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2012 120: 3670-3676


doi:10.1182/blood-2012-06-438804 originally published
online August 20, 2012

Rozrolimupab, a mixture of 25 recombinant human monoclonal RhD


antibodies, in the treatment of primary immune thrombocytopenia
Tadeusz Robak, Jerzy Windyga, Jacek Trelinski, Mario von Depka Prondzinski, Aristoteles
Giagounidis, Chantal Doyen, Ann Janssens, Mara Teresa lvarez-Romn, Isidro Jarque, Javier
Loscertales, Gloria Prez Rus, Andrzej Hellmann, Wieslaw Wiktor Jdrzejczak, Kazimierz
Kuliczkowski, Lana M. Golubovic, Dusica Celeketic, Andrei Cucuianu, Emanuil Gheorghita, Mihaela
Lazaroiu, Ofer Shpilberg, Dina Attias, Elena Karyagina, Kalinina Svetlana, Kateryna Vilchevska,
Nichola Cooper, Kate Talks, Mukhyaprana Prabhu, Prasad Sripada, T. P. R. Bharadwaj, Henrik
Nsted, Niels J. . Skartved, Torben P. Frandsen, Mimi F. Flensburg, Peter S. Andersen and Jrgen
Petersen

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CLINICAL TRIALS AND OBSERVATIONS

Rozrolimupab, a mixture of 25 recombinant human monoclonal RhD antibodies,


in the treatment of primary immune thrombocytopenia
Tadeusz Robak,1 Jerzy Windyga,2 Jacek Trelinski,1 Mario von Depka Prondzinski,3 Aristoteles Giagounidis,4
Chantal Doyen,5 Ann Janssens,6 Mara Teresa Alvarez-Roman,7 Isidro Jarque,8 Javier Loscertales,9 Gloria Perez Rus,10
Andrzej Hellmann,11 Wiesaw Wiktor Jedrzejczak,12 Kazimierz Kuliczkowski,13 Lana M. Golubovic,14 Dusica Celeketic,15
Andrei Cucuianu,16 Emanuil Gheorghita,17 Mihaela Lazaroiu,17 Ofer Shpilberg,18 Dina Attias,19 Elena Karyagina,20
Kalinina Svetlana,21 Kateryna Vilchevska,22 Nichola Cooper,23 Kate Talks,24 Mukhyaprana Prabhu,25 Prasad Sripada,26
T. P. R. Bharadwaj,27 Henrik Nsted,28 Niels J. . Skartved,28 Torben P. Frandsen,28 Mimi F. Flensburg,28
Peter S. Andersen,28 and Jrgen Petersen28
1Department of Hematology, Medical University of Lodz and Copernicus Memorial Hospital, Lodz, Poland; 2Instytut Hematologii i Transfuzjologii, Warsaw,
Poland; 3Werlhof Institut, Hannover, Germany; 4St Johannes Hospital, Duisburg, Germany; 5Department of Hematology, Cliniques Universitaires UCL de
Mont-Godinne, Yvoir, Belgium; 6Department of Haematology, UZ Leuven, Leuven, Belgium; 7Hospital la Paz, Madrid, Spain; 8Servicio de Hematologa, Hospital
Universitari i Polite`cnic La Fe, Valencia, Spain; 9Hospital Universitario de La Princesa, Madrid, Spain; 10Hospital General Universitario Gregorio Maranon,
Madrid, Spain; 11Department of Hematology and Transplantology, Medical University of Gdansk, Gdansk, Poland; 12Katedra i Klinika Hematologii, Onkologii i
Chorob, Warsaw, Poland; 13Klinika Hematologii Nowotworow Krwi i Transplantacji Szpiku, Wroclaw, Poland; 14Clinic for Haematology and Clinical Immunology,
Nis, Serbia; 15Clinical Center Zemun, Department for Haematology, Zemun, Serbia; 16Prof Dr Ion Chiricuta Oncology Institute Hematology Clinic, Cluj-Napoca,
Romania; 17Country Hospital, Brasov, Romania; 18Davidoff Center, Beilinson Hospital, Petach Tikva, Israel; 19Bnai-Zion Medical Center, Hematology
Department, Haifa, Israel; 20State Institution of Healthcare, Saint Petersburg, Russia; 21City Hospital #9, Department of Blood Systems Diseases, Kiev, Ukraine;
22Gusak Academy of AMS Ukraine, Donetsk, Ukraine; 23Department of Haematology, Catherine Lewis Centre Hammersmith Hospital, London, United Kingdom;
24Newcastle Biomedicine Clinical Research Platforms Level 6, Newcastle Upon Tyne, United Kingdom; 25Kasturba Medical College Hospital Manipal Center for
Clinical Research, Karnataka, India; 26Apollo Hospital AHERF Clinical Trial Unit, Andra Pradesh, India; 27Aysha Hospital Pvt Ltd, Chennai, India; and
28Symphogen A/S, Lyngby, Denmark

Rozrolimupab, a recombinant mixture of


25 fully human RhD-specific monoclonal
antibodies, represents a new class of
recombinant human antibody mixtures.
In a phase 1 or 2 dose escalation study,
RhD patients (61 subjects) with primary
immune thrombocytopenia received a
single intravenous dose of rozrolimupab
ranging from 75 to 300 g/kg. The primary outcome was the occurrence of
adverse events. The principal secondary
outcome was the effect on platelet levels

7 days after the treatment. The most common adverse events were headache and
pyrexia, mostly mild, and reported in
20% and 13% of the patients, respectively,
without dose relationship. Rozrolimupab
caused an expected transient reduction of
hemoglobin concentration in the majority of
the patients. At the dose of 300 g/kg platelet responses, defined as platelet count
> 30 109/L and an increase in platelet
count by > 20 109/L from baseline were
observed after 72 hours and persisted for

at least 7 days in 8 of 13 patients (62%).


Platelet responses were observed within
24 hours in 23% of patients and lasted for
a median of 14 days. Rozrolimupab was
well tolerated and elicited rapid platelet
responses in patients with immune thrombocytopenia and may be a useful alternative to plasma-derived products. This trial
is registered at www.clinicaltrials.gov
as #NCT00718692. (Blood. 2012;120(18):
3670-3676)

Introduction
Primary immune thrombocytopenia (ITP) is an autoimmune disease mediated by antiplatelet antibodies that cause opsonization of
platelets and elimination through binding to FcR-bearing phagocytic cells and subsequent phagocytosis.1 In addition, the same
autoantibodies bind to megakaryocytes and impair platelet
production.1
The annual incidence of ITP in the United States is estimated to
be 16 000 cases.2 Although the thrombocytopenia in ITP can be
severe, most patients have only minor signs of bleeding. Persistently low platelet counts ( 20 109/L), however, are associated
with an increased risk of serious bleeding, such as intracranial

hemorrhage.3 Treatment is indicated for ITP associated with


significant mucous membrane bleeding and is also indicated for
patients with risk factors for bleeding (eg, hypertension, peptic
ulcer disease, antiplatelet drug ingestion), in adult patients with a
platelet count 30 109/L, and in patients before surgical
procedures.3
The initial treatment for ITP is composed of corticosteroids,
intravenous high dose immunoglobulin (IVIg), or intravenous RhD
immune globulin (anti-D). These compounds act primarily by
interfering with platelet destruction4 and cytokine modulation.5
Immunomodulatory agents suppress the production of antiplatelet

Submitted June 25, 2012; accepted July 28, 2012. Prepublished online as
Blood First Edition paper, August 20, 2012; DOI 10.1182/blood-2012-06-438804.

The publication costs of this article were defrayed in part by page charge
payment. Therefore, and solely to indicate this fact, this article is hereby
marked advertisement in accordance with 18 USC section 1734.

Preliminary results of this study were presented at the 52nd Annual Meeting of
the American Society of Hematology, San Diego, CA, December 12, 2011.
There is an Inside Blood commentary on this article in this issue.

3670

2012 by The American Society of Hematology

BLOOD, 1 NOVEMBER 2012 VOLUME 120, NUMBER 18

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BLOOD, 1 NOVEMBER 2012 VOLUME 120, NUMBER 18

antibodies, but the use of immunosuppressive agents, corticosteroids, and later splenectomy may be associated with complications.
The platelet response to plasma-derived anti-D, including early
onset and duration of response, seems to be dose dependent6,7 and
at a dose of 75 g/kg anti-D has an effect similar to IVIg.6,8
However, these data were derived from studies in which human
plasma was the source of anti-D. Rozrolimupab, a mixture of
25 recombinant, fully human, RhD-specific monoclonal antibodies,
represents the first in class of recombinant human monoclonal
antibody mixtures9 that can be produced independently of human plasma supply. We here report safety and efficacy data from
a trial of a single dose of rozrolimupab in nonsplenectomized
adults with ITP.

Methods
Trial medication
Rozrolimupab is composed of 25 genetically unique IgG1 antibodies, all
specific for the RhD erythrocyte antigen, derived from B-lymphocytes of
8 RhD-negative female donors with high serum antibody titers against
RhD.9,10 The drug substance was produced by single batch manufacturing
of a working cell bank composed of an equal mixture of 25 CHO cell lines,
each expressing 1 particular human monoclonal antibody specific for RhD.9
Twenty antibodies have a -light chain and 5 antibodies a -light chain.10
The hypervariable regions of the heavy chains are homologous with
published human anti-RhD sequences.10 Rozrolimupab is composed of
antibodies specifically selected to recognize the complete D antigen
expressed in 99% of the human population, including rare D variants
DIII, DIV, DVI, and DVII expressed in 1% of the overall RhD-positive
population.11 The rozrolimupab drug product exhibits stable composition in
consecutive batches.12
Validated flow cytometry studies according to the European Pharmacopoeia demonstrated that rozrolimupab binds to RhD variants with a potency
comparable with that of 2 marketed plasma-derived anti-D products,
Rhophylac and WinRho.13 Explorative in vitro studies showed that
rozrolimupab mediated specific phagocytosis and antibody-dependent
cell-mediated cytotoxicity of RhD-expressing erythrocytes using either
normal human mononuclear cells or THP-1 monocytic leukemia cells
(ATCC) as effector cells. In the latter case, the potency of rozrolimupab
appeared 5-fold reduced compared with plasma-derived anti-D products
(data not shown).
Eligibility
Adult patients with ITP were enrolled at 27 investigational sites in Europe,
Israel, and India. Eligibility criteria included the diagnosis of primary ITP14
documented response after initial therapy with corticosteroids, anti-D or
IVIG defined as an increase in platelet count 30 109/L, and a
pretreatment platelet count of 30 109/L. Key exclusion criteria included prior splenectomy, secondary thrombocytopenia, clinical splenomegaly, a history of abnormal bone marrow examination (except for
megakaryocytosis), hemoglobin concentration 2 g/dL below the lower
limit of the normal range, and positive results of direct Coombs test.
Design
The trial was approved by independent ethics committees and the governmental authorities in each participating country, as required, and was
carried out in accordance with the Declaration of Helsinki (October 1996).
All patients provided oral and written informed consent before trial start.
This was an open-label, international, multicenter, exploratory dose
finding, phase 1 or 2 trial. The trial was designed to include cohorts
receiving a single dose of rozrolimupab 75, 100, 125, 150, 200, 250, 300,
and 350 g/kg, that each consisted of 5-11 patients. An Independent Data
Monitoring Committee evaluated safety and efficacy between each dose

ROZROLIMUPAB IN PRIMARY IMMUNE THROMBOCYTOPENIA

3671

escalation. Once the final dose level was achieved after this evaluation, the
final dose cohort was repeated.
All patients received a single intravenous dose of rozrolimupab. For
doses up to 150 g/kg, rozrolimupab was given as a slow bolus intravenous
injection of 3-5 minutes duration. For doses 150 g/kg, rozrolimupab
was added to a 100-mL sterile infusion bag containing 0.9% NaCl and
infused over 15-20 minutes using a sterile inline filter (0.2 m).
Patients were followed for 6 weeks.
The primary endpoint of the trial was the incidence and severity of
adverse events (AEs), including serious adverse events (SAEs), during the
6-week trial period. Secondary safety endpoints included laboratory
parameters (including maximum reduction of hemoglobin concentration),
and presence of human antihuman antibodies.
Efficacy endpoints included measures of platelet response and use of
rescue medication. Responders were defined as patients with platelet count
30 109/L and an increase in platelet count by 20 109/L from
baseline at 7 days after rozrolimupab treatment.
Analysis of hematology, clinical chemistry, coagulation, and hemolysis
parameters was performed before treatment and at predefined intervals after
treatment. The concentrations of IL-6, IL-10, monocyte chemotactic
protein-1 (MCP-1), and TNF- were measured by Luminex Technology kit
(Merck Millipore).
Rozrolimupab serum concentrations were measured by flow cytometry
as previously described.15 The lower limit of quantification was validated to
4 ng/mL in whole serum.
A double-antigen ELISA16 with detection limit of 6.3 ng/mL was used
to detect human antihuman antibodies. Analysis for the FcRIIA-131 H/R
and FcRIIIA-158 V/F genotypes was performed on DNA extracted from
blood samples.17,18
No formal sample size calculations were performed. Linear regression
was used to analyze possible relations between predictor and dependent
variables.

Results
Characteristics of patients

Patients had a median age of 51 years and were predominantly


female (64%; Table 1). The majority of patients (89%) were white.
The median baseline platelet counts varied between the cohorts
with the numerically highest baseline median counts in the
100-g/kg cohort, and the lowest in the 75-g/kg cohort. Across all
cohorts, 12 patients had a baseline platelet count 10 109/L.
The 100-g/kg cohort had a numerically younger group of patients
compared with the other cohorts.
The median time from ITP diagnosis until screening for all
patients was 21 months, spanning from a median of 5 months
(125-g/kg cohort) to a median of 68 months (75-g/kg cohort).
The most frequently used ITP-related medications before
enrolment were steroids (87%). IVIg had been used by 30% of the
patients, and 13% had used other immunosuppressants, such as
azathioprine. None of the patients had been treated with anti-D.
Safety

The dose escalation was suspended after reaching the 300-g/kg


level after evaluation of safety and efficacy data by an Independent
Data Monitoring Committee.
Forty-five patients reported a total of 198 AEs during the trial
(Table 2). Approximately 75% of the events (149 of 198) were
assessed to be mild in intensity. Eighty events were assessed as
related to rozrolimupab treatment. No AEs led to withdrawal from
trial, and no deaths were recorded.
Headache was the most frequently reported event with 12 patients reporting 16 events; 10 events were mild, 5 were moderate,

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3672

BLOOD, 1 NOVEMBER 2012 VOLUME 120, NUMBER 18

ROBAK et al

Table 1. Patient characteristics


Rozrolimupab dose groups
75 g/kg

100 g/kg

125 g/kg

150 g/kg

200 g/kg

250 g/kg

300 g/kg

All

11

10

10

13

61

Female

3 (27.3%)

9 (90.0%)

6 (60.0%)

4 (80.0%)

5 (83.3%)

5 (83.3%)

7 (53.8%)

39 (63.9%)

Male

8 (72.7%)

1 (10.0%)

4 (40.0%)

1 (20.0%)

1 (16.7%)

1 (16.7%)

6 (46.2%)

22 (36.1%)

Characteristic
N
Sex

Age, y
Median

51.0

40.0

41.0

52.0

60.5

42.5

55.0

51.0

Range

40.0-65.0

19.0-75.0

26.0-74.0

32.0-62.0

25.0-81.0

21.0-74.0

25.0-77.0

19.0-81.0

Age category
40 y

4 (40.0%)

5 (50.0%)

2 (40.0%)

2 (33.3%)

3 (50.0%)

4 (30.8%)

20 (32.8%)

40-60 y

10 (90.9%)

4 (40.0%)

3 (30.0%)

2 (40.0%)

1 (16.7%)

1 (16.7%)

7 (53.8%)

28 (45.9%)

60 y

1 (9.1%)

2 (20.0%)

2 (20.0%)

1 (20.0%)

3 (50.0%)

2 (33.3%)

2 (15.4%)

13 (21.3%)

Race
Asian

1 (16.7%)

5 (38.5%)

6 (9.8%)

White

11 (100%)

10 (100%)

9 (90.0%)

5 (100%)

6 (100%)

5 (83.3%)

8 (61.5%)

54 (88.5%)

Other

1 (10.0%)

1 (1.6%)

Body mass index, kg/m2


Median

26.0

23.6

25.9

28.9

27.2

27.3

26.7

26.1

Range

18.5-36.8

18.0-30.8

21.0-38.1

22.7-30.5

18.7-31.3

20.1-38.7

21.1-40.7

18.0-40.7

Time from first ITP diagnosis to screening, mo


Median

68

20

27

28

19

21

Range

1-166

4-354

2-187

4-141

1-117

3-223

1-273

1-354

Baseline platelet count, 109/L


Median

11.5

22.3

13.3

20.5

19.3

16.0

18.5

18.5

Range

5.0-24.5

10.5-26.5

3.0-26.5

4.5-21.5

3.0-26.0

6.0-26.0

7.3-27.0

3.0-27.0

and 1 was severe in intensity (Table 2). The majority of the events
resolved on the day of onset and was not treated. The single case of
severe headache was treated with paracetamol and had a duration
of 2.5 hours. The longest duration of headache was 20 days for an
event of moderate severity, which was treated with paracetamol.
Eleven of the 16 events of headache, including 3 of the moderate
events and the severe event, were reported in the 75- or 100-g/kg
cohorts.
A reduction in hemoglobin concentration was observed in the
majority of patients (Figure 1B) with a trend toward larger
reductions with increasing doses. All patients were direct Coombs
positive when tested 24 hours after treatment with rozrolimupab
and remained positive at 6 weeks, except for 1 patient in each of the
250- and 300-g/kg cohorts, respectively, who returned to negativity at 4 weeks and 6 weeks after treatment, respectively. A fall in
Table 2. Adverse events reported in > 5% of patients treated with a
single dose of rozrolimupab
Adverse event grading
Adverse events

Mild

Moderate

Severe

All

Headache

13.1

4.9

1.6

19.7

Pyrexia

9.8

3.3

0.0

13.1

Petechiae

8.2

0.0

1.6

9.8

Hematoma

9.8

0.0

0.0

9.8

Low platelet counts

1.6

6.6

1.6

9.8

Chills

9.8

0.0

0.0

9.8

Fatigue

6.6

1.6

0.0

8.2

Increased D-dimer

4.9

3.3

0.0

8.2

Decreased hemoglobin

3.3

3.3

0.0

6.6

Thrombocytopenia

0.0

1.6

4.9

6.6

Hematuria

4.9

1.6

0.0

6.6

Asthenia

4.9

1.6

0.0

6.6

Anemia

3.3

3.3

0.0

6.6

Dizziness

6.6

0.0

0.0

6.6

Values are percentages.

hemoglobin concentration 2.5 g/dL was observed at 72 hours


and 7 days after treatment in 11 (18%) and 15 (25%) of the patients,
respectively. No patient had a fall in hemoglobin concentration
5 g/dL. In the dose group of 300 g/kg, the hemoglobin
concentration returned to baseline in 8 of the 13 patients in a
median of 28 days (range, 1-43 days); none of the 13 patients
received blood transfusions. In the remaining dose cohorts, 1 patient received a blood transfusion on the day of treatment and
3 other patients received 1 or more blood transfusions after
treatment.
Increases in reticulocyte counts were observed in 1 of 6 patients
in the 200-g/kg cohort, 3 of 6 patients in the 250-g/kg cohort,
and in 5 of 13 patients in the 300-g/kg cohort, all of whom also
had lowering of their haptoblobin levels. Reduction in haptoglobin
without concomitant increase in reticulocytes was also seen in
3 patients in the 100-g/kg cohort and in additional patients in
the 200-, 250-, and 300-g/kg cohorts. On the day of treatment,
11 patients reported 19 events of fever and/or 6 events of chills. For
a 12th patient, an infusion reaction consisting of chills and rigors
was reported. Elevation of concentrations of IL-6, IL-10, MCP-1,
and TNF- after infusion with rozrolimupab was observed across
all dose cohorts, and median levels peaked 2-24 hours after
treatment with return to baseline levels by 2-7 days after treatment
(data not shown).
In the 200- to 300-g/kg cohorts, the FcIIA-131HH, -HR, and
-RR genotypes were found in 9, 14, and 4 patients, respectively.
The FcIIIA-158FF, -VF, and -VV genotypes were demonstrated
in 6, 17, and 4 patients, respectively. Patients with the FcIIA131HH genotype had the highest peak levels of all 4 cytokines,
whereas patients with FcIIA-131RR genotype had the lowest
peak levels. Patients with the FcIIIA-158VV genotype had the
highest peak levels of IL-6, IL-10, and MCP-1, whereas patients
with the FcIIIA-158FF genotype had the lowest peak values of
these 3 cytokines. There was no change in the hemolytic activity

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BLOOD, 1 NOVEMBER 2012 VOLUME 120, NUMBER 18

75 g/kg

100 g/kg

ROZROLIMUPAB IN PRIMARY IMMUNE THROMBOCYTOPENIA

125 g/kg 150 g/kg 200 g/kg

3673

250 g/kg 300 g/kg

Platelets10 /L

600
400
200
0
0 3 7

150 3 7

15 0 3 7

75 g/kg

100 g/kg

15 0 3 7 15 0 3 7
Day

15 0 3 7

125 g/kg 150 g/kg 200 g/kg

15 0 3 7

15

250 g/kg 300 g/kg

Hgb (g/dL)

18
16
14
12
10
8
0
0 3 7

150 3 7

15 0 3 7

15 0 3 7 15 0 3 7
Day

15 0 3 7

15 0 3 7

15

Figure 1. Effect of dose escalation of rozrolimupab on platelet and hemoglobin concentrations. Platelet responses (A) and corresponding values of hemoglobin in
individual patients (B) are shown. Continuous lines indicate patients treated without rescue medication; and dashed lines, patients who received rescue medication.

as measured by CH50 at the sampled time points (screening,


5-8 hours and day 7) for the 150-, 200-, 250-, or 300-g/kg cohorts.
Pretreatment values of D-dimer were within normal limits
across all dose groups (data not shown). A transient rise in the
concentration of D-dimer was seen in all cohorts in a dosedependent manner. The increase peaked at 24 hours after treatment
and returned toward baseline level by day 7 after treatment. The
largest increase was seen in a patient from the 300-g/kg cohort
(baseline: 0.166 g/mL; 24 hours: 9.41 g/mL). In the 300-g/kg
cohort, the D-dimer values returned to baseline levels after 7 days
in 5 of 13 patients. The rise in D-dimer levels was not associated
with clinical symptoms or changes in the other coagulation
parameters (prothrombin time, INR, fibrinogen and activated
partial thromboplastin time) or the hemolysis parameters (concentrations of hemoglobin, reticulocytes, haptoglobin, bilirubin, lactate dehydrogenase, and free hemoglobin).
SAEs were recorded in 9 patients during the trial. No SAEs
were recorded in the 125- or 300-g/kg cohorts. Four of these
events were assessed as related to rozrolimupab treatment: (1) a
decrease in hemoglobin concentration from 14.1 to 11.0 g/dL (mild
intensity) on day 8 was considered possibly related to rozrolimupab
treatment, lasted for 22 days, and recovered without treatment
(100-g/kg cohort); (2) extravascular hemolysis with reduction of
hemoglobin from 14.1 to 9.6 g/dL (severe intensity) with onset on
day 7 was reported in 1 patient in the 200-g/kg cohort who

received 2 blood transfusions; (3) increase in D-dimer (mild in


severity) with onset on the day of treatment and duration of 8 days
was reported in 1 patient in the 250-g/kg cohort; the patient had
no clinical symptoms; and (4) another case of increase in D-dimer,
reported as disseminated intravascular coagulation (DIC) of moderate severity, with onset on the infusion day was observed in the
250-g/kg cohort. The D-dimer levels returned toward baseline at
day 7, and the event was reported as probably related to trial drug.
The event was an isolated increase in D-dimer with no clinical
symptoms indicative of DIC.19
Platelet responses

Overall, there was a trend toward a dose-response with the


100-g/kg cohort as an outlier (Figure 1A). An analysis of platelet
response data by treatment groups is shown in Table 3. Across all
cohorts, 21 of 61 patients (34%) met the response criterion on day
7. The highest percentages of responders were seen in the 100- and
300-g/kg cohorts (70% and 62%, respectively). No patients from
the 75-g/kg cohort responded to the treatment. The highest
median platelet counts were recorded 7 days after treatment for all
patients (34 109/L), with the highest median values in the
300-g/kg cohort (130 109/L, range 15-634 109/L). Six weeks
after treatment, the median platelet count for all patients was
25 109/L. Again, the highest median platelet count after 6 weeks

Table 3. Number of patients with platelet responses on day 7 after a single dose of rozrolimupab
Dose of rozrolimupab

N
Responders,* no. (%)

75 g/kg

100 g/kg

125 g/kg

150 g/kg

200 g/kg

250 g/kg

11

10

10

13

0 (0.0)

7 (70.0)

2 (20.0)

2 (40.0)

2 (33.3)

3 (50.0)

8 (61.5)

*Only patients who did not receive rescue medication before day 8 are counted as responders.

300 g/kg

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3674

BLOOD, 1 NOVEMBER 2012 VOLUME 120, NUMBER 18

ROBAK et al

Table 4. Platelet responses over time for the 300-g/kg cohort


Time points

Responders,* no. (%)

2h

5-8 h

24 h

48 h

72 h

7d

14 d

0 (0.0)

3 (23.1)

4 (30.8)

6 (46.2)

8 (61.5)

8 (61.5)

7 (53.8)

*Only patients who did not receive rescue medication before the specific time points are counted as responders.

was recorded in the 300-g/kg cohort (35 109/L). Unlike the


other dose cohorts, the 300-g/kg dose was able to induce platelet
responses in both of 2 patients with baseline platelets 10 109/L.
The onset of platelet responses for the 300-g/kg cohort is
shown in Table 4. Already 5-8 hours after treatment, 23% of
patients had platelet responses. The number of patients with
platelet responses increased with time and peaked at 72 hours and
at day 7, where 8 of 13 patients had platelet responses (62%). The
median time to platelet response was 59 hours. The median duration of
the platelet response in the 300-g/kg cohort was 14 days.
No relationship between baseline hemoglobin concentrations
and platelet responses was found. For patients in the 300-g/kg
cohort, the relationship between platelet count at day 7 and
maximal decrease in hemoglobin concentration is shown in Figure
2. Linear regression with platelet count as dependent variable and
maximal decrease in hemoglobin concentration as predictor showed
a significant correlation (P .021; R2 0.40) between the absolute platelet count at day 7 and the maximal fall in hemoglobin
concentration. There was also a similar relationship between the
change in platelet count from baseline to day 7 and the maximal
decrease in hemoglobin concentration for this cohort (P .023;
R2 0.39; data not shown). No apparent relationships between
platelet response and FcRIIA or FcRIIIA genotype were found.
The majority of patients had a bleeding score of 0 or 1 during
the trial. Two patients with a WHO bleeding score of 2 at entry
recorded bleeding scores of 0 or 1 after treatment. Two other patients
with low platelet counts at baseline recorded scores 2 during the trial
and both received rescue medication.
Twenty-one of the 61 patients (34%) used rescue medication
during the trial, with IVIg and steroids (prednisolone or methylprednisolone) being the most commonly used. In the 300-g/kg dose
cohort, only 1 of 13 patients (8%) received rescue medication.
Pharmacokinetics and immunogenicity

Platelet change from baseline (109/L)

At 30 minutes after infusion, the maximal concentration of


rozrolimupab was 1% of the expected values as calculated by the
dose and plasma volume, arbitrarily set to 2.5 L, indicating that
rozrolimupab was already bound to RhD erythrocytes. Human
antihuman antibodies response of borderline magnitude was
observed in a single patient.
700
600
500
400
300
200
100
0
-100
-4.5

-4.0

-3.5
-3.0
-2.5
-2.0
-1.5
Maximum decrease in hemoglobin (g/dL)

-1.0

-0.5

Figure 2. The difference between baseline and day 7 hemoglobin concentration


(x-axis) and the corresponding values of platelet counts on day 7 (y-axis). The
graph represents the fitted linear regression line with 95% confidence limits.

Discussion
This dose escalation trial showed that rozrolimupab is active in
previously treated patients with ITP. The 300 g/kg was identified
as the optimal dose where 62% of patients achieved platelet
responses and only 1 of 13 patients needed rescue treatment.
Although a selection bias cannot be excluded as all patients in this
trial had responded to previous first-line treatment, this result
seems comparable with platelet responses after treatment with
plasma-derived anti-D7,8,20,21 and IVIg.6,22,23 Rozrolimupab demonstrated a rapid onset of effect, as 24% of patients treated with
300 g/kg had platelet responses within 24 hours, comparable with
observations after treatment with IVIg6 and anti-D at 75 g/kg.7
This rapid increase of platelets was associated with a reduced the
need for rescue medication and in the 300-g/kg cohort, where
only 1 patient (8%) received rescue medication during the trial. The
rapid increase of platelets in combination with a very short infusion
time of 15-20 minutes is an advantage for acute treatment of ITP in
nonsplenectomized patients with ITP.
The platelet responses to plasma-derived anti-D is dosedependent in terms of onset, magnitude, and duration,6,7 but not all
nonsplenectomized patients with ITP respond to the treatment.6,19,20,21,24 Response rates are generally high in children and in
young adults20 and generally lower in patients with pretreatment
platelet levels 10 109/L.6,24 The final dose of rozrolimupab
(300 g/kg) was established after dose escalation showing both a
trend toward dose-dependent platelet response (except for the
100-g/kg cohort) and a trend toward trend toward larger reductions of hemoglobin with increasing doses. In the 100-g/kg
cohort, the baseline platelet counts were numerically higher and
patients were younger compared with other cohorts. Both factors
may have contributed to the observed response rate of 70% at day
7. It is of note that the dose of 300 g/kg had a higher median
platelet count on day 7 than the other doses and elicited platelet
responses in patients with pretreatment platelet counts
10 109/L.
In this study, baseline hemoglobin levels did not correlate with
platelet responses, contrary to the findings of Scaradavou et al.24 In
this study, a significant correlation between the maximal fall in
hemoglobin concentration and the absolute platelet count at day
7 was found for patients in the 300-g/kg cohort. A similar
correlation was observed comparing the maximal reduction in
hemoglobin concentration and the change of platelets from baseline to day 7. If this correlation would be confirmed in a larger trial,
it may be possible to use the magnitude of the fall in hemoglobin
concentration as a predictor of response. During treatment with
plasma-derived anti-D, treatment doses of even 100 g/kg may be
beneficial in selected patients with absence of platelet responses at
lower doses.25 Further studies are needed to determine the therapeutic value of repeated rozrolimupab treatments for patients with ITP
with small reductions of hemoglobin concentration and lack of
platelet responses after treatment. In this study, we were not able to
confirm the predictive value of the FcIII genotypes for platelet

From bloodjournal.hematologylibrary.org by guest on April 2, 2014. For personal use only.


BLOOD, 1 NOVEMBER 2012 VOLUME 120, NUMBER 18

responses as reported by Cooper et al,5 most probably because of an


insufficient number of patients for this type of analysis.
The clinical value of any treatment for ITP lies in the rapidity
and duration of platelet concentration rise. Early onset and duration
of platelet response are important benchmarks for therapy with
anti-D. In this study, the median duration of response after
treatment with rozrolimupab was 2 weeks for the 300-g/kg
cohort. This observation is comparable with results obtained in
trials with IVIg.6,22,23 Most studies with anti-D reported an average
response duration of 3 weeks, although with large variations.7,20,21,24 However, a randomized study is needed to evaluate
the duration of response after treatment with rozrolimupab compared with IVIg or anti-D.
The safety profile of rozrolimupab was favorable. Approximately 75% of patients reported 1 or more AEs during the trial, but
75% of these 198 events were mild in intensity. It is of note that
only 20% of patients reported headaches after rozrolimupab
treatment. Most of the 16 events of headache were reported in the
75- or 100-g/kg cohorts, including 3 events of moderate intensity
and 1 of severe intensity. The majority of the headaches resolved on
the day of onset with little or no treatment. However, 1 patient had a
persistent headache for 20 days (treated with paracetamol) and
another had intermittent headaches over an 8-day period (not
treated). The prevalence (20%) and short duration of these headaches need confirmation in a randomized trial that include patients
with ITP treated with IVIg or anti-D.
Infusion reactions may occur during treatment with anti-D.6 In
this study, medications to alleviate possible infusion-related events
before the infusion of rozrolimupab were not planned per protocol.
Two events of pyrexia were reported in the same patient from the
75-g/kg cohort. All other treatment-related events of fever or
chills were reported in the 200-, 250-, or 300-g/kg cohorts. All
events were resolved on the day of onset, with the exception of one
event of pyrexia, which resolved after 33 hours. Fever and chills
coincided with the cytokine release that peaked 2-24 hours after the
infusion. The observation of maximal levels of IL-6, IL-10, and
MCP-1 among patients with the FcIIIA-158VV genotypes is in
accordance with previous findings.6
Based on the mechanism of action, some degree of extravascular hemolysis is an expected outcome of treatment with rozrolimupab. Approximately one-fourth of the patients had a fall in
hemoglobin concentration 2.5 g/dL, but dramatic changes
5.0 g/dL were not observed during the dose escalation. In the
highest dose group (300 g/kg), the hemoglobin concentration
returned to baseline in most patients within 28 days, and in this
dose cohort no blood transfusions were given. These observations
are in line with the reduction in hemoglobin concentration seen in
other trials of anti-D for ITP at 50-75 g/kg.7,20,21,24
Acute intravascular hemolysis and DIC have been described as
serious complications of anti-D treatment.26 It has been hypothesized that antibodies among anti-D preparations binding to blood
groups other than RhD may play a pathogenetic role for these
events.27 With rozrolimupab, containing only recombinant monoclonal antibodies specific to RhD, binding to antigens other than
RhD on the erythrocytes can be ruled out. Careful analysis of such
cases of intravascular hemolysis and DIC has, however, also
pointed to comorbidities among patients with ITP as risk factors
for the development of severe hemolysis and DIC.26-28 In this
study, frequent monitoring of coagulation parameters was
carried out, and a transient increase in D-dimer was observed
across all dose cohorts. This increase in D-dimer was not
accompanied by clinical symptoms or changes in other mea-

ROZROLIMUPAB IN PRIMARY IMMUNE THROMBOCYTOPENIA

3675

sured coagulation factors. A recent randomized study in patients


with ITP did not show changes in D-dimer levels after treatment
with IVIg and methylprednisolone, where patients in the
methylprednisolone treatment arm had low levels of protein S,
protein C, and antithrombin III that normalized after therapy.29
Similar changes of low levels of protein S and protein C after
treatment with methylprednisolone for ITP were demonstrated
in another recent report.30 The demonstrated changes in D-dimer
levels observed in the present study may represent compensatory mechanisms to maintain hemostasis, which merit further
exploration in future trials.
In conclusion, rozrolimupab is effective in the treatment of ITP
at a dose of 300 g/kg and exhibits a favorable safety profile at all
tested dose levels. Rozrolimupab has a rapid effect on platelet
levels that is sustained for a median of 14 days. Further randomized
studies are needed to compare the safety and efficacy of rozrolimupab with current treatment modalities for ITP, such as plasmaderived anti-D and IVIg.

Acknowledgments
The authors thank Jeff Craven, medical writer at Larix A/S, who
assisted in writing the remaining parts of the manuscript; as well as
the following collaborators who contributed to this study: Medical
University of Lodz and Copernicus Memorial Hospital, Lodz,
Poland: K. Chojnowski, M. Tybura; Instytut Hematologii i Transfuzjologii, Warsaw, Poland: S. Jurek, A. Sikorska; Werlhof Institut,
Hannover, Germany: T. Hobbel-Schnell, St Johannes Hospital,
Duisburg, Germany: M. Heinsch; Department of Hematology,
Cliniques Universitaires UCL de Mont-Godinne, Yvoir, Belgium:
A. Bosly, C. Chartelain, C. Graux, A. Sonet, F. Desquesnes; Department of Hematology, UZ Leuven, Belgium: J. Maertens, G. Verhoef, T. Devos, M. Delforge, D. Dierickx, S. Meers; Hospital la
Paz, Madrid, Spain: V. Jimenez-Yuste, M. Martin, M. G. Salvatierra; Hospital La Fe, Valencia, Spain: J. Palau, L. Senent; Hospital
General Universitario Gregorio Maranon, Madrid, Spain:
A. M. R. Huerta, C. P. Izquierdo; Department of Hematology and
Transplantology Medical University of Gdansk, Poland:
W. Prerjzner, M. Szarajko; Katedra i Klinika Hematologii, Onkologii i Chorob, Warsaw, Poland: J. Niesiobedzka-Krezel, M. Ziarkiewicz; Klinika Hematologii Nowotworow Krwi i Transplantologii
Szpiku, Wroclow, Poland: M. Podolak-Dawidziak, I. Prajs,
D. Urbaniak-Kujda; Clinic for Hematology and Clinical Immunology, Nis, Serbia: I. Cojbasic, V. Nikolic; Clinical Center Zemun,
Department for Hematology, Zemun, Serbia, Z. Cvetkovic,
A. Ivanovic, A. Novkovic, Z. Petrovic; Prof Dr Ion Chiricuta
Oncology Institute Hematology Clinic, Cluj-Napoca, Romania:
A. Bojan, A. Vasilache; Brasov Country Hospital, Romania: M. Lazaroiu, Davidoff Center; Beilinson Hospital, Petach Tikva, Israel:
A. Inbal, O. Bairey; Bnai-Zion Medical Center, Hematology Department, Haifa, Israel: R. Laor, L. Schliamser; Saint Petersburg State
Institution of Healthcare, Russia: N. Ilina, I. Samuskevich, T. Shelkovskaya; City Hospital #9, Department of Blood Systems Diseases,
Kiev, Ukraine: V. Mnyshenko, N. Tretyak; Gusak Academy of
AMS Ukraine, Donetsk, Ukraine: I. Lozhechnyk, S. Starchenko;
Department of Hematology, Catherine Lewis Center, Hammersmith Hospital, London, United Kingdom: D. Marin; Newcastle
Biomedicine Clinical Research Platforms Level 6, Newcastle On
Tyne, United Kingdom: J. Hanley; Kasturba Medical College
Hospital Manipal Center for Clinical Research, Karnataka, India:

From bloodjournal.hematologylibrary.org by guest on April 2, 2014. For personal use only.


3676

BLOOD, 1 NOVEMBER 2012 VOLUME 120, NUMBER 18

ROBAK et al

Y. Rao, M. Varma, S. Vidyasagar; Apollo Hospital AHERF Clinical Trial Unit, Andra Pradesh, India: P. Sripada; Aysha Hospital Pvt
Ltd, Chennai, India: Shabana; Swedish Orphan Biovitrum AB,
Stockholm, Sweden: M. Wiken, P. Hjalmstrom; and Symphogen
A/S, Lyngby, Denmark: U. Hansen.

Authorship
.-R.,
Contribution: T.R., J.W., J.T., M.v.D.P., A.G., C.D., A.J., M.T.A
I.J., J.L., G.P.R., A.H., W.W.J., K.K., L.M.G., D.C., A.C., E.G.,
M.L., O.S., D.A., E.K., K.S., K.V., N.C., K.T., M.P., P.S., and
T.P.R.B. identified and treated patients; H.N., N.J..S., T.P.F., and

P.S.A. developed analytical methods and assays to characterize the


rozrolimupab drug product; and T.R., M.F.F., and J.P. planned the
clinical trial, analyzed the data, and wrote major parts of the
manuscript.
Conflict-of-interest disclosure: The investigators received payments to cover trial-related expenses. H.N., N.J..S., T.P.F., P.S.A.,
M.F.F., and J.P. are employees of Symphogen A/S and have
received stock warrants. The remaining authors declare no competing financial interests.
Correspondence: Tadeusz Robak, Department of Hematology,
Medical University of Lodz, 93-513 Lodz, Pabianicka 62, Poland;
e-mail: robaktad@csk.umed.lodz.pl.

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