Patent Application
20240327529
A biomarker is termed as a defined characteristic that is measured as an indicator of normal biological processes, pathogenic processes or responses to an exposure or intervention. Predictive biomarkers may be used to predict response to therapy or disease course.
Systemic lupus erythematosus (SLE) is an autoimmune disease that causes significant morbidity and mortality1. Clinical manifestations of SLE include, but are not limited to constitutional symptoms, alopecia, rashes, serositis, arthritis, nephritis, vasculitis, lymphadenopathy, splenomegaly, hemolytic anemia, cognitive dysfunction and other nervous system involvement. These disease manifestations cause a significant burden of illness and can lead to reduced physical function, loss of employment, lower health-related quality of life (QoL) and a lifespan shortened by 10 years. Increased hospitalizations and side effects of medications including chronic oral corticosteroids (OCS) and other immunosuppressive treatments add to disease burden in SLE.
Despite intense SLE clinical trial activity, only one drug, belimumab, has received regulatory approval in the last 60 years. Many factors have contributed to drug development failures in SLE, including trial design challenges, heterogeneous patient populations, and a lack of robust endpoints. Treatment of SLE is challenging because of the limited efficacy and poor tolerability of standard therapy2. Many of the therapies currently used for the treatment of SLE have well known adverse effect profiles and there is a medical need to identify new targeted therapies, particularly agents that may reduce the requirement for corticosteroids and cytotoxic agents.
Most clinical trials for new treatments for SLE have failed to meet their primary and second endpoints. Part of the reason for the failure of these clinical trials may be the heterogeneity of disease manifestations in SLE patients. Furthermore, the extreme heterogeneity of the SLE has hindered the identification of biomarkers for predicting the response of SLE patients to therapy. Despite decades of investigation, there is currently no reliable biomarker for predicting the likelihood of patient response to treatment3. There is thus a need for predictive biomarkers to predict therapeutic responses in SLE patients.
The present invention solves one or more of the above-mentioned problems.
The present inventors surprisingly demonstrate that high baseline IL10 was associated with worse clinical response of SLE patients and that IL10-low patients respond better to treatment than other patients. The present invention therefore provides for the first time a predictive biomarker for response to therapy in SLE patients.
The invention relates to a method of selecting a subject with SLE for treatment with a type I IFN receptor (IFNR) inhibitor, the method comprising selecting the subject for treatment if the subject's IL-10 plasma concentration is lower than a predetermined value, wherein the treatment reduces SLE disease activity in the subject; and pharmaceutical compositions of use in such a method.
The invention also relates to a method of selecting a subject with SLE for treatment with a type I IFN receptor (IFNR) inhibitor and an IL-10 inhibitor, the method comprising selecting the subject for treatment if the subject's IL-10 plasma concentration is higher than a predetermined value, wherein the treatment reduces SLE disease activity in the subject; and pharmaceutical compositions of use in such a method.
The invention further relates to a method of treating SLE in a subject in need thereof, the method comprising administering a therapeutically effective amount of an IFNR inhibitor, wherein the subject is identified as having an IL-10 plasma concentration lower than a predetermined value, wherein the treatment reduces SLE disease activity; and pharmaceutical compositions of use in such a method.
The invention further relates to a method of selecting a subject with SLE for treatment with an anti-BAFF monoclonal antibody, the method comprising selecting the subject for treatment if the subject's IL-10 plasma concentration is higher than a predetermined value, wherein the treatment reduces SLE disease activity in the subject. The invention also relates to a method of treating SLE in a subject in need thereof, the method comprising administering a therapeutically effective amount of an anti-BAFF monoclonal antibody and an anti-CD20 antibody, wherein the subject is identified as having an IL-10 plasma concentration higher than a predetermined value, wherein the treatment reduces SLE disease activity.
The invention is supported inter alia by data presented for the first time herein. Administration of anifrolumab leads to a rapid (as early as Week 8) and sustained BICLA response in SLE patients as demonstrated in placebo controlled double-blinded clinical trials (see Examples 1 to 4). The treatment effect of anifrolumab relative to placebo was consistent across preconceived subgroups (by age, gender, race, ethnicity, disease severity [SLEDAI-2K at baseline], and baseline OCS use) (see Example 5). IFNGS test-high and IL10-low patients respond better to anifrolumab treatments than other patients (Examples 6 and 7). In particular, the present invention is based on the surprising observation by the inventors that SLE patients with low levels of IL-10 respond better to treatment with a type I IFN inhibitor than SLE patients expressing high levels of IL-10. The IL-10 levels in SLE patients are correlated with the type I IFN gene signature (IFNGS) and high IL-10 is associated with more severe SLE disease.
CP1013 (NCT01438489); CP1145 (NCT01753193); ANI: anifrolumab.
Groups are shown in Table 14-1.
Groups are shown in Table 14-1.
Groups are shown in Table 14-1.
APC: antigen presenting cells; pDC: plasmacytoid dendritic cells; mDC: monocytic dendritic cells.
Anti-dsDNA antibody levels were classified as positive (>15 U mL 1) or negative (≤15 U mL 1) and were measured in a central laboratory using an automated fluoroimmunoassay.
Y-axis is serum concentration of IL-10 (pg/ml). Complement levels were classified as abnormal (C3 <0.9 g L−1; C4 <0.1 g L−1) or normal (C3 ≥0.9 g L−1; C4 ≥0.1 g L−1) and were measured in a central laboratory.
Y-axis is serum concentration of IL-10 (pg/ml)
Y-axis is serum concentration of IL-10 (pg/ml)
BICLA, British Isles Lupus Assessment Group-based Composite Lupus Assessment; CI, confidence interval; IFNGS, interferon gene signature; OCS, oral corticosteroid; SLEDAI-2K, Systemic Lupus Erythematosus Disease Activity Index 2000. In TULIP-1, TULIP-2, and pooled TULIP data, restricted medication rules were according to the TULIP-2 protocol. Hazard ratios and 95% CIs are estimated using a Cox regression model with treatment groups and the stratification factors (SLEDAI-2K at screening, Day 1 OCS dosage, and type I IFNGS test result at screening) as covariates.
BICLA, British Isles Lupus Assessment Group-based Composite Lupus Assessment; IFNGS, interferon gene signature; OCS, oral corticosteroid; SLEDAI-2K, Systemic Lupus Erythematosus Disease Activity Index 2000. At early time points, P-values in TULIP-1 and TULIP-2 were 0.207 and 0.238 (Week 4), 0.020 and 0.004 (Week 8), and 0.054 and 0.029 (Week 12), respectively. In TULIP-1, TULIP-2, and pooled TULIP data, restricted medication rules were according to the TULIP-2 protocol. Responder rates are calculated using a stratified Cochran-Mantel-Haenszel approach, with stratification factors Day 1 OCS dosage, SLEDAI-2K, and type I IFNGS test result, both at screening. In the pooled analysis, an additional stratification factor is added for study. Vertical bars indicate 95% confidence intervals.
BMI, body mass index; BICLA, British Isles Lupus Assessment Group-based Composite Lupus Assessment; CI, Confidence interval; CMH, Cochran-Mantel-Haenszel. TULIP-1 data were analyzed incorporating the prespecified restricted medication rules. Differences in treatment estimates and associated 95% CIs were weighted and calculated using a stratified CMH approach.
BICLA, British Isles Lupus Assessment Group-based Composite Lupus Assessment; CI, confidence interval; CMH, Cochran-Mantel-Haenszel; SLEDAI-2K, Systemic Lupus Erythematosus Disease Activity Index 2000. TULIP-1 data were analyzed incorporating the prespecified restricted medication rules. Differences in treatment estimates and associated 95% CIs were weighted and calculated using a stratified CMH approach.
BICLA, British Isles Lupus Assessment Group-based Composite Lupus Assessment; CI, confidence interval; CMH, Cochran-Mantel-Haenszel; OCS, oral corticosteroid. TULIP-1 data were analyzed incorporating the prespecified restricted medication rules. Differences in treatment estimates and associated 95% CIs were weighted and calculated using a stratified CMH approach.
BICLA, British Isles Lupus Assessment Group-based Composite Lupus Assessment; CI, confidence interval; CMH, Cochran-Mantel-Haenszel; IFNGS, type I interferon gene signature; qPCR, quantitative polymerase chain reaction. aType I IFNGS was classified as either high or low by central laboratory screening using a 4-gene qPCR-based test from whole blood. TULIP-1 data were analyzed incorporating the prespecified restricted medication rules. Differences in treatment estimates and associated 95% CIs were weighted and calculated using a stratified CMH approach.
BILAG: British Isles Lupus Assessment Group. Note: Flare defined as 1≤ new BILAG-2004 A or 2≤ new (worsening) BILAG-2004 B domain scores as compared with the prior month's visit
BILAG: British Isles Lupus Assessment Group. Note: Flare defined as 1≤. New BILAG-2004 A or 2≤ new (worsening) BILAG-2004 B domain scores as compared with the prior month's visit. Time to first flare is derived as data of first flare minus date of first administration of investigational product. If the patient did not have a flare, the time to flare is censored at the end of the exposure time.
BILAG: British Isles Lupus Assessment Group; SLE, systemic lupus erythematosus. Flares were defined as 1≤ new BILAG-2004 A or 2≤ new BILAG-2004 B organ domain scores versus the prior visit.
CLASI, Cutaneous Lupus Erythematous Disease Area and Severity Index; CLASI-A, CLASI activity score; n, number of patients in analysis; N, number of patients in treatment group; NA, not available; OCS, oral corticosteroids. A response is defined as 50%≤ reduction in CLASI activity score from baseline for patients with baseline CLASI-A 10≤. Responder rates are calculated using a stratified Cochran-Mantel-Haenszel approach, with stratification factors SLEDAI-2K score at screening. Day 1 OCS dosage, type I IFN gene signature test result at screening, and study (TULIP-1 and TULIP-2). Nominal P-values are presented, *P<0.05; **P<0.01; ***P<0.001.
CLASI, cutaneous lupus erythematous disease area and severity index; CLASI-A, CLASI activity score; n, number of patients in analysis; N, number of patients in treatment group; NA, not available; OCS, oral corticosteroids. A response is defined as 50%≤ reduction in CLASI activity score from baseline for patients with baseline CLASI-A 10≤. Hazard ratios and 95% Cis were estimated using a Cox regression model with treatment groups with stratification (SLEDAI-2K score at screening. Day 1 OCS dosage, study, and type I IFN gene signature test result at screening) as covariates.
CLASI-A, Cutaneous Lupus Erythematosus Disease Area and Severity Index activity score. A response is defined as ≥50% reduction in CLASI-A from baseline for patients with baseline CLASI-A ≥10. In total, 13 anifrolumab-treated patients from 5 sites participated in skin photography; 2 patients had a CLASI-A response at Week 12.
55B: LS mean change in oral glucocorticoid daily dosage from baseline to Week 52 in all patients regardless of baseline oral glucocorticoid dosage. Error bars represent 95% CI.
Patients with response in (
Change from baseline to Week 52 in (
Table 6-1: BT-063 sequences
Table 6-2:21 interferon gene signature
Table 6-3: Examples of equivalent doses of oral prednisone
Table 6-4: Anifrolumab sequences
Table 6-5: anti-IFNAR antibody sequences
Table 6-6: Anti-BAFF sequences
Table 6-7: Belimumab dosage and administration
Table 6-8: Tabalumab dosage and administration
Table 11-1: BICLA response rate at Week 52
Table 12-1: Baseline Patient Demographics
Table 12-2: Baseline Disease Characteristics
Table 13-1: Anifrolumab induced changes in serum protein levels
Table 14-1: IL-10 patient groups
Table 18-1: Patient demographics and baseline clinical characteristics
Table 18-2: Patient demographics and baseline SLE medications for BICLA responders and nonresponders
Table 18-3: SLE flares in BICLA responders and nonresponders
Table 18-4: PRO scores at baseline in BICLA responders and nonresponders
Table 18-5: Medical resource utilization for BICLA responders and nonresponders
Table 18-6: Serology changes from baseline to Week 52 for BICLA responders and nonresponders
Table 18-7: AEs during treatment in BICLA responders and nonresponders
Table 18-8: PRO scores at baseline in BICLA responders and nonresponders
The present invention in a first aspect relates to a method of selecting a subject with SLE for treatment with a type I IFN receptor (IFNR) inhibitor, the method comprising selecting the subject for treatment if the subject's IL-10 plasma concentration is lower than a predetermined value, wherein the treatment reduces SLE disease activity in the subject.
The method may comprise selecting the subject for treatment if the subject has an elevated type I interferon gene signature (IFNGS) compared to a healthy subject. The healthy subject may be a subject who does not suffer from SLE. The healthy subject may be an adult subject who does not suffer from SLE.
The elevated IFNGS may comprises at least about four-fold increase in mRNA of at least four of IFI27, IFI44, IFI44L, IFI6, and RSAD2 in a sample from the subject and/or subjects, relative to a sample from a healthy subject. The elevated IFNGS may comprise at least about four-fold increase in messenger RNA (mRNA) of at least four of IFI27, IFI44, IFI44L, IFI6, and RSAD2 in a sample from the subject and/or subjects, relative to pooled samples from healthy patients. The mRNA is increased relative to the mRNA of one or more control genes present in the sample. The one or more control genes may be chosen from ACTB, GAPDH, and 18S rRNA.
The method may comprise detecting increased mRNA of IFI27, IFI44, IFI44L, and RSAD2 in the subject. Detecting increased mRNA may comprise routine techniques in the art for measuring mRNA levels in a sample, real-time quantitative polymerase chain reaction (RT-qPCR).
The method may comprise selecting the subject for treatment if the subject is undergoing treatment comprising administration of OCS at a dose of 10 mg or more. Patients to which higher doses of OCS are administered are at greater risk of adverse events associated with OCS use.
The method may be performed in vitro. In other words, the method may be a method that is not practiced on the human or animal body.
The present invention also relates to a method of selecting a subject with SLE for treatment with a type I IFN receptor (IFNR) inhibitor and an IL-10 inhibitor, the method comprising selecting the subject for treatment if the subject's IL-10 plasma concentration is higher than a predetermined value, wherein the treatment reduces SLE disease activity in the subject. The IL-10 may compensate for the lack of response to the type I IFN inhibitor in subjects with high levels of serum IL-10 compared to the average SLE patient.
The present invention also relates to a method of treating SLE in a subject in need thereof, the method comprising administering a therapeutically effective amount of an IFNR inhibitor, wherein the subject is identified as having an IL-10 plasma concentration lower than a predetermined value, wherein the treatment reduces SLE disease activity. The subject treated by the method may be identified as having an elevated IFNGS compared to a healthy subject. The elevated IFNGS in the subject treated by the method may comprise at least about four-fold increase in mRNA of at least four of IFI27, IFI44, IFI44L, IFI6, and RSAD2 in a sample from the subject, relative to a sample from a healthy subject. The elevated IFNGS may comprise at least about four-fold increase in mRNA of at least four of IFI27, IFI44, IFI44L, IFI6, and RSAD2 in a sample from the subject, relative to pooled samples from healthy patients. The mRNA may be increased relative to the mRNA of one or more control genes present in the sample. The one or more control genes may be chosen from ACTB, GAPDH, and 18S rRNA. The method may comprise detecting increased mRNA of IFI27, IFI44, IFI44L, and RSAD2 in the subject. The subject treated by the method may be undergoing treatment comprising administration of OCS at a dose of 10 mg or more pre-treatment with the IFNR inhibitor.
The present invention also relates to a method of treating SLE in a subject in need thereof, the method comprising administering a therapeutically effective amount of an IFNR inhibitor and an IL-10 inhibitor, wherein the subject is identified as having an IL-10 plasma concentration higher than a predetermined value, wherein the treatment reduces SLE disease activity.
The present invention also relates to a method of selecting a subject with SLE for treatment with an anti-BAFF monoclonal antibody, the method comprising selecting the subject for treatment if the subject's IL-10 plasma concentration is higher than a predetermined value, wherein the treatment reduces SLE disease activity in the subject. The anti-BAFF antibody may be belimumab or a functional variant thereof. The present invention therefore also relates to a method for using a predictive biomarker for response to combined belimumab and an anti-IL-10 antibody.
The present invention also relates to a method of treating SLE in a subject in need thereof, the method comprising administering a therapeutically effective amount of an anti-BAFF monoclonal antibody and an anti-CD20 antibody, wherein the subject is identified as having an IL-10 plasma concentration higher than a predetermined value, wherein the treatment reduces SLE disease activity. The anti-CD20 antibody may be rituximab and the anti-BAFF antibody may be belimumab. The present invention therefore also relates to a method for using a predictive biomarker for response to combined belimumab and rituximab.
The methods of the invention may also comprise determining the IL-10 concentration in a sample from the patient. The sample may be any sample taken for the body that can be used to assess serum levels of IL-10. In particular, the sample may be a blood, serum or plasma sample. In order to determine the IL-10 levels in the serum of the subject, the IL-10 concentration in the sample may be determined by enzyme-linked immunosorbent assay (ELISA) or any other technique known in the art.
The predetermined value may be about 1 to about 3.5 pg/ml. The predetermined value may be about 1.5 to about 2.5 pg/ml. The predetermined value may be about 1.7 to 2.3 pg/ml. The predetermined value may be about 1.0, about 1.1, about 1.2, about 1.3, about 1.4, about 1.5, about 1.6, about 1.7, about 1.8, about 1.9, about 2.0, about 2.1, about 2.2, about 2.3, about 2.4, about 2.5, about 2.6, about 2.7, about 2.8, about 2.9, about 3.0, about 3.1, about 3.2, about 3.3, about 3.4, about 3.5, about 1, about 2 or about 3. The predetermined value may be any of 0, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 2.0, 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8, 2.9, 3.0, 3.1, 3.2, 3.3, 3.4, 3.5, 1, 2 or 3 pg/ml.
The predetermined value may particularly be about 2 pg/ml. The predetermined value may particularly be 2 pg/ml. The predetermined value may be determined by: a) determining the IL-10 plasma concentrations of subjects in a sample population of subjects with SLE; b) determining the median IL-10 concentration in the population of subjects with SLE, wherein the predetermined value is the median determined in b).
The method of any preceding claim, wherein the subject is administered steroids at a dose of 10 mg or more before treatment.
Reducing SLE disease activity in the subject may comprise one or more of any of the following:
The methods of the invention may comprise measuring the subject's BILAG score before and after administration of the IFNAR inhibitor. The BICLA response may be sustained in the subject for at least 52 weeks. The method may comprise measuring PROs in the subject before and after administration of the IFNAR inhibitor. The PRO's may comprise the subject's Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Short Form 36 Health Survey version 2 (SF-36-v2), mental component summary (MCS), and/or SF-36, physical component summary (PCS) score.
The BICLA response may comprise reduction of the subject's BILAG-2004 A and B domain scores to B/C/D and C/D, respectively. Reducing the subject's CLASI score compared to the subject's CLASI score pre-treatment may comprise a reduction in the subject's CLASI-A score compared to the subject's CLASI-A score pre-treatment. Reducing the SLE disease activity in the subject may comprise reducing the anti-dsDNA levels in the subject. Reducing the SLE disease activity in the subject may comprise a BILAG-Based Composite Lupus Assessment (BICLA) response, wherein the method also comprises reducing the OCS dose administered to the subject compared to the OCS dose administered to the subject pre-treatment
The OCS comprises prednisone, prednisolone and/or methylprednisolone.
Reducing SLE disease activity in the subject may comprise a BILAG-Based Composite Lupus Assessment (BICLA) response by at least week 4 of treatment.
Reducing SLE disease activity may comprises a BILAG-Based Composite Lupus Assessment (BICLA) response by at least week 8 of treatment. Reducing SLE disease activity in the subject may comprise at least a 50% improvement in the tender joint count and swollen joint count in the subject compared to the tender joint and swollen count in the subject pre-treatment value. The reduction in the subject's CLASI score may be achieved by at least week 8 of treatment. Reduction in the subject's CLASI score may be achieved following 12 weeks of treatment. Reducing SLE disease activity in the subject may comprise at least 50% reduction in the subject's CLASI score compared to the subject's CLASI score pre-treatment. Reducing SLE disease activity in the subject may comprise reduction of the subject's CLASI-A score following 12 weeks of treatment. The subject may have a CLASI-A score of ≥10 pre-treatment. Reducing SLE disease activity in the subject may comprise the subject's BILAG-2004 score being C or better after 24 weeks of treatment. Reducing SLE disease activity in the subject may comprise the subject having a maximum of 1 BILAG-2004 B score after 24 weeks of treatment. Reducing SLE disease activity in the subject may comprise a reduction in the subject's BILAG-based annualized flare rate compared to the subject's BILAG-based annualized flare rate pre-treatment. Reducing SLE disease activity in the subject may comprise preventing flares in the subject.
A flare may be defined as ≥1 new BILAG-2004 A or ≥2 new (worsening) BILAG-2004 B domain scores compared to the subject's scores one month previously. Reducing SLE disease activity in the subject may comprise a reduced flare rate in the subject compared to the flare rate pre-treatment, wherein the method comprises reducing OCS dose administration to the subject compared to the OCS dose administered to the subject pre-treatment. The method may comprise selecting the subject for treatment, wherein the subject is selected for having active SLE. The subject may be selected for having moderate to severe SLE. The subject may be selected for having SLE that is unresponsive to OCS treatment.
The subject may be an adult.
The type I IFN receptor inhibitor (IFNR, IFNAR, IFNAR1) may be administered intravenously or subcutaneously. The type I IFN receptor inhibitor may be an anti-type I interferon receptor antibody or antigen binding fragment thereof that specifically binds IFNAR1. The antibody may be a monoclonal antibody. The antibody may be anifrolumab.
The IFN receptor inhibitor may comprise a heavy chain variable region complementarity determining region 1 (HCDR1) comprising the amino acid sequence of SEQ ID NO: 3; a heavy chain variable region complementarity determining region 2 (HCDR2) comprising the amino acid sequence of SEQ ID NO: 4; a heavy chain variable region complementarity determining region 3 (HCDR3) comprising the amino acid sequence of SEQ ID NO: 5; a light chain variable region complementarity determining region 1 (LCDR1) comprising the amino acid sequence SEQ ID NO: 6; a light chain variable region complementarity determining region 2 (LCDR2) comprising the amino acid sequence SEQ ID NO: 7; and/or a light chain variable region complementarity determining region 3 (LCDR3) comprising the amino acid sequence SEQ ID NO: 8.
The IFN receptor inhibitor may comprise (a) a human heavy chain variable region comprising the amino acid sequence of SEQ ID NO: 1; and (b) a human light chain variable region comprising the amino acid sequence of SEQ ID NO: 2. The IFN receptor inhibitor may comprise an Fc region comprising an amino acid substitution of L234F, as numbered by the EU index as set forth in Kabat, and wherein the antibody exhibits reduced affinity for at least one Fc ligand compared to an unmodified antibody, optionally wherein the antibody comprises in the Fc region an amino acid substitution of L234F, L235E and/or P331S, as numbered by the EU index as set forth in Kabat. The IFN receptor inhibitor may comprise (a) a human chain comprising the amino acid sequence of SEQ ID NO: 11; and (b) a human light chain comprising the amino acid sequence of SEQ ID NO: 12.
The type I IFN receptor inhibitor may comprise sifalimumab.
The method may comprise administering an anti-IL-10 antibody to the subject. The anti-IL-10 antibody may comprise (a) a heavy chain variable region comprising the amino acid sequence of SEQ ID NO: 18; and (b) a light chain variable region comprising the amino acid sequence of SEQ ID NO: 17.
The anti-IL-10 antibody may comprise a heavy chain variable region complementarity determining region 1 (HCDR1) comprising the amino acid sequence of SEQ ID NO: 22; a heavy chain variable region complementarity determining region 2 (HCDR2) comprising the amino acid sequence of SEQ ID NO: 23; a heavy chain variable region complementarity determining region 3 (HCDR3) comprising the amino acid sequence of SEQ ID NO: 24; a light chain variable region complementarity determining region 1 (LCDR1) comprising the amino acid sequence SEQ ID NO: 19; a light chain variable region complementarity determining region 2 (LCDR2) comprising the amino acid sequence SEQ ID NO: 20; and/or a light chain variable region complementarity determining region 3 (LCDR3) comprising the amino acid sequence SEQ ID NO: 21. The IL-10 antibody may be BT-063 or a functional equivalent thereof.
The method may comprise administering anifrolumab. The treatment may comprise administering 300 mg anifrolumab. Anifrolumab may be administered as an intravenous (IV) infusion. Anifrolumab may be administered every four weeks. Anifrolumab may be provided in a solution at a concentration of 150 mg/mL.
The method may comprise administrating a type I IFN receptor inhibitor and an IL-10 inhibitor.
The present invention also relates to a pharmaceutical composition for use in a method of treating SLE in a subject in need thereof, the method of treatment comprises administering a therapeutically effective amount of an IFNR inhibitor, wherein the subject is identified as having an IL-10 plasma concentration lower than a predetermined value, wherein the treatment reduces SLE disease activity. The IFNR inhibitor may be anifrolumab. The pharmaceutical composition may comprise anifrolumab at a concentration of 150 mg/mL. The pharmaceutical composition may comprise 150 mg/mL anifrolumab; 50 mM lysine HCl; 130 mM trehalose dihydrate; 0.05% polysorbate 80; 25 mM histidine/histidine HCl, wherein the pharmaceutical composition is at a pH of 5.9.
The method may comprise administering an intravenous dose of anifrolumab or the functional variant thereof to the subject. The intravenous dose may be ≥300 mg anifrolumab or the functional variant thereof. The intravenous dose may be ≤1000 mg. The intravenous dose may be about 300 mg, about 900 mg or about 1000 mg. The intravenous dose may be administered every four weeks (Q4W).
The method may comprise administering a subcutaneous dose of anifrolumab or the functional variant thereof. The subcutaneous dose may be >105 mg and <150 mg anifrolumab or the functional variant thereof. The subcutaneous dose may be ≤135 mg anifrolumab or the functional variant thereof. The subcutaneous dose may be about 120 mg. The subcutaneous dose may be administered in a single administration step. The subcutaneous dose may be administered at intervals of 6-8 days. The subcutaneous dose may be administered once per week. The subcutaneous dose may have a volume of about 0.5 to about 1 ml. The subcutaneous dose may have a volume of about 0.8 ml.
The invention also relate to a kit for use in any method of the invention. The kit may comprise the pharmaceutical composition of the invention. The kit may comprise instructions for use. The instructions for use may specify any method of the invention. The instructions for use may specify a method comprising selecting a subject with SLE for treatment with a type I IFN receptor (IFNR) inhibitor, the method comprising selecting the subject for treatment if the subject's IL-10 plasma concentration is lower than a predetermined value, wherein the treatment reduces SLE disease activity in the subject. The instructions for use may specify a method of selecting subject with SLE for treatment with a type I IFN receptor (IFNR) inhibitor and an IL-10 inhibitor, the method comprising selecting the subject for treatment if the subject's IL-10 plasma concentration is higher than a predetermined value, wherein the treatment reduces SLE disease activity in the subject. The instruction for use may specify a method of treating SLE in a subject in need thereof, the method comprising administering a therapeutically effective amount of an IFNR inhibitor and an IL-10 inhibitor, wherein the subject is identified as having an IL-10 plasma concentration higher than a predetermined value, wherein the treatment SLE disease activity. The instructions for use may specify a method of treating SLE in a subject in need thereof, the method comprising administering a therapeutically effective amount of an anti-BAFF monoclonal antibody and an anti-CD20 antibody, wherein the subject is identified as having an IL-10 plasma concentration higher than a predetermined value, wherein the treatment reduces SLE disease activity.
The kit may comprise anifrolumab or a functional equivalent thereof. The kit may comprise an anti-IL-10 antibody. The kit may comprise belimumab or a functional equivalent thereof.
IL-10 (also known as Cytokine Synthesis Inhibitory Factor (CSIF), T-Cell Growth Inhibitory Factor (TGIF); UniProtKB P22301) is a predominantly anti-inflammatory cytokine that inhibits T cell function by suppressing the expression of proinflammatory cytokines such as TNFα, IL-1 IL-1B, IL-6, IL-8, IL-10, granulocyte macrophage colony-stimulating factor (GM-CSF) and IL-12. IL-10 also reduces antigen presentation by monocytes. However, in addition to its anti-inflammatory role, IL-10 also promotes B-cell survival, proliferation, differentiation, and antibody production4.
In a small, open-label clinical trial, anti-IL-10 treatment (anti-IL-10 murine mAb (B-N10)) of lupus patients with cutaneous and joint manifestations resulted in improvement to clinically inactive disease in five of six patients within 6 months of the 3-week treatment regimen5.
SCH708980 is an anti-IL-10 monoclonal antibody investigated for the treatment of Visceral Leishmaniasis (NCT01437020). Anit-IL-10 monoclonal antibodies for the treatment of SLE are described in WO2005047326 and WO 2011.064399.
BT-063 is an anti-IL-10 antibody. BT-063 is described in WO 2011064399, which is incorporated herein by reference. The sequences of BT-063 are shown in Table 6-1.
Type I interferon (IFN) signalling drives pathology in a number of autoimmune diseases, in particular in systemic lupus erythematosus (SLE), and can be tracked via type I IFN-inducible transcripts present in whole blood—said transcripts provide a type I IFN gene signature. By way of example, Yao et al. (Hum Genomics Proteomics 2009, pii: 374312)6 describe the identification of an IFNα/β 21-gene signature and its use as a biomarker of type I IFN-related diseases or disorders.
Type I IFN has been considered to be important in SLE disease pathogenesis and inhibition of this pathway is targeted by anifrolumab. To understand the relationship between type I IFN expression and response to anti-IFN therapy, it is necessary to know if a subject's disease is driven by type I IFN activation. However, direct measurement of the target protein remains a challenge. As such, a transcript-based marker was developed to evaluate the effect of over expression of the target protein on a specific set of mRNA markers. The expression of these markers is easily detected in whole blood and demonstrates a correlation with expression in diseased tissue such as skin in SLE. The bimodal distribution of the transcript scores for SLE subjects supports defining an IFN test high and low subpopulation (
An IFN gene signature (IFNGS) can thus be used to identify patients with low or high levels of IFN inducible gene expression. In some embodiments, the IFNGS comprises Interferon Alpha Inducible Protein 27 (IFI27), Interferon Induced Protein 44 (IFI44) interferon induced protein 44 like (IFI44L), and Radical S-Adenosyl Methionine Domain Containing 2 (RSAD2). Up regulation or overexpression of the genes comprising the IFNGS can be calculated by well-known methods in the art. For example, the overexpression of the signature is calculated as the difference between the mean Ct (cycle threshold) for IFI27, IFI44, IFI44L, and RSAD2 and the mean Ct of three control genes; 18S, ACTB and GAPDH. The degree of increased expression of the IFNGS permits the identification of a fold change cutoff for identifying IFN-high and IFN-low patients. In one embodiment, the cutoff is at least about 2. In another embodiment, the cutoff is at least about 2.5. In another embodiment, the cutoff is at least about 3. In another embodiment, the cutoff is at least about 3.5. In another embodiment, the cutoff is at least about 4. In another embodiment, the cutoff is at least about 4.5. In another embodiment, the cutoff is chosen from at least 3.5, 3.6, 3.7, 3.8, 3.9, 4.0, 4.1, 4.2, 4.3, 4.4, and 4.5. In another embodiment the cutoff is between about 2 and about 8. The degree of increased expression of the IFNGS also permits the identification of a delta Ct cutoff for identifying IFN-high and IFN-low subpopulations.
The type I IFN gene signature (IFNGS) is described in WO 2011/028933, which is incorporated herein by reference in its entirety.
The group of genes included in the type I IFN gene signature (also referred to herein as the type I IFN or IFNa-inducible PD marker expression profile) of the patient are (a) IFI27, IFI44, IFI44L, IFI6 and RSAD2; or (b) IFI44, IFI44L, IFI6 and RSAD2; or (c) IFI27, IFI44L, IFI6 and RSAD2; or (d) IFI27, IFI44, IFI6 and RSAD2; or (e) IFI27, IFI44, IFI44L, and RSAD2; or (f) IFI27, IFI44, IFI44L, and IFI6.
In a specific embodiment, the group of genes included in the type I IFN or IFNa-inducible PD marker expression profile of the patient comprises IFI27, IFI44, IFI44L, IFI6 and RSAD2. In another specific embodiment, the group of genes included in the type I IFN or IFNa-inducible PD marker expression profile of the patient consists of IFI27, IFI44, IFI44L, IFI6 and RSAD2. In a further specific embodiment, the group of genes included in the type I IFN or IFNa-inducible PD marker expression profile of the patient comprises IFI27, IFI44, IFI44L, and RSAD2. In another specific embodiment, the group of genes included in the type I IFN or IFNa-inducible PD marker expression profile of the patient consists of IFI27, IFI44, IFI44L, and RSAD2.
The IFNa-inducible PD markers in an expression profile may include (a) IFI27, IFI44, IFI44L, IFI6 and RSAD2; or (b) IFI44, IFI44L, IFI6 and RSAD2; or (c) IFI27, IFI44L, IFI6 and RSAD2; or (d) IFI27, IFI44, IFI6 and RSAD2; or (e) IFI27, IFI44, IFI44L, and RSAD2; or (f) IFI27, IFI44, IFI44L, and IFI6.
The IFNa-inducible PD markers in an expression profile may consist of (a) IFI27, IFI44, IFI44L, IFI6 and RSAD2; or (b) IFI44, IFI44L, IFI6 and RSAD2; or (c) IFI27, IFI44L, IFI6 and RSAD2; or (d) IFI27, IFI44, IFI6 and RSAD2; or (e) IFI27, IFI44, IFI44L, and RSAD2; or (f) IFI27, IFI44, IFI44L, and IFI6.
Suitable primers and probes for detection of the genes may be found in WO2011028933, which is incorporated herein by reference in its entirety.
The IFN 21-gene signature (IFNGS) is a validated pharmacodynamic marker of type I IFN signaling10, that is elevated in patients with type I IFN-mediated disease, including SLE, lupus nephritis, myositis, Sjogren's and scleroderma.
A 4-gene IFNGS score is calculated by measurement of IFI27, IFI44, IFI44L, and RSAD2 expression. A 5-gene IFNGS score is calculated by measurement of IFI27, RSAD2, IFI44, IFI44L, IFI6 expression. A 21-gene IFNGS score is calculated by measurement of the genes shown in Table 6-2. Gene expression may be measured by detecting mRNA in the whole blood or tissue of the subject. A IFNGS (4-gene, 5-gene or 21-gene) score may be detected in a subject by measuring the IFNGS gene expression (e.g. mRNA) in the blood or tissue of the subject and comparing the gene expression levels to expression of house-keeping or control genes, e.g. ACTB, GAPDH, and 18S rRNA, in the blood or tissue.
The upregulation or downregulation of the type I IFN or IFNa-inducible PD markers in the patient's expression profile may be by any degree relative to that of a sample from a control (which may be from a sample that is not disease tissue of the patient (e.g., non-lesional skin of a psoriasis patient) or from a healthy person not afflicted with the disease or disorder) or may be relative to that of genes from the patient whose expression is not changed by the disease (so called “house keeping” genes.)
The degree upregulation or downregulation may be at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 75%, at least 80%, at least 85, at least 90%, at least 95%, at least 100%, at least 125%, at least 150%, or at least 200%, or at least 300%, or at least 400%, or at least 500% or more that of the control or control sample.
Type I IFN or IFNa-inducible PD marker expression profile may be calculated as the average fold increase in the expression or activity of the set of genes comprised by the PD marker. The Type I IFN or IFNa-inducible PD marker expression profile may also be calculated as the difference between the mean Ct (cycle threshold) for the four target genes and the mean Ct of three control genes.
The average fold increase in the expression or activity of the set of genes may be between at least about 2 and at least about 15, between at least about 2 and at least about 10, or between at least about 2 and at least about 5. The average fold increase in the expression or activity of the set of genes may be at least about 2, at least about 2.5, at least about 3, at least about 3.5, at least about 4, at least about 4.5, at least about 5, at least about 5.5, at least about 6, at least about 6.5, at least about 7, at least about 8, at least about 9 or at least about 10. [0047] The degree of increased expression permits the identification of a fold change cutoff for identifying signature positive and signature negative patients suffering from autoimmune diseases. In one embodiment, the cutoff is at least about 2. In another embodiment, the cutoff is at least about 2.5. In another embodiment, the cutoff is at least about 3. In another embodiment, the cutoff is at least about 3.5. In another embodiment, the cutoff is at least about 4. In another embodiment, the cutoff is at least about 4.5. In another embodiment, the cutoff is chosen from at least 3.5, 3.6, 3.7, 3.8, 3.9, 4.0, 4.1, 4.2, 4.3, 4.4, and 4.5. In another embodiment the cutoff is between about 2 and about 8. In one embodiment, the cutoff is the mean of the increased expression levels of at least four of IFI27, IFI44, IFI44L, IFI6 and RSAD2. In another embodiment, the cutoff is the median of the increased expression levels of at least four of IFI27, IFI44, IFI44L, IFI6 and RSAD2.
The degree of increased expression also permits the identification of a delta Ct cutoff for identifying signature positive and signature negative patients suffering from autoimmune diseases. In one embodiment, the cutoff is at least about 7.6. In another embodiment, the cutoff is 7.56. The fold change cutoff may be used to determine an appropriate delta Ct cutoff (e.g., 1<log2 of the fold change <3 corresponds to delta Ct range of 8.65 to 6.56.). Thus, in another embodiment, the delta Ct cutoff is between about 6.56 to about 8.56.
Furthermore, the patient may overexpress or have a tissue that overexpresses a type I IFN subtype at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 75%, at least 80%, at least 90%, at least 100%, at least 125%, at least 150%, or at least 200%, or at least 300%, or at least 400%, or at least 500% that of the control. The type I IFN subtype may be any one of IFNaI, IFNa2, IFNa4, IFNa5, IFNa6, IFNa7, IFNa8, IFNaIO, IFNaI4, IFNaI7, IFNa21, IFNp, or IFNco. The type I IFN subtypes may include all of IFNaI, IFNa2, IFNa8, and IFNaI4.
The up-regulated expression or activity of any gene detected in a sample, by probes, or by probes in kits in an IFNa-inducible PD marker expression profile may be at least 1.2-fold, at least 1.25-fold, at least 1.3-fold, at least 1.4-fold, at least 1.5-fold, at least 2.0-fold, at least 2.25-fold, at least 2.5-fold, at least 2.75-fold, at least 3.0-fold, at least 3.5-fold, at least 4.0-fold, at least 4.5-fold, at least 5.0-fold, at least 6.0-fold, at least 7.0-fold, at least 8.0-fold, at least 9.0-fold, at least 10.0-fold, at least 15.0-fold, at least 20.0-fold, at least 25.0-fold, or at least 50.0-fold relative to baseline levels of control cells, e.g., cells of healthy volunteers or cells of control animals or cells not exposed to IFNa in culture. All of the genes in the IFNa-inducible PD marker expression profile may have up-regulated expression or activity at the same fold increase. Alternatively, the genes in the PD marker expression profile may have varying levels of up-regulated expression or activity.
Up-or down-regulation of gene expression or activity of IFNa-inducible PD markers may be determined by any means known in the art. For example, up-or down-regulation of gene expression may be detected by determining mRNA levels. mRNA expression may be determined by northern blotting, slot blotting, quantitative reverse transcriptase polymerase chain reaction, or gene chip hybridization techniques. See U.S. Pat. Nos. 5,744,305 and 5,143,854 for examples of making nucleic acid arrays for gene chip hybridization techniques. The TAQMAN® method may be used for measuring gene expression7,8.
Primers that selectively bind to targets in polymerase chain reactions (PCR) can be chosen based on empirically determining primers that hybridize in a PCR reaction and produce sufficient signal to detect the target over background, or can be predicted using the melting temperature of the primentarget duplex as described in Maniatis et al. Molecular Cloning, Second Edition, Section 11.46. 1989. Similarly, probes for detecting PCR products in a TAQMAN® or related method can be empirically chosen or predicted. Such primers and probes (collectively “oligonucleotides”) may be between 10 and 30 nucleotides or greater in length.
Up- or down-regulation of gene expression or activity of IFNa-inducible PD markers may be determined by detecting protein levels. Methods for detecting protein expression levels include immuno-based assays such as enzyme-linked immunosorbant assays, western blotting, protein arrays, and silver staining. An IFNa-inducible PD marker expression profile may comprise a profile of protein activity. Up- or down-regulation of gene expression or activity of IFNa-inducible PD markers may be determined by detecting activity of proteins including, but not limited to, detectable phosphorylation activity, de-phosphorylation activity, or cleavage activity.
Furthermore, up-o r down-regulation of gene expression or activity of IFNa-inducible PD markers may be determined by detecting any combination of these gene expression levels or activities.
Samples may also be obtained from patients in the methods of the disclosure. Samples include any biological fluid or tissue, such as whole blood, saliva, urine, synovial fluid, bone marrow, cerebrospinal fluid, nasal secretions, sputum, amniotic fluid, bronchoalveolar lavage fluid, peripheral blood mononuclear cells, total white blood cells, lymph node cells, spleen cells, tonsil cells, or skin. The samples may be obtained by any means known in the art. VI. Methods of monitoring disease progression
In methods of monitoring disease progression of a patient samples from the patient may be obtained before and after administration of an agent, e.g., an agent that binds to and modulates type I IFN or IFNa activity, or an agent that binds to and does not modulate type I IFN or IFNa activity, or a combination of agents that may or may not include an agent that binds to and modulates type I IFN or IFNa activity. Type I IFN or IFNa inducible PD marker expression profiles are obtained in the (before and after agent administration) samples. The type I IFN or IFNa inducible PD marker expression profiles in the samples are compared. Comparison may be of the number of type I IFN or IFNa inducible PD markers present in the samples or may be of the quantity of type I IFN or IFNa inducible PD markers present in the samples, or any combination thereof. Variance indicating efficacy of the therapeutic agent may be indicated if the number or level (or any combination thereof) of up-regulated type I IFN or IFNa inducible PD markers decreases in the sample obtained after administration of the therapeutic agent relative to the sample obtained before administration of the therapeutic agent. The number of up-regulated type I IFN or IFNa inducible PD markers may decrease by at least 1, at least 2, at least 3, at least 4, at least 5, at least 6, at least 7, at least 8, at least 9, or at least 10 fold. The level of any given up-regulated type I IFN or IFNa inducible PD marker may decrease by at least 10%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, at least 90%, or at least 95%. The number of up-regulated type I IFN or IFNa inducible PD markers with decreased levels may be at least 1, at least 2, at least 3, or at least 4. Any combination of decreased number and decreased level of up-regulated type I IFN or IFNa inducible PD markers may indicate efficacy. Variance indicating efficacy of the therapeutic agent may be indicated if the number or level (or any combination thereof) of down-regulated type I IFN or IFNa inducible PD markers decreases in the sample obtained after administration of the therapeutic agent relative to the sample obtained before administration of the therapeutic agent.
The sample obtained from the patient may be obtained prior to a first administration of the agent, i.e., the patient is naive to the agent. Alternatively, the sample obtained from the patient may occur after administration of the agent in the course of treatment. For example, the agent may have been administered prior to the initiation of the monitoring protocol. Following administration of the agent an additional sample may be obtained from the patient and type I IFN or IFNa inducible PD markers in the samples are compared. The samples may be of the same or different type, e.g., each sample obtained may be a blood sample, or each sample obtained may be a serum sample. The type I IFN or IFNa inducible PD markers detected in each sample may be the same, may overlap substantially, or may be similar.
The samples may be obtained at any time before and after the administration of the therapeutic agent. The sample obtained after administration of the therapeutic agent may be obtained at least 2, at least 3, at least 4, at least 5, at least 6, at least 7, at least 8, at least 9, at least 10, at least 12, or at least 14 days after administration of the therapeutic agent. The sample obtained after administration of the therapeutic agent may be obtained at least 2, at least 3, at least 4, at least 5, at least 6, at least 7, or at least 8 weeks after administration of the therapeutic agent. The sample obtained after administration of the therapeutic agent may be obtained at least 2, at least 3, at least 4, at least 5, or at least 6 months following administration of the therapeutic agent.
Additional samples may be obtained from the patient following administration of the therapeutic agent. At least 2, at least 3, at least 4, at least 5, at least 6, at least 7, at least 8, at least 9, at least 10, at least 12, at least 15, at least 20, at least 25 samples may be obtained from the patient to monitor progression or regression of the disease or disorder over time. Disease progression may be monitored over a time period of at least 1 week, at least 2 weeks, at least 3 weeks, at least 4 weeks, at least 5 weeks, at least 6 weeks, at least 7 weeks, at least 2 months, at least 3 months, at least 4 months, at least 5 months, at least 6 months, at least 1 year, at least 2 years, at least 3 years, at least 4 years, at least 5 years, at least 10 years, or over the lifetime of the patient. Additional samples may be obtained from the patient at regular intervals such as at monthly, bi-monthly, once a quarter year, twice a year, or yearly intervals. The samples may be obtained from the patient following administration of the agent at regular intervals. For instance, the samples may be obtained from the patient at one week following each administration of the agent, or at two weeks following each administration of the agent, or at three weeks following each administration of the agent, or at one month following each administration of the agent, or at two months following each administration of the agent. Alternatively, multiple samples may be obtained from the patient following each administration of the agent.
Disease progression in a patient may similarly be monitored in the absence of administration of an agent. Samples may periodically be obtained from the patient having the disease or disorder. Disease progression may be identified if the number of type I IFN or IFNa inducible PD markers increases in a later-obtained sample relative to an earlier obtained sample. The number of type I IFN or IFNa inducible PD markers may increase by at least 1, at least 2, at least 3, at least 4, at least 5, at least 6, at least 7, at least 8, at least 9, or at least 10. Disease progression may be identified if level of any given up-regulated type I IFN or IFNa inducible PD marker increases by at least 10%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, at least 90%, or at least 95%. Disease progression may be identified if level of any given down-regulated type I IFN or IFNa inducible PD marker decreases by at least 10%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, at least 90%, or at least 95%. The number of up-regulated type I IFN or IFNa inducible PD markers with increased levels may be at least 1, at least 2, at least 3, at least 4, at least 5, at least 6, at least 7, at least 8, at least 9, at least 10, at least 15, at least 20, at least 25, at least 30, or at least 35. The number of down-regulated type I IFN or IFNa inducible PD markers with decreased levels may be at least 1, at least 2, at least 3, at least 4, at least 5, at least 6, at least 7, at least 8, at least 9, at least 10, at least 15, at least 20, at least 25, at least 30, or at least 35. Any combination of increased number and increased level of up-regulated type I IFN or IFNa inducible PD marker may indicate disease progression. Alternatively, or in combination, any combination of decreased number and decreased level of down-regulated type I IFN or IFNa inducible PD marker may indicate disease progression. Disease regression may also be identified in a patient having a disease or disorder, not treated by an agent. In this instance, regression may be identified if the number of type I IFN or IFNa inducible PD markers decreases in a later-obtained sample relative to an earlier obtained sample. The number of type I IFN or IFNa inducible PD markers may decrease by at least 1, at least 2, at least 3, at least 4, at least 5, at least 6, at least 7, at least 8, at least 9, or at least 10. Disease regression may be identified if level of any given up-regulated type I IFN or IFNa inducible PD marker decreases by at least 10%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, at least 90%, or at least 95%. Disease regression may be identified if level of any given down-regulated type I IFN or IFNa inducible PD marker increases by at least 10%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, at least 90%, or at least 95%. The number of up-regulated type I IFN or IFNa inducible PD markers with decreased levels may be at least 1, at least 2, at least 3, at least 4, at least 5, at least 6, at least 7, at least 8, at least 9, at least 10, at least 15, at least 20, at least 25, at least 30, or at least 35. The number of down-regulated type I IFN or IFNa inducible PD markers with increased levels may be at least 1, at least 2, at least 3, at least 4, at least 5, at least 6, at least 7, at least 8, at least 9, at least 10, at least 15, at least 20, at least 25, at least 30, or at least 35. Disease progression or disease regression may be monitored by obtaining samples over any period of time and at any interval. Disease progression or disease regression may be monitored by obtaining samples over the course of at least 1 week, at least 2 weeks, at least 3 weeks, at least 4 weeks, at least 5 weeks, at least 6 weeks, at least 7 weeks, at least 2 months, at least 3 months, at least 4 months, at least 5 months, at least 6 months, at least 1 year, at least 2 years, at least 3 years, at least 4 years, at least 5 years, at least 10 years, or over the lifetime of the patient. Disease progression or disease regression may be monitored by obtaining samples at least monthly, bi-monthly, once a quarter year, twice a year, or yearly. The samples need not be obtained at strict intervals.
The disclosure also encompasses kits and probes. The probes may be any molecule that detects any expression or activity of any gene that may be included in an IFNa-inducible PD marker expression profile.
The term “subject” is intended to include human and non-human animals, particularly mammals. The subject may be an adult human patient. The subject may be a patient with moderate to severe SLE.
The terms “treatment” or “treat” as used herein refer to both therapeutic treatment and prophylactic or preventative measures. Those in need of treatment include subjects having SLE as well as those prone to having SLE or those in which SLE is to be prevented. In some embodiments, the methods disclosed herein can be used to treat SLE.
The terms “administration” or “administering” as used herein refer to providing, contacting, and/or delivering a compound or compounds by any appropriate route to achieve the desired effect. Administration may include, but is not limited to, oral, sublingual, parenteral (e.g., intravenous, subcutaneous, intracutaneous, intramuscular, intraarticular, intraarterial, intrasynovial, intrasternal, intrathecal, intralesional, or intracranial injection), transdermal, topical, buccal, rectal, vaginal, nasal, ophthalmic, via inhalation, and implants.
The method may comprise administering an intravenous dose of anifrolumab or the functional variant thereof to the subject. The intravenous dose may be ≥300 mg anifrolumab or the functional variant thereof. The intravenous dose may be ≤1000 mg. The intravenous dose may be about 300 mg, about 900 mg or about 1000 mg. The intravenous dose may be administered every four weeks (Q4W).
The method may comprise administering a subcutaneous dose of anifrolumab or the functional variant thereof. The subcutaneous dose may be >105 mg and <150 mg anifrolumab or the functional variant thereof. The subcutaneous dose may be ≤135 mg anifrolumab or the functional variant thereof. The subcutaneous dose may be about 120 mg. The subcutaneous dose may be administered in a single administration step. The subcutaneous dose may be administered at intervals of 6-8 days. The subcutaneous dose may be administered once per week. The subcutaneous dose may have a volume of about 0.5 to about 1 m. The subcutaneous dose may have a volume of about 0.8 ml.
The terms “pharmaceutical composition” as used herein refers to a compound or composition capable of inducing a desired therapeutic effect when properly administered to a subject. In some embodiments, the disclosure provides a pharmaceutical composition comprising a pharmaceutically acceptable carrier and a therapeutically effective amount of at least one antibody of the disclosure.
The terms “pharmaceutically acceptable carrier” or “physiologically acceptable carrier” as used herein refer to one or more formulation materials suitable for accomplishing or enhancing the delivery of one or more antibodies of the disclosure.
The term “antigen-binding fragment” refers to one or more fragments of an antibody that retain(s) the ability to specifically bind to the antigen. Examples of antigen-binding fragments include the following: Fab fragment, F (ab′)2 fragment, Fd fragment, Fv fragment, dAb fragment, as well as a scFv.
Systemic lupus erythematosus (SLE) is a chronic, multisystemic, disabling autoimmune rheumatic disease of unknown etiology. Systemic lupus erythematosus predominantly affects women of childbearing years with a recent review reporting the female-to-male ratio in the childbearing years to be about 12:1. Accurate data on the current incidence and prevalence of SLE are largely lacking, however there are numerous indications that SLE is more common in non-Caucasian populations; for example, in the United States of America (USA), SLE is more prevalent in African-Americans, Hispanics, and Asians than Caucasians. As a result, SLE prevalence varies from country to country. In addition, variability of SLE prevalence within countries appears to be dependent upon racial, genetic differences, complex socioeconomic factors and age; the incidence of disease in females is usually highest between 15-44 years of age.
Clinical manifestations of SLE can include constitutional symptoms, alopecia and rashes, serositis, inflammatory arthritis, renal disease, systemic vasculitis, lymphadenopathy, splenomegaly, hemolytic anemia, cognitive dysfunction and other central nervous system (CNS) involvement. These disease manifestations cause a significant burden of illness and can cause reduced physical function, loss of employment, lower health-related quality of life (HRQoL), and a lifespan shortened by about 10 years. Increased hospitalizations and side effects of medications including chronic oral corticosteroids (OCS) and other immunosuppressive treatments add to disease burden in SLE At this time, belimumab is the only new treatment for SLE that has been approved by the Food and Drug Administration (FDA) in about 50 years since hydroxychloroquine was approved for use in discoid lupus and SLE. The existing standard of care treatment for SLE (SOC SLE) otherwise consists of off-label medications. lupus erythematosus.
CLASI is a tool used to measure disease severity and response to treatment. A 4-point or 20% decrease in CLASI activity score is commonly viewed as a cut-off for classifying subjects as responders to treatment. In particular embodiments, treatment using anifrolumab results in at least 50% reduction of a subject's CLASI score compared to the subject's baseline score.
The CLASI is a validated index used for assessing the cutaneous lesions of SLE and consists of 2 separate scores: the first summarizes the inflammatory activity of the disease; the second is a measure of the damage done by the disease. The activity score takes into account erythema, scale/hypertrophy, mucous membrane lesions, recent hair loss, and nonscarring alopecia. The damage score represents dyspigmentation, scarring/atrophy/panniculitis, and scarring of the scalp. Subjects are asked if their dyspigmentation lasted 12 months or longer, in which case the dyspigmentation score is doubled. Each of the above parameters is measured in 13 different anatomical locations, included specifically because they are most often involved in cutaneous lupus erythematosus (CLE). The most severe lesion in each area is measured.
In particular embodiments, treatment using anifrolumab reduces a subject's CLASI score by at least week 8, week 12, week 24, week 36, week 48, or week 52 of treatment. In particular embodiments, treatment using anifrolumab reduces a subject's CLASI score by at least week 8. In particular embodiments, treatment using anifrolumab reduces a subject's CLASI score by at least week 12.
In particular embodiments provided herein is a method of treating systemic lupus erythematosus in a subject in need thereof, comprising administering to the subject a therapeutically effective amount of anifrolumab, wherein the treatment results in a reduction in the Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) score compared to a patient receiving placebo.
Oral corticosteroids include prednisone, cortisone, hydrocortisone, methylprednisolone, prednisolone and triamcinolone.
In particular embodiments provided herein is a method of treating systemic lupus erythematosus in a subject in need thereof, wherein the subject is being treated with oral corticosteroids, comprising administering to the subject a therapeutically effective amount of anifrolumab, wherein the treatment results in a reduction in oral corticosteroid dosage in the subject to at least ≤5.5 mg/day, ≤6.5 mg/day, ≤7.5 mg/day, or ≤8.5 mg/day. In particular embodiments, the reduction in oral corticosteroid dosage in the subject is reduced to at least ≤7.5 mg/day. In particular embodiments, the treatment results in a reduction in oral corticosteroid dosage in the subject from ≥10 mg/day to ≤7.5 mg/day.
In particular embodiments provided herein is a method of treating systemic lupus erythematosus in a subject in need thereof, wherein the subject is being treated with oral corticosteroids, comprising administering to the subject a therapeutically effective amount of anifrolumab, wherein the treatment results in a reduction in oral corticosteroid dosage in the subject to at least ≤5.5 mg/day, ≤6.5 mg/day of prednisone or prednisone equivalent dose, ≤7.5 mg/day of prednisone or prednisone equivalent dose, or ≤8.5 mg/day of prednisone or prednisone equivalent dose. In particular embodiments, the reduction in oral corticosteroid dosage in the subject is reduced to at least ≤7.5 mg/day. In particular embodiments, the treatment results in a reduction in oral corticosteroid dosage in the subject from ≥10 mg/day to ≤7.5 mg/day of prednisone or prednisone equivalent dose.
Examples of equivalent doses of oral prednisone are shown in Table 6-3.
Type I interferons (IFN) are cytokines that form a crucial link between innate and adaptive immunity and are implicated in SLE by genetic susceptibility data and upregulated interferon-stimulated gene expression in the majority of SLE patients9.
Anifrolumab (MEDI-546, “ANI”, “anifro”) inhibits binding of type I IFN to type I interferon receptor (IFNAR) and inhibits the biologic activity of all type I IFNs. Anifrolumab (MEDI-546) is a human immunoglobulin G1 kappa (lgG1K) monoclonal antibody (mAb) directed against subunit 1 of the type I interferon receptor (IFNAR1). It is composed of 2 identical light chains and 2 identical heavy chains, with an overall molecular weight of approximately 148 kDa. Disclosure related to anifrolumab can be found in U.S. Pat. Nos. 7,662,381 and 9,988,459, which are incorporated herein by reference.
Anifrolumab is an IFNAR-blocking (antagonistic) antibody, and blocks the activity of the receptor's ligands, namely type I interferons such as interferon-α and interferon-β. Anifrolumab thus provides for downregulation of IFNAR signaling, and thus suppression of IFN-inducible genes.
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Thus, anifrolumab is an antibody comprising an HCDR1, HCDR2 and HCDR3 of SEQ ID NO: 3, SEQ ID NO: 4, and SEQ ID NO: 5, respectively (or functional variant thereof); and an LCDR1, LCDR2 and LCDR3 of SEQ ID NO: 6, SEQ ID NO: 7, and SEQ ID NO: 8, respectively (or functional variant thereof). In more detail, anifrolumab as referred to herein is an antibody comprising a VH of SEQ ID NO: 1 and a VL of SEQ ID NO: 2 (or functional variant thereof).
The present invention encompasses the antibodies defined herein having the recited CDR sequences or variable heavy and variable light chain sequences (reference (anifrolumab) antibodies), as well as functional variants thereof. A “functional variant” binds to the same target antigen as the reference (anifrolumab) antibody. The functional variants may have a different affinity for the target antigen when compared to the reference antibody, but substantially the same affinity is preferred.
In one embodiment functional variants of a reference (anifrolumab) antibody show sequence variation at one or more CDRs when compared to corresponding reference CDR sequences. Thus, a functional antibody variant may comprise a functional variant of a CDR. Where the term “functional variant” is used in the context of a CDR sequence, this means that the CDR has at most 2, preferably at most 1 amino acid differences when compared to a corresponding reference CDR sequence, and when combined with the remaining 5 CDRs (or variants thereof) enables the variant antibody to bind to the same target antigen as the reference (anifrolumab) antibody, and preferably to exhibit the same affinity for the target antigen as the reference (anifrolumab) antibody.
Without wishing to be bound by theory, since anifrolumab targets (e.g. blocks or antagonizes) IFNAR, it is believed that anifrolumab treats a disease (such as SLE) by blocking signaling initiated by type I interferons (IFNs). Type I IFNs are known to be important drivers of inflammation (e.g. by coordinating the type I interferon response), and thus play a pivotal role in the immune system. However, dysregulation of type I IFN-signaling can lead to aberrant (e.g. aberrantly high) levels of inflammation, and autoimmunity. Such dysregulation of type I IFN interferons has been reported in numerous autoimmune diseases.
For example, a variant of the reference (anifrolumab) antibody may comprise:
Preferably, a variant of the reference (anifrolumab) antibody may comprise:
In one embodiment a variant antibody may have at most 5, 4 or 3 amino acid differences total in the CDRs thereof when compared to a corresponding reference (anifrolumab) antibody, with the proviso that there is at most 2 (preferably at most 1) amino acid differences per CDR. Preferably a variant antibody has at most 2 (more preferably at most 1) amino acid differences total in the CDRs thereof when compared to a corresponding reference (anifrolumab) antibody, with the proviso that there is at most 2 amino acid differences per CDR. More preferably a variant antibody has at most 2 (more preferably at most 1) amino acid differences total in the CDRs thereof when compared to a corresponding reference (anifrolumab) antibody, with the proviso that there is at most 1 amino acid difference per CDR.
The amino acid difference may be an amino acid substitution, insertion or deletion. In one embodiment the amino acid difference is a conservative amino acid substitution as described herein.
In one embodiment a variant antibody may have at most 5, 4 or 3 amino acid differences total in the framework regions thereof when compared to a corresponding reference (anifrolumab) antibody, with the proviso that there is at most 2 (preferably at most 1) amino acid differences per framework region. Preferably a variant antibody has at most 2 (more preferably at most 1) amino acid differences total in the framework regions thereof when compared to a corresponding reference (anifrolumab) antibody, with the proviso that there is at most 2 amino acid differences per framework region. More preferably a variant antibody has at most 2 (more preferably at most 1) amino acid differences total in the framework regions thereof when compared to a corresponding reference (anifrolumab) antibody, with the proviso that there is at most 1 amino acid difference per framework region.
Thus, a variant antibody may comprise a variable heavy chain and a variable light chain as described herein, wherein:
The variant heavy or light chains may be referred to as “functional equivalents” of the reference heavy or light chains.
In one embodiment a variant antibody may comprise a variable heavy chain and a variable light chain as described herein, wherein:
Functional variants of anifrolumab are sequence variants that perform the same function as anifrolumab. Functional variants of anifrolumab are variants that bind the same target as anifrolumab and have the same effector function as anifrolumab. Functional anifrolumab variants include antigen-binding fragments of anifrolumab and antibody and immunoglobulin derivatives of anifrolumab. Functional variants include biosimilars and interchangeable products. The terms biosimilar and interchangeable product are defined by the FDA and EMA. The term biosimilar refers to a biological product that is highly similar to an approved (e.g. FDA approved) biological product (reference product, e.g. anifrolumab) in terms of structure and has no clinically meaningful differences in terms of pharmacokinetics, safety and efficacy from the reference product. The presence of clinically meaningful differences of a biosimilar may be assessed in human pharmacokinetic (exposure) and pharmacodynamic (response) studies and an assessment of clinical immunogenicity. An interchangeable product is a biosimilar that is expected to produce the same clinical result as the reference product in any given patient.
Thus, in one embodiment the type I interferon receptor inhibitor is anifrolumab or a functional variant thereof.
Functional variants of anifrolumab include the antibodies described in WO 2018/023976 A1, incorporated herein by reference (Table 6-5).
Functional variants include antibodies comprising the VH amino acid sequence SEQ ID NO: 13. Functional variants include antibodies comprising the VH amino acid sequence SEQ ID NO: 16. Functional variants include antibodies comprising the VL amino acid sequence SEQ ID NO: 14. Functional variants include antibodies comprising the VL amino acid sequence SEQ ID NO: 15. Functional variants include antibodies comprising the VL amino acid sequence SEQ ID NO: 16. Functional variants include antibodies comprising the VH sequence SEQ ID NO: 13 and VL amino acid sequence SEQ ID NO: 16. Functional variants include antibodies comprising the VH sequence SEQ ID NO: 13 and VL amino acid sequence SEQ ID NO: 15. Functional variants include antibodies comprising the VH sequence SEQ ID NO: 16 and VL amino acid sequence SEQ ID NO: 15. Functional variants include antibodies comprising the VH sequence SEQ ID NO: 16 and VL amino acid sequence SEQ ID NO: 14.
IFNAR inhibitors may be a monoclonal antibody comprising the VH amino acid sequence SEQ ID NO: 13. The anti-IFNAR antibodies may comprise the VH amino acid sequence SEQ ID NO: 16. The anti-IFNAR antibodies may comprise the VL amino acid sequence SEQ ID NO: 14. The anti-IFNAR antibodies may comprise the VL amino acid sequence SEQ ID NO: 15. The anti-IFNAR antibodies may comprise the VL amino acid sequence SEQ ID NO: 16. The anti-IFNAR antibodies may comprise the VH sequence SEQ ID NO: 13 and VL amino acid sequence SEQ ID NO: 16. The anti-IFNAR antibodies may comprise the VH sequence SEQ ID NO: 13 and VL amino acid sequence SEQ ID NO: 15. The anti-IFNAR antibodies may comprise the VH sequence SEQ ID NO: 16 and VL amino acid sequence SEQ ID NO: 15. The anti-IFNAR antibodies may comprise the VH sequence SEQ ID NO: 16 and VL amino acid sequence SEQ ID NO: 14.
Sifalimumab (MEDI-545) is a fully human, immunoglobulin G1K monoclonal antibody that binds to and neutralizes the majority of IFN-α subtypes10. Sifalimumab is described U.S. Pat. No. 7,741,449, which is incorporated herein by reference in its entirety. The efficacy and safety of sifalimumab were assessed in a phase IIb, randomised, double-blind, placebo-controlled study (NCT01283139) of adults with moderate to severe active systemic lupus erythematosus (SLE). 431 patients were randomised and received monthly intravenous sifalimumab (200 mg, 600 mg or 1200 mg) or placebo in addition to standard-of-care medications. The primary efficacy end point was the percentage of patients achieving an SLE responder index response at week 52. Compared with placebo, a greater percentage of patients who received sifalimumab (all dosages) met the primary end point (placebo: 45.4%; 200 mg: 58.3%; 600 mg: 56.5%; 1200 mg 59.8%).
Administration of sifalimumab to SLE patients having an elevated type I IFN signature neutralises the IFNGS11,12.
The swollen and tender joint count is based on left and right shoulder, elbow, wrist, metacarpophalangeal (MCP) 1, MCP2, MCP3, MCP4, MCP5, proximal interphalangeal (PIP) 1, PIP2, PIP3, PIP4, PIP5 joints of the upper extremities and left and right knee of the lower extremities. An active joint for the joint count assessment is defined as a joint with tenderness and swelling.
In particular embodiments provided herein is method of treating systemic lupus erythematosus in a subject in need thereof, comprising administering to the subject a therapeutically effective amount of anifrolumab, wherein the treatment results in at least 50% improvement from baseline value of tender joint count and swollen joint count compared to a patient receiving placebo.
The dose of the anifrolumab to be administered to the subject may vary depending, in part, upon the size (body weight, body surface, or organ size) and condition (the age and general health) of the subject.
In particular embodiments, the subject is administered one or more fixed doses of anifrolumab, wherein the dose is 150 mg, 200 mg, 250 mg, 300 mg, or 350 mg. In some embodiments, the subject is administered one or more fixed doses of anifrolumab wherein the dose is 300 mg.
In particular embodiments, anifrolumab is administered over a two-week treatment period, over a four-week treatment period, over a six-week treatment period, over an eight-week treatment period, over a twelve-week treatment period, over a twenty-four-week treatment period, or over a one-year or more treatment period. In particular embodiments, anifrolumab is administered over a three-week treatment period, over a six-week treatment period, over a nine-week treatment period, over a twelve-week treatment period, over a twenty-four-week treatment period, or over a one-year or more treatment period. In particular embodiments, anifrolumab is administered for at least 52 weeks.
In particular embodiments, anifrolumab is administered every week, every two weeks, every four weeks, every six weeks, every eight weeks, every ten weeks, or every twelve weeks.
When used for in vivo administration, the formulations of the disclosure should be sterile. The formulations of the disclosure may be sterilized by various sterilization methods, including, for example, sterile filtration or radiation. In one embodiment, the formulation is filter sterilized with a presterilized 0.22-micron filter. Sterile compositions for injection can be formulated according to conventional pharmaceutical practice as described in “Remington: The Science & Practice of Pharmacy,” 21st ed., Lippincott Williams & Wilkins, (2005).
In some embodiments, type I IFN inhibitor can be formulated for particular routes of administration, such as oral, nasal, pulmonary, topical (including buccal and sublingual), rectal, vaginal, and/or parenteral administration. The terms “parenteral administration” and “administered parenterally” as used herein refer to modes of administration other than enteral and topical administration, usually by injection, and includes, without limitation, intravenous, intramuscular, intraarterial, intrathecal, intracapsular, intraorbital, intracardiac, intradermal, intraperitoneal, transtracheal, subcutaneous, subcuticular, intraarticular, subcapsular, subarachnoid, intraspinal, epidural and intrasternal injection, and infusion.
In some embodiments, anifrolumab can be formulated for particular routes of administration, such as oral, nasal, pulmonary, topical (including buccal and sublingual), rectal, vaginal, and/or parenteral administration. The terms “parenteral administration” and “administered parenterally” as used herein refer to modes of administration other than enteral and topical administration, usually by injection, and includes, without limitation, intravenous, intramuscular, intraarterial, intrathecal, intracapsular, intraorbital, intracardiac, intradermal, intraperitoneal, transtracheal, subcutaneous, subcuticular, intraarticular, subcapsular, subarachnoid, intraspinal, epidural and intrasternal injection, and infusion.
The formulations can be presented in unit dosage form and can be prepared by any method known in the art of pharmacy. Actual dosage levels of the active ingredients in the formulation of the present disclosure may be varied so as to obtain an amount of the active ingredient which is effective to achieve the desired therapeutic response for a particular subject, composition, and mode of administration, without being toxic to the subject (e.g., “a therapeutically effective amount”). Dosages can also be administered via continuous infusion (such as through a pump). The administered dose may also depend on the route of administration.
The pharmaceutical composition may comprise about 150 mg/mL anifrolumab. The pharmaceutical composition may comprise 50 mM lysine HCl. The pharmaceutical composition may comprise 130 mM trehalose dihydrate. The pharmaceutical composition may comprise 0.05% polysorbate 80. The pharmaceutical composition may comprise 25 mM histidine/histidine HCl. The pharmaceutical composition may have a pH of 5.9.
Type I IFN is considered important in SLE disease pathogenesis and inhibition of this pathway is targeted by anifrolumab. To understand the relationship between type I IFN expression and response to anti-IFN therapy, it is necessary to know if a subject's disease is driven by type I IFN activation. However, direct measurement of the target protein remains a challenge. As such, a transcript-based marker was developed to evaluate the effect of over expression of the target protein on a specific set of mRNA markers. The expression of these markers is easily detected in whole blood and demonstrates a correlation with expression in diseased tissue such as skin in SLE. The bimodal distribution of the transcript scores for SLE subjects supports defining an IFN test high and low subpopulation (
A subject achieves SRI(4) if all of the following criteria are met:
SRI (X) (X=5, 6, 7, or 8) is defined by the proportion of subjects who meet the following criteria:
The BILAG-2004 is a translational index with 9 organ systems (General, Mucocutaneous, Neuropsychiatric, Musculoskeletal, Cardiorespiratory, Gastrointestinal, Ophthalmic, Renal and Haematology) that is able to capture changing severity of clinical manifestations. It has ordinal scales by design and does not have a global score; rather it records disease activity across the different organ systems at a glance by comparing the immediate past 4 weeks to the 4 weeks preceding them. It is based on the principle of physicians' intention to treat and categorises disease activity into 5 different levels from A to E:
Although the BILAG-2004 was developed based on the principle of intention to treat, the treatment has no bearing on the scoring index. Only the presence of active manifestations influences the scoring.
BICLA is a composite index that was originally derived by expert consensus of disease activity indices. BICLA response is defined as (1) at least one gradation of improvement in baseline BILAG scores in all body systems with moderate or severe disease activity at entry (e.g., all A (severe disease) scores falling to B (moderate), C (mild), or D (no activity) and all B scores falling to C or D); (2) no new BILAG A or more than one new BILAG B scores; (3) no worsening of total SLEDAI score from baseline; (4) no significant deterioration (≤10%) in physicians global assessment; and (5) no treatment failure (initiation of non-protocol treatment).
Particularly, a subject is a BICLA responder if the following criteria are met:
In particular embodiments, treatment using anifrolumab improves a subject's BICLA response rate by at least week 8, week 12, week 24, week 36, week 48, or week 52 of treatment. In particular embodiments, treatment using anifrolumab improves a subject's BICLA response rate by at least week 8.
In particular embodiments, while the subject shows improvement in the BICLA response, the subject does not show improvement in the Systemic Lupus Erythematosus Responder Index (SRI)4 score.
In particular embodiments provided herein is a method of treating systemic lupus erythematosus in a subject in need thereof, comprising administering to the subject a therapeutically effective amount of anifrolumab, wherein the treatment results in an improvement of the BILAG-Based Composite Lupus Assessment (BICLA) response rate compared to a patient receiving placebo. The improvement of the BILAG response rate may be statistically significant. The improvement of the BILAG response rate may be statistically significant after multiplicity adjustment. The improvement of the BILAG response rate may be statistically significant, wherein statistical significance is determined by p<0.05 or p<0.005.
Belimumab is an anti-BAFF antibody approved for the treatment of SLE patients with active, autoantibody-positive disease, who are already on standard therapy. Belimumab selectively binds to soluble human B lymphocyte stimulator protein (BAFF, also known as BLysS). Belimumab is a fully human lgG1λ recombinant monoclonal antibody directed against BLyS. Specific binding of belimumab with the soluble BLyS prevents the interaction of BLys with its receptors and decreases B-cell survival and production of autoantibodies.
Belimumab sequences are shown in Table 6-6.
The BLISS-52 (NCT00424476) and 76 (NCT00410384) were phase III randomised trials conducted to evaluate belimumab efficacy and safety throughout 52 and 76 weeks of treatment respectively. Not all SLE patients do not respond to belimumab treatment. A better response to belimumab treatment has been associated with higher baseline disease activity (SELENA-SLEDAI ≥10), anti-dsDNA positivity, low complement levels or corticosteroid treatment at baseline. The baseline levels of serum BAFF were not demonstrated as a predictor of clinical response13.
Belimumab is approved for the treatment of SLE administered by intravenous infusion, at a dose of 10 mg/kg at 2-week intervals for the first 3 doses and at 4-week intervals thereafter. Belimumab is also approved for the treatment of SLE administered by subcutaneous injection, at a dose of 200 mg once weekly. Belimumab formulations are described in US patent application US20180289804 A1 which is incorporated herein by reference in its entirety. Belimumab may be administered at a dose of 10 mg/kg on days 0, 14 and 28, and at 4-week intervals thereafter. Belimumab may be administered at 10 mg/kg every 2 weeks for the first three doses, and then given every 4 weeks. Dosage information for belimumab is provided in Table 6-7.
Tabalumab (LY2127399) is a human IgG4 monoclonal antibody that binds both soluble and membrane-bound B-cell activating factor (BAFF). The efficacy and safety of tabalumab was assessed in two 52-week, phase III, multicentre randomized, double-blind, placebo-controlled trial in patients with moderate-to-severe SLE (ILLUMINATE-1 and ILLUMINATE-2). The primary endpoint was proportion of patients achieving SLE Responder Index 5 (SRI-5) response at week 52. In ILLUMINATE-1 (NCT01196091), the primary endpoint was not met. Key secondary efficacy endpoints (OCS sparing, time to severe flare, worst fatigue in the last 24 hours) also did not achieve statistical significance, despite pharmacodynamic evidence of tabalumab biological activity (significant decreases in anti-dsDNA, total B-cells, and immunoglobulins)38. The primary endpoint was met in ILLUMINATE-2 (NCT01205438) in the higher dose group (tabalumab 120 mg every 2 weeks). However, no secondary endpoints were met, including OCS sparing39. Following ILLUMINATE-1 and ILLUMINATE-2, tabalumab development was suspended given the small effect size and inability to meet other important clinical endpoints. Dose information is provided in Table 6-8.
In particular embodiments, treatment using anifrolumab results in an MCR. In particular embodiments, treatment using anifrolumab results in a PCR.
The SF-36-v2 (acute) is a multipurpose, 36-item survey that measures 8 domains of health: physical functioning, role limitations due to physical health, bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional problems, and mental health. It yields scale scores for each of these 8 health domains, and summary measures of physical and mental health: the Physical Component Summary and Mental Component Summary.
The FACIT-F is a 13-item subject-completed questionnaire to assess the impact of fatigue over the previous 7 days. The responses range from 0 (Not at All) to 4 (Very Much). Final scores are the sum of the responses and range from 0 to 52; higher scores indicate better QoL (Yellen et al, 1997). Changes in scores >3 points are considered to be clinically meaningful.
The PtGA is a single-item question that takes into account all the ways in which illness and health conditions may affect the patient at this time. The patient should consider the previous week when answering this question. Responses range from very well to very poor on a 100 mm VAS. The physician and subject must complete the PGA and PtGA, respectively, independently of each other.
A Major Clinical Response (MCR) includes BICLA scores C or better at Week 24, maintained with no new A or B scores between Week 24-52. A Partial Clinical Response (PCR) includes a maximum of 1 BICLA score at Week 24, maintained without new A or >1 new B domain score through Week 52.
Physician Global Assessment (PGA) of Disease Activity refers to an assessment wherein a physician evaluates the status of a subject's psoriatic arthritis (PsA) by means of a visual analog scale (VAS). The subject is assessed according to how their current arthritis is. The VAS is anchored with verbal descriptors of “very good” to “very poor.”
The method may comprise measuring PROs in the subject before and after administration of anifrolumab. The PRO's may comprise the subject's Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Short Form 36 Health Survey version 2 (SF-36-v2), mental component summary (MCS), and/or SF-36, physical component summary (PCS) score.
The Examples that follow are illustrative of specific embodiments of the disclosure, and various uses thereof. They are set forth for explanatory purposes only and should not be construed as limiting the scope of the disclosure in any way.
Study 1013 (NCT01438489) was a Phase 2, multinational, multicenter, randomized, double-blind, placebo controlled, parallel-group study to evaluate the efficacy and safety of 2 intravenous (IV) treatment regimens in adult participants with chronic, moderately-to-severely active SLE with an inadequate response to SOC SLE. The investigational product (anifrolumab or placebo) was administered as a fixed dose every 4 weeks (28 days) for a total of 13 doses.
Study 1013 randomized 307 patients (1:1:1) and compared anifrolumab, 300 mg or 1000 mg, to placebo. The primary endpoint was a combined assessment of the SLE Responder Index (SRI-4, a composite endpoint) and the sustained reduction in OCS (<10 mg/day and ≤OCS dose at week 1, sustained for 12 weeks) measured at Week 24; a significantly higher proportion of anifrolumab 300 mg-treated patients achieved SRI-4 response and sustained OCS reduction (anifrolumab: placebo 34% vs 18%). Pre-specified analysis of disease activity measured by British Isles Lupus Assessment Group based Composite Lupus Assessment (BICLA) was 53% for anifrolumab and 25% placebo at Week 52. The dose-response modelling and benefit-risk profile supported the evaluation of the 300 mg dose in the subsequent studies.
Study 1145 (NCT01753193) was an open-label extension (OLE) for subjects completing study 1013. In particular, Study 1145 was a 3-year, multinational OLE in adults with moderate to severe SLE (per ACR classification criteria, assessed in Study 1013) who completed randomized treatment with anifrolumab 1000 or 300 mg or placebo in Study 1013 to Day 337 with follow-up to Day 422. All patients in Study 1145 initially received IV anifrolumab 1000 mg every 4 weeks (Q4W). After data from Study 1013 showed the 300-mg dose had a better benefit/risk profile, the dosage in Study 1145 was amended to 300 mg Q4W. Patients received anifrolumab Q4W over 156 weeks with 85 days of follow-up. The primary objective was to evaluate long-term safety/tolerability. Efficacy, pharmacodynamics, and health-related quality of life (HRQoL) were exploratory objectives. Safety was assessed at every visit; SLEDAI-2K and SLICC Damage Index were measured every 3 and 6 months, respectively.
Type I IFN inducible signature in whole blood was assessed by a 21-gene assay to be used as a PD marker to follow the biologic effect of anifrolumab on its target throughout the study. Whole blood was collected in order to evaluate the mRNA expression levels of 21 type I IFN-inducible genes (Table 6-2).
The purpose of these study was to evaluate the efficacy and safety of an intravenous treatment regimen of two doses of anifrolumab versus placebo in adult subjects with moderately to severely active, autoantibody-positive systemic lupus erythematosus (SLE). The studies were Phase 3, multi-centre, multinational, randomized, double-blind, placebo-controlled studies to evaluate the efficacy and safety of an intravenous treatment regimen of two doses of anifrolumab versus placebo in subjects with moderately to severely active, autoantibody-positive systemic lupus erythematosus (SLE) while receiving standard of care (SOC) treatment.
TULIP I and II were similar in design, the primary endpoint was improvement in disease activity evaluated at 52 weeks, measured by SRI-4 and BICLA, respectively. The common secondary efficacy endpoints included in both studies were the maintenance of OCS reduction, improvement in cutaneous SLE activity measured by Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI), and annualized flare rate. An assessment of improvement in joint activity was included as a secondary endpoint in TULIP II. Both studies evaluated the efficacy of anifrolumab 300 mg versus placebo; a dose of 150 mg was also evaluated for dose-response in TULIP I.
Patient demographics were generally similar in both trials; 92% and 93% were female, 71% and 60% were White, 14% and 12% were Black/African American, and 5% and 17% were Asian, in TULIP I and II respectively. In both trials, 72% of patients had high disease activity (SLEDAI-2K score ≥10). In TULIP I and II respectively, 48% and 49% had severe disease (BILAG A) in at least 1 organ system and 46% and 47% of patients had moderate disease (BILAG B) in at least 2 organ systems. The most commonly affected organ systems (BILAG A or B at baseline) were the mucocutaneous (TULIP I: 87%, TULIP II: 85%) and musculoskeletal (TULIP II: 89%, TULIP II: 88%) systems; 7.4% and 8.8% of patients had cardiorespiratory, and 7.9% and 7.5% had renal manifestations at baseline, in TULIP I and II respectively.
In TULIP I and II, 90% of patients (both trials) were seropositive for anti-nuclear antibodies (ANA), and 45% and 44% for anti-double-stranded DNA (anti-dsDNA) antibodies, 34% and 40% had low C3, and 21% and 26% had low C4. The majority of patients were classified as interferon gene signature test-high at baseline (TULIP 1: 82%, TULIP II: 83%). Baseline concomitant standard therapy medications included oral corticosteroids (TULIP I: 83%, TULIP II: 81%), antimalarials (TULIP 1: 73%, TULIP II: 70%) and immunosuppressants (TULIP 1: 47%, TULIP: II: 48%; including azathioprine, methotrexate, mycophenolate and mizoribine). For those patients taking OCS (prednisone or equivalent) at baseline, the mean daily dose was 12.3 mg in TULIP I and 10.7 mg in TULIP II. During Weeks 8-40, patients with a baseline OCS ≥10 mg/day were required to taper their OCS dose to ≤7.5 mg/day, unless there was worsening of disease activity.
Randomization was stratified by disease severity (SLEDAI-2K score at baseline, <10 vs ≥10 points), OCS dose on Day 1 (<10 mg/day vs ≥10 mg/day prednisone or equivalent) and interferon gene signature test results (high vs low).
TULIP I randomized 457 patients to receive anifrolumab 150 mg, 300 mg or placebo (1:2:2). The primary endpoint, SRI 4 response, was defined as meeting each of the following criteria at Week 52 compared with baseline:
For the primary endpoint (SRI-4 at Week 52), treatment with anifrolumab did not result in statistically significant improvements over placebo (p-value=0.455). The secondary endpoints were not formally tested; however, clinically meaningful improvements in BICLA response, sustained OCS dose reduction, CLASI response, flare rate and joint response were observed for patients receiving anifrolumab 300 mg compared to those receiving placebo. The BICLA responder rate was 47% (85/180) for anifrolumab 300 mg versus 30% (55/184) for placebo (difference 17%, 95% CI 7.2, 26.8, nominal p-value <0.001).
TULIP II randomized 362 patients (1:1) that receive anifrolumab 300 mg or placebo. The primary endpoint, BICLA response at Week 52, was defined as improvement in all organ domains with moderate or severe activity at baseline:
The primary endpoint was met; anifrolumab 300 mg demonstrated statistically significant and clinically meaningful efficacy in overall disease activity compared with placebo. Greater improvements in all components of the BICLA composite endpoint were observed for anifrolumab compared to placebo (Table 11-1).
Clinical meaningful difference in BICLA response rate were observed as early as Week 8. Compared to placebo, the clinical benefit of anifrolumab was maintained through Week 52 (
Treatment with anifrolumab reduced the time to the first visit at which BICLA response was attained and subsequently sustained up to, and including, Week 52. At any time during the study, patients treated with anifrolumab were 55% more likely to achieve a sustained BICLA response, relative to patients receiving placebo (hazard ratio=1.55, 95% CI 1.11, 2.18). Separation between the treatment arms began at approximately Week 4 (
The treatment effect of anifrolumab relative to placebo was consistent across subgroups (by age, gender, race, ethnicity, disease severity [SLEDAI-2K at baseline], and baseline OCS use). Pre-specified analysis of disease activity measured by SRI-4 was consistent with the response measured by BICLA (SRI-4 responder rate; anifrolumab 56% vs placebo 37%; difference 18% [95% CI 8.1, 28.3]).
In the 47% of patients with a baseline OCS use ≥10 mg/day, anifrolumab demonstrated a statistically significant and clinically meaningful reduction in OCS use, of at least 25% to ≤7.5 mg/day at Week 40 maintained through to Week 52 (p-value=0.004); 52% (45/87) of patients in the anifrolumab group versus 30% (25/83) in the placebo achieved this level of steroid reduction (difference 21% [95% CI 6.8, 35.7]). In patients with a baseline OCS use ≥10 mg/day, the median (min, max) cumulative OCS dose at Week 52 was 3197 mg (309, 13265) compared to 3640 mg (1745, 10920) for the anifrolumab and placebo groups, respectively.
In patients with moderate to severe skin disease at baseline (CLASI activity score ≥10; n=89), anifrolumab demonstrated statistically significant and clinically meaningful improvements in cutaneous lupus activity (CLASI response: defined as, at least 50% reduction in CLASI activity score compared to baseline) at Week 12 (responder rate 49% [24/49] and 25% [10/40] for the anifrolumab and placebo group, respectively; observed difference 24% [95% CI 4.3, 43.6], p-value=0.017). Compared to placebo, the treatment benefit of anifrolumab was maintained through Week 52. Patients with moderate to severe skin disease at baseline who received anifrolumab were 55% more likely to achieve a sustained CLASI response (defined as a CLASI response attained at any time during the study and subsequently sustained up to, and including Week 52) relative to patients receiving placebo (hazard ratio=1.55, 95% CI 0.87, 2.85).
Disease flare was defined as severe disease activity (BILAG A) in one or more new organ system, or moderate disease activity (BILAG B) in 2 or more new organ systems compared to the previous visit. Anifrolumab led to a clinically meaningful 33% reduction of the annual flare rate versus placebo (annualized rate 0.43 and 0.64 for the anifrolumab and placebo group, respectively; rate ratio 0.67 [95% CI 0.48, 0.94], p-value=0.020); this difference was not statistically significant following adjustment for multiple comparisons. In TULIP II, 69% (124/180) of patients receiving anifrolumab experienced no SLE flares compared to 58% (105/182) of patients receiving placebo, during the 52-week treatment period. The time to first flare was longer in the anifrolumab group, at any time during the study patients had a 35% lower risk of experiencing a first flare relative to patients receiving placebo (hazard ratio=0.65 [95% CI 0.46, 0.91]).
At baseline 44% of patients had ≥6 swollen and 26 tender joints. Response was defined as ≥50% improvement in swollen/tender joint count at Week 52. There was no notable difference in joint response between treatment groups (response rate 42% [30/71] and 38% [34/90] for the anifrolumab and placebo group, observed difference 4.7% [95% CI-10.6, 20.0], p-value=0.547).
To compare BICLA responses to anifrolumab vs placebo through Week 52 in protocol-defined subgroups of patients in TULIP-1 and TULIP-2 and across pooled TULIP-1 and TULIP-2 data. Baseline characteristics are shown in Table 12-1 and Table 12-2.
There was a robust BICLA response rates observed at Week 52 with anifrolumab across prespecified subgroups in TULIP-1, TULIP-2, and pooled TULIP data. There was no substantive impact on effect size of demographics (
As has been previously described, in the MUSE Phase IIb study, expression of type I IFN-inducible genes in whole blood using a 21-gene panel6 (pharmacodynamic [PD] marker) decreased following anifrolumab administration for all dose groups in subjects with a baseline positive type I IFN signature in whole blood14. Both the 300 mg and 1000 mg anifrolumab dose achieved and maintained 82 to 90% neutralization of the gene signature. In the placebo group no neutralization of the gene signature (>6%) was observed at any time point. Anifrolumab thus neutralizes the 21-gene type I IFN PD signature in the whole blood of SLE patients (
Serum samples were taken from patients in the MUSE trial pre-and post-treatment for placebo and anifrolumab treatment groups. The serum samples were analyzed for cytokine expression using Luminex® or ultrasensitive Simoa immunoassay, according to the standard protocols. The LLOQ of the Simoa assay is 0.037 pg/ml. Anifrolumab was shown to induce alterations in many serum proteins levels, indicating that anifrolumab has effects on multiple cell types (Table 13-1) (
Anifrolumab was found to induce long-term downregulation of both IL-10 and TNF-alpha (
Baseline IL-10 was correlated with baseline SLEDAI 2K total score (
Surprisingly, baseline IL10 level was associated with clinical response at day 365 after anifrolumab treatment (
Using an IL-10 low cut-off of less than 2 pg/ml IL-10, a higher response rate (SRI4 with steroid tapering compared to placebo) was observed after administration of anifrolumab was observed in subjects with a IFNGS test-high and IL-10 low profile compared to placebo (
The present inventors thus demonstrate that IFNGS/IL10 and steroid usage are significantly predictive factors of SRI4 response status after anifrolumab treatments (
These results were confirmed in TULIP I. The delta of the 300 mg group from placebo was double the level seen in the IL-10H (
In MUSE, anifrolumab administration significantly suppressed IL-10 plasma levels in SLE patients (
Without being bound by therapy, it is believed that a high IL-10 concentration leads to a hyper-activation of main disease drivers in SLE, for example, type I IFN, auto antibodies and cytotoxic cells, which cannot be sufficiently compensated by anifrolumab (
In summary, the present inventors disclose for the first time that high baseline IL-10 is associated with a worse clinical outcome for SLE patients, and surprisingly, IFNGS test-high and IL10-low patients respond better to anifrolumab treatments than other patients. A combination of a type I IFN receptor inhibitor (e.g. anifrolumab) and anti-IL10 antibody would thus plausibly be beneficial to IL10-high patients. IL-10 low patients further represent a sub-population of SLE patients that will respond to treatment with anifrolumab.
Early and Sustained Responses With Anifrolumab Treatment in Patients With Active Systemic Lupus Erythematosus (SLE) in 2 Phase 3 Trials
In the phase 3 TULIP-2 and TULIP-1 trials in SLE, treatment with the type I interferon receptor antibody anifrolumab resulted in higher percentages of patients with BICLA responses vs placebo at Week 52, with differences of 16.3% (primary endpoint; P=0.001, 95% CI 6.3-26.3) and 16.4% (secondary endpoint; 95% CI 6.7-26.2), respectively.
To better understand the time course of BICLA responses to anifrolumab, we examined responses over time compared with placebo in TULIP-2 and TULIP-1, including those that were sustained from attainment through Week 52. Major clinical response (MCR) and partial clinical response (PCR) were also assessed as alternative outcome measures. In particular, to compare BICLA responses to anifrolumab vs placebo over time in TULIP-1, TULIP-2, and pooled TULIP data at early time points, the time to onset of response sustained to Week 52 and the major and partial clinical response. The Major clinical response is defined as all BILAG-2004 scores C or better at Week 24, maintained through Week 52, with no new A or B scores between Weeks 24-52. The Partial clinical response is defined as a maximum of 1 BILAG-2004 B score at Week 24, maintained through Week 52, with no new A or >1 new B domain score through Week 52.
The TULIP-2 and TULIP-1 randomized, double-blind, placebo-controlled trials evaluated the efficacy and safety of anifrolumab (300 mg Q4W) over 52 weeks in patients with moderately to severely active SLE who were receiving standard-of-care treatment. Time to onset of BICLA response that was sustained from attainment through Week 52 was evaluated using a Cox proportional hazards model. MCR was defined as all BILAG-2004 scores C or better at Week 24, maintained with no new A or B scores between Weeks 24-52. PCR was defined as ≤1 BILAG-2004 B score at Week 24 maintained without a new A or >1 new B domain score through Week 52. For TULIP-1, BICLA response rate and time to onset of BICLA response were analyzed using the amended restricted medication rules; MCR and PCR were analyzed using the prespecified analysis plan.
There were more BICLA responders with anifrolumab vs placebo from early time points (
Rapid and durable BICLA responses support the clinical benefit of anifrolumab for patients with moderately to severely active SLE. In 2 Phase 3 studies, a greater proportion of patients achieved BICLA responses sustained from onset through Week 52 with anifrolumab treatment compared with placebo. Anifrolumab resulted in numerically favourable differences in time to onset of BICLA responses maintained through Week 52 across the TULIP studies. MCR and PCR also favoured anifrolumab. These data support the sustainability of clinical benefit derived from anifrolumab treatment of patients with active SLE.
Anifrolumab treatment resulted in improved British Isles Lupus Assessment Group (BILAG)-based Composite Lupus Assessment (BICLA) response rates in patients with systemic lupus erythematosus (SLE) in the phase 3 TULIP-2 and TULIP-1 trials. In addition, annualized flare rates were lower among the groups treated with anifrolumab compared with placebo
TULIP-2 and TULIP-1 data were analyzed to assess the effects of anifrolumab on the number of SLE flares and time to first flare during 52 weeks of treatment.
The randomized, double-blind, placebo-controlled TULIP-2 and TULIP-1 trials evaluated efficacy and safety of intravenous anifrolumab 300 mg vs placebo every 4 weeks for 48 weeks, with the primary endpoints assessed at Week 52, in patients with moderate to severe SLE despite standard-of-care treatment. Flares were defined as ≥1 new BILAG-2004 A or ≥2 new (worsening) BILAG-2004 B domain scores compared with the prior month's visit. Time to first flare was evaluated using a Cox proportional hazards model. Annualized flare rate was analyzed using a negative binomial regression model.
In TULIP-2 (anifrolumab, n=180; placebo, n=182) and TULIP-1 (anifrolumab, n=180; placebo, n=184), fewer patients experienced ≥1 BILAG-2004 flare in the anifrolumab groups (TULIP-2: 31.1%, n=56; TULIP-1: 36.1%, n=65) compared with the placebo groups (TULIP-2: 42.3%, n=77; TULIP-1: 43. 43.5%, n=80;
Across 2 phase 3 trials, we observed reductions in the total number of flares and annualized flare rates, as well as prolongation of time to first flare with anifrolumab treatment compared with placebo. These results support the potential of anifrolumab to reduce disease activity and reduce flares, benefiting patients with SLE. The results of the TULIP trials support the capacity of anifrolumab to not only reduce disease activity but also to reduce flares in the presence of OCS taper, an attribute that is vital to the long-term management of patients with SLE.
Skin is the second most commonly involved organ in SLE, with up to 85% of patients experiencing skin disease. The Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) is a validated index to measure skin disease severity with activity scores (CLASI-A) ranging from 0 (mild) to 70 (severe). CLASI-A includes measures for erythema, scale/hypertrophy, mucous membrane lesions, recent hair loss, and nonscarring alopecia. In the phase 3 TULIP-1 and-2 trials of patients with SLE, a greater proportion of patients with CLASI-A at baseline ≥10 achieved a ≥50% reduction of CLASI-A at Week 12 with anifrolumab compared with placebo. We further evaluated the effect of anifrolumab on skin-specific SLE disease activity using data pooled from TULIP-1 and -2.
TULIP-1 and-2 were 52-week randomized, double-blind, placebo-controlled trials that evaluated the efficacy and safety of anifrolumab (300 mg IV every 4 weeks for 48 weeks) in patients with moderately to severely active SLE despite standard-of-care treatment. TULIP-1 and -2 were analyzed separately using restricted medication rules per the TULIP-2 protocol, and data from both trials were pooled. We compared skin responses over time in patients receiving anifrolumab vs placebo. A CLASI-A response was defined as ≥50% reduction of CLASI-A score from baseline for patients with CLASI-A ≥10. Time to CLASI-A response was evaluated using a Cox proportional hazards model.
In total, 360 patients received anifrolumab and 366 received placebo. At baseline, mean (SD) CLASI-A score was 8.1 (7.41); 95.9% (696/726) of patients had baseline CLASI-A >0 and 27.7% (201/726) had baseline CLASI-A ≥10. In the subgroup of patients with baseline CLASI-A ≥10, CLASI-A response (≥50% reduction) was achieved by Week 8 for 36.0% (38/107) of patients receiving anifrolumab vs 21.7% (21/94) receiving placebo (difference 14.3; 95% CI 1.8%, 26.9%). (
Anifrolumab treatment was associated with rapid and durable improvements in skin-specific SLE disease activity, as assessed by CLASI, in a subgroup of patients with mild to severe cutaneous activity at baseline. These findings demonstrate the ability of anifrolumab to reduce skin disease activity in patients with moderately to severely active SLE.
The British Isles Lupus Assessment Group-based Composite Lupus Assessment (BICLA) is a validated global measure of treatment response in systemic lupus erythematosus (SLE) clinical trials. To understand the relevance of BICLA to clinical practice, the relationship between BICLA response and routine SLE assessments and patient-reported outcomes (PROs) was investigated.
The BICLA was developed following an expert panel review of disease activity indices used in SLE clinical trials. A BICLA response requires improvement in all domains affected at baseline, assessed by BILAG-2004, no worsening of other BILAG-2004 domains, no worsening versus baseline of both SLEDAI-2K and PGA, no initiation of nonprotocol treatment or use beyond protocol-allowed thresholds, and no discontinuation of investigational product. Thus, in contrast to the SRI, the driver of efficacy in the BICLA is BILAG-2004, whereas worsening is assessed with SLEDAI-2K and PGA in addition to BILAG. BILAG-2004-based BICLA weighs organ systems equally and distinguishes between inactive disease, partial and complete improvement, and deterioration of disease activity, whereas SLEDAI-2K-based SRI assigns weighting to organ systems and requires complete resolution of disease activity in the involved organ system to capture improvement.
Composite SLE assessments are not routinely used in clinical practice. The relevance of treatment response assessed in this way thus may not be appreciated by clinicians. We therefore investigated the relationship between BICLA response and other SLE disease measures that are meaningful in real-world clinical practice, including flares, oral glucocorticoid daily dosage and sustained oral glucocorticoid taper, PROs, medical resource utilization, and clinical and laboratory measures of global and organ-specific disease. These relationships were assessed between BICLA responders and nonresponders using pooled data from the phase 3 TULIP-1 and TULIP-2 trials of anifrolumab, regardless of treatment group assignment.
This was a post hoc analysis of pooled data from the phase 3 randomized, placebo-controlled, double-blind, 52-Week TULIP-1 and TULIP-2 trials. In brief, eligible patients were aged 18 to 70 years, fulfilled the American College of Rheumatology revised classification criteria for SLE (13), and had seropositive moderate to severe SLE despite standard of care treatment. Patients with active severe lupus nephritis or neuropsychiatric SLE were excluded. Patients were randomized to receive intravenous infusions of placebo or anifrolumab every 4 weeks for 48 weeks in addition to standard-of-care treatment (TULIP-1: placebo, anifrolumab 150 mg, or anifrolumab 300 mg [2:1:2]; TULIP-2: placebo or anifrolumab 300 mg [1:1]). Primary endpoints were assessed at Week 52. Other treatments were stable throughout the trial except those resulting from protocol-determined intent-to-taper oral glucocorticoids. For patients receiving oral glucocorticoid ≥10 mg/day at baseline, an attempt to taper oral glucocorticoid to ≥7.5 mg/day was required between Weeks 8 and 40; tapering was also permitted for patients receiving oral glucocorticoid <10 mg/day at baseline. Stable oral glucocorticoid dosage was required between Weeks 40 and 52.
BICLA response was defined as all of the following: reduction of all baseline BILAG-2004 A and B domain scores to B/C/D and C/D, respectively, and no worsening in other BILAG-2004 organ systems as defined by ≥1 new BILAG-2004 A or ≥2 new BILAG-2004 B domain scores; no increase in SLEDAI-2K score (from baseline); no increase in PGA score (≥0.3 points from baseline); no discontinuation of investigational product; and no use of restricted medications beyond protocol-allowed thresholds. Pooled data were analyzed according to the TULIP-2 restricted medication analytical rules to classify responders/nonresponders.
Clinical outcome measures were compared between BICLA responders and nonresponders at Week 52, regardless of treatment group assignment, and results are presented in a hierarchy of clinical relevance, agreed by consensus between the authors. Outcome measures include the percentage of patients with flares (defined as ≥1 new BILAG-2004 A or ≥2 new BILAG-2004 B domain scores compared with the prior visit) through Week 52, annualized flare rates, percentage of patients achieving sustained oral glucocorticoid taper (defined as oral glucocorticoid dosage reduction to ≤7.5 mg/day prednisone or equivalent, achieved by Week 40 and sustained through Week 52, in patients receiving ≥10 mg/day at baseline), and change in daily oral glucocorticoid dosage from baseline to Week 52. Changes in PROs were assessed from baseline to Week 52, including responses in Functional Assessment of Chronic Illness Therapy-Fatigue [FACIT-F] (defined as a >3-point improvement), responses in Short Form 36 Health Survey version 2 [SF-36-v2] [acute] physical component summary [PCS] and mental component summary [MCS] (defined as an improvement of >3.4 in the PCS and >4.6 in the MCS), and changes from baseline in Patient's Global Assessment [PtGA]). Medical resource utilization (health care visits, emergency department [ED] use, and hospital visits) was also assessed. Other indices compared between BICLA responders and nonresponders included changes from baseline to Week 52 in SLEDAI-2K, PGA, joint counts (active, swollen, tender), and the Cutaneous Lupus Erythematosus Disease Area and Severity Index Activity (CLASI-A) responses (defined as ≥50% reduction in CLASI-A score among patients with CLASI-A score ≥10 at baseline). Serologies (anti-double-stranded DNA [anti-dsDNA] antibodies and complement C3 and C4) were evaluated; anti-dsDNA antibody levels were classified as ‘positive’ (>15 U/mL) or ‘negative’ (≤15 U/mL), and complement levels were classified as ‘abnormal’ (C3, <0.9 g/L; C4, <0.1 g/L) or ‘normal’ (C3, ≥0.9 g/L; C4, ≥0.1 g/L). Adverse events (AEs) were also assessed.
The similar designs of the TULIP-1 and TULIP-2 studies allowed for the results to be pooled. Sample sizes were selected for TULIP-1 and TULIP-2 to acquire adequate safety database sizes and to assess key secondary endpoints. In TULIP-1 and TULIP-2, 180 subjects/arm yielded >99% and 88% power, respectively, to reject the hypothesis (no difference in the primary endpoint) using a 2-sided alpha of 0.05. Responder versus nonresponder rates were calculated using a stratified Cochran-Mantel-Haenszel approach, which included stratification factors of SLEDAI-2K score at screening (<10 or ≥10), baseline oral glucocorticoid dosage (<10 mg/day or ≥10 mg/day), and type I IFNGS test status at screening (test-low or test-high). Study was also included in the model. For all responder analyses, patients were considered nonresponders if they used restricted medications beyond the protocol-allowed thresholds or discontinued investigational product before the assessment. Comparison of estimated change from baseline to Week 52 between BICLA responders and nonresponders was assessed using a mixed repeated measures model with fixed effects for baseline value, group, visit, study, and the stratification factors used at screening; a group-by-visit interaction term was used and visit was a repeated variable in the model. Missing data were imputed using the last observation carried forward for the first visit with missing data; subsequent visits with missing data were not imputed. For responder analyses, if any component of the variable could not be derived owing to missing data, the patient was classified as a nonresponders for that visit.
Data were pooled for 457 patients in TULIP-1 and 362 patients in TULIP-2 (N=819). Across both trials, 360 patients received anifrolumab 300 mg, 93 patients received anifrolumab 150 mg, and 366 patients received placebo. Regardless of treatment group assignment, there were 318 BICLA responders and 501 BICLA nonresponders at Week 52. Patient demographics and baseline clinical characteristics were generally balanced across BICLA responders and nonresponders (Table 18-1 and Table 18-2). The majority of patients were female (92.5%, responders; 93.0%, nonresponders) and the mean (standard deviation [SDD]) age was 41.5 (11.67) years for responders and 41.7 (12.13) years for nonresponders. Similar proportions of BICLA responders and nonresponders were white (67.0% vs 65.9%), Black/African American (14.2% vs 12.6%), or Asian (9.1% vs 11.0%).
Overall, improved outcomes were observed in BICLA responders versus nonresponders.
aOral glucocorticoid includes prednisone or equivalent;
bAn active joint is defined as a joint with swelling and tenderness;
cAnti-dsDNA antibody ‘positive’ defined as a result of >15 U/mL.
dOnly patients with anti-dsDNA antibodies and abnormal complement levels at baseline are included in the summary statistics for the respective variables.
eComplement C3 ‘abnormal’ levels defined as a result of <0.9 g/L.
fComplement C4 ‘abnormal’ levels defined as a result of <0.1 g/L.
aRace data were missing from 16 patients (8 each in the responder and nonresponder groups);
bOral glucocorticoid included prednisone or equivalent;
cImmunosuppressant agents included azathioprine, methotrexate, mycophenolate mofetil, mycophenolic acid, and mizoribine.
More BICLA responders than nonresponders were flare free over the 52-week treatment period (76.1% vs 52.2%), meaning that fewer BICLA responders than nonresponders experienced ≥1 flare over the 52-week period (23.9% vs 47.8%; difference −23.9%; 95% confidence interval [CI] −30.4 to −17.5; nominal P<0.001) (
aPercentages, difference, Cl, and nominal P values are weighted and calculated using a stratified CMH approach.
bFlare rates calculated using a negative binomial regression model which included covariates of group and stratification factors. The logarithm to the (base e) of the follow-up time is used as an offset variable in the model to adjust for different exposure times.
Similar percentages of BICLA responders and nonresponders were receiving oral glucocorticoid at any dosage, and at ≥10 mg/day, at baseline. BICLA responders versus nonresponders had greater reductions in daily oral glucocorticoid dosage from baseline to Week 52 (least squares [LS] mean difference −4.29 mg/day, 95% CI −5.37 to −3.20, nominal P<0.001) (
FACIT-F, SF-36 MCS, and SF-36 PCS scores were similar for BICLA responders and nonresponders at baseline (Table 18-4). Improvement in FACIT-F was reported in more BICLA responders than nonresponders (55.6% vs 15.7%; difference 40.0%, 95% CI 33.6% to 46.3%, nominal P<0.001) (
PtGA scores were similar for BICLA responders and nonresponders at baseline. Greater improvements in PtGA scores from baseline to Week 52 were reported for BICLA responders than nonresponders (LS mean difference−11.1, 95% CI −14.9 to −7.3, nominal P<0.001) (
During the 52-week trials, fewer BICLA responders than nonresponders had health care visits (62.5% vs 70.7%; difference −8.3%, 95% CI −14.9% to −1.6%, nominal P=0.015) (Table 18-5). Fewer BICLA responders required emergency department (ED) visits compared with nonresponders (11.9% vs 21.8%; difference −9.9%, 95% CI −15.2% to −4.5%, nominal P=0.001), and fewer ED visits were related to increased SLE activity (2.6% vs 24.0%; difference −21.4%, 95% CI −35.3% to −7.5%, nominal P=0.003). Similarly, fewer BICLA responders than nonresponders had hospital visits (4.5% vs 14.4%; difference −10.0%, 95% CI −14.3% to −5.7%, nominal P<0.001), and no hospital visits were related to increased SLE activity among BICLA responders, compared with 38.5% among BICLA nonresponders (difference −38.5%, 95% CI −58.8% to −18.2%, nominal P<0.001).
aPercentages, differences, Cls, and nominal P values were calculated using a stratified CMH approach.
bData on hospital visits and emergency department visits were missing from 8 patients in the BICLA nonresponders group.
Mean (SD) SLEDAI-2K and PGA scores were similar between responders and nonresponders at baseline (Table 1). From baseline to Week 52, greater improvements were observed for BICLA responders versus nonresponders in total SLEDAI-2K (LS mean difference −3.5, 95% CI −4.1 to −3.0, nominal P<0.001) (
Overall, 32.4% of BICLA responders and 25.5% of nonresponders had a baseline CLASI-A ≥10 (Table 1). Among these patients, more BICLA responders achieved a ≥50% reduction in CLASI-A at Week 52 versus nonresponders (92.0% vs 23.2%; difference 68.8%, 95% CI 59.2% to 78.3%, nominal P<0.001) (
Mean (SD) active joint counts (defined as joints with swelling and tenderness) were 6.1 (5.22) and 6.9 (5.97) in BICLA responders and nonresponders, respectively, at baseline. Mean (SD) swollen joint counts were 6.5 (5.27) and 7.4 (6.08), respectively, and tender joint counts were 9.8 (6.94) and 11.1 (7.85), respectively. From baseline to Week 52, joint counts improved more for BICLA responders versus nonresponders for active (LS mean difference −1.9, 95% CI −2.4 to −1.4, nominal P<0.001), tender (LS mean difference −3.6, 95% CI −4.4 to −2.8, nominal P<0.001), and swollen (LS mean difference −2.1, 95% CI −2.7 to −1.6, nominal P<0.001) joints (
Equal percentages of patients were anti-dsDNA antibody positive at baseline between BICLA responders and nonresponders. Improvement from positive to negative anti-dsDNA antibody status \\was observed in similar percentages of BICLA responders and nonresponders (5.0% vs 4.4%) (Table 18-6).
aAnti-dsDNA antibody ‘positive’ or ‘negative’ defined as a result of >15 U/mL or ≤15 U/mL, respectively.
bComplement C3 ‘abnormal’ or ‘normal’ levels defined as a result of <0.9 g/L or C3, <0.9 g/L, respectively.
cComplement C4 ‘abnormal’ or ‘normal’ levels defined as a result of <0.1 g/L or C3, <0.1 g/L, respectively.
Only patients with baseline positive anti-dsDNA or abnormal complement C3 or C4 are included in the analysis. Percentage change, difference, CI, and nominal P values calculated using a repeated measures model with fixed effects for baseline value, group, visit, study, and stratification factors. A visit-by-group interaction term was used to account for different relationships across groups and visit was a repeated variable in the model. Percentages do not equal 100% owing to missing data.
Similar proportions of BICLA responders and nonresponders had abnormal C3 and C4 levels at baseline. Percentage changes from baseline to Week 52 in complement levels did not differ between BICLA responders versus nonresponders for C3 (LS mean difference 2.82, 95% CI −4.185 to 9.819, nominal P=0.429) or C4 (LS mean difference −9.63, 95% CI −25.174 to 5.910, nominal P=0.223) (Table 13). More BICLA responders than nonresponders had improvements from abnormal to normal C3 (10.4% vs 7.0%) and C4 (7.5% vs 4.8%).
AE frequencies were similar between BICLA responders and nonresponders (83.6% and 85.2%) (Table 18-7). Mild and moderate AEs were reported by similar percentages of BICLA responders and nonresponders, whereas fewer BICLA responders than nonresponders experienced severe AEs (3.8% vs 9.4%). There were no AEs leading to discontinuation (DAE) in BICLA responders compared with 8.2% DAEs in nonresponders. Fewer BICLA responders than nonresponders experienced serious AEs (5.0% vs 19.0%). Fewer BICLA responders than nonresponders had non-opportunistic serious infections (2.2% vs 6.8%). The percentage of patients with herpes zoster was similar in BICLA responders and nonresponders (4.7% vs 3.6%), as was the percentage of patients with influenza (1.9% vs 2.0%) or malignancy (0.6% vs 1.0%).
BICLA is a dichotomous SLE outcome measure that classifies a patient as a responder or nonresponder based on changes in organ domain activity. As BICLA is primarily used in the clinical trial setting, the aim of this study was to assess the meaningfulness of BICLA response in terms of outcomes that are relevant to patients and physicians. In this post hoc analysis of pooled data acquired from 819 patients enrolled in the TULIP-1 and TULIP-2 trials, BICLA response was significantly associated with improved clinical outcomes across a range of SLE assessments, key PROs, and medical resource utilization measures.
Flares, with or without an increase in glucocorticoid dose, pose significant risks to patients with SLE. In the long term, both disease flares and oral glucocorticoid use have been linked to organ damage, which itself increases mortality risk. Flares also associate with reduced health-related quality of life, and flare severity and oral glucocorticoid use correlates with health care costs. A key SLE treatment goal therefore is to prevent flares while minimizing oral glucocorticoid exposure, which in turn is expected to reduce medical resource utilization. We observed that BICLA responders had fewer disease flares together with a lower daily oral glucocorticoid dose. A greater percentage of BICLA responders achieved sustained oral glucocorticoid reduction to target dose. They also had fewer hospitalizations and ED visits than did nonresponders, including those related to increased SLE activity. Greater improvements in global and tissue-specific disease activity were also observed in responders versus nonresponders, as measured by PGA, SLEDAI-2K, CLASI-A, and joint counts. As improved patient outcomes in disease activity and oral glucocorticoid exposure have been shown to associate with reduced health care costs, BICLA responders may incur lower health care costs than nonresponders.
We also assessed adverse events in BICLA responders and nonresponders. Consistent with the lower flare rates, reduced medical resource utilization, and fewer SLE-related ED visits and hospitalizations associated with BICLA response, there were fewer SAEs in BICLA responders versus nonresponders. While discontinuation of investigational product for any reason led to a patient being classified as a BICLA nonresponder by definition, of note, BICLA nonresponders had a greater propensity to discontinue due to an AE than BICLA responders.
PROs have been incorporated into nearly all SLE clinical trials. However, analyses have often yielded discordance between clinical outcomes and PROs, as patient perceptions of disease activity and illness are heavily impacted by fatigue and quality of life and are not captured by the results of formal measures of disease activity. In the TULIP trials, BICLA responders had improvements in validated PROs, including the physical and mental components of the SF-36 health survey and the FACIT assessment of fatigue. Fatigue, a common symptom in patients with SLE, interferes with daily life, and more than one half of patients with BICLA responses experienced improvement in fatigue in the TULIP trials. PtGA and PGA scores showed concordance in improvement, and greater degrees of improvement among BICLA responders than nonresponders (Table 18-8). Our results demonstrate that BICLA response translates to general improvements in the physical and mental wellbeing of patients with SLE.
Investigation of correlations of SRI(4) response to clinical outcomes in pooled data from 2 phase 2b trials (sifalimumab and anifrolumab), as well as 2 phase 3 trials of belimumab, also demonstrated improved clinical outcomes in SRI(4) responders compared with nonresponders. Whereas changes in serologic outcomes were not significantly different between BICLA responders and nonresponders in the TULIP trials, SRI(4) response was associated with significant improvements in anti-dsDNA antibody and complement C3 levels (but not C4 levels) in the belimumab phase 3 trials. This discordance may be a reflection of the different mechanisms of action of the 2 evaluated drugs, and/or because the BILAG-2004, which measures improvement in BICLA, does not include serology in its scoring system.
The data confirm the value of BICLA as a clinical trial endpoint and that a BICLA response correlates with improvements in a range of other outcomes that resonate with the priorities of both clinicians and patients in everyday practice.
In the randomized, double-blind, phase 2b MUSE trial, anifrolumab treatment reduced disease activity vs placebo across multiple endpoints in patients with moderately to severely active SLE. The inventors assessed for the first time the safety and efficacy in patients coming off anifrolumab during the 12-week (wk) follow-up period in MUSE.
Patients were randomized 1:1:1 to receive placebo or anifrolumab 300 or 1000 mg every 4 wks; final study dose was Wk 48 and key efficacy endpoints were assessed at Wk 52. Patients were required to complete a 12-wk follow-up period and visits were conducted every 4 wks (±7 days) after the final study dose (
Of 305 patients randomized in MUSE, 229 completed the last study visit (Wk 52): 86, 75, and 68 from the anifrolumab 300-mg, 1000-mg, and placebo groups, respectively. From Wk 52 to Wk 60, IFNGS expression increased more rapidly in the anifrolumab 300-mg group (mean neutralization ratio: 55.6% to −81.8%) vs the 1000-mg group (71.7% to 31.9%), with negligible changes in the placebo group (−59.2% to −62.6%). From Wk 52 to the end of the follow-up period (Wk 60), mean global SLEDAI-2K scores increased in patients coming off anifrolumab 300 mg (4.3 to 5.0 [mean change: 0.7]) and 1000 mg (3.8 to 4.1 [0.3]) but not for the placebo group (5.9 to 5.8 [−0.1]). A similar trend was observed in mean global BILAG-2004 scores in patients coming off anifrolumab 300 mg (6.0 to 8.5 [2.4]) vs placebo (8.3 to 9.1 [0.8]).
Mucocutaneous was the most frequent organ system associated with worsening in patients ceasing anifrolumab, with shifts in the percentages of patients with BILAG C/D/E scores to BILAG A/B scores; similar trends were also observed in the musculoskeletal organ system. Worsening was most frequent in the mucocutaneous domain in patients coming off anifrolumab, with shifts in the percentages of patients with BILAG-2004 C/D/E to A/B scores (
Mean Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) scores increased slightly from Wk 52 to Wk 60 across the anifrolumab 300-mg, 1000-mg, and placebo groups (from 1.9 to 2.4, 1.8 to 2.2, and 3.5 to 4.0, respectively) (
From Wk 52 to Wk 60, IFNGS expression increased more rapidly in the anifrolumab 300-mg group (mean neutralization ratio: 55.6% to −81.8%) vs the 1000-mg group (71.7% to 31.9%), with negligible changes in the placebo group (−59.2% to −62.6%).
AEs during the 12-wk follow-up period were similar between the anifrolumab 300-mg and 1000-mg vs placebo groups (≥1 AE: 29.3% and 26.7% vs 24.8%; ≥1 serious AE: 3.0% and 3.8% vs 5.0%). Disease activity, measured using MDGA score, increased between Week 52 and Week 60 in both anifrolumab 300-mg and 1000-mg groups; there was no change in the placebo group. Active joint counts increased slightly from Week 52 to Week 60 across the anifrolumab 300-mg, anifrolumab 1000-mg, and placebo groups (
There was a notable trend toward worsening in disease activity in patients coming off anifrolumab vs placebo using SLEDAI-2K and BILAG-2004. This was associated with a rebound in IFNGS in patients previously treated with anifrolumab, an effect more apparent with 300 vs 1000 mg.
| Filing Document | Filing Date | Country | Kind |
|---|---|---|---|
| PCT/EP2021/081971 | 11/17/2021 | WO |
| Number | Date | Country | |
|---|---|---|---|
| 63115286 | Nov 2020 | US |
