Insights on Nefecon®, a Targeted-Release Formulation of Budesonide and Its Selective Immunomodulatory Effects in Patients with IgA Nephropathy

Immunoglobulin A nephropathy (IgAN) is a chronic, immune-mediated kidney disease characterized by the deposition of galactose-deficient immunoglobulin A1 (Gd-IgA1) in the kidneys. Excess Gd-IgA1 production in patients with IgAN is located within the mucosa-associated lymphoid tissue, particularly within the lamina propria in the distal ileum. Nefecon® is a targeted-release formulation of the corticosteroid budesonide, which became the first treatment approved by the US Food and Drug Administration (FDA; brand name, TARPEYO®) and European Medicines Agency (EMA; KINPEYGO®) for patients with primary IgAN at risk of rapid disease progression, after demonstrating clinically significant reduction of proteinuria in an interim analysis of the Phase III NefIgArd trial. After showing a significant reduction in estimated glomerular filtration rate decline in the full 2-year analysis of the trial, Nefecon was granted full approval by the FDA to reduce the loss of kidney function. Nefecon was specifically designed to deliver budesonide to the distal ileum, selectively targeting excess Gd-IgA1 production in the gut-associated lymphoid tissue. In this review, we describe the properties of Nefecon and the evidence to date that confirms its localized treatment effect. We also present unpublished evidence from Phase I trials investigating the pharmacokinetics and cortisol suppression effects of Nefecon in healthy participants. These studies demonstrated that Nefecon has a distinct pharmacokinetic profile from other budesonide products, allowing for targeted, localized action in the distal ileum. When considered alongside existing clinical trial data showing the effect of Nefecon on gut-associated biomarkers, available evidence indicates that Nefecon has a selective immunomodulatory mechanism of action and a direct disease-modifying effect in patients with IgAN, while having low systemic exposure and adverse effects

Efficacy and safety of a targeted-release formulation of budesonide in patients with primary IgA nephropathy (NefIgArd): 2-year results from a randomised phase 3 trial

BackgroundIgA nephropathy is a chronic immune-mediated kidney disease and a major cause of kidney failure worldwide. The gut mucosal immune system is implicated in its pathogenesis, and Nefecon is a novel, oral, targeted-release formulation of budesonide designed to act at the gut mucosal level. We present findings from the 2-year, phase 3 NefIgArd trial of Nefecon in patients with IgA nephropathy.MethodsIn this phase 3, multicentre, randomised, double-blind, placebo-controlled trial, adult patients (aged ≥18 years) with primary IgA nephropathy, estimated glomerular filtration rate (eGFR) 35-90 mL/min per 1·73 m2, and persistent proteinuria (urine protein-creatinine ratio ≥0·8 g/g or proteinuria ≥1 g/24 h) despite optimised renin-angiotensin system blockade were enrolled at 132 hospital-based clinical sites in 20 countries worldwide. Patients were randomly assigned (1:1) to receive 16 mg/day oral capsules of Nefecon or matching placebo for 9 months, followed by a 15-month observational follow-up period off study drug. Randomisation via an interactive response technology system was stratified according to baseline proteinuria (2), and region (Asia-Pacific, Europe, North America, or South America). Patients, investigators, and site staff were masked to treatment assignment throughout the 2-year trial. Optimised supportive care was also continued throughout the trial. The primary efficacy endpoint was time-weighted average of eGFR over 2 years. Efficacy and safety analyses were done in the full analysis set (ie, all randomly assigned patients). The trial was registered on ClinicalTrials.gov, NCT03643965, and is completed.FindingsPatients were recruited to the NefIgArd trial between Sept 5, 2018, and Jan 20, 2021, with 364 patients (182 per treatment group) randomly assigned in the full analysis set. 240 (66%) patients were men and 124 (34%) were women, and 275 (76%) identified as White. The time-weighted average of eGFR over 2 years showed a statistically significant treatment benefit with Nefecon versus placebo (difference 5·05 mL/min per 1·73 m2 [95% CI 3·24 to 7·38], p2 (95% CI -3·88 to -1·02) reported with Nefecon and -7·52 mL/min per 1·73 m2 (-8·83 to -6·18) reported with placebo. The most commonly reported treatment-emergent adverse events during treatment with Nefecon were peripheral oedema (31 [17%] patients, vs placebo, seven [4%] patients), hypertension (22 [12%] vs six [3%]), muscle spasms (22 [12%] vs seven [4%]), acne (20 [11%] vs two [1%]), and headache (19 [10%] vs 14 [8%]). No treatment-related deaths were reported.InterpretationA 9-month treatment period with Nefecon provided a clinically relevant reduction in eGFR decline and a durable reduction in proteinuria versus placebo, providing support for a disease-modifying effect in patients with IgA nephropathy. Nefecon was also well tolerated, with a safety profile as expected for a locally acting oral budesonide product.FundingCalliditas Therapeutics

The de-sequestering capacity of sevuparin in <i>P</i>. <i>falciparum</i> infected patients.

<p>A total of 44 patients were included in the efficacy part of the trial and were treated with oral atovaquone/proguanil with or without adjunctive treatment in the form of short i.v. infusions of sevuparin. The numbers of trophozoite and schizont IEs were estimated in the peripheral blood samples on thin and thick films that were taken at time points 0, 1, 2, 3, 4, 6, 8, 10, and 11 h and thereafter every 6 h until two consecutive blood samples were parasite negative. The relative numbers were calculated from the number of trophozoite and schizont IEs at one time point related to the baseline number of trophozoite and schizont IEs at time point 0 h (immediately prior to the first dose of sevuparin), and the mean was measured based on all subjects in one group. The red dotted line represents the sevuparin treated patients, and the blue line represents the control patients. Logarithmic y- axis is used. Significantly (p<0.05) higher numbers of trophozoite and schizont IEs were found in the sevuparin treated patients at time point 1 h (p = 0.0322). In a, the relative numbers (mean ± SD) of trophozoite and schizont parasites in the two study groups up to H30 are presented. In b, the detailed relative changes in the number of trophozoite and schizont parasites (mean ± SD) during the first 12 hours after the first injection of sevuparin are shown. In c, individual effects of sevuparin on the number of trophozoites and schizont parasites per patient is shown. The grey arrows indicate the periodic sevuparin infusions.</p

Sevuparin lowers the relative mean number of ring-stage IEs after a single sevuparin infusion in <i>P</i>. <i>falciparum</i> infected patients.

<p>A total of 44 patients were included in the efficacy part of the trial (part 2) and were treated with oral atovaquone/proguanil with or without adjunctive treatment in the form of i.v. infusions of sevuparin. The relative numbers were calculated from the number of ring IEs at one time point related to the baseline value of ring IEs at time point 0 h (immediately prior to the first dose of sevuparin), and the mean was measured based on all subjects in one group. a, The mean relative numbers (mean ± SD) of ring stage parasites in the two study groups from 0 h to 30 h. The numbers of ring-stage IEs were estimated in peripheral blood samples on thin and thick films that were taken at time points 0, 1, 2, 3, 4, 6, 8, 10, and 11 h and thereafter every 6 h until two consecutive blood samples were parasite negative. The red dotted line represents the patients treated with sevuparin (3 mg/kg) and oral atovaquone/proguanil, and the blue line represents the control patients who were given only oral atovaquone/proguanil, a logarithmic y-axis is used. Significantly lower levels of ring stage IEs were found in the sevuparin treated patients at time points 1 h (p = 0.0223), 2 h (p = 0.0246), 3 h (p = 0.0027), 4 h (p = 0.0278), and 6 h (p = 0.0346). (An outlier appears in the data but does not drive the difference as the statistical significant difference between the two groups remains even if data from this patient is excluded from the analysis since the tests used are non-parametric which are thus very robust against divergent.) b, Detailed mean relative changes in the number (mean ± SD) of ring stage parasites during the first 12 hours after the first injection of sevuparin. c, Numbers of ring-stage IEs levels in the individual patients. Oragne arrow indicate an outlier. Grey arrows indicate the short i.v. sevuparin infusions over five minutes.</p

Study design of phase I/II study in patients with uncomplicated <i>falciparum</i> malaria-TSM02.

<p>a, Overview of study design and dosing regimen for all patients in part 1. b, Overview of study design and dosing regimen for patients in part 2 randomized to the anti-malarial regimen (atovaquone and proguanil) alone or sevuparin plus anti-malarial regimen (atovaquone/proguanil).</p

Sevuparin inhibits merozoite invasion of <i>P</i>. <i>falciparum</i> clones, strains and fresh isolates <i>in vitro</i> at low concentrations, independently of parasite origin or phenotype.

<p>The invasion blocking capacity of sevuparin in 34 <i>in vitro</i> propagated <i>P</i>. <i>falciparum</i> isolates expressed as IC50. The inhibitory capacity of sevuparin was titrated in double dilution steps between 0.125 μg/mL and 1 mg sevuparin/mL culture. Ten laboratory isolates were either sensitive (3D7, 3D7PG12, Dd2, HB3) or resistant (R29, TM180, TM284, F32, 7G8, FCR3S1.2) to chloroquine. Three parasites of the W2mef background carried disrupted genes for EBA 140, EBA 175 or EBA 181 (EBA-KO). W2mef is a cloned line of parasites derived from the Indochina III-CDC strain. Of the fresh primary isolates 11 were from Ugandan children with either severe (dot) or uncomplicated (square) malaria and six isolates were from adults infected in Ethiopia/Eritrea, Kenya or Niger. Four Cambodian isolates were sensitive or resistant to artemisinin (red-circled square; IPC-4884, Pursut, artemisinin resistant (RSA 0-3h: 6,5%) and IPC 4912 artemisinin resistant (red circled square; RSA 0–3 h: 49%). ICP 5188 Rattanakiri and IPC 3663 Pailin were artemisinin sensitive (square).</p

Anticoagulant activity of sevuparin.

<p>Anticoagulant activity of sevuparin.</p