Pharmacokinetic Study of Linezolid for TB Meningitis
- Registration Number
- NCT03537495
- Lead Sponsor
- Universitas Padjadjaran
- Brief Summary
Tuberculosis meningitis (TBM) is the most severe manifestation of TB, resulting in death or neurological disability in up to 50% of affected patients, despite antibacterial treatment. This TBM treatment follows the model for pulmonary TB by using the same first-line TB drugs (a combination of rifampicin, isoniazid, pyrazinamide and ethambutol) and the same dosing guidelines, although it is known that penetration of two of these drugs (rifampicin and ethambutol) into cerebrospinal fluid (CSF) is limited. Improvement of treatment of TBM is urgently needed.
To do so, a combination of two interventions will be investigated in this study. A series of phase II clinical trials on higher doses of the pivotal TB drug rifampicin in Indonesian patients with TBM have shown that the dose of rifampicin can be increased from 10 mg/kg orally (standard dose) up to 30 mg/kg orally, resulting in a strong increase in exposure to this drug in plasma and CSF, no increase in grade III or IV adverse effects, and a reduction in mortality. Similarly, higher doses of rifampicin up to 35 mg/kg resulted in strong increases in plasma concentrations; the doses were well tolerated and reduced time to sputum conversion in African pulmonary TB patients.
Next to a higher dose of rifampicin, the approved antibacterial drug linezolid seems a good candidate for a new TBM regimen. The drug penetrates well into the CSF and is applied successfully against other central nervous system (CNS) infections (e.g. caused by penicillin-nonsusceptible Streptococcus pneumoniae, vancomycin-resistant enterococci and methicillin-resistant Staphylococcus aureus). In a study in China, linezolid in a dose of 600 mg BID orally strongly increased recovery of patients with TBM response. Linezolid is also being investigated as a new drug for (drug-resistant) pulmonary TB in numerous studies, in a dose of 1200 mg once daily. More severe adverse effects to this drug typically occur only after prolonged treatment during several months, not during short-term treatment.
Overall, linezolid is expected to be a promising and tolerable candidate for a new intensified TBM treatment regimen consisting of a backbone of high dose rifampicin plus linezolid.
- Detailed Description
Overall aim is to determine the most appropriate dose of linezolid in the treatment of TB meningitis, when combined with high-dose rifampicin (35 mg/kg orally), to be tested in larger clinical follow-up studies.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 36
- Age: 18 years old or older
- Clinically diagnosed as TB meningitis patient
- CSF/blood glucose ratio < 0.5
- Willing to participate in the study by signing informed consent
Patients who have one of the following criteria will be excluded:
- Failure to diagnostic lumbar puncture
- Confirmed cryptococcus meningitis (LFA) in HIV-positive patients; or diagnosed as bacterial meningitis based on clinical assessment and routine CSF examination.
- Treatment for tuberculosis for more than 3 days before admission
- History of TBM
- Current treatment with: MAO inhibitors, direct and indirect acting sympathomimetic drugs, vasopressive drugs, dopaminergic compounds, buspiron, serotonin reuptake inhibitors, tricyclic antidepressants, triptans, tramadol and meperidine
- History (< 2 weeks before start of linezolid) of taking any MAO inhibitors
- Pregnant or lactating females
- Hepatic insufficiency (ALT>5x upper normal limit)
- Kidney dysfunction (eGFR <50ml/min)
- Known hypersensitivity to rifampicin and/or linezolid
- Rapid clinical deterioration at time of presentation (sepsis, decreasing consciousness, or signs of cerebral oedema or herniation)
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Linezolid 600 Linezolid Subjects in this arm will receive 600 mg linezolid QD along with high-dose rifampicin (\~35 mg/kg, based on weight), isoniazid (H) 300 mg, pyrazinamide (Z) 1500 mg and ethambutol (E) 750 mg once daily administered orally for 14 days. Linezolid 1200 Linezolid Subjects in this arm will receive 1200 mg linezolid QD along with rifampicin 1350 mg (\~35 mg/kg, based on weight), isoniazid (H) 300 mg, pyrazinamide (Z) 1500 mg and ethambutol (E) 750 mg once daily administered orally for 14 days.
- Primary Outcome Measures
Name Time Method Linezolid exposure in blood and CSF day 2 and day 11 Linezolid exposure in blood (full plasma concentration-versus-time profiles (0-24h)) will be measured in 2 days, i.e. day 2 (+/- 1) and at day 11 (+/- 1) of TB treatment. In each sampling day, there will be 6 sampling points i.e. at 0 (pre-dose), 1, 2, 4, 8, and 12 h after study medication intake
One CSF sample per patient will be taken at the same day as PK sampling i.e. at 2, 4 or 8 hours post dose.
- Secondary Outcome Measures
Name Time Method Blood inflammatory response at PK days (day 2 and 11), and day 7 and 14 Profile of inflammatory response in blood
Serious adverse event Day 3, 7, 10 and 14 Serious adverse events assessed daily during the 14 days of intensified treatment (e.g. gastro-intestinal intolerance), and grade 1-4 adverse events (e.g. liver function and hematology) assessed at day 3, 7, 10 and 14.
Clinical response Day 3, 7 and 14. Clinical response includes resolution of fever, resolution of hyponatremia etc.
Mortality Within 14 days and 1 month after starting treatment mortality during the first month will be recorded and cause of death will be classified as neurologic or non-neurologic, if applicable
Neurological response Day 3, 7 and 14. Neurological response includes resolution of consciousness, development of raised intracranial pressure, etc.
CSF inflammatory response at PK sampling days (day 2 and 11) inflammatory response in CSF at PK sampling days
Trial Locations
- Locations (1)
Hasan Sadikin General Hospital
🇮🇩Bandung, Jawa Barat, Indonesia