AB0641 MANAGING ANKYLOSING SPONDYLITIS (AS) WITH SHORT TERM BIOSIMILAR ADALIMUMAB REGIMEN IN A RESOURCE STRAPPED SETTING: A PROTOCOL DRIVEN COMMUNITY CLINIC ORIENTED STUDY

Background:

We were handicapped by the exorbitant cost of innovator anti-Tumour Necrosis Factor (TNF) drugs. Despite limited use, we sometimes observed long-term benefits following short term induction like use. Emboldened by advent of biosimilars, we carried out an investigational study.

Objectives:

To evaluate the effectiveness of a short regimen of biosimilar (Bs) Adalimumab in AS

Methods:

50 consenting patients (86% B27+) naïve for biologics and negative for latent TB screen were enrolled into an observational design study of one year; Baseline mean values for age, duration, ASDAS and CRP was 31 years, 98.8 months, 4.6 and 64 mg per dl respectively. During the first year, patients were begun with 40 mg Bs Adalimumab (Bs-ADL) (Exemptia™), injected fortnight, for 12-16 weeks. No patient received DMARD or steroid in the first year of study. Patients continued standard of care follow up program in the clinic. The ASAS (Assessment Spondyloarthritis International Society) improvement indices were used. Standard intention-to-treat analysis was performed; significant p <0.05.

Results:

Optimum ASAS 40 improvement was observed at week 12 (68%); substantial improvement lasted till week 36. At one year, the ASAS 40 was 38%; ASAS partial remission 22% patients. Pro-inflammatory cytokines (IL-6, TNF α and IL-17) showed conspicuous reduction; maximum drop in IL-6 at week 24 (See Figure). 11 patients withdrew in the first year. 30 patients completed two years and 22 patients completed 3 year follow up. Over time, there was substantial loss in the ASAS 20 and 40 responses but patients seemed satisfied with the on-going symptomatic relief and improved function. Admittedly, patients showed more adherences to advice on physical exercise and stress reduction. Flares were more frequent after 1 year requiring short term round the clock NSAID; only 5 patients could afford to repeat a short term Bs-ADL regimen and one patient underwent hip arthroplasty. None received steroids and 5 patients were begun on Sulfasalazine in the second year and monitored. We could not evaluate structural modification (AS). Selected outcomes over 2 and 3 years from the current study will be compared to matched control (derived from the clinic database). None developed TB or any serious drug related toxicity. 2 patients developed recurrent uveitis.

Conclusion:

This real life documented experience unravelled impressive long term benefits following a kick start short term induction regimen of Biosimilar Adalimumab in AS. Though contrary to standard practice, this seemed a practical solution in our setting. We speculate a psychological and motivational boost rather than a prolonged real time biological effect (Bs-ADL) for this phenomenon. Our study has important socioeconomic bearing and merits validation.

Acknowledgement:

This was essentially a non-commercial investigator-initiated study. Zydus Cedilla India provided a generous research grant with free of cost Bs_ADL to several patients and a large concession in the cost to the rest.

Disclosure of Interests:

Arvind Chopra Grant/research support from: Zydus Pharamceutical Ltd India, Nagnath Khadke: None declared, Manjit Saluja: None declared, Toktam Kianifard: None declared, Anuradha Venugopalan: None declared

AB0585 SINGLE CENTER EXPERIENCE OF CLINICAL PROFILE OF INFLAMMATORY MYOSITIS FROM INDIA

Background:

Clinical profile of myositis differs in respect of the setting. We present a single center experience from a community based referral center

Objectives:

STUDY CLINICAL PROFILE OF INFLAMMATORY MYOSITIS (IM)

Methods:

We present data from 114 patients of connective tissue disorders (CTD) with dominant Inflammatory Myopathy(IM) evaluated in CRD where we have patient database since 1996. Standard investigations & ELISA, immunoblot and nephlometry to assay autoantibodies (AAb) were done. Data extraction done from 2005-2017

Results:

36 and 28 patients respectively diagnosed as dominant idiopathic dematomyositis (DM) and polymyositis (PM); remaining 41 patients showed overlap (OCTD). Mean onset age range 33-40 years in each subset with women dominance. Exclusive proximal muscle involvement seen 64% DM, 67% PM and 43% OCTD. 12 of OCTD showed classical DM rash. Raynauds’s phenomenon was seen in 38% (25% DM, 10% PM, 65% OCTD). 83% OCTD showed inflammatory polyarthritis; DM 29% and PM 42%. Two patients DM also diagnosed malignancy (ovarian CA). 25% DM, nil PM and 31.7% OCTD showed CT based lung findings. Mean creatinine phosphokinase at diagnosis were DM 1580, PM 2239 & OCTD 830. EMG required in 48 patients confirmed diagnosis (DM 17, PM 16 and OCTD 15). Seven patients with diagnostic dilemma/ poor therapy response required muscle histopathology confirmation. 59% DM,69% PM and 84% OCTD were seropositive ANA positive in 71%(ENA profile available for most). All Patients received steroids. Methotrexate prescribed in (92%), Azthioprine in (28%), hydroxychloroquine in (88%) with majority showing good response. Mycophenolate prescribed in (6%) for aggressive disease, IVIG in 2 patients for acute IIM with interstitial pneumonitis. Rituximab was prescribed in 4 resistant cases; all responding favourably. Mortality data of 4 patients(severe myositis(1), interstitial pneumonitis(1), ovarian cancer(1), septic shock(1)) was available. Antesynthatase syndrome noted in 9 patients.

Conclusion:

Overlap CTD with myositis seems more common profile than DM or PM. Response to therapy was satisfactory with steroids and methotrexate being the mainstay. Rituximab is a promising biological agent in chronic resistant cases.

References:

[1]A Kumar. Idiopathic Inflammatory Myopathies. Suppliment to JAPI, JUNE 2006, VOL. 54; Pg 62-66

[2]R Porkodi et al Clinical Spectrum of Inflammatory Myositis in South India - A Ten Year Study. J Assoc Physicians India 2002;50:1255-1258

[3]Chowdhary V, Aggarwal A, Misra R. Prevalence and clinical association of myositis-specific autoantibodies in North Indian patients with idiopathic inflammatory myopathy. APLAR J Rheumatol 2 001.

Acknowledgments :

STAFF AND PATIENTS OF CENTER FOR RHEUMATIC DISEASES, PUNE

Disclosure of Interests: :

NACHIKET KULKARNI Speakers bureau: PFIZER, NOVARTIS, YANSEN, Anuradha Venugopalan: None declared, MANJIT SALUJA: None declared, Arvind Chopra Grant/research support from: Zydus Pharamceutical Ltd India

Reprint of: Effect of fermentation parameters, elicitors and precursors on camptothecin production from the endophyte Fusarium solani

Volumetric productivity of camptothecin from the suspension culture of the endophyte Fusarium solani was enhanced up to ∼152 fold (from 0.19μgl(-1)d(-1) to 28.9μgl(-1)d(-1)) under optimized fermentation conditions including initial pH (6.0), temperature (32°C) and agitation speed (80rpm) with (5% (v/v)) ethanol as medium component. Among various elicitors and precursors studied, tryptamine (0.5mM) as precursor and bovine serum albumin (BSA) (0.075mM) as an elicitor added on day 6 of the cultivation period resulted in maximum enhancement of camptothecin concentration (up to 4.5 and 3.4-fold, respectively). These leads provide immense scope for further enhancement in camptothecin productivity at bioreactor level. The cytotoxicity analysis of the crude camptothecin extract from the fungal biomass revealed its high effectiveness against colon and mammary gland cancer cell lines.

Effect of fermentation parameters, elicitors and precursors on camptothecin production from the endophyte Fusarium solani

Volumetric productivity of camptothecin from the suspension culture of the endophyte Fusarium solani was enhanced up to ∼152 fold (from 0.19 μg l(-1) d(-1) to 28.9 μg l(-1) d(-1)) under optimized fermentation conditions including initial pH (6.0), temperature (32 °C) and agitation speed (80 rpm) with (5% (v/v)) ethanol as medium component. Among various elicitors and precursors studied, tryptamine (0.5 mM) as precursor and bovine serum albumin (BSA) (0.075 mM) as an elicitor added on day 6 of the cultivation period resulted in maximum enhancement of camptothecin concentration (up to 4.5 and 3.4-fold, respectively). These leads provide immense scope for further enhancement in camptothecin productivity at bioreactor level. The cytotoxicity analysis of the crude camptothecin extract from the fungal biomass revealed its high effectiveness against colon and mammary gland cancer cell lines.

Endophytes as in vitro production platforms of high value plant secondary metabolites

Many reports have been published on bioprospecting of endophytic fungi capable of producing high value bioactive molecules like, paclitaxel, vincristine, vinblastine, camptothecin and podophyllotoxin. However, commercial exploitation of endophytes for high value-low volume plant secondary metabolites remains elusive due to widely reported genomic instability of endophytes in the axenic culture. While most of the endophyte research focuses on screening endophytes for novel or existing high value biomolecules, very few reports seek to explore the possible mechanisms of production of host-plant associated or novel secondary metabolites in these organisms. With an overview of host-endophyte relationship and its possible impact on the secondary metabolite production potential of endophytes, the review highlights the evidence reported for and against the presence of host-independent biosynthetic machinery in endophytes. The review aims to address the question, why should and how can endophytes be exploited for large scale in vitro production of high value phytochemicals? In this regard, various bioprocess optimization strategies that have been applied to sustain and enhance the product yield from the endophytes have also been described in detail. Further, techniques like mixed fermentation/co-cultivation and use of epigenetic modifiers have also been discussed as potential strategies to activate cryptic gene clusters in endophytes, thereby aiding in novel metabolite discovery and overcoming the limitations associated with axenic culture of endophytes.

Endophytes as in vitro production platforms of high value plant secondary metabolites

Many reports have been published on bioprospecting of endophytic fungi capable of producing high value bioactive molecules like, paclitaxel, vincristine, vinblastine, camptothecin and podophyllotoxin. However, commercial exploitation of endophytes for high value-low volume plant secondary metabolites remains elusive due to widely reported genomic instability of endophytes in the axenic culture. While most of the endophyte research focuses on screening endophytes for novel or existing high value biomolecules, very few reports seek to explore the possible mechanisms of production of host-plant associated or novel secondary metabolites in these organisms. With an overview of host-endophyte relationship and its possible impact on the secondary metabolite production potential of endophytes, the review highlights the evidence reported for and against the presence of host-independent biosynthetic machinery in endophytes. The review aims to address the question, why should and how can endophytes be exploited for large scale in vitro production of high value phytochemicals? In this regard, various bioprocess optimization strategies that have been applied to sustain and enhance the product yield from the endophytes have also been described in detail. Further, techniques like mixed fermentation/co-cultivation and use of epigenetic modifiers have also been discussed as potential strategies to activate cryptic gene clusters in endophytes, thereby aiding in novel metabolite discovery and overcoming the limitations associated with axenic culture of endophytes.

Enhanced camptothecin production by ethanol addition in the suspension culture of the endophyte, Fusarium solani

Ethanolic extract of a non-camptothecin producing plant, Catharanthus roseus when added in the suspension culture of the endophyte Fusarium solani known to produce camptothecin, resulted in enhanced production of camptothecin by 10.6-fold in comparison to that in control (2.8 μg/L). Interestingly, addition of pure ethanol (up to 5% v/v) in the suspension culture of F. solani resulted in maximum enhancement in camptothecin production (up to 15.5-fold) from that obtained in control. In the presence of ethanol, a reduced glucose uptake (by ∼ 40%) and simultaneous ethanol consumption (up to 9.43 g/L) was observed during the cultivation period (14 days). Also, the total NAD level and the protein content in the biomass increased by 3.7- and 1.9-fold, respectively, in comparison to that in control. The study indicates a dual role of ethanol, presumably as an elicitor and also as a carbon/energy source, leading to enhanced biomass and camptothecin production.