UCL Institute of Immunity and Transplantation, Royal Free Hospital, Pond Street, London, NW3 2QG, UK.
Comprehensive Clinical Trials Unit, University College London, 90 High Holborn, 2nd Floor, London, WC1V 6LJ, UK.
Trials. 2021 Mar 8;22(1):193. doi: 10.1186/s13063-021-05139-2.
OBJECTIVES: The objective of this trial is to assess whether early antiviral therapy in outpatients with COVID-19 with either favipiravir plus lopinavir/ritonavir, lopinavir/ritonavir alone, or favipiravir alone, is associated with a decrease in viral load of SARS-CoV-2 compared with placebo. TRIAL DESIGN: FLARE is a phase IIA randomised, double-blind, 2x2 factorial placebo-controlled, interventional trial. PARTICIPANTS: This trial is being conducted in the United Kingdom, with Royal Free Hospital, London as the lead site. Participants are non-hospitalised adults with highly suspected COVID-19 within the first 5 days of symptom onset, or who have tested positive with SARS-CoV-2 causing COVID-19 within the first 7 days of symptom onset, or who are asymptomatic but tested positive for SARS-CoV-2 for the first time within the last 48 hours. Inclusion criteria are as follows: 1. Any adult with the following: Symptoms compatible with COVID-19 disease (Fever >37.8°C on at least one occasion AND either cough and/ or anosmia) within the first 5 days of symptom onset (date/time of enrolment must be within the first 5 days of symptom onset) OR ANY symptoms compatible with COVID-19 disease (may include, but are not limited to fever, cough, shortness of breath, malaise, myalgia, headache, coryza) and tested positive for SARS-CoV-2 within the first 7 days of symptom onset) (date/time of enrolment must be within the first 7 days of symptom onset) OR no symptoms but tested positive for SARS-CoV-2 within the last 48 hours (date/time of test must be within 48 hours of enrolment) 2. Male or female aged 18 years to 70 years old inclusive at screening 3. Willing and able to take daily saliva samples 4. Able to provide full informed consent and willing to comply with trial-related procedures Exclusion criteria are as follows: 1. Known hypersensitivity to any of the active ingredients or excipients in favipiravir and matched placebo, and in lopinavir/ritonavir and matched placebo (See Appendix 2) 2. Chronic liver disease at screening (known cirrhosis of any aetiology, chronic hepatitis (e.g. autoimmune, viral, steatohepatitis), cholangitis or any known elevation of liver aminotransferases with AST or ALT > 3 X ULN)* 3. Chronic kidney disease (stage 3 or beyond) at screening: eGFR < 60 ml/min/1.73m * 4. HIV infection, if untreated, detectable viral load or on protease inhibitor therapy 5. Any clinical condition which the investigator considers would make the participant unsuitable for the trial 6. Concomitant medications known to interact with favipiravir and matched placebo, and with lopinavir/ritonavir and matched placebo, and carry risk of toxicity for the participant 7. Current severe illness requiring hospitalisation 8. Pregnancy and/ or breastfeeding 9. Eligible female participants of childbearing potential and male participants with a partner of childbearing potential not willing to use highly effective contraceptive measures during the trial and within the time point specified following last trial treatment dose. 10. Participants enrolled in any other interventional drug or vaccine trial (co-enrolment in observational studies is acceptable) 11. Participants who have received the COVID-19 vaccine *Considering the importance of early treatment of COVID-19 to impact viral load, the absence of known chronic liver/ kidney disease will be confirmed verbally by the participant during pre-screening and Screening/Baseline visit. Safety blood samples will be collected at Screening/Baseline visit (Day 1) and test results will be examined as soon as they become available and within 24 hours. INTERVENTION AND COMPARATOR: Participants will be randomised 1:1:1:1 using a concealed online minimisation process into one of the following four arms: Arm 1: Favipiravir + Lopinavir/ritonavir Oral favipiravir at 1800mg twice daily on Day 1, followed by 400mg four (4) times daily from Day 2 to Day 7 PLUS lopinavir/ritonavir at 400mg/100mg twice daily on Day 1, followed by 200mg/50mg four (4) times daily from Day 2 to Day 7. Arm 2: Favipiravir + Lopinavir/ritonavir placebo Oral favipiravir at 1800mg twice daily on Day 1, followed by 400mg four (4) times daily from Day 2 to Day 7 PLUS lopinavir/ritonavir matched placebo at 400mg/100mg twice daily on Day 1, followed by 200mg/50mg four (4) times daily from Day 2 to Day 7. Arm 3: Favipiravir placebo + Lopinavir/ritonavir Oral favipiravir matched placebo at 1800mg twice daily on Day 1, followed by 400mg four (4) times daily from Day 2 to Day 7 PLUS lopinavir/ritonavir at 400mg/100mg twice daily on Day 1, followed by 200mg/50mg four (4) times daily from Day 2 to Day 7. Arm 4: Favipiravir placebo + Lopinavir/ritonavir placebo Oral favipiravir matched placebo at 1800mg twice daily on Day 1, followed by 400mg four (4) times daily from Day 2 to Day 7 PLUS lopinavir/ritonavir matched placebo at 400mg/100mg twice daily on Day 1, followed by 200mg/50mg four (4) times daily from Day 2 to Day 7. MAIN OUTCOMES: The primary outcome is upper respiratory tract viral load at Day 5. SECONDARY OUTCOMES: Percentage of participants with undetectable upper respiratory tract viral load after 5 days of therapy Proportion of participants with undetectable stool viral load after 7 days of therapy Rate of decrease in upper respiratory tract viral load during 7 days of therapy Duration of fever following commencement of trial medications Proportion of participants with hepatotoxicity after 7 days of therapy Proportion of participants with other medication-related toxicity after 7 days of therapy and 14 days post-randomisation Proportion of participants admitted to hospital with COVID-19 related illness Proportion of participants admitted to ICU with COVID-19 related illness Proportion of participants who have died with COVID-19 related illness Pharmacokinetic and pharmacodynamic analysis of favipiravir Exploratory: Proportion of participants with deleterious or resistance-conferring mutations in SARS-CoV-2 RANDOMISATION: Participants will be randomised 1:1:1:1 using a concealed online minimisation process, with the following factors: trial site, age (≤ 55 vs > 55 years old), gender, obesity (BMI <30 vs ≥30), symptomatic or asymptomatic, current smoking status (Yes = current smoker, No = ex-smoker, never smoker), ethnicity (Caucasian, other) and presence or absence of comorbidity (defined as diabetes, hypertension, ischaemic heart disease (including previous myocardial infarction), other heart disease (arrhythmia and valvular heart disease), asthma, COPD, other chronic respiratory disease). BLINDING (MASKING): Participants and investigators will both be blinded to treatment allocation (double-blind). NUMBERS TO BE RANDOMISED (SAMPLE SIZE): 240 participants, 60 in each arm. TRIAL STATUS: Protocol version 4.0 dated 7 January 2021. Date of first enrolment: October 2020. Recruitment is ongoing, with anticipated finish date of 31 March 2021. TRIAL REGISTRATION: The FLARE trial is registered with Clinicaltrials.gov, trial identifying number NCT04499677 , date of registration 4 August 2020. FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.
目的:本试验旨在评估 COVID-19 门诊患者接受法维拉韦联合洛匹那韦/利托那韦、洛匹那韦/利托那韦单独或法维拉韦单独治疗,与安慰剂相比,是否能降低 SARS-CoV-2 的病毒载量。 试验设计:FLARE 是一项 IIA 期随机、双盲、2x2 析因安慰剂对照、干预性试验。 参与者:该试验正在英国进行,以伦敦皇家自由医院为主要研究地点。参与者为高度疑似 COVID-19 的非住院成年人,症状发作后 5 天内首次就诊,或症状发作后 7 天内 SARS-CoV-2 检测阳性,或无症状但过去 48 小时内首次 SARS-CoV-2 检测阳性。纳入标准如下:1. 任何具有以下任何一种情况的成年人:症状与 COVID-19 疾病相符(至少一次发热>37.8°C),症状发作后 5 天内(登记日期/时间必须在症状发作后 5 天内),或任何与 COVID-19 疾病相符的症状(可能包括但不限于发热、咳嗽、呼吸急促、不适、肌痛、头痛、鼻塞),症状发作后 7 天内 SARS-CoV-2 检测阳性)(登记日期/时间必须在症状发作后 7 天内),或无症状但过去 48 小时内 SARS-CoV-2 检测阳性(检测日期必须在登记日期/时间的 48 小时内);2. 年龄在 18 岁至 70 岁之间的男性或女性;3. 愿意并能够每天提供唾液样本;4. 能够完全知情同意并愿意遵守试验相关程序。排除标准如下:1. 对法维拉韦和匹配安慰剂、洛匹那韦/利托那韦和匹配安慰剂中的任何一种活性成分或赋形剂已知过敏(见附录 2);2. 筛查时已知慢性肝病(任何病因引起的肝硬化、慢性肝炎(如自身免疫性、病毒性、胆汁性)、胆管炎或任何已知的肝氨基转移酶升高,AST 或 ALT>3×ULN);3. 筛查时慢性肾脏病(3 期或以上):eGFR<60ml/min/1.73m;4. 未经治疗的 HIV 感染、检测不到病毒载量或正在接受蛋白酶抑制剂治疗;5. 研究者认为会使参与者不适合参加试验的任何临床状况;6. 已知与法维拉韦和匹配安慰剂、洛匹那韦/利托那韦和匹配安慰剂相互作用并伴有毒性的同时用药;7. 目前需要住院治疗的严重疾病;8. 妊娠和/或哺乳;9. 有生育能力的女性参与者和有生育能力的男性参与者的伴侣不愿意在试验期间和最后一次试验治疗剂量后规定的时间内使用高效避孕措施;10. 参加任何其他干预性药物或疫苗试验(同时参加观察性研究是可以接受的);11. 已接受 COVID-19 疫苗的参与者。 考虑到 COVID-19 早期治疗对病毒载量的重要性,无症状或有症状参与者的慢性肝病/肾病缺失将在预筛选和筛选/基线访视期间由参与者口头确认。将在筛选/基线访视(第 1 天)时采集安全性血样,并在获得测试结果后尽快检查,在 24 小时内检查。 干预和比较:参与者将使用隐蔽的在线最小化过程,以 1:1:1:1 的比例随机分配到以下四个组之一:组 1:法维拉韦+洛匹那韦/利托那韦 第 1 天,每天两次口服 1800mg 法维拉韦,然后从第 2 天到第 7 天每天 4 次口服 400mg;第 1 天,每天两次口服洛匹那韦/利托那韦 400mg/100mg,然后从第 2 天到第 7 天每天 4 次口服 200mg/50mg。组 2:法维拉韦+洛匹那韦/利托那韦安慰剂 第 1 天,每天两次口服 1800mg 法维拉韦,然后从第 2 天到第 7 天每天 4 次口服 400mg;第 1 天,每天两次口服洛匹那韦/利托那韦匹配安慰剂,然后从第 2 天到第 7 天每天 4 次口服 200mg/50mg。组 3:法维拉韦安慰剂+洛匹那韦/利托那韦 第 1 天,每天两次口服法维拉韦匹配安慰剂 1800mg,然后从第 2 天到第 7 天每天 4 次口服 400mg;第 1 天,每天两次口服洛匹那韦/利托那韦,然后从第 2 天到第 7 天每天 4 次口服 200mg/50mg。组 4:法维拉韦安慰剂+洛匹那韦/利托那韦安慰剂 第 1 天,每天两次口服法维拉韦匹配安慰剂 1800mg,然后从第 2 天到第 7 天每天 4 次口服 400mg;第 1 天,每天两次口服洛匹那韦/利托那韦匹配安慰剂,然后从第 2 天到第 7 天每天 4 次口服 200mg/50mg。 主要结局:主要结局是第 5 天的上呼吸道病毒载量。 次要结局:治疗后 5 天内病毒载量不可检测的参与者比例 治疗后 7 天内粪便病毒载量不可检测的参与者比例 7 天治疗期间上呼吸道病毒载量下降率 开始试验药物后发热持续时间 治疗后 7 天内肝毒性的参与者比例 治疗后 7 天和 14 天内其他药物相关毒性的参与者比例 因 COVID-19 相关疾病住院的参与者比例 因 COVID-19 相关疾病入住 ICU 的参与者比例 因 COVID-19 相关疾病死亡的参与者比例 法维拉韦的药代动力学和药效学分析 探索性:具有 SARS-CoV-2 致突变或耐药性的参与者比例 随机分组:参与者将使用隐蔽的在线最小化过程,以 1:1:1:1 的比例随机分配,考虑以下因素:试验地点、年龄(≤55 岁与>55 岁)、性别、肥胖(BMI<30 与≥30)、症状或无症状、当前吸烟状态(是=当前吸烟者,否=前吸烟者,从不吸烟者)、种族(白种人、其他)和是否存在合并症(定义为糖尿病、高血压、缺血性心脏病(包括心肌梗死)、其他心脏病(心律失常和瓣膜性心脏病)、哮喘、COPD、其他慢性呼吸系统疾病)。 盲法(双盲):参与者和研究者都将对治疗分配进行盲法(双盲)。 随机分组人数(样本量):240 名参与者,每组 60 名。 试验状态:协议版本 4.0,日期 2021 年 1 月 7 日。首次入组日期:2020 年 10 月。招募正在进行中,预计完成日期为 2021 年 3 月 31 日。 试验注册:FLARE 试验在 Clinicaltrials.gov 上注册,试验识别号 NCT04499677,注册日期 2020 年 8 月 4 日。 完整协议:完整协议作为附加文件附加,可从试验网站访问(附加文件 1)。为了加快材料的传播,已省略了熟悉的格式;本函仅作为完整协议的关键要素摘要。
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