Realizing Effectiveness Across Continents with Hydroxyurea(REACH): A Phase I/II Pilot Study of Hyroxyurea for Children with Sickle Cell Anemia

利用羟基脲 (REACH) 在各大洲实现有效性：羟基脲治疗镰状细胞性贫血儿童的 I/II 期初步研究

• 批准号: 10679001
• 负责人: Russell E Ware
• 金额: $ 143.14万
• 依托单位: CINCINNATI CHILDRENS HOSP MED CTR
• 依托单位国家: 美国
• 财政年份: 2017
• 资助国家: 美国
• 起止时间: 2017-08-01 至 2027-07-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10679001
• 关键词: 11 year old; Acute; Address; Affect; Africa; Africa South of the Sahara; African; Age; Algorithms; Angola; Benefits and Risks; Biological Assay; Birth; Blood; Blood specimen; Brain; Cephalic; Cessation of life; Child; Chronic; Clinical; Collaborations; Country; DNA; Data; Databases; Democratic Republic of the Congo; Development; Diagnosis; Disease; Dose; Dose Limiting; Drug Kinetics; Dysmyelopoietic Syndromes; Effectiveness; Endothelium; Enrollment; Epidemiology; Erythrocytes; Event; Eye; Fetal Hemoglobin; Funding; Future; Genetic; Genetic Polymorphism; Genomic DNA; Genomic approach; Growth; Growth and Development function; Hematological Disease; Hematopoiesis; In Vitro; Incidence; Income; Inflammation; Inherited; Kenya; Kidney; Laboratories; Lead; Leukocytes; Long-Term Effects; Malaria; Maximum Tolerated Dose; Measures; Medical; Medicine; Methodology; Monitor; Morbidity - disease rate; Multilingualism; Mutation; Myeloid Leukemia; National Heart, Lung, and Blood Institute; Neonatal Screening; Oral; Organ; Organ Preservation; Parasitemia; Patients; Pharmaceutical Preparations; Pharmacodynamics; Pharmacogenomics; Phase; Physical assessment; Pilot Projects; Placebo Control; Predisposition; Prevention; Puberty; Reproductive Health; Research; Research Infrastructure; Research Personnel; Risk; Safety; Sexual Development; Sickle Cell Anemia; Single Nucleotide Polymorphism; Site; Spleen; Talents; Testing; Toxic effect; Training; Transfusion; Uganda; United States National Institutes of Health; World Health Organization; burden of illness; clinical research site; cohort; coronavirus disease; curative treatments; design; epidemiologic data; evidence base; exome sequencing; experience; feasibility testing; genome wide association study; hydroxyurea; improved; in vitro Assay; innovation; interpatient variability; malaria infection; mortality; neuroprotection; neutrophil; next generation; novel; open label; parasite invasion; prospective; reproductive; research study; safety and feasibility; safety testing; sickling; treatment effect; treatment response; virtual

ABSTRACT Sickle cell anemia (SCA) is among the world’s most common inherited blood disorders, and causes severe morbidity and early mortality. SCA is highly prevalent in sub-Saharan Africa, affecting over 300,000 births annually, with an estimated 30% increase in the next generation. To address the burden of SCA within Africa, neonatal screening is needed to establish the proper diagnosis, and hydroxyurea treatment is needed to ameliorate morbidity and decrease mortality. Hydroxyurea is listed by the World Health Organization as an Essential Medicine for children with SCA, representing the only realistic and affordable disease-modifying therapy in this setting. Until recently, hydroxyurea had been studied primarily in high-income countries, with virtually no data available regarding its safe and effective use in Africa. To address this critical unmet need, we designed and launched REACH (Realizing Effectiveness Across Continents with Hydroxyurea, NCT01966731), a prospective open-label study of hydroxyurea for young children with SCA in sub-Saharan Africa. In the current funding period, 606 children in four African countries received hydroxyurea escalated to maximum tolerated dose (MTD). Despite COVID, our research teams in Angola, Democratic Republic of Congo, Kenya, and Uganda collected unprecedented data on the safety, feasibility, and benefits of hydroxyurea for SCA in Africa, with >3000 patient-years of treatment. We documented reductions in sickle- related clinical events and found unexpected reductions in malaria, transfusions, and death. We performed whole exome sequencing to investigate inter-patient variability including hydroxyurea pharmacokinetics, pharmacodynamics, and pharmacogenomics. In the renewal, we will make additional contributions by extending hydroxyurea treatment to this unique cohort, whose average age is now 11 years and soon entering puberty, using a continued supply of hydroxyurea donated by Bristol Myers Squibb. Though our initial results are encouraging, REACH does not have a placebo-controlled cohort for comparison. Accordingly, we will enroll a new cohort of age-matched children with SCA at all four sites, to provide pre-treatment data for comparison to our treated cohort. In the first specific aim, we will assess the long-term effects of hydroxyurea at MTD to ameliorate SCA-related clinical complications and preserve organ function (especially brain but also kidneys, spleen, and eyes). We will obtain longitudinal data on the effects of hydroxyurea at MTD on physical growth, sexual development, and overall reproductive health, and collect serial DNA to test for the emergence of clonal hematopoiesis. In the second aim, we will investigate mechanisms by which hydroxyurea reduces malaria infections, combining epidemiological data with in vitro parasite invasion assays and an agnostic search for protective genetic polymorphisms. In the third aim, we will simplify and optimize hydroxyurea treatment using novel and innovative approaches, by testing the feasibility and safety of a pharmacokinetics-based dosing algorithm in the new patient cohort to minimize dose adjustments and lab monitoring, and then by validating our newly identified genetic polymorphisms that predict HbF treatment responses. REACH will expand hydroxyurea treatment in Africa, build local capacity, and establish a robust research infrastructure for future collaborations, including planned NIH curative therapies. REACH is uniquely poised to elucidate benefits and risks of extended hydroxyurea, allowing safe and evidence-based dosing in Africa.

抽象的 镰状细胞性贫血 (SCA) 是世界上最常见的遗传性血液疾病之一，会导致严重的发病率和早期 死亡。 SCA 在撒哈拉以南非洲地区非常普遍，每年影响超过 300,000 名新生儿，估计增加了 30% 在下一代。为了解决非洲 SCA 的负担，需要进行新生儿筛查以建立适当的 诊断，并且需要羟基脲治疗来改善发病率和降低死亡率。羟基脲列出 世界卫生组织将其列为 SCA 儿童的基本药物，代表了唯一现实且负担得起的药物 在这种情况下进行疾病修饰治疗。直到最近，羟基脲主要在高收入国家进行研究， 几乎没有关于其在非洲安全有效使用的数据。为了解决这一未满足的关键需求，我们设计了 并推出了前瞻性开放标签 REACH（通过羟基脲实现跨越大陆的有效性，NCT01966731） 羟基脲治疗撒哈拉以南非洲地区患有 SCA 的幼儿的研究。在当前资助期间，四个地区的 606 名儿童 非洲国家接受的羟基脲升级至最大耐受剂量（MTD）。尽管有新冠疫情，我们的研究团队 安哥拉、刚果民主共和国、肯尼亚和乌干达收集了有关安全性、可行性和安全性的前所未有的数据。 在非洲，羟基脲对 SCA 的疗效已超过 3000 例患者年。我们记录了镰刀的减少 相关的临床事件，并发现疟疾、输血和死亡意外减少。我们进行了全外显子组 测序以研究患者间变异性，包括羟基脲药代动力学、药效学和 药物基因组学。在更新中，我们将通过将羟基脲治疗扩展到此做出额外的贡献 独特的队列，其平均年龄现在为 11 岁，即将进入青春期，使用持续供应的羟基脲 由百时美施贵宝捐赠。尽管我们的初步结果令人鼓舞，但 REACH 并没有安慰剂对照的药物 队列进行比较。因此，我们将在所有四个地点招募一批新的年龄匹配的 SCA 儿童，以提供 治疗前数据用于与我们的治疗队列进行比较。在第一个具体目标中，我们将评估长期影响 在 MTD 中使用羟基脲可改善 SCA 相关的临床并发症并保护器官功能（尤其是大脑，但 还有肾脏、脾脏和眼睛）。我们将获得关于羟基脲在 MTD 对身体的影响的纵向数据。 生长、性发育和整体生殖健康，并收集序列 DNA 来测试克隆的出现 造血作用。在第二个目标中，我们将研究羟基脲减少疟疾感染的机制， 将流行病学数据与体外寄生虫入侵测定以及对保护性遗传的不可知论搜索相结合 多态性。在第三个目标中，我们将使用新颖和创新的方法简化和优化羟基脲治疗 方法，通过在新患者队列中测试基于药代动力学的剂量算法的可行性和安全性 最大限度地减少剂量调整和实验室监测，然后验证我们新发现的遗传多态性 预测 HbF 治疗反应。 REACH 将扩大非洲的羟基脲处理范围，建设当地能力，并 为未来的合作建立强大的研究基础设施，包括计划中的 NIH 治疗疗法。 REACH 是 旨在阐明延长羟基脲的益处和风险，从而在非洲实现安全且基于证据的剂量。

项目成果

Effective use of hydroxyurea for sickle cell anemia in low-resource countries.

• DOI: 10.1097/moh.0000000000000582
• 发表时间: 2020-05
• 期刊: CURRENT OPINION IN HEMATOLOGY
• 影响因子: 3.2
• 作者: Power-Hays, Alexandra;Ware, Russell E.
• 通讯作者: Ware, Russell E.