U.S. patent application number 12/845653 was filed with the patent office on 2011-02-03 for compositions and methods for treating gaucher disease.
Invention is credited to Peter Francis DANIEL, Michael W. Heartlein.
Application Number | 20110027254 12/845653 |
Document ID | / |
Family ID | 43527246 |
Filed Date | 2011-02-03 |
United States Patent
Application |
20110027254 |
Kind Code |
A1 |
DANIEL; Peter Francis ; et
al. |
February 3, 2011 |
COMPOSITIONS AND METHODS FOR TREATING GAUCHER DISEASE
Abstract
Methods and compositions for treating Gaucher disease are
described.
Inventors: |
DANIEL; Peter Francis;
(Natick, MA) ; Heartlein; Michael W.; (Boxborough,
MA) |
Correspondence
Address: |
LANDO & ANASTASI, LLP
ONE MAIN STREET, SUITE 1100
CAMBRIDGE
MA
02142
US
|
Family ID: |
43527246 |
Appl. No.: |
12/845653 |
Filed: |
July 28, 2010 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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61229195 |
Jul 28, 2009 |
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61303044 |
Feb 10, 2010 |
|
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61317513 |
Mar 25, 2010 |
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61333372 |
May 11, 2010 |
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61359338 |
Jun 28, 2010 |
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Current U.S.
Class: |
424/94.61 ;
435/7.92 |
Current CPC
Class: |
C12N 9/2402 20130101;
G01N 2800/044 20130101; A61K 9/0019 20130101; G01N 33/6854
20130101; C12Y 302/01045 20130101; G01N 2333/924 20130101; A61K
38/47 20130101; C12Y 302/01014 20130101; A61P 3/00 20180101; C12N
9/2442 20130101; A61K 45/06 20130101 |
Class at
Publication: |
424/94.61 ;
435/7.92 |
International
Class: |
A61K 38/46 20060101
A61K038/46; A61P 7/00 20060101 A61P007/00; A61P 1/16 20060101
A61P001/16; A61P 19/00 20060101 A61P019/00; G01N 33/53 20060101
G01N033/53 |
Claims
1. A method of treating a subject with Gaucher disease, the method
comprising administering a glucocerebrosidase enzyme replacement
therapy by intravenous infusion to the subject over a period of
less than 2 hours, to thereby treat the subject.
2. The method of claim 1, wherein the glucocerebrosidase enzyme
replacement therapy is administered over a period of 90 minutes or
less.
3. The method of claim 1, wherein the glucocerebrosidase enzyme
replacement therapy is administered over a period of 60 minutes or
less.
4. The method of claim 1, further comprising administering a second
glucocerebrosidase enzyme replacement therapy by intravenous
infusion to the subject over a period of less than 2 hours.
5. The method of claim 1, wherein the glucocerebrosidase enzyme
replacement therapy is selected from the group consisting of:
velaglucerase, imiglucerase and uplyso.
6. The method of claim 1, wherein the glucocerebrosidase enzyme
replacement therapy is administered at a dose of 15 to 60 U/kg.
7. A method for identifying a subject as suitable for treatment
with a glucocerebrosidase enzyme replacement therapy, comprising:
determining if neutralizing antibodies to a glucocerebrosidase
enzyme replacement therapy are present in a sample from the subject
to obtain a measured value of antibody to the therapy, wherein the
subject is currently being administered a first glucocerebrosidase
enzyme replacement therapy or has previously received a first
glucocerebrosidase enzyme replacement therapy, and comparing the
measured value of antibody to the therapy to a standard, wherein if
the measured antibody value is greater than the standard, the
subject is identified as having antibodies to the
glucocerebrosidase enzyme replacement therapy and as a candidate
for glucocerebrosidase enzyme replacement therapy with
velaglucerase, and if the measured antibody value is not greater
than the standard, identifying the subject as a candidate for
glucocerebrosidase enzyme replacement therapy with the first
glucocerebrosidase enzyme replacement therapy or an alternative
glucocerebrosidase enzyme replacement therapy.
8. The method of claim 7, wherein the first glucocerebrosidase
enzyme replacement therapy is imiglucerase or uplyso.
9. The method of claim 7, wherein the sample is a blood or serum
sample.
10. The method of claim 9, wherein the blood or serum sample has
been modified.
11. The method of claim 10, wherein the sample has been contacted
with an analytical reagent or substrate.
12. The method of claim 10, wherein the sample is a concentrated
portion of a blood or serum sample.
13. The method of claim 7, wherein the subject is identified as a
candidate for glucocerebrosidase enzyme replacement therapy with
velaglucerase, and the method further comprises administering
velaglucerase to the subject.
14. A method for treating a subject with Gaucher disease that is
currently taking or has previously received a glucocerebrosidase
enzyme replacement therapy, comprising: selecting a subject on the
basis that the subject has tested positive for the production of
antibodies to the therapy the subject is currently taking or has
previously taken for Gaucher disease, and administering
velaglucerase to the subject.
15. The method of claim 14, wherein the subject tested positive for
the production of IgE antibodies to the therapy the subject is
currently taking or has previously taken for Gaucher disease.
16. The method of claim 14, wherein the subject tested positive for
the production of IgM antibodies to the therapy the subject is
currently taking or has previously taken for Gaucher disease.
17. The method of claim 14, wherein the subject tested positive for
the production of IgG antibodies to the therapy the subject is
currently taking or has previously taken for Gaucher disease.
18. The method of claim 14, wherein the therapy the subject is
currently taking or has previously taken for Gaucher disease is
imiglucerase.
19. The method of claim 14, wherein the therapy the subject is
currently taking or has previously taken for Gaucher disease is
uplyso.
20. The method of claim 14, wherein velaglucerase is administered
at a dose of 15 to 60 U/kg.
21. The method of claim 14, wherein the velaglucerase is
administered to the subject by intravenous infusion over 90 minutes
or less.
22. The method of claim 1, further comprising administering an oral
therapy comprising a compound that reduces glucosylceramide.
23. The method of claim 1, further comprising administering a
pharmacological chaperone molecule.
Description
CROSS REFERENCE TO RELATED APPLICATIONS
[0001] This application claims priority to U.S. Ser. No.
61/229,195, filed on Jul. 28, 2009, U.S. Ser. No. 61/303,044, filed
on Feb. 10, 2010, U.S. Ser. No. 61/317,513, filed on Mar. 25, 2010,
U.S. Ser. No. 61/333,372, filed on May 11, 2010, and U.S. Ser. No.
61/359,338, filed on Jun. 28, 2010. The contents of the
aforementioned applications are hereby incorporated by reference in
their entirety.
BACKGROUND
[0002] Gaucher disease is an autosomal recessive lysosomal storage
disorder characterized by a deficiency in the lysosomal enzyme,
glucocerebrosidase (GCB). GCB hydrolyzes the glycolipid
glucocerebroside that is formed after degradation of
glycosphingolipids in the membranes of white blood cells and red
blood cells. The deficiency in this enzyme causes glucocerebroside
to accumulate in large quantities in the lysosomes of phagocytic
cells located in the liver, spleen and bone marrow of Gaucher
patients. Accumulation of these molecules causes a range of
clinical manifestations including splenomegaly, hepatomegaly,
skeletal disorder, thrombocytopenia and anemia. (Beutler et al.
Gaucher disease; In: The Metabolic and Molecular Bases of Inherited
Disease (McGraw-Hill, Inc, New York, 1995) pp. 2625-2639)
[0003] Treatments for patients suffering from this disease include
administration of analgesics for relief of bone pain, blood and
platelet transfusions and, in some cases, splenectomy. Joint
replacement is sometimes necessary for patients who experience bone
erosion.
[0004] Enzyme replacement therapy with GCB has been used as a
treatment for Gaucher disease. Current treatment of patients with
Gaucher disease includes administration of a carbohydrate remodeled
GCB derived from human placenta or Chinese hamster ovary (CHO)
cells transfected with a GCB expression construct and known as
alglucerase or imiglucerase, respectively.
SUMMARY
[0005] The disclosure is based, in part, on the discovery that
velaglucerase elicits less of an immune response (e.g., less
production of antibody, e.g., less production of neutralizing
antibody) than imiglucerase upon administration to a subject (e.g.,
a subject with Gaucher disease). The invention relates, inter alia,
to compositions and methods for selecting a treatment for a subject
with Gaucher disease, selecting subjects for treatment with
velaglucerase (e.g., alone or in combination with another therapy),
methods for reducing injection site reaction in subjects undergoing
treatment for Gaucher disease, and methods of treating Gaucher
disease. The invention also relates, inter alia, to methods of
determining antibody production, e.g., neutralizing antibody
production, in a subject being treated for Gaucher disease.
[0006] In some aspects, the disclosure features a method of
treating a subject with Gaucher disease (e.g., type I Gaucher
disease), the method comprising
[0007] administering a glucocerebrosidase enzyme replacement
therapy (e.g., velaglucerase, imiglucerase, or uplyso) by
intravenous infusion to the subject over a period of less than 2
hours, e.g., 90 minutes, 80 minutes, 70 minutes, 60 minutes, 50
minutes or 45 minutes, to thereby treat the subject.
[0008] In some embodiments, the glucocerebrosidase enzyme
replacement therapy (e.g., velaglucerase, imiglucerase, uplyso) is
administered more than once and each additional dose of the
glucocerebrosidase enzyme replacement therapy (e.g., velaglucerase,
imiglucerase, or uplyso) is administered by intravenous
administration over a period of less than 2 hours, e.g., 90
minutes, 80 minutes, 70 minutes, 60 minutes, 50 minutes or 45
minutes), to the subject.
[0009] In some embodiments, the glucocerebrosidase enzyme
replacement therapy (e.g., velaglucerase, imiglucerase, uplyso) is
administered at a dose of 15 to 60 U/kg (e.g., 30 U/kg to 60 U/kg,
e.g., 15 U/kg, 30 U/kg, 45 U/kg, or 60 U/kg), at a dose equal to or
below 22.5 U/kg, at a dose between 22.5 and 37.5 U/kg, at a dose
between 37.5 and 52.5 U/kg, or at a dose equal to or above 52.5
U/kg. In some embodiments, glucocerebrosidase enzyme replacement
therapy (e.g., velaglucerase, imiglucerase, uplyso) is administered
at a dose of 2.5 U/kg to 60 U/kg. In some embodiments, the
glucocerebrosidase enzyme replacement therapy (e.g., velaglucerase,
imiglucerase, uplyso) is administered every other week. In other
embodiments, the glucocerebrosidase enzyme replacement therapy
(e.g., velaglucerase, imiglucerase, uplyso) is administered every
week. In some embodiments, the velaglucerase is administered three
times a week by intravenous infusion, e.g., at a dose of 2.5
U/kg.
[0010] In some embodiments, the infusion of one or more dose (e.g.,
a dose described herein) occurs over 60 minutes.
[0011] In some embodiments, the glucocerebrosidase enzyme
replacement therapy is velaglucerase and the method includes:
reconstituting lyophilized velaglucerase with a pharmaceutically
acceptable carrier such as Sterile Water for Injection (e.g.,
reconstituting a 200 unit vial with 2.2 mL of Sterile Water for
Injection or a 400 unit vial with 4.3 mL Sterile Water for
Injection), thereby forming a solution, e.g., wherein the vial is
not shaken after addition of the Sterile Water for Injection;
optionally, inspecting the solution in the vials (and, e.g.,
optionally determining if the solution is discolored or if
particulate matter is present, and optionally deciding not to use
the solution if the solution is discolored or if particulate matter
is present);
[0012] withdrawing a volume of solution to provide a pre-selected
dose (e.g., a dose described herein such as 15 U/kg, 30 U/kg, 45
U/kg, or 60 U/kg);
[0013] diluting the volume, e.g., in 100 mL of 0.9% sodium chloride
solution suitable for intravenous administration, thereby forming a
diluted solution; optionally rocking the diluted solution gently,
but do not shaking the diluted solution; and
[0014] administering the diluted solution to the subject by
intravenous infusion, e.g., wherein the diluted solution is
administered over one hour or at a rate of 1 U/kg/minute.
[0015] In some embodiments, the glucocerebrosidase enzyme
replacement therapy is administered at an infusion rate of 2
U/kg/minute, 1.5 U/kg/minute, 1 U/kg/minute, or 0.5
U/kg/minute.
[0016] In some embodiments, the administering comprises home
therapy (e.g., in the subject's home, workplace, or other
non-clinical (e.g., non-hospital) setting). In some embodiments,
the administering (e.g., via infusion) is by a health care
professional (e.g., nurse or physician's assistant). For example,
if the subject has not experienced an adverse event (AE) (e.g., a
drug-related serious AE or an infusion-related AE, e.g., an event
described herein), e.g., after one, two, or three administrations
(e.g., via infusion) of the glucocerebrosidase enzyme replacement
therapy, the subject is eligible to receive home therapy for
subsequent administrations.
[0017] In another aspect, the disclosure provides a method for
identifying a subject as suitable for (e.g., being a candidate for)
treatment with glucocerebrosidase enzyme replacement therapy (e.g.,
velaglucerase). The method includes evaluating (e.g., measuring,
e.g., by a method described herein such as ELISA or
radioimmunoprecipitation assay (RIP)), for the presence of
antibodies (e.g., neutralizing antibodies) (e.g., IgE, IgM, IgG
and/or IgA antibodies) to a glucocerebrosidase enzyme replacement
therapy (e.g., to the therapy currently being administered to the
subject) (e.g., imiglucerase or uplyso) in a sample from the
subject, e.g., and comparing the measured value of antibody to the
therapy to a standard (e.g., a negative control). For example, if
the subject has measured antibody values that are greater than the
value measured for the negative control (e.g., a negative control
in an ELISA), the subject is identified as having antibodies to the
glucocerebrosidase enzyme replacement therapy. The subject is
optionally identified as suitable for treatment with an alternative
Gaucher disease treatment (e.g., treatment with velaglucerase),
e.g., if the measured value is greater than the value for the
standard, e.g., by more than 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%,
45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, or 90%.
[0018] In some embodiments, the sample is a blood or serum sample.
In some embodiments, the sample has been modified. For example, the
measured antibody values were obtained by contacting the sample
with an analytical reagent, e.g., a labeled reagent (e.g., labeled
glucocerebrosidase), and/or a substrate or cell, e.g., a substrate
or cell that binds to an antibody to the glucocerebrosidase enzyme
replacement therapy. In some embodiments, the measured antibody
values were obtained from a sample that has been enriched for
antibodies, e.g., a concentrated portion of a blood or serum
sample. In some embodiments, the evaluation was obtained by a
method described herein.
[0019] In some embodiments, the method includes measuring the
measured antibody value, e.g., by a method described herein.
[0020] In another aspect, the disclosure provides a method for
selecting a subject with Gaucher disease for treatment with a
glucocerebrosidase enzyme replacement therapy. Optionally, the
method includes selecting a subject for such treatment on the basis
that the subject has tested positive for the production of
antibodies (e.g., neutralizing antibodies) to the treatment the
subject is currently taking for Gaucher disease. The method
includes evaluating (e.g., measuring, e.g., by a method described
herein such as ELISA or radioimmunoprecipitation assay (RIP)) or
obtaining an evaluation of the presence of antibodies to a
glucocerebrosidase enzyme replacement therapy (e.g., to the therapy
currently being administered to the subject) (e.g., imiglucerase or
uplyso) in a sample from the subject, e.g., and comparing the
measured value of antibody to the therapy to a standard (e.g., a
negative control). For example, if the subject has measured
antibody values that are greater than the value measured for the
negative control (e.g., negative control in an ELISA), the subject
is identified as having antibodies to the glucocerebrosidase enzyme
replacement therapy. The methods optionally include, selecting an
alternative Gaucher disease treatment for the subject (e.g.,
treatment with velaglucerase), e.g., if the measured value is
greater than the value for the standard (e.g., negative control),
e.g., by more than 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%,
55%, 60%, 65%, 70%, 75%, 80%, 85%, or 90%.
[0021] In some embodiments, the sample is a blood or serum sample.
In some embodiments, the sample has been modified. For example, the
measured antibody values were obtained by contacting the sample
with an analytical reagent, e.g., a labeled reagent (e.g., labeled
glucocerebrosidase), and/or a substrate or cell, e.g., a substrate
or cell that binds to an antibody to the glucocerebrosidase enzyme
replacement therapy. In some embodiments, the measured antibody
values were obtained from a sample that has been enriched for
antibodies, e.g., a concentrated portion of a blood or serum
sample. In some embodiments, the evaluation was obtained by a
method described herein.
[0022] In some embodiments, the method includes measuring the
antibody value, e.g., by a method described herein.
[0023] In some embodiments, the subject tested positive for the
production of IgE antibodies to the treatment the subject is
currently taking for Gaucher disease (e.g., imiglucerase or
uplyso).
[0024] In some embodiments, the subject tested positive for the
production of IgM antibodies to the treatment the subject is
currently taking for Gaucher disease (e.g., imiglucerase or
uplyso).
[0025] In some embodiments, the subject tested positive for the
production of IgG and/or IgA antibodies to the treatment the
subject is currently taking for Gaucher disease (e.g., imiglucerase
or uplyso).
[0026] In another aspect, the disclosure provides a method for
treating a subject with Gaucher disease. The method includes
selecting a subject on the basis that the subject has tested
positive for the production of antibodies (e.g., neutralizing
antibodies) to the treatment the subject is currently taking for
Gaucher disease, e.g., by a method described herein, or on the
basis that the subject is at risk for developing antibodies (e.g.,
neutralizing antibodies) to a treatment for Gaucher disease (e.g.,
imiglucerase or uplyso) and administering velaglucerase to the
subject.
[0027] In some embodiments, the subject tested positive for the
production of IgE antibodies to the treatment the subject is
currently taking for Gaucher disease (e.g., imiglucerase or
uplyso).
[0028] In some embodiments, the subject tested positive for the
production of IgM antibodies to the treatment the subject is
currently taking for Gaucher disease (e.g., imiglucerase or
uplyso).
[0029] In some embodiments, the subject tested positive for the
production of IgG and/or IgA antibodies to the treatment the
subject is currently taking for Gaucher disease (e.g., imiglucerase
or uplyso).
[0030] In some embodiments, velaglucerase is administered at a dose
of 15 to 60 U/kg (e.g. 30 U/kg to 60 U/kg, e.g., 15 U/kg, 30 U/kg,
45 U/kg, or 60 U/kg), at a dose equal to or below 22.5 U/kg, at a
dose between 22.5 and 37.5 U/kg, at a dose between 37.5 and 52.5
U/kg, or at a dose equal to or above 52.5 U/kg. In some
embodiments, velaglucerase is administered at a dose of 2.5 U/kg to
60 U/kg. In some embodiments, the velaglucerase is administered
every other week by intravenous infusion. In other embodiments, the
velaglucerase is administered every week by intravenous infusion.
In some embodiments, the velaglucerase is administered three times
a week by intravenous infusion, e.g., at a dose of 2.5 U/kg.
[0031] In some embodiments, the infusion of the dose (e.g., a dose
described herein) occurs over less than 2 hours, e.g., 90 minutes,
80 minutes, 70 minutes, 60 minutes, 50 minutes or 45 minutes. In
preferred embodiments, the infusion of the dose occurs over 60
minutes.
[0032] In some embodiments, the method includes:
[0033] reconstituting lyophilized velaglucerase with a
pharmaceutically acceptable carrier such as a pharmaceutically
acceptable carrier such as Sterile Water for Injection (e.g.,
reconstituting a 200 unit vial with 2.2 mL of Sterile Water for
Injection or a 400 unit vial with 4.3 mL Sterile Water for
Injection), thereby forming a solution, e.g., wherein the vial is
not shaken after addition of the Sterile Water for Injection;
optionally, inspecting the solution in the vials (and, e.g.,
optionally determining if the solution is discolored or if
particulate matter is present, and optionally deciding not to use
the solution if the solution is discolored or if particulate matter
is present);
[0034] withdrawing a volume of solution to provide a pre-selected
dose (e.g., a dose described herein, e.g., 15 U/kg, 30 U/kg, 45
U/kg, or 60 U/kg);
[0035] diluting the volume, e.g., in 100 mL of 0.9% sodium chloride
solution suitable for intravenous administration, thereby forming a
diluted solution; optionally rocking the diluted solution gently,
but do not shaking the diluted solution; and
[0036] administering the diluted solution to the subject by
intravenous infusion.
[0037] In some embodiments, velaglucerase is administered at a rate
of 2 U/kg/minute, 1.5 U/kg/minute, 1 U/kg/minute, or 0.5
U/kg/minute.
[0038] In some embodiments, the administering comprises home
therapy (e.g., in the subject's home, workplace, or other
non-clinical (e.g., non-hospital) setting). In some embodiments,
the administering (e.g., via infusion) is by a health care
professional (e.g., nurse or physician's assistant). For example,
if the subject has not experienced an adverse event (AE) (e.g., a
drug-related serious AE or an infusion-related AE, e.g., an event
described herein), e.g., after one, two, or three administrations
(e.g., via infusion) of velaglucerase, the subject is eligible to
receive home therapy for subsequent administrations.
[0039] In another aspect, the disclosure provides a method for
identifying a subject as suitable for (e.g., being a candidate for)
treatment with glucocerebrosidase enzyme replacement therapy (e.g.,
velaglucerase). The method includes evaluating (e.g., measuring)
the subject for the presence of infusion site reaction (i.e.,
infusion-related adverse event) (e.g., during or within 12 hours of
infusion of glucocerebrosidase enzyme replacement therapy) (e.g.,
to the therapy currently being administered to the subject, e.g.,
imiglucerase or uplyso), e.g., and comparing the measured level of
the site reaction to a standard (e.g., a negative control). For
example, if the subject has a measured value of site reaction to
the treatment the subject is currently taking for Gaucher disease
that is greater than the value measured for the negative control
(e.g., the site reaction observed after placebo infusion in the
subject), the subject is identified as suitable for treatment with
an alternative Gaucher disease treatment (e.g., treatment with
velaglucerase), e.g., if the measured value of site reaction to the
treatment the subject is currently taking for Gaucher disease is
greater than the value for the standard, e.g., by more than 5%,
10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%,
75%, 80%, 85%, or 90%.
[0040] In some embodiments, the method includes determining the
infusion site value, e.g., by a method described herein.
[0041] In another aspect, the disclosure provides a method for
selecting a subject with Gaucher disease for treatment with
glucocerebrosidase enzyme replacement therapy. Optionally, the
method includes selecting a subject for such treatment on the basis
that the subject is in need of reduced infusion site reaction
(e.g., reduced as compared to the reaction associated with or
caused by the treatment the subject is currently taking for Gaucher
disease, e.g., imiglucerase or uplyso). The method includes
evaluating (e.g., measuring) or obtaining an evaluation of the
subject for the presence of infusion site reaction (i.e.,
infusion-related adverse event) (e.g., during or within 12 hours of
infusion of glucocerebrosidase enzyme replacement therapy) (e.g.,
to the therapy currently being administered to the subject, e.g.,
imiglucerase or uplyso), e.g., and comparing the measured level of
the site reaction to a standard (e.g., a negative control). For
example, if the subject has a measured value of site reaction to
the treatment the subject is currently taking for Gaucher disease
that is greater than (e.g., greater by more than 5%, 10%, 15%, 20%,
25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, or
90%) the value measured for the negative control (e.g., the site
reaction observed after placebo infusion in the subject), the
subject is selected for an alternative Gaucher disease treatment
(e.g., treatment with velaglucerase), e.g., if the measured value
of site reaction to the treatment the subject is currently taking
for Gaucher disease is greater than the value for the standard
(e.g., negative control), e.g., by more than 5%, 10%, 15%, 20%,
25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, or
90%.
[0042] In some embodiments, the method includes measuring the
antibody value, e.g., by a method described herein.
[0043] In another aspect, the disclosure provides a method for
treating a subject with Gaucher disease. The method includes
selecting a subject for such treatment on the basis that the
subject is in need of reduced infusion site reaction (e.g., reduced
as compared to the reaction associated with or caused by the
treatment the subject is currently taking for Gaucher disease,
e.g., imiglucerase or uplyso), e.g., by a method described herein,
and administering velaglucerase to the subject.
[0044] In some embodiments, velaglucerase is administered at a dose
of 15 to 60 U/kg (e.g. 30 U/kg to 60 U/kg, e.g., 15 U/kg, 30 U/kg,
45 U/kg, or 60 U/kg), at a dose equal to or below 22.5 U/kg, at a
dose between 22.5 and 37.5 U/kg, at a dose between 37.5 and 52.5
U/kg, or at a dose equal to or above 52.5 U/kg. In some
embodiments, velaglucerase is administered at a dose of 2.5 U/kg to
60 U/kg. In some embodiments, the velaglucerase is administered
every other week by intravenous infusion. In other embodiments, the
velaglucerase is administered every week by intravenous infusion.
In some embodiments, the velaglucerase is administered three times
a week by intravenous infusion, e.g., at a dose of 2.5 U/kg.
[0045] In some embodiments, the infusion of the dose (e.g., a dose
described herein) occurs over less than 2 hours, e.g., 90 minutes,
80 minutes, 70 minutes, 60 minutes, 50 minutes or 45 minutes.
[0046] In some embodiments, the method includes:
[0047] reconstituting lyophilized velaglucerase with a
pharmaceutically acceptable carrier, e.g., Sterile Water for
Injection (e.g., reconstituting a 200 unit vial with 2.2 mL of
Sterile Water for Injection or a 400 unit vial with 4.3 mL Sterile
Water for Injection), thereby forming a solution, e.g., wherein the
vial is not shaken after addition of the Sterile Water for
Injection; optionally, inspecting the solution in the vials (and,
e.g., optionally determining if the solution is discolored or if
particulate matter is present, and optionally deciding not to use
the solution if the solution is discolored or if particulate matter
is present);
[0048] withdrawing a volume of solution to provide a pre-selected
dose (e.g., a dose described herein such as 15 U/kg, 30 U/kg, 45
U/kg, or 60 U/kg);
[0049] diluting the volume, e.g., in 100 mL of 0.9% sodium chloride
solution suitable for intravenous administration, thereby forming a
diluted solution; optionally rocking the diluted solution gently,
but do not shaking the diluted solution; and [0050] administering
the diluted solution to the subject by intravenous infusion.
[0051] In some embodiments, the velaglucerase is administered at a
rate of 2.0 U/kg/minute, 1.5 U/kg/minute, 1.0 U/kg/minute, or 0.5
U/kg/minute.
[0052] In some embodiments, the administering comprises home
therapy (e.g., in the subject's home, workplace, or other
non-clinical (e.g., non-hospital) setting). In some embodiments,
the administering (e.g., via infusion) is by a health care
professional (e.g., nurse or physician's assistant). For example,
if the subject has not experienced an adverse event (AE) (e.g., a
drug-related serious AE or an infusion-related AE, e.g., an event
described herein), e.g., after one, two, or three administrations
(e.g., via infusion) of velaglucerase, the subject is eligible to
receive home therapy for subsequent administrations.
[0053] In some aspects, the disclosure features a method of
selecting a subject with Gaucher disease (e.g., type I Gaucher
disease) for treatment with velaglucerase, the method
comprising
[0054] identifying a subject with Gaucher disease that has received
a glucocerebrosidase enzyme replacement therapy (e.g., imiglucerase
or uplyso) and has a platelet count less than a standard; and
[0055] selecting the subject for treatment with velaglucerase on
the basis that the subject has a platelet count less than the
standard.
[0056] In some embodiments, the method includes evaluating (e.g.,
measuring platelet count or obtaining an evaluation of platelet
count of a sample from the subject, and comparing the measured
value of the platelet count to the standard (e.g., negative
control).
[0057] In some embodiments, the sample is a blood or serum sample.
In some embodiments, the sample has been modified. In some
embodiments, the measured antibody values were obtained from a
sample that has been enriched for platelets, e.g., a concentrated
portion of a blood sample. In some embodiments, the evaluation was
obtained by a method described herein.
[0058] In some embodiments, the method includes measuring the
platelet count, e.g., by a method described herein.
[0059] In some embodiments, the methods further includes
administering velaglucerase to the subject, e.g., at a dose and/or
dosing schedule described herein.
[0060] In some embodiments, the velaglucerase is administered by
intravenous infusion over a course of less than 2 hours, e.g., 90
minutes, 80 minutes, 70 minutes, 60 minutes, 50 minutes or 45
minutes. In some embodiments, the infusion occurs at a rate of 2
U/kg/minute, 1.5 U/kg/minute, 1 U/kg per minute or 0.5
U/kg/minute.
[0061] In some embodiments, the standard is a platelet count below
or equal to 80.times.10.sup.3 platelets/mm.sup.3. In some
embodiments, the standard is based on the percentage increase in
mean platelet count after 6, 9, or 12 months of treatment with the
glucocerebrosidase enzyme replacement therapy. For example, a
subject in which the mean platelet count increased by less than
80%, 75%, 70%, 65%, 60%, or 55% after 9 or 12 months of treatment
as compared to their baseline mean platelet count prior to
initiating the glucocerebrosidase enzyme replacement therapy (e.g.,
imiglucerase treatment, e.g., imiglucerase at a dose of 60 U/kg,
e.g., administered every other week for 9 months) is identified for
treatment with velaglucerase. As another example, a subject in
which the mean platelet count increased by less than 40%, 35%, 30%,
or 25% after 6 months of treatment as compared to their baseline
mean platelet count prior to initiating the glucocerebrosidase
enzyme replacement therapy (e.g., imiglucerase treatment, e.g.,
imiglucerase at a dose of 60 U/kg, e.g., administered every other
week for 6 months) is identified for treatment with
velaglucerase.
[0062] In some aspects, the disclosure features a method of
treating a subject with Gaucher disease (e.g., type I Gaucher
disease), the method comprising
[0063] selecting a subject with Gaucher disease that has received a
glucocerebrosidase enzyme replacement therapy (e.g., imiglucerase
or uplyso) and has a platelet count less than a standard, e.g., a
subject identified by a method described herein; and
[0064] administering velaglucerase to the subject.
[0065] In some embodiments, velaglucerase is administered at a dose
of 15 to 60 U/kg (e.g. 30 U/kg to 60 U/kg, e.g., 15 U/kg, 30 U/kg,
45 U/kg, or 60 U/kg), at a dose equal to or below 22.5 U/kg, at a
dose between 22.5 and 37.5 U/kg, at a dose between 37.5 and 52.5
U/kg, or at a dose equal to or above 52.5 U/kg. In some
embodiments, velaglucerase is administered at a dose of 2.5 U/kg to
60 U/kg. In some embodiments, the velaglucerase is administered
every other week by intravenous infusion. In other embodiments, the
velaglucerase is administered every week by intravenous infusion.
In some embodiments, the velaglucerase is administered three times
a week by intravenous infusion, e.g., at a dose of 2.5 U/kg.
[0066] In some embodiments, the infusion of the dose (e.g., a dose
described herein) occurs over less than 2 hours, e.g., 90 minutes,
80 minutes, 70 minutes, 60 minutes, 50 minutes or 45 minutes.
[0067] In some embodiments, the method includes:
[0068] reconstituting lyophilized velaglucerase with a
pharmaceutically acceptable carrier such as Sterile Water for
Injection (e.g., reconstituting a 200 unit vial with 2.2 mL of
Sterile Water for Injection or a 400 unit vial with 4.3 mL Sterile
Water for Injection), thereby forming a solution, e.g., wherein the
vial is not shaken after addition of the Sterile Water for
Injection; optionally, inspecting the solution in the vials (and,
e.g., optionally determining if the solution is discolored or if
particulate matter is present, and optionally deciding not to use
the solution if the solution is discolored or if particulate matter
is present);
[0069] withdrawing a volume of solution to provide a pre-selected
dose (e.g., a dose described herein such as 15 U/kg, 30 U/kg, 45
U/kg, or 60 U/kg);
[0070] diluting the volume, e.g., in 100 mL of 0.9% sodium chloride
solution suitable for intravenous administration, thereby forming a
diluted solution; optionally rocking the diluted solution gently,
but do not shaking the diluted solution; and
[0071] administering the diluted solution to the subject by
intravenous infusion.
[0072] In some embodiments, the velaglucerase is administered at a
rate of 2 U/kg/minute, 1.5 U/kg/minute, 1 U/kg/minute or 0.5
U/kg/minute.
[0073] In some embodiments, the administering comprises home
therapy (e.g., in the subject's home, workplace, or other
non-clinical (e.g., non-hospital) setting). In some embodiments,
the administering (e.g., via infusion) is by a health care
professional (e.g., nurse or physician's assistant). For example,
if the subject has not experienced an adverse event (AE) (e.g., a
drug-related serious AE or an infusion-related AE, e.g., an event
described herein), e.g., after one, two, or three administrations
(e.g., via infusion) of velaglucerase, the subject is eligible to
receive home therapy for subsequent administrations.
[0074] In another aspect, the disclosure provides a method for
evaluating a subject, e.g., a subject to whom a glucocerebrosidase
enzyme replacement therapy (e.g., imiglucerase, velaglucerase or
uplyso) is currently being administered. The method includes
evaluating (e.g., measuring) or obtaining an evaluation of one or
more (e.g., 1, 2, 3, 4, 5, 6, or 7) of the following parameters of
the subject:
[0075] hemoglobin concentration, platelet count, liver volume
(e.g., as a percentage of total body weight), spleen volume (e.g.,
as a percentage of total body weight), infusion site reaction, a
skeletal parameter, or presence of antibodies (e.g., neutralizing
antibodies) (e.g., IgE, IgM, IgG and/or IgA antibodies) to a
glucocerebrosidase enzyme replacement therapy (e.g., the mean value
of one or more (e.g., 1, 2, 3, 4, 5, 6, or 7) of these
parameters).
[0076] The skeletal parameter can be, e.g., bone mineral density
(BMD) (e.g., as measured by a change (e.g., improvement) in Z
score). BMD can be evaluated e.g., by dual energy X-ray
absorptiometry (DEXA). Other skeletal parameters that can be
evaluated include, e.g., T-score (e.g., to determine WHO
classification of normal bone, osteopenia, and osteoporosis),
growth of a subject (e.g., a pediatric subject); skeletal age of a
subject (e.g., a pediatric subject); and bone marrow burden (BMB)
(e.g., in an adult subject).
[0077] The evaluating can be performed, e.g., about every week,
about every two weeks, about every three weeks, about every four
weeks, about every two months, about every three months, about
every four months, about every five months, about every six months,
about every seven months, about every eight months, about every
nine months, about every ten months, about every eleven months, or
about every twelve months during the course of treatment. The
evaluating can also be performed prior to commencing treatment
(e.g., to establish a baseline value). The evaluating can include
comparing the value of the parameter from the subject to a standard
(e.g., a standard described herein, e.g., a negative control), and
optionally determining if a difference exists between the value of
the parameter from the subject and the value from the standard. The
standard can be, e.g., a value of the parameter measured in a
subject with Gaucher disease being treated with a different therapy
for Gaucher disease (e.g., a treatment described herein), or a mean
value for a cohort of such subjects (e.g., after the same length of
therapy), or the baseline value for the subject (or a mean baseline
value for a cohort of subjects with Gaucher disease) prior to
commencing therapy (e.g., prior to commencement of a
glucocerebrosidase enzyme replacement therapy (e.g., imiglucerase
or velaglucerase)). For example, a skeletal parameter (e.g., bone
mineral density) can be evaluated for long term changes, e.g.,
after 1, 2, 3, 4, or more years of glucocerebrosidase enzyme
replacement therapy (e.g., imiglucerase, velaglucerase or
uplyso).
[0078] The evaluating can include determining if one or more of the
following are present:
[0079] the difference between one or more of the hemoglobin
concentration, platelet count, liver volume, spleen volume, or a
skeletal parameter
[0080] and that of a standard (for the given parameter) is greater
than 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%,
65%, 70%, 75%, 80%, 85%, or 90%. Alternatively or in addition, the
evaluating can include determining if an infusion site reaction is
present (e.g., during or within 12 hours after infusion) and/or if
antibodies (e.g., neutralizing antibodies) (e.g., IgE, IgM, IgG
and/or IgA antibodies) to a glucocerebrosidase enzyme replacement
therapy (e.g., imiglucerase or uplyso) are present.
[0081] In some embodiments, the evaluation can be of one or more of
hemoglobin concentration, platelet count and determining if
antibodies (e.g., neutralizing antibodies) to a glucocerebrosidase
enzyme replacement therapy (e.g., imiglucerase or uplyso) are
present. In some embodiments, the evaluation for one or more of
these parameters is performed on a sample from the subject, e.g., a
blood or serum sample. In some embodiments, the sample has been
modified. For example, the values were obtained by contacting the
sample with an analytical reagent and/or a substrate or cell, e.g.,
a substrate or cell that binds to an antibody to the
glucocerebrosidase enzyme replacement therapy. In some embodiments,
the values were obtained from a sample that has been enriched for,
e.g., hemoglobin, platelets and/or antibodies, e.g., a concentrated
portion of a blood or serum sample. In some embodiments, the
evaluation was obtained by a method described herein.
[0082] Based on the determination, a treatment decision can be made
for the subject. For example, if a subject receiving a treatment
for Gaucher disease, such as a glucocerebrosidase enzyme
replacement therapy, e.g., imiglucerase or uplyso, has a value for
one or more of the parameters that differs from the value for a
standard (e.g., a subject with Gaucher disease who is receiving a
different therapy (velaglucerase)), a decision can be made to
transfer the subject currently receiving a glucocerebrosidase
enzyme replacement treatment (e.g., imiglucerase treatment) to a
different glucocerebrosidase enzyme replacement treatment (e.g.,
velaglucerase treatment). For example, if antibodies (e.g.,
neutralizing antibodies) (e.g., IgE, IgM, IgG and/or IgA
antibodies) to imiglucerase are detected in a subject undergoing
treatment with imiglucerase, the subject can be transferred to
treatment with velaglucerase. As another example, if an infusion
site reaction is detected during or within 12 hours of
administration of imiglucerase to a subject undergoing treatment
with imiglucerase, the subject can be transferred to treatment with
velaglucerase. As another example, if the mean platelet count in a
subject undergoing treatment with imiglucerase is lower (e.g., 5%,
10%, %, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%,
75%, 80%, 85%, or 90% lower) than the mean platelet count value
obtained for a cohort of subjects with Gaucher disease treated with
velaglucerase for the same duration at the same dose and same
frequency of treatment administration, the subject can be
transferred to velaglucerase treatment.
[0083] In another aspect, the disclosure provides a method of
selecting a treatment for administration to a subject with Gaucher
disease, the method comprising
[0084] selecting a treatment on the basis that the treatment can
increase hemoglobin concentration, increase platelet count,
decrease liver volume, decrease spleen volume, decrease likelihood
(e.g., relative to a standard, e.g., a standard described herein,
e.g., the likelihood for a cohort of subjects receiving a different
treatment (e.g., imiglucerase or uplyso) for Gaucher disease) of
infusion site reaction, change a skeletal parameter (e.g., increase
bone mineral density), and/or decrease likelihood (e.g., relative
to a standard, e.g., a standard described herein, e.g., the
likelihood for a cohort of subjects receiving a different treatment
(e.g., imiglucerase or uplyso) for Gaucher disease) of production
of antibodies (e.g., neutralizing antibodies) (e.g., IgE, IgM, IgG
and/or IgA antibodies) to the treatment. Optionally, the method can
include providing the treatment to the subject, e.g., wherein
providing includes administering the treatment or transferring the
treatment to the subject's possession. In some embodiments, the
treatment can be administered at a dose and/or dosing schedule
described herein.
[0085] The method can include evaluating (e.g., measuring) or
obtaining an evaluation of one or more of these parameters, e.g.,
by a method described herein.
[0086] In one aspect, the disclosure provides a method of selecting
a treatment for administration to a subject in need of an increase
in hemoglobin concentration, an increase in platelet level, a
decrease in liver volume, a decrease in spleen volume, a decreased
likelihood of injection site reaction, a change in a skeletal
parameter (e.g., an increase in bone mineral density), and/or a
decreased likelihood of production of antibodies to the treatment,
the method comprising
[0087] selecting a treatment on the basis that the treatment can
increase hemoglobin concentration, increase platelet count,
decrease liver volume, decrease spleen volume, decrease likelihood
(e.g., relative to a standard, e.g., a standard described herein,
e.g., the likelihood for a cohort of subjects receiving a different
treatment for Gaucher disease) of infusion site reaction, change a
skeletal parameter (e.g., increase bone mineral density), and/or
decrease likelihood (e.g., relative to a standard, e.g., a standard
described herein, e.g., the likelihood for a cohort of subjects
receiving a different treatment for Gaucher disease) of production
of antibodies (e.g., neutralizing antibodies) (e.g., IgE, IgM, IgG
and/or IgA antibodies) to the treatment. Optionally, the method can
include providing the treatment to the subject, e.g., wherein
providing includes administering the treatment or transferring the
treatment to the subject's possession. In some embodiments, the
treatment can be administered at a dose and/or dosing schedule
described herein.
[0088] The method can include evaluating (e.g., measuring) or
obtaining an evaluation of one or more of these parameters, e.g.,
by a method described herein.
[0089] In another aspect, the disclosure provides a method for
evaluating a subject, e.g., a subject who has been selected to
receive treatment with a glucocerebrosidase enzyme replacement
therapy (e.g., imiglucerase, velaglucerase or uplyso). The method
includes evaluating (e.g., measuring) one or more (e.g., 1, 2, 3,
4, 5, 6, or 7) of the following parameters of the subject:
[0090] hemoglobin concentration, platelet count, liver volume
(e.g., as a percentage of total body weight), spleen volume (e.g.,
as a percentage of total body weight), infusion site reaction, a
skeletal parameter, or presence of antibodies (e.g., neutralizing
antibodies) (e.g., IgE, IgM, IgG and/or IgA antibodies) to a
glucocerebrosidase enzyme replacement therapy (e.g., the mean value
of one or more (e.g., 1, 2, 3, 4, 5, 6, or 7) of these
parameters).
[0091] The skeletal parameter can be, e.g., bone mineral density
(BMD) (e.g., as measured by a change (e.g., improvement) in Z
score). BMD can be evaluated e.g., by dual energy X-ray
absorptiometry (DEXA). Other skeletal parameters that can be
evaluated include, e.g., T-score (e.g., to determine WHO
classification of normal bone, osteopenia, and osteoporosis),
growth of a subject (e.g., a pediatric subject); skeletal age of a
subject (e.g., a pediatric subject); and bone marrow burden (BMB)
(e.g., in an adult subject).
[0092] The evaluating can include comparing the value of the
parameter from the subject to a standard (e.g., a standard
described herein, e.g., a negative control), and optionally
determining if a difference exists between the value of the
parameter from the subject and the value from the standard. The
standard can be, e.g., a value of the parameter measured in a
subject with Gaucher disease being treated with a different therapy
for Gaucher disease (e.g., a treatment described herein), or a mean
value for a cohort of such subjects (e.g., after the same length of
therapy), or the baseline value for the subject (or a mean baseline
value for a cohort of subjects with Gaucher disease) prior to
commencing therapy.
[0093] The evaluating can include determining if:
[0094] the difference between one or more of the hemoglobin
concentration, platelet count, liver volume, spleen volume, or a
skeletal parameter (e.g., measured as bone mineral density (BMD))
and that of a standard (for the given parameter) is greater than
5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%,
70%, 75%, 80%, 85%, or 90%.
[0095] In some embodiments, the evaluation can be of one or more of
hemoglobin concentration, platelet count and determining if
antibodies (e.g., neutralizing antibodies) to a glucocerebrosidase
enzyme replacement therapy (e.g., imiglucerase or uplyso) are
present. In some embodiments, the evaluation for one or more of
these parameters is performed on a sample from the subject, e.g., a
blood or serum sample. In some embodiments, the sample has been
modified. For example, the values were obtained by contacting the
sample with an analytical reagent and/or a substrate or cell, e.g.,
a substrate or cell that binds to an antibody to the
glucocerebrosidase enzyme replacement therapy. In some embodiments,
the values were obtained from a sample that has been enriched for,
e.g., hemoglobin, platelets and/or antibodies, e.g., a concentrated
portion of a blood or serum sample. In some embodiments, the
evaluation was obtained by a method described herein.
[0096] In another aspect, the disclosure provides a method of
prescribing a glucocerebrosidase enzyme replacement therapy (e.g.,
imiglucerase, velaglucerase or uplyso), the method comprising:
[0097] receiving an identifier for the glucocerebrosidase enzyme
replacement therapy, e.g., the chemical structure, chemical name,
trade name or generic name of the glucocerebrosidase enzyme
replacement therapy; [0098] receiving information that the
glucocerebrosidase enzyme replacement therapy has one or more of
the following properties: can increase hemoglobin concentration,
increase platelet count, decrease liver volume, decrease spleen
volume, decrease likelihood (e.g., relative to a standard, e.g., a
standard described herein, e.g., the likelihood for a cohort of
subjects receiving a different treatment (e.g., imiglucerase or
uplyso) for Gaucher disease) of infusion site reaction, change a
skeletal parameter (e.g., increase in bone mineral density), and/or
decrease likelihood (e.g., relative to a standard, e.g., a standard
described herein, e.g., the likelihood for a cohort of subjects
receiving a different treatment (e.g., imiglucerase or uplyso) for
Gaucher disease) of production of antibodies (e.g., neutralizing
antibodies) (e.g., IgE, IgM, IgG and/or IgA antibodies) to the
treatment; [0099] selecting a subject in need of the
glucocerebrosidase enzyme replacement therapy, e.g., on the basis
that the subject is in need of one or more of: an increase
hemoglobin concentration, an increase platelet count, a decrease
liver volume, a decrease spleen volume, a decrease likelihood
(e.g., relative to a standard, e.g., a standard described herein,
e.g., the likelihood for a cohort of subjects receiving a different
treatment (e.g., imiglucerase or uplyso) for Gaucher disease) of
infusion site reaction, change a skeletal parameter (e.g., increase
bone mineral density), and/or decrease likelihood (e.g., relative
to a standard, e.g., a standard described herein, e.g., the
likelihood for a cohort of subjects receiving a different treatment
(e.g., imiglucerase or uplyso) for Gaucher disease) of production
of antibodies (e.g., neutralizing antibodies) (e.g., IgE, IgM, IgG
and/or IgA antibodies) to the treatment; and [0100] causing the
glucocerebrosidase enzyme replacement therapy to be prescribed,
dispensed, or administered to a subject.
[0101] In some embodiments, the subject is in need of one or more
of an increase in hemoglobin concentration, an increase in platelet
count and decrease in the likelihood of the production of
antibodies (e.g., neutralizing antibodies) to a glucocerebrosidase
enzyme replacement therapy (e.g., imiglucerase or uplyso). In some
embodiments, a determination that a subject is in need of one or
more of these changes is based upon an evaluation of one or more of
these parameters performed on a sample from the subject, e.g., a
blood or serum sample. In some embodiments, the sample has been
modified. For example, the values were obtained by contacting the
sample with an analytical reagent and/or a substrate or cell, e.g.,
a substrate or cell that binds to an antibody to the
glucocerebrosidase enzyme replacement therapy. In some embodiments,
the values were obtained from a sample that has been enriched for,
e.g., hemoglobin, platelets and/or antibodies, e.g., a concentrated
portion of a blood sample. In some embodiments, the evaluation was
obtained by a method described herein.
[0102] In another aspect, the disclosure provides a method of
providing a recipient with information about, or with guidelines
for, the use of a glucocerebrosidase enzyme replacement therapy
(e.g., imiglucerase or velaglucerase), the method comprising:
[0103] communicating to the recipient an identifier for the
glucocerebrosidase enzyme replacement therapy, e.g., the chemical
structure, chemical name, trade name or generic name of the
glucocerebrosidase enzyme replacement therapy; [0104] communicating
to the recipient information that the glucocerebrosidase enzyme
replacement therapy has one or more of the following properties:
can increase hemoglobin concentration, increase platelet count,
decrease liver volume, decrease spleen volume, decrease likelihood
(e.g., relative to a standard, e.g., a standard described herein,
e.g., the likelihood for a cohort of subjects receiving a different
treatment (e.g., imiglucerase or uplyso) for Gaucher disease) of
infusion site reaction, change a skeletal parameter (e.g., increase
bone mineral density), and/or decrease likelihood (e.g., relative
to a standard, e.g., a standard described herein, e.g., the
likelihood for a cohort of subjects receiving a different treatment
(e.g., imiglucerase or uplyso) for Gaucher disease) of production
of antibodies (e.g., neutralizing antibodies) (e.g., IgE, IgM, IgG
and/or IgA antibodies) to the treatment; [0105] receiving a request
from the recipient to purchase the glucocerebrosidase enzyme
replacement therapy; and [0106] selling, shipping or transferring
the glucocerebrosidase enzyme replacement therapy to the
recipient.
[0107] In another aspect, the disclosure provides a method of
providing a recipient with information about a glucocerebrosidase
enzyme replacement therapy (e.g., imiglucerase, velaglucerase or
uplyso), or with guidelines for, the use of a glucocerebrosidase
enzyme replacement therapy (e.g., imiglucerase or velaglucerase),
the method comprising: [0108] providing an identifier for the
glucocerebrosidase enzyme replacement therapy, e.g., the chemical
structure, chemical name, trade name or generic name of the
glucocerebrosidase enzyme replacement therapy; [0109] providing
information that the glucocerebrosidase enzyme replacement therapy
has one or more of the following properties: can increase
hemoglobin concentration, increase platelet count, decrease liver
volume, decrease spleen volume, decrease likelihood (e.g., relative
to a standard, e.g., a standard described herein, e.g., the
likelihood for a cohort of subjects receiving a different treatment
(e.g., imiglucerase) for Gaucher disease) of infusion site
reaction, change a skeletal parameter (e.g., increase bone mineral
density), and/or decrease likelihood (e.g., relative to a standard,
e.g., a standard described herein, e.g., the likelihood for a
cohort of subjects receiving a different treatment (e.g.,
imiglucerase) for Gaucher disease) of production of antibodies
(e.g., neutralizing antibodies) (e.g., IgE, IgM, IgG and/or IgA
antibodies) to the treatment; [0110] memorializing, e.g., in a
database, the identifier and the information; and [0111]
transferring the memorialization (e.g., the memorialized identifier
and information) to the recipient.
[0112] In another aspect, the disclosure provides a method of
providing a recipient with information about a glucocerebrosidase
enzyme replacement therapy (e.g., imiglucerase, velaglucerase or
uplyso), or with guidelines for the use of a glucocerebrosidase
enzyme replacement therapy (e.g., imiglucerase, velaglucerase or
uplyso), the method comprising: [0113] providing an identifier for
the glucocerebrosidase enzyme replacement therapy, e.g., the
chemical structure, chemical name, trade name or generic name of
the glucocerebrosidase enzyme replacement therapy; [0114] providing
information that the glucocerebrosidase enzyme replacement therapy
has one or more of the following properties: can increase
hemoglobin concentration, increase platelet count, decrease liver
volume, decrease spleen volume, decrease likelihood (e.g., relative
to a standard, e.g., a standard described herein, e.g., the
likelihood for a cohort of subjects receiving a different treatment
(e.g., imiglucerase or uplyso) for Gaucher disease) of infusion
site reaction, change a skeletal parameter (e.g., increase bone
mineral density), and/or decrease likelihood (e.g., relative to a
standard, e.g., a standard described herein, e.g., the likelihood
for a cohort of subjects receiving a different treatment (e.g.,
imiglucerase or uplyso) for Gaucher disease) of production of
antibodies (e.g., neutralizing antibodies) (e.g., IgE, IgM, IgG
and/or IgA antibodies) to the treatment; [0115] associating the
identifier with the information, e.g., in a database or by physical
association; and [0116] transferring the associated identifier and
information to the recipient.
[0117] In another aspect, the disclosure provides a database,
medium, or computer containing or programmed to contain: [0118] an
identifier for a glucocerebrosidase enzyme replacement therapy
(e.g., imiglucerase, velaglucerase or uplyso), e.g., the chemical
structure, chemical name, trade name or generic name of the
glucocerebrosidase enzyme replacement therapy; [0119] information
that the glucocerebrosidase enzyme replacement therapy has one or
more of the following properties: can increase hemoglobin
concentration, increase platelet count, decrease liver volume,
decrease spleen volume, decrease likelihood (e.g., relative to a
standard, e.g., a standard described herein, e.g., the likelihood
for a cohort of subjects receiving a different treatment (e.g.,
imiglucerase) for Gaucher disease) of infusion site reaction,
change a skeletal parameter (e.g., increase bone mineral density),
and/or decrease likelihood (e.g., relative to a standard, e.g., a
standard described herein, e.g., the likelihood for a cohort of
subjects receiving a different treatment (e.g., imiglucerase) for
Gaucher disease) of production of antibodies (e.g., neutralizing
antibodies) (e.g., IgE, IgM, IgG and/or IgA antibodies) to the
treatment; and [0120] an associative function associating the
identifier with the information, e.g., in a database or by physical
association.
[0121] In another aspect, the disclosure provides a method of
making a glucocerebrosidase enzyme replacement therapy (e.g.,
imiglucerase, velaglucerase or uplyso) available to a subject, the
method comprising: [0122] providing to the subject an identifier
for the glucocerebrosidase enzyme replacement therapy, e.g., the
chemical structure, chemical name, trade name or generic name of
the glucocerebrosidase enzyme replacement therapy; [0123] providing
to the subject information that the glucocerebrosidase enzyme
replacement therapy has one or more of the following properties:
can increase hemoglobin concentration, increase platelet count,
decrease liver volume, decrease spleen volume, decrease likelihood
(e.g., relative to a standard, e.g., a standard described herein,
e.g., the likelihood for a cohort of subjects receiving a different
treatment (e.g., imiglucerase or uplyso) for Gaucher disease) of
infusion site reaction, change a skeletal parameter (e.g., increase
bone mineral density), and/or decrease likelihood (e.g., relative
to a standard, e.g., a standard described herein, e.g., the
likelihood for a cohort of subjects receiving a different treatment
(e.g., imiglucerase or uplyso) for Gaucher disease) of production
of antibodies (e.g., neutralizing antibodies) (e.g., IgE, IgM, IgG
and/or IgA antibodies) to the treatment; and [0124] placing into
commerce, a dose of the glucocerebrosidase enzyme replacement
therapy which can be administered to, provided to, or purchased by
the subject.
[0125] In another aspect, the disclosure provides a method of
causing a subject to request a glucocerebrosidase enzyme
replacement therapy (e.g., imiglucerase, velaglucerase or uplyso),
the method comprising: [0126] providing to the subject an
identifier for the glucocerebrosidase enzyme replacement therapy,
e.g., the chemical structure, chemical name, trade name or generic
name of the glucocerebrosidase enzyme replacement therapy; [0127]
providing to the subject information that the glucocerebrosidase
enzyme replacement therapy has one or more of the following can
increase hemoglobin concentration, increase platelet count,
decrease liver volume, decrease spleen volume, decrease likelihood
(e.g., relative to a standard, e.g., a standard described herein,
e.g., the likelihood for a cohort of subjects receiving a different
treatment (e.g., imiglucerase or uplyso) for Gaucher disease) of
infusion site reaction, change a skeletal parameter (e.g., increase
bone mineral density), and/or decrease likelihood (e.g., relative
to a standard, e.g., a standard described herein, e.g., the
likelihood for a cohort of subjects receiving a different treatment
(e.g., imiglucerase or uplyso) for Gaucher disease) of production
of antibodies (e.g., neutralizing antibodies) (e.g., IgE, IgM, IgG
and/or IgA antibodies) to the treatment; and [0128] placing into
commerce, a dose of the glucocerebrosidase enzyme replacement
therapy which can be administered to, provided to, or purchased by
the subject.
[0129] In another aspect, the disclosure features a method of
selecting a payment class for a course of treatment with a
glucocerebrosidase enzyme replacement therapy (e.g., imiglucerase,
velaglucerase or uplyso) for a subject with Gaucher disease (e.g.,
type I Gaucher disease). The method includes providing (e.g.,
receiving) an evaluation of whether or not the subject experiences
an infusion site reaction to a glucocerebrosidase enzyme
replacement therapy or produces antibodies (e.g., neutralizing
antibodies) (e.g., IgE, IgM, IgG and/or IgA antibodies) to a
glucocerebrosidase enzyme replacement therapy; and performing at
least one of (1) if the subject experiences an infusion site
reaction to a glucocerebrosidase enzyme replacement therapy or
produces antibodies (e.g., neutralizing antibodies) (e.g., IgE,
IgM, IgG and/or IgA antibodies) to a glucocerebrosidase enzyme
replacement therapy selecting a first payment class, and (2) if the
subject does not experience an infusion site reaction to a
glucocerebrosidase enzyme replacement therapy or does not produce
antibodies (e.g., neutralizing antibodies) (e.g., IgE, IgM, IgG
and/or IgA antibodies) to a glucocerebrosidase enzyme replacement
therapy selecting a second payment class.
[0130] In some embodiments, assignment of the subject is to the
first class and the assignment authorizes payment for a course of
treatment (e.g., velaglucerase).
[0131] In some embodiments, assignment of the subject is to the
second class and the assignment authorizes payment for a course of
treatment (e.g., imiglucerase, velaglucerase or uplyso).
[0132] In some embodiments, the evaluation is whether or not a
subject produces antibodies (e.g., neutralizing antibodies) (e.g.,
IgE, IgM, IgG and/or IgA antibodies) to a glucocerebrosidase enzyme
replacement therapy and the evaluation was obtained by a method
described herein.
[0133] In another aspect, the disclosure features a method of
selecting a payment class for a course of treatment with a
glucocerebrosidase enzyme replacement therapy (e.g., imiglucerase,
velaglucerase or uplyso) for a subject with Gaucher disease (e.g.,
type I Gaucher disease). The method includes providing (e.g.,
receiving) an evaluation of whether or not the subject's mean
platelet count increased by less than 80%, 75%, 70%, 65%, 60%, or
55% after 9 or 12 months of treatment as compared to their baseline
mean platelet count prior to initiating the glucocerebrosidase
enzyme replacement therapy (e.g., imiglucerase treatment, e.g.,
imiglucerase at a dose of 60 U/kg, e.g., administered every other
week for 9 months) or whether the subject's mean platelet count
increased by less than 40%, 35%, 30%, or 25% after 6 months of
treatment as compared to their baseline mean platelet count prior
to initiating the glucocerebrosidase enzyme replacement therapy
(e.g., imiglucerase treatment, e.g., imiglucerase at a dose of 60
U/kg, e.g., administered every other week for 6 months); and
performing at least one of (1) if the subject's mean platelet count
increased by less than 80%, 75%, 70%, 65%, 60%, or 55% after 9 or
12 months of treatment as compared to their baseline mean platelet
count prior to initiating the glucocerebrosidase enzyme replacement
therapy (e.g., imiglucerase treatment, e.g., imiglucerase at a dose
of 60 U/kg, e.g., administered every other week for 9 months) or if
the subject's mean platelet count increased by less than 40%, 35%,
30%, or 25% after 6 months of treatment as compared to their
baseline mean platelet count prior to initiating the
glucocerebrosidase enzyme replacement therapy (e.g., imiglucerase
treatment, e.g., imiglucerase at a dose of 60 U/kg, e.g.,
administered every other week for 6 months), selecting a first
payment class, and (2) if the subject's mean platelet count
increased by 80%, 75%, 70%, 65%, 60%, or 55% after 9 or 12 months
of treatment as compared to their baseline mean platelet count
prior to initiating the glucocerebrosidase enzyme replacement
therapy (e.g., imiglucerase treatment, e.g., imiglucerase at a dose
of 60 U/kg, e.g., administered every other week for 9 months) or if
the subject's mean platelet count increased by 40%, 35%, 30%, or
25% after 6 months of treatment as compared to their baseline mean
platelet count prior to initiating the glucocerebrosidase enzyme
replacement therapy (e.g., imiglucerase treatment, e.g.,
imiglucerase at a dose of 60 U/kg, e.g., administered every other
week for 6 months), selecting a second payment class.
[0134] In some embodiments, assignment of the subject is to the
first class and the assignment authorizes payment for a course of
treatment (e.g., velaglucerase).
[0135] In some embodiments, assignment of the subject is to the
second class and the assignment authorizes payment for a course of
treatment (e.g., imiglucerase, velaglucerase or uplyso).
[0136] In some embodiments, the evaluation was obtained by a method
described herein.
[0137] In one aspect, the disclosure features a method of providing
information on which to make a decision about a subject with
Gaucher disease (e.g., type I Gaucher disease), or making such a
decision. The method includes providing (e.g., by receiving) an
evaluation of a subject, wherein the evaluation was made by a
method described herein, e.g., by optionally, administering a
glucocerebrosidase enzyme replacement therapy (e.g., imiglucerase,
velaglucerase or uplyso), to the subject; providing a determination
post administration of whether or not the subject experiences an
infusion site reaction to a glucocerebrosidase enzyme replacement
therapy or produces antibodies (e.g., neutralizing antibodies)
(e.g., IgE, IgM, IgG and/or IgA antibodies) to a glucocerebrosidase
enzyme replacement therapy, thereby providing a post administration
determination; providing a comparison of the post administration
determination with a standard (e.g., a standard described herein),
thereby, providing information on which to make a decision about a
subject, or making such a decision.
[0138] In some embodiments, the method includes making the
decision.
[0139] In some embodiments, the method also includes communicating
the information to another party (e.g., by computer, compact disc,
telephone, facsimile, email, or letter).
[0140] In some embodiments, the decision includes selecting a
subject for payment, making or authorizing payment for a first
course of action (e.g., treatment with velaglucerase) if the
subject experiences an infusion site reaction to a
glucocerebrosidase enzyme replacement therapy or produces
antibodies (e.g., neutralizing antibodies) (e.g., IgE, IgM, IgG
and/or IgA antibodies) to a glucocerebrosidase enzyme replacement
therapy and a second course of action (e.g., treatment with
imiglucerase, velaglucerase or uplyso) if the subject does not
experience an infusion site reaction to a glucocerebrosidase enzyme
replacement therapy or does not produce antibodies (e.g.,
neutralizing antibodies) (e.g., IgE, IgM, IgG and/or IgA
antibodies) to a glucocerebrosidase enzyme replacement.
[0141] In some embodiments, the subject experiences an infusion
site reaction to a glucocerebrosidase enzyme replacement therapy or
produces antibodies (e.g., neutralizing antibodies) (e.g., IgE,
IgM, IgG and/or IgA antibodies) to a glucocerebrosidase enzyme
replacement therapy and the course of action is authorization of a
course of therapy (e.g., treatment with velaglucerase).
[0142] In some embodiments, the subject experiences an infusion
site reaction to a glucocerebrosidase enzyme replacement therapy or
produces antibodies (e.g., neutralizing antibodies) (e.g., IgE,
IgM, IgG and/or IgA antibodies) to a glucocerebrosidase enzyme
replacement therapy and the course of action is assigning the
subject to a first class. In some embodiments, assignment to the
first class will enable payment for a treatment (e.g.,
velaglucerase) provided to the subject. In some embodiments,
payment is by a first party to a second party. In some embodiments,
the first party is other than the subject. In some embodiments, the
first party is selected from a third party payer, an insurance
company, employer, employer sponsored health plan, HMO, or
governmental entity. In some embodiments, the second party is
selected from the subject, a healthcare provider, a treating
physician, an HMO, a hospital, a governmental entity, or an entity
which sells or supplies the treatment. In some embodiments, the
first party is an insurance company and the second party is
selected from the subject, a healthcare provider, a treating
physician, an HMO, a hospital, a governmental entity, or an entity
which sells or supplies the treatment. In some embodiments, the
first party is a governmental entity and the second party is
selected from the subject, a healthcare provider, a treating
physician, an HMO, a hospital, an insurance company, or an entity
which sells or supplies the treatment.
[0143] In some embodiments, the subject does not experience an
infusion site reaction to a glucocerebrosidase enzyme replacement
therapy or does not produce antibodies (e.g., neutralizing
antibodies) (e.g., IgE, IgM, IgG and/or IgA antibodies) to a
glucocerebrosidase enzyme replacement and the course of action is
authorization of a course of therapy (e.g., imiglucerase,
velaglucerase or uplyso).
[0144] In some embodiments, the subject does not experience an
infusion site reaction to a glucocerebrosidase enzyme replacement
therapy or does not produce antibodies (e.g., neutralizing
antibodies) (e.g., IgE, IgM, IgG and/or IgA antibodies) to a
glucocerebrosidase enzyme replacement and the course of action is
assigning the subject to a second class. In some embodiments,
assignment to the second class will enable payment for a treatment
(e.g., imiglucerase, velaglucerase or uplyso) provided to the
subject. In some embodiments, payment is by a first party to a
second party. In some embodiments, the first party is other than
the subject. In some embodiments, the first party is selected from
a third party payer, an insurance company, employer, employer
sponsored health plan, HMO, or governmental entity. In some
embodiments, the second party is selected from the subject, a
healthcare provider, a treating physician, an HMO, a hospital, a
governmental entity, or an entity which sells or supplies the
treatment. In some embodiments, the first party is an insurance
company and the second party is selected from the subject, a
healthcare provider, a treating physician, an HMO, a hospital, a
governmental entity, or an entity which sells or supplies the
treatment. In some embodiments, the first party is a governmental
entity and the second party is selected from the subject, a
healthcare provider, a treating physician, an HMO, a hospital, an
insurance company, or an entity which sells or supplies the
treatment.
[0145] In one aspect, the disclosure features a method of providing
information on which to make a decision about a subject with
Gaucher disease (e.g., type I Gaucher disease), or making such a
decision. The method includes providing (e.g., by receiving) an
evaluation of a subject, wherein the evaluation was made by a
method described herein, e.g., by optionally, administering a
glucocerebrosidase enzyme replacement therapy (e.g., imiglucerase,
velaglucerase or uplyso), to the subject; providing a determination
post administration of whether or not the subject's mean platelet
count increased by less than 80%, 75%, 70%, 65%, 60%, or 55% after
9 or 12 months of treatment as compared to their baseline mean
platelet count prior to initiating the glucocerebrosidase enzyme
replacement therapy (e.g., imiglucerase treatment, e.g.,
imiglucerase at a dose of 60 U/kg, e.g., administered every other
week for 9 months) or whether the subject's mean platelet count
increased by less than 40%, 35%, 30%, or 25% after 6 months of
treatment as compared to their baseline mean platelet count prior
to initiating the glucocerebrosidase enzyme replacement therapy
(e.g., imiglucerase treatment, e.g., imiglucerase at a dose of 60
U/kg, e.g., administered every other week for 6 months), thereby
providing a post administration determination; providing a
comparison of the post administration determination with a standard
(e.g., a standard described herein), thereby, providing information
on which to make a decision about a subject, or making such a
decision.
[0146] In some embodiments, the method includes making the
decision.
[0147] In some embodiments, the method also includes communicating
the information to another party (e.g., by computer, compact disc,
telephone, facsimile, email, or letter).
[0148] In some embodiments, the decision includes selecting a
subject for payment, making or authorizing payment for a first
course of action (e.g., treatment with velaglucerase) if the
subject's mean platelet count increased by less than 80%, 75%, 70%,
65%, 60%, or 55% after 9 or 12 months of treatment as compared to
their baseline mean platelet count prior to initiating the
glucocerebrosidase enzyme replacement therapy (e.g., imiglucerase
treatment, e.g., imiglucerase at a dose of 60 U/kg, e.g.,
administered every other week for 9 months) or if the subject's
mean platelet count increased by less than 40%, 35%, 30%, or 25%
after 6 months of treatment as compared to their baseline mean
platelet count prior to initiating the glucocerebrosidase enzyme
replacement therapy (e.g., imiglucerase treatment, e.g.,
imiglucerase at a dose of 60 U/kg, e.g., administered every other
week for 6 months) and a second course of action (e.g., treatment
with imiglucerase, velaglucerase or uplyso) if the subject's mean
platelet count increased by 80%, 75%, 70%, 65%, 60%, or 55% after 9
or 12 months of treatment as compared to their baseline mean
platelet count prior to initiating the glucocerebrosidase enzyme
replacement therapy (e.g., imiglucerase treatment, e.g.,
imiglucerase at a dose of 60 U/kg, e.g., administered every other
week for 9 months) or if the subject's mean platelet count
increased by 40%, 35%, 30%, or 25% after 6 months of treatment as
compared to their baseline mean platelet count prior to initiating
the glucocerebrosidase enzyme replacement therapy (e.g.,
imiglucerase treatment, e.g., imiglucerase at a dose of 60 U/kg,
e.g., administered every other week for 6 months).
[0149] In some embodiments, the subject's mean platelet count
increased by less than 80%, 75%, 70%, 65%, 60%, or 55% after 9 or
12 months of treatment as compared to their baseline mean platelet
count prior to initiating the glucocerebrosidase enzyme replacement
therapy (e.g., imiglucerase treatment, e.g., imiglucerase at a dose
of 60 U/kg, e.g., administered every other week for 9 months) or
the subject's mean platelet count increased by less than 40%, 35%,
30%, or 25% after 6 months of treatment as compared to their
baseline mean platelet count prior to initiating the
glucocerebrosidase enzyme replacement therapy (e.g., imiglucerase
treatment, e.g., imiglucerase at a dose of 60 U/kg, e.g.,
administered every other week for 6 months) and the course of
action is authorization of a course of therapy (e.g., treatment
with velaglucerase).
[0150] In some embodiments, assignment of the subject is to the
first class and the assignment authorizes payment for a course of
treatment (e.g., velaglucerase).
[0151] In some embodiments, assignment of the subject is to the
second class and the assignment authorizes payment for a course of
treatment (e.g., imiglucerase, velaglucerase or uplyso).
[0152] In some embodiments, the subject's mean platelet count
increased by less than 80%, 75%, 70%, 65%, 60%, or 55% after 9 or
12 months of treatment as compared to their baseline mean platelet
count prior to initiating the glucocerebrosidase enzyme replacement
therapy (e.g., imiglucerase treatment, e.g., imiglucerase at a dose
of 60 U/kg, e.g., administered every other week for 9 months) or
the subject's mean platelet count increased by less than 40%, 35%,
30%, or 25% after 6 months of treatment as compared to their
baseline mean platelet count prior to initiating the
glucocerebrosidase enzyme replacement therapy (e.g., imiglucerase
treatment, e.g., imiglucerase at a dose of 60 U/kg, e.g.,
administered every other week for 6 months) and the course of
action is assigning the subject to a first class. In some
embodiments, assignment to the first class will enable payment for
a treatment (e.g., velaglucerase) provided to the subject. In some
embodiments, payment is by a first party to a second party. In some
embodiments, the first party is other than the subject. In some
embodiments, the first party is selected from a third party payer,
an insurance company, employer, employer sponsored health plan,
HMO, or governmental entity. In some embodiments, the second party
is selected from the subject, a healthcare provider, a treating
physician, an HMO, a hospital, a governmental entity, or an entity
which sells or supplies the treatment. In some embodiments, the
first party is an insurance company and the second party is
selected from the subject, a healthcare provider, a treating
physician, an HMO, a hospital, a governmental entity, or an entity
which sells or supplies the treatment. In some embodiments, the
first party is a governmental entity and the second party is
selected from the subject, a healthcare provider, a treating
physician, an HMO, a hospital, an insurance company, or an entity
which sells or supplies the treatment.
[0153] In some embodiments, the subject's mean platelet count
increased by 80%, 75%, 70%, 65%, 60%, or 55% after 9 or 12 months
of treatment as compared to their baseline mean platelet count
prior to initiating the glucocerebrosidase enzyme replacement
therapy (e.g., imiglucerase treatment, e.g., imiglucerase at a dose
of 60 U/kg, e.g., administered every other week for 9 months) or if
the subject's mean platelet count increased by 40%, 35%, 30%, or
25% after 6 months of treatment as compared to their baseline mean
platelet count prior to initiating the glucocerebrosidase enzyme
replacement therapy (e.g., imiglucerase treatment, e.g.,
imiglucerase at a dose of 60 U/kg, e.g., administered every other
week for 6 months) and the course of action is authorization of a
course of therapy (e.g., imiglucerase, velaglucerase or
uplyso).
[0154] In some embodiments, the subject's mean platelet count
increased by 80%, 75%, 70%, 65%, 60%, or 55% after 9 or 12 months
of treatment as compared to their baseline mean platelet count
prior to initiating the glucocerebrosidase enzyme replacement
therapy (e.g., imiglucerase treatment, e.g., imiglucerase at a dose
of 60 U/kg, e.g., administered every other week for 9 months) or if
the subject's mean platelet count increased by 40%, 35%, 30%, or
25% after 6 months of treatment as compared to their baseline mean
platelet count prior to initiating the glucocerebrosidase enzyme
replacement therapy (e.g., imiglucerase treatment, e.g.,
imiglucerase at a dose of 60 U/kg, e.g., administered every other
week for 6 months) and the course of action is assigning the
subject to a second class. In some embodiments, assignment to the
second class will enable payment for a treatment (e.g.,
imiglucerase, velaglucerase or uplyso) provided to the subject. In
some embodiments, payment is by a first party to a second party. In
some embodiments, the first party is other than the subject. In
some embodiments, the first party is selected from a third party
payer, an insurance company, employer, employer sponsored health
plan, HMO, or governmental entity. In some embodiments, the second
party is selected from the subject, a healthcare provider, a
treating physician, an HMO, a hospital, a governmental entity, or
an entity which sells or supplies the treatment. In some
embodiments, the first party is an insurance company and the second
party is selected from the subject, a healthcare provider, a
treating physician, an HMO, a hospital, a governmental entity, or
an entity which sells or supplies the treatment. In some
embodiments, the first party is a governmental entity and the
second party is selected from the subject, a healthcare provider, a
treating physician, an HMO, a hospital, an insurance company, or an
entity which sells or supplies the treatment.
[0155] In another aspect, the disclosure features a method of
selecting a payment class for a course of treatment with a
glucocerebrosidase enzyme replacement therapy (e.g., velaglucerase)
for a subject with Gaucher disease (type I Gaucher disease). The
method includes determining that an infusion site reaction during
or within 12 hours after infusion of the therapy is present in the
subject or that antibodies (e.g., neutralizing antibodies) (e.g.,
IgE, IgM, IgG and/or IgA antibodies) to the therapy are present in
the subject, e.g., by a method described herein, and approving,
making, authorizing, receiving, transmitting or otherwise allowing
payment of a selected course of treatment, e.g., velaglucerase.
[0156] In another aspect, the disclosure features a method of
selecting a payment class for a course of treatment with a
glucocerebrosidase enzyme replacement therapy (e.g., imiglucerase
velaglucerase, or uplyso) for a subject with Gaucher disease (type
I Gaucher disease). The method includes determining that an
infusion site reaction during or within 12 hours after infusion of
the therapy is not present in the subject or that antibodies (e.g.,
neutralizing antibodies) (e.g., IgE, IgM, IgG and/or IgA
antibodies) to the therapy are not present in the subject, e.g., by
a method described herein, and approving, making, authorizing,
receiving, transmitting or otherwise allowing payment of a selected
course of treatment, e.g., imiglucerase, velaglucerase or
uplyso.
[0157] In one aspect, the disclosure features a method of making a
data record. The method includes entering the result of a method
described herein into a record, e.g., a computer readable record.
In some embodiments, the record is available on the world wide web.
In some embodiments, the record is evaluated by a third party
payer, an insurance company, employer, employer sponsored health
plan, HMO, or governmental entity, or a healthcare provider, a
treating physician, an HMO, a hospital, a governmental entity, or
an entity which sells or supplies the treatment, or is otherwise
relied on in a method described herein.
[0158] In another aspect, the disclosure features a data record
(e.g., computer readable record), wherein the record includes
results from a method described herein. In some embodiments, the
record is available on the world wide web. In some embodiments, the
record is evaluated and/or transmitted to a third party payer, an
insurance company, employer, employer sponsored health plan, HMO,
or governmental entity, or a healthcare provider, a treating
physician, an HMO, a hospital, a governmental entity, or an entity
which sells or supplies the treatment.
[0159] In one aspect, the disclosure features a method of providing
data. The method includes providing data described herein, e.g.,
generated by a method described herein, to provide a record, e.g.,
a record described herein, for determining if a payment will be
provided. In some embodiments, the data is provided by computer,
compact disc, telephone, facsimile, email, or letter. In some
embodiments, the data is provided by a first party to a second
party. In some embodiments, the first party is selected from the
subject, a healthcare provider, a treating physician, an HMO, a
hospital, a governmental entity, or an entity which sells or
supplies the treatment. In some embodiments, the second party is a
third party payer, an insurance company, employer, employer
sponsored health plan, HMO, or governmental entity. In some
embodiments, the first party is selected from the subject, a
healthcare provider, a treating physician, an HMO, a hospital, an
insurance company, or an entity which sells or supplies the
treatment and the second party is a governmental entity. In some
embodiments, the first party is selected from the subject, a
healthcare provider, a treating physician, an HMO, a hospital, an
insurance company, or an entity which sells or supplies the
treatment and the second party is an insurance company.
[0160] In one aspect, the disclosure features a method of
transmitting a record described herein. The method includes a first
party transmitting the record to a second party, e.g., by computer,
compact disc, telephone, facsimile, email, or letter. In some
embodiments, the second party is selected from the subject, a
healthcare provider, a treating physician, an HMO, a hospital, a
governmental entity, or an entity which sells or supplies the
treatment. In some embodiments, the first party is an insurance
company or government entity and the second party is selected from
the subject, a healthcare provider, a treating physician, an HMO, a
hospital, a governmental entity, or an entity which sells or
supplies the treatment. In some embodiments, the first party is a
governmental entity or insurance company and the second party is
selected from the subject, a healthcare provider, a treating
physician, an HMO, a hospital, an insurance company, or an entity
which sells or supplies the treatment.
[0161] In one method, information, e.g., about whether or not a
subject with Gaucher disease experiences an infusion site reaction
to a glucocerebrosidase enzyme replacement therapy or produces
antibodies (e.g., neutralizing antibodies) (e.g., IgE, IgM, IgG
and/or IgA antibodies) to a glucocerebrosidase enzyme replacement
therapy (e.g., wherein the information is obtained as described
herein) is provided (e.g., communicated, e.g., electronically
communicated) to a third party, e.g., a hospital, clinic, a
government entity, reimbursing party or insurance company (e.g., a
life insurance company). For example, choice of medical procedure,
payment for a medical procedure, payment by a reimbursing party, or
cost for a service or insurance can be function of the information.
E.g., the third party receives the information, makes a
determination based at least in part on the information, and
optionally communicates the information or makes a choice of
procedure, payment, level of payment, coverage, etc. based on the
information.
[0162] In one method, information, e.g., whether or not the mean
platelet count of a subject with Gaucher disease increased by less
than 80%, 75%, 70%, 65%, 60%, or 55% after 9 or 12 months of
treatment as compared to their baseline mean platelet count prior
to initiating the glucocerebrosidase enzyme replacement therapy
(e.g., imiglucerase treatment, e.g., imiglucerase at a dose of 60
U/kg, e.g., administered every other week for 9 months) or whether
the subject's mean platelet count increased by less than 40%, 35%,
30%, or 25% after 6 months of treatment as compared to their
baseline mean platelet count prior to initiating the
glucocerebrosidase enzyme replacement therapy (e.g., imiglucerase
treatment, e.g., imiglucerase at a dose of 60 U/kg, e.g.,
administered every other week for 6 months) (e.g., wherein the
information is obtained as described herein) is provided (e.g.,
communicated, e.g., electronically communicated) to a third party,
e.g., a hospital, clinic, a government entity, reimbursing party or
insurance company (e.g., a life insurance company). For example,
choice of medical procedure, payment for a medical procedure,
payment by a reimbursing party, or cost for a service or insurance
can be function of the information. E.g., the third party receives
the information, makes a determination based at least in part on
the information, and optionally communicates the information or
makes a choice of procedure, payment, level of payment, coverage,
etc. based on the information.
[0163] In one embodiment, a premium for insurance (e.g., life or
medical) is evaluated as a function of information about whether or
not a subject with Gaucher disease experiences an infusion site
reaction to a glucocerebrosidase enzyme replacement therapy or
produces antibodies (e.g., neutralizing antibodies) (e.g., IgE,
IgM, IgG and/or IgA antibodies) to a glucocerebrosidase enzyme
replacement therapy. For example, premiums can be increased (e.g.,
by a certain percentage) if the subject experiences an infusion
site reaction to a glucocerebrosidase enzyme replacement or
produces antibodies (e.g., neutralizing antibodies) (e.g., IgE,
IgM, IgG and/or IgA antibodies) to a glucocerebrosidase enzyme
replacement therapy.
[0164] In one embodiment, a premium for insurance (e.g., life or
medical) is evaluated as a function of information about whether or
not the mean platelet count of a subject with Gaucher disease
increased by less than 80%, 75%, 70%, 65%, 60%, or 55% after 9 or
12 months of treatment as compared to their baseline mean platelet
count prior to initiating the glucocerebrosidase enzyme replacement
therapy (e.g., imiglucerase treatment, e.g., imiglucerase at a dose
of 60 U/kg, e.g., administered every other week for 9 months) or
whether the subject's mean platelet count increased by less than
40%, 35%, 30%, or 25% after 6 months of treatment as compared to
their baseline mean platelet count prior to initiating the
glucocerebrosidase enzyme replacement therapy (e.g., imiglucerase
treatment, e.g., imiglucerase at a dose of 60 U/kg, e.g.,
administered every other week for 6 months) (e.g., wherein the
information is obtained as described herein). For example, premiums
can be increased (e.g., by a certain percentage) if the subject's
mean platelet count increased by less than 80%, 75%, 70%, 65%, 60%,
or 55% after 9 or 12 months of treatment as compared to their
baseline mean platelet count prior to initiating the
glucocerebrosidase enzyme replacement therapy (e.g., imiglucerase
treatment, e.g., imiglucerase at a dose of 60 U/kg, e.g.,
administered every other week for 9 months) or whether the
subject's mean platelet count increased by less than 40%, 35%, 30%,
or 25% after 6 months of treatment as compared to their baseline
mean platelet count prior to initiating the glucocerebrosidase
enzyme replacement therapy (e.g., imiglucerase treatment, e.g.,
imiglucerase at a dose of 60 U/kg, e.g., administered every other
week for 6 months).
[0165] Information about whether or not a subject with Gaucher
disease experiences an infusion site reaction to a
glucocerebrosidase enzyme replacement therapy or produces
antibodies (e.g., neutralizing antibodies) (e.g., IgE, IgM, IgG
and/or IgA antibodies) to a glucocerebrosidase enzyme replacement
therapy can be used, e.g., in an underwriting process for life
insurance. The information can be incorporated into a profile about
a subject. Other information in the profile can include, for
example, date of birth, gender, marital status, banking
information, credit information, children, and so forth. An
insurance policy can be recommended as a function of the
information on whether or not a subject with Gaucher disease
experiences an infusion site reaction to a glucocerebrosidase
enzyme replacement therapy or produces antibodies (e.g.,
neutralizing antibodies) (e.g., IgE, IgM, IgG and/or IgA
antibodies) to a glucocerebrosidase enzyme replacement therapy. An
insurance premium or risk assessment can also be evaluated as
function of whether or not a subject with Gaucher disease
experiences an infusion site reaction to a glucocerebrosidase
enzyme replacement therapy or produces antibodies (e.g.,
neutralizing antibodies) (e.g., IgE, IgM, IgG and/or IgA
antibodies) to a glucocerebrosidase enzyme replacement therapy.
[0166] Information about whether or not the subject's mean platelet
count increased by less than 80%, 75%, 70%, 65%, 60%, or 55% after
9 or 12 months of treatment as compared to their baseline mean
platelet count prior to initiating the glucocerebrosidase enzyme
replacement therapy (e.g., imiglucerase treatment, e.g.,
imiglucerase at a dose of 60 U/kg, e.g., administered every other
week for 9 months) or whether the subject's mean platelet count
increased by less than 40%, 35%, 30%, or 25% after 6 months of
treatment as compared to their baseline mean platelet count prior
to initiating the glucocerebrosidase enzyme replacement therapy
(e.g., imiglucerase treatment, e.g., imiglucerase at a dose of 60
U/kg, e.g., administered every other week for 6 months) can be
used, e.g., in an underwriting process for life insurance. The
information can be incorporated into a profile about a subject.
Other information in the profile can include, for example, date of
birth, gender, marital status, banking information, credit
information, children, and so forth. An insurance policy can be
recommended as a function of the information on whether or not the
subject's mean platelet count increased by less than 80%, 75%, 70%,
65%, 60%, or 55% after 9 or 12 months of treatment as compared to
their baseline mean platelet count prior to initiating the
glucocerebrosidase enzyme replacement therapy (e.g., imiglucerase
treatment, e.g., imiglucerase at a dose of 60 U/kg, e.g.,
administered every other week for 9 months) or whether the
subject's mean platelet count increased by less than 40%, 35%, 30%,
or 25% after 6 months of treatment as compared to their baseline
mean platelet count prior to initiating the glucocerebrosidase
enzyme replacement therapy (e.g., imiglucerase treatment, e.g.,
imiglucerase at a dose of 60 U/kg, e.g., administered every other
week for 6 months). An insurance premium or risk assessment can
also be evaluated as function of whether or not whether or not the
subject's mean platelet count increased by less than 80%, 75%, 70%,
65%, 60%, or 55% after 9 or 12 months of treatment as compared to
their baseline mean platelet count prior to initiating the
glucocerebrosidase enzyme replacement therapy (e.g., imiglucerase
treatment, e.g., imiglucerase at a dose of 60 U/kg, e.g.,
administered every other week for 9 months) or whether the
subject's mean platelet count increased by less than 40%, 35%, 30%,
or 25% after 6 months of treatment as compared to their baseline
mean platelet count prior to initiating the glucocerebrosidase
enzyme replacement therapy (e.g., imiglucerase treatment, e.g.,
imiglucerase at a dose of 60 U/kg, e.g., administered every other
week for 6 months).
[0167] In one embodiment, information about whether or not a
subject with Gaucher disease experiences an infusion site reaction
to a glucocerebrosidase enzyme replacement therapy or produces
antibodies (e.g., neutralizing antibodies) (e.g., IgE, IgM, IgG
and/or IgA antibodies) to a glucocerebrosidase enzyme replacement
therapy is analyzed by a function that determines whether to
authorize the transfer of funds to pay for a service or treatment
provided to a subject (or make another decision referred to
herein). For example, the results (e.g., that the subject
experiences an infusion site reaction to a glucocerebrosidase
enzyme replacement therapy or produces antibodies (e.g.,
neutralizing antibodies) (e.g., IgE, IgM, IgG and/or IgA
antibodies) to a glucocerebrosidase enzyme replacement therapy) may
indicate that a subject is suitable for treatment (e.g.,
velaglucerase), suggesting that a treatment course (e.g., with
velaglucerase) is needed, thereby triggering an outcome that
indicates or causes authorization to pay for a service or treatment
(e.g., velaglucerase) provided to a subject. For example, an
entity, e.g., a hospital, care giver, government entity, or an
insurance company or other entity which pays for, or reimburses
medical expenses, can use the outcome of a method described herein
to determine whether a party, e.g., a party other than the subject
patient, will pay for services (e.g., a particular therapy) or
treatment provided to the patient. For example, a first entity,
e.g., an insurance company, can use the outcome of a method
described herein to determine whether to provide financial payment
to, or on behalf of, a patient, e.g., whether to reimburse a third
party, e.g., a vendor of goods or services, a hospital, physician,
or other care-giver, for a service or treatment (e.g.,
velaglucerase) provided to a patient. For example, a first entity,
e.g., an insurance company, can use the outcome of a method
described herein to determine whether to continue, discontinue,
enroll an individual in an insurance plan or program, e.g., a
health insurance or life insurance plan or program.
[0168] In one embodiment, information about whether or not the
subject's mean platelet count increased by less than 80%, 75%, 70%,
65%, 60%, or 55% after 9 or 12 months of treatment as compared to
their baseline mean platelet count prior to initiating the
glucocerebrosidase enzyme replacement therapy (e.g., imiglucerase
treatment, e.g., imiglucerase at a dose of 60 U/kg, e.g.,
administered every other week for 9 months) or whether the
subject's mean platelet count increased by less than 40%, 35%, 30%,
or 25% after 6 months of treatment as compared to their baseline
mean platelet count prior to initiating the glucocerebrosidase
enzyme replacement therapy (e.g., imiglucerase treatment, e.g.,
imiglucerase at a dose of 60 U/kg, e.g., administered every other
week for 6 months) is analyzed by a function that determines
whether to authorize the transfer of funds to pay for a service or
treatment provided to a subject (or make another decision referred
to herein). For example, the results (e.g., that the subject's mean
platelet count increased by less than 80%, 75%, 70%, 65%, 60%, or
55% after 9 or 12 months of treatment as compared to their baseline
mean platelet count prior to initiating the glucocerebrosidase
enzyme replacement therapy (e.g., imiglucerase treatment, e.g.,
imiglucerase at a dose of 60 U/kg, e.g., administered every other
week for 9 months) or whether the subject's mean platelet count
increased by less than 40%, 35%, 30%, or 25% after 6 months of
treatment as compared to their baseline mean platelet count prior
to initiating the glucocerebrosidase enzyme replacement therapy
(e.g., imiglucerase treatment, e.g., imiglucerase at a dose of 60
U/kg, e.g., administered every other week for 6 months)) may
indicate that a subject is suitable for treatment (e.g.,
velaglucerase), suggesting that a treatment course (e.g., with
velaglucerase) is needed, thereby triggering an outcome that
indicates or causes authorization to pay for a service or treatment
(e.g., velaglucerase) provided to a subject. For example, an
entity, e.g., a hospital, care giver, government entity, or an
insurance company or other entity which pays for, or reimburses
medical expenses, can use the outcome of a method described herein
to determine whether a party, e.g., a party other than the subject
patient, will pay for services (e.g., a particular therapy) or
treatment provided to the patient. For example, a first entity,
e.g., an insurance company, can use the outcome of a method
described herein to determine whether to provide financial payment
to, or on behalf of, a patient, e.g., whether to reimburse a third
party, e.g., a vendor of goods or services, a hospital, physician,
or other care-giver, for a service or treatment (e.g.,
velaglucerase) provided to a patient. For example, a first entity,
e.g., an insurance company, can use the outcome of a method
described herein to determine whether to continue, discontinue,
enroll an individual in an insurance plan or program, e.g., a
health insurance or life insurance plan or program.
[0169] In one aspect, the disclosure features a method of providing
data. The method includes providing data described herein, e.g.,
generated by a method described herein, to provide a record, e.g.,
a record described herein, for determining if a payment will be
provided. In some embodiments, the data is provided by computer,
compact disc, telephone, facsimile, email, or letter. In some
embodiments, the data is provided by a first party to a second
party. In some embodiments, the first party is selected from the
subject, a healthcare provider, a treating physician, a health
maintenance organization (HMO), a hospital, a governmental entity,
or an entity which sells or supplies the drug. In some embodiments,
the second party is a third party payer, an insurance company,
employer, employer sponsored health plan, HMO, or governmental
entity. In some embodiments, the first party is selected from the
subject, a healthcare provider, a treating physician, an HMO, a
hospital, an insurance company, or an entity which sells or
supplies the drug and the second party is a governmental entity. In
some embodiments, the first party is selected from the subject, a
healthcare provider, a treating physician, an HMO, a hospital, an
insurance company, or an entity which sells or supplies the drug
and the second party is an insurance company.
[0170] In some aspects, the disclosure provides the use of a
glucocerebrosidase enzyme replacement therapy (e.g., velaglucerase,
imiglucerase or uplyso), alone or in combination with another
agent(s) described herein (e.g., isofagomine tartrate, miglustat,
or Genz112638), for use in treatment.
[0171] In some aspects, the disclosure provides the use of a
glucocerebrosidase enzyme replacement therapy (e.g., velaglucerase
or imiglucerase), alone or in combination with another agent(s)
described herein (e.g., isofagomine tartrate, miglustat, or
Genz112638), for the preparation of a medicament, e.g., for
treating Gaucher disease.
[0172] In another aspect, the disclosure provides a pharmaceutical
composition of velaglucerase. The composition comprises:
velaglucerase, a lyoprotectant (e.g., a carbohydrate (e.g.,
sucrose)), a buffer salt (e.g., citrate and/or citric acid, e.g.,
sodium citrate and citric acid), and a stabilizing agent (e.g.,
polysorbate, e.g., polysorbate 20).
[0173] In some embodiments, the composition can be lyophilized. In
some embodiments, the moisture content of the lyophilized
composition is 1% to 6%, e.g., 1.3% to 6.2%. In some embodiments,
the moisture content of the lyophilized composition is 1% to 5%. In
some embodiments, the moisture content of the lyophilized
composition is 3% to 5%. In some embodiments, the moisture content
is greater than or equal to 3%. In some embodiments, the moisture
content is 3%.
[0174] In some embodiments, the lyophilized composition can be
evaluated. For example, the secondary structure of the lyophilized
composition can be evaluated, e.g., by FT-IR.
[0175] In other embodiments, the composition can be a reconstituted
solution. For example, the composition is a reconstituted solution
in a pharmaceutically acceptable carrier such as Sterile Water for
Injection (e.g., a 200 unit vial with 2.2 mL Sterile Water for
Injection or a 400 unit vial with 4.3 mL Sterile Water for
Injection). In some embodiments, the composition can further
comprise, or consist of, sodium chloride solution suitable for
intravenous administration (e.g., 0.9% sodium chloride solution
suitable for intravenous administration).
[0176] In some embodiments, the reconstituted solution can be
evaluated, e.g., for degradation. For example, the reconstituted
solution can be evaluated by SE-HPLC and/or RP-HPLC, e.g., for the
presence of degradation products.
[0177] In some embodiments, the reconstituted solution can be
evaluated for oxidation. For example, the reconstituted solution
can be evaluated by peptide mapping.
[0178] In some aspects, the disclosure features an assay (e.g.,
method) for detecting an anti-glucocerebrosidase antibody in a
sample (e.g., a patient sample, e.g., blood or serum). The method
includes:
[0179] providing a glucocerebrosidase (e.g., velaglucerase,
imiglucerase or uplyso) immobilized on a surface (e.g., a
microwell) (for example, the surface can be coated with a coupling
agent such as strepavidin and the glucocerebrosidase (e.g.,
velaglucerase, imiglucerase or uplyso) can be bound to an agent
(e.g., biotin) which associates with, e.g., binds to, the coupling
agent, e.g., the glucocerebrosidase (e.g., velaglucerase,
imiglucerase or uplyso) is immobilized to the surface via the
biotin binding to the strepavidin;
[0180] contacting the sample to the immobilized glucocerebrosidase
(e.g., velaglucerase, imiglucerase or uplyso), under conditions
that allow an anti-glucocerebrosidase antibody in the sample, if
present, to bind to the immobilized glucocerebrocidase, thereby
forming a mixture; optionally performing a wash step to remove from
the mixture any material in the sample that is not bound to the
immobilized glucocerebrosidase;
[0181] adding labeled glucocerebrosidase (e.g., velaglucerase or
imiglucerase), wherein the labeled glucocerebrosidase is labeled
with a detectable label (e.g., ruthenium-labeled
glucocerebrosidase), to the mixture under conditions that allow the
labeled glucocerebrosidase to bind to the anti-glucocerebrosidase
antibody (e.g., that is bound to the immobilized
glucocerebrosidase), if present, (preferably, the label is not the
same as the coupling agent and/or the agent that binds to the
coupling agent, e.g., if biotin is used to immobilize
glucocerebrosidase to the surface, the label is not biotin);
[0182] optionally performing a wash step to remove labeled
glucocerebrosidase that is not bound to the anti-glucocerebrosidase
antibody from the mixture; and
[0183] detecting (and optionally quantifying) the label in the
mixture, e.g., wherein detection of the label indicates that an
anti-glucocerebrosidase antibody is present in the sample.
[0184] In some embodiments, the detected label is quantified to a
value and compared to a control, e.g., a negative control, wherein
if the value of detected label is greater than the negative
control, the sample contains anti-glucocerebrosidase antibody. In
some embodiments, the negative control is the average negative
control value (e.g., background) for a plurality of negative
controls. For example, the negative control can be normal human
serum (NHS), and the average negative control value can be the
average for a plurality of NHS lots, or the average of the negative
control values obtained from a plurality of assays. For example,
the negative control value can be a value of 1, 2, 3, 4, 5 or 6
ng/ml of antibody, e.g., a value of greater than that number for a
sample indicates that an anti-glucocerebrosidase antibody is
present in the sample. As another example, the negative control
value can be 200, 250, 300 (e.g., 306), 350, or 400, e.g., a value
of greater than that number for a sample indicates that an
anti-glucocerebrosidase antibody is present in the sample.
[0185] In some embodiments, the assay is for detecting
anti-velaglucerase antibodies. In another embodiment, the assay is
for detecting anti-imiglucerase antibodies. In some embodiments,
the assay is for detecting anti-uplyso antibodies.
[0186] In some aspects, the disclosure features an assay for
detecting an anti-glucocerebrosidase antibody (e.g., IgG
anti-glucocerebrosidase antibody) in a sample (e.g., a patient
sample, e.g., blood or serum). The method includes:
[0187] contacting the sample to labeled glucocerebrosidase (e.g.,
velaglucerase or imiglucerase), wherein the glucocerebrosidase is
labeled with a detectable label (e.g., the glucocerebrosidase is
.sup.125I labeled), under conditions that allow an
anti-glucocerebrosidase antibody in the sample, if present, to bind
to labeled glucocerebrosidase, thereby forming a mixture;
[0188] applying the mixture to a resin (e.g., Protein G, Protein A,
Protein A/G, or Protein L resin) (e.g., a Protein G spin column)
under conditions that allow the anti-glucocerebrosidase antibody,
if present, to bind to the resin;
[0189] optionally performing a wash step to remove labeled
glucocerebrosidase that is not bound to the anti-glucocerebrosidase
antibody from the mixture; and
[0190] detecting (and optionally quantifying) the label in the
mixture (e.g., on the resin), e.g., wherein detection of the label
indicates that anti-glucocerebrosidase antibody is present in the
sample.
[0191] In some embodiments, the assay is for detecting
anti-velaglucerase antibodies. In another embodiment, the assay is
for detecting anti-imiglucerase antibodies. In some embodiments,
the assay is for detecting anti-uplyso antibodies.
[0192] In some embodiments, the detected label is quantified to a
value and compared to a control, e.g., a negative control, wherein
if the value of detected label is greater than the negative
control, the sample contains anti-glucocerebrosidase antibody. In
some embodiments, the negative control is the average negative
control value (e.g., background) for a plurality of negative
controls. For example, the negative control can be normal human
serum (NHS), and the average negative control value can be the
average for a plurality of NHS lots, or the average of the negative
control values obtained from a plurality of assays.
[0193] In some aspects, the disclosure features an assay for
detecting a human anti-glucocerebrosidase antibody in a sample
(e.g., a patient sample, e.g., blood or serum).
The method includes:
[0194] providing glucocerebrosidase (e.g., velaglucerase,
imiglucerase or uplyso) immobilized on a surface (e.g., a
microwell) (for example, the surface can be coated with a coupling
agent such as strepavidin and the glucocerebrosidase can be bound
to an agent (e.g., biotin) that associates with, e.g., binds to,
the coupling agent, e.g., the glucocerebrosidase is immobilized to
the surface via the biotin binding to the strepavidin);
[0195] contacting the sample to the immobilized glucocerebrosidase,
under conditions that allow a human anti-glucocerebrosidase
antibody in the sample, if present, to bind to the immobilized
glucocerebrosidase, thereby forming a mixture;
[0196] optionally performing a wash step to remove from the mixture
any material in the sample that is not bound to the immobilized
glucocerebrosidase;
[0197] adding an antibody that binds to the human
anti-glucocerebrosidase antibody to the mixture, wherein the
antibody that binds to the human anti-glucocerebrosidase antibody
is labeled with a detectable label (e.g., ruthenium or biotin),
under conditions that allow the labeled antibody that binds to the
human anti-glucocerebrosidase antibody to bind to the human
anti-glucocerebrosidase antibody (e.g., that is bound to the
immobilized glucocerebrosidase), if present, (preferably, the label
is not the same as the coupling agent and/or the agent that binds
to the coupling agent, e.g., if biotin is used to immobilize
glucocerebrosidase to the surface, the label is not biotin);
[0198] optionally performing a wash step to remove labeled antibody
that binds to the human anti-glucocerebrosidase antibody that is
not bound to the human anti-glucocerebrosidase antibody from the
mixture; and
[0199] detecting (and optionally quantifying) the label in the
mixture, e.g., wherein detection of the label indicates that human
anti-glucocerebrosidase antibody is present in the sample.
[0200] In some embodiments, the assay detects anti-velaglucerase
antibodies. In some embodiments, the assay detects
anti-imiglucerase antibodies. In some embodiments, the assay
detects anti-uplyso antibodies.
[0201] In some embodiments, the detected label is quantified to a
value and compared to a control, e.g., a negative control, wherein
if the value of detected label is greater than the negative
control, the sample contains anti-velaglucerase antibody. In some
embodiments, the negative control is the average negative control
value (e.g., background) for a plurality of negative controls. For
example, the negative control can be normal human serum (NHS), and
the average negative control value can be the average for a
plurality of NHS lots, or the average of the negative control
values obtained from a plurality of assays.
[0202] In some embodiments, the antibody that binds to the human
anti-glucocerebrosidase antibody is isotype specific, wherein the
isotype specific antibody that binds to the human
anti-glucocerebrosidase antibody binds specifically to a human
antibody of the isotype to which it is specific.
[0203] In some embodiments, the antibody that binds to the human
anti-glucocerebrosidase antibody is an IgA specific antibody and
binds to an IgA human anti-glucocerebrosidase antibody in the
sample.
[0204] In some embodiments, the antibody that binds to the human
anti-glucocerebrosidase antibody is an IgE specific antibody and
binds to an IgE human anti-glucocerebrosidase antibody in the
sample.
[0205] In some embodiments, the antibody that binds to the human
anti-glucocerebrosidase antibody is an IgM specific antibody and
binds to an IgM human anti-glucocerebrosidase antibody in the
sample.
[0206] In some embodiments, the antibody that binds to the human
anti-glucocerebrosidase antibody is an IgG specific antibody and
binds to an IgG human anti-glucocerebrosidase antibody in the
sample.
[0207] In some aspects, the disclosure features a method of
determining if an anti-glucocerebrosidase antibody (e.g., in a
sample) neutralizes (e.g., inhibits) glucocerebrosidase (e.g.,
velaglucerase or imiglucerase) activity. The method includes:
[0208] providing a cell (e.g., a human cell, e.g., a human
fibroblast cell) that expresses human macrophage mannose receptor
(MMR);
[0209] contacting the anti-glucocerebrosidase antibody to the cell,
thereby forming a mixture;
[0210] contacting labeled glucocerebrosidase (e.g., velaglucerase,
imiglucerase or uplyso) to the mixture, wherein the
glucocerebrosidase is labeled with a detectable label (e.g., the
glucocerebrosidase is labeled with a fluorescent label, e.g., a
green fluorescent dye, such as Alexa FLUOR.RTM. 488 or fluorescein
isothiocyanate (FITC)), under conditions that allow the labeled
glucocerebrosidase to bind to the MMR in the absence of an
anti-glucocerebrosidase antibody (e.g., wherein binding of
glucocerebrosidase to MMR allows cellular uptake of the
glucocerebrosidase);
[0211] removing unbound labeled glucocerebrosidase and labeled
glucocerebrosidase bound to the cell surface (e.g., via trypsin
digestion); and
[0212] measuring the amount of labeled glucocerebrosidase in the
cell.
[0213] In some embodiments, the levels of labeled
glucocerebrosidase are compared to a control, e.g., the level of
labeled glucocerebrosidase detected in the absence of the
anti-glucocerebrosidase antibody under identical conditions.
[0214] In some embodiments, the cells do not express an Fc receptor
(e.g., human Fc receptor).
[0215] In some embodiments, the method detects whether neutralizing
anti-velaglucerase antibodies are present. In some embodiments, the
method detects whether neutralizing anti-imiglucerase antibodies
are present. In some embodiments, the method detects whether
neutralizing anti-uplyso antibodies are present.
[0216] In some embodiments, the method detects whether an
anti-imiglucerase antibody neutralizes imiglucerase activity. In
some embodiments, the method detects whether an anti-velaglucerase
antibody neutralizes velaglucerase activity. In some embodiments,
the method detects whether an anti-uplyso antibody neutralizes
uplyso activity.
[0217] In some embodiments, the method detects whether an
anti-imiglucerase antibody neutralizes velaglucerase and/or uplyso
activity. In some embodiments, the method detects whether an
anti-velaglucerase antibody neutralizes imiglucerase and/or uplyso
activity. In some embodiments, the method detects whether an
anti-uplyso antibody neutralizes imiglucerase and/or velaglucerase
activity.
[0218] In some aspects, the disclosure features a method of
determining if an anti-velaglucerase antibody (e.g., in a sample)
neutralizes (e.g., inhibits) imiglucerase activity. The method
includes:
[0219] providing a cell (e.g., a human cell, e.g., a human
fibroblast cell) that expresses human macrophage mannose receptor
(MMR);
[0220] contacting the anti-velaglucerase antibody to the cell,
thereby forming a mixture;
[0221] contacting labeled imiglucerase to the mixture, wherein the
imiglucerase is labeled with a detectable label (e.g., the
imiglucerase is labeled with a fluorescent label, e.g., a green
fluorescent dye, such as Alexa FLUOR.RTM. 488 or fluorescein
isothiocyanate (FITC)), under conditions that allow the labeled
imiglucerase to bind to the MMR in the absence of an
anti-velaglucerase antibody (e.g., wherein binding of imiglucerase
to MMR allows cellular uptake of the imiglucerase);
[0222] removing unbound labeled imiglucerase and labeled
imiglucerase bound to the cell surface (e.g., via trypsin
digestion); and
[0223] measuring the amount of labeled imiglucerase in the
cell.
[0224] In some embodiments, the levels of labeled imiglucerase are
compared to a control, e.g., the level of labeled imiglucerase
detected in the absence of the anti-velaglucerase antibody under
identical conditions.
[0225] In some embodiments, the cells do not express an Fc receptor
(e.g., human Fc receptor).
[0226] In some aspects, the disclosure features a method of
determining if an anti-imiglucerase antibody (e.g., in a sample)
neutralizes (e.g., inhibits) velaglucerase activity. The method
includes:
[0227] providing a cell (e.g., a human cell, e.g., a human
fibroblast cell) that expresses human macrophage mannose receptor
(MMR);
[0228] contacting the anti-imiglucerase antibody to the cell,
thereby forming a mixture;
[0229] contacting labeled velaglucerase to the mixture, wherein the
velaglucerase is labeled with a detectable label (e.g., the
velaglucerase is labeled with a fluorescent label, e.g., a green
fluorescent dye, such as Alexa FLUOR.RTM. 488 or fluorescein
isothiocyanate (FITC)), under conditions that allow the labeled
velaglucerase to bind to the MMR in the absence of an
anti-imiglucerase antibody (e.g., wherein binding of velaglucerase
to MMR allows cellular uptake of the velaglucerase);
[0230] removing unbound labeled velaglucerase and labeled
velaglucerase bound to the cell surface (e.g., via trypsin
digestion); and
[0231] measuring the amount of labeled velaglucerase in the
cell.
[0232] In some embodiments, the levels of labeled velaglucerase are
compared to a control, e.g., the level of labeled velaglucerase
detected in the absence of the anti-imiglucerase antibody under
identical conditions.
[0233] In some embodiments, the cells do not express an Fc receptor
(e.g., human Fc receptor).
[0234] In some aspects, the disclosure features a hybrid antibody,
wherein the hybrid antibody comprises a non-human anti-drug
antibody and a human immunoglobulin (Ig).
[0235] In some embodiments, the non-human anti-drug IgG antibody is
a sheep anti-drug IgG antibody.
[0236] In some embodiments, the anti-drug antibody binds to
velaglucerase.
[0237] In some embodiments, the anti-drug antibody binds to
imiglucerase.
[0238] In some embodiments, the anti-drug antibody binds to
uplyso.
[0239] In some embodiments, the human Ig is IgA.
[0240] In some embodiments, the human Ig is IgE.
[0241] In some embodiments, the human Ig is IgM.
[0242] In some embodiments, the human Ig is IgG.
[0243] In some embodiments, the non-human anti-drug antibody is an
IgG antibody.
[0244] In some embodiments, the non-human anti-drug antibody and
the human Ig are conjugated together by a chemical crosslinker,
e.g., a long spacer arm cross linker, e.g., succinimidyl
6-[3'-2-pyridyldithio-propionamido]hexanoate (LC-SPDP).
[0245] In some embodiments, the hybrid antibody is used as a
positive control in assays that detect and/or measure levels and/or
isotypes of anti-drug antibody in a sample, e.g., in a method
described herein.
[0246] In some embodiments, the hybrid antibody is used as a
positive control in assays for determining if an
anti-glucocerebrosidase antibody (e.g., in a sample) neutralizes
(e.g., inhibits) glucocerebrosidase (e.g., velaglucerase or
imiglucerase) activity, e.g., in a method described herein. For
example, the hybrid antibody is used as an anti-glucocerebrosidase
antibody (e.g., in a sample) in the assay.
[0247] In some aspects, the disclosure features a method of
measuring cellular uptake (e.g., internalization) of
glucocerebrosidase (e.g., velaglucerase or imiglucerase) into a
cell. The method includes:
[0248] contacting glucocerebrosidase (e.g., velaglucerase or
imiglucerase) to a cell (e.g., a cell of a human leukemic monocyte
lymphoma cell line (e.g., U937) or a cell of a murine macrophage
cell line (e.g., J774)) to thereby form a mixture;
[0249] incubating the mixture (e.g., for 1, 2, 3, 4, 5, 6, or 7
hours or overnight), e.g., to allow cellular uptake of the
glucocerebrosidase (e.g., velaglucerase or imiglucerase) into the
cell; and
[0250] measuring the amount of uptake of glucocerebrosidase (e.g.,
velaglucerase or imiglucerase) into the cell.
[0251] In some embodiments, the amount of uptake is measured by
measuring glucocerebrosidase enzymatic activity in the cell. In
some embodiments, a synthetic substrate that fluoresces upon
cleavage (e.g., 4-MU-glc) is used.
[0252] In some embodiments, the amount of uptake is measured by
measuring intracellular glucocerebrosidase protein levels. In some
embodiments, Western blot analysis is used. In some embodiments,
immunohistochemistry analysis is used (e.g., immunohistochemistry
on permeabilized cells).
[0253] In some embodiments, the cell is washed one or more times
prior to the measuring step.
[0254] In some embodiments, the pH of the mixture is 7.5.
[0255] In some embodiments, mannose-6-phosphate (M6P) is present in
the mixture.
[0256] In some embodiments, mannan is present in the mixture.
[0257] In some embodiments, calcium is present in the mixture.
[0258] In some embodiments, the amount of uptake is compared to a
standard, e.g., the measured amount of uptake in the absence of
contacting glucocerebrosidase (e.g., velaglucerase or imiglucerase)
to the cell, or comparing the measured amount of uptake in the
presence and absence of mannose-6-phosphate, or comparing the
measured amount of uptake in the presence and absence of mannan, or
comparing the measured amount of uptake in the presence and absence
of calcium.
[0259] In some embodiments, the glucocerebrosidase is
velaglucerase.
[0260] In some embodiments, the glucocerebrosidase is
imiglucerase.
[0261] In some embodiments, the amount of uptake of velaglucerase
is compared to the amount of uptake of imiglucerase (e.g., under
the same conditions).
[0262] The term "subject" refers to any mammal, including but not
limited to, any animal classified as such, including humans, non
human primates, primates, baboons, chimpanzees, monkeys, rodents
(e.g., mice, rats), rabbits, cats, dogs, horses, cows, sheep,
goats, pigs, etc. The term "subject" can be used interchangeably
with the term "patient."
[0263] The term "isolated" refers to a molecule that is
substantially free of its natural environment. For instance, an
isolated protein is substantially free of cellular material or
other proteins from the cell or tissue source from which it is
derived. The term refers to preparations where the isolated protein
is sufficiently pure to be administered as a therapeutic
composition, or at least 70% to 80% (w/w) pure, more preferably, at
least 80% 90% (w/w) pure, even more preferably, 90 to 95% pure;
and, most preferably, at least 95%, 96%, 97%, 98%, 99%, 99.5%,
99.8% or 100% (w/w) pure.
[0264] As used herein, the term "about" refers to up to .+-.10% of
the value qualified by this term. For example, about 50 mM refers
to 50 mM.+-.5 mM; about 4% refers to 4%.+-.0.4%.
[0265] The terms "therapeutically effective dose," and
"therapeutically effective amount," refer to that amount of a
compound that results in prevention of symptoms (e.g., prevention
of 80%, 85%, 90%, 95%, 96%, 97%, 98%, or 99% of symptoms, e.g.,
symptoms of Gaucher disease in a subject diagnosed as having
Gaucher disease), delay of onset of symptoms, or amelioration of
symptoms of Gaucher disease. A therapeutically effective amount
will, for example, be sufficient to treat, prevent, reduce the
severity, delay the onset, and/or reduce the risk of occurrence of
one or more symptoms of a disorder associated with Gaucher disease.
The effective amount can be determined by methods well known in the
art and as described in subsequent sections of this
description.
[0266] The terms "treatment" and "therapeutic method" refer to
treatment of an existing disorder and/or prophylactic/preventative
measures. Those in need of treatment may include individuals
already having a particular medical disorder, as well as those at
risk or having, or who may ultimately acquire the disorder. The
need for treatment is assessed, for example, by the presence of one
or more risk factors associated with the development of a disorder,
the presence or progression of a disorder, or likely receptiveness
to treatment of a subject having the disorder. Treatment may
include slowing or reversing the progression of a disorder.
[0267] The term "treating" refers to administering a therapy in an
amount, manner, and/or mode effective to improve or prevent a
condition, symptom, or parameter associated with a disorder (e.g.,
a disorder described herein) or to prevent onset, progression, or
exacerbation of the disorder, to either a statistically significant
degree or to a degree detectable to one skilled in the art.
Accordingly, treating can achieve therapeutic and/or prophylactic
benefits. An effective amount, manner, or mode can vary depending
on the subject and may be tailored to the subject.
[0268] "Infusion site reaction" as used herein refers to one or
more symptom of hypersensitivity developed by a subject during or
shortly after an infusion of a glucocerebrosidase enzyme
replacement therapy (e.g., within 12 hours of infusion of a
glucocerebrosidase enzyme replacement treatment to the subject).
Symptoms include, for example, pruritus, burning, swelling or
abscess at the site of infusion, flushing, urticara/angioedema,
chest discomfort, tachycardia, cyanosis, respiratory symptoms and
paraesthesia.
[0269] The term "combination" refers to the use of the two or more
agents or therapies to treat the same patient, wherein the use or
action of the agents or therapies overlap in time. The agents or
therapies can be administered at the same time (e.g., as a single
formulation that is administered to a patient or as two separate
formulations administered concurrently) or sequentially in any
order.
[0270] All publications, patent applications, patents, and other
references mentioned herein are incorporated by reference in their
entirety. In the case of conflict, the present specification,
including definitions, controls. In addition, the materials,
methods, and examples are illustrative only and not intended to be
limiting.
[0271] The details of one or more embodiments of the invention are
set forth in the accompanying drawings and the description
below.
BRIEF DESCRIPTION OF THE DRAWINGS
[0272] FIG. 1 (a)-(f) depicts mean % change in hematological
values, organ values, and biomarkers in phase I/II trial.
[0273] FIG. 2 depicts mean % change of key clinical parameters in
phase I/II and extension trials.
[0274] FIG. 3 depicts TKT025EXT (N=10) mean hematological
parameters change from baseline in TKT025.
[0275] FIG. 4 depicts TKT025EXT (N=10) mean normalized organ
volumes change from baseline in TKT025.
[0276] FIG. 5 depicts TKT025 and TKT025EXT temporal change in mean
Z-scores of lumbar spine from baseline.
[0277] FIG. 6 depicts TKT025 and TKT025EXT temporal change in mean
Z-score of femoral neck from baseline.
[0278] FIG. 7 depicts TKT032 (N=25) mean hemoglobin concentration
change from baseline.
[0279] FIG. 8 depicts TKT032 (N=25) mean platelet count change from
baseline.
[0280] FIG. 9 depicts TKT032 (N=25) mean normalized spleen volume
change from baseline.
[0281] FIG. 10 depicts TKT032 (N=25) mean normalized liver volume
change from baseline.
[0282] FIG. 11 depicts HGT-GCB-039 (N=34) mean hemoglobin
concentration change from baseline.
[0283] FIG. 12 depicts HGT-GCB-039 (N=34) mean platelet count
change from baseline.
[0284] FIG. 13 depicts HGT-GCB-039 (N=34) mean change from baseline
of platelet count in patients without spleen.
[0285] FIG. 14 depicts HGT-GCB-039 (N=34) mean normalized liver
volume change from baseline.
[0286] FIG. 15 depicts TKT034 mean change from baseline in
hemoglobin concentration.
[0287] FIG. 16 depicts TKT034 mean n percent change from baseline
in platelet count.
[0288] FIG. 17 depicts TKT034 mean percent change from baseline in
normalized liver volume.
[0289] FIG. 18 depicts TKT034 mean percent change from baseline in
normalized spleen volume.
[0290] FIG. 19 depicts TKT034 mean percent change from baseline in
plasma chitotriosidase.
[0291] FIG. 20 depicts TKT034 mean percent change from baseline in
plasma CCL18.
[0292] FIG. 21 depicts an immunogenicity evaluation of patients in
velaglucerase alfa clinical studies.
[0293] FIG. 22 depicts an anti-drug antibody screening by
electro-chemiluminescence (ECL) immunoassay.
[0294] FIG. 23 depicts a screening assay dose response curve.
[0295] FIG. 24 depicts an IgG ADA confirmatory assay.
[0296] FIG. 25 depicts an RIP assay dose response curve.
[0297] FIG. 26 depicts IgA, IgM and IgE ADA confirmatory
assays.
DETAILED DESCRIPTION
[0298] The disclosure is based, in part, on the discovery that
velaglucerase elicits less of an immune response (e.g., less
production of antibody, e.g., less production of neutralizing
antibody) than imiglucerase upon administration to a subject (e.g.,
a subject with Gaucher disease). It was discovered that
velaglucerase elicits less infusion site reaction upon
administration to a subject (e.g., a subject with Gaucher disease)
than imiglucerase and velaglucerase can result in an increase in
platelet count when administered to a subject (e.g., a subject
having Gaucher disease) than imiglucerase. The invention relates,
inter alia, to compositions and methods for selecting a treatment
for a subject with Gaucher disease, selecting subjects for
treatment with velaglucerase (e.g., alone or in combination with
another therapy), and methods for reducing injection site reaction
in subjects undergoing treatment for Gaucher disease.
[0299] Velaglucerase
[0300] Velaglucerase is human .beta.-glucocerebrosidase produced by
gene-activation in a human cell line. Gene activation refers to
targeted recombination with a promoter that activates the
endogenous .beta.-glucocerebrosidase gene in the selected human
cell line. Velaglucerase is secreted as a monomeric glycoprotein of
approximately 63 kDa and is composed of 497 amino acids with a
sequence identical to the natural human protein. The amino acid
sequence of velaglucerase is described in Zimran et al. (2007)
Blood Cells Mol Dis, 39: 115-118.
[0301] Glycosylation of velaglucerase alfa is altered by using
kifunensine, a mannosidase I inhibitor, during cell culture, which
results in the secretion of a protein containing primarily
high-mannose type glycans having 6-9 mannose units per glycan. A
summary of the glycan structure of velaglucerase is provided
below.
TABLE-US-00001 Glycosylation Site Predominant Glycan Other Glycans
Asn19 High-mannose High-mannose (Man).sub.9(GlcNAc).sub.2
(Man).sub.6-8(GlcNAc).sub.2 Phosphorylated high-mannose
(Phos).sub.1(Man).sub.8-9(GlcNAc).sub.2 GlcNAc capped phosphate
(Phos).sub.1(Man).sub.8-9(GlcNAc).sub.3 Hybrid
(Hex).sub.2(Man).sub.3(GlcNAc).sub.3(Fuc).sub.1 Asn59 High-mannose
High-mannose (Man).sub.9(GlcNAc).sub.2 (Man).sub.5-8(GlcNAc).sub.2
Phosphorylated high-mannose (Phos).sub.1(Man).sub.7-9(GlcNAc).sub.2
GlcNAc capped phosphate (Phos).sub.1(Man).sub.8-9(GlcNAc).sub.3
Hybrid (NeuAc).sub.1(Gal).sub.1(Man).sub.5(GlcNAc).sub.3(Fuc).sub.1
Complex
(NeuAc).sub.0-2(Gal).sub.2(Man).sub.3(GlcNAc).sub.4(Fuc).sub.1
(Gal).sub.3(Man).sub.3(GlcNAc).sub.5(Fuc).sub.1 Asn146 High-mannose
High-mannose (Man).sub.9(GlcNAc).sub.2 (Man).sub.6-8(GlcNAc).sub.2
Phosphorylated high-mannose (Phos).sub.1(Man).sub.7-9(GlcNAc).sub.2
GlcNAc capped phosphate (Phos).sub.1(Man).sub.9(GlcNAc).sub.3
Hybrid (NeuAc).sub.1(Gal).sub.1(Man).sub.5(GlcNAc).sub.3(Fuc).sub.1
Asn270 High-mannose High-mannose (Man).sub.9(GlcNAc).sub.2
(Man).sub.6-8(GlcNAc).sub.2 Phosphorylated high-mannose
(Phos).sub.1(Man).sub.6-9(GlcNAc).sub.2 GlcNAc capped phosphate
(Phos).sub.1(Man).sub.9(GlcNAc).sub.3 Hybrid
(Gal).sub.1Man).sub.7GlcNAc).sub.3Fuc).sub.1
(NeuAc).sub.1(Gal).sub.1(Man).sub.5(GlcNAc).sub.3(Fuc).sub.1
Complex
(NeuAc).sub.2(Gal).sub.2(Man).sub.3(GlcNAc).sub.4(Fuc).sub.1 Asn462
Not Detected Not Detected
[0302] Velaglucerase has three non-contiguous domains, with the
catalytic site located in domain III (residues 76-381 and 416-430),
a (.beta./.alpha.).sub.8 (TIM) barrel.
[0303] Velaglucerase (VPRIV.TM.) is commercially available from
Shire Human Genetics Therapies, Inc. Methods of making
velaglucerase are described, for example, in U.S. Pat. No.
7,138,262.
[0304] Pharmaceutical Form. Velaglucerase (also referred to herein
as velaglucerase alfa) is a sterile, white to off-white,
preservative-free lyophilized powder for solution in single-use
vials for intravenous (IV) infusion after reconstitution with
Sterile Water for Injection.
[0305] Qualitative and Quantitative Composition. Upon
reconstitution with Sterile Water for Injection, each vial contains
approximately 2.5 mg/mL (40 U/mL) of velaglucerase alfa, 50 mg/mL
sucrose, 12.9 mg/mL sodium citrate dihydrate, 1.3 mg/mL citric acid
monohydrate and 0.11 mg/mL polysorbate 20. Each vial contains an
extractable volume of 2.0 mL for the 200 U vial and 4.0 mL for the
400 U vial. Velaglucerase is supplied in a 200 U/vial (5 mg) or 400
U/vial (10 mg) of velaglucerase alfa, one unit (U) of enzyme
activity being defined as the quantity of enzyme required to
convert one micromole of p-nitrophenyl .beta.-D-glucopyranoside to
p-nitrophenol per minute at 37.degree. C.
[0306] Container and Contents. Velaglucerase is a sterile,
lyophilized powder for solution supplied in either a 5 mL (200
U/vial presentation) or 20 mL (400 U/vial presentation) type I
glass vial. Each vial contains either 200 U (5 mg) or 400 U (10 mg)
of velaglucerase alfa. The vials are closed with a butyl rubber
stopper with a fluoro-resin coating and are sealed with an aluminum
overseal with a flip-off plastic cap.
[0307] Instructions for Use. Velaglucerase is a lyophilized powder
for solution intended for intravenous infusion. Vials are
single-use vials. Velaglucerase is not infused with other products
in the same infusion. The total volume of infusion is delivered
over a period of 60 minutes. Velaglucerase should be handled as
follows:
[0308] 1. Determine the number of vials to be reconstituted based
on the individual patient's weight and the prescribed dose.
[0309] 2. Remove the required number of vials from the
refrigerator. Reconstitute 200 unit vials with 2.2 mL of Sterile
Water for Injection and 400 unit vials with 4.3 mL Sterile Water
for Injection. Do not shake.
[0310] 3. Prior to dilution, visually inspect the solution in the
vials. Do not use if the solution is discolored or if particulate
matter is present.
[0311] 4. Withdraw the calculated volume of drug from the
appropriate number of vials.
[0312] 5. Dilute the total volume required in 100 mL of 0.9% sodium
chloride solution suitable for IV administration, rock gently, but
do not shake.
[0313] Dose. Velaglucerase is administered at doses between (and
including) 2.5 U/kg and 60 U/kg of subject body weight, e.g., 15
U/kg to 60 U/kg (e.g., 15 U/kg, 30 U/kg, 45 U/kg, or 60 U/kg).
Velaglucerase can be administered at a rate of 2 U/kg/minute, 1.5
U/kg/minute, 1 U/kg/minute or 0.5 U/kg/minute. The dose of
velaglucerase is administered to the subject every other week.
[0314] Velaglucerase can be administered at a dose of 15 to 60 U/kg
(e.g. 30 U/kg to 60 U/kg, e.g., 15 U/kg, 30 U/kg, 45 U/kg, or 60
U/kg), at a dose equal to or below 22.5 U/kg, at a dose between
22.5 and 37.5 U/kg, at a dose between 37.5 and 52.5 U/kg, or at a
dose equal to or above 52.5 U/kg. In some embodiments,
velaglucerase can be administered at a dose of 2.5 U/kg to 60 U/kg.
In some embodiments, the velaglucerase can be administered every
other week by intravenous infusion. In other embodiments, the
velaglucerase can be administered every week by intravenous
infusion. In some embodiments, the velaglucerase can be
administered three times a week by intravenous infusion, e.g., at a
dose of 2.5 U/kg.
[0315] In some embodiments, the infusion of the dose (e.g., a dose
described herein occurs over less than 2 hours, e.g., less than 90
minutes, 80 minutes, 70 minutes, 60 minutes, 50 minutes or 45
minutes.
[0316] Recombinantly produced human glucocerebrosidase. Other forms
of recombinantly-produced human glucocerebrosidase that can be used
in the compositions, assays and methods described herein. For
example, imiglucerase (Cerazyme.RTM.) is recombinately produced in
Chinese Hamster Ovary (CHO) cells and is commercially available. In
addition, uplyso, a recombinant glucocerebrosidase (prGCD)
expressed in plant cells, can be used. Plant recombinant
glucocerebrosidase can be obtained by methods described, e.g., in
U.S. Publication Nos: US 20090208477 and US 20080038232 and PCT
Publication Nos.: WO 2004/096978 and WO 2008/132743.
[0317] Maintenance Dose
[0318] Upon improvement of a subject's condition, a maintenance
dose of a treatment may be administered, if necessary.
Subsequently, the dosage or frequency of administration, or both,
may be reduced, as a function of the symptoms, to a level at which
the improved condition is retained. Subjects may, however, require
intermittent treatment on a long-term basis upon any recurrence of
disease symptoms.
[0319] Subjects treated with a dose of 60 U/kg of velaglucerase
every other week, and after about 15-18 months of total treatment
with velaglucerase, upon showing improvements in 2 of 4 recommended
therapeutic criteria (hemoglobin concentration, platelet counts,
liver volume, spleen volume), were switched to a reduced dose of 30
U/kg every other week. In spite of this dose reduction, these
subjects showed clinically meaningful changes in the 4 parameters
(hemoglobin concentration, platelet counts, spleen volume, and
liver volume) and Biomarkers (Chitotriosidase and CCL18) over the
course of 48 months.
[0320] Qualitative comparison between velaglucerase and
imiglucerase indicates potential additional benefit for Gaucher
subjects in that, in spite of a dose reduction to almost half of
that of imiglucerase, patients continued to improve clinically in
the 4 parameters demonstrating a marked increase in hemoglobin
concentration, continued increase in platelet count after 36
months, and a rate of decline in liver/spleen volume.
[0321] Alternative Therapy
[0322] The administration of velaglucerase (with or without the
additional agent) can be used as an alternative treatment, e.g.,
for subjects who were previously treated with another therapy
(i.e., a therapy other than velaglucerase, e.g., imiglucerase,
alglucerase, uplyso, isofagomine tartrate, miglustat, or
Genz112638). For example, a subject who is undergoing treatment for
Gaucher disease with another therapy can be transferred to
treatment with velaglucerase, e.g., if the subject is experiencing
a side effect or adverse effect from the other therapy. For
example, a subject who is undergoing treatment for Gaucher disease
with imiglucerase can be transferred to treatment with
velaglucerase, e.g., velaglucerase can be administered at the same
dose and with the same frequency at which the imiglucerase was
administered. For example, the subject may have experienced an
infusion site reaction upon or after administration of imiglucerase
and/or developed anti-imiglucerase antibodies (e.g., neutralizing
antibodies to imiglucerase).
[0323] Combination Therapy
[0324] A subject who has Gaucher disease can be administered a
therapy that includes velaglucerase in an amount and for a time to
provide an overall therapeutic effect. The velaglucerase can be
administered alone or in combination with an additional agent(s).
In the case of a combination therapy, the amounts and times of
administration can be those that provide, e.g., a synergistic
therapeutic effect, or an additive therapeutic effect.
[0325] In some embodiments, velaglucerase can be used in
combination with another therapy for Gaucher disease, e.g., a
therapy other than enzyme replacement therapy, e.g., isofagomine
tartrate, miglustat, or Genz112638.
[0326] Isofagomine tartrate. Isofagomine tartrate (AT-2101,
HGT-34100, PLICERA.RTM.)
((3R,4R,5R)-3,4-Dihydroxy-5-(hydroxymethyl)piperidine
L-(+)-tartrate; CAS No. 957230-65-8) selectively binds to and
stabilizes glucocerebrosidase and facilitates proper trafficking of
the enzyme to the lysosomes, the compartments in the cell where it
is needed to break down glucocerebroside. See also U.S. Pat. No.
7,501,439.
[0327] Miglustat. Miglustat (ZAVESCA.RTM.)
((2R,3R,4R,5S)-1-butyl-2-(hydroxymethyl)piperidine-3,4,5-triol; CAS
No. 72599-27-0) is an N-alkylated imino sugar, a synthetic analogue
of D-glucose and a white to off-white crystalline solid that has a
bitter taste. Miglustat exhibits a large volume of distribution and
has the capacity to access deep organs such as the brain, bone and
lung.
[0328] Miglustat inhibits glucosylceramide synthase an essential
enzyme for the synthesis of most glycosphingolipids. Miglustat is a
glucosylceramide synthase inhibitor. It works by blocking an enzyme
that reduces the formation of certain chemicals in the body
(glucosylceramide-based glycosphingolipids). Miglustat is used to
treat adults with mild to moderate type 1 Gaucher disease.
[0329] Genz112638. Genz112638 is glucosylceramide analog given
orally, and is designed to partially inhibit glucosylceramide
synthase, which results in reduced production of
glucosylceramide.
[0330] In addition, small molecules referred to as pharmacological
chaperones can be used to selectively bind to a target
macromolecule and increase its stability. For example, the binding
of a pharmacological chaperone can help a target molecule, such as
a protein (e.g., GCB) or other macromolecule (e.g.,
glucocerebroside), to fold into its correct three-dimensional
shape. This can facilitate the activity and cellular function of
the molecule (e.g., enzymatic activity in the case of GCB). In
addition or alternatively, the pharmacological chaperone can
facilitate trafficking of the chaperoned molecule from the ER to
the appropriate location in a cell. One or both of these functions
can reduce stress on cells.
[0331] Pharmacological chaperones also can decrease aggregation
and/or accumulation of misfolded macromolecules. In addition,
restoring trafficking of misfolded macromolecules (e.g., proteins)
and reducing their retention in the ER can have the added benefit
of alleviating the toxic effects (e.g., proteotoxic effects)
associated with mutant macromolecule accumulation and/or
aggregation.
[0332] In certain embodiments, combination therapies can include
one, two, or more glucocerebrosidase enzyme replacement therapies,
optionally in combination with one or more small molecule
therapies, such as isofagomine tartrate, miglustat, or Genz112638,
and/or optionally in combination with one or more pharmacological
chaperones and/or other agents.
[0333] In some embodiments, when velaglucerase is administered in
combination with an additional agent, the combination can result in
a lower dose of the additional agent or velaglucerase being needed,
such that side effects are reduced. The combination may result in
enhanced delivery and efficacy of one or both agents.
[0334] The agents or therapies can be administered at the same time
(e.g., as a single formulation that is administered to a patient or
as two separate formulations administered concurrently) or
sequentially in any order. Sequential administrations are
administrations that are given at different times. The time between
administration of the one agent and another agent can be minutes,
hours, days, or weeks. The use of velaglucerase can also be used to
reduce the dosage of another therapy, e.g., to reduce the
side-effects associated with another agent that is being
administered, e.g., to reduce the side-effects of a therapy other
than enzyme replacement therapy. Accordingly, a combination can
include administering a second agent at a dosage at least 10, 20,
30, or 50% lower than would be used in the absence of
velaglucerase.
[0335] A combination therapy can include administering an agent
that reduces the side effects of other therapies. For example, a
corticosteroid can be administered to a subject prior to
administration of the treatment for Gaucher disease to decrease
infusion site reaction. As another example, iron supplement therapy
can be given during the course of velaglucerase therapy.
[0336] Gaucher Disease
[0337] Gaucher disease is the most common of the lysosomal storage
diseases. It is caused by a hereditary deficiency of the enzyme
glucocerebrosidase (also known as acid .beta.-glucosidase). The
enzyme acts on a fatty substance glucocerebroside (also known as
glucosylceramide). When the enzyme is defective, the substance
accumulates, particularly in cells of the mononuclear cell lineage.
Fatty material can collect in the spleen, liver, kidneys, lungs,
brain and bone marrow. Symptoms may include enlarged spleen and
liver, liver malfunction, skeletal disorders and bone lesions that
may be painful, severe neurologic complications, swelling of lymph
nodes and (occasionally) adjacent joints, distended abdomen, a
brownish tint to the skin, anemia, low blood platelets and yellow
fatty deposits on the white of the eye (sclera). Persons affected
most seriously may also be more susceptible to infection. The
disease is caused by a recessive gene on chromosome 1 and affects
both males and females.
Gaucher disease has three common clinical subtypes:
[0338] Type I (or non-neuropathic type) is the most common form of
the disease, occurring in approximately 1 in 50,000 live births. It
occurs most often among persons of Ashkenazi Jewish heritage.
Symptoms may begin early in life or in adulthood and include
enlarged liver and grossly enlarged spleen (together
hepatosplenomegaly); the spleen can rupture and cause additional
complications. Skeletal weakness and bone disease may be extensive.
Spleen enlargement and bone marrow replacement cause anemia,
thrombocytopenia and leucopenia. The brain is not affected, but
there may be lung and, rarely, kidney impairment. Patients in this
group usually bruise easily (due to low levels of platelets) and
experience fatigue due to low numbers of red blood cells. Depending
on disease onset and severity, type 1 patients may live well into
adulthood. Many patients have a mild form of the disease or may not
show any symptoms. In some embodiments, the methods and
compositions described herein are used to treat type I Gaucher
disease.
[0339] Type II (or acute infantile neuropathic Gaucher disease)
typically begins within 6 months of birth and has an incidence rate
of approximately 1 in 100,000 live births. Symptoms include an
enlarged liver and spleen, extensive and progressive brain damage,
eye movement disorders, spasticity, seizures, limb rigidity, and a
poor ability to suck and swallow. Affected children usually die by
age 2.
[0340] Type III (the chronic neuropathic form) can begin at any
time in childhood or even in adulthood, and occurs in approximately
1 in 100,000 live births. It is characterized by slowly progressive
but milder neurologic symptoms compared to the acute or type 2
version. Major symptoms include an enlarged spleen and/or liver,
seizures, poor coordination, skeletal irregularities, eye movement
disorders, blood disorders including anemia and respiratory
problems. Patients often live into their early teen years and
adulthood.
[0341] Bone Mineral Density
[0342] As used herein bone density (or bone mineral density) refers
to the amount of matter per square centimeter of bones. Bone
density can be used in clinical medicine as an indirect indicator
of osteoporosis and/or fracture risk. BMD can be measured by a
number of procedures, e.g., dual energy X-ray absorptiometry (DXA
or DEXA), quantitative computed tomography (QCT), qualitative
ultrasound (QUS), single photon absorptiometry (SPA), dual photon
absorptiometry (DPA), digital X-ray radiogrammetry (DXR), and
single energy X-ray absorptiometry (SEXA). Measurements can be
made, e.g., over the lumbar spine, the upper part of the hip, or
the forearm.
[0343] Average bone mineral density can be defined as BMC/W
[g/cm.sup.2], wherein BMC=bone mineral content=g/cm, and W=width at
the scanned line
[0344] Densitometry results can be reported in, e.g., measured
density in g cm.sup.-3, z-score, and t-score. Negative scores
indicate lower bone density, and positive scores indicate
higher.
[0345] Z-score refers to the number of standard deviations above or
below the mean for the patient's age, sex and ethnicity.
[0346] T-score refers to the number of standard deviations above or
below the mean for a healthy 30 year old adult of the same sex and
ethnicity as the patient. The criteria of the World Health
Organization are: [0347] Normal is a T-score of -1.0 or higher.
[0348] Osteopenia is defined as less than -1.0 and greater than
-2.5. [0349] Osteoporosis is defined as -2.5 or lower, meaning a
bone density that is two and a half standard deviations below the
mean of a thirty year old woman.
Administration
[0350] The glucocerebrosidase enzyme replacement therapy described
herein can, for example, be administered by injection,
intravenously, intraarterially, subdermally, intraperitoneally,
intramuscularly, or subcutaneously. Preferably the
glucocerebrosidase enzyme replacement therapy is administered
invtravenously, with a dosage ranging from about 10, 15, 20, 25,
30, 35, 40, 45, 50, 55, 60, 65, 70, 75 or 80 U/kg, administered
every other week, or according to the requirements of the
particular compound. The methods herein contemplate administration
of an effective amount of compound or compound composition to
achieve the desired or stated effect. Typically, the
glucocerebrosidase enzyme replacement therapy can be administered
as a continuous infusion, e.g., a continuous infusion over 60
minutes, 90 minutes, 120 minutes, or 150 minutes. The amount of
active ingredient that may be combined with the carrier materials
to produce a single dosage form will vary depending upon the host
treated and the particular mode of administration. A typical
preparation will contain from 5% to 95% active compound (w/w).
Alternatively, such preparations contain from 20% to 80% active
compound.
[0351] Lower or higher doses than those recited above may be
required. Specific dosage and treatment regimens for any particular
subject will depend upon a variety of factors, including the
activity of the specific compound employed, the age, body weight,
general health status, sex, diet, time of administration, rate of
excretion, drug combination, the severity and course of the
disease, condition or symptoms, the subject's disposition to the
disease, condition or symptoms, and the judgment of the treating
physician.
[0352] Upon improvement of a subject's condition, a maintenance
dose of a compound, composition or combination of this invention
may be administered, if necessary. Subsequently, the dosage or
frequency of administration, or both, may be reduced, as a function
of the symptoms, to a level at which the improved condition is
retained. Subjects may, however, require intermittent treatment on
a long-term basis upon any recurrence of disease symptoms.
[0353] A compound, composition or combination of this invention may
be administered as a home therapy (e.g., in the subject's home,
workplace, or other non-clinical (e.g., non-hospital) setting). It
can be administered (e.g., via infusion) by a health care
professional (e.g., nurse or physician's assistant). For example,
if the subject has not experienced an adverse event (AE) (e.g., a
drug-related serious AE or an infusion-related AE, e.g., an event
described herein), e.g., after one, two, or three administrations
(e.g., via infusion) of the compound, composition or combination,
the subject is eligible to receive home therapy for subsequent
administrations.
Pharmaceutical Compositions
[0354] A glucocerebrosidase enzyme replacement therapy (e.g.,
velaglucerase) can be incorporated into a pharmaceutical
composition for administration to a subject. Such compositions
typically include the glucocerebrosidase enzyme replacement therapy
(e.g., velaglucerase) and a pharmaceutically acceptable
carrier.
[0355] As used herein, the language "pharmaceutically acceptable
carrier or adjuvant" includes solvents, dispersion media, coatings,
antibacterial and antifungal agents, isotonic and absorption
delaying agents, and the like, compatible with pharmaceutical
administration. Supplementary active compounds can also be
incorporated into the compositions. The term "pharmaceutically
acceptable carrier or adjuvant" refers to a carrier or adjuvant
that may be administered to a subject, together with
glucocerebrosidase, and which does not destroy the pharmacological
activity thereof and is nontoxic when administered in doses
sufficient to deliver a therapeutic amount of the
glucocerebrosidase.
[0356] A pharmaceutical composition is formulated to be compatible
with its intended route of administration. Examples of routes of
administration include parenteral, e.g., intravenous, intradermal
and subcutaneous. Solutions or suspensions used for parenteral,
intradermal, or subcutaneous application can include the following
components: a sterile diluent such as water for injection, saline
solution, fixed oils, polyethylene glycols, glycerine, propylene
glycol or other synthetic solvents; antibacterial agents such as
benzyl alcohol or methyl parabens; antioxidants such as ascorbic
acid or sodium bisulfite; chelating agents such as
ethylenediaminetetraacetic acid; buffers such as acetates, citrates
or phosphates and agents for the adjustment of tonicity such as
sodium chloride or dextrose. pH can be adjusted with acids or
bases, such as hydrochloric acid or sodium hydroxide. The
parenteral preparation can be enclosed in ampoules, disposable
syringes or multiple dose vials made of glass or plastic.
[0357] For intravenous administration, suitable carriers include
Sterile Water for Injection, physiological saline, bacteriostatic
water, CREMOPHOR EL.TM. (BASF, Parsippany, N.J.) or phosphate
buffered saline (PBS). In all cases, the composition must be
sterile and should be fluid to the extent that easy syringability
exists. It should be stable under the conditions of manufacture and
storage and must be preserved against the contaminating action of
microorganisms such as bacteria and fungi. The carrier can be a
solvent or dispersion medium containing, for example, water,
ethanol, polyol (for example, glycerol, propylene glycol, and
liquid polyetheylene glycol, and the like), and suitable mixtures
thereof. The proper fluidity can be maintained, for example, by the
use of a coating such as lecithin, by the maintenance of the
required particle size in the case of dispersion and by the use of
surfactants. Prevention of the action of microorganisms can be
achieved by various antibacterial and antifungal agents, for
example, parabens, chlorobutanol, phenol, ascorbic acid,
thimerosal, and the like. In many cases, it will be preferable to
include isotonic agents, for example, sugars such as sucrose,
polyalcohols such as manitol, sorbitol, sodium chloride in the
composition. Prolonged absorption of the injectable compositions
can be brought about by including in the composition an agent which
delays absorption, for example, aluminum monostearate and
gelatin.
[0358] The pharmaceutical composition can include, for example,
sterile water for injection, sucrose, sodium citrate, citric acid
and polysorbate.
[0359] Sterile injectable solutions can be prepared by
incorporating the glucocerebrosidase in the required amount in an
appropriate solvent with one or a combination of ingredients
enumerated above, as required, followed by filtered sterilization.
Generally, dispersions are prepared by incorporating the active
compound into a sterile vehicle which contains a basic dispersion
medium and the required other ingredients from those enumerated
above. In the case of sterile powders for the preparation of
sterile injectable solutions, the preferred methods of preparation
are vacuum drying and freeze-drying which yields a powder of the
active ingredient plus any additional desired ingredient from a
previously sterile-filtered solution thereof.
[0360] It is advantageous to formulate parenteral compositions in
dosage unit form for ease of administration and uniformity of
dosage. Dosage unit form as used herein refers to physically
discrete units suited as unitary dosages for the subject to be
treated; each unit containing a predetermined quantity of active
compound calculated to produce the desired therapeutic effect in
association with the required pharmaceutical carrier.
[0361] The pharmaceutical compositions can be included in a
container, pack, or dispenser together with instructions for
administration.
Kit
[0362] A glucocerebrosidase enzyme replacement therapy (e.g.,
velaglucerase) can be provided in a kit. The kit includes (a) the
glucocerebrosidase enzyme replacement therapy, e.g., a composition
that includes the glucocerebrosidase enzyme replacement therapy,
and (b) informational material. The informational material can be
descriptive, instructional, marketing or other material that
relates to the methods described herein and/or the use of the
glucocerebrosidase enzyme replacement therapy for the methods
described herein. For example, the informational material describes
methods for administering the glucocerebrosidase enzyme replacement
therapy to treat Gaucher disease.
[0363] In one embodiment, the informational material can include
instructions to administer the glucocerebrosidase enzyme
replacement therapy in a suitable manner, e.g., in a suitable dose,
dosage form, or mode of administration (e.g., a dose, dosage form,
or mode of administration described herein). In another embodiment,
the informational material can include instructions for identifying
a suitable subject, e.g., a human. The informational material of
the kits is not limited in its form. In many cases, the
informational material, e.g., instructions, is provided in printed
matter, e.g., a printed text, drawing, and/or photograph, e.g., a
label or printed sheet. However, the informational material can
also be provided in other formats, such as Braille, computer
readable material, video recording, or audio recording. In another
embodiment, the informational material of the kit is a link or
contact information, e.g., a physical address, email address,
hyperlink, website, or telephone number, where a user of the kit
can obtain substantive information about the modulator and/or its
use in the methods described herein. Of course, the informational
material can also be provided in any combination of formats.
[0364] In addition to the glucocerebrosidase enzyme replacement
therapy, the composition of the kit can include other ingredients,
such as a solvent or buffer, a stabilizer or a preservative, and/or
a second agent for treating Gaucher disease. Alternatively, the
other ingredients can be included in the kit, but in different
compositions or containers than the glucocerebrosidase enzyme
replacement therapy. In such embodiments, the kit can include
instructions for admixing the glucocerebrosidase enzyme replacement
therapy and the other ingredients (e.g., reconstituting a
lyophilized therapy and/or diluting the reconstituted therapy prior
to administration), or for using the glucocerebrosidase enzyme
replacement therapy together with the other ingredients.
[0365] The glucocerebrosidase enzyme replacement therapy can be
provided in any form, e.g., liquid, dried or lyophilized form. It
is preferred that the glucocerebrosidase enzyme replacement therapy
be substantially pure and/or sterile. When the glucocerebrosidase
enzyme replacement therapy is provided in a liquid solution, the
liquid solution preferably is an aqueous solution, with a sterile
aqueous solution being preferred. When the glucocerebrosidase
enzyme replacement therapy is provided as a dried form,
reconstitution generally is by the addition of a suitable solvent.
The solvent, e.g., sterile water or buffer, can optionally be
provided in the kit.
[0366] The kit can include one or more containers for the
composition containing the glucocerebrosidase enzyme replacement
therapy. In some embodiments, the kit contains separate containers,
dividers or compartments for the glucocerebrosidase enzyme
replacement therapy (e.g., in a composition) and informational
material. For example, the glucocerebrosidase enzyme replacement
therapy (e.g., in a composition) can be contained in a bottle,
vial, or syringe, and the informational material can be contained
in a plastic sleeve or packet. In other embodiments, the separate
elements of the kit are contained within a single, undivided
container. For example, the glucocerebrosidase enzyme replacement
therapy (e.g., in a composition) is contained in a bottle, vial or
syringe that has attached thereto the informational material in the
form of a label. In some embodiments, the kit includes a plurality
(e.g., a pack) of individual containers, each containing one or
more unit dosage forms (e.g., a dosage form described herein) of
the glucocerebrosidase enzyme replacement therapy (e.g., in a
composition). For example, the kit includes a plurality of
syringes, ampules, foil packets, or blister packs, each containing
a single unit dose of the glucocerebrosidase enzyme replacement
therapy. The containers of the kits can be air tight and/or
waterproof.
[0367] The glucocerebrosidase enzyme replacement therapy (e.g., in
a composition) can be administered to a subject with Gaucher
disease. The method can include evaluating a subject, e.g., as
described herein and thereby identifying a subject being in need of
treatment with the glucocerebrosidase enzyme replacement
therapy.
[0368] The following examples provide illustrative embodiments of
the invention. One of ordinary skill in the art will recognize the
numerous modifications and variations that may be performed without
altering the spirit or scope of the present invention. Such
modifications and variations are encompassed within the scope of
the invention. The Examples do not in any way limit the
invention.
EXAMPLES
[0369] The introduction of enzyme therapy has significantly
impacted the natural history of type 1 Gaucher disease.
Unfortunately, the existence of a single therapeutic option
represents an inherent vulnerability in the treatment of patients
with type 1 Gaucher disease. Approximately 15% of imiglucerase
treated patients have been reported to develop IgG antibodies and
approximately half of these patients reported symptoms of
hypersensitivity (Starzyk K et al., Molec Genet Metab. 2007;
90:157-163). Globally, the dependence upon a single product in the
treatment of Gaucher disease has been underscored by the recent
shortage of imiglucerase (Steinbrook R et al., N Engl J. Med. 2009;
361:1525-1527). Among those receiving imiglucerase infusions, an
unknown number of patients require pre-medication to mitigate a
potential immune-mediated response. In some instances patients
require hydrocortisone, which itself is associated with medical
risks including AVN. Furthermore, recently published data suggest
that 59% of GD1 patients treated with imiglucerase fail to achieve
at least one therapeutic goal following a minimum of 4 years of
treatment regardless of dose and duration of treatment (Weinreb N
et al., Am J. Hematol. 2008; 83: 890-895).
[0370] Velaglucerase alfa is a novel enzyme replacement therapy
(ERT) with unique characteristics (wild type amino acid sequence
and high .alpha.-mannosyl content) that distinguishes it from
imiglucerase. Some of the examples provided below describe clinical
trials and extension studies to evaluate the safety and efficacy of
velaglucerase alfa. These are the first clinical trial involving an
ERT to implement dose reduction and home therapy.
Example 1
TKT025 and TKT025EXT Studies
Summary
[0371] This example describes a nine-month Phase I/II open-label,
single center trial of velaglucerase alfa (TKT025) and ongoing
extension (TKT025EXT) study conducted to evaluate safety and
efficacy of velaglucerase alfa.
[0372] The primary objective of the Phase I/II trial was to assess
the safety of velaglucerase alfa administered intravenously at a
dose of 60 U/kg every-other-week for nine months in adult patients
with symptomatic type 1 (non-neuronopathic) Gaucher disease (GD1).
The secondary objective of this trial was to assess the clinical
activity of velaglucerase alfa on key disease features (Barton N W
et al. N Engl J. Med. 1991; 324:1464-1470). The extension study was
similarly designed to evaluate the long-term safety and assess the
effects of velaglucerase alfa on four disease measures, hemoglobin
concentration, platelet count, liver volume, and spleen volume
(Barton N W et al. N Engl J. Med. 1991; 324:1464-1470).
[0373] Twelve symptomatic adult patients with type 1 Gaucher
disease and intact spleens received velaglucerase alfa (60
U/kg/infusion) during the Phase I/II study. Originally thirteen
patients were screened to participate in the study, but one was
excluded because of the presence of anti-imiglucerase antibody. An
extension study was offered to patients who completed the trial and
a step-wise dose reduction (to 30 U/kg/infusion) was instituted.
Eleven patients completed Phase I/II; ten entered the extension
study; nine patients reached 39 months in the extension. No
drug-related serious adverse events or withdrawals, and no
antibodies were observed. Home therapy was successfully implemented
during the extension. Statistically significant improvements
(p<0.004) were noted in mean percent change from baseline to
nine months and baseline to 48 months for hemoglobin (+19.2%,
+21.7% respectively), platelet counts (+67.6%, +157.8%
respectively), normalized liver volume (-18.2%, -42.8%
respectively), and normalized spleen volume (-49.5%, -79.3%
respectively). These significant clinical changes and safety
profile led to Phase III trials and highlight the potential of
velaglucerase alfa as alternative therapy for type 1 Gaucher
disease.
Methods
[0374] The Phase I/II and extension study was conducted in a single
center (Gaucher Clinic, Shaare Zedek Medical Center; Jerusalem,
Israel).
Patients: Adult, symptomatic, enzymatically confirmed patients with
GD1 were screened. Eligibility criteria included age .gtoreq.18
years-old, an intact spleen, disease-related anemia (hemoglobin
values at least 1 g/dL below lower limit of normal (LLN) for
gender), thrombocytopenia (platelet counts below the LLN), and a
negative result for hepatitis B and C antigen and human
immunodeficiency virus. Patients were eligible if they were naive
to ERT or had not received imiglucerase within the 12 months prior
to enrollment and were imiglucerase antibody-negative. Patients
were excluded if they had received an investigational therapy for
any other indication .ltoreq.30 days prior to enrollment or if they
could not comply with the protocol for either medical or
non-medical reasons.
[0375] Preparation and Dosing: Velaglucerase alfa was supplied by
Shire HGT as a lyophilized product and shipped at
2.degree.-8.degree. C. The product was reconstituted with
preservative-free, sterile water for injection. The appropriate
amount of velaglucerase alfa (based on body weight) was slowly
mixed with normal saline to a final volume of 100 mL. The diluted
velaglucerase alfa was administered intravenously across a 0.2
.mu.m filter for a period of 60 minutes (maximum rate of 1.5
mg/kg/hour; 1 U/kg/min).
[0376] During the Phase I/II study, the first three patients
received velaglucerase alfa on an every-other-week schedule at the
trial site. Dose escalation was undertaken for the first three
patients whereby dosing doubled from an initial dose of 15 U/kg
until a final dose of 60 U/kg was achieved. The second and third
patients received their initial 15 U/kg infusion only after a 7-day
observation period was completed for the first and second patients
respectively. Once the third patient received a single dose of 60
U/kg and was observed for a period of 7 days, nine additional
patients were enrolled and received infusions of 60 U/kg
every-other-week for a total of 20 doses. The patients who had
undergone dose escalation were continued on an every-other-week
schedule for 17 further infusions at 60 U/kg for a total of 20
infusions. During the extension study, all patients were continued
at 60 U/kg/infusion every-other-week. After approximately 6-9
months of the extension study, patients who achieved at least 2 of
the 4 therapeutic goals for improvement in anemia,
thrombocytopenia, hepatomegaly, and/or splenomegaly (Pastores G M
et al., Semin Hematol. 2004; 41:4-14) were transitioned to 45
U/kg/infusion every-other-week for three months and then
transitioned to 30 U/kg/infusion every-other-week. This convention
of dose reduction based on achievement of therapeutic goals is in
accordance with recommendations for individualization of ERT in
patients on imiglucerase (Andersson H C et al., Genet Med. 2005;
7:105-110).
[0377] In addition, the seven patients residing in Israel were
transitioned to home therapy during the extension phase.
[0378] Safety Assessments: Safety was evaluated throughout the
study by every-other-week assessments of adverse events (including
infusion-related reactions), concomitant medications, and vital
signs performed before, during, and after infusions. Additional
safety assessments were conducted approximately every 12 weeks and
included physical examinations, clinical laboratory tests
(hematology, serum chemistry, urinalysis, and pregnancy test),
12-lead electrocardiograms and echocardiograms at the trial site.
Determination of the presence of anti-velaglucerase alfa antibodies
were conducted at 3-month intervals at Shire HGT.
[0379] Antibody Assays: All participants were screened for
circulating anti-velaglucerase alfa antibodies using a validated
indirect ELISA. Microwell plates were coated with velaglucerase
alfa, washed, and blocked with bovine serum albumin to limit
non-specific antibody binding. They were incubated with patient
serum samples diluted 100-fold in phosphate buffered saline
containing 0.05% Tween 20 for 60 minutes at 37.degree. C. The
microwells were washed and then incubated with the appropriate
horseradish peroxidase (HRP)-conjugated secondary antibody. They
were separately probed with the following HRP-antibody,
isotype-specific conjugates: 1) goat anti-human IgG Fc, 2) goat
anti-human IgA .alpha.-chain, 3) goat anti-human IgM .mu.-chain, or
4) goat anti-human IgE .epsilon.-chain secondary antibodies. The
microwells were washed one final time and incubated with the HRP
chromogenic substrate 3,3',5,5' tetramethyl benzidine. The reaction
was stopped by the addition of 2N sulfuric acid, and the absorbance
of each well was quantified at 450 nm (A.sub.450) using a Molecular
Devices SPECTRAmax Plus384 plate reader and SOFTMax PRO software.
Antibody-positive serum samples were obtained from patients
receiving imiglucerase. These patient antibodies cross-reacted with
velaglucerase alfa and were used as human positive controls in the
screening assay for anti-velaglucerase antibodies. These sera were
therefore both anti-imiglucerase and anti-velaglucerase alfa
positive. Negative, as well as positive, human serum controls were
included within every assay plate.
[0380] A robust ELISA antibody positive cutpoint absorbance for
anti-velaglucerase alfa antibodies was established from the mean
absorbance of ERT-naive Gaucher patient serum samples (N=108).
Parametric analysis of ELISA absorbance data was used to calculate
the antibody-positive lower limit (mean plus 1.645.times. standard
deviations; where 1.645 is the 95.sup.th percentile of the normal
distribution, thus potentially accepting a 5% false-positive rate)
for each antibody isotype (Mire-Sluis A R et al., J Immunol
Methods. 2004; 289:1-16). The ELISA A.sub.450 background for
ERT-naive Gaucher serum samples was calculated to be 0.040 for all
anti-velaglucerase alfa antibody isotype assays. The ELISA antibody
positive cutoff was established as a ratio .gtoreq.2.0 and an
A.sub.450.gtoreq.0.040, where ratio is the A.sub.450 of a patient
sample taken at any time point, divided by the A.sub.450 of the
patient sample taken at baseline prior to the first ERT treatment.
Any sample exceeding the ELISA positive cutoff would have been
confirmed by a quantitative radioimmunoprecipitation assay and
tested for neutralizing antibodies; however no sample achieved the
established cutoff criteria (Mire-Sluis A R et al., J Immunol
Methods. 2004; 289:1-16).
[0381] Clinical Activity: The main efficacy assessments of
hemoglobin concentration and platelet counts were evaluated at
pre-determined tri-monthly intervals. Liver and spleen volumes were
measured using quantitative abdominal MRI (on the same model
apparatus) performed at baseline, six- and nine-months (at the
Hadassah-Hebrew University Medical Center), and at 24, 33, and 45
months (at the MOR-MAR Imaging unit) during the extension study.
Liver and spleen volumes were assessed at the end of the trial by a
radiologist blinded to the patient's identity and the sequence by
which the quantitative abdominal MRIs were performed.
Chitotriosidase and CCL18 were measured at the Academic Medical
Center; Amsterdam, the Netherlands.
[0382] Statistical Analysis: The safety population, which was also
the intent-to-treat population, was defined as all enrolled
patients receiving at least one infusion (partial or full) of
velaglucerase alfa, and was used for all clinical activities. No
imputation was utilized.
[0383] For the primary clinical activity parameters of hemoglobin
concentration, platelet count, and liver and spleen volumes, the
null hypothesis is that there is no difference between the baseline
value and end-of-the study value (nine months), and baseline value
and end-of-48 month value. (i.e., the difference between the
members of each pair of observation has median value zero.)
Comparisons were performed using two-tailed hypothesis testing at
the 5% level of significance. Differences between baseline and end
of period values were analyzed using the Wilcoxon signed-rank test.
Changes from baseline were calculated and the percentage changes
from baseline are summarized using descriptive statistics.
[0384] For secondary clinical activity parameters, observed data,
change from baseline, and percent change from baseline were
summarized by visit including mean, standard error (SE) and median.
No formal statistical testing was applied to these data sets.
Results from TKT025 Study (9M, 60 U/kg Velaglucerase Alfa)
[0385] Velaglucerase alfa was well tolerated and no patient
developed antibodies. Clinically and statistically significant
improvements in hematological parameters and organ volumes were
observed as early as 3 to 6 months (Table 1).
TABLE-US-00002 TABLE 1 TKT025 Clinical Results (N = 12) Median Mean
Change from Clinical Activity Baseline Baseline .+-. standard
deviation Parameter Value Month 3 Month 6 Month 9 Hemoglobin
concentration (g/dL) 10.95 1.24 .+-. 0.90 1.92 .+-. 0.82 2.24 .+-.
0.89 Platelet count (.times.10.sup.9/L) 57.5 8.9 .+-. 11.20 23.4
.+-. 24.63 40.6 .+-. 30.68 Liver (% of body weight) 4.43 NA -0.67
.+-. 0.64 -0.79 .+-. 0.48 Spleen (% of body weight) 3.63 NA -1.62
.+-. 0.67 -1.89 .+-. 0.75
[0386] Demographics and disposition: A total of thirteen patients
were screened and all consented to participate in this study; one
patient (0004) was excluded because of imiglucerase antibodies. All
the patients were treatment-naive at advent according to the
protocol by virtue of not having been exposed to any
Gaucher-specific therapy in the 12 months prior to enrolment
although in the more distant past, 2 patients (0008 and 0009) had
each received 3 infusions of imiglucerase, one patient (0003) had
been exposed to miglustat, and two patients (0005 and 0007) had
been exposed to both miglustat and imiglucerase.
[0387] The intent-to-treat population (Table 2) included twelve
patients who received at least one dose of velaglucerase alfa; of
these, 11 patients (92%) completed the Phase I/II study (one
patient, 0006, withdrew after a sudden death in the family withdrew
consent after receiving three infusions).
[0388] At enrollment of the Phase I/II trial, seven patients (58%)
were female; mean age was 41.7 (SD.+-.17.3; range 19-70) years;
mean weight was 59.6 (SD.+-.9.1 range 50-73) kg and mean height was
169 (SD.+-.8.0; range 160-184) cm. Two patients (16.7%) had
avascular necrosis (AVN) of the hip joint at enrollment and another
had a destructive lesion in each ankle. Table 2 provides the
demographic, genotypic, and clinical characteristics at baseline,
as well as the clinical findings of each intent-to-treat patient at
key data collection points within the Phase I/II studies.
TABLE-US-00003 TABLE 2 Patient Demographics and Characteristics
Platelets, Hemoglobin g/dL 10/L 6 9 24 48 6 Patient Age Sex
Genotype BL Mo Mo Mo Mo BL Mo 1 24 F N370S/N370S 10.8 12.2 12.5
12.4 12.7 80 123 2 62 M N370S/L444P 12.7 14.1 14.8 14.3 14.2 69 74
3 35 M N370S/Other 13.5 15.7 16.5 15.7 16.0 48 95 5 35 F
N370S/N370S 10.6 11.7 12.0 52 68 6 44 F N370S/IVS2 + 1 10.9 56 7 42
F N370S/N370S 10.5 12.5 12.5 13.8 13.0 37 32 8 23 F N370S/RecNc1
10.0 12.1 11.8 12.7 14.2 65 137 9 25 M N370S/RecNc1 12.6 15.8 15.9
15.8 15.1 69 97 10 60 F N370S/N370S 10.1 11.1 12.5 12.4 12.4 48 60
11 18 F N370S/Other 11.0 13.8 13.6 13.6 12.6 59 98 12 69 M
N370S/N370S 13.5 14.4 14.1 59 65 13 56 M N370S/V394L 12.9 15.9 16.6
15.4 16.0 46 40 Normalized Normalized Platelets spleen volume,
multiple liver volume, 10/L of normal multiple of normal 9 24 48 6
9 24 45 6 9 24 45 Patient Mo Mo Mo BL Mo Mo Mo Mo BL Mo Mo Mo Mo 1
149 155 130 17.5 11.0 10.0 8.0 6.5 2.3 1.8 1.9 1.5 1.2 2 90 127 142
11.0 7.5 6.0 4.0 3.0 1.0 1.0 0.9 1.0 0.8 3 128 140 151 17.5 8.0 6.5
. . 2.2 1.6 1.7 1.3 1.2 5 72 32.5 23.0 24.5 1.7 1.8 1.6 6 16.0 2.1
7 39 42 95 21.0 13.5 13.0 7.0 4.0 1.8 1.7 1.6 1.4 1.0 8 150 154 203
19.0 9.0 7.0 3.5 3.5 2.2 1.6 1.6 1.2 1.2 9 120 178 183 28.0 12.5
10.0 4.0 2.5 2.0 1.4 1.4 1.1 0.9 10 86 121 139 19.0 11.0 8.5 3.5
3.0 1.4 1.2 1.0 0.8 0.8 11 110 122 130 15.0 9.0 8.0 5.0 3.5 1.4 1.1
1.0 1.1 0.8 12 99 13.0 9.0 7.5 1.0 1.0 1.0 13 36 111 135 19.5 10.0
8.0 4.5 2.5 1.0 0.8 0.8 0.8 0.7
[0389] Patient demographics and characteristics at baseline and at
select points of evaluation during the Phase I/II and extension
trials including the last values collected for each clinical
parameter for the cohort. Normalized liver and spleen volumes are
defined as 2.5% and 0.2% respectively of total body weight in
kilograms (Pastores G M et al., Semin Hematol. 2004; 41:4-14).
Multiples of normal is the observed organ volume divided by the
normalized organ volume. By 24 months, all patients demonstrated
normalization of hemoglobin concentrations and all but one patient
demonstrated platelet counts greater than 100*10.sup.9/L. BL,
baseline; Mo, month; M, male; F, Female; *Spleen volume not
interpretable due to technical artifact.
[0390] Results of liver and spleen magnetic resonance imaging (MRI)
scans were blinded and interpreted by a single reviewer to minimize
bias. Collection of baseline data from other clinical parameters
including PFTs (pulmonary function tests), MRI of the femora and
lumbar spine, and bone densitometry were also performed at various
time points throughout the study.
[0391] The study was comprised of 2 phases, a dose escalation phase
and a continuous dose phase. During the dose escalation phase, the
first patient was enrolled and administered Intravenous (IV)
velaglucerase alfa 15 U/kg, then was followed for 7 days for
assessment of safety. After safety was confirmed for the first
patient, 2 additional patients were enrolled and administered IV
velaglucerase alfa 15 U/kg and followed for 7 days for assessment
of safety. After safety was confirmed for all 3 patients who
received the 15 U/kg dose, the next two higher doses (30 and 60
U/kg) were administered in the same fashion. Once safety was
confirmed for all 3 patients, an additional 9 patients were
enrolled and administered the 60 U/kg dose. All patients then
received the 60 U/kg dose every other week for a total of 20 doses
of velaglucerase alfa.
[0392] Pharmacokinetics (PK) in humans were evaluated at Weeks 1,
3, 5, and 37/39 in TKT025. Additional PK studies were conducted at
Week 65 of Study TKT025EXT. Velaglucerase alfa was rapidly cleared
from blood with first-order elimination kinetics at each
evaluation. Elimination half-life values for patients following
initial exposure to velaglucerase alfa and following repeat
administration of velaglucerase alfa were similar. In contrast,
clearance and apparent volume of distribution values were reduced
following repeat administration of velaglucerase alfa.
[0393] Statistically significant mean increases from baseline in
hemoglobin concentration and platelet count were observed 3 months
after initiation of biweekly dosing of 60 U/kg velaglucerase alfa
in Study TKT025. By Week 25 (Month 6) in TKT025, mean hemoglobin
concentrations were 13.57 g/dL (within normal range) and remained
within normal ranges for the rest of the study. At the end of the
study, 10 of 11 patients experienced normalization of hemoglobin
concentration. Statistically significant increases from baseline
(57.3.times.10.sup.3/mm.sup.3) in mean platelet count were observed
by Week 13 (Month 3) and continued throughout the study. At Week
37, mean platelet counts had increased to
98.1.times.10.sup.3/mm.sup.3.
[0394] Additionally, statistically significant reductions from
baseline in mean and normalized (corrected by percentage of body
weight) liver and spleen volumes were observed 6 (Week 25) and 9
months (Week 37) after initiating velaglucerase alfa treatment.
Marked reductions in biomarker values (serum chitotriosidase and
Chemokine (C-C motif) ligand 18 [CCL18]) were observed by Month 3.
Overall, mean improvement in all of these parameters was continual
during the course of velaglucerase alfa administration. Moreover,
each patient experienced improvement in at least 2 of the 4
therapeutic parameters specific for Gaucher disease (e.g.,
hemoglobin concentrations, platelet counts, and spleen and liver
volumes).
[0395] In summary, FIGS. 1A-1F presents the mean percent change in
hematological parameters, organ volumes, and biomarkers for the
Phase I/II study. A marked increase in (a) hemoglobin concentration
and (b) platelet count is observed during weeks 25 and 37 along
with a marked reduction in (c) liver and (d) spleen volumes.
Although biomarker sampling for (e) chitotriosidase and (f) CCL18
was incomplete, a general decrease in both biomarkers relative to
baseline is observed per patient over time. Statistically
significant improvements (p<0.003) were noted in the mean
percent change from baseline to nine months for hemoglobin
concentration (+21.7%), platelet counts (+67.6%), normalized liver
volume (-18.2%), and normalized spleen volume (-49.5%), with
statistically significant improvements from baseline in both
hemoglobin concentration and platelet counts achieved within the
first 3 months (FIG. 2). In FIG. 2, the mean percent change in
hemoglobin concentration, platelet counts, liver volume and spleen
volume is plotted across time and demarcated for both the Phase
I/II and extension studies. A statistically significant change from
baseline is observed from baseline to 9 months (p<0.003) for
each parameter. The most marked changes were observed for platelet
count and spleen volume.
[0396] In TKT025, all 12 patients experienced 1 or more AEs
(Adverse events); in total, 103 AEs were reported. Two AEs
(dizziness and hyperhidrosis) were reported by 1 patient during the
15 U/kg dose; the remaining 101 AEs were reported by patients
receiving the 60 U/kg dose. The most frequently reported AEs were
dizziness, bone pain, and headache (5 patients each; 41.7%).
Arthralgia, back pain, pain in the extremities, influenza, upper
abdominal pain, and asthenia each occurred in 3 patients (25%). All
AEs were mild (Grade 1) except 1 event of bone pain, which was of
moderate (Grade 2) severity and unrelated to study drug. None of
the 103 AEs was considered severe or life threatening (Grade 3 or
4). No patient was withdrawn from the study due to an adverse
event.
[0397] The majority of AEs observed during TKT025 were determined
by the investigator as not related to administration of study drug
(Table 3A). Ten (10) patients experienced 22 AEs that were
considered possibly or probably related to study drug; most
commonly dizziness (3 patients); back pain, bone pain, headache,
increased body temperature, and nausea (each 2 patients). Nine (9)
patients experienced a total of 17 infusion-related adverse events,
which were defined in the protocol as an AE that occurred on the
day of the infusion, began either during or after the infusion, and
was judged as possibly or probably related to study drug. These AEs
included dizziness, headache, back pain, bone pain, body
temperature increased, each occurring in 2 patients. All
infusion-related adverse events were reported for patients
receiving the 60 U/kg dose. One patient was dose-increased to 60
U/kg/infusion every-other-week 24 months following dose reduction
because of worsening bone pain but experienced no relief following
dose increase. Therefore, there was no drug-related serious adverse
events, regardless of infusion setting. No pre-medications were
administered and no patient withdrew due to an adverse event. No
patient developed antibodies to velaglucerase alfa.
TABLE-US-00004 TABLE 3A Treatment emergent adverse events
determined to be possibly or probably related to velaglucerase alfa
(GA-GCB) administration observed during the phase I/II Trial
(TKT025) velaglucerase alfa 60 U/kg EOW n = 12 patients System
Organ Class Preferred Term Patients, n (%) Events, n (%) Any
Adverse Event 10 (83.3) 22 (21.8) Nervous System Disorders
Dizziness 3 (25.0) 4 (4.0) Headache 2 (16.7) 2 (2.0) Burning
sensation 1 (8.3) 1 (1.0) Migraine 1 (8.3) 3 (3.0) Tremor 1 (8.3) 1
(1.0) Gastrointestinal Disorders Nausea 2 (16.7) 2 (2.0) Upper
abdominal pain 1 (8.3) 1 (1.0) Musculoskeletal and Connective
Tissue Disorders Back pain 2 (16.7) 2 (2.0) Bone pain 2 (16.7) 2
(2.0) Pain in extremity 1 (8.3) 1 (1.0) General Disorders and
Administration Site Conditions Asthenia 1 (8.3) 1 (1.0)
Investigations Body temperature increased 2 (16.7) 2 (2.0)
Percentages of patients are based on the total number of patients
in the treatment group. Adverse events are coded using MedDRA
Version 7.0 dictionary. EOW: every other week.
Results from TKT025EXT (Long-Term, 30-60 U/Kg Velaglucerase
Alfa)
[0398] Summary: TKT025EXT is an open-label extension study of
velaglucerase alfa therapy in patients with type 1 Gaucher disease
who completed study TKT025. The primary objective of TKT025EXT is
to evaluate the long-term safety of velaglucerase alfa when
administered IV at a dose of 30 or 60 U/kg every other week for a
total of 4 years. The secondary objective is to continue to assess
the effects of velaglucerase alfa on clinical activity in these
patients as measured in hematological parameters and reductions in
liver and spleen volumes. Plasma chitotriosidase and CCL18 as well
as PFTs, MRI of the femoral neck and lumbar spine, skeletal survey,
and bone densitometry are also being evaluated.
[0399] Ten patients were elected to participate in this clinical
study. After 60 months of cumulative treatment (TKT025+TKT025EXT)
velaglucerase alfa was well tolerated and no patient developed
antibodies. Continued and sustained clinically and statistically
significant improvements in hematological parameters and organ
volumes continue to be seen (Table 4). FIG. 3 shows the increase of
mean hemoglobin concentration and platelet count from baseline in
the patients treated with velaglucerase alfa for 60 months. FIG. 4
shows the decrease of mean liver and spleen volumes from baseline
in patients treated with velaglucerase alfa for 60 months.
TABLE-US-00005 TABLE 4 TKT025EXT Clinical Results (N = 10) Median
Mean Change from Baseline Clinical Activity Baseline [95%
Confidence Interval] Parameter Value Month 24 Month 36.sup.a Month
48.sup.a Month 60.sup.a Hemoglobin 10.90 2.30 [1.78, 2.82] 2.13
[1.59, 2.67] 2.31 [1.66, 2.96] 2.38 [1.60, 3.16] concentration
(g/dL) Platelet count 55.5 66.5 [45.3, 87.7] 71.1 [53.6, 88.6] 82.3
[60.1, 104.5] 85.1 [59.8, 110.4] (.times.10.sup.9/L) Liver (% of
body 4.40 -1.29 [-1.91, -0.67] -1.37 [-1.90, -0.84] -1.74 [-2.40,
-1.08] -1.70 [-2.33, -1.07] weight) Spleen (% of body 3.80 -2.63
[-3.44, -1.83] -2.69 [-3.51, -1.87] -2.88 [-3.72, -2.03] -2.89
[-3.72, -2.06] weight) .sup.aOrgan volumes were assessed at Months
33, 45 and 57 from the start of TKT025
[0400] Demographics and disposition: Upon completion of Week 41
evaluations in TKT025, patients were eligible to participate in
TKT025EXT. Of the 11 patients who completed Study TKT025, 10
patients entered Study TKT025EXT. One patient (0012) did not
consent to enter the extension study because of the inconvenience
of every-other-week hospital attendance, and one patient (0005)
withdrew from the extension study because of pregnancy. Table 2
provides the demographic, genotypic, and clinical characteristics
at baseline, as well as the clinical findings of each
intent-to-treat patient at key data collection points within the
extension studies.
[0401] All patients enrolled initially received velaglucerase alfa
60 U/kg every other week. Doses were titrated down to 30 U/kg
provided patients had improvements in hematological parameters
(hemoglobin concentration or platelet levels) and/or improvements
in organ volumes (liver or spleen) after 1 year of cumulative
treatment. All 10 patients initially enrolled in TKT025EXT met the
required dose reduction criteria and were transitioned to the 30
U/kg dose.
[0402] All 9 patients in TKT025EXT had hemoglobin concentration and
platelet count data available up to Month 42, while 3 patients had
data available up to Month 45. The mean (standard error [SE])
changes in hemoglobin from pretreatment baseline at 42 months were
2.18 (0.25) g/dL (p=0.004), corresponding to a mean percent changes
from pretreatment baseline of 19.0%. With respect to platelet
count, the mean (SE) change from pretreatment baseline was 82.1
(8.4).times.10.sup.3/mm.sup.3 (p=0.004) at Month 42, corresponding
to a mean percent change from pretreatment baseline of 149.8%.
[0403] Liver and spleen volumes normalized for percent of body
weight were analyzed through Month 33; all 9 patients had liver
data available and 8 patients had spleen data available for this
assessment. The mean (SE) change from pretreatment baseline in
normalized liver and spleen volumes at Month 33 was -1.5 (0.22) and
-2.8 (0.37), respectively. The results corresponded to -34.0% and
-73.5% mean percent changes from pretreatment baseline for
normalized liver and spleen volumes, (p=0.004 and p=0.008,
respectively). Further improvements were also observed for both
plasma chitotriosidase and CCL18 parameters.
[0404] In summary, FIG. 2 presents the mean percent change in
hemoglobin concentration, platelet counts, liver volume and spleen
volume that is plotted across time and demarcated for the extension
studies. A statistically significant change is observed from
baseline to 48 months (p<0.004) for each parameter. The most
marked changes were observed for platelet count and spleen volume.
Hemoglobin values normalized for all patients by 24 months. Liver
volumes approached normal. Continuous improvement in these clinical
parameters was noted throughout the extension study (FIG. 2) and
normalization of hemoglobin was observed in all patients by 24
months (Table 2). The mean percent change from baseline to 48
months was statistically significant (p<0.004) for hemoglobin
concentration (+21.7%), platelet counts (+157.8%), liver volume
(-42.8%), and spleen volume (-79.3%).
[0405] Safety and clinical activity data for Study TKT025EXT
available up to a certain date were analyzed. Patients enrolled in
this study had a cumulative mean duration of exposure of 43.2
months (range: 13.2-45.0 months). A total of 248 adverse events
were reported among all 10 patients enrolled. The majority of AEs
were mild to moderate in severity. Three severe (Grade 3) adverse
events, considered unrelated to study drug by the Investigator,
were reported for 2 patients (arthralgia and aseptic necrosis bone
in 1 patient, and headache in 1 patient). Three (3) SAEs have been
reported (2 events of aseptic bone necrosis in 1 patient, and 1
event of scar in 1 patient). Each of these SAEs was considered
unrelated to study drug by the Investigator, and each resolved
without sequelae. The most frequently reported treatment-emergent
adverse events were influenza (8 patients, 24 events); arthralgia
(8 patients, 21 events); headache (6 patients, 13 events); back
pain (6 patients, 10 events); pharyngolaryngeal pain (5 patients, 7
events); abdominal pain upper (5 patients, 7 events); and gingival
bleeding, pyrexia and fatigue (each 4 patients, 4 events).
[0406] The majority of adverse events reported in TKT025EXT were
considered by the Investigator to be unrelated to study drug (Table
3B). A total of 7 treatment-related adverse events were reported in
4 patients, including epistaxis (2 patients, 1 event each)
abdominal pain (1 patient, 1 event), abdominal pain upper (1
patient, 1 event), fatigue (1 patient, 1 event), and pain
exacerbated (1 patient, 1 event). Two patients experienced 1
infusion-related AE each: moderate (Grade 2) pain in extremity in 1
patient, and mild (Grade 1) tremor in 1 patient. Therefore, there
was no drug-related serious adverse events regardless of infusion
setting. In addition, no patient had an infusion-related adverse
event requiring interruption of administration of velaglucerase
alfa.
[0407] No patient developed antibodies to velaglucerase alfa.
During the first year of the extension study all seven residents of
Israel were successfully transitioned to home therapy.
TABLE-US-00006 TABLE 3B Treatment emergent adverse events
determined to be possibly or probably related to velaglucerase alfa
(GA-GCB) administration observed during the extension study (TKT025
EXT) velaglucerase alfa 30 U/kg-60 U/kg EOW Patients, n (%) Events,
n (%) System organ class preferred term N = 10 N = 311 Any Related
Adverse Event 4 (40.0) 7 (2.8) Nervous System Disorders Tremors 1
(10.0) 1 (0.32) Respiratory, Thoracic or Mediastinal disorders
Epistaxis 2 (20.0) 2 (0.6) Gastrointestinal Disorders Abdominal
pain 2 (20.0) 2 (0.6) Musculoskeletal and Connective Tissue
Disorders Pain in extremity 1 (10.0) 1 (0.3) General Disorders and
Administration Site Conditions Fatigue 1 (10.0) 1 (0.3) Percentages
of patients are based on the total number of patients in the safety
population. Percentages of events are based on the total number of
events experienced by patients in the safety population. Adverse
events are coded using MedDRA Version 9.0 dictionary. EOW: every
other week.
Results of Bone Mineral Density in Type 1 Gaucher Disease Patients
in TKT025 and TKT025EXT
[0408] Long term bone mineral density (BMD) changes were evaluated
in Type 1 Gaucher disease patients treated with velaglucerase alfa.
Patients demonstrated significant and continuous improvement in
BMD.
[0409] Assessments: During TKT025 enrollment, skeletal surveys and
dual energy X-ray absorptiometry (DEXA) were used to evaluate
skeletal pathology. Z-scores of the lumbar spine and femoral neck
were analyzed at predefined times throughout the study. For some
patients, DEXA scans were performed, but Z-scores could not be
assessed from the scans. Missing Z-scores included: one
patient--femoral neck at baseline and Month 9; one patient--lumbar
spine at baseline; and one patient--femoral neck at Month 9. Lumbar
spine and femoral neck Z-scores were also not evaluated for two
patients after they withdrew from the study: one patient before
Month 24 and one patient before Month 57.
[0410] T-scores were used to compare bone density to a "young,
normal" healthy 30-year-old adult with peak bone density. Clinical
bone status at baseline and 69 months was characterized according
to the WHO criteria for T-scores: .gtoreq.-1 is normal; >-2.5
and <-1 is osteopenia; .ltoreq.-2.5 is osteoporosis.
[0411] Methods:
[0412] Analysis population: The primary analysis was conducted in
the intent-to-treat (ITT) population (N=10), defined as all
patients who signed the informed consent to participate in the
long-term extension study and received .gtoreq.1 full or partial
dose of velaglucerase alfa. The effect of velaglucerase alfa on BMD
was also assessed in subgroups who did or did not receive
bisphosphonates concomitant with ERT.
[0413] Statistical methodology: Missing baseline Z-scores were
replaced with the next value. Last observation carried forward
(LOCF) analysis was used for subsequent missing Z-scores. Linear
mixed models were used as a repeated measures analysis to analyze
Z-scores over time. The y-intercept and the slope estimate, showing
the annual increase in Z-score units, are displayed. A shift from
osteoporosis to osteopenia or normal, and from osteopenia to normal
was recorded and reported.
[0414] Results:
[0415] Baseline characteristics: All patients enrolled in TKT025EXT
had GD1-related bone pathology. Clinical status of lumber spine
(LS) bone pathology was: 1 patient (10%) was in the normal range; 8
patients (80%) had osteopenia; and 1 patient (10%) had
osteoporosis. Clinical status of femoral neck (FN) bone pathology
was: 1 patient (10%) was in the normal range; 5 patients (50%) had
osteopenia; and 4 patients (40%) patients had osteoporosis. DXA
Z-scores were (median [range]): LS, -1.8 [-2.9 to -0.4], FN -1.5
[-2.9 to -0.2]. Through 69 months the average velaglucerase alfa
dose was 40 U/kg. Four of ten patients were also treated with
bisphosphonates.
[0416] Z-scores: Z-scores at baseline and various timepoints for
ITT population (n=10), patients who received concomitant
bisphosphonates, and patients who did not received bisphosphonates
are shown in Tables 5-7, respectively. Temporal changes in mean
Z-scores of lumber spine and femoral neck are also shown in FIGS. 5
and 6, respectively.
TABLE-US-00007 TABLE 5 Z-scores; N = 10, ITT Z-Scores Lumbar Spine
Femur Time Mean [95% CI] Mean [95% CI] Baseline -1.59 [-2.17,
-1.01] -1.46 [-2.11, -0.81] Month 9 -1.50 [-2.05, -0.95] -1.39
[-2.06, -0.72] Month 24 -1.20 [-1.80, -0.60] -1.23 [-2.04, -0.42]
Month 33 -1.16 [-1.80, -0.52] -1.07 [-1.82, -0.32] Month 45 -1.12
[-1.72, -0.52] -1.14 [-1.86, -0.42] Month 57 -1.07 [-1.68, -0.46]
-1.10 [-1.89, -0.31] Month 69 -0.91 [-1.55, -0.27] -1.06 [-1.83,
-0.29]
TABLE-US-00008 TABLE 6 Z-scores; n = 4 [with bisphosphonates]
Z-Scores Lumbar Spine Femur Time Mean [95% CI] Mean [95% CI]
Baseline -1.88 [-3.25, -0.50] -1.70 [-3.13, -0.27] Month 9 -1.90
[-3.14, -0.66] -1.68 [-3.15, -0.20] Month 24 -1.78 [-2.89, -0.66]
-1.75 [-3.52, 0.02] Month 33 -1.68 [-3.14, -0.21] -1.45 [-3.19,
0.29] Month 45 -1.60 [-2.74, -0.46] -1.48 [-3.23, 0.28] Month 57
-1.50 [-2.96, -0.04] -1.40 [-3.25, 0.45] Month 69 -1.23 [-2.78,
0.33] -1.48 [-3.22, 0.27]
TABLE-US-00009 TABLE 7 Z-scores; n = 6 [no bisphosphonates]
Z-Scores Lumbar Spine Femur Time Mean [95% CI] Mean [95% CI]
Baseline -1.40 [-2.22, -0.58] -1.30 [-2.30, -0.30] Month 9 -1.23
[-1.97, -0.50] -1.20 [-2.22, -0.18] Month 24 -0.82 [-1.57, -0.06]
-0.88 [-2.03, 0.26] Month 33 -0.82 [-1.62, -0.02] -0.82 [-1.91,
0.28] Month 45 -0.80 [-1.64, 0.04] -0.92 [-1.95, 0.11] Month 57
-0.78 [-1.55, -0.01] -0.90 [-2.07, 0.27] Month 69 -0.70 [-1.61,
0.21] -0.78 [-1.91, 0.34]
[0417] Changes in Z-scores of lumbar spine (LS) and femoral neck
(FN) from baseline Z-scores during a course of 69 months are shown
in Table 8.
TABLE-US-00010 TABLE 8 Scheduled Visit No bisphosphonates n = 6
Bisphosphonates* n = 4 ITT Population N = 10 Lumbar Spine Change
From Baseline Z-scores (95% CI) Month 9 0.17 (-0.03, 0.36) -0.03
(-0.18, 0.13) 0.09 (-0.04, 0.22) Month 24 0.58 (0.08, 1.09) 0.10
(-0.27, 0.47) 0.39 (0.06, 0.72) Month 33 0.58 (-0.06, 1.22) 0.20
(-0.14, 0.54) 0.43 (0.06, 0.80) Month 45 0.60 (0.03, 1.17) 0.28
(-0.12, 0.67) 0.47 (0.14, 0.80) Month 57 0.62 (0.05, 1.18) 0.38
(-0.04, 0.79) 0.52 (0.20, 0.84) Month 69 0.70 (0.16, 1.24) 0.65
(-0.04, 1.34) 0.68 (0.35, 1.01) Femoral Neck Change From Baseline
Z-scores (95% CI) Month 9 0.10 (-0.03, 0.23) 0.03 (-0.18, 0.23)
0.07 (-0.02, 0.16) Month 24 0.42 (-0.04, 0.87) -0.05 (-0.47, 0.37)
0.23 (-0.08, 0.54) Month 33 0.48 (0.10, 0.87) 0.25 (-0.13, 0.63)
0.39 (0.16, 0.62) Month 45 0.38 (0.18, 0.59) 0.23 (-0.15, 0.60)
0.32 (0.17, 0.47) Month 57 0.40 (0.06, 0.74) 0.30 (-0.20, 0.80)
0.36 (0.14, 0.58) Month 69 0.52 (0.22, 0.81) 0.23 (-0.25, 0.70)
0.40 (0.18, 0.62) P .ltoreq. 0.05 vs baseline value
[0418] As shown in Table 8, BMD for the intent-to-treat population
improved significantly by Months 24 (LS: 0.39 (0.06, 0.72)) and
Months 33 (FN: 0.39 (0.16, 0.62). BMD for the patients who did not
receive concomitant bisphosphonates improved significant by Months
24 (LS: 0.58 (0.08, 1.09)) and Months 33 (FN: 0.48 (0.10,
0.87)).
[0419] Linear mixed model estimated Z-scores: Z-scores (ITT
population, n=10, 95% CI) were significantly lower than the
reference population (LS y-intercept=-1.56 [-2.09, -1.03];
P<0.0001) and FN (y-intercept=-1.42 [-2.06, -0.79]; P=0.0007).
Both parameters improved significantly over time (LS slope per
month=+0.011 [0.005, 0.017], P=0.0021 (slope+0.011 Z-score
units/month corresponds to +0.132/year); FN slope per month=+0.007
[0.004, 0.009], P=0.0005 (slope+0.007 Z-score units/month
corresponds to +0.084/year)).
[0420] Among patients who only received velaglucerase alfa (n=6,
95% CI), the Z-score LS y-intercept was -1.29 [-1.97, -0.62]
(P=0.0045), FN y-intercept was -1.24 [-2.21, -0.27] (P=0.0216) and
significant improvement was seen over time [LS slope per
month=+0.013 [0.002, 0.024] (P=0.028) (corresponds to +0.158 per
year), FN slope per month=+0.009 [0.004, 0.013] (P=0.0055)
(corresponds to +0.103 per year).
[0421] Among patients who received bisphosphonates concomitantly
(n=4, 95% CI), the Z-score LS y-intercept was -1.97 [-3.06, -0.88]
(P=0.0104), FN y-intercept was -1.71 [-3.02, -0.40] (P=0.0252) and
improvement was seen over time [LS slope per month=+0.009 [0.001,
0.017] (P=0.0351) (corresponds to +0.111 per year), FN slope per
month=+0.004 [-0.001, 0.010] (P=0.0867) (corresponds to +0.048 per
year).
[0422] In a linear mixed model based upon an analysis of an
observational database (International Collaborative Gaucher Group
Gaucher Registry), GD1 patients treated with the ERT imiglucerase
had significantly lower Z-scores than the reference population at
the start of follow-up (n=340, Y-intercept -1.17, P<0.001)
(Wenstrup et al. J Bone Min Res. 2007; 22: 119-26). However, a
dose-response improvement was observed in Z-score slopes per year
(15 U/kg [n=113]: +0.064; 30 U/kg [n=116]: +0.086; 60 U/kg [n=111]:
+0.132; all P<0.001) (Wenstrup et al. J Bone Min Res. 2007; 22:
119-26).
[0423] BMD status at baseline and 69 months: Clinical bone status
at baseline and 69 months was characterized using WHO criteria
(normal=T-scores: .gtoreq.-1; osteopenia=T-score>-2.5 and
<-1; osteoporosis=T-score.ltoreq.-2.5). Status change was
observed in patients who received velaglucerase alfa without
concomitant bisphosphonates (n=6). By 69 months, two LS and one FN
osteopenic patients normalized and one FN osteoporotic patient
became osteopenic. All four patients on bisphosphonates had no
change in WHO category.
[0424] Repeated measures analysis (longitudinal) slope estimates:
In the repeated measures analysis, Z-score estimates [95% CI] for
ITT population (N=10) were: LS intercept=-1.56 [-2.09, -1.03],
P<0.0001; LS slope (per month)=0.011 [0.005, 0.017], P=0.0021;
FN intercept=-1.42 [-2.06, -0.79], P=0.0007; LS slope (per
month)=0.007 [0.004, 0.009], P=0.0005. A lumbar spine slope of
0.011 increases per month corresponds to a 0.132 increase per year,
and a femoral neck slope of 0.007 increase per month corresponds to
a 0.084 increase per year.
[0425] Z-score estimates [95% CI] for patients who did not receive
bisphosphanates (N=6) were: LS intercept=-1.29 [-1.97, -0.62],
P=0.0045; LS slope (per month)=0.013 [0.002, 0.024], P=0.0280; FN
intercept=-1.24 [-2.21, -0.27], P=0.0216; LS slope (per
month)=0.009 [0.004, 0.013], P=0.0055. A lumbar spine slope of
0.013 increase per month corresponds to a 0.158 increase per year,
and a femoral neck slope of 0.009 increase per month corresponds to
a 0.103 increase per year.
[0426] Z-score estimates [95% CI] for patients who received
bisphosphanates (N=4) were: LS intercept=-1.97 [-3.06, -0.88],
P=0.0104; LS slope (per month)=0.009 [0.001, 0.017], P=0.0351; FN
intercept=-1.71 [-3.02, -0.40], P=0.0252; LS slope (per
month)=0.004 [-0.001, 0.010], P=0.0867. A lumbar spine slope of
0.009 increase per month corresponds to a 0.111 increase per year,
and a femoral neck slope of 0.004 increase per month corresponds to
a 0.048 increase per year.
[0427] The statistical model used all available data and no data
imputation was used.
[0428] Conclusions: In patients with Gaucher disease and baseline
osteopenia/osteoporosis who were treated with velaglucerase alfa,
BMD improved in both lumbar spine (Month 24) and femoral neck
(Month 36). Since the velaglucerase alfa dose was reduced from 60
to 30 unit/kg/infusion during Year 2, the improvement in bone
pathology was not dependent upon continuous high-dose therapy.
Achievement of Long-Term Therapeutic Goals
[0429] Therapeutic goals have been described to monitor
achievement, maintenance and continuity of therapeutic response in
patients with type 1 Gaucher disease receiving ERT (Pastores G et
al., (2004) Seminars in Hematology, 41 (suppl 5): 4-14)
[0430] To benchmark the impact of velaglucerase alfa treatment
against therapeutic goals for 5 key clinical parameters of type 1
Gaucher disease (anemia, thrombocytopenia, hepatomegaly,
splenomegaly and skeletal pathology), the proportion of patients at
goal for anemia, thrombocytopenia, hepatomegaly and splenomegaly at
baseline was compared with the proportion achieving each of these
goals at 4 years. Complete data for anemia, thrombocytopenia,
hepatomegaly, splenomegaly and skeletal pathology at baseline and 4
years are available for 8 patients (3 male, 5 female). The
proportion achieving the skeletal pathology goal at 4 years was
determined on the basis of Z-score improvement from baseline to 4
years. In addition, the proportion of patients who achieved all 5
goals at 4 years was compared with the proportion at goal for all 5
parameters at baseline.
[0431] At baseline, no patient was at goal for all clinical
parameters (Table 9). After 1 year of treatment, all patients
maintained goals present at baseline, and all achieved .gtoreq.2
goals. All 8 patients began step-wise dose reduction to
velaglucerase alfa 30 U/kg EOW between 15 and 18 months. By year 4
of treatment, all patients met goal for all 5 clinical parameters;
therefore, 100% achievement was seen for each of the 5 long-term,
therapeutic goals (Table 9).
TABLE-US-00011 TABLE 9 Baseline Year 4 Anemia 4/8 (50%) 8/8 (100%)
Thrombocytopenia 0/8 (0%) 8/8 (100%) Hepatomegaly 4/8 (50%) 8/8
(100%) Splenomegaly 0/8 (0%) 8/8 (100%) Skeletal pathology -- 8/8
(100%) All 5 goals 0/8 (0%) 8/8 (100%)
[0432] Skeletal pathology was measured as improvement in bone
mineral density (BMD) at year 4 relative to baseline.
[0433] In this velaglucerase alfa Phase I/II and extension study,
clinically meaningful achievement of each long-term, therapeutic
goal was observed for each patient, despite dose reduction after 1
year. This is the first report of a cohort where all patients
receiving ERT for type 1 Gaucher disease achieved all 5 of these
long-term, therapeutic goals within 4 years of starting
treatment.
Summary of Results from TKT025 and TKT025EXT
[0434] The findings reported herein demonstrate that adverse events
associated with velaglucerase alfa were generally mild in severity
and were mostly unrelated to therapy. Treatment-emergent adverse
events were mild to moderate and were mostly not drug-related. No
patient enrolled in these studies developed antibodies, no drug
related serious adverse events were observed regardless of infusion
setting or duration of exposure, and no patient withdrew from the
study because of adverse events. Following an initial period of
observation at the study site, eligible patients were successfully
transitioned to home-based, nurse-administered velaglucerase
alfa.
[0435] Velaglucerase alfa demonstrated efficacy in the four disease
parameters studied with statistically significant and clinically
meaningful improvements from baseline observed within the first six
months of treatment and throughout the course of the trial and
extension study. Within 24 months of initiation of therapy, all
patients achieved normalization of hemoglobin level, all but one
patient achieved platelet counts of greater than 100,000/mm.sup.3,
all patients achieved near normalization in liver volumes, and all
patients but one exhibited a reduction of more than 50% in spleen
volume. Moreover, these improvements were observed throughout the
duration of the studies, including the dose-reduction phase. The
only patient who was returned to the original dose of 60
U/kg/every-other-week did so at 39 months secondary to bone pain
following an initial dose reduction at 15 months. This patient had
boney destructive lesions in both her ankles at enrollment (imaging
pathology could not rule out AVN) and had a prior history of
osteomyelitis. The principle investigator (AZ) attributed the
worsening pain to the preexisting destructive lesion and prior
pathology, and likely not related to the dose reduction or
treatment failure.
[0436] The observed safety profile including the transition to home
treatment and the significant changes observed in the clinical
parameters despite dose reduction, have led to further three
subsequent Phase III trials for velaglucerase alfa (which allowed
children), as well as a global early access program, and an
FDA-accepted treatment protocol.
Example 2
TKT032 Study (12M, 45 or 60 U/kg Velaglucerase Alfa)
Example 2.1
Summary
[0437] This example describes a global, multicenter trial to
evaluate the efficacy and safety of velaglucerase alfa in type 1
GD. Twenty-five treatment-naive, anemic, type 1 GD patients (age
4-62 years) were randomized to intravenous velaglucerase alfa 60
U/kg (n=12) or 45 U/kg (n=13) every other week for 12 months.
[0438] Patients were randomized in 1:1 ratio to receive 45 U/kg
(N=13) or 60 U/kg (N=12) velaglucerase alfa. Stratification factors
included age (2-17; .gtoreq.18) and gender (male; female). The
baseline characteristics of the patients are listed in Table 10.
Clinically and statistically significant improvements in
hematological parameters and spleen volumes were observed at 12
months (Table 11). FIGS. 7 and 8 show the increase of mean
hemoglobin concentration and platelet count, respectively, from
baseline in the patients treated with 45 U/kg or 60 U/kg
velaglucerase alfa for 12 months. FIGS. 9 and 10 show the decrease
of mean normalized spleen volume and liver volume, respectively,
from baseline in patients treated with 45 U/kg or 60 U/kg
velaglucerase alfa for 12 months.
TABLE-US-00012 TABLE 10 TKT032 Baseline Characteristics
Velaglucerase alfa Velaglucerase alfa 45 U/kg 60 U/kg Total
Baseline Factor N = 13 N = 12 N = 25 2 to 17 years n (%) 3 (23.1) 4
(33.3) 7 (28.0) 2 to 4 years n (%) 0 1 (8.3) 1 (4.0) 5 to 17 years
n (%) 3 (23.1) 3 (25.0) 6 (24.0) .gtoreq.18 years n (%) 10 (76.9) 8
(66.7) 18 (72.0) Male n (%) 8 (61.5) 7 (58.3) 15 (60.0) Female n
(%) 5 (38.5) 5 (41.7) 10 (40.0) Hemoglobin concentration (g/dL)
10.90 [8.45, 12.85] 10.83 [7.05, 12.25] 10.85 [7.05, 12.85] Median
[Min, Max] Platelet count (.times.109/L) 58.00 [13.0, 264.0] 66.75
[47.0, 438.0] 65.50 [13.0, 438.0] Median [Min, Max]
TABLE-US-00013 TABLE 11 TKT032 Clinical Results (N = 25) Baseline
Mean Change n Median from Baseline to Month 12 95% CI P-value
Primary Endpoint Hemoglobin 60 U/kg 12 10.83 2.43 [1.72, 3.14]
<0.0001 Secondary Endpoints Hemoglobin 45 U/kg 13 10.90 2.44
[1.49, 3.39] 0.0001 Platelets 60 U/kg 12 66.75 50.88 [23.97, 77.78]
0.0016 Platelets 45 U/kg 13 58.00 40.92 [11.20, 70.64] 0.0111
Spleen 60 U/kg 12 2.80 -1.92 [-3.04, -0.79] 0.0032 Spleen 45 U/kg
13 2.90 -1.87 [-3.17, -0.57] 0.0085 Liver 60 U/kg 12 3.65 -0.84
[-1.58, -0.11] 0.0282a Liver 45 U/kg 13 3.50 -0.30 [-0.92, 0.32]
0.3149 aNot statistically significant after adjusting for multiple
testing.
[0439] Velaglucerase alfa was well tolerated. One patient developed
antibodies at the end of the study (12 months). Table 12 summarizes
the results of TKT032 safety test.
TABLE-US-00014 TABLE 12 TKT032 Safety Patients n (%) velaglucerase
alfa velaglucerase alfa 45 U/kg 60 U/kg Total DESCRIPTION N = 13 N
= 12 N = 25 Experienced No Adverse Events 2 (15.4) 0 2 (8.0)
Experienced At Least 1 Adverse Event 11 (84.6) 12 (100.0) 23 (92.0)
Experienced At Least 1 Drug-Related Adverse Event 9 (69.2) 6 (50.0)
15 (60.0) Experienced At Least 1 Infusion-Related Adverse Event 8
(61.5) 6 (50.0) 14 (56.0) Experienced At Least 1 Severe Or
Life-Threatening Adverse Event 2 (15.4) 0 2 (8.0) Experienced At
Least 1 Serious Adverse Event 0 1 (8.3) 1 (4.0) Discontinued Due To
An Adverse Event 0 0 0 Deaths 0 0 0 Developed anti-velaglucerase
alfa antibodies 1 (7.7) 0 1 (4.0)
[0440] At 12 months, mean hemoglobin concentration increased (60
U/kg: +23%; +2.4 g/dL [95% confidence interval (CI): 1.5, 3.4;
P<0.001]; 45 U/kg: +24%; +2.4 g/dL [95% CI: 1.5, 3.4;
P<0.001]), as did mean platelet count (60 U/kg: +65.9%;
+51.times.10.sup.9/L [95% CI: 24, 78; P=0.002]; 45 U/kg: +66%;
+41.times.10.sup.9/L [95% CI: 11, 71; P=0.01]). Mean spleen volume
decreased (60 U/kg: -50% [95% CI: -62, -39%] from 14.0 to 5.8
multiples of normal [MN] [P=0.003]; 45 U/kg: -40% [95% CI: -52,
-28%], from 14.5 to 9.5 MN [P=0.009]); as did mean liver volume (60
U/kg: -17% [95% CI: -27, -7%], from 1.5 to 1.2 MN [P=0.03]; 45
U/kg: -6% [95% CI: -18, 6%], from 1.4 to 1.2 MN [P=0.32]. No
drug-related serious adverse events or withdrawals were observed.
One patient developed antibodies.
Study Objectives
[0441] The primary objective of this study is to determine the
efficacy of every other week dosing of velaglucerase alfa at a dose
of 60 U/kg in patients with type 1 Gaucher disease as measured by
increases in hemoglobin concentration.
[0442] The secondary objectives of this study are to evaluate the
safety of every other week dosing of velaglucerase alfa at doses of
60 and 45 U/kg; to evaluate the efficacy of every other week dosing
of velaglucerase alfa at a dose of 45 U/kg as measured by increases
in hemoglobin concentration; to evaluate the efficacy of every
other week dosing of velaglucerase alfa at doses of 60 and 45 U/kg
by assessing increases in platelet counts, decreases in spleen and
liver volumes, and decreases in levels of plasma chitotriosidase
and Chemokine (C-C motif) ligand 18 (CCL18); to evaluate the effect
of every other week dosing of velaglucerase alfa at doses of 60 and
45 U/kg on overall quality of life (QoL); and to evaluate the
single- and repeat-dose pharmacokinetics of every other week dosing
of velaglucerase alfa when administered at doses of 60 and 45
U/kg.
[0443] The tertiary objectives of this study are to determine the
time from Baseline to achieve a hemoglobin response, defined as an
increase in hemoglobin concentration of 1 g/dL, after every other
week dosing with velaglucerase alfa at doses of 60 or 45 U/kg; to
evaluate the effect of every other week dosing of velaglucerase
alfa at doses of 60 and 45 U/kg on pulmonary function tests (PFTs)
in patients .gtoreq.18 years-old; to evaluate growth velocity and
Tanner staging in patients between 2 and 17 years-old; to evaluate
changes in skeletal age in patients between 2 and 17 years-old by
radiography of the left hand and wrist; to establish a Baseline
from which to evaluate bone disease in patients between 2 and 17
years-old by magnetic resonance imaging (MRI) of the lumbar spine
and femoral neck; and to establish a Baseline from which to
evaluate the long-term effect of velaglucerase alfa therapy on
Gaucher-related local and systemic bone disease in
patients.gtoreq.18 years-old by: DXA of the lumbar spine and
femoral neck (including coronal imaging); and serum alkaline
phosphatase, N-Telopeptide cross-links (NTx), and C-Telopeptide
cross-links (CTx).
Overall Study Design
[0444] This is a multicenter, Phase III randomized, double-blind,
parallel group, 2-dose study designed to evaluate the efficacy and
safety of velaglucerase alfa therapy for patients with type I
Gaucher disease.
[0445] This study was comprised of 5 phases as follows: (1)
Screening: Day -21 through Day -4; Baseline: Day -3 through Day 0
(prior to first dose); Treatment Phase: Week 1 (Day 1; first dose)
through Week 51 (a total of 26 infusions were administered per
patient); End of Study Visit: Week 53; Follow-up: 30 days after the
final infusion (for patients who discontinue/withdraw prior to the
Week 53 evaluation, or for patients who complete this study but do
not elect to enroll in the subsequent long-term clinical
study).
[0446] At Screening, patients who provided written informed consent
to participate in this study were reviewed against the study
entrance criteria to determine study eligibility and underwent
Screening evaluations. In particular, patients provided a blood
sample to measure hemoglobin concentration. Only those patients who
had a hemoglobin concentration that was at least 1 g/dL below the
lower limit of normal for age and gender were eligible to continue
into the baseline phase. For statistical analysis purposes, an
additional blood sample was collected at screening for evaluation
of hemoglobin concentration.
[0447] Patients who were eligible for study participation after
completing the Screening evaluations underwent Baseline procedures
and evaluations (i.e., Days -3 to 0) prior to the first dose. To
confirm that their hemoglobin concentration was at least 1 g/dL
below the lower limit of normal for age and gender, patients
provided a blood sample at Baseline. Hemoglobin concentration were
analyzed and reported. Only those patients who had a hemoglobin
concentration that was at least 1 g/dL below the lower limit of
normal for age and gender at both Screening and Baseline were
eligible for randomization. For statistical analysis purposes, an
additional blood sample was collected at Baseline for evaluation of
hemoglobin concentrations. Additional Baseline procedures and
evaluations were conducted prior to administration of the first
dose.
[0448] Following completion of Baseline evaluations and
confirmation of eligibility, patients were randomized in a 1:1
ratio to receive either velaglucerase alfa 60 U/kg or velaglucerase
alfa 45 U/kg via a computer generated randomization schedule.
[0449] Patients received a total of 26 IV infusions of double-blind
study medications at the clinical site once every other week for a
total of 51 weeks. Safety and efficacy assessments were made at
regular intervals during the treatment period. The final
assessments of safety and efficacy were made at the Week 51 and
Week 53 visits. Safety was assessed throughout the study by
assessments of adverse events (including infusion-related adverse
events), concomitant medications, and vital signs. Additional
safety assessments, including, 12-lead electrocardiograms, physical
examinations, clinical laboratory tests (hematology, serum
chemistry, and urinalysis), were made at Weeks 13, 25, 37, and 53.
Determination of the presence of anti-velaglucerase alfa antibodies
and enzyme neutralizing antibodies were conducted approximately
every 6 weeks until Week 53.
[0450] Efficacy was assessed via hemoglobin concentration and
platelet count, liver and spleen volume, and plasma chitotriosidase
and CCL18 level. Additional efficacy assessments included growth
velocity and Tanner staging, QoL indicators, skeletal growth and
pulmonary function testing.
[0451] Single-dose and repeat-dose velaglucerase alfa
pharmacokinetic profiles were also evaluated during the study.
Blood samples were collected at Week 1 (Day 1) and Week 37,
respectively, for these analyses.
[0452] Patients who completed this study were provided the
opportunity to enroll in a subsequent long-term clinical study. For
patients who elected to enroll in this long-term study, certain
assessments from the Week 51 and the Week 53 visits in TKT032 were
used as the Baseline assessments; patients received their first
velaglucerase alfa infusion for the long-term clinical study at the
Week 53 visit, after the Week 53 procedures scheduled for TKT032
were completed. Therefore, it was intended that patients would
receive continuous velaglucerase alfa treatment across the 2
studies. Patients who completed this study and did not elect to
enroll in the subsequent long-term clinical study would have a
safety evaluation by site visit or telephone 30 days after their
last infusion of velaglucerase alfa.
Selection of Study Population
[0453] Of 39 patients assessed, 14 were not eligible for
randomization (12 did not meet inclusion criteria; 2 did not meet
exclusion criteria). Twenty five participants were randomized to
velaglucerase alfa at a dose of 45 U/kg (n=13) or 60 U/kg (n=12).
All randomized patients who received at least 1 infusion (or
partial infusion) were included in the intent-to-treat (ITT)
patient population.
[0454] Eligible participants were males or females age .gtoreq.2
years with diagnosed type 1 Gaucher disease (deficient
glucocerebrosidase activity in leukocytes, or by genotype
analysis), and disease-related anemia (hemoglobin levels .gtoreq.1
g/dL below the local laboratory's lower limit of normal for age and
gender). Participants also had 1 or more of the following: at least
moderate splenomegaly (2 to 3 cm below the left costal margin) by
palpation; disease-related thrombocytopenia (platelet
count<90.times.10.sup.3 platelets/mm.sup.3); or readily palpable
enlarged liver. Participants could not have received treatment for
Gaucher disease within 30 months prior to study entry.
[0455] Participants were excluded if they had a splenectomy; had
(or were suspected of having) type 2 or 3 Gaucher disease; were
antibody-positive or had experienced an anaphylactic shock to
imiglucerase. Other exclusion criteria included treatment with any
non-Gaucher disease-related investigational drug or device within
30 days prior to study entry; positive test for HIV, or hepatitis B
or C; exacerbated anemia (vitamin B12, folic acid, or iron
deficiency-related), or any significant co-morbidity that could
affect study data. Pregnant or lactating women were excluded and
women of child-bearing potential were required to use a medically
acceptable method of contraception at all times.
Study Treatments
[0456] Treatment Assignment: Patients were randomized in a 1:1
ratio to receive: velaglucerase alfa 60 U/kg every other week for
51 weeks (12 patients, 26 infusions); or velaglucerase alfa 45 U/kg
every other week for 51 weeks (12 patients, 26 infusions).
[0457] Randomization: Following the completion of Baseline
evaluations and confirmation of eligibility, patients were
randomized in a ratio of 1:1 via a computer generated randomization
schedule to receive either velaglucerase alfa 45 U/kg or 60 U/kg
every other week infusions for 51 weeks.
[0458] The pursuit of balance on prognostic factors was important
in small trials on the grounds of statistical efficiency for the
primary analyses. To achieve this balance across a number of
prognostic factors (e.g., age and gender) dynamic allocation
techniques were used. For the dynamic randomization procedure, the
allocation of patients was influenced by the current balance on the
stratifying factors for the patient in question. This technique
used the approach as suggested by Pocock and Simon and was very
consistent with the guidance provided in ICH-9 (Pocock et al.
Biometrics. 1975; 31:105-115).
[0459] Treatment Schedule: Patients received their first infusion
at Week 1. All patients were treated every other week for 12 months
(51 weeks); therefore, a total of 26 infusions of velaglucerase
alfa were administered.
[0460] Dose Calculation: The actual dose of study drug was
calculated based on the patient's weight at Baseline. A change in
weight of .gtoreq.5% noted at Weeks 13, 25, or 37 from the prior
assessment would have required recalculation of the dose of study
medication.
[0461] Velaglucerase alfa Administration: Velaglucerase alfa was
administered as a continuous IV infusion at both the 60 and 45 U/kg
dose levels. All infusions were administered over a 1-hour
duration. All infusions were reconstituted in 4.3 mL of
preservative-free, Sterile Water for Injection, and then diluted in
normal saline (0.9% sodium chloride) to yield a 100 mL total
volume. Study drug infusions occurred on approximately the same day
of the week but might occur every 14 days (.+-.3 days) of the
scheduled day in order to facilitate patient scheduling.
Study Procedures and Data Collection Methods
[0462] Genotyping: All patients provided a blood sample at
Screening for Gaucher disease genotyping and plasma chitotriosidase
genotyping.
[0463] Medical History: At Screening, the patient's complete
medical history was recorded. This included a review of body
systems, documentation of current and prior medical procedures, and
documentation of current and prior concomitant medication usage,
and documentation that the patient had not been treated for Gaucher
disease within the 30 months prior to study entry.
[0464] Vital Signs: Vital signs parameters that were recorded
included pulse, blood pressure, respiration rate, and temperature.
The following schedule was followed for recording vital signs at
infusion visits: start of infusion (within 10 minutes prior to
starting the infusion), during infusion (30 minutes (.+-.5
minutes)), after infusion (within 5 minutes, 30 minutes (.+-.5
minutes), and 60 minutes (.+-.5 minutes) after completing the
infusion). At Screening, Baseline, and Week 53, vital signs were
collected at one time point only.
[0465] Physical Examinations: Physical examinations were performed
at Screening, Baseline and at Study Weeks 13, 25, 37, and 53.
Physical examinations included the following: general appearance,
endocrine, head and neck, cardiovascular, eyes, abdomen, ears,
genitourinary, nose, skin, throat, musculoskeletal, chest and
lungs, and neurological. In addition, liver and spleen palpations
were performed during Screening to confirm that the patient had
moderate splenomegaly (2 to 3 cm below the left costal margin) and
a Gaucher disease-related enlarged liver.
[0466] Height and Weight: Height and weight were recorded at
Baseline and at Study Weeks 13, 25, 37, and 53.
[0467] 12-Lead Electrocardiograms: A 12-Lead ECG was performed at
Baseline and Study Weeks 13, 25, 37, and 53. Each 12-lead ECG
included assessment of PR, QRS, QT, and QTc intervals, and heart
rate.
[0468] Clinical Laboratory Testing: Blood and urine samples were
collected as described below for clinical laboratory testing. All
blood samples were collected via venipuncture.
[0469] Hematology: Blood samples were collected at Screening,
Baseline, and Weeks
[0470] 13, 25, 37, and 53 for complete hematology testing. The
following hematology parameters were evaluated: complete blood
count (CBC) with differential, activated partial thromboplastin
time (aPPT), reticulocyte count (analyzed and reported by the
clinical site's local laboratory), platelet count, and prothrombin
time (PT). At Screening, Baseline, and at every study visit (except
at the Week 1 visit), blood samples were collected to measure
hemoglobin concentration and platelet count.
[0471] Serum Chemistry: Blood samples were collected for serum
chemistry testing at Screening, Baseline, and at Study Weeks 13,
25, 37, and 53. The following serum chemistry parameters were
evaluated: sodium, alanine aminotransferase, potassium, aspartate
aminotransferase, glucose, lactate dehydrogenase, total calcium,
gammaglutamyltransferase, total protein, creatinine phosphokinase,
albumin, NTx*, creatinine, CTx*, urea nitrogen, folic acid
(screening only), total bilirubin, vitamin B.sub.12 (screening
only), alkaline phosphatase* (* results were used for assessments
of bone biomarkers).
[0472] Urinalysis: Urine samples were collected for urinalysis at
Screening, Baseline, and at Study Weeks 13, 25, 37, and 53. The
following urinalysis parameters were evaluated: pH, macroscopic
evaluation, microscopic evaluation.
[0473] Serum Anti-imiglucerase Antibody Determination: All patients
had a blood sample collected during Screening only for
determination of serum anti-imiglucerase antibodies. Patients with
a positive result were excluded from the study.
[0474] Serum Anti-velaglucerase alfa Antibody Determination:
Patients provided blood samples to measure anti-velaglucerase alfa
antibodies in serum at Baseline and approximately every 6 weeks
during the treatment phase (Weeks 7, 13, 19, 25, 31, 37, 43, and
49), and at Week 53. During the treatment phase, these blood
samples were collected prior to the infusion.
[0475] Adverse Events: Adverse events were monitored throughout the
study from informed consent/assent through 30 days after the last
infusion for patients who completed the study and did not elect to
enroll in the long-term clinical study from the study prior to the
Week 53 visit. For patients who completed this study and elected to
enroll in the long-term clinical study, adverse events were
monitored from informed consent/assent through the Week 53
visit.
[0476] Prior and Concomitant Illnesses: Additional illnesses
present at Baseline were regarded as concomitant illnesses and were
documented on the appropriate pages of the medical history CRF.
Illnesses first occurring or detected during the study, or
worsening of a concomitant illness during the study, were regarded
as AEs and documented as such in the CRF.
[0477] Liver and Spleen MRI: Patients had MRI of the liver and
spleen at Baseline, Week 25 and Week 51. Liver and spleen size were
measured using quantitative abdominal MRI.
[0478] Plasma Chitotriosidase Levels: Blood samples (approximately
2.5 mL) were collected for the evaluation of plasma chitotriosidase
levels at Baseline, Weeks 13, 25, 37, and at Week 53.
[0479] Plasma CCL18 Levels: Blood samples (approximately 2.5 mL)
were collected for the evaluation of plasma CCL18 levels at
Baseline, Week 13, 25, 37 and at Week 53.
[0480] Quality of Life Testing: At Baseline and at Week 53,
patients' quality of life was evaluated using validated
questionnaires, including the Short Form 36 (SF-36), version 2 (for
patients .gtoreq.18 years-old) and the Childhood Health
Questionnaire (CHQ), PF50 (for patients 5 to 17 years-old).
[0481] Growth Velocity and Tanner Staging: For patients 2 to 17
years-old, growth was assessed at Baseline and Weeks 13, 25, 37,
and 53. Growth velocity was calculated using height and weight
measurements, recorded at regular time points during this study.
Growth rates of patients in this study were measured against growth
rates for normal individuals of comparable ages obtained from the
Centers for Disease Control and Prevention height and weight data.
Tanner stage was recorded at Baseline and Weeks 13, 25, 37, and
53.
[0482] Skeletal Growth: Patients between 2 and 17 years-old
underwent radiography of the left hand and wrist at Baseline and
Week 51 for evaluation of skeletal age.
[0483] Pulmonary Function Testing: At Baseline and Week 53,
patients .gtoreq.18 years-old who were enrolled at study sites with
the capability to perform spirometry had PFTs.
[0484] Spirometry was performed according to the guidelines
published by the American Thoracic Society or European Respiratory
Society for standardization of spirometry (American Thoracic
Society. Standardization of Spirometry. Am J Respir Crit. Care Med.
1995; 152:1107-1136; Quanjer et al. Eur Respir J. 1993;
16(Suppl):5-40) Both Forced Vital Capacity (FVC) and Forced
Expiratory Volume/second (FEV.sub.1) were expressed as absolute
values and % predicted of normal, which were calculated based on
published reference values for adults (Hankinson et al. Am J.
Respir. Crit. Care Med. 1999; 159:179-187). Current standing height
was used for the calculations.
[0485] Lung volume and Diffusion Capacity (DL.sub.CO)
determinations were performed at the same time as spirometric
testing. Lung volume measurements were include Total Lung Capacity
(TLC), and Residual Volume (RV), which were recorded as absolute
values and % predicted of normal based on published reference
values. DL.sub.CO was also expressed as absolute values and %
predicted of normal based on published reference values.
[0486] Pharmacokinetic Evaluations: For patients .gtoreq.18
years-old, blood samples were collected at the following times at
Week 1 (Day 1) and Week 37: immediately before first dose, during
infusion (sample collected at 5, 10, 15, 20, 40 and 60 (end of
infusion) minutes), and after infusion (sample collected at 65, 70,
80, 90, 105 and 120 minutes).
[0487] For patients 2 to 17 years-old, blood samples were collected
at the following times at Week 1 (Day 1) and Week 37: immediately
before first dose, during infusion (sample collected at 10, 20, 40
and 60 (end of infusion) minutes), and after infusion (sample
collected at 70, 80 and 90 minutes).
[0488] Serum samples were evaluated for the presence of
administered velaglucerase alfa using a glucocerebrosidase antigen
immunoassay. The following PK parameters were evaluated: AUC (Area
under the curve), C.sub.max (Maximum serum concentration),
T.sub.max (Time to maximum serum concentration), CL (mL/min/kg)
(Serum clearance, normalized for body weight), V.sub.ss (mL)
(Apparent volume of distribution at steady-state), V.sub.ss (% BW)
(V.sub.ss normalized for body weight), MRT (Mean residence time),
and T.sub.1/2 (Elimination half-life (analyzed with appropriate PK
models)
[0489] Bone Biomarkers: At Baseline only, patients .gtoreq.18
years-old underwent DXA of the lumbar spine and femoral neck,
including coronal imaging, to determine Gaucher-related local and
systemic bone disease. Bone loss and demineralization were also
evaluated by measuring serum alkaline phosphatase, NTx, and CTx.
Results for these parameters were obtained from blood samples
collected for clinical laboratory testing at Baseline only.
[0490] For patients 2 to 17 years-old, MRI of the femoral neck and
lumbar spine was obtained at Baseline (i.e., at the same time
patients underwent MRI of the liver and spleen). It was not
expected that any treatment effect would be apparent for these
parameters during this study; therefore, measurements were
collected at Baseline only to establish a reference point from
which to monitor these biomarkers during the long-term clinical
study.
Adverse Events
[0491] Adverse Event Definition: An adverse event (AE) is any
noxious, pathologic, or unintended change in anatomical,
physiologic, or metabolic function as indicated by physical signs,
symptoms, and/or laboratory changes occurring in any phase of a
clinical trial, and whether or not considered study drug-related.
This includes an exacerbation of a pre-existing condition. Adverse
events were collected from informed consent/assent until 30 days
after the last dose of study medication and/or until the event had
been resolved/stabilized or an outcome was reached, whichever came
first. For patients who completed this study and elected to enroll
in the subsequent long-term clinical study, adverse events were
monitored from the time the patient provided informed consent
through the Week 53 visit of TKT032.
[0492] AEs include: worsening (change in nature, severity, or
frequency) of conditions present at the onset of the study;
intercurrent illnesses; drug interactions; events related to or
possibly related to concomitant medications; abnormal laboratory
values (this includes significant shifts from Baseline within the
range of normal that the Investigator considers to be clinically
important); clinically significant abnormalities in physical
examination, vital signs, weight, and ECG.
[0493] In addition, AEs might also include unexpected laboratory
values that became significantly out of range and determined to be
clinically significant by the Investigator.
[0494] Infusion-Related Adverse Event Definition: An
infusion-related adverse event is defined as an adverse event that
1) begins either during or within 12 hours after the start of the
infusion, and 2) is judged as possibly or probably related to study
medication. Other AEs which occurred prior to the infusion, along
with AEs associated with protocol-defined testing and assessments
(e.g., laboratory testing, ECGs, and physical examinations) which
were performed prior to the infusion, are not defined as
infusion-related adverse events.
[0495] Serious Adverse Event Definition: A serious AE (SAE) is any
AE occurring at any dose that results in any of the following
outcomes: death, is life-threatening, requires inpatient
hospitalization, requires prolongation of existing hospitalization,
a persistent or significant disability/incapacity, and a congenital
anomaly/birth defect.
[0496] Important medical events that may not result in death, be
life-threatening, or require hospitalization may be considered as
SAEs when, based upon appropriate medical judgment, they may
jeopardize the patient and may require medical or surgical
intervention to prevent one of the outcomes listed above.
[0497] A life-threatening AE is defined as an AE that placed the
patient, in the view of the initial reporter, at immediate risk of
death from the AE as it occurred (i.e., it does not include an AE
that, had it occurred in a more severe form, might have caused
death).
[0498] Classification of Adverse Events and Serious Adverse Events:
The National Cancer Institute Common Toxicity Criteria (NCI CTC)
Version 3.0 grading scale was referenced when assessing the
severity of an AE. If an AE was not described in the NCI CTC, the
severity was recorded based on the scale below. The severity of all
AEs/SAEs were recorded on the appropriate CRF page as Grade 1, 2, 3
or 4 corresponding, respectively, to a severity of mild, moderate,
severe, or life-threatening. Grade 1 (mild) is defined as no
limitation of usual activities. Grade 2 (moderate) is defined as
some limitation of usual activities; Grade 3 (severe) is defined as
inability to carry out usual activities; and Grade 4
(life-threatening) is defined as immediate risk of death.
Relationship of an adverse event or serious adverse event to
blinded study medication was determined by the Investigator based
on the following definitions. "Not related" is defined as unrelated
to study drug. "Possibly related" is defined as a clinical
event/laboratory abnormality with a reasonable time sequence to
administration of study drug, but which could also be explained by
concurrent disease or other drugs/chemicals. "Probably related" is
defined as a clinical event/laboratory abnormality with a
reasonable time sequence to administration of study drug, unlikely
to be attributable to concurrent disease or other drugs and
chemicals and which follows a clinically reasonable response on
dechallenge. The association of the clinical event/laboratory
abnormality must also have some biologic plausibility, at least on
theoretical grounds.
[0499] Clarification between Serious and Severe: The term "severe"
is often used to describe the intensity (severity) of a specific
event (as in mild, moderate, or severe myocardial infarction); the
event itself, however, may be of relatively minor medical
significance (such as severe headache). This is not the same as
"serious," which is based on the outcome or action criteria usually
associated with events that pose a threat to life or functioning.
Seriousness (not severity) and causality serve as a guide for
defining regulatory reporting obligations.
[0500] Adverse Event Monitoring and Period of Observation: For the
purposes of this study, the period of observation extended from
informed consent/assent until the patient's final evaluation of the
study. For safety purposes, the final evaluation was defined as the
post-study safety evaluation performed approximately 30 days after
the last infusion for patients who completed the study and did not
elect to enroll in the long-term study. For patients who completed
this study and elected to enroll in the long-term clinical study,
adverse events were monitored from the time the patient provides
informed consent through the Week 53 visit of TKT032.
Statistical Methods
[0501] General Statistical Methodology: Statistical analyses were
based on the ITT principle for all efficacy variables. The ITT
analysis was based on all randomized patients who received at least
one infusion (full or partial infusion). Summary statistics were
provided for the changes and percent changes from Baseline for each
parameter by treatment group. Two-sided 95% confidence intervals in
the mean changes and mean percent changes from Baseline were
presented by treatment group for each endpoint.
[0502] Continuous data collected at Baseline and subsequent study
visits were summarized, and the mean, standard deviation, minimum,
maximum, and median values for each variable were tabulated to
facilitate the search for trends over time which might be
attributable to study drug. Categorical variables were presented in
terms of frequencies and percent. Within group changes were
examined using paired t-tests. Statistical significance was defined
at the 0.05 level.
[0503] Demographic and Baseline characteristics were summarized as
frequencies and percentages, and data were presented using
descriptive statistics. Additional analyses were conducted
specifically for patients between 2 and 17 years old.
[0504] In general, descriptive statistics and graphs were used for
presentation of study results, including, if relevant, graphs
showing the development over time for patients individually and for
each treatment group.
[0505] Safety was evaluated on the basis of AEs reported, clinical
laboratory data, ECG recordings, medical histories, vital signs,
and physical examinations. In addition, blood samples were analyzed
for determination of the presence of anti-velaglucerase alfa
antibodies.
[0506] Hypothesis Testing: All hypothesis testing was 2-sided and
was performed at the 0.05 level of significance. Each variable was
quantified as a mean change from Baseline or mean percent change
from Baseline. The null hypothesis for each variable being tested
is that, at Week 51 or Week 53, there is no change from Baseline.
The alternative hypothesis is that there is a change in either
direction from Baseline.
[0507] Screen Failures: The disposition of all patients screened
for entry into the study was tabulated along with reasons for
screen failure. The disposition of all randomized patients was
tabulated by treatment and visit, and reasons for discontinuation
were tabulated by treatment.
[0508] Sample Size Justification: The sample size for this study
was chosen to have a high power to detect a clinically significant
difference in mean hemoglobin concentrations from Baseline to 12
months. A total of 12 patients per treatment arm were required for
the primary analysis. This number was based on results from the
Phase I/II Study TKT025, examining the within patient change from
Baseline results. It was observed that at Week 25, the average
hemoglobin increase from Baseline was 1.92 g/dL with a standard
deviation of 0.824. The assumption was that the standard deviation
of the mean change was approximately the same. Using a two-sided
alpha level of 0.05 and assuming a 1-unit change in hemoglobin is
considered clinically significant, the standard deviation of the
change from Baseline is 0.824, then 10 patients would be needed for
the trial to have a power of 90%. Assuming a 20% drop out rate,
then 12 patients per treatment group would be needed. To gather
additional safety data and to protect against possible patient
dropout(s), and to achieve the target patient population, up to 30
patients could be enrolled in this study
[0509] Analysis Populations: The primary population for analyses of
efficacy data was the ITT patient population, defined as all
enrolled and treated patients who receive at least one
velaglucerase alfa infusion (or partial infusion). It was
anticipated that attrition from the original random sample due to
lack of post-Baseline data would be sufficiently small (5% or less)
so as to minimize concerns regarding bias due to the exclusion of
such patients.
[0510] The safety population consisted of all randomized patients
who received at least one study infusion (or partial infusion). Any
patient in the safety population who did not receive the study
infusion to which he or she was randomized was analyzed according
to the infusion they predominantly received rather than the
randomized treatment. Such patients were excluded from the
Per-Protocol (PP) patient population. The PP patient population is
defined as all randomized patients who have receive 80% of the
scheduled infusions, and who have valid Baseline and Week 51 and/or
Week 53 evaluations.
[0511] Efficacy Analyses: The disposition of all patients Screened
for entry into the study was tabulated, along with reason(s) for
Screening failure. The disposition of all randomized patients was
tabulated by treatment group and visit, and reason(s) for
discontinuation (s) was tabulated.
[0512] The primary clinical activity variable is hemoglobin
concentrations in the patients randomized to 60 U/kg of
velaglucerase alfa. The primary objective is to demonstrate
efficacy by showing a mean change in hemoglobin from Baseline to 12
months in patients randomized to 60 U/kg of velaglucerase alfa. For
analysis purposes, hemoglobin values collected at Screening and
Baseline were averaged to establish the Baseline used to calculate
change. The null hypothesis is that there will be no change from
Baseline in hemoglobin concentrations to 12 months. The mean
difference from Baseline to 12 months was tested using a paired
t-test or Wilcoxon signed rank test. A 95% confidence interval for
the mean difference was also presented.
[0513] Secondary and tertiary clinical activity variables are:
hemoglobin concentrations (change from Baseline to 12 months (Week
53) was assessed for the 45 U/kg group); platelet counts (change
from Baseline to 12 months (Week 53) was assessed for both
treatment groups); spleen volume (percent change from Baseline to
12 months (Week 51) was assessed for both treatment groups; in
addition to observed values, spleen volumes were normalized by body
weight and also presented by multiples of normal); liver volume
(percent change from Baseline to 12 months (Week 51) was assessed
for both treatment groups; in addition to observed values, liver
volumes were normalized by body weight and also presented by
multiples of normal); plasma chitotriosidase (change from Baseline
to 12 months (Week 53) was assessed for both treatment groups; a
statistically significant decrease expected after 12 months of
treatment); plasma CCL18 (change from Baseline to 12 months (Week
53) was assessed for both treatment groups; a statistically
significant decrease expected after 12 months of treatment);
quality of life (SF-36 and CHQ) (change from Baseline to 12 months
(Week 53) was assessed for both treatment groups); hemoglobin
response (time to achieve a hemoglobin response, defined as an
increase in hemoglobin concentration of .gtoreq.1 g/dL was assessed
for both treatment groups); growth velocity and Tanner staging
(change from Baseline to 12 months (Week 53) was evaluated for both
treatment groups in patients between 2 and 17 years-old); skeletal
age (change from Baseline to 12 months (Week 51) was evaluated for
both treatment groups, as measured by radiography of the left hand
and wrist, in patients 2 to 17 years-old); and PFTs (change from
Baseline to 12 months (Week 53) was assessed for both treatment
groups in patients .gtoreq.18 years-old).
[0514] For the secondary objective used to demonstrate a mean
change in hemoglobin from Baseline to 12 months (Week 53) in
patients randomized to 45 U/kg of velaglucerase alfa, the null
hypothesis is that there will be no change from Baseline to 12
months (Week 51 or Week 53). For analysis purposes, hemoglobin
values collected at Screening and Baseline were averaged to
establish the Baseline used to calculate change. The mean
difference from Baseline to 12 months (Week 51 or Week 53) was
tested using a paired t-test or Wilcoxon signed rank test. A 95%
confidence interval for the mean difference was also presented.
[0515] For the remaining secondary parameters, the null hypothesis
is that there will be no change from Baseline to 12 months (Week 51
or Week 53) for each treatment group. For analysis purposes,
platelet values collected at Screening and Baseline were averaged
to establish the Baseline used to calculate change for both the
treatment groups. The mean difference from Baseline to 12 months
(Week 51 or Week 53) was tested using a paired t-test or Wilcoxon
signed rank test. A 95% confidence interval for the mean difference
was also presented.
[0516] For time to hemoglobin response, Kaplan-Meier (product
limit) survival curves were presented for each treatment group. The
median time and 95% confidence interval were obtained. Patients who
did not experience the event at the end of the study (i.e., at Week
53) were censored at Week 53. In addition, the proportion of
patients who achieved a hemoglobin level within the normal range
during this study was presented.
[0517] For the remaining tertiary parameters that examine change
from Baseline, the null hypothesis is that there will be no change
from Baseline to 12 months (Week 51 or Week 53) for each treatment
group. The mean difference between Baseline to 12 months (Week 51
or Week 53) was tested using a paired t-test or Wilcoxon signed
rank test. A 95% confidence interval for the mean difference was
also presented.
[0518] Safety Analyses: All patients who received at least one dose
of study drug (or partial dose) were assessed for clinical safety
and tolerability. No formal statistical tests were performed on the
safety parameters. Vital signs, 12-lead ECG, clinical chemistry,
hematology, and urinalysis safety monitoring were listed for each
patient and abnormal values were flagged. For categorical
variables, such as AEs, the number and percentage of patients
experiencing each AE were tabulated. AEs were summarized by
severity of event. The number and percentage of patients
experiencing drug related AEs as well as AEs that were not
considered related to study drug were also displayed.
[0519] Clinical laboratory evaluations (hematology, serum
chemistry, urinalysis, and determination of anti-velaglucerase alfa
antibodies) were used to assess the safety of velaglucerase
alfa.
[0520] Analysis of Subgroups: Additional analyses were conducted
specifically for patients between 2 to 17 years old. Also,
consideration was given in the analysis to disease severity with
regard to hemoglobin Baseline values.
[0521] Pharmacokinetic Analyses: The single- and repeat-dose
pharmacokinetic profiles for velaglucerase alfa were established by
analyzing standard PK parameters at Week 1 and Week 37,
respectively.
Results
[0522] At 12 months, mean hemoglobin concentration increased in
both groups (60 U/kg: 23.3% increase, +2.4.+-.0.3 g/dL, P=0.0001;
45 U/kg: 23.8% increase, +2.4.+-.0.5 g/dL, P=0.0001), as did mean
platelet count (60 U/kg: 66% increase, +51.+-.12.times.10.sup.9/L,
P=0.0016; 45 U/kg: 66% increase, +41.+-.12.times.10.sup.9/L;
P=0.0111). Mean spleen volume decreased in both groups (60 U/kg:
50% decrease, -1.9.+-.0.5% body weight, P=0.0032, from 14.0
multiples of normal [MN] at baseline to 5.6 MN; 45 U/kg: 40%
decrease, -1.9.+-.0.6% body weight, P=0.0085; from 14.5 to 9.5 MN)
as did liver volume (60 U/kg: 17% decrease, 0.8.+-.3. % body
weight, P=0.0282, from 1.5 to 1.2 MN; 45 U/kg: 6% decrease,
-0.3.+-.0.3% body weight, P=0.3149, from 1.4 to 1.2 MN). In both
groups, three-quarters of patients achieved .gtoreq.1 g/dL increase
in hemoglobin concentration by Week 15; in the 60 U/kg group, all
patients achieved .gtoreq.1 g/dL increase by Week 27 vs Week 37 for
the 45 U/kg group.
[0523] Patients were excluded from the analysis of chitotriosidase
if they had 2 copies of the chitotriosidase mutation (patient 6, 45
U/kg) or if they had baseline chitotriosidase activity less than
5700 (patient 4, 60 U/kg; patient 15, 45 U/kg). Following 12 months
of treatment, mean plasma chitotriosidase activity decreased from
baseline for both treatment groups: by 83% (95% CI: -91.15,
-74.08%; N=11; p<0.001) in the 60 U/kg group and by 60% (95% CI:
-73.26, -46.63%; N=11; p<0.001) in the 45 U/kg group. Mean CCL18
levels also decreased over 1 year of treatment with velaglucerase
alfa 60 U/kg and 45 U/kg by 66% (95% CI: -77.81, -54.22;
p<0.001) and 47% (95% CI: -63.37, -30.15%; p<0.001),
respectively.
[0524] Velaglucerase alfa was generally well tolerated with no
drug-related serious AEs, and no patient withdrew due to an AE. The
most common AEs were headache, nasopharyngitis, injury, arthralgia,
cough, and pyrexia. A single patient developed antibodies.
[0525] In conclusion, in this global, multicenter study,
velaglucerase alfa 60 U/kg and 45 U/kg was generally well tolerated
and effective as a first-line treatment for adults and children
with type 1 Gaucher disease. Both doses were associated with rapid
improvement in hemoglobin values, with the majority of patients
responding as early as 15 weeks. All clinical parameters measured
demonstrated clinically meaningful improvements after 12 months,
with a greater response seen with velaglucerase alfa 60 U/kg.
Example 3
HGT-GCB-039 (9M, 60 U/kg Velaglucerase Alfa or Imiglucerase)
Summary
[0526] This example describes a multicenter, Phase III, randomized,
double-blind, parallel-group study designed to compare the safety
and efficacy of the enzyme replacement therapy velaglucerase alfa
with imiglucerase in the treatment of patients with type 1 Gaucher
disease.
[0527] The primary objective of this example is to demonstrate that
velaglucerase alfa is not inferior to imiglucerase as measured by a
change from baseline in hemoglobin concentration to Week 41 (9M).
The key secondary objective is to demonstrate that there are no
differences in increases in platelet counts or reductions in
liver/spleen volumes to Week 41 between the two groups.
[0528] Patients were randomized in 1:1 ratio to receive 60 U/kg of
velaglucerase alfa (N=17) or imiglucerase (N=17). The baseline
characteristics of the patients are listed in Tables 13 and 14.
Stratification factors included age (2-17; .gtoreq.18) and
splenectomy status (Y; N). Both primary and secondary objectives
were met. The results for the primary and secondary efficiency
assessments are shown in Tables 15 and 16, respectively. FIGS. 11
and 12 show the comparable increase of mean hemoglobin
concentration and platelet count, respectively, from baseline in
the patients treated with 60 U/kg velaglucerase alfa or
imiglucerase for 41 weeks. FIG. 13 shows the comparable increase of
mean platelet count from baseline in the patients without spleen
treated with 60 U/kg velaglucerase alfa or imiglucerase for 41
weeks. FIG. 14 shows the comparable decrease of mean normalized
liver volume from baseline in the patients treated with 60 U/kg
velaglucerase alfa or imiglucerase for 41 weeks. There were no
significant differences in safety between velaglucerase alfa and
imiglucerase. Treatment emergent adverse events are summarized in
Table 17. No patient receiving velaglucerase alfa developed
antibodies (Table 18). Four patients receiving imiglucerase
developed anti-imiglucerase antibodies (Table 18).
TABLE-US-00015 TABLE 13 HGT-GCB-039 Baseline Characteristics of ITT
velaglucerase alfa imiglucerase 60 U/kg 60 U/kg Baseline Factor N =
17 N = 17 2 to 17 years n (%) 4 (23.5) 5 (29.4) 2 to 4 years n (%)
0 4 (23.5) 5 to 17 years n (%) 4 (23.5) 1 (5.9) .gtoreq.18 years n
(%) 13 (76.5) 12 (70.6) Male n (%) 8 (47.1) 8 (47.1) Female n (%) 9
(52.9) 9 (52.9) Splenectomized 10 (58.8) 10 (58.8) With intact
spleen 7 (41.2) 7 (41.2) BL Hemoglobin 11.40 [9.65, 14.35] 10.60
[8.10, 13.05] concentration (g/dL) Median [Min, Max] BL Platelet
count 172.00 [44.0, 310.5] 188.00 [63.0, 430.5] (.times.10.sup.9/L)
Median [Min, Max]
TABLE-US-00016 TABLE 14 HGT-GCB-039 Baseline Characteristics by Age
Group 2-4 Years Old >5 Years Old Baseline Factor N = 4 N = 30
Male n (%) 4 (100.0) 12 (40.0) Female n (%) 0 18 (60.0)
Splenectomized 1 (25.0) 19 (63.3) With intact spleen 3 (75.0) 11
(36.7) BL Hemoglobin 9.275 [8.10, 9.70] 11.300 [8.95, 14.35]
concentration (g/dL) Median [Min, Max] BL Platelet count 70.75
[63.0, 188.0] 176.25 [44.0, 430.5] (.times.10.sup.9/L) Median [Min,
Max] BL Spleen Volume 8.90 [7.3, 8.9] 1.70 [0.6, 6.3] (% body
Weight) Median [Min, Max] BL Liver Volume 5.8 [5.4, 7.0] 3.85 [1.7,
12.2] (% body Weight) Median [Min, Max]
TABLE-US-00017 TABLE 15 HGT-GCB-039 Primary Efficacy Assessments -
Mean Change at Week 41 from Baseline in Hgb One-sided CI for
Non-inferiority (velaglucerase alfa - imiglucerase) Treatment
Difference in the Change from Baseline to Week 41 ITT Population
Per Protocol Population Mean Lower Bound Mean Lower Bound
Parameter/ Treatment of a 97.5% Treatment of a 97.5% Endpoint n
Difference One-sided CI n Difference One-sided CI Hemoglobin 34
0.135 -0.596 30 0.157 -0.599 Concentration (g/dL)
TABLE-US-00018 TABLE 16 HGT-GCB-039 Secondary Efficacy Assessments
- Difference in Mean Change at Week 41 from Baseline (velaglucerase
alfa - imiglucerase) Change from Baseline to Week 41 Mean Treatment
Parameter n Difference 95% CI Platelets.sup.a (.times.10{circumflex
over ( )}9/L) 34 -38.71 (-88.42, 10.99) Normalized Liver
Volume.sup.a (% of Body Weight) 34 -0.07 (-0.43, 0.29) Normalized
Spleen.sup.b Volume.sup.c 14 0.08 (-0.52, 0.68) (% of Body Weight)
Chitotriosidasea.sup.d (nmol/mL/h) 21 -703.6 (-11762.3, 10355.1)
Chemokine (C-C motif) Ligand 18 (ng/mL) 34 145.7 (-188.6, 480.0)
.sup.aBased on a mixed model adjusting for age at informed consent,
splenectomy status and baseline values. .sup.bThere are 20
splenectomized patient(s) excluded (10 velaglucerase alfa 60 U/kg;
10 imiglucerase 60 U/kg). .sup.cBased on a mixed model adjusting
for age at informed consent and baseline values. .sup.dThere are 13
patient(s) deficient in chitotriosidase activity excluded (7
velaglucerase alfa 60 U/kg; 6 imiglucerase 60 U/kg).
TABLE-US-00019 TABLE 17 HGT-GCB-039 Overall Summary of Treatment
Emergent Adverse Events Patients n (%) velaglucerase alfa
imiglucerase 60 U/kg 60 U/kg DESCRIPTION N = 17 N = 17 Experienced
No Adverse Events 1 (5.9) 1 (5.9) Experienced At Least 1 Adverse
Event 16 (94.1) 16 (94.1) Experienced At Least 1 8 (47.1) 6 (35.3)
Drug-Related Adverse Event Experienced At Least 1 5 (29.4) 4 (23.5)
Infusion-Related Adverse Event Experienced At Least 1 Severe 3
(17.6) 2 (11.8) Or Life-Threatening Adverse Event Experienced At
Least 1 3 (17.6) 0 Serious Adverse Event Experienced at least 1 1
(5.9) 0 drug-related SAE
TABLE-US-00020 TABLE 18 HGT-GCB-039 Antibodies velaglucerase alfa
imiglucerase 60 U/kg 60 U/kg N = 17 N = 17 n (%) n (%)
Anti-imiglucerase Antibody Result Negative 17 (100.0) 13 (76.5)
Positive.sup.a 0 4 (23.5) IgG 0 4 (23.5) IgA 0 0 IgM 0 0 IgE 0 0
Neutralizing antibodies 0 1 (5.9) Anti-velaglucerase alfa Antibody
Result Negative 17 (100.0) 16 (94.1) Positivea 0 1 (5.9) IgG 0 1
(5.9) IgA 0 0 IgM 0 0 IgE 0 0 Neutralizing antibodies 0 1 (5.9)
Study Objectives
[0529] The primary objective of this study was to compare the
effects of velaglucerase alfa and imiglucerase on hemoglobin
concentration in patients with type 1 Gaucher disease.
[0530] The secondary objectives of this study were: to compare the
effects of velaglucerase alfa and imiglucerase on platelet count;
to compare the effects of velaglucerase alfa and imiglucerase on
liver and spleen volumes (by MRI); to compare the effects of
velaglucerase alfa and imiglucerase on Gaucher disease-specific
biomarkers (plasma chitotriosidase and CCL18 levels); to evaluate
the safety of velaglucerase alfa and imiglucerase in patients with
type 1 Gaucher disease, as measured by standard clinical laboratory
assessments (including rates of antibody formation and enzyme
neutralizing antibody activity) and safety evaluations (including
rates of infusion-related adverse events and the proportion of
patients requiring premedication use to manage infusion-related
adverse events) for each treatment group; and to compare the
effects of velaglucerase alfa and imiglucerase on the earliest time
to response for hemoglobin (defined as a .gtoreq.1 g/dL improvement
in hemoglobin levels relative to Baseline).
[0531] The tertiary objectives of this study are: to evaluate the
effects of velaglucerase alfa and imiglucerase on growth velocity
and Tanner staging in patients between 2 and 17 years-old; to
evaluate the effects of velaglucerase alfa and imiglucerase on
changes in skeletal age in patients between 2 and 17 years-old by
radiography of the left hand and wrist; to evaluate the effects of
velaglucerase alfa and imiglucerase on changes in overall QoL, as
measured by the SF-36 for patients .gtoreq.18 years of age and the
CHQ PF-50 for patients 5 to 17 years-old; to evaluate the effects
of velaglucerase alfa and imiglucerase on immune and inflammatory
responses in patients .gtoreq.18 years of age as measured by
selected cytokine assessments (TNF-.alpha., IL6, IL1b, IL8, IL13,
CD14, and GM-CSF); to establish a baseline from which to evaluate
bone disease in patients between 2 and 17 years-old by MRI of the
lumbar spine and femoral neck; and to establish a baseline from
which to evaluate the long-term effect of velaglucerase alfa
therapy on Gaucher-related local and systemic bone disease in
patients .gtoreq.18 years-old by: dual energy X-ray absorptiometry
(DXA) of the lumbar spine and femoral neck, including coronal
imaging; and serum alkaline phosphatase, N-telopeptide cross-links
(NTx), and C-telopeptide cross-links (CTx).
Study Endpoints
[0532] The primary endpoint of this study is to measure the mean
change from Baseline to week 41/End of Study (EOS) in hemoglobin
concentration between the two treatment groups.
[0533] The secondary endpoints of this study are: to evaluate the
safety of velaglucerase alfa and imiglucerase, as assessed by
adverse events and infusion-related adverse events (and the
proportion of patients requiring premedication use to manage
infusion-related adverse events), clinical laboratory values, vital
signs, 12-lead electrocardiograms (ECG), antibody formation and
enzyme neutralizing antibody activity; to compare the mean and
percent changes from Baseline in platelet count between treatment
groups; to compare the mean and percent changes from Baseline in
liver and spleen volumes by MRI between treatment groups; to
compare the mean and percent changes from Baseline in plasma
chitotriosidase and plasma CCL18 levels between treatment groups;
and to compare time to response for hemoglobin concentration
(defined as a .gtoreq.1 g/dL improvement in hemoglobin levels
relative to Baseline) between treatment groups.
[0534] The tertiary endpoints of this study are: to evaluate change
from Baseline in growth velocity and Tanner staging for patients
between 2 and 17 years-old within each treatment group; to evaluate
change from Baseline in the SF-36 parameters for patients
.gtoreq.18 years-old within each treatment group; to evaluate the
effects of velaglucerase alfa and imiglucerase on immune and
inflammatory responses in patients .gtoreq.18 years-old as measured
by selected cytokine assessments (TNF-.alpha., IL6, IL1b, IL8,
IL13, CD14, and GM-CSF); to evaluate change from Baseline in the
CHQ (PF-50) parameters for patients 5 to 17 years-old within each
treatment group; and to evaluate change from Baseline in skeletal
age as measured by radiography of the left hand and wrist for
patients between 2 and 17 years old within each treatment
group.
Overall Study Design
[0535] This study was comprised of 5 phases as follows: Screening:
Day -21 through Day -4; Baseline: Day -3 through Day 0 (through
patient randomization); Treatment: Week 1 (Day 1, i.e., day of
first dose) through Week 39; End of Study Visit: Week 41; Follow-up
Contact: 30 days after the final infusion (for patients who
discontinue/withdraw prior to the Week 41 evaluation, or for
patients who do not elect to enroll in the long-term clinical
study).
[0536] At Screening, patients who provided written informed consent
to participate in this study were reviewed against the study
entrance criteria to determine eligibility. Patients provided blood
samples to measure hemoglobin concentration. Only those patients
who had a hemoglobin concentration that was below the lower limit
of normal for age and gender were eligible for enrollment. For
statistical analysis purposes, an additional blood sample was
collected at screening for evaluation of hemoglobin
concentration.
[0537] Patients who were eligible for study participation after
completing the Screening evaluations underwent Baseline procedures
and evaluations (i.e., Days -3 to 0). To confirm that their
hemoglobin concentration was below the lower limit of normal for
age and gender, patients provided a blood sample at Baseline.
Hemoglobin concentration was analyzed and reported. Only those
patients who had a hemoglobin concentration that was below the
lower limit of normal for age and gender at both Screening and
Baseline were eligible for enrollment. For statistical analysis
purposes, an additional blood sample was collected at Baseline for
evaluation of hemoglobin concentrations. Additional Baseline
procedures and evaluations were conducted prior to administration
of the first dose of blinded study medication.
[0538] Upon completion of Screening and Baseline procedures and
confirmation of patient eligibility, patients were randomized in a
1:1 ratio to receive double-blind study medication (either
velaglucerase alfa 60 U/kg or imiglucerase 60 U/kg). Randomization
was accomplished via a centralized procedure. A computer generated
randomization schedule was utilized to allocate patients to
treatment groups. An attempt was made to obtain treatment groups
that were comparable in certain prognostic variables, such as age,
hemoglobin concentration, and whether the patient had undergone
splenectomy. The randomization schedule was prepared prior to the
study.
[0539] Patients received a total of 20 IV infusions of double-blind
study medications at the clinical site once every other week for a
total of 39 Weeks. Safety and efficacy assessments were made at
regular intervals during the treatment phase. The final assessments
of safety and efficacy were made at the Week 41 visit (2 weeks
after the last infusion).
[0540] Safety was assessed throughout the study by assessments of
adverse events (including infusion-related adverse events),
concomitant medications, and vital signs. Additional safety
assessments, including, 12-lead electrocardiograms, physical
examinations, clinical laboratory tests (hematology, serum
chemistry, and urinalysis), were made at Weeks 13, 25, and 41.
Determination of the presence of anti-velaglucerase alfa or
anti-imiglucerase antibodies and enzyme neutralizing antibodies was
conducted approximately every 6 weeks until Week 41.
[0541] Efficacy was assessed via hemoglobin concentration and
platelet count, liver and spleen volume, and plasma chitotriosidase
and CCL18 level. Additional efficacy assessments included growth
velocity and Tanner staging, QoL indicators, skeletal growth.
Immune and inflammatory response (as measured by selected cytokine
parameters) was measured in patients who are .gtoreq.18 years of
age at study entry. The duration of treatment in this study was 39
weeks and the duration of patient participation in this study was
up to 11 months (from Screening through follow-up). Patients who
completed this study were provided the opportunity to enroll in a
subsequent open-label long-term clinical study, in which all
patients would receive velaglucerase alfa. For patients who elected
to enroll in the subsequent open-label long-term clinical study,
certain assessments from the Week 41 visit were used as the
baseline assessments for that clinical study; patients would
receive their first velaglucerase alfa infusion for the long-term
clinical study following completion of the Week 41 procedures and
evaluations scheduled for this study. Therefore, it was intended
that patients would receive continuous treatment across the 2
studies. Patients who completed this study and did not elect to
enroll in the long-term clinical study would have a safety
evaluation by site visit or telephone 30 days after their last
infusion in this study.
Selection of Study Population
[0542] 34 patients were enrolled (17 patients assigned to each
treatment group).
[0543] Eligible participants were males or females age .gtoreq.2
years with diagnosed type 1
[0544] Gaucher disease (deficient glucocerebrosidase activity in
leukocytes, or by genotype analysis), and disease-related anemia
(hemoglobin levels below the local laboratory's lower limit of
normal for age and gender). Participants also had 1 or more of the
following: at least moderate splenomegaly (2 to 3 cm below the left
costal margin) by palpation; disease-related thrombocytopenia
(platelet count<120.times.10.sup.3 platelets/mm.sup.3); or
readily palpable enlarged liver. Participants could not have
received treatment for Gaucher disease within 12 months prior to
study entry.
[0545] Participants were excluded if they had a splenectomy; had
(or were suspected of having) type 2 or 3 Gaucher disease; were
antibody-positive or had experienced an anaphylactic shock to
imiglucerase. Other exclusion criteria included treatment with any
non-Gaucher disease-related investigational drug or device within
30 days prior to study entry; positive test for HIV, or hepatitis B
or C; exacerbated anemia (vitamin B12, folic acid, or iron
deficiency-related), or any significant co-morbidity that could
affect study data. Pregnant or lactating women were excluded and
women of child-bearing potential were required to use a medically
acceptable method of contraception at all times.
Study Treatments
[0546] Treatment Assignment: Patients were randomized in a 1:1
ratio prior to administration of the first dose of: velaglucerase
alfa 60 U/kg every other week for 39 Weeks (up to 16 patients, 20
infusions), or imiglucerase 60 U/kg every other week for 39 Weeks
(up to 16 patients, 20 infusions). All study medication was
administered by IV infusion over 1 hour to maintain the treatment
blind.
[0547] Treatment Administration
[0548] Study Medication Infusions: Double-blind study medication
infusions were administered at the clinical site as a continuous
1-hour IV infusion to maintain the treatment blind. Study
medication infusions occurred on approximately the same day of the
week but occurred every 14 days (.+-.3 days) in order to facilitate
patient scheduling.
[0549] Dose Calculation: The first dose of double-blind study
medication was based on the patient's weight at Baseline. A change
in weight of .gtoreq.5% from Baseline or from the most recent
recorded measurement (Week 13 or Week 25) would require
recalculation of the dose of study medication.
[0550] Description of Study Medications
[0551] VELAGLUCERASE ALFA: Velaglucerase alfa is a lyophilized
product that was supplied and shipped to the clinical study site to
be stored at 2 to 8.degree. C.
[0552] Imiglucerase (Cerezyme.RTM.): Imiglucerase (Cerezyme) was
supplied as a sterile, non-pyrogenic, white to off-white
lyophilized product.
Study Procedures and Data Collection Methods
[0553] Study Entrance Criteria: At Screening patients were reviewed
for eligibility against the study entrance criteria. Patients who
did not meet the study entrance criteria were considered Screen
failures.
[0554] Confirmation of Eligibility: At Screening, patients provided
blood samples to measure hemoglobin concentration to determine
study eligibility. Only those patients who had a hemoglobin
concentration that was below the local laboratory's lower limit of
normal for age and gender were eligible for enrollment.
[0555] At Baseline, patients provided a blood sample to confirm
that their hemoglobin concentration was below the local
laboratory's lower limit of normal for age and gender. Only those
patients who had a hemoglobin concentration that was below the
lower limit of normal for age and gender at both Screening and
Baseline were confirmed eligible for this study.
[0556] Genotyping: All patients provided a blood sample at
Screening for Gaucher disease genotyping and plasma chitotriosidase
genotyping.
[0557] Medical History: At Screening, the patient's complete
medical history was recorded. This included a review of body
systems, documentation of current and prior medical procedures, and
documentation of current and prior concomitant medication usage,
and documentation that the patient had not been treated for Gaucher
disease within the 12 months prior to study entry.
[0558] Vital Signs: Vital signs parameters that were recorded
included pulse, blood pressure, respiration rate, and temperature.
The following schedule was followed for recording vital signs at
infusion visits: start of infusion (within 10 minutes prior to
starting the infusion), during infusion (30 minutes (.+-.5
minutes)), after infusion (within 5 minutes, 30 minutes (.+-.5
minutes), and 60 minutes (.+-.5 minutes) after completing the
infusion). At Screening, Baseline, and Week 41, vital signs were
collected at one time point only.
[0559] Physical Examinations: Physical examinations were performed
at Screening, Baseline and at Study Weeks 13, 25, and 41. Physical
examinations included the following: general appearance, endocrine,
head and neck, cardiovascular, eyes, abdomen, ears, genitourinary,
nose, skin, throat, musculoskeletal, chest and lungs, and
neurological. Any abnormal change in physical findings was recorded
as an adverse event on the appropriate CRF page(s).
[0560] Height and Weight: Height and weight were recorded at
Baseline and at Study Weeks 13, 25, and Week 41. For pediatric
patients (i.e., 2 to 17 years-old), height and weight assessments
were used to determine growth velocity.
[0561] 12-Lead Electrocardiograms: A 12-lead ECG was performed at
Baseline and at Study Weeks 13, 25, and 41, and included assessment
of PR, QRS, QT, and QTc intervals, and heart rate.
[0562] Clinical Laboratory Testing: Blood and urine samples were
collected as described below for clinical laboratory testing.
[0563] Hematology: Blood samples were collected during Screening
and at Baseline to measure hemoglobin levels for statistical
analysis. Blood samples were also collected at Screening, Baseline,
and Weeks 13, 25, and 41 for complete hematology testing. The
following hematology parameters were evaluated: complete blood
count (CBC) with differential, platelet count, activated partial
thromboplastin time (aPPT), reticulocyte count (analyzed and
reported by the clinical site's local laboratory), and prothrombin
time (PT). Blood samples were collected at Screening, Baseline, and
at every study visit (except at the Week 1 visit) to measure
hemoglobin concentration and platelet count.
[0564] Serum Chemistry: Blood samples were collected for serum
chemistry testing at Screening, Baseline, and at Study Weeks 13,
25, and 41. The following serum chemistry parameters were
evaluated: sodium, alanine aminotransferase, potassium, aspartate
aminotransferase, glucose, lactate dehydrogenase, total calcium,
gammaglutamyltransferase, total protein, creatinine phosphokinase,
albumin, NTx*, creatinine, CTx*, urea nitrogen, folic acid (to
determine study eligibility), total bilirubin, vitamin B.sub.12
(screening only), alkaline phosphatase* (* results were used for
assessments of bone biomarkers). Patients who at Screening had
folic acid and/or vitamin B.sub.12 deficiency-related anemia, and
so did not meet study entry criteria were considered a screen
failure.
[0565] Urinalysis: Urine samples were collected for urinalysis at
Screening, Baseline, and at Study Weeks 13, 25, and 41. The
following urinalysis parameters were evaluated: pH, microscopic
evaluation, and macroscopic evaluation.
[0566] Serum Anti-velaglucerase alfa Antibodies: Patients provided
blood samples to measure anti-velaglucerase alfa antibodies in
serum at Screening and approximately every 6 weeks during the
treatment phase (Weeks 7, 13, 19, 25, 31, and 37), and at Week 41.
During the treatment phase, these blood samples were collected
prior to the infusion of double-blind study medication.
[0567] Blood samples collected for anti-velaglucerase alfa antibody
determination were evaluated. These samples were screened using an
enzyme-linked immunosorbence assay (ELISA), and all positive
samples were confirmed positive using a radioimmunoprecipitaion
assay (RIP). Positive samples were isotyped (IgG, IgA, IgM, or
IgE). In addition, positive samples were tested for enzyme
neutralizing activity using an in vitro assay.
[0568] Serum Anti-imiglucerase Antibody Determination: Patients
provided blood samples at Screening to measure anti-imiglucerase
antibodies. The anti-imiglucerase antibody analyses were performed
using the same samples obtained for anti-velaglucerase alfa
antibody analyses.
[0569] These blood samples were evaluated to determine the presence
of anti-imiglucerase antibodies. These samples were screened using
an enzyme-linked immunosorbence assay (ELISA), and all positive
samples were confirmed positive using a radioimmunoprecipitaion
assay (RIP). Positive samples were isotyped (IgG, IgA, IgM, or
IgE). In addition, positive samples were tested for enzyme
neutralizing activity using an in vitro assay.
[0570] Patients who test positive for anti-imiglucerase antibodies
at Screening were not eligible for this study.
[0571] Antibody cross-reactivity testing (to velaglucerase alfa)
was conducted for patients who develop anti-imiglucerase antibodies
during this study.
[0572] Immune and Inflammatory Response Testing: Patients who were
.gtoreq.18 years of age provided blood samples for immune and
inflammatory response testing at Baseline and at Weeks 13, 25, and
41. One sample was obtained at Baseline. At Weeks 13, 25, and 41,
samples were obtained before, immediately following, and 1 hour
after each infusion with study drug.
[0573] Adverse Events: Adverse events were monitored throughout the
study from the time the patient provided informed consent through
30 days after the last infusion for patients who completed the
study and did not elect to enroll in the subsequent open-label
long-term clinical study, or for patients who discontinue or
withdraw from the study prior to the Week 41 visit. For patients
who completed this study and elected to enroll in the subsequent
open-label long-term clinical study, adverse events were monitored
from informed consent through completion of the Week 41 visit.
[0574] Management of Infusion-Related Adverse Events: Infusions of
proteins can be associated with reactions to the infusion. An
infusion-related adverse event is defined as an adverse event that
1) begins either during or within 12 hours after the start of the
infusion, and 2) is judged as possibly or probably related to
blinded study medications.
[0575] Liver and Spleen MRI: Patients underwent MRI of the liver
and spleen at Baseline and at Weeks 25 and 41/EOS. Liver and spleen
size were measured using quantitative abdominal MRI.
[0576] Plasma Chitotriosidase Levels: Blood samples were collected
for the evaluation of plasma chitotriosidase levels at Baseline and
at Weeks 1, 5, 9, 13, 17, 21, 25, 29, 33, 37, and Week 41.
Chitotriosidase was analyzed using an enzyme activity assay.
[0577] Plasma CCL18 Levels: Blood samples were collected for the
evaluation of plasma CCL18 levels at Baseline and at Weeks 1, 5, 9,
13, 17, 21, 25, 29, 33, 37, and Week 41. CCL18 levels were measured
by an enzyme-linked immunosorbent assay (ELISA) in a commercially
available kit.
[0578] Quality of Life Testing: At Baseline and Week 41, patients'
quality of life was evaluated using validated questionnaires,
including the Short Form 36 (SF-36), version 2, for patients
.gtoreq.18 years-old and the Childhood Health Questionnaire (CHQ),
PF50 for patients 5 to 17 years-old (Ware Arch Phys Med Rehabil Vol
84, Suppl 2, April 2003:43-51; SF-36v2.TM. Health Survey.COPYRGT.
1996, 2000 by QualityMetric Incorporated and Medical Outcomes
Trust. All Rights Reserved; Landgraf et al. Child Health
Questionnaire: A User's Manual. 2.sup.nd printing, Health Act,
Inc., Boston Mass., 1999; Landgraf et al. Quality of Life Research.
1998; 7(5):433-445).
[0579] Growth Velocity and Tanner Staging: For patients 2 to 17
years-old, growth was assessed at Baseline and Weeks 13, 25, and
41. Growth velocity was calculated using height and weight
measurements that were recorded at regular time points during this
study, and correlated with Tanner staging. Tanner stage was
recorded at Baseline and Weeks 13, 25, and 41. The change from
Baseline for each patient between 2 and 17-years old in each
treatment group was evaluated as a tertiary efficacy parameter.
[0580] Skeletal Growth: Patients between 2 and 17 years-old
underwent radiography of the left hand and wrist at Baseline and
Week 41 for evaluation of skeletal age.
[0581] Bone Biomarkers: At Baseline and Week 41, patients who were
18 years-old underwent DXA of the lumbar spine and femoral neck,
including coronal imaging, to determine Gaucher-related local and
systemic bone disease. Bone loss and demineralization were
evaluated for these patients by measuring serum alkaline
phosphatase, NTx, and CTx at Baseline and Week 41.
[0582] For patients 2 to 17 years-old, MRI of the femoral neck and
lumbar spine was obtained at Baseline and Week 41, at the same time
these patients underwent MRI of the liver and spleen.
[0583] It was not expected that any treatment effect would be
apparent for these parameters during this study, however, the
measurements collected at Baseline and Week 41 would be utilized to
establish a reference point from which to monitor these biomarkers
during the subsequent open-label long-term clinical study.
[0584] Prior and Concomitant Illnesses: Additional illnesses
present at Baseline were regarded as concomitant illnesses and were
documented on the appropriate pages of the medical history CRF.
Illnesses first occurring or detected during the study, or
worsening of a concomitant illness during the study, were regarded
as AEs and were documented as such in the CRF.
[0585] Patients did not receive treatment with red blood cell
growth factor or investigational drug(s) or device(s) at any point
during this study or within 30 days after the last infusion.
[0586] During the treatment phase of this study, patients might
receive corticosteroids as premedications to mitigate potential
infusion-related adverse events.
Adverse Events
[0587] Adverse Event Definition: An adverse event (AE) is any
noxious, pathologic, or unintended change in anatomical,
physiologic, or metabolic function as indicated by physical signs,
symptoms, and/or laboratory changes occurring in any phase of a
clinical trial, and whether or not considered study drug-related.
This includes an exacerbation of a pre-existing condition. Adverse
events were collected from the time the patient provides signed
informed consent until 30 days after the last dose of blinded study
medication and/or until the event had been resolved/stabilized or
an outcome was reached, whichever comes first. For patients who
discontinued or were withdrawn prior to the Week 41 visit, AEs were
followed up to 30 days after their last infusion. For patients who
completed this study and elected to enroll in the long-term
clinical study, adverse events were monitored from the time the
patient provides informed consent through the Week 41 visit.
[0588] AEs include: worsening (change in nature, severity, or
frequency) of conditions present at the onset of the study;
intercurrent illnesses; drug interactions; events related to or
possibly related to concomitant medications; abnormal laboratory
values (this includes significant shifts from Baseline within the
range of normal that the Investigator considers to be clinically
important); clinically significant abnormalities in physical
examination, vital signs, weight, and ECG.
[0589] In addition, AEs might also include unexpected laboratory
values that became significantly out of range and determined to be
clinically significant by the Investigator. In the event of an
unexpected out-of-range value, the laboratory test was repeated
until it returned to normal or could be explained and the patient's
safety was not at risk.
[0590] Infusion-Related Adverse Event Definition: An
infusion-related adverse event was defined as an adverse event that
1) begins either during or within 12 hours after the start of the
infusion, and 2) is judged as possibly or probably related to
blinded study medication. Other AEs which occurred prior to the
infusion, along with AEs associated with protocol-defined testing
and assessments (e.g., laboratory testing, ECGs, and physical
examinations) which were performed prior to the infusion, were not
defined as infusion-related adverse events.
[0591] Serious Adverse Event Definition: A serious AE (SAE) is any
AE occurring at any dose that results in any of the following
outcomes: death, is life-threatening, requires inpatient
hospitalization, requires prolongation of existing hospitalization,
a persistent or significant disability/incapacity, and a congenital
anomaly/birth defect.
[0592] Important medical events that may not result in death, be
life-threatening, or require hospitalization may be considered as
SAEs when, based upon appropriate medical judgment, they may
jeopardize the patient and may require medical or surgical
intervention to prevent one of the outcomes listed above.
[0593] A life-threatening AE is defined as an AE that placed the
patient, in the view of the initial reporter, at immediate risk of
death from the AE as it occurred (i.e., it does not include an AE
that, had it occurred in a more severe form, might have caused
death).
[0594] Classification of Adverse Events and Serious Adverse Events:
The National Cancer Institute Common Toxicity Criteria (NCI CTC)
Version 3.0 grading scale was referenced when assessing the
severity of an AE. If an AE was not described in the NCI CTC, the
severity was recorded based on the scale below. The severity of all
AEs/SAEs were recorded on the appropriate CRF page as Grade 1, 2, 3
or 4 corresponding, respectively, to a severity of mild, moderate,
severe, or life-threatening. Grade 1 (mild) is defined as no
limitation of usual activities. Grade 2 (moderate) is defined as
some limitation of usual activities; Grade 3 (severe) is defined as
inability to carry out usual activities; and Grade 4
(life-threatening) is defined as immediate risk of death.
Relationship of an adverse event or serious adverse event to
blinded study medication was determined by the Investigator based
on the following definitions. "Not related" is defined as unrelated
to study drug. "Possibly related" is defined as a clinical
event/laboratory abnormality with a reasonable time sequence to
administration of study drug, but which could also be explained by
concurrent disease or other drugs/chemicals.
[0595] "Probably related" is defined as a clinical event/laboratory
abnormality with a reasonable time sequence to administration of
study drug, unlikely to be attributable to concurrent disease or
other drugs and chemicals and which follows a clinically reasonable
response on dechallenge. The association of the clinical
event/laboratory abnormality must also have some biologic
plausibility, at least on theoretical grounds.
[0596] Clarification between Serious and Severe: The term "severe"
is often used to describe the intensity (severity) of a specific
event (as in mild, moderate, or severe myocardial infarction); the
event itself, however, may be of relatively minor medical
significance (such as severe headache). This is not the same as
"serious," which is based on the outcome or action criteria usually
associated with events that pose a threat to life or functioning.
Seriousness (not severity) and causality serve as a guide for
defining regulatory reporting obligations.
[0597] Adverse Event Monitoring and Period of Observation: For the
purposes of this study, the period of observation extended from the
time the patient provided informed consent until the patient's
final evaluation of the study. For safety purposes, the final
evaluation was defined as the post-study safety evaluation
performed approximately 30 days after the last infusion for
patients who completed the study and did not elect to enroll in the
long-term study, or for patients who discontinued or withdrew from
the study prior to the Week 41 visit. For patients who completed
this study and elected to enroll in the long-term clinical study,
adverse events were monitored from the time the patient provides
informed consent through the Week 41 visit. If the Investigator
considered it necessary to report an AE in a study patient after
the end of the observation period, he or she would contact the
Sponsor to determine how the AE should be documented and
reported.
Statistical Method
[0598] General Statistical Methodology: Two data sets were
considered for the statistical analyses of efficacy: 1) the
intention-to-treat (ITT) data set and 2) the per-protocol (PP) data
set. The ITT data set is comprised of all randomized patients who
received at least one full or partial dose of study drug. The PP
data set is a subset of the ITT data set, which includes patients
who completed 41 weeks of the study, had both the Baseline and the
Week 41 measurements of the primary efficacy variable collected,
and received at least 80% of their scheduled dose of infusion.
[0599] For variables following a continuous distribution, tabular
summaries consisted of n, mean, standard deviation, minimum,
maximum, and median. Graphs of the key efficacy variables were
presented by treatment groups. For categorical variables, tabular
summaries consisted of presenting the frequency and the percentage
in each category by treatment group. The primary efficacy variable
was presented by treatment group, and included: raw values: the
untransformed value of the variable in the originally reported
scale; the absolute change in the value from Baseline, i.e., X-B
(where B is the Baseline value and X is a post-Baseline value); and
the percent change in the value from Baseline, i.e., 100*(X-B)/B
(where B is the Baseline value and X is a post-Baseline value).
[0600] Hypothesis Testing: This study compared the effect of
velaglucerase alfa with imiglucerase. The intent was to show that
velaglucerase alfa was clinically at least as good as imiglucerase
at the 0.025 level of significance.
[0601] The null hypothesis for the primary efficacy endpoint is
that the mean change in hemoglobin concentration from Baseline to
Week 41 for velaglucerase alfa is at least 1 g/dL inferior to the
mean change in hemoglobin concentration from Baseline to Week 41
for imiglucerase. The hypothesis to be tested can be stated as:
H.sub.0: .mu..sub.Vela-.mu..sub.IMIG.ltoreq.-1 vs. H.sub.A:
.mu..sub.Vela-.mu..sub.IMIG>-1
Or
[0602] H.sub.0: velaglucerase alfa is inferior with respect to the
mean hemoglobin response H.sub.A: velaglucerase alfa is
non-inferior with respect to the mean hemoglobin response
[0603] Screen Failures and Patient Disposition: The disposition of
all patients screened for entry into the study was tabulated along
with reasons for screen failure. The disposition of all randomized
patients was tabulated by treatment arm and visit, and reasons for
discontinuation were tabulated by treatment arm.
[0604] Sample Size Justification: When the sample size in each
treatment group is 14, a two-group 0.025 one-sided t-test will have
an 80% power to reject the null hypothesis that the difference in
means for hemoglobin is .ltoreq.-1 g/dL in favor of the alternative
hypothesis that the difference in means is greater than -1,
assuming that the expected difference in means is 0, and the common
standard deviation is 0.90.
[0605] Assuming a 15% dropout, a total of 32 patients (16 patients
per treatment arm) were enrolled into the study.
[0606] Efficacy Analysis
[0607] Analysis Populations: Two data sets were considered for the
statistical analyses of efficacy (the intention-to-treat (ITT) data
set and the per-protocol (PP) data set).
[0608] Primary Efficacy Analyses: The primary efficacy endpoint is
the mean change from Baseline to Week 41 in hemoglobin
concentration between the two treatment groups. The primary
analysis was carried out using the ITT population. This is a
non-inferiority randomized controlled trial designed to demonstrate
that velaglucerase alfa is non-inferior to imiglucerase in terms of
efficacy in treating patients with type 1 Gaucher disease.
[0609] A one-sided 97.5% confidence interval was used.
Non-inferiority was demonstrated by either a one-sided confidence
interval or a hypothesis test for testing the null hypothesis that
the treatment difference is less than or equal to the lower
equivalence margin in hemoglobin (-1 g/dL) versus the alternative
that imiglucerase treatment difference is greater than the lower
equivalence margin. In other words, focusing on just one end of the
confidence interval and ignoring the other results in a one-sided
97.5% confidence interval [(a, .infin.)], where a is the lower
bound of the 1-sided confidence interval, an efficacy conclusion
could be drawn.
[0610] Secondary Efficacy Analyses: For the secondary efficacy
parameters (platelet counts, liver, and spleen volumes,
chitotriosidase, and CCL18) that compare changes from Baseline
between treatment groups, statistical tests evaluated if the mean
changes from Baseline to Week 41 between the two treatment groups
is statistically significant (statistically significant will be
defined as a p-value less than 0.05). A 95% confidence interval was
presented for the difference in mean changes from Baseline between
the two treatment arms using an analysis of covariance (ANCOVA)
model, which included, e.g., Baseline age as a covariate.
[0611] For time to event outcome measures (i.e., time to first
hemoglobin response .gtoreq.1 g/dL from baseline), Kaplan-Meier
(product limit) survival curves were presented for each treatment
group and a log-rank test were used to compare curves between
treatment groups. The median time and 95% confidence interval were
presented for each treatment group. Patients who did not experience
the event by the end of the study (i.e., by Week 41) were censored
at Week 41. Patients who withdrew or were discontinued prior to the
Week 41 evaluation and who did not achieve a response at the time
of withdrawal or discontinuation were censored at the time of the
last known evaluation for that patient. In addition, the proportion
of patients who responded versus non-responders were presented and
compared between treatment groups using Fisher's Exact Test.
[0612] Safety Analyses: All patients who received at least one dose
of study drug (or partial dose) were assessed for clinical safety
and tolerability. No formal statistical tests were performed on the
safety parameters. Vital signs, 12-lead ECG, clinical chemistry,
hematology, and urinalysis safety monitoring were summarized. For
categorical variables, such as AEs, the number and percentage of
patients experiencing each AE were tabulated. AEs were summarized
by severity of event. The number and percentage of patients
experiencing drug related AEs and infusion-related AEs, as well as
AEs that were not considered related to study drug will also be
displayed. Clinical laboratory evaluations (hematology, serum
chemistry, urinalysis, and determination of anti-velaglucerase alfa
antibodies) were used to assess the safety of velaglucerase
alfa.
Example 4
TKT034 Study (Multi-Center Open-Label Study in Patients Who
Transitioned from Treatment with Imiglucerase)
SUMMARY
[0613] This example describes a global, open-label, 12-month study
to examine the safety and efficacy of velaglucerase alfa in
patients with type 1 Gaucher disease previously receiving
imiglucerase. Patients aged .gtoreq.2 years received velaglucerase
alfa at a dose equal to their prior imiglucerase dose, with
infusions administered over 1 hour every other week.
[0614] Forty patients received velaglucerase alfa (18 male; 4
previously splenectomized; age range, 9-71 years). Median prior
imiglucerase use was 67 months (range 22-192 months). Velaglucerase
alfa doses were: 15-22.5 U/kg (n=14) ("the 15 U/kg group"),
22.5-37.5 U/kg (n=12) ("the 30 U/kg group"), 37.5-52.5 U/kg (n=7)
("the 45 U/kg group"), and >52.5 U/kg (n=7) ("the 60 U/kg
group"). Velaglucerase alfa was generally well tolerated with most
adverse events (AEs) of mild or moderate severity. Eleven patients
(28%) experienced an AE considered possibly or probably related to
study drug; the majority were considered infusion related. No
patient experienced a life-threatening AE. One serious AE was
considered probably related to treatment: one patient had a grade 2
hypersensitivity reaction during the first infusion, and chose to
discontinue the study. This patient tested negative for IgE, IgM,
IgG, IgA and neutralizing antibodies at the time of the infusion
and 2 weeks later. No patients developed IgG antibodies to
velaglucerase alfa. Hemoglobin concentration, platelet count, liver
and spleen volume were sustained at therapeutic levels through 1
year.
[0615] In conclusion, adult and pediatric patients with type 1
Gaucher disease, previously treated with imiglucerase for
.gtoreq.22 months, were successfully transitioned to velaglucerase
alfa, with stability in clinical disease measures over 12
months.
Study Objectives
[0616] The primary objective of this study was to evaluate the
safety of every other week dosing of velaglucerase alfa in patients
with type 1 Gaucher disease who were previously treated with
imiglucerase.
[0617] The secondary objectives were: to evaluate changes from
Baseline in hemoglobin concentration after every other week dosing
of velaglucerase alfa, to evaluate changes from Baseline in
platelet count after every other week dosing of velaglucerase alfa,
and to evaluate changes from Baseline in liver and spleen volume by
abdominal MRI after every other week dosing of velaglucerase
alfa.
[0618] The tertiary/exploratory objectives were: to evaluate
changes from Baseline in levels of plasma chitotriosidase and
Chemokine (C-C motif) ligand 18 (CCL18) after every other week
dosing of velaglucerase alfa, to evaluate changes in skeletal age
in patients between 2 and 17 years-old by radiography of the left
hand and wrist after every other week dosing of velaglucerase alfa,
to evaluate changes in growth velocity and Tanner staging in
patients between 2 and 17 years-old after every other week dosing
of velaglucerase alfa, to establish a Baseline from which to
monitor the long term effect of velaglucerase alfa therapy on
Gaucher-related local and systemic bone disease in patients 18
years-old, as measured by bone density (DXA) of the lumbar spine
and femoral neck (including coronal imaging), serum alkaline
phosphatase, N-telopeptide cross-links (NTx), and C-telopeptide
cross links (CTx), and to establish a Baseline from which to
evaluate bone disease in patients between 2 and 17 years-old by MRI
of the lumbar spine and femoral neck.
Overall Study Design
[0619] This is a multicenter, Phase II/III, open-label study
designed to evaluate the safety of velaglucerase alfa therapy for
patients currently receiving imiglucerase therapy for type I
Gaucher disease. 41 patients were enrolled to receive the same
number of units of velaglucerase alfa as their imiglucerase dose.
Doses ranged between 15 U/kg and 60 U/kg. Patients had received the
same dose of imiglucerase during the 6 months prior to study
enrollment. The overall duration of the study for each patient was
approximately 14 months (from Screening through the End of Study
and/or follow-up, as appropriate).
[0620] The study was comprised of 5 phases as follows: Screening
(Day -14 through Day -4), Baseline (Day -3 through Day 0 (prior to
first dose)), Treatment Phase: Week 1 (Day 1; first dose) through
Week 51 (a total of 26 infusions were administered per patient),
End of Study Visit: Week 53, Follow-up: 30 days after the final
infusion (for patients who discontinued/withdrew prior to the Week
53 evaluation, or for patients who completed this study but did not
elect to enroll in the subsequent long-term clinical study).
[0621] Patients (or parent/legal guardian) who provided written
informed consent underwent Screening evaluations within two weeks
prior to their first dose to determine eligibility for enrollment.
To determine study eligibility, a blood sample was collected from
each patient during Screening to evaluate hemoglobin concentration
and platelet count.
[0622] An additional blood sample was collected during Screening
for evaluation of hemoglobin concentration and platelet count for
statistical analysis purposes.
[0623] Administration of the first dose of study drug was defined
as Week 1 (Day 1). Velaglucerase alfa infusions were administered
every other week for 12 months (51 weeks) for a total of 26
infusions. Patients received the same number of units of
velaglucerase alfa as their imiglucerase dose. Doses ranged between
15 U/kg and 60 U/kg. Infusion time was 60 minutes (1 hour).
Increased infusion durations (e.g., 2 hours) were documented in the
source documentation and appropriate CRF. Infusions were not less
than 1 hour in duration.
[0624] The first 3 velaglucerase alfa infusions for each patient
were administered at the clinical site. Patients who did not
experience a treatment-related serious adverse event or a
velaglucerase alfa infusion-related adverse event might receive
their subsequent infusions at home by qualified and trained medical
personnel, per the discretion and direction of the Investigator.
Patients who experienced an infusion-related adverse event might be
re-evaluated at a later time point during the study for
consideration to transition to home infusions. Patients receiving
velaglucerase alfa as home therapy were required to return to the
clinical site at Weeks 7, 13, 19, 25, 31, 37, 45, and 51 and
53.
[0625] The study completion visit is defined as Week 53. Patients
were considered to have completed this study once they have 1)
completed the 51-week treatment period, and 2) complete the study
visits at Week 51 and Week 53.
[0626] Patients who completed this study were provided the
opportunity to enroll in a subsequent long-term open-label clinical
study. For patients who elect to enroll in the subsequent long-term
open-label clinical study, certain assessments from the Week 51 and
the Week 53 visits for this study (TKT034) were used as the
Baseline assessments for that study; patients would receive their
first infusion for the subsequent long-term open-label clinical
study at the Week 53 visit, after they completed all of the
assessments for that visit and provided written informed consent to
participate in the subsequent long-term open-label clinical study.
Therefore, it was intended that patients would receive continuous
velaglucerase alfa treatment across the 2 studies. Patients who
completed this study and did not elect to enroll in the subsequent
long-term open-label clinical study would have a safety assessment
(for collection of adverse events and concomitant medications) by
site visit or telephone 30 days after their last infusion.
Selection of Study Population
[0627] All enrolled patients who received at least 1 infusion (or
partial infusion) were included in the ITT patient population.
[0628] Eligible participants were males or females age .gtoreq.2
years with diagnosed type 1 Gaucher disease (deficient
glucocerebrosidase activity in leukocytes, or by genotype
analysis), who had received consistent treatment with imiglucerase
for a minimum of 30 consecutive months; one patient was allowed to
participate having had 22 consecutive months of previous treatment
with imiglucerase.
[0629] Participants were excluded if they had both hemoglobin
concentration .ltoreq.10 g/dL and platelet count
.ltoreq.80.times.10.sup.3 platelets/mm.sup.3; had unstable
hemoglobin concentration (exceeded a range of .+-.1 g/dL of the
screening value) or platelet count (exceeded .+-.20% of the
screening value) during the 6 months prior to screening; had (or
were suspected of having) type 2 or 3 Gaucher disease; had
experienced an anaphylactic shock to imiglucerase; had inconsistent
treatment with imiglucerase or had received miglustat in the 6
months prior to study entry; or had radiologically-confirmed
active, clinically significant spleen infarction or worsening bone
necrosis within 12 months of screening.
[0630] Other exclusion criteria included treatment with any
investigational drug or device within 30 days prior to study entry;
positive test for HIV, hepatitis B or C; non-Gaucher
disease-related anemia at screening; or any significant
co-morbidity that could affect study data. Pregnant or lactating
women were excluded and women of child-bearing potential were
required to use a medically acceptable method of contraception at
all times.
Study Treatments
[0631] Treatment Assignment: Patients received velaglucerase alfa
infusions every other week at the same number of units of as their
imiglucerase dose. The patient's current imiglucerase dose was
recorded at Baseline. Velaglucerase alfa doses ranged between 15
U/kg and 60 U/kg.
[0632] Treatment Schedule: Patients received their first infusion
on Week 1 (Day 1). All patients received velaglucerase alfa once
every other week for 12 months (51 weeks); therefore, a total of 26
infusions are to be administered.
[0633] All doses of velaglucerase alfa were administered as
continuous IV infusions at a maximum rate of 1 U/kg/minute.
Infusion time was 60 minutes (1 hour). Increased infusion durations
(e.g., 2 hours) were documented in the source documentation and
appropriate CRF. Infusions might not be less than 1 hour in
duration. Patients received their final imiglucerase dose a maximum
of 30 days prior to study entry and a minimum of 14 days prior to
study entry.
[0634] Dose Calculation: A change in weight of >5% from Baseline
or the previously recorded weight used to calculate dose at Weeks
13, 25, or 37 required recalculation of the dose of study
medication.
[0635] Dose Adjustments: Patients were monitored throughout the
treatment period for changes in clinical parameters (i.e.,
hemoglobin concentration, platelet count, and liver and spleen
volume). If a patient demonstrated a clinically significant change
in these parameters the investigator evaluated the option of
increasing the patient's dose by 15 U/kg. A dose adjustment was
considered if two or more of the following four criteria were met
and consistent over two consecutive evaluations: decrease from
Baseline in hemoglobin concentration of >1 g/dL; a decrease from
Baseline in platelet count of >20%; an increase in liver volume
as indicated by organ palpation and confirmed to be >15%
relative to Baseline as measured by MRI; and an increase in spleen
volume as indicated by organ palpation and confirmed to be >15%
relative to Baseline as measured by MRI.
[0636] If the clinical parameter values did not return to Baseline
levels within three months, the Investigator had the option of
increasing the dose by increments of 15 U/kg. No dose increase was
offered to patients receiving a dose of 60 U/kg, and no dose above
60 U/kg was allowed. If the patient failed to respond to the
maximum dose of 60 U/kg, the patient might be withdrawn if deemed
appropriate based on the Investigator's clinical judgment.
[0637] Velaglucerase alfa Administration
[0638] General Instructions for velaglucerase alfa administration:
Velaglucerase alfa was administered intravenously. Study drug
infusions occurred on approximately the same day of the week but
might occur every 14 days (.+-.3 days) of the target day in order
to facilitate patient scheduling. If at all possible, missed
infusions should be avoided. If a patient was not dosed within
17-days from their scheduled dose, the patient would receive the
next infusion as soon as possible after approval for the patient to
continue in the study. It might be acceptable to give the next
infusion as early as 7 days after the previous infusion. Subsequent
infusions would return to the original schedule.
[0639] Home Infusion Instructions for Velaglucerase alfa
Administration: The first three velaglucerase alfa infusions were
administered at the clinical site. After the first three doses,
patients who had not experienced a treatment-related serious
adverse event or an infusion-related adverse event might receive
their subsequent infusions at home. Patients who had experienced an
infusion-related adverse event might be re-evaluated at a later
time point during the study for consideration to transition to home
infusions. Patients receiving velaglucerase alfa as home therapy
were required to return to the clinical site at Weeks 7, 13, 19,
25, 31, 37, 45, 51, and 53.
[0640] In the home setting, vital signs and documentation of
adverse events were collected at each visit Management of
Infusion-Related Adverse Events: An infusion-related adverse event
was defined as an adverse event that 1) begins either during or
within 12 hours after the start of the infusion, and 2) is judged
as possibly or probably related to study drug.
[0641] Description of Study Drug: Velaglucerase alfa is a
lyophilized product that was supplied and shipped by a qualified
distributor to the clinical study site to be stored at 2 to
8.degree. C.
[0642] Gaucher Disease Specific Treatment History: At Screening,
all Gaucher disease-specific treatments, including the patient's
current imiglucerase dose, were recorded. The patient's initial
velaglucerase alfa dose was based on the current imiglucerase dose
recorded.
[0643] Historical Hemoglobin and Platelet Values: All evaluations
of hemoglobin concentration and platelet count within the 30 months
prior to study entry were collected and reviewed to determine
patient eligibility.
[0644] Gaucher Disease and Chitotriosidase Genotyping: At Screening
only, all patients had a blood sample collected for Gaucher disease
and plasma chitotriosidase genotyping.
[0645] Vital Signs: Vital signs parameters recorded included pulse,
blood pressure, respiration rate, and temperature.
[0646] The following schedule was followed for recording vital
signs at all infusion visits: start of infusion (within 10 minutes
prior to starting the infusion; during infusion (30 minutes (.+-.5
minutes)); after infusion (within 5 minutes after the infusion is
completed, 30 minutes (.+-.5 minutes) after completing the
infusion, and 60 minutes (.+-.5 minutes) after completing the
infusion)
[0647] Physical Examinations: Physical examinations were performed
at the Baseline visits, and at Weeks 13, 25, 37, 51 and 53.
Physical examinations included the following: general appearance,
endocrine, head and neck, cardiovascular, eyes, abdomen, ears,
genitourinary, nose, skin, throat, musculoskeletal, chest and
lungs, and neurological. Any abnormal change in physical findings
was recorded as an adverse event on the appropriate CRF
page(s).
[0648] Height and Weight: Height and weight were recorded at the
Baseline visit, and at Weeks 13, 25, 37 and 51. Growth velocity was
calculated using height and weight measurements, and correlated
with Tanner staging.
[0649] 12-Lead Electrocardiograms: A 12-Lead ECG was performed at
the Baseline visit, and at Weeks 13, 25, 37 and 51. Each 12-lead
ECG included assessment of PR, QRS, QT, and QTc intervals, and
heart rate.
[0650] Clinical Laboratory Testing: Blood and urine samples were
collected as described below for the following evaluations.
[0651] Hematology: Blood samples were collected for hematology
testing at the Screening and Baseline visits, and at Weeks 7, 13,
19, 25, 31, 37, 45, 51 and 53. The following hematology parameters
were evaluated: complete blood count (CBC) with differential,
activated partial thromboplastin time (aPPT), reticulocyte count
(performed by the site's local laboratory), platelet count, and
prothrombin time (PT). At Screening, Baseline, and at every study
visit (except at the Week 1 visit), blood samples were collected to
measure hemoglobin concentration and platelet count.
[0652] An additional blood sample was collected during Screening to
measure hemoglobin and platelet count for statistical analysis
purposes.
[0653] Serum Chemistry: Blood samples were collected for serum
chemistry testing at the Baseline visit, and at Weeks 13, 25, 37,
51 and 53.
[0654] The following serum chemistry parameters were evaluated:
sodium, total bilirubin, potassium, alkaline phosphatase*, glucose,
alanine aminotransferase, total calcium, aspartate
aminotransferase, total protein, lactate dehydrogenase,
albumin,
[0655] Gamma-glutamyl transferase, creatinine, creatinine
phosphokinase, urea nitrogen, CTx, NTx* (* results were used for
assessments of bone biomarkers). Patients who at Screening had
folic acid and/or vitamin B.sub.12 deficiency-related anemia, and
so did not meet study entry criteria were considered a screen
failure. These patients might be treated for their folic acid
and/or vitamin B.sub.12 deficiency-related anemia for up to 12
weeks at the Investigator's discretion, according to the clinical
site's standard practice. Such patients might be re-screened for
this study after they completed the folic acid and/or vitamin
B.sub.12 treatment regimen.
[0656] Urinalysis: Urine samples were collected for urinalysis at
the Baseline visit, and at Weeks 13, 25, 37, 51 and 53. The
following urinalysis parameters were evaluated: pH, microscopic
evaluation, and macroscopic evaluation.
[0657] Serum Anti-imiglucerase Antibody Determination: All patients
had a blood sample at Baseline only for determination of serum
anti-imiglucerase antibodies. Patients were eligible for enrollment
in this study regardless of their anti-imiglucerase antibody
status. Patients who were anti-imiglucerase antibody positive would
be allowed to enter this study. These blood samples were evaluated
to determine the presence of anti-imiglucerase antibodies.
[0658] Serum Anti-velaglucerase alfa Antibody Determination: Blood
samples were collected for determination of anti-velaglucerase alfa
antibodies at the Baseline visit, and at Weeks 7, 13, 19, 25, 31,
37, 45 and 51. Blood samples collected for anti-velaglucerase alfa
antibody determination were evaluated. These samples were screened
using an enzyme-linked immunosorbence assay (ELISA).
[0659] Adverse Events: Adverse events were monitored throughout the
study from the time the patient provides signed informed consent
through 30 days after their last infusion for patients who
completed the study and did not elect to enroll in the subsequent
long-term open-label clinical study, or for patients who
discontinued or withdrew from the study prior to the Week 53 visit.
For patients who completed this study and elected to enroll in the
subsequent long-term open-label clinical study, adverse events were
monitored from informed consent through the Week 53 visit of this
study (TKT034).
[0660] Prior and Concomitant Illnesses: Additional illnesses
present at Baseline were regarded as concomitant illnesses and were
documented on the appropriate medical history pages of the CRF.
Illnesses first occurring or detected during the study, or
worsening of a concomitant illness during the study, were regarded
as AEs and were documented as such in the CRF.
Study Procedures for Efficacy Evaluations
[0661] Hemoglobin concentration: Hemoglobin concentration was
measured at the time points described herein. The change from
Baseline to 12 months in hemoglobin concentration was a secondary
endpoint of this study.
[0662] Platelet count: Platelet count was measured at the time
points described herein. The change from Baseline to 12 months in
platelet count was a secondary endpoint of this study.
[0663] Liver and Spleen Volumes Measured by Abdominal MRI: Patients
underwent quantitative abdominal MRI of the liver and spleen at
Baseline, Week 25, and Week 51. The change from Baseline to 12
months in liver and spleen volume was a secondary endpoint of this
study.
[0664] Plasma Chitotriosidase and CCL19 Levels: Blood samples were
collected for the evaluation of plasma chitotriosidase and CCL18
levels at the Baseline visit, and at Weeks 13, 25, 37, 51 and 53.
The change from Baseline to 12 months in chitotriosidase and CCL18
levels was a tertiary endpoint of this study.
[0665] Growth Velocity and Tanner Staging: For patients 2 to 17
years-old, growth was assessed at the time points defined herein.
Growth velocity was calculated using height and weight measurements
recorded at regular time points during this study, and correlated
with Tanner staging. The change from Baseline to 12 months in
growth velocity and Tanner staging was a tertiary endpoint of this
study.
[0666] Skeletal Growth: Patients between 2 and 17 years-old
underwent radiography of the left hand and wrist at Baseline and
Week 51 for evaluation of skeletal age. The change from Baseline to
12 months in skeletal growth in patients 2 to 17 years of age was a
tertiary endpoint of this study.
Additional Study Procedures
[0667] Bone Biomarkers: At Baseline only, patients .gtoreq.18
years-old underwent DXA of the lumbar spine and femoral neck,
including coronal imaging, to determine Gaucher-related local and
systemic bone disease. Bone loss and demineralization were also
evaluated by measuring serum alkaline phosphatase, NTx, and CTx.
Results for these parameters were obtained from blood samples
collected for clinical laboratory testing at Baseline only.
[0668] For patients 2 to 17 years-old, MRI of the femoral neck and
lumbar spine were obtained at Baseline (at the same time patients
undergo MRI of the liver and spleen). It was not expected that any
treatment effect would be apparent for these parameters during this
study, therefore, measurements were collected at Baseline only to
establish a reference point from which to monitor these biomarkers
during the subsequent long-term open-label clinical study.
Adverse Events
[0669] Adverse Event Definition: An adverse event (AE) is any
noxious, pathologic, or unintended change in anatomical,
physiologic, or metabolic function as indicated by physical signs,
symptoms, and/or laboratory changes occurring in any phase of a
clinical study, and whether or not considered study drug-related.
This includes an exacerbation of a pre-existing condition. Adverse
events were collected from informed consent until 30 days after the
last dose of study drug and/or until the event had been
resolved/stabilized or an outcome was reached, whichever came
first. For patients who discontinued or were withdrawn prior to the
Week 53 visit, AEs were followed up to 30 days after their last
infusion of velaglucerase alfa.
[0670] AEs include: worsening (change in nature, severity, or
frequency) of conditions present at the onset of the study;
intercurrent illnesses; drug interactions; events related to or
possibly related to concomitant medications; abnormal laboratory
values (this includes significant shifts from Baseline within the
range of normal that the Investigator considers to be clinically
important); clinically significant abnormalities in physical
examination, vital signs, weight, and ECG.
[0671] In addition, AEs might also include unexpected laboratory
values that become significantly out of range and determined to be
clinically significant by the Investigator. In the event of an
unexpected out-of-range value, the laboratory test would be
repeated until it returns to normal or can be explained and the
patient's safety is not at risk.
[0672] Infusion-Related Adverse Event Definition: An
infusion-related adverse event was defined as an adverse event that
1) begins either during or within 12 hours after the start of the
infusion, and 2) is judged as possibly or probably related to study
drug. Other AEs which occurred prior to the infusion, along with
AEs associated with protocol-defined testing and assessments (e.g.,
laboratory testing, ECGs, and physical examinations) which were
performed prior to the infusion, was not be defined as
infusion-related adverse events. Infusion-related adverse events
were managed as defined above.
[0673] Serious Adverse Event Definition: A serious AE (SAE) is any
AE occurring at any dose that results in any of the following
outcomes: death, is life-threatening, requires inpatient
hospitalization, requires prolongation of existing hospitalization,
a persistent or significant disability/incapacity, and a congenital
anomaly/birth defect.
[0674] Important medical events that may not result in death, be
life-threatening, or require hospitalization may be considered as
SAEs when, based upon appropriate medical judgment, they may
jeopardize the patient and may require medical or surgical
intervention to prevent one of the outcomes listed above.
[0675] A life-threatening AE is defined as an AE that placed the
patient, in the view of the initial reporter, at immediate risk of
death from the AE as it occurred (i.e., it does not include an AE
that, had it occurred in a more severe form, might have caused
death).
[0676] Classification of Adverse Events and Serious Adverse Events:
The National Cancer Institute Common Toxicity Criteria (NCI CTC)
Version 3.0 grading scale was referenced when assessing the
severity of an AE. If an AE was not described in the NCI CTC, the
severity was recorded based on the scale below. The severity of all
AEs/SAEs were recorded on the appropriate CRF page as Grade 1, 2, 3
or 4 corresponding, respectively, to a severity of mild, moderate,
severe, or life-threatening. Grade 1 (mild) is defined as no
limitation of usual activities. Grade 2 (moderate) is defined as
some limitation of usual activities; Grade 3 (severe) is defined as
inability to carry out usual activities; and Grade 4
(life-threatening) is defined as immediate risk of death.
[0677] Relationship of an adverse event or serious adverse event to
blinded study medication was determined by the Investigator based
on the following definitions. "Not related" is defined as unrelated
to study drug. "Possibly related" is defined as a clinical
event/laboratory abnormality with a reasonable time sequence to
administration of study drug, but which could also be explained by
concurrent disease or other drugs/chemicals. "Probably related" is
defined as a clinical event/laboratory abnormality with a
reasonable time sequence to administration of study drug, unlikely
to be attributable to concurrent disease or other drugs and
chemicals and which follows a clinically reasonable response on
dechallenge. The association of the clinical event/laboratory
abnormality must also have some biologic plausibility, at least on
theoretical grounds.
[0678] Clarification between Serious and Severe: The term "severe"
is often used to describe the intensity (severity) of a specific
event (as in mild, moderate, or severe myocardial infarction); the
event itself, however, may be of relatively minor medical
significance (such as severe headache). This is not the same as
"serious," which is based on the outcome or action criteria usually
associated with events that pose a threat to life or functioning.
Seriousness (not severity) and causality serve as a guide for
defining regulatory reporting obligations.
[0679] Adverse Event Monitoring and Period of Observation: For the
purposes of this study, the period of observation extended from the
time the patient provides signed informed consent until the
patient's final evaluation of the study. For safety purposes, the
final evaluation was defined as the post-study safety evaluation
performed approximately 30 days after the last infusion for
patients who completed the study and did not elect to enroll in the
subsequent long-term open-label clinical study, or for patients who
discontinued or withdrew from the study prior to Week 53. For
patients who elected to enroll in the subsequent long-term
open-label clinical study, adverse events were monitored until Week
53; adverse events that had not resolved as of the Week 53 visit
for this study were recorded in the patient's medical history for
the subsequent long-term open-label clinical study.
Statistical Methods
[0680] General Statistical Methodology: The intent-to-treat (ITT)
patient population was defined as all enrolled patients who
received at least one infusion (full or partial infusion).
Statistical data analyses were performed on the ITT population.
Continuous data collected at Baseline and at subsequent study
visits were summarized using descriptive statistics (m, mean,
median, minimum, maximum, and standard deviation). Categorical data
were summarized as frequencies and percentages. Descriptive
statistics were presented for all patients in the ITT population
according to demographic and Baseline characteristics.
[0681] Analysis of the secondary endpoints (i.e., clinical
parameters) was based on a non-inferiority hypothesis as described
below.
[0682] Sample Size Justification: This was a safety trial, and it
was difficult to identify a single primary safety outcome variable
for the study. However, the sample size selected which was based on
the efficacy parameters was suitable for the evaluation of less
common adverse effects.
[0683] The inclusion of at least 26 patients provided basic
information on safety and tolerability. From the TKT025 study, the
average change at 6 months across patients does not indicate any
worsening of adverse events (AEs) from Baseline. Some patients will
have their AEs resolved, some patients a worsening of their AEs.
Assuming the natural variability of the patients, then the chance
of seeing a worsening for a single patient is 11%. This 11% failure
rate is for one patient. The likelihood that all 26 patients in the
trial will not have an SAE is equal to the likelihood of patient 1
not having an SAE multiplied by the likelihood of patient 2 not
having an SAE multiplied by ( . . . etc. . . . )
[0684] the likelihood of patient 26 not having an SAE. That is 95%
likelihood that at least one patient out of 26 will show a
worsening of an AE from Baseline [1-(0.89).sup.26=0.95]. N In other
words, for a sample size of 26, the probability of observing at
least one event will be 0.95, when the probability of the event is
0.11. Or, when no events are observed, to obtain an upper bound of
0.11 on the 95% confidence interval to the probability of a rare
event, would require a sample size of 26.
[0685] The null hypothesis is that the mean changes from Baseline
(i.e., the end of imiglucerase treatment) to Month 12 for each of
the selected clinical parameters (hemoglobin concentration,
platelet count, liver and spleen volumes) are within the
pre-specified clinically significantly values. Clinically
significant changes from Baseline to Week 53 for hemoglobin was
defined as a change of no less than 1 gm/dL, and a 20% change in
platelet count. For normalized liver and spleen volume, the changes
from Baseline to Week 53 were defined as being no more than 15%
increase. The sample size estimate of 26 patients was based on a
paired t-test of means, with a standard deviation of 0.671 with a
two-sided alpha level of 0.05, and 80% power.
[0686] Primary Analysis: All patients who received at least one
full or partial dose of study drug were assessed for clinical
safety and tolerability. Vital signs, clinical chemistry and
hematology that were collected for safety monitoring were listed
for each patient and abnormal values were flagged. For categorical
variables such as AEs, the number and percentage of patients
experiencing each AE were tabulated. AEs were summarized by
severity of event. The number and percentage of patients
experiencing drug related AEs and AEs that were not considered
related to study drug were also displayed. Infusion-related adverse
events reactions and rates of anti-velaglucerase alfa antibody
formation were also summarized.
[0687] The primary clinical variable was to evaluate the safety of
velaglucerase alfa administered every other week to patients with
type I Gaucher disease who were clinically stable on imiglucerase.
Safety was evaluated by assessing vital signs and documenting
adverse events (by type, frequency, and severity) at each study
visit, as well as by performance of physical examinations and
changes in laboratory assessments at required visits.
[0688] All AEs were coded using MedDRA Coding Dictionary. AE
summaries in general were based on all AEs occurring after the
patient's first infusion of study drug (treatment-emergent).
[0689] Secondary Analyses: Secondary endpoints of this study are:
change from Baseline to 12 months in hemoglobin concentration;
change from Baseline to 12 months in platelet count; change from
Baseline to 12 months in spleen volume by abdominal MRI (evaluated
as % change) (Spleen volumes were normalized by body weight); and
change from Baseline to 12 months in liver volume by abdominal MRI
(evaluated as % change) (Liver volumes were normalized by body
weight).
[0690] For each clinical activity parameter, the alternative
hypothesis is that the mean change from Baseline (i.e., the end of
imiglucerase treatment) to Month 12 was within the specified
clinically significant levels for the parameters to be evaluated
(where the population mean change from Baseline for hemoglobin is
within 1 g/dL, the platelet count is within 20%, and the liver and
spleen volumes are within 15%. This was evaluated using a 2-sided
90% confidence interval for the true difference from Baseline for
these clinical parameters. For example, efficacy of velaglucerase
alfa was concluded if the confidence interval for the change from
Baseline of hemoglobin was within the interval -1 to 1 g/dL.
[0691] The Sponsor's expectation is that the mean hemoglobin
concentration was essentially constant over the 12-month period.
For example, instead of using a 90% confidence interval for
secondary efficacy analysis for hemoglobin, the following pair of
statistical hypothesis tests, each at an alpha level of 0.05, could
be used.
[0692] H.sub.01: .mu..sub.d.gtoreq.1 Vs H.sub.11:
.mu..sub.d<-1
[0693] H.sub.02: .mu..sub.d.ltoreq.-1 Vs H.sub.21:
.mu..sub.d>-1
[0694] By rejecting the first null hypothesis (H.sub.01) in favor
of the first alternative hypothesis (H.sub.11), one concludes at
the 0.05 significance level that the treatment mean change from
Baseline for hemoglobin is less than 1 g/dL higher than the
Baseline value. By rejecting the second null hypothesis (H.sub.02)
in favor of the second alternative hypothesis (H.sub.21), one
concludes at the 0.05 significance level that the treatment mean
change from Baseline for hemoglobin is greater than 1 g/dL lower
than the Baseline value. Because H.sub.01 and H.sub.02 cannot be
simultaneously true, the overall Type I error rate is 0.05 for the
above pair of hypothesis tests. Therefore, by rejecting both null
hypotheses in favor of the alternative hypotheses, one concludes at
the 0.05 significance level that the treatment (velaglucerase alfa)
hemoglobin concentration is within is within the interval -1 to 1
g/dL.
[0695] The sponsor considers the confidence interval method to be
easier to interpret than the corresponding method using hypothesis
tests. Therefore the confidence interval method will be used for
the secondary inference.
[0696] Tertiary Analyses: The tertiary endpoints for this study
are: change from Baseline to 12 months in plasma chitotriosidase
and CCL18 levels; change from Baseline to 12 months in skeletal age
in patients 2 to 17 years old; and change from Baseline to 12
months in growth velocity and Tanner staging.
[0697] The tertiary endpoints were summarized using descriptive
statistics (mean, median, standard deviation, minimum and maximum)
at each time point. For endpoints where data were collected at
Baseline and other time points during the study, the within group
changes were examined.
[0698] Analysis of Subgroups: Additional analyses were conducted
specifically for patients between 2 to 17 years old. Also,
consideration was given in the analysis to disease severity with
regard to hemoglobin Baseline values.
Results
[0699] 40 patients were included in the intent-to-treat (ITT)
analysis (Table 19), and 38 patients (93%) completed the study. One
patient discontinued before receiving study drug; and two patients
in the 15 U/kg group discontinued, one due to an anaphylactoid
reaction during her first infusion with velaglucerase alfa, and one
at Week 31 because of a perceived lack of improvement in
Gaucher-related symptoms.
[0700] Patients received velaglucerase alfa at the same number of
units to their prior imiglucerase regimen. Median prior
imiglucerase use was 67 months (range 22-192 months). Velaglucerase
alfa doses were grouped into four ranges: .ltoreq.22.5 U/kg (n=14),
22.5-37.5 U/kg (n=12), 37.5-52.5 U/kg (n=7), and >52.5 U/kg
(n=7). Investigators had the option to increase the velaglucerase
alfa dose (to a maximum of 60 U/kg every other week) if a patient
demonstrated a clinically significant change in hemoglobin or
platelet counts. No dose adjustments were made during the
study.
TABLE-US-00021 TABLE 19 TKT034 Patient characteristics at baseline
ITT population (n = 40) Age, mean (range) 36 years (9-71 years);
25% <18 years Gender, n (%) 18 (45%) male/22 (55%) female
Clinical parameters, median (range) Hemoglobin 13.8 g/dL (10.4-16.5
g/dL) Platelet count 162 .times. 10.sup.9/L (29-399 .times.
10.sup.9/L) Liver volume* 0.8 MN (0.6-1.6 MN) Spleen volume** 2.5
MN (1.0-16.0 MN) Biomarkers, median Chitotriosidase 3071.3
nmol/mL/h C-C motif ligand 18 325.0 ng/mL chemokine (CCL18) Prior
imiglucerase use, 67 months (22-192 months) median (range)
Anti-imiglucerase antibody 3 (8%) positive prior to receiving
velaglucerase alfa, n (%) *A normal liver volume is 2.5% of body
weight. **In 36 patients with spleen intact; four patients had
undergone a splenectomy prior to enrollment. A normal spleen volume
is 0.2% of body weight. MN = multiples of normal.
[0701] Clinical parameters were sustained at therapeutic levels
through 1 year (Table 20).
TABLE-US-00022 TABLE 20 Mean change or % Baseline change from
baseline Clinically n median to month 12 90% CI significant cutoffs
Hemoglobin 40 10.8 -0.1 -0.3, 0.1 -1, 1 concentration (g/dL)
Platelet count (.times.10.sup.9/L) 40 162 7.0% 0.5%, 13.5% -20%,
20% Normalized liver volume 40 1.9 0.0% -2.6%, 2.6% -15%, 15% (% of
body weight) Normalized spleen 36 0.5 -5.6% -10.8%, -0.4% -15%, 15%
volume (% of body weight)
[0702] Velaglucerase alfa was generally well tolerated, with most
adverse events (AEs) of mild or moderate severity (Table 21). The
most frequently reported AEs were nasopharyngitis (8/40 patients),
arthralgia (9/40 patients), and headache (12/40 patients). Overall,
11 of 40 patients (28%) experienced an AE considered possibly or
probably related to study drug; the majority of these events were
considered infusion related. No patient experienced a
life-threatening AE. One severe adverse event was considered
probably related to treatment and occurred in a patient who had a
severe hypersensitivity reaction. This patient tested negative for
all 4 isotypes (IgE, IgM, IgG, IgA), including neutralizing
antibodies, both at the time of the infusion and 2 weeks later. One
patient (in the 15 U/kg group) experienced an anaphylactoid
reaction that led to discontinuation; no other patients
discontinued due to AEs. No patients developed IgG antibodies to
velaglucerase alfa, including three patients who tested positive
for anti-imiglucerase alfa antibodies at screening.
TABLE-US-00023 TABLE 21 TKT034 Safety summary Patients, n (%) Total
15 U/kg 30 U/kg 45 U/kg 60 U/kg (n = 40) (n = 15) (n = 12) (n = 6)
(n = 7) Experienced .gtoreq.1 34 (85) 12 (80) 11 (92) 5 (83) 6 (86)
treatment-emergent AE* Experienced .gtoreq.1 drug- 11 (28) 6 (40) 3
(25) 1 (17) 1 (14) related AE Experienced .gtoreq.1 9 (23) 6 (40) 2
(17) 0 1 (14) infusion-related AE.sup..dagger. Experienced
.gtoreq.1 5 (13) 0 2 (17) 1 (17) 2 (29) severe AE Experienced
.gtoreq.1 life- 0 0 0 0 0 threatening AE Experienced .gtoreq.1 4
(10) 1 (7) 1 (8) 2 (33) 0 serious AE Discontinued due to an 1 (3) 1
(7) 0 0 0 AE Deaths 0 0 0 0 0 Developed anti- 0 0 0 0 0
velaglucerase alfa antibodies *A treatment-emergent AEs was defined
AEs that occurred on or after the day of the first infusion until
30 days after the patient's last infusion. .sup..dagger.An
infusion-related AE was defined as an AE that 1) began either
during or within 12 hours after the start of the infusion, and 2)
was judged as possibly or probably related to study drug.
[0703] The first three infusions for each patient were administered
at the clinical site, after which patients who had not experienced
a drug-related serious AE or an infusion-related AE were eligible
to receive subsequent infusions at home. During the study, 25 (63%)
of 40 eligible patients received home therapy at least once, ten
patients (67%) in the 15 U/kg group, six (50%) in the 30 U/kg
group, five (83%) in the 45 U/kg group, and four (57%) in the 60
U/kg group.
[0704] For hemoglobin concentration, the mean change from Baseline
was -0.1 g/dL, with a 90% confidence interval of -0.3 to 0.1 g/dL,
within the predefined efficacy criterion of .+-.1 g/dL. For
platelet counts, the percent change from Baseline was +7.0%, with a
90% confidence interval of 0.5 to 13.5%, within the predefined
efficacy criterion of .+-.20%. For liver volume, the percent change
from Baseline was -0.0%, with a 90% confidence interval of -2.6 to
2.6% within the predefined efficacy criterion of .+-.15%. For
spleen volume, the percent change from Baseline was -5.6%, with a
90% confidence interval of -10.8 to -0.4% within the predefined
efficacy criterion of .+-.15%. Hemoglobin concentration, platelet
counts, and liver and spleen volume were sustained at therapeutic
levels through 1 year of velaglucerase alfa treatment, as
demonstrated by pre-specified efficacy criteria for clinically
significant change. Mean change in hemoglobin and mean percent
change in platelet count and organ volumes are shown in FIGS.
15-18. For each parameter, similar results were seen across the
four dose groups.
The percent change in plasma chitotriosidase and plasma CCL18 are
shown in FIGS. 19 and 20. Levels of both biomarkers were sustained
and possibly reduced over the 12-month treatment period.
Example 5
HGT-GCB-058 Study
Summary
[0705] HGT-GCB-058 is a multicenter, open-label treatment study to
observe the safety of velaglucerase alfa in patients with Gaucher
disease type 1 who were newly diagnosed (treatment naive) or
transitioned from imiglucerase to velaglucerase alfa. The study
design was for male or female patients two years old or older.
Velaglucerase was administered at a dose of 15-60 U/kg every other
week (EOW) by 1-hour intravenous (IV) infusion--Patients received
the same number of units of velaglucerase alfa as their prior
imiglucerase dose (patients receiving <15 U/kg imiglucerase EOW
received 15 U/kg velaglucerase alfa). The rate of infusion was a
maximum of 1 U/kg/minute.
Patients and Methods
[0706] HGT-GCB-058 was initiated to provide an alternative
treatment option for patients who would otherwise have limited or
no access to imiglucerase due to supply constraints. The primary
endpoint was to observe the safety of velaglucerase alfa.
[0707] For HGT-GCB-058, within 3 months of the first site
initiated, 20 clinical sites across the US were enrolling patients.
Between Sep. 1, 2009 and Jan. 31, 2010 more than 150 patients
enrolled onto HGT-GCB-058 and received at least one infusion of
velaglucerase alfa. Only 3 patients were treatment naive; all
others were previously treated with imiglucerase.
Preliminary Safety Results
[0708] Discontinued: <10%; Withdrawal of consent & other
(<10%); AE experience including SAE (<2%).
[0709] Treatment Emergent Adverse Events (TE-AE):
[0710] Treatment naive patients (n=3): No serious AEs; no severe
AEs; two patients experienced moderate AEs: headache (moderate) and
back pain (moderate) (infusion related--possibly related)
[0711] Previously treated with imiglucerase (n>150): 35.8% at
least one TE-AE; 18.2% at least one possibly/probably related
TE-AE; 13.8% at least one infusion related reaction;
<1%--serious AE (a 69-year-old female experienced a severe
cerebrovascular accident requiring hospitalization) not related;
3.1%--at least one severe AE: arthralgia (not related), fatigue
(probably related), bone pain (not related), pain in extremity (not
related), leucopenia (possibly related), cerebrovascular accident
(not related).
Example 6
Comparative Study
[0712] The objective of this example is to compare the efficacy of
Ceredase.RTM., Cerezyme.RTM., veluglucerase alfa, Genz-112638, and
Zavesca.RTM. in treating type 1 Gaucher disease. Hemoglobin
concentration, platelet count, liver volume, and spleen volumes
were measured after 6, 9, or 12 months of treatment.
[0713] Doses: Enzyme replacement therapy (ERT): 60 U/kg EOW;
Genz112638: 50 & 100 mg BID; Zavesca: 100 mg TID
[0714] Ratio of Males to Females: Cerezyme (8 to 7); Ceredase (3 to
2); Velaglucerase Ph I/II TKT025 study (5 to 7);
Velaglucerase-TKT032 study-45 U/kg dose (8 to 5);
Velaglucerase-TKT032 study-60 U/kg dose (7 to 5); Zavesca (1 to 1);
Genz-112638 (3 to 4)
[0715] Inclusion criteria:
[0716] Cerezyme & Ceredase: anemia & splenomegaly
[0717] Velaglucerase TKT025: anemia and thrombocytopenia
[0718] Genz-112638: anemia, thromb, & splenomegaly
[0719] Zavesca dose: organomegaly & <100/nL P1 or <11.5
Hb
[0720] Velaglucerase HGT-GCB-039 and TKT032: anemia and 1 other
parameter manifestation
[0721] Baseline comparison in naive patients is shown in Table
22.
TABLE-US-00024 TABLE 22 Hemoglobin Platelets Liver Vol. Spleen Vol.
(g/dL) (cells/nL) MN (L) MN (L) Ceredase .RTM. 10.8 71 1.83 24
Cerezyme .RTM. 10.7 72 1.65 19 Velaglucerase 11.6 57 1.95 (2.4 L)
19 (2.1 L) (Ph I/II TKT025) Velaglucerase 10.9 58 3.50 (% of 2.90
(% of (TKT032- body weight) body weight) 45 U/kg dose)
Velaglucerase 10.83 66 3.60 (% of 2.90 (% of (TKT032) body weight)
body weight) 60 U/kg dose Genz-112638 11 70 1.7 19 Zavesca .RTM.
11.9 77 (2.4 L) (1.6 L) MN = Multiple of Normal
[0722] Comparative results from patients treated with
Ceredase.RTM., Cerezyme.RTM., velaglucerase alfa, or Genz-112638
for six months are shown in Table 23.
TABLE-US-00025 TABLE 23 Mean Spleen Mean Liver Mean Platelet Mean
Volume Volume Increase (%) Hemoglobin Reduction (%) Reduction (%)
[actual] Increase (g/dL) Ceredase .RTM..sup.1 32.1 .+-. 8.8 11.4
.+-. 9.4 34 [16/nL] 1.60 6 mo Cerezyme .RTM..sup.1 37.3 .+-. 13.6
13.4 .+-. 13.1 22 [23/nL] 1.82 6 mo velaglucerase.sup.2 41.3 .+-.
9.8 14.7 .+-. 12.0 38 [23.4 .+-. 24.6/nL] 1.92 .+-. 0.82 6 mo (n =
11) Genz-112638.sup.3 27 7 18 [12.5/nL.sup.4] 0.9 6 mo (n = 17-21)
.sup.1Cerezyme and Ceredase data as reported by Grabowski et al.
(1995) Ann. Intern. Med. 122, 33-39. Mean increase in platelet
count in cells/nL for Cerezyme and Ceredase are from the Cerezyme
SBA. .sup.2velaglucerase alfa Phase I/II results .sup.3Oppenheimer
Analyst Report: May 8, 2008 from Genzyme Analyst Day 2008
.sup.4Calculated by multiplying baseline by percent change ERT
administered at 60 U/kg EOW, Genz112638 administered at 50 &
100 mg BID
[0723] Comparative results from patients treated with
Ceredase.RTM., Cerezyme.RTM., velaglucerase alfa, or Genz-112638
for nine and twelve months are shown in Table 24.
TABLE-US-00026 TABLE 24 Mean Spleen Mean Liver Mean Platelet Mean
Volume Volume Increase (%) Hemoglobin Reduction (%) Reduction (%)
[actual] Increase (g/dL) Ceredase.sup.1 9 mo (n = 15) 42.2 .+-. 6.9
16.4 .+-. 8.4 53.2 2.28 [25.1/nL] Cerezvme.sup.1 9 mo (n = 15) 47.1
.+-. 13.7 21.4 .+-. 10.8 43.5 2.54 [30.9/nL] velaglucerase.sup.2 9
mo 49.5 .+-. 12.6 18.2 .+-. 8.2 67.6 2.24 .+-. 0.89 (n = 11) [40.6
.+-. 30.7/nL] Velaglucerase.sup.3 1 yr not available not available
95.3 .+-. 21.2 2.35 .+-. 0.3 (n = 10) [54.9 .+-. 11.1]
Velaglucerase.sup.4 1 yr 50.4 .+-. 5.3 17.0 .+-. 4.5 65.9 .+-. 16.9
2.43 .+-. 0.3 (n = 12) [50.88 .+-. 12.2] Velaglucerase.sup.5 1 yr
40.92 2.44 (n = 10) Genz-1126383.sup.5 1 yr 40 17 40 [26/nL4] 1.6
(n = 11-13) .sup.1Cerezyme and Ceredase 9-Mo data as reported by
Grabowski et al. (1995) Ann. Intern. Med. 122, 33-39. Dose was 60
U/kg every other week (EOW). Mean increase in platelet count in
cells/nL calculated from raw data .sup.2velaglucerase alfa 9-Mo
data from TKT025 (Ph I/II) - 60 U/kg dose EOW .sup.3velaglucerase
alfa 12-Mo data from TKT025Extension - 60 U/kg dose EOW
.sup.4velaglucerase alfa 12 Mo data from TKT032 - 60 U/kg dose dose
EOW .sup.5velaglucerase afa 12 Mo data from TKT032 - 45 U/kg dose
EOW .sup.3WORLD meeting presentation, Feb. 20, 2009 - administered
at 50 & 100 mg BID
[0724] Conclusions: this study shows that velaglucerase alfa was at
least as effective as Ceredase.RTM., Cerezyme.RTM., Genz-112638,
and Zavesca.RTM. in treating type 1 Gaucher disease based on the
measurement of hemoglobin concentration, platelet count, liver
volume, and spleen volume, 6, 9, or 12 months after the treatment
was initiated.
Example 7
Anti-Drug Antibody (ADA) Assays
Summary
[0725] Development of antibodies to therapeutic proteins can impact
patient safety, efficacy and drug pharmacokinetics. A panel of
anti-drug antibody (ADA) and neutralizing antibody (NAb) assays
were developed and validated in order to evaluate and compare
antibody response in patients receiving velaglucerase alfa or
imiglucerase in one of three velaglucerase alfa Phase III
studies.
[0726] Assessment of potential immunogenicity of a biological
therapy such as enzyme replacement therapy (ERT) was performed by
the following steps: [0727] 1. Screen for antibody to the ERT
[0728] i. Allow for false positives [0729] ii. Broad specificity
for all isotypes [0730] iii. Tolerant to presence of drug [0731] 2.
Confirmatory step [0732] i. Rule out false positives [0733] ii.
Isotype specific [0734] 3. Titer step [0735] i. Relative
concentration [0736] 4. Test for neutralizing antibody [0737] i. In
vitro activity [0738] ii. In vitro cellular uptake
[0739] This assessment can be performed for any ERT.
[0740] An example of such an assessment is shown in FIG. 21.
Immunoassay Methods
[0741] Anti-velaglucerase alfa and anti-imiglucerase antibodies
were evaluated identically using bridge immunoassays and
immunoglobulin (Ig) subclass-specific indirect immunoassays, all
based on an electrochemiluminescent platform, as well as RIP
assays. The bridge electrochemiluminescent immunoassay detected all
immunoglobulin subclasses and was considered the antibody screening
assay. The Ig subclass electrochemiluminescent immunoassays were
confirmatory assays for the presence of IgA, IgM and IgE
antibodies, while the RIP assay was confirmatory for the presence
of IgG antibodies. The antibody screening assays and IgG assays
were calibrated, quantitative and utilized human antibody positive
controls. The IgA, IgM and IgE assays were semi-quantitative and
utilized hybrid (human-sheep) positive controls.
[0742] All anti-velaglucerase alfa and anti-imiglucerase
immunoassays were identical, including positive cut off criteria,
except that either velaglucerase alfa or imiglucerase were used to
interrogate the sample. These assays are high throughput, provide
increased surface area for detection, allow use of high serum
sample concentration with minimum non-specific binding and detect
all antibody subclasses.
Antibody Screening Assays
[0743] As shown in FIG. 22, anti-drug antibody screening can be
performed using an electrochemilluminescence (ECL) immunoassay.
[0744] Anti-velaglucerase alfa (anti-imiglucerase) antibodies were
detected using immobilized biotin-conjugated velaglucerase alfa (or
imiglucerase) on streptavidin-coated microwell plates. Immobilized
biotinylated velaglucerase alfa (or imiglucerase) captured
anti-velaglucerase alfa (anti-imiglucerase) antibodies present in
patients' sera and unbound proteins were removed by washing.
Ruthenium complex-labeled velaglucerase alfa (or imiglucerase) was
added to each microwell resulting in the formation of a complex
with the bound anti-velaglucerase alfa (anti-imiglucerase)
antibodies. This was followed by a second wash step, in which
unbound labeled proteins were removed.
[0745] Labeled molecules bound near the microwell surface emit
light in a process triggered by the electrochemiluminescent
reaction, measured by an MSD SECTOR
[0746] Imager 2400 instrument
(http://www.mesoscale.com/CatalogSystemWeb/WebRoot/products/imager.sub.---
2400.aspx). A mouse monoclonal antibody with cross-reactivity to
velaglucerase alfa and imiglucerase was used as a calibrator within
each assay plate and a human anti-imiglucerase antibody
cross-reactive with velaglucerase alfa was use as positive assay
control. The concentration of anti-velaglucerase alfa
(anti-imiglucerase) antibodies in test samples was estimated by
interpolating the unknown's measured electrochemiluminescent signal
on the calibration curve.
[0747] A minimum of 67 Gaucher patient baselines were tested in
order to set the antibody positive cut points for these assays. The
test design included at least three analysts testing replicate
samples using different plate lot numbers over a period of at least
14 days. At least three different microwell plate lots were used.
Two available MSD instruments were used randomly for a total of
1269 determinations for each assay. The assay cut point for
anti-velaglucerase alfa (anti-imiglucerase) antibodies was
established as the mean plus 1.645 standard deviation of
electrochemiluminescent values obtained as recommended in
Mire-Sluis, A R et al. Journal of Immunological Methods 289 (2004),
pp 1-16. The assay sensitivity was estimated to be 33.4 and 65.6
ng/mL for anti-velaglucerase alfa and anti-imiglucerase antibodies,
respectively.
[0748] The screening characteristics for this assay (using
velaglucerase as the drug) are shown in Table 25.
[0749] The specification for each parameter shows highly sensitive
and reproducible ADA screening assays were validated for evaluating
antibody response in patients receiving velaglucerase alfa or
imiglucerase.
TABLE-US-00027 TABLE 25 Parameter Specification Imprecision, % RSD
Intra assay .ltoreq.6.2 Inter assay .ltoreq.8.5 Accuracy, %
93.5-107.7 Sensitivity, 1 ng/mL 100 LOD, 2 ng/mL 5 LOQ, ng/mL 15
Positive controls Human & sheep ADA Calibrator Mouse monoclonal
ADA ADA = anti-drug antibody; LOD = limits of detection; LOQ =
limit of quantification; RSD = relative standard deviation
[0750] The screening assay dose response curve for velaglucerase is
shown in FIG. 23.
[0751] An example of the affinity and binding kinetics of a
monoclonal ADA on the BIACOR.RTM. .RTM. platform are shown in Table
26. Similar ligand affinity and binding kinetics were observed for
the ADA assay calibrator.
TABLE-US-00028 TABLE 26 Ligand ka (1/Ms) kd (1/s) KD (M)
velagucerase alfa 9.2E+05 2.7E-04 3.0E-10 imiglucerase 2.8E+06
1.0E-04 3.7E-10 Biotinylated 4.0E+05 2.2E-04 5.4E-10 velaglucerase
alfa Biotinylated 2.0E+06 9.5E-04 4.8E-10 imiglucerase
Radioimmunoprecipitation Assay
[0752] If anti-drug antibody is detected in a sample, confirmatory
assays to determine the Ig isotype of the antibody can be
performed. Immunoglobulin G (IgG) antibodies were detected using
radioimmunoprecipitation. A radioimmunoprecipitation (RIP) assay is
shown in FIG. 24.
[0753] In the radioimmunoprecipitation assay, anti-velaglucerase
alfa (anti-imiglucerase) IgG antibodies present in patient serum
bound .sup.125I-velaglucerase alfa (or imiglucerase) in solution
phase and formed antigen/antibody complexes that were captured
using Protein G mini-columns. The mini-columns were washed to
remove free label and quantified directly in a gamma counter. The
radioactive counts retained in the mini-column were proportional to
the concentration of anti-velaglucerase alfa (anti-imiglucerase)
IgG antibodies in the test sample. The concentration of
anti-velaglucerase alfa (anti-imiglucerase) IgG antibodies in test
samples was estimated from a calibration curve using the same
monoclonal antibody calibrator discussed above. The same human
antibody positive control described above was used in this
assay.
[0754] The least squares line fit to the high purity, monoclonal
antibody based calibration curve, using well characterized known
concentrations of antibody, provided a reliable and consistent
method for calculating uncertainty in assay determinations. This
tool allows for normalization of the cut point for inter-assay
changes in counts that may occur from reagent radiolabel decay,
radioautolysis and/or assay handling variability as well as
allowing for changes in non specific binding and for changing assay
readouts that may occur over time.
[0755] A total of 59 Gaucher patient baselines were tested in order
to set the antibody positive cut point for this assay. The assay
cut points for anti-velaglucerase alfa (imiglucerase) IgG were
established as described above and recommended in Mire-Sluis et
al.sup.2. Assay sensitivity was estimated to be 28.3 and 64.5 ng/mL
for the anti-velaglucerase alfa IgG and anti-imiglucerase IgG
assays, respectively.
[0756] An example of the results obtained with such an assay using
velaglucerase as the drug is shown in Table 27.
[0757] Highly sensitive and reproducible IgG ADA confirmatory
assays were validated for evaluating antibody response in patients
receiving velaglucerase alfa or imiglucerase.
TABLE-US-00029 TABLE 27 Parameter Specification Imprecision, % RSD
Intra assay .ltoreq.8.7 Inter assay .ltoreq.12.0 Accuracy, %
90.5-132.8 Sensitivity, 1 ng/mL 80 LOD, 2 ng/mL 4 LOQ, ng/mL 13
Positive controls Human & sheep ADA Calibrator Mouse monoclonal
ADA ADA = anti-drug antibody; LOD = limits of detection; LOQ =
limit of quantification; RSD = relative standard deviation
[0758] An example of a dose response curve obtained for a RIP assay
using velaglucerase is shown in FIG. 25.
Indirect Electrochemiluminescent Immunoassays
[0759] Parallel to screening for IgG antibodies, assays are
performed to screen for the presence of IgE antibodies. Assays can
also be performed to detect the presence of IgA and IgM
antibodies.
[0760] IgA, IgM, and IgE ADA were detected using ECL assays. An
example of such an assay is shown in FIG. 26.
[0761] Anti-velaglucerase alfa (imiglucerase) antibodies were
analyzed for their Ig subclass using indirect
electrochemiluminescent immunoassays. Antibodies were detected in
serum by immobilizing biotinylated velaglucerase alfa
(imiglucerase) on streptavidin-coated microwell plates. Diluted
serum samples were added to the immobilized velaglucerase alfa
(imiglucerase), which captured any anti-velaglucerase alfa
(anti-imiglucerase) antibodies present in the sample. After sample
incubation, the microwells were washed to remove unbound proteins.
Next, ruthenium complex-labeled anti-human secondary antibodies
against IgA, IgM or IgE were added separately and further incubated
resulting in the formation of an Ig class-specific complex with any
bound anti-velaglucerase alfa or imiglucerase antibodies. This was
followed by another wash step, in which unbound labeled secondary
antibody was removed. The labeled molecules bound near the
microwell surface then emit light as described above.
[0762] Artificial antibody positive controls were prepared for
these assays since anti-velaglucerase alfa (anti-imiglucerase) IgA,
IgM or IgE antibodies were not available. Human IgA-, IgM- and
IgE-antibody hybrids were synthesized by chemically cross-linking
purified, non-specific human IgA, IgM or IgE fragments to an
antibody raised in sheep hyperimmunized with velaglucerase alfa and
cross-reactive with imiglucerase. The IgA-, IgM- and IgE-antibody
hybrids therefore bound to velaglucerase alfa (or imiglucerase)
through the sheep antibody domain, and were detected using
ruthenium complex-tagged anti-human secondary antibodies against
the human IgA, IgM or IgE domains, respectively.
[0763] The assay cut points for anti-velaglucerase alfa
(imiglucerase) IgA, IgM and IgE were established as described above
and recommended in Mire-Sluis et al.sup.2. Assay sensitivity was
estimated to be 10.6 and 11.0 ng/mL for the anti-velaglucerase alfa
IgE and anti-imiglucerase IgE assays, respectively. For
anti-velaglucerase alfa (imiglucerase) IgA and IgM antibodies, the
assay positive cut points had to be met in addition to a ratio
greater than or equal to 2.0 of the time point signal to the
pre-infusion baseline signal.sup.3.
[0764] For these assays, hybrid positive controls can be used. For
example: [0765] Sheep ADA IgG, and human IgA, IgM and IgE are
treated to yield pyridylthiol-activated proteins (see Gu M. L.,
Feng S. L., and Glenn J. K. Development of an animal-human antibody
complex for use as a control in ELISA. J. Pharmaceutical and
Biomedical Analysis, 32 (2003), 523-529) [0766] Activated IgA, IgM
and IgE are reduced and desalted [0767] Activated IgG is mixed with
reduced IgA, IgM or IgE [0768] The formed hybrid antibodies were
characterized by size exclusion chromatography and ECL ELISA [0769]
Human/sheep molar ratios of 5 for IgA and IgM, and 2 for IgE were
obtained
[0770] An example of IgA, IgM and IgE confirmatory assay
characteristics (when velaglucerase was used as the drug) are shown
in Table 28.
[0771] Highly sensitive and reproducible IgA, IgM, and IgE ADA
isotyping assays were validated for evaluating antibody response in
patients receiving velaglucerase alfa or imiglucerase.
TABLE-US-00030 TABLE 28 IgA Assay IgM Assay IgE Assay
Parameter.sup.4 Specification Specification Specification
Imprecision, % RSD Intra assay .ltoreq.3.1 .ltoreq.6.2 .ltoreq.6.6
Inter assay .ltoreq.4.8 .ltoreq.3.7 .ltoreq.13.3 Specificity
.alpha.-chain Fc .mu.-chain Fc .epsilon.-chain Fc Linearity,.sup.1
ng/mL 156-2000 156-2500 156-10000 LOD,.sup.2 ECL counts 260.sup.
460.sup. 240.sup. Positive controls.sup.3 Hybrid ADA Hybrid ADA
Hybrid ADA .sup.1based on hybrid control response; .sup.2positive
cut point; ratio of time point to baseline must be .gtoreq.2.0;
.sup.3human/sheep ADA hybrid controls; .sup.4highly sensitive and
reproducible IgA, IgM and IgE ADA isotyping assays were validated
for evaluating antibody response in patients receiving
velaglucerase alfa or imiglucerase ADA = anti-drug antibody; LOD =
limits of detection; LOQ = limit of quantification; RSD = relative
standard deviation
Antibody Inhibition of In Vitro Enzymatic Activity
[0772] Inhibition of in vitro enzymatic activity by
anti-velaglucerase alfa (imiglucerase) antibodies was tested using
an assay that detects and quantifies antibodies that inhibit
velaglucerase alfa (imiglucerase) activity. The method is based on
a colorimetric activity assay that measures the ability of
velaglucerase alfa (imiglucerase) to hydrolyze the synthetic
substrate 4-nitrophenyl-.beta.-D-glucopyranoside to p-nitrophenol
and D-glucopyranoside.
[0773] Anti-velaglucerase alfa (imiglucerase) antibody positive
serum samples were pre-incubated with a fixed amount of
velaglucerase alfa or imiglucerase, respectively for 30 minutes at
37.degree. C. Sheep polyclonal antibodies known to inhibit
velaglucerase alfa and imiglucerase in vitro activity were used as
positive controls. The 4-nitrophenyl-.beta.-D-glucopyranoside
substrate solution was then added and incubated with the serum
sample/enzyme mixture for one hour at 37.degree. C. The enzymatic
reaction was stopped by addition of glycine/sodium carbonate buffer
(pH 10.7) and the product (p-nitrophenol) was measured at the
absorbance wavelength of 405 nm. One unit of velaglucerase alfa
(imiglucerase) activity was defined as the amount of enzyme
required to hydrolyze one .mu.mole of the substrate
4-nitrophenyl-.beta.-D-glucopyranoside in one minute at 37.degree.
C. Enzymatic activity was quantified by comparison of the released
p-nitrophenol in test samples and assay controls to a p-nitrophenol
calibration curve measured in the same assay plate. Results of the
test samples were expressed relative to the activity of
velaglucerase alfa (imiglucerase) measured in the absence of serum
sample and reported as % inhibition.
[0774] The assay cut point was determined from individual healthy
human donor sera (N=52) and enzyme replacement therapy-naive
Gaucher patients (N=35). The cut point for the velaglucerase alfa
and imiglucerase neutralizing antibody assays was defined as
inhibition >20.0% based on these 87 samples. Therefore, a
patient sample was considered to be negative for inhibitory
antibodies if the level of inhibition observed was .ltoreq.20.0%
and to be positive if inhibition >20.0%.
In Vitro Cell-Based Assay
[0775] An in vitro cell-based assay was used to assess anti-drug
antibodies to determine if the antibodies were neutralizing.
[0776] Table 29 shows the specification of assay characteristics
for neutralizing levels of anti-drug antibody (velaglucerase was
used as the drug).
TABLE-US-00031 TABLE 29 Parameter Specification Imprecision, % RSD
Intra assay .ltoreq.12.9 Inter assay .ltoreq.6.1 Accuracy, %
86.7-92.7 Linearity, mU/mL 0.3-33.3 Positive cut point,.sup.1 %
inhibition >20 LOD, mU/mL 0.3 LOQ, mU/mL 1.0 Positive controls
Human & sheep ADA .sup.1n = 104 NHS and 70 ERT-naive Gaucher
sera LOD = limits of detection; LOQ = limit of quantification; RSD
= relative standard deviation
[0777] With respect to neutralizing antibodies in ERT such as ERT
for Gaucher disease, points to consider include: [0778]
Receptor-mediated cell uptake is critical for in vivo function of
therapeutic agent [0779] Receptor binding interference by ADA can
hinder enzyme trafficking [0780] Inhibition of cell uptake is an
important tool to evaluate successful ERT since [0781] It closely
mimics the mechanism by which NAb may exert an effect in vivo, and
[0782] NAb could reduce or abolish the biological activity of the
therapeutic agent [0783] Cell-based assays provide the most
appropriate biological model for assessment of NAb
[0784] Samples from patients undergoing ERT in clinical trials for
Gaucher disease were evaluated for neutralizing antibodies to
velaglucerase or imiglucerase. Results are shown in Table 30.
TABLE-US-00032 TABLE 30 Inhibition of Inhibition of imiglucerase
uptake, velaglucerase alfa % mean uptake, % mean Visit Week Visit
Week Patient ID Treatment 0 13 19 41 0 13 19 41 032-191-0002
velaglucerase NS.sup.2 NS 039-009-0001 imiglucerase 039-194-0001
imiglucerase 039-194-0002 imiglucerase 039-167-0001 imiglucerase
NT3 38 38 33 NT 4 5 5 034-027-0002 imiglucerase.sup.1 NS NT.sup.3
NS NT 034-154-0001 imiglucerase.sup.1 5 10 034-164-0001
imiglucerase.sup.1 38 10 A marked cell-based inhibition of
imiglucerase uptake was observed in two ADA-positive patients
Cell-based inhibition of velaglucerase alfa uptake was either
negligible or not observed in any ADA-positive patient tested
.sup.1previously receiving imiglucerase treatment and switched to
velaglucerase alfa at trial inception; .sup.2not significant (less
than the limit of quantification); .sup.3 not tested as yet; time
point negative for anti-velaglucerase alfa antibodies
In Vitro Cell-Based Assay I
[0785] Major objectives: Experiments were conducted to determine
the ability of human antibodies reactive with velaglucerase alfa
and/or imiglucerase to inhibit (block or neutralize) CD206-mediated
uptake of the recombinant enzymes by a human cell line (HT1080)
engineered to express CD206, and to compare in this respect
anti-drug antibodies (ADA) produced in response to imiglucerase to
those produced in response to velaglucerase alfa. The hypothesis is
that antigenic differences exist between velaglucerase alfa and
imiglucerase; these epitopes will differentiate velaglucerase alfa
from imiglucerase with respect to the functional effect of ADA on
cell binding, cell internalization, and/or intracellular
trafficking of the therapeutic agent.
[0786] Materials and Equipment:
[0787] Critical Materials
[0788] 1. Cell line MRC1-18 is derived from the line HT1080 and is
stably-transfected with human CD206 (the macrophage mannose
receptor; MMR, also referred to as MRC1, mannose receptor C type
1). HT1080(saf) cells were transfected with an expression vector
carrying the gene encoding the MMR (that was isolated from a human
liver cDNA library) by electroporation and immediately plated into
96-well plates. Stable clones were selected using media containing
0.4 mg/mL G418. MRC1 expression was analyzed using FITC anti-MRC1
staining and analysis by fluorescence shift. Expression of MMR on
MRC1-18 was confirmed by surface staining with anti-MMR Ab.
Additionally, MRC1-18 has been verified by immunostaining and flow
cytometry to be negative for expression of Fc (gamma)
receptors.
[0789] 2. Alexa FLUOR.RTM. 488 conjugated velaglucerase alfa and
imiglucerase: velaglucerase alfa or imiglucerase was conjugated
with Alexa FLUOR.RTM. 488 using the Alexa FLUOR.RTM.r 488 protein
labeling kit following the manufacturer's protocol (Molecular
Probes, catalog #A 10235).
[0790] 3. Imiglucerase or velaglucerase alfa ADA-positive patient
sera from clinical trials TKT-032, TKT-034, and HGT-GCB-039 (see
Table 31 for sample IDs)
[0791] 4. Assay Positive Control (PC): 250 .mu.g/mL purified
polyclonal sheep anti-velaglucerase alfa antibody (G140) in Normal
Human Serum (NHS; BRH127439)
[0792] 5. Negative control samples: human serum samples from normal
healthy donors (Bioreclamation, Catalog #HMSM, BRH127438,
BRH127439), or baseline serum samples from patients enrolled in
clinical trial TKT-032 (N=25).
[0793] 6. Mannan: Sigma Catalog #M7054
[0794] 7. D-Mannose-6-phosphate: Sigma Catalog# M3655
[0795] 8. Growth medium: 50% CD-CHO (Invitrogen catalog #10743) and
50% CD-293 (Invitrogen catalog# 11913) supplemented with 4 mM
L-glutamine (Invitrogen Catalog# 25230) and 0.4 mg/mL Geneticin
(G418, Invitrogen Catalog #11811-031).
[0796] 9. 0.05% trypsin-EDTA: Invitrogen catalog# 25300
[0797] 10. Wash buffer: PBS/0.5% BSA
[0798] 11. BD Cytometer setup and tracking beads: BD Bioscience
catalog# 641319
[0799] Partial List of Equipment
[0800] 1. 37.degree. C. Incubator with 5% CO.sub.2: Form a
Scientific Model 3033
[0801] 2. Centrifuge: Thermo Scientific Model Sorvall Legend T+
[0802] 3. Cell counter: Mexcelom Bioscience LLC, Model Cellometer
Auto T 4
[0803] 4. Flow cytometer: BD Bioscience, FACSCanto II
[0804] Methods: Patient sera that tested positive for anti-drug
antibodies by antibody screening and confirmatory assay were
further examined by an in vitro cell uptake assay, utilizing an
HT1080 cell line engineered to express the human macrophage mannose
receptor (MMR). Briefly, MRC1-18 cells were maintained in CD media
supplemented with 0.5 mg/mL G418. For each assay,
1.5.times.10.sup.5 cells/well in CD media with G418 were added in a
flat bottom 96-well plate, and pre-incubated with 1:20 diluted test
patient serum samples, 1:20 diluted normal human serum (NHS), or
assay positive controls (G140 antibody, 5 mg/mL mannan) in 1:20
diluted NHS at 37.degree. C. for 15 minutes. Then 5 nM Alexa FLUORO
488 labeled velaglucerase alfa or imiglucerase was added, and
incubated at 37.degree. C. for an additional 2 hours. A calibration
curve of Alexa FLUORO 488 labeled velaglucerase alfa or
imiglucerase was included in each experiment by incubation of
MRC1-18 cells with Alexa FLUORO 488 labeled velaglucerase alfa or
imiglucerase (0-10 nM) in 1:20 diluted NHS at 37.degree. C. for 2
h.
[0805] After a 2-hour incubation, media was removed by
centrifugation, cells were treated with trypsin-EDTA for 3 minutes
to remove surface-bound velaglucerase alfa or imiglucerase, then
neutralized by addition of an equal volume of media with 10% FBS.
Cells were washed with PBS/0.5% BSA once, resuspended in PBS/0.5%
BSA and analyzed by BD FACS Canto II with the fixed instrument
setting. The Canto II instrument was set up with the BD Cytometer
setup and tracking beads before each analysis. The results were
analyzed with FlowJo software, and the mean fluorescence intensity
(MFI) for each sample recorded. The adjusted MFI was calculated by
subtraction of the MFI of the background sample (cells with 0 nM
drug) from the MFI of each sample. Inhibition of velaglucerase alfa
and imiglucerase uptake by patient samples was determined relative
to a normal human serum sample (NHS) or the patient's own naive
baseline sample, when available. Percent inhibition can be
calculated using the following equation:
% inhibition=1-(Adj. MFI of test sample/Adj. MFI of patient
baseline or NHS).times.100
[0806] Results:
[0807] Assay Development:
[0808] The following initial results were obtained upon development
of this assay (data not shown): [0809] The internalization of
velaglucerase alfa and imiglucerase by the MRC1-18 cell line is
dose dependent. [0810] The internalization of velaglucerase alfa
and imiglucerase by the MRC1-18 cell line is mediated by the
mannose receptor, since the internalization was inhibited by mannan
(5 mg/mL, >89%), but not by M6P (5 mM). [0811] G140 antibody
spiked in 1:20 diluted NHS (normal human serum) inhibits
velaglucerase alfa and imiglucerase uptake by the MRC1-18 cell
line. The inhibition is dose dependent. [0812] Twelve lots of NHS
tested at 1:20 dilution did not inhibit velaglucerase alfa uptake
by the MRC1-18 cell line.
[0813] Assay Variability:
[0814] Twenty-five individual naive Gaucher serum samples from a
clinical study were tested over three days (N=75) to establish the
baseline effect on the uptake of velaglucerase alfa or imiglucerase
into the MRC1-18 cell line.
[0815] The average baseline serum effect on the uptake of
velaglucerase alfa is similar to the baseline serum effect on the
uptake of imiglucerase. However, the variability, calculated as the
CV %, is much greater for imiglucerase than for velaglucerase alfa
(28% vs 15%) (data not shown).
[0816] ADA-Positive Patient Serum Samples Results and
Reproducibility of the Assay:
[0817] The inhibition of velaglucerase alfa and imiglucerase uptake
by patient serum samples previously determined to have antibodies
against imiglucerase or velaglucerase alfa was tested. Each serum
sample was tested in parallel for its ability to block imiglucerase
uptake as well as velaglucerase alfa uptake, regardless of which
enzyme preparation initially elicited the production of the
antibodies. Table 31 lists the patient serum samples and the
protein treatment received (only one antibody positive patient,
ENU, received treatment with velaglucerase alfa).
TABLE-US-00033 TABLE 31 ADA-Positive Patient Serum Samples Patient
Patient Initials Treatment Received 032-191-0002 E N U
Velaglucerase alfa 039-009-0001 R W imiglucerase 039-194-0001 G A J
imiglucerase 039-194-0002 A V L imiglucerase 039-167-0001 K M
imiglucerase 034-027-0002 S B imiglucerase 034-154-0001 J M S
imiglucerase 034-164-0001 M P Q imiglucerase
[0818] Samples from patients ENU, RW, GAJ, AVL, and SB showed no
inhibition of either imiglucerase or velaglucerase alfa uptake
(data not shown). The reproducibility of inhibition of
velaglucerase alfa and imiglucerase uptake by patient samples JMS,
KM, MPQ, and SB (as a negative control) was determined over three
days relative to a normal human serum sample or the patient's own
naive baseline sample, when available (Table 32).
[0819] Patient KM (039-167-0001) was naive at baseline and was then
treated with imiglucerase in a subsequent study. Samples from all
three visits showed a significant inhibition of imiglucerase uptake
(24-52% inhibition relative to its baseline), relative to the
equivalent inhibition of velaglucerase alfa uptake (0-15%, which is
within the range of variability of the assay).
[0820] Patients SB (034-027-0002), JMS (034-154-0001), and MPQ
(034-164-0001) were previously treated with imiglucerase. Serum
from patient SB showed no inhibition of either imiglucerase uptake
(0%) or of velaglucerase alfa uptake (0%) relative to a normal
human serum sample. The inhibition of imiglucerase uptake (0-14%)
by serum from patient JMS was consistent with the inhibition
observed of velaglucerase alfa uptake (0-20%). The inhibition of
imiglucerase uptake (32-45%) by serum from patient MPQ was
significantly greater than the equivalent inhibition of
velaglucerase alfa uptake (0-15%, which is within the range of
variability of the assay).
[0821] These preliminary results suggest that neutralizing
antibodies present in the serum from patients KM and MPQ inhibit
imiglucerase uptake but not velaglucerase alfa uptake into
cells.
TABLE-US-00034 TABLE 32 Inhibition of Imiglucerase or Velaglucerase
alfa Uptake by ADA- Positive Patient Samples Inhibition of
imiglucerase Inhibition of Uptake Velaglucerase Patient # Initials
Visit Treatment Day 1 Day 2 Day 3 Mean alfa Uptake 039- KM Week 13
naive at 38% 24% 52% 38% 0-8% 167- Week 19 baseline, 29% 45% 40%
38% 0001 Early then treated 28% 38% 33% 33% termination with
imiglucerase 034- SB Baseline Previously 0% 0% 0% 0% 0-14% 027-
visit treated with 0002 imiglucerase 034- JMS Baseline Previously
14% 0% 2% 5% 0-20% 154- visit treated with 0001 imiglucerase 034-
MPQ Baseline Previously 45% 32% 40% 38% 0-15% 164- visit treated
with 0001 imiglucerase
[0822] Inhibition of uptake of imiglucerase or velaglucerase alfa
by the mannose inhibitor mannan and by polyclonal sheep
anti-velaglucerase alfa antibody G140 (positive control) was also
determined over three days (Table 33). Mannan inhibits the uptake
of both imiglucerase and velaglucerase alfa into MRC1-18 cells
through the mannose receptor. The G140 antibody inhibits the uptake
of both imiglucerase and velaglucerase alfa into MRC1-18 cells by
an equivalent amount.
TABLE-US-00035 TABLE 33 Inhibition of Imiglucerase or Velaglucerase
alfa Uptake by Positive Controls Inhibition of Inhibition of
Imiglucerase Velaglucerase Uptake alfa Uptake Mean CV % Mean CV %
G140 5 .mu.g/mL 52% 37% 42% 14% G140 10 .mu.g/mL 78% 11% 71% 7%
Mannan 5 mg/mL 92% 3% 91% 3%
[0823] Conclusions: Velaglucerase alfa and imiglucerase differ
structurally, with regard to both protein sequence (e.g., R495H
mutation in imiglucerase) and carbohydrate structure. Experiments
were performed to address the hypotheses that antigenic differences
exist between velaglucerase alfa and imiglucerase, and that these
epitopes differentiate velaglucerase alfa from imiglucerase with
respect to the ability of anti-drug antibodies (ADA) to block cell
binding and/or cell internalization of each therapeutic.
Experiments were conducted using the recently developed HT1080 cell
line in which uptake of therapeutic is facilitated principally by
the MMR, and is minimally confounded by other known cell uptake
mechanisms. The inhibition of imiglucerase or velaglucerase alfa
uptake by patient serum samples was measured relative to each
other. The data show that out of a total of 7 serum samples taken
from patients that produced ADA in response to imiglucerase
treatment, and 1 serum sample taken from a patient that produced
ADA in response to velaglucerase alfa treatment, 2 sera (2/7=29%)
from patients that produced ADA in response to imiglucerase caused
24% to 52% inhibition of cell uptake of imiglucerase, but only
0-15% inhibition of cell uptake of velaglucerase alfa which is
within assay variability. In comparison, only one patient has been
identified to date that produced antibody in response velaglucerase
alfa treatment; this serum did not inhibit uptake.
[0824] Each serum sample was tested in parallel for its ability to
block imiglucerase uptake and/or velaglucerase alfa uptake,
regardless of which enzyme preparation initially elicited the
production of the antibodies. Such comparisons of the inhibition of
velaglucerase alfa uptake, versus inhibition of imiglucerase
uptake, allow for crude "mapping" of epitopes to
biologically-relevant portions of each therapeutic (with the caveat
that the antisera tested herein are polyclonal, and thus each
antiserum likely contains a mixture of antigen specificities,
perhaps recognizing multiple epitopes). With these precautions in
mind, the inhibition of uptake observed with anti-imiglucerase
antisera seems to be restricted to imiglucerase since the same
antisera do not inhibit internalization of velaglucerase alfa
tested in parallel. These data suggest that some ADA produced in
response to imiglucerase inhibit cellular internalization via
epitopes that are uniquely exposed in imiglucerase. Furthermore,
the difference in variability observed of the serum effect on
imiglucerase vs. velaglucerase alfa uptake can perhaps be due to a
greater homogeneity in the velaglucerase alfa preparation than in
the imiglucerase preparation in terms of post translational
modifications.
[0825] Inhibition of enzyme uptake by anti-velaglucerase alfa
(imiglucerase) antibodies was tested using a cell-based assay that
detects and quantifies antibodies that interfere with macrophage
mannose receptor (MMR)-mediated velaglucerase alfa (imiglucerase)
uptake. The method is based on quantification of
fluorescently-labeled velaglucerase alfa (imiglucerase) which is
internalized by MRC1-18 cells under defined conditions. MRC1-18 is
a cell line engineered at Shire HGT from HT1080 cells that were
stably-transfected with the human macrophage mannose receptor C,
type 1.
[0826] Briefly, anti-velaglucerase alfa (imiglucerase) antibody
positive serum samples were pre-incubated with MRC1-18 cells in
culture media in flat-bottom, 96-well plates at 37.degree. C. for
15 minutes. Pooled normal human serum (NHS) was used as negative
control. Sheep polyclonal antibodies known to inhibit velaglucerase
alfa and imiglucerase uptake as well as mannan, the MMR-specific
ligand (Sung S J et al. J. Cell Biol. 1983; 96:160-166) were used
as positive controls to block enzyme uptake.
[0827] Following preincubation, Alexa Fluor-488-labeled
velaglucerase alfa or imiglucerase was added, and incubated at
37.degree. C. for an additional 2 hours. A calibration curve
consisting of incubation of Alexa Fluor-488-labeled enzyme with
MRC1-18 cells was included in each experiment. After incubation,
media was removed by centrifugation, cells were treated with
trypsin-EDTA for 3 minutes to remove surface-bound enzyme, and
finally the reaction pH was returned to neutral with by addition of
an equal volume of culture media. Cells were washed once and
resuspended using phosphate buffered saline containing 0.5% BSA.
Cells were analyzed using a Becton Dickinson FACS Canto II
instrument calibrated before each analysis using the instrument's
cytometer setup and tracking beads.
[0828] The results were analyzed with the instrument's FlowJo
software, and the mean fluorescence intensity (MFI) for each sample
was recorded. The adjusted MFI was calculated by subtracting the
background MFI from sample wells containing no enzyme from each
unknown and control sample MFI. Inhibition of enzyme uptake by
patient serum samples was estimated relative to the NHS control
according to the following equation:
% Inhibition=[1-[Adjusted MFI of test sample/Adjusted MFI of
NHS]].times.100
[0829] The assay cut point was determined by analysis of 25
individual sera collected from treatment-naive Gaucher patients.
Each serum was tested on four separate days for a total of 100
values and the positive cut point was defined as inhibition greater
than the mean of these values plus 1.645 standard deviations.
[0830] In Vitro Cell-Based Assay II
[0831] This assay was developed to compare uptake of velaglucerase
alfa to imiglucerase.
[0832] Methods: For Design of Experiments (DOE) assays, general
factorial design was assisted by Statease DESIGN EXPERT.TM.
software. DOE utilized macrophages derived from phorbol myristate
acetate (PMA) induced U937 cells, and were conducted in the
presence of 5 mM mannose-6-phosphate (M6P). For internalization
comparisons, U937-derived macrophages were incubated for 3 hours
with GCB at pH 7.5 with 10 mM calcium. Internalized drug was
measured by an activity assay with a synthetic substrate (4-MU-glc)
that fluoresces upon cleavage.
[0833] Results: Comparison in U937 cells of the internalization
rates of velaglucerase alfa and imiglucerase showed that
velaglucerase alfa is internalized up to 2.5-fold more efficiently
than imiglucerase. This differentiation in cellular internalization
was also observed using the MMR-expressing murine cell line J774.
Under specific assay conditions, the addition of calcium mildly
inhibited the cellular uptake of imiglucerase while it enhanced the
uptake of velaglucerase alfa. The internalization of both enzymes
could be inhibited by addition of mannan to the culture medium,
although the inhibition of velaglucerase alfa uptake by J774 cells
was more complete than that of imiglucerase. DOE assays revealed
that: i) the interaction of calcium with pH greatly impacts uptake;
and ii) bioassay sample comparisons required the presence of
calcium, consistent with the known calcium-dependence of the MMR.
The presence of mannose-6-phosphate (M6P) in DOE experiments
ensured that the M6P receptor on U937 cells did not contribute to
the measured internalization.
[0834] These data suggest that velaglucerase alfa is internalized
more efficiently than imiglucerase. While both enzymes are
primarily internalized via the MMR, a small portion, greater for
imiglucerase than for velaglucerase alfa, is internalized by an
alternative mechanism. These data may prove valuable in
differentiating velaglucerase alfa, imiglucerase, and other future
therapies.
Summary
[0835] From these studies, a summary of antibody detection methods
is as follows: [0836] Equivalent assays validated for velaglucerase
alfa and imiglucerase ADA as per ICH and FDA guidelines. See, e.g.,
http://www.fda.gov/downloads/RegulatoryInformation/Guidances/UCM128049.pd-
f and http://www.ich.org/LOB/media/MEDIA417.pdf [0837] Screening
[0838] Confirmatory [0839] Titer [0840] Isotype [0841] Neutralizing
[0842] Masked patient specimens evaluated for velaglucerase alfa
and imiglucerase ADA in parallel [0843] Controls and calibrators
covered a broad range of antibody affinities [0844] Developed
isotype-specific hybrid controls when human positive sera not
found
[0845] Immunogenicity Status of Patients in Phase III Studies:
[0846] TKT032: patients randomized to velaglucerase alfa 60 U/kg or
45 U/kg EOW [0847] One patient ADA-negative at baseline developed
NAb in response to velaglucerase alfa [0848] TKT034: patients
previously stable on imiglucerase switched to velaglucerase alfa
15-60 U/kg [0849] Three patients anti-imiglucerase positive at
baseline, were anti-velaglucerase negative through the 12-month
treatment. [0850] HGT-GCB-039: patients randomized to velaglucerase
alfa 60 U/kg or imiglucerase 60 U/kg EOW [0851] Four patients
ADA-negative at baseline, seroconverted in response to imiglucerase
[0852] Of these, one developed NAb reactive against both
imiglucerase and velaglucerase alfa, while three developed
non-inhibitory IgG ADA reactive against only imiglucerase
[0853] The patient seroconversion summary is shown in Table 34. Of
the 99 patients who were treated, 82 received velaglucerase alfa
and 17 received imiglucerase. One of 82 patients receiving
velaglucerase alfa and four of 17 patients receiving imiglucerase
developed antibodies during the trials.
TABLE-US-00036 TABLE 34 U/kg Study Months Treatments EOW n
Seroconversion TKT032 12 months velaglucerase 60 12 0/12 patients
alfa velaglucerase 45 13 1/13 patients alfa TKT034 12 months
velaglucerase 15-60 40 To date: 0 patients alfa (3 patients
imiglucerase antibody-positive at baseline) HGT-GCB-039 9 months
velaglucerase 60 17 0/17 patients alfa imiglucerase 60 17 4/17
patients
[0854] The clinical implications of the studies discussed in this
example are as follows: [0855] Highly sensitive and equivalent
methods were developed, optimized and validated to directly assess
and compare patient antibody response to velaglucerase alfa and
imiglucerase treatments [0856] Results show seroconversion in 1% of
patients treated with velaglucerase alfa and 23% of patients who
were treated with imiglucerase, suggesting significant antigenic
differences between velaglucerase alfa and imiglucerase [0857] In
addition, there was marked cell uptake inhibition by ADA of
imiglucerase but not velaglucerase alfa
Example 8
Effect of Moisture Content on the Stability of a Lyophilized
Velaglucerase Product
[0858] Purpose: To assess the effect of moisture content on the
stability of a lyophilized velaglucerase product.
[0859] Methods: The protein was formulated into a
sucrose-containing solution and lyophilized using a FTS lab-scale
lyophilizer (Lyostar II). The lyophilized vials were removed at
intervals after primary drying with a sample thief to yield samples
with varying moisture content. The secondary structure of the
lyophilized protein was examined by FT-IR. The thermal stability of
these samples was characterized by physical appearance, moisture
content, size exclusion and reversed phase HPLC, and oxidation by
peptide mapping methods.
[0860] Upon reconstitution with Sterile Water for Injection, the
velaglucerase product contains approximately 2.5 mg/mL (40 U/mL) of
velaglucerase alfa, 50 mg/mL sucrose, 12.9 mg/mL sodium citrate
dihydrate, 1.3 mg/mL citric acid monohydrate and 0.11 mg/mL
polysorbate 20.
[0861] Results: A moisture content range of 1.3% to 6.2% was
achieved in the lyophilized product. Cake collapse was observed at
accelerated temperature (40.degree. C.) in drug product with high
moisture content (.gtoreq.5%). However, chemical stability testing
results for the reconstituted solution demonstrate that the samples
with higher moisture content (.gtoreq.3%) showed significantly less
degradation than the drier samples by both SE-HPLC and RP-HPLC
methods, as well as showing lower amounts of oxidation. This
stability trend correlates with changes observed in the secondary
structure by FT-IR of the dried product.
[0862] Conclusion: Higher moisture content resulted in better
chemical stability of a lyophilized protein. This stability trend
is explained by fewer changes to the secondary structure in the
solid phase with higher moisture content. A choice of proper
moisture content in the lyophilized product needs to balance both
structural stability of the cake and chemical stability of the
protein.
Example 9
Analysis of Therapeutic Goals for Velaglucerase Alfa
[0863] Therapeutic goals have been described to monitor
achievement, maintenance and continuity of therapeutic response in
patients with type 1 Gaucher disease receiving ERT (Pastores G et
al., (2004) Seminars in Hematology, 41 (suppl 5): 4-14)
[0864] To benchmark the impact of velaglucerase alfa treatment
against therapeutic goals for clinical parameters of type 1 Gaucher
disease (anemia, thrombocytopenia, hepatomegaly, and splenomegaly),
the proportion of patients at goal for anemia, thrombocytopenia,
hepatomegaly and splenomegaly at baseline was compared with the
proportion achieving each of these goals at 9 months or 1 year.
[0865] No data imputation was utilized. Only patients who have data
for each goal at both time points are included. For hematologic
parameters, Baseline was the average of the screening and baseline
values; 1 year therapeutic goal values were the average of Week 51
and Week 53 values for TKT032 and TKT034, and the average of Week
39 and Week 41 values for HGT-GCB-039. For organ volumes, Week 41
value was applied to 1 year therapeutic goal criteria in
HGT-GCB-039.
[0866] Therapeutic goals for TKT032, HGT-GCB-039, HGT-GCB-039
patients with intact spleen, HGT-GCB-039 splenectomized patients,
TKT034, and TKT025 are described in Tables 35-40.
TABLE-US-00037 TABLE 35 velaglucerase alfa 60 U/kg velaglucerase
alfa 45 U/kg velaglucerase alfa Therapeutic N = 12 N = 13 Overall N
= 25 goals Baseline 1 Year Baseline 1 Year Baseline 1 Year
Hemoglobin 2/12 (17%) 11/12 (92%) 3/13 (23%) 12/13 (92%) 5/25 (20%)
23/25 (92%) concentration Platelet count 2/11 (18%) 6/11 (55%) 4/13
(31%) 9/13 (69%) 6/24 (25%) 15/24 (63%) Liver 5/11 (45%) 11/11
(100%) 7/12 (58%) 8/12 (67%) 12/23 (52%) 19/23 (83%) Spleen 3/11
(27%) 11/11 (100%) 4/12 (33%) 11/12 (92%) 7/23 (30%) 22/23 (96%)
.gtoreq.3 goals 1/11 (9%) 10/11 (91%) 5/12 (42%) 9/12 (75%) 6/23
(26%) 19/23 (83%) All 4 goals 1/10 (10%) 6/10 (60%) 0/12 (0%) 7/12
(58%) 1/22 (5%) 13/22 (59%)
TABLE-US-00038 TABLE 36 velaglucerase alfa 60 U/kg imiglucerase 60
U/kg Therapeutic N = 17 N = 17 goals Baseline 9 Months Baseline 9
Months Hemoglobin 10/16 (63%) 15/16 (94%) 4/15 (27%) 12/15 (80%)
concentration Platelet count 8/16 (50%) 16/16 (100%) 9/15 (60%)
15/15 (100%) Liver 8/16 (50%) 15/16 (94%) 4/16 (25%) 16/16 (100%)
Spleen 1/6 (17%) 6/6 (100%) 3/6 (50%) 6/6 (100%) .gtoreq.3 goals
1/16 (6%) 14/16 (88%) 1/15 (7%) 12/15 (80%) All 4 goals 0/6 (0%)
6/6 (100%) 0/6 (0%) 6/6 (100%)
TABLE-US-00039 TABLE 37 velaglucerase alfa 60 U/kg imiglucerase 60
U/kg Therapeutic N = 7 N = 7 goals Baseline 9 Months Baseline 9
Months Hemoglobin 5/7 (71%) 7/7 (100%) 2/6 (33%) 6/6 (100%)
concentration Platelet count 0/7 (0%) 7/7 (100%) 0/6 (0%) 6/6
(100%) Liver 6/7 (86%) 7/7 (100%) 1/6 (17%) 6/6 (100%) Spleen 1/6
(17%) 6/6 (100%) 3/6 (50%) 6/6 (100%) .gtoreq.3 goals 1/7 (14%) 7/7
(100%) 1/6 (17%) 6/6 (100%) All 4 goals 0/6 (0%) 6/6 (100%) 0/6
(0%) 6/6 (100%)
TABLE-US-00040 TABLE 38 velaglucerase alfa 60 U/kg imiglucerase 60
U/kg Therapeutic N = 10 N = 10 goals Baseline 9 Months Baseline 9
Months Hemoglobin 5/9 (56%) 8/9 (89%) 2/9 (22%) 6/9 (67%)
concentration Platelet count 8/9 (89%) 9/9 (100%) 9/9 (100%) 9/9
(100%) Liver 2/9 (22%) 8/9 (89%) 3/10 (30%) 10/10 (100%) .gtoreq.2
goals 6/9 (67%) 9/9 (100%) 5/9 (56%) 9/9 (100%) All 3 goals 0/9
(0%) 7/9 (78%) 0/9 (0%) 6/9 (67%)
TABLE-US-00041 TABLE 39 velaglucerase alfa overall Therapeutic N =
40 goals Baseline 1 Year Hemoglobin 37/38 (97%) 37/38 (97%)
concentration Platelet count 29/36 (81%) 29/36 (81%) Liver 37/37
(100%) 37/37 (100%) Spleen 30/34 (88%) 31/34 (91%) .gtoreq.3 goals
32/37 (86%) 33/37 (89%) All 4 goals 26/32 (81%) 26/32 (81%)
TABLE-US-00042 TABLE 40 TKT025 TKT032 velaglucerase alfa 60
velaglucerase alfa 60 Therapeutic U/kg N = 12 U/kg N = 12 goals
Baseline Month 9 Baseline Year 1 Hemoglobin 5/10 (50%) 10/10 (100%)
2/12 (17%) 11/12 (92%) concentration Platelet count 0/10 (0%) 7/10
(70%) 2/11 (18%) 6/11 (55%) Liver 5/10 (50%) 7/10 (70%) 5/11 (45%)
11/11 (100%) Spleen 0/10 (0%) 9/10 (90%) 3/11 (27%) 11/11 (100%)
.gtoreq.3 goals 0/10 (10%) 8/10 (80%) 1/11 (9%) 10/11 (91%) All 4
goals 0/10 (10%) 5/10 (50%) 1/10 (10%) 6/10 (60%)
[0867] A number of embodiments of the invention have been
described. Nevertheless, it will be understood that various
modifications may be made without departing from the spirit and
scope of the invention. Accordingly, other embodiments are within
the scope of the following claims.
* * * * *
References