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Efficacy & Safety

ENVISION: The largest interventional study in acute hepatic porphyria (AHP)1

ENVISION is a randomized, double-blind, placebo-controlled, multinational Phase 3 study in patients with AHP (N=94), with a 30-month open-label extension (OLE) (N=93)1-3

Chart depicting the ENVISION study design
Chart depicting the ENVISION study design

*These measures were in AIP patients only.2

†All endpoints were considered exploratory in the ENVISION OLE period.3

‡A protocol amendment increased the dose for all patients to 2.5 mg/kg once monthly.3

ALA=delta-aminolevulinic acid; PBG=porphobilinogen; qM=once monthly; SC=subcutaneous.
  • Patients who experienced an AHP attack during the study were treated according to the local standard of care, which could include IV hemin1,2

ENVISION study patient population1-3

Baseline Demographic and Clinical Characteristics of Patients With AHP
GIVLAARI (N=48) Placebo (N=46) Overall (N=94)
Mean age, years (range) 42 (19, 65) 36 (20, 60) 37.5 (19, 65)
Female, n (%) 43 (90) 41 (89) 84 (89)
Caucasian, n (%) 39 (81) 34 (74) 73 (78)
AHP type, n (%)
– AIP 46 (96) 43 (93) 89 (95)
– HCP 1 (2) 0 (0) 1 (1)
– VP 1 (2) 1 (2) 2 (2)
– No identified mutation 0 (0) 2 (4) 2 (2)
Attacks* in past 6 months, median (range) 4 (2, 24) 3 (0, 25) 3 (0, 25)
Prior hemin prophylaxis, n (%) 20 (42) 18 (39) 38 (40)
Prior chronic opioid use, n (%)† 14 (29) 13 (28) 27 (29)
Prior chronic symptoms, n (%)‡ 23 (48) 26 (57) 49 (52)

*Attacks requiring hospitalization, urgent healthcare visit, or IV hemin administration at home.1

†Use of opioids was defined as chronic if patients reported taking them for porphyria daily, or on most days, when not having an attack.

‡Symptoms were chronic if patients experienced symptoms of porphyria daily, or on most days, when not having an attack. 

All eligible patients (93 of 94) enrolled in the open-label extension (OLE).3

Efficacy in the ENVISION 6-month double-blind period and 18-month interim analysis of the OLE

Double-blind Period

In patients with AHP in the ENVISION 6-month double-blind period

Treatment with GIVLAARI® (givosiran) led to a significant reduction in porphyria attacks1*

Average rate of study-defined porphyria attacks compared to those on placebo
Average rate of study-defined porphyria attacks compared to those on placebo
70% fewer attacks* on average with GIVLAARI vs placebo 70% fewer study-defined attacks* on average with GIVLAARI vs placebo
  • Attack* rate ratio: GIVLAARI vs placebo
    0.3 (95% CI: 0.2, 0.4; P<0.0001)

*Attacks requiring hospitalization, urgent healthcare visit, or IV hemin administration at home.1
OLE Period

In a 18-month interim analysis of patients with AHP in the ENVISION OLE

Patients who continued treatment with GIVLAARI® (givosiran) had sustained attack* reduction4

Chart showing the average number of attacks compared to those on placebo and crossover through OLE period

  • Attack* reduction was sustained in patients continuing treatment with GIVLAARI during the OLE period4
  • Patients who crossed over from placebo to GIVLAARI had attack* reduction in the OLE period (for a total of 12 months of treatment) similar to that seen in GIVLAARI patients in the double-blind period4†

Endpoints in the OLE period are exploratory3

*Attacks requiring hospitalization, urgent healthcare visit, or IV hemin administration at home.1

†The estimate for each 3-month interval is calculated as total number of attacks/total number of patients reached at 3 months. Three months=28 x 3 days.

‡Data for GIVLAARI 1.25 mg/kg and 2.5 mg/kg in the OLE period were pooled.4

Safety profile of GIVLAARI® (givosiran) in the ENVISION study1,4

Adverse reactions that occurred at least 5% more frequently in patients treated with GIVLAARI compared with patients receiving placebo in the 6-month double-blind period1
Adverse Reaction GIVLAARI (N=48)
n (%)		 Placebo (N=46)
n (%)
Nausea 13 (27) 5 (11)
Injection site reactions 12 (25) 0
Rash* 8 (17) 2 (4)
Serum creatinine increase† 7 (15) 2 (4)
Transaminase elevations 6 (13) 1 (2)
Fatigue 5 (10) 2 (4)

*Grouped term includes pruritus, eczema, erythema, rash, rash pruritic, urticaria.

†Grouped term includes blood creatinine increased, glomerular filtration rate decreased, chronic kidney disease (decreased estimated glomerular filtration rate).
  • Permanent discontinuation of GIVLAARI occurred in 1 patient (2.1%) due to elevated transaminases, in adherence with prespecified protocol-defined stopping rules1,3
  • The most frequently occurring (≥20%) adverse reactions reported in patients treated with GIVLAARI were nausea (27%) and injection site reactions (25%)1
  • The safety profile of GIVLAARI in the OLE period through month 18 was similar to that observed in the 6-month double-blind period4
    • During the OLE period, there was one treatment discontinuation due to hypersensitivity reaction between month 12 and 184

eGFR=estimated glomerular filtration rate; OLE=open-label extension.
Double-blind Period

In patients with AHP in the ENVISION 6-month double-blind period

A greater number of patients treated with GIVLAARI had zero attacks* vs placebo1,2

Zero attack rate chart through the 6-month double-blind period
Zero attack rate chart through the 6-month double-blind period
50% of patients receiving attack prevention treatment with GIVLAARI had zero attacks* in the 6-month DB period vs 17% of placebo patients 50% of patients receiving attack prevention treatment with GIVLAARI had zero attacks* in the 6-month DB period vs 17% of placebo patients

*Attacks requiring hospitalization, urgent healthcare visit, or IV hemin administration at home.1

AHP=acute hepatic porphyria; DB=double blind.
OLE Period

In a 18-month interim analysis of patients with AHP in the ENVISION OLE

The number of patients with zero attacks* increased with continued attack prevention treatment with GIVLAARI2,4†

Zero attack rate chart through the OLE period 

Endpoints in the OLE period are exploratory4  

In the patients who crossed over from placebo to GIVLAARI, more had zero attacks* after starting GIVLAARI2,4

Zero attack rate chart through the OLE period for patients who crossed over from placebo to GIVLAARI® (givosiran) 

*Attacks requiring hospitalization, urgent healthcare visit, or IV hemin administration at home.1


Endpoints in the OLE period are exploratory4  

 

†Data for GIVLAARI 1.25 mg/kg and 2.5 mg/kg in the OLE period were pooled.4

DB=double-blind; OLE=open-label extension.
Double-blind Period

In patients with AHP in the ENVISION 6-month double-blind period

Significantly less hemin was used by patients treated with GIVLAARI1

70% reduction in average days of hemin use with GIVLAARI vs placebo

Chart showing hemin use through the double-blind period
Chart showing hemin use through the double-blind period

In the ENVISION 6-month DB period, 54% of AIP patients (N=25/46) treated with GIVLAARI had zero days of hemin compared with 23% of patients (N=10/43) receiving placebo.2

  • Ratio of average days of hemin use (GIVLAARI:placebo): 0.3 (95% CI: 0.1, 0.5; P=0.0002)1

AHP=acute hepatic porphyria; AIP=acute intermittent porphyria; DB=double-blind.
OLE Period

In the 18-month interim analysis of patients with AHP in the ENVISION OLE

Days of hemin use decreased for patients who crossed over to GIVLAARI4

51%
of patients who crossed
over to GIVLAARI required
zero days of hemin use4

  • Patients who crossed over from placebo to GIVLAARI had hemin use reduction in the ENVISION OLE period (for a total of 12 months of treatment with GIVLAARI) similar to that seen in patients receiving GIVLAARI in the double-blind period2,4*

Endpoints in the OLE period are exploratory.3

*Data for GIVLAARI 1.25 mg/kg and 2.5 mg/kg in the OLE period were pooled.4
AHP=acute hepatic porphyria; DB=double-blind; OLE=open-label extension.
Double-blind Period

Daily worst pain in AIP patients in ENVISION 6-month period2,5

Daily worst pain score in AIP patients was a secondary endpoint2

  • Pain was measured using patient-reported daily worst pain scores based on a numeric rating scale (NRS)2

  • A statistical analysis of the change from baseline in daily worst pain score for GIVLAARI vs placebo was conducted2

  • A positive score represents a worsening in daily worst pain from baseline; a negative score represents an improvement from baseline2

  • GIVLAARI did not meet statistical significance for this endpoint based on the prespecified statistical method5

  • The daily worst pain scores were lower with GIVLAARI compared with placebo2

Daily worst pain scores in AIP patients (AUC of mean change from baseline)5
GIVLAARI (N=46)
(95% CI)		 Placebo (N=43)
(95% CI)		 Treatment difference
(95% CI)
-12.876 (-21.776, -3.976) -0.196 (-9.468, 9.077) -12.680 (-25.526, 0.166)

AIP=acute intermittent porphyria; AUC=area under the curve.
Double-blind Period

Analgesic use in AIP patients in the ENVISION 6-month double-blind period2,3

Analgesic use in AIP patients was a prespecified exploratory endpoint

Chart showing analgesic use during the double-blind period

  • Through Month 6, the proportion of days with opioid and non-opioid analgesic use was lower in patients treated with GIVLAARI compared to placebo

  • An evaluation compared to baseline analgesic use cannot be conducted because the proportion of days with analgesic use was not captured at baseline

AIP=acute intermittent porphyria.

GIVLAARI targets and causes degradation of ALAS1 mRNA, reducing the production of neurotoxic intermediates associated with AHP attacks and other disease manifestations.1,6

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References: 1. GIVLAARI [prescribing information]. Cambridge, MA: Alnylam Pharmaceuticals, Inc. 2. Balwani M, Sardh E, Ventura P, et al; ENVISION Investigators. N Engl J Med. 2020;382(24):2289-2301. 3. Data on file. Alnylam Pharmaceuticals, Inc. 4. Kuter DJ, Keel S, Parker C, et al. Eighteen-month interim analysis of efficacy and safety of givosiran, an RNAi therapeutic for acute hepatic porphyria, in the ENVISION open-label extension. Presented at: American Society of Hematology (ASH) Congress; December 5-8, 2020; virtual. 5. Gouya L, Sardh E, Balwani M, et al; ENVISION investigators. Poster presented at: International Congress on Porphyrins and Porphyrias; September 10, 2019; Milan, Italy. 6. Sardh E, Harper P, Balwani M, et al. N Engl J Med. 2019;380(6):549-558.
 

IMPORTANT SAFETY INFORMATION 

Contraindications

GIVLAARI® (givosiran) is contraindicated in patients with known severe hypersensitivity to givosiran. Reactions have included anaphylaxis.

Anaphylactic Reaction

Anaphylaxis has occurred with GIVLAARI treatment (<1% of patients in clinical trials). Ensure that medical support is available to appropriately manage anaphylactic reactions when administering GIVLAARI. Monitor for signs and symptoms of anaphylaxis. If anaphylaxis occurs, immediately discontinue administration of GIVLAARI and institute appropriate medical treatment.

Hepatic Toxicity

Transaminase elevations (ALT) of at least 3 times the upper limit of normal (ULN) were observed in 15% of patients receiving GIVLAARI in the placebo-controlled trial. Transaminase elevations primarily occurred between 3 to 5 months following initiation of treatment.

Measure liver function tests prior to initiating treatment with GIVLAARI, repeat every month during the first 6 months of treatment, and as clinically indicated thereafter. Interrupt or discontinue treatment with GIVLAARI for severe or clinically significant transaminase elevations. In patients who have dose interruption and subsequent improvement, reduce the dose to 1.25 mg/kg once monthly. The dose may be increased to the recommended dose of 2.5 mg/kg once monthly if there is no recurrence of severe or clinically significant transaminase elevations at the 1.25 mg/kg dose.

Renal Toxicity

Increases in serum creatinine levels and decreases in estimated glomerular filtration rate (eGFR) have been reported during treatment with GIVLAARI. In the placebo-controlled study, 15% of patients receiving GIVLAARI experienced a renally-related adverse reaction. The median increase in creatinine at Month 3 was 0.07 mg/dL. Monitor renal function during treatment with GIVLAARI as clinically indicated.

Injection Site Reactions

Injection site reactions were reported in 25% of patients receiving GIVLAARI in the placebo-controlled trial. Symptoms included erythema, pain, pruritus, rash, discoloration, or swelling around the injection site. One (2%) patient experienced a single, transient, recall reaction of erythema at a prior injection site with a subsequent dose administration.

Drug Interactions

Concomitant use of GIVLAARI increases the concentration of CYP1A2 or CYP2D6 substrates, which may increase adverse reactions of these substrates. Avoid concomitant use of GIVLAARI with CYP1A2 or CYP2D6 substrates for which minimal concentration changes may lead to serious or life-threatening toxicities. If concomitant use is unavoidable, decrease the CYP1A2 or CYP2D6 substrate dosage in accordance with approved product labeling.

Adverse Reactions

The most common adverse reactions that occurred in patients receiving GIVLAARI were nausea (27%) and injection site reactions (25%).

INDICATION

GIVLAARI is indicated for the treatment of adults with acute hepatic porphyria (AHP).

For additional information about GIVLAARI, please see full Prescribing Information.