-
In February 2013, GlaxoSmithKline (GSK) announced a commitment
to further clinical transparency through the public disclosure of
GSK Clinical Study Reports (CSRs) on the GSK Clinical Study
Register.
The following guiding principles have been applied to the
disclosure: Information will be excluded in order to protect the
privacy of patients and all namedpersons associated with the
study
Patient data listings will be completely removed* to protect
patient privacy. Anonymized
data from each patient may be made available subject to an
approved research
proposal. For further information please see the Patient Level
Data section of the GSK
Clinical Study Register. Aggregate data will be included; with
any direct reference to individual patients excluded
*Complete removal of patient data listings may mean that page
numbers are no longer consecutively
numbered
-
Stiefel, a GSK company
Calcipotriene Foam 0.005%, U0267-302 Clinical Study Report
Page 1
STIEFEL CONFIDENTIAL
A Multicenter, Randomized, Double-Blind, Phase 3 Study of the
Safety and Efficacy of
Emulsion Formulation Calcipotriene Foam, 0.005%, versus Vehicle
Foam in Subjects
with Plaque-type Psoriasis
Clinical Study Report U0267-302
Version 1.0
13 Aug 2009
Sponsored by:
Stiefel, a GSK company (“Stiefel”)
3160 Porter Drive
Palo Alto, CA 94304
USA
Conducted by:
Stiefel
3160 Porter Drive
Palo Alto, CA 94304
USA
THIS DOCUMENT CONTAINS CONFIDENTIAL AND/OR TRADE SECRET
INFORMATION THAT IS DISCLOSED ONLY IN CONNECTION WITH THE
LICENSING AND/OR REGISTRATION OF PRODUCTS FOR STIEFEL OR ITS
AFFILIATED COMPANIES. THIS DOCUMENT SHOULD NOT BE DISCLOSED
OR USED, IN WHOLE OR IN PART, FOR ANY OTHER PURPOSE WITHOUT
THE PRIOR WRITTEN CONSENT OF STIEFEL.
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Stiefel, a GSK company
Calcipotriene Foam 0.005%, U0267-302 Clinical Study Report
Page 2
STIEFEL CONFIDENTIAL
1 TITLE PAGE
A Multicenter, Randomized, Double-Blind, Phase 3 Study of the
Safety and Efficacy
of Emulsion Formulation Calcipotriene Foam, 0.005%, versus
Vehicle Foam in
Subjects with Plaque-type Psoriasis
Name of Investigational
Product
Emulsion Formulation Calcipotriene Foam 0.005%
Indication Plaque-type psoriasis
Sponsor Stiefel.
Protocol/Study Number U0267-302
Development Phase 3
Study Initiation Date 22 April 2008 (first subject, first
visit)
Study Completion Date 26 December 2008 (last subject, last
visit)
Sponsor’s Responsible
Medical Officer
, MD
Executive Director, Global Clinical Research
Stiefel.
Responsible Signatory , MD
Executive Director, Global Clinical Research
Stiefel.
Date of the report 13 Aug 2009
This study was performed in accordance with Good Clinical
Practices, including guidelines outlined by the
International Conference on Harmonisation.
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Stiefel, a GSK company
Calcipotriene Foam 0.005%, U0267-302 Clinical Study Report
Page 3
STIEFEL CONFIDENTIAL
2 SYNOPSIS
NAME OF SPONSOR/COMPANY:
Stiefel. INDIVIDUAL STUDY
TABLE REFERRING TO
PART OF THE DOSSIER
(FOR NATIONAL
AUTHORITY USE
ONLY)
NAME OF FINISHED PRODUCT:
Emulsion Formulation Calcipotriene Foam 0.005%
Volume:
Page:
NAME OF ACTIVE INGREDIENT:
Calcipotriene
Title of study: A Multicenter, Randomized, Double-Blind, Phase 3
Study of the Safety and Efficacy of
Emulsion Formulation Calcipotriene Foam, 0.005%, versus Vehicle
Foam in Subjects with Plaque-type
Psoriasis
Investigators: A complete list of investigators who participated
in this multicenter study is presented within
appendix 16.1.4, List and Description of Investigators and Other
Important Participants in the Study.
Study centers: This study was conducted at 12 study centers in
the United States. A complete list of the
names and addresses of study centers that participated in this
multicenter study are presented within
appendix 16.1.4, List and Description of Investigators and Other
Important Participants in the Study.
Publication (reference): None
Study initiation/completion dates:
First subject, first visit: 22 Apr 2008
Last subject, last visit: 26 Dec 2008
Phase of
Development: 3
Objectives: To evaluate the safety and efficacy of Emulsion
Formulation Calcipotriene Foam compared to
vehicle foam in subjects with plaque-type psoriasis.
Methodology: This was a multicenter, randomized, double-blind,
phase 3 study comparing calcipotriene
foam to vehicle foam in subjects with plaque-type psoriasis.
Application areas included psoriatic areas of the
body excluding those on the face and scalp. If new psoriatic
lesions appeared during the treatment period,
they were dosed as well. Subjects were randomized to 1 of 2
groups in a 2:1 ratio (calcipotriene foam: vehicle
foam). All study product was administered twice daily (morning
and evening) for 8 weeks. Visits occurred at
baseline, week 2, week 4, and week 8. Stiefel personnel,
investigators, subjects, and nurses/coordinators were
blinded to the study product assignment.
Number of subjects (planned and analyzed):
Planned: 327
Enrolled: 330
Treated: 323
Analyzed: Intent to treat (ITT) analysis set: 323
Per protocol (PP) analysis set: 261
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Stiefel, a GSK company
Calcipotriene Foam 0.005%, U0267-302 Clinical Study Report
Page 4
STIEFEL CONFIDENTIAL
NAME OF SPONSOR/COMPANY:
Stiefel. INDIVIDUAL STUDY
TABLE REFERRING TO
PART OF THE DOSSIER
(FOR NATIONAL
AUTHORITY USE
ONLY)
NAME OF FINISHED PRODUCT:
Emulsion Formulation Calcipotriene Foam 0.005%
Volume:
Page:
NAME OF ACTIVE INGREDIENT:
Calcipotriene
Diagnosis and Main Criteria for Inclusion: Subjects meeting all
of the following criteria were eligible for
enrolment:
1. Male or female subjects at least 12 years old and in good
general health.
2. Mild to moderate plaque-type psoriasis, as defined by an
Investigator’s Static Global Assessment (ISGA) score of 2 or 3 at
baseline.
3. Mild to moderate plaque-type psoriasis involving 2% to 20% of
total body surface area (BSA) (excluding the face and scalp).
4. Identification of a target lesion (>2 cm²) on the trunk or
extremities with a score of 2 or 3 on a 0 to 5 scale for each of
erythema, scaling, and plaque thickness. Lesions on palms/soles,
knees,
elbows, and intertriginous areas were not used as the target
lesion site.
Test Product, Dose and Mode of Administration, Batch No.:
Calcipotriene foam containing 0.005% calcipotriene in an
emulsion formulation foam vehicle, applied to
affected areas of skin twice daily, batch ZLS-C.
Duration of Study: Eight weeks.
Reference Therapy, Dose and Mode of Administration, Batch
No.:
Vehicle foam with identical ingredients and packaging as
calcipotriene foam but without the active ingredient
calcipotriene, applied to affected areas of skin twice daily,
batch ZLP-C.
Criteria for Evaluation:
Primary Efficacy Endpoint: The proportion of subjects who
achieved the following at week 8:
An ISGA score of clear (0) or almost clear (1), and
A minimum improvement in the ISGA score of 2 grades from
baseline to week 8.
Subjects with missing efficacy evaluations at week 8 were
considered to be treatment failures.
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Stiefel, a GSK company
Calcipotriene Foam 0.005%, U0267-302 Clinical Study Report
Page 5
STIEFEL CONFIDENTIAL
NAME OF SPONSOR/COMPANY:
Stiefel. INDIVIDUAL STUDY
TABLE REFERRING TO
PART OF THE DOSSIER
(FOR NATIONAL
AUTHORITY USE
ONLY)
NAME OF FINISHED PRODUCT:
Emulsion Formulation Calcipotriene Foam 0.005%
Volume:
Page:
NAME OF ACTIVE INGREDIENT:
Calcipotriene
Criteria for Evaluation (continued):
Key Secondary Efficacy Endpoints: The proportion of subjects who
achieved each of the following at week 8:
A target lesion score of 0 or 1 for erythema and at least a
2-grade improvement from baseline.
A target lesion score of 0 or 1 for scaling and at least a
2-grade improvement from baseline.
A target lesion score of 0 for plaque thickness.
An ISGA score of 0 or 1.
In addition, the primary endpoint was analyzed by baseline ISGA
score.
Additional Efficacy Endpoints:
Mean percent reduction in the percent of BSA involvement of
psoriasis at each visit.
The change in Dermatology Life Quality Index (DLQI) or
Children's DLQI (CDLQI) from baseline to week 8.
The proportion of subjects who had a Subject's Global Assessment
(SGA) score of 0 or 1 at each visit.
The primary and all key secondary endpoints by visit.
Safety was assessed by evaluation of adverse events (AEs), vital
signs, pregnancy, and concocmitant
medications.
Statistical Methods:
The primary efficacy endpoint was analyzed to test the
superiority of calcipotriene foam over vehicle foam
using the Cochran-Mantel-Haenszel (CMH) procedure stratified by
study center with a 2-sided 0.05
significance level. Consistency of the results across
investigative centers for the primary endpoint was verified
using the Breslow-Day test of homogeneity of the odds ratios,
using a 0.10 significance level. The ITT
analysis set (all subjects who received study product) was used
for the primary endpoint analysis; subjects
with missing week 8 efficacy evaluations were considered to be
treatment failures. Two additional sensitivity
analyses were performed for the primary endpoint, 1 using the PP
analysis set and the other using the ITT
analysis set where subjects with missing week 8 efficacy
assessments had their last non-missing response
carried forward.
The first 4 key secondary efficacy endpoints were analyzed using
the CMH procedure stratified by study
center. In the event that the primary analysis was significant
at the 0.05 level, the Holm stepwise closed
testing procedure was used to control multiplicity.
The final key secondary endpoint was primary endpoint by
baseline ISGA. It was analyzed using the CMH
procedure stratified by study center with a two-sided 0.05
significance level.
The additional efficacy endpoints were analyzed by analysis of
covariance (percent reduction in BSA
involvement, change in DLQI) or by the CMH procedure (SGA
score).
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Stiefel, a GSK company
Calcipotriene Foam 0.005%, U0267-302 Clinical Study Report
Page 6
STIEFEL CONFIDENTIAL
NAME OF SPONSOR/COMPANY:
Stiefel. INDIVIDUAL STUDY
TABLE REFERRING TO
PART OF THE DOSSIER
(FOR NATIONAL
AUTHORITY USE
ONLY)
NAME OF FINISHED PRODUCT:
Emulsion Formulation Calcipotriene Foam 0.005%
Volume:
Page:
NAME OF ACTIVE INGREDIENT:
Calcipotriene
SUMMARY – CONCLUSIONS
Demographic and Baseline Characteristics: The mean subject age
was 47.8 years (range, 12 to 88 years);
48% of subjects were male and 91% were White. There were no
meaningful differences between the
treatment groups in baseline disease characteristics.
Efficacy Results: Primary endpoint: The primary efficacy
endpoint was the percentage of subjects in the ITT analysis set
with
treatment success, defined as having an ISGA score of clear (0)
or almost clear (1) at week 8 and a minimum
improvement in the ISGA score of 2 grades from baseline to week
8. In the ITT analysis set, the proportion of
subjects achieving treatment success was higher in the
calcipotriene foam group than in the vehicle foam
group (27% of subjects versus 16%); this difference was
statistically significant (P = 0.016).
An additional analysis examined the primary endpoint in the PP
analysis set In the PP analysis set, treatment
success was achieved by 32% of calcipotriene foam group subjects
and 16% of vehicle foam group subjects
(P = 0.004).
An additional sensitivity analysis of the primary endpoint was
performed on the ITT analysis set using last
observation carried forward (LOCF). Sixty subjects (28%) in the
calcipotriene foam group achieved treatment
success compared with 17 subjects (16%) in the vehicle foam
group (P = 0.010, CMH test stratified by pooled
center).
At the request of the FDA, a post hoc sensitivity analysis of
the primary endpoint was performed on the ITT
analysis set. This analysis included only those subjects who had
a non-missing week 8 efficacy evaluation.
Fifty-eight subjects (31%) in the calcipotriene foam group
achieved treatment success compared with
17 subjects (18%) in the vehicle foam group (P = 0.010).
Key secondary endpoints: The analysis of 4 key secondary
endpoints in the ITT analysis set gave results
consistent between these endpoints: in each analysis, more
subjects in the calcipotriene foam group achieved
the endpoint than in the vehicle foam group. For 1 endpoint (a
target lesion score of 0 or 1 for scaling and at
least a 2-grade improvement from baseline at week 8), the
difference between groups was considered to be
statistically significant after multiplicity testing (P =
0.004). These analyses in the PP analysis set gave
similar results. Analysis of a final key secondary endpoint in
the ITT analysis set showed that for subjects
with a baseline ISGA score of 3 (moderate), more subjects in the
calcipotriene foam group achieved the
primary endpoint than in the vehicle foam group (32% versus 17%,
P = 0.015). The results for the PP analysis
set were similar (38% versus 19%, P = 0.013).
Additional efficacy analyses: The analysis of primary and
secondary endpoints by time point, and of
reduction in percent BSA involvement by time point showed that,
for both analyses and all time points, the
calcipotriene foam group showed greater improvement than the
vehicle foam group.
Quality-of-life/Pharmacoeconomic Results: Two additional
analyses addressed quality-of-life (QOL) endpoints: proportion of
subjects with an SGA score
of 0 or 1 by time point, and change in DLQI from baseline to end
of treatment. Neither of these analyses
showed a difference between the treatment groups.
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Stiefel, a GSK company
Calcipotriene Foam 0.005%, U0267-302 Clinical Study Report
Page 7
STIEFEL CONFIDENTIAL
NAME OF SPONSOR/COMPANY:
Stiefel. INDIVIDUAL STUDY
TABLE REFERRING TO
PART OF THE DOSSIER
(FOR NATIONAL
AUTHORITY USE
ONLY)
NAME OF FINISHED PRODUCT:
Emulsion Formulation Calcipotriene Foam 0.005%
Volume:
Page:
NAME OF ACTIVE INGREDIENT:
Calcipotriene
Safety Results: Adverse events were no more frequent in the
calcipotriene foam group than in the vehicle foam group (18% of
subjects vs. 20% respectively), and the 2 treatment groups did
not differ meaningfully in the distribution of
AEs according to system organ class (SOC). In the calcipotriene
foam group, the most common AEs were
application site-related, while in the vehicle foam group the
most common AEs were in the Infections and
Infestations SOC (only 1 of which was at the application site).
Adverse events considered by the investigator
to be related to the study product occurred with similar
frequencies in the calcipotriene foam group (6% of
subjects) and the vehicle foam group (5%). Adverse events rated
as severe in intensity were reported in 2% of
subjects in each treatment group.
There were no deaths during this study. Only one subject
experienced an SAE, deafness unilateral, which was
considered to be not related to study product. This subject was
in the vehicle foam group.
Seven subjects (3%) in the calcipotriene foam group and 1
subject (1%) in the vehicle foam group
discontinued the study due to AEs. Within both groups, all of
the AEs resulting in discontinuation were
application site-related.
Conclusions: Calcipotriene foam appears to be effective, safe,
and well-tolerated when used for 8 weeks for
treatment of plaque-type psoriasis in areas excluding the face
and scalp in the population studied.
Date of the report: 13 Aug 2009
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Page 8
STIEFEL CONFIDENTIAL
3 TABLE OF CONTENTS
1 TITLE PAGE
................................................................................................................
2
2 SYNOPSIS
....................................................................................................................
3
3 TABLE OF CONTENTS
..............................................................................................
8
3.1 List of In-Text Tables
.........................................................................................
12
4 LIST OF ABBREVIATIONS
.....................................................................................
14
5
ETHICS.......................................................................................................................
16
5.1 Independent Ethics Committee (IEC) or Institutional Review
Board (IRB) ...... 16
5.2 Ethical Conduct of Study
....................................................................................
16
5.3 Subject Information and Consent
........................................................................
17
5.4 Compliance Statement
........................................................................................
17
6 INVESTIGATORS AND STUDY ADMINISTRATIVE STRUCTURE
................. 18
7 INTRODUCTION
......................................................................................................
19
8 STUDY OBJECTIVES
...............................................................................................
21
9 INVESTIGATIONAL PLAN
.....................................................................................
22
9.1 Overall Study Design and Plan
...........................................................................
22
9.2 Discussion of Study Design
................................................................................
22
9.3 Selection of Study Population
.............................................................................
22
9.3.1 Inclusion Criteria
................................................................................................
22
9.3.2 Exclusion Criteria
...............................................................................................
23
9.3.3 Removal of Subjects from Therapy or Assessment
............................................ 24
9.3.3.1 Subject Discontinuation
..............................................................................
24
9.3.3.2 Subject Dropout
..........................................................................................
24
9.3.3.3 Screen Failures
............................................................................................
24
9.4 Study Product(s)
..................................................................................................
25
9.4.1 Study Products Administered
.............................................................................
25
9.4.2 Dose Modification
..............................................................................................
25
9.4.3 Identity of Study Product(s)
................................................................................
25
9.4.4 Method of Assigning Subjects to Groups
........................................................... 26
9.4.5 Selection of Doses in the Study
..........................................................................
26
9.4.6 Blinding
...............................................................................................................
26
9.4.7 Unblinding
..........................................................................................................
26
9.4.8 Prior and Concomitant Therapy
..........................................................................
26
9.4.8.1 Prohibited Concomitant Therapies
.............................................................
27
9.4.8.2 Permitted Concomitant
Therapies...............................................................
27
9.4.9 Treatment Compliance
........................................................................................
27
9.5 Efficacy and Safety Variables
.............................................................................
27
9.5.1 Efficacy Evaluations
...........................................................................................
27
9.5.2 Laboratory Evaluations
.......................................................................................
28
9.5.3 Safety Evaluations
..............................................................................................
28
9.5.4 Schedule of Study Procedures
............................................................................
28
9.5.5 Interim Visits and Post-Study Visits
...................................................................
32
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9.5.6 Primary Efficacy Endpoint
.................................................................................
32
9.5.7 Key Secondary Efficacy Endpoints
....................................................................
32
9.5.8 Additional Efficacy Endpoints
............................................................................
33
9.6 Data Quality Assurance
......................................................................................
33
9.6.1 Study Monitoring
................................................................................................
33
9.6.2 Source Data Verification
.....................................................................................
34
9.6.3 Quality Assurance Audits
...................................................................................
34
9.6.4 Direct Access, Data Handling, and Record-Keeping
.......................................... 34
9.6.4.1 Case Report Forms
......................................................................................
34
9.6.4.2 Data
Protection............................................................................................
34
9.7 Statistical Methods Planned in the Protocol and
Determination of Sample Size34
9.7.1 Statistical and Analytical Plans
...........................................................................
35
9.7.1.1 Primary Efficacy Endpoint
.........................................................................
35
9.7.1.2 Key Secondary Efficacy Endpoints
............................................................ 35
9.7.1.3 Additional Efficacy Endpoints
....................................................................
36
9.7.1.4 Safety Analysis
...........................................................................................
36
9.7.2 Determination of Sample Size
............................................................................
37
9.7.3 Analysis Sets
.......................................................................................................
37
9.8 Changes in the Conduct of the Study or Planned Analyses
................................ 38
10 STUDY SUBJECTS
...................................................................................................
39
10.1 Disposition of Subjects
.......................................................................................
39
10.2 Protocol Deviations
.............................................................................................
39
11 EFFICACY EVALUATION
......................................................................................
41
11.1 Data Sets Analyzed
.............................................................................................
41
11.2 Demographic and Other Baseline Characteristics
.............................................. 41
11.2.1 Demographics
.....................................................................................................
41
11.2.2 Disease Characteristics
.......................................................................................
43
11.2.3 Concomitant Medications
...................................................................................
44
11.3 Measurements of Dosing/Application Compliance
............................................ 46
11.4 Efficacy Results and Tabulations of Individual Subject Data
............................ 47
11.4.1 Analysis of Efficacy
............................................................................................
47
11.4.1.1 Primary Efficacy Endpoint
.....................................................................
47
11.4.1.2 Key Secondary Efficacy Endpoints
........................................................ 50
11.4.1.3 Additional Efficacy Analyses
.................................................................
53
11.4.2 Statistical/Analytical Issues
................................................................................
58
11.4.2.1 Adjustments for
Covariates.....................................................................
58
11.4.2.2 Handling of Dropouts or Missing Data
................................................... 58
11.4.2.3 Interim Analyses and Data
Monitoring...................................................
59
11.4.2.4 Multicenter Studies
.................................................................................
59
11.4.2.5 Multiple Comparisons/Multiplicity
........................................................ 59
11.4.2.6 Use of an Efficacy Subset of Subjects
.................................................... 59
11.4.2.7 Examination of Subgroups
......................................................................
60
11.4.3 Tabulation of Individual Response Data
.............................................................
60
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STIEFEL CONFIDENTIAL
11.4.4 Product Dose, Product Concentration, Relationships to
Response, and
Mechanism of Action
..........................................................................................
60
11.4.5 By-Subject Displays
............................................................................................
60
11.4.6 Efficacy Conclusions
..........................................................................................
60
12 SAFETY EVALUATION
..........................................................................................
62
12.1 Extent of Exposure
..............................................................................................
62
12.2 Adverse Events
...................................................................................................
64
12.2.1 Brief Summary of Adverse Events
.....................................................................
64
12.2.2 Display of Adverse Events
..................................................................................
64
12.2.3 Analysis of Adverse Events
................................................................................
65
12.2.3.1 Adverse Events by Relationship to Study Product
................................. 65
12.2.3.2 Severe Adverse Events
...........................................................................
67
12.2.4 Listing of Adverse Events by Subject
.................................................................
68
12.3 Deaths, Other Serious Adverse Events, and Other Significant
Adverse Events 68
12.3.1 Deaths
.................................................................................................................
68
12.3.2 Other Serious Adverse Events
............................................................................
68
12.3.3 Other Significant Adverse Events
.......................................................................
68
12.3.3.1 Adverse Events Leading to
Discontinuation........................................... 68
12.3.4 Listing of Deaths, Other Serious Adverse Events, and
Other Significant
Adverse Events
...................................................................................................
69
12.3.5 Narratives of Deaths, Other Serious Adverse Events, and
Certain Other
Significant Adverse Events
.................................................................................
69
12.3.6 Analysis and Discussion of Deaths, Other Serious Adverse
Events, and
Other Significant Adverse Events
.......................................................................
69
12.4 Clinical Laboratory Evaluation
...........................................................................
69
12.5 Vital Signs, Physical Findings, and Other Observations
Related to Safety ........ 69
12.6 Safety Conclusions
..............................................................................................
71
13 DISCUSSION AND OVERALL CONCLUSIONS
................................................... 72
13.1 Discussion
...........................................................................................................
72
13.2 Overall Conclusions
............................................................................................
72
14 TABLES, FIGURES AND GRAPHS REFERRED TO BUT NOT INCLUDED
IN THE TEXT
............................................................................................................
73
14.1 Subject Disposition and Demographic Data
....................................................... 73
14.2 Efficacy
Data.......................................................................................................
74
14.3 Safety Data
..........................................................................................................
75
14.4 Other Data
...........................................................................................................
76
14.5 Narratives of Deaths, Other Serious and Significant Adverse
Events ................ 77
14.5.1 Deaths
.................................................................................................................
77
14.5.2 Other Serious Adverse Events
............................................................................
77
15 REFERENCE LIST
....................................................................................................
78
16 APPENDICES
............................................................................................................
79
16.1 Study Information
...............................................................................................
80
16.1.1 Protocol and Protocol Amendments
...................................................................
80
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16.1.2 Sample Case Report Form
..................................................................................
81
16.1.3 List of Independent Ethics Committees
(IECs)/Institutional Review Boards
(IRBs) and Sample Consent Forms/Subject Information Sheets
........................ 82
16.1.4 List and Description of Investigators and Other Important
Participants in the
Study
...................................................................................................................
83
16.1.5 Signatures of Principal or Coordinating Investigator(s)
or Sponsor’s
Responsible Medical Officer
..............................................................................
84
16.1.6 Listing of Subjects Receiving Investigational Product(s)
from Specific
Batches
................................................................................................................
85
16.1.7 Randomization Scheme and Codes
.....................................................................
86
16.1.8 Audit Certificates
................................................................................................
87
16.1.9 Documentation of Statistical Methods
................................................................
88
16.1.9.1 Statistical Analysis Plan
..........................................................................
89
16.1.9.2 Additional Analyses
................................................................................
90
16.1.10 Documentation of Inter-laboratory Standardization Method
and Quality
Assurance Procedures
.........................................................................................
91
16.1.11 Publications Based on the Study
.....................................................................
92
16.1.12 Important Publications Referenced in the Report
........................................... 93
16.2 Subject Data Listings
..........................................................................................
94
16.2.1 Discontinued Subjects
.........................................................................................
94
16.2.2 Protocol Deviations
.............................................................................................
95
16.2.3 Subjects Excluded from the Efficacy Analysis
................................................... 96
16.2.4 Demographic Data
..............................................................................................
97
16.2.5 Compliance and/or Product Concentration Data
................................................ 98
16.2.6 Individual Efficacy Response Data
.....................................................................
99
16.2.7 Adverse Event Listings
.....................................................................................
100
16.2.8 Listing of Individual Laboratory Measurements
.............................................. 101
16.2.9 Other Safety Data
..............................................................................................
102
16.2.10 Other Data
.....................................................................................................
103
16.3 Case Report Forms
............................................................................................
104
16.3.1 CRFs for Deaths, Other Serious Adverse Events, and
Withdrawals for an
Adverse Event
...................................................................................................
104
16.3.2 Other CRFs Submitted
......................................................................................
105
16.4 Individual Subject Data Listings (US Archival Listings)
................................. 106
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3.1 List of In-Text Tables
Table 1: Schedule of Study Procedures
...........................................................................
29
Table 2: Disposition of Subjects (ITT Analysis Set)
....................................................... 39
Table 3: Summary of Reasons for Exclusion from Per Protocol
Analysis Set
(All Randomized Subjects)
...............................................................................
40
Table 4: Subject Demographics (ITT Analysis Set)
........................................................ 41
Table 5: Baseline Disease Characteristics (ITT Analysis Set)
........................................ 43
Table 6: Concomitant Medications by ATC Classification Used by
≥5% of Subjects
in Either Treatment Group (ITT Analysis Set)
................................................. 45
Table 7: Number of Study Product Applications (ITT Analysis Set)
............................. 46
Table 8: Primary Efficacy Endpoint: Subjects with Treatment
Success at Week 8
(ITT Analysis Set)
.............................................................................................
47
Table 9: Primary Efficacy Endpoint: Subjects with Treatment
Success at Week 8
(PP Analysis Set)
...............................................................................................
48
Table 10: Sensitivity Analysis of Primary Efficacy Endpoint:
Subjects with
Treatment Success at Week 8 (LOCF, ITT Analysis Set)
................................ 49
Table 11: Primary Efficacy Endpoint: Subjects with Treatment
Success at Week 8
(Subjects with Non-Missing Week 8 Evaluation, ITT Analysis Set)
............... 50
Table 12: Analysis of Key Secondary Endpoints (ITT Analysis Set)
............................... 51
Table 13: Analysis of Key Secondary Endpoints (PP Analysis Set)
................................. 52
Table 14: Subjects Achieving Treatment Success by Baseline ISGA
Score
(ITT Analysis Set)
.............................................................................................
52
Table 15: Subjects Achieving Treatment Success Analyzed by
Baseline ISGA Score
(PP Analysis Set)
...............................................................................................
53
Table 16: Primary and Key Secondary Efficacy Endpoints by Time
Point
(ITT Analysis Set)
.............................................................................................
54
Table 17: Change in Percent Body Surface Area Involvement by
Time Point
(ITT Analysis Set)
.............................................................................................
56
Table 18: Proportion of Subjects with a Subject's Global
Assessment Score of 0 or
1 by Time Point (ITT Analysis Set)
..................................................................
57
Table 19: Change in Dermatology Life Quality Index from Baseline
to End of
Treatment (ITT Analysis Set)
...........................................................................
58
Table 20: Duration of Study Treatment (ITT Analysis Set)
.............................................. 62
Table 21: Total Amount of Study Product Used (ITT Analysis Set)
................................ 63
Table 22: Mean and Median Daily Study Product Usage (ITT
Analysis Set) .................. 63
Table 23: Summary of Treatment-Emergent Adverse Events
Experienced by
>1 Subject in Either Group by System Organ Class and
Preferred Term
(ITT Analysis Set)
.............................................................................................
64
Table 24: Summary of Subjects with Study Product-Related
Treatment-Emergent
Adverse Events by System Organ Class and Preferred Term
(ITT Analysis Set)
.............................................................................................
66
Table 25: Summary of Treatment-Emergent Adverse Events Rated
Severe in Intensity
(ITT Analysis Set)
.............................................................................................
67
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Table 26: Adverse Events Leading to Discontinuation (ITT
Analysis Set) ...................... 68
Table 27: Vital Sign Changes from Baseline to Week 8/End of
Treatment
(ITT Analysis Set)
.............................................................................................
70
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4 LIST OF ABBREVIATIONS
AE adverse event
ANCOVA analysis of covariance
ATC anatomical therapeutic chemical
BSA body surface area
CDLQI Children’s Dermatology Life Quality Index
CFR Code of Federal Regulations
CMH Cochran-Mantel-Haenszel
CRF case report form
DLQI Dermatology Life Quality Index
FDA Food and Drug Administration
GCP Good Clinical Practice
HIPAA Health Insurance Portability and Accountability Act
ICH International Conference on Harmonisation
ICF informed consent form
IEC Independent Ethics Committee
IND Investigational New Drug
IRB Institutional Review Board
ISGA Investigator's Static Global Assessment
ITT intent to treat
IUD intrauterine device
LC/MS/MS liquid chromatography/mass spectrometry/mass
spectrometry
LOCF last observation carried forward
MedDRA Medical Dictionary for Regulatory Activities
PP per protocol
PUVA psoralen combined with exposure to ultraviolet light A
QOL quality of life
SAE serious adverse event
SD standard deviation
SDV source data verification
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SGA Subject’s Global Assessment
SOC system organ class
SOP standard operating procedure
TEAE treatment-emergent adverse event
UVB ultraviolet light B
US United States
WHODrug World Health Organization Drug Dictionary
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5 ETHICS
5.1 Independent Ethics Committee (IEC) or Institutional Review
Board (IRB)
The protocol and informed consent/assent form for this study
were approved by each
investigator's governing IRB (including a central IRB where
appropriate) before the study
was initiated; documentation of this approval was provided to
Stiefel. The IRB was required
to comply with current Food and Drug Administration (FDA)
regulations (21 Code of
Federal Regulations 56).
Other investigator responsibilities relative to the IRB included
the following:
1. Submit to the IRB for review any advertisements that will be
used to recruit subjects.
2. Submit to the IRB for review any patient information
documentation (eg, patient information sheets).
3. During the conduct of the study, submit progress reports to
the IRB, if required, and request re-review of the study at least
once a year.
4. Report, in writing, to the IRB any serious adverse event
(SAE) that occurred during the study.
5. If Stiefel notified the investigator about SAEs reported in
other studies or at other study sites using this study product,
report that information, in writing, to the IRB.
6. Inform the IRB of any changes in the protocol or informed
consent/assent form and obtain IRB approval of the changes prior to
implementing these changes.
7. Provide the IRB with any other information it requested
before or during the conduct of the study.
8. Maintain a file of study-related information, including
correspondence with the IRB and with Stiefel.
9. Within 3 months of study completion, provide the IRB with a
final report on the study.
NOTE: Copies of all communications between the investigator and
the IRB regarding the
study were provided to Stiefel.
A copy of the protocol is provided in appendix 16.1.1; a list of
IECs/IRBs is provided in
appendix 16.1.3.
5.2 Ethical Conduct of Study
This study was performed according to the recommendations made
in the Declaration of
Helsinki (South Africa, 1996) and with the laws and regulations
of the country in which the
study was conducted.
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For studies conducted in the United States (US) or under a US
Investigational New Drug
(IND) Application, the investigator ensured that the basic
principles of “Good Clinical
Practice” as outlined in the current version of 21 CFR,
subchapter D, part 312,
“Responsibilities of Sponsors and Investigators,” part 50,
“Protection of Human Subjects,”
and part 56, “Institutional Review Boards,” were adhered to.
5.3 Subject Information and Consent
The written informed consent form (ICF)/assent form was signed
by each subject or
parent/guardian at the first (baseline) study visit, prior to
any study procedures. The
investigator was responsible for the content of the informed
consent/assent form, but the
content was reviewed by Stiefel and approved by the IRB. It was
understood that the
process by which the investigator obtains informed
consent/assent was a matter solely within
the investigator-subject relationship and did not involve
Stiefel. However, the informed
consent/assent must have complied with FDA regulations (21 CFR
50.20–50.27). It also
included any additional information required by local laws
relating to institutional review.
The investigator was also responsible for obtaining informed
consent/assent from each
subject participating in the study. All pertinent aspects of the
study were explained to the
subject/legal guardian before he or she signed and dated the
informed consent/assent.
Informed consent/assent must have been obtained from the subject
before any activity or
treatment was undertaken that was not part of routine care. This
included, but was not
limited to, the performance of diagnostic or therapeutic
procedures and the administration of
the first dose of the study product.
It was documented in the source that written informed
consent/assent for each subject was
obtained prior to performing any screening procedures (21 CFR
312.62).
Copies of the ICF and assent form are provided in appendix
16.1.3.
5.4 Compliance Statement
It was the responsibility of the investigator to conduct this
study in strict compliance with
this protocol and FDA regulations and all applicable laws and
regulations.
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6 INVESTIGATORS AND STUDY ADMINISTRATIVE STRUCTURE
A list of investigators who participated in the study, along
with corresponding site addresses,
is presented in appendix 16.1.4. The curricula vitae for the
investigators who participated in
this study are included in appendix 16.1.4. The signature of the
sponsor’s responsible
medical officer is presented in appendix 16.1.5.
List of Suppliers:
Study Product: Fisher Clinical Services
7554 Schantz Road
Allentown, PA 18106
Photography:
Canfield Scientific, Inc.
263 Passaic Avenue
Fairfield, NJ 07004-2524
Central IRB:
Local IRBs:
Data Management:
ICON
1700 Pennbrook Parkway
North Wales, PA 19454
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7 INTRODUCTION
Psoriasis is a noncontagious skin disorder, most often appearing
as inflamed, thickened skin
covered with silvery white scales and involving areas of the
scalp, trunk, and limbs. The
most common type of psoriasis is plaque psoriasis, characterized
by raised lesions on the
scalp, trunk, and limbs. An estimated 4 to 5 million people
suffer from psoriasis in the US,
with approximately 150,000 new cases of psoriasis occurring
annually.1
Psoriasis, though rarely life-threatening, can cause significant
morbidity and disruption in a
person’s life. Topical medications may be used alone in mild to
moderate psoriasis or in
combination with systemic agents in moderate or severe
psoriasis. Topical vitamin D
analogs remain one of the most widely used therapeutic
modalities for psoriasis.2
Laboratory
research has shown that subjects with psoriasis have a shortened
epidermal cell cycle:
normally, keratinocytes require 28 to 44 days to migrate from
the basal cell layer of the
epidermis to the stratum corneum; in subjects with psoriasis,
this migration takes only
4 days.3 Vitamin D3 and its analogs inhibit keratinocyte
proliferation and induce terminal
differentiation.4
Calcipotriene, also called calcipotriol, is a synthetic vitamin
D3 derivative that has been used
effectively for many years for the treatment of plaque-type
psoriasis. Topical calcipotriene
(Dovonex) was first approved in the US in 1993 for the reversal
of the abnormal
keratinocyte changes seen in psoriasis. Calcipotriene is as
potent as 1,25(OH)2D3, the
naturally occurring active form of vitamin D, in regulating cell
proliferation and cell
differentiation, but is much less active than 1,25(OH)2D3 in its
effect on calcium
metabolism. Calcipotriene is currently approved in 3 different
dosage forms for topical use:
a cream, an ointment, and a solution for scalp application, all
at a strength of 0.005%.5,6,7
The current study investigated a new calcipotriene formulation,
Calcipotriene Emulsion
Formulation Foam 0.005% (hereafter referred to as calcipotriene
foam), which delivers the
active ingredient calcipotriene in a ethanol-free, aqueous-based
emulsion formulation foam.
Adequate and well-controlled studies of subjects treated with
the currently marketed version
of calcipotriene ointment and cream (Dovonex Ointment/Dovonex
Cream) have
demonstrated improvement usually beginning after 2 weeks of
therapy. This improvement
continued in subjects using Dovonex Ointment once daily and
twice daily. After 8 weeks of
twice daily use of Dovonex Ointment, approximately 56% of
subjects were evaluated as
being clear or almost clear using the Physician’s Global
Assessment (compared to
approximately 8% in the vehicle control group). Over 400
subjects have been treated in
open-label studies for over 1 year. In controlled clinical
studies, the most frequent adverse
reactions reported for Dovonex Ointment were burning, itching,
and skin irritation, which
occurred in approximately 10% to 15% of subjects. Erythema, dry
skin, peeling, rash,
dermatitis, worsening of psoriasis, including development of
facial/scalp psoriasis were
reported in 1% to 10% of subjects. Other adverse experiences
reported in less than 1% of
subjects included skin atrophy, hyperpigmentation,
hypercalcemia, and folliculitis.5,6
http://www.drugs.com/PDR/Dovonex_Ointment.html##
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Elevated albumin-adjusted serum calcium has also been observed
in subjects who used very
high doses of calcipotriene (>200 g/week).8
Two clinical studies using calcipotriene foam have been
conducted. One multicenter phase 2
study (CAL.201) enrolled 101 subjects with mild to moderate
plaque-type psoriasis. All
subjects were dosed twice daily for 8 weeks with either
calcipotriene foam, vehicle foam,
Dovonex Ointment (active control), or vehicle ointment. Efficacy
was defined as an
Investigator's Static Global Assessment (ISGA) score of clear or
almost clear and a
minimum improvement in the ISGA score of 2 grades from baseline
to week 8 (or early
termination). Treatment success was observed in 17% of subjects
treated with calcipotriene
foam, 35% of subjects treated with Dovonex Ointment, 3% of
subjects treated with vehicle
foam, and 0% of subjects treated with vehicle ointment.
The second study was a bioavailability study (CAL.203) conducted
in 32 subjects with
psoriasis. Subjects were randomized equally to either 2 weeks of
administration of
calcipotriene foam or Dovonex Ointment. In order to achieve
maximal exposure, subjects
were instructed to apply approximately 3.5 g of study product
twice daily (morning and
evening) and to cover all affected areas (except for the face
and scalp). Six of the 32
subjects had measurable levels of calcipotriene (at least 10
pg/mL) at various time points
during the study; 1 subject in the calcipotriene foam group had
a measurable level on day 8,
and 5 subjects in the Dovonex Ointment group had measurable
levels on days 8 and 15. All
measured calcipotriene levels were below 25 pg/mL. These results
are consistent with the
results of a radioabsorption assay that evaluated the systemic
exposure and elimination of
calcipotriene in subjects treated with Dovonex
Ointment.5,6,7
Safety in both studies was evaluated based on reported adverse
events (AEs) and
measurement of serum albumin-adjusted calcium levels. Neither
study reported clinically
meaningful changes in serum calcium in any treatment group.
There were no severe AEs,
deaths, or other SAEs in either study. Treatment-emergent
adverse events (TEAEs) were
infrequent and did not differ in nature or frequency between
treatment groups.
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8 STUDY OBJECTIVES
The primary objectives of this study were to evaluate the safety
and efficacy of calcipotriene
foam compared with vehicle foam in subjects with plaque-type
psoriasis.
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9 INVESTIGATIONAL PLAN
9.1 Overall Study Design and Plan
This was a multicenter, randomized, double-blind, phase 3 study
comparing calcipotriene
foam with vehicle foam in subjects with plaque-type psoriasis.
Application areas included
psoriatic areas of the body excluding those on the face and
scalp. If new psoriatic lesions
appeared during the treatment period, these were to have been
dosed as well. Approximately
327 male and female subjects with plaque-type psoriasis as
defined by an ISGA score of 2 or
3 were to have been enrolled. A subject’s extent of psoriasis
must have involved 2% to 20%
body surface area (BSA), excluding the face and scalp. Subjects
must have had a target
lesion >2 cm² on the trunk or extremities with a score of 2
or 3 for each of erythema, scaling,
and plaque thickness. Lesions on palms/soles, knees, elbows, and
intertriginous areas could
not be used as a target lesion site.
Subjects were randomized to 1 of 2 dose groups in a 2:1
(calcipotriene foam:vehicle foam)
ratio.
Stiefel personnel, investigators, subjects, and
nurse/coordinators were blinded to the study
product assignment. Visits occurred at baseline, week 2, week 4
and week 8.
9.2 Discussion of Study Design
The double-blinded, placebo controlled design of this study is
standard when the objective is
to demonstrate the superior efficacy of an active study product
over an inactive comparator
or placebo. The homogeneity of the study population was
maximized by requiring all
subjects to meet certain disease characteristic criteria at
entry and by randomly assigning
subjects to the 2 treatment groups. The inactive comparator
used, vehicle foam, did not
contain calcipotriene but was otherwise identical to the active
study product, permitting
between-group differences to be attributed to the presence or
absence of calcipotriene. The
double-blinding removed the chance of bias.
9.3 Selection of Study Population
9.3.1 Inclusion Criteria
Subjects were eligible to participate in the study if they met
all of the following criteria:
1. Male or female subjects at least 12 years old and in good
general health.
2. Mild to moderate plaque-type psoriasis, as defined by an ISGA
score of 2 or 3 at baseline(rating scale presented in appendix 3 of
the protocol [appendix 16.1.1]).
3. Mild to moderate plaque-type psoriasis involving 2% to 20% of
total BSA (excluding the face and scalp).
4. Identification of a target lesion (>2 cm²) on the trunk or
extremities with a score of 2 or 3 on a 0 to 5 scale for each of
erythema, scaling, and plaque thickness; the rating scale is
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presented in appendix 2 of the protocol (appendix 16.1.1).
Lesions on palms/soles,
knees, elbows, and intertriginous areas were not used as the
target lesion site.
5. The ability and willingness to follow all study procedures,
attend all scheduled visits, and successfully complete the
study.
6. The ability to understand and sign a written ICF and a Health
Insurance Portability and Accountability Act (HIPAA) authorization
form, which must have been obtained prior to
participation in this study. The HIPAA authorization may have
been incorporated in the
informed consent form.
9.3.2 Exclusion Criteria
Subjects were excluded from participation in the study if they
met any of the following
criteria:
1. Had participated in any previous Phase 1 or 2 calcipotriene
foam study.
2. Known allergy or other adverse reaction to calcipotriene or
other vitamin D analogs or to any component of the study
formulations.
3. History of hypercalcemia or of vitamin D toxicity.
4. Diagnosis of generalized pustular or erythrodermic
exfoliative psoriasis.
5. Other serious skin disorder or any chronic medical condition
that was not well controlled.
6. Use of nonbiologic systemic anti-psoriatic therapy (eg,
corticosteroids, psoralen combined with exposure to ultraviolet
light A [PUVA], ultraviolet light B [UVB],
retinoids, methotrexate, cyclosporine, other immunosuppressive
agents) or biologic
therapy (eg, alefacept, etanercept, efalizumab) within 4 weeks
of enrollment.
7. Use of topical therapies that have a known beneficial effect
on psoriasis, including but not limited to corticosteroids,
retinoids, vitamin D derivatives, tar, or anthralin, within
2 weeks of enrollment.
8. Systemic medications for other medical conditions that are
known to affect psoriasis (eg, lithium, beta-adrenergic blockers)
within 4 weeks of enrollment.
9. Use of any investigational therapy within 4 weeks of
enrollment.
10. Pregnant women, women who were breast feeding, or sexually
active women of childbearing potential who were not practicing an
acceptable method of birth control
(birth control pill, patch, implant, barrier with spermicidal
jelly, intrauterine device
[IUD], etc.), as determined by the investigator. An acceptable
method of birth control
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must have been used during the entire study in sexually active
women of childbearing
potential. A woman of childbearing potential was defined as one
who was biologically
capable of becoming pregnant. Abstinence was considered to be a
medically acceptable
form of contraception.
11. Current drug or alcohol abuse (drug screening not
required).
12. A history of any immunocompromising disease.
13. Any other condition which, in the judgment of the
investigator, would have put the subject at unacceptable risk for
participation in the study.
9.3.3 Removal of Subjects from Therapy or Assessment
9.3.3.1 Subject Discontinuation
A subject could have voluntarily withdrawn from the study at any
time he or she chose.
Subjects could have withdrawn from study product usage, but may
have agreed to return for
week 8/early termination visit evaluations. If the subject
withdrew consent for any further
participation in the study, no further study evaluations were
performed and no attempts were
made to collect additional data. The investigator could have
elected, at any time, to
withdraw a subject for reasons related or unrelated to the study
product or study procedures.
In either event, full details were documented in the case report
form (CRF). Subjects who
could not complete the study for administrative reasons (eg,
non-compliance, failure to meet
visit schedule) were discontinued from the study.
Any subject who became pregnant during the study was to be
immediately discontinued
from study activities. The subject or subject’s partner who
became pregnant during the
study was to be followed for safety evaluations and outcome of
pregnancy.
9.3.3.2 Subject Dropout
When a subject withdrew from the study, the week 8/early
termination visit evaluations were
to be performed, as described in section 9.5.4. The reason for
any subject's premature
withdrawal from the study was to have been fully documented on
the CRF. Subjects who
failed to attend a visit were contacted to find out if they had
withdrawn themselves from the
study. If a subject stopped the study product (either at their
own request or at the
investigator’s instruction), he/she was encouraged to return for
week 8/early termination
visit evaluations.
9.3.3.3 Screen Failures
Subjects who signed the ICF but who discontinued or were
withdrawn from the study before
study product administration were defined as screen
failures.
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9.4 Study Product(s)
9.4.1 Study Products Administered
Subjects were instructed to self-apply study product twice daily
(morning and evening) for
8 weeks, to continue to apply study product to areas originally
affected by psoriasis in the
event of clearing, and to apply study product to any new lesions
in the treatable area at the
first sign of flaring prior to the week 8 visit. The dose was
the smallest amount of study
product necessary to cover all treatable lesions (excluding the
face and scalp).
Subjects were instructed to dispense a small amount of foam and
gently massage (rub) the
study product into the affected areas. All areas affected with
psoriasis were to be treated
with the study product, with the exception of the face and
scalp. Hands were to be washed
after the application of study product to avoid inadvertent
transfer to the face and other body
parts. Treatable areas were not to be cleansed for at least 2
hours after study product
application. Study product was not to be applied within 4 hours
prior to a scheduled study
visit.
9.4.2 Dose Modification
No modifications were permitted to the dosing regimen, except
for study discontinuation as
outlined in section 9.3.3.
9.4.3 Identity of Study Product(s)
The study product, calcipotriene foam, contained 0.005%
calcipotriene in an emulsion
formulation foam vehicle consisting of cetyl alcohol, stearyl
alcohol, light mineral mil, white
petrolatum, isopropyl myristate, polyoxyl 20 cetostearyl ether,
vitamin E (dl-α-tocopherol),
purified water, edetate disodium (dihydrate), sodium phosphate
dibasic (anhydrous),
propylene glycol. Calcipotriene foam was packaged in a
pressurized, polyamide imide-lined
aluminum can pressurized with a hydrocarbon (propane/butane)
propellant.
The comparator, vehicle foam, had identical ingredients and
packaging as calcipotriene foam
but without the active ingredient calcipotriene.
The following batch numbers were used:
Study Product Batch No. Expiry date
Calcipotriene foam ZLS-C January 2009
Vehicle foam ZLP-C January 2009
Note: Study product used in this study was not marked with an
expiry date because stability
studies were ongoing. The expiry date of January 2009 is based
on the manufacture date of
January 2008 for all product used in this study and the proposed
1 year shelf life that is
based on stability data available at the start of this clinical
study. Because the study was
completed by January 2009, no update for the expiry date was
required.
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Study product was stored at the site in a locked room or cabinet
with limited access. At all
times, study product was stored at a controlled room temperature
(20-25°C/68-77°F). Study
product temperature was monitored at the site using a hi/low
thermometer or similar
recording device. Cans were not frozen or subjected to high
temperature.
9.4.4 Method of Assigning Subjects to Groups
Subjects were randomly assigned to 1 of 2 groups in a 2:1 ratio
(calcipotriene foam:vehicle
foam). The randomization schedule with study product assignments
was generated prior to
the start of the study. There was no stratification. Study
product kits were numbered in
sequential order and the contents (calcipotriene foam or vehicle
foam) were based on the
randomization code. The study staff responsible for dispensing
study product were
instructed to choose the next available study kit number as
subjects were enrolled in order to
randomize the subject. The kit number was also used as the
subject identification number.
The randomization scheme is provided in appendix 16.1.7.
Subjects were assigned sequential numbers upon assignment to
study product.
9.4.5 Selection of Doses in the Study
The dose was the smallest amount of study product necessary to
cover all treatable lesions
(excluding the face and scalp).
9.4.6 Blinding
The study was double-blinded to the use of calcipotriene foam or
vehicle foam. When a
subject entered into the study, he/she was assigned a subject
number that defined the type of
study product (calcipotriene foam or vehicle foam) the subject
received. Calcipotriene foam
and vehicle foam were packaged in identically appearing
containers so Stiefel personnel,
investigators, subjects, and nurse/coordinators did not know
which type of study product the
subject received.
9.4.7 Unblinding
The blind was to be broken after all data had been collected
from all subjects and validated
following applicable standard operating procedures (SOPs). There
were 2 possible
exceptions to this; the blind could be broken by the
investigator for all cases for which the
identification of the study product was required for determining
medical treatment, or for
regulatory reporting purposes.
9.4.8 Prior and Concomitant Therapy
All concomitant medications taken by the subject were recorded,
including over-the-counter
medications, vitamins, and natural supplements.
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9.4.8.1 Prohibited Concomitant Therapies
Other than the study product, no concomitant topical therapy or
phototherapy to evaluable
psoriatic lesions (ie, all lesions except those on the face and
scalp) was permitted.
No systemic therapies for the treatment of psoriasis were
permitted during the study. The
introduction of medications or therapies for other medical
conditions that are known to affect
psoriasis (eg, corticosteroids, PUVA, UVB, cyclosporine,
azathioprine, methotrexate,
lithium, beta-blockers) was not permitted during the interval
prior to entry into the study as
defined in the exclusion criteria and during the study (section
9.3.2). All drugs and therapies
listed in the exclusion criteria were also prohibited during the
study. No other
investigational therapy was permitted during the study.
9.4.8.2 Permitted Concomitant Therapies
Bland emollients such as Eucerin Cream were permitted for
application to evaluable
psoriatic lesions between applications of study product, but
were not to have been used
within 4 hours before a scheduled study visit. Study product was
to have been applied
before any emollients were used. Hands were to have been washed
between applications of
study product and other emollients/cosmetics.
Subjects were permitted to use bland emollients such as Eucerin
Cream for lesions on the
face and scalp.
The use of concomitant medications for other medical conditions
(eg, hypertension, diabetes,
acute infections) was permitted during this study. The use of
inhaled/intranasal steroids was
permitted prior to and during the conduct of the study if it was
already being used by the
subject.
9.4.9 Treatment Compliance
Subjects were provided with detailed instructions concerning
protocol requirements and
application of the study product at the baseline visit. Subjects
received a Study Product
Compliance Log to document the date and time (morning or
evening) of each missed study
product application. Subjects were asked at each visit about the
number of missed
applications of the study product and the reason for missed
applications. Additionally, study
product cans were collected and weighed at each subsequent visit
to confirm study product
compliance.
9.5 Efficacy and Safety Variables
9.5.1 Efficacy Evaluations
The following efficacy measures were collected:
The ISGA assessed over all treatable areas, excluding the face
and scalp at baseline, week 2, week 4, and week 8/early
termination. This instrument provides a rating of
visual assessment of all evaluable lesions on a scale of 0
(clear) to 4 (severe). The ISGA
is presented in appendix 3 of the protocol (appendix
16.1.1).
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Evaluation of a designated target lesion on a 0 to 5 scale for
erythema, scaling, and plaque thickness at baseline, week 2, week
4, and week 8/early termination. The
evaluation scale and criteria are presented in appendix 2 of the
protocol
(appendix 16.1.1).
The Subject's Global Assessment (SGA) at baseline, week 2, week
4, and week 8/early termination. This instrument provides a
subject's assessment of the status of all treatable
areas on a scale of 0 (skin is completely clear) to 5 (psoriasis
is severe). The SGA is
presented in appendix 4 of the protocol (appendix 16.1.1).
The Dermatology Life Quality Index (DLQI, age ≥17) or Children's
DLQI (CDLQI) (age
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Table 1: Schedule of Study Procedures
Assessment
Baseline
(Day 1)
Week 2
(Day 15 ± 2 days)
Week 4
(Day 29 ± 4 days)
Week 8/ET
(Day 57 ± 4 days)
Written informed
consent/assent/HIPAA
authorization
X
Concomitant medications query X X X X
Medical history/review of
systems
X
Vital signs measurements
(temperature, BP, pulse)
X X
Height and weight measurement X
Complete skin examination
(% BSA affected by psoriasis)
X X X X
ISGA X X X X
Evaluation of target lesion for
erythema, scaling and plaque
thickness
X X X X
Urine pregnancy test (all females
of childbearing potential)
X X
Adverse event query X X X
SGA X X X X
DLQI or CDLQI X X
Randomize subject to study
product
X
Weigh and dispense study
product
X X X
Collect and weigh study product X X X
Post-study questionnaire X
Abbreviations: BP = blood pressure; BSA = body surface area;
CDLQI = Children's Dermatology Life Quality
Index; DLQI = Dermatology Life Quality Index; ET = early
termination; HIPAA = Health Insurance
Portability and Accountability Act; ISGA = Investigator's Static
Global Assessment; SGA = Subject's Global
Assessment.
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Baseline (day 1)
Subjects must have met all inclusion/exclusion criteria at the
baseline visit.
1. Obtain written informed consent and HIPAA authorization prior
to performing any study procedures. Minor assent was obtained as
per IRB requirements and local regulations.
The date of consent/assent was recorded on the source
document.
2. Query the subject for concomitant medication use.
3. Complete medical history/review of systems and confirm
clinical diagnosis of plaque-type psoriasis.
4. Evaluate skin and record the extent of psoriatic involvement.
Body surface area involvement of psoriasis was to be 2% to 20%
(excluding the face and scalp).
5. Designate and grade a target lesion >2 cm² on the trunk or
extremities. The target lesion must have had a score of 2 or 3 on a
scale of 0 to 5 for each of erythema, scaling, and
plaque thickness. Lesions on palms/soles, knees, elbows, and
intertriginous areas could
not be used as a target lesion site.
6. Conduct urine pregnancy test (for females of childbearing
potential). If the subject was a minor, the investigator/designee
may have queried the subject regarding sexual activity
and birth control method in private and not in the presence of
the subject’s parent/legal
guardian.
7. Measure vital signs: temperature, blood pressure, pulse,
height, and weight.
8. Complete the ISGA for areas treatable with study product
(excluding the face and scalp). The ISGA score must have been 2 or
3 at baseline.
9. Administer the SGA.
10. Administer the DLQI (age ≥17 years) or CDLQI (age
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2. Evaluate and grade designated target lesion for erythema,
scaling, and plaque thickness.
3. Examine the skin and record the extent of treatable psoriasis
BSA involvement.
4. Complete the ISGA. Evaluations were assessed over all
treatable areas.
5. Query subject for concomitant medications use.
6. Query subject for AEs.
7. Study product accountability: Retrieve previously dispensed
container(s) and dispense study product container(s). Study product
containers were weighed upon dispensation
and return. Subjects were queried regarding their compliance
with study product.
8. Instruct subject to not apply study product within 4 hours
before their next scheduled study visit.
9. Schedule week 4 visit.
Week 4 (day 29 ± 4 days)
The following procedures were conducted at this visit:
1. Administer the SGA.
2. Evaluate and grade designated target lesion for erythema,
scaling, and plaque thickness.
3. Examine the skin and record the extent of treatable psoriasis
BSA involvement.
4. Complete the ISGA. Evaluations were assessed over all
treatable areas.
5. Query subject for concomitant medications use.
6. Query subject for AEs.
7. Study product accountability: Retrieve previously dispensed
container(s) and dispense study product container(s). Study product
containers were weighed upon dispensation
and return. Subjects were queried regarding their compliance
with study product.
8. Instruct subject not to apply study product within 4 hours
before their next scheduled study visit.
Week 8 (day 57 ± 4 days) or Early Termination
All subjects were required to complete the week 8/early
termination visit evaluation,
regardless of their response to study product prior to week 8.
The following procedures
were conducted at this visit:
1. Administer the SGA.
2. Measure vital signs: temperature, blood pressure, pulse.
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3. Evaluate and grade designated target lesion for erythema,
scaling, and plaque thickness.
4. Examine the skin and record the extent of treatable psoriasis
BSA involvement.
5. Complete the ISGA. Evaluations were assessed over all
treatable areas.
6. Administer the DLQI (age ≥17 years) or CDLQI (age
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9.5.8 Additional Efficacy Endpoints
The following endpoints were analyzed by group:
Mean percent reduction in the percent of BSA involvement of
psoriasis from baseline to week 8.
The proportion of subjects who had an SGA score of 0 or 1 at
week 8.
The change in DLQI score from baseline to week 8. (The CDLQI was
planned but not performed because of the small number of subjects
[n = 5] in the age group that was
administered this instrument.)
The primary endpoint and all key secondary endpoints at each
visit.
9.6 Data Quality Assurance
9.6.1 Study Monitoring
This study was closely monitored at all stages of its
development from inception to
conclusion. A qualified representative of Stiefel or designee
monitored the conduct of the
study. The study was monitored according to the International
Conference on
Harmonisation (ICH) guidelines on Good Clinical Practice (GCP)
and all applicable local
and national regulations.
Accuracy of the CRFs was authenticated by source data
verification (SDV). Subject medical
notes were treated with absolute confidentiality.
Investigators were required to permit study-related monitoring,
audits, IRB/IEC review, and
regulatory inspection(s), and to provide direct access to source
data/documents.
Investigators were also required to permit such inspection of
records and CRFs as was
deemed necessary by Stiefel for compliance with local and
national regulations governing
the conduct of investigational studies.
Principal areas subjected to monitoring included:
Continued acceptability of the investigator's facilities.
Adherence to the study protocol.
Investigator's compliance with local and national regulations
regarding his/her obligations (including those towards the
IRB/IEC).
Maintenance of complete, consistent, and accurate records
regarding clinical data and study product accountability.
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Verification of data entry on CRFs or into an electronic
database, as applicable.
Case report form SDV.
9.6.2 Source Data Verification
Source documents for this study were any document on which study
data were recorded for
the first time including the Subject Medical Notes, the Subject
Study Diaries,
Consent/Assent Forms, and any other relevant documentation
detailed in the source data
verification plan/monitoring plan.
Demographic data, inclusion and exclusion criteria, history of
condition, informed
consents/assents, AEs, visit dates, and concomitant medications
were to be source data
verified for all subjects.
Dispensing logs were to be routinely checked. The randomization
code break envelopes or
labels were to be periodically inspected to check for any
evidence that the study may have
been unblinded.
9.6.3 Quality Assurance Audits
In addition to study monitoring, the sponsor conducted routine
quality assurance audits at
3 sites; the audit certificates can be found in appendix
16.1.8.
9.6.4 Direct Access, Data Handling, and Record-Keeping
9.6.4.1 Case Report Forms
The investigator was required to maintain adequate and accurate
CRFs to record all
observations and other data relevant to the clinical
investigation. These forms were to have
been completed in a neat, legible manner with permanent ink to
ensure accurate
interpretation of data. A sample CRF is provided in appendix
16.1.2.
All required data were to be recorded in the CRFs in a timely
manner. All CRF data must
have been submitted to Stiefel throughout and at the end of the
study.
9.6.4.2 Data Protection
Stiefel complied with all applicable local and national laws and
regulations relating to data
protection.
9.7 Statistical Methods Planned in the Protocol and
Determination of Sample Size
The statistical analysis plan is provided in appendix
16.1.9.
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9.7.1 Statistical and Analytical Plans
Summary statistics consist of numbers and percentages of
responses in each category for
discrete measures; and descriptive statistics of means, medians,
and standard deviations; and
minimum and maximum values for continuous measures.
Missing values for all primary and key secondary endpoints were
counted as failures. An
additional sensitivity analysis was completed for the primary
analysis only, where a subject’s
last non-missing response was carried forward. Missing values
were not imputed for other
analyses.
Version 9.1.3 of the SAS statistical software package was used
to generate all tabular
summaries, data listings, figures, and statistical analyses.
9.7.1.1 Primary Efficacy Endpoint
The primary endpoint was analyzed to test the superiority of
calcipotriene foam over vehicle
foam. The hypothesis was tested using a Cochran-Mantel-Haenszel
(CMH) procedure
stratified by study center with a two-sided 0.05 significance
level. Consistency of the results
across investigative centers for the primary endpoint was
verified using the Breslow-Day test
of homogeneity of the odds ratios, using a significance level of
0.1.
Centers enrolling fewer than 12 subjects were combined as one
pooled center in the
analyses. In the event that pooling the centers with fewer than
12 still resulted in a pooled
center with less than 12, then the pooled center was combined
with the next highest center
until all pooled centers had at least 12 subjects.
The intent to treat (ITT) analysis set was used for the primary
analysis, including only
subjects who had an efficacy evaluation at week 8 (between study
days 47 and 67); subjects
without an efficacy evaluation at week 8 were counted as
treatment failures. Two additional
sensitivity analyses were completed for the primary endpoint:
(1) using the per protocol (PP)
analysis set and (2) using the ITT analysis set but carrying
forward earlier non-missing
responses for those subjects who did not have an efficacy
evaluation at week 8 (between
study days 47 and 67).
9.7.1.2 Key Secondary Efficacy Endpoints
All but 1 of the key secondary efficacy endpoints were analyzed
using the CMH procedure
stratified by study center. In the event that the primary
analysis was significant at the
0.05 level, the Holm stepwise closed testing procedure was to be
used to control multiplicity
for these 4 key secondary analyses.
The remaining key secondary efficacy endpoint, primary endpoint
by baseline ISGA score,
was analyzed using the CMH procedure stratified by study center
with a 2-sided 0.05
significance level.
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9.7.1.3 Additional Efficacy Endpoints
The additional efficacy endpoints of mean percent reduction in
the percent of BSA at each
visit and the change in DLQI or CDLQI score from baseline to
week 8 were analyzed using
analysis of covariance (ANCOVA) with baseline value, treatment,
center, and interaction of
treatment-center. If the treatment-center interaction was not
significant at the 0.1 level, this
interaction was to be excluded in the ANCOVA model.
The additional efficacy endpoint of proportion of subjects who
had an SGA score of 0 or 1 at
each visit was tested using CMH procedure stratified by
center.
The additional efficacy endpoint of all primary and key
secondary efficacy endpoints by visit
was tested using the CMH procedure stratified by study
center.
No further adjustment for multiplicity was made for the
additional efficacy endpoints.
9.7.1.4 Safety Analysis
9.7.1.4.1 Summary of Study Product Compliance and Exposure
Summary statistics and a categorical summary are presented for
both treatment duration and
days on study product. Additionally, a table is provided that
includes the total amount, in
grams, of study product used. Study product usage was defined as
the total container weight
dispensed minus the total container weight returned.
9.7.1.4.2 Adverse Events
Adverse events were coded using the Medical Dictionary for
Regulatory Activities
(MedDRA), Version 11.0. Treatment-emergent AEs (TEAEs) were
defined as those events
occurring during study treatment or up to 30 days after stopping
study treatment. Treatment-
emergent AEs are summarized in the following tables:
Incidence of AEs.
Incidence of severe AEs.
Incidence of severe related AEs