The Benefit/Risk Profile of AOP2014 in Low-risk Patients With PV (Low-PV)

The Benefit/Risk Profile of Pegylated Proline-Interferon Alpha-2b (AOP2014) Added to the Best Available Strategy Based on Phlebotomies in Low-risk Patients With Polycythemia Vera (PV). The Low-PV Randomized Trial

The Low-PV study is a multicenter, phase II, randomized trial aimed to assess whether the addition of Pegylated Proline-interferon-alpha-2b to the best therapeutic current strategy available based on phlebotomies and low dose acetylsalicylic acid (ASA) could improve the efficacy of treatment of patients with PV at low risk of thrombosis (younger than 60 years and without prior vascular events), in term of control of recommended level of hematocrit < 45%, over a period of 12 months.

It is an independent, investigator-generated, pragmatic trial including adult PV patients (aged 18-60) diagnosed according to World Health Organization 2008 criteria within the last 3 years before inclusion, without history of thrombosis and younger than 60 years ('low risk' patients). Eligible patients are randomized to be treated with the best available therapy (recommended for this risk class, standard arm) based on phlebotomy including administration of low-dose (100 mg/daily) of acetylsalicylic acid (ASA, when there are not contraindications) OR Pegylated Proline-Interferon alpha-2b (AOP2014) every 2 weeks in addition to the recommended available regimen (experimental arm), for up to 12 months. The allocation of patients to study arms is 1:1 and stratification at randomization will be performed according to age category (< 50 years old or > 50 years old) and time from diagnosis (naϊve or non-naϊve). Naive patients are defined as new cases coming to observation, diagnosed for the first time just before study entry and never treated; non-naive patients are old cases (diagnosis not older than 3 years before study entry) undergoing therapy with phlebotomy and/or low doses of ASA. Primary endpoint (PEp) is defined by the proportion (%) of patients who maintain the median value of hematocrit (HCT) below 45% during 12 months of treatment in each arm, without progression of disease and no need of any extra-protocol cytoreductive drug (responder patients). Secondary endpoints include evaluation of hematological and molecular response, histological remission and safety profile of the protocol therapy. Before randomization all patients undergo phlebotomies in order to reach an HCT below 45%. After randomization, according to current common clinical practice the regimen of phlebotomies must be selected accordingly to maintain the recommended level of HCT< 45%. Once normalization of the HCT has been achieved, blood counts at regular intervals (every 4 weeks) will establish the frequency of future phlebotomies. Sufficient blood is recommended to be removed in order maintain the hematocrit below 45%. Supplemental iron therapy should not be administered. All patients receive low-dose of ASA (100 mg/daily) as recommended by the current guidelines for low-risk subjects with PV. Patients allocated in the experimental group receive in addition a pre-filled auto-injection pen for the subcutaneous auto-administration (into the abdominal skin or the thigh) of 100 µg of Pegylated Proline-Interferon alpha-2b (AOP2014) once every 14 days. Patient visits are scheduled every month (4 weeks) for 12 months to assess and perform a reliable calculation of the primary end-point (% of patients with median HCT levels <45%). At each monthly visit a pre-filled auto-injection pen is delivered to the patients who have been randomized in the experimental arm. Assuming an expected drop-out rate of 12%, a total sample size of 150 patients (75 randomized in each group) will be randomized to reject the null hypothesis that the proportion of patients achieving the primary endpoint is 50% in favor of the alternative hypothesis that this proportion is 75% when AOP2014 is added to the phlebotomy based- therapy, with a power of 80% and an alpha error of 0.05 (two-tailed). Two interim-analysis are planned when 50 and 100 of randomized patients have completed the 12 months study, respectively, in order to evaluate and supervise both safety and primary endpoint. The Lan and DeMets (1983) spending function with O'Brien-Fleming type boundaries will be employed to preserve the overall two-sided type I error rate for effectiveness at the 0.05 level, regardless of the timing of the analysis. The results of the second interim analysis carried out at in April 2020 indicated a significant higher efficacy of the experimental arm than standard arm. The composite primary end-point was reached in 84% in patients of Ropeginterferon arm vs. 60% in standard arm (p=0.008, Odds Ratio=3.5, 95% CI: 1.3-10.4). This result, according to the statistical evaluation for futility and efficacy, reveals that , the null hypothesis is already been proven with first 100 patients randomized and cannot change in the future when 150 patients will enter the study. Therefore the data safety monitoring board and the steering committee agree that the accrual of new patients can be interrupted with 127 patients included. The primary endpoint assessment is performed after the completion of the first 12 months of therapy for all subjects enrolled ('core study'). A period of 12 months is expected for completion of the enrolment / randomization phase. The 'core study' itself will take 12 months of treatment per patient. Based on results from the 'core study' the extension phase will continue as follows: After 12 month patients who meet the primary endpoint following either conventional or experimental therapy will enter the extension phase and remain on their current regimen. non-responders, not meeting the primary endpoint after 12 months of conventional therapy will be switched to the experimental treatment. non-responder, not meeting the primary endpoint after 12 months of experimental therapy will be switched to conventional treatment. This extension phase will last for another 12 months from the Last Visit Last Patient included (LVLP) into the core study (matching cases 1 and 2 as defined above). Based on this, the overall length of the study is expected to cover a period of 36 months from the First Patient Included (FPI).

Conventional treatment based on phlebotomies, low dose (100 mg) of acetylsalicylic acid (ASA) plus the addition of 100 µg of Pegylated Proline-Interferon alpha-2b (AOP2014) once every 14 days (subcutaneously).

AOP2014 will be supplied to the patients as pre-filled auto-injection pens, containing 250 µg of active drug (0.5 ml solution for injection). One pen may be used twice within a time period of 4 weeks. Hence investigators will provide one prefilled pen at every monthly visit. AOP2014 will be self-injected subcutaneously by patients once every 14 days at the single doses of 100 µg (0.2 ml).

According to current common clinical practice the regimen must be selected accordingly to maintain the recommended level of HCT< 45%. Once normalization of the hematocrit has been achieved, blood counts at regular intervals (every 4 weeks) will establish the frequency of future phlebotomies. Sufficient blood should be removed to maintain the hematocrit below 45%.

100 mg/daily of ASA is recommended (when there are not contraindications) according with current guidelines for this risk class of patients

Number of patients who maintains the median value of HCT< 45%, along 12 months, on number of patients randomized in each arm, per cent

For each patient the median value of HCT percentage will be calculated from all measurements detected and reported every month (from baseline to 12-month visit or study end). A patient will be defined as responder (achieving PEp) when he maintains the median value of HCT < 45%, after undergoing treatments according to this protocol, for up 12 months. A patient will be defined as non-responder (not achieving PEp) when Does not maintain the median value of HCT < 45%, after undergoing treatments according to this protocol, for up 12 months, or Is in need of any additional chemotherapeutic and/or cytoreductive treatment aimed to manage disease due to disease progression.

The total number of phlebotomies will be calculated for each patients during 12 months of therapy (and then 24 months); Based on values obtained from point (1) in each arm-group of patients, the median number of phlebotomies performed in each therapy group will be calculated (and compared) after 12 and 24 months of therapy (or completion of the study)

Number of patients achieving hematological response (as defined below in 'Description') on number of patients randomized in each arm, per cent,

For each patient the median value of HCT (%), absolute white blood cells (WBCs) count and absolute platelets (PLTs) count will be calculated from all measurements detected and reported at least every month (from baseline to 12-month visit and then to 24-month visit/study completion). A patient will be defined as achieving hematological response when the median values of HCT < 45%, WBCs count < 10 x10*9/L and PLTs count < 400 x10*9/L is observed after 12 months of therapy (or 24 months). The proportion of patients who maintains this response after 24 months (or study completion) will be calculated (and compared) in each arm.

The proportion (rate per cent) of patients with not palpable spleen will be calculated in each arm as the ratio of number of patients with resolution of splenomegaly or persistence of not palpable spleen at palpation with respect to baseline, on number of patients randomized in each arm, after 12 and 24 months (study completion) of therapy, per cent.

Quantitative Janus kinase-2 measurements (central lab facility) will be performed at baseline and after 12 months of therapy for all patients; Janus kinase-2 assessment will be performed also after 24 months for patients receiving interferon (experimental therapy). Reduction of allele burden in each patient (with respect to baseline) will be assessed according to Jovanovic et al, Leukemia 2013. The proportion (rate per cent) of patients with Janus kinase-2 allele burden reduction or remission will be calculated in each arm (and compared).

Defined as presence of age-adjusted normocellularity and disappearance of trilinear hyperplasia, and absence of >grade 1 reticulin fibrosis. It will be assessed in each patient and then the proportion (rate per cent) of patients with bone marrow histological remission will be calculated in each arm (and compared).

The number of events will be recorded any time during the study in order to assess the frequency ,every 12 months and at completion of the study, and their incidence in each arm and whole population. Comparison between arms will be performed.

Incidence, causality and intensity of clinical relevant adverse events will be assessed in each arm and compared all over the study. The rate of assigned treatment withdrawal due to any protocol drug-related toxicity occurred any time will be compared. Number of adverse events, expressed as frequency in each arm, will be calculated (as ratio of number of patient experiencing adverse on the the number of patients randomized in each arm) and compared

Impact of PV and therapy on subjects will be evaluated through assessment of symptoms burden using Functional Assessment of cancer Therapy-Anaemia (FACT-An) and Myeloproliferative Neoplasm Symptom Assessment Form total symptom score (MPN-SAF TSS) questionnaires, that will be administered to subjects trimonthly

Inclusion Criteria: Age 18-60 years Diagnosis of Polycythemia Vera according to World Health Organization 2016 criteria Diagnosis of Polycythemia Vera including a recent bone marrow (BM) biopsy (performed within 3 years prior randomization in the study) and never treated with cytoreductive drugs HCT<45% Ability and willingness to comply with all study requirements Signed written informed consent. Exclusion Criteria: Any previous well documented cardiovascular PV-related events (see Appendix 1 for description) Previous cytoreductive drugs Known hypersensitivity or contraindications to the Investigational Medicinal Product (Pegylated Proline-Interferon alpha-2b) including: evidence of severe retinopathy (e.g. cytomegalovirus retinitis, macular degeneration) or clinically relevant ophthalmological disorder (due to diabetes mellitus or hypertension); thyroid dysfunction not adequately controlled; patients tested positively with Thyroglobulin antibody and / or TPOAb at screening; documented autoimmune disease at screening or in the medical history; history or presence of depression requiring treatment with antidepressant; any risk of suicide at screening or previous suicide attempts; Previous exposure to a non-pegylated or pegylated interferon α Clinically relevant pulmonary infiltrates, pneumonia, and pneumonitis Systemic infections, e.g. hepatitis B, hepatitis C, or HIV at screening Significant liver (AST or alanine aminotransferase > 2.5 times ULN) or renal disease (creatinine > 2 mg/ml) Presence of any life-threatening condition or of any disease (e.g. cancer) that is likely to significantly shorten life expectancy History of active substance or alcohol abuse within the last year Any condition that in the opinion of the investigator would jeopardize the evaluation of efficacy or safety or be associated with poor adherence to the protocol Pregnant or lactating women and women*/men of childbearing potential who are not using or are not willing to use any effective means of contraception (i.e. sexual abstinence, hormonal contraceptive, intra-uterine device, barrier method such as diaphragms or condoms, surgical methods). Pregnancy test will be performed in order to ascertain negativity of human chorionic gonadotropin (β-hCG) test and confirm that childbearing women are not pregnant.

U.O. Ematologia, Ospedale Casa Sollievo della Sofferenza Istituto di Ricovero e Cura a Carattere Scientifico

UCSC Ematologia, Fondazione Policlinico Universitario "Agostino Gemelli"Università Cattolica del Sacro Cuore

Unità Operativa Complessa di Emostasi Azienda Ospedaliero-Universitario "Policlinico Vittorio-Emanuele - Presidio Ospedaliero Ferrarotto

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