Effect of eritoran, an antagonist of MD2-TLR4, on mortality in patients with severe sepsis: the ACCESS randomized trial.

Abstract

IMPORTANCE:

Eritoran is a synthetic lipid A antagonist that blocks lipopolysaccharide (LPS) from binding at the cell surface MD2-TLR4 receptor. LPS is a major component of the outer membrane of gram-negative bacteria and is a potent activator of the acute inflammatory response.

OBJECTIVE:

To determine if eritoran, a TLR4 antagonist, would significantly reduce sepsis-induced mortality.

DESIGN, SETTING, AND PARTICIPANTS:

We performed a randomized, double-blind, placebo-controlled, multinational phase 3 trial in 197 intensive care units. Patients were enrolled from June 2006 to September 2010 and final follow-up was completed in September 2011.

INTERVENTIONS:

Patients with severe sepsis (n = 1961) were randomized and treated within 12 hours of onset of first organ dysfunction in a 2:1 ratio with a 6-day course of either eritoran tetrasodium (105 mg total) or placebo, with n = 1304 and n = 657 patients, respectively.

MAIN OUTCOME MEASURES:

The primary end point was 28-day all-cause mortality. The secondary end points were all-cause mortality at 3, 6, and 12 months after beginning treatment.

RESULTS:

Baseline characteristics of the 2 study groups were similar. In the modified intent-to-treat analysis (randomized patients who received at least 1 dose) there was no significant difference in the primary end point of 28-day all-cause mortality with 28.1% (366/1304) in the eritoran group vs 26.9% (177/657) in the placebo group (P = .59; hazard ratio, 1.05; 95% CI, 0.88-1.26; difference in mortality rate, -1.1; 95% CI, -5.3 to 3.1) or in the key secondary end point of 1-year all-cause mortality with 44.1% (290/657) in the eritoran group vs 43.3% (565/1304) in the placebo group, Kaplan-Meier analysis of time to death by 1 year, P = .79 (hazard ratio, 0.98; 0.85-1.13). No significant differences were observed in any of the prespecified subgroups. Adverse events, including secondary infection rates, did not differ between study groups.

CONCLUSIONS AND RELEVANCE:

Among patients with severe sepsis, the use of eritoran, compared with placebo, did not result in reduced 28-day mortality.

TRIAL REGISTRATION:

clinicaltrials.gov Identifier: NCT00334828.

• Authors: Steven M Opal, Pierre-Francois Laterre, Bruno Francois, Steven P LaRosa, Derek C Angus, Jean-Paul Mira, Xavier Wittebole, Thierry Dugernier, Dominique Perrotin, Mark Tidswell, Luis Jauregui, Kenneth Krell, Jan Pachl, Takeshi Takahashi, Claus Peckelsen, Edward Cordasco, Chia-Sheng Chang, Sandra Oeyen, Naoki Aikawa, Tatsuya Maruyama, Roland Schein, Andre C Kalil, Marc Van Nuffelen, Melvyn Lynn, Daniel P Rossignol, Jogadish Gogate, Mary B Roberts, Janice L Wheeler, Jean-Louis Vincent, ACCESS Study Group
• Journal: JAMA (JAMA) Vol. 309 Issue 11 Pg. 1154-62 (Mar 20 2013) ISSN: 1538-3598 [Electronic] United States
• PMID: 23512062 (Publication Type: Journal Article, Multicenter Study, Randomized Controlled Trial, Research Support, Non-U.S. Gov't)

Chemical References

• Disaccharides
• Sugar Phosphates
• Toll-Like Receptor 4
• eritoran

Topics

• Adolescent
• Adult
• Aged
• Aged, 80 and over
• Disaccharides (therapeutic use)
• Double-Blind Method
• Female
• Humans
• Kaplan-Meier Estimate
• Male
• Middle Aged
• Organ Dysfunction Scores
• Sepsis (drug therapy, mortality)
• Severity of Illness Index
• Sugar Phosphates (therapeutic use)
• Toll-Like Receptor 4 (antagonists & inhibitors)
• Young Adult