Clinical Study Report Synopsis An Explorative Clinical Trial to Evaluate an Intra Patient Comparison Design of Topical Agents in Adults with Mild to Moderate Atopic Dermatitis Design of trial: Single-centre, prospective, randomised, vehicle-controlled, investigator-blinded, stable lesion design The clinical trial, including the archival of essential documents, was conducted in compliance with the clinical trial protocol, GCP, and the applicable regulatory requirement(s). LEO Pharma A/S Trial ID: EXP-1184 Date: 03-May-2016 Version: Final 00594119
Trial ID: EXP-1184 03-May-2016 Page 2 of 7 Clinical Trial Report Synopsis Statement Approval Statement, LEO Pharma A/S The following persons have approved this clinical study report synopsis using electronic signatures as presented on the last page of this document:, PhD, MD Approval Statement, International Coordinating Investigator The international coordinating investigator approves the clinical study report synopsis by manually signing the International Coordinating Investigator Clinical Study Report Approval Form, which is a separate document adjoined to the clinical study report. The following person has approved this clinical study report synopsis:, MD International coordinating investigator
Trial ID: EXP-1184 03-May-2016 Page 3 of 7 Trial Registration Number NCT02376049 EudraCT number NA Title of Trial An explorative clinical trial to evaluate an intra patient comparison design of topical agents in adults with mild to moderate atopic dermatitis. Investigators, MD,, US, was appointed as signatory investigator. Trial Centres This trial was conducted at 1 centre in 1 country (Canada) and coordinated at, US. Publications None at the time of the final clinical trial report. Clinical Trial Period Date of First Subject First Visit: 23-Mar-2015 Date of Last Subject Last Visit: 17-Jul-2015 Development Phase Phase 1 Objectives Primary Objective: To evaluate a clinical trial model using intra-patient comparison of 3 marketed topical agents and a vehicle in adults with atopic dermatitis (AD). Exploratory Objectives: To assess: Change in target area disease severity Effect on trans-epidermal water loss (TEWL) Change in epidermal thickness measured by ultrasound and by histology Safety and tolerability Effect on biomarkers (histology/immunohistochemistry) Effect on RNA expression Methodology This was a phase 1, single-centre, randomised, vehicle-controlled, double-blind, 2-week intra-individual comparison trial in adult subjects with mild to moderate AD. Each subject was treated with 3 topical drugs and 1 emollient, which were applied once daily to 4 separate target areas (TAs) on the body (face and scalp excluded). Clinical assessments and measurement of TEWL and epidermal thickness took place on Day 1 (baseline), Day 8, and Day 15. Skin biopsies for biomarker assessments (histology, immunohistochemistry, mrna expression) were taken on Day 15. Adverse events (AEs) were assessed daily during the treatment period and were followed up for 14 days after end-oftreatment or until a final outcome was determined. Number of Subjects Planned and Analysed 30 subjects were planned and 30 subjects were allocated to treatment.
Trial ID: EXP-1184 03-May-2016 Page 4 of 7 Diagnosis and Main Criteria for Inclusion All of the following criteria needed to be met for a subject to be enrolled in the trial: 1. Informed Consent Form signed and dated prior to any trial-related procedures. 2. Subject (male or female) 18 years of age. 3. AD as defined by Hanifin and Rajka, with mild to moderate disease severity (Investigator s Global Assessment of 2 or 3) as assessed by a dermatologist at screening. 4. Four comparable TAs (excluding face and scalp) of at least 3 cm in diameter (complete AD lesion or part of an AD lesion); Total Sign Score (TSS) of at least 5 on all TAs; difference in TSS 2 between the TAs; sign score erythema 2 on all TAs. TAs should be at least 2 cm apart. 5. Physical examination of the skin must be without disease findings (other than AD) unless the investigator considers an abnormality to be irrelevant to the outcome of the clinical trial. 6. Female subjects must be of non-childbearing potential (surgically sterile or post-menopausal) or agree to use a reliable method of contraception, as specified in the clinical trial protocol.
Trial ID: EXP-1184 03-May-2016 Page 5 of 7 Test Product, Dose and Mode of Administration, Batch Number Once daily topical application of each of the following products, in a fixed volume of 30 µl per TA (approximately 1.5 to 2.0 mg per cm 2 ): Pimecrolimus 10 mg/g (Elidel 10 mg/g cream), batch number W1190 Betamethasone dipropionate 0.5 mg/g (Diprosone 0.05% w/w cream), batch numbers 4YTFZ02/5YTFZ01 Clobetasol propionate 0.5 mg/g (Dermovate cream), batch numbers 04013/64079 Duration of Treatment 14 days Reference Product, Dose and Mode of Administration, Batch Number Glaxal Base moisturising cream (referred to below as vehicle), once daily topical application of 30 µl (approximately 1.5 to 2.0 mg per cm 2 ), batch number 4K4203 Criteria for Evaluation Primary Endpoint: Change in TSS from baseline to end of treatment Exploratory Endpoints: Change in individual sign scores (erythema, oedema/papulation, oozing/crusting, excoriation, lichenification, dryness) during study Change in TA disease severity Change in TEWL Change in epidermal thickness (measured by sonography) AEs/SAEs Histological comparison between TAs on Day 15 in terms of: 1) epidermal thickness; expression of biomarkers for 2) selected immune cells and 3) skin barrier proteins Comparison of mrna expression of selected genes between TAs on Day 15 Statistical Methods The following analysis sets were used: Intent-to-treat (ITT) analysis set: all randomised subjects who had been administered at least one dose of investigational medicinal product (IMP) Per-protocol (PP) analysis set: all subjects in the ITT analysis set whose clinical outcome after treatment was evaluated at least once (on Day 8 or Day 15) Safety analysis set: equivalent to ITT analysis set The primary endpoint was analysed for the ITT and PP analysis sets using a mixed-effect model approach, with percentage change from baseline calculated from the least squares means. The exploratory efficacy endpoints were analysed for the ITT and PP analysis sets as follows: For ordinal clinical outcomes (change in individual sign scores and TA disease severity), changes on Day 15 were compared using Wilcoxon signed-rank test. An additional analysis included ordinal logistic models accounting for the dependency of the repeated measures. For continuous outcomes (change in TEWL and epidermal thickness, and cell counts from histology/immunohistochemistry biomarker analysis), similar mixed-effect models as for the primary outcome were used. For mrna expression analysis, the human acidic ribosomal protein gene was used to normalise each sample and each gene. Values below the level of quantification by quantitative real-time polymerase chain reaction (RT-PCR) were imputed using 20% of the smallest normalised value observed for that gene across all samples above the limit of detection. Imputed data were log2 transformed prior to analysis. All other missing values were considered as missing. Changes in gene expression levels across treatments were evaluated using a mixed-effect model, as for the primary outcome. The safety endpoint was evaluated for the safety analysis set by tabulating AEs based on Common Terminology Criteria for Adverse Events system organ class (SOC) or preferred term, and by severity, relatedness, and expectedness. Each subject was counted only once within a SOC or preferred term using the AEs with the highest severity within each category.
Trial ID: EXP-1184 03-May-2016 Page 6 of 7 Summary of Results Trial Population 30 subjects were treated with at least one application of IMP, and 29 subjects completed the trial. 1 subject was withdrawn from the trial on Day 7, owing to the use of prohibited medication, and was consequently excluded from the PP analysis set. Of the 29 subjects completing the trial, 28 subjects received the full regimen of once daily treatment with all 4 IMPs for 14 days, and 1 subject missed one treatment (Day 7). The trial population was representative of a Western adult population with AD, comprising 16 men and 14 women, aged 18 to 71 (median age 29 years), most of whom were white with Fitzpatrick skin type II or III and AD since an early age (median duration 25 years). Efficacy and Biomarker Results Primary Endpoint: All IMPs led to significant reduction (p<0.001) in TSS from baseline to end of treatment. At baseline, the least square mean of TSS was 7.4 for all 4 IMPs. The change to Day 15 was: 76% reduction for clobetasol, 67% reduction for betamethasone, 40% reduction for pimecrolimus, and 30% reduction for vehicle. The difference between clobetasol and betamethasone was not statistically significant (p=0.3); neither was the difference between pimecrolimus and vehicle (p=0.26). The effects of clobetasol and betamethasone, however, were significantly larger than those of pimecrolimus and vehicle (p 0.002). Exploratory Endpoints: For most of the parameters measured in the exploratory endpoints (listed below), the effects of the 2 corticosteroids, clobetasol and betamethasone, were also statistically significantly larger than those of pimecrolimus and vehicle. Individual sign scores and TA disease severity gradually decreased in severity during treatment with all 4 IMPs, corresponding well to the reduction in TSS. The improvement in individual sign scores also corresponded to their contributions to TSS at baseline, in order from largest to smallest: erythema, oedema, dryness, excoriation, lichenification, and oozing. TEWL was reduced for all 4 IMPs during the trial. At baseline, the mean TEWL values for the 4 IMPs were comparable, ranging from 65.9 to 69.9 g/m 2 /h. On Day 15, the mean change values were, in order from largest to smallest: -33.9 g/m 2 /h for betamethasone, -32.2 g/m 2 /h for clobetasol, -21.1 g/m 2 /h for pimecrolimus, and -19.0 g/m 2 /h for vehicle. Epidermal thickness estimates obtained by sonography were inconsistent with those obtained by histology. The sonographic estimates of mean epidermal thickness on Day 15 were similar for all 4 IMPs, ranging from 172 to 186 µm, whereas the histological estimates were: 82 µm for clobetasol, 99 µm for betamethasone, 136 µm for pimecrolimus, 158 µm for vehicle (and 65 µm for non-lesional skin). The lack of differentiation between IMPs and the larger estimates of epidermal thickness obtained by sonography, compared with those obtained by histology, suggest that the end of the echo-poor band measured in sonography did not indicate the dermo-epidermal transition, as intended, but rather represented a structure in the upper dermis. Immunohistochemical cell markers and skin barrier markers assessed on Day 15 indicated reduced infiltration of T cells, dendritic cells, and Langerhans cells, as well as normalisation of epidermal proliferation (keratin 16 expression) and differentiation (filaggrin expression), in TAs for clobetasol and betamethasone approaching the levels in non-lesional skin. mrna expression profiles assessed on Day 15 showed marked and overall similar effects of clobetasol and betamethasone, compared with pimecrolimus and vehicle. The effects included reduced mrna expression of immune response genes, including key markers representing the Th1, Th2, Th17 and Th22 pathways, as well as increased mrna expression of 3 steroid response genes. Expression of the epidermal proliferation marker keratin 16 was reduced and expression of terminal differentiation genes (filaggrin, loricrin, and periplakin) was increased in TAs for the 2 corticosteroids, particularly for clobetasol. Overall, clobetasol and betamethasone changed the expression of key AD biomarkers to levels similar to or beyond those in non-lesional, that is, closer to the expression in normal skin. Safety Results There were no deaths or other serious/significant AEs. Of the 30 subjects in the safety analysis set, 13 subjects (43.3%) had a total of 22 AEs. All of the AEs were considered not related to the IMPs and were defined as either mild (20 AEs) or moderate (2 AEs: rhinitis, headache) in severity. None of the AEs were defined as serious, and none led to withdrawal of subjects from the trial. The most common AEs (occurring in 5% of subjects) were headache, nasopharyngitis, and nausea, each of which occurred in 2 subjects. A single AE (inflammation at biopsy site; severity: mild) was reported as related to a TA. The investigator deemed this AE related solely to the biopsy procedure (not to the study medication).
Trial ID: EXP-1184 03-May-2016 Page 7 of 7 Conclusion This trial has demonstrated the feasibility of detecting clinically relevant and statistically significant differences in the efficacy of topically applied AD treatments, using a clinical trial model based on the plaque test model previously validated for assessing psoriasis treatments. With a sample size of 30 subjects, this model enabled intra-individual comparison of IMPs applied to lesional AD skin areas as small as 3 cm. The trial showed significant improvements by clobetasol and betamethasone, compared with pimecrolimus and an emollient, in the epidermal pathology and inflammatory pathways of AD as assessed by clinical, cellular, and gene expression markers. The trial did not differentiate between betamethasone and clobetasol, or between pimecrolimus and the emollient. No unexpected or clinically relevant safety issues were identified during the trial.
EXP-1184 Clinical Study Report Synopsis -English ELECTRONIC SIGNATURES Electronic signahtre made within edoc LEO by LEO Pharma AIS employees or employees of any LEO Pharma AIS affiliate located anywhere in the world, are to be considered to be legally binding equivalent of traditional handwritten signahtres. Signed by Meaning of Signature, Medical Approval HH:mm 'GMT'Z 11-May-2016 15:20 GMT+O Approval, Biostatistical 11-May-2016 16:49 GMT+O