AB0358 SAFETY, TOLERABILITY, PHARMACOKINETICS, RECEPTOR OCCUPANCY, AND SUPPRESSION OF T-CELL-DEPENDENT ANTIBODY RESPONSE IN A PHASE 1 STUDY WITH KPL-404, AN ANTI-CD40 MONOCLONAL ANTIBODY

Background

T-cell priming and T-cell-dependent B-cell responses require an intact cluster of differentiation (CD)40/CD40L pathway. CD40 is expressed on the surface of B-cells, dendritic cells, antigen-presenting cells, and non-immune cell types; its ligand, CD40L (CD154), is expressed on the surface of activated T-cells, platelets, and other cell types. Blockade of CD40/CD40L interaction has been shown to ablate primary and secondary T-cell dependent antibody response (TDAR).

Objectives

We hypothesized that KPL-404, an anti-CD40 monoclonal antibody which inhibits interaction between CD40 and CD40L, would block T-cell dependent, B-cell-mediated autoimmunity in this Phase 1 study in healthy participants.

Methods

This randomized, double-blind, placebo-controlled, first-in-human study of KPL-404 in healthy participants was designed with two single-ascending-dose arms: single intravenous (IV) doses of 0.03 mg/kg, 0.3 mg/kg, 1 mg/kg, 3 mg/kg, or 10 mg/kg and single subcutaneous (SC) doses of 1 mg/kg or 5 mg/kg. The primary objective was safety and tolerability of KPL-404; secondary and exploratory objectives included pharmacokinetic (PK) parameters, TDAR inhibition, and receptor occupancy (RO). To evaluate TDAR inhibition, participants post-KPL-404 administration were immunized with 1 mg intramuscular injection of the test antigen Keyhole Limpet Hemocyanin (KLH) on day 4 and day 29 to elicit a primary and secondary Immunoglobulin (Ig) response, respectively. To evaluate RO, free and total CD40 receptor levels (percent change from baseline) on B-cells (whole blood) were measured using flow cytometry.

Results

There were no dose-limiting or dose-related safety findings in healthy participants after KPL-404 administration. One unrelated serious adverse event (patella fracture following a fall) occurred in the 10 mg/kg IV arm. The PK profile of KPL-404 in serum after IV or SC administration had low to moderate variability between individuals; elimination was dose-dependent and consistent with target-mediated drug disposition (TMDD) (Figure 1a). For participants receiving 10 mg/kg IV, full receptor occupancy was observed through day 71 (Figure 1b), complete TDAR suppression was observed through Day 57 (Figure 1c), and anti-drug antibodies to KPL-404 were suppressed for at least 57 days; the suppression of antibody responses to the drug itself is an independent indicator of target engagement and pharmacodynamic effect. For participants receiving 5 mg/kg SC, full receptor occupancy was observed through day 43 (Figure 1b), and complete TDAR suppression was observed through Day 29 (Figure 1c). The TDAR response to KLH antigen correlated with the observed full RO.

Conclusion

The safety and tolerability data and the PK/PD profile of KPL-404 support further investigation of KPL-404 in a broad range of autoimmune diseases, including rheumatoid arthritis. These data support the optionality for studying chronic KPL-404 dosing in patients with subcutaneous and/or intravenous administration.

Disclosure of Interests

Manoj Samant Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., Alistair Wheeler Consultant of: Kiniksa Pharmaceuticals Corp., Guang-Liang Jiang Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., Moses Njenga Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., Madeline Spiers Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., Arian Pano Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., John F. Paolini Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp.

AB0379 DOSE-DEPENDENT SUPPRESSION OF T CELL-DEPENDENT ANTIBODY RESPONSE IN HEALTHY VOLUNTEERS BY KPL-404, AN ANTI-CD40 MONOCLONAL ANTIBODY, SUPPORTS CHRONIC DOSING STUDY IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

An unmet need remains in patients with failure and/or inadequate response (IR) to biological disease-modifying antirheumatic drugs (bDMARD-IR) and/or Janus kinase inhibitors (JAKi-IR). The CD40/CD40L (CD154) costimulatory pathway is linked to inflammation and joint destruction in RA via production of autoantibodies and inflammatory mediators. KPL-404 is a humanized IgG4 antibody engineered to bind CD40 without triggering Fc effector functions (Muralidharan, 2019), which are known to have been associated with thromboembolic events seen in the first generation of CD40L-targeting therapies.

In a first-in-human Phase 1 single ascending dose study, 52 healthy volunteers received single doses of KPL-404 administered either subcutaneously (SC) or intravenously (IV) with no dose-limiting safety findings, infectious episodes, or toxicities (Samant, 2021). The study demonstrated that with 10 mg/kg IV, full receptor occupancy (RO) was observed through day 71, and there was complete suppression of T-cell dependent antibody response (TDAR) to keyhole limpet hemocyanin challenge on day 1 and re-challenge on day 29 through day 57. With 5 mg/kg SC, full RO was observed through day 43, and there was complete suppression of TDAR through at least day 29. Complete suppression of ADA to KPL-404, an independent indicator of target engagement, was also observed while KPL-404 serum concentrations were above approximately 0.1 to 0.2 µg/mL and continued for at least 50 days and 57 days after 5 mg/kg SC and 10 mg/kg IV administration, respectively.

Objectives

Using Phase 1 and nonclinical data, identify chronic dosing regimens anticipated to yield PK in the sub-therapeutic, therapeutic, and supra-therapeutic ranges to be utilized in a Multiple Ascending Dose Phase 2 Study.

Methods

A PK model was used to simulate multiple dosing scenarios, including: 2.5, 5, and 10 mg/kg SC qwk, q2wk, and q4wk, as well as 10 mg/kg IV q4wk. The model was used to identify optimal Phase 2 dosing schedules by generating 1000 virtual subjects using the typical parameter estimates with between-subject variability included.

Results

Following SC administration, all subjects were predicted to achieve complete ADA suppression for the full dosing interval at/above 2.5 mg/kg SC q2wk. At 2 mg/kg SC q2wk (starting dose level), simulated steady-state 8-week data predicted PK in a sub-therapeutic range for most subjects and an approximately 31- and 18-fold safety margin relative to preclinical NOAEL dose. At 5 mg/kg SC q2wk, 100% of patients were predicted to be in a therapeutic range, indicating a potential practical efficacious dose level. At 10 mg/kg SC q2wk, 100% of patients were predicted to be in the supratherapeutic range.

These results support a Multiple Ascending Dose (MAD) Phase 2 study design, with PK lead-in comprised of 3 Cohorts at 2, 5, or 10 mg/kg SC q2wk (each randomized 6:2) and Proof-of-Concept phase (Cohort 4) comprised of 48-60 subjects randomized 1:1:1 to 10 mg/kg, 5 mg/kg, and placebo SC q2wk. The ongoing study will evaluate efficacy (Disease Activity of 28 joints using C-reactive protein [DAS28-CRP]), safety, PK, and pharmacodynamics (PD) of escalating doses levels of KPL-404 compared with placebo in patients with moderate to severe RA (bDMARD-IR or JAKi-IR). The study also allows the flexibility of optional cohorts including additional dosing regimens and/or subpopulations identified based on clinical response and biomarkers.

Conclusion

Inhibition of the CD40-CD154 co-stimulatory interaction holds promise for the management of a spectrum of autoimmune diseases. KPL-404 demonstrated prolonged absorption/excretion capable of suppressing TDAR for extended periods allowing for use of extended dosing intervals irrespective of IV or SC dosing. These analyses supported the design of the ongoing Phase 2 study assessing the efficacy and safety KPL-404 in RA.

References

[1]Muralidharan S et al. 2019. Poster at Keystone Symposia

[2]Samant M et al. Arthritis Rheumatol. 2021; 73(suppl 10)

Disclosure of Interests

Anastassia Papandrikopoulou Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., Gerd Rüdiger Burmester Speakers bureau: Abbvie, Amgen, BMS, Lilly, MSD, Pfizer, Roche, Sanofi, Consultant of: Abbvie, Amgen, BMS, Kiniksa, Lilly, MSD, Pfizer, Roche, Sanofi, Fang Fang Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., Alan Kivitz Shareholder of: Amgen, Gilead Sciences, Inc., GlaxoSmithKline, Novartis, Pfizer, Sanofi,, Speakers bureau: AbbVie, Celgene, Flexion, Genzyme, GlaxoSmithKline, Lilly, Merck, Novartis, Pfizer, Sanofi, UCB, Horizon, Consultant of: AbbVie, Boehringer Ingelheim, Flexion, Gilead Sciences, Inc., Janssen, Pfizer, Sanofi, SUN Pharma Advanced Research, Moses Njenga Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., Arian Pano Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., Costantino Pitzalis Speakers bureau: Abbott/AbbVie, Astra-

Zeneca/MedImmune, BMS, Janssen/J&J, MSD, Pfizer, Roche/Genentech/Chugai, UCB.,, Consultant of: Abbott/AbbVie, Astellas, Astra-Zeneca/MedImmune, BMS, CelGene, Grunenthal, GSK,

Janssen/J&J, Kiniksa, MSD, Pfizer, Sanofi, Roche / Genentech / Chugai, UCB., Grant/research support from: Abbott/AbbVie, Astellas, Astra-Zeneca/MedImmune, BMS, Janssen/J&J, MSD, Pfizer, Roche/Genentech/Chugai, UCB., Manoj Samant Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., Steve Schmitz Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., Madeline Spiers Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., Eben Tessari Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp., John Ziemniak Consultant of: Kiniksa Pharmaceuticals, Ltd., John F. Paolini Shareholder of: Kiniksa Pharmaceuticals Corp., Employee of: Kiniksa Pharmaceuticals Corp.

Preoperative assessment in the elderly: evaluation of a new clinical service

Older people represent the fastest growing sector of society and a growing proportion of those undergoing elective surgery. Older people are at the highest risk of increased length of stay and postoperative complications. We evaluated the development of a nurse-led multidimensional preoperative assessment for older people. An older people's preassessment nurse reviewed consecutive patients undergoing elective surgery who met the inclusion criteria. In the first five months control phase, assessment was not acted on. Following the intervention, patients were referred to appropriate specialties for input. A total of 141 patients were reviewed before and 172 patients reviewed after the introduction of the pilot. Length of stay was reduced from 8.9 to 4.9 days after the introduction of the pilot ( P < 0.001). Delays were reduced from 9.9% to 2.3% ( P = 0.004) and fewer procedures were cancelled at pre-assessment (17.7% before, 5.2% after; P < 0.001). Serious postoperative complications were reduced from 8.5% to 2.3% ( P = 0.01). Coordinated multidisciplinary preoperative assessment in the elderly may reduce complications and length of stay.

Prospective analysis of stoma-related complications

BACKGROUND

Stoma-related complication rates vary between 10% and 70%, possibly because of varying lengths of follow-up. It is thought that most of the complications improve with time. Furthermore, little is known about the commonly neglected but potentially quite distressing complications such as leakage, soiling and night-time emptying. The aim of this audit was to examine prospectively whether there was any difference in the complication rates at different time-points during the postoperative follow up period.

METHOD

A prospective study on 408 consecutive patients with either colostomy or ileostomy was conducted over a period of at least 2 years. Both emergency and elective procedures were included. Stoma related complications were analysed at 10 days, 3 months, 6 months, 1 year and 2 years postoperatively.

RESULTS

Both elective and emergency stomas had similar complication rates. The percentage of patients who had stenosis (1-2%), retraction (8-22%), prolapse (1-3%) or odour (6-9%) did not significantly change with time. The complication rates for skin excoriation, leakage, soiling or night-time emptying were higher amongst the ileostomy patients, and these rates did not improve with time. The proportion of patients who had parastomal hernias increased with time (from 0 to 40% in the colostomy and 0 to 22% in the ileostomy group). Daytime leakage, night-time leakage, soiling and night-time emptying were more problematic in the ileostomy group.

CONCLUSIONS

The proportion of patients who had postoperative stoma-related complications did not improve with time, but the rate of parastomal hernias in both groups and night-time emptying in the ileostomy group was worse with time. Ileostomy patients had a higher incidence of skin excoriation, leakage, soiling, and night-time emptying, and they should receive additional support.

Client-centred standards: risk implications for boards and management

The author argues that the Canadian Council on Health Services Accreditation standards have acquired the status of law and that, therefore, there may be an increased risk of legal liability inherent in the use of the council's new client-centred standards. As survey teams focus less on structure and more on the individual client, the potential for instances of substandard care to be uncovered and documented as part of the survey process escalates.

Reliability of reliability coefficients in the estimation of asymmetry

Although promising to provide insight into the interaction between genotype and environment, investigations into fluctuating asymmetry suffer from a lack of standardization in the reporting of measurement error. In the present paper we show, using both anthropometric and odontometric data, that the use of the reliability coefficient calculated for a bilateral measurement provides no indication of the reliability of the corresponding asymmetry estimate, because reliability of asymmetry depends on the relationship between measurement error and the difference between sides. Thus, we suggest that future investigations either provide reliability coefficients for asymmetry estimates specifically, or use methods that account for measurement error.

Social cognitive factors in brain injury-associated personality change

Often social difficulties are the most enduring difficulties after a head injury. The social deficits most frequently reported by relatives 6-12 months post-injury include egocentric styles of social interaction characterized by family members as a change in the head-injured patient's personality style. The described characteristics of head-injured patients in terms of social perspective-taking abilities are similar to those of children reported in the cognitive developmental literature. To demonstrate the nature of the social deficits in head-injured participants, social perspective-taking paradigms in the development literature were used to construct a task to be administered to both head-injured and non-head-injured adults. Results of the comparison between the two groups suggest deficits in social perspective-taking abilities in head-injured adults similar to the level demonstrated by pre-adolescent children.

Thoughts on reform in long-term care

The authors, drawing on their experience as administrators at Winnipeg's Deer Lodge Centre, ponder the challenges facing long-term care facilities in light of improving community-supported care, changing resident's needs, and the fragile state of today's health care economy. This article identifies the need for fresh, resident-oriented thinking among administrators and staff in the distribution of power in long-term care facilities, and proposes new social interactions that can enliven and humanize residents' and staff's mutual roles and behaviours.

Biological and neuropsychological characterization of physostigmine responders and nonresponders in Alzheimer's disease

To assess the efficacy of oral physostigmine for the treatment of Alzheimer's disease, 20 patients were entered into a clinical trial. All patients underwent a dose-finding phase (two weeks), followed by an open trial (two weeks), and a double-blind crossover phase (two weeks drug, two weeks placebo). Extensive neuropsychological testing (Buschke Selective Reminding procedure, category generation, picture recognition, finger tapping) and measurement of systemic cholinergic parameters were measured during each of these phases. Patients were classified as physostigmine responders and nonresponders based on a priori established criteria. Using these, nine patients were found to respond to physostigmine, while 11 were classified as nonresponders. During baseline conditions, responders when compared to nonresponders were found to have higher concentrations of red blood cell (RBC) choline (Ch) and higher ratios of RBC Ch to plasma Ch. Neuropsychological tests were found to fall into one of three categories. The first group of tests were sensitive to drug effects and differentiated physostigmine responders from nonresponders; the second group was found to predict responsiveness; and the third group was neither predictive nor sensitive to drug effects.