A randomised, double-blind study of combination antifungal therapy with voriconazole and anidulafungin versus voriconazole monotherapy for primary treatment of invasive aspergillosis Kieren A. Marr,1 Haran Schlamm,2 Scott T. Rottinghaus,2 Shyla Jagannatha,2 Eric J. Bow,3 John R. Wingard,4 Peter Pappas,5 Raoul Herbrecht,6 Thomas J. Walsh,7 Johan Maertens8 and the Mycoses Study Group 1Johns Hopkins University School of Medicine, Baltimore, MD, USA; 2Pfizer Inc, New York, NY, USA;3 CancerCare Manitoba, University of Manitoba, Winnipeg, Canada; 4University of Florida Shands Cancer Center, Gainesville, FL, USA; 5University of Alabama, Birmingham, AL, USA; 6Department of Oncology & Hematology, Hôpital de Hautepierre, LB 2812 Strasbourg, France; 7Weill Cornell Medical College, New York, NY, USA; 8Department of Hematology, University Hospital Gasthuisberg, Leuven, Belgium

Introduction a) MITT population a) MITT population, probable IA based on GM only – Invasive aspergillosis (IA) is a frequent cause of death in patients with Voriconazole/anidulafungin (n=135) haematological malignancies and recipients of allogeneic haematopoietic 1.00 1.00 Voriconazole/anidulafungin (n=108) stem cell transplants (allo-HSCT).1,2 Voriconazole/placebo (n=142) Voriconazole/placebo (n=110) – Voriconazole, a third-generation triazole, was approved for treatment of IA based on results of a prospective, randomised trial in which voriconazole was superior to amphotericin B as primary therapy for IA.3

– In vitro, animal and clinical observational studies each support the use of 0.75 0.75 combination antifungal therapy with voriconazole and an echinocandin to treat IA.4-8 – Clinicians are increasingly using combination therapy to treat IA; however, robust evidence for the efficacy of combination therapy has so far been unavailable. – Here, we present the results of the first prospective, randomised, double-blind

clinical trial of combination therapy for IA. b) Mortality at Week 6 b) Mortality at Week 6 0.50 0.50 27.5% 27.3% Methods p=0.0868 30/110 95% CI -19.0, 1.5 pϽ0.05

19.3% Survival distribution function – This was a prospective, randomised, double-blind clinical trial in allo-HSCT Survival distribution function 95% CI -22.7, -0.4 recipients and patients with haematological malignancies with proven or 15.7% probable IA according to the European Organization for Research and 0.25 0.25 17/108 Treatment of Cancer and the Mycoses Study Group consensus criteria.9 – Patients were randomised 1:1 to receive either voriconazole plus placebo (monotherapy) or voriconazole plus anidulafungin (combination therapy). – All subjects received primary therapy with open-label voriconazole (6 mg/kg Vori/anid Vori/placebo Vori/anid Vori/placebo intravenously [IV] every 12 hours on day 1, followed by 4 mg/kg IV every 0.00 0.00 12 hours) and blinded anidulafungin (200 mg IV on day 1, followed by 0 10 20 30 40 50 60 70 80 100 mg IV every 24 hours) or blinded anidulafungin placebo. 0 10 20 30 40 50 60 70 80 90 Time to death (days) – Combination therapy was administered for 2–4 weeks; after 2 weeks, Time to death (days) the investigator could switch to voriconazole monotherapy, to complete at least 6 weeks of antifungal treatment. – A switch to oral voriconazole (300 mg every 12 hours) was allowed at the Figure 1. (a) Kaplan-Meier survival curves for the overall modified intent-to-treat population (MITT) Figure 2. Outcomes in patients with probable invasive aspergillosis (IA), based on a positive investigator’s discretion after at least 7 days of IV therapy. (circles represent censored data), and b) overall mortality in the MITT population with p value using bronchoalveolar lavage or serum galactomannan test; a) Kaplan-Meier survival curves (circles mortality estimates adjusted for randomisation strata. represent censored data), b) all-cause mortality rate at week 6 with p value using mortality – The primary endpoint was overall survival at 6 weeks in patients with proven estimates adjusted for randomisation strata. or probable IA confirmed by day 7 (modified intent-to-treat population, MITT). – Global response was higher in monotherapy recipients. Of 135 people in the – Secondary endpoints included week 6 global response, all-cause mortality combination arm, 44 (32.6%) were considered to have successful therapy, at 12 weeks, time to death, and safety/tolerability. Global response was a compared to 61 of 142 (43.0%) monotherapy recipients. Interpretation of 40 composite of clinical and radiological responses, with successful responses Voriconazole / anidulafungin global response between treatment groups was confounded by a large Voriconazole / placebo requiring clinical improvement and .50% radiographic improvement. 35 proportion of patients (~40%) who were categorised by the DRC as 40% ‘not evaluable’ – A data review committee (DRC), blinded to treatment, assessed entry and final ‘not evaluable’ (Figure 3). 30 44/142

diagnosis (possible, probable, proven IA) and outcomes, including global response 39/142 36/135 at weeks 2, 4, and 6, and whether death by week 6 was attributable to IA. – There was no difference in death rates between treatment groups in patients who 25 31/135 had received an allo-HSCT and those who had not. Mortality rates at 6 weeks in 20 the monotherapy arm were 28.6% in allo-HSCT recipients and 27.5% in others; 26/135 26/135 Results in the combination arm, rates were 22.7% and 17.9%, respectively. 15 19/142 17/142 10 16/142 – Between 9 July 2008 and 8 April 2011, 454 patients were enrolled from – All 454 patients who received study treatment were included in the safety

analysis. Proportions of people who developed adverse events and serious Global response at 6 weeks (%) 8/135 8/135 93 sites in 24 countries, and 277 patients with DRC adjudicated proven 5 7/142 or probable IA were included in the primary analysis. The two groups had adverse events that were considered to be treatment related did not differ 0 similar demographics, underlying conditions, and IA diagnoses (Table 1). between arms (Table 3). Complete Partial Stable Failure Not Not evaluable evaluable – Of the 135 patients who received combination therapy, 26 (19.3%) died by (expired) (survived) Table 2. Outcomes according to regimen in the modified intent-to-treat population1 week 6, compared to 39/142 (27.5%) monotherapy recipients (two-sided Global response criteria p=0.09, 95% confidence intervals [CI] -18.99, 1.51; relative risk reduction Outcome Voriconazole monotherapy Combination therapy p value 95% CI 29.9%; number needed to treat to prevent a death 12). Time to death and Death (week 6), n (%) 39 (27.5) 26 (19.3) 0.0868 -19, 1.5 Figure 3. Data review committee assessment of global response between treatment groups. mortality at Week 6 in the MITT population is shown in Figure 1. Differences in Secondary endpoints primary and secondary outcomes, adjusted for randomisation strata, are shown Death (week 12), n (%) 55 (39.4) 39 (29.3) 0.0766 -21.4, 1.09 in Table 2. Death due to IA (week 6), n (%) 33 (23.9) 23 (17.3) 0.2058 -15.9, 3.42 Global response – success, n (%) 61 (43) 44 (32.6) 0.0782 -21.6, 1.15 Conclusions – Of the 277 patients in the MITT population, 218 were diagnosed based on a Complete response 17 (12) 8 (5.9) positive serum or bronchoalveolar lavage galactomannan (GM) only. In a Partial response 44 (31) 36 (26.7) Stable response 19 (13.4) 26 (19.3) – Our study is the first prospective, randomised, double-blind clinical trial post-hoc analysis of these patients, 17/108 (15.7%) receiving combination Failure 7 (4.9) 8 (5.9) of combination therapy for IA. therapy died by week 6, compared to 30/110 (27.3%) receiving monotherapy. Death, probable IA, n (%)2 39 (27.9) 24 (18.2) 0.0504 -20.1, 0.3 The difference was statistically significant (p<0.05, 95% CI -22.69, -0.41) Death, probable IA – GM only3 30 (27.3) 17 (15.7) 0.0372 -22.7, -0.4 (Figure 2). In the probable and proven cases of IA that were not diagnosed by 1p values based on two-sided Z test for the difference in response rates, adjusted for randomisation strata, using the normal approximation to the binomial distribution; – The addition of anidulafungin to voriconazole results in a trend towards 2 3 a positive GM, 9/32 patients died in the monotherapy group, compared with Calculated from 272 patients with probable IA; Calculated from 218 patients with probable IA based on positive GM only CI, confidence interval; GM, galactomannan; IA, invasive aspergillosis improved overall survival in patients with proven or probable IA diagnosed 9/27 patients in the combination group. after allo-HSCT or treatment of haematological malignancies.

Table 1. Patient demographics and baseline characteristics Table 3. Summary of safety – Results of subgroup analyses demonstrated that the combination Variable Voriconazole Combination Variable Voriconazole Combination Voriconazole monotherapy Combination therapy monotherapy therapy monotherapy therapy n (%) n (%) increased the rate of overall 6-week survival in the subset of patients MITT population, n 142 135 Underlying diseases, non-HSCT 97 86 Subjects in safety population 226 228 with antigen-diagnosed disease. This survival difference was Age, years Acute leukaemia 2 (2) 1 (1) AEs All-causality 219 (96.9) 219 (96.1) Mean 51.6 52.2 Acute lymphoblastic leukaemia 19 (20) 12 (14) Treatment-related – voriconazole 99 (43.8) 106 (46.5) statistically significant. Range 18–83 18–79 Acute myeloid leukaemia 43 (44) 47 (55) Treatment-related – anidulafungin/placebo 42 (18.6) 53 (23.2) Aplastic anaemia 1 (1) 1 (1) Race, n (%) Serious AEs All-causality 104 (46.0) 115 (50.4) Chronic lymphocytic leukaemia 8 (8) 5 (6) White 98 (69) 99 (73) Treatment-related – voriconazole 12 (5.3) 20 (8.8) Chronic myeloid leukaemia 1 (1) 0 Black 3 (2) 3 (2) Treatment-related – anidulafungin/placebo 8 (3.5) 11 (4.8) Acknowledgements Lymphoma 13 (13) 12 (14) Asian 35 (25) 31 (23) Other 6 (4) 1 (2) Multiple myeloma 3 (3) 2 (2) All-causality Treatment-related* – Treatment-related* – Myelodysplastic syndrome 7 (7) 2 (2) voriconazole anidulafungin The study was designed in consultation with an international steering committee Male gender, n (%) 82 (58) 74 (55) 0 2 (2) Myeloproliferative syndrome AEs by system organ class Mono Combi Mono Combi Mono Combi coordinated by the Mycoses Study Group (MSG) and was funded by Pfizer Inc. BMI, mean (SD) 24.0 (4.8) 24.0 (5.1) Non haematological 0 2 (2) n (%) n (%) n (%) n (%) n (%) n (%) Editorial support was provided by Dean Clarke at Complete Medical Communications Host factor, n (%)1 Neutropenic,3 n (%) 86 (61) 77 (57) Blood and lymphatic system disorders 43 (19.0) 36 (15.8) 2 (0.9) 1 (0.4) 1 (0.4) 1 (0.4) Allogeneic HCT 42 (30) 44 (33) Prolonged steroids4 Cardiac disorders 45 (19.9) 43 (18.9) 2 (0.9) 5 (2.2) 1 (0.4) 4 (1.8) and was funded by Pfizer Inc. Non-allogeneic HCT/no HCT 100 (70) 91 (67) Avg. 0.3 mg/kg/day 9 (6) 6 (4) Congenital familial and genetic disorders 2 (0.9) 2 (0.9) 0 1 (0.4) - - HCT type2 – n (%) Avg. 1.0 mg/kg/day 10 (7) 12 (9) Ear and labyrinth disorders 7 (3.1) 7 (3.1) 0 1 (0.4) 0 1 (0.4) HLA-matched and related 17 (12) 14 (10) Endocrine disorders 1 (0.4) 4 (1.8) - - - - Treatment with T cell 17 (12) 22 (16) HLA-mismatched or 25 (18) 30 (21) Eye disorders 58 (25.7) 49 (21.5) 30 (13.3) 21 (9.2) 5 (2.2) 2 (0.9) immunosuppressants5 References unrelated donor Gastrointestinal disorders 133 (58.8) 130 (57.0) 8 (3.5) 15 (6.6) 8 (3.5) 12 (5.3) 6 Stem cell type,2 n (%) Probable IA, n (%) General disorders and administration site conditions 127 (56.2) 120 (52.6) 6 (2.7) 5 (2.2) 1 (0.4) 2 (0.9) Bone marrow 6 (4) 14 (10) Histopathology without culture 0 4 (3) Hepatobiliary disorders 19 (8.4) 29 (12.7) 8 (3.5) 21 (9.2) 3 (1.3) 8 (3.5) 1. Fukuda T et al. Blood 2003; 102: 827–33. Peripheral blood 33 (23) 30 (22) Culture or cytology of BAL 30 (21) 20 (15) Immune system disorders 4 (1.8) 8 (3.5) 1 (0.4) 0 - - Cord blood 5 (4) 5 (4) Positive GM only 110 (77) 108 (80) Infections and infestations 99 (43.8) 105 (46.1) 3 (1.3) 2 (0.9) 3 (1.3) 2 (0.9) 2. Garcia-Vidal C et al. Clin Infect Dis 2008; 47: 1041–50. Positive BAL GM and serum GM 12 (8) 7 (5) Injury poisoning and procedural complications 22 (9.7) 35 (15.4) - - - - Conditioning therapy,2 n (%) Positive serum GM only 64 (45) 61 (45) 3. Herbrecht R et al. N Engl J Med 2002; 347: 408–15. Myeloablative 28 (20) 29 (22) Investigations 67 (29.6) 78 (34.2) 32 (14.2) 42 (18.4) 15 (6.6) 22 (9.6) Positive BAL GM only 34 (24) 40 (30) Metabolism and nutrition disorders 82 (36.3) 91 (39.9) 4 (1.8) 9 (3.9) 5 (2.2) 6 (2.6) Reduced intensity 13 (9) 16 (12) 4. Kirkpatrick WR et al. Antimicrob Agents Chemother 2002; 46: 2564–8. Proven IA, n (%) Musculoskeletal and connective tissue disorders 44 (19.5) 50 (21.9) 1 (0.4) 5 (2.2) 0 3 (1.3) Underlying diseases, HSCT 45 49 Neoplasms benign 12 (5.3) 25 (11.0) - - - - Acute leukaemia 0 1 (2) Histopathology with culture 0 1 (1) 5. Marr KA et al. Clin Infect Dis 2004; 39: 797–802. Nervous system disorders 63 (27.9) 65 (28.5) 7 (3.1) 14 (6.1) 1 (0.4) 12 (5.3) Acute lymphoblastic 7 (16) 8 (26) Culture of tissue 0 2 (1) leukaemia Histopathology without culture 2 (1) 0 Psychiatric disorders 73 (33.8) 77 (32.3) 25 (11.1) 22 (9.6) 4 (1.8) 3 (1.3) 6. Perea S et al. Antimicrob Agents Chemother 2002; 46: 3039–41. Acute myeloid leukaemia 16 (36) 22 (45) Renal and urinary disorders 42 (18.6) 48 (21.1) 1 (0.4) 2 (0.9) 0 1 (0.4) Aplastic anaemia 4 (9) 0 15 people in combination arm and 3 people in monotherapy arm Reproductive system and breast disorders 4 (1.8) 3 (1.3) - - - - 7. Petraitis V et al. Antimicrob Agents Chemother 2009; 53: 2382–91. Chronic lymphocytic 1 (2) 1 (2) received autologous transplants; 2Among 86 allogeneic HCT recipients; Respiratory thoracic and mediastinal disorders 106 (46.9) 110 (48.2) 2 (0.9) 3 (1.3) 1 (0.4) 3 (1.3) 3 3 4 5 leukaemia Absolute neutrophil count <500/mm ; >3 weeks; such as ciclosporin, 8. Singh N et al. Transplantation 2006; 81: 320–6. TNFa blockers, specific monoclonal antibodies (such as alemtuzumab), Skin and subcutaneous tissue disorders 79 (35.0) 83 (36.4) 12 (5.3) 9 (3.9) 5 (2.2) 7 (3.1) Chronic myeloid leukaemia 1 (2) 4 (8) or nucleoside analogues, during the past 90 days; 6Data review committee- Surgical and medical procedures 0 1 (0.4) - - - - 9. De Pauw B et al. Clin Infect Dis 2008; 46: 1813–21. Lymphoma 8 (18) 5 (10) adjudicated diagnosis by Day 7 Vascular disorders 54 (23.9) 76 (33.3) 4 (1.8) 1 (0.4) 3 (1.3) 3 (1.3) Multiple myeloma 2 (4) 4 (8) BAL, bronchoalveolar lavage; BMI, body mass index; GM, galactomannan; HCT, haematopoietic cell transplantation; HLA, human leukocyte antigen; Myelodysplastic syndrome 6 (13) 2 (4) *AEs were considered to be treatment-related by the investigator HSCT, haematopoietic stem cell transplantation; IA, invasive aspergillosis; Poster presented at the 22nd European Congress of Clinical Microbiology and Infectious Myeloproliferative syndrome 0 2 (4) MITT, modified intent to-treat; SD, standard deviation AE, adverse event; mono, monotherapy; combi, combination therapy Diseases (ECCMID), London, UK, 31 March – 3 April 2012