Long-term treatment with recombinant human pentraxin 2 protein in patients with idiopathic pulmonary fibrosis: an open-label extension study

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Long-term treatment with recombinant human pentraxin 2 protein in patients with idiopathic pulmonary fibrosis: an open-label extension study Ganesh Raghu, Bernt van den Blink, Mark J Hamblin, A Whitney Brown, Jeffrey A Golden, Lawrence A Ho, Marlies S Wijsenbeek, Martina Vasakova, Alberto Pesci, Danielle E Antin-Ozerkis, Keith C Meyer, Michael Kreuter, Donna Moran, Hugues Santin-Janin, Francois Aubin, Geert-Jan Mulder, Renu Gupta, Luca Richeldi

Summary

Background Patients with idiopathic pulmonary fibrosis (IPF) treated with PRM-151, a recombinant human pentraxin 2 protein, in a phase 2 double-blind, randomised controlled trial had significantly reduced decline in percentage of predicted forced vital capacity (FVC) and stabilised 6-min walking distance compared with placebo over a 28-week period. Here we report the 76-week results of an open-label extension study. Methods Patients who completed the 28-week double-blind period of the PRM-151-202 trial were eligible to participate in the open-label extension study. Patients previously enrolled in the PRM-151 group continued this treatment and those previously in the placebo group crossed over to PRM-151. All patients received PRM-151 in 28-week cycles with loading doses of 10 mg/kg by 60 min intravenous infusions on days 1, 3, and 5 in the first week of each cycle followed by one infusion of 10 mg/kg every 4 weeks. The primary objective of the open-label extension study was to assess the long-term safety and tolerability of PRM-151, which were assessed by analysing adverse events (AEs) up to week 76 in all patients who received at least one dose of PRM-151 during the open-label extension study. Exploratory efficacy analyses were done by assessing changes from baseline in percentage of predicted FVC and 6-min walking distance, with descriptive statistics to week 76 and with random-intercept mixed models to week 52. This study is registered with ClinicalTrials.gov, number NCT02550873, and with EudraCT, number 2014-004782-24. Findings Of 116 patients who completed the double-blind treatment period, 111 entered the open-label extension study (74 from the PRM-151 group and 37 from the placebo group). 84 (76%) of 111 patients received concomitant IPF therapy (pirfenidone n=55 or nintedanib n=29). AEs were consistent with long-term IPF sequelae. 31 (28%) patients had serious AEs. Those occurring in two or more patients were pneumonia (six [5%] of 111), IPF exacerbation (four [4%]), IPF progression (four [4%]), and chest pain (two [2%]). 21 (19%) patients had severe AEs, of which IPF exacerbation and IPF progression each occurred in two (2%) patients. Two (2%) patients experienced life-threatening AEs (one had pneumonia and one had small-cell lung cancer extensive stage). A persistent treatment effect was observed for PRM-151 in patients who continued treatment, with a decline in percentage of predicted FVC of −3∙6% per year and in 6-min walking distance of −10∙5 m per year at week 52. In patients who started PRM-151 during the open-label extension study, compared with the slopes for placebo, decline reduced for percentage of predicted FVC (from −8∙7% per year in weeks 0–28 to −0∙9% per year in weeks 28–52, p<0∙0001) and 6-min walking distance (from −54∙9 m per year to −3∙5 m per year, p=0∙0224). Interpretation Long-term treatment with PRM-151 was well tolerated and the effects on percentage of predicted FVC and 6-min walking distance were persistent on continuation and positive in patients who crossed over from placebo. These findings support further study of PRM-151 in larger populations of patients with IPF. Funding Promedior. Copyright © 2019 Elsevier Ltd. All rights reserved.

Introduction Idiopathic pulmonary fibrosis (IPF) is a serious and progressive disease. Patients with IPF have irreversible loss of lung function, diminished functional capacity, and a poor prognosis.1 The median survival is 2–5 years.2,3 Currently, pirfenidone and nintedanib are the only approved IPF therapies, but neither stops disease progression or improves any objective measures of disease or functional status.4,5 Although improving www.thelancet.com/respiratory Vol 7 August 2019

quality of life and survival are worthwhile goals in patients with IPF, the unmet needs of halting the underlying disease process and maintaining the patient’s functional status are most important. PRM-151 is a recombinant human pentraxin 2 protein that significantly decreased the rate of decline in percentage of predicted forced vital capacity ([FVC] absolute effect size 2∙3%) and stabilised 6-min walking distance (effect size 31∙3 m) after 28 weeks of treatment

Lancet Respir Med 2019; 7: 657–64 Published Online May 20, 2019 http://dx.doi.org/10.1016/ S2213-2600(19)30172-9 See Comment page 640 Center for Interstitial Lung Diseases, Department of Medicine and Laboratory Medicine, University of Washington, Seattle, WA, USA (Prof G Raghu MD, L A Ho MD); Promedior, Lexington, MA, USA (B van den Blink MD, D Moran BS, G-J Mulder MD, R Gupta MD); Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, KS, USA (M J Hamblin MD); Inova Fairfax Hospital, Falls Church, VA, USA (A W Brown MD); Department of Medicine, University of California, San Francisco, San Francisco, CA, USA (Prof J A Golden MD); Department of Respiratory Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands (M S Wijsenbeek MD); Department of Respiratory Medicine, First Faculty of Medicine of Charles University and Thomayer Hospital, Prague, Czech Republic (M Vasakova MD); School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy (A Pesci MD); Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT, USA (D E Antin-Ozerkis MD); Department of Medicine, Division of Pulmonary and Critical Care, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA (K C Meyer MD); Center for Interstitial and Rare Lung Diseases, Thoraxklinik, University of Heidelberg and German Center for Lung Research, Heidelberg, Germany

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(M Kreuter, MD); Venn Life Sciences, Paris, France (H Santin-Janin PhD, F Aubin MD); and Fondazione Policlinico Universitario A Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy (Prof L Richeldi MD) Correspondence to: Prof Ganesh Raghu, Center for Interstitial Lung Diseases, University of Washington Medical Center, Campus Box 356175, Seattle, WA 98195, USA [email protected]

Research in context Evidence before this study In the phase 2 double-blind randomised trial PRM-151-202, patients with idiopathic pulmonary fibrosis (IPF) treated with PRM-151, a recombinant human pentraxin 2 protein, had a significantly decreased rate of decline in percentage of predicted forced vital capacity (FVC) and stable 6-min walking distance from baseline to week 28 compared with those receiving placebo. The adverse events were primarily limited to symptoms common in patients with IPF. We searched PubMed for all articles published up to Feb 25, 2019, assessing pentraxin 2 treatment of patients with IPF with the search terms “pentraxin 2” and “idiopathic pulmonary fibrosis.” Before PRM-151-202, phase 1 studies assessing PRM-151 described the pharmacokinetics of the study drug and established its safety and tolerability profile. Patients who completed the phase 2 portion of the study were eligible to participate in an open-label extension study to assess the long-term safety and efficacy of PRM-151.

compared with placebo in a phase 2 double-blind randomised controlled trial (PRM-151-202).6 A difference of 24–45 m in the 6-min walking test is clinically important in patients with IPF,7 and loss of more than 25 m over 24 weeks is an independent predictor of 1-year all-cause mortality.8 The observed effect of PRM-151 on the 6-min walking distance was novel and encouraging because this was the first clinical trial in the past 25 years to have shown stabilisation of patients’ functional status.9 Patients who completed the PRM-151-202 phase 2 study were eligible to participate in an open-label extension study to assess long-term safety and efficacy of PRM-151. Here we present an analysis of the safety and efficacy with up to 76 weeks of treatment with PRM-151.

Methods

Study design and patients PRM-151-202 was a randomised, double-blind, placebocontrolled phase 2 trial assessing the safety and efficacy of 24 weeks of treatment with PRM-151 in adult patients with IPF. Details of the trial design and primary outcomes have been described previously.6 Briefly, eligible patients were aged 40–80 years with a diagnosis of IPF according to the 2011 American Thoracic Society/ European Respiratory Society/Japanese Respiratory Society/Latin American Thoracic Association criteria.10 Other inclusions criteria were FVC of at least 50% and no more than 90% of predicted, diffusing capacity for carbon monoxide of at least 25% and no more than 90% of predicted, minimum 6-min walking distance of 150 m, and an FEV₁/FVC ratio greater than 0∙70. All patients who completed 24 weeks of treatment and attended a follow-up visit at week 28 without rapid disease progression or discontinuation of study treatment due to toxic effects (as assessed by investigators) were eligible to 658

Added value of this study In this analysis at 76 weeks in the ongoing open-label extension study of PRM-151 treatment, no new adverse events were seen. The adverse events that did occur were consistent with those previously reported and were mostly symptoms and complications of IPF. The effects of PRM-151 on the percentage of predicted FVC and 6-min walking distance were consistent with those seen in the first 28 weeks of treatment. Favourable effects were also seen in patients who started PRM-151 during the open-label extension study. Implications of all the available evidence Long-term assessment suggests that PRM-151 is safe and well tolerated and slows the rate of decline in patients with IPF. These findings support further study of PRM-151 in larger populations with IPF.

continue in an open-label extension study up to week 128. Patients who had been randomly assigned PRM-151 continued this treatment, and those previously assigned placebo crossed over to PRM-151. All patients received PRM-151 in 28-week cycles. In week 1 of each cycle, patients received loading doses of 10 mg/kg PRM-151 as 60 min intravenous infusions on days 1, 3, and 5, followed by one infusion of 10 mg/kg every 4 weeks (figure 1). From the start of the open-label extension study patients could begin, restart, or switch between IPF treatment with pirfenidone or nintedanib, although they were not allowed to use both drugs simultaneously. Adherence to treatment was evaluated by comparing the number of infusions administered with the number intended up to week 76 or study discontinuation. The trial was done in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. The protocol was reviewed and approved by the institutional review board or ethics committee at each participating site before the study. Written informed consent was obtained from each patient or caregiver as appropriate before screening except in two sites where consent was given separately at the start of the phase 2 trial and of the open-label extension study.

Safety and efficacy assessments Safety was assessed by analysing adverse events (AEs) reported during the open-label extension period to week 76. Efficacy was assessed every 4 weeks up to week 52 and then every 12 weeks thereafter to week 76 by measurement of percentage of predicted FVC, FVC, and 6-min walking distance.

Statistical analysis The primary objective of the open-label extension study was to assess the long-term safety of PRM-151. Safety www.thelancet.com/respiratory Vol 7 August 2019

Articles

Open-label extension study

Double-blind trial Patient randomisation*

10 mg/kg PRM-151 by 60 min IV infusion

Follow-up visit

PRM-151 10 mg/kg by 60 min IV infusion

Placebo by 60 min IV infusion

W1

W4

W8

W12 W16 W20 W24

W28

W32

Loading doses on days 1, 3, and 5 of week 1 then one infusion every 4 weeks for 24 weeks

W36

W40

W44 W48

W52

W56

W60 W64 W68

W72

W76

28-week cycles with loading doses on days 1, 3, and 5 of week 1 followed by one infusion every 4 weeks. Safety assessed every visit, efficacy assessed every 4 weeks to week 52 and every 12 weeks thereafter

Treatment dosing

Figure 1: Study design IV=intravenous. W=week. *Randomisation was 2:1 in favour of PRM-151.

analyses were done in patients who had received at least one dose of PRM-151 during the open-label extension study period. Efficacy analyses were exploratory and were assessed by descriptive statistics for observed values of percentage of predicted FVC, FVC, and 6-min walking distance reported at follow-up visits up to week 76 for all patients who had received at least one dose of study drug or placebo from the phase 2 baseline (all-treated set). Changes in percentage of predicted FVC, FVC, and 6-min walking distance over time were analysed with three linear mixed models with random intercepts for all patients in the all-treated set up to week 52 (ie, based on data collected every 4 weeks). Model 1 allowed only for a linear trend in both treatment groups and was fitted with raw values reported at each timepoint from week 4 to week 52 and included response variable (outcome) and baseline score, stratum (by concurrent IPF treatment status), treatment, time (continuous variable calculated as the actual number of days since baseline), and treatment by time interaction as explanatory variables.6 Model 2 evaluated the benefit of starting PRM-151 in the open-label extension study and allowed for a change in slope at week 28 (piecewise regression) in the placebo crossover group. Model 3 allowed for a change in slope at week 28 in all patients in the open-label extension study. All models were fitted and compared with the Akaike information criterion11 and are reported as least squares means with 95% CIs. Further details of model descriptions and selection are provided in the appendix. To inform the design of longer-term studies of PRM-151 (eg, 1 year), we derived estimates of the annual rates of decline in percentage of predicted FVC, FVC, and 6-min walking distance for the all-treated set from the most parsimonious model. Significance was determined using a two-sided type I error rate of 0·05. Patients were analysed by study treatment received during the double-blind portion of the study. SAS version 9∙4 was used for all statistical analyses. This study is registered with ClinicalTrials.gov, number NCT02550873, and with EudraCT, number 2014-004782-24. www.thelancet.com/respiratory Vol 7 August 2019

111 patients entered into open-label extension after randomised double-blind trial

74 continued PRM-151

37 crossed over from placebo to PRM-151

10 discontinued study at week 52 5 patients’ request* 3 adverse events 1 IPF progression 1 other†

5 discontinued study at week 52 1 patient’s request‡ 2 adverse events 1 IPF progression 1 other§

18 discontinued study at week 76 7 patients’ request* 5 adverse events 4 IPF progression 2 other†

10 discontinued study at week 76 2 patients’ request‡ 4 adverse events 3 IPF progression 1 other§

56 continuing in open-label extension study

27 continuing in open-label extension study

Figure 2: Open-label extension study profile Data are cumulative at weeks 52 and 76; reasons in footnotes occurred up to week 52 unless stated otherwise. IPF=interstitial pulmonary fibrosis. *Difficulty travelling to study site (n=4 [n=1 after week 52]), desire to participate in another study (n=1), disease progression or did not feel that treatment would help (n=1), and relocation for lung transplant (n=1). †Lung transplant (n=1) and patient’s choice (n=1 after week 52). ‡On lung transplant waiting list (n=1) and no reason provided (n=1 after week 52). §Lung transplant.

Role of the funding source The funder of the study had a role in study design, data collection, data analysis, data interpretation, and writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

See Online for appendix

Results The first patient was enrolled into the open-label extension study on March 21, 2016, and the last was enrolled on May 2, 2017. The data cutoff date for this analysis was Sept 20, 2018. Among the 116 patients who received treatment in the double-blind phase 2 trial, 111 completed treatment, attended the 28-week follow-up visit, and entered the open-label extension study (74 of 77 patients who had previously been assigned to receive 659

Articles

Age (years)

Double-blind trial

Open-label extension study

PRM-151 (n=77)

Continued PRM-151 Started PRM-151 (n=74) (n=37)

Placebo (n=39)

69·0 (6·3)

67·6 (7·1)

69·7 (6·3)

68·4 (6·9)

Men

65 (84%)

29 (74%)

62 (84%)

27 (73%)

Women

12 (16%)

10 (26%)

12 (16%)

10 (27%)

39 (100%)

71 (96%)

37 (100%)

Sex

Race White

74 (96%)

Asian

1 (1%)

0

1 (1%)

0

Black

1 (1%)

0

1 (1%)

0

Hispanic

1 (1%)

0

1 (1%)

0

3·7 (2·2)

3·9 (2·6)

4·4 (2·2)

4·5 (2·7)

Time since IPF diagnosis (years) FVC Percentage predicted FVC (mL)

67·7 (10·9)

67·4 (11·4)

65·1 (11·1)*

63·6 (11·2)†

2733 (630)

2763 (654)

2607 (573)*

2562 (635)†

435 (93)

458 (118)

434 (109)

434 (128)

7 (18%)

30 (41%)

7 (19%)

6-min walking test Distance (m) Used oxygen during test

25 (32%)

Data are mean (SD) or n (%). Data were collected at baseline of the phase 2 double-blind, randomised PRM-151-202 trial and on entry into the open-label extension study. IPF=idiopathic pulmonary fibrosis. FVC=forced vital capacity. *Data were missing from seven patients. †Data were missing from two patients.

Table 1: Demographics and characteristics of patients in the all-treated set

PRM-151 and 37 of 39 who had previously been assigned to receive placebo, figure 2). Between entry into the openlabel extension study and week 52, 15 patients had discontinued the study, and by week 76, 28 had discontinued the study (figure 2). The main reasons for study discontinuation up to week 76 were patient’s requests and adverse events (figure 2). Patients’ characteristics at baseline of the double-blind trial and at entry into the open-label extension study are shown in table 1. At the start of the open-label extension study, patients were predominantly men (80%), the mean age was 69∙2 (SD 6∙5) years, and the mean time since IPF diagnosis was 4∙4 (SD 2∙3) years. The mean values for percentage of predicted FVC and FVC were lower in patients who started PRM-151 in the open-label extension study than in those who continued PRM-151. Mean 6-min walking distances were similar in the two groups at the start of the open label extension study because values in the PRM-151 group changed little during the phase 2 double-blind study but those in the placebo group started higher and declined. Use of supplemental oxygen at any time after double-blind trial baseline is shown in the appendix. 91 (78%) of 116 patients were receiving concurrent pirfenidone or nintedanib at base­ line of the double-blind trial compared with 84 (76%) of 111 at entry to the open-label extension study, 73 (77%) of 95 at week 52, and 62 (75%) of 83 at week 76 (appendix). Of the 24 patients who entered the open-label extension study without previously taking concurrent IPF therapy, eight (33%) started nintedanib, one (4%) started 660

pirfenidone, and one patient (4%) started pirfenidone and then switched to nintedanib. Among 30 patients who were taking nintedanib at baseline of the double-blind trial, two (7%) switched to pirfenidone during the openlabel extension study, and of 57 taking pirfenidone, one (2%) and nine (16%) switched to nintedanib at the start and during the open-label period, respectively. Patients who continued PRM-151 in the open-label extension study received a median of 26 infusions (IQR 22–26), with a mean exposure of 15∙4 months (SD 4∙3). Placebo crossover patients received a median of 17 infusions (IQR 15–17) of PRM-151 with a mean exposure of 9∙5 months (SD 2∙9). Treatment adherence was 99.4% in patients who continued PRM-151 and 98.8% in patients who started PRM-151 in the open-label extension study. 103 (93%) of 111 patients had AEs in the open-label extension study (table 2). The most frequently reported AEs (occurring in ≥10% patients in either the PRM-151 continuation or placebo crossover group) were symptomes related to IPF or upper respiratory tract infections. 30 events in 21 patients were coded as IPF, of which five (in four patients) were exacerbation events and the remaining events were IPF progression. 13 (12%) of 111 patients experienced AEs that led to discontinuation of PRM-151. Among these, those considered by investigators to be related to the study treatment were exacerbation of IPF, tendonitis (two events), and dysgeusia, each in one patient among those who continued PRM-151, and cardio­ myopathy (two events) in one patient who crossed over to PRM-151. Among the remaining nine (8%) patients with AEs that led to study discontinuation, two had pneumonia, one had two events of tendonitis and one of dysguesia, and each of the following AEs was seen in one patient: B-cell lymphoma, cardiomyopathy, depression, IPF exacerbation, myocardial infarction, pulmonary embol­ism. 31 (28%) of 111 patients had serious AEs. Those occurring in two or more patients were pneumonia (six [5%] patients), IPF exacerbation (four [4%]), IPF progression (four [4%]), and chest pain (two [2%]). 21 (19%) of 111 patients had severe AEs, of which IPF exacerbation and IPF progression occurred in two (2%) patients each. Two (2%) of 111 patients had life-threatening AEs (one had pneumonia and one had small-cell lung cancer extensive stage). The eight (7%) of 111 patients who had died between the start of the openlabel extension study and week 76 had pneumonia (n=3), IPF exacerbation, IPF progression, myocardial infarction, or pulmonary embolism (all n=1), or IPF exacerbation, IPF progression, and hypotension (n=1). Eight (7%) of 111 patients had infusion-related reactions during the open-label extension study, among whom five had continued PRM-151 and three had crossed over to PRM-151. Blood-pressure fluctuation (not characterised by hypotension) was the only event experienced by more than one patient (eight events [seven moderate and one mild] in six [6%] of 111 patients). Two events of tendonitis occurred in one patient, both of which were serious and one of which was severe. www.thelancet.com/respiratory Vol 7 August 2019

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Model 2, which allowed for a change in slope at week 28 for patients who started PRM-151 in the open-label extension study, was found to be the most parsimonious for percentage of predicted FVC, FVC, and 6-min walking distance (appendix). The observed mean change in percentage of predicted FVC from baseline to week 28 during the double-blind trial was −2∙7 (SD 4∙2) in patients randomly assigned to receive PRM-151 compared with −3∙8 (5∙5) in patients assigned to receive placebo (figure 3). At weeks 52 and 76, the mean differences from baseline of the double-blind trial were similar in patients who continued and started PRM-151 in the open-label extension period (−4∙0 [SD 6∙3] vs −4∙2 [3∙9] at week 52 and −3∙7 [4∙3] vs −4∙4 [4∙0] at week 76; figure 3). As reported for the double-blind portion of the study, the least squares mean change in percentage of predicted FVC from baseline to week 28 was −2∙5 for patients treated with PRM-151 and −4∙8 for patients treated with placebo (p=0∙0014, figure 3).6 In the open-label extension study, among patients who continued PRM-151 the least squares mean change from baseline to week 52 was −3∙6 (95% CI −4∙3 to −2∙9) and for patients who crossed over from placebo at week 28, the change was −5∙1 (−6∙1 to −4∙2; figure 3). A significant difference in the slope for percentage of predicted FVC among crossover patients was seen between these two timepoints, from −8∙7% change per year for weeks 0−28 to −0∙9% per year for weeks 28−52 (p<0∙0001). The observed mean changes in FVC from baseline to week 28 of the double-blind trial were −126∙9 mL (SD 180∙7) in the PRM-151 group and −157∙1 mL (222∙0) in the placebo group (appendix). At week 52, the change from baseline was similar for patients who continued PRM-151 and those patients who started PRM-151 in the open-label extension period (mean −192∙8 [SD 268∙5] vs −187∙6 mL [142∙8]). Likewise, at week 76 there was little difference (mean −191∙7 mL [SD 197∙4] in patients who continued PRM-151 vs −213∙1 mL [190∙3] in those who started PRM-151 in the open-label extension study). The slope estimate for the placebo arm was −380∙6 mL per year from weeks 0 to 28 and improved to −68∙0 mL per year from week 28 to week 52 after starting PRM-151 (p<0∙0001). The slope estimate from week 0 to 52 for patients who continued PRM-151 was −178∙9 mL per year. At week 52, the least squares mean change from baseline for FVC was −178∙7 mL (95% CI −206∙9 to −150∙6) for patients who continued PRM-151 and −235∙7 mL (−275∙6 to −195∙8) for patients who crossed over to PRM-151. The observed mean change in 6-min walking distance from baseline to week 28 in the double-blind trial was 1∙1 m (SD 62∙1) with PRM-151 compared with −22∙8 m (65∙5) with placebo; figure 4). The mean change from phase 2 study baseline to week 52 was −1∙6 m (SD 73∙4) for patients who continued PRM-151 and −14∙5 m (62∙2) for those who crossed over from placebo to PRM-151, and at week 76 the respective changes were −5∙9 m (62∙6) www.thelancet.com/respiratory Vol 7 August 2019

Double-blind trial

Any AE

Open-label extension study

PRM-151 (n=77)

Placebo (n=39)

Continued PRM-151 (n=74)

Started PRM-151 (n=37)

71 (92%)

36 (92%)

68 (92%)

35 (95%) 8 (22%)

Most frequent AEs* IPF

11 (14%)

5 (13%)

13 (18%)

Exacerbation

1 (1%)

1 (3%)

3 (4%)†

1 (3%)

Progression

10 (13%)

4 (10%)

11 (15%)†

7 (19%)

Upper respiratory tract infection Cough Dyspnoea

7 (9%)

5 (13%)

14 (19%)

7 (19%)

14 (18%)

2 (5%)

9 (12%)

9 (24%) 4 (11%)

7 (9%)

4 (10%)

12 (16%)

Fatigue

13 (17%)

4 (10%)

12 (16%)

4 (11%)

Nasopharyngitis

12 (16%)

9 (23%)

9 (12%)

4 (11%)

Diarrhoea

9 (12%)

2 (5%)

10 (14%)

2 (5%)

Pneumonia

1 (1%)

2 (5%)

6 (8%)

4 (11%)

Bronchitis

8 (10%)

5 (13%)

5 (7%)

4 (11%)

6 (8%)

4 (10%)

20 (27%)

11 (30%)

Severe AEs

7 (9%)

2 (5%)

14 (19%)

Life-threatening AEs

2 (3%)

2 (5%)

0

Fatal AEs

0

1 (3%)

6 (8%)‡

2 (5%)§

AEs leading to treatment discontinuation

2 (3%)

1 (3%)

7 (10%)

6 (16%)

AEs leading to study discontinuation

1 (1%)

1 (3%)

5 (7%)

4 (11%)

Serious AEs

7 (19%) 2 (5%)

AE=adverse event. *Incidence ≥10% in either group in the open-label extension study. †One patient had exacerbation and progression and is included in both counts. ‡Reasons include pneumonia (n=2), IPF exacerbation (n=1), IPF progression (n=1), myocardial infarction (n=1), and pulmonary embolism (n=1). §Reasons include pneumonia (n=1), and IPF exacerbation, IPF progression, and hypotension (n=1).

Table 2: Numbers of patients with adverse events in all-treated set

and −35∙2 (52∙0). In the double-blind segment of the study, the least squares mean change in 6-min walking distance from baseline to week 28 was −0∙5 m for patients who received PRM-151 and −31∙8 m for those who received placebo (p=0∙0001, figure 4).6 At week 52, the least squares mean change from baseline was −10∙4 m (95% CI −18∙5 to −2∙4) for patients who continued PRM-151 and −31∙0 m (−42∙4 to −19∙7) for patients who crossed over from placebo to PRM-151 (figure 4). The slope of the decline in the 6-min walking distance in patients who continued PRM-151 in the openlabel extension period was −10∙5 m per year up to week 52. The slope changed from −54∙9 m per year between weeks 0 and 28 to −3∙5 m per year between weeks 28 and 52 for patients who started PRM-151 during the open-label extension period (p=0∙0224).

Discussion This analysis of the open-label extension study of the PRM-151-202 trial provided safety and efficacy data for treatment with PRM-151, with or without approved IPF therapy, up to 76 weeks. The types of AEs reported were similar to those reported during the randomised doubleblind phase 2 study.6 The frequency of serious AEs increased, but this change was expected for patients with 661

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Double-blind trial

4

B

OLE study

0

0 –2 –4 –6 –8 Started and continued PRM-151 Started placebo and crossed over to PRM-151 in OLE

–10 –12

OLE study

–1 Change from baseline (%)

Change from baseline (%)

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Double-blind trial

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Number of patients* Continued PRM-151 77 in OLE Crossed over to 39 PRM-151 in OLE

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8

12

16

20

24

28

32

36

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76

–2 –3 –4 –5 –6 –7

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67

67

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36

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32

34

33

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26

PRM-151 Placebo Continued Crossed (n=77) (n=39) PRM-151 over to (n=77) PRM-151 (n=39) Study group

Figure 3: Changes from baseline in percentage of predicted FVC (A) Observed mean (SD) changes from baseline of the double-blind phase 2 study to week 76. (B) Modelled least squares mean (95% CI) changes from baseline of the double-blind phase 2 study to week 52 (all-treated set). FVC=forced vital capacity. OLE=open-label extension. *Numbers of patients with available data at each time point.

A

Double-blind trial

75

B

OLE study

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OLE study

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25

Change from baseline (m)

Change from baseline (m)

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Double-blind trial

0 –25 –50 –75 Started and continued PRM-151 Started placebo and crossed over to PRM-151 in OLE

–100 –125 0 Number of patients* Continued PRM-151 77 in OLE Crossed over to 39 PRM-151 in OLE

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16

20

24

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36 40 44 Time (weeks)

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PRM-151 Placebo Continued Crossed (n=77) (n=39) PRM-151 over to (n=77) PRM-151 (n=39) Study group

Figure 4: Change from baseline in 6-min walking distance (A) Observed mean (SD) changes from baseline of the double-blind phase 2 study to week 76. (B) Modelled least squares mean (95% CI) changes from baseline of the double-blind phase 2 study to week 52 (all-treated set). OLE=open-label extension. *Number of patients with available data at each timepoint.

IPF and is consistent with findings in other long-term studies.12,13 We found a persistent treatment effect of PRM-151 in the open-label extension study among patients who continued this treatment after the doubleblind trial. Additionally, the slopes of decline for percentage of predicted FVC and 6-min walking distance decreased for patients who crossed over from placebo to PRM-151 in the open-label extension study. The types and frequencies of AEs did not differ greatly between patients who continued and those who started PRM-151 in the open-label extension study. The most 662

frequently reported AEs were IPF exacerbation or progression and upper respiratory tract infections, which are consistent with long-term disease sequelae. Likewise, the frequencies of serious and severe AEs were similar in the two groups of patients. Few infusion-related reactions were seen in the open-label extension period, and among these only one event of tendonitis was serious. Discontinuation of treatment because of AEs was more frequent among patients who crossed over from placebo than among those who took PRM-151 during the doubleblind trial.6 Most AEs reported were not judged to be www.thelancet.com/respiratory Vol 7 August 2019

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related to treatment and might have been due to underlying disease for which effects were seen over the longer treatment duration than the 28 weeks of the double-blind trial. Similar to the published resuts of the double-blind trial, treatment with PRM-151 in the open-label extension study did not halt FVC decline, which is not unexpected for IPF. Of note, though, the rate of decline was slowed for patients who crossed over from placebo to PRM-151 in the open-label extension study. The results of 6-min walking testing are encouraging because stabilisation of the distance walked has not been observed in other randomised trials of IPF, including those of the approved antifibrotics.9 In this study, patients who continued taking PRM-151 in the open-label extension study had an overall mean decline of 10 m at 1 year, which is notable given that decline by more than 25 m in 24 weeks is independently predictive of 1-year all-cause mortality in patients with IPF.8 For those patients who crossed over from placebo to PRM-151 in this study, the total mean decline from randomisation to week 52 was 31·0 m. Given that at week 28 with placebo the mean decline was 31∙8 m, this finding indicates stabilisation of test results after starting PRM-151. Overall, these findings are encouraging and further insight into the mechanisms underlying stabilisation of patients’ functional status should be studied in larger phase 3 trials. Caution is warranted when interpreting the results of this 76-week analysis. The double-blind trial was only powered to test the primary endpoint of least squares mean change in percentage of predicted FVC from baseline to week 28, and the lack of a comparator group in the open-label extension study precludes further direct comparisons. Additional limitations of the double-blind trial design not specific to this analysis are discussed elsewhere.6 The differences between this trial and phase 3 studies of pirfenidone and nintedanib inform future trial design but do not allow direct comparisons between data sets. Although efficacy data from the open-label extension study at 52 weeks showed encouraging results, further study of PRM-151 in larger clinical trials is warranted. During the longer-term observation period enabled by the open-label extension study patients treated with PRM-151 experienced AEs that were similar to those previously reported during the double-blind trial and primarily reflect the long-term sequelae of IPF. Percentage of predicted FVC and 6-min walking distance results indicated the persistence of the treatment effect seen with PRM-151 after 28 weeks and a positive effect in patients who crossed over from placebo to PRM-151 in the open-label extension study. Our data support further study of PRM-151 in larger populations of patients with IPF. Contributors GR, BvdB, JAG, MSW, G-JM, and LR designed the study. BvdB, HS-J, FA, and RG did the statistical analysis. GR, BvdB, MSW, MV, AP, KCM,

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MK, RG, and LR provided study supervision. All authors had full access to all the study data, were involved in the interpretation of data, and development, critical review, and approval of the manuscript. GR and LR wrote the drafts and had the final decision to submit the manuscript for publication. Declaration of interests GR has received personal fees for consultation services from Boehringer Ingelheim, Fibrogen, Promedior, Revistan, Sanofi, Veracyte, and Zambon, and has provided consultation services to Avalyn, Bellorophon, Bridge Biotherapeutics, Blade therapeutics, Bristol-Myers Squibb, Gilead Sciences, Nitto, and Roche/Genentech. BvdM, DM, and RG are employees of Promedior. MJH has received grants from Biogen, Boehringer Ingelheim, Fibrogen, Genentech, Global Blood Therapeutics, and Promedior, and speaker fees from Boehringer Ingelheim and Genentech. AWB has received grants and personal fees from Promedior, personal fees from Genentech, PILOT for IPF, and Theravance Biopharma. JAG has received a grant from Promedior. LAH has received personal fees from Boehringer Ingelheim and Genentech. MSW has received grants to her institution from Boehringer Ingelheim and InterMune/Roche, personal fees and other financial rewards from Boehringer Ingelheim and InterMune/ Roche, and other financial rewards or awards to her institution from Galapagos. MV has received grants to her institution from Boehringer Ingelheim and InterMune/Roche and consulting fees from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, and Roche/ Genentech. AP has received personal fees from Boehringer Ingelheim and Roche/Genentech. DEA-O has received grants to her institution from Boehringer Ingelheim, Fibrogen, Genentech, and Promedior. KCM has received grants from Genentech/Roche, Inter/Mune, Nivalis, Parion, and Promedior, and speaker fees from the University of Nebraska, the Practice Point Communications, and National Jewish Health. MK has received research support to his institution from Boehringer Ingelheim and Roche, personal fees from Boehringer Ingelheim and Roche, and consulting fees from AstraZeneca, Chiesi, Galapagos, and GlaxoSmithKline. HS-J and FA are employees of Venn Life Sciences, the contractor that provided statistical analysis for this study. G-JM is a non-executive director on the board of Promedior. LR has received grants from InterMune and personal fees from Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, DynaMed, Fibrogen, ImmuneWorks, InterMune, Nitto, Promedior, Sanofi, and Shionogi. Data sharing Individual participant data that underlie the results reported in this article (text, tables, figures, and appendices) can be made available after deidentification. The study protocol and statistical analysis plan are provided as part of the submission to the journal. Data will be made available to researchers who provide a methodologically sound proposal to achieve the aims of the approved proposal, beginning 9 months and ending 36 months after publication. Proposals should be directed to [email protected]. To gain access, data requesters will need to sign a data access agreement. Acknowledgments This work was supported by Promedior. We thank the patients for their time and participation in the trial; study coordinators at each study site; Brigitte Mahnert, Venn Life Sciences, Paris, France, for medical monitoring; Apurva H Davé, Medical Expressions, Chicago, IL, USA, for preparing the first draft of the manuscript (under the direction of GR and LR and compensated by Promedior); and Kevin Anstrom, Duke University Clinical Research Institute, Durham, NC, USA, for helpful comments and careful review of the manuscript. We thank also the clinical investigators in the study: Andreas Günther, Univeritatsklinikum Geissen, Geissen, Germany; Maria Molina, University Hospital of Bellvitge, Barcelona, Spain; Carlo Vancheri, University of Catania, Catania, Italy; Romain Lazor, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Tristan Huie, National Jewish Health and University of Colorado, Denver, CO, USA; Corey Dean Kershaw, University of Texas Southwestern Medical Center, Dallas, TX, USA; Rafael Perez, University of Louisville, Louisville, KY, USA; and Leo Ginns, Massachusetts General Hospital, Boston, MA, USA.

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References 1 Raghu G, Remy-Jardin M, Myers JL, et al. Diagnosis of idiopathic pulmonary fibrosis. an official ATS/ERS/JRS/ALAT clinical practice guideline. Am J Respir Crit Care Med 2018; 198: e44–68. 2 Richeldi L, Collard HR, Jones MG. Idiopathic pulmonary fibrosis. Lancet 2017; 389: 1941–52. 3 Lederer DJ, Martinez FJ. Idiopathic pulmonary fibrosis. N Engl J Med 2018; 379: 797–98. 4 King TE, Jr, Bradford WZ, Castro-Bernardini S, et al. A phase 3 trial of pirfenidone in patients with idiopathic pulmonary fibrosis. N Engl J Med 2014; 370: 2083–92. 5 Richeldi L, du Bois RM, Raghu G, et al. Efficacy and safety of nintedanib in idiopathic pulmonary fibrosis. N Engl J Med 2014; 370: 2071–82. 6 Raghu G, van den Blink B, Hamblin MJ, et al. Effect of recombinant human pentraxin 2 vs placebo on change in forced vital capacity in patients with idiopathic pulmonary fibrosis: a randomized clinical trial. JAMA 2018; 319: 2299–307. 7 du Bois RM, Weycker D, Albera C, et al. Six-minute-walk test in idiopathic pulmonary fibrosis: test validation and minimal clinically important difference. Am J Respir Crit Care Med 2011; 183: 1231–37.

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du Bois RM, Albera C, Bradford WZ, et al. 6-Minute walk distance is an independent predictor of mortality in patients with idiopathic pulmonary fibrosis. Eur Respir J 2014; 43: 1421–29. Raghu G. Idiopathic pulmonary fibrosis: lessons from clinical trials over the past 25 years. Eur Respir J 2017; 50: 1701209. Raghu G, Collard HR, Egan JJ, et al. An official ATS/ERS/JRS/ALAT statement: idiopathic pulmonary fibrosis: evidence-based guidelines for diagnosis and management. Am J Respir Crit Care Med 2011; 183: 788–824. Burnham KP, Anderson DR. Model selection and multimodel inference: a practical information-theoretic approach, 2nd edn. New York: Springer-Verlag, 2002. Costabel U, Albera C, Lancaster LH, et al. An open-label study of the long-term safety of pirfenidone in patients with idiopathic pulmonary fibrosis (RECAP). Respiration 2017; 94: 408–15. Crestani B, Huggins JT, Kaye M, et al. Long-term safety and tolerability of nintedanib in patients with idiopathic pulmonary fibrosis: results from the open-label extension study, INPULSIS-ON. Lancet Respir Med 2019; 7: 60–68.

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