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 |
Trial |
|||||
120 |
120 |
Placebo |
120 |
120 |
Placebo |
|
Enrollment |
387 |
389 |
388 |
372 |
376 |
376 |
Efficacy |
||||||
Primary |
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 |
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 |
HR: p=0.724 |
HR: p=0.204 |
HR: p=0.480 |
HR: p=0.910 |
||
Worst |
LSM: p=0.163 |
LSM: p=0.081 |
LSM: |
LSM: p=0.276 |
LSM: p=0.556 |
LSM: |
Safety |
||||||
Safety |
386 |
389 |
387 |
371 |
374 |
376 |
Deaths |
n=3 Anti-phospholipid |
n=2 Pneumonia; |
n=2 Deathe; CVA |
n=1 Traffic |
n=2 Septic |
n=3 Brain cardiac |
Serious |
5.2% |
4.9% |
4.4% |
4.3% |
5.9% |
6.6% |
Urinary |
18.9% |
13.9% |
13.4% |
14.6% |
16.3% |
17.0% |
Opportunistic |
||||||
Herpes |
3.4% |
1.0% |
2.6% |
1.6% |
2.7% |
1.6% |
Disseminated |
0.3% |
0% |
0% |
0% |
0% |
0% |
Pulmonary |
0% |
0% |
0% |
0% |
0% |
0.3% |
Cytomegalovirus |
0% |
0.3% |
0% |
0% |
0% |
0% |
Treatment-emergent |
0.5% |
0.8% |
3.1% |
0.8% |
1.1% |
1.9% |
Abbreviations: aPrimary Endpoint: SLE Responder Index 5 (SRI-5) – a reduction of Concomitant Trial bCorticosteroid sparing definition – for those patients receiving > cTime to severe flare – a severe flare was defined by the dWorst fatigue in 24 hours – worst level of fatigue during the ePreferred term; verbatim reported by investigator was unknown cause 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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ACR Meeting Abstracts - https://acrabstracts.org/abstract/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/