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Abstract Number: L25

Efficacy and Safety of Subcutaneous Tabalumab in Patients with Systemic Lupus Erythematosus (SLE): Results from 2 Phase 3, 52-Week, Multicenter, Randomized, Double-Blind, Placebo-Controlled Trials

David A. Isenberg1, Murray B. Urowitz2, Joan T. Merrill3, Robert W. Hoffman4, Matthew D. Linnik4, MaryAnn Morgan-Cox4, Melissa F. Veenhuizen4, Noriko Iikuni4, Michelle Petri5 and ILLUMINATE-1 Investigators, 1University College London, London, United Kingdom, 2University of Toronto, Toronto Western Hospital, Toronto, ON, 3Department of Clinical Pharmacology, Oklahoma Medical Research Foundation, Oklahoma City, OK, 4Eli Lilly and Company, Indianapolis, IN, 5Johns Hopkins University School of Medicine, Baltimore, MD

Meeting: 2014 ACR/ARHP Annual Meeting

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Background/Purpose:
B-cell Activating Factor (BAFF) is a key regulator of B-cell development, survival, and activation. Tabalumab is a human IgG4 monoclonal antibody, administered subcutaneously, that binds and neutralizes membrane-bound and soluble BAFF. Two trials evaluated the efficacy and safety of tabalumab plus standard of care (SoC) compared to placebo plus SoC at 52 weeks in patients with SLE.

Methods:
ANA-positive patients were enrolled with active, moderate-to-severe SLE, defined as SELENA-SLEDAI score of ≥6 at baseline. Patients with severe active renal or CNS disease were excluded. Patients received subcutaneous injections of tabalumab or placebo, with a loading dose (240 mg or placebo) at Week 0, followed by 120 mg every 2 weeks (120 Q2W), or 120 mg every 4 weeks (120 Q4W), or placebo Q2W. The primary outcome measure was the proportion of patients achieving a SLE Responder Index 5 (SRI-5) response at Week 52 adhering to concomitant medication rules (Table 1). Key secondary endpoints included time to severe flare, corticosteroid sparing, and worst level of fatigue over last 24 hours (Table 1).

Results:
Baseline disease activity and clinical characteristics were balanced across treatment groups in both Trial 1 (N=1164) and Trial 2 (N=1124). The primary endpoint of SRI-5 was not met in Trial 1 but was met in Trial 2 for the 120 Q2W dose (p=0.002; Table 1). Key secondary efficacy endpoints (corticosteroid sparing, time to severe flare, worst fatigue in the last 24 hours) did not achieve statistical significance. Reduction in anti-dsDNA antibodies was observed as well as increases in complement C3 and C4 and reduction in total B cells and immunoglobulins.

Across both studies, serious adverse events (AEs) were similar between the tabalumab (120 Q2W + 120 Q4W) and placebo groups (13.5%, 15.9%; studies and tabalumab doses integrated), as were treatment-emergent AEs (82.2%, 80.9%) and discontinuations due to an AE (6.1%, 7.2%). Thirteen deaths occurred (4 in 120 Q2W, 4 in 120 Q4W, 5 in placebo; Table 1). The frequency of treatment-emergent anti-drug antibodies was low (Table 1).

Conclusion:
Tabalumab administration had biologic activity consistent with inhibition of the BAFF pathway, as demonstrated by changes in anti-dsDNA, complement, B cells, and immunoglobulins. The primary endpoint of SRI-5 was met in Trial 2 for the tabalumab 120 Q2W dose. Key secondary efficacy endpoints (corticosteroid sparing, time to severe flare, worst fatigue in the last 24 hours) did not achieve statistical significance. The safety profile of the tabalumab and placebo groups was similar across both trials.

Table 1 Enrollment, Key Efficacy Endpoints, and Safety

Trial
1

Trial
2

120
Q2W

120
Q4W

Placebo

120
Q2W

120
Q4W

Placebo

Enrollment

387

389

388

372

376

376

Efficacy

Primary
Endpointa

31.8%

p=0.409

35.2%

p=0.052

29.3%

38.4%

p=0.002

34.8%

p=0.051

27.7%

Corticosteroid
sparingb

23.4%

p=0.280

17.5%

p=0.747

18.9%

22.5%

p=0.051

17.5%

p=0.342

13.9%

Time
to severe flarec

HR:
0.94

p=0.724

HR:
0.79

p=0.204

HR:
0.88

p=0.480

HR:
0.98

p=0.910

Worst
fatigue in Last 24 hoursd

LSM:
-1.31

p=0.163

LSM:
-1.38

p=0.081

LSM:
-1.01

LSM:
-0.73

p=0.276

LSM:
-0.66

p=0.556

LSM:
‑0.57

Safety

Safety
Population

386

389

387

371

374

376

Deaths

n=3

Anti-phospholipid
syndrome; pulmonary embolism; disseminated tuberculosis

n=2

Pneumonia;
SLE

n=2

Deathe;

CVA

n=1

Traffic
accident

n=2

Septic
shock; squamous cell carcinoma

n=3

Brain
edema; cardio-pulmonary failure;

cardiac
failure

Serious
Infectionsf

5.2%

4.9%

4.4%

4.3%

5.9%

6.6%

Urinary
tract infection

18.9%

13.9%

13.4%

14.6%

16.3%

17.0%

Opportunistic
infections

Herpes
zoster

3.4%

1.0%

2.6%

1.6%

2.7%

1.6%

Disseminated
tuberculosis

0.3%

0%

0%

0%

0%

0%

Pulmonary
tuberculosis

0%

0%

0%

0%

0%

0.3%

Cytomegalovirus

0%

0.3%

0%

0%

0%

0%

Treatment-emergent
anti-drug antibodies

0.5%

0.8%

3.1%

0.8%

1.1%

1.9%

Abbreviations:
120 Q2W = loading dose of tabalumab 240 mg followed
by tabalumab 120 mg every 2 weeks; 120 Q4W =
loading dose of tabalumab 240 mg followed by tabalumab 120 mg every 4 weeks; HR = hazard ratio; LSM =
least squares mean; SELENA-SLEDAI = Safety of Estrogens in Lupus
Erythematosus National Assessment – SLE Disease Activity Index; Trial 1 = ILLUMINATE-1
(H9B-MC-BCDS); Trial 2 = ILLUMINATE-2 (H9B-MC-BCDT).

aPrimary Endpoint: SLE Responder Index 5 (SRI-5) – a reduction of
≥5 points from baseline in SELENA-SLEDAI score, no new BILAG A or no
more than 1 new BILAG B disease activity scores, and no worsening (defined as
an increase of ≥0.3 points from baseline) in Physician’s Global
Assessment (PGA).

Concomitant
medication rules defining nonresponse:

Trial
1: Unable to taper to baseline dose of corticosteroids; After Week 24,
increase in corticosteroid dose; or initiate or require an increase or
decrease in dose of any allowed concomitant antimalarial or immunosuppressant
at any time. Trial 2: allowed for decrease in concomitant antimalarial or immunosuppressants.

bCorticosteroid sparing definition – for those patients receiving >
7.5 mg/day of prednisone (or equivalent) at baseline, a patient will have
achieved corticosteroid sparing if they reduce their corticosteroid dose by
at least 25% to ≤ 7.5 mg/day for at least three consecutive months (84
days) during Weeks 24 through 52 without an increase in dose of either antimalarials or immunosuppressants
at any time during the treatment period.

cTime to severe flare – a severe flare was defined by the
modified SELENA-SLEDAI Flare Index using the SELENA-SLEDAI score, disease
activity scenarios, treatment changes and PGA within 52 week treatment
period.

dWorst fatigue in 24 hours – worst level of fatigue during the
past 24 hours from baseline to Week 52 from the Brief Fatigue Inventory.

ePreferred term; verbatim reported by investigator was unknown cause
of death.

fIdentified by System Organ Class Infections and infestations.

 

 

 


Disclosures

D. A. Isenberg, Eli Lilly and Company; M. B. Urowitz, Eli Lilly and Company; J. T. Merrill, Eli Lilly and Company, Eli Lilly and Company, GlaxoSmithKline, GlaxoSmithKline, EMD Serono, EMD Serono; R. W. Hoffman, Eli Lilly and Company , Eli Lilly and Company; M. D. Linnik, Eli Lilly and Company, Eli Lilly and Company; M. Morgan-Cox, Eli Lilly and Company; M. F. Veenhuizen, Eli Lilly and Company, Eli Lilly and Company; N. Iikuni, Eli Lilly and Company, Eli Lilly and Company; M. Petri, Eli Lilly and Company.

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