Cenicriviroc for the Treatment of Liver Fibrosis in Adults with Nonalcoholic

Contemporary Clinical Trials 89 (2020) 105922

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Contemporary Clinical Trials

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Cenicriviroc for the treatment of liver ﬁbrosis in adults with nonalcoholic steatohepatitis: AURORA Phase 3 study design T ⁎ Quentin M. Ansteea, , Brent A. Neuschwander-Tetrib, Vincent Wai-Sun Wongc, Manal F. Abdelmalekd, Zobair M. Younossie, Jiacheng Yuanf, Maria Lucia Pecorarog, Star Seyedkazemig, Laurent Fischerg, Pierre Bedossah, Zachary Goodmane, Naim Alkhourii, Frank Tackej, Arun Sanyalk a Institute of Translational & Clinical Research, 4th ﬂoor, William Leech Building, The Medical School, Framlington Place, Newcastle University, Newcastle upon Tyne NE2 4HH, UK b Division of Gastroenterology and Hepatology, Saint Louis University, 3635 Vista Avenue, St. Louis, MO 63110, USA c Chinese University of Hong Kong, Department of Medicine and Therapeutics, 9/F, Lui Che Woo Clinical Sciences Building, Prince of Wales Hospital, Shatin, NT, Hong Kong, China d Duke University, 40 Duke Medicine Circle, Durham, NC 27710, USA e Center for Liver Diseases and Department of Medicine, Inova Fairfax Medical Campus, 3300 Gallows Road, Falls Church, VA 22042, USA f Allergan plc, 2525 Dupont Drive, Irvine, CA 92612, USA g Allergan plc, 701 Gateway Boulevard, South San Francisco, CA 94080, USA h Hôpital Beaujon, 100 Boulevard du Général Leclerc, 92110 Clichy, France i Texas Liver Institute, University of Texas Health Science Center, 607 Camden Street, Suite 108, San Antonio, TX 78215, USA j Charité University Medical Center Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany k Virginia Commonwealth University, 1201 East Marshall Street, Richmond, VA 23298, USA

ARTICLE INFO ABSTRACT

Keywords: Introduction: Nonalcoholic steatohepatitis (NASH) is a sub-classification of nonalcoholic fatty liver disease Nonalcoholic steatohepatitis (NAFLD) characterized by increased risk of progressive liver fibrosis. Cenicriviroc (CVC) is a novel, orally ad- Nonalcoholic fatty liver disease ministered, potent chemokine 2 and 5 receptor antagonist currently in development for the treatment of liver fi Liver brosis fibrosis in adults with NASH. Cenicriviroc Methods and analysis: Efficacy and safety of CVC will be comprehensively evaluated in a global, Phase 3, multicenter, randomized, double-blind, placebo-controlled study (AURORA, NCT03028740) of subjects with NASH and Stage F2 or F3 fibrosis. Approximately 2000 adults (Part 1, 1200 subjects; Part 2, 800 additional subjects) aged 18–75 years with histological evidence of NASH with Stage F2 or F3 fibrosis (NASH Clinical Research Network classification system) will be randomized 2:1 to CVC 150 mg or placebo orally once daily. Primary efficacy endpoints will include the proportion of subjects with ≥1-stage improvement in liver fibrosis and no worsening of steatohepatitis at Month 12 relative to screening (Part 1), and time to first occurrence of any adjudicated event: death; histopathologic progression to cirrhosis; liver transplant; Model of End-Stage Liver Disease score ≥ 15; ascites; hospitalization due to liver decompensation (Part 2). Patient-reported outcomes will assess changes in health outcomes from baseline (Chronic Liver Disease Questionnaire - NAFLD; Work Productivity and Activity Impairment in NASH; 36-Item Short Form Health Survey version 2). Adverse events will be assessed throughout the study. As there are currently no approved treatments indicated for NASH, the AURORA CVC Phase 3 study addresses an unmet medical need.

Abbreviations: AE, adverse event; ALT, alanine aminotransferase; APRI, AST to platelets ratio index; AST, aspartate aminotransferase; CCR, C-C chemokine receptor; CI, confidence interval; CLDQ-NAFLD-NASH, Chronic Liver Disease Questionnaire – Nonalcoholic Fatty Liver Disease; CVC, cenicriviroc; FIB-4, fibrosis-4 index; HIV, human immunodeficiency virus; ITT, intent-to-treat; MELD, Model of End-Stage Liver Disease; mITT, modified intent-to-treat; NASH CRN, Nonalcoholic steatohepatitis Clinical Research Network; NASH, nonalcoholic steatohepatitis; NAFLD, nonalcoholic fatty liver disease; NAS, NAFLD activity score; NCI, National Cancer Institute; SF-36, 36-Item Short Form Health Survey; T2DM, type 2 diabetes mellitus; ULN, upper limit of normal; WPAI-NASH, Work Productivity and Activity Impairment in NASH ⁎ Corresponding author. E-mail address: [email protected] (Q.M. Anstee). https://doi.org/10.1016/j.cct.2019.105922 Received 9 October 2019; Received in revised form 20 December 2019; Accepted 23 December 2019 Available online 24 December 2019 1551-7144/ © 2019 Published by Elsevier Inc. Q.M. Anstee, et al. Contemporary Clinical Trials 89 (2020) 105922

1. Introduction with Stage F3 fibrosis will be enrolled in the study overall. Part 2 will assess clinical outcomes and will end when adjudicated events have Nonalcoholic fatty liver disease (NAFLD) is a common, often “silent” been accrued in approximately 367 individual subjects across both liver disease associated with metabolic disorders [1]. It is characterized parts of the study. The treatment duration is estimated to be 60 months by accumulation of fat in the liver (steatosis), unrelated to excessive for subjects participating in the study and will vary depending on the alcohol consumption [2–5]. Up to 44% of individuals with NAFLD will time taken to accrue the necessary number of adjudicated events. progress to nonalcoholic steatohepatitis (NASH) [6–8], which is characterized by steatosis, hepatocellular ballooning, and lobular in- 2.2. Study endpoints flammation, and can progress to cirrhosis and hepatocellular carcinoma [9–11]. The increasing prevalence of obesity-related disorders has The objective of Part 1 is to demonstrate the superiority of CVC contributed to a rapid increase in the prevalence of NASH (3–5% in the compared to placebo on liver histology at Month 12 relative to US) [12], now the most common indication for liver transplantation in screening. The primary endpoint is the proportion of subjects with women in the US and second most common in men [13]. The increasing improvement in liver fibrosis by ≥1 stage AND no worsening of stea- burden of NASH on patients and healthcare providers [14], combined tohepatitis, defined as no worsening of lobular inflammation or hepa- with an absence of approved therapies, represents an unmet medical tocellular ballooning grade. The key and other secondary endpoints are need. shown in Table 1, with exploratory objectives including the proportion Liver inflammation is regulated by chemokines that control the of subjects with resolution of steatohepatitis AND no worsening of fi- activities and migration of various hepatic and immune cells [15]. The brosis, the proportion of subjects with improvement in fibrosis by ≥1 CeC chemokine receptor types 2 (CCR2) and 5 (CCR5) and their re- stage (using a modified Ishak system), the proportion of subjects with spective ligands (CCL2 and CCL3–5) are involved in the pathogenesis of histopathologic progression to cirrhosis, the proportion of subjects with liver inflammation and fibrosis, contributing to the development of hepatic decompensation, and the change from baseline in non-invasive NAFLD and NASH [15–17]. CCL2 and its receptor CCR2 become up- assessments of liver fibrosis. regulated in the liver, promoting macrophage accumulation, in- The objective of Part 2 is to demonstrate the superiority of CVC flammation, fibrosis, and steatosis [15], while CCL5 exhibits profibrotic compared to placebo on the composite endpoint of histopathologic activity and also induces steatosis and pro-inflammatory factors in he- progression to cirrhosis (NASH Clinical Research Network [CRN] clas- patocytes via the CCR5 receptor [16]. In mouse models, CCR2 [18,19] sification system, Stage F4), liver-related clinical outcomes, and all- or CCR5 [20,21] inhibition resulted in a reduction in liver fibrosis and cause mortality. The primary and secondary endpoints are shown in de-activation of immune cells. Therefore, CCR2 and CCR5 have been Table 1, with exploratory objectives including: the time to first occur- established as promising therapeutic targets for NASH. rence of ascites (requiring intervention) or hospitalization for onset of Cenicriviroc (CVC) is a novel, orally administered, and potent CCR2 variceal bleeding, hepatic encephalopathy (West Haven Stage ≥2), or and CCR5 receptor antagonist which is currently in clinical develop- spontaneous bacterial peritonitis; the proportion of subjects with his- ment for the treatment of liver fibrosis in adults with NASH, having topathologic progression to cirrhosis (NASH CRN Stage F4); and the received Fast Track designation by the US Food and Drug effect of CVC compared to placebo on liver histology. Administration. CVC demonstrated antifibrotic effects in animal models [ 22–26], and also blocked CCR2 and CCR5 in Phase 2 studies in sub- 2.3. Sample size jects with human immunodeficiency virus (HIV) [27,28]. In the Phase 2b CENTAUR study in adults with NASH and liver fibrosis [29], CVC The planned sample size for Part 1 (800 subjects in the CVC arm and treatment improved fibrosis, the histological feature consistently linked 400 in the placebo arm) is based on the primary binary endpoint at with clinical outcomes in NAFLD [30–32], and was twice as likely to Month 12, and is expected to provide 84% power to demonstrate strong provide an antifibrotic benefit compared with placebo [33]. Among the evidence with a single study (two-sided significance level of 0.0012), Phase 3 target population in the Phase 2b study, subjects with NASH assuming a 15% response rate for the placebo arm and a 25% response and Stage F2 or F3 liver fibrosis, 28% of CVC-treated subjects achieved rate for CVC (based on the effect observed in the Phase 2b CENTAUR ≥1 stage improvement in liver fibrosis without worsening of NASH study results). compared to 16% on placebo (odds ratio 2.2; 95% confidence interval The sample size for the Part 2 primary endpoint analysis is based on [CI] 1.00–4.69; p = .049) [33]; most maintained efficacy at Year 2, an estimated event-free survival rate of 80% for the placebo group with a greater effect observed in those with more advanced fibrosis (based on observed cumulative survival free of transplants in patients [33]. Overall, CVC has shown a favorable safety and tolerability profile with NASH and any stage of fibrosis, and taking into account that in > 1200 subjects [34], including those with cirrhosis and hepatic subjects enrolled in AURORA will have Stages F2 or F3 fibrosis), and a impairment [33,35]. hazard ratio of 0.62 by the end of the study, corresponding to a median Following these promising Phase 2 results, the AURORA Phase 3 event-free survival time of approximately 15 years for placebo and study aims to evaluate and confirm the efficacy and safety of CVC for 25 years for CVC [30]. A total of 2000 subjects enrolled for an overall the treatment of liver fibrosis in adults with NASH. study duration of 8 years, with dropout rate estimated at 20%, is expected to lead to approximately 367 events. This calculation gives 85% 2. Study design power to demonstrate strong evidence of superiority of CVC over placebo (two-sided 0.00125 significance level), and 99% power to test the 2.1. Structure superiority of CVC over placebo (two-sided 0.05 significance level). East® 6.4 software (Cytel, Cambridge, MA, USA) was used for the cal- AURORA (NCT03028740) is a global, Phase 3, multicenter, rando- culation. mized, double-blind, placebo-controlled study, which will be conducted in two parts (Fig. 1). In Part 1, approximately 1200 subjects with his- 3. Study procedures tological evidence of NASH and Stage F2 or F3 fibrosis will be randomized 2:1 to CVC 150 mg orally or placebo once daily to evaluate a 3.1. Recruitment and screening processes surrogate histology endpoint at Year 1. There will be approximately 2000 subjects in Part 2, including approximately 1200 subjects from Centers in North, Central, and South America, Europe, and Asia Part 1 and 800 newly randomized subjects, also with histological evi- Pacific will participate in the AURORA study. The study will be con- dence of NASH and Stage F3 fibrosis. A target of at least 60% of subjects ducted in accordance with the Declaration of Helsinki, International

2 Q.M. Anstee, et al. Contemporary Clinical Trials 89 (2020) 105922

Fig. 1. AURORA study design schematic. aApproximately 2000 subjects will be randomized; the ﬁrst ~1200 subjects will be included in the analysis of endpoints in Part 1 and all subjects will be included in the analysis of endpoints in Part 2. CVC, cenicriviroc.

Table 1 Study endpoints.

Part 1 Part 2

Primary efficacy endpoints Proportion of subjects with improvement in fibrosis by ≥1 stagea AND no worsening of Time to first occurrence of any of the following adjudicated events: death (any cause); steatohepatitisb on liver histology at Month 12 relative to the screening biopsy histopathologic progression to cirrhosisa; liver transplant; MELD score ≥ 15; ascites (requiring intervention); and hospitalization due to liver decompensation

Secondary efficacy endpoints Key secondary efficacy endpoint: Proportion of subjects with improvement in fibrosis by Proportion of subjects with improvement in fibrosis by ≥2 stages AND no worsening ≥2 stages AND no worsening of steatohepatitisb on liver histology at Month 12 of steatohepatitisb on liver histology at Month 12 relative to the screening biopsy relative to the screening biopsy (subjects newly randomized in Part 2 only) Proportion of subjects with improvement in fibrosis by ≥1 stage, regardless of effect on Proportion of subjects with improvement in fibrosis by ≥1 stage, regardless of effect steatohepatitis, at Month 12 relative to the screening biopsy on steatohepatitis, at Month 12 relative to the screening biopsy (subjects newly randomized in Part 2 only) Proportion of subjects with improvement in fibrosis by ≥2 stages, regardless of effect on Proportion of subjects with improvement in fibrosis by ≥2 stages, regardless of effect steatohepatitis, at Month 12 relative to the screening biopsy on steatohepatitis, at Month 12 relative to the screening biopsy (subjects newly randomized in Part 2 only) Proportion of subjects with improvement in fibrosis by ≥1 stage AND no worsening of steatohepatitisb on liver histology at Month 12 relative to the screening biopsy (subjects newly randomized in Part 2 only) Four further secondary endpoints will analyze all of the above sets of criteria using the Month 60 biopsy (all subjects)

MELD, Model of End-Stage Liver Disease; NASH CRN, Nonalcoholic Steatohepatitis Clinical Research Network. a NASH CRN system used to classify fibrosis stage in all primary and secondary efficacy endpoints. b No worsening of lobular inflammation or hepatocellular ballooning grade.

Conference on Harmonisation E6 Good Clinical Practice guidelines, and (NASH CRN Stage F4) and/or hepatic decompensation including as- all local and national regulations, and will be approved by the relevant cites, hepatic encephalopathy, or variceal bleeding; other known causes institutional review board or independent ethics committee. Written, of chronic liver disease; prior or planned liver transplantation; HIV-1 or informed consent will be required from all subjects prior to participa- HIV-2 infection; inability to undergo a liver biopsy; hepatitis B surface tion. antigen-positive; alcohol consumption > 21 units/week for males or Screening will take place no > 12 weeks before the baseline visit. In 14 units/week for females (one unit of alcohol is defined in this study as Part 2, a screening visit will only be required for newly enrolled sub- a half pint of beer [285 mL; 9.64 oz], one glass of spirits [25 mL; jects. 0.85 oz], or one glass of wine [125 mL; 4.23 oz]); > 5 × upper limit of normal (ULN) aspartate aminotransferase (AST) [ULN range: 31–37 U/ L] or alanine aminotransferase (ALT) [ULN range: 32–43 U/L] and 3.2. Eligibility glycated hemoglobin > 9% (> 75 mmol/mol) at screening; total bilir- ubin > 1.3 mg/dL (> 22.2 μmol/L); international normalized ratio > – Key inclusion criteria are: adults aged 18 75 years with histo- 1.3; and Model for End-Stage Liver Disease (MELD) score > 12. pathological evidence of NASH based on central reading of biopsy Concomitant medications will be allowed unless they are in- fi fi slides, with Stages F2 or F3 liver brosis for subjects in Part 1 (de ned vestigational or if they are CYP3A4 substrates with a narrow ther- fi using NASH CRN system) and Stage F3 liver brosis for subjects newly apeutic index, or strong inducers or inhibitors of CYP3A4 or CYP2C8. enrolled in Part 2 (NASH CRN), at screening or based on historical The use of pioglitazone or vitamin E (> 400 IU/day) will be disallowed evidence (if the following conditions are met: historical biopsy obtained based on the potential for confounding effect on the study efficacy fi no > 6 months prior to the rst day of screening; hepatic tissue avail- endpoints [36]. able for central histological evaluation; no new pharmacological intervention for NASH made during the period between the biopsy and screening; and subjects have been metabolically stable since the 3.3. AURORA Toolbox biopsy); females of child-bearing potential and males must use at least two approved methods of contraception throughout the study and for A major challenge encountered in previous clinical trials, including 30 days after stopping the study drug; females who are postmenopausal CENTAUR, was the high screening failure rate observed in NASH pa- must have documentation of cessation of menses for ≥12 months tients. This may be up to 80% of screened cases, the majority of which without an alternative medical cause. fail due to insufficiently meeting the required histological criteria for Key exclusion criteria include: a history or presence of cirrhosis study entry. To mitigate this, a non-invasive testing strategy was

3 Q.M. Anstee, et al. Contemporary Clinical Trials 89 (2020) 105922 developed using a number of readily available and cost-effective stage as follows: none (Stage F0); perisinusoidal or periportal (Stage screening tools. F1); mild, zone 3, perisinusoidal (Stage F1a); moderate, zone 3, peri- As a result, the AURORA Toolbox, a novel online portal, will be sinusoidal (Stage F1b); portal/periportal only (Stage F1c); perisinu- made available to investigators as a non-mandatory pre-screening tool. soidal and portal/periportal (Stage F2); bridging fibrosis (Stage F3); The Toolbox aids assessment of subjects for clinically significant NAFLD and cirrhosis (Stage F4) [40]. based on clinical characteristics, non-invasive serum fibrosis measures As the original Ishak staging system was designed for chronic viral (fibrosis-4 index [FIB-4]; NAFLD fibrosis score; AST to platelets ratio hepatitis [41], a modified Ishak system will be used to classify NASH index [APRI]) and other laboratory values, as well as liver stiffness fibrosis stage, as it provides additional granularity at higher fibrosis measure and controlled attenuation parameter via transient elasto- stages. Stages F0–F2 will use the same histologic definitions as the graphy (FibroScan®, Echosens, Paris, France). The Toolbox will NASH CRN system (without further classification of Stage F1 into F1a, leverage the high negative predictive value of these non-invasive tests F1b, or F1c), and Stages F3–F6 will be defined as follows: occasional to assess individual risk of fibrotic NASH [37–39]. For each test, the bridging fibrosis (< 50% linkage of portal and/or central zones) [Stage Toolbox classifies risk as low, intermediate, or high. These outputs help F3]; marked bridging fibrosis (> 50% linkage of portal and/or central inform pre-screening at sites, indicating patients at a low probability of zones but not yet cirrhosis) [Stage F4]; early or incomplete cirrhosis passing the histological threshold for trial inclusion, and therefore (Stage F5); and established or advanced cirrhosis (Stage F6) [42]. helping investigators select appropriate patients and minimize the number of “low inclusion probability” patients undergoing liver biop- 4.2. Patient-reported outcomes sies during screening. Three patient-reported outcomes measures will assess change in 3.4. Randomization health outcomes from baseline: the Chronic Liver Disease Questionnaire – Nonalcoholic Fatty Liver Disease (CLDQ-NAFLD-NASH) [43], Work Randomization will be performed centrally using an interactive Productivity and Activity Impairment in NASH (WPAI-NASH) [44], and response system. In Part 1, at baseline (Day 1), eligible subjects will be 36-Item Short Form Health Survey (SF-36) version 2 (health-related assigned to treatment arms (2:1 CVC or placebo) using permuted block quality of life index) [45,46]. Data will be collected at baseline, Months randomization stratified by NASH CRN fibrosis stage (F2 or F3) and the 6 and 12 for Part 1; at baseline and Month 12 for newly randomized presence or absence of documented T2DM (“yes” or “no”). Additional subjects in Part 2; and annually thereafter for all study subjects. subjects in Part 2 will be randomized at Part 2 baseline (Day 1) using the same method, and stratified only based on presence or absence of 4.3. Safety assessments documented T2DM. Adverse events (AEs) will be assessed at each study visit and clas- 3.5. Study drug administration sified as shown in Table 2. AEs of special interest include elevations in biochemistry associated with liver injury. Various laboratory tests will Subjects will take one 150 mg tablet of study drug (double-blinded be performed periodically throughout the study, and confirmation of CVC or placebo) daily with food. Subjects, investigators, and all site compliance with eligibility criteria regarding concomitant medications personnel will be blinded to CVC and placebo individual treatment and alcohol consumption will be obtained at each study visit. Popula- assignment until Part 2 is complete and the database has been locked. tion pharmacokinetics of CVC will also be assessed: pre-dose and 1 h Blinding will be accomplished by the sponsor providing the study drug, post-dosing plasma samples will be collected at Months 3 and 12 of Part and packaging for active and placebo products will be identical apart 1; at Month 6, plasma samples will be collected pre-dose and 2–6 h post from a unique bottle identification number on the label. Data will be dosing. unblinded at the end of Part 1 to allow for data analysis, although in- An independent data and safety monitoring board will review the dividual subject treatment assignments will not be provided to sites or safety data from the study. An independent adjudication committee will subjects until the analysis of Part 2 is completed. Emergency unblinding review all events which may potentially contribute to the Part 2 pri- may take place where immediate knowledge of the treatment received mary endpoint; only events confirmed by the adjudication committee (CVC versus placebo) is necessary for the management of the subject will be included in this analysis. and may be requested via the interactive response system. 4.4. Study discontinuation 4. Study assessments The study drug will be discontinued in the following instances: 4.1. Efficacy assessments suspected drug-induced liver injury (criteria based on ALT and AST elevations); unacceptable toxicity; acute viral hepatitis (hepatitis A, B, Liver biopsies will be performed at screening, and at Months 12 and C, D, or E), autoimmune or alcoholic hepatitis, hypoxic/ischemic he- 60, to evaluate the histological features of NASH, including fibrosis patopathy, or biliary tract disease during the study; hepatocellular stage (using both NASH CRN and modified Ishak systems). The liver carcinoma; liver transplant; pregnancy; a subject requests to dis- biopsy for each subject will be evaluated by an independent central continue treatment for any reason; and discontinuation of the study at pathologist that is blinded to treatment arm designation and without the request of the sponsor, a regulatory agency, institutional review regard to histology assessments performed at any previous timepoints; board, independent ethics committee, or data and safety monitoring if possible, the same pathologist will evaluate all biopsies from an in- board. dividual subject. The drug will be permanently discontinued if a confirmed Grade 4 The NASH CRN uses a defined and validated semiquantitative (life-threatening) laboratory abnormality or clinical event is considered scoring system [40], the NAFLD activity score (NAS), which is used to related to study drug, or if AST or ALT elevations meet the following assess overall histological change based on an unweighted sum of criteria upon repeat testing within 48–72 h: > 3 × ULN and > grades of steatosis (0–3), lobular inflammation (0–3), and hepatocel- 5 × baseline measure, if baseline value < 2 × ULN; > 3 × baseline lular ballooning (0–2). Histopathological diagnosis of NASH requires measure, if baseline value 2 ≤ ULN < 5; or > 2 × baseline measure, the presence of steatosis, lobular inflammation, and ballooning in a if baseline value ≥5 × ULN (ULN range: 31–37 U/L for AST; 32–43 U/ characteristic pattern, and will be determined by the central patholo- L for ALT). Dosing should be interrupted if a confirmed Grade 3 la- gist. The NASH CRN fibrosis staging system will be used to score fibrosis boratory abnormality or clinical event is considered related to study

4 Q.M. Anstee, et al. Contemporary Clinical Trials 89 (2020) 105922

Table 2 Adverse events.

AE terminology Deﬁnition

AE Any untoward medical occurrence in a subject administered a pharmaceutical product, which does not necessarily have a causal relationship with this treatment AE classificationa Grade 1 (mild) Asymptomatic or mild symptoms; clinical or diagnostic observations only; intervention not indicated Grade 2 (moderate) Minimal, local, or non-invasive intervention indicated; limiting instrumental activities of daily living Grade 3 (severe) Medically significant but not immediately life-threatening; hospitalization indicated; disabling; limiting self-care activities Grade 4 (life-threatening) Life-threatening consequences; urgent intervention indicated Grade 5 (death) Death related to the AE Treatment-emergent adverse event An AE beginning on or after the date of the first dose of study drug, or an exacerbation of a chronic or intermittent pre-existing condition, up until 30 days after the last dose of study drug Serious adverse event AE resulting in death, immediate risk of death (life-threatening), hospitalization, persistent or significant incapacity, congenital anomaly, or important medical event requiring medical or surgical intervention to prevent the above AE of special interest In this study, these include elevations in biochemistry associated with liver injury AE assessed as related to study drug Temporal relationship between AE onset and administration of the study drug that cannot be readily explained by the subject's clinical state or concomitant therapies Furthermore, the AE appears with some degree of certainty to be related, based on the known therapeutic and pharmacologic actions or AE profile of the study drug. If the dose is reduced or drug withdrawn, the AE abates or resolves, and reappears upon rechallenge AE assessed as not related to study drug Evidence exists that the AE has an etiology other than the study drug; for serious AEs, an alternative causality must be provided (e.g. pre-existing condition, underlying disease, intercurrent illness, concomitant medication)

AE, adverse event; NCI, National Cancer Institute. a Classification according to NCI Common Terminology Criteria for Adverse Events. drug. For laboratory abnormalities or clinical events considered un- treatment group using descriptive statistics (mITT analysis set). related to study drug, the drug may be continued at the discretion of the investigator, with appropriate follow up and management. 4.6. Missing data For subjects who discontinue study participation, every effort will be made to ensure that they return for early discontinuation procedures For the Part 1 primary efficacy analysis, any available liver biopsy within 48 h. These subjects will also be required to return to the clinic obtained after receipt of at least 6 months of assigned study drug but 30 days after the last dose of study drug for a follow-up visit. If feasible, before 15 months of follow up may be used for the Month 12 biopsy. and if the study drug was received for at least 6 months, this visit should For subjects with multiple liver biopsies, the evaluable biopsy closest to include a biopsy. Subjects who discontinue will be encouraged to the Month 12 visit will be used. Subjects without an evaluable liver continue with all other evaluations as scheduled in the protocol. biopsy at both screening and Month 12 will be included as non-re- sponders. Sensitivity analyses will account for both “missing at random” and “missing not at random” scenarios. 4.5. Statistical analyses For the Part 2 primary efficacy analysis, any available liver biopsy after baseline may be used. If a subject has any biopsy that meets the For Part 1, two-sided 95% CI for the proportion who meet the pri- primary endpoint definition (determined by the adjudication com- mary efficacy endpoint will be calculated using Wilson's method for CI. mittee), this will be included as an event. Subjects without evaluable The key secondary endpoint will be tested only when the primary biopsies at screening and post baseline will be included as non-events, endpoint result is significant (Table 1). The surrogate endpoint will be unless they meet criteria for a primary endpoint component unrelated tested at 0.0012 (two-sided) level to manifest strong evidence from a to the biopsy. A sensitivity analysis assuming data are “missing not at single confirmatory study, and 0.048 (two-sided) level for study suc- random” will be reported [47]. cess. Cochran–Mantel–Haenszel tests will be used, stratified by fibrosis stage (F2 or F3) and presence or absence of T2DM at baseline, to compare the rates in the two randomized treatment arms. The primary 5. Discussion efficacy endpoint will be evaluated in the modified intent-to-treat (mITT) population (all subjects in the intent-to-treat [ITT] analysis set As there are currently no approved treatments specifically for who received at least one dose of the study drug), and sensitivity NASH, the AURORA CVC Phase 3 study is an important clinical trial in analyses will be performed using the ITT and per-protocol populations. this disease area. The AURORA population consists of subjects shown to Exploratory efficacy endpoints will be summarized by randomized be more likely to benefit from treatment – those with Stage F2 or F3 treatment group using descriptive statistics for the mITT set. fibrosis – following results from the Phase 2b CENTAUR study which The Part 2 analysis will take place when adjudicated events have demonstrated significant improvements in fibrosis in this group after been accrued in approximately 367 unique subjects. Time-to-event 1 year of treatment [29]. analyses will be performed using the Kaplan–Meier product-limit This design has a number of advantages. The primary endpoint (the method and will be analyzed with the stratified logrank test, stratified proportion of subjects with improvement in fibrosis by ≥1 stage [NASH by fibrosis stage and presence or absence of T2DM at baseline, to CRN system] and no worsening of steatohepatitis) is measurable, sen- compare the rates between treatment arms (mITT analysis set). To sitive to change and the effects of treatment, and is consistently quan- manifest strong evidence from a single confirmatory study, a sig- tifiable [48,49]. Although there are currently no validated surrogate nificance level of 0.00125 (two-sided) will be used if the test of the endpoints for NASH, published evidence already supports the assertion surrogate endpoint in Part 1 is successful; a level of 0.00005 (two-sided) that fibrosis stage is an independent predictor of mortality [32,50]; in will be used otherwise. For study success, a 0.05 (two-sided) sig- this context, it is plausible that any sustained improvement in fibrosis nificance level will be used if the test of the surrogate endpoint is observed in this trial has important implications regarding improved successful and a 0.002 (two-sided) level will be used otherwise. hard outcomes such as liver-related mortality. The histological surro- Analysis of Part 2 efficacy endpoints will use similar methods to Part 1. gate endpoints used in this trial may therefore predict clinical benefitin Exploratory efficacy endpoints will be summarized by randomized preventing cirrhosis and death.

5 Q.M. Anstee, et al. Contemporary Clinical Trials 89 (2020) 105922

Use of histological methods to assess clinical benefit also serves as a Star Seyedkazemi – Employment: Allergan plc. limitation of the design, as liver biopsies are invasive, can be painful, Laurent Fischer – Employment: Allergan plc. are associated with risk of complications and may be subject to sam- Pierre Bedossa – Research funding: Allergan, Bristol-Myers Squibb, pling error [48,51]. However, liver biopsy is currently the only reliable Cirius Therapeutics, Diafir, Echosens, Genfit, Glympse Bio, Intercept, and generally accepted method for assessing the severity of NASH [52]. Inventiva, Madrigal, Merck, Novo Nordisk, OWL, Pfizer, Sanyal With this in mind, non-invasive markers may prove useful for sup- Biotechnology. Management position: Liverpat. porting evidence of efficacy [48,49], which is reflected in the choice of Zachary Goodman – Research funding: Alexion, Allergan, Bristol- secondary endpoints [53]. They may also be useful in optimizing sub- Myers Squibb, Conatus, Galectin, Gilead, Intercept, Novartis. ject selection, as per the AURORA Toolbox, which provides a novel and Naim Alkhouri – Research funding: Ackero, Albireo, Allergan, innovative method for classifying subjects' a priori risk for clinically Boehringer Ingelheim, Bristol-Myers Squibb, Galmed, Genfit, Gilead, significant fibrotic NASH, aiding pre-screening efforts by investigators Intercept, Madrigal, MedImmune, Novartis, Novo Nordisk, Pfizer, and potentially reducing the need for screening biopsies. Poxel, Zydus; Speaker: AbbVie, Alexion, Allergan, Eisai, Exelixis, While there are currently no approved treatments for NASH, obe- Gilead, Intercept, Salix; Consultant: Allergan, Gilead, Intercept. ticholic acid, resmetirom, and elafibranor are also undergoing clinical Frank Tacke – Research funding: Allergan, Bristol-Myers Squibb, investigations in Phase 3 trials in the setting of non-cirrhotic NASH, Galapagos, Inventiva; Consultant: Allergan, Bayer, Boehringer with similar development timelines (NCT02548351 [REGENERATE]; Ingelheim, Galapagos, Galmed, Intercept, Inventiva. NCT03900429 [MAESTRO-NASH]; NCT02704403 [RESOLVE-IT], re- Arun Sanyal – Advisory committees or review panels: Abbott, spectively). However, to date, comprehensive study designs have only Bristol-Myers Squibb, Genfit, Gilead, Ikaria, Intercept, Novartis, Pfizer, been published for REGENERATE [54]. Virology Education, Sanofi; Consulting: Ardelyx, Echosens, Enanta, In conclusion, the AURORA Phase 3 study has been carefully de- Exalenz, Genentech, Immuron, Islet Sciences, JD Pharma, Merck, signed based on the clinically meaningful results of the well-powered Nimbus, Salix, Takeda, Zafgen; Grant/research support: Galmed, Phase 2b CENTAUR study to ensure a comprehensive assessment of the Genentech, Gilead, Ikaria, Intercept, Novartis, Salix, Takeda, Tobira efficacy and safety of CVC treatment compared to placebo in adult Therapeutics; Independent contractor: Elsevier, UpToDate; subjects with NASH and Stage F2 or F3 liver fibrosis. This assessment is Management position: Sanyal Biotechnology; Stock shareholder: consistent with the recently recommended baseline assessments of pa- Akarna, Exalenz, Genfit, HemoShear, Tiziana. tients in NASH trials for harmonizing clinical trial data across trials [3]. Acknowledgments Disclosures This study was sponsored by Allergan plc, Dublin, Ireland. Writing Quentin M. Anstee – Research funding: AbbVie, Allergan, and editorial assistance was provided to the authors by Helena Cant, AstraZeneca, GlaxoSmithKline, Novartis, Pfizer, Vertex; Research col- MChemPhys, of Complete HealthVizion, Inc., Chicago, IL, USA and laborations: AbbVie, Allergan, Antaros, AstraZeneca, Boehringer funded by Allergan plc, Dublin, Ireland. All authors met the Ingelheim, Ellegaard Göttingen Minipigs, Exalenz, Genfit, International Committee of Medical Journal Editors (ICMJE) authorship GlaxoSmithKline, Intercept, iXscient, Lilly, Nordic Bioscience, Novartis, criteria. Neither honoraria nor payments were made for authorship. The Novo Nordisk, One Way Liver Genomics, Perspectum Diagnostics, sponsor and authors would like to acknowledge the contributions of Dr. Pfizer, Sanofi, SomaLogic, Takeda; Consultant: Abbott, Acuitas Medical, Jean Paul Nicandro, formerly of Allergan plc, to the design of the Allergan, E3Bio, EcoR1, Galmed, Genfit, Gilead, HistoIndex, Imperial AURORA study and to the development of this manuscript. They would Innovations, Intercept, Inventiva, IQVIA, Janssen, Kenes, Lilly, also like to express their gratitude to Dr. Eric Lefebvre, formerly of Madrigal, MedImmune, NewGene, NGM, Novartis, Pfizer, Poxel, Allergan plc, and acknowledge his contributions to the clinical devel- Raptor, Servier; Speaker: Abbott, Allergan, Bristol-Myers Squibb, opment of cenicriviroc and to the design of the AURORA study. Clinical Care Options, Falk, Genfit, Gilead, Viking. Brent A. 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