Otezla® (apremilast) was evaluated in a robust global clinical development program for plaque psoriasis that enrolled over 1200 patients1,2
ESTEEM 1 & ESTEEM 2 Details
ESTEEM Study Design
LIBERATE Study Design
ESTEEM® 1 and ESTEEM 21-3
--In ESTEEM 1, patients were switched to Otezla if they lost their PASI-75, but no later than at week 52. In ESTEEM 2, patients were switched to Otezla if they lost 50% of the PASI improvement obtained at week 32 compared to baseline, but no later than at week 52.
aDoses of Otezla were titrated during the first week of administration.
bA responder was defined as a patient achieving
≥PASI-75; a partial responder was defined as a patient achieving PASI-50 to PASI-74; a nonresponder was defined as a patient achieving <PASI-50 in both ESTEEM 1 and ESTEEM 2 at week 32.
cAt week 32, nonresponders and partial responders (ESTEEM 1) or nonresponders only (ESTEEM 2) had the option of adding topical and/or UVB therapy. The decision could be made at week 32 and was based on the discretion of the investigator.
BID, twice daily; ESTEEM, Efficacy and Safety Trial Evaluating the Effects of Apremilast in Psoriasis; PASI, Psoriasis Area and Severity Index.
Weeks 0 to 16 (placebo-controlled phase): Patients were randomized 2:1 to Otezla twice daily or placebo2,3
Weeks 16 to 32 (maintenance phase): All patients received Otezla2,3
Weeks 32 to 52 (withdrawal phase)2,3
Patients originally randomized to Otezla who achieved at least a 75% reduction in PASI score (PASI-75) in ESTEEM 1, or at least a 50% reduction in PASI score (PASI-50) in ESTEEM 2 at week 32, were re-randomized 1:1 to either placebo or Otezla. Patients who were re-randomized to placebo and who lost their PASI-75 response (ESTEEM 1), or 50% of the improvement that they achieved at week 32 compared to baseline (ESTEEM 2), were re-treated with Otezla, but no later than week 52. Patients who did not achieve the designated PASI response by week 32 had the option of adding topical and/or UVB therapy
Patients originally randomized to placebo and transitioned to Otezla, who then achieved at least PASI-75 in ESTEEM 1, or at least PASI-50 in ESTEEM 2, at week 32, were allowed to continue on Otezla. Patients who did not achieve the designated PASI response by week 32 had the option of adding topical and/or UVB therapy
Weeks 52 to 260 (long-term extension phase)2,3
Patients entering a long-term extension phase could be treated through 5 years
Otezla was evaluated in 2 multicenter, double-blind, placebo-controlled trials of similar design. Patients ≥18 years of age (N = 1257) with moderate to severe plaque psoriasis were randomized to placebo (n = 419) or Otezla (n = 836) given orally twice daily. These studies had a similar design through week 32.2-4
ESTEEM® 1 and ESTEEM 2 criteria and endpoints
Selected inclusion criteria4:
BSA involvement of ≥10%
sPGA of ≥3 (moderate or severe disease)
PASI score ≥12
Candidates for phototherapy or systemic therapy
Selected exclusion criteria:
Active TB or incompletely treated TB; however, there was no requirement for latent TB screening1-3
Hepatitis B or hepatitis C positive at screening1
History of HIV1
The proportion of patients who achieved PASI-75 at week 16
Selected secondary endpoints:
Proportion of patients who achieved sPGA score of clear (0) or almost clear (1) at week 162,3
Change from baseline in pruritus VAS at week 161
Selected exploratory endpoints1:
Percent change from baseline in NAPSI score at week 16 for patients with baseline nail psoriasis
Proportion of patients with scalp psoriasis with improvement of ScPGA scores to 0 (clear) and 1 (minimal) at week 16
46 years (18 to 83 years)
Mean baseline BSA involvement4:
Mean baseline PASI score4:
Proportion of patients with baseline sPGA score 3 (moderate)4:
Proportion of patients with baseline sPGA score 4 (severe)4:
Prior psoriasis therapy:
Phototherapy - 30%4
Systemic therapy - 54%4
Conventional systemic therapy - 37%4
Biologic therapy - 30%4
No prior phototherapy, conventional systemic therapy, or biologics - 35%1
History of psoriatic arthritis4:
Concomitant psoriasis medications allowed2,3:
Low-potency topical corticosteroids for face, axillae, and groin psoriatic lesions
Coal tar shampoo and/or salicylic acid preparations for scalp lesions
All the above permitted except within 24 hours before each study visit
BSA, body surface area; HIV, human immunodeficiency virus; ESTEEM, Efficacy and Safety Trial Evaluating the Effects of Apremilast in Psoriasis; NAPSI, Nail Psoriasis Severity Index; PASI, Psoriasis Area and Severity Index; ScPGA, Scalp Physician Global Assessment; sPGA, static Physician Global Assessment; TB, tuberculosis; VAS, visual analog scale.
LIBERATE® criteria and endpoints5
A global, phase 3b, placebo-controlled, double-blind, double-dummy study
evaluating patients with moderate to severe plaque psoriasis for up to 104 weeks
Patients were randomized 1:1:1 to either
Otezla 30 mg (n = 83) twice daily, etanercept 50 mg (n = 83) once weekly, or placebo (n = 84) through week 16. At week 16, all patients crossed over to the Otezla arm
This study was not designed for apremilast vs etanercept comparisons
Selected inclusion criteria:
Chronic plaque psoriasis for ≥12 months
PASI score ≥12
sPGA score ≥3
Inadequate response, intolerance or contraindication to ≥1 conventional systemic agent for treatment of psoriasis
Candidates for phototherapy or systemic (including etanercept) therapy
No prior exposure to a biologic therapy for psoriasis or psoriatic arthritis
Selected exclusion criteria:
Prior failure of >3 systemic agents for treatment of psoriasis
History of known demyelinating diseases such as multiple sclerosis or optic neuritis or history of/concurrent congestive heart failure, including medically controlled, asymptomatic congestive heart failure
Other clinically significant or major uncontrolled disease
Latent, active, or history of incompletely treated TB
The proportion of patients treated with apremilast or placebo who achieved a PASI-75 at week 16
Proportion of patients treated with etanercept or placebo who achieved PASI-75 at week 16
Otezla, 46 years; placebo, 43 years; etanercept, 47 years
Mean baseline BSA involvement:
Otezla, 27.1%; placebo, 27.3%; etanercept, 28.4%
Mean baseline PASI score:
Otezla, 19.3; placebo, 19.4; etanercept, 20.3
Concomitant psoriasis medications allowed:
Low-potency topical corticosteroids as background therapy for treatment of face, axillae, and groin
Coal tar shampoo and/or salicylic acid scalp preparations for scalp lesions
All were permitted except within 24 hours before study visits
BSA, body surface area; LIBERATE, Evaluation in a Placebo-Controlled Study of Oral Apremilast and Etanercept in Plaque Psoriasis; PASI, Psoriasis Area and Severity Index; sPGA, static Physician Global Assessment; TB, tuberculosis.
References:1. Data on file, Celgene Corporation.
2. Papp K, Reich K, Leonardi CL, et al. J Am Acad Dermatol. 2015;73(1):37-49.
3. Paul C, Cather J, Gooderham M, et al. Br J Dermatol. 2015;173(6):1387-1399.
4. Otezla [package insert]. Summit, NJ: Celgene Corporation.
5. Reich K, Gooderham M, Green L, et al. J Eur Acad Dermatol Venereol. 2017;31:507-517.
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