Causal cascade of direct and indirect effects of anifrolumab on patient-reported outcomes: structural equation modelling of two Phase 3 trials

OBJECTIVES

SLE significantly impairs health-related quality of life (HRQoL). In this post hoc analysis, structural equation modelling was used to examine the 'causal cascade' of interaction between anifrolumab, disease activity and patient-reported outcomes (PROs) in pooled data from the phase 3 TULIP-1 and TULIP-2 trials.

METHODS

Data were pooled from the TULIP-1 (n = 364) and TULIP-2 (n = 362) randomized, placebo-controlled, 52-week trials of intravenous anifrolumab (300 mg every 4 weeks for 48 weeks). We evaluated changes from baseline to week 24 and week 52 in four clinical (BICLA, BILAG-2004, SLEDAI-2K and changes in glucocorticoid dosage) and six PRO measures (SF-36, FACIT-F, EQ-5D, LupusQoL, PHQ-8 and pain NRS) in our hypothesized model of interactions.

RESULTS

Our hypothesized model had an acceptable fit to the pooled TULIP trial data. At week 24, significant paths revealed that when compared with placebo, anifrolumab treatment improved disease activity as measured by BICLA, BILAG-2004, SLEDAI-2K and changes to glucocorticoid dosage. In turn, these clinical measures reduced pain, which improved fatigue, physical functioning, mood/emotions and HRQoL. When the model incorporated number of glucocorticoid tapers as the measure of change in glucocorticoid dosage, treatment effects of anifrolumab on glucocorticoid tapers were not retained at week 52. However, at week 52 treatment indirectly improved HRQoL through its direct effects on BICLA.

CONCLUSIONS

Anifrolumab is associated with significant patient-reported improvements in aspects of HRQoL including pain, fatigue, mood and physical function. These benefits are from the direct effect of anifrolumab treatment on disease activity and reduction in glucocorticoid dosage.

AB0289 PATIENT REPORTED PHYSICAL HEALTH COMPARED TO CLINICIAN RECORDED BILAG-2004 MUSCULOSKELETAL SYSTEM SCORES – DISCORDANCE BETWEEN PATIENTS AND CLINICIANS

Background:

The musculoskeletal organ system BILAG-2004 (MSK BILAG) assessment is of critical importance in SLE clinical trials. Severe active polyarthritis, MSK BILAG A, by definition includes significant impairment of basic activities of daily living (ADLs), as opposed to MSK BILAG C, D, or E where ability to perform ADLs is expected to be preserved. In clinical trials, BILAG is scored by clinicians without formal review of patient reported outcomes (PROs). The Physical Health domain of the LupusQoL (LQol PH) (range 0 – 100) can be used to assess the patient’s physical function and ADLs. LQoL PH score thresholds defining impairment severity have not been established; however, a transformed LQoL PH score ≤50 suggests more impaired function, which would not be expected in MSK BILAG C, D, or E. Conversely, a score >50 implies no major issues with ADLs, which would be contradictory to the definition of MSK BILAG A.

Objectives:

To assess correlation of patient reported LQoL PH with MSK BILAG scores recorded by clinicians at various timepoints using data from the phase 3 TULIP studies 1,2 and to investigate the percent of discordance between patients and clinicians.

Methods:

Data from TULIP 1 and 2 studies (anifrolumab 300 mg and placebo arms) were pooled to evaluate the relationship between LQoL PH and MSK BILAG scores at baseline, weeks 24 and 52 using Spearman correlations as post-hoc analysis. Mean LQoL PH scores were assessed for each MSK BILAG category at the three timepoints using one-way ANOVA. Percent of patients with MSK BILAG A and LQoL PH scores >50 and patients with MSK BILAG C, D, or E and LQoL PH scores ≤50 was calculated at baseline, week 24 and 52. MSK BILAG B was excluded from the analysis because discordance could not be easily defined for this category compared with the more extreme MSK BILAG categories.

Results:

Total of 690 patients were included in the pooled analysis (Table 1). Significant correlations between LQoL PH and MSK BILAG scores were found at each time point (nominal p<0.0001); this relationship became stronger over time. Mean LQoL PH scores were different in each MSK BILAG category, with the highest in MSK BILAG D/E and the lowest in the MSK BILAG A category, thus confirming the discriminatory ability of the LQoL PH (Table 1).

Table 1.

Correlation coefficients (CC) between LQoL PH and MSK BILAG scores, and mean LQoL PH scores with standard deviations (SD) per each MSK BILAG category at baseline, weeks 24 and 52.

BaselineWeek 24Week 52CCNCCNCCNTotal Population-0.25690-0.36626-0.41552MSK BILAGMean LQoL PH Score (SD)Mean LQoL PH Score (SD)Mean LQoL PH Score (SD)0 (D/E)69.3 (24.7)1774.2 (22.1)18674.5 (21.3)2371 (C)62.3 (25.4)6064.0 (23.9)23360.6 (22.5)1848 (B)56.6 (24.4)39855.1 (24.2)16351.3 (24.3)10512 (A)44.9 (25.8)21543.9 (25.9)4444.2 (26.2)26

At baseline, 40% of patients who were assessed by clinicians as having MSK BILAG A reported minimal impairment in physical function and ADLs (LQoL PH >50) and 24.1% who had MSK BILAG C, D, or E reported difficulties with ADLs (LQoL HP ≤50), suggesting discordance between patients and clinicians. This discordance slightly decreased over time (Figure 1).

Figure 1.

Percent of patients with MSK BILAG A and LQoL PH scores >50 and patients with MSK BILAG C, D, or E and LQoL PH scores ≤50 at baseline, weeks 24 and 52.

Conclusion:

Patient reported LQoL PH scores correlated with MSK BILAG scores and showed discriminant validity for MSK BILAG scores. Greater discordance was seen between LQoL PH and MSK BILAG A compared with C, D, or E. These findings suggest a need for further investigation of a role for PROs in MSK BILAG scoring. Formal review of PROs by clinicians during MSK BILAG assessment could be considered in future SLE clinical trials.

References:

[1]Furie R et al. Lancet 2019

[2]Morand EF et al. N Engl J Med 2020

Acknowledgements:

This study was sponsored by AstraZeneca.

Disclosure of Interests:

Ewa Olech Speakers bureau: Abbvie, Amgen, Merck, Pfizer, and UCB, Grant/research support from: BMS, Donald Stull: None declared, Betsy Williams: None declared, Stephanie Bean: None declared, Gabriel Abreu Employee of: AstraZeneca, Erik Schwetje Employee of: AstraZeneca, Raj Tummala Employee of: AstraZeneca, Sean O’Quinn Shareholder of: AstraZeneca, Employee of: AstraZeneca

Relative efficacy of interventions in the treatment of second-line non-small cell lung cancer: a systematic review and network meta-analysis

BACKGROUND

Locally advanced or metastatic non-small cell lung cancer (NSCLC) that has progressed after first-line treatment has a poor prognosis. Recent randomized clinical trials (RCTs) have demonstrated survival benefits of alternative treatments to docetaxel. However, information is lacking on which patients benefit the most and what drug or regimen is optimal. We report a systematic review and network meta-analysis (NMA) of second-line treatments in all subgroup combinations determined by histology, programmed death ligand 1 (PD-L1) expression, and epidermal growth factor receptor (EGFR) mutation.

METHODS

MEDLINE, PubMed, EMBASE, Biosciences Information Service (using the Dialog Platform), Cochrane Library, and abstracts from scientific meetings were searched for RCTs published up to September 2015. Key outcomes were overall survival (OS) and progression-free survival (PFS). Bayesian hierarchical exchangeable NMAs were conducted to calculate mean survival times and relative differences for eight subgroups, using docetaxel as the reference comparator. For OS, the NMA was based on hazard ratios applied to a first-order fractional polynomial model fitted to the reference treatment. For PFS, a second-order fractional polynomial model was fitted to reconstructed patient-level data for the entire network of evidence.

RESULTS

The search identified 30 studies containing 17 different treatment regimens. Docetaxel plus ramucirumab was associated with a significant improvement in OS and PFS, relative to docetaxel, regardless of patient type. Docetaxel plus nintedanib showed similar efficacy to docetaxel plus ramucirumab in the nonsquamous populations. EGFR tyrosine kinase inhibitors (TKIs) erlotinib and gefitinib showed superior levels of efficacy in EGFR mutation-positive populations and the one PD-1 immunotherapy (nivolumab) studied showed superior efficacy in the populations exhibiting high PD-L1 expression.

CONCLUSIONS

In the absence of head-to-head comparisons, we performed a mixed-treatment analysis to synthesize evidence of the efficacy of each treatment. Benefits are optimized by targeting specific treatments to individual patients guided by histology, PD-L1 expression, and EGFR mutation status.

SYSTEMATIC REVIEW REGISTRATION

This review is registered in PROSPERO (registration number: CRD42014013780 available at www.crd.york.ac.uk/PROSPERO ).

Improvement of sleep in patients with chronic idiopathic/spontaneous urticaria treated with omalizumab: results of three randomized, double-blind, placebo-controlled studies

Background

Patients with chronic idiopathic/spontaneous urticaria (CIU/CSU) report difficulty with sleep.

Methods

We examined the effect of omalizumab on sleep-related outcomes during 3–6 months omalizumab or placebo treatment and a 16-week follow-up period within three Phase III double-blind randomized placebo-controlled pivotal trials in CIU/CSU: ASTERIA I, ASTERIA II, and GLACIAL. Sleep quality was assessed in all three studies using sleep-related questions included in an electronic diary, the Chronic Urticaria Quality of Life Questionnaire, and the Medical Outcomes Study Sleep Scale. Score changes from baseline in the treatment arms were compared with that in the placebo arm and adjusted for baseline score and weight. We also examined correlations of sleep scores at baseline, week 12, and week 24 and the slopes of change between sleep and itch and hive.

Results

Patients treated with omalizumab reported a larger reduction in sleep problems than those in the placebo arm; omalizumab 300 mg demonstrated the greatest improvement on all sleep components among all treatment arms. The largest reduction in sleep problems was reported within the first 4 weeks of therapy. After treatment discontinuation, sleep quality worsened. Sleep scores demonstrated moderate-to-strong correlation between them, and the change in sleep scores was associated with changes in itch and hives.

Conclusions

Improvement in sleep was reported after the first dose of omalizumab. Sleep continued to improve throughout the active treatment period. Patients receiving omalizumab 300 mg achieved greater improvement in sleep than those in other treatment arms.

Trial registration ClinicalTrials.gov, NCT01287117 (ASTERIA I), NCT01292473 (ASTERIA II), and NCT01264939 (GLACIAL)

Electronic supplementary material

The online version of this article (doi:10.1186/s13601-016-0120-0) contains supplementary material, which is available to authorized users.

Cost Utility of Omalizumab Compared with Standard of Care for the Treatment of Chronic Spontaneous Urticaria

BACKGROUND

Chronic spontaneous urticaria (CSU) negatively impacts patient quality of life and productivity and is associated with considerable indirect costs to society.

OBJECTIVE

The aim of this study was to assess the cost utility of add-on omalizumab treatment compared with standard of care (SOC) in moderate or severe CSU patients with inadequate response to SOC, from the UK societal perspective.

METHODS

A Markov model was developed, consisting of health states based on Urticaria Activity Score over 7 days (UAS7) and additional states for relapse, spontaneous remission and death. Model cycle length was 4 weeks, and total model time horizon was 20 years in the base case. The model considered early discontinuation of non-responders (response: UAS7 ≤6) and retreatment upon relapse (relapse: UAS7 ≥16) for responders. Clinical and cost inputs were derived from omalizumab trials and published sources, and cost utility was expressed as incremental cost-effectiveness ratios (ICERs). Scenario analyses included no early discontinuation of non-responders and an altered definition of response (UAS7 <16).

RESULTS

With a deterministic ICER of £3183 in the base case, omalizumab was associated with increased costs and benefits relative to SOC. Probabilistic sensitivity analysis supported this result. Productivity inputs were key model drivers, and individual scenarios without early discontinuation of non-responders and adjusted response definitions had little impact on results. ICERs were generally robust to changes in key model parameters and inputs.

CONCLUSIONS

In this, the first economic evaluation of omalizumab in CSU from a UK societal perspective, omalizumab consistently represented a treatment option with societal benefit for CSU in the UK across a range of scenarios.

Reliability and validity of the Personal and Social Performance scale in patients with schizophrenia

OBJECTIVE

The construct validity and test-retest reliability of the Personal and Social Performance (PSP) scale were used to assess social functioning in a cohort of ethnically diverse UK patients with schizophrenia.

METHODS

A total of 73 patients with schizophrenia took part in the study. At baseline, the PSP, two symptomatology scales and two other functioning scales were administered. A subset of the sample (N=40) took part in a retest where the Clinical Global Impression-Severity (CGI-S) and PSP scales were administered 8-10 days later.

RESULTS

PSP significantly correlated with all other measures, Positive and Negative Syndrome Scale (PANSS), Global Assessment of Functioning (GAF) and Quality of Life Scale (QLS) at baseline (p<0.02) and with CGI-S at follow-up (p<0.01). In addition, the PSP scale was moderately sensitive to the severity of illness. Test-retest reliability for the PSP score was 0.45 and the scale was able to discriminate between known groups (mild and severe patients).

CONCLUSION

The PSP was easy to administer in this predominantly inpatient cohort and was moderately correlated with all other functioning measures tested. Due to patient homogeneity, the test-retest reliability statistic of the PSP was lower than that observed in other studies.

Assessing the effect of darbepoetin alfa on patient-reported fatigue in chemotherapy-induced anemia in four randomized, placebo-controlled clinical trials

PURPOSE

This analysis examined the effects of darbepoetin alfa on hemoglobin and fatigue outcomes in patients with cancer using latent growth curve modeling (LGM).

METHODS

Data from 4 clinical trials of darbepoetin alfa in lung cancer (2 studies; n = 547; n = 288), lymphoproliferative malignancies (n = 339), and non-myeloid malignancies (n = 320) were analyzed separately. Fatigue was assessed using the FACT-Fatigue (FACT-F) scale. Effects of darbepoetin alfa on changes in hemoglobin and FACT-F scores were evaluated using LGM, controlling for age, gender, Eastern Cooperative Oncology Group performance status, health status, and total transfusions.

RESULTS

Patients receiving darbepoetin alfa had higher rates of change in hemoglobin (standardized regression coefficient [[Formula: see text]] = 0.30 to 0.53, all P < 0.05) than placebo. Patients with greater rates of change in hemoglobin reported improvements in fatigue outcomes ([Formula: see text] = 0.28 to 0.59, all P < 0.05). The total standardized effect of darbepoetin alfa on fatigue outcomes corresponded to a mean change of 0.9 to 3.5 points in FACT-F scores, with one trial demonstrating changes exceeding the minimal important difference of 3 points.

CONCLUSIONS

Darbepoetin alfa improved hemoglobin which was associated with improved fatigue across the 4 trials. Clinically, meaningful improvement in fatigue was seen in 2 trials. More complex statistical analysis models of treatment may assist in understanding the effects of erythropoiesis-stimulating agents on patient-reported outcomes.

Social support and caregiver distress: a replication analysis

OBJECTIVES

Prior studies have conceptualized and operationalized social support in different ways, making it difficult to determine if the inconsistencies in findings are due to differences in study design, samples, conceptualization, or measurement. The present study examined the replicability of models of social support and caregiver distress across 4 community-based caregiving studies representative of many conducted in the past 10 years. The goal was to identify areas of consistency in findings across the data sets.

METHODS

The authors analyzed 3 models specifying patterns of relationship between social support and depression (main effect, mediation effect, and moderation effect) separately within data sets using hierarchical ordinary least squares regression. Results were compared across data sets.

RESULTS

The replication analysis confirmed the robustness of behavior problems and caregiver health as important contributors to caregiver distress. Results of hypotheses examining the pattern of relationship between social support and distress were inconsistent, however. Only 1 type of social support was associated with distress in the expected direction: Less emotional support was associated with higher levels of distress in 2 of the 4 data sets.

DISCUSSION

More complex theoretical models that incorporate common measures to represent the linkages between types of stressor, types of support, and their interactions are needed to foster replicability and generalizability of research results.

Constitutive production of interleukin 2 activity by a T cell hybridoma

Several laboratories have recently confirmed the importance that interleukin 2 (IL-2, formerly referred to as T cell growth factor) plays not only in the maintenance of cultured functional T cell lines but also as a potent regulator of immune responses. Despite the development of preparative IL-2 purification procedures, as well as identification of IL-2 producer tumor cell lines, simple sources of lectin-free IL-2 containing conditioned medium remain undefined. In hopes of establishing such a source of mitogen-free IL-2, we elected to fuse the high titer IL-2 producer tumor cell line, LBRM-33, with a drugmarked T cell lymphoma. In this communication we report the successful isolation of a T cell hybridoma that constitutively synthesizes and secretes biologically active IL-2. Hybridoma conditioned medium contained approximately 10 to 100 times the amount of IL-2 produced by conventional T cell mitogen-stimulated murine splenocyte preparations. In addition to providing a simple means for producing IL-2 containing conditioned medium without the presence of contaminating lectin, we hope that constitutive IL-2 producer hybrid cell lines will prove interesting as vehicles for dissection of the molecular events involved in IL-2 biosynthesis.

Constitutive production of interleukin 2 activity by a T cell hybridoma

Several laboratories have recently confirmed the importance that interleukin 2 (IL-2, formerly referred to as T cell growth factor) plays not only in the maintenance of cultured functional T cell lines but also as a potent regulator of immune responses. Despite the development of preparative IL-2 purification procedures, as well as identification of IL-2 producer tumor cell lines, simple sources of lectin-free IL-2 containing conditioned medium remain undefined. In hopes of establishing such a source of mitogen-free IL-2, we elected to fuse the high titer IL-2 producer tumor cell line, LBRM-33, with a drugmarked T cell lymphoma. In this communication we report the successful isolation of a T cell hybridoma that constitutively synthesizes and secretes biologically active IL-2. Hybridoma conditioned medium contained approximately 10 to 100 times the amount of IL-2 produced by conventional T cell mitogen-stimulated murine splenocyte preparations. In addition to providing a simple means for producing IL-2 containing conditioned medium without the presence of contaminating lectin, we hope that constitutive IL-2 producer hybrid cell lines will prove interesting as vehicles for dissection of the molecular events involved in IL-2 biosynthesis.