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Molnupiravir versus placebo in unvaccinated and vaccinated patients with early SARS-CoV-2 infection in the UK (AGILE CST-2): a randomised, placebo-controlled, double-blind, phase 2 trial.
Khoo, Saye H; FitzGerald, Richard; Saunders, Geoffrey; Middleton, Calley; Ahmad, Shazaad; Edwards, Christopher J; Hadjiyiannakis, Dennis; Walker, Lauren; Lyon, Rebecca; Shaw, Victoria; Mozgunov, Pavel; Periselneris, Jimstan; Woods, Christie; Bullock, Katie; Hale, Colin; Reynolds, Helen; Downs, Nichola; Ewings, Sean; Buadi, Amanda; Cameron, David; Edwards, Thomas; Knox, Emma; Donovan-Banfield, I'ah; Greenhalf, William; Chiong, Justin; Lavelle-Langham, Lara; Jacobs, Michael; Northey, Josh; Painter, Wendy; Holman, Wayne; Lalloo, David G; Tetlow, Michelle; Hiscox, Julian A; Jaki, Thomas; Fletcher, Thomas; Griffiths, Gareth.
  • Khoo SH; Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK; Tropical and Infectious Disease Unit, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK. Electronic address: khoo@liverpool.ac.uk.
  • FitzGerald R; Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK; NIHR Royal Liverpool and Broadgreen Clinical Research Facility, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK.
  • Saunders G; Southampton Clinical Trials Unit, University of Southampton, Southampton, UK.
  • Middleton C; Southampton Clinical Trials Unit, University of Southampton, Southampton, UK.
  • Ahmad S; NIHR Manchester Clinical Research Facility, Manchester University NHS Foundation Trust, Manchester, UK.
  • Edwards CJ; Human Development and Health School, University of Southampton, Southampton, UK; NIHR Southampton Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
  • Hadjiyiannakis D; NIHR Lancashire Clinical Research Facility, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK.
  • Walker L; Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK; NIHR Royal Liverpool and Broadgreen Clinical Research Facility, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK.
  • Lyon R; NIHR Royal Liverpool and Broadgreen Clinical Research Facility, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK.
  • Shaw V; Clinical Directorate, University of Liverpool, Liverpool, UK.
  • Mozgunov P; MRC Biostatistics Unit, University of Cambridge, Cambridge, UK.
  • Periselneris J; NIHR Kings Clinical Research Facility, King's College Hospital NHS Foundation Trust, London, UK.
  • Woods C; NIHR Royal Liverpool and Broadgreen Clinical Research Facility, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK.
  • Bullock K; Molecular & Clinical Cancer Medicine, University of Liverpool, Liverpool, UK.
  • Hale C; NIHR Royal Liverpool and Broadgreen Clinical Research Facility, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK.
  • Reynolds H; Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK.
  • Downs N; Southampton Clinical Trials Unit, University of Southampton, Southampton, UK.
  • Ewings S; Southampton Clinical Trials Unit, University of Southampton, Southampton, UK.
  • Buadi A; NIHR Southampton Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
  • Cameron D; NIHR Lancashire Clinical Research Facility, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK.
  • Edwards T; Centre for Drugs and Diagnostics, Liverpool, UK.
  • Knox E; Southampton Clinical Trials Unit, University of Southampton, Southampton, UK.
  • Donovan-Banfield I; Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; National Institute of Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK.
  • Greenhalf W; Molecular & Clinical Cancer Medicine, University of Liverpool, Liverpool, UK.
  • Chiong J; Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK.
  • Lavelle-Langham L; Molecular & Clinical Cancer Medicine, University of Liverpool, Liverpool, UK.
  • Jacobs M; Infectious Diseases, Royal Free London NHS Foundation Trust, London, UK.
  • Northey J; Southampton Clinical Trials Unit, University of Southampton, Southampton, UK.
  • Painter W; Ridgeback Biotherapeutics, Miami, FL, USA.
  • Holman W; Ridgeback Biotherapeutics, Miami, FL, USA.
  • Lalloo DG; Liverpool School of Tropical Medicine, Liverpool, UK.
  • Tetlow M; Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK.
  • Hiscox JA; Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; National Institute of Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK.
  • Jaki T; MRC Biostatistics Unit, University of Cambridge, Cambridge, UK; Computational Statistics, University of Regensburg, Regensburg, Germany.
  • Fletcher T; Tropical and Infectious Disease Unit, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK; Clinical Sciences, Liverpool, UK.
  • Griffiths G; Southampton Clinical Trials Unit, University of Southampton, Southampton, UK.
Lancet Infect Dis ; 2022 Oct 19.
Article in English | MEDLINE | ID: covidwho-2231863
ABSTRACT

BACKGROUND:

The antiviral drug molnupiravir was licensed for treating at-risk patients with COVID-19 on the basis of data from unvaccinated adults. We aimed to evaluate the safety and virological efficacy of molnupiravir in vaccinated and unvaccinated individuals with COVID-19.

METHODS:

This randomised, placebo-controlled, double-blind, phase 2 trial (AGILE CST-2) was done at five National Institute for Health and Care Research sites in the UK. Eligible participants were adult (aged ≥18 years) outpatients with PCR-confirmed, mild-to-moderate SARS-CoV-2 infection who were within 5 days of symptom onset. Using permuted blocks (block size 2 or 4) and stratifying by site, participants were randomly assigned (11) to receive either molnupiravir (orally; 800 mg twice daily for 5 days) plus standard of care or matching placebo plus standard of care. The primary outcome was the time from randomisation to SARS-CoV-2 PCR negativity on nasopharyngeal swabs and was analysed by use of a Bayesian Cox proportional hazards model for estimating the probability of a superior virological response (hazard ratio [HR]>1) for molnupiravir versus placebo. Our primary model used a two-point prior based on equal prior probabilities (50%) that the HR was 1·0 or 1·5. We defined a priori that if the probability of a HR of more than 1 was more than 80% molnupiravir would be recommended for further testing. The primary outcome was analysed in the intention-to-treat population and safety was analysed in the safety population, comprising participants who had received at least one dose of allocated treatment. This trial is registered in ClinicalTrials.gov, NCT04746183, and the ISRCTN registry, ISRCTN27106947, and is ongoing.

FINDINGS:

Between Nov 18, 2020, and March 16, 2022, 1723 patients were assessed for eligibility, of whom 180 were randomly assigned to receive either molnupiravir (n=90) or placebo (n=90) and were included in the intention-to-treat analysis. 103 (57%) of 180 participants were female and 77 (43%) were male and 90 (50%) participants had received at least one dose of a COVID-19 vaccine. SARS-CoV-2 infections with the delta (B.1.617.2; 72 [40%] of 180), alpha (B.1.1.7; 37 [21%]), omicron (B.1.1.529; 38 [21%]), and EU1 (B.1.177; 28 [16%]) variants were represented. All 180 participants received at least one dose of treatment and four participants discontinued the study (one in the molnupiravir group and three in the placebo group). Participants in the molnupiravir group had a faster median time from randomisation to negative PCR (8 days [95% CI 8-9]) than participants in the placebo group (11 days [10-11]; HR 1·30, 95% credible interval 0·92-1·71; log-rank p=0·074). The probability of molnupiravir being superior to placebo (HR>1) was 75·4%, which was less than our threshold of 80%. 73 (81%) of 90 participants in the molnupiravir group and 68 (76%) of 90 participants in the placebo group had at least one adverse event by day 29. One participant in the molnupiravir group and three participants in the placebo group had an adverse event of a Common Terminology Criteria for Adverse Events grade 3 or higher severity. No participants died (due to any cause) during the trial.

INTERPRETATION:

We found molnupiravir to be well tolerated and, although our predefined threshold was not reached, we observed some evidence that molnupiravir has antiviral activity in vaccinated and unvaccinated individuals infected with a broad range of SARS-CoV-2 variants, although this evidence is not conclusive.

FUNDING:

Ridgeback Biotherapeutics, the UK National Institute for Health and Care Research, the Medical Research Council, and the Wellcome Trust.

Full text: Available Collection: International databases Database: MEDLINE Type of study: Experimental Studies / Prognostic study / Randomized controlled trials Topics: Vaccines / Variants Language: English Journal subject: Communicable Diseases Year: 2022 Document Type: Article

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Full text: Available Collection: International databases Database: MEDLINE Type of study: Experimental Studies / Prognostic study / Randomized controlled trials Topics: Vaccines / Variants Language: English Journal subject: Communicable Diseases Year: 2022 Document Type: Article