Phase 3 Study of Obeticholic Acid in Patients With Primary Biliary Cirrhosis (POISE)

A Phase 3, Double-Blind, Placebo-Controlled Trial and Long-Term Safety Extension of Obeticholic Acid in Patients With Primary Biliary Cirrhosis

The main objectives of the study were to assess the effects of Obeticholic Acid (OCA) on serum alkaline phosphatase (ALP) and total bilirubin, together as a composite endpoint and on safety in participants with primary biliary cirrhosis (PBC).

Study Overview

• Status: Completed
• Conditions: Primary Biliary Cirrhosis
• Intervention / Treatment: Drug: Obeticholic Acid (OCA); Drug: Placebo

Detailed Description

The study included 2 phases: a 12-month randomized, double-blind (DB), placebo-controlled, parallel group phase, followed by a long-term safety extension (LTSE) phase up to 5 years. Participants from the 12-month DB phase, including those who received placebo, were eligible to participate in the open-label LTSE phase. The Month 12 visit from the DB phase served as the Day 1 visit of the LTSE phase. After completion of the 12-month DB phase all participants were offered the opportunity to enter an open-label LTSE for up to 5 years beginning at 5 mg OCA.

Data for the LTSE phase is reported by the randomized dose group assigned in the DB phase.

• Study Type: Interventional
• Enrollment (Actual): 217
• Phase: Phase 3

Contacts and Locations

Study Locations

• Australia
  • New South Wales
    • Camperdown, New South Wales, Australia, 2050
      • Royal Prince Alfred Hospital
  • Victoria
    • Heidelberg, Victoria, Australia, 3084
      • Austin Hospital
    • Melbourne, Victoria, Australia, 3004
      • The Alfred Hospital
• Austria
  • Innsbruck, Austria, 6020
    • Medizinische Universität Innsbruck
  • Wien, Austria, 1090
    • Medizinische Universitat Wien
• Belgium
  • Leuven, Belgium, B-3000
    • UZ Leuven
• Canada
  • Ontario
    • Toronto, Ontario, Canada, M5T 2S8
      • Toronto Western Hospital Liver Centre
  • Quebec
    • Montreal, Quebec, Canada, H2X 3J4
      • CHUM Hopital St-Luc
• France
  • Pessac, France, 33604
    • Hôpital Haut-Lévêque
• Germany
  • Aachen, Germany, D-52074
    • Universitätsklinikum Aachen
  • Erlangen, Germany, D-91054
    • Friedrich-Alexander-Universität Erlangen
  • Frankfurt am Main, Germany, 60590
    • Klinikum der Johann-Wolfgang Goethe Universität Frankfurt am Main
  • Hamburg, Germany, 20246
    • Universitatsklinikum Hamburg Eppendorf
  • Hannover, Germany, D-30625
    • Medizinische Hochschule Hannover
  • Heidelberg, Germany, D-69120
    • Medizinische Universitätsklinik
  • Herne, Germany, D-44623
    • Gastroenterologische Gemeinschaftspraxis, Dres. Felten / Hartmann / Hüppe
  • Homburg, Germany, 66421
    • Universitätsklinikum des Saarlandes
  • Leipzig, Germany, 04103
    • Universitätsklinikum Leipzig
  • München, Germany, D-81377
    • LMU Klinikum der Universität München
• Italy
  • Bologna, Italy, 40138
    • Dip. Medicina Clinica - Università di Bologna
  • Bologna, Italy, 40138
    • Dip. Medicina Clinica- Università di Bologna
  • Padova, Italy, 35128
    • Azienda Ospedaliera di Padova - Gastroenterologia
  • Rozzano (MI), Italy, 20089
    • Istituto Clinico Humanitas
• Netherlands
  • Amsterdam, Netherlands, 1105 AZ
    • AMC Amsterdam
  • Amsterdam, Netherlands, 1081 HV
    • VUMC Amsterdam
  • Nijmegen, Netherlands, 6525
    • UMC St. Radboud, Nijmegen
  • Utrecht, Netherlands, 3508 GA
    • UMC Utrecht
• Poland
  • Katowice, Poland, 40-660
    • All-Medicus
  • Katowice, Poland, 40-752
    • Klinika Gastroenterologii i Hepatologii SP CSK im. prof. K. Gibinskiego SUM
  • Lublin, Poland, 20-954
    • Samodzielny Publiczny Szpital Kliniczny nr 4 w Lublinie
  • Szczecin, Poland, 70-361
    • Niepubliczny Zakład Opieki Zdrowotnej "SONOMED"
  • Warszawa, Poland, 02-781
    • Centrum Onkologii - Instytut im. Marii Skłodowskiej - Curie, Klinika Gastroenterologii
• Spain
  • Barcelona, Spain, 08036
    • Hospital Clinic De Barcelona
  • Barcelona, Spain, 08035
    • Hospital Vall d'Hebron
• Sweden
  • Gothenburg, Sweden, SE-41345
    • Sahlgrenska University Hospital
• United Kingdom
  • Birmingham, United Kingdom, B15 2TH
    • Queen Elizabeth Hospital
  • Bristol, United Kingdom, BS2 8HW
    • Bristol Royal Infirmary
  • Dundee, United Kingdom, DD1 9SY
    • Ninewells Hospital Dundee
  • Larbert, United Kingdom, FK5 4WR
    • Forth Valley Royal Hospital
  • London, United Kingdom, NW3 2QG
    • The Royal Free Hospital
  • Manchester, United Kingdom, M13 9WL
    • Manchester Royal Infirmary
  • Newcastle Upon Tyne, United Kingdom, NE2 4 HH
    • Institute of Cellular Medicine, Newcastle University
  • Nottingham, United Kingdom, NG7 2UH
    • Nottingham University Hospitals NHS Trust
  • Oxford, United Kingdom, OX3 9DU
    • Oxford University Hospitals Trust
• United States
  • California
    • Sacramento, California, United States, 95817
      • UC Davis Medical Center
    • San Diego, California, United States, 92037
      • Scripps Clinic
  • Colorado
    • Aurora, Colorado, United States, 80045
      • University of Colorado, Denver
  • Illinois
    • Chicago, Illinois, United States, 60637
      • University of Chicago
  • Indiana
    • Indianapolis, Indiana, United States, 46202
      • Indiana University School of Medicine
  • Michigan
    • Detroit, Michigan, United States, 48377
      • Henry Ford Health System
  • Missouri
    • Saint Louis, Missouri, United States, 63104
      • St. Louis University
  • New York
    • New York, New York, United States, 10003
      • Beth Israel Medical Center
  • North Carolina
    • Durham, North Carolina, United States, 27710
      • Duke University Medical Center
  • Texas
    • Dallas, Texas, United States, 75390
      • University of Texas Southwestern Medical Center
    • Houston, Texas, United States, 77030
      • Baylor College of Medicine
  • Virginia
    • Newport News, Virginia, United States, 23602
      • Liver Institute of Virginia
    • Richmond, Virginia, United States, 23226
      • Liver Institute of Virginia
    • Richmond, Virginia, United States, 23249
      • Virginia Commonwealth University/McGuire DVAMC
  • Washington
    • Seattle, Washington, United States, 98101
      • Swedish Medical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. Definite or probable PBC diagnosis (consistent with American Association for the Study of Liver Disease [AASLD] and European Association for Study of the Liver [EASL] Practice Guidelines; [Lindor 2009; EASL 2009]), as demonstrated by the presence of ≥ 2 of the following 3 diagnostic factors:

   • History of elevated alkaline phosphatase (ALP) levels for at least 6 months
   • Positive antimitochondrial antibodies (AMA) titer or if AMA negative or in low titer (<1:80) PBC specific antibodies (anti-GP210 and/or anti-SP100 and/or antibodies against the major M2 components (pyruvate dehydrogenase complex-E2 [PDC-E2], 2-oxo-glutaric acid dehydrogenase complex)
   • Liver biopsy consistent with PBC

2. At least 1 of the following qualifying biochemistry values:

   • ALP ≥ 1.67x upper limit of normal (ULN)
   • Total bilirubin > ULN but < 2x ULN
3. Age ≥ 18 years
4. Taking ursodeoxycholic acid (UDCA) for at least 12 months (stable dose for ≥ 3 months) prior to Day 0, or unable to tolerate UDCA (no UDCA for ≥ 3 months) prior to Day 0.

5. Contraception: Female participants must be postmenopausal, surgically sterile, or if premenopausal, be prepared to use ≥ 1 effective (≤ 1% failure rate) method of contraception during the trial and for 30 days after the end of treatment (EOT) visit. Effective methods of contraception are considered to be:

   • Hormonal (for example, contraceptive pill, patch, intramuscular implant or injection); or
   • Double barrier method, that is, (a) condom (male or female) or (b) diaphragm, with spermicide; or
   • Intrauterine device (IUD); or
   • Vasectomy (partner); or
   • Sexual abstinence
6. Must provide written informed consent and agree to comply with the trial protocol.

Exclusion Criteria:

1. History or presence of other concomitant liver diseases including:

   • Hepatitis C virus (HCV) infection; participants with active hepatitis B (HBV) infection will be excluded, however, participants who have seroconverted (hepatitis B surface antigen [Hbs Ag] and hepatitis B e antigen [Hbe Ag] negative) may be included after consultation with the medical monitor.
   • Primary sclerosing cholangitis (PSC)
   • Alcoholic liver disease
   • Definite autoimmune liver disease or overlap hepatitis
   • Nonalcoholic steatohepatitis (NASH)
   • Gilbert's Syndrome (due to interpretability of bilirubin levels)

2. Presence of clinical complications of PBC or clinically significant hepatic decompensation, including:

   • History of liver transplantation, current placement on a liver transplant list or current Model for End Stage Liver Disease (MELD) score ≥ 15
   • Portal hypertension with complications, including: known gastric or large esophageal varices, poorly controlled or diuretic resistant ascites, history of variceal bleeds or related therapeutic or prophylactic interventions (for example, beta blockers, insertion of variceal bands or transjugular intrahepatic portosystemic shunt [TIPS]), or hepatic encephalopathy
   • Cirrhosis with complications, including history or presence of: spontaneous bacterial peritonitis, hepatocellular carcinoma, bilirubin > 2x ULN
   • Hepatorenal syndrome (type I or II) or Screening serum creatinine > 2 mg/deciliter dL) (178 micromole [µmol])/liter [L])
3. Participants with severe pruritus or those requiring systemic treatment for pruritus (for example, with bile acid sequestrants [BAS] or rifampicin) within 2 months of Day 0 will be excluded

4. Administration of the following medications is prohibited as specified below:

   • Prohibited 6 months prior to Day 0 and throughout the trial (that is, to last dose and/or EOT): azathioprine, colchicine, cyclosporine, methotrexate, mycophenolate mofetil, pentoxifylline; fenofibrate or other fibrates; budesonide and other systemic corticosteroids; potentially hepatotoxic drugs (including α-methyl-dopa, sodium valproic acid, isoniazide, or nitrofurantoin)
   • Prohibited 12 months prior to Day 0 and throughout the trial (that is, to last dose and/or EOT): antibodies or immunotherapy directed against interleukins or other cytokines or chemokines
5. Participants who have previously participated in a clinical trial of OCA will not be allowed to participate
6. History or presence of clinically concerning cardiac arrhythmias likely to affect survival during the trial, or prolongation of Screening (pretreatment) QT or QTc interval of > 500 milliseconds (msec)
7. If female: known pregnancy, or has a positive urine pregnancy test (confirmed by a positive serum pregnancy test), or lactating
8. Known history of human immunodeficiency virus (HIV) infection
9. Presence of any other disease or condition that is interfering with the absorption, distribution, metabolism, or excretion of drugs including bile salt metabolism in the intestine. Participants with inflammatory bowel disease or who have undergone gastric bypass procedures will be excluded (gastric lap band is acceptable).
10. Medical conditions that may cause nonhepatic increases in ALP (for example, Paget's disease) or which may diminish life expectancy to < 2 years, including known cancers (except carcinomas in situ or other stable, relatively benign conditions such as chronic lymphatic leukemia)
11. Other clinically significant medical conditions that are not well controlled or for which medication needs are anticipated to change during the trial
12. Anticipated changes to current concomitant medications during the course of the trial
13. History of alcohol abuse, defined as consumption of more than 210 mL of alcohol per week (that is, the equivalent of fourteen 4-ounce (125 mL) glasses of wine or fourteen 12 ounce cans/bottles of beer), or other substance abuse within 1 year prior to Day 0
14. Participation in another investigational drug, biologic, or medical device trial within 30 days prior to Screening
15. History of noncompliance with medical regimens, or participants who are considered to be potentially unreliable
16. Blood or plasma donation within 30 days prior to Day 0
17. Mental instability or incompetence, such that the validity of informed consent or compliance with the trial is uncertain

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

4

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: DB OCA 5-10 mg; OCA 5 milligram (mg) for 6 months and then titrating up to 10 mg based on tolerability and response for remaining 6 months of the DB phase.	Drug: Obeticholic Acid (OCA); OCA was administered orally once daily and provided in tablet form in 2 strengths: 5 mg and 10 mg.; Other Names: INT-747; 6α-ethyl chenodeoxycholic acid (6-ECDCA)
Experimental: DB OCA 10 mg; OCA 10 mg for 12 months during the DB phase.	Drug: Obeticholic Acid (OCA); OCA was administered orally once daily and provided in tablet form in 2 strengths: 5 mg and 10 mg.; Other Names: INT-747; 6α-ethyl chenodeoxycholic acid (6-ECDCA)
Placebo Comparator: DB Placebo; Matching placebo for 12 months during the DB phase.	Drug: Placebo; Matching placebo tablets were administered orally once daily.
Experimental: LTSE OCA; After completion of the 12-month DB phase all participants were offered the opportunity to enter an open-label LTSE for up to 5 years beginning at 5 mg OCA. Initially, participants were allowed to titrate to doses up to 25 mg, however, the maximum dose was then limited to 10 mg. Participants who were previously titrated above 10 mg OCA daily were down-titrated to ≤10 mg OCA daily.	Drug: Obeticholic Acid (OCA); OCA was administered orally once daily and provided in tablet form in 2 strengths: 5 mg and 10 mg.; Other Names: INT-747; 6α-ethyl chenodeoxycholic acid (6-ECDCA)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
DB Phase: Composite Endpoint Alkaline Phosphatase (ALP) And Total Bilirubin, 10 mg OCA Versus Placebo	Percentage of participants at Month 12 with ALP < 1.67 x upper limit of normal (ULN) and total bilirubin ≤ ULN and ALP decrease of ≥ 15% from baseline.	DB Month 12
LTSE Phase: Composite Endpoint ALP And Total Bilirubin	Percentage of participants at Months 24, 36, 48, and 60 with ALP < 1.67x ULN and total bilirubin ≤ ULN and ALP decrease of ≥ 15% from baseline. DB Month 12 is the baseline for the LTSE phase.	Baseline (DB Month 12), LTSE Months 24, 36, 48, and 60

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
DB Phase: Composite Endpoint ALP And Total Bilirubin, 10 mg Versus Placebo	Percentage of participants at Month 6 with ALP < 1.67x ULN and total bilirubin ≤ ULN and ALP decrease of ≥ 15% from baseline.	DB Month 6
DB Phase: Composite Endpoint ALP And Total Bilirubin, 5-10 mg Versus Placebo	Percentage of participants at Month 12 with ALP < 1.67x ULN and total bilirubin ≤ ULN and ALP decrease of ≥ 15% from baseline.	DB Month 12
DB Phase: Composite Endpoint ALP And Total Bilirubin, 5-10 mg Versus Placebo	Percentage of participants at Month 6 with ALP < 1.67x ULN and total bilirubin ≤ ULN and ALP decrease of ≥ 15% from baseline.	DB Month 6
DB Phase: ALP Absolute Change From Baseline To Month 12	Blood samples were evaluated for ALP levels. ALP Absolute Change From Baseline (ALP at Month 12 - ALP at Baseline) is presented.	Baseline, DB Month 12
DB Phase: Total Bilirubin Absolute Change From Baseline To Month 12	Blood samples were evaluated for bilirubin levels. Total bilirubin absolute change from baseline (total bilirubin at Month 12 - total bilirubin at Baseline) is presented.	Baseline, DB Month 12
DB Phase: Direct Bilirubin Absolute Change From Baseline To Month 12	Blood samples were evaluated for bilirubin levels. Direct bilirubin absolute change from baseline (direct bilirubin at Month 12 - direct bilirubin at Baseline) is presented.	Baseline, DB Month 12
DB Phase: Alanine Aminotransferase (ALT) Absolute Change From Baseline To Month 12	Blood samples were evaluated for ALT levels. ALT absolute change from baseline (ALT at Month 12 - ALT at Baseline) is presented.	Baseline, DB Month 12
DB Phase: Aspartate Aminotransferase (AST) Absolute Change From Baseline To Month 12	Blood samples were evaluated for AST levels. AST absolute change from baseline (AST at Month 12 - AST at Baseline) is presented.	Baseline, DB Month 12
DB Phase: Gamma-glutamyltransferase (GGT) Absolute Change From Baseline To Month 12	Blood samples were evaluated for GGT levels. GGT absolute change from baseline (GGT at Month 12 - GGT at Baseline) is presented.	Baseline, DB Month 12
LTSE Phase: ALP Levels	Blood samples were evaluated for ALP levels.	LTSE Day 0 and LTSE Months 12, 24, 36, 48, and 60
LTSE Phase: ALP Change From DB Baseline	Blood samples were evaluated for ALP levels. ALP Change From Baseline (ALP at LTSE Months 12, 24, 36, 48, and 60 - ALP at Baseline) is presented. DB baseline is the mean of all available evaluations prior to DB treatment.	DB Baseline, LTSE Months 12, 24, 36, 48, and 60

Collaborators and Investigators

• Sponsor: Intercept Pharmaceuticals
• Investigators: Study Chair: Christian Weyer, MD, Intercept Pharmaceuticals, Inc.

Publications and helpful links

General Publications

• Lindor KD, Gershwin ME, Poupon R, Kaplan M, Bergasa NV, Heathcote EJ; American Association for Study of Liver Diseases. Primary biliary cirrhosis. Hepatology. 2009 Jul;50(1):291-308. doi: 10.1002/hep.22906. No abstract available.
• Nevens F, Andreone P, Mazzella G, Strasser SI, Bowlus C, Invernizzi P, Drenth JP, Pockros PJ, Regula J, Beuers U, Trauner M, Jones DE, Floreani A, Hohenester S, Luketic V, Shiffman M, van Erpecum KJ, Vargas V, Vincent C, Hirschfield GM, Shah H, Hansen B, Lindor KD, Marschall HU, Kowdley KV, Hooshmand-Rad R, Marmon T, Sheeron S, Pencek R, MacConell L, Pruzanski M, Shapiro D; POISE Study Group. A Placebo-Controlled Trial of Obeticholic Acid in Primary Biliary Cholangitis. N Engl J Med. 2016 Aug 18;375(7):631-43. doi: 10.1056/NEJMoa1509840.
• Trauner M, Nevens F, Shiffman ML, Drenth JPH, Bowlus CL, Vargas V, Andreone P, Hirschfield GM, Pencek R, Malecha ES, MacConell L, Shapiro D. Long-term efficacy and safety of obeticholic acid for patients with primary biliary cholangitis: 3-year results of an international open-label extension study. Lancet Gastroenterol Hepatol. 2019 Jun;4(6):445-453. doi: 10.1016/S2468-1253(19)30094-9. Epub 2019 Mar 26.
• Harms MH, Hirschfield GM, Floreani A, Mayo MJ, Pares A, Liberman A, Malecha ES, Pencek R, MacConell L, Hansen BE. Obeticholic acid is associated with improvements in AST-to-platelet ratio index and GLOBE score in patients with primary biliary cholangitis. JHEP Rep. 2020 Sep 29;3(1):100191. doi: 10.1016/j.jhepr.2020.100191. eCollection 2021 Feb.
• Bowlus CL, Pockros PJ, Kremer AE, Pares A, Forman LM, Drenth JPH, Ryder SD, Terracciano L, Jin Y, Liberman A, Pencek R, Iloeje U, MacConell L, Bedossa P. Long-Term Obeticholic Acid Therapy Improves Histological Endpoints in Patients With Primary Biliary Cholangitis. Clin Gastroenterol Hepatol. 2020 May;18(5):1170-1178.e6. doi: 10.1016/j.cgh.2019.09.050. Epub 2019 Oct 10.
• Mousa HS, Lleo A, Invernizzi P, Bowlus CL, Gershwin ME. Advances in pharmacotherapy for primary biliary cirrhosis. Expert Opin Pharmacother. 2015 Apr;16(5):633-43. doi: 10.1517/14656566.2015.998650. Epub 2014 Dec 29.

Study record dates

Study Major Dates

• Study Start: January 1, 2012
• Primary Completion (Actual): December 1, 2013
• Study Completion (Actual): December 17, 2018

Study Registration Dates

• First Submitted: November 14, 2011
• First Submitted That Met QC Criteria: November 16, 2011
• First Posted (Estimate): November 17, 2011

Study Record Updates

• Last Update Posted (Actual): May 6, 2021
• Last Update Submitted That Met QC Criteria: April 9, 2021
• Last Verified: April 1, 2021

More Information

Terms related to this study

• Keywords: Cirrhosis; Liver; Primary Biliary Cholangitis; PBC; Primary Biliary Cirrhosis
• Additional Relevant MeSH Terms: Digestive System Diseases; Pathologic Processes; Liver Diseases; Biliary Tract Diseases; Bile Duct Diseases; Cholestasis, Intrahepatic; Cholestasis; Fibrosis; Liver Cirrhosis; Liver Cirrhosis, Biliary; Gastrointestinal Agents; Cathartics; Chenodeoxycholic Acid
• Other Study ID Numbers: 747-301