Trikafta is a next-generation combination of three cystic fibrosis (CF) medications: elexacaftortezacaftor, and ivacaftor.

Vertex Pharmaceuticals developed the triple-combination therapy, which the U.S. Food and Drug Administration (FDA) approved in October 2019 to treat CF patients, ages 12 and older, with at least one F508del mutation. The F508del mutation is the most common CF-causing genetic defect, seen in about 90% of all people with the disease.

In December 2020, the U.S. regulatory agency expanded the number of approved mutations for Trikafta, meaning the therapy can now be used to treat a broader range of CF patients. The FDA again expanded Trikafta’s approval, to cover children as young as 6, in 2021.

The European Commission (EC) approved the Vertex triple combo — marketed in the EU under the brand name Kaftrio — in combination with Kalydeco in August 2020 for patients with two F508del mutations or one F508 del and one minimal function mutation. In 2021, the EC also expanded the list of approved secondary mutations that can be treated with the triple combination.

What is CF?

CF is a rare genetic disease caused by mutations in the CFTR gene. This gene provides the instructions necessary for cells to make the CFTR protein, which is a transporter protein that controls the movement of charged ions across cell membranes.

Mutations in CFTR mean that salts cannot cross cell membranes normally. This leads to the build-up of thick, sticky mucus in different tissues and organs, especially the lungs and the digestive tract. In the lungs, this mucus can interfere with breathing, and make patients more susceptible to respiratory infections.

The F508del mutation results in a premature stop signal in the genetic code, causing cells to make a truncated or shorter-than-normal CFTR protein. The cells cannot shuttle this truncated protein to the surface as efficiently as normal CFTR, resulting in abnormal ion transport.

How does Trikafta work?

Trikafta is a CFTR modulator that helps defective CFTR proteins work more effectively.

Both elexacaftor and tezacaftor work as correctors. They bind to the faulty CFTR protein and help it fold correctly. This way, cells can shuttle more of it to the membrane instead of degrading it. Ivacaftor — also marketed independently as Kalydeco — is a potentiator: it binds to the CFTR protein and holds the channel open so that more salt can pass through it.

With a combination of all three therapies, more CFTR protein reaches the cell membrane, and these proteins are more active and functional.

Trikafta in clinical trials

The FDA approved Trikafta based on the results of two Phase 3 clinical trials: AURORA F/MF (NCT03525444) and AURORA F/F (NCT03525548).

The first trial enrolled 403 CF patients with one F508del mutation and one minimal function mutation (F/MF). It tested the effect of Trikafta against a placebo for 24 weeks, about six months.

In the second trial, 107 patients with two F508del mutations (F/F) received either Trikafta or Symdeko, which contains tezacaftor and ivacaftor. The primary outcome measure was the change in percent predicted forced expiratory volume in one second (ppFEV1), a measure of lung function. A secondary measure was the number of pulmonary exacerbations, or periods of worsening respiratory symptoms.

Data from both studies showed significant improvements in lung function in Trikafta-treated patients, with ppFEV1 improving by an average of 14.3% for this group in AURORA F/MF, and by 10% for those in AURORA F/F. Patients generally tolerated the treatment well.

Vertex announced positive results from another Phase 3 trial (NCT03691779) in September 2020. The trial investigated the pharmacokinetics (movement in the body), pharmacodynamics (effect on the body), safety, tolerability, and efficacy of Trikafta in children, ages 6 to 11. It recruited 66 children with either F/F or F/MF mutations for 24 weeks of treatment.

The results showed that the children tolerated Trikafta well. They also showed improvements in ppFEV1, sweat chloride, and a number of other metrics.

Other information

Trikafta is also under priority review by Health Canada, which will decrease the review time from 300 days to around 180 days (about six months). The company expects a decision in the first half of 2021.

Common side effects of Trikafta include headache, upper respiratory infection, rash, abdominal pain, and nasal congestion. Liver damage, nasal symptoms, and increased levels of bilirubin — an orange-yellow pigment that occurs normally when part of the body’s red blood cells break down — also are common side effects of the medication.

Before Trikafta’s FDA approval, researchers had already assessed two components of the therapy in CF patients. The FDA approved the two components either as a monotherapy or as a dual combination therapy.

Kalydeco was approved in 2012, while Orkambi — a combination of lumacaftor and ivacaftor — received approval in 2015. In addition, Symdeko, marketed as Symkevi in the European Union, was approved in 2018.

Last updated: June 9, 2021


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