Rationale and study design for a phase I/IIa trial of anakinra in children with Kawasaki disease and early coronary artery abnormalities (the ANAKID trial)
Section snippets
Introduction and rationale
Kawasaki disease (KD), the most common cause of acquired heart disease in children in Western developed countries and Asia, is a systemic vasculitis of unknown etiology. KD causes both a myocarditis and a vasculitis that damages the coronary arteries and other medium-sized muscular arteries leading to the formation of aneurysms [49], [53]. The major sequelae of aneurysms include thrombosis, late coronary artery stenosis, myocardial ischemia, myocardial infarction, and death [10], [15], [27].
Objectives
The goal of this study is to determine the safety, pharmacokinetics, and activity of anakinra in acute KD patients at least 8 months of age with a coronary artery Z score (internal dimension of the coronary artery normalized for body surface area and expressed as standard deviations from the mean) ≥ 3.0 in the right coronary artery (RCA) and/or left anterior descending (LAD) artery. This study is viewed as preparatory to a Phase III trial of anakinra to prevent or attenuate coronary artery damage
Study design
This two-center dose-escalation Phase I/IIa trial (See Dose Levels Table 2) will determine the safety, tolerability and immunomodulatory effects of anakinra in 30 acute KD patients at least 8 months old with CAA. The enrollment age limit is a condition of our IND and was imposed by the FDA until safety data for KD could be reviewed after completion of this trial. Enrollment will occur at two study sites: Rady Children's Hospital San Diego and Children's Hospital of Boston.
All subjects will be
Inclusion and exclusion criteria
Infants and children at least 8 months of age (age limited by Food and Drug Administration) within the first 20 days after fever onset who meet American Heart Association criteria for KD and have a Z score of ≥ 3.0 of the LAD and/or RCA or an aneurysm are study eligible (Table 4). Subjects with an active, culture-positive bacterial infection will be excluded.
Primary and secondary endpoints
The primary endpoint of the study is safety and tolerability of anakinra in the study population. The pre-specified secondary endpoints are the pharmacokinetics of anakinra, the changes in echocardiographic assessment of the internal diameters of the coronary arteries expressed as Z scores over the course of the study, and the change in biomarkers of inflammation including levels of hsCRP, α1-antitrypsin and fibrinogen, and the WBC and ESR. Innate immune cells and T cells will be studied prior
Ethics and informed consent
The study protocol was reviewed and approved by the Institutional Review Board at the University of California San Diego and Boston Children's Hospital. Written informed consent will be obtained from the parents or legal guardians and assent, when appropriate, will be obtained from the patient. This trial is registered with clinicaltrials.gov (NCT02179853).
Data analysis
All enrolled subjects at the maximum tolerated dose will be included in a case:control study and matched with historical controls from each center for age, sex, illness day, adjunctive therapies in addition to IVIG, and the worst coronary artery Z score for the RCA and LAD on the initial, pre-treatment echocardiogram. Measures of inflammation, including hsCRP, ESR and WBC, at two weeks will be compared to that of matched controls via paired statistical tests (e.g. McNemar's test for categorical
Discussion
Despite timely treatment with high dose IVIG and aspirin, some infants and children with KD develop CAA. However, there is no recommended therapy to halt the progression of arterial wall damage and prevent aneurysm formation. Thus, aneurysm prevention is a primary goal of treatment during the acute phase of the disease and is the focus of this trial. Data from both animal studies and evaluation of the IL-1 pathway in patients with acute KD support IL-1 blockade as a therapeutic option.
Studies
Conclusion
Thus, this dose-escalation Phase I/IIa trial will determine the safety, tolerability and immunomodulatory effects of anakinra in KD patients at least 8 months of age.
Acknowledgements
This work is supported by a University of California San Diego Department of Pediatrics Intramural Clinical Research grant (awarded to AHT), a Rady Children's Hospital San Diego Academic Enrichment grant (awarded to AHT), and a grant from the Gordon and Marilyn Macklin Foundation grant (awarded to JCB). Ancillary study support was provided by the Clinical and Translational Study Unit at Boston Children's Hospital. Anakinra was donated by the manufacturer, Sobi Pharmaceuticals.
References (54)
- et al.
Interleukin-1 promotes proliferation of vascular smooth muscle cells in coordination with PDGF or a monocyte derived growth factor
Exp. Cell Res.
(1989) - et al.
When children with Kawasaki disease grow up myocardial and vascular complications in adulthood
J. Am. Coll. Cardiol.
(2009) Therapy of autoinflammatory syndromes
J. Allergy Clin. Immunol.
(2009)- et al.
Reduced atherosclerosis and inflammatory cytokines in apolipoprotein-E-deficient mice lacking bone marrow-derived interleukin-1α
Biochem. Biophys. Res. Commun.
(2011) - et al.
Endothelial cell activation and high interleukin-1 secretion in the pathogenesis of acute Kawasaki disease
Lancet
(1989) - et al.
An autoinflammatory disease with deficiency of the interleukin-1-receptor antagonist
N. Engl. J. Med.
(2009) - et al.
Genetic inactivation of IL-1 signaling enhances atherosclerotic plaque instability and reduces outward vessel remodeling in advanced atherosclerosis in mice
J. Clin. Invest.
(2012) - et al.
Anakinra use during pregnancy in patients with cryopyrin-associated periodic syndromes (CAPS)
Arthritis Rheum.
(2014) - et al.
A child with severe relapsing Kawasaki disease rescued by IL-1 receptor blockade and extracorporeal membrane oxygenation
Ann. Rheum. Dis.
(2012) - et al.
Treating inflammation by blocking interleukin-1 in a broad spectrum of diseases
Nat. Rev. Drug Discov.
(2012)