Funded by the European Union Influenza like Illness? A rCt of Clinical and Cost effectiveness in primary CarE (ALIC 4 E ) Chris Butler, Theo Verheij, Alike

Funded by the European Union

Influenza like Illness? A rCt of Clinical and Cost

effectiveness in primary CarE (ALIC4E)

Chris Butler, Theo Verheij, Alike van der Velden, Johanna Cook

Venice 2015.



Chris Butler’s declaration of interests

• Gave a talk at the Alliance for the Prudent Use of Antibiotic’s in Boston• Gave a talk at a MIMS Clinical update on urinary tract infection• Attended a sponsored meeting on eustacean tube dysfunction• Attended a sponsored advisory board on pain management for Grünenthal• Gave a talk on point of care testing for common infections sponsored by

Alere• Attended and advisory meeting on point off care testing sponsored by Alere• Alere is providing unconditional support in the form of providing of CRP

testing devices and kits for a publically funded research project I am leading on acute exacerbations of chronic obstructive airways disease

• I have a range of publically funded research grants, which aim to generate evidence to enhance the management of common infections in primary care


Three muskateers


The engine roomCentral coordination• Chris Butler (Ox)• Johanna Cook (Ox)• Alike van der Velden (U)• Theo Verheij (U)

National networkCoordinatorSupporting staf

National networkCoordinatorSupporting staff

National networkCoordinatorSupporting staff

Local laboratory Local laboratory Local laboratory

Health centres Health centres Health centres


Background and Research Gaps• When reflecting on the recent H1N1 pandemic, primary care

clinicians and public health physicians often ask whether the liberal use of oseltamivir was justified?

• Was syndromic diagnosis (as opposed to point-of-care test guided treatment) the most cost-effective?

• All POCs have problems of diagnostic performance, take too long, or are insufficiently user-friendly.

• The same questions arise annually for seasonal influenza. • Currently, most European primacy care services promote self-care

for patients with ILI, but guidelines suggest treat high risk groups and severe cases

• Changing current practice has far reaching implications on primary health care delivery and organisation and patients (help seeking).


Influenza in primary care is…

• Very unpleasant• Can be dangerous• Mean time off work and school• Represents a big potential market• Represents a big problem for health care delivery• Represents opportunity for de-medicalising illness and

promoting self care



Oseltamivir…

• Sales of oseltamivir expected to reach 562 million Euro this year.

• First approval by the US FDA in 1999, yet no large-scale, international, non-industry sponsored pragmatic trial of cost-effectiveness of oseltamivir in primary care.


Key questions

• Are antivirals cost effective in primary care for high risk groups?

• Are antivirals cost effective in primary care for all with ILI?

• Are antivirals cost effective in primary care for flu positives?


Equipoise


Key reviews• Dobson J, Whitley RJ, Pocock S, Monto AS. Lancet. 2015 Jan 30. pii: S0140-

6736(14)62449-1. doi: 10.1016/S0140-6736(14)62449-1) (MUGAS Multi-party Group for Advice on Science)

• Jefferson T, Jones MA, Doshi P, Del Mar CB, Hama R, Thompson MJ, Spencer EA, Onakpoya I, Mahtani KR, Nunan D, Howick J, Heneghan CJ. Neuraminidase inhibitors for preventing and treating influenza in healthy adults and children. Cochrane Database of Systematic Reviews 2014, Issue 4.

• Okoli GN, Otete HE, Beck CR, Nguyen-Van-Tam JS Use of Neuraminidase Inhibitors for Rapid Containment of Influenza: A Systematic Review and Meta-Analysis of Individual and Household Transmission Studies. PLoS ONE 2014 9(12): e113633.

• Muthuri SG et al. Effectiveness of neuraminidase inhibitors in reducing mortality in patients admitted to hospital with influenza A H1N1pdm09 virus infection: a meta-analysis of individual participant data. Lancet Respiratory Diseases 2014

• Muthuri SG, Myles PR, Venkatesan S, Leonardi-Bee J, Nguyen-Van-Tam JS. Impact of neuraminidase inhibitor treatment on outcomes of public health importance during the 2009-10 influenza A(H1N1) pandemic: a systematic review and metaanalysis in hospitalized patients. Journal of Infectious Disease 2012

• Hsu J, Santesso N, Mustafa R, Brozek J, Chen YL, Hopkins JP, et al. Ann Intern Med. 2012 Apr 3;156(7):512-24.)


The reviews and our questions… Jefferson 2014

(Cochrane)Dobson 2015

(MUGAS)Muthuri 2014 (PRIDE) Muthuri 2012 (PRIDE) Hsu 2102

Pandemic or seasonal Seasonal Seasonal Pandemic H1N1 Pandemic H1N1 Seasonal

Risk groups Not addressed No benefit in over 65’s Benefit in pregnant womenAdj OR for mortality 0.27 p<0.001

Does not address this issue

Oseltamivir compared with no treatment may reduce:mortality OR 0.23 [0.13 to 0.43]; (low-quality evidence) hospitalization (OR 0.75 [0.66 to 0.89]; low-quality evidence) Duration of symptoms (33 hours [CI, 21 to 45]; very low–quality evidence

Healthy people who develop severe ‘flu

Not addressed Not addressed Adults admitted to critical care adj OR for mortality 0.72, p=0.02 . No benefit in children

Not addressed Not addressed

Treat all Reduction in symptom duration : Oseltamivir 17 hrs, p<0.001: Zanamivir 0.6 days, p<0.001Reduction in non-verified pneumonia with oseltamivir but not ‘confirmed’ pneumonia No effect o on hospitalisationNo effect of zanamivir on pneumonia

Reduction in time to alleviation of symptoms: 17 hours in all patients and 25 hours in patients with confirmed influenzaReduced LRTIs and hospitalisations

NI treatment associated with lower mortality risk

Adj OR 0.81, p<0.01 No benefit seen in children No benefit If treatment started >2 days: increased mortality with later treatmentCrude mortality rates 9.2% (959/10 431) without treatment and 9.7% (1825/18 803) with NIs

No benefit in mortality OR 0.72 0.51-1.01 Mortality benefit seen with treatment <48 hours after symptoms OR 0.35 0.18 -0.71 compared to no treatment

“Therapy with oral oseltamivir and inhaled zanamivirMay provide a net benefit over no treatment of influenza. However,as with the randomized trials, the confidence in the estimatesof the effects for decision making is low to very low”

Cost effectiveness Not addressed Not addressed Not addressed Not addressed Not addressed


Lots of controversy• Pharma sponsorship…..• Pre-published protocol?• The missing trials and access to data• Dobson: NNT to prevent 1 hospitalization >3000• Treating in primary care=spreading illness• Self report ‘pneumonia’ or pre-established outcome

measure in CRF and confirmed• Subsequent antibiosis: a valid outcomes measure?• Retrospective data from case notes… high levels of

missing data• Many primary studies did not control for confounders• Many studies did not compare Nis to no antivirals


Nitazoxanide• Licensed in the US giardia lamblia and cryptosporidium parvum diarrhoea

since 1996. • Nitazoxanide and its active metabolite, tizoxanide, active against a number

of RNA and DNA viruses,

• Phase 2b/3 randomised, placebo controlled trial evaluated nitazoxanide in doses of 300mg and 600mg for patients with acute uncomplicated ILI aged between 12 and 65 years. 600mg twice daily for 5 days significantly reduced the time from first dose to alleviation of symptoms (from a mean of 117 hours to 96 hours) compared with placebo, with no increase in adverse events; the 300mg dose reduced time to first alleviation of symptom (to 109 hours): latter difference was not statistically significant.

• Symptomatic benefit from nitazoxanide treatment those patients with ILI who turned out to test positive for influenza as well as those with ILI who tested negative for influenza.

Effect of nitazoxanide in adults and adolescents with acute uncomplicated influenza: a double-blind, randomised, placebo-controlled, phase 2b/3 trial. Haffizulla et al. Lancet 2014; 14 : 609 – 18


Conclusion of current state of art?

• “A large, definitive set of clinical trials performed by an independent group and focused on patient groups that are currently under studied, including children, has yet to be conducted. Until it is, we know too little about the heterogeneity of effects and whether there are people more likely to benefit and less likely to be harmed.”

(BMJ 2014;348: G2548)


Objectives of ALIC4E To determine whether adding antiviral treatment to defined usual care:• Reduces time to return to usual activities• Is cost effective • Decreases the incidence of hospital admissions • Decreases complications related to ILI, especially pneumonia• Decreases repeat attendance at the GP • Decreases time to alleviation of ILI symptoms• Decreases the incidence of new or worsening symptoms• Decreases time to initial reduction in severity of symptoms• Decreases duration of symptoms that are moderately severe or worse• Reduces the use of additional symptomatic and prescribed medication,

including antibiotics• Reduces new household cases• Recuses use of symptomatic medication

• POCT EVALUATION



Trial architecture: with thanks to Berry Consulting for an inspiring collaboration!• Open, pragmatic trial: We want to know the effect of a drug

when people know what they are taking as in real life

• Adaptive platform design: – Bayesian approach– More efficient– Arms can be dropped or added: THANK HEAVENS– We will adapt for age (<12, 12-64, >64 yrs), severity of

symptoms (low, medium, high), comorbidity (yes/no), duration of symptoms (<48hours/>48hours).

• Sample size– 4500

• POCT sub studies: analytic performance and ‘congeniality’ study


IS there any point in the last horse continuing to run?


What if it becomes rapidly apparent that your thoroughbred is a donkey? Get another ‘stallion’!


If it a tie, keep on running!


Inclusion criteria

• Presenting with ILI in primary care during a period of increased influenza activity. (ILI=sudden onset of self-reported fever, with at least one respiratory symptom (cough, sore throat, running or congested nose) and one systematic symptom (headache, muscle ache, sweats or chills or tiredness)

• symptom duration of 72 hours or less• Able and willing to comply with all trial requirements• Willing and able to give informed consent • Agrees not to take antiviral agents apart from a study

antiviral agents according to patient randomisation


Exclusion criteria• Known chronic renal failure e.g. known or estimated creatinine glomerular filtration rate < 60 mg/l

(known = recorded in GP notes)• Known condition or treatment associated with significant impaired immunity (e.g. long-term oral

steroids or chemotherapy, immune disorder) (known = recorded in GP notes)• Those who in the opinion of the responsible clinician should be prescribed immediate antiviral

treatment• Allergic to oseltamivir, nitazoxanide, or any other trial medication• Scheduled elective surgery or other procedures requiring general anaesthesia during the

subsequent two weeks• Participant with life expectancy estimate by a clinician to be less than 6 months• Responsible clinician considers urgent hospital admission is required • Any other significant disease or disorder which, in the opinion of the responsible clinician, may

either put the participants at risk because of participation in the trial, or may influence the result of the trial, or may affect the participant’s ability to participate in the trial

• Involvement, including completion of any follow up procedures, in another clinical trial of an investigational medicinal product in the last 90 days

• Previous ALIC4E trial participation • Patients unable to be randomised within 24 hours of initial eligibility check, or patients unable to

be randomised with 72 hours after onset of symptoms• Requirement for any live viral vaccine in next 7 days


Interventions

•Oseltamivir: Oral

≥12 years: 75mg tablets twice a day, for 5 days

1 - <12:, 10-15kg: 30mg, 15-25kg: 45mg, 25-40kg: 60mg, >40kg: 75mg oral suspension in water

•Nitazoxanide: Oral

≥13 years: 600mg tablets twice a day, for 5 days

Reduced doses for under 12s as oral suspension in water

•Defined ususal care: includes a recommendation to take paracetamol in the recommended dose every six hours.

•Additional agents can be added in


Research Work 2: Process evaluation

• Quantitative survey and qualitative study of the perspectives of clinicians and patient participants to evaluate trail logistics, organisation, and perceptions of barriers and opportunities for effective inter- and intra-pandemic clinical research

• All clinicians recruiting participants will be asked to fill in a brief questionnaire.

• Purposive sub-sample of approximately 50 clinicians and 50 patient participants will be interviewed using a semi-structured topic guide (which is usually sufficient to achieve data saturation in qualitative studies of this kind).

• Opportunity to contribute a smaller number of more intensively sampled patients for an observational, pathogenesis study: WP3


Deliverables!


• 4.1 Final report on the effects and cost-effectiveness of oseltamivir on patients with influenza-like illness and patients with confirmed influenza. M60

• 4.2 Final report on the diagnostic value of the POCT under study. M60

• 4.3 Final report on recommendations from clinicians participating in the trial on rapid and safe inter and intra-pandemic clinical research (M60)


Milestones

MS6: Known efficacy and safety of ostltamivit for treating ILI and influenza in primary care M60

MS7: Known diagnostivc vaklue of POCT in PC M60


Many thanks!

Documents

Funded by the European Union Influenza like Illness? A rCt of Clinical and Cost effectiveness in primary CarE (ALIC 4 E ) Chris Butler, Theo Verheij, Alike