Romosozumab in patients who experienced an on-study fracture: post hoc analyses of the FRAME and ARCH phase 3 trials

Post hoc analysis of FRAME and ARCH revealed that on-study nonvertebral and vertebral fractures by Month 12 were less common in women initially treated with romosozumab versus placebo or alendronate. Recurrent fracture risk was also lower in romosozumab‑treated patients, and there were no fracture‑related complications. Results support continuing romosozumab treatment post‑fracture.

PURPOSE

Post hoc analysis evaluating efficacy and safety of romosozumab, administered in the immediate post‑fracture period, in the FRAME and ARCH phase 3 trials.

METHODS

In FRAME (NCT01575834) and ARCH (NCT01631214), postmenopausal women with osteoporosis were randomized 1:1 to romosozumab 210 mg monthly or comparator (FRAME, placebo; ARCH, alendronate 70 mg weekly) for 12 months, followed by antiresorptive therapy (FRAME, denosumab; ARCH, alendronate). In patients who experienced on-study nonvertebral or new/worsening vertebral fracture by Month 12, we report the following: fracture and treatment‑emergent adverse event (TEAE) incidence through 36 months, bone mineral density changes (BMD), and romosozumab timing. Due to the sample sizes employed, meaningful statistical comparisons between treatments were not possible.

RESULTS

Incidence of on-study nonvertebral and vertebral fractures by Month 12 was numerically lower in romosozumab- versus comparator-treated patients (FRAME, 1.6% and 0.5% versus 2.1% and 1.6%; ARCH, 3.4% and 3.3% versus 4.6% and 4.9%, respectively). In those who experienced on-study nonvertebral fracture by Month 12, recurrent nonvertebral and subsequent vertebral fracture incidences were numerically lower in patients initially treated with romosozumab versus comparator (FRAME, 3.6% [2/56] and 1.8% [1/56] versus 9.2% [7/76] and 3.9% [3/76]; ARCH, 10.0% [7/70] and 5.7% [4/70] versus 12.6% [12/95] and 8.4% [8/95], respectively). Among those with on-study vertebral fracture by Month 12, recurrent vertebral and subsequent nonvertebral fracture incidences were numerically lower with romosozumab versus comparator (FRAME, 0.0% [0/17] and 0.0% [0/17] versus 11.9% [7/59] and 8.5% [5/59]; ARCH, 9.0% [6/67] and 7.5% [5/67] versus 15.0% [15/100] and 16.0% [16/100], respectively). In patients with fracture by Month 12, no fracture‑related complications were reported in romosozumab-treated patients. BMD gains were numerically greater with romosozumab than comparators.

CONCLUSION

Data suggest support for the efficacy and safety of continuing romosozumab treatment following fracture.

TRIAL REGISTRATIONS

NCT01575834; NCT01631214.

Effectiveness of a remote care program in the management of patients with resistant hypertension or multiple medication intolerances

Background

A remote hypertension (HTN) program, designed and implemented at Mass General Brigham (MGB), has demonstrated improved HTN control, reduced need for in-person visits, and increased access to care. The program excluded patients with resistant HTN or multiple intolerances/allergies to guideline-directed therapies, whose blood pressure (BP) is difficult to manage.

Purpose

To develop a more intensive but still remote program (“HTN-Plus”) for patients with resistant HTN or intolerances/allergies to multiple medications, and to assess its effectiveness for BP control.

Methods

From 10/2020 through 11/2021, we identified a subset of hypertensive patients from the total pool of those enrolled in our remote HTN management program, who required more personalized and intensive therapy than the overall remote management program provided. We developed ancillary management for these patients, who included: 1) patients with apparent resistant HTN (ARH), ie with uncontrolled BP despite maximum tolerated doses of at least three anti-HTN medications including a diuretic, and 2) patients with multiple medication intolerances or allergies that precluded appropriate triple therapy or limited dose-optimization. A nurse practitioner provided education and advice on BP measurement technique, lifestyle modifications, and adherence. Evaluation for primary aldosteronism (PA) was undertaken in those with ARH.

Results

We enrolled 3658 patients with uncontrolled HTN, of whom 117 qualified for the HTN-Plus program. The average BP on entry was 143/80 mmHg. 68% had apparent resistant HTN and 32% had multiple medication intolerances/allergies. Among all patients, 30% had incorrect BP-measurement technique upon interview, 10% who were tested for PA had a positive screening test, 56% had a history suggestive of an unmanaged secondary cause, and only 6% admitted imperfect adherence, but urine testing was not done. 74% of patients completed the program meaning they were reachable through the end and did not drop out. Across the program, 72 new medications were started, and 84 medication titrations were made. 50% of patients who enrolled in HTN-plus achieved BP <130/80 mmHg. 22% achieved BP control with education and coaching alone. For patients who completed the program, the average entry and final BPs were 139/78 mmHg and 126/70 mmHg respectively, with an average BP decrease of 13/8 mmHg.

Conclusions

In patients who remain hypertensive despite maximally tolerated guideline-directed medication utilization, our intensified but still entirely remote HTN management program helped patients reach their BP goal through education, coaching, and medication management. Nearly a quarter were able to achieve BP control with education and coaching alone. These results suggest that a significant value of remote care in patients with resistant HTN or medication intolerances/allergies lies in ongoing education and coaching, for which more cost-effective solutions may be considered.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): Mass General Brigham as part of quality improvement initiative

Heavy clinical and economic burden of osteoporotic fracture among elderly female Medicare beneficiaries

We comprehensively described elderly Medicare women with an outpatient visit in 2011 and fracture within 2 years before. These women were at very high risk for subsequent fracture and high healthcare utilization and cost, especially those with vertebral or multiple fractures. However, rates of fracture prevention treatments were low.

INTRODUCTION

Postmenopausal women with osteoporosis are stratified to high and very-high fracture risk categories, and this categorization drives algorithms for osteoporosis management in osteoporosis treatment guidelines. This study comprehensively describes a very-high-risk cohort.

METHODS

This retrospective cohort study used the Medicare 20% database; elderly women with an outpatient visit in 2011 and fracture within 2 years before the visit were included. Outcomes included fracture risk, all-cause and fracture-related healthcare resource utilization and cost, and osteoporosis medication use in the 5 years after the visit.

RESULTS

Overall, 43,193 patients were included. The 5-year probability was 0.36 for major fracture and 0.11 and 0.17 for hip fracture and vertebral fracture, respectively, much higher than the guidelines' 10-year probability thresholds for very-high-risk (0.3 for major fracture, 0.045 for hip fracture). Rates of hospitalizations, emergency department visits or observation stays, and skilled nursing facility stays in year 1 were 53.7, 57.0, and 18.8 per 100 patient-years, respectively, decreasing slightly in subsequent years. Mean healthcare cost was $23,700 in year 1, decreasing to $18,500 in year 5. About 29.1% of patients received osteoporosis medications in year 1, decreasing to 16.9% by year 5. Rates for all outcomes, especially fractures, were much higher among vertebral and multiple fracture cohorts.

CONCLUSION

Elderly women with a fracture within last 2 years were at very-high-risk for subsequent fracture and high healthcare utilization and cost, especially those with vertebral or multiple fractures. However, rates of fracture prevention treatments were low. More effort is needed to identify and treat patients at very-high-risk for fracture.

OP0297 EFFICACY AND SAFETY OF ROMOSOZUMAB AMONG POSTMENOPAUSAL WOMEN WITH OSTEOPOROSIS AND MILD-TO-MODERATE CHRONIC KIDNEY DISEASE

Background:

Osteoporosis and renal insufficiency are coexisting disease states in a substantial proportion of postmenopausal women. Since bisphosphonates are generally contraindicated in patients with estimated glomerular filtration rate (eGFR) <35 mL/min, it is important to evaluate other osteoporosis treatments in this setting.

Objectives:

To determine if baseline renal function affects the efficacy and safety of romosozumab.

Methods:

We performed post hoc analyses of two clinical trials of romosozumab in postmenopausal women with osteoporosis. In ARCH (NCT01631214), 4,093 patients were randomised 1:1 to romosozumab 210 mg monthly or alendronate 70 mg weekly for 12 months (mean age: 74.3 years; 96.1% with prevalent vertebral fractures [VFx]). In FRAME (NCT01575834), 7,180 patients were randomised 1:1 to romosozumab 210 mg or placebo monthly for 12 months (mean age: 70.9 years; 18.3% with prevalent VFx). For these analyses, patients were categorised by baseline eGFR (mL/min/1.73m2): normal renal function (eGFR ≥90), mild renal insufficiency (eGFR 60–89), or moderate renal insufficiency (eGFR 30–59). Least squares mean (LSM) percent change from baseline in bone mineral density (BMD) at the lumbar spine, total hip, and femoral neck; incidence of new VFx and adverse events (AEs); and changes in renal function were assessed for each eGFR category at Month 12 of the double-blind treatment period.

Results:

At baseline, most patients had mild/moderate renal insufficiency: 84% in ARCH, 88% in FRAME. In both studies, change from baseline in BMD was significantly higher in the romosozumab group across baseline eGFR categories (Figure). There was an interaction between BMD increase and renal function, and although BMD increase was not as large in women with impaired renal function, differences between romosozumab and control groups remained significant (Figure). In ARCH, among patients with eGFR ≥90, 60–89, and 30–59, the incidence of new VFx (romosozumab vs alendronate) at Month 12 was 3.3% vs 7.3%, 3.2% vs 3.9%, and 3.4% vs 6.2% in ARCH. In FRAME, the incidence of new VFx (romosozumab vs placebo) at Month 12 was 0.5% vs 3.0%, 0.4% vs 1.5%, and 0.6% vs 2.1%.

In both studies, the incidences of AEs and serious AEs were similar in both treatment groups within and across eGFR categories. AEs of mild-to-moderate hypocalcaemia (investigator reported) occurred in two patients in ARCH (one romosozumab [eGFR 60–89] and one alendronate [eGFR ≥90]), and one patient in FRAME (romosozumab [eGFR 60–89]). Five patients in ARCH (all in the alendronate group) and 19 patients in FRAME (14 romosozumab, 5 placebo) had decreases in serum Ca levels (albumin adjusted); in the romosozumab group all were mild (<LLN–8.0 mg/dL) or moderate (<8.0–7.0 mg/dL). A similar percentage of patients in each group had changes in renal function over 12 months of treatment.

Conclusion:

The efficacy and safety of romosozumab vs alendronate or placebo was similar among postmenopausal women with osteoporosis and different levels of renal function.

Acknowledgments:

This study was funded by Amgen, Astellas and UCB Pharma. Editorial services were provided by Costello Medical.

Disclosure of Interests:

Paul Miller Grant/research support from: Amgen, Radius Health, Ultragenyx, Consultant of: Amgen, Radius Health, Jonathan Adachi Consultant of: Amgen, Speakers bureau: Amgen, Ben-Hur Albergaria Consultant of: Amgen Inc., Eli Lilly, Speakers bureau: Amgen Inc., Eli Lilly, Angela M Cheung Consultant of: Amgen, Eli Lilly, Arkadi Chines Shareholder of: Amgen Inc., Employee of: Amgen Inc., Evelien Gielen Consultant of: Amgen Inc., Takeda, Sandoz and UCB Pharma, Speakers bureau: Amgen Inc., Takeda, Sandoz and UCB Pharma, Bente Langdahl Grant/research support from: Amgen, NovoNordisk, Consultant of: Amgen Inc., Eli Lilly, UCB Pharma, Akimitsu Miyauchi Consultant of: Amgen Inc., Astellas BioPharma K.K., Teijin Pharma, Mary Oates Shareholder of: Amgen Inc., Employee of: Amgen Inc., Ian Reid Consultant of: Amgen Inc., Eli Lilly, Speakers bureau: Amgen Inc., Eli Lilly, Norma Ruiz Santiago Shareholder of: Amgen Inc., Employee of: Amgen Inc., Mark Vanderkelen Employee of: UCB Pharma, Wenjing Yang Shareholder of: Amgen Inc., Employee of: Amgen Inc., Zhigang Yu Shareholder of: Amgen Inc., Employee of: Amgen Inc.

Glucocorticoid resistance in chronic lymphocytic leukaemia is associated with a failure of upregulated Bim/Bcl-2 complexes to activate Bax and Bak

Glucocorticoids (GCs) represent an important component of modern treatment regimens for fludarabine-refractory or TP53-defective chronic lymphocytic leukemia (CLL). However, GC therapy is not effective in all patients. The molecular mechanisms responsible for GC-induced apoptosis and resistance were therefore investigated in primary malignant cells obtained from a cohort of 46 patients with CLL. Dexamethasone-induced apoptosis was unaffected by p53 dysfunction and more pronounced in cases with unmutated IGHV genes. Cross-resistance was observed between dexamethasone and other GCs but not fludarabine, indicating non-identical resistance mechanisms. GC treatment resulted in the upregulation of Bim mRNA and protein, but to comparable levels in both GC-resistant and sensitive cells. Pre-incubation with Bim siRNAs reduced GC-induced upregulation of Bim protein and conferred resistance to GC-induced apoptosis in previously GC-sensitive cells. GC-induced upregulation of Bim was associated with the activation of Bax and Bak in GC-sensitive but not -resistant CLL samples. Co-immunoprecipitation experiments showed that Bim does not interact directly with Bax or Bak, but is almost exclusively bound to Bcl-2 regardless of GC treatment. Taken together, these findings suggest that the GC-induced killing of CLL cells results from the indirect activation of Bax and Bak by upregulated Bim/Bcl-2 complexes, and that GC resistance results from the failure of such activation to occur.

The angiogenic potential of three-dimensional open porous synthetic matrix materials

Angiogenesis is a complex multistage process involving multiple factors and numerous cells. The use of the Chorioallantoic Membrane (CAM) assay is well documented as a method to investigate angiogenesis. This technique is ideal for screening samples, but requires an objective analysis technique. The angiogenic response of vascular endothelial growth factor (VEGF) was used to confirm that computer-based image analysis was able to quantify angiogenesis. Image analysis was used on samples of increasing porosity of PLLA to determine the effect of pore size on angiogenesis. Another effect also noted was that of an inflammatory response co-incident with angiogenesis. The difference in pore size made a difference to both angiogenesis and inflammation. Real-time polymerase chain reaction (PCR) was used with primers for TNF-alpha to demonstrate and measure the presence of an inflammatory response.

Impact of a multiple, IVF birth on post-partum mental health: a composite analysis

BACKGROUND

This study explored the impact of a multiple IVF birth on maternal mental health in the early post-partum period.

METHODS

A prospective study of 207 women who had conceived following IVF treatment and followed up at 6 weeks post-partum. Mothers rated their mood using the Edinburgh postnatal depression scale (EPDS) and their baby's behaviour using the Unsettled and Irregular Behaviour scale. Mothers' emotional well-being was explored using theme analysis of semi-structured telephone interviews.

RESULTS

Of the 175 (84.5%) followed up post-partum, 56 (32%) had a multiple birth (7 triplets, 49 twins). Nearly 16% of mothers in the multiple group scored>12 on the EPDS indicating clinically significant symptoms, which represented a 3-fold increased risk compared to mothers of singletons (Odds ratio=3.4, Confidence Interval=1.011-11.618, P=0.048). Unsettled and irregular infant behaviour was another independent risk factor. Qualitative analysis of interviews identified 12 themes. Mothers of multiples were more likely to express negative themes including 'tiredness' (P<0.01), 'feelings of stress/depression' (P<0.05) and 'questioning parenthood' (P<0.05). Mothers of singletons were more likely to be 'feeling wonderful', reflecting their delight in parenthood (P<0.05).

CONCLUSIONS

Mothers of multiples are at increased risk of poorer emotional well-being. Clinicians should focus on the psychological benefits of a singleton birth.

Chronic leptin administration in developing rats reduces stress responsiveness partly through changes in maternal behavior

In adult rodents, leptin has been shown to significantly alter the activity of several neuroendocrine functions, including the activity of the hypothalamic-pituitary-adrenal (HPA) axis. Leptin is generally believed to be inhibitory to HPA activity in adults. Developing rat pups have high circulating levels of leptin, which begs the question of leptin's physiological role in controlling basal and stress-induced adrenocortical activity in neonatal rats. In this study, we treated rat pups daily from days 2-9 (or 6-10) of life with either vehicle or leptin (1 or 3 mg/kg body wt, ip) and determined the effects on body weight gain, fat pad deposits, and HPA activity in 10-day-old pups. We measured hypothalamic CRF mRNA levels in vehicle- and leptin-treated pups by in situ hybridization and determined plasma ACTH, corticosterone, and leptin concentrations under basal conditions or following exposure to a 3-min ether stress. Because leptin activates sympathetic activity and energy expenditure in adults and possibly also in rat pups, and because litter temperature is an important determinant of maternal behavior, we also investigated whether chronic leptin administration would modify aspects of maternal care that are important for the maintenance of HPA function. Chronic leptin treatment increased circulating levels of leptin and had significant dose-related metabolic effects, including reduced body weight gain and fat pad weight in 10-day-old pups. Basal expression of CRF mRNA in the PVN or secretion of ACTH and corticosterone was not modified by leptin treatment. In contrast, chronically elevated leptin concentrations during the neonatal period significantly lowered CRF expression in the PVN 60 min after stress and reduced the duration of the ACTH response to stress in pups, suggesting that glucocorticoid feedback on the HPA axis might be altered by this treatment. In addition, mothers caring for pups injected with leptin displayed longer bouts of anogenital licking of pups than mothers of vehicle-treated rats. Given that this particular type of pup stimulation has been shown to influence stress responsiveness, it is possible that the maternal response modulates the effects of exogenous leptin treatment. In conclusion, our results demonstrate that the leptin signal is functional during the early developmental period and that leptin can modulate the hormonal response to stress in young rats either by a direct effect on the HPA axis or indirectly through changing some aspects of maternal behavior.

Topoisomerase I and II activity in human breast, cervix, lung and colon cancer

The identification of human DNA topoisomerases as cellular targets for active anti-cancer drugs has stimulated further interest in topoisomerase function in tumour biology. Topoisomerase I and II catalytic activity is detectable in many normal and malignant tissues. However, little is known about the expression of topoisomerases in most human solid tumours. The present study evaluated topoisomerase I and II activity in biopsy samples from 86 patients with breast, lung, cervix or colon cancers. Significant intra- and inter-tumour variation in topoisomerase expression was observed. Topoisomerase I activity was relatively high in cervix and colon tumours in comparison to lung and breast cancers. Topoisomerase II activity was high in cervix, colon and lung cancers relative to breast cancer. Topoisomerase I and II activity co-segregated in individual colon tumour samples, but no correlation was observed in cervix, lung or breast tumours. The large heterogeneity in both topoisomerase I and II activity within a tumour type suggests a mechanism for variable response to topoisomerase-directed therapy. The differences in activity between tumour groups suggest that the potential efficacy of inhibitors of topoisomerase I in colon and cervical tumours may be greater than in lung and breast tumours. Future in vivo evaluation is required to establish the clinical relevance of the observed heterogeneity in topoisomerase activity.

Prepartum psychosis

Four patients are described who suffered from postpartum psychosis, and also from similar episodes starting in late pregnancy. It is argued that these patients provide evidence for the prepartum onset of postpartum psychosis in a small minority of patients. The relevance of this to the aetiology of puerperal psychosis is discussed.

Normal emotional changes in pregnancy and the puerperium

There is tremendous individual variation in the response to the inherent emotional, psychological and cognitive changes that take place during pregnancy and puerperium, particularly in first-time mothers. Although the psychological changes, particularly in terms of emotional and behavioural changes, have probably been overstated in pregnancy, there are undoubtedly marked changes in such aspects of functioning following delivery. Women should be aware of these changes and be prepared for them, and obstetricians and midwives should incorporate them into their management of patients. All women have valid psychological needs during pregnancy and in the puerperium, and these must be met in order to ensure maternal and infant health and maximum satisfaction with the experience. Antenatal and postnatal care should not result in a struggle for power and control between patient and obstetrician. Emotional reassurance and support can only follow upon adequate information. The best antenatal care and management of delivery requires a spirit of mutual trust and active participation on the part of the patient in the decision-making process. There is ample evidence to support the theory that continuity of care and the continuous supporting role of the midwife, particularly during delivery, exerts a favourable outcome in mothers and children.