1. Novel use Of Hydroxyurea in an African Region with Malaria (NOHARM) A Randomized Double-Blinded Placebo-Controlled Trial for Children with Sickle Cell Anemia (Makerere University-University of Minnesota Collaboration) Principal Investigators: Chandy C. John and Christopher Ndugwa Co-investigators: Robert Opoka, Phillip Kasirye, Heather Hume, Russell Ware

2. Sickle cell anemia (SCA) and malaria burden Sickle cell anemia : Approx. 300,000 neonates are born with SCA annually; > 75% of them from sub-Saharan Africa 1 SCA accounts for at least 6.4% of U5M in Africa 2 and 16% in Uganda, Estimated 70-80% of children die before their 5 th birthday 3 Malaria: Caused 627,000 malaria deaths, 77% of them being U5 in Africa 4 (WHO report) Sickle cell trait (HbAS) offers some protection against malaria BUT HbSS & those with normal Hb have increased mortality if they develop malaria 5 Rees DC, Williams TN, Gladwin MT. Sickle-cell disease. Lancet. 2010;376(9757):2018-2031

3. Hydroxyurea (HU) use in SCA Several studies have shown that HU prevents acute painful episodes and reduces the need for blood transfusions in SCA by increasing production of nitric oxide (NO) and HbF, however, there are no studies on hydroxyurea’s toxicities in a malaria endemic area NO & HbF have been shown to offer protection against malaria But HU may also affect factors implicated in the pathogenesis of severe malaria (e.g. ICAM-1, TNF-α and VCAM-1) -Some studies show that hydroxyurea increases ICAM-1 and TNF-α -Other studies show that hydroxyurea has no effect on ICAM-1 and TNF-α

4. Equipoise regarding the effect of HU on ICAM-1 and TNF-α

5. History of hydroxyurea (HU) 1984, U.S.A. Platt et al.: HU increases HbF in SCA 1995, U.S.A. & Canada MSH: HU decreases pain, acute chest, and transfusion in adults with SCA 1869, Germany Hydroxyurea (HU) synthesized 1967, U.S.A. FDA approves HU for treatment of neoplastic diseases 1998, U.S.A. FDA approves HU for use in adults with SCA 1999, U.S.A. HUG-KIDS: HU is safe for children, no adverse effects on growth 2001, U.S.A. HUSOFT: HU therapy for infants is feasible, may delay functional asplenia and maintains high HbF levels 2011, U.S.A. BABY-HUG: HU decreases pain, hospitalizations, transfusions in infants & young children 2003, Europe EMA gives HU orphan drug designation for use in adults, adolescents and children over 2 yrs old with SCA 2014, Uganda NOHARM study…

6. Problem statement and study justification If ICAM-1 and TNF-α are increased by HU, children in malaria endemic areas who receive HU could be at increased risk of severe malaria (and death) This risk may outweigh any benefit HU provides in terms of decreasing pain and the need for transfusions A randomized, placebo-controlled trial is the only way to accurately determine the safety of HU in children with SCA in a malaria endemic region If found safe this could transform therapy for children with SCA throughout sub-Saharan Africa

7. NOHARM Study question: Is hydroxyurea safe and efficacious for children with SCA living in malaria-endemic regions of the world? Study site: Mulago Hospital Sickle Cell Clinic, Kampala

8. NOHARM: Specific aims 1.Determine the incidence of malaria in children with SCA treated with HU vs. placebo 2.Establish the frequency of hematologic toxicities and adverse events in children with SCA treated with HU vs. placebo 3.Define the relationship between HU treatment and: a) HbF, soluble ICAM-1 (sICAM-1) and nitric oxide (NO) levels, b) between levels of these factors and risk of subsequent malaria. (changes in the concentration of VCAM, VWF and TNF-α will also be studied)

9. NOHARM: Study design Randomized double-blinded placebo-controlled trial N= 200 (HbSS patients aged 1-3.99 years) N=100 Hydroxyurea N=100 Placebo 12 months study treatment & scheduled evaluations Evaluation of study endpoints 12 months open label & follow-up Block randomization and consecutive enrollment after obtaining consent and eligibility screening If hydroxyurea is found to be beneficial, all participants will be offered one additional year of free hydroxyurea treatment, donated by Addmedica. We will work with the Ministry of Health, Addmedica and other partners to find ways to make subsidized hydroxyurea treatment available to all children with SCA who would benefit from its treatment. 1.Incidence of malaria 2.Frequency of hematologic toxicities and adverse events 3.Change in factors and subsequent risk of malaria

10. NOHARM: Study design Inclusion criteria: 1. Documented sickle cell anemia 2.Age range of 1.00-3.99 years, inclusive, at the time of enrollment 3.Weight at least 5.0 kg at the time of enrollment 4.Willingness to comply with all study-related treatments, evaluations, and follow-up Exclusion criteria: 1.Active use of hydroxyurea on a regular basis 2.Known chronic medical condition eg. HIV 3.Severe malnutrition 4.Pre-existing severe hematological toxicity 5.ALT or creatinine >2X the upper limit of normal for age 6.Blood transfusion within 30 days of enrollment

11. NOHARM: Schedule of evaluations

12. Assessments and study treatment continued Participants to continue receiving routine care at the clinic ( Folic acid, Penicillin prophylaxis, Sulfadoxine/ Primethamine prophylaxis, deworming, pain treatment and rehydration) Bednets & pneumococcal vaccine offered for those without Scheduled visits include: – Every 2 weeks until Month 1, then monthly until Month 4 – Every 2 months until Month 12 & at Months 18, 24 Parents of children in the study are asked to bring their child back to Mulago Hospital for any illness at any time ( sick visits) Acute illnesses managed by Mulago hospital team

13. NOHARM: Projected timeline May 2014May 2015May 2016May 2017July 2017Dec 2017 Begin enrollment Complete enrollment First set of participants completes the study (12 months of randomized treatment and 12 months of open label treatment) Last set of participants completes the study (12 months of randomized treatment and 12 moths of open label treatment) Database lock Study results published

14. Current status (Aug 2015) Enrolment left with 10 participants, to be completed by end of August 1 st participant completes 1 year on Sept. 14, 2015 Sixty (60) patients reached 6 months follow up We have had a DSMB sitting and positive comments made to continue with the study 3 participants with drawn and One death ( acute watery diarrhea & vomiting with dehydration-died in acute care unit

15. Thank you