Clinical Pharmacology for Praluent
Mechanism Of Action
Alirocumab is a human monoclonal antibody that binds to proprotein convertase subtilisin kexin type 9 (PCSK9). PCSK9 binds to the low-density lipoprotein (LDL) receptors (LDLR) on the surface of hepatocytes to promote LDLR degradation within the liver. By inhibiting the binding of PCSK9 to LDLR, alirocumab increases the number of LDLRs available to clear LDL, thereby lowering LDL-C levels.
Pharmacodynamics
Alirocumab reduced free PCSK9 in a concentration-dependent manner. Following a single subcutaneous administration of alirocumab 75 or 150 mg, maximal suppression of free PCSK9 occurred within 4 to 8 hours. Free PCSK9 concentrations returned to baseline when alirocumab concentrations decreased below the limit of quantitation.
Pharmacokinetics
Absorption
After subcutaneous administration of 75 mg to 300 mg alirocumab, median times to maximum serum concentrations (tmax) were 3-7 days. The pharmacokinetics of alirocumab after single subcutaneous administration of 75 mg into the abdomen, upper arm, or thigh were similar. The absolute bioavailability of alirocumab after subcutaneous administration was about 85% as determined by population pharmacokinetics analysis. A slightly greater than dose proportional increase was observed, with a 2.1-fold to 2.7-fold increase in total alirocumab concentrations for a 2-fold increase in dose from 75 mg every 2 weeks to 150 mg every 2 weeks. Monthly dose normalized exposure with 300 mg every 4 weeks treatment was similar to that of 150 mg every 2 weeks. Steady state was reached after 2 to 3 doses with an accumulation ratio up to a maximum of about 2-fold.
Distribution
Following intravenous administration, the volume of distribution was about 0.04 to 0.05 L/kg indicating that alirocumab is distributed primarily in the circulatory system.
Elimination
Specific metabolism studies were not conducted, because alirocumab is a protein. Alirocumab is expected to degrade to small peptides and individual amino acids. In clinical studies where alirocumab was administered in combination with atorvastatin or rosuvastatin, no relevant changes in statin concentrations were observed in the presence of repeated administration of alirocumab, indicating that cytochrome P450 enzymes (mainly CYP3A4 and CYP2C9) and transporter proteins such as P-gp and OATP were not affected by alirocumab.
Two elimination phases were observed for alirocumab. At low concentrations, the elimination is predominately through saturable binding to target (PCSK9), while at higher concentrations the elimination of alirocumab is largely through a non-saturable proteolytic pathway.
Based on a population pharmacokinetic analysis, the median apparent half-life of alirocumab at steady state was 17 to 20 days in patients receiving alirocumab at subcutaneous doses of 75 mg every 2 weeks or 150 mg every 2 weeks.
Specific Populations
A population pharmacokinetic analysis was conducted on data from 2799 patients. Age, body weight, gender, race, and creatinine clearance were found not to significantly influence alirocumab pharmacokinetics.
Pediatric Patients
The pharmacokinetics of alirocumab were evaluated in 140 pediatric patients aged 8 to 17 years with HeFH. Steady-state concentrations were reached at or before week 8 (first PK sampling during repeated dosing) with recommended dosing regimen [see DOSAGE AND ADMINISTRATION].
Renal Impairment
Since monoclonal antibodies are not known to be eliminated via renal pathways, renal function is not expected to impact the pharmacokinetics of alirocumab.
No data are available in patients with severe renal impairment.
Hepatic Impairment
Following administration of a single 75 mg SC dose, alirocumab pharmacokinetic profiles in patients with mild and moderate hepatic impairment were similar to those in patients with normal hepatic function.
No data are available in patients with severe hepatic impairment.
Drug-Drug Interactions
The median apparent half-life of alirocumab is reduced to 12 days when administered with a statin; however, this difference is not clinically meaningful.
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 trials described below with the incidence of anti-drug antibodies in other trials, including those of PRALUENT or of other alirocumab products.
In adult patients with cardiovascular disease (Trial 1), the incidence of anti-alirocumab antibody (ADA) formation was 5.5% (504/9,091) in patients treated with PRALUENT 75 mg and/or 150 mg every 2 weeks for up to 5 years (with a median treatment exposure of 31 months). Neutralizing antibody (NAb) responses were observed in 0.5% (43/9,091) of all patients treated with PRALUENT. Of the patients who developed ADA, 8.5% (43/504) tested positive for NAb.
- While reductions in LDL-C were generally comparable in patients with or without ADA, including NAbs, some adult patients treated with PRALUENT with persistent or neutralizing antibodies experienced attenuation in LDL-C efficacy.
- Adult patients who developed ADA had a higher incidence of injection site reactions compared to patients without ADA (7.5% vs 3.6%) [see ADVERSE REACTIONS].
In a pool of placebo-controlled and active-controlled trials of adult patients treated with PRALUENT 75 mg and/or 150 mg every 2 weeks as well as in a separate clinical trial of patients treated with PRALUENT 75 mg every 2 weeks or 300 mg every 4 weeks (including some patients with dose adjustment to 150 mg every 2 weeks), during the treatment period ranging from 6 to 24 months, the incidence of detecting ADA was 4.8% (147/3033) and NAb was 1.2% (36/3,033), which was similar to the results from the trial described above.
In pediatric patients aged 8 to 17 years with HeFH (Trial 12), the incidence of ADA for patients treated with PRALUENT was 3% (3/98) with a median treatment exposure of 24 weeks in patients receiving PRALUENT once every 2 weeks and 23 weeks in patients receiving PRALUENT once every 4 weeks with an optional up-titration. Of the 3 pediatric patients who developed ADA, no one tested positive for NAb.
Because of the low occurrence of ADA and the small number of pediatric patients enrolled, the effect of these antibodies on the pharmacokinetics, pharmacodynamics, safety, and/or effectiveness of PRALUENT in pediatric patients is unknown.
Animal Toxicology And/Or Pharmacology
During a 13-week toxicology study of 75 mg/kg once weekly alirocumab in combination with 40 mg/kg once daily atorvastatin in adult monkeys, there were no effects of PRALUENT on the humoral immune response to keyhole limpet hemocyanin (KLH) after one to two months at exposures 100-fold greater than the exposure at the maximum recommended human dose of 150 mg every two weeks, based on AUC.
Clinical Studies
Cardiovascular Outcome Trial In Adult Patients With Established
Cardiovascular Disease
Trial 1 (ODYSSEY OUTCOMES, NTC01663402) was a multicenter, double-blind, placebo-controlled trial in 18,924 adult patients (9,462 PRALUENT; 9,462 placebo) followed for up to 5 years. Patients had an acute coronary syndrome (ACS) event 4 to 52 weeks prior to randomization and were treated with a lipid-modifying therapy (LMT) regimen that was statin-intensive (defined as atorvastatin 40 or 80 mg, or rosuvastatin 20 or 40 mg) or at maximally tolerated dose of a statin, with or without other LMT. Patients were randomized to receive either PRALUENT 75 mg or placebo once every two weeks.
At month 2, if additional LDL-C lowering was required based on pre-specified LDL-C criteria (LDL-C ≥50 mg/dL), PRALUENT was adjusted to 150 mg every 2 weeks. For patients who had their dose adjusted to 150 mg every 2 weeks and who had two consecutive LDL-C values below 25 mg/dL, down-titration from 150 mg every 2 weeks to 75 mg every 2 weeks was performed. Patients on 75 mg every 2 weeks who had two consecutive LDL-C values below 15 mg/dL were switched to placebo in a blinded fashion. Approximately 2615 (27.7%) of 9,451 patients treated with PRALUENT required dose adjustment to 150 mg every 2 weeks. Of these 2,615 patients, 805 (30.8%) were down-titrated to 75 mg every 2 weeks. Overall, 730 (7.7%) of 9,451 patients switched to placebo.
A total of 99.5% of patients were followed for survival until the end of the trial. The median follow-up duration was 33 months.
Baseline Disease And Demographic Characteristics
The mean age at baseline was 59 years (range 39-92), with 25% female, and 27% at least 65 years old. The trial population was 79% White, 3% Black or African American and 13% Asian; 17% identified as Hispanic or Latino ethnicity. The index ACS event was a myocardial infarction in 83% of patients and unstable angina in 17% of patients. Prior to the index ACS event, 19% had prior myocardial infarction and 23% had coronary revascularization procedures (CABG/PCI). Selected additional baseline risk factors included hypertension (65%), diabetes mellitus (25%), New York Heart Association class I or II congestive heart failure (15%), and eGFR <60 mL/min/1.73 m² (13%). Most patients (89%) were receiving statin-intensive therapy with or without other LMT at randomization. The mean LDL-C value at baseline was 92.4 mg/dL.
Endpoint Results
PRALUENT significantly reduced the risk for the primary composite endpoint (time to first occurrence of coronary heart disease death, non-fatal myocardial infarction, fatal and non-fatal ischemic stroke, or unstable angina requiring hospitalization: p=0.0003). The results are presented in Table 2.
Table 2: Cardiovascular Outcomes in Adult Patients with Established Cardiovascular Disease
| Endpoint |
PRALUENT
N=9,462 |
Placebo
N=9,462 |
Hazard Ratio (95% CI)a |
| n (%) |
Incidence Rate per 100 Patient Years (95% CI) |
n (%) |
Incidence Rate per 100 Patient Years (95% CI) |
| Primary composite endpointb |
903 (9.5%) |
3.5 (3.3 to 3.8) |
1052 (11.1%) |
4.2 (3.9 to 4.4) |
0.85 (0.78, 0.93) |
| Components of the Primary Composite Endpointc |
| CHD death |
205 |
0.8 |
222 |
0.8 |
0.92 |
| (2.2%) |
(0.7 to 0.9) |
(2.3%) |
(0.7 to 0.9) |
(0.76, 1.11) |
| Non-fatal MId |
626 |
2.4 |
722 |
2.8 |
0.86 |
| (6.6%) |
(2.2 to 2.6) |
(7.6%) |
(2.6 to 3.0) |
(0.77, 0.96) |
| Fatal or non-fatal ischemic stroked |
111 |
0.4 |
152 |
0.6 |
0.73 |
| (1.2%) |
(0.3 to 0.5) |
(1.6%) |
(0.5 to 0.7) |
(0.57, 0.93) |
| Unstable angina requiring hospitalizationd |
37 |
0.1 |
60 |
0.2 |
0.61 |
| (0.4%) |
(0.1 to 0.2) |
(0.6%) |
(0.2 to 0.3) |
(0.41, 0.92) |
| Mortality Endpoint (not statistically significant per pre-specified method to control for type I error) |
| All-cause mortality |
334 (3.5%) |
1.2 (1.1 to 1.4) |
392 (4.1%) |
1.5 (1.3 to 1.6) |
0.85 (0.73, 0.98) |
a Cox-proportional hazards model with treatment as a factor and stratified by geographic region
b Primary composite endpoint defined as: time to first occurrence of coronary heart disease death, non-fatal myocardial infarction, fatal and non-fatal ischemic stroke, or unstable angina requiring hospitalization
c First occurrence of specified event at any time; patients may have experienced more than one adjudicated event
d Statistical testing performed outside hierarchy; therefore not considered statistically significant |
The Kaplan-Meier estimates of the cumulative incidence of the primary endpoint over time is presented in Figure 1.
Figure 1: Primary Composite Endpoint Cumulative Incidence over 4 Years in ODYSSEY OUTCOMES
Clinical Trials In Adult Patients With Primary Hyperlipidemia (including HeFH) And HoFH
Primary Hyperlipidemia
Trial 2 (ODYSSEY LONG TERM, NCT01507831) was a multicenter, double-blind, placebo-controlled trial that randomly assigned 1,553 adult patients to PRALUENT 150 mg every 2 weeks and 788 adult patients to placebo. All patients were taking maximally tolerated doses of statins with or without other lipid-modifying therapy and required additional LDL-C reduction.
Baseline Disease And Demographic Characteristics
The mean age was 61 years (range 18-89), 38% were female, 93% were White, 3% were Black or African American, and 5% identified as Hispanic or Latino ethnicity. The average LDL-C at baseline was 122 mg/dL.
Endpoint Results
At week 24, the treatment difference between PRALUENT and placebo in mean LDL-C percent change was -58% (95% CI: -61%, -56%; p-value: <0.0001).
The proportion of patients who prematurely discontinued trial drug prior to the 24-week primary endpoint was 8% among those treated with PRALUENT and 8% among those treated with placebo.
For additional results see Table 3 and Figure 2.
Table 3: Mean Percent Change from Baseline and Differencea from Placebo in Lipid Parameters at Week 24 in ODYSSEY LONG TERMb
| Treatment Group |
LDL-C |
Total-C |
Non-HDL-C |
Apo B |
| Week 24 (Mean Percent Change from Baseline) |
| Placebo (n=788) |
1 |
0 |
1 |
1 |
| PRALUENT 150 mg (n=1,553) |
-58 |
-36 |
-49 |
-50 |
| Difference from placebo (LS Mean) (95% CI) |
-58 (-61, -56) |
-36 (-37, -34) |
-50 (-52, -47) |
-51 (-53, -48) |
a Difference is PRALUENT minus Placebo
b A pattern-mixture model approach was used with multiple imputation of missing post-treatment values based on a patient’s own baseline value and multiple imputation of missing on-treatment values based on a model including available on-treatment values |
Figure 2: Mean Percent Change from Baseline in LDL-C Over 52 Weeks in Adult Patients on Maximally Tolerated Statin Treated with PRALUENT 150 mg Every 2 Weeks and Placebo Every 2 Weeks (ODYSSEY LONG TERM)a
a The means were estimated based on all randomized patients, with multiple imputation of missing data taking into account treatment adherence
b Number of patients with observed data
Trial 3 (ODYSSEY COMBO I, NCT01644175) was a multicenter, double-blind, placebo-controlled trial that randomly assigned 209 adult patients to PRALUENT and 107 adult patients to placebo. Patients were taking maximally tolerated doses of statins with or without other lipid-modifying therapy and required additional LDL-C reduction.
Baseline Disease And Demographic Characteristics
The mean age was 63 years (range 39-87), 34% were female, 82% were White, 16% were Black or African American, and 11% were Hispanic or Latino. Mean baseline LDL-C was 102 mg/dL.
Endpoint Results
At week 12, the mean percent change from baseline in LDL-C was -45% with PRALUENT compared to 1% with placebo, and the treatment difference between PRALUENT 75 mg every 2 weeks and placebo in mean LDL-C percent change was -46% (95% CI: -53%, -39%).
At week 12, if additional LDL-C lowering was required based on pre-specified LDL-C criteria, PRALUENT was up-titrated to 150 mg every 2 weeks for the remainder of the trial. The dose was up-titrated to 150 mg every 2 weeks in 32 (17%) of 191 patients treated with PRALUENT for at least 12 weeks. At week 24, the mean percent change from baseline in LDL-C was -44% with PRALUENT and -2% with placebo, and the treatment difference between PRALUENT and placebo in mean LDL-C percent change was -43% (95% CI: -50%, -35%; p-value: <0.0001).
The proportion of patients who prematurely discontinued trial drug prior to the 24-week primary endpoint was 11% among those treated with PRALUENT and 12% among those treated with placebo.
Trials 4 (ODYSSEY FH I, NCT01623115) and 5 (ODYSSEY FH II, NCT01709500) were multicenter, double-blind, placebo-controlled trials that, combined, randomly assigned 490 adult patients to PRALUENT and 245 adult patients to placebo. The trials were similar with regard to both design and eligibility criteria. All patients had HeFH, were taking a maximally tolerated dose of statin with or without other lipid-modifying therapy, and required additional LDL-C reduction. The diagnosis of HeFH was made either by genotyping or clinical criteria (“definite FH” using either the Simon Broome or WHO/Dutch Lipid Network criteria).
Baseline Disease And Demographic Characteristics
The mean age was 52 years (range 20-87), 45% were female, 94% were White, 1% were Black or African American, and 3% identified as Hispanic or Latino ethnicity. The average LDL-C at baseline was 141 mg/dL.
Endpoint Results
At week 12, the treatment difference between PRALUENT 75 mg every 2 weeks and placebo in mean LDL-C percent change was -48% (95% CI: -52%, -44%).
At week 12, if additional LDL-C lowering was required based on pre-specified LDL-C criteria, PRALUENT was up-titrated to 150 mg every 2 weeks for the remainder of the trials. The dose was up-titrated to 150 mg every 2 weeks in 196 (42%) of 469 patients treated with PRALUENT for at least 12 weeks. At week 24, the mean treatment difference between PRALUENT and placebo in mean LDL-C percent change from baseline was -54% (95% CI: -59%, -50%; p-value: <0.0001). The LDL-C-lowering effect was sustained to week 52.
Considering both trials together, the proportion of patients who prematurely discontinued trial drug prior to the 24-week primary endpoint was 6% among those treated with PRALUENT and 4% among those treated with placebo.
For additional results see Table 4 and Figure 3.
Table 4: Mean Percent Change from Baseline and Differencea from Placebo in Lipid Parameters at Week 12 and Week 24 in Adult Patients with HeFH (ODYSSEY FH I and FH II Pooled)b
| Treatment Group |
LDL-C |
Total-C |
Non-HDL-C |
Apo B |
| Week 12 (Mean Percent Change from Baseline) |
| Placebo (n=245) |
5 |
4 |
5 |
2 |
| PRALUENT 75 mg (n=490) |
-43 |
-27 |
-38 |
-34 |
| Difference from placebo (LS Mean) (95% CI) |
-48
(-52, -44) |
-31
(-34, -28) |
-42
(-46, -39) |
-36
(-39, -33) |
| Week 24 (Mean Percent Change from Baseline) |
| Placebo (n=245) |
7 |
5 |
7 |
2 |
| PRALUENT 75 mg/150 mgc (n=490) |
-47 |
-30 |
-42 |
-40 |
| Difference from placebo (LS Mean) (95% CI) |
-54
(-59, -50) |
-36
(-39, -33) |
-49
(-53, -45) |
-42
(-45, -39) |
a Difference is PRALUENT minus Placebo
b A pattern-mixture model approach was used with multiple imputation of missing post-treatment values based on a patient’s own baseline value and multiple imputation of missing on-treatment values based on a model including available on-treatment values
c Dose was up-titrated to 150 mg every 2 weeks in 196 (42%) patients treated for at least 12 weeks |
Figure 3: Mean Percent Change from Baseline in LDL-C Over 52 Weeks in Adult Patients with HeFH on Maximally Tolerated Statin Treated with PRALUENT 75/150 mg Every 2 Weeks and Placebo every 2 weeks (ODYSSEY FH I and FH II Pooled)a
a The means were estimated based on all randomized patients, with multiple imputation of missing data taking into account treatment adherence
b Number of patients with observed data
Trial 6 (ODYSSEY HIGH FH, NCT01617655) was a multicenter, double-blind, placebo-controlled trial that randomly assigned 72 adult patients to PRALUENT 150 mg every 2 weeks and 35 adult patients to placebo. Patients had HeFH with a baseline LDL-C ≥160 mg/dL while taking a maximally tolerated dose of statin with or without other lipid-modifying therapy.
Baseline Disease And Demographic Characteristics
The mean age was 51 years (range 18-80), 47% were female, 88% were White, 2% were Black or African American, and 6% identified as Hispanic or Latino ethnicity. The average LDL-C at baseline was 198 mg/dL.
Endpoint Results
At week 24, the mean percent change from baseline in LDL-C was -43% with PRALUENT and -7% with placebo, and the treatment difference between PRALUENT and placebo in mean LDL-C percent change was -36% (95% CI: -49%, -24%; p-value: <0.0001).
The proportion of patients who discontinued trial drug prior to the 24-week primary endpoint was 10% among those treated with PRALUENT and 0% among those treated with placebo.
Trial 7 (ODYSSEY CHOICE I, NCT01926782) was a multicenter, double-blind, placebo-controlled trial that randomly assigned 458 adult patients with primary hyperlipidemia to PRALUENT 300 mg every 4 weeks, 115 adult patients to PRALUENT 75 mg every 2 weeks, and 230 adult patients to placebo. Patients were stratified based on whether or not they were treated concomitantly with statin.
Baseline Disease And Demographic Characteristics
The mean age was 61 years (range 21-88), 42% were female, 87% were White, 11% were Black or African American, and 3% identified as Hispanic or Latino ethnicity.
Endpoint Results
In the cohort of patients on background statin, the mean LDL-C at baseline was 113 mg/dL. At week 12, the treatment difference between PRALUENT 300 mg every 4 weeks and placebo in mean percent change in LDL-C from baseline was -54% (97.5% CI: -61%, -48%), and the treatment difference between PRALUENT 75 mg every 2 weeks and placebo in mean percent change in LDL-C was -44% (97.5% CI: -53%, -35%) (Figure 4).
Figure 4: Mean Percent Change from Baseline in LDL-C up to Week 12 in Adult Patients on Concomitant Statin Treated with PRALUENT 75 mg Every 2 Weeks, PRALUENT 300 mg Every 4 Weeks or Placeboa
a The means were estimated based on all randomized patients, with multiple imputation of missing data taking into account treatment adherence
At week 12, if additional LDL-C lowering was required based on pre-specified LDL-C criteria, PRALUENT was adjusted to 150 mg every 2 weeks for the remainder of the trial. The dose was adjusted to 150 mg every 2 weeks in approximately 20% of patients treated with PRALUENT 75 mg every 2 weeks or 300 mg every 4 weeks for at least 12 weeks.
At week 24, the treatment difference between initial assignment to PRALUENT 300 mg every 4 weeks and placebo in mean percent change in LDL-C from baseline was -56% (97.5% CI: Â62%, -49%; p-value: <0.0001), and the treatment difference between initial assignment to PRALUENT 75 mg every 2 weeks and placebo in mean percent change in LDL-C from baseline was -48% (97.5% CI: -57%, -39%).
In the cohort of patients not treated with a concomitant statin, the mean LDL-C at baseline was 142 mg/dL. The treatment difference between PRALUENT and placebo were similar to the cohort of patients treated with a concomitant statin.
The proportion of patients who discontinued trial drug prior to the 24-week primary endpoint was 12% among those treated with PRALUENT 300 mg every 4 weeks, 14% among those treated with PRALUENT 75 mg every 2 weeks, and 15% among those treated with placebo.
Trial 8 (ODYSSEY ESCAPE, NCT02326220) was a multicenter, double-blind, placebo-controlled trial that randomly assigned adult patients with HeFH who were undergoing LDL apheresis to PRALUENT 150 mg every 2 weeks (N=41) or placebo (N=21). Patients were treated in combination with their usual LDL apheresis schedule for 6 weeks.
Baseline Disease And Demographic Characteristics
The mean age was 59 years (range 27-79), 42% were female, 97% were White, 3% were Black or African American, and 0% identified as Hispanic or Latino ethnicity. The mean LDL-C at baseline, measured before the apheresis procedure, was 181 mg/dL.
Endpoint Results
At week 6, the mean percent change from baseline in pre-apheresis LDL-C was -53% in patients in the PRALUENT group compared to 1% in patients who received placebo.
The proportion of patients who discontinued study drug prior to the 6-week endpoint was 2% among those treated with PRALUENT 150 mg every 2 weeks and 5% among those treated with placebo.
Trial 9 (ODYSSEY COMBO II, NCT01644188) was a multicenter, double-blind, ezetimibeÂcontrolled trial that randomly assigned 479 adult patients to PRALUENT 75 mg every 2 weeks/150 mg every 2 weeks and 241 adult patients to ezetimibe 10 mg/day. Patients were taking a maximally tolerated dose of a statin and required additional LDL-C reduction.
Baseline Disease And Demographic Characteristics
The mean age was 62 years (range 29-88), 26% were female, 85% were White, 4% were Black or African American, and 3% identified as Hispanic or Latino ethnicity. Mean baseline LDL-C was 107 mg/dL.
Endpoint Results
At week 12, the mean percent change from baseline in LDL-C was -50% with PRALUENT compared to -22% with ezetimibe, and the treatment difference between PRALUENT and ezetimibe in mean LDL-C percent change was -28% (95% CI: -32%, -23%).
At week 12, if additional LDL-C lowering was required based on pre-specified LDL-C criteria, PRALUENT was up-titrated to 150 mg every 2 weeks for the remainder of the trial. The dose was up-titrated to 150 mg every 2 weeks in 82 (18%) of 446 patients treated with PRALUENT for at least 12 weeks. At week 24, the mean percent change from baseline in LDL-C was -48% with PRALUENT and -20% with ezetimibe, and the treatment difference between PRALUENT and ezetimibe in mean LDL-C percent change was -28% (95% CI: -33%, -23%; p-value: <0.0001).
The proportion of patients who prematurely discontinued trial drug prior to the 24-week primary endpoint was 9% among those treated with PRALUENT and 10% among those treated with ezetimibe.
Trial 10 (ODYSSEY MONO, NCT01644474) was a multicenter, double-blind, ezetimibe-controlled trial in adult patients with a moderate CV risk, not taking statins or other lipid-modifying therapies, and a baseline LDL-C between 100 mg/dL to 190 mg/dL that randomly assigned 52 patients to PRALUENT 75 mg every 2 weeks and 51 patients to ezetimibe 10 mg/day.
Baseline Disease And Demographic Characteristics
The mean age was 60 years (range 45-72), 47% were female, 90% were White and 10% were Black or African American, and 1% identified as Hispanic or Latino ethnicity. Mean baseline LDL-C was 140 mg/dL.
Endpoint Results
At week 12, the mean percent change from baseline in LDL-C was -48% with PRALUENT compared to -19% with ezetimibe, and the treatment difference between PRALUENT 75 mg every 2 weeks and ezetimibe in mean LDL-C percent change was -29% (95% CI: -37%, -22%).
At week 12, if additional LDL-C lowering was required based on pre-specified LDL-C criteria, PRALUENT was up-titrated to 150 mg every 2 weeks for the remainder of the trial. The dose was up-titrated to 150 mg every 2 weeks in 14 (30%) of 46 patients treated with PRALUENT for at least 12 weeks. At week 24, the mean percent change from baseline in LDL-C was -45% with PRALUENT and -14% with ezetimibe, and the treatment difference between PRALUENT and ezetimibe in mean LDL-C percent change was -31% (95% CI: -40%, -22%; p-value: <0.0001).
The proportion of patients who prematurely discontinued trial drug prior to the 24-week endpoint was 15% among those treated with PRALUENT and 14% among those treated with ezetimibe.
Adult Patients With HoFH
Trial 11 (ODYSSEY HoFH, NCT03156621) was a multicenter, double-blind, placebo-controlled trial that randomly assigned 45 adult patients to PRALUENT 150 mg every 2 weeks and 24 adult patients to placebo. Patients were taking maximally tolerated doses of statins with or without other lipid-lowering therapy and required additional LDL-C reduction. Randomization was stratified by LDL apheresis treatment status. The diagnosis of HoFH was made by either clinical diagnosis, which included a history of an untreated total cholesterol concentration >500 mg/dL together with either xanthoma before 10 years of age or with a history of total cholesterol >250 mg in both parents, or by genetic testing.
Baseline Disease And Demographic Characteristics
The mean age was 43 years (range 19-81), 51% were female, 78% were White, 3% were Black or African American, 17% were Asian, and 3% identified as Hispanic or Latino ethnicity. Mean baseline LDL-C was 283 mg/dL with 97% on statins, 72% on ezetimibe, and 14% on lomitapide.
Endpoint Results
At week 12, the treatment difference between PRALUENT and placebo in mean LDL-C percent change from baseline was -36% (95% CI: -51% to -20%; p <0.0001) (see Figure 5). For the effect of PRALUENT on lipid parameters as compared to placebo, see Table 5. No patient discontinued from the trial prior to the 12-week primary endpoint.
Patients with two LDL-receptor negative alleles (little to no residual function) had a minimal to absent response to PRALUENT.
Figure 5: LS Mean Percent Change from Baseline in LDL-C Over 12 Weeks in Adult Patients with HoFH (ODYSSEY HoFH)
Table 5: Effect of PRALUENT on Lipid Parameters in Adult Patients with HoFH (LS Mean Percent Change from Baseline to Week 12 in ODYSSEY HoFH)
| Treatment Group |
LDL-C |
Apo B |
Non-HDL-C |
Total Cholesterol |
| Placebo (n=24) |
9 |
7 |
8 |
7 |
| PRALUENT 150 mg every 2 weeks (n=45) |
-27 |
-23 |
-25 |
-20 |
| Difference from placebo (LS Mean) (95% CI) |
-36
(-51, -20) |
-30
(-42, -17) |
-33
(-48, -18) |
-27
(-39, -14) |
Clinical Trials In Pediatric Patients With HeFH
Trial 12 (EFC14643, NCT03510884) was a randomized, multicenter, placebo controlled, double blind, 24 week trial in 153 pediatric patients aged 8 to 17 years with HeFH. Patients were on a low-fat diet and receiving background lipid-lowering therapy.
Patients were randomized in a 2:1 ratio to receive PRALUENT or placebo. In the PRALUENT group dosed every 2 weeks, 49 patients received a dose of 40 mg for body weight less than 50 kg or 75 mg for body weight 50 kg or more. The 40 mg dosage every 2 weeks is not approved [see DOSAGE AND ADMINISTRATION]. In the PRALUENT group dosed every 4 weeks, 52 patients received a dose of 150 mg for body weight less than 50 kg or 300 mg for body weight 50 kg or more. Dose adjustment of PRALUENT to 75 mg every 2 weeks for body weight less than 50 kg or 150 mg every 2 weeks for body weight 50 kg or more occurred at week 12 in patients with LDL-C ≥110 mg/dL.
Baseline Disease And Demographic Characteristics
The diagnosis of HeFH was made based on criteria from Simon Broome Register Group (1991) or by genetic testing. The mean age was 13 years (range: 8 to 17 years); 57% female; 82% White, 2% Black or African American, 10% American Indian or Alaska Native, and <1% not reported; 18% Hispanic/Latino ethnicity. Mean body weight was 53kg. The mean LDL-C at baseline was 174mg/dL; Of the patients receiving PRALUENT once every 2 weeks with an optional up-titration, 99% were on statins and 7% were on ezetimibe at baseline. Of the patients receiving PRALUENT once every 4 weeks with an optional up-titration, 91% were on statins and 20% were on ezetimibe at baseline.
Endpoint Results
At week 24 in the group receiving treatment every 4 weeks, the treatment difference between the PRALUENT and placebo groups in LS mean LDL-C percent change from baseline was -31.4% (97.5% CI: -45.0 to -17.9; p<0.0001) (see Table 6 and Figure 6). For the effect of PRALUENT on lipid parameters as compared to placebo see Table 6.
Figure 6: LDL-C LS Mean Percent Change from Baseline Over Time Through Week 24 in Pediatric Patients (aged 8 to 17 years) with HeFH Treated with PRALUENT Every 4 Weeks or Placeboa
a A pattern-mixture approach was used with multiple imputation of missing post-treatment values based on a patient’s own baseline value and multiple imputation of missing on-treatment values based on a model including available on-treatment values
b Number of patients with observed data
Table 6: Mean Percent Change from Baseline and Difference from Placebo in Lipid Parameters at Week 24 in Pediatric Patients (aged 8 to 17 years)
| Treatment Groupe |
LDL-C |
Apo B |
Non-HDL-C |
Total Cholesterol |
| PRALUENT once every 4 weeks (150 mg for body weight less than 50 kg or 300 mg for body weight 50 kg or more) a |
| LS Mean: Placebo (n=27) |
-5.2 |
-3.3 |
-4.1 |
-4.4 |
| LS Mean: PRALUENT (n=52) |
-36.6 |
-33.0 |
-34.2 |
-26.7 |
| LS Mean Difference from Placebod (97.5% CI) |
-31.4
(-45.0, -17.9) |
-29.7
(-41.1, -18.2) |
-30.1
(-43.0, -17.2) |
-22.3
(-33.0, -11.6) |
| PRALUENT once every 2 weeks (40 mg for body weight less than 50 kg or 75 mg for body weight 50 kg or more)b,c |
| LS Mean: Placebo (n=25) |
9.7 |
10.4 |
9.7 |
7.4 |
| LS Mean: PRALUENT (n=49) |
-31.9 |
-25.7 |
-29.5 |
-22.4 |
| LS Mean Difference from Placebod (97.5% CI) |
-41.7
(-54.2, -29.1) |
-36.2
(-45.8, -26.5) |
-39.2
(-50.6, -27.8) |
-29.8
(-38.7, -21.0) |
a In the PRALUENT group 52 patients received a dose of 150 mg every 4 weeks (body weight less than 50 kg) or 300 mg every 4 weeks (body weight 50 kg or more). At week 12, a total of 15 (28.8%) patients had an automatic blinded dose adjustment to 75 mg every 2 weeks (body weight less than 50 kg) or 150 mg every 2 weeks (body weight 50 kg or more).
b In the PRALUENT group dosed every 2 weeks, 49 patients received a dose of 40 mg for body weight less than 50 kg or 75 mg for body weight 50 kg or more. At week 12, a total of 22 (44.9%) patients had an automatic blinded dose adjustment to 75 mg every 2 weeks (body weight less than 50 kg) or 150 mg every 2 weeks (body weight 50 kg or more).
c The 40 mg dosage every 2 weeks is not approved
d A pattern-mixture approach was used with multiple imputation of missing post-treatment values based on a patient’s own baseline value and multiple imputation of missing on-treatment values based on a model including available on-treatment values
e The percent of missing data was 5% in the every 2 week group and 13% in the every 4 week group |