OP0269 BIOMARKERS TO PREDICT RISK OF VENOUS THROMBOEMBOLISM IN PATIENTS WITH RHEUMATOID ARTHRITIS RECEIVING TOFACITINIB OR TUMOUR NECROSIS FACTOR INHIBITORS

Background

In the ORAL Surveillance study of patients (pts) aged ≥50 yrs with moderate to severe rheumatoid arthritis (RA) and ≥1 additional cardiovascular risk factor (NCT02092467), the incidence of pulmonary embolism was higher with tofacitinib than with tumour necrosis factor inhibitors (TNFi).1

Objectives

To explore whether biomarkers explained the associations of tofacitinib vs TNFi with venous thromboembolism (VTE) in ORAL Surveillance.

Methods

ORAL Surveillance was a prospective, open-label, event-driven, noninferiority, post-authorisation safety study. Pts were randomised 1:1:1 to receive tofacitinib 5 or 10 mg twice daily or a TNFi (adalimumab 40 mg every 2 weeks or etanercept 50 mg once weekly). For this exploratory post hoc analysis, 294 soluble, proteomic, genetic and antibody biomarkers were assessed (of which 79 have a known role in inflammation, coagulation, vascular biology and/or Janus kinase signalling). Biomarkers were quantified in serum collected at baseline (BL) and Month (M)12 in VTE cases and 4:1 matched controls. D-dimer was analysed with a larger control group (all eligible pts without VTE) and final adjudicated data from BL, M12 and study end.

Results

Of the 4362 randomised and treated pts, D-dimer was quantified in 3732 pts (54 with VTE; 3678 without) and the remaining biomarkers were analysed in 285 pts (57 VTE cases; 228 matched controls). BL characteristics were generally similar in those with or without VTE and between treatment groups. At BL, D-dimer levels were ≥2×upper limit of normal for ~50% of controls and 67% of VTE cases. Mean D-dimer levels decreased from BL to M12 in controls across treatment groups (Figure 1). Key findings from the biomarker analyses are shown in the Table 1. No biomarker showed a clear mechanistic association with the increased risk of VTE for tofacitinib vs TNFi, or demonstrated adequate performance for prognostic use in pts with RA.

Table 1.

Summary of results from biomarker analyses

BiomarkerKey resultsTier 1C-reactive protein•No association with VTE in any treatment arm at BL or M12D-dimer Thrombopoietin•Higher M12 levels were prospectively associated with greater risk of subsequent VTE with tofacitinib 10 mg BID ◦ For D-dimer, the same effect was observed with tofacitinib 5 mg BID •Treatment specificity of effects could not be establishedTier 2Factor VIII Thrombin–antithrombin complex Tissue factor pathway inhibitor Plasminogen activator inhibitor-1 Protein C Antithrombin Apolipoprotein C-III Leptin•No clinically meaningful differences across treatment armsTiers 3 & 4Exploratory proteomic assays (276 markers from multiplex panels)•Two biomarkers with no known relationship to VTE (angiogenin and TNFSF13B) showed significant associations with pulmonary embolism in the tofacitinib 10 mg BID arm ◦ Treatment specificity of effects could not be established for either analyteGenetic biomarkersFactor V Leiden R506Q, prothrombin G20210A and JAK2 V617F mutations•Factor V Leiden and prothrombin risk alleles, individually or combined, were associated with increased incidence of VTE but did not explain excess events with tofacitinib •No VTE cases or matched controls had the JAK2 mutationAntibody biomarkersACA IgG and IgM, anti-β2GP1 IgG and IgM•No statistical differences were observed between treatment arms or between VTE cases and matched controls

ACA, anticardiolipin antibody; β2GP1, beta-2-glycoprotein 1; IgG, immunoglobulin G; IgM, immunoglobulin M; JAK2, Janus kinase 2; TNFSF13B, tumour necrosis factor ligand superfamily member 13B

Conclusion

This post hoc exploratory analysis did not identify biomarkers at BL or M12 that explain the increased VTE risk for tofacitinib vs TNFi. Notably, ORAL Surveillance was neither designed nor powered to compare the risk of VTE across treatments or to identify biomarkers with a mechanistic relationship to VTE. Individual VTE risk should be considered when making decisions about initiation or maintenance of tofacitinib treatment.

References

[1]Ytterberg et al. N Engl J Med 2022; 386: 316-326.

Acknowledgements

Study sponsored by Pfizer Inc. Medical writing support was provided by Julia King, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests

Zoltán Szekanecz Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer Inc, Roche and Sanofi, Paid instructor for: AbbVie, Eli Lilly, Gedeon Richter, Novartis, Pfizer Inc and Roche, Consultant of: AbbVie, Eli Lilly, Novartis, Pfizer Inc, Roche and Sanofi, Grant/research support from: Pfizer Inc, Christina Charles-Schoeman Consultant of: AbbVie, Gilead Sciences, Pfizer Inc and Sanofi-Regeneron, Grant/research support from: AbbVie, Bristol-Myers Squibb and Pfizer Inc, Ivana Vranic Shareholder of: Pfizer Inc, Employee of: Pfizer Ltd, Burak Sahin Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Sara A Paciga Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Zhenyu Wang Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Craig Hyde Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, David Martin Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Jeffrey I Weitz Speakers bureau: Anthos, Bayer AG, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Ionis, Janssen, Novartis, Pfizer Inc, PhaseBio, Portola and Servier Pharmaceuticals, Grant/research support from: Bayer AG and Boehringer Ingelheim

Widespread white matter microstructural differences in schizophrenia across 4322 individuals: results from the ENIGMA Schizophrenia DTI Working Group

The regional distribution of white matter (WM) abnormalities in schizophrenia remains poorly understood, and reported disease effects on the brain vary widely between studies. In an effort to identify commonalities across studies, we perform what we believe is the first ever large-scale coordinated study of WM microstructural differences in schizophrenia. Our analysis consisted of 2359 healthy controls and 1963 schizophrenia patients from 29 independent international studies; we harmonized the processing and statistical analyses of diffusion tensor imaging (DTI) data across sites and meta-analyzed effects across studies. Significant reductions in fractional anisotropy (FA) in schizophrenia patients were widespread, and detected in 20 of 25 regions of interest within a WM skeleton representing all major WM fasciculi. Effect sizes varied by region, peaking at (d=0.42) for the entire WM skeleton, driven more by peripheral areas as opposed to the core WM where regions of interest were defined. The anterior corona radiata (d=0.40) and corpus callosum (d=0.39), specifically its body (d=0.39) and genu (d=0.37), showed greatest effects. Significant decreases, to lesser degrees, were observed in almost all regions analyzed. Larger effect sizes were observed for FA than diffusivity measures; significantly higher mean and radial diffusivity was observed for schizophrenia patients compared with controls. No significant effects of age at onset of schizophrenia or medication dosage were detected. As the largest coordinated analysis of WM differences in a psychiatric disorder to date, the present study provides a robust profile of widespread WM abnormalities in schizophrenia patients worldwide. Interactive three-dimensional visualization of the results is available at www.enigma-viewer.org.

GBA mutations in Parkinson disease: earlier death but similar neuropathological features

BACKGROUND AND PURPOSE

Mutations in the glucocerebrosidase (GBA) gene are known to be a risk factor for Parkinson's disease (PD). Data on clinicopathological correlation are limited. The purpose of this study was to determine the clinicopathological findings that might distinguish PD cases with and without mutations in the GBA gene.

METHODS

Data from the Arizona Study of Aging and Neurodegenerative Disorders were used to identify autopsied PD cases that did or did not have a GBA gene mutation. Clinical and neuropathological data were compared.

RESULTS

Twelve PD cases had a GBA mutation and 102 did not. The GBA mutation cases died younger (76 vs. 81 years of age) but there was no difference in disease duration or clinical examination findings. No neuropathological differences were found in total or regional semi-quantitative scores for Lewy-type synucleinopathy, senile plaques, neurofibrillary tangles, white matter rarefaction or cerebral amyloid angiopathy scores.

CONCLUSIONS

In longitudinally assessed, autopsied PD cases, those with GBA mutations had a younger age at death but there was no evidence for clinical or neuropathological differences compared to cases without GBA mutations. Due to the small GBA group size, small differences cannot be excluded.

Genome-wide association study of borderline personality disorder reveals genetic overlap with bipolar disorder, major depression and schizophrenia

Borderline personality disorder (BOR) is determined by environmental and genetic factors, and characterized by affective instability and impulsivity, diagnostic symptoms also observed in manic phases of bipolar disorder (BIP). Up to 20% of BIP patients show comorbidity with BOR. This report describes the first case-control genome-wide association study (GWAS) of BOR, performed in one of the largest BOR patient samples worldwide. The focus of our analysis was (i) to detect genes and gene sets involved in BOR and (ii) to investigate the genetic overlap with BIP. As there is considerable genetic overlap between BIP, major depression (MDD) and schizophrenia (SCZ) and a high comorbidity of BOR and MDD, we also analyzed the genetic overlap of BOR with SCZ and MDD. GWAS, gene-based tests and gene-set analyses were performed in 998 BOR patients and 1545 controls. Linkage disequilibrium score regression was used to detect the genetic overlap between BOR and these disorders. Single marker analysis revealed no significant association after correction for multiple testing. Gene-based analysis yielded two significant genes: DPYD (P=4.42 × 10-7) and PKP4 (P=8.67 × 10-7); and gene-set analysis yielded a significant finding for exocytosis (GO:0006887, PFDR=0.019; FDR, false discovery rate). Prior studies have implicated DPYD, PKP4 and exocytosis in BIP and SCZ. The most notable finding of the present study was the genetic overlap of BOR with BIP (rg=0.28 [P=2.99 × 10-3]), SCZ (rg=0.34 [P=4.37 × 10-5]) and MDD (rg=0.57 [P=1.04 × 10-3]). We believe our study is the first to demonstrate that BOR overlaps with BIP, MDD and SCZ on the genetic level. Whether this is confined to transdiagnostic clinical symptoms should be examined in future studies.

Potassium channel gene associations with joint processing speed and white matter impairments in schizophrenia

Patients with schizophrenia show decreased processing speed on neuropsychological testing and decreased white matter integrity as measured by diffusion tensor imaging, two traits shown to be both heritable and genetically associated indicating that there may be genes that influence both traits as well as schizophrenia disease risk. The potassium channel gene family is a reasonable candidate to harbor such a gene given the prominent role potassium channels play in the central nervous system in signal transduction, particularly in myelinated axons. We genotyped members of the large potassium channel gene family focusing on putatively functional single nucleotide polymorphisms (SNPs) in a population of 363 controls, 194 patients with schizophrenia spectrum disorder (SSD) and 28 patients with affective disorders with psychotic features who completed imaging and neuropsychological testing. We then performed three association analyses using three phenotypes - processing speed, whole-brain white matter fractional anisotropy (FA) and schizophrenia spectrum diagnosis. We extracted SNPs showing an association at a nominal P value of <0.05 with all three phenotypes in the expected direction: decreased processing speed, decreased FA and increased risk of SSD. A single SNP, rs8234, in the 3' untranslated region of voltage-gated potassium channel subfamily Q member 1 (KCNQ1) was identified. Rs8234 has been shown to affect KCNQ1 expression levels, and KCNQ1 levels have been shown to affect neuronal action potentials. This exploratory analysis provides preliminary data suggesting that KCNQ1 may contribute to the shared risk for diminished processing speed, diminished white mater integrity and increased risk of schizophrenia.

Genome-wide association study identifies multiple novel loci associated with disease progression in subjects with mild cognitive impairment

Alzheimer's disease (AD) is the leading cause of dementia among the elderly population; however, knowledge about genetic risk factors involved in disease progression is limited. We conducted a genome-wide association study (GWAS) using clinical decline as measured by changes in the Clinical Dementia Rating-sum of boxes as a quantitative trait to test for single-nucleotide polymorphisms (SNPs) that were associated with the rate of progression in 822 Caucasian subjects of amnestic mild cognitive impairment (MCI). There was no significant association with disease progress for any of the recently identified disease susceptibility variants in CLU, CR1, PICALM, BIN1, EPHA1, MS4A6A, MS4A4E or CD33 following multiple testing correction. We did, however, identify multiple novel loci that reached genome-wide significance at the 0.01 level. These top variants (rs7840202 at chr8 in UBR5: P=4.27 × 10(-14); rs11637611 with a cluster of SNPs at chr15q23 close to the Tay-Sachs disease locus: P=1.07 × 10(-15); and rs12752888 at chr1: P=3.08 × 10(-11)) were also associated with a significant decline in cognition as well as the conversion of subjects with MCI to a diagnosis of AD. Taken together, these variants define approximately 16.6% of the MCI sub-population with a faster rate of decline independent of the other known disease risk factors. In addition to providing new insights into protein pathways that may be involved with the progress to AD in MCI subjects, these variants if further validated may enable the identification of a more homogeneous population of subjects at an earlier stage of disease for testing novel hypotheses and/or therapies in the clinical setting.