AB0294 PERSISTENCE WITH ABATACEPT VERSUS TUMOR NECROSIS FACTOR-INHIBITORS FOR RHEUMATOID ARTHRITIS COMPLICATED BY POSITIVE ANTI-CYCLIC CITRULLINATED PEPTIDE/RHEUMATOID FACTOR OR OTHER POOR PROGNOSTIC FACTORS

Background:

Rheumatoid arthritis (RA) treatment usually begins with a non-biologic disease-modifying antirheumatic drug (DMARD), followed by a biologic DMARD (including abatacept or tumor necrosis factor-inhibitors [TNFis]) in non-responsive patients.1Since, treatments are switched if disease activity does not improve, it is valuable to understand treatment persistence and switch patterns in RA patients with poor prognostic factors in a real-world setting.

Objectives:

To assess 12-month treatment persistence in early-line abatacept versus TNFi treated patients with RA complicated by poor prognostic factors.

Methods:

We performed a multi-center retrospective medical record review of adult RA patients with poor prognostic factors treated at 6 United States clinics. Patients were treated with abatacept or TNFi as the first biologic treatment at the clinic. Poor prognostic factors included positive anti-cyclic citrullinated peptide antibodies (ACPA+), positive rheumatoid factor antibodies (RF+), increased C-reactive protein levels, elevated erythrocyte sedimentation rate levels, or presence of joint erosions. TNFis included adalimumab, etanercept, infliximab (and their biosimilars), certolizumab pegol, or golimumab. Data were collected from first biologic treatment for ≥1 year. Patients with Crohn’s disease, ankylosing spondylitis, ulcerative colitis, psoriatic arthritis, or anal fistula were excluded. Demographic, disease, and treatment information (start, stop, reason for discontinuation) was abstracted. Treatment persistence (continuation of index treatment with gap ≤60 days) at 12 months and time to discontinuation were reported. Multivariate logistic and Cox regressions were used to compare 12-month persistence and risk of discontinuation between abatacept and TNFi, controlling for demographic and clinical characteristics (age, sex, Charlson comorbidity index [CCI], RA duration), baseline utilization, and clinic. Findings among a subgroup of ACPA+ and/or RF+ patients are reported.

Results:

Data on 265 patients (100 abatacept, 165 TNFi) were collected, including 163 ACPA+ and/or RF+ patients (55 abatacept, 108 TNFi). Overall, abatacept patients were older than TNFi patients (67.0 vs. 60.3 years, p<0.001), but there were no statistically significant differences in gender, comorbidities, or duration of treatment at the clinic. At 12 months, 83.0% of abatacept patients were persistent vs. 66.1% of TNFi patients (p=0.003). Persistence was similar among ACPA+ and/or RF+ patients (83.6% vs. 64.8%, p=0.012). Median time to discontinuation was 1,423 days for abatacept vs. 690 days for TNFi (p=0.014) (961 days vs. 581 days among ACPA+ and/or RF+ patients, p=0.048) (Figures 1,2). In the adjusted analysis, risk of all-cause discontinuation was statistically significantly higher among TNFi than abatacept patients (1.7 [95% CI: 1.1-2.6], p=0.012). The odds of TNFi patients being persistent at 12 months was 51% lower than abatacept patients, although not statistically significant (p=0.071). More TNFi than abatacept patients discontinued index treatment due to disease progression (27.3% vs. 12.0%, p=0.003). Adjusted analyses showed that TNFi patients had a statistically significantly higher risk of discontinuing index treatment due to disease progression (3.4 [95% CI: 1.6-7.2], p=0.001).

Figure 1.

Time to discontinuation of index treatment among all patients (N=265)

Conclusion:

In a real-world setting, RA patients with ACPA or RF positivity or other poor prognostic factors are less likely to discontinue abatacept compared with TNFi and are more likely to be persistent on their early line treatment. This difference may be explained by the lower proportion of patients discontinuing abatacept due to disease progression.

References:

[1]Singh et al.Arthritis Care Res. 2012;64(5):625-639. doi:10.1002/acr.21641

Figure 2.

Time to discontinuation of index treatment among ACPA+ and/or RF+ patients (N=163)

Disclosure of Interests:

Xue Han Employee of: BMS, Irina Yermilov Employee of: I am an employee of the Partnership for Health Analytic Research (PHAR) LLC, which was paid by BMS to conduct the research described in this abstract., Sarah Gibbs Employee of: I am an employee of the Partnership for Health Analytic Research (PHAR) LLC, which was paid by BMS to conduct the research described in this abstract., Michael Broder Employee of: I am an employee of the Partnership for Health Analytic Research (PHAR) LLC, which was paid by BMS to conduct the research described in this abstract.

Therapie von Fibrinogenmangelzuständen

Im Rahmen einer Anwendungbeobachtung an 96 Patienten wurden die Indikationen, Dosierung, Wirksamkeit und Verträglichkeit des Fibrinogenkonzentrats Haemocomplettan HS 1 g/2g dokumentiert, ausgewertet und mit den Daten einer Zwischenauswertung (51 Patienten) verglichen. Hauptindikationen waren Fibrinogenmangelzustände bei Blutungen, Leberschäden, DIC, Hyperfibrinolysen und Leukämien. Im Mittel wurden in 3 Dosen 5,6 g Fibrinogen verabreicht; bei Leberschäden war die Dosierung meist höher als bei anderen Erkrankungen. Durch die Substitution wurde ein Fibrinogenanstieg um etwa 1,1 g/l auf 1,9 g/l erreicht. Haemocomplettan HS wurde allein oder in Kombination mit anderen Gerinnungspräparaten (AT III, PPSB, FFP, Heparin) als sehr wirksames Medikament beurteilt: Bei fast allen Patienten (97,3%) gelang eine Anhebung bzw. Normalisierung des Fibrinogenspiegels. Bei 75% aller Patienten blieb der Fibrinogenspiegel dauerhaft im Normbereich. Blutungen konnten bei 89,1% und die Grundkrankheit bei 82,1% der Fälle erfolgreich behandelt werden. Die Er-gebnisse der Zwischenauswertung wurden damit voll bestätigt.

Effect of the 12-gene colon cancer assay results on adjuvant treatment recommendations in patients with stage II colon cancer

INTRODUCTION

The 12-gene colon cancer Recurrence Score assay is a clinically validated predictor of recurrence risk in stage II colon cancer patients. A survey was performed characterizing the assay's impact on treatment recommendations for these patients.

METHODS

US medical oncologists (n = 346) who ordered the assay for ≥3 stage II colon cancer patients were asked to complete a web-based survey regarding their most recent such patient. Physicians surveyed represented users of the assay within the first 2 years of commercial availability which may include 'early adopters'.

RESULTS

Most of 116 eligible physicians were in community practice (86%), with median 14.5 years' experience (range = 2-40). Mean patient age was 61 years (range = 32-85); 81% had T3 disease, and 38% had comorbidities. Of 76 patients tested for mismatch-repair/microsatellite-instability (MMR/MSI), 13 (17%) were MMR-deficient/MSI-high; 46 (61%) MMR-proficient/MSI-low; and 17 (22%) unknown. Most patients (84%) had ≥12 nodes examined. Median Recurrence Score result was 20 (range = 1-77). Before assay, treatment recommendations were specified for 92 (79%) patients, with no recommendation for 24 (21%). Of the 92 with pre-assay recommendations, chemotherapy was planned for 52 (57%) and observation for 40 (43%); the assay changed recommendations for 27 (29%). Treatment intensity decreased for 18 (67%) and increased for nine (33%) patients; it was more likely to decrease for lower Recurrence Score values and increase for higher values (p < 0.001).

CONCLUSION

For stage II colon cancer patients receiving Recurrence Score testing, 29% of treatment recommendations were changed. Use of the assay may lead to reductions in treatment intensity. Study limitations include retrospective design, data gathering during the first 2 years of assay availability only, and potential non-representativeness of respondents.

Effect of 21-Gene Recurrence Score Results on Treatment Recommendations in Patients with Lymph Node-Positive, Estrogen Receptor-Positive Breast Cancer

Background: Results of recent Oncotype DX® studies indicate that the Recurrence Score (RS) can identify node-positive, estrogen receptor-positive (N+/ER+) patients who may not benefit from chemotherapy and have a low risk of distant recurrence with hormonal therapy alone. Based on these results, the Oncotype DX® breast cancer assay has been ordered for N+/ER+ patients. There are no data, however, on the impact of the assay on adjuvant treatment planning in N+ patients. We performed a survey to characterize the effect of the Oncotype DX® breast cancer assay on adjuvant treatment recommendations in N+/ER+ breast cancer.Methods: U.S. medical oncologists (N=1,017) who ordered Oncotype DX® for at least 1 patient with N+/ER+ breast cancer were contacted and asked to complete a web-based survey regarding the single most recent N+/ER+ patient for whom the Oncotype DX® assay was ordered. The survey was developed through cognitive interviews with four medical oncologists, and the protocol was institutional review board approved.Results: We analyzed surveys from 160 individual physicians for 160 N+/ER+ patients. Physicians were in community practices (71%) more often than in academic practice settings, they were equally dispersed geographically, and they had a median of 11 years (range, 1–45) of practice experience. The median patient age was 61 years (range, 34–82), and 79% were postmenopausal. T1, T2, or T3 disease was reported in 62%, 35%, and 3% of patients, respectively (unknown in 1 patient). One, two, three, or 4+ nodes were reported in 69%, 18%, 6%, and 3%, respectively (unknown in 8 patients). Fifty-four percent of N+/ER+ patients had an RS &lt;18; 38% had an RS of 18–30; and 8% had an RS ≥31. Before obtaining the RS, chemotherapy was planned in 89 patients (56%), endocrine therapy was planned in 46 patients (29%), there was no recommendation for 22 patients (14%), and other treatments for 3 patients (1%). After obtaining the RS, recommended treatment changed from hormonal therapy plus chemotherapy to hormonal therapy alone in 48 patients (35%) and from hormonal therapy to hormonal therapy plus chemotherapy in 14 patients (10%).Discussion: These findings indicate that for N+/ER+ patients, the RS score is used more often (but not exclusively) in patients with 1–3 positive nodes and T1 or T2 stage disease. Treatment recommendations for these patients with N+ disease were frequently changed by the RS results, with an overall reduction in the recommendation for chemotherapy treatment.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2031.

Can we achieve international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding?

BACKGROUND

There is considerable worldwide confusion in the use of terminologies and definitions around the symptom of abnormal uterine bleeding (AUB), and these are leading increasingly to difficulties in setting up multinational clinical trials and in interpreting the results of studies undertaken in single centres. An international initiative was established to develop an agreement process to recommend clear, simple terminologies and definitions with the potential for wide acceptance.

METHODS

After widespread consultation with relevant international and national organizations, journal editors and individuals, a modified Delphi process was developed to assess the current use of terminologies followed by a structured face-to-face meeting of 35 clinicians (mostly gynaecologists) and scientists in Washington. Focused small group discussions led to plenary assessment of concepts and recommendations using an electronic keypad voting system.

RESULTS

There was almost universal agreement that poorly defined terms of classical origin used in differing ways in the English medical language should be discarded and that these should be replaced by simple, descriptive terms with clear definitions which have the potential to be understood by health professional and patient alike and which can be translated into most languages. The major recommendations were to replace terms such as menorrhagia, metrorrhagia, hypermenorrhoea and dysfunctional uterine bleeding. Suggestions for potentially suitable replacement terms and definitions are made.

CONCLUSIONS

A simple terminology has been recommended for the description and definition of symptoms and signs of AUB. This manuscript should be a living document and should be part of an ongoing process with international medical and community debate. Classification of causes, investigations and cultural and quality of life issues should be part of the ongoing process.

A controlled trial of intravenous immune globulin for the prevention of serious infections in adults with advanced human immunodeficiency virus infection

BACKGROUND

Studies on human immunodeficiency virus-infected children suggest that high-dose immune globulin therapy might be beneficial in reducing the episodes of recurrent infections. In adults, comparable studies are not available.

OBJECTIVE

To determine the efficacy of intravenous (IV) immune globulin therapy in preventing infections and reducing days with fever, as well as the duration and frequency of hospitalization for human immunodeficiency virus-infected adults, in a prospective, randomized outpatient clinical trial.

METHODS

Adult patients who met Centers for Disease Control and Prevention criteria B and C were randomized to be treated with (n = 70) or without (n = 57) IV immune globulin. Patients who were assigned to treatment with IV immune globulin received 400 and 200 mg/kg of this drug initially and every 21 days thereafter, respectively. Primary end points were the occurrence of laboratory-proved or clinically diagnosed infections and death caused by infection.

RESULTS

In comparison with patients in the control group, IV immune globulin treatment significantly increased the time for which the patients who met Centers for Disease Control and Prevention criteria B and C were free from serious infection (P < .001). Twelve (17%) of the patients who received IV immune globulin had infection-related deaths compared with 20 (35%) of the control patients; however, this was not statistically significant (P = .06). Furthermore, immune globulin treatment was associated with an overall reduction in the number and duration of hospitalizations for short-term care (P = .002), days with fever (P < .001), and frequency of diarrhea (P < .001). Because of these results, the study was stopped by the local ethical board.

CONCLUSION

Prophylactic IV immune globulin treatment in human immunodeficiency virus-infected adults decreases the frequency of serious infections and is associated with a reduction of hospitalization for short-term care.