3
|
Foley JF, Defer G, Ryerson LZ, Cohen JA, Arnold DL, Butzkueven H, Cutter G, Giovannoni G, Killestein J, Wiendl H, Smirnakis K, Xiao S, Kong G, Kuhelj R, Campbell N, Dwyer C, Buzzard K, Spies J, Parratt J, van Pesch V, Willekens B, Perrotta G, Bartholomé E, Grand'Maison F, Jacques F, Giacomini P, Vosoughi R, Girard JM, de Seze J, Lebrun Frenay C, Ruet A, Laplaud DA, Reifschneider G, Wagner B, Rauer S, Pul R, Seipelt M, Berthele A, Klotz L, Kallmann BA, Paul F, Achiron A, Lus G, Centonze D, Patti F, Grimaldi L, Hupperts R, Frequin S, Fermont J, Madueno SE, Alonso Torres AM, Costa-Frossard França L, Meca-Lallana JE, Ruiz LB, Pearson O, Rog D, Evangelou N, Ismail A, Lathi E, Fox E, Leist T, Sloane J, Wu G, Khatri B, Steingo B, Thrower B, Gudesblatt M, Calkwood J, Bandari D, Scagnelli J, Laganke C, Robertson D, Kipp L, Belkin M, Cohan S, Goldstick L, Courtney A, Vargas W, Sylvester A, Srinivasan J, Kannan M, Picone M, English J, Napoli S, Balabanov R, Zaydan I, Nicholas J, Kaplan J, Lublin F, Riser E, Miller T, Alvarez E, Wray S, Gross J, Pawate S, Hersh C, McCarthy L, Crayton H, Graves J. Comparison of switching to 6-week dosing of natalizumab versus continuing with 4-week dosing in patients with relapsing-remitting multiple sclerosis (NOVA): a randomised, controlled, open-label, phase 3b trial. Lancet Neurol 2022; 21:608-619. [PMID: 35483387 DOI: 10.1016/s1474-4422(22)00143-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 02/28/2022] [Accepted: 03/31/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Treatment with natalizumab once every 4 weeks is approved for patients with relapsing-remitting multiple sclerosis, but is associated with a risk of progressive multifocal leukoencephalopathy. Switching to extended-interval dosing is associated with lower progressive multifocal leukoencephalopathy risk, but the efficacy of this approach is unclear. We aimed to assess the safety and efficacy of natalizumab once every 6 weeks compared with once every 4 weeks in patients with relapsing-remitting multiple sclerosis. METHODS We did a randomised, controlled, open-label, phase 3b trial (NOVA) at 89 multiple sclerosis centres across 11 countries in the Americas, Europe, and Western Pacific. Included participants were aged 18-60 years with relapsing-remitting multiple sclerosis and had been treated with intravenous natalizumab 300 mg once every 4 weeks with no relapses for at least 12 months before randomisation, with no missed doses in the previous 3 months. Participants were randomly assigned (1:1), using a randomisation sequence generated by the study funder and contract personnel with interactive response technology, to switch to natalizumab once every 6 weeks or continue with once every 4 weeks. The centralised MRI reader, independent neurology evaluation committee, site examining neurologists, site backup examining neurologists, and site examining technicians were masked to study group assignments. The primary endpoint was the number of new or newly enlarging T2 hyperintense lesions at week 72, assessed in all participants who received at least one dose of assigned treatment and had at least one postbaseline MRI, relapse, or neurological examination or efficacy assessment. Missing primary endpoint data were handled under prespecified primary and secondary estimands: the primary estimand included all data, regardless of whether participants remained on the assigned treatment; the secondary estimand classed all data obtained after treatment discontinuation or study withdrawal as missing. Safety was assessed in all participants who received at least one dose of study treatment. Study enrolment is closed and an open-label extension study is ongoing. This study is registered with EudraCT, 2018-002145-11, and ClinicalTrials.gov, NCT03689972. FINDINGS Between Dec 26, 2018, and Aug 30, 2019, 605 patients were assessed for eligibility and 499 were enrolled and assigned to receive natalizumab once every 6 weeks (n=251) or once every 4 weeks (n=248). After prespecified adjustments for missing data, mean numbers of new or newly enlarging T2 hyperintense lesions at week 72 were 0·20 (95% CI 0·07-0·63) in the once every 6 weeks group and 0·05 (0·01-0·22) in the once every 4 weeks group (mean lesion ratio 4·24 [95% CI 0·86-20·85]; p=0·076) under the primary estimand, and 0·31 (95% CI 0·12-0·82) and 0·06 (0·01-0·31; mean lesion ratio 4·93 [95% CI 1·05-23·20]; p=0·044) under the secondary estimand. Two participants in the once every 6 weeks group with extreme new or newly enlarging T2 hyperintense lesion numbers (≥25) contributed most of the excess lesions. Adverse events occurred in 194 (78%) of 250 participants in the once every 6 weeks group and 190 (77%) of 247 in the once every 4 weeks group, and serious adverse events occurred in 17 (7%) and 17 (7%), respectively. No deaths were reported. There was one case of asymptomatic progressive multifocal leukoencephalopathy (without clinical signs) in the once every 6 weeks group, and no cases in the once every 4 weeks group; 6 months after diagnosis, the participant was without increased disability and remained classified as asymptomatic. INTERPRETATION We found a numerical difference in the mean number of new or newly enlarging T2 hyperintense lesions at week 72 between the once every 6 weeks and once every 4 weeks groups, which reached significance under the secondary estimand, but interpretation of statistical differences (or absence thereof) is limited because disease activity in the once every 4 weeks group was lower than expected. The safety profiles of natalizumab once every 6 weeks and once every 4 weeks were similar. Although this trial was not powered to assess differences in risk of progressive multifocal leukoencephalopathy, the occurrence of the (asymptomatic) case underscores the importance of monitoring and risk factor consideration in all patients receiving natalizumab. FUNDING Biogen.
Collapse
Affiliation(s)
- John F Foley
- Rocky Mountain MS Clinic, Salt Lake City, UT, USA.
| | - Gilles Defer
- Department of Neurology, Centre Hospitalier Universitaire de Caen, Caen, France
| | | | - Jeffrey A Cohen
- Mellen MS Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Douglas L Arnold
- Montreal Neurological Institute, McGill University, Montréal, QC, Canada; NeuroRx Research, Montréal, QC, Canada
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Gary Cutter
- University of Alabama at Birmingham, School of Public Health, Birmingham, AL, USA
| | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK; Queen Mary University of London, London, UK
| | - Joep Killestein
- Department of Neurology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, Netherlands
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Butzkueven H, Kappos L, Spelman T, Trojano M, Wiendl H, Su R, Liao S, Hyde R, Licata S, Ho PR, Campbell N. No evidence for loss of natalizumab effectiveness with every-6-week dosing: a propensity score-matched comparison with every-4-week dosing in patients enrolled in the Tysabri Observational Program (TOP). Ther Adv Neurol Disord 2021; 14:17562864211042458. [PMID: 34603507 PMCID: PMC8481711 DOI: 10.1177/17562864211042458] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/10/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Extended interval dosing of natalizumab is associated with significantly lower progressive multifocal leukoencephalopathy risk compared with every-4-week (Q4W) dosing in patients with relapsing-remitting multiple sclerosis. Previous studies have suggested that natalizumab effectiveness is maintained in patients who switch from Q4W to extended interval dosing but have been limited by a lack of well-matched patient cohorts. Methods: Tysabri Observational Program (TOP) data as of November 2019 were used to identify patients with relapsing-remitting multiple sclerosis treated with natalizumab Q4W and those with a single physician-indicated dosing change from Q4W to every-6-week (Q6W) dosing after ⩾1 year of Q4W treatment. Patients were propensity score matched at the time of the switch from Q4W to Q6W dosing. Clinical outcomes (annualized relapse rate and probability of remaining relapse free or free of 24-week confirmed disability worsening) and safety outcomes were assessed for the two cohorts. Results: This study included 219 pairs of propensity score–matched Q6W and Q4W patients. Annualized relapse rates were similar for Q6W (0.150) and Q4W (0.157) patients. The probability of remaining relapse free [hazard ratio = 1.243 (95% confidence interval = 0.819–1.888); p = 0.307] and of remaining free of 24-week confirmed disability worsening [hazard ratio = 0.786 (95% confidence interval = 0.284–2.176); p = 0.644] did not differ significantly between Q6W and Q4W patients. Summarized safety results for the matched Q6W and Q4W patients are also presented. Conclusion: These real-world findings in well-matched patient cohorts from TOP demonstrate that natalizumab effectiveness is maintained in patients who switch to Q6W dosing after ⩾1 year of Q4W dosing. ClinicalTrials.gov identifier: NCT00493298
Collapse
Affiliation(s)
- Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Alfred Centre, Melbourne, VIC 3004, Australia. Department of Neurology, Box Hill Hospital, Monash University, Box Hill, VIC, Australia
| | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience Basel, Departments of Medicine, Clinical Research, Biomedicine, and Biomedical Engineering, University Hospital and University of Basel, Basel, Switzerland
| | - Tim Spelman
- Department of Medicine and Melbourne Brain Centre, Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Maria Trojano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari, Bari, Italy
| | - Heinz Wiendl
- Department of Neurology, University of Münster, Münster, Germany
| | - Ray Su
- Biogen, Cambridge, MA, USA, at the time of this analysis
| | - Shirley Liao
- Biogen, Cambridge, MA, USA, at the time of this analysis
| | | | | | - Pei-Ran Ho
- Biogen, Cambridge, MA, USA, at the time of this analysis
| | | |
Collapse
|
7
|
Ryerson LZ, Foley J, Chang I, Kister I, Cutter G, Metzger RR, Goldberg JD, Li X, Riddle E, Smirnakis K, Kasliwal R, Ren Z, Hotermans C, Ho PR, Campbell N. Risk of natalizumab-associated PML in patients with MS is reduced with extended interval dosing. Neurology 2019; 93:e1452-e1462. [PMID: 31515290 PMCID: PMC7010325 DOI: 10.1212/wnl.0000000000008243] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 06/11/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To use the large dataset from the Tysabri Outreach: Unified Commitment to Health (TOUCH) program to compare progressive multifocal leukoencephalopathy (PML) risk with natalizumab extended interval dosing (EID) vs standard interval dosing (SID) in patients with multiple sclerosis (MS). METHODS This retrospective cohort study included anti-JC virus antibody-positive patients (n = 35,521) in the TOUCH database as of June 1, 2017. The effect of EID on PML risk was evaluated with 3 planned analyses using Kaplan-Meier methods stratified by prior immunosuppressant use. Risk of PML was analyzed by Cox regression adjusted for age, sex, prior immunosuppressants, time since natalizumab initiation, and cumulative number of infusions. RESULTS This study included 35,521 patients (primary analysis: 1,988 EID, 13,132 SID; secondary analysis: 3,331 EID, 15,424 SID; tertiary analysis: 815 EID, 23,168 SID). Mean average dosing intervals were 35.0 to 43.0 and 29.8 to 30.5 days for the EID and SID cohorts, respectively. Hazard ratios (95% confidence intervals) of PML risk for EID vs SID were 0.06 (0.01-0.22, p < 0.001) and 0.12 (0.05-0.29, p < 0.001) for the primary and secondary analyses, respectively. Relative risk reductions were 94% and 88% in favor of EID for the primary and secondary analyses, respectively. The tertiary analysis included no cases of PML with EID. CONCLUSION Natalizumab EID is associated with clinically and statistically significantly lower PML risk than SID. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for patients with MS, natalizumab EID is associated with a lower PML risk than SID.
Collapse
Affiliation(s)
- Lana Zhovtis Ryerson
- From the Department of Neurology (L.Z.R., I.K.), NYU Langone Health, New York University, New York; Rocky Mountain MS Clinic (J.F., R.R.M.), Salt Lake City, UT; Biogen (I.C., E.R., K.S., R.K., Z.R., C.H., P-R.H., N.C.), Cambridge, MA; University of Alabama School of Public Health (G.C.), Birmingham; and Division of Biostatistics (J.D.G., X.L.), New York University School of Medicine, New York
| | - John Foley
- From the Department of Neurology (L.Z.R., I.K.), NYU Langone Health, New York University, New York; Rocky Mountain MS Clinic (J.F., R.R.M.), Salt Lake City, UT; Biogen (I.C., E.R., K.S., R.K., Z.R., C.H., P-R.H., N.C.), Cambridge, MA; University of Alabama School of Public Health (G.C.), Birmingham; and Division of Biostatistics (J.D.G., X.L.), New York University School of Medicine, New York
| | - Ih Chang
- From the Department of Neurology (L.Z.R., I.K.), NYU Langone Health, New York University, New York; Rocky Mountain MS Clinic (J.F., R.R.M.), Salt Lake City, UT; Biogen (I.C., E.R., K.S., R.K., Z.R., C.H., P-R.H., N.C.), Cambridge, MA; University of Alabama School of Public Health (G.C.), Birmingham; and Division of Biostatistics (J.D.G., X.L.), New York University School of Medicine, New York
| | - Ilya Kister
- From the Department of Neurology (L.Z.R., I.K.), NYU Langone Health, New York University, New York; Rocky Mountain MS Clinic (J.F., R.R.M.), Salt Lake City, UT; Biogen (I.C., E.R., K.S., R.K., Z.R., C.H., P-R.H., N.C.), Cambridge, MA; University of Alabama School of Public Health (G.C.), Birmingham; and Division of Biostatistics (J.D.G., X.L.), New York University School of Medicine, New York
| | - Gary Cutter
- From the Department of Neurology (L.Z.R., I.K.), NYU Langone Health, New York University, New York; Rocky Mountain MS Clinic (J.F., R.R.M.), Salt Lake City, UT; Biogen (I.C., E.R., K.S., R.K., Z.R., C.H., P-R.H., N.C.), Cambridge, MA; University of Alabama School of Public Health (G.C.), Birmingham; and Division of Biostatistics (J.D.G., X.L.), New York University School of Medicine, New York
| | - Ryan R Metzger
- From the Department of Neurology (L.Z.R., I.K.), NYU Langone Health, New York University, New York; Rocky Mountain MS Clinic (J.F., R.R.M.), Salt Lake City, UT; Biogen (I.C., E.R., K.S., R.K., Z.R., C.H., P-R.H., N.C.), Cambridge, MA; University of Alabama School of Public Health (G.C.), Birmingham; and Division of Biostatistics (J.D.G., X.L.), New York University School of Medicine, New York
| | - Judith D Goldberg
- From the Department of Neurology (L.Z.R., I.K.), NYU Langone Health, New York University, New York; Rocky Mountain MS Clinic (J.F., R.R.M.), Salt Lake City, UT; Biogen (I.C., E.R., K.S., R.K., Z.R., C.H., P-R.H., N.C.), Cambridge, MA; University of Alabama School of Public Health (G.C.), Birmingham; and Division of Biostatistics (J.D.G., X.L.), New York University School of Medicine, New York
| | - Xiaochun Li
- From the Department of Neurology (L.Z.R., I.K.), NYU Langone Health, New York University, New York; Rocky Mountain MS Clinic (J.F., R.R.M.), Salt Lake City, UT; Biogen (I.C., E.R., K.S., R.K., Z.R., C.H., P-R.H., N.C.), Cambridge, MA; University of Alabama School of Public Health (G.C.), Birmingham; and Division of Biostatistics (J.D.G., X.L.), New York University School of Medicine, New York
| | - Evan Riddle
- From the Department of Neurology (L.Z.R., I.K.), NYU Langone Health, New York University, New York; Rocky Mountain MS Clinic (J.F., R.R.M.), Salt Lake City, UT; Biogen (I.C., E.R., K.S., R.K., Z.R., C.H., P-R.H., N.C.), Cambridge, MA; University of Alabama School of Public Health (G.C.), Birmingham; and Division of Biostatistics (J.D.G., X.L.), New York University School of Medicine, New York
| | - Karen Smirnakis
- From the Department of Neurology (L.Z.R., I.K.), NYU Langone Health, New York University, New York; Rocky Mountain MS Clinic (J.F., R.R.M.), Salt Lake City, UT; Biogen (I.C., E.R., K.S., R.K., Z.R., C.H., P-R.H., N.C.), Cambridge, MA; University of Alabama School of Public Health (G.C.), Birmingham; and Division of Biostatistics (J.D.G., X.L.), New York University School of Medicine, New York
| | - Rachna Kasliwal
- From the Department of Neurology (L.Z.R., I.K.), NYU Langone Health, New York University, New York; Rocky Mountain MS Clinic (J.F., R.R.M.), Salt Lake City, UT; Biogen (I.C., E.R., K.S., R.K., Z.R., C.H., P-R.H., N.C.), Cambridge, MA; University of Alabama School of Public Health (G.C.), Birmingham; and Division of Biostatistics (J.D.G., X.L.), New York University School of Medicine, New York
| | - Zheng Ren
- From the Department of Neurology (L.Z.R., I.K.), NYU Langone Health, New York University, New York; Rocky Mountain MS Clinic (J.F., R.R.M.), Salt Lake City, UT; Biogen (I.C., E.R., K.S., R.K., Z.R., C.H., P-R.H., N.C.), Cambridge, MA; University of Alabama School of Public Health (G.C.), Birmingham; and Division of Biostatistics (J.D.G., X.L.), New York University School of Medicine, New York
| | - Christophe Hotermans
- From the Department of Neurology (L.Z.R., I.K.), NYU Langone Health, New York University, New York; Rocky Mountain MS Clinic (J.F., R.R.M.), Salt Lake City, UT; Biogen (I.C., E.R., K.S., R.K., Z.R., C.H., P-R.H., N.C.), Cambridge, MA; University of Alabama School of Public Health (G.C.), Birmingham; and Division of Biostatistics (J.D.G., X.L.), New York University School of Medicine, New York
| | - Pei-Ran Ho
- From the Department of Neurology (L.Z.R., I.K.), NYU Langone Health, New York University, New York; Rocky Mountain MS Clinic (J.F., R.R.M.), Salt Lake City, UT; Biogen (I.C., E.R., K.S., R.K., Z.R., C.H., P-R.H., N.C.), Cambridge, MA; University of Alabama School of Public Health (G.C.), Birmingham; and Division of Biostatistics (J.D.G., X.L.), New York University School of Medicine, New York
| | - Nolan Campbell
- From the Department of Neurology (L.Z.R., I.K.), NYU Langone Health, New York University, New York; Rocky Mountain MS Clinic (J.F., R.R.M.), Salt Lake City, UT; Biogen (I.C., E.R., K.S., R.K., Z.R., C.H., P-R.H., N.C.), Cambridge, MA; University of Alabama School of Public Health (G.C.), Birmingham; and Division of Biostatistics (J.D.G., X.L.), New York University School of Medicine, New York.
| |
Collapse
|