Efgartigimod PH20 SC 1000 mg を7 日ごと(q7d)に4 回投与した場合のPD 効果が、efgartigimod 10 mg/kg をq7d で4 回IV 投与した場合のPD 効果に劣らないことを検証する。/ To demonstrate that the PD effect of injections of 1000 mg efgartigimod PH20 SC, administered every 7 days (q7d) for 4 administrations, is noninferior to that of IV infusions of efgartigimod at a dose of 10 mg/kg administered q7d for 4 administrations.
The median age was 53.5 years (range: 19 to 84 years), with more of the participants across both arms in the 18 to <65 years age category (80 [72.7%]). There were more female participants (65 [59.1%]) than male participants. A total of 8 (7.3%) participants met the definition of a Japanese participant.
Overall, most participants had Myasthenia Gravis Foundation of America (MGFA) classification at screening that was Class II-IIb to Class III-IIIa, indicative of a patient population with mild to moderate disease severity. Most participants were AChR-Ab (anti-acetylcholine receptor antibody) seropositive (91 [82.7%] participants), with 45 and 46 participants in the efgartigimod PH20 SC and IV arms, respectively.
The primary objective of this study was to demonstrate that the efgartigimod PH20 SC formulation was noninferior (NI) to the IV formulation using total IgG percent reduction at day 29 based on an NI (noninferior(ity)) margin of 10% in participants with gMG (generalized myasthenia gravis). The primary endpoint was met. Additionally, efgartigimod PH20 SC was NI to efgartigimod IV based on AChR-Ab percent reduction at day 29.
The clinical efficacy of efgartigimod PH20 SC, assessed over time using validated clinical outcome scales including the participant-reported MG-ADL (Myasthenia Gravis Activities of Daily Living) scale and the physician-assessed QMG (Quantitative Myasthenia Gravis) scale, was similar to the clinical efficacy of efgartigimod IV after 1 treatment cycle of 4 weekly administrations.
In both the efgartigimod PH20 SC and efgartigimod IV arms, total IgG reduction was associated with a clinical response in participants with gMG, as measured by the percentage of MG-ADL responders.
ADA (antidrug antibody(ies)) or NAb (neutralizing antibody (ies)) against efgartigimod or antibodies and NAb against rHuPH20 did not have an apparent impact on the PK, PD, clinical efficacy, or safety parameters of efgartigimod.
Both efgartigimod PH20 SC and efgartigimod IV were well tolerated and had a favorable safety profile in participants with gMG, with most AEs being mild to moderate in severity. The overall benefit-risk ratio of efgartigimod PH20 SC in the treatment of participants with gMG was assessed as positive.
Efgartigimod PH20 SC 1000 mg provides an alternative to efgartigimod IV 10 mg/kg, providing patients with gMG treatment optionality and flexibility.
The number of patients or subjects at each stage of the study are as follows:
- The number of eligible patients projected before the study initiation: 14 (Japan), 110 (overall)
- The number of patients who underwent screening for eligibility: 9 (Japan), 159 (overall)
- The number of patients confirmed to be eligible: 9 (Japan), 120 (overall)
- The number of subjects enrolled in the study: 8 (Japan), 111 (overall)
- The number of subjects who completed this study and rolled over to the subsequent ARGX-113-2002 study: 8 (Japan), 109 (overall)
- The number of subjects included in the analysis set: 8 (Japan), 110 (overall)
Both efgartigimod PH20 SC and efgartigimod IV were well tolerated and had a favorable safety profile in participants with gMG, with most AEs being mild to moderate in severity. There were no deaths during the study and no grade 4 AEs were reported. The higher incidence of AEs, in the efgartigimod PH20 SC arm was due to Injection site reactions (defined by the Medical Dictionary for Regulatory Activities high-level term of Injection site reactions). The higher incidence of SAEs, and AEs of NCI CTCAE grade >=3 AEs was due to Myasthenia gravis events. The percentage of participants with AEs leading to treatment interruption and discontinuation was low.
The most commonly reported AEs (>=5% participants) were Headache (14 [12.7%] participants), Injection site rash (8 [7.3%] participants), and Myasthenia gravis and Injection site erythema (7 [6.4%] participants each). Across both arms, most SAEs occurred in 1 (1.8%) participant each. The most commonly reported SAE (>=5% of participants) was Myasthenia gravis, which occurred in 5 (9.1%) participants in the efgartigimod PH20 SC arm and 1 (1.8%) participant in the efgartigimod IV arm. Across both arms, most SAEs of Myasthenia gravis were reported toward the end of the 7-week follow-up period, during which time participants were not receiving efgartigimod. None of the SAEs were considered by the investigator to be related to efgartigimod. One (1.8%) participant in the efgartigimod PH20 SC arm had a related, nonserious grade 2 AE of Injection site rash, which led to IMP (investigational medicinal product) interruption. Two (3.6%) participants in the efgartigimod PH20 SC arm had AEs leading to treatment discontinuation that were unrelated to efgartigimod. One (1.8%) participant had a grade 1 nonserious AE of COVID-19 on day 3 (efgartigimod was discontinued per protocol), and 1 (1.8%) participant had a grade 3 SAE of Myasthenia gravis on day 1. There were no events leading to treatment interruption or discontinuation in the efgartigimod IV arm. In the efgartigimod PH20 SC arm, 21 (38.2%) participants had localized Injection site reactions.
All of the Injection site reactions were grade 1 or 2. None of the events were reported as serious. The events were not treatment-limiting, and none of the events led to treatment discontinuation. The frequency of adverse events of special interest (AESI*) was consistent across the efgartigimod PH20 SC and IV arms. No grade 4 events were reported.
Overall, changes from baseline in the clinical chemistry, hematology, and urinalysis parameters were consistent across the efgartigimod PH20 SC and IV arms. There were no clinically meaningful changes from baseline in vital signs, electrocardiograms, or physical examination findings.
* An AESI is an event of scientific and medical concern specific to the sponsor product or program (eg, an underlying condition being investigated, a mechanism of action/potential immunosuppression). Efgartigimod treatment induces reductions in the IgG levels and there is a potential risk for infections associated with low IgG levels. As such, any infections are considered AESIs in this study.
As a consequence, the following medical information was collected in a standardized way:
-Location of the infection
-Relationship to the underlying condition, medical history, and concomitant medications
-Reoccurrence of previous infection
-Previous rescue therapy
-Any confirmatory procedure, culture, or urgent medical intervention
Primary Endpoint:
The primary PD endpoint was the percent reduction from baseline in total IgG levels at day 29 (i.e. 7 days after the fourth IV or SC administration).
The primary endpoint was met. Total IgG reduction at day 29 in participants with gMG who received efgartigimod PH20 SC 1000 mg was NI to that in participants who received efgartigimod IV 10 mg/kg after 1 treatment cycle of 4 weekly administrations. The least-squares mean difference between the 2 arms (efgartigimod PH20 SC vs efgartigimod IV) was -4.2% (95% CI: -7.73 to -0.66) in favor of efgartigimod PH20 SC. Additionally, AChR-Ab reduction at day 29 in participants with gMG who received efgartigimod PH20 SC 1000 mg was NI to that in participants who received efgartigimod IV 10 mg/kg after 1 treatment cycle of 4 weekly administrations. The least-squares mean difference between the 2 arms (efgartigimod PH20 SC vs efgartigimod IV) was -2.5% (95% CI: -7.45 to 2.41).
Secondary Efficacy Endpoints:
The clinical efficacy of efgartigimod PH20 SC, using validated clinical outcome scales including the participant-reported MG-ADL scale and the physician-assessed QMG scale, was similar to the clinical efficacy of efgartigimod IV after 1 treatment cycle of 4 weekly administrations.
In the overall population (including AChR-Ab seropositive and negative participants), the percentage of MG-ADL responders, based on a reduction of >=2 points from baseline on the MG-ADL score for >=4 consecutive weeks, was the same for participants in the efgartigimod PH20 SC and IV arms (38 [69.1%] participants each). The percentage of MG-ADL responders in the overall population was similar to the percentage of MG-ADL responders in the AChR-Ab seropositive population (71.1% and 71.7% in the efgartigimod PH20 SC and IV arms, respectively). The mean change from baseline in MG-ADL total score over time was similar for participants in the efgartigimod PH20 SC and IV arms. The maximum reduction in MG-ADL total score was at week 4 (1 week after the last injection); the mean change from baseline at week 4 was -5.1 versus -4.7 in the efgartigimod PH20 SC and IV arms, respectively. The mean change from baseline in MG-ADL total score over time for the AChR-Ab seropositive population was similar to the overall population. Similar results were observed in the AChR-Ab seronegative population.
In the overall population, the percentage of QMG responders, based on a reduction of >=3 points from baseline on the QMG score for >=4 consecutive weeks, was 65.5% and 51.9% for participants in the efgartigimod PH20 SC and IV arms, respectively. The percentage of QMG responders for the AChR-Ab seropositive population was similar to the overall population.
Similar results were observed in the AChR-Ab seronegative population.
The maximum reduction in QMG total score was at week 4; the mean QMG change from baseline at week 4 was -6.1 versus -5.2 in the efgartigimod PH20 SC and IV arms, respectively.
The mean change from baseline in QMG total score over time for the AChR-Ab seropositive population was similar to the overall population. Similar results were observed in the AChR-Ab seronegative population
A total of 111 participants were enrolled and randomized: 55 participants in the efgartigimod PH20 SC arm and 56 in the efgartigimod IV arm. Both efgartigimod PH20 SC and efgartigimod IV were well tolerated and had a favorable safety profile in participants with gMG, with most AEs being mild to moderate in severity. The overall benefit-risk ratio of efgartigimod PH20 SC in the treatment of participants with gMG was considered positive.
A Phase 3, Randomized, Open-Label, Parallel-Group Study to Compare the Pharmacodynamics, Pharmacokinetics, Efficacy, Safety, Tolerability, and Immunogenicity of Multiple Subcutaneous Injections of Efgartigimod PH20 SC With Multiple Intravenous Infusions of Efgartigimod in Patients With Generalized Myasthenia Gravis (ADAPT SC)
全身型重症筋無力症患者を対象としたEfgartigimod PH20 SCの第3相試験
A Phase 3 study of Efgartigimod PH20 SC in patient with Generalized Myasthenia Gravis
National Hospital Organization Sendai Medical Center
/
/
千葉大学医学部附属病院
Chiba University Hospital
/
/
独立行政法人国立病院機構 北海道医療センター
National Hospital Organization Hokkaido medical center
/
/
東京医科大学病院
Tokyo Medical University Hospital
/
/
広島大学病院
Hiroshima University Hospital
/
/
東邦大学医療センター大森病院
Toho University Omori Medical Center
2 試験等の目的及び内容並びにこれに用いる医薬品等の概要
(1)試験等の目的及び内容
Efgartigimod PH20 SC 1000 mg を7 日ごと(q7d)に4 回投与した場合のPD 効果が、efgartigimod 10 mg/kg をq7d で4 回IV 投与した場合のPD 効果に劣らないことを検証する。/ To demonstrate that the PD effect of injections of 1000 mg efgartigimod PH20 SC, administered every 7 days (q7d) for 4 administrations, is noninferior to that of IV infusions of efgartigimod at a dose of 10 mg/kg administered q7d for 4 administrations.
3
2021年04月23日
2021年05月12日
2021年03月15日
2022年07月31日
実施予定被験者数 / Sample Size
10
試験等の種類 /
Study Type
介入研究
Interventional
試験等のデザイン
Study Design
無作為化 / allocation
無作為化比較
randomized controlled trial
盲検化 /masking
非盲検
open(masking not used)
対照 / control
実薬(治療)対照
active control
割付け / assignment
並行群間比較
parallel assignment
研究目的 / purpose
治療
treatment purpose
プラセボの有無
なし
盲検の有無
なし
無作為化の有無
あり
保険外併用療養費の有無
あり
実施国(日本以外) /
Countries of Recruitment(Except Japan)
Belgium/Czech Republic/Germany/Hungary/Italy/Netherlands/Poland/Spain/Bosnia and Herzegovina/Georgia/Serbia/Russia/the UK/the US
研究対象者の適格基準 / Key inclusion & exclusion criteria
主たる選択基準 / Inclusion Criteria
1.署名した文書での同意が可能で、同意文書(ICF)及び本治験の治験実施計画書に記載されている要件と制限を遵守する意思及び能力があること
2. ICF への署名の時点で20 歳以上の患者
3. gMG と診断され、以下の少なくとも1 項目に該当すること:
a. 単繊維筋電図検査又は反復神経刺激によって示される異常な神経筋伝達の病歴を有する
b. 塩化エドロホニウム検査陽性の病歴を有する
c. 治療責任医師によって評価された、経口アセチルコリンエステラーゼ(AChE)阻害剤による治療で
gMG 徴候の実証された改善が認められた
4. 米国重症筋無力症財団(MGFA)によるクラスII、III、IVa 又はIVb で定義される臨床基準を満たす患者
1. Must be capable of giving signed informed consent, which includes compliance with the requirements and restrictions listed in the informed consent form (ICF) and in this protocol.
2. At least 20 years of age at the time of signing the ICF.
3. Diagnosed with gMG with confirmed documentation and supported by at least 1 of the following:
a. History of abnormal neuromuscular transmission demonstrated by single fiber electromyography or
repetitive nerve stimulation
b. History of positive edrophonium chloride test
c. Demonstrated improvement in MG signs upon treatment with oral acetylcholinesterase (AChE) inhibitors
as assessed by the treating physician
4. Meeting the clinical criteria as defined by the Myasthenia Gravis Foundation of America (MGFA) class II,
III, IVa, or IVb
主たる除外基準 / Exclusion Criteria
1. 妊娠中及び授乳中の女性、並びに治験期間中及び治験薬の最終投与後90 日間以内に妊娠を希望する女性
2. 以下のいずれかの健康状態に該当する場合:
a. スクリーニング時に臨床的に重要な制御されていない活動性又は慢性の細菌、ウイルス又は真菌感染
がある
b. 重症筋無力症の臨床症状の適正な評価を阻害したり、患者を過度のリスクにさらしたりするその他の
既知の自己免疫疾患があると治験責任(分担)医師が判断した
c. 悪性腫瘍の病歴を有する患者。治験薬の初回投与前3 年間以上にわたって再発を示す所見がなく、適
切な治療によって治癒したとみなされる場合を除く。以下のがん患者は随時登録可能である:
− 適切に治療された皮膚の基底細胞癌又は扁平上皮癌
− 子宮頚部上皮内癌
− 乳房上皮内癌
− 偶発的組織学的所見を示した前立腺癌(TNMステージT1a 又はT1b)
d. その他の重大かつ重篤な疾患の臨床所見を有する患者、大手術を最近受けた、又は治験期間中に受け
る予定がある患者、若しくは治験の結果に影響を及ぼす又は患者を過度のリスクにさらす可能性があ
ると治験責任(分担)医師が判断した患者
1. Are pregnant or lactating, or intend to become pregnant during the study or within 90 days after the last d
ose of IMP.
2. Has any of the following medical conditions:
a. Clinically significant uncontrolled active or chronic bacterial, viral, or fungal infection at screening
b. Any other known autoimmune disease that, in the opinion of the investigator, would interfere with an ac
curate assessment of clinical symptoms of myasthenia gravis or put the participant at undue risk
c. History of malignancy unless deemed cured by adequate treatment with no evidence of reoccurrence f
or >=3 years before the first administration of the IMP. Participants with the following cancers can be
included at any time:
- adequately treated basal cell or squamous cell skin cancer
- carcinoma in situ of the cervix
- carcinoma in situ of the breast
- incidental histological findings of prostate cancer (TNM Classification of Malignant Tumors stage T1a
or T1b).
d. Clinical evidence of other significant serious diseases, or the participant has had a recent major surger
y, or who have any other condition that, in the opinion of the investigator, could confound the results of
the study or put the participant at undue risk.
年齢下限 / Age Minimum
20歳 以上
20age old over
年齢上限 / Age Maximum
上限なし
No limit
性別 / Gender
男性・女性
Both
中止基準
対象疾患名 / Health Condition(s) or Problem(s) Studied
全身型重症筋無力症(gMG)
Generalized Myasthenia Gravis (gMG)
対象疾患コード / Code
対象疾患キーワード / Keyword
介入の有無
あり
介入の内容 / Intervention(s)
週1回のEfgartigimod PH20 SCの皮下投与又はARGX-113の静脈投与
Subcutaneous administration of Efgartigimod PH20 SC or intravenous administration of ARGX-113 once a week