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Dougados M, Charles-Schoeman C, Szekanecz Z, Giles JT, Ytterberg SR, Bhatt DL, Koch GG, Vranic I, Wu J, Wang C, Kwok K, Menon S, Connell CA, Yndestad A, Rivas JL, Buch MH. Impact of cardiovascular risk enrichment on incidence of major adverse cardiovascular events in the tofacitinib rheumatoid arthritis clinical programme. Ann Rheum Dis 2023; 82:575-577. [PMID: 36720582 PMCID: PMC10086292 DOI: 10.1136/ard-2022-223406] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/06/2022] [Indexed: 02/02/2023]
Affiliation(s)
- Maxime Dougados
- Department of Rheumatology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
- INSERM (U1153): Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris, France
| | - Christina Charles-Schoeman
- Division of Rheumatology, Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Zoltán Szekanecz
- Division of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Jon T Giles
- Division of Rheumatology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | | | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA
| | - Gary G Koch
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Joseph Wu
- Pfizer Inc, Groton, Connecticut, USA
| | | | | | | | | | | | | | - Maya H Buch
- Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Charles-Schoeman C, Buch MH, Dougados M, Bhatt DL, Giles JT, Ytterberg SR, Koch GG, Vranic I, Wu J, Wang C, Kwok K, Menon S, Rivas JL, Yndestad A, Connell CA, Szekanecz Z. Risk of major adverse cardiovascular events with tofacitinib versus tumour necrosis factor inhibitors in patients with rheumatoid arthritis with or without a history of atherosclerotic cardiovascular disease: a post hoc analysis from ORAL Surveillance. Ann Rheum Dis 2023; 82:119-129. [PMID: 36137735 PMCID: PMC9811099 DOI: 10.1136/ard-2022-222259] [Citation(s) in RCA: 56] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 08/11/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Evaluate risk of major adverse cardiovascular events (MACE) with tofacitinib versus tumour necrosis factor inhibitors (TNFi) in patients with rheumatoid arthritis (RA) with or without a history of atherosclerotic cardiovascular disease (ASCVD) in ORAL Surveillance. METHODS Patients with RA aged ≥50 years with ≥1 additional CV risk factor received tofacitinib 5 mg or 10 mg two times per day or TNFi. Hazard rations (HRs) were evaluated for the overall population and by history of ASCVD (exploratory analysis). RESULTS Risk of MACE, myocardial infarction and sudden cardiac death were increased with tofacitinib versus TNFi in ORAL Surveillance. In patients with history of ASCVD (14.7%; 640/4362), MACE incidence was higher with tofacitinib 5 mg two times per day (8.3%; 17/204) and 10 mg two times per day (7.7%; 17/222) versus TNFi (4.2%; 9/214). HR (combined tofacitinib doses vs TNFi) was 1.98 (95% confidence interval (CI) 0.95 to 4.14; interaction p values: 0.196 (for HR)/0.059 (for incidence rate difference)). In patients without history of ASCVD, MACE HRs for tofacitinib 5 mg two times per day (2.4%; 30/1251) and 10 mg two times per day (2.8%; 34/1234) versus TNFi (2.3%; 28/1237) were, respectively, 1.03 (0.62 to 1.73) and 1.25 (0.76 to 2.07). CONCLUSIONS This post hoc analysis observed higher MACE risk with tofacitinib versus TNFi in patients with RA and history of ASCVD. Among patients without history of ASCVD, all with prevalent CV risk factors, MACE risk did not appear different with tofacitinib 5 mg two times per day versus TNFi. Due to the exploratory nature of this analysis and low statistical power, we cannot exclude differential MACE risk for tofacitinib 5 mg two times per day versus TNFi among patients without history of ASCVD, but any absolute risk excess is likely low. TRIAL REGISTRATION NUMBER NCT02092467.
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Affiliation(s)
- Christina Charles-Schoeman
- Division of Rheumatology, Department of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Maya H Buch
- Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK,NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Maxime Dougados
- Université de Paris; Department of Rheumatology, Hôpital Cochin; Assistance Publique-Hôpitaux de Paris, Paris, France,INSERM (U1153): Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris, France
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jon T Giles
- Division of Rheumatology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | | | - Gary G Koch
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Joseph Wu
- Pfizer Inc, Groton, Connecticut, USA
| | | | | | | | | | | | | | - Zoltan Szekanecz
- Division of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Ytterberg SR, Bhatt DL, Mikuls TR, Koch GG, Fleischmann R, Rivas JL, Germino R, Menon S, Sun Y, Wang C, Shapiro AB, Kanik KS, Connell CA. Cardiovascular and Cancer Risk with Tofacitinib in Rheumatoid Arthritis. N Engl J Med 2022; 386:316-326. [PMID: 35081280 DOI: 10.1056/nejmoa2109927] [Citation(s) in RCA: 549] [Impact Index Per Article: 274.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Increases in lipid levels and cancers with tofacitinib prompted a trial of major adverse cardiovascular events (MACE) and cancers in patients with rheumatoid arthritis receiving tofacitinib as compared with a tumor necrosis factor (TNF) inhibitor. METHODS We conducted a randomized, open-label, noninferiority, postauthorization, safety end-point trial involving patients with active rheumatoid arthritis despite methotrexate treatment who were 50 years of age or older and had at least one additional cardiovascular risk factor. Patients were randomly assigned in a 1:1:1 ratio to receive tofacitinib at a dose of 5 mg or 10 mg twice daily or a TNF inhibitor. The coprimary end points were adjudicated MACE and cancers, excluding nonmelanoma skin cancer. The noninferiority of tofacitinib would be shown if the upper boundary of the two-sided 95% confidence interval for the hazard ratio was less than 1.8 for the combined tofacitinib doses as compared with a TNF inhibitor. RESULTS A total of 1455 patients received tofacitinib at a dose of 5 mg twice daily, 1456 received tofacitinib at a dose of 10 mg twice daily, and 1451 received a TNF inhibitor. During a median follow-up of 4.0 years, the incidences of MACE and cancer were higher with the combined tofacitinib doses (3.4% [98 patients] and 4.2% [122 patients], respectively) than with a TNF inhibitor (2.5% [37 patients] and 2.9% [42 patients]). The hazard ratios were 1.33 (95% confidence interval [CI], 0.91 to 1.94) for MACE and 1.48 (95% CI, 1.04 to 2.09) for cancers; the noninferiority of tofacitinib was not shown. The incidences of adjudicated opportunistic infections (including herpes zoster and tuberculosis), all herpes zoster (nonserious and serious), and adjudicated nonmelanoma skin cancer were higher with tofacitinib than with a TNF inhibitor. Efficacy was similar in all three groups, with improvements from month 2 that were sustained through trial completion. CONCLUSIONS In this trial comparing the combined tofacitinib doses with a TNF inhibitor in a cardiovascular risk-enriched population, risks of MACE and cancers were higher with tofacitinib and did not meet noninferiority criteria. Several adverse events were more common with tofacitinib. (Funded by Pfizer; ORAL Surveillance ClinicalTrials.gov number, NCT02092467.).
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Affiliation(s)
- Steven R Ytterberg
- From the Division of Rheumatology, Mayo Clinic, Rochester, MN (S.R.Y.); the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (D.L.B.); the Division of Rheumatology, University of Nebraska Medical Center, Omaha (T.R.M.); the Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill (G.G.K.); Metroplex Clinical Research Center and University of Texas Southwestern Medical Center, Dallas (R.F.); Pfizer, Madrid (J.L.R.); Pfizer, New York (R.G.); Pfizer, Groton, CT (S.M., C.W., K.S.K., C.A.C.); Pfizer, Shanghai, China (Y.S.); and Pfizer, Peapack, NJ (A.B.S.)
| | - Deepak L Bhatt
- From the Division of Rheumatology, Mayo Clinic, Rochester, MN (S.R.Y.); the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (D.L.B.); the Division of Rheumatology, University of Nebraska Medical Center, Omaha (T.R.M.); the Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill (G.G.K.); Metroplex Clinical Research Center and University of Texas Southwestern Medical Center, Dallas (R.F.); Pfizer, Madrid (J.L.R.); Pfizer, New York (R.G.); Pfizer, Groton, CT (S.M., C.W., K.S.K., C.A.C.); Pfizer, Shanghai, China (Y.S.); and Pfizer, Peapack, NJ (A.B.S.)
| | - Ted R Mikuls
- From the Division of Rheumatology, Mayo Clinic, Rochester, MN (S.R.Y.); the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (D.L.B.); the Division of Rheumatology, University of Nebraska Medical Center, Omaha (T.R.M.); the Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill (G.G.K.); Metroplex Clinical Research Center and University of Texas Southwestern Medical Center, Dallas (R.F.); Pfizer, Madrid (J.L.R.); Pfizer, New York (R.G.); Pfizer, Groton, CT (S.M., C.W., K.S.K., C.A.C.); Pfizer, Shanghai, China (Y.S.); and Pfizer, Peapack, NJ (A.B.S.)
| | - Gary G Koch
- From the Division of Rheumatology, Mayo Clinic, Rochester, MN (S.R.Y.); the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (D.L.B.); the Division of Rheumatology, University of Nebraska Medical Center, Omaha (T.R.M.); the Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill (G.G.K.); Metroplex Clinical Research Center and University of Texas Southwestern Medical Center, Dallas (R.F.); Pfizer, Madrid (J.L.R.); Pfizer, New York (R.G.); Pfizer, Groton, CT (S.M., C.W., K.S.K., C.A.C.); Pfizer, Shanghai, China (Y.S.); and Pfizer, Peapack, NJ (A.B.S.)
| | - Roy Fleischmann
- From the Division of Rheumatology, Mayo Clinic, Rochester, MN (S.R.Y.); the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (D.L.B.); the Division of Rheumatology, University of Nebraska Medical Center, Omaha (T.R.M.); the Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill (G.G.K.); Metroplex Clinical Research Center and University of Texas Southwestern Medical Center, Dallas (R.F.); Pfizer, Madrid (J.L.R.); Pfizer, New York (R.G.); Pfizer, Groton, CT (S.M., C.W., K.S.K., C.A.C.); Pfizer, Shanghai, China (Y.S.); and Pfizer, Peapack, NJ (A.B.S.)
| | - Jose L Rivas
- From the Division of Rheumatology, Mayo Clinic, Rochester, MN (S.R.Y.); the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (D.L.B.); the Division of Rheumatology, University of Nebraska Medical Center, Omaha (T.R.M.); the Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill (G.G.K.); Metroplex Clinical Research Center and University of Texas Southwestern Medical Center, Dallas (R.F.); Pfizer, Madrid (J.L.R.); Pfizer, New York (R.G.); Pfizer, Groton, CT (S.M., C.W., K.S.K., C.A.C.); Pfizer, Shanghai, China (Y.S.); and Pfizer, Peapack, NJ (A.B.S.)
| | - Rebecca Germino
- From the Division of Rheumatology, Mayo Clinic, Rochester, MN (S.R.Y.); the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (D.L.B.); the Division of Rheumatology, University of Nebraska Medical Center, Omaha (T.R.M.); the Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill (G.G.K.); Metroplex Clinical Research Center and University of Texas Southwestern Medical Center, Dallas (R.F.); Pfizer, Madrid (J.L.R.); Pfizer, New York (R.G.); Pfizer, Groton, CT (S.M., C.W., K.S.K., C.A.C.); Pfizer, Shanghai, China (Y.S.); and Pfizer, Peapack, NJ (A.B.S.)
| | - Sujatha Menon
- From the Division of Rheumatology, Mayo Clinic, Rochester, MN (S.R.Y.); the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (D.L.B.); the Division of Rheumatology, University of Nebraska Medical Center, Omaha (T.R.M.); the Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill (G.G.K.); Metroplex Clinical Research Center and University of Texas Southwestern Medical Center, Dallas (R.F.); Pfizer, Madrid (J.L.R.); Pfizer, New York (R.G.); Pfizer, Groton, CT (S.M., C.W., K.S.K., C.A.C.); Pfizer, Shanghai, China (Y.S.); and Pfizer, Peapack, NJ (A.B.S.)
| | - Yanhui Sun
- From the Division of Rheumatology, Mayo Clinic, Rochester, MN (S.R.Y.); the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (D.L.B.); the Division of Rheumatology, University of Nebraska Medical Center, Omaha (T.R.M.); the Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill (G.G.K.); Metroplex Clinical Research Center and University of Texas Southwestern Medical Center, Dallas (R.F.); Pfizer, Madrid (J.L.R.); Pfizer, New York (R.G.); Pfizer, Groton, CT (S.M., C.W., K.S.K., C.A.C.); Pfizer, Shanghai, China (Y.S.); and Pfizer, Peapack, NJ (A.B.S.)
| | - Cunshan Wang
- From the Division of Rheumatology, Mayo Clinic, Rochester, MN (S.R.Y.); the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (D.L.B.); the Division of Rheumatology, University of Nebraska Medical Center, Omaha (T.R.M.); the Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill (G.G.K.); Metroplex Clinical Research Center and University of Texas Southwestern Medical Center, Dallas (R.F.); Pfizer, Madrid (J.L.R.); Pfizer, New York (R.G.); Pfizer, Groton, CT (S.M., C.W., K.S.K., C.A.C.); Pfizer, Shanghai, China (Y.S.); and Pfizer, Peapack, NJ (A.B.S.)
| | - Andrea B Shapiro
- From the Division of Rheumatology, Mayo Clinic, Rochester, MN (S.R.Y.); the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (D.L.B.); the Division of Rheumatology, University of Nebraska Medical Center, Omaha (T.R.M.); the Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill (G.G.K.); Metroplex Clinical Research Center and University of Texas Southwestern Medical Center, Dallas (R.F.); Pfizer, Madrid (J.L.R.); Pfizer, New York (R.G.); Pfizer, Groton, CT (S.M., C.W., K.S.K., C.A.C.); Pfizer, Shanghai, China (Y.S.); and Pfizer, Peapack, NJ (A.B.S.)
| | - Keith S Kanik
- From the Division of Rheumatology, Mayo Clinic, Rochester, MN (S.R.Y.); the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (D.L.B.); the Division of Rheumatology, University of Nebraska Medical Center, Omaha (T.R.M.); the Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill (G.G.K.); Metroplex Clinical Research Center and University of Texas Southwestern Medical Center, Dallas (R.F.); Pfizer, Madrid (J.L.R.); Pfizer, New York (R.G.); Pfizer, Groton, CT (S.M., C.W., K.S.K., C.A.C.); Pfizer, Shanghai, China (Y.S.); and Pfizer, Peapack, NJ (A.B.S.)
| | - Carol A Connell
- From the Division of Rheumatology, Mayo Clinic, Rochester, MN (S.R.Y.); the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (D.L.B.); the Division of Rheumatology, University of Nebraska Medical Center, Omaha (T.R.M.); the Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill (G.G.K.); Metroplex Clinical Research Center and University of Texas Southwestern Medical Center, Dallas (R.F.); Pfizer, Madrid (J.L.R.); Pfizer, New York (R.G.); Pfizer, Groton, CT (S.M., C.W., K.S.K., C.A.C.); Pfizer, Shanghai, China (Y.S.); and Pfizer, Peapack, NJ (A.B.S.)
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Winthrop KL, Curtis JR, Yamaoka K, Lee EB, Hirose T, Rivas JL, Kwok K, Burmester GR. Clinical Management of Herpes Zoster in Patients With Rheumatoid Arthritis or Psoriatic Arthritis Receiving Tofacitinib Treatment. Rheumatol Ther 2021; 9:243-263. [PMID: 34870800 PMCID: PMC8814083 DOI: 10.1007/s40744-021-00390-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/21/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction Risk of herpes zoster (HZ) is increased with Janus kinase inhibitor use. We evaluated clinical study data relating to HZ management in patients with rheumatoid arthritis (RA) or psoriatic arthritis (PsA) receiving tofacitinib. Methods This post hoc analysis included data from 21 RA and 3 PsA clinical studies; data were pooled for tofacitinib doses. Outcomes of HZ events (serious and non-serious) and tofacitinib treatment changes were evaluated in response to first and second HZ events. Median time to resolution was stratified by dermatomal involvement, history of HZ prior to tofacitinib, changes to tofacitinib treatment, anti-viral and corticosteroid use, and tofacitinib dose. Results Seven hundred eighty-three (11.1%, N = 7061) patients with RA experienced ≥ 1 HZ event, 63 (8.0%) of whom had ≥ 2 HZ events. In patients with PsA, 36 (4.6%, N = 783) experienced ≥ 1 HZ event, 1 (2.8%) of whom had ≥ 2 HZ events. For most HZ events, tofacitinib treatment was unchanged or temporarily discontinued. The majority of patients received anti-viral treatment, most within 3 days of onset. Post-herpetic neuralgia developed in 6.9% and 3.2% of patients with RA with first and second events, respectively, and in 2.8% of patients with PsA with a first event. Most first and second events resolved (RA: 97.6% and 96.8%, respectively; PsA: 94.4% and 100%, respectively). Median time to resolution was 22.0 days for first and 15.0 days for second events for RA and 20.5 days for first and 11.0 days for second events (n = 1) for PsA. Time to resolution of first events for RA and PsA was generally numerically shorter for patients with single dermatomal HZ, history of HZ, or anti-viral use versus those without. Conclusion Among patients receiving tofacitinib, recurrent events were more common in patients with RA versus PsA; HZ duration was shorter for repeat events. Trial Registration NCT01262118, NCT01484561, NCT00147498, NCT00413660, NCT00550446, NCT00603512, NCT00687193, NCT01164579, NCT00976599, NCT01059864, NCT01359150, NCT02147587, NCT00960440, NCT00847613, NCT00814307, NCT00856544, NCT00853385, NCT01039688, NCT02187055, NCT00413699, NCT00661661, NCT01877668, NCT01882439, NCT01976364. Supplementary Information The online version contains supplementary material available at 10.1007/s40744-021-00390-0. Patients with rheumatoid arthritis (RA) or psoriatic arthritis (PsA) have weakened immune responses and are more likely to get herpes zoster (HZ; also known as shingles) infections compared with the general population. Patients who receive treatments for RA or PsA that have an effect on their immune system are more likely to get HZ. Here, we assessed how common HZ was in patients with RA or PsA who were given tofacitinib during clinical trials, the management of these infections, and how this affected the course of the infection. Approximately 1 in 10 patients with RA and 1 in 20 patients with PsA had HZ. Of those patients who had HZ, 1 in 12 with RA and 1 in 36 with PsA were infected again at a later point. A small number of patients also had long-lasting pain after HZ infection. When patients had a HZ infection, most either continued treatment with tofacitinib or paused treatment for a period of time. Pausing or continuing treatment did not appear to affect how long the infection lasted or whether patients had another infection. Most patients received treatment for HZ infection, and patients who were treated had shorter infections. In most patients, infections cleared up and were more likely to clear up more quickly when patients had HZ previously.
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Affiliation(s)
- Kevin L Winthrop
- OHSU-PSU School of Public Health, Oregon Health and Science University, OHSU Mail Code GH1043181 S.W. Sam Jackson Rd, Portland, OR, 97239, USA.
| | | | | | - Eun Bong Lee
- Seoul National University College of Medicine, Seoul, Republic of Korea
| | | | | | | | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
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Citera G, Mysler E, Madariaga H, Cardiel MH, Castañeda O, Fischer A, Richette P, Chartrand S, Park JK, Strengholt S, Rivas JL, Thorat AV, Girard T, Kwok K, Wang L, Ponce de Leon D. Incidence Rates of Interstitial Lung Disease Events in Tofacitinib-Treated Rheumatoid Arthritis Patients: Post Hoc Analysis From 21 Clinical Trials. J Clin Rheumatol 2021; 27:e482-e490. [PMID: 32826657 PMCID: PMC8612919 DOI: 10.1097/rhu.0000000000001552] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
BACKGROUND/OBJECTIVE Tofacitinib is an oral Janus kinase inhibitor for the treatment of rheumatoid arthritis (RA). Interstitial lung disease (ILD) is an extra-articular manifestation of RA. We investigated incidence rates of ILD in patients with RA, receiving tofacitinib 5 or 10 mg twice daily, and identified potential risk factors for ILD. METHODS This post hoc analysis comprised a pooled analysis of patients receiving tofacitinib 5 or 10 mg twice daily or placebo from 2 phase (P)1, 10 P2, 6 P3, 1 P3b/4, and 2 long-term extension studies. Interstitial lung disease events were adjudicated as "probable" (supportive clinical evidence) or "possible" (no supportive clinical evidence) compatible adverse events. Incidence rates (patients with events per 100 patient-years) were calculated for ILD events. RESULTS Of 7061 patients (patient-years of exposure = 23,393.7), 42 (0.6%) had an ILD event; median time to ILD event was 1144 days. Incidence rates for ILD with both tofacitinib doses were 0.18 per 100 patient-years. Incidence rates generally remained stable over time. There were 17 of 42 serious adverse events (40.5%) of ILD; for all ILD events (serious and nonserious), 35 of 42 events (83.3%) were mild to moderate in severity. A multivariable Cox regression analysis identified age 65 years or older (hazard ratio 2.43 [95% confidence interval, 1.13-5.21]), current smokers (2.89 [1.33-6.26]), and Disease Activity Score in 28 joints-erythrocyte sedimentation rate score (1.30 [1.04-1.61]) as significant risk factors for ILD events. CONCLUSIONS Across P1/2/3/4/long-term extension studies, incidence rates for ILD events were 0.18 following tofacitinib treatment, and ILD events were associated with known risk factors for ILD in RA.
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Affiliation(s)
| | - Eduardo Mysler
- Organización Médica de Investigación, Buenos Aires, Argentina
| | | | | | | | - Aryeh Fischer
- Department of Medicine, University of Colorado, Denver, CO
| | - Pascal Richette
- Department of Rheumatology, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sandra Chartrand
- Department of Medicine, Hôpital Maisonneuve-Rosemont Affiliated to Université de Montréal, Montreal, Quebec, Canada
| | - Jin Kyun Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
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Kremer JM, Bingham CO, Cappelli LC, Greenberg JD, Madsen AM, Geier J, Rivas JL, Onofrei AM, Barr CJ, Pappas DA, Litman HJ, Dandreo KJ, Shapiro AB, Connell CA, Kavanaugh A. Postapproval Comparative Safety Study of Tofacitinib and Biological Disease-Modifying Antirheumatic Drugs: 5-Year Results from a United States-Based Rheumatoid Arthritis Registry. ACR Open Rheumatol 2021; 3:173-184. [PMID: 33570260 PMCID: PMC7966883 DOI: 10.1002/acr2.11232] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 12/17/2020] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Tofacitinib is an oral Janus kinase inhibitor for the treatment of rheumatoid arthritis (RA). We compared 5-year adverse event (AE) incidence rates (IRs) between patients initiating tofacitinib and those initiating new biological disease-modifying antirheumatic drugs (bDMARDs) within the United States (US) Corrona RA registry. METHODS IRs (number of first events/100 patient-years) of major adverse cardiovascular events (MACE), serious infection events (SIEs), herpes zoster (HZ), malignancies, and death were estimated among tofacitinib and bDMARD initiators, regardless of dose/schedule, between November 6, 2012 (US Food and Drug Administration tofacitinib approval), and July 31, 2018 (follow-up through January 31, 2019). Propensity score (PS) methods were used to control for nonrandom prescribing practices. Hazard ratios (HRs) were calculated to compare rates using multivariable-adjusted Cox regression. Different risk windows were used for acute (MACE, SIEs, HZ, and venous thromboembolic events [VTEs]) and long-term (malignancy and death) events. VTEs were assessed descriptively. RESULTS For MACE, SIEs, and HZ, 1999 (3152.1 patient-years) and 8358 (12 869.4 years) tofacitinib and bDMARD initiators were included, respectively; for malignancy/death, 1999 (4505.6 patient-years) and 6354 (16 670.8 patient-years) initiators were included, respectively. AE rates were similar across cohorts, except for HZ, which was significantly higher with tofacitinib versus bDMARDs (PS-trimmed adjusted HR 2.32; 95% confidence interval [CI] 1.43-3.75). There were 45 (zero serious) and 88 (five serious) HZ events with tofacitinib and bDMARDs, respectively. Sensitivity analyses demonstrated similar results. VTE IRs (95% CI) were 0.29 (0.13-0.54) and 0.33 (0.24-0.45) for tofacitinib and bDMARDs, respectively. CONCLUSION In this registry analysis, both cohorts had similar MACE, SIE, malignancy, death, and VTE rates; HZ rates were higher for tofacitinib initaitors than for bDMARD initiators.
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Affiliation(s)
- Joel M. Kremer
- Albany Medical CollegeCenter for RheumatologyAlbanyNew York
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Cohen SB, Greenberg JD, Harnett J, Madsen A, Smith TW, Gruben D, Zhang R, Lukic T, Woolcott J, Dandreo KJ, Litman HJ, Blachley T, Lenihan A, Chen C, Rivas JL, Dougados M. Real-World Evidence to Contextualize Clinical Trial Results and Inform Regulatory Decisions: Tofacitinib Modified-Release Once-Daily vs Immediate-Release Twice-Daily for Rheumatoid Arthritis. Adv Ther 2021; 38:226-248. [PMID: 33034006 PMCID: PMC7854470 DOI: 10.1007/s12325-020-01501-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 09/05/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Tofacitinib is an oral Janus kinase inhibitor for the treatment of rheumatoid arthritis (RA). To provide additional clinical evidence in regulatory submissions for a modified-release (MR) once-daily (QD) tofacitinib formulation, we compared real-world adherence and effectiveness between patients initiating the MR QD formulation and patients initiating an immediate-release (IR) twice-daily (BID) formulation. METHODS Two noninterventional cohort studies were conducted. First, adherence and two effectiveness proxies were compared between patients with RA who newly initiated tofacitinib MR 11 mg QD or IR 5 mg BID in the IBM® MarketScan® Commercial and Medicare Supplemental US insurance claims databases (March 2016-October 2018). Second, using data collected in the Corrona US RA Registry (February 2016-August 2019), two Clinical Disease Activity Index (CDAI)-based measures of effectiveness were compared between tofacitinib MR 11 mg QD and IR 5 mg BID, and against noninferiority criteria derived from placebo-controlled clinical trials of the tofacitinib IR formulation. Multiple sensitivity analyses of the registry data were conducted to reassure regulators of consistent results across different assumptions. RESULTS In each study, approximately two-thirds of patients initiated the MR formulation. In the claims database study, improved adherence and at least comparable effectiveness were observed with tofacitinib MR vs IR over 12 months, particularly in patients without prior advanced therapy. In the registry study, the noninferiority of tofacitinib MR vs IR was demonstrated for both CDAI outcomes at ~6 months; this finding was robust across multiple sensitivity analyses. CONCLUSION These results demonstrate the value of real-world evidence from complementary data sources in understanding the impact of medication adherence with a QD formulation in clinical practice. These analyses were suitable for regulatory consideration as an important component of evidence for the comparability of tofacitinib MR 11 mg QD vs IR 5 mg BID in patients with RA. TRIAL REGISTRATION Claims database study: ClinicalTrials.gov identifier NCT04018001, retrospectively registered July 12, 2019. Corrona US RA Registry study: ClinicalTrials.gov identifier NCT04267380, retrospectively registered February 12, 2020.
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Affiliation(s)
- Stanley B Cohen
- Metroplex Clinical Research Center and University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Maxime Dougados
- Department of Rheumatology, Université de Paris, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
- INSERM (U1153): Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris, France
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Rivas JL, Jones T, Connell CA. Serious infection with tofacitinib in patients with rheumatoid arthritis: the importance of context. Lancet Rheumatol 2020; 2:e738. [PMID: 38273630 DOI: 10.1016/s2665-9913(20)30211-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/03/2020] [Indexed: 01/27/2024]
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Cohen SB, Pope J, Haraoui B, Irazoque-Palazuelos F, Korkosz M, Diehl A, Rivas JL, Lukic T, Liu S, Stockert L, Iikuni N, Keystone EC. Methotrexate withdrawal in patients with rheumatoid arthritis who achieve low disease activity with tofacitinib modified-release 11 mg once daily plus methotrexate (ORAL Shift): a randomised, phase 3b/4, non-inferiority trial. Lancet Rheumatol 2019; 1:e23-e34. [PMID: 38229356 DOI: 10.1016/s2665-9913(19)30005-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 06/19/2019] [Accepted: 06/20/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Tofacitinib is an oral Janus kinase (JAK) inhibitor used for the treatment of rheumatoid arthritis. We assessed the efficacy and safety of tofacitinib after methotrexate withdrawal in patients who achieved low disease activity (LDA) with tofacitinib in combination with methotrexate. METHODS ORAL Shift was a phase 3b/4 non-inferiority trial in patients aged at least 18 years with moderate-to-severe rheumatoid arthritis and an inadequate response to methotrexate done in 109 centres across 16 countries. After 24 weeks of open-label tofacitinib modified-release 11 mg once daily plus methotrexate, patients who achieved LDA (clinical disease activity index [CDAI] ≤10) were randomly assigned 1:1 via an automated web-based response system to receive tofacitinib plus placebo (tofacitinib monotherapy; ie, masked methotrexate withdrawal) or continue tofacitinib plus methotrexate for 24 weeks in a double-blind manner. The primary endpoint was the least squares mean change from week 24 to week 48 in disease activity score in 28 joints with four variables, including erythrocyte sedimentation rate (DAS28-4[ESR]). The primary analysis was done in all patients who received at least one dose of study treatment in both phases, and safety was assessed in all patients who received at least one dose of study treatment since enrolment. Non-inferiority of tofacitinib monotherapy versus tofacitinib plus methotrexate was declared if the upper bound of the 95% CI for the difference in change in DAS28-4(ESR) between treatment groups was less than 0·6. Safety was assessed in both phases. The trial is registered with ClinicalTrials.gov, NCT02831855, and is complete. FINDINGS Between Sept 1, 2016, and Nov 1, 2017, 694 patients were enrolled in the open-label phase and 623 received study treatment for 24 weeks. 533 achieved CDAI-defined LDA and were randomly assigned into the double-blind phase (267 in the tofacitinib monotherapy group and 266 in the tofacitinib plus methotrexate group). Three participants in the monotherapy group did not start treatment so were not included in the primary analysis. Non-inferiority was demonstrated (difference 0·30 [95% CI 0·12-0·48]). 107 (41%) of 264 patients in the tofacitinib monotherapy group and 109 (41%) of 266 in the tofacitinib plus methotrexate group had adverse events; five patients from each group discontinued because of adverse events; two patients died in the tofacitinib plus methotrexate group. No new safety findings were reported up to 48 weeks. INTERPRETATION Patients with rheumatoid arthritis who achieve LDA with a combination of tofacitinib plus methotrexate may consider withdrawing methotrexate without significant worsening of disease activity or unexpected safety issues. FUNDING Pfizer.
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Affiliation(s)
- Stanley B Cohen
- Metroplex Clinical Research Center and University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | | | - Boulos Haraoui
- Institut de Rhumatologie de Montréal, Montreal, QC, Canada
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de Miguel E, Pecondón-Español A, Castaño-Sánchez M, Corrales A, Gutierrez-Polo R, Rodriguez-Gomez M, Pinto-Tasende JA, Rivas JL, Ivorra-Cortés J. A reduced 12-joint ultrasound examination predicts lack of X-ray progression better than clinical remission criteria in patients with rheumatoid arthritis. Rheumatol Int 2017; 37:1347-1356. [PMID: 28389854 DOI: 10.1007/s00296-017-3714-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 03/30/2017] [Indexed: 11/30/2022]
Abstract
To study the predictive value of clinical remission definitions and ultrasound (US) examination on X-ray progression in rheumatoid arthritis (RA). This was an observational prospective multicenter 1-year follow-up cohort of RA patients with moderate disease activity (3.2 < DAS28 ≤ 5.1) who started anti-TNF therapy. DAS28ESR, DAS28CRP, SDAI, CDAI, and ACR/EULAR remission criteria were applied and reduced 12-joint US examination was performed at baseline and at 6 and 12 months. At baseline and month 12, radiographs of hands and feet were obtained in a subset of patients. A blind independent reader scored radiographs. X-ray progression was defined as Sharp van der Heijde change score >1 and no progression was defined as ≤0. 319 of 357 patients completed the study; patients had a mean (SD) age of 53.5 (13.1) years, with a disease duration of 7.5 (7.1) years. Laboratory, clinical, and US values significantly improved at month 6, except CRP, with additional improvement at month 12. Remission and low disease activity rates increased at follow-up. In the subset of 115 patients with radiological studies, clinical remission by any definition was not significantly associated with X-ray progression. Patients without PD signal at baseline and month 6 were a lower risk of X-ray progression than patients with PD signal, OR 0.197 (95% CI 0.046-0.861) and 0.134 (95% CI 0.047-0.378), respectively. Absence of PD signal, but not clinical remission predicts lack of X-ray progression. A feasible 12-joint US examination may add relevant information to RA remission criteria.
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Affiliation(s)
- Eugenio de Miguel
- Rheumatology Department, Hospital Universitario La Paz, Pº de la Castellana 261, 28046, Madrid, Spain.
| | | | - Manuel Castaño-Sánchez
- Rheumatology Department, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Alfonso Corrales
- Rheumatology Department, Hospital Marqués de Valdecilla, Santander, Spain
| | | | | | - Jose A Pinto-Tasende
- Rheumatology Department, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain
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