Ilaris® for active systemic juvenile idiopathic arthritis

The condition is characterised by spiking fever, rash and arthritis that can affect children as young as two years old and can continue into adulthood.[2,3]

This opinion was based on two Phase III trials in SJIA patients, aged 2-19, which showed significant improvement in the majority of Ilaris-treated patients.[1] Study 1 showed that 84% of patients treated with one subcutaneous dose of Ilaris achieved the primary endpoint of the adapted paediatric American College of Rheumatology 30 (ACR30), compared to 10% achievement of ACR30 for placebo at Day 15.[1]

In the open-label part of Study 2, 92 of 128 patients attempted ‘corticosteroid tapering’. Of those 92 patients, 62% were able to substantially reduce their use of corticosteroids, and 46% completely discontinued corticosteroids.[1] In the controlled portion of Study 2, there was a 64% relative reduction in the risk of flare for patients in the Ilaris group as compared to those in the placebo group (hazard ratio of 0.36; 95% CI: 0.17 to 0.75).[1]

CHMP recommended Ilaris for the treatment of active SJIA in patients aged two years and older who have responded inadequately to previous therapy with non-steroidal anti-inflammatory drugs (NSAIDs) and systemic corticosteroids. CHMP stated that Ilaris can be given as monotherapy or in combination with methotrexate.

“If approved, Ilaris would provide a new treatment option for patients whose choice of therapy has, to date, been very limited,” said Timothy Wright, MD, Global Head of Development, Novartis Pharmaceuticals. “This positive opinion by the CHMP is an important step towards the approval of Ilaris for SJIA in the EU.”

The European Commission generally follows the recommendations of the CHMP and usually delivers its final decision within three months of the CHMP recommendation.

The incidence of SJIA in Europe is thought to be around 0.4-0.8 per 100 000,[3] with a prevalence estimated at 1-10 in 30,000 children.[4] Although the disease can be life-threatening, treatment options are limited. Corticosteroids are often used to treat symptoms and pain despite their long term use being associated with potentially serious adverse effects, including Cushing syndrome, growth suppression and osteoporosis.[1]

Ilaris is being investigated in a number of inflammatory diseases where interleukin-1 (IL-1) beta is a key component of disease pathogenesis. These include rare autoinflammatory conditions for which approved treatments do not exist, including, Tumour Necrosis Factor Receptor-Associated Periodic Syndrome (TRAPS), colchicine-resistant Familial Mediterranean Fever (FMF) and Hyper IgD Syndrome (HIDS). Ilaris is considered an investigational agent for these conditions at this point in time. As such, the role that Ilaris could play in treating these conditions and potential benefit to patients is still being determined.

Study 1, a 4-week, randomised, double-blind, placebo-controlled study, involved 84 patients between the ages of two and 19 years with active SJIA.[1,2] Patients were treated with either a single subcutaneous dose of Ilaris (4 mg/kg, up to 300 mg) (n=43) or placebo (n=41).[1] The primary endpoint was the proportion of patients achieving the adapted paediatric American College of Rheumatology (ACR) 30 response criteria and resolution of fever from baseline at Day 15.[1] This means that patients had at least a 30% improvement in systemic and arthritic symptoms versus baseline. The study met its primary endpoint.

Study 2, a two-part study, had an open-label, single-arm active treatment in Part I followed by a randomised, double-blind, placebo-controlled, event-driven withdrawal design in Part II.[1] A total of 177 patients between the ages of two and 19 years with active SJIA were enrolled in the study.[1] Some of these patients had previously participated in the Study 1. In Part I, patients received a subcutaneous dose of Ilaris (4 mg/kg, up to 300mg) every four weeks.[1] The primary endpoint of Part I was to assess whether treatment with Ilaris allowed successful tapering of corticosteroids in at least 25% of SJIA patients who entered the study using a corticosteroid.

In Part II of the study, patients were randomised to either continue receiving Ilaris, or to receive placebo every four weeks (‘placebo-after-Ilaris group’), until a pre-specified number (37) of flare-events (‘flares’) had occurred.[1] The primary endpoint of Part II was to demonstrate that the time to flare was longer with Ilaris than with placebo.

The primary endpoints for Study 1 and Study 2 were all met.

Ilaris is a selective, fully human, monoclonal antibody that inhibits IL-1 beta, which is an important part of the body’s immune system defences.[1] Excessive production of IL-1 beta plays a prominent role in certain inflammatory diseases.[5] Ilaris works by neutralising IL-1 beta for a sustained period of time, therefore inhibiting inflammation.[1]

Ilaris is approved for the treatment of SJIA in the US and for the symptomatic treatment of refractory acute gouty arthritis in the EU. Ilaris is also approved in more than 60 countries, including in the EU, US, Switzerland and Japan for the treatment of Cryopyrin-Associated Periodic Syndromes (CAPS), a rare, lifelong, genetic disorder with debilitating symptoms. The approved indication may vary depending upon the individual country.

References:

1. Ruperto N, Brunner H, Constantin T, et al. Baseline characteristics of patients with active Systemic JIA successfully discontinuing corticosteroid while receiving canakinumab: secondary analysis from a pivotal phase 3 trial. Abstract presented at European League Against Rheumatism, Madrid 12-15 June, 2013.
2. Woo P. Systemic juvenile idiopathic arthritis: diagnosis, management, and outcome. Nat Clin Pract Rheumatol 2006; 2(1):28-34.
3. Ramanan AV, Grom AA. Does systemic-onset juvenile idiopathic arthritis belong under juvenile idiopathic arthritis? Rheumatology (Oxford) 2005; 44(11):1350-3.
4. ORPHANET – http://www.orpha.net/consor/cgi-bin/OC_Exp.php?Lng=EN&Expert=85414. Accessed 12th June 2013.
5. Martinon F, Petrilli V. Gout-associated uric acid crystals activate the NALP3 inflammasome. Nature 2006; 440(9): 237-241.