Treating eumycetoma (fungal mycetoma) is a challenge. The antifungals ketoconazole and itraconazole are currently the only therapies available, but they are expensive, not very effective, and have serious side effects. People with eumycetoma must often undergo multiple amputations, which sometimes result in death. Safe, effective antifungal treatments for eumycetoma that are appropriate for use in rural settings are urgently needed.

Fosravuconazole, an orally bioavailable azole developed for onychomycosis by Eisai Ltd (Japan), could be an effective and affordable treatment for eumycetoma. Its pharmacokinetic properties are favourable, and its toxicity is low. Fosravuconazole, a prodrug, is rapidly converted to ravuconazole, which has been shown to have potent in vitro activity against one of the causative agents of eumycetoma, M. mycetomatis.

In 2017, the Mycetoma Research Centre (MRC), a WHO Collaborating Centre in Khartoum, Sudan, began enrolling patients in the first-ever double-blind, randomized clinical trial for eumycetoma treatment. The trial is studying the efficacy of treating moderate-sized lesions with a weekly dose of fosravuconazole over a period of 12 months, compared to daily treatment with itraconazole, the current standard of care.

Fosravuconazole is also being evaluated by DNDi for Chagas disease.

Project updates

2020

By the end of 2020, 104 patients had been enrolled in the study, but the target was to enrol 165 patients by that time. Recruitment was put on hold while a second interim analysis is prepared. After this analysis is completed in mid-2021, the clinical trial may be terminated or may progress until full completion of the recruitment is concluded in 2022. Discussions with regulatory authorities in Sudan to obtain conditional approval for compassionate use of the drug will also begin in 2021.

2019

The first-ever double-blind study to determine whether the new chemical entity fosravuconazole could be an effective and affordable treatment for eumycetoma is ongoing. By January 2020, 101 patients had been enrolled in the study, which should reach the targeted enrollment of 165 patients by the end of 2020. A Data and Safety Monitoring Board (DSMB) meeting was held in 2019 after the study reached the threshold for interim analysis (84 participants). The DSMB reviewed study data and decided to continue with all three treatment arms (200 mg vs 300 mg of fosravuconazole weekly vs daily itraconazole).

2018

Following slower than anticipated recruitment, a protocol review and amendment was conducted in 2018 to extend the inclusion criteria in relation to lesion size and site, and age range of participants. By January 2019, 84 patients had been enrolled, reaching the threshold for interim analysis. This analysis will determine which of two treatment arms will be retained for the remainder of the trial (200mg vs 300mg of fosravuconazole weekly).

2017

After receiving regulatory and ethical approval in March 2017, the Mycetoma Research Centre, a WHO Collaborating Centre, began recruiting patients into the first-ever double-blind, randomized Phase II/III clinical trial for eumycetoma. The clinical trial, which plans to recruit 138 patients, evaluates the efficacy of the anti-fungal fosravuconazole in moderate lesions in comparison with the current treatment, itraconazole.

The primary objective of this single-centre study conducted in Sudan is to demonstrate the superiority of fosravuconazole over itraconazole after 12 months’ treatment. By the end of 2017, 20 patients had been enrolled into the trial, a pace of enrolment that was slower than anticipated. In 2018, a satellite site will be established to screen more patients and refer them for treatment and care.

2016

Protocols of the phase II/III aiming at assessing the comparative efficacy, safety, and tolerability of fosravuconazole in patients with eumycetoma caused by Madurella mycetomatis were finalized in 2016 and recruitment of patients (with a target of 136 participants) should start early 2017. An interim analysis will be conducted at three months.

2015

DNDi is currently preparing for a Phase II/III randomized controlled trial that will be conducted with the WHO Collaborating Centre on Mycetoma in Khartoum to study the efficacy of fosravuconazole in moderate lesions in comparison with the current treatment, itraconazole. The primary objective of this double-blind, randomized, single-centre study will be to demonstrate superiority of fosravuconazole over itraconazole after 12 months’ treatment in patients with eumycetoma caused by Madurella mycetomatis.