TOGETHER Trial

TOGETHER Trial

About

Overview

Can we use existing medications to treat people with early diagnosed COVID-19?

The TOGETHER trial is the result of a partnership between health researchers in Brazil and Canada. As the result of the COVID-19 pandemic and the serious implications for people living in low and medium-income countries, a partnership was rapidly formed to find affordable and effective treatments from existing medications already used to treat other health conditions, with the aim of saving lives.

The TOGETHER Trial consists of 22 sites across Brazil, where patients are being treated with a range of potential new COVID-19 therapeutic agents. The aim is to give these potential therapies at the early stages of infection, in order to prevent more serious complications or death. All of these 22 trial sites share and compare their data to generate more statistically meaningful results. The trial has now expanded to South Africa led by Francois Venter, Pakistan led by Zulfiquar Bhutta, and Rwanda led by Sabin Nsanzimana.

Another exciting element of the TOGETHER Trial is our ability to scan the global research frontier and look for evidence emerging from similar studies. Our adaptive platform design allows us to incorporate relevant data from other research studies, along with our own results, to yield more meaningful findings overall.

Data emerging from our clinical trials is reviewed regularly, so that those treatments showing to be useful can be used to treat patients early on. This will give health professionals more options to support people with COVID-19 and improve health outcomes.

The development of effective vaccines against the COVID-19 virus holds tremendous potential to slow and eventually halt this pandemic altogether. Unfortunately, access to vaccines in low and middle-income countries is a challenge, and people are suffering as a consequence. This reality makes the need for effective treatments in the early stages of infection all the more important.

An international research collaboration.

The TOGETHER Trial represents a truly international collaboration in response to an unprecedented pandemic in modern times. As a multination institutional partnership, resources and expertise from all countries working in the TOGETHER network are being brought to bear in order to identify new potential uses of existing medications, which can be re-purposed to prevent COVID-19 related morbidity and mortality.

This international trial is financially supported by private sector philanthropic agencies, which have dedicated financial resources to the fight against COVID-19 in low and middle-income countries.

All Regions
  • All Regions
  • Bahamas
  • Brazil
  • Democratic Republic of Congo
  • Rwanda
  • South Africa
  • USA, Florida Area
  • All Regions
  • Bahamas
  • Brazil
  • Democratic Republic of Congo
  • Rwanda
  • South Africa
  • USA, Florida Area

All Regions

XX

Sites

XX

Population

XX

Enrolled Participants

All Regions
All Regions
Bahamas
Brazil
Congo
Florida
Hungary
Israel
Mongolia
New South Wales
Ontario
Pakistan
Romania
Rwanda
South Africa
Vietnam

All Regions

0

Sites

0

Population

0

Enrolled Participants

Bahamas

1

Sites

270000

Population

0

Enrolled Participants

Brazil

22

Sites

8000000

Population

25000

Enrolled Participants

Congo

14

Sites

55000000

Population

0

Enrolled Participants

Florida

1

Sites

21000000

Population

0

Enrolled Participants

Hungary

1

Sites

9000000

Population

0

Enrolled Participants

Israel

2

Sites

9000000

Population

0

Enrolled Participants

Mongolia

1

Sites

3000000

Population

0

Enrolled Participants

New South Wales

2

Sites

8000000

Population

0

Enrolled Participants

Ontario

1

Sites

14600000

Population

0

Enrolled Participants

Pakistan

25

Sites

200000000

Population

0

Enrolled Participants

Romania

1

Sites

19000000

Population

0

Enrolled Participants

Rwanda

6

Sites

4000000

Population

0

Enrolled Participants

South Africa

18

Sites

16000000

Population

0

Enrolled Participants

Vietnam

1

Sites

8000000

Population

0

Enrolled Participants

Innovative research methods for real-life challenges.

Clinical trials are rooted in rigorous research, which involve strict controls and repeated measurements. Not surprisingly, this takes time and money, and rightfully so, given the risks.

Typically, health research involves people being assigned to either experimental groups, where they receive the treatment under investigation, or control groups where they do not. By observing how hundreds, or even thousands of people respond to the experimental therapy, when compared to those who do not receive it, conclusions are drawn about safety and effectiveness.

The TOGETHER Trial is using a new type of research strategy, called adaptive platform trials. Adaptive platform trials are an effective research strategy when investigating multiple treatments for the same condition, such as COVID-19. Some of the features of adaptive platform trials that make it unique include:

  • Reviewing data as it emerges from the study in real-time, rather than waiting until the end of the trial.
  • Responding to emerging trial data sooner, which allows investigators to make the trial safer for participants.
  • Adaptive platform trials are able to test multiple treatments against a condition at the same time, and using only one control group.
  • Trials for specific treatments can be stopped sooner, if the data suggests that they are not working, or working very well. This saves both valuable time and money.

These efficiencies lead to the faster development and approval of new treatments, especially when every single day matters.

The TOGETHER Trials have received research ethics approval in both Brazil (CEP/CONEP#: 41174620.0.1001.5120) and in Canada (HiREB#: 13390). An independent data and safety monitoring committee is providing ongoing oversight of our work.

Sponsors

McMaster University

PUC Minas

Partners

Cytel

uOttawa

UFOP

Cardiolab

Funders

Fast Grants

Rainwater

Unitaid

FTX Foundation

Investigators

Dr. Ed Mills

Co-principle Investigator
Professor, Health Research Methods, Evidence, and Impact, McMaster University

Dr. Gilmar Reis

Co-principal Investigator
Associate Professor, Division of Medicine, Pontifica Universidade Catòlica de Minas Gerais

Dr. Gordon Guyatt

Senior Investigator
Distinguished Professor, Health Research Methods, Evidence and Impact, McMaster University

Dr. Lehana Thabane

Senior Investigator
Professor, Health Research Methods, Evidence and Impact, McMaster University. President-elect, Society for Clinical Trials (SCT)

Dr. Craig Rayner

Senior Investigator
Associate Professor, Monash University. President, Integrated Drug Development, Certara Inc

Dr. David Boulware

Senior Investigator
Professor, Medicine, Microbiology and immunology, Stanford University

Dr. Jeffrey Glenn

Senior Investigator
Professor, Medicine, Microbiology and immunology, Stanford University

Dr. Francois Venter

Senior Investigator
Professor, Divisional Director of Ezintsha at the University of the Witwatersrand, Johannesburg

Dr. Zulfiqar Bhutta

Senior Investigator
Professor, Department of Nutritional Sciences and the Division of Epidemiology, University of Toronto

Dr. Mark Dybul

Senior Investigator
Professor, Department of Medicine at the Medical Center, Georgetown University

Dr. Sabin Nsanzimana

Senior Investigator
Director General of The University Teaching Hospital of Butare

Specifications

Summary

The TOGETHER Clinical Trial was initiated in June of 2020, as an international collaboration in response to the worsening pandemic of SARS-CoV-2 / COVID-19. Utilizing an adaptive platform trial design, the international researchers and teams in Brazil, Canada, Australia, and the United States sought to identify evidence-informed therapeutics, through the re-purposing of existing medications.

The randomized adaptive platform trial aims to investigate the efficacy of repurposed treatments for COVID-19 disease among high-risk adult outpatients. Currently, there are 22 identified research sites in Brazil, and over 6,000 research participants.

Clinical Trials

As of the most recent update, the TOGETHER Trial has concluded investigations on five medications (hydroxychloroquine, lopinavir / ritonavir, ivermectin, fluvoxamine maleate, and metformin), and two investigations (doxazosin and Peginterferon Lambda) are continuing (see Table 1). A summary of the progression of clinical trials is presented in Figure 1.

Recruitment for the Trial began in 2020 and has been ongoing to present day. Eligible patients are randomized with equal chance to an investigational product (IP) or to placebo. Patients are included if they are:

  • 18 years of age
  • have a positive antigen test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
  • have an indication for high risk of disease severity, including co-morbidities, older age, or high body mass index.

Research Sites

The 22 clinical research sites are located in the southeast Brazilian State of Minas Gerais, and include the following locations:

  • Sete Lagoas
  • Ibirité
  • Brumadinho
  • Governador Valadares
  • Montes Claros
  • Nova Lima
  • Santa Luzia
  • Ouro Preto
  • Belo Horizonte
  • Betim
  • Odilon Behrens

Investigational Products

Hydroxychloroquine
Doxazosin
Lopinavir/Ritonavir
Fluvoxamine Maleate
Ivermectin – High Dose
Ivermectin – Low Dose
Metformin
Peginterferon Lambda
Fluvoxamine + Inhaled Budesonide
Hydroxychloroquine
Doxazosin
Lopinavir/Ritonavir
Fluvoxamine Maleate
Ivermectin – High Dose
Ivermectin – Low Dose
Metformin
Peginterferon Lambda
Fluvoxamine + Inhaled Budesonide

Hydroxychloroquine

Dosage
800 mg loading dose, then 400 mg daily for 9 days
Endpoint
COVID-19–associated hospitalization and death at 90 days after randomization
Patients Recruited
214 participants were randomized
Result
Trial was stopped at first interim analysis for futility, as no significant differences were found between intervention and placebo

Doxazosin

Dosage
progressive dosing based on systolic blood pressure <120mmHg. 0.5 tablet on Day 1-2, 1 tablet pn Day 3-4, 2 tablets Day 8-10, 4 tablets on day 11-14
Endpoint
Hospitalization
Patients Recruited
291
Result
Intervention arm was stopped due to concerns about patient safety.

Lopinavir/Ritonavir

Dosage
Loading dose of 800 mg and 200 mg, respectively, every 12 hours followed by 400 mg and 100 mg, respectively, every 12 hours for the next 9 days
Endpoint
COVID-19–associated hospitalization and death at 90 days after randomization
Patients Recruited
244 participants were randomized
Result
This intervention was stopped at first interim analysis for futility

Fluvoxamine Maleate

Dosage
100 mg twice daily for 10 days
Endpoint
Hospitalisation defined as either retention in a COVID-19 emergency setting or transfer to tertiary hospital due to COVID-19 up to 28 days post-random assignment
Patients Recruited
741 patients were randomized
Result
Found participants in the fluvoxamine arm to have a 32% reduced risk of hospitalization

Ivermectin – High Dose

Dosage
400 μg per kilogram of body weight for 3 days
Endpoint
Hospitalization defined as either retention in a COVID-19 emergency setting for > 6 h or transfer to tertiary hospital due to COVID-19 at 28 days post randomization
Patients Recruited
679 patients randomized
Result
There was no significant effects of ivermectin use compared to placebo

Ivermectin – Low Dose

Dosage
400 μg per kilogram of body weight for 1 day
Endpoint
Hospitalization defined as either retention in a COVID-19 emergency setting for > 6 h or transfer to tertiary hospital due to COVID-19 at 28 days post randomization.
Patients Recruited
77 patients recruited
Result
Originally our ivermectin arm was designed for a one-day dose until feedback from advocacy groups had us increase our dosage

Metformin

Dosage
750 mg twice daily for 10 days or placebo, twice daily for 10 days
Endpoint
primary outcome was hospitalization defined as either retention in a COVID-19 emergency setting for > 6 h or transfer to tertiary hospital due to COVID-19 at 28 days post randomization
Patients Recruited
215 participants randomized
Result
Intervention arm was stopped early due to futility, as there was no significant difference between metformin and placebo

Peginterferon Lambda

Dosage
180mcg in 0.45mL, one subcutaneous injection of peginterferon lambda
Endpoint
Medical admission to hospital
Patients Recruited
931 participants recruited
Result
The risk of COVID-19–related hospitalization or retention in an emergency setting was reduced by 51% in the peginterferon lambda vs. placebo groups

Fluvoxamine + Inhaled Budesonide

Dosage
Fluvoxamine (100 mg twice daily for 10 days) plus inhaled budesonide (800 μg twice daily for 14 days
Endpoint
COVID-19 emergency setting retention or hospitalization from COVID-19 up to 28 days
Patients Recruited
743
Result
The combination of fluvoxamine and inhaled Budesonide reduced risk of hospitalization by 52%

Investigational Products

Table 1: Interventions investigated

Trial Schema

Services

Feasibility

We assessed individual sites for capabilities to perform the master protocol.
image-feasibility@3x

Master Protocol

We designed a master protocol to allow the easy addition and removal of new intervention arms.
image-master-protocol@3x

Recruitment

We operate in five continents and are able to recruit patients fast, with a high level of patient adherence and follow-up. We are connected to over 100 clinical sites that are linked to outpatient clinics, universities and academic centers.

Data Management

We use Veeva and distributed systems with automated workflows to optimize hybrid data collection, with best-in-class quality and digital infrastructure. Our global trials are designed to operate seamlessly with consistent and compliant data collection and reporting practices.

Analytic

We designed a Statistical Analysis Plan, completed analysis of all fully recruited evaluations and published findings of these results.
image-analytic@3x

Regulatory Affairs and Quality Assurance

Our global platform has worked successfully with local regulators on all aspects of clinical trials. Our collective team has a long and established history of working with many regulatory bodies around the world.

Trial

We successfully recruited over 6,000 patients across eleven intervention arms.
image-trial@3x

Trial Results

Hydroxychloroquine or Lopinavir / Ritonavir
RCT: Effect of Early Treatment with Hydroxychloroquine (HCQ) or Lopinavir / ritonavir (LPV / r) on Risk of Extended Emergency Care or Hospitalization Among Patients with COVID-19
Metformin
RCT: Effect of Early Treatment with Metformin on Risk of Emergency Care and Hospitalization Among Patients with COVID-19
Fluvoxamine
RCT: Effect of Early Treatment with Fluvoxamine on Risk of Emergency Care and Hospitalization Among Patients with COVID-19
Ivermectin
RCT: Effect of Early Treatment with Ivermectin on Risk of Emergency Care and Hospitalization Among Patients with COVID-19