MENDEL-2 MS Supplement (Koren) J Am Coll Cardiol
Appendix
Anti-PCSK9 Monotherapy for Hypercholesterolemia – The MENDEL-2 Randomized,
Controlled Phase 3 Clinical Trial of Evolocumab
Michael J. Koren, MD*, Pernille Lundqvist, MD†, Michael Bolognese, MD‡,
Joel M. Neutel, MD§, Maria Laura Monsalvo, MDǁ, Jingyuan Yang, PhDǁ, Jae B. Kim, MDǁ,
Rob Scott, MDǁ, Scott M Wasserman, MDǁ, Harold Bays, MD¶ for the MENDEL-2
Investigators
*Jacksonville Center for Clinical Research, Jacksonville, FL, USA; †Center for Clinical and
Basic Research, Ballerup, Denmark; ‡Bethesda Health Research Center, Bethesda, MD,
USA; §Orange County Research Center, Tustin, CA, USA; ǁAmgen Inc., Thousand Oaks, CA,
USA, ¶L-MARC Research Center, Louisville, KY, USA
Supplementary Methods. ..................................................................................................... Page S2
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Supplementary Methods
Key exclusion criteria
Key exclusion criteria included heart failure; CHD history; recent deep vein thrombosis or
pulmonary embolism; uncontrolled cardiac arrhythmia or hypertension; diabetes mellitus;
thyroid, liver, gastrointestinal, endocrine, or renal dysfunction; malignancies within 5 years
except for non-melanoma skin cancers or carcinoma in situ; or use of lipid-regulating drugs
within 3 months.
Study drug preparation
Evolocumab and placebo SC were presented as a sterile, preservative-free solution in a
single use, disposable, handheld (spring-based) prefilled auto-injector pen. Study drug
administration occurred after all assessments and blood drawing procedures. Subcutaneous
study drug was administered either as one injection of 1.0 mL of 140 mg/mL evolocumab or
placebo biweekly or three administrations within 30 minutes of 1.0 mL of 140 mg/ mL (420
mg) evolocumab or placebo monthly. Day 1, week 2, week 8, and week 10 treatments
occurred at study sites administered by site staff or patient self- injection. Patients selfadministered injections at week 4 and week 6 in non-clinical settings. All patients received
oral ezetimibe or placebo. To enable blinding, ezetimibe or placebo were administered in
over-encapsulated 10 mg tablets. Telephone assessments were made at week 14 for
biweekly patients.
Laboratory methods
Research sites collected samples for lipid measurements after ≥9 hours of fasting. LDL-C
levels were calculated using the Friedewald equation (Friedewald et al. Clin Chem
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1972;18:499-502). For calculated LDL-C values <40 mg/dL or triglycerides >400 mg/dL,
ultracentrifugation determined LDL-C was measured and reported. All analyses were
performed in a Center for Disease Control Part III standardized central laboratory, Medpace
Reference Laboratory (Cincinnati, OH and Leuven, Belgium). Safety testing was conducted
in an accredited central laboratory as previously described (Raal et al. Circulation
2012;126:2408-17). Immunoassays for detection of anti-evolocumab binding antibodies were
conducted by EMD Millipore Corporation (St. Charles, MO) and Amgen Inc.
Statistical analysis
The planned enrollment of 600 patients (300 evolocumab) had ≥92% power to detect the
superiority of both evolocumab administration regimens over placebo and ezetimibe based
on a 2-sided t-test with a 0.025 significance level for each co-primary endpoint.
Efficacy and safety analysis included all randomized patients who received at least one dose
of the study drug. The co-primary and co-secondary efficacy endpoints were analyzed using
a repeated measures linear effects model for each dose frequency with no imputation of
missing data, except for achievement of LDL-C <70 mg/dL, which was analyzed using the
Cochran-Mantel-Haenszel test. Multiplicity adjustment was based on a combination of
sequential testing, the Hochberg procedure (Hochberg. Biometrika 1988;75:800-2), and
fallback procedure to control the overall significance level for all primary and secondary
endpoints. Sensitivity analyses were conducted by applying a repeated measures linear
effects model and Quade test (Quade. J Am Stat Assoc. 1967;62:1187-1200) to patients who
adhered to the scheduled study drug administration and had non-missing co-primary
endpoints. Covariate analysis was conducted using a similar repeated measures model but
included the covariates of interest, one at a time, as a fixed effect.
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MENDEL-2 MS Supplement (Koren) J Am Coll Cardiol
Safety analyses were conducted using descriptive statistics. Adverse events were classified
by MedDRA (version 16.1).
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