Improving resource utilisation in SLE drug development through innovative trial design

SLE is a complex autoimmune disease with considerable unmet need. Numerous clinical trials designed to investigate novel therapies are actively enrolling patients straining limited resources and creating inefficiencies that increase enrolment challenges. This has motivated investigators developing novel drugs and treatment strategies to consider innovative trial designs that aim to improve the efficiency of generating evidence; these strategies propose conducting fewer trials, involving smaller numbers of patients, while maintaining scientific rigour in safety and efficacy data collection and analysis. In this review we present the design of two innovative phase IIb studies investigating efavaleukin alfa and rozibafusp alfa for the treatment of SLE which use an adaptive study design. This design was selected as a case study, investigating efavaleukin alfa, in the Food and Drug Administration's Complex Innovative Trial Design Pilot Program. The adaptive design approach includes prospectively planned modifications at predefined interim timepoints. Interim assessments of futility allow for a trial to end early when the investigational therapy is unlikely to provide meaningful treatment benefits to patients, which can release eligible patients to participate in other-potentially more promising-trials, or seek alternative treatments. Response-adaptive randomisation allows randomisation ratios to change based on accumulating data, in favour of the more efficacious dose arm(s), while the study is ongoing. Throughout the trial the placebo arm allocation ratio is maintained constant. These design elements can improve the statistical power in the estimation of treatment effect and increase the amount of safety and efficacy data collected for the optimal dose(s). Furthermore, these trials can provide the required evidence to potentially serve as one of two confirmatory trials needed for regulatory approval. This can reduce the need for multiple phase III trials, the total patient requirements, person-exposure risk, and ultimately the time and cost of investigational drug development programmes.

Examining the potential direct cardiovascular benefit of tumor-necrosis factor inhibitor in rheumatoid arthritis: Natural and controlled direct effect analyses

BACKGROUND/PURPOSE

Tumor necrosis factor inhibitors (TNFi) may have a direct benefit on cardiovascular (CV) disease beyond reducing rheumatoid arthritis (RA) disease activity measured by the Clinical Disease Activity Index (CDAI).

METHODS

We compared TNFi initiators and methotrexate (MTX) monotherapy initiators from the CorEvitas RA registry. Two approaches to the "direct effect" of TNFi beyond CDAI were used. In the natural direct effect (NDE) analysis, the potential CV benefit of TNFi was partitioned into NDE and the natural indirect effect (NIE) mediated by CDAI during the first 6 months. We also estimated the controlled direct effects (CDE), corresponding to the direct benefit of TNFi when CDAI trajectories were hypothetically equalized between the initiators of TNFi and MTX monotherapy at a constant value. Estimates were given on the hazard ratio scale.

RESULTS

We identified 5764 initiators of TNFi and 3588 initiators of MTX monotherapy. TNFi initiators were younger (58 vs. 64 years) with a shorter disease duration. Our total effect estimates (TNFi vs. MTX [reference]) were protective in direction (0.76-0.91). The NDE estimate was 0.76 [95% confidence interval (CI) 0.59, 0.98], whereas the NIE estimate was 1.00 [95%CI 1.00, 1.00]. In the CDE analyses accounting for longitudinal CDAI, the CDE estimates was 1.27 [95%CI 0.60, 2.69].

CONCLUSIONS

We could not convincingly demonstrate a direct benefit of TNFi outside its impact on CDAI. At present, the emphasis should be on the stringent control of RA disease activity, a known important CV risk factor, regardless of medication choice.

Effects of Disease-Worsening Following Withdrawal of Etanercept or Methotrexate on Patient-Reported Outcomes in Patients With Rheumatoid Arthritis: Results From the SEAM-RA Trial

BACKGROUND/OBJECTIVE

The effect of treatment withdrawal on patient-reported outcomes (PROs) in patients with rheumatoid arthritis (RA) whose disease is in sustained remission has not been well described. This analysis aimed to compare PRO changes in patients with RA following medication withdrawal and disease worsening.

METHODS

SEAM-RA (Study of Etanercept and Methotrexate in Combination or as Monotherapy in Subjects With Rheumatoid Arthritis) was a phase 3, multicenter, randomized withdrawal, double-blind controlled study in patients with RA taking methotrexate plus etanercept and in remission (Simple Disease Activity Index ≤3.3). Patient's Global Assessment of Disease Activity, Patient's Assessment of Joint Pain, Health Assessment Questionnaire-Disability Index, and 36-Item Short-Form Health Survey were evaluated for 48 weeks following methotrexate or etanercept withdrawal. Treatment differences for patients with versus without disease worsening were evaluated using a 2-sample t test for continuous end points and log-rank test for time-to-event end points.

RESULTS

Of 253 patients, 121 experienced disease worsening and 132 did not. All PRO scores were similar to those of a general population at baseline and deteriorated over time across the study population. The PtGA and Patient's Assessment of Joint Pain values deteriorated less in those on etanercept monotherapy compared with methotrexate monotherapy. More patients with versus without disease worsening experienced deterioration that was greater than the minimal clinically important difference (MCID) for all PROs tested. In patients with disease worsening, PtGA deterioration more than the MCID preceded Simple Disease Activity Index disease worsening.

CONCLUSIONS

Etanercept monotherapy showed benefit over methotrexate in maintaining PRO scores. Patients with disease worsening experienced a more rapid worsening of PtGA beyond the MCID versus patients without disease worsening.Categories: autoinflammatory disease, biological therapy, DMARDs, rheumatoid arthritis.

Time-Varying Association of Rheumatoid Arthritis Disease Activity to Subsequent Cardiovascular Risk

Objective

It is unknown how the relationship between disease activity in rheumatoid arthritis (RA) and cardiovascular (CV) events may change over time. We examined the potentially time‐varying association of RA disease activity to CV events.

Methods

We used the CorEvitas prevalent RA registry. The Clinical Disease Activity Index (CDAI) score category, averaged within each 6‐month window since enrollment, was the exposure, and the outcome was major adverse CV events (MACEs). We used marginal structural models to estimate the hazard ratio (HR), comparing each CDAI score category with remission, allowing for differential association over time. We predicted MACE‐free survival under several CDAI score scenarios.

Results

We found 44,816 eligible patients (77% female; mean age 58 years) with a crude event rate of 5.3/1000 person‐years (median follow‐up 3.4 years). The strongest association between higher CDAI score and MACEs was observed during the first 6 months of enrollment (HR for CDAI score low 2.29 [95% CI: 1.21‐4.36], moderate 2.81 [95% CI: 1.46‐5.43], and high 2.99 [95% CI: 1.48‐6.02]). These estimates gradually diminished; by year 5, the HRs were 1.00 (95% CI: 0.49‐2.05) for low, 1.18 (95% CI: 0.51‐2.71) for moderate, and 1.04 (95% CI: 0.45‐2.40) for high CDAI score. Predicted MACE‐free survival suggested a potential decrease in MACEs with a hypothetical earlier transition to remission.

Conclusion

The association of higher disease activity with CV events may be stronger earlier in the disease course of RA. Interventional studies may be warranted to precisely determine the effect of disease activity suppression on CV events in RA.

Association of physician specialty with psoriatic arthritis treatment and costs

OBJECTIVES

To describe current psoriatic arthritis treatment and costs by provider specialty using real-world claims data.

STUDY DESIGN

Observational, retrospective cohort study of patients in the IBM MarketScan Commercial and supplemental Medicare databases.

METHODS

Eligible patients had newly diagnosed psoriatic arthritis with 12 months of continuous enrollment pre- and post index date for their initial claim. Patients were assigned to 1 of 5 provider specialty cohorts. During the 1-year follow-up period, we collected psoriatic arthritis treatment agent and regimen type and total annual medical and health care costs. We used multivariate regression models to determine the conditional associations of provider specialty with costs.

RESULTS

A total of 2132 patients with incident psoriatic arthritis qualified. Most providers were rheumatologists (n = 1365; 64%). Rheumatologists commonly prescribed oral small molecules (methotrexate, 56.3% of prescriptions; sulfasalazine, 8.6%; apremilast, 7.0%) as the index therapy, whereas 23.8% of prescriptions were for tumor necrosis factor inhibitors (adalimumab, 14.2%; etanercept, 7.9%; and infliximab, 1.7%). Compared with other specialists, dermatologists prescribed biologics and other specialty drugs more frequently-adalimumab (32.7%), apremilast (14.3%), etanercept (11.6%), and ustekinumab (8.8%)-and methotrexate less frequently (30.6%). The greatest unadjusted median health care costs were observed among dermatologists ($45,548) compared with rheumatologists ($30,411), primary care physicians ($29,927), rheumatologists/dermatologists ($27,393), and other specialists ($27,774). However, after adjusting for patient-level factors, multivariate regression analyses found that provider specialty was not associated with higher health care costs.

CONCLUSIONS

In patients with newly diagnosed psoriatic arthritis, physician specialty was associated with different medication choices but not costs.

OP0118 EFFECT OF WITHDRAWING ETANERCEPT OR METHOTREXATE ON PATIENT-REPORTED OUTCOMES IN RHEUMATOID ARTHRITIS PATIENTS IN REMISSION ON COMBINATION THERAPY: RESULTS FROM THE SEAM-RA TRIAL

Background:

Limited studies have assessed the effect of withdrawal of either methotrexate (MTX) or etanercept (ETN) on patient-reported outcomes (PROs) in rheumatoid arthritis (RA).

Objectives:

To evaluate the baseline and change in PROs following withdrawal of MTX or ETN in RA patients with sustained remission receiving combination ETN+MTX.

Methods:

Adult patients with RA on ETN+MTX and in remission (SDAI ≤3.3) for ≥12 months (including a 24-week, open-label, run-in period) were randomized to a 48-week double-blind period to receive ETN 50 mg weekly (N=101), oral MTX 10-25 mg weekly (N=101) or continue ETN+MTX (N=51). The primary endpoint was maintenance of SDAI remission without disease worsening (DW) at week 48 between ETN and MTX groups. Patients who experienced SDAI >11 at any time after randomization, or SDAI >3.3 and ≤11 during 2 consecutive or on 3 non-consecutive visits were considered to have DW and resumed ETN+MTX. PROs assessed were patient global assessment of disease activity (PtGA, 0-100 mm), patient joint pain (PtJP, 0-100 mm), Health Assessment Questionnaire-Disability Index (HAQ-DI), and the 36-item short-form health survey (SF-36) component and domain scores. A 2-sample t-test was used to compare the treatment differences between groups. A subgroup analysis for patients with DW was also performed (DW analysis set) and compared PROs between ETN vs MTX arms (ETN+MTX not shown given the small sample size).

Results:

Of the 253 patients randomized, 121 (47.8%) experienced DW and were included in the DW analysis set. Baseline demographics were generally balanced between the 3 treatment groups. Most patients were women (76.3%), White (87.0%), and with a mean age of 55.6 years. The mean (SD) MTX dose was 16.3 (4.69) mg and the mean (SD) duration of RA was 10.3 (7.8) years. At week 48, a significantly greater proportion of patients on ETN vs MTX monotherapy maintained SDAI remission (49.5% vs 28.7%; P=0.004) after therapy withdrawal. In the overall population, PtGA and PtJP scores were very low at baseline (PtGA–MTX: 4.4, ETN: 4.5, ETN+MTX: 3.5; PtJP–MTX: 4.9, ETN: 5.5, ETN+MTX: 3.5) and showed some worsening over the study period in all treatment groups, with a mean change at week 48 ranging from 5.0 to 10.0 units for PtGA and 3.7 to 8.1 units for PtJP. Patients on ETN had less worsening, with a nominally significant treatment difference observed between ETN and MTX monotherapy groups for PtGA at almost all timepoints, and for PtJP at weeks 12 and 36 (Figure). Mean HAQ-DI (MTX: 0.32; ETN: 0.26; ETN+MTX: 0.28) and SF-36 scores (physical component [PCS]–MTX: 52.1, ETN: 52.7, ETN+MTX: 52.3; mental component [MCS]–MTX: 55.5, ETN: 55.8, ETN+MTX: 57.1) at baseline show that patients had low disability and excellent health-related quality of life compared with normative values for the general non-RA population. HAQ-DI scores were well maintained at weeks 24 and 48 (change from baseline at week 48–MTX: 0.14; ETN: 0.15; ETN+MTX: 0.21). The SF-36 PCS, MCS, and domain scores decreased minimally from baseline with treatment differences that were not nominally significant between groups. Among patients with DW during the study, those on ETN showed less PtGA and PtJP worsening from baseline than those on MTX at weeks 12, 36, and 48 (Figure). Other PROs (HAQ-DI [change from baseline at week 24–ETN: 0.34; MTX: 0.21; at week 48–ETN: 0.15; MTX: 0.15], SF-36 PCS, MCS, and domain scores) showed a similar degree of worsening in both the MTX and ETN arms.

Conclusion:

In patients with sustained SDAI remission on ETN+MTX, mental and physical health as measured by SF-36 was comparable with that of the non-RA population. Withdrawal of ETN (MTX monotherapy) resulted in a greater worsening of PtGA and PtJP than withdrawal of MTX (ETN monotherapy), and patients on ETN monotherapy restored these scores close to baseline towards the end of the treatment period. These findings demonstrate that ETN monotherapy has a greater effect on maintaining overall patient assessment of disease and joint pain compared with MTX monotherapy.

Disclosure of Interests:

Jeffrey Curtis Speakers bureau: AbbVie, BMS, Gilead, Lilly, Novartis, Sanofi, Scipher, Amgen, Corrona, Janssen, Myriad, and Pfizer, Consultant of: AbbVie, BMS, Gilead, Lilly, Novartis, Sanofi, Scipher, Amgen, Corrona, Janssen, Myriad, and Pfizer, Grant/research support from: AbbVie, BMS, Gilead, Lilly, Novartis, Sanofi, Scipher, Amgen, Corrona, Janssen, Myriad, and Pfizer, Elaine Karis Shareholder of: Amgen Inc., Employee of: Amgen Inc., Vivian Bykerk Speakers bureau: Amgen, BMS, Gilead, Pfizer, Sanofi-Genzyme/Regeneron, Scipher Medicine, and UCB., Consultant of: Amgen, BMS, Gilead, Pfizer, Sanofi-Genzyme/Regeneron, Scipher Medicine, and UCB., Grant/research support from: Amgen and Novartis, Greg Kricorian Shareholder of: Amgen Inc., Employee of: Amgen Inc., Priscilla Yen Shareholder of: Amgen Inc., Employee of: Amgen Inc., Paul Emery Speakers bureau: AbbVie, BMS, Celltrion, Gilead, Lilly, MSD, Novartis, Pfizer, Roche, Samsung, Sandoz, and UCB., Consultant of: AbbVie, BMS, Celltrion, Gilead, Lilly, MSD, Novartis, Pfizer, Roche, Samsung, Sandoz, and UCB., Paul Haraoui Speakers bureau: AbbVie, Celgene, Janssen, Pfizer, and UCB., Consultant of: AbbVie, Amgen, BMS, Celgene, Eli Lilly, Janssen, Merck, Pfizer, Roche, Sandoz, Sanofi-Genzyme, and UCB., Grant/research support from: Roche, AbbVie, Amgen, Merck, and Pfizer, David Collier Shareholder of: Amgen Inc., Employee of: Amgen Inc., Brad Stolshek Shareholder of: Amgen Inc., Employee of: Amgen Inc.

OP0101 RHEUMATOID ARTHRITIS DISEASE ACTIVITY OVER TIME AND SUBSEQUENT CARDIOVASCULAR RISKS

Background:

Rheumatoid arthritis (RA) patients have an increased risk of cardiovascular (CV) events not fully explained by traditional CV risk factors. The relationship between fluctuating inflammation due to RA disease activity and CV events is of interest.

Objectives:

To examine the influence of time-varying disease activity on the subsequent risks of CV disease.

Methods:

We followed patients from a large US registry of clinically diagnosed RA patients, starting at their first visit with a Clinical Disease Activity Index (CDAI) through the end of follow-up or first CV event. Exposure of interest was disease activity measured by categorical CDAI (high, moderate, low, and remission) averaged within each 6-month window. The outcome of interest was major adverse CV events (MACE) defined as non-fatal myocardial infarction, non-fatal stroke (excluding transient ischemic attacks), and CV death. For baseline confounders we considered age, gender, race, disease duration, Health Assessment Questionnaire, hypertension, diabetes, hyperlipidemia, family history of premature (age<50) CV events, and RF/ACPA seropositivity. For time-varying variables we considered tumor necrosis factor inhibitor (TNFi), non-TNFi biologic, methotrexate, oral glucocorticoid, non-steroidal anti-inflammatory drugs, statin, and aspirin use. We used the marginal structural model (MSM) framework to examine the impact of CDAI at each 6-month interval on MACE. We estimated time-varying hazard ratios (HRs) comparing high CDAI during follow-up to CDAI remission. Several predicted survival curves were constructed under different hypothetical CDAI scenarios, such as early and late transition to CDAI remission.

Results:

40,721 patients were eligible for our analyses. 77% were female and 84% were Caucasian. The mean age was 58 (SD 13) years with mean disease duration of 8.8 (median 5) years. Mean CDAI at their first registry visit was 14 (SD 13; remission 19%, low 31%, moderate 28%, and high 22%). Other baseline characteristics include: 41% current/former smokers, 31.5% with hypertension, 8.6% with diabetes, 18% with hyperlipidemia, and 52% seropositive. The average follow-up duration after baseline was 4.4 (median 3.3; max. 17.6) years. The crude event count of MACE was 1,050 events / 180,402 person-years.

In the MSM analysis, the average HRs, assuming a constant HR, were 1.31 [0.90, 1.90] for low, 1.46 [1.01, 2.10] for moderate, and 1.43 [0.89, 2.31] for high CDAI disease activity categories during each 6-month interval. When approximating time-varying HR with linear trends, the highest estimates during the first 6 months of follow up were 1.61 [0.93, 2.77] for low CDAI, 1.97 [1.13, 3.43] for moderate CDAI, and 2.11 [1.13, 3.96] for high CDAI. These HRs gradually diminished during the follow up (Table). When we constructed hypothetical survival curves with transition to CDAI remission at different time points, earlier transition to CDAI remission was related to better event-free survival (Figure).

Table 1.

Time-varying hazard ratio estimates [95% confidence intervals] by duration in study

Disease activity measured by CDAIYearRemissionLowModerateHigh0.51.00 [ref]1.61 [0.93, 2.77]1.97 [1.13, 3.43]2.11 [1.13, 3.96]11.00 [ref]1.54 [0.97, 2.44]1.85 [1.17, 2.93]1.94 [1.13, 3.31]21.00 [ref]1.42 [1.00, 2.01]1.63 [1.16, 2.29]1.62 [1.04, 2.54]31.00 [ref]1.31 [0.90, 1.90]1.43 [0.97, 2.11]1.36 [0.80, 2.31]41.00 [ref]1.20 [0.72, 2.02]1.26 [0.72, 2.21]1.14 [0.55, 2.36]51.00 [ref]1.11 [0.54, 2.26]1.11 [0.51, 2.42]0.96 [0.36, 2.53]Figure 1.

MACE-free survival curves under hypothetical CDAI scenarios

Conclusion:

High and moderate CDAI were associated with higher hazard of MACE during the earlier period of follow-up, but the increased hazard diminished over time. In hypothetical senarios, earlier transition to CDAI remission would improve MACE free-survival.

Acknowledgements:

This study was sponsored by Corrona, LLC. Corrona is supported through contracted subscriptions with multiple pharmaceutical companies. The analysis was financially supported by Amgen Inc.

Disclosure of Interests:

Kazuki Yoshida Consultant of: OM1, Inc., Grant/research support from: Corrona, LLC., Hongshu Guan: None declared, Scott Stryker Shareholder of: Amgen, Inc., Employee of: Amgen, Inc., Elaine Karis Shareholder of: Amgen, Inc., Employee of: Amgen, Inc., Leslie Harrold Consultant of: AbbVie, Bristol-Myers Squibb, Genentech/Roche, Grant/research support from: Pfizer, Daniel Solomon Grant/research support from: DHS receives salary support from research contracts through Brigham and Women’s Hospital with Abbvie, Amgen, Corrona, Genentech and Janssen.

Etanercept or Methotrexate Withdrawal in Rheumatoid Arthritis Patients in Sustained Remission

OBJECTIVE

Patients with rheumatoid arthritis (RA) in whom remission is achieved following combination therapy with methotrexate plus etanercept face an ongoing medication burden. This study was undertaken to investigate whether sustained remission achieved on combination therapy can be maintained with either methotrexate or etanercept monotherapy, as assessed following discontinuation of one or the other medication from the combination.

METHODS

Of the 371 adult patients with RA who received combination therapy with methotrexate plus etanercept, remission (defined as a Simplified Disease Activity Index [SDAI] score of ≤3.3) was sustained in 253 patients through a 24-week open-label period. These 253 patients then entered a 48-week, double-blind period and were randomized to receive either 1) methotrexate monotherapy (n = 101), 2) etanercept monotherapy (n = 101), or 3) methotrexate plus etanercept combination therapy (n = 51). Patients who subsequently experienced disease-worsening received rescue therapy with the combination regimen at the same dosages as used in the initial run-in period. The primary end point was the proportion of patients in whom SDAI-defined remission was maintained without disease-worsening at week 48 in the etanercept monotherapy group as compared to the methotrexate monotherapy group. Secondary end points included time to disease-worsening, and the proportion of patients in whom SDAI-defined remission was recaptured after initiation of rescue therapy.

RESULTS

Baseline demographic and clinical characteristics of the RA patients were similar across the treatment groups. At week 48, SDAI-defined remission was maintained in significantly more patients in the etanercept monotherapy group than in the methotrexate monotherapy group (49.5% versus 28.7%; P = 0.004). Moreover, as a secondary end point, sustained SDAI-defined remission was achieved in significantly more patients who received combination therapy than in those who received methotrexate monotherapy (52.9% versus 28.7%; P = 0.006). Time to disease-worsening was shorter in those who received methotrexate monotherapy than in those who received etanercept monotherapy or those who received combination therapy (each P < 0.001 versus methotrexate monotherapy). Among the patients who received rescue therapy, SDAI-defined remission was recaptured in 70-80% in each treatment group. No new safety signals were reported.

CONCLUSION

The efficacy of etanercept monotherapy was superior to that of methotrexate monotherapy and similar to that of combination therapy in maintaining remission in patients with RA. SDAI-defined remission was recaptured in most of the patients who were given rescue therapy. These data could inform decision-making when withdrawal of therapy is being considered to reduce treatment burden in patients with well-controlled RA.

Maintenance of Sustained Low Disease Activity or Remission in Patients With Rheumatoid Arthritis Treated With Etanercept Monotherapy: Results from the Corrona Registry

Objective

The purpose of this study was to evaluate maintenance of remission/low disease activity (LDA) in patients with rheumatoid arthritis (RA) who achieved remission/LDA with etanercept (ETN) plus a conventional synthetic disease‐modifying antirheumatic drug (csDMARD) and to compare patients who discontinued csDMARD to receive ETN monotherapy (Mono) with those remaining on combination therapy (Combo).

Methods

Patients from the Corrona RA registry between October 1, 2001, and August 31, 2017, were eligible. The index date for the Mono cohort was the csDMARD discontinuation date; the index visit for the Combo cohort was estimated from time between ETN initiation and csDMARD discontinuation in the Mono cohort. The main outcome calculated was maintenance of remission/LDA. Patients were censored if they switched to or added a biologic DMARD, discontinued ETN, when a csDMARD was reintroduced (Mono), or if methotrexate increased more than 5 mg/d (Combo). Trimming was used to balance demographic and clinical characteristics between groups. Cox regression models were adjusted for the remaining differences across groups.

Results

We identified 182 Mono and 403 Combo patients; 120 Mono and 207 Combo patients remained after trimming. Most patients (approximately 80%) were biologic medication–naive before initiating ETN. At 24 months postindex, modeled percentages of patients remaining in remission/LDA were 75% for Mono and 86% for Combo (overall adjusted P = 0.057). More patients were censored for therapy change in Mono than in Combo groups (37% versus 5%), largely due to reintroduction of csDMARDs in the Mono group.

Conclusion

Many patients with RA who achieved remission/LDA on combination therapy maintained remission/LDA with ETN monotherapy for 2 years after csDMARD discontinuation. ETN monotherapy may be a viable option for patients who discontinue csDMARDs after achieving LDA/remission.

SAT0150 CHANGES IN PATIENT-REPORTED OUTCOME (PRO) SCORES FOR NAUSEA AND FATIGUE FOLLOWING WEEKLY METHOTREXATE DOSE IN A REAL-WORLD SAMPLE OF RA AND PSA PATIENTS IN THE ARTHRITISPOWER REGISTRY

Background:

Methotrexate (MTX) is frequently used in patients with rheumatoid arthritis (RA) or psoriatic arthritis (PsA) because of its beneficial effects in both populations1-3. Despite the well-known benefits of MTX, it is associated with a number of potential side effects4-6These include nausea and fatigue, are often temporally related to the timing of weekly MTX administration, and can be severe. The combined patient-reported side effects, along with potential of long-term toxicity, may make use of MTX more burdensome. Currently, there is a gap in patient-centered studies that focus on patients’ experience with MTX.

Objectives:

Examine patient temporal experience of fatigue and nausea relating to oral MTX therapy for the treatment of RA and PsA.

Methods:

Adult US patients in the ArthritisPower registry with self-reported RA or PsA taking MTX for less than 10 years were invited to participate in the study via email invitation. Participants (pts) completed a screener and brief online survey. In an ancillary study to the ArthritisPower registry and using a self-controlled case series study design where pts serve as their own control to avoid between-person confounding, pts were asked to complete a set of up to 8 assessments within 6-36 hours (‘risk’) and 96-144 hours (‘control’) after taking their oral dose of MTX each week, for up to 4 weeks. Risk and control windows were selected based on the expected temporal relationship between MTX use and peak onset of these symptoms. Assessments included PROMIS short forms for same-day Fatigue, same-day Nausea/Vomiting, and Patient Global. Descriptive statistics were conducted using paired t-tests two-way comparisons. Within-person change in PROMIS scores between the risk (1-2 days after MTX) and control (4-6 days after MTX) windows were analyzed using mixed models for repeated measures, stratified on whether pts reported fatigue or nausea with MTX at baseline. Recruitment for this study is ongoing.

Results:

As of December 2019, 91 pts had participated, of whom 76.9% were living with RA and 28.6% with PsA, with mean baseline PROMIS Patient Global score (SD) of 39.5 (7.1). Mean age (SD) was 50.9 (12.0) years, 84.6% female, 92.3% White, with mean BMI 33.7 (8.8). Mean duration of MTX treatment among current users was 2.1 (2.8) years. Among pts, 41.8% were on a biologic DMARD and 58.2% on non-biologic DMARDs only. Among pts reporting baseline nausea (n=30, 33.0%) where paired within-week measures were observed (n=64 observations among 20 pts), the mean increase in the PROMIS Nausea score was 4.5 units (adjusted p=0.003). Among those reporting MTX-associated fatigue (n=39, 42.9%) as a side effect of MTX on their baseline survey where paired within-week measures were observed (n=96 observations among 28 pts), the mean increase in PROMIS Fatigue was 4.7 (adjusted p=0.004) units. In those pts, the proportion of pts with worsened nausea and fatigue with minimally important difference of >5 units7-8was 40.0% (nausea), and 60.7% (fatigue) [Figures 1 and 2].

Conclusion:

People taking MTX to manage RA or PsA commonly experience bothersome side effects, notably fatigue and nausea, that are temporally related to weekly MTX dosing. In this sample, one-third or more of pts were bothered by nausea or fatigue shortly after MTX dosing, many of them with clinically meaningful symptoms.

References:

[1]Singh JA, et al.Arthritis Rheumatol. 2016;68:1-26.

[2]Singh JA, et al.Arthritis Rheumatol. 2019;71:5-32.

[3]Mease P.Bull NYU Hosp Jt Dis. 2013;71.(suppl 1):S41.

[4]Wang W, et al.Eur J Med Chem. 2018;158:502-516.

[5]Wilsdon TD, et al.Cochrane Database Syst Rev. 2019;1:CD012722.

[6]Husted JA, et al.Ann Rheum Dis. 2009;68:1553-1558.

[7]Norman GR, et al.Med Care. 2003;41:582-92.

[8]Bingham CO, et al.J Patient Rep Outcomes. 2019;3:14.

Disclosure of Interests:

W. Benjamin Nowell: None declared, Elaine Karis Shareholder of: Amgen Inc., Employee of: Amgen Inc., Kelly Gavigan: None declared, Laura Stradford: None declared, Scott Stryker Shareholder of: Amgen Inc., Employee of: Amgen Inc., Huifeng Yun Grant/research support from: Bristol-Myers Squibb and Pfizer, Shilpa Venkatachalam: None declared, Greg Kricorian Shareholder of: Amgen Inc., Employee of: Amgen Inc., Lang Chen: None declared, Hong Zhao: None declared, Fenglong Xie: None declared, Jeffrey Curtis Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB

FRI0351 DOES SEX OR BODY MASS INDEX IMPACT RESPONSE TO THERAPY IN PSORIATIC ARTHRITIS?: RESULTS FROM A PHASE 3, DOUBLE-BLIND, RANDOMIZED TRIAL EXAMINING METHOTREXATE AND ETANERCEPT AS MONOTHERAPY OR IN COMBINATION FOR TREATING PSORIATIC ARTHRITIS

Background:

In psoriatic arthritis (PsA), contextual factors such as sex and body mass index (BMI) may affect response to therapy.

Objectives:

To examine if sex and BMI influenced 24-week (wk) outcomes in a 48-wk PsA trial of methotrexate (MTX) and etanercept (ETN) as monotherapy (mono) or combined.1

Methods:

MTX- and biologic-naïve adult patients with active PsA were randomized to weekly: MTX 20mg (n=284), ETN 50mg (n=284), or MTX 20mg+ETN 50mg (n=283). Wk-24 outcomes included ACR 20, MDA, VLDA, PASDAS, DAPSA, LDI, SPARCC, BSA, sPGA, and mNAPSI. Descriptive statistics examined outcomes in each treatment arm by sex (male vs female) or BMI (≤30kg/m2vs >30kg/m2). Modeling analyses also examined sex or BMI effect on outcomes when comparing MTX mono to the ETN-containing arms (analyses were adjusted for any prior use of a nonbiologic disease-modifying antirheumatic drug; the model for the influence of sex also adjusted for baseline BMI status). Nominal P-values are provided.

Results:

Baseline disease activity was slightly higher in women, especially with MTX+ETN. Descriptive statistics showed men and women had similar results at wk 24 in the MTX mono and ETN mono arms; with MTX+ETN, men had better outcomes for ACR20, MDA, VLDA, and PASDAS. In treatment-interaction analyses, men had more favorable responses at wk 24 with MTX+ETN vs MTX mono for PASDAS, MDA, and LDI (Table).

Baseline disease activity was similar in both BMI categories. Descriptive statistics in each treatment arm showed no consistent differences in results at wk 24 between BMI categories. In treatment-interaction analyses, BMI ≤30kg/m2had a more favorable response at wk 24 with MTX+ETN vs MTX mono for sPGA (Table).

Conclusion:

Results suggest contextual factors may affect response to therapy in PsA. The treatment-interaction analyses suggest disparate responses to MTX+ETN by sex; BMI only affected skin response.

References:

[1]Mease et al.Arthritis Rheumatol. 2019;71:1112-24

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, 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, Joseph F. Merola Consultant of: Merck, AbbVie, Dermavant, Eli Lilly, Novartis, Janssen, UCB Pharma, Celgene, Sanofi, Regeneron, Arena, Sun Pharma, Biogen, Pfizer, EMD Sorono, Avotres and LEO Pharma, Atul Deodhar Grant/research support from: AbbVie, Eli Lilly, GSK, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Alexis Ogdie Grant/research support from: Novartis, Pfizer – grant/research support, Consultant of: AbbVie, BMS, Eli Lilly, Novartis, Pfizer, Takeda – consultant, David Collier Shareholder of: Amgen Inc., Employee of: Amgen Inc., Elaine Karis Shareholder of: Amgen Inc., Employee of: Amgen Inc., Lyrica Liu Shareholder of: Amgen Inc., Employee of: Amgen Inc., Arthur Kavanaugh Grant/research support from: AbbVie, Amgen, Eli Lilly, Novartis, Janssen, Pfizer, Gilead, UCB, Consultant of: AbbVie, Amgen, Eli Lilly, Novartis, Janssen, Pfizer, Gilead, UCB

Decreased Injection Site Pain Associated with Phosphate-Free Etanercept Formulation in Rheumatoid Arthritis or Psoriatic Arthritis Patients: A Randomized Controlled Trial

Introduction

Etanercept, a tumor necrosis factor inhibitor, is used to treat rheumatoid arthritis (RA) and psoriatic arthritis (PsA), and is administered via subcutaneous injection. Injection site pain (ISP) associated with subcutaneous administration may affect compliance or hinder initiation of prescribed medications. To improve the patient experience, a new phosphate-free formulation of etanercept was evaluated for reduced ISP associated with administration.

Methods

This phase 3b, multicenter, randomized, double-blind, cross-over study compared the prior formulation of etanercept to a phosphate-free formulation. Etanercept-naïve adults with RA or PsA indicated for treatment with etanercept were eligible. Patients were randomized (1:1) to receive both etanercept formulations (50 mg) in one of two crossover sequences: prior formulation followed by phosphate-free formulation (sequence AB) or phosphate-free formulation followed by prior formulation (sequence BA) at visits 1 week apart. Patients self-reported ISP using a fit-for-purpose 100-mm visual analog scale within 30 s after injection. Safety outcomes included incidence of treatment-emergent adverse events. Mixed-effects analysis of variance model was used to assess ISP, with treatment, study period, sequence, and disease indication as fixed-effect covariates and patient-within-sequence as random effect.

Results

A total of 111 patients enrolled (56 sequence AB; 55 sequence BA). Mean ISP score for prior formulation was 23.1 mm and for phosphate-free formulation was 19.1 mm (mean difference − 4 mm; 95% confidence interval: − 8.0, 0.0; P = 0.048). Patients with the highest ISP scores from the prior formulation (by quartile cut points) had the largest reduction in pain with phosphate-free formulation. Injection site reactions were few in number and similar between formulations; no new safety signals were observed.

Conclusions

The new phosphate-free formulation of etanercept had statistically significantly lower mean pain scores than the prior formulation, with largest pain reductions observed among patients who reported highest pain with the prior formulation.

Trial Registration

ClinicalTrials.gov: NCT02986139.

Funding

Amgen Inc, Thousand Oaks, CA USA.