Inhibitor development according to FVIII concentrate in PUPs: how to interpret current evidence? Alfonso Iorio Health Information Research Unit & Hamilton-Niagara Hemophilia Program McMaster University

Disclosures for Alfonso Iorio In compliance with COI policy, EAHAD requires the following disclosures to the session audience: ShareholderNo relevant conflicts of interest to declare Grant / Research SupportBayer, Baxter, Biogen Idec, Novo Nordisk, Pfizer ConsultantBayer, Baxter, Novo Nordisk EmployeeNo relevant conflicts of interest to declare Paid InstructorNo relevant conflicts of interest to declare Speaker bureauNo relevant conflicts of interest to declare HonorariaBayer, Baxter, CSL, Octapharma, Pfizer Presentation includes discussion of the following off-label use of a drug or medical device:

Overview 1)Assessing causality: methodological notes 2)Appraising data on the concentrate dependent risk of inhibitors 3)Implications and perspectives

Overview 1)Assessing causality: methodological notes 2)Appraising data on the concentrate dependent risk of inhibitors 3)Implications and perspectives

TREATMENT ADVATE KOGENATE 0 ED 50 KOGENATE ADVATE

TREATMENT ADVATE KOGENATE RANDOM NEXT PATIENT Large deletion Deletion + history Point + history Point mutation Family history Point mutation Family history Point mutation Point + history Family history Deletion + history MULTIVARIABLE ANALYSIS MULTIVARIABLE ANALYSIS

Family history Gene mutation Brand MULTIVARIABLE ANALYSIS MULTIVARIABLE ANALYSIS

Gene mutation Family history Brand MULTIVARIABLE ANALYSIS MULTIVARIABLE ANALYSIS ??Unknow n ?? ??Unknow n ?? ?

Gene mutation Family history Brand MULTIVARIABLE ANALYSIS MULTIVARIABLE ANALYSIS ??Unknow n ?? ??Unknow n ?? Kogenate/ Advate ?

Assessing causality – summary notes Selection by indication Selection by indication – Unbalanced risk of event at baseline Center effect – The effect of center is a proxy for what you cannot measure it is constantly checked even in randomized trials Methods exists for small centers – Center effect and “center size” effect ARE NOT the same McGilchrist, CA et al. Regression with frailty in survival analysis. Biometrics, , Hougaard, P. Frailty models for survival data. Lifetime Data Analysis, 1995, 1,

Overview 1)Assessing causality: methodological notes 2)Appraising data on the concentrate dependent risk of inhibitors 3)Implications and perspectives

Concentrate based risk of inhibitors RODIN France Coag UK UKHCDO Vazina EUHASS EAHAD Metanalysis For each one: Design Main result Key to appraisal Does it point to a true difference of K vs A as the most likely explanation?

Evidence profiling StudyDesignMain resultinterpretationContribution RODIN UKHCDO France C Vezina EUHASS EAHAD IPD

Evidence profiling StudyDesignMain resultinterpretationContribution RODINP, R, IC, MC Year: Tot: 340 (574) RC, RD: 28.2, 9.0% Post hoc Multivariable (+) Hypothesis generation UKHCDO France C Vezina EUHASS EAHAD IPD P = prospective; R = retrospective; IC – Inception cohort; MC = Multisite

Evidence profiling StudyDesignMain resultinterpretationContribution RODINP, R, MCYear: Tot: 340 (574) RC, RD: 28.2, 9.0% Post hoc Multivariable (+) Hypothesis generation UKHCDOR, IC, SCYear: Tot: 300 (407) RC, RD: 23.8, 11.3% Time effect, B-DD f-VIII, RODIN effect Generate alternative hypothesis France C Vezina EUHASS EAHAD IPD P = prospective; R = retrospective; IC – Inception cohort; MC = Multisite, SC = single country

Kogenate Advate Dashed line = RODIN centers Advate 3/1226/11713/43 Kogenate 24/6516/315/32 UKHCDO cohort: effect of time and … RODIN?

Evidence profiling StudyDesignMain resultinterpretationContribution RODINP, R, IC, MC Year: Tot: 340 (574) RC, RD: 28.2, 9.0% Post hoc Multivariable (+) Hypothesis generation UKHCDOR, IC, SCYear: Tot: 300 (407) RC, RD: 23.8, 11.3% Time effect, Refacto, RODIN effect Generate alternative hypothesis France CoagR, IC, SCYear: Tot: 234 (303) RC, RD: 30.0, 15.0% “center” effect Multivariable (-) RODIN effect ?? Generate a second alternative hypothesis Vezina EUHASS EAHAD IPD P = prospective; R = registry; MC = multiple centers/countries, IC = inception cohort, SC = single country

Kreuz W, Gill JC, Rothchild C et al. Thrombosis and Haemostasis 2005; 93: % inhibitor rate with Kogenate ( )

Evidence profiling StudyDesignMain resultinterpretationContribution RODINP, R, IC, MC Year: Tot: 340 (574) RC, RD: 28.2, 9.0% Post hocHypothesis generation UKHCDOR, IC, SCYear: Tot: 300 (407) RC, RD: 23.8, 11.3% Time effect, B-DD f-VIII, RODIN effect Generate alternative hypothesis France CR, IC, SCYear: Tot: 234 (303) RC, RD: 30.0, 15.0% Strong “center” effect RODIN effect ?? Generate a second alternative hypothesis VezinaS, SCY: Tot:86 (99) RC, RD: 36.0, 6.0% Higher rate with Advate You cannot “export” results? EUHASS EAHAD IPD P = prospective; R = registry; MC = multiple centers/countries, IC = inception cohort, SC = single country; S = survey

Evidence profiling StudyDesignMain resultinterpretationContribution RODINP, R, IC, MC Year: Tot: 340 (574) RC, RD: 28.2, 9.0% Post hocHypothesis generation UKHCDOR, IC, SCYear: Tot: 300 (407) RC, RD: 23.8, 11.3% Time effect, B-DD f-VIII, RODIN effect Generate alternative hypothesis France CR, IC, SCYear: Tot: 234 (303) RC, RD: 30.0, 15.0% Strong “center” effect RODIN effect ?? Generate a second alternative hypothesis VezinaS, SCY: Tot:86 (99) RC, RD: 36.0, 6.0% Higher rate with Advate You cannot “export” results? EUHASSP, DC, MCY: Tot: 284 (417) RC, RD: 26.2, 4.5% RODIN effectNon-confirmatory EAHAD IPD P = prospective; R = registry; MC = multiple centers/countries, IC = inception cohort, SC = single country; S = survey; DC = dynamic cohort;

EUHASS EUHASS - RODIN P95% CIP Plasma D Recomb Advate Helixate Kogenate Refacto

Evidence profiling StudyDesignMain resultinterpretationContribution RODINP, R, IC, MC Year: Tot: 340 (574) RC, RD: 28.2, 9.0% Post hocHypothesis generation UKHCDOR, IC, SCYear: Tot: 300 (407) RC, RD: 23.8, 11.3% Time effect, B-DD f-VIII, RODIN effect Generate alternative hypothesis France CR, IC, SCYear: Tot: 234 (303) RC, RD: 30.0, 15.0% Strong “center” effect RODIN effect ?? Generate a second alternative hypothesis VezinaS, SCY: Tot:86 (99) RC, RD: 36.0, 6.0% Higher rate with Advate You cannot “export” results? EUHASSP, DC, MCY: Tot:284 (417) RC, RD: 26.2, 4.5% RODIN effectNon-confirmatory EAHAD IPD MA, MCY: Tot: 80 (761) RC, RD: 40, 6.6% Any of the previous Non confirmatory Direction of effect Inconsistency P = prospective; R = registry; MC = multiple centers/countries, IC = inception cohort, SC = single country; S = survey; DC = dynamic cohort; MA = meta-analysis

Appraisal: final notes Substantial unexplained variability – UK: by year, RODIN participation – France-Coag: by center effect – RODIN: details unreported !!!! “Discordant” evidence – From different designs Meta-analysis Dynamic cohort – From different populations ??? PTP EUHASS, Xi

Overview 1)Assessing causality: methodological notes 2)Appraising data on the concentrate dependent risk of inhibitors 3)Implications and perspectives

Randomized controlled trial – Objective: ruling out OR 1.6 – Sample size requirements

Implications If we trust RODIN & Co, we would have to: – Consider extensive testing in at least 150 PUPs for 50 ED before feeling safe – Consider implications for PTPs

EUHASS – PTPs Advate 0.11 (0.03 – 0.25) Kogenate 0.17 ( ) OR = 1.54 (0.24 – 12) Xi, PTP meta-analysis Advate 0.10 (0.05 – 0.18) Kogenate 0.26 ( ) Kogenate 0.11 ( ) OR = 2.6 (0.88 – 8.8) Aledort BDD meta-analysis Kogenate vs Advate High titer HR = 1.75 (0.05 – 65.5) All inhibitors HR, 2.43 (0.31–19.2) Kogenate Advate

Conclusion Is the RODIN & Co party over? The is no free lunch at the “risk of inhibitor study club” Either we accept to adopt better methods for prospective assessment, or we have to adapt to live with some uncertainty

Thank you !!! Download these slides at: Hemophilia.mcmaster.ca Join the WAPPS network at: