Long-term efficacy and safety of inotersen in patients with hereditary transthyretin amyloid polyneuropathy with or without cardiomyopathy: post hoc analysis of NEURO-TTR open-label extension
Authors: Whelan C , Coelho T , Conceicao I , Brannagan Iii T H , Wang A K , Polydefkis M J , Dyck P J , Berk J L , Obici L , Kristen A , Narayana A , Olugemo K , Aquino P , Benson M D , Gertz M ,   NEURO-TTR Open-Label Extension Investigators
Published: October 2021

Abstract

Background/Introduction
Cardiomyopathy (CM) with associated heart failure and polyneuropathy (PN) are common manifestations of hereditary transthyretin amyloidosis (ATTRv), a progressive, debilitating, and fatal disease that results from the deposition of misfolded transthyretin (TTR) protein throughout the body. NEURO-TTR (NCT01737398) showed that inotersen, an antisense oligonucleotide inhibitor of TTR protein production, slowed the progression of PN and maintained quality of life in patients with ATTRv.

Purpose
To report efficacy and safety from the open-label extension (OLE) of the NEURO-TTR study in patients with ATTRv PN overall and in CM subgroups.

Methods
Patients who completed NEURO-TTR, enrolled in the OLE (NCT02175004), and either switched from placebo in NEURO-TTR to inotersen in the OLE (placebo-inotersen) or received inotersen in NEURO-TTR and remained on inotersen in the OLE (inotersen-inotersen) were included. Assessments included the modified Neuropathy Impairment Score +7 composite score (mNIS+7 [range –22.3 to 346.3], a measure of neuropathy with higher scores indicative of poorer function), TTR levels, and safety monitoring. Utilizing patients from Europe and North America (EU+NA) as of 28 July 2020, this post hoc analysis examined two subgroups: CM ECHO and severe CM ECHO. CM was defined as a diagnosis of ATTRv CM at study entry or all of the following criteria: a left ventricular wall thickness of ≥1.3 cm on transthoracic echocardiography at baseline, no known history of persistent hypertension (systolic blood pressure ≥150 mm Hg) within 12 months before study screening, and evaluable baseline ECHO obtained by central assessment. Severe CM was defined as an interventricular septum thickness ≥1.5 cm at baseline. Descriptive statistics are reported.

Results
In the overall population and both CM subgroups, the placebo-inotersen group demonstrated slowing of neurological disease progression compared with natural history based on NEURO-TTR placebo projection (estimated natural history will be presented). Furthermore, in the overall population and both CM subgroups, the inotersen-inotersen group demonstrated sustained benefit compared with the placebo-inotersen group (Table). Change in serum TTR levels will be presented. There have been no reports of grade 4 thrombocytopenia or acute glomerulonephritis under enhanced monitoring in patients in the EU+NA despite the increased duration of exposure. No new safety concerns were identified.

Conclusions
Inotersen treatment for &gt;3 years slowed the progression of PN associated with ATTRv in patients with CM, including severe CM. In both subgroups, greater neurological preservation was observed in those who initiated inotersen earlier (inotersen-inotersen group), underscoring the benefits of early treatment. No new safety signals were detected in this OLE analysis; enhanced monitoring is successful in managing the risk for thrombocytopenia and acute glomerulonephritis.

Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): This study was sponsored by Akcea Therapeutics, an affiliate of Ionis Pharmaceuticals, Inc.