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Goh YT, Yap ES, Tan CW, Tan D, Loh YSM, Lee YS, Chong LL, Lim ZY, Than H. Consensus recommendations for optimising the diagnosis and treatment of paroxysmal nocturnal haemoglobinuria in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2024; 53:371-385. [PMID: 38979993 DOI: 10.47102/annals-acadmedsg.202475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
Introduction Paroxysmal nocturnal haemoglobinuria (PNH) is a rare haematologic disease characterised by intravascular haemolysis, thrombophilia and bone marrow failure. There is a lack of established clinical guidance on the screening, diagnosis and manage-ment of PNH in Singapore. A relatively low level of awareness among healthcare professionals regarding PNH manifestations further contributes to diagnostic delays. Additionally, limited access to complement inhibitors, like eculizumab, may delay treatment and impact patient outcomes. Method Nine haematologists from different institu-tions in Singapore convened to formulate evidence-based consensus recommendations for optimising the diagnosis and management of patients with PNH and improving access to novel treatments. The experts reviewed the existing literature and international guidelines published from January 2010 to July 2023, focusing on 7 clinical questions spanning PNH screening, diagnostic criteria, investigations, treatment and monitoring of subclinical and classic disease, PNH with underlying bone marrow disorders, and PNH in pregnancy. A total of 181 papers were reviewed to formulate the statements. All experts voted on the statements via 2 rounds of Delphi and convened for an expert panel discussion to finetune the recommendations. Results Sixteen statements have been formulated for optimising the screening, diagnosis and management of PNH. Upon confirmation of PNH diagnosis, individuals with active haemolysis and/or thrombosis should be considered for anti-complement therapy, with eculizumab being the only approved drug in Singapore. Conclusion The current recommendations aim to guide the clinicians in optimising the screening, diagnosis and management of PNH in Singapore.
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Affiliation(s)
- Yeow Tee Goh
- Department of Haematology, Singapore General Hospital, Singapore
| | - Eng Soo Yap
- Department of Laboratory Medicine, National University of Singapore, Singapore
| | - Chuen Wen Tan
- Department of Haematology, Singapore General Hospital, Singapore
| | - Daryl Tan
- Department of Haematology, Mount Elizabeth Novena Specialist Centre, Singapore
| | | | - Yuh Shan Lee
- Department of Haematology, Mount Elizabeth Novena Specialist Centre and Gleneagles Hospital, Singapore
| | - Lip Leong Chong
- Department of Haematology, Tan Tock Seng Hospital, Singapore
| | - Zi Yi Lim
- Centre for Clinical Haematology, Mount Elizabeth Novena Specialist Centre, Singapore
| | - Hein Than
- Department of Haematology, Singapore General Hospital, Singapore
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Peffault de Latour R, Griffin M, Kelly RJ, Szer J, de Castro C, Horneff R, Tan L, Yeh M, Panse J. Hemolysis events in the phase 3 PEGASUS study of pegcetacoplan in patients with paroxysmal nocturnal hemoglobinuria. Blood Adv 2024; 8:2718-2725. [PMID: 38593241 PMCID: PMC11170155 DOI: 10.1182/bloodadvances.2024012672] [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: 01/16/2024] [Revised: 03/24/2024] [Accepted: 03/26/2024] [Indexed: 04/11/2024] Open
Abstract
ABSTRACT Patients with paroxysmal nocturnal hemoglobinuria (PNH) experience complement-mediated intravascular hemolysis leading to anemia, fatigue, and potentially life-threatening thrombotic complications. Pegcetacoplan, a C3 inhibitor, demonstrated sustained improvements in hematologic and clinical parameters in the phase 3 PEGASUS trial in patients with PNH who remained anemic despite C5 inhibitor therapy. The present post hoc analysis describes 26 hemolysis adverse events (AEs) experienced in 19 patients during pegcetacoplan therapy in PEGASUS and baseline patient characteristics potentially associated with increased hemolysis risk. Lactate dehydrogenase (LDH) ≥2× the upper limit of normal (ULN) was observed in 19 events, including 2 with LDH ≥10× ULN. All patients experienced decreased hemoglobin during hemolysis (mean decrease, 3.0 g/dL). In 16 events (62%), a potential complement-amplifying condition underlying the event could be identified. Hemolysis AEs led to study discontinuation in 5 patients. However, of 26 hemolysis AEs, 17 (65%) were manageable without pegcetacoplan discontinuation. A greater proportion of patients with hemolysis AEs (n = 19) had key characteristics of higher disease activity at baseline compared to patients without hemolysis AEs (n = 61), namely higher-than-label eculizumab dose (53% vs 23%), detectable CH50 (total complement function; 74% vs 54%), and ≥4 transfusions in the previous 12 months (68% vs 51%). These characteristics may be useful predictors of potential future hemolysis events. This trial was registered at www.ClinicalTrials.gov as #NCT03500549.
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Affiliation(s)
- Régis Peffault de Latour
- French Reference Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Paris, France
| | - Morag Griffin
- Department of Haematology, St James’s University Hospital, Leeds, United Kingdom
| | - Richard J. Kelly
- Department of Haematology, St James’s University Hospital, Leeds, United Kingdom
| | - Jeff Szer
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Australia
| | - Carlos de Castro
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University, Durham, NC
| | | | - Lisa Tan
- Swedish Orphan Biovitrum AB, Stockholm, Sweden
- Lisa Tan Pharma Consulting Ltd, Cambridge, United Kingdom
| | | | - Jens Panse
- Department of Oncology, Hematology, Hemostaseology, and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Centre for Integrated Oncology Aachen Bonn Cologne Düsseldorf, Aachen, Germany
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Griffin M, Kelly RJ, Panse J, de Castro C, Szer J, Horneff R, Tan L, Yeh M, Peffault de Latour R. Management of acute breakthrough hemolysis with intensive pegcetacoplan dosing in patients with PNH. Blood Adv 2024; 8:1776-1786. [PMID: 38315872 PMCID: PMC10985803 DOI: 10.1182/bloodadvances.2023011691] [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: 09/15/2023] [Revised: 01/24/2024] [Accepted: 01/24/2024] [Indexed: 02/07/2024] Open
Abstract
ABSTRACT Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by complement-mediated intravascular hemolysis leading to anemia, fatigue, and potentially life-threatening thrombotic complications. Breakthrough hemolysis (BTH) was first described in patients with PNH treated with terminal complement C5 inhibitors when intravascular hemolysis reoccurred despite treatment. Pegcetacoplan, the first proximal complement C3 inhibitor, offers broad hemolysis control in patients with PNH. While experience of managing BTH on C5 inhibitors is documented, very limited guidance exists for proximal complement inhibitors. This interim analysis assessed the effect of intensive treatment with pegcetacoplan following an acute BTH event in a subset of patients enrolled in the ongoing open-label extension study of pegcetacoplan in PNH. Thirteen patients with acute BTH included in the analysis received either a single IV dose of 1080 mg (n = 4) or 1080 mg subcutaneous (SC) dosing on 3 consecutive days (n = 9). A potential, clinically-relevant complement-amplifying condition, such as infection or vaccination, was reported in approximately half of the patients experiencing an acute BTH. Lactate dehydrogenase (LDH) levels decreased between day 1 and day 2 in 8 of 12 evaluable patients and in all 13 patients at day 7 to 12. Nine of 13 patients (69%) achieved LDH <2× the upper limit of normal by day 14 to 19. All adverse events associated with the acute BTH event were considered resolved by the investigators. Overall, intensive treatment with pegcetacoplan was safe and well tolerated. These novel data support effective management of acute BTH events in patients on pegcetacoplan with intensive IV or SC pegcetacoplan dosing. This trial was registered at www.clinicaltrials.gov as #NCT03531255.
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Affiliation(s)
- Morag Griffin
- Department of Haematology, St James’s University Hospital, Leeds, United Kingdom
| | - Richard J Kelly
- Department of Haematology, St James’s University Hospital, Leeds, United Kingdom
| | - Jens Panse
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Centre for Integrated Oncology (CIO), Aachen Bonn Cologne Düsseldorf (ABCD), Aachen, Germany
| | - Carlos de Castro
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University, Durham, NC
| | - Jeff Szer
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | | | - Lisa Tan
- Swedish Orphan Biovitrum AB, Stockholm, Sweden
- Lisa Tan Pharma Consulting Ltd, Cambridge, UK
| | | | - Régis Peffault de Latour
- French Reference Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Saint-Louis Hospital, Paris, France
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West EE, Woodruff T, Fremeaux-Bacchi V, Kemper C. Complement in human disease: approved and up-and-coming therapeutics. Lancet 2024; 403:392-405. [PMID: 37979593 PMCID: PMC10872502 DOI: 10.1016/s0140-6736(23)01524-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/07/2023] [Accepted: 07/20/2023] [Indexed: 11/20/2023]
Abstract
The complement system is recognised as a protector against blood-borne pathogens and a controller of immune system and tissue homoeostasis. However, dysregulated complement activity is associated with unwanted or non-resolving immune responses and inflammation, which induce or exacerbate the pathogenesis of a broad range of inflammatory and autoimmune diseases. Although the merit of targeting complement clinically has long been acknowledged, the overall complement drug approval rate has been modest. However, the success of the humanised anti-C5 antibody eculizumab in effectively treating paroxysmal nocturnal haemoglobinuria and atypical haemolytic syndrome has revitalised efforts to target complement therapeutically. Increased understanding of complement biology has led to the identification of novel targets for drug development that, in combination with advances in drug discovery and development technologies, has resulted in a surge of interest in bringing new complement therapeutics into clinical use. The rising number of approved drugs still almost exclusively target rare diseases, but the substantial pipeline of up-and-coming treatment options will possibly provide opportunities to also expand the clinical targeting of complement to common diseases.
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Affiliation(s)
- Erin E West
- Complement and Inflammation Research Section, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Trent Woodruff
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Veronique Fremeaux-Bacchi
- Inserm UMRS1138, Centre de Recherche des Cordeliers, Inflammation, Complement, and Cancer Team, Paris, France; Department of Immunology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Claudia Kemper
- Complement and Inflammation Research Section, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
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Cheng WY, Fishman J, Yenikomshian M, Mahendran M, Kunzweiler C, Vu JD, Duh MS. Dosing Patterns of Patients with Paroxysmal Nocturnal Hemoglobinuria Treated with Ravulizumab in the United States: A Retrospective Claims-Based Analysis. Adv Ther 2024; 41:413-430. [PMID: 37999832 PMCID: PMC10796480 DOI: 10.1007/s12325-023-02725-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/30/2023] [Indexed: 11/25/2023]
Abstract
INTRODUCTION Complement factor 5 inhibitors eculizumab and, recently, ravulizumab are standard therapies for paroxysmal nocturnal hemoglobinuria (PNH). However, some patients experience suboptimal response and may benefit from dosage adjustments. Ravulizumab is administered less frequently than eculizumab on the basis of patient's body weight. This retrospective analysis of insurance claims investigated ravulizumab dosing patterns among patients with PNH from the USA. METHODS Patients aged ≥ 12 years with ≥ 2 ravulizumab infusions between June 21, 2019 and May 6, 2021, and ≥ 6 months of continuous clinical activity prior to first ravulizumab infusion (index date) were identified from the Symphony Health Integrated Dataverse (IDV®) database. Observed mean (standard deviation, SD) ravulizumab doses administered were reported and stratified by previous eculizumab use. Scenarios adjusting for patients' body weights (unavailable in Symphony Health IDV) based on the US general population distribution were performed to estimate percentages of patients receiving label-recommended doses. RESULTS Among 433 patients (mean [SD] age 47 [17] years), the mean (SD) loading dose was 3316.3 (2931.7) mg, greater than the maximal label-recommended loading dose (3000 mg for patients ≥ 100 kg). The mean (SD) loading doses were 3581.3 (3673.7) mg for eculizumab-naive versus 3093.1 (2096.8) mg for eculizumab-experienced patients. Over a mean (SD) treatment period of 11.8 (6.9) months, the mean (SD) average maintenance dose was 3403.7 (1024.4) mg, falling between label-recommended maintenance dose categories (3300 mg for ≥ 60 to < 100 kg; 3600 mg for ≥ 100 kg). Estimated percentages of patients receiving label-recommended loading and maintenance doses were 23.1% and 39.2%, respectively; 59.1% and 28.4% were estimated to receive above label-recommended loading and average maintenance doses, respectively. CONCLUSION Although limited by missing clinical characteristics including body weight, this study of ravulizumab dosing patterns in patients with PNH identified potential deviations from label-recommended dosing, warranting further investigations of treatment response to complement inhibitors in PNH.
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Affiliation(s)
- Wendy Y Cheng
- Analysis Group, Inc., 111 Huntington Ave, 14th Floor, Boston, MA, USA
| | | | | | - Malena Mahendran
- Analysis Group, Inc., 111 Huntington Ave, 14th Floor, Boston, MA, USA
| | - Colin Kunzweiler
- Analysis Group, Inc., 111 Huntington Ave, 14th Floor, Boston, MA, USA
| | - Jensen Duy Vu
- Analysis Group, Inc., 111 Huntington Ave, 14th Floor, Boston, MA, USA
| | - Mei Sheng Duh
- Analysis Group, Inc., 111 Huntington Ave, 14th Floor, Boston, MA, USA.
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Lee J, Lee H, Kim S, Suh HS. Efficacy of complement inhibitors for patients with paroxysmal nocturnal hemoglobinuria: a systematic review and meta-analysis. Ther Adv Hematol 2023; 14:20406207231216080. [PMID: 38105771 PMCID: PMC10725119 DOI: 10.1177/20406207231216080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 10/19/2023] [Indexed: 12/19/2023] Open
Abstract
Background Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired hematological disease. The development of complement inhibitors such as eculizumab, ravulizumab, and pegcetacoplan has revolutionized the management of PNH, leading to improvements in overall survival and quality of life for patients. Objectives This systematic review aims to provide comprehensive evidence of the efficacy of complement inhibitors in relation to treatment duration. Design This is a systematic review and meta-analysis. Data sources and methods A thorough literature search was conducted in MEDLINE, EMBASE, and the Cochrane Library up to 3 May 2022. We included all prospective interventional studies including single-arm trials. The primary outcomes of interest were lactate dehydrogenase (LDH) levels, hemoglobin (Hb) concentrations, transfusion avoidance, and Functional Assessment of Chronic Illness Therapy Fatigue (FACIT-F) scores. Results Our study included a total of 27 studies, comprising 5 randomized controlled trials and 11 single-arm trials, with a total of 912 patients with PNH. We stratified the studies according to treatment duration, based on the most frequently reported period of 26 weeks. Our analysis showed that treatment-naïve patients who received complement inhibitors had a pooled estimate of a decrease in LDH levels from baseline by -1462.0 U/L (95% CI: -1735.6 to -1188.5) for treatment ⩽26 weeks and -1696.5 U/L (95% CI: -2122.7 to -1270.2) for treatment >26 weeks. The mean Hb levels were increased by 1.4 g/dL (95% CI: 0.5-2.3) and 1.9 g/dL (95% CI: 0.7-3.1) in each group. Treatment with any complement inhibitor prevented the need for transfusion in at least 50% of patients with PNH in all treatment periods. Clinically meaningful improvements in FACIT-F were observed both before and after 26 weeks, with a pooled estimate of 6.8 (95% CI: 6.0-7.6) and 9.5 (95% CI: 7.0-12.0), respectively. Conclusion Our findings suggest that complement inhibitors can result in positive treatment outcomes and sustained benefits for patients with PNH.
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Affiliation(s)
- Jiyeon Lee
- Department of Regulatory Science, Graduate School, Kyung Hee University, Seoul, Republic of Korea
- Institute of Regulatory Innovation Through Science, Kyung Hee University, Seoul, Republic of Korea
| | - Haeseon Lee
- Department of Regulatory Science, Graduate School, Kyung Hee University, Seoul, Republic of Korea
- Institute of Regulatory Innovation Through Science, Kyung Hee University, Seoul, Republic of Korea
| | - Siin Kim
- College of Pharmacy, Woosuk University, Wanju-gun, Republic of Korea
| | - Hae Sun Suh
- Department of Regulatory Science, Graduate School, Kyung Hee University, Seoul, Republic of Korea
- Institute of Regulatory Innovation Through Science, Kyung Hee University, Seoul, Republic of Korea
- College of Pharmacy, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Republic of Korea
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Hall FC, Cheriyan J, Cope AP, Galloway J, Wilkinson I, Bond S, Norton S, Banham-Hall E, Bayes H, Kostapanos M, Nodale M, Petchey WG, Sheeran T, Underwood J, Jayne DR. Efficacy and safety of baricitinib or ravulizumab in adult patients with severe COVID-19 (TACTIC-R): a randomised, parallel-arm, open-label, phase 4 trial. THE LANCET. RESPIRATORY MEDICINE 2023; 11:1064-1074. [PMID: 37977159 PMCID: PMC10682367 DOI: 10.1016/s2213-2600(23)00376-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 08/31/2023] [Accepted: 10/03/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND From early in the COVID-19 pandemic, evidence suggested a role for cytokine dysregulation and complement activation in severe disease. In the TACTIC-R trial, we evaluated the efficacy and safety of baricitinib, an inhibitor of Janus kinase 1 (JAK1) and JAK2, and ravulizumab, a monoclonal inhibitor of complement C5 activation, as an adjunct to standard of care for the treatment of adult patients hospitalised with COVID-19. METHODS TACTIC-R was a phase 4, randomised, parallel-arm, open-label platform trial that was undertaken in the UK with urgent public health designation to assess the potential of repurposing immunosuppressants for the treatment of severe COVID-19, stratified by a risk score. Adult participants (aged ≥18 years) were enrolled from 22 hospitals across the UK. Patients with a risk score indicating a 40% risk of admission to an intensive care unit or death were randomly assigned 1:1:1 to standard of care alone, standard of care with baricitinib, or standard of care with ravulizumab. The composite primary outcome was the time from randomisation to incidence (up to and including day 14) of the first event of death, invasive mechanical ventilation, extracorporeal membrane oxygenation, cardiovascular organ support, or renal failure. The primary interim analysis was triggered when 125 patient datasets were available up to day 14 in each study group and we included in the analysis all participants who were randomly assigned. The trial was registered on ClinicalTrials.gov (NCT04390464). FINDINGS Between May 8, 2020, and May 7, 2021, 417 participants were recruited and randomly assigned to standard of care alone (145 patients), baricitinib (137 patients), or ravulizumab (135 patients). Only 54 (39%) of 137 patients in the baricitinib group received the maximum 14-day course, whereas 132 (98%) of 135 patients in the ravulizumab group received the intended dose. The trial was stopped after the primary interim analysis on grounds of futility. The estimated hazard ratio (HR) for reaching the composite primary endpoint was 1·11 (95% CI 0·62-1·99) for patients on baricitinib compared with standard of care alone, and 1·53 (0·88-2·67) for ravulizumab compared with standard of care alone. 45 serious adverse events (21 deaths) were reported in the standard-of-care group, 57 (24 deaths) in the baricitinib group, and 60 (18 deaths) in the ravulizumab group. INTERPRETATION Neither baricitinib nor ravulizumab, as administered in this study, was effective in reducing disease severity in patients selected for severe COVID-19. Safety was similar between treatments and standard of care. The short period of dosing with baricitinib might explain the discrepancy between our findings and those of other trials. The therapeutic potential of targeting complement C5 activation product C5a, rather than the cleavage of C5, warrants further evaluation. FUNDING UK Medical Research Council, UK National Institute for Health Research Cambridge Biomedical Research Centre, Eli Lilly and Company, Alexion Pharmaceuticals, and Addenbrooke's Charitable Trust.
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Affiliation(s)
- Frances C Hall
- Department of Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | - Joseph Cheriyan
- Department of Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrew P Cope
- Centre for Rheumatic Diseases, Kings's College London, London, UK
| | - James Galloway
- Centre for Rheumatic Diseases, Kings's College London, London, UK
| | - Ian Wilkinson
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Simon Bond
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sam Norton
- Centre for Rheumatic Diseases, Kings's College London, London, UK
| | - Edward Banham-Hall
- Department of Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Hannah Bayes
- Department of Respiratory Medicine, Glasgow Royal Infirmary, Glasgow, UK
| | - Michalis Kostapanos
- Department of Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Marianna Nodale
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - William G Petchey
- Department of Nephrology, West Suffolk NHS Foundation Trust, Bury St Edmunds, UK
| | - Thomas Sheeran
- Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | | | - David R Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
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Vu T, Wiendl H, Katsuno M, Reddel SW, Howard JF. Ravulizumab in Myasthenia Gravis: A Review of the Current Evidence. Neuropsychiatr Dis Treat 2023; 19:2639-2655. [PMID: 38059203 PMCID: PMC10697093 DOI: 10.2147/ndt.s374694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/17/2023] [Indexed: 12/08/2023] Open
Abstract
The terminal complement C5 inhibitor ravulizumab was engineered from the humanized monoclonal antibody eculizumab to have an extended half-life and duration of action. It binds to human terminal complement protein C5, inhibiting its cleavage into C5a and C5b, thus preventing the cascade of events that lead to architectural destruction of the postsynaptic neuromuscular junction membrane by the membrane attack complex, and consequent muscle weakness in patients with anti-acetylcholine receptor (AChR) antibody-positive generalized myasthenia gravis (gMG). The 26-week randomized, placebo-controlled period (RCP) of the phase 3 CHAMPION MG study demonstrated the rapid efficacy of ravulizumab in reducing MG symptoms. Weight-based dosing of ravulizumab every 8 weeks provided sustained efficacy, in terms of patient-reported (Myasthenia Gravis-Activities of Daily Living) and clinician-reported (Quantitative Myasthenia Gravis) endpoints in patients with anti-AChR antibody-positive gMG. Pharmacokinetic and pharmacodynamic analyses showed therapeutic serum ravulizumab concentrations (>175 µg/mL) were achieved immediately after the first dose and were maintained throughout 26 weeks, irrespective of patient body weight; inhibition of serum free C5 was immediate, complete (<0.5 μg/mL), and sustained in all patients. Interim results from the open-label extension (OLE) showed that after 60 weeks, efficacy was maintained in patients continuing on ravulizumab. Rapid and sustained improvements in efficacy, similar to those seen in patients initiating ravulizumab in the RCP, were observed after initiation of ravulizumab treatment in patients who switched from placebo in the RCP to ravulizumab in the OLE. The findings from the RCP and OLE support ravulizumab's favorable safety profile. In conclusion, ravulizumab has a simple weight-based administration and long dosing interval. Its targeted mechanism of action without generalized immunosuppression is reflected in its rapid onset of symptom improvement, sustained efficacy and good safety profile in the treatment of patients with anti-AChR antibody-positive gMG.
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Affiliation(s)
- Tuan Vu
- Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Stephen W Reddel
- Department of Neurology, Concord Hospital, University of Sydney, Sydney, NSW, Australia
| | - James F Howard
- Department of Neurology, The University of North Carolina, Chapel Hill, NC, USA
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Bodó I, Amine I, Boban A, Bumbea H, Kulagin A, Lukina E, Piekarska A, Zupan IP, Sokol J, Windyga J, Cermak J. Complement Inhibition in Paroxysmal Nocturnal Hemoglobinuria (PNH): A Systematic Review and Expert Opinion from Central Europe on Special Patient Populations. Adv Ther 2023; 40:2752-2772. [PMID: 37072660 PMCID: PMC10112829 DOI: 10.1007/s12325-023-02510-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/28/2023] [Indexed: 04/20/2023]
Abstract
INTRODUCTION Hemolysis in paroxysmal nocturnal hemoglobinuria (PNH) is complement-mediated due to the lack of complement inhibitors in the hemopoietic cell membranes, making complement inhibition the best approach to manage PNH. Three complement inhibitors are approved by the European Medicines Agency as targeted therapy for PNH: eculizumab and ravulizumab, two humanized monoclonal antibodies targeting the same complement 5 (C5) epitope, approved in 2007 and 2019, respectively, and the more recently approved cyclic peptide, the complement 3 (C3) inhibitor pegcetacoplan. Although national and international PNH treatment guidelines exist, they do not take into consideration the latest clinical trial evidence. Given the lack of evidence-based data for some clinical situations encountered in real life, we identified specific populations of patients who may benefit from switching to proximal C3 from terminal C5 inhibition. METHODS The expert recommendations presented here were created using a Delphi-like process by a group of expert PNH specialists across Central Europe. Based on an initial advisory board meeting discussion, recommendations were prepared and reviewed as part of a Delphi survey to test agreement. RESULTS Using a systematic approach, literature databases were searched for relevant studies, and 50 articles were reviewed by the experts and included as supporting evidence. CONCLUSION Implementation of these recommendations uniformly across healthcare institutions will promote the best use of complement inhibition in managing PNH, and has the potential to positively impact patient outcomes in Central Europe and worldwide.
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Affiliation(s)
- Imre Bodó
- Department of Internal Medicine and Hematology, Semmelweis University, 46 Szentkirályi u., Budapest, 1088, Hungary.
| | - Ismail Amine
- Department of Hematology, Tokuda Hospital Sofia, Sofia, Bulgaria
| | - Ana Boban
- Division of Haematology, Department of Internal Medicine, University Hospital Center Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Horia Bumbea
- Bone Marrow Transplant Unit, Department of Hematology, Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Alexander Kulagin
- RM Gorbacheva Research Institute, Pavlov University, St. Petersburg, Russia
| | - Elena Lukina
- Department of Orphan Diseases, National Research Medical Center for Hematology, Moscow, Russia
| | - Agnieszka Piekarska
- Department of Hematology and Transplantology Medical, University of Gdansk, Gdansk, Poland
| | - Irena Preloznik Zupan
- Department of Hematology, University Medical Centre Ljubljana, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Juraj Sokol
- Department of Hematology and Transfusion Medicine, Jessenius Medical Faculty in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Jaroslav Cermak
- Institute of Hematology and Blood Transfusion, Prague, Czech Republic
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Vu T, Ortiz S, Katsuno M, Annane D, Mantegazza R, Beasley KN, Aguzzi R, Howard JF. Ravulizumab pharmacokinetics and pharmacodynamics in patients with generalized myasthenia gravis. J Neurol 2023; 270:3129-3137. [PMID: 36890354 PMCID: PMC10188401 DOI: 10.1007/s00415-023-11617-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 03/10/2023]
Abstract
INTRODUCTION The terminal complement C5 inhibitor ravulizumab has a long elimination half-life, allowing maintenance dosing every 8 weeks. In the 26-week, double-blind, randomized, placebo-controlled period (RCP) of the CHAMPION MG study, ravulizumab provided rapid and sustained efficacy and was well tolerated in adults with anti-acetylcholine receptor antibody-positive (AChR Ab+) generalized myasthenia gravis (gMG). This analysis evaluated the pharmacokinetics (PK), pharmacodynamics (PD), and potential immunogenicity of ravulizumab in adults with AChR Ab+ gMG. METHODS Data were analyzed from 86 patients who received ravulizumab in the CHAMPION MG RCP. Ravulizumab dosing was weight-based: initial loading dose of 2400/2700/3000 mg on Day 1 and maintenance doses of 3000/3300/3600 mg on Day 15 and then every 8 weeks. PK parameters were estimated from serum ravulizumab concentrations determined pre- and post-dose; PD effects of ravulizumab on serum free C5 concentrations were measured; and immunogenicity was assessed using anti-drug antibody and neutralizing-antibody assays. RESULTS Target serum ravulizumab concentrations (> 175 µg/mL) were achieved immediately after the first ravulizumab dose (within 30 min of infusion completion) and maintained throughout the 26-week treatment period irrespective of patient body weight. Following the final maintenance dose, mean Cmax was 1548 µg/mL and Ctrough 587 µg/mL; no meaningful differences were noted among body-weight categories. Inhibition of serum free C5 was immediate, complete (< 0.5 μg/mL), and sustained throughout treatment in all patients. No treatment-emergent anti-drug antibodies were observed. CONCLUSIONS PK/PD evidence supports the use of ravulizumab every 8 weeks for immediate, complete, and sustained inhibition of terminal complement C5 in adults with AChR Ab+ gMG. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT03920293 (April 18, 2019).
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Affiliation(s)
- Tuan Vu
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | | | | | - Djillali Annane
- Hôpital Raymond Poincaré, University of Versailles, Garches, France
| | | | | | - Rasha Aguzzi
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
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11
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Ręka G, Stefaniak M, Lejman M. Novel Molecular Therapies and Genetic Landscape in Selected Rare Diseases with Hematologic Manifestations: A Review of the Literature. Cells 2023; 12:cells12030449. [PMID: 36766791 PMCID: PMC9913931 DOI: 10.3390/cells12030449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/25/2023] [Accepted: 01/26/2023] [Indexed: 02/03/2023] Open
Abstract
Rare diseases affect less than 1 in 2000 people and are characterized by a serious, chronic, and progressive course. Among the described diseases, a mutation in a single gene caused mastocytosis, thrombotic thrombocytopenic purpura, Gaucher disease, and paroxysmal nocturnal hemoglobinuria (KIT, ADAMTS13, GBA1, and PIG-A genes, respectively). In Castleman disease, improper ETS1, PTPN6, TGFBR2, DNMT3A, and PDGFRB genes cause the appearance of symptoms. In histiocytosis, several mutation variants are described: BRAF, MAP2K1, MAP3K1, ARAF, ERBB3, NRAS, KRAS, PICK1, PIK3R2, and PIK3CA. Genes like HPLH1, PRF1, UNC13D, STX11, STXBP2, SH2D1A, BIRC4, ITK, CD27, MAGT1, LYST, AP3B1, and RAB27A are possible reasons for hemophagocytic lymphohistiocytosis. Among novel molecular medicines, tyrosine kinase inhibitors, mTOR inhibitors, BRAF inhibitors, interleukin 1 or 6 receptor antagonists, monoclonal antibodies, and JAK inhibitors are examples of drugs expanding therapeutic possibilities. An explanation of the molecular basis of rare diseases might lead to a better understanding of the pathogenesis and prognosis of the disease and may allow for the development of new molecularly targeted therapies.
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Affiliation(s)
- Gabriela Ręka
- Independent Laboratory of Genetic Diagnostics, Medical University of Lublin, A. Gębali 6, 20-093 Lublin, Poland
- Correspondence:
| | - Martyna Stefaniak
- Student Scientific Society of Independent Laboratory of Genetic Diagnostics, Medical University of Lublin, A. Gębali 6, 20-093 Lublin, Poland
| | - Monika Lejman
- Independent Laboratory of Genetic Diagnostics, Medical University of Lublin, A. Gębali 6, 20-093 Lublin, Poland
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12
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Experience of compassionate-use pegcetacoplan for paroxysmal nocturnal hemoglobinuria. Blood 2023; 141:116-120. [PMID: 36054920 DOI: 10.1182/blood.2022017266] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/12/2022] [Accepted: 08/12/2022] [Indexed: 01/10/2023] Open
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13
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Panse J, Sicre de Fontbrune F, Burmester P, Piggin M, Matos JE, Costantino H, Wilson K, Hakimi Z, Nazir J, Desgraz R, Fishman J, Persson E, Kulasekararaj A. The burden of illness of patients with paroxysmal nocturnal haemoglobinuria receiving C5 inhibitors in France, Germany and the United Kingdom: Patient-reported insights on symptoms and quality of life. Eur J Haematol 2022; 109:351-363. [PMID: 35746830 PMCID: PMC9545353 DOI: 10.1111/ejh.13816] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/31/2022] [Accepted: 06/02/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To assess the clinical, humanistic and economic burden of paroxysmal nocturnal haemoglobinuria (PNH) among C5 inhibitor (C5i)-treated patients with PNH. METHODS This was a web-based, cross-sectional survey (01FEB2021-31MAR2021) of adults with PNH treated with eculizumab (France, Germany, United Kingdom) or ravulizumab (Germany). Self-reported outcomes included: patient characteristics; patient-reported symptoms; and standardised patient-reported outcomes (e.g. Functional Assessment of Chronic Illness Therapy [FACIT]-Fatigue, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 [EORTC QLQ-C30]). RESULTS Among 71 included patients, 98.6% were C5i-treated for ≥3 months (88.7% ≥12 months); among those with self-reported haemoglobin (Hb) levels (n = 63), most (85.7%) were anaemic (defined as ≤12.0 g/dL). Fatigue was the most common symptom at both diagnosis (73.2%) and survey time (63.4%); there were no statistically significant differences in symptom prevalence between treatment subgroups (eculizumab vs. ravulizumab). Total FACIT-Fatigue and EORTC QLQ-C30 scores were substantially lower than European general population references, but there were no statistically significant differences between treatment subgroups. Hb-level subgroups (<10.5 g/dL vs. ≥10.5 d/dL) followed similar trends for all measures, with few significant subgroup differences. CONCLUSIONS Results suggest that there remains a considerable burden and unmet need among C5i-treated patients with PNH that requires improved therapies.
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Affiliation(s)
- Jens Panse
- Department of Oncology, Hematology, Hemostaseology and Stem Cell TransplantationUniversity Hospital RWTH AachenAachenGermany
- Center for Integrated Oncology (CIO) Aachen, Bonn, Cologne, DuesseldorfAachenGermany
| | - Flore Sicre de Fontbrune
- Hematology transplant Unit—French Reference Center for Aplastic AnemiaHôpital Saint‐LouisParisFrance
| | | | | | | | | | - Koo Wilson
- Swedish Orphan Biovitrum ABStockholmSweden
| | | | | | | | - Jesse Fishman
- Department of HaematologyKing's College HospitalLondonUK
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14
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de Latour RP, Szer J, Weitz IC, Röth A, Höchsmann B, Panse J, Usuki K, Griffin M, Kiladjian JJ, de Castro CM, Nishimori H, Ajayi T, Al-Adhami M, Deschatelets P, Francois C, Grossi F, Risitano AM, Hillmen P. Pegcetacoplan versus eculizumab in patients with paroxysmal nocturnal haemoglobinuria (PEGASUS): 48-week follow-up of a randomised, open-label, phase 3, active-comparator, controlled trial. Lancet Haematol 2022; 9:e648-e659. [PMID: 36055332 DOI: 10.1016/s2352-3026(22)00210-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/16/2022] [Accepted: 06/17/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND In the PEGASUS trial, the complement C3 inhibitor, pegcetacoplan, showed superiority to eculizumab in improving haematological outcomes in adult patients with paroxysmal nocturnal haemoglobinuria and suboptimal response to eculizumab at 16 weeks. The aim of the open-label period was to evaluate the long-term efficacy and safety of pegcetacoplan through to 48 weeks. METHODS PEGASUS was a phase 3, randomised, open-label, active-comparator controlled trial conducted in 44 centres in Australia, Belgium, Canada, France, Germany, Japan, Russia, South Korea, Spain, the UK, and the USA. Eligible participants were aged 18 years or older, had paroxysmal nocturnal haemoglobinuria, and had a haemoglobin concentration of less than 10·50 g/dL after 3 months or longer of stable eculizumab treatment. After a 4-week run-in with eculizumab plus pegcetacoplan, patients were randomly assigned (1:1) by interactive response technology to pegcetacoplan (1080 mg subcutaneously twice weekly) or eculizumab (according to their regimen at enrolment) for 16 weeks and could continue to the open-label period (32 weeks of pegcetacoplan monotherapy [pegcetacoplan-to-pegcetacoplan] or 28 weeks of pegcetacoplan monotherapy [eculizumab-to-pegcetacoplan]). Randomisation was stratified by platelet count and number of previous blood transfusions. The primary endpoint was change from baseline in haemoglobin at week 16, which has previously been reported. The outcomes of the open-label period (week 16 to week 48) are reported here. At 48 weeks, efficacy (including mean haemoglobin concentration and quality of life measured on the Functional Assessment of Chronic Illness Therapy [FACIT]-Fatigue scale) was assessed in the intention-to-treat population and safety was assessed per protocol. This trial was registered with ClinicalTrials.gov, NCT03500549, and has been completed. FINDINGS Between June 14, 2018, and Nov 14, 2019, 80 patients were randomly assigned to receive treatment with pegcetacoplan (41 patients) or eculizumab (39 patients). Most participants were women (49 [61%]) and 31 (39%) were men; 12 (15%) were Asian, two (3%) were Black, 49 (61%) were White, and 17 (21%) were another race or did not report their race. The open-label period had 77 participants (38 pegcetacoplan-to-pegcetacoplan, 39 eculizumab-to-pegcetacoplan). Patients in the pegcetacoplan-to-pegcetacoplan group maintained high mean haemoglobin concentrations between 16 weeks (11·54 g/dL [SD 1·96]) and 48 weeks (11·30 g/dL [1·77]; p=0·14). Patients in the eculizumab-to-pegcetacoplan group had significantly greater mean haemoglobin concentrations at 48 weeks (11·57 g/dL [2·21]) versus 16 weeks (8·58 g/dL [0·96]; p<0·0001). Clinically meaningful improvements in FACIT-Fatigue scores were observed at 48 weeks, with a mean change from baseline for all patients receiving pegcetacoplan monotherapy of 9·89 points (SD 9·63), for patients in the pegcetacoplan-to-pegcetacoplan group mean 10·14 points (9·06), and for patients in the eculizumab-to-pegcetacoplan group mean 9·62 points (10·34). During the entire study period, 13 (16%) of 80 patients discontinued treatment (three [7%] of 41 through to week 16 due to breakthrough haemolysis, and ten [13%] of 77 due to severe treatment-emergent adverse events) and 18 patients (eight pegcetacoplan-to-pegcetacoplan, ten eculizumab-to-pegcetacoplan) had at least one serious treatment-emergent adverse event during the open-label period, four were considered to be related to pegcetacoplan treatment. The most common treatment-emergent adverse events (in ≥10% patients) among both pegcetacoplan-treated groups during the open-label period were injection site reactions (in 20 [26%] of 77 patients), haemolysis (15 [19%]), nasopharyngitis (12 [16%]), and diarrhoea (ten [13%]). No treatment-related deaths occurred throughout the duration of the study. INTERPRETATION The durability of improved haematological outcomes and favourable safety profile over 48 weeks of treatment suggests that pegcetacoplan has the potential to improve treatment benefit and alter treatment goals in patients with paroxysmal nocturnal haemoglobinuria. FUNDING Apellis Pharmaceuticals.
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Affiliation(s)
- Régis Peffault de Latour
- French Reference Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Université Paris Cité, Saint-Louis Hospital, Paris, France; Assistance Publique-Hôpitaux de Paris, Department of Hematology and Bone Marrow Transplantation, Saint-Louis Hospital, Université Paris Cité, Paris, France.
| | - Jeff Szer
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Ilene C Weitz
- Jane Anne Nohl Division of Hematology, Keck-University of Southern California School of Medicine, Los Angeles, CA, USA
| | - Alexander Röth
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Britta Höchsmann
- Institute of Transfusion Medicine, University of Ulm, Ulm, Germany; Institute of Clinical Transfusion Medicine and Immunogenetics, German Red Cross Blood Transfusion Service, Baden-Württemberg-Hessen and University Hospital of Ulm, Ulm, Germany
| | - Jens Panse
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany; Center for Integrated Oncology, Aachen Bonn Cologne Düsseldorf, Aachen, Germany
| | - Kensuke Usuki
- Department of Hematology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Morag Griffin
- Department of Haematology, Saint James University Hospital, Leeds, UK
| | - Jean-Jacques Kiladjian
- Université Paris Cité, Assistance Publique-Hôpitaux de Paris, Hoôpital Saint-Louis, Centre d'Investigations Cliniques, INSERM, CIC1427, Paris, France
| | - Carlos M de Castro
- Department of Medicine, Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, NC, USA
| | - Hisakazu Nishimori
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | | | | | | | | | | | - Antonio M Risitano
- Hematology and BMT Unit, AORN San Giuseppe Moscati, Avellino, Italy; Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - Peter Hillmen
- Department of Haematology, Saint James University Hospital, Leeds, UK
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15
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Shammo J, Gajra A, Patel Y, Tomazos I, Kish J, Hill A, Sierra JR, Araten D. Low Rate of Clinically Evident Extravascular Hemolysis in Patients with Paroxysmal Nocturnal Hemoglobinuria Treated with a Complement C5 Inhibitor: Results from a Large, Multicenter, US Real-World Study. J Blood Med 2022; 13:425-437. [PMID: 35983240 PMCID: PMC9380823 DOI: 10.2147/jbm.s361863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/29/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Most patients with paroxysmal nocturnal hemoglobinuria (PNH) treated with a complement protein 5 (C5) inhibitor achieve full control of terminal complement activity and intravascular hemolysis. The minority remains anemic and transfusion dependent despite this control. Etiology for ongoing anemia is multifactorial and includes bone marrow failure, breakthrough hemolysis, extravascular hemolysis (EVH) and nutritional deficiencies. Patients and Methods To evaluate the potential etiologies of hemoglobin levels <10 g/dL despite receiving C5 inhibitor therapy, we performed a retrospective US chart review of adult patients with PNH and treated for at least 12 months with eculizumab (n=53), ravulizumab (n=32), or eculizumab followed by ravulizumab (n=15). Clinically evident EVH was defined as at least one transfusion, reticulocyte count ≥120×109/L and hemoglobin level ≤9.5 g/dL. Safety data were not collected. Mean treatment duration was 26.5±17.2 months. Results Treatment with C5 inhibitors significantly improved hemoglobin, lactate dehydrogenase, and number of transfusions versus baseline. Among the patients with hemoglobin <10 g/dL during the last 6 months of treatment (n=38), one patient (eculizumab) had clinically evident EVH, and 10 patients had active concomitant bone marrow failure. Bone marrow failure was a major contributor to hemoglobin <10 g/dL and transfusion dependence; clinically evident EVH was uncommon. Conclusion A range of hematologic causes need to be considered when evaluating anemia in the presence of treatment with a C5 inhibitor.
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Affiliation(s)
- Jamile Shammo
- Rush Hematology, Oncology and Cell Therapy, Rush University Medical Center, Chicago, IL, USA
| | | | - Yogesh Patel
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
| | | | | | - Anita Hill
- Alexion, AstraZeneca Rare Disease, Inc., Leeds, UK
| | | | - David Araten
- Division of Hematology, New York University School of Medicine, New York, NY, USA
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16
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Fernandez-Ruiz R, Belmont HM. The role of anticomplement therapy in lupus nephritis. Transl Res 2022; 245:1-17. [PMID: 35158097 DOI: 10.1016/j.trsl.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 02/03/2022] [Accepted: 02/07/2022] [Indexed: 10/19/2022]
Abstract
The complement system plays crucial roles in homeostasis and host defense against microbes. Deficiency of early complement cascade components has been associated with increased susceptibility to systemic lupus erythematosus (SLE), whereas excessive complement consumption is a hallmark of this disease. Although enhanced classical pathway activation by immune complexes was initially thought to be the main contributor to lupus nephritis (LN) pathogenesis, an increasing body of evidence has suggested the alternative and the lectin pathways are also involved. Therapeutic agents targeting complement activation have been used in LN patients and clinical trials are ongoing. We review the mechanisms by which complement system dysregulation contributes to renal injury in SLE and summarize the latest evidence on the use of anticomplement agents to manage this condition.
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Affiliation(s)
- Ruth Fernandez-Ruiz
- Division of Rheumatology, NYU Grossman School of Medicine, New York, New York
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17
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Fattizzo B, Cavallaro F, Oliva EN, Barcellini W. Managing Fatigue in Patients with Paroxysmal Nocturnal Hemoglobinuria: A Patient-Focused Perspective. J Blood Med 2022; 13:327-335. [PMID: 35747742 PMCID: PMC9211741 DOI: 10.2147/jbm.s339660] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 05/23/2022] [Indexed: 11/23/2022] Open
Abstract
The most frequently reported symptom in patients with paroxysmal nocturnal hemoglobinuria (PNH), a disease characterized by complement mediated hemolysis and chronic anemia, is "fatigue". The latter seems the best word to communicate patient' perception of personal health status and disease impact on daily living, namely quality of life (QoL). Objectivating QoL and grading patient's fatigue is one of the most difficult medical tasks given the highly heterogeneous communication skills of patients and caregivers and the multitude of meanings that might be attributed to this term. Along with anemia, QoL in PNH is also affected by the emotional burden of a chronic life-long disease with heterogeneous treatment requirement, risk of hemolytic exacerbations (breakthrough hemolysis) and of thrombosis. In the last decade, structured surveys and scores have been adapted from cancer settings to evaluate fatigue and QoL in patients with PNH, and to assess the benefit of complement inhibitors in this setting. Eculizumab was the first drug utilized and was shown to improve QoL scores in the registrative trials. However, the intravenous fortnightly administration, the presence of residual anemia, and the risk of extravascular hemolysis are some of the unmet needs impacting QoL under eculizumab. Several novel drugs have been designed to improve patients' convenience and alleviate anemia and fatigue. In this review, we focus on available studies that evaluated fatigue and QoL in PNH patients, and the effect of old and new therapeutic strategies.
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Affiliation(s)
- Bruno Fattizzo
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico - Haematology Unit, Milan, Italy
- Università degli Studi di Milano - Department of Oncology and Hemato-Oncology, Milan, Italy
| | - Francesca Cavallaro
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico - Haematology Unit, Milan, Italy
- Università degli Studi di Milano - Department of Oncology and Hemato-Oncology, Milan, Italy
| | - Esther Natalie Oliva
- Grande Ospedale Metropolitano Bianchi Melacrino Morelli - Hematology Division, Reggio, Calabria, Italy
| | - Wilma Barcellini
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico - Haematology Unit, Milan, Italy
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18
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Kulasekararaj AG, Brodsky RA, Nishimura JI, Patriquin CJ, Schrezenmeier H. The importance of terminal complement inhibition in paroxysmal nocturnal hemoglobinuria. Ther Adv Hematol 2022; 13:20406207221091046. [PMID: 35663504 PMCID: PMC9160915 DOI: 10.1177/20406207221091046] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/14/2022] [Indexed: 11/30/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, chronic hematologic disorder associated with inappropriate terminal complement activity on blood cells that can result in intravascular hemolysis (IVH), thromboembolic events (TEs), and organ damage. Untreated individuals with PNH have an increased risk of morbidity and mortality. Patients with PNH experiencing IVH often present with an elevated lactate dehydrogenase (LDH; ⩾ 1.5 × the upper limit of normal) level which is associated with a significantly higher risk of TEs, one of the leading causes of death in PNH. LDH is therefore used as a biomarker for IVH in PNH. The main objective of PNH treatment should therefore be prevention of morbidity and mortality due to terminal complement activation, with the aim of improving patient outcomes. Approval of the first terminal complement inhibitor, eculizumab, greatly changed the treatment landscape of PNH by giving patients an effective therapy and demonstrated the critical role of terminal complement and the possibility of modulating it therapeutically. The current mainstays of treatment for PNH are the terminal complement component 5 (C5) inhibitors, eculizumab and ravulizumab, which have shown efficacy in controlling terminal complement-mediated IVH, reducing TEs and organ damage, and improving health-related quality of life in patients with PNH since their approval by the United States Food and Drug Administration in 2007 and 2018, respectively. Moreover, the use of eculizumab has been shown to reduce mortality due to PNH. More recently, interest has arisen in developing additional complement inhibitors with different modes of administration and therapeutics targeting other components of the complement cascade. This review focuses on the pathophysiology of clinical complications in PNH and explores why sustained inhibition of terminal complement activity through the use of complement inhibitors is essential for the management of patients with this chronic and debilitating disease.
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Affiliation(s)
- Austin G. Kulasekararaj
- Department of Haematological Medicine, King’s College Hospital, Denmark Hill, London SE5 9RS, UK
- National Institute of Health Research/Wellcome King’s Clinical Research Facility and King’s College London, London, UK
| | | | - Jun-ichi Nishimura
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Christopher J. Patriquin
- Division of Medical Oncology & Hematology, University Health Network – Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Hubert Schrezenmeier
- Institute of Transfusion Medicine, University of Ulm, and Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, and University Hospital Ulm, Ulm, Germany
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19
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Iptacopan monotherapy in patients with paroxysmal nocturnal hemoglobinuria: a 2-cohort open-label proof-of-concept study. Blood Adv 2022; 6:4450-4460. [PMID: 35561315 DOI: 10.1182/bloodadvances.2022006960] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/05/2022] [Indexed: 11/20/2022] Open
Abstract
Iptacopan (LNP023) is a novel, oral selective inhibitor of complement factor B under clinical development for paroxysmal nocturnal hemoglobinuria (PNH). In this ongoing open-label phase 2 study, PNH patients with active hemolysis were randomized to receive single-agent iptacopan twice-daily, at a dose of either 25 mg for 4 weeks followed by 100 mg for up to 2 years (cohort 1) or 50 mg for 4 weeks followed by 200 mg for up to 2 years (cohort 2). At the time of interim analysis, of 13 PNH patients enrolled, all 12 evaluable for efficacy achieved the primary endpoint of reduction in serum lactate dehydrogenase (LDH) levels by at least 60% by week 12 as compared to baseline; mean LDH levels dropped rapidly and durably, namely by 77% and 85% at week 2 and by 86% and 86% at week 12 in cohorts 1 and 2, respectively. Most patients achieved a clinically meaningful improvement in hemoglobin levels and all but one patient remained transfusion-free up to week 12. Other markers of hemolysis, including bilirubin, reticulocytes and haptoglobin, showed consistent improvements. No thromboembolic events were reported, and iptacopan was well tolerated, with no severe or serious adverse events reported up until the data cutoff. In addition to the previously reported beneficial effect of iptacopan add-on therapy to eculizumab, this study showed that iptacopan monotherapy in treatment-naïve PNH patients resulted in normalization of hemolytic markers and rapid transfusion-free improvement of hemoglobin levels in most patients. Registered at www.clinicaltrials.gov as NCT03896152.
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20
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Kulasekararaj AG, Griffin M, Langemeijer S, Usuki K, Kulagin A, Ogawa M, Yu J, Mujeebuddin A, Nishimura JI, Lee JW, Peffault de Latour R. Long-term safety and efficacy of ravulizumab in patients with paroxysmal nocturnal hemoglobinuria: 2-year results from two pivotal phase 3 studies. Eur J Haematol 2022; 109:205-214. [PMID: 35502600 PMCID: PMC9546219 DOI: 10.1111/ejh.13783] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The complement component 5 (C5) inhibitor ravulizumab demonstrated non-inferiority to eculizumab following 26 weeks of treatment in complement inhibitor-naïve and complement inhibitor-experienced patients with paroxysmal nocturnal hemoglobinuria (PNH; studies 301 and 302, respectively). This study aims to describe the results of both studies from 27 weeks to 2 years. METHODS Patients (N = 441) continued to receive ravulizumab throughout the extension period. Efficacy endpoints included lactate dehydrogenase (LDH) normalization, transfusion avoidance and fatigue score (FACIT-F). Safety analyses were also performed. RESULTS From 27 weeks to 2 years, improvements in LDH levels were maintained in both study populations. Transfusion avoidance was maintained in 81.9% (study 301) and 85.6% (study 302) of patients, and FACIT-F scores remained stable. Ravulizumab was well tolerated, and the incidence of adverse events (AEs) were similar between patients of both studies. Incidence of serious AEs deemed related to ravulizumab treatment was low (<3%). CONCLUSIONS This study reports, to date, the longest period of follow-up in over 400 patients with PNH treated with ravulizumab (662 patient-years). Long-term, ravulizumab demonstrated durable efficacy and was well tolerated, highlighting the importance of C5 inhibitors as the mainstay of PNH treatment.
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Affiliation(s)
- Austin G Kulasekararaj
- Department of Haematological Medicine, King's College Hospital, National Institute for Health Research and Wellcome King's Clinical Research Facility and King's College London, London, UK
| | | | | | | | - Alexander Kulagin
- RM Gorbacheva Research Institute, Pavlov University, St Petersburg, Russia
| | - Masayo Ogawa
- Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | - Ji Yu
- Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | | | | | - Jong Wook Lee
- Department of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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21
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Gurnari C, Nautiyal I, Pagliuca S. Current Opinions on the Clinical Utility of Ravulizumab for the Treatment of Paroxysmal Nocturnal Hemoglobinuria. Ther Clin Risk Manag 2021; 17:1343-1351. [PMID: 34934322 PMCID: PMC8684432 DOI: 10.2147/tcrm.s273360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 11/28/2021] [Indexed: 01/15/2023] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disorder of hematopoietic stem cells genetically defined by the acquisition of somatic mutations in the X-linked phosphatidylinositol glycan anchor biosynthesis, class A (PIGA) gene. PIGA is essential for the synthesis of glycosyl phosphatidylinositol (GPI) anchor proteins and its mutations result in a deficiency of such molecules on the membrane of blood cells derived from the mutant clone. In particular, the lack of the GPI-linked complement regulatory proteins CD55 and CD59 is responsible for the increased sensitivity of PNH erythrocytes to complement-mediated destruction. Indeed, the classical clinical picture of PNH includes signs and symptoms of intravascular hemolysis along with variable degrees of cytopenia and a strong tendency to thrombosis, hallmarks of the disease. Before the introduction of anti-complement inhibitors, PNH was characterized by a high mortality primarily due to thrombotic events. The approval of the terminal anti-complement inhibitor eculizumab in 2007 introduced a paradigm shift in the treatment of the disease with improvement of the chronic hemolytic process and dramatic reduction of the thrombotic rate. However, eculizumab has a relatively short half-life when considering a life-long treatment, with obvious consequences as to the quality of life of treated patients necessitating relatively frequent drug administrations. Moreover, up to 30% of PNH patients undergoing eculizumab therapy show a suboptimal response, continuing to require red cell transfusions because of extravascular hemolysis or breakthrough hemolytic episodes. In 2019, the FDA approved the second-generation C5 inhibitor ravulizumab, a long-lasting agent with a better control of disease manifestations. Herein, we discuss the use of ravulizumab in PNH, its differences with first-generation C5 inhibitors, the research evidence supporting the safety and efficacy of this drug and its impact on costs for health systems and quality of life of PNH patients.
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Affiliation(s)
- Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Center, Cleveland Clinic Foundation, Cleveland, OH, USA
- Department of Biomedicine and Prevention, PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, Rome, Italy
| | - Ishani Nautiyal
- Department of Translational Hematology and Oncology Research, Taussig Cancer Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Simona Pagliuca
- Department of Translational Hematology and Oncology Research, Taussig Cancer Center, Cleveland Clinic Foundation, Cleveland, OH, USA
- ED561 Hematology, Oncogenesis and Biotherapies, University of Paris, Paris, France
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22
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Risitano AM, Peffault de Latour R. How we('ll) treat paroxysmal nocturnal haemoglobinuria: diving into the future. Br J Haematol 2021; 196:288-303. [PMID: 34355382 PMCID: PMC9291300 DOI: 10.1111/bjh.17753] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Paroxysmal nocturnal haemoglobinuria (PNH) is characterized by complement-mediated intravascular haemolysis, severe thrombophilia and bone marrow failure. While for patients with bone marrow failure the treatment follows that of immune-mediated aplastic anaemia, that of classic, haemolytic PNH is based on anti-complement medication. The anti-C5 monoclonal antibody eculizumab has revolutionized treatment, resulting in control of intravascular haemolysis and thromboembolic risk, with improved long-term survival. Novel strategies of complement inhibition are emerging. New anti-C5 agents reproduce the safety and efficacy of eculizumab, with improved patient convenience. Proximal complement inhibitors have been developed to address C3-mediated extra-vascular haemolysis and seem to improve haematological response.
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Affiliation(s)
- Antonio Maria Risitano
- Department of Onco-Hematology, AORN San Giuseppe Moscati Avellino, Avellino, Italy.,Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy.,Severe Aplastic Anaemia Working Party (SAAWP) of the European Group for Bone Marrow Transplantation (EBMT), Leiden, the Netherlands
| | - Régis Peffault de Latour
- Severe Aplastic Anaemia Working Party (SAAWP) of the European Group for Bone Marrow Transplantation (EBMT), Leiden, the Netherlands.,French Reference Centre for Aplastic Anaemia and Paroxysmal Nocturnal Haemoglobinuria, Assistance Publique - Hôpitaux de Paris, Saint-Louis Hospital, Paris, France.,Bone Marrow Transplant Unit, Université de Paris, Denis Diderot, Paris, France
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23
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Kulasekararaj AG, Hill A, Langemeijer S, Wells R, González Fernández FA, Gaya A, Ojeda Gutierrez E, Piatek CI, Mitchell L, Usuki K, Bosi A, Brodsky RA, Ogawa M, Yu J, Ortiz S, Röth A, Lee JW, Peffault de Latour R. One-year outcomes from a phase 3 randomized trial of ravulizumab in adults with paroxysmal nocturnal hemoglobinuria who received prior eculizumab. Eur J Haematol 2021; 106:389-397. [PMID: 33301613 PMCID: PMC8246907 DOI: 10.1111/ejh.13564] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/04/2020] [Accepted: 12/07/2020] [Indexed: 11/29/2022]
Abstract
Ravulizumab every 8 weeks showed non‐inferiority to eculizumab every 2 weeks in a 26‐week, phase 3, randomized controlled trial in adults with paroxysmal nocturnal hemoglobinuria (PNH) who were clinically stable on eculizumab (NCT03056040). We report results from the first 26 weeks of the extension period in which patients continued ravulizumab (n = 96) or switched from eculizumab to ravulizumab (n = 95). At week 52, mean (SD) lactate dehydrogenase levels increased 8.8% (29%) with ravulizumab‐ravulizumab and 5.8% (27%) with eculizumab‐ravulizumab from primary evaluation period baseline. During the extension period, four patients (ravulizumab‐ravulizumab, n = 3; eculizumab‐ravulizumab, n = 1) experienced breakthrough hemolysis, but none associated with serum free C5 ≥ 0.5 μg/mL. Mean Functional Assessment of Chronic Illness Therapy (FACIT)‐Fatigue scores remained stable through week 52. During the extension period, proportions of patients avoiding transfusion remained stable (ravulizumab‐ravulizumab, 86.5%; eculizumab‐ravulizumab, 83.2%); 81.2% and 81.1%, respectively, had stabilized hemoglobin. All patients maintained serum free C5 levels < 0.5 μg/mL. Adverse events were generally similar between groups, and rates were lower in the extension period. Adults with PNH on stable eculizumab therapy who received ravulizumab over 52 weeks experienced durable efficacy, with consistent efficacy in patients who received eculizumab during the primary evaluation period and then switched to ravulizumab. Ravulizumab was well tolerated.
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Affiliation(s)
- Austin G Kulasekararaj
- Department of Haematological Medicine, King's College Hospital, National Institute of Health Research/Wellcome King's Clinical Research Facility and King's College London, London, UK
| | - Anita Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | | | - Richard Wells
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - F Ataúlfo González Fernández
- Department of Hematology, Hospital Clinico Universitario San Carlos, The Clınic Institute of Haematological and Oncological Diseases, Madrid, Spain
| | - Anna Gaya
- Department of Hematology, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Caroline I Piatek
- Jane Anne Nohl Division of Hematology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | | | - Alberto Bosi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Robert A Brodsky
- The John Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Ji Yu
- Alexion Pharmaceuticals, Inc., Boston, MA, USA
| | | | - Alexander Röth
- Department of Hematology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Jong Wook Lee
- Department of Hematology, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Régis Peffault de Latour
- Bone Marrow Transplantation Unit, Saint Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,French Reference Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Saint Louis Hospital and University Paris Diderot, Paris, France.,Severe Aplastic Anemia Working Party of the European Group for Blood and Marrow Transplantation, Leiden, the Netherlands
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