TY - JOUR
T1 - Nebulised ALX-0171 for respiratory syncytial virus lower respiratory tract infection in hospitalised children :a double-blind, randomised, placebo-controlled, phase 2b trial
AU - Cunningham, Steve
AU - Piedra, Pedro A.
AU - Martinon-Torres, Federico
AU - Szymanski, Henryk
AU - Brackeva, Benedicte
AU - Dombrecht, Evelyne
AU - Detalle, Laurent
AU - Fleurinck, Carmen
AU - RESPIRE study group
A2 - Piedra, Pedra A.
A2 - Verhulst, Stijn
A2 - Matthijs, Inge
A2 - Proesmans, Marijke
A2 - Goetghebuer, Tessa
A2 - Bosheva, Miroslava
A2 - Dosev, Svilen
A2 - Nikolova, Olga
A2 - Chakarova, Petranka
A2 - Wu Hupat, Elba
A2 - Mesa Monsalve, Juan
A2 - Turkalj, Mirjana
A2 - Mesaric Antoncic, Natasa
A2 - Tesovic, Goran
A2 - SIPL, Mirna
A2 - Kljaic Bukvic, Blazenka
A2 - Ivkovic-Jurekovic, Irena
A2 - Cicak, Biserka
A2 - Skalova, Sylva
A2 - Horneff, Gerd
A2 - Vogelberg, Christian
A2 - Gacs, Éva
A2 - Kalocsai, Krisztina
A2 - Madarasi, Anna
A2 - Kovacs, Lajos
A2 - Novak, Zoltan
A2 - Bene, Zsolt
A2 - Ashkenazi, Shai
A2 - Goldbart, Aviv
A2 - Bentur, Lea
A2 - Kolosa, Nadezda
A2 - Gardovska, Dace
A2 - Khaw, Poh Guan
A2 - Toh, Teck Hock
A2 - De Bruyne, Jessie Anne
A2 - Tan, Kah Kee
A2 - Alberto, Edison
A2 - Sablan, Benjamin, Junior
A2 - de Leon, Anjanette
A2 - Repko, Miroslav
A2 - Kralinsky, Karol
A2 - Salamanca de la Cueva, Ignacio
N1 - Funding Information:
We acknowledge the contribution to this study report by statistician Rupam Ranjan Pal and programmer Abdelhamid Ouakasse, both employees of Ablynx, a Sanofi company. Nanobody is a registered trademark of Ablynx NV, a Sanofi Company.
Publisher Copyright:
© 2021 Elsevier Ltd
PY - 2021/1
Y1 - 2021/1
N2 - Background: Respiratory syncytial virus (RSV) is the most common cause of severe lower respiratory tract infection, with a high global health burden. There are no effective treatments available. ALX-0171 is a novel trivalent Nanobody with antiviral properties against RSV. We aimed to assess the safety and antiviral activity of nebulised ALX-0171 in children admitted to hospital with RSV lower respiratory tract infection. Methods: This double-blind, randomised, placebo-controlled, phase 2b trial was done in 50 hospital paediatric departments across 16 countries. Previously healthy children aged between 28 days to younger than 24 months who were admitted to hospital with RSV acute severe lower respiratory tract infection were randomly assigned in three sequential safety cohorts (3:1) to receive nebulised ALX-0171 (cohort 1 received 3 mg/kg, cohort 2 received 6 mg/kg, and cohort 3 received 9 mg/kg) or placebo once daily for 3 days using web-based randomisation in the sequential safety part (first block size 12, subsequently four). In a parallel part of the study, participants (cohort 4) were randomly assigned (parallel 1:1:1:1) to receive nebulised ALX-0171 3 mg/kg, 6 mg/kg, 9 mg/kg, or placebo (blocks of eight by restricted randomisation). Study drug masking was by two consecutive nebulisations (each either ALX-0171 or placebo) depending on assigned treatment group. The primary outcome was to evaluate time for the RSV viral load to drop to below quantifiable limit, measured by plaque assay on mid-turbinate nasal swabs. Safety, clinical efficacy, pharmacokinetics, viral load by RT-qPCR, and immunogenicity were secondary outcomes. Analysis, including of the primary outcome, was by modified intention to treat (participants receiving at least one dose of study drug as assigned), and safety was assessed in all children who received at least one administration of study drug, as treated. This trial is registered with EudraCT, 2016-001651-49. Findings: Between Jan 10, 2017, and April 26, 2018, 175 children (median age 4·8 months [IQR 2·0–10·8]), received at least one dose of study drug (45 received 3 mg/kg of ALX-0171, 43 received 6 mg/kg of ALX-0171, 45 received 9 mg/kg of ALX-0171, and 42 received placebo; the modified intention-to-treat population) commencing at a mean 3·3 days (SD 1·1) from symptom onset. Median time for the viral load to drop to below quantifiable limit on plaque assay was significantly faster for the 3 mg/kg group (median 14·2 h [IQR 5·0–28·0]), 6 mg/kg group (5·1 h [4·7–28·5]), and 9 mg/kg group (5·1 h [4·6–5·9]) than the placebo group (46·1 h [25·2–116·7]; hazard ratio [HR] all ALX-0171 groups vs placebo 2·6 [1·7–3·9]; p<0·0001). Median time for the viral load to drop below quantification limit with RT-qPCR was 95·9 h (IQR 26·7 to not estimable) for the placebo group (n=35) versus 49·4 h (25·1 to 351·4) for all ALX-0171 groups (n=118). Clinical outcomes were not improved by ALX-0171 compared with placebo, with no difference in time to clinical response (oxygen saturation >92% for 4 h in room air and adequate oral feeding) in ALX-0171 groups and the placebo group (median 43·8 h [IQR 21·7–68·5] vs 47·9 h [22·5–76·4]; HR 1·1 [95% CI 0·8–1·6]) or change in the global severity score from baseline to 5 h post-dose on day 2 (−4 [IQR −6 to −2] vs −4 [–6 to −1]; difference in least-squares mean −0·45 [95% CI −1·39 to 0·49]). Serum concentrations of ALX-0171 on day 2 exceeded the concentration estimated to give full RSV neutralisation in the lung at 6 mg/kg and 9 mg/kg doses. Treatment-emergent antidrug antibodies were detected at day 14 in 46 (34%) of 135 patients who received ALX-0171 and ten (26%) of 39 patients who received placebo. Serious adverse events were reported in five (13%) of 40 children in the placebo group and ten (7%) of 135 children in all ALX-0171 groups, leading to study drug discontinuation in three children (two in the 3 mg/kg group and one in the 6 mg/kg group). 13 of 15 serious adverse events (three of four in the 3 mg/kg group, two of three in the 6 mg/kg group, three of three in the 9 mg/kg group, and five of five in the placebo group) were related to worsening respiratory status, and none were considered to be related to the study drug. Interpretation: Antivirals against RSV might be unable to improve clinical course once RSV lower respiratory tract infection is established. Future studies of RSV antivirals should focus on earlier intervention and more precise measurement of objective outcomes before the onset of significant lower respiratory tract inflammation. Funding: Ablynx, a Sanofi Company.
AB - Background: Respiratory syncytial virus (RSV) is the most common cause of severe lower respiratory tract infection, with a high global health burden. There are no effective treatments available. ALX-0171 is a novel trivalent Nanobody with antiviral properties against RSV. We aimed to assess the safety and antiviral activity of nebulised ALX-0171 in children admitted to hospital with RSV lower respiratory tract infection. Methods: This double-blind, randomised, placebo-controlled, phase 2b trial was done in 50 hospital paediatric departments across 16 countries. Previously healthy children aged between 28 days to younger than 24 months who were admitted to hospital with RSV acute severe lower respiratory tract infection were randomly assigned in three sequential safety cohorts (3:1) to receive nebulised ALX-0171 (cohort 1 received 3 mg/kg, cohort 2 received 6 mg/kg, and cohort 3 received 9 mg/kg) or placebo once daily for 3 days using web-based randomisation in the sequential safety part (first block size 12, subsequently four). In a parallel part of the study, participants (cohort 4) were randomly assigned (parallel 1:1:1:1) to receive nebulised ALX-0171 3 mg/kg, 6 mg/kg, 9 mg/kg, or placebo (blocks of eight by restricted randomisation). Study drug masking was by two consecutive nebulisations (each either ALX-0171 or placebo) depending on assigned treatment group. The primary outcome was to evaluate time for the RSV viral load to drop to below quantifiable limit, measured by plaque assay on mid-turbinate nasal swabs. Safety, clinical efficacy, pharmacokinetics, viral load by RT-qPCR, and immunogenicity were secondary outcomes. Analysis, including of the primary outcome, was by modified intention to treat (participants receiving at least one dose of study drug as assigned), and safety was assessed in all children who received at least one administration of study drug, as treated. This trial is registered with EudraCT, 2016-001651-49. Findings: Between Jan 10, 2017, and April 26, 2018, 175 children (median age 4·8 months [IQR 2·0–10·8]), received at least one dose of study drug (45 received 3 mg/kg of ALX-0171, 43 received 6 mg/kg of ALX-0171, 45 received 9 mg/kg of ALX-0171, and 42 received placebo; the modified intention-to-treat population) commencing at a mean 3·3 days (SD 1·1) from symptom onset. Median time for the viral load to drop to below quantifiable limit on plaque assay was significantly faster for the 3 mg/kg group (median 14·2 h [IQR 5·0–28·0]), 6 mg/kg group (5·1 h [4·7–28·5]), and 9 mg/kg group (5·1 h [4·6–5·9]) than the placebo group (46·1 h [25·2–116·7]; hazard ratio [HR] all ALX-0171 groups vs placebo 2·6 [1·7–3·9]; p<0·0001). Median time for the viral load to drop below quantification limit with RT-qPCR was 95·9 h (IQR 26·7 to not estimable) for the placebo group (n=35) versus 49·4 h (25·1 to 351·4) for all ALX-0171 groups (n=118). Clinical outcomes were not improved by ALX-0171 compared with placebo, with no difference in time to clinical response (oxygen saturation >92% for 4 h in room air and adequate oral feeding) in ALX-0171 groups and the placebo group (median 43·8 h [IQR 21·7–68·5] vs 47·9 h [22·5–76·4]; HR 1·1 [95% CI 0·8–1·6]) or change in the global severity score from baseline to 5 h post-dose on day 2 (−4 [IQR −6 to −2] vs −4 [–6 to −1]; difference in least-squares mean −0·45 [95% CI −1·39 to 0·49]). Serum concentrations of ALX-0171 on day 2 exceeded the concentration estimated to give full RSV neutralisation in the lung at 6 mg/kg and 9 mg/kg doses. Treatment-emergent antidrug antibodies were detected at day 14 in 46 (34%) of 135 patients who received ALX-0171 and ten (26%) of 39 patients who received placebo. Serious adverse events were reported in five (13%) of 40 children in the placebo group and ten (7%) of 135 children in all ALX-0171 groups, leading to study drug discontinuation in three children (two in the 3 mg/kg group and one in the 6 mg/kg group). 13 of 15 serious adverse events (three of four in the 3 mg/kg group, two of three in the 6 mg/kg group, three of three in the 9 mg/kg group, and five of five in the placebo group) were related to worsening respiratory status, and none were considered to be related to the study drug. Interpretation: Antivirals against RSV might be unable to improve clinical course once RSV lower respiratory tract infection is established. Future studies of RSV antivirals should focus on earlier intervention and more precise measurement of objective outcomes before the onset of significant lower respiratory tract inflammation. Funding: Ablynx, a Sanofi Company.
UR - http://www.scopus.com/inward/record.url?scp=85092628373&partnerID=8YFLogxK
U2 - 10.1016/s2213-2600(20)30320-9
DO - 10.1016/s2213-2600(20)30320-9
M3 - Article
C2 - 33002427
AN - SCOPUS:85092628373
SN - 2213-2600
VL - 9
SP - 21
EP - 32
JO - The Lancet Respiratory Medicine
JF - The Lancet Respiratory Medicine
IS - 1
ER -