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    Clinical Trial Results:
    A prospective, randomized, active controlled, parallel group, multi-center trial to assess the efficacy and safety of mycophenolate mofetil (MMF) in inducing response and maintaining remission in subjects with lupus nephritis. The study was divided into two phases, the induction phase and the maintenance phase designed to compare MMF with azathioprine over a maximum 3 year period. Here only results for the induction phase are described.

    Summary
    EudraCT number
    2004-004917-41
    Trial protocol
    DE   GB   HU   CZ   ES   BE   PT   AT   IT  
    Global end of trial date
    16 Mar 2007

    Results information
    Results version number
    v1(current)
    This version publication date
    26 Feb 2017
    First version publication date
    26 Feb 2017
    Other versions
    Summary report(s)
    WX17801_Vifor Pharma

    Trial information

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    Trial identification
    Sponsor protocol code
    WX17801
    Additional study identifiers
    ISRCTN number
    -
    US NCT number
    -
    WHO universal trial number (UTN)
    -
    Sponsors
    Sponsor organisation name
    Aspreva Pharmaceuticals Corporation
    Sponsor organisation address
    1203-4464, Markham Street, Victoria, Canada, V8Z 7X8
    Public contact
    Udo-Michael Göhring , Aspreva Pharmaceuticals Corporation, udo-michael.goehring@viforpharma.com
    Scientific contact
    Udo-Michael Göhring , Aspreva Pharmaceuticals Corporation, udo-michael.goehring@viforpharma.com
    Paediatric regulatory details
    Is trial part of an agreed paediatric investigation plan (PIP)
    No
    Does article 45 of REGULATION (EC) No 1901/2006 apply to this trial?
    No
    Does article 46 of REGULATION (EC) No 1901/2006 apply to this trial?
    Yes
    Results analysis stage
    Analysis stage
    Final
    Date of interim/final analysis
    06 May 2008
    Is this the analysis of the primary completion data?
    Yes
    Primary completion date
    16 Mar 2007
    Global end of trial reached?
    Yes
    Global end of trial date
    16 Mar 2007
    Was the trial ended prematurely?
    No
    General information about the trial
    Main objective of the trial
    Primary Objective for Induction: To assess the efficacy of MMF compared to intravenous cyclophosphamide (IVC) in inducing response in subjects with lupus nephritis (LN).
    Protection of trial subjects
    This study was conducted in accordance with the principles of the Declaration of Helsinki and its amendments, or with local laws and regulations if these afforded greater protection to the individual. Additionally, the study was performed according to the principles of Good Clinical Practice (GCP). The protocol and all accompanying material provided to the subject (eg, subject information and informed consent forms) as well as any advertising or compensation given to the subjects were submitted by the investigators to an Independent Ethics Committee (IEC) or Institutional Review Board (IRB). Approval from the committee was obtained before starting the study. In addition, a blinded Clinical Endpoints Committee (CEC) was formed comprising two physicians with proven expertise in LN and a biostatistician experienced in the conduct and data handling of large clinical trials. The CEC adjudicated the primary endpoint in the induction phase (response) for all enrolled subjects. The CEC had the responsibility for ensuring that defined clinical endpoints were substantiated by the evidence. The CEC’s role included identifying protocol violations and adjudicating the appropriateness of withdrawals.
    Background therapy
    All subjects received concomitant corticosteroid therapy consisting of oral prednisolone (or equivalent) starting at 0.75-1.0 mg/kg/day (maximum 60 mg/day). Prednisolone was tapered according to the following schedule: • Decreased by 10 mg/day every two weeks to 40 mg/day, followed by • Decreased by 5 mg/day every two weeks to 10 mg/day Reductions below 10 mg/day were allowed after four weeks of stable response. Subjects with lack of response were allowed one 4-week interval without dose reduction or one dose escalation to the previous dose for two weeks, at any time up to Week 24. Lack of response was defined as no or minimal change per investigator judgment over three months or deterioration not meeting the criteria for withdrawal.
    Evidence for comparator
    The active comparator during the induction phase was IVC plus corticosteroid. In the National Institutes of Health (NIH) series of trials, IVC was shown to be more effective than corticosteroid alone in preventing end stage renal disease and death. In a meta analysis, cyclophosphamide plus steroids reduced the risk of doubling of serum creatinine compared to steroids alone. In these studies, IVC was administered as six, monthly infusions, with an initial dose of 0.5 g/m2, and subsequent infusions of 0.5 to 1.0 g/m2, with a target dose 1.0 g/m2. By consensus of the Steering Committee of the study and investigators, IVC was administered according to a modified NIH regimen, which differed from the NIH regimen in that the initial infusion dose was 0.75 g/m2. IVC and MMF were given with concomitant corticosteroids.
    Actual start date of recruitment
    13 Jul 2005
    Long term follow-up planned
    No
    Independent data monitoring committee (IDMC) involvement?
    Yes
    Population of trial subjects
    Number of subjects enrolled per country
    Country: Number of subjects enrolled
    Portugal: 3
    Country: Number of subjects enrolled
    Spain: 11
    Country: Number of subjects enrolled
    United Kingdom: 6
    Country: Number of subjects enrolled
    Belgium: 8
    Country: Number of subjects enrolled
    Czech Republic: 5
    Country: Number of subjects enrolled
    France: 9
    Country: Number of subjects enrolled
    Germany: 9
    Country: Number of subjects enrolled
    Hungary: 1
    Country: Number of subjects enrolled
    Italy: 7
    Country: Number of subjects enrolled
    Argentina: 52
    Country: Number of subjects enrolled
    Australia: 5
    Country: Number of subjects enrolled
    Brazil: 14
    Country: Number of subjects enrolled
    Canada: 1
    Country: Number of subjects enrolled
    China: 94
    Country: Number of subjects enrolled
    Costa Rica: 12
    Country: Number of subjects enrolled
    Greece: 2
    Country: Number of subjects enrolled
    Malaysia: 23
    Country: Number of subjects enrolled
    Mexico: 28
    Country: Number of subjects enrolled
    South Africa: 6
    Country: Number of subjects enrolled
    United States: 74
    Worldwide total number of subjects
    370
    EEA total number of subjects
    61
    Number of subjects enrolled per age group
    In utero
    0
    Preterm newborn - gestational age < 37 wk
    0
    Newborns (0-27 days)
    0
    Infants and toddlers (28 days-23 months)
    0
    Children (2-11 years)
    0
    Adolescents (12-17 years)
    24
    Adults (18-64 years)
    345
    From 65 to 84 years
    1
    85 years and over
    0

    Subject disposition

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    Recruitment
    Recruitment details
    The study was conducted with an enrollment target of 358 subjects at 100 sites across the world.

    Pre-assignment
    Screening details
    At the Baseline visit prior to the induction phase, subjects were randomly assigned to a treatment group. The randomization was stratified according to key prognostic factors (race, biopsy class).

    Period 1
    Period 1 title
    Induction phase (overall period)
    Is this the baseline period?
    Yes
    Allocation method
    Randomised - controlled
    Blinding used
    Not blinded
    Blinding implementation details
    Blinding a study of this type was not practical for ethical and operational reasons. In order to reduce the risk of bladder toxicity and dehydration, subjects treated with IVC must be hydrated adequately before, during, and immediately after each infusion, including intravenous saline infusions prior to dosing and at least four liters of oral fluids for 24 h after dosing. Administration of this volume of fluid represented an unnecessary risk to subjects with renal dysfunction treated with MMF.

    Arms
    Are arms mutually exclusive
    Yes

    Arm title
    Mycophenolate mofetil (MMF)
    Arm description
    Dosing of MMF started at 500 mg twice daily (BID) for the first week, increasing to 1 g BID for the second week and 1.5 g BID for the third and subsequent weeks. Subjects took 500 mg tablets BID (morning and evening), before meals with a glass of water. If a dose was missed, the subject took the next correct dose rather than “doubling up” at the next dosing time point.
    Arm type
    Experimental

    Investigational medicinal product name
    Mycophenolate mofetil (MMF)
    Investigational medicinal product code
    Other name
    CellCept
    Pharmaceutical forms
    Film-coated tablet
    Routes of administration
    Oral use
    Dosage and administration details
    1.5 g orally BID plus corticosteroid for 24 weeks.

    Arm title
    Intravenous cyclophosphamide (IVC)
    Arm description
    IVC doses were administered every four weeks (monthly) to a total of six infusions. Dosing was started at 0.75 g/m2 of body surface area (BSA) for the first month, with subsequent doses at 0.5-1.0 g/m2. The target dose was 1.0 g/m2, but doses were titrated by 0.25 g/m2 increments to maintain nadir leukocyte count between 2500-4000/mm3. A 25% reduction for age greater than 60 years and a 25% reduction for serum creatinine >300 μmol/L (3.4 mg/dL) was allowed.
    Arm type
    Active comparator

    Investigational medicinal product name
    Intravenous cyclophosphamide (IVC)
    Investigational medicinal product code
    Other name
    Endoxan
    Pharmaceutical forms
    Infusion
    Routes of administration
    Intravenous use
    Dosage and administration details
    0.5 to 1.0 g/m2 BSA. Monthly infusions plus corticosteroid for 24 weeks.

    Number of subjects in period 1
    Mycophenolate mofetil (MMF) Intravenous cyclophosphamide (IVC)
    Started
    185
    185
    Completed
    150
    156
    Not completed
    35
    29
         Adverse event, serious fatal
    3
    1
         Consent withdrawn by subject
    6
    5
         Physician decision
    1
    3
         Reason for withdrawal is not noted
    -
    2
         Adverse event, non-fatal
    21
    12
         Withdrawal criteria
    1
    2
         Non-compliance
    -
    1
         Lost to follow-up
    1
    2
         Sponsor decision
    2
    1

    Baseline characteristics

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    Baseline characteristics reporting groups
    Reporting group title
    Mycophenolate mofetil (MMF)
    Reporting group description
    Dosing of MMF started at 500 mg twice daily (BID) for the first week, increasing to 1 g BID for the second week and 1.5 g BID for the third and subsequent weeks. Subjects took 500 mg tablets BID (morning and evening), before meals with a glass of water. If a dose was missed, the subject took the next correct dose rather than “doubling up” at the next dosing time point.

    Reporting group title
    Intravenous cyclophosphamide (IVC)
    Reporting group description
    IVC doses were administered every four weeks (monthly) to a total of six infusions. Dosing was started at 0.75 g/m2 of body surface area (BSA) for the first month, with subsequent doses at 0.5-1.0 g/m2. The target dose was 1.0 g/m2, but doses were titrated by 0.25 g/m2 increments to maintain nadir leukocyte count between 2500-4000/mm3. A 25% reduction for age greater than 60 years and a 25% reduction for serum creatinine >300 μmol/L (3.4 mg/dL) was allowed.

    Reporting group values
    Mycophenolate mofetil (MMF) Intravenous cyclophosphamide (IVC) Total
    Number of subjects
    185 185 370
    Age categorical
    Units: Subjects
        In utero
    0 0 0
        Preterm newborn infants (gestational age < 37 wks)
    0 0 0
        Newborns (0-27 days)
    0 0 0
        Infants and toddlers (28 days-23 months)
    0 0 0
        Children (2-11 years)
    0 0 0
        Adolescents (12-17 years)
    10 14 24
        Adults (18-64 years)
    174 171 345
        From 65-84 years
    1 0 1
        85 years and over
    0 0 0
    Age continuous
    Units: years
        arithmetic mean (standard deviation)
    32.4 ± 11.17 31.3 ± 10.25 -
    Gender categorical
    Units: Subjects
        Female
    157 156 313
        Male
    28 29 57

    End points

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    End points reporting groups
    Reporting group title
    Mycophenolate mofetil (MMF)
    Reporting group description
    Dosing of MMF started at 500 mg twice daily (BID) for the first week, increasing to 1 g BID for the second week and 1.5 g BID for the third and subsequent weeks. Subjects took 500 mg tablets BID (morning and evening), before meals with a glass of water. If a dose was missed, the subject took the next correct dose rather than “doubling up” at the next dosing time point.

    Reporting group title
    Intravenous cyclophosphamide (IVC)
    Reporting group description
    IVC doses were administered every four weeks (monthly) to a total of six infusions. Dosing was started at 0.75 g/m2 of body surface area (BSA) for the first month, with subsequent doses at 0.5-1.0 g/m2. The target dose was 1.0 g/m2, but doses were titrated by 0.25 g/m2 increments to maintain nadir leukocyte count between 2500-4000/mm3. A 25% reduction for age greater than 60 years and a 25% reduction for serum creatinine >300 μmol/L (3.4 mg/dL) was allowed.

    Subject analysis set title
    Asia - MMF
    Subject analysis set type
    Intention-to-treat
    Subject analysis set description
    Subjects included in MMF group from Asia region.

    Subject analysis set title
    Asia - IVC
    Subject analysis set type
    Intention-to-treat
    Subject analysis set description
    Subjects included in IVC group from Asia region.

    Subject analysis set title
    Latin America - MMF
    Subject analysis set type
    Intention-to-treat
    Subject analysis set description
    Subjects included in MMF group from Latin America region.

    Subject analysis set title
    Latin America - IVC
    Subject analysis set type
    Intention-to-treat
    Subject analysis set description
    Subjects included in IVC group from Latin America region.

    Subject analysis set title
    US/Canada - MMF
    Subject analysis set type
    Intention-to-treat
    Subject analysis set description
    Subjects included in MMF group from US/Canada region.

    Subject analysis set title
    US/Canada -IVC
    Subject analysis set type
    Intention-to-treat
    Subject analysis set description
    Subjects included in IVC group from US/Canada region.

    Subject analysis set title
    Rest of World - MMF
    Subject analysis set type
    Intention-to-treat
    Subject analysis set description
    Subjects included in MMF group from Rest of World region.

    Subject analysis set title
    Rest of World - IVC
    Subject analysis set type
    Intention-to-treat
    Subject analysis set description
    Subjects included in IVC group from Rest of World region.

    Primary: Number (percentage) of subjects showing treatment response at 24 weeks

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    End point title
    Number (percentage) of subjects showing treatment response at 24 weeks
    End point description
    Treatment response was defined as follows: a) Decrease in proteinuria, defined as a decrease in the urine protein to creatinine ratio to <3 in subjects with baseline nephrotic range proteinuria (≥3 urine protein to creatinine ratio) or a decrease in the urine protein to creatinine ratio by ≥50% in subjects with subnephrotic proteinuria (<3 urine protein to creatinine ratio at Baseline). Urine protein to creatinine ratios were derived from the 24 hour urine collection. b) Stabilization of serum creatinine (ie, at Week 24 serum creatinine level ±25% of baseline), or improvement. The results are described for the intent-to-treat (ITT) population consisting of all subjects who were randomized to the study and had at least one post-Baseline efficacy assessment (the subject was assessed for response by the CEC). The primary efficacy objective of demonstrating that MMF was statistically significantly superior to IVC was not met because of multifactorial reasons.
    End point type
    Primary
    End point timeframe
    From Baseline to 24 weeks.
    End point values
    Mycophenolate mofetil (MMF) Intravenous cyclophosphamide (IVC) Asia - MMF Asia - IVC Latin America - MMF Latin America - IVC US/Canada - MMF US/Canada -IVC Rest of World - MMF Rest of World - IVC
    Number of subjects analysed
    185
    185
    57
    60
    56
    50
    37
    38
    35
    37
    Units: percent
        number (not applicable)
    56.2
    53
    52.6
    65
    60.7
    32
    56.8
    47.4
    54.3
    67.6
    Statistical analysis title
    Comparison between treatment groups
    Statistical analysis description
    OR = (Odds of response in MMF)/(Odds of response in IVC). OR >1.0 indicated that MMF was associated with a higher response rate than IVC. p-value for between-group comparison of MMF versus IVC was based on logistic regression. The primary analysis (logistic regression) had a significant interaction between treatment and region that showed that the differences in response between the MMF and IVC groups depended on the region of the world.
    Comparison groups
    Intravenous cyclophosphamide (IVC) v Mycophenolate mofetil (MMF)
    Number of subjects included in analysis
    370
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    P-value
    = 0.478
    Method
    Regression, Logistic
    Parameter type
    Odds response MMF/Odds response IVC
    Point estimate
    1.2
    Confidence interval
         level
    95%
         sides
    2-sided
         lower limit
    0.8
         upper limit
    1.8
    Statistical analysis title
    Comparison between treatment groups - Asia
    Statistical analysis description
    OR = (Odds of response in MMF)/(Odds of response in IVC). OR >1.0 indicated that MMF was associated with a higher response rate than IVC. p-value for between-group comparison of MMF versus IVC was based on logistic regression.
    Comparison groups
    Asia - MMF v Asia - IVC
    Number of subjects included in analysis
    117
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    P-value
    = 0.176
    Method
    Regression, Logistic
    Parameter type
    Odds response MMF/Odds response IVC
    Point estimate
    0.6
    Confidence interval
         level
    95%
         sides
    2-sided
         lower limit
    0.3
         upper limit
    1.3
    Statistical analysis title
    Comparison between treatment groups -Latin America
    Statistical analysis description
    OR = (Odds of response in MMF)/(Odds of response in IVC). OR >1.0 indicated that MMF was associated with a higher response rate than IVC. p-value for between-group comparison of MMF versus IVC was based on logistic regression.
    Comparison groups
    Latin America - MMF v Latin America - IVC
    Number of subjects included in analysis
    106
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    P-value
    = 0.003
    Method
    Regression, Logistic
    Parameter type
    Odds response MMF/Odds response IVC
    Point estimate
    3.4
    Confidence interval
         level
    95%
         sides
    2-sided
         lower limit
    1.5
         upper limit
    7.7
    Statistical analysis title
    Comparison between treatment groups - US/Canada
    Statistical analysis description
    OR = (Odds of response in MMF)/(Odds of response in IVC). OR >1.0 indicated that MMF was associated with a higher response rate than IVC. p-value for between-group comparison of MMF versus IVC was based on logistic regression.
    Comparison groups
    US/Canada - MMF v US/Canada -IVC
    Number of subjects included in analysis
    75
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    P-value
    = 0.363
    Method
    Regression, Logistic
    Parameter type
    Odds response MMF/Odds response IVC
    Point estimate
    1.5
    Confidence interval
         level
    95%
         sides
    2-sided
         lower limit
    0.6
         upper limit
    3.9
    Statistical analysis title
    Comparison between treatment groups -Rest of World
    Statistical analysis description
    OR = (Odds of response in MMF)/(Odds of response in IVC). OR >1.0 indicated that MMF was associated with a higher response rate than IVC. p-value for between-group comparison of MMF versus IVC was based on logistic regression.
    Comparison groups
    Rest of World - MMF v Rest of World - IVC
    Number of subjects included in analysis
    72
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    P-value
    = 0.256
    Method
    Regression, Logistic
    Parameter type
    Odds response MMF/Odds response IVC
    Point estimate
    0.6
    Confidence interval
         level
    95%
         sides
    2-sided
         lower limit
    0.2
         upper limit
    1.5

    Secondary: Complete remission as defined by return to normal serum creatinine, proteinuria ≤500 mg/24 hours, and an inactive urinary sediment

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    End point title
    Complete remission as defined by return to normal serum creatinine, proteinuria ≤500 mg/24 hours, and an inactive urinary sediment
    End point description
    Number (%) of subjects achieving complete remission. Complete remission was defined as return to normal serum creatinine, proteinuria ≤500 mg/24 hours and an inactive urinary sediment (absence of red blood cells, white blood cells or cellular or granular casts) after 24 weeks. Subjects who did not show complete remission at Week 24 or who had insufficient information (including missing values) were considered as not achieving complete remission.
    End point type
    Secondary
    End point timeframe
    From Baseline to Week 24.
    End point values
    Mycophenolate mofetil (MMF) Intravenous cyclophosphamide (IVC)
    Number of subjects analysed
    185
    185
    Units: percent
        number (not applicable)
    8.6
    8.1
    Statistical analysis title
    Complete remission for serum creatinine
    Statistical analysis description
    Complete remission was defined by return to normal serum creatinine.
    Comparison groups
    Mycophenolate mofetil (MMF) v Intravenous cyclophosphamide (IVC)
    Number of subjects included in analysis
    370
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    Method
    Parameter type
    Mean difference (final values)
    Point estimate
    2.7
    Confidence interval
         level
    95%
         sides
    2-sided
         lower limit
    -6.7
         upper limit
    12.1
    Statistical analysis title
    Complete remission for urine protein
    Statistical analysis description
    Complete remission was defined by return to proteinuria ≤500 mg/24 hours.
    Comparison groups
    Mycophenolate mofetil (MMF) v Intravenous cyclophosphamide (IVC)
    Number of subjects included in analysis
    370
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    Method
    Parameter type
    Mean difference (final values)
    Point estimate
    -3.2
    Confidence interval
         level
    95%
         sides
    2-sided
         lower limit
    -12.1
         upper limit
    5.6
    Statistical analysis title
    Complete remission for urine microscopy
    Statistical analysis description
    Complete remission was defined by return to inactive urinary sediment (absence of red blood cells, white blood cells or cellular or granular casts) after 24 weeks.
    Comparison groups
    Mycophenolate mofetil (MMF) v Intravenous cyclophosphamide (IVC)
    Number of subjects included in analysis
    370
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    Method
    Parameter type
    Mean difference (final values)
    Point estimate
    7.6
    Confidence interval
         level
    95%
         sides
    2-sided
         lower limit
    -1.5
         upper limit
    16.6

    Secondary: Proportion of subjects meeting complete remission criteria in at least one of the individual parameters (serum creatinine, urine protein, urine microscopy)

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    End point title
    Proportion of subjects meeting complete remission criteria in at least one of the individual parameters (serum creatinine, urine protein, urine microscopy)
    End point description
    At least one complete remission criteria was defined as a subject who met any one of the three criteria : return to normal serum creatinine, return to proteinuria ≤500 mg/24 hours or return to inactive urinary sediment after 24 weeks. Subjects who did not meet meet at least one criteria for complete remission at Week 24, or who withdrew earlier than Week 24 or who did not have sufficient information (including missing values) were considered as “No”.
    End point type
    Secondary
    End point timeframe
    From Baseline to Week 24.
    End point values
    Mycophenolate mofetil (MMF) Intravenous cyclophosphamide (IVC)
    Number of subjects analysed
    185
    185
    Units: percent
        number (not applicable)
    76.2
    75.7
    Statistical analysis title
    Comparison between groups at Week 24
    Comparison groups
    Mycophenolate mofetil (MMF) v Intravenous cyclophosphamide (IVC)
    Number of subjects included in analysis
    370
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    Method
    Parameter type
    Mean difference (final values)
    Point estimate
    0.5
    Confidence interval
         level
    95%
         sides
    2-sided
         lower limit
    -8.2
         upper limit
    9.3

    Adverse events

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    Adverse events information
    Timeframe for reporting adverse events
    Adverse events (AEs) were monitored from the time of informed consent throughout the course of the study, at every visit (including screening). A follow-up phone call was made 2 weeks after the last study visit (last dosing of study medication).
    Adverse event reporting additional description
    The Safety population (364 subjects) was considered for AEs. It comprised all subjects who were randomized, received at least one dose of study medication during the 24 week induction phase of the study, and had at least one post-Baseline safety assessment during this phase.
    Assessment type
    Systematic
    Dictionary used for adverse event reporting
    Dictionary name
    MedDRA
    Dictionary version
    9.1
    Reporting groups
    Reporting group title
    Mycophenolate mofetil (MMF)
    Reporting group description
    -

    Reporting group title
    Intravenous cyclophosphamide (IVC)
    Reporting group description
    -

    Serious adverse events
    Mycophenolate mofetil (MMF) Intravenous cyclophosphamide (IVC)
    Total subjects affected by serious adverse events
         subjects affected / exposed
    51 / 184 (27.72%)
    41 / 180 (22.78%)
         number of deaths (all causes)
    9
    5
         number of deaths resulting from adverse events
    7
    2
    Vascular disorders
    Deep vein thrombosis
         subjects affected / exposed
    1 / 184 (0.54%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 1
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Subclavian vein thrombosis
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Hypertension
         subjects affected / exposed
    1 / 184 (0.54%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Venous stenosis
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Pregnancy, puerperium and perinatal conditions
    Pregnancy
         subjects affected / exposed
    2 / 184 (1.09%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 20
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    General disorders and administration site conditions
    Death
         subjects affected / exposed
    1 / 184 (0.54%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 1
         deaths causally related to treatment / all
    0 / 1
    0 / 1
    Pyrexia
         subjects affected / exposed
    1 / 184 (0.54%)
    3 / 180 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
    2 / 4
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Oedema
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Immune system disorders
    Anaphylactic reaction
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Reproductive system and breast disorders
    Uterine haemorrhage
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Respiratory, thoracic and mediastinal disorders
    Dyspnoea
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    1 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Haemoptysis
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    1 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Pulmonary haemorrhage
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Interstitial lung disease
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    1 / 1
    0 / 0
         deaths causally related to treatment / all
    1 / 1
    0 / 0
    Pulmonary embolism
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Respiratory failure
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Lupus pneumonitis
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Pharyngolaryngeal pain
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Psychiatric disorders
    Depression
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Psychotic disorder
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Investigations
    Platelet count decreased
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    1 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    White blood cell count decreased
         subjects affected / exposed
    1 / 184 (0.54%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    1 / 1
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    International normalised ratio increased
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Alanine aminotransferase increased
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Blood creatine increased
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Biopsy kidney
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Injury, poisoning and procedural complications
    Overdose
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Head injury
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Cardiac disorders
    Acute coronary syndrome
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    1 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Myocardial infarction
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Cardiac arrest
         subjects affected / exposed
    1 / 184 (0.54%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Pericardial effusion
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Nervous system disorders
    Headache
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Brain oedema
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Cerebrovascular accident
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Syncope
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Lupus encephalitis
         subjects affected / exposed
    0 / 184 (0.00%)
    2 / 180 (1.11%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 2
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Convulsion
         subjects affected / exposed
    0 / 184 (0.00%)
    3 / 180 (1.67%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 3
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Blood and lymphatic system disorders
    Anaemia
         subjects affected / exposed
    2 / 184 (1.09%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    2 / 2
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Leukopenia
         subjects affected / exposed
    1 / 184 (0.54%)
    2 / 180 (1.11%)
         occurrences causally related to treatment / all
    1 / 1
    2 / 2
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Neutropenia
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    1 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Thrombotic thrombocytopenic purpura
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Thrombocytopenia
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Gastrointestinal disorders
    Diarrhoea
         subjects affected / exposed
    3 / 184 (1.63%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    3 / 3
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Vomiting
         subjects affected / exposed
    2 / 184 (1.09%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    2 / 2
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Dyspepsia
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    1 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Abdominal pain
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Gastrooesophageal reflux disease
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Abdominal distension
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Gingivitis
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Hepatobiliary disorders
    Hepatic function abnormal
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Skin and subcutaneous tissue disorders
    Dermatitis exfoliative
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Panniculitis
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Rash maculo-papular
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Renal and urinary disorders
    Renal failure acute
         subjects affected / exposed
    3 / 184 (1.63%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 3
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Renal failure
         subjects affected / exposed
    1 / 184 (0.54%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Renal impairment
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Renal failure chronic
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Lupus nephritis
         subjects affected / exposed
    2 / 184 (1.09%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 2
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Proteinuria
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 2
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Nephrotic syndrome
         subjects affected / exposed
    0 / 184 (0.00%)
    2 / 180 (1.11%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 2
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Musculoskeletal and connective tissue disorders
    Systemic lupus erythematosus
         subjects affected / exposed
    2 / 184 (1.09%)
    4 / 180 (2.22%)
         occurrences causally related to treatment / all
    0 / 2
    0 / 5
         deaths causally related to treatment / all
    0 / 0
    0 / 2
    Arthralgia
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Pain in extremity
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Costochondritis
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Myositis
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Infections and infestations
    Pneumonia
         subjects affected / exposed
    5 / 184 (2.72%)
    3 / 180 (1.67%)
         occurrences causally related to treatment / all
    4 / 5
    2 / 3
         deaths causally related to treatment / all
    0 / 2
    0 / 2
    Bronchitis
         subjects affected / exposed
    1 / 184 (0.54%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    1 / 1
    2 / 2
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Bronchopneumonia
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    1 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Lung infection
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    1 / 1
    0 / 0
         deaths causally related to treatment / all
    1 / 1
    0 / 0
    Lobar pneumonia
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Herpes zoster
         subjects affected / exposed
    5 / 184 (2.72%)
    2 / 180 (1.11%)
         occurrences causally related to treatment / all
    5 / 5
    2 / 2
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Herpes simplex
         subjects affected / exposed
    1 / 184 (0.54%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 1
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Septic shock
         subjects affected / exposed
    2 / 184 (1.09%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    1 / 2
    0 / 0
         deaths causally related to treatment / all
    1 / 2
    0 / 0
    Acinetobacter bacteraemia
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Meningitis tuberculous
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    1 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Pulmonary tuberculosis
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    1 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Tuberculosis gastrointestinal
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    1 / 1
    0 / 0
         deaths causally related to treatment / all
    1 / 1
    0 / 0
    Gastroenteritis
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    1 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Retroperitoneal abscess
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    1 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Gastrointestinal infection
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Skin infection
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    1 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Subcutaneous abscess
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Fungaemia
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Respiratory tract infection
         subjects affected / exposed
    1 / 184 (0.54%)
    2 / 180 (1.11%)
         occurrences causally related to treatment / all
    1 / 1
    2 / 2
         deaths causally related to treatment / all
    1 / 1
    0 / 0
    Infection
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    1 / 1
    Meningitis streptococcal
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Viral infection
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Gastroenteritis viral
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Cellulitis
         subjects affected / exposed
    0 / 184 (0.00%)
    2 / 180 (1.11%)
         occurrences causally related to treatment / all
    0 / 0
    2 / 2
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Meningitis bacterial
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Subacute endocarditis
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    1 / 1
    Upper respiratory tract infection
         subjects affected / exposed
    0 / 184 (0.00%)
    4 / 180 (2.22%)
         occurrences causally related to treatment / all
    0 / 0
    3 / 4
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Tonsillitis
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Metabolism and nutrition disorders
    Hypokalaemia
         subjects affected / exposed
    2 / 184 (1.09%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 2
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Hyperkalaemia
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Diabetes mellitus
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Dehydration
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Fluid overload
         subjects affected / exposed
    1 / 184 (0.54%)
    0 / 180 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Hypoalbuminaemia
         subjects affected / exposed
    0 / 184 (0.00%)
    1 / 180 (0.56%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Frequency threshold for reporting non-serious adverse events: 5%
    Non-serious adverse events
    Mycophenolate mofetil (MMF) Intravenous cyclophosphamide (IVC)
    Total subjects affected by non serious adverse events
         subjects affected / exposed
    176 / 184 (95.65%)
    171 / 180 (95.00%)
    Vascular disorders
    Hypertension
         subjects affected / exposed
    25 / 184 (13.59%)
    24 / 180 (13.33%)
         occurrences all number
    25
    27
    General disorders and administration site conditions
    Oedema peripheral
         subjects affected / exposed
    35 / 184 (19.02%)
    30 / 180 (16.67%)
         occurrences all number
    46
    37
    Fatigue
         subjects affected / exposed
    18 / 184 (9.78%)
    18 / 180 (10.00%)
         occurrences all number
    20
    29
    Pyrexia
         subjects affected / exposed
    12 / 184 (6.52%)
    30 / 180 (16.67%)
         occurrences all number
    13
    37
    Oedema
         subjects affected / exposed
    11 / 184 (5.98%)
    16 / 180 (8.89%)
         occurrences all number
    11
    17
    Asthenia
         subjects affected / exposed
    9 / 184 (4.89%)
    15 / 180 (8.33%)
         occurrences all number
    11
    19
    Chest pain
         subjects affected / exposed
    8 / 184 (4.35%)
    10 / 180 (5.56%)
         occurrences all number
    9
    15
    Respiratory, thoracic and mediastinal disorders
    Cough
         subjects affected / exposed
    24 / 184 (13.04%)
    16 / 180 (8.89%)
         occurrences all number
    25
    20
    Dyspnoea
         subjects affected / exposed
    10 / 184 (5.43%)
    6 / 180 (3.33%)
         occurrences all number
    10
    6
    Psychiatric disorders
    Insomnia
         subjects affected / exposed
    10 / 184 (5.43%)
    11 / 180 (6.11%)
         occurrences all number
    10
    18
    Investigations
    White blood cell count decreased
         subjects affected / exposed
    5 / 184 (2.72%)
    15 / 180 (8.33%)
         occurrences all number
    7
    26
    Cardiac disorders
    Palpitations
         subjects affected / exposed
    11 / 184 (5.98%)
    6 / 180 (3.33%)
         occurrences all number
    11
    9
    Tachycardia
         subjects affected / exposed
    10 / 184 (5.43%)
    6 / 180 (3.33%)
         occurrences all number
    10
    6
    Nervous system disorders
    Headache
         subjects affected / exposed
    38 / 184 (20.65%)
    47 / 180 (26.11%)
         occurrences all number
    53
    106
    Dizziness
         subjects affected / exposed
    8 / 184 (4.35%)
    10 / 180 (5.56%)
         occurrences all number
    8
    13
    Blood and lymphatic system disorders
    Anaemia
         subjects affected / exposed
    23 / 184 (12.50%)
    11 / 180 (6.11%)
         occurrences all number
    25
    11
    Leukopenia
         subjects affected / exposed
    10 / 184 (5.43%)
    36 / 180 (20.00%)
         occurrences all number
    13
    52
    Neutropenia
         subjects affected / exposed
    2 / 184 (1.09%)
    12 / 180 (6.67%)
         occurrences all number
    2
    13
    Gastrointestinal disorders
    Diarrhoea
         subjects affected / exposed
    52 / 184 (28.26%)
    23 / 180 (12.78%)
         occurrences all number
    72
    30
    Nausea
         subjects affected / exposed
    27 / 184 (14.67%)
    82 / 180 (45.56%)
         occurrences all number
    37
    167
    Vomiting
         subjects affected / exposed
    25 / 184 (13.59%)
    67 / 180 (37.22%)
         occurrences all number
    29
    143
    Abdominal pain
         subjects affected / exposed
    19 / 184 (10.33%)
    13 / 180 (7.22%)
         occurrences all number
    23
    21
    Abdominal pain upper
         subjects affected / exposed
    15 / 184 (8.15%)
    18 / 180 (10.00%)
         occurrences all number
    19
    25
    Constipation
         subjects affected / exposed
    12 / 184 (6.52%)
    9 / 180 (5.00%)
         occurrences all number
    14
    11
    Dyspepsia
         subjects affected / exposed
    10 / 184 (5.43%)
    5 / 180 (2.78%)
         occurrences all number
    14
    6
    Skin and subcutaneous tissue disorders
    Alopecia
         subjects affected / exposed
    20 / 184 (10.87%)
    64 / 180 (35.56%)
         occurrences all number
    22
    75
    Rash
         subjects affected / exposed
    19 / 184 (10.33%)
    21 / 180 (11.67%)
         occurrences all number
    24
    23
    Acne
         subjects affected / exposed
    9 / 184 (4.89%)
    9 / 180 (5.00%)
         occurrences all number
    11
    10
    Erythema
         subjects affected / exposed
    5 / 184 (2.72%)
    10 / 180 (5.56%)
         occurrences all number
    5
    10
    Endocrine disorders
    Cushingoid
         subjects affected / exposed
    9 / 184 (4.89%)
    11 / 180 (6.11%)
         occurrences all number
    9
    12
    Musculoskeletal and connective tissue disorders
    Arthralgia
         subjects affected / exposed
    29 / 184 (15.76%)
    43 / 180 (23.89%)
         occurrences all number
    48
    66
    Back pain
         subjects affected / exposed
    19 / 184 (10.33%)
    16 / 180 (8.89%)
         occurrences all number
    24
    24
    Muscle spasms
         subjects affected / exposed
    19 / 184 (10.33%)
    17 / 180 (9.44%)
         occurrences all number
    25
    29
    Pain in extremity
         subjects affected / exposed
    6 / 184 (3.26%)
    9 / 180 (5.00%)
         occurrences all number
    10
    14
    Arthritis
         subjects affected / exposed
    4 / 184 (2.17%)
    10 / 180 (5.56%)
         occurrences all number
    4
    16
    Infections and infestations
    Nasopharyngitis
         subjects affected / exposed
    25 / 184 (13.59%)
    29 / 180 (16.11%)
         occurrences all number
    37
    42
    Urinary tract infection
         subjects affected / exposed
    19 / 184 (10.33%)
    17 / 180 (9.44%)
         occurrences all number
    21
    22
    Upper respiratory tract infection
         subjects affected / exposed
    17 / 184 (9.24%)
    28 / 180 (15.56%)
         occurrences all number
    23
    37
    Herpes zoster
         subjects affected / exposed
    14 / 184 (7.61%)
    5 / 180 (2.78%)
         occurrences all number
    15
    6
    Metabolism and nutrition disorders
    Hypokalaemia
         subjects affected / exposed
    11 / 184 (5.98%)
    3 / 180 (1.67%)
         occurrences all number
    11
    4

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    Substantial protocol amendments (globally)

    Were there any global substantial amendments to the protocol? Yes
    Date
    Amendment
    25 Jan 2005
    PROTOCOL AMENDMENT 1 • Added statistical analysis of efficacy and safety of induction phase.•Reorganized sections on analysis of maintenance phase • Removed secondary analysis of response in induction • Replaced randomization by minimization algorithm with randomization by stratification • Clarified number of subjects required for induction phase • Added description of Steering Committee, Clinical Endpoints CEC, and Publications Committee • Added sparse sampling population pharmacokinetics analysis • Clarified preparation of IV cyclophosphamide • Clarified calculation of azathioprine dosing • Rationalized and clarified allowed and prohibited medications • Clarified instructions on contraception • Clarified criteria for use of IV prednisone • Amended Screening Visit -7 days to -1 days prior to Baseline to -10 days to -1 day prior to Baseline • Clarified Visit 9 (end of induction phase) requirements • Clarified requirements for hematology laboratory monitoring per label requirements for induction and maintenance phases • Added hormone tests • Corrected overlap of requirements for urinary protein • Amended reference to registry study • Amended number and location of centers from 50 to 100 worldwide • Added rationale for including patients with Class V lupus nephritis • Revised schedule of assessments for usability and to reflect protocol revisions • Clarified instructions for reporting of serious adverse events • Replaced lower case Roman numeral page numbers in synopsis with continuous numeric page numbers • Renumbered references • Amended clinical phase of study from Phase III /IV to Phase III • Changed Project Leader and Project Statistician • Correction of minor typographic errors
    26 Apr 2005
    PROTOCOL AMENDMENT 2 • Study title and overall study objectives were updated • Duration of induction phase treatment has been fixed at 24 weeks for all patients • The description of the primary efficacy analysis for the end of induction phase was clarified • Maintenance phase will continue until sufficient subjects have experienced treatment failure to maintain the power of the study, or until the last subject has been followed for 36 months, whichever is earlier • Treatment with pulse IV corticosteroids, plasmapheresis, or intravenous immunoglobulin, formerly permitted within the protocol, is now prohibited • Requirement for discussions with medical monitor were clarified • Required follow-up of subjects withdrawn was added • Inclusion and exclusion criteria were clarified. • Text was added regarding dosing of subjects aged 12-18 years • Low dose aspirin is added as an allowed medication • Serum pregnancy test must be completed within 7 days of Baseline • Description of pharmacokinetic sampling and analysis was expanded • Frequency of the SELENA-SLEDAI was reduced to 3-month intervals • Frequency of some laboratory tests were reduced • ECGs will be determined at Baseline, end of induction/beginning of maintenance, and end of maintenance • GFR will be determined at screening and all visits for which a 24-hour urine will be collected • Conversion of value for serum creatinine >300 umol/l was corrected in suggested dose adjustments for IVC dosing in renal insufficiency • Determination of urine protein:creatinine ratio was clarified • Urinalysis and urine microscopy were added to Schedule of Assessments • Schedule of CBCs was amended during the induction phase to create a consensus schedule fulfilling monitoring requirements for both study treatments, so that timing of CBCs would not reveal treatment assignments to blinded reviewers • Instructions for preparation of IV cyclophosphamide were clarified • Justification for sample size
    30 Jun 2005
    PROTOCOL AMENDMENT 3 • Amended sample size and statistical analysis according to FDA Special Protocol Assessment requirement that primary efficacy analysis be for superiority rather than non-inferiority • Amended long title to reflect induction phase being unblinded • Clarified definition of treatment response (primary endpoint of induction phase and required for entry into maintenance) • Clarified IVC dosing, number of doses, target dose, and adjustment of doses • Clarified that secondary efficacy endpoints during the induction phase would be analysed descriptively • Corrected footnote in Table of Assessments for induction regarding frequency of pregnancy tests • Amended reference to BILAG from 'organ' to ‘system’ in secondary endpoints • Corrected glossary of abbreviations • Corrected typographic error in Appendix 3 • Corrected arithmetic error in conversion of serum creatinine units
    23 Aug 2006
    PROTOCOL AMENDMENT 4 • A full pharmacokinetic (PK) profiling for a subset of subjects was added.
    22 Feb 2007
    PROTOCOL AMENDMENT 5 • Temporary dose stoppage of IVC was allowed for no more than 7 days in total. • Urine protein to creatinine ratio was clarified to specify that the ratio was derived from the 24 hour urine protein and creatinine measurements. • Hierarchical testing for the key secondary endpoints in the induction phase was included in the statistical analysis following feedback from the FDA. • The interpretation of what constitutes high dose phenobarbital was clarified to reflect that it was the judgment of the investigators. • The Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) flare instrument was removed and the procedure for calculating the total for the SLEDAI was corrected. The flare instrument that was part of the Safety of Exogenous Estrogens in Lupus Erythematosus National Assessment (SELENA)-SLEDAI scale, which appeared in Appendix 7 of the protocol but was not used for the study, was deleted due to the potential for confusion with study flare definitions. • The visit window at the beginning of induction was increased. Due to practical difficulties regarding the availability of laboratory results required for randomization, the window for the beginning of the induction visit (Visit 2) was increased from 10 to 14 days from Screening and the end of induction (Visit 9) was increased from 7 to 10 days. • The BILAG worksheet in Appendix 5 of the protocol was updated to conform to the latest version that was used in the clinical study.
    16 Mar 2007
    PROTOCOL AMENDMENT 6 Protocol Amendment 6, dated April 12, 2007 was approved by the IECs/IRBs before implementation. Last subject, last visit on March 16, 2007 was completed but the database had not been locked prior to implementation of this amendment. • The primary analysis for the induction phase of protocol was changed from a Fisher’s Exact Test comparing the proportion of responders in the two treatment groups, to a logistic regression comparing the proportion of responders in the two treatment groups. The rationale for this change in statistical test was that the logistic regression included the covariates race (Caucasian/Asian/Other), and World Health Organization (WHO) LN Class (V only, others) (the stratification variables used for the randomization), and geographical region (US/Canada, Latin America, Asia and Rest of the World). Analysis with these covariates is common in LN trials and provided a more meaningful analysis of the response to treatment than the Fisher’s Exact Test. Fisher’s Exact Test is used primarily when the expected number of subjects in a treatment by response cell is less than five, which was unlikely to be the case in this study. • Partial remission was one of the secondary efficacy parameters for efficacy assessments at the end of the induction phase. This parameter of partial remission was removed from the protocol, since it was felt that the primary endpoint of response was more clinically meaningful and more robust. • For the purpose of clarification, the complete remission criteria were amended to “proportion of subjects meeting remission criteria for each individual parameter AND proportion of subjects meeting at least one criterion for complete remission”. The secondary efficacy parameter was changed from the “number of” subjects to the “proportion of” subjects. • Clarification of the hierarchical testing of the secondary efficacy variables in the induction phase was added to the synopsis.

    Interruptions (globally)

    Were there any global interruptions to the trial? No

    Limitations and caveats

    Limitations of the trial such as small numbers of subjects analysed or technical problems leading to unreliable data.
    None reported
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