Introduction: The Shifting Paradigm in ATTR-CM Therapy
Transthyretin amyloid cardiomyopathy (ATTR-CM) has transitioned from being considered a rare, terminal condition to a frequently diagnosed cause of heart failure, particularly in the elderly and those with heart failure with preserved ejection fraction (HFpEF). The disease is characterized by the systemic or localized deposition of misfolded transthyretin (TTR) proteins as insoluble amyloid fibrils in the myocardium. This leads to progressive restrictive cardiomyopathy, conduction disturbances, and eventually, death.
Until recently, the therapeutic landscape was dominated by TTR stabilizers, such as tafamidis, which prevent the dissociation of the TTR tetramer into the monomers that form fibrils. While stabilizers and newer TTR silencers (RNA interference or antisense oligonucleotides) have significantly improved survival and reduced hospitalizations, they share a common limitation: they primarily address the production or stability of new TTR proteins without actively removing the amyloid already deposited in the heart. The Coramitug Phase 2 trial represents a critical pivot toward ‘amyloid clearance,’ utilizing a humanized monoclonal antibody to stimulate the body’s own immune system to resolve existing deposits.
Highlights of the Trial
– Coramitug 60 mg/kg achieved a 48% reduction in NT-proBNP compared to placebo (P=0.0017) at 52 weeks.
– The therapy was well tolerated with a safety profile comparable to placebo, even when used alongside standard-of-care stabilizers like tafamidis.
– While functional capacity (6MWT) did not show a statistical difference within the 12-month window, improvements in echocardiographic functional parameters were observed.
– The trial provides the first clinical evidence that an antibody-mediated phagocytosis approach can significantly impact validated biomarkers of ATTR-CM progression.
Background and Mechanism: Beyond Stabilization
Coramitug is a humanized monoclonal antibody designed to target a specific cryptic epitope that is exposed only when the transthyretin protein is misfolded or aggregated. By binding to these misfolded proteins within the amyloid deposits, coramitug is intended to trigger antibody-mediated phagocytosis, primarily through macrophages. This mechanism is fundamentally different from tafamidis (which stabilizes the protein) or vutrisiran (which silences production). In theory, clearing existing amyloid should improve myocardial compliance and diastolic function more rapidly than simply preventing new growth.
Study Design and Participant Characteristics
This Phase 2, randomized, multicenter, double-blind, placebo-controlled trial enrolled 104 participants across multiple global sites. The study population was representative of the typical ATTR-CM demographic:
– Median age: 77 years.
– Gender: 93% men.
– Clinical status: 84% were New York Heart Association (NYHA) class II.
– Genotype: 13% had variant ATTR-CM, while the remainder had the wild-type form.
– Baseline NT-proBNP: Median 1985 pg/mL.
Participants were randomized in a 1:1:1 ratio to receive intravenous infusions every four weeks of either coramitug 10 mg/kg, coramitug 60 mg/kg, or a placebo for 52 weeks. Notably, 90% of the cohort were already receiving disease-modifying therapy, with 84% on tafamidis and a small percentage on TTR silencers. This allowed investigators to assess the efficacy of coramitug as an ‘add-on’ therapy, reflecting real-world clinical practice.
Key Findings: Biomarker and Functional Outcomes
NT-proBNP: A Robust Signal of Efficacy
The primary success of the trial was observed in the 60 mg/kg dose group. At the 52-week mark, these patients experienced a 48% reduction in NT-proBNP levels compared to the placebo group (95% CI: -65%, -22%; P=0.0017). NT-proBNP is a well-validated marker of cardiac wall stress and a strong predictor of mortality in ATTR-CM. The magnitude of this reduction suggests a substantial easing of the amyloid burden or an improvement in myocardial hemodynamics.
Six-Minute Walk Test (6MWT)
Regarding the other primary endpoint, the change in 6MWT distance from baseline to week 52 did not reach statistical significance for either the 10 mg/kg or 60 mg/kg doses compared to placebo. While this may initially seem disappointing, clinical experts suggest that functional improvements in 6MWT often lag behind biomarker changes in amyloidosis trials, particularly in a population where 84% are already stabilized on tafamidis. Furthermore, the 52-week timeframe may be insufficient to capture the physical rehabilitation that follows biochemical amyloid clearance.
Secondary and Exploratory Parameters
Interestingly, the 60 mg/kg dose was associated with improvements in functional echocardiographic parameters. These data support the hypothesis that the reduction in NT-proBNP is linked to improved cardiac mechanics. The 10 mg/kg dose did not show the same level of efficacy, indicating a dose-dependent response that will be crucial for the design of future Phase 3 trials.
Safety and Tolerability
Safety is a paramount concern for monoclonal antibodies in an elderly population with significant cardiac comorbidities. Coramitug was remarkably well tolerated. Treatment-emergent adverse events (TEAEs) were generally mild to moderate and balanced across the coramitug and placebo arms. There were no signals of increased all-cause mortality or significant cardiovascular events (such as urgent heart failure visits) attributable to the drug. This safety profile is particularly encouraging given the potential for inflammatory responses during the phagocytosis of amyloid deposits.
Expert Commentary: Clinical Implications
The Coramitug Phase 2 results are being hailed as a significant step toward a ‘cure’ or at least a ‘reversal’ strategy for ATTR-CM. Dr. Marianna Fontana and colleagues note that the reduction in NT-proBNP is one of the most significant seen in a Phase 2 trial for this condition. However, the lack of 6MWT improvement remains a point of discussion. It highlights the difficulty of using functional tests in an elderly population where orthopedic issues and other comorbidities often confound the results of walking tests.
Mechanistically, the data support the idea that we can move beyond the ‘baseload’ of stabilization. For clinicians, the trial suggests that even patients who are ‘stable’ on tafamidis might benefit from additional therapies that target the existing amyloid plaque. Future research must determine whether these biomarker improvements eventually translate into hard clinical outcomes, such as reduced mortality and hospitalization over a 2- to 3-year period.
Conclusion
The Phase 2 trial of coramitug successfully met its biomarker objectives, demonstrating that a 60 mg/kg dose can significantly reduce NT-proBNP in patients with ATTR-CM. The drug’s safety profile and its ability to work synergistically with existing stabilizers mark it as a promising candidate for the next generation of amyloidosis care. While the 52-week data did not show a functional change in walking distance, the underlying cardiac improvements suggest that coramitug may indeed be clearing the ‘unclearable’ amyloid.
Funding and Trial Information
This trial was supported by the developers of coramitug. Detailed information can be found at clinicaltrials.gov under the study identifier (Reference: Circulation. 2025 Nov 10. doi: 10.1161/CIRCULATIONAHA.125.077304).
References
1. Fontana M, Garcia-Pavia P, Grogan M, et al. Coramitug, a Humanized Monoclonal Antibody for the Treatment of Transthyretin Amyloid Cardiomyopathy: a Phase 2, Randomized, Multicenter, Double-Blind, Placebo-Controlled Trial. Circulation. 2025; Epub ahead of print. PMID: 41212997.
2. Maurer MS, Schwartz JH, Gundapaneni B, et al. Tafamidis Treatment for Patients with Transthyretin Amyloid Cardiomyopathy. N Engl J Med. 2018;379(11):1007-1016.
3. Gillmore JD, Gane E, Taubel J, et al. CRISPR-Cas9 In Vivo Gene Editing for Transthyretin Amyloidosis. N Engl J Med. 2021;385(6):493-502.
