Low-dose sevoflurane co-administered with propofol-based general anaesthesia obliterates intra-operative neurophysiological monitoring in an infant

The influence of general anaesthetic agents on intra-operative neurophysiological monitoring in neonates and infants has rarely been reported. Propofol-based anaesthesia is recommended to avoid suppression of neurophysiological monitoring. However, the administration of propofol in children undergoing prolonged procedures, especially those younger than six months, should be carefully controlled due to the potential risk of propofol infusion syndrome. Adding a small dose of inhalational anaesthetic can be an option to reduce propofol requirements. Recent guidelines in Japan suggest limiting inhalational anaesthetics to less than 0.5 minimum alveolar concentrations when co-administered with low-dose propofol during intra-operative neuromonitoring. However, there is still insufficient evidence regarding the impact of sevoflurane on neurophysiological monitoring when co-administered with propofol in infants. This report describes a case of a three-month-old infant undergoing spinal lipoma resection in which there was a dramatic suppression of neurophysiological monitoring with the addition of 0.35-0.45% sevoflurane to propofol-based anaesthesia.

Effect of iodine concentration and body size on iodine subtraction in virtual non-contrast imaging: A phantom study

INTRODUCTION

Dual-energy computed tomography (DECT) can generate virtual non-contrast (VNC) images. Herein, we sought to improve the accuracy of VNC images by identifying the optimal slope of contrast media (SCM) for VNC-image generation based on the iodine concentration and subject's body size.

METHODS

We used DECT to scan a multi-energy phantom including four iodine concentration rods (15, 10, 5, and 2 mg/mL), and 240 VNC images (eight SCM ranging from 0.49 to 0.56 × three body sizes × ten scans) that were generated by three-material decomposition. The CT number of each iodine and solid water rod part was measured in each VNC image. The difference in the CT number between the iodine and the solid water rod part was calculated and compared using paired t-test or repeated measures ANOVA.

RESULTS

The SCM that achieved an absolute value of the difference in CT number of <5.0 Hounsfield units (HU) for all body sizes simultaneously was greater at lower iodine concentration (SCM of 0.5, 0.51, and 0.53 at 10, 5, and 2 mg/mL iodine, respectively). At an iodine concentration of 15 mg/mL, no SCM achieved an absolute difference of <5.0 HU in CT number for all body sizes simultaneously. At all iodine concentrations, the SCM achieving the minimal difference in the CT number increased with the increase in body size.

CONCLUSION

By adjusting the SCM according to the iodine concentration and body size, it is possible to generate VNC images with an accuracy of <5.0 HU.

IMPLICATIONS FOR PRACTICE

Improving the accuracy of VNC images minimizing incomplete iodine subtraction would make it possible to replace true non-contrast (TNC) images with VNC images and reduce the radiation dose.

Comprehensive clinical and molecular characterization of claudin 18.2 expression in advanced gastric or gastroesophageal junction cancer

BACKGROUND

We conducted comprehensive clinical and molecular characterization of claudin 18.2 expression (CLDN18.2) in advanced gastric or gastroesophageal junction cancer (GC/GEJC).

PATIENTS AND METHODS

Patients with advanced GC/GEJC who received systemic chemotherapy from October 2015 to December 2019 with available tumor specimens were analyzed. We evaluated clinicopathological features of CLDN18.2 expression with four molecular subtypes: mismatch repair deficient, Epstein-Barr virus-positive, human epidermal growth factor receptor 2-positive, and others. In addition, programmed death-ligand 1 (PD-L1) combined positive score (CPS), genomic alterations, and the expression of immune cell markers were assessed. Clinical outcomes of standard first- or second-line chemotherapy and subsequent anti-programmed cell death protein 1 (anti-PD-1) therapy were also investigated according to CLDN18.2 expression.

RESULTS

Among 408 patients, CLDN18.2-positive (moderate-to-strong expression in ≥75%) was identified in 98 patients (24.0%) with almost equal distribution in the four molecular subtypes or CPS subgroups. CLDN18.2-positive was associated with Borrmann type 4, KRAS amplification, low CD16, and high CD68 expression. Overall survival with first-line chemotherapy was not significantly different between CLDN18.2-positive and -negative groups [median 18.4 versus 20.1 months; hazard ratio 1.26 (95% confidence interval 0.89-1.78); P = 0.191] regardless of stratification by PD-L1 CPS ≥5. Progression-free survival and objective response rates of first- and second-line chemotherapy, and anti-PD-1 therapy also showed no significant differences according to CLDN18.2 status.

CONCLUSIONS

CLDN18.2 expression in advanced GC/GEJC was associated with some clinical and molecular features but had no impact on treatment outcomes with chemotherapy or checkpoint inhibition. CLDN18.2-positive also had no impact on overall survival. This information could be useful to interpret the results from currently ongoing clinical trials of CLDN18.2-targeted therapies for advanced GC/GEJC and to consider a treatment strategy for CLDN18.2-positive GC/GEJC.

Detection of current-sheet and bipolar ion flows in a self-generated antiparallel magnetic field of laser-produced plasmas for magnetic reconnection research

Magnetic reconnection in laser-produced magnetized plasma is investigated by using optical diagnostics. The magnetic field is generated via the Biermann battery effect, and the inversely directed magnetic field lines interact with each other. It is shown by self-emission measurement that two colliding plasmas stagnate on a midplane, forming two planar dense regions, and that they interact later in time. Laser Thomson scattering spectra are distorted in the direction of the self-generated magnetic field, indicating asymmetric ion velocity distribution and plasma acceleration. In addition, the spectra perpendicular to the magnetic field show different peak intensity, suggesting an electron current formation. These results are interpreted as magnetic field dissipation, reconnection, and outflow acceleration. Two-directional laser Thomson scattering is, as discussed here, a powerful tool for the investigation of microphysics in the reconnection region.

High-power laser experiment on developing supercritical shock propagating in homogeneously magnetized plasma of ambient gas origin

A developing supercritical collisionless shock propagating in a homogeneously magnetized plasma of ambient gas origin having higher uniformity than the previous experiments is formed by using high-power laser experiment. The ambient plasma is not contaminated by the plasma produced in the early time after the laser shot. While the observed developing shock does not have stationary downstream structure, it possesses some characteristics of a magnetized supercritical shock, which are supported by a one-dimensional full particle-in-cell simulation taking the effect of finite time of laser-target interaction into account.

Glycaemic management in a child with ornithine transcarbamylase deficiency undergoing cardiac surgery with hypothermic cardiopulmonary bypass

There is a lack of evidence regarding the optimal intra-operative glycaemic level of patients with ornithine transcarbamylase deficiency to prevent cerebral oedema due to protein catabolism and hyperammonemia. We describe a case of a two-year-old girl with ornithine transcarbamylase deficiency who underwent cardiac surgery requiring cardiopulmonary bypass. A high-dose dextrose infusion to prevent protein catabolism was given throughout surgery, which caused uncontrollable hyperglycaemia unresponsive to high-dose insulin administration. Factors contributing to the hyperglycaemia may have included surgical stress, steroid administration and hypothermia. During invasive surgery, anaesthetists should carefully adjust the rates of dextrose and insulin infusions, guided by close monitoring of blood ammonia, glucose and lactate.

Direct observations of pure electron outflow in magnetic reconnection

Magnetic reconnection is a universal process in space, astrophysical, and laboratory plasmas. It alters magnetic field topology and results in energy release to the plasma. Here we report the experimental results of a pure electron outflow in magnetic reconnection, which is not accompanied with ion flows. By controlling an applied magnetic field in a laser produced plasma, we have constructed an experiment that magnetizes the electrons but not the ions. This allows us to isolate the electron dynamics from the ions. Collective Thomson scattering measurements reveal the electron Alfvénic outflow without ion outflow. The resultant plasmoid and whistler waves are observed with the magnetic induction probe measurements. We observe the unique features of electron-scale magnetic reconnection simultaneously in laser produced plasmas, including global structures, local plasma parameters, magnetic field, and waves.

OP0062 EFFICACY AND SAFETY OF ADALIMUMAB WITH LOW AND HIGH DOSE-METHOTREXATE IN PATIENTS WITH RHEUMATOID ARTHRITIS WITH INADEQUATE RESPONSE TO METHOTREXATE: THE RANDOMISED CONTROLLED MIRACLE STUDY

Background

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that causes not only joint pain but also bone destruction resulting in impairment of quality of life. Tumor necrosis factor inhibitors have improved prognosis of patients with rheumatoid arthritis dramatically, especially in combination with methotrexate, however, the optimal dose of the concomitant methotrexate is unclear.

Objectives

To evaluate the efficacy and safety of adalimumab in combination with reduced dose of methotrexate in patients with early RA with inadequate response to methotrexate.

Methods

The MIRACLE study was a multinational, randomized, open-label study in patients with RA with inadequate response to methotrexate conducted in Asia. It compared low dose and high dose methotrexate upon starting adalimumab. Methotrexate-naive patients with RA with a disease duration of less than two years started methotrexate at 6 to 8 mg/week and increased it to the maximum tolerable dose by week 12. Patients who have not achieved remission according to simplified disease activity index (SDAI) despite methotrexate ≥ 10 mg/week at week 24 were randomised to the maximum tolerable dose of methotrexate group (10 to 25 mg/week) or the reduced dose group (6 to 8 mg/week) and started to receive subcutaneous adalimumab 40 mg every other week. The primary endpoint was non-inferiority in the achievement of SDAI remission at week 48 in the reduced dose group compared with the maximum tolerable dose group with a non-inferiority margin of -15% based on two-sided 90% confidence interval. (NCT03505008)

Results

A total of 300 patients were enrolled in the study. Among them, 291 started methotrexate and were included in the analysis. The mean age was 57.7±15.2 years, female was 74.6%, and the mean disease duration from the diagnosis of RA was 21.1±56.2 days. Anti-CCP antibody was positive in 211 (73.0%) and the mean SDAI at study enrollment was 26.5±12.4. At week 24, with the mean dose of methotrexate of 12.6±2.9 mg/week, 108 patients (37.1%) achieved remission according to SDAI and continued MTX monotherapy. 134 patients (46.0%) were randomised and started adalimumab with 68 patients in the maximum tolerable dose group and 66 patients in the reduced dose group. At week 48, the remission achievement rates were 38.4 % and 44.8 %, respectively, with the adjusted risk difference of the reduced dose group to the maximum tolerable dose group of 6.4% (-7.0% to 19.8%, 90% CI), which met the criterion for noninferiority. No significant difference was found in health assessment questionnaire disability index ≤0.5 (59.1% vs 62.0%, respectively, p=0.72) and in radiological remission rates (Δmodified total Sharp score ≤0.5, 66.3% vs 62.0 %, respectively, p=0.59). Adverse drug reactions tended to be more frequent in the maximum tolerable dose group than in the reduced dose group (22.1% vs 9.1%, respectively, p=0.06).

Conclusion

The MIRACLE randomised study demonstrated that, in patients with inadequate response to methotrexate, the efficacy of adalimumab with reduced dose of concomitant methotrexate was not inferior to that with maximum tolerable dose of methotrexate with better safety profile.

Disclosure of Interests

Hiroya Tamai Speakers bureau: Eisai, Grant/research support from: Eisai, Kei Ikeda Speakers bureau: AbbVie, Eisai, Eli Lilly, Novartis, Gilead, Asahi-Kasei, Grant/research support from: Mitsubishi-Tanabe, Toshiaki Miyamoto: None declared, Hiroaki Taguchi: None declared, Chang-Fu Kuo: None declared, Kichul Shin: None declared, Shintaro Hirata Speakers bureau: AbbVie, Asahi-Kasei, Astellas, Ayumi, Bristol Myers Squibb, Celgene, Chugai, Eisai, Eli Lilly, Gilead, Glaxo SmithKline, Janssen, Kyorin, Novartis, Pfizer, Sanofi, Tanabe-Mitsubishi, UCB, Paid instructor for: AbbVie, Mitsubishi-Tanabe, Consultant of: AbbVie, Astellas, Bristol Myers Squibb, Eisai, Gilead, Ily Lilly, Grant/research support from: AbbVie, Asahi-Kasei, Eisai, Otsuka, Sanofi, Shionogi, Chugai, Pfizer, Tanabe-Mitsubishi, Eli Lilly, UCB, yutaka okano: None declared, Shinji Sato Speakers bureau: AbbVie, Eisai, Grant/research support from: AbbVie, Eisai, Hidekata Yasuoka Speakers bureau: AbbVie, Asahi Kasei Pharma, Astellas, Daiichi-Sankyo, Eisai, Kissei, Takeda, Mitsubishi-Tanabe, Chugai, Novartis, Eli Lilly, Pfizer, Janssen, Sanofi, Teijin, Boehringer-Ingelheim, Bayer, Glaxo Smith Kline, Paid instructor for: AbbVie, Consultant of: AbbVie, Asahi Kasei, Grant/research support from: Mitsubishi-Tanabe, Takeda, Daiichi-Sankyo, Chugai, Bristol-Myers, MSD, Astellas, In Ah Choi Speakers bureau: Abbvie, Eisai, Sung-Hwan Park: None declared, Meng-Yu Weng Paid instructor for: Novartis, Eli Lilly, ChuGai, Abbvie, Consultant of: Abbvie, Masataka Kuwana Speakers bureau: Astellas, Asahi Kasei Pharma, Boehringer-Ingelheim, Chugai, Eisai, Janssen, Mochida, Nippon Shinyaku, Ono Pharmaceuticals, Pfizer, Mitsubishi-Tanabe, Consultant of: Boehringer-Ingelheim, Kissei, Mochida, Grant/research support from: AbbVie, Asahi Kasei Pharma, Boehringer-Ingelheim, Chugai, Eisai, MBL, Nippon Shinyaku, Ono Pharmaceuticals, Mitsubishi-Tanabe, Yun Jong Lee Grant/research support from: Yuhan, Tomonori Ishii Speakers bureau: Chugai, Mitsubishi-Tanabe, Glaxo Smith Kline, Pfizer, Eli Lilly, Janssen, AbbVie, Eisai, Astellas, Jinhyun Kim: None declared, Hideto Kameda Speakers bureau: AbbVie, Pfizer, Consultant of: AbbVie, Grant/research support from: AbbVie, Eisai, Toshihisa Kojima Speakers bureau: AbbVie, Pfizer, Eisai, Grant/research support from: AbbVie, Han Joo Baek: None declared, Ping-Ning Hsu: None declared, Chun-Ming Huang Paid instructor for: Abbvie, Pfizer, Tien-Tsai Cheng Paid instructor for: Abbvie, Grant/research support from: Abbvie, Wan-Yu Sung: None declared, Takehiro Taninaga Shareholder of: Eisai.co.,Ltd., Employee of: Eisai.co.,Ltd., Masahiko Mori Shareholder of: Eisai.co.,Ltd., Employee of: Eisai.co.,Ltd., Hideaki Miyagishi Shareholder of: Eisai.co.,Ltd., Employee of: Eisai.co.,Ltd., Yasunori Sato Speakers bureau: Eisai Co., Ltd. Kowa Company, Ltd., Consultant of: MOCHIDA PHARMACEUTICAL CO., LTD, Tsutomu Takeuchi Speakers bureau: Astellas, AbbVie, Ayumi, Bristol Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Glaxo Smith Kline, Janssen, Mitsubishi-Tanabe, Nippon-kayaku, Novartis, Pfizer, Sanofi, UCB, Grant/research support from: Asahi Kasei, AbbVie, Ayumi, Boehringer-Ingelheim, Chugai, Eisai, Eli Lilly, Mitsubishi-Tanabe, Sanofi, UCB, Yuko Kaneko Speakers bureau: Asahi Kasei, Astellas, Ayumi, Bristol Myers Squibb, Chugai, Eisai, Elli Lilly, Mitsubishi-Tanabe, Novartis, UCB, Grant/research support from: AbbVie, Chugai, Eisai, Mitsubishi-Tanabe, UCB.

High-power laser experiment forming a supercritical collisionless shock in a magnetized uniform plasma at rest

We present an experimental method to generate quasiperpendicular supercritical magnetized collisionless shocks. In our experiment, ambient nitrogen (N) plasma is at rest and well magnetized, and it has uniform mass density. The plasma is pushed by laser-driven ablation aluminum (Al) plasma. Streaked optical pyrometry and spatially resolved laser collective Thomson scattering clarify structures of plasma density and temperatures, which are compared with one-dimensional particle-in-cell simulations. It is indicated that just after the laser irradiation, the Al plasma is magnetized by a self-generated Biermann battery field, and the plasma slaps the incident N plasma. The compressed external field in the N plasma reflects N ions, leading to counterstreaming magnetized N flows. Namely, we identify the edge of the reflected N ions. Such interacting plasmas form a magnetized collisionless shock.

Pembrolizumab versus chemotherapy for patients with esophageal squamous cell carcinoma enrolled in the randomized KEYNOTE-181 trial in Asia

BACKGROUND

In the randomized phase III KEYNOTE-181 study, pembrolizumab prolonged overall survival (OS) compared with chemotherapy as second-line therapy in patients with advanced esophageal cancer and programmed death-ligand 1 (PD-L1) combined positive score (CPS) ≥10. We report a post hoc subgroup analysis of patients with esophageal squamous cell carcinoma (ESCC) enrolled in KEYNOTE-181 in Asia, including patients from the KEYNOTE-181 China extension study.

PATIENTS AND METHODS

Three hundred and forty Asian patients with advanced/metastatic ESCC were enrolled in KEYNOTE-181, including the China cohort. Patients were randomly assigned 1 : 1 to receive pembrolizumab 200 mg every 3 weeks for ≤2 years or investigator's choice of paclitaxel, docetaxel, or irinotecan. OS, progression-free survival, response, and safety were analyzed without formal comparisons. OS was evaluated based on PD-L1 CPS expression level.

RESULTS

In Asian patients with ESCC, median OS was 10.0 months with pembrolizumab and 6.5 months with chemotherapy [hazard ratio (HR), 0.63; 95% CI 0.50-0.80; nominal P < 0.0001]. Median progression-free survival was 2.3 months with pembrolizumab and 3.1 months with chemotherapy (HR, 0.79; 95% CI 0.63-0.99; nominal P = 0.020). Objective response rate was 17.1% with pembrolizumab and 7.1% with chemotherapy; median duration of response was 10.5 months and 7.7 months, respectively. In patients with PD-L1 CPS <1 tumors (pembrolizumab versus chemotherapy), the HR was 0.99 (95% CI 0.56-1.72); the HR (95% CI) for death was better for patients with PD-L1 CPS cut-offs >1 [CPS ≥1, 0.57 (0.44-0.75); CPS ≥5, 0.56 (0.41-0.76); CPS ≥10, 0.53 (0.37-0.75)]. Treatment-related adverse events were reported in 71.8% of patients in the pembrolizumab group and 89.8% in the chemotherapy group; grade 3-5 events were reported in 20.0% and 44.6%, respectively.

CONCLUSIONS

Pembrolizumab monotherapy demonstrated promising efficacy in Asian patients with ESCC, with fewer treatment-related adverse events than chemotherapy. PD-L1 CPS ≥1 is an appropriate cut-off and a predictive marker of pembrolizumab efficacy in Asian patients with ESCC.

AB0233 REASONS AND RISK FACTOR FOR DISCONTINUATION OF BIOLOGIC AGENTS FOR RHEUMATOID ARTHRITIS PATIENTS IN LONG-TERM OBSERVATION

Background:

Rheumatoid arthritis (RA) patients who failed a first biologic agent due to any reasons have the option of switching to a second one along with the strategy of biologic agent treatment. Patients go over switching to the next one at failing their biologic agent. On the other hand, there are some patients who discontinue any biologic agent treatment due to various reasons such as tolerability concern, complications, economic issue, remission and so on1 2. The impact of this concern has been less studied.

Objectives:

The objective of this study was to investigate the reasons and the risk factors for discontinuation any biologic agent in RA patients.

Methods:

To Include patients who are observed long-term, patients who underwent biologic agent treatment between 2003 and 2007 at Nagoya University Hospital and 12 other institutes (Tsurumai Biologics Communication Study Group) were enrolled. 570 patients who were confirmed continuation or discontinuation of biologic agent treatment were enrolled. The last observation was September 2017. We analyzed the retention rate of biologic agent treatment and the reasons for discontinuation. To identify the risks for discontinuation, baseline demographics were compared between the continuing group and the disc continuing group using cox hazard regression analysis.

Results:

In total 570 patients, the average duration of treatment with biologics was 6.6±3.3 (years) and total patient-year was 3739 in this study. 458 patients were administered biologics continuously, 112 patients were withdrawn. Table 1 showed the demographic data in total patients. The retention rate was 96.0% (discontinuation n=23) at least 1 year from starting biologics treatment, 92.6% (n=42) at 3 years, 88.2% (n=67) at 5 years, 84.4% (n=89) at 7 years, 81.1% (n=108) at 10 years. In 112 patients who discontinued, the reasons were adverse events in 74 patients, lack of effectiveness in 11 patients, others in 27 patients. Comparison of incidence for discontinuation using cumulative hazard function, the reason of adverse events was significantly higher than others reasons (Figure 1). To identify the risks of discontinuation, we analyzed by multivariable Cox proportional hazard modeling in patients who discontinued treatment due to adverse events, the risk factors (hazard ratio: HR, confidence interval: CI) were over 3 of Steinblocker class (HR 1.85 [1.02-2.04]), age (HR:1.07 [1.04-1.10]) and Non-concomitant with methotrexate (HR 1.90 [1.08-3.33]) (Figure 2).

Table 1.Age (years)56.1 ± 13.4Gender n (% male)110 (19%) n (% female)460 (81%)Disease duration (years)11.1 ± 9.8stage 1,2104 (19%) 3,4455 (81%)class 1,2336 (60%) 3,4225 (40%)Methotrexate use, no (%)400 (70%)Glucocorticoid use, no (%)262 (47%)Rheumatoid Factor, no (%)287 (65%)anti CCP antibody, no (%)137 (87%)

Conclusion:

The most common reason for discontinuation was adverse events in long term observation. The risk factors for discontinuation were class, age, and non-concomitant MTX. These results suggested that comorbidity has a significant impact on continuation rates because there are some reasons of non-concomitant MTX in addition to relate with age and the activities of daily living.

References:

[1]Marussa B, et al. j.clin thera. 2011; 33(7): 901-913

[2]Alejandro S, et al. Rheumatol. 2016; 55(3): 523-34

Disclosure of Interests:

KENYA TERABE: None declared, Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Shuji Asai Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Janssen, Takeda, and UCB Japan, Yuji Hirano Speakers bureau: Tanabe-Mitsubishi, Pfizer, Eisai, Abbie, Chugai, Bristol-Meyers, Jansen, Astellas, UCB, Eli-Lilly, Asahikasei, Daiichi-Sankyo, Amgen, Yasuhide Kanayama: None declared, Toshihisa Kojima Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Consultant of: AbbVie, Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis

AB0253 COMPARISON OF PHARMACODYNAMICS OF METHOTREXATE AS METHOTREXATE-POLYGLUTAMATES CONCENTRATIONS IN RHEUMATOID ARTHRITIS; INTERIM DATA EVALUATION OF MIRACLE STUDY CONDUCTED IN JAPAN, KOREA AND TAIWAN

Background:

Methotrexate (MTX) is the first-line therapy for rheumatoid arthritis (RA). The concentrations of MTX-polyglutamates (PG) in erythrocytes, an active form of MTX, are useful markers for the optimal usage of MTX in patients with RA. The concentrations of MTX-PG have been reported to be different between Japanese and Caucasians. However, the difference among Asian ethnicity remains unclear.

Objectives:

To examine MTX-PG concentrations in association with MTX dose during the first 24 weeks after the initiation of MTX for newly diagnosed RA patients in Japan, Korea and Taiwan.

Methods:

MIRACLE study is a multicenter, open-label, randomized, 48 weeks interventional study conducted in Japan, Korea and Taiwan to evaluate non-inferiority of low dose to high dose of MTX as an add-on therapy to adalimumab in 300 patients with RA who do not achieve remission after 24 weeks MTX monotherapy in stipulated dosage. In the first 24 weeks, MTX was started at 6 to 8 mg/week for newly diagnosed RA patients, and promptly escalated to the maximum tolerable dose in 12 weeks in principle. This interim data evaluation was intended to investigate the differences among countries in the relationship between MTX dose, safety and MTX-PG concentrations in erythrocytes during the first 24 weeks. The efficacy of the treatment is not included at this point.

Results:

A total of 166 patients (106 in Japan, 35 in Korea, 25 in Taiwan) were included in this interim data. The age at treatment initiation was 57.2 years old on average and female was 79.5%. The time course changes in total and individual MTX-PG levels differed in the three countries. At 24 weeks, whereas the mean total MTX-PG concentrations were comparable (112.9 nmol/L in Japan, 104.4 nmol/L in Korea, and 115.7 nmol/L in Taiwan) with a dose of MTX of 12.3 mg/week, 14.1 mg/week, and 12.2 mg/week, respectively, the individual MTX-PG concentrations were different. The MTX-PG1 and MTX-PG2 concentrations were lower in Korea than Japan and Taiwan whereas MTX-PG3, MTX-PG4 and MTX-PG5 concentrations were the highest in Korea.

Conclusion:

The distribution of short-chain and long-chain MTX-PG concentrations were various among Asian countries despite similar dose of MTX administration: NCT03505008.

Disclosure of Interests:

Hiroya Tamai: None declared, Yuko Kaneko Speakers bureau: AbbVie, Astellas, Ayumi, Bristol–Myers Squibb, Chugai, Eisai, Eli Lilly, Hisamitsu, Jansen, Kissei, Kirin, Pfizer, Sanofi, Takeda, Tanabe-Mitsubishi, and UCB., Grant/research support from: Sanofi, Hideto Kameda Speakers bureau: AbbVie, Pfizer, Consultant of: AbbVie, Grant/research support from: AbbVie, Eisai, Masataka Kuwana Speakers bureau: Astellas, Asahi Kasei Pharma, Boehringer- Ingelheim, Chugai, Eisai, Janssen, Mochida, Nippon Shinyaku, Ono Pharmaceuticals, Pfizer, Mitsubishi-Tanabe, Consultant of: Corbus, Grant/research support from: AbbVie, Asahi Kasei Pharma, Boehringer- Ingelheim, Chugai, Eisai, MBL, Nippon Shinyaku, Ono Pharmaceuticals, Mitsubishi-Tanabe, Yutaka Okano: None declared, Tomonori Ishii Speakers bureau: Chugai, Mitsubishi- Tanabe, Glaxo Smith Kline, Pfizer, Eli Lilly, Janssen, AbbVie, Eisai, Astellas, Kei Ikeda Speakers bureau: AbbVie, Eli Lilly, Novartis, Mitsubishi-Tanabe, Eisai, BMS, Grant/research support from: Mitsubishi-Tanabe, Hiroaki Taguchi: None declared, Shinji Sato: None declared, Toshiaki Miyamoto: None declared, Shintaro Hirata Speakers bureau: AbbVie, Asahi Kasei Pharma, Astellas, Ayumi, Bristol Myers Squibb, Chugai, Eisai, Eli Lilly, Janssen, Glaxo Smith Kline, Kissei, Pfizer, Sanofi, Mitsubishi- Tanabe, UCB, Paid instructor for: AbbVie, Mitsubishi- Tanabe, Consultant of: AbbVie, Eisai, Gilead, Grant/research support from: AbbVie, Chugai, Mitsubishi-Tanabe, UCB, Hidekata Yasuoka Speakers bureau: AbbVie, Asahi Kasei Pharma, Astellas, Daiichi- Sankyo, Eisai, Kissei, Takeda, Mitsubishi- Tanabe, Chugai, Novartis, Eli Lilly, Pfizer, Janssen, Sanofi, Teijin, Boehringer- Ingelheim, Bayer, Glaxo Smith Kline, Paid instructor for: AbbVie, Consultant of: AbbVie, Asahi Kasei, Grant/research support from: Mitsubishi-Tanabe, Takeda, Daiichi-Sankyo, Chugai, Bristol-Myers, MSD, Astellas, Toshihisa Kojima Speakers bureau: AbbVie, Pfizer, Eisai, Grant/research support from: AbbVie, Sung-Hwan Park: None declared, Kichul Shin: None declared, Han Joo Baek: None declared, Yun Jong Lee Grant/research support from: research fund, In Ah Choi Speakers bureau: Abbvie, Eizai, Grant/research support from: Abbvie, Eizai, Jinhyun Kim: None declared, Ping-Ning Hsu: None declared, Chang-Fu Kuo: None declared, Chun-Ming Huang Paid instructor for: AbbVie, Pfizer, Meng-Yu Weng Consultant of: AbbVie, Wan-Yu Sung: None declared, Wen-Chan Tsai: None declared, Tien-Tsai Cheng Paid instructor for: AbbVie, Grant/research support from: AbbVie, Takehiro Taninaga Shareholder of: Eisai Co., Ltd., Employee of: Eisai Co., Ltd., Masahiko Mori Shareholder of: Eisai Co., Ltd., Employee of: Eisai Co., Ltd., Hideaki Miyagishi Employee of: Eisai Co., Ltd., Yasunori Sato: None declared, Tsutomu Takeuchi Speakers bureau: Astellas, Abbvie, Daiichi Sankyo, Ayumi, Eisai, GlaxoSmithKline, Mitsubishi Tanabe, Chugai, Novartis, Eli Lilly, Pfizer, Bristol Myers Squibb, Janssen, UCB, TaishoToyama, Sanofi–Aventis, Nipponkayaku, Taiho, Gilead, Boehringer Ingelheim, Grant/research support from: Asahikasei, Astellas, Abbvie, Daiichi Sankyo, Ayumi, Eisai, Takeda, Mitsubishi Tanabe, Chugai, Eli Lilly, UCB, Sanofi–Aventis, Nipponkayaku, Boehringer Ingelheim

Uninterrupted twice-daily direct oral anticoagulants are safer than once-daily ones for atrial fibrillation catheter ablation

Background

In patients undergoing AF catheter ablation (CA), uninterpreted DOACs reduced bleeding events without increasing ischemic events compared with vitamin K antagonist, and the continuation of anticoagulants is recommended for AF ablation. However, in the past studies, patients received once-daily DOACs in the evening, not in the morning of the procedure day. Moreover, there has been no study comparing uninterrupted 4 DOACs; therefore, the safety and effect of uninterpreted DOACs taken just in the morning of AF ablation is unknown.

Objective

The purpose of this study was to compare bleeding complications and thromboembolism events between 4 DOACs in patients undergoing AF ablation.

Method

This study was the retrospective single-center cohort study of consecutive patients who underwent AF ablation between April 2014 to July 2019. All patients continued DOAC uninterruptedly including just in the morning of the procedure. The primary endpoint included major bleeding events within the first 30 days after CA. The secondary endpoints included the composite events of ischemic stroke, systemic embolism, myocardial infarction, and vascular death.

Result

A total of 713 patients (mean age 64±12 years, 72% male) were included in this analysis; enrolled patients were 88, 238, 218, and 169 respectively in dabigatran, rivaroxaban, apixaban and edoxaban group. At the baseline, the ratio of age ≥75 years and CHADS2 score was higher in apixaban group, though all other baseline variables were similar between them.

The primary endpoint was observed 0%, 2.1%, 0.45%, and 4.7% respectively in dabigatran, rivaroxaban, apixaban, and edoxaban group (P=0.013) without significant difference about secondary endpoint between them (P=0.3).

Comparing twice-daily vs once-daily DOACs, the primary endpoint was observed significantly lower in the twice-daily group than in once-daily group (0.32% and 3.2% respectively, P=0.0054), without any significant difference about secondary endpoint (0% and 0.73% respectively, P=0.26).

Conclusion

Taking DOACs also in the morning of AF ablation, uninterrupted twice-daily DOACs are safer than once-daily DOACs without increasing ischemic event, although twice-daily DOACs, especially apixaban, were used in higher aged patients.

Figure 1

Funding Acknowledgement

Type of funding source: None

Cardiac factors as well as non-cardiac factors were associated with frailty in patients with heart failure with preserved ejection fraction

Background

Frailty is associated with malnutrition and poor prognosis in patients with heart failure with preserved ejection fraction (HFpEF). However, the cardiac factors associated with frailty have not been fully examined in patients with HFpEF.

Purpose

The purpose of this study is to clarify the cardiac factors related to frailty in patients with HFpEF.

Methods

Of the 756 patients who registered prospective, multicenter, observational study of patients with HFpEF (PURSUIT-HFpEF) registry, 481 cases with clinical frailty score (CFS) and prognosis after discharge were examined. Frailty was defined as CFS ≥5. Outcomes were composite endpoint of all-cause death and heart failure readmission, and all-cause mortality. We compared outcomes between patients without and with frailty, and sought to identify factors which were associated with increase in clinical frailty score by the correlation analysis and linear regression analysis.

Results

Of 481 patients, 131 patients (27.2%) were frail. Male gender was less in patients with frailty than those without frailty (26.7% vs 73.3%, P&lt;0.001). Frail patients had higher age (85.2±7.3 vs 78.7±9.4 years, P&lt;0.001). During follow-up period of 396 [343, 697] days, composite endpoint (Kaplan-Meier event rate estimates, 77% vs. 60%; log-rank P&lt;0.001), and all-cause mortality (Kaplan-Meier event rate estimates, 57% vs. 28%; log-rank P&lt;0.001) was higher in patients with frailty than those without frailty. Multivariate Cox regression analysis revealed frailty was significantly and independently associated with mortality (HR=1.40, 95% CI=1.17–1.68, P&lt;0.001). CFS was significantly correlated with age (r=0.401, P&lt;0.001), sex (r=0.223, P&lt;0.001), body mass index (r=−0.146, P=0.001), hemoglobin (r=−0.148, P=0.001), albumin (r=−0.222, P&lt;0.001), left ventricular diastolic diameter (r=−0.184, P&lt;0.001), interventricular septum thickness (r=−0.124, P=0.008), left ventricular mass (r=−0.217, P&lt;0.001), tricuspid annular plane systolic excursion (r=−0.165, P=0.001), and tricuspid regurgitation pressure gradient (TRPG) (r=0.189, P&lt;0.001). Multivariate linear regression analysis using these factors as covariates revealed age (standardized β: 0.337, P&lt;0.001), sex (standardized β: 0.120, P=0.014), albumin (standardized β: −0.151, P=0.003) and TRPG (standardized β: 0.129, P=0.005) were significantly and independently associated with increase in clinical frailty score.

Conclusion

Our results suggest that not only nutritional factors but also a cardiac factor were associated with frailty, and frailty was associated with mortality in patients with HFpEF. Improvement of hemodynamics in HFpEF patients as well as improvement of nutrition might contribute to alleviation of frail in HFpEF patients.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnostics K.K.; Fuji Film Toyama Chemical Co. Ltd.

Exploratory open-label clinical study to determine the S-588410 cancer peptide vaccine-induced tumor-infiltrating lymphocytes and changes in the tumor microenvironment in esophageal cancer patients

Cancer vaccines induce cancer-specific T-cells capable of eradicating cancer cells. The impact of cancer peptide vaccines (CPV) on the tumor microenvironment (TME) remains unclear. S-588410 is a CPV comprising five human leukocyte antigen (HLA)-A*24:02-restricted peptides derived from five cancer testis antigens, DEPDC1, MPHOSPH1, URLC10, CDCA1 and KOC1, which are overexpressed in esophageal cancer. This exploratory study investigated the immunologic mechanism of action of subcutaneous S-588410 emulsified with MONTANIDE ISA51VG adjuvant (median: 5 doses) by analyzing the expression of immune-related molecules, cytotoxic T-lymphocyte (CTL) response and T-lymphocytes bearing peptide-specific T-cell receptor (TCR) sequencing in tumor tissue or blood samples from 15 participants with HLA-A*24:02-positive esophageal cancer. Densities of CD8+, CD8+ Granzyme B+, CD8+ programmed death-1-positive (PD-1+) and programmed death-ligand 1-positive (PD-L1+) cells were higher in post- versus pre-vaccination tumor tissue. CTL response was induced in all patients for at least one of five peptides. The same sequences of peptide-specific TCRs were identified in post-vaccination T-lymphocytes derived from both tumor tissue and blood, suggesting that functional peptide-specific CTLs infiltrate tumor tissue after vaccination. Twelve (80%) participants had treatment-related adverse events (AEs). Injection site reaction was the most frequently reported AE (grade 1, n = 1; grade 2, n = 11). In conclusion, S-588410 induces a tumor immune response in esophageal cancer. Induction of CD8+ PD-1+ tumor-infiltrating lymphocytes and PD-L1 expression in the TME by vaccination suggests S-588410 in combination with anti-PD-(L)1 antibodies may offer a clinically useful therapy.Trial registration UMIN-CTR registration identifier: UMIN000023324.

AB0353 COMPARATIVE STUDY OF PATIENT BACKGROUND AND TREATMENT OUTCOME BY BARICITINIB DOSE UNDER REAL CLINICAL CONDITIONS

Background:

Balicitinib (BAR) is one of the Janus kinase (JAK) inhibitors, which mainly inhibits JAK1 and JAK2 and has an anti-inflammatory effect on rheumatoid arthritis(RA). In Japan, it is necessary to use different doses of BAR depending on the RA patient’s estimated glomerular filtration rate (eGFR). The RA-BEACOM and RA-BUILD trials reported the treatment effects by BAR dose at 24 weeks and concluded that there was no difference in DAS(disease activity score)28CRP between BAR 2mg and 4mg. The patient background treated in these double-blind RCTs is uniform even at different BAR doses.There is uncertainty about the difference in the therapeutic effects of BAR dose under the real clinical setting where the patient background differs from that of the trial patients.

Objectives:

To compare patient backgrounds and treatment outcome by Baricitinib dose under real clinical setting.

Methods:

113 RA patients taking BAR who were registered in the Nagoya University Orthopedic Surgery Multicenter Study (TBCR) were included in this study. Patient characteristics (such as age, illness duration, combined anti-rheumatic drugs, eGFR) and DAS28CRP, clinical and simplified disease activity index(CDAI, SDAI respectively) up to 24 weeks were compared between BAR 2mg and 4mg groups. The continuation rates, including the discontinuation due to ineffectiveness and adverse events (AEs), were also compared between the two groups. For these comparisons, Student’s t-test and Pearson’s chi-square test, Kaplan-Meier survival curve were used. Missing data due to discontinuation of BAR was complemented by LOCF method and analyzed statistically. The significance level was set to less than 0.05.

Results:

There were 39 subjects (8 males and 31 females) in BAR2mg group and 74 patients (17 males and 57 females) in BAR4mg group. There was a significant difference in mean age (73.5 vs. 62.3 years old,p<0.001), average eGFR (65.1vs 84.8ml / min / 1.73m2,p<0.001), methotrexete(MTX) use rate (28 vs 58%,p<0.01), average MTX dose (3.0 vs 5.5mg,p<0.01),glucocorticoid(GC) use rate(51.3 vs 33.8%,p<0.01) between the two groups(Table). DAS28CRP improved from week 0 (3.2 vs 3.5) to week 24 (2.5 vs 2.4), and no significant difference was observed between the two groups at each time point (Fig.1-A). The same was true for CDAI and SDAI(Fig.1-B,-C). The rate of DAS28CRP remission and low disease activity was not significantly different at 24 weeks (0.64 vs. 0.69, Fig.1-D). The same was true for CDAI and SDAI(Fig.1-E,-F). Kaplan-Meier analysis showed that there was no difference in discontinuation rate due to ineffectiveness in the two groups. The same was true for the discontinuation rate due to AEs (Figure 2-B,-C). The total continuation rate including discontinuation due to ineffectiveness and AEs was significantly lower in BAR2mg group (0.691 vs 0.843,p<0.05, Fig.2-A).

Conclusion:

BAR2mg group under real clinical setting was older and had lower eGFR than BAR4mg group. Although the treatment effect for 24 weeks was similar, safety management was considered more important because the discontinuation rate due to AEs tended to be higher in BAR2mg group.

References:

[1]Taylor PC, (2017) The New England journal of medicine. 376(7), 652.

[2]Takeuchi T, Ann Rheum Dis 2019;78:171–178.

[3]Keystone EC, Ann Rheum Dis 2015;74:333–340

Table 1.

ITT outcomes at week 13

BAR2mg (n=39)BAR4mg (n=74)pvalueAge, years old73.5±9.762.3±12.6<0.001Female31(79)57(77)0.767Disease duration, year13.7±11.314.2±15.40.857Stage(1/2/3/4)6/17/8/815/24/14/210.473ACPA >4.5U/ml29(74.4)59(79.7)0.629eGFR, ml/min/1.73m265.1±27.784.8±23.2<0.001MTX dose, mg/week3.03±4.835.54±5.480.018MTX use11(28.2)41(55.4)0.003GC dose, mg/day1.91±2.361.32±2.200.191GC use20(51.3)25(33.8)0.007DAS28CRP3.42±1.043.52±13.00.689CDAI12.6±7.615.1±10.90.222SDAI14.7±9.716.2±11.40.279

Values are the mean±SD or the number (%).

Disclosure of Interests:

Tsuyoshi Nishiume: None declared, Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Shuji Asai Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Janssen, Takeda, and UCB Japan, Kenya Terabe: None declared, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama

FRI0107 EFFECTIVENESS OF ABATACEPT ON CLINICAL DISEASE ACTIVITY AND RADIOGRAPHIC PROGRESSION IN RHEUMATOID ARTHRITIS PATIENTS IN DAILY CLINICAL PRACTICE IN JAPAN: COMPARISONS ACCORDING TO ACPA STATUS

Background:

The clinical effectiveness of abatacept (ABA) in rheumatoid arthritis (RA) patients has been reported to be higher when the patients’ anti-cyclic citrullinated peptide antibody (ACPA) status is positive. The report from the ORA registry demonstrated that the ACPA positivity was associated with a better response to ABA [1]. In a sub-analysis of the AMPLE trial, patients with very high ACPA titers who were treated with ABA had a statistically significant response compared to patients with lower titers [2]. However, these studies did not demonstrate the data regarding the structural progression.

Objectives:

This study aimed to evaluate the effectiveness of ABA on the clinical disease activity as well as the radiographic progression in patients with RA in the clinical settings.

Methods:

All eligible patients were registered in the TBCR, a Japanese multicenter registry system for RA patients treated with biologics [3]. The present study included 553 consecutive patients whose ACPA data were obtained, treated with ABA and observed for longer than 52 weeks. We primarily compared the status of disease activity (SDAI) and radiographic progression (van der Heijde modified total Sharp score: mTSS) between ACPA-positive [ACPA (+)] and ACPA-negative [ACPA (-)] RA patients. The ACPA positive was defined as ≥13.5 U/ml of anti-CCP antibody.

Results:

Number of cases was 446/ 107 [ACPA (+)/ ACPA (-)], respectively. Baseline characteristics between groups were quite similar; mean age was 68.0/ 67.3 years, rate of methotrexate (MTX) use rate was 41.2/ 50.0%, rate of bio-naive was 28.0/ 31.8%, and mean SDAI score was 22.2/ 20.8. Significant difference was observed in mean change in SDAI score from baseline to 52 weeks between the ACPA (+) and ACPA (-) group (-13.4 vs -9.9, p = 0.027) (Figure 1A). Proportion of patents that achieved low disease activity (LDA; SDAI ≤11) at 52 weeks was significantly higher in the ACPA (+) group compared to the ACPA (-) group (72.1 vs 56.0%, p < 0.01) (Figure 1B). In univariate and multivariate logistic regression analysis, ACPA positivity was an independent predictor for achievement of LDA at 52 weeks (Table). There observed no significant difference between ACPA (+) and ACPA (-) group in the proportion of patients that achieved structural remission (ΔmTSS ≤0.5) at 52 weeks (66.2 vs 62.1%) (Figure 2A) as well as mean change in mTSS (1.66 vs 1.17), erosion score (0.60 vs 0.53), and joint narrowing (JSN) score (1.06 vs 0.64) (Figure 2B).

Table.UnivariateMultivariateVariablesOR (95%CI)p-valueadjusted OR (95%CI)p-valueAge0.99 (0.98-1.01)0.4391.00 (0.97-1.02)0.749male (vs female)1.12 (0.70-1.80)0.6340.79 (0.40-1.58)0.511disease duration0.99 (0.97-1.00)0.0530.99 (0.97-1.01)0.468Biologics-naïve1.23 (0.81-1.85)0.3351.18 (0.67-2.08)0.575Concomitant MTX use1.12 (0.75-1.69)0.5851.14 (0.66-1.95)0.649Concomitant PSL use0.82 (0.55-1.23)0.3290.97 (0.58-1.64)0.923SDAI @baseline0.96 (0.94-0.97)<0.0010.96 (0.94-0.98)<0.001mHAQ @baseline0.50 (0.36-0.69)<0.0010.57 (0.38-0.86)0.008ACPA positive2.03 (1.29-3.17)0.0022.61 (1.36-5.00)0.004Bold italic, p<0.05

Conclusion:

Consistent with previous reports, the ACPA-positive group demonstrated significantly higher LDA achievement rate at 52 weeks and indeed the ACPA positivity was significantly associated with LDA achievement in multivariate analysis. However, the ACPA-negative group demonstrated quite similar transition of SDAI score and LDA achievement rate except at 52 weeks compared with the ACPA-positive group. Additionally, there was no significant difference in the structural progression at 52 weeks between the groups. ABA treatment may be considered not only in the ACPA-positive RA patients but also in the ACPA-negative patients in the clinical practice.

References:

[1]Gottenberg JE, et al. Ann Rheum Dis. 2012;71:1815.

[2]Sokolove J, et al. Ann Rheum Dis. 2016;75:709.

[3]Takahashi N, et al. Rheumatology (Oxford). 2015;54:854.

Disclosure of Interests:

Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Shuji Asai Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Janssen, Takeda, and UCB Japan, Kenya Terabe: None declared, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama

AB0178 PERIARTICULAR OSTEOPHYTE FORMATION PROTECTS AGAINST TOTAL KNEE ARTHROPLASTY IN RHEUMATOID ARTHRITIS PATIENTS WITH ADVANCED JOINT DAMAGE

Background:

New medications including biologics and aggressive treatment strategies can halt the inflammatory and destructive disease processes in patients with rheumatoid arthritis (RA), and in some cases repair damaged joints. In the process of damaged joint repair, periarticular osteophyte formation might be detected radiographically (1). However, little is known about the clinical and functional role of osteophyte formation in RA joints. Total joint arthroplasty, a common procedure for treating damaged large joints, can serve as a surrogate for the long-term outcome of large joint destruction in patients with RA.

Objectives:

To determine the influence of periarticular osteophyte formation on the incidence of total knee arthroplasty (TKA) in patients with RA.

Methods:

This retrospective longitudinal study used data from a registry of patients with RA starting biologics. A flow chart summarizing the study design is shown in Figure 1. A total of 130 symptomatic (tender and/or swollen) knee joints in 80 patients were studied with a median follow-up of 12 years. All data were analyzed using the knee joint as the statistical unit of analysis. The cumulative incidences of TKA were estimated using Kaplan-Meier curves, and compared according to the presence or absence of osteophyte on plain anteroposterior radiograph [osteophyte (+/-)] and the extent of advanced joint damage as defined by Larsen’s grading system (0-II vs. III-V).

Results:

Baseline characteristics of all subjects included in this study are shown in Table 1. A total of 42 knees underwent TKA during the follow-up period. There was no significant difference in the cumulative incidence of TKA between the osteophyte (+) and osteophyte (-) groups (31% vs. 34% at 10 years, P=0.718) (Fig. 2A). The cumulative incidence of TKA was significantly higher for the Larsen grade III-V group compared to the Larsen grade 0-II group (56% vs. 10% at 10 years, P<0.001) (Fig. 2B). While no significant difference was observed in the cumulative incidence of TKA between the osteophyte (+) and osteophyte (-) groups in the Larsen grade 0-II group (9% vs. 10% at 10 years, P=0.774) (Fig. 2C), the cumulative incidence of TKA was significantly lower for the osteophyte (+) group compared to the osteophyte (-) group in the Larsen grade III-V group (38% vs. 74% at 10 years, P=0.010) (Fig. 2D). Multivariate analysis using Cox proportional hazards models revealed that older age [hazard ratio (HR): 1.04 per 1 year, 95% confidence interval (CI): 1.01-1.08] and osteophyte formation (HR: 0.39, 95% CI: 0.19-0.79) independently predicted TKA in the Larsen grade III-V group, whereas none of the assessed variables predicted TKA in the Larsen grade 0-II group.

Table 1.

Baseline characteristics by presence or absence of osteophyte formation

TotalOsteophyte (+)Osteophyte (-)Characteristicsn = 130n = 44n = 86PvalueAge, years57(41-63)59(52-65)56(39-63)0.051Sex, female, n (%)108(83)40(91)68(80)0.137Body mass index21.3(19.0-23.8)21.3(18.9-24.4)21.2(19.0-23.7)0.744Disease duration, years8(3-12)9(5-18)7(3-11)0.007Larsen grade, n (%)<0.001Grade 0-II66(51)11(25)55(64)Grade III-V64(59)33(75)31(36)Osteophyte formation, n (%)44(34)---RF or ACPA positive, n (%)85(83)35(90)50(78)0.183CRP, mg/dl3.2(1.5-4.9)2.9(1.0-4.1)3.4(1.8-5.2)0.172First biologic agent, n (%)1.000Infliximab57(44)19(43)38(44)Etanercept73(56)25(57)48(56)Use of methotrexate, n (%)98(75)33(75)65(76)1.000Methotrexate dose, mg/week*8(6-10)8(6-9)8(6-10)0.104Use of glucocorticoids, n (%)79(61)22(50)57(66)0.088Glucocorticoid dose, mg/day*†5.0(5.0-7.5)5.0(5.0-5.0)5.0(5.0-7.8)0.204

Data are presented as median (interquartile range) or number of subjects (percentages). *Median among subjects receiving the drug. †Prednisolone equivalent (mg/day).

Conclusion:

Osteophyte formation reduces the incidence of TKA in patients with RA who have advanced joint damage.

References:

[1]Rau R. Clin Exp Rheumatol 2006;24:S-41-4.

Disclosure of Interests:

Shuji Asai Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Janssen, Takeda, and UCB Japan, Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, KENYA TERABE: None declared, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama

FRI0103 ASSOCIATION BETWEEN SEROPOSITIVITY AND DISCONTINUATION OF INFLIXIMAB IN RHEUMATOID ARTHRITIS

Background:

Infliximab is still a widely used biologic agent in treatment of rheumatoid arthritis (RA). Because infliximab is expensive and can have adverse events, identification of factors that predict an adequate response to this treatment has been investigated.

Objectives:

In this study, we investigated the association between rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPA) status and the discontinuation of infliximab therapy due to adverse events or insufficient response in bio-naïve patients with RA.

Methods:

This study included patients enrolled in the Tsurumai Biologic Communication Registry in Japan. A crude comparison of infliximab discontinuation between seropositive and seronegative patients was using Kaplan-Meier analysis and log-rank test. We evaluated the associations between the specified baseline characteristics and discontinuation of infliximab therapy using Cox proportional hazard regression. We could not perform simultaneous assessments of the impact of RF and ACPA seropositivity on clinical efficacy becasue of collinearity.

Results:

Baseline characteristics of the patients included in this study are shown in Table 1 and the crude comparison between RF and ACPA status is shown in Figure 1. RF and ACPA seropositivity was significantly predictive of discontinuation of infliximab therapy after adjusting for baseline characteristics, including age, sex, stage, class, disease activity at baseline, and prednisolone use (Table 2). The hazard ratio was 1.99 (95% confidence interval 1.25, 3.18) for RF and 2.73 (95% confidence interval 1.24, 6.02) for ACPA.

Table 1.

Characteristics of RA patients at baseline by RF and ACPA status

RF (n = 344;ACPA (n = 250;985 patient-years)824 patient-years)RFRFACPAACPApositivenegativepositivenegative(n = 263)(n = 81)P†(n = 211)(n = 39)P†Age, years (SD)55.7 (12.3)54.6 (13.9)0.4855.4 (12.3)49.7 (14.3)0.01Female, no. (%)205 (78.2)66 (81.5)0.64170 (80.6)28 (71.8)0.28DAS28ESR (SD)5.50 (1.33)4.95 (1.51)0.0055.54 (1.28)4.61 (1.82)0.0005Stage I+II/III+IV, no. (%)81/174 (31.8/68.2)25/50 (33.3/66.7)0.7861/139 (30.5/69.5)15/20 (42.9/57.1)0.17Class I+II/III+IV, no. (%)155/102 (60.3/39.7)52/22 (70.3/29.7)0.14126/72 (63.6/36.4)23/12 (65.7/34.3)0.85Current MTX treatment, %10010011001001MTX dose, mg/week (SD) ‡7.56 (2.16)7.80 (2.22)0.47.82 (2.20)7.31 (2.66)0.22Current PSL treatment, no. (%)141 (68.1)37 (56.1)0.077128 (67.4)19 (55.9)0.24PSL dose, mg/day (SD) ‡3.98 (3.91)2.70 (2.74)0.013.73 (3.78)2.63 (2.85)0.11BMI, kg/m2(SD)22.6 (3.88)21.3 (4.22)0.122.0 (4.10)22.5 (3.33)0.68

Data are presented as mean, unless otherwise stated. SD: standard deviation

† Chi-square test for categorical variables and t-test for continuous variables.

‡ MTX dose and PSL dose were mean value in patients with concomitant MTX and PSL treatment, respectively.

Table 2.

Cox proportional hazard regression for infliximab therapy due to adverse event and insufficient response

Model including RF status (n = 226)Model including ACPA status (n = 182)VariableHR (95% CI)PVariableHR (95% CI)PRF positive1.99 (1.25-3.18)0.0037ACPA positive2.73 (1.24-6.02)0.012Age at baseline0.99 (0.98-1.01)0.43Age at baseline0.99 (0.98-1.01)0.36Sex (referent: male)1.21 (0.76-1.94)0.41Sex (referent: male)0.99 (0.60-1.62)0.96Prednisolone use1.03 (0.71-1.49)0.85Prednisolone use1.02 (0.67-1.56)0.92Stage III + IV (referent: I + II)1.01 (0.99-1.03)0.17Stage III + IV (referent: I + II)1.01 (0.98-1.03)0.54Class III + IV (referent: I + II)0.99 (0.98-1.02)0.73Class III + IV (referent: I + II)0.99 (0.97-1.01)0.55DAS28ESR at baseline0.95 (0.83-1.10)0.54DAS28ESR at baseline0.99 (0.84-1.18)0.97

Conclusion:

RF and ACPA seropositivity in bio-naïve patients with RA correlated with a higher rate of infliximab discontinuation due to adverse events or ineffectiveness.

Disclosure of Interests:

Yoshikazu Ogawa: None declared, Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama

SAT0472 GOAL-DIRECTED TREATMENT OF OSTEOPOROSIS IN PATIENTS WITH RHEUMATOID ARTHRITIS USING DENOSUMAB FOR FIVE YEARS

Background:

Osteoporosis (OP) is frequent complication identified in patients with rheumatoid arthritis (RA). Effective treatment must be provided to treat OP in RA (RAOP). Denosumab (DMB) is one of the promising drugs that are currently being used for the treatment of RAOP. We reported the results of 12-month DMB treatment for RAOP as part of Japanese multicenter registry study (TBCR-BONE) in EULAR2016 [1]. Recently, a treatment goal of OP was reported by the American Society for Bone and Mineral Research and the National Osteoporosis Foundation (ASBMR-NOF) working group [2]. This report advocated that the goal of treatment is a T-score of >-2.5 at the femoral neck, total hip (TH) or lumbar spine (LS) on DXA if the primary reason for starting treatment was a T-score of ≤-2.5 at the abovementioned skeletal sites. The working group noted that it was reasonable to expect that initial treatment should offer at least a 50% chance of achieving the treatment goal within 3 to 5 years of initiating therapy. We have reported the achievement rates of treatment goal in RAOP with 3-year DMB treatment on RAOP in EULAR2019 [3].

Objectives:

The aim of this retrospective study was to evaluate whether 5-year DMB treatment can achieve treatment goal of OP using data from TBCR-BONE.

Methods:

The study included 46 female patients who had completed 5-year DMB treatment. The LS-BMD analysis included 22 patients with a baseline (BL) LS-BMD T-score of ≤ -2.5. The TH-BMD analysis included 29 patients with a BL TH-BMD T-score of ≤ -2.5. Similar to clinical setting in Japan, 60mg of DMB was administered once every 6 months with a vitamin D3 supplement. BL characteristics, change in T-score over time, and achievement of the treatment goal (T-score>-2.5) were evaluated.

Results:

BL characteristics of the 46 female patients included: mean age of 69.1 years and RA duration of 16 years. Prednisolone was administered to 37% of the patients. In the LS-BMD analysis, T-scores improved significantly; the mean value at BL was −3.4, which increased to −3.0 at 1 year, −2.6 at 3 years, and ultimately to −2.5 at 5 years. The fraction of patients who achieved the treatment goal was as follows: 36.4% at 1 year, 40.9% at 2 years, 45.5% at 3 years, 50.0% at 4 years, and 54.5% at 5 years (Fig. 1A). The patients who achieved this treatment goal were those who had a significantly lower risk of fracture at BL as determined by FRAX (17.9% vs. 32.2%, p = 0.044), who had significantly higher BL serum TRACP-5b level (572.8 vs. 401.0: p = 0.03), and who had significantly better BL LS-BMD T-scores (−3.0 vs. −3.9, p < 0.01) than the nonachievers. In the TH-BMD analysis, T-scores improved significantly; the mean value at BL was −3.0, and it increased to −3.0 at 1 year, −2.7 at 3 years, and reached −2.7 at 5 years. The fraction of patients who achieved the treatment goal was as follows: 20.7% at 1 year, 31.0% at 2 years, 34.5% at 3 years, 31.0% at 4 years, and 37.9% at 5 years (Fig. 1B). The patients who achieved this treatment goal were those who had significantly better BL TH-BMD T-scores (−2.7 vs. −3.2: p < 0.01) than the nonachievers. Cut-off values at BL for achievement of the treatment goal determined using ROC analysis were −3.1 for the LS-BMD (sensitivity 83.3%, specificity 90.0%) and −2.85 for the TH-BMD (sensitivity 100.0%, specificity 81.0%).

Conclusion:

The results of this study suggested that achievement of the treatment goal was comparatively easy for those with LS-BMD loss; however, it was comparatively difficult for those with TH-BMD loss. Early initiation or longer duration of DMB therapy may be necessary to improve achievement rates. Likewise, other agents, such as romosozumab, may be considered for those with significant TH-BMD loss.

References:

[1]Hiranoet al.Ann Rheum Dis 2016; 75 (Suppl 2): 94

[2]Cummingset al.J Bone Miner Res 2017; 32: 3-10

[3]Hiranoet al.Ann Rheum Dis 2019; 78 (Suppl 2): A940

Disclosure of Interests:

Yuji Hirano Speakers bureau: Tanabe-Mitsubishi, Pfizer, Eisai, Abbie, Chugai, Bristol-Meyers, Jansen, Astellas, UCB, Eli-Lilly, Asahikasei, Daiichi-Sankyo, Amgen, Yasuhide Kanayama: None declared, Hironobu Kosugiyama: None declared, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda

THU0182 THE EFFECTIVENESS OF BIOLOGICAL AGENTS CONCOMITANT WITH TACROLIMUS IN RHEUMATOID ARTHRITIS

Background:

In Japan, oral tacrolimus (TAC) was approved for the treatment of RA in 2005 and the improvement of symptoms thorough the use concomitant with disease modifying antirheumatic drugs (DMARDs), including MTX has been reported1 2. On the other hand, the efficacy and tolerance of biological agents therapy concomitant with TAC are unknown.

Objectives:

The objective of this study was to investigate the efficacy and tolerance of biological agents concomitant with TAC in Japanese patients with RA using retention rate analysis.

Methods:

Total patients (n=2860) who underwent 5 biological agents (etanercept: ETN, adalimumab: ADA, golimumab:GLM, tocilizumab: TCZ, abatacept: ABT) treatment between 2003 and 2017 at Nagoya University Hospital and 12 other institutes (Tsurumai Biologics Communication Study Group) were enrolled3. In each biologics analysis, patients were divided into three groups: (1) concomitant only MTX (MTX group) (2) concomitant only TAC (TAC group) (3) others (others group). In TAC or MTX group, these drugs were only ones which concomitant with biologics. Kaplan-Meier analysis was used to estimate retention rate in each biologics group. To estimate the tolerance of concomitant biologics with TAC, cumulative hazard function in adverse events rate was performed in each biologics group. In both analyses, hazard ratios (HR) were assessed by Cox proportional hazards modeling adjusted for age, sex, disease duration and previously used biologics.

Results:

In total 2860 patients, 142 patients (5.0%) administered each biologics concomitant with TAC (ETN: n=47, ADA: n=10 GLM: n=14, TCZ: n=27, ABT: n=49). Baseline characteristics of 142 patients were shown in table 1. Average dosages of TAC at starting were ETN: 2.2±0.7mg ADA: 2.4±1.0mg GLM: 1.9±1.0mg TCZ: 1.7±0.9mg ABT: 1.9±0.9mg. With comparison of retention rate between 3 groups in each biologics under analysis of cox proportional hazard modeling, in ETN and ABT analysis, the retention rate of TAC group was higher than others group (table 2, figure 1). Comparison of incidence of adverse event between 3 group using cumulative hazard function and cox proportional hazard modeling in ETN and ABT analysis. In ETN analysis, incident rate of other group was higher than TAC group. In ABT analysis, there was no significant difference between 3 gruops (figure 2).

Table 1.Baseline characteristic (n=142)age (years)63 ± 3gendermale33 (23%)female109 (77%)disease duration (years)12.0 ± 7.8stage1,234 (24%)3,4108 (76%)class1,299 (70%)3,443 (30%)naïve vs switchnaïve71 (50%)switch71 (50%)corticosteroid use, no (%)+98 (75%)-32 (25%)corticosteroid dose (mg)5.6 ± 3.2DAS28-ESR4.71 ± 1.55Table 2.HR (95%CI)/p-valuen (MTX/TAC/others)ETNADAGLMTCZABT(774/ 47/ 486)(339/ 10/ 135)(156/ 14/ 61)(272/ 27/ 207)(213/ 49/ 178)TAC vs others0.27 (0.16-0.45)<0.0010.9 (0.37-2.20)ns0.46 (0.13-1.63)ns0.55 (0.24-1.31)ns0.51 (0.26-0.97)<0.05TAC vs MTX0.65 (0.38-1.08)ns1.42 (0.61-3.31)ns0.83 (0.24-2.87)ns0.5 (0.21-1.17)ns0.74 (0.39-1.42)nsMTX vs others0.42 (0.35-0.50)<0.0010.9 (0.50-0.88)<0.0010.56 (0.33-0.96)<0.051.01 (0.78-1.57)ns0.68 (0.46-0.99)<0.05

Bold italic: p<0.05CI: confidence interval ns: not significant

Conclusion:

We suspected that, in ETN and ABT treatment, combination therapy with TAC are subsequent options for treatment to RA patients, especially in whom MTX cannot be administration.

References:

[1]Kino T, et al. Antibiot. 1987 Sep 40(9): 1256-65

[2]Kondo H, et al. J Rheumatol. 2004 Feb;31(2):243-51

[3]Kojima T, et al. Mod Rheumatol. 2011 Sep 3.

Disclosure of Interests:

KENYA TERABE: None declared, Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Shuji Asai Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Janssen, Takeda, and UCB Japan, Atsushi Kaneko Speakers bureau: Abbvie, Asahi-Kasei, Astellas, Bristol-Myers Squibb, Chugai, Eisai, Eli Lily, Mitsubishi-Tanabe, Pfizer, and UCB Japan, Yuji Hirano Speakers bureau: Tanabe-Mitsubishi, Pfizer, Eisai, Abbie, Chugai, Bristol-Meyers, Jansen, Astellas, UCB, Eli-Lilly, Asahikasei, Daiichi-Sankyo, Amgen, Yasuhide Kanayama: None declared, Yuichiro Yabe Speakers bureau: Asahi Kasei, Janssen, and Mitsubishi Tanabe, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama

FRI0135 PREDICTORS FOR SHORT-TERM CLINICAL EFFECTIVENESS OF BARICITINIB IN RHEUMATOID ARTHRITIS PATIENTS IN ROUTINE CLINICAL PRACTICE: DATA FROM A JAPANESE MULTICENTER REGISTRY

Background:

Baricitinib is considered as a specific JAK1/2 inhibitor. While a number of randomized controlled trials have reported on the clinical efficacy and safety profile of baricitinib in rheumatoid arthritis (RA) patients, clinical data for RA patients in routine clinical practice are scarce.

Objectives:

This study aimed to evaluate the short-term effectiveness and safety profiles of baricitinib and explore factors associated with improved short-term effectiveness in patients with RA in clinical settings.

Methods:

A total of 113 consecutive RA patients who had been treated with baricitinib were registered in the TBCR, a Japanese multicenter registry for RA patients treated with biologics or JAK inhibitors (targeted DMARDs) [3], and followed for at least 24 weeks. Univariate and multivariate logistic regression analysis was used to study predictive factors for achievement of low disease activity (LDA) at 24 weeks.

Results:

Mean age was 66.1 years, mean RA disease duration was 14.0 years, 71.1% had a history of use targeted DMARDs, and 48.3% and 40.0% were receiving concomitant methotrexate (MTX) and oral prednisone, respectively. Mean DAS28-CRP significantly decreased from 3.55 at baseline to 2.32 at 24 weeks (Figure 1A). At 24 weeks, 68.2% and 64.1% of patients achieved LDA and moderate or good response, respectively (Figure 1B). Multivariate logistic regression analysis revealed that no previous targeted DMARD use and lower DAS28-CRP score at baseline were independently associated with achievement of LDA at 24 weeks (Table). While the percent change in DAS28-CRP was similar regardless of whether patients used concomitant MTX (Figure 2A), patietns with previous use of targeted DMARDs (Switch group) showed lower percent improvement in DAS28-CRP compared to targeted DMARDs-naïve patients (Naïve group) (Figure 2B). The overall retention rate for baricitinib was 86.5% at 24 weeks, as estimated by Kaplan-Meier analysis. The discontinuation rate due to adverse events was 6.5% at 24 weeks. In the present study cohort, seven patients developed herpes zoster, with an incidence rate of 8.4 per 100 patient-years. All seven patients were treated with antiviral agents for herpes zoster and restarted baricitinib treatment.

TableUnivariateMultivariatevariablesOR (95%CI)p-valueadjusted OR (95%CI)p-valueMale1.17 (0.43-3.16)0.755Age, <65 years1.46 (0.62-3.44)0.388Disease duration, <10 years1.41 (0.61-3.23)0.419ACPA positive1.56 (0.51-4.80)0.433no previous biological DMARDs4.67 (1.49-14.66)0.00833.4 (2.53-442.62)0.008concomitant MTX0.860 (0.40-2.02)0.789concomitant PSL0.24 (0.10-0.56)0.001DAS28-CRP@baseline0.55 (0.38-0.80)0.0020.28 (0.13-0.62)0.002mHAQ@baseline0.27 (0.09-0.77)0.015Bold italic, p<0.05

Conclusion:

In this study, we demonstrated the short-term clinical effectiveness and safety profile of baricitinib in Japanese RA patients in the ‘real-world’ setting. To the best of our knowledge, this study is the first to report the clinical outcomes of baricitinib in routine clinical practice in Japan. Baricitinib significantly improved disease activity, with an expected safety profile. We observed some interesting features regarding the effectiveness of baricitinib. Baricitinib was significantly more effective when used as a first-line targeted DMARD and may play a key role in the modern treatment strategy for RA, although careful observation is necessary for possible complications and AEs including herpes zoster.

References:

[1]Taylor PC, et al. (2017) The New England journal of medicine. 376(7), 652.

[2]Tanaka Y, et al. (2018) Modern rheumatology. 28(1), 20-9.

[3]Takahashi N, et al. (2014) Rheumatology (Oxford) 2014.

Disclosure of Interests:

Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Shuji Asai Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Janssen, Takeda, and UCB Japan, Kenya Terabe: None declared, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama

THU0088 PREDICTORS OF DISEASE FLARE AFTER DISCONTINUATION OF CONCOMITANT METHOTREXATE IN JAPANESE PATIENTS WITH RHEUMATOID ARTHRITIS TREATED WITH TOCILIZUMAB

Background:

All biologics should primarily be combined with a conventional synthetic DMARD, such as methotrexate (MTX), in rheumatoid arthritis (RA) patients. However, the use of MTX may lead to the development of adverse events (AEs), and de-escalation of MTX while maintaining a favorable disease activity state may be beneficial from the perspective of reducing AEs during long-term RA treatment. Several studies have evaluated the impact of MTX discontinuation in RA patients who achieved good clinical response with tocilizumab (TCZ) plus MTX combination therapy, finding that discontinuing MTX is noninferior to continuing MTX in terms of maintaining clinical response (1-3). However, information on risk factors for disease flare after MTX discontinuation is lacking.

Objectives:

To investigate predictors of disease flare after MTX discontinuation in Japanese RA patients with sustained low disease activity undergoing TCZ plus MTX combination therapy.

Methods:

Participants of this multicenter, open-label, uncontrolled, prospective study were RA patients maintaining low disease activity (Clinical Disease Activity Index [CDAI] ≤10) for ≥12 weeks with TCZ plus MTX. Patients had to be receiving MTX orally at a stable dose of ≥6 mg/week, and TCZ at a stable dosage regimen irrespective of the route of administration, for ≥12 weeks prior to obtaining informed consent. MTX was discontinued after 12 weeks of biweekly administration while continuing TCZ therapy (Fig. 1). Disease flare was defined as a CDAI score >10 or intervention with rescue treatments for any reason. The impact of baseline characteristics on disease flare at week 64 (52 weeks after MTX discontinuation) was assessed with logistic regression models.

Results:

Efficacy analyses were performed in 49 patients, of whom 15 had a disease flare by week 64. The proportion [95% confidence interval (CI)] of patients who maintained low disease activity without a flare at week 64 was 69.4% (54.6 – 81.8%) (Fig. 2A). According to Kaplan-Meier estimates, the cumulative flare-free rate was 70.0% at week 64 (Fig. 2B). The dosing interval of TCZ was longer than that described on the drug label (i.e., intravenously every 4 weeks, or subcutaneously every 2 weeks) in 27% and 6% of patients with and without a flare, respectively (Table 1). Multivariate analysis revealed that male sex [odds ratio (OR): 18.00, 95% CI: 2.80-115.56] and extended dosing interval of TCZ (OR: 12.00, 95% CI: 1.72-83.80) were independent predictors of disease flare.

Table 1.

Impact of baseline variables on disease flare

Non-flareFlareOdds ratio (95% confidence interval)(n=34)(n=15)UnivariateMultivariateAge, years62 ± 1163 ± 91.01 (0.95-1.08)aMale, %64010.67 (1.83-62.18)*18.00 (2.80-115.56)*Weight, kg54 ± 858 ± 151.03 (0.98-1.09)aDisease duration, years11 ± 813 ± 91.03 (0.95-1.11)aRF positive, %76861.85 (0.34-10.04)ACPA positive, %85100-bRoute of TCZ, intravenous, %59802.80 (0.66-11.79)Extended TCZ dosing interval, %6275.82 (0.93-36.28)†12.00 (1.72-83.80)*MTX dose, mg/week8.2±2.28.0±2.60.95 (0.73-1.25)aUse of glucocorticoids, %26331.39 (0.37-5.18)Use of csDMARDs other than MTX, %9335.17 (1.04-25.57)*-Previous biologic use, %56803.16 (0.75-13.26)CDAI remission, %65731.50 (0.39-5.75)CRP, mg/dl0.04 ± 0.060.04 ± 0.060.42 (0.00-15115.38)aMMP-3, ng/ml58.5 ± 22.476.6 ± 37.61.02 (1.00-1.05)a†-

Data are shown as mean ± SD or percentage.aOdds ratio for 1-unit increase in each item.bOdds ratio was not evaluated. *P<0.05. †P<0.10.

Conclusion:

Male patients and those receiving TCZ at an extended dosing interval are at high risk of disease flare after discontinuation of concomitant MTX.

This work was supported by Chugai Pharmaceutical Co., Ltd.

References:

[1]Kremer JM. Arthritis Rheumatol 2018.

[2]Edwards CJ. Rheumatology (Oxford) 2018.

[3]Pablos JL. Clin Exp Rheumatol 2019.

Disclosure of Interests:

Shuji Asai Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Janssen, Takeda, and UCB Japan, Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Yachiyo Kuwatsuka: None declared, Masahiko Ando: None declared, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda

AB1172 IMPROVEMENT OF DEPRESSION BY JOINT SURGERY IN ESTABLISHED RHEUMATOID ARTHRITIS; RESULTS FROM MULTICENTER PROSPECTIVE COHORT STUDY FOR EVALUATION OF JOINT SURGERY ON PATIENT’S REPORTED OUTCOME

Background:

Total management including reconstructive joint surgery and rehabilitation should be needed for further improvements of physical function for long-standing RA patients. In these days, it is very important to evaluate the effectiveness of joint surgery as well as drug therapy based on patient-reported outcome (PRO)

Objectives:

The purpose of this study is to explore the relationship among depression, clinical variables and other PROs including physical function and to explore whether joint surgery can improve the depression.

Methods:

Multicenter prospective observational cohort study was conducted among patients who underwent elective joint surgery for RA from April 2012 to March 2016 (Study registration: UMIN000012649). In this study, we collected data at baseline and at 6 or 12 months after the surgery. These data were as follow; age, sex, disease duration, drug therapies, and disease activity (DAS), TUG, and patient-reported outcome [HAQ-DI, EQ-5D (QOL), pain and BDI-II (depression)]. Correlation between BDI-II and other variables were determined using multiple liner regression analysis.

Results:

Totally, 346 patients before elective joint surgery were analyzed cross-sectionally. Mean age, disease duration, pain VAS, DAS28, HAQ-DI, EQ-5D and BDI-II were 64.2 years, 17.0 years, 36.2 mm, 3.02, 1.11, 0.641 and 13.0, respectively. 52.6% of elective joint surgeries were in upper limbs and 47.4% were in lower limbs. Multiple liner regression analysis showed that HAQ-DI [B:-0.099 (95%CI:-0.117- -0.08) β:-0.48] pain VAS [B:-0.002 (95%CI:-0.002- -0.001) β:-0.26] and BDI-II [B:-0.003 (95%CI:-0.005- -0.002) β:-0.19] had significant impact on EQ-5D. Furthermore, HAQ-DI [B:3.78 (95%CI:2.54- 5.06) β: 0.33] and pain VAS [B: 0.062 (95%CI: 0.023- 0.101) β 0.17] had significant impact on BDI-II. Especially, walking and eating were independent factors for BDI-II in HAQ-DI categories. These results were confirmed in longitudinal analyses using results from joint surgery in lower limbs (LL; n=138) and upper limbs (UL; n=165), respectively. BDI-II was remarkably improved from 12.1 (mean) to 10.5 in LL and from 14.2 (mean) to 11.9 in UL. Change in HAQ-DI had significant impact on that in BDI-II [LL; B:3.183 (95%CI:0.301- 6.065) β:0.229, and UL; B:2.55 (95%CI:0.19- 4.92) β:0.19] while that in painVAS did not. Especially, the improving in walking category by LL [B:1.38 (95%CI:0.06- 2.70) β:0.18] and in hygiene category by UL [B:2.11 (95%CI:0.79- 3.42) β:0.24] were relevant factors for improving of BDI-II.

Conclusion:

Depression is an important patient-reported outcome for QOL in established RA patients. Improving of physical function with joint surgery in both lower and upper limbs caused improving of depression status. Rheumatologists should take the joint surgery into consideration as effective intervention for treatment of established RA patients with treatment.

Acknowledgments:

This study was funded by a grant from the Ministry of Health, Labour and Walfare (h2424YN002-00) to Naoki Ishiguro.

We thank Drs Tanaka S, Haga N, Yukioka M, Hashimoto J, Miyahara H, Niki Y, Kimura T, Oda H, Funahashi K for their contribution to this study and all medical staff members of each institute for their data collection efforts for their data collection efforts.

Disclosure of Interests:

Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Masayo Kojima: None declared, Hajime Ishikawa: None declared, Keiichiro Nishida Grant/research support from: K. Nishida has received scholarship donation from CHUGAI PHARMACEUTICAL Co., Eisai Co., Mitsubishi Tanabe Pharma and AbbVie GK., Speakers bureau: K. Nishida has received speaking fees from CHUGAI PHARMACEUTICAL Co., Eli Lilly, Janssen Pharmaceutical K.K., Eisai Co. and AYUMI Pharmaceutical Corporation., Shuji Asai Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Janssen, Takeda, and UCB Japan, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama

THU0171 EFFICACY OF ABATACEPT FOR SUPPRESSING RADIOGRAPHIC PROGRESSION OF CERVICAL LESIONS IN PATIENTS WITH RHEUMATOID ARTHRITIS COMPARISON WITH METHOTREXATE TREATMENT; TWO YEARS OF FOLLOW-UP ~A MULTICENTER REGISTRY STUDY ~

Background:

Cervical lesions are known to occur at high frequency as a complication of rheumatoid arthritis (RA). Treatment with biological agents are more clinically effective than the DMARDs that were in use previously, in particular, with their efficacy in suppressing joint destruction having been emphasized. We reported the efficacy of infliximab, anti-tumor necrosis factor antibodies for suppressing the radiographic progression of RA cervical lesions at ACR2009, EULAR2010, 11, 12, 13, 14,16 and 18. However there is still few studies of efficacy of against RA cervical lesions of Abatacept (ABT) that inhibits T cell activation by binding to CD80/86.

Objectives:

To evaluate the efficacy of ABT for suppressing the radiographic progression of RA cervical lesions comparison with MTX for 2 years.

Methods:

We used ABT or MTX for treating Japanese patients with active RA who fulfilled the ACR criteria in 1987. The final study cohort of each 60 and 75 patients received continuous ABT and MTX treatment for at least 2 years. For evaluation of cervical lesions, the atlanto-dental interval (ADI), the space available for the spinal cord (SAC), and the Ranawat value were measured by plain lateral radiographs in the flexion position, at initiation and Year 1,2.

Results:

In the patients receiving ABT (n=60) and MTX (n =75), the number of female were each 48(80%) and 52(69%) cases(p=0.160). The mean age was 67.7 ± 12.9 and 63.6 ± 11.0 years old (p=0.004); disease duration was 16.7 ± 14.2 and 8.0 ± 9.5 years (p<0.001) and the mean dose of MTX was 8.4 ± 3.6 and 8.2 ± 2.9 mg/w (p=0.804). Clinical findings related to RA were as follows; CRP 2.2± 2.1 and 1.7± 2.3 mg/dl(p=0.008); ESR 47.2 ± 23.4 and 31.9 ± 21.8mm/h(p<0.001); MMP3 253 ± 280 and 223 ± 350ng/ml(p=0.003); the number of RF-positive 57(95%) and 60(80%) cases(p=0.011); DAS28-ESR 5.13 ± 0.99 and 4.30 ± 1.38 (p<0.001); ADI 3.6 ± 2.1 and 2.6 ± 1.6mm(p=0.003); SAC 18.5 ± 2.8 and 20.8 ± 2.5mm(p<0.001) and Ranawat value 14.4 ± 1.9 and 16.0 ± 1.5mm (p<0.001). The respective changes in cervical lesion parameters after 1 year were as follows: ADI: 0.20 ± 0.40 and 0.27 ± 0.45 mm (p = 0.367); SAC: −0.12 ± 0.32 and −0.17 ± 0.38 mm (p = 0.359); and Ranawat value: −0.15 ± 0.36 and −0.13 ± 0.34 mm (p = 0.783). The respective changes in cervical lesion parameters after 2 years were as follows: ADI: 0.35 ± 0.58 and 0.55 ± 0.70 mm (p = 0.099); SAC: −0.25 ± 0.47 and −0.45 ± 0.62 mm (p = 0.047); and Ranawat value: −0.23 ± 0.47 and −0.33 ± 0.55 mm (p = 0.293) in the patients receiving ABT and MTX (Fig. 1). The numbers of patients who did not showed progression in ADI, SAC and Ranawat value were each 42(70%) and 43(57%) cases(p=0.130); 46(77%) and 46(61%) cases(p=0.057) and 47(78%) and 53(71%) cases(p=0.313) after 2 years. Also the number who was able to suppress progression in all three parameters were each 42 cases (70%) receiving ABT and 43 cases (57%) receiving MTX (p=0.130) after 2 years (Fig. 2).

Conclusion:

This study suggested that ABT treatment can be used to suppress the progression of RA cervical lesions more than MTX treatment.

Disclosure of Interests:

Yasuhide Kanayama: None declared, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Yuji Hirano Speakers bureau: Tanabe-Mitsubishi, Pfizer, Eisai, Abbie, Chugai, Bristol-Meyers, Jansen, Astellas, UCB, Eli-Lilly, Asahikasei, Daiichi-Sankyo, Amgen, Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Yukiyoshi Oishi: None declared, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama

SAT0122 HIGHER DOSES OF METHOTREXATE ASSOCIATED WITH DISCONTINUATION OF ORAL GLUCOCORTICOIDS AFTER INITIATION OF BIOLOGICAL DMARDS: A RETROSPECTIVE OBSERVATIONAL STUDY BASED ON DATA FROM A JAPANESE MULTICENTER REGISTRY STUDY

Background:

Glucocorticoids exert anti-inflammatory effects and are important drugs used to treat rheumatoid arthritis(1). We recommend glucocorticoid discontinuation as soon as possible because glucocorticoid caused several side effects, but many patients continue to take oral glucocorticoids long-term in daily clinical practice. The frequency of use of glucocorticoid has gradually declined, and there are several reports on discontinuation of glucocorticoid due to the initiation of biological disease-modifying antirheumatic drugs (bDMARDs)(2). However, there is no report showing the relation between discontinuation of glucocorticoid and MTX dose.

Objectives:

The present study aimed to explore factors associated with glucocorticoid discontinuation at 52 weeks after initiating bDMARDs.

Methods:

We established the large observational cohort, the Nagoya University orthopedic facility multicenter study (TBCR), and a total of 3119 patients used bDMARD and examined the status of oral glucocorticoid use at 52 weeks after initiating the 1stbDMARD. In predictive analyses, the outcome variable was glucocorticoid discontinuation at 52 weeks after bDMARD initiation. Factors associated with baseline characteristics at bDMARD initiation were assessed with univariate and stepwise forward multivariate logistic regression analyses. This cohort study was not randomized. Propensity score (PS) matching was used to align patient backgrounds to avoid selection bias.

Results:

Subjects were 564 patients administered glucocorticoids and methotrexate (MTX) following initiation of the 1stbDMARD (Figure 1). Mean DAS28-CRP at bDMARD initiation was 4.70 ± 1.16. Percentages of patients with low, moderate, and high disease activity as evaluated by DAS28-CRP at bDMARD initiation were 4.7%, 23.5%, and 71.8%, respectively. By 52 weeks after bDMARD initiation, 164 patients (29.1%) discontinued glucocorticoids. Multivariate analysis identified age (odds ratio (OR), 0.98), MTX dose (OR, 1.11), and glucocorticoid dose (OR, 0.87) as factors independently associated with glucocorticoid discontinuation at the time of bDMARD initiation (Table 1). After adjusting for baseline characteristics using propensity score matching among patient groups administered MTX ≤ 8 mg/week and MTX > 8 mg/week, 105 pairs remained. Among patients administered MTX > 8 mg/week, 41.0% discontinued glucocorticoids. Among those administered MTX ≤ 8 mg/week, 22.9% discontinued glucocorticoids, with a significant difference between the two groups (Figure 2, P=0.007).

Table 1.

Factors associated with baseline characteristics at bDMARD initiation

Continuation(n=400)Discontinuation(n=164)UnivariateOdds ratio (95% CI)MultivariateOdds ratio (95% CI)Age, years58.4 ± 12.954.3 ± 14.30.98 (0.97-0.99)*0.98 (0.97-0.99)*Disease duration, years9.4 ± 9.47.5 ± 8.50.98 (0.95-0.99)*–Female, %80.381.11.06 (0.67-1.68)–DAS28-CRP4.78 ± 1.154.50 ± 1.160.81 (0.69-0.96)*–Seropositivity, %90.086.10.69 (0.38-1.25)–MTX dose, mg/week7.7 ± 2.58.8 ± 3.01.16 (1.09-1.24)*1.11 (1.03-1.21)*Glucocorticoid dose, mg/day4.9 ± 2.14.3 ± 2.10.86 (0.78-0.95)*0.87 (0.78-0.97)*TNF inhibitor use, %88.885.40.74 (0.43-1.26)-

Data are presented as mean ± standard deviation.

Conclusion:

Data from the TBCR revealed that, from a clinical perspective, glucocorticoid use decreased among RA patients treated with bDMARDs. Higher doses of MTX (> 8 mg/week) at the time of bDMARD initiation were found to be associated with glucocorticoid discontinuation in patients treated with bDMARDs. In addition, we found that aggressive use of MTX was sufficient to fulfill the Treat-to-Target approach, demonstrating that glucocorticoid discontinuation is a viable option.

References:

[1]Smolen JS. Ann Rheum Dis. 2014;73(3):492-509.

[2]Shimizu Y. Mod Rheumatol. 2018;28(3):461-7.

Disclosure of Interests:

Mochihito Suzuki Speakers bureau: Bristol-Myers Squibb, Eisai, and Asahi Kasei, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Shuji Asai Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Janssen, Takeda, and UCB Japan, Kenya Terabe: None declared, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama

OP0207 MECHANISM OF CHONDROPROTECTIVE EFFECTS OF 2-DEOXYGLUCOSE

Background:

We recently reported that the inhibitor of hyaluronan (HA) biosynthesis, 4-methylumbelliferone (4-MU) blocked IL-1β activation of MMP13 mRNA and protein expression in human osteoarthritic (OA), bovine as well as bovine or OA cartilage explants [1]. This was a somewhat counterintuitive observation because we have also demonstrated that the overexpression of HAS2 (HAS2-OE) exerted the same chondroprotective effects on human and bovine chondrocytes. Others [2] have reported that HAS2-OE in tumor cells generates a flux in intracellular UDP-sugar pools that resulted in changes in cell metabolism; switching from a dependence on glycolysis to aerobic respiration. HAS2-OE and 4-MU likely also cause dramatic fluxes in intracellular UDP-GlcUA pools. From these results, we hypothesized that the effect of HAS2-OE and 4-MU relate to changing metabolism and the possibility of inhibition of glycolysis induce chondroprotective effect. To determine that, we used the glycolysis inhibitor, 2-Deoxyglucose (2DG) as an alternative agent to change metabolism in chondrocytes.

Objectives:

The objective of this study was to investigate the mechanism of chondroprotective effects of 2DG

Methods:

Bovine and human chondrocyte were stimulated with IL-1β (2ng/ml) in the presence or absence of 4MU (1.0 mM), 2DG (0.2-20 mM). Bovine chondrocytes were tested using Seahorse Flux Analyzer (Agilent Tech) to determine rate changes in medium accumulation of +H protons (indicative of lactic acid accumulation: ECAR) and for O2 consumption (indicative of mitochondrial respiration: OCR). Accumulation of MMP13 and phosphor AMPK (pAMPK) protein was quantified with Western blotting. Human and Bovine cartilage explants were cultured with L-1β in the presence or absence of 2DG (20 mM) and d 5-Aminoimidazole-4-carboxamide 1-β-D-ribofuranoside (AICAR) to pharmacologically induce AMPK for 7 days and stained with Safranin O.

Results:

Reduced mitochondrial potential and enhanced dependence on glycolysis was observed in IL-1β stimulated chondrocytes. Co-treatment with 4-MU and 2DG returned the cell metabolism to levels at or below baseline (Fig 1A, B). The Seahorse ATP Rate Assay means the contributions of glycolysis and mitochondrial respiration to chondrocyte ATP production (Fig 1C). In control chondrocytes, the use of glycolysis contributes to the majority of ATP produced (grey bars) approximately 1/5th from the TCA cycle (red bars). IL1β-activated chondrocytes display increase in glycolysis and decrease in mitochondrial contributions. These changes are reversed by co-treatment with 4MU and 2DG. As shown in Figs 2A, 2DG reversed the IL1β-induced increases accumulation of MMP13 protein in human OA chondrocytes by Western blotting analysis. Although IL-1β lost safranin O staining in human and bovine samples, co-incubation with 2DG blocked in the loss of proteoglycan (Fig 2B). pAMPK is associate with energy homeostasis in chondrocytes. IL-1β treatment decreased accumulation of phosphor AMPK. Co-treatment with 4-MU and 2DG resulted in a rescue of the pAMPK status (Figure 3A). Co treatment with AICAR, which is inducer of AMPK, also blocked in the loss of proteoglycan (Fig 3B).

Conclusion:

4-MU and 2DG have chondroprotective effect by changing metabolism and upregulate AMPK. We propose that 4MU and 2DG become useful when these endogenous responses are not enough to rescue cells from a pro-catabolic phenotype.

References:

[1]J. Biol. Chem. 291:12087, 2016; [2] J. Biol. Chem. 291:24105, 2016

Disclosure of Interests:

KENYA TERABE: None declared, Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Ohashi Yoshifumi: None declared, Maeda Masataka: None declared, Warren Knudson: None declared, Cheryl Knudson: None declared, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama

AB0348 THE EFFECTIVENESS AND SAFETY OF BARICITINIB AFTER INSUFFICIENT RESPONSE TO BDMARDS OR TSDMARDS IN PATIENTS WITH RA FROM JAPANESE MULTI-CENTER REGISTRY: 24-WEEK OUTCOMES

Background:

EULAR has issued updated guidelines for the management of rheumatoid arthritis (RA) using conventional, biologic, and targeted synthetic DMARDs. In the 2019 update, the task force revised the preference of bDMARDs over tsDMARDs. In routine clinical practice, baricitinib is commonly used as second line or after. However, there is little information about the clinical efficacy and safety profile of baricitinib after failure of the previous agent, including another tsDMARD.

Objectives:

The aim of this study was to evaluate the short-term effectiveness and safety profiles of baricitinib after insufficient response (IR) to bDMARDs or tsDMARDs in patients with RA in clinical settings.

Methods:

RA patients who had been treated with baricitinib after failure of the previous agent were registered in the TBCR, a Japanese multicenter registry for RA patients treated with biologics or JAK inhibitors and followed for at least 24 weeks. Patients were divided into two groups according to the cause of failure of the previous treatment; IR (“After IR” group) and the others (“After non-IR” group). “After IR” group was further divided into four groups according to the previous agent; TNF inhibitor (TNFi group), IL-6 receptor inhibitor (IL-6Ri group), abatacept (ABT group) and tofacitinib (Tofa group). We assessed disease activities by CDAI score and drug retention rates between these groups. Furthermore, discontinuation rates due to IRs and adverse events (AEs) were evaluated.

Results:

A total of 86 consecutive RA patients were registered in this study. The previous treatment was as follows; TNF inhibitor: 38 (44.2%), IL-6 receptor inhibitor: 23 (26.7%), abatacept: 11 (12.8%), tofacitinib: 13 (15.1%) and the other: 1 (1.2%).The cause of failure of the previous therapy were IRs (n=74: 86%), AEs:(n=6: 7.0%) and the others (n=6: 7.0%). In “After IR” group, the most common previous agents were TNFis (Table 1). While the percent change in CDAI was decreased at week 12 in all groups, those in Tofa group showed lower rates of improvement in CDAI compared to the others at week 24 (Figure 1). Drug retention rate at 24-week was 59.4% in TNFi group, 90.5% in IL-6Ri group, 54.5% in ABT group and 77.8% in Tofa group (Figure 2). In the present study cohort, seven patients developed herpes zoster. All seven patients were treated with antiviral agents for herpes zoster and restarted baricitinib treatment (these cases were not treated as discontinuation due to AEs in this study). The overall Cumulative discontinuation rate due to IRs and AEs at 24 weeks were 9.7% and 7.3%, respectively.

Table.

Clinical characteristics of the BAR2mg group and the BAR4mg group

GroupsCases; n (%)TNFi group32 (43.2)IL-6R group21 (28.4)ABT group11 (14.9)Tofa group9 (12.2)The oter1 (1.4)

Conclusion:

In this study, we demonstrated the short-term effectiveness and safety profiles of baricitinib after insufficient response to bDMARDs or tsDMARDs in patients with RA in the ‘real-world’ setting. Baricitinib improved disease activity after failure of the previous agent, even after IR to another tsDMARD. With respect to safety, the profile is almost tolerable, although careful observation is necessary for possible complications and AEs including herpes zoster.

Disclosure of Interests:

Hanabayashi Masahiro Speakers bureau: Astellas Pharma Inc., Mitsubishi Tanabe Pharma Corporation, Eisai Pharma Corporation, Chugai Pharma Corporation, abbvie, Bristol-Myers Squibb, Pfizer, Janssen Pharmaceutical K.K., Eli Lilly Japan K.K. and UCB Japan, Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda

P5734The outcome of intra-aortic balloon pumping support for acute myocardial infarction with extracorporeal membrane oxygenation therapy

Background

It has been reported that intra-aortic balloon pumping (IABP) support for acute myocardial infarction (AMI) with cardiogenic shock did not reduce short and long-term mortality. However, the significance of IABP support for AMI patients with extracorporeal membrane oxygenation (ECMO) therapy remains unclear. The aim of this study was to investigate the effect of IABP support for the short and long-term outcome in AMI patients who received ECMO.

Methods

Using the database of the Osaka Acute Coronary Insufficiency Study (OACIS), 12,093 consecutive AMI patients were enrolled in this analysis. Among these, we analyzed 520 patients with ECMO. We classified the patients into two groups, patients who received IABP support [IABP group (n=460)] and patients who did not [no IABP group (n=60)]. Primary outcome was all-cause death.

Results

Study patients had following baseline clinical characteristics, age: 66.8±12.0 year old, male: 78.3%, diabetes mellitus: 41.0%, Killip class≥II: 66.2%, multi-vessel disease: 72.3%, peak creatine phosphokinase >3000IU/L: 68.1%. During a mean follow-up period of 349±625 days, Kaplan-Meier analysis revealed that the all-cause death was significantly lower in IABP group than no IABP group for 30-day (45.5% vs 72.7%, log-rank p<0.001) and long-term (66.2% vs 78.4%, Log rank p=0.005) follow-up period. Cox multivariate analysis revealed that IABP support was significantly associated with a reduced risk of mortality (Hazard ratio 0.445, 95% confidence interval 0.289 to 0.687, p<0.001).

Conclusions

IABP support for AMI patients with ECMO was significantly associated with reduced risks of the short and long-term mortality, suggesting that IABP support might contribute to improvement of the survival in AMI patients with ECMO.