First line therapy for IA ECIL II 2007IDSA 2008BSH 2008 VoriconazoleA I (oral CIII)A I (1° line)Recommended L-AMBB IA I (1° line for some pts)Recommended ABLCB II-- ABCDD I-- D-AMBD I-Not recommended - A I CaspofunginC IIIAlternativeRecommended MicafunginAlternative- PosaconazoleAlternative- ItraconazoleC IIIAlternative- CombinationD IIINot recommended – B IIDiscouraged – A I Surgery (selected pts) C IIIB III

Salvage therapy ECIL II 2007IDSA 2008BSH 2008 LF-AMBB IIIA II No recommendation The design of these trials is so heterogeneous that it is not possible to make a recommendation on the basis of their evidence. ABLCB III PosaconazoleB II VoricoB II ItraconazoleC IIIB II CaspofunginB II MicafunginB II Combination therapy C II (Caspo + L-AMB or Caspo + Vori) B II

Pivotal factors associated with evaluation of outcome in IA Reaching the right blood levels with voriconazole Disease certainty –Micro-confirmed vs non micro-confirmed Underlying condition –Status of underlying disease –Transplant vs non transplant –Type of transplant –Neutropenia Outcome definition

Pharmacokinetics of Voriconazole Influence of CYP2C19 genotype FDA - Briefing document for Voriconazole - Pfizer, October 2001 courtesy of Dr. N. Wood, Pfizer Central Research

Pascual A et al. CID 2008; 46: Voriconazole: variability of blood concentrations

Voriconazole trough blood levels and clinical response to antifungal therapy Pascual A et al. CID 2008; 46:

Voriconazole trough blood levels and safety of antifungal therapy Pascual A et al. CID 2008; 46:

Pivotal factors associated with evaluation of outcome in IA Reaching the right blood levels with voriconazole Disease certainty –Micro-confirmed vs non micro-confirmed Underlying condition –Status of underlying disease –Transplant vs non transplant –Type of transplant –Neutropenia Outcome definition

Fungal infection: level of certainty Proven Probable Possible

Host factors One micro criterion One major or 2 minor clinical criteria++ Probable invasive fungal infection

Host factors One micro criterion Clinical criteria (halo sign)++ Modified EORTC_MSG criteria used in many clinical trials

CID 2007

HR (95% CI) P Proven IA2.2 ( )<.0001

CID 2008

Reference categoryHR (95% CI) P Degree of certainty of IA diagnosis Possible vs.Proven or probable0.5 ( ).010

Drug performance in patients with true probable/proven IA Denning, vorico phase II –Response overall 54% –Response in proven/probable38% Herbrecht, vorico phase III –Response overall 53% –Response proven/probable46% Ambiload, 3 mg/Kg arm –Response overall 50% –Response proven/probable39% Caspofungin –Only proven/probable (both AL and HSCT)35% EXTRAPOLATED FROM AVAILABLE PUBLICATIONS

Pivotal factors associated with evaluation of outcome in IA Reaching the right blood levels with voriconazole Disease certainty –Micro-confirmed vs non micro-confirmed Underlying condition –Status of underlying disease –Transplant vs non transplant –Type of transplant –Neutropenia Outcome definition

Upton et al CID 2007

Nivoix et al, CID 2008

Difference in proportions (%) and 95% CI VoriAmpho B Overall (MITT) Pulmonary only Extra pulmonary Allogeneic HSCT Other hemat. dis. Other Non-neutropenic Definite IA Neutropenic Probable IA Overall (ITT) Week 12 successful response rate (%) Favors vori Favors AmB

Cornely O et al, CID

BMT 2009 In our study, a relapsing underlying disease was strongly associated with the risk of developing invasive aspergillosis and was also associated with the risk of dying from aspergillosis (OR=3.8)

Multicenter, open, phase II study to estimate the activity and safety of caspofungin as first-line therapy of probable and proven invasive aspergillosis in: -patients with hematological malignances or recipients of autologous HSCT -recipients of allogeneic HSCT Viscoli C, Herbrecht R, Akan H, Baila L, Doyen C, Gallamini A, Giagounidis A, Marchetti O, Martino R, Meert L, Paesmans M, Shivaprakash M, Ullmann AJ and Maertens J for the Infectious Disease Group of the EORTC 8

The EORTC studies of caspofungin in IA Open label, phase II, non comparative studies in: Open label, phase II, non comparative studies in: –Hematological patients undergoing standard chemotherapy or autologous HSCT –Hematological patients undergoing allogeneic HSCT

Main methodological characteristics Only patients with proven/probable IA (i.e. only cases supported or proven by positive microbiology or GM antigen detection test). Only patients with proven/probable IA (i.e. only cases supported or proven by positive microbiology or GM antigen detection test). Sample size calculation based on results of the only available study, at that time, although designed differently, i.e. the voriconazole vs. AmB deaxy study (52% for standard chemo, 32% for allaHSCT) Sample size calculation based on results of the only available study, at that time, although designed differently, i.e. the voriconazole vs. AmB deaxy study (52% for standard chemo, 32% for allaHSCT) Very sick patients not excluded a priori Very sick patients not excluded a priori Evaluation End of Treatment (EOT) Evaluation End of Treatment (EOT) Patients with less than 50% reduction in the sum of the areas at CT scan considered as stable disease (i.e. failure) at EOT Patients with less than 50% reduction in the sum of the areas at CT scan considered as stable disease (i.e. failure) at EOT

Schema of the study HM or auto/allo HSCT Signs, symptoms and/or laboratory/radiological data suggestive of probable/proven/possible IA Proven/probablePossible Registration/start study treatment Yes Continue study treatment End of study treatment (min 14 days – max 84 days) SUCCESSFAILURE Shifting to oral drugs allowed for maintenance or secondary prophylaxis Further treatment at the discretion of the investigator No Upgraded to probable/proven IA within 7 days from registration, based on tests performed prior to or within 48 hrs after registration Stop study treatment (evaluable for safety) 12

Efficacy Response at EOT by Specific Outcome – MITT Analysis Hemato (N=61) Allo-HSCT (N=24) Complete Response 1 (2%)0 (0%) Partial Response19 (31%)10 (42%) Stable Disease9 (15%)1 (4%) Progression of Disease31 (51%)11 (46%) Not Done or Unknown1 (2%)2 (8%)

Survival at Day 84 - MITT AnalysisHemato(N=61)Allo-HSCT(N=24) Alive 32 (54%) 11 (46%) Death Main Cause of Death (according to DRC) IA IA Haemorrhage with IA Haemorrhage with IA Underlying Disease with Aspergillosis Underlying Disease with Aspergillosis IA + Concomitant Infection IA + Concomitant Infection Other Other 28 (44%) (50%) Unknown (Lost to Follow Up) 1 (2%) 1 (4%)

Baseline Characteristics - MITT AnalysisCharacteristicHemato(N=61)Allo-HSCT(N=24) Gender Gender Male Male Female Female 43 (70%) 18 (30%) 8 (33%) 16 (67%) Age Age Median (range) Median (range) 64 (19-86) 50 (19-65) Uncontrolled Cancer Uncontrolled Cancer (not in remission) (not in remission) 46 (75%) 4 (20%) Underlying Condition Underlying Condition ALL ALL AML AML Chronic leukemias Chronic leukemias Lymphoma (NHL/HD) Lymphoma (NHL/HD) Other Other 4 (7%) 34 (56%) 9 (15%) 11 (18%) 3 (5%) 2 (8%) 9 (38%) 4 (17%) 6 (25%) 3 (13%)

Baseline Characteristics - MITT Analysis (cont.)Hemato(N=61)Allo-HSCT(N=24) Diagnosis of IA Diagnosis of IA Proven Proven Probable Probable Possible at Baseline, upgraded to Probable within 7 days Possible at Baseline, upgraded to Probable within 7 days 1 (2%) 36 (59%) 24 (39%) - 11 (46%) 13 (54%) Site of Infection Site of Infection Lower Respiratory Tract Lower Respiratory Tract Sinonasal Infection Sinonasal Infection 60 (98%) 1 (2%) 24 (100%) - Neutropenia (<500/mm 3 ) at start of study treatment Neutropenia (<500/mm 3 ) at start of study treatment 51 (85%) 12 (50%)

Factor associated with survival at multivariate analysis (57/61 pts) ORpvalue Karnofsky score Underlying disease not in remission Neutropenia at EOT < Only hematological patients

Survival at 12 weeks in the caspofungin, voriconazole and liposomal-AmB trials VoricoD-AmBL-AmB3 L-AmB10 Caspo Overall In pts with non progressing Cancer In pts with progressing cancer ?? ? ? Numbers are percentages

Difference in proportions (%) and 95% CI VoriAmpho B Overall (MITT) Pulmonary only Extra pulmonary Allogeneic HSCT Other hemat. dis. Other Non-neutropenic Definite IA Neutropenic Probable IA Overall (ITT) Week 12 successful response rate (%) Favors vori Favors AmB

Cornely O et al, CID

All differences are not statistically significant Caspo study EORTC

Pivotal factors associated with evaluation of outcome in IA Reaching the right blood levels with voriconazole Disease certainty –Micro-confirmed vs non micro-confirmed Underlying condition –Status of underlying disease –Transplant vs non transplant –Type of transplant –Neutropenia Outcome definition

CID 2008

Outcome Definitions (Standard Response Criteria) Complete Response Complete Response Resolution of all attributable clinical signs and symptoms Resolution of all attributable clinical signs and symptoms No new clinical signs or radiological abnormalities compatible with IA No new clinical signs or radiological abnormalities compatible with IA Disappearance of all radiological lesions attributable to aspergillosis. Disappearance of all radiological lesions attributable to aspergillosis. Partial Response Partial Response Major improvement of fever and attributable clinical signs and symptoms Major improvement of fever and attributable clinical signs and symptoms No new clinical signs or radiological abnormalities compatible with IA No new clinical signs or radiological abnormalities compatible with IA At least 50% decrease in the sum of the area of the attributable measurable lesions; At least 50% decrease in the sum of the area of the attributable measurable lesions; Progression Progression Worsening of clinical signs and symptoms Worsening of clinical signs and symptoms New clinical signs or radiological abnormalities compatible with IA New clinical signs or radiological abnormalities compatible with IA Increase in the sum of the area of the attributable measurable lesions Increase in the sum of the area of the attributable measurable lesions Stable Disease Stable Disease Criteria for complete or partial remission or progression are not met Criteria for complete or partial remission or progression are not met

Correlation between EOT response and change in size of the radiological lesions (available in 45/61 pts) ResponseMedian change in size (95% CI) Partial Stable Progression - 73% (60-81) - 36% 103% (69-421) 29 Only hematological patients

CR/PR (N = 20) SD (N = 9) PD (N = 31) Difference in size of the lesions N19830 Median (95% CI*)Reduction of 75% (65%-82%) Reduction of 36% Increase of 103% (69% - 421%) Fever Improvement55%(11/20)78%(7/9)32%(10/31) Stabilization40%(8/20)22%(2/9)61%(19/31) Deteroriation5%(1/20)--6%(2/31) Galactomannan Improvement64%(9/14)100%(6/6)42%(11/26) Stabilization36%(5/14)--50%(13/26) Deteroriation----8%(2/26) Sputum production Improvement30%(6/20)11%(1/9)19%(6/31) Stabilization65%(13/20)89%(8/9)71%(22/31) Deteroriation5%(1/20)--10%(3/31) Cough Improvement45%(9/20)67%(6/9)33%(10/30) Stabilization45%(9/20)22%(2/9)47%(14/30) Deteroriation10%(2/20)11%(1/9)20%(6/30) Dyspnea Improvement40%(8/20)33%(3/9)6%(2/31) Stabilization55%(11/20)44%(4/9)35%(11/31) Deteroriation5%(1/20)22%(2/9)58%(18/31) Chest Pain Improvement30%(6/20)56%(5/9)24%(7/29) Stabilization70%(14/20)44%(4/9)76%(22/29) Deteroriation There was no clinical difference between patients with partial remission and stable disease. The only difference was in the degree of reduction in the size of the lesion

Conclusion Voriconazole blood levels should probably be monitored Results of therapy of IA may vary substantially based upon: lDisease certainty lSeverity of underlying conditions lHSCT vs non HSCT (???) Role of neutropenia not clear A stable disease might be considered as success in very sick patients

Infections in compromised patients are unique because we treat an infection in a patient with another disease. The backgroud noise of the other disease is crucial in evaluating the results of the antinfective therapy

Thank you for your attention

HR (95% CI) P Proven IA2.7 ( )<.0001

Nivoix et al, CID 2008 Including possible HR (95% CI) P Degree of certainty of IA diagnosis Possible vs Proven or probable0.5 ( ).001

Nivoix et al, CID 2008

Upton et al CID 2007

Response to treatment with stable disease as failure or success with vorico, L.Amb, caspo (Numbers are percentages) Vorico (NEJM 2002)52vs58 L-AmB 3 (CID 2007)50vs57 Caspo (TIMM 2007, ICAAC 2008)35vs47 Just an exercise. I know that different studies cannot be compared

Outcomes by neutropenia P value for response EOT by history of neutropenia= 0.04 All other p values are not statistically significant