Takeda Pharmaceutical Company Limited (TSE:4502/NYSE:TAK) (“Takeda”) today announced further results from the VARSITY study, which demonstrated the superiority of the gut-selective biologic vedolizumab (Entyvio®) to the anti-tumor necrosis factor-alpha (anti-TNFα) biologic adalimumab (Humira®) in achieving the primary endpoint of clinical remission* at week 52 in patients with moderately to severely active ulcerative colitis (UC), have been published in The New England Journal of Medicine (NEJM).1 Clinical remission rates at week 52 were superior with vedolizumab at 31.3% (n=120/383) versus 22.5% (n=87/386) with adalimumab (p=0.006).1
New exploratory data^ published in the NEJM showed vedolizumab achieved higher percentages of clinical remission at week 52 compared to adalimumab in both anti-TNFα-naïve patients (34.2% [n=104/304] vedolizumab vs. 24.3% [n=74/305] adalimumab) and anti-TNFα-experienced patients with UC (20.3% [n=16/79] vedolizumab vs. 16.0% [n=13/81] adalimumab).1 Further exploratory data showed 26.6% (n=102/383) of vedolizumab-treated patients achieved clinical remission at week 14 as compared to 21.2% (n=82/386) treated with adalimumab.1 Durable clinical remission† was achieved in 18.3% (n=70/383) of patients with vedolizumab and 11.9% (n=46/386) of patients with adalimumab respectively.1
In the secondary endpoints of the study, treatment with vedolizumab was associated with significantly higher percentages of mucosal healing** at week 52 compared to patients treated with adalimumab (39.7% [n=152/383] vs. 27.7% [n=107/386]; p<0.001).1 Vedolizumab was not superior to adalimumab in the percentage of patients using oral corticosteroids at baseline who discontinued corticosteroids and were in clinical remission*** at week 52 (12.6% [n=14/111] vs. 21.8% [n=26/119]).1 Exploratory results for the median change in oral corticosteroid use from baseline to week 52 were -10.0 mg in the vedolizumab group compared to -7.0 mg in the adalimumab group.1
Further exploratory results published in the NEJM showed that treatment with vedolizumab was associated with improvements in quality of life, with 52.0% (n=199/383) of vedolizumab-treated versus 42.2% (n=163/386) of adalimumab-treated patients reporting a ≥16-point improvement in total Inflammatory Bowel Disease Questionnaire (IBDQ) scores from baseline to week 52.1 The IBDQ examines the impact of inflammatory bowel disease on four aspects of patients’ lives: symptoms directly related to the primary bowel disturbance, systemic symptoms, and emotional and social function.2
“In a chronic, debilitating condition like ulcerative colitis, it is essential that patients gain relief from the many different aspects of the disease,” said Dr. Bruce E. Sands, primary investigator of the VARSITY study and Chief of the Dr. Henry D. Janowitz Division of Gastroenterology at The Mount Sinai Hospital and the Icahn School of Medicine at Mount Sinai in New York. “The VARSITY results provide physicians with valuable insights to support their treatment decisions when initiating biologic therapy in patients with ulcerative colitis.”
An exploratory analysis was also performed to evaluate the effect of vedolizumab and adalimumab therapy on clinical response and absence of active histologic disease. The exploratory analysis showed that 67.1% (n=257/383) of patients receiving vedolizumab achieved clinical responseǂ at week 14 compared to 45.9% (n=177/386) treated with adalimumab.1 A separation between the treatment groups was seen as early as week 6, favoring vedolizumab.3 Absence of active histologic disease±, as defined by the Geboes Score (<3.2) and Robarts Histopathology Index (<5), was achieved at week 52 in 33.4% (n=128/383) and 42.3% (n=162/383) of patients treated with vedolizumab, respectively, compared with 13.7% (n=53/386) and 25.6% (n=99/386) of patients treated with adalimumab, respectively.1
“The VARSITY study, a first-of-its-kind comparison of two biologics in ulcerative colitis, shows the benefits vedolizumab treatment provides to patients versus adalimumab across efficacy outcomes, in addition to improvements in overall quality of life,” said Jeff Bornstein, M.D., Executive Medical Director, Takeda. “These data further support the use of vedolizumab as a first-line biologic therapy in ulcerative colitis.”
While the study was not powered to compare the safety of the two biologics, patients treated with vedolizumab (62.7%; n=240/383) had a lower percentage of overall adverse events over 52 weeks than patients treated with adalimumab (69.2%; n=267/386). The percentage of serious adverse events was also lower in vedolizumab-treated patients than adalimumab (11.0% [n=42/383] vs. 13.7% [n=53/386] respectively).1 The proportion of patients who discontinued treatment because of adverse events was similar in both groups.1
^Exploratory endpoints were not powered for superiority in the VARSITY study. All endpoints other than the primary and two secondary endpoints are considered exploratory endpoints.
* Primary endpoint: Clinical remission is defined as a complete Mayo score of ≤2 points and no individual subscore ˃1 point. Mayo score: instrument designed to measure disease activity of ulcerative colitis.1,4
** Secondary endpoint: Mucosal healing (termed endoscopic improvement in the NEJM publication) is defined as a Mayo endoscopic subscore of ≤1 point.1,4
*** Secondary endpoint: Corticosteroid-free clinical remission is defined as patients using oral corticosteroids at baseline (week 0) who have discontinued oral corticosteroids and are in clinical remission at week 52.1,4
† Exploratory endpoint: Durable clinical remission is defined as clinical remission at week 52 among patients in clinical remission at week 14.1
ǂ Exploratory endpoint: Clinical response based on complete Mayo score at week 14 is defined as a reduction in complete Mayo score of ≥3 points and ≥30% from baseline with an accompanying decrease in rectal bleeding subscore of ≥1point or absolute rectal bleeding subscore of ≤1 point. Patients with missing clinical response status were considered non-responders.1
± Exploratory endpoint: Histologic disease activity is an endpoint assessing the degree of microscopic inflammation in the gut. Absence of active histologic disease (termed minimal histologic disease activity in the NEJM manuscript) is achieved when inflammation is less than a pre-defined severity threshold. Absence of active histologic disease is defined as a Geboes Score (<3.2) or Robarts Histopathology Index (<5).1,5,6
VARSITY is a Phase 3b, randomized, double-blind, double-dummy, multi-center, active-controlled study to evaluate the efficacy and safety of vedolizumab intravenous (IV) compared to adalimumab subcutaneous (SC) at week 52 in patients with moderately to severely active ulcerative colitis (UC). The study treated 769 patients (vedolizumab n=383 or adalimumab n=386), all of whom had inadequate response with, loss of response to, or intolerance to corticosteroids, immunomodulators, or one tumor necrosis factor-alpha (TNFα)-antagonist other than adalimumab prior to being enrolled. Prior TNFα-antagonist exposure was capped at 25% of the patient population in the study, with 609 patients being anti-TNFα-naïve versus 160 being anti-TNFα-experienced.1,4
Patients were randomized into one of two treatment groups, vedolizumab IV and placebo SC or adalimumab SC and placebo IV. Patients in the vedolizumab group were administered vedolizumab IV 300 mg at weeks 0, 2, 6 and every 8 weeks thereafter until week 46, along with placebo SC at week 0 and every 2 weeks until week 50. The adalimumab group were administered adalimumab SC 160 mg at week 0, 80 mg at week 2 and 40 mg every 2 weeks until week 50, along with placebo IV at weeks 0, 2, 6 and every 8 weeks thereafter until week 46. Dose escalation was not permitted in either treatment arm during the study.1,4
Ulcerative colitis (UC) is one of the most common forms of inflammatory bowel disease (IBD).7 UC is a chronic, relapsing, remitting, inflammatory condition of the gastrointestinal tract that is often progressive in nature, and involves the innermost lining of the large intestine.8,9 UC commonly presents with symptoms of abdominal discomfort and loose bowel movements, including blood or pus.9,10 The cause of UC is not fully understood; however, recent research suggests hereditary, genetics, environmental factors, and/or an abnormal immune response to microbial antigens in genetically predisposed individuals can lead to the condition.9,11,12
Vedolizumab is a gut-selective biologic and is approved as an intravenous (IV) formulation.13 It is a humanized monoclonal antibody designed to specifically antagonize the alpha4beta7 integrin, inhibiting the binding of alpha4beta7 integrin to intestinal mucosal addressin cell adhesion molecule 1 (MAdCAM-1), but not vascular cell adhesion molecule 1 (VCAM-1).14 MAdCAM-1 is preferentially expressed on blood vessels and lymph nodes of the gastrointestinal tract.15 The alpha4beta7 integrin is expressed on a subset of circulating white blood cells.14 These cells have been shown to play a role in mediating the inflammatory process in ulcerative colitis (UC) and Crohn’s disease (CD).14,16,17 By inhibiting alpha4beta7 integrin, vedolizumab may limit the ability of certain white blood cells to infiltrate gut tissues.14
Vedolizumab IV is approved for the treatment of adult patients with moderately to severely active UC and CD, who have had an inadequate response with, lost response to, or were intolerant to either conventional therapy or a tumor necrosis factor-alpha (TNFα)-antagonist.13 Vedolizumab IV has been granted marketing authorization in over 60 countries, including the United States and European Union, with more than 330,000 patient years of exposure to date.18
Vedolizumab is indicated for the treatment of adult patients with moderately to severely active ulcerative colitis who have had an inadequate response with, lost response to, or were intolerant to either conventional therapy or a tumor necrosis factor-alpha (TNFα) antagonist.
Vedolizumab is indicated for the treatment of adult patients with moderately to severely active Crohn’s disease who have had an inadequate response with, lost response to, or were intolerant to either conventional therapy or a tumor necrosis factor-alpha (TNFα) antagonist.
Hypersensitivity to the active substance or to any of the excipients.
Special warnings and special precautions for use
Vedolizumab should be administered by a healthcare professional prepared to manage hypersensitivity reactions, including anaphylaxis, if they occur. Appropriate monitoring and medical support measures should be available for immediate use when administering vedolizumab. Observe patients during infusion and until the infusion is complete.
In clinical studies, infusion-related reactions (IRR) and hypersensitivity reactions have been reported, with the majority being mild to moderate in severity. If a severe IRR, anaphylactic reaction, or other severe reaction occurs, administration of vedolizumab must be discontinued immediately and appropriate treatment initiated (e.g., epinephrine and antihistamines). If a mild to moderate IRR occurs, the infusion rate can be slowed or interrupted and appropriate treatment initiated (e.g., epinephrine and antihistamines). Once the mild or moderate IRR subsides, continue the infusion. Physicians should consider pre-treatment (e.g., with antihistamine, hydrocortisone and/or paracetamol) prior to the next infusion for patients with a history of mild to moderate IRR to vedolizumab, in order to minimize their risks.
Vedolizumab is a gut-selective integrin antagonist with no identified systemic immunosuppressive activity. Physicians should be aware of the potential increased risk of opportunistic infections or infections for which the gut is a defensive barrier. Vedolizumab treatment is not to be initiated in patients with active, severe infections such as tuberculosis, sepsis, cytomegalovirus, listeriosis, and opportunistic infections until the infections are controlled, and physicians should consider withholding treatment in patients who develop a severe infection while on chronic treatment with vedolizumab. Caution should be exercised when considering the use of vedolizumab in patients with a controlled chronic severe infection or a history of recurring severe infections. Patients should be monitored closely for infections before, during and after treatment. Before starting treatment with vedolizumab, screening for tuberculosis may be considered according to local practice. Some integrin antagonists and some systemic immunosuppressive agents have been associated with progressive multifocal leukoencephalopathy (PML), which is a rare and often fatal opportunistic infection caused by the John Cunningham (JC) virus. By binding to the α4β7 integrin expressed on gut-homing lymphocytes, vedolizumab exerts an immunosuppressive effect specific to the gut. Although no systemic immunosuppressive effect was noted in healthy subjects, the effects on systemic immune system function in patients with inflammatory bowel disease are not known. Healthcare professionals should monitor patients on vedolizumab for any new onset or worsening of neurological signs and symptoms, and consider neurological referral if they occur. If PML is suspected, treatment with vedolizumab must be withheld; if confirmed, treatment must be permanently discontinued. Typical signs and symptoms associated with PML are diverse, progress over days to weeks, and include progressive weakness on one side of the body, clumsiness of limbs, disturbance of vision, and changes in thinking, memory, and orientation leading to confusion and personality changes. The progression of deficits usually leads to death or severe disability over weeks or months.
The risk of malignancy is increased in patients with ulcerative colitis and Crohn’s disease. Immunomodulatory medicinal products may increase the risk of malignancy.
Prior and concurrent use of biological products
No vedolizumab clinical trial data are available for patients previously treated with natalizumab. No clinical trial data for concomitant use of vedolizumab with biologic immunosuppressants are available. Therefore, the use of vedolizumab in such patients is not recommended.
Prior to initiating treatment with vedolizumab all patients should be brought up to date with all recommended immunizations. Patients receiving vedolizumab may receive non-live vaccines (e.g., subunit or inactivated vaccines) and may receive live vaccines only if the benefits outweigh the risks.
Adverse reactions include: nasopharyngitis, headache, arthralgia, upper respiratory tract infection, bronchitis, influenza, sinusitis, cough, oropharyngeal pain, nausea, rash, pruritus, back pain, pain in extremities, pyrexia, fatigue and anaphylaxis.
Please consult with your local regulatory agency for approved labeling in your country.
Gastrointestinal (GI) diseases can be complex, debilitating and life-changing. Recognizing this unmet need, Takeda and our collaboration partners have focused on improving the lives of patients through the delivery of innovative medicines and dedicated patient disease support programs for over 25 years. Takeda aspires to advance how patients manage their disease. Additionally, Takeda is leading in areas of gastroenterology associated with high unmet need, such as inflammatory bowel disease, acid-related diseases and motility disorders. Our GI Research & Development team is also exploring solutions in celiac disease and liver diseases, as well as scientific advancements through microbiome therapies.
Takeda Pharmaceutical Company Limited (TSE:4502/NYSE:TAK) is a global, values-based, R&D-driven biopharmaceutical leader headquartered in Japan, committed to bringing Better Health and a Brighter Future to patients by translating science into highly-innovative medicines. Takeda focuses its R&D efforts on four therapeutic areas: Oncology, Gastroenterology (GI), Rare Diseases, and Neuroscience. We also make targeted R&D investments in Plasma-Derived Therapies and Vaccines. We are focusing on developing highly innovative medicines that contribute to making a difference in people's lives by advancing the frontier of new treatment options and leveraging our enhanced collaborative R&D engine and capabilities to create a robust, modality-diverse pipeline. Our employees are committed to improving quality of life for patients and to working with our partners in health care in approximately 80 countries and regions.
For more information, visit https://www.takeda.com.
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