1044479 research-article20212021 MSJ0010.1177/13524585211044479Multiple Sclerosis JournalA Bar-Or, H Wiendl MULTIPLE SCLEROSIS MSJ JOURNAL Original Research Paper Rapid and sustained B-cell depletion with Multiple Sclerosis Journal 2022, Vol. 28(6) 910­–924 subcutaneous ofatumumab in relapsing DOI: 10.1177/ https://doi.org/10.1177/13524585211044479 13524585211044479 https://doi.org/10.1177/13524585211044479 multiple sclerosis: APLIOS, a randomized © The Author(s), 2021. phase-2 study Article reuse guidelines: sagepub.com/journals- permissions Amit Bar-Or, Heinz Wiendl , Xavier Montalban, Enrique Alvarez, Maria Davydovskaya, Silvia R Delgado, Evgeniy P Evdoshenko, Natasa Giedraitiene, Katrin Gross-Paju, Sulev Haldre, Craig E Herrman, Guillermo Izquierdo, Guntis Karelis, Fritz Leutmezer, Miroslav Mares, Jose E Meca-Lallana, Dalia Mickeviciene, Jacqueline Nicholas, Derrick S Robertson, Denis V Sazonov, Kenneth Sharlin, Bharathy Sundaram, Natalia Totolyan, Marta Vachova, Martin Valis, Morten Bagger, Dieter A Häring, Inga Ludwig , Roman Willi , Martin Zalesak, Wendy Su, Martin Merschhemke and Edward J Fox; on behalf of the APLIOS trial investigators* Abstract Correspondence to: A Bar-Or Background: Ofatumumab, the first fully human anti-CD20 monoclonal antibody, is approved in several Center for Neuroinflammation and countries for relapsing multiple sclerosis (RMS). Experimental Therapeutics Objective: To demonstrate the bioequivalence of ofatumumab administered by an autoinjector versus a and Department of Neurology, Perelman School pre-filled syringe (PFS) and to explore the effect of ofatumumab on B-cell depletion. of Medicine, University of Pennsylvania, 3400 Spruce Methods: APLIOS (NCT03560739) is a 12-week, open-label, parallel-group, phase-2 study in patients Street - 3 Gates Building, with RMS receiving subcutaneous ofatumumab 20 mg every 4 weeks (q4w) (from Week 4, after initial Philadelphia, PA 19104, USA. doses on Days 1, 7, and 14). Patients were randomized 10:10:1:1 to autoinjector or PFS in the abdomen, amitbar@pennmedicine. or autoinjector or PFS in the thigh, respectively. Bioequivalence was determined by area under the curve upenn.edu Amit Bar-Or (AUCτ) and maximum plasma concentration (Cmax) for Weeks 8–12. B-cell depletion and safety/tolerabil- Center for ity were assessed. Neuroinflammation and Experimental Therapeutics Results: A total of 256 patients contributed to the bioequivalence analyses (autoinjector-abdomen, n = and Department of 128; PFS-abdomen, n = 128). Abdominal ofatumumab pharmacokinetic exposure was bioequivalent for Neurology, Perelman School of Medicine, University of autoinjector and PFS (geometric mean AUCτ, 487.7 vs 474.1 h × µg/mL (ratio 1.03); Cmax, 1.409 vs 1.409 Pennsylvania, Philadelphia, PA, USA µg/mL (ratio 1.00)). B-cell counts (median cells/µL) depleted rapidly in all groups from 214.0 (baseline) Heinz Wiendl to 2.0 (Day 14). Ofatumumab was well tolerated. Department of Neurology with Institute of Translational Conclusion: Ofatumumab 20 mg q4w self-administered subcutaneously via autoinjector is bioequivalent Neurology, University of to PFS administration and provides rapid B-cell depletion. Münster, Münster, Germany Xavier Montalban Keywords: Ofatumumab, bioequivalence, pharmacokinetics, pre-filled syringe, autoinjector pen, mul- Centre d’Esclerosi Múltiple tiple sclerosis de Catalunya (Cemcat), Hospital Universitari Vall d’Hebron, Barcelona, Spain Date received: 9 April 2021; revised: 19 July 2021; accepted: 7 August 2021 Enrique Alvarez Department of Neurology, Rocky Mountain MS Center, University of Colorado, Aurora, CO, USA Introduction and ofatumumab, demonstrate differences in epitope Maria Davydovskaya Pirogov Russian National Disease-modifying therapies (DMTs) for multiple scle- binding and induction of immune response.4,5 Research Medical University, rosis (MS) include anti-CD20 monoclonal antibodies Moscow, Russian Federation (mAbs). These highly effective treatments target Ofatumumab is the first fully human anti-CD20 mAb Silvia R Delgado MS Center and Department B-cells and a small subset of CD20-expressing T-cells, for the treatment of MS and, owing to its unique bind- of Neurology, Miller School causing their rapid depletion.1–3 Various anti-CD20 ing site, has a mode of action that is different to those of Medicine, University of Miami, Miami, FL, USA mAbs, such as rituximab, ocrelizumab, ublituximab, of other anti-CD20 mAbs. Ofatumumab binds to two 910 journals.sagepub.com/home/msj A Bar-Or, H Wiendl et al. distinct, non continuous regions on a unique confor- Harmonisation guidelines for Good Clinical Evgeniy P Evdoshenko St Petersburg Center mational epitope of the CD20 receptor, including the Practice,15 local regulatory requirements, and the for Multiple Sclerosis small and large extracellular loops.6 This results in a principles of the Declaration of Helsinki.16 The study and Other Autoimmune Diseases, St Petersburg, slower off-rate and an increased binding affinity com- protocol was approved by an independent ethics com- Russian Federation pared with previously developed anti-CD20 mAbs.1 mittee or institutional review board for each study Natasa Giedraitiene Clinic of Neurology and These properties allow induction of B-cell lysis, pri- site, and all patients provided written informed con- Neurosurgery, Institute marily occurring through pronounced complement- sent before commencing trial-related procedures. of Clinical Medicine, Faculty of Medicine, dependent cytotoxicity and efficient B-cell Vilnius University, depletion.6–8 Ofatumumab has similar clinical effi- Vilnius, Lithuania cacy to, and more favorable safety and tolerability Study design and patients Katrin Gross-Paju West-Tallinn Central profiles than other highly efficacious mAb DMTs (i.e. APLIOS was a randomized, open-label, multicenter, Hospital, Tallinn, alemtuzumab, natalizumab, and ocrelizumab).2,9–13 parallel-group, 12-week, phase-2 study conducted at Estonia/Institute of Health Care Technology, 30 centers in nine countries (Austria, Bulgaria, Czech TalTech, Tallinn, Estonia Previously approved anti-CD20 mAb treatments cannot Republic, Estonia, Latvia, Lithuania, Russian Sulev Haldre be easily and conveniently used by the patient at home Federation, Spain, and the United States). A parallel- Department of Neurology and Neurosurgery, and are typically administered in infusion centers for group, rather than a traditional crossover pharmacoki- University of Tartu, ease of safety monitoring.14 In contrast, ofatumumab netic (PK), study design was used to avoid potential Tartu, Estonia/Neurology Clinic, Tartu University has been developed for subcutaneous self-administra- carry-over treatment effects. Hospital, Tartu, Estonia tion at home at monthly doses of 20 mg (in 0.4 mL).1 Craig E Herrman Key inclusion criteria were as follows: age of 18–55 JWM Neurology, Indianapolis, IN, USA In the phase-3 ASCLEPIOS I/II trials in patients with years; a diagnosis of MS according to the 2010 revised Guillermo Izquierdo relapsing multiple sclerosis (RMS), ofatumumab 20 mg McDonald criteria,17 and RMS (relapsing–remitting Multiple Sclerosis Unit, Hospital Vithas NISA administered subcutaneously every 4 weeks (q4w) was MS or secondary progressive multiple sclerosis Sevilla, Sevilla, Spain superior to oral teriflunomide 14 mg once daily, with (SPMS) with disease activity) as defined by Lublin Guntis Karelis greater reductions in relapse rates, close to complete et al.;18 an Expanded Disability Status Scale score of Neurology and Neurosurgery abrogation of focal inflammatory disease activity on 0–5.5 (inclusive); a history of at least one relapse or a Department, Riga East magnetic resonance imaging (MRI), and greater delays gadolinium-enhancing (Gd+) T1 lesion in the previ- University Hospital and Riga Stradins University, in disability worsening.1 The majority of patients self- ous year, or of two relapses in the previous 2 years; Riga, Latvia injected ofatumumab at home with a pre-filled syringe and neurologically stable disease in the month before Fritz Leutmezer (PFS) after training and following the initial doses, randomization. Department of Neurology, Medical which were administered under medical supervision.1 University of Vienna, Key exclusion criteria were as follows: primary pro- Vienna, Austria Subcutaneous self-administration of ofatumumab in a gressive MS or SPMS without disease activity; Miroslav Mares Department of Neurology, nonclinical setting may offer advantages for patients, immune system diseases other than MS; an immuno- Pardubice Regional such as flexibility and convenience, as well as time deficiency syndrome; active systemic infections; and Hospital, Pardubice, Czech Republic and cost savings, owing to the avoidance of infusion suspected or confirmed progressive multifocal leu- Jose E Meca-Lallana procedures. An autoinjector (AI) pen could help facil- koencephalopathy. Pregnant or lactating women and Multiple Sclerosis CSUR, Department of itate self-administration at home, thus further reduc- women of childbearing potential, unless using highly Neurology, Virgen de ing treatment burden on patients. effective methods of contraception, were also la Arrixaca Clinical University Hospital— excluded. A full list of exclusion criteria is given in IMIB-Arrixaca, APLIOS was a 12-week, open-label, phase-2 study in the Supplementary Appendix. Murcia, Spain/Clinical Neuroimmunology patients with RMS designed to test bioequivalence and Multiple Sclerosis between ofatumumab 20 mg q4w administered sub- Cathedra, Universidad Católica San Antonio cutaneously by a PFS and by an AI pen. The course of Study procedures (UCAM), Murcia, Spain B-cell depletion associated with ofatumumab treat- Using interactive response technology, eligible patients Dalia Mickeviciene ment and MRI lesion activity were explored to char- were randomly assigned in a 10:10:1:1 ratio, respec- Lithuanian University of Health Sciences, Kaunas, acterize the effects of ofatumumab further. tively, to one of the following four groups (all using 20 Lithuania mg subcutaneous injection): (1) AI-abdomen—injection Jacqueline Nicholas with AI pen administered in the abdomen; (2) PFS- OhioHealth Riverside Methodist Hospital, Methods abdomen—injection with PFS administered in the abdo- Columbus, OH, USA men; (3) AI-thigh—injection with AI pen administered Derrick S Robertson Trial oversight: standard protocol approvals, in the thigh; and (4) PFS-thigh—injection with PFS Multiple Sclerosis Division, Department registrations, and patient consents administered in the thigh. The primary comparison was of Neurology, Morsani The APLIOS study (NCT03560739) was conducted between AI-abdomen and PFS-abdomen. Comparison College of Medicine, University of South in accordance with the International Conference on between abdomen and thigh groups was performed for Florida, Tampa, FL, USA journals.sagepub.com/home/msj 911 Multiple Sclerosis Journal 28(6) Denis V Sazonov PK profiles, with no formal testing. Randomization was included: (1) AUCτ and Cmax; (2) proportion of patients Department of Clinical Trials FSBIH SDMC stratified by body weight (<60, 60–90, and >90 kg) to with anti-ofatumumab antibodies (analyzed by a Meso of FMBA of Russia, ensure a balanced distribution between groups, thus lim- Scale Discovery electrochemiluminescence assay); and Novosibirsk, Russian Federation iting the potential effect of weight on the primary end- (3) adverse events (AEs), including injection-related Kenneth Sharlin points in this parallel-group design. systemic reactions (i.e. systemic reactions occurring in Sharlin Health and the 24 hours after an injection) and injection site reac- Neurology, Ozark, MO, USA All patients received open-label ofatumumab for 12 tions (i.e. reactions localized to the injection site), Bharathy Sundaram weeks, starting with initial 20 mg doses on Days 1, 7, abnormalities in vital signs, laboratory evaluations and Texas Institute for Neurological Disorders, and 14, followed by subsequent dosing of 20 mg q4w electrocardiograms, and electronic Columbia Suicide Sherman, TX, USA from Week 4 onwards (on Days 28, 56, and 84). Key Severity Rating Scale scores. AE severity was graded Natalia Totolyan assessment schedules included PK sampling on Days according to the Common Terminology Criteria for Department of Neurology, First 1, 4, 7, 14, 28, 42, 56, 57, 59, 63, 70, 77, and 84, with Adverse Events (CTCAE), version 5 (except change in Pavlov State Medical PK samples from Days 56–84 (Weeks 8–12) being serum amylase, which was assessed using version University of St Petersburg, St used for bioequivalence testing; immunogenicity at 4.03).19 Petersburg, Russian baseline and on Days 28, 56, and 84; B-cell counts at Federation baseline and on Days 1, 4, 7, 14, 28, 42, 56, and 84; and Exploratory endpoints included depletion of CD19+ Marta Vachova Department of MRI scans at screening and on Days 28, 56, and 84. B cells (as a surrogate for CD20+ B cells) and MRI Neurology, Teplice parameters (including new or persistent Gd+ T1 Hospital, Teplice, Czech Republic At the end of Week 12 (study completion), eligible lesions). Martin Valis patients could continue treatment with ofatumumab Department of by enrolling in an “umbrella,” open-label, phase-3b, Neurology, Faculty of Medicine in Hradec extension study (ALITHIOS (NCT03650114)). Statistical analyses Králové, Charles Patients who did not enter the extension study (n = 3) A sample size of 150 patients (124 in the abdomen University in Prague and University Hospital were followed up every 3 months for at least 9 months groups and 26 in the thigh groups) was calculated to Hradec Králové, or until B-cell repletion (i.e. until levels returned to provide at least 90% power for bioequivalence testing Hradec Králové, Czech Republic baseline values or to the lower limit of normal (LLN, between the PFS-abdomen and AI-abdomen groups, Morten Bagger 80 cells/µL), whichever came first) after study-drug assuming a PK variability not exceeding 85%, as meas- Dieter A Häring Inga Ludwig discontinuation. Further information on B-cell reple- ured by the coefficient of variation (CV). An interim Roman Willi tion following cessation of ofatumumab treatment analysis was planned to assess PK variability and to Martin Zalesak Martin Merschhemke will be collected as part of the ongoing ALITHIOS provide an opportunity to increase the sample size, if Novartis Pharma AG, study. needed, so that sufficient power for bioequivalence test- Basel, Switzerland ing could be achieved even with variability being higher Wendy Su Novartis Pharmaceutical than anticipated. After review of the CV for the initial Corporation, East Study objectives and outcome measures 36 patients, the total sample size was increased to 284 Hanover, NJ, USA The primary objective was to demonstrate bioequiva- patients, randomly assigned to the AI-abdomen (n = Edward J Fox Central Texas lence for injections of ofatumumab 20 mg in the 128), PFS-abdomen (n = 130), AI-thigh (n = 13), and Neurology Consultants abdomen administered via AI pen and those adminis- PFS-thigh (n = 13) groups. This was estimated to pro- PA, Round Rock, TX, USA tered via PFS. The primary endpoints were area under vide approximately 80% power for bioequivalence test- *A complete list of the plasma concentration–time curve over the dosing ing for CVs up to approximately 240%. investigators is provided interval (AUCτ) and maximum plasma concentration in the Supplementary Appendix. (Cmax) following drug administration. Assessment of Analysis of bioequivalence between abdominal PFS PK endpoints was based on data collected between and AI pen administration was conducted using the Weeks 8 and 12, during which approximate steady- reference-scaled average bioequivalence approach for state PK was anticipated. Plasma concentrations of highly variable drugs, which is recommended by the ofatumumab were determined by validated enzyme- US Food and Drug Administration,20,21 modified for a linked immunosorbent assay. A modified reference- parallel-group study design. Bioequivalence was scaled average bioequivalence approach was used to declared if the approximate 95% upper confidence establish bioequivalence, as described in the statisti- bound of the linearized criterion was equal to, or less cal analysis section. than, 0 and if the geometric mean ratio was contained within the predefined limits (0.80–1.25). As per the Secondary objectives included (1) comparison of PK protocol, bioequivalence testing was performed for profiles for ofatumumab injection in the abdomen ver- AUCτ and Cmax separately on all patients randomized sus the thigh; (2) assessment of ofatumumab immuno- to the PFS-abdomen and AI-abdomen groups with genicity; and (3) assessment of the safety and tolerability valid PK data during the dosing interval (Weeks 8–12; of ofatumumab. Endpoints for the secondary objectives n = 256). 912 journals.sagepub.com/home/msj A Bar-Or, H Wiendl et al. Screened patients N = 344 Excluded patients n = 60 Randomized patients N = 284 Ofatumumab 20 mg Ofatumumab 20 mg Ofatumumab 20 mg Ofatumumab 20 mg AI-abdomen PFS-abdomen AI-thigh PFS-thigh n = 128 n = 130 n = 13 n = 13 Patients contributing to Patients contributing to Patients contributing to Patients contributing to bioequivalence, bioequivalence analysis: PK and safety analyses: PK and safety analyses: PK, and safety analyses: n = 128 n = 13 n = 13 n = 128 Patients contributing to PK and safety analyses: n = 130 Figure 1. APLIOS patient flow chart. One patient in the PFS-abdomen group discontinued the study following a Grade-2 AE (blood IgM level decreased). Two patients in the PFS-abdomen group, including the patient who discontinued the study, did not contribute to the bioequivalence analysis because they missed the dose at Week 8 and had no data available for the dosing interval (Weeks 8–12). AE: adverse event; AI: autoinjector; PFS: pre-filled syringe; PK, pharmacokinetic. For the comparison of PK endpoints between abdomi- Results nal and thigh injection locations, sample size require- Of the 344 patients screened, 284 were randomly ments (26 patients, 13 per group) were based on the assigned to open-label ofatumumab in one of the conventional size of studies of this type and considered four groups. Most screening failures (57/60) were dropout rate (i.e. no formal statistical testing was due to patients not meeting inclusion/exclusion cri- planned). teria. In total, 258 patients (i.e. both abdomen groups) were initially planned for inclusion in the For secondary endpoints, summary statistics of ofatu- bioequivalence analysis but, given that two patients mumab plasma concentrations by time point were missed the Week-8 dose, data from 256 patients provided for the four groups contributing to the PK (PFS-abdomen: n = 128; AI-abdomen: n = 128) analysis (i.e. all randomized patients with PK data were included in the bioequivalence testing. Data during dose administration). Safety analyses, as well from all 284 randomized patients were included in as analyses of B-cell and Gd+ T1 lesion data, were the PK, safety, B-cell, and MRI analyses. Nearly all also conducted in all randomized patients who patients (n/N = 283/284, >99%) completed the received at least one dose of study drug. study; one patient in the PFS-abdomen group dis- continued owing to an AE (Figure 1). Baseline Statistical methods used in this study will be described demographics and disease characteristics were in detail in a separate article. broadly similar between the PFS-abdomen and AI-abdomen groups (Table 1). Data availability statement The APLIOS data are available on reasonable request, Pharmacokinetics provided that the request is in line with current ethical Primary endpoint: bioequivalence between AI pen and and intellectual property requirements surrounding PFS administration. Based on the reference-scaled the use of data. Requests should be directed through average bioequivalence approach, abdominal adminis- ClinicalStudyDataRequest.com. tration of ofatumumab via AI pen showed journals.sagepub.com/home/msj 913 Multiple Sclerosis Journal 28(6) Table 1. Baseline demographics and disease characteristics. Characteristic Ofatumumab 20 mg AI-abdomen, PFS-abdomen, AI-thigh, PFS-thigh, All patients, n = 128 n = 130 n = 13 n = 13 N = 284 Age, mean (SD), years 37.8 (9.37) 37.4 (8.66) 35.4 (8.75) 33.2 (6.18) 37.3 (8.92) Female, n (%) 92 (71.9) 90 (69.2) 9 (69.2) 8 (61.5) 199 (70.1) Race, n (%) American Indian or Alaska Native 1 (0.8) 0 0 0 1 (0.4) Black or African American 2 (1.6) 4 (3.1) 0 0 6 (2.1) White 125 (97.7) 125 (96.2) 13 (100) 12 (92.3) 275 (96.8) Mixed 0 1 (0.8) 0 1 (7.7) 2 (0.7) Ethnicity, n (%) Hispanic or Latino 5 (3.9) 4 (3.1) 0 1 (7.7) 10 (3.5) Not Hispanic or Latino 116 (90.6) 117 (90.0) 12 (92.3) 11 (84.6) 256 (90.1) Not reported 2 (1.6) 2 (1.5) 1 (7.7) 0 5 (1.8) Unknown 5 (3.9) 7 (5.4) 0 1 (7.7) 13 (4.6) Weight, mean (SD), kg 73.4 (17.8) 73.9 (19.0) 79.4 (21.3) 68.9 (14.7) 73.7 (18.4) BMI, mean (SD), kg/m2 25.5 (6.0) 25.6 (6.2) 26.8 (7.3) 24.0 (5.0) 25.5 (6.1) Duration of MS since diagnosis, mean (SD), years 6.9 (6.8) 6.9 (6.7) 5.2 (5.7) 2.3 (3.0) 6.6 (6.6) Duration of MS since first symptom, mean (SD), 9.4 (8.0) 9.6 (7.6) 7.2 (5.9) 6.8 (8.6) 9.3 (7.8) years Previous DMT, n (%) Treatment-naivea 40 (31.3) 38 (29.2) 4 (30.8) 8 (61.5) 90 (31.7) Previously treatedb 88 (68.8) 92 (70.8) 9 (69.2) 5 (38.5) 194 (68.3) Number of relapses in the 12 months before 1.3 (0.7) 1.4 (0.7) 1.5 (0.9) 1.2 (0.6) 1.3 (0.7) screening, mean (SD) Number of relapses in the 12–24 months before 1.0 (2.0) 1.0 (1.2) 0.8 (1.4) 0.6 (0.7) 1.0 (1.6) screening, mean (SD) Type of MS at study entry, n (%) RRMS 123 (96.1) 122 (93.8) 13 (100) 13 (100) 271 (95.4) SPMS 5 (3.9) 8 (6.2) 0 0 13 (4.6) EDSS score, mean (SD) 2.8 (1.3) 3.1 (1.3) 3.0 (1.0) 2.3 (1.1) 3.0 (1.3) Number of Gd+ T1 lesions, mean (SD) 1.0 (2.5) 2.0 (6.6) 3.0 (6.5) 0.3 (0.5) 1.5 (5.0) Patients free of Gd+ lesions, n (%) 83 (64.8) 78 (60.0) 8 (61.5) 8 (61.5) 177 (62.3) Total volume of T2 lesions, mean (SD), cm3 13.1 (16.6) 14.4 (15.9) 17.2 (27.6) 7.7 (9.1) 13.6 (16.7) Normalizedc brain volume, mean (SD), cm3 1446.4 (77.3) 1437.2 (81.4) 1465.9 (69.6) 1457.1 (49.3) 1443.7 (77.8) AI: autoinjector; PFS: pre-filled syringe; SD: standard deviation; BMI: body mass index; MS: multiple sclerosis; RRMS: relapsing–remitting MS; SPMS: secondary progressive MS; EDSS: Expanded Disability Status Scale; Gd+: gadolinium enhancing. aTreatment-naive patients have not received a prior MS (DMT). bA wash-out period was required for patients receiving certain MS DMTs before entering the APLIOS trial. Details of wash-out periods are included in the Supplementary Appendix. cNormalized for skull size. bioequivalence to that via PFS for both AUCτ and Cmax across groups regardless of administration device or in the dosing interval (Weeks 8–12; Table 2). The 95% injection site (Figure 2). Mean AUCτ and Cmax at upper bound of the linearized criterion was below 0 for Week 8 were also similar across groups regardless of both AUCτ (–0.3131) and Cmax (–0.2446). Geometric administration device or injection site (Table 3). mean ratios were contained within the predefined limits (0.8–1.25) for both AUCτ (1.03) and Cmax (1.00). Immunogenicity of ofatumumab Comparison of PK by injection site. Plasma concen- Results of ofatumumab anti-drug antibody (ADA) test- trations of ofatumumab at each time point were similar ing were positive in 7/284 patients (2.5%); however, 914 journals.sagepub.com/home/msj A Bar-Or, H Wiendl et al. Table 2. Bioequivalence testing of AUCτ and Cmax between AI-abdomen and PFS-abdomen during the dosing interval (Weeks 8–12). Ofatumumab 20 Ofatumumab 20 Treatment Meet Bioequivalence mg AI-abdomen, mg PFS-abdomen, comparison criteria criteria, n = 128 n = 130 (AI vs PFS) RSABE AUCτ  Patients with no missing 128 128 – – – values, n Geometric mean, h × µg/mL 487.7 474.1 – – – Geometric CV, % 103.5 79.7 – – – SDlog 0.854 0.701 – – – GMR – – 1.03 Yes 0.80–1.25  95% upper bound of the – – −0.3131 Yes ⩽0 linearized criterion Cmax  Patients with no missing 128 128 – – – values, n Geometric mean, µg/mL 1.409 1.409 – – – Geometric CV, % 89.2 67.9 – – – SDlog 0.765 0.616 – – – GMR – – 1.00 Yes 0.80–1.25  95% upper bound of the – – −0.2446 Yes ⩽0 linearized criterion AUCτ: area under the plasma concentration–time curve over the dosing interval; Cmax: maximum concentration; AI: autoinjector; PFS: pre-filled syringe; RSABE: reference-scaled average bioequivalence; CV: coefficient of variation; SDlog: standard deviation of data in log-scale; GMR: geometric mean ratio; BE: bioequivalence; SDlogr: standard deviation of reference group (PFS) in log-scale. −1 Geometric CV (%) was calculated as: ( variance for log − transformed data ) × 100 . RSABE method (applies if SDlog ⩾ 0.294): conclude BE if both the GMR and the 95% upper bound of the linearized criterion meet the specified criteria. Linearized criterion was calculated as: (log − scale mean difference) − θ × SDlogr , with θ = ln(1.25)/0.25. 2 2 2 six of these patients had a positive ADA test result at of patients with subsequent injections. The most fre- baseline, likely reflecting false-positive findings. Only quently reported symptoms associated with injection- one patient (0.4%) who did not have a positive ADA related systemic reactions were headache, chills, and test result at baseline had a transiently positive ADA fever, reported in 12.7%, 8.8%, and 8.5% of patients, test result at Week 8. There was no observed impact of respectively. Typically, symptoms resolved within 48 ADA on PK exposure or B-cell depletion. No patients hours for most patients. Injection site reactions were developed neutralizing antibodies to ofatumumab, as reported in 6.0% of patients with the first injection and assessed by a cell-based assay. ⩽3.2% of patients with subsequent injections. The most frequently reported symptoms associated with injection site reactions were erythema/redness and Safety and tolerability profile pain, reported in 5.3% and 3.2% of patients, respec- The overall incidence of AEs and serious AEs in the tively. Most AEs (97.5%) were CTCAE Grade-1/2 study population was 57.4% and 2.1%, respectively (mild/moderate). The overall incidence of Grade-3 (Table 4). The incidence of AEs leading to study-drug (severe) AEs was low (2.5%); all Grade-3 AEs were discontinuation was 0.4%. No deaths occurred during isolated events, each occurring in a single patient across the study. Commonly reported AEs (i.e. in ⩾2% of the groups. No Grade-4 AEs were reported. patients) are summarized in Table 4. Injection-related reactions were predominantly observed with the first Nearly all injection-related reactions were Grade-1/2 injection in all groups (Supplemental Figure S1). (mild/moderate); there was one Grade-3 (severe) Injection-related systemic reactions were reported in reaction with the first injection in one patient in the 25.0% of patients with the first injection, 8.1% of PFS-abdomen group. The patient had abdominal pain, patients with the second injection, and fewer than 2.8% arthralgia, asthenia, chills, dizziness, fatigue, fever, journals.sagepub.com/home/msj 915 Multiple Sclerosis Journal 28(6) Ofatumumab 20 mg AI-abdomen (n = 128) Ofatumumab 20 mg PFS-abdomen (n = 130) Ofatumumab 20 mg AI-thigh (n = 13) Ofatumumab 20 mg PFS-thigh (n = 13) 6 Ofatumumab plasma concentration (µg/mL) 5 4 3 2 1 0 1 4 7 14 28 42 56 57 59 63 70 77 84 Day Figure 2. Plasma concentrations of ofatumumab by nominal visit. The blue vertical arrows indicate the timing of dose administration. The shaded region indicates the Week 8−12 dosing interval that was considered for bioequivalence testing. AI: autoinjector; PFS: pre-filled syringe. Table 3. Summary statistics of AUCτ and Cmax at Week 8 dosing interval. Statistic Ofatumumab 20 mg AI-abdomen, PFS-abdomen, AI-thigh, PFS-thigh, All patients, n = 128 n = 130 n = 13 n = 13 N = 284 AUCτ Patients with no missing values, n 128 128 13 13 282 Mean, h × µg/mL 665.9 594.5 556.8 667.2 628.6 SD, h × µg/mL 545.96 412.66 283.01 329.23 470.32 CV, % 81.98 69.41 50.83 49.35 74.83 Cmax Patients with no missing values, n 128 128 13 13 282 Mean, µg/mL 1.827 1.684 1.850 1.792 1.761 SD, µg/mL 1.3016 1.0290 1.0332 0.7227 1.1477 CV, % 71.25 61.12 55.84 40.34 65.17 AUCτ: area under the plasma concentration–time curve over the dosing interval; Cmax: maximum concentration; AUC: area under the curve; AI: autoinjector; PFS: pre-filled syringe; SD: standard deviation; CV: coefficient of variation. headache, myalgia, nausea, and rash (alongside most commonly reported infections (occurring in milder site reactions), which lasted for 6 days. The ⩾2% of patients overall) were nasopharyngitis (2.8%) patient continued study treatment per protocol until and rhinitis (2.5%). Two serious infections (appendi- Week 12 (end of study). citis and pneumonia, both in the PFS-abdomen group) were reported in one patient each but neither led to Infections were reported in 58/284 patients (20.4%) study-drug discontinuation. No opportunistic infec- overall, with similar incidences across groups. The tions were reported. 916 journals.sagepub.com/home/msj A Bar-Or, H Wiendl et al. Table 4. Summary of AEs. Preferred term Ofatumumab 20 mg AI-abdomen, PFS-abdomen, AI-thigh, PFS-thigh, All patients, n = 128, n (%) n = 130, n (%) n = 13, n (%) n = 13, n (%) N = 284, n (%) Patients with AE(s) 79 (61.7) 70 (53.8) 7 (53.8) 7 (53.8) 163 (57.4) Common AE(s) (⩾2%)  Injection-related systemic 41 (32.0) 29 (22.3) 5 (38.5) 6 (46.2) 81 (28.5) reaction Injection site reaction 11 (8.6) 17 (13.1) 0 (0.0) 1 (7.7) 29 (10.2) Headache 13 (10.2) 7 (5.4) 0 (0.0) 1 (7.7) 21 (7.4) Diarrhea 6 (4.7) 4 (3.1) 1 (7.7) 0 (0.0) 11 (3.9) Fatigue 3 (2.3) 5 (3.8) 1 (7.7) 0 (0.0) 9 (3.2) Nasopharyngitis 2 (1.6) 5 (3.8) 0 (0.0) 1 (7.7) 8 (2.8) Rhinitis 3 (2.3) 3 (2.3) 0 (0.0) 1 (7.7) 7 (2.5) Patients with serious or other significant treatment-emergent events Death 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) SAE(s) 2 (1.6) 4 (3.1) 0 (0.0) 0 (0.0) 6 (2.1) Serious infections 0 (0.0) 2 (1.5) 0 (0.0) 0 (0.0) 2 (0.7)  Discontinued study treatment 0 (0.0) 1 (0.8) 0 (0.0) 0 (0.0) 1 (0.4) owing to any AE(s) AE: adverse event; AI: autoinjector; PFS: pre-filled syringe; SAE: serious adverse event. The number of patients with at least one event and the percentage of all patients in each group are shown. B-cell depletion Discussion By Day 14, B-cell counts were below the LLN (80 This randomized, open-label, phase-2 APLIOS study cells/µL) for all patients with available data (n = demonstrates bioequivalence between ofatumumab 273) who were receiving ofatumumab. Median 20 mg q4w administered subcutaneously in the abdo- B-cell counts were reduced from 214.0 cells/µL at men by AI pen and by PFS. Initial dosing with ofatu- baseline to 2.0 cells/µL at Day 14 (99.1% deple- mumab 20 mg on Days 1, 7, and 14 provided rapid tion) before administration of the third dose. At B-cell depletion, with subsequent doses q4w main- Week 4 (i.e. between the third and fourth doses), taining a continuous and almost complete B-cell median B-cell count was reduced to 1.0 cells/µL depletion throughout the study. This rapid and con- and remained at this level until Week 12 (end of tinuous B-cell depletion was seen for all patients study) (Figure 3(a)). The overall proportion of regardless of administration device, injection site, or patients with a B-cell count below 10 cells/µL was body weight. Notably, the efficient B-cell depletion 84.6% at Day 14, 94.0% at Week 4, 95.9% at Week was accompanied by marked reductions in Gd+ T1 8, and 98.2% at Week 12 (Figure 3(b)). B-cell lesion activity as early as Week 8, reaching more than depletion was similar across all body-weight quar- a 90% reduction compared with baseline by Week 12. tiles (Figure 3(c)). Alongside the pivotal phase-3 ASCLEPIOS I/II stud- ies, APLIOS provides further evidence for the rapid abrogation of new inflammatory disease activity with MRI endpoints ofatumumab. Systemic ofatumumab exposure was The mean number of new or persisting Gd+ T1 lesions similar between injection sites (abdomen or thigh). decreased from 1.5 at baseline to 0.8, 0.3, and 0.1 by The number of injection site reactions following Weeks 4, 8, and 12, respectively (Figure 4(a)). The administration via AI pen was slightly lower than that proportion of patients free of Gd+ T1 lesions increased following administration via PFS, which may influ- over time in all ofatumumab groups (Table 5). Across ence patient satisfaction (although this was not all groups, the proportions of patients free of Gd+ T1 assessed in the APLIOS study). lesions at baseline and Weeks 4, 8, and 12 were 64.2%, 66.5%, 86.7%, and 94.1%, respectively (Figure 4(b); The sustained B-cell suppression with ofatumumab, Table 5). regardless of body weight, was consistent with that journals.sagepub.com/home/msj 917 Multiple Sclerosis Journal 28(6) (a) 500 Ofatumumab 20 mg (N = 284) 400 B-cell counts (cells/µL) 300 200 100 0 1 4 7 14 28 42 56 84 Day (b) 100 80 with <10 B cells/µL (%) Proportion of patients 60 40 20 Ofatumumab 20 mg (N = 284) 0 1 4 7 14 28 42 56 84 Day (c) 100 80 with <10 B cells/µL (%) Proportion of patients 60 40 Ofatumumab 20 mg body weight Q1 ≤61.23 kg (n = 72) 20 Ofatumumab 20 mg body weight Q2 ≤61.23–70.00 kg (n = 72) Ofatumumab 20 mg body weight Q3 ≤70.00–84.85 kg (n = 69) Ofatumumab 20 mg body weight Q4 >84.85 kg (n = 71) 0 1 4 7 14 28 42 56 84 Day Figure 3. (a) Median number of B-cells over 12 weeks with subcutaneous ofatumumab 20 mg (N = 284), (b) proportion of patients with B-cells < 10 µL over time (N = 284), and (c) proportion of patients with B-cells < 10 µL over time stratified by body-weight quartile. The blue vertical arrows indicate the timing of dose administration. The analysis considered data until 30 days after the last injection. The shaded bands in parts (a) and (b) are 95% confidence intervals calculated using the Clopper–Pearson method. Q: quartile. 918 journals.sagepub.com/home/msj A Bar-Or, H Wiendl et al. (a) 2.5 Mean number of Gd+ T1 lesions 2.0 1.5 1.0 0.5 Ofatumumab 20 mg (N = 284) 0.0 0 4 8 12 Week (b) 100 Proportion of patients free 80 of Gd+ T1 lesions (%) 60 40 20 Ofatumumab 20 mg (N = 284) 0 0 4 8 12 Week Figure 4. (a) Number of new or persistent Gd+ T1 lesions and (b) proportion of patients free of Gd+ T1 lesions over 12 weeks with ofatumumab treatment. Pre-dose MRI assessments are displayed as time 0 on the x-axis. The analysis considers scans collected until 30 days after the last injection date. Gd+ T1 lesion counts from scans collected in the 14 days after termination of steroid therapy are excluded from the analysis. The shaded bands are 95% confidence intervals calculated (a) from bootstrap and (b) using the Clopper–Pearson method. Gd+: gadolinium-enhancing. Table 5. Proportion of patients free of Gd+ T1 lesions at Weeks 4, 8, and 12. Ofatumumab 20 mg AI-abdomen, PFS-abdomen, AI-thigh, n = 13, PFS-thigh, All patients, n = 128, n/M (%) n = 130, n/M (%) n/M (%) n = 13, n/M (%) N = 284, n/M (%) Baseline 82/126 (65.1) 78/123 (63.4) 8/13 (61.5) 8/12 (66.7) 176/274 (64.2) Week 4 82/121 (67.8) 75/116 (64.7) 8/12 (66.7) 8/11 (72.7) 173/260 (66.5) Week 8 105/124 (84.7) 107/122 (87.7) 11/12 (91.7) 12/13 (92.3) 235/271 (86.7) Week 12 114/122 (93.4) 115/123 (93.5) 13/13 (100) 12/12 (100) 254/270 (94.1) Gd+: gadolinium-enhancing; AI: autoinjector; n/M, number of patients who are in the corresponding category/total number of patients with a value for a specific visit window; PFS: pre-filled syringe. Gd+ T1 lesion counts from scans collected in the 14 days after termination of steroid therapy were excluded from the analysis. The analysis considers scans collected until 30 days after the last injection date. observed in the ASCLEPIOS I/II studies.1 Moreover, levels, which remained relatively stable between the sustained B-cell depletion associated with ofatu- doses. In contrast, a high-dose intravenous anti-CD20 mumab was achieved at low systemic drug exposure mAb administered every 6 months showed greater journals.sagepub.com/home/msj 919 Multiple Sclerosis Journal 28(6) overall fluctuations in plasma drug levels, with ini- findings that ofatumumab, given at low monthly tially high concentrations decreasing over time, thus doses of 20 mg (after initial dosing on Days 1, 7, and potentially allowing partial B-cell repletion between 14), exhibits favorable properties with regard to fast doses.22 In animal models, subcutaneous administra- and continuous B-cell depletion in all patients with tion of antibodies, compared with infusion, has been RMS. The APLIOS study demonstrated that this shown to permit more direct access to the lymph highly effective MS therapy with favorable safety and nodes via absorption into the lymphatic system, rather tolerability profiles can be administered using an AI than via the bloodstream,23,24 thus targeting B cells in device, allowing for home-based self-administration, the lymph nodes directly and sparing those in the thus reducing patient burden. spleen. This has been hypothesized to help to preserve immunosurveillance. Acknowledgements The authors thank patients for their participation in, In the APLIOS study, ofatumumab had favorable and commitment to, APLIOS and the clinical study safety and tolerability profiles, in line with those team for the conduct of the study. The authors are reported in the ASCLEPIOS I/II trials.1 The majority grateful to Xixi Hu and Mikhail Mikhaylov for gener- of injection-related systemic reactions in APLIOS ating data outputs for this article, to Angela Pozo were mild or moderate in severity and mostly associ- Ramajo and Karol Bociek (Oxford PharmaGenesis ated with the first injection. Injection-related reac- Ltd, Oxford, UK) for providing medical writing sup- tions with ofatumumab were less frequent in an port, and to Alessia Gonzato (Oxford PharmaGenesis indirect comparison with other anti-CD20 treatments Ltd, Oxford, UK) for providing editorial support. These that are administered at higher intravenous doses and services were sponsored by Novartis Pharma AG. require premedication, such as ocrelizumab (particu- larly when comparing early doses).25 Indeed, in the Author Contributions ASCLEPIOS I/II studies, there were no notable dif- See Appendix 1. ferences between ofatumumab and placebo injections (used in the teriflunomide arm to maintain treatment Declaration of Conflicting Interests blinding) in the frequency of injection-related reac- The author(s) declared the following potential conflicts tions after the first dose.1 The generally favorable of interest with respect to the research, authorship, and/ safety profile of ofatumumab may be related to its or publication of this article: A.B-O. reports grants and fully human nature and unique binding site, as well as personal fees from Biogen Idec and Genentech; and to the relatively low dose. personal fees from Atara Biotherapeutics, Brainstorm, Celgene/Receptos, GlaxoSmithKline, Janssen/Actelion, Compared with intravenous administration, subcuta- MAPI Pharma, MedImmune, Merck/EMD Serono, neous administration offers several advantages for Novartis, Roche, and Sanofi Genzyme, outside the sub- patients, including that it affords the flexibility and mitted work. H.W. reports grants and personal fees from convenience of self-administration at home or else- AbbVie, Biogen, Merck Serono, and Sanofi Genzyme; where, without the need to book an infusion appoint- personal fees from Actelion, Alexion, Evgen, F. ment or to travel to a clinic. This may be of particular Hoffmann-La Roche, Gemeinnützige Hertie-Stiftung, relevance in the context of the current coronavirus Immunic, Lundbeck, MedDay Pharmaceuticals, disease 2019 (COVID-19) pandemic and any similar Novartis, Roche Pharma AG, Teva, and WebMD Global; future situations. Moreover, subcutaneous administra- and grants from Deutsche Forschungsgesellschaft tion is likely to be more cost-effective than intrave- (DFG), Else Kröner Fresenius Foundation, European nous administration owing to the resource efficiency Union, Fresenius Foundation, German Ministry for of home-based administration.26 Patient preference Education and Research (BMBF), GlaxoSmithKline, for route of drug administration may also have impli- Hertie Foundation, Interdisciplinary Center for Clinical cations for treatment persistence and quality of life.26 Studies (IZKF) Muenster, NRW Ministry of Education Subcutaneous administration with AI pen, rather than and Research, PML Consortium, RE Children’s with PFS, is likely to offer further advantages, such as Foundation, and Swiss MS Society, outside the submit- reductions in perceived pain.27 ted work. X.M. reports personal fees and non financial support from Actelion, Biogen, Celgene, Excemed, F. Hoffmann-La Roche, Merck Serono, MSIF, National Conclusion Multiple Sclerosis Society (NMSS), Novartis, Sanofi The APLIOS study demonstrated bioequivalence Genzyme, and Teva, outside the submitted work. E.A. between ofatumumab administered into the abdomen reports compensation for activities such as advisory by AI pen and by PFS, and corroborated previous boards, lectures, and consultancy from Actelion/ 920 journals.sagepub.com/home/msj A Bar-Or, H Wiendl et al. Janssen, Alexion, Bayer, Biogen, Celgene/Bristol Pharma, Merck, Novartis, Receptos, Roche, Sanofi, and Myers Squibb, EMD Serono/Merck, Genentech/Roche, TG Therapeutics. M.V.1 reports speaker fees and con- Genzyme, Novartis, Sanofi, and TG Therapeutics; and sultant fees from Biogen Idec, Merck Serono, Novartis, research support from Biogen, Genentech/Roche, Roche, Sanofi Genzyme, and Teva. M.V.2 reports com- National Institutes of Health (NIH), NMSS, Novartis, pensation for travel, speaker fees, and consultant fees Patient-Centered Outcomes Research Initiative, Rocky from Biogen Idec, Merck Serono, Novartis, Roche, Mountain MS Center, and TG Therapeutics. M.D. Sanofi Genzyme, and Teva. M.B., D.A.H., I.L., R.W., reports grants and consulting or speaking fees from M.Z., W.S., and M.M.2 are employees of Novartis Biogen Idec, Celgene/Receptos, Janssen/Actelion, Pharma AG. E.J.F. reports compensation for research, Merck/EMD Serono, Novartis, Roche, and Sanofi consulting, speakers bureau, and/or advisory work Genzyme; S.R.D. reports grants and consulting fees from AbbVie, Alexion, Biogen, Bristol Myers Squibb, from Novartis; and grants from MAPI Pharma, NIH/ Chugai, EMD Serono, Genentech/Roche, MedDay, NINDS, and NMSS, outside the submitted work. E.P.E. Novartis, Sanofi Genzyme, and TG Therapeutics. reports grants and consulting or speaking fees from Biogen Idec, Celgene/Receptos, Janssen/Actelion, Funding MedImmune, Merck/EMD Serono, Novartis, Roche, The author(s) disclosed receipt of the following and Sanofi Genzyme. N.G. reports grants and consult- financial support for the research, authorship, and/or ing fees from Biogen, Merck Serono, Novartis, Roche, publication of this article: the APLIOS trial was Sanofi Genzyme, and Teva. K.G-P. reports grants and funded by Novartis Pharmaceuticals. Novartis consulting fees from Merck/EMD Serono, Novartis, Pharmaceuticals supported the development of this Roche, Sanofi Genzyme, and Teva. S.H. reports grants manuscript, provided data analyses according to the and consulting fees from Merck/EMD Serono, Roche, direction of the authors, and paid for medical writing Sanofi Genzyme, and Teva. C.E.H. has nothing to support. disclose. G.I. reports receiving fees for participating in speaker bureaus and/or advisory boards from ORCID iDs Actelion, Bayer, Biogen Idec, Celgene, Merck Serono, Heinz Wiendl https://orcid.org/0000-0003-4310- Novartis, Roche, Sanofi, and Teva. G.K. has nothing to 3432 disclose. F.L. reports grants and personal fees from Inga Ludwig https://orcid.org/0000-0002-2963- Biogen and Novartis; and personal fees from Celgene, 5179 MedDay, Merck, Roche, Sanofi Genzyme, and Teva. Roman Willi https://orcid.org/0000-0001-9612- M.M.1 has nothing to disclose. J.E.M-L. reports grants 9877 and consulting or speaking fees from Almirall, Biogen, Bristol Myers Squibb, Genzyme, Merck, Novartis, Supplemental Material Roche, and Teva. D.M. reports grants and consulting Supplemental material for this article is available fees from Merck/EMD Serono, Novartis, Roche, and online. Sanofi Genzyme, outside the submitted work. J.N. reports grants and consulting fees from Alexion, Biogen Idec, Genentech, Genzyme, and Novartis; consulting fees from EMD Serono and Greenwich Biosciences; References and speaking fees from Biogen Idec, Consortium of 1. Hauser SL, Bar-Or A, Cohen JA, et al. Ofatumumab Multiple Sclerosis Centers (CMSC), EMD Serono, versus teriflunomide in multiple sclerosis. N Engl J Genentech, Novartis, and Viela Bio. D.S.R. reports Med 2020; 383: 546–557. grant support from Janssen, MedDay Pharmaceuticals, 2. Hauser SL, Bar-Or A, Comi G, et al. Ocrelizumab Patient-Centered Outcomes Research Institute, and TG versus interferon beta-1a in relapsing multiple Therapeutics; grants and personal fees from Biogen, sclerosis. N Engl J Med 2017; 376: 221–234. EMD Serono, Genentech, Mallinckrodt, Novartis, Prime CME, and Sanofi Genzyme; and personal fees 3. Hauser SL, Waubant E, Arnold DL, et al. B-cell depletion with rituximab in relapsing-remitting from Alexion, Bristol Myers Squibb, CMSC, and multiple sclerosis. N Engl J Med 2008; 358: 676–688. Multiple Sclerosis Association of America. D.V.S. reports personal fees from BIOCAD and Novartis. K.S. 4. Du FH, Mills EA and Mao-Draayer Y. Next- reports receiving fees for participating in speakers generation anti-CD20 monoclonal antibodies bureaus from AbbVie and Biohaven Pharmaceuticals. in autoimmune disease treatment. Auto Immun B.S. has nothing to disclose. N.T. reports institutional Highlights 2017; 8: 12. research fees and personal fees from Actelion/Janssen, 5. Kaplon H and Reichert JM. Antibodies to watch in Alexion, BIOCAD (Russia), Generium (Russia), MAPI 2021. MAbs 2021; 13(1): 1860476. journals.sagepub.com/home/msj 921 Multiple Sclerosis Journal 28(6) 6. Lin TS. Ofatumumab: A novel monoclonal anti-CD20 17. Polman CH, Reingold SC, Banwell B, et al. antibody. Pharmgenomics Pers Med 2010; 3: 51–59. Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald criteria. Ann Neurol 2011; 7. Engelberts PJ, Voorhorst M, Schuurman J, et al. 69(2): 292–302. Type I CD20 antibodies recruit the B cell receptor for complement-dependent lysis of malignant B cells. 18. Lublin FD, Reingold SC, Cohen JA, et al. Defining J Immunol 2016; 197: 4829–4837. the clinical course of multiple sclerosis: The 2013 revisions. Neurology 2014; 83: 278–286. 8. Semple KM, Gonzaléz CM, Zarr M, et al. Evaluation of the ability of immune humanized mice to 19. US Department of Health and Human Services. demonstrate CD20-specific cytotoxicity induced by Common Terminology Criteria for Adverse Events ofatumumab. Clin Transl Sci 2019; 12(3): 283–290. (CTCAE), version 5.0, https://ctep.cancer.gov/ protocoldevelopment/electronic_applications/docs/ 9. Samjoo IA, Worthington E, Drudge C, et al. CTCAE_v5_Quick_Reference_8.5x11.pdf (2017, Comparison of ofatumumab and other disease- accessed 12 March 2020). modifying therapies for relapsing multiple sclerosis: A network meta-analysis. J Comp Eff Res 2020; 20. US Food and Drug Administration. Guidance 9(18): 1255–1274. document: Statistical approaches to establishing bioequivalence, https://www.fda.gov/regulatory- 10. Cohen JA, Coles AJ, Arnold DL, et al. Alemtuzumab information/search-fda-guidance-documents/ versus interferon beta 1a as first-line treatment for statistical-approaches-establishing-bioequivalence patients with relapsing-remitting multiple sclerosis: (2001, accessed 12 February 2020). A randomised controlled phase 3 trial. Lancet 2012; 380: 1819–1828. 21. Davit BM, Chen ML, Conner DP, et al. Implementation of a reference-scaled average 11. Coles AJ, Twyman CL, Arnold DL, et al. bioequivalence approach for highly variable Alemtuzumab for patients with relapsing multiple generic drug products by the US Food and Drug sclerosis after disease-modifying therapy: A Administration. AAPS J 2012; 14(4): 915–924. randomised controlled phase 3 trial. Lancet 2012; 380: 1829–1839. 22. Genentech. Ocrevus (Clinical Pharmacology and Biopharmaceutics Review). Genentech, https://www. 12. Kapoor R, Ho PR, Campbell N, et al. Effect of accessdata.fda.gov/drugsatfda_docs/nda/2017/761 natalizumab on disease progression in secondary 053Orig1s000ClinPharmR.pdf (2016, accessed 9 progressive multiple sclerosis (ASCEND): A phase November 2020). 3, randomised, double-blind, placebo-controlled trial with an open-label extension. Lancet Neurol 2018; 23. Kähäri L, Fair-Mäkelä R, Auvinen K, et al. 17(5): 405–415. Transcytosis route mediates rapid delivery of intact antibodies to draining lymph nodes. J Clin Invest 13. Polman CH, O’Connor PW, Havrdova E, et al. A 2019; 129: 3086–3102. randomized, placebo-controlled trial of natalizumab for relapsing multiple sclerosis. N Engl J Med 2006; 24. Theil D, Smith P, Huck C, et al. Imaging mass 354: 899–910. cytometry and single-cell genomics reveal differential depletion and repletion of B-cell populations 14. Genentech, Inc. Ocrevus (prescribing information). following ofatumumab treatment in cynomolgus San Francisco, CA: Genentech, Inc., https:// monkeys. Front Immunol 2019; 10: 1340. www.accessdata.fda.gov/drugsatfda_docs/ nda/2017/761053Orig1s000Lbl.pdf (2017, accessed 25. Mayer L, Kappos L, Racke MK, et al. Ocrelizumab 28 January 2021). infusion experience in patients with relapsing and primary progressive multiple sclerosis: Results from 15. European Medicines Agency. International the phase 3 randomized OPERA I, OPERA II, and Conference on Harmonisation: Guideline for good ORATORIO studies. Mult Scler Relat Disord 2019; clinical practice E6(R2), https://www.ema.europa. 30: 236–243. eu/en/documents/scientific-guideline/ich-e-6-r2- guideline-good-clinical-practice-step-5_en.pdf (2016, 26. Stoner KL, Harder H, Fallowfield LJ, et al. accessed 28 January 2021). Intravenous versus subcutaneous drug administration. Which do patients prefer? A systematic review. 16. World Medical Association. WMA Declaration of Patient 2015; 8: 145–153. Helsinki—ethical principles for medical research involving human subjects, https://www.wma.net/ 27. Cramer JA, Cuffel BJ, Divan V, et al. Patient policies-post/wma-declaration-of-helsinki-ethical- satisfaction with an injection device for multiple principles-for-medical-research-involving-human- sclerosis treatment. Acta Neurol Scand 2006; 113(3): subjects/ (2018, accessed 4 November 2020). 156–162. 922 journals.sagepub.com/home/msj A Bar-Or, H Wiendl et al. Appendix 1. Author contributions. Name Contribution Amit Bar-Or Trial design, responses to queries, data analysis, data review; manuscript review for intellectual content; and final manuscript approval Heinz Wiendl Trial design, data collection, responses to queries, and data review; manuscript review for intellectual content; and final manuscript approval Xavier Montalban Trial design, data collection, responses to queries, and data review; manuscript review for intellectual content; and final manuscript approval Enrique Alvarez Data collection and responses to queries; manuscript review for intellectual content; and final manuscript approval Maria Davydovskaya Data collection and responses to queries; manuscript review for intellectual content; and final manuscript approval Silvia R Delgado Data collection and responses to queries; manuscript review for intellectual content; and final manuscript approval Evgeny P Evdoshenko Data collection and responses to queries; manuscript review for intellectual content; and final manuscript approval Natasa Giedraitiene Data collection and responses to queries; manuscript review for intellectual content; and final manuscript approval Katrin Gross-Paju Data collection and responses to queries; manuscript review for intellectual content; and final manuscript approval Sulev Haldre Data collection and responses to queries; manuscript review for intellectual content; and final manuscript approval Craig E Herrman Data collection and responses to queries; manuscript review for intellectual content; and final manuscript approval Guillermo Izquierdo Data collection and responses to queries; manuscript review for intellectual content; and final manuscript approval Guntis Karelis Data collection and responses to queries; manuscript review for intellectual content; and final manuscript approval Fritz Leutmezer Data collection and responses to queries; manuscript review for intellectual content; and final manuscript approval Miroslav Mares Data collection and responses to queries; manuscript review for intellectual content; and final manuscript approval Jose E Meca-Lallana Data collection, responses to queries, data review, and safety data review; manuscript review for intellectual content; and final manuscript approval Dalia Mickeviciene Data collection and responses to queries; manuscript review for intellectual content; and final manuscript approval Jacqueline Nicholas Data analysis, data review, and safety data review; manuscript review for intellectual content; and final manuscript approval Derrick S Robertson Data collection and responses to queries; manuscript review for intellectual content; and final manuscript approval Denis V Sazonov Data collection and responses to queries; manuscript review for intellectual content; and final manuscript approval Kenneth Sharlin Data collection and responses to queries; manuscript review for intellectual content; and final manuscript approval Bharanthy Sundaram Data collection and responses to queries; manuscript review for intellectual content; and final manuscript approval Natalia Totolyan Data collection, responses to queries, and safety data review; manuscript review for intellectual content; and final manuscript approval Marta Vachova Data collection and responses to queries; manuscript review for intellectual content; and final manuscript approval Martin Valis Data collection and responses to queries; manuscript review for intellectual content; and final manuscript approval Morten Bagger Trial design, data collection, responses to queries, data analysis, data review, and writing of the manuscript; manuscript review for intellectual content; and final manuscript approval (Continued) journals.sagepub.com/home/msj 923 Multiple Sclerosis Journal 28(6) Appendix 1. (Continued) Name Contribution Dieter A Häring Trial design, statistical analysis, data review, data interpretation, and writing of the manuscript; review of the manuscript for intellectual content; and final manuscript approval Inga Ludwig Statistical analysis, data review, data interpretation, and writing of the manuscript; manuscript review for intellectual content; and final manuscript approval Roman Willi Data collection, responses to queries, data review, and writing of the manuscript; manuscript review for intellectual content; and final manuscript approval Martin Zalesak Data collection, responses to queries, data review, and safety data review; manuscript review for intellectual content; and final manuscript approval Wendy Su Data collection, responses to queries, data analysis, data review, and safety data review; manuscript review for intellectual content; and final manuscript approval Martin Merschhemke Data collection, responses to queries, data analysis, data review, and safety data review; Visit SAGE journals online journals.sagepub.com/ manuscript review for intellectual content; and final manuscript approval home/msj Edward J Fox Data collection and responses to queries; manuscript review for intellectual content; and final manuscript approval SAGE journals 924 journals.sagepub.com/home/msj