Canakinumab: Miracle drug or glorified Aspirin?

Clinical Brief – September, 7th

The Brief

Canakinumab (Ilaris) is an anti-inflammatory biologic. Studies published recently showed that canakinumab may offer protection against some heart diseases and was tied to significantly lower risk of lung cancer.

Sounds impressive, but did you know that Aspirin might give the same degree of protection against heart disease and cancer? Albeit colorectal cancer and not lung cancer, but still.


What were the canakinumab studies?

In a back-to-back publication, the CANTO trial tested canakinumab in about 10k patients at risk of heart disease and lung cancer. Patients were divided up into four groups to receive three doses of canakinumab or placebo.

After four years, they found that mid-to-high dose canakinumab reduced the risk of heart attack, stroke, or cardiovascular death, by about 15% vs placebo.

However, take a closer look at the stats and count each of these outcomes individually, we see that most of this benefit was because canakinumab reduced the risk of heart attacks, but not stroke or cardiovascular deaths.

Canakinumab also reduced the risk of lung cancer by 39% at the medium dose vs placebo; 67% at the highest dose.

Fatal infections were more frequent with canakinumab than placebo. The overall mortality risk was the same between treatments.


Compare this against Aspirin.

STAT News reported that the lead author Dr Ridker suggests that these benefits of canakinumab were the result of its anti-inflammatory effects.

But wait. Aspirin is an anti-inflammatory too. It’s also been shown to protect against heart diseases and a particular type of cancer.

How does canakinumab stack up against Aspirin? The short answer is: About par.

An analysis of trials showed that Aspirin reduced the risk of heart attack, stroke, or cardiovascular death, by about 12% vs controls.

Looking at each of these outcomes individually, we also find that the benefit is mainly due to Aspirin’s protection against heart attacks, but not stroke or cardiovascular deaths.

Aspirin was also shown to protect against cancer. It’s not lung cancer though, but colorectal cancer.

In a separate trial, treatment with Aspiring for at least 2 years reduced the risk of colorectal cancer by 59% vs placebo.

In the heart-disease analysis, Aspirin was linked to major bleeding inside the gut and brain. In the cancer-prevention trial, Aspirin had a similar safety profile as placebo.


Bottom line

I was first piqued by headlines about canakinumab being the “biggest breakthrough since statins” and having a “welcome side effect” by reducing the risk of lung cancer.

The thing is, I don’t think canakinumab is likely to do all that much better than Aspirin for protection against either heart disease or cancer. Granted though, that canakinumab was tested for lung cancer and Aspirin for colorectal cancer, so there may be some merit in that.

But get this. A year’s supply of Aspirin costs less than $8 USD. Canakinumab? $60k USD per year. It’s gotta do a lot better than this to justify this kind of a premium.

Now, I know the comparison I’m drawing here is a statistical sin. I did not run a meta-analysis to compare across very different trials. But I wanted to show the general ballpark of the Aspirin effect to give context to what we are seeing now about canakinumab.

Hopefully, this can give a trialist some ideas.

 

 

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