Calquence demonstrated fewer incidences of atrial fibrillation versus ibrutinib in previously treated patients with chronic lymphocytic leukaemia and sustained patient benefit at four years in the front-line setting.-AstraZeneca
At a median follow up of 40.9 months, the ELEVATE-RR trial met its primary endpoint of PFS non-inferiority versus ibrutinib with a median PFS of 38.4 months in both arms (based on a hazard ratio [HR] of 1.0, 95% confidence interval [CI] 0.79-1.27). Patients treated with Calquence had a statistically significantly lower incidence of all-grade atrial fibrillation compared with patients treated with ibrutinib (9.4% versus 16.0%), a key secondary endpoint. Atrial fibrillation is an irregular heart rate that can increase the risk of stroke, heart failure and other heart-related complications. John C. Byrd, MD, Distinguished University Professor, The Ohio State University, and lead investigator of the ELEVATE-RR trial, said: “Cardiac adverse events are an important consideration for treating chronic lymphocytic leukaemia patients with Bruton’s tyrosine kinase inhibitors because they can produce significant morbidity in some cases and also lead patients to discontinue treatment. These data provide compelling evidence that acalabrutinib is a more tolerable option with reduced cardiovascular toxicity and overall fewer discontinuations due to adverse events, giving clinicians further reassurance when prescribing this medicine that patients can stay on treatment while maintaining ongoing control of their disease.”. ELEVATE-RR : Calquence versus ibrutinib in relapsed or refractory CLL : ELEVATE-RR (ACE-CL-006) is the first Phase III trial to compare two Bruton’s tyrosine kinase (BTK) inhibitors in patients with previously treated CLL with presence of 17p deletion or presence of 11q deletion. The trial met the non-inferiority endpoint for PFS defined by the trial for Calquence (n=268) versus ibrutinib (n=265) in patients with previously treated CLL with certain high-risk prognostic factors. i. Patients treated with Calquence had statistically significantly lower incidence of all-grade atrial fibrillation, a key secondary endpoint, compared with patients treated with ibrutinib (9.4% [n=25/266] versus 16.0% [n=42/263]; p=0.02). ii. A lower frequency of adverse events (AEs) was observed with Calquence versus ibrutinib including lower common AEs, Grade 3 or higher AEs, serious AEs, treatment discontinuations due to AEs and overall cardiac events. The safety and tolerability of Calquence in ELEVATE-RR was consistent with the known profile of Calquence. iii. Adverse events led to treatment discontinuation in 14.7% of patients on Calquence and 21.3% of patients on ibrutinib.ii. AEs of clinical interest for Calquence versus ibrutinib included cardiac events (all grade, 24.1%, and 30.0%, respectively), bleeding events (all grade, 38.0% and 51.3%, respectively), hypertension (all grade, 9.4% and 23.2%, respectively), infections (all grade, 78.2% and 81.4%, respectively), interstitial lung disease/pneumonitis (all grade, 2.6% and 6.5%, respectively) and second primary malignancies excluding non-melanoma skin cancer (all-grade, 9.0% and 7.6%, respectively).iii. Serious AEs (any grade) occurred in 53.8% of patients on Calquence versus 58.6% of patients receiving ibrutinib. iv.Median overall survival (OS) was not reached in either arm, with 63 (23.5%) patients in the Calquence arm, and 73 (27.5%) patients in the ibrutinib arm experiencing an event (HR of 0.82, 95% CI 0.59-1.15). ELEVATE-TN : Four-year follow up for Calquence in previously untreated CLL:ELEVATE-TN (ACE-CL-007) is a randomised, multicentre, open-label Phase III trial evaluating the safety and efficacy of Calquence in combination with obinutuzumab or alone versus chlorambucil in combination with obinutuzumab in previously untreated patients with CLL. The trial met its primary endpoint (IRC-assessed PFS with Calquence plus obinutuzumab versus chlorambucil plus obinutuzumab) at the data cut-off for the interim analysis after a median follow up of 28.3 months. After a median follow up of 46.9 months, the ELEVATE-TN Phase III trial showed Calquence plus obinutuzumab reduced the risk of disease progression or death by 90% (HR 0.10, 95% CI 0.07-0.17) and as a monotherapy by 81% (HR 0.19, 95% CI 0.13-0.28) compared with chlorambucil plus obinutuzumab. Estimated PFS rates at 48 months for Calquence plus obinutuzumab or as monotherapy were 87% and 78%, respectively, versus 25% for chlorambucil plus obinutuzumab. PFS findings were consistent across high-risk subgroups. Median PFS was not yet reached for either Calquence arm at four years of follow up. Median OS was not reached in any treatment arm with a trend toward significance in the Calquence plus obinutuzumab group (p=0.0604). The safety profile remained largely unchanged from the interim analysis at 24 months , with similar treatment discontinuation rates across arms (25.1%, 30.7% and 22.6% for Calquence plus obinutuzumab, Calquence monotherapy and chlorambucil plus obinutuzumab, respectively). The most common reasons for treatment discontinuation were AEs (12.8%, 12.34% and 14.7%, respectively) and progressive disease (4.5%, 7.8% and 1.7%, respectively). Selected AEs of interest of any grade in the Calquence combination arm (n=178), Calquence monotherapy arm (n=179) and chlorambucil plus obinutuzumab arm (n=169) included cardiac events (20.8%, 19.0% and 7.7%, respectively), bleeding (47.2%, 41.9% and 11.8%, respectively), hypertension (7.9%, 7.3% and 4.1%, respectively), infections (75.3%, 73.7% and 44.4%, respectively) and second primary malignancies (15.7%, 13.4% and 4.1%, respectively). The results of both trials were presented during the 2021 American Society of Clinical Oncology (ASCO) Annual Meeting on 7 June 2021. See-Byrd JC, Hillmen P, Ghia P, et al. "First Results of a Head-to-Head Trial of Acalabrutinib versus Ibrutinib in Previously Treated Chronic Lymphocytic Leukemia". Oral presentation at: American Society for Clinical Oncology (ASCO) Annual Meeting; June 4-8, 2021; virtual. Abstract ID: 7500.
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