To cite this article: Reding MT, Ng HJ, Poulsen LH, Eyster ME, Pabinger I, Shin H-J, Walsch R, Lederman M, Wang M, Hardtke M, Michaels LA. Safety and efficacy of BAY 94-9027, a prolonged-half-life factor VIII. J Thromb Haemost 2017; 15: 411-9. Essentials• Recombinant factor VIII BAY 94-9027 conjugates in a site-specific manner with polyethylene glycol.• BAY 94-9027 was given to patients with severe hemophilia A as prophylaxis and to treat bleeds.• BAY 94-9027 prevented bleeds at dose intervals up to every 7 days and effectively treated bleeds.• BAY 94-9027 treatment was mainly well tolerated and no patient developed factor VIII inhibitors. tional weeks until randomization arms were filled. Patients who were eligible but not randomized continued twiceweekly prophylaxis. The primary efficacy outcome was annualized bleeding rate (ABR). Results: The intent-totreat population included 132 patients (prophylaxis, n = 112; on demand, n = 20). Median ABR (quartile [Q1; Q3]) for patients treated two times per week who were not eligible for randomization (n = 13) improved after dose increase (17.4 [14.3; 26.0] to 4.1 [2.0; 10.6]). Median ABR for patients randomized to every-5-days treatment (n = 43) was 1.9 (0; 4.2), similar to patients eligible for randomization but who continued treatment two times per week (n = 11). Median ABR for 32/43 patients (74%) who continued every-7-days prophylaxis until study end was 0.96 (0.0; 4.3). Six hundred and thirty-six of 702 bleeds (90.6%) were controlled with ≤ 2 infusions. No patient developed a FVIII inhibitor. Conclusions: BAY 94-9027 prevented bleeding across three individually tailored dose regimens and was effective for treatment of bleeds.

Introduction:The most serious and challenging complication of haemophilia treatment is development of inhibitors to replacement factors VIII or IX. Innovative therapies currently being explored for patients with haemophilia and inhibitors include BAY 86-6150, a modified recombinant activated factor VII (FVIIa). Immunogenicity remains a substantial barrier in this endeavour. Aim: To present safety and efficacy results of the BAY 86-6150 study in patients with inhibitors and report detailed analysis of epitope mapping in a patient who developed anti-BAY 86-6150 antibodies. Methods: Patients aged 12-62 years with moderate or severe haemophilia A or B were eligible for the phase 3 TRUST trial if they had a history of high-titre inhibitors. Four escalating doses of BAY 86-6150 (6.5, 20, 50, 90 lg kg À1 ) were planned with ≥10 patients per dose level. Bleeding episodes were treated with BAY 86-6150. Development of anti-BAY 86-6150 antibodies was considered a serious adverse event. Results: TRUST was discontinued after one patient in the 6.5-lg kg À1 cohort developed anti-BAY 86-6150 neutralizing antibodies following three exposures. The anti-BAY 86-6150 antibodies crossreacted with and neutralized wild-type FVIIa (WT-FVIIa). Post hoc epitope mapping using peripheral blood mononuclear cells from the responding patient found that none of the 14 peptides unique to BAY 86-6150 were recognized by the patient's T cells, but strong responses were detected against 2 WT-FVIIa peptides. Conclusion: In the single patient with haemophilia A who developed anti-BAY 86-6150 antibodies, results of Tcell epitope mapping indicated BAY 86-6150 was no more immunogenic than WT-FVIIa.

ObjectiveTo assess whether the combined oral contraceptive (COC) ethinylestradiol (EE) 20 μg/drospirenone 3 mg taken in a 24/4-day regimen (ie, 4-day hormone-free interval) is more effective than an EE 20 μg/desogestrel (DSG) 150 μg COC taken in a 21/7-day regimen (ie, 7-day hormone-free interval) in reducing hormone withdrawal-associated symptoms (HWAS).MethodsThis double-blind, randomized study (NLM identifier: NCT01076582) was conducted at 34 centers in 12 countries. Otherwise healthy women who experienced ≥2 HWAS of headache, pelvic pain, and/or bloating when using their current COCs in a 21/7-day regimen were recruited. Subjects rated the severity of their HWAS daily on a seven-point Likert scale during a baseline cycle and during four 28-day cycles with EE/drospirenone 24/4 (n=290) or EE/DSG 21/7 (n=304). The primary variable was the mean change from baseline to cycle 4 in the composite HWAS score (sum of scores for all three symptoms) during cycle days 22–28.ResultsIn the EE/drospirenone 24/4 group, the mean (standard deviation) composite HWAS score during cycle days 22–28 was reduced from 42.2 (24.8) at baseline to 12.8 (13.4) at cycle 4 (change from baseline: −30.3 [22.9]). In the EE/DSG 21/7 group, the corresponding value was reduced from 41.9 (25.8) to 14.3 (13.2) (change from baseline: −27.7 [24.8]), not significantly different versus EE/drospirenone 24/4. Bleeding pattern, treatment response, rescue medication use, compliance, quality of life, and tolerability were similar between treatments.ConclusionBoth EE/drospirenone 24/4 and EE/DSG 21/7 reduced the composite HWAS score from baseline to cycle 4 in otherwise healthy women. The differences between treatments were too small to be statistically significant.

Introduction Up to 30% of patients with hemophilia A and 5% of patients with hemophilia B develop neutralizing antibodies (inhibitors) against replacement factor VIII or factor IX, respectively. Acute bleeding episodes in these patients with inhibitors are treated with bypassing agents, which include activated recombinant factor VII (rFVIIa). BAY 86-6150 is a modified rFVIIa which in preclinical studies was shown to have prolonged half-life and improved potency compared with currently available rFVIIa. In a phase 1, randomized, double-blind trial, BAY 86-6150 was not associated with any clinically significant adverse events (AEs). We report the immunologic response to BAY 86-6150 in a phase 2/3 clinical trial in patients with hemophilia with inhibitors. Methods TRUST (Treatment with Unique Recombinant FVII Study) was a multicenter, open-label, 2-part study (part A and part B) which included males aged 12−62 years with moderate or severe hemophilia A or B, with a history of high-titer inhibitors (≥5 Bethesda units), and ≥4 bleeding episodes in the 6 months prior to enrollment. Part A was a sequential dose-escalation study of 4 BAY 86-6150 dose levels (6.5, 20, 50, and 90 μg/kg body weight; n≥10/cohort). Dose escalation was dependent on both efficacy and an Independent Data Monitoring Committee (IDMC) approval of safety in 10 patients per cohort who had ≥1 bleeding episode treated with BAY 86-6150. Part B was designed as a single-arm investigation of the efficacy and safety of the recommended dose of BAY 86-6150 determined in all patients from Part A. Safety endpoints were AEs and immunogenicity. Anti-drug antibody testing was performed at screening (prior to exposure), after the second exposure, then every fifth exposure, and at the end of study visit in both part A and part B. Anti-BAY 86-6150 binding antibodies were measured using a validated enzyme-linked immunosorbent assay (ELISA). Samples that revealed a specific immunoreactivity in this assay were further characterized for neutralizing activity using a validated platelet-activated clotting assay. Additional functional assays were performed to determine the cross-reactive neutralizing effect on rFVIIa (NovoSeven®) of any detected anti-BAY 86-6150 antibodies. The presence of neutralizing antibodies was considered a serious adverse event (SAE) requiring prompt IDMC review. Results In cohort 1, 10 patients (mean age, 27.4 years) were treated with 6.5 mg/kg BAY 86-6150. These patients had a total of 73 bleeding events and received a total of 84 study drug injections. No anti-drug antibodies or anti-FVIIa was detected in the patients at screening prior to exposure to the study drug. BAY 86-6150 was well tolerated in all patients with no clinical or laboratory symptoms or signs of venous thromboembolism. Binding antibodies to BAY 86-6150 were detected on a scheduled screening visit in 1 patient after 3 exposures to BAY 86-6150; these anti-BAY 86-6150 antibodies displayed neutralizing activity against BAY 86-6150 and were also cross-reactive and neutralizing for rFVIIa. The affected patient had received rFVIIa before entry into the study. At the time of diagnosis of binding and neutralizing antibodies, the affected patient was not bleeding and did not require emergency treatment. Exposure to BAY 86-6150 was stopped and the trial was terminated at the first cohort. Subsequent bleeding episodes in this patient were successfully managed with FEIBATM (Factor Eight Inhibitor Bypass Activity). No other treatment-related AEs or SAEs were reported in this study. Additionally, the IDMC has recommended safety follow-up assessments for all the patients who actively participated in the trial. Conclusions The TRUST trial has been discontinued as a precautionary measure because of potential safety concerns related to the detection of the antidrug antibodies in 1 patient. Development of neutralizing antibodies against BAY 86-6150 that had a cross-reactive neutralizing effect on rFVIIa was considered a serious risk because of the limited treatment options in patients with inhibitors. These results underline the fact that it is currently not possible to predict immunologic response based on preclinical and phase 1 studies. Disclosures: Hardtke: Bayer Pharma AG: Employment. Schroeder:Bayer Pharma AG: Employment.

Bypassing agents such as activated recombinant factor VII (rFVIIa) are used to treat acute bleeding episodes in patients with hemophilia and inhibitors to coagulation factors VIII (FVIII) or IX. BAY 86-6150 is a modified rFVIIa protein with 6 amino acid substitutions in the rFVII molecule that prolong half-life and improve potency compared with the currently available rFVIIa. In a dose-escalation clinical study, 1 patient out of a cohort of 10 treated with 6.5 μg/kg BAY 86-6150 developed low-titer neutralizing antibodies that were detected after the third exposure. The patient's anti-BAY 86-6150 antibodies also cross-reacted with and neutralized wild-type FVIIa (WT-FVIIa) in vitro. T-cell epitope mapping was performed to identify BAY 86-6150 sequence(s) that may have contributed to the immunogenic response in the patient by measuring CD4+ T-cell response to individual 15-mer peptides spanning BAY 86-6150. The epitope mapping study did not identify any of the 14 peptides unique to BAY 86-6150 as epitopes recognized by the patient's T cells. However, strong responses were detected against 2 WT-FVIIa peptides, WT p6-20 (EELRPGSLERECKEE) and WT p156-170 (GKVCPKGECPWQVLL), indicating that CD4+ T helper cells recognizing these WT peptides may have contributed to the immune response that resulted in the production of anti-BAY 86-6150 antibodies during treatment. It should be noted that although the patient had no detectable anti-FVIIa antibodies before the start of the study, he had been treated with factor eight inhibitor bypassing activity (FEIBA), which contains active FVII, on 3 consecutive days 3 months before entry into the study. Hence it is possible that the patient had been primed for a response against FVIIa that was triggered by the subsequent exposure to BAY 86-6150. The fact that the patient's T cells only responded to WT-FVIIa peptides might be explained if the WT-FVIIa peptides were seen as foreign/non-self peptides by his T-cell repertoire. Unfortunately, the patient's FVII gene sequence was not obtainable, and this possibility remains unanswered. The Universal Protein Resource (UniProt) database reports 2 natural FVII gene variants that encompass the WT p6-20 sequence (Millar, et al. Hum Genet. 2000;107:327-42; Herrmann, et al. Haemophilia. 2009;15:267-280) and one for the WT p156-170 sequence (Wulff and Herrmann. Hum Mutat. 2000;15:489-496) that resulted from single amino acid substitutions. Hence the possibility exists that the patient's T-cell repertoire sees WT-FVIIa sequences as foreign and immunogenic. T cells from 40 healthy donors were also tested for reactivity against the peptide panel to assess relative immunogenicity of BAY 86-6150 vs WT-FVIIa. Seven BAY 86-6150 neoepitopes were stimulatory for 8 unrelated healthy donor T cells, but their mean stimulation indices were not statistically higher than those observed against WT FVIIa peptides. Mean % stimulation values of the positive responses against the 7 BAY 86-6150 neoepitopes versus 39 WT FVIIa peptides were 1.09 (N=13 responses) vs 1.01 (N=70 responses; P=0.5059). Statistical analysis of the in vitro T-cell response indicates that specific mutations to BAY 86-6150 do not result in BAY 86-6150 being more immunogenic than WT FVIIa. This would suggest that BAY 86-6150 will not elicit stronger or higher frequency of anti-FVIIa antibody response than WT FVIIa in patients with hemophilia. Disclosures Paz: Bayer HealthCare: Employment. Schroeder:Bayer Pharma AG: Employment. Mathew:Bayer HealthCare Pharmaceuticals: Employment. Hardtke:Bayer Pharma AG: Employment. Aswad:Bayer HealthCare: Employment.