Risankizumab; moderate to severe Crohn's disease; open-label extension study
Abstract :
[en] BACKGROUND: Risankizumab, an anti-interleukin 23 antibody, was superior to placebo in achieving clinical and endoscopic remission at week 12 in a randomised, phase 2 induction study in patients with moderately to severely active Crohn's disease. Here we aimed to assess the efficacy and safety of extended intravenous induction and subcutaneous maintenance therapy with risankizumab. METHODS: All patients who completed the 12-week induction phase of the double-blind phase 2 induction study were included in this open-label extension study. Patients who did not achieve deep remission, defined as clinical remission (Crohn's Disease Activity Index [CDAI] <150) and endoscopic remission (Crohn's Disease Endoscopic Index of Severity [CDEIS] </=4, or </=2 for patients with isolated ileitis), at week 12 received open-label intravenous therapy with 600 mg risankizumab every 4 weeks for 12 weeks; patients in deep remission at week 12 entered a 12-week washout phase. Patients in clinical remission at week 26 were invited to participate in the maintenance phase of the study, in which they received open-label subcutaneous risankizumab (180 mg) every 8 weeks for 26 weeks. 26-week efficacy endpoints were the proportion of patients in clinical remission (CDAI <150), and the proportion of patients who achieved clinical response (either CDAI of <150 or a reduction from baseline of at least 100 points). 52-week efficacy endpoints were the proportion of patients achieving: clinical remission; clinical response; endoscopic response (>50% CDEIS reduction from baseline); endoscopic remission, as defined previously; mucosal healing; and deep remission. Safety was assessed in patients who received at least one dose of the study drug during the open-label phases of the study. This study is registered with ClinicalTrials.gov, number NCT02031276. FINDINGS: Of the 108 patients who completed the 12-week double-blind induction trial, six patients were in deep remission and entered the 12-week washout phase. 102 patients were not in deep remission, 101 of whom received 12 weeks of 600 mg risankizumab (33 from the original placebo group, 34 from the 200 mg risankizumab group, and 34 from the 600 mg risankizumab group); the other patient declined to continue the study. At week 26, 54 (53%) of 101 patients treated with 600 mg rizankizumab were in clinical remission. Among patients included in the open-label extension trial, clinical remission rates at week 26 versus week 12 were: 18 (55%) versus six (18%) of 33 patients in the original placebo group; 20 (59%) versus seven (21%) of 34 patients in the original 200 mg risankizumab group; and 16 (47%) versus nine (26%) of 34 patients in the original 600 mg risankizumab group. 62 patients received risankizumab maintenance treatment, including the 54 patients who achieved clinical remission at week 26, the six patients who had achieved deep remission at week 12, and one patient because of a protocol violation. At week 52, clinical remission was maintained in 44 (71%) patients; 50 (81%) patients had a clinical response, 22 (35%) patients were in endoscopic remission, and 34 (55%) patients had an endoscopic response. 15 (24%) patients had mucosal healing and 18 (29%) patients achieved deep remission at week 52. Risankizumab was well tolerated with no new safety signals noted. The most frequent treatment-emergent adverse events were arthralgia (25 [22%] of 115 patients), headache (23 [20%]), abdominal pain (21 [18%]), nasopharyngitis (18 [16%]), nausea (18 [16%]), and pyrexia (15 [13%]). Most adverse events were mild or moderate and considered to be unrelated to study treatment. There were no treatment-related deaths. INTERPRETATION: Extended induction treatment with open-label intravenous risankizumab was effective in increasing clinical response and remission rates at week 26. Open-label subcutaneous risankizumab maintained remission until week 52 in most patients who were in clinical remission at week 26. Selective blockade of interleukin 23 warrants further investigation as a treatment for Crohn's disease. FUNDING: Boehringer Ingelheim.
Disciplines :
Gastroenterology & hepatology
Author, co-author :
Feagan, Brian G.
Panes, Julian
Ferrante, Marc
Kaser, Arthur
D'Haens, Geert R.
Sandborn, William J.
Louis, Edouard ; Université de Liège - ULiège > Département des sciences cliniques > Hépato-gastroentérologie
Gomollon, F, Dignass, A, Annese, V, et al. 3rd European evidence-based consensus on the diagnosis and management of Crohn's disease 2016: Part 1: diagnosis and medical management. J Crohns Colitis 11 (2017), 3–25.
Terdiman, JP, Gruss, CB, Heidelbaugh, JJ, Sultan, S, Falck-Ytter, YT, American Gastroenterological Association Institute guideline on the use of thiopurines, methotrexate, and anti-TNF-α biologic drugs for the induction and maintenance of remission in inflammatory Crohn's disease. Gastroenterology 145 (2013), 1459–1463.
Peyrin-Biroulet, L, Deltenre, P, de Suray, N, Branche, J, Sandborn, WJ, Colombel, JF, Efficacy and safety of tumor necrosis factor antagonists in Crohn's disease: meta-analysis of placebo-controlled trials. Clin Gastroenterol Hepatol 6 (2008), 644–653.
Gordon, JP, McEwan, PC, Maguire, A, Sugrue, DM, Puelles, J, Characterizing unmet medical need and the potential role of new biologic treatment options in patients with ulcerative colitis and Crohn's disease: a systematic review and clinician surveys. Eur J Gastroenterol Hepatol 27 (2015), 804–812.
Lichtenstein, GR, Abreu, MT, Cohen, R, Tremaine, W, American Gastroenterological Association Institute medical position statement on corticosteroids, immunomodulators, and infliximab in inflammatory bowel disease. Gastroenterology 130 (2006), 935–939.
Duerr, RH, Taylor, KD, Brant, SR, et al. A genome-wide association study identifies IL23R as an inflammatory bowel disease gene. Science 314 (2006), 1461–1463.
Geremia, A, Arancibia-Carcamo, CV, Fleming, MP, et al. IL-23-responsive innate lymphoid cells are increased in inflammatory bowel disease. J Exp Med 208 (2011), 1127–1133.
Uhlig, HH, McKenzie, BS, Hue, S, et al. Differential activity of IL-12 and IL-23 in mucosal and systemic innate immune pathology. Immunity 25 (2006), 309–318.
Kullberg, MC, Jankovic, D, Feng, CG, et al. IL-23 plays a key role in Helicobacter hepaticus-induced T cell-dependent colitis. J Exp Med 203 (2006), 2485–2494.
Gaffen, SL, Jain, R, Garg, AV, Cua, DJ, The IL-23–IL-17 immune axis: from mechanisms to therapeutic testing. Nat Rev Immunol 14 (2014), 585–600.
Neurath, MF, IL-23: a master regulator in Crohn disease. Nat Med 13 (2007), 26–28.
Campa, M, Mansouri, B, Warren, R, Menter, A, A review of biologic therapies targeting IL-23 and IL-17 for use in moderate-to-severe plaque psoriasis. Dermatol Ther (Heidelb) 6 (2016), 1–12.
Gaspari, AA, Tyring, S, New and emerging biologic therapies for moderate-to-severe plaque psoriasis: mechanistic rationales and recent clinical data for IL-17 and IL-23 inhibitors. Dermatol Ther 28 (2015), 179–193.
Feagan, BG, Sandborn, WJ, Gasink, C, et al. Ustekinumab as induction and maintenance therapy for Crohn's disease. N Engl J Med 375 (2016), 1946–1960.
Sandborn, WJ, Gasink, C, Gao, LL, et al. Ustekinumab induction and maintenance therapy in refractory Crohn's disease. N Engl J Med 367 (2012), 1519–1528.
Baker, KF, Isaacs, JD, Novel therapies for immune-mediated inflammatory diseases: what can we learn from their use in rheumatoid arthritis, spondyloarthritis, systemic lupus erythematosus, psoriasis, Crohn's disease and ulcerative colitis?. Ann Rheum Dis 77 (2018), 175–187.
Hueber, W, Sands, BE, Lewitzky, S, et al. Secukinumab, a human anti-IL-17A monoclonal antibody, for moderate to severe Crohn's disease: unexpected results of a randomised, double-blind placebo-controlled trial. Gut 61 (2012), 1693–1700.
Targan, SR, Feagan, B, Vermeire, S, et al. A randomized, double-blind, placebo-controlled phase 2 study of brodalumab in patients with moderate-to-severe Crohn's disease. Am J Gastroenterol 111 (2016), 1599–1607.
Singh, S, Kroe-Barrett, RR, Canada, KA, et al. Selective targeting of the IL23 pathway: Generation and characterization of a novel high-affinity humanized anti-IL23A antibody. MAbs 7 (2015), 778–791.
Feagan, BG, Sandborn, WJ, D'Haens, G, et al. Induction therapy with the selective interleukin-23 inhibitor risankizumab in patients with moderate-to-severe Crohn's disease: a randomised, double-blind, placebo-controlled phase 2 study. Lancet 389 (2017), 1699–1709.
Sands, BE, Feagan, BG, Rutgeerts, P, et al. Effects of vedolizumab induction therapy for patients with Crohn's disease in whom tumor necrosis factor antagonist treatment failed. Gastroenterology 147 (2014), 618–627.
Levesque, BG, Sandborn, WJ, Ruel, J, Feagan, BG, Sands, BE, Colombel, JF, Converging goals of treatment of inflammatory bowel disease from clinical trials and practice. Gastroenterology 148 (2015), 37–51.
Krueger, JG, Ferris, LK, Menter, A, et al. Anti-IL-23A mAb BI 655066 for treatment of moderate-to-severe psoriasis: safety, efficacy, pharmacokinetics, and biomarker results of a single-rising-dose, randomized, double-blind, placebo-controlled trial. J Allergy Clin Immunol 136 (2015), 116–124.
Vuitton, L, Marteau, P, Sandborn, WJ, et al. IOIBD technical review on endoscopic indices for Crohn's disease clinical trials. Gut 65 (2016), 1447–1455.
Novak, G, Parker, CE, Pai, RK, et al. Histologic scoring indices for evaluation of disease activity in Crohn's disease. Cochrane Database Syst Rev, 7, 2017 CD012351.