Mifamurtide
Clinical Study Report C23001 Synopsis
Millennium Pharmaceuticals, Inc.
CLINICAL STUDY REPORT C23001 SYNOPSIS
Study Title An Open-Label, Single-Dose Study to Evaluate the Safety and Pharmacokinetics of
Liposomal Muramyltripeptide Phosphatidylethanolamine (L-MTP-PE) in Subjects With Mild or
Moderate Chronic Renal Insufficiency Compared to Healthy, Adult Subjects
Investigators Harry Alcorn Jr, PharmD, Courtney Cannon, Kambiz Farbakhsh, MD, Thomas
Marbury, MD, Heather Muster, MD, William Smith, MD, and Suzanne Swan, MD.
Study Centers Subjects were enrolled at 2 of the 3 investigative sites in the United States.
Publication (reference) None at the time of report finalization.
Phase 1
Initiation Date (first subject enrolled) 30 August 2010
Completion Date (last subject completed) 17 June 2011
Study Objectives
Primary objective

To evaluate the safety and pharmacokinetics of total muramyltripeptide
phosphatidylethanolamine (MTP-PE) following a single dose of L-MTP-PE in subjects with
mild or moderate chronic renal insufficiency compared to healthy, adult subjects
Exploratory objectives

To evaluate the pharmacokinetics of free (nonliposome-associated) MTP-PE and its active
metabolite muramyl dipeptide (MDP) following a single dose of L-MTP-PE in subjects with
mild or moderate chronic renal insufficiency and in healthy, adult subjects

To evaluate the urinary excretion of MTP-PE and MDP following a single dose of L-MTP-PE in
subjects with mild or moderate chronic renal insufficiency and in healthy, adult subjects

To evaluate the pharmacodynamics of a single dose of L-MTP-PE in subjects with mild or
moderate chronic renal insufficiency and in healthy, adult subjects, as assessed by measurements
of changes in serum interleukin (IL)-6, tumor necrosis factor (TNF)-α, and C-reactive protein
(CRP)
METHODS
Design
This was an open-label, parallel-group, single-dose, multicenter study to evaluate the
pharmacokinetics of MTP-PE after a fixed, 4-mg dose of systemically administered liposomal
mifamurtide (as an intravenous [IV] infusion over 1 hour) in subjects with mild or moderate chronic
renal insufficiency compared to healthy adult subjects. Subjects were classified into renal function
groups based on creatinine clearance (CLcr) calculated with the Cockroft-Gault equation. The
healthy subjects in the respective control groups were to be age-, weight-, and sex-matched
(± 10 years, ± 10 kg, and ± 2 per sex) to the subjects in the mild or moderate renal insufficiency
groups.
On Day 0 (the day before the day of liposomal mifamurtide administration), subjects underwent
determination of iohexol clearance, a measure of glomerular filtration rate (GFR). After liposomal
mifamurtide administration on Day 1, blood samples for plasma pharmacokinetic (PK) evaluation
and urine samples were collected over a 72-hour period. Blood samples for exploratory
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Mifamurtide
Clinical Study Report C23001 Synopsis
Millennium Pharmaceuticals, Inc.
pharmacodynamic (PD) measurements additionally were collected for measurement of serum
concentrations of IL-6, TNF-α, and CRP. Adverse events (AEs) were assessed, and laboratory
values, vital signs, and electrocardiograms (ECGs) were obtained to evaluate the safety and
tolerability of liposomal mifamurtide.
Number of Subjects (planned and analyzed) Planned: A total of 32 subjects were planned and
included 8 subjects with mild chronic renal insufficiency, 8 subjects who were healthy matches for
those with mild chronic renal insufficiency, 8 subjects with moderate chronic renal insufficiency, and
8 subjects who were healthy matches for those with moderate chronic renal insufficiency.
Analyzed: A total of 33 subjects were enrolled and included 9 subjects with mild chronic renal
insufficiency, 8 subjects who were healthy matches for those with mild chronic renal insufficiency,
8 subjects with moderate chronic renal insufficiency, and 8 subjects who were healthy matches for
those with moderate chronic renal insufficiency.
Diagnosis and Main Criteria for Inclusion
Male and nonpregnant female subjects between 18 and 75 years of age, inclusive, were enrolled in
this study. In the healthy control group, subjects had normal renal function results, as defined by
CLcr > 80 mL/min, as estimated with the Cockroft-Gault equation. Subjects were also considered
healthy by the investigator on the basis of medical history, physical examination, and clinical
laboratory evaluations, including screens for drugs of abuse and urine cotinine level. Prescription
medications were prohibited for healthy subjects within the 14 days before the first dose of study
drug with the exception of hormonal contraceptives for women of childbearing potential.
In the groups with renal insufficiency, subjects had either mild (50 mL/min ≤ CLcr ≤ 80 mL/min) or
moderate (30 mL/min ≤ CLcr < 50 mL/min) renal insufficiency and a documented history of stable
renal disease for 1 month before screening and clinical laboratory test results consistent with the
underlying disease. Subjects with diabetes were to maintain stable antidiabetic therapy, which may
include diet and exercise, for 6 weeks before screening through the duration of the study. Subjects
who were positive for hepatitis C were permitted to enroll if their liver enzyme results were within
normal range.
Test Product, Dose and Mode of Administration, Batch Number Each subject received a single,
IV infusion of 4 mg of liposomal mifamurtide over 1 hour. Batch numbers used in this study were
36E001A, 101067, and 100986.
Duration of Treatment A single dose of study drug was given on Day 1. Subjects remained housed
at the unit through Day 4 and were contacted by telephone on Day 8 to assess safety.
Reference Therapy, Dose and Mode of Administration, Batch Number Not applicable.
Pharmacokinetic Assessments
Blood samples were collected over a 72-hour period after drug administration for plasma PK
evaluation at the following time points: predose, 0.25, 0.5, and 0.75 hours after the start of the
infusion; at the end of the infusion (ie, 1 hour after the start of the infusion; immediately before the
infusion pump was switched off); at 0.083 (ie, 5 minutes), 0.25, 0.5, 1, 2, 3, 4, 6, 8, and 11 hours
after the end of the infusion; and at 24, 36, 48, and 72 hours after the start of the infusion. Plasma
concentrations of total MTP-PE were measured with a validated liquid chromatography-tandem mass
spectrometry method under Good Laboratory Practices.
Additionally, urine PK samples were collected predose and over specified collection intervals (0 to
12 hours, 12 to 24 hours, 24 to 48 hours, and 48 to 72 hours postdose) throughout the 72-hour time
frame postdose for exploratory assessments of urinary excretion as permitted by the data.
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Mifamurtide
Clinical Study Report C23001 Synopsis
Millennium Pharmaceuticals, Inc.
Pharmacodynamic Assessments
Blood samples were collected for exploratory PD measurements of serum concentrations of IL-6,
TNF-α, and CRP at the following time points: before start of the infusion (predose) (IL-6, TNF-α,
and CRP); at the end of the infusion (ie, 1 hour after the start of the infusion) with this sample to be
drawn immediately before switching off the infusion pump (IL-6, TNF-α); at 1, 2, 3, 6, and 8 hours
after the end of the infusion (IL-6, TNF-α); and at 24 hours (IL-6, TNF-α, and CRP) and 72 hours
(CRP) after the start of the infusion.
Safety Assessments The safety assessments included AEs, clinical laboratory data, vital signs,
ECGs, and physical examinations. Monitoring of AEs was conducted throughout the study. Clinical
laboratory data, vital sign measurements, ECG data, and physical examination observations were
collected at the times specified in the Schedule of Events. Severity of AEs and laboratory data were
determined using the National Cancer Institute Common Terminology Criteria for Adverse Events
v4.0 criteria.
Statistical Methods Linear regression analyses were done to evaluate the relationship between the
baseline measures of renal function and the clearance of MTP-PE. All other statistical analyses for
PK, PD, and safety data were descriptive and graphical in nature. A formal statistical analysis plan
was developed and completed before database lock. The analysis populations that were used
included the following:
The safety population was defined as all enrolled subjects who received any amount of study
medication.
The PK population was defined as enrolled subjects who received the full dose (infusion) of
L-MTP-PE and had adequate samples to enable determination of PK parameters. Pharmacokinetic
analyses were performed in the PK population.
The PD population included enrolled subjects who received the full dose (infusion) of liposomal
mifamurtide and had adequate samples to enable determination of PD parameters.
Pharmacodynamic analyses were performed in the PD population.
Pharmacokinetic parameters for total MTP-PE and free (nonliposome-associated) MTP-PE were
calculated using noncompartmental analysis. Pharmacokinetic parameters were not calculated for
MDP because the incurred sample reanalysis assessment for the analysis of MDP plasma
concentrations in this study did not meet acceptance criteria (memorandum). Data for MDP
concentrations were, therefore, considered to be unreliable and thus not reported.
Pharmacokinetic parameters included the following: observed maximum concentration (Cmax), area
under the plasma concentration time-curve from time 0 to time of last quantifiable concentration
(AUClast), area under the plasma concentration time-curve from time 0 to infinity (AUCinf), clearance
(CL), terminal phase volume of distribution (Vz), volume of distribution at steady state (Vss), and
terminal half-life (t½) of total MTP-PE.
Pharmacokinetic parameters (Cmax, AUClast, AUCinf, t1/2) of total MTP-PE and free
(nonliposome-associated) MTP-PE were compared between healthy, adult subjects and subjects with
mild or moderate chronic renal insufficiency in graphical displays of the parameters versus renal
function, as measured with CLcr.
The primary analysis used CLcr estimated using the Cockroft-Gault equation. Additional graphical
displays of the PK parameters versus renal function, as measured by estimated glomerular filtration
rate (eGFR) estimated using the Modification of Diet in Renal Disease (MDRD) formula, and
iohexol clearance, were also presented.
The maximum tolerated dose of liposomal mifamurtide in humans was 4 to 6 mg/m2, ie, 2 to 3 times
the recommended clinical dose of liposomal mifamurtide of 2 mg/m2. A fixed dose of 4 mg
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Mifamurtide
Clinical Study Report C23001 Synopsis
Millennium Pharmaceuticals, Inc.
(~2 mg/m2) was being used in this study. Based on these considerations, if the data from this study
indicated that systemic exposure of total MTP-PE in subjects with mild or moderate renal
insufficiency was increased by more than 50% compared with subjects with normal renal function,
an appropriate algorithm for dosing recommendations was to be developed.
The following PD parameters were calculated for each PD biomarker on change from baseline data:
maximum effect (Emax), time of first occurrence of maximum effect (TEmax), and area under the
effect-time curve from time 0 to time of last point of quantifiable effect (AUEClast).
Safety analyses were performed in the safety population. Summary analyses for safety assessments
included AEs, clinical laboratory data, and vital signs. The presentations included number and
percentage for categorical data and descriptive statistics (number, mean, SD, minimum, median, and
maximum) for continuous data.
RESULTS
Demographic Results A total of 33 subjects were enrolled in the study and received study
medication. Of the 33 subjects, 9 had mild chronic renal insufficiency; 8 were healthy matches for
those with mild chronic renal insufficiency; 8 had moderate chronic renal insufficiency; and 8 were
healthy matches for those with moderate chronic renal insufficiency.
Thirty-two subjects (97%) completed the study. One subject (3%) in the mild chronic renal
insufficiency group was discontinued due to urinary incontinence because he was unable to provide
urine samples for PK analysis.
Subject Disposition
Renal Function Group
Mild Chronic
Renal
Insufficiency
Healthy Match
for Mild
Moderate
Chronic Renal
Insufficiency
Healthy Match
for Moderate
Treated
33
9
8
8
8
Completed
32
8
8
8
8
Discontinued
1
1
0
0
0
Pharmacokinetic Population
33
9
8
8
8
Pharmacodynamic Population
33
9
8
8
8
Analyzed for Safety
33
9
8
8
8
The overall proportion of male subjects was slightly higher than the proportion of female subjects
(19 subjects [58%] versus 14 subjects [42%], respectively). The majority of subjects were European
White (19 subjects [58%]), followed by 10 subjects (30%) who were Black or African-American,
2 subjects (6%) who were American Indian or Alaska natives, and 2 subjects (6%) with race of other.
Overall, the median age was 62.0 years with a range of 41 to 75 years, inclusive. The median body
mass index was 26.828 kg/m2 for the all healthy subjects group, 27.943 kg/m2 for the mild chronic
renal insufficiency group, and 28.088 kg/m2 for the moderate chronic renal insufficiency group.
According to local laboratory creatinine clearance values, all subjects in the healthy match groups
and the mild chronic insufficiency groups met the respective inclusion criteria. A minimum
creatinine clearance value of 29.44 mL/min, which was numerically but not clinically meaningfully
below the inclusion criterion of 30 mL/min, was recorded for a subject in the moderate chronic renal
insufficiency group.
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Mifamurtide
Clinical Study Report C23001 Synopsis
Millennium Pharmaceuticals, Inc.
Pharmacokinetic Results Plasma concentrations of total MTP-PE increased during the 1-hour IV
infusion administration of 4 mg L-MTP-PE. Following completion of the IV infusion, MTP-PE
concentrations declined biexponentially across the renal function groups. The PK profiles were
characterized by a rapid initial distribution phase characterized by a steep decline in plasma
concentrations (> 90% decrease from peak concentrations within 30 minutes of cessation of the
infusion) followed by a slower decline in plasma concentrations in the terminal phase, with plasma
concentrations falling below the lower limit of quantification (0.1 nM) in most subjects by 24 hours
after dosing. Mean plasma concentrations of total MTP-PE were superimposable across the renal
insufficiency groups and healthy matched subjects.
Mean values of all PK parameters (AUCinf, Cmax, CL, Vss, and t1/2) of total MTP-PE were similar
between subjects with mild or moderate renal insufficiency and their respective matched healthy
subject groups with normal renal function. The t1/2 of total MTP-PE was short, ranging from 2.03 to
2.27 hours across the renal function groups.
No discernible associations were observed between any of the evaluated baseline measures of renal
function (CLcr, eGFR, iohexol clearance) and the clearance of MTP-PE. In all 3 linear regression
analyses, 95% confidence intervals of the estimated slopes included zero, without meaningful
correlations between the baseline measures of renal function and MTP-PE clearance (r2 < 0.01).
Mean plasma concentrations of free MTP-PE were similar across the renal insufficiency groups and
healthy matched subjects. Across the renal function groups, mean AUCinf and Cmax of free MTP-PE
were similar, and the t1/2 of free MTP-PE ranged from 2.12 to 2.24 hours. The systemic exposure
(AUCinf) of free MTP-PE ranged from 18.6 to 22 nM*hr across the renal function groups;
corresponding estimates of AUCinf of total MTP-PE ranged from 89.5 to 95.4 nM*hr, indicating that
free MTP-PE systemic exposure is approximately one-fifth to one-fourth of the corresponding total
MTP-PE exposure.
Concentrations of MTP-PE were below the limit of assay quantitation in all urine samples; therefore,
renal excretion and renal clearance of MTP-PE could not be reported and are inferred to be
negligible.
Pharmacodynamic Results Maximum increases in serum concentration of IL-6 generally occurred
by 3 to 4 hours after the infusion was initiated, returning towards baseline at 7 hours following
initiation of the infusion. The baseline-adjusted IL-6 PD parameters are generally similar across
renal function groups when viewed in the context of the high PD variability.
Maximum increases in serum concentration of TNF-α generally occurred by 3 hours after the
infusion was initiated, returning towards baseline at 7 hours following initiation of the infusion.
When viewed in the context of the observed extent of PD variability, the baseline-adjusted TNF-α
PD parameters were generally similar across renal function groups.
Serum levels of CRP were increased following L-MTP-PE infusion in all renal function groups at
24 hours. The baseline-adjusted Emax values for increases in serum CRP were generally similar
across renal function groups.
Safety Results All 33 subjects had at least 1 treatment-emergent adverse event (TEAE) that was
considered related to study drug. None of the TEAEs were considered Grade 3 or higher, and no
deaths or serious adverse events occurred during the study. The most commonly reported
drug-related TEAEs (≥ 25% of the total population) were chills (23 subjects [70%]), headache
(19 subjects [58%]), hypotension (16 subjects [48%]), vomiting (14 subjects [42%]), pyrexia
(13 subjects [39%]), tachycardia (13 subjects [39%]), nausea (12 subjects [36%]), and orthostatic
hypotension (10 subjects [30%]). No notable differences were noted between treatment groups for
these common events.
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Mifamurtide
Clinical Study Report C23001 Synopsis
Millennium Pharmaceuticals, Inc.
Among the subjects with hypotension or orthostatic hypotension events, 1 subject in the moderate
chronic renal insufficiency group did not require concomitant treatment for the event (Subject
58001-127). All of the remaining subjects received IV saline on the day of the hypotension or
orthostatic hypotension event. For subjects who experienced both hypotension and orthostatic
hypotension events, treatment was noted for at least 1 of the events. The use of IV saline was
comparable across the renal function groups and included 5 to 7 subjects per group.
None of the laboratory results were considered clinically significant, and none met the National
Cancer Institute Common Terminology Criteria for Adverse Events v 4.0 criteria for Grade 3 or
higher. Transient decreases in systolic and diastolic blood pressure and increases in heart rate were
noted in all renal functions groups after the end of the infusion period. The incidence of vascular
hypotension AEs and tachycardia AEs was fairly similar between renal function groups.
CONCLUSIONS
There was no effect of mild (50 mL/min  CLcr  80 mL/min) or moderate
(30 mL/min  CLcr < 50 mL/min) renal insufficiency on the clinical pharmacokinetics of total
MTP-PE or free MTP-PE, when compared with the clinical pharmacokinetics observed in age-,
weight- and sex-matched healthy adult subjects with normal renal function (CLcr > 80 mL/min).
The PD effects of L-MTP-PE, characterized by post-infusion increases in serum concentrations of
IL-6, TNF- α, and CRP, were similar between subjects with mild or moderate renal insufficiency and
age-, weight-, and sex-matched healthy adult subjects with normal renal function.
The safety profile of liposomal mifamurtide was similar across renal function groups in incidence of
common drug-related TEAEs, a lack of severe or serious AEs, and similar effects on blood pressure
and heart rate after infusion.
The results of this study support the conclusion that no dose modifications of L-MTP-PE are needed,
on the basis of clinical pharmacologic considerations, in patients with mild or moderate renal
insufficiency.
Date of Report: 19 June 2012
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