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March 22, 1995

Efficacy and Safety of Monoclonal Antibody to Human Tumor Necrosis Factor α in Patients With Sepsis SyndromeA Randomized, Controlled, Double-blind, Multicenter Clinical Trial

Edward Abraham, MD; Richard Wunderink, MD; Henry Silverman, MD; et al Trish M. Perl, MD, MSc; Stanley Nasraway, MD; Howard Levy, MD; Roger Bone, MD; Richard P. Wenzel, MD, MSc; Robert Balk, MD; Randy Allred, PhD; James E. Pennington, MD; Janice C. Wherry, MD, PhD; Paul Bellamy, MD; Henry Cryer, MD; Ronald Busuttil, MD; Drew Winston, MD; Cindy Perry, RN; Kenneth V. Leeper Jr, MD; Carol Jones, RN, BSN; Michael Martin, MD; Pam Tuma, RN; Ian Baird, MD; Jane Brooks, RN; Rebecca Baird, RN; Sigfrido Rangel, MD, MSc; Nancy Wagner, RN; Michele Costigan, RN; Guillermo Gutierrez, MD; Phillip Johnson, MD; Cinda Clark, RN; Cindy Grover, RN; Peter C. Gay, MD; Jim Stekelberg, MD; Phillip Van Steinburg, RN; Jorge Ortiz, MD; Pamel Sigel, RN; Anne Murphy, RN; William Lahey, RN; Joseph Plouffe, MD; Robert J. Fass, MD; Jane Russell, RN; Richard E. Crowell, MD; Steven Q. Simpson, MD; Mary Neidhart, RN; Mark Dunn, MD; Louis Saravolatz, MD; Neena Griffin, RN; Tobias C. Samo, MD; Victor Feinstein, MD; Kay Doyle, RN; Collette Tuttle, RN; Richard Brown, MD; Jay Steingrub, MD; Mary Jo Safford, RN; Alfred Bacon III, MD; William Holloway, MD; Shirly Amato, RN; Fay Schneider, RN; Galen B. Toews, MD; Robert Fekety Jr, MD; Julie Kugler, RN; Janet Hampton, RN; Faroque A. Kahn, MD; Ashok Karnik, MD; Michael Niederman, MD; Burke Cunha, MD; Nancy Clare, RN; James Leatherman, MD; Philip K. Peterson, MD; Charlotte Doak, RN; Laurie Zimmerman, RN; Jonathan E. Gottlieb, MD; Lisa Stokes, RN; Curtis Sessler, MD; Karen Deere, RN; Debbie Gloskey, RN; David Longworth, MD; Laura Liucchi, RN; Charles Strange, MD; Ruth Oser, RN, MS; David Gilbert, MD; James E. Leggett, MD; Kay Waite, RN; Nicolas V. Christou, MD; Sheldon Magder, MD; Micheline Bonneau, RN; James S. Tan, MD; Thomas File, MD; Sara Jane Salstrom, MT; Sydney Eaton, RN; Gary Garber, MD; Gynne Jones, MD; Isabel Seguin, RN; Anthony W. Chow, MD; Martin Tweeddale, MD; Linda Schwartz, RN; George Pankey, MD; Joan Vollenweider, RN; Harold Neu; Glenda Garvey, MD; Patricia Dorney, RN; Richard A. Jacobs, MD; Michael Bernstein, MD; Jackie Octavio, RN; Brian Schillinger, RN; Thomas Iberti, MD; James Russell, MD; John Sheagren, MD; Donald Craven, MD; Lona Poole, MD; Warren Myers; Maureen Ash, PhD; Nancy Czarny; George Arcieri, MD; Gary Koch, PhD; Johann Prove, PhD; Daniel Remick, MD; Michael Fournel
Author Affiliations

University of California at Los Angeles; University of Tennessee; University of Maryland; Riverside Methodist Hospital; University of Iowa; Hermann Hospital; Mayo Clinic; St Vincent Hospital; Ohio State University; University of New Mexico—Howard Levy, MD; Henry Ford Hospital; Methodist Hospital; Baystate Hospital; Medical Center of Delaware; University of Michigan; Nassau County Medical Center; Winthrop University Hospital; University of Minnesota; Jefferson Medical College; Medical College of Virginia; Lea Watson, RN; Rush-Presbyterian-St Luke's Hospital; Cleveland Clinic; Medical University of South Carolina; Providence Medical Center; Royal Victoria Hospital; Akron City Hospital; Ottawa General Hospital; Vancouver General Hospital; Ochsner Clinic; Columbia University; University of California at San Francisco; Scientific External Review Committee
From the Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Denver (Dr Abraham); Department of Medicine/Pulmonary Division, University of Tennessee, Memphis (Dr Wunderink); Division of Pulmonary and Critical Care Medicine, University of Maryland. Baltimore (Dr Silverman); Division of General Medicine/ Clinical Epidemiology and Health Services Research, University of Iowa College of Medicine, Iowa City (Drs Perl and Wenzel); Department of Anesthesiology, New England Medical Center, Boston, Mass (Dr Nasraway); Department of Medicine, University of New Mexico, Albuquerque (Dr Levy); Department of Medicine, Rush-Presbyterian-St Luke's Medical Center, Chicago, Ill (Drs Bone and Balk); and Clinical Research Department, Miles Inc, Berkeley, Calif (Drs Allred, Pennington, and Wherry). Dr Bone is now president of the Medical College of Ohio, Toledo.

JAMA. 1995;273(12):934-941. doi:10.1001/jama.1995.03520360048038

Objective.  —To evaluate the efficacy and safety of anti—tumor necrosis factor α monoclonal antibody (TNF-α MAb) in the treatment of patients with sepsis syndrome.

Design.  —Randomized, prospective, multicenter, double-blind, placebo-controlled clinical trial.

Setting.  —A total of 31 hospitals in the United States and Canada.

Patients.  —There were 994 patients with sepsis syndrome enrolled in this clinical trial, and 971 patients were infused with the study drug.

Intervention.  —Patients were prospectively stratified into shock or nonshock groups and then randomized to receive a single infusion of 15 mg/kg of TNF-α MAb, 7.5 mg/kg of TNF-α MAb, or placebo. Patients received standard aggressive medical and surgical care during the 28-day postinfusion period.

Outcome Measure.  —Twenty-eight-day all-cause mortality.

Results.  —The distribution of variables describing demographics, organ system dysfunction or failure, preinfusion Acute Physiology and Chronic Health Evaluation II score, number of organs failing at baseline, initial sites of infection, infecting microorganisms, antimicrobials used, and initial invasive procedures was similar among patients in the TNF-α MAb and placebo treatment arms. Among all infused patients, there was no difference in all-cause mortality in patients who received placebo as compared with those who received TNF-α MAb. In septic patients with shock (n=478), there was a trend toward a reduction in all-cause mortality, which was most evident 3 days after infusion: 25 of 162 patients treated with 15 mg/kg of TNF-α MAb died, 22 of 156 patients treated with 7.5 mg/kg of TNF-α MAb died, and 44 of 160 patients in the placebo group died (15 mg/kg: 44% reduction vs placebo, P=.01; 7.5 mg/kg: 48.7% reduction vs placebo, P=.004). At day 28, the reduction in mortality for shock patients was not significant for either dose of TNF-α MAb relative to placebo (15 mg/kg, 61 deaths among 162 patients [37.7% mortality]; 7.5 mg/kg, 59 deaths among 156 patients [37.8% mortality]; placebo, 73 deaths among 160 patients [45.6% mortality]; P=.20 for 7.5 mg/kg and P=.15 for 15 mg/kg). Serious adverse events were reported in 4.6% of all infused patients. No immediate hypersensitivity allergic reactions due to TNF-α MAb were reported. Serum sickness—like reactions were seen in 2.5% of patients receiving TNF-α MAb.

Conclusions.  —There was no decrease in mortality between placebo and TNF-α MAb in all infused patients. In septic shock patients who received TNF-α MAb, a significant reduction in mortality was present 3 days after infusion. Although a trend toward reduced mortality continued at 28 days following treatment with TNF-α MAb, the difference in mortality among shock patients treated with placebo or TNF-α MAb was not significant.(JAMA. 1995;273:934-941)