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Positive Efficacy And Tolerability Study Of Repatha® (evolocumab) In Statin-Intolerant Patients Published In Journal of the American Medical Association
Data from prespecified co-primary endpoints showed the mean LDL-C reduction from baseline at weeks 22 and 24 was 54.5 percent for Repatha compared to 16.7 percent for ezetimibe (p<0.001). At week 24, LDL-C reduction was 52.8 percent for Repatha compared to 16.7 percent for ezetimibe (p<0.001). At baseline, the mean LDL-C level was 219.9 mg/dL for all patients entering the active-controlled part of the trial. Muscle-related side effects were reported in 20.7 percent of Repatha patients and 28.8 percent of ezetimibe patients. In patients treated with ezetimibe, active study drug was stopped for muscle symptoms in 6.8 percent of patients, compared to 0.7 percent of patients treated with Repatha.
"Statin-associated muscle symptoms represent a major unresolved challenge in the care of patients with cardiovascular disease," said
The GAUSS-3 study built upon knowledge gained from the GAUSS-1 and GAUSS-2 studies, which used patient-reported incidence of statin-related side effects. GAUSS-3 employed a rigorous active statin rechallenge in patients with history of intolerance to two or more statins to determine a patient population that experienced MRSE on statin therapy but not on placebo. Despite the short, 10-week rechallenge, more than 40 percent of patients rechallenged with atorvastatin developed intolerable muscle side effects to atorvastatin and not placebo.
"By employing a unique crossover design, these study results provide insights into our understanding of statin intolerance, which can be difficult to define from patient-reported symptoms alone," said co-lead author
In the GAUSS-3 trial there were no new safety findings. The most common adverse events that occurred in greater than 5 percent of patients in the Repatha group were myalgia (13.8 percent Repatha; 21.9 percent ezetimibe), nasopharyngitis (9.7 percent Repatha; 2.7 percent ezetimibe), muscle spasms (9.0 percent Repatha; 6.8 percent ezetimibe), arthralgia (9.0 percent Repatha; 1.4 percent ezetimibe), pain in extremity (9.0 percent Repatha; 1.4 percent ezetimibe), fatigue (8.3 percent Repatha; 6.8 percent ezetimibe), headache (6.9 percent Repatha; 9.6 percent ezetimibe) and back pain (6.9 percent Repatha; 8.2 percent ezetimibe).
GAUSS-3 Study Design
GAUSS-3 (Goal Achievement After Utilizing an Anti-PCSK9 Antibody in Statin Intolerant Subjects-3) is a Phase 3, multicenter, randomized, double-blind, placebo-controlled statin rechallenge trial designed to evaluate the safety, tolerability and efficacy of Repatha in 491 patients with high cholesterol who could not tolerate statins due to MRSE.
The study was divided into three parts (A, B, C):
- Part A was a two-period, double-blind, placebo-controlled, 24-week cross-over rechallenge of atorvastatin 20 mg in 491 patients with a history of statin intolerance to confirm the presence of statin-related MRSE. In Part A, patients were randomized in a 1:1 ratio to receive either atorvastatin 20 mg daily or oral placebo daily for 10 weeks (period one) before undergoing a two-week washout procedure and crossing over to the alternate therapy for a second 10 weeks (period two).
- Upon completion of both periods one and two in Part A, patients who reported MRSE on atorvastatin and absence of MRSE on placebo entered into another two-week washout period and advanced to Part B. Patients who did not develop MRSE on atorvastatin or developed MRSE on placebo were removed from the study.
- During Part A, patients who experienced a creatine kinase (CK) elevation >10x upper limit of normal (ULN) accompanied by muscle symptoms, with resolution of both CK elevation and muscle symptoms upon discontinuation of statin therapy, were considered the equivalent of intolerable MRSE and also advanced to Part B.
- Part B was a 24-week double-blind, double-dummy, active-controlled comparison of Repatha and ezetimibe in 218 patients. In Part B, patients were re-randomized 2:1 to receive either subcutaneous Repatha 420 mg once monthly and daily oral placebo or oral ezetimibe 10 mg daily and subcutaneous placebo monthly through week 48.
- Part C is an ongoing, two-year, open-label extension, during which all patients who completed Part B receive Repatha to evaluate its long-term safety and efficacy in patients with objectively-documented statin intolerance. All patients in the open-label extension portion receive subcutaneous Repatha 140 mg every two weeks or 420 mg once monthly. Data from the open label extension may be subject of a future presentation or publication.
The co-primary endpoints were the mean percent reductions from baseline in LDL-C at weeks 22 and 24 and the percent reduction from baseline in LDL-C at week 24 in Part B. Secondary efficacy endpoints included means at weeks 22 and 24 and at week 24 for the following: change from baseline in LDL-C; LDL-C response <70 mg/dL; change from baseline in total cholesterol (TC); change from baseline in non-high-density lipoprotein cholesterol (non-HDL-C), apolipoprotein B (ApoB), TC/HDL-C ratio, ApoB/apolipoprotein A1 (ApoA1) ratio, lipoprotein(a), triglycerides, HDL-C and very low-density lipoprotein cholesterol (VLDL-C).
About Repatha® (evolocumab)
Repatha® (evolocumab) is a human monoclonal antibody that inhibits proprotein convertase subtilisin/kexin type 9 (PCSK9). Repatha binds to PCSK9 and inhibits circulating PCSK9 from binding to the low-density lipoprotein (LDL) receptor (LDLR), preventing PCSK9-mediated LDLR degradation and permitting LDLR to recycle back to the liver cell surface. By inhibiting the binding of PCSK9 to LDLR, Repatha increases the number of LDLRs available to clear LDL from the blood, thereby lowering LDL-C levels.1
GLAGOV, the intravascular ultrasound study, is underway to determine the effect of Repatha on coronary atherosclerosis in approximately 950 patients undergoing cardiac catheterization to test the hypothesis of robust LDL-C reduction leading to a reduction or a change in the build-up of plaque in the arteries. Results from the GLAGOV study are expected in the second half of 2016.
The FOURIER outcomes trial is designed to evaluate whether treatment with Repatha in combination with statin therapy, compared to placebo plus statin therapy, reduces the risk of cardiovascular events in patients with high cholesterol and clinically evident cardiovascular disease, and completed patient enrollment in June 2015. Top-line results from the approximately 27,500-patient event-driven FOURIER study are anticipated in the second half of 2016.
Repatha is approved in
Important U.S. Product Information
Repatha® is indicated as an adjunct to diet and:
- Maximally tolerated statin therapy for treatment of adults with heterozygous familial hypercholesterolemia (HeFH) or clinical atherosclerotic cardiovascular disease (ASCVD), who require additional lowering of low-density lipoprotein cholesterol (LDL-C)
- Other LDL-lowering therapies (e.g., statins, ezetimibe, LDL apheresis) in patients with homozygous familial hypercholesterolemia (HoFH) who require additional lowering of LDL-C
The effect of Repatha® on cardiovascular morbidity and mortality has not been determined.
The safety and effectiveness of Repatha® have not been established in pediatric patients with HoFH who are younger than 13 years old.
The safety and effectiveness of Repatha® have not been established in pediatric patients with primary hyperlipidemia or HeFH.
Important Safety Information
Contraindication: Repatha® is contraindicated in patients with a history of a serious hypersensitivity reaction to Repatha®.
Allergic reactions: Hypersensitivity reactions (e.g. rash, urticaria) have been reported in patients treated with Repatha®, including some that led to discontinuation of therapy. If signs or symptoms of serious allergic reactions occur, discontinue treatment with Repatha®, treat according to the standard of care, and monitor until signs and symptoms resolve.
Adverse reactions: The most common adverse reactions (>5% of Repatha®-treated patients and more common than placebo) were: nasopharyngitis, upper respiratory tract infection, influenza, back pain, and injection site reactions.
In a 52-week trial, adverse reactions led to discontinuation of treatment in 2.2% of Repatha®-treated patients and 1% of placebo-treated patients. The most common adverse reaction that led to Repatha® treatment discontinuation and occurred at a rate greater than placebo was myalgia (0.3% versus 0% for Repatha® and placebo, respectively).
Adverse reactions from a pool of the 52-week trial and seven 12-week trials:
Local injection site reactions occurred in 3.2% and 3.0% of Repatha®-treated and placebo-treated patients, respectively. The most common injection site reactions were erythema, pain, and bruising. The proportions of patients who discontinued treatment due to local injection site reactions in Repatha®-treated patients and placebo-treated patients were 0.1% and 0%, respectively.
Allergic reactions occurred in 5.1% and 4.7% of Repatha®-treated and placebo-treated patients, respectively. The most common allergic reactions were rash (1.0% versus 0.5% for Repatha® and placebo, respectively), eczema (0.4% versus 0.2%), erythema (0.4% versus 0.2%), and urticaria (0.4% versus 0.1%).
Neurocognitive events were reported in less than or equal to 0.2% in Repatha®-treated and placebo-treated patients.
In a pool of placebo- and active-controlled trials, as well as open-label extension studies that followed them, a total of 1,988 patients treated with Repatha® had at least one LDL-C value <25 mg/dL. Changes to background lipid-altering therapy were not made in response to low LDL-C values, and Repatha® dosing was not modified or interrupted on this basis. Although adverse consequences of very low LDL-C were not identified in these trials, the long-term effects of very low levels of LDL-C induced by Repatha® are unknown.
Musculoskeletal adverse reactions were reported in 14.3% of Repatha®-treated patients and 12.8% of placebo-treated patients. The most common adverse reactions that occurred at a rate greater than placebo were back pain (3.2% versus 2.9% for Repatha® and placebo, respectively), arthralgia (2.3% versus 2.2%), and myalgia (2.0% versus 1.8%).
Homozygous Familial Hypercholesterolemia (HoFH): In 49 patients with homozygous familial hypercholesterolemia studied in a 12-week, double-blind, randomized, placebo-controlled trial, 33 patients received 420 mg of Repatha® subcutaneously once monthly. The adverse reactions that occurred in at least 2 (6.1%) Repatha®-treated patients and more frequently than in placebo-treated patients, included upper respiratory tract infection (9.1% versus 6.3%), influenza (9.1% versus 0%), gastroenteritis (6.1% versus 0%), and nasopharyngitis (6.1% versus 0%).
Immunogenicity: Repatha® is a human monoclonal antibody. As with all therapeutic proteins, there is a potential for immunogenicity with Repatha®.
Please contact Amgen Medinfo at 800-77-AMGEN (800-772-6436) or 844-REPATHA (844-737-2842) regarding Repatha® availability or find more information, including full Prescribing Information, at www.amgen.com and www.Repatha.com.
About Amgen Cardiovascular
Building on more than three decades of experience in developing biotechnology medicines for patients with serious illnesses,
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- Repatha® U.S. Prescribing Information.
Amgen. World Health Organization. Cardiovascular diseases (CVDs) fact sheet. http://www.who.int/mediacentre/factsheets/fs317/en/. Accessed March 2016.
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