Effect of baseline disease severity on achievement of treatment target with apremilast: results from a pooled analysis

BACKGROUND

Treating to absolute treatment targets rather than relative measures such as Psoriasis Area and Severity Index (PASI)-75 is emerging as an important clinical concept included in psoriasis guidelines and clinical practice. Achieving treatment targets is associated with achievement of long-term outcomes.

OBJECTIVE

To evaluate the relationship between psoriasis severity, disease characteristics and achievement of PASI ≤2 with apremilast in a pooled analysis of the phase 3 ESTEEM 1 and 2 (NCT01194219 and NCT01232283), phase 3b LIBERATE (NCT01690299) and phase 4 UNVEIL (NCT02425826) clinical trials.

METHODS

Pooled data from patients with moderate-to-severe plaque psoriasis randomized to apremilast 30 mg BID were analysed by baseline PASI quartiles (Q1: 2.4-13.1; Q2: 13.2-15.9; Q3: 16.0-20.0; Q4: 20.1-57.8). Assessments included PASI, Dermatology Life Quality Index (DLQI), Scalp Physician's Global Assessment (ScPGA; ScPGA ≥1) and target (worst) Nail Psoriasis Severity Index (NAPSI; NAPSI ≥1).

RESULTS

Of 1062 patients, 963 had ScPGA ≥1 and 643 had NAPSI ≥1; 771 patients with baseline and Week 32 PASI assessments were included in analyses of Week 32 PASI target achievement. Rates of PASI ≤2 at Week 32 were greater in lower PASI quartiles (Q1: 43.5%; Q2: 31.2%; Q3: 26.8%; Q4: 18.4%). Most patients achieving PASI ≤2 target (83.6%) achieved DLQI ≤5 at Week 32; 59.3% of patients who did not achieve PASI ≤2 target achieved DLQI ≤5. At Week 32, mean improvements in ScPGA and NAPSI were similar with more moderate vs. more severe disease (ScPGA, range: 1.1-1.4; NAPSI, range: 1.6-2.5). In a subgroup analysis, achievement of PASI ≤2 target was higher in the lowest PASI quartile and with disease duration <5 years.

CONCLUSIONS

Greater achievement of PASI ≤2 was observed in patients with more moderate vs. more severe skin disease. Apremilast may be particularly beneficial in more moderate disease early in the treatment paradigm.

FRI0356 BURDEN OF DISEASE IN PATIENTS INITIATING APREMILAST TREATMENT: 2014-2019 FINDINGS FROM THE CORRONA PSORIATIC ARTHRITIS/SPONDYLOARTHRITIS REGISTRY

Background:

The prospective, US-based, observational Corrona PsA/SpA Registry collects real-world data on patients (pts) with PsA provided by pts and their providers.

Objectives:

To examine trends in characteristics of pts initiating apremilast (APR) from 2014-2019 and compare characteristics of treatment-naive pts initiating APR or methotrexate (MTX).

Methods:

PsA pts aged ≥18 yrs enrolled in the registry who initiated APR, MTX, and/or biologics for PsA from January 2014-August 2019 were included and stratified by year of initiation (2014-2015, 2016-2017, or 2018-2019). Demographics, clinical characteristics, treatment history, disease activity, and pt-reported outcomes (PROs) were analyzed at treatment initiation. Comparisons between treatment-naive APR vs MTX initiators during the entire 2014-2019 study period were summarized descriptively.

Results:

1460 PsA pts initiated APR (n=238), MTX (n=178), and/or a biologic (n=1044), including treatment-naive APR (n=20) and MTX (n=99) initiators from 2014-2019. For APR initiators in the 3 successive time periods, respectively, mean disease duration was 10.5, 12.2, and 11.4 yrs, and 87.5%, 82.5%, and 68.6% of pts had prior use of csDMARDs (similar to biologic initiators: 77.9%, 77.2%, and 68.8%). Over time, lower joint, enthesitis, and dactylitis counts, composite disease activity, and PRO measures of disease burden were observed (Table). Compared with treatment-naive MTX initiators, treatment-naive APR initiators had longer duration of PsA (8.5 vs 5.5 yrs) and time since PsA diagnosis (3.3 vs 1.8 yrs). Rates of comorbidities such as hypertension (50.0% vs 37.8%), diabetes mellitus (38.9% vs 13.3%), and metabolic syndrome (33.3% vs 8.9%) were higher in treatment-naive APR vs MTX initiators. Greater proportions of treatment-naive APR initiators had high/very high disease activity according to CDAI, DAPSA, cDAPSA, PASDAS, and DAS-28 vs MTX initiators.

Conclusion:

In this Corrona Registry analysis, PsA pts initiating APR had lower disease burden in recent vs prior yrs, indicating use of APR earlier in the course of PsA is increasing in real-world practice. Treatment-naive APR initiators had greater disease activity and severity vs MTX initiators. Comorbidities were common at APR initiation.

Table:Disease Severity and Activity, and PROs for APR Initiators in the Corrona PsA/SpA RegistryCharacteristic2014-2015n=722016-2017n=802018-2019n=86SJC (0-66), median (IQR)2.0 (4.0)1.0 (3.0)0.0 (3.0)TJC (0-68), median (IQR)5.0 (14.0)2.0 (4.0)2.0 (10.0)SPARCC enthesitis*, mean (SD)4.7 (3.0)3.8 (2.2)3.7 (3.1)Dactylitis count†, mean (SD)2.5 (2.5)2.3 (1.0)2.2 (2.3)cDAPSA category, n (%)Remission4 (7.4)8 (14.8)13 (15.9)Low disease activity12 (22.2)18 (33.3)30 (36.6)Minimal disease activity, n (%)8 (15.1)14 (26.9)21 (25.6)DAS-28 remission, n (%)5 (19.2)8 (32.0)24 (43.6)Pain VAS (0-100 mm) >15, n (%)47 (85.5)47 (83.9)60 (73.2)Pt’s Global Assessment of Arthritis VAS (0-100 mm) >20, n (%)47 (82.5)45 (77.6)54 (65.9)HAQ >0.5, n (%)39 (69.6)35 (59.3)44 (53.7)Fatigue VAS (0-100 mm), mean (SD)56.7 (25.4)49.8 (25.945.6 (31.5)Spine pain VAS (0-100 mm), mean (SD)38.8 (27.6)36.5 (29.6)28.8 (34.1)BASDAI‡, mean (SD)5.4 (2.4)4.9 (2.5)4.4 (2.6)Morning stiffness VAS (0-100 mm), mean (SD)52.8 (27.3)51.4 (28.3)48.0 (31.2)

The n represents the total sample. Number of pts with data available may vary. *Among pts with enthesitis at baseline. †Among pts with dactylitis at baseline. ‡Among pts thought to have spondylitis by the investigator. IQR=interquartile range.

Disclosure of Interests:

Alexis Ogdie Grant/research support from: Novartis, Pfizer – grant/research support, Consultant of: AbbVie, BMS, Eli Lilly, Novartis, Pfizer, Takeda – consultant, Mei Liu Shareholder of: Corrona, LLC – shareholder at the time of study conduct, Employee of: Corrona, LLC – employment at the time of study conduct, Meghan Glynn Shareholder of: Corrona, LLC – shareholder, Grant/research support from: Pfizer – grant/research support, Employee of: Corrona, LLC – employment, Kelechi Emeanuru Employee of: Corrona, LLC – employment, Leslie Harrold Shareholder of: Corrona, LLC – shareholder, Grant/research support from: Pfizer – grant/research support, Consultant of: AbbVie, BMS, Roche – consultant, Employee of: Corrona, LLC – employment, Jennifer Mohawk Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Sven Richter Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Benoit Guerette Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Philip J Mease Grant/research support from: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – grant/research support, Consultant of: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – consultant, Speakers bureau: Abbott, Amgen, Biogen Idec, BMS, Eli Lilly, Genentech, Janssen, Pfizer, UCB – speakers bureau

SAT0425 NOVEL COMPUTER-ASSISTED METHODOLOGY FOR QUANTITATIVE ASSESSMENT OF MRI TREATMENT RESPONSES TO APREMILAST IN PATIENTS WITH PSORIATIC ARTHRITIS

Background:

Response to treatment in psoriatic arthritis (PsA) can be captured using the OMERACT PsA Magnetic Resonance Imaging Score (PsAMRIS). While reliable and valid, PsAMRIS interpretation requires a trained reader to assess inflammatory lesions such as synovitis and flexor tenosynovitis on a discrete scale ranging from 0 to 3, which might not have sufficient sensitivity to capture early and subtle changes in inflammation in small cohorts.

Objectives:

To propose a novel computer-assisted imaging quantitative methodology to assess early response to treatment on a continuous scale and compare its results with those of PsAMRIS.

Methods:

Patients with active PsA in the hand and wrist were treated with apremilast 30 mg twice daily after a 5-day titration period. A total of 29 patients underwent MRI scans at baseline and months 3, 6, and 12. Images were scored for synovitis using the PsAMRIS interpreted by an experienced reader and were read in blinded sequences. Images for 13 patients with involvement of the wrist and metacarpophalangeal (MCP) joints and MRI available at baseline, 3 months, and 6 months were further processed using a novel computer-assisted imaging quantitative methodology. Images were scored concurrently, with the reader blinded to the order of visits. An experienced reader pre-defined regions of interest (ROIs) around the wrist, MCP joints (MCP-2 to MCP-5), and flexor and extensor tendons of the fingers and wrist (as applicable) with adjacent blood vessels and possible artifacts excluded from ROIs. From these ROIs, the normalized volume of inflammation (NormI) was calculated in each joint and tendon. This was done by automatically counting the pixels that were enhanced above the intensity level of a muscle. Each enhanced pixel was given a weight corresponding to the degree of enhancement, allowing differentiation of areas of residual inflammation and high perfusion. This method has been validated, tested, and implemented in the CE/FDA510-cleared software package Dynamika (IAG, Image Analysis Group). PsAMRIS responses were compared with those of the computer-assisted imaging quantitative methodology at baseline, 3 months, and 6 months. A heat map of normalized intensities was produced, highlighting areas of perfusion higher than that of healthy muscle. Changes from baseline were tested for significance using at-test. Patients with non-missing data were included in the final statistical analysis.

Results:

The generated NormI map highlighted a reduction in wrist inflammation activity after 3 and 6 months of treatment with apremilast. In all cases, a downward trend in inflammatory activity in the wrist and MCP joints was observed at 3 months, indicating a reduction following treatment with apremilast (Figures 1 and 2). Similar improvements were observed in tenosynovitis (Figures 1 and 2).

Conclusion:

In this pilot assessment, apremilast was associated with improvements in synovitis and tenosynovitis over a period of 6 months using PsAMRIS. Assessment of images using NormI, a methodology allowing quantification of inflammatory activity within a joint or tendon, demonstrated the same trends over 6 months. Further studies are planned to determine the sensitivity of this novel computer-assisted imaging quantitative methodology relative to that of PsAMRIS and whether it could be used to provide early indications of treatment response in small cohorts of patients.

Disclosure of Interests:

Paul Bird Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Janssen, Novartis, Pfizer – advisor, Speakers bureau: AbbVie, Celgene Corporation, Eli Lilly, Janssen, Novartis, Pfizer, Mikael Boesen Consultant of: AbbVie, AstraZeneca, Eli Lilly, Esaote, Glenmark, Novartis, Pfizer, UCB, Paid instructor for: IAG, Image Analysis Group, AbbVie, Eli Lilly, AstraZeneca, esaote, Glenmark, Novartis, Pfizer, UCB (scientific advisor)., Speakers bureau: Eli Lilly, Esaote, Novartis, Pfizer, UCB, Mark Hinton: None declared, Eser Sanverdi Employee of: Image Analysis Group – employment, Romiesa Hagoug Employee of: Image Analysis Group – employment, Christoper Sabin Employee of: Image Analysis Group – employment, Priscila Nakasato Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Benoit Guerette Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Olga Kubassova Shareholder of: IAG, Image Analysis Group, Consultant of: Novartis, Takeda, Lilly, Employee of: IAG, Image Analysis Group

FRI0352 PROBABILITY OF ACHIEVING LOW DISEASE ACTIVITY OR REMISSION WITH APREMILAST TREATMENT AMONG DMARD-NAIVE SUBJECTS WITH ACTIVE PSORIATIC ARTHRITIS

Background:

Apremilast (APR) is associated with comparable ACR response rates in DMARD-naive vs DMARD-experienced patients (pts) with psoriatic arthritis (PsA).1,2A question that remains is if DMARD-naive pts treated with APR have greater chances of achieving treatment targets than DMARD-experienced pts. cDAPSA is a commonly used treatment target.

Objectives:

To assess the predictive value of baseline (BL) clinical disease status on achieving long-term cDAPSA treatment targets at Wk 52 among DMARD-naive subjects in PALACE 4; to compare these findings vs those recently reported from the PALACE 1-3 studies in subjects with prior exposure to DMARDs; and to provide further evidence that at a group level, achievement of cDAPSA disease targets with APR is associated with no or mild articular and extra-articular disease activity by Wk 52.

Methods:

This post hoc analysis included subjects assigned to APR 30 mg twice daily at BL who had available cDAPSA data at BL. We calculated the probabilities of shifting across different cDAPSA categories (remission [REM]: ≤4; low disease activity [LDA]: >4 to ≤13; moderate disease activity [Mod]: >13 to ≤27; high disease activity [HDA]: >273) from BL to Wk 52. Mean values of articular and non-articular variables (e.g., PASI, SJC/TJC, MASES, dactylitis) from BL to Wk 52 were assessed by cDAPSA category achieved at Wk 52 to determine the association between achievement of targets and control of articular and non-articular manifestations. Results from the current analyses were compared with the previously reported results from PALACE 1-3.

Results:

A total of 175 subjects receiving APR were included; at BL, 66.3% were in HDA, 31.4% in Mod, and 2.3% were in LDA. Overall, subjects who achieved treatment targets (LDA or REM) by Wk 52 had lower levels of disease activity at BL, as shown by a lower number of swollen and tender joints and lower presence of enthesitis and dactylitis. Higher prevalence of psoriasis-involved body surface area ≥3% at BL was observed. Subjects in Mod at BL were estimated to be more than twice as likely to achieve REM or LDA at Wk 52 vs subjects in HDA at BL; for subjects in LDA at BL, the estimated probability of achieving cDAPSA treatment targets was 100% (Figure). PALACE 4 subjects with LDA and Mod at BL exhibited higher estimated probabilities of achieving treatment targets (100.0% and 61.7%, respectively) than those observed in the DMARD-experienced population of PALACE 1-3 (71.1% and 46.9%). Subjects in PALACE 4 who achieved REM or LDA by Wk 52 showed no or mild articular and extra-articular disease activity by Wk 52, similar to what was observed in the PALACE 1-3 population.4

Conclusion:

DMARD-naive subjects in PALACE 4 who had LDA or Mod at BL had the highest likelihood of achieving treatment targets (cDAPSA REM or LDA) by Wk 52 with continued APR treatment. Results from the current probability analyses revealed higher probability rates than those observed in the DMARD-experienced PALACE 1-3 population; control of articular and extra-articular manifestations was observed in the DMARD-naive and DMARD-experienced populations.

References:

[1]Wells AF, et al. Rheumatology. 2018;57:1253-63. 2. Kavanaugh A, et al. Arthritis Res Ther. 2019;21:118. 3. Machado PM. Ann Rheum Dis. 2016;75:787-90. 4. Mease PJ, et al. Arthritis Care Res. 2020 Jan 7.

Disclosure of Interests:

Philip J Mease Grant/research support from: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – grant/research support, Consultant of: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – consultant, Speakers bureau: Abbott, Amgen, Biogen Idec, BMS, Eli Lilly, Genentech, Janssen, Pfizer, UCB – speakers bureau, Arthur Kavanaugh Grant/research support from: Abbott, Amgen, AstraZeneca, BMS, Celgene Corporation, Centocor-Janssen, Pfizer, Roche, UCB – grant/research support, Alexis Ogdie Grant/research support from: Novartis, Pfizer – grant/research support, Consultant of: AbbVie, BMS, Eli Lilly, Novartis, Pfizer, Takeda – consultant, Alvin F. Wells Grant/research support from: AbbVie, Celgene Corporation, Lilly – grant/research support, Consultant of: AbbVie, Alexion, Amgen, BMS, Celgene Corporation, Horizon, Lilly, Novartis, UCB – consultant, Speakers bureau: AbbVie, Alexion, Amgen, BMS, Celgene Corporation, Horizon, Lilly, Novartis, UCB – speakers bureau, Martin Bergman Shareholder of: Johnson & Johnson – stockholder, Consultant of: AbbVie, BMS, Celgene Corporation, Genentech, Janssen, Merck, Novartis, Pfizer, Sanofi – consultant, Speakers bureau: AbbVie, Celgene Corporation, Novartis, Pfizer, Sanofi – speakers bureau, Dafna D Gladman Grant/research support from: AbbVie, Amgen Inc., BMS, Celgene Corporation, Janssen, Novartis, Pfizer, UCB – grant/research support, Consultant of: AbbVie, Amgen Inc., BMS, Celgene Corporation, Janssen, Novartis, Pfizer, UCB – consultant, Frank Behrens Grant/research support from: AbbVie, Chugai, Janssen, Roche, Pfizer – grant/research support, Consultant of: AbbVie Biotest, Boehringer Ingelheim, Celgene Corporation, Chugai, Eli Lilly, Genzyme, Janssen, Novartis, Pfizer, Roche, UCB – consultant, Speakers bureau: AbbVie, Biotest, BMS, Celgene Corporation, Chugai, Eli Lilly, Genzyme, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sandoz, UCB - speaker, Sven Richter Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Michele Brunori Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Lichen Teng Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Benoit Guerette Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Josef S. Smolen Grant/research support from: AbbVie, Eli Lilly, Janssen, Merck Sharp & Dohme, Pfizer, Roche – grant/research support, Consultant of: AbbVie, Amgen Inc., AstraZeneca, Astro, Celgene Corporation, Celtrion, Eli Lilly, Glaxo, ILTOO, Janssen, Medimmune, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Samsung, Sanofi, UCB – consultant, Speakers bureau: AbbVie, Amgen Inc., AstraZeneca, Astro, Celgene Corporation, Celtrion, Eli Lilly, Glaxo, ILTOO, Janssen, Medimmune, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Samsung, Sanofi, UCB – speaker

Resting lymphocyte kinase (Rlk/Txk) targets lymphoid adaptor SLP-76 in the cooperative activation of interleukin-2 transcription in T-cells

Rlk/Txk is a T-cell-specific member of the Btk/Tec family of tyrosine kinases, whereas SLP-76 is a lymphoid adaptor that is essential for pre-TcR and mature TcR signaling. Although Rlk deficient T-cells show partial defects in T-cell proliferation, Rlk can complement ITK-/- cells with multiple defects in TcR initiated early events and interleukin (IL)-2 production. A key question is the nature of the target of Rlk responsible for bridging the TcR with the activation of IL-2 transcription. In this study, we identify a pathway in which Rlk phosphorylates SLP-76 leading to the phosphorylation of PLCgamma1, activation of ERKs, and the synergistic up-regulation of TcR-driven IL-2 NFAT/AP-1 transcription. Rlk phosphorylated the N-terminal region of SLP-76, a region that has been previously shown to serve as a target for ZAP-70. Loss of N-terminal YESP/YEPP sites of SLP-76 or the Rlk kinase activity attenuated cooperativity between Rlk and SLP-76. These observations support a model where the TcR can utilize Rlk (as well as ZAP-70) in the phosphorylation of key sites in SLP-76 leading to the up-regulation of Th1 preferred cytokine IL-2.

Immunosuppression with monoclonal antibodies and CTLA4-Ig after myoblast transplantation in mice

Various combinations of monoclonal antibodies specific for lymphocyte cell surface antigens and a recombinant molecule (CTLA4-Ig) were used to immunosuppress mice after transplantation of MHC-incompatible myoblasts. To assess the effectiveness of the immunosuppression, the donor myoblasts were obtained from a transgenic mouse (TnI LacZ1/29) containing a beta-galactosidase (beta-gal) reporter gene under the control of a muscle-specific promoter. No muscle fibers expressing beta-gal were observed 1 month after the myoblast transplantation, when the animals were not immunosuppressed or were treated with CTLA4-Ig alone. Approximately 50% of the muscle fibers expressed the beta-gal reporter gene 1 month after transplantation in mice treated with CTLA4-Ig combined with an anti-CD4 monoclonal antibody and in mice treated with a combination of anti-CD4, anti-CD8, and anti-lymphocyte function-associated antigen-1. The percentage of beta-gal-labeled muscle fibers increased to 94% when this combination of the three monoclonal antibodies was administrated weekly for 3 weeks. Although excellent graft survival rates were obtained 1 month after transplantation, reflecting an effective immunosuppression by these three treatments, no beta-gal-positive fibers were found 2 months after the transplantation, indicating the inability of these immunosuppressive agents to maintain long-term graft survival and induce tolerance to the myoblasts and muscle fibers of donor origin.