1
|
Guarina A, Farruggia P, Mariani E, Saracco P, Barone A, Onofrillo D, Cesaro S, Angarano R, Barberi W, Bonanomi S, Corti P, Crescenzi B, Dell'Orso G, De Matteo A, Giagnuolo G, Iori AP, Ladogana S, Lucarelli A, Lupia M, Martire B, Mastrodicasa E, Massaccesi E, Arcuri L, Giarratana MC, Menna G, Miano M, Notarangelo LD, Palazzi G, Palmisani E, Pestarino S, Pierri F, Pillon M, Ramenghi U, Russo G, Saettini F, Timeus F, Verzegnassi F, Zecca M, Fioredda F, Dufour C. Diagnosis and management of acquired aplastic anemia in childhood. Guidelines from the Marrow Failure Study Group of the Pediatric Haemato-Oncology Italian Association (AIEOP). Blood Cells Mol Dis 2024; 108:102860. [PMID: 38889660 DOI: 10.1016/j.bcmd.2024.102860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 05/28/2024] [Accepted: 05/28/2024] [Indexed: 06/20/2024]
Abstract
Acquired aplastic anemia (AA) is a rare heterogeneous disorder characterized by pancytopenia and hypoplastic bone marrow. The incidence is 2-3 per million population per year in the Western world, but 3 times higher in East Asia. Survival in severe aplastic anemia (SAA) has improved significantly due to advances in hematopoietic stem cell transplantation (HSCT), immunosuppressive therapy, biologic agents, and supportive care. In SAA, HSCT from a matched sibling donor (MSD) is the first-line treatment. If a MSD is not available, options include immunosuppressive therapy (IST), matched unrelated donor, or haploidentical HSCT. The purpose of this guideline is to provide health care professionals with clear guidance on the diagnosis and management of pediatric patients with AA. A preliminary evidence-based document prepared by a group of pediatric hematologists of the Bone Marrow Failure Study Group of the Italian Association of Pediatric Hemato-Oncology (AIEOP) was discussed, modified and approved during a series of consensus conferences that started online during COVID 19 and continued in the following years, according to procedures previously validated by the AIEOP Board of Directors.
Collapse
Affiliation(s)
- A Guarina
- Pediatric Onco-Hematology Unit, A.R.N.A.S. Civico Hospital, Palermo, Italy
| | - P Farruggia
- Pediatric Onco-Hematology Unit, A.R.N.A.S. Civico Hospital, Palermo, Italy
| | - E Mariani
- Scuola di Specializzazione in Pediatria, University of Milano-Bicocca, Milan, Italy; Pediatric Hematology and Bone Marrow Transplant Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - P Saracco
- Hematology Unit, "Regina Margherita" Children's Hospital, Turin, Italy
| | - A Barone
- Pediatric Onco-Hematology Unit, University Hospital, Parma, Italy
| | - D Onofrillo
- Hematology Unit, Hospital of Pescara, Pescara, Italy
| | - S Cesaro
- Pediatric Hematology Oncology Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - R Angarano
- Pediatric Oncology-Hematology Unit, AOU Policlinico, Bari, Italy
| | - W Barberi
- Hematology, Department of Hematology, Oncology and Dermatology, AOU Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - S Bonanomi
- Pediatric Hematology and Bone Marrow Transplant Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - P Corti
- Pediatric Hematology and Bone Marrow Transplant Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - B Crescenzi
- Hematology and Bone Marrow Transplantation Unit, Hospital of Perugia, Perugia, Italy
| | - G Dell'Orso
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - A De Matteo
- Oncology Hematology and Cell Therapies Department, AORN Santobono-Pausilipon, Naples, Italy
| | - G Giagnuolo
- Oncology Hematology and Cell Therapies Department, AORN Santobono-Pausilipon, Naples, Italy
| | - A P Iori
- Hematology and HSCT Unit, University La Sapienza, Rome, Italy
| | - S Ladogana
- Pediatric Onco-Hematology Unit, Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | - A Lucarelli
- Pediatric Emergency Department, Giovanni XXIII Pediatric Hospital, University of Bari, Bari, Italy
| | - M Lupia
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - B Martire
- Pediatrics and Neonatology Unit, Maternal-Infant Department, "Monsignor A.R. Dimiccoli" Hospital, Barletta, Italy
| | - E Mastrodicasa
- Hematology and Bone Marrow Transplantation Unit, Hospital of Perugia, Perugia, Italy
| | - E Massaccesi
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - L Arcuri
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - M C Giarratana
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - G Menna
- Oncology Hematology and Cell Therapies Department, AORN Santobono-Pausilipon, Naples, Italy
| | - M Miano
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - L D Notarangelo
- Medical Direction, Children's Hospital, ASST-Spedali Civili, Brescia, Italy
| | - G Palazzi
- Department of Mother and Child, University Hospital of Modena, Modena, Italy
| | - E Palmisani
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - S Pestarino
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - F Pierri
- HSCT Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - M Pillon
- Maternal and Child Health Department Pediatric Hematology, Oncology and Stem Cell Transplant Center, University of Padua, Padua, Italy
| | - U Ramenghi
- Hematology Unit, "Regina Margherita" Children's Hospital, Turin, Italy
| | - G Russo
- Division of Pediatric Hematology/Oncology, University of Catania, Catania, Italy
| | - F Saettini
- Centro Tettamanti, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - F Timeus
- Pediatrics Department, Chivasso Hospital, Turin, Italy
| | - F Verzegnassi
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - M Zecca
- Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - F Fioredda
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - C Dufour
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy.
| |
Collapse
|
2
|
Röth A, He G, Tong H, Lin Z, Wang X, Chai-Adisaksopha C, Lee JH, Brodsky A, Hantaweepant C, Dumagay TE, Demichelis-Gómez R, Rojnuckarin P, Sun J, Höglund M, Jang JH, Gaya A, Silva F, Obara N, Kelly RJ, Beveridge L, Buatois S, Chebon S, Gentile B, Lundberg P, Sreckovic S, Nishimura JI, Risitano A, Han B. Phase 3 randomized COMMODORE 2 trial: Crovalimab versus eculizumab in patients with paroxysmal nocturnal hemoglobinuria naive to complement inhibition. Am J Hematol 2024; 99:1768-1777. [PMID: 38884175 DOI: 10.1002/ajh.27412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/10/2024] [Accepted: 05/29/2024] [Indexed: 06/18/2024]
Abstract
Crovalimab is a novel C5 complement inhibitor that enables rapid and sustained C5 inhibition with subcutaneous, low-volume self-administration every 4 weeks. COMMODORE 2 (NCT04434092) is a global, randomized, open-label, multicenter, phase 3 trial evaluating the non-inferiority of crovalimab versus eculizumab in patients with paroxysmal nocturnal hemoglobinuria not previously treated with C5 inhibition. C5 inhibitor-naive patients with lactate dehydrogenase (LDH) ≥2 × upper limit of normal (ULN) were randomized 2:1 to crovalimab or eculizumab. Co-primary efficacy endpoints were proportion of patients with hemolysis control (centrally assessed LDH ≤1.5 × ULN) and proportion with transfusion avoidance. Secondary efficacy endpoints were proportions of patients with breakthrough hemolysis, stabilized hemoglobin, and change in FACIT-Fatigue score. The primary treatment period was 24 weeks. Two hundred and four patients were randomized (135 crovalimab; 69 eculizumab). Crovalimab was non-inferior to eculizumab in the co-primary endpoints of hemolysis control (79.3% vs. 79.0%; odds ratio, 1.0 [95% CI, 0.6, 1.8]) and transfusion avoidance (65.7% vs. 68.1%; weighted difference, -2.8 [-15.7, 11.1]), and in the secondary efficacy endpoints of breakthrough hemolysis (10.4% vs. 14.5%; weighted difference, -3.9 [-14.8, 5.3]) and hemoglobin stabilization (63.4% vs. 60.9%; weighted difference, 2.2 [-11.4, 16.3]). A clinically meaningful improvement in FACIT-Fatigue score occurred in both arms. Complete terminal complement activity inhibition was generally maintained with crovalimab. The safety profiles of crovalimab and eculizumab were similar with no meningococcal infections. Most patients who switched from eculizumab to crovalimab after the primary treatment period preferred crovalimab. These data demonstrate the positive benefit-risk profile of crovalimab.
Collapse
Affiliation(s)
- Alexander Röth
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Guangsheng He
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Hongyan Tong
- Department of Hematology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zenghua Lin
- Department of Hematology, Affiliated Hospital of Nantong University, Jiangsu, China
| | - Xiaoqin Wang
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai, China
| | | | - Je-Hwan Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Andres Brodsky
- Hematology Division, Hospital de Clínicas José de San Martín, University of Buenos Aires, Buenos Aires, Argentina
| | - Chattree Hantaweepant
- Faculty of Medicine Siriraj Hospital, Division of Hematology, Department of Medicine, Mahidol University, Bangkok, Thailand
| | - Teresita E Dumagay
- Division of Hematology, Department of Medicine, University of the Philippines, Philippine General Hospital, Manila, Philippines
| | - Roberta Demichelis-Gómez
- Department of Hematology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ponlapat Rojnuckarin
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Jing Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Martin Höglund
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Jun Ho Jang
- Department of Hematology-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Anna Gaya
- Hematology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Fernando Silva
- Hematology Department, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Naoshi Obara
- Department of Hematology, University of Tsukuba Hospital, Ibaraki, Japan
| | - Richard J Kelly
- Division of Haematology and Immunology, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | | | | | | | | | | | | | | | - Antonio Risitano
- Hematology and BMT Unit, AORN San Giuseppe Moscati, Avellino, Italy
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Peking, China
| |
Collapse
|
3
|
Lommerse IN, Hinnen C, van Vliet LM, Schubert B, Panse J, Halkes CJM, Tjon JML. Quality of life after immune suppressive therapy in aplastic anemia. Ann Hematol 2024; 103:2113-2121. [PMID: 38578507 DOI: 10.1007/s00277-024-05731-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 03/26/2024] [Indexed: 04/06/2024]
Abstract
Acquired aplastic anemia (AA) is a rare form of immune-mediated bone marrow failure, which can result in life-threatening infections or bleeding if left untreated. Treatment consists of either immune suppressive therapy (IST) or allogeneic stem cell transplantation (alloHSCT). While considerable research has been published regarding survival, response rate and toxicity of both treatments, knowledge on the impact on quality of life (QoL) is scarce. We used the recently developed AA-specific QoL questionnaire (QLQ-AA/PNH-54) to evaluate QoL in a single center cohort of AA patients who were successfully treated with IST. The 54 questions represent 12 different QoL domains. Results were analyzed for all patients and grouped based on hematologic response (complete response (CR) or partial response (PR)). Thirty-six successfully treated adult patients (15 in CR, 21 in PR) completed the questionnaire (median age 54 years, range 21-71; median time since last IST 5 years, range 0-41). Fatigue was experienced by 83% of patients. Even though total QoL scores did not significantly differ between patients with PR and CR (105 vs 92, p-value 0,17) there appeared to be a trend towards higher scores in patients with PR, especially in domains concerning psychological wellbeing. This trend was most clear in the domains fear of progression (2,12 in PR patients vs 1,73 in CR patients; p-value 0,08) and role functioning (2,22 vs 1,88; p-value 0,07). In conclusion, patients with AA continue to experience psychological and physical effects despite successful IST.
Collapse
Affiliation(s)
- Iris N Lommerse
- Department of Hematology, Leiden University Medical Centre, Leiden, The Netherlands.
| | - Chris Hinnen
- Department of Psychology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Liesbeth M van Vliet
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, The Netherlands
| | - Beke Schubert
- Department of Hematology, HagaZiekenhuis, The Hague, the Netherlands
| | - Jens Panse
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | | | - Jennifer M-L Tjon
- Department of Hematology, Leiden University Medical Centre, Leiden, The Netherlands
| |
Collapse
|
4
|
Waheed A, Shammo J, Dingli D. Paroxysmal nocturnal hemoglobinuria: Review of the patient experience and treatment landscape. Blood Rev 2024; 64:101158. [PMID: 38071133 DOI: 10.1016/j.blre.2023.101158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 03/12/2024]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disorder caused by complement-mediated hemolysis and thrombosis through the alternative pathway. The most common symptom of PNH is fatigue due to chronic anemia, which can negatively impact quality of life (QoL) and affect overall well-being. The currently approved therapies for PNH significantly limit intravascular hemolysis (IVH) and reduce the risk of thrombosis; however, they are associated with an infusion schedule that can become burdensome, and not all patients experience complete disease control. Several new complement inhibitors are in development that address the need for convenient routes of administration and aim to provide better disease control. With the variety of new treatment options on the horizon, hematologic markers as well as QoL concerns, patient opinion, and lifestyle factors should be considered to choose the optimal PNH treatment for each specific patient.
Collapse
Affiliation(s)
- Anem Waheed
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - Jamile Shammo
- Division of Hematology Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America.
| | - David Dingli
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States of America.
| |
Collapse
|
5
|
Liu T, Pan Y, Ye M, Sun Q, Ding X, Xu M. Experience of life quality from patients with aplastic anemia: a descriptive qualitative study. Orphanet J Rare Dis 2023; 18:393. [PMID: 38129869 PMCID: PMC10740222 DOI: 10.1186/s13023-023-02993-y] [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: 07/15/2023] [Accepted: 12/12/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Despite the increasing incidence of aplastic anemia in China, few studies have explored its effect on the patients' quality of life from the perspective of these patients. In fact, patients with aplastic disorder live with the disease for a long time, and need to face a variety of difficult realities, including multiple disease symptoms and drug side effects, heavy burden of medical costs, difficulties in social reintegration, and negative emotional distress. Therefore, this study used descriptive qualitative research to explore the direct and rich quality-of-life experiences of patients with aplastic anemia. METHODS A total of 19 patients with aplastic anemia were recruited in this study using purposive sampling combined with maximum variation strategy. 5 of the patients with AA were from northern China, and the others were from southern China. Data were collected using semi-structured interviews and analyzed using the conventional content analysis method. RESULTS This study yielded important information about the experiences of patients with aplastic anemia in China. The content analysis method finally identified 3 themes and 9 sub-themes, including: physical symptoms (declining physical capacity, treatment-related symptoms, changes in body image), psychological symptoms (mood changes related to the stage of the disease, change in self-image, growth resulting from the disease experience), social burden (decline in career development, perceived burden to the family, social stigma). Patients with AA from different regions didn't show much difference in quality of life. CONCLUSIONS Aplastic anemia affects the physical, psychological, and social aspects of patients' lives. Therefore, health care providers need to consider the patients' physical response and psychological feelings to provide relevant medical guidance and multi-channel social support that would improve their confidence and quality of life. CLINICAL TRIAL REGISTRATION Name: Development and preliminary application of Quality of Life Scale for Patients with Aplastic Anemia. Number: ChiCTR2100047575. URL: http://www.chictr.org.cn/login.aspx?referurl=%2flistbycreater.aspx .
Collapse
Affiliation(s)
- Ting Liu
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, No.548 Binwen Road, Binjiang District, Hangzhou, Zhejiang Province, China
- School of Nursing, Zhejiang Chinese Medical University, No.548 Binwen Road, Binjiang District, Hangzhou, Zhejiang Province, China
| | - Yue Pan
- School of Nursing and Health, Zhejiang Changzheng Vocational and Technical College, No.525 Liuhe Road, Xihu District, Hangzhou, Zhejiang Province, China
| | - Menghua Ye
- The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medcine), No.54 Youdian Road, Shangcheng District, Hangzhou, Zhejiang Province, China
| | - Qiuhua Sun
- School of Nursing, Zhejiang Chinese Medical University, No.548 Binwen Road, Binjiang District, Hangzhou, Zhejiang Province, China
| | - Xinghong Ding
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, No.548 Binwen Road, Binjiang District, Hangzhou, Zhejiang Province, China.
| | - Min Xu
- The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medcine), No.54 Youdian Road, Shangcheng District, Hangzhou, Zhejiang Province, China.
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Quist SW, Postma AJ, Myrén KJ, de Jong LA, Postma MJ. Cost-effectiveness of ravulizumab compared with eculizumab for the treatment of paroxysmal nocturnal hemoglobinuria in the Netherlands. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:1455-1472. [PMID: 36633725 PMCID: PMC10550878 DOI: 10.1007/s10198-022-01556-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/22/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate the cost-effectiveness of ravulizumab compared with eculizumab for the treatment of adult patients with paroxysmal nocturnal hemoglobinuria (PNH) in the Netherlands. METHODS A cost-effectiveness analysis was conducted based on a Markov cohort model simulating the course of patients with PNH with clinical symptom(s) indicative of high disease activity, or who are clinically stable after having been treated with eculizumab for at least the past six months. Costs, quality of life, and the incremental cost-effectiveness ratio (ICER) were estimated over a lifetime horizon from a Dutch societal perspective. Several additional analyses were performed, including a one-way sensitivity analysis, a probabilistic sensitivity analysis, and scenario analysis. RESULTS When compared with eculizumab, ravulizumab saves €266,833 and 1.57 quality adjusted life years (QALYs) are gained, resulting in a dominant ICER. Drug costs account for the majority of the total costs in both intervention groups. Cost savings were driven by the difference in total treatment costs of ravulizumab compared with eculizumab caused by the reduced administration frequency, accounting for 98% of the total cost savings. The QALY gain with ravulizumab is largely attributable to the improved quality of life associated with less frequent infusions and BTH events. At a willingness-to-pay threshold of €20,000/QALY, there is a 76.6% probability that ravulizumab would be cost-effective. CONCLUSIONS The cost reduction and QALY gain associated with the lower rates of BTH and less frequent administration make ravulizumab a cost-saving and clinically beneficial substitute for eculizumab for adults with PNH in the Netherlands.
Collapse
Affiliation(s)
- S W Quist
- Asc Academics, Groningen, The Netherlands.
| | - A J Postma
- Asc Academics, Groningen, The Netherlands
| | - K J Myrén
- Alexion, AstraZeneca Rare Disease, Stockholm, Sweden
| | - L A de Jong
- Department of Health Sciences, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - M J Postma
- Department of Health Sciences, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
- Department of Economics, Econometrics and Finance, University of Groningen, Groningen, The Netherlands
| |
Collapse
|
8
|
Biomarkers and laboratory assessments for monitoring the treatment of patients with paroxysmal nocturnal hemoglobinuria: Differences between terminal and proximal complement inhibition. Blood Rev 2023; 59:101041. [PMID: 36732204 DOI: 10.1016/j.blre.2023.101041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/15/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, life-threatening, acquired disease in which blood cells lacking complement regulatory proteins are destroyed because of uncontrolled complement activity. Since 2007, terminal complement inhibitors have revolutionized the treatment of this disease. However, patients treated with these inhibitors can still experience anemia because of C3-mediated extravascular hemolysis and clinically relevant levels of breakthrough or residual intravascular hemolysis. Proximal complement inhibitors, which are only just beginning to emerge, have the potential to address this problem by targeting components of the pathway upstream of C5, thereby protecting patients against both intra- and extravascular hemolysis. In this review, we describe different biomarkers that can be used to monitor complement pathway blockade and discuss key laboratory assessments for evaluating treatment efficacy. We also consider how these assessments are affected by each class of inhibitor and highlight how evolving treatment goals may influence the relative importance of these assessments.
Collapse
|
9
|
Decision analysis of allogeneic bone marrow transplantation versus immunosuppressive therapy for young adult patients with aplastic anemia. Int J Hematol 2023; 117:660-668. [PMID: 36595144 DOI: 10.1007/s12185-022-03530-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 12/27/2022] [Accepted: 12/27/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Allogeneic bone marrow transplantation (BMT) from an HLA-matched sibling donor is recommended as an initial treatment for young patients. However, immunosuppressive therapy (IST) with cyclosporine and anti-thymocyte globulin may be a viable option even when an HLA-identical sibling donor is available. METHODS We constructed a Markov model to simulate the 10-year clinical course of patients aged 21-40 years with newly diagnosed severe aplastic anemia. Immediate BMT and IST were compared as an initial treatment assuming the availability of an HLA-identical sibling donor. Transition probabilities after treatment were determined based on a registry data analysis for BMT and a long-term prospective study for IST. RESULTS Quality-adjusted life years (QALYs) after treatment selection were 6.77 for BMT and 6.74 for IST. One-way sensitivity analysis revealed that the utility for being alive without GVHD after BMT, that for being alive with partial response after IST, and the response rate after initial IST strongly affected the results. CONCLUSIONS BMT and IST produced similar QALY for young patients with severe aplastic anemia. An estimation of the response rate to the initial IST may enable an individualized comparison between BMT and IST.
Collapse
|
10
|
Panse J. Paroxysmal nocturnal hemoglobinuria: Where we stand. Am J Hematol 2023; 98 Suppl 4:S20-S32. [PMID: 36594182 DOI: 10.1002/ajh.26832] [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: 10/19/2022] [Revised: 12/26/2022] [Accepted: 12/27/2022] [Indexed: 01/04/2023]
Abstract
For the last 20 years, therapy of paroxysmal nocturnal hemoglobinuria (PNH) relied-up until recently-on antibody based terminal complement inhibitionon. PNH pathophysiology-a mutational defect leading to partial or complete absence of complement-regulatory proteins on blood cells-leads to intravascular hemolysis and consequences such as thrombosis and other sequelae. A plethora of new drugs interfering with the proximal and terminal complement cascade are under recent development and the first "proof-of-pinciple" proximal complement inhibitor targeting C3 has been approved in 2021. "PNH: where we stand" will try to give a brief account on where we came from and where we stand focusing on approved therapeutic options. The associated improvements as well as potential consequences of actual and future treatments as well as their impact on the disease will continue to necessitate academic and scientific focus on improving treatment options as well as on side effects and outcomes relevant to individual patient lives and circumstances in order to develop effective, safe, and available treatment for all hemolytic PNH patients globally.
Collapse
Affiliation(s)
- Jens Panse
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Center for Integrated Oncology (CIO), Aachen Bonn Cologne Düsseldorf (ABCD), Aachen, Germany
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Meunier A, Soare A, Chevrou-Severac H, Myren KJ, Murata T, Longworth L. Indirect and Direct Mapping of the Cancer-Specific EORTC QLQ-C30 onto EQ-5D-5L Utility Scores. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2022; 20:119-131. [PMID: 34554442 DOI: 10.1007/s40258-021-00682-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/25/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE The aim of this study was to develop a response mapping algorithm to predict EQ-5D-5L utilities from European Organisation for Research and Treatment Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) scores and compare performance with direct mapping approaches to identify the best performing algorithm. METHODS The Multi-Instrument Comparison dataset contains responses to both the EQ-5D-5L and QLQ-C30 questionnaires from 692 individuals with a broad range of cancers. Response mapping was conducted, fitting ordered logistic regressions to predict response levels for each of the five EQ-5D dimensions and utilities were predicted using the US and Japanese EQ-5D-5L value sets to test the algorithm performance. Various direct mapping models were fitted: ordinary least squares, tobit, two-part (TPM), adjusted limited dependent variable mixture and beta mixture models. Model assessment and recommendations regarding the best mapping algorithm was based on goodness-of-fit statistics, predictive ability (measures of error, distribution of predicted utilities) and in sample cross-validation. RESULTS The response mapping model performed well in terms of predictive ability and measurement error using the US or Japanese value set, with mean absolute error ranging from 0.0708 to 0.0988, and comparably to the TPM, which was the best performing direct algorithm. CONCLUSION The developed mapping algorithms enable the prediction of EQ-5D-5L utilities from QLQ-C30 scores when EQ-5D-5L data have not been directly collected in clinical trials. The response mapping model offers the possibility of predicting EQ-5D-5L utility values using any national value set and can be generalised to multiple countries and oncology settings.
Collapse
Affiliation(s)
- Aurelie Meunier
- PHMR Limited, Berkeley Works, Berkley Grove, London, NW1 8XY, UK.
| | - Alexandra Soare
- PHMR Limited, Berkeley Works, Berkley Grove, London, NW1 8XY, UK
| | | | | | | | - Louise Longworth
- PHMR Limited, Berkeley Works, Berkley Grove, London, NW1 8XY, UK
| |
Collapse
|
13
|
Daly RP, Jalbert JJ, Keith S, Symonds T, Shammo J. A novel patient-reported outcome instrument assessing the symptoms of paroxysmal nocturnal hemoglobinuria, the PNH-SQ. J Patient Rep Outcomes 2021; 5:102. [PMID: 34581910 PMCID: PMC8479131 DOI: 10.1186/s41687-021-00376-0] [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: 05/27/2021] [Accepted: 09/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patient-reported outcome measures (PROs) used to measure symptoms of patients with paroxysmal nocturnal hemoglobinuria (PNH) in trials do not measure PNH symptoms comprehensively and do not assess daily fluctuations in symptoms. Following a literature review and consultation with a PNH expert, we drafted the PNH Symptom Questionnaire (PNH-SQ) and a patient-centric conceptual model of PNH symptoms and impacts. We then interviewed 15 patients with PNH to assess comprehensiveness of symptom capture from the patient perspective and to cognitively debrief the PNH-SQ. Patient interview data were also used to finalize the PNH conceptual model. RESULTS Participants mentioned 27 signs or symptoms of PNH spontaneously or after being probed; 93% reported experiencing ≥ 1 PNH symptom. Concept saturation was reached for all PNH symptoms. Further, interviews confirmed the instrument captured the most common PNH symptoms, including fatigue (87%), abdominal pain (60%), and difficulty swallowing (47%), with fatigue ranked as the most bothersome symptom. The interviews demonstrated that participants understood the items of the PNH-SQ (90-100%); considered the symptoms relevant (> 50- > 90%); the recall period appropriate (> 80-100%); and the response options suitable (> 80-100%). Participants also suggested changes regarding item redundancy and relevance; this feedback was used to finalize the instrument. CONCLUSIONS The finalized PNH-SQ assesses the presence and severity of 10 symptoms-abdominal pain, chest discomfort, difficulty sleeping, difficulty swallowing, difficulty thinking clearly, fatigue, headache, muscle weakness, pain in the legs or back, and shortness of breath-over 24 h. The PNH-SQ is a content-valid questionnaire suitable for assessing daily symptom presence and severity in PNH clinical trials.
Collapse
Affiliation(s)
| | - Jessica J Jalbert
- Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Rd, Tarrytown, NY, 10591, USA.
| | | | | | | |
Collapse
|
14
|
Ariceta G, Dixon BP, Kim SH, Kapur G, Mauch T, Ortiz S, Vallee M, Denker AE, Kang HG, Greenbaum LA. The long-acting C5 inhibitor, ravulizumab, is effective and safe in pediatric patients with atypical hemolytic uremic syndrome naïve to complement inhibitor treatment. Kidney Int 2020; 100:225-237. [PMID: 33307104 DOI: 10.1016/j.kint.2020.10.046] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/16/2020] [Accepted: 10/30/2020] [Indexed: 12/13/2022]
Abstract
Ravulizumab, a long-acting complement C5 inhibitor engineered from eculizumab, allows extending maintenance dosing from every 2-3 weeks to every 4-8 weeks depending on bodyweight. Here, we evaluated the efficacy and safety of ravulizumab in complement inhibitor-naïve children (under 18 years) with atypical hemolytic uremic syndrome. In this phase III, single-arm trial, ravulizumab was administered every eight weeks in patients 20 kg and over, and four weeks in patients under 20 kg. The primary endpoint was a complete thrombotic microangiopathy response (normalization of platelet count and lactate dehydrogenase, and a 25% or more improvement in serum creatinine) through 26 weeks. Secondary endpoints included change in hematologic parameters and kidney function. 18 patients with a median age of 5.2 years were evaluated. At baseline, symptoms of atypical hemolytic uremic syndrome outside the kidney were present in 72.2% of patients and 38.9% had been in intensive care. Baseline estimated glomerular filtration rate was 22 mL/min/1.73 m2. By week 26, 77.8% of patients achieved a complete thrombotic microangiopathy response; 94.4%, 88.9% and 83.3% of patients achieved platelet normalization, lactate dehydrogenase normalization and a 25% or more improvement in serum creatinine, respectively. By week 50, 94.4% patients had achieved a complete thrombotic microangiopathy response. Median improvement in platelet count was 246 and 213 x109/L through week 26 and week 50, respectively. The median increase above baseline in estimated glomerular filtration rate was 80 and 94 mL/min/1.73m2 through week 26 and week 50, respectively. No unexpected adverse events, deaths, or meningococcal infections occurred. Thus, ravulizumab rapidly improved hematologic and kidney parameters with no unexpected safety concerns in complement inhibitor-naïve children with atypical hemolytic uremic syndrome.
Collapse
Affiliation(s)
- Gema Ariceta
- Paediatric Nephrology Department, University Hospital Vall d'Hebron, Barcelona, Spain.
| | - Bradley P Dixon
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Seong Heon Kim
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
| | - Gaurav Kapur
- Faculty of Pediatric Sciences, Central Michigan University, Mount Pleasant, Michigan, USA
| | - Teri Mauch
- Division of Pediatric Nephrology, University of Nebraska Medical Center, Omaha Children's Hospital and Medical Center, Omaha, Nebraska, USA; Department of Nephrology and Hypertension, Division of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Stephan Ortiz
- Clinical and Non-Clinical Pharmacology, Alexion Pharmaceuticals Inc., Boston, Massachusetts, USA
| | - Marc Vallee
- Biostatistics, Alexion Pharmaceuticals Inc., Boston, Massachusetts, USA
| | - Andrew E Denker
- Clinical Development, Alexion Pharmaceuticals Inc., Boston, Massachusetts, USA
| | - Hee Gyung Kang
- Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Larry A Greenbaum
- Division of Pediatric Nephrology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | | |
Collapse
|
15
|
Bektas M, Copley-Merriman C, Khan S, Sarda SP, Shammo JM. Paroxysmal nocturnal hemoglobinuria: patient journey and burden of disease. J Manag Care Spec Pharm 2020; 26:S8-S14. [PMID: 33356781 PMCID: PMC10408416 DOI: 10.18553/jmcp.2020.26.12-b.s8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Patients with paroxysmal nocturnal hemoglobinuria (PNH) often experience a lengthy path to diagnosis. Fewer than 40% of patients with PNH receive a diagnosis within 12 months of symptom onset, and 24% of all PNH diagnoses can take 5 years or longer. Diagnostic delay is a source of distress and can affect emotional well-being for patients with PNH. In PNH disease management, patients and care providers focus on risk of organ failure and mortality related to disease progression; nonetheless, patients' health-related quality of life (HRQOL) is largely affected by extensive treatment requirements and nonfatal complications of disease, such as fatigue. In particular, thrombosis is associated with significant impairments in physical and social functioning and global health status and significant fatigue. Among patients with anemia who are transfusion dependent, the burden of transfusion is considerable. Transfusion dependence has a negative effect on HRQOL; is associated with risks and complications, including iron overload; and results in lost productivity due to travel times to and time spent at infusion centers. DISCLOSURES: This research was developed under a research contract between RTI Health Solutions and Apellis Pharmaceuticals and was funded by Apellis Pharmaceuticals. Bektas, Copley-Merriman, and Khan are employees of RTI Health Solutions. Sarda is an employee of Apellis Pharmaceuticals. Shammo consults for Apellis Pharmaceuticals.
Collapse
Affiliation(s)
- Meryem Bektas
- Market Access and Outcomes Strategy, RTI Health Solutions, Research Triangle, NC
| | | | - Shahnaz Khan
- Market Access and Outcomes Strategy, RTI Health Solutions, Research Triangle, NC
| | - Sujata P Sarda
- Global Health Economics and Outcomes Research, Apellis Pharmaceuticals, Waltham, MA
| | - Jamile M Shammo
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL
| |
Collapse
|
16
|
Weisshaar K, Ewald H, Halter J, Gerull S, Schönfeld S, Senft Y, Martinez M, Leuppi-Taegtmeyer A, Khanna N, Maier B, Risitano A, Peffault de Latour R, Tichelli A, Passweg J, Drexler B. Development of a patient-reported outcome questionnaire for aplastic anemia and paroxysmal nocturnal hemoglobinuria (PRO-AA/PNH). Orphanet J Rare Dis 2020; 15:249. [PMID: 32943103 PMCID: PMC7495826 DOI: 10.1186/s13023-020-01532-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 09/07/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The introduction of new therapy modalities has significantly improved the outcome of aplastic anemia (AA) and paroxysmal nocturnal hemoglobinuria (PNH) patients. However, relatively little is known about the exact disease burden of AA/PNH since standardized assessments of symptoms including health-related quality of life (HRQoL) are frequently missing or inadequately designed for this rare patient group. We aimed to develop AA/PNH-specific questionnaires for self-reporting of symptoms, which could be included in electronic platforms for data collection and patient care. METHODS By scoping review, we extracted any reported symptoms in AA/PNH and their prevalence from the literature (Phase I). Consensus rounds with patients and medical experts were conducted to identify core symptoms reported in the literature and to add missing items (Phase II). Ultimately, AA/PNH-specific patient-reported outcome (PRO) questionnaires including the selected measures were designed (Phase III). RESULTS AA symptoms from 62 and PNH symptoms from 45 observational studies were extracted from the literature. Twenty-four patients and seven medical experts identified 11 core symptoms including HRQoL issues after three consensus rounds. Significant differences in the symptom ranking of patients versus medical experts could be observed. Therefore, patient- as well as expert-centered PRO questionnaires in AA and PNH were created following the concepts of validated instruments. CONCLUSION The development of symptom self-reporting questionnaires for AA and PNH was feasible and the disease-specific PRO questionnaires can now be validated within a web-based workflow in a subsequent feasibility study.
Collapse
Affiliation(s)
- Kimmo Weisshaar
- Division of Hematology, University Hospital Basel, 4031, Basel, Switzerland
| | - Hannah Ewald
- University Medical Library, University of Basel, 4051, Basel, Switzerland
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, 4031, Basel, Switzerland
| | - Jörg Halter
- Division of Hematology, University Hospital Basel, 4031, Basel, Switzerland
| | - Sabine Gerull
- Division of Hematology, University Hospital Basel, 4031, Basel, Switzerland
| | - Sandra Schönfeld
- Division of Hematology, University Hospital Basel, 4031, Basel, Switzerland
| | - Yuliya Senft
- Division of Hematology, University Hospital Basel, 4031, Basel, Switzerland
| | - Maria Martinez
- Department of Diagnostic Hematology, University of Basel, 4051, Basel, Switzerland
| | - Anne Leuppi-Taegtmeyer
- Department of Clinical Pharmacology and Toxicology, University and University Hospital Basel, 4051, Basel, Switzerland
| | - Nina Khanna
- Infectious Diseases and Hospital Epidemiology, University Hospital Basel, 4031, Basel, Switzerland
| | - Birgit Maier
- Department of Psychosomatic Medicine, University Hospital Basel, 4031, Basel, Switzerland
| | - Antonio Risitano
- Hematology, Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
- Severe Aplastic Anemia Working Party of the European Group for Blood and Marrow Transplantation, Leiden, Netherlands
| | - Regis Peffault de Latour
- Severe Aplastic Anemia Working Party of the European Group for Blood and Marrow Transplantation, Leiden, Netherlands
- French Reference Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Saint Louis Hospital and University Paris Diderot, Paris, France
| | - Andre Tichelli
- Division of Hematology, University Hospital Basel, 4031, Basel, Switzerland
| | - Jakob Passweg
- Division of Hematology, University Hospital Basel, 4031, Basel, Switzerland
| | - Beatrice Drexler
- Division of Hematology, University Hospital Basel, 4031, Basel, Switzerland.
| |
Collapse
|
17
|
Peipert JD, Kulasekararaj AG, Gaya A, Langemeijer SMC, Yount S, Gonzalez-Fernandez FA, Ojeda Gutierrez E, Martens C, Sparling A, Webster KA, Cella D, Tomazos I, Ogawa M, Piatek CI, Wells R, Sicre de Fontbrune F, Röth A, Mitchell L, Hill A, Kaiser K. Patient preferences and quality of life implications of ravulizumab (every 8 weeks) and eculizumab (every 2 weeks) for the treatment of paroxysmal nocturnal hemoglobinuria. PLoS One 2020; 15:e0237497. [PMID: 32886668 PMCID: PMC7473546 DOI: 10.1371/journal.pone.0237497] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 07/27/2020] [Indexed: 01/26/2023] Open
Abstract
Background Eculizumab has transformed management of paroxysmal nocturnal hemoglobinuria (PNH) since its approval. However, its biweekly dosing regimen remains a high treatment burden. Ravulizumab administered every 8 weeks demonstrated noninferiority to eculizumab in two phase 3 trials. In regions where two PNH treatment options are available, it is important to consider patient preference. Objective The aim of this study was to assess patient preference for ravulizumab or eculizumab. Methods Study 302s (ALXN1210-PNH-302s) enrolled PNH patients who participated in the extension period of phase 3 study ALXN1210-PNH-302. In the parent study, eculizumab-experienced adult PNH patients received ravulizumab or eculizumab during a 26-week primary evaluation period. All patients in the extension period received ravulizumab. In study 302s, patient treatment preference was evaluated using an 11-item PNH-specific Patient Preference Questionnaire (PNH-PPQ©). Of 98 patients, 95 completed PNH-PPQ© per protocol for analysis. Results Overall, 93% of patients preferred ravulizumab whereas 7% of patients either had no preference (6%) or preferred eculizumab (1%) (P < 0.001). For specific aspects of treatment, ravulizumab was preferred (in comparison to no preference or eculizumab) on infusion frequency (98% vs. 0% vs. 2%), ability to plan activities (98% vs. 0% vs. 2%), and overall quality of life (88% vs. 11% vs. 1%), among other aspects. Most participants selected frequency of infusions as the most important factor determining preference (43%), followed by overall quality of life (23%). Conclusion This study shows that a substantial proportion of patients preferred ravulizumab over eculizumab and provides an important patient perspective on PNH treatment when there is more than one treatment option.
Collapse
Affiliation(s)
- John Devin Peipert
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Austin G. Kulasekararaj
- Department of Haematological Medicine, King’s College Hospital, NIHR/Wellcome King’s Clinical Research Facility, and King’s College London, London, United Kingdom
| | - Anna Gaya
- Department of Hematology, Hospital Clinic de Barcelona, Spain
| | | | - Susan Yount
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | | | - Emilio Ojeda Gutierrez
- Department of Hematology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Christa Martens
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Amy Sparling
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Kimberly A. Webster
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - David Cella
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Ioannis Tomazos
- Alexion Pharmaceuticals, Inc., Boston, MA, United States of America
| | - Masayo Ogawa
- Alexion Pharmaceuticals, Inc., Boston, MA, United States of America
| | - Caroline I. Piatek
- Department of Medicine, Jane Anne Nohl Division of Hematology, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States of America
| | - Richard Wells
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Flore Sicre de Fontbrune
- Centre de Référence Aplasie Médullaire, Service d'Hématologie Greffe, Assistance Publique des Hôpitaux de Paris, Hôpital Saint-Louis, Paris, France
| | - Alexander Röth
- Department of Hematology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Lindsay Mitchell
- Department of Hematology, University Hospital Monklands, North Lanarkshire, Scotland
| | - Anita Hill
- Department of Haematology, St James' Institute of Oncology, Leeds, United Kingdom
| | - Karen Kaiser
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
- * E-mail:
| |
Collapse
|
18
|
The long-acting C5 inhibitor, Ravulizumab, is effective and safe in adult patients with atypical hemolytic uremic syndrome naïve to complement inhibitor treatment. Kidney Int 2020; 97:1287-1296. [PMID: 32299680 DOI: 10.1016/j.kint.2020.01.035] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 01/17/2020] [Accepted: 01/24/2020] [Indexed: 11/20/2022]
Abstract
Ravulizumab is a long-acting C5 inhibitor engineered from eculizumab with increased elimination half-life, allowing an extended dosing interval from two to eight weeks. Here we evaluate the efficacy and safety of ravulizumab in adults with atypical hemolytic uremic syndrome presenting with thrombotic microangiopathy. In this global, phase 3, single arm study in complement inhibitor-naïve adults (18 years and older) who fulfilled diagnostic criteria for atypical hemolytic uremic syndrome, enrolled patients received ravulizumab through a 26-week initial evaluation period. The primary endpoint was complete thrombotic microangiopathy response defined as normalization of platelet count and lactate dehydrogenase and 25% or more improvement in serum creatinine. Secondary endpoints included changes in hematologic variables and renal function. Safety was also evaluated. Ravulizumab treatment resulted in an immediate, complete, and sustained C5 inhibition in all patients. Complete thrombotic microangiopathy response was achieved in 53.6% of patients. Normalization of platelet count, lactate dehydrogenase and 25% or more improvement in serum creatinine was achieved in 83.9%, 76.8% and 58.9% of patients, respectively. Improvement in estimated glomerular filtration rate by one or more stage was achieved in 68.1% of patients by day 183. No unexpected adverse events were reported across a safety analysis set of 58 patients. Four deaths occurred (three within one month of study initiation, including one in a patient excluded based on eligibility criteria after the first dose) with none considered treatment-related by the study investigator. Thus, treatment with ravulizumab once every eight weeks resulted in rapidly improved hematologic and renal endpoints with no unexpected adverse events in adults with atypical hemolytic uremic syndrome.
Collapse
|
19
|
Clucas DB, Fox LC, Wood EM, Hong FS, Gibson J, Bajel A, Szer J, Blombery P, McQuilten ZK, Hiwase D, Firkin F, Cole-Sinclair MF. Revisiting acquired aplastic anaemia: current concepts in diagnosis and management. Intern Med J 2019; 49:152-159. [PMID: 30324755 DOI: 10.1111/imj.14140] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 07/26/2018] [Accepted: 09/30/2018] [Indexed: 12/24/2022]
Abstract
Acquired aplastic anaemia is a rare, serious, immunologically mediated bone marrow failure syndrome, characterised by marrow hypoplasia of varying severity and significant pancytopenia. Careful attention and investigation, including molecular testing, is required to confirm the diagnosis and exclude other mimicking conditions, such as inherited bone marrow failure syndromes. In a proportion of patients, the disease evolves to myelodysplasia or acute myeloid leukaemia and in some there is an association with paroxysmal nocturnal haemoglobinuria. The disease has a major impact on patient quality of life. Haemopoietic stem/progenitor cell transplantation for eligible patients with an available donor is the only current curative therapy. Other patients may receive immunosuppression, most commonly with anti-thymocyte globulin and cyclosporin. An initial response to immunosuppression is often encouraging, but relapse is common. Supportive care, including management of transfusion requirements and infections, is central to management. Promising new diagnostic tools and emerging therapies will likely transform approaches to this important, chronic and life-threatening condition.
Collapse
Affiliation(s)
- Danielle B Clucas
- Department of Clinical Haematology, Alfred Hospital, Monash University, Melbourne, Victoria, Australia
| | - Lucy C Fox
- Department of Clinical Haematology, Epworth Hospital, Monash University, Melbourne, Victoria, Australia.,Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Erica M Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Clinical Haematology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Frank S Hong
- Department of Clinical Haematology, The Northern Hospital, Melbourne, Victoria, Australia.,Clinical Services and Research, Australian Red Cross Blood Service, Melbourne, Victoria, Australia
| | - John Gibson
- Institute of Haematology, Royal Prince Alfred Hospital, Adelaide, South Australia, Australia.,The University of Sydney, Sydney, South Australia, Australia
| | - Ashish Bajel
- Integrated Haematology Service, Victorian Comprehensive Cancer Centre (The Royal Melbourne Hospital/Peter MacCallum Cancer Centre), Melbourne, Victoria, Australia
| | - Jeff Szer
- Integrated Haematology Service, Victorian Comprehensive Cancer Centre (The Royal Melbourne Hospital/Peter MacCallum Cancer Centre), Melbourne, Victoria, Australia
| | - Piers Blombery
- Molecular Haematology Laboratory, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Zoe K McQuilten
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Clinical Haematology, Monash Medical Centre, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Devendra Hiwase
- Department of Clinical Haematology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,The University of Adelaide, Adelaide, South Australia, Australia
| | - Frank Firkin
- Haematology Department, St Vincent's Hospital, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia
| | - Merrole F Cole-Sinclair
- Haematology Department, St Vincent's Hospital, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia
| | | |
Collapse
|
20
|
Goal attainment scaling as an outcome measure in rare disease trials: a conceptual proposal for validation. BMC Med Res Methodol 2019; 19:227. [PMID: 31801463 PMCID: PMC6894223 DOI: 10.1186/s12874-019-0866-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 11/12/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Goal Attainment Scaling (GAS) is an instrument that is intended to evaluate the effect of an intervention by assessing change in daily life activities on an individual basis. However, GAS has not been validated adequately in an RCT setting. In this paper we propose a conceptual validation plan of GAS in the setting of rare disease drug trials, and describe a hypothetical trial where GAS could be validated. METHODS We have used the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) taxonomy to deduce which measurement properties of GAS can be evaluated, and how. As individual GAS scores cannot be interpreted outside the context of a RCT, the validation of GAS needs to be done on trial as well as on individual level. RESULTS The procedure of GAS consists of three steps. For the step of goal selection (step 1) and definition of levels of attainment (step 2), face validity may be assessed by clinical experts. For the evaluation of the goal attainment (step 3), the inter and intra rater reliability can be evaluated on an individual level. Construct validity may be evaluated by comparison with change scores on other instruments measuring in the same domain as particular goals, if available, and by testing hypotheses about differences between groups. A difference in mean GAS scores between a group who received an efficacious intervention and a control group is an indication of well-chosen goals, and corroborates construct validity of GAS on trial level. Responsiveness of GAS cannot be evaluated due to the nature of the construct being assessed. CONCLUSION GAS may be useful as an instrument to assess functional change as an outcome measure in heterogeneous chronic rare diseases, but it can only be interpreted and validated when used in RCTs with blinded outcome assessment. This proposed theoretical validation plan can be used as a starting point to validate GAS in specific conditions.
Collapse
|
21
|
Tremblay G, Said Q, Roy AN, Cai B, Ashton Garib S, Hearnden J, Forsythe A. Budget Impact Of Eltrombopag As First-Line Treatment For Severe Aplastic Anemia In The United States. CLINICOECONOMICS AND OUTCOMES RESEARCH 2019; 11:673-681. [PMID: 31814747 PMCID: PMC6858800 DOI: 10.2147/ceor.s226323] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/09/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Severe aplastic anemia (SAA) is a rare autoimmune condition resulting in low blood cell counts across lineages. Immunosuppressive therapy (IST) has demonstrated low response, toxicity, and risk of transformation. In a Phase I/II trial, the addition of eltrombopag to first-line IST increased response rates relative to an IST-only historical cohort. METHODS A model was developed to estimate the budget impact of treating SAA with eltrombopag-based therapy from a US private healthcare system perspective. A simulated cohort of newly diagnosed SAA patients based on the total US population received 6 months of IST ± eltrombopag and were followed for 1 year, with mutually exclusive patient cohorts entering in years 1, 2, and 3. The model assessed the budget impact of first-year treatment for each cohort without considering subsequent years. At 6 months, responders in either arm received maintenance therapy (low-dose cyclosporine), and non-responders received 6 months of second-line eltrombopag monotherapy. Costs considered included first-line, maintenance, and second-line therapy, administration, routine care, mortality, and adverse events (AEs). All cost data were reported in 2018 US dollars. RESULTS The annual incidence of aplastic anemia was 0.000234%, with 83.8% of cases assumed to be SAA. Based on trial data, 94% of patients receiving eltrombopag and IST responded versus 66% of patients receiving IST, with a 0.3% reduction in the annual risk of mortality for the eltrombopag + IST group. Use of first-line eltrombopag in a model SAA population based on the total US population increased overall costs by $50 million over 3 years. First-line drug costs accounted for an increase of $69 million, while improved response produced $19 million in secondary therapy cost savings. Sensitivity analyses confirmed the robustness of the analysis. CONCLUSION High response rates combined with reduced rescue medication use and mortality in patients treated with eltrombopag and IST mediated higher medication costs.
Collapse
Affiliation(s)
| | - Qayyim Said
- Novartis Pharmaceutical Corporation, East Hanover, NJ, USA
| | | | - Beilei Cai
- Novartis Pharmaceutical Corporation, East Hanover, NJ, USA
| | | | | | | |
Collapse
|
22
|
Stern RM, Connell NT. Ravulizumab: a novel C5 inhibitor for the treatment of paroxysmal nocturnal hemoglobinuria. Ther Adv Hematol 2019; 10:2040620719874728. [PMID: 31534662 PMCID: PMC6737867 DOI: 10.1177/2040620719874728] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 08/19/2019] [Indexed: 12/25/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare stem cell disorder characterized by hemolytic anemia, bone marrow failure, and thrombosis. Until recently, the complement inhibitor, eculizumab, was the only United States Food and Drug Administration (US FDA)-approved therapy for the treatment of PNH. Although effective, eculizumab requires a frequent dosing schedule that can be burdensome for some patients and increases the risk of breakthrough intravascular hemolysis. Ravulizumab, an eculizumab-like monoclonal antibody engineered to have a longer half-life, is intended to provide the same benefits as eculizumab but with a more convenient and effective dosing schedule. In two recently published phase III non-inferiority trials, ravulizumab was found to be non-inferior to eculizumab both in efficacy and safety for the treatment of patients with PNH. Based on these results, ravulizumab was approved by the US FDA on 21 December 2018 and is currently under regulatory review in both the European Union and Japan.
Collapse
Affiliation(s)
- Robert M Stern
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Nathan T Connell
- Hematology Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| |
Collapse
|
23
|
Design and development of a disease-specific quality of life tool for patients with aplastic anaemia and/or paroxysmal nocturnal haemoglobinuria (QLQ-AA/PNH)-a report on phase III. Ann Hematol 2019; 98:1547-1559. [PMID: 31115593 PMCID: PMC6591198 DOI: 10.1007/s00277-019-03681-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 03/28/2019] [Indexed: 12/20/2022]
Abstract
To date, instruments to measure quality of life (QoL) specifically for patients with acquired aplastic anaemia (AA) and paroxysmal nocturnal haemoglobinuria (PNH) are lacking altogether. As a consequence, this issue is either underevaluated or alternatively, instruments originally designed for cancer patients are being used. We therefore started to systematically develop a AA/PNH-specific QoL (QLQ-AA/PNH) instrument in these ultra-rare diseases according to European Organisation for Research and Treatment of Cancer (EORTC) guidelines. While phases I and II of the process have previously been published, we now report on the resulting instrument (phase III of this process). As part of the phase III of the evaluation process, we approached patients through physicians, patient support groups, and patient conferences. After participants completed the preliminary questionnaire and reported socio-demographic data, they were interviewed in person or via phone with a debriefing interview to find out whether the items were relevant, easy to understand, and acceptable to patients and whether there was anything missing in the questionnaire. We hypothesised what items could be combined into a scale and calculated Cronbach’s alpha to define its preliminary internal consistency. After definition of a priori criteria to keep or delete items, a group of six experts met in person, discussed the results, and decided on in- or exclusion. A total of 48 patients were enrolled, 21 of those suffered from AA (44%), 13 from PNH (27%), and 14 from AA/PNH syndrome (29%). The median time to complete the 69 items was 10 min (range 5–20), mean time 11 min. The compliance criterion (> 95% completion) was fulfilled by 57 items. Twenty-three items were mentioned as especially relevant by ≥ 2% of the patients. Cronbach’s alpha of the hypothesised scales ranged from 0.63 (social support) to 0.92 (fear of progression and illness intrusiveness). Finally, 47 items were kept; 16 were deleted, and 5 were changed, while 1 item expanded. This resulted in 54 items in total. As no issues were mentioned to lacking by a minimum of five patients, no items were added to the questionnaire. After completion, the AA/PNH-QoL tool (QLQ-AA/PNH) was translated according to EORTC guidelines into English, French, and Italian. For patients with PNH and AA until now, the standard assessment for QoL was to use the EORTC Quality of Life Questionnaire (QLQ-C30) or the Functional Assessment of Chronic Illness Therapy Fatigue Instrument (FACIT-Fatigue). We herewith present a new instrument aimed to be better tailored to the needs of PNH and AA patients. The anticipated fourth development phase will be performed for psychometric validation; however, we already explored the internal consistency of the hypothesised scales and found the results to be very good. Hence, the new QLQ-AA/PNH with 54 items can be used in trials and clinical studies from now on, according to EORTC strategy even if the scoring algorithm at this point is preliminary and the QLQ-AA/PNH might change slightly after phase IV. This is important, as there are no other disease-specific instruments available for AA/PNH patients right now.
Collapse
|
24
|
Ravulizumab (ALXN1210) vs eculizumab in C5-inhibitor-experienced adult patients with PNH: the 302 study. Blood 2018; 133:540-549. [PMID: 30510079 DOI: 10.1182/blood-2018-09-876805] [Citation(s) in RCA: 230] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 11/18/2018] [Indexed: 12/13/2022] Open
Abstract
Ravulizumab, a new complement component C5 inhibitor administered every 8 weeks, was noninferior to eculizumab administered every 2 weeks in complement-inhibitor-naive patients with paroxysmal nocturnal hemoglobinuria (PNH). This study assessed noninferiority of ravulizumab to eculizumab in clinically stable PNH patients during previous eculizumab therapy. In this phase 3, open-label, multicenter study, 195 PNH patients on labeled-dose (900 mg every 2 weeks) eculizumab for >6 months were randomly assigned 1:1 to switch to ravulizumab (n = 97) or continue eculizumab (n = 98). Primary efficacy end point was percentage change in lactate dehydrogenase (LDH) from baseline to day 183. Key secondary end points included proportion of patients with breakthrough hemolysis, change in Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue score, transfusion avoidance, and stabilized hemoglobin. In 191 patients completing 183 days of treatment, ravulizumab was noninferior to eculizumab (P inf < .0006 for all end points), including percentage change in LDH (difference, 9.21% [95% confidence interval (CI), -0.42 to 18.84], P = .058 for superiority), breakthrough hemolysis (difference, 5.1 [95% CI, -8.89 to 18.99]), change in FACIT-Fatigue score (difference, 1.47 [95% CI, -0.21 to 3.15]), transfusion avoidance (difference, 5.5 [95% CI, -4.27 to 15.68]), and stabilized hemoglobin (difference, 1.4 [95% CI, -10.41 to 13.31]). The most frequently reported adverse event was headache (26.8%, ravulizumab; 17.3%, eculizumab). No meningococcal infections or discontinuations due to adverse events occurred. Patients with PNH may be safely and effectively switched from labeled-dose eculizumab administered every 2 weeks to ravulizumab administered every 8 weeks. This trial was funded by Alexion Pharmaceuticals, Inc., and is registered at www.clinicaltrials.gov as #NCT03056040.
Collapse
|
25
|
Sheridan D, Yu ZX, Zhang Y, Patel R, Sun F, Lasaro MA, Bouchard K, Andrien B, Marozsan A, Wang Y, Tamburini P. Design and preclinical characterization of ALXN1210: A novel anti-C5 antibody with extended duration of action. PLoS One 2018; 13:e0195909. [PMID: 29649283 PMCID: PMC5897016 DOI: 10.1371/journal.pone.0195909] [Citation(s) in RCA: 154] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 04/02/2018] [Indexed: 11/24/2022] Open
Abstract
Eculizumab, a monoclonal antibody (mAb) directed against complement protein C5, is considered to be the current standard of care for patients with paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome. This study describes the generation and preclinical attributes of ALXN1210, a new long-acting anti-C5 mAb, obtained through select modifications to eculizumab to both largely abolish target-mediated drug disposition (TMDD) and increase recycling efficiency via the neonatal Fc receptor (FcRn). To attenuate the effect of TMDD on plasma terminal half-life (t1/2), histidine substitutions were engineered into the complementarity-determining regions of eculizumab to enhance the dissociation rate of the mAb:C5 complex in the acidic early endosome relative to the slightly basic pH of blood. Antibody variants with optimal pH-dependent binding to C5 exhibited little to no TMDD in mice in the presence of human C5. To further enhance the efficiency of FcRn-mediated recycling of the antibody, two additional substitutions were introduced to increase affinity for human FcRn. These substitutions yielded an additional doubling of the t½ of surrogate anti-mouse C5 antibodies with reduced TMDD in transgenic mice expressing the human FcRn. In conclusion, ALXN1210 is a promising new therapeutic candidate currently in clinical development for treatment of patients with PNH and atypical hemolytic uremic syndrome.
Collapse
Affiliation(s)
- Douglas Sheridan
- Research, Alexion Pharmaceuticals, Inc., New Haven, Connecticut, United States of America
- * E-mail:
| | - Zhao-Xue Yu
- Research, Alexion Pharmaceuticals, Inc., New Haven, Connecticut, United States of America
| | - Yuchun Zhang
- Research, Alexion Pharmaceuticals, Inc., New Haven, Connecticut, United States of America
| | - Rekha Patel
- Product Characterization, Alexion Pharmaceuticals, Inc., New Haven, Connecticut, United States of America
| | - Fang Sun
- Research, Alexion Pharmaceuticals, Inc., New Haven, Connecticut, United States of America
| | - Melissa A. Lasaro
- Research, Alexion Pharmaceuticals, Inc., New Haven, Connecticut, United States of America
| | - Keith Bouchard
- Research, Alexion Pharmaceuticals, Inc., New Haven, Connecticut, United States of America
| | - Bruce Andrien
- Early Assay Development, Alexion Pharmaceuticals, Inc., New Haven, Connecticut, United States of America
| | - Andre Marozsan
- Research, Alexion Pharmaceuticals, Inc., New Haven, Connecticut, United States of America
| | - Yi Wang
- Research, Alexion Pharmaceuticals, Inc., New Haven, Connecticut, United States of America
| | - Paul Tamburini
- Research, Alexion Pharmaceuticals, Inc., New Haven, Connecticut, United States of America
| |
Collapse
|
26
|
Effects of eculizumab treatment on quality of life in patients with paroxysmal nocturnal hemoglobinuria in Japan. Int J Hematol 2018; 107:656-665. [PMID: 29383624 DOI: 10.1007/s12185-018-2409-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 01/24/2018] [Accepted: 01/24/2018] [Indexed: 10/18/2022]
Abstract
In paroxysmal nocturnal hemoglobinuria (PNH), various symptoms due to intravascular hemolysis exert a negative impact on patients' quality of life (QOL). To determine clinical factors related with improvements in QOL in PNH patients treated, we analyzed changes in QOL scales in PNH patients treated with eculizumab based on data collected from post-marketing surveillance in Japan. Summary statistics were obtained using figures from QOL scoring systems and laboratory values, and evaluated by t test. One-year administration of eculizumab improved the most QOL items in comparison with the baseline. In particular, significant improvement of EORTC QLQ-C30 was observed in fatigue, dyspnea, physical function, and global health status. Canonical correlation analysis revealed a high correlation between QOL and laboratory values. Changes in serum lactate dehydrogenase (LDH) and hemoglobin showed strong correlations with QOL improvement. Quality of life improvement was independent of patients' baseline characteristics of co-occurrence of bone marrow failure (BMF), or the degree of LDH. In this analysis, we found that the degree of QOL improvement was independent of the baseline LDH before eculizumab treatment and of co-occurrence of BMF. Paroxysmal nocturnal hemoglobinuria patients who have not received eculizumab treatment due to mild hemolysis may benefit from eculizumab treatment.
Collapse
|