Triple Therapy for Cystic Fibrosis Phe508del –Gating and –Residual Function Genotypes

Abstract

BACKGROUNDElexacaftor-tezacaftor-ivacaftor is a small-molecule cystic fibrosis transmembrane conductance regulator (CFTR) modulator regimen shown to be efficacious in patients with at least one Phe508del allele, which indicates that this combination can modulate a single Phe508del allele.In patients whose other CFTR allele contains a gating or residual function mutation that is already effectively treated with previous CFTR modulators (ivacaftor or tezacaftor-ivacaftor), the potential for additional benefit from restoring Phe508del CFTR protein function is unclear. METHODSWe conducted a phase 3, double-blind, randomized, active-controlled trial involving patients 12 years of age or older with cystic fibrosis and Phe508del-gating or Phe508del-residual function genotypes.After a 4-week run-in period with ivacaftor or tezacaftor-ivacaftor, patients were randomly assigned to receive elexacaftortezacaftor-ivacaftor or active control for 8 weeks.The primary end point was the absolute change in the percentage of predicted forced expiratory volume in 1 second (FEV 1 ) from baseline through week 8 in the elexacaftor-tezacaftor-ivacaftor group. RESULTSAfter the run-in period, 132 patients received elexacaftor-tezacaftor-ivacaftor and 126 received active control.Elexacaftor-tezacaftor-ivacaftor resulted in a percentage of predicted FEV 1 that was higher by 3.7 percentage points (95% confidence interval [CI], 2.8 to 4.6) relative to baseline and higher by 3.5 percentage points (95% CI, 2.2 to 4.7) relative to active control and a sweat chloride concentration that was lower by 22.3 mmol per liter (95% CI, 20.2 to 24.5) relative to baseline and lower by 23.1 mmol per liter (95% CI, 20.1 to 26.1) relative to active control (P<0.001 for all comparisons).The change from baseline in the Cystic Fibrosis Questionnaire-Revised respiratory domain score (range, 0 to 100, with higher scores indicating better quality of life) with elexacaftor-tezacaftor-ivacaftor was 10.3 points (95% CI, 8.0 to 12.7) and with active control was 1.6 points (95% CI, -0.8 to 4.1).The incidence of adverse events was similar in the two groups; adverse events led to treatment discontinuation in one patient (elevated aminotransferase level) in the elexacaftor-tezacaftor-ivacaftor group and in two patients (anxiety or depression and pulmonary exacerbation) in the active control group. CONCLUSIONSElexacaftor-tezacaftor-ivacaftor was efficacious and safe in patients with Phe508delgating or Phe508del-residual function genotypes and conferred additional benefit relative to previous CFTR modulators.(Funded by Vertex Pharmaceuticals; VX18-445-104 ClinicalTrials.govnumber, NCT04058353.