Intercept Pharma (ICPT) Announces NEJM Published Results of Phase 3 POISE Trial of Ocaliva for PBC
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Intercept Pharmaceuticals, Inc. (Nasdaq: ICPT) announced that the New England Journal of Medicine published the key results of the Phase 3 POISE trial of Ocaliva (obeticholic acid) for the treatment of patients with primary biliary cholangitis, formerly known as primary biliary cirrhosis (PBC). On a background of standard of care or given as monotherapy, Ocaliva met the primary endpoint of the POISE trial and improved multiple biochemical disease markers as compared to placebo with high statistical significance.
The POISE trial evaluated the safety and efficacy of once-daily treatment with Ocaliva in PBC patients with an inadequate therapeutic response to, or who are unable to tolerate, ursodeoxycholic acid (UDCA). The trial's primary endpoint was a reduction in alkaline phosphatase (ALP) to below a threshold of 1.67 times the upper limit of the normal range, with a reduction of at least 15% from baseline, and a total bilirubin level at or below the upper limit of the normal range after 12 months of Ocaliva therapy. These liver biomarkers have been shown to be reasonably likely to predict progression to liver failure and resulting liver transplant or premature death in patients with PBC. Ocaliva 5-10 mg (46%) and Ocaliva 10 mg (47%) were both statistically superior to placebo (10%) in achieving the primary endpoint (p<0.001). Most Ocaliva-treated patients had liver biochemical improvements even if they did not achieve the composite primary endpoint, with a significantly higher percent of patients achieving ≥15% ALP reduction with Ocaliva 5-10 mg and Ocaliva 10 mg (both groups 77%) compared to placebo (29%) (p<0.001). The majority of patients (93%) continued receiving UDCA therapy during the trial.
"The POISE data support Ocaliva as an important new treatment option for the substantial group of PBC patients who have an inadequate response to, or cannot tolerate, UDCA and therefore remain at risk of adverse outcomes," said Frederik Nevens, M.D., Ph.D., University Hospitals Leuven & KU Leuven, Belgium, and the lead author of the paper. “For nearly 20 years, we only had one option to help our PBC patients. The introduction of Ocaliva provides physicians and patients with an opportunity to rethink treatment goals and take action when ALP and/or bilirubin remain elevated despite UDCA therapy.”
On May 27, 2016, the U.S. Food and Drug Administration (FDA) granted accelerated approval to Ocaliva for the treatment of PBC in combination with UDCA in adults with an inadequate response to UDCA, or as monotherapy in adults unable to tolerate UDCA. An improvement in survival or disease-related symptoms has not been established.
In addition to the primary composite endpoint, the POISE study evaluated the effect of Ocaliva on biochemical disease markers of PBC using descriptive statistics with nominal p-values. ALP improved in both Ocaliva groups versus placebo at all visits (p<0.001), with reductions from baseline of -113±14 U/L in the Ocaliva 5-10 mg group and -130±15 U/L in the Ocaliva 10 mg group, compared to -14±15 U/L for placebo at 12 months. Reductions were observed as early as two weeks and were maintained at each time point thereafter. There was additional benefit observed in patients who titrated from 5 mg to 10 mg, compared to those who remained on a 5 mg dose.
An exploratory secondary analysis showed that patients treated with placebo experienced total bilirubin increases over the 12-month study period, while Ocaliva-treated patients experienced decreases in total bilirubin. While the changes in total bilirubin were within the normal range, the difference between groups was statistically significant (p<0.001).
Additional exploratory secondary analyses indicated that other liver enzymes (gamma-glutamyl transferase, alanine transaminase, aspartate transaminase and conjugated bilirubin) all improved from baseline in both Ocaliva groups (p<0.001 for all end of study evaluations compared with placebo).
Safety and Tolerability
Pruritus (itch) is the most common symptom in patients with PBC and was also the most common adverse event in the trial, with a higher incidence reported in the Ocaliva 5-10 mg (56%) and Ocaliva 10 mg (68%) groups, compared to placebo (38%). The implementation of the Ocaliva 5-10 mg titration strategy decreased the incidence of pruritus and was associated with a lower discontinuation rate due to pruritus (one patient, 1%) compared with starting at a higher dose of 10 mg (seven patients, 10%). Additional side effects observed during the trial included fatigue, abdominal pain and discomfort, rash, oropharyngeal pain, dizziness, constipation, arthralgia, thyroid function abnormality, and eczema.
High density lipoprotein cholesterol, which was elevated at baseline (consistent with PBC-associated hyperlipidemia), decreased within two weeks in Ocaliva-treated patients, but stabilized and remained within the normal range after 12 months.
In an exploratory assessment, the rates of bone fracture were similar among the trial groups, but dual energy X-ray absorption indicated a smaller decrease in femoral bone mineral density T-score in both Ocaliva groups versus placebo (p<0.05).
The majority (97%) of the patients who completed the double-blind phase of the POISE trial entered an open-label extension (which will continue for five years). Patients who had received Ocaliva in the double-blind phase experienced sustained improvements in ALP and bilirubin, demonstrating a durable response through two years of treatment. Placebo patients initiating treatment with Ocaliva in the open-label extension demonstrated similar improvements in ALP and bilirubin to the Ocaliva-treated patients in the double-blind phase, including reversal of previous increases in total bilirubin to levels comparable to baseline.
The severity and incidence of pruritus were reduced in the open-label extension compared to the double-blind phase in patients originally randomized to Ocaliva. Other adverse events during the open-label extension were observed at comparable rates to the double-blind phase and no new safety findings were observed.
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