Long-term safety and effectiveness of canakinumab in patients with monogenic autoinflammatory diseases: results from the interim analysis of the RELIANCE registry

OBJECTIVE

Interim analysis of the RELIANCE registry, an on-going, non-interventional, open-label, multicentre, prospective study evaluating the long-term safety, dosing regimens and effectiveness of canakinumab in patients with cryopyrin-associated periodic syndromes (CAPS), familial Mediterranean fever (FMF), tumour-necrosis factor receptor-associated periodic syndrome (TRAPS) or mevalonate-kinase deficiency (MKD)/hyperimmunoglobulin-D syndrome (HIDS).

METHODS

From September 2017 for patients with CAPS, and June 2018 for patients with FMF, TRAPS or MKD/HIDS, the registry enrolled paediatric (aged ≥2 years) and adult patients (aged ≥18 years) receiving canakinumab as part of their routine medical care. Safety, canakinumab dose, disease activity and quality of life outcome measures were evaluated at baseline and every 6 months until end of study visit.

RESULTS

At the analysis cut-off date (December 2020), 168 patients (91 CAPS, 54 FMF, 16 TRAPS and 7 MKD/HIDS) were enrolled. 85 (50.9%) patients were female and 72 (43.1%) were children (<18 years). The median patient age was 20.0 years (range 2.0-79.0 years). In the CAPS cohort, serious infections and serious adverse drug-reactions were more common in patients receiving higher than the recommended starting dose (SD) of canakinumab. A trend to receive >SD of canakinumab was observed in the pooled population. The majority of patients were reported as having either absent or mild/moderate disease activity (physician's global assessment) from baseline to Month 30, with a stable proportion of patients (~70%) in remission under canakinumab treatment. Patient-reported disease activity (Visual Analogue Scale (VAS), Autoinflammatory Disease Activity Index), fatigue (VAS); markers of inflammation (C-reactive protein, serum amyloid A and erythrocyte sedimentation rate) remained well-controlled throughout.

CONCLUSION

Data from this analysis confirm the long-term safety and effectiveness of canakinumab for the treatment of CAPS, FMF, TRAPS and MKD/HIDS.

POS1374 LONG-TERM SAFETY OF CANAKINUMAB IN PATIENTS WITH AUTOINFLAMMATORY DISEASES - INTERIM ANALYSIS OF THE RELIANCE REGISTRY

Background

Autoinflammatory diseases (AID) are characterized by severe systemic and organ inflammation as well as high burden of disease for patients and their families. Treatment with the monoclonal antibody canakinumab (CAN), an interleukin-1β inhibitor, has been proven to be safe and effective in clinical trials and real-life.

Objectives

The present study explores the long-term efficacy and safety of CAN in routine clinical practice conditions in pediatric (age ≥2 years) and adult patients with CAPS (cryopyrin-associated periodic syndromes), FMF (familial Mediterranean fever), TRAPS (tumor necrosis factor receptor-associated periodic syndrome) and HIDS/MKD (hyperimmunoglobulinemia D syndrome/mevalonate kinase deficiency).

Methods

RELIANCE is a prospective, non-interventional, observational study based in Germany. Patients with clinically confirmed diagnoses of AID routinely receiving CAN are enrolled. Besides efficacy parameters regarding disease activity and remission, safety parameters were recorded at baseline and assessed at 6-monthly intervals.

Results

Here, we present the interim analysis of patients with AID (N=199) enrolled in the RELIANCE Registry between October 2017 and December 2021. Mean age in this cohort was 24.4 years (2–79 years) and the proportion of female patients was 53% (N=104). At baseline, median duration of prior CAN treatment was 2 years (0–12 years).

A total of 123 patients (62%) experienced any AE (N=653) among which nasopharyngitis, increase of inflammatory markers and pyrexia were the most frequent AE with incidence rates per 100 patient years (IR) of 8.3, 6.2, and 6.2, respectively.

29 patients (15%) were affected by severe AE (SAE, total number N=90) including 11 patients (6%) with SAE suspected to be drug-related (SADR; total number N=30) with IR from 0.2 to 0.7 (Table 1). Overall, 16 AE comprised upper respiratory tract infections (URI). One death (COVID-19, not related) and one malignancy (skin papilloma, not related) were reported. No vertigo and no hypersensitivity reactions were observed. N=10 (IR 2.36) vaccination reactions were reported (no SAE).

Table 1.

Overview of the CAN safety data of the RELIANCE study across all study indications (N=199 patients).

Type of eventNumber of eventsIR‡AE total653154.43AE non-serious563133.15AE, non-serious, not related31774.97AE, URI163.78AE, non-serious adverse drug reaction24658.18SAE, total9021.28SAE, not related6014.19SADR#, total307.09

#Abdominal pain; Alport’s syndrome, appendicitis, arthralgia, blister, cardiovascular disorder, chest pain, circulatory collapse, dehydration, diplopia, dyspnoea, erythema, febrile convulsion, gastroenteritis, glomerulonephritis, Haemophilus test positive, myalgia, oedema, pneumonia, premature delivery, skin discoloration, tachycardia, tonsillitis bacterial, tonsillitis streptococcal, vision blurred (each n=1 event, IR 0.24‡), tonsillectomy (2 events, IR 0.47‡), pyrexia (3 events, IR 0.71‡), not yet coded (hospital admission due to exsiccosis upon gastroenteritis, 1 event, IR 0.35‡)

‡IR, incidence rate per 100 patient years; AE, adverse event; URI, upper respiratory tract infection; SAE, severe adverse event, SADR, severe adverse drug reaction

Incidence rate = number of events * 36,525 / sum of observation days (=154,442)

Conclusion

The interim data from the RELIANCE study, the longest running real-life canakinumab registry, confirm safety of long-term canakinumab treatment across the entire study population. A trend for dose-related increase of SAE/SADR requires continuous close monitoring and awareness in patient groups (children, severe phenotypes, certain genotypes) requiring greater than standard dose treatment regimens.

Disclosure of Interests

J. B. Kuemmerle-Deschner Consultant of: Novartis, AbbVie, Sobi, Grant/research support from: Novartis, AbbVie, Sobi, Jörg Henes Consultant of: Novartis, AbbVie, Sobi, Roche, Janssen, Boehringer-Ingelheim, Grant/research support from: Novartis, Roche, Birgit Kortus-Goetze Consultant of: Novartis, Tilmann Kallinich Consultant of: Sobi, Novartis, Roche, Grant/research support from: Novartis, Prasad Oommen Grant/research support from: Novartis, Jürgen Rech Speakers bureau: Abbvie, Biogen, BMS, Chugai, GSK, Janssen, Lilly, MSD; Mylan, Novartis, Roche, Sanofi, Sobi, UCB, Consultant of: Abbvie, Biogen, BMS, Chugai, GSK, Janssen, Lilly, MSD, Mylan, Novartis, Roche, Sanofi, Sobi, UCB, Grant/research support from: Novartis, Sobi, Tobias Krickau Speakers bureau: Novartis, Consultant of: Novartis, Grant/research support from: Novartis, Frank Weller-Heinemann: None declared, Gerd Horneff Speakers bureau: AbbVie, Bayer, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Grant/research support from: AbbVie, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Ales Janda: None declared, Ivan Foeldvari Consultant of: Novartis, Hexal, Medac, Pfizer, Catharina Schuetz: None declared, Frank Dressler Consultant of: Abbvie, Mylan, Novartis, Pfizer, Grant/research support from: Novartis, Michael Borte Grant/research support from: Pfizer, Shire, Markus Hufnagel Consultant of: Novartis and SOBI, Florian Meier Speakers bureau: Novartis, Michael Fiene: None declared, Julia Weber-Arden Employee of: Novartis, Norbert Blank Consultant of: Novartis, Sobi, Lilly, Pfizer, Abbvie, BMS, MSD, Actelion, UCB, Boehringer-Ingelheim, Roche, Grant/research support from: Novartis, Sobi

FRI0365 REAL-WORLD EFFECTIVENESS AND SAFETY OF APREMILAST IN A LARGE COHORT OF GERMAN PATIENTS WITH PSORIATIC ARTHRITIS: 1-YEAR ANALYSIS OF AN ONGOING MULTICENTER, PROSPECTIVE, NON-INTERVENTIONAL STUDY

Background:

Apremilast (APR) has been studied extensively in phase III randomized, controlled trials. However, real-world information is limited on the effectiveness and safety of APR in patients with psoriatic arthritis (PsA).

Objectives:

To assess the effectiveness and safety of APR in a large cohort of patients with active PsA from routine clinical practice settings in Germany.

Methods:

In this multicenter, prospective, non-interventional study, the primary endpoint was the proportion of patients reaching ≥1 point (≥20%) improvement from baseline (BL) in the Physician’s Global Assessment of Disease Activity (PhGA) score. Other endpoints included effects on swollen and tender joint counts (SJC/TJC), psoriasis-involved body surface area (BSA), enthesitis, dactylitis, Patient’s Global Assessment of Disease Activity score (PtGA), Psoriatic Arthritis Impact of Disease (PsAID) tool, pain, and pruritus. The current analysis is based on observed data through 1 year of study duration.

Results:

A total of 545 German patients were enrolled and followed up to 12 months of APR treatment; 488 patients were included in the safety analysis and 418 in the full analysis set. The mean age was 55 years, mean body mass index was 29.5 kg/m2, and 60% were female. The mean duration of psoriasis and PsA was 26 years and 18 years, respectively. At BL, 46.7% of patients had enthesitis based on the Leeds Enthesitis Index (LEI; mean [SD]: 2.9 [1.72]) and 23% had dactylitis (mean [SD]: 2.2±2.03); 74% of patients were biologic-naive. Effectiveness is shown after ~1 month (Visit 1 [V1]) and ~4 months (Visit 2 [V2]) and for up to 225 patients after 12 months (Visit 5 [V5]) of treatment (Table).

Improvements were also seen in PtGA, overall pain, and pruritus. A subanalysis suggests APR was associated with greater benefits in biologic-naive patients compared with patients who previously received biologic therapy. Observed safety and tolerability through V5 were consistent with the known overall safety profile of APR. Common adverse events in clinical trials were similar, with a lower incidence of diarrhea (11.1%), nausea (7.0%), headache (3.9%), and respiratory tract infection (0.8%).

Conclusion:

Data from this large, real-world cohort of patients with PsA show the effectiveness of APR. In patients with up to 12 months of follow-up, APR was associated with rapid and maintained improvements in physician-assessed and patient-reported outcomes. Safety and tolerability were consistent with the known profile of APR.

Table.

Disclosure of Interests:

Jürgen Wollenhaupt Grant/research support from: Abbott, BMS, MSD, Pfizer, UCB – grant/research support, Consultant of: Abbott, BMS, MSD, Pfizer, UCB – consultant, Harald Strothmeyer: None declared, Michael Fiene: None declared, Stephan Morys Employee of: Amgen Inc. – employment; Celgene GmbH – employment at the time of study conduct, Christian Bach Employee of: Amgen Inc. – employment; Celgene GmbH – employment at the time of study conduct, Josefine Roemmler-Zehrer Employee of: Amgen Inc. – employment; Celgene GmbH – employment at the time of study conduct

Geriatric nutritional risk index correlates with length of hospital stay and inflammatory markers in older inpatients

BACKGROUND & AIMS

Malnutrition is a prevalent condition in older inpatients and has been shown to increase morbidity and direct medical costs. A number of established tools to assess malnutrition are available but malnourished patients rarely receive adequate nutritional assessment and treatment. The medical and economic consequences of malnutrition in hospitalized patients are therefore often underestimated. This study investigates whether the Geriatric Nutritional Risk Index (GNRI) predicts hospital mortality, correlates with length of hospital stay (LOS) and inflammatory markers in older inpatients.

METHODS

We conducted a prospective monocentric study in 500 hospital patients over 65 years of age (female: 248; male: 252; age: 76.3 ± 0.31 years). GNRI was correlated to C-reactive protein (CRP), lymphocyte count, LOS and all-cause mortality, adjusted for potential confounders.

RESULTS

The median body mass index was 24.1 (25th percentile: 21.1; 75th percentile: 27.8) kg/m² and the mean GNRI 82.2 ± 0.56. A higher risk GNRI was associated with increased CRP levels (p < 0.05) and low lymphocyte counts (p < 0.05) after multivariable adjustment. Moreover, we found positive correlation between a higher risk GNRI and length of hospital stay, whereas, the association with in-hospital mortality was not significant.

CONCLUSIONS

The GNRI correlates well with indicators of inflammation and the length of hospital stay. The routine implementation of the GNRI for the nutritional assessment of older patients could have a significant medical and socio-economic impact.

Acquired hemophilia with inhibitors presenting as an emergency: misinterpretation of clotting results during direct oral anticoagulation

BACKGROUND

Direct oral anticoagulants (DOACs) were recently introduced and are being increasingly prescribed. Most DOACs alter the values of traditional coagulation tests, such as the international normalized ratio (INR) or the activated partial thromboplastin time (aPTT). Although vitamin K antagonists raise the INR value to an extent that mirrors their anticoagulant effect, DOACs do not, in general, alter standard clotting values in any consistent way. Thus, there is a risk that abnormal INR and aPTT values can be misinterpreted.

CASE ILLUSTRATION

A woman taking rivaroxaban, a DOAC, presented with ileus and was scheduled for urgent surgery. A prolonged aPTT was, at first, wrongly attributed to rivaroxaban, delaying the correct diagnosis of autoantibody-associated acquired hemophilia (a rare condition with incidence, 1.34-1.48 cases per million people per year). The patient had a history of unusually intense bleeding in the skin and mucous membranes during anticoagulant treatment. Her aPTT had been prolonged even before any anticoagulants were taken.

COURSE

The operation was delayed to await the elimination of rivaroxaban. The aPTT was still prolonged 24 hours later. The diagnosis of autoantibody-associated acquired hemophilia was suspected and then confirmed by the measurement of a factor VIII residual activity of 1% and the demonstration of factor VIII inhibition at an intensity of 9.2 Bethesda units per mL.

CONCLUSION

The causes of abnormal clotting test results must be clarified before beginning anticoagulant therapy. Unusually intense bleeding during oral anticoagulation should arouse suspicion of a previously undiagnosed acquired coagulopathy, e.g., antibody-associated acquired hemophilia.

Treatment of severe neurological deficits with IgG depletion through immunoadsorption in patients with Escherichia coli O104:H4-associated haemolytic uraemic syndrome: a prospective trial

BACKGROUND

In May 2011, an outbreak of Shiga toxin-producing enterohaemorrhagic E coli O104:H4 in northern Germany led to a high proportion of patients developing post-enteritis haemolytic uraemic syndrome and thrombotic microangiopathy that were unresponsive to therapeutic plasma exchange or complement-blocking antibody (eculizumab). Some patients needed ventilatory support due to severe neurological complications, which arose 1 week after onset of enteritis, suggesting an antibody-mediated mechanism. Therefore, we aimed to assess immunoadsorption as rescue therapy.

METHODS

In our prospective non-controlled trial, we enrolled patients with severe neurological symptoms and confirmed recent E coli O104:H4 infection without other acute bacterial infection or raised procalcitonin concentrations. We did IgG immunoadsorption processing of 12 L plasma volumes on 2 consecutive days, followed by IgG replacement (0·5 g/kg intravenous IgG). We calculated a composite neurological symptom score (lowest score was best) every day and assessed changes before and after immunoadsorption.

FINDINGS

We enrolled 12 patients who initially presented with enteritis and subsequent renal failure; 10 (83%) of 12 patients needed renal replacement therapy by a median of 8·0 days (range 5-12). Neurological complications (delirium, stimulus sensitive myoclonus, aphasia, and epileptic seizures in 50% of patients) occurred at a median of 8·0 days (range 5-15) and mandated mechanical ventilation in nine patients. Composite neurological symptom scores increased in the 3 days before immunoadsorption to 3·0 (SD 1·1, p=0·038), and improved to 1·0 (1·2, p=0·0006) 3 days after immunoadsorption. In non-intubated patients, improvement was apparent during immunoadsorption (eg, disappearance of aphasia). Five patients who were intubated were weaned within 48 h, two within 4 days, and two patients needed continued ventilation for respiratory problems. All 12 patients survived and ten had complete neurological and renal function recovery.

INTERPRETATION

Antibodies are probably involved in the pathogenesis of severe neurological symptoms in patients with E coli O104:H4-induced haemolytic uraemic syndrome. Immunoadsorption can safely be used to rapidly ameliorate these severe neurological complications.

FUNDING

Greifswald University and Hannover Medical School.

[Assessment and implementation of guidelines]

The importance of guidelines increases continuously on the political level whereas on the user level reservations and uncertainty persist. Consequently guidelines are not considered as they should be. Guidelines will develop their effectiveness only if they are firmly implemented in the delivery process. Acceptance problems spring from problems in development and from aspects of dissemination and implementation not sufficiently considered so far. Therefore a lot of countries have developed quality criteria for guidelines and programmes for quality promotion. To further the use of guidelines in the care process aspects of dissemination and implementation have to be recognized even in the development process. This has not been recognized sufficiently so far. Implementation of guidelines is a systematic approach which has to be connected seamlessly with other activities (e. g. quality management). The implementation process should be accompanied and evaluated so that a continuous adjustment is possible. Most of the existing guideline programmes do not consider this sufficiently. The following contribution gives a survey of results and introduces means and instruments for assessment and implementation of guidelines.

MedCIRCLE: collaboration for Internet rating, certification, labelling and evaluation of health information on the World-Wide-Web

We describe MedCIRCLE, an EU-funded semantic web project to implement the first steps towards a global, collaborative rating and guidance system for health information proposed in the MedCERTAIN project. In MedCIRCLE, three European gateway sites for consumer health information will implement the metadata vocabulary HIDDEL (Health Information Disclosure, Description and Evaluation Language). HIDDEL allows portals and gateways to make the results of their evaluations accessible as XML/RDF. The three participating national portals are: AQUMED (Agency for Quality in Medicine) patienten-information, de, COMB (Official Medical College of Barcelona) and CISMeF, a quality-controlled health gateway developed at Rouen University Hospital. Other health subject gateways, accreditation, or rating services are invited to join the collaboration simply by implementing HIDDEL on their gateways. Widespread implementation HIDDEL will allow intelligent agents or client-side software to harvest statements and opinions about the trustworthiness of other websites, assisting users in selecting trustworthy websites. The MedCIRCLE project builds on, expands and continues work on rating health information on the Internet piloted within the MedCERTAIN project. While MedCERTAIN provided the core technologies and software for rating and "trustmarking" health information, MedCIRCLE is built around these technologies and involves a wider medical community to assess health information, demonstrating the power of collaborative and interoperable evaluations in a semantic web environment. MedCIRCLE is a project with the overall objective to develop and promote technologies able to guide consumers to trustworthy health information on the Internet, to establish a global web of trust for networked health information, and to empower consumers to positively select high quality health information on the web. Other aims include refinement and expansion of HIDDEL, to become a standard vocabulary and interchange format for self- and third-party ratings of health information.

[Current initiatives in Germany for translating national guidelines into reality - a survey]

The role of practice guidelines as a tool for quality management in health care is now widely accepted in Germany- not only by health professionals, but also in politics. The physicians' professional associations as well as health care authorities (physicians' self-governmental bodies) and parliament introduced several incentives and regulations, aiming at a regular use of guidelines in health care. Among these the German guideline clearinghouse with the systematic approach towards identification, dissemination, and implementation of best available evidence-based guidelines, as well as the country-wide implementation of disease management guidelines seem to be effective and efficient in quality management as well as in patient care management in the German health care system. The article gives an overview on background, procedures and barriers to country-wide implementation of clinical practice guidelines within a social security health care system.