POS0670 ROUTINE ASSESSMENT OF PATIENT INDEX DATA 3 (RAPID3) IN PATIENTS WITH RHEUMATOID ARTHRITIS TREATED WITH LONG-TERM UPADACITINIB THERAPY

Background:

Routine Assessment of Patient Index Data 3 (RAPID3) is a pooled index of 3 patient-reported measures: patient global assessment, pain, and physical function. RAPID3 was shown to correlate with other composite measures of disease activity1 and is recommended by the American College of Rheumatology for use in clinical practice.2

Objectives:

To evaluate the impact of upadacitinib (UPA) versus comparators on RAPID3 over 60 weeks, as well as the correlation of RAPID3 scores with other disease measures in the UPA phase 3 SELECT clinical program.

Methods:

This post hoc analysis included placebo-controlled (SELECT-NEXT, -BEYOND, and -COMPARE) and active comparator-controlled (SELECT-EARLY, -MONOTHERAPY, and -COMPARE) trials. Patients received UPA as monotherapy or in combination with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). Mean change from baseline in RAPID3 and the proportion of patients reporting RAPID3 remission (≤3), low (LDA, >3 to ≤6), moderate (MDA, >6 to ≤12), and high disease activity (HDA, >12) were assessed. Correlations between absolute scores for RAPID3 and Clinical Disease Activity Index (CDAI), Simplified Disease Activity Index (SDAI), and 28-joint Disease Activity Score with C-reactive protein (DAS28[CRP]) were assessed using Spearman correlation coefficients. All data are as observed.

Results:

A total of 661, 498, 648, 1629, and 945 patients were included from SELECT-NEXT, -BEYOND, -MONOTHERAPY, -COMPARE, and -EARLY. At baseline, the majority of patients across all studies were in RAPID3 HDA (mean baseline RAPID3 [across all studies], 17.2–19.2) (Table 1 and Figure 1). Improvements from baseline in RAPID3 were observed with UPA 15 mg and 30 mg through Week 60, with numerically greater improvements observed with UPA compared with active comparators (Table 1). Across studies, mean improvements in RAPID3 exceeded the minimal clinically important difference (MCID) with UPA and adalimumab (ADA) treatment (MCID=3.83). By Week 60, approximately one-half of UPA-treated patients were in RAPID3 remission or LDA, with only 10–25% remaining in HDA, except for the more refractory population in SELECT-BEYOND, in which ~38% of patients remained in HDA (Figure 1). RAPID3 scores moderately to strongly correlated with CDAI (ρ=0.69–0.83), SDAI (ρ=0.69–0.82), and DAS28(CRP) (ρ=0.58–0.77), across all studies, at Week 60 (all p<0.001).

Conclusion:

UPA, as monotherapy or in combination with csDMARDs, was associated with improvements in patient-reported disease activity, pain, and physical function, as assessed by RAPID3 over 60 weeks in the phase 3 SELECT clinical program. RAPID3 continues to be an important tool in clinical practice to assess disease activity, as it was shown to correlate to other disease activity measures and allows for rapid scoring.

References:

[1]Pincus T, et al. Arthritis Care Res (Hoboken) 2010;62:181–9.

[2]England BR, et al. Arthritis Care Res (Hoboken) 2019;71:1540–55.

[3]Ward MM, et al. J Rheumatol 2019;46:27–30.

Table 1.

Change from BL in RAPID3 at Week 60 (as observed)

Phase 3 studyGroupnaMean (SD) BL scoreMean (SD) change from BLbSELECT-EARLYc(MTX-naïve)MTX23618.5 (5.6)−9.6 (7.5)UPA 15 mg QD26918.9 (5.6)−12.0 (7.6)UPA 30 mg QD25318.2 (5.6)−13.4 (7.2)SELECT-NEXT(csDMARD-IR)UPA 15 mg QD17217.7 (5.1)−11.1 (7.3)UPA 30 mg QD17217.6 (5.3)−10.4 (6.8)SELECT-MONOTHERAPY(MTX-IR)UPA 15 mg QD17217.4 (5.8)−9.6 (7.4)UPA 30 mg QD18017.2 (5.9)−10.6 (7.2)SELECT-COMPAREc(MTX-IR)UPA 15 mg QD55218.5 (5.5)−10.2 (7.1)ADA 40 mg EOW26418.7 (5.4)−8.8 (6.7)SELECT-BEYOND(bDMARD-IR)UPA 15 mg QD13319.2 (5.1)−8.6 (6.8)UPA 30 mg QD11818.5 (5.3)−9.3 (7.3)

b, biologic; BL, baseline; EOW, every other week; IR, inadequate response; MTX, methotrexate; QD, once daily; SD, standard deviation

aNumber of patients with RAPID3 values at both BL and Week 60. bNegative values indicate improvement from BL. cObserved data include patients rescued to UPA and/or ADA; treatment effect may include both the randomized and switch treatments in these patients

Acknowledgements:

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data; and participated in the writing, review, and approval of the abstract. No honoraria or payments were made for authorship. Medical writing support was provided by Grant Kirkpatrick, MSc, of 2 the Nth (Cheshire, UK), and was funded by AbbVie.

Disclosure of Interests:

Martin Bergman Shareholder of: Johnson & Johnson, Speakers bureau: AbbVie, Celgene, GSK, MSD, Novartis, Pfizer, and Sanofi/Regeneron, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Genentech/Roche, Gilead, Horizon, Janssen, MSD, Novartis, Pfizer, Sandoz, Sanofi/Regeneron, and Scipher, Maya H Buch Consultant of: AbbVie, Eli Lilly, Merck-Serono, Pfizer, Sandoz, and Sanofi, Grant/research support from: Pfizer, Roche, and UCB, Yoshiya Tanaka Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi Sankyo, Eisai, Eli Lilly, GSK, Janssen, Mitsubishi Tanabe, Novartis, Pfizer, Sanofi, Takeda, UCB, and YL Biologics, Grant/research support from: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi Sankyo, Eisai, Mitsubishi Tanabe, MSD, Ono, Taisho Toyama, and Takeda, Gustavo Citera Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Genzyme, Pfizer, and Roche, Sami Bahlas: None declared, Ernest Wong Consultant of: AbbVie, Chugai, Eli Lilly, MSD, Novartis, Pfizer, Roche, and UCB, Grant/research support from: AbbVie, Chugai, Novartis, and UCB, Yanna Song Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Namita Tundia Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Jessica Suboticki Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Vibeke Strand Consultant of: AbbVie, Amgen, Arena, AstraZeneca, Bayer, Bristol-Myers Squibb, Boehringer Ingelheim, Celltrion, Eli Lilly, Gilead, Ichnos, Inmedix, Janssen, Kiniksa, MSD, Myriad Genetics, Novartis, Pfizer, Regeneron, Samsung, Sandoz, Sanofi, Scipher, Setpoint, and UCB.

POS0691 EFFECTS OF ANIFROLUMAB ON RENAL DISEASE IN PATIENTS WITH SLE

Background:

The type I interferon (IFN) receptor antibody anifrolumab has shown efficacy in patients with systemic lupus erythematosus (SLE) in the phase 3 TULIP-1 and TULIP-2 trials.1,2 Type I IFN dysregulation is associated with lupus nephritis (LN) pathogenesis.3

Objectives:

Pooled TULIP data were analyzed post hoc to assess baseline characteristics of patients with and without renal involvement and to evaluate the effects of anifrolumab on renal disease.

Methods:

TULIP-1 (NCT02446912) and TULIP-2 (NCT02446899) were randomized, placebo-controlled, 52-week trials of intravenous anifrolumab every 4 weeks in patients with moderate to severe SLE despite standard therapy, which excluded patients with severe active LN.1,2 Renal involvement at baseline was defined as any of the following: BILAG-2004 renal score A–C; SLEDAI-2K renal score >0; urine protein–creatinine ratio (UPCR) >0.5 mg/mg. Baseline characteristics were evaluated in patients with and without renal involvement, and the following endpoints were compared for the anifrolumab 300 mg and placebo groups: cumulative UPCR (area under the curve, AUC) through Week (W)52; percentage of patients with UPCR >0.5 mg/mg at baseline who improved to UPCR ≤0.5 mg/mg at W52; percentage of patients with renal flares (new BILAG-2004 A/B renal score vs prior visit); cumulative glucocorticoid (GC) use (AUC) through W52; and percentage changes in complement C3/C4 from baseline to W52.

Results:

Of the 726 patients in TULIP-1/-2 (anifrolumab, n=360; placebo, n=366), 99 had renal involvement at baseline (anifrolumab, n=45; placebo, n=54), 57 of whom had UPCR >0.5 mg/mg (anifrolumab, n=24; placebo, n=33). Patients with renal involvement vs without renal involvement had a lower mean age (37.8 vs 42.4 years) and were more likely to be male (14.1% vs 6.1%), Asian (16.2% vs 9.6%), IFN gene signature test–high (89.9% vs 81.5%), and anti-dsDNA positive (69.7% vs 40.4%); have a SLEDAI-2K score ≥10 (91.9% vs 68.4%); and be receiving GC ≥10 mg/day (67.7% vs 49.1%) or mycophenolate (26.3% vs 11.5%) at baseline. Among patients with baseline renal involvement, anifrolumab treatment was associated with a numerically greater improvement vs placebo in cumulative UPCR (AUC) through W52 (LS mean difference [SE]: –54.1 [54.26]) (Table 1). Numerically more patients improved from UPCR >0.5 mg/mg at baseline to ≤0.5 mg/mg at W52 with anifrolumab vs placebo (difference [SE], 4.9% [13.3]). Among all TULIP patients, fewer had ≥1 BILAG-2004 renal flare with anifrolumab vs placebo (5.0% vs 7.4%).4 Among patients with renal involvement, cumulative GC use (AUC) through W52 was lower with anifrolumab vs placebo (LS mean difference [SE]: –210.3 mg [332.6]) and there were numerically greater improvements in C3 and C4 from baseline to W52 (Table 1).

Conclusion:

TULIP data suggest renal benefit with anifrolumab in patients with SLE with mild/stable renal disease, supporting further investigation into anifrolumab’s efficacy in patients with active LN.

References:

[1]Furie R. Lancet Rheumatol. 2019;1:e208–19.

[2]Morand E. N Engl J Med. 2020;382:211–21.

[3]Feng X. Arthritis Rheum. 2006;54:2951–62.

[4]Furie R [abstract]. Arthritis Rheumatol. 2020;72(supp 10).

Table 1.

Renal Endpoints in TULIP-1 and TULIP-2

Endpoint (baseline to Week 52)PlaceboAnifrolumab 300 mgUPCR AUCan5445LS mean (SE)271.8 (54.8)217.7 (60.0)LS mean difference (SE), 95% CI−54.1 (54.3), −161.9, 53.6Improvement from >0.5 to ≤0.5 mg/mg UPCRbn3324Patients with improvement (%)36.341.2Difference, % (SE), 95% CI4.9 (13.3), −21.1, 30.9Glucocorticoid AUCan5445LS mean (SE)3524.5 (339.0)3314.2 (365.2)LS mean difference (SE), 95% CI−210.3 (332.6), −870.7, 450.1Change in C3/C4 (%)cC3N3121Mean (SE)20.3 (6.2)26.6 (5.0)C4N1914Mean (SE)29.1 (12.0)38.7 (13.8)

AUC, area under the curve; CI, confidence interval; LS, least squares; UPCR, urine protein–creatinine ratio; SE, standard error.

n, number satisfying baseline inclusion criteria for subgroup.

aPatients with baseline renal involvement; analysis of covariance.

bStratified Cochran–Mantel–Haenszel.

cPatients with renal involvement and abnormal C3/C4 at baseline.

Acknowledgements:

Writing assistance by Rosie Butler, PhD, of JK Associates Inc. part of Fishawack Health. This study was sponsored by AstraZeneca.

Disclosure of Interests:

Eric F. Morand Speakers bureau: AstraZeneca, Consultant of: AstraZeneca, Grant/research support from: AstraZeneca, Richard Furie Consultant of: AstraZeneca, Grant/research support from: AstraZeneca, Yoshiya Tanaka Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, GSK, Janssen, Mitsubishi-Tanabe, Novartis, Pfizer, Sanofi, and YL Biologics, Grant/research support from: AbbVie, Chugai, Daiichi-Sankyo, Eisai, Mitsubishi-Tanabe, Takeda, and UCB, Tsutomu Takeuchi Speakers bureau: AbbVie GK., Bristol–Myers K.K., Chugai Pharmaceutical Co,. Ltd., Mitsubishi Tanabe Pharma Co., Pfizer Japan Inc., Astellas Pharma Inc, Daiichi Sankyo Co., Ltd., Eisai Co., Ltd., Sanofi K.K., Teijin Pharma Ltd., Takeda Pharmaceutical Co., Ltd., Novartis Pharma K.K., Consultant of: AstraZeneca K.K., Eli Lilly Japan K.K., Novartis Pharma K.K., Mitsubishi Tanabe Pharma Co., Abbvie GK, Nipponkayaku Co.Ltd, Janssen Pharmaceutical K.K., Astellas Pharma Inc,. Taiho Pharmaceutical Co., Ltd., Chugai Pharmaceutical Co, Ltd., Grant/research support from: Astellas Pharma Inc, Chugai Pharmaceutical Co, Ltd., Daiichi Sankyo Co., Ltd., Takeda Pharmaceutical Co., Ltd., AbbVie GK, Asahikasei Pharma Corp., Mitsubishi Tanabe Pharma Co., Pfizer Japan Inc., Eisai Co., Ltd., AYUMI Pharmaceutical Corporation, Nipponkayaku Co.Ltd., Novartis Pharma K.K., Gabriel Abreu Employee of: AstraZeneca, Raj Tummala Employee of: AstraZeneca, Catharina Lindholm Employee of: AstraZeneca

POS0877 THE EFFECT OF PLATELET INHIBITORS ON DIGITAL ULCERS IN SYSTEMIC SCLEROSIS - A DERIVATION AND VALIDATION EUSTAR STUDY

Background:

Digital ulcers (DUs) affect half of the patients with systemic sclerosis (SSc) and can be complicated by gangrene and amputation. The direct involvement of platelets in the development of DUs has been suggested by in vitro studies, which encouraged physicians to consider platelet inhibitors as a therapeutic option in the management of DUs. However, until now, there is no clinical study to assess the efficacy of platelet inhibitors for DUs in SSc patients.

Objectives:

To demonstrate a possible relationship between treatment with platelet inhibitors and the occurrence of DUs at the next follow-up visit in patients with SSc.

Methods:

This study used prospectively collected data from the European Scleroderma Trials and Research group (EUSTAR) registry. Patients fulfilling the 2013 ACR/EULAR SSc classification criteria with complete longitudinal data on the presence of DUs and platelet inhibitors were included in the analysis. Multiple imputation using a random forest algorithm was implemented to handle missing values.

The dataset was split into a derivation and validation cohort. To investigate the response for the binary dependent variable of DUs, a generalized linear mixed model (GLMM) was developed in the derivation cohort and validated using ROC analysis and Brier scores to address discrimination and calibration, respectively.

Results:

Of 3,463 patients (2,961 in the derivation cohort, 722 in the validation cohort), 453 had current DUs at the baseline and 245 were exposed to platelet inhibitors (table 1).

Our GLMM revealed that the exposure to platelet inhibitors is associated with a reduced risk of DUs at the next follow up visit (OR = 0.33, 95% CI = [0.13 to 0.82]). Further factors associated with absence or presence of DUs at the next follow-up visit are shown in figure 1. This confirmed the previously identified risk factors for the presence of DUs, supporting the overall robustness and the validity of our model.

The performance was evaluated by ROC curve analysis and showed an AUC = 97.97% (95% CI = [96.93% to 97.67%]) for the derivation cohort and AUC = 77.3% (95% CI = [74.01% to 81.39%]) for the validation cohort, respectively, showing an acceptable discrimination. The Brier score was 0.05 in the derivation cohort and 0.07 in the validation cohort, suggesting a good calibration of the model.

Conclusion:

Our model, with acceptable discrimination and good calibration, suggests a positive treatment effect of platelet inhibitors on DUs in clinical practice.

Table 1.

Baseline characteristics of patients before imputation

CharacteristicsOverallDerivation setValidation setn3,4632,691772Age (median [IQR])56.00 [47.00, 66.00]56.00 [47.00, 65.00] 57.00 [48.00, 67.00]Disease duration (median [IQR]) 9.00 [4.00, 16.00] 9.00 [4.00, 16.00] 8.00 [4.00, 15.00]Disease subset = Limited cutaneous SSc (%) 1562 (65.2) 1164 (64.6) 398 (66.9)DUs (%): Current 453 (13.1) 378 (14.0) 75 (9.7)DUs (%): Never 1783 (51.5) 1326 (49.3) 457 (59.2)DUs (%): Previously 1227 (35.4) 987 (36.7) 240 (31.1)mRSS (median [IQR]) 5.00 [2.00, 11.00] 6.00 [2.00, 12.00] 4.00 [1.00, 11.00]Joint Contractures = Yes (%) 881 (26.8) 770 (29.4) 111 (16.5)LVEF (median [IQR])62.00 [60.00, 65.00]60.00 [60.00, 65.00] 65.00 [60.00, 67.00]Dyspnea NYHA III and IV (%)300 (9.5)214 (8.6)86 (12.7)Pulmonary hypertension = Yes (%) 244 (10.7) 200 (11.3) 44 (8.4)Lung fibrosis on HRCT = Yes (%) 685 (46.6) 600 (47.7) 85 (39.7)FVC % predicted (median [IQR])97.00 [82.00, 111.00]95.00 [81.00, 110.00]101.00 [85.00, 115.00]Serum creatinine mg/dl (median [IQR]) 0.70 [0.60, 0.90] 0.70 [0.60, 0.90] 0.70 [0.70, 0.90]Anti-Scl-70 positive = Yes (%) 1147 (33.1) 958 (35.6) 189 (24.5)CRP elevation = Yes (%) 639 (21.1) 490 (20.8) 149 (22.1)Platelet inhibitors therapy = Yes (%) 245 (7.1) 206 (7.7) 39 (5.1)Oral anti-coagulants therapy = Yes (%) 53 (1.5) 50 (1.9) 3 (0.4)

Disclosure of Interests:

None declared

POS0604 LONG TERM SAFETY AND TOLERABILITY WITH ETANERCEPT BIOSIMILAR (YLB113), RESULTS FROM A 2-YEAR OPEN LABEL EXTENSION STUDY (STUDY NO. YLB113-003)

Background:

Eligible subjects with moderate-to-severely active rheumatoid arthritis (RA) who completed a phase 3 double-blind comparative efficacy and safety study (Study No. YLB113-002; Yamanaka et al, 2019) of 50 mg etanercept biosimilar (YLB113) or etanercept reference product (RP) by subcutaneous administration with concomitant MTX treatment for 52 weeks, were enrolled in this open label extension (OLE) study (Study No. YLB113-003) to assess the long-term safety and tolerability of YLB113 through to 3 years.

Objectives:

This OLE study aimed to evaluate the long-term safety of YLB113 administration in subjects with RA who received RP or YLB113 in a phase 3 active comparator study. The main parameters assessed were safety and tolerability in terms of adverse events (AEs) and injection site reactions (ISRs), incidence of immunogenicity and efficacy as DAS28 improvement (disease activity score in 28 joints).

Methods:

Subjects received 50 mg of YLB113 subcutaneously once every 1 to 2 weeks. Safety was assessed by AEs after study drug administration, ISRs, physical examination findings, and immunogenicity. Efficacy (DAS28 score) was assessed at the time of transition to the OLE study (Week 0), and at weeks 12, 24, 48, 72, 96 and at the end of the study.

Results:

201 (Full analysis set [FAS]) subjects received the study drug and 184 subjects completed the study (91.5% completion rate). The average drug exposure in 94 subjects who continued to receive YLB113 and completed the study (94.0% completion rate) and 90 subjects who switched from RP to YLB113 and completed the study (89.1% completion rate) was 103 weeks providing the long-term drug exposure data of YLB113.

The CTCAE Grade of TEAEs and ADRs observed were Grade 2 or less in severity (with no Grade ≥3). The overall incidence of ISRs was 10.0% (20/201 subjects) 77 events. All the ISRs reported were Grade 1 except for one Grade 2.

An overview of the AEs experienced by the subjects is summarized in the Table 1.

Table 1.

Overview of Adverse events in OLE study

FASn (%)Number of eventsNumber of subjects201-Treatment emergent adverse events (TEAEs)188(93.5)975Adverse drug reactions (ADRs)82(40.8)221Serious adverse events (SAEs)21(10.4)27Serious adverse drug reactions (SADRs)7(3.5)7AEs leading to premature study discontinuation4(2.0)6ADRs leading to premature study discontinuation3(1.5)4SAEs leading to premature study discontinuation3(1.5)4SADRs leading to premature study discontinuation2(1.0)2

n - number of subjects with at least 1 AE in the category

The mean DAS28 (mean ± S.D.) of 2.22 ± 0.95 at the study transition was 2.10 ± 0.91 at Week 72 and 2.06 ± 0.89 at the end of the study. It was confirmed that DAS28 slightly decreased with time after the study transition and continued until the end of the study. The average DAS28 value remained low even with long-term administration of YLB113, suggesting that the effects of the study drug was sustained (Figure 1).

Figure 1.

DAS28 over time with YLB113 N: Number of subjects. * The administration period at the study completion differs for each subject, because the study transition time differs for each subject.

cts who tested positive for anti-drug antibodies (ADA) at least once in the OLE study were 1.0% (2/200 subjects). All ADA were transient and disappeared at study completion. Such transient ADA formation was reported in the phase 3 study as well. In the phase 3 study, ADA formation was more frequent in subjects who received RP at 24 weeks, but all subjects were negative in the OLE study after switching. Therefore, switching did not affect immunogenicity.

Conclusion:

The safety, efficacy and immunogenicity profile of YLB113 was maintained over the long-term through to 3 years. Switching from RP to YLB113 did not impact safety or immunogenicity.

References:

[1]Yamanaka H, Kamatani N, Tanaka Y, et al. A Comparative Study to Assess the Efficacy, Safety, and Immunogenicity of YLB113 and the Etanercept Reference Product for the Treatment of Patients with Rheumatoid Arthritis. Rheumatol Ther. 2020 Mar;7(1):149-163.

Disclosure of Interests:

Yamanaka Hisashi Speakers bureau: YL Biologics Ltd, Consultant of: YL Biologics Ltd, Yoshiya Tanaka Speakers bureau: Received speaking fees and/or honoraria from Daiichi-Sankyo, Eli Lilly, Novartis, YL Biologics, Bristol-Myers, Eisai, Chugai, Abbvie, Astellas, Pfizer, Sanofi, Asahi-kasei, GSK, Mitsubishi-Tanabe, Gilead, Janssen., Grant/research support from: Received research grants from Abbvie, Mitsubishi-Tanabe, Chugai, Asahi-Kasei, Eisai, Takeda, Daiichi-Sankyo., Toshihiko Hibino: None declared, Chirag Shah Shareholder of: Lupin LTD, Employee of: Lupin LTD, Dhananjay Bakhle Shareholder of: As part of Employee Stock Options Plan of Lupin LTD, Employee of: Lupin LTD, Dimitris Stefanidis Employee of: Sr. Director, Global Medical Affairs Lead, Immunology Biosimilars for Viatris GmbH

POS0336 PATTERNS OF LARGE-VESSEL LESIONS AND POOR TREATMENT OUTCOMES IN PATIENTS WITH LARGE-VESSEL GIANT CELL ARTERITIS

Background:

Giant cell arteritis (GCA) is characterized by cranial symptoms and large-vessel lesions (LVL) in the aorta or its branches. We retrospectively analyzed the Japanese patients newly diagnosed as GCA between 2007 and 2014, and subsequently treated with glucocorticoid (GC). The imaging studies revealed that LVLs were observed in approximately half of the GCA patients, and the LVLs were significantly associated with the increased probability of poor treatment outcomes (1).

Objectives:

The objective of this study is to evaluate whether the distribution of LVLs of GCA was associated with poor treatment response.

Methods:

In a retrospective, multi-centric, nationwide registry of GCA patients treated with GCs between 2007 and 2014, 68 newly-diagnosed GCA with LVLs by imaging were detected. All investigators were members of Japan Research Committee of the Ministry of Health, Labour, and Welfare for Intractable Vasculitis (JPVAS). Poor treatment outcomes (non-achievement of clinical remission by week 24 or relapse during 104 weeks) were primarily evaluated. Cumulative rates and median time to the first event were analyzed by the Kaplan-Meier method and the log-rank test. Associated factors with the outcomes were analyzed by using the Cox proportional hazard model.

Results:

The mean age was 70.5 years, and 70.6% were women. Twenty-seven (39.7%) of the 68 patients were diagnosed as having GCA by both positive temporal artery biopsy and positive imaging, and 41 (60.3%) by positive imaging. Aortic lesions were detected in 72.1% (group 2, n=49) of the 68 GCA patients with LVLs. Patients without aortic lesions were categorized into two phenotypes: large-vessel GCA with subclavian lesions (group 1, n=9) and atypical large-vessel GCA without subclavian lesions (group 3, n=10). Cranial lesions were observed in 66.7%, 55.1%, and 80.0% in the group 1, 2, and 3, respectively. The initial mean dose (SD) of prednisolone was 0.74 (0.26) mg/kg/day, and 20.6 % received methotrexate for remission induction therapy. Baseline dose of GCs and mean time to achievement of low-dose GCs (prednisolone ≤ 5 mg/day) was not significantly different among the three groups.

Overall, 35 (51.5%) of the 68 patients had the event of poor treatment outcomes. Eleven patients were not able to achieve clinical remission by week 24. Relapse after achievement of clinical remission was reported in total of 24 patients; 9 between week 0 and 24, 12 between week 24 and 52, 3 between week 52 and 104. The cumulative rate of events of poor treatment outcomes over the two years was 11.1% in patients with group 1, 55.3% in those with group 2, and 88.0% in those with group 3. Mean time to events was significantly different among the three groups. Multivariable analysis showed the risk of poor treatment outcomes was likely to decrease in the group 1 (hazard ratio 0.14 [95% CI 0.02-1.03], p=0.054), while it increased in the group 3 (hazard ratio 2.22 [95% CI 1.06-4.68], p=0.035).

Conclusion:

The distribution of LVLs were associated with poorer treatment outcomes. A half of the patients with aortic lesions had poor treatment outcomes while subclavian arteritis without aortic lesions had better clinical outcomes. Atypical large vessel-GCA without the aortic and subclavian artery involvement was the worst prognostic phenotype of LV-GCA. Extent of LVLs by imaging should be considered when determining the treatment strategy for GCA.

References:

[1]Sugihara T, et al. Arthritis Res Ther. 2020;22(1):72

Acknowledgements:

The authors would like to acknowledge Mitsuaki Isobe (Sakakibara Heart Institute), Yoshihiro Arimura (Kichijoji Asahi Hospital), and all the investigators in the Japan Research Committee of the Ministry of Health, Labour, and Welfare for Intractable Vasculitis (JPVAS). In addition to the authors, the following investigators and institutions participated in this study: Department of Internal Medicine, Juntendo University Koshigaya Hospital (Shigeto Kobayashi); Niigata Rheumatic Center (Satoshi Ito); Niigata Prefectural Shibata Hospital (Noriyuki Homma).

Disclosure of Interests:

takahiko sugihara Speakers bureau: TS has received honoraria from Abbvie Japan Co., Ltd., AsahiKASEI Co., Ltd., Astellas Pharma Inc., Ayumi Pharmaceutical, Bristol Myers Squibb K.K., Chugai Pharmaceutical Co., Ltd., Eli Lilly Japan K.K., Mitsubishi-Tanabe Pharma Co., Ono Pharmaceutical, Pfizer Japan Inc., Takeda Pharmaceutical Co. Ltd., and UCB Japan Co. Ltd., Grant/research support from: TS has received research grants from AsahiKASEI Co., Ltd., Daiichi Sankyo., and Ono Pharmaceutical., Haruhito A. Uchida Grant/research support from: HAU belongs to the Department of Chronic Kidney

Disease and Cardiovascular Disease which is endowed by Chugai Pharmaceutical, MSD, Boehringer Ingelheim, and Kawanishi Holdings., Hajime Yoshifuji Speakers bureau: HY has received lecture fees from Chugai Pharmaceutical Co., Ltd. and Nihon Medi-Physics Co., Ltd., Yasuhiro Maejima Speakers bureau: YM have received honoraria from Chugai Pharmaceutical Co., Ltd.., Taio Naniwa Speakers bureau: TN has received lecture fees from Chugai Pharmaceutical Co., Ltd.., Grant/research support from: TN has received research grants from Chugai Pharmaceutical Co., Ltd.., Yasuhiro Katsumata Speakers bureau: YK has received honoraria from Chugai Pharmaceutical Co., Ltd., Glaxo-Smithkline K.K., Sanofi K.K., Pfizer Japan Inc., and Asahi Kasei Pharma Corp., Takahiro Okazaki Grant/research support from: TO has received research grants from Chugai Pharmaceutical Co., Ltd., Eisai Pharmaceutical., and Actelion, Jun Ishizaki: None declared, Yohko Murakawa Speakers bureau: YM has received honoraria from Abbvie, Astellas, Ayumi Pharmaceutical, Bristol Myers Squibb, Chugai Pharmaceutical, Eisai Pharmaceutical, Janssen Pharmaceutical, Kissei Pharmaceutical, Nippon Kayaku, Pfizer Pharmaceutical, Takeda Pharmaceutical, UCB Pharmaceutical, Grant/research support from: YM has received research grant support from Asahi Kasei Pharma, AbbVie Japan, Chugai Pharmaceutical, Daiichi Sankyo, Eisai Pharmaceutical, Mitsubishi Tanabe Pharma, Nippon Kayaku, Gilead Sciences Inc, Janssen Pharmaceutical, and Teijin Pharma., Noriyoshi Ogawa: None declared, Hiroaki Dobashi: None declared, Tetsuya Horita: None declared, Yoshiya Tanaka Speakers bureau: YT has received consulting fees, speaking fees, and/or honoraria from Daiichi-Sankyo, Astellas, Pfizer, Mitsubishi-Tanabe, Bristol-Myers, Chugai, YL Biologics, Eli Lilly, Sanofi, Janssen, UCB, Grant/research support from: YT has received research grants from Mitsubishi-Tanabe, Takeda, Bristol-Myers, Chugai, Astellas, Abbvie, MSD, Daiichi-Sankyo, Pfizer, Kyowa- Kirin, Eisai, Ono., Shunsuke Furuta: None declared, Tsutomu Takeuchi Speakers bureau: TT has served on speakers’ fees for AbbVie, Bristol-Myers Squibb, Chugai, Mitsubishi Tanabe, Pfizer, Astellas, Daiichi Sankyo, Eisai, Sanofi, Teijin, Takeda, and Novartis., Consultant of: TT has received consulting fees from Astra Zeneca, Eli Lilly, Novartis, Mitsubishi Tanabe, AbbVie, Nippon Kayaku, Janssen, Astellas, Taiho, Chugai, Taisho Toyama, GlaxoSmithKline, and UCB., Grant/research support from: TT has received research grants from Astellas, Chugai, Daiichi Sankyo, Takeda, AbbVie, Asahi Kasei, Mitsubishi Tanabe, Pfizer, Eisai, AYUMI, Nippon Kayaku, and Novartis., Yoshinori Komagata Speakers bureau: YK has received speakers’ fees from Bristol-Myers Squibb, Eli Lilly, Janssen, Novartis, Daiichi Sankyo, AbbVie, Nippon Shinyaku, Towa., Consultant of: YK has received consulting fees from Chugai, Kyowa Hakko Kirin, Asahi Kasei, UCB, Yoshikazu Nakaoka Speakers bureau: YN has received lecture fees from Astellas, Takeda, Daiichi Sankyo, Actelion, and Japan Blood Products Organization (JB)., Consultant of: YN has received consulting fees and/or lecture fees from AbbVie and Chugai, Grant/research support from: YN has received research grants from Chugai and Bayer Yakuhin, Ltd, masayoshi harigai Speakers bureau: MH has received speaker’s fee from AbbVie Japan GK, Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc.,Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Kissei Pharmaceutical Co., Ltd., Pfizer Japan Inc., Takeda Pharmaceutical Co., Ltd., and Teijin Pharma Ltd., Consultant of: MH is a consultant for AbbVie, Boehringer-ingelheim, Bristol Myers Squibb Co., Kissei Pharmaceutical Co.,Ltd. and Teijin Pharma., Grant/research support from: MH has received research grants from AbbVie Japan GK, Asahi Kasei Corp., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Daiichi-Sankyo, Inc.,Eisai Co., Ltd., Kissei Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Nippon Kayaku Co., Ltd., Sekiui Medical, Shionogi & Co., Ltd., Taisho Pharmaceutical Co., Ltd., Takeda Pharmaceutical Co., Ltd., and Teijin Pharma Ltd.

POS0087 LONG-TERM SAFETY AND EFFICACY OF UPADACITINIB OR ADALIMUMAB IN PATIENTS WITH RHEUMATOID ARTHRITIS: RESULTS AT 3 YEARS FROM THE SELECT-COMPARE STUDY

Background:

In the SELECT-COMPARE study, the Janus kinase inhibitor, upadacitinib (UPA), demonstrated significant improvements in the signs and symptoms of rheumatoid arthritis (RA) when administered at 15 mg once daily (QD) on background methotrexate (MTX) compared with adalimumab (ADA) plus MTX at Week 12 that were maintained through 72 weeks in patients with prior inadequate response to MTX.1

Objectives:

To assess the long-term safety and efficacy of UPA vs ADA over 3 years in the ongoing long-term extension (LTE).

Methods:

Patients receiving background MTX were randomized 2:2:1 to UPA 15 mg QD, placebo (PBO), or ADA 40 mg every other week. Between Weeks 14-26, rescue was mandated for either lack of response (<20% improvement in tender or swollen joint counts: Weeks 14, 18, 22) or failure to achieve a targeted disease outcome (CDAI low disease activity: Week 26). Patients who completed the 48-week double-blind period could enter an LTE for up to 10 years total. This analysis describes patients through 3 years of treatment. Treatment-emergent adverse events (TEAEs) per 100 patient years (PY), including events of special interest (AESI), were summarized up to 3 years based on exposure to UPA and to ADA. Efficacy was analyzed by original randomized groups. Patients who were rescued or prematurely discontinued study drug were categorized as non-responders for visits after rescue or discontinuation. Descriptive analyses were performed without formal statistical comparisons.

Results:

In total, 651, 651, and 327 patients were randomized at baseline to receive UPA, PBO, and ADA, respectively. Between Weeks 14-26, 252 (39%) patients were rescued from UPA to ADA, 159 (49%) were rescued from ADA to UPA, and all PBO patients were switched to UPA by Week 26.1 A higher proportion of patients randomized to UPA completed 3 years without rescue compared to those randomized to ADA (47% vs 36%, respectively). UPA was generally well-tolerated as assessed by the rates of TEAEs, including serious AEs, AEs leading to discontinuation of study drug, and AESIs, including serious and opportunistic infections, malignancies, adjudicated major adverse cardiac events or venous thromboembolism; Figure 1). Consistent with previous analyses, the event rates of AESIs were generally comparable between the UPA and ADA groups, while herpes zoster, lymphopenia, hepatic disorder, and CPK elevation were reported at higher rates with UPA. Consistent with earlier time points, greater proportions of patients randomized to UPA achieved low disease activity and remission at 3 years based on CDAI, as well as DAS28(CRP) ≤3.2 or <2.6, compared with patients randomized to ADA (Table 1).

Conclusion:

The safety profile of UPA was consistent with the results reported previously and with the integrated Phase 3 safety analysis.1,2 Higher levels of clinical response continued to be observed with UPA vs ADA through 3 years of treatment.

References:

[1]Fleischmann R, et al. Ann Rheum Dis 2020;79:323.

[2]Cohen SB, et al. Ann Rheum Dis 2020; doi: 10.1136/annrheumdis-2020-218510.

Table 1.

Efficacy Endpoints at 3 Years (NRI)

Endpoints, % (95% CI)UPA 15 mg QDN=651*ADA 40 mg EOWN=327*CDAI ≤1039 (36, 43)29 (24, 34)CDAI ≤2.824 (21, 28)17 (12, 21)DAS28(CRP) ≤3.237 (33, 41)26 (21, 31)DAS28(CRP) <2.632 (29, 36)22 (17, 26)

ADA, adalimumab; CI, confidence interval; DAS28(CRP), Disease Activity Score for 28-joints C-Reactive Protein; CDAI, clinical disease activity index; EOW, every other week; NRI, non-responder imputation; QD, once daily; UPA, upadacitinib.

*Patients who were rescued prior to/at Week 26 were considered non-responders. 252/651 and 159/327 patients were rescued of those randomized to UPA and ADA, respectively.

Acknowledgements:

AbbVie and the authors thank the patients, trial sites, and investigators who participated in this clinical trial. AbbVie, Inc was the trial sponsor, contributed to trial design, data collection, analysis & interpretation, and to writing, reviewing, and approval of final version. No honoraria or payments were made for authorship. The authors thank Dr. Tim Shaw of AbbVie Inc. for his support with the interpretation of the data. Medical writing support was provided by Ramona Vladea, PhD, of AbbVie, Inc.

Disclosure of Interests:

Roy Fleischmann Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, GSK, Janssen, Novartis, Pfizer Inc, Sanofi-Aventis, and UCB, Grant/research support from: AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Genentech, Janssen, Novartis, Pfizer Inc, Regeneron, Roche, Sanofi-Aventis and UCB, Eduardo Mysler Consultant of: AbbVie, AstraZeneca, Lilly, Pfizer, Roche, BMS, Sandoz, GSK, Janssen, Grant/research support from: AbbVie, AstraZeneca, Lilly, Pfizer, Roche, BMS, Sandoz, GSK, Janssen, Louis Bessette Consultant of: Amgen, BMS, Janssen, Roche, UCB, AbbVie, Pfizer, Merck, Celgene, Sanofi, Eli Lilly, Novartis, Gilead, Grant/research support from: Amgen, BMS, Janssen, Roche, UCB, AbbVie, Pfizer, Merck, Celgene, Sanofi, Eli Lilly, Novartis, Gilead, Charles Peterfy Shareholder of: Spire Sciences, Inc, Speakers bureau: Amgen, Bristol-Myers Squibb, Consultant of: Aclaris, Centrexion, Daiichi Sankyo, EMD, Serono, Five Prime, Flexion Therapeutics, Genentech, Gilead, GlaxoSmithKline, Istresso, Eli Lilly, Myriad Genetics, Novartis, Roche, SetPoint, Sorrento, UCB, Employee of: Spire Sciences, Inc, Patrick Durez Speakers bureau: BMS, Sanofi, Eli Lilly, Celltrion, Yoshiya Tanaka Speakers bureau: Daiichi-Sankyo, Astellas, Chugai, Eli Lilly, Pfizer, AbbVie, YL Biologics, Bristol-Myers, Takeda, Mitsubishi-Tanabe, Novartis, Eisai, Janssen, Teijin, Consultant of: Daiichi-Sankyo, Astellas, Chugai, Eli Lilly, Pfizer, AbbVie, YL Biologics, Bristol-Myers, Takeda, Mitsubishi-Tanabe, Novartis, Eisai, Janssen, Teijin, Grant/research support from: Asahi-kasei, Mitsubishi-Tanabe, Chugai, Takeda, Sanofi, Bristol-Myers, UCB, Daiichi-Sankyo, Eisai, Ono, Jerzy Swierkot Speakers bureau: AbbVie, Sandoz, Pfizer, Roche, BMS, UCB, MSD, Accord, Janssen, Consultant of: AbbVie, Sandoz, Pfizer, Roche, BMS, UCB, MSD, Accord, Janssen, Grant/research support from: AbbVie, Sandoz, Pfizer, Roche, BMS, UCB, MSD, Accord, Janssen, Nasser Khan Shareholder of: AbbVie, Employee of: AbbVie, Xianwei Bu Shareholder of: AbbVie, Employee of: AbbVie, Yihan Li Shareholder of: AbbVie, Employee of: AbbVie, In-Ho Song Shareholder of: AbbVie, Employee of: AbbVie.

AB0132 THE STUDY OF SUBCLINICAL SYNOVITIS DETECTED BY ULTRASONOGRAPHY AND MRI IN RA PATIENTS AFTER REACHING CLINICAL REMISSION ON PATIENT’S SUBJECTIVE SYMPTOMS

Background:

The goal of treatment in rheumatoid arthritis (RA) is to achieve remission. There is the patient with residual symptoms in the Japanese RA patient who achieved clinical remission. There are not many studies to examine the relation between everyday life, social activity and evaluation of disease activities using high-sensitivity image examinations (musculoskeletal ultrasound (MSKUS) and MRI).

Objectives:

To examine the relationship between subjective residual symptoms and imaging examinations in RA patients who have achieved clinical remission.

Methods:

30 RA patients who achieved SDAI remission during RA treatment. Age, sex, disease duration, physical findings, serological markers, disease activity, HAQ, EQ-5D-5L, FACIT-F, Patient Reported Outcomes (PROs), EGA and medications were evaluated. 44 joints were assessed by MSKUS with gray scale (GS) and power doppler (PD) and contrast-enhanced bilateral joint MRI scoring with OMERACT-RAMRIS scoring.

Results:

1. The mean SDAI of the 30 RA patients was 1.3. 2.In the analysis of the presence or absence of subjective residual symptoms that led to remission of SDAI (Table 1).

Table 1.Subjective residual symptoms/presence (N=17)Subjective residual symptoms/absence (N=13)Univariate analysisp valueMultivariate logistic analysisp valueTJC0.0±0.00.3±0.50.0173HAQ0.4±0.40.05±0.10.00950.00181EQ5D-5L0.8±0.10.9±0.00.0001FACIT-F14.5±9.84.6±4.30.0233Morning stiffness (min)256.5±564.80.0±0.00.0210Pain (VAS) (mm)9.2±9.50.9±1.50.00440.0455PGA (mm)7.7±9.00.5±1.10.0013

(1). In the univariate analysis, the number of tender joints, HAQ, EQ-5D-5L, FACIT-F, morning stiffness, and pain VAS were extracted with significant differences.

(2). In multivariate logistic analysis, HAQ and pain VAS were extracted as independent factors with significant differences. 3.In univariate analysis of the association between HAQ and pain VAS extracted in multivariate logistic analysis and imaging examinations (MSKUS/MRI), MRI-synovitis was extracted with a significant difference in HAQ.

Conclusion:

1. It was suggested that Pain VAS and HAQ due to RA could be identified in patients reaching SDAI remission. 2. In patients reaching SDAI remission, Pain VAS ≤10 or HAQ ≤0.5 suggested that subjective residual symptoms may be eliminated. 3. HAQ ≤ 0.5 suggests that synovitis is less likely to be detected on MRI. 4. In patients who have reached SDAI remission, little residual inflammation was observed on US, suggesting that induction of remission is important not only to prevent joint destruction, but also to improve and maintain long-term QoL.

Disclosure of Interests:

MASAO NAWATA Grant/research support from: I have received research funding from Eli Lilly Japan K.K., Kazuki Someya: None declared, Takafumi Aritomi: None declared, Masashi funada: None declared, Katsumi Nakamura: None declared, SAITO KAZUYOSHI Grant/research support from: I have received research funding from Eli Lilly Japan K.K., Yoshiya Tanaka Speakers bureau: I have received speaking fees from Abbvie, Daiichi-Sankyo, Chugai, Takeda, Mitsubishi-Tanabe, Bristol-Myers, Astellas, Eisai, Janssen, Pfizer, Asahi-kasei, Eli Lilly, GlaxoSmithKline, UCB, Teijin, MSD, and Santen, Consultant of: I have received consulting fees from Abbvie, Daiichi-Sankyo, Chugai, Takeda, Mitsubishi-Tanabe, Bristol-Myers, Astellas, Eisai, Janssen, Pfizer, Asahi-kasei, Eli Lilly, GlaxoSmithKline, UCB, Teijin, MSD, and Santen, Grant/research support from: I have received research grants from Mitsubishi-Tanabe, Takeda, Chugai, Astellas, Eisai, Taisho-Toyama, Kyowa-Kirin, Abbvie, and Bristol-Myers

POS0028 DEFINING THE PREVALENCE OF UNMET NEED IN SLE: DATA FROM A LARGE MULTINATIONAL LONGITUDINAL SLE COHORT

Background:

The recent prospectively validated definition of the lupus low disease activity state (LLDAS) allows characterisation of patients not achieving a treatment goal, providing impetus for an analysis of unmet needs in SLE using formal definitions. Other recently described definitions of high disease burden include disease activity over time, high disease activity status (HDAS) episodes, and the combination of high disease activity, serological activity and glucocorticoid (GC) use (HDAS+SA+GC).

Objectives:

To determine the prevalence of formal categories of unmet need, and the association of these with adverse outcomes, in SLE.

Methods:

Data from a 13-country longitudinal SLE cohort (ACR/SLICC criteria) were collected between 2013 and 19 using standard templates. Unmet need was defined as (i) patients never attaining LLDAS defined as in Golder et al., 2019 [1], (ii) having persistently active disease (time adjusted mean SLEDAI-2K (AMS) > 4), (iii) ever exhibiting high disease activity status (HDAS; SLEDAI-2K ≥10[2]), or (iv) ever exhibiting all of SLEDAI≥10, serological activity, and glucocorticoid use (HDAS+SA+GC)[3]. Health-related quality of life (HRQoL) was assessed using SF36 (v2) surveys and damage accrual using SLE Damage Index (SDI).

Results:

3,384 SLE patients were followed for 30,313 visits over median [IQR] 2.4 [0.4, 4.3] years. 53% of all visits were not in LLDAS; 813 patients (24%) never achieved LLDAS during observation. Median AMS was 3.0 [1.4, 4.9] and 34% of patients had AMS > 4 throughout the study. 25% of patients had at least one episode of HDAS, representing 8% of visits. 702 patients (21%) had at least one episode of HDAS+SA+GC, representing 8% of visits. Each of never-LLDAS, AMS>4, ever-HDAS, and ever-HDAS+SA+GC were associated with significantly greater number of physician visits, higher mean glucocorticoid dose, lower HRQoL and higher mortality. 31%, 58% and 83% of never-LLDAS, AMS>4, and ever-HDAS patients respectively were also HDAS+SA+GC on at least one occasion.

Conclusion:

Data from a multinational longitudinal SLE cohort indicate that unmet need, defined by LLDAS-never, AMS>4, HDAS, or HDAS+SA+GC, is prevalent in SLE, and that these definitions are associated with poor outcomes.

References:

[1]Golder, V., et al., Lupus low disease activity state as a treatment endpoint for systemic lupus erythematosus: a prospective validation study. The Lancet Rheumatology, 2019. 1(2): p. e95-e102.

[2]Koelmeyer, R., et al., High disease activity status suggests more severe disease and damage accrual in systemic lupus erythematosus. Lupus Sci Med, 2020. 7(1).

[3]van Vollenhoven, R.F., et al., Belimumab in the treatment of systemic lupus erythematosus: high disease activity predictors of response. Annals of the Rheumatic Diseases, 2012. 71(8): p. 1343-1349.

Acknowledgements:

The APLC acknowledges all the Data Collectors and Patients for their valuable contributions to research.

Disclosure of Interests:

Rangi Kandane-Rathnayake: None declared, Worawit Louthrenoo: None declared, Alberta Hoi Consultant of: Abbvie and GSK, Grant/research support from: AstraZeneca, GSK, BMS, Janssen, and Merck Serono, Vera Golder: None declared, Yi-Hsing Chen Speakers bureau: Pfizer, Novartis, Abbvie, Johnson & Johnson, BMS, Roche, Lilly, AstraZeneca, Sanofi, MSD, Guigai, Astellas, Inova Diagnostics, UCB, Agnitio Science Technology, United Biopharma, Thermo Fisher, Consultant of: Pfizer, Novartis, Abbvie, Johnson & Johnson, BMS, Roche, Lilly, AstraZeneca, Sanofi, MSD, Guigai, Astellas, Inova Diagnostics, UCB, Agnitio Science Technology, United Biopharma, Thermo Fisher, Gilead, Grant/research support from: Pfizer, Norvatis, BMS, Abbevie, Johnson & Johnson, Roche, Sanofi, Guigai, Roche, Boehringer Ingelheim, UCB, MSD, Astra-Zeneca, Astellas, Gilead, Shue Fen Luo: None declared, Yeong-Jian Jan Wu Speakers bureau: Pfizer, Lilly, Novartis, Abbvie, Aisha Lateef: None declared, Jiacai Cho: None declared, Laniyati Hamijoyo Speakers bureau: Pfizer, Novartis, Abbot, Chak Sing Lau Shareholder of: Pfizer, Sanofi, and Janssen, Sandra Navarra Speakers bureau: Pfizer, Johnson & Johnson, Novartis, Astellas, Grant/research support from: Astellas, Johnson & Johnson, Leonid Zamora: None declared, Zhanguo Li Speakers bureau: Eli, Lilly, Novartis, GSK, AbbVie, Paid instructor for: Pfizer, Roche, Johnson., Consultant of: Lilly, Pfizer, Grant/research support from: Pfizer, Yuan An: None declared, Sargunan Sockalingam Speakers bureau: Pfizer, Roche, Novartis, Grant/research support from: Roche and Novartis, Yasuhiro Katsumata Speakers bureau: Chugai Pharmaceutical Co., Ltd., Glaxo-Smithkline K.K., and Sanofi K.K., masayoshi harigai Speakers bureau: AbbVie Japan GK, Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc.,Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Kissei Pharmaceutical Co., Ltd., Pfizer Japan Inc., Takeda Pharmaceutical Co., Ltd., and Teijin Pharma Ltd., Consultant of: AbbVie, Boehringer-ingelheim, Bristol Myers Squibb Co., Kissei Pharmaceutical Co.,Ltd. and Teijin Pharma., Grant/research support from: AbbVie Japan GK, Asahi Kasei Corp., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Daiichi-Sankyo, Inc.,Eisai Co., Ltd., Kissei Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Nippon Kayaku Co., Ltd., Sekiui Medical, Shionogi & Co., Ltd., Taisho Pharmaceutical Co., Ltd., Takeda Pharmaceutical Co., Ltd., and Teijin Pharma Ltd., Yanjie Hao: None declared, Zhuoli Zhang Speakers bureau: Norvatis, GSK, Pfizer, Jun Kikuchi: None declared, Tsutomu Takeuchi Speakers bureau: AbbVie AYUMI Pharmaceutical Corp. Bristol-Myers Squibb Chugai Pharmaceutical Co, Ltd. Daiichi Sankyo Co., Ltd. Eisai Co., Ltd. Eli Lilly Japan, Gilead Sciences, Inc. Mitsubishi-Tanabe Pharma Corp. Pfizer Japan Inc. Sanofi K.K., Consultant of: Astellas Pharma, Inc. Chugai Pharmaceutical Co, Ltd. Eli Lilly Japan, Mitsubishi-Tanabe Pharma Corp., Grant/research support from: AbbVie, Asahikasei Pharma Corp. Chugai Pharmaceutical Co, Ltd. Mitsubishi-Tanabe Pharma Corp. Sanofi K.K., BMDB Basnayake: None declared, Fiona Goldblatt: None declared, Madelynn Chan Speakers bureau: AbbVie, Novartis, Consultant of: Pfizer, Eli-Lilly, Kristine Ng Speakers bureau: Abbvie, Novartis, Janssen, Sang-Cheol Bae: None declared, Shereen Oon: None declared, Sean O’Neill Consultant of: GSK, Kathryn Gibson Speakers bureau: UCB, Consultant of: Novartis, Janssen, Grant/research support from: Novartis, Sunil Kumar: None declared, Nicola Tugnet: None declared, Yoshiya Tanaka Speakers bureau: Daiichi-Sankyo, Eli Lilly, Novartis, YL Biologics, Bristol-Myers, Eisai, Chugai, Abbvie, Astellas, Pfizer, Sanofi, Asahi-kasei, GSK, Mitsubishi-Tanabe, Gilead, Janssen, Grant/research support from: Abbvie, Mitsubishi-Tanabe, Chugai, Asahi-Kasei, Eisai, Takeda, Daiichi-Sankyo, Mandana Nikpour Speakers bureau: Actelion, GSK, Janssen, Pfizer, UCB, Paid instructor for: UCB, Consultant of: Actelion, Boehringer Ingelheim, Certa Therapeutics, Eli Lilly, GSK, Janssen, Pfizer, UCB, Grant/research support from: Actelion, Astra Zeneca, BMS, GSK, Janssen, UCB, Eric F. Morand Speakers bureau: AstraZeneca, Paid instructor for: Eli Lilly, Consultant of: AstraZeneca, Amgen, Biogen, BristolMyersSquibb, Eli Lilly, EMD Serono, Genentech, Janssen, Grant/research support from: AstraZeneca, BristolMyersSquibb, Eli Lilly, EMD Serono, Janssen.

POS0653 IMPACT OF UPADACITINIB OR ADALIMUMAB AS INITIAL THERAPY ON THE ACHIEVEMENT OF 48-WEEK TREATMENT GOALS IN PATIENTS WITH RHEUMATOID ARTHRITIS AND INADEQUATE RESPONSE TO METHOTREXATE: POST HOC ANALYSIS OF A PHASE 3 STUDY

Background:

In the randomized, double-blinded, Phase 3 SELECT-COMPARE study, upadacitinib (UPA) + MTX demonstrated greater clinical and functional responses vs adalimumab (ADA) + MTX in patients (pts) with RA and inadequate response to MTX.1,2 Pts with insufficient response to initial therapy were switched from UPA to ADA (and vice versa) according to treat-to-target (T2T) principles.

Objectives:

We analyzed 1-year treatment outcomes in SELECT-COMPARE according to initial randomization group, regardless of whether pts subsequently switched therapy.

Methods:

Pts initially randomized to UPA 15 mg once daily (QD) or ADA 40 mg every other week (EOW; both + MTX) for up to 48 weeks in SELECT-COMPARE were included in the analysis. As per the protocol-directed rescue strategy, pts experiencing <20% improvement in tender or swollen joint counts at Week 14, 18, or 22, or Clinical Disease Activity Index (CDAI) >10 at Week 26, were switched from UPA to ADA or ADA to UPA in a blinded fashion. Efficacy outcomes included CDAI remission (≤2.8) and low disease activity (LDA; ≤10), DAS of 28 joints using CRP (DAS28[CRP]) <2.6 and ≤3.2, and a composite of “deep response” (CDAI remission, HAQ-Disability Index <0.5, and pain score <20). Data are presented and attributed to initial randomized group (UPA or ADA) regardless of any subsequent switch in therapy. Time-averaged response rates were calculated as area under the curve of response rate standardized by 48 weeks. The proportions of pts who maintained Week 26 responses through 6 months of follow-up are also reported.

Results:

This analysis included 651 pts initially randomized to UPA (of whom 245 switched to ADA) and 327 pts initially randomized to ADA (of whom 157 switched to UPA). Baseline characteristics including age, sex, and BMI were generally well balanced between randomized groups. At Week 48, similar proportions of pts initially randomized to UPA or ADA therapy achieved CDAI remission/LDA (27.6%/61.9% vs 24.8%/59.0%) and DAS28(CRP) <2.6/≤3.2 (45.0%/60.2% vs 43.7%/59.0%) (Figure 1). However, a small but significantly greater proportion of pts achieved a deep response with initial UPA vs initial ADA therapy (17.8% vs 12.8%; p<0.05). In addition, time-averaged response rates over 48 weeks were higher for initial UPA vs initial ADA therapy across efficacy outcomes. Similar trends were observed for other outcomes. Additionally, similar proportions of pts maintained Week 26 responses with initial UPA vs initial ADA therapy based on CDAI remission/LDA and DAS28(CRP) <2.6/≤3.2 during 6-month follow-up (Table 1).

Conclusion:

Using a stringent T2T approach to RA management, rates of LDA or remission at 1 year were similar, regardless of whether pts were initially randomized to UPA or ADA. However, initial UPA therapy led to more frequent deep responses and higher time-averaged response rates vs initial ADA therapy.

References:

[1]Fleischmann R, et al. Arthritis Rheumatol 2019;71:1788–800.

[2]Fleischmann R, et al. Ann Rheum Dis 2019;78:1454–62.

Table 1.

Proportion of patients maintaining Week 26 CDAI and DAS28(CRP) responses during 6-month follow-up by initial therapy with UPA or ADA in SELECT-COMPAREa-c

UPA 15 mg QDADA 40 mg EOWCDAI LDA (≤10)43.936.3CDAI Remission (≤2.8)35.022.7DAS28(CRP) ≤3.239.135.3DAS28(CRP) <2.630.530.1

aAs observed.

bBlinded rescue from UPA to ADA or ADA to UPA was permitted at Week 14, 18, and 22 for patients with <20% improvement in TJC or SJC and at Week 26 for patients with a CDAI <10. Data are presented and attributed to original randomized group (UPA or ADA) regardless of any subsequent switch in therapy.

cMaintaining response defined as never losing response at any visit during ~6 months (22–26 weeks) follow up after first achieving response before or at Week 26.

ADA, adalimumab; CDAI, Clinical Disease Activity Index; DAS28(CRP), DAS of 28 joints using CRP; EOW, every other week; QD, once daily; SJC, swollen joint count; TJC, tender joint count; UPA, upadacitinib.

Acknowledgements:

AbbVie funded this study and participated in the study design, research, analysis, data collection, interpretation of data, reviewing, and approval of the publication. All authors had access to relevant data and participated in the drafting, review, and approval of this publication. No honoraria or payments were made for authorship. Medical writing assistance was provided by Frances Smith, PhD, of 2 the Nth, which was funded by AbbVie.

Disclosure of Interests:

Eduardo Mysler Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Janssen, Pfizer, Roche, and Sandoz., Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Janssen, Pfizer, Roche, and Sandoz., Yoshiya Tanaka Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Eli Lilly, Chugai, Daiichi-Sankyo, Eisai, Gilead, GlaxoSmithKline, Janssen, Mitsubishi-Tanabe, Novartis, Pfizer, Sanofi, and YL Biologics, Consultant of: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Eli Lilly, Chugai, Daiichi-Sankyo, Eisai, Gilead, GlaxoSmithKline, Janssen, Mitsubishi-Tanabe, Novartis, Pfizer, Sanofi, and YL Biologics, Grant/research support from: AbbVie, Chugai, Daiichi-Sankyo, Eisai, Mitsubishi-Tanabe, Takeda, and UCB., Arthur Kavanaugh Consultant of: AbbVie, Amgen, AstraZeneca, Bristol-Myers Squibb, Celgene, Janssen, Pfizer, Roche, and UCB., Grant/research support from: AbbVie, Amgen, AstraZeneca, Bristol-Myers Squibb, Celgene, Janssen, Pfizer, Roche, and UCB., Daniel Aletaha Consultant of: AbbVie, Amgen, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, Roche, Sanofi, and UCB., Grant/research support from: AbbVie, Amgen, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, Roche, Sanofi, and UCB., Peter C. Taylor Speakers bureau: AbbVie, Biogen, Bristol-Myers Squibb, Celgene, Celltrion, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Janssen, Fresenius, Nordic Pharma, Pfizer, Roche, Sanofi, and UCB., Consultant of: AbbVie, Biogen, Bristol-Myers Squibb, Celgene, Celltrion, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Janssen, Fresenius, Nordic Pharma, Pfizer, Roche, Sanofi, and UCB., Grant/research support from: AbbVie, Biogen, Bristol-Myers Squibb, Celgene, Celltrion, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Janssen, Fresenius, Nordic Pharma, Pfizer, Roche, Sanofi, and UCB., In-Ho Song Shareholder of: AbbVie, Employee of: AbbVie, Tim Shaw Shareholder of: AbbVie, Employee of: AbbVie, Yanna Song Shareholder of: AbbVie, Employee of: AbbVie, Ryan DeMasi Shareholder of: AbbVie, Employee of: AbbVie, Mira Ali Shareholder of: AbbVie, Employee of: AbbVie, Roy Fleischmann Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Gilead, GlaxoSmithKline, Janssen, Novartis, Pfizer, Sanofi-Aventis, and UCB., Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Gilead, GlaxoSmithKline, Janssen, Novartis, Pfizer, Sanofi-Aventis, and UCB.

Cell fate analysis of zone 3 hepatocytes in liver injury and tumorigenesis

Background & Aims

Liver lobules are typically subdivided into 3 metabolic zones: zones 1, 2, and 3. However, the contribution of zonal differences in hepatocytes to liver regeneration, as well as to carcinogenic susceptibility, remains unclear.

Methods

We developed a new method for sustained genetic labelling of zone 3 hepatocytes and performed fate tracing to monitor these cells in multiple mouse liver tumour models.

Results

We first examined changes in the zonal distribution of the Wnt target gene Axin2 over time using Axin2-Cre^ERT2;Rosa26-Lox-Stop-Lox-tdTomato mice (Axin2;tdTomato). We found that following tamoxifen administration at 3 weeks of age, approximately one-third of total hepatocytes that correspond to zone 3 were labelled in Axin2;tdTomato mice; the tdTomato⁺ cell distribution closely matched that of the zone 3 marker CYP2E1. Cell fate analysis revealed that zone 3 hepatocytes maintained their own lineage but rarely proliferated beyond their liver zonation during homoeostasis; this indicated that our protocol enabled persistent genetic labelling of zone 3 hepatocytes. Using this system, we found that zone 3 hepatocytes generally had high neoplastic potential, which was promoted by constitutive activation of Wnt/β-catenin signalling in the pericentral area. However, the frequency of zone 3 hepatocyte-derived tumours varied depending on the regeneration pattern of the liver parenchyma in response to liver injury. Notably, Axin2-expressing hepatocytes undergoing chronic liver injury significantly contributed to liver regeneration and possessed high neoplastic potential. Additionally, we revealed that the metabolic phenotypes of liver tumours were acquired during tumorigenesis, irrespective of their spatial origin.

Conclusions

Hepatocytes receiving Wnt/β-catenin signalling from their microenvironment have high neoplastic potential, and Wnt/β-catenin signalling is a potential drug target for the prevention of hepatocellular carcinoma.

Lay summary

Lineage tracing revealed that zone 3 hepatocytes residing in the pericentral niche have high neoplastic potential. Under chronic liver injury, hepatocytes receiving Wnt/β-catenin signalling broadly exist across all hepatic zones and significantly contribute to liver tumorigenesis as well as liver regeneration. Wnt/β-catenin signalling is a potential drug target for the prevention of hepatocellular carcinoma.

•

We developed a new method for sustained genetic labelling of Zone 3 hepatocytes.

•

Lineage tracing revealed that Zone 3 hepatocytes generally have high neoplastic potential.

•

The frequency of Zone 3 hepatocyte-derived tumours varied depending on the regeneration pattern of liver parenchyma.

•

Under chronic liver injury, hepatocytes receiving Wnt/β-catenin signalling significantly contributed to tumorigenesis.

•

Wnt/β-catenin signalling is a potential drug target for the prevention of HCC.

POS0220 INTEGRATED SAFETY PROFILE OF UPADACITINIB WITH UP TO 4.5 YEARS OF EXPOSURE IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

The safety and efficacy of the oral Janus kinase inhibitor upadacitinib (UPA) has been evaluated across a spectrum of patients with rheumatoid arthritis (RA) in the phase 3 SELECT clinical program.1–6

Objectives:

To describe the long-term integrated safety profile of UPA relative to active comparators (cutoff date: June 30, 2020) in patients with RA treated in the SELECT clinical program.

Methods:

This analysis included updated data from 6 randomized controlled UPA RA trials.1–6 Treatment-emergent adverse events (TEAEs; onset after first dose and ≤30 days after last dose of study drug or ≤70 days for adalimumab [ADA]) including AEs of special interest were summarized as follows: pooled UPA 15 mg once daily (QD; UPA15, 6 trials); pooled UPA 30 mg QD (UPA30, 4 trials); methotrexate (MTX, 1 trial), and ADA (1 trial). TEAEs were reported as exposure-adjusted adverse event rates (EAERs; events/100 patient-years [E/100 PY]), which included both incident and recurrent events.

Results:

4413 patients (UPA15, n=3209; UPA30, n=1204) received ≥1 dose of UPA, providing 10,115.4 PY of exposure. EAERs for AEs, serious AEs (SAEs), and AEs leading to discontinuation were similar for UPA15, MTX, and ADA; rates for UPA30 were numerically higher than UPA15 (Table 1). The most common AEs were upper respiratory tract infection, nasopharyngitis, and urinary tract infection for both UPA doses, and for UPA30 only, increased creatine phosphokinase (CPK). Pneumonia was the most common SAE for both UPA15 and UPA30. Serious infection rates were similar for UPA15, MTX, and ADA but higher for UPA30 (Figure 1). Rates of herpes zoster (HZ) were higher for both UPA groups (dose-dependent) vs MTX and ADA. Most HZ cases with UPA were non-serious (94%) and involved a single dermatome (74%). CPK elevations, which were mostly asymptomatic, were more common for both UPA groups (dose-dependent) vs MTX and ADA. EAERs of adjudicated gastrointestinal perforations were <0.1 and 0.2 E/100 PY for UPA15 and UPA30, respectively. Rates of non-melanoma skin cancer (due in part to more recurrent events with UPA30), anemia, and neutropenia were higher with UPA30 vs other treatment groups. Events of anemia and neutropenia were generally mild/moderate and treatment discontinuation due to these events was uncommon (<0.4%). Rates of other AEs of special interest, including major adverse cardiovascular and venous thromboembolic events, were broadly similar across treatment groups. The rate of deaths in UPA-treated patients with RA was not higher than expected for the general population (standardized mortality ratio [95% confidence interval (CI)]: UPA15, 0.43 [0.29, 0.63]; UPA30, 0.68 [0.40, 1.08]).

Table 1.

TEAEs in patients treated with UPA, MTX, and ADA

UPA 15 mg QDUPA 30 mg QDADA 40 mg EOWMTXn32091204579314ExposureTotal, PY7023.83091.61051.8637.4Mean (SD), weeks114 (64)134 (66)95 (70)106 (67)Median (range), weeks136 (0, 232)160 (0, 231)118 (2, 231)144 (1, 221)E/100 PY (95% CI)Any AE230.7 (227.2, 234.3)283.6 (277.7, 289.6)216.6 (207.8, 225.7)227.8 (216.2, 239.8)Any SAE13.0 (12.2, 13.9)18.8 (17.3, 20.4)13.3 (11.2, 15.7)10.4 (8.0, 13.2)Any AE leading to discontinuation of study drug5.6 (5.0, 6.1)8.5 (7.5, 9.6)6.8 (5.3, 8.5)6.3 (4.5, 8.5)Deathsa0.4 (0.3, 0.6)0.6 (0.3, 0.9)0.9 (0.4, 1.6)0.5 (0.1, 1.4)

aBoth treatment and non-treatment-emergent deaths

EOW, every other week

Conclusion:

The updated safety profile of UPA with up to 4.5 years of exposure in patients with RA was comparable to previous analyses,7 with no new safety signals reported. With the exception of HZ and elevated CPK, the safety profile of UPA15, the approved dose for RA, was similar to that observed for ADA.

References:

[1]Burmester GR, et al. Lancet 2018;391:2503–12;

[2]Smolen JS, et al. Lancet 2019;393:2303–11;

[3]Fleischmann R, et al. Arthritis Rheumatol 2019;71:1788–800;

[4]Genovese MC, et al. Lancet 2018;391:2513–24;

[5]van Vollenhoven R, et al. Arthritis Rheumatol 2020;72:1607–20;

[6]Rubbert-Roth A, et al. N Engl J Med 2020;383:1511–21;

[7]Cohen SB, et al. Ann Rheum Dis 2020;79(Suppl 1):319–20.

Acknowledgements:

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data; and participated in the writing, review, and approval of the abstract. No honoraria or payments were made for authorship. Medical writing support was provided by Hilary Wong, PhD, of 2 the Nth (Cheshire, UK), and was funded by AbbVie.

Disclosure of Interests:

Stanley B. Cohen Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Gilead, Pfizer, Roche, and Sandoz, Grant/research support from: AbbVie, Amgen, Boehringer Ingelheim, Gilead, Pfizer, Roche, and Sandoz, Ronald van Vollenhoven Consultant of: AbbVie, AstraZeneca, Biotest, Bristol-Myers Squibb, Celgene, Eli Lilly, GSK, Janssen, Medac, MSD, Novartis, Pfizer, Roche, and UCB, Grant/research support from: AbbVie, Arthrogen, Bristol-Myers Squibb, Eli Lilly, GSK, Pfizer, and UCB, Jeffrey R. Curtis Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Crescendo, Janssen, Pfizer, Sanofi/Regeneron, and UCB, Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Crescendo, Janssen, Pfizer, Sanofi/Regeneron, and UCB, Leonard Calabrese Speakers bureau: AbbVie, Crescendo, Genentech, Horizon, Janssen, Novartis, and Sanofi, Consultant of: AbbVie, Bristol-Myers Squibb, Crescendo, Genentech, Gilead, GSK, Horizon, Janssen, Novartis, and Sanofi, Cristiano Zerbini Speakers bureau: MSD, Pfizer, and Sanofi, Consultant of: MSD, Pfizer, and Sanofi, Grant/research support from: Amgen, Eli Lilly, GSK, MSD, Novartis, Pfizer, Roche, Sanofi, and Servier, Yoshiya Tanaka Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi Sankyo, Eisai, Eli Lilly, Gilead, GSK, Janssen, Mitsubishi Tanabe, Novartis, Pfizer, Sanofi, and YL Biologics, Grant/research support from: Asahi Kasei, Chugai, Daiichi Sankyo, Eisai, Mitsubishi Tanabe, Takeda, and UCB, Louis Bessette Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Pfizer, Roche, Sanofi, and UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Pfizer, Roche, Sanofi, and UCB, Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Pfizer, Roche, Sanofi, and UCB, Christophe Richez Speakers bureau: AbbVie, Amgen, AstraZeneca, Biogen, Bristol-Myers Squibb, Eli Lilly, GSK, MSD, and Pfizer, Consultant of: AbbVie, Amgen, AstraZeneca, Biogen, Bristol-Myers Squibb, Eli Lilly, GSK, MSD, and Pfizer, Ivan Lagunes-Galindo Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Jianzhong Liu Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Heidi Camp Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Yanna Song Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Samuel Anyanwu Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Gerd Rüdiger Burmester Speakers bureau: AbbVie, Eli Lilly, Gilead, Janssen, MSD, Pfizer, Roche, and UCB, Consultant of: AbbVie, Eli Lilly, Gilead, Janssen, MSD, Pfizer, Roche, and UCB

Post-treatment cell-free DNA as a predictive biomarker in molecular-targeted therapy of hepatocellular carcinoma

BACKGROUND

Liquid biopsies, particularly those involving circulating tumor DNA (ctDNA), are rapidly emerging as a non-invasive alternative to tumor biopsies. However, clinical applications of ctDNA analysis in hepatocellular carcinoma (HCC) have not been fully elucidated.

METHODS

We measured the amount of plasma-derived cell-free DNA (cfDNA) in HCC patients before (n = 100) and a few days after treatment (n = 87), including radiofrequency ablation, transarterial chemoembolization, and molecular-targeted agents (MTAs), and prospectively analyzed their associations with clinical parameters and prognosis. TERT promoter mutations in cfDNA were analyzed using droplet digital PCR. Furthermore, we performed a comprehensive mutational analysis of post-treatment cfDNA via targeted ultra-deep sequencing (22,000× coverage) in a panel of 275 cancer-related genes in selected patients.

RESULTS

Plasma cfDNA levels increased significantly according to HCC clinical stage, and a high cfDNA level was independently associated with a poor prognosis. TERT promoter mutations were detected in 45% of all cases but were not associated with any clinical characteristics. cfDNA levels increased significantly a few days after treatment, and a greater increase in post-treatment cfDNA levels was associated with a greater therapeutic response to MTAs. The detection rate of TERT mutations increased to 57% using post-treatment cfDNA, suggesting that the ctDNA was enriched. Targeted ultra-deep sequencing using post-treatment cfDNA after administering lenvatinib successfully detected various gene mutations and obtained promising results in lenvatinib-responsive cases.

CONCLUSIONS

Post-treatment cfDNA analysis may facilitate the construction of biomarkers for predicting MTA treatment effects.

Osteoporosis case ascertainment strategies in European and Asian countries: a comparative review

While many clinical guidelines recommend screening for osteoporosis for early detection and treatment, there is great diversity in the case-finding strategies globally. We sought to compare case-finding strategies, focusing on the approaches used in European and Asian countries. This article provides an overview of the current case-finding strategies in the UK, Germany (including Austria and German-speaking regions of Switzerland), China, Japan, and Korea. We conducted a review of current treatment guidelines in each country and included expert opinions from key opinion leaders. Most countries define osteoporosis among patients with a radiographically identified fracture of the hip or the vertebrae. However, for other types of fractures, or in the absence of a fracture, varying combinations of risk-factor assessment and areal bone mineral density (aBMD) assessed by dual X-ray absorptiometry are used to define osteoporosis cases. A T-score ≤ - 2.5 is accepted to identify osteoporosis in the absence of a fracture; however, not all countries accept DXA alone as the sole criteria. Additionally, the critera for requiring clinical risk factors in addition to aBMD differ across countries. In most Asian countries, aBMD scanning is only provided beyond a particular age threshold. However, all guidelines recommend fracture risk assessment in younger ages if risk factors are present. Our review identified that strategies for case-finding differ regionally, particularly among patients without a fracture. More homogenized ways of identifying osteoporosis cases are needed, in both the Eastern and the Western countries, to improve osteoporosis case-finding before a fracture occurs.Case-finding in osteoporosis is essential to initiate treatment and minimize fracture risk. We identified differences in case-finding strategies between Eastern and Western countries. In the absence of a diagnosed fracture, varying combinations of risk factors and bone density measurements are used. Standardized case-finding strategies may help improve treatment rates.

Impaired preload reserve is an important haemodynamic characteristics that discriminates between physiological ageing and overt heart failure with preserved ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Background

 Ageing process per se is a major risk factor for heart failure (HF). In fact, the incidence of HF with preserved ejection fraction (HFpEF) dramatically increases with age. Although ageing plays a central role in the development of HFpEF, not all the elderly patients develop clinical HFpEF. Multiple abnormalities in the cardiovascular system have been proposed to contribute to the development of HFpEF. However, the pathophysiology that discriminates between physiological ageing and overt HFpEF is incompletely understood.

Purpose

 The purpose of this study was to assess the effects of ageing on the cardiac structures and haemodynamics. Moreover, we evaluated the determinant factor that discriminates between physiological ageing and overt HFpEF by non-invasive preload increasing manoeuvre using leg-positive pressure (LPP) stress echocardiography.

Methods

 A total of 91 subjects were prospectively recruited in this study: 22 patients with HFpEF and 69 healthy controls. Normal controls were further stratified into 3 age groups: young (n = 19, 20-40 years of age), middle-aged (N = 25, 40-65 years) and elderly (n = 25, &gt;65 years). All subjects underwent LPP stress with a continuous external pressure of 90 mmHg around both lower limbs using dedicated airbags (Fig.). 

Results

 The left ventricular mass index (LVMI; young, 68 ± 19 g/m²; middle-age, 70 ± 18 g/m²; elderly, 84 ± 21 g/m²) and also the relative wall thickness (RWT; young, 0.34 ± 0.09; middle-age, 0.41 ± 0.06; elderly 0.55 ± 0.10) increased with ageing, which was accelerated in HFpEF (LVMI: 111 ± 32 g/m², RWT; 0.63 ± 0.19, ANOVA P &lt; 0.001, respectively). Although baseline LV ejection fraction and cardiac output were quite comparable between groups, E/e’ ratio significantly increased with with ageing (ANOVA P &lt; 0.001, Fig.). During LPP stress, E/e’ ratio significantly increased in the middle-aged and elderly groups (from 8.8 ± 2.7 to 9.7 ± 3.3, and from 11.4 ± 2.4 to 13.0 ± 2.2, P &lt; 0.05, respectively), which was further deteriorated in HFpEF (from 16.8 ± 5.8 to 18.0 ± 7.6, P &lt; 0.05). On the other hand, stroke volume index (SVi) significantly increased in each healthy group during LPP stress (young; from 45 ± 10 to 50 ± 11 mL/m², middle-age; from 39 ± 7 to 44 ± 6 mL/m² and elderly; from 37 ± 7 to 43 ± 8 mL/m², all P &lt; 0.001), while SVi failed to increase in the HFpEF group (from 45 ± 13 to 45 ± 14 mL/m², P = 0.60). In a multivariate logistic regression analysis, LVMI (hazard ratio; HR 1.055, P &lt; 0.05), baseline E/e’ (HR 1.444; P &lt; 0.05), and ΔSVi (HR 0.755; P &lt; 0.05) during LPP stress were the independent parameters that characterised overt HFpEF.

Conclusions

 Striking parallels between structure-function alterations were observed in the physiological cardiovascular ageing process, which was further accelerated in patients with HFpEF. Not only structural remodeling and impaired diastolic function, but also impaired systolic reserve during preload stress is important haemodynamic feature that characterise the pathophysiology of HFpEF.

Abstract Figure.

Association between clinical risk factors and left ventricular function in patients with breast cancer following chemotherapy

Funding Acknowledgements

Type of funding sources: None.

Background

The sequential or concurrent use of two different types of agents such as anthracyclines and trastuzumab may increase myocardial injury and cancer therapeutics-related cardiac dysfunction (CTRCD), which is often the result of the combined detrimental effect of the two therapies for breast cancer patients. For risk stratification to detect the development of CTRCD, the current position paper from the European Society of Cardiology (ESC) lists several factors associated with risk of cardiotoxicity.

Purpose

Our purpose was to investigate the impact of baseline risk factors on left ventricular (LV) function in patients with preserved LV ejection fraction (LVEF) who have undergone chemotherapy for breast cancer.

Methods

We studied 86 breast cancer patients treated with anthracyclines, trastuzumab, or both. Mean age was 59 ± 13 years and LVEF was 67 ± 5%. In accordance with the current definition, CTRCD was defined as a decline in LVEF of &gt;10% to an absolute value of &lt;53% after chemotherapy. Based on the 2016 ESC position paper, clinical risk factors for CTRCD were defined as: (1) a cumulative total doxorubicin dose of ≥ 240mg/m², (2) age ≥ 65-year-old, (3) body mass index ≥ 30kg/m², (4) a previous history of radiation therapy to chest or mediastinum, (5) B-type natriuretic peptide ≥ 100pg/mL, (6) a previous history of cardiovascular disease, (7) atrial fibrillation, (8) hypertension, (9) diabetes mellitus, (10) current or ex-smoker.

Results

The relative decrease in LVEF after chemotherapy for patients with more than four risk factors was significantly greater than that for patients without (-9.3 ± 10.8% vs. -2.2 ± 10.2%; p = 0.02). However, this finding did not apply to patients with more than one, two or three risk factors. Patients with more than four risk factors also tended to show a higher prevalence of CTRCD than those without (14.3% vs. 2.8%, p = 0.12). Moreover, patients with more than four risk factors were more likely to have higher LV mass index (109.3 ± 29.0g/m² vs. 83.2 ± 21.0g/m², p &lt; 0.001), lower global longitudinal strain (18.4 ± 2.8% vs. 20.0 ± 2.6%, p = 0.06) and higher E/e’ (10.4 (8.9-13.0) vs. 9.0 (7.4-10.9), p = 0.06) compared to those without. 

Furthermore, receiver-operator characteristics curve analysis showed that an optimal cut off value of a cumulative total doxorubicin dose for developing LV dysfunction in patients with more than any of four risk factors was lower than that in those without (180 mg/m² vs. 280 mg/m²).

Conclusions

Association between clinical risk factors and LV dysfunction following chemotherapy became stronger with an increase in the number of risk factors in breast cancer patients, and was especially strong for patients treated with chemotherapy who had more than four risk factors. Our findings can thus be expected to have clinical implications for better management of patients with breast cancer referred for chemotherapy.

Abstract Figure.

Preload stress echocardiography by using dynamic postural alteration can identify high risk patients with heart failure with reduced ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Background

Haemodynamic assessment during stress testing is not commonly performed for patients with heart failure with reduced ejection fraction (HFrEF) due to its invasiveness, less feasibility, and safety concerns. Passive leg-lifting (PLL) manoeuvres have been introduced as a simple alternative for non-invasive preload stress testing; however, the haemodynamic load imposed on the cardiovascular system is unsatisfactory, which precludes the accurate assessment of the preload reserve for patients with HF.

Purpose

The purpose of this study was to assess the haemodynamic characteristics of patients with HFrEF in response to a preload stress during dynamic postural alterations by combining the semi-sitting position (SSP) and PLL. We also evaluated whether combined postural stress could be used for risk stratification for these patients.

Methods

For this study, 101 patients with HFrEF and 35 age- and sex-matched normal controls were prospectively recruited. At each postural position (i.e., baseline, SSP, and PLL), all standard echocardiographic and Doppler variables were obtained. Adverse cardiac events were prespecified as the combined endpoints of death from or hospitalisation for deteriorated HF, or sudden cardiac death. Clinical follow-up was conducted for a median of 7 months.

Results

During PLL stress, the stroke volume index (SVi) significantly increased in both controls (from 40 ± 6 to 43 ± 6 mL/m², P = 0.03) and HFrEF patients (from 31 ± 9 to 34 ± 10 mL/m², P = 0.03). Conversely, during SSP stress, the SVi significantly decreased for both controls (from 40 ± 6 to 37 ± 6 mL/m², P = 0.03) and HFrEF patients (31 ± 9 to 28 ± 8 mL/m², P = 0.03). During the follow-up period, 16 patients developed cardiac events. In patients without events, the Frank-Starling mechanism was well preserved (Fig. A). Namely, the SVi significantly increased from 31 ± 9 to 35 ± 10 mL/m² (P = 0.02) during PLL stress, while the SVi significantly decreased from 31 ± 8 to 28 ± 8 mL/m² (P = 0.02) during SSP stress. In contrast, for patients with cardiac events, the SVi did not change during postural alterations (n.s), which indicated that the failing heart operates on the flat portion of the Frank-Starling curve (Fig. A). When patients were divided into three equal sub-groups based on the total difference in the SVi during dynamic postural stress, patients with impaired preload reserve (third trimester, ΔSVi ≤ 3.0 mL/m²) showed significantly worse event-free survival than the other two sub-groups (Fig. B; P &lt; 0.001). In a Cox proportional-hazard analysis, baseline LVEF (hazard ratio 0.93; P = 0.04), and ΔSVi during postural stress (hazard ratio 0.76; P = 0.004) were predictors of future cardiac events.

Conclusions

The combined assessment of dynamic postural stress during PLL and SPP is a simple, time-saving, and easy-to-use clinical tool for the assessment of preload reserve for patients with HFrEF. Moreover, postural stress echocardiography proved to contribute to the risk stratification for these patients.

Abstract Figure.

Cardiac resynchronization therapy improves left atrial reservoir function through resynchronization of the left atrium in patients with heart failure

Funding Acknowledgements

Type of funding sources: None.

Background

The structural remodeling of the left atrium (LA) has been proposed as an important determinant of adverse outcomes in patients with heart failure (HF). However, little is known about the potential impact of LA mechanical dyssynchrony on its reservoir function and the prognosis of patients with HF. In addition, it has not been fully investigated whether cardiac resynchronization therapy (CRT) is also beneficial to LA function.

Purposes

The purposes of this study were to test whether left ventricular (LV) dyssynchrony may negatively affect LA synchronicity and reservoir function, and to assess whether residual LA dyssynchrony after CRT affects the prognosis in patients with HF with reduced ejection fraction (HFrEF).

Methods

This study included total of 90 subjects: 40 HFrEF with a wide-QRS complex (≧130 ms), 28 HFrEF with a narrow-QRS, and 22 age- and sex-matched normal controls. LA global longitudinal strain (LA-GLS) and LA dyssynchrony were quantified using speckle-tracking strain analysis. LA dyssynchrony was defined as the maximal difference of time-to-peak strain (LA time-diff). All wide-QRS HFrEF received CRT, and event-free survival was tracked for 24 months.

Results

At baseline, HFrEF patients showed significant LA remodeling coupled with the reduced LA reservoir function, as evidenced by larger LA volume index (LAVi: 46 ± 16 vs. 30 ± 14 mL/m², P &lt; 0.01) and smaller LA-GLS (13.0 ± 4.8 vs. 30.6 ± 10.7%, P &lt; 0.01). Of note was that, not only LV dyssynchrony (381 ± 178 vs. 177 ± 62 ms, P &lt; 0.01) but also LA dyssynchrony (298 ± 136 vs. 186 ± 78 ms, P &lt; 0.01) were significantly larger in patients with HFrEF compared to normal subjects and this applied even more to patients with a wide-QRS complex. All patients with a wide-QRS complex underwent CRT, and only responders exhibited the significant decrease in LA time-diff (from 338 ± 123 to 245 ± 141 ms, P &lt; 0.05) and increase in LA-GLS (from 11.9 ± 4.7 to 19.6 ± 10.1%, P &lt; 0.05) in parallel with the reduction in LAVi (from 48 ± 17 to 37 ± 18 mL/m², P &lt; 0.05) at 6 months after CRT. Receiver operating characteristic curve analysis identified the optimal cut-off value of LA time-diff at 6 months after CRT as 202 ms (P &lt; 0.05) and that of LA-GLS as 14.6% (P &lt; 0.05) for predicting adverse cardiac events. The patients whose LA time-diff reduced &lt;202 ms after CRT showed significantly favorable event-free survival than the others. Similarly, the patients whose LA-GLS improved &gt;14.6% after CRT exhibited significantly favorable event-free survival than the others (P &lt; 0.05, respectively). Of note was that, when the patients were restricted to CRT responders only, those who showed LA time-diff less than 202 ms at 6 months after CRT almost never experienced cardiac events (P &lt; 0.05).

Conclusions

The improved LV coordination by CRT also resulted in resynchronization of discoordinated LA wall motion and a consecutive improvement of LA reservoir function, which ultimately lead to the favorable outcome for HFrEF patients with wide-QRS complex.

Abstract Figure.

preoperative right ventricular overwork is a major determinant of residual pulmonary arterial hypertension in patients with repaired arterial septal defect

Funding Acknowledgements

Type of funding sources: None.

Background

The haemodynamic effect of atrial septal defect (ASD) is a chronic volume overload of the right heart and pulmonary vasculature. Pulmonary overcirculation is generally compensated for by the right ventricular (RV) and pulmonary arterial (PA) reserve. However, in a subset of patients, prolonged pulmonary overcirculation insidiously induces obstructive pulmonary vasculopathy, which results in postoperative residual pulmonary arterial hypertension (PAH) after ASD closure. Postoperative PAH is a major concern because it is closely associated with poor outcomes and impaired quality of life. However, to date, no clinically robust predictors of postoperative residual PAH have been clearly identified.

Purpose

This study sought to assess the haemodynamic characteristics of ASD patients in terms of mechano-energetic parameters and to identify the predictors of postoperative residual PAH in these patients.

Methods

A total of 120 ASD patients (age: 58 ± 17 years) and 46 normal controls were recruited. As previously reported, the simplified RV contraction pressure index (sRVCPI) was calculated as an index of RV external work by multiplying the tricuspid annular plane systolic excursion (TAPSE) by the pressure gradient between the RV and right atrium. RV- PA coupling was evaluated using TAPSE divided by PA systolic pressure as an index of the RV length-force relationship. These parameters were measured both at baseline and 6 months after ASD closure.

Results

As expected, baseline sRVCPI was significantly greater in patients with ASD than in controls (775 ± 298 vs. 335 ± 180 mm Hg • mm, P &lt; 0.01), which indicated significant "RV overwork". As a result, RV-PA coupling in ASD patients was significantly impaired compared to that in controls (0.9 ± 0.8 vs. 3.5 ± 1.7 mm/mm Hg, P &lt; 0.01). All 120 ASD patients underwent transcatheter or surgical shunt closure; 15 of them had residual PAH after closure. After 6 months, RV-PA coupling index significantly improved in patients without residual PAH, from 0.96 ± 0.81 to 1.27 ± 1.24 mm/mm Hg (P = 0.02). Furthermore, RV load was markedly reduced, with sRVCPI falling from 691 ± 258 to 434 ± 217 mm Hg • mm, P &lt; 0.01). However, in patients with residual PAH, RV-PA coupling index deteriorated from 0.64 ± 0.23 to 0.53 ± 0.12 mm/mm Hg (P &lt; 0.01). As a result, RV overload was not significantly relieved (sRVCPI; from 971 ± 382 to 783 ± 166 mm Hg • mm, P = 0.22). In a multivariate analysis, baseline pulmonary vascular resistance (hazard ratio 1.009; P &lt; 0.01) and preoperative sRVPCI (hazard ratio 1.003; P &lt; 0.01) revealed to be independent predictors of residual PAH.

Conclusion

In terms of mechano-energetic function, preoperative "RV overwork" can be used as a robust predictor of an impaired RV-PA relationship in ASD patients. Moreover, periodic assessment of sRVPCI may contribute to the better management for patients with unrepaired ASD.

Abstract Figure.

Inhibition of histone methyltransferase G9a attenuates liver cancer initiation by sensitizing DNA-damaged hepatocytes to p53-induced apoptosis

While the significance of acquired genetic abnormalities in the initiation of hepatocellular carcinoma (HCC) has been established, the role of epigenetic modification remains unknown. Here we identified the pivotal role of histone methyltransferase G9a in the DNA damage-triggered initiation of HCC. Using liver-specific G9a-deficient (G9a^ΔHep) mice, we revealed that loss of G9a significantly attenuated liver tumor initiation caused by diethylnitrosamine (DEN). In addition, pharmacological inhibition of G9a attenuated the DEN-induced initiation of HCC. After treatment with DEN, while the induction of γH2AX and p53 were comparable in the G9a^ΔHep and wild-type livers, more apoptotic hepatocytes were detected in the G9a^ΔHep liver. Transcriptome analysis identified Bcl-G, a pro-apoptotic Bcl-2 family member, to be markedly upregulated in the G9a^ΔHep liver. In human cultured hepatoma cells, a G9a inhibitor, UNC0638, upregulated BCL-G expression and enhanced the apoptotic response after treatment with hydrogen peroxide or irradiation, suggesting an essential role of the G9a-Bcl-G axis in DNA damage response in hepatocytes. The proposed mechanism was that DNA damage stimuli recruited G9a to the p53-responsive element of the Bcl-G gene, resulting in the impaired enrichment of p53 to the region and the attenuation of Bcl-G expression. G9a deletion allowed the recruitment of p53 and upregulated Bcl-G expression. These results demonstrate that G9a allows DNA-damaged hepatocytes to escape p53-induced apoptosis by silencing Bcl-G, which may contribute to the tumor initiation. Therefore, G9a inhibition can be a novel preventive strategy for HCC.

Association between clinical risk factors and left ventricular function in patients with breast cancer following chemotherapy

Background

The sequential or concurrent use of two different types of agents such as anthracyclines and trastuzumab may increase myocardial injury and cancer therapeutics-related cardiac dysfunction (CTRCD), which is often the result of the combined detrimental effect of the two therapies for breast cancer patients. For risk stratification to detect the development of CTRCD, the current position paper from the European Society of Cardiology (ESC) lists several factors associated with risk of cardiotoxicity following treatment with chemotherapy. However, the association between clinical risk factors and left ventricular (LV) function in breast cancer patients is currently unclear.

Purpose

Our purpose was to investigate the impact of baseline risk factors on LV function in patients with preserved LV ejection fraction (LVEF) who have undergone anthracycline or trastuzumab chemotherapy for breast cancer.

Methods

We studied 86 breast cancer patients treated with anthracyclines, trastuzumab, or both. Mean age was 59±13 years and LVEF was 67±5%. In accordance with the current definition, CTRCD was defined as a decline in LVEF of &gt;10% to an absolute value of &lt;53% after chemotherapy. Based on the 2016 ESC position paper, clinical risk factors for CTRCD were defined as: (1) a cumulative total doxorubicin dose of ≥240 mg/m2, (2) age ≥65-year-old, (3) body mass index ≥30 kg/m2, (4) a previous history of radiation therapy to chest or mediastinum, (5) B-type natriuretic peptide ≥100pg/mL, (6) a previous history of cardiovascular disease, (7) atrial fibrillation, (8) hypertension, (9) diabetes mellitus, (10) current or ex-smoker.

Results

The relative decrease in LVEF after chemotherapy for patients with more than four risk factors was significantly greater than that for patients without (−9.3±10.8% vs. −2.2±10.2%; p=0.02). However, this finding did not apply to patients with more than one, two or three risk factors. Patients with more than four risk factors also tended to show a higher prevalence of CTRCD than those without (14.3% vs. 2.8%, p=0.12). Moreover, patients with more than four risk factors were more likely to have higher LV mass index (109.3±29.0 g/m2 vs. 83.2±21.0g /m2, p&lt;0.001), lower global longitudinal strain (18.4±2.8% vs. 20.0±2.6%, p=0.06) and higher E/e' (10.4 (8.9–13.0) vs. 9.0 (7.4–10.9), p=0.06) compared to those without.

Conclusions

Association between clinical risk factors and LV dysfunction following chemotherapy became stronger with an increase in the number of risk factors in breast cancer patients, and was especially strong for patients treated with chemotherapy who had more than four risk factors. Our findings can thus be expected to have clinical implications for better management of patients with breast cancer referred for chemotherapy.

Funding Acknowledgement

Type of funding source: None

Consideration of non-valvular atrial fibrillation with left atrial appendage thrombus formation despite under appropriate oral anticoagulation therapy

Background

Atrial fibrillation (AF) is the most frequently sustained cardiac arrhythmia, with a prevalence of about 2–3% in the general population. In accordance with CHADS2 or CHA2DS2-VASc score, appropriate oral anticoagulation therapy such as warfarin or direct oral anticoagulants (DOAC) significantly reduced the risk of thromboembolic events. However, left atrial (LA) thrombus can be detected in the LA appendage (LAA) in AF patients despite appropriate oral anticoagulation therapy.

Purpose

Our purpose was to investigate the associated factors of LAA thrombus formation in non-valvular atrial fibrillation (NVAF) patients despite under appropriate oral anticoagulation therapy.

Methods

We retrospectively studied consecutive 286 NVAF patients for scheduled catheter ablation or electrical cardioversion for AF in our institution between February 2017 and September 2019. Mean age was 67.1±9.4 years, 79 patients (29.5%) were female, and 140 (52.2%) were paroxysmal AF. All patients underwent transthoracic and transesophageal echocardiography before catheter ablation or electrical cardioversion. All patients received appropriate oral anticoagulation therapy including warfarin or DOAC for at least 3 weeks prior to transesophageal echocardiography based on the current guidelines. LAA thrombus was defined as an echodense intracavitary mass distinct from the underlying endocardium and not caused by pectinate muscles by at least three senior echocardiologists.

Results

Of 286 NVAF patients with under appropriate oral anticoagulation therapy, LAA thrombus was observed in 9 patients (3.3%). Univariate logistic regression analysis showed that age, paroxysmal AF, CHADS2 score ≥3, left ventricular end-diastolic volume index (LVEDVI), left ventricular ejection fraction (LVEF), left ventricular mass index (LVMI), LA volume index (LAVI), mitral inflow E and mitral e' annular velocities ratio (E/e'), and LAA flow were associated with LAA thrombus formation. It was noteworthy that multivariate logistic regression analysis showed that LAA flow was independent predictor of LAA thrombus (OR: 0.72, 95% CI: 0.59–0.89, p&lt;0.005) as well as LVEF. Furthermore, receiver operating characteristic (ROC) curve analysis identified the optimal cutoff value of LAA flow for predicting LAA thrombus as ≤15cm/s, with a sensitivity of 88%, specificity of 93%, and area under the curve (AUC) of 0.95.

Conclusions

LAA flow was strongly associated with LAA thrombus formation even in NVAF patients with appropriate oral anticoagulation therapy. According to our findings, further strengthen of oral anticoagulation therapy or percutaneous transcatheter closure of the LAA may be considered in NVAF patients with appropriate oral anticoagulation therapy but low LAA flow, especially &lt;15cm/s.

Funding Acknowledgement

Type of funding source: None

Novel method of ASV titration for patient with severe heart failure. (Not for AHI improvement but for cardiac output)

Background

Adaptive servo-ventilation (ASV) is reportedly beneficial for the treatment of heart failure in patients with central sleep apnea syndrome. However, the recent SERVE-HF trial reported that ASV treatment increased mortality in these patients. One cause of the negative result was considered to be the low output induced by high expiratory positive airway pressure (EPAP) against the background of low left ventricular ejection fraction (LVEF).

Hypothesis

We hypothesized that optimized ASV settings can be determined by evaluating outflow by using echocardiography, thereby ensuring benefits for patients with severe heart failure (HF).

Methods

Between July 2016 and March 2017, we optimized ASV settings by using hemodynamic parameters on echocardiography in hospitalized patients with severe HF treated with catecholamine or who were candidates for heart transplantation. We calculated stroke volume (SV) by using the time-velocity integral in the left ventricular outflow tract and compared the response to ASV with EPAP settings of 2, 4, 6, or 8 mmHg. We determined the optimal setting at which the SV reached the maximum value and compared this with the settings at baseline and discharge. We also compared rehospitalization and all-cause mortality between the patients who used ASV with titration (n=28) and without titration (n=37).

Result

We evaluated 28 patients with severe HF (mean EF, 32%). ASV treatment improved the SV (from 53.4 to 58.8 ml, P&lt;0.05) when optimal settings were used. However, the SV decreased when ASV was performed with a higher-than-optimal EPAP setting. Moreover, at discharge, the EPAP setting was lower than at baseline (mean EPAP, 4.75 cmH2O decreased to 3.71 cmH2O, P&lt;0.05). During the follow-up (median, 420 days), more hospitalizations and deaths occurred in the patients without ASV titration (48.8% vs 37.8%) than in those with ASV titration (28.6% vs 21.4%, respectively; Figure 1).

Conclusion

In patients with severe HF, high EPAP decreased the SV and optimal settings were different at baseline and after treatment. The result indicated that the optimal setting for ASV may be beneficial for preventing rehospitalization and death. Whether optimal ASV settings reduce mortality in these patients must be investigated.

Figure 1

Funding Acknowledgement

Type of funding source: None