Randomized double blind placebo-controlled clinical safety, tolerability and pharmacokinetic/-dynamic study on the effects of escalating single intravenous doses of EA-230 on the innate immune response during experimental human endotoxemia

Although the immune system is essential to survival, a variety of diseases
originate from inappropriate activation of the immune response. Besides a range
of auto-inflammatory disease like rheumatoid arthritis, inappropriate or
undesirable activation of the immune system can occur during infectious
diseases like sepsis, after major surgery like cardiac artery bypass grafting,
after radiation therapy in the treatment of cancer, or after organ
transplantation.
For auto-inflammatory diseases, in the last decades therapies have come
available that specifically target parts of the immune system. The development
of *biologicals*, recombinant antibodies that specifically block one antigen or
receptor, has had an enormous impact on the treatment of chronic autoimmune
diseases. However, these treatments have been shown not to be effective in
other types of (acute) systemic inflammation, like sepsis.
Of the many downstream consequences of exaggerated inflammatory response, organ
injury and failure is the most serious, most often involving the kidneys
(Cartin-Ceba et al. 2012, ). This also holds true for cardiac surgery with
cardiopulmonary bypass, in which various factors, including the inflammatory
cascade, cause a temporarily decline or even permanent loss of renal function
(Moss and Lamarche 2012). As kidney failure is an independent prognostic factor
for mortality in critically ill patients, treatments aimed at preventing acute
kidney injury are warranted.
EA-230 is a novel pharmacological compound being developed for the treatment of
systemic inflammatory states like sepsis, and for the treatment of inflammation
associated organ dysfunction like acute kidney injury (AKI). It*s a linear
tetrapeptide derived from the human chorionic gonadotropin hormone (hCG). It
has shown anti-inflammatory properties and protects against organ failure in
several pre-clinical models of sepsis or systemic inflammation which will be
described in more detail below. Most notably, EA-230 has shown marked
protective effects in the kidney during abdominal sepsis in animals. As EA-230
attenuates the pro-inflammatory response in neutrophils and monocytes ex vivo,
and neutrophil influx in tissues during systemic inflammation in vivo is
abrogated, it is thought that EA-230 acts by protecting the host against the
detrimental effects of neutrophils during acute systemic inflammatory diseases,
thereby preventing organ damage, especially in the kidney.
Having performed extensive research into the pharmacology, pharmacokinetics and
toxicology of EA-230, a first in human study was previously conducted with
escalating single doses of EA-230 (NCTxxx) , which showed that EA-230 was well
tolerated up to i.v. doses of 30 mg/kg three times a day (daily dose of 90
mg/kg) for three days, and did not result in adverse events that were related
to the study treatment. In a human model of systemic inflammation elicited by
the administration of a low dose of endotoxin (NCTxxxx), EA-230 showed to
attenuate the innate immune response at a single i.v. dose of 10 mg/kg, even
though EA-230 was administered 30 minutes after endotoxin administration. A
full dose- and concentration-response profile was not collected in that study.
In addition, until now, only bolus administrations of EA-230 were tested,
whereas in view of the short terminal half life of less than 15 minutes, a
continuous administration of EA-230 over a longer time interval may be more
effective.
For that reason, an additional phase I study in healthy volunteers is required
to complete the profile of EA-230 response in inflammation before a dose or
dose range can be chosen for a first *prove-of-concept* study in patients. The
safety profile of EA-230 has to be extended beyond the daily dose of 90 mg/kg
addressed to date; the dose- and concentration response information collected
during escalation will provide the dose for proof-of-concept testing in
patients.

Part 1: To assess the safety, tolerability and pharmacokinetic-dynamic
response, of single escalating doses of EA-230 in healthy subjects.

Part 2: To assess the dose-and plasma concentration-response relation of single
escalating doses EA-230 on inflammation and LPS-induced changes in markers for
renal function, and to assess safety, tolerability and PK of EA-230 under the
condition of experimental endotoxemia.

The trial consists of two parts, both with a prospective, monocentric,
double-blind, placebo-controlled, randomized, single-dose design in healthy
subjects. Part 1 is a phase I trial in which single escalating doses of EA-230
will be administered to healthy volunteers. In part 2, the administration of
single escalating doses of EA-230 to healthy volunteers, are combined with the
intravenous administration of a low dose of E. Coli endotoxin (also known as
lipopoysaccharide or LPS).
A total number of 60 subjects will be examined in the two study parts according
to the schedule below. Both study parts are placebo controlled. Placebo
treatments are randomly divided over the treatment groups in a double blind
fashion.

In our opinion, the risks for participation in this study are low, and we have
made every effort to minimize risks or counteract potential adverse reactions.
EA-230 has been well tolerated in healthy volunteers up to doses of 90
mg/kg*day. In addition, the slow infusion rate (infusion in 2 hours) combined
with the short terminal half life of EA-230 enables us to stop the infusion at
any time during administration after which side effects will most likely
rapidly decline.
We are experienced in handling the potential side effects of LPS
administration. Iohexol and PAH administration is regarded safe, with the most
likely adverse reaction being an allergic reaction, which we will be capable of
managing on our well equipped and staffed research facility. Therefore, we feel
that the remaining risks are acceptable and do not outweigh the scientific and
medical relevance of this study.