E.1 Medical condition or disease under investigation |
E.1.1 | Medical condition(s) being investigated |
alpha-1 antitrypsin deficiency (AATD)-associated liver disease |
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E.1.1.1 | Medical condition in easily understood language |
alpha-1 antitrypsin deficiency (AATD)-associated liver disease |
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E.1.1.2 | Therapeutic area | Diseases [C] - Digestive System Diseases [C06] |
MedDRA Classification |
E.1.2 Medical condition or disease under investigation |
E.1.2 | Version | 23.0 |
E.1.2 | Level | LLT |
E.1.2 | Classification code | 10001806 |
E.1.2 | Term | Alpha-1 anti-trypsin deficiency |
E.1.2 | System Organ Class | 10001806 - Alpha-1 anti-trypsin deficiency |
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E.1.3 | Condition being studied is a rare disease | Yes |
E.2 Objective of the trial |
E.2.1 | Main objective of the trial |
Part A:
• To select a single dose level for use in Part B of the study based on a combined evaluation of safety and pharmacodynamic dose response in each Part A cohort using change over time from baseline to Day 113 in serum Z-AAT levels
Part B:
• To evaluate efficacy (as assessed by the proportion of ARO-AAT treated patients relative to placebo achieving a 2-point improvement in a histologic grading scale of alpha-1 antitrypsin deficiency associated liver disease AND no worsening of liver fibrosis based on Ishak score on end of study biopsy). |
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E.2.2 | Secondary objectives of the trial |
Part B:
• To evaluate change in total liver Z-AAT (insoluble + soluble) protein at end of study versus baseline
• To evaluate change in liver Z-AAT soluble protein at end of study versus baseline
• To evaluate change in liver Z-AAT insoluble protein at end of study versus baseline
• To determine the effect of multiple doses of ARO-AAT on circulating levels of total and Z-AAT alpha-1 antitrypsin at multiple post-dose time points versus baseline
• To evaluate change from baseline on a histologic grading scale of alpha-1 antitrypsin deficiency (AATD)-associated liver disease on end of study biopsy in ARO-AAT treated patients relative to placebo
• To evaluate the effect of ARO-AAT on changes in serum biomarkers including PT, PTT, INR, albumin, ALT, AST, GGT, platelet count, total bilirubin, and alkaline phosphatase at timepoints throughout the study versus baseline
• Safety of ARO-AAT administration versus placebo based on occurrence of adverse events (AEs) |
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E.2.3 | Trial contains a sub-study | No |
E.3 | Principal inclusion criteria |
1. Male or non-nursing female patients 18-75 years of age, inclusive, at the time of Screening with previous diagnosis of PiZZ genotype Alpha-1 Antitrypsin Deficiency. PiZZ diagnosis from source verifiable medical records is permitted. Otherwise, patients must undergo PiZZ confirmatory testing at Screening. PiMZ or PiSZ genotypes are not permitted.
2. Able and willing to provide written informed consent prior to the performance of any study specific procedures.
3. Liver biopsy indicating a liver fibrosis score less than F4 based on local pathologist read.
a. Metavir F1- F3 (or equivalent on other grading scales) may participate in Part A and Part B. A previous biopsy conducted as part of an AROAAT study within 1 year is acceptable if there is sufficient baseline material for Part B analysis.
b. A patient with no fibrosis (F0) may participate in Part A only. A previous biopsy conducted within 1 year is acceptable if source verifiable medical record specifies F0.
4. A 12-lead ECG at Screening that, in the opinion of the Investigator, has no new acute abnormalities (e.g., new onset atrial fibrillation) that compromise participant’s safety in this study. Stable disease (e.g., stable atrial fibrillation) is acceptable.
5. Non-smoker (defined as does not smoke cigarettes daily for at least 12 months) with current non-smoking status confirmed by urine cotinine at screening AND any previous smoking history prior to 12 months must be < 15 pack years. Patients may be on nicotine replacement (patch or gum). e-cigarettes (vapor) is not permitted. A positive urine cotinine result due to nicotine replacement is acceptable for enrollment at the discretion of the Investigator.
6. Participants using highly effective contraception during the study and for 3 months following the last dose of ARO-AAT. Males must not donate sperm for at least 3 months post last dose of study treatment. Females of childbearing potential must have a negative urine pregnancy test at Screening and on Day 1 pre-dose. Females not of childbearing potential must be post-menopausal (defined as cessation of regular menstrual periods for at least 12 months), confirmed by follicle-stimulating hormone (FSH) consistent with post-menopausal state based on lab reference ranges.
• Using twice the normal protection of birth control by using a condom AND one other form of either birth control pills (The Pill), depot or injectable birth control, IUD (Intrauterine Device), birth Control Patch (e.g., Ortho Evra), NuvaRing®, OR Surgical sterilization as a single form of birth control: i.e., tubal ligation, hysterectomy, bilateral oophorectomy, vasectomy or equivalently effective surgical form of birth control, is acceptable.
• True Subject abstinence for the duration of the study and 12 weeks after the dose of ARO-AAT is acceptable only when in line with the preferred and usual lifestyle of the subject. Periodic abstinence (calendar, symptothermal, post-ovulation methods), withdrawal (coitus interruptus), spermicides only, and lactational amenorrhea methods are not considered “true” abstinence and are not acceptable methods of contraception.
* All laboratory tests used as inclusion criteria may be repeated once and the repeat value may be used for inclusion purposes.
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E.4 | Principal exclusion criteria |
1. INR ≥ 1.2 at Screening (one retest permitted). If based on opinion of Investigator and/or prescribing physician patient is appropriate for anticoagulant holiday, patient may stop taking anticoagulant for an appropriate washout period and if indicated a repeat INR within < 1.2 would be acceptable. Vitamin K may be used for reversal. If INR is not indicated (direct thrombin inhibitors or Xa inhibitors) then appropriate washout period alone may be acceptable.
2. Platelet count < 150 x 109/L at Screening (one retest permitted)
3. ALT and AST levels > 250 U/L at Screening (one retest permitted)
4. eGFR < 60ml/min at Screening (one retest permitted)
5. FEV1 <65% of predicted (preferentially post-bronchodilator reading) at Screening (one retest permitted)
6. Recent (last 3 months) pneumonia or lower respiratory infection (which must be verifiable from the medical record). Patient reported infection is not sufficient to meet this criterion.
7. Unavoidable exposure to inhaled environmental toxins that in the clinical judgement of the investigator could impair pulmonary function significantly over the course of the study.
8. Human immunodeficiency virus infection, as shown by the presence of anti-HIV antibody (sero-positive)
9. Seropositive for HBV (HBsAg positive at Screening) or HCV (detectable HCV RNA at Screening). Cured HCV (positive antibody test without detectable HCV RNA is acceptable).
10. Uncontrolled hypertension (Systolic BP > 170 and diastolic BP >100 mmHg at Screening). Patients may rescreen once BP is successfully controlled.
11. A history of torsades de pointes, ventricular rhythm disturbances (e.g., ventricular tachycardia or fibrillation), untreated heart block (excluding first-degree block, being PR interval prolongation only), congenital long QT syndrome or new acute ST segment elevation or depression or new acute Q wave on ECG. Stable atrial dysrhythmias (e.g., stable atrial fibrillation) are acceptable.
12. Symptomatic heart failure (per NYHA guidelines), unstable angina, myocardial infarction, severe cardiovascular disease (ejection fraction < 20%, transient ischemic attack (TIA) or cerebrovascular accident (CVA) within 6 months prior to Screening
13. History of malignancy within the last 1 year except for adequately treated basal cell carcinoma, squamous cell skin cancer, superficial bladder tumors, or in situ cervical cancer.
14. History of major surgery within the prior 1 month prior to Screening
15. Regular use of alcohol within one month prior to the Screening visit (i.e., more than 14 units of alcohol per week [1 Unit = 150 mL of wine, 360 mL of beer, or 45 mL of 40% alcohol])
16. Use of illicit drugs (such as cocaine, phencyclidine [PCP]) within 1 year prior to the Screening visit or positive urine drug screen at Screening (a urine drug screen positive for benzodiazepines, opioids or THC is acceptable for enrollment at the discretion of the Investigator).
17. Use of an investigational agent or device within 30 days prior to dosing or current participation in an investigational study involving a therapeutic intervention.
18. Blood donation (≥500 mL) within 7 days prior to study treatment administration.
19. Any concomitant medical or psychiatric condition or social situation that would make it difficult to comply with protocol requirements or put the participant at additional safety risk. Patients with NASH, NAFLD, metabolic syndrome, well controlled diabetes mellitus (even if on insulin) or hemochromatosis are acceptable if disease is stable and does not pose a significant threat to subject participation.
20. A history of thromboembolic disease (including deep vein thrombosis or pulmonary embolism), myocardial infarction, stroke within three (3) months of screening.
21. Any other condition or finding of clinical relevance at Screening, that in the opinion of the Investigator would render the participant unsuitable for enrollment or could interfere with participating in and completing the study.
22. Previous diagnosis of definitive liver cirrhosis based on biopsy or complications of cirrhosis (e.g., varices, ascites, hepatic encephalopathy) based on source verifiable medical record.
23. Patients who have undergone lung or liver transplant for AATD are excluded.
24. Diagnosis of F4 (Metavir) or similar grading scale equivalent indicating definitive cirrhosis on pre-dose liver biopsy completed as part of the AROAAT2001 study based on local pathologist read or based on historical liver biopsy (last 12 months from consent) with a source verifiable pathologist read of definitive liver cirrhosis.
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E.5 End points |
E.5.1 | Primary end point(s) |
The primary efficacy endpoint of Part B of the study is the proportion of ARO-AAT treated patients relative to placebo who achieve a 2-point improvement in a histologic grading scale of alpha-1 antitrypsin associated liver disease AND no worsening of liver fibrosis based on Ishak fibrosis score on end of study biopsy. |
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E.5.1.1 | Timepoint(s) of evaluation of this end point |
Part A:
-Patients without fibrosis (F0) are not eligible to participate in Part B and will only receive study treatment on Days 1 and 29 in Part A.
-Patients with Metavir F1-F3 fibrosis (or equivalent) are eligible for Part B and will receive study treatment on Days 1, 29, 113, and every 84 days thereafter until roll over into Part B.
Part B:
Days 1, 29, 113 then every 84 days (Days 197, 281, 365, 449, 533, 617) |
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E.5.2 | Secondary end point(s) |
Part B secondary endpoints include:
1) change in total liver Z-AAT (insoluble + soluble) protein at end of study versus baseline
2) change in liver Z-AAT soluble protein at end of study versus baseline
3) change in liver Z-AAT insoluble protein at end of study versus baseline
4) the effect of multiple doses of ARO-AAT on circulating levels of total and Z-AAT alpha-1 antitrypsin at multiple post-dose time points versus baseline
5) changes from baseline on a histologic grading scale (including, but not limited to histological features such as inflammation, PASD globules, cell death, steatosis, etc.) of AATD-associated liver disease on end of study biopsy in ARO-AAT treated patients relative to placebo
6) the effect of ARO-AAT on changes in serum biomarkers including PT, PTT, INR, albumin, ALT, AST, GGT, platelet count, total bilirubin and alkaline phosphatase at timepoints throughout the study versus baseline
7) safety of ARO-AAT administration versus placebo based on occurrence of AEs |
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E.5.2.1 | Timepoint(s) of evaluation of this end point |
Part B:
Days 1, 29, 113 then every 84 days (Days 197, 281, 365, 449, 533, 617) |
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E.6 and E.7 Scope of the trial |
E.6 | Scope of the trial |
E.6.1 | Diagnosis | No |
E.6.2 | Prophylaxis | No |
E.6.3 | Therapy | No |
E.6.4 | Safety | Yes |
E.6.5 | Efficacy | Yes |
E.6.6 | Pharmacokinetic | Yes |
E.6.7 | Pharmacodynamic | Yes |
E.6.8 | Bioequivalence | No |
E.6.9 | Dose response | Yes |
E.6.10 | Pharmacogenetic | No |
E.6.11 | Pharmacogenomic | No |
E.6.12 | Pharmacoeconomic | No |
E.6.13 | Others | No |
E.7 | Trial type and phase |
E.7.1 | Human pharmacology (Phase I) | No |
E.7.1.1 | First administration to humans | No |
E.7.1.2 | Bioequivalence study | No |
E.7.1.3 | Other | No |
E.7.1.3.1 | Other trial type description | |
E.7.2 | Therapeutic exploratory (Phase II) | Yes |
E.7.3 | Therapeutic confirmatory (Phase III) | Yes |
E.7.4 | Therapeutic use (Phase IV) | No |
E.8 Design of the trial |
E.8.1 | Controlled | Yes |
E.8.1.1 | Randomised | Yes |
E.8.1.2 | Open | No |
E.8.1.3 | Single blind | No |
E.8.1.4 | Double blind | Yes |
E.8.1.5 | Parallel group | Yes |
E.8.1.6 | Cross over | No |
E.8.1.7 | Other | Yes |
E.8.1.7.1 | Other trial design description |
Phase 2 to Phase 3 adaptive design |
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E.8.2 | Comparator of controlled trial |
E.8.2.1 | Other medicinal product(s) | No |
E.8.2.2 | Placebo | Yes |
E.8.2.3 | Other | No |
E.8.2.4 | Number of treatment arms in the trial | 3 |
E.8.3 |
The trial involves single site in the Member State concerned
| Yes |
E.8.4 | The trial involves multiple sites in the Member State concerned | No |
E.8.5 | The trial involves multiple Member States | Yes |
E.8.5.1 | Number of sites anticipated in the EEA | 15 |
E.8.6 Trial involving sites outside the EEA |
E.8.6.1 | Trial being conducted both within and outside the EEA | Yes |
E.8.6.2 | Trial being conducted completely outside of the EEA | No |
E.8.6.3 | If E.8.6.1 or E.8.6.2 are Yes, specify the regions in which trial sites are planned |
Canada |
Ireland |
Italy |
Netherlands |
Poland |
Portugal |
Spain |
Sweden |
United States |
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E.8.7 | Trial has a data monitoring committee | Yes |
E.8.8 |
Definition of the end of the trial and justification where it is not the last
visit of the last subject undergoing the trial
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E.8.9 Initial estimate of the duration of the trial |
E.8.9.1 | In the Member State concerned years | 2 |
E.8.9.1 | In the Member State concerned months | 10 |
E.8.9.1 | In the Member State concerned days | 0 |
E.8.9.2 | In all countries concerned by the trial years | 2 |
E.8.9.2 | In all countries concerned by the trial months | 10 |
E.8.9.2 | In all countries concerned by the trial days | 0 |