Published online: 2021-02-13 THIEME 1400 Coagulation and Fibrinolysis Simoctocog Alfa (Nuwiq) in Previously Untreated Patients with Severe Haemophilia A: Final Results of the NuProtect Study Ri J. Liesner1 Aby Abraham2 Carmen Altisent3 Mark J. Belletrutti4 Manuel Carcao5 Manuela Carvalho6 Hervé Chambost7 Anthony K. C. Chan8 Leonid Dubey9 Jonathan Ducore10 Michael Gattens11 Paolo Gresele12 Yves Gruel13 Benoit Guillet14 Victor Jimenez-Yuste15 Lidija Kitanovski16 Anna Klukowska17 Sunil Lohade18 Maria Elisa Mancuso19 Johannes Oldenburg20 Anna Pavlova20 Berardino Pollio21 Marianne Sigaud22 Vladimir Vdovin23 Kateryna Vilchevska24 John K. M. Wu25 Martina Jansen26 Larisa Belyanskaya27 Olaf Walter27 Sigurd Knaub27 Ellis J. Neufeld28 1 Great Ormond Street Hospital for Children NHS Trust Haemophilia Address for correspondence Ri J. Liesner, MA, MBBChir, MD, FRCP, Centre, NIHR GOSH BRC, London, United Kingdom FRCPath, MRCPCH, Great Ormond Street Hospital for Children NHS 2 Department of Hematology, Christian Medical College, Vellore, India Trust Haemophilia Centre, NIHR GOSH BRC, London, United Kingdom 3 Unitat d’Hemofilia, Hospital Vall D’Hebron, Barcelona, Spain (e-mail: Ri.Liesner@gosh.nhs.uk). 4 Pediatric Hematology, Department of Pediatrics, University of Alberta, Edmonton, Canada 15 Servicio de Hematología, Hospital Univeristario La Paz, Autónoma 5 Division of Haematology/Oncology and Child Health Evaluative University, Madrid, Spain Sciences, Department of Paediatrics, Research Institute, Hospital 16 Department of Haemato-Oncology, University Medical Center for Sick Children, Toronto, Canada Ljubljana, Ljubljana, Slovenia 6 Congenital Coagulopathies Reference Centre, São João University 17 Department of Pediatrics, Haematology and Oncology, Warsaw Hospital Centre, Porto, Portugal Medical University, Warsaw, Poland 7 AP-HM, Department of Pediatric Hematology Oncology, Children 18 Department of Hematology, Sahyadri Speciality Hospital, Pune, India Hospital La Timone, Aix Marseille Univ, INSERM, INRA, C2VN, 19 Center for Thrombosis and Hemorrhagic Diseases, Humanitas Marseille, France 8 Division of Pediatric Hematology/Oncology, McMaster University, Clinical and Research Center - IRCCS, Rozzano, Milan, Italy 20 Institute of Experimental Haematology and Transfusion Medicine, Hamilton, Canada 9 Department of Pediatrics, Western Ukrainian Specialized Children’s University Clinic Bonn, Bonn, Germany 21 Department of Transfusion Medicine, Regina Margherita Children Medical Centre, Lviv, Ukraine 10 Department of Pediatrics, University of California Davis Medical Hospital of Turin, Turin, Italy 22 Centre Régional de Traitement de I’Hémophilie, University Hospital Center, Sacramento, United States 11 Department of Paediatric Haematology and Oncology, of Nantes, Nantes, France 23 Department of Hematology, Morozovskaya Children’s Hospital, Addenbrooke’s Hospital, Cambridge University Hospital NHS Moscow, Russian Federation Foundation Trust, Cambridge, United Kingdom 24 Department of Hematology, State Institution “Institute of Urgent 12 Department of Medicine and Surgery, University of Perugia, and Reconstructive Surgery named after V.K. Gusak of National Perugia, Italy 13 Centre Régional de Traitement de l’Hémophilie, Hôpital Trousseau, Academy of Medical Sciences of Ukraine,” Donetsk, Ukraine 25 British Columbia Children’s Hospital, Vancouver, Canada Tours, France 26 Octapharma Pharmazeutika Produktionsges.mbH, Vienna, Austria 14 Haemophilia Treatment Centre, Univ Rennes, CHU Rennes, Inserm, 27 Octapharma AG, Lachen, Switzerland EHESP, Irset (Institut de recherche en santé, environnement et 28 St. Jude Children’s Research Hospital, Memphis, Tennessee, United States travail) - UMR_S 1085, Rennes, France Thromb Haemost 2021;121:1400–1408. received DOI https://doi.org/ © 2021. The Author(s). October 14, 2020 10.1055/s-0040-1722623. This is an open access article published by Thieme under the terms of the accepted after revision ISSN 0340-6245. Creative Commons Attribution License, permitting unrestricted use, December 4, 2020 distribution, and reproduction so long as the original work is properly cited. published online (https://creativecommons.org/licenses/by/4.0/) February 13, 2021 Georg Thieme Verlag KG, Rüdigerstraße 14, 70469 Stuttgart, Germany NuProtect—Simoctocog Alfa and FVIII Inhibitors in PUPs Liesner et al. 1401 Abstract Introduction FVIII inhibitor development is the most serious contemporary treat- ment complication in haemophilia A, particularly in previously untreated patients (PUPs). No inhibitors developed in clinical trials in previously treated patients treated with simoctocog alfa (Nuwiq), a fourth-generation recombinant FVIII produced in a human cell line. Methods The NuProtect study investigated the immunogenicity of simoctocog alfa in PUPs. NuProtect was a prospective, multinational, open-label, non-controlled, phase III study. PUPs with severe haemophilia A (FVIII:C <1%) of any age and ethnicity were treated with simoctocog alfa for 100 exposure days or a maximum of 5 years. Patients were true PUPs without prior exposure to FVIII concentrates or blood components. Inhibitor titres were measured with the Nijmegen-modified Bethesda assay; cut-off for positivity was 0.6 BU mL1 (0.6 to <5 low-titre, 5 high titre). Results A total of 108 PUPs with a median age at first treatment of 12.0 months (interquartile range: 8.0–23.5) were treated with simoctocog alfa. F8 mutation type was known for 102 patients (94.4%) of whom 90 (88.2%) had null F8 mutations and 12 (11.8%) had non-null mutations. Of 105 PUPs evaluable for inhibitor development, 28 (26.7%) developed inhibitors; 17 high titre (16.2%) and 11 low titre (10.5%). No PUPs with non-null F8 mutations developed inhibitors. Keywords Conclusion In the NuProtect study, the rate of inhibitor development in PUPs with ► coagulation severe haemophilia A treated with simoctocog alfa was lower than the rate reported for ► FVIII inhibitors hamster-cell-derived recombinant factor VIII products in other recent clinical trials. No ► haemophilia inhibitors were reported in PUPs with non-null F8 mutations. Introduction derived (pd) FVIII concentrates,15–17 other reports suggest no difference in inhibitor risk with respect to product type.18–20 Haemophilia A is an X-linked bleeding disorder that is The SIPPET study was the only prospective, randomised, usually diagnosed in infancy, especially in severe cases controlled study to compare the immunogenicity of pdFVIII (factor VIII coagulant activity [FVIII:C] <1% of normal).1 versus rFVIII (all derived from hamster cell lines).21 The Patients with haemophilia A require life-long treatment to cumulative incidence of all and high-titre inhibitors in prevent or control bleeding.2,3 patients treated with pdFVIII was 26.8% (95% confidence When FVIII treatment is started, previously untreated interval [CI]: 18.4–35.2%) and 18.6% (95% CI: 11.2–26.0%), patients (PUPs) with severe haemophilia A face a period of respectively. In patients treated with rFVIII, the cumulative high risk for development of FVIII-neutralising antibodies incidence of all and high-titre inhibitors was 44.5% (95% CI: (inhibitors), which interfere with the haemostatic function of 34.7–54.3%) and 28.4% (95% CI: 19.6–37.2%), respectively.21 FVIII treatment. The highest risk is present usually during the As SIPPET enrolled patients between 2010 and 2014, rFVIII first 20 exposure days (EDs) to exogenous FVIII but a residual products licensed after 2014 were not included in the study. risk persists until the completion of 75 EDs.4,5 Inhibitors Simoctocog alfa (Nuwiq; Octapharma AG) is a fourth- typically develop in up to 40% of PUPs6 and are widely generation rFVIII product22 manufactured using a human considered the most serious treatment-related complication cell line without chemical modification or protein fusion, of haemophilia A due to the detrimental impact on bleeding with the aim of reducing inhibitor development by replicating rates, mortality, quality of life and treatment costs.7–10 the native human FVIII protein and avoiding incorporation of Remaining free from inhibitors is important to enable effec- potentially immunogenic elements of animal cell origin.23–26 It tive FVIII treatment for bleeding events or surgery, as well as contains only human post-translational modifications24 and is to remain eligible for potential future treatment options such free of any added human or animal impurities.23,26 Simoctocog as gene therapy.6,11 alfa is fully sulphated at Tyr1680, which confers a high binding Several patient- and treatment-related risk factors for affinity for its natural carrier protein, von Willebrand factor inhibitor development have been identified, such as severity (VWF).24,25 These properties of simoctocog alfa may lower its of haemophilia A, a family history of inhibitors, ethnicity, immunogenic potential by shielding potentially antigenic type of F8 mutation, polymorphisms of immune response epitopes from recognition by the immune system and inhibit- genes, treatment intensity and product type.4,12–14 Whereas ing uptake of FVIII by antigen-presenting cells.12 Additionally, some reports suggest an increased inhibitor risk associated simoctocog alfa contains only human glycans and is devoid of with the use of recombinant (r) FVIII compared with plasma- potentially immunogenic glycan epitopes present in rFVIII Thrombosis and Haemostasis Vol. 121 No. 11/2021 © 2021. The Author(s). 1402 NuProtect—Simoctocog Alfa and FVIII Inhibitors in PUPs Liesner et al. products derived from hamster cell lines.27,28 A combination of Inhibitor Analysis high VWF affinity and absence of antigenic glycans has the potential to reduce the overall immunogenic challenge. The The primary endpoint of the study was the incidence of anti- efficacy and safety of simoctocog alfa were demonstrated in FVIII inhibitors after simoctocog alfa administration. Inhibitor studies of previously treated patients (PTPs) with severe titres were measured in plasma by the Nijmegen-modified haemophilia A, and no inhibitors were reported in 201 PTPs, Bethesda assay (cut-off: 0.6 Bethesda units [BU] mL1).31 including 59 PTPs below 12 years of age.29 Inhibitor activity was determined at a central laboratory The NuProtect study was initiated in 2013 to assess the (LabCorp Clinical Trials, Colorado, United States) at baseline immunogenicity of simoctocog alfa in patients without any (screening), every 3 to 4 EDs until ED 20, every 10 to 12 EDs or previous exposure to FVIII concentrates or any blood prod- every 3 months  2 weeks after ED 20 and at study comple- ucts containing FVIII (true PUPs) who were treated with tion. Additionally, inhibitor activity was tested at any time simoctocog alfa for 100 EDs or up to 5 years, whichever came during the study if inhibitor development was suspected. In first. Here we report the final inhibitor data of the NuProtect the case of a positive inhibitor result, a retest of the first study; efficacy and safety data will be reported separately. sample was done and a second blood sample was drawn and tested at the central laboratory. Inhibitors were confirmed if the retest or second sample was positive or a subsequent test Methods at any time in the study was positive. The day of the first Details of the study design and clinical assessments have positive inhibitor test was used to calculate the time to been published previously30 and are provided in brief here inhibitor development. The definitions for inhibitor thresh- with respect to inhibitor development. olds were 0.6 to <5 BU mL1 for low-titre and 5 BU mL1 for high-titre inhibitors. Inhibitors were regarded as tran- sient if they occurred without any clinical symptoms, re- Study Design and Patients quired no increase in FVIII dosing and decreased to <0.6 BU The NuProtect study (www.clinicaltrials.gov NCT01712438; mL1 within a period of 6 months after first detection. EudraCT 2012–002554–23) was a prospective, multicentre, Patients who developed a non-transient, low- or high-titre multinational, open-label, non-controlled, phase III study. inhibitor were offered the option to start immune tolerance Male PUPs with severe haemophilia A (FVIII:C < 1%) of any induction (ITI) treatment with simoctocog alfa within the age and ethnicity were enrolled and treated with simoctocog study; ITI data are not reported here. alfa from the first ED. Exclusion criteria included previous The incidence of FVIII inhibitors was examined according to exposure to any FVIII concentrates or blood components, patient-related variables: race, family history of inhibitors and diagnosis of any coagulation disorder other than haemophilia F8 mutation type (performed by J. Oldenburg and A. Pavlova, A, concomitant treatment with systemic immunosuppressive University Clinic Bonn, Bonn, Germany). Intron 22 inversions, drugs, participation in other interventional clinical studies intron 1 inversions, nonsense mutations, splice site mutations, currently or within previous 4 weeks and severe liver or kidney small duplications, small deletions (excluding in-frame and disease. The trial was approved by all relevant independent within a poly-A run) and large deletions were classified as null ethics committees and institutional review boards and was mutations. All other mutations were classified as non-null conducted in accordance with the ethical principles of the mutations. The effect of treatment-related variables, including Declaration of Helsinki. Written informed consent was pro- treatment regimen (prophylaxis vs. on-demand), surgery, vided by the parent/legal guardian of all participants. peak treatment moments (3 subsequent days with FVIII dosing and/or at least 1 day with prophylactic doses of >50 IU kg1) and dose (<40 vs. 40 IU kg1 day1), were Study Treatment also examined. Patients received simoctocog alfa for prophylaxis or on-demand treatment, as well as for the treatment of break- Statistical Analyses through bleeding episodes during prophylaxis and to cover surgical procedures. The type of treatment and the dose were No inferential analysis involving formal testing was planned determined by investigators based on the clinical situation of in this non-controlled study. Therefore, no formal sample the patient. size estimation was performed, but the sample size was The recommended dose for prophylaxis was 20 to 50 IU chosen to satisfy European Medicines Agency guidelines FVIII kg1 and patients could switch between on-demand current at the time the study was initiated (EMA/CHMP/ and prophylactic treatment during the study. Use of FVIII BPWP/144533/2009). concentrates other than simoctocog alfa was prohibited, Statistical analyses were exploratory and were performed by except in emergency situations. Patients permanently Clinipace (Marburg, Germany). Absolute and cumulative inhib- switching to another FVIII product within the study partici- itor incidences were calculated. Cumulative incidences and 95% pation period were assessed as treatment failures in the CIs were calculated using Kaplan–Meier methods relative to the efficacy analyses. The treatment period was 100 EDs or population size and accounted for changes over time in the 5 years, whichever occurred first. number of patients remaining at risk of developing inhibitors. Thrombosis and Haemostasis Vol. 121 No. 11/2021 © 2021. The Author(s). NuProtect—Simoctocog Alfa and FVIII Inhibitors in PUPs Liesner et al. 1403 Fig. 1 Patient disposition. with low-titre inhibitors had transient inhibitors with titres Results becoming undetectable without the need for treatment Patients regimen modification and all were subsequently treated The study was conducted at 38 sites in 17 countries. A total of for 100 EDs. In 97 patients who were treated for 75 EDs 110 patients were screened, 108 (98%) were treated with (or developed an inhibitor), the absolute inhibitor incidences simoctocog alfa and 105 (97%) underwent inhibitor testing at were 28.9, 17.5 and 11.3%, for all, high- and low-titre least once during the study (►Fig. 1). Three patients dis- inhibitors, respectively. continued the study after 1 ED without an inhibitor test and The cumulative inhibitor incidence was 27.9% (95% CI: were not included in the inhibitor analysis. A total of 19.1–36.7%) for all inhibitors, 17.6% (95% CI: 10.0–25.3%) for 105 patients underwent inhibitor testing and were included high-titre inhibitors and 12.3% (95% CI: 5.5–19.2%) for low- in the immunogenicity analyses. The 105 patients were titre inhibitors (►Fig. 2). treated for a median of 100 EDs (interquartile range [IQR]: The median (IQR) peak (maximum) inhibitor titre was 15–102), excluding treatment for ITI. Ninety-six patients 154.8 (38.2–300.5) BU mL1 during the study for high-titre completed the study, i.e. received simoctocog alfa for inhibitors and 3.0 (2.3–4.0) BU mL1 for low-titre inhibitors. 100 EDs without developing an inhibitor (including The median (range) time to inhibitor development was 11.0 5 patients with 97–99 EDs due to miscounting) and/or (4–34) EDs for all inhibitors (9.0 [4–24] EDs and 12.0 [6–34] developed an inhibitor. Five patients who developed a EDs for high- and low-titre inhibitors, respectively). Inhib- transient inhibitor subsequently reached 100 EDs. Nine itors developed after ED 20 in only 3 cases (1 high titre patients discontinued the study after a median of 14 EDs [ED 24], 2 low titre [ED 25 and ED 34]). (IQR: 5–32) without developing an inhibitor. Of 90 patients with null F8 mutations, 27 (30.0%) developed Baseline demographics are shown in ►Table 1. At ED 1, the inhibitors of which 17 (18.9%) were high titre (no mutation median age of enrolled patients at first treatment was was found for one patient with a low-titre inhibitor); the 12.0 months (IQR: 8.0–23.5), and 82 (75.9%) were aged cumulative incidence was 30.9% (95% CI: 21.2–40.6%) for all 24 months. F8 mutation type was known for 102/108 inhibitors and 20.3% (95% CI: 11.6–28.9%) for high-titre inhib- (94.4%) and 90 of them (88.2%) had null F8 mutations. Patients itors (►Fig. 3). No patients with non-null F8 mutations (n ¼ 12) with null mutations received their first treatment at a median developed inhibitors. Patients with large F8 deletions (n ¼ 5) age of 12.0 months (IQR: 8.0–22.8) and those with non-null had the highest inhibitor incidence (80%) (►Fig. 4). Patients mutations at a median of 14.0 months (IQR: 10.5–21.3). with a family history of inhibitors (n ¼ 13) had a higher A family history of haemophilia was present in 42 (38.9%) incidence of inhibitors (46.2%) compared with those without patients of whom 13 (31.0%) also had a family history (n ¼ 92) (23.9%; ►Fig. 4). Patients aged 1 to 6 months (37.5%; of inhibitors. n ¼ 8) and aged >6–12 months (36.2%; n ¼ 47) at first treat- ment had a higher incidence of inhibitors compared with Inhibitor Development patients aged >12–24 months (20.0%; n ¼ 25) or >24 months Of the 105 patients who underwent inhibitor testing, 28 (12.5%; n ¼ 24) (►Fig. 4). (26.7%) developed inhibitors, which were high titre in 17 Treatment-related factors (treatment regimen, surgery, (16.2%) and low titre in 11 (10.5%). Five of the 11 patients peak treatment moments and dose) did not have a significant Thrombosis and Haemostasis Vol. 121 No. 11/2021 © 2021. The Author(s). 1404 NuProtect—Simoctocog Alfa and FVIII Inhibitors in PUPs Liesner et al. Table 1 Patient demographics Parameter All patients (N ¼ 108) Age at first treatment, 12.0 mo, median (IQR) (8.0–23.5) Age at first treatment, N (%) < 1 mo 1 (0.9) 1–6 mo 9 (8.3) > 6–12 mo 47 (43.5) > 12–24 mo 25 (23.1) > 24 mo 26 (24.1) Fig. 2 Cumulative incidence of inhibitor development. Kaplan–Meier Race, N (%) estimate. White 89 (82.4) Asian 14 (13.0) Native American/Alaska native 1 (0.9) Other 4 (3.7) Gene mutation defect, N (%) Intron 1 inversion 3 (2.8) Intron 22 inversion 47 (43.5) Large deletion 5 (4.6) Missense 12 (11.1) Nonsense 11 (10.2) Small deletion 14 (13.0) Fig. 3 Cumulative incidence of inhibitor development by null or non- Small duplication 6 (5.6) null F8 gene mutation. Kaplan–Meier estimate. Splice site mutation 4 (3.7) No mutation found 2 (1.9) lower than the rates reported for the rFVIII arm in the SIPPET Missing 4 (3.7) study, all derived from hamster cell lines (cumulative inci- F8 mutation type,a N (%) dence 44.5% for all inhibitors and 28.4% for high-titre inhib- itors), and in line with results obtained for the pdFVIII arm of Null mutations 90 (88.2) b the SIPPET study (26.8 and 18.6% for all and high-titre Non-null mutations 12 (11.8) inhibitors, respectively).21 Family history of haemophilia, N (%) 42 (38.9) Recently published phase III PUP trials32,33 addressing the Family history of inhibitors, N (%) 13 (31.0c) risk of inhibitor development with other single rFVIII products (all derived from hamster cell lines) have reported inhibitor Abbreviation: IQR, interquartile range. a rates in line with those reported for the rFVIII arm of the SIPPET Data for 102 patients with genotype classification. b All non-null mutations were missense mutations. study and hence higher than those reported with simoctocog c Percentage of those with a family history of haemophilia. alfa in our study. In a study of 58 PUPs treated with turoctocog alfa (NovoEight), 25 (43.1%) developed inhibitors of which 16 effect on the incidence of inhibitors up to ED 35 or over the (27.6%) were high titre.32 In a study of 23 PUPs treated with whole study period (data not shown). single-chain rFVIII (Afstyla), 12 (52%) developed inhibitors of which 6 (26%) were high titre.33 F8 mutation type had an influence on the risk of inhibitor Discussion development in our study as has been previously reported.13 We present the final results on inhibitor development in the None of the 12 patients with non-null F8 mutations devel- NuProtect study with simoctocog alfa, a fourth-generation oped inhibitors with simoctocog alfa, which is consistent human cell-line-derived rFVIII. This analysis reports inhibi- with what was reported for patients treated with pdFVIII in a tor data for 105 PUPs treated with simoctocog alfa, making it post-hoc analysis of SIPPET data.34 Among SIPPET patients the largest prospective study in true PUPs with a single FVIII with null F8 mutations, the cumulative incidence of inhib- product. The absolute incidence of all and high-titre inhib- itors was 31% in 101 patients treated with pdFVIII and 47% in itors in NuProtect was 26.7 and 16.2%, respectively. The 96 patients treated with rFVIII. Among SIPPET patients cumulative incidence of all and high-titre inhibitors was with non-null F8 mutations, no inhibitors developed in 27.9 and 17.6%, respectively. These rates are considerably 16 patients receiving pdFVIII treatment, whereas the Thrombosis and Haemostasis Vol. 121 No. 11/2021 © 2021. The Author(s). NuProtect—Simoctocog Alfa and FVIII Inhibitors in PUPs Liesner et al. 1405 Fig. 4 Incidence of inhibitors in subgroups. Forest plot of absolute incidence percentages including exact 95% confidence interval. cumulative incidence of inhibitors was 43% in 22 patients these studies were not controlled for other risk factors.36,37 treated with rFVIII.34 These results suggest that simoctocog Later studies that adjusted for confounders did not report an alfa appears to follow the pattern exhibited by pdFVIII effect of age on inhibitor risk.16,38 concentrates rather than that of the hamster-cell derived There is also some evidence in the literature to suggest rFVIII concentrates (►Fig. 5). Notably, the distribution of F8 that treatment-related factors, particularly intensity of treat- mutations was similar in NuProtect and SIPPET (►Fig. 6). ment, influence inhibitor development.14,39 In our study, There is evidence in the literature that a family history of treatment-related factors did not have a significant effect on inhibitors is associated with an increased risk of inhibitor inhibitor risk, which we speculate might be indicative of a development.35 In NuProtect, the incidence of inhibitors in lower immunogenic potential of Nuwiq. patients with a family history of inhibitors (46.2%; n ¼ 13) A limitation of the NuProtect study is that almost all was double that of patients without a family history (23.9%; patients (95.4%) enrolled across 17 countries were white n ¼ 92). This difference was not statistically significant, but or Asian, and no patients of African origin who have been this may have been influenced by the relatively low number reported to be at higher risk of inhibitor development40,41 of patients with a family history of inhibitors. were enrolled. A strength of the study is the inclusion of only In NuProtect, age 12 months at first treatment was an true PUPs, i.e., without prior exposure to FVIII concentrates independent prognostic factor for the development of inhib- or any other blood products that may otherwise have miti- itors. PUPs aged 1 to 6 months at first treatment had the gated or confounded the risk attributable to the study highest risk and those aged >24 months had the lowest risk product. In addition, extensive immunogenicity testing for developing inhibitors. There are conflicting published was done throughout the study and all analyses were per- data regarding the impact of age at first treatment on the risk formed at a central laboratory. for inhibitor formation. In two cohort studies, the risk of In conclusion, the data from the NuProtect study show inhibitor development was higher in younger patients, but that PUPs with severe haemophilia A treated with Thrombosis and Haemostasis Vol. 121 No. 11/2021 © 2021. The Author(s). 1406 NuProtect—Simoctocog Alfa and FVIII Inhibitors in PUPs Liesner et al. Fig. 5 Cumulative inhibitor incidence in the current study (NuProtect) and the SIPPET34 study. Data are shown by F8 mutation (null or non-null) for all inhibitors (A) and high-titre inhibitors (B). What is known about this topic? • FVIII inhibitor development in previously untreated patients (PUPs) is the most serious contemporary treatment complication in haemophilia A. • FVIII inhibitors develop in up to 40% of PUPs and have a detrimental impact on bleeding rates, quality of life and treatment costs. What does this paper add? • The NuProtect study was a multinational, prospective, open-label, phase III study investigating the immuno- genicity of simoctocog alfa (Nuwiq), a recombinant FVIII produced in a human cell line, in PUPs. • Inhibitors developed in 26.7% of 105 PUPs treated with simoctocog alfa; high-titre inhibitors in 16.2%. • The NuProtect study is the largest prospective study in PUPs with a single FVIII product. • The study demonstrates that PUPs with severe haemo- philia A treated with simoctocog alfa had a lower rate of high-titre inhibitor development than that reported for rFVIII products in other recent clinical trials. Fig. 6 Distribution of genetic defects. (A) F8 gene defect in the current study (NuProtect), the SIPPET study,21 and a meta-analysis 13 of patients with severe haemophilia A and (B) percentage null or non- null mutations in NuProtect and SIPPET. 21 Author Contribbutions R. J. Liesner designed the research, analysed the data and wrote the first draft of the manuscript. All authors pro- vided input, reviewed and approved the manuscript. simoctocog alfa had a lower high-titre inhibitor rate than that reported for hamster-cell-derived rFVIII products in Funding other recent clinical trials and no inhibitors were observed This trial was sponsored by Octapharma AG (Lachen, in patients with non-null F8 gene mutations. Switzerland) with medical writing assistance provided Thrombosis and Haemostasis Vol. 121 No. 11/2021 © 2021. The Author(s). NuProtect—Simoctocog Alfa and FVIII Inhibitors in PUPs Liesner et al. 1407 by nspm ltd, Meggen, Switzerland, and funded by Octa- J. Yuste has received reimbursement for attending symposia/ pharma AG. congresses and/or honoraria for speaking and/or honoraria for consulting, and/or funds for research from Shire, Bayer, Conflict of Interest CSL Behring, Grifols, Novo Nordisk, SOBI, Octapharma and R. J. Liesner, A. Abraham, C. Altisent, M. J. Belletrutti, M. Pfizer. A. Klukowska has received personal fees from CSL Carcao, M. Carvalho, H. Chambost, A. K. C. Chan, L. Dubey, J. Behring, Novo Nordisk, Octapharma, Pfizer, Roche, Shire and Ducore, M. Gattens, P. Gresele, Y. Gruel, B. Guillet, V. J. Yuste, L. SOBI. M. E. Mancuso has received speaker and/or consultancy Kitanovski, A. Klukowska, S. Lohade, J. Oldenburg, A. Pavlova, fees from Bayer Healthcare, CSL Behring, Takeda, Octa- B. Pollio, M. Sigaud, V. Vdovin, K. Vilchevska, J. K. M. Wu and E. pharma, Roche, Pfizer, Kedrion, Grifols, Novo Nordisk and J. Neufeld were clinical study investigators for the NuProtect SOBI. J. Oldenburg has received reimbursement for attending Study (Octapharma-sponsored). R. J. Liesner has received symposia/congresses or honoraria for speaking or honoraria grants/research support from Octapharma, Bayer, Baxalta, for consulting, or funds for research from Bayer, Biogen Idec, Novo Nordisk and Roche, has acted as a consultant for Bayer Biotest, Chugai, CSL Behring, Grifols, Novo Nordisk, Octa- and Baxalta, and has participated in speaker bureaus for pharma, Pfizer, Roche, Shire and SOBI. A. Pavlova has partic- Novo Nordisk, Octapharma and SOBI. A. Abraham has re- ipated in studies sponsored by Octapharma AG. B. Pollio has ceived grants/research support from Novo Nordisk and received support for attending scientific meetings and hon- Roche, and has received support for attending scientific oraria (speaker fees/consultant in advisory boards) from meetings from Novo Nordisk. C. Altisent has been a member Baxalta (Shire), Bayer Healthcare, CSL Behring, Kedrion, of advisory boards and/or speaker bureaus for Baxalta Novo Nordisk, Octapharma, Pfizer and SOBI. M. Sigaud has (Shire), Bayer, CSL Behring, Grifols, Octapharma, Novo Nor- received reimbursement for attending symposia/congresses, disk, Pfizer, Roche and SOBI. M. J. Belletrutti has received honoraria for speaking or for consulting from Biomarin, CSL research support from Octapharma, has acted as a consultant Behring, Novo Nordisk, Octapharma, Roche and Shire/ for Roche Canada, Sanofi and Takeda Canada, and has Takeda. J. K. M. Wu received funding to attend meetings participated in speaker bureaus for Octapharma Canada and has participated in Octapharma-funded clinical and Takeda Canada. M. Carcao received research support/ research. M. Jansen is a full-time employee of Octapharma grants from Bayer, Novo Nordisk, Pfizer, Sanofi and Takeda, GmbH, Vienna, Austria. L. Belyanskaya, O. Walter and and has participated in speaker bureaus for Bayer, CSL S. Knaub are employees of Octapharma AG, Lachen, Behring, Grifols, LFB, Novo Nordisk, Octapharma, Pfizer, Switzerland. E. J. Neufeld has received honoraria and partici- Roche, Sanofi and Takeda. M. Carvalho has been an investi- pated in advisory boards for Octapharma. He has been a gator on clinical trials sponsored by CSL Behring, Novo consultant for Genentech and Pfizer, and has participated in Nordisk, Octapharma and Roche, and has received support advisory boards for Novo Nordisk, Kedrion, Genentech, for attending scientific meetings and honoraria (speaker Baxalta/Shire (now Takeda), Novartis and CSL-Behring dur- fees/consultant in advisory boards) for Bayer, Baxalta (Shire), ing the course of the NuProtect study. He has served on data CSL Behring, Novo Nordisk, Octapharma, Pfizer, Siemens, monitoring committees for Bayer, Acceleron Pharma and SOBI and Stago. H. Chambost has received research support ApoPharma (now Chiesi), and received research funding from CSL Behring, LFB, Novo Nordisk, Octapharma, Roche/ from the American Thrombosis and Hemostasis Network Chugaï, Shire/Takeda, SOBI; honoraria from Bayer, LFB, Octa- (ATHN). L. Dubey, M. Gattens, P. Gresele, L. Kitanovski, pharma, Pfizer, Roche and SOBI. A. K. C. Chan has been an S. Lohade, V. Vdovin and K. Vilchevska declare no competing investigator on clinical trials sponsored by Bayer, Biogen, CSL, financial interests. Novo Nordisk, Octapharma and Shire and has received grants/research support from Bayer and Pfizer, and has Acknowledgments participated in advisory boards for Bayer, Biogen, BioMarin, We thank patients/caregivers for their participation and Novo Nordisk and Octapharma. J. Ducore has been an all trial personnel and investigators (including Marina investigator on clinical trials sponsored by Octapharma, Abashidze, Irmel Alaya, Olga Aleinikova, Shashikant CSL Behring, OPKO Biologics, Bayer, Baxalta (Shire), Sparks Apte, Annie Borel-Derlon, Mohamed El Khorassani, Jörg Therapeutics, Biogen, Pfizer, Genentech (Roche), LFB and Faber, Annie Harroche, Silvia Horneff, Natalya Kavarda- RevBio, has provided consultancy services to Octapharma, kova, Christoph Königs, Thierry Lambert, Dinesh Nayak, Bayer, Baxalta (Shire), Biogen and LFB, and is a speaker for Alexandra Russo, Amparo Santamaria and Valentin Turea). Bayer. Y. Gruel has received support for attending scientific meetings and honoraria (speaker fees/consultant in advisory References boards) from Baxalta (Shire), Bayer Healthcare, CSL Behring, 1 Konkle BA, Huston H, Fletcher SN. Hemophilia A. In: Adam MP, LFB, Novo Nordisk, Octapharma, Pfizer, Roche and SOBI, has Ardinger HH, Pagon RA, et al., eds. 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