POS0712 YEAR-4 OBSERVATIONAL FOLLOW-UP OF BELIMUMAB SAFETY (MORTALITY AND MALIGNANCIES) IN PATIENTS WITH SLE WHO COMPLETED A PHASE 4, 52-WEEK, RANDOMISED, DOUBLE-BLIND PLACEBO-CONTROLLED SAFETY STUDY

Background

Belimumab (BEL) is an approved systemic lupus erythematosus (SLE) treatment. Despite BEL clinical studies demonstrating a favourable benefit–risk profile, varying incidence rates of mortality and adverse events of special interest, including malignancies, require further evaluation.

Objectives

To assess long-term safety following BEL therapy.

Methods

This was a Year (Yr)-4 post-treatment follow-up of the Phase 4, double-blind, placebo (PBO)-controlled Belimumab Assessment of Safety in SLE (BASE) study (GSK Study BEL115467; NCT01705977).1 Overall, 4003 adults with active, autoantibody-positive SLE received BEL (10 mg/kg IV) or PBO, plus standard therapy (ST), for 48 weeks. Patients (pts) then entered a Yr 2–5 follow-up period in which they received physician-directed ST. All pts were contacted annually by telephone, including pts who discontinued treatment. Mortality and new malignancies (including nonmelanoma skin cancer) were the endpoints collected, and rates summarised. We present Yr-4 follow-up data by Yr-1 treatment received.

Results

Baseline characteristics for the Yr-4 follow-up population (N=3204) were similar to the Yr-1 double-blind study population (N=4003). By the Yr-4 follow-up, cumulatively 12.7% and 11.0% of pts in the BEL and PBO Yr-1 groups had received BEL as part of physician-directed care, respectively (data not shown). As shown in the Table 1, cumulative follow-up adjusted mortality rates were lower in the BEL vs PBO Yr-1 treatment group for Yrs 2 to 4. Cumulative follow-up adjusted new primary malignancy rates were lower in the BEL vs PBO Yr-1 treatment group for Yrs 2 and 3, but similar in Yr 4.

Table 1.

Yr 1 plus Yrs 2–4 post-treatment* follow-up mortality and new primary malignancy rates by Yr-1 study treatment

Pts with events per yr, n (%)Pt incidence rate per 100 pt-yrs(Cumulative rate, %)BELPBOTotalBELPBOTotalYr-1 (as-treated) populationN=2002N=2001N=4003Deaths13 (0.65)22 (1.10)35 (0.87)0.66 (0.65)1.11 (1.10)0.87New primary malignancies†9 (0.45)10 (0.50)19 (0.47)0.450.500.47Yr-2 (as-treated in Yr-1) populationN=1695N=1670N=3365Deaths9 (0.53)21 (1.26)30 (0.89)0.60 (1.10)1.18 (2.15)0.89 (1.62)New primary malignancies3 (0.18)7 (0.42)10 (0.30)0.34 (0.60)0.48 (0.85)0.41 (0.72)Yr-3 (as-treated in Yr-1) populationN=1659N=1630N=3289Deaths9 (0.54)17 (1.04)26 (0.79)0.58 (1.55)1.14 (3.00)0.86 (2.27)New primary malignancies, n (%)7 (0.42)9 (0.55)16 (0.49)0.37 (0.95)0.49 (1.25)0.43 (1.10)Yr-4 (as-treated in Yr-1) populationN=1622N=1582N=3204Deaths by MedDRA SOC14 (0.86)13 (0.82)27 (0.84)0.65 (2.25)1.07 (3.65)0.86 (2.95)Infections/infestations4 (0.25)5 (0.32)9 (0.28)Cardiac disorders2 (0.12)1 (0.06)3 (0.09)General disorders/ administration site conditions2 (0.12)2 (0.13)4 (0.12)Respiratory/thoracic/ mediastinal disorders2 (0.12)1 (0.06)3 (0.09)Nervous system disorders2 (0.12)1 (0.06)3 (0.09)Other‡2 (0.12)3 (0.18)5 (0.15)New primary malignancies10 (0.62)5 (0.32)15 (0.47)0.43 (1.45)0.44 (1.45)0.43 (1.45)

*Pts in the post-treatment follow-up period are no longer receiving study treatment. †Includes nonmelanoma skin cancer.

‡Contains 1 event for 5 distinct pts of each of renal/urinary disorders, and neoplasms (BEL); musculoskeletal/connective tissue disorders, injury/poisoning/procedural complications, and vascular disorders (PBO).

MedDRA, Medical Dictionary for Regulatory Activities; SOC, system organ class

Conclusion

Post-treatment Yr-4 follow-up results in BASE, the largest double-blind trial in pts with SLE to date, support the safety of BEL therapy, with no new BEL safety concerns identified in this analysis.

References

[1]Sheikh SZ, et al. Lancet Rheumatol 2020;3:e122–30

Acknowledgements

This analysis was funded by GlaxoSmithKline (GSK). Medical writing support was provided by Lulu Hill, MPharmacol, Fishawack Indicia Ltd. UK, part of Fishawack Health, and was funded by GSK.

Disclosure of Interests

Saira Sheikh Consultant of: GSK, Grant/research support from: Pfizer, Morton Scheinberg Consultant of: GSK, Pfizer, Alnylam, AbbVie, PTC Therapeutics, James Cheng-Chung Wei Consultant of: TSH Biopharm, AbbVie, BMS, Celgene, Chugai, Eisai, Janssen, Novartis, Pfizer, Sanofi-Aventis, and UCB Pharma, Grant/research support from: AbbVie, Amgen, Astellas, BMS, Celgene, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, Sun and UCB Pharma, Dana Tegzová: None declared, William Stohl Consultant of: GSK, Grant/research support from: GSK, Pfizer, Gilead, RICARDO ACAYABA DE TOLEDO Speakers bureau: AbbVie, Janssen, UCB, Novartis, Celltrion, Consultant of: AbbVie, Janssen, Novartis, UCB, Grant/research support from: Pfizer, AbbVie, Novartis, GSK, Tamara Mucenic Speakers bureau: Novartis, Janssen, BMS, AbbVie, Pfizer, Roche, Grant/research support from: GSK, Janssen, Roche, Eli Lilly, Gilead, UCB, Mauricio R Abello Banfi: None declared, Kathleen Maksimowicz-McKinnon Grant/research support from: Chemocentryx, Carlos Abud-Mendoza Speakers bureau: GSK, Lilly, Pfizer, Sandra Navarra Speakers bureau: Pfizer, Novartis, Johnson & Johnson, Consultant of: Biogen, Boehringer Ingelheim, Grant/research support from: Astellas, Mercedes García Speakers bureau: GSK, Janssen, Pfizer, Ignacio Garcia-De La Torre: None declared, Andrew Liu Shareholder of: GSK, Employee of: GSK, Abhishek Roy Employee of: GSK, Paul Wilde Shareholder of: GSK, Employee of: GSK, Sofia Fernandes Shareholder of: GSK, Employee of: GSK, Julia Harris Shareholder of: GSK, Employee of: GSK, David Roth Shareholder of: GSK, Employee of: GSK

Oxidized low-density lipoprotein and β2-glycoprotein I in patients with systemic lupus erythematosus and increased carotid intima-media thickness: implications in autoimmune-mediated atherosclerosis

Oxidative stress and LDL modification (oxLDL) are early pro-atherogenic events. OxLDL binds β2GPI producing immunogenic oxLDL/β2GPI complexes. Antibodies to these complexes have been associated with arterial thrombosis in patients with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS). Circulating oxLDL/β2GPI complexes, IgG and IgM antibodies to these complexes were measured by ELISA in 30 SLE patients asymptomatic for cardiovascular disease (mean age 31 years) and 27 age/sex matched healthy controls. Carotid intima-media thickness (IMT) was measured by ultrasound in all patients and controls. Forty-seven percent of SLE presented plaques (median IMT of 0.65 ± 0.12 mm) while only 7% of the controls had plaques (median IMT of 0.50 ± 0.04 mm, P < 0.001). Median optical density (OD450nm) for oxLDL/β2GPI complexes in SLE was 0.244 ± 0.07, higher than controls (0.174 ± 0.09, P < 0.001). Median OD for IgG anti-oxLDL/β2GPI antibodies was also higher in SLE (0.297 ± 0.26) compared to controls (0.194 ± 0.07, P < 0.001) while the median OD for IgM antibodies in SLE (0.444 ± 0.46) was not different than controls (0.326 ± 0.22, P = 0.267). There was no correlation between IMT and oxLDL/β2GPI complexes, IgG or IgM antibodies, possibly reflecting the complex interrelationship between these serologic elements and tissue factors in the arterial wall. These results support the hypothesis that oxLDL/β2GPI complexes and IgG (not IgM) anti-oxLDL/β2GPI antibodies contribute to the development of autoimmune-mediated atherosclerosis

Report on the second International Consensus on ANA Pattern (ICAP) workshop in Dresden 2015

The second meeting for the International Consensus on Antinuclear antibody (ANA) Pattern (ICAP) was held on 22 September 2015, one day prior to the opening of the 12th Dresden Symposium on Autoantibodies in Dresden, Germany. The ultimate goal of ICAP is to promote harmonization and understanding of autoantibody nomenclature, and thereby optimizing ANA usage in patient care. The newly developed ICAP website www.ANApatterns.org was introduced to the more than 50 participants. This was followed by several presentations and discussions focusing on key issues including the two-tier classification of ANA patterns into competent-level versus expert-level, the consideration of how to report composite versus mixed ANA patterns, and the necessity for developing a consensus on how ANA results should be reported. The need to establish on-line training modules to help users gain competency in identifying ANA patterns was discussed as a future addition to the website. To advance the ICAP goal of promoting wider international participation, it was agreed that there should be a consolidated plan to translate consensus documents into other languages by recruiting help from members of the respective communities.

International recommendations for the assessment of autoantibodies to cellular antigens referred to as anti-nuclear antibodies

Anti-nuclear antibodies (ANA) are fundamental for the diagnosis of autoimmune diseases, and have been determined by indirect immunofluorescence assay (IIFA) for decades. As the demand for ANA testing increased, alternative techniques were developed challenging the classic IIFA. These alternative platforms differ in their antigen profiles, sensitivity and specificity, raising uncertainties regarding standardisation and interpretation of incongruent results. Therefore, an international group of experts has created recommendations for ANA testing by different methods. Two groups of experts participated in this initiative. The European autoimmunity standardization initiative representing 15 European countries and the International Union of Immunologic Societies/World Health Organization/Arthritis Foundation/Centers for Disease Control and Prevention autoantibody standardising committee. A three-step process followed by a Delphi exercise with closed voting was applied. Twenty-five recommendations for determining ANA (1-13), anti-double stranded DNA antibodies (14-18), specific antibodies (19-23) and validation of methods (24-25) were created. Significant differences between experts were observed regarding recommendations 24-25 (p<0.03). Here, we formulated recommendations for the assessment and interpretation of ANA and associated antibodies. Notably, the roles of IIFA as a reference method, and the importance of defining nuclear and cytoplasmic staining, were emphasised, while the need to incorporate alternative automated methods was acknowledged. Various approaches to overcome discrepancies between methods were suggested of which an improved bench-to-bedside communication is of the utmost importance. These recommendations are based on current knowledge and can enable harmonisation of local algorithms for testing and evaluation of ANA and related autoantibodies. Last but not least, new more appropriate terminologies have been suggested.

Factitious disorders mimicking systemic lupus erythematosus

Factitious disorders are one of the most difficult challenges to the sagacity of the physician. Self-inflicted injuries and diseases have been recognized since Biblical times. In the Middle Ages, hysterics were known to place leeches in their mouths to simulate hemoptysis and to abrade their skin to reproduce skin conditions. Münchausen syndrome, originally described in 1951, is the term applied to persons who seek medical care by feigning illness in the absence of any organic medical or surgical disease. Since the first report of the syndrome, many case reports have documented the performance of unneeded operations and the administration of dangerous drugs to these patients. Rheumatologic manifestations in this syndrome are rare, and include septic arthritis, osteomyelitis, destructive arthropathy, reflex sympathetic dystrophy and systemic lupus erythematosus (SLE). We reviewed the English literature for the past 29 years and found only 8 patients with Münchausen syndrome who simulated SLE. It is interesting to consider the damage mechanisms (some of the patients satisfied 4 or more of the criteria for the classification of SLE) and how a complex disease with a broad spectrum of manifestations such as lupus can be simulated, the only limits being the patient's knowledge and imagination.

Diffuse alveolar hemorrhage in limited cutaneous systemic sclerosis with positive perinuclear antineutrophil cytoplasmic antibodies

A 54-year-old woman with limited cutaneous systemic sclerosis (SSc) developed repeated diffuse alveolar hemorrhage with positive perinuclear antineutrophil cytoplasmic antibodies (pANCA). Reports of diffuse alveolar hemorrhage in SSc have been rarely described only in the diffuse clinical variant. To our knowledge, this is the first report of pANCA positive diffuse alveolar hemorrhage in the limited form of SSc. Diffuse alveolar hemorrhage is a rare, but potentially life threatening cause of respiratory distress in the limited form of SSc that should be recognized and treated effectively.

Autoimmune phenomena in leprosy, particularly antinuclear antibodies and rheumatoid factor

Recent reports have emphasized the importance of the rheumatic manifestations in leprosy, especially the lepromatous form. Lepromatous leprosy has been associated with the production of autoantibodies of various types. The incidence and potential pathogenetic significance of autoantibodies, especially rheumatoid factor and antinuclear antibodies in patients with leprosy is reviewed.

Prevalence of antinuclear antibodies in patients with habitual abortion and in normal and toxemic pregnancies

The prevalence of antinuclear antibodies (ANA) was investigated in the sera from patients with habitual abortion (HA) and in normal (NP) and toxemic pregnancies (TP). ANAs were more prevalent in patients with HA (30%) as compared with TP (15%) and the control group (6.6%). Only one patient, from the HA group, fulfilled four criteria for systemic lupus erythematosus (SLE). Most other patients with positive ANAs had some of the criteria for SLE, but none of the ANA negative patients had any of them. These studies suggest that there is a high prevalence of ANA in our group of women with HA and their identification may help to identify those patients who may eventually develop SLE which has been reported to be preceded in many women by repeated spontaneous abortions. In addition, immunological factors, at least in some cases, could play a role in the pathogenesis of HA.