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, launched the first-ever double-blind, randomized clinical trial for eumycetoma treatment. The trial studied 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, both in combination with surgery at 6 months. The results presented at ECTMIH in November 2023 showed that fosravuconazole is safe, patient-friendly, and effective in treating mycetoma.

Fosravuconazole is also being evaluated by DNDi for Chagas disease.

Project updates

2023

The long-term follow-up study was completed in 2023. The results of the Phase II clinical trial were presented at the 13th European Congress on Tropical Medicine and International Health (ECTMIH), held in November 2023 in Utrecht, Netherlands. The clinical study report was finalized and a publication of the final results is under preparation.

2022

The database lock for the Phase II clinical trial was conducted in March 2022. The top-line results were presented at the 21st Congress of the International Society for Human and Animal Mycology (ISHAM), held in September 2022 in New Delhi, India. The clinical study report is under review and expected to be finalized in early 2023.

To determine the long-term post-treatment recurrence of eumycetoma, an observational study has begun at the Mycetoma Research Center in Khartoum, Sudan. It will follow patients who did not have a recurrence by the end of the Phase II clinical trial.

 

2021

Although challenged by the COVID-19 pandemic which resulted in a country-wide lockdown in Sudan, patient follow-up continued in 2021. The study was reviewed by the data and safety monitoring board in late 2021, and it was decided that the study could be stopped, and the results analysed in early 2022. A strategy was developed to register fosravuconazole in Sudan, initially on a compassionate or conditional basis in advance of full registration. In addition, an access strategy is under development.     

2020

By March 2020, 104 patients had been enrolled in the study, but the target was to enrol 165 patients by the end of the year. 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.