Burosumab treatment of X-linked hypophosphatemia patients: interim analysis of the SUNFLOWER longitudinal, observational cohort study

Abstract

X-linked hypophosphatemia (XLH) is a genetic disease that results in excessive FGF23, chronic hypophosphatemia, and musculoskeletal abnormalities, with affected patients experiencing symptoms such as bone pain, bone deformity, fracture, and pseudofracture. Burosumab is a fully human monoclonal antibody that binds to FGF23, improving lowered serum 1,25(OH)₂D and phosphate levels in patients with XLH. There are insufficient data on the use of burosumab, its safety, and the outcomes of treated patients in a real-world setting. The SUNFLOWER (Study of longitUdinal observatioN For patients with X-Linked hypOphosphatemic rickets/osteomalacia in collaboration With Asian partnERs) study is an ongoing longitudinal, observational cohort study of patients with XLH in Japan and South Korea. Enrollment occurred between April 2018 and December 2020. This interim analysis compared the background characteristics of patients who received burosumab with those who did not, and assessed improvements in biomarkers, physical and motor function, health-related quality-of-life (HRQOL) and other patient-reported outcome (PRO) measures, as well as the safety of burosumab treatment in 143 Japanese patients from 15 institutions over 6 mo. The patients had a median [interquartile range] age of 17.5 [11.0, 38.8] yr and 98 (68.5%) were female. Among patients aged <18 and ≥18 yr, 40/73 (54.8%) and 25/70 (35.7%) received burosumab, respectively. More patients aged ≥18 who received burosumab had bone pain at baseline vs those not treated with burosumab (6/25, 24.0% vs 2/45, 4.4%, p=.021). Patients treated with burosumab had improved serum phosphate and 1,25(OH)₂D levels; moreover, rickets severity and HRQOL/PRO measures, such as pain, appeared to improve over 6 mo of burosumab treatment, and no new safety concerns were identified. This study identified trends in the background characteristics of patients with XLH who receive burosumab in real-world clinical practice. Furthermore, the results support the use of burosumab therapy in real-world settings.

Keywords: PTH/Vit D/FGF23; bone turnover markers; disorders of calcium/phosphate metabolism; osteomalacia; rickets.

Figure 1

Changes in biomarkers for phosphate metabolism and bone turnover over 6 mo of burosumab treatment in patients aged <18 yr. (A) Phosphate levels. (B) Calcium levels. (C) 1,25(OH)₂D levels. (D) 25(OH)D levels. (E) Albumin levels. (F) iPTH levels. (G) Creatinine levels. (H) ALP levels. The horizontal line indicates the median, upper and lower box edges show the interquartile range, whiskers represent minimum and maximum values, and the diamond represents the mean. ALP levels were determined using the JSCC method. ALP, alkaline phosphatase; iPTH, intact PTH; JSCC, Japan Society of Clinical Chemistry.

Figure 2

Changes in biomarkers for phosphate metabolism and bone turnover over 6 mo of burosumab treatment in patients aged ≥18 yr. (A) Phosphate levels. (B) Calcium levels. (C) 1,25(OH)₂D levels. (D) 25(OH)D levels. (E) Albumin levels. (F) iPTH levels. (G) Creatinine levels. (H) BALP levels. The horizontal line indicates the median, upper and lower box edges show the interquartile range, whiskers represent minimum and maximum values, and the diamond represents the mean. BALP, bone-specific alkaline phosphatase; iPTH, intact PTH.

Figure 3

Changes in RSS over 6 mo of burosumab treatment in patients aged <18 yr. The horizontal line indicates the median, upper and lower box edges show the interquartile range, whiskers represent minimum and maximum values, and the diamond represents the mean. RSS, Rickets Severity Score.