Precision RNAi using synthetic shRNAmir target sites

Loss-of-function genetic tools are widely applied for validating therapeutic targets, but their utility remains limited by incomplete on- and uncontrolled off-target effects. We describe artificial RNA interference (ARTi) based on synthetic, ultra-potent, off-target-free shRNAs that enable efficient and inducible suppression of any gene upon introduction of a synthetic target sequence into non-coding transcript regions. ARTi establishes a scalable loss-of-function tool with full control over on- and off-target effects.

Nonclinical safety evaluation of a novel ionizable lipid for mRNA delivery

mRNA vaccines hold tremendous potential in disease control and prevention for their flexibility with respect to production, application, and design. Recent breakthroughs in mRNA vaccination would have not been possible without major advances in lipid nanoparticles (LNPs) technologies. We developed an LNP containing a novel ionizable cationic lipid, Lipid-1, and three well known excipients. An in silico toxicity hazard assessment for genotoxicity, a genotoxicity assessment, and a dose range finding toxicity study were performed to characterize the safety profile of Lipid-1. The in silico toxicity hazard assessment, utilizing two prediction systems DEREK and Leadscope, did not find any structural alert for mutagenicity and clastogenicity, and prediction in the statistical models were all negative. In addition, applying a read-across approach a structurally very similar compound was tested negative in two in vitro assays confirming the low genotoxicity potential of Lipid-1. A dose range finding toxicity study in rabbits, receiving a single intramuscular injection of either different doses of an mRNA encoding Influenza Hemagglutinin H3 antigen encapsulated in the LNP containing Lipid-1 or the empty LNP, evaluated local tolerance and systemic toxicity during a 2-week observation period. Only rabbits exposed to the vaccine were able to develop a specific IgG response, indicating an appropriate vaccine take. The vaccine was well tolerated up to 250 μg mRNA/injection, which was defined as the No Observed Adverse Effect Level (NOAEL). These results support the use of the LNP containing Lipid-1 as an mRNA delivery system for different vaccine formulations and its deployment into clinical trials.

OP0252 FACTORS ASSOCIATED WITH SEVERE COVID-19 OUTCOMES IN PATIENTS WITH IDIOPATHIC INFLAMMATORY MYOPATHY: RESULTS FROM THE COVID-19 GLOBAL RHEUMATOLOGY ALLIANCE PHYSICIAN-REPORTED REGISTRY

Background

There is a paucity of data in the literature about the outcome of patients with idiopathic inflammatory myopathy (IIM) who have been infected with SARS-CoV-2.

Objectives

To investigate factors associated with severe COVID-19 outcomes in patients with IIM.

Methods

Data on demographics, number of comorbidities, region, COVID-19 time period, physician-reported disease activity, anti-rheumatic medication exposure at the clinical onset of COVID-19, and COVID-19 outcomes of IIM patients were obtained from the voluntary COVID-19 Global Rheumatology Alliance physician-reported registry of adults with rheumatic disease (from 17 March 2020 to 27 August 2021). An ordinal COVID-19 severity scale was used as primary outcome of interest, with each outcome category being mutually exclusive from the other:a) no hospitalization, b) hospitalization (and no death), or c) death. Odds ratios (OR) were estimated using multivariable ordinal logistic regression. In ordinal logistic regression, the effect size of a categorical predictor can be interpreted as the odds of being one level higher on the ordinal COVID-19 severity scale than the reference category.

Results

Complete hospitalization and death outcome data was available in 348 IIM cases. Mean age was 53 years, and 223 (64.1%) were female. Overall, 167/348 (48.0%) people were not hospitalized, 136/348 (39.1%) were hospitalized (and did not die), and 45/348 (12.9%) died. Older age (OR=1.59 per decade of life, 95%CI 1.32-1.93), male sex (OR=1.63, 95%CI 1.004-2.64; versus female), high disease activity (OR=4.05, 95%CI 1.29-12.76; versus remission), presence of two or more comorbidities (OR=2.39, 95%CI 1.22-4.68; versus none), prednisolone-equivalent dose >7.5 mg/day (OR=2.37, 95%CI 1.27-4.44; versus no glucocorticoid intake), and exposure to rituximab (OR=2.60, 95%CI 1.23-5.47; versus csDMARDs only) were associated with worse COVID-19 outcomes (Table 1).

Table 1.

Multivariable logistic regression analysis of factors associated with the ordinal COVID-19 severity outcomes. AZA, azathioprine; CI, confidence interval; combo, combination; CSA, ciclosporin; CYC, cyclophosphamide; DMARD, disease-modifying anti-rheumatic drug; b/tsDMARD, biologic/targeted synthetic DMARD, csDMARD, conventional synthetic DMARD; HCQ, hydroxychloroquine; IVIg, intravenous immunoglobulin; LEF, leflunomide; MMF, mycophenolate mofetil; mono, monotherapy; MTX, methotrexate; OR, odds ratio; Ref, reference; RTX, rituximab; SSZ, sulfasalazine; TAC, tacrolimus.

VariableOR (95%CI)P-valueVariableOR (95%CI)P-valueAge (per decade)1.59 (1.32-1.93)<0.001ComorbiditiesMale sex1.63 (1.004-2.64)0.048NoneRefNAPrednisolone-equivalent doseOne1.46 (0.79-2.72)0.228NoneRefNATwo or more2.39 (1.22-4.68)0.011>0 to 7.5mg/day1.10 (0.57-2.11)0.779Physician-reported disease activity>7.5mg/day2.37 (1.27-4.44)0.007RemissionRefNAIVIg0.41 (0.15-1.16)0.093Low/moderate1.23 (0.67-2.28)0.504DMARDsHigh4.05 (1.29-12.76)0.018csDMARD only (mono or combi - HCQ, MTX, LEF, SSZ)RefNARegionNo DMARD1.84 (0.90-3.75)0.094EuropeRefNAb/tsDMARD mono or combi (except RTX)1.60 (0.49-5.26)0.435North America0.89 (0.49-1.61)0.694CSA/CYC/TAC mono or combi (except RTX or b/tsDMARDs)1.55 (0.52-4.58)0.429Other4.25 (2.21-8.16)<0.001AZA mono1.70 (0.69-4.19)0.249Time periodMMF mono1.22 (0.53-2.82)0.634Before 15 June 2020RefNAAZA/MMF combi (except RTX or b/tsDMARDs)0.71 (0.25-2.00)0.51716 June - 30 September 20200.58 (0.26-1.27)0.171RTX mono or combi2.60 (1.23-5.47)0.012After 1 October 20200.58 (0.35-0.95)0.032

Conclusion

These are the first global registry data on the impact of COVID-19 on IIM patients. Older age, male gender, higher comorbidity burden, higher disease activity, higher glucocorticoid intake and rituximab exposure were associated with worse outcomes. These findings will inform risk stratification and management decisions for IIM patients.

References

None

Disclosure of Interests

Su-Ann Yeoh: None declared, Milena Gianfrancesco: None declared, Saskia Lawson-Tovey: None declared, Kimme Hyrich Speakers bureau: AbbVie unrelated to this work, Grant/research support from: Pfizer, BMS, both unrelated to this work, Anja Strangfeld Speakers bureau: AbbVie, Celltrion, MSD, Janssen, Lilly, Roche, BMS, Pfizer, all unrelated to this work, Laure Gossec Consultant of: AbbVie, Amgen, BMS, Galapagos, Gilead, GSK, Janssen, Lilly, Novartis, Pfizer, Samsung Bioepis, Sanofi-Aventis, UCB, all unrelated to this work, Grant/research support from: Amgen, Galapagos, Lilly, Pfizer, Sandoz, all unrelated to this work, Loreto Carmona: None declared, Elsa Mateus Consultant of: Boehringer Ingelheim Portugal, not related to this work, Martin Schaefer: None declared, Christophe Richez Speakers bureau: Abbvie, Amgen, Astra Zeneca, Biogen, BMS, Celltrion, Eli Lilly, Galapagos, GSK, MSD, Novartis, and Pfizer, all unrelated to this abstract, Consultant of: Abbvie, Amgen, Astra Zeneca, Biogen, BMS, Celltrion, Eli Lilly, Galapagos, GSK, MSD, Novartis, and Pfizer, all unrelated to this abstract, Eric Hachulla Speakers bureau: Johnson & Johnson, GlaxoSmithKline, Roche-Chugai, all unrelated to this work, Consultant of: Bayer, Boehringer Ingelheim, GlaxoSmithKline, Johnson & Johnson, Roche-Chugai, Sanofi-Genzyme, all unrelated to this work, Grant/research support from: CSL Behring, GlaxoSmithKline, Johnson & Johnson, Roche-Chugai, Sanofi-Genzyme, all unrelated to this work, Marie Holmqvist: None declared, Carlo Alberto Scirè Grant/research support from: AbbVie, Lilly, both unrelated to this work, Rebecca Hasseli: None declared, Arundathi Jayatilleke: None declared, Tiffany Hsu: None declared, Kristin D’Silva: None declared, Victor Pimentel-Quiroz: None declared, Monica Vasquez del Mercado: None declared, Samuel Katsuyuki Shinjo: None declared, Edgard Reis Neto: None declared, Laurindo Rocha Jr: None declared, Ana Carolina de Oliveira e Silva Montandon Speakers bureau: GSK, not related to this work, Paula Jordan: None declared, Emily Sirotich: None declared, Jonathan Hausmann Speakers bureau: Novartis, Biogen, Pfizer, not related to this work, Consultant of: Novartis, Biogen, Pfizer, not related to this work, Jean Liew Grant/research support from: Pfizer research grant, completed in 2021, not related to this work, Lindsay Jacobsohn: None declared, Monique Gore-Massy Speakers bureau: Aurinia Pharmaceuticals, Boehringer Ingelheim, Bristol-Myers Squibb, not related to this work, Consultant of: Aurinia Pharmaceuticals, Boehringer Ingelheim, Bristol-Myers Squibb, not related to this work, Paul Sufka: None declared, Rebecca Grainger Speakers bureau: AbbVie, Janssen, Novartis, Pfizer and Cornerstones, all unrelated to this work, Consultant of: AbbVie, Novartis, both unrelated to this work, Suleman Bhana Shareholder of: Pfizer, Inc, Speakers bureau: AbbVie, Horizon, Novartis, and Pfizer, all unrelated to this work, Consultant of: AbbVie, Horizon, Novartis, and Pfizer, all unrelated to this work, Employee of: Pfizer, Inc, Zachary Wallace: None declared, Philip Robinson Speakers bureau: Abbvie, Janssen, Roche, GSK, Novartis, Lilly, UCB, all unrelated to this work, Paid instructor for: Lilly, unrelated to this work, Consultant of: GSK, Kukdong, Atom Biosciences, UCB, all unrelated to this work, Grant/research support from: Janssen, Pfizer, UCB and Novartis, all unrelated to this work, Jinoos Yazdany Consultant of: Aurinia, Astra Zeneca, Pfizer, all unrelated to this work, Grant/research support from: Astra Zeneca, Gilead, BMS Foundation, all unrelated to this work, Pedro Machado Speakers bureau: Abbvie, BMS, Celgene, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB, all unrelated to this work., Consultant of: Abbvie, BMS, Celgene, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB, all unrelated to this work.

OP0306 IMPACT OF INFLAMMATION ON INTERSTITIAL LUNG DISEASE IN PATIENTS WITH RHEUMATOID ARTHRITIS - AN ANALYSIS OF THE GERMAN BIOLOGICS REGISTER RABBIT

Background

Ten percent of patients with prevalent rheumatoid arthritis (RA) develop an interstitial lung disease (ILD), which is associated with higher mortality (1). A previous study identified high/moderate disease activity, but not CRP, as a risk factor for RA-ILD (2).

Objectives

To analyse whether systemic inflammation (CRP and ESR) and/or disease activity measured with a composite score (DAS28-ESR) are associated with the occurrence of ILD in patients with RA.

Methods

Data from RA patients observed in the biologics register RABBIT until 10/2020 were included. Patients with incident ILD were selected as cases and matched 1:5 to controls using a modified risk-set sampling (controls had no ILD during the entire observation time). Matching criteria were age, sex, RA duration, date of enrolment and observation time. Odds ratios (OR) and 95% confidence intervals (CI) were computed by conditional logistic regression and adjusted for factors identified by a directed acyclic graph (DAG), namely smoking, rheumatoid factor (RF), chronic obstructive pulmonary disease, number of biologics until index date (date of ILD-diagnosis in cases, date after the respective observation time in controls) and mean glucocorticoid dosage (12 months prior index date). For the regression, CRP and ESR were log-transformed due to their skewed distribution, and missing values were addressed by multiple imputations (n=10).

Results

Out of 19,148 RA patients enrolled since 2001, 133 patients with incident ILD were identified. Half of the ILDs were diagnosed by computed tomography (n=67), 8% by x-ray (n=10) and in 42% the method was unknown (n=56).

At baseline, cases and controls had a mean age of 61 years, 68% were female, and mean RA disease duration was 9 years. Differences were observed in smoking status (59% ever smokers in cases vs. 48% in controls), RF positivity (84% vs. 72%) and the sum of comorbidities (means 3.1 vs. 2.3).

During the 12 months prior to the index date, mean values of CRP and especially of ESR were significantly higher in cases compared to controls. This difference was not observed for DAS28 (Figure 1, upper figures). Furthermore, more cases than controls were in a high inflammatory status, but not in at least moderate disease activity (Figure 1, lower figures). The adjusted regression analyses confirmed these results: CRP and ESR were significantly associated with incident ILD both at the time of diagnosis and in the 12 previous months, and results were even more pronounced with elevated CRP and ESR, which was not the case for DAS28 (Table 1).

Table 1.

Results of the conditional logistic regression for the risk of ILD.

Crude OR (95% CI)Adjusted OR (95% CI)At index dateLog CRP1.55 (1.25 – 1.92)1.55 (1.24 – 1.94)CRP≥5 vs. CRP<52.43 (1.55 – 3.81)2.41 (1.49 – 3.88)Log ESR1.56 (1.22 – 2.00)1.56 (1.21 – 2.01)ESR >21 vs. ESR ≤212.12 (1.40 – 3.19)2.12 (1.37 – 3.29)DAS281.17 (1.01 – 1.35)1.16 (0.99 – 1.35)DAS28 >3.2 vs. DAS28 ≤3.21.31 (0.86 – 1.99)1.32 (0.85 – 2.06)Within 12 months prior to index dateLog CRP1.41 (1.14 – 1.75)1.38 (1.09 – 1.74)CRP≥5 vs. CRP<52.60 (1.59 – 4.27)2.60 (1.54 – 4.41)Log ESR1.65 (1.26 – 2.16)1.60 (1.21 – 2.12)ESR >21 vs. ESR ≤212.43 (1.53 – 3.86)2.35 (1.45 – 3.81)DAS281.16 (0.99 – 1.36)1.13 (0.95 – 1.34)DAS28 >3.2 vs. DAS28 ≤3.21.37 (0.82 – 2.30)1.37 (0.79 – 2.35)Figure 1

. Upper Figures. Unimputed and untransformed CRP, ESR and DAS28 12 months prior to the index date as means with 95% CI, computed by mixed models with matching strata as random effects. The left y-axis refers to CRP and ESR, the right to DAS28. Lower Figures. Percentages of patients with CRP≥5, ESR>21 and DAS28>3.2 12 months prior to the index date.

Conclusion

In contrast to other data, our analyses found that markers of systemic inflammation, but not the DAS28 composite score, are associated with the occurrence of incident ILD in patients with RA and can be predictors for the development of RA-ILD. Therefore, in a treat-to-target approach, rheumatologists should pay particular attention to controlling systemic inflammation.

References

[1]PMID: 20851924

[2]PMID: 30951251

Acknowledgements

RABBIT is supported by a joint, unconditional grant from AbbVie, Amgen, BMS, Fresenius-Kabi, Galapagos, Hexal, Lilly, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi-Aventis, Viatris and UCB.

Disclosure of Interests

Ronja Ramien: None declared, Tatjana Rudi: None declared, Matthias Schneider Speakers bureau: Astra-Zeneca; Biogen; BMS; Celgene; Chugai; GSK; Janssen-Cilag; Lilly; Pfizer; UCB, Paid instructor for: Lilly, Consultant of: Abbvie; Astra-Zeneca; Boehringer-Ingelheim; GSK; Lilly; Novartis; Pfizer; Protagen; Roche; Sanofi-Aventis; UCB, Grant/research support from: Abbvie; Astra-Zeneca; GSK; UCB, Sabine Balzer: None declared, Andreas Krause Speakers bureau: AbbVie, BMS, Boehringer Ingelheim, Celgene, Galapagos, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Consultant of: AbbVie, BMS, Boehringer Ingelheim, Galapagos, Janssen, Lilly, MSD, Mylan, Novartis, Pfizer, Roche, Grant/research support from: AbbVie, UCB, Martin Schaefer: None declared, Yvette Meissner Speakers bureau: Pfizer, Anja Strangfeld Speakers bureau: AbbVie, Amgen, BMS, Celltrion, Janssen, Lilly, Pfizer, Roche, Sanofi, UCB.

OP0135 RISK OF CARDIOVASCULAR EVENTS UNDER JANUS KINASE INHIBITORS IN PATIENTS WITH RHEUMATOID ARTHRITIS: OBSERVATIONAL DATA FROM THE GERMAN RABBIT REGISTER

Background

In 2021, the European and US-American regulatory agencies EMA and FDA issued warnings about the cardiovascular (CV) safety of the Janus kinase inhibitor (JAKi) tofacitinib and required changes in labelling. These actions were based on results of the post-authorisation safety trial Oral Surveillance(1).

Objectives

To analyse major cardiovascular events (MACE) under treatment with JAKi, tumor necrosis factor inhibitors (TNFi) or conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs - bionaive) in patients with rheumatoid arthritis (RA) observed in daily rheumatological care.

Methods

Data from patients enrolled in the biologics register RABBIT with treatment episodes from 01/2017 - 04/2021 were included. Incidence rates (IR) of MACE per 100 patient-years (PY) with 95% confidence intervals (CI) and adjusted risk ratios (RR) were calculated for all and for high-risk patients (age ≥ 50 years and ≥ 1 CV risk factor). Poisson regression analysis was adjusted for age, sex, smoking, disease activity, prior therapies, glucocorticoids and comorbidities.

Results

Starting from 2017, 2030 JAKi, 2338 TNFi and 871 csDMARD initiations were documented. Patients with a JAKi start were slightly older, more often women and had a longer RA disease duration (Table 1). The proportion with positive autoantibodies was higher than in the TNFi and csDMARD group, the physical function was lower, and they had received more previous biologic treatments. Characteristics of high-risk patients are also given in the Table 1.

Table 1.

Patient characteristics at the start of a JAKi, TNFi or csDMARD.

ALL PATIENTSHIGH RISK PATIENTS*JAKiTNFicsDMARDJAKiTNFicsDMARD# treatment starts2030233887112151254508Age59.9 ± 11.657.6 ± 13.059.5 ± 12.764.3 ± 8.963.5 ± 8.964.4 ± 9.2Women1573 (77.5)1707 (73.0)627 (72.0)907 (74.7)864 (68.9)355 (69.9)Disease duration12.6 ± 9.68.9 ± 8.55.7 ± 6.613.3 ± 9.99.7 ± 9.16.0 ± 7.0Rheumatoid factor/ ACPA positive1531 (79.2)1672 (74.2)548 (66.3)917 (79.7)890 (73.7)321 (66.5)# previous bDMARDs2.0 ± 1.80.7 ± 1.202.0 ± 1.80.7 ± 1.20DAS28-ESR4.2 ± 1.44.5 ± 1.44.2 ± 1.34.4 ± 1.54.7 ± 1.34.3 ± 1.3Percentage of full physical function63.3 ± 24.168.6 ± 22.472.3 ± 21.960.3 ± 24.264.4 ± 23.369.6 ± 22.7Glucocorticoids ≥10 mg/d170 (17.5)239 (21.5)49 (12.4)112 (18.6)142 (22.3)23 (10.0)BMI >30 kg/m2565 (28.2)631 (27.4)271 (31.7)383 (31.8)413 (33.3)180 (36.0)Sum of comorbidities2.9 ± 2.52.6 ± 2.42.2 ± 2.23.7 ± 2.63.5 ± 2.53.1 ± 2.3Current smokers461 (26.3)617 (28.5)274 (33.5)355 (33.5)466 (39.5)202 (42.3)Previous smokers551 (31.4)692 (31.9)230 (28.1)300 (28.3)338 (28.6)114 (23.9)

Values are given as mean ± standard deviation or number (percentage). *Age ≥50 years and ≥ 1 CV risk factor (hypertension, coronary heart disease, diabetes, hyperlipoproteinaemia, current smoking)

In total, 28 incident MACE were reported. Patients under treatment with JAKi, TNFi and csDMARD showed comparable IR for MACE between 0.26 and 0.41 events per 100 PY (Figure 1). High-risk patients showed higher IRs. The median time under treatment was 10 months on JAKi and TNFi, and 12 months on csDMARDs. The majority of events were reported in the first year after treatment start. In the adjusted analyses, JAKi (RR 0.94 [95% CI 0.39; 2.28]) and csDMARDs (RR 0.85 [0.25; 2.88]) did not show a significantly increased risk for MACE compared with TNFi in unselected patients, and also not in high-risk patients (JAKi: RR 0.90 [0.37; 2.17]; csDMARDs: RR 0.61 [0.16; 2.28]).

Figure 1.

Incidence rates of MACE per 100 patient years by treatment group.

Conclusion

IR of MACE in patients receiving JAKi in a real-world setting was lower than the IR reported for tofacitinib in the Oral Surveillance study. We found no evidence of an increased risk of MACE with JAKi compared to TNFi, although patients in the JAKi group were older and had longer disease duration.

References

[1]Pfizer Press Release (27 Jan 2021):https://www.pfizer.com/news/press-release/press-release-detail/pfizer-shares-co-primary-endpoint-results-post-marketing

Acknowledgements

RABBIT is supported by a joint, unconditional grant from AbbVie, Amgen, BMS, Fresenius-Kabi, Galapagos, Hexal, Lilly, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi-Aventis, VIATRIS and UCB.

Disclosure of Interests

Yvette Meissner Speakers bureau: Pfizer, Katinka Albrecht: None declared, Jörn Kekow: None declared, Silke Zinke Speakers bureau: Biogen, Galapagos, UCB, Lilly, Consultant of: Abbvie, Biogen, Galapagos, Novartis, Hans-Peter Tony Consultant of: AbbVie, Astra-Zeneca, BMS, Chugai, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, Sanofi, Martin Schaefer: None declared, Anja Strangfeld Speakers bureau: AbbVie, Amgen, BMS, Celltrion, Janssen, Lilly, Pfizer, Roche, Sanofi, UCB.

OP0249 CHARACTERISTICS ASSOCIATED WITH POOR COVID-19 OUTCOMES IN PEOPLE WITH PSORIASIS AND SPONDYLOARTHRITIS: DATA FROM THE COVID-19 PsoProtect AND GLOBAL RHEUMATOLOGY ALLIANCE PHYSICIAN-REPORTED REGISTRIES

Background

Some factors associated with severe COVID-19 outcomes have been identified in patients with psoriasis (PsO) and inflammatory/autoimmune rheumatic diseases, namely older age, male sex, comorbidity burden, higher disease activity, and certain medications such as rituximab. However, information about specificities of patients with PsO, psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), including disease modifying anti-rheumatic drugs (DMARDs) specifically licensed for these conditions, such as IL-17 inhibitors (IL-17i), IL-23/IL-12 + 23 inhibitors (IL-23/IL-12 + 23i), and apremilast, is lacking.

Objectives

To determine characteristics associated with severe COVID-19 outcomes in people with PsO, PsA and axSpA.

Methods

This study was a pooled analysis of data from two physician-reported registries: the Psoriasis Patient Registry for Outcomes, Therapy and Epidemiology of COVID-19 Infection (PsoProtect), comprising patients with PsO/PsA, and the COVID-19 Global Rheumatology Alliance (GRA) registry, comprising patients with PsA/axSpA. Data from the beginning of the pandemic up to 25 October, 2021 were included. An ordinal severity outcome was defined as: 1) not hospitalised, 2) hospitalised without death, and 3) death. A multivariable ordinal logistic regression model was constructed to assess the relationship between COVID-19 severity and demographic characteristics (age, sex, time period of infection), comorbidities (hypertension, other cardiovascular disease [CVD], chronic obstructive lung disease [COPD], asthma, other chronic lung disease, chronic kidney disease, cancer, smoking, obesity, diabetes mellitus [DM]), rheumatic/skin disease (PsO, PsA, axSpA), physician-reported disease activity, and medication exposure (methotrexate, leflunomide, sulfasalazine, TNFi, IL17i, IL-23/IL-12 + 23i, Janus kinase inhibitors (JAKi), apremilast, glucocorticoids [GC] and NSAIDs). Age-adjustment was performed employing four-knot restricted cubic splines. Country-adjustment was performed using random effects.

Results

A total of 5008 individuals with PsO (n=921), PsA (n=2263) and axSpA (n=1824) were included. Mean age was 50 years (SD 13.5) and 51.8% were male. Hospitalisation (without death) was observed in 14.6% of cases and 1.8% died. In the multivariable model, the following variables were associated with severe COVID-19 outcomes: older age (Figure 1), male sex (OR 1.53, 95%CI 1.29-1.82), CVD (hypertension alone: 1.26, 1.02-1.56; other CVD alone: 1.89, 1.22-2.94; vs no hypertension and no other CVD), COPD or asthma (1.75, 1.32-2.32), other lung disease (2.56, 1.66-3.97), chronic kidney disease (2.32, 1.50-3.59), obesity and DM (obesity alone: 1.36, 1.07-1.71; DM alone: 1.85, 1.39-2.47; obesity and DM: 1.89, 1.34-2.67; vs no obesity and no DM), higher disease activity and GC intake (remission/low disease activity and GC intake: 1.96, 1.36-2.82; moderate/severe disease activity and no GC intake: 1.35, 1.05-1.72; moderate/severe disease activity and GC intake 2.30, 1.41-3.74; vs remission/low disease activity and no GC intake). Conversely, the following variables were associated with less severe COVID-19 outcomes: time period after 15 June 2020 (16 June 2020-31 December 2020: 0.42, 0.34-0.51; 1 January 2021 onwards: 0.52, 0.41-0.67; vs time period until 15 June 2020), a diagnosis of PsO (without arthritis) (0.49, 0.37-0.65; vs PsA), and exposure to TNFi (0.58, 0.45-0.75; vs no DMARDs), IL17i (0.63, 0.45-0.88; vs no DMARDs), IL-23/IL-12 + 23i (0.68, 0.46-0.997; vs no DMARDs) and NSAIDs (0.77, 0.60-0.98; vs no NSAIDs).

Conclusion

More severe COVID-19 outcomes in PsO, PsA and axSpA are largely driven by demographic factors (age, sex), comorbidities, and active disease. None of the DMARDs typically used in PsO, PsA and axSpA, were associated with severe COVID-19 outcomes, including IL-17i, IL-23/IL-12 + 23i, JAKi and apremilast.

Acknowledgements

We thank all the contributors to the COVID-19 PsoProtect, GRA and EULAR Registries.

Disclosure of Interests

None declared

In silico approaches in organ toxicity hazard assessment: current status and future needs in predicting liver toxicity

Hepatotoxicity is one of the most frequently observed adverse effects resulting from exposure to a xenobiotic. For example, in pharmaceutical research and development it is one of the major reasons for drug withdrawals, clinical failures, and discontinuation of drug candidates. The development of faster and cheaper methods to assess hepatotoxicity that are both more sustainable and more informative is critically needed. The biological mechanisms and processes underpinning hepatotoxicity are summarized and experimental approaches to support the prediction of hepatotoxicity are described, including toxicokinetic considerations. The paper describes the increasingly important role of in silico approaches and highlights challenges to the adoption of these methods including the lack of a commonly agreed upon protocol for performing such an assessment and the need for in silico solutions that take dose into consideration. A proposed framework for the integration of in silico and experimental information is provided along with a case study describing how computational methods have been used to successfully respond to a regulatory question concerning non-genotoxic impurities in chemically synthesized pharmaceuticals.

In silico approaches in organ toxicity hazard assessment: Current status and future needs for predicting heart, kidney and lung toxicities

The kidneys, heart and lungs are vital organ systems evaluated as part of acute or chronic toxicity assessments. New methodologies are being developed to predict these adverse effects based on in vitro and in silico approaches. This paper reviews the current state of the art in predicting these organ toxicities. It outlines the biological basis, processes and endpoints for kidney toxicity, pulmonary toxicity, respiratory irritation and sensitization as well as functional and structural cardiac toxicities. The review also covers current experimental approaches, including off-target panels from secondary pharmacology batteries. Current in silico approaches for prediction of these effects and mechanisms are described as well as obstacles to the use of in silico methods. Ultimately, a commonly accepted protocol for performing such assessment would be a valuable resource to expand the use of such approaches across different regulatory and industrial applications. However, a number of factors impede their widespread deployment including a lack of a comprehensive mechanistic understanding, limited in vitro testing approaches and limited in vivo databases suitable for modeling, a limited understanding of how to incorporate absorption, distribution, metabolism, and excretion (ADME) considerations into the overall process, a lack of in silico models designed to predict a safe dose and an accepted framework for organizing the key characteristics of these organ toxicants.

OP0105 FEASIBILITY AND USEFULNESS OF MAPPING BIOLOGIC REGISTRIES TO A COMMON DATA MODEL: ILLUSTRATION USING COMORBIDITIES

Background:

The Observational and Medical Outcomes Partnerships (OMOP) common data model (CDM) provides a framework for standardising health data with a view towards federated analyses, thus maximising the use and power of combining disparate datasets.

Objectives:

To assess feasibility and usefulness of mapping biologic registry data from different European countries to the OMOP CDM and present initial descriptive data regarding comorbidities.

Methods:

Five biologic registries, as part of a funded FOREUM project, have been mapped to the OMOP CDM: 1) the Czech biologics register (ATTRA), 2) Registro Español de Acontecimientos Adversos de Terapias Biológicas en Enfermedades Reumáticas (BIOBADASER), 3) British Society for Rheumatology Biologics Register for Rheumatoid Arthritis (BSRBR-RA), 4) German biologics register ‘Rheumatoid arthritis observation of biologic therapy’ (RABBIT), and 5) Swiss register ‘Swiss Clinical Quality Management in Rheumatic Diseases’ (SCQM). The mapping includes socio-demographic, observation period within the studies, baseline comorbidities, and baseline medications. Only patients with RA were included. Using R, registers received identical scripts to run on their mapped databases to produce an initial description of patient characteristics without the need to share patient-level data.

Results:

A total of 54,458 individuals are included the five registries being mapped to the OMOP CDM, see table. Age and gender distribution was similar across registries. All registers reported on cardiovascular system comorbidities, diabetes mellitus, mental disorders, and respiratory system comorbidities. However, it was noted that results of comorbidity mapping relies on what each register collect on each patient at the point of registration.

Whilst the Charlson comorbidity index could be calculated within each registry, due to lack of the specific coding needed, such as “uncomplicated diabetes mellitus” / “end-organ damage diabetes mellitus”, it was felt to be an inaccurate measure. The granularity of the comorbidities was insufficient, as many registers coded, for example, diabetes mellitus without any extra information.

Table 1.

OARSI scores

RegistryATTRABIOBADASERBSRBR-RARABBITSCQMCountryCzechiaSpainUnited KingdomGermanySwitzerlandNumber of Participants23343012251791365210281Gender FemaleMale1808 (77%)526 (23%)2372 (79%)640 (21%)18995 (75%)6184 (25%)10191 (75%)3461 (25%)7584 (74%)2697 (26%)Age at observation start date59 (52, 66)56 (47, 63)58 (49, 66)58 (50, 67)57 (47, 66)First observation start dateFeb-2002Oct-1999Oct-2001Aug-2006March-1995Number of comorbidities1 (1, 2)1 (0, 2)1 (0, 2)2 (1, 3)2 (1, 4)Disorder of cardiovascular system1609 (69%)208 (7%)2239 (9%)6330 (46%)3969 (39%)Diabetes mellitus331 (14%)273 (9%)1770 (7%)1591 (12%)792 (8%)Depressive Disorder165 (7%)04971 (20%)1023 (7%)1337 (13%)Disorder of respiratory system215 (9%)209 (7%)4125 (16%)1282 (9%)1630 (16%)

Conclusion:

This is the first analysis of data from the newly mapped OMOP CDM across five European registers. Through mapping the registers into a CDM, and using the same script, the ability to undertake collaborative analysis without sharing patient level data outside of the country can be realised. Due to differences in study design and data capture, there needs to be a focus on harmonising the coding and analysing of the comorbidities and drugs across registries.

Disclosure of Interests:

Lianne Kearsley-Fleet: None declared, Kimme Hyrich: None declared, Martin Schaefer: None declared, Doreen Huschek: None declared, Anja Strangfeld: None declared, Jakub Zavada Speakers bureau: Abbvie, Eli-Lilly, UCB, Sanofi., Consultant of: Abbvie, UCB, Sanofi, Gilead., Markéta Lagová: None declared, Delphine Courvoisier Speakers bureau: Medtalks Switzerland, Christoph Tellenbach: None declared, Kim Lauper Speakers bureau: Medtalks Switzerland, Carlos Sánchez-Piedra: None declared, Nuria Montero: None declared, Jesús-Tomás Sánchez-Costa: None declared, Daniel Prieto-Alhambra Consultant of: Amgen (speaker fees and advisory board membership fees paid to DPA’s department) and UCB (consultancy fees paid to DPA’s department), Grant/research support from: grants and other from AMGEN, grants, non-financial support and other from UCB Biopharma, grants from Les Laboratoires Servier, outside the submitted work., Edward Burn: None declared

OP0116 ELDERLY PATIENTS ARE NOT AT INCREASED RISK OF SERIOUS INFECTIONS WHEN RECEIVING BDMARDS OR JAK INHIBITORS COMPARED TO CSDMARD TREATMENT

Background:

Elderly rheumatoid arthritis (RA) patients are generally at increased risk of serious infections (SI). At the same time, treatment with bDMARDs has been associated with a higher SI risk than treatment with csDMARDs (1). However, long-term use of bDMARDs did not increase the risk of SI in a small group of elderly patients over 65 (2). The extent to which elderly patients are exposed to a higher SI risk when treated with JAK inhibitors (JAKi) is an open question.

Objectives:

To assess the effects of bDMARDs and specifically JAKi on the risk of SI in elderly patients with RA.

Methods:

The German register RABBIT is a prospective, longitudinally followed cohort of RA patients enrolled with a new start of a DMARD after at least one csDMARD failure. This analysis comprises patients over 70 years of age who were enrolled between 01/2007 and 04/2020 and had at least one follow-up.

Results:

Of 13,491 patients followed-up in RABBIT, 2274 with an age > 70 years were included in the analysis. 626 SI were observed in 425 of these patients. Baseline characteristics at start of the respective DMARD are shown in Table 1. In most characteristics, patients on JAKi were more comparable to patients under bDMARDs than to those on csDMARDs. JAKi patients received glucocorticoids (GC) less frequently than patients on other treatments. The HR for SI was lower than 1 in patients receiving bDMARDs or JAKi compared to csDMARDs, but without statistical significance (Figure 1). GC use (HR 1.6, 95% CI: 1.2 – 2.2 for ≤ 10 mg/d), higher DAS28-ESR values (HR 1.1, 95% CI: 1.0 – 1.2 per 1 point increase), COPD or pulmonary fibrosis (HR 1. 8, 95% CI: 1.3 – 2.4), chronic kidney disease (HR 1.5, 95% CI: 1.2 – 1.9) and diabetes mellitus (HR 1.3, 95% CI: 1.0 – 1.7) were associated with an increased risk of SI. Better physical capacity was associated with a decreased risk of SI (HR 0.9, 95% CI: 0.88 – 0.98 for a 10 point increase).

Table 1.

Patient characteristics by treatment at baseline

ParametercsDMARDsTNFiRTXABAIL-6iJAKiN=758N=840N=209N=147N=212N=108Age (years)75.9 (3.9)75.5 (3.6)74.8 (3.6)76.1 (3.9)75.9 (3.7)76.7 (3.7)Male sex184 (24.3)220 (26.2)50 (23.9)36 (24.5)46 (21.7)28 (25.9)Ever smoker249 (32.8)287 (34.2)77 (36.8)50 (34)73 (34.4)39 (36.1)Disease duration (years)7.9 (8.8)12.3 (11.4)17 (11.1)12.8 (10)13.8 (11.7)11.9 (10.9)Seropositivity487 (64.3)671 (79.9)201 (96.2)126 (85.4)182 (85.8)79 (73.5)Number of previous DMARDs1.4 (0.7)2.5 (1.3)4.2 (1.8)3.6 (1.9)3.3 (1.8)2.6 (1.5)DAS28-ESR4.6 (1.2)5.1 (1.2)5.4 (1.3)5.3 (1.3)5.3 (1.3)5 (1.2)Proportion of full physical function64.8 (23.1)57.1 (23.6)50.4 (23.7)52.9 (23.5)55.3 (24.1)55.2 (23.7)Number of comorbidities3.1 (2.5)3.8 (2.6)4.2 (2.6)4.6 (2.9)3.6 (2.4)3.8 (2.2)No comorbidity52 (6.9)29 (3.5)4 (1.9)4 (2.7)9 (4.2)5 (4.6)Three and more comorbidities385 (50.8)528 (62.9)147 (70.3)107 (72.8)131 (61.8)76 (70.4)COPD or pulmonary fibrosis69 (9.1)89 (10.6)29 (13.9)26 (17.7)12 (5.7)11 (10.2)Chronic kidney disease94 (12.4)151 (18)28 (13.4)21 (14.3)39 (18.4)22 (20.4)Diabetes mellitus151 (19.9)172 (20.5)31 (14.8)23 (15.6)42 (19.8)25 (23.1)GCs (last 6 months)347 (45.8)526 (62.6)143 (68.8)82 (56.2)127 (59.9)44 (40.7)GCs (<5mg)447 (58.9)384 (45.7)101 (48.2)88 (60)118 (55.8)72 (66.7)GCs (5-9mg)252 (33.3)375 (44.6)81 (38.7)43 (29)72 (34.2)27 (25.1)GCs (>=10mg)59 (7.8)82 (9.8)274 (13.1)16 (11)21 (10)9 (8.2)

Results are presented as mean ± SD for continuous variables and number (percentage) for discrete variables.

Figure 1.

Hazard ratios for serious infections with 95% confidence intervals

Conclusion:

Treatment with JAKi as well as treatment with bDMARDs was not associated with an increased risk of SI in elderly patients above 70 years of age. Key comorbidities such as diabetes mellitus, chronic pulmonary and kidney diseases were associated with increased risk, as was concomitant GC use and higher disease activity.

References:

[1] Listing J et al., Rheumatology 2013; 52 (1): 53-61.

[2] Kawashima H. et al., Rheum. Intern. 2017; 37: 369-376.

Acknowledgements:

RABBIT is supported by a joint, unconditional grant from AbbVie, Amgen, BMS, Celltrion, Fresenius-Kabi, Gilead, Hexal, Lilly, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi-Aventis, UCB, and Viatris.

Disclosure of Interests:

None declared

Abstract 6221: Targeting IAP in cancer: BI 891065 a potent small molecule SMAC mimetic that synergizes with immune checkpoint inhibition

Background: Engagement of Tumor Necrosis Factor-α (TNF-α) with its receptor can lead to dramatically different cellular outcomes ranging from regulating cell survival and inflammation to induction of programmed forms of cell death. A critical proximal checkpoint determining the nature of TNF-α signaling is put in place by the cellular inhibitor of apoptosis proteins (cIAPs). In the context of cancer therapy these constitute an attractive target as they (1) block the TNF-α induced activation of apoptotic/necroptotic cues and (2) are negatively regulated by a highly selective endogenous ligand (i.e. SMAC), which served as a blueprint for the development of small molecule inhibitors of IAP (so called SMAC mimetics).

Methods: Here we investigated the efficacy of SMAC mimetic BI891065 in enhancing targeted and chemotherapeutic approaches in preclinical mouse cancer models and describe immune-modulatory effects in syngeneic settings. To identify responding indications, a large pan-cancer cell line panel screening comprising 246 cell lines was performed (Eurofins). Proliferation of cells treated with increasing concentrations of BI 891065 combined with a fixed concentration of TNF-α was assessed by high-content screening. Furthermore, to gain a better understanding of the molecular determinants associated with sensitivity to SMAC mimetic treatment, genome-wide CRISPR/Cas9 drug modifier screens were performed.

Results: Here we present key data demonstrating antitumor activity of BI891065 in preclinical models, our efforts towards understanding of genetic determinants of SMAC sensitivity and of potential responsive indications. By using genome-wide CRISPR/Cas9 drug modifier screens we not only demonstrated the feasibility of such unbiased approaches, as we identified many known (e.g. TNF Receptor 1, RIPK1, Caspase 8 and members of the NFκB signaling pathways) - but also potentially novel - regulators of TNF-α/SMAC mimetic induced cell death. In addition, to identify potential responsive indications to BI891065, extensive profiling of in vitro drug sensitivity across a large set of cancer cell types was performed. As a result of this, colorectal cancer (n=56) was identified as a promising indication: 5% of cell lines were found to be sensitive to BI 891065 single treatment. This could be further extended by the exogenous supply of TNF-α to BI 891065, increasing the number of sensitive cells to 21%.

Conclusion: The presented data demonstrate the potential of BI 891065 to facilitate tumor cell death and to enhance anti-tumor immune responses, and nominate the compound as an attractive combination partner in cancer therapy. Our results led to the identification of potentially novel modulators of SMAC mimetic sensitivity via genome-wide CRISPR/Cas9 drug sensitizer screens and suggest colorectal cancer as a promising indication for clinical positioning.

Citation Format: Martin Aichinger, Valeria Santoro, Ksenija Slavic-Obradovic, Stefanie Ruhland, Andreas Wernitznig, Andrea Neudolt, Markus Schaefer, Sabine Kallenda, Daniel Zach, Sabine Olt, Carina Salomon, Sarah Rieser, Martina Weissenboeck, Florian Ebner, Andreas Schlattl, Melanie Talata De Almeida, Rebecca Langlois, Martina Sykora, Markus Reschke, Thomas Zichner, Daniel Gerlach, Julian Jude, Michaela Fellner, Dirk Scharn, Norbert Kraut, Juergen Moll, Johannes Zuber, Sebastian Carotta, Maria Antonietta Impagnatiello, Ulrike Tontsch-Grunt. Targeting IAP in cancer: BI 891065 a potent small molecule SMAC mimetic that synergizes with immune checkpoint inhibition [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 6221.

OP0012 TNF INHIBITORS ARE ASSOCIATED WITH A REDUCED RISK OF VENOUS THROMBOEMBOLISM COMPARED TO CSDMARDS IN RA PATIENTS

Background:

While the short-term use of bDMARDs up to 180 days has been associated with an increased risk of venous thromboembolism (VTE) compared to csDMARDs in patients with rheumatoid arthritis (RA), the long term use of more than 730 days has been associated with a decreased risk based on claims data [1]. Among patients with inflammatory bowel disease, observational data indicated that TNF inhibitors may have a protective effect regarding the VTE risk [2].

Objectives:

To assess the effects of TNF inhibitors and newer bDMARDs (including abatacept, rituximab, sarilumab, and tocilizumab) on the VTE risk based on observational data from RA patients.

Methods:

The German register RABBIT is a prospective longitudinally followed cohort of RA patients enrolled with a new start of a DMARD after at least one csDMARD failure. This analysis comprises patients who were enrolled with start of a bDMARD between 01/2009 and 04/2019 and had at least one follow-up.

Cox regression models were used to calculate hazard ratios (HRs) for VTEs, for csDMARDs, TNF inhibitors and other bDMARDs. Propensity score weighting was used to adjust for confounding by indication.

Results:

Patients receiving TNF inhibitors or other bDMARDs on average had higher CRP levels and a higher prevalence of cardiovascular diseases at baseline than patients receiving csDMARDs. They also received more often glucocorticoids (Table 1).

The HR of patients receiving TNF inhibitors for a serious VTE event was 0.53 (95% CI: 0.33 – 0.86) compared to csDMARDs, while the HR for patients receiving other bDMARDs was 0.66 (95% CI: 0.40 – 1.09). A CRP level of more than 5 mg/L (HR 2.09, 95% CI: 1.39 – 3.14) and an age above 65 years (HR 2.96, 95% CI: 1.94 – 4.52) increased the risk for a serious VTE event. Better physical function was associated with a decreased risk for VTEs (Table 2).

Table 1.

Patient characteristics at baseline for DMARD groups

Parameter (at time of event/end of observation unless specified otherwise)Hazard ratio95% confidence intervalTNF inhibitors (reference: csDMARDs)0.530.330.86Other bDMARDs (reference: csDMARDs)0.660.401.09Age ≥ 65 years (baseline)2.961.944.52CRP ≥ 5 ml2.091.393.14> 5 mg and ≤ 10 mg glucocorticoids/day1.040.551.98> 10 mg and ≤ 15 mg glucocorticoids/day2.350.816.79> 15 mg glucocorticoids/day2.030.765.41% of full physical capacity (per 10 percentage points increase, time of event)0.850.780.92Current smoking (baseline)0.980.611.55Former smoking (baseline)0.800.451.43Table 2.

Hazard ratios for VTE events

ParametercsDMARDsTNFiOther bDMARDsN350050602534VTE event38 (1.1)55 (1.1)23 (0.9)Age [years]58.8 (12.6)56.5 (12.9)58.1 (12.4)Female sex2575 (73.6)3734 (73.8)1933 (76.3)Disease duration [years]6.2 (7.2)9.4 (8.6)11.9 (9.2)Seropositivity2189 (62.6)3739 (73.9)2048 (80.8)Joint erosions1024 (31.0)2566 (52.4)1523 (63.3)Prior bDMARD therapies0 (0.2)0.3 (0.6)1.2 (1.2)CRP8.8 (8.1)11.6 (10.6)12.4 (11.8)DAS28-ESR4.4 (1.3)4.9 (1.2)5.1 (1.3)% of full physical capacity71.3 (21.8)66.2 (22.6)62.1 (23.5)Current glucocorticoid therapy2564 (73.3)3951 (78.1)2036 (80.4)Heart failure36 (1)113 (2.2)93 (3.7)Coronary artery disease196 (5.6)326 (6.4)183 (7.2)Cerebrovascular disease60 (1.7)86 (1.7)44 (1.7)Osteoporosis400 (11.4)771 (15.2)530 (20.9)Ever smoker1875 (53.6)2738 (54.1)1402 (55.3)

Results are presented as mean ± SD or number (percentage).

Conclusion:

Treatment with TNF inhibitors (compared to csDMARDs) and better physical function significantly reduced the risk of serious VTE events, while age above 65 years and high CRP levels increased this risk.

References:

[1]Kim S. C. et al. Am. J. Med. 2015; 128(5): 539.e7–539.e17.

[2]Desaj R.J. et al. CMAJ 2017; 189:E1438-47.

Acknowledgments:

RABBIT is supported by a joint, unconditional grant from AbbVie, Amgen, BMS, Fresenius-Kabi, Hexal, Lilly, MSD, Mylan, Pfizer, Roche, Samsung Bioepis, Sanofi-Aventis, and UCB.

Disclosure of Interests:

Martin Schaefer: None declared, Matthias Schneider Grant/research support from: GSK, UCB, Abbvie, Consultant of: Abbvie, Alexion, Astra Zeneca, BMS, Boehringer Ingelheim, Gilead, Lilly, Sanofi, UCB, Speakers bureau: Abbvie, Astra Zeneca, BMS, Chugai, GSK, Lilly, Pfizer, Sanofi, Anett Graessler: None declared, Wolfgang Ochs: None declared, Angela Zink Speakers bureau: AbbVie, Amgen, BMS, Gilead, Hexal, Janssen, Lilly, MSD, Pfizer, Roche, Sanofi Aventis, UCB, Anja Strangfeld Speakers bureau: AbbVie, BMS, Pfizer, Roche, Sanofi-Aventis

SAT0088 NO INCREASED RISK OF FALLS IN PATIENTS TREATED WITH BIOLOGICS COMPARED TO THOSE UNDER CSDMARDS

Background:

Adults with rheumatoid arthritis (RA) have an increased risk of falling. Previous studies on causes of falls have neither sufficiently nor adequately considered the effects of bDMARDs. In addition, a risk analysis of the individual substances has been lacking until now.

Objectives:

To analyze the fall risk under exposure to TNFi’s, abatacept (ABA), rituximab (RTX) and tocilizumab (TOC) in comparison to csDMARDs taking co-medication and other risk factors such as disease activity, comorbidities and other biological risks into account.

Methods:

Data of RA patients observed in RABBIT from 01/2009 - 02/2018 with a follow-up of up to 5 years was used for the analysis. In accordance with consensus guidelines, a fall was defined as “an unexpected event in which participants come to rest on the ground, floor or other lower level” [1].

Effects of bDMARDs were examined using “inverse probability weighting“ (IPW) with time-varying treatment on a monthly basis. Directed acyclic graphs were applied to support causal considerations.

Results:

The percentage of patients with falls (2.7%) was significantly lower than the previously reported 10% and 50% [2]. This underreporting is explained by the fact that falls in RABBIT are reported by the physicians and are not recorded in patient diaries. In line with other studies, falls occurred with older age, longer disease duration, poorer physical function and higher DAS28. Patients with a higher number of comorbidities had a significantly higher risk of falling. The number of patients treated with analgesics was higher in the fall group and fallers had higher glucocorticoid doses. However, the values for pain and fatigue were comparable between the two groups (Table 1). The descriptive analysis showed that patients starting second / third line biologics therapy had a shorter duration from the initiation of treatment to the fall event than patients starting with csDMARDs. None of the regression models showed an increased risk for biologics compared to csDMARDs.

Table 1.

Characteristics at baseline in fallers and non-fallers

FallerNon- FallerN2639405Age, years62.9 (11.9)57.3 (12.6)BMI, kg/m227.4 (5.8)27.3 (5.5)Female, %79.574.2Disease duration, years10.8 (9.8)8.7 (8.5)ACPA+, %46.455.1RF+, %59.765.3DAS285 (1.3)4.8 (1.3)% of full physical function61.2 (24.2)67.3 (22.7)Joint replacement, yes %16.39.8Pain, 0 – 10 scale5.8 (2.3)5.8 (2.3)Fatigue, 0 – 10 scale5.1 (2.7)5.2 (2.7)No. of comorbidities3.4 (3)2.2 (2.2)Osteoporosis, %33.514.4Analgesics, yes %2415.8Glucocorticoid dose, mg/d6 (5.1)5.4 (6.3)

Values are means (SDs) unless otherwise specified

Conclusion:

None of the inferential analyses could demonstrate an increased risk of falling for any of the bDMARDs compared to csDMARDs. Although descriptive analyses pointed to an earlier fall event in patients treated with second-/third line biologics, these results could be explained by their particular characteristics. These patients tended to be older and were more affected by RA. This suggests that these risks override the effects of bDMARDs.

Table 2.

Results of weighted* Cox regression, Reference are csDMARDs

VariablesUnivariate HR95% CIWeighted HR95% CITNFi‘s1.12(0.85; 1.48)1.05(0.80; 1.39)ABA1.00(0.57; 1.74)0.98(0.57; 1.70)RTX1.39(0.88; 2.22)1.09(0.65; 1.81)TOC0.88(0.59; 1.33)0.77(0.50; 1.18)

*Include: age, disease duration, gender, education, joint replacement, fatigue, functional status, pain, stiffness, analgesics, no. of comorbidities, selected comorbidities

References:

[1] Lamb SE, et al. Journal of the American Geriatrics Society. 2005;53(9):1618-22.

[2] Brenton-Rule A, et al.Seminars in Arthritis and Rheumatism. 2015;44(4):389-98.

Acknowledgments :

RABBIT is supported by a joint, unconditional grant from AbbVie, Amgen, BMS, Fresenius Kabi, Hexal, Lilly, MSD, Mylan, Pfizer, Roche, Samsung Bioepis, Sanofi-Aventis, and UCB.

Disclosure of Interests:

Tatjana Rudi: None declared, Martin Schaefer: None declared, Bernhard Manger Consultant of: Lilly, Celgene, Janssen, MSD, UCB, Speakers bureau: AbbVie, AstraZeneca, Alexion, Berlin-Chemie, BMS, Celgene, Chugai, Sanofi-Genzyme, GSK, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, SOBI, UCB, Angela Zink Speakers bureau: AbbVie, Amgen, BMS, Gilead, Hexal, Janssen, Lilly, MSD, Pfizer, Roche, Sanofi Aventis, UCB, Anja Strangfeld Speakers bureau: AbbVie, BMS, Pfizer, Roche, Sanofi-Aventis

OP0020 IMPACT OF BDMARDS WITH DIFFERENT MODES OF ACTION ON FATIGUE IN RA PATIENTS

Background:

Fatigue is an important patient-reported outcome. It has been reported to be potentially targetable by DMARDs with specific modes of action, particularly IL-6 inhibition [1].

Objectives:

To assess to which extent patients on DMARDs with different modes of action reach fatigue levels of 2 or less on a 0 (no fatigue) to 10 (high fatigue) scale after 6 months of treatment.

Methods:

The German register RABBIT is a prospective longitudinally followed cohort of RA patients enrolled with a new start of a DMARD after at least one csDMARD failure. This analysis comprises bionaive patients who were enrolled with start of a b/tsDMARD between 01/2009 and 04/2019, who had at least 1 follow-up, did not switch during the first 3 months and afterwards only within the same substance, and presented fatigue levels of > 2 at baseline.

Poisson regression models with a robust error variance were used to calculate risk ratios (RRs) for reaching fatigue values ≤ 2, for all DMARD modes of action. Propensity score weighting was used to adjust for confounding by indication. Multiple imputation of missing values was performed.

Results:

Baseline fatigue levels were 5.1 overall and 6.1 among patients with a fatigue level of > 2 points on average. They were comparable among different DMARD modes of action. csDMARD patients had lower values than others regarding disease duration, disease activity, or joint erosions (Table 1).

Table 1.

Patient characteristics for different DMARD modes of action

ParametercsDMARDsTNFiRTXABAIL-6JAKiN23762772115166357110Fatigue at baseline5.9 (2)6.1 (2)5.9 (2)5.9 (1.9)6.1 (2)6.3 (1.9)Age [years]58.5 (12.7)56.3 (12.4)62.7 (10.9)59.7 (12.6)57.9 (12.5)61.5 (11.5)Female sex1809 (76.1)2060 (74.3)82 (71.2)118 (71)272 (76.3)79 (70.1)Disease duration [years]6.2 (7.2)8.7 (8.1)10.8 (9.7)9.8 (9.2)7.9 (7.6)8.5 (10)Joint erosions634 (28.4)1358 (50.5)62 (56.8)91 (55.4)158 (46.4)45 (41.3)Prior csDMARD therapies1.3 (0.6)2.3 (1)2.5 (1.1)2.2 (1)2.2 (0.9)1.8 (0.8)DAS28-ESR4.6 (1.2)5 (1.2)5.3 (1.3)5.3 (1.2)5.2 (1.3)4.9 (1.3)% of full physical capacity67.4 (21.6)64.6 (22)57 (23.5)59.5 (21.3)63.8 (20.9)61.6 (23)Glucocorticoid therapy (last 6 months)1161 (48.9)1747 (63)76 (66.4)93 (56)198 (55.5)42 (38.1)Fibromyalgia73 (3.1)111 (4)6 (5.2)7 (4.2)11 (3.1)1 (0.9)Depression180 (7.6)218 (7.9)10 (8.7)14 (8.4)26 (7.3)16 (14.6)Ever smoker1252 (52.7)1497 (54)68 (59)84 (50.7)200 (56)59 (53.5)

Results are presented as mean ± SD or number (percentage). Absolute numbers may be rounded due to multiple imputation.

The RR of IL-6 inhibitors for achieving a fatigue level of ≤ 2 was 1.34 (95% CI: 1.09 – 1.64) compared to csDMARDs. Among other factors, current smoking, prevalent fibromyalgia and depression had a negative impact on achieving a low fatigue level (Table 2).

Table 2.

Risk ratios for achieving fatigue levels ≤2

Parameter (at baseline)RR95% confidence intervalFatigue (1 point higher)0.83(0.80;0.86)TNF inhibitor (vs. csDMARDs)1.11(0.99;1.24)Rituximab (vs. csDMARDs)1.10(0.71;1.68)Abatacept (vs. csDMARDs)1.13(0.82;1.54)IL-6 inhibitor (vs. csDMARDs)1.34(1.09;1.64)JAK inhibitor (vs. csDMARDs)1.19(0.81;1.75)Age (5 years more)0.97(0.95;0.99)Female sex0.83(0.74;0.92)Patient global health (1 point higher)0.97(0.94;0.997)Joint erosions1.19(1.07;1.32)Current smoking0.86(0.76;0.98)Former smoking0.92(0.82;1.04)Fibromyalgia0.56(0.35;0.90)Depression0.75(0.59;0.95)

Conclusion:

Treatment with IL-6 inhibitors significantly increases the chance of reaching low fatigue levels within half a year in RA patients, while current smoking reduces it.

References:

[1]Choy E.H.S. and Calabrese L. H Rheumatology 2018;57:1885-95.

Acknowledgments:

RABBIT is supported by a joint, unconditional grant from AbbVie, Amgen, BMS, Fresenius Kabi, Hexal, Lilly, MSD, Mylan, Pfizer, Roche, Samsung Bioepis, Sanofi-Aventis, and UCB.

Disclosure of Interests:

Martin Schaefer: None declared, Peter Herzer Speakers bureau: AbbVie, Novartis, Sanofi, Janssen, Cornelia Kühne Grant/research support from: Novartis, Amgen, Roche/Chugai, Pfizer, Celgene, AbbVie, Sanofi, Herbert Kellner Grant/research support from: Biogen, Consultant of: Biogen, Speakers bureau: Biogen, Angela Zink Speakers bureau: AbbVie, Amgen, BMS, Gilead, Hexal, Janssen, Lilly, MSD, Pfizer, Roche, Sanofi Aventis, UCB, Anja Strangfeld Speakers bureau: AbbVie, BMS, Pfizer, Roche, Sanofi-Aventis

OP0285 TOWARDS IMPLEMENTING THE OMOP CDM ACROSS FIVE EUROPEAN BIOLOGIC REGISTRIES

Background:

The Observational and Medical Outcomes Partnerships (OMOP) common data model (CDM) provides a framework for standardising health data.

Objectives:

To map national biologic registry data collected from different European countries to the OMOP CDM.

Methods:

Five biologic registries are currently being mapped to the OMOP CDM: 1) the Czech biologics register (ATTRA), 2) Registro Español de Acontecimientos Adversos de Terapias Biológicas en Enfermedades Reumáticas (BIOBADASER), 3) British Society for Rheumatology Biologics Register for Rheumatoid Arthritis (BSRBR-RA), 4) German biologics register ‘Rheumatoid arthritis observation of biologic therapy’ (RABBIT), and 5) Swiss register ’Swiss Clinical Quality Management in Rheumatic Diseases’ (SCQM).

Data collected at baseline are being mapped first. Details that uniquely identify individuals are mapped to the person table, with the observation_period table defining the time a person may have had clinical events recorded. Baseline comorbidities are mapped to the condition_occurrence CDM table, while baseline medications are mapped to the drug_exposure CDM table. This mapping is summarised in Figure 1.

Figure 1.

Overview of initial mapping

Results:

A total of 64,901 individuals are included in the 5 registries being mapped to the OMOP CDM, see table 1. The number of unique baseline conditions being mapped range from 17 in BSRBR-RA to 108 in RABBIT, while the number of baseline medications range from 26 in ATTRA to 802 in BSRBR-RA. Those registries which captured more comorbidities or medications generally allowed for these to be inputted as free text.

Table 1.

Summary of initial code mapping

RegistryNumber of individualsNumber of mapped baseline conditionsNumber of mapped baseline medicationsATTRA5,3262626BIOBADASER6,4963051BSRBR-RA21,69517802RABBIT13,06210878SCQM18,3222633

Conclusion:

Due to differences in study design and data capture, the baseline information captured on comorbidities and drugs across registries varies greatly. However, these data have been mapped and mapping biologic registry data to the OMOP CDM is feasible. The adoption of the OMOP CDM will facilitate collaboration across registries and allow for multi-database studies which include data from both biologic registries and other sources of health data which have been mapped to the CDM.

Disclosure of Interests:

Edward Burn: None declared, Lianne Kearsley-Fleet: None declared, Kimme Hyrich Grant/research support from: Pfizer, UCB, BMS, Speakers bureau: Abbvie, Martin Schaefer: None declared, Doreen Huschek: None declared, Anja Strangfeld Speakers bureau: AbbVie, BMS, Pfizer, Roche, Sanofi-Aventis, Jakub Zavada Speakers bureau: Abbvie, UCB, Sanofi, Elli-Lilly, Novartis, Zentiva, Accord, Markéta Lagová: None declared, Delphine Courvoisier: None declared, Christoph Tellenbach: None declared, Kim Lauper: None declared, Carlos Sánchez-Piedra: None declared, Nuria Montero: None declared, Jesús-Tomás Sanchez-Costa: None declared, Daniel Prieto-Alhambra Grant/research support from: Professor Prieto-Alhambra has received research Grants from AMGEN, UCB Biopharma and Les Laboratoires Servier, Consultant of: DPA’s department has received fees for consultancy services from UCB Biopharma, Speakers bureau: DPA’s department has received fees for speaker and advisory board membership services from Amgen

P4722Using the multidimensional prognostic index (MPI) to predict outcome in patients undergoing transcatheter mitral valve repair with MitraClip: a prospective observational single centre study

Background

Selection of patients who benefit from percutaneous mitral valve repair (PMVR) is challenging. We used the multidimensional prognostic index (MPI) to evaluate patients' prognosis.

Methods

We conducted a prospective observational single centre study, including patients who did undergo PMVR from 11/2017 to 07/2018. MPI score was used for geriatric assessment and calculated from 63 separate items distributed in eight domains including instrumental activities of daily living, mental status, nutrition, risk of pressure ulcers, comorbidity, medication and marital/cohabitation status.

Results

82 patients were included. Mean MPI-Score was 0.22±0.21. 41 patients (50%) belonged to MPI-1 group (low risk), 37 (45.1%) to MPI-2 group (medium risk) und 4 patients (4.9%) to MPI-3 group (high risk). Due to the low number of patients in MPI-3 group, MPI-2 group and MPI-3 group were combined for statistical analysis. Baseline characteristics, functional assessment and outcome of patients are shown in Table1. During follow-up 4 patients died. All of these belonged to the higher risk group MPI 2/3.

Table1 MPI 1 MPI 2+3 p value Age 73.2±8.8 78.9±7.6 0.002 6 min walk 303±107 175±122 <0.001 EuroScore II (%) 6.61±7.24 7.6±5.55 0.49 EF (%) 43.7±17.2 39.4±15.6 0.36 NT-pro BNP 4611±5413 6045±12670 0.54 Diabetes 7 (17.1) 16 (39) 0.027 Coronary artery disease 25 (61) 26 (63.4) 0.82 Arterial hypertension 26 (63.4) 31 (75.6) 0.23 Barthel index baseline 98±4 80±24 <0.001 Barthel index 30 days 97±5 82±24 <0.001 MLWHFQ baseline 45.7±20.9 49.1±14.5 0.39 MLWHFQ 30 days 38.4±25 34.7±18.2 0.53 ICU stay (days) 1.7±1.2 3.9±7.4 0.069 Death at 30 days 0 4 (10.5) 0.033

Conclusion

The MPI score is associated with age and impaired functional capacity at baseline but not with traditional cardiovascular prognostic markers. Thus, MPI may provide additional prognostic information on mortality and functional outcome of patients beyond established risk scores.

Acceptance of a medication refill reminder service in German community pharmacy practice

Medication refill reminder services (MRRS), having the potential to support the detection of non-adherence and to promote periodic medication refilling by addressing forgetfulness, are not generally available in community pharmacy practice. Based on a new software module, a MRRS was developed. The acceptance of this service was tested in community pharmacies in Germany. Patients were recruited by trained pharmacy staff. Supported by the software, the pharmacies reminded patients to refill their prescription. After 7 months, the service was evaluated by patients and pharmacy staff. The pharmacy owners/managers were interviewed. Ten pharmacies applied the service to 148 patients, with 806 refill reminders for 391 drugs. Seventy-five patients (50.7%) chose to be reminded by a phone call, followed by text message (n=25), and email (n=18). Of all patients, 75 (50.7%) completed the paper-based questionnaire. Sixty-eight (90.7%) rated the service as good or very good and 54 (72.0%) felt more satisfied with their pharmacy. Sixty-four patients (85.3%) considered the service as supportive and wanted to continue. Thirty-nine pharmacy staff members (61.9%) answered the online questionnaire. Twenty-four (61.5%) stated that they found it difficult to use and apply the MRRS; twenty-six (66.6%) experienced technical problems. The service was rated good by 16 (41.0%) pharmacy staff members. They regarded the service helpful for some patients and wanted to continue after the end of the study. The majority of the ten interviewed pharmacy owners/managers expressed the opinion that the service was not very suitable for increasing customer loyalty and not cost-effective. Nevertheless, six (60.0%) of them wanted to continue using the service. The MRRS seems to be feasible, apart from technical difficulties. Patients rated the service as supportive, and the personal contact seems to be of high importance; most patients would like to continue the service. However, offering the service to patients turned out to be challenging in daily German community pharmacy practice.

Assessing the impacts of bait collection on inter-tidal sediment and the associated macrofaunal and bird communities: The importance of appropriate spatial scales

Bait collection is a multibillion dollar worldwide activity that is often managed ineffectively. For managers to understand the impacts on protected inter-tidal mudflats and waders at appropriate spatial scales macrofaunal surveys combined with video recordings of birds and bait collectors were undertaken at two UK sites. Dug sediment constituted approximately 8% of the surveyed area at both sites and is less muddy (lower organic content) than undug sediment. This may have significant implications for turbidity. Differences in the macrofaunal community between dug and undug areas if the same shore height is compared as well as changes in the dispersion of the community occurred at one site. Collection also induces a 'temporary loss of habitat' for some birds as bait collector numbers negatively correlate with wader and gull abundance. Bait collection changes the coherence and ecological structure of inter-tidal mudflats as well as directly affecting wading birds. However, as β diversity increased we suggest that management at appropriate hectare/site scales could maximise biodiversity/function whilst still supporting collection.

Mechanical stability of talin rod controls cell migration and substrate sensing

Cells adhere to the surrounding tissue and probe its mechanical properties by forming cell-matrix adhesions. Talin is a critical adhesion protein and participates in the transmission of mechanical signals between extracellular matrix and cell cytoskeleton. Force induced unfolding of talin rod subdomains has been proposed to act as a cellular mechanosensor, but so far evidence linking their mechanical stability and cellular response has been lacking. Here, by utilizing computationally designed mutations, we demonstrate that stepwise destabilization of the talin rod R3 subdomain decreases cellular traction force generation, which affects talin and vinculin dynamics in cell-matrix adhesions and results in the formation of talin-rich but unstable adhesions. We observed a connection between talin stability and the rate of cell migration and also found that talin destabilization affects the usage of different integrin subtypes and sensing of extracellular matrix proteins. Experiments with truncated forms of talin confirm the mechanosensory role of the talin R3 subdomain and exclude the possibility that the observed effects are caused by the release of talin head-rod autoinhibition. In conclusion, this study provides evidence into how the controlled talin rod domain unfolding acts as a key regulator of adhesion structure and function and consequently controls central cellular processes such as cell migration and substrate sensing.

Alloreactive T Cells to Identify Risk HLA Alleles for Retransplantation After Acute Accelerated Steroid-Resistant Rejection

The risk of rejection by cellular alloreactivity to the transplant donor is not routinely assessed. Here we analyzed alloreactive T cells in kidney transplant recipients and report how their detection may have helped to prevent rejection of a second kidney graft in a patient with a history of acute accelerated steroid-resistant nonhumoral rejection. Alloreactive CD4 and CD8 T cells were quantified using a flow-cytometric mixed lymphocyte reaction assay based on interferon-γ induction. A group of 16 nonrejecting transplant recipients did not show any alloreactive T-cell immunity to their respective donors, whereas alloreactivity to third-party controls was detectable. In the patient with rejection, HLA-specific antibodies were not detectable before and shortly after rejection, but after transplantation the patient showed exceptionally high frequencies of alloreactive T cells against 2 of 11 HLA-typed controls (0.604% and 0.791% alloreactive CD4 T cells and 0.792% and 0.978% alloreactive CD8 T cells) who shared HLA alleles (HLA-A*24, -B*44, -C*02, -DQB1*5) with the kidney donor. These HLA alleles were subsequently excluded for allocation of a second graft. No alloreactive T cells were observed toward the second kidney donor, and this transplantation was performed successfully. Thus, shared HLA alleles between the donor and third-party controls may suggest that alloreactive T cells had contributed to rejection of the first graft. The rejecting patient highlights that determination of cellular alloreactivity before transplantation may be applied to identify unacceptable mismatches and to reduce the risk for acute cellular rejection episodes.

Bat auditory cortex – model for general mammalian auditory computation or special design solution for active time perception?

Audition in bats serves passive orientation, alerting functions and communication as it does in other vertebrates. In addition, bats have evolved echolocation for orientation and prey detection and capture. This put a selective pressure on the auditory system in regard to echolocation-relevant temporal computation and frequency analysis. The present review attempts to evaluate in which respect the processing modules of bat auditory cortex (AC) are a model for typical mammalian AC function or are designed for echolocation-unique purposes. We conclude that, while cortical area arrangement and cortical frequency processing does not deviate greatly from that of other mammals, the echo delay time-sensitive dorsal cortex regions contain special designs for very powerful time perception. Different bat species have either a unique chronotopic cortex topography or a distributed salt-and-pepper representation of echo delay. The two designs seem to enable similar behavioural performance.

Citrus fruit and fabacea secondary metabolites potently and selectively block TRPM3

BACKGROUND AND PURPOSE

The melastatin-related transient receptor potential TRPM3 is a calcium-permeable nonselective cation channel that can be activated by the neurosteroid pregnenolone sulphate (PregS) and heat. TRPM3-deficient mice show an impaired perception of noxious heat. Hence, drugs inhibiting TRPM3 possibly get in focus of analgesic therapy.

EXPERIMENTAL APPROACH

Fluorometric methods were used to identify novel TRPM3-blocking compounds and to characterize their potency and selectivity to block TRPM3 but not other sensory TRP channels. Biophysical properties of the block were assessed using electrophysiological methods. Single cell calcium measurements confirmed the block of endogenously expressed TRPM3 channels in rat and mouse dorsal root ganglion (DRG) neurones.

KEY RESULTS

By screening a compound library, we identified three natural compounds as potent blockers of TRPM3. Naringenin and hesperetin belong to the citrus fruit flavanones, and ononetin is a deoxybenzoin. Eriodictyol, a metabolite of naringenin and hesperetin, was still biologically active as a TRPM3 blocker. The compounds exhibited a marked specificity for recombinant TRPM3 and blocked PregS-induced [Ca(2+)]i signals in freshly isolated DRG neurones.

CONCLUSION AND IMPLICATIONS

The data indicate that citrus fruit flavonoids are potent and selective blockers of TRPM3. Their potencies ranged from upper nanomolar to lower micromolar concentrations. Since physiological functions of TRPM3 channels are still poorly defined, the development and validation of potent and selective blockers is expected to contribute to clarifying the role of TRPM3 in vivo. Considering the involvement of TRPM3 in nociception, TRPM3 blockers may represent a novel concept for analgesic treatment.

Interaction of DPP10a with Kv4.3 channel complex results in a sustained current component of human transient outward current Ito

The sustained component of the K(+) outward current in human atrial myocytes is believed to be due to the slowly inactivating ultra-rapid potassium current I Kur and not to the fast inactivating transient outward current Ito. Here we provide evidence for contribution of Ito to this late current due to the effects of dipeptidyl peptidase-like protein (DPP) 10 (DPP10a) interacting with Kv4.3 channels. We studied the late current component of Ito in human atrial myocytes and CHO cells co-expressing Kv4.3 or Kv4.3/KChIP2 (control) and DPP proteins using voltage-clamp technique and a pharmacological approach. A voltage dependent and slowly inactivating late current (43% of peak amplitude) could be observed in atrial myocytes. We found a similar current in CHO cells expressing Kv4.3/KChIP2 + DPP10a, but not in cells co-expressing Kv4.3 + DPP or Kv4.3/KChIP2 + DPP6-S. Assuming that DPP10a influences atrial Ito, we detected DPP10 expression of three alternatively spliced mRNAs, DPP10 protein and colocalization of Kv4.3 and DPP10 proteins in human atrial myocytes. DPP10a did not affect properties of expressed Kv1.5 excluding a contribution to the sustained IKur in atrial cells. To test for the contribution of Kv4-based Ito on sustained K(+) outward currents in human atrial myocytes, we used 4-AP to block IKur, in combination with Heteropoda toxin 2 to block Kv4 channels. We could clearly separate an Ito fraction of about 19% contributing to the late current in atrial myocytes. Thus, the interaction of DPP10a, expressed in human atrium, with Kv4.3 channels generates a sustained current component of Ito, which may affect late repolarization phase of atrial action potentials.

Bladder augmentation with small intestinal submucosa leads to unsatisfactory long-term results

PURPOSE

To evaluate the use of small intestinal submucosa (SIS) for bladder augmentation in a series of select patients.

MATERIAL AND METHODS

Six patients (age 6.5-15.4, mean 9.8 years) underwent bladder augmentation with SIS: one after a cloacal exstrophy repair, one after multiple surgery of the bladder because of vesicoureteral reflux, two with spina bifida, two after bladder exstrophy repair. All suffered from a microbladder with a mean volume of 61.5 ml (range 15-120, 7-36% of expected bladder capacity for age). Preoperative bladder compliance ranged from 1.0 to 3.3 (mean 1.3) ml/cmH2O.

RESULTS

Follow-up time ranged from 4.6 to 33.5 (mean 24.4) months. An increase of bladder volume was achieved in four patients (53-370 ml, 16-95% of expected bladder capacity for age). Bladder compliance postoperatively ranged from 0.9 to 5.6 (mean 3.0) ml/cmH2O. Histological examinations showed a complete conversion of SIS, leaving irregular urothelial lining and bladder wall containing muscular, vascular and relatively thick connective tissue in four patients and regular urothelium in two patients. Major complications were bladder stones in two patients and a bladder rupture in one patient.

CONCLUSION

Bladder augmentation with SIS in humans failed to fulfill the hopes raised by animal studies. Due to the insufficient increase in bladder compliance and therefore failure to accomplish sufficient protection of the upper urinary tract, bladder augmentation with SIS cannot be recommended as a substitute for enterocystoplasty.

Positive allosteric modulation by ivermectin of human but not murine P2X7 receptors

BACKGROUND AND PURPOSE

In mammalian cells, the anti-parasitic drug ivermectin is known as a positive allosteric modulator of the ATP-activated ion channel P2X4 and is used to discriminate between P2X4- and P2X7-mediated cellular responses. In this paper we provide evidence that the reported isoform selectivity of ivermectin is a species-specific phenomenon.

EXPERIMENTAL APPROACH

Complementary electrophysiological and fluorometric methods were applied to evaluate the effect of ivermectin on recombinantly expressed and on native P2X7 receptors. A biophysical characterization of ionic currents and of the pore dilation properties is provided.

KEY RESULTS

Unexpectedly, ivermectin potentiated currents in human monocyte-derived macrophages that endogenously express hP2X7 receptors. Likewise, currents and [Ca(2+) ](i) influx through recombinant human (hP2X7) receptors were potently enhanced by ivermectin at submaximal or saturating ATP concentrations. Since intracellular ivermectin did not mimic or prevent its activity when applied to the bath solution, the binding site of ivermectin on hP2X7 receptors appears to be accessible from the extracellular side. In contrast to currents through P2X4 receptors, ivermectin did not cause a delay in hP2X7 current decay upon ATP removal. Interestingly, NMDG(+) permeability and Yo-Pro-1 uptake were not affected by ivermectin. On rat or mouse P2X7 receptors, ivermectin was only poorly effective, suggesting a species-specific mode of action.

CONCLUSIONS AND IMPLICATIONS

The data indicate a previously unrecognized species-specific modulation of human P2X7 receptors by ivermectin that should be considered when using this cell-biological tool in human cells and tissues.

Accessory subunits alter the temperature sensitivity of Kv4.3 channel complexes

In human atrial myocytes the transient outward current I(to) develops a conspicuous faster inactivation with increasing temperatures. Since β-subunits are known to modulate I(to) current kinetics, we hypothesized that the temperature sensitivity of I(to) is not only determined by the property of the ion-passing α-subunit Kv4.3 but also by its interaction with accessory β-subunits. We therefore studied the influence of the transmembrane β-subunits KCNE1, KCNE2 and DPP6 on Kv4.3/KChIP2 channels in CHO cells at room temperature and at physiological temperature. Exposure to 37°C caused a significant acceleration of the channel kinetics, whereas current densities and voltage dependences remained unaltered at 37°C compared to 23°C. However, Kv4.3/KChIP2 channels without transmembrane β-subunits showed the strongest temperature sensitivity with considerably increased rates of activation and inactivation at 37°C. KCNE2 significantly slowed the current kinetics at 37°C compared to Kv4.3/KChIP2 channels, whereas KCNE1 did not influence the channel properties at both temperatures. Interestingly, the accelerating effects of DPP6 on current kinetics described at 23°C were diminished at physiological temperature, thus at 37°C current kinetics became remarkably similar for channel complexes Kv4.3/KChIP2 with and without DPP6 isoforms. A Markov state model was developed on the basis of experimental measurements to simulate the influence of β-subunits on Kv4.3 channel complex at both temperatures. In conclusion, the remarkably fast kinetics of the native I(to) at 37°C could be reproduced by co-expressing Kv4.3, KChIP2, KCNE2 and DPP6 in CHO cells, whereas the high temperature sensitivity of human I(to) could be not mimicked.

Influence of helix 12 of Ultraspiracle on Drosophila melanogaster ecdysone receptor function

Although it has no ligand, helix 12 in the ligand binding domain of Ultraspiracle (USP) is locked in an antagonistic position. To investigate whether this position is of functional importance, we enhanced the flexibility of helix 12 by mutating two amino acids (259, located in L1-3 and F491 in helix 12). Mutated USP reduces the stability of USP and all isoforms of the ecdysone receptor (EcR) and impairs nuclear localization and DNA binding of EcR/USP(L259A/F491/A), resulting in lower levels of basal transcriptional activity. Although the affinity of the ligand ponasterone A to EcR/USP(L259/F491) is moderately diminished, hormone-induced stimulation of transcriptional activity is normal. Potentiation of the ecdysone response by juvenile hormone (JH) is selectively increased in mutated heterodimers with EcR-B1, demonstrating that the antagonistic position impairs functional interaction of the EcR complex with JHIII.

[Epithelial neoplasia of the appendix: what has recently changed?]

Appendicular tumors are mostly found incidentally in up to 1.5% of all appendectomies. Neuroendocrine tumors are the commonest malignancies, and are associated with an excellent long-term prognosis. While small lesions located at the appendicular tip can be treated with simple appendectomy, advanced tumors require right hemicolectomy. Goblet cell carcinoids are rare tumors showing a mixed phenotype. Long-term outcome is impaired, and for most cases a right hemicolectomy is mandatory. Colonic-type adenocarcinomas have a similar behavior like conventional colonic cancer and should be treated similarly. Mucinous neoplasias possess the characteristic of extensive mucin production with intraperitoneal spread. Treatment options are ranging from right hemicolectomy to multivisceral resection with intraperitoneal chemotherapy.

[Preoperative nutrition in abdominal surgery: recommendations and reality]

Malnutrition concerns up to 50% at in-hospital admission. Its diagnosis and treatment are fundamental parts of the surgical approach because nutritional status directly influences the clinical outcome. The Nutritional Risk Score (NRS-2002) represents the recommended screening tool by the European Society of Parenteral and Enteral Nutrition (ESPEN). Patients with a score > or = 3 and aged > 70 years old, should receive a nutritional support during 7-14 day before surgery. Depending on patient's clinical conditions, the enteral route of administration should be preferred. Despite strong evidence in favor of nutritional supplementation, much effort must be done to implement these supportive strategies in the everyday clinical practice.

[Time required and associated costs for implementation of home medication review with associated pharmaceutical and medical evaluation in the ambulatory health care sector]

INTRODUCTION

We aimed to estimate the time which is needed to conduct a home medication review (HMR) in the context of the AGnES implementation studies (AGnES=GP-supporting, community-based, e-health-assisted, systemic intervention). In a subsequent step associated costs were calculated.

METHODS

IT-supported HMR were conducted by specially qualified AGnES-practice assistants to detect selected drug-related problems (DRP). The patient received pharmaceutical care by their local pharmacist and medical evaluation by their GP, respectively.

RESULTS

The data from 471 patients (w: 339; m: 132) were evaluated (median age: w=81; m=78). The interview to detect selected DRP was 6 min (median) long. The subsequent drug record took 14.4 min. There was an additional effort for documentation of 5 min. The local pharmacist needed a median time of 15 min for pharmaceutical evaluation, whereas the GP needed 8 min. The estimated costs accounted for: AGnES-practice assistant: 9.12 €; pharmacist: 11.05 €; GP: 6.30 €. The overall estimated costs were 26.47 €.

CONCLUSION

For the first time we present objective costs which were associated with the implementation of HMR. Due to high DRP-induced costs the HMR should be mandatory for groups with a high risk like for the occurrence of DRP.

Interaction of the N-terminus of ecdysone receptor isoforms with the ligand-binding domain

Ecdysone receptor (EcR) isoforms exert different biological functions, although they vary only in their N-terminal domain. Despite identical C-termini, which mediate hormone-induced activity, the influence of ligand is isoform specific, which indicates an N/C-interaction. The position of helix 12 with and without hormone varies among isoforms and modifies N/C-interaction determined by fluorescence resonance-energy transfer (FRET), which depends on the salt bridge between helices 4 and 12 of the ligand-binding domain (LBD). Disruption of the salt bridge by mutation of K497 (helix 4) had no effect on basal N/C-interaction, but prevented the hormone-induced increase, which was partially restored by a salt bridge with reversed polarity. The heterodimerization partner Ultraspiracle (Usp) can compensate for the disruption of the salt bridge. Without ligand the AB-domains of EcR-A and EcR-B1, but not EcR-B2, interact with the LBD via K497 and repress transcriptional activity. This intramolecular cross talk between N- and C-terminus along with the position of helix 12 stabilized by K497 regulates transcriptional activity of EcR isoforms.

Factors influencing long-term changes in mental health after interferon-alpha treatment of chronic hepatitis C

BACKGROUND

Antiviral treatment with interferon-alpha (IFN-alpha) is associated with several acute psychiatric side effects. Little is known about long-term effects on mental health after treatment independent from viral response and the influence of pre-existing psychiatric risk-factors.

AIM

To evaluate long-term effects of antiviral treatment with interferon-alpha (IFN-alpha) on mental health in patients with psychiatric risk factors.

METHOD

We prospectively investigated long-term mental health changes in 81 hepatitis C virus-infected patients. Psychiatric outcome was measured with the Montgomery-Asberg Depression Scale (MADRS), Brief Psychiatric Rating Scale, the Global Social Functioning Scale and the Global Clinical Impression Scale 6 months after the end of antiviral treatment with IFN-alpha and ribavirin.

RESULTS

Six months after antiviral therapy, 49% of the patients showed a worsening and 27.2% an improvement of depression scores. The most important predictor for a long-term improvement of depression scores was a pre-treatment MADRS score > or =5 (OR 14.21, 95% CI: 2.51-81.30). Patients with pre-existing psychiatric disorders (OR = 0.117, 95% CI: 0.024-0.558), methadone substitution (OR = 0.20, 95% CI: 0.045-0.887) or genotype 2/3 (OR = 0.341, 95% CI: 0.138-0.845) were significantly less likely to show a long-term worsening of depressive symptoms.

CONCLUSIONS

Pre-existing psychiatric risk factors increase the chance for a long-term improvement and reduce the risk for a long-term worsening of mental health after antiviral treatment of chronic hepatitis C with IFN-alpha.