Long-term safety and effectiveness of berotralstat for hereditary angioedema: The open-label APeX-S study

BACKGROUND

Berotralstat (BCX7353) is an oral, once-daily inhibitor of plasma kallikrein recently approved for prevention of angioedema attacks in adults and adolescents with hereditary angioedema (HAE). The objective of this report is to summarize results from an interim analysis of an ongoing long-term safety study of berotralstat in patients with HAE.

METHODS

APeX-S is an ongoing, phase 2, open-label study conducted in 22 countries (ClinicalTrials.gov, NCT03472040). Eligible patients with a clinical diagnosis of HAE due to C1 inhibitor deficiency (HAE-C1-INH) were centrally allocated to receive berotralstat 150 or 110 mg once daily. The primary objective was to determine long-term safety and the secondary objective was to evaluate effectiveness.

RESULTS

Enrolled patients (N = 227) received berotralstat 150 mg (n = 127) or 110 mg (n = 100) once daily. The median (range) duration of exposure was 342 (11-540) and 307 (14-429) days for the 150-mg and 110-mg groups, respectively. Treatment-emergent adverse events (TEAEs) occurred in 91% (n = 206) of patients. The most common TEAEs across treatment groups were upper respiratory tract infection (n = 91, 40%), abdominal pain (n = 57, 25%), headache (n = 40, 18%), and diarrhea (n = 31, 14%) and were mostly mild to moderate. Fifty percent (n = 113) of patients had at least one drug-related adverse event (AE; 150 mg, n = 57 [45%]; 110 mg, n = 56 [56%]), and discontinuations due to AEs occurred in 19 (8%) patients (150 mg, n = 13 [10%]; 110 mg, n = 6 [6%]). Three (1.3%) patients experienced a drug-related serious TEAE. Among patients who received berotralstat through 48 weeks (150 mg, n = 73; 110 mg, n = 30), median HAE attack rates were low in month 1 (150 mg, 1.0 attacks/month; 110 mg, 0.5 attacks/month) and remained low through 12 months (0 attacks/month in both dose groups). Mean HAE attack rates followed a similar trend, and no evidence for patient tolerance to berotralstat emerged. In both dose groups, angioedema quality of life scores showed clinically meaningful changes from baseline.

CONCLUSIONS

In this analysis, both berotralstat doses, 150  and 110 mg once daily, were generally well tolerated. Effectiveness results support the durability and robustness of berotralstat as prophylactic therapy in patients with HAE.

TRIAL REGISTRATION

The study is registered with ClinicalTrials.gov (NCT03472040).

OP0068 EFFICACY AND SAFETY OF TNF-Α ANTAGONISTS AND TOCILIZUMAB IN TAKAYASU ARTERITIS: MULTICENTER WORLDWIDE RETROSPECTIVE STUDY OF 209 PATIENTS

Background:

In this large worldwide TAK registry, we report 209 patients treated with TNF-α antagonists and tocilizumab aiming to compare their safety and efficacy, and determine the predictive factors of treatment response and relapse.

Objectives:

To assess safety and efficacy of TNF-α antagonists and tocilizumab in patients with Takayasu arteritis (TAK).

Methods:

We conducted a retrospective multicenter study in referral centers from France, Italy, Spain, Israel, Japan, Tunisia and Russia about biological-targeted therapies in TAK during the period from January 2017 to September 2019 for the data collection.

Results:

Two-hundred nine patients with TAK [median age of 29 years [7-62], and 186 (89%) females] were included. They received either TNF-α antagonists [n=132 (63%) with 172 lines; infliximab (n=109), adalimumab (n=45), golimumab (n=8), certolizumab (n=6) and etanercept (n=5)], or tocilizumab [n=77 (37%) with 121 lines; intravenous and subcutaneous in 95 and 26 cases, respectively]. A complete response at 6 months was evidenced in 101/152 (66%) on TNF-α antagonists and 75/107 (70%) on tocilizumab, respectively. Age ≥ 30 years [OR= 2.09 [1.09; 3.99]] was associated with complete response, whereas vascular signs [0.26 [0.1;0.65]], baseline prednisone ≥ 20 mg/day [0.51 [0.28;0.93]] were negatively associated with the complete response to TNF-α antagonists or tocilizumab. During a median follow-up of 36 months, 103 relapses were noted. Supra-aortic branches and thoracic aorta involvements [HR 2.44 (1.06;5.65) and 3.66 (1.18;11.4), respectively], and systemic signs at baseline [HR 2.01 (1.30;3.11)] were significantly associated with relapse. The cumulative incidence of treatment discontinuation and relapse were similar in TNFα antagonists and tocilizumab. Fifty-eight (20%) adverse effects occurred on biological-targeted therapies of whom 37 (21%) and 21 (17%), (p=0.4) on TNF-α antagonists and tocilizumab, respectively

Conclusion:

This large multicenter study shows high efficacy of biological-targeted treatments in refractory TAK. Efficacy, relapse and drug retention rate were equivalent with TNF-α antagonists and tocilizumab.

Disclosure of Interests:

None declared

Efficacité du Tocilizumab dans la COVID-19 modérée à sévère : une cohorte française exposé-non exposé

Introduction

L’infection par le SARS-CoV-2 peut mener à un syndrome de détresse respiratoire aigu dont la mortalité était estimée à 50 % au début de l’épidémie. Ces formes sévères étant significativement associées à un état d’hyperinflammation, et notamment à un niveau élevé d’interleukine-6, il a été proposé que cibler la voie de signalisation de cette interleukine majoritairement pro-inflammatoire, puisse réduire la mortalité de la COVID-19. Pour autant, un an après le début de la pandémie, la place de ces inhibiteurs, dont le Tocilizumab, un anticorps monoclonal dirigé contre le récepteur de l’interleuline-6, reste à déterminer.

Patients et méthodes

Cohorte exposé-non exposé en vie réelle, monocentrique et menée à l’hôpital Saint-Antoine, Paris, France, avant la mise en place de l’essai randomisé CORIMUNO-TOCI. Etaient inclus les patients de plus de 18 ans qui présentaient une forme modérée à sévère de COVID-19, selon la définition de l’OMS, et qui nécessitaient une oxygéno-requerance ≥ 4 L/min, associée à un syndrome inflammatoire biologique (CRP > 50 mg/L). Etaient exclus les patients qui portaient des contre-indications au Tocilizumab (antécédent de sigmoïdite ou de diverticulite, une cytolyse hépatique supérieure à 5 N, une allergie connue au Tocilizumab, ou une infection bactérienne active.) Par ailleurs, les patients qui étaient transférés en soins intensifs dans les premières 24 h après l’injection de Tocilizumab étaient exclus de notre étude, puisque ils étaient inclus dans une étude qui évaluait le Tocilizumab en réanimation. Les patients du groupe Tocilizumab recevaient une injection de 8 mg/kg (maximum 800 mg) de Tocilizumab associée aux soins courants et les patients du groupe soins courants ne recevaient que les soins courants. Pour assurer la comparabilité des deux groupes nous avons utilisé le score de propension. Notre critère de jugement principal était le délai de sevrage en oxygène. Les critères de jugement secondaire étaient : le transfert en soins intensifs, le besoin de ventilation mécanique, le décès toutes causes confondues, le décès au dixi^e jour, la durée d’hospitalisation ainsi que les scores composites intubation ou décès et transfert en soins intensifs ou décès.

Résultats

Cinquante patients ont été inclus dans le groupe Tocilizumab et 52 patients dans le groupe soins courants. L’âge moyen était de 68,9 ± 2 ans et 71 % des patients étaient des hommes. Les patients du groupe Tocilizumab étaient plus fréquemment diabétique (34 % vs 13 % ; p = 0,02), et avaient un niveau d’oxygène moyen plus élevé (9,1 L/min vs 6,8 L/min ; p = 0,0002). Les patients du groupe Tocilizumab avaient reçu plus de corticoïdes que les patients du groupe soins courants (53 % vs 6 % ; p < 0,0001). Le délai de sevrage en oxygène n’était pas diffèrent dans les deux groupes, 14,1 [IQR 7-19] jours dans le groupe Tocilizumab versus 12,2 [IQR 7,5-14] jours dans le groupe soins courants, hazard ratio ajusté à 1,53 (IC95 % (0,96-2,45) ; p = 0,073). Il n’y avait pas non plus de différence concernant les critères de jugement secondaires.

Discussion

Dans cet essai, nous rapportons une absence de bénéfice du Tocilizumab dans les formes modérées à sévères de la COVID-19. L’injection de Tocilizumab à la posologie de 8 mg/kg n’améliorait pas le délai de sevrage en oxygène, et ne réduisait pas la nécessité d’intubation, de transfert en soins intensifs ou la mortalité. Cette absence de différence peut être expliquée, en partie, par le fait que les patients du groupe Tocilizumab étaient plus graves (oxygéno-requerance plus élevée) et comorbides (plus fréquemment diabétiques). En revanche, ces patients avaient reçu plus de corticoides qui est aujourd’hui un traitement recommandé dans la prise en charge des patients sous oxygène, atteints de la COVID-19. Notre étude manque aussi de puissance, une récente méta-analyse estimait à 2300 patients (dans chaque bras) le nombre de sujet nécessaire pour mettre en évidence une différence significative si celle-ci existait.

Conclusion

Un essai randomisé récent qui incluait un nombre de sujet suffisant, en cours de publication, a montré des résultats encourageants, avec une diminution de la mortalité à 28 jours chez les patients traités par Tocilizumab (majoritairement en associations au corticoïdes). Toutefois la question du meilleur moment de l’injection de Tocilizumab chez les patients atteints de COVID-19 reste entière.

Acute Myocarditis Revealing Adult-Onset Still's Disease

A 34-year-old man presented with fever, palpitations, maculopapular rash, pharyngitis, left cheilitis, and bilateral gonalgia. High-sensitivity troponin I concentration was 4,900 ng/l. Transthoracic echocardiogram revealed reduced global longitudinal strain. Cardiac magnetic resonance imaging showed acute myocarditis. Adult-onset Still’s disease was diagnosed, and treatment with intravenous corticosteroids and tocilizumab was initiated. (Level of Difficulty: Beginner.)

Clinical spectrum, outcome and management of immune thrombocytopenia associated with myelodysplastic syndromes and chronic myelomonocytic leukemia

Myelodysplastic syndromes (MDS) and chronic myelomonocytic leukemia (CMML) are associated with systemic inflammatory or autoimmune diseases in 10-20 % of cases. Among them, immune thrombocytopenia (ITP) has been reported but large studies assessing this association are missing. Whether such patients have a particular phenotype and require particular management is unclear. This study analyzes the clinical spectrum, outcome and therapeutic management of patients with ITP associated with MDS or CMML, in comparison (i) to patients with primary ITP without MDS/CMML and (ii) to patients with MDS/CMML without ITP. Forty-one MDS/CMML-associated ITP patients were included, with chronic ITP in 26 (63%) patients, low-risk myelodysplasia in 30 (73%) patients and CMML in 24 (59%) patients. An associated autoimmune disease was noted in 10 (24%) patients. In comparison to primary ITP patients, MDS/CMML-associated ITP patients had a higher occurrence of severe bleeding despite similar platelet counts at diagnosis. First-line treatment consisted of glucocorticoids (98%) and intravenous immunoglobulin (IVIg) (56%). Response achievement with IVIg was more frequent in primary ITP than in MDS/CMML-associated ITP patients. Response rates to second-line therapies were not statistically different between primary ITP and MDS/CMMLassociated ITP patients. Ten percent (n=4) of patients with MDS/CMML-associated ITP had multirefractory ITP versus none in primary ITP controls. After a median follow-up of 60 months, there was no difference in overall survival between MDS/CMML-associated ITP and primary ITP patients. Leukemia-free-survival was significantly better in MDS/CMMLassociated ITP patients than in MDS/CMML without ITP MDS/CMML-associated ITP have a particular outcome with more severe bleeding and multirefractory profile than primary ITP, similar response profile to primary ITP therapy except for IVIg, and less progression toward acute myeloid leukemia than MDS/CMML without ITP.

Unexplained recurrent miscarriages: predictive value of immune biomarkers and immunomodulatory therapies for live birth

INTRODUCTION

Recurrent miscarriages are defined as three or more early miscarriages before 12 weeks of gestation. The aim of this study was to describe a cohort of women with unexplained recurrent miscarriages, evaluate several potential biomarkers of immune origin, and describe the outcome of pregnancies under immunomodulatory therapies.

METHODS

Women having a history of at least 3 early miscarriages without any etiology were recruited from 3 university hospitals.

RESULTS

Among 101 women with recurrent miscarriages, overall, 652 pregnancies have been included in the analysis. Women which experienced miscarriages were older (33.3 ± 5.4 versus 31.9 ± 6.7; p = 0.03), with history of more pregnancies (4 (2-6) versus 3.5 (1-5.75); p 0.0008), and less frequently the same partner (406 (74%) versus 79 (86%); p=0.01). There was no difference in the level and frequencies of biomarkers of immune origin (NK, lymphocyte, gamma globulins and blood cytokine levels and endometrial uNK activation status), except the higher rates of positive antinuclear antibodies in women with live birth (12 (13%) versus 36 (7%); p=0.03). Among the 652 pregnancies, 215 (33%) have been treated and received either aspirin/low weighted molecular heparin (LMWH) and/or combined to different lines of immunomodulatory treatment. Patients with pregnancy under treatment had a significantly higher rate of cumulative live birth rate than those with untreated ones (43.0% vs 34.8%; p = 0.04). When compared to patients with untreated pregnancies, patients with steroids during the pregnancy had twice more chances to obtain live birth (OR 2.0, CI95% 1.1 - 3.7, p = 0.02).

CONCLUSIONS

Unexplained recurrent miscarriages could have improved obstetrical outcome under immunomodulatory therapies and in particular steroids.

Unexplained recurrent implantation failures: Predictive factors of pregnancy and therapeutic management from a French multicentre study

INTRODUCTION

Recurrent implantation failure is defined as the absence of pregnancy after at least three transfers of good-quality embryos after in vitro fecundation/intracytoplasic sperm injection.

AIM

The aim of this study was to describe a multicentre cohort of women with unexplained RIF, to analyse the factors associated with clinical pregnancy and to evaluate the immunomodulatory therapies efficacy.

METHODS

Women were consecutively recruited from university departments with unexplained RIF.

RESULTS

Sixty-four women were enrolled with mean age 36 ± 3 years. The rates of clinical pregnancy in 64 women were compared in untreated and treated cycles and according to therapies used during the last prospectively followed embryo transfer. A clinical pregnancy after the transfer was noted in 56 % pregnancies on intralipids and in 50 % on prednisone, versus 5 % in untreated ones (p < 0.001). The 340 embryo transfers of these 64 women resulted in 68 clinical pregnancies and 18 live births. Clinical pregnancies were significantly more frequent in treated versus untreated embryo transfers (44 % vs 9 %; p < 0.001) with odds ratio at 8.13 (95 % CI 4.49-14.72, p < 0.0001). Cumulative pregnancy rates were higher for steroid-treated transfers than for untreated transfers when considering overall transfers before and after using steroids and also only those under steroids. Cumulative pregnancy rates were not different from steroid- and intralipid-treated embryo transfers CONCLUSIONS: In this multicentre study of women with unexplained RIF, use of immunomodulatory treatments before embryo transfer resulted in higher clinical pregnancy. Randomised, well-designed studies in well-defined population of RIF women are necessary to confirm our preliminary data.

Apremilast in Refractory Behçet's Syndrome: A Multicenter Observational Study

Objective

Mucocutaneous and joint disorders are the most common manifestations in Behçet's syndrome (BS) and are frequently clustered in the so-called minor forms of BS. There remains a need for safe and effective treatment for joint lesions in BS. We report the long-term safety and effectiveness of apremilast in refractory joint and mucocutaneous manifestations of BS.

Methods

French nationwide multicenter study including 50 BS patients with either active joint and/or mucocutaneous manifestations resistant to colchicine and/or DMARDs. Patients received apremilast 30 mg twice a day. Primary effectiveness endpoint was the proportion of patients with complete response (CR) of articular symptoms at month 6 (M6), defined as resolution of inflammatory arthralgia and arthritis, with joint count equal to zero.

Results

At inclusion, the median tender and swollen joint count was of 4 [2-6] and 2 [1-2], respectively. The proportion of CR in joint disease at M6 was 65% (n = 15/23), and 17% (n = 4/23) were partial responders. CR of oral and genital ulcers, and pseudofolliculitis at M6 was 73% (n = 24/33), 94% (n = 16/17) and 71% (n = 10/14), respectively. The overall response at M6 was 74% for the entire cohort and 70% for the mucocutaneous-articular cluster (n = 27). The median Behçet's syndrome activity score significantly decreased during study period [50 (40-60) vs. 20 (0-40); p <0.0001]. After a median follow-up of 11 [6-13] months, 27 (54%) patients were still on apremilast. Reasons for apremilast withdrawal included adverse events (n = 15, 30%) and treatment failure (n = 8, 16%). Thirty-three (66%) patients experienced adverse events, mostly diarrhea (n = 19, 38%), nausea (n = 17, 34%) and headache (n = 16, 32%).

Conclusion

Apremilast seems effective in BS-related articular disease refractory to colchicine and DMARDs. Discontinuation rates were significantly higher than that reported in clinical trials.

Endometriosis with infertility: A comprehensive review on the role of immune deregulation and immunomodulation therapy

BACKGROUND

Endometriosis is a multifactorial pathology dependent on intrinsic and extrinsic factors, but the immune deregulation seems to play a pivotal role. In endometriosis-associated infertility, this could raise the benefit of immunomodulatory strategies to improve the results of ART. In this review, we will describe (1) sera and peritoneal fluid cytokines and immune markers; (2) autoantibodies; and (3) immunomodulatory treatments in endometriosis with infertility.

METHODS

The literature research was conducted in MEDLINE, Embase, and Cochrane Library with the following keywords: "endometriosis", "unexplained miscarriage", "implantation failure", "recurrent implantation failure » and « IVF-ICSI », « biomarkers of autoimmunity", "TNF-α", "TNF-α antagonists", "infliximab", "adalimumab", "etanercept", "immunomodulatory treatment", "steroids", "intralipids", "intravenous immunoglobulins", "G-CSF", "pentoxyfylline".

RESULTS

Several studies analyzed the levels of pro-inflammatory cytokines in sera and peritoneal fluid of endometriosis-associated infertility, in particular TNF-α. Various autoantibodies have been found in peritoneal fluid and sera of infertile endometriosis women even in the absence of clinically defined autoimmune disease, as antinuclear, anti-SSA, and antiphospholipid autoantibodies. In few uncontrolled studies, steroids and TNF-α antagonists could increase the pregnancy rates in endometriosis-associated infertility, but well-designed trials are lacking.

CONCLUSION

Endometriosis is characterized by increased levels of cytokines and autoantibodies. This suggests the role of inflammation and immune cell deregulation in infertility associated with endometriosis. The strategies of immunomodulation to regulate these immune deregulations are poorly studied, and well-designed studies are necessary.

Acute and Chronic Sarcoid Arthropathies: Characteristics and Treatments From a Retrospective Nationwide French Study

Introduction: We aimed to analyze patients with acute and chronic joint involvements in sarcoidosis.

Methods: This is a retrospective multicenter analysis of patients with proven sarcoidosis, as defined by clinical, radiological, and histological criteria, with at least one clinical and/or ultrasonographic synovitis.

Results: Thirty-nine patients with sarcoid arthropathy were included, and among them 19 had acute sarcoidosis (Lofgren's syndrome). Joint involvement and DAS44-CRP were not significantly different in acute and chronic sarcoid arthropathies. Acute forms were more frequent than chronic sarcoid arthropathy in Caucasians, without any difference of sex or age between these 2 forms. Joint involvement was frequently more symmetrical in acute than chronic forms (100 vs. 70%; p < 0.05), with a more frequent involvement in wrists and ankles in acute forms, whereas the tender and swollen joint counts and the DAS44-CRP were similar between the 2 groups. Skin lesions were significantly more frequent in patients with acute forms [17 (89%) vs. 5 (25%); p < 0.05] and were erythema nodosum in all patients with Löfgren's syndrome and sarcoid skin lesions in those with chronic sarcoidosis. Among 20 patients with chronic sarcoidosis, treatment was used in 17 (85%) cases, and consisted in NSAIDs alone (n = 5; 25%), steroids alone (n = 5; 25%), hydroxychloroquine (n = 2; 20%), methotrexate (n = 3; 15%), and TNF inhibitors (n = 2; 10%). A complete/partial joint response was noted in 14 (70%) cases with a DAS44-CRP reduction of 2.07 [1.85–2.44] (from 3.13 [2.76–3.42] to 1.06 [0.9–1.17]; p < 0.05).

Conclusion: Sarcoid arthropathies have different clinical phenotypes in acute and chronic forms and various treatment regimens such as hydroxychloroquine and methotrexate could be used in chronic forms.