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Sandborn WJ, Panés J, Danese S, Sharafali Z, Hassanali A, Jacob-Moffatt R, Eden C, Daperno M, Valentine JF, Laharie D, Baía C, Atreya R, Panaccione R, Rydzewska G, Aguilar H, Vermeire S. Etrolizumab as induction and maintenance therapy in patients with moderately to severely active Crohn's disease (BERGAMOT): a randomised, placebo-controlled, double-blind, phase 3 trial. Lancet Gastroenterol Hepatol 2023; 8:43-55. [PMID: 36240801 DOI: 10.1016/s2468-1253(22)00303-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/02/2022] [Accepted: 09/05/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Etrolizumab is a gut-targeted anti-β7 monoclonal antibody targeting α4β7 and αEβ7 integrins. We aimed to compare the safety and efficacy of two doses of etrolizumab with placebo in patients with Crohn's disease. METHODS BERGAMOT was a randomised, placebo-controlled, double-blind, phase 3 study done at 326 treatment centres worldwide. We included patients aged 18-80 years with moderately to severely active Crohn's disease (Crohn's Disease Activity Index [CDAI] score of 220-480, and a mean daily stool frequency score of ≥6 or a mean daily stool frequency score of >3, and a mean daily abdominal pain score of >1, as well as the presence of active inflammation on screening ileocolonoscopy) who had intolerance, inadequate response, or no response to one or more of corticosteroids, immunosuppressants, or anti-TNF therapy within the past 5 years. BERGAMOT consisted of three induction cohorts (a placebo-controlled, double-blind exploratory cohort [cohort 1]; an active treatment cohort not containing a placebo control [cohort 2]; and a placebo-controlled, double-blind pivotal cohort [cohort 3]) and one maintenance cohort. In induction cohort 3, during the 14-week induction, patients were randomly assigned (2:3:3) to receive matched placebo, 105 mg etrolizumab subcutaneously every 4 weeks (at weeks 0, 4, 8, and 12) or 210 mg etrolizumab subcutaneously (at weeks 0, 2, 4, 8, and 12), stratified by concomitant treatment with oral corticosteroids, concomitant treatment with immunosuppressants, baseline disease activity, and previous exposure to anti-TNF therapy. To preserve masking, all patients received two injections at weeks 0, 4, 8, and 12 and one injection at week 2. Week 14 etrolizumab responders from all cohorts were re-randomly assigned (1:1) to receive 105 mg etrolizumab (etrolizumab maintenance group) or placebo (placebo maintenance group) every 4 weeks for 52 weeks; patients in the induction placebo group underwent a sham re-randomisation to preserve masking. During maintenance, randomisation was stratified by CDAI remission status, concomitant treatment with oral corticosteroids, induction dose regimen, and previous exposure to anti-TNF therapy. All participants and study site personnel were masked to treatment assignment for both induction and maintenance. Co-primary induction endpoints at week 14 (placebo vs 210 mg etrolizumab) were clinical remission (mean stool frequency ≤3 and mean abdominal pain ≤1, with no worsening) and endoscopic improvement (≥50% reduction in Simple Endoscopic Score for Crohn's Disease [SES-CD]). Co-primary maintenance endpoints at week 66 (placebo vs etrolizumab) were clinical remission and endoscopic improvement. Efficacy was analysed using a modified intention-to-treat (mITT) population, defined as all randomised patients who received at least one dose of study drug (induction) and as all patients re-randomised into maintenance who received at least one dose of study drug in the maintenance phase (maintenance). Safety analyses included all patients who received at least one dose of study drug. Maintenance safety analyses include all adverse events occurring in both induction and maintenance. This trial is registered with ClinicalTrials.gov, NCT02394028, and is closed to recruitment. FINDINGS Between March 20, 2015, and Sept 7, 2021, 385 patients (209 [54%] male and 326 [85%] white) were randomly assigned in induction cohort 3 to receive placebo (n=97), 105 mg etrolizumab (n=143), or 210 mg etrolizumab (n=145). 487 patients had a CDAI-70 response in any of the induction cohorts and were enrolled into the maintenance cohort, of whom 434 had a response to etrolizumab and were randomly assigned to placebo (n=217) or 105 mg etrolizumab (n=217). At week 14, 48 (33%) of 145 patients in the 210 mg induction etrolizumab group versus 28 (29%) of 96 patients in the placebo induction group were in clinical remission (adjusted treatment difference 3·8% [95% CI -8·3 to 15·3]; p=0·52), and 40 (27%) versus 21 (22%) showed endoscopic improvement (5·8% [-5·4 to 17·1]; p=0·32). At week 66, a significantly higher proportion of patients receiving etrolizumab than those receiving placebo had clinical remission (76 [35%] of 217 vs 52 [24%] of 217; adjusted treatment difference 11·3% [95% CI 2·7-19·7]; p=0·0088) and endoscopic improvement (51 [24%] vs 26 [12%]; 11·5% [4·1-18·8]; p=0·0026). Similar proportions of patients reported one or more adverse events during induction (95 [66%] of 143 in the 105 mg etrolizumab group, 85 [59%] of 145 in the 210 mg etrolizumab group, and 51 [53%] of 96 in the placebo group) and maintenance (189 [87%] of 217 in the etrolizumab group and 190 [88%] of 217 in the placebo group). During induction, the most common treatment-related adverse events were injection site erythema (six [4%] of 143 in the 105 mg etrolizumab group, four [3%] of 145 in the 210 mg etrolizumab group, and none of 96 in the placebo group), and arthralgia (two [1%], one [1%], and four [4%]). In the maintenance cohort, the most common treatment-related adverse events were injection site erythema (six [3%] of 217 in the etrolizumab group vs 14 [6%] of 217 in the placebo: group), arthralgia (five [2%] vs eight [4%]), and headache (five [2%] vs seven [3%]). The most common serious adverse event was exacerbation of Crohn's disease (14 [6%] of 217 patients taking placebo and four [2%] of 217 patients taking 105 mg etrolizumab in the maintenance cohort). INTERPRETATION A significantly higher proportion of patients with moderately to severely active Crohn's disease achieved clinical remission and endoscopic improvement with etrolizumab than placebo during maintenance, but not during induction. FUNDING F Hoffmann-La Roche.
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Affiliation(s)
- William J Sandborn
- Department of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Julian Panés
- Biomedical Research Networking Center in Hepatic and Digestive Diseases, August Pi i Sunyer Biomedical Research Institute, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | | | | | | | | | - Marco Daperno
- SC Gastroenterologia AO Ordine Mauriziano di Torino, Turin, Italy
| | - John F Valentine
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah, Salt Lake City, UT, USA
| | - David Laharie
- Centre Hospitalier Universitaire de Bordeaux, Hôpital Haut-Lévêque, Service d'Hépato-gastroentérologie et Oncologie Digestive - Université de Bordeaux, Bordeaux, France
| | - Carolina Baía
- Médica Gastroenterologista em Belo Horizonte, Minas Gerais, Brazil
| | - Raja Atreya
- Medical Clinic 1, University Hospital Erlangen, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | - Remo Panaccione
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Grazyna Rydzewska
- Central Clinical Hospital of the Ministry of Interior in Warsaw, Warsaw, Poland
| | | | - Séverine Vermeire
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.
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Dai B, Hackney JA, Ichikawa R, Nguyen A, Elstrott J, Orozco LD, Sun KH, Modrusan Z, Gogineni A, Scherl A, Gubatan J, Habtezion A, Deswal M, Somsouk M, Faubion WA, Chai A, Sharafali Z, Hassanali A, Oh YS, Tole S, McBride J, Keir ME, Yi T. Dual targeting of lymphocyte homing and retention through α4β7 and αEβ7 inhibition in inflammatory bowel disease. Cell Rep Med 2021; 2:100381. [PMID: 34467254 PMCID: PMC8385326 DOI: 10.1016/j.xcrm.2021.100381] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 03/09/2021] [Accepted: 07/22/2021] [Indexed: 01/07/2023]
Abstract
Anti-integrins are therapeutically effective for inflammatory bowel disease, yet the relative contribution of α4β7 and αEβ7 to gut lymphocyte trafficking is not fully elucidated. Here, we evaluate the effect of α4β7 and αEβ7 blockade using a combination of murine models of gut trafficking and longitudinal gene expression analysis in etrolizumab-treated patients with Crohn's disease (CD). Dual blockade of α4β7 and αEβ7 reduces CD8+ T cell accumulation in the gut to a greater extent than blockade of either integrin alone. Anti-αEβ7 reduces epithelial:T cell interactions and promotes egress of activated T cells from the mucosa into lymphatics. Inflammatory gene expression is greater in human intestinal αEβ7+ T cells. Etrolizumab-treated patients with CD display a treatment-specific reduction in inflammatory and cytotoxic intraepithelial lymphocytes (IEL) genes. Concurrent blockade of α4β7 and αEβ7 promotes reduction of cytotoxic IELs and inflammatory T cells in the gut mucosa through a stepwise inhibition of intestinal tissue entry and retention.
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Affiliation(s)
- Bingbing Dai
- Departments of Immunology Discovery, Genentech, Inc. 1 DNA Way, South San Francisco, CA 94080, USA
| | - Jason A. Hackney
- OMNI Biomarker Development, Genentech, Inc. 1 DNA Way, South San Francisco, CA 94080, USA
| | - Ryan Ichikawa
- Biomarker Discovery OMNI, Genentech, Inc. 1 DNA Way, South San Francisco, CA 94080, USA
| | - Allen Nguyen
- OMNI Biomarker Development, Genentech, Inc. 1 DNA Way, South San Francisco, CA 94080, USA
| | - Justin Elstrott
- Biomedical Imaging, Genentech, Inc. 1 DNA Way, South San Francisco, CA 94080, USA
| | - Luz D. Orozco
- Bioinformatics, Genentech, Inc. 1 DNA Way, South San Francisco, CA 94080, USA
| | - Kai-Hui Sun
- Molecular Biology, Genentech, Inc. 1 DNA Way, South San Francisco, CA 94080, USA
| | - Zora Modrusan
- Molecular Biology, Genentech, Inc. 1 DNA Way, South San Francisco, CA 94080, USA
| | - Alvin Gogineni
- Biomedical Imaging, Genentech, Inc. 1 DNA Way, South San Francisco, CA 94080, USA
| | - Alexis Scherl
- Pathology, Genentech, Inc. 1 DNA Way, South San Francisco, CA 94080, USA
| | - John Gubatan
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Aida Habtezion
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Monika Deswal
- University of California, San Francisco (UCSF), San Francisco, CA 94143, USA
| | - Ma Somsouk
- University of California, San Francisco (UCSF), San Francisco, CA 94143, USA
| | - William A. Faubion
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
| | - Akiko Chai
- Product Development, Genentech, Inc. 1 DNA Way, South San Francisco, CA 94080, USA
| | - Zaineb Sharafali
- Product Development, Genentech, Inc. 1 DNA Way, South San Francisco, CA 94080, USA
| | - Azra Hassanali
- Product Development, Genentech, Inc. 1 DNA Way, South San Francisco, CA 94080, USA
| | - Young S. Oh
- Product Development, Genentech, Inc. 1 DNA Way, South San Francisco, CA 94080, USA
| | - Swati Tole
- Product Development, Genentech, Inc. 1 DNA Way, South San Francisco, CA 94080, USA
| | - Jacqueline McBride
- OMNI Biomarker Development, Genentech, Inc. 1 DNA Way, South San Francisco, CA 94080, USA
| | - Mary E. Keir
- Biomarker Discovery OMNI, Genentech, Inc. 1 DNA Way, South San Francisco, CA 94080, USA
| | - Tangsheng Yi
- Departments of Immunology Discovery, Genentech, Inc. 1 DNA Way, South San Francisco, CA 94080, USA
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