AB0379 DOSE-DEPENDENT SUPPRESSION OF T CELL-DEPENDENT ANTIBODY RESPONSE IN HEALTHY VOLUNTEERS BY KPL-404, AN ANTI-CD40 MONOCLONAL ANTIBODY, SUPPORTS CHRONIC DOSING STUDY IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

An unmet need remains in patients with failure and/or inadequate response (IR) to biological disease-modifying antirheumatic drugs (bDMARD-IR) and/or Janus kinase inhibitors (JAKi-IR). The CD40/CD40L (CD154) costimulatory pathway is linked to inflammation and joint destruction in RA via production of autoantibodies and inflammatory mediators. KPL-404 is a humanized IgG4 antibody engineered to bind CD40 without triggering Fc effector functions (Muralidharan, 2019), which are known to have been associated with thromboembolic events seen in the first generation of CD40L-targeting therapies.

In a first-in-human Phase 1 single ascending dose study, 52 healthy volunteers received single doses of KPL-404 administered either subcutaneously (SC) or intravenously (IV) with no dose-limiting safety findings, infectious episodes, or toxicities (Samant, 2021). The study demonstrated that with 10 mg/kg IV, full receptor occupancy (RO) was observed through day 71, and there was complete suppression of T-cell dependent antibody response (TDAR) to keyhole limpet hemocyanin challenge on day 1 and re-challenge on day 29 through day 57. With 5 mg/kg SC, full RO was observed through day 43, and there was complete suppression of TDAR through at least day 29. Complete suppression of ADA to KPL-404, an independent indicator of target engagement, was also observed while KPL-404 serum concentrations were above approximately 0.1 to 0.2 µg/mL and continued for at least 50 days and 57 days after 5 mg/kg SC and 10 mg/kg IV administration, respectively.

Objectives

Using Phase 1 and nonclinical data, identify chronic dosing regimens anticipated to yield PK in the sub-therapeutic, therapeutic, and supra-therapeutic ranges to be utilized in a Multiple Ascending Dose Phase 2 Study.

Methods

A PK model was used to simulate multiple dosing scenarios, including: 2.5, 5, and 10 mg/kg SC qwk, q2wk, and q4wk, as well as 10 mg/kg IV q4wk. The model was used to identify optimal Phase 2 dosing schedules by generating 1000 virtual subjects using the typical parameter estimates with between-subject variability included.

Results

Following SC administration, all subjects were predicted to achieve complete ADA suppression for the full dosing interval at/above 2.5 mg/kg SC q2wk. At 2 mg/kg SC q2wk (starting dose level), simulated steady-state 8-week data predicted PK in a sub-therapeutic range for most subjects and an approximately 31- and 18-fold safety margin relative to preclinical NOAEL dose. At 5 mg/kg SC q2wk, 100% of patients were predicted to be in a therapeutic range, indicating a potential practical efficacious dose level. At 10 mg/kg SC q2wk, 100% of patients were predicted to be in the supratherapeutic range.

These results support a Multiple Ascending Dose (MAD) Phase 2 study design, with PK lead-in comprised of 3 Cohorts at 2, 5, or 10 mg/kg SC q2wk (each randomized 6:2) and Proof-of-Concept phase (Cohort 4) comprised of 48-60 subjects randomized 1:1:1 to 10 mg/kg, 5 mg/kg, and placebo SC q2wk. The ongoing study will evaluate efficacy (Disease Activity of 28 joints using C-reactive protein [DAS28-CRP]), safety, PK, and pharmacodynamics (PD) of escalating doses levels of KPL-404 compared with placebo in patients with moderate to severe RA (bDMARD-IR or JAKi-IR). The study also allows the flexibility of optional cohorts including additional dosing regimens and/or subpopulations identified based on clinical response and biomarkers.

Conclusion

Inhibition of the CD40-CD154 co-stimulatory interaction holds promise for the management of a spectrum of autoimmune diseases. KPL-404 demonstrated prolonged absorption/excretion capable of suppressing TDAR for extended periods allowing for use of extended dosing intervals irrespective of IV or SC dosing. These analyses supported the design of the ongoing Phase 2 study assessing the efficacy and safety KPL-404 in RA.

References

[1]Muralidharan S et al. 2019. Poster at Keystone Symposia

[2]Samant M et al. Arthritis Rheumatol. 2021; 73(suppl 10)

Disclosure of Interests

Anastassia Papandrikopoulou Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., Gerd Rüdiger Burmester Speakers bureau: Abbvie, Amgen, BMS, Lilly, MSD, Pfizer, Roche, Sanofi, Consultant of: Abbvie, Amgen, BMS, Kiniksa, Lilly, MSD, Pfizer, Roche, Sanofi, Fang Fang Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., Alan Kivitz Shareholder of: Amgen, Gilead Sciences, Inc., GlaxoSmithKline, Novartis, Pfizer, Sanofi,, Speakers bureau: AbbVie, Celgene, Flexion, Genzyme, GlaxoSmithKline, Lilly, Merck, Novartis, Pfizer, Sanofi, UCB, Horizon, Consultant of: AbbVie, Boehringer Ingelheim, Flexion, Gilead Sciences, Inc., Janssen, Pfizer, Sanofi, SUN Pharma Advanced Research, Moses Njenga Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., Arian Pano Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., Costantino Pitzalis Speakers bureau: Abbott/AbbVie, Astra-

Zeneca/MedImmune, BMS, Janssen/J&J, MSD, Pfizer, Roche/Genentech/Chugai, UCB.,, Consultant of: Abbott/AbbVie, Astellas, Astra-Zeneca/MedImmune, BMS, CelGene, Grunenthal, GSK,

Janssen/J&J, Kiniksa, MSD, Pfizer, Sanofi, Roche / Genentech / Chugai, UCB., Grant/research support from: Abbott/AbbVie, Astellas, Astra-Zeneca/MedImmune, BMS, Janssen/J&J, MSD, Pfizer, Roche/Genentech/Chugai, UCB., Manoj Samant Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., Steve Schmitz Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., Madeline Spiers Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., Eben Tessari Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., John Ziemniak Consultant of: Kiniksa Pharmaceuticals, Ltd., John F. Paolini Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp.

Clinical efficacy of trauma-focused psychotherapies in treatment-resistant depression (TRD) in-patients: A randomized, controlled pilot-study

In major depressive disorder (MDD) patients, life stress events represent a risk factor for a severe, early-onset, treatment-resistant and chronic endophenotype. Treatment-resistant depression (TRD) patients who have experienced traumatic events could benefit from evidence-based trauma-focused psychotherapies. Because this topic has never been investigated, the aim of this pilot trial was to evaluate whether trauma-focused cognitive-behavioural therapy (TF-CBT) and/or eye movement desensitization and reprocessing (EMDR) can help achieve depressive symptom remission in TRD patients. We carried out a single-blind randomized controlled trial with TRD patients and we compared EMDR (N = 12) with TF-CBT (N = 10). Patients received 3 individual sessions per week over a period of 8 weeks. The symptomatological assessments were performed at 4 timepoints: baseline (T0), 4 (T4), 8 (T8) and 12 (T12) weeks. After 24 weeks, a clinical interview was carried out by phone. All TRD patients showed a significant improvement in depressive symptomatology; however, post hoc comparisons showed a significant difference between the two treatment groups, with lower depressive symptom scores in the EMDR than in the TF-CBT group at the follow-up (T12). This effect was partly maintained at 24 weeks. This pilot study suggests that evidence-based trauma-focused psychotherapies, particularly EMDR, can represent effective interventions to treat TRD patients.

MTHFR: Genetic variants, expression analysis and COMT interaction in major depressive disorder

BACKGROUND

Methylenetetrahydrofolate reductase (MTHFR) genetic variations have been widely studied in major depressive disorder (MDD) and antidepressants outcome. An interaction with catechol-O-methyltransferase (COMT) has also been proved affecting depression. The aim of this study was to clarify the role of the most commonly studied single nucleotide polymorphisms (SNPs) of MTHFR gene in MDD and in treatment response mechanisms, along with the impact of the interaction with COMT.

METHODS

A total of 613 MDD patients, of whom 389 were classified as having treatment resistant depression (TRD), and 463 controls were enrolled. The A1298C, C677T and COMT Val158Met were genotyped. Genetic data were integrated with a transcriptional level analysis in peripheral blood cells (PBCs) and fibroblasts.

RESULTS

The A1298C CC homozygotes were more frequent in MDD patients compared to controls in women, increasing twice the genetic risk to develop depression. Moreover this genotype resulted in epistasis with COMT Met carriers in association with MDD. No significant effects were obtained concerning response to treatment. Transcriptional analyses highlighted a strong correlation between the mRNA levels of MTHFR in fibroblasts and COMT genotypes whereas no significant association with MDD was found. PBCs results revealed relevant influences of environmental factors.

LIMITATION

We did not measure folate and homocisteine levels.

CONCLUSION

This study showed the involvement of A1298C, Val158Met and their interaction in MDD. The transcriptional analyses supported the participation of COMT in the folate pathway, which partakes in the complex network of gene×gene and gene×environment interactions of MDD etiopathogenesis.

PCLO gene: its role in vulnerability to major depressive disorder

BACKGROUND

A recent genome-wide association study on Major Depressive Disorder (MDD) identified a specific association with a non-synonymous polymorphism (rs2522833) of a gene encoding the presynaptic protein piccolo (PCLO). A high percentage of patients who develop MDD have particular temperamental traits, such as passivity, pessimism, indecisiveness, and low self-esteem, which are related to the subsequent development of depression. The aims of this study were to perform a replicate case-control study and to conduct the first association study between the rs2522833 polymorphism and depression-related personality traits using the Temperament and Character Inventory (TCI) in a healthy subject sample.

METHODS

A total of 522 MDD patients and 375 healthy volunteers were enrolled in the study. Two hundred and forty-six controls agreed to fill out the TCI.

RESULTS

The results showed that rs2522833 CC homozygotes were more frequent among the depressed patients than in the controls (p<0.01). The C allele distribution showed a trend in the same direction (p=0.08). Among controls, we found that the C allele carriers were associated with personality traits increasing vulnerability to depression, including higher Harm Avoidance (HA) and lower in Novelty Seeking (NS). In particular, C allele carriers were more fearful (HA2) and fatigable (HA4), and less impulsive/more deliberate (NS2) and less extravagant/more frugal (NS3).

LIMITATIONS

The absence of possible epistatic interaction effect.

CONCLUSIONS

These results provide further support for the involvement of the PCLO gene in MDD and show that this effect may be mediated by influencing personality traits that increase the risk of major depression.

[Adjuvant chemotherapy after radical liver resection in the treatment of metastases from colorectal carcinoma]

Liver metastases are the leading cause of death in patients with colorectal carcinoma: approximately 25% present with metastases at diagnosis of the primary tumor and 30-50% will eventually develop metastases. Surgical therapy for metastases is the only curative treatment that will ensure five-year survival in 30-60% of patients; however, in 30-50% of these patients liver disease will recur. To improve these rates, various different studies have investigated the efficacy of postsurgical adjuvant therapy. The majority of randomized studies evaluated the efficacy of intra-arterial infusion associated or not with postsurgical systemic adjuvant treatment: this approach demonstrated benefit in terms of control of recurrent of liver disease but not in terms of overall survival. A reduction in the recurrence of liver disease was found in the two randomized studies published to date on the efficacy of systemic adjuvant therapy, and an improvement in survival in one trial. Given these data and the results obtained with the use of last generation chemotherapeutic agents (oxaliplatin and irinotecan) in the treatment of unresectable liver metastases from colorectal carcinoma, it can be conjectured that ongoing randomized clinical trials may confirm a significant advantage of adjuvant chemotherapy in the control of recurrence of liver disease and overall survival.

Efficacy of the alcohol use disorders identification test as a screening tool for hazardous alcohol intake and related disorders in primary care: a validity study

OBJECTIVE

To determine the properties of the alcohol use disorders identification test in screening primary care attenders for alcohol problems.

DESIGN

A validity study among consecutive primary care attenders aged 18-65 years. Every third subject completed the alcohol use disorders identification test (a 10 item self report questionnaire on alcohol intake and related problems) and was interviewed by an investigator with the composite international diagnostic interview alcohol use module (a standardised interview for the independent assessment of alcohol intake and related disorders).

SETTING

10 primary care clinics in Verona, north eastern Italy.

PATIENTS

500 subjects were approached and 482 (96.4%) completed evaluation.

RESULTS

When the alcohol use disorders identification test was used to detect subjects with alcohol problems the area under the receiver operating characteristic curve was 0.95. The cut off score of 5 was associated with a sensitivity of 0.84, a specificity of 0.90, and a positive predictive value of 0.60. The screening ability of the total score derived from summing the responses to the five items minimising the probability of misclassification between subjects with and without alcohol problems provided an area under the receiver operating characteristic curve of 0.93. A score of 5 or more on the five items was associated with a sensitivity of 0.79, a specificity of 0.95, and a positive predictive value of 0.73.

CONCLUSIONS

The alcohol use disorders identification test performs well in detecting subjects with formal alcohol disorders and those with hazardous alcohol intake. Using five of the 10 items on the questionnaire gives reasonable accuracy, and these are recommended as questions of choice to screen patients for alcohol problems.