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Jones SA, Morand EF. Targeting Interferon Signalling in Systemic Lupus Erythematosus: Lessons Learned. Drugs 2024; 84:625-635. [PMID: 38807010 PMCID: PMC11196297 DOI: 10.1007/s40265-024-02043-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 05/30/2024]
Abstract
The development of new medicines for systemic lupus erythematosus (SLE) has not addressed unmet clinical need, with only three drugs receiving regulatory approval for SLE in the last 60 years, one of which was specifically licensed for lupus nephritis. In the last 20 years it has become clear that activation of type 1 interferons (IFN) is reproducibly detected in the majority of SLE patients, and the actions of IFN in the immune system and on target tissues is consistent with a pathogenic role in SLE. These findings led to considerable drug discovery activity, first with agents directly targeting IFN family cytokines, with results that were encouraging but underwhelming. In contrast, targeting the type I IFN receptor with the monoclonal antibody anifrolumab, thereby blocking all IFN family members, was effective in a phase II clinical trial. This led to a pair of phase III trials, one of which was negative and the other positive, reflecting the difficulty of obtaining outcomes from trials in this complex disease. Nonetheless, the balance of evidence resulted in approval of anifrolumab in multiple jurisdictions from 2021 onwards. Multiple approaches to targeting the type 1 IFN pathway have subsequently had positive phase II clinical trials, including antibodies targeting cells that produce IFN, and small molecules targeting the receptor kinase TYK2, required for IFN signalling. Despite multiple hurdles, it is clear that IFN targeting in SLE is here to stay. The story of IFN-targeting therapy in SLE has lessons for drug development overall in this disease.
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Affiliation(s)
- Sarah A Jones
- Centre for Inflammatory Disease, Monash University, Clayton, Australia
| | - Eric F Morand
- Centre for Inflammatory Disease, Monash University, Clayton, Australia.
- Department of Rheumatology, Monash Health, Melbourne, Australia.
- Monash Medical Centre, 246 Clayton Rd, Clayton, VIC, 3168, Australia.
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2
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Morand E, Merola JF, Tanaka Y, Gladman D, Fleischmann R. TYK2: an emerging therapeutic target in rheumatic disease. Nat Rev Rheumatol 2024; 20:232-240. [PMID: 38467779 DOI: 10.1038/s41584-024-01093-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2024] [Indexed: 03/13/2024]
Abstract
Tyrosine kinase 2 (TYK2) is a member of the JAK kinase family of intracellular signalling molecules. By participating in signalling pathways downstream of type I interferons, IL-12, IL-23 and IL-10, TYK2 elicits a distinct set of immune events to JAK1, JAK2 and JAK3. TYK2 polymorphisms have been associated with susceptibility to various rheumatic diseases including systemic lupus erythematosus and dermatomyositis. In vitro and animal studies substantiate these findings, highlighting a role for TYK2 in diseases currently managed by antagonists of cytokines that signal through TYK2. Various inhibitors of TYK2 have now been studied in human disease, and one of these inhibitors, deucravacitinib, has now been approved for the treatment of psoriasis. Phase II trials of deucravacitinib have also reported positive results in the treatment of psoriatic arthritis and systemic lupus erythematosus, with a preliminary safety profile that seems to differ from that of the JAK1, JAK2 and JAK3 inhibitors. Two other inhibitors of TYK2, brepocitinib and ropsacitinib, are also in earlier stages of clinical trials. Overall, TYK2 inhibitors hold promise for the treatment of a distinct spectrum of autoimmune diseases and could potentially have a safety profile that differs from other JAK inhibitors.
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Affiliation(s)
- Eric Morand
- Centre for Inflammatory Diseases, Monash University, and Department of Rheumatology, Monash Health, Clayton, Victoria, Australia.
| | - Joseph F Merola
- Department of Medicine, Division of Rheumatology and Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Dafna Gladman
- Schroeder Arthritis Institute, Krembil Research Institute, Toronto Western Hospital, Division of Rheumatology University of Toronto, Toronto, Ontario, Canada
| | - Roy Fleischmann
- Metroplex Clinical Research Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
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3
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Inês LS, Fredi M, Jesus D, Shumilova A, Franceschini F, Vital EM. What is the best instrument to measure disease activity in SLE? - SLE-DAS vs Easy BILAG. Autoimmun Rev 2024; 23:103428. [PMID: 37634675 DOI: 10.1016/j.autrev.2023.103428] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/24/2023] [Indexed: 08/29/2023]
Abstract
Systemic lupus erythematosus (SLE) is a heterogeneous condition making assessment of disease activity challenging. However, thorough assessment is essential to evaluate patients longitudinally, to guide therapeutic decisions, and for clinical trials. Currently, the most popular disease activity index in clinical practice and trials is SLEDAI-2K. Its main advantage is ease of use, but significant weaknesses of SLEDAI-2K are omission of several serious manifestations, inability to capture change within an organ system, and fixed severity weightings that are often inappropriate. Recently several groups have developing improved tools. We report here the debate held at CORA meeting on this issue. SLE-DAS includes 17 weighted clinical and laboratory parameters including continuous measures in 4 items with an online calculator. A higher sensitivity to change compared to SLEDAI-2K has been demonstrated in its validation studies. Easy BILAG is an improved format of the BILAG-2004 that retains its content but greatly simplified. Its scoring using a single-page form that incorporates concise definitions for key terms next to clinical items. Easy-BILAG demonstrates higher accuracy and less variability and increased and better user feedback compared to the standard BILAG-2004 format. Both the indices discussed at CORA showed an advantage in measuring disease activity compared to SLEDAI.
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Affiliation(s)
- Luís Sousa Inês
- Faculty of Health Sciences, Universidade da Beira Interior, Covilhã, Portugal; CHUC Lupus Clinic, Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - Micaela Fredi
- Rheumatology and Clinical Immunology Unit and Clinical and Experimental Science Department ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Diogo Jesus
- Faculty of Health Sciences, Universidade da Beira Interior, Covilhã, Portugal; Rheumatology Department, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Anastasiia Shumilova
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom; V.A. Nasonova Research Institute of Rheumatology, Moscow, Russian Federation
| | - Franco Franceschini
- Rheumatology and Clinical Immunology Unit and Clinical and Experimental Science Department ASST Spedali Civili and University of Brescia, Brescia, Italy.
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
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Cruciani C, Zen M, Gatto M, Morand E, Doria A. Assessment of disease activity and damage in SLE: Are we there yet? Best Pract Res Clin Rheumatol 2023; 37:101896. [PMID: 38044231 DOI: 10.1016/j.berh.2023.101896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/13/2023] [Indexed: 12/05/2023]
Abstract
Systemic Lupus Erythematosus is a systemic autoimmune disease characterized by a great heterogenicity in course and clinical manifestations. Although prognosis improved in the last decades of the 20th century, mortality remains higher than in the general population and uncontrolled disease activity and therapy-related adverse effects have been identified as major contributors to damage accrual and poor outcomes. Assessment of disease activity and damage in SLE represents a great challenge even to the expert rheumatologist. Global disease activity indices are tools developed to assess activity across multiple organ systems. Several disease activity indices have been developed over the years, each with its own strengths and weaknesses, and knowing them is essential for understanding research studies, such as clinical trials, in which they are used. Organ-specific activity indices have been developed concurrently to represent organ involvement such as glomerulonephritis, cutaneous and musculoskeletal lupus manifestations. Regarding damage, the SLICC/ACR damage index has proven to be an effective tool for damage accrual assessment, yet not devoid of drawbacks. This review provides an overview of the most frequently utilized indices developed for the assessment of activity and damage in SLE highlighting their pros and cons when applied to the research and clinical setting.
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Affiliation(s)
- Claudio Cruciani
- Division of Rheumatology, Department of Internal Medicine, Azienda Ospedaliera di Padova, University of Padova, Padova, Veneto, Italy.
| | - Margherita Zen
- Division of Rheumatology, Department of Internal Medicine, Azienda Ospedaliera di Padova, University of Padova, Padova, Veneto, Italy.
| | - Mariele Gatto
- Rheumatology Unit, Department of Clinical and Biological Sciences, University of Turin and Turin Mauriziano Hospital, Turin, Italy.
| | - Eric Morand
- Centre for Inflammatory Diseases, Monash University, Rheumatology Unit, Monash Health, Melbourne, Australia.
| | - Andrea Doria
- Division of Rheumatology, Department of Internal Medicine, Azienda Ospedaliera di Padova, University of Padova, Padova, Veneto, Italy.
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5
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Connelly K, Eades LE, Koelmeyer R, Ayton D, Golder V, Kandane-Rathnayake R, Gregory K, Brunner H, Burke L, Arnaud L, Askanase A, Aranow C, Vital E, Pons-Estel G, Dantata K, Andersen J, Cornet A, Buie J, Sun Y, Tanaka Y, Simon L, Lahoud Y, Friedman A, Kalunian K, Zuraw Q, Werth V, Garces S, Morand EF. Towards a novel clinical outcome assessment for systemic lupus erythematosus: first outcomes of an international taskforce. Nat Rev Rheumatol 2023; 19:592-602. [PMID: 37433880 DOI: 10.1038/s41584-023-00993-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2023] [Indexed: 07/13/2023]
Abstract
Systemic lupus erythematosus (SLE) is a disease of high unmet therapeutic need. The challenge of accurately measuring clinically meaningful responses to treatment has hindered progress towards positive outcomes in SLE trials, impeding the approval of potential new therapies. Current primary end points used in SLE trials are based on legacy disease activity measures that were neither specifically designed for the clinical trial context, nor developed according to contemporary recommendations for clinical outcome assessments (COAs), such as that substantial patient input should be incorporated into their design. The Treatment Response Measure for SLE (TRM-SLE) Taskforce is a global collaboration of SLE clinician-academics, patients and patient representatives, industry partners and regulatory experts, established to realize the goal of developing a new COA for SLE clinical trials. The aim of this project is a novel COA designed specifically to measure treatment effects that are clinically meaningful to patients and clinicians, and intended for implementation in a trial end point that supports regulatory approval of novel therapeutic agents in SLE. This Consensus Statement reports the first outcomes of the TRM-SLE project, including a structured process for TRM-SLE development.
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Affiliation(s)
- Kathryn Connelly
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.
| | - Laura E Eades
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Rachel Koelmeyer
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Darshini Ayton
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Vera Golder
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | | | - Kate Gregory
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Hermine Brunner
- Division of Rheumatology, Cincinnati Children's Hospital, University of Cincinnati, Cincinatti, OH, USA
| | | | - Laurent Arnaud
- Department of Rheumatology, National Reference Center for Autoimmune Diseases (RESO), Hopitaux Universitaires de Strasbourg, Strasbourg, Alsace, France
| | - Anca Askanase
- Lupus Center, Columbia University Medical Center, New York City, NY, USA
| | - Cynthia Aranow
- Lupus Centre of Excellence, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Ed Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Guillermo Pons-Estel
- Departamento de Medicina Interna, Centro Regional de Enfermedades Autoinmunes y Reumáticas de Grupo Oroño (GO CREAR), Rosario, Argentina
| | | | | | | | - Joy Buie
- Lupus Foundation of America, Washington, DC, USA
| | - Ying Sun
- Merck Healthcare KGaA, Darmstadt, Hesse, Germany
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Fukuoka, Japan
| | | | | | | | - Kenneth Kalunian
- Division of Rheumatology, Allergy and Immunology, University of California, San Diego, CA, USA
| | - Qing Zuraw
- Janssen Research and Development, Spring House, PA, USA
| | - Victoria Werth
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Eric F Morand
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
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6
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Morand EF, Vital EM, Petri M, van Vollenhoven R, Wallace DJ, Mosca M, Furie RA, Silk ME, Dickson CL, Meszaros G, Jia B, Crowe B, de la Torre I, Dörner T. Baricitinib for systemic lupus erythematosus: a double-blind, randomised, placebo-controlled, phase 3 trial (SLE-BRAVE-I). Lancet 2023; 401:1001-1010. [PMID: 36848918 DOI: 10.1016/s0140-6736(22)02607-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/30/2022] [Accepted: 12/02/2022] [Indexed: 03/01/2023]
Abstract
BACKGROUND Baricitinib is an oral selective inhibitor of Janus kinase 1 and 2 approved for the treatment of rheumatoid arthritis, atopic dermatitis, and alopecia areata. In a 24-week phase 2 study in patients with systemic lupus erythematosus (SLE), baricitinib 4 mg significantly improved SLE disease activity compared with placebo. The objective of this trial was to evaluate the efficacy and safety of baricitinib in patients with active SLE in a 52-week phase 3 study. METHODS In a multicentre, double-blind, randomised, placebo-controlled, parallel-group, phase 3 study, SLE-BRAVE-I, patients (aged ≥18 years) with active SLE receiving stable background therapy were randomly assigned 1:1:1 to baricitinib 4 mg, 2 mg, or placebo once daily for 52 weeks with standard of care. Glucocorticoid tapering was encouraged but not required per protocol. The primary endpoint was the proportion of patients reaching an SLE Responder Index (SRI)-4 response at week 52 in the baricitinib 4 mg treatment group compared with placebo. The primary endpoint was assessed by logistic regression analysis with baseline disease activity, baseline corticosteroid dose, region, and treatment group in the model. Efficacy analyses were done on a modified intention-to-treat population, comprising all participants who were randomly assigned and received at least one dose of investigational product. Safety analyses were done on all randomly assigned participants who received at least one dose of investigational product and who did not discontinue from the study for the reason of lost to follow-up at the first post-baseline visit. This study is registered with ClinicalTrials.gov, NCT03616912. FINDINGS 760 participants were randomly assigned and received at least one dose of baricitinib 4 mg (n=252), baricitinib 2 mg (n=255), or placebo (n=253). A significantly greater proportion of participants who received baricitinib 4 mg (142 [57%]; odds ratio 1·57 [95% CI 1·09 to 2·27]; difference with placebo 10·8 [2·0 to 19·6]; p=0·016), but not baricitinib 2 mg (126 [50%]; 1·14 [0·79 to 1·65]; 3·9 [-4·9 to 12·6]; p=0·47), reached SRI-4 response compared with placebo (116 [46%]). There were no significant differences between the proportions of participants in either baricitinib group reaching any of the major secondary endpoints compared with placebo, including glucocorticoid tapering and time to first severe flare. 26 (10%) participants receiving baricitinib 4 mg had serious adverse events, 24 (9%) participants receiving baricitinib 2 mg, and 18 (7%) participants receiving placebo. The safety profile of baricitinib in participants with SLE was consistent with the known baricitinib safety profile. INTERPRETATION The primary endpoint in this study was met for the 4 mg baricitinib group. However, key secondary endpoints were not. No new safety signals were observed. FUNDING Eli Lilly and Company.
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Affiliation(s)
- Eric F Morand
- Centre for Inflammatory Disease, Monash University, Melbourne, VIC, Australia; School of Clinical Sciences, Monash University Clayton, Melbourne, VIC, Australia.
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Michelle Petri
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ronald van Vollenhoven
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam, Netherlands
| | - Daniel J Wallace
- Division of Rheumatology, Cedars-Sinai Medical Center, University of California at Los Angeles, Los Angeles, CA, USA
| | - Marta Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Richard A Furie
- Division of Rheumatology, Northwell Health and Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | | | | | | | - Bochao Jia
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | | | - Thomas Dörner
- Department of Rheumatology and Clinical Immunology, Charite Universitätsmedizin Berlin, Berlin, Germany; Deutsches Rheumaforschungszentrum, Berlin, Germany
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7
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Petri M, Bruce IN, Dörner T, Tanaka Y, Morand EF, Kalunian KC, Cardiel MH, Silk ME, Dickson CL, Meszaros G, Zhang L, Jia B, Zhao Y, McVeigh CJ, Mosca M. Baricitinib for systemic lupus erythematosus: a double-blind, randomised, placebo-controlled, phase 3 trial (SLE-BRAVE-II). Lancet 2023; 401:1011-1019. [PMID: 36848919 DOI: 10.1016/s0140-6736(22)02546-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 12/02/2022] [Indexed: 03/01/2023]
Abstract
BACKGROUND Baricitinib is an oral selective inhibitor of Janus kinase 1 and 2 approved for the treatment of rheumatoid arthritis, atopic dermatitis, and alopecia areata. In a 24-week phase 2 study in patients with systemic lupus erythematosus (SLE), baricitinib 4 mg significantly improved SLE disease activity compared with placebo. In this Article, we report the evaluation of efficacy and safety of baricitinib in patients with SLE in a 52-week phase 3 study. METHODS In this phase 3 double-blind, randomised, placebo-controlled study, SLE-BRAVE-II, patients (aged ≥18 years) with active SLE receiving stable background therapy were randomly assigned 1:1:1 to baricitinib 4 mg, baricitinib 2 mg, or placebo once daily for 52 weeks. The primary endpoint was the proportion of patients with an SLE Responder Index (SRI)-4 response at week 52 in the baricitinib 4 mg treatment group compared with placebo. Glucocorticoid tapering was encouraged but not required per protocol. The primary endpoint was assessed by logistic regression analysis with baseline disease activity, baseline corticosteroid dose, region, and treatment group in the model. Efficacy analyses were done on an intention-to-treat population, comprising all participants who were randomly assigned and received at least one dose of investigational product and who did not discontinue from the study for the reason of lost to follow-up at the first post-baseline visit. Safety analyses were done on all randomly assigned participants who received at least one dose of investigational product and who did not discontinue. This study is registered with ClinicalTrials.gov, NCT03616964, and is complete. FINDINGS A total of 775 patients were randomly assigned and received at least one dose of baricitinib 4 mg (n=258), baricitinib 2 mg (n=261), or placebo (n=256). There was no difference in the primary efficacy outcome of the proportion of SRI-4 responders at week 52 between participants who received baricitinib 4mg (121 [47%]; odds ratio 1·07 [95% CI 0·75 to 1·53]; difference with placebo 1·5 [95% CI -7·1 to 10·2]), 2 mg (120 [46%]; 1·05 [0·73 to 1·50]; 0·8 [-7·9 to 9·4]) and placebo (116 [46%]). None of the major secondary endpoints, including glucocorticoid tapering and time to first severe flare, were met. Serious adverse events were observed in 29 (11%) participants in the baricitinib 4 mg group, 35 (13%) in the baricitinib 2 mg group, and 22 (9%) in the placebo group. The safety profile of baricitinib in patients with SLE was consistent with the known baricitinib safety profile. INTERPRETATION Although phase 2 data suggested baricitinib as a potential treatment for patients with SLE, which was supported in SLE-BRAVE-I, this result was not replicated in SLE-BRAVE-II. No new safety signals were observed. FUNDING Eli Lilly and Company.
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Affiliation(s)
- Michelle Petri
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Ian N Bruce
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK; National Institute for Health Research Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Thomas Dörner
- Department of Rheumatology and Clinical Immunology, Charite Universitätsmedizin Berlin, Berlin, Germany; Deutsches Rheumaforschungszentrum, Berlin, Germany
| | - Yoshiya Tanaka
- University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Eric F Morand
- Centre for Inflammatory Disease, Monash University, Melbourne, VIC, Australia
| | - Kenneth C Kalunian
- Division of Rheumatology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Mario H Cardiel
- Centro de Investigación Clínica de Morelia SC, Morelia, Michoacán, Mexico
| | | | | | | | - Lu Zhang
- Eli Lilly and Company, Indianapolis, IN, USA
| | - Bochao Jia
- Eli Lilly and Company, Indianapolis, IN, USA
| | - Youna Zhao
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Marta Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Morand E, Pike M, Merrill JT, van Vollenhoven R, Werth VP, Hobar C, Delev N, Shah V, Sharkey B, Wegman T, Catlett I, Banerjee S, Singhal S. Deucravacitinib, a Tyrosine Kinase 2 Inhibitor, in Systemic Lupus Erythematosus: A Phase II, Randomized, Double-Blind, Placebo-Controlled Trial. Arthritis Rheumatol 2023; 75:242-252. [PMID: 36369798 PMCID: PMC10100399 DOI: 10.1002/art.42391] [Citation(s) in RCA: 61] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/04/2022] [Accepted: 10/14/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of deucravacitinib, an oral, selective, allosteric inhibitor of TYK2, in a phase II trial in adult patients with active systemic lupus erythematosus (SLE). METHODS Adults with active SLE were enrolled from 162 sites in 17 countries. Patients (n = 363) were randomized 1:1:1:1 to receive deucravacitinib 3 mg twice daily, 6 mg twice daily, 12 mg once daily, or placebo. The primary end point was SLE Responder Index 4 (SRI-4) response at week 32. Secondary outcomes assessed at week 48 included SRI-4, British Isles Lupus Assessment Group-based Composite Lupus Assessment (BICLA) response, Cutaneous Lupus Erythematosus Disease Area and Severity Index 50 (CLASI-50), Lupus Low Disease Activity State (LLDAS), and improvements in active (swollen plus tender), swollen, and tender joint counts. RESULTS At week 32, the percentage of patients achieving SRI-4 response was 34% with placebo compared to 58% with deucravacitinib 3 mg twice daily (odds ratio [OR] 2.8 [95% confidence interval (95% CI) 1.5, 5.1]; P < 0.001 versus placebo), 50% with 6 mg twice daily (OR 1.9 [95% CI 1.0, 3.4]; P = 0.02 versus placebo), and 45% with 12 mg once daily (OR 1.6 [95% CI 0.8, 2.9]; nominal P = 0.08 versus placebo). Response rates were higher with deucravacitinib treatment for BICLA, CLASI-50, LLDAS, and joint counts compared to placebo. Rates of adverse events were similar across groups, except higher rates of infections and cutaneous events, including rash and acne, with deucravacitinib treatment. Rates of serious adverse events were comparable, with no deaths, opportunistic infections, tuberculosis infections, major adverse cardiovascular events, or thrombotic events reported. CONCLUSION Deucravacitinib treatment elicited higher response rates for SRI-4 and other end points compared with placebo, with an acceptable safety profile, in adult patients with active SLE.
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Affiliation(s)
- Eric Morand
- Monash University and Department of Rheumatology, Monash Health, Victoria, Australia
| | - Marilyn Pike
- MedPharm Consulting, Inc., Raleigh, North Carolina
| | | | | | - Victoria P Werth
- University of Pennsylvania and the Michael J. Crescenz VA Medical Center, Philadelphia
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9
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Connelly K, Kandane-Rathnayake R, Hoi A, Louthrenoo W, Hamijoyo L, Cho J, Lateef A, Fen Luo S, Wu YJJ, Li Z, Navarra S, Zamora L, Sockalingam S, Hao Y, Zhang Z, Katsumata Y, Harigai M, Oon S, Chan M, Chen YH, Bae SC, O'Neill S, Goldblatt F, Kikuchi J, Takeuchi T, Ling Ng KP, Tugnet N, Basnayake BMDB, Ohkubo N, Tanaka Y, Sing Lau C, Nikpour M, Golder V, Morand EF. Associations of improvement in laboratory tests with clinical outcomes in patients with active systemic lupus erythematosus: a multinational longitudinal cohort study. THE LANCET. RHEUMATOLOGY 2022; 4:e831-e841. [PMID: 38261391 DOI: 10.1016/s2665-9913(22)00307-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/05/2022] [Accepted: 10/06/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The selection and categorisation of laboratory tests in disease activity measures used within systemic lupus erythematosus (SLE) trial endpoints lack strong evidence. We aimed to determine whether longitudinal improvements in routinely measured laboratory tests are associated with measures of clinical improvement in patients with baseline active SLE. METHODS We included patients from a multicentre longitudinal cohort (recruited between May 1, 2013, and Dec 31, 2019) with active SLE (SLEDAI-2K ≥6) coinciding with an abnormality in at least one of 13 routine laboratory tests, at a visit designated as baseline. At 12 months, we analysed associations between thresholds of improvement in individual laboratory test results, measured as continuous variables, and five clinical outcomes using logistic regression. Primary outcomes were damage accrual and lupus low disease activity state (LLDAS), and secondary outcomes were modified SLE responder index (mSRI), physician global assessment (PGA) improvement of at least 0·3, and flare. FINDINGS We included 1525 patients (1415 [93%] women and 110 [7%] men, 1328 [87%] Asian ethnicity) in separate subsets for each laboratory test. The strongest associations with LLDAS and damage protection were seen with improvements in proteinuria (complete response: adjusted odds ratio [OR] 62·48, 95% CI 18·79-208·31 for LLDAS, OR 0·22, 95% CI 0·10-0·49 for damage accrual), albumin (complete response: adjusted OR 6·46, 95% CI 2·20-18·98 for LLDAS, OR 0·42, 95% CI 0·20-1·22 for damage accrual), haemoglobin (complete response: adjusted OR 1·97, 95% CI 1·09-3·53 for LLDAS, OR 0·33, 95% CI 0·15-0·71 for damage accrual), erythrocyte sedimentation rate (complete response: adjusted OR 1·71, 95% CI 1·10-2·67 for LLDAS, OR 0·53, 95% CI 0·30-0·94 for damage accrual), and platelets (complete response: adjusted OR 4·82, 95% CI 1·54-15·07 for LLDAS, OR 0·49, 95% CI 0·20-1·19 for damage accrual). Improvement in serological tests were mainly associated with PGA and mSRI. White cell and lymphocyte count improvements were least predictive. INTERPRETATION Improvements in several routine laboratory tests correspond with clinical outcomes in SLE over 12 months. Tests with the strongest associations were discrepant with laboratory tests included in current trial endpoints, and associations were observed across a range of improvement thresholds including incomplete resolution. These findings suggest the need to revise the use of laboratory test results in SLE trial endpoints. FUNDING Abbvie.
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Affiliation(s)
- Kathryn Connelly
- School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia.
| | | | - Alberta Hoi
- School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Worawit Louthrenoo
- Division of Rheumatology, Department of Internal Medicine, Chiang Mai University Hospital, Chiang Mai, Thailand
| | - Laniyati Hamijoyo
- Division of Rheumatology, Department of Internal Medicine, Padjadjaran University, Bandung, Indonesia
| | - Jiacai Cho
- Rheumatology Division, University Medical Cluster, National University Hospital, Singapore
| | - Aisha Lateef
- Rheumatology Division, University Medical Cluster, National University Hospital, Singapore
| | - Shue Fen Luo
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Yeong-Jian J Wu
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Zhanguo Li
- Department of Rheumatology and Immunology, People's Hospital Peking University Health Science Center, Beijing, China
| | - Sandra Navarra
- Bone and Joint Center, University of Santo Tomas Hospital, Manila, Philippines
| | - Leonid Zamora
- Bone and Joint Center, University of Santo Tomas Hospital, Manila, Philippines
| | | | - Yanjie Hao
- Department of Rheumatology and Immunology, Peking University First Hospital, Beijing, China
| | - Zhuoli Zhang
- Department of Rheumatology and Immunology, Peking University First Hospital, Beijing, China
| | - Yasuhiro Katsumata
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masayoshi Harigai
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Shereen Oon
- Department of Rheumatology, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Madelynn Chan
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Yi-Hsing Chen
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung City, Taiwan
| | - Sang-Cheol Bae
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, South Korea
| | - Sean O'Neill
- Rheumatology Department, Liverpool Hospital, Liverpool, NSW, Australia
| | - Fiona Goldblatt
- Department of Rheumatology, Flinders Medical Centre and Royal Adelaide Hospital, Bedford Park, SA, Australia
| | - Jun Kikuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University, Tokyo, Japan
| | | | - Nicola Tugnet
- Department of Rheumatology, Greenlane Clinical Centre, Auckland, New Zealand
| | | | - Naoaki Ohkubo
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Chak Sing Lau
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Mandana Nikpour
- Department of Rheumatology, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Vera Golder
- School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Eric F Morand
- School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
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Long-Term Clinical Outcome in Systemic Lupus Erythematosus Patients Followed for More Than 20 Years: The Milan Systemic Lupus Erythematosus Consortium (SMiLE) Cohort. J Clin Med 2022; 11:jcm11133587. [PMID: 35806873 PMCID: PMC9267338 DOI: 10.3390/jcm11133587] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/31/2022] [Accepted: 06/16/2022] [Indexed: 12/14/2022] Open
Abstract
Tackling active disease to prevent damage accrual constitutes a major goal in the management of patients with systemic lupus erythematosus (SLE). Patients with early onset disease or in the early phase of the disease course are at increased risk of developing severe manifestations and subsequent damage accrual, while less is known about the course of the disease in the long term. To address this issue, we performed a multicentre retrospective observational study focused on patients living with SLE for at least 20 years and determined their disease status at 15 and 20 years after onset and at their last clinical evaluation. Disease activity was measured through the British Isles Lupus Assessment Group (BILAG) tool and late flares were defined as worsening in one or more BILAG domains after 20 years of disease. Remission was classified according to attainment of lupus low-disease-activity state (LLDAS) criteria or the Definitions Of Remission In SLE (DORIS) parameters. Damage was quantitated through the Systemic Lupus Erythematosus International Collaborating Clinics/American College of Rheumatology damage index (SLICC/ACR-DI). LLAS/DORIS remission prevalence steadily increased over time. In total, 84 patients had a late flare and 88 had late damage accrual. Lack of LLDAS/DORIS remission status at the 20 year timepoint (p = 0.0026 and p = 0.0337, respectively), prednisone dose ≥ 7.5 mg (p = 9.17 × 10−5) or active serology (either dsDNA binding, low complement or both; p = 0.001) were all associated with increased late flare risk. Late flares, in turn, heralded the development of late damage (p = 2.7 × 10−5). These data suggest that patients with longstanding SLE are frequently in remission but still at risk of disease flares and eventual damage accrual, suggesting the need for tailored monitoring and therapeutic approaches aiming at effective immunomodulation besides immunosuppression, at least by means of steroids.
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11
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Bruce IN, Furie RA, Morand EF, Manzi S, Tanaka Y, Kalunian KC, Merrill JT, Puzio P, Maho E, Kleoudis C, Albulescu M, Hultquist M, Tummala R. Concordance and discordance in SLE clinical trial outcome measures: analysis of three anifrolumab phase 2/3 trials. Ann Rheum Dis 2022; 81:962-969. [PMID: 35580976 PMCID: PMC9213793 DOI: 10.1136/annrheumdis-2021-221847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/09/2022] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Ian N Bruce
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal & Dermatological Sciences, The University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Richard A Furie
- Division of Rheumatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York, USA
| | - Eric F Morand
- Center for Inflammatory Disease, Monash University, Melbourne, Victoria, Australia
| | - Susan Manzi
- Department of Medicine, Lupus Center of Excellence, Autoimmunity Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Yoshiya Tanaka
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kenneth C Kalunian
- Division of Rheumatology, Allergy, and Immunology, University of California San Diego, La Jolla, California, USA
| | - Joan T Merrill
- Arthritis and Clinical Immunology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Patricia Puzio
- BioPharmaceuticals R&D, AstraZeneca US, Gaithersburg, Maryland, USA
| | | | - Christi Kleoudis
- BioPharmaceuticals R&D, AstraZeneca US, Durham, North Carolina, USA
| | | | - Micki Hultquist
- BioPharmaceuticals R&D, AstraZeneca US, Gaithersburg, Maryland, USA
| | - Raj Tummala
- BioPharmaceuticals R&D, AstraZeneca US, Gaithersburg, Maryland, USA
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12
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'Not at target': prevalence and consequences of inadequate disease control in systemic lupus erythematosus-a multinational observational cohort study. Arthritis Res Ther 2022; 24:70. [PMID: 35287720 PMCID: PMC8919535 DOI: 10.1186/s13075-022-02756-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 02/28/2022] [Indexed: 12/15/2022] Open
Abstract
Background The unmet need in systemic lupus erythematosus (SLE) with the current standard of care is widely recognised, but few studies have quantified this. The recent definition of treat-to-target endpoints and other thresholds of uncontrolled disease activity provide an opportunity to formally define unmet need in SLE. In this study, we enumerated the prevalence of these states and examined their association with adverse outcomes. Methods Data were collected prospectively in a 13-country longitudinal SLE cohort between 2013 and 2019. Unmet need was defined as never attaining lupus low disease activity state (LLDAS), a time-adjusted mean SLEDAI-2K (AMS) > 4, or ever experiencing high disease activity status (HDAS; SLEDAI-2K ≥10). Health-related quality of life (HRQoL) was assessed using SF36 (v2) and damage accrual using the SLICC-ACR SLE Damage Index (SDI). Results A total of 3384 SLE patients were followed over 30,313 visits (median [IQR] follow-up 2.4 [0.4, 4.3] years). Eight hundred thirteen patients (24%) never achieved LLDAS. Median AMS was 3.0 [1.4, 4.9]; 34% of patients had AMS > 4. Twenty-five per cent of patients had episodes of HDAS. Each of LLDAS-never, AMS>4, and HDAS-ever was strongly associated with damage accrual, higher glucocorticoid use, and worse HRQoL. Mortality was significantly increased in LLDAS-never (adjusted HR [95% CI] = 4.98 [2.07, 12.0], p<0.001) and HDAS-ever (adjusted hazard ratio (HR) [95% CI] = 5.45 [2.75, 10.8], p<0.001) patients. Conclusion Failure to achieve LLDAS, high average disease activity, and episodes of HDAS were prevalent in SLE and were significantly associated with poor outcomes including organ damage, glucocorticoid exposure, poor quality of life, and mortality. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-022-02756-3.
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13
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Connelly K, Morand EF. Easy-BILAG: as easy as ABC? Rheumatology (Oxford) 2022; 61:3879-3880. [PMID: 35171270 DOI: 10.1093/rheumatology/keac062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 01/25/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kathryn Connelly
- School of Clinical Sciences, Monash University, Clayton, Australia.,Department of Rheumatology, Monash Health, Clayton, Australia
| | - Eric F Morand
- School of Clinical Sciences, Monash University, Clayton, Australia.,Department of Rheumatology, Monash Health, Clayton, Australia
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14
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Connelly K, Vettivel J, Golder V, Kandane-Rathnayake R, Morand EF. Measurement of specific organ domains in lupus randomised controlled trials: a scoping review. Rheumatology (Oxford) 2021; 61:1341-1353. [PMID: 34664636 DOI: 10.1093/rheumatology/keab777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/08/2021] [Accepted: 10/11/2021] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Randomised controlled trials (RCTs) in systemic lupus erythematosus (SLE, lupus) typically adopt composite responder definitions as primary efficacy endpoints, however outcomes within individual organ domains are also important to understand. The aim of this scoping review was to evaluate how organ-specific disease activity and therapeutic responses have been measured and reported in lupus RCTs. METHODS We searched MEDLINE, EMBASE, Cochrane registry and clinicaltrials.gov. Eligible studies were RCTs investigating efficacy of an immune-directed drug therapy in active SLE, published January 2000-March 2021, excluding studies limited to lupus nephritis. Data were extracted independently in duplicate into a template and summarised descriptively. RESULTS Thirty-four RCTs were included, of which 32 (94%) reported activity and/or responses in at least one organ domain. Study populations had a high, although variable, frequency of baseline musculoskeletal and mucocutaneous activity and low but also variable representation of other domains. Definitions of organ-specific responses were inconsistent, even within individual instruments. Response in most organ domains were evaluated using BILAG and SLEDAI components but meaningful comparison between treatment arms was limited by small subgroups analysed in a post hoc fashion. Specific mucocutaneous and arthritis instruments were also used, including within pre-specified organ-specific endpoints, which discriminated between treatment arms in some studies. CONCLUSION Mucocutaneous and musculoskeletal manifestations predominate in SLE RCTs. Organ-specific outcome measures are commonly reported, but definitions of involvement and response are inconsistent. Research into the development of new outcome measures for key organ domains, and validation and comparison of response definitions using existing instruments, is needed.
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Affiliation(s)
- Kathryn Connelly
- School of Clinical Sciences, Monash University, Clayton VIC 3168, Australia.,Department of Rheumatology, Monash Health, Clayton VIC 3168, Australia
| | - Jeevan Vettivel
- School of Clinical Sciences, Monash University, Clayton VIC 3168, Australia
| | - Vera Golder
- School of Clinical Sciences, Monash University, Clayton VIC 3168, Australia.,Department of Rheumatology, Monash Health, Clayton VIC 3168, Australia
| | | | - Eric F Morand
- School of Clinical Sciences, Monash University, Clayton VIC 3168, Australia.,Department of Rheumatology, Monash Health, Clayton VIC 3168, Australia
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