Principal Investigator: Dr. Bharti R. Daswani
A Comparative Open Labeled Clinical Study to Evaluate the Efficacy and Tolerability ofTwo Different Intravaginal Formulations Containing a Combination of Clindamycin and Clotrimazolein Patients of Bacterial, Trichomonal, Candidial and Mixed Vaginal Infections
Principal Investigator: Dr. Bharti R. Daswani
Co-Investigators: Dr. PW Sambarey
Dr. BB Ghongane
Dr. Renu Bhardwaj
Dr. Shilpa Naik
Dr. Meghana Palewar
INTRODUCTION AND BACKGROUND KNOWLEDGE:
Vaginal discharge and associated vulval itching are the most common reasons for a woman to seek gynecological care.
It is estimated that approximately 80% of non-pregnancy, non-routine visits to a gynaecologist are prompted by the presence of a vaginal discharge.
Infections are involved in more than 90% of the cases coming to observation for vaginal irritation and discharge. Other, less frequent causes may be mechanical, chemical, or allergic reactions (e.g., to latex).
Furthermore, treatment success rates as low as 52% and recurrence rates 50% within 6-12 months are common.
Thus, vaginal infections represent a relatively benign disease that is associated with frequent recurrence and huge healthcare costs. Furthermore they are associated with Gynecologic complications like increased risk of HIV, recurrent cystitis, PID [including post-abortion and subclinical PID],cervicitis, postsurgical gynecologic infections and obstetric complications like early spontaneous abortion , preterm labor, premature rupture of membranes. Chorioamnionitis, higher risk of low-birth-weight infants, postpartum endometritis.
Hence, a timely diagnosis followed by appropriate treatment may well be more than cost-effective
CAUSATIVE ORGANISMS: Trichomonas vaginalis, a protozoan and a fungus, Candida albicans, are the micro-organisms frequently involved as causative agents, while bacterial vaginosis is a polymicrobial infection associated with dramatic increases in anaerobic bacteria (Prevotella spp, Peptostreptococcus spp, Mobiluncus spp, Bacteroides spp, Eubacterium spp) and facultative bacteria (Gardnerella vaginalis, Mycoplasma hominis, enterococcus, and group B streptococcus). Mixed infections are believed to occur in approximately 25% of cases.
Thus, the presenting symptoms may be similar, but different micro-organisms may be responsible for the infection. Hence, there are different therapeutic strategies that need to be adopted.
Current Treatment Recommendations
Bacterial Vaginosis
Metronidazole 500mg PO bid for 7 days
Clindamycin 300mg PO bid for 7 days
Metronidazole gel 0.75% bid per vagina for 5 days
Clindamycin cream 2% per vagina for 7 nights
Trichomonas
Metronidazole 2g PO, single dose
Metronidazole 500mg PO for 7 days
Clotrimazole single 500mg tablet or cream used once intravaginally at night, or 200mg suppository inserted intravaginally once daily at bedtime for 3 consecutive days or 100mg suppository inserted intravaginally once daily at bedtime for 6-7 consecutive days
Candida
Intravaginal imidazoles and triazoles like
Clotrimazole given as single 500mg tablet intravaginally at bed time or as 200mg tablet inserted intravaginally once daily at bedtime for 3 consecutive days) or 1% cream/ 100mg tablet used once intravaginally at night for 7 days
Fluconazole 150mg PO single dose[weekly for up to 12 consecutive weeks for recurrent infections]
Boric acid 600mg gelatin capsule per vagina bid for 10 days
Thus, appropriate treatment is based on diagnosis by routine staining methods, culture and sensitivity reports and molecular probes available. However, sensitivity of the routine methods is questionable as it is not 100% and if one selects molecular probes, the most accurate method for diagnosis, high costs and the expertise needed to run them routinely are a problem.
Therefore there is a need of treatment that covers all the common pathogens associated with vaginal infections.
Clotrimazole is an imidazole anti-fungal agent with broad spectrum action. It brings about its therapeutic effect by inhibiting ergosterol synthesis. Inhibition of ergosterol synthesis alters the permeability of the cell membrane of sensitive fungi and leads to structural and functional impairment of the cytoplasmic membrane. It is active against trichomonas and candida.
Clindamycin is an antibacterial that acts against both aerobic and anaerobic bacteria.
It is a derivative of the amino acidtrans-L-4-n-propylhygrinic acid, attached to a sulphur containing derivative of an octase. It is congener of lincomycin. Clindamycin binds exclusively to the 50S subunit of bacterial ribosomes and suppresses protein synthesis.
Thus, together clindamycin and clotrimazole act against candida, trichomonas and bacteria involved in the pathogenesis of vaginitis.
Hence, an intravaginal formulation that contains clindamycin and clotrimazole may be suitable for most cases of bacterial, trichomonal, candidial as well as mixedvaginitis.
Two different intravaginal formulations of such a combination of clindamycin and clotrimazole are available. One is a soft gelatin vaginal capsule that releases the drugs immediately, while the other is an extended release vaginal tablet containing clindamycin and clotrimazole as anovel mucoadhesive vaginal drug delivery system that swells in the presence of vaginal fluid to form a spongy, soft mass that adheres to the vaginal mucosa and releases the drugs over a period of 4-8hours. This novel design is claimed to overcome the drawbacks of conventional vaginal preparations such as unpredictable drug delivery, low residence time, leakage of liquid and messiness. Thus, the novel extended release tablet may provide sustained drug delivery giving greater effectiveness complemented with less side effects and less discomfort due to formation of non-abrasive, spongy, soft mass.
AIMS AND OBJECTIVES:
To compare the effectiveness of 3 day treatment with intravaginal soft gelatin capsule of clindamycin and clotrimazole versus intravaginal extended release [ER]tabletsof clindamycin and clotrimazolein patients of bacterial, trichomonal, candidial or mixed vaginitis with respect to clinical manifestations
To evaluate the effectiveness of 3 day treatment with intravaginal soft gelatin capsule of clindamycin and clotrimazole versus intravaginal ER tablets of clindamycin and clotrimazolein patients of bacterial, trichomonal, candidial or mixed vaginitis with respect to microbiological findings
To assess the tolerability of 3 day treatment with intravaginal soft gelatin capsule of clindamycin and clotrimazole versus intravaginal ER tablets of clindamycin and clotrimazolein patients of bacterial, trichomonal, candidial or mixed vaginitis
To study the in vitrodrug release pattern of intravaginal soft gelatin capsule and intravaginal ER tablets containing clindamycin and clotrimazole by HPLC analysis
Primary Endpoint:
Effectiveness of 3 day treatment with the combination of clindamycin and clotrimazole in inducing remission in patients with vaginal discharge and clinical diagnosis of bacterial, trichomonal, candidial, mixed vaginitis.
Secondary End points:
Effectiveness of 3 day treatment with the combination of clindamycin and clotrimazolein maintaining remission in patients with vaginal discharge and clinical diagnosis of bacterial, trichomonal, candidial, mixed vaginitis.
Tolerability of the 3 day treatment with the combination of clindamycin and clotrimazolein patients with vaginal discharge and clinical diagnosis of bacterial, trichomonal, candidial, mixed vaginitis.
SUBJECTS AND METHODS:
STUDY DESIGN:
This is a Randomized, Comparative, Prospective, Open label, single center study of efficacy and tolerability of two different intravaginalformulations containing a combination of clindamycin and clotrimazole in patients with vaginal discharge and clinical diagnosis of infective vaginitis [bacterial, trichomonal, candidial, mixed].
The study will be conducted by the Department of Gynaecology& Obstetrics, Department of Pharmacology, Department of Microbiology in, B.J. Medical College, and Sassoon General Hospitals, Pune. The study will be completed in 60 patients [30 patients in each group].
STUDY POPULATION:
Inclusion Criteria:
Women with symptoms of vaginal discharge and/or odor and a clinical diagnosis of vaginitis of infective origin [based on symptoms and signs on per speculum examination]
Age at least 18 years
Capable of giving written informed consent
Agree to no intercourse for 8 days from the day of start of treatment
Agree not to douche or use any intravaginal products during the study period (including tampons, medications and devices)
Exclusion Criteria:
Post-menopausal women
Menstruating at diagnosis
Pregnancy
Any antifungal or antibiotic use 14 days prior to enrolment
Use of oral or intravaginal antibiotics within the past 2 weeks
Immunosuppressive drug within 4 months
Presence of vaginal/ vulval ulcer
Presence of any other vulval, vaginal or medical condition, including cervical neoplasia/treatment that might confound treatment response
Inability to keep return appointments
History of hypersensitivity to clotrimazole, clindamycin or lincomycin
History of regional enteritis, ulcerative colitis or ‘antibiotic associated’ colitis
Significant disease or acute illness that in the Investigator's assessment could complicate the evaluation
Intrauterine Device
During the initial visit, the gynaecologist will take a history. After a speculum and manual pelvic examination the findings will be noted. Cases with vaginal discharge and clinical diagnosis of vaginitis of infective origin [bacterial, trichomonal, candidial, mixed] on the basis of symptoms and per speculum examination will be informed about the study, and will be given a handout explaining the study. If the woman is interested in participating, she will be given a consent form to sign. Subsequently 1 swab will be obtainedfrom high in the vagina for microbiological investigation. Per vaginal discharge will also be collected on microscopy slides for Whiff test and assessing its pH.
Whiff test will be performed by adding a small amount of10% potassium hydroxide to a microscopic slide containing the vaginal discharge.
pH of the discharge will be checked using a pH paper. A pH greater than 4.5 will be considered as alkaline.
The swab will be sent to the microbiology laboratory for microbiological diagnosis using
1)Wet mount [for presence of Trichomonas vaginalisand cluecells [epithelial cells that are coated with bacteria];
2)Quantification by culture on Sabourands medium [for Candida albicans]; and
3)Gram’s stain of smear [for Bacterial vaginosis]: The smear will be scored from Grade 1 - 3 by Hay/Ison criteria as follows:
Grade 1 (Normal): Lactobacillus morphotypes predominate.
Grade 2 (Intermediate): Mixed flora with some Lactobacilli present, but Gardnerella or Mobiluncus morphotypes also present.
Grade 3 (Bacterial Vaginosis): Predominantly Gardnerella and/or Mobiluncus morphotypes. Few or absent Lactobacilli. (Hay et al., 1994)
Drug Administration:
After baseline examination and swab collection, the eligible subjects will be randomized into 2 groups. Subjects belonging to Group A will receive intravaginal soft gelatin capsule of clindamycin and clotrimazole combination while subjects belonging to Group B will receive intravaginal extended release [ER] tablets of clindamycin and clotrimazole combination.
The first dose will be inserted by the gynaecologist as deep into the vagina as possible. The patient will be trained for insertion of the intravaginal formulation with hands thoroughly washed before insertion. This will be considered as Day 1 of the study. The procedure will be repeated by the patient for 2 consecutive days [Day 2 and Day 3 of the study].The patient will be asked to refrain from any activity such as standing, walking, running etc. for at least 4 hoursafter insertion of either of the 2 intravaginal formulations, and abstain from sexual intercoursefor 8 days following initiation of drug administration [i.e.Day1 to Day 8].
Follow-up:
The patients will be reassessed once on the 8thday after start of the 3 day course of drug administration [follow-up visit 1] for evaluating the success of treatment and again on the 29thday after the start of drug therapy [follow-up visit 2] for studying recurrence. A flexibility of + or - 7 days will be permissible for the second follow-up visit in case the patient is unable to report for follow up on the 29th day after the start of drug therapy.
At each of these visits the patient will be enquired for presence or absence of symptoms of vaginitis. She will undergo per speculum examination and findings will be noted. Again 1 swab will be obtainedfrom high in the vaginafor microbiological examination and vaginal discharge will be collected on microscopy slides for whiff test and pH assessmentas above.
At each visit, the patients will also be asked to fill in details of the subjective evaluation head of the Case Record Form which includes questions related to vaginal discharge, itching and tolerability of the test formulation (side-effect profile) [Vide Case Record Form: Section on “Subjects’ assessment of the test formulation”].
Primary Outcome Measures:
Effectiveness at 8th day after start of treatment.
If the woman has no sign suggestive of infective vaginitis and vaginal swab is negative for bacterial, trichomonal or candidial vaginitis at 8th day after start of treatment, this will be considered a treatment successaddressing our primary endpoint for effectiveness. However, if at the 8th day after initiation of treatment, the vaginal swab is still positive for bacterial, trichomonal or candidial vaginitis irrespective of presence or absence of signs and symptoms, this will be considered a treatment failure addressing our primary endpoint for effectiveness.
Secondary Outcome Measures:
Effectiveness at 29th day after start of treatment.
If at the 29th day after initiation of treatment, the patient does not have any signs suggestive of infective vaginitis and vaginal swab is negative for bacterial, trichomonal or candidial vaginitis, this will be considered a treatment success addressing our secondary endpoint for effectiveness at 29thday of the study.
However, if at the 29th day after initiation of treatment, the vaginal swab is positive for bacterial, trichomonal or candidial vaginitisirrespective of presence or absence of signs and symptoms despite treatment success at the 8th day after start of treatment, this will be considered a treatment failure addressing our secondary endpoint for effectiveness.
Tolerability
If the patient completed the 3 day course without any break and did not experience intolerable side effects, this will be considered as treatment success referring to our secondary endpoint for tolerability.
However, if the patient discontinued the treatment during the 3 days because of side effects or complained of intolerable side effects from the treatment this will be considered as treatment failure addressing our secondary endpoint for tolerability.
Study of in vitro release pattern of Clindamycin and Clotrimazole by HPLC analysis:
Vaginal simulate fluid medium will be prepared by adding NaCl, 3.51g; KOH, 1.40g; Ca(OH)2, 0.222g; bovine serum albumin, 0.018g; lactic acid, 2.00g; acetic acid, 1.00g; glycerol, 0.16g; urea, 0.4g; glucose, 5.0g to sufficient quantity of distilled water to make 1 litre. This simulant has the physical and chemical properties such as pH [pH 4.2] and osmolarity similar to those known to govern drug release and distribution from per vaginal route.
1 tablet of either of the formulations will be placed in 100 mL of vaginal simulate fluid medium providing sink conditions.The medium will be maintained at 37ºC and stirred at 100 rpm.
1 mL of dissolution fluid will be collected at 0.5,1,2,3,4,6,8,10,12 and 24 hours. The medium will be replaced with an equal volume of vaginal simulate fluid equilibrated to temperature. Levels of clindamycin and clotrimazole in the samples will be analyzed using HPLC,Release of the drug will be expressed as percentage of total drug present in each tablet. The procedure will be repeated for 6 soft gelatin capsules and 6extended release [ER] tablets.
STATISTICAL ANALYSIS:
The results will be analyzed on per-protocol basis.
Number of patients achieving primary end-point for effectivenessat 8th day after start of treatmentin both the groups will be analyzed using Chi-square test.
Number of the patients achieving secondary end-point for effectivenessat 29th day of the studyin both the groups will be analyzed using Chi-square test.
Number of the patients achieving secondary end-point for tolerability in both the groups will be analyzed using Chi-square test.
Number of the patients showing reduction in vaginal pH to 4.5 at second and third visit in both the groups will be analyzed using Chi-square test.
Number of the patients achieving improvement in scores for quantity of vaginal discharge and itching by at least 1 unit from first to second [Measure of Treatment] and first to third visit [Measure of Recurrence] in both the groups will be analyzed using Chi-square test.
REFERENCES:
Ison, CA; Hay, PE (2002).
Validation of a simplified grading of Gram stained vaginal smears for use in genitourinary medicine clinics.
Sex Transm Infect 78 (6): 413–5.
Amsel R, Totten PA, Spiegel CA, Chen KC, Eschenbach D, Holmes KK (1983).
Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations
Am. J. Med. 74 (1): 14–22
Nugent RP, Krohn MA, Hillier SL (1991).
Reliability of diagnosing bacterial vaginosis is improved by a standardized method of gram stain interpretation.
J. Clin. Microbiol. 29 (2): 297–301
Owen DH, Katz DF
A vaginal fluid simulant
Contraception. 1999 Feb;59(2):91-5
Paavonen J; Mangioni C; Martin MA; Wajszczuk CP
Vaginal clindamycin and oral metronidazole for bacterial vaginosis: a randomized trial.
Obstet Gynecol 2000 Aug;96(2):256-60
Broumas AG; Basara LA
Potential patient preference for 3-day treatment of bacterial vaginosis: responses to new tablet form of clindamycin.
Adv Ther 2000 May-Jun;17(3):159-66
McCormack WM; Covino JM; Thomason JL; Eschenbach DA; Mou S; Kapernick P; McGregor J; Rein MF; Hillier SL Comparison of clindamycin phosphate vaginal cream with triple sulfonamide vaginal cream in the treatment of bacterial vaginosis.
Sex Transm Dis 2001 Oct;28(10):569-75
Sobel J; Peipert JF; McGregor JA; Livengood C; Martin M; Robbins J; Wajszczuk CP
Efficacy of clindamycin vaginal ovule (3-day treatment) vs. clindamycin vaginal cream (7-day treatment) in bacterial vaginosis.
Infect Dis Obstet Gynecol 2001;9(1):9-15
Milani M; Barcellona E; Agnello A
Efficacy of the combination of 2 g oral tinidazole and acidic buffering vaginal gel in comparison with vaginal clindamycin alone in bacterial vaginosis: a randomized, investigator-blinded, controlled trial.
Eur J Obstet Gynecol Reprod Biol 2003 Jul 1;109(1):67-71
Erem Bilensoy, M. Abdur Rouf, Imran Vural, Murat Şen, A. Atilla Hıncal
Mucoadhesive, Thermosensitive, Prolonged-Release Vaginal Gel for Clotrimazole:β-Cyclodextrin Complex
AAPS PharmSciTech 2006; 7 (2) Article 38: E1-E7
Mohd Aftab Alam, Farhan Jalees Ahmad, Zeenat Iqbal Khan, Roop Krishen Khar, Mushir Ali
Development and Evaluation of Acid-buffering Bioadhesive Vaginal for Mixed Vaginal Infections
AAPS PharmSciTech 2007; 8 (4) Article 109:E1-E8
Ya W, Reifer C, Miller LE.
Efficacy of vaginal probiotic capsules for recurrent bacterial vaginosis: a double-blind, randomized, placebo-controlled study.
Am J Obstet Gynecol 2010;203:120.e1-6.