Early bactericidal activity and pharmacokinetics of the Diarylquinoline TMC 207 in ACCEPTED

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1 AAC Accepts, published online ahead of print on 27 May 2008 Antimicrob. Agents Chemother. doi: /aac Copyright 2008, American Society for Microbiology and/or the Listed Authors/Institutions. All Rights Reserved. Early bactericidal activity and pharmacokinetics of the Diarylquinoline TMC 207 in pulmonary tuberculosis R. Rustomjee*, A. H. Diacon, J. Allen*, A. Venter, C. Reddy*, R. F. Patientia**, T. C. P. Mthiyane*, T. De Marez, R. van Heeswijk, R. Kerstens, A. Koul, K. De Beule, P. R. Donald, D. F. Mc Neeley *Unit for Clinical and Biomedical Tuberculosis Research, Medical Research Council, Durban, South Africa Centre for Clinical Tuberculosis Research, DST/NRF Centre of Excellence for Biomedical TB Research (AHD, AV), and Paediatrics and Child Health (PRD), Faculty of Health Sciences, University of Stellenbosch, Cape Town, South Africa **Tiervlei Trial Centre, Karl Bremer Hospital, Bellville, South Africa Tibotec, Inc., Yardley, PA, USA Tibotec, BVBA, Mechelen, BE Key Words: Early bactericidal activity, R207910, TMC207, isoniazid, rifampin Running Title: Early bactericidal activity of TMC207 Corresponding author: Dr DF McNeeley, Tibotec, Stony Hill Rd, Suite 300, Yardley, PA 19067, USA. Phone: +1 (609) , Fax: +1 (609) ,

2 Abstract Tibotec Medicinal Compound 207 (TMC207) is a novel diarylquinoline with a unique mode of action that targets mycobacterial ATP synthase. TMC207 exhibits high in vitro activity against mycobacterial strains either susceptible or resistant to all first line and many second line drugs, including fluoroquinolones, and has shown exceptional in vivo activity against several mycobacterial species in different animal models. In this early bactericidal activity study 75 treatment-naïve patients with smear-positive pulmonary tuberculosis (TB) were randomized to once daily oral TMC207 (25mg, 100mg, or 400mg), rifampin (RIF) 600mg, or isoniazid (INH) 300mg for 7 days. Sixteen-hour overnight sputum collected at baseline and on each treatment day was plated in serial dilutions on selective agar plates. The bactericidal activity was expressed as the log 10 decrease in colony forming units (CFU)/ml sputum/day. Pharmacokinetic sampling was performed on day 7 of TMC207 administration up to 24 hours post-dose. The decrease in log 10 CFU counts (±SD) from baseline to day 7 was 0.04 ±0.46 for TMC207 25mg (n=14), 0.26 ±0.64 for TMC mg (n=14), 0.77 ±0.58 for TMC mg (n=14), 1.88 ±0.74 for INH (n=11) and 1.70 ±0.71 for RIF (n=14). Significant bactericidal activity of TMC mg was observed from day 4 onwards and was similar in magnitude to INH and RIF over the same period. The pharmacokinetics of TMC207 were linear across the dose range. In summary, TMC207 demonstrated bactericidal activity with a delayed onset, was well tolerated and no study drug related serious adverse events occurred. 2

3 Introduction Tuberculosis (TB) has re-emerged as one of the most deadly infectious diseases worldwide, killing approximately 1.7 million people in 2004 (25). In Africa, more than 30% of new adult TB cases are co-infected with human immunodeficiency virus (HIV) (5). Widespread efforts to control the resurgence of TB, such as the implementation of outcome driven treatment programs (16) and the introduction of directly observed therapy short-course (DOTS) (26), have had limited success, in part due to constrained public health resources and the length of treatment needed to sterilize infectious TB lesions. The global situation is deteriorating further with the spread of multidrug-resistant (MDR) TB (7, 8) and, more recently, extensively drug-resistant (XDR) TB (9). There is an urgent need for new anti-tuberculosis agents that can shorten treatment duration and are effective in treating drug-sensitive, drug-resistant, and latent TB infection (22). Tibotec Medicinal Compound 207 (TMC207, also known as R207910) belongs to a newly identified chemical class with anti-mycobacterial properties. TMC207 demonstrates unique and specific anti-mycobacterial activity by inhibiting the oligomeric and proteolipic subunit c of mycobacterial ATP-synthase, a critical enzyme in the synthesis of ATP (17). Binding of TMC207 to subunit-c leads to inhibition of ATP synthesis, which subsequently results in bacterial death. In-vitro mycobacterial susceptibility experiments have shown that TMC207 potently inhibits drug-sensitive as well as drug-resistant M tuberculosis at a MIC of 0.03mcg/ml (2). In the mouse model, the activity of TMC207 exceeded the bactericidal activity of isoniazid (INH) and 3

4 rifampin (RIF) and accelerated culture conversion (2). In the absence of RIF and INH, TMC207 increased the activity of standard second line regimens in mice (19). These results suggest that TMC207 may be able to shorten anti-tuberculosis treatment and be effective in patients with drug-susceptible or drug-resistant TB. This paper reports the results of a phase IIa, open-label, randomized clinical trial designed to evaluate the pharmacokinetics, safety, tolerability and extended early bactericidal activity of 3 different daily oral doses of TMC207 administered as monotherapy over a treatment period of 7 days in treatment-naïve patients with sputum smear-positive, pulmonary TB. TMC207 is the first novel anti-tuberculosis compound to be studied in patients in nearly 4 decades. Methods Study design, study setting and patients This was a parallel-group, open-label, randomized phase IIa trial with 3 different doses of TMC207 (25mg, 100mg and 400mg once daily), RIF (600mg once daily) and INH (300mg once daily), that was conducted simultaneously at 2 centres in Cape Town and in Durban, South Africa. Patients were randomized centrally. TMC207 doses were selected to provide exposure above MIC with the higher doses potentially permitting less than daily dosing in future clinical trials. TMC207 up to 400mg daily had been generally safe and well tolerated in Phase I trials. The protocol was approved by the Medicines Control 4

5 Council of South Africa, the Biomedical Ethics Committee of the University of KwaZulu-Natal (ref T014/05) and Pharma-Ethics Independent Research Ethics Committee for the Cape Town site (ref ). The trial was conducted in accordance to South African Guidelines for Good Clinical Practice and the Helsinki Declaration of 1975, as revised in The trial is registered at All patients provided written informed consent. Treatment-naïve sputum smear-positive patients ( 1+) aged between 18 and 65 years were included if they were found free of underlying medical conditions that would make participation inadvisable, such as drug or alcohol abuse, disseminated TB or diabetes mellitus necessitating insulin treatment. HIV-positive individuals on antiretroviral therapy were excluded. Subjects with an estimated overnight sputum production of less than 15ml and those with bacilli resistant to RIF as determined by the FASTPlaqueTB assay (Biotec, Ipswich, UK) were not included (1). Recent exposure to INH was excluded by urine testing (BBL Taxo INH Test Strips, Becton Dickinson, Franklin Lakes, NJ, USA). Study procedures Patients were hospitalized for the whole period of study medication intake. Sputum was collected for 16 hours overnight at baseline and for 7 nights following study drug intake, and for one additional night following the first dose of standard antituberculosis treatment. Patients collected sputum in pre-labelled, wide mouthed 150ml containers with a screw cap that was left at the bedside for the collection period and subsequently 5

6 refrigerated until processing. At discharge, all patients were referred to continue standard antituberculous chemotherapy according to South African TB Control Programme Guidelines. A single outpatient visit 30 to 35 days after the last study drug intake was followed by telephonic follow-up for the duration of TB treatment. Safety monitoring was performed at screening, daily during hospitalisation and at follow-up, and included medical history, physical examination, complete blood counts, electrolytes, biochemistry panels, urine analysis and ECG s at predefined time-points. Microbiology Sputum smears, CFU counts and susceptibility testing for first-line drugs (MGIT SIRE kit, Becton Dickinson, Franklin Lakes, NJ, USA) were performed at both centres (Durban: J.A., Cape Town: A.V.) using standardized protocols. For CFU counting, sputum was homogenized with magnetic stirring. Dithiothreitol (1:20 dilution; Sputasol, Oxoid, Cambridge, UK) was added to a maximum of 10ml of homogenised sputum in equal volume, vortexed for 20 seconds and left to digest at room temperature for 20 minutes. 1ml of this mixture was used to prepare a range of 10-fold dilutions from 10 0 to µl from each dilution was plated in quadruplicate on 7H11 agar plates (Becton Dickinson, Franklin Lakes, NJ, USA) that contained 200 units/ml of polymixin B, 10 µg/ml of amphotericin B, 100 µg/ml of ticarcillin and 10 µg/ml of trimethoprim (Selectatab, Mast, Merseyside, UK). CFU were counted after 3 to 4 weeks of incubation at 37 C at the dilution that yielded visible colonies (6). Cultures from the baseline and the last overnight sputum collection were used for susceptibility testing. TMC207 sensitivity was analysed with Resazurin Microtiter Assay (Institute of Tropical 6

7 Medicine, Antwerp Belgium) (20). Mycobacteria were identified with Mycobacterium tuberculosis Complex Direct Detection assay (Becton Dickinson, Franklin Lakes, NJ, USA; performed by Covance, Geneva, Switzerland) (24). Pharmacokinetic Analysis Medication intakes were directly observed once daily within 30 minutes after breakfast. Pharmacokinetic profiles for TMC207 and its active N-monodesmethyl metabolite (M2) were determined up to 24 hours post-dose on day 7. Plasma was collected immediately before drug intake, and 1, 2, 3, 4, 5, 6, 8, 12 and 24 hours post-dose. In addition, pre-dose samples were collected on days 5 and 6. TMC207 and M2 concentrations in heparinized plasma were determined centrally using a validated Liquid Chromatography/Mass Spectrometry/Mass Spectrometry (LC-MS/MS) method as briefly described below. 100µl aliquots of plasma were spiked with a mixture of 2 stable isotope labelled internal standards (one for TMC207 and one for M2) followed by protein precipitation with 400µl of a 70% ethanol solution. A 4µl aliquot of the supernatant was analyzed by LC-MS/MS. Chromatography was on a Polaris C18-A column operating at 40 ºC with a mobile phase of 0.01 M ammonium formiate (ph4)/acetonitrile at a flow rate of 1.5 ml/min. Detection was by tandem MS (API4000) with Ion Spray operated in the positive ion mode. Analytes and internal standards were monitored at mass transitions m/z to 58; to 64; to 480 and to 480 for TMC207, its internal standard, M2 and its internal standard, respectively. The validated range was 1 to 2000 ng/ml for both analytes. Inter-run accuracy from quality control samples analyzed along with the study samples ranged from 103.3% to 107.7% for TMC207 and from 101.5% to 105.3% for 7

8 M2. Inter-run precision (%C.V.) ranged from 2.2% to 12.6% for TMC207 and 2.3% to 7.2% for M2. Pharmacokinetic parameters were estimated with non-compartmental analysis. The area under the plasma concentration-time curve from 0-24 hours (AUC 24h ) was determined using the linear trapezoidal rule. Statistical methods The efficacy of treatments was assessed by the change in log 10 CFU/ml sputum from baseline. The average decrease per treatment day was calculated as log 10 CFU/ml sputum - log 10 CFU/ml sputum day x) / x. For CFU count of 0 the log 10 CFU count was set to 0. The population for analysis was defined as patients who received at least one dose of study drug (intention to treat population). All statistical tests were interpreted at the 2- tailed 5% significance level. Statistical analysis was conducted using SAS (version 9.1.3; SAS Institute Inc., Cary, NC, USA). As this was an exploratory study no formal sample size calculation was performed. Results Study population From 01 June 2005 to 6 September out of 120 screened individuals were randomized to 5 treatment groups. Sixty-seven subjects (89%) completed the 7-day treatment period (Figure 1). Patients were 60% male with a median age of 34 years (range 18-61). Fifty-seven percent were black. The majority of patients were active 8

9 smokers (56%). One third (31%) were HIV-positive, with a median CD4 T-cell count of 510 cells/ml. Median body mass index was 19.3kg/m 2 (range 15-33kg/m 2 ). Demographic and disease characteristics were similarly distributed among treatment groups. Bactericidal activity The mean changes of CFU counts from baseline are presented in Table 1 and Figure 2. Pre-treatment CFU counts were comparable between treatment groups and in agreement with known values in patients with smear-positive TB. All patients isolates were susceptible to the investigational drug at baseline and at day 7. As expected, RIF and INH showed clear bactericidal activity with the largest decrease in CFU counts observed during the first 3 days of treatment. The bactericidal activity for TMC207 became apparent comparatively late and resulted in a smaller absolute decrease in log 10 CFU counts. Over days 4 to 7, 400mg TMC207 induced daily CFU falls similar in magnitude to INH and RIF over the same period. TMC mg reached a statistically significant fall in CFU at the end of the 7-day period as compared to baseline sputum CFU counts. Mean CFU falls with TMC mg were significantly different from baseline from day 4 onwards (p<0.05, two-sided Wilcoxon signed rank test). As expected, the addition of standard antituberculous treatment on day 8 resulted in an additional CFU fall, which was more pronounced in TMC207 treated subjects than in RIF and INH treated subjects. The fall in CFU counts from baseline to day 7 for individual study subjects by treatment group is illustrated in Figure 3. 9

10 Pharmacokinetics The exposure to TMC207 and the N-monodesmethyl metabolite increased proportional to the dose across the range evaluated. Maximal plasma concentrations were reached after about 4 hours post-dose across the dosages. Based on plasma predose concentrations on days 5, 6 and 7, steady-state conditions were not yet reached after 7 days of treatment. The extent of N-demethylation of TMC207 was dose-independent within the dose range of 25mg to 400mg q.d. (data not shown). Detailed pharmacokinetic data are given in Table 2. Safety The TMC207 treatment regimens were generally safe and well tolerated. The incidence of adverse events (AE) was similar across all treatment groups. The most commonly reported AE was hemoptysis, reported by 1 patient (6.3%) on TMC mg, 3 patients (21.4%) on TMC mg and by 2 patients (13.3%) on INH 300mg. All AE s were considered not related or doubtfully related to the study medication except for rash (n=1, 7%) in the 100mg TMC207 group and diarrhea (n=1, 7%) and somnolence (n=1, 7%) in the 400mg TMC207 group, which were rated possibly related to study drug. Two patients treated with TMC mg died 14 and 34 days after the end of TMC207 treatment, respectively. Deaths were due to hemoptysis secondary to TB, complications of TB and Acquired Immunodeficiency Syndrome and were not considered related to the study drug. ECG assessments determined average increases of more than 10ms in the QT interval corrected by the Fredericia method post dose on Day 7 in the RIF, INH, TMC mg and TMC mg groups (mean increase ±SD for RIF: 13 ±21.9ms; INH

11 ±13.2ms; TMC207 25mg: -1.9 ±14.8ms; TMC mg: 7.1 ±9.5ms; TMC mg: 18.8 ±27.7ms). No pathologically prolonged QT and QTc values were observed in any treatment group. Discussion This study has confirmed bactericidal activity of TMC207 in treatment-naïve patients with sputum smear-positive pulmonary TB. While none of the TMC207 doses demonstrated a clear response in the initial days of treatment, a decline in CFU was observed from day 4 onwards for the TMC mg group. As expected, INH showed early bactericidal response from the first day onwards and a similar response was also found with RIF. No serious adverse events attributable to the study drug occurred during the trial. The exposure to TMC207 was linearly related to the dose. Steady-state plasma concentrations were not reached within the 7-day period of drug administration. Early bactericidal activity (EBA) studies, traditionally carried out over 2 days, measure the ability of a single antituberculosis agent to kill rapidly metabolizing mycobacteria present in tuberculous pulmonary cavities (6, 13, 14). EBA studies also offer the opportunity to evaluate short-term toxicity and dose ranging of TB drugs. Mycobacteria in cavities exist as heterogeneous populations which are either actively replicating or in a hypometabolic state (10). Semi-replicating or hypo-metabolic bacteria are more resistant to killing by conventional bactericidal anti-tb drugs. Although it is clear that the results of 2-day EBA studies bear little relationship to the ability of an agent to sterilize 11

12 tuberculosis lesions, extending the period of drug treatment to 5-days or longer potentially offers the opportunity to measure the killing of hypo-metabolic organisms and thus might provide a preliminary assessment of the sterilizing activity of an agent (11, 15). This may also be indicative of the ability of a drug to prevent relapse of TB (13). Drugs that have effective sterilizing properties are essential to shorten the treatment duration of TB. Interestingly, similar to TMC207, pyrazinamide (PZA) also has almost no bactericidal action during the first 2-4 days of treatment (3, 13, 14), but none-the-less kills consistently thereafter and is one of the most important components of TB standard of care regimens (27). Significant synergy is found between PZA and TMC207 in mice, which together with the similar EBA profile in man might suggest possible similarities in the mechanism of mycobacterial killing (12). The ability to deplete mycobacterial energy stores may give TMC207 the potential to become an important sterilizing agent of TB lesions and thus further shorten TB treatment. It was shown that the ATP synthase enzyme complex is down regulated during dormancy as a result of overall shutdown of metabolic pathways (23). This results in lower ATP stores, which make dormant bacteria exquisitely vulnerable to further ATP depletion. The log kill obtained with a single dose of standard therapy following the experimental phase was greater in TMC207-treated subjects compared to RIF- and INH-treated subjects. This suggests that TMC207 may be acting on a population distinct from the one targeted by the existing first-line drugs and may indicate that increased activity could be expected if TMC207 were added to the standard treatment regimen. 12

13 The reasons for the slow onset of action of TMC207 in patients remain speculative. It may be suggested that energy depletion and disruption of intracellular ph homeostasis as the result of the action of TMC207 (2) may require a few days to affect mycobacterial viability. This might be because at any given time point in a cell there is a cellular-atppool present which may allow bacteria to survive transiently. This probably interferes, albeit for a short period, with any block of ATP synthesis mediated by TMC207 s inhibition of the ATP-synthase enzyme. The activity of TMC207 found in humans in the present study fits in well in vitro and animal data. In vitro, TMC207 has time-dependent activity driven by the time over MIC (2). TMC207 at 10*MIC or 100*MIC in 7H9 broth was highly bactericidal against Mycobacterium tuberculosis, but this was only observed after six days of incubation and not earlier. The most impressive activity of TMC207 in animal models was observed after treatment for at least 1 month in studies conducted in mice infected with drug sensitive TB and non-established (2) and established infection (2, 12) or MDR-TB (19). In guinea pigs, where TB bacilli are preferentially found extracellular and not intracellular as in mice, similar activity was found (18). These animal studies demonstrated killing in one week of treatment with TMC207 in the same range as found in the present study. The activity of TMC207 beyond 7 days in humans remains unknown and needs further investigation. Having confirmed bactericidal activity of TMC207 in the context of an EBA study in patients with tuberculosis, the next step is evaluation of its activity over a longer period of time. The rapid development of resistance of Mycobacterium tuberculosis to agents given in monotherapy limits the duration of single-agent EBA studies. In a previous study 13

14 that included the sterilizing drugs PZA and RIF, 90-95% of patients demonstrated culture negativity at 2-months following treatment, superior to results in regimens that did not include these agents (21). In a recent study, substitution of the fluoroquinolone moxifloxacin for EMB in a regimen containing RIF and PZA, did not result in a significant difference in the 2-month sputum culture-negativity, although the moxifloxacin regimen did lead to a significantly higher rate of culture negativity at 1 month (4). The potency of RIF and PZA to sterilize sputum during the first 2 months of tuberculosis treatment complicates the evaluation of new anti-tuberculosis agents in combination therapy with these drugs. An alternative approach would be the addition of TMC207 to second-line agents in the treatment of MDR-TB, where the use of first line agents is limited and the remaining drugs would be expected to be less efficient. It is possible that the addition of TMC207 to an MDR-TB regimen, even those containing a fluoroquinolone, would enhance the ability to determine the intrinsic sterilizing activity of TMC207. A trial to assess the activity, safety and tolerability of TMC207 in patients with MDR pulmonary TB is currently in progress. In conclusion the present study has shown that oral once daily administration of TMC207 has bactericidal activity at a dose of 400mg when administered as monotherapy for 7 days in patients with pulmonary TB. When compared to INH and RIF, the bactericidal activity of 400mg of TMC207 started later but was of similar magnitude on days 4 to 7. Serious adverse events related to study drug did not occur. Further evaluation of the agent in MDR pulmonary TB is now ongoing. 14

15 Acknowledgements Financial support: Tibotec, Inc., Yardley, PA, USA Manuscript preparation: Tibotec provided assistance with study design, statistical and other analyses and in preparing and editing the manuscript. Conflict of interest: T.D.M., R.V.H., R.K., A.K., K.D.B., and D.F.M. are employees of Tibotec. P.R.D. acted as a consultant to Tibotec. R.R., A.H.D., J.A., A.V., C.R., R.F.P., and T.C.P.M. have no conflict of interest to declare. 15

16 Figure legends: Figure 1 Study flow diagram. Eight patients did not complete the treatment phase. Five patients were withdrawn due to screening laboratory values that emerged only after randomization (5 with a positive urine drug screen for cannabinoids, 1 with elevated liver enzymes). 2 individuals in the INH group were withdrawn following hemoptysis. Two patients died during follow-up (details see text). Figure 2 Bactericidal activity for days 0-7 by treatment regimen. The activity of isonazid 300mg and rifampin 600mg is of immediate onset and continuous over 7 days. TMC207 shows delayed onset of activity from day 4. Values are means. Error bars are 95% confidence intervals. CFU = colony forming units. Figure 3 Decline in CFU from baseline to day 7 for individual subjects by treatment group. Log Fall = change in log 10 CFU/ml sputum from baseline to day 7. CFU = colony forming units. 16

17 References 1. Albert, H., A. P. Trollip, R. J. Mole, S. J. Hatch, and L. Blumberg Rapid indication of multidrug-resistant tuberculosis from liquid cultures using FASTPlaqueTB-RIF, a manual phage-based test. Int J Tuberc Lung Dis 6: Andries, K., P. Verhasselt, J. Guillemont, H. W. Gohlmann, J. M. Neefs, H. Winkler, J. Van Gestel, P. Timmerman, M. Zhu, E. Lee, P. Williams, D. de Chaffoy, E. Huitric, S. Hoffner, E. Cambau, C. Truffot-Pernot, N. Lounis, and V. Jarlier A diarylquinoline drug active on the ATP synthase of Mycobacterium tuberculosis. Science 307: Botha, F. J., F. A. Sirgel, D. P. Parkin, B. W. van de Wal, P. R. Donald, and D. A. Mitchison Early bactericidal activity of ethambutol, pyrazinamide and the fixed combination of isoniazid, rifampicin and pyrazinamide (Rifater) in patients with pulmonary tuberculosis. S Afr Med J 86: Burman, W. J., S. Goldberg, J. L. Johnson, G. Muzanye, M. Engle, A. W. Mosher, S. Choudhri, C. L. Daley, S. S. Munsiff, Z. Zhao, A. Vernon, and R. E. Chaisson Moxifloxacin versus ethambutol in the first 2 months of treatment for pulmonary tuberculosis. Am J Respir Crit Care Med 174: Corbett, E. L., C. J. Watt, N. Walker, D. Maher, B. G. Williams, M. C. Raviglione, and C. Dye The growing burden of tuberculosis: global trends and interactions with the HIV epidemic. Arch Intern Med 163:

18 6. Donald, P. R., F. A. Sirgel, A. Venter, D. P. Parkin, H. I. Seifart, B. W. van de Wal, J. S. Maritz, and P. B. Fourie Early bactericidal activity of antituberculosis agents. Expert Rev Anti Infect Ther 1: Edlin, B. R., J. I. Tokars, M. H. Grieco, J. T. Crawford, J. Williams, E. M. Sordillo, K. R. Ong, J. O. Kilburn, S. W. Dooley, K. G. Castro, and et al An outbreak of multidrug-resistant tuberculosis among hospitalized patients with the acquired immunodeficiency syndrome. N Engl J Med 326: Frieden, T. R., L. F. Sherman, K. L. Maw, P. I. Fujiwara, J. T. Crawford, B. Nivin, V. Sharp, D. Hewlett, Jr., K. Brudney, D. Alland, and B. N. Kreisworth A multi-institutional outbreak of highly drug-resistant tuberculosis: epidemiology and clinical outcomes. Jama 276: Gandhi, N. R., A. Moll, A. W. Sturm, R. Pawinski, T. Govender, U. Lalloo, K. Zeller, J. Andrews, and G. Friedland Extensively drug-resistant tuberculosis as a cause of death in patients co-infected with tuberculosis and HIV in a rural area of South Africa. Lancet 368: Gomez, J. E., and J. D. McKinney M. tuberculosis persistence, latency, and drug tolerance. Tuberculosis (Edinb) 84: Gosling, R. D., L. O. Uiso, N. E. Sam, E. Bongard, E. G. Kanduma, M. Nyindo, R. W. Morris, and S. H. Gillespie The bactericidal activity of moxifloxacin in patients with pulmonary tuberculosis. Am J Respir Crit Care Med 168: Ibrahim, M., K. Andries, N. Lounis, A. Chauffour, C. Truffot-Pernot, V. Jarlier, and N. Veziris Synergistic activity of R combined with 18

19 pyrazinamide against murine tuberculosis. Antimicrob Agents Chemother 51: Jindani, A., V. R. Aber, E. A. Edwards, and D. A. Mitchison The early bactericidal activity of drugs in patients with pulmonary tuberculosis. Am Rev Respir Dis 121: Jindani, A., C. J. Dore, and D. A. Mitchison Bactericidal and sterilizing activities of antituberculosis drugs during the first 14 days. Am J Respir Crit Care Med 167: Johnson, J. L., D. J. Hadad, W. H. Boom, C. L. Daley, C. A. Peloquin, K. D. Eisenach, D. D. Jankus, S. M. Debanne, E. D. Charlebois, E. Maciel, M. Palaci, and R. Dietze Early and extended early bactericidal activity of levofloxacin, gatifloxacin and moxifloxacin in pulmonary tuberculosis. Int J Tuberc Lung Dis 10: Kochi, A The global tuberculosis situation and the new control strategy of the World Health Organization. Tubercle 72: Koul, A., N. Dendouga, K. Vergauwen, B. Molenberghs, L. Vranckx, R. Willebrords, Z. Ristic, H. Lill, I. Dorange, J. Guillemont, D. Bald, and K. Andries Diarylquinolines target subunit c of mycobacterial ATP synthase. Nat Chem Biol 3: Lenaerts, A. J., D. Hoff, S. Aly, S. Ehlers, K. Andries, L. Cantarero, I. M. Orme, and R. J. Basaraba Location of persisting mycobacteria in a Guinea pig model of tuberculosis revealed by r Antimicrob Agents Chemother 51:

20 19. Lounis, N., N. Veziris, A. Chauffour, C. Truffot-Pernot, K. Andries, and V. Jarlier Combinations of R with drugs used to treat multidrugresistant tuberculosis have the potential to shorten treatment duration. Antimicrob Agents Chemother 50: Martin, A., M. Camacho, F. Portaels, and J. C. Palomino Resazurin microtiter assay plate testing of Mycobacterium tuberculosis susceptibilities to second-line drugs: rapid, simple, and inexpensive method. Antimicrob Agents Chemother 47: Mitchison, D. A Assessment of new sterilizing drugs for treating pulmonary tuberculosis by culture at 2 months. Am Rev Respir Dis 147: O'Brien, R. J., and P. P. Nunn The need for new drugs against tuberculosis. Obstacles, opportunities, and next steps. Am J Respir Crit Care Med 163: Shi, L., C. D. Sohaskey, B. D. Kana, S. Dawes, R. J. North, V. Mizrahi, and M. L. Gennaro Changes in energy metabolism of Mycobacterium tuberculosis in mouse lung and under in vitro conditions affecting aerobic respiration. Proc Natl Acad Sci U S A 102: Wang, S. X., L. H. Sng, and L. Tay Preliminary study on rapid identification of Mycobacterium tuberculosis complex isolates by the BD ProbeTec ET system. J Med Microbiol 53: World Health Organization. Fact Sheet Tuberculosis. Available at: Accessed 17 August

21 26. World Health Organization. WHO Tuberculosis Programme: Framework for effective Tuberculosis Control. Geneva, Switzerland: World Health Organization; 1994 Publication WHO/TB/ Zhang, Y., and D. Mitchison The curious characteristics of pyrazinamide: a review. Int J Tuberc Lung Dis 7:

22 Table 1 Mean Changes in Sputum CFU Counts from Baseline TCM207 25mg q.d. 100mg q.d. 400mg q.d. Rifampin 600mg q.d. Isoniazid 300mg q.d. N Mean (SD) N Mean (SD) N Mean (SD) N Mean (SD) N Mean (SD) Baseline (0.68) (1.14) (1.14) (1.02) (0.93) Changes from Baseline After Starting Monotherapy Day (0.52) (0.52) (0.26) (0.36) (0.47) Day (0.27) (0.68) (0.60) (1.05) (1.21) Day 3 15 Day 4 14 Day (0.36) (0.57) (0.52) (0.66) (0.40) (0.80) (0.38) (0.62) (0.43) (0.99) (0.49) Day 6 14 Day (0.59) (0.46) (0.48) (0.42) (1.08) (0.57) (0.76) (0.46) (1.24) (0.60) (0.64) (0.58) (0.71) (0.74) Changes from Baseline After Starting Standard TB Therapy Day (0.58) (0.70) (0.65) (0.96) (0.87) N= number of individuals with values. All values in log 10 CFU/ml sputum. 22

23 Table 2 Pharmacokinetics of TMC207 after Oral Administration at Different Doses Day 7 (N) C oh, ng/ml C min, ng/ml C max, ng/ml t max, h AUC 24h, ng*h/ml C ss,av, ng/ml FI, % All doses q.d. for 7 days TMC207 25mg TMC mg TMC mg ± ± ± ( ) 3973 ± ± ± ± ± ± ( ) ± ± ± ± ± ± ( ) ± ± ± Data expressed as (mean ± SD), for t max: median (range) N = number of subjects with values. 23

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