A Safety and Tolerability Study of Nitazoxanide in HIV-HCV Treatment Failures
Information source: National Institutes of Health Clinical Center (CC)
Information obtained from ClinicalTrials.gov on October 04, 2010
Link to the current ClinicalTrials.gov record.
Condition(s) targeted: HIV; HCV; HCV Genotype 1
Intervention: Nitazoxanide (Drug)
Phase: Phase 1/Phase 2
Sponsored by: National Institutes of Health Clinical Center (CC)
Patient Recruitment and Public Liaison Office, Phone: (800) 411-1222, Email: firstname.lastname@example.org
- Chronic hepatitis C (CHC) is a major health problem that particularly affects
individuals with human immunodeficiency virus (HIV) infection, and can lead to
cirrhosis and liver failure. Standard treatment for people with HIV and CHC is a
48-week course of pegylated-interferon alfa 2a (peg-IFN) and ribavirin (RBV), but
better treatments are needed for those who either do not respond to the drugs or who
relapse after treatment.
- Nitazoxanide has been approved by the Food and Drug Administration primarily to treat
diarrhea caused by parasites, and it has been studied in the treatment of CHC
infection. However, it has not been tested in persons infected with HIV and CHC
co-infection. Researchers are interested in determining whether nitazoxanide is a safe
and tolerable treatment for CHC in individuals with HIV.
- To assess the safety and tolerability of using nitazoxanide to treat chronic hepatitis C
infection in individuals with HIV who have not responded to standard treatment for hepatitis
- Individuals at least 18 years of age who have been diagnosed with both HIV and chronic
hepatitis C, and who have either not responded to or relapsed after previous hepatitis C
- Participants will be screened with a physical examination and medical history; blood
and urine tests; imaging studies; possible heart, lung, and psychological tests; and a
liver biopsy if one has not been done in the past 3 years.
- Participants will receive nitazoxanide, the medication being studied, to take by mouth
for 4 weeks, and will provide blood samples during this time.
- After 4 weeks, participants will receive the first dose of peg-IFN and RBV.
Participants will have weekly injections of peg-IFN and continue to take nitazoxanide
and RBV by mouth for 48 weeks. Individuals who are slow to respond to this combined CHC
treatment (nitazoxanide, peg-IFN, and RBV) by week 12 will continue to have the
combined treatment for an extended period, a total of 72 weeks.
- Participants will have study visits to provide blood samples and have other tests two
times in the first month of combined treatment, and then at months 2, 3, 4, 7, 10, 13,
19; and month 25 only in participants slow to respond to combined treatment.
- Some participants who are on specific HIV treatment regimens may enroll in a substudy
that will require three separate 12-hour visits for repeated blood samples and other
Official title: An Open-Label Safety and Tolerability Study of Nitazoxanide, Pegylated-Interferon Alfa 2a and Ribavirin in HIV/HCV Co-Infected Genotype 1 Prior Treatment Relapsers and Non-Responders
Study design: Allocation: Non-Randomized, Control: Uncontrolled, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Single Group Assignment, Masking: Open Label, Primary Purpose: Treatment
Chronic hepatitis C (CHC) viral infection is a major health problem affecting 130-170
million worldwide, and 2. 7-3. 9 million in the US, more than 3 times those with HIV
infection. One-third of persons with HIV have CHC, a more rapid progression to cirrhosis and
liver failure, with liver disease as one of the leading causes of mortality.
Standard treatment, pegylated-interferon (IFN) alfa and ribavirin (RBV), has an efficacy,
sustained virologic response (SVR), of less than 50% in those with HCV genotype 1 (GT 1);
and only about 25% of those with HIV-HCV GT1 co-infection. SVR is even lower in those
retreated, who were prior treatment relapsers or non-responders; few published studies
exist, especially in those with HIV. Improved therapy is imperative given increasing
morbidity and mortality and the proportion of persons who are relapsers or non-responders.
Newer and promising anti-HCV therapies, directly acting antivirals (DAA), are in
development. However, only 2 are in Phase 3 clinical trials and most remain far from FDA
An oral agent, nitazoxanide (NTZ), with broad in vitro anti-microbial activity and a good
safety profile, has higher efficacy rates in treatment na ve participants mono-infected with
HCV GT 1 or 4. There have not been studies in HIV co-infected persons, nor pharmacokinetic
(PK) studies in liver or renal disease. In vitro studies suggest that NTZ has both a direct
suppressive effect on HCV replication, as well as a sensitizing effect on IFN-mediated
suppression of HCV replication, yet the exact mechanism of action giving rise to higher SVR
rates is not well understood.
This is an open-label study in 35 HIV-HCV GT 1 co infected persons, prior relapsers (n=25)
or non-responders (n=10) after a full course of IFN and RBV therapy. Participants will
receive 4 weeks of NTZ lead-in therapy, followed by NTZ/peg-IFN/RBV triple combination
therapy for an additional 48 weeks. Slow responders will receive 72 weeks of triple therapy
after the 4-week NTZ lead-in.
The primary endpoint is safety and tolerability of NTZ. Secondary endpoints are
exploratory: (1) efficacy rate estimation, (2) viral dynamics assessment, and determination
of predictive response, (3) pharmacologic level assessment, (4) indirect mechanistic action
evaluation of NTZ through virologic response, and, (5) IFN-stimulated genetic expression
evaluation and determination of predictive response. There will be a sub-study evaluating
the PK of NTZ in a group of 10 participants who are on a ritonavir-based HIV antiretroviral
Minimum age: 18 Years.
Maximum age: N/A.
- ELIGIBILITY CRITERIA:
To be eligible for participation on this protocol, a participant must satisfy all of the
Be greater than or equal to 18 years old and have an identifiable Primary Care Provider.
Have documentation of HIV-1 infection by licensed enzyme-linked immunosorbent assay
(ELISA) and confirmed by a Western Blot.
Have documentation of chronic HCV (CHC) infection by demonstration of a positive test for
hepatitis C antibocy and HCV RNA of 2,000 IU/mL or greater
Have histopathologic features consisten with CHC at the time of enrollment. A liver
biopsy done for a participant with 36 months prior to his or her participant may be used
as the baseline biopsy. Participants can opt out of a biopsy if they had one or more than
36 months prior and have a contraindication, sucha as receiving chronic anticoagulation
therapy. Participants with decompensated liver disease are excluded from study.
Are co-infected infected with HCV genotype 1 and HIV viruses.
1. Relapsers: Participants who had an undetectable HCV RNA (< 10 IU/mL) at the end of
prior treatment (ETR) but have detectable HCV RNA at Week 72.
2. Non-responders: Participants who have received at least 12 weeks of treatment with
any IFN alfa 2a or 2b with ribavirin and have not achieved either a 2 log (10) drop
in HCV viral levels at week 12 (null responder) nor has not achieved a HCV RNA below
the level of detection by Week 24 (< 10 IU/mL).
3. Washout period from prior treatment of at least 3 months.
Participants with CD(4) cell counts greater than or equal to 100 cells/mm(3)
Capacity to understand and sign or thumbprint the Informed Consent document, as well
as willingness to comply with the study requirements and clinic policies.
Absolute neutrophil count > 1,000 cells/mm3.
Platelets > 50,000/mm3.
Hemoglobin > 10. 5 mg/dL.
Not pregnant or breast-feeding. Serum pregnancy test must be negative 2 weeks prior
to Day - 28 and to Day 0 prior to dosing with study medications for female
If the participant is able to become pregnant, then she must use 2 effective methods
of contraception during the study. Effective contraceptive methods include
abstinence, surgical sterilization of either partner, barrier methods such as
diaphragm, condom, cap, or sponge, or use of hormonal contraception with an anti-HIV
regimen that will not alter metabolism of hormonal contraception. This is advised on
the basis of using ribavirin, which may have a potential teratogenic effect on the
fetus in pregnant women. NTZ had not been studied during lactation.
Be willing to not become pregnant until 6 months after completion of ribavirin
Male participants who are not documented to be sterile agree to either abstain from
intercourse or consistently and correctly use a condom while their female partner (if
applicable) agrees to use one of the appropriate medically accepted methods of birth
control listed above from the date of screening until 6 months after their last dose
Participants with documented illicit drug use must demonstrate ability to adhere to
HIV medication (with an undetectable or stable HIV viral load) and their prior
primary care provider appointments (more than 80% as scheduled).
Be willing to abstain from alcohol use during the trial and enter treatment program
Be able to learn to safely inject medication, be able to find another person or a
clinic to inject the medication for him/her, or is willing to come to the clinic for
Be willing to allow stored blood or tissue samples to be used in the future.
A participant will be ineligible to participate on this study if any of the following
criteria are met:
A participant cannot be on other experimental therapies (including expanded
access/compassionate use of antiretrovirals) for 28 days prior to Day - 28 and during
his/her participation in this protocol.
Mixed genotypes (e. g., 1 & 2, 1 & 3,1 & 4). Mixed genotype 1a/1b will be enrolled.
Has any other known, or clinically suspected, cause of liver disease, including
active hepatitis B.
For participants with cirrhosis, a Child Turcotte Pugh score > 7, or Child's B or C
Has a prothrombin time International Normalized Ratio (PT-INR) > 2 and is not on
chronic anti-coagulation medications, or has a history of hemophilia.
Has had an organ transplantation other than cornea or hair.
Has an estimated creatinine clearance (estimated glomerular flow rate) < 50 mL/min.
For a participant with higher than 20 ng/mL of alpha-fetoprotein, a negative
ultrasound or computerized tomography scan to rule out hepatoma is required for
Has any neoplastic disease EXCEPT for (1) Kaposi's sarcoma not requiring systemic
chemotherapy, (2) any non-metastatic skin cancer that has been resected or (3)
non-metastatic cervical or anal cancer that has been resected.
Has evidence of severe cardiac disease (greater than or equal to Grade 3 congestive
cardiac failure, symptomatic coronary artery disease, significant arrhythmias, or
uncontrolled hypertension) despite intervention or medical therapy.
Has evidence of severe chronic pulmonary disease with functional impairment or a DLCO
(diffusing capacity of the lung for carbon monoxide) less than or equal to 70% at
Has a severe psychiatric disorder that would interfere with the adherence to protocol
requirements, and that is not stably treated with risk of decompensation.
Has evidence of autoimmune disorders including inflammatory bowel diseases,
psoriasis, and optic neuritis.
Has evidence of an uncontrolled seizure disorder defined as more than 1 episode of
generalized seizure within the past year.
Has chronic pancreatitis.
Has severe retinopathy, as determined by the ophthalmologist.
Has any hemoglobinopathy (e. g., Thalassemia, sickle cell disease).
Is currently taking didanosine or d4T as part of antiretroviral regimen.
Has a direct bilirubin greater than or equal to 0. 6 mg/dL.
Concurrent use of any immunosuppressive therapy, including systemic steroids
(prednisone equivalent of > 10 mg/day) for a duration of 6 weeks or more within 6
months prior to enrollment. Inhaled steroids will be allowed, even with ritonavir.
Has active systemic infections other than HCV and HIV.
Has a hepatic mass suggestive of hepatocellular carcinoma as detected by ultrasound
scan, dual-phase computerized tomography, or magnetic resonance imaging.
Has evidence of moderate or heavy alcohol use (> 50 grams/day), or substance abuse,
within the past 6 months that potentially could interfere with participant
compliance. (Urine toxicology will be completed at screening.)
Currently uses warfarin, ganciclovir, isoniazid, pyrazinamide, rifabutin,
rifampin/rifampicin, thalidomide, or theophylline.
Has a history of esophageal or gastric varices.
Has any systemic illness that will make it unlikely that the participant will be able
to return for the required study visits.
Has evidence of gastrointestinal malabsorption, chronic nausea, or vomiting.
The participant is the male partner of a pregnant woman and does not always use a
condom during intercourse.
Women who are pregnant.
Women who are breast-feeding.
Has a hypersensitivity to NTZ, interferon products, or ribavirin.
Has ingested silymarin (milk thistle), s-adenosylmethionine (SAM-e), glycyrrhizin,
Sho-saiko-to (SST), or other herbal supplements that may be either liver beneficial
or toxic, within 28 days prior to Day - 28.
Locations and Contacts
Patient Recruitment and Public Liaison Office, Phone: (800) 411-1222, Email: email@example.com
Whitman Walker Clinic, NW, Washington, DC, District of Columbia, United States; Recruiting
Unity Health Care/Walker Jones, NE, Washington, DC, District of Columbia, United States; Recruiting
Family Medical and Counseling Services, SE, Washington, DC, District of Columbia, United States; Recruiting
National Institutes of Health Clinical Center, 9000 Rockville Pike, Bethesda, Maryland 20892, United States; Recruiting
NIH Clinical Center Detailed Web Page
Seeff LB, Buskell-Bales Z, Wright EC, Durako SJ, Alter HJ, Iber FL, Hollinger FB, Gitnick G, Knodell RG, Perrillo RP, et al. Long-term mortality after transfusion-associated non-A, non-B hepatitis. The National Heart, Lung, and Blood Institute Study Group. N Engl J Med. 1992 Dec 31;327(27):1906-11.
Seeff LB. Natural history of chronic hepatitis C. Hepatology. 2002 Nov;36(5 Suppl 1):S35-46. Review.
Staples CT Jr, Rimland D, Dudas D. Hepatitis C in the HIV (human immunodeficiency virus) Atlanta V.A. (Veterans Affairs Medical Center) Cohort Study (HAVACS): the effect of coinfection on survival. Clin Infect Dis. 1999 Jul;29(1):150-4.
Starting date: August 2010
Last updated: September 29, 2010