Clinical characteristics and outcomes of pheochromocytoma crisis: a literature review of 200 cases

PURPOSE

Pheochromocytoma crisis is a life-threatening endocrine emergency that requires prompt diagnosis and treatment. Because of its rarity, sudden onset, and lack of internationally uniform and validated diagnostic criteria, pheochromocytoma crisis remains to be fully clarified. Therefore, we aimed to describe the clinical characteristics and outcomes of pheochromocytoma crisis through a literature review.

METHODS

We performed a systematic literature search of PubMed/MEDLINE database, Igaku-Chuo-Zasshi (Japanese database), and Google Scholar to identify case reports of pheochromocytoma crisis published until February 5, 2021. Information was extracted and analyzed from the literature that reported adequate individual patient data of pheochromocytoma crisis in English or Japanese. Cases were also termed as pheochromocytoma multisystem crisis (PMC) if patients had signs of hyperthermia, multiple organ failure, encephalopathy, and labile blood pressure.

RESULTS

In the 200 cases of pheochromocytoma crisis identified from 187 articles, the mean patient age was 43.8 ± 15.5 years. The most common symptom was headache (39.5%). The heart was the most commonly damaged organ resulting from a complication of a pheochromocytoma crisis (99.0%), followed by the lungs (44.0%) and the kidney (21.5%). PMC accounted for 19.0% of all pheochromocytoma crisis cases. After excluding 12 cases with unknown survival statuses, the mortality rate was 13.8% (26/188 cases). Multivariable logistic regression analysis revealed that nausea and vomiting were significantly associated with a higher mortality rate.

CONCLUSION

Pheochromocytoma can present with different symptomatology, affecting different organ systems. Clinicians should be aware that patients with nausea or vomiting are at a higher risk of death because of pheochromocytoma crisis.

Nailfold microvascular abnormalities are associated with a higher prevalence of pulmonary arterial hypertension in patients with MCTD

OBJECTIVE

MCTD manifests with microvasculopathy and overlapping clinical features of SLE, SSc and idiopathic inflammatory myopathies (IIM). The aim of this study was to investigate the clinical significance of microvasculopathy in patients with MCTD using nailfold videocapillaroscopy (NVC).

METHODS

Fifty patients with newly diagnosed and untreated MCTD were enrolled in this multicentre, prospective and observational study. Clinical features and NVC findings were assessed at baseline and after 1 year post-intervention, along with disease controls [SLE (n = 40), SSc (n = 70) and IIM (n = 50)].

RESULTS

All MCTD patients presented Raynaud's phenomenon and were positive for anti-U1 RNP antibodies, and 22.0% (11/50) had pulmonary arterial hypertension (PAH). The prevalence of NVC scleroderma patterns in MCTD was 38.0%, which was lower than SSc (88.6%) but higher than SLE (10.0%). In addition, when we divided MCTD patients into two groups by presence or absence of NVC scleroderma patterns, we found a higher prevalence of PAH in patients with NVC scleroderma patterns. Namely, NVC scleroderma patterns were observed in all MCTD patients with PAH, and in 21.0% of those without PAH. After intensive immunosuppressive therapy, NVC scleroderma patterns disappeared in half of the MCTD patients but were not changed in SSc patients.

CONCLUSIONS

MCTD differed from SLE, SSc and IIM in terms of the prevalence and responsiveness of NVC scleroderma patterns to immunosuppressive therapy. Detection of nailfold microvascular abnormalities in MCTD could contribute to predicting PAH and help us to understand further aspects of the pathogenesis of MCTD.

Evaluation of VTE, MACE, and Serious Infections Among Patients with RA Treated with Baricitinib Compared to TNFi: A Multi-Database Study of Patients in Routine Care Using Disease Registries and Claims Databases

INTRODUCTION

The aim of this work is to evaluate baricitinib safety with respect to venous thromboembolism (VTE), major adverse cardiovascular events (MACE), and serious infection relative to tumor necrosis factor inhibitors (TNFi) in patients with rheumatoid arthritis (RA).

METHODS

Patients with RA from 14 real-world data sources (three disease registries, eight commercial and three government health insurance claims databases) in the United States (n = 9), Europe (n = 3), and Japan (n = 2) were analyzed using a new user active comparator design. Propensity score matching (1:1) controlled for potential confounding. Meta-analysis of incidence rate ratios (IRR) and incidence rate differences (IRD) for each outcome, from each data source was executed using modified Poisson regression and Cochran-Mantel-Haenszel analysis.

RESULTS

Of 9013 eligible baricitinib-treated patients, 7606 were propensity score-matched with TNFi-treated patients, contributing 5879 and 6512 person-years of baricitinib and TNFi exposure, respectively. Across data sources, 97 patients (56 baricitinib) experienced VTE during follow-up, 93 experienced MACE (54 baricitinib), and 321 experienced serious infection (176 baricitinib). Overall IRRs comparing baricitinib with TNFi treatment were 1.51 (95% CI 1.10, 2.08) for VTE, 1.54 (95% CI 0.93, 2.54) for MACE, and 1.36 (95% CI 0.86, 2.13) for serious infection. IRDs for VTE, MACE, and serious infection, respectively, were 0.26 (95% CI -0.04, 0.57), 0.22 (95% CI -0.07, 0.52), and 0.57 (95% CI -0.07, 1.21) per 100 person-years greater for baricitinib than TNFi.

CONCLUSIONS

Overall results suggest increased risk of VTE with baricitinib versus TNFi, with consistent point estimates from the two largest data sources. A numerically greater risk was observed for MACE and serious infection when comparing baricitinib versus TNFi, with different point estimates from the two largest data sources. Findings from this study and their impact on clinical practice should be considered in context of limitations and other evidence regarding the safety and efficacy of baricitinib and other Janus kinase inhibitors.

TRIAL REGISTRATION

EU PAS Register ( http://encepp.eu ), identifier #32271.

IL-6 production through repression of UBASH3A gene via epigenetic dysregulation of super-enhancer in CD4+ T cells in rheumatoid arthritis

Background

Rheumatoid arthritis (RA) is associated with immune dysfunction. UBASH3A as a negative regulator of T cell receptors (TCRs) signaling is a susceptible factor in RA. The aim of this study was to determine the role of UBASH3A in RA pathogenesis, by assessing the role of super-enhancer (SE) in the control of UBASH3A expression in CD4⁺ T cells and the contribution of the latter in proinflammatory cytokine production in patients with RA.

Methods

UBASH3A mRNA and protein levels were quantified by PCR and western blotting, respectively. The cells were treated with a locked nucleic acid to inhibit enhancer RNA (eRNA) expression. Chromatin immunoprecipitation was used to identify the factors recruited to UBASH3A loci displaying SE architecture. CD4⁺ T cells were transfected with UBASH3A plasmids, and cytokine levels were measured by a cytometric bead array.

Results

UBASH3A was extracted as a RA susceptibility gene associated with SNPs in the SEs that are highly expressed in CD4⁺ T cells by in silico screening. UBASH3A mRNA and protein expression levels were lower in CD4⁺ T cells of RA patients than in the control. eRNA_1 and eRNA_3 knockdown reduced UBASH3A mRNA levels. RA patients exhibited accumulation of BTB and CNC homology 2 (BACH2), the silencing transcription factor, at the UBASH3A loci in CD4⁺ T cells, but not the SE-defining factor, mediator complex subunit 1 (MED1)/bromodomain 4 (BRD4). However, opposite changes were observed in the control. Stimulation of TCRs expressed on CD4⁺ T cells of RA patients resulted in interleukin (IL)-6 production, while UBASH3A over-expression significantly inhibited the production.

Conclusions

In RA, transcription of UBASH3A is suppressed via epigenetic regulation of SE in CD4⁺ T cells. Low UBASH3A levels result in excessive TCR signal activation with subsequent enhancement of IL-6 production.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41232-022-00231-9.

Association Between Time in Range and Postprandial Glucose Contribution Rate in Non-Insulin-Treated Type 2 Diabetes Patients: Inverse Correlation of Time in Range with Postprandial Glucose Contribution Rate

Background: Whether time in range (TIR), a parameter derived from continuous glucose monitoring (CGM), is a marker of postprandial hyperglycemia remains to be determined. In this study, we examined the association between TIR and postprandial glucose in non-insulin-treated type 2 diabetic patients. Methods: Our cross-sectional study included 729 non-insulin-treated patients with type 2 diabetes who underwent CGM without any changes in drug therapy on admission. The 24-h CGM record was analyzed for average glucose, standard deviation, percentage coefficient of variation, time above range, TIR, time below range, area under the curve (AUC) of basal glucose, AUC of postprandial glucose, and postprandial glucose contribution rate (%). The primary endpoint was the association between TIR and the postprandial glucose contribution rate. Results: We made TIR groups divided into 10% increments for a 7-group and compared with <40% to >90%. The basal and postprandial glucose AUCs correlated negatively with TIR. The postprandial glucose contribution rate correlated with TIR. The cutoff value for TIR, where postprandial glucose contribution rate was lower than the basal glucose contribution rate, was 66.3%. Conclusions: In non-insulin-treated type 2 diabetic patients, postprandial glucose AUC was higher in the high TIR group, whereas the basal glucose AUC was higher in the low TIR group. Good glycemic control can be achieved with therapeutic interventions that target postprandial glucose and basal glucose in patients with TIR ≥66.3% and <66.3%, respectively. University Medical Information Network [UMIN] ID: UMIN0000254333.

Multi-ancestry genome-wide association analyses identify novel genetic mechanisms in rheumatoid arthritis

Rheumatoid arthritis (RA) is a highly heritable complex disease with unknown etiology. Multi-ancestry genetic research of RA promises to improve power to detect genetic signals, fine-mapping resolution and performances of polygenic risk scores (PRS). Here, we present a large-scale genome-wide association study (GWAS) of RA, which includes 276,020 samples from five ancestral groups. We conducted a multi-ancestry meta-analysis and identified 124 loci (P < 5 × 10-8), of which 34 are novel. Candidate genes at the novel loci suggest essential roles of the immune system (for example, TNIP2 and TNFRSF11A) and joint tissues (for example, WISP1) in RA etiology. Multi-ancestry fine-mapping identified putatively causal variants with biological insights (for example, LEF1). Moreover, PRS based on multi-ancestry GWAS outperformed PRS based on single-ancestry GWAS and had comparable performance between populations of European and East Asian ancestries. Our study provides several insights into the etiology of RA and improves the genetic predictability of RA.

Phase II/III Results of a Trial of Anti-Tumor Necrosis Factor Multivalent NANOBODY Compound Ozoralizumab in Patients With Rheumatoid Arthritis

OBJECTIVE

To assess the efficacy and safety of subcutaneous administration of 30 mg or 80 mg of ozoralizumab plus methotrexate (MTX) in patients with rheumatoid arthritis (RA) whose disease remained active despite MTX therapy.

METHODS

In this multicenter, double-blind, parallel-group, placebo-controlled phase II/III trial, 381 patients were randomized to receive placebo, ozoralizumab 30 mg, or ozoralizumab 80 mg, plus MTX subcutaneously injected every 4 weeks for 24 weeks. The primary end points were the response rates based on the American College of Rheumatology 20% improvement criteria (ACR20) at week 16 and change in the Sharp/van der Heijde score (ΔSHS) from baseline to week 24.

RESULTS

The proportion of patients with an ACR20 response at week 16 was significantly higher (P < 0.001) in both ozoralizumab groups (79.6% for 30 mg, 75.3% for 80 mg), compared with placebo (37.3%); these improvements were observed from the first week of treatment. The proportion of the patients with structural nonprogression (ΔSHS ≤0) was significantly higher in both ozoralizumab groups than in the placebo group. For some secondary end points, significantly greater improvements were observed starting from as early as day 3. Serious adverse events occurred in 4 patients in the ozoralizumab 30-mg group and 5 patients in the ozoralizumab 80-mg group.

CONCLUSION

In patients with active RA who received ozoralizumab in combination with MTX, the signs and symptoms of RA were significantly reduced as compared with the outcomes in those receiving placebo. Ozoralizumab demonstrated acceptable tolerability with no new safety signals when compared with other antibodies against tumor necrosis factor.

Comprehensive immunophenotypic analysis reveals the pathological involvement of Th17 cells in Graves' disease

Graves' disease (GD) is an organ-specific autoimmune disease, but there are a few studies that have evaluated how immunophenotypes are related to clinical symptoms and intractable pathology, or the effects of treatment on immunophenotypes. We performed peripheral blood immunophenotyping in GD. We assessed the proportion of functional subsets of T helper cells (such as Th1, Th17, Treg and Tfh cells), B cells (Naïve, IgM memory, Class-switched, IgD⁻CD27⁻ double negative and Plasmablasts cells), Monocytes, Dendritic cells and NK cells, and evaluated the relationship of immunophenotypes with clinical indices, disease activity, risk of relapse, and changes in immunophenotypes after treatment with antithyroid drugs. The activated Th17 cells, activated T follicular helper (Tfh) cells, and IgD⁻CD27⁻ double-negative B cells were higher in newly onset GD compared with healthy participants. Th17 cells were associated with thyroid autoantibodies, thyroid function, thyroid enlargement, and Graves' Recurrent Events After Therapy (GREAT) score; while double-negative B cells were associated with thyroid autoantibodies. Treatment with antithyroid drugs decreased the activated Tfh cells in parallel with the improvement in thyroid function. However, activated Th17 cells were not associated with clinical improvement and remained unchanged. Peripheral blood immunophenotyping identified the differential involvement of T and B cell subsets in the pathogenesis of GD. Abnormalities in the differentiation of Th17, Tfh, and double-negative B cells reflected the clinical pathology associated with autoantibody production and excess thyroid hormones. And Th17 cells are significantly associated with the marker for resistance to treatment. These results suggest the involvement of Th17 cell activation in the intractable pathology associated with potential immune abnormalities in GD.

Clinical trial registration: #UMIN000017726 (Date: June 1st, 2015).

Changes in Glucose Intolerance after Treatment with Antithyroid Drugs in Patients with Graves' Disease Using Continuous Glucose Monitoring: A Pilot Study

Objective Graves' disease (GD) is known to cause glucose intolerance. The present study used continuous glucose monitoring (CGM) in 15 patients newly diagnosed with GD to evaluate changes in glucose trends following improvement in the thyroid function. Methods At the time of the diagnosis of GD, each participant wore a CGM monitor for seven days, and the data recorded on days 3 to 5 were analyzed. The clinical status before treatment with antithyroid drugs was evaluated. Following successful treatment with antithyroid drugs and improvement of free thyroxine (fT4) to within the normal range, CGM was used again to evaluate the same variables after treatment. Results The primary outcome, the standard deviation (SD) of glucose, improved from a baseline value of 28.9±4.9 to a post-treatment value of 22.2±5.1 mg/dL (p=0.001). Other variables also improved after treatment, including the mean amplitude of glycemic excursion (MAGE), daily average glucose level, nocturnal average glucose level (0:00-05:59), maximum and minimum glucose, percent time with glucose at >140 mg/dL, and percent time with glucose at >180 mg/dL; however, the coefficient of variation (CV) and percent time with glucose at <70 mg/dL did not improve. A univariate analysis showed the significant correlation of the SD with TSH receptor antibody (TRAb) and 1,5-Anhydro-D-Glucitol (1,5-AG). Conclusions Our results showed that CGM-based markers of mean glucose and glucose variability improved with the improvement of the thyroid function in newly diagnosed GD patients treated with antithyroid drugs.

Routine Assessment of Patient Index Data 3 (RAPID3) in Patients with Rheumatoid Arthritis Treated with Long-Term Upadacitinib Therapy in Five Randomized Controlled Trials

Introduction

The Routine Assessment of Patient Index Data 3 (RAPID3) is a patient-reported outcome tool recommended for the assessment of disease activity in patients with rheumatoid arthritis (RA) in clinical practice. This analysis evaluated the long-term effect of upadacitinib vs. comparators on RAPID3 scores in patients with RA in the phase 3 SELECT clinical trial program.

Methods

This post hoc analysis included data from five randomized controlled trials (RCTs) in patients receiving upadacitinib 15 mg or 30 mg once daily (QD) as monotherapy or in combination with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). The proportions of patients reporting RAPID3 remission (scores ≤ 3) were assessed at week 60. 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]) at week 60 were assessed using Spearman correlation coefficients.

Results

A total of 3117 patients were included from the SELECT-NEXT, -BEYOND, -MONOTHERAPY, -COMPARE, and -EARLY trials. By week 60, 32–52% of methotrexate-naïve and csDMARD inadequate responder (IR) patients treated with either upadacitinib 15 mg QD or upadacitinib 30 mg QD reported RAPID3 scores consistent with remission. The proportions were slightly lower in the biologic DMARD-IR SELECT-BEYOND population (19–28%). RAPID3 scores highly correlated (Spearman correlation values ≥ 0.58) with CDAI, SDAI, and DAS28(CRP) scores through week 60 (all p < 0.001).

Conclusions

Upadacitinib, as monotherapy or in combination with csDMARDs, was associated with patient-reported remission assessed by RAPID3 over 60 weeks across the SELECT RCTs in patients with RA.

Trial registration

SELECT-BEYOND (NCT02706847); SELECT-NEXT (NCT02675426); SELECT-MONOTHERAPY (NCT02706951); SELECT-EARLY (NCT02706873); SELECT-COMPARE (NCT02629159).

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-022-00483-4.

Rheumatoid arthritis (RA) is a disease that causes inflammation of the joints. Doctors have several ways of assessing how bad a patient’s disease is, and these often use a combination of signs and symptoms to develop a ‘score’. One method is called RAPID3, which is a score based on an overall assessment of the disease by the patient, the level of pain, and the amount of physical disability. An advantage of RAPID3 is that it is quick and easy to use, and since it uses only patient-reported symptoms, it can be measured easily via telemedicine, without the need for an in-person consultation. In this study, we decided to look into the effect of upadacitinib, a drug used for the treatment of RA, on RAPID3 score in patients with RA. We also investigated whether RAPID3 correlates with other ways of measuring RA severity, including scores that use physician-measured factors such as number of affected joints, as this can help show whether RAPID3 is a valid and useful tool. We found that upadacitinib led to long-term improvements in RAPID3 score, and that results were the same in different studies and patient groups, including patients who had not responded well to other treatments. We also found that RAPID3 correlated well with other measures, i.e., improvements in RAPID3 happened in parallel with improvements in other scores. Overall, these results suggest that RAPID3 can be a useful tool in patients with RA.

Role of DNA dioxygenase Ten-Eleven translocation 3 (TET3) in rheumatoid arthritis progression

Background

Rheumatoid arthritis (RA) patients present with abnormal methylation patterns in their fibroblast-like synoviocytes (FLS). Given that DNA demethylation is critical for producing DNA methylation patterns, we hypothesized that DNA demethylation may facilitate RA progression. Therefore, we designed this study to examine the role of DNA dioxygenase family, Ten-Eleven translocation (TET1/2/3), in the pathological process of RA.

Methods

Synovial tissues and FLS were obtained from patients with RA and Osteoarthritis. K/BxN serum-induced arthritis was induced in Wild-type (WT) and TET3 heterozygous-deficient (TET3^+/−) C57BL/6 mice.

Results

We found that both TET3 and 5-hydroxymethylcytosine (5hmC) were upregulated in synovitis tissues from RA patients and confirmed this upregulation in the cultured FLS derived from synovitis tissues. Tumor necrosis factor α (TNFα) upregulated TET3 and 5hmC levels in cultured FLS, and the stimulated FLS exhibited high cell mobility with increased transcription of cellular migration-related factors such as C-X-C motif chemokine ligand 8 (CXCL8) and C-C motif chemokine ligand 2 (CCL2) in a TET3-dependent manner. In addition, TET3 haploinsufficiency lowered RA progression in a mouse model of serum-induced arthritis.

Conclusions

Based on these findings, we can assume that TET3-mediated DNA demethylation acts as an epigenetic regulator of RA progression.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02908-5.

Enhancer RNA commits osteogenesis via microRNA-3129 expression in human bone marrow-derived mesenchymal stem cells

Background

Highly regulated gene expression program underlies osteogenesis of mesenchymal stem cells (MSCs), but the regulators in the program are not entirely identified. As enhancer RNAs (eRNAs) have recently emerged as a key regulator in gene expression, we assume a commitment of an eRNA in osteogenesis.

Methods

We performed in silico analysis to identify potential osteogenic microRNA (miRNA) gene predicted to be regulated by super-enhancers (SEs). SE inhibitor treatment and eRNA knocking-down were used to confirm the regulational mechanism of eRNA. miRNA function in osteogenesis was elucidated by miR mimic and inhibitor transfection experiments.

Results

miR-3129 was found to be located adjacent in a SE (osteoblast-specific SE_46171) specifically activated in osteoblasts by in silico analysis. A RT-quantitative PCR analysis of human bone marrow-derived MSC (hBMSC) cells showed that eRNA_2S was transcribed from the SE with the expression of miR-3129. Knockdown of eRNA_2S by locked nucleic acid as well as treatment of SE inhibitors JQ1 or THZ1 resulted in low miR-3129 levels. Overexpression of miR-3129 promoted hBMSC osteogenesis, while knockdown of miR-3129 inhibited hBMSC osteogenesis. Solute carrier family 7 member 11 (SLC7A11), encoding a bone formation suppressor, was upregulated following miR-3129-5p inhibition and identified as a target gene for miR-3129 during differentiation of hBMSCs into osteoblasts.

Conclusions

miR-3129 expression is regulated by SEs via eRNA_2S and this miRNA promotes hBMSC differentiation into osteoblasts through downregulating the target gene SLC7A11. Thus, the present study uncovers a commitment of an eRNA via a miR-3129/SLC7A11 regulatory pathway during osteogenesis of hBMSCs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41232-022-00228-4.

Efficacy and tolerability of subcutaneously administered methotrexate including dose escalation in long-term treatment of rheumatoid arthritis in a Japanese population

OBJECTIVES

To evaluate the efficacy and safety of subcutaneously administered methotrexate (MTX) for Japanese patients with active rheumatoid arthritis (RA).

METHODS

MTX-naïve patients were randomized in a 1:1 ratio to receive a 12-week administration of either 7.5 mg MTX subcutaneously (MJK101, a prefilled syringe for subcutaneous injection) or 8 mg MTX orally in Part 1 of the trial. The primary endpoint was a 20% improvement in American College of Rheumatology criteria (ACR20) at Week 12. In the second part, all enrolled patients received MJK101 weekly for 52 weeks with doses starting from 7.5 mg to 15 mg with 2.5 mg increments with the option of self-administration of MJK101.

RESULTS

Efficacy of MJK101 was comparable to oral MTX following 12 weeks treatment at the starting doses. A numerically higher ACR20 response rate and fewer adverse events (AEs) in particular gastrointestinal AEs were observed. During long-term subcutaneous treatment MJK101 was well tolerated across all tested doses. Patients clinically improved upon dose escalation.

CONCLUSIONS

Subcutaneously applied MTX (MJK101) was efficient and well tolerated over a long-term treatment period in the Japanese population with doses up to 15 mg/week. Subcutaneous administration of MTX is a beneficial option for Japanese patients with RA.

Impact of initial therapy with upadacitinib or adalimumab on achievement of 48-week treatment goals in patients with rheumatoid arthritis: post hoc analysis of SELECT-COMPARE

OBJECTIVES

Evaluate the importance of treatment sequencing in SELECT-COMPARE, assessing potential differences between starting upadacitinib or adalimumab therapy following inadequate MTX response.

METHODS

Patients from SELECT-COMPARE were randomized to upadacitinib 15 mg once daily, placebo, or adalimumab 40 mg. Per protocol, patients with <20% improvement in tender or swollen joint counts (weeks 14, 18, 22) or failure to achieve CDAI LDA at week 26 were blindly switched from upadacitinib to adalimumab or vice versa. Treatment outcomes, including clinical remission/LDA, physical function, pain, and a novel combined end point for deep response, were evaluated through 48 weeks and corresponding time-averaged response rates determined. Data were analysed by initial randomized group regardless of any subsequent switch in therapy.

RESULTS

This post hoc analysis included 651 patients initially randomized to upadacitinib (of whom 252 switched to adalimumab) and 327 patients initially randomized to adalimumab (of whom 159 switched to upadacitinib). At week 48, patients randomized to either therapy demonstrated similar achievement of most treatment endpoints. Greater improvements in the total time spent in a lower disease state were observed for initial upadacitinib versus initial adalimumab therapy across most clinical and patient-reported outcomes through 48 weeks, and the median time to DAS28(CRP) <2.6/≤3.2 occurred 6-8 weeks earlier among those randomized to upadacitinib.

CONCLUSION

Following a modified treat-to-target strategy, rates of CDAI remission/LDA and DAS28(CRP) <2.6/≤3.2 at 48 weeks were similar, regardless of starting therapy. However, patients initially receiving upadacitinib reached treatment targets more quickly and spent more time in clinical targets over the initial 48 weeks of treatment.

TRIAL REGISTRATION

ClinicalTrials.gov, https://clinicaltrials.gov, NCT02629159.

Mechanism of action of baricitinib and identification of biomarkers and key immune pathways in patients with active systemic lupus erythematosus

OBJECTIVES

To elucidate the mechanism of action of baricitinib, a Janus kinase (JAK) 1/2 inhibitor, and describe immunological pathways related to disease activity in adults with systemic lupus erythematosus (SLE) receiving standard background therapy in a phase II trial.

METHODS

Patients with SLE were treated with baricitinib 2 mg or 4 mg in a phase II randomised, placebo-controlled study. Sera from 239 patients (baricitinib 2 mg: n=88; baricitinib 4 mg: n=82; placebo: n=69) and 49 healthy controls (HCs) were collected at baseline and week 12 and analysed using a proximity extension assay (Target 96 Inflammation Panel (Olink)). Interferon (IFN) scores were determined using an mRNA panel. Analytes were compared in patients with SLE versus HCs and in changes from baseline at week 12 between baricitinib 2 mg, 4 mg and placebo groups using a restricted maximum likelihood-based mixed models for repeated measures. Spearman correlations were computed for analytes and clinical measurements.

RESULTS

At baseline, SLE sera had strong cytokine dysregulation relative to HC sera. C-C motif chemokine ligand (CCL) 19, C-X-C motif chemokine ligand (CXCL) 10, tumour necrosis factor alpha (TNF-α), TNF receptor superfamily member (TNFRSF)9/CD137, PD-L1, IL-6 and IL-12β were significantly reduced in patients treated with baricitinib 4 mg versus placebo at week 12. Inflammatory biomarkers indicated correlations/associations with type I IFN (CCL19, CXCL10, TNF-α and PD-L1), anti-double stranded DNA (dsDNA) (TNF-α, CXCL10) and Systemic Lupus Erythematosus Disease Activity Index-2000, tender and swollen joint count and worst joint pain (CCL19, IL-6 and TNFRSF9/CD137).

CONCLUSION

These results suggest that baricitinib 4 mg downregulated key cytokines that are upregulated in patients with SLE and may play a role in a multitargeted mechanism beyond the IFN signature although clinical relevance remains to be further delineated.

TRIAL REGISTRATION NUMBER

NCT02708095.

Multi-trait and cross-population genome-wide association studies across autoimmune and allergic diseases identify shared and distinct genetic component

OBJECTIVES

Autoimmune and allergic diseases are outcomes of the dysregulation of the immune system. Our study aimed to elucidate differences or shared components in genetic backgrounds between autoimmune and allergic diseases.

METHODS

We estimated genetic correlation and performed multi-trait and cross-population genome-wide association study (GWAS) meta-analysis of six immune-related diseases: rheumatoid arthritis, Graves' disease, type 1 diabetes for autoimmune diseases and asthma, atopic dermatitis and pollinosis for allergic diseases. By integrating large-scale biobank resources (Biobank Japan and UK biobank), our study included 105 721 cases and 433 663 controls. Newly identified variants were evaluated in 21 778 cases and 712 767 controls for two additional autoimmune diseases: psoriasis and systemic lupus erythematosus. We performed enrichment analyses of cell types and biological pathways to highlight shared and distinct perspectives.

RESULTS

Autoimmune and allergic diseases were not only mutually classified based on genetic backgrounds but also they had multiple positive genetic correlations beyond the classifications. Multi-trait GWAS meta-analysis newly identified six allergic disease-associated loci. We identified four loci shared between the six autoimmune and allergic diseases (rs10803431 at PRDM2, OR=1.07, p=2.3×10-8, rs2053062 at G3BP1, OR=0.90, p=2.9×10-8, rs2210366 at HBS1L, OR=1.07, p=2.5×10-8 in Japanese and rs4529910 at POU2AF1, OR=0.96, p=1.9×10-10 across ancestries). Associations of rs10803431 and rs4529910 were confirmed at the two additional autoimmune diseases. Enrichment analysis demonstrated link to T cells, natural killer cells and various cytokine signals, including innate immune pathways.

CONCLUSION

Our multi-trait and cross-population study should elucidate complex pathogenesis shared components across autoimmune and allergic diseases.

Consensus statement on blocking interleukin-6 receptor and interleukin-6 in inflammatory conditions: an update

BACKGROUND

Targeting interleukin (IL)-6 has become a major therapeutic strategy in the treatment of immune-mediated inflammatory disease. Interference with the IL-6 pathway can be directed at the specific receptor using anti-IL-6Rα antibodies or by directly inhibiting the IL-6 cytokine. This paper is an update of a previous consensus document, based on most recent evidence and expert opinion, that aims to inform on the medical use of interfering with the IL-6 pathway.

METHODS

A systematic literature research was performed that focused on IL-6-pathway inhibitors in inflammatory diseases. Evidence was put in context by a large group of international experts and patients in a subsequent consensus process. All were involved in formulating the consensus statements, and in the preparation of this document.

RESULTS

The consensus process covered relevant aspects of dosing and populations for different indications of IL-6 pathway inhibitors that are approved across the world, including rheumatoid arthritis, polyarticular-course and systemic juvenile idiopathic arthritis, giant cell arteritis, Takayasu arteritis, adult-onset Still's disease, Castleman's disease, chimeric antigen receptor-T-cell-induced cytokine release syndrome, neuromyelitis optica spectrum disorder and severe COVID-19. Also addressed were other clinical aspects of the use of IL-6 pathway inhibitors, including pretreatment screening, safety, contraindications and monitoring.

CONCLUSIONS

The document provides a comprehensive consensus on the use of IL-6 inhibition to treat inflammatory disorders to inform healthcare professionals (including researchers), patients, administrators and payers.

Safety and Efficacy of Filgotinib for Japanese Patients with RA and Inadequate Response to MTX: FINCH 1 52-Week Results and FINCH 4 48-Week Results

OBJECTIVE

To present safety and efficacy of the JAK1 preferential inhibitor filgotinib in Japanese patients with prior inadequate response (IR) to methotrexate (MTX) from a 52-week randomised controlled parent study (PS) and long-term extension (LTE) through June 2020.

METHODS

The PS (NCT02889796) randomised MTX-IR patients to filgotinib 200 (FIL200) or 100 mg (FIL100), adalimumab (ADA) 40 mg, or placebo; all took stable background MTX. At week (W) 24, placebo patients were rerandomised to FIL200 or FIL100. The primary endpoint was W12 American College of Rheumatology 20% improvement (ACR20); safety was assessed by adverse event (AE) reporting. For the LTE (NCT03025308), eligible filgotinib patients continued FIL200/FIL100; ADA patients were rerandomised (blinded) to FIL200 or FIL100; all continued MTX.

RESULTS

114/147 Japanese patients completed the PS; 115 enrolled in LTE; 103 remained on study in June 2020. In the PS, AEs were consistent with the overall population, and W24 efficacy was maintained or improved through W52, comparable with the overall population. LTE AE incidences were similar between doses; filgotinib efficacy was consistent from baseline to W48 and similar between PS ADA and filgotinib patients.

CONCLUSION

Among MTX-IR Japanese patients, filgotinib maintained efficacy over 1 year; LTE safety was consistent with the PS.

Long-Term Safety and Efficacy of Filgotinib Treatment for Rheumatoid Arthritis in Japanese Patients Naïve to MTX Treatment (FINCH 3)

OBJECTIVES

To evaluate long-term safety and efficacy of filgotinib for Japanese patients with rheumatoid arthritis (RA) and limited/no prior methotrexate (MTX) exposure. We present a Japanese population subanalysis of a global randomised-controlled trial at Week 52 and interim long-term extension (LTE) to Week 48 through June 2020.

METHODS

Patients were randomised to filgotinib 200 mg plus MTX, filgotinib 100 mg plus MTX, filgotinib 200 mg, or MTX for 52 weeks. At completion, eligible patients could enrol in the LTE. Those receiving filgotinib continued; those receiving MTX were rerandomised (blinded) to filgotinib 200 or 100 mg upon discontinuation of MTX. After a 4-week washout period, MTX could be re-added.

RESULTS

Adverse event rates at Week 52 and in the LTE to Week 48 were comparable across treatment groups. Week 52 American College of Rheumatology 20% improvement (ACR20) rates were 83% (19/23), 82% (9/11), 75% (9/12), and 76% (19/25) for filgotinib 200 mg plus MTX, filgotinib 100 mg plus MTX, filgotinib 200 mg, and MTX, respectively. Through LTE Week 48, ACR20 rates were maintained.

CONCLUSIONS

In the 56 Japanese patients treated with filgotinib, efficacy was maintained through Week 52 and beyond, with no increases in the incidence of adverse events.

Management of non-renal manifestations of systemic lupus erythematosus: A systematic literature review for the APLAR consensus statements

The prevalence of systemic lupus erythematosus (SLE) is higher in Asians than Caucasians, with higher frequency of renal and other major organ manifestations that carry a poorer prognosis. The outcome of SLE is still unsatisfactory in many parts of the Asia Pacific region due to limited access to healthcare systems, poor treatment adherence and adverse reactions to therapies. The Asia Pacific League of Associations for Rheumatology (APLAR) SLE special interest group has recently published a set of consensus recommendation statements for the management of SLE in the Asia Pacific region. The current article is a supplement of systematic literature search (SLR) to the prevalence and treatment of non-renal manifestations of SLE in Asian patients.

Precision medicine based on the phenotypic differences in peripheral T helper cells in patients with psoriatic arthritis: One year follow-up outcomes

Purpose

We validated the one-year effectiveness of strategic treatment with biological disease-modifying anti-rheumatic drugs (bDMARDs) based on peripheral T-lymphocytic phenotyping and explored the impact of treatment on T helper lymphocytic phenotypes.

Methods

Ninety-seven patients were registered in this study. One-year treatment response was compared between the two groups: the strategic bDMARDs treatment group (n = 41), in which bDMARDs were selected based on peripheral blood lymphocyte analysis, and the standard bDMARDs treatment group (n = 56), in which the patients underwent no strategic selection of bDMARDs and phenotyping. Changes in helper T lymphocytic phenotypes were evaluated after 1-year post-treatment.

Results

In the standard bDMARDs treatment group, 23 patients (42.6%) achieved disease activity in psoriatic arthritis (DAPSA)-remission (REM), and 23 of 46 (50.0%) achieved PASI 90. In the strategic bDMARDs treatment group, 22 (53.7%) achieved DAPSA-REM, and 26 of 35 (74.2%) achieved PASI90. The rate of achieving minimal disease activity (MDA) and DAPSA-REM at month 6, DAPSA-low disease activity (LDA) at months 6 and 12, and PASI 90 at month 12 were significantly higher in the strategic bDMARDs treatment group. After treatment with ustekinumab, the proportion of aTh1/CD4 (%) significantly decreased. The percent reduction in activated Th17 cells was significantly higher in IL-17-i cells than in UST/TNF-i cells.

Conclusions

The results of this study demonstrate the 1-year effectiveness of precision medicine based on peripheral T-lymphocytic phenotyping in terms of DAPSA and MDA. Analysis of data from real-world clinical practice showed that the impact on the immune system varied among bDMARDs. However, because psoriatic arthritis has very high heterogeneity, it may be necessary to conduct studies with a larger sample size, perhaps drawing samples from multiple institutions.

Phase 3, multicentre, randomised, placebo-controlled study evaluating the efficacy and safety of ustekinumab in patients with systemic lupus erythematosus

OBJECTIVE

Evaluate the efficacy and safety of ustekinumab, an anti-interleukin-12/23 p40 antibody, in a phase 3, randomised, placebo-controlled study of patients with active systemic lupus erythematosus (SLE) despite receiving standard-of-care.

METHODS

Active SLE patients (SLE Disease Activity Index 2000 (SLEDAI-2K) ≥6 during screening and SLEDAI-2K ≥4 for clinical features at week 0) despite receiving oral glucocorticoids, antimalarials, or immunomodulatory drugs were randomised (3:2) to receive ustekinumab (intravenous infusion ~6 mg/kg at week 0, followed by subcutaneous injections of ustekinumab 90 mg at week 8 and every 8 weeks) or placebo through week 48. The primary endpoint was SLE Responder Index (SRI)-4 at week 52, and major secondary endpoints included time to flare through week 52 and SRI-4 at week 24.

RESULTS

At baseline, 516 patients were randomised to placebo (n=208) or ustekinumab (n=308). Following the planned interim analysis, the sponsor discontinued the study due to lack of efficacy but no safety concerns. Efficacy analyses included 289 patients (placebo, n=116; ustekinumab, n=173) who completed or would have had a week 52 visit at study discontinuation. At week 52, 44% of ustekinumab patients and 56% of placebo patients had an SRI-4 response; there were no appreciable differences between the treatment groups in the major secondary endpoints. Through week 52, 28% of ustekinumab patients and 32% of placebo patients had a British Isles Lupus Assessment Group flare, with a mean time to first flare of 204.7 and 200.4 days, respectively. Through week 52, 70% of ustekinumab patients and 74% of placebo patients had ≥1 adverse event.

CONCLUSIONS

Ustekinumab did not demonstrate superiority over placebo in this population of adults with active SLE; adverse events were consistent with the known safety profile of ustekinumab.

TRIAL REGISTRATION NUMBER

NCT03517722.

Optimization of a Stacked-design Core-body-temperature Sensor for Long-period Human Trials

We fabricated a wearable sensor that can be attached to the skin surface and continuously measure core body temperature (CBT) wirelessly over a long period. CBT is calculated from skin-surface temperature and heat flux passing through the sensor. Since heat flux is lost to the surroundings of the probe, the slightest change in convection in daily life will degrade the measurement accuracy of the sensor. Accordingly, we previously proposed a heat-flux-path control structure to reduce the absolute amount of heat-flux loss. To make wearable sensors for long-term human trials, we proposed an integrated design in which a sensor probe, a circuit board, and a battery are stacked. We optimized the proposed design by computer simulation and evaluated the fabricated sensor by a phantom experiment in which the convectional state was changed. The evaluation results demonstrate that the sensor has limits of agreement (LOA) of [-0.13; 0.03]°C under 1-m/s-wind convection. Moreover, a preliminary human trial conducted under daily-life conditions (including convectional changes) demonstrated that the sensor has LOA of [-0.18; 0.22]°C. These results demonstrate that the fabricated sensor is suitable for CBT measurement.

P-603 Presence of an asymmetrical response to ovarian stimulation in patients with low ovarian reserve

Study question

Does ovarian reserve decline with a symmetrical manner between right and left ovaries in poor responders (POR) with diminished ovarian reserve (DOR)?

Summary answer

Asymmetrical ovarian response to ovarian stimulation with the left-side dominance was found in POR with DOR.

What is known already

Ovarian follicles are produced during fetal stage and not regenerated after birth. Thus, the number of ovarian follicles declines with age, resulting in infertile POR with DOR. In the morphometric study of human neonatal ovaries, no significant difference was found in the number of follicles between the right and left ovaries in the same individual. A previous study demonstrated that there is a difference in the number of follicles between right and left ovaries in patients with normal ovarian reserve with the right-side dominance, suggesting the asymmetrical activation and growth of follicles.

Study design, size, duration

A retrospective analysis was conducted in patients with POR with DOR based on the Bologna Criteria. Inclusion criteria was patients who received more than five times of ovarian stimulations followed by oocyte retrievals. Data were obtained from a total of 265 participants who received IVF-ET treatments from April 2015 to March 2021 after receiving written informed consents under an approval from the institutional ethical committee. Patients with the history of previous ovarian surgery were excluded.

Participants/materials, setting, methods

The enrolled patients were received ovarian simulation under short or GnRH antagonist protocols for oocyte retrieval. We collected the data of retrieved oocyte number as well as the outcome of IVF from medical chart. We defined the right-left asymmetry of ovarian reserve (%) based on the number of retrieved oocytes from dominant side ovary per total number of retrieved oocytes. Statistical significance was determined using Dunnett or chi-square tests, with P &lt; 0.05 being statistically significant.

Main results and the role of chance

The average age of participants was 37.2±5.99 years of age exhibiting low serum AMH levels (average 0.09±0.20 ng/ml). We analyzed 2,181 cycles of ovarian stimulation (average 8.3±3.9 cycles/patient). The number of retrieved oocytes were 3, 882 in total cycles (average 12.8±7.1/patient). Among participants, 22 cases (8.4%) showed left and right equal in the number of retrieved oocytes, whereas &gt;70% asymmetry was observed in 107 cases (40.7%) and &gt;80% asymmetry was detected in 60 cases (22.8%). In 18 cases (6.9%), oocytes were collected from one side ovary only showing 100% asymmetry. In the cases with &gt;70 and 100% asymmetry, the left-side dominance was 1.3-fold and 5.0-fold higher than right-side dominance, respectively. In cases with 100% asymmetry, there was no difference in the number of cryopreserved high-quality embryos between left and right sides of ovary.

Limitations, reasons for caution

Although we enrolled POR with DOR patients who received ovarian stimulations more than five times, the duration of ovarian stimulation was different among patients. It affects the numbers of ovarian stimulation cycles and retrieved oocytes in each patient.

Wider implications of the findings

Considering the finding of right-side dominance in the number of follicles with normal ovarian reserve, the activation and development of follicles might be accelerated in the right side due to asymmetric blood supply to the ovaries, and thus follicles are likely remained in the left-side ovary with low ovarian reserve.

Trial registration number

not applicable

A case of mixed connective tissue disease complicated by pulmonary hypertension and ascites after addition of pulmonary vasodilators

We present the case of a 54-year-old woman with a long history of pulmonary hypertension associated with mixed connective tissue disease. She was being treated with pulmonary vasodilators, including epoprostenol and bosetan, but her mean pulmonary arterial pressure (mPAP) gradually worsened. Although her mPAP began to improve with adding sildenafil, ascites occurred. Discontinuing newly initiated drugs and starting diuretics improved her ascites. This suggested that an intensification of the treatment with vasodilators might have led to ascites (on a background of a probable arteriovenous shunt formation) in this patient with a long history of pulmonary hypertension.

A case of simultaneous onset of highly active systemic lupus erythematosus and IgG4-related renal disease

The patient was a 73-year-old woman who had hair loss, purpura, and numbness of the soles for past 1 year. Three months prior, she was diagnosed with interstitial lung disease (ILD) and was admitted to our department. She was diagnosed with systemic lupus erythematosus (SLE) based on positive antinuclear antibodies 1280× (speckled type), hair loss, low white blood cell count, positive anti-cardiolipin and anti-ds-DNA antibodies, and lupus retinopathy. In addition, the patient was also diagnosed with immunoglobulin G (IgG)4-related disease (IgG4RD) based on high serum IgG4 levels, ILD, urine occult blood, protein, and cast, and renal histological findings showed endocapillary proliferative glomerulonephritis, increased IgG4 positive plasma cells, and characteristic storiform fibrosis. High-dose glucocorticoid therapy, hydroxychloroquine, and belimumab were administered, which improved the SLE symptoms of lupus retinopathy and peripheral neuropathy, as well as the IgG4RD symptoms of ILD and urinary findings. Herein, we report a rare case of simultaneous onset of IgG4-related nephropathy with active glomerular lesions and SLE, in which renal histology, including fluorescent antibodies, was crucial for diagnosis.

Pentacyclic triterpenoid ursolic acid induces apoptosis with mitochondrial dysfunction in adult T-cell leukemia MT-4 cells to promote surrounding cell growth

We investigated the antitumor effects of oleanolic acid (OA) and ursolic acid (UA) on adult T-cell leukemia cells. OA and UA dose-dependently inhibited the proliferation of adult T-cell leukemia cells. UA-treated cells showed caspase 3/7 and caspase 9 activation. PARP cleavage was detected in UA-treated MT-4 cells. Activation of mTOR and PDK-1 was inhibited by UA. Autophagosomes were detected in MT-4 cells after UA treatment using electron microscopy. Consistently, mitophagy was observed in OA- and UA-treated MT-4 cells by confocal microscopy. The mitochondrial membrane potential in MT-4 cells considerably decreased, and mitochondrial respiration and aerobic glycolysis were significantly reduced following UA treatment. Furthermore, MT-1 and MT-4 cells were sorted into two regions based on their mitochondrial membrane potential. UA-treated MT-4 cells from both regions showed high activation of caspase 3/7, which were inhibited by Z-vad. Interestingly, MT-4 cells cocultured with sorted UA-treated cells showed enhanced proliferation. Finally, UA induced cell death and ex vivo PARP cleavage in peripheral blood mononuclear cells from patients with adult T-cell leukemia. Therefore, UA-treated MT-4 cells show caspase activation following mitochondrial dysfunction and may produce survival signals to the surrounding cells.

LB0001 BIMEKIZUMAB IN BDMARD-NAIVE PATIENTS WITH PSORIATIC ARTHRITIS: 24-WEEK EFFICACY & SAFETY FROM BE OPTIMAL, A PHASE 3, MULTICENTRE, RANDOMISED, PLACEBO-CONTROLLED, ACTIVE REFERENCE STUDY

Background

Bimekizumab (BKZ) is a monoclonal IgG1 antibody that selectively inhibits IL-17F in addition to IL-17A.

Objectives

Assess BKZ efficacy and safety vs PBO in bDMARD-naïve pts with active PsA to Wk 24 of BE OPTIMAL.

Methods

BE OPTIMAL (NCT03895203) comprises 16 wks double-blind PBO-controlled and 36 wks treatment-blind. Pts were ≥18 yrs, bDMARD-naïve, with adult-onset, active PsA, ≥3 tender and ≥3 swollen joints. Pts randomised 3:2:1, subcutaneous BKZ 160 mg Q4W:PBO:adalimumab (ADA; reference arm) 40 mg Q2W. From Wk 16, PBO pts received BKZ 160 mg Q4W. Primary endpoint: ACR50 at Wk 16.

Results

821/852 (96.4%) pts completed Wk 16 and 806 (94.6%) Wk 24. Mean age 48.7 yrs, BMI 29.2 kg/m2; since diagnosis: 5.9 yrs; 46.8% male. BL characteristics comparable across arms. Primary endpoint met (Wk 16 ACR50: 43.9% BKZ vs 10.0% PBO, p<0.001; ADA: 45.7%; Figure 1). All ranked secondary endpoints met at Wk 16 (Table 1). As early as Wk 2, ACR20 was higher in BKZ vs PBO (27.1% vs 7.8%, nominal p<0.001; ADA: 33.6%). Outcomes continued to improve at Wk 24 (Table 1). To Wk 16, pts with ≥1 TEAE, BKZ: 59.9%; PBO: 49.5%; ADA: 59.3%. SAE rate low (1.6%; 1.1%; 1.4%). Most frequent (≥5%) AEs for all arms: nasopharyngitis (9.3%; 4.6%; 5.0%), URTI (4.9%; 6.4%; 2.1%), increased ALT (0.7%; 0.7%; 5.0%). Candida infections: 2.6%, 0.7%, 0%; no systemic candidiasis. 2 malignancies (BKZ: basal cell carcinoma; PBO: breast cancer stage 1); no MACE, uveitis, IBD or deaths.

Table 1.

Wk 16 and 24 efficacy

BLWk 16Wk 24PBO N=281BKZ 160 mg Q4W N=431ADA 40 mg Q2W N=140†PBO N=281BKZ 160 mg Q4W N=431ADA 40 mg Q2W N=140†p value (BKZ vs PBO)PBO→ BKZ 160 mg Q4WaN=281BKZ 160 mg Q4W N=431ADA 40 mg Q2W N=140†Ranked endpointsbACR50 [NRI],–––28189 (43.9)64<0.00110119666n (%)-10-45.7(35.9)(45.5)-47.1HAQ-DI CfB [MI],0.890.820.86−0.09 (0.03)−0.26 (0.02)−0.33<0.001c−0.28−0.30−0.34mean (SE)-0.04-0.03-0.05(0.04)(0.03)(0.02)(0.05)PASI90d [NRI],–––4133 (61.3)f28<0.00186 (61.4)e158 (72.8)f32n (%)(2.9)e(41.2)g(47.1)gSF-36 PCS CfB [MI],36.938.137.62.36.36.8<0.001c6.27.37.3mean (SE)-0.6-0.5-0.7-0.5-0.4-0.8-0.5-0.4-0.8MDA [NRI],51413719463<0.00110620967n (%)-1.8-3.2-0.7-13.2(45.0)-45(37.7)(48.5)-47.9vdHmTSS CfB (subgroup)h [MI], mean (SE)15.67 (1.80)i15.56 (1.69)j17.39 (2.89)k0.36 (0.10)i−0.01 (0.04)j−0.06 (0.08)k<0.001c–––vdHmTSS CfB [MI],mean (SE)13.31 (1.56)l13.44 (1.47)m14.55 (2.44)n0.31 (0.09)l0(0.04)m−0.03 (0.07)n0.001c–––Other endpointsACR20 [NRI],–––6726896<0.001o17528299n (%)-23.8(62.2)-68.6(62.3)(65.4)-70.7ACR70 [NRI],–––1210539<0.001o5312642n (%)-4.3(24.4)-27.9-18.9(29.2)-30PASI100d [NRI],–––3103f14<0.001o6012226n (%)(2.1)e(47.5)(20.6)g(42.9)e (56.2)f(38.2)gTJC CfB [MI],17.116.817.5−3.2−10.0−10.9<0.001o−9.4−11.5−11.8mean (SE)-0.7-0.6-1.1(0.7) (0.5)-1(0.7)(0.5)-0.9SJC CfB [MI],9.599.6−3.0 (0.5)−6.6 (0.3)−7.5<0.001o−6.8 (0.4)−7.2 (0.3)−7.9mean (SE)-0.4-0.3-0.6-0.6-0.6

Randomised set. Interim results.

†Reference arm; study not powered for statistical comparisons of ADA to BKZ or PBO.

aPBO→BKZ pts received PBO to Wk 16, switched to BKZ 160 mg Q4W through Wk 24 (8 wks BKZ);

bResolution of enthesitis/dactylitis in pts with LEI>0/LDI>0 at BL pooled with BE COMPLETE (Wk 16 LEI=0 BKZ: 124/249 [49.8%], PBO: 37/106 [34.9%], p=0.008; LDI=0 BKZ: 68/90 [75.6%], PBO: 24/47 [51.1%], p=0.002);

cContinuous outcome p values calculated with RBMI data;

dPts with PSO and ≥3% BSA at BL;

en=140;

fn=217;

gn=68;

hPts with hs-CRP ≥6 mg/L and/or bone erosion at BL;

in=221;

jn=357;

kn=108;

ln=261;

mn=416;

nn=131;

oNominal, not powered for multiplicity.

Conclusion

Dual inhibition of IL-17A and IL-17F with BKZ in bDMARD-naïve pts with active PsA resulted in rapid, clinically relevant improvements in musculoskeletal and skin outcomes vs PBO. No new safety signals observed.1,2

References

[1]Ritchlin CT Lancet 2020;395(10222):427–40; 2. Coates LC Ann Rheum Dis 2021;80:779–80(POS1022).

Disclosure of Interests

Iain McInnes Consultant of: AbbVie, BMS, Boehringer Ingelheim, Celgene, Eli Lilly, Janssen, Novartis, and UCB Pharma, Grant/research support from: BMS, Boehringer Ingelheim, Celgene, Janssen, UCB Pharma, Laura Coates Consultant of: AbbVie, Amgen, Boehringer Ingelheim, BMS, Celgene, Domain, Eli Lilly, Gilead, Galapagos, Janssen, Moonlake, Novartis, Pfizer, and UCB Pharma, Speakers bureau: AbbVie, Amgen, Biogen, Celgene, Eli Lilly, Galapagos, Gilead, GSK, Janssen, Medac, Novartis, Pfizer, and UCB Pharma, Grant/research support from: AbbVie, Amgen, Celgene, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, and UCB Pharma, Robert B.M. Landewé Consultant of: Abbott, Ablynx, Amgen, AstraZeneca, BMS, Centocor, GSK, Novartis, Merck, Pfizer, Roche, Schering-Plough, UCB Pharma, and Wyeth, Speakers bureau: Abbott, Amgen, BMS, Centocor, Merck, Pfizer, Roche, Schering-Plough, UCB Pharma, and Wyeth, Grant/research support from: Abbott, Amgen, Centocor, Novartis, Pfizer, Roche, Schering-Plough, UCB Pharma, and Wyeth, Philip J Mease Consultant of: AbbVie, Amgen, BMS, Boehringer Ingelheim, Eli Lilly, Galapagos, Gilead, GSK, Janssen, Novartis, Pfizer, Sun Pharma and UCB Pharma, Speakers bureau: AbbVie, Amgen, Eli Lilly, Janssen, Novartis, Pfizer and UCB Pharma, Grant/research support from: AbbVie, Amgen, BMS, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, Sun Pharma and UCB Pharma, Christopher T. Ritchlin Consultant of: AbbVie, Amgen, Eli Lilly, Gilead, Janssen, Novartis, Pfizer and UCB Pharma, Grant/research support from: AbbVie, Amgen and UCB Pharma, Yoshiya Tanaka Consultant of: AbbVie, Ayumi, Daiichi-Sankyo, Eli Lilly, GSK, Sanofi, and Taisho, Speakers bureau: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer-Ingelheim, Chugai, Eisai, Eli Lilly, Gilead, Mitsubishi-Tanabe, and YL Biologics, Grant/research support from: AbbVie, Asahi-Kasei, Boehringer-Ingelheim, Chugai, Corrona, Daiichi-Sankyo, Eisai, Kowa, Mitsubishi-Tanabe, and Takeda, Akihiko Asahina Grant/research support from: AbbVie, Amgen, Eisai, Eli Lilly, Janssen, Kyowa Kirin, LEO Pharma, Maruho, Mitsubishi Tanabe Pharma, Pfizer, Sun Pharma, Taiho Pharma, Torii Pharmaceutical, and UCB Pharma, Laure Gossec Consultant of: AbbVie, Amgen, BMS, Celltrion, Galapagos, Gilead, GSK, Janssen, Lilly, Novartis, Pfizer and UCB Pharma, Grant/research support from: Amgen, Galapagos, Lilly, Pfizer, Sandoz and UCB Pharma, Alice B Gottlieb Consultant of: Amgen, AnaptsysBio, Avotres Therapeutics, Boehringer Ingelheim, BMS, Dermavant, Eli Lilly, Incyte, Janssen, Novartis, Pfizer, Sanofi, Sun Pharma, UCB Pharma, and XBiotech, Grant/research support from: Boehringer Ingelheim, Janssen, Novartis, Sun Pharma, UCB Pharma, and XBiotech: all funds go to Mount Sinai Medical School, Richard B. Warren Consultant of: AbbVie, Almirall, Amgen, Arena, Astellas, Avillion, Biogen, BMS, Boehringer Ingelheim, Celgene, Eli Lilly, GSK, Janssen, LEO Pharma, Novartis, Pfizer, Sanofi, and UCB Pharma, Paid instructor for: Astellas, DiCE, GSK, and Union, Grant/research support from: AbbVie, Almirall, Janssen, LEO Pharma, Novartis, and UCB Pharma, Barbara Ink Shareholder of: GSK, UCB Pharma, Employee of: UCB Pharma, Deepak Assudani Shareholder of: UCB Pharma, Employee of: UCB Pharma, Jason Coarse Shareholder of: UCB Pharma, Employee of: UCB Pharma, Rajan Bajracharya Shareholder of: UCB Pharma, Employee of: UCB Pharma, Joseph F. Merola Consultant of: AbbVie, Amgen, Biogen, BMS, Dermavant, Eli Lilly, Janssen, Leo Pharma, Novartis, Pfizer, Regeneron, Sanofi, Sun Pharma, and UCB Pharma, Paid instructor for: Amgen, Abbvie, Biogen, BMS, Dermavant, Eli Lilly, Janssen, Leo Pharma, Novartis, Pfizer, Regeneron, Sanofi, Sun Pharma, and UCB Pharma

POS0734 THE CLINICAL JUDGMENT FOR THE ACCEPTABILITY OF PREGNANCY IN PATIENTS WITH SEROLOGICALLY ACTIVE SLE IN JAPAN: A NATIONWIDE ONLINE SURVEY FROM THE VIGNETTE STUDY

Background

The risk of pregnancy complications, such as gestational hypertension is high in pregnancies with SLE. In addition, the risk of flare is elevated if pregnancy occurs during the high disease activity. The EULAR recommendation provides a checklist for preconception counseling, in which patients with SLE desiring pregnancy were required the condition that the disease activity prior to pregnancy should be stable for 6-12 months in terms of serological activity (1). However, it does not provide specific criteria for serological activity so that physicians should evaluate the risk of pregnancy in each case by their clinical intuitions.

Objectives

In order to uncover the present clinical situation for the acceptability of pregnancy in patients with SLE, we performed questionnaire survey to physicians regarding to the degree of serological activity.

Methods

This cross-sectional study was performed to physicians registered with the Japanese College of Rheumatology from December 2020 to January 2021 using the online survey. The questionnaire asked about the characteristics of physicians, facilities and the permission of pregnancies with SLE using vignette scenarios. In this study, data from vignettes of women visiting a regular outpatient clinic were used. The vignettes varied in age (28 or 35 years), duration of stable disease and serological activity. Analysis methods were descriptive statistics, chi-square test. generalized estimating equations (GEE) was performed to investigate the relationship between the determining permission for pregnancy and the scenario patient’s characteristics (age, period of stable disease, titer of anti ds-DNA antibody)

Results

The questionnaire was distributed to 4946 physicians, and 463 responded. Completion rate (ratio agreed to participate/finished survey) of survey was 91.1%. The median age of physicians was 46 (interquartile range (IQR) 2-10). The specialty was rheumatology (84.9%), other internal medicine (8%), and pediatrics (5.6%). There were no significant differences in patient’s age about the acceptability of pregnancy (coeffficianet -0.02, 95% CI -0.17 -0.01, p=0.42). Case who had been stable for 6 months were more tolerant of pregnancy than case who had been stable for 3 months (coeffficianet 0.12, 95% CI 0.09-0.15, P<0.001) Pregnancy was not allowed in case with mild or high serological activity (mild: coefficient -0.49, 95% CI -0.29- -0.22, p <0.001, high: -0.64, 95% CI -0.65 - -0.61, p <0.001). In contrast, as many as 92 (19.2%) physicians tolerated pregnancy even in the presence of residual high anti ds-DNA antibody titers. Female physicians are significantly more cautious about pregnancy than male when patients have a serologically high activity (12% vs 37.5%, p<0.001). There were no significant differences in specialty status or clinical experience.

Conclusion

We found that even mild serological activity alone had a significant negative effect on the physician’s decision to allow pregnancy. We conclude that current physicians make cautious decisions about pregnancies of patients with SLE following the recommendation. On the other hand, an additional investigation should be performed about the results of pregnancies in patients with serological abnormalities, since there are some physicians who thought that pregnancy may be acceptable for patients with only serological abnormalities if the clinical symptoms are stable.

References

[1]Ann Rheum Dis．2017 Mar;76(3):476-485

Acknowledgements

I would like to express my gratitude to the members of Japan College of Rheumatology who cooperated in filling out the questionnaire.

Disclosure of Interests

Sakiko Isojima: None declared, Nobuyuki Yajima: None declared, Ryo Yanai: None declared, Yoko Miura: None declared, Shingo Fukuma: None declared, Kayoko Kaneko: None declared, Keishi Fujio: None declared, Kenji Oku: None declared, Masakazu Matsushita: None declared, Takako Miyamae: None declared, Takashi Wada: None declared, Yuko Kaneko: None declared, Yoshiya Tanaka Speakers bureau: Y. Tanaka has received speaking fees and/or honoraria from Gilead, Abbvie, Behringer-Ingelheim, Eli Lilly, Mitsubishi-Tanabe, Chugai, Amgen, YL Biologics, Eisai, Astellas, Bristol-Myers, Astra-Zeneca, Grant/research support from: Y. Tanaka has received research grants from Asahi-Kasei, Abbvie, Chugai, Mitsubishi-Tanabe, Eisai, Takeda, Corrona, Daiichi-Sankyo, Kowa, Behringer-Ingelheim, and consultant fee from Eli Lilly, Daiichi-Sankyo, Taisho, Ayumi, Sanofi, GSK, Abbvie., Ayako Nakajima: None declared, ATSUKO MURASHIMA: None declared

POS0676 EFFICACY AND SAFETY OF FILGOTINIB IN PATIENTS AGED ≥75 YEARS: A POST HOC SUBGROUP ANALYSIS OF THE FINCH 4 LONG-TERM EXTENSION (LTE) STUDY

Background

Filgotinib (FIL) is a Janus kinase 1 preferential inhibitor for the treatment of moderate to severe rheumatoid arthritis (RA)1. The recommended dose for adults with RA is 200 mg (FIL200); however, a starting dose of 100 mg (FIL100) is recommended for those aged ≥75 years (y) in view of limited clinical experience1. An important consideration is the generally higher incidence of adverse events (AEs) in the elderly due to comorbidities.

Objectives

To evaluate the efficacy and safety of FIL100 and FIL200 in patients with RA aged ≥75 y.

Methods

FINCH 4 (NCT03025308) is an ongoing phase 3 open-label LTE study of FIL100 and FIL200 for RA. Eligible patients completed a prior phase 3 randomized double-blind study of FIL lasting 52 weeks (FINCH 1 or 3) or 24 weeks (FINCH 2). In this post hoc analysis, safety and efficacy were assessed in patients aged <75 and ≥75 y in FINCH 4. Efficacy measures were American College of Rheumatology (ACR)20/50/70 responses, clinical disease activity index (CDAI) ≤10/≤2.8, disease activity score (DAS)28 <2.6/≤3.2 and health assessment questionnaire-disability index (HAQ-DI).

Results

At LTE Week 48, 52% and 44% of patients aged <75 and ≥75 y, respectively, were on methotrexate. In both age groups, response rates for key efficacy measures at LTE Week 48 were generally maintained from LTE baseline (Figure 1) in patients with and without prior FIL exposure in FINCH 1–3, and were numerically higher with FIL200 vs FIL100. Mean change from baseline in HAQ-DI with FIL200 and FIL100 was 0.61 and 0.74 in those aged <75 y and 1.04 and 0.98 in those aged ≥75 y, respectively.

Figure 1.

The exposure-adjusted incidence rate (EAIR) of serious AEs and AEs of special interest (AESI) was generally higher in patients aged ≥75 y than <75 y. In those aged ≥75 y, the EAIR of AEs leading to premature study discontinuation, treatment-emergent AEs (TEAEs), and serious TEAEs was higher with FIL200 vs FIL100; the incidence of major adverse cardiovascular events, venous thrombotic and embolic events, serious infections, herpes zoster and malignancies was low in both dose groups (Table 1). Three patients died, all from the FIL200 group; each had a medical history relevant to the cause of death.

Table 1.

Exposure-adjusted incidence rate (95% CI) of AEs at Week 48 as events per 100 years of exposure

FIL200FIL100Age, years<75≥75<75≥75n=1469n=61n=1136n=63(PYE 2253.9)(PYE 92.2)(PYE 1753.7)(PYE 98.4)With prior FIL exposure, n (%)1142 (77.7)53 (86.9)830 (73.1)33 (52.4)TEAE48.3 (45.5, 51.3)55.3 (42.1, 72.8)48.7 (45.5, 52.1)42.7 (31.6, 57.8)Serious TEAE6.8 (5.8, 8.0)17.4 (10.6, 28.3)7.4 (6.2, 8.7)14.2 (8.4, 24.0)AE leading to premature study discontinuation2.9 (2.3, 3.7)9.8 (5.1, 18.8)3.9 (3.1, 5.0)4.1 (1.5, 10.8)AE leading to death0.5 (0.3, 0.9)3.3 (0.7, 9.5)*0.3 (0.2, 0.8)0.0 (0.0, 3.8)Infections28.8 (26.6, 31.1)29.3 (20.1, 42.7)27.4 (25.0, 29.9)26.4 (18.0, 38.8)Serious infections1.6 (1.2, 2.2)2.2 (0.5, 8.7)1.7 (1.1, 2.4)3.1 (1.0, 9.5)Herpes zoster1.6 (1.2, 2.3)2.2 (0.5, 8.7)1.0 (0.6, 1.6)3.1 (1.0, 9.5)Adjudicated major adverse cardiovascular event0.4 (0.2, 0.7)2.2 (0.5, 8.7)0.5 (0.2, 0.9)1.0 (0.1, 7.2)Venous thrombotic and embolic events0.3 (0.1, 0.6)2.2 (0.5, 8.7)0.2 (0.1, 0.5)1.0 (0.1, 7.2)Malignancy excluding NMSC0.7 (0.4, 1.2)4.3 (1.6, 11.6)0.7 (0.4, 1.2)3.1 (1.0, 9.5)NMSC0.4 (0.2, 0.8)1.1 (0.0, 6.0)0.2 (0.1, 0.6)0.0 (0.0, 3.8)

*Cause of death: esophageal carcinoma; cardiovascular; unknown. FIL(100/200), filgotinib (100/200 mg); NMSC, nonmelanoma skin cancer; PYE, patient years of exposure; (TE)AE, (treatment-emergent) adverse event

Conclusion

In the ≥75 y group, response rates for key efficacy measures remained stable to Week 48 and were generally higher with FIL200 vs FIL100. The incidence of serious AEs and AESI was higher in those aged ≥75 than <75 y. Patient numbers/exposure time may have been insufficient to show potential between-group differences in safety/efficacy outcomes.

References

[1]Filgotinib SmPC

Acknowledgements

The FINCH studies were funded by Gilead Sciences (Foster City, CA, United States). We thank the physicians and patients who participated in the studies. Medical writing support was provided by Debbie Sherwood, BSc (Aspire Scientific Ltd, Bollington, UK) and funded by Galapagos NV (Mechelen, Belgium).

Disclosure of Interests

Daniel Aletaha Speakers bureau: AbbVie, Amgen, Lilly, Janssen, Merck, Novartis, Pfizer, Roche, and Sandoz, Consultant of: AbbVie, Amgen, Lilly, Janssen, Merck, Novartis, Pfizer, Roche, and Sandoz, Grant/research support from: AbbVie, Amgen, Lilly, Novartis, Roche, SoBi, and Sanofi, Rene Westhovens Speakers bureau: Celltrion, Galapagos, and Gilead, Consultant of: Celltrion, Galapagos, and Gilead, Bernard Combe Speakers bureau: AbbVie, BMS, Celltrion, Eli Lilly, Gilead-Galapagos, Janssen, MSD, Novartis, Pfizer, and Roche-Chugai, Consultant of: AbbVie, Celltrion, Eli Lilly, Gilead-Galapagos, Janssen, and Roche-Chugai, Jacques-Eric Gottenberg Consultant of: AbbVie, BMS, Galapagos, Gilead, Lilly, and Pfizer, Grant/research support from: BMS and Pfizer, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Galapagos, Gilead, and Pfizer, Grant/research support from: Gilead and Pfizer, Roberto Caporali Speakers bureau: AbbVie, Amgen, BMS, Celltrion, Galapagos, Janssen, Lilly, MSD, Novartis, Pfizer, Sandoz, and UCB, Consultant of: AbbVie, Amgen, BMS, Celltrion, Fresenius-Kabi, Galapagos, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, Sandoz, and UCB, José A Gómez-Puerta Speakers bureau: AbbVie, BMS, Galapagos, GSK, Lilly, MSD, Novartis, Pfizer, Roche, and Sanofi, Consultant of: GSK, Roche, and Sanofi, Paul Van Hoek Employee of: Galapagos, Vijay Rajendran Employee of: Galapagos, Pieter-Jan Stiers Shareholder of: Galapagos, Employee of: Galapagos, Thijs Hendrikx Employee of: Galapagos, Gerd Rüdiger Burmester Consultant of: AbbVie, Amgen, BMS, Galapagos, Lilly, MSD, Pfizer, Roche, and Sanofi, Yoshiya Tanaka Speakers bureau: AbbVie, Amgen, Astellas, Astra-Zeneca, Boehringer-Ingelheim, BMS, Chugai, Eisai, Eli Lilly, Gilead, Mitsubishi-Tanabe, and YL Biologics, Consultant of: AbbVie, Ayumi, Daiichi-Sankyo, Eli Lilly, GSK, Sanofi, and Taisho, Grant/research support from: AbbVie, Asahi-Kasei, Boehringer-Ingelheim, Chugai, Corrona, Daiichi-Sankyo, Eisai, Kowa, Mitsubishi-Tanabe, and Takeda

POS1014 IMPACT OF SERUM INTERLEUKIN 22 AS A BIOMARKER FOR THE DIFFERENTIAL USE OF MOLECULAR TARGETED DRUGS FOR PSORIATIC ARTHRITIS

Background

Although each bDMARD target different molecules, no optimal drug selection method has been established. Because studies directly comparing TNF-i and IL-17-i have shown that these drugs are equally effective, the establishment of an optimal selection method for these drugs can contribute to better patient outcomes. We reported the possibility of stratification of patients by peripheral blood lymphocytes phenotyping and precision medicine based on the selective use of bDMARDs in psoriatic arthritis (PsA). However, since peripheral blood lymphocytes phenotyping is complex, the development of simple methods using biomarkers to stratify patients and simple treatment strategies based on such methods is needed to promote precision medicine in a real-world clinical setting.

Objectives

We explored whether serum cytokines could be used as biomarkers for optimal use TNF-i and IL-17-i in patients with PsA.

Methods

In cohort 1 (IL-17-i [n=23] or TNF-i [n=24] for ≥1 year), we identified serum cytokines that predicted the achievement of DAPSA remission (REM), PASI 90 and Minimal Disease Activity after 1 year of TNF-i or IL-17-i therapy. Subsequently, we developed treatment strategies based on the identified cytokines. In cohort 2, treatment responses were compared between the strategic treatment group (n=17), which was treated based on the treatment strategies, and the mismatched treatment group (n=17) to verify the validity of the treatment strategies developed using serum cytokines as biomarkers.

Results

In cohort 1, serum IL-22 concentrations were statistically identified as a predictor of DAPSA remission after 1 year of IL-17-i therapy. However, no baseline serum cytokines were identified as factors contributing to achievement of DAPSA-REM in the TNF-i-treated group or achievement of PASI90 and Minimal Disease Activity in either group. Using a cut-off value of 0.61376 (sensitivity, 81.8%; specificity, 91.7%; area under the curve, 0.848) determined by a ROC analysis, we stratified 47 patients into the IL-22 high group (n=25) (0.61376<) and the IL-22 low group (n=22) (< 0.61376). Serum IL-17 concentrations were significantly higher in both the IL-22 high and IL-22 low groups than in the healthy control (HC), whereas no significant difference was observed between the IL-22 high and IL-22 low groups. The serum TNF-α concentrations did not significantly differ between the IL-22 low and HC; however, they were significantly higher in the IL-22 high group than in the HC and IL-22 low groups. Based on these results, we created treatment strategies using TNF-i and IL-17-i based on serum IL-22 concentrations, that is, initiation of IL-17-i therapy in patients with low IL-22 concentrations and TNF-i therapy in patients with high IL-22 concentrations. To validate the efficacy of the treatment strategies, we retrospectively compared the efficacy of the bDMARDs at 1 year between the following groups in cohort 2. The strategic treatment group (n=17) included patients with low IL-22 concentrations who were treated with IL-17-i and those with high IL-22 concentrations who were treated with TNF-i. The mismatched treatment group (n=17) included patients with low IL-22 concentrations who were treated with TNF-i and those with high IL-22 concentrations who were treated with IL-17-i. No statistically significant differences were observed between the two groups in baseline characteristics at the initiation of bDMARD. After initiation of bDMARD, tender joint counts, swollen joint counts, CRP, DAPSA, and PASI were significantly improved in both groups. When the treatment responses over 1 year were compared between the two groups, the rate of achieving DAPSA-REM (58.8% vs. 25.3%, P=0.0399) and Minimal Disease Activity (82.3% vs. 41.2%, P=0.0162) at M12 was significantly higher in the strategic treatment group. There were no statistically significant differences in the rates of achieving PASI75 or PASI90 at M 6 or 12.

Conclusion

We verified that serum IL-22 can be used as a simple biomarker for the proper selection of TNF-i and IL-17-i.

Acknowledgements

The authors thank the study participants, without whom this study could not have been

accomplished, and all medical staff at all participating institutions for providing the data,

especially Ms. Hiroko Yoshida, Ms. Youko Saitou, Ms. Machiko Mitsuiki and Ms. Ayumi

Maruyama for the excellent data management. The authors thank Ms. M.

Hirahara for providing excellent technical assistance. We also thank Dr Kazuyoshi Saito at

Tobata General Hospital; Dr Kentaro Hanami and Dr Shunsuke Fukuyo at Wakamatsu Hospital

of the University of Occupational and Environmental Health; Dr Keisuke Nakatsuka at Fukuoka

Yutaka Hospital, and all staff members at Kitakyushu General Hospital and Shimonoseki

Saiseikai Hospital. Nakama Municipal Hospital, and Steel Memorial Yawata Hospital for their

engagement in data collection.

Disclosure of Interests

Ippei Miyagawa: None declared, Shingo Nakayamada Speakers bureau: consulting fees, speaking fees, and/or honoraria from Bristol-Myers, Pfizer, GlaxoSmithKline, Sanofi, Astellas, Asahi-kasei, and Boehringer Ingelheim and research grants from Mitsubishi-Tanabe and Novartis., Masanobu Ueno: None declared, Yusuke Miyazaki: None declared, Yoshiya Tanaka Speakers bureau: 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, and Janssen, Consultant of: consultant fees from Eli Lilly, Daiichi-Sankyo, Taisho, Ayumi, Sanofi, GSK, and Abbvie., Grant/research support from: research grants from Abbvie, Mitsubishi-Tanabe, Chugai, Asahi-Kasei, Eisai, Takeda, and Daiichi-Sankyo

POS0579 ABSENCE OF ASSOCIATION BETWEEN ABATACEPT EXPOSURE LEVELS AND INITIAL INFECTION IN PATIENTS WITH RA: A POST HOC ANALYSIS OF THE RANDOMIZED, PLACEBO-CONTROLLED AVERT-2 STUDY

Background

Infections are the most commonly reported AE observed in patients with RA treated with immunosuppressive therapies and can be clinically significant. A recent review reported differences in the risk of infection for some biologics such as tocilizumab and TNF inhibitors.1 Abatacept selectively modulates T-cell co-stimulation and is approved for the treatment of RA. In patients with polyarticular-course juvenile idiopathic arthritis, no association was found between higher serum abatacept exposure and the incidence of infection.2 This has not been evaluated for adult patients with RA.

Objectives

To determine if higher serum abatacept exposure during treatment with SC abatacept was associated with increased risk of infection in adult patients with RA.

Methods

AVERT-2 (Assessing Very Early Rheumatoid arthritis Treatment-2) was a randomized, placebo-controlled study of SC abatacept + MTX vs abatacept placebo + MTX in MTX-naive, anti-citrullinated protein antibody–positive patients with early, active RA.3 A post hoc population pharmacokinetic (PK) analysis was performed using PK-evaluable patient data from the induction period (year 1) of AVERT-2. Association between steady-state abatacept exposure (min plasma concentration [Cmin], max plasma concentration [Cmax], and average plasma concentration [Cavg]) and first infection was evaluated using Kaplan–Meier plots of probability vs time on treatment by abatacept exposure quartiles and Cox proportional-hazards models.

Results

PK of SC abatacept was defined as a linear 2-compartment model with first-order absorption and first-order elimination. The findings of the updated PK analysis were consistent with those reported in prior population analyses of abatacept PK in adults with RA. The final model included effects of baseline body weight, estimated glomerular filtration rate, sex, age, albumin, MTX use, NSAID use, SJC, and race on abatacept clearance. The only covariate with a clinically relevant effect was higher body weight, which caused an increase in clearance and volume. Infections occurred in a total of 330/693 (47.6%; serious, 1.6%) patients treated with abatacept, and 134/301 (44.5%; serious, 1.3%) with placebo during the first year of AVERT-2. In patients taking abatacept, the mean (SD) study exposure to abatacept was 376 (60) days, while mean (SD) prednisone equivalent dose was 6.7 (3.8) mg/day and mean (SD) MTX dose was 9.6 (3.0) mg/week. No exposure–response relationship was observed between the probability of first infection and steady-state abatacept exposure quartiles (Cavg, Cmin, and Cmax), or compared with placebo (Figure 1A–C). Kaplan–Meier assessment also showed no increase in risk of infection with concomitant use of MTX and glucocorticoids.

Conclusion

No association was found between initial infection and steady-state abatacept exposure (Cavg, Cmin, Cmax) or MTX and glucocorticoid use in patients with RA treated with SC abatacept.

References

[1]Jani M, et al. Curr Opin Rheumatol 2019;31:285–92.

[2]Ruperto N, et al. J Rheumatol 2021;48:1073–81.

[3]Emery P, et al. Arthritis Rheumatol 2019;71(suppl 10):L11.

Acknowledgements

This study was sponsored by Bristol Myers Squibb. Writing and editorial assistance were provided by Fiona Boswell, PhD, of Caudex, and was funded by Bristol Myers Squibb. Support was provided by Sandra Overfield as Protocol Manager, and Prema Sukumar and Renfang Hwang as Data Science Leads.

Disclosure of Interests

Paul Emery Consultant of: AbbVie, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Eli Lilly, Galapagos, Gilead, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Samsung, Grant/research support from: AbbVie, Bristol Myers Squibb, Eli Lilly, Novartis, Pfizer, Roche, Samsung, Roy Fleischmann Consultant of: Amgen, AbbVie, Bristol Myers Squibb, Gilead, GlaxoSmithKline, Novartis, Pfizer, Grant/research support from: Amgen, AbbVie, Arthrosi, Biosplice, Bristol Myers Squibb, Gilead, GlaxoSmithKline, Horizon, Novartis, Pfizer, Regeneron, TEVA, UCB, Robert Wong Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Karissa Lozenski Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Yoshiya Tanaka Speakers bureau: AbbVie, Amgen, Astellas, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Chugai, Eisai, Eli Lilly, Gilead, Mitsubishi Tanabe, YL Biologics, Consultant of: AbbVie, Ayumi, Daiichi Sankyo, Eli Lilly, GlaxoSmithKline, Taisho, Sanofi, Grant/research support from: AbbVie, Asahi Kasei, Boehringer Ingelheim, Chugai, Corrona, Daiichi Sankyo, Eisai, Kowa, Mitsubishi Tanabe, Takeda, Vivian Bykerk Consultant of: Amgen, Bristol Myers Squibb, Genzyme Corporation, Gilead, Regeneron, UCB, Grant/research support from: Amgen, Bristol Myers Squibb, Genzyme Corporation, Pfizer, Regeneron, Sanofi Aventis, UCB, Clifton Bingham Consultant of: AbbVie, Bristol Myers Squibb, Eli Lilly, Janssen, Pfizer, Sanofi, Grant/research support from: Bristol Myers Squibb, Thomas Huizinga Speakers bureau: Abblynx, Abbott, Biotest AG, Bristol Myers Squibb, Crescendo Bioscience, Eli Lilly, Epirus, Galapagos, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi- Aventis, UCB, Consultant of: Abblynx, Abbott, Biotest AG, Bristol Myers Squibb, Crescendo Bioscience, Eli Lilly, Epirus, Galapagos, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi- Aventis, UCB, Grant/research support from: Abblynx, Abbott, Biotest AG, Bristol Myers Squibb, Crescendo Bioscience, Eli Lilly, Epirus, Galapagos, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi- Aventis, UCB, Gustavo Citera Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Eli Lilly, Janssen, Pfizer, Sandoz, Consultant of: AbbVie, Amgen, Bristol Myers Squibb, Pfizer, Grant/research support from: Pfizer, Yedid Elbez Consultant of: Bristol Myers Squibb, Employee of: Signifience, Vidya Perera Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Bindu Murthy Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Kelly Maxwell Consultant of: Bristol Myers Squibb, Employee of: Cognigen Corporation, Julie Passarell Consultant of: Bristol Myers Squibb, Employee of: Cognigen Corporation, William Hedrich: None declared, Daphne Williams Consultant of: Black Diamond Network, Joule, Syneos, Employee of: Bristol Myers Squibb.

POS0714 POOLED SAFETY ANALYSIS OF BARICITINIB IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: RESULTS FROM THREE RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED, CLINICAL TRIALS

Background

Baricitinib (BARI), an oral selective inhibitor of Janus kinase 1 and 2 approved for the treatment of rheumatoid arthritis and atopic dermatitis, has been evaluated in clinical studies in patients with systemic lupus erythematosus (SLE).

Objectives

To assess the safety profile of BARI in patients with SLE.

Methods

Patients with SLE receiving stable background therapy were randomised 1:1:1 to BARI 2-mg, 4-mg, or placebo (PBO) once daily in one 24-week, phase 2 (NCT02708095) and two 52-week, phase 3, PBO controlled studies (NCT03616912 and NCT03616964).

Results

A total of 1,849 patients were included in this pooled analysis, representing 1,463.5 patient years of exposure (PYE). The incidence rates per 100 PYR at risk (IR/100 PYR) for serious adverse events (SAEs) were 9.5, 14.7, and 14.1 respectively for PBO, BARI 2-mg, and BARI 4-mg. There were no clinically meaningful differences between treatment groups for discontinuations due to AEs or death (Table 1).

Table 1.

Overview of safety measures of baricitinib in patients with SLE

Safety measurePBOBARI 2-mgBARI 4-mgPooled-BARIN=614N=621N=614N=1235PYE=488.1PYE=494.0PYE=481.4PYE=975.4n(%)n(%)n(%)n(%)PYRPYRPYRPYR[IR; 95%CI][IR; 95%CI][IR; 95%CI][IR; 95%CI]SAEs45 (7.3)70 (11.3)*65 (10.6)*135 (10.9)*473.2476.6461.9938.5[9.5; 6.9, 12.7][14.7; 11.5, 18.6][14.1; 10.9, 17.9][14.4; 12.1, 17.0]Discontinuation of study drug due to AE48 (7.8)58 (9.3)57 (9.3)115 (9.3)485.3492.3480.6973.0[9.9; 7.3, 13.1][11.8; 8.9, 15.2][11.9; 9.0, 15.4][11.8; 9.8, 14.2]Death4 (0.7)1 (0.2)4 (0.7)5 (0.4)488.2494.0481.5975.5[0.8; 0.2, 2.1][0.2; 0.0, 1.1][0.8; 0.2, 2.1][0.5; 0.2, 1.2]Serious infections12 (2.0)22 (3.5)28 (4.6)*50 (4.0)*484.3487.2472.5959.7[2.5; 1.3, 4.3][4.5; 2.8, 6.8][5.9; 3.9, 8.6][5.2; 3.9, 6.9]Herpes Zoster18 (2.9)17 (2.7)29 (4.7)46 (3.7)481.1486.5468.6955.1[3.7; 2.2, 5.9][3.5; 2.0, 5.6][6.2; 4.1, 8.9][4.8; 3.5, 6.4]VTEs#6 (1.2)3 (0.6)1 (0.2)4 (0.4)444.0450.2438.1888.3[1.4; 0.5, 2.9][0.7; 0.1, 1.9][0.2; 0.0, 1.3][0.5; 0.1, 1.2]MACE#01 (0.2)3 (0.6)4 (0.4)443.9450.1438.1888.3[0.0; NA, 0.8][0.2; 0.0, 1.2][0.7; 0.1, 2.0][0.5; 0.1, 1.2]Malignancy excluding NMSC2 (0.3)3 (0.5)2 (0.3)5 (0.4)488.0494.1481.4975.5[0.4; 0.0, 1.5][0.6; 0.1, 1.8][0.4; 0.1, 1.5][0.5; 0.2, 1.2]NMSC2 (0.3)000*486.7494.0481.4975.4[0.4; 0.0, 1.5][0.0; NA, 0.7][0.0; NA, 0.8][0.0; NA, 0.4]

Data are n (%) patients PYR [IR; 95% CI]. #Phase 2 study data not included. AE=adverse event; CI=confidence interval; MACE=major adverse cardiac event; NMSC=non-melanoma skin cancers; VTE=venous thrombotic event (includes deep vein thrombosis and pulmonary embolism); IR=incidence rate (100 times the number of patients reporting an adverse event divided by the event-specific exposure to treatment); N=number of patients in the analysis population; n=number of patients in the specified category; PYE=patient-year of exposure; PYR=patient years at risk; SAE=serious adverse event. *p≤0.05 vs placebo.

The IR/100 PYR for serious infections were 2.5, 4.5, and 5.9 respectively for PBO, BARI 2-mg, and BARI 4-mg. The risk of Herpes Zoster was higher in BARI 4-mg (4.7%) vs PBO (2.9%) (Table 1).

The IR/100 PYR for positively adjudicated venous thrombotic events (VTEs) were 1.4, 0.7, and 0.2 respectively for PBO, BARI 2-mg, and BARI 4-mg. The IR/100 PYR for positively adjudicated major adverse cardiac event (MACE) was numerically higher in BARI 2-mg (0.2) and BARI 4-mg (0.7) vs PBO (0.0), however the pooled-BARI IR/PYR (0.5) was within the range of background disease (1). No increased risk for malignancies was observed.

Conclusion

The safety profile of BARI in SLE patients was consistent with the known BARI safety profile. There was no increased risk of VTE in BARI treatment groups.

References

[1]Barbhaiya M, Feldman CH, et al. Arthritis Rheumatol. 2017;69(9):1823-31.

Disclosure of Interests

Thomas Dörner Speakers bureau: Eli Lilly and Company and Roche, Consultant of: AbbVie, Celgene, Eli Lilly and Company, Janssen, Novartis, Roche, Samsung and UCB, Grant/research support from: Chugai, Janssen, Novartis and Sanofi, Yoshiya Tanaka Speakers bureau: Gilead, Abbvie, Behringer-Ingelheim, Eli Lilly, Mitsubishi-Tanabe, Chugai, Amgen, YL Biologics, Eisai, Astellas, Bristol-Myers, Astra-Zeneca, Consultant of: Eli Lilly, Daiichi-Sankyo, Taisho, Ayumi, Sanofi, GSK, Abbvie, Grant/research support from: Asahi-Kasei, Abbvie, Chugai, Mitsubishi-Tanabe, Eisai, Takeda, Corrona, Daiichi-Sankyo, Kowa, Behringer-Ingelheim, Marta Mosca Speakers bureau: Eli Lilly, GSK, Astra Zeneca, Consultant of: Eli Lilly, GSK, Astra Zeneca, Ian N. Bruce Speakers bureau: GSK, Astra Zeneca, UCB, Consultant of: Eli Lilly, GSK, UCB, BMS, Merck Serono, Astra Zeneca, IL-TOO, Aurinia, Grant/research support from: GSK, Janssen, Mario Cardiel Speakers bureau: Eli Lilly, Pfizer, Abbvie, Consultant of: Eli Lilly, Pfizer, Grant/research support from: Pfizer, Gilead, Roche, Janssen, Eric F. Morand Speakers bureau: AstraZeneca, Eli Lilly, Novartis, Consultant of: Amgen, AstraZeneca, Asahi Kasei, Biogen, BristolMyersSquibb, Capella, Eli Lilly, EMD Serono, Genentech, GlaxoSmithKline, Janssen, Neovacs, Sanofi, Servier, UCB, Wolf, Grant/research support from: Janssen, AstraZeneca, BristolMyersSquibb, Eli Lilly, EMD Serono, GlaxoSmithKline, Michelle A Petri Consultant of: Eli Lilly, Grant/research support from: Eli Lilly, Maria Silk Shareholder of: Eli Lilly, Employee of: Eli Lilly, christina dickson Shareholder of: Eli Lilly, Employee of: Eli Lilly, Gabriella Meszaros Shareholder of: Eli Lilly, Employee of: Eli Lilly, Maher Issa Shareholder of: Eli Lilly, Employee of: Eli Lilly, Lu Zhang Shareholder of: Eli Lilly, Employee of: Eli Lilly, Daniel J. Wallace Consultant of: Amgen, Eli Lilly and Company, EMD Merck Serono and Pfizer

POS0704 EFFICACY AND SAFETY OF FILGOTINIB IN PATIENTS WITH INADEQUATE RESPONSE TO METHOTREXATE, WITH 4 OR <4 POOR PROGNOSTIC FACTORS: A POST HOC ANALYSIS OF THE FINCH 1 STUDY

Background

Patients (pts) with rheumatoid arthritis (RA) and poor prognostic factors1 (PPF) are at risk for progression without adequate treatment. Filgotinib (FIL) is a once daily Janus kinase 1 preferential inhibitor. In FINCH 1 (NCT02889796), FIL 200 mg (FIL200) was effective vs placebo (PBO) and noninferior to adalimumab (ADA) in pts with RA and inadequate response to methotrexate (MTX-IR); FIL200 and FIL 100 mg (FIL100) were well tolerated.2

Objectives

This post hoc, exploratory analysis examined efficacy and safety of FIL in MTX-IR pts with 4 or <4 PPF.

Methods

The FINCH 1 52-week (W), double-blind trial randomised MTX-IR pts with moderate–severe RA to FIL200 or FIL100, ADA, or PBO; all received background MTX. PBO pts were rerandomised, blinded, at W24 to FIL200 or FIL100. We examined pts with 4 PPF at baseline (BL): erosions on X-ray, seropositivity for rheumatoid factor or anticyclic citrullinated peptide, high-sensitivity C-reactive protein (hsCRP) ≥6 mg/L, and disease activity score in 28 joints with CRP (DAS28[CRP]) >5.1, along with those with <4 PPF. Efficacy included DAS28(CRP) <2.6 and modified Total Sharp Score (mTSS) change from baseline (CFB). Fisher’s exact test was used for DAS28(CRP); the mixed-effects model was used to generate least squares mean mTSS CFB. P values were nominal, not adjusted for multiplicity.

Results

At BL, of 1755 randomized, treated pts, 687 had 4 PPF, and 1068 had <4 PPF. Among pts with <4PPF, 804 [75%] had erosions, 810 [76%] were seropositive, 377 [35%] had hsCRP ≥6 mg/L, 638 [60%] had DAS28[CRP] >5.1). Pts with 4 vs <4 PPF were aged 53 vs 52 years, had RA duration 8.3 vs 7.4 years, DAS28(CRP) 6.3 vs 5.4, and SDAI 45.6 vs 37.7. In pts with 4 or <4 PPF, higher proportions receiving FIL200 or FIL100 achieved DAS28(CRP) <2.6 at W12 vs PBO (nominal P <.001); proportions with DAS28(CRP) <2.6 increased with FIL200, FIL100, or ADA at W52 (Figure 1). DAS28(CRP) responses for FIL200 at W52 were similar in 4 vs <4 PPF pts; FIL100 and ADA responses were numerically higher in <4 vs 4 PPF pts. At W24, mTSS CFB in pts with 4 PPF was 0.21, 0.23, 0.30, and 0.66 for FIL200, FIL100, ADA, and PBO (P <.05 for FIL200 and FIL100 vs PBO); corresponding changes in <4 PPF pts were 0.08, 0.10, 0.11, and 0.24 (P >.05). At W52, mTSS CFB in 4 PPF pts was 0.29, 0.84, and 0.80 for FIL200, FIL100, and ADA, respectively, and 0.14, 0.25, and 0.53 in <4 PPF pts. Rates of adverse events (AEs), including AEs of interest, were comparable for pts with 4 PPF and <4 PPF for all treatment arms (Table 1).

Table 1.

AEs and AEs of interest in BL 4 PPF and <4 PPF subgroups

4 PPF<4 PPFFIL200FIL100ADAPBO beforeFIL200FIL100ADAPBO(n = 191)(n = 189)(n = 126)W24 switch (n = 181)(n = 284)(n = 291)(n = 199)before W24 switch (n = 294)All AEs146 (76.4)136 (72.0)85 (67.5)90 (49.7)206 (72.5)214 (73.5)154 (77.4)164 (55.8)AEs of interestSerious infectious AE5 (2.6)4 (2.1)6 (4.8)2 (1.1)8 (2.8)9 (3.1)4 (2.0)2 (0.7)Opportunistic infections001 (0.8)0001 (0.5)0Active tuberculosis0000001 (0.5)0Herpes zoster1 (0.5)1 (0.5)1 (0.8)05 (1.8)3 (1.0)1 (0.5)2 (0.7)Hepatitis B or C01 (0.5)001 (0.5)01 (0.5)0MACE01 (0.5)01 (0.6)01 (0.3)1 (0.5)1 (0.3)VTE001 (0.8)1 (0.6)1 (0.4)001 (0.3)DVT001 (0.8)1 (0.6)0001 (0.3)PE00001 (0.4)000Malignancy0003 (1.7)2 (0.7)2 (0.7)2 (1.0)0(non-NMSC)GI perforation00001 (0.4)000

Values are n (%). ADA, adalimumab; AE, adverse event; BL, baseline; DVT, deep vein thrombosis; FIL100, filgotinib 100 mg; FIL200; filgotinib 200 mg; GI, gastrointestinal; MACE, major adverse cardiac event; NMSC, nonmelanoma skin cancer; PBO, placebo; PE, pulmonary embolism; PPF, poor prognostic factor; VTE, venous thromboembolism; W, week.

Conclusion

In high-risk (4 PPF) pts with MTX-IR RA, FIL200 and FIL100 showed similar reductions in disease activity vs PBO at W12 as in pts with <4 PPF; mTSS in FIL200 pts changed little from W24 to W52. Tolerability was comparable across treatment arms, regardless of presence of 4 or <4 PPF.

References

[1]Smolen JS et al. Ann Rheum Dis. 2020;79:685–99.

[2]Combe B et al. Ann Rheum Dis. 2021;80:848–58.

Acknowledgements

This study was funded by Gilead Sciences, Inc., Foster City, CA. Medical writing support was provided by Rob Coover, MPH, of AlphaScientia, LLC, San Francisco, CA, and was funded by Gilead Sciences, Inc., Foster City, CA. Funding for this analysis was provided by Gilead Sciences, Inc. The sponsors participated in the planning, execution, and interpretation of the research.

Disclosure of Interests

Bernard Combe Speakers bureau: AbbVie, Bristol-Myers Squibb, Celltrion, Eli Lilly, Gilead-Galapagos, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, and Roche-Chugai, Consultant of: AbbVie, Bristol-Myers Squibb, Celltrion, Eli Lilly, Gilead-Galapagos, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, and Roche-Chugai, Grant/research support from: Pfizer and Roche-Chugai, Yoshiya Tanaka Speakers bureau: AbbVie, Amgen, Astellas, AstraZeneca, Behringer-Ingelheim, Bristol-Myers, Chugai, Eisai, Eli Lilly, Gilead Sciences, Inc., Mitsubishi-Tanabe, and YL Biologics, Paid instructor for: AbbVie, Amgen, Astellas, AstraZeneca, Behringer-Ingelheim, Bristol-Myers, Chugai, Eisai, Eli Lilly, Gilead Sciences, Inc., Mitsubishi-Tanabe, and YL Biologics, Grant/research support from: AbbVie, Asahi-Kasei, Boehringer-Ingelheim, Chugai, Corrona, Daiichi-Sankyo, Eisai, Kowa, Mitsubishi-Tanabe, and Takeda, Maya H Buch Speakers bureau: AbbVie, Eli Lilly, Gilead Sciences, Inc., Merck-Serono, Pfizer, Roche, Sanofi, and UCB, Paid instructor for: AbbVie, Eli Lilly, Gilead Sciences, Inc., Merck-Serono, Pfizer, Roche, Sanofi, and UCB, Consultant of: AbbVie, Eli Lilly, Gilead Sciences, Inc., Merck-Serono, Pfizer, Roche, Sanofi, and UCB, Grant/research support from: AbbVie, Eli Lilly, Gilead Sciences, Inc., Merck-Serono, Pfizer, Roche, Sanofi, and UCB, Gerd Rüdiger Burmester Speakers bureau: AbbVie, Eli Lilly, Pfizer, and Gilead Sciences, Inc., Consultant of: AbbVie, Eli Lilly, Pfizer, and Gilead Sciences, Inc., Beatrix Bartok Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Alena Pechonkina Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Ling Han Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Kahaku Emoto Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences K.K., Shungo Kano Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences K.K., Thijs Hendrikx Employee of: Galapagos BV, Daniel Aletaha Speakers bureau: Bristol-Myers Squibb, Merck Sharp & Dohme, and UCB; AbbVie, Amgen, Celgene, Eli Lilly, Medac, Merck, Novartis, Pfizer, Roche, Sandoz, and Sanofi/Genzyme., Consultant of: AbbVie, Amgen, Celgene, Eli Lilly, Medac, Merck, Novartis, Pfizer, Roche, Sandoz, and Sanofi/Genzyme; Janssen, Grant/research support from: from AbbVie, Merck Sharp & Dohme, Novartis, and Roche

POS0708 EVALUATING THE HYPERSENSITIVITY PROFILE OF ANIFROLUMAB AND THE NEED FOR PREINFUSION PROPHYLACTIC TREATMENT IN PATIENTS WITH SLE

Background

Anifrolumab, a human monoclonal antibody (mAb), is approved in Canada, Japan, and the United States for the treatment of patients with systemic lupus erythematosus (SLE) based on results from the phase 2b MUSE and the phase 3 TULIP-1/-2 trials.1–3 Anaphylactic reactions (ARs), hypersensitivity reactions (HSRs), and infusion-related reactions (IRRs) are risks of mAb infusions, so physicians prescribing anifrolumab may wish to understand the hypersensitivity profile and whether prophylactic pretreatments are required to mitigate HSR/IRRs.

Objectives

To evaluate the hypersensitivity profile of anifrolumab and the need for pretreatment.

Methods

Pooled data were analyzed from patients with moderate to severe SLE despite standard therapy who received intravenous infusions (every 4 weeks, 48 weeks) of anifrolumab or placebo in the randomized, 52-week MUSE (NCT01438489),1 TULIP-1 (NCT02446912),2 and TULIP-2 (NCT02446899)3 trials. An AR (analyzed in the anifrolumab 150/300/1000 mg and placebo groups) was defined as acute illness onset within minutes to several hours of infusion with involvement of skin and/or mucosal tissue, and/or respiratory compromise, and/or reduced blood pressure, and/or persistent gastrointestinal symptoms. HSRs and IRRs were analyzed in the anifrolumab 300 mg group (as this is the approved dose) and the placebo group. An HSR was defined as acute illness onset with involvement of skin and/or mucosal tissue during infusion (not meeting the AR definition); IRR was defined as any other reaction occurring during/within 24 hours of infusion. Patients did not receive pretreatment unless they had experienced a previous IRR/HSR in the program. Pretreatment was assumed if a patient received prophylactic antihistamine, corticosteroid, non-steroidal anti-inflammatory drug, and/or dopamine antagonist 1 day before/on the day of infusion.

Results

Of patients who received anifrolumab 300 mg (n=459), anifrolumab 1000 mg (n=105), or placebo (n=466), none experienced ARs; 1 patient who received anifrolumab 150 mg (n=93) experienced an AR. HSRs occurred in 3% (n=12) of anifrolumab 300 mg-treated patients (of whom 4 had a history of HSRs) vs 1% (n=3) in the placebo group. IRRs occurred in 9% (n=43) of anifrolumab-treated patients vs 7% (n=33) in the placebo group. All HSRs and IRRs were mild/moderate in intensity. There were no discontinuations due to HSRs or IRRs in the anifrolumab group, while there were 2 in the placebo group (HSR: n=1; IRR: n=1). In the anifrolumab 300 mg and placebo groups, more patients experienced HSR/IRRs with the initial (1–6) vs later infusions (Figure 1). In the anifrolumab group, the median (median absolute deviation) time to first HSR or IRR was 30.5 (29.5) days or 27.0 (26.0) days, respectively. Of the 12 anifrolumab-treated patients with ≥1 HSR, 3 received subsequent pretreatment, and none had any HSR after the use of pretreatment. Of the 43 anifrolumab-treated patients with ≥1 IRR, 2 received pretreatment, of whom 1 had an IRR after pretreatment and anifrolumab dosage remained unchanged.

Conclusion

Following anifrolumab infusion, ARs were uncommon, and few (3%) patients experienced HSRs. HSRs and IRRs with the approved anifrolumab 300 mg dose were mild to moderate, occurred early in treatment, did not lead to discontinuation, and only rarely required pretreatment. Our data support a safe and manageable hypersensitivity profile for anifrolumab.

References

[1]Furie R, et al. Arthritis Rheumatol. 2017;69:376–86.

[2]Furie R, et al. Lancet Rheumatol. 2019;1:e208–19.

[3]Morand E, et al. N Engl J Med. 2020;382:211–21.

Acknowledgements

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

Disclosure of Interests

Kenneth C Kalunian Consultant of: Aurinia, Equillium, Kezar, BMS, Chemocentryx, Eli Lilly, Biogen, Roche/Genentech, Grant/research support from: Horizon, UCB, Yoshiya Tanaka Speakers bureau: Gilead, Abbvie, Behringer-Ingelheim, Eli Lilly, Mitsubishi-Tanabe, Chugai, Amgen, YL Biologics, Eisai, Astellas, Bristol-Myers, Astra-Zeneca, Consultant of: Eli Lilly, Daiichi-Sankyo, Taisho, Ayumi, Sanofi, GSK, Abbvie, Grant/research support from: Asahi-Kasei, Abbvie, Chugai, Mitsubishi-Tanabe, Eisai, Takeda, Corrona, Daiichi-Sankyo, Kowa, Behringer-Ingelheim, Ihor Hupka Employee of: AstraZeneca, Lijin (Jinny) Zhang Shareholder of: AstraZeneca, Employee of: AstraZeneca, Manish Shroff Employee of: AstraZeneca, Shanti Werther Shareholder of: AstraZeneca, Employee of: AstraZeneca, Gabriel Abreu Employee of: AstraZeneca AB, Catharina Lindholm Employee of: AstraZeneca, Raj Tummala Shareholder of: AstraZeneca, Employee of: AstraZeneca

POS0190 EFFICACY AND SAFETY OF BARICITINIB IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: RESULTS FROM TWO RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED, PARALLEL-GROUP, PHASE 3 STUDIES

Background

In a 24-week, phase 2 clinical study (NCT02708095) in patients with systemic lupus erythematosus (SLE), baricitinib (BARI), an oral selective inhibitor of Janus kinase 1 and 2 approved for the treatment of rheumatoid arthritis and atopic dermatitis, inhibited the type l interferon gene signature, multiple other cytokine pathways, and improved disease activity (1) (2).

Objectives

To further evaluate the efficacy and safety of BARI in patients with SLE.

Methods

Patients with active SLE receiving stable background therapy were randomised 1:1:1 to BARI 2-mg, 4-mg, or placebo (PBO) once daily in two identically designed, 52-week, phase 3 randomised, PBO-controlled studies. In SLE-BRAVE-I (NCT03616912) and -II (NCT03616964), 760 and 775 patients, respectively were enrolled in a balanced manner across regions, although different countries per region participated in each study. The primary endpoint for both studies was the proportion of patients achieving an SLE Responder Index-4 (SRI-4) response at week 52. Glucocorticoid tapering was encouraged but not required per protocol.

Results

The mean Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) at baseline was 10.1 for both SLE-BRAVE-I and -II participants; musculoskeletal and mucocutaneous domains were the most common domains involved at baseline. In SLE-BRAVE-I, the proportion of SRI-4 responders at week 52 among patients treated with BARI 4-mg (56.7%), but not BARI 2-mg (49.8%), was significantly greater than in patients treated with PBO (45.9%, p = 0.016) (Table 1). No difference was seen in SLE-BRAVE-II (47.1%, 46.3%, and 45.6%, BARI 4-mg, 2-mg, and PBO, respectively). None of the key secondary endpoints, including glucocorticoid tapering or time to first severe flare (SFI), were met in either study. The proportions of patients with serious adverse events (SAEs) were 7.1% and 8.6% for PBO, 9.4% and 13.4% for BARI 2-mg and 10.3% and 11.2% for BARI 4-mg in SLE-BRAVE-I and II, respectively.

Table 1.

Efficacy and safety of baricitinib in patients with SLE-BRAVE-I and -II

SLE-BRAVE-ISLE-BRAVE-IIEfficacy measurePBO (N=253)BARI 2-mg (N=255)BARI 4-mg (N=252)PBO (N=256)BARI 2-mg (N=261)BARI 4-mg (N=258)SRI-4 (W52)116 (45.9)126 (49.8)142 (56.7)*116 (45.6)120 (46.3)121 (47.1)SRI-4 (W24)99 (39.1)114 (44.8)117 (46.5)98 (38.6)104 (40.0)108 (42.1)Severe Flares (n, events)38 (15.0)34 (13.3)26 (10.3)26 (10.2)29 (11.1)29 (11.2)HR for time to first severe flare (SFI) HR [CI]NA0.8 [0.52, 1.32]0.65 [0.40, 1.08]NA1.1 [0.65, 1.89]1.1 [0.67, 1.94]Glucocorticoid sparing36 (30.8)31 (29.2)36 (34.0)33 (31.7)34 (29.8)36 (34.3)LLDAS (W52)66 (26.2)65 (25.7)74 (29.7)59 (23.2)62 (24.0)65 (25.4)Safety measureTEAE210 (83.0)210 (82.4)208 (82.5)198 (77.3)199 (76.2)200 (77.5)SAE18 (7.1)24 (9.4)26 (10.3)22 (8.6)35 (13.4)29 (11.2)

Data are n (%) patients, unless otherwise indicated. BARI=baricitinib; CI=confidence interval; HR=hazard ratio compared with PBO; LLDAS=lupus low disease activity state; N=number of patients in the analysis population; n=number of patients in the specified category; PBO=placebo; TEAE=treatment-emergent adverse event; SAE=serious adverse event; W=week. *p≤0.05 vs PBO.

Conclusion

Although phase 2 data suggested BARI as a potential treatment for patients with SLE (2), the SLE-BRAVE-I and -II phase 3 study results were discordant for the primary outcome measure, with only SLE-BRAVE-I positive, making it difficult to elucidate benefit. Additional analyses are being performed to understand this discordance. No new safety signals were observed.

References

[1]Dörner T, Tanaka Y, et al. Lupus Sci Med. 2020;7(1).

[2]Wallace DJ, Furie RA, et al. Lancet. 2018;392(10143):222-31.

Disclosure of Interests

Eric F. Morand Speakers bureau: Astra Zeneca, Eli Lilly, Novartis, Sanofi, Consultant of: Amgen, AstraZeneca, Asahi Kasei, Biogen, BristolMyersSquibb, Capella, Eli Lilly, EMD Serono, Genentech, Glaxosmithkline, Janssen, Neovacs, Sanofi, Servier, UCB, Wolf, Grant/research support from: Janssen, AstraZeneca, BristolMyersSquibb, Eli Lilly, EMD Serono, GlaxoSmithKline, Yoshiya Tanaka Speakers bureau: Gilead, Abbvie, Behringer-Ingelheim, Eli Lilly, Mitsubishi-Tanabe, Chugai, Amgen, YL Biologics, Eisai, Astellas, Bristol-Myers, Astra-Zeneca, Consultant of: Eli Lilly, Daiichi-Sankyo, Taisho, Ayumi, Sanofi, GSK, Abbvie, Grant/research support from: Asahi-Kasei, Abbvie, Chugai, Mitsubishi-Tanabe, Eisai, Takeda, Corrona, Daiichi-Sankyo, Kowa, Behringer-Ingelheim, Richard Furie Consultant of: Eli Lilly, Edward Vital Consultant of: Eli Lilly (consultant and honoraria), Ronald van Vollenhoven Consultant of: Abbvie, Biotest, BMS, Celgene, Crescendo, Eli Lilly and Company, GSK, Janssen, Merck, Novartis, Pfizer, Roche, UCB, Vertex, Grant/research support from: Abbvie, Amgen, BMS, GSK, Pfizer, Roche, UCB, Kenneth Kalunian Consultant of: Eli Lilly, Marta Mosca Consultant of: Eli Lilly, GSK, Astra Zeneca, Thomas Dörner Speakers bureau: AbbVie, Eli Lilly, BMS, Novartis, BMS/Celgene, Janssen, Consultant of: AbbVie, Eli Lilly, BMS, Novartis, BMS/Celgene, Janssen, Daniel J. Wallace Consultant of: Amgen, Eli Lilly and Company, EMD Merck Serono, and Pfizer, Maria Silk Shareholder of: Eli Lilly, Employee of: Eli Lilly, christina dickson Shareholder of: Eli Lilly, Employee of: Eli Lilly, Inmaculada De La Torre Shareholder of: Eli Lilly, Employee of: Eli Lilly, Gabriella Meszaros Shareholder of: Eli Lilly, Employee of: Eli Lilly, Bochao Jia Shareholder of: Eli Lilly, Employee of: Eli Lilly, Brenda Crowe Shareholder of: Eli Lilly, Employee of: Eli Lilly, Michelle A Petri Consultant of: Eli Lilly

POS0235 INTEGRATED SAFETY ANALYSIS UPDATE FOR FILGOTINIB (FIL) IN PATIENTS (PTS) WITH MODERATELY TO SEVERELY ACTIVE RHEUMATOID ARTHRITIS (RA) RECEIVING TREATMENT OVER A MEDIAN OF 2.2 YEARS (Y)

Background

The preferential Janus kinase-1 inhibitor FIL significantly improved signs and symptoms of RA in Phase 2 and 3 trials.1–5 FIL is approved for treatment of moderate to severe active RA in Europe and Japan. Integrated safety analysis of FIL with patient data through 2019 was presented at the 2020 ACR virtual meeting.6

Objectives

To report updated, as-treated data from the FIL integrated safety analysis with increased study drug exposure.

Methods

Data were integrated from 2 Phase 2 (NCT01668641, NCT01894516), 3 Phase 3 (NCT02889796, NCT02873936, NCT02886728), and 2 long-term extension (LTE) (NCT02065700, NCT03025308) trials. Phase 2 and 3 LTE data were through Nov 2020 and Jan 2021, respectively. The as-treated analysis set included all available data for pts receiving ≥1 dose FIL 200 (FIL200) or 100 mg (FIL100), including those rerandomized to FIL for LTE. Exposure-adjusted incidence rates (EAIR)/100 patient-y exposure (PYE) of treatment-emergent adverse events (TEAEs; onset after first dose and no later than 30 days after last dose or new drug first dose date −1 day) and TEAEs of special interest (AESIs) are presented.

Results

3691 pts received FIL200 or FIL100 for 8085.1 PYE (median 2.2, maximum 6.8 y). In the as-treated set, 61% of FIL200 and 45% of FIL100 pts received FIL for ≥2 y, 19% and 5% for ≥3 y, and 11% and 0.5% for ≥4.5 y, respectively. EAIR for TEAEs was higher with FIL100 than FIL200; EAIRs for deaths were 0.5 and 0.3 for FIL200 and FIL100 (Figure 1). Incidences of infections and serious infections were numerically greater for FIL100 vs FIL200, while EAIRs for other AESIs were comparable between doses (Table 1). EAIRs for AESIs tended to decrease since the previous update, except for venous thromboembolism (total FIL 0.1 to 0.2) and malignancies excluding NMSC (total FIL 0.5 to 0.6).

Table 1.

TEAEs of special interest, as-treated set

TEAE, n (%) and EAIR per 100 PYE (95% CI)FIL 200 mgn=2267PYE=5302.5FIL 100 mgn=1647PYE=2782.6Total FILN=3691PYE=8085.1Infectious AEs1206 (53.2)747 (45.4)1927 (52.2)EAIR21.1 (19.7, 22.5)30.2 (26.8, 34.0)21.0 (19.9, 22.3)Serious infectious AEs80 (3.5)57 (3.5)137 (3.7)EAIR1.5 (1.1, 1.9)2.7 (1.9, 3.9)1.6 (1.3, 2.0)Opportunistic infections5 (0.2)4 (0.2)9 (0.2)EAIR0.1 (0, 0.2)*0.1 (0.1, 0.4)*0.1 (0.1, 0.2)*Active tuberculosis03 (0.2)3 (<0.1)EAIR00.1 (0, 0.3)*0 (0, 0.1)*Herpes zoster84 (3.7)30 (1.8)114 (3.1)EAIR1.6 (1.2, 2.0)1.1 (0.8, 1.5)*1.4 (1.1, 1.7)Major adverse cardiovascular eventsa19 (0.8)14 (0.9)33 (0.9)EAIR0.3 (0.2, 0.5)0.5 (0.3, 0.8)*0.4 (0.2, 0.6)Venous thromboembolismb11 (0.5)4 (0.2)15 (0.4)EAIR0.2 (0.1, 0.4)*0.1 (0.1, 0.4)*0.2 (0.1, 0.3)*Atrial systemic thrombotic eventsa1 (<0.1)1 (<0.1)2 (<0.1)EAIR0 (0, 0.1)0 (0, 0.3)0 (0, 0.1)Malignancy excluding NMSC32 (1.4)17 (1.0)49 (1.3)EAIR0.6 (0.4, 0.9)0.6 (0.4, 1.0)*0.6 (0.4, 0.8)NMSC15 (0.7)5 (0.3)20 (0.5)EAIR0.3 (0.2, 0.5)*0.2 (0.1, 0.4)*0.2 (0.2, 0.4)*Gastrointestinal perforations3 (0.1)1 (<0.1)4 (0.1)EAIR0.1 (0, 0.2)*0 (0, 0.3)*0 (0, 0.1)*

*Except when any study had 0 event within the treatment, the Poisson model was not adjusted by study. PYE was defined as (last dose date − first dose date + 1)/365.25.

a

Positively adjudicated.

b

Adjudicated as deep vein thrombosis or pulmonary embolism.

NMSC, nonmelanoma skin cancer

Conclusion

With 1 additional year of exposure since the 2020 report, FIL continues to be well tolerated with no new safety concerns emerging. EAIRs of TEAEs, including deaths, and AESIs remained stable or decreased since the 2020 report, except for slight increases in rates of NMSC and malignancies excluding NMSC. In the context of demonstrated efficacy, both FIL doses had an acceptable risk/benefit profile.

References

[1]Westhovens R et al. Ann Rheum Dis 2017;76:998–1008.

[2]Kavanaugh A et al. Ann Rheum Dis 2017;76:1009–19.

[3]Combe B et al. Ann Rheum Dis 2021;80:848–58.

[4]Genovese MC et al. JAMA 2019;322:315–25.

[5]Westhovens R et al. Ann Rheum Dis 2021;80:727–38.

[6]Winthrop K et al. Arthritis Rheumatol 2020;72(suppl 10); abstract 0229.

Acknowledgements

Funding for DARWIN 1 and 2 was provided by Galapagos NV, and funding for DARWIN 3, FINCH 1, 2, 3, and 4 was provided by Gilead Sciences, Inc., Foster City, CA. Funding for this analysis was provided by Gilead Sciences, Inc. The sponsors participated in the planning, execution, and interpretation of the research. Medical writing support was provided by Gregory Bezkorovainy, MA, of AlphaScientia, LLC, San Francisco, CA; and funded by Gilead Sciences, Inc., Foster City, CA.

Disclosure of Interests

Kevin Winthrop Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly and Co., Galapagos NV, Gilead Sciences, Inc., GlaxoSmithKline, Pfizer, Roche, Regeneron, Sanofi, and UCB, Grant/research support from: AbbVie, Bristol Myers Squibb, and Pfizer, Yoshiya Tanaka Speakers bureau: Daiichi-Sankyo, Eli Lilly, Novartis, YL Biologics, Bristol Myers Squibb, Eisai, Chugai, AbbVie, Astellas, Pfizer, Sanofi, Asahi-Kasei, GSK, Mitsubishi-Tanabe, Gilead Sciences, Inc., and Janssen, Consultant of: AbbVie, Ayumi, Daiichi-Sankyo, Eli Lilly, GSK, Taisho, and Sanofi, Grant/research support from: AbbVie, Asahi-Kasei, Chugai, Daiichi-Sankyo, Eisai, Mitsubishi-Tanabe, and Takeda, Tsutomu Takeuchi Speakers bureau: AbbVie, AYUMI, Bristol Myers Squibb, Chugai, Daiichi Sankyo, Dainippon Sumitomo, Eisai, Eli Lilly Japan, Gilead Sciences, Inc., Mitsubishi-Tanabe, Novartis, Pfizer Japan, and Sanofi, Consultant of: Astellas, Chugai, and Eli Lilly Japan, Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi Sankyo, Eisai, Mitsubishi-Tanabe, Shionogi, Takeda, and UCB Japan, Alan Kivitz Shareholder of: Amgen, Gilead Sciences, Inc., GlaxoSmithKline, Pfizer, and Sanofi, Speakers bureau: AbbVie, Celgene, Flexion, Genzyme, Horizon, Merck, Novartis, Pfizer, Regeneron, and Sanofi, Paid instructor for: Celgene, Genzyme, Horizon, Merck, Novartis, Pfizer, Regeneron, and Sanofi, Consultant of: AbbVie, Boehringer Ingelheim, Flexion, Genzyme, Gilead Sciences, Inc., Janssen, Novartis, Pfizer, Regeneron, Sanofi, and SUN Pharma Advanced Research, Mark C. Genovese Shareholder of: Gilead Sciences, Inc., Consultant of: AbbVie, Amgen, Beigene, Eli Lilly and Co., Genentech, Inc., Gilead Sciences, Inc., Sanofi Genzyme, RPharm, and SetPoint, Employee of: Gilead Sciences, Inc., Alena Pechonkina Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Franziska Matzkies Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Beatrix Bartok Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Kun Chen Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Deyuan Jiang Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Iyabode Tiamiyu Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Robin Besuyen Shareholder of: Galapagos BV, Employee of: Galapagos BV, Sander Strengholt Shareholder of: Galapagos BV, Employee of: Galapagos BV, Gerd Rüdiger Burmester Speakers bureau: AbbVie, Eli Lilly and Co., Galapagos, Gilead Sciences, Inc., and Pfizer, Consultant of: AbbVie, Eli Lilly and Co., Galapagos, Gilead Sciences, Inc., and Pfizer, Jacques-Eric Gottenberg Speakers bureau: AbbVie, Eli Lilly and Co., Galapagos BV, Gilead Sciences, Inc., Roche, Sanofi Genzyme, and UCB, Consultant of: Bristol Myers Squibb, Sanofi Genzyme, and UCB, Grant/research support from: Bristol Myers Squibb and Pfizer

OP0142 COMPARISON OF ATTAINMENT AND PROTECTIVE EFFECTS OF THE LUPUS LOW DISEASE ACTIVITY STATE IN PATIENTS WITH NEWLY DIAGNOSED VERSUS ESTABLISHED SLE - A MULTICENTRE PROSPECTIVE STUDY

Background

Lupus low disease activity state (LLDAS) attainment has been reported to be associated with reduced damage accrual, flare, and mortality, as well as improved quality of life, in cohorts of SLE patients with established disease. Whether these associations are present in recent-onset disease is less well known.

Objectives

To evaluate the associations of LLDAS attainment with outcomes in patients with recent onset SLE.

Methods

Data from a 13-country longitudinal SLE cohort (ACR/SLICC criteria) were collected prospectively between 2013 and 2020 using standard templates. Organ damage and flare were captured using SLICC Damage Index and SELENA-SLEDAI Flare Index, respectively. LLDAS was defined as Golder et al., 2019 [1]. An inception cohort was defined based on duration since SLE diagnosis<1 year at enrolment. Patient characteristics between inception and non-inception cohorts were compared using Wilcoxon rank-sum (continuous variables) or Pearson’s Chi-squared tests (categorical variables). Survival analyses were performed to examine the association between LLDAS attainment and damage accrual and flare.

Results

The study cohort included 4,106 patients of whom 680 (16%) were recruited within 1 year of SLE diagnosis (inception cohort). Compared to the non-inception cohort, inception cohort patients were significantly younger, had higher disease activity (SLEDAI-2K and physician global assessment), used more glucocorticoids and immunosuppressants but had less organ damage at enrolment and only 88 (13.6%) patients accrued damage during a median 2.2 years follow-up (Table 1).

Table 1.Non-inception cohortInception cohortp-valuen=3426n=680Age at enrolment (years), median [IQR]40 [31, 51]33 [25, 44]<0.001Age at diagnosis (years), median [IQR]28 [21, 38]33 [25, 43]<0.001SLE duration at enrolment (years), median [IQR]10 [5, 16]1 [0, 1]<0.001Study duration (years), median [IQR]2.5 [1.0, 5.4]2.2 [0.9, 3.7]<0.001Females, n (%)3155 (92.1%)623 (91.6%)0.68Asian ethnicity, n (%)3037 (89.1%)595 (88.1%)0.49Prednisolone (PNL) use - ever, n (%)2865 (83.6%)620 (91.2%)<0.001Time adjusted mean (TAM)-PNL, median [IQR]5.0 [2.2, 8.6]6.2 [3.2, 10.3]<0.001Cumulative PNL (g), median [IQR]3.4 [0.5, 9.7]3.8 [1.1, 8.5]0.26Anti-Malarial use - ever, n (%)2669 (77.9%)569 (83.7%)<0.001Immunosupressant use -ever, n (%)2367 (69.1%)521 (76.6%)<0.001AMS (TAM-SLEDAI-2K), median [IQR]2.8 [1.2, 4.6]3.1 [1.6, 5.0]0.002TAM-PGA, median [IQR]0.4 [0.2, 0.7]0.4 [0.3, 0.8]<0.001Mild/moderate/severe flare ever, n (%)1789 (52.2%)391 (57.5%)0.012Organ damage accrual, n (%)629 (20.8%)88 (13.6%)<0.001LLDAS at baseline, n (%)1730 (50.5%)195 (28.7%)<0.001LLDAS-ever (at least once), n (%)2637 (78.2%)492 (73.9%)0.014≥50% time in LLDAS (LLDAS-5), n (%)1612 (50.6%)256 (41.1%)<0.001

Significantly fewer inception cohort patients were in LLDAS at enrolment than the non-inception cohort (29% vs. 51%, p<0.001). However, 74% of inception and 78% of non-inception cohort patients achieved LLDAS at least once during follow-up. Limiting analysis only to patients not in LLDAS at enrolment, time to first LLDAS attainment was assessed: inception cohort patients were 60% more likely to attain their first LLDAS (HR = 1.60 (95%CI: 1.40, 1.82), p<0.001) than non-inception cohort patients. LLDAS attainment was significantly protective against flare in the inception (HR, 95% CI) and non-inception (HR, 95% CI) cohorts. Trends towards protection against damage accrual in association with LLDAS in the inception cohort were not significant.

Conclusion

LLDAS attainment is protective from flare in recent onset SLE. Significant protection from damage accrual was not observed, due to low rates of damage accrual in the first years after SLE diagnosis.

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.

Acknowledgements

We thank all patients participating in the Asia Pacific Lupus Collaboration (APLC) cohort, and all data collectors for their ongoing support for APLC research activities.

The APLC has received unrestricted project grants from AstraZeneca, BMS, Eli Lily, Janssen, Merck Serono, and UCB to support data collection contributing to this work.

Disclosure of Interests

Vera Golder: None declared, Rangi Kandane-Rathnayake: None declared, Worawit Louthrenoo: None declared, Yi-Hsing Chen Speakers bureau: Pfizer, Novartis, Abbvie, Johnson & Johnson, BMS, Roche, Lilly, GSK, Astra& Zeneca, Sanofi, MSD, Guigai, Astellas, Inova Diagnostics, UCB, Agnitio Science Technology, United Biopharma, Thermo Fisher, Consultant of: Pfizer, Novartis, Abbvie, Johnson & Johnson, BMS, Roche, Lilly, GSK, Astra and Zeneca, Sanofi, Guigai, Astellas, Inova Diagnostics, UCB, Agnitio Science Technology, United Biopharma, Thermo Fisher, Gilead, Grant/research support from: Yes. Clinical trials and/or research grants from Pfizer, Norvatis, BMS, Abbevie, Johnson & Johnson, Roche,Sanofi, Guigai, Roche, Boehringer Ingelheim, UCB, MSD, Astra-Zeneca,Astellas, Gilead, Jiacai Cho: None declared, Aisha Lateef: None declared, Laniyati Hamijoyo Speakers bureau: Pfizer, Novartis, Abbot, Shue Fen Luo: None declared, Yeong-Jian Jan Wu Speakers bureau: Pfizer, Lilly, Novartis, Abbvie, 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: Yes. 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: 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., Yanjie Hao: None declared, Zhuoli Zhang Speakers bureau: Norvatis, GSK, Pfizer, BMDB Basnayake: None declared, Madelynn Chan Speakers bureau: AbbVie, Novartis, Consultant of: Advisory Board member for Pfizer, Eli-Lilly, 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, Sang-Cheol Bae: None declared, Sean O’Neill Paid instructor for: Advisory board member for GSK, Fiona Goldblatt: None declared, Shereen Oon: None declared, Kathryn Gibson Speakers bureau: UCB, Consultant of: Novartis – co-chair for NSW and steering committee member for ARISE meeting Feb 2021

Janssen Pharmaceuticals – advisory board, Grant/research support from: Novartis, Employee of: Eli Lilly, Kristine Ng Speakers bureau: speaker fees and advisory board (Abbvie, Novartis, Janssen), Annie Law: None declared, Nicola Tugnet: None declared, Sunil Kumar: None declared, Cherica Tee: None declared, Michael Tee: 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: Daiichi-Sankyo, Eli Lilly, Novartis, YL Biologics, Bristol-Myers, Eisai, Chugai, Abbvie, Astellas, Pfizer, Sanofi, Asahi-kasei, GSK, Mitsubishi-Tanabe, Gilead, Janssen, C.S. Lau Shareholder of: Pfizer, Sanofi and Janssen, 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, Alberta Hoi Consultant of: AH is on the advisory board for Abbvie and GSK, Grant/research support from: AH has received research support from AstraZeneca, GSK, BMS, Janssen, and Merck Serono, 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

POS0387 RISK STRATIFICATION APPROACHES PERFORM DIFFERENTLY IN SSc-ASSOCIATED PAH IN EUSTAR

Background

Pulmonary arterial hypertension (PAH) is a major clinical challenge in systemic sclerosis (SSc), and is associated with high mortality. Risk stratification provides an estimate for individual patient risk of 1-year mortality. The aim is to detect patients with the worst prognosis to optimize management strategies. Nine risk stratification approaches have been proposed in PAH, but have not been validated in SSc-PAH.

Objectives

To assess four risk stratification models and their performance to predict 1- and 3- year mortality and to identify the best risk assessment approach for SSc-PAH.

Methods

We included all patients with SSc diagnosed with PAH by right heart catheterization (RHC) from the European scleroderma trial and research (EUSTAR) database from 2001 to February 2021. PAH was defined as mean pulmonary arterial pressure (mPAP) ≥25 mmHg, pulmonary artery wedge pressure (PAWP) ≤15mmHg, and pulmonary vascular resistance (PVR) >3 Wood units (WU) in the absence of significant interstitial lung disease. We applied four different approaches for risk stratification at time of PAH diagnosis. Risk parameters included New York Heart Association (NYHA) class, 6-minute walk distance (6MWD), NT-proBNP or BNP, and echocardiographic and hemodynamic parameters with cut-off values based on the 2015 ESC/ERS Guidelines. Model 1 and 2 stratified patients into low, intermediate and high-risk categories; while Model 3 and 4 stratified the patients into four categories (low, intermediate-low, intermediate-high and high).

Model 1: Patients with ≥ 1 high-risk parameter were considered at high risk; with ≥ 1 intermediate-risk parameter at intermediate risk, otherwise at low risk1

Model 2: Each variable was graded from 1 to 3 representing low to high risk. The mean of available risk parameters was rounded to the nearest integer to define the risk category2

Model 3: Equals Model 2, but the intermediate risk group was divided into intermediate-low and intermediate-high based on the mean score3

Model 4: Stratifies patients into four risk categories based on the proportion of low-risk parameters3

We performed analysis of 1- and 3- year mortality in patients with a minimum follow-up of 1 and 3 years, respectively.

Results

Of 911 patients who conducted RHC, 273 (30%) were diagnosed with SSc-PAH according to the inclusion criteria (Table 1). Median follow-up time was 2.8 years (IQR 1.3-5.3). The models varied in their ability to predict mortality (Figure 1). Model 1 and 4 either over- or underestimated mortality. Model 2 stratified patients according to the expected 1-year mortality of <5%, 5-10% and >10% suggested by the ESC/ERS Guidelines. Model 3, which divided the intermediate risk group in two different risk groups, segregated the risk of mortality further within this group.

Table 1.

Demographic and clinical characteristics of patients segregated by risk stratification (Model 3)

NAll patients (n=273)Low-risk (n=78)Intermediate-low (n=118)Intermediate-high (n=56)High-risk (n=21)Age, years (SD)27365 (10.7)65 (10.3)65 (10.7)65 (10.8)67 (12.8)Female sex, n (%)273230 (84)64 (82)98 (83)48 (86)20 (95)lcSSc, n (%)263221 (84)60 (80)99 (86)47 (90)15 (71)NYHA 3 or 4, n (%)261155 (59)12 (16)75 (68)49 (89)19 (95)NT-proBNP, pg/ml (IQR)1111941 (230-1485)215 (103-377)763 (325-1418)1926 (1051-5681)3314 (1129-6553)6MWD, m (SD)196321 (124.1)404 (119.7)314 (99.9)262 (128.6)215 (96.0)RHC:- mPAP, mmHg (SD)27340 (11.0)35 (8.8)41 (11.5)41 (10.8)45 (11.6)- PAWP, mmHg (SD)2739 (3.2)9 (3.0)9 (3.4)9 (3.2)8 (3.1)- Cardiac index, l/min/m2(SD)2602.8 (0.8)3.2 (0.7)2.7 (0.8)2.6 (1.0)2.0 (0.5)- PVR, WU (SD)2737.4 (4.1)5.3 (2.8)7.9 (4.0)7.9 (4.2)11.3 (4.7)Figure 1.

1- and 3-year mortality according to risk category in the four different models

Conclusion

Model 3 provides signals for a better risk stratification of patients with newly diagnosed SSc-PAH, with progressively increasing mortality across the categories. This may provide guidance for optimized management in clinical practice.

References

[1]Hoffmann-Vold, Rheum 2018

[2]Kylhammar, Eur Heart J 2018

[3]Kylhammar, ERJ open 2021

Acknowledgements

The authors thank all EUSTAR collaborators.

Disclosure of Interests

Hilde Jenssen Bjørkekjær: None declared, Cosimo Bruni Speakers bureau: Actelion, Consultant of: Boehringer-Ingelheim, Patricia Carreira: None declared, Paolo Airò Speakers bureau: Boehringer Ingelheim, Bristol-Myers-Squibb, Consultant of: Bristol-Myers-Squibb, Grant/research support from: Bristol-Myers-Squibb, Roche, Janssen, CSL Behring, Carmen Pilar Simeón-Aznar Speakers bureau: Janssen, Boehringer Ingelheim and MSD, Consultant of: Janssen, Boehringer Ingelheim, Marie-Elise Truchetet: None declared, Alessandro Giollo: None declared, Alexandra Balbir-Gurman: None declared, Mickael Martin: None declared, Christopher P Denton Speakers bureau: Boehringer Ingelheim; Janssen, Consultant of: Boehringer Ingelheim; GSK; Corbus; Sanofi; Roche; Horizon; CSL Behring; Acceleron, Grant/research support from: CSL Behring; Horizon; GSK; Servier, Armando Gabrielli: None declared, Håvard Fretheim Consultant of: Bayer, GSK, Actelion, Imon Barua: None declared, Helle Bitter Speakers bureau: Boehringer Ingelheim, Øyvind Midtvedt: None declared, Kaspar Broch: None declared, Arne Andreassen: None declared, Yoshiya Tanaka Speakers bureau: Gilead, Abbvie, Behringer-Ingelheim, Eli Lilly, Mitsubishi-Tanabe, Chugai, Amgen, YL Biologics, Eisai, Astellas, Bristol-Myers, Astra-Zeneca, Consultant of: Eli Lilly, Daiichi-Sankyo, Taisho, Ayumi, Sanofi, GSK, Abbvie, Grant/research support from: Asahi-Kasei, Abbvie, Chugai, Mitsubishi-Tanabe, Eisai, Takeda, Corrona, Daiichi-Sankyo, Kowa, Behringer-Ingelheim, Gabriela Riemekasten: None declared, Ulf Müller-Ladner: None declared, Marco Matucci-Cerinic: None declared, Ivan Castellví: None declared, Elise Siegert: None declared, Eric Hachulla Speakers bureau: Johnson & Johnson, GlaxoSmithKline, Roche-Chugai, Consultant of: Bayer, Boehringer Ingelheim, GlaxoSmithKline, Johnson & Johnson, Roche-Chugai, Sanofi-Genzyme, Grant/research support from: CSL Behring, GlaxoSmithKline, Johnson & Johnson, Roche-Chugai, Sanofi-Genzyme, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim

OP0112 THE EVER-LARGEST ASIAN GWAS FOR SYSTEMIC SCLEROSIS AND TRANS-POPULATION META-ANALYSIS IDENTIFIED SEVEN NOVEL LOCI AND A CANDIDATE CAUSAL SNP IN A CIS-REGULATORY ELEMENT OF THE FCGR REGION

Background

Genome-wide association studies (GWASs) have identified 29 disease-associated single nucleotide polymorphisms (SNPs) for systemic sclerosis (SSc) in non-human leukocyte antigen (HLA) regions (1-7). While these GWASs have clarified genetic architectures of SSc, study subjects were mainly Caucasians limiting application of the findings to Asians.

Objectives

The study was conducted to identify novel causal variants for SSc specific to Japanese subjects as well as those shared with European population. We also aimed to clarify mechanistic effects of the variants on pathogenesis of SSc.

Methods

A total of 114,108 subjects comprising 1,499 cases and 112,609 controls were enrolled in the two-staged study leading to the ever-largest Asian GWAS for SSc. After applying a strict quality control both for genotype and samples, imputation was conducted using the reference panel of the phase 3v5 1,000 genome project data combined with a high-depth whole-genome sequence data of 3,256 Japanese subjects. We conducted logistic regression analyses and also combined the Japanese GWAS results with those of Europeans (6) by an inverse-variance fixed-effect model. Polygenicity and enrichment of functional annotations were evaluated by linkage disequilibrium score regression (LDSC), Haploreg and IMPACT programs. We also constructed polygenic risk score (PRS) to predict SSc development.

Results

We identified three (FCRLA-FCGR, TNFAIP3, PLD4) and four (EOMES, ESR1, SLC12A5, TPI1P2) novel loci in Japanese GWAS and a trans-population meta-analysis, respectively. One of Japanese novel risk SNPs, rs6697139, located within FCGR gene clusters had a strong effect size (OR 2.05, P=4.9×10-11). We also found the complete LD variant, rs10917688, was positioned in cis-regulatory element and binding motif for an immunomodulatory transcription factor IRF8 in B cells, another genome-wide significant locus in our trans-ethnic meta-analysis and the previous European GWAS. Notably, the association of risk allele of rs10917688 was significant only in the presence of the risk allele of the IRF8. Intriguingly, rs10917688 was annotated as one enhancer-related histone marks, H3K4me1, in B cells, implying that FCGR gene(s) in B cells may play an important role in the pathogenesis of SSc. Furhtermore, significant heritability enrichment of active histone marks and a transcription factor C-Myc were found in B cells both in European and Japanese populations by LDSC and IMPACT, highlighting a possibility of a shared disease mechanism where abnormal B-cell activation may be one of the key drivers for the disease development. Finally, PRS using effects sizes of European GWAS moderately fit in the development of Japanese SSc (AUC 0.593), paving a path to personalized medicine for SSc.

Conclusion

Our study identified seven novel susceptibility loci in SSc. Downstream analyses highlighted a novel disease mechanism of SSc where an interactive role of FCGR gene(s) and IRF8 may accelerate the disease development and B cells may play a key role on the pathogenesis of SSc.

References

[1]F. C. Arnett et al. Ann Rheum Dis, 2010.

[2]T. R. Radstake et al. Nat Genet, 2010.

[3]Y. Allanore et al. PLoS Genet, 2011.

[4]O. Gorlova et al. PLoS Genet, 2011.

[5]C. Terao et al. Ann Rheum Dis, 2017.

[6]E. López-Isac et al. Nat Commun, 2019.

[7]W. Pu et al. J Invest Dermatol, 2021.

Disclosure of Interests

None declared

POS0679 CLINICAL OUTCOMES UP TO WEEK (W) 48 IN THE ONGOING FILGOTINIB (FIL) LONG-TERM EXTENSION (LTE) TRIAL OF RHEUMATOID ARTHRITIS (RA) PATIENTS (pts) WITH INADEQUATE RESPONSE (IR) TO METHOTREXATE (MTX) INITIALLY TREATED WITH FIL OR ADALIMUMAB (ADA) DURING THE PHASE 3 PARENT STUDY (PS)

Background

The preferential Janus kinase-1 inhibitor FIL is approved for treatment of moderate to severe active RA in Europe and Japan.

Objectives

Efficacy and safety of FIL were assessed in pts with IR to MTX who completed a Phase 3 trial (NCT02889796)1 and enrolled in an LTE (NCT03025308).

Methods

Pts completing the PS1 on study drug were eligible to enter the LTE (data cutoff: June 1, 2020). Median exposure: 2.2 years (y). Efficacy data to W48 are reported for 4 treatment groups (all with background MTX): pts receiving FIL 200 mg (FIL200) or FIL 100 mg (FIL100) in the PS and continuing their dose in LTE (FIL200/FIL200, FIL100/FIL100) and ADA pts rerandomized, double blind, to FIL200 or FIL100 for LTE (ADA/FIL200, ADA/FIL100); safety data are reported.

Results

As of June 1, 2020, 522/571 (91%) FIL200/FIL200, 502/570 (88%) FIL100/FIL100, 118/128 (92%) ADA/FIL200, and 115/130 (89%) ADA/FIL100 pts remained on study drug. LTE baseline disease characteristics were similar between groups: mean duration of RA approximately 8.7 y; DAS28(CRP) 2.55, and mean concurrent MTX dosage was 15.0 mg/week. Proportions of pts achieving ACR20/50/70, DAS28(CRP) ≤3.2, <2.6, and CDAI ≤10, ≤2.8 were generally maintained in all LTE groups through W48 (Figure 1). Numerically greater proportions of pts met response criteria at W48 in the FIL200 groups vs FIL100, regardless of PS treatment. Treatment-emergent AEs (TEAE), serious AEs, and AEs Grade ≥3 were largely comparable between groups and lowest in ADA/FIL100. There were 10 deaths (Table 1). Exposure-adjusted incidence rates (EAIRs)/100 pt-y of exposure for deaths were lower for FIL/FIL vs ADA/FIL.

Table 1.

EAIRs of TEAEs in LTE, as of June 1, 2020

1TEAE, n (%)3FIL200+MTX → FIL200+MTX6ADA+MTX → FIL200+MTX9FIL100+MTX → FIL100+MTX12ADA+MTX → FIL100+MTX2EAIR (95% CI)4n=5717n=12810n=57013n=1305PYE=859.48PYE=197.811PYE=852.314PYE=192.6TEAE429 (75.1)91 (71.1)443 (77.7)88 (67.7)49.9 (45.4, 54.9)46.0 (37.5, 56.5)52.0 (47.4, 57.0)45.7 (37.1, 56.3)TEAE Grade ≥364 (11.2)15 (11.7)72 (12.6)7 (5.4)7.4 (5.8, 9.5)7.6 (4.6, 12.6)8.4 (6.7, 10.6)3.6 (1.7, 7.6)TE serious AE52 (9.1)13 (10.2)60 (10.5)9 (6.9)6.1 (4.6, 7.9)6.6 (3.8, 11.3)7.0 (5.5, 9.1)4.7 (2.4, 9.0)Death3 (0.5)2 (1.6)3 (0.5)2 (1.5)0.3 (0.1, 1.1)1.0 (0.3, 4.0)0.4 (0.1, 1.1)1.0 (0.3, 4.2)TE infections243 (42.6)52 (40.6)249 (43.7)43 (33.1)28.3 (24.9, 32.1)26.3 (20.0, 34.5)29.2 (25.8, 33.1)22.3 (16.6, 30.1)TE serious infections7 (1.2)2 (1.6)13 (2.3)1 (0.8)0.8 (0.4, 1.7)1.0 (0.3, 4.0)1.5 (0.9, 2.6)0.5 (0.1, 3.7)Opportunistic infections2 (0.4)02 (0.4)00.2 (0, 0.8)0 (0, 1.9)0.2 (0, 0.8)0 (0, 1.9)TE herpes zoster16 (2.8)5 (3.9)13 (2.3)1 (0.8)1.9 (1.1, 3.0)2.5 (1.1,6.1)1.5 (0.9, 2.6)0.5 (0.1, 3.7)TE MACE (adjudicated)1 (0.2)03 (0.5)3 (2.3)01 (0, 0.6)0 (0, 1.9)0.4 (0.1, 1.1)1.6 (0.5, 4.8)TE DVT/PE (adjudicated)3 (0.5)03 (0.5)00.3 (0.1, 1.0)0 (0, 1.9)0.4 (0.1, 1.0)0 (0, 1.9)Malignancies (excluding NMSC)5 (0.9)3 (2.3)4 (0.7)00.6 (0.2, 1.4)1.5 (0.5, 4.7)0.5 (0.1, 1.2)0 (0, 1.9)NMSC3 (0.5)02 (0.4)00.3 (0.1, 1.0)0 (0, 1.9)0.2 (0, 0.8)0 (0, 1.9)

DVT, deep vein thrombosis; MACE, major adverse cardiovascular event; NMSC, nonmelanoma skin cancer; PE, pulmonary embolism; TE, treatment-emergent

Figure 1.

Conclusion

During the LTE through W48, response rates generally were maintained for FIL/FIL and ADA/FIL pts. Though there were differences between LTE groups, safety was largely comparable and consistent with PS observations1 and previously reported results from 7 trials2: rates of AEs of special interest were low; all confidence intervals were overlapping. Limitation: the LTE was not formally randomized for comparison between FIL/FIL and ADA/FIL treatment groups, the groups were of unequal size, and the switch from ADA to FIL for LTE was by design, rather than based on disease activity.

References

[1]Combe B et al. Ann Rheum Dis 2021;80:848–58.

[2]Winthrop K et al. Arthritis Rheumatol 2020;72(suppl 10); abstract 0229.

Acknowledgements

This study was funded by Gilead Sciences, Inc., Foster City, CA. Medical writing support was provided by Claudine Bitel, PhD, of AlphaScientia, LLC, San Francisco, CA; and funded by Gilead Sciences, Inc., Foster City, CA.

Disclosure of Interests

Bernard Combe Speakers bureau: BMS, Eli Lilly & Co., Gilead Sciences, Inc., MSD, Pfizer, Roche-Chugai, and UCB, Consultant of: AbbVie, Eli Lilly & Co., Gilead Sciences, Inc., Janssen, Pfizer, Roche-Chugai, and Sanofi, Grant/research support from: Novartis, Pfizer, and Roche-Chugai, Yoshiya Tanaka Speakers bureau: AbbVie, Asahi-Kasei, Astellas, Bristol-Myers, Chugai, Daiichi- Sankyo, Eli Lilly, Eisai, Gilead, GSK, Janssen, Mitsubishi-Tanabe, Novartis, Pfizer, Sanofi, and YL Biologics, Consultant of: AbbVie, Ayumi, Daiichi- Sankyo, Eli Lilly, GSK, Sanofi, and Taisho, Grant/research support from: AbbVie, Asahi-Kasei, Chugai, Daiichi-Sankyo, Eisai, Mitsubishi-Tanabe, and Takeda, Paul Emery Consultant of: AbbVie, BMS, Celltrion, Gilead, Lilly, Novartis, Roche, Samsung, and Sandoz, Grant/research support from: AbbVie, BMS, Lilly, and Samsung, Alena Pechonkina Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Albert Kuo Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Qi Gong Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Katrien Van Beneden Shareholder of: Galapagos NV, Employee of: Galapagos NV, Vijay Rajendran Shareholder of: Galapagos NV, Employee of: Galapagos NV, Hendrik Schulze-Koops Speakers bureau: AbbVie, Amgen, BMS, Celgene, Celltrion, Chugai, Gilead, Janssen, Eli Lilly and Company, Merck Sharp & Dohme, Novartis-Sandoz, Pfizer, Roche, and Sanofi, Consultant of: AbbVie, Amgen, BMS, Celgene, Celltrion, Chugai, Gilead, Janssen, Eli Lilly and Company, Merck Sharp & Dohme, Novartis-Sandoz, Pfizer, Roche, and Sanofi, Grant/research support from: AbbVie and Novartis

Risk Factor Analysis for Type 2 Diabetes Patients About Hypoglycemia Using Continuous Glucose Monitoring: Results from a Prospective Observational Study

Introduction: To determine the relationship between hypoglycemia and glucose variability in outpatients with type 2 diabetes mellitus (T2DM). Materials and Methods: The study participants were 999 outpatients with T2DM who used the FreeStyle Libre Pro for continuous glucose monitoring (FLP-CGM). Hypoglycemia was defined as glucose level of <3.0 mM, and the frequency of episodes and duration of hypoglycemia were evaluated by comparing patients who did or did not achieve time-below-range <3.0 mM (TBR^<3.0) of <1% of the time. The association of TBR^<3.0 and long% coefficient of variation (%CV) with medications used was examined using multivariate analysis with a proportional odds model. Results: The average TBR^<3.0 was 0.33% (4.75 min). The TBR^<3.0 >1% group comprised 71/999 patients. Patients of the TBR^<3.0 >1% group had lower body mass index, longer disease duration, and poorer renal function. For the TBR^<3.0 >1% group, the predicted cutoff values were 7.19 mM average glucose (AG), and 30.30% for %CV. When AG <7.19 mM and %CV >30.30% were considered as hypoglycemic risk factors, the frequency and duration of hypoglycemia increased as the risk factor values increased. In multivariate analysis, sulfonylurea (SU) use, insulin use, and low blood glucose index correlated significantly with increased length of TBR^<3.0 and %CV, even after adjustment for concomitant diabetes medications. Conclusion: In T2DM, maintaining TBR^<3.0 <1% requires to keep AG >7.2 mM and %CV <30%, in addition to comprehensive management of CGM metrics. Since SU and insulin use is associated with prolonged TBR^<3.0 and increased %CV, their doses should be adjusted to avoid excessive fall in AG and raising %CV.

POS0664 RADIOGRAPHIC CHANGE IN PATIENTS WITH RHEUMATOID ARTHRITIS AND ESTIMATED BASELINE YEARLY PROGRESSION ≥5 OR <5: POST HOC ANALYSIS OF TWO PHASE 3 TRIALS OF FILGOTINIB

Background

In some patients (pts) with rheumatoid arthritis (RA), especially those with joint damage early in the disease, first-line methotrexate (MTX) treatment may not suffice to prevent further rapid radiographic progression (RRP).1 In FINCH 1 (NCT02889796), filgotinib 200 mg (FIL200) and 100 mg (FIL100) reduced change in modified total Sharp score (mTSS) vs placebo (PBO) in pts with RA and inadequate response to MTX (MTX-IR).2 In FINCH 3 (NCT02886728), FIL200 and FIL100 reduced change in mTSS vs MTX monotherapy (MTX mono) in MTX-naïve pts.3

Objectives

To evaluate, via post hoc analysis of 2 trials, filgotinib’s effects on radiographic progression vs MTX mono in pts with estimated baseline (BL) yearly progression ≥5 or <5 mTSS units/year.

Methods

The double-blind 52-week (W) FINCH 1 study randomised MTX-IR pts with moderate–severe active RA to FIL200 or FIL100, subcutaneous adalimumab (ADA) 40 mg, or PBO; at W24, PBO pts were rerandomised blinded to FIL200 or FIL100; all took stable background MTX.2 In FINCH 3, MTX-naïve pts were randomised, blinded, to FIL200 + MTX, FIL100 + MTX, FIL200 alone, or MTX mono for up to W52.3 This analysis examined subgroups by estimated BL yearly progression (BL mTSS/duration in years of RA diagnosis), based on ≥5 or <5 mTSS units/year,4 a threshold commonly used to define RRP. We assessed effects of filgotinib vs ADA or PBO in mTSS change from BL (CFB) at W24/W52 (using a mixed model for repeated measures) and percentages with no W24 progression (mTSS change ≤0, ≤0.5, ≤smallest detectable change [SDC], using Fisher’s exact test).

Results

At BL, 558/1755 MTX-IR and 787/1249 MTX-naïve pts had BL estimated yearly progression ≥5. Median mTSS in pts with BL yearly progression ≥5 and <5 was 53.25 vs 5.00 respectively in the MTX-IR trial and 6.00 vs 2.50 in the MTX-naïve trial. At W24, the mTSS CFB in pts with BL yearly progression ≥5 and <5 was 0.84 and 0.22 in MTX-IR pts taking PBO + MTX, and 0.67 and 0.25 in MTX-naïve pts taking MTX mono. At W52, in pts with BL yearly progression ≥5, FIL200 + MTX reduced mTSS change vs PBO + MTX in the MTX-IR trial and vs MTX mono in the MTX-naïve trial (Figure 1). At W24, among pts with estimated BL yearly progression ≥5, FIL200 + MTX increased odds of no progression (≤0.5 or ≤0) vs PBO + MTX in MTX-IR pts and vs MTX mono in MTX-naïve pts (Table 1).

Table 1.

Ratio of no radiographic progression at W24

FINCH 1: MTX-IRFIL200 + MTXFIL100 + MTXADA + MTXPBO + MTXBL yearly progression≥5(n = 138)<5(n = 267)≥5(n = 139)<5(n = 265)≥5(n = 91)<5(n = 180)≥5(n = 101)<5(n = 250)% with no progression (≤0.5)87.797.088.592.587.993.976.291.6OR2.22*2.97*2.40*1.12††††% with no progression (≤0)80.491.881.388.380.289.467.386.4OR2.00*1.752.11*1.19††††% with no progression (≤SDC [1.36])91.398.192.196.692.395.681.294.0OR2.43*3.35*2.70*1.82††††FINCH 3: MTX-naïveFIL200 + MTXFIL100 + MTXFIL200 monoMTXBL yearly progression≥5<5≥5<5≥5<5≥5<5(n = 221)(n = 134)(n = 121)(n = 63)(n = 115)(n = 58)(n = 224)(n = 132)% with no progression (≤0.5)86.994.083.593.789.689.778.687.9OR1.81*2.171.382.032.34*1.20††% with no progression (≤0)78.783.672.784.180.087.967.980.3OR1.75*1.251.261.31.89*1.79††% with no progression (≤SDC [1.53])93.797.891.796.895.796.689.395.5OR1.772.081.331.452.641.33††

MTX-IR ORs are FIL vs PBO + MTX; MTX-naïve are FIL vs MTX. *Nominal P<.05. †Not applicable.

ADA, adalimumab; FIL, filgotinib; IR, inadequate response; mTSS, modified total Sharp score; MTX, methotrexate; OR, odds ratio; SDC, smallest detectable change; W, week.

Conclusion

These data suggest filgotinib’s inhibition of radiographic progression was numerically greater than MTX monotherapy in RA pts with high estimated BL yearly progression. In those with a more moderate estimated rate of progression, filgotinib suppressed progression comparably to ADA and/or MTX.

References

[1]Smolen J et al. Ann Rheum Dis 2018;77:1566–1572.

[2]Combe B et al. Ann Rheum Dis 2021;80:848–858.

[3]Westhovens R et al. Ann Rheum Dis 2021;80:727–738.

[4]Vastesaeger N et al. Rheumatology. 2009;48:1114–1121.

Acknowledgements

This study was funded by Gilead Sciences, Inc., Foster City, CA. Medical writing support was provided by Rob Coover, MPH, of AlphaScientia, LLC, San Francisco, CA; and funded by Gilead Sciences, Inc., Foster City, CA. Funding for this analysis was provided by Gilead Sciences, Inc. The sponsors participated in the planning, execution, and interpretation of the research.

Disclosure of Interests

Yoshiya Tanaka Speakers bureau: AbbVie, Amgen, Astellas, AstraZeneca, Behringer-Ingelheim, Bristol-Myers Squibb, Chugai, Eisai, Eli Lilly, Gilead, Mitsubishi-Tanabe, and YL Biologics, Grant/research support from: AbbVie, Asahi-Kasei, Boehringer-Ingelheim, Chugai, Corrona, Daiichi Sankyo, Eisai, Kowa, Mitsubishi-Tanabe, and Takeda, Tatsuya Atsumi Paid instructor for: Gilead Sciences, Inc.; Mitsubishi Tanabe; Chugai; Astellas Pharma; Takeda; Pfizer; AbbVie: Eisai; Daiichi Sankyo; Bristol-Myers Squibb; UCB Japan Co. Ltd.; Eli Lilly Japan K.K., Otsuka Pharmaceutical Co., Ltd.; and Alexion Inc., Grant/research support from: Gilead Sciences, Inc.; Mitsubishi Tanabe; Chugai; Astellas Pharma; Takeda; Pfizer; AbbVie: Eisai; Daiichi Sankyo; Bristol-Myers Squibb; UCB Japan Co. Ltd.; Eli Lilly Japan K.K., Otsuka Pharmaceutical Co., Ltd.; and Alexion Inc., Daniel Aletaha Speakers bureau: AbbVie; Amgen; Celgene; Eli Lilly; Medac; Merck; Novartis; Pfizer; Roche; Sandoz; and Sanofi/Genzyme; Bristol-Myers Squibb, Merck Sharp & Dohme, and UCB, Consultant of: Janssen; AbbVie; Amgen; Celgene; Eli Lilly; Medac; Merck; Novartis; Pfizer; Roche; Sandoz; and Sanofi/Genzyme, Grant/research support from: AbbVie, Merck Sharp & Dohme, Novartis, and Roche, Robert B.M. Landewé Paid instructor for: AbbVie, AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Galapagos NV, Novartis, Pfizer, and UCB, Consultant of: AbbVie, AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Galapagos NV, Novartis, Pfizer, and UCB, Beatrix Bartok Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc, Alena Pechonkina Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Zhaoyu Yin Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Ling Han Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Kahaku Emoto Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences K.K., Shungo Kano Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences K.K., Vijay Rajendran Employee of: Galapagos BV, Tsutomu Takeuchi Speakers bureau: AbbVie, Ayumi Pharmaceutical Corporation, Bristol-Myers Squibb, Chugai, Daiichi Sankyo, Dainippon Sumitomo Eisai, Eli Lilly Japan, Mitsubishi-Tanabe, Novartis, Pfizer Japan, Sanofi, and Gilead Sciences, Inc., Consultant of: Astellas, Chugai, and Eli Lilly Japan, Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi Sankyo, Eisai, Mitsubishi-Tanabe, Shionogi, Takeda, and UCB Japan

OP0255 BIMEKIZUMAB IN PATIENTS WITH ACTIVE PSORIATIC ARTHRITIS AND AN INADEQUATE RESPONSE TO TUMOUR NECROSIS FACTOR INHIBITORS: 16-WEEK EFFICACY & SAFETY FROM BE COMPLETE, A PHASE 3, MULTICENTRE, RANDOMISED PLACEBO-CONTROLLED STUDY

Background

Bimekizumab (BKZ) is a monoclonal IgG1 antibody that selectively inhibits IL-17F in addition to IL-17A. BKZ has shown sustained efficacy and tolerability up to 152 wks in a phase 2b study in patients (pts) with active psoriatic arthritis (PsA).1,2

Objectives

To assess efficacy and safety of BKZ vs placebo (PBO) in pts with active PsA and prior inadequate tumour necrosis factor inhibitor (TNFi) response in the 16-wk pivotal phase 3 study, BE COMPLETE.

Methods

BE COMPLETE (NCT03896581) comprises a 16-wk double-blind, PBO-controlled period. Pts were aged ≥18 yrs, had a diagnosis of adult-onset, active PsA with ≥3 tender joints and ≥3 swollen joints, and inadequate response or intolerance to treatment with 1 or 2 TNFi. Pts were randomised 2:1 to BKZ 160 mg Q4W or PBO. From Wk 16, pts were eligible to enter an open-label extension, receiving BKZ 160 mg Q4W. The primary endpoint was a ≥50% improvement in American College of Rheumatology response criteria (ACR50) at Wk 16. Primary and ranked secondary efficacy endpoints were assessed at Wk 16.

Results

Of 400 randomised pts (BKZ: 267; PBO: 133), 388 (97.0%) completed Wk 16 (BKZ: 263 [98.5%]; PBO: 125 [94.0%]). Baseline characteristics were comparable between groups: mean age 50.5 yrs, weight 86.0 kg, BMI 29.8 kg/m2, time since diagnosis 9.5 yrs; 47.5% pts were male.

At Wk 16, the primary endpoint (ACR50: 43.4% BKZ vs 6.8% PBO; p<0.001; Figure 1) and all ranked secondary endpoints (HAQ-DI CfB, PASI90, SF-36 PCS CfB and MDA response) were met (all p<0.001; Table 1). The ACR50 response was rapid with separation from PBO observed from Wk 4 (nominal p<0.001). Additional outcomes, including ACR20/70, TJC and SJC CfB, and PASI75/100, demonstrated numerical improvement with BKZ compared to PBO at Wk 16 (all nominal p<0.001; Table 1).

Table 1.

Disease characteristics at baseline and efficacy at Wk 16

PBO N=133BKZ 160 mg Q4W N=267p valueBaseline characteristicsTJCmean (SD)19.3 (14.2)18.4 (13.5)-SJCmean (SD)10.3 (8.2)9.7 (7.5)-PtGA-PsAmean (SD)63.0 (22.0)60.5 (22.5)-PtAAPmean (SD)61.7 (24.6)58.3 (24.2)-Psoriasis BSAn (%)<3%45 (33.8)91 (34.1)-≥3 to ≤10%63 (47.4)109 (40.8)->10%25 (18.8)67 (25.1)-PASIamean (SD)8.5 (6.6)b10.1 (9.1)c-Prior TNFin (%)Inadequate response to 1 TNFi103 (77.4)204 (76.4)-Inadequate response to 2 TNFi15 (11.3)29 (10.9)-Intolerance to TNFi15 (11.3)34 (12.7)-Current cDMARDsn (%)63 (47.4)139 (52.1)-Ranked endpoints in hierarchical orderACR50* [NRI] n (%)9 (6.8)116 (43.4)<0.001HAQ-DI CfB† [RBMI] mean (SE)–0.1 (0.0)–0.4 (0.0)<0.001PASI90†a [NRI]n (%)6 (6.8)b121 (68.8)c<0.001SF-36 PCS CfB† [RBMI]mean (SE)1.4 (0.7)7.3 (0.5)<0.001MDA Response† [NRI]n (%)8 (6.0)118 (44.2)<0.001Other endpointsACR20† [NRI]n (%)21 (15.8)179 (67.0)<0.001‡ACR70† [NRI] n (%)1 (0.8)71 (26.6)<0.001‡TJC CfB [MI] mean (SE)–2.4 (0.9)–10.9 (0.8)<0.001‡SJC CfB [MI] mean (SE)–2.0 (0.5)–7.0 (0.4)<0.001‡PASI75a [NRI]n (%)9 (10.2)b145 (82.4)c<0.001‡PASI100a [NRI]n (%)4 (4.5)b103 (58.5)c<0.001‡

Randomised set (N=400). *Primary endpoint; †Secondary endpoint; ‡Nominal p value. aIn patients with ≥3% BSA with PSO at BL; bn=88; cn=176.

Over 16 wks, 107/267 (40.1%) pts on BKZ had ≥1 TEAE vs 44/132 (33.3%) pts on PBO; the three most frequent TEAEs on BKZ were nasopharyngitis (BKZ: 3.7%; PBO: 0.8%), oral candidiasis (BKZ: 2.6%; PBO: 0%) and upper respiratory tract infection (BKZ: 2.2%; PBO: 1.5%). Incidence of SAEs was low (BKZ: 1.9%; PBO: 0%); none led to discontinuation. 2 pts on BKZ discontinued due to a TEAE (BKZ: 0.7%; PBO: 0%). No systemic candidiasis, cases of IBD, MACE, uveitis, VTE or deaths were reported.

Conclusion

Dual inhibition of IL-17A and IL-17F with BKZ in pts with active PsA and prior inadequate TNFi response resulted in rapid, clinically relevant and statistically significant improvements in efficacy outcomes vs PBO. No new safety signals were observed.1,2

References

[1]Ritchlin C.T. Lancet 2020;395(10222):427–40; 2. Coates L.C. Ann Rheum Dis 2021;80:779–80(POS1022).

Acknowledgements

This study was funded by UCB Pharma. Editorial services were provided by Costello Medical.

Disclosure of Interests

Joseph F. Merola Paid instructor for: Amgen, Abbvie, Biogen, BMS, Dermavant, Eli Lilly, Janssen, Leo Pharma, Novartis, Pfizer, Regeneron, Sanofi, Sun Pharma and UCB Pharma, Consultant of: Amgen, Abbvie, Biogen, BMS, Dermavant, Eli Lilly, Janssen, Leo Pharma, Novartis, Pfizer, Regeneron, Sanofi, Sun Pharma and UCB Pharma, Iain McInnes Consultant of: AbbVie, BMS, Boehringer Ingelheim, Celgene, Eli Lilly, Janssen, Novartis, and UCB Pharma, Grant/research support from: BMS, Boehringer Ingelheim, Celgene, Janssen, UCB Pharma, Christopher T. Ritchlin Consultant of: Amgen, AbbVie, Eli Lilly, Gilead, Janssen, Novartis, Pfizer and UCB Pharma, Grant/research support from: AbbVie, Amgen and UCB Pharma, Philip J Mease Speakers bureau: AbbVie, Amgen, Eli Lilly, Janssen, Novartis, Pfizer and UCB Pharma, Consultant of: AbbVie, Amgen, BMS, Boehringer Ingelheim, Eli Lilly, Galapagos, Gilead, GSK, Janssen, Novartis, Pfizer, Sun Pharma and UCB Pharma, Grant/research support from: AbbVie, Amgen, BMS, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, Sun Pharma and UCB Pharma, Robert B.M. Landewé Speakers bureau: Abbott, Amgen, BMS, Centocor, Merck, Pfizer, Roche, Schering-Plough, UCB Pharma, and Wyeth, Consultant of: Abbott, Ablynx, Amgen, AstraZeneca, BMS, Centocor, GSK, Novartis, Merck, Pfizer, Roche, Schering-Plough, UCB Pharma, and Wyeth, Grant/research support from: Abbott, Amgen, Centocor, Novartis, Pfizer, Roche, Schering-Plough, UCB Pharma, and Wyeth, Akihiko Asahina Grant/research support from: AbbVie, Amgen, Eisai, Eli Lilly, Janssen, Kyowa Kirin, LEO Pharma, Maruho, Mitsubishi Tanabe Pharma, Pfizer, Sun Pharma, Taiho Pharma, Torii Pharmaceutical, and UCB Pharma, Yoshiya Tanaka Speakers bureau: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer-Ingelheim, Chugai, Eisai, Eli Lilly, Gilead, Mitsubishi-Tanabe, and YL Biologics, Consultant of: AbbVie, Ayumi, Daiichi-Sankyo, Eli Lilly, GSK, Sanofi, and Taisho, Grant/research support from: Asahi-Kasei, AbbVie, Boehringer-Ingelheim, Chugai, Corrona, Daiichi-Sankyo, Eisai, Kowa, Mitsubishi-Tanabe, and Takeda, Richard B. Warren Paid instructor for: Astellas, DiCE, GSK, and Union, Consultant of: AbbVie, Almirall, Amgen, Arena, Astellas, Avillion, Biogen, BMS, Boehringer Ingelheim, Celgene, Eli Lilly, GSK, Janssen, LEO Pharma, Novartis, Pfizer, Sanofi, and UCB Pharma, Grant/research support from: AbbVie, Almirall, Janssen, LEO Pharma, Novartis, and UCB Pharma, Laure Gossec Consultant of: AbbVie, Amgen, BMS, Galapagos, Gilead, GSK, Janssen, Lilly, Novartis, Pfizer, Samsung Bioepis, Sanofi-Aventis, and UCB Pharma, Grant/research support from: Amgen, Galapagos, Lilly, Pfizer, and Sandoz, Dafna D Gladman Consultant of: AbbVie, Amgen, BMS, Eli Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, and UCB Pharma, Grant/research support from: AbbVie, Amgen, Eli Lilly, Janssen, Novartis, Pfizer, and UCB Pharma, Frank Behrens Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Chugai, Eli Lilly, Genzyme, Janssen, MSD, Novartis, Pfizer, Roche, and Sanofi, Barbara Ink Shareholder of: GSK, UCB Pharma, Employee of: UCB Pharma, Deepak Assudani Shareholder of: UCB Pharma, Employee of: UCB Pharma, Rajan Bajracharya Shareholder of: UCB Pharma, Employee of: UCB Pharma, Jason Coarse Shareholder of: UCB Pharma, Employee of: UCB Pharma, Laura Coates Speakers bureau: AbbVie, Amgen, Biogen, Celgene, Eli Lilly, Galapagos, Gilead, GSK, Janssen, Medac, Novartis, Pfizer, and UCB Pharma, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, BMS, Celgene, Eli Lilly, Gilead, Galapagos, Janssen, Moonlake, Novartis, Pfizer, and UCB Pharma, Grant/research support from: AbbVie, Amgen, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, and UCB Pharma

Effect of active vitamin D treatment on development of type 2 diabetes: DPVD randomised controlled trial in Japanese population

OBJECTIVE

To assess whether eldecalcitol, an active vitamin D analogue², can reduce the development of type 2 diabetes among adults with impaired glucose tolerance.

DESIGN

Double blinded, multicentre, randomised, placebo controlled trial.

SETTING

Three hospitals in Japan, between June 2013 and August 2019.

PARTICIPANTS

People aged 30 years and older who had impaired glucose tolerance defined by using a 75 g oral glucose tolerance test and glycated haemoglobin level.

INTERVENTIONS

Participants were randomised to receive active vitamin D (eldecalcitol 0.75 μg per day; n=630) or matching placebo (n=626) for three years.

MAIN OUTCOMES

The primary endpoint was incidence of diabetes. Prespecified secondary endpoints were regression to normoglycaemia and incidence of type 2 diabetes after adjustment for confounding factors at baseline. In addition, bone densities and bone and glucose metabolism markers were assessed.

RESULTS

Of the 1256 participants, 571 (45.5%) were women and 742 (59.1%) had a family history of type 2 diabetes. The mean age of participants was 61.3 years. The mean serum 25-hydroxyvitamin D concentration at baseline was 20.9 ng/mL (52.2 nmol/L); 548 (43.6%) participants had concentrations below 20 ng/mL (50 nmol/L). During a median follow-up of 2.9 years, 79 (12.5%) of 630 participants in the eldecalcitol group and 89 (14.2%) of 626 in the placebo group developed type 2 diabetes (hazard ratio 0.87, 95% confidence interval 0.67 to 1.17; P=0.39). Regression to normoglycaemia was achieved in 145 (23.0%) of 630 participants in the eldecalcitol group and 126 (20.1%) of 626 in the placebo group (hazard ratio 1.15, 0.93 to 1.41; P=0.21). After adjustment for confounding factors by multivariable fractional polynomial Cox regression analysis, eldecalcitol significantly lowered the development of diabetes (hazard ratio 0.69, 0.51 to 0.95; P=0.020). In addition, eldecalcitol showed its beneficial effect among the participants with the lower level of basal insulin secretion (hazard ratio 0.41, 0.23 to 0.71; P=0.001). During follow-up, bone mineral densities of the lumbar spine and femoral neck and serum osteocalcin concentrations significantly increased with eldecalcitol compared with placebo (all P<0.001). No significant difference in serious adverse events was observed.

CONCLUSIONS

Although treatment with eldecalcitol did not significantly reduce the incidence of diabetes among people with pre-diabetes, the results suggested the potential for a beneficial effect of eldecalcitol on people with insufficient insulin secretion.

TRIAL REGISTRATION

UMIN Clinical Trials Registry UMIN000010758.

Concordance and discordance in SLE clinical trial outcome measures: analysis of three anifrolumab phase 2/3 trials

Objectives

In the anifrolumab systemic lupus erythematosus (SLE) trial programme, there was one trial (TULIP-1) in which BILAG-based Composite Lupus Assessment (BICLA) responses favoured anifrolumab over placebo, but the SLE Responder Index (SRI(4)) treatment difference was not significant. We investigated the degree of concordance between BICLA and SRI(4) across anifrolumab trials in order to better understand drivers of discrepant SLE trial results.

Methods

TULIP-1, TULIP-2 (both phase 3) and MUSE (phase 2b) were randomised, 52-week trials of intravenous anifrolumab (300 mg every 4 weeks, 48 weeks; TULIP-1/TULIP-2: n=180; MUSE: n=99) or placebo (TULIP-1: n=184, TULIP-2: n=182; MUSE: n=102). Week 52 BICLA and SRI(4) outcomes were assessed for each patient.

Results

Most patients (78%–85%) had concordant BICLA and SRI(4) outcomes (Cohen’s Kappa 0.6–0.7, nominal p<0.001). Dual BICLA/SRI(4) response rates favoured anifrolumab over placebo in TULIP-1, TULIP-2 and MUSE (all nominal p≤0.004). A discordant TULIP-1 BICLA non-responder/SRI(4) responder subgroup was identified (40/364, 11% of TULIP-1 population), comprising more patients receiving placebo (n=28) than anifrolumab (n=12). In this subgroup, placebo-treated patients had lower baseline disease activity, joint counts and glucocorticoid tapering rates, and more placebo-treated patients had arthritis response than anifrolumab-treated patients.

Conclusions

Across trials, most patients had concordant BICLA/SRI(4) outcomes and dual BICLA/SRI(4) responses favoured anifrolumab. A BICLA non-responder/SRI(4) responder subgroup was identified where imbalances of key factors driving the BICLA/SRI(4) discordance (disease activity, glucocorticoid taper) disproportionately favoured the TULIP-1 placebo group. Careful attention to baseline disease activity and monitoring glucocorticoid taper variation will be essential in future SLE trials.

Trial registration numbers

NCT02446912 and NCT02446899.

Prophylaxis against pneumocystis pneumonia in rheumatoid arthritis patients treated with b/tsDMARDs: insights from 3787 cases in the FIRST registry

OBJECTIVES

The use of biologic and targeted synthetic (b/ts) DMARDs in the treatment of RA is increasing. Therefore, prevention of b/tsDMARDs-induced infection is important. Here we describe a prophylaxis protocol for preventing pneumocystis pneumonia (PCP) in RA patients treated with b/tsDMARDs.

METHODS

The study subjects were 3787 RA patients from the FIRST registry. They were divided into cohort 1 (n = 807, requiring prophylaxis against PCP based on physicians' assessment at the point of new treatment with or switch to b/tsDMARDs) and cohort 2 (n = 2980, receiving strategic PCP prophylaxis). The incidence and risk factors for PCP were investigated.

RESULTS

Twenty-six PCP cases were observed throughout the study. After the introduction of strategic PCP prophylaxis, PCP incidence diminished from 0.51/100 person-years (PYs) to 0.21/100 PYs (risk ratio = 0.42). Sulfamethoxazole and trimethoprim in combination (SMX-TMP) showed greater efficacy in the prevention of PCP than pentamidine inhalation (P <0.0001). The prophylaxis rate increased chronologically despite the falls in the average SMX-TMP dose and in the incidence of PCP. Subanalysis of the data for 929 patients from both groups who did not receive prophylaxis showed that old age, high BMI, coexisting lung diseases, low lymphocyte count, and low serum IgG levels increased the risk of PCP development. Development of PCP could be predicted (using an equation based on these variables) in patients not treated with glucocorticoids [area under the curve (AUC) = 0.910)], but less accurately in those on glucocorticoids (AUC = 0.746).

CONCLUSIONS

Our study clarified the risk factors for PCP in RA patients on b/tsDMARDs treatment and highlighted and defined the criteria for effective prophylaxis against PCP.