Efficacy and Safety of Anifrolumab Compared to Placebo in Adult Subjects With Active Systemic Lupus Erythematosus

• ClinicalTrials.gov Identifier: NCT02446899
• Recruitment Status: Completed
• First Posted: May 18, 2015
• Results First Posted: March 18, 2020
• Last Update Posted: April 21, 2020
• Sponsor: AstraZeneca
• Collaborator: PRA Health Sciences
• Information provided by (Responsible Party): AstraZeneca

Tracking Information

• First Submitted Date: May 14, 2015
• First Posted Date: May 18, 2015
• Results First Submitted Date: March 5, 2020
• Results First Posted Date: March 18, 2020
• Last Update Posted Date: April 21, 2020
• Actual Study Start Date: July 9, 2015
• Actual Primary Completion Date: September 27, 2018 (Final data collection date for primary outcome measure)

Current Primary Outcome Measures (submitted: April 10, 2020)

Number of Participants Who Achieved the British Isles Lupus Assessment Group Based Composite Lupus Assessment (BICLA) Response at Week 52 [ Time Frame: Baseline; Week 52 ]

Composite endpoint BICLA was defined by meeting all of the following criteria:

• Reduction of all baseline British Isles Lupus Assessment Group (BILAG)-2004 A to B/C/D and baseline BILAG-2004 B to C/D, and no BILAG-2004 worsening in other organ systems, as defined by ≥1 new BILAG-2004 A or ≥2 new BILAG-2004 B
• No worsening from baseline in Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K), where worsening is defined as an increase from baseline of >0 points in SLEDAI-2K
• No worsening from baseline in participants' lupus disease activity, where worsening is defined by an increase ≥0.30 points on a 3-point Physician's Global Assessment (PGA) visual analogue scale (VAS)
• No discontinuation of investigational product
• No use of restricted medications beyond the protocol allowed threshold before assessment

Original Primary Outcome Measures (submitted: May 14, 2015)

To evaluate the effect of anifrolumab compared to placebo on disease activity as measured by the difference in the proportion of subjects who achieve an SLE Responder Index of ≥4 (SRI[4]) at Week 52 [ Time Frame: Week 52 ]

Composite endpoint SRI(4), defined by the following criteria:

• Reduction from baseline of ≥4 points in the SLEDAI-2K and
• No new organ system affected as defined by 1 or more British Isles Lupus Assessment Group (BILAG) 2004 A or 2 or more BILAG-2004 B items compared to baseline using BILAG-2004 and
• No worsening from baseline in subjects' lupus disease activity defined by an increase ≥0.30 points on a 3 point Physician's Global Assessment (PGA) visual analogue scale (VAS) and
• No discontinuation of investigational product or use of restricted medications beyond the protocol allowed threshold before assessment

Current Secondary Outcome Measures (submitted: April 10, 2020)

• Number of Participants Who Achieved the British Isles Lupus Assessment Group Based Composite Lupus Assessment (BICLA) Response at Week 52 in the IFN Test-High Sub-group [ Time Frame: Baseline; Week 52 ]
  Defined by meeting all of the following criteria:

  • Reduction of all baseline British Isles Lupus Assessment Group (BILAG)-2004 A to B/C/D and baseline BILAG-2004 B to C/D, and no BILAG-2004 worsening in other organ systems, as defined by ≥1 new BILAG-2004 A or ≥2 new BILAG-2004 B
  • No worsening from baseline in Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K), where worsening is defined as an increase from baseline to >0 points in SLEDAI-2K
  • No worsening from baseline in participants' lupus disease activity, where worsening is defined by an increase ≥0.30 points on a 3-point Physician's Global Assessment (PGA) visual analogue scale (VAS)
  • No discontinuation of investigational product
  • No use of restricted medications beyond the protocol allowed threshold before assessment
• Number of Participants Who Achieved and Maintained an Oral Corticosteroids (OCS) Dose of ≤7.5 mg/Day at Week 52 in the Sub-Group of Participants With Baseline OCS ≥10 mg/Day [ Time Frame: Week 40; Week 52 ]
  Maintained OCS reduction was defined by meeting all of the following criteria:

  • Achieve an OCS dose of ≤7.5 mg/day prednisone or equivalent by Week 40
  • Maintain an OCS dose ≤7.5 mg/day prednisone or equivalent from Week 40 to Week 52
  • No discontinuation of investigational product
  • No use of restricted medications beyond the protocol allowed threshold before assessment
• Number of Participants With a ≥50% Reduction in Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) Activity Score at Week 12 in The Sub-Group of Participants With Baseline CLASI Activity Score of ≥10 [ Time Frame: Baseline; Week 12 ]
  50% reduction in CLASI activity score compared to baseline was defined by meeting all of the following criteria:

  • Achieve ≥50% reduction of CLASI activity score at Week 12 compared to baseline
  • No discontinuation of investigational product
  • No use of restricted medications beyond the protocol allowed threshold before assessment
• Number of Participants With ≥50% Reduction in Joint Counts at Week 52 in The Sub-group of Participants With ≥6 Swollen and ≥6 Tender Joints at Baseline [ Time Frame: Baseline; Week 52 ]
  50% reduction in the number of swollen and tender joints compared to baseline was defined by meeting all of the following criteria:

  • Achieve ≥50% reduction from baseline in the number of swollen and tender joints, separately
  • No discontinuation of investigational product
  • No use of restricted medications beyond the protocol allowed threshold before assessment
• Annualised Flare Rate Through 52 Weeks [ Time Frame: Baseline to Week 52 ]
  A flare was defined as either 1 or more new British Isle Lupus Assessment Group (BILAG-2004) A or 2 or more new BILAG-2004 B items compared to the previous visit. The occurrence of a new flare was checked for each available visit versus the previous available visit up to Week 52. If no new flares occurred, the number of flares was set to 0. Otherwise all flares were counted leading to the maximum number of flares of 13. The annualized flare rate was calculated as the number of flares divided by the flare exposure time in days multiplied with 365.25 (1 year). The flare exposure time is the time up to Week 52 (date of BILAG-2004 assessment at Week 52) or up to the date of last available BILAG-2004 assessment.
• Number of Participants With One or More Adverse Events (AEs) [ Time Frame: Baseline to end of study (Maximum of 60 weeks) ]
  An AE is the development of an undesirable medical condition or the deterioration of a pre-existing medical condition following or during exposure to a pharmaceutical product, whether or not considered causally related to the product. AEs were collected throughout the duration of the study, from baseline until end of follow-up (a maximum of 12 weeks post last dose [Week 48]), or until Week 52 for participants who enrolled onto the long term extension (LTE). The reported value is inclusive of serious and non-serious AEs.
• Number of Participants With One or More Adverse Events of Special Interest (AESIs) [ Time Frame: Baseline to end of study (Maximum of 60 weeks) ]
  An AESI is an adverse event (AE) of scientific and medical concern specific to understanding biologics. An AESI may be serious or non-serious. AESI are serious infections, including non-opportunistic serious infections, opportunistic infections, anaphylaxis, malignancy, herpes zoster, tuberculosis (TB) (including latent TB), influenza, vasculitis (non-systemic lupus erythematosus [SLE]), and major adverse cardiovascular events (MACE) (including stroke, myocardial infarction [MI], or cardiovascular death). AESIs were collected throughout the study, from baseline until end of follow-up (a maximum of 12 weeks post last dose [Week 48]), or until Week 52 for participants who enrolled onto the long term extension (LTE).
• Number of Participants With a Potentially Clinically Important Change From Baseline in Vital Sign Measurements [ Time Frame: Baseline to end of study (Maximum of 60 weeks) ]
  Vital sign measurements included oral temperature, blood pressure (BP), pulse rate, and respiratory rate. Vital signs were collected throughout the duration of the study, from baseline until end of follow-up (a maximum of 12 weeks post last dose [Week 48]), or until Week 52 for participants who enrolled onto the long term extension (LTE).
• Number of Participants With a Potentially Clinically Important Change From Baseline in Clinical Laboratory Tests [ Time Frame: Baseline to end of study (Maximum of 60 weeks) ]
  Clinical laboratory tests were analyzed in a central clinical laboratory and included hematology, serum chemistry and urinalysis tests. Laboratory values were collected throughout the duration of the study, from baseline until end of follow-up (a maximum of 12 weeks post last dose [Week 48]), or until Week 52 for participants who enrolled onto the long term extension (LTE).

Original Secondary Outcome Measures (submitted: May 14, 2015)

• To evaluate the effect of anifrolumab compared to placebo on the proportion of subjects with SRI(4) at Week 52 in the IFN test-high sub-group [ Time Frame: Week 52 ]
  Composite endpoint SRI(4), defined by the following criteria:

  • Reduction from baseline of ≥4 points in the SLEDAI-2K and
  • No new organ system affected as defined by 1 or more British Isles Lupus Assessment Group (BILAG) 2004 A or 2 or more BILAG-2004 B items compared to baseline using BILAG-2004 and
  • No worsening from baseline in subjects' lupus disease activity defined by an increase ≥0.30 points on a 3 point Physician's Global Assessment (PGA) visual analogue scale (VAS) and
  • No discontinuation of investigational product or use of restricted medications beyond the protocol allowed threshold before assessment
• To evaluate the effect of anifrolumab compared to placebo on the proportion of subjects who achieve an OCS dose ≤7.5 mg/day at Week 40, which is maintained through Week 52 in the sub-group of subjects with baseline OCS ≥10 mg/day [ Time Frame: Week 52 ]
  Maintained OCS reduction defined by the following criteria:

  • Achieve an OCS dose of ≤7.5 mg/day prednisone or equivalent by Week 40 and
  • Maintain an OCS dose ≤7.5 mg/day prednisone or equivalent from Week 40 to Week 52 and
  • No discontinuation of investigational product or use of restricted medications beyond the protocol allowed threshold before assessment
• To evaluate the effect of anifrolumab compared to placebo on the proportion of subjects with a ≥50% reduction in CLASI activity score at Week 12 in the sub-group of subjects with baseline CLASI activity score ≥10 [ Time Frame: Week 12 ]
  50% reduction in CLASI activity score compared to baseline defined by the following criteria:

  • Achieve ≥50% reduction of CLASI activity score at Week 12 compared to baseline and
  • No discontinuation of investigational product or use of restricted medications beyond the protocol allowed threshold before assessment
• To evaluate the effect of anifrolumab compared to placebo on the proportion of subjects with SRI(4) at Week 24 [ Time Frame: Week 24 ]
  Composite endpoint SRI(4), defined by the following criteria:

  • Reduction from baseline of ≥4 points in the SLEDAI-2K and
  • No new organ system affected as defined by 1 or more British Isles Lupus Assessment Group (BILAG) 2004 A or 2 or more BILAG-2004 B items compared to baseline using BILAG-2004 and
  • No worsening from baseline in subjects' lupus disease activity defined by an increase ≥0.30 points on a 3 point Physician's Global Assessment (PGA) visual analogue scale (VAS) and
  • No discontinuation of investigational product or use of restricted medications beyond the protocol allowed threshold before assessment
• To evaluate the effect of anifrolumab compared to placebo on the annualised flare rate through 52 weeks [ Time Frame: Week 0- 52 ]
  Annualised flare rate with flare defined as either 1 or more new BILAG 2004 A or 2 or more new BILAG 2004 B items compared to the previous visit
• To evaluate the safety and tolerability of anifrolumab [ Time Frame: Week 0-52 ]
  Adverse events (AEs) (including adverse events of special interest [AESIs]), vital signs, physical examination, 12-lead electrocardiograms, modified SLEDAI Flare Index based flares, clinical laboratory tests (haematology, clinical chemistry, urinalysis), Columbia Suicide Severity Rating Scale, and Personal Health Questionnaire Depression Scale-8

• Current Other Pre-specified Outcome Measures: Not Provided
• Original Other Pre-specified Outcome Measures: Not Provided

Descriptive Information

• Brief Title: Efficacy and Safety of Anifrolumab Compared to Placebo in Adult Subjects With Active Systemic Lupus Erythematosus
• Official Title: A Multicentre, Randomised, Double-blind, Placebo-controlled, Phase 3 Study Evaluating the Efficacy and Safety of Anifrolumab in Adult Subjects With Active Systemic Lupus Erythematosus
• Brief Summary: The purpose of this study is to evaluate the efficacy and safety of an intravenous treatment regimen of anifrolumab versus placebo in adult participants with moderately to severely active, autoantibody-positive systemic lupus erythematosus (SLE).

Detailed Description

This is a Phase 3, multicentre, multinational, randomised, double-blind, placebo-controlled study to evaluate the efficacy and safety of an intravenous treatment regimen of anifrolumab versus placebo in participants with moderately to severely active, autoantibody-positive systemic lupus erythematosus (SLE) while receiving standard of care (SOC) treatment. Participants must be taking either 1 or any combination of the following: oral corticosteroids (OCS), antimalarial, and/or immunosuppressants. The study will be performed in adult participants aged 18 to 70 years of age.

Approximately 360 participants receiving SOC treatment will be randomised in a 1:1 ratio to receive a fixed intravenous dose of anifrolumab 300 mg or placebo every 4 weeks for a total of 13 doses (Week 0 to Week 48), with the primary endpoint evaluated at the Week 52 visit. Investigational product will be administered as an intravenous infusion (IV) via an infusion pump over a minimum of 30 minutes, every 4 weeks.

• Study Type: Interventional
• Study Phase: Phase 3
• Study Design: Allocation: Randomized; Intervention Model: Parallel Assignment; Masking: Double (Participant, Investigator); Primary Purpose: Treatment
• Condition: Active Systemic Lupus Erythematosus

Intervention

• Biological: Anifrolumab
  Intravenous infusion (IV)
• Drug: Placebo
  Intravenous infusion (IV)

Study Arms

• Experimental: Anifrolumab
  Anifrolumab 300 mg intravenous infusion (IV) administered every 4 weeks for a total of 13 doses.
  Intervention: Biological: Anifrolumab
• Placebo Comparator: Placebo
  Placebo intravenous infusion (IV) administered every 4 weeks for a total of 13 doses.
  Intervention: Drug: Placebo

Publications *

• Bruce IN, Furie RA, Morand EF, Manzi S, Tanaka Y, Kalunian KC, Merrill JT, Puzio P, Maho E, Kleoudis C, Albulescu M, Hultquist M, Tummala R. Concordance and discordance in SLE clinical trial outcome measures: analysis of three anifrolumab phase 2/3 trials. Ann Rheum Dis. 2022 Jul;81(7):962-969. doi: 10.1136/annrheumdis-2021-221847. Epub 2022 May 17.
• Vital EM, Merrill JT, Morand EF, Furie RA, Bruce IN, Tanaka Y, Manzi S, Kalunian KC, Kalyani RN, Streicher K, Abreu G, Tummala R. Anifrolumab efficacy and safety by type I interferon gene signature and clinical subgroups in patients with SLE: post hoc analysis of pooled data from two phase III trials. Ann Rheum Dis. 2022 Jul;81(7):951-961. doi: 10.1136/annrheumdis-2021-221425. Epub 2022 Mar 25.
• Loncharich MF, Anderson CW. Interferon Inhibition for Lupus with Anifrolumab: Critical Appraisal of the Evidence Leading to FDA Approval. ACR Open Rheumatol. 2022 Jun;4(6):486-491. doi: 10.1002/acr2.11414. Epub 2022 Feb 14.
• Chia YL, Zhang J, Tummala R, Rouse T, Furie RA, Morand EF. Relationship of anifrolumab pharmacokinetics with efficacy and safety in patients with systemic lupus erythematosus. Rheumatology (Oxford). 2022 May 5;61(5):1900-1910. doi: 10.1093/rheumatology/keab704.
• Furie R, Morand EF, Askanase AD, Vital EM, Merrill JT, Kalyani RN, Abreu G, Pineda L, Tummala R. Anifrolumab reduces flare rates in patients with moderate to severe systemic lupus erythematosus. Lupus. 2021 Jul;30(8):1254-1263. doi: 10.1177/09612033211014267. Epub 2021 May 12.
• Furie R, Morand EF, Bruce IN, Isenberg D, van Vollenhoven R, Abreu G, Pineda L, Tummala R. What Does It Mean to Be a British Isles Lupus Assessment Group-Based Composite Lupus Assessment Responder? Post Hoc Analysis of Two Phase III Trials. Arthritis Rheumatol. 2021 Nov;73(11):2059-2068. doi: 10.1002/art.41778. Epub 2021 Sep 22.
• Hannon CW, McCourt C, Lima HC, Chen S, Bennett C. Interventions for cutaneous disease in systemic lupus erythematosus. Cochrane Database Syst Rev. 2021 Mar 9;3:CD007478. doi: 10.1002/14651858.CD007478.pub2.
• Morand EF, Furie R, Tanaka Y, Bruce IN, Askanase AD, Richez C, Bae SC, Brohawn PZ, Pineda L, Berglind A, Tummala R; TULIP-2 Trial Investigators. Trial of Anifrolumab in Active Systemic Lupus Erythematosus. N Engl J Med. 2020 Jan 16;382(3):211-221. doi: 10.1056/NEJMoa1912196. Epub 2019 Dec 18.

Recruitment Information

• Recruitment Status: Completed
• Actual Enrollment (submitted: December 20, 2017): 373
• Original Estimated Enrollment (submitted: May 14, 2015): 360
• Actual Study Completion Date: September 27, 2018
• Actual Primary Completion Date: September 27, 2018 (Final data collection date for primary outcome measure)

Eligibility Criteria

Inclusion Criteria:

1. Aged 18 through 70 years at the time of screening
2. Diagnosis of paediatric or adult SLE with a diagnosis of SLE according to the ACR 1982 revised criteria ≥24 weeks prior to signing the Informed Consent form (ICF)

3. Currently receiving at least 1 of the following:

   1. Where prednisone is the single standard of care medication (ie, the subject is not concurrently receiving any medication listed in inclusion criterion 3(c)), a dose of oral prednisone ≥7.5 mg/day but ≤40 mg/day (or prednisone equivalent) for a minimum of 8 weeks prior to Day 1. In addition, the dose of oral prednisone or prednisone equivalent the subject is taking must be stable for a minimum of 2 weeks prior to randomisation
   2. Where prednisone is not the single standard of care medication (ie, the subject is concurrently receiving at least one medication listed in inclusion criterion 3(c), a dose of oral prednisone (≤40 mg/day) (or prednisone equivalent) for a minimum of 2 weeks prior to signing of the ICF. In addition, the dose of oral prednisone or prednisone equivalent the subject is taking must be stable for a minimum of 2 weeks prior to randomisation.
   3. Any of the following medications administered for a minimum of 12 weeks prior to signing the informed consent, and at a stable dose for a minimum of 8 weeks prior to signing the informed consent and through Day 1:

   (i) Azathioprine ≤200 mg/day (ii) Antimalarial (eg, chloroquine, hydroxychloroquine, quinacrine) (iii) Mycophenolate mofetil ≤2 g/day or mycophenolic acid ≤1.44 g/day (iv) Oral, subcutaneous (SC), or intramuscular methotrexate ≤25 mg/week (v) Mizoribine ≤150 mg/day

4. Fulfils at least 4 of the 11 ACR modified 1982 classification criteria for SLE, at least 1 of which must be:

   1. Positive antinuclear antibody (ANA) test at screening by immunofluorescent assay (IFA) at the central laboratory with titre ≥1:80; OR
   2. Anti-dsDNA antibodies at screening elevated to above normal (including indeterminate), as per the central laboratory; OR
   3. Anti-Smith (anti-Sm) antibody at screening elevated to above normal as per the central laboratory

5. At Screening, Disease Activity Adjudication Group confirmation of:

   SLEDAI-2K Criteria: SLEDAI-2K score ≥6 points and "Clinical" SLEDAI-2K score ≥4 points. The "Clinical" SLEDAI-2K is the SLEDAI-2K assessment score without the inclusion of points attributable to any urine or laboratory results including immunologic measures.

6. Must not have active or latent TB on either chest radiograph or by quantiferon gold test
7. Day 1 "Clinical" SLEDAI-2K score ≥4 points
8. OCS dose stable for at least 2 weeks prior to randomisation
9. Stable SLE SOC treatment at the time of randomisation
10. Women of child-bearing potential must have a negative serum β-hCG test at and negative urine pregnancy test at randomisation prior to administration of investigational product

Exclusion Criteria:

1. Receipt of any investigational product (small molecule or biologic agent) within 4 weeks or 5 half-lives prior to signing of the ICF, whichever is greater

2. Receipt of any of the following:

   (a) Intra-articular, intramuscular or IV glucocorticosteroids within 6 weeks prior to Day 1

3. History of, or current diagnosis of, a clinically significant non SLE-related vasculitis syndrome.
4. Active severe or unstable neuropsychiatric SLE
5. Active severe SLE-driven renal disease
6. Diagnosis (within 1 year of signing the ICF) of mixed connective tissue disease or any history of overlap syndromes of SLE or SSc.
7. History of, or current, inflammatory joint or skin disease other than SLE
8. History of any non-SLE disease that has required treatment with oral or parenteral corticosteroids for more than 2 weeks within the last 24 weeks prior to signing the ICF
9. 26.27. Known history of a primary immunodeficiency, splenectomy, or any underlying condition that predisposes the subject to infection, or a positive result for human immunodeficiency virus (HIV) infection confirmed by central laboratory at screening. Subjects refusing HIV testing during the screening period will not be eligible for study participation
10. Confirmed positive test for hepatitis B or hepatitis C
11. Any severe herpes infection at any time prior to Week 0 (Day 1)
12. Opportunistic infection requiring hospitalisation or intravenous antimicrobial treatment within 3 years prior to randomization

13. History of cancer, apart from:

    1. Squamous or basal cell carcinoma of the skin that has been successfully treated
    2. Cervical cancer in situ that has been successfully treated

Sex/Gender

• Sexes Eligible for Study: All

• Ages: 18 Years to 70 Years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Contacts: Contact information is only displayed when the study is recruiting subjects
• Listed Location Countries: Argentina, Belgium, Brazil, Bulgaria, Canada, France, Germany, Japan, Korea, Republic of, Lithuania, Mexico, Russian Federation, South Africa, Spain, United States
• Removed Location Countries: Czech Republic, Czechia, Singapore

Administrative Information

• NCT Number: NCT02446899
• Other Study ID Numbers: D3461C00004
• Has Data Monitoring Committee: Yes

U.S. FDA-regulated Product

• Studies a U.S. FDA-regulated Drug Product: Yes
• Studies a U.S. FDA-regulated Device Product: No

• IPD Sharing Statement: Not Provided
• Current Responsible Party: AstraZeneca
• Original Responsible Party: Same as current
• Current Study Sponsor: AstraZeneca
• Original Study Sponsor: Same as current
• Collaborators: PRA Health Sciences

Investigators

• Study Director: Lilia Pineda, MD; Medical Science Director

• PRS Account: AstraZeneca
• Verification Date: April 2020