Phase III Randomized COMMODORE 1 Trial: 2-Year Safety and Efficacy of Crovalimab in Patients with Paroxysmal Nocturnal Hemoglobinuria (PNH) Who Switched from Eculizumab

Introduction Crovalimab (crova; PiaSky®) is a novel C5 inhibitor (C5i) allowing for maintenance subcutaneous (SC) injection every 4 wks (Q4W). Results from the 24-wk primary treatment period of the global, randomized, Phase III COMMODORE 1 trial (NCT04432584) showed that crova was well tolerated and had similar efficacy in patients (pts) who switched from eculizumab (ecu) to crova vs pts who continued ecu (Scheinberg Am J Hematol 2024). These data, in conjunction with the COMMODORE 2 trial (NCT04434092) that demonstrated non-inferior efficacy of crova vs ecu in C5i-naive pts (Röth Am J Hematol 2024), highlight the overall favorable benefit-risk profile of crova. Here, we report 2-y COMMODORE 1 data. Methods Adult pts with PNH receiving ecu for ≥24 wks at study start with lactate dehydrogenase (LDH) ≤1.5×upper limit of normal (ULN) were randomized 1:1 to switch to crova (Arm A) or continue ecu (Arm B) for a 24-wk primary treatment period. Crova was given as a weight-based tiered dosing regimen that included loading doses followed by SC Q4W maintenance. Ecu was given via IV infusion at 900 mg every 2 wks. After primary treatment, pts in Arm A continued crova, and pts in Arm B switched from ecu to crova if continuing in the extension period (Arm B switch). In the COMMODORE trials, crova self-administration by pts was permitted from Wk (W)9, after training and confirmation of proficiency by a healthcare provider. Long-term data were only reported in Arm A and Arm B switch pts who received crova. Long-term safety was evaluated from after the 1st crova dose up to the clinical cutoff date (CCOD) pooled across both arms. Long-term efficacy was evaluated up to W97 in the extension period in each arm, as the majority of pts had reached this visit. Efficacy endpoints included the proportion of pts with hemolysis control (LDH≤1.5×ULN) at each visit from W25-97, and proportions of pts with transfusion avoidance (TA), breakthrough hemolysis (BTH), and hemoglobin stabilization; data were reported over consecutive 24-wk intervals in the extension period from W25-49, W49-73, and W73-97. Mean Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue score was assessed at scheduled visits. Results All 44 pts from Arm A (crova) continued crova and 40 of 42 pts from Arm B (ecu) switched to crova in the extension period after W25. At CCOD (Mar 12, 2024), 42 pts in Arm A and 32 in Arm B switch were receiving crova. Median treatment duration was 106.2 wks (range, 3.1-180.0). Across Arm A and Arm B switch, 84 pts (173.4 pt years [PY]) were evaluated for the long-term safety of crova. Incidence of adverse events (AEs) per 100 PY (95% CI) was 362.8 (335.0, 392.3) for all AEs, 50.8 (40.7, 62.5) for treatment-related AEs, 45.6 (36.1, 56.8) for Grade ≥3 AEs, and 29.4 (21.9, 38.7) for serious AEs. The rate of fatal AEs was 0.58 (0.01, 3.21) per 100 PY; the 1 death was unrelated to treatment per the investigator. Transient immune complex reactions (TICRs; one-time events that some pts may have when switching between crova and another C5i) occurred in 18% of pts (15/84). The reported signs and symptoms of TICRs were mainly skin and joint abnormalities (rash and arthralgia), with no renal manifestations. Most TICRs were mild/moderate, with no life-threatening or fatal events, and resolved with no change in crova treatment. No meningococcal infections occurred. Mean normalized LDH was maintained at ≤1.5xULN in both arms, with 77%-94% of pts in Arm A and 89%-100% in Arm B switch having LDH≤1.5×ULN at each visit from W25-97. Over consecutive 24-wk intervals in the extension, TA was achieved by 76%-84% of pts in Arm A and 75%-81% in Arm B switch; hemoglobin stabilization was achieved in 68%-73% and 60%-70% of pts, respectively. Proportion of pts with a BTH event remained low and generally stable (7%-11% in Arm A and 3%-18% in Arm B switch). Mean FACIT-Fatigue scores remained stable from W25-97, ranging from 40.8-42.9 in Arm A and 38.2-40.8 in Arm B switch. Conclusions In COMMODORE 1, crova was well tolerated and disease control was maintained over a 2-y median treatment duration in pts who switched from ecu to crova, showing a durable and consistent efficacy profile. The overall safety profile of crova was consistent with that of other C5is, except for the identified risk of usually mild/moderate and manageable TICRs in pts when switching between crova and another C5i. Overall, results support the long-term favorable benefit-risk profile of crova.