Enhancing clinical and immunological effects of anti-PD-1 with belapectin, a galectin-3 inhibitor

BACKGROUND

PD-1/PD-L1 engagement and overexpression of galectin-3 (Gal-3) are critical mechanisms of tumor-induced immune suppression that contribute to immunotherapy resistance. We hypothesized that Gal-3 blockade with belapectin (GR-MD-02) plus anti-PD-1 (pembrolizumab) would enhance tumor response in patients with metastatic melanoma (MM) and head and neck squamous cell carcinoma (HNSCC).

METHODS

We performed a phase I dose escalation study of belapectin+pembrolizumab in patients with advanced MM or HNSCC (NCT02575404). Belapectin was administered at 2, 4, or 8 mg/kg IV 60 min before pembrolizumab (200 mg IV every 3 weeks for five cycles). Responding patients continued pembrolizumab monotherapy for up to 17 cycles. Main eligibility requirements were a functional Eastern Cooperative Oncology Group status of 0-2, measurable or assessable disease, and no active autoimmune disease. Prior T-cell checkpoint antibody therapy was permitted.

RESULTS

Objective response was observed in 50% of MM (7/14) and and 33% of HNSCC (2/6) patients. Belapectin+pembrolizumab was associated with fewer immune-mediated adverse events than anticipated with pembrolizumab monotherapy. There were no dose-limiting toxicities for belapectin within the dose range investigated. Significantly increased effector memory T-cell activation and reduced monocytic myeloid-derived suppressor cells (M-MDSCs) were observed in responders compared with non-responders. Increased baseline expression of Gal-3+ tumor cells and PD-1+CD8+ T cells in the periphery correlated with response as did higher serum trough levels of pembrolizumab.

CONCLUSIONS

Belapectin+pembrolizumab therapy has activity in MM and HNSCC. Increased Gal-3 expression, expansion of effector memory T cells, and decreased M-MDSCs correlated with clinical response. Further investigation is planned.

The impact of coronary heart disease on productivity in Australia over ten years

Background

Coronary heart disease (CHD) is the highest individual disease burden in Australia and associated with productivity losses through unplanned absence from work, reduced output while at work and early labour force withdrawal. Approximately eighty per cent of CHD cases in Australia are preventable, suggesting the potential benefit of employing preventive strategies addressing populations at risk of CHD.

Purpose

To determine the preventable productivity burden attributable to CHD over the next ten years, using the novel productivity measure: the “productivity-adjusted life year” (PALY).

Methods

A dynamic life table model was constructed for the total Australian population, separated by CHD status. Analysis was limited to the Australian working-age population (15–69 years) over ten years (2020–2029). Australian age- and sex-specific prevalence, incidence, migration and mortality data was employed, and productivity estimates were sourced from the literature. The PALY was ascribed a financial value in terms of gross domestic product (GDP) per equivalent full-time worker. The total number of years lived, total PALYs, and total economic burden (in terms of cost of PALYs) were estimated for each year. The model simulation was repeated assuming incidence was reduced, and the differences represented the preventable productivity burden attributable to CHD. All outcomes beyond the first year were discounted by 5% per annum.

Results

Over the next ten years, the total projected years lived and PALYs among the Australian working-age population (with and without CHD) were approximately 132 million and 83 million, respectively, amounting to A$17.2 trillion (€10.5 trillion) in GDP. We predicted nearly 40,000 new (incident) CHD cases over this ten-year period. If, however, we could prevent these new cases of CHD, a total of 14,000 deaths could be averted, resulting in more than 8,000 years of life saved and 100,000 PALYs gained, equivalent to A$21 billion (€12.9 billion) in GDP.

Conclusion

Prevention of CHD will prolong both years of life lived and productive life years, resulting in substantial economic benefit. Policy makers and employers are encouraged to engage in preventive measures addressing CHD.

Funding Acknowledgement

Type of funding source: None

Cost-effectiveness of dapagliflozin in chronic heart failure: an analysis from the Australian healthcare perspective

Background

The Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) trial demonstrated that dapagliflozin reduced heart failure hospitalisations and mortality in patients with established heart failure, regardless of diabetic status.

Purpose

To assess the cost-effectiveness of dapagliflozin in addition to standard care versus standard care alone in patients with chronic heart failure, from the perspective of the Australian public healthcare system.

Methods

A Markov model populated with 1000 hypothetical individuals was constructed based on the DAPA-HF trial to assess the clinical outcomes and costs of patients with established heart failure and reduced ejection fraction over a lifetime time horizon. The model consisted of three health states: “Alive and event-free”, “Alive after non-fatal hospitalisation for heart failure” or “Dead”. Costs and utilities were estimated from published sources. Outcomes of interest were the incremental cost-effectiveness ratios (ICERs) in terms of cost per quality-adjusted life year (QALY) gained and cost per year of life saved (YoLS). All outcomes were discounted at a rate of 5% annually.

Results

Over a lifetime analysis, addition of dapagliflozin to standard care in patients with chronic heart failure prevented 88 acute heart failure hospitalisations (including readmission), and saved 416 (discounted) years of life and 288 (discounted) QALYs, at an additional cost of A$3,692,440 or €2,263,204 (discounted). This resulted in ICERs of A$8,875 (€5,439) per YoLS and A$12,482 (€7,650) per QALY gained, well below the Australian arbitrary willingness-to-pay threshold of A$50,000 (€30,645).

Conclusion

From the Australian public healthcare perspective, dapagliflozin is cost-effective when used as an adjunct therapy to standard care compared to standard care alone for the treatment of chronic heart failure with reduced ejection fraction.

Funding Acknowledgement

Type of funding source: None

Effects of Belapectin, an Inhibitor of Galectin-3, in Patients With Nonalcoholic Steatohepatitis With Cirrhosis and Portal Hypertension

BACKGROUND & AIMS

Increased levels of galectin 3 have been associated with nonalcoholic steatohepatitis (NASH) and contribute to toxin-induced liver fibrosis in mice. GR-MD-02 (belapectin) is an inhibitor of galectin 3 that reduces liver fibrosis and portal hypertension in rats and was safe and well tolerated in phase 1 studies. We performed a phase 2b, randomized trial of the safety and efficacy of GR-MD-02 in patients with NASH, cirrhosis, and portal hypertension.

METHODS

Patients with NASH, cirrhosis, and portal hypertension (hepatic venous pressure gradient [HVPG] ≥ 6 mm Hg) from 36 centers were randomly assigned, in a double-blind manner, to groups that received biweekly infusions of belapectin 2 mg/kg (n = 54), 8 mg/kg (n = 54), or placebo (n = 54) for 52 weeks. The primary endpoint was change in HVPG (Δ HVPG) at the end of the 52-week period compared with baseline. Secondary endpoints included changes in liver histology and development of liver-related outcomes.

RESULTS

We found no significant difference in ΔHVPG between the 2 mg/kg belapectin group and placebo group (-0.28 mm HG vs 0.10 mm HG, P = 1.0) or between the 8 mg/kg belapectin and placebo group (-0.25 mm HG vs 0.10 mm HG, P = 1.0). Belapectin had no significant effect on fibrosis or nonalcoholic fatty liver disease activity score, and liver-related outcomes did not differ significantly among groups. In an analysis of a subgroup of patients without esophageal varices at baseline (n = 81), 2 mg/kg belapectin was associated with a reduction in HVPG at 52 weeks compared with baseline (P = .02) and reduced development of new varices (P = .03). Belapectin (2 mg/kg) was well tolerated and produced no safety signals.

CONCLUSIONS

In a phase 2b study of 162 patients with NASH, cirrhosis, and portal hypertension, 1 year of biweekly infusion of belapectin was safe but not associated with significant reduction in HVPG or fibrosis compared with placebo. However, in a subgroup analysis of patients without esophageal varices, 2 mg/kg belapectin did reduce HVPG and development of varices. ClinicalTrials.gov number: NCT02462967.

LC-Receptorgram: A Method for Identification and Quantitation of β-Lactams in Milk by Liquid Chromatography with Microbial Receptor Assay

A rapid determinative method was developed for identification and quantitation of common β-lactam drugs (e.g., amoxicillin, ampicillin, cephapirin, penicillin G, ceftiofur, and cloxacillin) in milk. This method combines the advantages of liquid chromatography (LC) with the selectivity and sensitivity of a microbial receptor assay. This LC-receptorgram procedure identifies and quantitates β-lactams at 10 ppb or lower within 3 h. A simple purification scheme, using solid-phase extraction, gave recoveries ranging from 50% for amoxicillin to 80-90% for other β-lactams. Individual drugs were separated by LC using a reversed-phase C8 column and an isocratic buffer system containing methanol (35%) in phosphate buffer (50 mM, pH 6.0). The Charm II quantitative procedure was used to detect (5-lactams in the LC fractions. In a blind study of raw milk fortified with β-lactams, the coefficients of variance for quantitation of 6 β-lactams at the safe levels ranged from 4.1 to 13%. The confidence level for selectivity was greater than 99%, and for detection of positives at safe levels, it was 95% or greater. Analysis of 6 β-lactams in incurred samples showed that all 6 drugs are depleted to below 10 ppb in less than 48 h. Incurred samples with cephapirin and ceftiofur contained active metabolites, in addition to parent drug, that were detected by the LC-receptorgram. In market milk samples that screened positive in routine testing programs, penicillin G, cephapirin, and ceftiofur were identified by the LC-receptorgram as the most common contaminants. In several samples containing cephapirin or ceftiofur, an active metabolite was detected in addition to the parent drug. Only the parent drug was detected for other β-lactams.

Forecasting the future burden of opioids for osteoarthritis

OBJECTIVE

To quantify the current national burden of opioids for osteoarthritis (OA) pain in Australia in terms of number of dispensed opioid prescriptions and associated costs, and to forecast the likely burden to the year 2030/31.

DESIGN

Epidemiological modelling.

METHODS

Published data were obtained on rates of opioid prescribing for people with OA and national OA prevalence projections. Trends in opioid dispensing from 2006 to 2016, and average costs for common opioid subtypes were obtained from the Pharmaceutical Benefits Scheme and Medicare Australia Statistics. Using these inputs, a model was developed to estimate the likely number of dispensed opioid prescriptions and costs to the public healthcare system by 2030/31.

RESULTS

In 2015/16, an estimated 1.1 million opioid prescriptions were dispensed in Australia for 403,954 people with OA (of a total 2.2 million Australians with OA). Based on recent dispensing trends and OA prevalence projections, the number of dispensed opioid prescriptions is expected to nearly triple to 3,032,332 by 2030/31, for an estimated 562,610 people with OA. The estimated cost to the Australian healthcare system was $AUD25.2 million in 2015/16, rising to $AUD72.4 million by 2030/31.

CONCLUSION

OA-related opioid dispensing and associated costs are set to increase substantially in Australia from 2015/16 to 2030/31. Use of opioids for OA pain is concerning given joint disease chronicity and the risk of adverse events, particularly among older people. These projections represent a conservative estimate of the full financial burden given additional costs associated with opioid-related harms and out-of-pocket costs borne by patients.

Interventions that cause weight loss and the impact on cardiovascular risk factors: a systematic review and meta-analysis

Overweight and obesity increase the risks of diabetes and cardiovascular disease (CVD). This has been shown to be reversed with weight loss. A systematic review and meta-analysis were performed to determine the effect of weight loss in the primary prevention of CVD. PubMed, Embase and the Cochrane Library databases were searched electronically through to May 2013. Randomized controlled trials assessing weight loss and cardiovascular risk factors and outcomes were included. A random effects meta-analysis, with sub-group analyses for degree of weight loss, and age were performed. Because few studies reported clinical outcomes of CVD, analyses were limited to cardiovascular risk factors (83 studies). Interventions that caused any weight loss significantly reduced systolic blood pressure (-2.68 mmHg, 95% CI -3.37, -2.11), diastolic blood pressure (-1.34 mmHg, 95% CI -1.71, -0.97), low-density lipoprotein cholesterol (-0.20 mmol L(-1) , 95% CI -0.29, -0.10), triglycerides (-0.13 mmol L(-1) , 95% CI -0.22, -0.03), fasting plasma glucose (-0.32 mmol L(-1) , 95% CI -0.43, -0.22) and haemoglobin A1c(-0.40%, 95% CI -0.52, -0.28) over 6-12 months. Significant changes remained after 2 years for several risk factors. Similar results were seen in sub-group analyses. Interventions that cause weight loss are effective at improving cardiovascular risk factors at least for 2 years. © 2016 World Obesity.

Effectiveness and cost-effectiveness of a cardiovascular risk prediction algorithm for people with severe mental illness

Introduction

Cardiovascular risk prediction tools are important for cardiovascular disease (CVD) prevention, however, which algorithms are appropriate for people with severe mental illness (SMI) is unclear.

Objectives/aims

To determine the cost-effectiveness using the net monetary benefit (NMB) approach of two bespoke SMI-specific risk algorithms compared to standard risk algorithms for primary CVD prevention in those with SMI, from an NHS perspective.

Methods

A microsimulation model was populated with 1000 individuals with SMI from The Health Improvement Network Database, aged 30–74 years without CVD. Four cardiovascular risk algorithms were assessed; (1) general population lipid, (2) general population BMI, (3) SMI-specific lipid and (4) SMI-specific BMI, compared against no algorithm. At baseline, each cardiovascular risk algorithm was applied and those high-risk (> 10%) were assumed to be prescribed statin therapy, others received usual care. Individuals entered the model in a ‘healthy’ free of CVD health state and with each year could retain their current health state, have cardiovascular events (non-fatal/fatal) or die from other causes according to transition probabilities.

Results

The SMI-specific BMI and general population lipid algorithms had the highest NMB of the four algorithms resulting in 12 additional QALYs and a cost saving of approximately £37,000 (US$ 58,000) per 1000 patients with SMI over 10 years.

Conclusions

The general population lipid and SMI-specific BMI algorithms performed equally well. The ease and acceptability of use of a SMI-specific BMI algorithm (blood tests not required) makes it an attractive algorithm to implement in clinical settings.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Therapy of experimental NASH and fibrosis with galectin inhibitors

Non-alcoholic steatohepatitis (NASH) and resultant liver fibrosis is a major health problem without effective therapy. Some data suggest that galectin-3 null mice are resistant to the development of NASH with fibrosis. We examined the ability of two complex carbohydrate drugs that bind galectin-3, GM-CT-01 and GR-MD-02, to treat NASH with fibrosis in a murine model. GR-MD-02 treatment resulted in marked improvement in liver histology with significant reduction in NASH activity and collagen deposition. Treatments seemed also to improve both glomerulopathy and interstitial fibrosis observed in kidneys. The improvement in liver histology was evident when animals were treated early in disease or after establishment of liver fibrosis. In all measures, GM-CT-01 had an intermediate effect between vehicle and GR-MD-02. Galectin-3 protein expression was increased in NASH with highest expression in macrophages surrounding lipid laden hepatocytes, and reduced following treatment with GR-MD-02, while the number of macrophages was unchanged. Treatment with GR-MD-02 also reduced the expression of pathological indicators including iNOS, an important TH1 inflammatory mediator, CD36, a scavenger receptor for lipoproteins on macrophages, and α-smooth muscle actin, a marker for activated stellate cells which are the primary collagen producing cells in liver fibrosis. We conclude that treatment with these galectin-3 targeting drugs improved histopathological findings of NASH and markedly reduced fibrosis in a murine model of NASH. While the mechanisms require further investigation, the treatment effect is associated with a reduction of galectin-3 expressed by activated macrophages which was associated with regression of NASH, including hepatocellular fat accumulation, hepatocyte ballooning, intra-portal and intra-lobular inflammatory infiltrate, and deposition of collagen. Similar effects were found with GM-CT-01, but with approximately four-fold lower potency than GR-MD-02. The results, in combination with previous experiments in toxin-induced fibrosis, suggest that these galectin-targeting drugs may have potential in human NASH with fibrosis.

Regression of fibrosis and reversal of cirrhosis in rats by galectin inhibitors in thioacetamide-induced liver disease

Galectin-3 protein is critical to the development of liver fibrosis because galectin-3 null mice have attenuated fibrosis after liver injury. Therefore, we examined the ability of novel complex carbohydrate galectin inhibitors to treat toxin-induced fibrosis and cirrhosis. Fibrosis was induced in rats by intraperitoneal injections with thioacetamide (TAA) and groups were treated with vehicle, GR-MD-02 (galactoarabino-rhamnogalaturonan) or GM-CT-01 (galactomannan). In initial experiments, 4 weeks of treatment with GR-MD-02 following completion of 8 weeks of TAA significantly reduced collagen content by almost 50% based on Sirius red staining. Rats were then exposed to more intense and longer TAA treatment, which included either GR-MD-02 or GM-CT-01 during weeks 8 through 11. TAA rats treated with vehicle developed extensive fibrosis and pathological stage 6 Ishak fibrosis, or cirrhosis. Treatment with either GR-MD-02 (90 mg/kg ip) or GM-CT-01 (180 mg/kg ip) given once weekly during weeks 8–11 led to marked reduction in fibrosis with reduction in portal and septal galectin-3 positive macrophages and reduction in portal pressure. Vehicle-treated animals had cirrhosis whereas in the treated animals the fibrosis stage was significantly reduced, with evidence of resolved or resolving cirrhosis and reduced portal inflammation and ballooning. In this model of toxin-induced liver fibrosis, treatment with two galectin protein inhibitors with different chemical compositions significantly reduced fibrosis, reversed cirrhosis, reduced galectin-3 expressing portal and septal macrophages, and reduced portal pressure. These findings suggest a potential role of these drugs in human liver fibrosis and cirrhosis.

[New conjugates of antitumor antibiotic doxorubicin with water-soluble galactomannan: synthesis and biological activity]

New water-soluble conjugates in the form of Schiff bases (DGM-1 and DGM-2) were prepared by the interaction of water-soluble periodate-oxidized galactomannan with doxorubicin or N-(L-lysyl)doxorubicin, respectively. The water-soluble galactomannan (DAVANAT a commercial product of Pro-Pharmaceuticals company) was obtained by partial acidic hydrolysis of high-molecular-mass galactomannan from Cyamopsis tetragonoloba (guar gum) seeds. The conjugate stability was studied in aqueous solutions. The DGM-1 antiproliferative activity was comparable with that of doxorubicin on three models: cell lines of murine melanoma B 16-F1, human breast cancer MCF-7 (HTB-22), and human colon cancer HT-29 (HTB-38). DGM-2 was poorly active in all the three tests. DGM- 1 can thus be regarded as a high-molecular-mass depot form of doxorubicin.

A biodistribution of 5-fluorouracil co-administered with and without galactomannan derivative, in athymic mice implanted with COLO 205 human xenografts

12027

Background: The polysaccharide [(1–4)-linked β-D-mannopyranose]17- [(1–6)-linked-α-D-galactopyranose]10 (Davanat [D]), enhances activity of 5-Fluorouracil (5-FU) in 5-FU refractory murine colon tumor models. D binds to surface lectins and promotes transport of 5-FU into the tumor cells. Lectins are present in large amounts on the surface of metastatic tumor cells, and may mediate cell association, apoptosis and metastasis. Method: A preclinical biodistribution study was initiated to evaluate the intravenous (i.v.) administration of 5-FU (36 mg/kg/dose) in the absence and presence of D (60 mg/kg/dose) in female athymic mice with tumors. Forty mice either received 5-FU alone or with D on days 24–27 (Q1d × 4) after tumor implantation. On day 27, a (2-14C) labeled 5-FU was added to the regimen. After the injection, ten mice per time point (0.5, 1.5, 4 and 24 h) were bled, euthanized and then the plasma, tumor and tissues were assayed for radioactivity by a liquid scintillation analyzer. Objectives were to determine the biodistribution of 14C-5-FU in the absence and presence of D in plasma, tumor and tissues. Results: 14C-5-FU disappeared in a bi-phasic manner after i.v. injection both in the presence and absence of D. Addition of D increased the amount of 5-FU exposure as measured by area under the curve (AUC) from 1.5 to 24 hours post-dose. This finding confirms results from a Phase I study where administering escalating doses 30 to 280 mg/m2 D with fixed 500 mg/m2 5-FU also demonstrated an increase in 5-FU systemic exposure as the D dose increased to 280 mg/m2 Conclusions: In mice, 14C-5-FU dosed with D increased the overall exposure of 14C-5-FU during the 1.5 to 24 hr sampling time duration in plasma, tumor and kidneys, when compared to 14C-5-FU dosed alone. These results, and the results obtained from a Phase I study where D was co-administered with 5-, warrants further testing in a Phase II/III clinical trial.

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Use of a new rapid bioluminescence method for screening organophosphate and N-Methylcarbamate insecticides in processed baby foods

An enzyme with high specific affinity for organophosphate and N-methylcarbamate insecticides has been incorporated into a new test for detection of these insecticides at the level of parts per billion (ppb) (commercially available as the Charm Pesticide Test). To measure the extent of insecticide inhibition of the enzyme, a specific bioluminescent substrate is used. The signal is counterproportional to the amount of insecticides. Random sampling of four baby food brands and testing for the cumulative levels of organophosphate and N-methylcarbamate insecticides found carbaryl to be the most common residue. Out of the 155 samples tested there were 132 negative samples (85.2%) and 23 suspected positive samples (14.2%). The suspected positive samples were further analyzed by high-performance liquid chromatography (HPLC) and gas chromatography/mass spectrometry (GC/MS). Carbaryl was confirmed in 18 of the samples. One of the samples contained an active metabolite of tetrachlorvinphos and in 3 of the positive samples an insecticide could not be identified by GC/MS. One positive sample was not processed for confirmation due to high fat content.

[Critical illness polyneuropathy]

Critical illness polyneuropathy is a syndrome of neuromuscular complications after artificial respiration. The authors present the data of their own 22 patients all suffering from severe flaccid tetraparesis, areflexia and muscle atrophy, after an average of two weeks on artificial respiration. The prognosis is relatively favourable. The multi-conditional causes are discussed with emphasis on the combination of polyneuropathy and myopathy. The role of plasma factors such as cachectin, which is identical to tumour necrosis factor (TNF), is described. Attention is drawn to this important illness which occurs especially in patients in the intensive care unit with problems in the weaning from artificial respiration.

Confirmation of Widespread Sulfonamide Contamination in Northeast U.S. Market Milk

Seventy percent of "off the shelf" and tanker milk tested in the northeast U.S. was contaminated with sulfonamide at above 5 ppb with 35% having more than 25 ppb (equivalent sulfamethazine). In this study milk was screened with an A.O.A.C. receptor assay and with a newly developed growth inhibition assay for sulfonamides with sensitivity of 10 - 20 ppb. Sulfamethazine was found as the major sulfonamide contaminant but not the only one as determined by high pressure liquid chromatography and mass spectrometry. An incurred residue study with long acting sulfamethazine boluses showed residue persisting in milk above 25 ppb after 7 d. Sulfonamides are readily available as "over the counter" drugs in agricultural stores and are frequently used for treatment by veterinarians. The regulatory disc assay which is insensitive to sulfonamides failed to protect the milk supply in the Northeast against sulfonamide contamination.