Protein Kinase C Inhibitor Sotrastaurin in De Novo Liver Transplant Recipients: A Randomized Phase II Trial

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1 American Journal of Transplantation 2015; 15: Wiley Periodicals Inc. C copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons doi: /ajt Protein Kinase C Inhibitor Sotrastaurin in De Novo Liver Transplant Recipients: A Randomized Phase II Trial A. Pascher 1, *, P. Simone De 2, J. Pratschke 3, E. Salamé 4,J.Pirenne 5, H. Isoneimi 6,M.Bijarnia 7, I. Krishnan 8 and J. Klupp 8 1 Charité - Universitaetsmedizin Berlin, Berlin, Germany 2 Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy 3 Medical University of Innsbruck, Innsbruck, Austria 4 CHU Tours, Hôpital Trousseau, Tours, France 5 Gasthuisber University Hospital, Leuven, Belgium 6 Helsinki University Hospital, Helsinki, Finland 7 Novartis Healthcare Pvt. Ltd., Hyderabad, India 8 Novartis Pharma AG, Basel, Switzerland Corresponding author: Andreas Pascher, andreas.pascher@charite.de C virus; HIV, human immunodeficiency virus; IVRS, interactive voice response system; IWRS, interactive web response system; MDRD, Modification of Diet in Renal Disease; MELD, Model for End-stage Liver Disease; MMF, mycophenolate mofetil; MPA, mycophenolic acid; NODM, new-onset diabetes mellitus; PKC, protein kinase C; SAE, serious adverse events; SGOT, serum glutamic oxaloacetic transaminase; SGPT, serum glutamic-pyruvic transaminase; STN, sotrastaurin; TAC, tacrolimus; ULN, upper limit of normal Received 16 July 2014, revised 30 October 2014 and accepted for publication 16 November 2014 Efficacy and safety of protein kinase C inhibitor sotrastaurin (STN) with tacrolimus (TAC) was assessed in a 24-month, multicenter, phase II study in de novo liver transplant recipients. A total of 204 patients were randomized (1:1:1:1) to STN 200 mg b.i.d. þ standardexposure TAC (n ¼ 50) or reduced-exposure TAC (n ¼ 52), STN 300 mg b.i.d. þ reduced-exposure TAC (n ¼ 50), or mycophenolate mofetil (MMF) 1 g b.i.- d. þ standard-exposure TAC (control, n ¼ 52); all with steroids. Owing to premature study termination, treatment comparisons were only conducted for Month 6. At Month 6, composite efficacy failure rates (treated biopsy-proven acute rejection episodes of Banff grade 1, graft loss, or death) were 25.0%, 16.5%, 20.9% and 15.9% for STN 200 mg þ standard TAC, STN 200 mg þ reduced TAC, STN 300 mg þ reduced TAC and control groups, respectively. Median estimated glomerular filtration rates were 84.0, 83.3, 81.1 and 75.3 ml/min/1.73 m 2, respectively. Gastrointestinal events (constipation, diarrhea, and nausea), infection, and tachycardia were more frequent in STN groups. More patients in STN groups experienced serious adverse events compared with the control group ( % vs. 51.9%). STN-based regimens were associated with a higher efficacy failure rate and higher incidence of adverse events with no significant difference in renal function between the groups. Abbreviations: AE, adverse events; BPAR, biopsyproven acute rejection; CI, confidence interval; CMV, cytomegalovirus; CNI, calcineurin inhibitor; CS, corticosteroids; ECG, electrocardiogram; egfr, estimated glomerular filtration rate; HbsAg, hepatitis B surface antigen; HCC, hepatocellular carcinoma; HCV, hepatitis Introduction Introduction of calcineurin inhibitors (CNIs) has enabled the success of liver transplantation over the past few decades. However, nephrotoxicity associated with CNIs (1 3) limits their long-term use. Availability of sufficiently efficacious non-nephrotoxic immunosuppressants is a current unmet need in liver transplantation especially due to increased incidence of pre- and post-transplantation renal impairment in the Model for End-stage Liver Disease (MELD) era (4). Therefore, identifying immunosuppressive drugs/regimens that minimize renal dysfunction remains one of the key areas of research in liver transplantation. The protein kinase C (PKC) family of isozymes play an important role in allograft rejection by T cell activation mediated via the transcription factor nuclear factor-kappa B. Sotrastaurin (STN), a novel PKC-inhibitor, exerts its immunosuppressive activity by blocking early T cell activation (5). STN has a distinct mechanism of action and side-effect profile than CNIs as it acts on a calcineurin-independent pathway. STN has been evaluated in two phase II clinical trials in renal transplant recipients without proving non-inferiority to the current standard immunosuppressive regimens. In the A2214 study, Russ et al (6) compared varying doses of STN (100 mg, 200 mg and 300 mg b.i.d.) in combination with standard- or reducedexposure tacrolimus (TAC) versus a control regimen of enteric-coated mycophenolic acid (MPA) plus standard TAC in de novo renal transplant recipients. STN in 100 and 200 mg dosing showed comparable antirejection efficacy 1283

2 Pascher et al with no significant benefit in renal function versus MPA. The A2206 study compared the efficacy and safety of STN with cyclosporine in a CNI-free regimen with all patients receiving basiliximab induction, everolimus and prednisone. STN was associated with higher efficacy failure rate and higher treatment discontinuation rate with some improvement in renal function compared with cyclosporine (7). In liver transplantation, clinical and pharmacokinetic data showed that a single-dose of STN in de novo liver transplant recipients was well absorbed and well tolerated during the first week post transplantation (8). This phase II trial was undertaken to evaluate the efficacy and safety of STNbased regimens and to assess if STN-based i can minimize renal impairment versus a mycophenolate mofetil (MMF)/ TAC-based control regimen in de novo liver transplant recipients. After a sufficient benefit-risk balance over standard-of-care could not be established in kidney transplantation, the decision was taken to stop enrollment into this study prematurely and to convert all patients to standard-of-care. The authors feel obliged to report these limited results in order to enable a proper evaluation of the PKC inhibitor class. Material and Methods Study design and conduct This was a 24-month randomized, multicenter, partially-blinded, 4-arm study (ClinicalTrials.gov: NCT ) conducted at 36 centers in 12 countries from April 2010 to July All study participants provided written informed consent. The study protocol was approved by the institutional review board of each institution and the study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Trial design, data acquisition, data analysis and data presentation were performed according to the CONSORT guidelines (www. consort-statement.org). OnMarch 27, 2012 thesponsorinformed allparticipating investigators about the termination of the development of STN in transplantation. This decision was based on insufficient benefit of STN in the kidney studies over standard of care. Following this decision, all patients and ethics committees in this study were informed and all the patients were converted to standard immunosuppressive care within 12 weeks from notification. Patients Adult recipients (aged 18 years) of a primary orthotopic liver transplant from a deceased donor were eligible for inclusion. The key exclusion criteria included a history of prior transplantation, multiple organ transplant, human immunodeficiency virus (HIV)-positive recipient, HCV-positive recipient, HCC exceeding Milan criteria, ABO incompatible allograft, MELD score >35 within 1 month prior to transplantation, serum creatinine 3.0 mg/dl (265 mmol/l) or on renal replacement therapy for >1 week, and acute liver failure. Patients at a high risk of cardiac diseases (e.g. QTc >470 msec [females] and >450 msec [males], long QT-syndrome, left branch bundle block, hospitalization for heart failure or left-ventricular dysfunction, persistent arrhythmias and symptomatic coronary artery disease) were also excluded. Donor-related exclusion criteria included age <12 years, living donor liver transplantation, cardiac death/non-heart beating, HIV-positive and hepatitis B surface antigen (HbsAg)-positive, cold ischemic time >15 h and macrosteatosis >50%. Intervention and concomitant medication The randomization list was generated by the interactive voice/web response system (IVRS/IWRS) provider using a validated system that automated the random assignment of patient numbers to randomization numbers. Treatment allocation was done via the IVRS. Randomization was stratified by renal function (serum creatinine <1.7 mg/dl or 1.7 mg/dl) and recipient hepatitis C virus (HCV) status (positive or negative). Eligible patients were randomized (1:1:1:1) within 24 h after reperfusion of the allograft to one of the following four treatment arms: STN 200 mg/standard TAC: STN 200 mg b.i.d. þ standard-exposure TAC þ corticosteroids (CS) STN 200 mg/reduced TAC: STN 200 mg b.i.d. þ reduced-exposure TAC þ CS STN 300 mg/reduced TAC: STN 300 mg b.i.d. þ reduced-exposure TAC þ CS MMF/standard TAC: MMF 1 g b.i.d. þ standard-exposure TAC þ CS (control group) STN 300 mg/reduced TAC arm was planned to be a CNI-free regimen with TAC withdrawal at Month 6. However, in November 2011, when approximately 60 patients had reached Month 6, an independent Data Monitoring Committee recommended to reintroduce TAC due to increased rate of acute rejections seen following withdrawal of TAC. STN doses were blinded in STN 200 mg/reduced TAC and STN 300 mg/reduced TAC treatment groups through Month 6 visit. The first dose of the study medication was administered immediately after randomization, but within 24 h after reperfusion. In patients with renal dysfunction, TAC administration was delayed by 48 h. In the two reduced TAC groups, TAC dose was adjusted to achieve a trough concentration of 2 5 ng/ml. In the control group and STN 200 mg/standard TAC group, target TAC concentration was in the range of 5 10 ng/ml. All patients received corticosteroids (Figure 1). The expected trough levels for STN were between 50 ng/ml and 3000 ng/ml. A broad range was used in order to explore the full potential range of STN exposure in liver transplant recipients. STN blood levels were analyzed by a central laboratory but not reported to the sites except as an alert for patients who were outside of the expected range. Study endpoints Study visits took place on Days 1, 2, 3, 4, 8, 15, 22, 30, and monthly thereafter until Month 12; then visits were performed every three months until Month 24. The primary efficacy end point was the incidence of efficacy failure (defined as a composite efficacy end point of treated biopsy-proven acute rejections [BPAR] episodes of Banff grade 1, graft loss, or death) for each STN arm relative to the control arm at Month 6 post-transplantation. All suspected cases of rejections were assessed by a graft core biopsy. Acute rejection was treated with adjustment of TAC, as per center practice. Based on the premature termination of the study the main safety endpoint renal function at Month 12 assessed by estimated glomerular filtration rate (egfr) using the Modification of Diet in Renal Disease (MDRD) formula was assessed at Month 6 only. Key secondary end points were planned to be analyzed at Month 3, 6, 9, 12 and 24 and included the incidence of components of the primary efficacy end point the incidence of a composite of secondary efficacy failures (defined as treated BPAR episodes of Banff grade 1 that were steroid-resistant, acute rejections requiring T cell depleting treatment, graft loss, or death) for each STN arm relative to the control arm. Owing to premature study termination, treatment comparisons were only conducted at Month 6 including all analyses originally planned for Month 6, Month 12 and Month 24. Safety was assessed on the basis of the occurrence of any adverse events (AEs) and serious AEs (SAEs), incidence of new onset diabetes, infections and malignancy, findings on physical 1284 American Journal of Transplantation 2015; 15:

3 Sotrastaurin in Liver Transplantation STN 200 mg b.i.d + standard TAC (C ng/ml) + steroids STN 200 mg b.i.d + reduced TAC (C0 2-5 ng/ml) + steroids Transplant surgery 24 hours STN 300 mg b.i.d + reduced TAC (C0 2-5 ng/ml) + steroids MMF 1 g b.i.d + standard TAC (C ng/ml) + steroids RND Month 6 Month 12 Month 24 Partially blinded* Primary analysis Open label Figure 1: Study design. *STN was provided as blinded supplies for STN 200 mg/reduced TAC and STN 300 mg/reduced TAC arms. b.i.d., twice daily; C0, trough level; MMF, mycophenolate mofetil; RND, randomization; STN, sotrastaurin; TAC, tacrolimus. examination and laboratory evaluations during the study. Any type of malignancy (including skin neoplasms) was entered as an SAE on the AE electronic case report form. Statistical analysis Non-inferiority of each STN arm to the control arm was tested with respect to composite efficacy failure at Month 6 using a non-inferiority margin of 10%. However, the study was not formally designed as a noninferiority study as the primary focus was to provide an estimation to inform the design of future studies. A sample size of 60 patients per arm (total 240 patients) was calculated to provide 73% power at the one-sided a ¼ to demonstrate that an STN-based regimen was not more than 10% worse than the control regimen. The primary efficacy failure rates were estimated using the Kaplan Meier (K-M) product-limit formula. Greenwood s formula was used to estimate the variance of the estimated failure rates and to derive the two-sided 95% normal distribution approximation based confidence intervals (CI) for the difference in failure rates between each STN arm and the control arm at Month 6. Descriptive statistics were presented for on-treatment renal safety parameters (egfr and serum creatinine) by visit. The difference between STN arms and the control arm in egfr at Month 6 (raw values) was evaluated using the Wilcoxon Mann Whitney test. Efficacy analyses were based on full analysis set, comprising all randomized patients. Safety analyses including renal function were based on the safety population, which included all randomized patients who received at least one dose of the study medication. Results Patient population A total of 204 patients were randomized (STN 200 mg/ standard TAC, n ¼ 50; STN 200 mg/reduced TAC, n ¼ 52; STN 300 mg/reduced TAC, n ¼ 50; MMF/standard TAC, n ¼ 52). One patient in each group was discontinued immediately after American Journal of Transplantation 2015; 15: randomization due to misrandomization; therefore, the full analysis set comprised 200 patients. One patient from the STN 200 mg/standard TAC group never received STN and was therefore analyzed under the MMF/standard TAC group. Two patients from the STN 300 mg/reduced TAC group did not take more 200 mg per day and were therefore analyzed in the STN 200 mg/reduced TAC group. Two patients, both from the STN 300 mg/reduced TAC group, were excluded from all safety analyses because they did not receive any study medication. Thus, the safety population comprised 198 patients (STN 200 mg/standard TAC, n ¼ 48; STN 200 mg/reduced TAC, n ¼ 53; STN 300 mg/reduced TAC, n ¼ 45; MMF/standard TAC, n ¼ 52). The proportions of patients that completed 6 months were: 63.3% in the STN 200 mg/standard TAC group, 74.5% each in the STN 200 mg/ reduced TAC group and the MMF/standard TAC group, and 71.4% in the STN 300 mg/reduced TAC group. Before study termination, a higher proportion of patients in the STN 200 mg/standard TAC (53.1%) and the STN 300 mg/reduced TAC groups (46.9%) discontinued the study medication compared with the other two groups (Figure 2). Baseline characteristics were well-balanced amongst the treatment groups except for relatively more males in the STN groups compared with the control group (Table 1). Immunosuppression In the STN arms, the majority of patients were within the expected trough levels for STN ( ng/ml) until Month 15. Across the time windows, % of patients in the STN 200 mg/standard TAC group and % of patients in the two STN/reduced TAC groups were within the expected trough levels. In terms of the TAC levels, there was a trend towards more patients with TAC trough levels above the target range in the two STN/reduced TAC groups than 1285

4 Pascher et al Figure 2: Patient disposition. *One patient in each group was discontinued immediately after randomization due to misrandomization. **Patients who discontinued study medication or study before study termination. MMF, mycophenolate mofetil; STN, sotrastaurin; TAC, tacrolimus. the two standard TAC groups until Month 12. Across the time windows, % of patients in the STN 200 mg/ reduced TAC group and % of patients in the STN 300 mg/reduced TAC group had TAC trough levels above the target range. Whereas,8 50% of patients in the STN 200 mg/standard TAC group, and % of the patients in the MMF/standard TAC group had TAC trough levels above the target range. Efficacy An early increase in the composite efficacy failure events was observed for two of the three STN arms. The STN 200 mg/reduced TAC group maintained efficacy closer to the MMF/standard TAC group (Figure 3). At Month 6, the primary endpoint of composite efficacy failure (treated BPAR episodes of Banff grade 1, graft loss, or death) occurred in 12/49 patients in the STN 200 mg/standard TAC arm, 8/51 in the STN 200 mg/reduced TAC group, 10/49 in the STN 300 mg/reduced TAC group and 8/51 in the MMF/ standard TAC group. The respective KM failure rates were 25.0%, 16.5%, 20.9% and 15.9%. The STN treatment groups could not be shown to be non-inferior to the MMF/ standard TAC group (Table 2). This result was largely driven by a higher incidence of death in the STN 300 mg/reduced TAC and STN 200 mg/standard TAC groups. Particularly the STN 300 mg/reduced TAC and STN 200 mg/standard TAC groups also had higher rates of the composite secondary efficacy failure (treated BPAR episodes of Banff grade 1 that were steroid-resistant, acute rejection requiring T cell depleting treatment, graft loss, or death) as well as of the composite of graft loss or death than the MMF/standard TAC group. The event rates of the STN 200 mg/reduced TAC group were more in line with the rates seen in the control group with the lowest incidence of treated BPAR events and graft loss of all groups. However, the incidence of death (6.7% vs. 2.0%) and composite secondary efficacy failure (12.7% vs. 5.9%) was higher in the STN 200 mg/reduced TAC group compared to the MMF/standard TAC group. Renal function Median egfr (MDRD) at Month 6 was numerically higher in all STN treatment groups compared with the MMF/ standard TAC group, with the difference according to Hodges Lehmann estimates being highest in the STN 200 mg/reduced TAC group (Table 2). Median egfr was higher in the STN treatment groups than the MMF/standard TAC group at all time-points from Months 1 6; although, this difference was small compared with the variation, and the magnitude of the effect declined over time (Figure 4). Hepatic function and hepatotoxicity Hepatotoxicity, as an AE, was reported in one patient in the STN 200 mg/standard TAC group and hyperbilirubinemia was reported in one patient in the MMF/standard TAC group. Hepatic failure was reported in two patients in the STN groups 1286 American Journal of Transplantation 2015; 15:

5 Sotrastaurin in Liver Transplantation Table 1: Recipient demographics and baseline clinical characteristics (full analysis set) STN 200 mg/standard TAC N ¼ 49 STN 200 mg/reduced TAC N ¼ 51 STN 300 mg/reduced TAC N ¼ 49 MMF/standard TAC N ¼ 51 Age (years), mean (SD) 56.4 (8.44) 53.8 (11.34) 55.1 (8.86) 53.3 (10.20) Male gender, n (%) 37 (75.5) 39 (76.5) 33 (67.3) 27 (52.9) Ethnicity, n (%) Caucasian 45 (91.8) 45 (88.2) 48 (98.0) 45 (88.2) Black African 0 (0.0) 1 (2.0) 0 (0.0) 0 (0.0) Asian 2 (4.1) 1 (2.0) 0 (0.0) 1 (2.0) Others 2 (4.1) 4 (7.8) 1 (2.0) 5 (9.8) Weight (kg) 79.3 (16.01) 80.6 (15.63) 82.2 (21.48) 74.4 (14.23) HCV positive, n (%) 0 (0.0) 2 (3.9) 1 (2.0) 2 (3.9) CMV positive, n (%) 28 (57.1) 28 (54.9) 34 (69.4) 35 (68.6) EBV positive, n (%) 39 (79.6) 42 (82.4) 41 (83.7) 41 (80.4) egfr (MDRD) (ml/min/1.73(2)) (47.86) (38.10) (38.08) (36.92) End-stage disease leading to transplantation, n (%) Primary biliary cirrhosis 0 (0.0) 1 (2.0) 4 (8.2) 5 (9.8) Sclerosing cholangitis 7 (14.3) 3 (5.9) 2 (4.1) 3 (5.9) Biliary atresia 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) Metabolic disease 0 (0.0) 0 (0.0) 2 (4.1) 1 (2.0) Hepatitis B 5 (10.2) 4 (7.8) 1 (2.0) 1 (2.0) Hepatitis C 0 (0.0) 1 (2.0) 1 (2.0) 0 (0.0) Alcoholic cirrhosis 21 (42.9) 16 (31.4) 20 (40.8) 18 (35.3) Cryptogenic cirrhosis 0 (0.0) 1 (2.0) 3 (6.1) 2 (3.9) Hepatocellular carcinoma 11 (22.4) 14 (27.5) 9 (18.4) 8 (15.7) Others 5 (10.2) 11 (21.6) 7 (14.3) 13 (25.5) MELD score, mean (SD) 15.9 (6.77) 16.6 (5.72) 16.0 (6.11) 15.7 (6.86) Donor age (years) 60.8 (16.21) 52.8 (18.61) 53.5 (17.34) 57.6 (15.01) Cold ischemia time (h) 7.4 (2.87) 7.4 (2.76) 7.6 (3.05) 7.6 (2.18) CMV, cytomegalovirus; EBV, Epstein-Barr Virus; egfr, estimated glomerular filtration rate; HCV, hepatitis C virus; MDRD, Modification of Diet in Renal Disease; MELD, model for end-stage liver disease; SD, standard deviation. 0.5 STN 200 mg/standard TAC STN 200 mg/reduced TAC STN 300 mg/reduced TAC MMF/standard TAC 0.4 Proportion of patients with event Figure 3: Kaplan Meier plot of time to primary composite efficacy failure of treated BPAR episodes of Banff grade 1, graft loss, or death (full analysis set). MMF, mycophenolate mofetil; STN, sotrastaurin; TAC, tacrolimus. 0.0 Bsl No. of patients at risk STN 200/ standard TAC STN 200/ reduced TAC STN 300/ reduced TAC MMF/ standard TAC Days since start of study medication American Journal of Transplantation 2015; 15:

6 Pascher et al Table 2: Primary efficacy end point, selected secondary end points, and renal function at Month 6 STN 200 mg/standard TAC N ¼ 49 STN 200 mg/reduced TAC N ¼ 51 STN 300 mg/reduced TAC N ¼ 49 MMF/standard TAC N ¼ 51 Primary efficacy endpoint 1 n Kaplan-Meier incidence rate at Month Difference (95% CI) vs. MMF/TAC standard 9.1 ( 6.8, 25.0) 0.6 ( 14.0, 15.2) 5.0 ( 10.3, 20.3) p-value vs. MMF/TAC standard Non-inferiority shown 2 No No No Secondary efficacy endpoints, n (%) 3 Treated BPAR (Banff 1) 5 (10.5) 4 (8.0) 5 (11.3) 6 (12.1) Graft loss 4 3 (6.5) 1 (2.0) 3 (6.2) 2 (3.9) Death 7 (15.2) 3 (6.7) 5 (10.7) 1 (2.0) Graft loss or death 8 (16.7) 4 (8.6) 7 (14.7) 2 (3.9) Composite secondary efficacy failure 5 9 (18.8) 6 (12.7) 8 (16.8) 3 (5.9) BPAR 6 (12.2) 7 (13.7) 10 (20.4) 7 (13.7) Steroid-resistant BPAR 1 (2.0) 1 (2.0) 2 (4.1) 1 (2.0) BPAR that requires T cell depleting treatment 1 (2.0) 2 (3.9) 1 (2.0) 1 (2.0) Renal function 6 N ¼ 48 N ¼ 53 N ¼ 45 N ¼ 52 Median egfr (MDRD, ml/min/1.73 m 2 ) Difference (95% CI) 7 vs. MMF/TAC standard 4.6 ( 8.3, 17.0) 7.1 ( 6.1, 19.2) 3.8 ( 9.0, 16.3) p-value vs. MMF/TAC standard BPAR, biopsy proven acute rejection; egfr, estimated glomerular filtration rate; MDRD, Modification of Diet in Renal Disease. 1 Treated BPAR episodes of Banff grade 1, graft loss, or death. 2 Non-inferiority was shown if the upper limit of the 95% CI of difference to control was lower than 10%. 3 Kaplan Meier estimates. 4 Graft loss was defined as need for re-transplantation or death due to liver failure. 5 Treated BPAR episodes of Banff grade 1 that are steroid resistant, acute rejection that requires T cell depleting treatment, graft loss, or death. 6 Renal function was assessing using safety population. 7 Hodges Lehmann estimates STN 200 mg/ standard TAC STN 300 mg/ reduced TAC STN 200 mg/ reduced TAC MMF/standard TAC egfr (MDRD) (ml/min/1.73 m 2 ) Baseline Week 1 Month 1 Month 2 Month 3 Month 6 Visit window Figure 4: egfr (MDRD) at selected time points (safety population). Median values are connected over time. Whiskers extend to the 10th and 90th percentiles. egfr, estimated glomerular filtration rate; MDRD, Modification of Diet in Renal Disease; MMF, mycophenolate mofetil; STN, sotrastaurin; TAC, tacrolimus American Journal of Transplantation 2015; 15:

7 Sotrastaurin in Liver Transplantation (one patient each in STN 200 mg/standard TAC and STN 200 mg/reduced TAC groups) and two patients in the MMF/ standard TAC group. After the first month, a higher incidence of abnormal serum glutamic oxaloacetic transaminase (SGOT) or serum glutamic-pyruvic transaminase (SGPT) levels (>3 time upper limit of normal [ULN]) was observed in the STN 200 mg/reduced TAC (25%) and STN 300 mg/reduced TAC groups (15%) than in the standard groups (9.5% in STN 200 mg/standard TAC, 4.5% in MMF/standard TAC). Safety Nearly all patients experienced at least one AE during the study. Gastrointestinal disorders, metabolism and nutrition disorders and infections and infestations were the most commonly affected system organ class with a slightly higher incidence in the STN 300 mg/reduced TAC group than in other groups (Table 3). The incidence of SAEs was higher in the STN treatment groups (70.8% in STN 200 mg/ standard TAC group, 62.3% in STN 200 mg/reduced TAC Table 3: Adverse events and serious adverse events during the study (safety population) STN 200 mg/standard TAC N ¼ 48 STN 200 mg/reduced TAC N ¼ 53 STN 300 mg/reduced TAC N ¼ 45 MMF/standard TAC N ¼ 52 Any adverse event 47 (97.9) 51 (96.2) 45 (100.0) 51 (98.1) Any serious adverse event 34 (70.8) 33 (62.3) 31 (68.9) 27 (51.9) Any infection 32 (66.7) 30 (56.6) 33 (73.3) 33 (63.5) Any serious infection 18 (37.5) 10 (18.9) 11 (24.4) 8 (15.4) Adverse events leading to study drug discontinuation 21 (43.8) 12 (22.6) 13 (28.9) 12 (23.1) Most frequent adverse events (15% in any treatment group), n (%) Nausea 13 (27.1) 17 (32.1) 22 (48.9) 12 (23.1) Vomiting 15 (31.3) 14 (26.4) 19 (42.2) 13 (25.0) Anemia 12 (25.0) 13 (24.5) 17 (37.8) 11 (21.2) Diarrhea 9 (18.8) 20 (37.7) 16 (35.6) 11 (21.2) Constipation 16 (33.3) 15 (28.3) 15 (33.3) 11 (21.2) Insomnia 13 (27.1) 12 (22.6) 14 (31.1) 7 (13.5) Pleural effusion 12 (25.0) 13 (24.5) 13 (28.9) 10 (19.2) Abdominal pain 13 (27.1) 13 (24.5) 12 (26.7) 16 (30.8) Hypertension 11 (22.9) 19 (35.8) 12 (26.7) 16 (30.8) Back pain 6 (12.5) 9 (17.0) 10 (22.2) 8 (15.4) Cholestasis 9 (18.8) 10 (18.9) 9 (20.0) 10 (19.2) Cytomegalovirus infection 4 (8.3) 5 (9.4) 9 (20.0) 3 (5.8) Tremor 6 (12.5) 2 (3.8) 9 (20.0) 10 (19.2) Cholangitis 8 (16.7) 10 (18.9) 8 (17.8) 3 (5.8) Peripheral edema 10 (20.8) 9 (17.0) 8 (17.8) 6 (11.5) Renal impairment 8 (16.7) 4 (7.5) 8 (17.8) 3 (5.8) Renal failure 1 13 (27.1) 14 (26.4) 14 (31.1) 16 (30.8) Urinary tract infection 8 (16.7) 5 (9.4) 8 (17.8) 7 (13.5) Headache 10 (20.8) 7 (13.2) 7 (15.6) 8 (15.4) Hypokalemia 5 (10.4) 6 (11.3) 7 (15.6) 2 (3.8) Hypomagnesemia 8 (16.7) 7 (13.2) 7 (15.6) 4 (7.7) Wound complication 3 (6.3) 2 (3.8) 7 (15.6) 6 (11.5) Leukopenia 3 (6.3) 4 (7.5) 6 (13.3) 14 (26.9) Hypophosphatemia 4 (8.3) 8 (15.1) 5 (11.1) 3 (5.8) Procedural pain 8 (16.7) 13 (24.5) 5 (11.1) 4 (7.7) Pyrexia 13 (27.1) 12 (22.6) 5 (11.1) 16 (30.8) Hyperglycemia 7 (14.6) 11 (20.8) 4 (8.9) 7 (13.5) Pruritus 7 (14.6) 9 (17.0) 4 (8.9) 5 (9.6) Tachycardia 8 (16.7) 7 (13.2) 4 (8.9) 1 (1.9) Hyperkalemia 10 (20.8) 4 (7.5) 3 (6.7) 9 (17.3) Pneumonia 9 (18.8) 1 (1.9) 2 (4.4) 5 (9.6) Thrombocytopenia 8 (16.7) 2 (3.8) 2 (4.4) 9 (17.3) Other events of clinical interest, n (%) CMV syndrome 2 (4.2) 1 (1.9) 6 (13.3) 3 (5.8) CMV disease 1 (2.1) 1 (1.9) 3 (6.7) 1 (1.9) New-onset diabetes mellitus 2 13 (40.6) 17 (42.5) 13 (41.9) 16 (38.1) CMV, cytomegalovirus. Includes acute renal failure. 2 New-onset diabetes mellitus (NODM) was assumed if any of the criteria for NODM was fulfilled: two consecutive fasting plasma glucose (FPG) 7.0 mmol/l after Day 30; HbA1c >6.5% (only from Day 75 onward); AE related to diabetes mellitus prevalent after Day 30; concomitant medication related to DM prevalent after Day 30. American Journal of Transplantation 2015; 15:

8 Pascher et al group and 68.9% STN 300 mg/reduced TAC group) than in the MMF/standard TAC group (51.9%). Of the individual events, the incidence of leukopenia and thrombocytopenia was higher in the MMF/standard TAC group (26.9% and 17.3%) compared with the STN treatment groups (6.3% and 16.7% in the 200 mg/standard TAC group, 7.5% and 3.8% in the 200 mg/reduced TAC group and 13.3% and 4.4% in the 300 mg/reduced TAC group). Gastrointestinal events such as constipation, diarrhea and nausea were more frequent with STN treatment, and abdominal pain, hypertension and pyrexia were more common in the MMF/standard TAC group. The proportion of patients who developed new-onset diabetes mellitus (NODM) was similar between the treatment groups. Overall, 20 deaths were reported in the study (9 in STN 200 mg/standard TAC group, 3 in STN 200 mg/reduced TAC group, 5 in STN 300 mg/reduced TAC group and 3 in MMF/ standard TAC group), out of which 15 deaths were reported during the first 6 months (7 in STN 200 mg/standard TAC group, 3 in STN 200 mg/reduced TAC group, 4 in STN 300 mg/reduced TAC group and 1 in MMF/standard TAC group). Eleven deaths occurred within 30 days of discontinuation of the study medication and 9 deaths after 30 days of discontinuation of the study medication. The most common cause of death was sepsis/infection (4 in STN 200 mg/standard TAC group, 2 in STN 200 mg/reduced TAC group, 2 in STN 300 mg/reduced TAC group and 1 in MMF/ standard TAC group). The other causes were metastatic hepatic carcinoma in 3 patients (including two cases of recurrent hepatocellular carcinoma [HCC]); lung carcinoma leading to respiratory failure in 1 patient; and hepatopulmonary syndrome, sudden death, mesenteric infarction, cerebral hemorrhage and intestinal hemorrhage in 1 patient each. Primary non-functioning graft leading to liver failure was the cause of death in 2 cases; 1 each in STN 300 mg/ reduced TAC and MMF/standard TAC groups. Malignancies were reported in five STN 200 mg/standard TAC patients (2 cases of bile duct cancer, 2 cases of recurrent HCC and 1 case of malignant lung neoplasm); three STN 200 mg/reduced TAC patients (2 cases of recurrent malignant hepatic neoplasm and 1 case of basal cell carcinoma); and one patient each in STN 300 mg/ reduced TAC (unspecified malignancy) and MMF/standard TAC group (recurrent hepatic carcinoma). One patient in the STN 200 mg/reduced TAC group discontinued the study medication due to metastatic hepatic cancer, and one patient each in the STN 200 mg/standard TAC group and the MMF/standard TAC group discontinued the study medication due to malignant hepatic neoplasm. The overall incidence of infections was higher in the STN 300 mg/reduced TAC group (73.3%) compared with the other treatment groups (66.7% in STN 200 mg/standard TAC group, 56.6% in STN 200 mg/reduced TAC group and 63.5% in MMF/standard TAC group); however, serious infections were more frequent in the STN 200 mg/standard TAC group compared with the other groups. Cytomegalovirus (CMV) syndrome and CMV disease were reported in more patients in the STN 300 mg/reduced TAC group compared with the other groups. Tachycardia and sinus tachycardia was reported in more patients in the STN treatment groups than in the MMF/ standard TAC group. Five patients reported pulmonary embolism (three in the STN 200 mg/standard TAC group and one each in the STN 200 mg/reduced TAC group and STN 300 mg/reduced TAC group) and two patients reported deep vein thrombosis (one each in the STN 200 mg/ standard TAC group and STN 300 mg/reduced TAC group). No thromboembolic events were reported in the MMF/ standard TAC group. The STN groups showed a higher incidence of QT prolongation, heart rate increase and arrhythmia based on electrocardiogram (ECG) evaluations (70.8% in STN 200 mg/standard TAC group, 64.2% in STN 200 mg/reduced TAC group, 75.6% in STN 300 mg/reduced TAC group vs. 42.3% in MMF/standard TAC group). Discontinuation of the study drug due to AEs occurred more frequently in the STN 200 mg/standard TAC group (43.8%) compared with the other treatment groups (22.6% in STN 200 mg/reduced TAC group, 28.9% in STN 300 mg/reduced TAC group and 23.1% in MMF/standard TAC group). The most common AEs leading to discontinuation were sepsis (3 patients) in STN 200 mg/standard TAC group; vomiting (2 patients) in STN 200 mg/reduced TAC group; liver transplant rejection (2 patients) in STN 300 mg/reduced TAC group; and leukopenia (3 patients) in MMF/standard TAC group. Discussion This phase II study was conducted to evaluate if STN-based immunosuppression can provide renal function benefit over the current standard-of-care, in order to address the unmet need of renal dysfunction post-liver transplantation. Higher efficacy failure was observed in the STN treatment groups compared with the MMF/standard TAC group mainly due to higher incidence of deaths in the STN groups. Consequently, the STN-based regimens could not be proven non-inferior to the MMF/standard TAC group. Noteworthy, the incidence of composite efficacy failure in the STN 200 mg/reduced TAC group (16.5%) came close to the one observed in the MMF/ standard TAC group (15.9%). The time to composite endpoint failure analysis was different between the three STN arms, with fewer early events observed in the STN 200 mg/reduced TAC arm compared to other arms. Overall, no clear relationship between drug exposure level and efficacy was observed. This was evident from the highest efficacy failure rates in the STN 200 mg/standard TAC group. Graft loss occurred in 7 patients in the STN groups and two in the MMF/standard TAC group. In total, there were 20 deaths in the study, of which 17 were in the STN groups. All 1290 American Journal of Transplantation 2015; 15:

9 Sotrastaurin in Liver Transplantation cases of deaths were reviewed by an independent expert panel who concluded that the incidence and cause of death in the STN groups were consistent with expectations for the transplant population. However, the imbalance in deaths, although with no clear pattern, cannot be disregarded. At Month 6, a slight improvement in renal function was observed in the STN treatment groups compared with the MMF/standard TAC group, but this was not statistically significant. Notably, a substantial proportion of patients in the reduced TAC arms had TAC levels above the protocol specified range. This suggests that greater improvement in renal function might have been achieved if patients had maintained the protocol-specified target trough levels for TAC. We speculate that the investigators were hesitant in reducing the TAC exposure to the levels defined in the protocol in combination with a new drug. From Month 1 6, renal function was numerically better in the STN arms than in the MMF/standard TAC arm; however, the magnitude of effect reduced over time. Importantly, all the treatment arms had good renal function at baseline (median egfr ranging from 94.9 to ml/min/1.73 m 2 ). These results are consistent with findings of the A2214 study that used the same regimen in renal transplant recipients: also in A2214 study there was no significant renal function improvement (egfr measured by MDRD formula) for the STN groups at Month 6 and beyond. The STN 100 and 200 mg groups had lower egfr than the MPA control arm, whereas renal function was numerically better in the STN 300 mg group with reduced TAC (6). In the second renal transplant study A2206 that used a CNI-free regimen, improvement in renal function was seen in the STN arms (STN 200 mg/300 mg plus everolimus) versus the control arm (everolimus plus cyclosporine) at nearly all time points with significant differences between the groups at Month 6. However, the degree of improvement gradually declined over time and the trade-off was a higher efficacy failure rate (7). In the presented study in liver transplant recipients, no new safety signals were identified for the STN-based regimens. As previously observed, gastrointestinal disorders and infections were more frequent in patients receiving STN, with a relatively higher incidence in STN 300 mg/reduced TAC group. In addition, a numerically higher proportion of patients in the STN groups reported SAEs and serious infections. The STN 200 mg/standard TAC dosing was associated with markedly higher number of discontinuations due to AEs. Leukopenia, pyrexia and abdominal pain occurred more frequently in the patients receiving MMF/ standard TAC than the patients in STN groups. Compared with patients receiving MMF/standard TAC, rates of tachycardia and thromboembolic events were higher in the STN groups. Furthermore, central ECG evaluations revealed a higher incidence of QT prolongation, heart rate increase and arrhythmia in the STN groups. Among the three STN arms, the STN 200 mg/reduced TAC arm had overall fewer adverse events, serious adverse events, American Journal of Transplantation 2015; 15: study drug discontinuations and infections. Overall, the safety profile of STN observed in this study is consistent with the safety profile seen in the renal transplant study A2214 (6) with respect to higher incidence of overall AEs and SAEs; higher incidence of infections malignancies and gastrointestinal disorders; but also lower rates of myelotoxic adverse events compared to control. One of the main limitations of the study warranting caution in interpreting the results is its premature termination. The small number of patients followed beyond 6 months did not allow a meaningful comparison between the treatment groups over longer time. Nonetheless, results at 6 months showed that STN provides no clear benefit over the current standard-of-care in liver transplant recipients. The data from this prematurely terminated study of the protein kinase C (PKC) inhibitor STN did not allow to derive the optimal dose, type and timing of an immunosuppressant combination that would provide sufficient benefits over currently available treatments. The differences between the STN 200 mg and STN 300 mg groups and the comparability of the STN 200 mg/reduced TAC group with the MMF/standard TAC group in terms of primary composite efficacy failure and most secondary efficacy endpoints give place for speculations about possible approaches using even lower doses of STN in conjunction with an IL-2R-directed induction therapy and a delayed onset of TAC. However, the lack of a clear dose-response relationship and the higher incidence of death in all STN arms observed in the study do not allow defining a direction of future development for this molecule. Conclusion In conclusion, STN-based regimens showed higher efficacy failure rates with higher incidence of adverse events and a modest renal function benefit compared with MMF/TAC control in liver transplant recipients. STN showed no benefit over standard-of-care in renal transplant recipients (6,7), which lead to the decision of the sponsor to halt further development of STN in transplantation. This study was terminated prematurely following the decision. Analyzed data at 6 months did not indicate that STN would have provided an advantage over available regimens in liver transplantation; however, interpretation is limited by the shorter than planned study duration. Nevertheless, the findings of this study may provide suggestions for the development of other molecules of this class in transplantation. Acknowledgments The study was funded by Novartis Pharma AG, Basel Switzerland. We thank Heike Schwende, Ph.D, Novartis Pharma AG, Switzerland, for organizing the development of the manuscript and Seema Dimri, Novartis Healthcare Pvt. Ltd. India, for providing the medical writing assistance. 1291

10 Pascher et al Disclosure The authors of this manuscript have conflicts of interest to disclose as described by the American Journal of Transplantation. PDS is on the speaker s bureau of Novartis. ES is a member of scientific board and scientific expertise of Novartis and a member scientific board, scientific expertise and courses of Astellas. IK, MB and JK are employees of Novartis. All other authors have no conflicts of interest to disclose. References 1. Ojo AO,Held PJ, Port FK, et al. Chronic renal failure after transplantation of a nonrenal organ. N Engl J Med 2003; 349: Lebron Gallardo, Herrera M, Gutierrez ME, et al. Risk factors for renal dysfunction in the postoperative course of liver transplant. Liver Transpl 2004; 11: Pawarode A, Fine DM, Thuluwath PJ. Independent risk factors and natural history of renal dysfunction in liver transplant recipients. Liver Transpl 2003; 9: Sharma P, Welch K, Eikstadt R, Marrero JA, Fontana RJ, Lok AS. Renal outcomes after liver transplantation in the model for endstage liver disease era. Liver Transpl 2009; 15: Evenou JP, Wagner J, Zenke G, Brinkmann V, Wagner K, Kovarik J, et al. The potent protein kinase C-selective inhibitor AEB071 (sotrastaurin) represents a new class of immunosuppressive agents affecting early T-cell activation. J Pharmacol Exp Ther 2009; 330: Russ GR, Tedesco-Silva H, Kuypers DR, et al. Efficacy of sotrastaurin plus tacrolimus after de novo kidney transplantation: Randomized, phase II trial results. Am J Transplant 2013; 13: Tedesco-Silva H, Kho MM, Hartmann A, et al. Sotrastaurin in calcineurin inhibitor-free regimen using everolimus in de novo kidney transplant recipients. Am J Transplant 2013; 13: Kovarik JM, Neuhaus P, Cillo U, et al. Sotrastaurin single-dose pharmacokinetics in de novo liver transplant recipients. Transpl Int 2011; 24: American Journal of Transplantation 2015; 15: