Safety and Sustained Efficacy of the Farnesoid X Receptor (FXR) Agonist Cilofexor Over a 96-Week Open-label Extension in Patients With PSC

Abstract

Primary sclerosing cholangitis (PSC) is a major unmet medical need in clinical hepatology. Cilofexor is a nonsteroidal farnesoid X receptor agonist being evaluated for the treatment of PSC. Here, we describe the safety and preliminary efficacy of cilofexor in a 96-week, open-label extension (OLE) of a phase II trial. Noncirrhotic subjects with large-duct PSC who completed the 12-week, blinded phase of a phase II study (NCT02943460) were eligible, after a 4-week washout period, for a 96-week OLE with cilofexor 100 mg daily. Safety, liver biochemistry, and serum markers of fibrosis, cellular injury, and pharmacodynamic effects of cilofexor (fibroblast growth factor 19, C4, and bile acids [BAs]) were evaluated. Among 52 subjects enrolled in the phase II study, 47 (90%) continued in the OLE phase (median age, 44 years; 60% male patients, 60% with inflammatory bowel disease, and 45% on ursodeoxycholic acid [UDCA]). At OLE baseline (BL), the median serum alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT) were 368 U/L (interquartile range [IQR], 277-468 U/L) and 417 U/L (IQR, 196-801 U/L), respectively. Of the 47 subjects enrolled, 15 (32%) discontinued treatment prematurely (pruritus [n= 5], other adverse events [n= 5], subject decision/investigator discretion [n= 5]). At week 96, reductions in liver biochemistry parameters occurred, including serum ALP (median,-8.3% [IQR,-25.9% to 11.0%]; P= .066), GGT (-29.8% [IQR,-42.3% to-13.9%]; P < .001), alanine aminotransaminase (ALT) (-29.8% [IQR,-43.7% to-6.6%]; P= .002), and aspartate aminotransaminase (AST) (-16.7% [IQR,-35.3% to 1.0%]; P= .010), and rebounded after 4 weeks of untreated follow-up. ALP response (≥20% reduction from BL to week 96) was similar in the presence or absence of UDCA therapy (29% vs 39%; P= .71). At week 96, cilofexor treatment was associated with a significant reduction in serum 7α-hydroxy-4-cholesten-3-one (C4) (-29.8% [IQR,-64.3% to-8.5%]; P= .001). In subjects with detectable serum BAs at BL (n= 40), BAs decreased-23.9% (IQR,-44.4% to-0.6%; P= .006) at week 48 (n= 28) and-25.7% (IQR,-35.9% to 53.7%; P= .91) at week 96 (n= 26). Serum cytokeratin 18 (CK18) M30 and M65 were reduced throughout the OLE; significant reductions were observed at week 72 (CK18 M30,-17.3% [IQR,-39.3% to 8.8%]; P= .018; CK18 M65,-43.5% [IQR,-54.9% to 15.3%]; P= .096). At week 96, a small, but statistically significant absolute increase of 0.15 units inEnhanced Liver Fibrosis score was observed compared with BL (median, 9.34 vs 9.53; P=.028). In this 96-week OLE of a phase II study of PSC, cilofexor was safe and improved liver biochemistry and biomarkers of cholestasis and cellular injury. gov identifier: NCT02943460.