Real-World Treatment Patterns, Clinical Outcomes, and Symptom Burden in Patients With Psoriatic Arthritis Prescribed Ixekizumab in the United States

OBJECTIVE

The objective of this study was to describe the real-world characteristics and clinical status of patients with psoriatic arthritis (PsA) currently prescribed ixekizumab.

METHODS

Data were drawn from the Adelphi PsA Plus Disease Specific Programme (DSP), a cross-sectional survey conducted in the United States between September 2021 and March 2022. Rheumatologists provided data for their next five consulting patients currently receiving ixekizumab, including demographic and clinical characteristics, disease severity, treatment history, reasons for treatment choice, satisfaction with current treatment, and current and historic symptom burden. Patients voluntarily completed questionnaires, providing perceptional data on symptom burden and satisfaction with current treatment.

RESULTS

Overall, 68 rheumatologists provided data on 275 patients with PsA, 90 of whom completed the voluntary questionnaire. Patients had been prescribed ixekizumab for a mean of 11.7 (SD 10.6) months. Clinical characteristics, disease severity, and symptom burden of patients with PsA improved significantly from ixekizumab initiation to the most recent consultation, including symptom burden, tender and swollen joint counts, and body surface area affected by psoriasis (all P < 0.001). Both rheumatologists and patients were satisfied with ixekizumab treatment and reported improvements in pain and fatigue. Improvements were noted after more than three months of ixekizumab treatment duration and regardless of whether the patients had prior exposure to an advanced therapy or were treatment naïve.

CONCLUSION

Our results indicate that ixekizumab was efficacious in the treatment of PsA in real-world clinical practice, complementing efficacy data from randomized controlled clinical trials. The results of this study may assist rheumatologists and their patients in making informed treatment choices.

Disproportionate articular pain is a frequent phenomenon in rheumatoid arthritis and responds to treatment with sarilumab

OBJECTIVES

In some patients with RA, joint pain is more severe than expected based on the amount of joint swelling [referred to as disproportionate articular pain (DP)]. We assessed DP prevalence and the effects of sarilumab, an IL-6 inhibitor, on DP.

METHODS

Data from RA patients treated with placebo or 200 mg sarilumab in the phase 3 randomized controlled trials (RCTs) MOBILITY and TARGET, adalimumab 40 mg or sarilumab 200 mg in the phase 3 RCT MONARCH and sarilumab 200 mg in open-label extensions (OLEs) were used. DP was defined as an excess tender 28-joint count (TJC28) over swollen 28-joint count (SJC28) of ≥7 (TJC28 - SJC28 ≥ 7). Treatment response and disease activity were determined for patients with and without DP.

RESULTS

Of 1531 sarilumab 200 mg patients from RCTs, 353 (23%) had baseline DP. On average, patients with DP had higher 28-joint DAS using CRP (DAS28-CRP) and pain scores than patients without DP, whereas CRP levels were similar. After 12 and 24 weeks, patients with baseline DP treated with sarilumab were more likely to be DP-free than those treated with placebo or adalimumab. In RCTs, more sarilumab-treated patients achieved low disease activity vs comparators, regardless of baseline DP status. In OLEs, patients were more likely to lose rather than gain DP status.

CONCLUSION

About one-quarter of patients with RA experienced DP, which responded well to sarilumab. These data support the concept that other mechanisms (potentially mediated via IL-6) in addition to inflammation may contribute to DP in RA.

TRIAL REGISTRATIONS

NCT01061736, NCT02332590, NCT01709578, NCT01146652.

Comparative effectiveness of TNF inhibitor vs IL-6 receptor inhibitor as monotherapy or combination therapy with methotrexate in biologic-experienced patients with rheumatoid arthritis: An analysis from the CorEvitas RA Registry

OBJECTIVE

Randomized controlled trials (RCTs) in biologic-naïve rheumatoid arthritis (RA) patients with high disease activity and inadequate response/intolerance to methotrexate have shown interleukin-6 (IL-6) receptor inhibitors (IL-6Ri) to be superior to tumor necrosis factor inhibitors (TNFi) as monotherapy. This observational study aimed to compare the effectiveness of TNFi vs IL-6Ri as mono- or combination therapy in biologic/targeted synthetic (b/ts) -experienced RA patients with moderate/high disease activity.

METHODS

Eligible b/ts-experienced patients from the CorEvitas RA registry were categorized as TNFi and IL-6Ri initiators, with subgroups initiating as mono- or combination therapy. Mixed-effects regression models evaluated the impact of treatment on Clinical Disease Activity Index (CDAI), patient-reported outcomes, and disproportionate pain (DP). Unadjusted and covariate-adjusted effects were reported.

RESULTS

Patients initiating IL-6Ri (n = 286) vs TNFi monotherapy (n = 737) were older, had a longer RA history and higher baseline CDAI, and were more likely to initiate as third-line therapy; IL-6Ri (n = 401) vs TNFi (n = 1315) combination therapy initiators had higher baseline CDAI and were more likely to initiate as third-line therapy. No significant differences were noted in the outcomes between TNFi and IL-6Ri initiators (as mono- or combination therapy).

CONCLUSION

This observational study showed no significant differences in outcomes among b/ts-experienced TNFi vs IL-6Ri initiators, as either mono- or combination therapy. These findings were in contrast with the previous RCTs in biologic-naïve patients and could be explained by the differences in the patient characteristics included in this study. Further studies are needed to help understand the reasons for this discrepancy in the real-world b/ts-experienced population.

POS0646 RAPID AND CONCURRENT IMPROVEMENTS IN PATIENT-REPORTED OUTCOMES OF RHEUMATOID ARTHRITIS WITH BARICITINIB IN RA-BEAM

Background:

The efficacy and safety of baricitinib (BARI), an oral selective Janus kinase (JAK)1/JAK2 inhibitor, were evaluated in the randomized, controlled trial, RA-BEAM (NCT01710358), in patients (pts) with active rheumatoid arthritis (RA) and inadequate responses (IR) to methotrexate (MTX).1,2,3

Objectives:

To compare the time to onset and magnitude of improvement across different patient-reported outcomes (PROs) of BARI, adalimumab (ADA) and placebo (PBO) during the first 12 weeks of treatment in RA-BEAM.

Methods:

1,305 patients on stable background MTX were randomized 3:3:2 to PBO, BARI 4 mg, or ADA 40 mg. In this intent-to-treat analysis, least-squares mean changes and percentage changes from baseline were assessed up to Week 12 for pain (0-100 mm visual analog scale [VAS]), SF-36 physical component summary (PCS, 0-100), morning joint stiffness (MJS) severity (0-10), Health Assessment Questionnaire-Disability Index (HAQ-DI, 0-3), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F, 0-52), and Patient Global Assessment of disease activity (PtGA, 0-100 mm VAS) scores. PROs were compared between treatments with ANCOVA; the model included change from baseline as the response variable, baseline of interest, regional baseline, joint erosion status, and treatment as explanatory variables. Last-observation-carried-forward was applied to impute missing data. Speed of onset and magnitude of PRO improvement are presented in spydergrams.

Results:

Statistically significant improvements (P<0.05) with BARI and ADA vs. PBO were reported as early as Week 1 for pain, MJS severity, HAQ-DI, and PtGA and at Week 4 for FACIT-F and SF-36 PCS scores. Statistically significantly larger improvements (P<0.05) with BARI vs. ADA were observed as early as Week 2 for pain, PtGA, Week 3 for MJS severity, and Week 4 for HAQ-DI and SF-36 PCS scores. These improvements were maintained to Week 12.

Conclusion:

Among MTX-IR pts, BARI and ADA treatment resulted in improvements across all PROs by Week 4, and as early as Week 1, for all but FACIT-F and SF-36 PCS scores. Statistically significant larger improvements for BARI compared with ADA were reported for all PROs, except FACIT-F, by Week 12.

References:

[1]Taylor et al. NEJM, 2017;376: 652-62

[2]Keystone et al. Ann Rheum Dis, 2017;76:1853-61

[3]Strand et al. Ann Rheum Dis, 2020; 79: 599-600

Table 1.

Change from baseline in patient-reported outcomes at Weeks 4 and 12

Week 4Week 12LSM Change from BaselinePBOADABARIPBOADABARIPain VAS-12.6-22.3***-27.1***††-17.1-26.4***-31.5***††SF-36 PCS3.05.7***6.9***††4.27.2***8.7***††MJS severity-0.9-1.5***-1.9***††-1.4-2.0***-2.5***†††HAQ-DI-0.26-0.47***-0.54***†-0.34-0.56***-0.66***††FACIT-F5.26.9**7.8***6.78.7***9.1***PtGA-14.2-23.7***-26.8***†-16.7-26.6***-31.2***††

*p≤0.05, **p≤0.01, ***p≤0.001 vs PBO; †p≤0.05, ††p≤0.01, †††p≤0.001 vs. ADA

ADA: adalimumab; BARI: baricitinib; FACIT-F: Functional Assessment of Chronic Illness Therapy-Fatigue; HAQ-DI: Health Assessment Questionnaire-Disability Index; MJS: morning joint stiffness; PBO: placebo; PCS: physical component scale; PtGA: Patient Global Assessment; VAS: visual analog scale

Figure 1.

Percentage improvement from baseline to Week 12 in PROs of patients with RA in RA-BEAM

Acknowledgements:

The authors would like to acknowledge Molly Tomlin, with Eli Lilly and Company, for medical writing and project management support

Disclosure of Interests:

Vibeke Strand Consultant of: AbbVie, Amgen, Arena, AstraZeneca, Bayer Pharmaceuticals, Boehringer Ingelheim, Bristol-Myers Squibb, Celltrion, Eli Lilly and Company, Galapagos NV, Genentech, Gilead, GlaxoSmithKline, Ichnos, Inmedix, Janssen, Kiniksa, Merck, Myriad Genetics, Novartis, Pfizer, Regeneron, Samsung, Sandoz, Sanofi, Scipher, Setpoint, Sun Pharma, and UCB Pharma, Anthony Sebba Speakers bureau: Eli Lilly and Company, Genentech, Sanofi, Regeneron, Consultant of: Amgen, Eli Lilly and Company, Genentech, Gilead Sciences, Novartis, Sanofi, Regeneron, Bochao Jia Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Julie Birt Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Amanda Quebe Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Hong Zhang Consultant of: Eli Lilly and Company, Peter C. Taylor Consultant of: AbbVie, Biogen, Galapagos, Gilead, GlaxoSmithKline, Janssen, Lilly, BMS, Pfizer, Roche, Celltrion, Sanofi, Nordic Pharma, Fresenius and UCB, Grant/research support from: Celgene, Galapagos, Janssen, Lilly

Pain: A Review of Interleukin-6 and Its Roles in the Pain of Rheumatoid Arthritis

Pain is a major and common symptom reported as a top priority in patients with rheumatoid arthritis (RA). Intuitively, RA-related pain is often considered to be a natural consequence of peripheral inflammation, so treatment of RA is expected to manage pain concurrently as part of inflammation control. However, pain in patients with RA can be poorly correlated with objective measures of inflammation, for example, in patients who are otherwise in remission. Joint damage appears to account for only a fraction of this residual pain. Emerging evidence suggests that alteration of peripheral and central pain processing contributes to RA-related pain; this is parallel to, but somewhat independent of, joint inflammation. Interleukin (IL)-6 is a proinflammatory cytokine that contributes to the pathogenesis of RA. It exerts systemic effects via signaling through soluble forms of the IL-6 receptor (“trans-signaling”). Evidence from preclinical studies demonstrates that intra-articular IL-6 can produce long-lasting peripheral sensitization to mechanical stimulation and suggests an important role for IL-6 in central pain sensitization. This may be partly explained by its ability to activate neurons through trans-signaling, affecting nociceptive plasticity and nerve fiber regrowth. Local activity at neuron endings may culminate in altered pain processing in the central nervous system because of persistent signaling from sensitized peripheral neurons. Peripheral and central sensitization can promote the development of chronic pain, which can have a significant impact on patients’ health and quality of life. A proportion of pain in RA may be more appropriately managed as an entity separate from inflammation. Both the peripheral and central nervous systems should be recognized as important potential systems targeted by RA. The substantial burden of RA-related chronic pain suggests that pain should be a key focus in RA management and should be assessed and addressed early and separately from the inflammatory component.

The Jak/STAT pathway: A focus on pain in rheumatoid arthritis

Pain is a manifestation of rheumatoid arthritis (RA) that is mediated by inflammatory and non-inflammatory mechanisms and negatively affects quality of life. Recent findings from a Phase 3 clinical trial showed that patients with RA who were treated with a Janus kinase 1 (Jak1) and Janus kinase 2 (Jak2) inhibitor achieved significantly greater improvements in pain than those treated with a tumor necrosis factor blocker; both treatments resulted in similar changes in standard clinical measures and markers of inflammation. These findings suggest that Jak1 and Jak2 inhibition may relieve pain in RA caused by inflammatory and non-inflammatory mechanisms and are consistent with the overarching involvement of the Jak-signal transducer and activator of transcription (Jak/STAT) pathway in mediating the action, expression, and regulation of a multitude of pro- and anti-inflammatory cytokines. In this review, we provide an overview of pain in RA, the underlying importance of cytokines regulated directly or indirectly by the Jak/STAT pathway, and therapeutic targeting of the Jak/STAT pathway in RA. As highlighted herein, multiple cytokines directly or indirectly regulated by the Jak/STAT pathway play important roles in mediating various mechanisms underlying pain in RA. Having a better understanding of these mechanisms may help clinicians make treatment decisions that optimize the control of inflammation and pain.

OP0228 EFFICACY AND SAFETY OF IXEKIZUMAB VERSUS ADALIMUMAB (SPIRIT-H2H) WITH AND WITHOUT CONCOMITANT CONVENTIONAL SYNTHETIC DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARD) IN BIOLOGIC DMARD-NAÏVE PATIENTS WITH PSORIATIC ARTHRITIS: 52-WEEK RESULTS

Background:

Ixekizumab (IXE), a high-affinity monoclonal antibody selectively targeting IL-17A, was superior to adalimumab (ADA) at Week (Wk) 24 for simultaneous achievement of ACR50 and 100% improvement from baseline in the Psoriasis Area and Severity Index (PASI 100) (primary endpoint) in patients (pts) with active PsA from SPIRIT-H2H1. SPIRIT-H2H had two major secondary endpoints and achieved both: noninferiority of IXE to ADA for ACR50 at Wk 24, and superiority of IXE to ADA for PASI 100 at Wk 24.

Objectives:

To determine how concomitant conventional synthetic DMARD (csDMARD) use affects safety and efficacy of IXE and ADA in prespecified subgroups defined by biologic monotherapy, concomitant MTX use, and concomitant csDMARD use through Wk 52 in SPIRIT-H2H.

Methods:

SPIRIT-H2H (NCT03151551) was a 52-week, multicentre, randomised, open-label, assessor-blinded, parallel-group study evaluating the efficacy and safety of IXE versus ADA in adults with PsA and naïve to biologic DMARDs. Patients were required to have active PsA fulfilling Classification for Psoriatic Arthritis (CASPAR) criteria and ≥3/68 tender and ≥3/66 swollen joints, ≥3% plaque psoriasis BSA involvement, no prior treatment with bDMARDs, and with prior inadequate response to ≥1 csDMARD (but not necessarily current treatment with csDMARDs). Randomization (1:1) was stratified by concomitant use of csDMARD and the presence/absence of moderate to severe PsO (baseline: BSA≥10% + PASI≥12, + static Physician’s Global Assessment≥3). Patients (N=566) received IXE/ADA through 52 wks according to the labelled dose dependent on presence/absence of moderate-to-severe PsO. In this prespecified subgroup analysis by presence or absence of csDMARDs, efficacy outcomes through wk 52 were compared between IXE and ADA using logistic regression models and Fisher’s exact tests. Missing data were imputed using non-responder imputation.

Results:

At baseline, 167 of 283 IXE-treated patients and 169 of 283 ADA-treated patients had concomitant MTX use. Of these, 9.0% (15/167) and 7.1% (12/169) treated with IXE and ADA, respectively, were taking an additional csDMARD (sulfasalazine, cyclosporine, or leflunomide). A significantly greater proportion of patients on IXE versus ADA achieved the primary endpoint or PASI 100 when used as monotherapy or in combination with csDMARD (Figure 1A and 1C). At Wk 52, the proportion of patients achieving ACR50 was not statistically different between IXE and ADA, regardless of monotherapy or concomitant csDMARD use (Figure 1B). A significantly higher proportion of patients achieved MDA on IXE compared to ADA in the monotherapy subgroup (49% vs 33%), while the response rates were similar in both combination subgroups (Figure 1D). These data support consistent ACR50, PASI 100, and MDA response for IXE across all three subgroups. Frequencies of adverse events were similar across the three subgroups for IXE and ADA (Figure 2).

Conclusion:

As with prior studies,2,3consistent efficacy across multiple PsA disease-specific endpoints was observed with IXE in SPIRIT-H2H, regardless of whether IXE was taken as monotherapy or in combination with MTX or another csDMARD. No unexpected safety signals were found for either agent.

References:

[1]Mease et al, Ann Rheum Dis 2020;79:123-31.

[2]Coates et al, RMD Open 2017;3:e000567.

[3]Nash et al, RMD Open 2018;4:e000692.

Disclosure of Interests:

Josef S. Smolen Grant/research support from: AbbVie, AstraZeneca, Celgene, Celltrion, Chugai, Eli Lilly, Gilead, ILTOO, Janssen, Novartis-Sandoz, Pfizer Inc, Samsung, Sanofi, Consultant of: AbbVie, AstraZeneca, Celgene, Celltrion, Chugai, Eli Lilly, Gilead, ILTOO, Janssen, Novartis-Sandoz, Pfizer Inc, Samsung, Sanofi, Anthony Sebba Consultant of: Genentech, Gilead, Lilly, Regeneron Pharmaceuticals Inc., Sanofi, Speakers bureau: Lilly, Roche, Sanofi, Eric Ruderman Consultant of: Pfizer, Amanda Gellett Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Christophe Sapin Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Aubrey Trevelin Sprabery Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Soyi Liu Leage Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Sreekumar Pillai Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Paulo Reis Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Peter Nash Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Gilead, Janssen, MSD, Novartis, Pfizer Inc, Roche, Sanofi, UCB, Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Pfizer Inc, Roche, Sanofi, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Pfizer Inc, Roche, Sanofi, UCB

SAT0102 NONINFLAMMATORY PAIN IS A FREQUENT PHENOMENON IN RHEUMATOID ARTHRITIS AND RESPONDS WELL TO TREATMENT WITH SARILUMAB

Background:

Inflammation is clearly a key driver of pain in rheumatoid arthritis (RA). However, in some patients the level of pain exceeds what would be expected based on the amount of synovitis observed, which may indicate the presence of noninflammatory pain (NIP). Interleukin-6 (IL-6) has been shown in animal models to increase sensitization to pain and may play a role in NIP.

Objectives:

To assess the effect of sarilumab, a human IL-6 receptor inhibitor approved for the treatment of adults with moderate to severely active RA, on NIP and disease activity, stratified by baseline (BL) NIP status.

Methods:

The analysis included data from three Phase 3 studies of sarilumab: MOBILITY (NCT01061736), MONARCH (NCT02332590), and TARGET (NCT01709578). Patients received double-blind placebo or sarilumab 150 mg or 200 mg subcutaneously (SC) every 2 weeks (q2w), plus weekly csDMARD (MOBILITY and TARGET), or adalimumab 40 mg or sarilumab 200 mg SC q2w as monotherapy (MONARCH).

NIP was defined using an established formula: tender 28-joint count (TJC) – swollen 28-joint count (SJC) ≥7.1,2Patients were assessed for NIP at study BL and for change in NIP status at Weeks 12 and 24. The proportion of patients achieving ACR20/50/70, Clinical Disease Activity Index (CDAI) ≤10, and DAS28-CRP <3.2 at Week 24 was assessed in patients with and without BL NIP. No inferential statistics were performed.

Results:

Of 2112 patients in the analysis, 490 (23%) met the criteria for NIP at study BL: MOBILITY, n = 294/1197 (25%); MONARCH, n = 90/369 (24%); TARGET, n = 106/546 (19%). BL demographics were similar for patients with or without BL NIP: mean age (SD) was 52.6 (10.7) versus 51.2 (12.3) years, and 85% versus 81% were female. Patients with BL NIP had higher CDAI, DAS28-CRP, pain Visual Analog Scale (VAS), and TJC at BL versus patients without NIP (Table). Of patients with NIP at BL, those who received sarilumab were more likely to have no NIP at Weeks 12 and 24 versus patients who received placebo or adalimumab (Figure 1). The percentage of patients achieving improvements in disease activity at Week 24 was greater for sarilumab versus adalimumab among both patients with and without BL NIP, and these differences were larger among patients with BL NIP for all assessments except ACR50 (Figure 2).

Table.

Baseline characteristics

Patients with TJC – SCJ ≥7Mean (SD)Yes (n = 490)No (n = 1622)Duration of RA, years9.1 (8.6)9.7 (8.4)TJC, 0–2821.7 (4.7)14.3 (6.2)SJC, 0–2810.7 (4.3)13.1 (6.0)CRP, mg/L22.7 (27.0)22.9 (24.0)HAQ-DI, 0–31.8 (0.6)1.7 (0.6)DAS28-CRP6.4 (0.7)5.9 (0.9)CDAI46.0 (9.4)40.4 (13.0)Pain VAS72.3 (18.2)67.0 (20.7)

Conclusion:

NIP was prevalent at BL in the patient populations assessed. Among patients with BL NIP, a lower proportion continued to have NIP at Weeks 12 and 24 when treated with sarilumab versus placebo or adalimumab. Patients with and without BL NIP had greater improvements in pain when treated with sarilumab versus adalimumab. The difference in clinical improvement was greater among patients with BL NIP versus without BL NIP for most measures. These trends support the emerging concept that mechanisms other than direct inflammation may contribute to pain in RA, potentially mediated via IL-6 signaling.

References:

[1]Durán J et al.Rheumatology. 2015;54:2166–70

[2]Pollard LC et al.Rheumatology. 2010;49:924–8

Acknowledgments:

Study funding and medical writing support (Joseph Hodgson, PhD, Adelphi Communications Ltd, Macclesfield, UK) provided by Sanofi Genzyme (Cambridge, MA, USA) and Regeneron Pharmaceuticals, Inc. (Tarrytown, NJ, USA) in accordance with GPP3 guidelines.

Disclosure of Interests:

Ernest Choy Grant/research support from: Amgen, Bio-Cancer, Chugai Pharma, Ferring Pharmaceuticals, Novimmune, Pfizer, Roche, UCB, Consultant of: AbbVie, Amgen, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Chelsea Therapeutics, Chugai Pharma, Daiichi Sankyo, Eli Lilly, Ferring Pharmaceuticals, GlaxoSmithKline, Hospita, Ionis, Janssen, Jazz Pharmaceuticals, MedImmune, Merck Sharp & Dohme, Merrimack Pharmaceutical, Napp, Novartis, Novimmune, ObsEva, Pfizer, R-Pharm, Regeneron Pharmaceuticals, Inc., Roche, SynAct Pharma, Sanofi Genzyme, Tonix, UCB, Speakers bureau: Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Chugai Pharma, Eli Lilly, Hospira, Merck Sharp & Dohme, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Roche, Sanofi-Aventis, UCB, Vivian Bykerk: None declared, Yvonne Lee Shareholder of: Cigna-Express Scripts, Grant/research support from: Pfizer, Consultant of: Highland Instruments, Inc., Gregory St John Shareholder of: Regeneron Pharmaceuticals, Inc., Employee of: Regeneron Pharmaceuticals, Inc., Hubert van Hoogstraten Shareholder of: Sanofi, Employee of: Sanofi, Kerri Ford Shareholder of: Sanofi Genzyme, Employee of: Sanofi Genzyme, Amy Praestgaard Employee of: Sanofi Genzyme, Anthony Sebba Consultant of: Genentech, Gilead, Lilly, Regeneron Pharmaceuticals Inc., Sanofi, Speakers bureau: Lilly, Roche, Sanofi

SAT0121 PAIN AND OTHER PATIENT-REPORTED OUTCOMES IN PATIENTS WITH RHEUMATOID ARTHRITIS WHO DID OR DID NOT ACHIEVE TREATMENT RESPONSE BASED ON IMPROVEMENT IN SWOLLEN JOINTS IN TOCILIZUMAB CLINICAL TRIALS

Background:

Significant improvements in pain and other patient-reported outcomes (PROs) have been shown in large clinical trials in patients with rheumatoid arthritis (RA) who receive tocilizumab (TCZ) compared with placebo (PBO). Recent data suggest that pain in RA may be noninflammatory as well as inflammatory, and improvement in pain scores and other PROs may be seen in patients who do not respond to treatment based on disease activity measures that evaluate inflammation.

Objectives:

To assess changes in pain scores and other PROs in patients with RA who did or did not achieve ≥ 20% improvement in SJC in TCZ clinical trials.

Methods:

Data from patients with active RA who received intravenous TCZ 8 mg/kg + MTX or PBO + MTX in 3 Phase III studies (OPTION [NCT00106548], TOWARD [NCT00106574] and LITHE [NCT00109408]) were included. All patients had moderate to severe RA with an inadequate response or intolerance of MTX (OPTION, LITHE) or conventional synthetic disease-modifying antirheumatic drugs (csDMARDs; TOWARD). Changes in pain (visual analog scale [VAS], 0-100 mm), Health Assessment Questionnaire Disability Index (HAQ-DI, 0-3), 36-Item Short Form Survey (SF-36) physical component score (PCS) and mental component score (MCS; 0-50) and Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue score (0-52) from baseline to Week 24 were evaluated. Results were compared between patients receiving TCZ + MTX and those receiving PBO + MTX in both patients who achieved ≥ 20% improvement in SJC (responders) and those who did not (nonresponders). The changes from baseline were analyzed using a mixed model with repeated measures, including the following covariates and interactions: treatment, visit, baseline of endpoint, region, baseline DAS28 and interactions of visit with treatment and baseline of endpoint.

Results:

Data from 1254 responders (TCZ + MTX, n = 831; PBO + MTX, n = 423) and 620 nonresponders (TCZ + MTX, n = 225; PBO + MTX, n = 395) were included. Patients receiving TCZ + MTX had significantly greater improvement in pain scores and HAQ-DI compared with PBO + MTX in the responder group (–27.19 vs –16.77 and –0.55 vs –0.34, respectively;P< 0.0001 for both) and nonresponder group (–9.59 vs 2.53 and –0.20 vs 0.01;P< 0.0001 for both) at Week 24 (Figure 1). Similar results were seen at Week 16 in the nonresponder group (–11.06 vs –2.38 and –0.23 vs –0.04;P< 0.0001 for both) prior to initiation of rescue treatment. At Week 24 in the responder group, patients receiving TCZ + MTX had significantly greater improvements compared with PBO + MTX in SF-36 PCS and MCS (9.16 vs 5.71 and 6.55 vs 3.79, respectively;P< 0.0001 for both) (Figure 2) and FACIT-Fatigue (8.39 vs 5.11;P< 0.0001). In the nonresponder group, patients receiving TCZ + MTX had significantly greater improvements compared with PBO + MTX in SF-36 PCS at Week 16 (3.81 vs 1.65;P= 0.0006) and Week 24 (4.42 vs 1.01;P< 0.0001) (Figure 2) and FACIT-Fatigue at Week 16 (3.82 vs 1.32;P= 0.0039) and Week 24 (3.90 vs 1.40;P= 0.0111).

Conclusion:

Patients with RA who received TCZ + MTX had significantly greater improvements in pain score and other PROs than those who received PBO + MTX regardless of whether they achieved ≥ 20% improvement in SJC. Clinical outcome at Week 24 correlated well with PROs, with a relatively larger improvement in pain score and other PROs in the responder group than in the nonresponder group; relative to PBO + MTX, these improvements appear numerically similar in the responder and nonresponder groups with consistently smaller difference between the groups in TCZ-treated arms. The consistent effect of TCZ on PROs in both responder and nonresponder groups warrants further study on the impact of TCZ on sources of pain independent of that caused by joint inflammation.

Figure:

Acknowledgments:

This study was sponsored by Genentech, Inc. Support for third-party writing assistance, furnished by Health Interactions, Inc, was provided by Genentech, Inc.

Disclosure of Interests:

Anthony Sebba Consultant of: Genentech, Gilead, Lilly, Regeneron Pharmaceuticals Inc., Sanofi, Speakers bureau: Lilly, Roche, Sanofi, Jian Han Shareholder of: Genentech, Inc., Employee of: Genentech, Inc., Shalini Mohan Shareholder of: Genentech, Inc., Employee of: Genentech, Inc.

P236 Baricitinib provides better pain relief across all disease activity levels compared with placebo and adalimumab in RA

Background

In this post hoc analysis, we assessed relationship between pain improvement and disease activity and evaluated whether baricitinib (BARI) provided additional pain improvement vs. PBO and adalimumab (ADA) across levels of disease activity.

Methods

1,305 patients on stable background MTX were randomized 3:2:3 (PBO:40-mg subcutaneous ADA every other week:daily, oral 4-mg BARI). Pain was assessed with 0-100-mm VAS; pain improvement (baseline to Week 12) was grouped by ≤ 30%, &gt;30% to ≤ 50%, &gt;50% to ≤ 70%, &gt;70%. Disease activity was measured with CDAI, SDAI, DAS28 with CRP, and DAS28 with ESR. To evaluate change in pain with disease activity, regression was used with continuous change in pain VAS score from baseline to Week 12 as outcome and continuous CDAI/SDAI/DAS28-CRP/DAS28-ESR values, treatment, and interaction term between treatment and disease activity as explanatory variables. Last observation carried forward was used to impute missing values. Pain VAS change (Week 12) was estimated if patients achieved remission (REM)/low disease activity (LDA)/moderate disease activity (MDA) as defined by the corresponding clinical measure. Analyses were not adjusted for multiplicity. Data visualization (percentage of pain VAS improvement vs. disease activity) was created to examine pain improvement with treatment over time.

Results

With CDAI, 91%/9% of patients had high disease activity/MDA across all treatments (baseline). Percentage of patients achieving REM with PBO, ADA, and BARI were 2%, 7%, 8%; for LDA: 15%, 27%, 33%; for MDA: 33%, 40%, 38%. At all CDAI values, estimated change in pain VAS for BARI was greater vs. PBO and ADA (Week 12). Similar trends were observed with other measures (Table). BARI demonstrated greater pain improvement vs. ADA and PBO in percentage of patients with ≤30%, &gt;30% to ≤ 50%, &gt;50% to ≤ 70%, and &gt;70% pain improvement from baseline at Week 12. . With CDAI/SDAI, greater differentiation between BARI and ADA was observed as CDAI/SDAI values increased.

Conclusion

BARI provided additional pain improvement vs. PBO and ADA when disease activity was controlled, across all levels of disease activity, measured by CDAI, SDAI, DAS28-CRP, or DAS28-ESR (Week 12).

Disclosures

P.C. Taylor (Presenter): Consultancies; PCT has been a consultant and/or received research support from: AbbVie, Eli Lilly and Company, Galapagos, and Pfizer. J. Pope: Consultancies; JP has been a consultant and/or has received grant/research support from: AbbVie, Amgen, Bayer, BMS, Eli Lilly and Company, Merck, Novartis, Pfizer, Roche, Sanofi, Sandoz, and UCB. K. Ikeda: Consultancies; KI has been a consultant and/or received research support and/or honoraria from: AbbVie, Astellas Pharma, Bristol-Myers K.K., Chugai Pharmaceutical, Eisai, Eli Lilly and Company, Kyowa Hakko Kir. X. Zhang: Corporate appointments; XZ is an employee of Eli Lilly and Company. Shareholder/stock ownership; XZ is a shareholder of Eli Lilly and Company. B. Jia: Corporate appointments; BJ is an employee of Eli Lilly and Company. Shareholder/stock ownership; BJ is a shareholder of Eli Lilly and Company. H. Zhang: None. A. Quebe: Corporate appointments; AQ is an employee of Eli Lilly and Company. Shareholder/stock ownership; AQ is a shareholder of Eli Lilly and Company. Y. Chen: Corporate appointments; Y-FC is an employee of Eli Lilly and Company. Shareholder/stock ownership; Y-FC is a shareholder of Eli Lilly and Company. C.L. Kannowski: Corporate appointments; CLK is an employee of Eli Lilly and Company. Shareholder/stock ownership; CLK is a shareholder of Eli Lilly and Company. T. Holzkaemper: Corporate appointments; TH is an employee of Eli Lilly and Company. Shareholder/stock ownership; TH is a shareholder of Eli Lilly and Company. A. Cardoso: Corporate appointments; AC is an employee of Eli Lilly and Company. Shareholder/stock ownership; AC is a shareholder of Eli Lilly and Company. A. Sebba: Consultancies; AS has been a consultant and/or speaker for: Eli Lilly and Company, Genentech, and Novartis.

Effect of tocilizumab on neutrophils in adult patients with rheumatoid arthritis: pooled analysis of data from phase 3 and 4 clinical trials

Objectives

To investigate changes in neutrophil count and occurrences of infection in RA patients treated with the IL-6 receptor-α inhibitor tocilizumab (TCZ).

Methods

Data were pooled from patients who received i.v. TCZ (4 mg/kg + MTX, 8 mg/kg ± DMARDs, 10 mg/kg) or placebo + DMARDs in phase 3/4 clinical trials, long-term extensions or a pharmacology study. Neutrophil counts were measured routinely according to the Common Toxicity Criteria for Adverse Events grades; TCZ dosing was adjusted if necessary. Covariates associated with decreased neutrophil counts were assessed with multivariate regression analysis. Infection rates within 30 days of neutrophil count changes were calculated per 100 patient-years of TCZ exposure.

Results

In placebo-controlled parts of trials, more TCZ-treated than placebo-treated patients had grade 1/2 or 3/4 neutrophil counts (TCZ: 28.2%/3.1%; placebo: 8.9%/0.2%). In placebo-controlled trials + long-term extensions, 4171 patients provided 16204.8 patient-years of TCZ exposure. Neutrophil counts decreased through week 6 from baseline [mean ( s . d .) change, -2.17 (2.16) × 10 9 /l) and remained stable thereafter. Rates (95% CI) of serious infections within 30 days of normal [4.66 (4.31, 5.03)], grade 1/2 [2.48 (1.79, 3.34)] and 3/4 [2.77 (0.34, 10.01)] neutrophil counts were similar. Baseline neutrophil count <2 × 10 9 /l and female gender were associated with grade 3/4 neutrophil counts [odds ratio (OR) (95% CI): 19.02 (6.76, 53.52), 2.55 (1.40, 4.66)]. Patients who stopped TCZ in response to decreased neutrophil count returned more quickly to normal levels than patients who reduced or continued their dose.

Conclusion

Decreases in neutrophil counts in patients taking TCZ do not appear to be associated with serious infections and are normalized by current risk mitigation guidelines.

Five-year Efficacy and Safety of Tocilizumab Monotherapy in Patients with Rheumatoid Arthritis Who Were Methotrexate- and Biologic-naive or Free of Methotrexate for 6 Months: the AMBITION Study

Objective.

To report on the 5-year efficacy and safety results of the AMBITION (Actemra versus Methotrexate double-Blind Investigative Trial In mONotherapy) monotherapy study (ClinicalTrials.gov: NCT00109408, NCT00720798).

Methods.

Patients with rheumatoid arthritis for whom biologics had not failed or who did not discontinue methotrexate because of lack of efficacy or tolerability were followed up for 5 years to assess the efficacy and serious adverse events (SAE) of tocilizumab (TCZ) monotherapy.

Results.

Longterm efficacy results showed that efficacy was maintained or improved for up to 264 weeks in patients receiving TCZ monotherapy. Serious infection was the most frequent SAE; no new safety signals were reported.

Conclusion.

Longterm monotherapy with TCZ demonstrated continuing efficacy and safety.

Malignancy rates in patients with rheumatoid arthritis treated with tocilizumab

Objective

To analyse malignancy rates in patients with rheumatoid arthritis (RA) treated with tocilizumab.

Methods

Patients who received tocilizumab or placebo+methotrexate/disease-modifying antirheumatic drugs in the double-blind phases of 5-phase three trials or who received at least 1 dose of tocilizumab in the long-term extension studies were analysed up to the 2 May 2012 cut-off date. Malignancies were monitored throughout the studies, analysed and adjudicated as malignant by medical review. Risk was compared with that in the general population using standardised incidence ratios (SIRs) based on data from the Surveillance Epidemiology and End Results SEER (US general population) and GLOBOCAN (non-US general population) databases.

Results

In total, 4009 patients in the tocilizumab all-exposure population were included. Mean treatment duration was 4.0 years (mean 5.1 (range 0.0–6.8); total observation time was 16 120.1 patient-years (PY). The adjudicated malignancy rate (95% CI) was 1.26/100 PY (1.09 to 1.44) and remained constant over time. The SIR (95% CI) for all malignancies combined, excluding non-melanoma skin cancer, was 1.36 (1.01 to 1.80) for US and 1.81 (1.44 to 2.23) for non-US populations, driven primarily by higher rates in lung and bronchus (US/non-US) malignancies and prostate cancer and non-Hodgkin lymphoma (non-US), in contrast to those for the general populations; these higher rates are in line with those expected in patients with RA or in the geographic regions studied.

Conclusions

Malignancy rates remained stable with long-term tocilizumab treatment, and malignancy types and rates were consistent with those expected in patients with RA.

Biologic and oral disease-modifying antirheumatic drug monotherapy in rheumatoid arthritis

Clinical evidence demonstrates coadministration of tumour necrosis factor inhibitor (TNFi) agents and methotrexate (MTX) is more efficacious than administration of TNFi agents alone in patients with rheumatoid arthritis, leading to the perception that coadministration of MTX with all biologic agents or oral disease-modifying antirheumatic drugs is necessary for maximum efficacy. Real-life registry data reveal approximately one-third of patients taking biologic agents use them as monotherapy. Additionally, an analysis of healthcare claims data showed that when MTX was prescribed in conjunction with a biologic agent, as many as 58% of patients did not collect the MTX prescription. Given this discrepancy between perception and real life, we conducted a review of the peer-reviewed literature and rheumatology medical congress abstracts to determine whether data support biologic monotherapy as a treatment option for patients with rheumatoid arthritis. Our analysis suggests only for tocilizumab is there evidence that the efficacy of biologic monotherapy is comparable with combination therapy with MTX.

The Direct Assessment of Nonvertebral Fractures in Community Experience (DANCE) study: 2-year nonvertebral fragility fracture results

This observational study evaluated the occurrence of nonvertebral fragility fractures (NVFX) in over 4,000 men and women with osteoporosis treated with teriparatide (TPTD). The incidence of new NVFX decreased for patients receiving TPTD treatment for greater than 6 months. No new significant safety findings were observed in this large trial.

INTRODUCTION

The Direct Assessment of Nonvertebral Fractures in Community Experience (DANCE) study evaluated the occurrence of NVFX in patients receiving TPTD for osteoporosis in a real-world setting.

METHODS

DANCE is a multicenter, prospective, observational trial that examined the long-term effectiveness of TPTD in men and women with osteoporosis whom study physicians judged to be suitable for TPTD therapy. Patients received 20 μg TPTD per day by subcutaneous injection for up to 24 months and were followed for 24 months after treatment cessation. The incidence of patients experiencing a new NVFX, defined as a fracture associated with low trauma, was evaluated during four 6-month periods in both the treatment and cessation phases with >0 to ≤6 months serving as the reference. We also observed the spectrum and occurrence of serious adverse events.

RESULTS

Of the 4,167 patients enrolled, 4,085 took one or more doses of TPTD (safety population); 3,720 were included in the efficacy analysis. The incidence of patients experiencing a NVFX was 1.42, 0.91, 0.70, and 0.81 % for the four treatment periods, respectively, and 0.80, 0.68, 0.33, and 0.33 % for the four periods after treatment cessation. Differences for each period were statistically significant compared with the reference period (first 6-month interval, each p < 0.05). No new significant safety findings were observed.

CONCLUSIONS

In this study, the incidence of NVFX decreased for patients receiving TPTD for all three treatment periods >6 months compared to 0 to ≤6 months, and this trend persisted throughout the cessation phase. TPTD was generally well tolerated.

Longterm safety and efficacy of tocilizumab in patients with rheumatoid arthritis: a cumulative analysis of up to 4.6 years of exposure

OBJECTIVE

To assess the longterm safety and efficacy of tocilizumab (TCZ) in patients with moderate to severe rheumatoid arthritis (RA).

METHODS

Patient data were from 5 randomized controlled TCZ trials (n = 4211), their open-label extension phases (n = 3512), and a drug interaction study (n = 23). All randomly assigned patients, regardless of previous RA treatment, were analyzed. Measures of safety included number of adverse events (AE), serious AE (SAE), AE leading to treatment discontinuation, laboratory tests, and deaths. Efficacy measures included American College of Rheumatology (ACR) 20/50/70 responses, tender joint count (TJC), swollen joint count (SJC), ACR core set components, and low disease activity (LDA) or Disease Activity Score in 28 joints (DAS28) remission. ACR/European League Against Rheumatism (EULAR) disease remission was a posthoc exploratory analysis.

RESULTS

Total duration of observation was 12,293 patient-years (PY). No new safety signals were identified; infections were the most common AE and SAE. The rate of serious infections was 4.5/100 PY. Improvements from baseline in clinical efficacy, measured as ACR20/50/70 responses, TJC, SJC, ACR core set components, and LDA and DAS28 remission, were generally sustained through at least 216 weeks of followup. ACR/EULAR disease remission was attained by 16.5% (Boolean) and 22.7% (index) of patients at Week 216.

CONCLUSION

TCZ has to date been studied for up to 4.6 years (240 weeks) of treatment in patients with RA. Our analysis reveals a longer-term safety profile consistent with previous observations, no new safety signals, and durable efficacy of TCZ in a large clinical trial program.

Efficacy and safety of the human anti-IL-1β monoclonal antibody canakinumab in rheumatoid arthritis: results of a 12-week, Phase II, dose-finding study

Background

Canakinumab is a fully human anti-interleukin IL-1beta monoclonal antibody, being investigated for the treatment of rheumatoid arthritis (RA). This multicenter, phase II, randomized, double-blind, placebo-controlled, parallel-group, dose-finding study investigated the efficacy and safety of canakinumab in patients with active RA despite ongoing therapy at stable doses of methotrexate.

Methods

Patients were randomized to receive one of four regimens, in addition to methotrexate, for 12 weeks: canakinumab 150 mg subcutaneously (SC) every 4 weeks (q4wk), canakinumab 300 mg SC (2 injections of 150 mg SC) every 2 weeks, a 600 mg intravenous loading dose of canakinumab followed by 300 mg SC every 2 weeks', or placebo SC every 2 weeks.

Results

Among 274 patients with evaluable efficacy data, the percentage of responders according to American College of Rheumatology 50 criteria (the primary endpoint, based on a 28-joint count) was significantly higher with canakinumab 150 mg SC q4wk than with placebo (26.5% vs. 11.4%, respectively; p = 0.028). Compared to placebo, this dosage of canakinumab was also associated with significantly more favorable responses at week 12 with respect to secondary endpoints including the Disease Activity Score 28, scores on the Health Assessment Questionnaire and Functional Assessment of Chronic Illness Therapy-Fatigue, swollen 28-joint count, and patient's and physician's global assessments of disease activity. No safety concerns were raised with canakinumab therapy, particularly with regard to infections. Few injection-site reactions occurred.

Conclusion

The addition of canakinumab 150 mg SC q4wk improves therapeutic responses among patients who have active RA despite stable treatment with methotrexate.

Trial Registration

(ClinicalTrials.gov identifier: NCT00784628)

Comparison of tocilizumab monotherapy versus methotrexate monotherapy in patients with moderate to severe rheumatoid arthritis: the AMBITION study

Background:

The anti-interleukin (IL) 6 receptor antibody tocilizumab inhibits signalling of IL6, a key cytokine in rheumatoid arthritis (RA) pathogenesis.

Objective:

To evaluate through the AMBITION study the efficacy and safety of tocilizumab monotherapy versus methotrexate in patients with active RA for whom previous treatment with methotrexate/biological agents had not failed.

Methods:

This 24-week, double-blind, double-dummy, parallel-group study, randomised 673 patients to either tocilizumab 8 mg/kg every 4 weeks, or methotrexate, starting at 7.5 mg/week and titrated to 20 mg/week within 8 weeks, or placebo for 8 weeks followed by tocilizumab 8 mg/kg. The primary end point was the proportion of patients achieving American College of Rheumatology (ACR) 20 response at week 24.

Results:

The intention-to-treat analysis demonstrated that tocilizumab was better than methotrexate treatment with a higher ACR20 response (69.9 vs 52.5%; p<0.001), and 28-joint Disease Activity Score (DAS28) <2.6 rate (33.6 vs 12.1%) at week 24. Mean high-sensitivity C-reactive protein was within the normal range from week 12 with tocilizumab, whereas levels remained elevated with methotrexate. The incidence of serious adverse events with tocilizumab was 3.8% versus 2.8% with methotrexate (p = 0.50), and of serious infections, 1.4% versus 0.7%, respectively. There was a higher incidence of reversible grade 3 neutropenia (3.1% vs 0.4%) and increased total cholesterol ⩾240 mg/dl (13.2% vs 0.4%), and a lower incidence of alanine aminotransferase elevations >3×–<5× upper limit of normal (1.0% vs 2.5%), respectively.

Conclusion:

Tocilizumab monotherapy is better than methotrexate monotherapy, with rapid improvement in RA signs and symptoms, and a favourable benefit–risk, in patients for whom treatment with methotrexate or biological agents has not previously failed.

Trial registration number:

NCT00109408

Comparing non-vertebral fracture risk reduction with osteoporosis therapies: looking beneath the surface

Data from pivotal trials of pharmacologic agents used to treat osteoporosis differ, suggesting that these agents vary in ability to reduce the risk of non-vertebral fractures (NVFs). However, variability among clinical trials in inclusion criteria, baseline characteristics, and definition of NVFs may account for many of these apparent differences.

INTRODUCTION

Data from pivotal trials of individual pharmacologic agents for osteoporosis differ, and suggest that differences may exist between anti-resorptive agents in their ability to reduce the risk of NVFs. Careful examination of these trials' inclusion criteria and patient characteristics indicates substantial differences between patient populations with respect to the baseline risk of NVFs. When baseline fracture risk is lower, the ability to produce a statistically significant reduction in fracture risk over the course of a clinical trial is reduced.

METHODS

Analysis of clinical trials reveals that the number and type of baseline vertebral fractures and also baseline bone mineral density, all associated with the risk of vertebral fracture, vary.

DISCUSSION AND CONCLUSION

The propensity to fall and patient frailty are additional factors associated with fracture risk that may influence study outcomes. One of the most significant variables, which also often differs considerably between trials, is the definition of an NVF. Variability between clinical trials in inclusion criteria, patients' baseline characteristics, and how NVFs are defined may account for much of the apparent difference between agents in their ability to reduce NVF risk.

Prediction of changes in bone mineral density in postmenopausal women treated with once-weekly bisphosphonates

BACKGROUND

In clinical practice, bone mineral density (BMD) determined by dual-energy x-ray absorptiometry is used to monitor response to osteoporosis therapy. However, 1 to 2 yr are usually required to assess patients' BMD responses. The possibility of earlier indicators of a response or nonresponse to treatment, such as changes in bone turnover markers (BTMs), is of interest to physicians and patients.

METHODS

In this post hoc analysis of women treated with once-weekly bisphosphonates, we examined the association of tertile percentage change from baseline in BTMs at 3 or 6 months and association of several baseline clinical characteristics with 24-month percentage change from baseline in BMD and with percentage of patients showing BMD nonresponse (defined as BMD loss at two or more of four sites) at 24 months. Multivariable analysis was performed to determine which factors were independently associated with BMD nonresponse.

RESULTS

Patients in the tertile with the greatest decrease in each of the BTMs had the greatest mean increase in BMD and the lowest percentage of BMD nonresponders at 24 months. Several characteristics were independently associated with BMD nonresponse, including smaller 3-month reductions from baseline in serum C-terminal telopeptide of type 1 collagen, bone-specific alkaline phosphatase, and N-terminal propeptide of type 1 procollagen; younger age of menopause; a family history of osteoporosis; and higher baseline trochanteric BMD. Baseline BTMs were not predictive of 24-month BMD response to therapy. The strongest associations were for changes in BTMs with treatment.

CONCLUSION

In groups of patients, short-term changes in markers of bone turnover appear to be predictors of longer term BMD response and nonresponse to bisphosphonate therapy.

Osteoporosis: how long should we treat?

PURPOSE OF REVIEW

Bisphosphonates are the most commonly used treatment for osteoporosis. The pharmacology of bisphosphonates suggests the possibility of discontinuing treatment for a period, and patients frequently ask about this. In an attempt to help answer these questions, this review will consider recent data relevant to continuing and discontinuing long-term bisphoshonate therapy and other osteoporosis therapy.

RECENT FINDINGS

Morphometric vertebral fracture protection continues for 1 year after discontinuation of risedronate for 3 years and there are now similar bishosphonate data for hip fractures. Nonvertebral fractures -in high-risk women - and perhaps clinical vertebral fractures may be reduced in women treated for 10 years with alendronate compared with those who stopped treatment after 5 years. After discontinuing bisphosphonates, bone mineral density appears to deplete more rapidly in the spine than in the hip and biochemical markers appear to increase. These changes occur very rapidly after discontinuing denosumab. Fractures at unusual sites have been reported with long-term bisphosphonate use.

SUMMARY

It appears that a drug holiday can be considered in many patients, although high-risk patients may benefit from continued bisphosphonate therapy. Recent unusual fracture cases need to be considered in making long-term treatment decisions.

Tocilizumab: the first interleukin-6-receptor inhibitor

PURPOSE

The pharmacology, pharmacokinetics, clinical efficacy, safety, and role of tocilizumab in rheumatoid arthritis (RA) are reviewed.

SUMMARY

Tocilizumab is a novel monoclonal antibody that competitively inhibits the binding of interleukin-6 (IL-6) to its receptor (IL-6R). Inhibiting the entire receptor complex prevents IL-6 signal transduction to inflammatory mediators that summon B and T cells. Tocilizumab has a nonlinear pharmacokinetic profile. The hypothesis that targeting and inhibiting IL-6R with tocilizumab can result in significant improvement of the signs and symptoms of RA appears to have been substantiated in one Phase III and two Phase II clinical trials, which have demonstrated a marked reduction in disease activity and the acute-phase response. The results of these studies indicate that tocilizumab treatment, both as a combination with methotrexate and as monotherapy, has a safety profile consistent with that of other biological and immunosuppressive therapies. In general, tocilizumab as monotherapy and in combination with methotrexate appears to be well tolerated. Adverse events were not dose dependent and were of similar frequency in all groups. Tocilizumab appears to provide an additional option for those patients who do not respond sufficiently to methotrexate. Since IL-6R inhibition has a distinct mechanism of action, some patients who do not respond to antitumor necrosis factor agents or who have a partial response may respond to tocilizumab.

CONCLUSION

Tocilizumab, a novel IL-6R inhibitor, may be beneficial for the treatment of RA in patients who do not respond to methotrexate or disease-modifying antirheumatic drugs. A large clinical trial is needed to confirm tocilizumab's clinical efficacy and safety.

Comparison of weekly treatment of postmenopausal osteoporosis with alendronate versus risedronate over two years

OBJECTIVE

A 1-yr extension of the Fosamax Actonel Comparison Trial was completed to compare changes in bone mineral density (BMD), bone turnover, and upper gastrointestinal tolerability over 2 yr of treatment.

DESIGN

This was a randomized, double-blind extension conducted at 72 U.S. sites.

PATIENTS AND METHODS

Of the 1053 women who completed yr 1, 833 postmenopausal women with low BMD entered the extension, continuing their same treatment allocation [once-weekly (OW) alendronate 70 mg or OW risedronate 35 mg]. Changes in BMD at the hip trochanter, total hip, femoral neck, and lumbar spine and in markers of bone turnover were compared at 24 months. Tolerability was assessed by adverse experience reporting.

RESULTS

Alendronate produced greater increases from baseline in BMD at 24 months than did risedronate at the trochanter (alendronate, 4.6%; risedronate, 2.5%, P < 0.001) as well as at all other BMD sites. Significantly more alendronate than risedronate patients had measured BMD increases of 0% or more and 3% or more at all BMD sites (P < 0.001), and fewer alendronate patients had measured decreases of 3% or more at all BMD sites. Significantly greater reductions in all biochemical markers of bone turnover occurred with alendronate, compared with risedronate. No differences were seen in occurrence or discontinuations due to upper gastrointestinal adverse experiences.

CONCLUSIONS

Patients receiving 70 mg OW alendronate had greater gains in BMD, were more likely to maintain or gain BMD, and had greater reductions in bone turnover markers than patients receiving 35 mg OW risedronate after 24 months, with no differences in upper gastrointestinal tolerability.

Optimizing Administration of Bisphosphonates in Women with Postmenopausal Osteoporosis

Bisphosphonates have been approved in the US as oral medication for the treatment of osteoporosis for about 10 years. Efficacy data exists for fracture reduction for the commonly used oral bisphosphonates but not for intravenous formulations. Based on the mechanism of action that appears to allow for longer intervals between doses, it has been possible to extend the treatment choices from the original more demanding daily oral dose to an array of options including oral weekly and more recently monthly treatment (so-called cyclical therapy) and intravenous treatment with various administration regimens. The possibility of treatment with an annual (or less frequent) intravenous administration with zoledronic acid exists. Compliance, adverse effects, and efficacy vary with each administration regimen.