First Human Trial of FTY720, a Novel Immunomodulator, in
`Stable Renal Transplant Patients
`
`J Am Soc Nephrol 13: 1073-1083, 2002
`
`KLEMENS BUDDE,* ROBERT L. SCHMOUDER,t REINHARD BRUNKHORST,1
`BJORN NASHAN,§ PETER W. LOCKER:11 THOMAS MAYER,11
`SOMESH CHOUDHURY,t ANDREJ SKERJANEC,t GEROLF KRAUS,t and
`HANS H. NEUMAYER*
`*University Hospital Charite, Department of Nephrology, Berlin, Germany; tClinical Pharmacology and Drug
`Metabolism and Pharmacokinetics, Novartis Pharma, Basel, Switzerland and East Hanover, New Jersey;
`IOststadt Krankenhaus Hannover, Hannover, Germany; Wedizinische Hochschule Hannover, Klinik fur
`Viszeral and Transplantationschirurgie, Hannover, Germany; lInstitute far Klinische Pharmakologie
`Bobenheim, Griienstadt, Germany.
`
`Abstract. FTY720 is a novel immunomodulator to be devel-
`oped for use in organ transplantation. The primary objective of
`this study was to measure safety, single-dose pharmacokinet-
`ics, and pharmacodynamics in stable renal transplant pa-
`tients—the first human use of FTY720. This study used a
`randomized, double-blind, placebo-controlled design that ex-
`plored single oral doses of FTY720 from 0.25 to 3.5 mg in 20
`stable renal transplant patients on a cyclosporine-based regi-
`men. Safety assessments and blood samples were taken pre-
`dose and at multiple time points during a 96-h period postdose.
`Standard pharmacokinetic parameters were derived from the
`FTY720 whole blood concentrations, measured by HPLC/MS/
`MS. FTY720 was well tolerated, with no serious adverse
`events. Transient, asymptomatic bradycardia occurred after
`administration in 10 of 24 doses of FTY720. Pharmacokinetics
`are characterized by a prolonged absorption phase; the terminal
`
`elimination phase started 36 h after the administration, with
`elimination half-life (t112) ranging from 89 to 157 h indepen-
`dent of dose. Maximum plasma concentration and AUC were
`proportional to dose with low intersubject variability, the ap-
`parent volume of distribution (Vd/F) ranged from 1116 to 1737
`L. FTY pharmacodynamics were characterized by a reversible
`transient lymphopenia within 6 h, the nadir being 42% of
`baseline. The lymphocyte count returned to baseline within
`72 h in all dosing cohorts except the highest. Single oral doses
`of FTY720 ranging from 0.25 to 3.5 mg were well tolerated
`and caused a reversible selective lymphopenia. Transient, but
`asymptomatic bradycardia was the most common adverse
`event. The long t112 suggests less frequent dosing intervals. The
`size of Vd/F is in excess of blood volume, consistent with
`widespread tissue distribution
`
`The new immunosuppressant FTY720 (FTY) is a synthetic
`analogue of a natural compound derived from the fungus Isaria
`sinclairii (1,2). The mechanism of action of FTY appears to be
`specific and distinct from that of any other drug approved or
`being developed for use in solid organ transplantation. In
`experimental animals, FTY rapidly and transiently reduces
`circulating mature lymphocytes in peripheral blood (3), effect-
`ing T cells more than B cells; the CD3±, CD4±, and CD8± T
`cell lines appear to decrease the most (6-8). It was initially
`thought that FTY reduced circulating lymphocytes via induc-
`tion of lymphocyte apoptosis (4,5). However, recent data in-
`dicate that FTY induces the accelerated homing of lympho-
`cytes to lymph nodes and Peyer's patches (6-8). The
`
`Received October 28, 2001. Accepted November 15, 2001.
`Correspondence to: Dr. Klemens Budde, Charite University Hospital, Schu-
`mannstrasse 20-21, 10117 Berlin, Germany. Phone: 49-3045-051-4002; Fax:
`49-3045-051-4900; E-mail: klemens.budde@charite.de
`1046-6673/1304-1073
`Journal of the American Society of Nephrology
`Copyright © 2002 by the American Society of Nephrology
`
`lymphocyte sequestration might be mediated by an enhanced
`migratory response to homing chemokines (6-9).
`Studies in allograft transplantation using different animal
`species and organs demonstrated the efficacy of FTY as a
`potent immunosuppressant at doses ranging from 0.05 to 10
`mg/kg per day (9-15). In studies assessing its usefulness in
`combination therapy, synergy between FTY and cyclosporine
`(CsA) was demonstrated in multiple animal allograft models
`(9,10,12,14,16). Importantly, coadministration of FTY with
`CsA did not affect the blood concentration of either drug
`(15,17). To date, the pharmacokinetic data on FTY has been
`limited to animal studies. FTY bioavailability is 60 to 90% in
`rats and dogs, with a higher concentration in blood cells than
`plasma at steady state (data on file, Novartis Pharmaceuticals,
`East Hanover, NJ). The half-life of FTY in animals varies: 12 h
`in rats, 29 h in dogs, and 36 h in baboons (18). Maximal blood
`concentrations were reached after 7 to 8 h and 2 to 24 h in dogs
`and baboons, respectively. A near linear relationship between
`FTY dose and concentration was observed in these studies.
`FTY is metabolized to produce carboxylic acid derivatives that
`are devoid of immunosuppressive activity and ultimately ex-
`creted in urine and feces (19).
`
`ARGENTUM EX1008
`
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`1074 (cid:9)
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`Journal of the American Society of Nephrology (cid:9)
`
`J Am Soc Nephrol 13: 1073-1083, 2002
`
`The objective of this study was to determine the safety, the
`lymphocyte response as a pharmacodynamic measure, and
`pharmacokinetics of whole blood FTY concentrations after
`single oral doses in stable human renal transplant patients. In
`preclinical studies, FTY was well tolerated in different species
`without evidence of renal, pancreatic, gastrointestinal, or bone
`marrow toxicity. In toxicology studies, increasing FTY expo-
`sure (>0.1 mg/kg for 1 mo) was associated first with reversible
`lung toxicity, second with heart, and then with central nervous
`system. Applying interspecies scaling, a no-toxic-effect dose in
`humans was estimated (20). The predicted FTY-AUC for the
`starting dose (0.004 mg/kg for 70-kg subject), using allometric
`modeling, falls 1.5 logs below the AUC associated with any
`organ toxicity in the most sensitive animal species. A consis-
`tent feature of all animal models treated at pharmacologic
`doses of FTY720 is a decrease in lymphocyte count, which
`returns to baseline with cessation of drug dosing. The pharm-
`codynamic effect of FTY720 is lymphopenia (13,14); there-
`fore, a dose range was calculated that was one log-unit below
`the toxicity level. As a consequence, the pharmacodynamic
`response to FTY with the onset of significant lymphopenia was
`chosen as the stop point for further dose escalation.
`
`Materials and Methods
`Study Design
`This was a randomized, double-blind, placebo-controlled, time-
`lagged, two-center, ascending single oral dose study. Entry criteria
`included subjects, aged 18 to 65 yr, who had received their first or
`second renal transplant (cid:9)
`mo before randomization and who were
`treated with a CsA-based (Neoral; Novartis, Basel, Switzerland) im-
`munosuppressive regimen. For inclusion, patients had to be medically
`stable for at least 3 mo with serum creatinine (cid:9)
`mg/dl. All subjects
`weighed at least 50 kg and were between —15 and +40% of normal
`for their height and frame size. The study was approved by the local
`ethics committee, and subjects gave informed consent before study
`participation.
`Subjects were excluded if graft rejection had occurred in the
`previous 6 mo, if they had received lympholytic therapy (OKT3,
`antithymocyte globulin) within the previous year, had consistent lym-
`phocyte counts <1500/mm3, or had any significant medical condition,
`which might interfere with absorption, distribution, or metabolism.
`Concomitant immunosuppressive therapy with mycophenolate
`mofetil, azathioprine, or cyclophosphamide was prohibited.
`Subjects were prohibited from strenuous physical exercise for 7 d
`before dosing and until after study completion. Subjects were domi-
`ciled from 24 h before dosing until 96 h after dosing. Subjects were
`required to fast overnight before study medication and to follow a
`standard weight maintenance diet. Unless performing a study assess-
`ment, subjects had to rest quietly in the upright position for the next
`4 h after administration of the drug.
`The doses selected for the study were 0.25, 0.5, 0.75, 1.0, 2.0, and
`3.5 mg. For each dosing cohort, three patients were randomized to
`FTY and one to placebo. After subjects completed one dose, and if
`overall safety, tolerability, pulmonary function, and lymphocyte
`counts were acceptable, the next higher dose was administered. At the
`investigators discretion, the same dose could be used again in an
`additional cohort to expand the data for that particular dose. Dose
`escalation was terminated if significant toxicity occurred or if two or
`more subjects in a group developed a nadir lymphopenia . 20% of the
`
`average baseline lymphocyte count. If only one of four subjects
`manifested lymphopenia, then testing at that dose was repeated in a
`different subject group. Subjects from a lower dose group could
`reenter into a higher dose group 1 mo later if all inclusion and
`exclusion criteria were still met and they reconsented.
`
`Safety Assessments
`Before oral dosing with FTY, all subjects had a physical examina-
`tion with vital signs, a 12-lead electrocardiogram, pulmonary function
`testing, cardiopulmonary exercise testing, and a standard laboratory
`screen, including hematology and clinical chemistry. Vital signs,
`including supine and standing diastolic and systolic BP, radial pulse,
`and oral body temperature were recorded the day before dosing and
`immediately predose. Physical examinations, vital signs, an electro-
`cardiogram, and standard laboratory tests were performed at regular
`intervals after dosing. BP and pulse were assessed after the subject has
`rested in the supine position for at least 3 min and after 3 min in the
`standing position. BP was measured on the same arm for each time of
`determination. Adverse events, serious adverse events, and co-medi-
`cation were recorded as they occurred throughout the study according
`to good clinical practice guidelines.
`Pulmonary function and cardiopulmonary exercise testing were
`repeated 48 and 96 h after dosing. Pulmonary function testing in-
`cluded measurements of the forced expiratory volume at 1 s (FEV,),
`forced vital capacity (FVC), and diffusion capacity of the lung for
`carbon dioxide (DSO). The tests were conducted in a manner con-
`sistent with standard pulmonary laboratory practice. Cardiopulmonary
`exercise testing was conducted to measure the degree of hypoxemia
`induced by a moderate level of exercise. The test was conducted by
`using a modified Bruce treadmill protocol to achieve and maintain a
`heart rate of 0.7 of maximal heart rate (=220-age) for 4 to 6 min.
`During this time, the oxygen saturation percentage was monitored by
`finger oximetry. If the subject was unlikely to achieve a moderate
`tachycardia, then the subject exercised to the point of moderate
`relative perceived exertion. A 20% decrease in pulmonary function
`tests and (cid:9)
`decline from resting percentage oxygen saturation
`were defined as adverse events.
`
`Methods of Measuring FTY
`Samples of whole blood were drawn into ethylenediaminetetraace-
`tic acid (EDTA)— containing tubes before FTY dosing and at multiple
`time points postdosing. Blood samples were frozen within 60 min of
`venipuncture and stored at —20°C pending analysis. Whole blood
`FTY concentrations were measured using HPLC/MS/MS. Within-
`study assay validation was performed by analysis of quality control
`samples together with the study samples. Limit of quantitation was
`0.065 ng/ml. The method has been validated extensively with a mean
`accuracy and precision for different nominal concentrations of 104 to
`109%, and 5 to 15%, respectively.
`
`Pharmacodynamic Assessments
`The lymphocyte count was the primary pharmacodynamic measure
`of this study. Whole blood was drawn by venipuncture from a pe-
`ripheral forearm vein or indwelling venous cannula at screening (day
`—21 to day —2), baseline (day —1), 1 h and immediately predose, and
`at 0.5, 1, 2, 6, 12, 24, 48, 72, and 96 h postdosing into EDTA-
`containing tubes for differential blood counts, determining the abso-
`lute lymphocyte counts. Absolute counts were analyzed with a Micro-
`Diff II cell counter (Coulter-Immunotech Diagnostics, Hamburg,
`Germany).
`
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`J Am Soc Nephrol 13: 1073-1083, 2002
`
`Human Safety and Pharmacokinetics of FTY720 (cid:9)
`
`1075
`
`Descriptive statistics were computed for lymphocyte variables.
`Results from placebo subjects were pooled across groups. The abso-
`lute lymphocyte count data collected over time was used to derive the
`following variables:
`
`1. Average baseline lymphocyte count defined as the mean of the
`baseline lymphocyte count taken the day before dosing and the
`lymphocyte count at time -1 h and 0 h (predose).
`2. Nadir lymphocyte count defined as the lowest lymphocyte count
`measured at any time after the dose through 96 h postdose.
`3. Time to nadir lymphocyte count.
`4. Lymphocyte and nadir lymphocyte count as a percentage of base-
`line defined as the lymphocyte or nadir lymphocyte count divided
`by the average baseline lymphocyte count multiplied by 100.
`
`Pharmacokinetic and Statistical Analyses
`Descriptive statistics were computed for all pharmacokinetic con-
`centrations and for derived model-independent pharmacokinetic pa-
`rameters separately by treatment, with and without log-transforma-
`tion. The following parameters were determined for FTY by using
`noncompartmental methods: area under the concentration:time curve
`from time 0 to infinity (AUC (cid:9)
`maximum plasma concentration
`(Cmax), time to Cm (t.), elimination half-life (t112), apparent total
`oral clearance (Cl-1./F), and apparent volume of distribution (Vd/F).
`Pharmacokinetic values are expressed as means together with the
`percentage coefficient of variation (CV%). The geometric means were
`reported for the log-transformed pharmacokinetic parameters, and the
`median was presented for tmax.
`A regression analysis was conducted to investigate the dose pro-
`portionality of the AUC and Cmd.. The regression model was fitted to
`the raw and logarithmically transformed pharmacokinetic parameters
`with an intercept and a predictor variable in the model. For each
`model, the fit of the model was tested by using the ratio between the
`mean square of lack of fit and the mean square of pure error. The
`intercept of the regression line on the untransformed data were ex-
`amined as to whether its 95% confidence interval included 0 (dose
`proportional). If the 95% confidence interval of the slope of the
`regression line for log-transformed data included 1, the pharmacoki-
`netic parameter was considered dose proportional. Results from pla-
`cebo subjects were pooled across groups. Descriptive statistics were
`computed for test results. Paired t tests were performed in normal
`distributed variables with a P < 0.05 considered to be significant.
`
`Results
`A total of 20 subjects were enrolled, with 12 re-enrolling in
`later dose groups, for a total of 32 subject profiles (24 on drug,
`8 placebo). According to the protocol, four additional subjects
`were enrolled into the first two dose cohorts (0.25 mg and 0.5
`mg) to more clearly define the safety and tolerability of
`FTY720 in the early phase of the trial.
`The demographics of the subjects are summarized in Table
`1. All patients received a Neoral-based immunosuppressive
`regimen, all but one in combination with low-dose steroids
`(prednisolone, n = 14; methylprednisolone, n = 5). Except for
`clinically insignificant abnormalities, the safety lab was unre-
`markable in pretreatment evaluations with normal leukocyte
`(7.19 ± 1.92 X 109/L) and lymphocyte (2.456 ± 0.796 X
`109/L) counts and an acceptable kidney function as measured
`by calculated creatinine clearance of 70.3 ± 19.0 ml/min
`(range, 42 to 128 ml/min). At the inclusion, 19 subjects had
`
`Table 1. Demographics of subjects enrolled in study
`
`Variable
`
`Gender (M/F)
`Age (yr)
`White race
`Time after Tx (yr)
`Height (cm)
`Weight (kg)
`Body mass index
`
`Mean (SD)
`
`19/1
`43.2 (9.8)
`20
`8.7 (3.9)
`177 (6.7)
`84.7 (14.0)
`26.8 (4.1)
`
`hypertension; BP (134 ± 9 / 88 ± 7 mmHg) was well controlled
`in all patients. All 8 subjects who received placebo and 22 out
`of 24 subjects randomized to FTY treatment were receiving
`cardiovascular drug therapy. The most common drugs were
`(3-blockers (n = 15), Ca-antagonists (n = 14), angiotensin-
`converting enzyme inhibitors/angiotensin II receptor blockers
`(n = 11), and diuretics (n = 9). Concomitant therapy remained
`unchanged throughout the dosing interval.
`
`Safety Assessments
`Adverse Events. No serious adverse events were reported
`during or after the administration of FTY. One serious adverse
`event, transient diplopia lasting 1 h, was reported in a subject
`randomized to placebo. A neurologic evaluation of this subject
`was unremarkable. A total of 28 adverse events were recorded.
`These events, stratified by FTY treatment group, are presented
`in Table 2. Adverse events occurred in 91% of subjects ran-
`domized to FTY and in 75% if subjects randomized to placebo.
`The most common of the 28 reported adverse events were
`bradycardia (n = 10) and headache. Headache of mild to
`moderate severity occurred in two subjects receiving placebo
`and four receiving FTY. One patient on placebo was the only
`subject to receive concomitant medication as a result of an
`adverse event (he . (cid:9) rInche), for which paracetamol was
`administered.
`Heart Rate. Transient, asymptomatic bradycardia oc-
`curred in ten subjects randomized to FTY (42%) but none
`randomized to placebo (Figure 1A). Bradycardia was diag-
`nosed in these subjects when heart rate decreased below base-
`line to an extent judged significant by the study physician.
`Higher doses of FTY were more frequently associated with
`bradycardia: 9 out of 12 subjects randomized to 0.75 mg of
`FTY developed bradycardia; however, only 1 of 12 subjects
`receiving 0.25 to 0.5 mg of FTY. Six out of ten subjects had
`baseline bradycardia (heart rate, .60). Only one of four pa-
`tients with heart rate X60 receiving a lower dose of FTY (0.25
`to 0.5 mg) developed bradycardia. However, in five of six
`patients with baseline bradycardia, the pulse rate further de-
`creased after receiving higher doses of FTY ( .0.75 mg). In
`contrast, the pulse rate did not decrease in four patients with
`baseline bradycardia receiving placebo treatment. No apparent
`relationship was identified between subjects with bradycardia
`and their cardiovascular medical history or current cardiovas-
`cular drug therapy, including the use of 13-blockers. Seven out
`
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`
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`1076 (cid:9)
`
`Journal of the American Society of Nephrology
`
`J Am Soc Nephrol 13: 1073-1083, 2002
`
`Table 2. Summary of adverse events by FTY720 treatment group
`
`Event
`
`Placebo (cid:9)
`(n = 8) (cid:9)
`
`0.25 mg (cid:9)
`(n = 6) (cid:9)
`
`0.5 mg (cid:9)
`(n = 6) (cid:9)
`
`0.75 mg (cid:9)
`(n = 3) (cid:9)
`
`1.0 mg (cid:9)
`(n = 3) (cid:9)
`
`2.0 mg (cid:9)
`(n = 3) (cid:9)
`
`3.5 mg
`(n = 3)
`
`Headache
`Lumbar pain
`Bradycardia
`Prolonged PR interval
`Sweating
`Decreased DLCO
`Increased lipase/amylase
`Cold (upper respiratory tract
`Ankle joint pain
`Transient diplopia
`Dyspnea
`Tiredness
`Abnormal T waves on ECG
`Total events
`
`infection) (cid:9)
`
`2
`1
`
`1
`1
`1
`
`6
`
`1
`
`1
`
`3
`
`1
`
`2
`
`1
`1
`
`1
`1
`
`2
`
`2
`
`1
`
`6
`
`5
`
`2
`
`1
`1
`
`4
`
`2
`
`1
`
`1
`4
`
`of 12 subjects in the lower FTY dose groups (0.25 to 0.5 mg)
`were on P-blockers; however, the subject who developed bra-
`dycardia was not on 13-blocker therapy. In higher dose groups
`(0.75 mg) 8 of 12 subjects were on p-blocker treatment; all
`but one developed bradycardia. Again, two of four patients
`experienced bradycardia even though they were not on
`p-blocker treatment (baseline heart rate, 74 and 52 bpm). The
`observation of a relationship between bradycardia and FTY
`dose was strengthened by the 11 subjects who reenrolled in the
`study receiving a higher FTY dose (0.75 mg) during their
`second treatment period. Only 1 of 11 subjects had experienced
`bradycardia during the first treatment period (placebo treat-
`ment, n = 3; 0.25 to 0.5 mg FTY, n = 8), but 8 of 11 patients
`were reported to manifest bradycardia when rechallenged with
`a higher FTY dose (0.75 mg).
`As shown in Figure 1B, heart rates reached nadir approx-
`imately 4 to 8 h after FTY dosing. Even the patients who
`were randomized to FTY but did not develop overt brady-
`cardia (n = 14) had a small but significant (P < 0.05)
`decline in heart rate 4 to 12 h after the dosing (baseline, 67
`± 10 bpm; 8 h after dosing, 60 ± 10 bpm). Although
`placebo-treated patients had no significant changes in heart
`rate over time, FTY-treated subjects experienced a decline
`in heart rate as early as 2 h after dosing and lasting for up
`to 24 h. Again, low-dose—treated cohorts (n = 12) experi-
`enced only a minor decrease in heart rate (from baseline, 66
`± 11 bpm; to nadir after 8 h, 59 ± 12 bpm; P < 0.05).
`Patients treated with .0.75 mg of FTY had a more pro-
`nounced decline in heart rate (from 61 ± 10 bpm at baseline
`to 50 ± 8 bpm 8 h after dosing; P < 0.001).
`It is important to point out that the patients did not
`experience any symptoms throughout the course of brady-
`cardia. BP and standing BP were not affected, but standing
`heart rate declined as well (baseline, 71 ± 13 bpm; to nadir
`58 ± 10 bpm; P < 0.001). All patients randomized to FTY
`had normal BP recordings at the time of nadir heart rate
`
`(supine BP, 128 ± 11/81 ± 8 mmHg; systolic range, 110 to
`160 mmHg), and no patient developed an orthostatic reac-
`tion (standing BP, 130 ± 13/85 ± 8 mmHg; systolic range,
`105 to 150 mmHg).
`Electrocardiogram. One subject with a prolonged PR
`interval of 240 msec predose developed a transient prolonga-
`tion of PR interval (320 msec, 24 h post-dose). Another subject
`had inverted T-waves in V5-V6 on electrocardiogram 48 h
`after dosing. Both patients were asymptomatic and had normal
`vital signs. All other electrocardiogram variables (including
`QRS time, QT time, and PR interval) remained within normal
`limits. The QT interval increased in concordance with the
`lower heart rates, but it remained within the normal range for
`all patients.
`Safety Laboratory Data. Two subjects, randomized to
`0.5 mg FTY, developed rising amylase and lipase after the
`FTY administration. In the first subject, the lipase and
`amylase returned to the normal range 1 wk after study
`completion. The second patient had elevated amylase and
`lipase at screening; therefore, later elevated values were
`judged as not clinically significant and unrelated to FTY
`exposure. In this patient, these levels were still elevated at
`screening for the next dosing period (2 mg); by 24 h post-
`dose, amylase and lipase were within the normal range. One
`patient (0.75 mg) experienced elevated lipase without raise
`in amylase. Patients did not manifest symptoms of pancre-
`atitis. The safety laboratory studies (notably electrolytes and
`liver enzymes) of all other patients revealed only minor
`changes throughout the study, judged as clinically NS by the
`investigators. The kidney function, as measured by calcu-
`lated creatinine clearance (predose, 68 ± 18 ml/min; 24 h
`after intake, 64 ± 16 ml/min) and serum creatinine (predose,
`132 ± 34 µmol/L; 96 h, 125 ± 32 µmon) remained stable
`in FTY-treated subjects. Platelet and erythrocyte counts
`were not affected by FTY treatment. FTY had no effect on
`the white blood cells including differential blood count
`
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`J Am Soc Nephrol 13: 1073-1083, 2002
`
`Human Safety and Pharmacokinetics of FTY720 (cid:9)
`
`1077
`
`A
`90 -
`bpm
`
`80 -
`
`70 -
`
`Ce 60 -
`a)
`
`d. • 50 -
`
`40 -
`
`30
`-24
`
`B
`80
`bpm
`
`70
`
`co rL 60
`rn
`
`50
`
`40
`-24
`
`0
`
`24
`
`time
`
`48
`
`72
`
`hours 96
`
`Figure 1. (A) Heart rate for ten
`subjects in FTY720-treated dose
`groups with bradycardia. (B) Mean
`heart rate in placebo-treated sub-
`jects (n = 8) and in patients after
`receiving a low (0.25 to 0.5 mg; n
`= 12) or a high (0.75 to 3.5 mg; n
`= 12) dose of FTY720.
`
`Placebo
`FTY low dose
`FTY high dose
`
`24 time
`
`48
`
`72
`
`hours 96
`
`(predose, 6.62 ± 1.59 X 109/L; 24 h, 6.59 ± 1.47 X 109/L;
`48 h, 6.82 ± 1.49 X 109/L; 96 h, 6.72 ± 1.62 X 109/L), with
`the exception of the highest dosing cohort. In this dose
`group white blood cells decreased 24 h after dosing in all 3
`subjects (7.4 X 109/L to 4.8 X 109/L). Differential blood
`count revealed 75% neutrophils (3.7 X 109/L) but only 19%
`lymphocytes (0.82 X 109/L) at this time point, a 54%
`decline (range, 42 to 63%) compared with baseline (1.82 X
`109/L lymphocytes). Low leukocyte numbers (5.2 X 109/L)
`persisted throughout the study, with 3.84 X 109/L neutro-
`phils and 0.96 X 109/L lymphocytes after 96 h in this
`cohort.
`
`Pulmonary Function Testing. During the study, no subject
`manifested a worsening of FEVi or FVC of .10% compared
`with baseline. A high degree of variability was seen with DLCO.
`One subject in the 0.5-mg FTY group had •20% decrease in
`DLCO compared with baseline (20.7% decrease) 96 h after dos-
`ing. This patient was asymptomatic and had normal FEVi, FVC,
`and exercise oximetry at the same time point. In contrast, four
`patients (one placebo and three FTY treatment) had an increase of
`.20% compared with baseline, changes interpreted as within the
`margin of error for the test. The most sensitive test for pulmonary
`dysfunction, cardiopulmonary testing with exercise oximetry, was
`normal for all subjects at 48 and 96 h postdosing.
`
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`1078 (cid:9)
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`Journal of the American Society of Nephrology (cid:9)
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`J Am Soc Nephrol 13: 1073-1083, 2002
`
`Table 3. Summary of lymphocyte counta
`
`FTY720 Dose (mg)
`
`Placebo
`0.25
`0.5
`0.75
`1.0
`2.0
`3.5
`
`Baseline
`Lymphocyte
`Countb
`(cells/p13)
`
`2730 ± 585
`2284 ± 690
`2307 ± 585
`2457 ± 435
`2760 ± 393
`2844 ± 616
`3002 ± 1491
`
`n
`
`8
`6
`6
`3
`3
`3
`3
`
`Nadir
`Lymphocyte
`Count
`(cells/µ13)
`
`1728 ± 215
`1057 ± 524
`1127 ± 298
`1220 ± 303
`1203 ± 267
`853 ± 239
`730 ± 212
`
`Time to
`Nadir
`(h)
`
`Mean
`Decrease in
`Nadir
`(% baseline)
`
`3.6
`6.3
`8.0
`4.7
`8.0
`6.0
`8.0
`
`66 ± 15
`46 ± 17
`48 ± 11
`50 ± 9
`44 ± 13
`31 ± 8
`27 ± 11
`
`24-h
`Lymphocyte
`Count
`(cells/µ13)
`
`2771 ± 836
`1740 ± 353
`1927 ± 724
`2057 ± 340
`2353 ± 278
`2163 ± 425
`1007 ± 133
`
`96-h
`Lymphocyte
`Count
`(cells/µ13)
`
`2861 ± 731
`2089 ± 759
`2165 ± 524
`2357 ± 424
`2643 ± 678
`2430 ± 557
`1180 ± 327
`
`a Values are mean ± SD, except Time to Nadir (mean).
`b Average baseline: baseline, -1 h, and predose.
`
`Pharmacodynamics
`The average baseline lymphocyte counts for all treatment
`groups (2.59 ± 0.76 X 109/L) were very near the normal
`average lymphocyte count of 2.50 X 109/L. The mean coeffi-
`cient of variation for the baseline values was 14% (range, 0.3
`to 38%), similar across all dosing cohorts. Table 3 provides the
`mean and SD of baseline values for all dosing cohorts.
`The mean lymphocyte count of the placebo group (n = 8)
`dropped from 2.73 X 109/L to a nadir of 1.73 X 109/L over the
`first day postdosing. This nadir lymphocyte count being 66%
`of the baseline count (Figure 2), and the range of this drop
`being from 49 to 13% of baseline with an average of 3.6 ±
`2.6 h after administration of placebo (range, 0.5 to 6 h). As
`early as 1 h after intake of morning medication, lymphocytes
`started to decline (2.26 ± 0.41 X 109/L; 84% of baseline; P <
`0.01). The maximal mean decrease of lymphocyte numbers
`was observed 6 h after intake of placebo (1.85 ± 0.30 X 109/L;
`
`P < 0.01; 71% of baseline; Figure 2), with a considerable
`variability between individuals (range, 4 to 49% decrease
`compared with baseline). No significant changes occurred in
`placebo-treated patients at any time thereafter. During the
`observational period, lymphocytes did not fall below 1.50 X
`109/L in any placebo-treated patient. The patient who did not
`receive any corticosteroid treatment exhibited only minor
`changes in lymphocyte counts (2.1 to 2.6 X 109/L; maximal
`decrease, 13%) over 24 h, which was comparable with his
`baseline values (2.1 to 2.9 X 109/L) and similar to his indi-
`vidual baseline coefficient of variation (11%).
`All treated groups, 0.25 to 3.5 mg of FTY720, consistently
`manifested a more pronounced decrease in lymphocyte counts
`compared with the placebo group; the mean nadir range ap-
`proximately 0.5 to 1.0 X 109/L lower than that measured in the
`placebo group (Table 3; Figure 2). The majority of FTY-
`treated subjects (83%) had a nadir below 1.5 X 109/L, with a
`
`Figure 2. Lymphocytes as percent of
`baseline (mean for different dosing
`cohorts) versus hours postdose.
`
`-°- 0,25mg (cid:9)
`--.- 0,5mg
`
`-A- 0,75mg
`1,0mg
`A (cid:9)
`
`o (cid:9)
`-A (cid:9)
`
`placebo
`2,0mg
` 3,5mg
`
`24
`
`48
`
`time
`
`72
`
`hours 96
`
`120
`
`100
`
`80
`
`60
`
`% baseline
`
`40
`
`20
`
`0
`
`Page 6
`
`(cid:9)
`(cid:9)
`(cid:9)
`(cid:9)
`

`

`J Am Soc Nephrol 13: 1073-1083, 2002
`
`Human Safety and Pharmacokinetics of FTY720 (cid:9)
`
`1079
`
`Table 4. Number of subjects and pharmacokinetics of single oral doses of FTY at each dose levels
`
`Dose mg
`
`0.25
`0.5
`0.75
`1.0
`2.0
`3.5
`Mean
`
`4
`6
`3
`3
`3
`3
`22
`
`'mac
`h
`
`18
`18
`36
`36
`36
`12
`24
`
`Cmax
`ng/ml (CV%)
`
`AUC
`ng • h/ml (CV%)
`
`0.158 (12)
`0.282 (10)
`0.520 (21)
`0.713 (9)
`1.195 (22)
`2.823 (6)
`
`28 (26)
`42 (12)
`91 (17)
`120 (16)
`275 (33)
`434 (20)
`
`t1/2
`h (CV%)
`
`119 (43)
`89 (18)
`93 (21)
`104 (17)
`157 (12)
`100 (24)
`108 (30)
`
`Vd/F
`L (CV%)
`
`1489 (30)
`1526 (13)
`1116 (17)
`1264 (7)
`1737 (24)
`1162 (7)
`1407 (23)
`
`CiT/F
`ml/min (CV%)
`
`155 (23)
`200 (12)
`140 (18)
`142 (18)
`130 (31)
`139 (22)
`158 (24)
`
`a tmax, time to maximum plasma concentration; Cam, maximum plasma concentration; t112, elimination half-life; Vd/F, apparent volume
`of distribution; C1T/F, apparent total oral clearance.
`
`A
`
`" -a 3.0 -
`ro' 2.5
`0
`0
`E
` 2.0 •
`
`CNI
`
`1.5 -
`Q 1.o -
`>-
`u_ 0.5 -
`0.0 (cid:9)
`
`
`0.25 0.5 0.75 1.0
`
`2.0
`
`3.5
`
`Dose (mg)
`
`•
`
`3.5
`
`•
`
`•
`
`0.25 0.5 0.75 1.0
`
`2.0
`Dose (mg)
`
`E (cid:9)
`
`600 (cid:9) -
`
`500
`
`400 -
`
`300
`
`200
`
`100
`
`x
`
`a
`
`FTY72(
`
`Figure 4. FTY720 maximum concentration (A) and area under the
`concentration time curve (B) compared with dose.
`
`percentage of baseline values of 17% and 24%, respectively, at
`which time dose escalation was terminated. This degree of
`lymphocyte drop met the study termination criterion according
`the protocol. This dosing cohort exhibited a much more sus-
`tained response with persistent lymphopenia after 96 h (mean,
`1.18 ± 0.33; range, 0.93 to 1.55 X 109/L; 42% of baseline).
`One subject randomized to 3.5 mg FTY had the lowest abso-
`lute lymphocyte count nadir, 0.49 X 109/L at 6 h postdose.
`Lymphopenia persisted through discharge at 96 h in this sub-
`ject, but the lymphocyte count at 240 h postdose was normal
`again (1.60 X 109/L).
`The observed difference between placebo and FTY was
`further confirmed in four patients who received placebo and
`
`mean nadir of 42 ± 14% compared with baseline (range, 17 to (cid:9)
`77%). All FTY-randomized groups manifested a temporal pat- (cid:9)
`tern of relative lymphopenia, detected at the latest by 6 h (cid:9)
`postdose. Similar to placebo-treated patients, most patients (cid:9)
`(71%) throughout the different dosing cohorts had the lympho-
`cyte nadir after 6 h (mean, 6.9 ± 2.9; range, 2 to 12 h). (cid:9)
`Twenty-four hours after dosing, the lymphocyte numbers had (cid:9)
`returned to the normal range, with values of approximately (cid:9)
`80% of baseline in most patients, a consistent finding in all (cid:9)
`groups except the highest. By 72 and 96 h postdose, the
`lymphocyte numbers of all dose groups (cid:9)
`mg FTY had
`returned to baseline values (96 h, 2.28 ± 0.59; 93 ± 14% of
`baseline). (cid:9)
`At FTY doses ranging from 0.5 mg to 3.5 mg, no clear dose
`response relationship was detected, but the two highest dose (cid:9)
`
`groups exhibited a more pronounced decline in lymphocyte (cid:9)
`numbers. FTY doses of .2.0 mg were associated with a more (cid:9)
`rapid onset of lymphopenia (31 to 43% decrease after 2 h). The (cid:9)
`three subjects treated with 3.5 mg FTY manifested the most
`prolonged and intensive lymphopenia. The mean lymphocyte (cid:9)
`count decreased from 3.00 X 109/L at baseline to a nadir of
`0.73 X 109/L. Two subjects in this group manifested nadir
`
`30
`
`25
`
`20
`
`1.5
`
`10
`
`05
`
`00
`
`0 (cid:9)
`
`2 (cid:9)
`
`4 (cid:9)
`
`e (cid:9)
`8 (cid:9)
`Time (noun)
`
`10 (cid:9)
`
`12
`
`,oid I an s•01.1.11.1i eimme .4 I I 1St
`
`-
`
`
`
`4IMM'a=1111D.I.IM