A randomized, cross-over study to evaluate the safety, tolerability, pharmacokinetics, and pharmacodynamics of milvexian with single and dual antiplatelet therapy in healthy participants

Background

According to scientific evidence, modulation of Factor XI (FXI) function may provide a novel mechanism for systemic anticoagulation without increasing the risk of clinically relevant bleeding in a variety of conditions associated with a high risk of thrombotic events. Milvexian (BMS-986177/JNJ-70033093) is an oral small molecule that binds reversibly to and inhibits the active form of FXI (FXIa) with high affinity and selectivity. Depending on the patient population, milvexian is expected to provide benefit to patients as replacement or add on therapy to current guideline-recommended antithrombotic agents which include aspirin and/or clopidogrel.

Purpose

This DDI study aimed to investigate the safety and to identify possible pharmacokinetic (PK) or pharmacodynamic (PD) interaction of milvexian when co-administered with aspirin and/or clopidogrel.

Methods

The study consisted of 3 parts, each of which was a single DDI study using a randomized, 3-period, 3-treatment crossover design. Six unique treatment sequences were utilized in the study. Milvexian was placebo controlled and blinded when co-administered with aspirin and clopidogrel (Part 1), with clopidogrel (Part 2), or with aspirin (Part 3). In each case the subjects crossed over to milvexian monotherapy. Subjects were randomly assigned into 1 part of the study only.

Results

Overall, multiple dose milvexian 200 mg given BID for 5 days with and without dual antiplatelet therapy (clopidogrel given as 300 mg on Day 1 followed by 4 days of 75 mg clopidogrel, and aspirin 325 mg once daily given for 5 days) was safe and well tolerated. There were 8 mild bleeding adverse events (AEs) reported from 5 subjects in various treatment groups; no trend towards increased bleeding potential was observed when milvexian was co-administered with dual antiplatelet therapy or separately with aspirin or clopidogrel. After co-administration of aspirin and clopidogrel with milvexian, peak (Cmax) and total exposure [AUC(TAU)] of milvexian were reduced 17% and 15%, respectively, on Day, 1 but were not changed on Day 5, compared to milvexian administered alone. After co-administration of clopidogrel or aspirin separately with milvexian, peak and total exposures of milvexian were not changed, compared to milvexian administered alone. Exposure-dependent prolongation of activated partial thromboplastin time (aPTT) and reduction of Factor XI clotting activity (FXIc) were observed with milvexian administration. Effects were similar when milvexian was administered alone or in combination with aspirin and/or clopidogrel.

Conclusion

This Phase 1 study in healthy adults demonstrated administration of milvexian alone or in combination with aspirin and/or clopidogrel was not associated with a trend towards AE's including bleeding. Milvexian steady-state exposure and PD effects were similar when milvexian was administered alone or in combination with aspirin and/or clopidogrel.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Bristol Myers Squibb and Janssen Pharmaceuticals

Single-dose pharmacokinetics of BMS-986177/JNJ-70033093 in participants with mild or moderate hepatic impairment compared to healthy participants

Background

According to the scientific evidence accumulated to date (ie, genetic, epidemiological, preclinical, clinical), the modulation of Factor XI (FXI) function may provide a novel mechanism for systemic anticoagulation without increasing the risk of clinically significant bleeding in a variety of conditions predisposing patients to a high risk of thrombotic or bleeding events. BMS-986177/JNJ-70033093 (BMS-177/JNJ-3093) is a small molecule that inhibits the active form of FXI (FXIa) with high affinity and selectivity. Depending on the indication, BMS-177/JNJ-3093 may provide benefit to patients as add-on or potentially replacement therapy to the current standard of care antithrombotic agents. Patients with hepatic impairment may have an increased risk of bleeding when using existing antithrombotic agents and therefore may benefit from drugs with an improved safety profile.

Purpose

To assess the effect of mild or moderate hepatic impairment on the pharmacokinetic (PK) properties of BMS-177/JNJ-3093.

Methods

This was a multicenter, open-label, non-randomized, single-dose study. A single 60-mg oral dose of BMS-177/JNJ-3093 was administered to 9 participants with mild hepatic impairment (Child-Pugh class A), 8 participants with moderate hepatic impairment (Child-Pugh class B), and 9 healthy participants with normal hepatic function. Healthy participants were matched to participants with hepatic impairment in each Child-Pugh class with regard to body weight. To assess the effects of hepatic impairment on BMS-177/JNJ-3093 PK, an analysis of variance was performed on the natural log-transformed Cmax, AUC(INF), and AUC(0-T) with hepatic function group as a fixed effect.

Results

BMS-177/JNJ-3093 was well tolerated when administered as an oral dose of 60 mg in participants with mild or moderate hepatic impairment and healthy participants with normal hepatic function. There were no deaths, serious adverse events (AEs), severe AEs, bleeding AEs, or discontinuations due to an AE reported during the study. The geometric mean ratios (GMRs) (90% CI) comparing mild hepatic impairment to normal hepatic function were 1.180 (0.735, 1.895) and 1.168 (0.725, 1.882) for total BMS-177/JNJ-3093 maximum concentration (Cmax) and area under the curve from time 0 to infinity (AUC(INF)), respectively. The GMRs (90% CI) comparing moderate hepatic impairment to normal hepatic function were 1.140 (0.699, 1.857) and 0.996 (0.609, 1.628) for total BMS-177/JNJ-3093 Cmax and AUC(INF), respectively. Overall, levels of activated partial thromboplastin time (aPTT) increased in an exposure-related manner following single oral doses of 60 mg BMS-177/JNJ-3093 in all groups.

Conclusion

BMS-177/JNJ-3093 was well tolerated in the normal healthy participants and those with mild or moderate hepatic impairment. The observed changes indicate that a dose adjustment in these populations may not be necessary.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): This work was sponsored by Bristol-Myers Squibb and Janssen Research & Development, LLC

Diabetes Screening in Canada (DIASCAN) Study: prevalence of undiagnosed diabetes and glucose intolerance in family physician offices

OBJECTIVE

To assess the prevalence of undiagnosed diabetes and glucose intolerance in individuals > or =40 years of age who contacted their family physician for routine care.

RESEARCH DESIGN AND METHODS

The study used a stratified randomized selection of family physicians across Canada that was proportional to provincial and urban/rural populations based on Statistics Canada Census data (1996). Consecutive patients > or =40 years of age were screened for diabetes. If a casual fingerprick blood glucose was >5.5 mmol/l, the patient returned for a fasting venous blood glucose test. If the fasting blood glucose was 6.1-6.9 mmol/l, a 2-h 75-g post-glucose load venous blood glucose was obtained. Results of these tests were used to classify patients in diagnostic categories.

RESULTS

Data were available for 9,042 patients. Previously undiagnosed diabetes was discovered in 2.2% of the patients, and new glucose intolerance was found in an additional 3.5% of patients. Overall, 16.4% of patients had previously known diabetes. The decrease in fasting plasma glucose criterion from 7.8 to 7.0 mmol/l resulted in a 2.2% versus a 1.6% prevalence of new diabetes. Several risk factors were reported in a significantly greater proportion of patients with new glucose intolerance and either new and known diabetes compared with the normal glucose tolerance group of patients.

CONCLUSIONS

Routine screening for diabetes by family physicians is justified in patients > or =40 years of age, given the finding of previously undiagnosed diabetes in 2.2% of these patients and newly diagnosed glucose intolerance in an additional 3.5% of these patients. Another 16.4% of primary care patients > or =40 years of age have known diabetes. This has important implications regarding health resources and physician education.

Modafinil: a double-blind multicentric study

Modafinil is a central putative alpha-1 postsynaptic agonist with vigilance-promoting properties. Fifty narcoleptics (33 male and 17 female) participated in a multicentric study aimed at assessing the effects of the compound on night sleep, feeling on awakening, excessive daytime sleepiness and cataplexy. Modafinil was administered in a double-blind cross-over design at a daily dosage of 300 mg versus placebo. The duration of the study was 12 weeks, including a 2-week "run in" period with placebo, a first 4-week treatment period with either modafinil or placebo, a 2-week wash-out period with placebo and a second 4-week treatment period with either placebo or modafinil. Daily evaluation was based on a sleep log, visual analog scales, a sleep questionnaire and a clinical global index. Sleep laboratory evaluation took place on nights 1, 28, 42 and 70. It included 1 night of polysomnography preceded by a questionnaire on therapeutic and side effects, and a maintenance of wakefulness test (MWT). Sleep logs did not show any modification of night sleep, but a reduction of daytime sleepiness and sleep. Feeling on awakening was not modified. An overall benefit was noted by physicians as well as by patients. MWT disclosed a positive effect of modafinil on excessive daytime sleepiness. Cataplexy was not modified.

Factors associated with low cognitive performance in general practice

In the preparatory phase of a randomised controlled trial data were collected to assess the magnitude of changes on cognitive functions in 1628 volunteers (age range 45-75 years) that were recruited from general practitioners' patient population. Subjects were administered a short neuropsychological battery of tests including three paper-and-pencil tests, which assessed immediate recall, delayed memory, and attention. Being on antihypertensive medication was associated with low results for all three tests in every age group, and in all strata according to blood pressure levels. Psychotropic drug use was correlated with low results for all three tests. Differences between psychotropic drug users and nonusers increased with age. Antihypertensive treatment and psychotropic drug use seem to be important to consider in longitudinal studies of cognitive decline in aging.

Are automobile head restraints used effectively?

Observation of 992 motor vehicles and their drivers revealed that most drivers do not have their head restraints effectively positioned. Improper positioning was more common with adjustable restraints, in commercial vehicles, and among male drivers. Some head restraints could not be adjusted properly. Improvements in headrest adjustment might help decrease morbidity in motor vehicle accidents.

Effects of modafinil on symptomatology of human narcolepsy

We studied the effects of modafinil, a putative central alpha-1 agonist, on the excessive daytime sleepiness (EDS) of 10 narcoleptic patients while using a double-blind design and objective measurements of vigilance. There were two treatment periods, in which either modafinil or placebo was used; each lasted four weeks and was preceded by a 2-week "run-in" period and separated by a 2-week "wash-out" period. The effects of treatment on EDS were evaluated by daily home questionnaires and a psychomotor performance test, the Four Choice Reaction Time Test (FCRTT). Modafinil reduced the daily number of sleep attacks significantly, and markedly improved performances during the FCRTT. Results of this study suggest that modafinil is effective in treating EDS in narcolepsy, and that noradrenergic mechanisms could be involved in the physiopathology of EDS in that disorder.

[Effect of phloroglucinol on rectosigmoid motility stimulated by a test meal. Study in patients with irritable bowel syndrome]

Twenty patients (15 women, 5 men, mean age: 46.3 +/- 11.82 years, mean weight: 70.9 +/- 8.83 kg) presenting with a 8.5 +/- 4.7 years' history of irritable bowel syndrome associated predominantly with postprandial abdominal pain were recruited into the study. They underwent, after an enema, a rectosigmoid manometry (4 channels, low compliant infusion pump and catheters) before and after a 1000 kcal standardized meal. At the end of the meal they were administered intravenously phloroglucinol (two 40 mg ampoules) or placebo (two ampoules). Both treatments were strictly similar and the order of administration was randomly assigned Motor activity at the rectum, rectosigmoid, lower sigmoid and sigmoid level was determined using a motor index calculated for each 15 min period. Three preprandial and four postprandial indices were calculated. Both groups were statistically similar for sex ratio, age and history of disease. A slight difference was noted for mean weight: the caloric instake per kg of weight was a little higher in the phloroglucinol group. Mean preprandial indices were comparable in both groups. Variance analysis showed that the increase in postprandial motor indices was statistically less pronounced in the phloroglucinol group than in the placebo group. In the placebo group a clear cut increase in motor activity was assessed, which was not observed in the phloroglucinol group. This variation of motricity, which was observed at every level, was more pronounced for the first two postprandial indices than for the last two ones. These results suggest that phloroglucinol is able to reduce rectosigmoid motor response after a test meal. This could explain its activity in abdominal pain associated with irritable bowel syndrome.

Glucose Control and Diabetic Complications: Is tight control of IDDM justified?

Tight glucose control is clearly beneficial in the pregnant insulin-dependent diabetic. In other areas (retinopathy, established nephropathy, and hypoglycemia) the question whether tight control of diabetes is justified remains unanswered. Preliminary evidence suggests that tight control, if begun early, can prevent clinical nephropathy and neuropathy.

[Noradrenaline and cerebral aging]

The central functions of norepinephrine (NE) are a recent discovery: regulation of alertness and of the wakefulness-sleep cycle, maintenance of attention, memory and learning, cerebral plasticity and neuro-protection. The anatomical, histological, biochemical and physiological properties of the central noradrenergic system: extreme capacity for ramification and arborization; slow conduction, non-myelinized axons with extrasynaptic varicosities producing and releasing NE; frequency of co-transmission phenomena, and; neuromodulation with fiber effect responsible for improvement in the signal over background noise ratio and selection of significant stimuli form a true interface between the outside world and the central nervous system, notably for the neocortex in the context of the cognitive treatment of information. This central noradrenergic system is involved in the neurophysiology and the clinical features of cerebral aging (ideation-motor and cognitive function slowing down, loss of behavioral adjustment), neuro-degenerative disorders (SDAT, Parkinson's disease), certain aspects of depression and less obvious conditions (head injuries, sequelae of cerebrovascular accidents, sub-cortical dementia). The recent development of medications improving alertness (adrafinil, modafinil) with a pure central action and specifically noradrenergic, may contribute to an improvement in these multifactorial disorders.

The appropriate use of oxygen

The scientific evidence for the efficacy of oxygen therapy in acute hypoxemia is limited. In chronic hypoxemia continuous oxygen therapy appears to decrease mortality. Current indications for oxygen treatment are PaO(2) less than 60 in acute hypoxemia and less than 55 in chronic hypoxemia. Physical and physiological hazards of oxygen are reviewed. Three syndromes of pulmonary oxygen toxicity are described: tracheobronchitis, adult respiratory distress syndrome, and bronchopulmonary dysplasia.

Family-practice anesthesia in british columbia

This study of family practitioners as anesthetists is based on data extracted from records of the Medical Services Plan of British Columbia. During the period from 1976 to 1986, the proportion of anesthetics that were administered by non-certified anesthetists declined from 28.3% to 22.1% of the total number. Small and medium-sized hospitals continue to depend on family-physician anesthetists. Family practitioners make up 96.9% of all anesthetists practising in hospitals with fewer than 50 beds and 88.2% of anesthetists in hospitals with 50-99 beds. Rural areas are served almost exclusively by family-practice anesthetists, since 16 of 29 B.C. regional districts have one or no certified anesthetists. The author discusses the implications of this situation for the future of family-practice anesthesia.

[Sudden death during continous electrocardiographic recording by Holter's method]

The case of a 79 year old patient who died during continuous electrocardiographic recording by Holter monitoring is reported. There was a previous history of respiratory insufficiency, postero diaphragmatic myocardial infarction and left hemiplegia. Death occurred suddenly at home after defecation. Analysis of the recording showed multiple polymorphic ventricular extra-systoles, often occuring in doublets at the beginning of the record. Death was caused by a salvo of three ventricular extrasystoles triggering ventricular tachycardia which rapidly degraded to irreversible ventricular fibrillation. This major arrhythmia may have been due either to adrenergic stimulation from the effort of defecation or to acute myocardial infarction. This case underlies the value of Holter monitoring in the assessment of the gravity of an arrhythmia. It is also of interest because of the absence of an R on T phenomenon before the terminal event.