MANDARA Phase III data published in New England Journal of Medicine show remission is an achievable goal in eosinophilic granulomatosis with polyangiitis (EGPA) with FASENRA
- Positive results from the MANDARA Phase III trial for FASENRA in EGPA patients
- More than half of patients achieved remission with eosinophil-targeting biologic therapies
- Benralizumab met the primary endpoint and demonstrated non-inferior rates of remission compared to mepolizumab
- FASENRA enabled patients to taper off oral corticosteroids while preventing relapses
- Higher proportion of FASENRA-treated patients were able to fully taper off OCS during weeks 48 through 52
- None.
Insights
The recent findings from the MANDARA Phase III trial for FASENRA (benralizumab) signify a notable advancement in the treatment of Eosinophilic Granulomatosis with Polyangiitis (EGPA), a rare autoimmune disease. The trial's results, which indicate that FASENRA can enable patients to taper off oral corticosteroids while maintaining remission, have profound implications for patient quality of life and healthcare costs. Corticosteroids, while effective, are associated with severe side effects and the ability to reduce their use without compromising disease control is a significant benefit. The data suggests that benralizumab could become a preferred treatment option, potentially impacting the market share of current treatments like mepolizumab.
From a research perspective, the trial is groundbreaking as it is the first head-to-head comparison of biologic therapies in EGPA. The reported non-inferiority to mepolizumab and the high rate of remission achieved by benralizumab-treated patients (59%) underscore the efficacy of eosinophil-targeting biologic therapies in managing this condition. Furthermore, the reduction in blood eosinophil counts and the well-tolerated profile of benralizumab align with the drug's known mechanism of action, which involves the depletion of eosinophils, a type of white blood cell implicated in the pathophysiology of EGPA.
The data presented from the MANDARA trial could have a significant impact on AstraZeneca's financial performance, considering the potential for FASENRA to capture a larger segment of the market for EGPA treatment. The trial's positive outcome positions FASENRA favorably against mepolizumab, the only other approved treatment for EGPA, which could lead to increased market penetration and revenue growth for AstraZeneca. The ability to administer FASENRA as a single monthly subcutaneous injection offers a convenience factor that could be appealing to both patients and healthcare providers, potentially increasing adoption rates.
Furthermore, the safety profile and efficacy in reducing the need for oral corticosteroids may lead to cost savings for healthcare systems and payers, as the reduction in long-term steroid use could decrease the incidence of steroid-related adverse effects and subsequent medical costs. As AstraZeneca seeks regulatory approval for benralizumab in EGPA, investors should monitor the company's progress, as approval could lead to an uptick in the company's stock value, driven by the expansion of FASENRA's label and its potential market growth.
EGPA is a rare disease with a relatively small patient population, yet the economic burden is considerable due to the chronic nature of the disease and the high costs associated with long-term corticosteroid use and its complications. The introduction of a treatment like FASENRA, which can reduce reliance on corticosteroids, has the potential to alleviate some of this economic burden. By improving the management of EGPA and reducing the frequency of relapses, healthcare systems may see a decrease in hospital admissions and a reduction in the need for additional treatments for steroid-induced side effects.
It is also important to consider the broader economic implications of improved disease management. Patients who achieve remission and can taper off corticosteroids are likely to experience an overall improvement in health-related quality of life, which can translate into increased productivity and reduced absenteeism from work. These factors contribute to the societal value of effective treatments like FASENRA and should be taken into account when assessing the drug's economic impact.
FASENRA enabled patients to taper off oral corticosteroids while preventing relapses
MANDARA compared benralizumab to mepolizumab in patients with EGPA receiving oral corticosteroids (OCS) with or without stable immunosuppressive therapy.2 Patients were randomized to receive either a single 30 mg subcutaneous injection of benralizumab, or three separate 100 mg subcutaneous injections of mepolizumab, once every four weeks.2 Full results showed that benralizumab met the primary endpoint of the trial and demonstrated non-inferior rates of remission compared to mepolizumab.1 The primary endpoint of adjusted rate of remission was
A higher proportion of FASENRA-treated patients were able to fully taper off OCS during weeks 48 through 52 (
Dr. Michael Wechsler, Professor of Medicine and Director of The Asthma Institute at National Jewish Health, and International Coordinating Investigator of the MANDARA trial said: “Patients with EGPA typically rely on long-term, high-dose OCS, which can cause serious and lasting side effects, and often suffer recurrent relapses when attempting to taper off their treatment. These findings are an exciting step forward as they affirm that eosinophil-targeting biologic treatments helped more patients achieve remission and taper off of steroid therapy.”
Sharon Barr, Executive Vice President, BioPharmaceuticals R&D, AstraZeneca said, “The results from this trial are an important step forward for the EGPA community, as this is the first trial to demonstrate that remission from EGPA with an eosinophil-targeting biologic is achievable for the majority of patients. This is a significant advancement and shows that benralizumab helped patients achieve remission and reduce chronic OCS usage, in a convenient, single, monthly subcutaneous injection, and could alleviate some of the impact of this debilitating disease.”
Elevated levels of eosinophils play a central role in EGPA disease pathophysiology.4 All patients with EGPA have very high levels of eosinophils at some point in their disease, both in peripheral blood and in affected tissues or organs.5,6 Approximately half of patients with EGPA have concomitant, adult-onset severe eosinophilic asthma, and often have sinus and nasal symptoms.5,7
FASENRA has a unique mode of action that leads to near complete depletion of eosinophils.8,9 Treatment with benralizumab was associated with a greater reduction of blood eosinophil counts from week 1 compared to mepolizumab and maintained at all timepoints.1 At week 1 mean blood eosinophil count ratio to baseline was 0.15 vs. 0.39 respectively (adjusted geometric mean ratio: 0.38;
FASENRA is currently approved as an add-on maintenance treatment for SEA in 80 countries including the US,
AstraZeneca has been working with regulatory authorities around the world in order to bring benralizumab to EGPA patients as quickly as possible.
IMPORTANT SAFETY INFORMATION
CONTRAINDICATIONS
Known hypersensitivity to benralizumab or excipients.
WARNINGS AND PRECAUTIONS
Hypersensitivity Reactions
Hypersensitivity reactions (eg, anaphylaxis, angioedema, urticaria, rash) have occurred after administration of FASENRA. These reactions generally occur within hours of administration, but in some instances have a delayed onset (ie, days). Discontinue in the event of a hypersensitivity reaction.
Acute Asthma Symptoms or Deteriorating Disease
FASENRA should not be used to treat acute asthma symptoms, acute exacerbations, or acute bronchospasm.
Reduction of Corticosteroid Dosage
Do not discontinue systemic or inhaled corticosteroids abruptly upon initiation of therapy with FASENRA. Reductions in corticosteroid dose, if appropriate, should be gradual and performed under the direct supervision of a physician. Reduction in corticosteroid dose may be associated with systemic withdrawal symptoms and/or unmask conditions previously suppressed by systemic corticosteroid therapy.
Parasitic (Helminth) Infection
It is unknown if FASENRA will influence a patient’s response against helminth infections. Treat patients with pre-existing helminth infections before initiating therapy with FASENRA. If patients become infected while receiving FASENRA and do not respond to anti-helminth treatment, discontinue FASENRA until infection resolves.
ADVERSE REACTIONS
The most common adverse reactions (incidence ≥
Injection site reactions (eg, pain, erythema, pruritus, papule) occurred at a rate of
USE IN SPECIFIC POPULATIONS
A pregnancy exposure registry monitors pregnancy outcomes in women exposed to FASENRA during pregnancy. To enroll call 1-877-311-8972 or visit www.mothertobaby.org/fasenra.
The data on pregnancy exposure from the clinical trials are insufficient to inform on drug-associated risk. Monoclonal antibodies such as benralizumab are transported across the placenta during the third trimester of pregnancy; therefore, potential effects on a fetus are likely to be greater during the third trimester of pregnancy.
INDICATION
FASENRA is indicated for the add-on maintenance treatment of patients with severe asthma aged 12 years and older, and with an eosinophilic phenotype.
- FASENRA is not indicated for treatment of other eosinophilic conditions
- FASENRA is not indicated for the relief of acute bronchospasm or status asthmaticus
Please read full Prescribing Information, including
Patient Information and Instructions for Use.
You may report side effects related to AstraZeneca products.
Notes
Eosinophilic granulomatosis with polyangiitis
EGPA, formerly known as Churg-Strauss Syndrome, is a rare, immune-mediated inflammatory disease that is caused by inflammation of small to medium-sized blood vessels.4,5 It is estimated that 118,000 people throughout the world live with EGPA.14
EGPA can result in damage to multiple organs, including lungs, upper airway, skin, heart, gastrointestinal tract and nerves.5 The most common symptoms and signs include extreme fatigue, weight loss, muscle and joint pain, rashes, nerve pain, sinus and nasal symptoms, and shortness of breath.5,6 Without treatment, the disease may be fatal.5,6 Almost half (
There are limited treatment options for EGPA. Patients are often treated with chronic high-dose OCS and experience recurrent relapses when attempting to taper off OCS.6,16 Mepolizumab is currently the only approved treatment for EGPA.17
MANDARA
MANDARA was a randomized, double blind, double-dummy, active-controlled, parallel group, multicentre 52-week Phase III trial which compared the efficacy and safety of FASENRA to mepolizumab in adult patients with relapsing or refractory EGPA.2 In the blinded trial, 140 patients were randomized 1:1 (70 per treatment group) to receive either a single 30mg subcutaneous injection of FASENRA or three separate 100mg subcutaneous injections of mepolizumab once every four weeks.1
The primary endpoint was the proportion of patients who were in remission at both weeks 36 and 48.2 Remission is defined as Birmingham Vasculitis Activity Score (BVAS)=0 and OCS dose less than or equal to 4 mg/day.2 FASENRA remission was compared to the historical placebo rate from mepolizumab’s Phase III trial, MIRRA.18 The primary statistical analysis was to demonstrate non-inferiority of FASENRA versus mepolizumab based on the primary endpoint.1
All patients who complete the 52-week double-blind treatment period were eligible to continue into an ongoing open label extension (OLE) period, intended to allow each patient at least one year of treatment with open-label FASENRA.2
Mepolizumab is a humanized IL-5 antagonist monoclonal antibody.3
FASENRA
FASENRA is a monoclonal antibody that binds directly to IL-5 receptor alpha on eosinophils and attracts natural killer cells to induce rapid and near-complete depletion of blood and tissue eosinophils in most patients via apoptosis (programmed cell death).8,9
FASENRA (benralizumab) is currently approved in more than 80 countries, including the US, EU,
FASENRA is in development for other diseases including chronic obstructive pulmonary disease, chronic rhinosinusitis with nasal polyps and hypereosinophilic syndrome.20-22
FASENRA was developed by AstraZeneca and is in-licensed from BioWa, Inc., a wholly-owned subsidiary of Kyowa Kirin Co., Ltd.,
Respiratory & Immunology
Respiratory & Immunology, part of AstraZeneca BioPharmaceuticals, is a key disease area and growth driver to the Company.
AstraZeneca is an established leader in respiratory care with a 50-year heritage and a growing portfolio of medicines in immune-mediated diseases. The Company is committed to addressing the vast unmet needs of these chronic, often debilitating, diseases with a pipeline and portfolio of inhaled medicines, biologics and new modalities aimed at previously unreachable biologic targets. Our ambition is to deliver life-changing medicines that help eliminate COPD as a leading cause of death, eliminate asthma attacks and achieve clinical remission in immune-mediated diseases.
AstraZeneca
AstraZeneca (LSE/STO/Nasdaq: AZN) is a global, science-led biopharmaceutical company that focuses on the discovery, development, and commercialization of prescription medicines in Oncology, Rare Diseases, and BioPharmaceuticals, including Cardiovascular, Renal & Metabolism, and Respiratory & Immunology. Based in
References
1. Wechsler ME, et al. Benralizumab versus Mepolizumab for Eosinophilic Granulomatosis with Polyangiitis. N Engl J Med. 2024.
2. Clinicaltrials.gov. Efficacy and Safety of Benralizumab in EGPA Compared to Mepolizumab. (MANDARA). Available at: https://classic.clinicaltrials.gov/ct2/show/NCT04157348. [Last accessed: January 2024].
3. Late Breaking Abstracts Presented at Scientific Sessions 2024 AAAAI Annual Meeting February 23-26, 2024. Available at: https://www.jacionline.org/pb-assets/Health Advance/journals/ymai/AAAAI_2024_LateBreaking_Abstracts-1707140446317.pdf. [Last accessed: February 2024].
4. Furuta S, et al. Update on eosinophilic granulomatosis with polyangiitis. Allergol Int. 2019;68:430-436.
5. American Partnership for Eosinophilic Disorders. Eosinophilic Granulomatosis with Polyangiitis (EGPA). Available at: https://apfed.org/about-ead/eosinophilic-granulomatosis-with-polyangiitis/. [Last accessed: January 2024].
6. Baldini C, et al. Clinical Manifestations and Treatment of Churg-Strauss Syndrome. Rheum Dis Clin N Am. 2010;36:527–543.
7. Cottin V, et al. Respiratory manifestations of eosinophilic granulomatosis with polyangiitis (Churg–Strauss). Eur Respir J. 2016;48:1429-1441.
8. Kolbeck R, et al. MEDI-563, a humanized anti-IL-5 receptor a mAb with enhanced antibody-dependent cell-mediated cytotoxicity function. J Allergy Clin Immunol. 2010;125:1344-1353.e2.
9. Pham TH, et al. Reductions in eosinophil biomarkers by benralizumab in patients with asthma. Respir Med. 2016;111:21-29.
10. AstraZeneca news release. Available at: https://www.astrazeneca.com/media-centre/press-releases/2019/fasenra-approved-in-the-us-for-self-administration-in-a-new-pre-filled-auto-injector-the-fasenra-pen-04102019.html. [Last accessed: January 2024].
11. AstraZeneca news release. Available at: https://www.astrazeneca.com/media-centre/press-releases/2019/fasenra-receives-positive-eu-chmp-opinion-for-self-administration-and-the-new-fasenra-pen-a-pre-filled-single-use-auto-injector-01072019.html. [Last accessed: January 2024].
12. AstraZeneca Annual Report 2023. Available at: https://www.astrazeneca.com/content/dam/az/Investor_Relations/annual-report-2023/pdf/AstraZeneca_AR_2023.pdf. [Last accessed: February 2024].
13. AstraZeneca news release. Fasenra met the primary endpoint in the MANDARA Phase III trial in eosinophilic granulomatosis with polyangiitis (EGPA). Available at: https://www.astrazeneca.com/media-centre/press-releases/2023/fasenra-phase-iii-egpa-trial-met-primary-endpoint.html#:~:text=Positive%20high%2Dlevel%20results%20from,EGPA)%20who%20were%20receiving%20oral. [Last accessed: February 2024].
14. AstraZeneca Data on file. 2022. REF-167820.
15. Wechsler ME, et al. Mepolizumab or Placebo for Eosinophilic Granulomatosis with Polyangiitis. N Engl J Med. 2017:376;1921-1932.
16. Bell CF, et al. Burden of illness and costs associated with eosinophilic granulomatosis with polyangiitis: evidence from a managed care database in
17. Mepolizumab US prescribing information. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/125526Orig1s021,761122Orig1s011Corrected_lbl.pdf [Last accessed: January 2024].
18. AstraZeneca Data on file. 2023. REF-196096.
19. AstraZeneca Data on File. 2022. REF-153839
20. Clinicaltrials.gov. Efficacy and Safety of Benralizumab in Moderate to Very Severe Chronic Obstructive Pulmonary Disease (COPD) With a History of Frequent Exacerbations (RESOLUTE). Available from: https://clinicaltrials.gov/ct2/show/NCT04053634. [Last accessed: September 2023].
21. Clinicaltrials.gov. Efficacy and Safety Study of Benralizumab in Patient With Eosinophilic Chronic Rhinosinusitis With Nasal Polyps (ORCHID). Available at: https://clinicaltrials.gov/ct2/show/NCT04157335. [Last accessed: January 2024].
22. Clinicaltrials.gov. A Phase 3 Study to Evaluate the Efficacy and Safety of Benralizumab in Patients With Hypereosinophilic Syndrome (HES) (NATRON). Available from: https://clinicaltrials.gov/ct2/show/NCT04191304. [Last accessed: January 2024].
Veeva ID: Z4-61457 Date of Preparation: Feb 2024
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Source: AstraZeneca
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