Decentralising DOT for drug-susceptible TB from the health facilities to the community level in Togo

In Togo, the COVID-19 pandemic paved the way for decentralising directly observed treatment (DOT) to the community level through the evaluation of two innovative community-based DOT approaches-a community health worker-based (CHW-DOT) and family-based (FB-DOT). METHODS We conducted an observational prospective study from April 2021 to January 2022. Sputum conversion at Month 2 and favourable treatment outcomes at Month 6 were assessed and compared between the two groups. Sociodemographic and clinical factors related to these outcomes were identified. RESULTS A total of 182 TB patients were enrolled. The CHW-DOT group had significantly increased odds of sputum conversion (aOR 2.95, 95% CI 1.09-7.98) and lower odds of unsuccessful treatment outcomes (aOR 0.37, 95% CI 0.13-1.1). Non-smokers had 4.85 higher odds of converting than smokers (aOR 4.85, 95% CI 1.76-13.42) and lower odds of an unsuccessful treatment than smokers (aOR 0.11, 95% CI 0.04-0.32). CONCLUSION CHW-DOT is associated with higher sputum smear conversion rates and a more favourable treatment outcome. The use of tobacco, significantly associated with outcomes, also suggests that a smoking cessation component may be a valuable adjunct to a CHW-DOT approach during TB treatment..

Extracardiac Manifestations Fail to Predict the Severity of Cardiac Phenotype in Children and Young Adults with Marfan Syndrome

We performed a secondary analysis of the Pediatric Heart Network Marfan Trial public-use database to evaluate associations between extracardiac features and cardiac and aortic phenotypes in study participants. Aortic aneurysm phenotype was defined as aortic root Z-score ≥ 4.5, aortic root growth rate ≥ 75th percentile, aortic dissection, and aortic surgery. Severe cardiac phenotype was defined as aortic dissection, aortic Z-score ≥4.5, aortic valve surgery, at least moderate mitral regurgitation, mitral valve surgery, left ventricular dysfunction, or death. Extracardiac manifestations were characterized by specific organ system involvement and by a novel aggregate extracardiac score that was created for this study based on the original Ghent nosology. Logistic regression analysis compared aggregate extracardiac score and systems involvement to outcomes. Of 608 participants (60% male), the median age at enrollment was 10.8 years (interquartile range: 6, 15.4). Aortic aneurysm phenotype was observed in 71% of participants and 64% had severe cardiac phenotype. On univariate analysis, skeletal (OR: 1.95, 95% CI: 1.01, 3.72; p = 0.05), skin manifestation (OR: 1.62, 95% CI: 1.13, 2.34; p = 0.01) and aggregate extracardiac score (OR: 1.17, 95% CI: 1.02, 1.34; p = 0.02) were associated with aortic aneurysm phenotype but were not significant in multivariate analysis. There was no association between extracardiac manifestations and severe cardiac phenotype. Thus, the severity of cardiac manifestations in Marfan syndrome was independent of extracardiac phenotype and aggregate extracardiac score. Severity of extracardiac involvement did not appear to be a useful clinical marker for cardiovascular risk-stratification in this cohort of children and young adults with Marfan syndrome.

Prospective Comparative Study of Quality of Life in Bladder Cancer Patients Undergoing Cystectomy or Bladder Preservation

PURPOSE/OBJECTIVE(S)

Health-related Quality of life (HRQOL) may be decisive when different treatments yield comparable survival outcomes. We compared QOL in patients undergoing radical cystectomy with ileal conduit (RCIC) or bladder preservation (BP) with (chemo)radiotherapy for bladder cancer.

MATERIALS/METHODS

Patients with histological diagnosis of bladder cancer, stage T1-T4, N0-N1, M0 with a minimum follow-up of 6 months from the last treatment intervention (RCIC or BP) and alive without disease at the time of QOL assessment were eligible for inclusion. After ethics committee approval, two HRQOL instruments were translated, validated and administered: Bladder cancer index (BCI) for bladder cancer-specific HRQOL, which includes 36 items under three domains - bladder, bowel and sexual function and the EORTC QLQ C30 which includes 30 items under three domains - functional, symptom and global health. The mean QOL scores across various domains and specific questions were compared between the two treatment groups using the independent t-test.

RESULTS

Of the 104 patients enrolled, 56 had RCIC, and 48 received BP, and included 95 (91.3%) males. The median time from treatment completion to QOL assessment was 22 months (IQR 10-56). The median age for the entire cohort was 62 years (IQR 55-68), 65.5 years (IQR 55-71) in BP and 59.5 years (IQR 55-66) in RCIC. Overall, mean BCI urinary scores and bowel scores were high in both groups, with no significant difference in function or bother subdomains between the two groups (Table 1). Overall, BCI sexual scores were low in both the groups but significantly better after BP (BPmean 56.9, RCICmean 41.5, p = 0.01). Mean scores for sexual function BPmean 38.4 and RCIC mean 25 p (0.07) and sexual bother BPmean 81 RCICmean 62 (p 0.02) subdomains. There was no significant difference in EORTC QOL outcomes in functional (BPmean 91.4, RCICmean 88.7 p 0.23), symptom (BPmean 89.8, RCICmean 89, p = 0.68) and global health scale (BPmean 76.8, RCICmean 78.5, p = 0.69) in both groups. On question-wise assessment, the ability to perform an exercise (BPmean 94.2, RCICmean 85, p = 0.06) and urinary leakage at night time (BPmean 91.7, RCICmean 77.6, p = 0.01) were better in the BP group, while scores for blood in the urine (BPmean 89.1, RCICmean 97, p = 0.05) were better in the RCIC group compared to BP.

CONCLUSION

Overall, QOL was good in both groups in the urinary and bowel domains while it was low in the sexual domain. However, bladder preservation performed significantly better in the sexual domain than RCIC.

Cardiac Magnetic Resonance Imaging to Determine Single Ventricle Function in a Pediatric Population is Feasible in a Large Trial Setting: Experience from the Single Ventricle Reconstruction Trial Longitudinal Follow up

The Single Ventricle Reconstruction (SVR) Trial was a randomized prospective trial designed to determine survival advantage of the modified Blalock-Taussig-Thomas shunt (BTTS) vs the right ventricle to pulmonary artery conduit (RVPAS) for patients with hypoplastic left heart syndrome. The primary aim of the long-term follow-up (SVRIII) was to determine the impact of shunt type on RV function. In this work, we describe the use of CMR in a large cohort follow up from the SVR Trial as a focused study of single ventricle function. The SVRIII protocol included short axis steady-state free precession imaging to assess single ventricle systolic function and flow quantification. There were 313 eligible SVRIII participants and 237 enrolled, ages ranging from 10 to 12.5 years. 177/237 (75%) participants underwent CMR. The most common reasons for not undergoing CMR exam were requirement for anesthesia (n = 14) or ICD/pacemaker (n = 11). A total of 168/177 (94%) CMR studies were diagnostic for RVEF. Median exam time was 54 [IQR 40-74] minutes, cine function exam time 20 [IQR 14-27] minutes, and flow quantification time 18 [IQR 12-25] minutes. There were 69/177 (39%) studies noted to have intra-thoracic artifacts, most common being susceptibility artifact from intra-thoracic metal. Not all artifacts resulted in non-diagnostic exams. These data describe the use and limitations of CMR for the assessment of cardiac function in a prospective trial setting in a grade-school-aged pediatric population with congenital heart disease. Many of the limitations are expected to decrease with the continued advancement of CMR technology.

Study Protocol of the Bladder Adjuvant RadioTherapy (BART) Trial: A Randomised Phase III Trial of Adjuvant Radiotherapy Following Cystectomy in Bladder Cancer

AIMS

To assess the efficacy and safety of adjuvant radiotherapy in patients with high-risk muscle-invasive bladder cancer (MIBC) following radical cystectomy (RC) and chemotherapy.

MATERIALS AND METHODS

The BART (Bladder Adjuvant RadioTherapy) trial is an ongoing multicentric, randomised, phase III trial comparing the efficacy and safety of adjuvant radiotherapy versus observation in patients with high-risk MIBC. The key eligibility criteria include ≥pT3, node-positive (pN+), positive margins and/or nodal yield <10, or, neoadjuvant chemotherapy for cT3/T4/N+ disease. In total, 153 patients will be accrued and randomised, in a 1:1 ratio, to either observation (standard arm) or adjuvant radiotherapy (test arm) following surgery and chemotherapy. Stratification parameters include nodal status (N+ versus N0) and chemotherapy (neoadjuvant chemotherapy versus adjuvant chemotherapy versus no chemotherapy). For patients in the test arm, adjuvant radiotherapy to cystectomy bed and pelvic nodes is planned with intensity-modulated radiotherapy to a dose of 50.4 Gy in 28 fractions using daily image guidance. All patients will follow-up with 3-monthly clinical review and urine cytology for 2 years and subsequently 6 monthly until 5 years, with contrast-enhanced computed tomography abdomen pelvis 6 monthly for 2 years and annually until 5 years. Physician-scored toxicity using Common Terminology Criteria for Adverse Events version 5.0 and patient-reported quality of life using the Functional Assessment of Cancer Therapy - Colorectal questionnaire is recorded pre-treatment and at follow-up.

ENDPOINTS AND STATISTICS

The primary endpoint is 2-year locoregional recurrence-free survival. The sample size calculation was based on the estimated improvement in 2-year locoregional recurrence-free survival from 70% in the standard arm to 85% in the test arm (hazard ratio 0.45) using 80% statistical power and a two-sided alpha error of 0.05. Secondary endpoints include disease-free survival, overall survival, acute and late toxicity, patterns of failure and quality of life.

CONCLUSION

The BART trial aims to evaluate whether contemporary radiotherapy after standard-of-care surgery and chemotherapy reduces pelvic recurrences safely and also potentially affects survival in high-risk MIBC.

Splenic surprise in a case of renal cell carcinoma: Unusual case or association?

Littoral cell angioma (LCA) is a rare benign tumor originating exclusively from the venous sinus lining cells of the splenic red pulp. These cells are unique in having a distinctive hybrid endothelial/histiocytic phenotype. Also, there are reports of the association of LCA with internal malignancies. We present a case report highlighting an unusual association of LCA with conventional renal cell carcinoma (RCC), masquerading as a metastatic lesion. Knowledge of such an association is necessary to avoid misdiagnosis and prevent potential overtreatment.

WHO 2022 classification of penile and scrotal cancers: updates and evolution

Squamous cell carcinoma (SCC) is the most common malignant tumour of the penis. The 2022 WHO classification reinforces the 2016 classification and subclassifies precursor lesions and tumours into human papillomavirus (HPV)-associated and HPV-independent types. HPV-associated penile intraepithelial neoplasia (PeIN) is a precursor lesion of invasive HPV- associated SCC, whereas differentiated PeIN is a precursor lesion of HPV-independent SCC. Block-type positivity of p16 immunohistochemistry is the most practical daily utilised method to separate HPVassociated from HPVindependent penile SCC. If this is not feasible, the term SCC, not otherwise specified (NOS) is appropriate. Certain histologies that were previously classified as "subtypes" are now grouped, and coalesced as "patterns", under the rubric of usual type SCC and verrucous carcinoma (e.g. usual-type SCC includes pseudohyperplastic and acantholytic/pseudoglandular carcinoma, and carcinoma cuniculatum is included as a pattern of verrucous carcinoma). If there is an additional component of the usual type of invasive SCC (formerly termed hybrid histology), the tumour would be a mixed carcinoma (e.g. carcinoma cuniculatum or verrucous carcinoma with usual invasive SCC); in such cases, reporting of the relative percentages in mixed tumours may be useful. The consistent use of uniform nomenclature and reporting of percentages will inform the refinement of future reporting classification schemes and guidelines/recommendations. The classification of scrotal tumours is provided for the first time in the fifth edition of the WHO Blue book, and it follows the schema of penile cancer classification for both precursor lesions and the common SCC of the scrotum. Basal cell carcinoma of the scrotum may have a variable clinical course and finds a separate mention.

Impact of Udenafil on Echocardiographic Indices of Single Ventricle Size and Function in FUEL Study Participants

BACKGROUND

The FUEL trial (Fontan Udenafil Exercise Longitudinal) demonstrated statistical improvements in exercise capacity following 6 months of treatment with udenafil (87.5 mg po BID). The effect of udenafil on echocardiographic measures of single ventricle function in this cohort has not been studied.

METHODS

The 400 enrolled participants were randomized 1:1 to udenafil or placebo. Protocol echocardiograms were obtained at baseline and 26 weeks after initiation of udenafil/placebo. Linear regression compared change from baseline indices of single ventricle systolic, diastolic and global function, atrioventricular valve regurgitation, and mean Fontan fenestration gradient in the udenafil cohort versus placebo, controlling for ventricular morphology (left ventricle versus right ventricle/other) and baseline value.

RESULTS

The udenafil participants (n=191) had significantly improved between baseline and 26 weeks visits compared to placebo participants (n=195) in myocardial performance index (P=0.03, adjusted mean difference [SE] of changes between groups -0.03[0.01]), atrioventricular valve inflow peak E (P=0.009, 3.95 [1.50]), and A velocities (P=0.034, 3.46 [1.62]), and annular Doppler tissue imaging-derived peak e' velocity (P=0.008, 0.60[0.23]). There were no significant differences in change in single ventricle size, systolic function, atrioventricular valve regurgitation severity, or mean fenestration gradient. Participants with a dominant left ventricle had significantly more favorable baseline values of indices of single ventricle size and function (lower volumes and areas, E/e' ratio, systolic:diastolic time and atrioventricular valve regurgitation, and higher annular s' and e' velocity).

CONCLUSIONS

FUEL participants who received udenafil demonstrated a statistically significant improvement in some global and diastolic echo indices. Although small, the changes in diastolic function suggest improvement in pulmonary venous return and/or augmented ventricular compliance, which may help explain improved exercise performance in that cohort.

REGISTRATION

URL: https://clinicaltrials.gov; Unique Identifier: NCT02741115.

POS0239 RISK OF VENOUS THROMBOEMBOLIC EVENTS IN PATIENTS WITH RHEUMATOID ARTHRITIS AGED ≥50 YEARS WITH ≥1 CARDIOVASCULAR RISK FACTOR: RESULTS FROM A PHASE 3b/4 RANDOMISED STUDY OF TOFACITINIB VS TUMOUR NECROSIS FACTOR INHIBITORS

Background

ORAL Surveillance (NCT02092467) was a randomised, open-label, non-inferiority, Phase 3b/4 study assessing the relative risk of major adverse cardiovascular (CV) events (MACE) and malignancies with tofacitinib vs TNF inhibitors (TNFi) in patients (pts) with moderate to severe rheumatoid arthritis despite methotrexate (MTX) and a high risk of MACE (aged ≥50 yrs; ≥1 additional CV risk factor).

Objectives

To assess risk of venous thromboembolic events (VTE; including deep vein thrombosis [DVT] and pulmonary embolism [PE]) in ORAL Surveillance.

Methods

Pts on stable MTX received tofacitinib 5 or 10 mg twice daily (BID) or a TNFi (etanercept 50 mg weekly or adalimumab 40 mg once every 2 weeks). Incidence rates (IRs; pts with first events/100 pt-yrs [PY]) and 95% CIs were calculated for adjudicated VTE, DVT and PE (overall by 6-month interval and for pts with/without history of VTE). For overall VTE, DVT and PE, numbers needed to harm (NNH; tofacitinib 5 or 10 mg BID vs TNFi) were calculated post hoc. Multivariate Cox models were used post hoc to identify overall independent baseline (BL) risk factors for PE. Censoring time was a 28-day on-treatment period (minimum of last contact date or last study treatment dose date +28 days).

Results

Analysis included 1455, 1456 and 1451 pts receiving tofacitinib 5 mg BID, 10 mg BID and TNFi, respectively. Generally, across 6-month intervals to >54 months, VTE, DVT and PE IRs were numerically higher with both tofacitinib doses vs TNFi, and with tofacitinib 10 vs 5 mg BID; IRs were consistent across time (data not shown). Across treatments, VTE, DVT and PE IRs were higher in pts with vs without history of VTE; however, only a small number of pts per treatment had history of VTE (Figure 1). NNH for tofacitinib 5 and 10 mg BID, respectively, vs TNFi were 763 and 198 PY for VTE, 1347 and 589 PY for DVT, and 870 and 229 PY for PE, or, over 5 yrs, 153 and 40 pts for VTE, 269 and 118 pts for DVT, and 174 and 46 pts for PE. Identified BL risk factors for PE across treatments included history of VTE, antidepressant use, body mass index ≥30 kg/m2, corticosteroid use, male sex, age ≥65 yrs, oral contraceptives/hormone-replacement therapy (HRT) use, and history of hypertension (Table 1).

Table 1.

Multivariate Cox analyses to identify overall independent BL risk factors for PE across treatments

HR (95% CI)p valueBL covariateHistory of VTE7.06 (2.46, 20.25)0.0003Antidepressant usea2.94 (1.44, 6.02)0.0032Body mass index ≥30 kg/m22.97 (1.40, 6.32)0.0047Corticosteroid useb3.01 (1.40, 6.46)0.0047Proton pump inhibitor use0.32 (0.15, 0.71)0.0052Male sexc2.18 (1.06, 4.48)0.0340Age ≥65 yrs2.00 (1.03, 3.88)0.0401Oral contraceptives/HRT use3.56 (1.05, 12.10)0.0422History of hypertension2.57 (0.98, 6.76)0.0554

aBL antidepressant use was an indicator of an underlying condition of depression, and subgroup analysis did not identify the difference in HRs for depression across treatments

bProxy for elevated BL disease activity; HRs for BL corticosteroid use were similar between all tofacitinib doses combined and TNFi; includes any BL corticosteroid use

cImpact of sex on PE risk considered inconclusive

Multivariate Cox model using backward selection included treatment effects (not subject to model selection) and overall potential independent risk factors (those affecting PE IRs equally across treatments; subject to model selection) identified from a prior set of Cox regression analyses (which included treatment and a single candidate risk factor in each model fitting, cycling through a predetermined set of risk factors); cut-off for risk factor to stay in multivariate model was p<0.10; nominal p value and HR (95% CI) based on this model

HR, hazard ratio

Conclusion

Generally, in ORAL Surveillance, VTE, DVT and PE IRs were numerically higher for tofacitinib (10 > 5 mg BID) vs TNFi across 6-month intervals, and for pts with vs without history of VTE. Multivariate Cox models identified BL risk factors for PE that may help support future treatment decisions.

Acknowledgements

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

Disclosure of Interests

Christina Charles-Schoeman Consultant of: AbbVie, Gilead Sciences, Pfizer Inc and Regeneron-Sanofi, Grant/research support from: AbbVie, Bristol-Myers Squibb and Pfizer Inc, Roy M. Fleischmann Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Galvani, Gilead Sciences, GSK, Janssen, Novartis, Pfizer Inc, Sanofi-Aventis and UCB, Grant/research support from: AbbVie, Amgen, AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Flexion, Galapagos, Galvani, Genentech, Gilead Sciences, GSK, Horizon, Janssen, Novartis, Noven, Pfizer Inc, Samumed, Sanofi Aventis, SciSelecta, Teva Pharmaceuticals, UCB, Viela and Vorso, Eduardo Mysler Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, Janssen, Pfizer Inc, Roche and Sanofi, Grant/research support from: Eli Lilly, Pfizer Inc and Roche, Maria Greenwald Grant/research support from: AbbVie, Eli Lilly, Galapagos, Gilead Sciences, Novartis and Pfizer Inc, Cunshan Wang Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, All-shine Chen Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Carol A. Connell Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, John Woolcott Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Sujatha Menon Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Yan Chen Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Kristen Lee Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, 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

POS0674 RISK FACTORS FOR MAJOR ADVERSE CARDIOVASCULAR EVENTS IN PATIENTS AGED ≥50 YEARS WITH RHEUMATOID ARTHRITIS AND ≥1 ADDITIONAL CARDIOVASCULAR RISK FACTOR: A POST HOC ANALYSIS OF ORAL SURVEILLANCE

Background

ORAL Surveillance (NCT02092467) was a post-approval safety study of tofacitinib vs TNF inhibitors (TNFi) in rheumatoid arthritis (RA) patients (pts) aged ≥50 yrs with ≥1 additional cardiovascular (CV) risk factor and an inadequate response to methotrexate (MTX).

Objectives

To identify independent risk factors for major adverse CV events (MACE) in ORAL Surveillance.

Methods

Pts on stable MTX were randomised 1:1:1 to receive tofacitinib 5 or 10 mg twice daily (BID) or a TNFi (adalimumab 40 mg every 2 weeks or etanercept 50 mg once weekly). Incidence rates (IRs; pts with first events/100 pt-yrs) and hazard ratios (HRs; tofacitinib vs TNFi) were assessed for adjudicated MACE (total/fatal/non-fatal), sudden cardiac death, and total/fatal/non-fatal myocardial infarction (MI) and stroke. Post hoc univariate Cox model analyses identified potentially independent baseline (BL) risk factors for MACE across treatments; those with p<0.10 were entered into a multivariate Cox model using backward selection (p<0.10 stay criteria). MACE HRs were produced for subgroups for BL risk factors with p<0.05 in the final multivariate Cox model.

Results

4362 pts were included (tofacitinib 5 mg BID, n=1455; tofacitinib 10 mg BID, n=1456; TNFi, n=1451). IRs for total/fatal/non-fatal MACE, sudden cardiac death, and total/non-fatal MI were higher with tofacitinib vs TNFi (Table 1). Fatal MI and stroke (including fatal/non-fatal events) IRs were similar across treatments (Table 1). Total MACE and MI IRs and risk were higher with tofacitinib vs TNFi (HRs >1) and higher for non-fatal MI for tofacitinib 5 mg BID (Table 1). Current smoking, aspirin use, history of chronic lung disease, history of diabetes, male sex and older age were BL risk factors for MACE. While MACE risk was generally higher with tofacitinib vs TNFi across all BL risk factors, increased risk was clearest in current/past smokers (vs never smoked) and aspirin users (vs non-users) (Figure 1). When age and smoking status were considered in combination, pts aged ≥65 yrs or who had ever smoked had a particularly elevated MACE risk vs never smokers aged ≥50–<65 yrs (Figure 1).

Table 1.

MACE, MI and stroke IRs (pts with first events/100 pt-yrs; 95% CI) and HRs (tofacitinib vs TNFi; 95% CI)

Tofacitinib 5 mg BID(N=1455)Tofacitinib 10 mg BID(N=1456)TNFi(N=1451)nIRHRnIRHRnIR(95% CI)(95% CI)(95% CI)(95% CI)(95% CI)MACE470.911.24511.051.43370.73(0.67, 1.21)(0.81, 1.91)(0.78, 1.38)(0.94, 2.18)(0.52, 1.01)Fatal MACE140.271.14190.391.63120.24(0.15, 0.45)(0.53, 2.47)(0.23, 0.60)(0.79, 3.36)(0.12, 0.41)Non-fatal MACE330.641.29320.661.33250.50(0.44, 0.90)(0.77, 2.17)(0.45, 0.93)(0.79, 2.24)(0.32, 0.73)Sudden cardiac death100.191.22130.261.6780.16(0.09, 0.35)(0.48, 3.10)(0.14, 0.45)(0.69, 4.04)(0.07, 0.31)MI190.371.69190.391.80110.22(0.22, 0.57)(0.80, 3.55)(0.23, 0.61)(0.85, 3.77)(0.11, 0.39)Fatal MI00NI30.061.0330.06(0.00, 0.07)(0.01, 0.18)(0.21, 5.11)(0.01, 0.17)Non-fatal MI190.372.32160.332.0880.16(0.22, 0.57)(1.02, 5.30)a(0.19, 0.53)(0.89, 4.86)(0.07, 0.31)Stroke180.351.03180.371.10170.34(0.21, 0.55)(0.53, 2.00)(0.22, 0.58)(0.57, 2.13)(0.20, 0.54)Fatal stroke40.08NI20.04NI00.00(0.02, 0.20)(0.00, 0.15)(0.00, 0.07)Non-fatal stroke140.270.80160.330.97170.34(0.15, 0.45)(0.40, 1.63)(0.19, 0.53)(0.49, 1.93)(0.20, 0.54)

aHR 95% CI excludes 1.

Data collected after pts who were randomised to tofacitinib 10 mg BID had their dose reduced to 5 mg. BID were included in the tofacitinib 10 mg BID group

. HRs (95% CI) were not informative when one of the treatments in the comparison had 0 events.

Risk period was defined as time from first dose to last dose +60 days or to the last contact date, whichever was earlier.

CI, confidence interval; NI, non-informative

Conclusion

MACE IRs and risk were higher with tofacitinib vs TNFi in ORAL Surveillance. BL risk factor findings could aid identification of RA pts with potentially highest risk for MACE, with a view to informing treatment decisions.

Acknowledgements

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

Disclosure of Interests

Christina Charles-Schoeman Consultant of: AbbVie, Gilead Sciences, Pfizer Inc and Sanofi-Regeneron, Grant/research support from: AbbVie, Bristol-Myers Squibb and Pfizer Inc, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Eli Lilly, Gilead Sciences, MSD, Pfizer Inc and Roche, Grant/research support from: Pfizer Inc, Roche and UCB, Maxime Dougados Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Merck, Novartis, Pfizer Inc, Roche and UCB, Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly, Merck, Novartis, Pfizer Inc, Roche and UCB, Deepak L Bhatt Grant/research support from: Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Cardax, Chiesi, CSL Behring, Eli Lilly, Eisai, Ethicon, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, HLS Therapeutics, Idorsia, Ironwood, Ischemix, Janssen, Lexicon, Medtronic, MyoKardia, Novo Nordisk, Owkin, Pfizer Inc, PhaseBio, PLx Pharma, Regeneron, Roche, Sanofi, Synaptic and The Medicines Company, Jon T Giles Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Genentech, Gilead Sciences and UCB, Grant/research support from: Pfizer Inc, Steven R. Ytterberg Consultant of: Corbus Pharmaceuticals, Kezar Life Sciences and Pfizer Inc, Gary G Koch Shareholder of: IQVIA, Grant/research support from: AbbVie, Acceleron, Amgen, Arena, AstraZeneca, Cytokinetics, Eli Lilly, Gilead, GSK, Huya Bioscience International, Johnson & Johnson, Landos Biopharma, Merck, Momentum, Novartis, Otsuka, Pfizer Inc, Sanofi and vTv Therapeutics, Employee of: University of North Carolina at Chapel Hill, Ivana Vranic Shareholder of: Pfizer Inc, Employee of: Pfizer Ltd, Joseph Wu Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Cunshan Wang Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Sujatha Menon Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Jose L. Rivas Shareholder of: Pfizer Inc, Employee of: Pfizer SLU, Arne Yndestad Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Carol A. Connell Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, 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

OP0264 IMPACT OF BASELINE CARDIOVASCULAR RISK ON THE INCIDENCE OF MAJOR ADVERSE CARDIOVASCULAR EVENTS IN THE TOFACITINIB RHEUMATOID ARTHRITIS CLINICAL PROGRAMME

Background

Results from ORAL Surveillance, a post-authorisation safety study, indicated that patients (pts) with rheumatoid arthritis (RA) aged ≥50 yrs with ≥1 additional cardiovascular (CV) risk factor have an increased risk of major adverse CV events (MACE) with tofacitinib vs tumour necrosis factor inhibitors.1

Objectives

To evaluate the impact of baseline (BL) CV risk on MACE in the wider tofacitinib RA clinical programme.

Methods

Data for pts who received ≥1 tofacitinib dose in 21 Phase 1–3b/4 (excluding ORAL Surveillance) and 2 long-term extension tofacitinib RA studies were pooled and analysed post hoc as two cohorts: (1) overall cohort and (2) CV risk-enriched cohort (pts aged ≥50 yrs with ≥1 additional CV risk factor [current smoker, hypertension, HDL-cholesterol <40 mg/dL, diabetes mellitus, history of myocardial infarction (MI) or coronary heart disease (CHD)]). Data were summarised by average tofacitinib 5 or 10 mg twice daily (BID; average total daily dose of <15 or ≥15 mg, respectively). Incidence rates (IRs; pts with first events/100 pt-yrs) for adjudicated MACE were calculated. MACE IRs were stratified by pts’ BL CV risk profile: pts were first categorised by history of coronary artery disease (HxCAD), then pts without a HxCAD were categorised by 10-yr risk of MACE, per the ASCVD-PCE risk calculator2 with a 1.5 multiplier applied.3

Results

The overall cohort included 7964 pts (average tofacitinib 5 mg BID, n=3969; average tofacitinib 10 mg BID, n=3995); of these, 3125 (39.2%) pts were included in the CV risk-enriched cohort (average tofacitinib 5 mg BID, n=1614; average tofacitinib 10 mg BID, n=1511). In both treatment arms, as expected, higher proportions of pts in the CV risk-enriched cohort had a HxCAD or a high or intermediate 10-yr predicted risk of MACE at BL vs the overall cohort (Table 1). MACE IRs (95% CIs) were lower in the overall cohort (0.38 [0.26, 0.54] and 0.37 [0.27, 0.48] for average tofacitinib 5 and 10 mg BID, respectively) vs the CV risk-enriched cohort (0.72 [0.46, 1.09] and 0.67 [0.46, 0.93], respectively), and were similar between treatment arms. MACE IRs were lower than reported in ORAL Surveillance.1 In the overall cohort, adjudicated MACE most commonly occurred in pts with a HxCAD (IR [95% CI] 0.98 [0.02, 5.47] and 1.05 [0.13, 3.78] for average tofacitinib 5 and 10 mg BID, respectively), or in pts with a high 10-yr risk of MACE at BL (Figure 1). A lower predicted 10-yr MACE risk was associated with lower MACE IRs (Figure 1); trends were similar for the CV risk-enriched cohort (data not shown).

Table 1.

Proportions of pts with a HxCAD and pts without a HxCAD categorised by 10-yr risk of MACE, per ASCVD-PCE risk calculator2 with a 1.5 multiplier applied3

Average tofacitinib 5 mg BIDAverage tofacitinib 10 mg BIDOverall cohort(N=3969)CV risk-enriched cohort(N=1614)Overall cohort(N=3995)CV risk-enriched cohort(N=1511)HxCAD, n (%)61 (1.5)61 (3.8)65 (1.6)60 (4.0)No HxCAD: 10-yr risk of MACE, n (%)High (≥20%)440 (11.1)365 (22.6)337 (8.4)276 (18.3)Intermediate (≥7.5–<20%)853 (21.5)593 (36.7)788 (19.7)530 (35.1)Borderline (≥5–<7.5%)435 (11.0)234 (14.5)404 (10.1)195 (12.9)Low (<5%)2133 (53.7)342 (21.2)2058 (51.5)307 (20.3)Missing data47 (1.2)19 (1.2)343 (8.6)143 (9.5)

CAD is defined as any of MI or CHD.

n, number of pts with specified characteristic; N, number of evaluable pts

Conclusion

In the tofacitinib RA clinical programme, MACE were largely associated with BL CV risk in the overall cohort, consistent with results of ORAL Surveillance, although results should be interpreted with caution due to low pt-yrs of exposure in some pt groups. Noting this limitation, these findings emphasise the importance of assessing and addressing BL CV risk when treating pts with RA.

References

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

[2]American College of Cardiology, American Heart Association. ASCVD risk estimator. https://tools.acc.org/ldl/ascvd_risk_estimator/index.html#!/calulate/estimator/.

[3]Agca et al. Ann Rheum Dis 2017; 76: 17-28.

Acknowledgements

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

Disclosure of Interests

Maxime Dougados Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Merck, Novartis, Pfizer Inc, Roche and UCB, Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly, Merck, Novartis, Pfizer Inc, Roche and UCB, Christina Charles-Schoeman Consultant of: AbbVie, Gilead Sciences, Pfizer Inc and Sanofi-Regeneron, Grant/research support from: AbbVie, Bristol-Myers Squibb and Pfizer Inc, 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, Jon T Giles Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Genentech, Gilead Sciences and UCB, Grant/research support from: Pfizer Inc, Steven R. Ytterberg Consultant of: Corbus Pharmaceuticals, Kezar Life Sciences and Pfizer Inc, Deepak L Bhatt Grant/research support from: Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Cardax, Chiesi, CSL Behring, Eisai, Eli Lilly, Ethicon, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, HLS Therapeutics, Idorsia, Ironwood, Ischemix, Janssen, Lexicon, Medtronic, MyoKardia, Novo Nordisk, Owkin, Pfizer Inc, PhaseBio, PLx Pharma, Regeneron, Roche, Sanofi, Synaptic and The Medicines Company, Gary G Koch Grant/research support from: AbbVie, Acceleron, Amgen, Arena, AstraZeneca, Cytokinetics, Eli Lilly, Gilead Sciences, GSK, Huya Bioscience International, Johnson & Johnson, Landos Biopharma, Merck, Momentum, Novartis, Otsuka, Pfizer Inc, Sanofi and vTv Therapeutics, Employee of: University of North Carolina at Chapel Hill, Ivana Vranic Shareholder of: Pfizer Inc, Employee of: Pfizer Ltd, Joseph Wu Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Cunshan Wang Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Kenneth Kwok Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Sujatha Menon Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Carol A. Connell Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Arne Yndestad Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Jose L. Rivas Shareholder of: Pfizer Inc, Employee of: Pfizer SLU, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Eli Lilly, Gilead Sciences, MSD, Pfizer Inc and Roche, Grant/research support from: Pfizer Inc, Roche and UCB

POS0520 ASSOCIATION BETWEEN BASELINE STATIN TREATMENT AND MAJOR ADVERSE CARDIOVASCULAR EVENTS IN PATIENTS WITH RHEUMATOID ARTHRITIS: A POST HOC ANALYSIS OF ORAL SURVEILLANCE

Background

ORAL Surveillance (NCT02092467) was a post-authorisation safety study of tofacitinib vs tumour necrosis factor inhibitors (TNFi) in patients (pts) with rheumatoid arthritis (RA) aged ≥50 years (yrs) with ≥1 additional cardiovascular (CV) risk factor and an inadequate response to methotrexate (MTX). Statins are used to treat coronary artery disease (CAD) and are recommended by the American College of Cardiology/American Heart Association (ACC/AHA) for the management of pts at risk of atherosclerotic CV disease (ASCVD),1 such as those with ≥7.5% 10-yr risk of major adverse CV events (MACE) or diabetes mellitus.

Objectives

To examine the association between baseline (BL) statin use and MACE in ORAL Surveillance.

Methods

Pts with RA on stable MTX were randomised 1:1:1 to receive tofacitinib 5 or 10 mg twice daily (BID) or TNFi (adalimumab 40 mg every 2 weeks or etanercept 50 mg once weekly). Pts were stratified post hoc by BL statin use (yes/no). Pts were further categorised by history of CAD (HxCAD), BL CV risk score per ACC/AHA guidelines1 (for pts without HxCAD; 10-yr risk of MACE per the ASCVD-pooled cohort equations risk calculator2 with a 1.5 multiplier applied3), and separately by BL diabetes status. CV risk score/BL diabetes status categories were: high (≥20%)/HxCAD (yes), intermediate (≥7.5–<20%) or low-borderline (<7.5%), and diabetes status (yes). For the overall population and each treatment group, risk of MACE was compared between BL statin use (yes vs no) via Cox analyses for each CV risk category and diabetes status (yes). Incidence rates (IRs; pts with first events/100 pt-yrs) and hazard ratios (HRs; BL statin use: yes vs no) were evaluated for adjudicated MACE.

Results

Of 4362 pts (tofacitinib 5 mg BID, n=1455; tofacitinib 10 mg BID, n=1456; TNFi, n=1451), 497 had a HxCAD, and 3813 without a HxCAD had CV risk scores determined; 789 had BL diabetes. Overall, 1020 (23.4%) pts reported BL statin use. Across CV risk score categories for all treatment groups, <50% of pts received statins at BL, with statin use highest in the high/HxCAD category pts (35.7–40.6%) and pts with diabetes (35.7–44.2%) (Table 1). Across categories, no interpretable associations between BL statin use and MACE were found. However, in the overall population, MACE IRs were lower in pts with vs without BL statin use in the high/HxCAD category, and in pts with diabetes (Figure 1). In pts receiving tofacitinib 5 mg BID and TNFi, MACE IRs were lower in pts with vs without BL statin use across all categories (Figure 1).

Table 1.

Proportion of pts receiving statins at BL, by CV risk category and presence of diabetes

n/N (%)OverallTofacitinibTofacitinibTNFi5 mg BID10 mg BIDHigh (≥20%)/HxCAD525/1370 (38.3)168/435 (38.6)193/475 (40.6)164/460 (35.7)Intermediate (≥7.5–<20%)302/1511 (20.0)110/490 (22.4)94/516 (18.2)98/505 (19.4)Low-borderline (<7.5%)178/1429 (12.5)66/513 (12.9)57/446 (12.8)55/470 (11.7)Diabetes (yes)320/789 (40.6)111/251 (44.2)114/272 (41.9)95/266 (35.7)

N, number of pts in each category; n, number of pts receiving BL statins

Conclusion

In this post hoc analysis of data from ORAL Surveillance, most pts did not receive BL statin treatment. This suggests suboptimal CV risk management, particularly in pts at high risk of CV events. There was no interpretable association between BL statin use and MACE. However, pts in the higher risk categories, particularly those receiving tofacitinib 5 mg BID, had lower MACE IRs with vs without BL statin use. This analysis did not take into account initiation or dose adjustment of statin treatment during the study, and had low yrs of exposure in some categories.

References

[1]Arnett et al. J Am Coll Cardiol 2019; 74: e177-232.

[2]American College of Cardiology, American Heart Association. ASCVD risk estimator. https://tools.acc.org/ldl/ascvd_risk_estimator/index.html#!/calulate/estimator/.

[3]Agca et al. Ann Rheum Dis 2017; 76: 17-28.

Acknowledgements

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

Disclosure of Interests

Jon T Giles Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Genentech, Gilead Sciences and UCB, 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, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Eli Lilly, Gilead Sciences, MSD, Pfizer Inc and Roche, Grant/research support from: Pfizer Inc, Roche and UCB, Maxime Dougados Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Merck, Novartis, Pfizer Inc, Roche and UCB, Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly, Merck, Novartis, Pfizer Inc, Roche and UCB, 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 Lily, Novartis, Pfizer Inc, Roche and Sanofi, Steven R. Ytterberg Consultant of: Corbus Pharmaceuticals, Kezar Life Sciences and Pfizer Inc, Gary G Koch Shareholder of: IQVIA, Grant/research support from: AbbVie, Acceleron, Amgen, Arena, AstraZeneca, Cytokinetics, Eli Lilly, Gilead Scienes, GlaxoSmithKline, Huya Bioscience International, Johnson & Johnson, Landos Biopharma, Merck, Momentum, Novartis, Otsuka, Pfizer Inc, Sanofi and vTv Therapeutics, Employee of: University of North Carolina at Chapel Hill, Joseph Wu Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Cunshan Wang Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Kenneth Kwok Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Sujatha Menon Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Yan Chen Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Teoman Yusuf Cesur Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Jose L. Rivas Shareholder of: Pfizer Inc, Employee of: Pfizer SLU, Arne Yndestad Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Annette Diehl Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Deepak L Bhatt Grant/research support from: Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Cardax, Chiesi, CSL Behring, Eisai, Ethicon, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, HLS Therapeutics, Idorsia, Ironwood, Ischemix, Janssen, Lexicon, Lilly, Medtronic, MyoKardia, Novo Nordisk, Owkin, Pfizer Inc, PhaseBio, PLx Pharma, Regeneron, Roche, Sanofi, Synaptic and The Medicines Company.

POS0519 RELATIONSHIP BETWEEN DISEASE ACTIVITY AND MAJOR ADVERSE EVENTS IN PATIENTS WITH RHEUMATOID ARTHRITIS ON TOFACITINIB OR TNF INHIBITORS: A POST HOC ANALYSIS OF ORAL SURVEILLANCE

Background

Uncontrolled rheumatoid arthritis (RA) activity and acute disease flares are associated with higher risk of adverse outcomes such as cardiovascular (CV) disease, venous thromboembolism (VTE), malignancy and infection.1-4

Objectives

To evaluate associations of acute and cumulative Clinical Disease Activity Index (CDAI) measurements with major CV, malignancy, or infectious adverse events (AEs) of special interest in ORAL Surveillance.

Methods

ORAL Surveillance (NCT02092467) was a post-authorisation safety study of tofacitinib vs TNF inhibitors (TNFi) in patients (pts) aged ≥50 yrs with active RA despite methotrexate (MTX), and ≥1 additional CV risk factor. Pts were randomised 1:1:1 to tofacitinib 5 or 10 mg twice daily (BID) or subcutaneous TNFi. Two post hoc analyses were performed: (1) a time-varying multivariate Cox model examined risks of major AEs when pts were in CDAI-defined low (>2.8–≤10; LDA), moderate (>10–≤22; MDA) or high (>22; HDA) disease activity vs remission (≤2.8). The Cox model also included pt demographics, medical history, RA characteristics, prior treatments, baseline (BL) medications and treatment arm, pre-selected using backward selection; (2) area under the curve (AUC) per yr for CDAI prior to event or to study end (pts without event) was calculated and compared using an analysis of variance model with treatment arm, event status and interaction (supportive). Nominal p values <0.10 were considered evidence of associations.

Results

4362 pts were included. Mean RA duration at BL was approximately 10 yrs. All pts were on MTX at BL, and 28% had previously been on one other synthetic disease-modifying antirheumatic drug (DMARD). Overall, 10% of pts had been on one biologic DMARD. Hazard ratios suggested that when pts had LDA, MDA or HDA vs remission, they were potentially at higher risk of developing major adverse CV events (MACE), VTE and non-serious infections (NSIs) excluding herpes zoster (HZ), but not malignancies, serious infections or HZ (Figure 1). Similarly, mean CDAI AUC trended higher for MACE, VTE and NSIs (Table 1).

Table 1.

Cumulative CDAI (from BL to event) for pts with vs without events (AUC/yr)

Major AEPts with eventsPts without eventsLS mean difference in pts with vs without eventsp valueTreatmentnLS mean AUC/yrnLS mean AUC/yrMACETofacitinib 5 mg BID426275.413364607.31668.10.0018*Tofacitinib 10 mg BID505237.413064482.6754.80.1253TNFi365234.513124851.5383.00.5069VTETofacitinib 5 mg BID156546.713634614.41932.30.0293*Tofacitinib 10 mg BID316688.213234458.52229.70.0003*TNFi86423.613394839.41584.10.1907Malignancy excl. NMSCTofacitinib 5 mg BID595249.313194618.9630.40.1655Tofacitinib 10 mg BID554793.713014482.2311.50.5077TNFi395561.413084826.3735.10.1854Serious infectionsTofacitinib 5 mg BID1275710.212424577.51132.70.0004*Tofacitinib 10 mg BID1505425.211974476.4948.80.0013*TNFi1056058.412404807.71250.70.0003*HZTofacitinib 5 mg BID1755184.511994738.1446.40.1101Tofacitinib 10 mg BID1635549.111864481.31067.80.0002*TNFi565667.212914875.5791.80.0930*NSIs excl. HZTofacitinib 5 mg BID7606608.34635122.51485.8<0.0001*Tofacitinib 10 mg BID7506587.84265009.61578.2<0.0001*TNFi7226737.65215217.51520.1<0.0001*

*p<0.10. Data collected after pts who were randomised to tofacitinib 10 mg BID had their dose reduced to 5 mg BID were included in the tofacitinib 10 mg BID group LS, least squares; n, number of pts in analysis of variance model

Conclusion

In ORAL Surveillance, the risk of MACE, VTE and NSIs excluding HZ appeared higher when pts had active disease than when in remission. Greater cumulative RA disease activity was seen in pts who suffered these AEs vs those who did not. Our findings support treat-to-target recommendations for RA.

References

[1]Molander et al. Ann Rheum Dis 2021; 80: 169-175.

[2]Maradit-Kremers et al. Arthritis Rheum 2005; 52: 722-732.

[3]Au et al. Ann Rheum Dis 2011; 70: 785-791.

[4]Baecklund et al. Arthritis Rheum 2006; 54: 692-701.

Acknowledgements

Study sponsored by Pfizer Inc. Medical writing support was provided by Karen Thompson, PhD, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests

George Karpouzas Speakers bureau: Sanofi-Genzyme-Regeneron, Consultant of: Janssen and Sanofi-Genzyme-Regeneron, Grant/research support from: Pfizer Inc, 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, Eva Baecklund: None declared, Ted Mikuls Paid instructor for: Pfizer Inc, Consultant of: Gilead Sciences, Horizon and Sanofi, Grant/research support from: Bristol-Myers Squibb and Horizon, Deepak L Bhatt Grant/research support from: Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Cardax, Chiesi, CSL Behring, Eisai, Eli Lilly, Ethicon, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, HLS Therapeutics, Idorsia, Ironwood, Ischemix, Janssen, Lexicon, Medtronic, MyoKardia, Novo Nordisk, Owkin, Pfizer Inc, PhaseBio, PLx Pharma, Regeneron, Roche, Sanofi, Synaptic and The Medicines Company, Harry Shi Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Cunshan Wang Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Gosford Sawyerr Consultant of: Pfizer Inc, Employee of: Syneos Health Inc, Yan Chen Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Sujatha Menon Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Carol A. Connell Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Steven R. Ytterberg Consultant of: Corbus Pharmaceuticals, Kezar Life Sciences and Pfizer Inc, Mahta Mortezavi Shareholder of: Pfizer Inc, Employee of: Pfizer Inc.

POS0296 INTEGRATED SAFETY ANALYSIS OF TOFACITINIB IN ANKYLOSING SPONDYLITIS CLINICAL TRIALS

Background

Tofacitinib is an oral JAK inhibitor for the treatment of adults with ankylosing spondylitis (AS).

Objectives

To describe the tofacitinib safety profile from an integrated analysis of randomised controlled trials (RCTs) in patients (pts) with active AS.

Methods

Pooled data from Phase (P)2 (NCT01786668) and P3 (NCT03502616) RCTs in pts with AS were analysed in 3 cohorts (Table 1): the 16-Week (Wk) placebo (PBO)-controlled cohort (pts receiving tofacitinib 5 mg twice daily [BID] or PBO from Wks 0–12 [P2 RCT] or Wks 0–16 [P3 RCT]), the 48-Wk all tofacitinib 5 mg BID cohort and the 48-Wk all tofacitinib cohort (pts receiving ≥1 dose of tofacitinib 2, 5 or 10 mg BID), including pts receiving tofacitinib from Wks 0–12 (P2 RCT) or Wks 0–48 (P3 RCT). Pts receiving tofacitinib 5 mg BID were included in the 16-Wk PBO-controlled cohort and both 48-Wk tofacitinib cohorts. Adverse event (AE)/AEs of special interest incidence rates (IRs; pts with events/100 pt-yrs) were reported based on a 28-day risk period (time of first to last study drug dose +28 days). Baseline (BL) cardiovascular (CV) risk was calculated post hoc by the atherosclerotic CV disease (ASCVD)-pooled cohort equations calculator for pts without history of coronary artery disease (48-Wk tofacitinib cohorts).

Results

At BL, most pts (>76%) in the 48-Wk tofacitinib cohorts had <5% (low) 10-yr ASCVD risk (Figure 1). The most common treatment-emergent AEs were nasopharyngitis/upper respiratory tract infection. Serious AE IRs were higher with tofacitinib 5 mg BID vs PBO in the 16-Wk PBO-controlled cohort, and similar in the 48-Wk tofacitinib cohorts (Table 1). Discontinuation due to AEs was similar between groups in the 16-Wk PBO-controlled cohort and between the 48-Wk tofacitinib cohorts (Table 1). One pt receiving tofacitinib 5 mg BID (included in the 16-Wk PBO-controlled and both 48-Wk tofacitinib cohorts) had a serious infection (SI; meningitis; Table 1). No SIs with PBO. Herpes zoster (HZ; all non-serious) occurred in the 48-Wk all tofacitinib 5 mg BID (5 pts [1.6%]) and 48-Wk all tofacitinib cohorts (7 pts [1.7%]; Table 1) only. Most cases involved a single dermatome, but 1 pt (tofacitinib 10 mg BID) had HZ involving 2 adjacent dermatomes. Across cohorts, there were no deaths or adjudicated opportunistic infections (OIs), OIs excluding tuberculosis (TB), TB, malignancies excluding non-melanoma skin cancer (NMSC), NMSC, major adverse CV events, thromboembolic events, gastrointestinal perforation or interstitial lung disease. Uveitis was reported in 1 (0.5%), 3 (1.6%), 4 (1.3%) and 6 (1.4%) pts in the tofacitinib 5 mg BID, PBO, 48-Wk all tofacitinib 5 mg BID and 48-Wk all tofacitinib groups, respectively; all but 1 pt (tofacitinib 2 mg BID) had history of uveitis. Psoriasis occurred in 1 (0.5%) pt (PBO) with history of psoriasis. There were no AEs of inflammatory bowel disease.

Table 1.

AEs and AEs of special interest

16-Wk PBO-controlled cohort48-Wk tofacitinib cohortsTofacitinib 5 mg BID N=185PBO N=18748-Wk all tofacitinib 5 mg BID N=31648-Wk all tofacitinib N=420AE, n (%), IR [95% CI per 100 pt-yrs]Serious AE3 (1.6) 5.28 [0.00, 11.25]2 (1.1) 3.56 [0.00, 8.49]8 (2.5) 3.49 [1.51, 6.87]9 (2.1) 3.45 [1.58, 6.55]Discontinuation due to AEs4 (2.2) 7.04 [0.14, 13.94]4 (2.1) 7.10 [0.14, 14.05]11 (3.5) 4.77 [2.38, 8.54]12 (2.9) 4.58 [2.37, 8.00]SI1 (0.5) 1.77 [0.00, 5.89]0 0.00 [0.00, 3.31]1 (0.3) 0.43 [0.01, 2.41]1 (0.2) 0.38 [0.01, 2.12]HZ0 0.00 [0.00, 3.28]0 0.00 [0.00, 3.31]5 (1.6) 2.18 [0.71, 5.08]7 (1.7) 2.68 [1.08, 5.53]All-cause mortality0 0.00 [0.00, 3.28]0 0.00 [0.00, 3.31]0 0.00 [0.00, 1.59]0 0.00 [0.00, 1.40]Malignancies excluding NMSC0 0.00 [0.00, 3.28]0 0.00 [0.00, 3.31]0 0.00 [0.00, 1.59]0 0.00 [0.00, 1.40]Major adverse CV event0 0.00 [0.00, 3.28]0 0.00 [0.00, 3.31]0 0.00 [0.00, 1.59]0 0.00 [0.00, 1.40]Venous thromboembolism0 0.00 [0.00, 3.28]0 0.00 [0.00, 3.31]0 0.00 [0.00, 1.59]0 0.00 [0.00, 1.40]

CI, confidence interval; n, number of pts with event within 28-day risk period

Conclusion

Tofacitinib 5 mg BID was well tolerated over 48 Wks in pts with AS, and safety was consistent with the established safety profile of tofacitinib.

Acknowledgements

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

Disclosure of Interests

Atul Deodhar Consultant of: AbbVie, Amgen, Aurinia, Boehringer Ingelheim, Bristol-Myers Squibb, Celegene, Eli Lilly, GlaxoSmithKline, Janssen, MoonLake, Novartis, Pfizer Inc and UCB, Grant/research support from: AbbVie, Eli Lilly, GlaxoSmithKline, Novartis, Pfizer Inc and UCB, Servet Akar Speakers bureau: AbbVie, Amgen, Eli Lilly, MSD, Novartis, Pfizer Inc and UCB, Consultant of: AbbVie, Amgen, Eli Lilly, MSD, Novartis, Pfizer Inc and UCB, Grant/research support from: Pfizer Inc, Jeffrey Curtis Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, CorEvitas, LLC (formerly Corrona, LLC), Eli Lilly, Janssen, Myriad, Pfizer Inc, Radius, Roche and UCB, Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, CorEvitas, LLC (formerly Corrona, LLC), Eli Lilly, Janssen, Myriad, Pfizer Inc, Radius, Roche and UCB, Bassel Zorkany Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Eva, Eli Lilly, Hekma, Janssen, MSD, New Bridge, Novartis, Pfizer Inc, Roche, Sanofi-Aventis and Servier, Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Eva, Eli Lilly, Hekma, Janssen, MSD, New Bridge, Novartis, Pfizer Inc, Roche, Sanofi-Aventis and Servier, Marina Magrey Consultant of: AbbVie, Eli Lilly, Novartis, Pfizer Inc and UCB, Grant/research support from: AbbVie and UCB, Cunshan Wang Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Joseph Wu Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Solomon B Makgoeng Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Ivana Vranic Shareholder of: Pfizer Inc, Employee of: Pfizer Ltd, Sujatha Menon Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Dona Fleishaker Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Annette Diehl Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Lara Fallon Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Arne Yndestad Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Robert B.M. Landewé Consultant of: AbbVie, AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Galapagos NV, Novartis, Pfizer Inc and UCB

Impact of Adjuvant Treatment in pN3 Penile Cancer

AIMS

Due to the lack of high-quality evidence and consensus on adjuvant treatment for locoregionally advanced penile cancer, we reviewed the outcomes of pN3 patients to determine the suitable adjuvant treatment options.

PATIENTS AND METHODS

All consecutive pN3 penile cancer patients treated at our institution between January 2010 and December 2018 were reviewed to assess the impact of demographical, pathological and treatment factors on disease-free survival (DFS) and overall survival. The DFS and overall survival were estimated using the Kaplan-Meier method and association was tested using the Cox regression model (two-sided test with P < 0.05 considered significant).

RESULTS

Of 128 patients, 31 (24%) had pelvic nodal involvement. Twenty-six patients (20.3%) received no adjuvant treatment, 40 (31.3%) received single modality adjuvant treatment and 62 (48.4%) received multimodality adjuvant treatment (a combination of chemotherapy and radiotherapy). At a median follow-up of 22 months, the DFS and overall survival were 55.4 and 62%, respectively. The best DFS and overall survival was noted with chemotherapy followed by concurrent chemoradiation (C-CTRT; 93% each). On multivariate analysis, both DFS and overall survival were worse with pelvic node involvement (2.2 [1.3-4], P = 0.027 and 2.2 [1.3-4], P = 0.027, respectively) and better with any adjuvant treatment (single modality: 3 [1.5-5.5], P < 0.001; multimodality: 3.1 [1.6-6], P < 0.001). C-CTRT was associated with improved DFS over chemotherapy alone (0.17 [0.4-0.78], P = 0.02) but not over radiotherapy alone (0.35 [0.07-1.6], P = 0.19). In patients with no pelvic nodes involved, chemotherapy and radiotherapy as single modalities were associated with similar DFS and overall survival. In patients with pelvic nodes, multimodality treatment was associated with better DFS than single modality treatment (0.3 [0.1-1], P = 0.05).

CONCLUSION

pN3 penile cancer is a diverse prognostic group with poorer outcomes associated with pelvic nodes. Single modality adjuvant treatment may be adequate in inguinal nodes with extranodal extension, but multimodality treatment should be given in patients with pelvic nodal involvement.

Radiotherapy for Post-Chemotherapy Residual Mass in Advanced Seminoma: A Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography-Based Risk-adapted Approach

AIMS

There is a lack of consensus regarding the management of post-chemotherapy residual mass in classical seminoma. The use of fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) may aid the detection of residual masses harbouring viable disease and help to tailor therapy. The aim of this study was to evaluate if PET-CT could identify patients who will benefit from locoregional radiotherapy.

MATERIALS AND METHODS

This ethics-approved study included patients with advanced classical seminoma primarily treated with standard platinum-based first-line chemotherapy. Patients were either observed or given adjuvant radiotherapy based on the clinician's preference and followed up. For this study, patients were stratified into two groups based on FDG PET-CT residual nodal maximum standardised uptake value (SUVmax): low risk (SUVmax <3) and high risk (SUVmax ≥3). Further subgroup analysis was carried out for patients with residual nodal size ≥3 cm and SUVmax ≥3, and this was considered as the very high risk group. The diagnostic accuracy of FDG PET-CT was assessed and survival was compared between the different groups.

RESULTS

Sixty-nine patients were included in the study: 48 patients were observed and 21 received radiotherapy. The low and high risk groups contained 50.7% and 49.3% of the patients, respectively. The very high risk subgroup had 24 patients. At a median follow-up of 44 months, locoregional failures in the radiotherapy and observation cohorts were 0% and 30% (P = 0.059) in the very high risk subgroup and 5.8% and 29.4% (P = 0.078) in the high risk group. The positive predictive value for the very high risk and high risk groups was 30% and 17.1%, respectively. The benefit of locoregional control failed to translate into overall survival benefit.

CONCLUSION

A tailored, FDG PET-based risk-adapted treatment approach can refine the management of post-chemotherapy residual masses in seminoma. In this study, with the largest cohort of advanced seminoma patients treated with radiotherapy reported to date, radiotherapy seems to benefit patients with post-chemotherapy residual mass SUVmax ≥3.

Thrombotic microangiopathy following heart transplant in pediatric Danon disease

This case describes an uncommon acute complication of diffuse thrombotic angiopathy and associated aHUS/TTP in an 11-year-old girl with Danon disease who underwent orthotopic heart transplant. Shortly after transplant, despite an uncomplicated operative course, the patient developed severe kidney injury and progressive altered mental status, culminating in cerebral edema, brain herniation, and death. She had received a single dose of tacrolimus (FK506) and a single dose of antithymocyte globulin. Sources of progressive somnolence, including oversedation from impaired renal clearance of opiates, and severe myopathy as has been previously described in Danon disease, were ruled out, and the patient continued to decline. Initial brain CT scan early after transplant showed no signs of cerebral edema, but repeat CT indicated severe cerebral edema. Based on autopsy, diffuse thrombotic angiopathy, with signs of hemolytic anemia with schistocytes, was likely responsible for her deterioration in the broader condition of aHUS/TTP.

Adaptive Radiotherapy for Carcinoma of the Urinary Bladder: Long-term Outcomes With Dose Escalation

AIMS

To report long-term outcomes with dose-escalated, image-guided adaptive radiotherapy (ART) for bladder preservation in muscle-invasive bladder cancer (MIBC).

MATERIALS AND METHODS

All MIBC patients receiving bladder-preserving ART at our institute from 2009 to 2018 were analysed. For ART, three anisotropic planning target volumes (PTV) were concentrically grown around the simulation bladder volume. A library of intensity-modulated radiotherapy plans was created for each patient. A total dose of 64 Gy in 32 fractions to the entire bladder and 55 Gy to pelvic nodes was planned, with 68 Gy to the tumour bed (2 Gy equivalent dose = 68.7 Gy, α/β = 10) as simultaneous integrated boost for solitary tumours. The most appropriate PTV encompassing the bladder ('plan-of-the-day') was chosen daily using on-board megavoltage imaging. Neoadjuvant and concurrent chemotherapy was prescribed for medically fit patients.

RESULTS

Of a total of 106 patients, most had T2 (68%) or T3 (19%) disease. Ninety-two patients (87%) completed 64 Gy to the whole bladder. Sixty-three patients (59%) received 68 Gy as tumour bed boost. Seventy-six per cent received concurrent weekly chemotherapy. At a median follow-up of 26 months, 3-year locoregional control, disease-free survival and overall survival were 74.3, 62.9 and 67.7%, respectively. Eighty-two per cent of patients retained disease-free bladder. Radiation Therapy Oncology Group grade III/IV acute genitourinary and gastrointestinal toxicities were 7.5% and 0%, respectively, and late genitourinary/gastrointestinal toxicities were 6.5% and 3.8%, respectively. Overall survival, disease-free survival, locoregional control and grade III/IV genitourinary/gastrointestinal toxicities did not differ significantly with dose escalation.

CONCLUSION

Plan-of-the-day ART is clinically safe and effective for bladder preservation and can be implemented in routine clinical practice. A high bladder preservation rate is achievable without compromising on survival or toxicities. Dose escalation does not seem to affect outcomes.

Cell-free DNA noninvasive prenatal screening for aneuploidy versus conventional screening: A systematic review of economic evaluations

Although noninvasive prenatal testing (NIPT) for aneuploidies using cell-free fetal DNA in maternal blood has been reported to have a high accuracy, only little evidence about its cost-effectiveness is available. We systematically reviewed and assessed quality of economic evaluation studies published between January 1, 2009 and January 1, 2016 where NIPT was compared to the current screening practices consisting of biochemical markers with or without nuchal translucency (NT) and/or maternal age. We included 16 studies and we found that, at current level of NIPT prices, contingent NIPT provide the best value for money, especially for publicly funded screening programs. NIPT as first-line test was found not cost-effective in the majority of studies. The NIPT unit cost, the risk cut-offs for current screening practice, the screening uptake rates (first- and second-line screening) as well as the costs and uptake rates of invasive diagnostic screening were the most common uncertain variables. The overall quality of included studies was fair. Considering a possible drop in prices and an ongoing NIPT expansion to include other chromosomes abnormalities other than T21, T18, T13 and sex chromosomes aneuploidies, future research are needed to examine the potential cost-effectiveness of implementing NIPT as first-line test.