Efficacy, Safety, Pharmacokinetics and Pharmacodynamics Study, Assessing Multiple LNP023 Doses in Adult Patients With Paroxysmal Nocturnal Hemoglobinuria

Study Overview
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Brief Summary
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This was a Phase II randomized, open-label, multicenter, efficacy, safety, pharmacokinetic and pharmacodynamic study assessing four iptacopan doses in adult Paroxysmal nocturnal hemoglobinuria (PNH) patients with active hemolysis who were not on eculizumab or any other complement inhibitor less than 3 months prior to first iptacopan dose. Active hemolysis was defined by a lactate dehydrogenase (LDH) value ≥ 1.5 × ULN.

Detailed Description
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LNP023 is a novel oral small molecular weight compound, that inhibits alternative complement pathway (AP). Blockade of the AP with oral LNP023 has the potential to prevent both intra - and extravascular hemolysis. The total study duration from Screening until end of study (EOS) was approximately 28 months. This three-period study included: Screening phase: of up to 8 weeks Period 1: a 4-week treatment period of iptacopan at the first dose in the assigned sequence Period 2: an 8-week treatment period at the second dose in the assigned sequence Period 3: an approximate 2-year treatment extension period for patients who responded to iptacopan treatment Taper down period of 2 weeks was applicable only for patients discontinuing iptacopan treatment (Week 13 for non-responders or Week 109 for responders who did not enter the rollover extension program (REP) (Study CLNP023C12001B / NCT04747613)). During this taper down period, patients were to receive 25 mg qd (once a day) of iptacopan for 7 days, followed by 10 mg qd for 7 additional days. An EOS visit that took place 1 week after the last iptacopan administration for patients not joining the REP. For patients joining the REP, the last treatment visit was the EOS visit. A safety follow-up call 30 days after the last administration of iptacopan was performed for patients not joining the REP. Patients were randomized to Sequence 1 or Sequence 2 in a 1:1 ratio. Sequence 1: Four weeks of treatment with iptacopan 25 mg bid (Twice daily) in Period 1 followed by treatment with 100 mg bid in Period 2 and Period 3. If during Period 1, LDH was not reduced by ≥ 40% from the mean of pretreatment values by Week 2 (Day 15 study visit), the iptacopan dose was to be up-titrated to 100 mg bid (starting from Study Day 17). If LDH was not reduced by ≥ 40% from the mean of pretreatment values at Week 4 (Day 29), the iptacopan dose was to be up-titrated to 200 mg bid in Period 2 and Period 3 (starting from Study Day 30). In the approximate 2-year treatment extension (Period 3), patients maintained the same treatment regimen as used in Period 2. Sequence 2: Four weeks of treatment with iptacopan 50 mg bid in Period 1 followed by treatment with 200 mg bid in Period 2 and Period 3. If during Period 1, LDH was not reduced by ≥ 40% from the mean of pretreatment values by Week 2 (Day 15 study visit), the iptacopan dose was to be up-titrated to 200 mg bid (starting from Study Day 17). In the approximate 2-year treatment extension (Extension Period 3), patients remained on 200 mg bid. No further up-titration was possible

Official Title
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A Multi-center, Randomized, Open-label, Efficacy, Safety, Pharmacokinetics and Pharmacodynamics Study, Assessing Multiple LNP023 Doses in Adult Patients With Paroxysmal Nocturnal Hemoglobinuria and Active Hemolysis

Conditions
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Paroxysmal Nocturnal Hemoglobinuria

Intervention / Treatment
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* Drug: LNP023


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Written informed consent must be obtained before any assessment is performed. Male and female patients at least 18 years old at baseline. Diagnosis of active PNH based on documented clone size of ≥10% by RBCs and/or granulocytes, measured by GPI-deficiency on flow cytometry (screening or medical history data acceptable). LDH values > 1.5 x upper limit of the normal range (ULN) for at least 3 measurements over a maximum of 8 weeks prior to Day 1 (Screening, baseline or medical history data acceptable). Hemoglobin level < 10.5 g/dL at Baseline. For Period 3 of the study, patients who as per judgment of Investigator benefit from LNP023 treatment based on reduced hemolytic parameters as compared to Screening and Baseline. Vaccinations against N. meningitidis, S. pneumoniae and H. influenzae is required at least 4 weeks prior to first dosing with LNP023 (existing vaccinations should provide effective titers at time of LNP023 treatment start). If LNP023 treatment has to start earlier than 4 weeks post vaccination, prophylactic antibiotic treatment must be initiated. Able to communicate well with the investigator, to understand and comply with the requirements of the study. - Exclusion Criteria: Participation in any other investigational drug trial or use of other investigational drugs at the time of enrollment, or within 5 elimination half-lives of enrollment, or within 30 days, whichever is longer; or longer if required by local regulations. Patients treated with eculizumab or any other complement inhibitor less than 3 months prior to study Day 1 Known or suspected hereditary or acquired complement deficiency. History of currently active primary or secondary immunodeficiency. History of splenectomy. History of bone marrow/ hematopoietic stem cell or solid organ transplants (e.g. heart, lung, kidney, liver). Evidence of malignant disease, or malignancies diagnosed within the previous 5 years. Patients with laboratory evidence of bone marrow failure (reticulocytes < 60x10E9/L, or platelets < 50x10E9/L or neutrophils < 1x10E9/L) verified both at screening and baseline. History of recurrent meningitis, history of meningococcal infections despite vaccination, as verified at both screening and baseline. Presence or suspicion (based on judgment of the investigator) of active infection within 2 weeks prior to first dose of LNP023, or history of severe recurrent bacterial infections. A positive HIV, Hepatitis B (HBV) or Hepatitis C (HCV) test result at screening. Patients on immunosuppressive agents such, as but not limited to, cyclosporine, tacrolimus, mycophenolate or mycophenolic acid, cyclophosphamide, methotrexate or IV immunoglobulins, less than 8 weeks prior to first treatment with LNP023, unless on a stable regimen for at least 3 months prior to first LNP023 dose. Systemic corticosteroids unless on a stable dose for at least 4 weeks before randomization. Severe concurrent co-morbidities not amenable to active treatment; e.g., patients with severe kidney disease (CKD stage 4, dialysis), advanced cardiac disease (NYHA class IV), severe pulmonary arterial hypertension (WHO class IV), or unstable thrombotic event, as judged by the investigator, both at screening and baseline (unless baseline was skipped). Any medical condition deemed likely to interfere with the patient's participation in the study, or likely to cause serious adverse events during the study. History of hypersensitivity to the study treatment or its excipients or to drugs of similar chemical classes. Female patients who are pregnant or breastfeeding, or intending to conceive during the course of the study. Women of child-bearing potential, defined as all women physiologically capable of becoming pregnant, unless they are using highly effective methods of contraception during dosing and for 1 week after stopping of investigational drug

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Randomized, open label study
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: LNP023 25 mg bid/100 mg bid<br>Four weeks of treatment with iptacopan 25 mg bid in Period 1 followed by treatment with 100 mg bid in Period 2 and Period 3. | Drug: LNP023<br>* approximately 2 year of Treatment with LNP023<br>* Other names: iptacopan;|
| Experimental: LNP023 50 mg bid/200 mg bid<br>Four weeks of treatment with iptacopan 50 mg bid in Period 1 followed by treatment with 200 mg bid in Period 2 and Period 3. | Drug: LNP023<br>* approximately 2 year of Treatment with LNP023<br>* Other names: iptacopan;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Summary of Lactate Dehydrogenase (LDH) Responders | A responder was defined as a patient with at least 60% reduction in LDH compared to Baseline or LDH below the upper limit of normal at any time up to and including Week 12 for that patient. | Week 2, week 4, week 8 and week 12 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Percent Change From Baseline in LDH Levels | LDH was used as a hemolysis marker to determine the dose-response effect of iptacopan on the reduction of Paroxysmal nocturnal hemoglobinuria (PNH)-associated hemolysis. Active hemolysis is defined by an LDH value ≥ 1.5x upper limit of normal (ULN) Baseline LDH was calculated as the average of the last three screening values prior to randomization. Serum was used to calculate the LDH values | Baseline, week 2, week 4, week 8 and week 12 | 
| Change From Baseline in Hemoglobin | Hemoglobin was used as a hemolysis marker to determine the dose-response effect of iptacopan on the reduction of PNH-associated hemolysis. Whole blood was used to calculate the hemoglobin values. | Baseline, Week 2, week 4, week 8 and week 12 | 
| Change From Baseline in Free Hemoglobin | Free hemoglobin was used as a hemolysis marker to determine the dose-response effect of iptacopan on the reduction of PNH-associated hemolysis. Whole blood was used to calculate the hemoglobin values. | Baseline, Week 2, week 4, week 8 and week 12 | 
| Change From Baseline in Carboxyhemoglobin | Carboxyhemoglobin was used as a marker of intravascular and extravascular hemolysis to assess the effect of iptacopan. Whole blood was used to calculate the carboxyhemoglobin values. | Baseline, Week 2, week 4, week 8 and week 12 | 
| Change From Baseline in Absolute Reticulocyte Count (ARC) | Reticulocyte count was used as a marker of intravascular and extravascular hemolysis to assess the effect of iptacopan. Whole blood was used to calculate the absolute reticulocyte count. | Baseline, week 2, week 4, week 8 and week 12 | 
| Red Blood Cell Count: Change From Baseline in Erythrocytes | Erythrocytes were used as a marker of intravascular and extravascular hemolysis to assess the effect of iptacopan. Whole blood was used to calculate erythrocytes values. | Baseline, week 2, week 4, week 8 and week 12 | 
| Change From Baseline in C3 Fragment Deposition on PNH RBC | C3 fragment deposition on paroxysmal nocturnal hemoglobinuria red blood cell (PNH RBC) was used as a marker of intravascular and extravascular hemolysis to assess the effect of iptacopan. Accumulation of C3 fragments on red blood cells make them prone to phagocytosis causing extravascular hemolysis. Whole blood was used to calculate C3 fragment deposition on PNH RBC values. | Baseline, week 2, week 4, week 8 and week 12 | 
| Mean Haptoglobin Levels | Haptoglobin levels were used as a hemolysis marker to determine the effect of iptacopan on the reduction of PNH-associated hemolysis. Serum was used to calculate haptoglobin levels. | Baseline, week 2, week 4, week 8 and week 12 | 
| Change From Baseline in Total Bilirubin | Bilirubin levels were used as a hemolysis marker to determine the effect of iptacopan on the reduction of PNH-associated hemolysis. Serum was used to calculate bilirubin levels. | Baseline, week 2, week 4, week 8 and week 12 | 
| Mean Platelets Count | Platelet counts were used as a marker of intravascular and extravascular hemolysis to assess the effect of iptacopan. Whole blood was used to calculate platelets count. | Baseline, week 2, week 4, week 8 and week 12 | 
| Mean Ferritin Levels | Ferritin levels were used as a marker of intravascular and extravascular hemolysis to assess the effect of iptacopan. Serum was used to calculate ferritin levels. | Baseline, Week 4, Week 8 and week 12 | 
| Mean Clone Size | PNH clone size was used as a marker of intravascular and extravascular hemolysis to assess the effect of iptacopan. Whole blood was used to calculate clone size values. | Baseline, week 2, week 4, week 8 and week 12 | 
| Pharmacokinetics Profile: Maximum Plasma Concentration (Cmax) | Cmax is the maximum (peak) observed plasma drug concentration after single dose administration (mass x volume-1). PK parameters were determined, using non-compartmental method(s) with Phoenix WinNonlin (Version 8.3), from the plasma concentration-time data. | Day 29 and 57 | 
| Pharmacokinetics Profile: Area Under the Curve Tau (AUCtau) | The AUCtau is the area under the plasma concentration-time curve calculated to the end of a dosing interval (tau) at steady-state (amount x time x volume-1). AUCtau was estimated by imputing the 12-hour iptacopan plasma concentration as the PK profile's corresponding pre-dose (0-hour) value, that is, by assuming that at steady-state the iptacopan plasma concentration is the same as the beginning (pre-dose) and end (12 hours postdose) of the dosing interval. PK parameters were determined, using non-compartmental method(s) with Phoenix WinNonlin (Version 8.3), from the plasma concentration-time data. | Days 29 and 57 | 
| Pharmacokinetics Profile: Minimum Plasma Concentration (Cmin) | Cmin is the lowest plasma concentration observed during a dosing interval at steady state [mass / volume]. PK parameters were determined, using non-compartmental method(s) with Phoenix WinNonlin (Version 8.3), from the plasma concentration-time data. | Days 29 and 57 | 
| Pharmacokinetics Profile: Time to Reach Maximum Plasma Concentration (Tmax) | Tmax is the time to reach maximum (peak) plasma drug concentration after single dose administration (time). PK parameters were determined, using non-compartmental method(s) with Phoenix WinNonlin (Version 8.3), from the plasma concentration-time data. | Days 29 and 57 | 
| Mean Fibrinogen Levels | Fibrinogen level was used as a marker associated with risk of thrombosis. Plasma was used to calculate fibrinogen levels. | Baseline, week 2, week 4, week 8 and week 12 | 
| Mean Prothrombin Time (PT) | Prothrombin time was used as a marker associated with risk of thrombosis. Plasma was used to calculate prothrombin time. | Baseline, week 2, week 4, week 8 and week 12 | 
| Mean Activated Partial Thromboplastin Time (aPTT) | Activated partial thromboplastin time was used as a marker associated with risk of thrombosis. Plasma was used to calculate activated partial thromboplastin time. | Baseline, week 2, week 4, week 8 and week 12 | 
| Mean D-dimer Levels | D-dimer levels were used as a marker associated with risk of thrombosis. Plasma was used to calculate D-dimer levels. | Baseline, week 2, week 4, week 8 and week 12 | 
| Mean Thrombin Clotting Time | thrombin clotting time was used as a marker associated with risk of thrombosis. Plasma was used to calculate thrombin clotting time. | Baseline, Week 4, Week 8 and Week 12 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Complement, alternative pathway, paroxysmal nocturnal hemoglobinuria, hemolysis, LNP023, PNH, LDH, hemoglobin, Iptacopan