natalizumab safety update september 2012
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TY-PAN-0463r Date of preparation: September 2012
Natalizumab Safety Update & PML
Risk Stratification
Barts Health
September 2012
Gavin Giovannoni Professor of Neurology
TY-PAN-0463r Date of preparation: September 2012
Benefit / Risk
Benefit
Risk
Natalizumab
81% reduction in
relapse rate1
64% reduction in
disability
progression1
>1 in 3 patients free
of disease activity2
PML risk ≈
2.63 in 1,000
Other Adverse
Events Per
Labelling
How can the risk of PML be minimised?
1. Hutchinson et al. J Neurol 2009;256:405-415.
2. Havrdova E et al. Lancet Neurol 2009;8(3):254-60
3. Biogen Idec Data on File
TY-PAN-0463r Date of preparation: September 2012
PML Risk Hypothesis PML is rare and likely caused by interplay between multiple factors
Patients at higher risk of developing PML are
likely those:
• Who have JC virus and have the
pathogenic form of the virus (i.e. has an
altered NCCR and has a pathogenic
mutation in VP1).
• Who have a compromised immune system
that permits viral replication in the brain
• Who may have other risk factors such as
host genetic factors that make them
susceptible to JC virus infection and/or
PML development VP1 mutations
NCCR rearrangements
Immune function
Host genetic factors
Immunomodulating therapy
TY-PAN-0463r Date of preparation: September 2012
A Hypothetical Risk Stratification Tool
Anti-JCV Antibody Status
Negative Positive
Prior Immunosuppressant
Use
Natalizumab Treatment
>2 Years
Natalizumab Treatment
>2 Years
No Yes
No Yes No Yes
Lowest Highest
Relative PML Risk
TY-PAN-0463r Date of preparation: September 2012
A Hypothetical Risk Stratification Tool
Anti-JCV Antibody Status
Negative Positive
Prior Immunosuppressant
Use
Natalizumab Treatment
>2 Years
Natalizumab Treatment
>2 Years
No Yes
No Yes No Yes
Lowest Highest
Relative PML Risk
1 in 1,786 1 in 217 1 in 625 1 in 90 < 1 in 11,000
TY-PAN-0463r Date of preparation: September 2012
Key Learnings: PML Risk
• Duration of natalizumab dosing prior to PML diagnosis ranged from 8 to
72 doses.1
– Mean duration of natalizumab dosing at time of PML diagnosis was
approximately 37.5 months1
• Overall incidence: 2.63 per 1000 patients (95% CI; range: 2.33 to 2.95
per 1000 patients)1
– Currently the average post-marketing natalizumab exposure worldwide is
approximately 2 or more years of natalizumab exposure.
• Factors that increase the risk of PML have been identified 2 – JCV exposure indicated by anti-JCV antibody positive status
– Receiving an immunosuppressant prior to receiving Natalizumab
– Natalizumab treatment duration, especially >2 years.
1. Biogen Idec Data on file.
2. Natalizumab SPC
TY-PAN-0463r Date of preparation: September 2012
Natalizumab PML Incidence Estimates by
Treatment Duration
Biogen Idec Data on File
Calculations based on exposure through August 31, 2012 and 285 confirmed cases as of September 5, 2012
Inc
ide
nc
e p
er
10
00
pa
tie
nts
2.95
4.20
4.79
5.34 5.07
4.83 4.57
3.71
2.33
3.31
3.76
4.15
3.81
3.47
3.10
2.23
2.63
3.74
4.25
4.72
4.41 4.11
3.78
2.90
0.0
1.0
2.0
3.0
4.0
5.0
6.0
TY-PAN-0463r Date of preparation: September 2012
Natalizumab PML Incidence Estimates by
Treatment Epoch
Biogen Idec Data on File
Calculations based on exposure through August 31, 2012 and 285 confirmed cases as of September 5, 2012
Inc
ide
nc
e p
er
10
00
pa
tie
nts
2.95
0.11
0.82
2.32
2.79
2.63
2.33
0.02
0.45
1.54
1.76
1.38
2.63
0.05
0.61
1.90
2.23
1.94
0.0
0.5
1.0
1.5
2.0
2.5
3.0
TY-PAN-0463r Date of preparation: September 2012
Natalizumab PML Incidence Estimates by
Treatment Epoch
Biogen Idec Data on File
Calculations based on exposure through August 31, 2012 and 285 confirmed cases as of September 5, 2012
Inc
ide
nc
e p
er
10
00
pa
tie
nts
2.95
0.11
0.82
2.32
2.79
2.63
2.33
0.02
0.45
1.54
1.76
1.38
2.63
0.05
0.61
1.90
2.23
1.94
0.0
0.5
1.0
1.5
2.0
2.5
3.0
1 in 20,000
1 in 380
1 in 1639
1 in 526
1 in 448 1 in 515
Please note 285 cases of PML!
TY-PAN-0463r Date of preparation: September 2012
Use of Natalizumab in the Post-Marketing Setting*
Patients
Patients
Worldwide post-marketing data from 23 Nov 2004 to 30 June 2012
224,718 Patient-Years
of Natalizumab exposure
*Post-marketing data includes patients exposed since 23 November 2004. This excludes approximately 5,000 patients exposed
in clinical trials: 2,200 exposed for ≥ 12 months; 1,900 exposed for ≥ 18 months; 1,600 exposed for ≥ 24 months; 1,300
exposed for ≥ 30 months; 1,000 exposed for ≥ 36 months; and 700 exposed for ≥ 42 months. Exposure are estimates and may
not fully reflect treatment interruptions that are used in certain patients. Biogen Idec, Data on file.
104,300
72,400
60,300
50,300
41,400
33,500
26,100
19,600
OverallExposure
≥12 Months
≥18 Months
≥24 Months
≥30 Months
≥36 Months
≥42 Months
≥48 Months
TY-PAN-0463r Date of preparation: September 2012
Anti-JCV Antibody testing
• Current data on the assay as a risk stratification tool:
- Irrespective of MS treatment, across studies in MS patients, approximately 50-60% of
the population tested anti-JCV antibody positive1
- Preliminary data suggest that ~2-3% of patients seroconvert annually2.
• Seroconversion is defined as a patient who changed from negative to positive and remained
positive
- Low false negative rate
• STRATA: 2.5% (95% CI 0.05-4.9%)2,3
• STRATIFY-1: 2.7% (95% CI 0.9-6.2%)4
- Preliminary data suggest that ~5-10% of patients will change serostatus from anti-JCV
antibody negative to positive on retest. These patients include true seroconverters, and
those with anti-JCV antibody levels that fluctuate around the cut-point of the anti-JCV
assay2.
1. Bozic et al. Presented at AAN: April 21-28, 2012; New Orleans, LA. S41.002
2. Biogen Idec, data on file.
3. Gorelik et al. Ann Neurol 2010. 68: 295-303
4. Bozic et al. Ann Neurol 2011 Nov;70(5):742-50
TY-PAN-0463r Date of preparation: September 2012
Anti-JCV Antibody testing
• As of 5th September 2012, 91 natalizumab-treated MS PML patients with known pre-PML
anti-JCV antibody status who had samples tested for anti-JCV antibodies, all of which were
collected at least 6 months prior to PML diagnosis (range 6-187 months). Of these 91
patients:
– 89 (98%) patients tested anti-JCV antibody positive at all time points where samples were available.
– 1 recent patient (1%) tested anti-JCV antibody negative 9 months prior to PML diagnosis and anti-
JCV antibody positive 6.5 months prior to PML diagnosis. The patient had > 5 years of natalizumab
therapy + prior IS use.
– 1 patient (1%) tested anti-JCV antibody negative 9 months prior to PML diagnosis; no additional pre-
PML samples were available. The patient had received ~ 3-4 years of therapy + no prior IS use.
• A sample obtained from one CD clinical trial patient prior to PML diagnosis tested positive.
• In addition, one MS patient tested anti-JCV antibody negative 15 months prior to PML
diagnosis and tested positive two months before PML diagnosis. The patient had received >
3 years of natalizumab + no prior IS use. At the time of testing positive, the patient had
detectable IgM and IgG antibodies. The patient changed antibody status at some point, but
the time of serochange is unknown. The patient’s anti-JCV antibody status 6 months prior to
PML diagnosis is unknown.
Biogen Idec, data on file.
TY-PAN-0463r Date of preparation: September 2012
Anti-JCV Antibody testing
• As of 5th September, 2012, there are 118 natalizumab-treated MS PML patients who had at
least one sample collected at or around the time of PML diagnosis. All tested anti-JCV
antibody positive1.
– In addition, a sample collected at the time of PML diagnosis after plasma exchange
(PLEX) tested negative1.
– Data from a Biogen Idec study of PLEX in natalizumab-treated MS patients
demonstrated that anti-JCV antibody levels are decreased 2-5 fold after PLEX and may
lead to a negative result in some patients. Anti-JCV antibody testing should not be
performed during or for at least two weeks following PLEX2.
1. Biogen Idec, data on file.
2. Natalizumab SPC
TY-PAN-0463r Date of preparation: September 2012
Geographic Distribution
• Of the 285 cases reported through 5th September 2012:
– 102 are from the United States
– 169 are from the European Economic Area
– 14 are from the rest of the world
Biogen Idec Data on file.
TY-PAN-0463r Date of preparation: September 2012
Status of PML Cases
*Natalizumab SPC
Biogen Idec Data on file.
• As of 5th September 2012:
– 62 patients have died (22%)
• Most of the deaths have occurred within approximately 2-3 months after PML diagnosis
– 223 patients are alive (78%)
• It is too early to draw conclusions about the outcomes of patients who develop PML while on natalizumab treatment
• PML may be fatal or result in severe disability*
The median time to death was 2.2 months (range, 0.1 to 15.2 months) for 44 deaths as of 29th February, 2012.
The median duration of follow-up in survivors was 13.7 months (0.5 – 44.3 months) for 166 survivors as of
29th February, 2012.
TY-PAN-0463r Date of preparation: September 2012
Estimated PML Risk Associated with Prior IS Use
• Prior IS use in the overall natalizumab-treated population was not
known and was therefore estimated from TYGRIS*
• Compared to patients who have never been treated with a prior IS
therapy, patients with prior IS use have ~3-4-fold greater risk of PML
*http://clinicaltrials.gov/ct2/show/NCT00477113 and
http://clinicaltrials.gov/ct2/show/NCT00483847
Biogen Idec Data on file.
TY-PAN-0463r Date of preparation: September 2012
No Specific Pattern in Type of Prior IS Use Identified in
Patients with PML
• Type of prior IS use varied:
– Some patients had received more than one type of IS therapy
– Types of prior IS use included*
• Mitoxantrone (n=38) • Azathioprine (n=11) • Methotrexate (n=9) • Cyclophosphamide (n=14) • Mycophenolate (n=6) • Other (n=8)
*Based on 68 out of 197 patients with PML as of February 29th 2012
(Prior IS status was unknown for 15 patients and they were excluded from the analysis).
Biogen Idec Data on file.
TY-PAN-0463r Date of preparation: September 2012
No Specific Pattern in Duration of Prior IS Use or Time from
Last Dose of IS in Patients with PML
• Duration of prior IS use varied:
– Mean 19.9 months, median 12.5 months (minimum 0.03 month,
maximum 204 months)
• Time from last dose of IS until start of natalizumab varied:
– Mean 25.8 months, median 17.2 months (minimum 0.5 months
and maximum 95.4 months)
Data based on prior IS agents reported in 68 out of 197 patients with PML as of 29th February 2012 (prior
IS status was unknown for 15 patients and they were excluded from the analysis)
Biogen Idec Data on file.
TY-PAN-0463r Date of preparation: September 2012
Risk Stratification Tool: The Presence of Anti-JCV Antibodies, Prior
Immunosuppressant Use, Treatment Duration*
Data beyond 4 years of treatment are limited. *Based on Natalizumab exposure data as of February 29, 2012; PML incidence data based on 212 confirmed PML cases as of February 29, 2012;
prior IS data in overall natalizumab-treated patients based on proportion of patients with IS use prior to Natalizumab therapy in TYGRIS as of May
2011; and prior IS data in PML patients as of September 1, 2011. The analysis assumes that 55% of natalizumab-treated MS patients were anti-JCV
antibody positive and that all PML patients test positive for anti-JCV antibodies prior to the onset and diagnosis of PML. The estimate of PML incidence
in anti-JCV antibody negative patients is based on the assumption that all patients received at least 1 dose of Natalizumab and assumes 1 hypothetical
PML case that tested negative for anti-JCV antibodies prior the onset and diagnosis of PML. Assuming that all patients received at least 18 doses of
Natalizumab and that there was 1 hypothetical PML case that tested anti-JCV antibody negative prior to PML diagnosis, the estimate of PML incidence
in anti-JCV antibody negative patients was generally consistent, 0.14 (95% CI: 0.00–0.79).
≤0.09/1000 95% CI 0-0.48
No Yes
Anti-JCV
Antibody Status
Negative Positive
Prior IS Use
Natalizumab
Exposure No Prior IS Use Prior IS Use
1–24 months 0.56/1000 95% CI 0.36-0.83
1.6/1000 95% CI 0.91-2.6
25–48 months 4.6/1000 95% CI 3.7-5.6
11.1/1000 95% CI 8.3-14.5
Bloomgren et al. N Engl J Med. 2012;366:1870-80
TY-PAN-0463r Date of preparation: September 2012
Risk Stratification Tool: The Presence of Anti-JCV Antibodies, Prior
Immunosuppressant Use, Treatment Duration*
≤0.09/1000 95% CI 0-0.48
No Yes
Anti-JCV
Antibody Status
Negative Positive
Prior IS Use
Natalizumab
Exposure No Prior IS Use* Prior IS Use*
1–24 months 0.56/1000 95% CI 0.36-0.83
1.6/1000 95% CI 0.91-2.6
25–48 months 4.6/1000 95% CI 3.7-5.6
11.1/1000 95% CI 8.3-14.5
Bloomgren et al. N Engl J Med. 2012;366:1870-80
1 in 1,786
1 in 217
1 in 625
1 in 90 < 1 in 11,000
*IS = immunosuppression
TY-PAN-0463r Date of preparation: September 2012
1. Clifford DB, et al. Lancet Neurol. 2010;9:438–446
2. Biogen Idec Data on file.
• Heightened clinical vigilance led to prompt natalizumab discontinuation upon first signs or symptoms suggestive of PML
– Median duration from symptom onset to PML diagnosis is approximately 1 month 1
• The majority of patients who developed PML in the post-marketing setting received plasma exchange (PLEX) and/or immunoadsorption (IA) to accelerate removal of natalizumab
• In the majority of natalizumab-treated patients with PML, Immune Reconstitution Inflammatory Syndrome (IRIS) has occurred after discontinuation or removal (by PLEX) of natalizumab
• In patients who have undergone PLEX, IRIS has occurred within days to several weeks2
Key Learnings: PML Management
TY-PAN-0463r Date of preparation: September 2012
At this time, there are insufficient data to predict survival outcomes in patients treated with natalizumab who develop PML.
Longer-term data are required in order to more accurately predict such outcomes.
Factors that may affect survival in Patients with PML
Vermersch P et al. Neurology 2011; 76: 1697 – 1704
Biogen Idec Data on file.
• Gender
• Prior immunosuppressant
therapy
• MS duration
• Natalizumab exposure at
PML diagnosis
• JCV DNA load in CSF at PML
diagnosis
• Gd enhancement on MRI at
diagnosis
Factors that appear to be
associated with decreased
survival Factors that do not appear to affect
survival
Factors that appear to be
associated with improved
survival
• Younger age at PML
diagnosis
• Lower pre-PML EDSS
• Shorter time from first
symptoms of PML to
diagnosis
• Localized PML extension
on MRI at diagnosis
TY-PAN-0463r Date of preparation: September 2012
Clinical Status of PML Cases Based on outcomes from the 140 survivors out of the 175 confirmed PML cases as of 21st
October 2011
Follow-up Time From PML Diagnosis (months)
Survivors at Follow-up Time with Karnofsky** reported, n
Functional Status of Survivors
Mild Disability,
n (%)
Moderate Disability,
n (%)
Severe Disability, n
(%)
≥ 6 58 6 (10%) 29 (50%) 23 (40%)*
≥ 9 28 3 (11%) 16 (57%) 9 (32%)
*Majority of patients with severe disability at ≥ 6 months from diagnosis (21/23, 91%) had Karnofsky scores of 40
which is at the interface between moderate and severe disability
• Of the 58 patients with ≥ 6 months follow-up and Karnofsky scores, 19 patients also had pre-PML Karnofsky scores
reported:
• Mean change in Karnofsky following PML: Decrease by 26
• Median change in Karnofsky following PML: Decrease by 20
Biogen Idec, Data on file.
** Karnofsky DA, Burchenal JH. In: MacLeod CM, ed. Evaluation of Chemotherapeutic Agents.
New York, NY: Columbia University Press; 1948:196.
Pre-PML Functional Status (N=19) Functional Status following PML
Mild disability pre-PML (N=12) Mild Disability 2 (16%)
Moderate Disability 5 (42%)
Severe Disability 5 (42%)
Moderate disability pre-PML (N=7) Moderate Disability 6 (86%)
Severe Disability 1 (14%)
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