Longer-term safety of alirocumab with 24,610 patient-years of placebo-controlled observation: further insights from the ODYSSEY OUTCOMES trial

Background

In the ODYSSEY OUTCOMES trial (NCT01663402), alirocumab, a monoclonal antibody to proprotein convertase subtilisin/kexin type 9 (PCSK9), lowered low-density lipoprotein cholesterol from ∼2.3 mmol/L to ∼1.0 mmol/L at 4 months, reduced the risk of major adverse cardiovascular events (MACE: coronary heart disease death, nonfatal myocardial infarction, fatal/nonfatal ischemic stroke, unstable angina requiring hospitalization), and was associated with fewer deaths compared with placebo in 18924 patients (pts) with recent acute coronary syndrome followed for up to 5 years (yrs).

Purpose

In the ODYSSEY OUTCOMES trial, the overall safety of alirocumab and placebo was similar, except for an excess of local injection-site reactions with alirocumab. However, the safety among pts eligible for longer follow-up has not been fully explored.

Methods

The present post hoc analyses describe the efficacy and safety of alirocumab in a pre-specified subgroup (for efficacy) of pts eligible for a minimum of 3 and up to 5 yrs of follow-up.

Results

There were 8242 pts (43.5%) eligible for ≥3 yrs follow-up, of whom 8228 received at least one dose of study medication, comprising 24,610 pt-years of observation with a median follow-up of 3.3 yrs; 6651 pts were eligible for 3 up to 4 yrs, and 1574 patients were eligible for 4–5 yrs, follow-up. As previously reported in a pre-specified analysis of this subgroup, alirocumab significantly reduced death (4.7% vs. 5.9%; p=0.01) compared with placebo. In the present post hoc analysis, alirocumab also significantly reduced MACE vs. placebo (12.0% vs. 14.2%; Hazard Ratio 0.83 [95% CI 0.74 to 0.94]; p=0.003). In a safety analysis, 3217 (78.3%) vs. 3303 (80.2%) pts in the alirocumab vs. placebo group had at least one adverse event (AE) of whom 27.5% vs. 29.4% had a serious AE (Fig. 1). The frequency of permanent discontinuation of study drug due to AEs, incident diabetes, diabetes worsening or complications, neurocognitive events, elevations of ALT>3, AST>3, bilirubin>2, and creatine phosphokinase>10 times the upper limit of normal, were similar with alirocumab vs. placebo (Fig. 1). While pt-reported local injection-site reactions occurred more frequently with alirocumab, the Kaplan-Meier cumulative incidence for time to first local injection site reaction in the longer-term follow-up subgroup was <5% over ∼4 yrs, with most occurring within the first 6 months (Fig. 2).

Conclusions

In an 8228-pt subgroup of the ODYSSEY OUTCOMES trial eligible for at least 3, and up to 5 yrs follow-up, the safety of alirocumab was similar to placebo except for an excess of local injection site reactions. This subgroup also derived significant benefit from reduced MACE and death. Thus, alirocumab appears to be both a safe and effective lipid-modifying treatment when used for up to 5 yrs.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Sanofi and Regeneron

Lipoprotein(a) and the effect of alirocumab on coronary and non-coronary revascularization following acute coronary syndrome

Background

Many patients require arterial revascularization after an index ACS. Lipoprotein(a) is thought to play a pathogenic role in atherothrombosis. In the ODYSSEY OUTCOMES trial, the PCSK9 inhibitor alirocumab reduced major adverse cardiovascular events after ACS, with greater reduction among those with higher lipoprotein(a).

Objectives

We determined whether the risk of first coronary or any (coronary, peripheral artery or carotid) revascularization after ACS was modified by the level of lipoprotein(a) and treatment with alirocumab or placebo.

Methods

The ODYSSEY OUTCOMES trial (NCT01663402) compared alirocumab with placebo in 18,924 patients with ACS and elevated atherogenic lipoproteins despite optimized statin treatment. Treatment effects were summarized by competing-risks proportional hazard models.

Results

A total of 1559 (8.2%) patients had coronary, 204 (1.1%) peripheral artery, and 40 (0.2%) carotid revascularization after randomization. Alirocumab reduced first coronary revascularization (9.6% vs. 11.3% at 4 years; hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.80–0.97; p=0.01) and any first revascularization (10.8% vs. 13.0%; HR 0.85, 95% CI 0.78–0.94; p=0.001). Baseline lipoprotein(a) quartile was directly associated with risk of coronary or any revascularization in the placebo arm (ptrend <0.0001) and inversely related to treatment HRs (ptrend <0.001). The greatest benefits of alirocumab on coronary or any revascularization were observed in patients with baseline lipoprotein(a) in the top quartile (≥59.6 mg/dL) (figures).

Conclusions

Alirocumab reduced revascularization after ACS. The risk of revascularization and reduction in that risk with alirocumab were greatest in patients with elevated lipoprotein(a) at baseline.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): SanofiRegeneron Pharmaceuticals

Administration of hepatitis A vaccine at 6 and 12 months of age concomitantly with hexavalent (DTaP-IPV-PRP approximately T-HBs) combination vaccine

BACKGROUND

Administration of two doses of hepatitis A (HA) vaccine to children > or = 2 years of age has been shown to be protective. The present study assessed whether HA vaccine can be administered as early as 6 months of age and whether it can be administered concomitantly with a hexavalent (HV) vaccine at this age.

METHODS

In an open label, randomized, parallel group study, the liquid HV vaccine (HEXAVAC) (diphtheria, tetanus, 2-component acellular pertussis, inactivated poliomyelitis vaccine, Haemophilus influenzae type b conjugated to tetanus protein and hepatitis B) was administered at 2, 4, 6, and 12 months of age to all children. HA vaccine (VAQTA) was given at 7 and 13 months in the separate administration group (Group 1) and at 6 and 12 months in the concomitant administration group (Group 2). Serum samples were obtained at 2, 7, 12, and 14 months in Group 1 and at 2, 7, 12, and 13 months in Group 2. The primary immunogenicity outcomes were the seroconversion rates for HA 1 month after the second dose of HA vaccine in initially seronegative subjects, and the seroconversion rates for each HV antigen 1 month after the third dose of the HV vaccine (both at 7 months of age).

RESULTS

HA seropositivity rates 1 month after the second dose were 100% in both groups, regardless of initial serostatus. The responses to each HV antigen 1 month after the third dose were similar in both groups. The vaccines were generally well tolerated in both groups regardless of vaccine(s) administered.

CONCLUSIONS

A schedule of two doses of HA vaccine, 6 months apart beginning at 6 months of age is highly immunogenic and well tolerated when administered alone or concomitantly with HV vaccine at 6 and 12 months of age.

[Effects of rilmenidine (hyperium) on lipid balance in hyperlipidemic hypertensive patients. Randomized, controlled, double-blind 8-week study vs. captopril in parallel groups]

Rilmenidine (dose of 1 mg once or twice a day) is the first oxazoline compound with antihypertensive properties. Its effects on lipid parameters [total cholesterol, HDL and LDL fractions, triglycerides, apolipoprotein A1 and B, lipoprotein (a)] were compared under double-blind conditions and in parallel groups to those of captopril (50 to 100 mg per day, in 2 divided doses) over a period of 8 weeks, in 51 hyperlipidaemic hypertensive patients [age: 56.3 +/- 1.5 years, systolic and diastolic blood pressure (SBP/DBP): 165.1 +/- 2.0/99.1 +/- 0.6 mmHg, LDL cholesterol: 5.38 +/- 0.16 mmol/L]. No significant difference was demonstrated between the groups on inclusion for any of the clinical parameters (SBP, DBP, heart rate (HR)) and laboratory parameters, apart from apolipoprotein A1, for which the mean value was higher in the rilmenidine group than in the captopril group (p < 0.05). No difference between the groups was demonstrated during the 8 weeks of treatment for the course of blood pressure: SBP and DBP decreased by 20.5 and 13.9 mmHg, respectively, in the rilmenidine group and by 21.3 and 13.1 mmHg in the captopril group (no significant difference: NS). HR decreased by 0.3 beats per minute (bpm) in the rilmenidine group and by 4.1 bpm in the captopril group (NS). No statistically significant difference in lipid parameters was observed between the two groups. No clinically significant variation in any of the lipid parameters was observed after 8 weeks of treatment with rilmenidine or captopril. These results confirm the antihypertensive efficacy and neutrality of rilmenidine on lipid metabolism over a period of 8 weeks. Rilmenidine therefore represents a useful alternative in the first-line treatment of hypertension in hyperlipidaemic hypertensive patients.

The effects of rilmenidine and atenolol on mental stress, dynamic exercise and autonomic function in mild to moderate hypertension

1. The effects of 4 week treatment with rilmenidine or atenolol on tests of mental stress, dynamic exercise, autonomic function and psychometric tests were evaluated in a randomized, double-blind, placebo-controlled, cross-over study. 2. After a 4 week placebo run-in, 12 patients with essential hypertension (blood pressure [BP] 160/95 +/- 15/7 mmHg) received rilmenidine 1-2 mg day-1, and atenolol 50-100 mg day-1, each for 4 weeks, with a 4 week placebo wash-out between drug treatments. 3. Both agents produced a comparable reduction in supine and erect BP. During the mental arithmetic test, BP and heart rate (HR) responses were similar for rilmenidine and atenolol. 4. During bicycle exercise, the increase in HR was significantly greater after rilmenidine (+50 vs 41 beats min-1, P = 0.04). During recovery, the areas under the curve for diastolic BP (46,450 vs 51,400 mmHg s, P = 0.02) and HR (49,445 vs 63,597 beats min-1 s, P = 0.001) were significantly less with atenolol than rilmenidine. 5. Neither rilmenidine nor atenolol affected mental performance as judged by arithmetic and psychomotor tests. Physiological responses to autonomic function tests (deep breathing, facial immersion, isometric handgrip and cold pressor) were preserved with both drugs. The standing to lying ratio was higher on atenolol (P = 0.01) and Valsalva ratio was higher on rilmenidine (P = 0.03). 6. In conclusion, rilmenidine and atenolol exerted comparable antihypertensive effects both at rest and during mental and dynamic stress. Atenolol attenuated HR responses to dynamic exercise and the Valsalva manoeuvre; rilmenidine did not interfere with the physiological responses of BP and HR during autonomic function tests.

Dose-effect relationship of rilmenidine after chronic administration

The antihypertensive efficacy and acceptability of 3 doses of rilmenidine (0.5, 1 and 2 mg, once daily) and a placebo over a 4 week period have been compared in a randomised, double-blind, parallel-group trial in 60 mild to moderate hypertensive patients. Six patients dropped out: 4 in the 2 mg-group and one in the 1 mg-group because of adverse events, and one in the placebo group for personal reason. The blood pressure was significantly decreased after the 1 and 2 mg doses with the maximum antihypertensive effect already being obtained after 1 mg. A significant dose-effect relationship was shown for supine systolic blood pressure (P = 0.05) but not for the supine diastolic blood pressure. The most beneficial efficacy/acceptability ratio was achieved at the dose of 1 mg once daily, which demonstrated the maximum antihypertensive effect associated with a low incidence of adverse events.

[Radiculomyeloencephalitis caused by Angiostrongylus cantonensis in children]

A case of radiculoencephalomyelitis caused by central nervous system involvement by Angiostrongylus cantonensis is reported in a 14 month-old girl. Evolution was spontaneously favourable, which is not usual in severe types. Lesions concerned the nevraxe and especially the spinal cord and are due to the migration of the larvae, creating eosinophilic inflammatory reactions.