CLINICAL TRIALS CVO+ MADAGASCAR

1. Randomized clinical trial, phase 3, to evaluate the efficacy of
CVO + versus placebo for the treatment of COVID-
19.
Promotor Pharmalagasy
PI RAKOTO Alson Olivat, Pofessor
RAKOTOSAONA Rianasoambolanoro, PhD, HDR
Scientifc responsible RATSIMBASOA Claude Arsène, MD,PhD,HDR
Technical collaborators Ministry of Public Health
WHO Madagascar
INSTAT
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2. 1. Context and justification
2. Purpose of the trial
3. Methods
 Desing and setting of study
 Study schema
 Population: list inclusion criteria
 Allocation to intervention
 Conduct of the study
 Outcomes
 Statistical analysis
 Adverse effect
 Ethics approval
 Chronogram
4. Results 2
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Plan

3. 3
SRAS-COV-2 infection
Context
Research stage
Retrieved june, 21,2021

4. 4
SRAS-COV-2 infection
• Non-curative treatment without there being reasonable
• Vaccine effective at preventing severe forms of diseases , not for the treatment
• Madagascar (2020):
 Randomized clinical trial, phase 2, to evaluate the efficacy of Artesunate IV alone or combined
with vitamin C IV for the treatment of COVID-19.
 CERBM ID n° : 073 MINSANP/SG/AGMED/CERBM
 PACTR ID n° : PACTR20210399597082
 Promoter: Malagasy governement
Context
« . This study demonstrates the efficacy of artesunate IV alone. Howether, this study is limited, the
requested analysis was not performed because of insufficient sample. Interventions recommended
for large-scale deployment .

5. 5
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Assumption
• Disavantages of Artesunate IV:
 Injectable form,
 Number of days of treatment : 7 days,
 Clinical surveillance +++
BUT
• Artésunate IV group alone demonstrated progressive decrease of viral load median and result
becomes negative at day 14.
• Viral load increases at day 21 and decreases at day 28. The increase on day 21 suggests that the
duration of treatment is not sufficient.
ENDEED
• Assumption : Treatment duration should be prolonged and a new galenic formulation (eg oral)
would be more appropriate for a better therapeutic response.
Context

6. 6
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Evidence base
• Rapidly metabolized to DHA in the liver with
involvement of cytochrome P450
• Rapid but incomplete absorbtion (low
aqueous solubility)
• Low and variable bioavailability by the oral
administration . The use of
betacyclodextrins as an excipient increases
the stability and solubility and therefore the
bioavailability of artemisinin.
• Rapidly metabolized to DHA in the liver with
involvement of cytochrome P450
• Rapid absorbtion
• High biovalability
Artemisinin
Artesunate
Context
)
)

7. 7
Therapeutic potentiel of CVO +
Antiviral :
• interactions with Lys353 and Lys31 binding
hotspots of SARS COV-2 spike protein. (1).
• SARS COV-2 protease inhibitor (2)
• Anti-SARS COV-2 in vitro (Vero E6 cells) (3)
anti-inflammatory
Inhibits IL-1β production. IL-6. by inhibition of the NF-
κB signaling pathway. IL-10
(1) Sehailia. M. et al.. Journal of Biomolecular Structure and Dynamics 2020. 1–11.
(2) Banerjee. R.; et al.. Drug Discovery Today 2020.
(3) CAO. et al ACS Infectious Diseases. 2020. Vol. 6. n° 9. pp. 2524-2531
(4) KSHIRSAGAR. Suhas G. et RAO. Rammohan 2021. vol. 57. no 3. p. 217.
Antiviral :
• SARS inhibitor COV-2 proteinase Mpro
necessary for its reproduction (6)
Anti-inflammatory
• Inhibits IL-1β.TNF-α production (7)
• Improves respiratory function tests. anti-asthma
and anti-bronchial inflammatory
(6) SHARMA. Arun D. et al. Notulae Scientia Biologicae. 2020. Vol. 12. n° 3. pp. 536-545.
(7) FEUILLET. Vincent et Al. Trends in Immunology. 2021. Vol. 42. n° 1. pp. 31-44.
Context
)

8. Composition Quantity
Artemisia annua extract dosed with
Artemisinin 150 mg
Flavonoïd extract 3.3 mg
Terpenic extract 4 mg
Essential oil of Cinnamomum camphora dosed with
1.8 cineol (eucalyptol) 7.1 mg
Excipients
Beta cyclodextrine and magnesium stearate Qsp
Pharmaceutical form : capsule
8

9. 9
CONTEXT
Objective
To assess the efficacy of curative CVO + in significantly reducing or completely
eliminating the SARS-CoV-2 virus in Oro-pharyngeal samples
Based on WHO/AFRO’s master protocol

10. 10
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Methods
• Study area: Analamanga region
• recruitment site: Voara village. CSB 2 Antananarivo Renivohitra
• Follow up : CNARP
• Type of study: quasi experimental study .exposed vs unexposed
CVO+
curative
Placebo
Random
allocation
sick
Not sick
Sick
Before test
Before test After test
After test
Effect or impact
measure
Not sick
Subject
group

11. 11
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Methods
• Placebo effect+++
CVO+
curative
Placebo
Spontaneous
evolution
Spontaneous
evolution
Pharmacological Effet
Initial
effect
Initial
effect
Treatement
effect
Treatement
effect
Final state
Final state
Placebo effect
Medical doctor
Environment
Patient personality
Avalaibility of treatement
Comprehensive
treatement progam

12. 12
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Methods
• Treatment assignment method:
 randomized
 In double blind
• Clinical question:
P
I
C
O
Patient. population or population?
Patient infected with COVID-19: moderate form.
Comparaison
Placebo.
Outcome
Significant reduction or complete elimination of SARS-CoV-2 in Oro-pharyngeal samples « End-point analysis ».
Intervention
CVO plus curatif.
Intervention Placebo
Dose 150 mg 3 times
per day
3 capsules per
day
duration 15 days 15 days
Description Artemisinine +
cineol
capsules like
intervention
without active
substance

13. 13
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Inclusion criteria
 Participant (or legally authorized representative) provides written informed consent prior to
initiation of any study procedures.
 Understands and agrees to comply with planned study procedures.
 Agrees to the collection of OP swabs and venous blood per protocol.
 Male or non-pregnant female (pregnancy test) adult ≥18 years of age at time of enrolment.
 Laboratory-confirmed SARS-CoV-2 infection as determined by PCR at a Government approved
lab. from throat/nasopharyngeal swab.
 Illness of any duration, and at least one of the following:
 Radiographic infiltrates by imaging (chest x-ray, CT scan, etc.), or
 Clinical assessment (evidence of rales/crackles on exam) or
 Requiring mechanical ventilation and/or supplemental oxygen.
 Creatinine ≤ 110 µmol/L, creatinine clearance rate (EGFR) ≥ 60 ml / min / 1.73m2, AST and
ALT ≤ 5 × ULN, TBIL ≤ 2 × ULN;
 A Normal ECG Baseline result, which is maintained throughout the study.
Methods

14. 14
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Exclusion criteria
Participants with the following conditions will be excluded from the study:
 ALT/AST > 5 times the upper limit of normal.
 Stage 4 severe chronic kidney disease or requiring dialysis (i.e. eGFR < 30)
 Pregnancy or breast feeding.
 Anticipated transfer to another hospital which is not a study site within 72 hours.
 Allergy to any study medication
 Shortness of breath
 Known prolonged QT syndrome
 Use of concomitant medications that prolong the QT/QTc interval
 Subject with other viral pneumonia
 Participants with allergies to artemisinin containing products
 History of allergic reactions to any investigational medical product ingredient
 Participants who in the opinion of the investigators after assessing all relevant parameters are
unsuitable for the study.
Methods

15. 15
Conduct of the study
Pre-
inclusion
Day 0 Day 7 Day 14 Day 21 Day 28
Consent x
inclusions/exclusion criteria x x
Medical history x
Physical check-up x x x x x
Vital signs x x x x x
Laboratory analysis x x x x x x
Concomitant treatments x x x x x
Adverse events x x x x
Randomization x
Methods

16. 16
Endpoint
• Primary endpoint:
Significant reduction or complete clearance of SARS-CoV-2 virus in the OP samples on Day
28 and absence of serious adverse events.« endpoint analysis »
• Secondary endpoint:
Recovery time, time to clinical improvement, duration of hospitalization, date and cause of
death (if applicable), grade 3 and 4 adverse events, SAEs, white cell count, hemoglobin,
platelets, creatinine, glucose, total bilirubin, ALT, and AST on days 7,14, 21 and 28.
Methods

17. 17
Data collection tools
• Monitoring: RCF
• Data Management
 Data centralization: encrypted server
 Computerization - Data entry:
• Analysis of biological data in collaboration with :
Confidentiality clause ++++
Methods

18. 18
Statistical considerations
• Sample size calculation
 Level of confidentiality : 95%
 Level of Confidentiality = 95%
 Error of Margin = 0.03
 Ratio N2/N1=1
 N = 397,942
 Treatment efficacy hypothesis : Superior efficacy for the CVO+ arm
 For Placebo arm with standard care=40%
 For CVO+ arm=60%
 N=306 with 153 patient per group
 Addition of 10% for deaths and withdrawals brings total sample size to 338.
Methods

19. 19
Statistical considerations
• Frequency of statistical analyses: no intermediate analyses
• Analysis strategies
 Intent-to-treat analysis
 Consideration of protocol deviations
 Consideration of missing data
• Statistical methods and software used:
• Analysis plan and statistical analysis in collaboration with
• Description of inclusions and follow-ups
• Characteristics of the patients included in the analysis
• Description of the analysis methods for the primary and secondary
Methods

20. 20
Tolerance
• Definitions of an adverse event (AE) and a serious adverse event (SAE)
• Fatality; A life-threatening AE;
• Hospitalization or extension of an existing hospitalization;
• Persistent or significant disability or substantial impairment of the ability to carry out normal
life functions;
• Birth defect/congenital malformation;
• Significant medical events that may not result in death but life-threatening. when based on
appropriate medical judgment
• Follow-up of Adverse Events
Methods

21. 21
Ethical and regulatory considerations
• Respect for good clinical practices
• Submission to the Ethics Committee :
 CERBM ID n°: 216 MINSANP/SG/AGMED/CERBM
 PACTR ID n°: PACTR 20210601407640
• Informed consent: voluntary participation. right to withdraw at any time during the study
• Data confidentiality: anonymity. data security
• Storage of biological materials: at the laboratory level
• Storage of research documents: CNARP
• No compensation to subjects
Methods

22. 22
Chronogram
• Approval request CERBM : December 2020
• Start of recruitment: January 18, 2021
• End of inclusion: May 4, 2021 (N=339)
• End of data entry: June 7, 2021
• Data cleaning, analysis: Beginning of June 2021
• Data validation by the scientific committee: June 21, 2021
• Final report CERBM : June 22, 2021
Methods

23. 23
Méthodes
Results

24. 24
Flowshart of the study
Méthodes
PCR Tests
1 576
included
339
Placebo
157
Placebo
144
withdrew
3
Lost to
follow-up
8
CURATIVE CVO+
161
CURATIVE CVO+
132
withdrew
8
Lost to
follow-up
6
Incomplete
information at D0
21
Withdrew consent
252
PCR-negatives
985
Assessed for eligibility
N=591
Randomized
N=318
Analyzed
N=276
57.3%
Results

25. 25
Méthodes
• Baseline characteristics of patients
variables Placebo CVO+ CURATIVE p-value
Age median (IQR) 34.3 (27.3 – 43.2) 34.4 (28.8 – 42.0) 0.9a
gender
Male 76 (52.8) 79 (59.9)
0.2b
Female 68 (47.2) 53 (40.1)
Sex-ratio 1.1 1.4
Signes généraux
FR med (IQR) 19 (18 - 22) 19 (18 – 22) 0.4a
FC med (IQR) 78 (70 – 89) 78 (69 – 87) 0.6a
TAS med (IQR) 110 (100 – 120) 110 (100 – 120) 0.3c
TAD med (IQR) 70 (60 – 80) 70 (60 – 80) 0.2c
Results
a: Wilcoxon test (Mann-Whitney)
b: Chi2 test
c: Student test
Patients features

26. 26
Patients features
Méthodes
variables
Placebo
n (%)
CVO+ CURATIF
n (%)
p-valuea
Dyspnea 8 (5.6) 10 (7.6) 0.4
fever 29 (20.1) 31 (23.5) 0.5
cough 70 (48.6) 50 (37.9) 0.07
Asthenia 67 (46.5) 53 (40.1) 0.2
Aching 42 (29.8) 41 (31.0) 0.7
Odynophagia 9 (6.2) 5 (3.8) 0.3
Chest pain 21 (14.6) 25 (18.9) 0.3
Diarrhea 12 (8.3) 14 (10.6) 0.5
Agueusia 37 (25.7) 21 (15.9) 0.04
Anosmia 59 (40.9) 43 (32.6) 0.1
Résultats
a: Chi2 test
• Initial vital signs (D0)

27. 27
Méthodes
variables Placebo
Median (IQR)
CVO+ CURATIVE
Median (IQR)
p-valuea Référence values
Hematology
Leukocytes 3.0 (2.1 – 3.7) 3.1 (1.6 – 3.9) 0.9 2.0 – 7.5 g/L
Lymphocyte 1.8 (1.5 – 2.3) 1.8 (1.3 – 2.3) 0.6 1.0 – 4.8 g/L
ESR 21 (10 – 33) 12 (4.5 – 28.5) 0.2 <10 mm
Liver function
AST 40 (32 – 52) 41 (35 – 52) 0.4 < 40 U/L
ALT 24.5 (17 – 41) 25 (16 – 35) 0.8 < 40 U/L
Renal function
Creatinine levels 71 (63 – 81)
90.5 (83.5 – 101.5)
78 (69 – 89)
94 (82 – 106)
0.06
0.4
Female 44-105 µmol/L
Male 53-115 µmol/L
blood sugar levels 5.1 (4.7 – 5.9) 5.1 (4.6 – 5.5) 0.2 4.10 – 5.90 mmol/L
Résultats
a: Wilcoxon test (Mann-Whitney)
Patients features
• Initial laboratory data

28. 28
Therapeutic efficacy
Méthodes
• Therapeutic efficacy « End-point analysis »
group
Success Failure Total
p-value*
n (%) 95% CI n (%) N (%)
Placebo 108 (75.0) 67.8 – 82.1 36 (25.0)
144
(100.0)
0.011
CVO+
CURATIVE
115 (87.1) 81.3 - 92.9 17 (12.9)
132
(100.0)
Global 223 (80.8) 77.1 – 86.2 53 (19.2)
276
(100.0)
* chi2 test
Significant difference between Placebo and CVO+ CURATIVE, with p= 0.011 and with
RR 2.25, the chance of recovery is 2.25 times higher with CVO+ CURATIVE versus
Placebo
Relative Risk [CI à 95% ] = 2.25 [1.19 – 4.24] , p=0.001
Results

29. 29
Méthodes
• Therapeutic efficacy per follow-up day
Results
N
Placebo
n (%)
CVO+ CURATIF
n (%)
p-value* Risk difference
Recover Total recover Total M-H; [95% CI]
D7 253 84 (65.1) 129 82 (66.1) 124 0.865 -0.01 [-0.12; 0.10]
D14 255 95 (73.6) 129 116 (92.1) 126 <0.001 -0.18 [-0.27 ; -0.09]
D21 233 94 (77.7) 121 99 (88.4) 112 0.030 -0.10 [-0.20; -0.01]
D28 227 94 (79.6) 118 98 (89.9) 109 0.033 - 0.10 [-0.19 ; -0.01]
At D14 there were 18 more times ( p<0.001) successes in the CVO
plus curative group versus the placebo group ...
Therapeutic efficacy

30. 30
Survival analysis
Méthodes
• Kaplan-Meier estimator
N Median
Placebo 144 21
CVO+ CURATIF 132 14
Global 276 14
• Recovery time
Results
CVO+ CURATIVE: rapid recovery rate compared to placebo; 70.45%
of patients recovered by day 14

31. 31
Serious adverse events
• Therapeutic faliure : withdrew by medical decision
Withdrew by
medical
decision
YES
n (%)
No
n (%)
Total
Placebo 8 (5.6) 136 (94.4) 144 (100)
CVO+
CURATIF
6 (4.6) 126 (95.4) 132 (100)
Global 14 (5.1) 262 (94.9) 276 (100)
• incessant vomiting at D4
• onset of dyspnea at day 3
• introduction of other treatment and azythromycin at
day 9
• prescription of dexamethasone at D3 because of
increased clinical signs
• discontinuation of treatment for cardiac
complications
• discontinuation of treatment for dyspnea at D7
• Occurrence of severe form at D6 of treatment
• Occurrence of cardiac complications
• discontinuation of treatment at D9 because of BBC)
Results
Fisher test, p-value= 0.7
• Hospitalized at D3 because 25% of the lungs were
affected.
• Hospitalized at D4 at CTC Alarobia for dyspnea
• Hospitalized at D2 at CHU Anosiala for asthenia
• Hospitalized at D2 at CHU Anosiala for dyspnea
• Less hospitalization in CVO+ CURATIVE arm
• No significant difference between the 2 groups
• No deaths during the trial

32. 32
Clinical tolerance
Méthodes
• Proportion of Adverse Events
Results
0
2
4
6
8
10
12
14
16
18
Placebo CVO+
curatif
Placebo CVO+
curatif
Placebo CVO+
curatif
Placebo CVO+
curatif
D7 D14 D21 D28
Somatic
Pulmonary
Neurological
Muscular
Digestive
Cutaneous
Cardiac
Deterioration of general condition

33. 33
Méthodes
• Adverse events at D7
AE
Placebo
n (%)
CVO+
CURATIVE
n (%)
Total
n (%)
DGC 1 (0,7) 1 (0,4)
Cardiac 1 (0,8) 1 (0,4)
Cutaneous 3 (2,1) 3 (1,1)
Digestive 5 (3,5) 9 (6,8) 14 (5,1)
Muscular
Neurological 5 (3,5) 7 (5,3) 12 (4,3)
Pulmonary
Somatic
Total AE 14 (9,7) 17 (12,9) 31 (11,2)
N 144 (100) 132 (100) 276 (100)
• vomiting
• Epigastralgia
• Pruritus and hives
• tingling of the hands
• dizziness
• agueusia
• nausea + vomiting + abdominal pain asthenia
(GDC)
• pruritic skin rash
• diarrhea
• fluid diarrhea
• GERD
• tinnitus
• headache
• abdominal pain
• Bitter sensation in the mouth
• Precordialgia
Results
Clinical tolerance

34. 34
Méthodes
• Adverse events at D14
AE
Placebo
n (%)
CVO+
CURATIF
n (%)
Total
n (%)
DGC
Cardiac
Cutaneous 5 (3,5) 3 (2,3) 8 (2,9)
Digestive 6 (4,2) 1 (0,8) 7 (2,5)
Muscular
Neurological 2 (1,5) 12 (4,3)
Pulmonary
Somatic 1 (0,8) 1 (0,4)
Total AE 11 (7,6) 7 (5,3) 18 (6,5)
N 144 (100) 132 (100) 276 (100)
• Insomnia in the 2nd half of the night
• pruritus of the face
• feeling of heat for about 2 hours a day relief
after taking water
• nausea
• pruritus
• GERD
• pruritus of the throat
• perineal pruritus
• epigastralgia
• Hair loss
• Headache
• thirst
Results
Clinical tolerance

35. 35
Méthodes
• Adverse events at D14
AE
Placebo
n (%)
CVO+
CURATIVE
n (%)
Total
n (%)
DGC
Cardiac
Cutaneous 2 (1,4) 2 (0,7)
Digestive 3 (2,1) 1 (0,8) 4 (1,4)
Muscular 2 (1,4) 2 (0,7)
Neurological 3 (2,1) 3 (1,1)
Pulmonary 2 (1,4) 1 (0,8) 3 (1,1)
Somatic
Total 12 (8,3) 2 (1,5) 14 (5,1)
N 144 (100) 132 (100) 276 (100)
• Short nocturnal dyspnea
• Permanent dizziness
• nocturnal chest pain
• facial pruritus
• paresthesia of the extremities of the upper limbs
• cramp and muscular contracture in the hands and
feet (trousseau’s sign)
• pain in the right arm
• vertigo
• pain in the left breast like burning, exacerbated
by touch
• Epigastralgia
• GERD
• Diarrhea
• transient chest pain
Results
Clinical tolerance

36. 36
Méthodes
• Adverse events at D28
AE
Placebo
n (%)
CVO+
CURATIVE
n (%)
Total
n (%)
DGC
Cardiac
Cutaneous 1 (0,7) 1 (0,4)
Digestive 4 (2,8) 1 (0,8) 5 (1,8)
Muscular 1 (0,8) 1 (0,4)
Neurological 1 (0,8) 1 (0,4)
Pulmonary 1 (0,8) 1 (0,4)
Somatic
Total 5 (3,5) 4 (3,0) 9 (3,3)
N 144 (100) 132 (100) 276 (100)
• chest pain with discontinuous compression
• vertigo for half a day
• sudden internal lumbago
• pruritus of the face
• Sore throat
• liquid diarrhea for 2 days
• Epigastralgia
• dry throat
• paresthesia of the left hemisphere
• tinnitus
Results
Clinical tolerance

37. 37
Evolution of biological parameters
Méthodes
• Hematology: evolution of Leukocytes and Lymphocytes
Results
Leukocytes Lymphocytes
Reference values : 2.0 – 7.5 g/L Reference values : 1.0 – 4.8 g/L

38. 38
Méthodes
• Hematology: evolution of the ESR levels
Results
ESR
Reference values : <10 mm
Evolution of biological parameters

39. 39
Méthodes
• Liver function: evolution of AST and ALT levels
Results
AST ALT
Reference values : <40 U/L
Evolution of biological parameters

40. 40
Méthodes
• Renal function: evolution of creatinine levels
Results
Male Female
Reference values : 53-115 µmol/L Reference values : 44-105 µmol/L
Evolution of biological parameters

41. 41
Méthodes
• Evolution of blood sugar levels
Results
Blood sugar levels
Reference values : 4.10 – 5.90 mmol/L
Evolution of biological parameters

42. • Efficacy of CVO PLUS CURATIVE in the treatment of non severe Covid-19 patient is
87.1% (CI : 95%: 81.3% - 92.9%) and 70.45% of them were cured by day 14.
• No patient treated with CVO PLUS CURATIVE progressed to the severe form
• All patients had preserved liver, kidney and metabolic functions.
42
Conclusion
Méthodes

43. • Ratsimbasoa Arsène : Faculty of Medicine University of Fianarantsoa
• Tehindrazanarivelo Alain Djacoba : World Health Organization
• Razafindrabe Falihery : World Health Organization
• Rakotoarivelo Rivo : Faculty of Medicine University of Fianarantsoa
• Randriamanantany Zely : Faculty of Medicine University of
Fianarantsoa
• Rakoto Fanomezantsoa : Military Hospital
• Rapelanoro Rabenja : Faculty of Medicine University of Antananarivo
43
Scientific review comitee
Team

44. • Rakoto Alson Olivat : Faculty of Medicine University of Antananarivo
• Rakotosaona Rianasoambolanoro : Centre National d’Application de
Recherches Pharmaceutiques
44
Principal investigators
Team

45. • Ravelo Arsène : Institut National de la Statistique
• Mioramalala Sedera : Centre National d’Application de Recherches
Pharmaceutiques
• Franchard Thierry : World Health Organization
• Mavuto Mukaka : Centre for Tropical Medicine and Global Health,
Oxford, UK
45
Data analysis
Team

46. Co-investigateurs:
MIORAMALALA Sedera
RAKOTONDRANDRIANA Antsa
MAMINIAINA Fridolin
RAKOTOARISOA Malala Arinomenjanahary
RANDRIANARIVO Emmanuel
RAZAFIMANDIMBY Dominique
RAHANTAMALALA Mirana
46
investigators
Team

47. Thank you!
47