Clinical Pharmacology for Adakveo
Mechanism Of Action
Crizanlizumab-tmca is a humanized IgG2 kappa monoclonal antibody that binds to P-selectin and blocks interactions with its ligands, including P-selectin glycoprotein ligand 1 (PSGL-1). Crizanlizumab can also dissociate preformed P-selectin/PSGL-1 complex.
Binding P-selectin on the surface of the activated endothelium and platelets blocks interactions between endothelial cells, platelets, red blood cells, and leukocytes.
Pharmacodynamics
ADAKVEO resulted in a dose-dependent P-selectin inhibition (measured ex vivo) in patients with sickle cell disease and healthy volunteers.
Pharmacokinetics
The pharmacokinetics of crizanlizumab-tmca were evaluated in healthy volunteers and patients with sickle cell disease. The mean crizanlizumab-tmca Cmax, AUClast, or AUCinf increased disproportionally over the dose range of 0.2 to 8 mg/kg (0.04 to 1.6 times the approved recommended dosage) in healthy volunteers. In healthy volunteers administered the 5 mg/kg dose, the mean [coefficient of variation (CV%)] crizanlizumab-tmca Cmax, AUClast, or AUCinf were 0.16 (15.3%) mg/mL, 33.6 (12.6%) mg*hr/mL and 34.6 (13.1%) mg*hr/mL, respectively.
Distribution
The mean (% CV) volume of distribution was 4.26 (25.1%) L after a single crizanlizumab-tmca 5 mg/kg intravenous infusion in healthy volunteers.
Elimination
The mean (% CV) terminal elimination half-life (t½) of crizanlizumab-tmca was 10.6 (20.5%) days and the mean clearance was 11.7 (16.2%) mL/hr at 5 mg/kg doses in healthy volunteers. The mean (% CV) elimination t½ of crizanlizumab-tmca was 11.4 (31.5%) days during dosing interval in patients with sickle cell disease.
Metabolism
Crizanlizumab-tmca is expected to be metabolized into small peptides by catabolic pathways.
Specific Populations
The effect of renal or hepatic impairment on the pharmacokinetics of crizanlizumab-tmca is unknown.
Drug Interaction Studies
Hydroxyurea had no clinically meaningful effect on crizanlizumab-tmca pharmacokinetics in patients in clinical studies.
Immunogenicity
The observed incidence of anti-drug antibodies is highly dependent on the sensitivity and specificity of the assay. Differences in assay methods preclude meaningful comparisons of the incidence of anti-drug antibodies in the studies described below with the incidence of anti-drug antibodies in other studies, including those of ADAKVEO or of other crizanlizumab products.
The immunogenicity of ADAKVEO was evaluated using a validated bridging immunoassay for the detection of binding anti-crizanlizumab-tmca antibodies. In a single arm, open label multiple dose study, 0 of the 45 patients with sickle cell disease treated with ADAKVEO 5 mg/kg tested positive for treatment-induced anti-crizanlizumab-tmca antibodies. In a single-dose study in healthy subjects, 1 of the 61 (1.6%) evaluable subjects tested positive for a treatment-induced antiÂcrizanlizumab-tmca antibodies. No treatment induced anti-crizanlizumab-tmca antibodies were detected (0 of 84 patients) in a phase 3 study at 5 mg/kg over the 52 week time period (samples collected at baseline, weeks 3, 15, 19, 27 and 51). Therefore, no significant effect on pharmacokinetics or pharmacodynamics has been observed or is expected.
Animal Toxicology And/Or Pharmacology
In the 26-week repeat-dose toxicity study, administration of crizanlizumab-tmca in cynomolgus monkeys at dose levels up to 50 mg/kg/dose once every 4 weeks resulted in inflammation of the vessels in multiple tissues in 2 out of 10 animals.
Clinical Studies
Sustain
The efficacy of ADAKVEO was evaluated in patients with sickle cell disease in SUSTAIN [NCT01895361], a 52-week, randomized, multicenter, placebo-controlled, double-blind study. A total of 198 patients with sickle cell disease, any genotype (HbSS, HbSC, HbS/beta0-thalassemia, HbS/beta+-thalassemia, and others), and a history of 2-10 VOCs in the previous 12 months were eligible for inclusion. Patients were randomized 1:1:1 to ADAKVEO 5 mg/kg (N = 67), ADAKVEO 2.5 mg/kg (N = 66), or placebo (N = 65) administered over a period of 30 minutes by intravenous infusion on Week 0, Week 2, and every 4 weeks thereafter for a treatment duration of 52 weeks. Randomization was stratified by patients already receiving hydroxyurea (Y/N) and by the number of VOCs in the previous 12 months (2 to 4, 5 to 10).
Patients received ADAKVEO (with or without hydroxyurea) and were allowed to receive occasional transfusions and pain medications [i.e., acetaminophen, NSAIDs, and opioids] on an as needed basis.
Patients recruited in the study had complications associated with sickle cell disease and other comorbidities, including a history of acute chest syndrome (18%); pulmonary hypertension (8%); priapism (7%); psychiatric manifestations (25%), including depression and anxiety; hypertension (17%); cholelithiasis (17%). Demographic and other baseline characteristics were similar among the treatment groups (see Table 3).
Table 3: Demographics and Baseline Characteristics in SUSTAIN Study
|
ADAKVEO 5 mg/kg
(N = 67) |
Placebo
(N = 65) |
| Age (years) |
| Median |
29 |
26 |
| Range |
16, 63 |
16, 56 |
| Gender, n (%) |
| Male |
32 (48%) |
27 (42%) |
| Female |
35 (52%) |
38 (59%) |
| Ethnicity, n (%) |
| Hispanic or Latino |
20 (30%) |
11 (17%) |
| Not Hispanic or Latino |
45 (67%) |
53 (82%) |
| Unknown |
2 (3%) |
1 (2%) |
| Race |
| Black or African American |
60 (90%) |
60 (92%) |
| White |
4 (6%) |
3 (5%) |
| Other |
3 (5%) |
2 (3%) |
| Sickle cell disease genotype, n (%) |
| HbSS |
47 (70%) |
47 (72%) |
| HbSC |
9 (13%) |
8 (12%) |
| HbS/beta0 - thalassemia |
3 (5%) |
7 (11%) |
| HbS/beta+ - thalassemia |
7 (10%) |
1 (2%) |
| Other |
1 (2%) |
2 (3%) |
| Hydroxyurea use, n (%) |
| Yes |
42 (63%) |
40 (62%) |
| No |
25 (37%) |
25 (39%) |
| Number of VOCs in previous 12 months, n (%) |
| 2 to 4 |
42 (63%) |
41 (63%) |
| 5 to 10 |
25 (37%) |
24 (37%) |
| Abbreviation: VOCs, vasoocclusive crises. |
Efficacy was evaluated in the SUSTAIN study by the annual rate of VOCs leading to a healthcare visit. A VOC leading to a healthcare visit was defined as an acute episode of pain with no cause other than a vasoocclusive event that required a medical facility visit and treatment with oral or parenteral opioids, or parenteral NSAIDs. Acute chest syndrome, hepatic sequestration, splenic sequestration, and priapism (requiring a visit to a medical facility) were also considered VOCs.
Patients with sickle cell disease who received ADAKVEO 5 mg/kg had a lower median annual rate of VOC compared to patients who received placebo (1.63 vs. 2.98) which was statistically significant (p = 0.010). Reductions in the frequency of VOCs were observed among patients regardless of sickle cell disease genotype and/or hydroxyurea use.
Thirty-six percent (36%) of patients treated with ADAKVEO 5 mg/kg did not experience a VOC compared to 17% of placebo-treated patients. The median time to first VOC from randomization was 4.1 months in the ADAKVEO 5 mg/kg arm compared to 1.4 months in the placebo.
The main efficacy results of the pivotal study, SUSTAIN, are summarized in Table 4.
Table 4: Efficacy Results From SUSTAIN Trial in Sickle Cell Diseasea
| Event |
ADAKVEO, 5 mg/kgb
(n = 67) |
Placebob
(n = 65) |
Treatment Difference Estimatec |
| Annual rate of VOCa |
1.63 |
2.98 |
HL = -1.01, (-2.00, 0.00) |
| Annual rate of days hospitalized |
4 |
6.87 |
|
Abbreviations: HL, hodges-lehmann; VOC, vasoocclusive crises.
aVOCs were as assessed by an independent review committee.
bStandard median.
cHL median difference [95% confidence interval (CI)]. |
STAND
The efficacy of two doses of ADAKVEO, with or without HU/HC, was evaluated, but not established, in the STAND trial [NCT03814746], a randomized, placebo-controlled, double-blind, multicenter clinical study in adolescent and adult sickle cell disease patients with a history of VOCs. The efficacy results of STAND study are summarized in Table 6 below.
In this study, VOC was defined as a pain crisis (acute onset of pain for which there is no other medically determined explanation other than vaso-occlusion) which requires therapy with oral or parenteral opioids or parenteral NSAID. Acute chest syndrome (ACS), priapism and hepatic or splenic sequestration were considered VOCs in this study.
A total of 252 sickle cell disease patients were randomized to the study, 85 in placebo arm, 84 in ADAKVEO 5 mg/kg arm and 83 in ADAKVEO 7.5 mg/kg arm. The 7.5 mg/kg ADAKVEO dose is not approved and is not recommended for use. Demographic and other baseline characteristics were similar among the treatment groups (see Table 5).
Table 5: Demographics and Baseline Characteristics in STAND Study
|
ADAKVEO 5 mg/kg
(N=84) |
Placebo
(N=85) |
| Age (years) |
| Median |
24 |
25 |
| Range |
12, 64 |
12, 68 |
| Gender, n (%) |
| Female |
45 (54%) |
49 (58%) |
| Male |
39 (46%) |
36 (42%) |
| Race, n (%) |
| Black or African American |
46 (55%) |
43 (51%) |
| White |
27 (32%) |
26 (31%) |
| Asian |
6 (7%) |
6 (7%) |
| Other |
5 (6%) |
10 (12%) |
| Genotype, n (%) |
| HbSS |
58 (69%) |
58 (68%) |
| HbSC |
11 (13%) |
12 (14%) |
| HbS/beta+ - thalassemia |
8 (10%) |
8 (9%) |
| HbS/beta0 - thalassemia |
5 (6%) |
6 (7%) |
| Other |
2 (2%) |
1 (1%) |
| Ethnicity, n (%) |
| Not Hispanic or Latino |
54 (64%) |
57 (67%) |
| Hispanic or Latino |
22 (26%) |
18 (21%) |
| Other (not reported/unknown) |
8 (10%) |
10 (12%) |
| Hydroxyurea use, n (%) |
| Yes |
62 (74%) |
61 (72%) |
| No |
20 (24%) |
23 (27%) |
| Missing |
2 (2%) |
1 (1%) |
| Number of VOC leading to healthcare visit in the last 12 months, n (%) |
| <5 |
62 (74%) |
58 (68%) |
| ≥5 |
21 (25%) |
27 (32%) |
| Missing |
1 (1%) |
0 |
The percentages for subgroups of race and genotype donot add up to 100% due to rounding to 1 decimal place.The results of the efficacy analysis did not confirm the statistical superiority of ADAKVEO over placebo in reducing VOCs leading to a healthcare visit over the first-year post randomization.
Table 6. Efficacy Results from STAND Trial in Sickle Cell Disease
| Treatment |
n |
Adjusted annualized rate of VOC |
(95% CI) |
Between-treatment: comparison |
| Comparison |
Rates ratio |
(95% CI) |
| Adakveo 5 mg/kg |
84 |
2.49 |
(1.90, 3.26) |
vs Placebo |
1.08 |
(0.76, 1.55)* |
| Placebo |
85 |
2.3 |
(1.75, 3.01) |
|
|
|
n:Total number of participants included in the analysis.
Obtained from fitting a negative binomial regression model with treatment and randomization stratification factors (baseline VOC and HU/HC) as covariates. The natural log of the observation period was used as offset.
*The 95% CI includes 1, which indicates that the result is not statistically significant. |