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    Clinical Trial Results:
    Safety and Efficacy of turoctocog alfa in Prevention and Treatment of Bleeds in Paediatric Previously Untreated Patients with Haemophilia A

    Summary
    EudraCT number
    2011-001033-16
    Trial protocol
    GB   AT   ES   GR   DK   HU   LT   PL   PT  
    Global end of trial date
    05 Dec 2018

    Results information
    Results version number
    v1(current)
    This version publication date
    20 Jun 2019
    First version publication date
    20 Jun 2019
    Other versions

    Trial information

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    Trial identification
    Sponsor protocol code
    NN7008-3809
    Additional study identifiers
    ISRCTN number
    -
    US NCT number
    NCT01493778
    WHO universal trial number (UTN)
    U1111-1119-6116
    Sponsors
    Sponsor organisation name
    Novo Nordisk A/S
    Sponsor organisation address
    Novo Allé, Bagsvaerd, Denmark, 2880
    Public contact
    Clinical Reporting Anchor and Disclosure (1452), Novo Nordisk A/S, clinicaltrials@novonordisk.com
    Scientific contact
    Clinical Reporting Anchor and Disclosure (1452), Novo Nordisk A/S, clinicaltrials@novonordisk.com
    Paediatric regulatory details
    Is trial part of an agreed paediatric investigation plan (PIP)
    Yes
    EMA paediatric investigation plan number(s)
    EMEA-000428-PIP01-08
    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
    02 Apr 2019
    Is this the analysis of the primary completion data?
    Yes
    Primary completion date
    16 Aug 2017
    Global end of trial reached?
    Yes
    Global end of trial date
    05 Dec 2018
    Was the trial ended prematurely?
    No
    General information about the trial
    Main objective of the trial
    To evaluate safety of turoctocog alfa in paediatric previously untreated patients (PUP) with haemophilia A.
    Protection of trial subjects
    The trial was conducted in accordance with the Declaration of Helsinki (2008) and ICH Good Clinical Practice (1996).
    Background therapy
    Not applicable
    Evidence for comparator
    Not applicable
    Actual start date of recruitment
    17 Sep 2012
    Long term follow-up planned
    No
    Independent data monitoring committee (IDMC) involvement?
    No
    Population of trial subjects
    Number of subjects enrolled per country
    Country: Number of subjects enrolled
    Algeria: 4
    Country: Number of subjects enrolled
    Austria: 2
    Country: Number of subjects enrolled
    China: 7
    Country: Number of subjects enrolled
    Denmark: 1
    Country: Number of subjects enrolled
    Greece: 3
    Country: Number of subjects enrolled
    Hong Kong: 1
    Country: Number of subjects enrolled
    Hungary: 1
    Country: Number of subjects enrolled
    Japan: 3
    Country: Number of subjects enrolled
    Lithuania: 1
    Country: Number of subjects enrolled
    Poland: 2
    Country: Number of subjects enrolled
    Russian Federation: 5
    Country: Number of subjects enrolled
    Serbia: 2
    Country: Number of subjects enrolled
    Spain: 3
    Country: Number of subjects enrolled
    Turkey: 6
    Country: Number of subjects enrolled
    United States: 19
    Worldwide total number of subjects
    60
    EEA total number of subjects
    13
    Number of subjects enrolled per age group
    In utero
    0
    Preterm newborn - gestational age < 37 wk
    0
    Newborns (0-27 days)
    2
    Infants and toddlers (28 days-23 months)
    55
    Children (2-11 years)
    3
    Adolescents (12-17 years)
    0
    Adults (18-64 years)
    0
    From 65 to 84 years
    0
    85 years and over
    0

    Subject disposition

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    Recruitment
    Recruitment details
    Subjects were enrolled at 40 sites in 15 countries: Algeria (1 site), Austria (2 sites), China (6 sites), Denmark (1 site), Greece (2 sites), Hong Kong (1 site), Hungary (1 site), Japan (2 sites), Lithuania (1 site), Poland (2 sites), Russian Federation (2 sites), Serbia (1 site), Spain (3 sites), Turkey (3 sites), United States (12 sites).

    Pre-assignment
    Screening details
    60 subjects were enrolled in the trial and received at least one dose of turoctocog alfa. The trial consisted of two phases: the main phase and an extension phase. 26 subjects developed inhibitors during the course of the trial and followed an alternative treatment regimen (inhibitor cohort).

    Period 1
    Period 1 title
    Overall Study (overall period)
    Is this the baseline period?
    Yes
    Allocation method
    Non-randomised - controlled
    Blinding used
    Not blinded
    Blinding implementation details
    Not applicable

    Arms
    Arm title
    Turoctocog alfa : Overall study
    Arm description
    Subjects received turoctocog alfa for the prevention of bleeding. The investigator decided the dose of turoctocog alfa based on the child’s clinical profile. The trial consists of two phases. The main phase was completed when either the patient received treatment with turoctocog alfa for at least 50 exposure days (ED) or developed FVIII inhibitors. After completing the main phase, the patient could transition to the extension phase, if the main phase was completed without inhibitors, or start an alternative visit schedule, if FVIII inhibitors were detected. Subjects developing inhibitors anytime during the trial were considered as a separate 'inhibitor' cohort and evaluated accordingly. Upon successful eradication of the inhibitors these patients enter the extension phase (if the inhibitor developed during the main phase) or re-enter it (if it had developed after they had started the extension phase). The total duration of the trial was around 7 years.
    Arm type
    Experimental

    Investigational medicinal product name
    turoctocog alfa 2000 IU/vial
    Investigational medicinal product code
    Other name
    NovoEight®/Novoeight®
    Pharmaceutical forms
    Powder and solvent for solution for injection
    Routes of administration
    Intravenous use
    Dosage and administration details
    Subjects received turoctocog alfa doses of 15−60 IU/kg body weight (BW) administered as an intravenous (i.v) injection for the prevention of bleeding. The investigator decided the dose based on the child’s clinical profile. Preventive treatment: A bolus dose of turoctocog alfa was administered intravenously at each administration day, preferably in the morning. A starting dose of 15 −50 IU/kg BW once weekly was recommended with gradual increases to 20−50 IU/kg BW every second day or 20−60 IU/kg BW two or three times weekly. Treatment of bleeds: Investigators determined the doses based on recommendations from the World Federation of Haemophilia (WFH) guidelines. Treatment of surgery: According to standard of practice at the participating site. The post injection level of FVIII for major surgery was to be at least 0.50 IU/mL. Treatment of subjects with inhibitors: Treatment with turoctocog alfa for up to 24 months.

    Number of subjects in period 1
    Turoctocog alfa : Overall study
    Started
    60
    Completed
    52
    Not completed
    8
         Consent withdrawn by subject
    1
         Adverse event, non-fatal
    2
         2 unclassified and 3 withdrawal criteria
    5

    Baseline characteristics

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    Baseline characteristics reporting groups
    Reporting group title
    Turoctocog alfa : Overall study
    Reporting group description
    Subjects received turoctocog alfa for the prevention of bleeding. The investigator decided the dose of turoctocog alfa based on the child’s clinical profile. The trial consists of two phases. The main phase was completed when either the patient received treatment with turoctocog alfa for at least 50 exposure days (ED) or developed FVIII inhibitors. After completing the main phase, the patient could transition to the extension phase, if the main phase was completed without inhibitors, or start an alternative visit schedule, if FVIII inhibitors were detected. Subjects developing inhibitors anytime during the trial were considered as a separate 'inhibitor' cohort and evaluated accordingly. Upon successful eradication of the inhibitors these patients enter the extension phase (if the inhibitor developed during the main phase) or re-enter it (if it had developed after they had started the extension phase). The total duration of the trial was around 7 years.

    Reporting group values
    Turoctocog alfa : Overall study Total
    Number of subjects
    60 60
    Age categorical
    Units: Subjects
        Newborns (0-27 days)
    2 2
        Infants and toddlers (28 days-23 months)
    55 55
        Children (2-11 years)
    3 3
    Age Continuous
    Units: months
        arithmetic mean (standard deviation)
    10.2 ± 7.88 -
    Sex: Female, Male
    Units: Subjects
        Female
    0 0
        Male
    60 60

    End points

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    End points reporting groups
    Reporting group title
    Turoctocog alfa : Overall study
    Reporting group description
    Subjects received turoctocog alfa for the prevention of bleeding. The investigator decided the dose of turoctocog alfa based on the child’s clinical profile. The trial consists of two phases. The main phase was completed when either the patient received treatment with turoctocog alfa for at least 50 exposure days (ED) or developed FVIII inhibitors. After completing the main phase, the patient could transition to the extension phase, if the main phase was completed without inhibitors, or start an alternative visit schedule, if FVIII inhibitors were detected. Subjects developing inhibitors anytime during the trial were considered as a separate 'inhibitor' cohort and evaluated accordingly. Upon successful eradication of the inhibitors these patients enter the extension phase (if the inhibitor developed during the main phase) or re-enter it (if it had developed after they had started the extension phase). The total duration of the trial was around 7 years.

    Subject analysis set title
    Turoctocog alfa: Main Phase (On-demand)
    Subject analysis set type
    Full analysis
    Subject analysis set description
    Children ≤2 years received on-demand treatment while waiting to start on a preventive regimen. This treatment period included Visit 2 to first preventive dose. Subjects received turoctocog alfa doses of 15-60 IU/kg body weight (BW) administered as an intravenous injection for the prevention of bleeding. The investigator decided what dose of turoctocog alfa to give based on the child’s clinical profile.

    Subject analysis set title
    Turoctocog alfa: Main Phase (Preventive treatment)
    Subject analysis set type
    Full analysis
    Subject analysis set description
    Subjects received prophylactic factor VIII replacement therapy (preventive treatment) until Visit 5 or until development of inhibitor, whichever came first. Subjects received turoctocog alfa doses of 15-60 IU/kg body weight (BW) administered as an intravenous injection for the prevention of bleeding. The investigator decided what dose of turoctocog alfa to give based on the child’s clinical profile.

    Subject analysis set title
    Turoctocog alfa: Main Phase (On-demand+Preventive treatment)
    Subject analysis set type
    Full analysis
    Subject analysis set description
    Subjects who completed the main phase of the trial. These included children ≤2 years who received on-demand treatment while waiting to start on a preventive regimen and subjects on prophylactic factor VIII replacement therapy until Visit 5 or until development of inhibitor, whichever came first.

    Subject analysis set title
    Turoctocog alfa: Extension phase (Preventive treatment)
    Subject analysis set type
    Full analysis
    Subject analysis set description
    Subjects received prophylactic treatment administered from completion of the main phase or completion of the inhibitor cohort until the end-of-trial visit in the extension phase. Subjects received turoctocog alfa doses of 15-60 IU/kg body weight (BW) administered as an intravenous injection for the prevention of bleeding. The investigator decided what dose of turoctocog alfa to give based on the child’s clinical profile.

    Subject analysis set title
    Turoctocog alfa: Inhibitor cohort
    Subject analysis set type
    Full analysis
    Subject analysis set description
    Subjects who developed an inhibitor during the course of the trial and followed an alternative treatment regimen. They were offered continued treatment with turoctocog alfa for up to 24 months.

    Primary: Incidence rate of FVIII inhibitors (≥0.6 BU)

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    End point title
    Incidence rate of FVIII inhibitors (≥0.6 BU) [1]
    End point description
    The incidence rate of FVIII inhibitors is defined as inhibitor titres ≥0.6 bethesda unit (BU) for main phase of the trial. The result is presented as percentage of subjects who developed FVIII inhibitor during the main phase out of subjects who have completed the main phase (N=58). The time frame for the main phase of the trial was from Visit 2 (21 days after screening) to Visit 5 (50-55 exposure day). Analysis population: The full analysis set included all subjects who completed the main phase.
    End point type
    Primary
    End point timeframe
    Evaluated for the main phase of the trial.
    Notes
    [1] - No statistical analyses have been specified for this primary end point. It is expected there is at least one statistical analysis for each primary end point.
    Justification: As there is no comparator arm, the primary endpoint was analysed based on exact calculation of a binomial distribution.
    End point values
    Turoctocog alfa: Main Phase (On-demand+Preventive treatment)
    Number of subjects analysed
    58
    Units: Percentage of participants
        number (confidence interval 95%)
    43.1 (30.2 to 56.8)
    No statistical analyses for this end point

    Secondary: Haemostatic effect of turoctocog alfa on treatment of bleeds assessed on a predefined four point scale: Excellent, Good, Moderate and None: Main phase

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    End point title
    Haemostatic effect of turoctocog alfa on treatment of bleeds assessed on a predefined four point scale: Excellent, Good, Moderate and None: Main phase
    End point description
    The haemostatic effect of turoctocog alfa was summarised by frequency tables and assessed on a predefined four point scale: excellent, good, moderate and none. The analysis was based on the total number of bleeds and their response to treatment. Results are presented for the main phase of the trial (from Visit 2 (21 days after screening) to Visit 5 (50-55 exposure day)). Analysis population: The full analysis set included all dosed subjects with data after dosing.
    End point type
    Secondary
    End point timeframe
    Main phase of the trial
    End point values
    Turoctocog alfa: Main Phase (On-demand) Turoctocog alfa: Main Phase (Preventive treatment)
    Number of subjects analysed
    36 [2]
    38 [3]
    Units: Bleeds
        Excellent
    53
    83
        Good
    36
    29
        Moderate
    5
    12
        None
    0
    1
        Missing
    4
    8
    Notes
    [2] - Out of 51 subjects, 36 had 98 bleeds.
    [3] - Out of 58 subjects, 38 had 133 bleeds.
    No statistical analyses for this end point

    Secondary: Haemostatic effect of turoctocog alfa on treatment of bleeds assessed on a predefined four point scale: Excellent, Good, Moderate and None: Extension phase

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    End point title
    Haemostatic effect of turoctocog alfa on treatment of bleeds assessed on a predefined four point scale: Excellent, Good, Moderate and None: Extension phase
    End point description
    The haemostatic effect of turoctocog alfa was summarised by frequency tables containing count of all bleeds and assessed on a predefined four point scale: excellent, good, moderate and none. The analysis was based on the total number of bleeds and their response to treatment. The results are presented for the extension phase of the trial (from completion of the main phase or completion of the inhibitor cohort until the end-of-trial visit). Analysis population: The full analysis set included all dosed subjects treated for prevention in the extension phase.
    End point type
    Secondary
    End point timeframe
    Extension phase of the trial
    End point values
    Turoctocog alfa: Extension phase (Preventive treatment)
    Number of subjects analysed
    40 [4]
    Units: Bleeds
        Excellent
    161
        Good
    73
        Moderate
    31
        None
    1
        Missing
    3
    Notes
    [4] - Out of 49 subjects, 40 had 269 bleeds
    No statistical analyses for this end point

    Secondary: Haemostatic effect of turoctocog alfa on treatment of bleeds assessed on a predefined four point scale: excellent, good, moderate and none: Combined main and extension phases

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    End point title
    Haemostatic effect of turoctocog alfa on treatment of bleeds assessed on a predefined four point scale: excellent, good, moderate and none: Combined main and extension phases
    End point description
    The haemostatic effect of turoctocog alfa was summarised by frequency tables containing count of all bleeds and assessed on a predefined four point scale: Excellent, Good, Moderate and None. The analysis was based on the total number of bleeds and their response to treatment. The results are presented for the combined main and extension phases for preventive treatment of the trial (from visit 2 to until end of trial). The results of inhibitor cohort are also presented. Analysis population: The full analysis set included all dosed subjects treated for prevention in the main and extension phase.
    End point type
    Secondary
    End point timeframe
    Combined main and extension phases
    End point values
    Turoctocog alfa : Overall study Turoctocog alfa: Inhibitor cohort
    Number of subjects analysed
    59 [5]
    19 [6]
    Units: Bleeds
        Excellent
    244
    9
        Good
    102
    19
        Moderate
    43
    10
        None
    2
    4
        Missing
    11
    137
    Notes
    [5] - Out of 60 subjects, 59 had 402 bleeds.
    [6] - Out of 26 subjects, 19 had 179 bleeds.
    No statistical analyses for this end point

    Secondary: Annualised bleeding rate: Main phase

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    End point title
    Annualised bleeding rate: Main phase
    End point description
    Mean annualised bleeding rate defined as number of bleeds in total per patient per year following treatment were estimated by a Poisson model allowing for over-dispersion. The Poisson estimate is presented with a 95% confidence interval (CI). Results are presented for the main phase of the trial (from Visit 2 (21 days after screening) to Visit 5 (50-55 exposure day)). Analysis population: The full analysis set included all dosed subjects with data after dosing.
    End point type
    Secondary
    End point timeframe
    Main phase of the trial
    End point values
    Turoctocog alfa: Main Phase (On-demand) Turoctocog alfa: Main Phase (Preventive treatment)
    Number of subjects analysed
    51 [7]
    57 [8]
    Units: bleeds/patient/year
        least squares mean (confidence interval 95%)
    4.27 (3.09 to 5.89)
    5.63 (4.27 to 7.43)
    Notes
    [7] - 98 bleeds of 51 subjects were analysed
    [8] - 133 bleeds of 57 subjects were analysed
    No statistical analyses for this end point

    Secondary: Annualised bleeding rate: Extension phase

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    End point title
    Annualised bleeding rate: Extension phase
    End point description
    Mean annualised bleeding rate defined as number of bleeds in total per patient per year following treatment were estimated by a Poisson model allowing for over-dispersion. The Poisson estimate is presented with a 95% confidence interval (CI). The results are presented for the extension phase of the trial (from completion of the main phase or completion of the inhibitor cohort until the end-of-trial visit). Analysis population: The full analysis set included all dosed subjects with data after dosing.
    End point type
    Secondary
    End point timeframe
    Extension phase of the trial
    End point values
    Turoctocog alfa: Extension phase (Preventive treatment)
    Number of subjects analysed
    49 [9]
    Units: bleeds/patient/year
        least squares mean (confidence interval 95%)
    3.81 (2.84 to 5.11)
    Notes
    [9] - 269 bleeds of 49 subjects was analysed.
    No statistical analyses for this end point

    Secondary: Annualised bleeding rate: Combined main and extension phases

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    End point title
    Annualised bleeding rate: Combined main and extension phases
    End point description
    Mean annualised bleeding rate defined as number of bleeds in total per patient per year following treatment were estimated by a Poisson model allowing for over-dispersion. The Poisson estimate is presented with a 95% confidence interval (CI). The results are presented for the combined main and extension phases of the trial (from visit 2 to until end of trial). The results of inhibitor cohort are also presented. Analysis population: The full analysis set included all dosed subjects except one subject, with data after dosing. One subject with only one exposure day during main and total period was excluded from the analysis.
    End point type
    Secondary
    End point timeframe
    Combined main and extention phases
    End point values
    Turoctocog alfa : Overall study Turoctocog alfa: Inhibitor cohort
    Number of subjects analysed
    58 [10]
    26 [11]
    Units: bleeds/patient/year
        least squares mean (confidence interval 95%)
    4.26 (3.34 to 5.44)
    6.09 (3.77 to 9.84)
    Notes
    [10] - 402 bleeds of 58 patients was analysed
    [11] - 179 bleeds of 26 subjects was anlysed
    No statistical analyses for this end point

    Secondary: Incidence rate of FVIII inhibitors (≥0.6 BU): Extension phase

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    End point title
    Incidence rate of FVIII inhibitors (≥0.6 BU): Extension phase
    End point description
    The incidence rate of FVIII inhibitors is defined as inhibitor titres ≥0.6 bethesda unit (BU) for extension phase of the trial. The result is presented as percentage of subjects who developed FVIII inhibitor during the extension phase out of subjects were exposed in the extension phase without inhibitor in the main phase. Analysis population: The full analysis set included all subjects who were exposed in the extension phase without inhibitor in the main phase.
    End point type
    Secondary
    End point timeframe
    Extension phase of the trial
    End point values
    Turoctocog alfa: Extension phase (Preventive treatment)
    Number of subjects analysed
    33
    Units: Percentage of participants
        number (confidence interval 95%)
    3.0 (0.1 to 15.8)
    No statistical analyses for this end point

    Secondary: Incidence rate of FVIII inhibitors (≥0.6 BU): Combined main and extension phases

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    End point title
    Incidence rate of FVIII inhibitors (≥0.6 BU): Combined main and extension phases
    End point description
    The incidence rate of FVIII inhibitors is defined as inhibitor titres ≥0.6 bethesda unit (BU) for the combined main and extension phase of the trial. The result is presented as percentage of subjects who developed FVIII inhibitor during the combined main and extension phase out of subjects who completed the main phase. Analysis population: The full analysis set included all subjects who completed the main phase.
    End point type
    Secondary
    End point timeframe
    Combined main and extension phases
    End point values
    Turoctocog alfa : Overall study
    Number of subjects analysed
    58
    Units: percentage
        number (confidence interval 95%)
    44.8 (31.7 to 58.5)
    No statistical analyses for this end point

    Adverse events

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    Adverse events information
    Timeframe for reporting adverse events
    Adverse events from the first trial related activity after the patient had signed the informed consent (visit 1) until the end-of-trial visit.
    Adverse event reporting additional description
    Analysis population: Safety analysis set, which included all dosed subjects with data after dosing. All reported adverse events in this trial were treatment emergent adverse events (TEAEs).
    Assessment type
    Systematic
    Dictionary used for adverse event reporting
    Dictionary name
    MedDRA
    Dictionary version
    21
    Reporting groups
    Reporting group title
    Turoctocog alfa
    Reporting group description
    Subjects received turoctocog alfa for the prevention of bleeding. The investigator decided the dose of turoctocog alfa based on the child’s clinical profile. The trial consists of two phases. The main phase was completed when either the patient received treatment with turoctocog alfa for at least 50 exposure days (ED) or developed FVIII inhibitors. After completing the main phase, the patient could transition to the extension phase, if the main phase was completed without inhibitors, or start an alternative visit schedule, if FVIII inhibitors were detected. Subjects developing inhibitors anytime during the trial were considered as a separate 'inhibitor' cohort and evaluated accordingly. Upon successful eradication of the inhibitors these patients enter the extension phase (if the inhibitor developed during the main phase) or re-enter it (if it had developed after they had started the extension phase). The total duration of the trial was around 7 years.

    Serious adverse events
    Turoctocog alfa
    Total subjects affected by serious adverse events
         subjects affected / exposed
    36 / 60 (60.00%)
         number of deaths (all causes)
    0
         number of deaths resulting from adverse events
    0
    Vascular disorders
    Haematoma
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Poor venous access
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Phlebitis deep
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Surgical and medical procedures
    Central venous catheter removal
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 2
         deaths causally related to treatment / all
    0 / 0
    Central venous catheterisation
         subjects affected / exposed
    2 / 60 (3.33%)
         occurrences causally related to treatment / all
    0 / 2
         deaths causally related to treatment / all
    0 / 0
    Circumcision
         subjects affected / exposed
    2 / 60 (3.33%)
         occurrences causally related to treatment / all
    0 / 2
         deaths causally related to treatment / all
    0 / 0
    Hospitalisation
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    General disorders and administration site conditions
    Catheter site haematoma
         subjects affected / exposed
    2 / 60 (3.33%)
         occurrences causally related to treatment / all
    0 / 2
         deaths causally related to treatment / all
    0 / 0
    Catheter site oedema
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Pyrexia
         subjects affected / exposed
    4 / 60 (6.67%)
         occurrences causally related to treatment / all
    0 / 4
         deaths causally related to treatment / all
    0 / 0
    Immune system disorders
    Drug hypersensitivity
         subjects affected / exposed
    2 / 60 (3.33%)
         occurrences causally related to treatment / all
    0 / 2
         deaths causally related to treatment / all
    0 / 0
    Respiratory, thoracic and mediastinal disorders
    Acute respiratory failure
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Status asthmaticus
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Product issues
    Device dislocation
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Device damage
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Injury, poisoning and procedural complications
    Accidental overdose
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Concussion
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Head injury
         subjects affected / exposed
    3 / 60 (5.00%)
         occurrences causally related to treatment / all
    0 / 3
         deaths causally related to treatment / all
    0 / 0
    Traumatic haemorrhage
         subjects affected / exposed
    4 / 60 (6.67%)
         occurrences causally related to treatment / all
    0 / 5
         deaths causally related to treatment / all
    0 / 0
    Congenital, familial and genetic disorders
    Cryptorchism
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Hydrocele
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Nervous system disorders
    Haemorrhage intracranial
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Intracranial haematoma
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Blood and lymphatic system disorders
    Anaemia
         subjects affected / exposed
    3 / 60 (5.00%)
         occurrences causally related to treatment / all
    0 / 3
         deaths causally related to treatment / all
    0 / 0
    Factor VIII inhibition
         subjects affected / exposed
    25 / 60 (41.67%)
         occurrences causally related to treatment / all
    27 / 27
         deaths causally related to treatment / all
    0 / 0
    Gastrointestinal disorders
    Gastritis
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Mouth haemorrhage
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 2
         deaths causally related to treatment / all
    0 / 0
    Musculoskeletal and connective tissue disorders
    Joint effusion
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Infections and infestations
    Bacteraemia
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Bronchitis
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Catheter site infection
         subjects affected / exposed
    2 / 60 (3.33%)
         occurrences causally related to treatment / all
    0 / 6
         deaths causally related to treatment / all
    0 / 0
    Device related infection
         subjects affected / exposed
    3 / 60 (5.00%)
         occurrences causally related to treatment / all
    0 / 5
         deaths causally related to treatment / all
    0 / 0
    Gastroenteritis
         subjects affected / exposed
    2 / 60 (3.33%)
         occurrences causally related to treatment / all
    0 / 3
         deaths causally related to treatment / all
    0 / 0
    Gastrointestinal infection
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Nasopharyngitis
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Otitis media acute
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Staphylococcal bacteraemia
         subjects affected / exposed
    2 / 60 (3.33%)
         occurrences causally related to treatment / all
    0 / 3
         deaths causally related to treatment / all
    0 / 0
    Staphylococcal infection
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Streptococcal bacteraemia
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Systemic bacterial infection
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Upper respiratory tract infection
         subjects affected / exposed
    2 / 60 (3.33%)
         occurrences causally related to treatment / all
    0 / 2
         deaths causally related to treatment / all
    0 / 0
    Viral infection
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Injection site infection
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Respiratory tract infection
         subjects affected / exposed
    1 / 60 (1.67%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Vascular device infection
         subjects affected / exposed
    2 / 60 (3.33%)
         occurrences causally related to treatment / all
    0 / 2
         deaths causally related to treatment / all
    0 / 0
    Frequency threshold for reporting non-serious adverse events: 5%
    Non-serious adverse events
    Turoctocog alfa
    Total subjects affected by non serious adverse events
         subjects affected / exposed
    55 / 60 (91.67%)
    Investigations
    Body temperature increased
         subjects affected / exposed
    3 / 60 (5.00%)
         occurrences all number
    4
    Injury, poisoning and procedural complications
    Arthropod bite
         subjects affected / exposed
    4 / 60 (6.67%)
         occurrences all number
    5
    Contusion
         subjects affected / exposed
    6 / 60 (10.00%)
         occurrences all number
    9
    Head injury
         subjects affected / exposed
    5 / 60 (8.33%)
         occurrences all number
    9
    Blood and lymphatic system disorders
    Anaemia
         subjects affected / exposed
    6 / 60 (10.00%)
         occurrences all number
    8
    Factor VIII inhibition
         subjects affected / exposed
    4 / 60 (6.67%)
         occurrences all number
    4
    Iron deficiency anaemia
         subjects affected / exposed
    8 / 60 (13.33%)
         occurrences all number
    12
    General disorders and administration site conditions
    Catheter site inflammation
         subjects affected / exposed
    3 / 60 (5.00%)
         occurrences all number
    3
    Pyrexia
         subjects affected / exposed
    32 / 60 (53.33%)
         occurrences all number
    85
    Gastrointestinal disorders
    Constipation
         subjects affected / exposed
    3 / 60 (5.00%)
         occurrences all number
    3
    Diarrhoea
         subjects affected / exposed
    12 / 60 (20.00%)
         occurrences all number
    25
    Teething
         subjects affected / exposed
    3 / 60 (5.00%)
         occurrences all number
    3
    Vomiting
         subjects affected / exposed
    11 / 60 (18.33%)
         occurrences all number
    19
    Reproductive system and breast disorders
    Balanoposthitis
         subjects affected / exposed
    3 / 60 (5.00%)
         occurrences all number
    3
    Respiratory, thoracic and mediastinal disorders
    Cough
         subjects affected / exposed
    15 / 60 (25.00%)
         occurrences all number
    26
    Nasal congestion
         subjects affected / exposed
    4 / 60 (6.67%)
         occurrences all number
    6
    Rhinorrhoea
         subjects affected / exposed
    7 / 60 (11.67%)
         occurrences all number
    10
    Skin and subcutaneous tissue disorders
    Dermatitis diaper
         subjects affected / exposed
    3 / 60 (5.00%)
         occurrences all number
    3
    Eczema
         subjects affected / exposed
    5 / 60 (8.33%)
         occurrences all number
    6
    Rash
         subjects affected / exposed
    5 / 60 (8.33%)
         occurrences all number
    11
    Rash papular
         subjects affected / exposed
    3 / 60 (5.00%)
         occurrences all number
    3
    Infections and infestations
    Bronchitis
         subjects affected / exposed
    7 / 60 (11.67%)
         occurrences all number
    7
    Ear infection
         subjects affected / exposed
    6 / 60 (10.00%)
         occurrences all number
    10
    Gastroenteritis
         subjects affected / exposed
    8 / 60 (13.33%)
         occurrences all number
    8
    Hand-foot-and-mouth disease
         subjects affected / exposed
    4 / 60 (6.67%)
         occurrences all number
    5
    Influenza
         subjects affected / exposed
    5 / 60 (8.33%)
         occurrences all number
    5
    Nasopharyngitis
         subjects affected / exposed
    16 / 60 (26.67%)
         occurrences all number
    36
    Otitis media
         subjects affected / exposed
    4 / 60 (6.67%)
         occurrences all number
    4
    Otitis media acute
         subjects affected / exposed
    4 / 60 (6.67%)
         occurrences all number
    7
    Pharyngitis
         subjects affected / exposed
    4 / 60 (6.67%)
         occurrences all number
    4
    Pneumonia
         subjects affected / exposed
    5 / 60 (8.33%)
         occurrences all number
    5
    Upper respiratory tract infection
         subjects affected / exposed
    15 / 60 (25.00%)
         occurrences all number
    64
    Viral infection
         subjects affected / exposed
    7 / 60 (11.67%)
         occurrences all number
    9
    Viral upper respiratory tract infection
         subjects affected / exposed
    4 / 60 (6.67%)
         occurrences all number
    11
    Catheter site infection
         subjects affected / exposed
    3 / 60 (5.00%)
         occurrences all number
    7
    Conjunctivitis
         subjects affected / exposed
    3 / 60 (5.00%)
         occurrences all number
    3
    Gastroenteritis viral
         subjects affected / exposed
    3 / 60 (5.00%)
         occurrences all number
    4
    Tonsillitis
         subjects affected / exposed
    3 / 60 (5.00%)
         occurrences all number
    6
    Varicella
         subjects affected / exposed
    3 / 60 (5.00%)
         occurrences all number
    3
    Metabolism and nutrition disorders
    Iron deficiency
         subjects affected / exposed
    4 / 60 (6.67%)
         occurrences all number
    4

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    Substantial protocol amendments (globally)

    Were there any global substantial amendments to the protocol? Yes
    Date
    Amendment
    17 Mar 2012
    Amendment 1: In Section 1, 3, 5, and 6 the number of patients and number of ED were reduced. In Section 12.5.2 and 18.4, number of pre-planned safety interim analysis was reduced from two to one. In Section 6.2, an inclusion criteria “Immunocompetent, defined as eithercells >200 cells/μl”, was added. In Section 6.4, one withdrawal criteria,“For inhibitor patients – inhibitor treatment failure with N8 treatment”, was removed. In Section 12.1.2, All hypersensitivity reactions reported as MESIs were to be followed up with a hypersensitivityquestionnaire was added under Adverse events of special interest. Several minor inconsistencies /ambiguities, and apparent mistakes were corrected in the protocol.
    13 Oct 2012
    Amendment 5: In Section 1, 2, the concept of two different phases of the trial, a main phase and an extension phase was introduced. In Section 4.2, secondary endpoints were updated, “The secondary endpoints will be evaluated for the main phase of trial, for the extension phase of trial, and for the combined main and extension phases.” In Section 5.1, trial duration extended from approximately 50 months to 5 years. In Section 5.3.4, treatment schedule for patients who develop inhibitors was changed, “If needed and decided by the Investigator, the initiation of the inhibitor treatment with turoctocog alfa can be delayed for up to 6 months from the time of diagnosis of inhibitor. If the inhibitor disappears (BU <0.6/mL) during the ITI treatment, the patient should resume preventive treatment as recommended in this protocol, following the visit schedule in the extension phase. For patients still with positive inhibitors after 12 months ITI treatment, continued trial participation will be evaluated based on the level of inhibitors.” In Section 6.1, the planned number of patients to be screened (i.e. documented informed consent) was decreased from 75 to 65. In Section 6.4, one withdrawal criteria, “Haemostasis not achievable with turoctocog alfa: The bleed could not be controlled after 48 hours using recommended doses of turoctocog alfa”, was removed. In Section 8.1, visit details were updated including Extension phase visit, EoT visit In Section, 8.2.9, pulse and blood pressure were removed from the list of vital signs assessment. In Section 18.2.4, supportive secondary efficacy and safety endpoints were updated according to the concept of main phase and extension phase.
    19 Jan 2013
    Amendment 6: In Section 2 and 5.1, Visit 1 and Visit 2 combined to be performed at the same occasion. This was done to minimize the bleeding risks in untreated patients. In Section 6.2, “Immunocompetent, defined as either HIV negative or if HIV positive, CD4+ cells >200 cells/μL” was removed from inclusion criteria since the immune competency was expected to be present in the vast majority of PUP. This criteria was removed so as to avoid having unnecessary criteria. In Section 6.2, inclusion criteria #2 was updated. Patients had to be diagnosed as opposed to be presenting with congenital severe haemophilia A (FVIII ≤1%). • In Section 6.3, Platelet count <50,000 platelets/μL was removed from exclusion criteria. The exclusion criteria “patients with FVIII inhibitor (>0.6 BU) should be excluded from the trial” was removed. Exclusion criterion was updated to “Any history of FVIII inhibitor”. In Section 12.1.2, Inhibitor formation against FVIII was updated to be always considered as MESI. Analysis of haematology to be performed at central lab. However, if an investigator obtains any indication of inhibitor formation by clinical signs or local laboratory results, it should be reported as MESIs.
    03 Feb 2014
    Amendment 7: In Section 5.1 and 7, the trial duration (from 5 to 7 years) and end-of-trial date were revised. In Section 5.3, the duration and conditions for the treatment of patients with inhibitors were redefined. In Section 6.1, planned number of patients to complete the main phase of the trial was updated. In Section 6.4, below withdrawal criteria were updated to ensure the safety of patients, who do not benefit from inhibitor treatment with turoctocog alfa. * “Inhibitor treatment has not been started within 6 months from the date of confirmation of positive FVIII inhibitor (BU ≥ 0.6/mL) * FVIII inhibitor titre decline from peak level is less than 20% after 12 months of inhibitor treatment * FVIII inhibitor is positive (BU ≥ 0.6/mL) after 24 months of inhibitor treatment. *After completed inhibitor treatment (maximum 24 months), preventive treatment as described in the protocol is not resumed/started.” In Section 7, trial schedule was updated including details about LPLV, Planned completion of main and updated clinical trial report protocol exceptions. In Section 8.2.2.2, non-neutralising antibodies were defined. In Section 8.3.1, definition of bleeds, severe bleed, and re-bleed were defined. In Section 12.1, definitions of serious adverse events were re-defined, final outcome of an AE and MESI were updated. The possibility to further investigate immunogenicity of turoctocog alfa e.g. binding antibody assessment and HLA genotyping was introduced.
    04 Sep 2014
    Amendment 9: In Section 7, recruitment period was prolonged to ensure possibility of recruiting Chinese patients as the clinical trial application (CTA) in China was delayed In Section 12.5.2, timing of interim analysis changed to ensure timely interim analysis independent of number of inhibitor patients Number of planned sites increased to fulfil the number of planned recruited patients. Exclusion criteria “Preventive treatment not initiated at age of 24 months” was added In Section 8.2.6, a withdrawal criteria about Lupus Anticoagulant test – (preventive treatment not initiated at age 24 months), long-term retention of blood samples, a new preventive treatment (2x weekly), monitoring visits every 12 weeks – was added. This was done to align with other PUP trials in aemophilia and to ensure better evaluation of inhibitor patients Twice weekly dosing option was introduced. This was done since the gap from once weekly to 3 times weekly infusion of preventive treatment was too big. Sites requested twice weekly frequency to avoid overdosing of patients. Definition of ‘disease-related’ bleeding was changed from being AE to not AE. This was done to align with other guardian protocols and Global Safeties current definition of disease related bleedings In Section, 5.3.2, Guide for dosing in bleeding episodes was added on request of sites. In Section 25, methods of retention of blood samples were defined.
    18 Jan 2016
    Amendment 10: In Section 7, planned duration of recruitment was increased from 39 to 45 months. Planned dates for last patient first visit (LPFV) and LPLV were also updated. Minor inconsistencies, ambiguities and typographical errors were corrected.

    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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