Voriconazole With or Without Interferon Gamma in Treating Patients With Aspergillosis or Other Fungal Infections

A Prospective, Randomized, Double-Blind, Multicenter Pilot Study Of The Safety And Efficacy Of Interferon Gamma- 1b (IFN-y 1b) Plus Voriconazole Versus Placebo Plus Voriconazole In The Treatment Of Invasive Aspergillosis And Other Filamentous Fungal Infections

RATIONALE: Antifungals such as voriconazole may be effective in controlling fungal infections. Combining voriconazole with interferon gamma may be more effective than voriconazole alone in treating fungal infections.

PURPOSE: Randomized phase II trial to compare the effectiveness of voriconazole with or without interferon gamma in treating patients who have aspergillosis or other fungal infections.

OBJECTIVES:

• Determine the safety profile of voriconazole and interferon gamma in patients with invasive aspergillosis or other filamentous fungal infections.
• Compare the efficacy and possible heterogeneity in efficacy of voriconazole with or without interferon gamma across different patient sub-populations, in terms of designing a larger phase II or pivotal phase III study.
• Determine the time to partial or complete response and rate of response (at weeks 6 and 12 or at end of treatment and follow-up) in patients receiving interferon gamma.
• Compare the proportion of patients with at least a two-fold reduction in the galactomannan antigenemia titer at 6 and 12 weeks or at end of treatment with these regimens.
• Determine surrogate immunologic markers for response to interferon gamma, functional integrity and anti-fungal activity of phagocytic cells (neutrophils, monocytes, and macrophages), and nonphagocytic effector cells (natural killer and T cells) in these patients.

OUTLINE: This is a randomized, double-blind, multicenter, pilot study. Patients are stratified according to age (under 18 vs 18 and over) and absolute neutrophil count (less than 500/mm^3 vs at least 500/mm^3). Patients are randomized to 1 of 2 treatment arms.

• Arm I: Patients receive voriconazole (IV over 80-120 minutes for the first 3 doses and orally every 12 hours for subsequent doses) 3 times per week and interferon gamma subcutaneously (SC) 3 times per week.
• Arm II: Patients receive voriconazole as in arm I and placebo SC 3 times per week.

In both arms, treatment continues for 12 weeks in the absence of disease progression or unacceptable toxicity.

Patients are followed at 4 weeks.

PROJECTED ACCRUAL: A total of 88 patients (44 per treatment arm) will be accrued for this study.

DISEASE CHARACTERISTICS:

• Proven or probable invasive aspergillosis or other filamentous fungal infection by cytology, histopathology, or culture within the past 7 days

• Presenting with 1 of the following:

  • Cancer
  • Aplastic anemia
  • Inherited immunodeficiencies
  • Autoimmune deficiency disorders
  • Acquired immunodeficiencies
  • Recipient of autologous peripheral blood stem cell or bone marrow transplantation

• CNS aspergillosis or other filamentous fungal infection allowed

• No invasive zygomycosis infection

PATIENT CHARACTERISTICS:

Age

• 2 and over

Performance status

• Not specified

Life expectancy

• At least 7 days

Hematopoietic

• Not specified

Hepatic

• ALT no greater than 5 times upper limit of normal

Renal

• Creatinine clearance at least 30 mL/min

Other

• Not pregnant or nursing
• Negative pregnancy test
• Fertile patients must use effective barrier contraception
• No prior significant CNS disorder (e.g., multiple sclerosis or uncontrolled seizures)
• No prior grade 3 or 4 toxicity or severe allergic reaction to interferon gamma
• No prior intolerance or hypersensitivity to voriconazole or other azoles
• No acute or chronic graft-versus-host disease
• No conditions that would preclude study compliance

PRIOR CONCURRENT THERAPY:

Biologic therapy

• See Disease Characteristics
• No prior allogeneic peripheral blood or bone marrow transplantation
• No concurrent interferon alfa

Chemotherapy

• Not specified

Endocrine therapy

• Not specified

Radiotherapy

• Not specified

Surgery

• No prior solid organ transplantation

Other

• Prior voriconazole allowed

• At least 24 hours since prior administration of any of the following:

  • Astemizole
  • Cisapride
  • Pimozide
  • Quinidine
  • Sirolimus
  • Terfenadine
  • Rifabutin
  • Ergot alkaloids
  • Sildenafil citrate
  • Amiodarone
  • Flecainide
  • Systemic lidocaine

• More than 14 days since prior long-acting barbiturates, carbamazepine, or rifampin

• No other concurrent systemic antifungal drugs

• No other concurrent investigational agents