in dengue with hyperinflammation * To assess the effect of anakinra therapy in patients with dengue on physiological, clinical and virological parameters * To assess the immunomodulation effects of anakinra in dengue * Immune cell signatures in dengue with and without anakinra * To assess difference in gene expression between treatment group compared to non-treatment population
Detailed description
This is a randomized double blinded placebo controlled trial investigating the effects of four days of anakinra treatment on dengue patients with hyperinflammatory syndrome. The anakinra/placebo will be given to eligible participants admitted to the Hospital for Tropical Diseases (HTD) in Ho Chi Minh City, Vietnam. 160 dengue patients will be randomly assigned to either anakinra or placebo intervention group to receive treatment for 4 days. Patients admitted to the HTD with a clinical diagnosis of dengue and at least 1 warning sign(s) or severe dengue to Emergency department / inpatient wards / Intensive Care Units (ICU), will be invited to participate in the trial. Eligible patients will be invited to participate in the screening phase during which, the collection of clinical information about this acute illness episode as well as some screening tests will be performed, including measurement ferritin, creatinine, pregnancy test (for all females). \- If ferritin level is greater than 2000ng/mL and meet all other inclusion/exclusion criteria, patients will be invited to participate in the randomization phase (second consent), which they will be randomly given either anakinra or placebo intravenous (IV) for four days. The intervention: * (i) 200mg bid for four days in adults participants (≥ 16 years) or in children (12-16 years), with weight \> 50kg; and * (ii) 2mg/kg bid for four days in children (12-16 years), with weight \< 50Kg. All patients will be followed up daily at the clinical wards until discharge. Details of all AEs and SAEs will be recorded on specific forms, together with an assessment as to whether the events are likely to have been related to any treatment received. All SAEs will be reported promptly to the DMC and ECs according to policy. In cases of discontinuation due to AEs, participants will be followed up until the events have resolved or stabilized.
Interventions
DRUGPlacebo
Drug: Placebo, with visually matched clear syringes * Adults (≥16 years) and children (12-16 years, \> 50Kg) will receive 2 syringes of placebo via IV route, twice daily for 4 days * Children (12-16 years, \< 50Kg) will receive no more than 1 syringe of placebo via IV route, twice daily for 4 days
DRUGAnakinra
Drug: Anakinra * Adults (≥16 years) and children (12-16 years, \> 50Kg) will receive 200mg of anakinra (2 syringes) via IV route, twice daily for 4 days * Children (12-16 years, \< 50Kg) will receive 2mg/Kg of anakinra via IV route, twice daily for 4 days (no more than 1 syringe of anakinra, twice daily for 4 days)
Sponsors
Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
Wellcome Trust
Oxford University Clinical Research Unit, Vietnam
Study design
Allocation
RANDOMIZED
Intervention model
SEQUENTIAL
Primary purpose
TREATMENT
Masking
DOUBLE (Subject, Investigator)
Masking description
Double blinded
Intervention model description
This is a randomized, double blinded, placebo controlled trial of anakinra in patients with dengue with warning signs or severe dengue
Eligibility
Sex/Gender
ALL
Age
12 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Patients hospitalised with a clinical diagnosis of dengue and at least 1 warning sign(s) (see appendix) or severe dengue to Emergency department/inpatient wards/Intensive Care wards (ICU), * Ferritin levels \> 2000ng/mL * ≥ 12 years of age * Written informed consent or assent to participate in the study * Agree to come back for 2 follow up visits around day 30 of illness (maximum 5 weeks) and at 3 months
Exclusion criteria
* Pregnancy * Localizing features suggesting an alternative/additional diagnosis, e.g. pneumonia, sepsis * Patients taking immunosuppressive drugs or other biologics in last 1 month * Patients with underlying malignancy or immunosuppression * Children \<12 years * Have end-stage renal failure (baseline GFR \< 30ml/min) * Being treated for TB * Taking any drug with significant interaction with anakinra * The study physician judges that the patient is unlikely to attend follow up visit at around 3-4 weeks after fever onset - e.g. due to long travelling distance from the clinic
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change in modified Sequential Organ Failure Assessment score (mSOFA core, modified for limited resource settings and dengue) within 4 days | baseline, up to day 4 | Change in mSOFA score over 4 days after randomization (min score= 0, max score = 24, higher scores mean worse outcomes) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Mortality | Up to day 30 | Number of death up to day 30 |
| Change in modified Sequential Organ Failure Assessment score (mSOFA core, modified for limited resource settings and dengue) at day 7 | baseline, day 7 | Change in mSOFA score at day 7 post randomization (min score= 0, max score = 24, higher scores mean worse outcomes) |
| Number of days treated in Intensive care unit (ICU) | Up to day 30 | Number of days treated in ICU |
| Number of days treated in hospital | Up to day 30 | Number of days treated in hospital |
| Number of participants with Serious Adverse Events (SAEs) | Day 1-5 and Day 6-30 | Number of participants having SAEs within 2 time-periods, 1- 5 days and 6-30 days |
| Number of Adverse Events (AEs) per participant | Up to day 30 | Number of AEs per individual |
| Change in Platelets count | Up to day 5, at day 30 | Change in blood levels (Platelets) over 5 days following randomization and at day 30 |
| Change in neutrophils count | Up to day 5, at day 30 | Change in blood levels (neutrophils) over 5 days following randomization and at day 30 |
| Change of Ferritin levels | Up to day 5, at day 30 | Change in blood levels (Ferritin) over 5 days following randomization and at day 30 |
| Change of CRP levels | Up to day 5, at day 30 | Change in blood levels (CRP) over 5 days following randomization and at day 30 |
| Time to normalization of blood levels | Up to day 30 | Time to normalization of platelets (defined as \>150 x109/l) and neutrophils (\>2 x109/l) |
| Platelet nadir | Up to day 30 | Lowest platelet count recorded during admission |
| Fever clearance time | Up to day 30 | Time to temperature \<37.5 for at least 48 hours |
| Duration of viraemia | Up to day 30 | Number of days from enrollment to the first undetectable viraemia (negative in qPCR and NS1) |
| Area under the curve (AUC) of the serial viral load measurements during hospital stay | at discharge (assessed up to day 8) | AUC of viral load measurements during hospital stay will be reported |
| Patients' quality of life questionnaire score | at discharge (assessed up to day 8) and at day 30 | Patients' quality of life during their hospitalisation will be explored at discharge and day 30 using the EQ-5D questionnaire. |
| Change of ALT levels | Up to day 5, at day 30 | Change in blood levels (ALT) over 5 days following randomization and at day 30 |
Other
| Measure | Time frame | Description |
|---|---|---|
| Change in immune cells | Up to day 90 | Phenotyping CD8/4+T and NK cells will be assessed |
Countries
Vietnam
Outcome results
None listed