Current Therapy - News of Note

Biologics Updates

Dupilumab helps patients with COPD, type 2 inflammation avoid negative outcomes

SAN FRANCISCO, CA — The likelihood for avoidance of five clinically important outcomes in patients with COPD and type 2 inflammation was greater with dupilumab vs. placebo, according to findings from a win ratio analysis. “Dupilumab is already approved for eligible patients with uncontrolled COPD, but these data provide further granularity on the potential impact,” said Sanjay Ramakrishnan, PhD, MBBS, FRACP, senior lecturer at The University of Western Australia and research group leader at the Institute for Respiratory Health. These data on dupilumab (Dupixent; Sanofi, Regeneron) were presented at the American Thoracic Society International Conference. 

“When compared to placebo, patients on dupilumab had a decreased likelihood of a composite of events including death, hospitalization, worsening symptoms and lung function decline. “Physicians can now clearly explain to patients the ways in which they stand to benefit with adding dupilumab into their COPD management plan: running the COPD race with dupilumab means you are 31% more likely to avoid a combination of potentially debilitating outcomes,” Ramakrishnan said.

In this win ratio analysis, Ramakrishnan and colleagues assessed adults with moderate to severe COPD and type 2 inflammation (blood eosinophil count ≥ 300 cells/μL) receiving triple therapy from the BOREAS and NOTUS phase 3 trials to find out the difference in clinically important endpoints at 52 weeks between patients receiving 300 mg dupilumab every 2 weeks (n = 938) and patients receiving placebo (n = 936). Notably, a win ratio analysis is “a simple way to appreciate the benefit of [a] treatment” using the most clinically important outcomes, Ramakrishnan told Healio. “Assessing multiple endpoints simultaneously in clinical trials can be challenging because not all outcomes have equivalent clinical importance,” Ramakrishnan said. “A win ratio analysis provides a way to evaluate key outcomes in tandem, but also ranks them in order of clinical importance, allowing for a more complete and appropriate comparison of multiple endpoints between dupilumab and placebo.” The most clinically important outcome in this patient population was “avoiding hospital,” according to the analysis. Researchers also identified moderate exacerbations, lung function loss and symptom deterioration as clinically important outcomes. All four factors plus death made up one outcome. “The approach creates a single measurement that provides a more accurate reflection of treatment efficacy that takes into account the impact of different clinical outcomes on a patient’s life,” Ramakrishnan said. All incorporated into one outcome, researchers reported that the likelihood for avoidance of death, hospitalization, exacerbations, worsening symptoms and worsening lung function was 31% greater (win ratio, 1.31; 95% CI, 1.15-1.48) in the dupilumab vs. placebo group.

“Patients receiving dupilumab are 31% more likely than placebo to ‘win’ on a combination of important outcomes,” Ramakrishnan said. Dupilumab continued to be favored over placebo when broken down into the individual clinically important outcomes, according to the analysis.

Researchers highlighted that dupilumab had more wins — achievement of the more desirable outcome — vs. losses than placebo for death or a hospital admission/ED visit lasting 24 hours or longer (7.6% vs. 5.6%), moderate exacerbation or ED visit lasting less than 24 hours (22.1% vs. 17.9%) and total number of moderate or severe exacerbations during the evaluated 52 weeks (3.8% vs. 2.8%). “What was quite striking was every 16th patient treated with dupilumab stopped having exacerbations completely,” Ramakrishnan said. “This is incredible, considering participants were having an average of two exacerbations in the previous year.”

Dupilumab also had more wins vs. losses for percent-predicted post-bronchodilator FEV1 worsening of at least 100 mL at week 52 compared with placebo (12.1% vs. 8.2%), according to the analysis. Lastly, improvement in St. George’s Respiratory Questionnaire or Respiratory Symptom Tool for COPD scores was won more than lost by dupilumab vs. placebo (2% vs. 1.5%). “We are pleased that the results were in line with what we would have expected based on the pivotal phase 3 trials for dupilumab in COPD, underscoring how it improves multiple, clinically important signs and symptoms of disease compared to placebo,” Ramakrishnan said. Looking ahead, Ramakrishnan said this analysis may have an impact on future trials in patients with COPD.

“These data could inform novel ways of conducting clinical trials in COPD to researchers and funders, by demonstrating a robust unified approach to simultaneously rank and assess outcomes of clinical importance to patients,” Ramakrishnan told Healio.

For more information: https://tinyurl.com/2rk3938e

Dupilumab Improves Quality of Life for COPD Patients 

BOSTON, MA - Patients with chronic obstructive pulmonary disease (COPD) and type 2 inflammation had greater improvements in quality of life with dupilumab (Dupixent) versus placebo, according to a pooled analysis of data from the phase III BOREAS and NOTUS trials. At 52 weeks, the least-squares mean difference from baseline in the total St. George's Respiratory Questionnaire (SGRQ) score with dupilumab versus placebo was -3.4 points (95% CI -5.0 to -1.8, nominal P<0.0001), reported Surya Bhatt, MD, of the University of Alabama at Birmingham, during the CHEST annual meeting hosted by the American College of Chest Physicians. For individual SGRQ domain scores, the least-squares mean differences at 52 weeks with dupilumab versus placebo were:

Symptoms: -3.5 (95% CI -5.5 to -1.5, nominal P<0.0006)

Impacts: -2.9 (95% CI -4.6 to -1.1, nominal P=0.0012)

Activity: -4.0 (95% CI -5.9 to -2.1, nominal P<0.0001)

Impairments in quality of life "contribute significantly to morbidity in COPD," Bhatt told attendees. "The total SGRQ score changed quickly," he noted. "Within 4 weeks there was a big difference between the placebo arm and the [dupilumab] arm, and this difference persisted over the 52-week time period." "Even in the subdomains, this trend was very similar," he added. "Dupilumab has a significant impact on quality of life in addition to its primary impact on exacerbation reduction and secondary reduction improvements in lung function" in patients with COPD. The 36-item SGRQ measures patient-reported impacts of obstructive airway diseases on overall health, common daily activities, and perceived well-being. The total SGRQ score and those of three domains range from 0 to 100, with higher scores indicating poorer health-related quality of life. At baseline, the total SGRQ score "was quite high, to the tune of almost 50 on average in both groups," Bhatt pointed out. For the specific domains across both groups, the mean activity score was approximately 66, the symptoms domain score was roughly 59, and the impacts domain score was about 38. "Although dupilumab appears to be a promising biologic treatment for COPD, its use is currently limited to those with an eosinophilic phenotype, which represents a minority of patients with the disease," session moderator Subhakar Kandi, MBBS, MD, of Kamineni Hospitals in Hyderabad, India, told MedPage Today. 

More treatments are desperately needed for COPD because of its substantial burden on patients and caregivers, he emphasized. However, he noted that he would have liked to see data from the analysis broken down according to disease severity or exacerbation risk. Dupilumab, an injectable interleukin (IL)-4 and IL-13 pathway inhibitor, recently received FDA approval as the first-ever biologic for treatment of COPD. It is indicated as an add-on maintenance treatment for inadequately controlled COPD with an eosinophilic phenotype. Primary support for the approval came from the phase III BOREAS trial, showing that dupilumab led to a 30% reduction in annual exacerbations, and from the phase III NOTUS trial, which showed a 34% reduction. The BOREAS and NOTUS trials assessed the efficacy and safety of dupilumab as add-on therapy in patients with COPD and type 2 inflammation (blood eosinophil count ≥300 cells/µL) who had moderate-to-severe airflow limitation and were taking inhaled triple therapy. This prespecified pooled analysis assessed the change from baseline in the SGRQ total and domain scores at week 52 in patients enrolled in those trials. The final population in this analysis included 830 patients in the dupilumab group (mean age 65, 65.9% men) and 830 in the placebo group (mean age 65, 67.6% men). Most patients were former smokers (70-71%).

For more information: https://tinyurl.com/2vedt6v5