Study of Efficacy and Safety of Twice Daily Oral LNP023 in Adult PNH Patients With Residual Anemia Despite Anti-C5 Antibody Treatment

Paroxysmal Nocturnal Hemoglobinuria (PNH) Clinical Trial

— APPLY-PNH  

Official title:

A Randomized, Multicenter, Active-comparator Controlled, Open-label Trial to Evaluate Efficacy and Safety of Oral, Twice Daily LNP023 in Adult Patients With PNH and Residual Anemia, Despite Treatment With an Intravenous Anti-C5 Antibody.

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT04558918
• Other study ID #: CLNP023C12302
• Secondary ID: 2019-004665-40
• Status: Completed
• Phase: Phase 3
• Start date: January 25, 2021
• Est. completion date: March 6, 2023

Study information

• Verified date: February 2024
• Source: Novartis
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

This study was a multi-center, randomized, open-label, active comparator-controlled, parallel group study.

The purpose of this Phase 3 study in PNH patients presenting with residual anemia despite treatment with anti-C5 antibody, was to determine whether iptacopan is efficacious and safe for the treatment of PNH through demonstration of superiority of iptacopan compared to anti-C5 antibody treatment.

Description:

The study comprised three periods:

• A screening period lasting up to 8 weeks (unless there was a need to extend it for vaccinations required for inclusion, vaccinations were started as early as possible to avoid extension of the screening period)

• A 24-week randomized, open-label, active controlled, treatment period for the primary efficacy and safety analyses. Patients who met the eligibility criteria at screening were stratified based on the type of prior anti-C5 antibody treatment (eculizumab or ravulizumab) and based on the transfusion history as reported during the last 6 months prior to randomization (i.e. transfusion received/not received). Patients were randomized to one of the two treatment groups in an 8:5 ratio to either iptacopan monotherapy at a dose of 200 mg orally b.i.d. or i.v. anti-C5 antibody treatment (patients continued with the same regimen during the randomized treatment period as they were prior to randomization), respectively.

• A 24-week open-label, iptacopan treatment extension period. The patients randomized to the active comparator group were offered to switch to iptacopan on Day 168 (Week 24 visit) and entered the treatment extension period, after receiving a last dose of anti-C5 antibody treatment (eculizumab or ravulizumab). For patients in the comparator group not agreeing to switch treatment, Week 24 visit was the End of Study visit for the trial with no participation in the treatment extension period. For patients agreeing to switch to oral iptacopan, the Extension treatment started on the day after completion of the Week 24 visit. The patients in the iptacopan group who, in the opinion of investigator, benefitted from treatment and were taking iptacopan at Week 24 visit (i.e. did not permanently discontinue study medication), were offered the opportunity to continue oral iptacopan treatment during the treatment extension period.

• Data cut-off date used for the primary results submission was 26- Sep-2022

Recruitment information / eligibility

• Status: Completed
• Enrollment: 97
• Est. completion date: March 6, 2023
• Est. primary completion date: September 26, 2022
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• Male and female participants = 18 years of age with a diagnosis of PNH confirmed by high-sensitivity flow cytometry with clone size = 10%

• Stable regimen of anti-C5 antibody treatment (either eculizumab or ravulizumab) for at least 6 months prior to randomization

• Mean hemoglobin level <10 g/dL

• Vaccination against Neisseria meningitidis infection is required prior to the start of treatment.

• If not received previously, vaccination against Streptococcus pneumoniae and Haemophilus influenzae infections should be given

Exclusion Criteria:

• Participants on a stable eculizumab dose but with a dosing interval of 11 days or less or patients on stable ravulizumab dose but with a dosing interval of less than 8 weeks.

• Known or suspected hereditary complement deficiency at screening

• History of hematopoietic stem cell transplantation

• Patients with laboratory evidence of bone marrow failure (reticulocytes <100x10E9/L; platelets <30x10E9/L; neutrophils <500x10E6/L).

• Active systemic bacterial, viral (incl. COVID-19), or fungal infection within 14 days prior to study drug administration

• A history of recurrent invasive infections caused by encapsulated organisms, e.g. meningococcus or pneumococcus.

• Major concurrent comorbidities including but not limited to severe kidney disease (e.g., eGFR < 30 mL/min/1.73 m2, dialysis), advanced cardiac disease (e.g., NYHA class IV), severe pulmonary disease (e.g., severe pulmonary hypertension (WHO class IV)), or hepatic disease (e.g., active hepatitis) that in the opinion of the investigator precludes participant's participation in the study.

Related Conditions & MeSH terms

• Anemia
• Hemoglobinuria
• Hemoglobinuria, Paroxysmal
• Paroxysmal Nocturnal Hemoglobinuria (PNH)

Intervention

Drug:
• LNP023
Taken Orally b.i.d. Dosage Supplied: 200 mg Dosage form: Hard gelatin capsule Route of Administration: Oral
• Eculizumab
Administered as intravenous infusion every 2 weeks as per the stable regimen, the maintenance dose is a fixed dose. Dosage Supplied: 300 mg/30mL Dosage form: Concentrate solution for infusion
• Ravulizumab
Administered as intravenous infusion every 8 weeks, the maintenance dose is based on body weight. Dosage Supplied: 300 mg/30mL Dosage form: Concentrate solution for infusion

Locations

Country	Name	City	State
Brazil	Novartis Investigative Site	Santo Andre	SP
Brazil	Novartis Investigative Site	Sao Paulo	SP
Czechia	Novartis Investigative Site	Ostrava	Poruba
France	Novartis Investigative Site	Lille
France	Novartis Investigative Site	Paris 10
France	Novartis Investigative Site	Toulouse
Germany	Novartis Investigative Site	Aachen
Germany	Novartis Investigative Site	Essen
Germany	Novartis Investigative Site	Hamburg
Germany	Novartis Investigative Site	Riesa
Germany	Novartis Investigative Site	Ulm
Italy	Novartis Investigative Site	Ascoli Piceno	AP
Italy	Novartis Investigative Site	Avellino	AV
Italy	Novartis Investigative Site	Bassano Del Grappa	VI
Italy	Novartis Investigative Site	Firenze	FI
Italy	Novartis Investigative Site	Milano	MI
Italy	Novartis Investigative Site	Roma	RM
Italy	Novartis Investigative Site	Torino	TO
Japan	Novartis Investigative Site	Fukushima city	Fukushima
Japan	Novartis Investigative Site	Kanazawa-city	Ishikawa
Japan	Novartis Investigative Site	Kyoto
Japan	Novartis Investigative Site	Nagoya	Aichi
Japan	Novartis Investigative Site	Shinjuku-ku	Tokyo
Japan	Novartis Investigative Site	Suita	Osaka
Japan	Novartis Investigative Site	Suwa	Nagano
Korea, Republic of	Novartis Investigative Site	Seoul
Netherlands	Novartis Investigative Site	Nijmegen
Spain	Novartis Investigative Site	Barcelona	Catalunya
Spain	Novartis Investigative Site	San Sebastian	Pais Vasco
Spain	Novartis Investigative Site	Santiago De Compostela	Galicia
Taiwan	Novartis Investigative Site	Hualien
Taiwan	Novartis Investigative Site	Taipei
United Kingdom	Novartis Investigative Site	Leeds
United Kingdom	Novartis Investigative Site	London
United States	Augusta University Georgia Patient Treatment	Augusta	Georgia
United States	Levine Cancer Insitute Carolinas Healthcare System	Charlotte	North Carolina
United States	Cleveland Clinic Foundation Dept.ofTaussigCancer Center	Cleveland	Ohio
United States	City Of Hope National Med Center City of Hope Medical Center	Duarte	California
United States	Univ Cali Irvine ALS Neuromuscular	Orange	California

Sponsors (1)

Lead Sponsor	Collaborator
Novartis Pharmaceuticals

Countries where clinical trial is conducted

United States,  Brazil,  Czechia,  France,  Germany,  Italy,  Japan,  Korea, Republic of,  Netherlands,  Spain,  Taiwan,  United Kingdom, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Other	Change From Baseline in Absolute Reticulocyte Count at Day 336	Change from baseline in absolute reticulocyte count at visit Day 336. Patients randomized to anti-C5 antibody were switched to LNP023 (iptacopan) on Day 169 and were treated until Day 336 (treatment extension period).	Baseline and Day 336
Other	Ratio to Baseline in Log-transformed LDH at Visit Day 336	Average of the Lactate dehydrogenase (LDH) log transformed ratio to baseline at visit Day 336.The log transformation used refers to the natural log (base of e).; Patients randomized to anti-C5 treatment switched to LNP023 (iptacopan) on Day 169 and were treated until Day 336 (treatment extension period).	Baseline and Day 336
Primary	Marginal Proportion (Expressed as Percentages) of Participants With Sustained Increase in Hemoglobin Levels From Baseline of = 2 g/dL in the Absence of Red Blood Cell Transfusions	Sustained increase in hemoglobin levels (responder) is defined as an increase from baseline in hemoglobin levels = 2 g/dL on three out of four measurements taken at the visits occurring in last six weeks (between Day 126 and 168) of the randomized treatment period, without requiring red blood cell (RBC) transfusions between Day 14 and Day 168. Requiring RBC transfusions refers to any patient receiving transfusions or meeting protocol defined criteria (Hemoglobin level = 9 g/dL with signs /and or symptoms of sufficient severity to warrant a transfusion or Hemoglobin of = 7 g/dL, regardless of presence of clinical signs and/or symptoms).; The term 'marginal proportion' can be interpreted as the population average probability of being a responder for each treatment group. These values include adjustment for baseline covariates and missing data has also been taken into account.	Baseline, hemoglobin between Day 126 and Day 168 and absence of transfusions between Day 14 and Day 168
Primary	Marginal Proportion (Expressed as Percentages) of Participants With Sustained Hemoglobin Levels of = 12 g/dL in the Absence of Red Blood Cell Transfusions	Sustained hemoglobin levels (responder) is defined as hemoglobin levels = 12 g/dL on three out of four measurements taken at the visits occurring in last six weeks (between Day 126 and 168) of the randomized treatment period, without requiring red blood cell (RBC) transfusions between Day 14 and Day 168. Requiring RBC transfusions refers to any patient receiving transfusions or meeting protocol defined criteria (Hemoglobin level = 9 g/dL with signs /and or symptoms of sufficient severity to warrant a transfusion or Hemoglobin of = 7 g/dL, regardless of presence of clinical signs and/or symptoms).; The term 'marginal proportion' can be interpreted as the population average probability of being a responder for each treatment group. These values include adjustment for baseline covariates and missing data has also been taken into account.	Hemoglobin between Day 126 and Day 168 and absence of transfusions between Day 14 and Day 168
Primary	Percentage of Patients Meeting Hematological Response Criterion After the Start of LNP023 Treatment	Patients with hematological response are those with = 2g/dL increase in hemoglobin from baseline regardless of transfusions and patients with Hb = 12g/dL regardless of transfusions.; Patients in the LNP023-LNP023 group received iptacopan from Day 1 to Day 336 (48 weeks) while patients in the anti-C5 antibody-LNP023 group received iptacopan from Day 169 to Day 336 (treatment extension period - 24 weeks).	Up to 48 weeks
Primary	Number of Patients Not Requiring RBC Transfusions After the Start of LNP023 Treatment	Requiring RBC transfusions refers to any patient receiving transfusions or meeting protocol defined criteria (Hemoglobin level = 9 g/dL with signs /and or symptoms of sufficient severity to warrant a transfusion or Hemoglobin of = 7 g/dL, regardless of presence of clinical signs and/or symptoms).; Patients randomized to anti-C5 treatment switched to LNP023 (iptacopan) on Day 169 and were treated until Day 336 (treatment extension period).	Up to 48 weeks
Primary	Change From Baseline in Hemoglobin at Visit Day 336	Patients randomized to anti-C5 treatment switched to LNP023 (iptacopan) on Day 169 and were treated until Day 336 (treatment extension period).	Baseline, Day 336
Primary	Change From Baseline in FACIT-Fatigue Questionnaire at Day 336	The FACIT-Fatigue is a 13-item questionnaire with support for its validity and reliability in PNH that assesses patient self-reported fatigue and its impact on daily activities and function. All FACIT scales are scored so that a high score is better. As each of the 13 items of the FACIT-F Scale ranges from 0-4, the range of possible scores is 0-52, with 0 being the worst possible score and 52 the best.; Patients randomized to anti-C5 treatment switched to LNP023 (iptacopan) on Day 169 and were treated until Day 336 (treatment extension period).	Baseline, Day 336
Primary	Adjusted Annualized Clinical BTH Rate After the Start of LNP023 Treatment	This endpoint is considering clinical BTH events after the start of LNP023 treatment. Therefore, results are presented in a single arm on LNP023 since it includes all patients in the Combined Full analysis set.; Adjusted annualized rate of clinical breakthrough hemolysis (BTH) events are from negative binomial model. A patient with multiple occurrences of an event under one treatment is counted only once for that treatment.The breakthrough is defined clinical if either there is a decrease in hemoglobin levels equal to or more than 2 g/dL (compared to the latest assessment, or within 15 days) or if patients present signs or symptoms of gross hemoglobinuria, painful crisis, dysphagia or any other significant clinical PNH-related signs & symptoms, in presence of laboratory evidence of intravascular hemolysis.	Up to 336 Days
Primary	Adjusted Annualized Major Adverse Vascular Events Rate After the Start of LNP023 Treatment	This endpoint is considering clinical BTH events after the start of LNP023 treatment. Therefore, results are presented in a single arm on LNP023 since it includes all patients in the Combined Full analysis set.; Adjusted annualized Major Adverse Vascular Events (MAVEs incl. thrombosis) rate. A MAVE is defined as: acute peripheral vascular occlusion, amputation (non-traumatic; nondiabetic), cerebral arterial occlusion/cerebrovascular accident, cerebral venous occlusion, dermal thrombosis, gangrene (non-traumatic; nondiabetic), hepatic/portal vein thrombosis (Budd-Chiari syndrome), mesenteric/visceral arterial, thrombosis or infarction, mesenteric/visceral vein thrombosis or infarction, myocardial infarction, pulmonary embolus, renal arterial thrombosis, renal vein thrombosis, thrombophlebitis / deep vein thrombosis, transient ischemic attack, unstable angina or other.; A patient with multiple occurrences of an event under one treatment is counted only once for that treatment.	Up to 336 Days
Secondary	Marginal Proportion (Expressed as Percentages) of Participants Who Remain Free From Transfusions	Marginal proportion (expressed as percentages) of participants who did not require transfusions between Day 14 and Day 168. Requiring red blood cell transfusions refers to any patient receiving transfusions or meeting protocol defined criteria (Hemoglobin level = 9 g/dL with signs /and or symptoms of sufficient severity to warrant a transfusion or Hemoglobin of = 7 g/dL, regardless of presence of clinical signs and/or symptoms). The term 'marginal proportion' can be interpreted as the population average probability of being a responder for each treatment group. These values include adjustment for baseline covariates and missing data has also been taken into account.	Between Day 14 and Day 168
Secondary	Change From Baseline in Hemoglobin Between Day 126 and 168	Change from baseline in hemoglobin levels as mean of visits between Day 126 and Day 168.; For this analysis, in order to factor out the effect of transfusions, if a patient had a transfusion during the randomized treatment period, then the hemoglobin values 30 days following the transfusion were excluded and hemoglobin data were imputed.	Baseline and mean of visits between Day 126 and 168
Secondary	Change From Baseline in FACIT-Fatigue Questionnaire in the Randomized Treatment Period	The FACIT-Fatigue is a 13-item questionnaire with support for its validity and reliability in PNH that assesses patient self-reported fatigue and its impact on daily activities and function. All FACIT scales are scored so that a high score is better. As each of the 13 items of the FACIT-F Scale ranges from 0-4, the range of possible scores is 0-52, with 0 being the worst possible score and 52 the best.	Baseline, mean of visits between Day 126 and Day 168
Secondary	Change From Baseline in Absolute Reticulocyte Count in the Randomized Treatment Period	Change from baseline in absolute reticulocyte count as mean of visits between Day 126 and Day 168	Baseline and mean of visits between Day 126 and 168
Secondary	Ratio to Baseline in Log-transformed LDH in the Randomized Treatment Period	Average of the Lactate dehydrogenase (LDH) log transformed ratio to baseline in each treatment estimated between Day 126 and Day 168.The log transformation used refers to the natural log (base of e).	Baseline and mean of visits between Day 126 and 168
Secondary	Adjusted Annualized Clinical BTH Rate in the Randomized Treatment Period	Adjusted annualized rate of clinical breakthrough hemolysis (BTH) events are from negative binomial model.; A patient with multiple occurrences of an event under one treatment is counted only once for that treatment.; The breakthrough is defined clinical if either there is a decrease in hemoglobin levels equal to or more than 2 g/dL (compared to the latest assessment, or within 15 days) or if patients present signs or symptoms of gross hemoglobinuria, painful crisis, dysphagia or any other significant clinical PNH-related signs & symptoms, in presence of laboratory evidence of intravascular hemolysis.	Between Day 1 and Day 168
Secondary	Adjusted Annualized Major Adverse Vascular Events Rate in the Randomized Treatment Period	Adjusted annualized Major Adverse Vascular Events (MAVEs incl. thrombosis) rate. A MAVE is defined as: acute peripheral vascular occlusion, amputation (non-traumatic; nondiabetic), cerebral arterial occlusion/cerebrovascular accident, cerebral venous occlusion, dermal thrombosis, gangrene (non-traumatic; nondiabetic), hepatic/portal vein thrombosis (Budd-Chiari syndrome), mesenteric/visceral arterial, thrombosis or infarction, mesenteric/visceral vein thrombosis or infarction, myocardial infarction, pulmonary embolus, renal arterial thrombosis, renal vein thrombosis, thrombophlebitis / deep vein thrombosis, transient ischemic attack, unstable angina or other.; A patient with multiple occurrences of an event under one treatment is counted only once for that treatment.	Between Day 1 and Day 168

External Links

•   NovCTR-CLNP023C12302_27_Feb_2024_clean.docx attachment has been refreshed from the Clinical Trials Results Word Form template. Data may be populated from the following (as available) : Study (128.0), Protocol (3.139), Results(1.30)