AB1204 COST-EFFECTIVENESS OF ABATACEPT IN SPAIN IN SEROPOSITIVE BIOLOGIC-NAÏVE EARLY RHEUMATOID ARTHRITIS PATIENTS WITH SHARED EPITOPE

Background:

The HLA class II Shared Epitope (SE) is a known Rheumatoid Arthritis (RA) risk allele linked to autoantibody production and disease progression. The recent Early AMPLE study suggests an enhanced treatment benefit of abatacept (ABA) over adalimumab (ADA) in SE positive patients with early seropositive RA.1Economic implications beyond the trial follow-up duration are unknown.

Objectives:

To estimate the cost-effectiveness of ABA vs ADA in biologic-naive RA patients seropositive for anti-citrullinated protein antibody and rheumatoid factor based on the Early AMPLE study.

Methods:

We developed a microsimulation model to estimate clinical response, medical cost, quality of life and survival from a Spanish payer perspective. The model captures the patient’s disease and treatment journey using response outcomes and the Health Assessment Questionnaire (HAQ) score. Patients who fail to respond switch to the next treatment line. Six treatment lines are included to capture a lifetime horizon. Responding patients (ACR50 and EULAR response) achieve an improvement in their HAQ score. Patient mortality was modelled as a function of HAQ. For both the overall Early AMPLE population and SE+ patients, incremental monthly cost per response over 2 years and incremental cost per QALY over a lifetime were estimated. Costs were based on local tariffs in Spain.

Results:

Baseline characteristics for the Early AMPLE (n=80) and the SE+ (n=61) patients were well balanced between the treatment groups.2Compared to ADA, the ABA cohort had a lower cost per response and the difference was more pronounced in the SE+ population, compared to the entire Early AMPLE population for both the response criteria (Table 1). Compared with ADA, the ABA cohort showed greater quality adjusted life years (QALYs) gains, and a modest increase in cost due to a prolonged time on treatment (Table 2). The incremental cost per QALY over a lifetime fell below commonly used thresholds in Spain (25-60 thousand Euros per QALY).3

Table 1.

Cost per response results

Full Early AMPLEACR50EULARABAADAABAADACost per response (€) – 2 years25,86040,65426,99340,643Incremental monthly cost per response (€)-616-569SE positiveACR 50EULARABAADAABAADACost per response (€) – 2 years24,27240,24925,33741,425Incremental monthly cost per response (€)-666-670

All incremental results are for ABA – ADA

Table 2.

Cost-effectiveness results (discounted)

Full Early AMPLEACR50EULARABAADAABAADALYs*30.1430.0630.1130.03QALYs8.327.817.577.12Time on treatment (years)4.172.035.143.06Costs (€)75,54768,15785,12280,933Incremental LYs*0.080.08Incremental QALYs0.520.45Incremental Costs (€)7,3904,189Incremental cost per QALY (€)14,3089,275SE positiveACR50EULARABAADAABAADALYs*30.3830.2230.1630.09QALYs8.207.597.406.90Time on treatment (years)4.482.025.383.02Costs (€)78,11368,65187,58681,321Incremental LYs*0.150.06Incremental QALYs0.610.50Incremental Costs (€)9,4626,265Incremental cost per QALY (€)15,41012,503

*LY results are presented undiscounted. All incremental results are for ABA – ADA

Conclusion:

Compared with ADA, ABA is a cost-effective alternative and is associated with a lower 2 years cost per response for both populations. The economic benefit and quality of life gain is greater in a SE+ patient population.

References:

[1]Rigby W, et al. EULAR Annual Meeting, June 2019; Poster LB0008

[2]Buckner J, et al. ACR/ARP Annual Meeting, Nov 2019; Poster 1424

[3]Sacristán JA, et al.Gaceta Sanitaria2019

Disclosure of Interests:

José M. Rodríguez-Heredia: None declared, Lisanne Verburg-Baltussen Consultant of: Consultant for Bristol-Myers Squibb, Paid instructor for: Training sessions for Pharmaceutical companies, Dhanda Devender Shareholder of: BMS, Employee of: BMS, Nicholas Durno Consultant of: Consultant for Bristol-Myers Squibb, Paid instructor for: Training sessions for Pharmaceutical companies, Carlos Sanchez Shareholder of: Shareholder of Bristol-Myers Squibb, Employee of: Bristol Myers-Squibb, Neelanjana Ray Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Maarten Treur Consultant of: Consultant for Bristol-Myers Squibb, Paid instructor for: Training sessions for Pharmaceutical companies, Joe Zhuo Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb

OP0039 HOSPITALIZATION AND MORTALITY OUTCOMES IN RHEUMATOID ARTHRITIS PATIENTS WITH LUNG DISEASE

Background:

Pulmonary manifestations such as interstitial lung disease (ILD) and chronic obstructive pulmonary disease (COPD) are frequent extra-articular features that carry a poor prognosis in rheumatoid arthritis (RA). Prior studies have demonstrated that respiratory-related mortality is the most overrepresented cause of death in RA.

Objectives:

To assess the risk of all-cause and respiratory-related hospitalization and mortality in RA patients with comorbid lung disease (LD) in comparison to those without and the differential risks associated with DMARD treatments.

Methods:

Eligible RA patients included those enrolled in the Forward Databank with ≥1 year observation after 2000 and had initiated a DMARD. Forward is a large longitudinal rheumatic disease registry in the US. RA patients’ diagnoses were rheumatologist-confirmed, and every 6 months participants completed comprehensive questionnaires regarding symptoms, disease outcomes, medications, and clinical events. LD was defined as one of the following: emphysema, asthma, bronchitis, COPD, pleural effusion, fibrosis of the lung, “RA lung“, or ILD (England 2019). DMARDs were categorized hierarchically into four groups: csDMARDs, TNFi and NTNFi (bDMARDs), and tsDMARDs. Patients were followed from DMARD initiation until event (death and/or hospitalization) or end of follow-up, whatever came first. Events were validated using medical records and the US National Death Index. Respiratory hospitalizations and deaths were identified with ICD9 (460-519). Events were analyzed using incidence rates (IR) and Cox regression models. Models were adjusted for LD, DMARDs, age, sex, education, HAQ disability, Rheumatic Disease comorbidity index, smoking, pain, glucocorticoids, year of entry, prior bDMARDs and csDMARDs counts and MRC breath scale.

Results:

Of the 21,525 eligible RA patients, 13.8% had LD at the time of DMARD initiation. Patients had 59 years old in both groups and 15% were male for LD+ vs 21% for LD-. Patients with LD+ showed worse disease outcomes (HAQ: 1.3 (0.7) vs 1.0 (0.7)) and comorbidities (2.9 (1.9) vs 1.5 (1.4)) overall and for all treatment groups, especially for NTNFi and tsDMARDi. The overall IR of any all-cause or respiratory-related events were higher in LD+ than LD- RA patients and across any DMARD treatments, with NTNFi having higher IR (Figure). In survival analyses, LD+ was associated with an increased risk for all-cause hospitalizations/deaths (HR 1.3; 95% CI 1.1-1.4) and a 3.95-fold increased risk of respiratory-related events (HR 4.0; 3.2-4.9) (Table). These risks did not differ significantly across DMARD treatment groups. Increased age, HAQ disability, comorbidities, glucocorticoids, prior bDMARDs and worse MRC breath scales were associated with an increased risk in both outcomes and smoking in respiratory-specific events.

Conclusion:

An increased risk of hospitalizations and/or deaths was demonstrated for RA patients with lung disease, most notably a 4-fold increased risk for respiratory-related events. No differences were found between incident DMARD groups. Additional studies accounting for channeling of treatments by baseline health status are needed.

References:

[1]England BR, et alArth Care Res. doi:10.1002/acr.24043.

Figure.

 IR (95% CI): all-cause and respiratory-related events by LD+/LD- and DMARDs

Table.

HR (95% CI) for Cox models.

VariablesAll causeAll respiratory specificLD+ vs LD-1.34.0(1.1 - 1.4)(3.2 - 4.9)Tnf vs csDMARD1.01.1(0.8 - 1.1)(0.8 - 1.5)NTNF vs csDMARD1.00.9(0.8 - 1.2)(0.6 - 1.5)tsDMARD vs csDMARD0.81.8(0.4 - 1.4)(0.7 - 4.7)

Disclosure of Interests:

Sofia Pedro: None declared, Ted Mikuls Grant/research support from: Horizon Therapeutics, BMS, Consultant of: Pfizer, Joe Zhuo Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Kaleb Michaud Grant/research support from: Janssen

THU0497 MAINTENANCE OF MINIMAL DISEASE ACTIVITY OR INACTIVE DISEASE STATUS AND PATIENT-REPORTED OUTCOMES IN INDIVIDUAL PAEDIATRIC PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS TREATED WITH SUBCUTANEOUS ABATACEPT

Background:

Maintenance of clinical response over time has been shown in individual patients (pts) with polyarticular-course juvenile idiopathic arthritis (pJIA) treated with SC abatacept (ABA).1It is unknown whether each individual pt with sustained efficacy also consistently maintains the previously reported shorter-term benefits on patient-reported outcomes (PROs)2,3over time.

Objectives:

Investigate whether combined efficacy and stringent, optimal PRO responses to ABA treatment are maintained by individual pts with pJIA over time.

Methods:

In this analysis of the intent-to-treat population, pts in two age cohorts (2–5 and 6–17 yrs) who achieved clinical response to weekly SC ABA (10–<25 kg [50 mg], 25–<50 kg [87.5 mg], ≥50 kg [125 mg]) at Mo 4 (time point of primary pharmacokinetic endpoint4) were followed for 2 yrs. Stringent efficacy outcomes (Juvenile Arthritis Disease Activity Score 27 [JADAS27] minimal disease activity [MDA; ≤3.8] and inactive disease [ID; ≤1] status) were combined with optimal PRO endpoints (childhood [C]HAQ-DI=0, Parental Global Assessment [PaGA] ≤1 and Pain visual analogue scale [VAS] <35). Combined efficacy and PRO responses were analysed at Mos 4, 13 and 21.

Results:

219 pts entered the study (46 [21.0%] 2–5 yrs; 173 [79.0%] 6–17 yrs); a subgroup of these pts achieved a clinical response at Mo 4 (Table 1). Many pts who achieved JADAS27 MDA or JADAS27 ID combined with optimal PROs at Mo 4 sustained their response at Mo 13, and at both Mo 13 and Mo 21 in the 2–5-yr and 6–17-yr cohorts (Table 1). Across the cohorts, 33–88% of pts maintained a combined JADAS27 MDA with optimal PRO responses through Mo 21. Where estimable, median times to combined efficacy and specific optimal PRO responses were consistent across the cohorts (Table 2; Figs 1, 2).

Table 1.

Proportion of pts with combined efficacy and optimal PRO responses at Mos 4, 13 and 21

EndpointResponders at Mo 4Responders at Mos 4 and 13*Responders at Mos 4, 13 and 21*2–5 yrs (n=46)6–17 yrs (n=173)2–5 yrs6–17 yrs2–5 yrs6–17 yrsJADAS27 MDA and CHAQ-DI=09 (20)34 (20)5/9 (56)25/34 (74)3/9 (33)16/34 (47)JADAS27 MDA and PaGA ≤18 (17)14 (8)8/8 (100)7/14 (50)7/8 (88)5/14 (36)JADAS27 MDA and Pain VAS <35 mm28 (61)70 (41)25/28 (89)58/70 (83)21/28 (75)43/70 (61)JADAS27 ID and CHAQ-DI=07 (15)20 (12)2/7 (29)13/20 (65)1/7 (14)9/20 (45)JADAS27 ID and PaGA ≤16 (13)10 (6)4/6 (67)4/10 (40)4/6 (67)4/10 (40)JADAS27 ID and Pain VAS <35 mm17 (37)31 (18)10/17 (59)22/31 (71)8/17 (47)17/31 (55)

Data are n (%) or n/N (%). *% based on n of pts who achieved response at Mo 4 (denominator)

Table 2.

Kaplan–Meier estimates for median (95% CI) times (mos) to achieving combined efficacy and optimal PRO responses

Endpoint2–5 yrs6–17 yrsJADAS27 MDA and CHAQ-DI=021.5 (6.8, NE)21.5 (13.1, 24.4)JADAS27 MDA and PaGA ≤1NE (15.9, NE)24.6 (24.3, NE)JADAS27 MDA and Pain VAS <35 mm2.8 (1.9, 2.9)3.8 (3.7, 6.6)JADAS27 ID and CHAQ-DI=0NE (18.4, NE)24.4 (18.7, NE)JADAS27 ID and PaGA ≤1NE (21.3, NE)24.6 (24.3, NE)JADAS27 ID and Pain VAS <35 mm3.8 (3.8, 10.3)13.2 (10.3, 15.9)

NE=not estimable

Conclusion:

Many individuals with pJIA who achieved stringent efficacy and PRO measures with weekly SC abatacept by Mo 4 sustained them over 2 years. Time to achieve combined efficacy and Pain VAS <35 response was shorter than that for PaGA ≤1 and CHAQ-DI=0.

References:

[1]Ruperto N, et al.Ann Rheum Dis2019;78:99–100 (abstr OP0056)

[2]Brunner H, et al.Arthritis Rheumatol2019;71(suppl 10):abstr 2707

[3]Ruperto N, et al.Ann Rheum Dis2017;76:75 (abstr OP0058)

[4]Brunner HI, et al.Arthritis Rheumatol2018;70:1144–54

Acknowledgments:

Katerina Kumpan, PhD, Caudex; funding: Bristol-Myers Squibb

Disclosure of Interests: :

Hermine Brunner Consultant of: Hoffman-La Roche, Novartis, Pfizer, Sanofi Aventis, Merck Serono, AbbVie, Amgen, Alter, AstraZeneca, Baxalta Biosimilars, Biogen Idec, Boehringer, Bristol-Myers Squibb, Celgene, EMD Serono, Janssen, MedImmune, Novartis, Pfizer, and UCB Biosciences, Speakers bureau: GSK, Roche, and Novartis, Nikolay Tzaribachev: None declared, Ingrid Louw Consultant of: Amgen, Novartis, Pfizer, Roche (advisory boards), Inmaculada Calvo Grant/research support from: Bristol-Myers Squibb, Clementia, GlaxoSmithKline, Hoffman-La Roche, Merck Sharpe & Dohme, Novartis, Pfizer, Sanofi, Speakers bureau: AbbVie, GlaxoSmithKline, Hoffman-La Roche, Novartis, Francisco Zapata: None declared, Gerd Horneff Grant/research support from: AbbVie, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Speakers bureau: AbbVie, Bayer, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Ivan Foeldvari Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Chugai, Eli Lilly, Novartis, Pfizer, Daniel Kingsbury: None declared, Maria Gastanaga Grant/research support from: Amgen, Bristol-Myers Squibb, GlaxoSmithKline, Novartis, Pfizer, Roche, Speakers bureau: AbbVie, Roche, Carine Wouters Grant/research support from: GlaxoSmithKline, Pfizer, Roche, Johannes Breedt: None declared, Robert Wong Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Marleen Nys Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Margarita Askelson Consultant of: Bristol-Myers Squibb, Joe Zhuo Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Alberto Martini Consultant of: AbbVie, Eli Lily, EMD Serono, Janssen, Novartis, Pfizer, UCB, Daniel J Lovell Consultant of: Abbott (consulting and PI), AbbVie (PI), Amgen (consultant and DSMC Chairperson), AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb (PI), Celgene, Forest Research (DSMB Chairman), GlaxoSmithKline, Hoffman-La Roche, Janssen (co-PI), Novartis (consultant and PI), Pfizer (consultant and PI), Roche (PI), Takeda, UBC (consultant and PI), Wyeth, Employee of: Cincinnati Children’s Hospital Medical Center, Speakers bureau: Wyeth, Nicolino Ruperto Grant/research support from: Bristol-Myers Squibb, Eli Lily, F Hoffmann-La Roche, GlaxoSmithKline, Janssen, Novartis, Pfizer, Sobi (paid to institution), Consultant of: Ablynx, AbbVie, AstraZeneca-Medimmune, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lily, EMD Serono, GlaxoSmithKline, Hoffmann-La Roche, Janssen, Merck, Novartis, Pfizer, R-Pharma, Sanofi, Servier, Sinergie, Sobi, Takeda, Speakers bureau: Ablynx, AbbVie, AstraZeneca-Medimmune, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lily, EMD Serono, GlaxoSmithKline, Hoffmann-La Roche, Janssen, Merck, Novartis, Pfizer, R-Pharma, Sanofi, Servier, Sinergie, Sobi, Takeda

SAT0061 ROLE OF SHARED EPITOPE IN THE PROGNOSIS OF RHEUMATOID ARTHRITIS IN RELATION TO ACPA POSITIVITY

Background:

The mechanistic association ofHLA-DRB1alleles that code a “shared epitope” (SE) with rheumatoid arthritis (RA) is not yet clear. Previous data has suggested the carriage of SE is associated with the production of cyclic citrullinated peptide antibodies (anti-CCP)1and severe RA2-4. The interrelationship among SE, anti-citrullinated protein antibody (ACPA) positivity and disease outcomes is not fully understood.

Objectives:

To assess the RA prognosis associated with the carriage of SE, in relation to ACPA positivity.

Methods:

Pts enrolled in a large RA registry, Brigham and Women’s Hospital RA Sequential Study between March 2003 to June 2018, with known SE and ACPA status were included in the analysis. HLA-DRB1 SE status was determined by allele-specific polymerase chain reaction and DNA sequencing for most of the subjects and by GWAS-based imputation for the rest. Disease activity (DA) was measured at baseline (BL) and 1-year follow-up by DAS28(CRP), CDAI and SDAI. Pts were stratified by SE+ (1 or 2 SE alleles) and SE- (0 alleles) and ACPA status. We analyzed the relationship of SE with ACPA positivity and change in DA by a linear regression model separately. A mediation analysis was used to examine the mediating effect of ACPA on association between SE and change in DA.

Results:

Out of 926 pts included in the analysis, 65.1% were SE+, of whom 75.6% were ACPA+. In comparison, 51.7% were ACPA+ in SE- pts. SE+ pts were similar with SE- pts in age, gender, BMI and smoking status, but had longer disease duration, were more likely to be rheumatoid factor positive, have erosive disease and higher comorbidity burden irrespective of ACPA status. The differences were more pronounced if the pts were also ACPA+. Adjusting for BL differences, pts with SE 1 and 2 alleles (vs 0) had an odd ratio of 1.97 (95% CI:1.36-2.84; p=0.0003) and 3.82 (95% CI: 2.44-5.98; p<.0001) to be ACPA +, respectively. The regression analysis suggests that SE+ (vs SE-) pts had an average increase in DAS28 (CRP) of 0.22 (p=0.033), CDAI of 2.07 (p=0.045) and SDAI of 2.43 (p=0.029) over a year (Fig 1). Using a mediation analysis, the direct effect of SE+ account for 78.8% to 81.0% of total effect in the increase in DAS28 (CRP), CDAI and SDAI, and the indirect effect mediated by ACPA account for 19.0% to 21.2% (Table 1).

Table 1.

Mediation Analysis for SE and ACPA Association with Change in DA

ParameterChange in DAS28 CRP (N=666)Change in CDAI (N=653)Change in SDAI (N=629)EstimateP-valueEstimateP-valueEstimateP-valueTotal Effect of SE on DA change0.220.0342.050.0472.400.030Direct effect of SE on DA change excluding mediation of ACPA0.170.1011.570.1401.890.098Indirect effect of SE on DA change due to ACPA mediation and interaction0.040.1830.480.1330.510.143

The model is adjusted with other covariates: Age, Gender, Charlson comorbidity score; baseline biologic use, Smoking status, baseline DA, Interaction term (ACPA*SE)

Figure 1.

Linear Regression Model for SE Association with Change in Disease Activity *Estimates, p-values are shown as data labels on the graphs; Change in disease activity (DA) = (follow-up DA- baseline DA); The above model is adjusted for age, gender, CCI, baseline DA, baseline biologic use, SE status and smoking status

Conclusion:

SE is strongly related to ACPA and a greater burden of disease in RA pts. In pts receiving standard treatments including biologics, SE is predictive of a greater increase in DA, which is partially mediated by the presence of ACPA.

References:

[1] Dayan I, et al.,Arch of Rheumatology, 2010;25:012-018.

[2] Gregerson PK, et al,Arthritis Rheum. 1987;30:1205-1213.

[3] Turesson C, et al.Arthritis Res Ther. 2005;7:R1386-1393.

[4] Moreno I, et al.J Rheumatol. 1996;23:6-9.

Disclosure of Interests:

Joe Zhuo Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Joshua Bryson Shareholder of: I own shares of Bristol-Myers Squibb Company, Employee of: I am a paid employee of Bristol-Myers Squibb Company, Qian Xia Shareholder of: I own shares of Bristol-Myers Squibb Company, Employee of: I am a paid employee of Bristol-Myers Squibb Company, Niyati Sharma Consultant of: I work as a consultant for Bristol-Myers Squibb Company, Sheng Gao Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Sonie Lama Shareholder of: I own shares of Bristol-Myers Squibb Company., Employee of: I am a paid employee of Bristol-Myers Squibb Company., Michael E. Weinblatt Grant/research support from: BMS, Amgen, Lilly, Crescendo and Sonofi-Regeneron, Consultant of: Horizon Therapeutics, Bristol-Myers Squibb, Amgen, Abbvie, Crescendo, Lilly, Pfizer, Roche, Gilead, Nancy Shadick Grant/research support from: Mallinckrodt, BMS, Lilly, Amgen, Crescendo Biosciences, and Sanofi-Regeneron, Consultant of: BMS

FRI0072 DISCONTINUATION OF DMARD USE IN RHEUMATOID ARTHRITIS PATIENTS WITH LUNG DISEASE

Background:

Pulmonary manifestations such as interstitial lung disease (ILD) and chronic obstructive pulmonary disease (COPD) are frequent extra-articular features that carry a poor prognosis in Rheumatoid Arthritis (RA). Little data is available on how RA patients (pts) with pulmonary disease are managed in real-world settings.

Objectives:

To assess treatment patterns and DMARD discontinuation in RA patients with comorbid lung disease in comparison with other RA patients.

Methods:

The study included RA Patients enrolled in the Forward Databank with ≥1 year observation after 2000 initiating a DMARD. Forward is a large longitudinal rheumatic disease registry in the US. RA patients’ diagnoses were rheumatologist-confirmed, and every 6 months participants completed comprehensive questionnaires regarding symptoms, disease outcomes, medications, and clinical events. Lung disease (LD+) was defined as at least one of the following: emphysema, asthma, bronchitis, COPD, pleural effusion, fibrosis of the lung, “RA lung”, or ILD, the later classified by ICD9 codes (England 2019). DMARDs were categorized hierarchically into four groups: csDMARDs, TNFi and NTNFi (bDMARDs), and tsDMARDs. Percentage of patients who initiated different DMARDs were reported for pts with LD+/LD-. Discontinuation was analyzed by Kaplan Meier (KM) curves, log-ranks tests, and Cox regression models using time-varying covariates. Best models were created using backward selection models (10% probability of removal) and pre-defined clinical models.

Results:

Of the 21,525 eligible RA patients, 13.8% had LD+ at the time they initiated a DMARD (follow-up: 69,597 pt-yrs (median 1.9 yrs/pt)). LD+ patients tended to have more severe RA outcomes and comorbidities. MTX-monotherapy (48% vs 44%, p<0.001) and NTNFi were initiated more frequently in LD+ pts with lower use of TNFi (Figure). DMARD discontinuation rates were higher among LD+ patients for all DMARD groups, but KM curves were only significantly different for csDMARDs and TNFi. Different HRs for LD+ were found depending on the model used ranging from 1.18 to 1.28, and all models revealed an increased risk of discontinuation for LD+ patients. Compared to csDMARDs, TNFi were more often discontinued (Table). Other variables associated with an increased risk of discontinuation included: HAQ, Rheumatoid Disease (RD) comorbidity index, pain, prior bDMARDs, and csDMARDs.

Conclusion:

Different DMARD treatment patterns were found for LD+ patients, who tended to initiate more csDMARD and NTNFi and less likely to initiate a TNFi. LD+ patients were at a higher risk of discontinuation irrespectively of the DMARD treatment, but with greater risk for TNF users.

References:

[1]England BR, et al. Arth Care Res. doi:10.1002/acr.24043.

Figure.

DMARD treatment initiators by disease group

Table .

Cox models for DMARD discontinuation by stepwise (removal probability 10%) and clinical models including DMARD treatment.

Model of DMARD persistence*Model 1- Stepwise-Without drugsModel 2 – StepwiseModel 3 - ClinicalLD+ vs LD–1.181.281.20(1.08 - 1.29)(1.13 - 1.45)(1.08 - 1.34)TNF vs csDmard1.321.22(1.08 - 1.63)(1.04 - 1.44)NTNF vs csDmard1.131.13(0.83 - 1.52)(0.90 - 1.41)tsDmard vs csDmard1.301.02(0.65 - 2.60)(0.64 - 1.62)

*Best models searched/Clinical adjusted for LD+/LD-, DMARDs, age, sex, education, HAQ disability, RD comorbidity index, smoking, pain, glucocorticoids, year of entry, prior bDMARDs and csDMARDs counts and MRC breath scale.

Disclosure of Interests:

Sofia Pedro: None declared, Ted Mikuls Grant/research support from: Horizon Therapeutics, BMS, Consultant of: Pfizer, Joe Zhuo Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Kaleb Michaud: None declared

Carotid Bulb Webs as a Cause of "Cryptogenic" Ischemic Stroke

BACKGROUND AND PURPOSE

Carotid webs are intraluminal shelf-like filling defects at the carotid bulb with recently recognized implications in patients with recurrent ischemic stroke. We sought to determine whether carotid webs are an under-recognized cause of "cryptogenic" ischemic stroke and to estimate their prevalence in the general population.

MATERIALS AND METHODS

A retrospective review of neck CTA studies in young patients with cryptogenic stroke over the past 6 years (n = 33) was performed to determine the prevalence of carotid webs compared with a control group of patients who received neck CTA studies for reasons other than ischemic stroke (n = 63).

RESULTS

The prevalence of carotid webs in the cryptogenic stroke population was 21.2% (95% CI, 8.9%-38.9%). Patients with symptomatic carotid webs had a mean age of 38.9 years (range, 30-48 years) and were mostly African American (86%) and women (86%). In contrast, only 1.6% (95% CI, 0%-8.5%) of patients in the control group demonstrated a web. Our findings demonstrate a statistically significant association between carotid webs and ischemic stroke (OR = 16.7; 95% CI, 2.78-320.3; P = .01).

CONCLUSIONS

Carotid webs exhibit a strong association with ischemic stroke, and their presence should be suspected in patients lacking other risk factors, particularly African American women.

The Efficacy of Shielding Systems for Reducing Operator Exposure during Neurointerventional Procedures: A Real-World Prospective Study

BACKGROUND AND PURPOSE

Neurointerventional surgery may expose patients and physician operators to substantial amounts of ionizing radiation. Although strategies for reducing patient exposure have been explored in the medical literature, there has been relatively little published in regards to decreasing operator exposure. The purpose of this study was to evaluate the efficacy of shielding systems in reducing physician exposure in a modern neurointerventional practice.

MATERIALS AND METHODS

Informed consent was obtained from operators for this Health Insurance Portability and Accountability Act-compliant, institutional review board-approved study. Operator radiation exposure was prospectively measured during 60 consecutive neurointerventional procedures from October to November 2013 using a 3-part lead shielding system. Exposure was then evaluated without lead shielding in a second 60-procedure block from April to May 2014. A radiation protection drape was randomly selected for use in half of the cases in each block. Two-way analysis of covariance was performed to test the effect of shielding systems on operator exposure while controlling for other covariates, including procedure dose-area product.

RESULTS

Mean operator procedure dose was 20.6 μSv for the entire cohort and 17.7 μSv when using some type of shielding. Operator exposure significantly correlated with procedure dose-area product, but not with other covariates. After we adjusted for procedure dose-area product, the use of lead shielding or a radiation protection drape significantly reduced operator exposure by 45% (F = 12.54, P < .0001) and 29% (F = 7.02, P = .009), respectively. The difference in protection afforded by these systems was not statistically significant (P = .46), and their adjunctive use did not provide additional protection.

CONCLUSIONS

Extensive lead shielding should be used as much as possible in neurointerventional surgery to reduce operator radiation exposure to acceptable levels. A radiation protection drape is a reasonable alternative when standard lead shielding is unavailable or impractical to use without neglecting strategies to minimize the dose.

Postnatal growth of the human optic nerve

PurposeAlthough the length of the average human adult optic nerve (ON) is known, the average length of the normal full-term, newborn ON has never been adequately evaluated, nor has the in vivo growth rate of the human ON been determined. We wanted to identify both the average length of the newborn human ON and its rate of anteroposterior growth.Patients and methodsUsing MRIs from a newly generated set of normal newborn infants rescanned at 1 year, and from different aged groups, we calculated average newborn ON length and growth rate.ResultsThe newborn human ON is 25.3±0.3 mm in length from globe to chiasm, and grows by 80% in length after birth, with maximum speed of elongation occurring in the first 3 years of life, attaining full length by 15 years of age.ConclusionThe human ON grows dramatically in the first 3 years of life, and continues to grow for the first two decades. These data are relevant for pediatric treatments that may impede or alter orbital growth in infants, and maximal susceptibility to oncological procedures in early childhood.

A Subgroup Analysis of Chinese Patients Switched to Paliperidone Palmitate One-Month Injectable by Prior Oral Antipsychotic Treatment

INTRODUCTION

Safely tapering current antipsychotic medication, while balancing efficacy and tolerability, is an important consideration when switching patients from their antipsychotic therapy to a new treatment. The efficacy and tolerability of paliperidone palmitate one-month (PP1M) in Chinese patients switched from previous antipsychotic treatments were examined in order to develop effective switching and dosing strategies.

METHODS

A 13-week open-label, single arm, prospective, interventional study was conducted in Chinese patients (n = 610) with acute schizophrenia to examine their response, by previous treatment group, when switched to PP1M (75-150 mg eq).

RESULTS

Among 610 patients with ≥ 30% reduction in PANSS total score were 191/263 (72.6%) risperidone/paliperidone extended-release patients, 36/52 (69.2%) olanzapine patients, and 214/293 (73.0%) other antipsychotic patients. Patient functioning and adherence were significantly (p ≤ 0.05) improved for all subgroups.

DISCUSSION

Patients on higher doses of prior antipsychotics generally took longer to withdraw from their current medication. Most patients were administered the 100 mg eq dose, and all subgroups received a similar mean dose (114-119 mg eq) of PP1M. Recommendations for transitioning patients to PP1M from each subgroup are discussed.

Correlation of contrast-enhanced ultrasound with two distinct types of blood vessels for the assessment of angiogenesis in lewis lung carcinoma

OBJECTIVE

The aim of our study was to evaluate tumor angiogenesis in Lewis lung carcinoma (LLC) of mice using a contrast-enhanced ultrasound (CEUS) examination, and to determine the correlation of contrast-enhanced ultrasonographic parameters with different blood vessel markers of microvessel density (MVD).

MATERIALS AND METHODS

Subcutaneous Lewis lung carcinomas were established in 25 mice, which were evaluated by contrast-enhanced US using SonoVue (a second-generation US contrast agent). The results were recorded as digital video images and the time-intensity curves and hemodynamic parameters were analyzed. Pathological tumor specimens were obtained just after US examination. Tumor specimens were stained with hematoxylin and eosin (H & E) and expression of CD31 and CD34, the different endothelial cell markers, was determined by immunohistochemical straining. Then the relationship between the CEUS parameters and the level of MVD was analyzed.

RESULTS

Two distinct types of microvessels were identified in Lewis lung carcinoma: differentiated (CD34 +) and undifferentiated (CD31 +) vessels. A significant correlation was found between CEUS parameters and undifferentiated MVD (CD31 + vessels) in LLC (P < 0.05). There was a reverse correlation between the different MVDs.

CONCLUSION

The study showed that among the distinct types of vasculature (CD31 + and CD34 +) in Lewis lung carcinoma, the former correlated with the CEUS parameters. Therefore, CEUS using a second-generation US contrast agent may be useful for the evaluation of tumor angiogenesis of LLC of mice.

Differentiation of benign from malignant thyroid nodules with acoustic radiation force impulse technique

OBJECTIVE

The aim of our study was to assess the performance of acoustic radiation force impulse (ARFI) imaging to differentiate benign from malignant thyroid nodules.

METHODS

182 patients who needed thyroid surgery were examined. All patients and 50 healthy volunteers underwent ARFI sonoelastography, which quantitatively analysed the elasticity and hardness of the nodule's centre and periphery.

RESULTS

ARFI values showed a statistical significance between malignant nodules and benign nodules and common thyroid parenchyma, in both the centre and periphery of nodules (p < 0.01). There was no significant difference between benign nodules and common thyroid parenchyma in either the nodule's centre or periphery (p > 0.05). There was no significant difference between the nodule's centre and periphery of the elastic parameters in both the benign and malignant nodules. There was a statistically significant difference among the two areas (the central group and the peripheral group) under the receiver operating characteristic curve, and the optimal model was the peripheral group. For differentiation of malignant from benign nodules, the sensitivity and specificity were 96.3% and 96.2%, respectively, when 2.545 m s(-1) was chosen as a cut-off value in the peripheral group.

CONCLUSION

ARFI imaging may be helpful to differentiate benign nodules from malignant thyroid nodules. The selecting measurement position is important in ARFI imaging, and it has good diagnostic value in clinical applications.

ADVANCES IN KNOWLEDGE

This study shows the diagnostic contribution of ARFI imaging in thyroid lesions.

Modelling the transmission dynamics of meticillin-resistant Staphylococcus aureus in Beijing Tongren hospital

Semi-professional volunteers work in many tertiary care hospitals in China as healthcare assistants. Proper infection control measures are needed to reduce nosocomial transmission involving volunteers. A compartmental model was constructed to describe the transmission characteristics of meticillin-resistant Staphylococcus aureus (MRSA) in the emergency ward (EW) and respiratory intensive care unit (RICU) for volunteers in Beijing Tongren Hospital, Beijing, China. The model consists of components describing uncolonized and colonized patients, uncontaminated and contaminated healthcare workers (HCWs), and uncontaminated and contaminated volunteers. The basic reproduction number (R(0)) was calculated, and the dependence of R(0) on various model parameters was analysed. Moreover, simulations of the model were performed for comparision with the reported data on the numbers of colonized patients in the EW and RICU from 3 March 2009 to 28 February 2010, respectively. Sensitivity analysis of R(0) showed that increasing handwashing compliance among HCWs and volunteers would reduce the risk of transmission dramatically. As volunteers care for patients on a one-to-one basis, this study showed that the number of MRSA-positive patients would increase if volunteers were replaced by HCWs. Therefore, in addition to improving hand hygiene among HCWs, the employment of properly trained volunteers is an attractive alternative to decrease MRSA and other multi-drug resistant bacteria infections in the hospital setting.

Diffusion tensor MR imaging in cervical spine trauma

BACKGROUND AND PURPOSE

Our aim was to investigate the extent and severity of changes in spinal cord diffusion tensor imaging (DTI) parameters in patients with cervical cord injury.

MATERIALS AND METHODS

DTI was performed in 20 symptomatic patients (mean, 45.7 +/- 17.7 years of age; 2 women, 18 men) with cervical spine trauma and 8 volunteers (mean, 34.2 +/- 10.7 years of age; 6 men, 2 women). The whole cord and regional apparent diffusion coefficient (ADC), fractional anisotropy (FA), relative anisotropy (RA), and volume ratio (VR) of patients and volunteers were compared. DTI parameters were calculated in 16 patients. MR imaging demonstrated hemorrhagic cord contusions (n = 6), nonhemorrhagic cord contusions (n = 4), and soft-tissue injury (n = 6). Medical records were reviewed for extent of neurologic deficit.

RESULTS

Regional ADC values differed significantly between upper and mid and upper and lower (both, P < .004) cervical cord sections. FA was significantly different between upper and lower sections (P < .03). Whole cord ADC values were significantly lower in patients than in volunteers (P < .0001). Whole spine FA was not significantly decreased in patients (P < .06). ADC and FA values were significantly decreased at injury sites when compared with volunteers (P < .031 and .0001, respectively). The greatest differences in whole cord ADC, FA, RA, and VR were in patients with hemorrhagic cord contusions compared with healthy volunteers (P < .0001, .003, .0005, and .008, respectively).

CONCLUSION

DTI parameters are sensitive markers of cervical cord injury, with ADC showing the greatest sensitivity. Changes in DTI parameters are most marked at injury sites and reflect the severity of cord injury.

Efficient induction of immune tolerance to coagulation factor IX following direct intramuscular gene transfer

BACKGROUND

The formation of inhibitory anti-factor IX (anti-FIX) antibodies is a major complication of FIX protein replacement-based treatment for hemophilia B. It is difficult to treat patients with anti-FIX antibodies. Gene therapy is emerging as a potentially effective treatment for hemophilia. Direct i.m. injection of adeno-associated virus (AAV) is a safe and efficient procedure for hemophilia B gene therapy. However, the development of anti-FIX antibodies following i.m. of AAV may impede its application to patients.

OBJECTIVE

We aimed to investigate induction of immune tolerance to human FIX (hFIX) by i.m. of AAV1, further validating i.m. of AAV1 for hemophilia B gene therapy.

METHODS AND RESULTS

Cohorts of hemostatically normal and hemophilia B mice with diverse genetic and MHC backgrounds received i.m. of AAV-hFIX. Human FIX antigen and anti-hFIX antibodies were examined. I.m. of 1 x 10(11) vector genomes (VG) of AAV2 elicits formation of anti-hFIX antibodies comparable to those by hFIX protein replacement. I.m. of 1 x 10(11) VG of AAV1 results in expression of therapeutic levels of hFIX (up to 950 ng mL(-1), mean = 772 ng mL(-1), SEM +/- 35.7) and hFIX-specific immune tolerance in C57BL/6 mice.

CONCLUSIONS

A single i.m. of AAV1 can result in efficient expression of therapeutic levels of hFIX and induction of hFIX tolerance in hemostatically normal and hemophilic B mice. Our results substantiate the prospect of i.m. of AAV1 for hemophilia B gene therapy and FIX tolerance induction.

Evaluation of metallothionein and p53 expression as potential prognostic markers for laryngeal squamous cell carcinoma

The aim of the study was to determine the contribution of metallothionein (MT) and p53 expression in predicting laryngeal squamous cell carcinoma (SCC) recurrence. This was a retrospective study in which MT and p53 immunopositive staining in 32 laryngeal SCC paraffin-embedded sections, were correlated with clinical recurrence. Recurrence was observed in 8 cases with MT expression (42.1%) and 1 case with no expression (7.7%). Moderate and strong MT expression was associated with 14.3% and 58.3% recurrence, respectively. Recurrence was similar for both p53-negative (21.1%) and p53-positive (27.3%) groups. One third of the patients expressing both p53 and MT simultaneously had recurrence. Thus, the combined expression of p53 and MT did not improve the predictive value for recurrence compared to MT alone. MT over-expression may be an independent risk factor for laryngeal SCC recurrence.