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Combination of 3 repurposed drugs after chemotherapy failure in lung cancer

A prospective phase II, randomised multi-center trial of a biomodulatory treatment with metronomic low-dose treosulfan, pioglitazone and clarithromycin versus nivolumab in patients with squamous cell lung cancer and non-squamous cell lung cancer, respectively, after platin failure (ModuLung).

Cancer types
Lung cancer
Trial phase


ACF donation
Estimated trial cost

Why this trial

Lung cancer is the most common cancer type worldwide and the most common cause of death from cancer. Non-small cell lung cancer (NSCLC) is the main type of lung cancer, accounting for approximately 85% of all lung cancer cases. Approximately 15% of patients survive for at least 5 years after being diagnosed with NSCLC.

In cases where the tumour is small or confined to only one lung, it can be cured by surgery or radiotherapy. Unfortunately, at the time of diagnosis, NSCLCs are often too large, or have spread to other parts of the body. In this case, standard treatment consists of platinum-based chemotherapy. If this first chemotherapy treatment fails, the next option is the recently approved nivolumab.

Scientific data suggest that it is important to act on several aspects of the tumour to achieve a long-term benefit. Preventing the formation of blood vessels that are needed for tumour growth, modulating the inflammatory and immune environment of the tumour, and changing tumour cell behaviour may be more effective, provide a survival benefit, as well as improve the quality of life in patients with advanced cancers.

This study compared the standard treatment with nivolumab to the experimental treatment, which consisted of a combination of 3 oral drugs that are currently on the market for other indications than lung cancer. These drugs could be potentially useful in the treatment of NSCLC because they have shown an effect on both the tumour environment and the tumour cells.

Why this intervention

Clarithromycin is an antibiotic that affects inflammation. In a small trial completed in Japan, NSCLC patients who received clarithromycin showed prolonged survival compared to the group that received standard treatment. In addition, there is evidence that clarithromycin controls tumour-associated inflammation and improves cachexia (a condition in which the patient loses weight and muscle tissue and is weak and tired).

Pioglitazone, currently on the market to treat diabetes, affects the growth of (tumour) cells and cell death.

Treosulfan is a chemotherapeutic drug which will be used at a “metronomic dose”, i.e. at a lower but more frequent dose than the usual schedule.

Trial design

This was a prospective phase II, randomised trial in 10 German centres. Of the randomised NSCLC patients, half received the experimental treatment with treosulfan, pioglitazone and clarithromycin and the other half received nivolumab.

The main objective was to compare the efficacy of the experimental therapy to the efficacy of nivolumab in this specific patient population. Safety and quality of life was also evaluated.



The trial had to be closed pre-maturely due to major changes in first-line treatment for lung cancer patients.  At the moment of closure, 40 patients were included and treated in the trial.

The first results of the ModuLung trial were presented at the European Society of Medical Oncology Congress in October 2019 through a poster presentation. The final results of the trial were published in March 2021.

In the trial, the experimental treatment was as effective as the standard treatment, be it much less toxic and therefore better tolerated than the standard treatment.

However, both the standard treatment and the new treatment are not sufficiently effective.

In other words, the new treatment didn’t improve the outcomes of the patients compared to the standard treatment.



  • Prof. A. Reichle, University Hospital Regensburg, Regensburg, Germany (Coordinating Investigator)
  • Prof. C. Schulz, University Hospital Regensburg, Regensburg, Germany


  • University Hospital Regensburg, Regensburg, Germany

Our role

Financial support
Protocol writing

Why we support this trial

Intervention has little or no commercial value

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Expected survival benefit

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No major hurdle for clinical implementation

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ACF donation
Estimated trial cost

Questions about participation?

Albrecht Reichle
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Questions about this trial?

The Anticancer Fund
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More info on NCT02852083

Mikasa, K., et al. (1997). Significant Survival Benefit to Patients with Advanced Non-Small-Cell Lung Cancer from Treatment with Clarithromycin. Chemotherapy, 43, 288-296. doi:10.1159/000239580

Kazandjian, D., et al. (2016). FDA Approval Summary: Nivolumab for the Treatment of Metastatic Non-Small Cell Lung Cancer With Progression On or After Platinum-Based Chemotherapy. The Oncologist, 21(5), 634-42. doi: 10.1634/theoncologist.2015-0507

NSCLC Meta-Analyses Collaborative Group. (2008). Chemotherapy in addition to supportive care improves survival in advanced non-small-cell lung cancer: a systematic review and meta-analysis of individual patient data from 16 randomized controlled trials. Journal of clinical oncology, 26(28), 4617-25. doi: 10.1200/JCO.2008.17.7162

Reichle, A. (2013). Evolution-adjusted tumor pathophysiology. Springer. doi:10.1007/978-94-007-6866-6

Reichle, A. (2010). From Molecular to Modular Tumor Therapy: Tumors are Reconstructible Communicatively Evolving Systems. Springer. doi:10.1007/978-90-481-9531-2

Heudobler, D. (2021). A Randomized Phase II Trial Comparing the Efficacy and Safety of Pioglitazone, Clarithromycin and Metronomic Low-Dose Chemotherapy with Single-Agent Nivolumab Therapy in Patients with Advanced Non-small Cell Lung Cancer Treated in Second or Further Line (ModuLung). Frontiers in Pharmacology.

Last updated: March 2024.