Post-Marketing Safety Surveillance of Tofacitinib over 9 Years in Patients with Psoriatic Arthritis and Rheumatoid Arthritis

INTRODUCTION

The safety of tofacitinib in psoriatic arthritis (PsA) and rheumatoid arthritis (RA) has been demonstrated in clinical studies of ≤ 4 and 9.5 years, respectively. Post-marketing surveillance (PMS) data for tofacitinib from spontaneous and voluntary adverse event (AE) reports have been published for RA, but not PsA. To inform the real-world safety profile of tofacitinib in PsA, we evaluated AE reports submitted to the Pfizer safety database (including RA data for context).

METHODS

Endpoints included AEs, serious AEs (SAEs), AEs of special interest (AESIs; serious infections, herpes zoster, cardiovascular events, malignancies, venous thromboembolism), and fatal cases. Exposure was estimated using IQVIA global commercial sales data. Number, frequency, and reporting rates (RRs; number of events/100 patient-years' [PY] exposure) were summarized by indication and formulation (immediate release [IR] 5 or 10 mg twice daily], modified release [MR] 11 mg once daily, or all tofacitinib). The data-collection period differed by indication (PsA: 14 December 2017 [US approval, IR/MR] to 6 November 2021; RA: 6 November 2012 [US approval, IR] to 6 November 2021; MR approval, 24 February 2016).

RESULTS

A total of 73,525 case reports were reviewed (PsA = 5394/RA = 68,131), with 20,706/439,370 PY (PsA/RA) of exposure. More AEs were reported for IR versus MR (IR/MR: PsA = 8349/7602; RA = 137,476/82,153). RRs for AEs (IR/MR: PsA = 59.6/113.4; RA = 44.0/64.8) and SAEs (PsA = 8.1/13.6; RA = 8.0/9.5) were higher with MR versus IR. AE RRs (RA) in the first 4 years after IR approval were 95.9 (IR; 49,439 PY) and 147.0 (MR; 2000 PY). Frequency of SAEs, AESIs, and fatal cases was mostly similar across formulations and indications. The most frequently-reported AE Preferred Terms (PsA/RA) included drug ineffective (20.0%/17.8%), pain (9.7%/10.6%), condition aggravated (9.9%/10.5%), headache (8.8%/7.9%) and, for PsA, off-label use (10.5%/3.4%).

CONCLUSIONS

Tofacitinib PMS safety data from submitted AE reports were consistent between PsA and RA, and aligned with its known safety profile. Exposure data (lower MR versus IR; estimation from commercial sales data), reporting bias, reporter identity, and regional differences in formulation use limit interpretation.

Sex differences in the efficacy, safety and persistence of patients with psoriatic arthritis treated with tofacitinib: a post-hoc analysis of phase 3 trials and long-term extension

BACKGROUND

Evaluate the impact of sex on tofacitinib efficacy, safety and persistence (time to discontinuation) in patients with psoriatic arthritis (PsA).

METHODS

Data were pooled from two phase 3 randomised controlled trials. Patients were randomised to tofacitinib 5 mg or 10 mg two times per day, adalimumab 40 mg every 2 weeks or placebo. Efficacy outcomes to month 12 included American College of Rheumatology (ACR)20/50/70, minimal disease activity (MDA), Psoriasis Area Severity Index (PASI)75, change from baseline (∆) in Health Assessment Questionnaire-Disability Index (HAQ-DI) and ∆Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F). Safety was assessed to month 12 and persistence was assessed to month 42 of a long-term extension study.

RESULTS

Overall, 816 patients were included (54.3% females). At baseline, higher tender joint counts, enthesitis scores and worse HAQ-DI and FACIT-F were reported in females versus males; presence of dactylitis and PASI were greater in males versus females. At month 3, tofacitinib efficacy generally exceeded placebo in both sexes. Overall, similar ACR20/50/70, PASI75, ∆HAQ-DI and ∆FACIT-F were observed for tofacitinib between sexes; females were less likely to achieve MDA. Similar proportions of males/females receiving tofacitinib (both doses) experienced treatment-emergent adverse events (AEs). Serious AEs occurred in 3.4%/6.6% and 4.0%/5.9% males/females with tofacitinib 5 mg and 10 mg two times per day. Persistence was generally similar between sexes.

CONCLUSION

Tofacitinib efficacy exceeded placebo in both sexes and was comparable between sexes. Consistent with previous studies of PsA treatments, females were less likely to achieve MDA, likely due to baseline differences. Safety and time to discontinuation were generally similar between sexes.

TRIAL REGISTRATION NUMBER

NCT01877668; NCT01882439; NCT01976364.

Effectiveness and Safety of Tofacitinib in Canadian Patients With Rheumatoid Arthritis: Primary Results From a Prospective Observational Study

OBJECTIVE

The Canadian Tofacitinib for Rheumatoid Arthritis Observational (CANTORAL) is the first Canadian prospective, observational study assessing tofacitinib. The objective was to assess effectiveness and safety for moderate to severe rheumatoid arthritis (RA). Coprimary and secondary outcomes are reported from an interim analysis.

METHODS

Patients initiating tofacitinib from October 2017 to July 2020 were enrolled from 45 Canadian sites. Coprimary outcomes (month 6) included the Clinical Disease Activity Index (CDAI)-defined low disease activity (LDA) and remission. Secondary outcomes (to month 18) included the CDAI and the 4-variable Disease Activity Score in 28 joints (DAS28) using the erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP) level to define LDA and remission; the proportions of patients achieving mild pain (visual analog scale <20 mm), and moderate (≥30%) and substantial (≥50%) pain improvements; and the proportions of patients achieving a Health Assessment Questionnaire disability index (HAQ DI) score greater or equal to  normative values (≤0.25) and a HAQ DI score greater or equal to minimum clinically important difference (MCID) (≥0.22). Safety was assessed to month 36.

RESULTS

Of 504 patients initiating tofacitinib, 44.4% received concomitant methotrexate. At month 6, 52.9% and 15.4% of patients were in CDAI-defined LDA and remission, respectively; a similar proportion of patients achieved outcomes by month 3 (first post-baseline assessment). By month 3, 27.2% and 41.7% of patients, respectively, were in DAS28-ESR-defined LDA and DAS28-CRP <3.2; 14.7% and 25.8% achieved DAS28-ESR remission and DAS28-CRP <2.6. By month 3, mild pain and moderate and substantial pain improvements occurred in 29.6%, 55.6%, and 42.9% of patients, respectively; 19.9% and 53.7% of patients achieved a HAQ DI score greater than or equal to normative values and a HAQ DI score greater than or equal to MCID, respectively. Outcomes were generally maintained to month 18. Incidence rates (events per 100 patient-years) for treatment-emergent adverse events (AEs), serious AEs, and discontinuations due to AEs were 126.8, 11.9, and 14.5, respectively, and AEs of special interest were infrequent.

CONCLUSION

Tofacitinib was associated with early and sustained improvement in RA signs and symptoms in real-world patients. Effectiveness and safety were consistent with the established tofacitinib clinical profile.

Efficacy and safety of tofacitinib in Chinese patients with active psoriatic arthritis: a phase 3, randomised, double-blind, placebo-controlled study

OBJECTIVES

Efficacy and safety of tofacitinib, an oral Janus kinase inhibitor, were evaluated in a 6-month, double-blind, phase 3 study in Chinese patients with active (polyarthritic) psoriatic arthritis (PsA) and inadequate response to ≥1 conventional synthetic disease-modifying antirheumatic drug.

METHODS

Patients were randomised (2:1) to tofacitinib 5 mg twice daily (N=136) or placebo (N=68); switched to tofacitinib 5 mg twice daily after month (M)3 (blinded).

PRIMARY ENDPOINT

American College of Rheumatology (ACR50) response at M3. Secondary endpoints (through M6) included: ACR20/50/70 response; change from baseline in Health Assessment Questionnaire-Disability Index (HAQ-DI); ≥75% improvement in Psoriasis Area and Severity Index (PASI75) response, and enthesitis and dactylitis resolution. Safety was assessed throughout.

RESULTS

The primary endpoint was met (tofacitinib 5 mg twice daily, 38.2%; placebo, 5.9%; p<0.0001). M3 ACR20/ACR70/PASI75 responses, and enthesitis and dactylitis resolution rates, were higher and HAQ-DI reduction was greater for tofacitinib 5 mg twice daily versus placebo. Incidence of adverse events (AEs)/serious AEs (M0-3): 68.4%/0%, tofacitinib 5 mg twice daily; 75.0%/4.4%, placebo. One death was reported with placebo→tofacitinib 5 mg twice daily (due to accident). One serious infection, non-serious herpes zoster, and lung cancer case each were reported with tofacitinib 5 mg twice daily; four serious infections and one non-serious herpes zoster case were reported with placebo→tofacitinib 5 mg twice daily (M0-6). No non-melanoma skin cancer, major adverse cardiovascular or thromboembolism events were reported.

CONCLUSION

In Chinese patients with PsA, tofacitinib efficacy was greater than placebo (primary and secondary endpoints). Tofacitinib was well tolerated; safety outcomes were consistent with the established safety profile in PsA and other indications.

TRIAL REGISTRATION NUMBER

NCT03486457.

POS0671 IMPACT OF RACE ON THE EFFICACY AND SAFETY OF TOFACITINIB IN PATIENTS WITH RHEUMATOID ARTHRITIS: A POST HOC ANALYSIS OF PHASE 2, 3 AND 3B/4 CLINICAL TRIALS

Background

While racial disparities in clinical outcomes for rheumatoid arthritis (RA) patients (pts) have been described,1 there is a paucity of data on racial differences in response to advanced therapies.

Objectives

To evaluate impact of self-reported race on tofacitinib efficacy/safety in RA pts.

Methods

This post hoc analysis used pooled data from 8 Phase (P)2, 6 P3 and 1 P3b/4 randomised controlled trials (RCTs) of RA pts treated with tofacitinib 5 or 10 mg twice daily (BID), adalimumab (ADA; 40 mg once every 2 weeks) or placebo (PBO), stratified by self-reported pt race (White, Black, Asian, Other) at baseline (BL). Efficacy outcomes (Month [M]3): ACR20/50/70 and CDAI/DAS28-4(ESR) low disease activity (LDA; scores ≤10 and ≤3.2, respectively) rates, and least squares (LS) mean change from BL (Δ) in DAS28-4(ESR) and HAQ-DI. Incidence rates (IRs; unique pts with events/100 pt-yrs) were estimated for adverse events (AEs) and serious AEs.

Results

6355 pts were included (White, n=4145; Black, n=213; Asian, n=1348; Other, n=649). BL characteristics were generally similar across treatment/racial groups, excepting higher prior bDMARD exposure rates in White/Black vs Asian/Other pts. Across treatments, White, Black, Asian and Other pts most commonly enrolled from Europe (40.9%), North America (68.1%), East/South Asia (97.9%) and Latin America (80.6%), respectively; most Other pts self-reported as Hispanic and/or Latino (52.4%), followed by mixed race (36.8%) and unspecified (4.6%). At M3, ACR50 rates were higher in Other vs White pts with tofacitinib, similar across racial groups with ADA, and numerically higher in Black vs White/Asian/Other pts with PBO (Figure 1); broadly similar trends were seen with ACR20/70 and CDAI LDA rates (data not shown [DNS]). DAS28-4(ESR) LDA rates, and LS mean ΔDAS28-4(ESR) and ΔHAQ-DI were generally comparable across racial groups with active treatment, and numerically higher in Black vs White/Asian/Other pts with PBO (DNS). Across efficacy outcomes, PBO-adjusted response rates and improvements generally supported the trends observed with active treatments (Figure 1; DNS). Safety outcomes were broadly similar across treatment arms, with some higher IRs for AEs observed with Black/Other vs White/Asian pts (Table 1). Results should be interpreted with caution due to low pt numbers in some groups and the heterogenous nature of the Other pts group.

Table 1.

AEs and SAEs, stratified by race

WhiteBlackAsianOthernIR (95% CI)nIR (95% CI)nIR (95% CI)nIR (95% CI)Tofacitinib 5 mg BIDN=1699; PY=1588.3N=93; PY=81.8N=560; PY=548.8N=257; PY=245.9AE1150141.976244.1382150.0205227.1(133.8, 150.3)(192.4, 305.6)(135.4, 165.9)(197.1, 260.4)SAE1469.11519.16111.3176.7(7.7, 10.7)(10.7, 31.4)(8.6, 14.5)(3.9, 10.8)Tofacitinib 10 mg BIDN=1264; PY=1175.4N=60; PY=49.8N=462; PY=487.2N=238; PY=239.8AE919188.548434.3338178.4190234.3(176.5, 201.1)(320.2, 575.8)(159.9, 198.5)(202.2, 270.1)SAE1038.923.9479.7156.2(7.3, 10.8)(0.5, 14.3)(7.1, 12.9)(3.5, 10.2)ADAN=484; PY=390.4N=22; PY=18.6N=73; PY=60.1N=64; PY=49.5AE318140.416162.251157.044161.6(125.4, 156.7)(92.7, 263.4)(116.9, 206.5)(117.4, 216.9)SAE317.6210.3914.511.9(5.2, 10.8)(1.3, 37.4)(6.6, 27.5)(0.1, 10.4)PBON=698; PY=177.3N=38; PY=10.0N=253; PY=72.3N=90; PY=24.5AE369311.623424.9122251.548271.4(280.6, 345.1)(269.4, 637.6)(208.9, 300.3)(200.1, 359.8)SAE2312.519.4810.9311.5(7.9, 18.7)(0.2, 52.2)(4.7, 21.4)(2.4, 33.6)

n, number of pts with events; PY, pt-yrs; SAE, serious AE

Conclusion

Across racial groups, tofacitinib efficacy/safety was consistent with previous tofacitinib RA clinical programme findings. Some racial differences in clinical outcomes were observed, which may reflect regional practice norms or demographic differences. Future analyses should focus on the impact of socioeconomic, cultural, genetic or practice-based differences that may underpin these results.

References

[1]Greenberg et al. Am J Med 2013; 126: 1089-1098.

Acknowledgements

Study sponsored by Pfizer Inc. Medical writing support was provided by Kirsten Woollcott, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests

Grace C. Wright Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Myriad Autoimmune, Novartis and UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Janssen, Myriad Autoimmune, Novartis, Pfizer Inc and UCB, Employee of: Association of Women in Rheumatology, United Rheumatology, Eduardo Mysler Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, Janssen, Pfizer Inc, Roche and Sanofi, Grant/research support from: Eli Lilly, Pfizer Inc and Roche, Yi-Hsing Chen Grant/research support from: Bristol-Myers Squibb, GSK and Pfizer Inc, Cassandra Kinch Shareholder of: Pfizer Inc, Employee of: Pfizer Canada ULC, Arne Yndestad Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Kenneth Kwok Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Mary Jane Cadatal Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Rebecca Germino Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Alexis Ogdie Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, CorEvitas, Eli Lilly, Gilead Sciences, GSK, Janssen, Novartis, Pfizer Inc and UCB, Grant/research support from: AbbVie, Amgen, Novartis and Pfizer Inc

POS0652 SEX DIFFERENCES IN THE EFFICACY AND SAFETY OF TOFACITINIB IN RHEUMATOID ARTHRITIS PATIENTS: A POST HOC ANALYSIS OF PHASE 3 AND LONG-TERM EXTENSION TRIALS

Background:

Differences in efficacy outcomes favouring males vs females with rheumatoid arthritis (RA) have been reported with conventional synthetic (cs) disease-modifying antirheumatic drugs (DMARDs) and tumour necrosis factor inhibitors; results with Janus kinase inhibitors are less clear.

Objectives:

To assess the impact of sex on efficacy, safety and persistence in tofacitinib RA clinical trials.

Methods:

Efficacy and safety analyses included data pooled from Phase (P)3 randomised controlled trials (RCTs) of patients (pts) with RA and an inadequate response (IR) to methotrexate (NCT00847613; NCT00853385) or ≥1 DMARD (NCT00856544) who received tofacitinib 5 or 10 mg twice daily (BID), adalimumab (ADA) 40 mg Q2W or placebo (PBO), with background csDMARDs. Persistence analyses of pts receiving tofacitinib 5 or 10 mg BID ± csDMARDs used data pooled from two long-term extension trials (NCT00661661; NCT00413699). Efficacy outcomes to Month (M)12 included: ACR20/50/70 responses, changes from baseline (Δ; BL) in DAS28-4(ESR), CDAI, HAQ-DI and FACIT-F, and DAS28-4(ESR) remission (<2.6). Safety was evaluated to M24 for tofacitinib and ADA. Kaplan-Meier persistence analysis estimated time to discontinuation.

Results:

2265 pts were included from P3 RCTs. Demographics and BL characteristics were comparable across sexes and treatments. Tofacitinib or ADA vs PBO generally led to significantly higher ACR20/50/70 responses in both sexes through M6. To M12, ACR20/50/70 responses were broadly comparable across active treatments and between sexes, with significant differences favouring males at some time points, including M3 (Figure 1). Statistically significant differences favouring males vs females were observed in DAS28-4(ESR) remission rates at most time points, including M3 (Figure 1); a similar trend was observed for ΔDAS28-4(ESR). ΔCDAI, ΔHAQ-DI and ΔFACIT-F significantly favoured males vs females receiving tofacitinib 5 mg BID at most time points, while ΔHAQ-DI and ΔFACIT-F tended to favour females receiving tofacitinib 10 mg BID. Rates of adverse events (AEs), serious AEs (SAEs), severe AEs and discontinuations due to AEs were slightly higher in females vs males with tofacitinib 5 mg BID; this was generally reversed with tofacitinib 10 mg BID and ADA (Table 1). AEs of special interest (AESI) were comparable between sexes with tofacitinib and ADA, although low event numbers limit interpretation (Table 1). Time to all-cause discontinuation and discontinuation due to AEs/lack of efficacy with tofacitinib 5 mg BID was similar between sexes. Numerical differences favouring females vs males were observed for time to all-cause discontinuation and discontinuation due to AEs with tofacitinib 10 mg BID.

Table 1.

Safety summary to M24 in pooled DMARD-IR P3 RCTs

Tofacitinib5 mg BIDTofacitinib10 mg BIDADAPts with events,n (%)Females(N=707)Males(N=133)Females(N=698)Males(N=137)Females(N=162)Males(N=42)AEs562 (79.5)85 (63.9)529 (75.8)107 (78.1)119 (73.5)30 (71.4)SAEs107 (15.1)17 (12.8)71 (10.2)24 (17.5)13 (8.0)6 (14.3)Severe AEs86 (12.2)12 (9.0)55 (7.9)22 (16.1)14 (8.6)5 (11.9)Discontinuations due to AEs87 (12.3)10 (7.5)88 (12.6)10 (7.3)17 (10.5)5 (11.9)Death6 (0.8)4 (3.0)03 (2.2)1 (0.6)2 (4.8)AESISerious infections28 (4.0)6 (4.5)27 (3.9)6 (4.4)2 (1.2)1 (2.4)All HZ (non-serious/serious)35 (5.0)7 (5.3)43 (6.2)5 (3.6)2 (1.2)3 (7.1)MACE5 (0.7)02 (0.3)3 (2.2)03 (7.1)Malignancies (excl. NMSC)7 (1.0)1 (0.8)9 (1.3)1 (0.7)01(2.4)NMSC2 (0.3)5 (3.8)4 (0.6)2 (1.5)1 (0.6)1 (2.4)Venous thromboembolism3 (0.4)03 (0.4)1 (0.7)00

HZ, herpes zoster; MACE, major adverse cardiovascular events; NMSC, non-melanoma skin cancer

Conclusion:

Efficacy outcomes with tofacitinib and ADA were generally higher in males and comparable in females vs previously reported mixed population response rates for advanced therapies. Safety findings did not reveal a consistent pattern between sexes. Tofacitinib persistence was similar between sexes.

Acknowledgements:

Study sponsored by Pfizer Inc. Medical writing support was provided by Christina Viegelmann, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests:

H Niall Jones Consultant of: Pfizer Inc, Vibeke Strand Consultant of: AbbVie, Amgen, Arena, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Celltrion, Corrona, Eli Lilly, Galapagos, Genentech/Roche, Gilead, GlaxoSmithKline, Ichnos, Inmedix, Janssen, Kiniksa, Merck, Myriad Genetics, Novartis, Pfizer Inc, Regeneron, Samsung, Sandoz, Sanofi, Scipher, SetPoint Medical, UCB, Hendrik Schulze-Koops Consultant of: AbbVie, Amgen, Biogen, Bristol-Myers Squibb, Celgene, Eli Lilly, Gilead Sciences, Hexal Sandoz, Hospira, Janssen-Cilag, MSD, Novartis, Pfizer Inc, Roche, UCB, Grant/research support from: Novartis, Pfizer Inc, Eduardo Mysler Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, Janssen, Pfizer Inc, Roche, Sanofi, Grant/research support from: Eli Lilly, Pfizer Inc, Roche, Cassandra Kinch Shareholder of: Pfizer Canada ULC, Employee of: Pfizer Canada ULC, David C Gruben Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Rebecca Germino Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Carol A. Connell Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Lihi Eder Speakers bureau: AbbVie, UCB, Consultant of: AbbVie, Celgene, Eli Lilly, Novartis, Pfizer Inc, UCB, Grant/research support from: AbbVie, Eli Lilly, Pfizer Inc, UCB

Altered glycosylation of proteins in cancer: what is the potential for new anti-tumour strategies

It is becoming increasingly apparent that cell surface oligosaccharides play pivotal roles as recognition molecules in a range of cell communication and adhesion processes. Alterations in cellular glycosylation are also associated with diseases, including cancer, and may have functional significance. This paper gives an overview of the complex topic of cellular glycosylation mechanisms and reviews the well-documented alterations in cellular glycosylation of proteins in malignancy. One particular type of cancer-associated glycosylation change, the incomplete synthesis of O-linked glycans, is highlighted, and its possible functional significance in cancer cell metastatic mechanisms is discussed. The significance that cancer-associated changes in glycoprotein glycosylation may have in new approaches to anti-tumour therapies is explored.