Further information and details on theNASH-CX results summarized above is available in public presentations posted to our website and filed with the SEC.
NASH-RX Trial:The NASH-RX Trial is a phase 3 trial of GR-MD-02 in NASH cirrhosis patients. We have met with the FDA to discuss the results of the NASH-CX trial in an End of Phase 2 meeting as disclosed in our May 14, 2018 press release. The proposed target population of the Phase 3 clinical trial will be patients with well compensated established NASH cirrhosis and portal hypertension.Patients will be selected based on criteria commonly used in clinical practice to identify patients with portal hypertension who are at risk of developing esophageal varices. Ongoing conversations with FDA included a recent Type C Meeting via teleconference with the Agency on February 6, 2019, to discuss Galectin’s proposal for use of progression to varices as the primary surrogate endpoint moving forward.
In the meeting, FDA confirmed that the Agency is supportive of the use of progression to varices as a potential surrogate endpoint and progression to large varices as a component of a composite clinical benefit endpoint pending additional requested information. Galectin will address and implement additional FDA requests and considerations for the Phase 3 trial, when and where possible. Given the newness of the endpoint and the new information to be generated in the trial, some information requested may not currently be available or may not be able to be addressed fully until data from the Phase 3 trial is available to address the information requests.
The focus and goal of the therapeutic program is to stop the progression of and reverse the fibrosis and/or portal hypertension in the liver and, thereby improve liver function and prevent the development of complications of fibrosis/cirrhosis and liver-related mortality in patients. The results of the NASH-CX trial substantiate that, subject to confirmation in later stage clinical trials, we believe that this goal is achievable in a significant portion of the NASH cirrhosis patient population i.e. those NASH cirrhosis patients with portal hypertension at risk of developing esophageal varices that may bleed and experience other decompensating events. The trial design has been refined with external consultants and sent out to potential CROs in a confidential Request for Proposal (RFP) process.
The final primary endpoint and additional aspects of the Phase 3 clinical trial design, including projected timing and costs will be announced once the final protocol is completed and filed with FDA. The study is a parallel group, randomized, placebo-controlled, double-blinded trial, of either 2 mg/kg or 4 mg/kg GR-MD-02 or placebo administered by i.v. infusion every two weeks for two years to NASH Cirrhosis patients who did not have esophageal varices at baseline. The surrogate endpoint is the proportion of patients in treatment groups who develop esophageal varices vs placebo after 2 years of treatment under an accelerated approval (Subpart H) pathway. Various secondary and exploratory endpoints are planned to be included which amongst other items may include HVPG determination in a subset of patients, liver biopsies to qualify the underlying disease state, various biomarkers, and digital video EGDs (esophagogastroduodenoscopy) at baseline and every six months thereafter. There will be adjudication panels/central readers for the critical endpoints. No interim analysis is included in the study design. Primary inclusion criteria is based on using modified Baveno VI criteria amongst other factors. This represents those criteria commonly used in clinical practice to identify patients with portal hypertension who are at risk of developing esophageal varices.
The key milestones and associated target dates for the NASH-RX trial are subject to change as are elements of design of the trial following FDA feedback on the recent submission. These target dates currently include: First Patient Fall, 2019; Enrollment Period Estimated: 12-14 months; Last Patient enrolled: Q4, 2020; Estimated Last Patient completion: Fall, 2022 and Top Line Data: around the end of 2022. The study will involve approximately 500 patients at up to 130 sites in 11 countries in North America, Europe, Asia, and Australia and will continue for two years of dosing.
Following a Request for Proposal process involving six global Contract Research Organizations (CROs), Covance has been selected as our CRO for the NASH- RX Phase 3 trial. Covance’s extensive experience in conducting clinical trials in liver-related diseases was an important consideration in evaluating CROs. We are particularly impressed by its work with clinical trials involving assessment and adjudication of video endoscopies, the critical variable of the primary endpoint in our Phase 3 trial. Covance has already begun extensive work on site and vendor startup activities. We are also including a NASH-specific site network to accelerate site startup and patient enrollment for this trial. The global medical team at Covance, together with our two co-primary investigators (Co-PI), who are also key opinion leaders in NASH, dedicated considerable time and effort to design and optimize the study design for success and to maximize the likelihood of attracting and retaining patients during the two years of extensive assessments and treatments. A startup agreement has been executed with Covance which allowed them to start work on protocols development, statistical analysis plans, support us in addressing some of FDAs questions, and to engage vendors for various activities in support of the NASH-RX trial.
We addressed FDAs questions from the February 2019 meeting in a large, detailed response which was submitted on July 17, 2019 to FDA for assessment of the revised Phase 3 protocol for using belapectin (GR-MD-02) for the treatment of compensated non-alcoholic steatohepatitis (NASH) cirrhosis without esophageal varices (the NASH-RX trial). The plans, which are subject to FDA’s acceptance of the submission for review and acknowledgement, were put forward via a Type C Written Response Only (WRO) submission to the U.S. Food and Drug Administration (FDA) with the goal of finalizing the protocol and initiating the Phase 3 trial in the fourth quarter of this year.
In our previous meeting with the FDA in February 2019, the Agency stated that while it is supportive of the potential use of progression to varices as a surrogate endpoint and progression to large varices as a component of a composite clinical benefit endpoint, several items should be addressed before it could agree on trial design and the endpoints. The purpose of the recent submission is to address these items and gain the FDA’s endorsement of the planned protocol.
In support of the Phase 3 protocol, at the request of the Agency, we have also submitted the current clinical development plan, a draft Phase 4 study synopsis, a draft SAP for the Phase 4 study, an esophagogastroduodenoscopy (EGD) procedure manual to standardize centralized evaluation of the primary and key secondary esophageal varices endpoints, and an updated Investigator Brochure suitable for international studies, as well as complete responses to the FDA’s comments from the previous meeting, including the justification for dose selection and foregoing a dedicated hepatic impairment study.
Cancer Immunotherapy. We believe there is potential for galectin inhibition to play a key role in the burgeoning area of cancer immunotherapy. For example, there have been several recent approvals of drugs that enhance a patient’s immune system to fight cancer. It is our goal to use a galectin inhibitor to further enhance the immune system function to fight cancer in a way that complements other approaches to this type of therapy. This hypothesis is supported by the fact thatgalectin-3 is expressed at high levels in multiple types of tumors, adds to the malignant nature of the tumors, and protects the tumors from immune system attack. Our drug candidates provide a promising new therapeutic approach to enhance the activity of the immune system against cancer cells. Preclinical studies have indicated thatGR-MD-02 enhances the immune response to cancer cells, increased tumor shrinkage and enhanced survival in immune competent mice with prostate, breast, melanoma and sarcoma cancers when combined with one of the immune checkpoint inhibitors,anti-CTLA-4 oranti-PD-1, or with the immune cell activator anti-OX40. These preclinical data led to the filing of two Investigator-sponsored INDs and the initiation of studies ofGR-MD-02 in combination with Yervoy® (ipilimumab) and KEYTRUDA (pembrolizumab) in Phase 1B studies of patients with metastatic melanoma. The KEYTRUDA trial has also been expanded to include patients withnon-small cell lung cancer and head and neck squamous cell carcinoma. These studies are being conducted under the sponsorship of Providence Portland Medical Center’s Earle A. Chiles Research Institute (EACRI).
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