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Röth A, Berentsen S, Barcellini W, D’Sa S, Jilma B, Michel M, Weitz IC, Yamaguchi M, Nishimura JI, Vos JM, Cid J, Storek M, Wong N, Yoo R, Jayawardene D, Srivastava S, Wardęcki M, Shafer F, Lee M, Broome CM. Long-term efficacy and safety of continued complement C1s inhibition with sutimlimab in cold agglutinin disease: CADENZA study Part B. EClinicalMedicine 2024; 74:102733. [PMID: 39091672 PMCID: PMC11293518 DOI: 10.1016/j.eclinm.2024.102733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/27/2024] [Accepted: 06/27/2024] [Indexed: 08/04/2024] Open
Abstract
Background Cold agglutinin disease (CAD) is a rare autoimmune haemolytic anaemia mediated by the classical complement pathway (CP). Sutimlimab selectively targets complement C1s inhibiting classical CP activation. In CADENZA Part A (26-weeks), a placebo-controlled study in patients without recent transfusion history, sutimlimab reduced haemolysis, anaemia, and fatigue, and was generally well tolerated. Methods The CADENZA study (NCT03347422) started in March 2018 (Part A) and completed in December 2021 (Part B). All patients in Part B were eligible to receive sutimlimab for up to 1 year after the last patient completed Part A. Efficacy and safety was assessed throughout Part B, until the last on-treatment visit with available assessment (LV), and after a 9-week washout. Findings In total, 32/39 patients completed Part B; median treatment duration: 99 weeks. Similar sustained improvements in haemolysis, anaemia, and quality of life were observed in patients switching to sutimlimab and those continuing sutimlimab. Mean LV values for the combined group (ie, placebo-to-sutimlimab group and sutimlimab-to-sutimlimab group) improved from baseline for haemoglobin (≥11.0 g/dL on-treatment vs 9.3 g/dL at baseline), bilirubin (≤20.0 μmol/L on-treatment vs 35.0 μmol/L at baseline), and FACIT-Fatigue scores. Following a 9-week washout, inhibition of CP activity was reversed, and haemolytic markers approached baseline levels. Overall, sutimlimab was generally well tolerated throughout the study. No patients developed systemic lupus erythematosus or meningococcal infections. During the 9-week washout, most adverse events could be attributed to recurrence of underlying CAD. Interpretation The CADENZA Part B results support the sustained efficacy and safety of sutimlimab for treatment of CAD; however, upon discontinuation disease activity reoccurs. Funding Sanofi.
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Affiliation(s)
- Alexander Röth
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Haugesund, Norway
| | - Wilma Barcellini
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Shirley D’Sa
- UCLH Centre for Waldenström's Macroglobulinemia and Related Conditions, University College London Hospitals NHS Foundation Trust, London, UK
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Marc Michel
- Henri-Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, UPEC, Créteil, France
| | | | | | | | | | - Joan Cid
- Department of Hemotherapy and Hemostasis, ICMHO, IDIBAPS, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | | | | | | | | | | | | | | | - Catherine M. Broome
- Division of Hematology, MedStar Georgetown University Hospital, Washington, DC, USA
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Röth A, Broome CM, Barcellini W, Tvedt THA, Miyakawa Y, D’Sa S, Cella D, Bozzi S, Jayawardene D, Yoo R, Shafer F, Wardęcki M, Weitz IC. Long-term sutimlimab improves quality of life for patients with cold agglutinin disease: CARDINAL 2-year follow-up. Blood Adv 2023; 7:5890-5897. [PMID: 37459203 PMCID: PMC10558612 DOI: 10.1182/bloodadvances.2022009318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 07/07/2023] [Indexed: 10/01/2023] Open
Abstract
Cold agglutinin disease (CAD) is a rare form of autoimmune hemolytic anemia with a substantial burden on patient's quality of life. CARDINAL was a 2-part, open-label, single-arm, multicenter phase 3 study evaluating the C1s inhibitor, sutimlimab, for treatment of CAD. Part A consisted of the pivotal study phase, with the part B extension phase assessing long-term safety and durability of response including patient-reported outcomes, which is the focus of this report. Altogether, 22 patients continued from part A to part B, majority female (68.2%) with a median age of 71.5 years (range, 55-85). Throughout treatment, score improvement on the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue scale exceeded a predefined, group-level clinically important change of ≥5 points vs baseline, with a mean (standard error [SE]) change of 11.7 (3.7) points at week 135. The 12-Item Short Form Health Survey physical and mental component scores remained above baseline, with week 123 mean change (SE) exceeding clinically important changes of 3.9 for physical and 2.8 for mental component scores at 4.7 (2.8) and 3.8 (5.7) points, respectively. EuroQol Visual Analogue Scale, scoring patients' self-rated health, also remained above baseline with a change of 17.1 (5.6) points at week 135. Patient Global Impression of (fatigue) Severity improved vs baseline, corroborating FACIT-Fatigue scores. Patient Global Impression of Change indicated a reduction in perceived disease burden. Data from CARDINAL part B support sustained alleviation of CAD disease burden after long-term treatment with sutimlimab over 2 years, returning toward baseline upon treatment cessation. This trial was registered at www.clinicaltrials.gov as #NCT03347396.
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Affiliation(s)
- Alexander Röth
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Catherine M. Broome
- Division of Hematology, MedStar Georgetown University Hospital, Washington, DC
| | - Wilma Barcellini
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Yoshitaka Miyakawa
- Department of Hematology, Saitama Medical University Hospital, Saitama, Japan
| | - Shirley D’Sa
- UCLH Centre for Waldenström’s Macroglobulinemia and Related Conditions, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - David Cella
- Department of Medical Social Sciences, Center for Patient-Centered Outcomes, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | | | | | | | - Ilene C. Weitz
- Jane Anne Nohl Division of Hematology, Department of Medicine, University of Southern California–Keck School of Medicine, Los Angeles, CA
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Moore DC, Arnall JR. Sutimlimab: A Complement C1s Inhibitor for the Management of Cold Agglutinin Disease-Associated Hemolysis. Ann Pharmacother 2023; 57:970-977. [PMID: 36476151 DOI: 10.1177/10600280221138802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVE To review the pharmacology, pharmacokinetics, efficacy, safety, dosing and administration, and place in therapy of sutimlimab for the management of cold agglutinin disease (CAD)-associated hemolysis. DATA SOURCES A literature search of PubMed (1966-October 2022) was conducted using the keywords sutimlimab, BIVV009, and cold agglutinin. Data were also obtained from prescribing information, meeting abstracts, and clinicaltrials.gov. STUDY SELECTION AND DATA EXTRACTION All published prospective clinical trials, prescribing information, and meeting abstracts on sutimlimab for the treatment of CAD were reviewed. DATA SYNTHESIS Sutimlimab is a first-in-class complement C1s inhibitor indicated for the treatment of CAD-associated hemolysis. This approval was based on the phase III CARDINAL trial, which evaluated sutimlimab in patients with CAD-associated hemolysis. The primary endpoint of achieving a hemoglobin of ≥12 g/dL or increase of ≥2 above baseline was achieved by 54% of patients with sutimlimab in the 26-week trial. The phase III CADENZA trial was a placebo-controlled trial in which sutimlimab has demonstrated a significant improvement in the composite endpoint of hemoglobin increase of ≥1.5 g/dL, avoidance of transfusion, and avoidance of additional CAD therapies (73% sutimlimab vs 15% placebo). RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE IN COMPARISON WITH EXISTING DRUGS Sutimlimab rapidly halts hemolysis, improves hemoglobin, and improves quality-of-life in patients with CAD. Safety issues with sutimlimab include infusion-related reactions and risk of serious infections with encapsulated bacteria. CONCLUSIONS Sutimlimab provides an additional therapeutic option in the treatment of CAD-associated hemolysis that can lead to rapid improvement in hemoglobin and anemia-related symptoms.
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Affiliation(s)
- Donald C Moore
- Department of Pharmacy, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Justin R Arnall
- Specialty Pharmacy Service, Atrium Health, Charlotte, NC, USA
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de Boer ECW, Jalink M, Delvasto-Nuñez L, Meulenbroek EM, Baas I, Janssen SR, Folman CC, Gelderman KA, Wouters D, Engel MD, de Haas M, Kersten MJ, Jongerius I, Zeerleder S, Vos JMI. C1-inhibitor treatment in patients with severe complement-mediated autoimmune hemolytic anemia. Blood Adv 2023; 7:3128-3139. [PMID: 36920779 PMCID: PMC10362545 DOI: 10.1182/bloodadvances.2022009402] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/16/2023] [Accepted: 03/09/2023] [Indexed: 03/16/2023] Open
Abstract
Complement-mediated (CM) autoimmune hemolytic anemia (AIHA) is characterized by the destruction of red blood cells (RBCs) by autoantibodies that activate the classical complement pathway. These antibodies also reduce transfusion efficacy via the lysis of donor RBCs. Because C1-inhibitor (C1-INH) is an endogenous regulator of the classical complement pathway, we hypothesized that peritransfusional C1-INH in patients with severe CM-AIHA reduces complement activation and hemolysis, and thus enhances RBC transfusion efficacy. We conducted a prospective, single-center, phase 2, open-label trial (EudraCT2012-003710-13). Patients with confirmed CM-AIHA and indication for the transfusion of 2 RBC units were eligible for inclusion. Four IV C1-INH doses (6000, 3000, 2000, and 1000 U) were administered with 12-hour intervals around RBC transfusion. Serial blood samples were analyzed for hemolytic activity, RBC opsonization, complement activation, and inflammation markers. Ten patients were included in the study. C1-INH administration increased plasma C1-INH antigen and activity, peaking at 48 hours after the first dose and accompanied by a significant reduction of RBC C3d deposition. Hemoglobin levels increased briefly after transfusion but returned to baseline within 48 hours. Overall, markers of hemolysis, inflammation, and complement activation remained unchanged. Five grade 3 and 1 grade 4 adverse event occurred but were considered unrelated to the study medication. In conclusion, peritransfusional C1-INH temporarily reduced complement activation. However, C1-INH failed to halt hemolytic activity in severe transfusion-dependent-CM-AIHA. We cannot exclude that posttransfusional hemolytic activity would have been even higher without C1-INH. The potential of complement inhibition on transfusion efficacy in severe CM-AIHA remains to be determined.
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Affiliation(s)
- Esther C. W. de Boer
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, Amsterdam University Medical Centre, Amsterdam Infection and Immunity Institute, Amsterdam, The Netherlands
- Department of Pediatric Immunology, Rheumatology, and Infectious Diseases, Emma Children’s Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Marit Jalink
- Department of Clinical Transfusion Research, Sanquin Research, Amsterdam, The Netherlands
- Department of Hematology, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Department of Transfusion Medicine, Sanquin Blood Supply, Amsterdam, The Netherlands
| | - Laura Delvasto-Nuñez
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, Amsterdam University Medical Centre, Amsterdam Infection and Immunity Institute, Amsterdam, The Netherlands
| | - Elisabeth M. Meulenbroek
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, Amsterdam University Medical Centre, Amsterdam Infection and Immunity Institute, Amsterdam, The Netherlands
| | - Inge Baas
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, Amsterdam University Medical Centre, Amsterdam Infection and Immunity Institute, Amsterdam, The Netherlands
| | - Susanne R. Janssen
- Department of Hematology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Claudia C. Folman
- Department of Immunohematology Diagnostics, Sanquin, Amsterdam, The Netherlands
| | | | - Diana Wouters
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Marije D. Engel
- Department of Hematology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Masja de Haas
- Department of Clinical Transfusion Research, Sanquin Research, Amsterdam, The Netherlands
- Department of Immunohematology Diagnostics, Sanquin, Amsterdam, The Netherlands
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marie José Kersten
- Department of Hematology, Amsterdam University Medical Centers, Location University of Amsterdam, Cancer Center Amsterdam and Lymphoma and Myeloma Center Amsterdam, Amsterdam, The Netherlands
| | - Ilse Jongerius
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, Amsterdam University Medical Centre, Amsterdam Infection and Immunity Institute, Amsterdam, The Netherlands
- Department of Pediatric Immunology, Rheumatology, and Infectious Diseases, Emma Children’s Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Sacha Zeerleder
- Department of Hematology, Luzerner Kantonsspital, Luzern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Josephine M. I. Vos
- Department of Immunohematology Diagnostics, Sanquin, Amsterdam, The Netherlands
- Department of Hematology, Amsterdam University Medical Centers, Location University of Amsterdam, Cancer Center Amsterdam and Lymphoma and Myeloma Center Amsterdam, Amsterdam, The Netherlands
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Cavallaro F, Barcellini W, Fattizzo B. Antibody based therapeutics for autoimmune hemolytic anemia. Expert Opin Biol Ther 2023; 23:1227-1237. [PMID: 37874225 DOI: 10.1080/14712598.2023.2274912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/20/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Autoimmune hemolytic anemia (AIHA) treatment has been revolutionized by the introduction of target therapies, mainly monoclonal antibodies (MoAbs). AREAS COVERED The anti-CD20 rituximab, which targets Ab production by B-cells, induces 80% of response in warm-type AIHA (wAIHA) and 50-60% in cold agglutinin disease (CAD). Other B-cell targeting MoAbs including ianalumab, povetacicept, and obexelimab are under active study. The anti-CD38 MoAb daratumumab has been used in several reports to target long-lived plasma-cells responsible for AIHA relapse, being effective even in multi-refractory cases. Anti-complement MoAbs will soon change the treatment paradigm in CAD; the anti-C1s sutimlimab rapidly increased Hb in more than 80% of the cases. Finally, MoAbs inhibiting the neonatal Fc receptor (FcRn), such as nipocalimab, can reduce the half-life of the pathogenic autoAbs, representing a promising treatment for wAIHA. EXPERT OPINION MoAbs offer the potential to improve efficacy by reducing toxicity. However, there is a huge need for clinical trials exploring response duration rather than short-term efficacy. Complement inhibitors and anti-FcRns do not abrogate autoAb production and are being developed as long-term therapies. Thus, the combination of B-cell/plasma cell targeting drugs deserves to be explored. On the other hand, their rapid efficacy should be exploited for the acute AIHA phase.
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Affiliation(s)
- Francesca Cavallaro
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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Berentsen S. Sutimlimab for the Treatment of Cold Agglutinin Disease. Hemasphere 2023; 7:e879. [PMID: 37153870 PMCID: PMC10155901 DOI: 10.1097/hs9.0000000000000879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 03/15/2023] [Indexed: 05/10/2023] Open
Abstract
Cold agglutinin disease (CAD) is a rare autoimmune hemolytic anemia and a bone marrow clonal lymphoproliferative disorder. Hemolysis in CAD is complement-dependent and mediated by the classical activation pathway. Patients also frequently suffer from fatigue and cold-induced circulatory symptoms. Although not all patients need treatment, the symptom burden has previously been underestimated. Effective therapies target the clonal lymphoproliferation or the complement activation. Sutimlimab, a humanized monoclonal IgG4 antibody that binds and inactivates complement protein C1s, is the most extensively investigated complement inhibitor for the treatment of CAD. This review addresses the preclinical studies of sutimlimab and the studies of pharmacokinetics and pharmacodynamics. We then describe and discuss the prospective clinical trials that established sutimlimab as a rapidly acting, highly efficacious, and low-toxic therapeutic agent. This complement inhibitor does not improve the cold-induced circulatory symptoms, which are not complement-mediated. Sutimlimab is approved for the treatment of CAD in the US, Japan, and the European Union. A tentative therapeutic algorithm is presented. The choice of therapy for CAD should be based on an individual assessment, and patients requiring therapy should be considered for inclusion in clinical trials.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway
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Berentsen S, Fattizzo B, Barcellini W. The choice of new treatments in autoimmune hemolytic anemia: how to pick from the basket? Front Immunol 2023; 14:1180509. [PMID: 37168855 PMCID: PMC10165002 DOI: 10.3389/fimmu.2023.1180509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/13/2023] [Indexed: 05/13/2023] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is defined by increased erythrocyte turnover mediated by autoimmune mechanisms. While corticosteroids remain first-line therapy in most cases of warm-antibody AIHA, cold agglutinin disease is treated by targeting the underlying clonal B-cell proliferation or the classical complement activation pathway. Several new established or investigational drugs and treatment regimens have appeared during the last 1-2 decades, resulting in an improvement of therapy options but also raising challenges on how to select the best treatment in individual patients. In severe warm-antibody AIHA, there is evidence for the upfront addition of rituximab to prednisolone in the first line. Novel agents targeting B-cells, extravascular hemolysis, or removing IgG will offer further options in the acute and relapsed/refractory settings. In cold agglutinin disease, the development of complement inhibitors and B-cell targeting agents makes it possible to individualize therapy, based on the disease profile and patient characteristics. For most AIHAs, the optimal treatment remains to be found, and there is still a need for more evidence-based therapies. Therefore, prospective clinical trials should be encouraged.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway
- *Correspondence: Sigbjørn Berentsen,
| | - Bruno Fattizzo
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, and Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Wilma Barcellini
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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