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Published on 12 November 2012

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Positive outcomes in largest liver transplant trial to date

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Novartis today announced new two-year results from the largest Phase III study ever in liver transplantation that confirmed comparable efficacy to control and superior renal function results previously seen at 12 months. [1] The trial evaluated the introduction of Certican (everolimus) with reduced exposure tacrolimus administered twice-daily starting one month after liver transplantation versus standard-exposure tacrolimus.[1]
“Novartis has a longstanding commitment to the transplant community and to research into potential treatment options to help improve patient outcomes,” said Tim Wright, Global Head of Development, Novartis Pharma. “The promising renal function results seen in this study represent yet another potential advance for patients and build upon the recent approval of Certican for adult liver transplant patients by the European Health Authorities.” 
The data were presented at the 63rd Annual Meeting of the American Association for the Study of Liver Diseases (AASLD) in Boston, MA, USA.
“These results showed that treatment with Certican with reduced tacrolimus led to a clinically relevant retention of renal function compared to standard tacrolimus, with no compromise in rejection,” said John Fung, MD, PhD, Director, Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH. “The two-year results suggest that a treatment regimen of Certican with reduced tacrolimus is not only possible, but also sustainable, and that’s exciting news for patients and their healthcare providers who are concerned about the impact of CNIs on renal function.” 
A large, independent registry study of nearly 70,000 patients who received a non-renal solid organ transplant between 1990 and 2000 showed that the incidence of chronic renal failure was greater in liver transplant recipients than in recipients of all other solid organ transplants, except intestinal transplants.[4] Calcineurin inhibitors (CNIs), such as tacrolimus, are part of the standard-of-care treatment regimen for immunosuppression in liver transplantation, but they can contribute to complications, including impaired renal function.[2,3] Certican works by binding to a protein called mammalian target of rapamycin (mTOR), and acts synergistically with CNIs, offering an opportunity to lower CNI exposure. [5,6]
In October 2012, European Health Authorities approved Certican (RAD001/everolimus) for the prophylaxis of organ rejection in adult patients receiving a liver transplant. In the US, RAD001 is an investigational agent for the prevention of organ rejection in adult patients receiving a liver transplant and a decision by the US Food and Drug Administration is expected by the end of 2012.
Study Details: Certican with Reduced-Dose Tacrolimus: New 24-Month Results
The 24-month results are from a Phase III, multicentre, open-label, randomised, controlled study conducted in 719 de novo liver transplant patients.Four weeks following liver transplantation, patients treated with tacrolimus and corticosteroids (with or without mycophenolate mofetil) were randomised to one of three groups: Certican (C0 3-8ng/mL) in combination with reduced-exposure tacrolimus (C0 3-5ng/mL) (n=245), Certican (C0 6-10ng/mL) followed by tacrolimus withdrawal at four months (n=231) or standard-exposure tacrolimus (C0 6-10ng/mL) only (control, n=243).
All three study arms included twice-daily treatment. Additionally, all arms included corticosteroids for at least six months post-transplant. Enrollment into the tacrolimus withdrawal arm was prematurely halted due to a higher incidence of acute rejection episodes and adverse events leading to treatment discontinuation, clustered around the time of tacrolimus elimination at four months post randomisation.[1] The study protocol was amended at that time.
The original study protocol included two co-primary endpoints, which were composite efficacy failure and renal function measured by estimated glomerular filtration rate (eGFR) based on the four-variable Modification of Diet in Renal Disease (MDRD4) equation at 12 months after liver transplantation. Both co-primary endpoints were met. In the original study protocol, composite efficacy failure was defined as graft loss, death or lost-to-follow-up.[7]
The amended endpoints assessed at 24 months included the composite efficacy failure rate (treated biopsy proven acute rejection [tBPAR], graft loss, or death) and its individual components, and change in renal function. Key safety endpoints included the incidence of adverse events (AEs) and serious AEs (SAEs).[1]
At 24 months, the incidence of composite efficacy failure (Kaplan-Meier estimates) was numerically lower with Certican with reduced tacrolimus compared to the tacrolimus control group (10.3% vs. 12.5%; risk difference -2.2%; [97.5% CI: -8.8%, 4.4%]; p=0.452). The incidence of BPAR was significantly lower with Certican with reduced tacrolimus compared to the tacrolimus control group (6.1% vs. 13.3%; risk difference: -7.2% [95% CI: -13.5%, -0.9%]; p=0.010). The incidence rates of graft loss, death, and tBPAR were comparable between the two groups. Superior renal function was maintained at month 24 with Certican with reduced tacrolimus compared with standard tacrolimus (mean difference in eGFR change: 6.7 mL/min/1.73m2 [97.5% CI: 1.9, 11.42]; p=0.0018) (ITT population). For on-treatment patients, the difference in eGFR at month 24 was 11.5 mL/min in favour of Certican with reduced tacrolimus. [1,8]
At month 24, the incidence rates for Certican with reduced tacrolimus vs. the tacrolimus control group for any AEs (96.3% vs. 97.9%) and any SAEs (56.3% vs. 54.1%) were comparable.The most common AEs reported in either Certican with reduced tacrolimus or the tacrolimus control groups were: headache, hypertension, diarrhoea, peripheral edema, pyrexia, abdominal pain, nausea, hepatitis C, leukopenia, fatigue, hypercholesterolemia, tremor, renal failure, nasopharyngitis, back pain, abnormal liver function tests. There was a numerical difference in the incidence of malignant tumours in the Certican with reduced tacrolimus group (11) compared to the tacrolimus control group (16).[1]
The 12-month results from this study were first presented as a scientific poster at the 62nd AASLD Annual Meeting in November 2011, as well as at the International Liver Transplantation Society (ILTS) 18th Annual International Congress in May 2012 and the American Transplant Congress (ATC) 2012 Annual Meeting in June 2012. In August 2012, the 12-month study results were published in the American Journal of Transplantation (AJT).
About Certican (everolimus)
Everolimus is the most-extensively studied immunosuppressant in solid organ transplantation with more than 10,000 transplant recipients enrolled in Novartis-sponsored clinical trials worldwide.[9] Under the trade name Certican®, it is approved in more than 90 countries to prevent organ rejection for renal and heart transplant patients, and in addition, is approved in the EU, Chile and Philippines to prevent organ rejection for liver transplant patients. In the US, under the trade name Zortress®, the drug is approved for the prophylaxis of organ rejection in adult patients at low-moderate immunologic risk receiving a kidney transplant.
Everolimus is also available from Novartis in different dosage strengths and for different uses in non-transplant patient populations under the brand names Afinitor® and Votubia®. It is also exclusively licensed to Abbott and sublicensed to Boston Scientific for use in drug-eluting stents.
Not all indications are available in every country. As an investigational compound, the safety and efficacy profile of everolimus has not yet been established outside the approved indications. Because of the uncertainty of clinical trials, there is no guarantee that everolimus will become commercially available for additional indications anywhere else in the world.
References
  1. Saliba, F., De Simone, P., Nevens, F., et al. Everolimus-Facilitated Reduction of Tacrolimus Provides Comparable Efficacy and Superior Renal Function Versus Standard Tacrolimus In de novo Liver Transplant Recipients:  24-Month Results of a Randomized Trial. To be presented at the 63rd Annual Meeting of the American Association for the Study of Liver Diseases; November 9-13, 2012; Boston, MA, USA.
  2. McGuire B.M., Rosenthal P., Brown C.C., et al. Long-term Management of the Liver Transplant Patient: Recommendations for the Primary Care Doctor. American Journal of Transplantation 2009; 9: 1988-2003.
  3. Venkataramanan, R., Shaw, L.M., Sarkozi, L., et al. Clinical Utility of Monitoring Tacrolimus Blood Concentrations in Liver Transplant Patients. J Clin Pharmacol, 2001; 41:542-551.
  4. Ojo, A., Held, P., Port, F., et al. Chronic Renal Failure after Transplantation of a Nonrenal Organ. New Eng J Med, 2003;349:931-940.
  5. Certican® Prescribing Information.
  6. Schuurman, HJ., Cottens, S., Fuchs, S., et al. SDZ RAD, A new rapamycin derivative: Synergism with cyclosporine. Trans, 1997;64,1;32-35.
  7. De Simone, P., Nevens, F., De Carlis, L., et al. Everolimus with reduced tacrolimus improves renal function in de novo liver transplant recipients: a randomized controlled trial. American Journal of Transplantation.  2012.
  8. Saliba, F., De Simone, P., Nevens, F., et al. Everolimus-Facilitated Reduction of Tacrolimus Provides Comparable Efficacy and Superior Renal Function Versus Standard Tacrolimus In de novo Liver Transplant Recipients:  24-Month Results of a Randomized Trial. Abstract.
  9. Novartis Data on File: DSUR. July 2012.


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