Skip to content

Study of Efficacy and Safety of QAW039 in Patients With Severe Asthma Inadequately Controlled With Standard of Care Asthma Treatment.

A 52-week, Multicenter, Randomized, Double-blind, Placebo-controlled Study to Assess the Efficacy and Safety of QAW039 When Added to Existing Asthma Therapy in Patients With Uncontrolled Severe Asthma.

Status
Completed
Phases
Phase 3
Study type
Interventional
Source
ClinicalTrials.gov
Registry ID
NCT02563067
Enrollment
877
Registered
2015-09-29
Start date
2015-12-03
Completion date
2019-08-02
Last updated
2021-05-03

For informational purposes only — not medical advice. Sourced from public registries and may not reflect the latest updates. Terms

Conditions

Asthma

Keywords

Asthma, QAW039

Brief summary

This study aimed to determine the efficacy and safety of QAW039 and QAW039 450 mg compared to placebo, when added to GINA (Global Initiative for Asthma) steps 4 and 5 standard-of- care (SoC) asthma therapy (GINA 2016) in the following two populations: * patient with inadequately controlled severe asthma and high eosinophil counts (eosinophil count at Visit 1 ≥250 cells/ µl) (sub-population) * patients with inadequately controlled severe asthma (overall study population) Inadequate control is defined as partly controlled or uncontrolled asthma (GINA 2016)

Detailed description

This study used a randomized, multicenter, double-blind, placebo-controlled parallel-group design in which QAW039 (150 mg and 450 mg) or placebo was added to GINA steps 4 and 5 asthma therapy. The study included: * Screening period of up to 2 weeks to assess eligibility; * Run-in period of approximately 2 weeks and a maximum of 6 weeks on placebo to collect baseline data for efficacy variables and compliance with the Electronic Peak Flow/ eDiary device. Upon completion of the run-in period, all patients who met the eligibility criteria were randomized to one of three treatments: QAW039 150 mg or QAW039 450 mg or placebo once daily in a ratio of 1:1:1. * Treatment period of 52 weeks (assessment period for all Primary and Secondary Outcome Measures). Clinic visits were scheduled approximately 4 weeks after randomization and then at approximately 8-week intervals during the active-treatment period. Phone calls occurred at specified time points between visits occurring at 8-week intervals. Patients who had successfully completed 52 weeks of treatment in this study were offered an optional participation in a safety study (CQAW039A2315). * Follow-up period of 4 weeks, investigational and drug-free, following the last dose of study drug. A follow-up visit occurred approximately 4 weeks (i.e., approximately 30 days) following the last dose of study therapy to complete safety assessments and pregnancy testing (if applicable). The follow-up period applied to all patients except those patients who had entered the optional safety study (CQAW039A2315) directly after the Week 52 study visit

Interventions

DRUGQAW039

QAW039 150 mg once daily

DRUGPlacebo

Placebo once daily

Sponsors

Novartis Pharmaceuticals
Lead SponsorINDUSTRY

Study design

Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
DOUBLE (Subject, Investigator)

Eligibility

Sex/Gender
ALL
Age
12 Years to No maximum
Healthy volunteers
No

Inclusion criteria

* Written informed consent. * Male and female patients aged ≥12 years. * A diagnosis of severe asthma, uncontrolled on GINA 4/5 asthma medication. * Evidence of airway reversibility or airway hyper- reactivity. * FEV1 ≤80% of the predicted normal value for patients aged ≥18 years; FEV1 of ≤90% for patients aged 12 to \<18 years * An ACQ score ≥1.5 * A history of 2 or more asthma exacerbations within the 12 months prior to entering the study.

Exclusion criteria

* Use of other investigational drugs within 5 half-lives of study entry, or within 30 days, whichever is longer. * Subjects who have participated in another trial of QAW039. * A QTcF (Fridericia) ≥450 msec (male) or ≥460 msec (female). * History of malignancy with the exception of local basal cell carcinoma of the skin. * Pregnant or nursing (lactating) women. * Serious co-morbidities. * Patients on \>20 mg of simvastatin, \> 40 mg of atorvastatin, \>40 mg of pravastatin, or \>2 mg of pitavastatin.

Design outcomes

Primary

MeasureTime frameDescription
Rate of Moderate-to-severe Asthma Exacerbations During the 52-week Treatment Period in High Eosinophils Subpopulation52 weeksA severe asthma exacerbation is defined as treatment with 'rescue' systemic corticosteroids for greater than or equal to 3 days and hospitalization; or treatment with 'rescue' systemic corticosteroids for greater than or equal to 3 days and emergency department visit (greater than 24 hours\*); or death due to asthma. A moderate asthma exacerbation is defined as treatment with 'rescue' systemic corticosteroids for greater than or equal to 3 days either as an outpatient or in emergency department visits (Emergency department visit less than or equal to 24 hours). The high eosinophils subpopulation consists of all patients with blood eosinophil count ≥ 250 cells/μL at baseline.
Rate of Moderate-to-severe Asthma Exacerbations During the 52-week Treatment Period in Overall Population52 weeksA severe asthma exacerbation is defined as treatment with 'rescue' systemic corticosteroids for greater than or equal to 3 days and hospitalization; or treatment with 'rescue' systemic corticosteroids for greater than or equal to 3 days and emergency department visit (greater than 24 hours\*); or death due to asthma. A moderate asthma exacerbation is defined as treatment with 'rescue' systemic corticosteroids for greater than or equal to 3 days either as an outpatient or in emergency department visits (Emergency department visit less than or equal to 24 hours).

Secondary

MeasureTime frameDescription
Change From Baseline to Week 52 in Pre-dose Forced Expiratory Volume in 1 Second (FEV1) in High Eosinophils SubpopulationBaseline, Week 52Forced Expiratory Volume in one second (FEV1) is calculated as the volume of air forcibly exhaled in one second as measured by a spirometer. Baseline is defined as the last available FEV1 measurement taken prior to the first dose of randomized study drug. The high eosinophils subpopulation consists of all patients with blood eosinophil count ≥ 250 cells/μL at baseline.
Change From Baseline to Week 52 in Asthma Quality of Life Questionnaire for Participants 12 Years and Older (AQLQ+12) Score in Overall PopulationBaseline, Week 52AQLQ is a 32-item instrument administered as a self-assessment. AQLQ+12 is a modified version of AQLQ developed to measure functional impairments of participants aged 12-70 years. It is divided into 4 domains: activity limitation, symptoms, emotional function, and environmental stimuli. Participants were asked to recall their experiences during the last 2 weeks and respond to each question on a 7-point scale (1=severe impairment, 7=no impairment), where higher scores indicated better quality of life. Overall AQLQ+12 score is the mean of all 32 responses.
Change From Baseline to Week 52 in Asthma Quality of Life Questionnaire for Participants 12 Years and Older (AQLQ+12) Score in High Eosinophils SubpopulationBaseline, Week 52AQLQ is a 32-item instrument administered as a self-assessment. AQLQ+12 is a modified version of AQLQ developed to measure functional impairments of participants aged 12-70 years. It is divided into 4 domains: activity limitation, symptoms, emotional function, and environmental stimuli. Participants were asked to recall their experiences during the last 2 weeks and respond to each question on a 7-point scale (1=severe impairment, 7=no impairment), where higher scores indicated better quality of life. Overall AQLQ+12 score is the mean of all 32 responses. The high eosinophils subpopulation consists of all patients with blood eosinophil count ≥ 250 cells/μL at baseline.
Change From Baseline to Week 52 in Pre-dose Forced Expiratory Volume in 1 Second (FEV1) in Overall PopulationBaseline, Week 52Forced Expiratory Volume in one second (FEV1) is calculated as the volume of air forcibly exhaled in one second as measured by a spirometer. Baseline is defined as the last available FEV1 measurement taken prior to the first dose of randomized study drug.
Change From Baseline to Week 52 in Asthma Control Questionnaire-5 (ACQ-5) Score in Overall PopulationBaseline, Week 52The ACQ-5 is a five-item, self-completed questionnaire, which is used as a measure of asthma control of a participant. The five questions (concerning nocturnal awakening, waking in the morning, activity limitation, shortness of breath and wheeze) enquire about the frequency and/or severity of symptoms over the previous week. The response options for all these questions range from zero (no impairment/limitation) to six (total impairment/ limitation) scale. The ACQ-5 score is the average of the individual item scores and ranges from 0 to 6. Higher scores indicates worsening of condition.
Change From Baseline to Week 52 in Asthma Control Questionnaire-5 (ACQ-5) Score in High Eosinophils SubpopulationBaseline, Week 52The ACQ-5 is a five-item, self-completed questionnaire, which is used as a measure of asthma control of a participant. The five questions (concerning nocturnal awakening, waking in the morning, activity limitation, shortness of breath and wheeze) enquire about the frequency and/or severity of symptoms over the previous week. The response options for all these questions range from zero (no impairment/limitation) to six (total impairment/ limitation) scale. The ACQ-5 score is the average of the individual item scores and ranges from 0 to 6. Higher scores indicates worsening of condition. The high eosinophils subpopulation consists of all patients with blood eosinophil count ≥ 250 cells/μL at baseline.

Countries

Argentina, Canada, Czechia, Greece, India, Israel, Italy, Japan, Lebanon, Malaysia, Mexico, Netherlands, Russia, Serbia, Slovakia, South Africa, Spain, Taiwan, United States

Participant flow

Recruitment details

Participants were recruited from centers in Argentina (18), Canada (5), Czech Republic (7), Greece (6), India (12), Israel (5), Italy (22), Japan (16), Lebanon (3), Malaysia (4), Mexico (3), Netherlands (4), Russian Federation (11), Serbia (4), Slovakia (11), South Africa (3), Spain (13), Taiwan (3) and the United States (19).

Pre-assignment details

The study included a Screening period of up to 2 weeks and a Placebo Run-in period of 2 to 6 weeks, during which eligibility for randomization was determined

Participants by arm

ArmCount
QAW039 150 mg
QAW039 150 mg once daily
296
QAW039 450 mg
QAW039 450 mg once daily
294
Placebo
Placebo once daily
287
Total877

Withdrawals & dropouts

PeriodReasonFG000FG001FG002
Overall StudyAdverse Event210
Overall StudyDeath011
Overall StudyDeath post Treatment/safety period100
Overall StudyLack of Efficacy100
Overall StudyLost to Follow-up120
Overall StudyPhysician Decision013
Overall StudySubject/guardian decision142016
Overall StudyTechnical problems010

Baseline characteristics

CharacteristicQAW039 150 mgQAW039 450 mgPlaceboTotal
Age, Continuous49.8 years
STANDARD_DEVIATION 14.6
49.6 years
STANDARD_DEVIATION 15.25
50.9 years
STANDARD_DEVIATION 14.16
50.1 years
STANDARD_DEVIATION 14.68
Race/Ethnicity, Customized
Asian
44 Participants41 Participants41 Participants126 Participants
Race/Ethnicity, Customized
Black
6 Participants4 Participants1 Participants11 Participants
Race/Ethnicity, Customized
Caucasian
234 Participants235 Participants227 Participants696 Participants
Race/Ethnicity, Customized
Native American
2 Participants2 Participants4 Participants8 Participants
Race/Ethnicity, Customized
Other
8 Participants10 Participants11 Participants29 Participants
Race/Ethnicity, Customized
Unknown
2 Participants2 Participants3 Participants7 Participants
Sex: Female, Male
Female
165 Participants178 Participants177 Participants520 Participants
Sex: Female, Male
Male
131 Participants116 Participants110 Participants357 Participants

Adverse events

Event typeEG000
affected / at risk
EG001
affected / at risk
EG002
affected / at risk
deaths
Total, all-cause mortality
0 / 2961 / 2931 / 287
other
Total, other adverse events
181 / 296183 / 293180 / 287
serious
Total, serious adverse events
20 / 29620 / 29318 / 287

Outcome results

Primary

Rate of Moderate-to-severe Asthma Exacerbations During the 52-week Treatment Period in High Eosinophils Subpopulation

A severe asthma exacerbation is defined as treatment with 'rescue' systemic corticosteroids for greater than or equal to 3 days and hospitalization; or treatment with 'rescue' systemic corticosteroids for greater than or equal to 3 days and emergency department visit (greater than 24 hours\*); or death due to asthma. A moderate asthma exacerbation is defined as treatment with 'rescue' systemic corticosteroids for greater than or equal to 3 days either as an outpatient or in emergency department visits (Emergency department visit less than or equal to 24 hours). The high eosinophils subpopulation consists of all patients with blood eosinophil count ≥ 250 cells/μL at baseline.

Time frame: 52 weeks

Population: Full Analysis Set (FAS) in high eosinophils subpopulation (count ≥ 250 cells/μL)

ArmMeasureValue (LEAST_SQUARES_MEAN)
QAW039 150 mgRate of Moderate-to-severe Asthma Exacerbations During the 52-week Treatment Period in High Eosinophils Subpopulation0.73 Events/year
QAW039 450 mgRate of Moderate-to-severe Asthma Exacerbations During the 52-week Treatment Period in High Eosinophils Subpopulation0.76 Events/year
PlaceboRate of Moderate-to-severe Asthma Exacerbations During the 52-week Treatment Period in High Eosinophils Subpopulation1.06 Events/year
p-value: 0.05995% CI: [0.5, 0.96]negative binomial regression model
p-value: 0.11495% CI: [0.52, 1.01]negative binomial regression model
Primary

Rate of Moderate-to-severe Asthma Exacerbations During the 52-week Treatment Period in Overall Population

A severe asthma exacerbation is defined as treatment with 'rescue' systemic corticosteroids for greater than or equal to 3 days and hospitalization; or treatment with 'rescue' systemic corticosteroids for greater than or equal to 3 days and emergency department visit (greater than 24 hours\*); or death due to asthma. A moderate asthma exacerbation is defined as treatment with 'rescue' systemic corticosteroids for greater than or equal to 3 days either as an outpatient or in emergency department visits (Emergency department visit less than or equal to 24 hours).

Time frame: 52 weeks

Population: Full Analysis Set (FAS), including all randomized patients who received at least one dose of study drug.

ArmMeasureValue (LEAST_SQUARES_MEAN)
QAW039 150 mgRate of Moderate-to-severe Asthma Exacerbations During the 52-week Treatment Period in Overall Population0.76 Events/year
QAW039 450 mgRate of Moderate-to-severe Asthma Exacerbations During the 52-week Treatment Period in Overall Population0.70 Events/year
PlaceboRate of Moderate-to-severe Asthma Exacerbations During the 52-week Treatment Period in Overall Population0.93 Events/year
p-value: 0.36995% CI: [0.62, 1.07]negative binomial regression model
p-value: 0.34895% CI: [0.58, 1]negative binomial regression model
Secondary

Change From Baseline to Week 52 in Asthma Control Questionnaire-5 (ACQ-5) Score in High Eosinophils Subpopulation

The ACQ-5 is a five-item, self-completed questionnaire, which is used as a measure of asthma control of a participant. The five questions (concerning nocturnal awakening, waking in the morning, activity limitation, shortness of breath and wheeze) enquire about the frequency and/or severity of symptoms over the previous week. The response options for all these questions range from zero (no impairment/limitation) to six (total impairment/ limitation) scale. The ACQ-5 score is the average of the individual item scores and ranges from 0 to 6. Higher scores indicates worsening of condition. The high eosinophils subpopulation consists of all patients with blood eosinophil count ≥ 250 cells/μL at baseline.

Time frame: Baseline, Week 52

Population: Full Analysis Set (FAS) in high eosinophils subpopulation (count ≥ 250 cells/μL)

ArmMeasureValue (LEAST_SQUARES_MEAN)Dispersion
QAW039 150 mgChange From Baseline to Week 52 in Asthma Control Questionnaire-5 (ACQ-5) Score in High Eosinophils Subpopulation-0.92 units on a scaleStandard Error 0.067
QAW039 450 mgChange From Baseline to Week 52 in Asthma Control Questionnaire-5 (ACQ-5) Score in High Eosinophils Subpopulation-0.84 units on a scaleStandard Error 0.068
PlaceboChange From Baseline to Week 52 in Asthma Control Questionnaire-5 (ACQ-5) Score in High Eosinophils Subpopulation-0.75 units on a scaleStandard Error 0.069
p-value: 0.36995% CI: [-0.36, 0.01]ANCOVA
p-value: 0.82495% CI: [-0.28, 0.1]ANCOVA
Secondary

Change From Baseline to Week 52 in Asthma Control Questionnaire-5 (ACQ-5) Score in Overall Population

The ACQ-5 is a five-item, self-completed questionnaire, which is used as a measure of asthma control of a participant. The five questions (concerning nocturnal awakening, waking in the morning, activity limitation, shortness of breath and wheeze) enquire about the frequency and/or severity of symptoms over the previous week. The response options for all these questions range from zero (no impairment/limitation) to six (total impairment/ limitation) scale. The ACQ-5 score is the average of the individual item scores and ranges from 0 to 6. Higher scores indicates worsening of condition.

Time frame: Baseline, Week 52

Population: Full Analysis Set (FAS), including all randomized patients who received at least one dose of study drug.

ArmMeasureValue (LEAST_SQUARES_MEAN)Dispersion
QAW039 150 mgChange From Baseline to Week 52 in Asthma Control Questionnaire-5 (ACQ-5) Score in Overall Population-0.83 units on a scaleStandard Error 0.055
QAW039 450 mgChange From Baseline to Week 52 in Asthma Control Questionnaire-5 (ACQ-5) Score in Overall Population-0.77 units on a scaleStandard Error 0.055
PlaceboChange From Baseline to Week 52 in Asthma Control Questionnaire-5 (ACQ-5) Score in Overall Population-0.70 units on a scaleStandard Error 0.055
p-value: 0.82495% CI: [-0.28, 0.03]ANCOVA
p-value: 0.82495% CI: [-0.23, 0.08]ANCOVA
Secondary

Change From Baseline to Week 52 in Asthma Quality of Life Questionnaire for Participants 12 Years and Older (AQLQ+12) Score in High Eosinophils Subpopulation

AQLQ is a 32-item instrument administered as a self-assessment. AQLQ+12 is a modified version of AQLQ developed to measure functional impairments of participants aged 12-70 years. It is divided into 4 domains: activity limitation, symptoms, emotional function, and environmental stimuli. Participants were asked to recall their experiences during the last 2 weeks and respond to each question on a 7-point scale (1=severe impairment, 7=no impairment), where higher scores indicated better quality of life. Overall AQLQ+12 score is the mean of all 32 responses. The high eosinophils subpopulation consists of all patients with blood eosinophil count ≥ 250 cells/μL at baseline.

Time frame: Baseline, Week 52

Population: Full Analysis Set (FAS) in high eosinophils subpopulation (count ≥ 250 cells/μL)

ArmMeasureValue (LEAST_SQUARES_MEAN)Dispersion
QAW039 150 mgChange From Baseline to Week 52 in Asthma Quality of Life Questionnaire for Participants 12 Years and Older (AQLQ+12) Score in High Eosinophils Subpopulation0.73 units on a scaleStandard Error 0.061
QAW039 450 mgChange From Baseline to Week 52 in Asthma Quality of Life Questionnaire for Participants 12 Years and Older (AQLQ+12) Score in High Eosinophils Subpopulation0.71 units on a scaleStandard Error 0.062
PlaceboChange From Baseline to Week 52 in Asthma Quality of Life Questionnaire for Participants 12 Years and Older (AQLQ+12) Score in High Eosinophils Subpopulation0.58 units on a scaleStandard Error 0.062
p-value: 0.36995% CI: [-0.02, 0.32]ANCOVA
p-value: 0.82495% CI: [-0.04, 0.3]ANCOVA
Secondary

Change From Baseline to Week 52 in Asthma Quality of Life Questionnaire for Participants 12 Years and Older (AQLQ+12) Score in Overall Population

AQLQ is a 32-item instrument administered as a self-assessment. AQLQ+12 is a modified version of AQLQ developed to measure functional impairments of participants aged 12-70 years. It is divided into 4 domains: activity limitation, symptoms, emotional function, and environmental stimuli. Participants were asked to recall their experiences during the last 2 weeks and respond to each question on a 7-point scale (1=severe impairment, 7=no impairment), where higher scores indicated better quality of life. Overall AQLQ+12 score is the mean of all 32 responses.

Time frame: Baseline, Week 52

Population: Full Analysis Set (FAS), including all randomized patients who received at least one dose of study drug.

ArmMeasureValue (LEAST_SQUARES_MEAN)Dispersion
QAW039 150 mgChange From Baseline to Week 52 in Asthma Quality of Life Questionnaire for Participants 12 Years and Older (AQLQ+12) Score in Overall Population0.62 units on a scaleStandard Error 0.05
QAW039 450 mgChange From Baseline to Week 52 in Asthma Quality of Life Questionnaire for Participants 12 Years and Older (AQLQ+12) Score in Overall Population0.67 units on a scaleStandard Error 0.05
PlaceboChange From Baseline to Week 52 in Asthma Quality of Life Questionnaire for Participants 12 Years and Older (AQLQ+12) Score in Overall Population0.55 units on a scaleStandard Error 0.051
p-value: 0.82495% CI: [-0.07, 0.21]ANCOVA
p-value: 0.82495% CI: [-0.02, 0.26]ANCOVA
Secondary

Change From Baseline to Week 52 in Pre-dose Forced Expiratory Volume in 1 Second (FEV1) in High Eosinophils Subpopulation

Forced Expiratory Volume in one second (FEV1) is calculated as the volume of air forcibly exhaled in one second as measured by a spirometer. Baseline is defined as the last available FEV1 measurement taken prior to the first dose of randomized study drug. The high eosinophils subpopulation consists of all patients with blood eosinophil count ≥ 250 cells/μL at baseline.

Time frame: Baseline, Week 52

Population: Full Analysis Set (FAS) in high eosinophils subpopulation (count ≥ 250 cells/μL)

ArmMeasureValue (LEAST_SQUARES_MEAN)Dispersion
QAW039 150 mgChange From Baseline to Week 52 in Pre-dose Forced Expiratory Volume in 1 Second (FEV1) in High Eosinophils Subpopulation0.192 LiterStandard Error 0.0306
QAW039 450 mgChange From Baseline to Week 52 in Pre-dose Forced Expiratory Volume in 1 Second (FEV1) in High Eosinophils Subpopulation0.162 LiterStandard Error 0.0311
PlaceboChange From Baseline to Week 52 in Pre-dose Forced Expiratory Volume in 1 Second (FEV1) in High Eosinophils Subpopulation0.124 LiterStandard Error 0.0313
p-value: 0.36995% CI: [-0.018, 0.154]ANCOVA
p-value: 0.82495% CI: [-0.048, 0.124]ANCOVA
Secondary

Change From Baseline to Week 52 in Pre-dose Forced Expiratory Volume in 1 Second (FEV1) in Overall Population

Forced Expiratory Volume in one second (FEV1) is calculated as the volume of air forcibly exhaled in one second as measured by a spirometer. Baseline is defined as the last available FEV1 measurement taken prior to the first dose of randomized study drug.

Time frame: Baseline, Week 52

Population: Full Analysis Set (FAS), including all randomized patients who received at least one dose of study drug.

ArmMeasureValue (LEAST_SQUARES_MEAN)Dispersion
QAW039 150 mgChange From Baseline to Week 52 in Pre-dose Forced Expiratory Volume in 1 Second (FEV1) in Overall Population0.153 LiterStandard Error 0.0247
QAW039 450 mgChange From Baseline to Week 52 in Pre-dose Forced Expiratory Volume in 1 Second (FEV1) in Overall Population0.164 LiterStandard Error 0.0249
PlaceboChange From Baseline to Week 52 in Pre-dose Forced Expiratory Volume in 1 Second (FEV1) in Overall Population0.103 LiterStandard Error 0.025
p-value: 0.36995% CI: [-0.019, 0.119]ANCOVA
p-value: 0.59595% CI: [-0.008, 0.13]ANCOVA
Post Hoc

All Collected Deaths

Total Deaths are presented from first dose of study treatment until discontinuation of trial, up to maximum duration of 56 weeks. Deaths on-treatment are presented from first dose of study treatment until last dose of study treatment plus 30 days, up to maximum duration of 56 weeks.

Time frame: up to 56 weeks

Population: Safety Set (SAF), including all randomized patients who received at least one dose of study drug

ArmMeasureGroupValue (NUMBER)
QAW039 150 mgAll Collected DeathsTotal Deaths1 Participants
QAW039 150 mgAll Collected DeathsDeaths on-treatment0 Participants
QAW039 450 mgAll Collected DeathsTotal Deaths1 Participants
QAW039 450 mgAll Collected DeathsDeaths on-treatment1 Participants
PlaceboAll Collected DeathsTotal Deaths1 Participants
PlaceboAll Collected DeathsDeaths on-treatment1 Participants

Source: ClinicalTrials.gov · Data processed: Mar 7, 2026