Supplementary appendix

Transcription

1 Supplementary appendix This appendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors. Supplement to: Raal FJ, Stein EA, Dufour R, et al, for the RUTHERFORD-2 Investigators. PCSK9 inhibition with evolocumab (AMG 145) in heterozygous familial hypercholesterolaemia (RUTHERFORD-2): a randomised, double-blind, placebocontrolled trial. Lancet 2014; published online Oct 2.

2 Evolocumab in HeFH Patients 1 PCSK9 inhibition with evolocumab (AMG 145) in heterozygous familial hypercholesterolaemia (RUTHERFORD-2): a randomised, double-blind, placebocontrolled trial Frederick Raal, Evan A. Stein, Robert Dufour, Traci Turner, Fernando Civeira, Lesley Burgess, Gisle Langslet, Russell Scott, Anders G. Olsson, David Sullivan, G. Kees Hovingh, Bertrand Cariou, Ioanna Gouni-Berthold, Ransi Somaratne, Ian Bridges, Rob Scott, Scott M. Wasserman, and Daniel Gaudet for the RUTHERFORD-2 Investigators Contents Study Investigators 2 Supplemental Methods.. 4 Supplemental Tables Supplemental Figures.. 12

3 Evolocumab in HeFH Patients 2 RUTHERFORD-2 Study Investigators Principal Investigator Institution Name Australia City, State (if applicable) Sullivan, David Building 65 Missenden Road Camperdown Watts, Gerald 50 Murray Street, Level 3, 35 Stirling Highway Perth Canada Dufour, Robert 110 Pine Avenue West Montreal, QC Frohlich, Jiri 1081 Burrard Street Vancouver, BC Hegele, Robert Schulich School of Medicine and Dentistry, London, ON Gaudet, Daniel Ecogene-21 Chicoutimi, QC Genest, Jacques 687 Avenue des Pins Ouest Montreal, QC France Bruckert, Eric Hopital Pitie-Salpetriere Paris Cariou, Bertrand Boulevard du Pr Jacques Nantes Moulin, Philippe 28 Avenue du Doyen Lépine Bron Germany Gouni-Berthold, Ioanna Steinhagen-Thiessen, Elisabeth Tomlinson, Brian Kerpener Strasse 62 Augustenburger Platz 1 Hong Kong Ngan Shing Street Netherlands Köln Berlin Basart, Dirk Nieuwe Steen 32 Hoorn Hermann, Johannes Oosterpark 9 Amsterdam Hovingh, G. Kees Academisch Medisch Centrum Amsterdam Janssen, Stan Heidelberglaan 100 Utrecht Kamphuisen, Pieter Ingang 24, 1e Verdieping Groningen Rensma, Pieter Hilvarenbeekseweg 60 Tilburg Koster, Ted Bleulandweg 10 Gouda

4 Evolocumab in HeFH Patients 3 Van de Wiel, Albert Maatweg 3 Amersfoort New Zealand Scott, Russell 40 Stewart Street Christchurch Norway Langslet, Gisle Forskningsveien 2 B Oslo South Africa Blom, Dirk University of Cape Town Health Sciences Faculty Western Cape Burgess, Lesley Tread Research, Cardiology Unit Western Cape Jacovides, Andrew 1 Health Emporium Midrand Raal, Frederick University of the Witwatersrand Johannesburg Spain Civeira, Fernando Pº de Isabel La Católica, 1-3 Zaragoza Karlezi, Rodrigo Alonso, Alberto Plaza de Cristo Rey 1 Madrid Marin, Luis Masana Avinguda del Dr Josep Laporte 1 Cataluña Miranda, Jose Lopez Avenida Menendez Pidal s/n Cordoba Sweden Eriksson, Mats Karolinska Universitetssjukhuset Huddinge Stockholm Olsson, Anders Bergviksvägen 48 Stockholm Switzerland Miserez, André Kägenstrasse 17 Reinach Kwok, See Le Roux, Carel Murthy, Narasimha Khan, Michael Wierzbicki, Anthony Stein, Evan Turner, Traci United Kingdom Hathersage Road Fulham Palace Road Clifford Bridge Road Westminster Bridge Road United States Metabolic and Atherosclerosis Research Center Manchester London Conventry London Cincinnati, OH

5 Evolocumab in HeFH Patients 4 Methods Patients Patients were excluded at screening if they had a known clinical or genetic diagnosis consistent with homozygous familial hypercholesterolaemia; low-density lipoprotein or plasma apheresis within the preceding 4 months; heart failure of New York Heart Failure Association class III or IV or left ventricular fraction ejection of <30%; any acute or unstable cardiac event within 3 months of randomization; planned cardiac surgery; or treatment with fibrates within 6 weeks of screening. Patients were also excluded if they had type 1 diabetes mellitus or newly-diagnosed or poorly-controlled type 2 diabetes mellitus (defined as HbA1c >8 5%); uncontrolled hypertension (defined as systolic blood pressure >160 mm Hg or diastolic blood pressure >100 mm Hg); uncontrolled hypo- or hyperthyroidism (defined as thyroid-stimulating hormone <1X the lower limit of normal or >1 5X the upper limit of normal [ULN]); moderate-to-severe renal dysfunction (defined as estimated glomerular filtration rate <30 ml/min/1 73 m 2 ); active liver disease (defined as aspartate aminotransferase or alanine aminotransferase >2X ULN); creatine kinase >3X ULN; or previous participation in a study of PCSK9 inhibition. Definitions Intensive statin use was defined as daily treatment with 80 mg simvastatin, 40 mg atorvastatin, 20 mg rosuvastatin, or any dose of statin together with ezetimibe; non-intensive statin use was defined as treatment with any statin at any dose not included in the intensive group. If treatment with more than one statin was recorded, the most recent one was used. Statistical analysis No multiplicity adjustments were made between the dose frequencies (biweekly and

6 Evolocumab in HeFH Patients 5 monthly). In order to preserve the familywise error rate at 0 05, each independent dose frequency (biweekly and monthly) was allocated a significance level of If the treatment effects from the primary analysis of the co-primary endpoints were both significant at a significance level of 0 05, statistical testing of the secondary efficacy endpoints was to be conducted using a combination of the Hochberg procedure and the fallback procedure.

7 Evolocumab in HeFH Patients 6 Supplementary Table 1. Baseline demographics and lipid parameters in patients in the genetic sub-analysis LDLR Mutation (n=195) Negative (n=66) Defective (n=75) Unclassified (n=54) ApoB Mutation (n=9) HoFH/Compound HeFH (n=7) No Mutation Identified (n=53) a Age (years), mean (SD) 48 1 (13 0) 49 5 (12 3) 51 0 (12 8) 57 1 (11 2) 53 0 (10 3) 57 4 (11 6) Female, n (%) 25 (37 9) 31 (41 3) 21 (38 9) 7 (77 8) 2 (28 6) 25 (47 2) LDL-C b (mmol/l), mean (SD) 4 4 (1 3) 3 9 (1 0) 4.0 (1 2) 3 7 (1 0) 5 3 (2 8) 3 7 (0 9) ApoB (g/l), mean (SD) 1 2 (0 3) 1 1 (0 2) 1 2 (0 3) 1 0 (0 2) 1 5 (0 6) 1 1 (0 2) HDL-C (mmol/l), mean (SD) 1 2 (0 3) 1 3 (0.4) 1 3 (0 3) 1 5 (0 6) 1 1 (0 3) 1 6 (0 5) ApoA1 (g/l), mean (SD) 1 4 (0 3) 1 4 (0 3) 1 3 (0 3) 1 5 (0 3) 1.3 (0 3) 1 6 (0 3) Triglycerides (mmol/l), median (Q1, Q3) Lp(a) c (nmol/l), median (Q1, Q3) hscrp (nmol/l), median (Q1, Q3) Unbound PCSK9 (nmol/l), mean (SD) 1 4 (1 0, 1 8) 1 2 (0 9, 1 8) 1 1 (0 8, 1 6) 0 9 (0 8, 1 2) 1 9 (1 8, 3 0) 1 3 (1 1, 1 9) 50 8 (25 0, 187 0) 60 5 (18 0, 200 5) 84 5 (36 0, 199 0) 42 0 (16 0, 194 0) 29 0 (6 0, 74 0) (23 0, 212 0) 12.4 (5.2, 25.7) 8.8 (4.3, 13.8) 8.8 (5.1, 19.3) 15.2 (6.2, 36.6) 11.7 (7.4, 19.3) 12.5 (5.0, 22.8) 6 5 (2 3) 6 5 (1 8) 6 4 (1 8) 6 2 (1 5) 7 0 (1 7) 5 2 (1 9) Coronary artery disease, n (%) 23 (34 8) 15 (20 0) 23 (42 6) 2 (22 2) 4 (57 1) 15 (28 3) HeFH classification, d n (%) Definite 57 (86 4) 66 (88 0) 44 (81 5) 6 (66 7) 5 (71 4) 27 (50 9) Possible 9 (13 6) 9 (12 0) 10 (18 5) 3 (33 3) 2 (28 6) 26 (49 1) a No mutation was identified in the LDLR or ApoB genes

8 Evolocumab in HeFH Patients 7 b Determined by the Friedewald formula with reflexive testing via preparative ultracentrifugation when calculated LDL-C was 1 0 mmol/l, or triglyceride levels were 4 5 mmol/l c To covert to mg/dl, multiply by 2 4 d Based on Simon Broome criteria Abbreviations: Apo, apolipoprotein; HDL-C, high-density lipoprotein cholesterol; HeFH, heterozygous familial hypercholesterolaemia; HoFH, homozygous familial hypercholesterolaemia; hscrp, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein cholesterol; LDLR, lowdensity lipoprotein receptor; Lp(a), lipoprotein (a); PCSK9, proprotein convertase subtilisin/kexin type 9; Q1, Q3, 25 th and 75 th percentiles; SD, standard deviation

9 Evolocumab in HeFH Patients 8 Supplementary Table 2. Lipid efficacy at week 12 based on causative genetic defect in patients treated with evolocumab 140 mg or 420 mg QM a (n=5) LDLR Negative (n=66) LDLR Defective (n=75) LDLR Unclassified (n=54) No mutation identified (n=53) 140 mg (n=29) QM (n=13) 420 mg QM (n=19) (n=16) 140 mg (n=17) QM (n=19) 420 mg QM (n=23) LDL-C c Change from baseline (%) LS mean % CI -17 7, , , , , , , , , , , , , , (n=11) 140 mg (n=17) QM (n=5) 420 mg QM (n=21) (n=10) 140 mg (n=17) QM (n=7) 420 mg QM (n=19) -27 9, , Treatment difference LS mean % CI -77 3, , , , , , , , P-value < < < < < < < < Change from baseline (mmol/l) b Mean (SE) ApoB (%) Change from baseline LS mean % CI -19 6, , , , , , , , , , , , , , , , Treatment difference LS mean % CI -63 4, , , , , , , , P-value < < < < < < < Lp(a) (%) Change from baseline LS mean Treatment difference LS mean % CI -72 4, , , , , , , ,-6 5 P-value < , % CI -9 4, , , , , , , , , , , , , , , a Least-squares mean (95% CI) unless otherwise indicated b Unadjusted c Determined by the Friedewald formula with reflexive testing via preparative ultracentrifugation when calculated LDL-C was 1 0 mmol/l, or triglyceride levels were 4 5 mmol/l P-values are versus placebo in the same dosing interval; estimates and standard error; analysed using a repeated measures model which included terms for treatment group, stratification factors (screening LDL-C < or 4 1 mmol/l and baseline ezetimibe use), scheduled visit, and the interaction of treatment with scheduled visit as covariates

10 Evolocumab in HeFH Patients 9 Abbreviations: Apo, apolipoprotein; CI, confidence interval;, evolocumab; HeFH, heterozygous familial hypercholesterolaemia; HoFH, homozygous familial hypercholesterolaemia; LDL-C, low-density lipoprotein cholesterol; LDLR, LDL receptor; Lp(a), lipoprotein (a);, placebo; PCSK9, proprotein convertase subtilisin/kexin type 9; Q1, Q3, 25 th and 75 th percentiles;, biweekly; QM, monthly; SE, standard error

11 Evolocumab in HeFH Patients 10 Supplementary Table 3. Efficacy on other lipid fractions, high-sensitivity C-reactive protein and PCSK9 levels at week 12 based on causative genetic defect in patients treated with evolocumab 140 mg or 420 mg QM a LDLR Negative (n=66) LDLR Defective (n=75) LDLR Unclassified (n=54) No mutation identified (n=53) (n=5) 140 mg (n=29) QM (n=13) 420 mg QM (n=19) (n=16) 140 mg (n=17) QM (n=19) 420 mg QM (n=23) (n=11) 140 mg (n=17) QM (n=5) 420 mg QM (n=21) (n=10) 140 mg (n=17) QM (n=7) 420 mg QM (n=19) HDL-C (%) Change from baseline LS mean % CI -10 4, , , , , , , , , , , , , , , ,12 1 Treatment difference LS mean % CI -6 0, , 2 0, , , , , , P-value ApoA1 (%) Change from baseline LS mean % CI -16 0, , , , , , , , , , , , , , , ,13 6 Treatment difference LS mean % CI 3 1, , , , , , , ,16 6 P-value Triglycerides (%) Change from baseline LS mean % CI -26 1, , , , , , , , , , , , , , , , 13 7 Treatment difference LS mean % CI -33 8, , -39 5, , , , , , P-value hscrp b Change from baseline (%) Median Q1, Q3-29 6, , , , Change from baseline (nmol/l) -11.7, , , , , , , , , , , Median Q1, Q3-1 2, -10 7, , , , , , , , , , , , , , , Unbound PCSK9 b Change from baseline (%) Mean SE Change from baseline (nmol/l) Mean SE , 41 7

12 Evolocumab in HeFH Patients 11 a Least-squares mean (95% confidence intervals) unless otherwise indicated b Unadjusted P-values are versus placebo in the same dosing interval; estimates and standard error; analysed using a repeated measures model which included terms for treatment group, stratification factors (screening LDL-C < or 4 1 mmol/l and baseline ezetimibe use), scheduled visit, and the interaction of treatment with scheduled visit as covariates Abbreviations: Apo, apolipoprotein; CI, confidence interval;, evolocumab; HDL-C, high-density lipoprotein cholesterol; HeFH, heterozygous familial hypercholesterolaemia; HoFH, homozygous familial hypercholesterolaemia; hscrp, high-sensitivity C-reactive protein; LDLR, low-density lipoprotein receptor;, placebo; PCSK9, proprotein convertase subtilisin/kexin type 9; Q1, Q3, 25 th and 75 th percentiles;, biweekly; QM, monthly; SE, standard error

13 Evolocumab in HeFH Patients 12 Figure Legends Supplementary Figure 1. Percent of patients achieving a low-density lipoprotein cholesterol (LDL-C) goal 1 8 mmol/l at the mean of weeks 10 and 12 (A), and week 12 (B). a P< evolocumab treatment difference vs. placebo; analysed using the Cochran-Mantel-Haenszel test, stratified by the stratification factors (screening LDL-C <4 1 or 4 1 mmol/l and baseline ezetimibe use) Abbreviations:, biweekly, QM, monthly Supplementary Figure 2. Mean (SE) percent change from baseline in low-density lipoprotein cholesterol (LDL-C) a in patients with heterozygous familial hypercholesterolaemia by genetic subgroup treated with evolocumab 140 mg (A) and 420 mg QM (B). a Determined by the Friedewald formula with reflexive testing via preparative ultracentrifugation when calculated LDL-C was <1 0 mmol/l, or triglyceride levels were >4 5 mmol/l. Injections given in the clinic on day 1 and weeks 2, 8, and 10 Abbreviations:, biweekly, QM, monthly; SE, standard error Supplementary Figure 3. Individual patient percent change from baseline to week 12 in low-density lipoprotein cholesterol (LDL-C) in patients with heterozygous familial hypercholesterolaemia by genetic subgroup treated with evolocumab 140 mg (A) and 420 mg QM (B). a Determined by the Friedewald formula with reflexive testing via preparative ultracentrifugation when calculated LDL-C was 1 0 mmol/l, or triglyceride levels were 4 5 mmol/l

14 Evolocumab in HeFH Patients 13 Supplementary Figure 1 A B

15 Evolocumab in HeFH Patients 14 Supplementary Figure 2 A B

16 Evolocumab in HeFH Patients 15 Supplementary Figure 3 A B