Evaluation of Safety, Efficacy and Pharmacodynamic Effect of Bertilimumab in Patients With Bullous Pemphigoid

An Open-Label, Proof of Concept Study Designed to Evaluate the Safety, Efficacy and Pharmacodynamic Effect of Bertilimumab in Patients With Newly Diagnosed, Moderate to Extensive Bullous Pemphigoid

This is an open-label, proof-of-concept, single group study in adult patients with newly diagnosed, moderate to extensive BP.

The study will consist of three periods: a screening period of up to 2 weeks, an open-label treatment period lasting 4 weeks consisting of IV infusion of bertilimumab on Days 0 and 14 and 28, and a safety and efficacy follow-up period of approximately 13 weeks.

Patients will receive concomitant oral steroids during the treatment and follow-up period.

Study Overview

• Status: Completed
• Conditions: Pemphigoid, Bullous
• Intervention / Treatment: Biological: Bertilimumab

Detailed Description

This is an open-label, proof-of-concept, single group study in adult patients with newly diagnosed, moderate to extensive BP.

The study will consist of three periods: a screening period of up to 2 weeks, an open-label treatment period lasting 4 weeks consisting of IV infusion of bertilimumab on Days 0 and 14 and Day 28, and a safety and efficacy follow-up period of approximately 13 weeks.

Patients will receive concomitant oral steroids during the treatment and follow-up period. They will start on 30 mg prednisone daily (or equivalent). The initial dose will be maintained for at least 1 week, commencing on Day 0, until blister formation has ceased, crusts and erosions have disappeared and reepithelialization of lesions has started. The corticosteroid dose will then be reduced to 20 mg daily for 5 to 14 days. According to clinical response, this will be followed by corticosteroid dose reduction in 5 mg steps every 5 to 14 days until a dose of 10 mg daily is reached and then corticosteroid dose reduction in 2.5 mg steps every 5 to 14 days until the end of the study.

• Study Type: Interventional
• Enrollment (Actual): 11
• Phase: Phase 2

Contacts and Locations

Study Locations

• Israel
  • Ramat Gan, Israel, 5262100
    • Chaim Sheba MC, Tel-Hashomer
  • Tel Aviv, Israel, 64239
    • Sourasky-Ichilov Tel Aviv Medical Center
• United States
  • Iowa
    • Iowa City, Iowa, United States
      • University of Iowa
  • New York
    • Buffalo, New York, United States
      • University at Buffalo
    • New York, New York, United States
      • Icahn School of Medicine at Mount Sinai
  • North Carolina
    • Durham, North Carolina, United States
      • Duke University Medical Center
  • Ohio
    • Cleveland, Ohio, United States, 10900
      • University of Cleveland
  • Utah
    • Salt Lake City, Utah, United States
      • University of Utah

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 60 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. Males or females, ≥ 60 years of age.
2. Karnofsky performance status > 60%

3. Newly diagnosed, Bullous Pemphigoid per standard diagnostic criteria:

   • Clinical presentation [2]
   • Skin biopsy from a fresh blister showing subepidermal clefting and an inflammatory infiltrate consisting mainly of eosinophils
   • Immunofluorescence (IF) studies performed on uninvolved skin collected approximately 1 cm away from a fresh blister showing linear deposition of IgG and/or C3 along the basement membrane zone.
4. Moderate to extensive Bullous Pemphigoid defined by the mean number of new bullae and urticarial plaques that have appeared over the course of 3 days as determined by the investigator or referring physician (moderate disease defined by > 1 and ≤ 10 new bullae daily and ≥ 5 urticarial plaques and extensive disease by >10 new bullae daily) [3].
5. Adequate cardiac, renal and hepatic function as determined by the Investigator and demonstrated by screening laboratory evaluations, vital sign measurement, ECG recording and physical examination results.
6. Females of childbearing potential must agree to use effective contraception consistently throughout the study (such as hormonal contraception or two forms of barrier contraception) and have a negative serum pregnancy test at screening and a negative urine pregnancy test per the schedule of visits. Women are considered post-menopausal and not of childbearing potential if they have had 12 months of amenorrhea or have had surgical bilateral oophorectomy (with or without hysterectomy) or tubal ligation at least six weeks previously.
7. Males must have had a vasectomy or have expressed that they have no interest in fertility in the future.
8. Fertile males must agree to use effective contraception consistently throughout the study and for a period of four months following the end of study drug administration.
9. Willing and able to adhere to the study visit schedule and other protocol requirements.
10. Willing and able to provide voluntary written informed consent or written informed consent from a legally authorized representative with assent from the patient.

Exclusion criteria:

1. Patients with severe medical or surgical conditions at screening or baseline including, but not limited to, severe dementia or mental impairment, severe stroke, severe cardiac insufficiency, severe arterial hypertension, severe or uncontrolled renal, hepatic, hematological, gastrointestinal, endocrine, pulmonary, cardiac, neurologic, cerebral, psychiatric, or any other severe acute or chronic medical condition that may increase the risk associated with study participation/treatment or may interfere with the interpretation of study results and, in the Investigator's opinion, would make the patient inappropriate for study entry.
2. Presence of any malignancy that has been under active treatment (e.g., radiotherapy or chemotherapy) within the 2 years prior to baseline or is anticipated to require treatment during the study period (including follow up) with the exception of patients with removal of uncomplicated basal cell carcinoma or cutaneous squamous cell carcinoma, who may take part in the study.
3. Congenital or acquired immunodeficiency (e.g., common variable immunodeficiency, organ transplantation).
4. Clinically significant vital sign measurements or ECG findings as determined by the Investigator.

5. Clinically significant abnormal laboratory test results, unless regarded by the Investigator as related to BP, including but not limited to:

   • Hemoglobin level <10.0 g/dL
   • White blood cell count < 3 x 103/μL
   • Lymphocyte count < 0.5 x 103/μL
   • Platelet count <100 x 103/μL or >1200 x 103/μL
   • Alanine aminotransferase (ALT) or aspartate aminotransferase (AST) >3 the upper limit of normal (ULN)
   • Alkaline phosphatase >3 ULN
   • Serum creatinine >2 ULN
6. Patients with mild, relapsed or refractory Bullous Pemphigoid. Mild disease defined by the mean number of new lesions that have appeared over the course of 3 days as determined by the investigator or referring physician, as follows: ≤ 1 bulla or < 5 urticarial plaques.
7. Concomitant skin conditions preventing physical evaluation of Bullous Pemphigoid.
8. Active or recent history of clinically significant infection within 1 month of baseline.
9. Pregnant or breast-feeding, or planning to become pregnant during the study.
10. Participation in a clinical trial of an investigational (unapproved) product within 4 weeks of baseline.
11. Known hypersensitivity to bertilimumab or any of the drug excipients.
12. Use of prednisone or other systemic steroids (excluding inhaled or ocular use of steroids) within 4 weeks prior to baseline. (Concomitant oral corticosteroids administered as part of the study protocol, from Day 0 onward, are allowed). Use of class 1 and 2 topical steroids (such as clobetasol propionate cream, reference Appendix D for further guidance) within 4 weeks prior to baseline. (Use of other topical steroids is allowed throughout the study at the discretion of the investigator).
13. Treatment with immunosuppressants (e.g., azathioprine, methotrexate) within 4 weeks prior to baseline.
14. Treatment with biologics (e.g., etanercept, adalimumab, ustekinumab, infliximab, intravenous Ig) within 4 months of baseline. Patients who have received rituximab within 1 year of baseline will be excluded from study participation.
15. Treatment with macrolides or tetracyclines within 4 weeks prior to baseline.
16. Received a vaccine or other immunostimulator within 4 weeks prior to baseline. Subject has current clinical, radiographic or laboratory evidence of active mycobacterium tuberculosis (TB) infection or prior evidence of active TB that, in the opinion of the investigator, has not been adequately treated or controlled and that represents a reactivation risk. If in the investigator's opinion the patient is at risk for latent TB, the patient should be evaluated for active/latent TB as applicable (e.g. PPD, QFT, and/or chest x-ray).

18. Evidence of an active disease of hepatitis B (HBsAg positive or HBcAb positive) or hepatitis C (HCV ab positive), CMV (IgM positive) or human immunodeficiency virus (HIV) infection (HIV1/2 Ab positive 19. Active abuse of alcohol or drugs. 20. Any other condition, which in the opinion of the Investigator would place the patient at an unacceptable risk if participating in the study protocol.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Bertilimumab; Intravenous injection over 30 minutes of 10 mg/kg of Bertilimumab in physiological solution (PBS)	Biological: Bertilimumab

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Safety Endpoints	Safety outcome would be assessed as the number of the following events which the participants experienced throughout the study: Number if Adverse events (AE); Injection site reactions after infusions; Abnormal Physical findings during the examination; Abnormal Vital signs (blood pressure, heart rate, temperature); Abnormal ECG; Number of Concomitant medications taken; Abnormal Laboratory values; Development of anti-bertilimumab antibodies	Participants will be followed for the duration of the study , an expected average of 118 days

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Efficacy Endpoint: Change in Bullous Pemphigoid Disease Area Index (BPDAI)	The BPDAI is a validated measure of bullous pemphigoid disease activity consisting of four subscores: skin blistering (0-120), uricaria (0-120), mucosal blistering (0-120) and damage/pigmentation (0-12). The activity score consists of the first three subscored (0-360) • Change in BPDAI Activity Score at each scheduled measurement timepoint	Participants will be followed for the duration of the study, an expected average of 84 days
Efficacy Endpoint: BPDAI responders	• Proportion of subjects who achieve a reduction in BPDAI Activity Score of at least 50%, 75% and 90% at Days 42, 56, 70 or 84	Participants will be followed for the duration of the study, an expected average of 84 days
Efficacy Endpoint: Prednisone dose	• Proportion of subjects who have tapered to prednisone dose of ≤10 mg/day at at Days 42, 56, 70 or 84	Participants will be followed for the duration of the study, an expected average of 84 days
Efficacy Endpoint: Change in BPDAI pruritus component	• Change in pruritus visual analog scale (the sum of three 0-10 pruritus assessments: pruritus intensity over the prior day, week and month) at each scheduled measurement timepoint	Participants will be followed for the duration of the study, an expected average of 84 days
Efficacy Endpoint: Change in Autoimmune Bullous Disease Quality of Life (ABQOL)	The ABQOL questionnaire is a validated 17 item questionnaire (range 0-51) assessing quality of life in patients with autoimmune blistering diseases • ABQOL assessed at each scheduled measurement timepoint	Participants will be followed for the duration of the study, an expected average of 84 days
Efficacy Endpoint: Control of disease activity	Control of disease activity is defined as the time when at least two of the following occur: new lesions cease to form, established lesions begin to heal and/or pruritic symptoms start to abate. • Mean time from baseline to control of disease activity	Participants will be followed for the duration of the study, an expected average of 84 days

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pharmacokinetic (PK) Endpoints - Cmax	• PK analysis for bertilimumab concentration: blood samples will be collected on dosing days (pre-dose, and at 30 minutes and 4 hours following initiation of study drug infusion) and once at remaining study visits (excluding screening). The following PK parameters will be calculated, to the degree possible given the number of timepoints: Cmax, Tmax, AUC, Vdist and t1/2. Additional standard and exploratory PK parameters will be calculated if deemed necessary. Cmax is the maximum bertilimumab serum concentration observed.	Participants will be followed the duration of the study, an expected average of 84 days
Pharmacokinetic (PK) Endpoints - Tmax	• Tmax is the time until Cmax	Participants will be followed the duration of the study, an expected average of 84 days
Pharmacokinetic (PK) Endpoints - AUC	• AUC is the area under the curve	Participants will be followed the duration of the study, an expected average of 84 days
Pharmacokinetic (PK) Endpoints - Vdist	• Vdist is the volume of ditribution	Participants will be followed the duration of the study, an expected average of 84 days
Pharmacokinetic (PK) Endpoints - T1/2	• T1/2 is the elimination half life	Participants will be followed the duration of the study, an expected average of 84 days
Pharmacodynamic Endpoint: Change in autoantibody titres	• Change in BP180 and BP230 autoantibody titres at each scheduled sampling timepoint compared to baseline	Participants will be followed the duration of the study, an expected average of 84 days
Pharmacodynamic Endpoint: Change in blood eosinophil count	• Change in blood eosinophil count at each scheduled sampling timepoint compared to baseline	Participants will be followed the duration of the study, an expected average of 84 days
Pharmacodynamic Endpoint: Change in tissue eosinophil count	• Change in tissue eosinophil count assessed on biopsy at the scheduled timepoint compared to screening	Participants will be followed the duration of the study, an expected average of 84 days
Pharmacodynamic Endpoint: Change in serum eotaxin-1 level	• Change in serum eotaxin-1 level at each scheduled sampling timepoint compared to baseline	Participants will be followed the duration of the study, an expected average of 84 days
Exploratory Endpoint: Change in biomarkers	Change in PBMC biomarkers at each scheduled timepoint compared to baseline, including but not limited to: CD4, CD25, CD8, CD69, CD62L, CCR3 and Foxp3 via flow cytometry analyses.; Change in Eosinophil Cationic Protein serum levels	Participants will be followed the duration of the study, an expected average of 84 days

Collaborators and Investigators

• Sponsor: Immune Pharmaceuticals
• Investigators: Principal Investigator: Eli Sprecher, MD, Sourasky-Ichilov Tel Aviv Medical Center

Study record dates

Study Major Dates

• Study Start (Actual): February 1, 2016
• Primary Completion (Actual): April 1, 2018
• Study Completion (Actual): April 1, 2018

Study Registration Dates

• First Submitted: July 27, 2014
• First Submitted That Met QC Criteria: August 26, 2014
• First Posted (Estimate): August 27, 2014

Study Record Updates

• Last Update Posted (Actual): May 23, 2018
• Last Update Submitted That Met QC Criteria: May 21, 2018
• Last Verified: May 1, 2018

More Information

Terms related to this study

• Keywords: BP; Blisters; Pemphigoid Bullous; Bullous; SKIN DISEASES
• Additional Relevant MeSH Terms: Skin Diseases; Immune System Diseases; Autoimmune Diseases; Skin Diseases, Vesiculobullous; Pemphigoid, Bullous
• Other Study ID Numbers: Immune/BRT/BP-01