Clinical Effects of the Self-administered Subcutaneous Complement Inhibitor Zilucoplan in Patients With Moderate to Severe Generalized Myasthenia Gravis: Results of a Phase 2 Randomized, Double-Blind, Placebo-Controlled, Multicenter Clinical Trial | Myasthenia Gravis | JAMA Neurology | JAMA Network
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Figure 1.  CONSORT Diagram of the Zilucoplan Phase 2 Study in Patients With Acetylcholine Receptor Autoantibody (AChR-Ab)–Positive Generalized Myasthenia Gravis
CONSORT Diagram of the Zilucoplan Phase 2 Study in Patients With Acetylcholine Receptor Autoantibody (AChR-Ab)–Positive Generalized Myasthenia Gravis

Two patients discontinued the study drug before week 12: 1 placebo-treated patient discontinued owing to an adverse event of worsening myasthenia gravis and 1 patient receiving zilucoplan, 0.3 mg/kg, discontinued because of a prolonged admission at an outside hospital owing to exacerbation of preexisting diverticulitis with paracolic abscess.

Figure 2.  Change From Baseline Over 12 Weeks for 0.3-mg/kg Zilucoplan vs Placebo in Quantitative Myasthenia Gravis (QMG), Myasthenia Gravis Activities of Daily Living (MG-ADL), Myasthenia Gravis Quality-of-Life Revised Scale (MG-QoL15r), and Myasthenia Gravis Composite (MGC)
Change From Baseline Over 12 Weeks for 0.3-mg/kg Zilucoplan vs Placebo in Quantitative Myasthenia Gravis (QMG), Myasthenia Gravis Activities of Daily Living (MG-ADL), Myasthenia Gravis Quality-of-Life Revised Scale (MG-QoL15r), and Myasthenia Gravis Composite (MGC)

CFB indicates change from baseline.

aP < .10.

Figure 3.  Categorical End Points
Categorical End Points

A, Responder analysis for Quantitative Myasthenia Gravis (QMG) score with 0.3-mg/kg zilucoplan daily subcutaneously. B, Minimal symptom expression (MSE), defined as Myasthenia Gravis Activities of Daily Living score of 0 or 1 at 12 weeks. C, Patients who received treatment with rescue therapy with intravenous immunoglobulin or plasma exchange.

Table 1.  Demographics and Baseline Characteristics
Demographics and Baseline Characteristics
Table 2.  Clinical Efficacy Outcomes at Week 12
Clinical Efficacy Outcomes at Week 12
1.
Gilhus  NE.  Myasthenia gravis.   N Engl J Med. 2016;375(26):2570-2581. doi:10.1056/NEJMra1602678PubMedGoogle ScholarCrossref
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Gilhus  NE, Tzartos  S, Evoli  A, Palace  J, Burns  TM, Verschuuren  JJGM.  Myasthenia gravis.   Nat Rev Dis Primers. 2019;5(1):30. doi:10.1038/s41572-019-0079-yPubMedGoogle ScholarCrossref
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Engel  AG, Lindstrom  JM, Lambert  EH, Lennon  VA.  Ultrastructural localization of the acetylcholine receptor in myasthenia gravis and in its experimental autoimmune model.   Neurology. 1977;27(4):307-315. doi:10.1212/WNL.27.4.307PubMedGoogle ScholarCrossref
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Howard  JF  Jr, Utsugisawa  K, Benatar  M,  et al; REGAIN Study Group.  Safety and efficacy of eculizumab in anti-acetylcholine receptor antibody-positive refractory generalised myasthenia gravis (REGAIN): a phase 3, randomised, double-blind, placebo-controlled, multicentre study.   Lancet Neurol. 2017;16(12):976-986. doi:10.1016/S1474-4422(17)30369-1PubMedGoogle ScholarCrossref
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Muppidi  S, Utsugisawa  K, Benatar  M,  et al; Regain Study Group.  Long-term safety and efficacy of eculizumab in generalized myasthenia gravis.   Muscle Nerve. 2019;60(1):14-24. doi:10.1002/mus.26447PubMedGoogle Scholar
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Ricardo  A, Arata  M, DeMarco  S,  et al.  Preclinical evaluation of RA101495, a potent cyclic peptide inhibitor of C5 for the treatment of paroxysmal nocturnal hemoglobinuria  [abstract].  Blood. 2015;126:939. doi:10.1182/blood.V126.23.939.939Google ScholarCrossref
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Jackson  MB, Stephens  CL, Lecar  H.  Single channel currents induced by complement in antibody-coated cell membranes.   Proc Natl Acad Sci U S A. 1981;78(10):6421-6425. doi:10.1073/pnas.78.10.6421PubMedGoogle ScholarCrossref
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Farmakidis  C, Pasnoor  M, Dimachkie  MM, Barohn  RJ.  Treatment of myasthenia gravis.   Neurol Clin. 2018;36(2):311-337. doi:10.1016/j.ncl.2018.01.011PubMedGoogle ScholarCrossref
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Hartung  HP.  Advances in the understanding of the mechanism of action of IVIg.   J Neurol. 2008;255(suppl 3):3-6. doi:10.1007/s00415-008-3002-0PubMedGoogle ScholarCrossref
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Howard  JF  Jr, Barohn  RJ, Cutter  GR,  et al; MG Study Group.  A randomized, double-blind, placebo-controlled phase II study of eculizumab in patients with refractory generalized myasthenia gravis.   Muscle Nerve. 2013;48(1):76-84. doi:10.1002/mus.23839PubMedGoogle ScholarCrossref
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Myasthenia Gravis Foundation of America. Myasthenia gravis: a manual for the health care provider. https://myasthenia.org/Portals/0/Provider%20Manual_ibook%20version.pdf. Accessed September 3, 2019.
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Barohn  RJ, McIntire  D, Herbelin  L, Wolfe  GI, Nations  S, Bryan  WW.  Reliability testing of the quantitative myasthenia gravis score.   Ann N Y Acad Sci. 1998;841:769-772. doi:10.1111/j.1749-6632.1998.tb11015.xPubMedGoogle ScholarCrossref
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Katzberg  HD, Barnett  C, Merkies  IS, Bril  V.  Minimal clinically important difference in myasthenia gravis: outcomes from a randomized trial.   Muscle Nerve. 2014;49(5):661-665. doi:10.1002/mus.23988PubMedGoogle ScholarCrossref
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Wolfe  GI, Herbelin  L, Nations  SP, Foster  B, Bryan  WW, Barohn  RJ.  Myasthenia gravis activities of daily living profile.   Neurology. 1999;52(7):1487-1489. doi:10.1212/WNL.52.7.1487PubMedGoogle ScholarCrossref
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Burns  TM, Conaway  MR, Cutter  GR, Sanders  DB; Muscle Study Group.  Less is more, or almost as much: a 15-item quality-of-life instrument for myasthenia gravis.   Muscle Nerve. 2008;38(2):957-963. doi:10.1002/mus.21053PubMedGoogle ScholarCrossref
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Burns  TM, Grouse  CK, Conaway  MR, Sanders  DB; MG Composite and MG-QoL15 study group.  Construct and concurrent validation of the MG-QOL15 in the practice setting.   Muscle Nerve. 2010;41(2):219-226. doi:10.1002/mus.21609PubMedGoogle Scholar
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Muppidi  S, Wolfe  GI, Conaway  M, Burns  TM; MG Composite And MG-QoL15 Study Group.  MG-ADL: still a relevant outcome measure.   Muscle Nerve. 2011;44(5):727-731. doi:10.1002/mus.22140PubMedGoogle ScholarCrossref
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Burns  TM, Conaway  M, Sanders  DB; MG Composite and MG-QOL15 Study Group.  The MG composite: a valid and reliable outcome measure for myasthenia gravis.   Neurology. 2010;74(18):1434-1440. doi:10.1212/WNL.0b013e3181dc1b1ePubMedGoogle ScholarCrossref
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Burns  TM, Sadjadi  R, Utsugisawa  K,  et al.  International clinimetric evaluation of the MG-QOL15, resulting in slight revision and subsequent validation of the MG-QOL15r.   Muscle Nerve. 2016;54(6):1015-1022. doi:10.1002/mus.25198PubMedGoogle ScholarCrossref
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Vissing  J, Jacob  S, Fujita  K, O’Brien  F, Howard  JF  Jr.  Minimal symptom expression with eculizumab in myasthenia gravis.   Muscle Nerve. 2018;58:S98. doi:10.1002/mus.26353Google ScholarCrossref
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Socié  G, Caby-Tosi  MP, Marantz  JL,  et al.  Eculizumab in paroxysmal nocturnal haemoglobinuria and atypical haemolytic uraemic syndrome: 10-year pharmacovigilance analysis.   Br J Haematol. 2019;185(2):297-310. doi:10.1111/bjh.15790PubMedGoogle ScholarCrossref
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Ruff  RL, Lisak  RP.  Nature and action of antibodies in myasthenia gravis.   Neurol Clin. 2018;36(2):275-291. doi:10.1016/j.ncl.2018.01.001PubMedGoogle ScholarCrossref
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Grob  D, Brunner  N, Namba  T, Pagala  M.  Lifetime course of myasthenia gravis.   Muscle Nerve. 2008;37(2):141-149. doi:10.1002/mus.20950PubMedGoogle ScholarCrossref
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Cutter  G, Xin  H, Aban  I,  et al.  Cross-sectional analysis of the Myasthenia Gravis Patient Registry: disability and treatment.   Muscle Nerve. 2019;60(6):707-715. doi:10.1002/mus.26695PubMedGoogle ScholarCrossref
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    Original Investigation
    February 17, 2020

    Clinical Effects of the Self-administered Subcutaneous Complement Inhibitor Zilucoplan in Patients With Moderate to Severe Generalized Myasthenia Gravis: Results of a Phase 2 Randomized, Double-Blind, Placebo-Controlled, Multicenter Clinical Trial

    Author Affiliations
    • 1University of North Carolina, Chapel Hill
    • 2Yale School of Medicine, New Haven, Connecticut
    • 3University at Buffalo, Buffalo, New York
    • 4Ohio State University, Columbus
    • 5University of South Florida, Tampa
    • 6Infirmary Health, Mobile, Alabama
    • 7University of Miami, Miami, Florida
    • 8Ra Pharmaceuticals Inc, Cambridge, Massachusetts
    • 9George Washington University, Washington, DC
    JAMA Neurol. 2020;77(5):582-592. doi:10.1001/jamaneurol.2019.5125
    Key Points

    Question  What are the clinical effects of zilucoplan, a subcutaneously self-administered macrocyclic peptide inhibitor of complement component 5, in a broad population of patients with moderate to severe acetylcholine receptor autoantibody–positive generalized myasthenia gravis?

    Findings  In a randomized, double-blind, placebo-controlled, multicenter phase 2 trial, zilucoplan yielded rapid, clinically meaningful, statistically significant, and sustained improvements in the primary and key secondary end points. Near-complete complement inhibition was associated with a faster onset and greater magnitude of benefit than submaximal complement inhibition, and favorable safety and tolerability were observed.

    Meaning  The findings support a potential therapeutic role for zilucoplan in generalized myasthenia gravis and further evaluation in a phase 3 study.

    Abstract

    Importance  Many patients with generalized myasthenia gravis (gMG) have substantial clinical disability, persistent disease burden, and adverse effects attributable to chronic immunosuppression. Therefore, there is a significant need for targeted, well-tolerated therapies with the potential to improve disease control and enhance quality of life.

    Objective  To evaluate the clinical effects of zilucoplan, a subcutaneously (SC) self-administered macrocyclic peptide inhibitor of complement component 5, in a broad population of patients with moderate to severe gMG.

    Design, Setting, and Participants  This randomized, double-blind, placebo-controlled phase 2 clinical trial at 25 study sites across North America recruited participants between December 2017 and August 2018. Fifty-seven patients were screened, of whom 12 did not meet inclusion criteria and 1 was lost to follow-up after randomization but before receiving study drug, resulting in a total of 44 acetylcholine receptor autoantibody (AChR-Ab)–positive patients with gMG with baseline Quantitative Myasthenia Gravis (QMG) scores of at least 12, regardless of treatment history.

    Interventions  Patients were randomized 1:1:1 to a daily SC self-injection of placebo, 0.1-mg/kg zilucoplan, or 0.3-mg/kg zilucoplan for 12 weeks.

    Main Outcomes and Measures  The primary and key secondary end points were the change from baseline to week 12 in QMG and MG Activities of Daily Living scores, respectively. Significance testing was prespecified at a 1-sided α of .10. Safety and tolerability were also assessed.

    Results  The study of 44 patients was well balanced across the 3 treatment arms with respect to key demographic and disease-specific variables. The mean age of patients across all 3 treatment groups ranged from 45.5 to 54.6 years and most patients were white (average proportions across 3 treatment groups: 78.6%-86.7%). Clinically meaningful and statistically significant improvements in primary and key secondary efficacy end points were observed. Zilucoplan at a dose of 0.3 mg/kg SC daily resulted in a mean reduction from baseline of 6.0 points in the QMG score (placebo-corrected change, –2.8; P = .05) and 3.4 points in the MG Activities of Daily Living score (placebo-corrected change, –2.3; P = .04). Clinically meaningful and statistically significant improvements were also observed in other secondary end points, the MG Composite and MG Quality-of-Life scores. Outcomes for the 0.1-mg/kg SC daily dose were also statistically significant but slower in onset and less pronounced than with the 0.3-mg/kg dose. Rescue therapy (intravenous immunoglobulin or plasma exchange) was required in 3 of 15, 1 of 15, and 0 of 14 participants in the placebo, 0.1-mg/kg zilucoplan, and 0.3-mg/kg zilucoplan arms, respectively. Zilucoplan was observed to have a favorable safety and tolerability profile.

    Conclusions and Relevance  Zilucoplan yielded rapid, meaningful, and sustained improvements over 12 weeks in a broad population of patients with moderate to severe AChR-Ab–positive gMG. Near-complete complement inhibition appeared superior to submaximal inhibition. The observed safety and tolerability profile of zilucoplan was favorable.

    Trial Registration  ClinicalTrials.gov Identifier: NCT03315130.

    Introduction

    Myasthenia gravis (MG) is a rare autoimmune disease characterized by the production of autoantibodies targeting proteins that are critical for normal neuromuscular synaptic transmission.1 The most common target of autoantibodies in MG is the nicotinic acetylcholine receptor (AChR), with approximately 80% to 88% of all patients with generalized MG (gMG) having detectable anti-AChR antibodies.2-5

    Quiz Ref IDThere is substantial evidence supporting a role for the terminal complement cascade in the pathogenesis of all patients with AChR autoantibody (AChR-Ab)–positive gMG. Activation of the classical complement cascade is initiated by AChR-specific autoantibodies (typically complement-activating immunoglobulin [IgG1 and IgG3 isotypes]) but not by anti–muscle-specific kinase autoantibodies (typically IgG4 isotype, which does not bind complement).2,6,7 Complement-mediated structural disruption and simplification of the postsynaptic membrane and reduced AChR density at the postsynaptic membrane are the ultrastructural correlates of impaired neuromuscular signal transduction in gMG.8,9 A phase 3 clinical trial with eculizumab, a monoclonal antibody complement component 5 (C5) inhibitor, restricted to patients considered refractory to prior therapies, validated complement inhibition as a new therapeutic approach in AChR-Ab–positive gMG that led to its approval by the US Food and Drug Administration in 2017.10-12

    Quiz Ref IDZilucoplan is a small (3.5 kDa), 15–amino acid macrocyclic peptide that binds to C5 with high affinity and specificity. This prevents the cleavage of C5 into complement components C5a and C5b. Zilucoplan binds to the domain of C5 that corresponds to C5b and thereby blocks binding of C5b to complement component C6.13 This dual mechanism of action prevents activation of the terminal complement pathway and prevents assembly of the terminal complement complex (previously known as membrane attack complex [C5b-9]), a large hydrophilic pore that can damage and destroy the postsynaptic membrane, disrupt ionic channel conductance, and impair neuromuscular transmission.2,14 Complement inhibition represents a targeted approach toward addressing the main mechanism of tissue damage in gMG. This contrasts with existing therapies, which focus on nonspecifically augmenting the AChR signal (eg, pyridostigmine) or nonspecifically suppressing the autoimmune response (eg, corticosteroids and other immunosuppressants).15 These treatments lack strong evidence from clinical trials to support their efficacy,15 are often poorly tolerated, and can be associated with considerable long-term toxicities.1 Nonspecific depletion of circulating antibodies by plasma exchange (PLEX) or intravenous immunoglobulin (IVIg), with the latter also considered to have broader immunomodulatory effects,16 carries a significant treatment burden and can only partially and transiently reduce autoantibody load, given that complete antibody elimination is not feasible and would incur significant safety risk. While these medications have had a meaningful effect on survival and quality of life of patients with gMG over the last 30 years, they are fraught with significant short-term and long-term toxicities and considerable treatment burden, and improved treatment options are needed for patients with gMG.1

    We conducted a randomized, double-blind, placebo-controlled, multicenter phase 2 clinical trial to explore the clinical effect of self-administered subcutaneous (SC) zilucoplan, at 0.1 mg/kg or 0.3 mg/kg daily, in adult patients with AChR-Ab–positive gMG. In addition, this study was designed to determine whether near-complete complement inhibition is necessary to achieve maximal clinical benefit in patients with gMG, as well as whether complement inhibition can be effective across a broad spectrum of patients with AChR-Ab–positive gMG regardless of duration of disease, treatment history, or response to prior therapies (ie, including both refractory and nonrefractory patients).

    Methods
    Trial Design

    This was a randomized, double-blind, placebo-controlled, multicenter phase 2 clinical trial designed to explore the clinical effects of zilucoplan in adult patients with AChR-Ab–positive gMG. Participants were randomly assigned 1:1:1 to zilucoplan, 0.1 mg/kg or 0.3 mg/kg, or placebo daily over 12 weeks. A study period of 12 weeks was considered of appropriate and sufficient duration based on the characteristics of response to complement inhibition observed in prior MG studies.10,17 Eligible participants had the opportunity to enter an open-label extension thereafter. Participants were evaluated at baseline and weeks 1, 2, 4, 8, and 12.

    Participants were required to continue taking their existing standard-of-care treatments for MG, with no change in dose, during the 12-week placebo-controlled study period. In the event of worsening MG, administration of IVIg or PLEX was allowed as rescue therapy per investigator discretion.

    The study was conducted in accordance with the International Conference on Harmonisation Guideline for Good Clinical Practice and applicable regulatory standards in the United States and Canada. Independent ethics committees or institutional review boards provided written approval for the study protocol and all amendments. The formal trial protocol can be found in Supplement 1.

    Participants

    Twenty-five study sites across North America recruited participants. All participants were required to provide written informed consent. Participants were enrolled between December 2017 and August 2018.

    Key eligibility criteria included age 18 to 85 years; clinically confirmed diagnosis of MG (Myasthenia Gravis Foundation of America [MGFA] Class II-IVa)18; presence of AChR-Ab; Quantitative Myasthenia Gravis (QMG) score of at least 12 points with at least 4 items having a score of 2 or more; no change in standard-of-care therapy for MG, including pyridostigmine, corticosteroids, and immunosuppressive therapy, for 4 weeks before randomization; no thymectomy within the past 6 months; no IVIg or PLEX administration for 4 weeks before randomization; and no rituximab treatment for 6 months before randomization. A full list of inclusion and exclusion criteria can be found in the protocol.

    Intervention

    The study drug (0.1-mg/kg or 0.3-mg/kg zilucoplan or matching placebo) was provided in identical prefilled syringes (BD UltraSafe PLUS; BD Medical) for daily SC self-injection, using a 29-gauge autoretracting needle. Nominal doses of zilucoplan were provided in 3 weight-bracketed presentations. Dosing was based on each participant’s weight at screening. Each prefilled syringe contained a single dose of zilucoplan in a volume less than 1 mL. Participants were instructed and trained on how to self-inject the study drug at the baseline visit and subsequently continued to self-administer the study drug at home throughout the 12-week study period. Electronic device–based reminders were used to enhance compliance with daily self-administration.

    Randomization and Blinding

    Participants were randomized 1:1:1 to placebo, 0.1-mg/kg zilucoplan, or 0.3-mg/kg zilucoplan using a central computerized randomization algorithm at an independent vendor (Bioclinica). Randomization was stratified based on the screening QMG score (≤17 vs ≥18). All site investigators, participants, and study personnel, including the sponsor and their representatives, remained blinded to treatment assignment for the study duration and until after database lock.

    Outcome Measures
    Efficacy Assessments

    Quiz Ref IDThe prespecified primary end point was the change in QMG score19 from baseline to week 12. The QMG score is a 13-item categorical scale assessing muscle weakness, with each item scored from 0 to 3 points. A total score of 0 represents no weakness, and a score of 39 represents severe weakness. Improvements in the QMG score of 2 to 3 points may be considered clinically meaningful depending on baseline disease severity.19,20 Participants were required to be not receiving pyridostigmine for at least 10 hours before performing each QMG assessment.

    The key secondary end point was the change in MG Activities of Daily Living (MG-ADL) score21 from baseline to week 12. The MG-ADL is an 8-item categorical scale that assesses the effect of MG on daily functions that are typically affected by the disease, with each item scored from 0 to 3 points. A total score of 0 represents normal function, and a score of 24 represents a severe effect on activities of daily living from MG (total score of 0-24). The MG-ADL has been shown to correlate with other validated MG outcome measures including the QMG, the MG Composite (MGC), and the 15-item Myasthenia Gravis Quality-of-Life Revised Scale (MG-QoL15r).21-24 A 2-point improvement in MG-ADL score is considered clinically meaningful.24

    Additional secondary end points included the change in MGC25 and MG-QoL15r23,26 scores from baseline to week 12; the proportion of patients with at least a 3-point improvement in the QMG score; and the proportion of participants requiring rescue therapy with PLEX or IVIg. In addition, the proportion of patients with minimal symptom expression (MSE; defined as MG-ADL of 0 or 1),27 a newly defined end point published after finalization of the protocol, was added as a predefined end point in the statistical analysis plan before database lock. All clinical evaluators underwent standardized training on the measurement of the primary and secondary end points, and patients were expected to be assessed by the same evaluator throughout the study.

    Pharmacodynamic and Safety Assessments

    Plasma samples were analyzed for the ability of zilucoplan to inhibit classical complement pathway-mediated hemolysis ex vivo in an antibody-sensitized sheep red blood cell lysis assay.28 Safety assessments included clinical evaluations, adverse event (AE) collection, standard laboratory assessments, evaluation of injection-site reactions (ISRs), and immunogenicity. Long-term pharmacologic inhibition of C5 with eculizumab, as well as inherited deficiencies of terminal complement pathway proteins, are both known to increase the susceptibility to infection with encapsulated bacteria, in particular Neisseria meningitidis.29,30 Therefore, all participants were required to receive meningococcal vaccination according to local standard of care at least 2 weeks before starting study treatment.

    Statistical Methods and Sample Size Calculation

    For the primary efficacy end point (change from baseline to week 12 in QMG score), group differences were assessed using an analysis of covariance model, with treatment as a factor and baseline QMG score as a covariate. For the continuous primary and secondary efficacy end points, least-squares means are presented. Observations occurring after rescue medication use were censored and imputed using the last observation carried forward method. The primary comparison was 0.3-mg/kg zilucoplan vs placebo at a 1-sided α of .10. Continuous secondary end points were analyzed similarly. Categorical end points were analyzed using Fisher exact test.

    The planned enrollment of 36 participants provided approximately 81% power to detect a difference between groups on the primary end point (mean change from baseline to week 12 in QMG score), assuming a group mean difference of 4.5 in the QMG score and an SD of 5.0.

    Results
    Baseline Data

    Forty-five of 57 screened patients were randomized (Figure 1). One patient was lost to follow-up shortly after randomization but before receiving the study drug. Owing to high demand for participation and a rapid surge in screenings over the last 2 months of the enrollment period, the study recruited more participants (n = 45) than originally planned (n = 36). A total of 44 patients received doses in the study, all of whom were included in the analyses (Figure 1). All participants completed the 12-week study period with no early withdrawals.

    The study population was representative of a broad range of patients with gMG and was well balanced across the 3 treatment arms with respect to key demographic and disease-specific variables (Table 1). Time since diagnosis of MG ranged widely, from 1 month to 26 years. Except for 1 patient who was naive to all standard-of-care therapies for MG (Table 1), patients had previously received pyridostigmine (93% to 100% for the 3 treatment arms), corticosteroids (87% to 100%), and/or immunosuppressive treatment (64% to 80%). More than one-half of patients had also been treated with IVIg (53% to 71%) and/or PLEX (47% to 60%). A small number of patients had previously received less frequently used immunosuppressive therapies, including cyclosporine (n = 4), rituximab (n = 3), methotrexate (n = 2), tacrolimus (n = 2), cyclophosphamide (n = 1), and eculizumab (n = 1; remote history of exposure 8 years before randomization during a clinical trial). One-third of patients had a history of thymoma (27% to 33%), and fewer than half had undergone thymectomy (33% to 53%).

    Mean baseline QMG, MG-ADL, MGC, and MG-QoL15r scores confirmed that, as intended, moderately to severely affected patients were enrolled (mean [SD] baseline QMG score, 18.8 [4.3]), with approximately half of the population being MGFA class III or IV at baseline. All disease severity measures were well balanced across treatment arms except for the MG-QoL15r, which was approximately 3 points higher in the 0.1-mg/kg zilucoplan arm than in the other 2 arms at baseline.

    Efficacy Analyses

    Quiz Ref IDThe study met its prespecified primary efficacy end point, showing a rapid, statistically significant and clinically meaningful difference in the QMG score between the 0.3-mg/kg zilucoplan and placebo arms, favoring zilucoplan (Figure 2A). The mean change from baseline to week 12 in the QMG score was –6.0 points in the 0.3-mg/kg zilucoplan arm compared with –3.2 points in the placebo arm, with a mean difference of –2.8 (P = .05; Table 2). The onset of action was rapid, with separation of the 0.3-mg/kg arm from the placebo arm beginning after 1 week (Figure 2A).

    The magnitude of the response with 0.1-mg/kg zilucoplan, although still clinically meaningful and statistically significant, was less pronounced and exhibited a slower onset of action, with separation from placebo beginning only after 4 weeks of therapy (eFigure 1A in Supplement 2).

    Consistent with the primary end point, the MG-ADL showed a rapid, clinically meaningful, and statistically significant mean reduction from baseline of 3.4 points (placebo-corrected change, –2.3; P = .04), favoring 0.3-mg/kg zilucoplan at week 12 (Table 2 and Figure 2B). Similarly, the response with the 0.1-mg/kg zilucoplan dose was delayed and less pronounced, although still statistically significant when compared with placebo at week 12 (Table 2; eFigure 1B in Supplement 2).

    The MG-QoL15r and MGC followed a similar pattern (Table 2 and Figure 2C and D; eFigure 1C and D in Supplement 2), although the MG-QoL15r showed a reversal of the dose response, perhaps a result of higher baseline scores in the 0.1-mg/kg zilucoplan arm (Table 1). An analysis of covariance sensitivity analysis evaluated the relevance of additional covariates on QMG and MG-ADL response and found that only the baseline value of each outcome variable proved significant (data not shown). Additional covariates, including age, sex, duration of disease, treatment history, prior thymectomy, and history of thymoma, were not significant in the analysis of covariance model (eTable 1 in Supplement 2).

    A remarkable consistency in the response with zilucoplan was observed across all continuous clinical outcome measures tested (QMG, MG-ADL, MGC, and MG-QoL15r) with continued improvement through week 8 (eFigure 2A in Supplement 2). This contrasted with the placebo arm, where the effect was most pronounced during the first week, with some fluctuations thereafter (eFigure 2B in Supplement 2).

    A higher proportion of patients achieved at least a 3-point difference in the QMG score with zilucoplan compared with placebo, although this difference did not reach statistical significance. More patients receiving zilucoplan improved by progressively higher scores, and, in contrast to placebo, none in the 0.3-mg/kg zilucoplan arm experienced worsening (Figure 3A). The proportion of participants achieving MSE (defined as MG-ADL of 0 or 1) was also higher with 0.3-mg/kg zilucoplan (n = 5 [35.7%]) than with 0.1-mg/kg zilucoplan (n = 4 [26.7%]) or placebo (n = 2 [13.3%]) (Figure 3B), although this did not reach statistical significance.

    All participants remained receiving stable doses of their prior gMG therapy. Rescue therapy (IVIg or PLEX only) was administered per investigator’s discretion in 3 of 15 participants (20%) receiving placebo, 1 of 15 (7%) receiving 0.1-mg/kg zilucoplan, and none (0 of 14) receiving 0.3-mg/kg zilucoplan (Figure 3C). Although not statistically significant, the trend in these results is consistent with other efficacy analyses.

    Pharmacodynamic Analyses

    Daily self-administered SC 0.3-mg/kg zilucoplan achieved rapid, sustained, and near-complete complement inhibition as measured in the sheep red blood cell lysis assay, with greater than 97% inhibition at trough. In contrast, the 0.1-mg/kg zilucoplan dose achieved rapid, sustained but submaximal (approximately 88%) complement inhibition at trough (eFigure 3 in Supplement 2).

    Safety Analyses

    All 44 of 45 randomized patients who received the study drug completed the 12-week placebo-controlled study. The study drug was well tolerated, with a low incidence of local ISRs (2 of 15, 4 of 15, and 3 of 14 patients receiving placebo, 0.1-mg/kg zilucoplan, and 0.3-mg/kg zilucoplan, respectively). The only moderate ISR occurred in a placebo-treated patient. All other ISRs were mild, and there was no difference in patterns between the zilucoplan and placebo arms. Thirty-nine participants reported treatment-emergent AEs, with no apparent pattern across treatment arms (eTable 2 in Supplement 2). Most events were mild, considered unrelated to the study drug, and resolved spontaneously without modification of study drug administration. Eight serious AEs were reported, none of which were considered related to the study drug: 3 in the placebo arm, 0 in the 0.1-mg/kg zilucoplan arm, and 5 in the 0.3-mg/kg zilucoplan arm. Two patients discontinued the study drug before week 12: 1 placebo-treated patient owing to an AE of worsening MG and 1 patient receiving 0.3-mg/kg zilucoplan because of a prolonged admission at an outside hospital owing to exacerbation of preexisting diverticulitis with paracolic abscess. There were no meningococcal infections, life-threatening AEs, or deaths during the study. No antizilucoplan antibodies were detected.

    Discussion

    The SC peptide C5 inhibitor zilucoplan met the prespecified primary efficacy end point and demonstrated a favorable safety and tolerability profile in this multicenter, randomized, double-blind, placebo-controlled phase 2 clinical trial, assessing a broad spectrum of patients with moderate to severe gMG regardless of their treatment history.

    Consistent with the primary efficacy analysis, all continuous secondary end points also demonstrated clinically meaningful and statistically significant improvements except for the MGC score between the 0.1-mg/kg zilucoplan and placebo arms. The proportion of participants requiring rescue therapy (a proxy for patients’ use of health care resources) and the proportion of participants achieving MSE also favored zilucoplan over placebo. The totality of the clinical efficacy data supports further investigation of the 0.3-mg/kg daily SC dose of zilucoplan, which showed a more rapid and profound improvement in clinical disease measures compared with the 0.1-mg/kg dose.

    Although none of the participants receiving the 0.3-mg/kg dose deteriorated, and most improved significantly, it is interesting that 28% of participants did not improve by the minimal clinically important difference of 3 points on the QMG. We speculate that failure to respond to near-complete C5 inhibition in this subset of patients may be attributed to one or more of the following factors: insensitivity of the outcome measures to detect clinical improvement; previously unrecognized fixed weakness; or the complement-independent effects of blocking or modulating autoantibodies that sterically hinder binding of ACh to the receptor or decrease AChR density, respectively.2,31

    Until this study, to our knowledge, it was not known whether complete inhibition of the terminal complement pathway is necessary to achieve optimal clinical response in patients with AChR-Ab–positive gMG. Our data suggest that maximal complement inhibition is necessary to provide rapid and pronounced disease suppression, although submaximal inhibition was still superior to placebo.

    Although cross-study comparisons of clinical effects must be made with caution, the magnitude of the clinical effect of zilucoplan in this study appears similar to that observed in prior studies of the complement inhibitor eculizumab conducted in a restricted population of patients defined as having refractory gMG.10,17 Importantly, this study provides evidence for the efficacy of C5 inhibition in a broader population of patients with moderate to severe gMG than were enrolled in the eculizumab studies, including those early in their disease course, without regard to failure of prior therapies, and inclusive of patients with a history of thymoma. This observation is important because in gMG, disease severity frequently peaks within the first few years after diagnosis, before all treatment options have been exhausted32 and before patients may be formally declared treatment refractory. A 2019 analysis33 of the MGFA Patient Registry showed that many patients with MG, including those who have not yet been treated with multiple immunosuppressive therapies, experience considerable disease burden.33 Taken together, these findings indicate that there is no biologic relevance of refractory disease with respect to complement inhibition and no scientific rationale for C5 inhibitors to be reserved for use as a last-line option only. Indeed, C5 inhibition deployed earlier in the disease course may have the potential to reduce or eliminate the need for more invasive treatments, as reflected by abrogation of the need for rescue therapy in the high-dose zilucoplan arm.

    Strengths and Limitations

    As a self-administered C5 inhibitor, zilucoplan was well tolerated, and the safety profile was similar across the zilucoplan and placebo arms. Quiz Ref IDAll participants were vaccinated against N meningitidis, and no cases of Neisseria infection were observed during the study. However, the overall exposure was too limited to allow for a complete characterization of the risk profile given that the absolute incidence rate of Neisseria infection associated with C5 inhibition is extremely low.30 Furthermore, it is noteworthy that zilucoplan administration was not associated with any AEs suggestive of local or systemic inflammatory reactions.

    Our phase 2 study was designed to provide an initial assessment of clinical activity and to support dose selection for phase 3. Given the similarity in the safety profile for both doses, as well as the more rapid and pronounced clinical effect seen with 0.3-mg/kg zilucoplan, this dose has been selected for further testing in a pivotal phase 3 study (ClinicalTrials.gov Identifier: NCT04115293).

    Conclusions

    In summary, our study suggests that complement inhibition appears to be effective across a broad spectrum of patients with moderate to severe AChR-Ab–positive gMG, regardless of prior therapies; that near-complete complement inhibition is superior to submaximal complement inhibition; and that the safety and tolerability profile of zilucoplan in gMG appears to be favorable. Confirmation of the clinical effect of zilucoplan in gMG will be further assessed through the open-label long-term extension of the phase 2 study and an upcoming registrational phase 3 clinical program.

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    Article Information

    Accepted for Publication: December 12, 2019.

    Published Online: February 17, 2020. doi:10.1001/jamaneurol.2019.5125

    Zilucoplan MG Study Group Authors: Richard Barohn, MD; Mazen Dimachkie, MD; Mamatha Pasnoor, MD; Constantine Farmakidis, MD; Tina Liu, MBA, BS; Samantha Colgan, BS; Michael G. Benatar, MD, PhD; Tulio Bertorini, MD; Rekha Pillai, MD; Robert Henegar, LPN; Mark Bromberg, MD, PhD; Summer Gibson, MD; Teresa Janecki, BS; Miriam Freimer, MD; Bakri Elsheikh, MD, MMBS/FRCP; Paige Matisak, BS; Angela Genge, MD, FRCPC, eMBA; Amanda Guidon, MD; William David, MD, PhD; Ali A. Habib, MD; Veena Mathew, MSc; Tahseen Mozaffar, MD; John L. Hinton, MD; William Hewitt, MD; Deborah Barnett, CCRC; Patricia Sullivan; Doreen Ho, MD; James F. Howard Jr, MD; Rebecca E. Traub, MD; Manisha Chopra, MD, MBBS; Henry J. Kaminski, MD; Radwa Aly, MSc; Elham Bayat, MD; Mohammad Abu-Rub, MD; Shaida Khan, DO; Dale Lange, MD; Shara Holzberg, MS, CCC-SLP; Bhupendra Khatri, MD; Emily Lindman, BS; Tayo Olapo, BS; Lisa M. Sershon, MMS, PA-C, MSCS; Robert P. Lisak, MD; Evanthia Bernitsas, MD; Kelly Jia, MD; Rabia Malik, MD; Tiffany D. Lewis-Collins, BA, CMA; Michael Nicolle, MD, FRCPC, DPhil; Richard J. Nowak, MD; Aditi Sharma, MBBS; Bhaskar Roy, MD; Joan Nye, BS; Michael Pulley, MD, PhD; Alan Berger, MD; Yasmeen Shabbir, MBBS; Amit Sachdev, MD, MS; Kimberly Patterson, BAS, R EEG T; Zaeem Siddiqi, MD, PhD; Mark Sivak, MD; Joan Bratton, BA; George Small, MD; Anem Kohli, MBBS, BS; Mary Fetter, BS; Tuan Vu, MD; Lucy Lam, MS, BS; Brittany Harvey, BA; Gil I. Wolfe, MD; Nicholas Silvestri, MD; Kara Patrick, MS; Karen Zakalik, MBA, BA; Petra W. Duda, MD, PhD; James MacDougall, PhD; Ramin Farzaneh-Far, MD; Angela Pontius, BA; Michelle Hoarty, MS, BA.

    Affiliations of Zilucoplan MG Study Group Authors: University of North Carolina, Chapel Hill (Howard Jr, Traub, Chopra); Yale School of Medicine, New Haven, Connecticut (Nowak, Sharma, Roy, Nye); University at Buffalo, Buffalo, New York (Wolfe, Silvestri, Patrick, Zakalik); Ohio State University, Columbus (Freimer, Elsheikh, Matisak); University of South Florida, Tampa (Vu, Lam, Harvey); Infirmary Health, Mobile, Alabama (Hinton, Hewitt, Barnett, Sullivan); University of Miami, Miami, Florida (Benatar); Ra Pharmaceuticals Inc, Cambridge, Massachusetts (Duda, MacDougall, Farzaneh-Far, Pontius, Hoarty); George Washington University, Washington, DC (Kaminski, Aly, Bayat, Abu-Rub); University of Kansas, Fairway (Barohn, Dimachkie, Pasnoor, Farmakidis, Liu, Colgan); Wesley Neurology Clinic, Cordova, Tennessee (Bertorini, Pillai, Henegar); University of Utah, Salt Lake City (Bromberg, Gibson, Janecki); Montreal Neurological Institute, Montreal, Quebec, Canada (Genge); Massachusetts General Hospital, Boston (Guidon, David); University of California, Irvine, Orange (Habib, Mathew, Mozaffar); Lahey Hospital, Burlington, Massachusetts (Ho); University of Texas Southwestern, Dallas, Irving (Khan); Hospital for Special Surgery, New York, New York (Lange, Holzberg); Center for Neurological Disorders, St Francis Hospital at Ascension, Milwaukee, Wisconsin (Khatri, Lindman, Olapo, Sershon); Wayne State University, Detroit, Michigan (Lisak, Bernitsas, Jia); Rush University, Chicago, Illinois (Malik, Lewis-Collins); London Health Sciences Center, London, Ontario, Canada (Nicolle); University of Florida, Jacksonville (Pulley, Berger, Shabbir); Michigan State University, East Lansing (Sachdev, Patterson); University of Alberta, Edmonton, Alberta, Canada (Siddiqi); Mount Sinai Hospital, New York, New York (Sivak, Bratton); Allegheny Neurological Associates, Pittsburgh, Pennsylvania (Small, Kohli, Fetter).

    Corresponding Author: James F. Howard Jr, MD, University of North Carolina, 170 Manning Dr, 2200 Physician Office Bldg, CB No. 7025, Chapel Hill, NC 27599-7026 (howardj@neurology.unc.edu).

    Open Access: This is an open access article distributed under the terms of the CC-BY-NC-ND License. © 2020 Howard JF Jr et al. JAMA Neurology.

    Author Contributions: Dr Howard had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Howard, Nowak, Benatar, Duda, Farzaneh-Far, Kaminski, Barohn, Mozaffar, Sullivan, Olapo, Lisak, Pontius, Hoarty.

    Acquisition, analysis, or interpretation of data: Howard, Nowak, Wolfe, Freimer, Vu, Hinton, Duda, MacDougall, Farzaneh-Far, Kaminski, Barohn, Dimachkie, Pasnoor, Farmakidis, Liu, Colgan, Bertorini, Pillai, Henegar, Bromberg, Gibson, Janecki, Elsheikh, Matisak, Genge, Guidon, David, Habib, Mathew, Mozaffar, Hewitt, Barnett, Sullivan, Ho, Traub, Chopra, Aly, Bayat, Abu-Rub, Khan, Lange, Holzberg, Khatri, Lindman, Sershon, Lisak, Bernitsas, Jia, Malik, Lewis-Collins, Nicolle, Sharma, Roy, Nye, Pulley, Berger, Shabbir, Sachdev, Patterson, Siddiqi, Sivak, Bratton, Small, Kohli, Fetter, Lam, Harvey, Silvestri, Patrick, Zakalik, Pontius, Hoarty.

    Drafting of the manuscript: Howard, Nowak, Duda, Farzaneh-Far, Kaminski, Barohn, Lewis-Collins, Nye, Sivak, Fetter, Lam, Pontius.

    Critical revision of the manuscript for important intellectual content: Howard, Nowak, Wolfe, Freimer, Vu, Hinton, Benatar, Duda, MacDougall, Farzaneh-Far, Kaminski, Barohn, Dimachkie, Pasnoor, Farmakidis, Liu, Colgan, Bertorini, Pillai, Henegar, Bromberg, Gibson, Janecki, Elsheikh, Matisak, Genge, Guidon, David, Habib, Mathew, Mozaffar, Hewitt, Barnett, Sullivan, Ho, Traub, Chopra, Aly, Bayat, Abu-Rub, Khan, Lange, Holzberg, Khatri, Lindman, Olapo, Sershon, Lisak, Bernitsas, Jia, Malik, Nicolle, Sharma, Roy, Pulley, Berger, Shabbir, Sachdev, Patterson, Siddiqi, Bratton, Small, Kohli, Harvey, Silvestri, Patrick, Zakalik, Pontius, Hoarty.

    Statistical analysis: MacDougall, Farzaneh-Far, Barohn, Sivak, Hoarty.

    Obtained funding: Farzaneh-Far, Barohn.

    Administrative, technical, or material support: Vu, Hinton, Barohn, Henegar, Matisak, Genge, Guidon, Barnett, Sullivan, Chopra, Holzberg, Bernitsas, Jia, Lewis-Collins, Nicolle, Roy, Nye, Shabbir, Patterson, Small, Fetter, Lam, Pontius.

    Supervision: Freimer, Duda, Farzaneh-Far, Kaminski, Barohn, Mozaffar, Khatri, Sershon, Shabbir, Sachdev.

    Conflict of Interest Disclosures: Dr Howard has received research support from Alexion Pharmaceuticals, argenx BVBA, the US Centers for Disease Control and Prevention, the Muscular Dystrophy Association (MDA), the National Institutes of Health (NIH; including the National Institute of Neurological Disorders and Stroke and the National Institute of Arthritis and Musculoskeletal and Skin Diseases), argenx and Ra Pharmaceuticals; honoraria/consulting fees from Alexion Pharmaceuticals, argenx, Ra Pharmaceuiticals, and Viela Bio; and nonfinancial support from Alexion Pharmaceuticals, argenx BVBA, Ra Pharmaceuticals, and Toleranzia. Dr Nowak has received research support from the NIH, Genentech, Alexion Pharmaceuticals, Ra Pharmaceuticals, Myasthenia Gravis Foundation of America, Momenta, and Grifols and has served as consultant/advisor for Alexion Pharmaceuticals, CSL Behring, Grifols, Ra Pharmaceuticals, Roivant Sciences, and Momenta. Dr Wolfe is a consultant for Grifols, Takeda, argenx, and Momenta; is on speaker’s bureaus for Grifols and Alexion Pharmaceuiticals; and has received grant/research support from Alexion Pharmaceuticals, argenx, Ra Pharmaceuticals, and Immunovant. Dr Freimer has received honoraria from argenx and Alexion and research support from Catalyst Pharmaceuticals, Ra Pharmaceuticals, Amicus Therapeutics, Alexion Pharmaceuticals, Momenta, Alnylam Pharmaceuticals, UCB, Orphazyme, and NIH (NeuroNExt). Dr Vu serves as site principal investigator for MG clinical trials sponsored by Alexion Pharmaceuticals, argenx, NIH, Grifols, Ra Pharmaceuticals, and UCB and is on speaker’s bureaus for Alexion Pharmaceuticals, Mitsubishi Tanabe Pharma America, CSL Behring, and Allergan. Dr Benatar was site investigator for MG trials sponsored by UCB, Alexion Pharmaceuticals, and an NIH-funded study of rituximab; has reported personal fees from AveXis, Biogen, Genentech, Mitsubishi Tanabe Pharma, and Ra Pharmaceuticals; has provided consulting services to UCB; and has a patent pending for determining the onset of amyotrophic lateral sclerosis. Drs Duda and Farzaneh-Far and Mss Pontius and Hoarty are employees of Ra Pharmaceuticals. Dr Kaminski has received grant 508240 from the MDA; is a consultant for Alnylam Pharmaceuticals, Ra Pharmaceuticals, and UCB; and is CEO and CMO of ARC Biotechnology, LLC, based on US patent 8961981. Dr MacDougall is a consultant for Ra Pharmaceuticals. Dr Barohn served as a consultant for NuFactor and Momenta and receives research support from PTC Therapeutics, Ra Pharmaceuticals, Orphazyme, Sanofi Genzyme, the US Food and Drug Administration (FDA) Office of Orphan Products Development (OOPD), NIH, and Patient-Centered Outcomes Research Institute (PCORI). Dr Dimachkie recently served as a consultant or on speaker’s bureaus for Alnylam, Audentes, CSL Behring, Sanofi Genzyme, Momenta, NuFactor, RMS Medical, Shire Takeda and Terumo and received grants from Alexion Pharmaceuticals, Alnylam Pharmaceuticals, Amicus Therapeutics, Biomarin, Bristol-Myers Squibb, Catalyst, CSL Behring, FDA/OPD, GlaxoSmithKline, Genentech, Grifols, MDA, NIH, Novartis, Genzyme, Octapharma, Orphazyme, UCB, ViroMed Laboratories, and TMA Pharma. Dr Pasnoor has served as a medical advisor or consultant for CSL Behring, Momenta, Alexion Pharmaceuticals, and Terumo BCT. Dr Farmakidis has served as a consultant for Momenta and participated in an advisory board for Terumo BCT. Dr Elsheikh received research support from Biogen, Alexion Pharmaceuticals, and UCB and served as a consultant for Biogen and Bio-Stealth. Dr Gibson has received travel subsidies and honoraria for time spent on advisory boards for Cytokinetics and CSL Behring. Dr Genge is a consultant for Biogen, Sanofi Genzyme, CSL Behring, Mitsubishi Tanabe Pharma America, AL-S Pharma, AB Sciences, Novartis, Wave Life Sciences, argenx, Alexion Pharmaceuticals, AveXis, Akcea Therapeutics, and Cytokinetics. Dr Guidon has been a consultant for Momenta; participated on a medical advisory board with Alexion; has received royalties from Oakstone Publishing; and received clinical trial support from Momenta and PCORI. Dr David has received royalties from Oakstone Publishing. Dr Habib serves on advisory boards for Alexion Pharmaceuticals, and argenx; is on a speaker’s bureau for Alexion Pharmaceuticals; and has received research support from Alexion Pharmaceuticals, Ra Pharmaceuticals, Immunovant, UCB, Acceleron Pharma, and Catalyst Pharmaceuticals. Ms Mathew served as the primary coordinator and evaluator for myasthenia gravis clinical trials sponsored by Alexion Pharmaceuticals, argenx, Grifols, Ra Pharmaceuticals, and UCB and is a consultant for Ra Pharmaceuticals. Dr Mozaffar has received travel subsidies and honoraria for time spent on advisory boards for aTyr Pharma, Alnylam Pharmaceuticals, Alexion Pharmaceuticals, Amicus Therapeutics, argenx, Audentes Therapeutics, Sanofi Genzyme, Sarepta Therapeutics, Spark Therapeutics, Mitsubishi Tanabe Pharma America, and Ultragenyx; served on speaker’s bureaus for Alexion Pharmaceuticals, CSL Behring, Grifols, and Sanofi-Genzyme; received research funding from the Myositis Association, the MDA, the NIH, Alexion Pharmaceuticals, Amicus Therapeutics, argenx, aTyr Pharma, Bristol-Myers Squibb, Idera, Ionis Pharmaceuticals, Grifols, Momenta, Ra Pharmaceuticals, Sanofi-Genzyme, Spark Therapeutics, UCB, Ultragenyx, and Valerion Therapeutics; and serves on the data safety monitoring board for Acceleron and AveXis. Dr Traub has received research support from Alnylam Pharmaceuticals, Akcea Therapeutics, and Vertex Pharmaceuticals and received honoraria/consulting fees from Alnylam Pharmaceuticals, Akcea Therapeutics, and CSL Behring. Dr Chopra has received honoraria from Alexion Pharmaceuticals, and Ra Pharmaceuticals. Dr Khan has participated in advisory boards for Alexion and received a Wellstone trainee clinical fellowship award and NIH research grant 1U54HD08735-01 (2016-2018). Dr Lange has received research support from Cytokinetics, Orion, Orphazyme, Northeast ALS Consortium (NEALS), Lilly/ALS Pharma, ALS Association of Greater New York, Alexion Pharmaceuticals, Acorda Therapeutics, Momenta, Immunovant, UCB, Ra Pharmaceuticals, Baxalta, CSL Behring, and the MDA. Ms Holzberg has received research support from Cytokinetics, Orion, Orphazyme, NEALS, Lilly/ALS Pharma, ALS Association of Greater New York, Alexion Pharmaceuticals, Acorda Therapeutics, Momenta, Immunovant, UCB, Ra Pharmaceuticals, Baxalta, CSL Behring, and the MDA. Dr Khatri has received financial compensation for speaking and research from Teva, Bayer, Biogen, Sanofi Genzyme, Serono EMD, Novartis, Genentech, Acorda, Mallinckrodt, Terumo, and Celgene. Mrs Sershon has received financial compensation for speaking, advisory boards, and consulting from Biogen, Sanofi Genzyme, Serono EMD, Novartis, Genentech, Celgene, and Alexion. Dr Lisak has received research support from the National Multiple Sclerosis Society, the NIH, and Mallinckrodt; participated in clinical trials for Teva, Chugai, MedImmune, Novartis, Genentech (Roche), Alexion Pharmaceuticals, argenx, Ra Pharmaceuticals, and Catalyst Pharmaceuticals; has consulted for and received honoraria from Novartis, argenx, Mallinckrodt, GLG Consulting, Slingshot Consulting, Guidepoint Consulting, Insights Consulting, Schlesinger Group, Clearview Consulting, Alpha Sites Consulting, Putnam Group Consulting, Health Advances, Haven Consulting, Decision Resources Group, and ck2 Medical Communications; has received honoraria from MedDay Pharmaceuticals; has participated in a speaker’s bureau for Teva Pharmaceuticals; and receives publishing royalties from Blackwell Publishers (International Neurology, 2nd edition) and Oxford University Press (Neuroimmunology). Dr Bernitsas has received research support from the NIH, Merck/EMD Serono, Genentech (Roche), Sanofi Genzyme, Mallinckrodt, Chugai, MedImmune, and Novartis and participated in speaker’s bureaus and/or consulted for Celgene, Biogen, Merck/EMD Serono, Bayer, and Sanofi Genzyme. Dr Malik has received research support from Catalyst Pharmaceuticals and PCORI and serves as the director of the MDA-funded clinic at Rush University Medical Center. Ms Lewis-Collins has served as a site clinical research coordinator for Catalyst Pharmaceuticals, PCORI, and Ra Pharmaceuticals. Dr Nicolle has received honoraria from Alexion Pharmaceuticals. Dr Roy has received honoraria from Alexion Pharmaceuticals. Dr Pulley has participated in advisory board meetings for Alexion Pharmaceuticals, Bio Products Laboratory, Stealth BioTherapeutics, CSL Behring, Mitsubishi Tanabe Pharma America, and Catalyst Pharmaceuticals. Dr Berger has received consulting fees for Best Doctors Inc. Dr Sachdev has participated in speaker’s bureaus for CSL Behring, Alexion Pharmaceuticals, Strongbridge Biopharma, and Akcea Therapeutics; has acted as a consultant for argenx and Alexion Pharmaceuticals; has participated as a principal investigator for Catalyst Pharmaceuticals, Alexion Pharmaceuticals, Momenta, Ra Pharmaceuticals, Eisai Corporation, and the MDA; and has been a grant recipient for MDA. Ms Harvey serves as a consultant for Syneos and Ra Pharmaceuticals. Dr Silvestri has served as a consultant for Alexion and argenx, received royalties from Springer Publishing, and has been a speaker for Strongbridge Biopharma. Dr Howard reported grants and nonfinancial support from Ra Pharmaceuticals during the conduct of the study; grants, personal fees, and nonfinancial support from Alexion Pharmaceuticals, and argenx BVBA; and grants from MDA, US Centers for Disease Control and Prevention, and the NIH outside the submitted work. Dr Nowak reported grants and personal fees from Ra Pharmaceuticals during the conduct of the study; grants and personal fees from Alexion Pharmaceuticals, Momenta, Immunovant, argenx; and grants from Annexon Biosciences and Grifols outside the submitted work. Dr Wolfe reported grants from Ra Pharmaceuticals during the conduct of the study; grants from argenx and CSL Behring; and personal fees from Alexion outside the submitted work. Dr Freimer reported personal fees and other support from Ra Pharmaceuticals during the conduct of the study and the submitted work. Dr Vu reported serving as a speaker for Alexion; consulting work for argenx and UCB; and participating in trials in MG sponsored by Alexion Pharmaceuticals, argenx, UCB, and Grifols. Dr Hinton reported grants, personal fees, and nonfinancial support from Ra Pharmaceuticals during the conduct of the study and nonfinancial support from Immunovant outside the submitted work. Dr Benatar reported personal fees from Ra Pharmaceuticals and Viela Bio during the conduct of the study; in addition, Dr Benatar had a patent to Determining Onset of ALS pending. Dr Duda reported other support from Ra Pharmaceuticals during the conduct of the study; in addition, Dr Duda had a patent to listed as an inventor on a patent application relevant to this work pending. Dr MacDougall reported personal fees from Ra Pharmaceuticals during the conduct of the study. Dr Farzaneh-Far is an employee of Ra Pharmaceuticals and holds equity in the company. Dr Kaminski reported personal fees from Ra Pharmaceuticals during the conduct of the study; personal fees from UCB outside the submitted work; and serving as principal investigator for Rare Disease Clinical Research Network for Myasthenia Gravis (MGNet, U54 NS115054). Dr Dimachkie reported grants from University of Kansas during the conduct of the study. Dr Farmakidis reported personal fees from Momenta and Terumo BCT outside the submitted work. Dr Bromberg reported personal fees from Grifols, Alexion Pharmaceuticals, Accordant, and Genzyme outside the submitted work. Dr Elsheikh reported grants and nonfinancial support from Ra Pharmaceuticals during the conduct of the study; grants, personal fees, and nonfinancial support from Biogen; and grants and nonfinancial support from Alexion Pharmaceuticals, UCB, Momenta, and Catalyst Pharmaceuticals outside the submitted work. Dr Genge reported being a site principal investigator for phase 2 study in MG. Dr Guidon reported personal fees and other support from Momenta and other support from Oakstone Publishing and Alexion outside the submitted work. Dr Habib reported grants from Ra Pharmaceuticals during the conduct of the study; grants and other support from Alexion Pharmaceuticals, and argenx; and grants from Immunovant outside the submitted work. Dr Mathew reported personal fees from Ra Pharmaceuticals outside the submitted work. Dr Chopra reported other support from Ra Pharmaceuticals and Alexion Pharmaceuticals, and nonfinancial support from argenx during the conduct of the study. Dr Khan reported personal fees from Alexion and Ra Pharmaceuticals and grants from NIH outside the submitted work. Dr Lange reported grants from Ra Pharmaceuticals during the conduct of the study and from Alexion Pharmaceuticals, Momenta, and Immunovant outside the submitted work. Dr Holzberg reported grants from Ra Pharmaceuticals during the conduct of the study and grants from NIH outside the submitted work. Dr Khatri reported personal fees and nonfinancial support from Biogen, Alexion Pharmaceuticals, Genentech, Sanofi Genzyme, Celgene, and Serono outside the submitted work. Dr Sershon reported personal fees from Alexion Pharmaceuticals, Biogen, Sanofi Genzyme, Novartis, EMD Serono, and Celgene outside the submitted work. Dr Lisak reported grants from Ra Pharmaceuticals during the conduct of the study; grants from Alexion Pharmaceuticals, Genentech (Roche), and MedImmune; grants and personal fees from argenx, Teva, and Catalyst Pharmaceuticals; personal fees from Novartis, Mallinckrodt, GLG Consulting, Alpha Sites, Schelsinger Group, Insights Consulting, Slingshots Consulting, Informa Pharmaceutical Consulting, Health Choices, and Adivo Consulting; and other support from Anavex outside the submitted work. Dr Bernitsas reported grants from Genentech (Roche), Chugai, and Novartis; and personal fees from Biogen and EMD Serono outside the submitted work. Dr Malik reported grants from Ra Pharmaceuticals during the conduct of the study and personal fees from MDA and Conquer MG outside the submitted work. Dr Roy reported grants from Ra Pharmaceuticals during the conduct of the study and personal fees from Alexion Pharmaceuticals, outside the submitted work. Dr Pulley reported personal fees from Alexion Pharmaceuticals, argenx, Bio Products Laboratory, Catalyst Pharmaceuticals, and CSL Behring outside the submitted work. Dr Berger reported grants from University of Florida during the conduct of the study. Dr Shabbir reported grants from Ra Pharmaceuticals during the conduct of the study. Dr Sachdev reported grants from Ra Pharmaceuticals during the conduct of the study; grants and personal fees from Alexion Pharmaceuticals; personal fees from CSL Behring, Strongbridge Biopharma, Akcea Therapeutics, and argenx; and grants from Catalyst Pharmaceuticals, Momenta, Eisai Corporation, and MDA outside the submitted work. Dr Harvey reported personal fees from Alexion Pharmaceuticals, Inc and Ra Pharmaceuticals outside the submitted work. Dr Silvestri reported personal fees from Alexion Pharmaceuticals, and argenx outside the submitted work. Dr Pontius is an employee and holds stock and stock options of Ra Pharmaceuticals outside the submitted work. No other disclosures were reported.

    Funding/Support: Editorial assistance and graphic support, provided by Jessica Deckman, PhD, of The Lockwood Group (Stamford, Connecticut), was supported by funding from Ra Pharmaceuticals Inc. This study was funded by Ra Pharmaceuticals Inc.

    Role of the Funder/Sponsor: The funding source contributed to the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.

    Data Sharing Statement: See Supplement 3.

    Additional Contributions: We thank Andrea Bozoki, MD, Michigan State University, East Lansing, and Gilles Hoffman, PhD, Rush University, Chicago, Illinois. No compensation was received from a funding source.

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