POS0367 IMPROVEMENT OF INDIVIDUAL MUCOCUTANEOUS MANIFESTATIONS IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS TREATED WITH ANIFROLUMAB

Background

Patients with cutaneous lupus erythematosus (CLE) experience disfiguring and painful lesions that can lead to psychological distress and significant impacts on quality of life.1 Treatment of patients with systemic lupus erythematosus (SLE) with anifrolumab, a type I interferon receptor antagonist, was associated with CLE Disease Area and Severity Index–Activity (CLASI-A) improvements compared with placebo through Week 52 in the phase 3 TULIP-1 and TULIP-2 SLE trials.2,3 CLASI assesses overall skin improvement and may be driven by erythema over the other components.4

Objectives

To better understand the effect of anifrolumab on mucocutaneous SLE manifestations by analyzing the individual domains of CLASI-A using pooled data from the TULIP trials.

Methods

TULIP-1 (NCT02446912) and TULIP-2 (NCT02446899) were randomized, double-blind, placebo-controlled, 52-week trials that evaluated efficacy and safety of intravenous anifrolumab administered every 4 weeks in patients with moderate to severe SLE despite standard therapy.2,3 In a post hoc analysis, individual CLASI-A domains (erythema, scale/hypertrophy, alopecia, and mucosal) were assessed at Week 24 (time point chosen to ensure adequate duration for improvement in slow-remitting manifestations [eg, scale, alopecia]) in 2 patient subgroups: 1) the “chronic” mucocutaneous subgroup (resembling chronic/discoid CLE), defined as patients with a baseline erythema score ≥4 and scale score ≥2, and alopecia score ≥1 or baseline mucosal lesions or ulceration score of 1; and 2) the “extended” mucocutaneous subgroup (resembling all CLE subtypes), defined as patients who met the “chronic” criteria or those who had a baseline erythema score ≥8.

Results

Across the pooled TULIP trials, 360 patients received anifrolumab 300 mg and 366 patients received placebo. In patients with assessments at Week 24 in the “chronic” (anifrolumab n=58, placebo n=50) and “extended” (anifrolumab n=104, placebo n=96) subgroups, anifrolumab led to a greater mean percent reduction from baseline compared with placebo in erythema (chronic: −63.6% vs −39.9%; extended: −63.7% vs −41.2%) and scale/hypertrophy (chronic: −72.2% vs −42.6%; extended: −45.3% vs −7.3%). Anifrolumab-treated patients in both subgroups had no worsening in alopecia (chronic: 93.3% [56/60] vs 96.0% [48/50]; extended: 95.3% [102/107] vs 95.8% [92/96]) or mucous membrane (chronic: 95.0% [57/60] vs 96.0% [48/50]; extended: 96.3% [103/107] vs 94.8% [91/96]) from baseline vs placebo (Table 1).

Table 1.

Skin Responses at Week 24 Compared With Baseline

Criteria, n (%)Chronic subgroupExtended subgroupAnifrolumab 300 mg (n=60)Placebo (n=50)Anifrolumab 300 mg (n=107)Placebo (n=96)Erythema score reduction≥25%53 (88.3)32 (64.0)93 (86.9)68 (70.8)≥50%42 (70.0)22 (44.0)71 (66.4)47 (49.0)≥60%34 (56.7)18 (36.0)61 (57.0)32 (33.3)Scale/hypertrophy score reduction≥10%49 (81.7)34 (68.0)55 (51.4)38 (39.6)≥25%47 (78.3)30 (60.0)53 (49.5)34 (35.4)≥50%46 (76.7)28 (56.0)51 (47.7)31 (32.3)No new/worsened lesions in any individual body area44 (73.3)26 (52.0)81 (75.7)56 (58.3)Alopecia≥1-point decreasea25 (41.7)19 (38.0)35 (32.7)27 (28.1)No worsening56 (93.3)48 (96.0)102 (95.3)92 (95.8)Mucosal lesion/ulceration1-point decreaseb25 (41.7)13 (26.0)39 (36.4)23 (24.0)No worsening57 (95.0)48 (96.0)103 (96.3)91 (94.8)

aIf baseline score ≥1.

bIf baseline score =1.

Conclusion

In the phase 3 TULIP trials, SLE patients with mucocutaneous manifestations treated with anifrolumab experienced numerical improvements in erythema and scale/hypertrophy and no worsening in alopecia or mucous membrane CLASI-A domains compared with placebo, regardless of whether skin disease was classified by chronic or extended definitions. These encouraging data support further evaluation of anifrolumab in patients with CLE.

References

[1]Klein R. J Am Acad Dermatol. 2011;64:849–58.

[2]Furie RA. Lancet Rheumatol. 2019;1:e208–19.

[3]Morand EF. N Engl J Med. 2020;382:211–21.

[4]Albrecht J. J Invest Dermatol. 2005;125:889–94.

Acknowledgements

Writing assistance by Naomi Atkin (Fishawack Health). This study was sponsored by AstraZeneca.

Disclosure of Interests

Victoria Werth Consultant of: Celgene, Medimmune, Resolve, Genentech, Idera, Janssen, Lilly, Pfizer, Biogen, BMS, Gilead, Amgen, Medscape, Nektar, Incyte, EMD Sorona, CSL Behring, Principia, Crisalis, Viela Bio, Argenx, Kwoya Kirin, Regeneron, AstraZeneca, Abbvie, Octapharma, GSK, Cugene, UCB, Corcept, Beacon Bioscience, Rome Pharmaceuticals, Horizon, Merck, Kezar, Sanofi, Bayer, Akari, Grant/research support from: Celgene, Janssen, Pfizer, Biogen, Gilead, Corbus Pharmaceuticals, Genentech, AstraZeneca, Viela, Syntimmune, Amgen, Regeneron, Argenx, CSL Behring, Ventus, q32 Bio, BMS, Jenny Wissmar Shareholder of: AstraZeneca, Employee of: AstraZeneca, Anna Strömbeck Employee of: AstraZeneca, Raj Tummala Shareholder of: AstraZeneca, Employee of: AstraZeneca, Christi Kleoudis Shareholder of: AstraZeneca, Employee of: AstraZeneca, Marius Albulescu Shareholder of: AstraZeneca Ltd, Consultant of: UCB, Kymab Ltd, Employee of: AstraZeneca Ltd

Concordance and discordance in SLE clinical trial outcome measures: analysis of three anifrolumab phase 2/3 trials

Objectives

In the anifrolumab systemic lupus erythematosus (SLE) trial programme, there was one trial (TULIP-1) in which BILAG-based Composite Lupus Assessment (BICLA) responses favoured anifrolumab over placebo, but the SLE Responder Index (SRI(4)) treatment difference was not significant. We investigated the degree of concordance between BICLA and SRI(4) across anifrolumab trials in order to better understand drivers of discrepant SLE trial results.

Methods

TULIP-1, TULIP-2 (both phase 3) and MUSE (phase 2b) were randomised, 52-week trials of intravenous anifrolumab (300 mg every 4 weeks, 48 weeks; TULIP-1/TULIP-2: n=180; MUSE: n=99) or placebo (TULIP-1: n=184, TULIP-2: n=182; MUSE: n=102). Week 52 BICLA and SRI(4) outcomes were assessed for each patient.

Results

Most patients (78%–85%) had concordant BICLA and SRI(4) outcomes (Cohen’s Kappa 0.6–0.7, nominal p<0.001). Dual BICLA/SRI(4) response rates favoured anifrolumab over placebo in TULIP-1, TULIP-2 and MUSE (all nominal p≤0.004). A discordant TULIP-1 BICLA non-responder/SRI(4) responder subgroup was identified (40/364, 11% of TULIP-1 population), comprising more patients receiving placebo (n=28) than anifrolumab (n=12). In this subgroup, placebo-treated patients had lower baseline disease activity, joint counts and glucocorticoid tapering rates, and more placebo-treated patients had arthritis response than anifrolumab-treated patients.

Conclusions

Across trials, most patients had concordant BICLA/SRI(4) outcomes and dual BICLA/SRI(4) responses favoured anifrolumab. A BICLA non-responder/SRI(4) responder subgroup was identified where imbalances of key factors driving the BICLA/SRI(4) discordance (disease activity, glucocorticoid taper) disproportionately favoured the TULIP-1 placebo group. Careful attention to baseline disease activity and monitoring glucocorticoid taper variation will be essential in future SLE trials.

Trial registration numbers

NCT02446912 and NCT02446899.

A CD40L-targeting protein reduces autoantibodies and improves disease activity in patients with autoimmunity

The CD40/CD40L axis plays a central role in the generation of humoral immune responses and is an attractive target for treating autoimmune diseases in the clinic. Here, we report the generation and clinical results of a CD40L binding protein, VIB4920, which lacks an Fc domain, therefore avoiding platelet-related safety issues observed with earlier monoclonal antibody therapeutics that targeted CD40L. VIB4920 blocked downstream CD40 signaling events, resulting in inhibition of human B cell activation and plasma cell differentiation, and did not induce platelet aggregation in preclinical studies. In a phase 1 study in healthy volunteers, VIB4920 suppressed antigen-specific IgG in a dose-dependent fashion after priming and boosting with the T-dependent antigen, KLH. Furthermore, VIB4920 significantly reduced circulating Ki67⁺ dividing B cells, class-switched memory B cells, and a plasma cell gene signature after immunization. In a phase 1b proof-of-concept study in patients with rheumatoid arthritis, VIB4920 significantly decreased disease activity, achieving low disease activity or clinical remission in more than 50% of patients in the two higher-dose groups. Dose-dependent decreases in rheumatoid factor autoantibodies and Vectra DA biomarker score provide additional evidence that VIB4920 effectively blocked the CD40/CD40L pathway. VIB4920 demonstrated a good overall safety profile in both clinical studies. Together, these data demonstrate the potential of VIB4920 to significantly affect autoimmune disease and humoral immune activation and to support further evaluation of this molecule in inflammatory conditions.

A Randomized Phase IIb Study of Mavrilimumab and Golimumab in Rheumatoid Arthritis

Objective

This 24‐week, phase IIb, double‐blind study was undertaken to evaluate the efficacy and safety of mavrilimumab (a monoclonal antibody to granulocyte–macrophage colony‐stimulating factor receptor α) and golimumab (a monoclonal antibody to tumor necrosis factor [anti‐TNF]) in patients with rheumatoid arthritis (RA) who have had an inadequate response to disease‐modifying antirheumatic drugs (DMARDs) (referred to as DMARD‐IR) and/or inadequate response to other anti‐TNF agents (referred to as anti‐TNF–IR).

Methods

Patients with active RA and a history of DMARD‐IR (≥1 failed regimen) or DMARD‐IR (≥1 failed regimen) and anti‐TNF–IR (1–2 failed regimens) were randomized 1:1 to receive either mavrilimumab 100 mg subcutaneously every other week or golimumab 50 mg subcutaneously every 4 weeks alternating with placebo every 4 weeks, administered concomitantly with methotrexate. The primary end points were the American College of Rheumatology 20% improvement (ACR20), 50% improvement, and 70% improvement response rates at week 24, percentage of patients achieving a Disease Activity Score in 28 joints using C‐reactive protein level (DAS28‐CRP) of <2.6 at week 24, percentage of patients with a score improvement of >0.22 on the Health Assessment Questionnaire (HAQ) disability index (DI) at week 24, and safety/tolerability measures. This study was not powered to formally compare the 2 treatments.

Results

At week 24, differences in the ACR20, ACR50, and ACR70 response rates between the mavrilimumab treatment group (n = 70) and golimumab treatment group (n = 68) were as follows: in all patients, −3.5% (90% confidence interval [90% CI] −16.8, 9.8), −8.6% (90% CI −22.0, 4.8), and −9.8% (90% CI −21.1, 1.4), respectively; in the anti‐TNF–IR group, 11.1% (90% CI −7.8, 29.9), −8.7% (90% CI −28.1, 10.7), and −0.7% (90% CI −18.0, 16.7), respectively. Differences in the percentage of patients achieving a DAS28‐CRP of <2.6 at week 24 between the mavrilimumab and golimumab groups were −11.6% (90% CI −23.2, 0.0) in all patients, and −4.0% (90% CI −20.9, 12.9) in the anti‐TNF–IR group. The percentage of patients achieving a >0.22 improvement in the HAQ DI score at week 24 was similar between the treatment groups. Treatment‐emergent adverse events were reported in 51.4% of mavrilimumab‐treated patients and 42.6% of golimumab‐treated patients. No deaths were reported, and no specific safety signals were identified.

Conclusion

The findings of this study demonstrate the clinical efficacy of both treatments, mavrilimumab at a dosage of 100 mg every other week and golimumab at a dosage of 50 mg every 4 weeks, in patients with RA. Both regimens were well‐tolerated in patients who had shown an inadequate response to DMARDs and/or other anti‐TNF agents.

Mavrilimumab, a Fully Human Granulocyte-Macrophage Colony-Stimulating Factor Receptor α Monoclonal Antibody: Long-Term Safety and Efficacy in Patients With Rheumatoid Arthritis

Objective

Mavrilimumab, a human monoclonal antibody, targets granulocyte–macrophage colony‐stimulating factor receptor α. We undertook to determine the long‐term safety and efficacy of mavrilimumab in rheumatoid arthritis patients in 2 phase IIb studies (1071 and 1107) and in 1 open‐label extension study (ClinicalTrials.gov identifier: NCT01712399).

Methods

In study 1071, patients with an inadequate response to disease‐modifying antirheumatic drugs (DMARDs) received mavrilimumab (30, 100, or 150 mg) or placebo every other week plus methotrexate. In study 1107, patients with an inadequate response to anti–tumor necrosis factor agents and/or DMARDs received 100 mg mavrilimumab every other week or 50 mg golimumab every 4 weeks plus methotrexate. Patients entering the open‐label extension study received 100 mg mavrilimumab every other week plus methotrexate. Long‐term safety and efficacy of mavrilimumab were assessed.

Results

A total of 442 patients received mavrilimumab (14 of 245 patients from study 1071, 9 of 70 patients from study 1107, and 52 of 397 patients from the open‐label extension study discontinued mavrilimumab treatment throughout the studies). The cumulative safety exposure was 899 patient‐years; the median duration of mavrilimumab treatment was 2.5 years (range 0.1–3.3 years). The most common treatment‐emergent adverse events (AEs) were nasopharyngitis (n = 69; 7.68 per 100 patient‐years) and bronchitis (n = 51; 5.68 per 100 patient‐years). At weeks 74 and 104, 3.5% and 6.2% of patients, respectively, demonstrated reduction in forced expiratory volume in 1 second, while 2.9% and 3.4% of patients, respectively, demonstrated reduction in forced vital capacity (>20% reduction from baseline to <80% predicted). Most pulmonary changes were transient and only infrequently associated with AEs. Mavrilimumab at 100 mg every other week demonstrated sustained efficacy; at week 122, 65.0% of patients achieved a Disease Activity Score in 28 joints using the C‐reactive protein level (DAS28‐CRP) of <3.2, and 40.6% of patients achieved a DAS28‐CRP of <2.6.

Conclusion

Long‐term treatment with mavrilimumab maintained response and was well‐tolerated with no increased incidence of treatment‐emergent AEs. Safety data were comparable with those from both phase IIb qualifying studies.