Maribavir for Refractory Cytomegalovirus Infections With or Without Resistance Post-Transplant: Results From a Phase 3 Randomized Clinical Trial
Robin K Avery, Sophie Alain, Barbara D Alexander, Emily A Blumberg, Roy F Chemaly, Catherine Cordonnier, Rafael F Duarte, Diana F Florescu, Nassim Kamar, Deepali Kumar, Johan Maertens, Francisco M Marty, Genovefa A Papanicolaou, Fernanda P Silveira, Oliver Witzke, Jingyang Wu, Aimee K Sundberg, Martha Fournier, SOLSTICE Trial Investigators, Robin K Avery, Sophie Alain, Barbara D Alexander, Emily A Blumberg, Roy F Chemaly, Catherine Cordonnier, Rafael F Duarte, Diana F Florescu, Nassim Kamar, Deepali Kumar, Johan Maertens, Francisco M Marty, Genovefa A Papanicolaou, Fernanda P Silveira, Oliver Witzke, Jingyang Wu, Aimee K Sundberg, Martha Fournier, SOLSTICE Trial Investigators
Abstract
Background: Therapies for refractory cytomegalovirus infections (with or without resistance [R/R]) in transplant recipients are limited by toxicities. Maribavir has multimodal anti-cytomegalovirus activity through the inhibition of UL97 protein kinase.
Methods: In this phase 3, open-label study, hematopoietic-cell and solid-organ transplant recipients with R/R cytomegalovirus were randomized 2:1 to maribavir 400 mg twice daily or investigator-assigned therapy (IAT; valganciclovir/ganciclovir, foscarnet, or cidofovir) for 8 weeks, with 12 weeks of follow-up. The primary endpoint was confirmed cytomegalovirus clearance at end of week 8. The key secondary endpoint was achievement of cytomegalovirus clearance and symptom control at end of week 8, maintained through week 16.
Results: 352 patients were randomized (235 maribavir; 117 IAT). Significantly more patients in the maribavir versus IAT group achieved the primary endpoint (55.7% vs 23.9%; adjusted difference [95% confidence interval (CI)]: 32.8% [22.80-42.74]; P < .001) and key secondary endpoint (18.7% vs 10.3%; adjusted difference [95% CI]: 9.5% [2.02-16.88]; P = .01). Rates of treatment-emergent adverse events (TEAEs) were similar between groups (maribavir, 97.4%; IAT, 91.4%). Maribavir was associated with less acute kidney injury versus foscarnet (8.5% vs 21.3%) and neutropenia versus valganciclovir/ganciclovir (9.4% vs 33.9%). Fewer patients discontinued treatment due to TEAEs with maribavir (13.2%) than IAT (31.9%). One patient per group had fatal treatment-related TEAEs.
Conclusions: Maribavir was superior to IAT for cytomegalovirus viremia clearance and viremia clearance plus symptom control maintained post-therapy in transplant recipients with R/R cytomegalovirus. Maribavir had fewer treatment discontinuations due to TEAEs than IAT. Clinical Trials Registration. NCT02931539 (SOLSTICE).
Keywords: antiviral agents; cytomegalovirus; drug resistance; maribavir; transplant recipients.
Conflict of interest statement
Potential conflicts of interest. R. K. A.: study grant support: AiCuris, Astellas, Chimerix, Merck, Oxford Immunotec, Qiagen, and Takeda/Shire. S. A.: research funding as a scientific expert and site principal investigator: Altona, BioMérieux, Biotest, GlaxoSmithKline, Merck, Merck Sharp & Dohme, Qiagen, Shire, a Takeda company; honoraria for lectures paid to their institution: Biotest, Merck Sharp & Dohme, IQone; support for attending meetings: BioMérieux, Biotest, Quality Control for Molecular Diagnostics; advisory board (unpaid): Quality Control for Molecular Diagnostics. Primary investigator for this study in France. B. D. A.: research funding for work as an investigator: Scynexis, Shire, a Takeda company; research funding to institution for work as an investigator: Astellas, Cidara, F2G, Leadiant; royalties or licenses: UpToDate; consulting fees: Astellas, Scynexis; leadership or fiduciary role: Past President Infectious Diseases Society of America. E. A. B.: research support to their institution: Hologic, Merck, Takeda; scientific medical advisor (unpaid): Merck; Data and Safety Monitoring Board: Amplyx; leadership or fiduciary role: board member (including office holder) American Society of Transplantation. R. F. C.: institutional research grants: AiCuris, Ansun Biopharma, Chimerix, Janssen, Karius, Merck, Novartis, Oxford Immunotec, Pulmotect, Shire, a Takeda company, Viracor; consulting fees: ADMA Biologics, Ansun Biopharma, Janssen, Merck, Molecular Partners, Qiagen, Shire, a Takeda company; honoraria: Genentech, Merck, Oxford Immunotec, Partner Therapeutics, Pulmotect, Shire, a Takeda company; Data Safety Monitoring Board or Advisory Board: Enanta, Duke; stock or stock options: Xenex. C. C.: departmental research funding: Merck, Shire, a Takeda company; consulting fees for advisory board and speaker bureau participation: Merck, Takeda. R. F. D.: departmental research funding: Janssen, Merck, Novartis, Omeros, Roche Diagnostics; consulting fees for advisory boards and speaker bureau participation: Bristol Myers Squibb, Gilead Sciences, Incyte, Jazz Pharmaceuticals, Merck, Omeros, Pfizer, Sanofi Oncology, Sobi, Shire, a Takeda company. D. F. F.: research support for work as an investigator: Astellas, Merck, Nobelpharma, Novavax, Shire, a Takeda company; Data Safety Monitoring Board: Amplyx; advisory boards: Merck, Takeda. N. K.: advisory board and speaker’s fees: Astellas, Biotest, Chiesi, CSL Behring, Merck Sharp & Dohme, Neovii, Novartis Pharma, Sandoz, Sanofi, Shire, a Takeda company. D. K.: consultant: Roche, Sanofi, Takeda; grant/research support: Merck, Qiagen, Roche, Takeda; speaking fee: Astellas. J. M.: consulting fees from Shire/Takeda during the conduct of the study, as well as consulting fees and nonfinancial support from Amgen, Astellas Pharma, Basilea, Cidara, F2G, Schering-Plough, Scynexis; and grants, consulting fees, and nonfinancial support from Bio-Rad, Gilead Sciences, Merck, Pfizer Inc, outside the submitted work; honoraria: Astellas, F2G, Gilead, Pfizer Inc, Merck Sharp & Dohme, Mundipharma. F. M. M.: consultant: AlloVir, Amplyx, Avir, Emcure, F2G, Gilead, Janssen, Kyorin, Merck, Regeneron, ReViral, Symbio, United Medical; investigator and research funding: Ansun, Chimerix, Cidara, Scynexis, Shire, a Takeda company, WHISCON; research funding: AlloVir, Amplyx, F2G, Gilead, Merck, Regeneron. G. A. P.: consulting fees: ADMA Biologics, AlloVir, Amplyx, Astellas, Behring, Cidara, Octapharma, Partner Therapeutics, Shionogi, Shire, a Takeda company, Siemens Healthineers; investigator: Merck, Shire, a Takeda company; honoraria for speaking engagement: Basilea, Merck, Merck Sharp & Dohme Europe. F. P. S.: research support for work as an investigator: Ansun Biopharma, Gilead, Merck, Novartis, Qiagen, Shire, a Takeda company, SlieaGen, WHISCON; travel funding to meetings: Shire, a Takeda company; lecture honoraria: Janssen; consulting fees: Takeda. O. W.: research grants for clinical studies, speaker’s fees, honoraria, and travel expenses: Alexion, Amgen, Astellas, Basilea, Biotest, Bristol Myers Squibb, Chiesi, Correvio, Gilead, Hexal, Janssen, Dr. F. Köhler Chemie, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sanofi, Takeda, Teva, UCB; unrestricted grant from the Rudolf-Ackermann-Stiftung (Stiftung für Klinische Infektiologie). J. W., A. K. S., and M. F.: employees of and holding stock/stock options in: Takeda Development Center Americas, Inc. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
© The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society of America.
Figures
References
- Haidar G, Boeckh M, Singh N.. Cytomegalovirus infection in solid organ and hematopoietic cell transplantation: state of the evidence. J Infect Dis 2020; 221:S23–31.
- Felipe CR, Ferreira AN, Bessa A, et al. . The current burden of cytomegalovirus infection in kidney transplant recipients receiving no pharmacological prophylaxis. J Bras Nefrol 2017; 39:413–23.
- Teira P, Battiwalla M, Ramanathan M, et al. . Early cytomegalovirus reactivation remains associated with increased transplant-related mortality in the current era: a CIBMTR analysis. Blood 2016; 127:2427–38.
- Beam E, Lesnick T, Kremers W, Kennedy CC, Razonable RR.. Cytomegalovirus disease is associated with higher all-cause mortality after lung transplantation despite extended antiviral prophylaxis. Clin Transplant 2016; 30:270–8.
- Avery RK, Arav-Boger R, Marr KA, et al. . Outcomes in transplant recipients treated with foscarnet for ganciclovir-resistant or refractory cytomegalovirus infection. Transplantation 2016; 100:e74–80.
- Fisher CE, Knudsen JL, Lease ED, et al. . Risk factors and outcomes of ganciclovir-resistant cytomegalovirus infection in solid organ transplant recipients. Clin Infect Dis 2017; 65:57–63.
- Vejrazkova E, Pliskova L, Hubacek P, et al. . Clinical and genotypic CMV drug resistance in HSCT recipients: a single center epidemiological and clinical data. Bone Marrow Transplant 2019; 54:146–9.
- Liu J, Kong J, Chang YJ, et al. . Patients with refractory cytomegalovirus (CMV) infection following allogeneic haematopoietic stem cell transplantation are at high risk for CMV disease and non-relapse mortality. Clin Microbiol Infect 2015; 21:1121.
- Bonatti H, Sifri CD, Larcher C, Schneeberger S, Kotton C, Geltner C.. Use of cidofovir for cytomegalovirus disease refractory to ganciclovir in solid organ recipients. Surg Infect (Larchmt) 2017; 18(2):128–36.
- Pierce B, Richardson CL, Lacloche L, Allen A, Ison MG.. Safety and efficacy of foscarnet for the management of ganciclovir-resistant or refractory cytomegalovirus infections: a single-center study. Transpl Infect Dis 2018; 20:e12852.
- Khawaja F, Batista MV, El Haddad L, Chemaly RF.. Resistant or refractory cytomegalovirus infections after hematopoietic cell transplantation: diagnosis and management. Curr Opin Infect Dis 2019; 32:565–74.
- Razonable RR, Humar A.. Cytomegalovirus in solid organ transplant recipients—Guidelines of the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13512.
- Mehta Steinke SA, Alfares M, Valsamakis A, et al. . Outcomes of transplant recipients treated with cidofovir for resistant or refractory cytomegalovirus infection. Transpl Infect Dis 2021;. 23:e13521. doi:10.1111/tid.13521
- Maffini E, Giaccone L, Festuccia M, Brunello L, Busca A, Bruno B.. Treatment of CMV infection after allogeneic hematopoietic stem cell transplantation. Expert Rev Hematol 2016; 9:585–96.
- Mavrakanas TA, Fournier MA, Clairoux S, et al. . Neutropenia in kidney and liver transplant recipients: risk factors and outcomes. Clin Transplant 2017; 31. doi:10.1111/ctr.13058
- Chou S, Marousek GI.. Accelerated evolution of maribavir resistance in a cytomegalovirus exonuclease domain II mutant. J Virol 2008; 82:246–53.
- Krosky PM, Baek MC, Coen DM.. The human cytomegalovirus UL97 protein kinase, an antiviral drug target, is required at the stage of nuclear egress. J Virol 2003; 77:905–14.
- Prichard MN. Function of human cytomegalovirus UL97 kinase in viral infection and its inhibition by maribavir. Rev Med Virol 2009; 19:215–29.
- Hamirally S, Kamil JP, Ndassa-Colday YM, et al. . Viral mimicry of Cdc2/cyclin-dependent kinase 1 mediates disruption of nuclear lamina during human cytomegalovirus nuclear egress. PLoS Pathog 2009; 5:e1000275.
- Drew WL, Miner RC, Marousek GI, Chou S.. Maribavir sensitivity of cytomegalovirus isolates resistant to ganciclovir, cidofovir or foscarnet. J Clin Virol 2006; 37:124–7.
- Chou S, Wu J, Song K, Bo T.. Novel UL97 drug resistance mutations identified at baseline in a clinical trial of maribavir for resistant or refractory cytomegalovirus infection. Antiviral Res 2019; 172:104616.
- Papanicolaou GA, Silveira FP, Langston AA, et al. . Maribavir for refractory or resistant cytomegalovirus infections in hematopoietic-cell or solid-organ transplant recipients: a randomized, dose-ranging, double-blind, phase 2 study. Clin Infect Dis 2019; 68:1255–64.
- Maertens J, Cordonnier C, Jaksch P, et al. . Maribavir for preemptive treatment of cytomegalovirus reactivation. N Engl J Med 2019; 381:1136–47.
- Ljungman P, Griffiths P, Paya C.. Definitions of cytomegalovirus infection and disease in transplant recipients. Clin Infect Dis 2002; 34:1094–7.
- Ljungman P, Boeckh M, Hirsch HH, et al. . Definitions of cytomegalovirus infection and disease in transplant patients for use in clinical trials. Clin Infect Dis 2017; 64:87–91.
- Natori Y, Alghamdi A, Tazari M, et al. . Use of viral load as a surrogate marker in clinical studies of cytomegalovirus in solid organ transplantation: a systematic review and meta-analysis. Clin Infect Dis 2018; 66:617–31.
- Song IH, Ilic K, Murphy J, Lasseter K, Martin P.. Effects of maribavir on P-glycoprotein and CYP2D6 in healthy volunteers. J Clin Pharmacol 2020; 60:96–106.
- Koszalka GW, Johnson NW, Good SS, et al. . Preclinical and toxicology studies of 1263W94, a potent and selective inhibitor of human cytomegalovirus replication. Antimicrob Agents Chemother 2002; 46:2373–80.
- El Chaer F, Shah DP, Chemaly RF.. How I treat resistant cytomegalovirus infection in hematopoietic cell transplantation recipients. Blood 2016; 128:2624–36.
- Biron KK, Harvey RJ, Chamberlain SC, et al. . Potent and selective inhibition of human cytomegalovirus replication by 1263W94, a benzimidazole L-riboside with a unique mode of action. Antimicrob Agents Chemother 2002; 46:2365–72.
- Marty FM, Ljungman P, Papanicolaou GA, et al. . Maribavir prophylaxis for prevention of cytomegalovirus disease in recipients of allogeneic stem-cell transplants: a phase 3, double-blind, placebo-controlled, randomised trial. Lancet Infect Dis 2011; 11:284–92. doi:10.1016/S1473-3099(11)70024-X
- Winston DJ, Saliba F, Blumberg E, et al. . Efficacy and safety of maribavir dosed at 100 mg orally twice daily for the prevention of cytomegalovirus disease in liver transplant recipients: a randomized, double-blind, multicenter controlled trial. Am J Transplant 2012; 12:3021–30.
- Marty FM, Boeckh M.. Maribavir and human cytomegalovirus–what happened in the clinical trials and why might the drug have failed?. Curr Opin Virol 2011; 1:555–62.
- Kotton CN, Kumar D, Caliendo AM, et al. . The third international consensus guidelines on the management of cytomegalovirus in solid-organ transplantation. Transplantation 2018; 102:900–31.
- Ljungman P, de la Camara R, Robin C, et al. . Guidelines for the management of cytomegalovirus infection in patients with haematological malignancies and after stem cell transplantation from the 2017 European Conference on Infections in Leukaemia (ECIL 7). Lancet Infect Dis 2019; 19:e260–72.
Source: PubMed