Pooled safety analysis of baricitinib in adult patients with atopic dermatitis from 8 randomized clinical trials

BACKGROUND

Janus kinase (JAK) inhibition is a new mode of action in atopic dermatitis (AD); clarity about drug class safety considerations in the context of AD is important. Baricitinib, an oral, reversible, selective inhibitor of JAK1/JAK2, is in late-stage development for adult patients with moderate-to-severe AD.

OBJECTIVE

To report pooled safety data for baricitinib in patients with moderate-to-severe AD in the clinical development program including long-term extension (LTE) studies.

METHODS

This analysis included patient-level safety data from six double-blinded, randomized, placebo-controlled studies (one phase 2 and five phase 3), one double-blinded, randomized, LTE study and one open-label LTE study, reported in three data sets: placebo-controlled, 2-mg - 4-mg extended and All-bari AD. Safety outcomes include treatment-emergent adverse events, adverse events of special interest and abnormal laboratory changes. Proportions of patients with events and incidence rates were calculated.

RESULTS

Data were collected for 2531 patients who were given baricitinib for 2247 patient-years (median duration 310 days). The frequency of serious infections, opportunistic infections and conjunctival disorders was low and similar between treatment groups in the placebo-controlled period. The most common serious infections were eczema herpeticum [n = 11, incidence rates (IR) = 0.5], cellulitis (n = 6, IR = 0.3) and pneumonia (n = 3, IR = 0.1). There were four opportunistic infections (IR = 0.2). No malignancies, gastrointestinal perforations, positively adjudicated cardiovascular events or tuberculosis were reported in the placebo-controlled period in baricitinib-treated patients. Frequency of herpes simplex was higher in the 4-mg group (6.1%) vs. the 2-mg (3.6%) and placebo group (2.7%); IRs in the extended data set (2-mg IR = 9.6; 4-mg IR = 14.5) were lower vs. the placebo-controlled data set (2-mg IR = 12.4; 4-mg IR = 21.3). In the All-bari AD data set, there were two positively adjudicated major adverse cardiovascular events (2-mg group): two venous thrombosis events (4-mg group) and one death.

CONCLUSION

This integrated safety analysis in patients with moderate-to-severe AD confirms the established safety profile of baricitinib.

The ReFRAME library as a comprehensive drug repurposing library and its application to the treatment of cryptosporidiosis

The chemical diversity and known safety profiles of drugs previously tested in humans make them a valuable set of compounds to explore potential therapeutic utility in indications outside those originally targeted, especially neglected tropical diseases. This practice of "drug repurposing" has become commonplace in academic and other nonprofit drug-discovery efforts, with the appeal that significantly less time and resources are required to advance a candidate into the clinic. Here, we report a comprehensive open-access, drug repositioning screening set of 12,000 compounds (termed ReFRAME; Repurposing, Focused Rescue, and Accelerated Medchem) that was assembled by combining three widely used commercial drug competitive intelligence databases (Clarivate Integrity, GVK Excelra GoStar, and Citeline Pharmaprojects), together with extensive patent mining of small molecules that have been dosed in humans. To date, 12,000 compounds (∼80% of compounds identified from data mining) have been purchased or synthesized and subsequently plated for screening. To exemplify its utility, this collection was screened against Cryptosporidium spp., a major cause of childhood diarrhea in the developing world, and two active compounds previously tested in humans for other therapeutic indications were identified. Both compounds, VB-201 and a structurally related analog of ASP-7962, were subsequently shown to be efficacious in animal models of Cryptosporidium infection at clinically relevant doses, based on available human doses. In addition, an open-access data portal (https://reframedb.org) has been developed to share ReFRAME screen hits to encourage additional follow-up and maximize the impact of the ReFRAME screening collection.

The nicotinic α6 subunit gene determines variability in chronic pain sensitivity via cross-inhibition of P2X2/3 receptors

Chronic pain is a highly prevalent and poorly managed human health problem. We used microarray-based expression genomics in 25 inbred mouse strains to identify dorsal root ganglion (DRG)-expressed genetic contributors to mechanical allodynia, a prominent symptom of chronic pain. We identified expression levels of Chrna6, which encodes the α6 subunit of the nicotinic acetylcholine receptor (nAChR), as highly associated with allodynia. We confirmed the importance of α6* (α6-containing) nAChRs by analyzing both gain- and loss-of-function mutants. We find that mechanical allodynia associated with neuropathic and inflammatory injuries is significantly altered in α6* mutants, and that α6* but not α4* nicotinic receptors are absolutely required for peripheral and/or spinal nicotine analgesia. Furthermore, we show that Chrna6's role in analgesia is at least partially due to direct interaction and cross-inhibition of α6* nAChRs with P2X2/3 receptors in DRG nociceptors. Finally, we establish the relevance of our results to humans by the observation of genetic association in patients suffering from chronic postsurgical and temporomandibular pain.

Internet-based recruitment system for HIV and STI screening for men who have sex with men in Estonia, 2013: analysis of preliminary outcomes

The aim of the current project was to develop an Internet-based recruitment system for HIV and sexually transmitted infection (STI) screening for men who have sex with men (MSM) in Estonia in order to collect biological samples during behavioural studies. In 2013, an Internet-based HIV risk-behaviour survey was conducted among MSM living in Estonia. After completing the questionnaire, all participants were offered anonymous and free-of-charge STI testing. They could either order a urine sample kit by post to screen for chlamydia infections (including lymphogranuloma venereum (LGV)), trichomoniasis, gonorrhoea and Mycoplasma genitalium infections, or visit a laboratory for HIV, hepatitis A virus, hepatitis B virus,hepatitis C virus and syphilis screening. Of 301 participants who completed the questionnaire, 265 (88%),reported that they were MSM. Of these 265 MSM,68 (26%) underwent various types of testing. In the multiple regression analysis, Russian as the first language,previous HIV testing and living in a city or town increased the odds of testing during the study. Linking Internet-based behavioural data collection with biological sample collection is a promising approach. As there are no specific STI services for MSM in Estonia,this system could also be used as an additional option for anonymous and free-of-charge STI screening.

Abstract P2-09-03: Antitumor activity of the glutaminase inhibitor, CB-839, in triple-negative breast cancer

Glutamine (Gln) serves as an important source of energy and building blocks for many tumor cells. The first step in Gln utilization is its conversion to glutamate (Glu) by the mitochondrial enzyme glutaminase. CB-839 is a potent, selective, and orally bioavailable inhibitor of both splice variants of glutaminase (KGA and GAC). CB-839 inhibits recombinant GAC with an IC50 of <15 nM. Treatment of the triple-negative breast cancer (TNBC) cell line MDA-MB-231 in vitro with CB-839 reduced cell viability and suppressed cellular Glu pools with comparable potency (IC50 ∼15 nM). TNBC breast cancer cell lines have been reported to have a heightened dependence on exogenous Gln for growth relative to estrogen receptor (ER) positive cells (Kung et al, 2011). Consistent with this observation, an analysis of 58 breast cancer cell lines in the Cancer Cell Line Encyclopedia revealed that low ER and/or Her2 expression is correlated with high glutaminase expression (particularly the GAC isoform) and low expression of glutamine synthetase (GLUL), an enzyme that converts Glu to Gln. This reciprocal pattern of GAC and GLUL expression suggests that TNBC may be particularly sensitive to glutaminase inhibition. To test this hypothesis, the anti-tumor activity of CB-839 was evaluated on a panel of breast tumor cell lines (n>25) that included a mixture of TNBC and ER/Her2-positive subtypes. The TNBC subtype displayed the greatest sensitivity to CB-839 treatment (IC50s ranging from 5-100 nM) and this sensitivity was correlated with: i) dependence on extracellular Gln for growth (r = 0.83, p<0.0001); ii) GAC (but not KGA) expression (r = -0.76, p<0.0001); iii) glutaminase activity in cell lysates (r = -0.75, p = 0.0002); and iv) the ratio of cellular Glu to Gln (r = 0.53, p = 0.014) indicative of efficient Gln to Glu conversion. CB-839 also displayed significant anti-tumor activity in two TNBC xenograft models: 1) as a single agent in a patient-derived tumor chosen based on Gln utilization biomarkers and 2) in a cell line model (JIMT1) both as a single agent and in combination with paclitaxel. To determine if potential markers of Gln utilization and CB-839 sensitivity are reflected in primary tumors, an analysis of large mRNA expression and metabolomic datasets was undertaken. Consistent with the observations in cell lines, there was significantly elevated expression of GAC and reduced expression of GLUL in TNBC tumors relative to the ER+ population in The Cancer Genome Atlas mRNA expression dataset (n = 756). Likewise, analysis of the metabolite levels in 262 primary breast tumors showed that the Glu to Gln ratio in the ER- populations was significantly elevated relative to the ER+ population (fold increase = 3.2, p = 8.0E-09). This elevated metabolite ratio in the ER- population was also significantly correlated with the mRNA expression level of GLUL (r = -0.27, p = 0.001). These observations suggest that biomarkers of Gln utilization and CB-839 sensitivity extend to primary TNBC tumors. Together with the in vitro and in vivo preclinical anti-tumor activity of CB-839 in TNBC models, this primary tumor biomarker evaluation provides a strong rationale for the clinical investigation of CB-839 as a targeted therapeutic in TNBC patients.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-09-03.

Pathway Reporter Assays Reveal Small Molecule Mechanisms of Action

Cell-based, phenotypic screening of small molecules often identifies compounds with provocative biological properties. However, determining the cellular target(s) and/or mechanism of action (MoA) of lead compounds remains an extremely challenging and time-consuming exercise. To provide insights into a compound's cellular action and greatly reduce the time required for MoA determination, we have developed a screening platform consisting of an extensive series of reporter gene assays (RGAs). A collection of > 11,000 compounds of known MoA (e.g., World Drug Index entries) were screened against the entire panel. The output provided evidence that an RGA signature could be ascribed to numerous, biologically diverse MoAs. The reference database generated suggested novel biological activity for particular compounds. For example, the profiling data led to the prediction that the cellular target of the natural product terprenin was dihydroorotate dehydrogenase (DHODH), which was confirmed experimentally. The screening methodology developed for this endeavor renders it amenable to the future examination of compounds with unknown MoA, in an automated, inexpensive, and time-efficient manner.

BioGPS: an extensible and customizable portal for querying and organizing gene annotation resources

BioGPS is a community based customisable gene annotation portal bringing together gene annotation resources on to a single platform.

Online gene annotation resources are indispensable for analysis of genomics data. However, the landscape of these online resources is highly fragmented, and scientists often visit dozens of these sites for each gene in a candidate gene list. Here, we introduce BioGPS http://biogps.gnf.org, a centralized gene portal for aggregating distributed gene annotation resources. Moreover, BioGPS embraces the principle of community intelligence, enabling any user to easily and directly contribute to the BioGPS platform.

A genome-wide RNAi screen for modifiers of the circadian clock in human cells

Two decades of research identified more than a dozen clock genes and defined a biochemical feedback mechanism of circadian oscillator function. To identify additional clock genes and modifiers, we conducted a genome-wide small interfering RNA screen in a human cellular clock model. Knockdown of nearly 1000 genes reduced rhythm amplitude. Potent effects on period length or increased amplitude were less frequent; we found hundreds of these and confirmed them in secondary screens. Characterization of a subset of these genes demonstrated a dosage-dependent effect on oscillator function. Protein interaction network analysis showed that dozens of gene products directly or indirectly associate with known clock components. Pathway analysis revealed these genes are overrepresented for components of insulin and hedgehog signaling, the cell cycle, and the folate metabolism. Coupled with data showing many of these pathways are clock regulated, we conclude the clock is interconnected with many aspects of cellular function.

A registry of patients treated with drotrecogin alfa (activated) in Belgian intensive care units--an observational study

BACKGROUND

Drotrecogin alfa (activated) [DrotAA] is the only specific sepsis therapy that has been shown to reduce mortality. The objectives of this study were to document the profile of patients treated with DrotAA in Belgian intensive care units (ICUs), using data from a database established as part of drug reimbursement conditions in Belgium, and to compare the observed hospital mortality of these patients with their expected mortality, calculated using data from non-DrotAA-treated patients from the Belgian section of PROGRESS, a separate, voluntary, international sepsis registry collecting data from patients with severe sepsis.

MATERIAL AND METHODS

Data from the non-DrotAA-treated patients in PROGRESS were used to calculate the expected mortality rates for DrotAA-treated patients in the Belgian registry. Using a logistic regression equation, these rates were controlled for age and the presence or absence of organ dysfunction in each of 5 organ systems. The same logistic regression technique was used to control the mortality rates observed in the DrotAA-treated patients from the Belgian registry for age and the presence or absence of each of the 5 organ dysfunctions. Adjusted expected and observed hospital mortality rates could then be compared.

RESULTS

There were 436 DrotAA patients in the Belgian registry. Almost all the patients (99.5%) had at least 2 organ failures and the hospital mortality was 51.6%. Two hundred and eighty-six of the patients had enough baseline data to be included in the regression model. Using data from the PROGRESS non-DrotAA patients, the predicted hospital mortality, controlled for age and organ dysfunction, of Belgian registry patients, had they not been treated with DrotAA, was 63.5%. The observed hospital mortality, again controlled for age and organ dysfunction, of the 286 Belgian registry patients was 50.7%, implying an adjusted absolute mortality reduction of 12.8%.

CONCLUSIONS

Comparing Belgian reimbursement registry data with those of a voluntary severe sepsis register provides support for the observation that DrotAA reduces mortality rates in severe sepsis and septic shock.

Estimating P-coverage of biosynthetic pathways in DNA libraries and screening by genetic selection: biotin biosynthesis in the marine microorganism Chromohalobacter

Traditional approaches to natural product discovery involve cell-based screening of natural product extracts followed by compound isolation and characterization. Their importance notwithstanding, continued mining leads to depletion of natural resources and the reisolation of previously identified metabolites. Metagenomic strategies aimed at localizing the biosynthetic cluster genes and expressing them in surrogate hosts offers one possible alternative. A fundamental question that naturally arises when pursuing such a strategy is, how large must the genomic library be to effectively represent the genome of an organism(s) and the biosynthetic gene clusters they harbor? Such an issue is certainly augmented in the absence of expensive robotics to expedite colony picking and/or screening of clones. We have developed an algorism, named BPC (biosynthetic pathway coverage), supported by molecular simulations to deduce the number of BAC clones required to achieve proper coverage of the genome and their respective biosynthetic pathways. The strategy has been applied to the construction of a large-insert BAC library from a marine microorganism, Hon6 (isolated from Honokohau, Maui) thought to represent a new species. The genomic library is constructed with a BAC yeast shuttle vector pClasper lacZ paving the way for the culturing of libraries in both prokaryotic and eukaryotic hosts. Flow cytometric methods are utilized to estimate the genome size of the organism and BPC implemented to assess P-coverage or percent coverage. A genetic selection strategy is illustrated, applications of which could expedite screening efforts in the identification and localization of biosynthetic pathways from marine microbial consortia, offering a powerful complement to genome sequencing and degenerate probe strategies. Implementing this approach, we report on the biotin biosynthetic pathway from the marine microorganism Hon6.

Genomewide association analysis in diverse inbred mice: power and population structure

The discovery of quantitative trait loci (QTL) in model organisms has relied heavily on the ability to perform controlled breeding to generate genotypic and phenotypic diversity. Recently, we and others have demonstrated the use of an existing set of diverse inbred mice (referred to here as the mouse diversity panel, MDP) as a QTL mapping population. The use of the MDP population has many advantages relative to traditional F(2) mapping populations, including increased phenotypic diversity, a higher recombination frequency, and the ability to collect genotype and phenotype data in community databases. However, these methods are complicated by population structure inherent in the MDP and the lack of an analytical framework to assess statistical power. To address these issues, we measured gene expression levels in hypothalamus across the MDP. We then mapped these phenotypes as quantitative traits with our association algorithm, resulting in a large set of expression QTL (eQTL). We utilized these eQTL, and specifically cis-eQTL, to develop a novel nonparametric method for association analysis in structured populations like the MDP. These eQTL data confirmed that the MDP is a suitable mapping population for QTL discovery and that eQTL results can serve as a gold standard for relative measures of statistical power.

An efficient rapid system for profiling the cellular activities of molecular libraries

Rapid quantitative methods for characterizing small molecules, peptides, proteins, or RNAs in a broad array of cellular assays would allow one to discover new biological activities associated with these molecules and also provide a more comprehensive profile of drug candidates early in the drug development process. Here we describe a robotic system, termed the automated compound profiler, capable of both propagating a large number of cell lines in parallel and assaying large collections of molecules simultaneously against a matrix of cellular assays in a highly reproducible manner. To illustrate its utility, we have characterized a set of 1,400 kinase inhibitors in a panel of 35 activated tyrosine-kinase-dependent cellular assays in dose-response format in a single experiment. Analysis of the resulting multidimensional dataset revealed subclusters of both inhibitors and kinases with closely correlated activities. The approach also identified activities for the p38 inhibitor BIRB796 and the dual src/abl inhibitor BMS-354825 and exposed the expected side activities for Glivec/STI571, including cellular inhibition of c-kit and platelet-derived growth factor receptor. This methodology provides a powerful tool for unraveling the cellular biology and molecular pharmacology of both naturally occurring and synthetic chemical diversity.

HierS: hierarchical scaffold clustering using topological chemical graphs

An exhaustive ring-based algorithm, HierS, has been developed in order to provide an intuitive approach to compound clustering for analyzing high-throughput screening results. The recursive algorithm rapidly identifies all possible ring-delimited substructures within a set of compounds. Molecules are grouped by shared ring substructures (scaffolds) so that common scaffolds obtain higher membership. Once all of the scaffolds for a set of compounds are identified, the hierarchical structural relationships between the scaffold structures are established. The complex network of hierarchical relationships is then utilized to navigate compounds in a structurally directed fashion. When the scaffold hierarchy is traversed, over-represented structural features can be rapidly identified so that excess compounds that contain them can be removed without significantly impacting the structural diversity landscape of the compound set. Furthermore, the removed compounds can provide the opportunity to follow-up on active compounds that had previously been discarded because of practical limitations on follow-up capacity. A Web-based interface has been developed that incorporates this algorithm in order to allow for an interactive analysis. In addition, biological data are coupled to scaffolds by the inclusion of activity histograms, which indicate how the compounds in each scaffold class performed in previous high-throughput screening campaigns.

An assessment of the ability of impedance respirometry distinguish oesophageal from tracheal intubation

Accidental oesophageal intubation is still an important cause of anaesthetic morbidity and mortality. This study investigated the use of impedance respirometry to determine the position of a tracheal tube. Seventy-nine patients undergoing general anaesthesia requiring tracheal intubation with muscle relaxation were recruited to the study. After pre-oxygenation, tracheal tubes were placed in both the oesophagus and trachea; a breathing system was attached to one tube chosen randomly. A blinded observer was required to correctly identify the position of the tube within six tidal ventilations. The position of every tube connected to the breathing system was correctly identified. The median time to correctly identify tracheal and oesophageal tubes was 3 and 5 s, respectively. The median number of breaths to identify tracheal and oesophageal tubes was two for both groups. Every tube position was identified within the required six breaths. Impedance respirometry is a reliable method for diagnosing tracheal tube position.

Development of a genetic selection for catalytic antibodies

The design and evaluation of a new genetic selection system for evolving catalytic antibodies with aldolase activity are described. Through a series of model selections, we have identified selection conditions where expression of a catalytically active antibody confers a growth advantage to Escherichia coli. In addition, we provide evidence that the growth advantage is a direct result of catalytic activity.

Their own worst enemy? Management and prevention of self-harm

1. Self-harm is both cause and effect in the wider context of abuse in the family. 2. There are four main areas of self-harm: self-inflicted injury, eating disorders, legal and illegal drug abuse. 3. Community nurses have a central role in caring for clients with conditions arising from self-harm. 4. The health education and promotion role of the community nurse is targeted at individuals, groups, families and society itself.

Support to show they are not alone. Stress in district nursing

The growing emphasis on community care and the comparative isolation of its role is making district nursing increasingly stressful. Support from colleagues and management can help relieve the pressure, and will ultimately benefit patient care.

Recent developments in the management of paracetamol (acetaminophen) poisoning

Paracetamol (acetaminophen) poisoning accounts for almost a third of admissions to our district poisons unit, and is the commonest cause of death in such patients. Antidotal treatment may be effective up to 10h after overdose with oral methionine or up to 24h with acetylcysteine (not 15h as previously suggested for the latter). Patients taking paracetamol overdose while also receiving drugs which induce hepatic enzymes are more susceptible to liver damage, and antidotal treatment may be necessary at lower plasma paracetamol concentrations (50% of the normal treatment line). As survival following liver transplantation is now increasing, it is important to identify early prognostic indicators in fulminant hepatic failure, so that those patients with a high chance of fatal outcome can be considered for transplantation. Useful indicators are the presence of acidosis, marked prolongation of prothrombin time or a continued rise in prothrombin time on day 4 after the overdose. There is no evidence that paracetamol or acetylcysteine are teratogenic in pregnancy. Delays in administering acetylcysteine after paracetamol poisoning in pregnancy have been shown to increase the risk of spontaneous abortion and fetal death. Thus, acetylcysteine should be started as early as possible where treatment is indicated.

Developing an undispersed VUV beamline for large area surface processing

A versatile windowless beamline for undispersed VUV radiation in the energy range between 10 eV and 100 eV is presented. An adjustable light guiding assembly with two glass capillary arrays as vacuum interfaces is constructed to assure high optical transmission (~30%) of white synchrotron light. Three differential pumping stages reduce the pressure of a reaction gas from 1 mbar to 5 x 10(-9) mbar. Estimate of the optical transmission of the system are given. The beamline was designed to irradiate a large area of a semiconductor surface for synchroton photon enhanced etching and deposition processes.

Results of survey--unit-dose repackaging

A survey was conducted to determine drugs that hospitals frequently package in unit-dose. There were 116 responses, identifying 606 line items of tablets or capsules, liquids, and more or less than one dosage unit being packaged. In all three categories there were 108 drugs packaged by four or more hospitals. These results have been shared with the respective manufacturers, to use in marketing these drugs in unit-dose packages.