Sex hormones, sex chromosomes, and microbiota: Identification of Akkermansia muciniphila as an estrogen-responsive microbiota

Microbiota composition is known to be linked to sex. However, separating sex hormones and sex chromosome roles in gut microbial diversity is yet to be determined. To investigate the sex chromosome role independent of sex hormones, we used the four-core genotype mouse model. In this mouse model, males with testes and females with ovaries have XX or XY sex chromosome complement. In gonadectomized four-core genotype mice, we observed a significant decrease in the levels of estradiol (P<0.001) and progesterone (P<0.03) in female and testosterone (P<0.0001) in male mice plasma samples. Independent of sex chromosome complement, microbial α diversity was increased in gonadectomized female but not male mice compared to sex-matched gonad-intact controls. β diversity analysis showed separation between male (P<0.05) but not female XX and XY mice. Importantly, Akkermansia muciniphila was less abundant in gonadectomized compared to gonadal intact female mice (P<0.0001). In the presence of β-estradiol, Akkermansia muciniphila growth exponentially increased, providing evidence for the identification of a female sex hormone-responsive bacterium (P<0.001).

Epigenetic histone modification by butyrate downregulates KIT and attenuates mast cell function

Short-chain fatty acid butyrate is produced from the bacterial fermentation of indigestible fiber in the intestinal lumen, and it has been shown to attenuate lung inflammation in murine asthma models. Mast cells (MCs) are initiators of inflammatory response to allergens, and they play an important role in asthma. MC survival and proliferation is regulated by its growth factor stem cell factor (SCF), which acts through the receptor, KIT. It has previously been shown that butyrate attenuates the activation of MCs by allergen stimulation. However, how butyrate mechanistically influences SCF signalling to impact MC function remains unknown. Here, we report that butyrate treatment triggered the modification of MC histones via butyrylation and acetylation, and inhibition of histone deacetylase (HDAC) activity. Further, butyrate treatment caused downregulation of SCF receptor KIT and associated phosphorylation, leading to significant attenuation of SCF-mediated MC proliferation, and pro-inflammatory cytokine secretion. Mechanistically, butyrate inhibited MC function by suppressing KIT and downstream p38 and Erk phosphorylation, and it mediated these effects via modification of histones, acting as an HDAC inhibitor and not via its traditional GPR41 (FFAR3) or GPR43 (FFAR2) butyrate receptors. In agreement, the pharmacological inhibition of Class I HDAC (HDAC1/3) mirrored butyrate's effects, suggesting that butyrate impacts MC function by HDAC1/3 inhibition. Taken together, butyrate epigenetically modifies histones and downregulates the SCF/KIT/p38/Erk signalling axis, leading to the attenuation of MC function, validating its ability to suppress MC-mediated inflammation. Therefore, butyrate supplementations could offer a potential treatment strategy for allergy and asthma via epigenetic alterations in MCs.

Genetically engineered Lactobacillus paracasei rescues colonic angiotensin converting enzyme 2 (ACE2) and attenuates hypertension in female Ace2 knock out rats

Engineered gut microbiota represents a new frontier in medicine, in part serving as a vehicle for the delivery of therapeutic biologics to treat a range of host conditions. The gut microbiota plays a significant role in blood pressure regulation; thus, manipulation of gut microbiota is a promising avenue for hypertension treatment. In this study, we tested the potential of Lactobacillus paracasei, genetically engineered to produce and deliver human angiotensin converting enzyme 2 (Lacto-hACE2), to regulate blood pressure in a rat model of hypertension with genetic ablation of endogenous Ace2 (Ace2-/- and Ace2-/y). Our findings reveal a sex-specific reduction in blood pressure in female (Ace2-/-) but not male (Ace2-/y) rats following colonization with the Lacto-hACE2. This beneficial effect of lowering blood pressure was aligned with a specific reduction in colonic angiotensin II, but not renal angiotensin II, suggesting the importance of colonic Ace2 in the regulation of blood pressure. We conclude that this approach of targeting the colon with engineered bacteria for delivery of ACE2 represents a promising new paradigm in the development of antihypertensive therapeutics.

Loss of toll-like receptor 5 potentiates spontaneous hepatocarcinogenesis in farnesoid X receptor-deficient mice

BACKGROUND

HCC is the most common primary liver cancer and a leading cause of cancer-related mortality. Gut microbiota is a large collection of microbes, predominately bacteria, that harbor the gastrointestinal tract. Changes in gut microbiota that deviate from the native composition, that is, "dysbiosis," is proposed as a probable diagnostic biomarker and a risk factor for HCC. However, whether gut microbiota dysbiosis is a cause or a consequence of HCC is unknown.

METHODS

To better understand the role of gut microbiota in HCC, mice deficient of toll-like receptor 5 (TLR5, a receptor for bacterial flagellin) as a model of spontaneous gut microbiota dysbiosis were crossed with farnesoid X receptor knockout mice (FxrKO), a genetic model for spontaneous HCC. Male FxrKO/Tlr5KO double knockout (DKO), FxrKO, Tlr5KO, and wild-type (WT) mice were aged to the 16-month HCC time point.

RESULTS

Compared with FxrKO mice, DKO mice had more severe hepatooncogenesis at the gross, histological, and transcript levels and this was associated with pronounced cholestatic liver injury. The bile acid dysmetabolism in FxrKO mice became more aberrant in the absence of TLR5 due in part to suppression of bile acid secretion and enhanced cholestasis. Out of the 14 enriched taxon signatures seen in the DKO gut microbiota, 50% were dominated by the Proteobacteria phylum with expansion of the gut pathobiont γ-Proteobacteria that is implicated in HCC.

CONCLUSIONS

Collectively, introducing gut microbiota dysbiosis by TLR5 deletion exacerbated hepatocarcinogenesis in the FxrKO mouse model.

Survey and Evaluation of Hypertension Machine Learning Research

Background Machine learning (ML) is pervasive in all fields of research, from automating tasks to complex decision-making. However, applications in different specialities are variable and generally limited. Like other conditions, the number of studies employing ML in hypertension research is growing rapidly. In this study, we aimed to survey hypertension research using ML, evaluate the reporting quality, and identify barriers to ML's potential to transform hypertension care. Methods and Results The Harmonious Understanding of Machine Learning Analytics Network survey questionnaire was applied to 63 hypertension-related ML research articles published between January 2019 and September 2021. The most common research topics were blood pressure prediction (38%), hypertension (22%), cardiovascular outcomes (6%), blood pressure variability (5%), treatment response (5%), and real-time blood pressure estimation (5%). The reporting quality of the articles was variable. Only 46% of articles described the study population or derivation cohort. Most articles (81%) reported at least 1 performance measure, but only 40% presented any measures of calibration. Compliance with ethics, patient privacy, and data security regulations were mentioned in 30 (48%) of the articles. Only 14% used geographically or temporally distinct validation data sets. Algorithmic bias was not addressed in any of the articles, with only 6 of them acknowledging risk of bias. Conclusions Recent ML research on hypertension is limited to exploratory research and has significant shortcomings in reporting quality, model validation, and algorithmic bias. Our analysis identifies areas for improvement that will help pave the way for the realization of the potential of ML in hypertension and facilitate its adoption.

Host-Microbiota Communication in Spontaneously Hypertensive Rats Generates Unique IgA-Coated Gut Microbes

Background Hypertension is associated with gut dysbiosis, altered intestinal immunity, and gut pathology in animal models and humans. Although these findings have implicated impaired interactions between gut and gut microbiota in hypertension, little is known about the specific functional gut microbes that interact with intestinal mucosa. Methods and Results To identify these microbes, we sorted Immunoglobin A (IgA)-coated (IgA⁺) and IgA-noncoated (IgA^-) bacteria using a combination of magnetic-activated cell sorting and fluorescence-activated cell sorting, and subsequently performed 16 S rRNA gene sequencing (IgA-SEQ) to determine the microbial composition of IgA⁺ and IgA^- fractions in spontaneously hypertensive rats (SHR) and normotensive Wistar Kyoto rats. We observed a significant decrease in IgA⁺ bacteria in SHR compared with Wistar Kyoto and a distinct composition of IgA⁺ and IgA^- bacteria between Wistar Kyoto and SHR, showing more IgA-bound Proteobacteria, Bacteroidetes and Actinobacteria but less of Firmicutes in SHR at the phylum level. We further identified enriched IgA-coated Romboutsia, Turicibacter, Ileibacterium, and Dubosiella in SHR that were negatively correlated with the various pathways including antigen presentation, immune response, cell junction organization, epithelium development, and defense response to virus. Conclusions We demonstrate new IgA-coated bacteria that participate in host-microbiota communication in hypertension, suggesting promising therapeutic interventions targeting these bacteria for hypertension management.

Repurposing a Drug Targeting Inflammatory Bowel Disease for Lowering Hypertension

Background The gut and gut microbiota, which were previously neglected in blood pressure regulation, are becoming increasingly recognized as factors contributing to hypertension. Diseases affecting the gut such as inflammatory bowel disease (IBD) present with aberrant energy metabolism of colonic epithelium and gut dysbiosis, both of which are also mechanisms contributing to hypertension. We reasoned that current measures to remedy deficits in colonic energy metabolism and dysbiosis in IBD could also ameliorate hypertension. Among them, 5-aminosalicylic acid (5-ASA; mesalamine) is a PPARγ (peroxisome proliferator-activated receptor gamma) agonist. It attenuates IBD by a dual mechanism of selectively enhancing colonic epithelial cell energy metabolism and ameliorating gut dysbiosis. Methods and Results A total of 2 groups of 11- to 12-week-old male, hypertensive, Dahl salt-sensitive (S) rats were gavaged with (n=10) or without (n=10) 5-aminosalicylic acid (150 mg/kg) for 4 weeks. Rats receiving 5-aminosalicylic acid treatment had a lower mean blood pressure than controls (145±3 mm Hg versus 153±4 mm Hg; P<0.0001). This reduction in blood pressure was accompanied by increased activity of PPARγ, increased expression of energy metabolism-related genes, and lowering of the Firmicutes/Bacteroidetes ratio in the colon, the reduction of which is a marker for the correction of gut dysbiosis. Furthermore, these data were consistent with the American Gut Project wherein the Firmicutes/Bacteroidetes ratio of non-IBD (n=611) patients was significantly lower than patients with IBD (n=631). Conclusions 5-Aminosalicylic acid could be repurposed for hypertension by specifically enhancing the gut energy metabolism and correction of microbiota dysbiosis.

Abstract P001: Repurposing A Drug Targeting Inflammatory Bowel Disease For Lowering Hypertension

Both the gut per se and its residents, the gut microbiota are linked to blood pressure (BP) regulation, whereby, the gut can be recognized as a previously neglected target organ for hypertension. Hypertension and gut diseases such as inflammatory bowel disease (IBD) share commonalities of host inflammation in the gut and microbiota dysbiosis. Therefore, we reasoned that current treatments to remedy gut inflammation and dysbiosis in IBD could be repurposed to ameliorate hypertension. IBD is commonly treated with 5-Aminosalicylic acid (5-ASA, Mesalamine), which is a selective PPAR-γ agonist to prevent gut inflammation. Clinical use of 5-ASA is also reported to ameliorate gut dysbiosis in IBD. Based on this premise, in this study we chose to test our hypothesis that 5-ASA is an antihypertensive drug owing to its dual ability to enhance PPAR-γ in the gut and to correct gut dysbiosis. 2 groups of 11-12 weeks old male genetically hypertensive Dahl salt-sensitive (S) rats were radiotelemetrically monitored for BP, and orally gavaged with (n=9) or without (n=7) 5-ASA (150 mg/kg) for 4 weeks. PPAR-γ expression was assessed by RT-qPCR. Fecal microbiota were profiled by 16S gene sequencing. Lastly, for translational significance, F/B ratio of non-IBD (n=611) patients was compared with that of IBD (n=631) patients in the American Gut Project data for their Firmicutes/Bacteroidetes (F/B) ratio, elevation of which is a marker of gut dysbiosis. 5-ASA significantly lowered BP of the S rat (mean BP without 5-ASA, 153±1 mm Hg; mean BP with 5-ASA, 145±1 mm Hg, P <0.0001). PPAR-γ gene expression was significantly higher in proximal colon, but not in the heart or kidney. In addition, treatment with 5-ASA corrected gut dysbiosis as observed by a significant reduction in the F/B ratio compared to control. In accordance, humans without IBD had a similar lower F/B ratio, which was consistent with the data presented here comparing S rats with 5-ASA. Collectively, these data support our hypothesis that 5-ASA, an FDA-approved anti-IBD drug, could be repurposed to treat hypertension by specifically enhancing the gut PPAR-γ mediated anti-inflammatory effect while also correcting microbiota dysbiosis to lower BP.

AB0425 WHAT DOES IT MEAN TO BE A DUAL BICLA AND SRI(4) RESPONDER? A POOLED ANALYSIS OF TWO PHASE 3 TRIALS IN PATIENTS WITH SLE

Background

The BILAG–based Composite Lupus Assessment (BICLA) and SLE Responder Index ≥4 (SRI[4], based on SLEDAI-2K) are validated composite global measures of clinically meaningful improvement in SLE disease activity. BICLA and SRI(4) responses were endpoints in the phase 2b MUSE and phase 3 TULIP-1/-2 trials.1–3 In a post hoc analysis, more patients met both the BICLA and SRI(4) response criteria at Week 52 (dual responders) with anifrolumab 300 mg vs placebo across trials (MUSE: 48.5% vs 19.9%; TULIP-1: 42.2% vs 27.9%; TULIP-2: 43.4% vs 26.4%; all nominal P<0.01).4 Whereas the clinical benefit of BICLA responses alone have been characterized,5 the added benefit of dual BICLA/SRI(4) responses remains unknown.

Objectives

To understand the clinical benefits (SLE clinical assessments, patient-reported outcomes [PROs], and healthcare utilization) of having a dual BICLA/SRI(4) response vs a response for just one endpoint or nonresponse for both, irrespective of treatment assignment.

Methods

This was a post hoc analysis of pooled data from the randomized, 52-week, double-blind TULIP-1 (NCT02446912) and TULIP-2 (NCT02446899) trials in which patients with moderate to severe SLE despite standard therapy received intravenous anifrolumab (150/300 mg) or placebo every 4 weeks for 48 weeks.1,2 Patients were categorized as dual responders (met both BICLA and SRI[4] response criteria at Week 52), single responders (met one of either BICLA or SRI[4] response criteria), or dual nonresponders (did not meet either response criteria). SLE clinical assessments, PROs, and healthcare utilization through Week 52 were evaluated for each group. Statistical comparisons were conducted for dual responders vs single responders and dual nonresponders.

Results

Patient demographics and baseline characteristics were generally balanced across dual responders (n=288), single responders (n=122), and dual nonresponders (n=409). At Week 52, dual responders had greater improvements in SLE-related measures compared with dual nonresponders across all evaluated clinical, PRO, and healthcare utilization outcomes (Figure, A–E).

Compared with single responders, dual responders had a significantly greater mean change from baseline in SLEDAI-2K score (−8.2 vs −5.1; nominal P<0.0001), PGA score (−1.3 vs −0.9; nominal P<0.0001), and swollen joint counts (−6.2 vs −4.5; nominal P<0.0001) (Panel A); there was also a numerically greater proportion with ≥50% reduction in CLASI-A score (91% vs 76%; nominal P=0.078) (Panel B). Dual responders had a greater mean reduction in baseline oral glucocorticoid (GC) daily dose (−5.6 vs −3.4; nominal P=0.006) vs single responders (Panel A).

For PROs, compared with single responders, dual responders had a greater mean change in baseline PtGA score (−17.7 vs −8.6; nominal P=0.001), and a higher proportion had clinically meaningful improvements from baseline to Week 52 in fatigue (FACIT-F; 56% vs 43%; nominal P=0.014) and SF-36 physical component scores (60% vs 34%; nominal P<0.0001) (Panel C–D). Healthcare utilization (ED visits and hospitalizations) was lower in dual responders vs single responders; however, this comparison did not reach nominal significance (nominal P=0.462 and 0.311, respectively) (Panel E).

Conclusion

Patients with SLE with dual responses in two validated outcome measures have significantly better outcomes across a range of clinical, PRO, and healthcare utilization measures compared with dual nonresponders. The higher degree of improvement in disease activity, especially in arthritis, and the greater reduction in oral GC dose compared with single responders is reflected in improved patient well-being, physical functioning, and fatigue. Being a dual responder offers a profound and clinically meaningful outcome for both the clinician and patient.

References

[1]Furie R. Lancet Rheumatol. 2019;1:e208–19.

[2]Morand EF. N Engl J Med. 2020;382:211–21.

[3]Furie R. Arthritis Rheumatol. 2017;69:376–86.

[4]Isenberg D. Ann Rheum Dis. 2021;80:586–7.

[5]Furie R. Arthritis Rheumatol. 2021;73:2059–68.

Acknowledgements

Writing assistance was provided by Matilda Shackley of JK Associates Inc., part of Fishawack Health. This study was sponsored by AstraZeneca.

Disclosure of Interests

Ian N. Bruce Speakers bureau: GSK, UCB, Astra Zeneca, Consultant of: AstraZeneca, GSK, UCB, Aurinia, Eli Lilly, BMS, Grant/research support from: GSK, Janssen, Konstantina Psachoulia Shareholder of: AstraZeneca, Employee of: AstraZeneca, Emmanuelle Maho Employee of: AstraZeneca, David Isenberg Consultant of: AstraZeneca, Amgen, Servier, Eli Lilly, UCB, Merck Serono, Ronald van Vollenhoven Speakers bureau: AbbVie, Galapagos, GSK, Janssen, Pfizer, R-Pharma, UCB, Consultant of: AbbVie, AstraZeneca, Biogen, BMS, Galapagos, Janssen, Miltenyi, Pfizer, UCB, Grant/research support from: MSD, Pfizer, Roche, BMS, GSK, UCB, Richard Furie Speakers bureau: AstraZeneca, Genentech, Consultant of: AstraZeneca, Grant/research support from: AstraZeneca, Eric F. Morand Speakers bureau: GSK, Novartis, Paid instructor for: AstraZeneca, Biogen, Eli Lilly, Consultant of: AstraZeneca, Biogen, Bristol Myers Squibb, Eli Lilly, EMD Serono, Genentech, GSK, Janssen, Servier, Grant/research support from: Abbvie, AstraZeneca, Bristol Myers Squibb, GSK, Janssen, Catharina Lindholm Employee of: AstraZeneca, Micki Hultquist Shareholder of: AstraZeneca, J&J, Employee of: AstraZeneca, Raj Tummala Shareholder of: AstraZeneca, Employee of: AstraZeneca

POS0731 ASSOCIATION OF PATIENT-REPORTED OUTCOMES WITH TYPE I INTERFERON GENE SIGNATURE FROM THE INTERNATIONAL SYSTEMIC LUPUS ERYTHEMATOSUS PROSPECTIVE OBSERVATIONAL COHORT STUDY (SPOCS)

Background

The aim of the Systemic Lupus Erythematosus Prospective Observational Cohort Study (SPOCS) is to examine the disease course of patients with systemic lupus erythematosus (SLE) in relation to their type I interferon gene signature (IFNGS) status.1 IFNGS has been associated with SLE disease activity.2

Objectives

To identify associations between IFNGS status and patient-reported outcomes (PROs) among patients receiving clinical care while enrolled in SPOCS.

Methods

This noninterventional, international, prospective, observational cohort study included adult patients (≥18 years) with moderate to severe SLE receiving standard therapy. Short Form 36 Health Survey version 2 (SF-36; 0–100), Lupus Quality of Life (LupusQoL; 0–100) and Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F; 0–52) were assessed at baseline, 6 months, and 12 months. Higher scores indicate better outcomes. Analyses were stratified by high or low IFNGS status (4-gene test) at baseline.

Results

Of 827 patients, mean (standard deviation [SD]) age was 45.1 (14.0) years, 771 (93%) were female, 525 (63%) were IFNGS high, and 219 (26%) were IFNGS low. IFNGS-high patients were younger than IFNGS-low (mean [SD] 43.0 [13.7] vs 50.7 [12.9] years), had fewer comorbidities (83% vs 91%) and similar baseline disease activity (mean [SD]: SLE Disease Activity Index 2000, 9.8 [4.3] vs 9.2 [5.2]; Physician’s Global Assessment, both 1.5 [0.6]). At baseline, there were some differences in PROs between IFNGS-high and -low patients. At Month 12, changes in most domains did not meet the minimal clinically important difference (MCID). Slight improvement was observed only in selected domains in the IFNGS-high group. This group was younger and had fewer comorbidities at baseline. (Table 1, Figure 1).

Table 1.

PRO Scores at Baseline and Month 12 by IFNGS Status

BaselineMonth 12Change From BaselineMCID (≥)PROTotal (n=810)IFNGS HighIFNGS Low (n=219)Total (n=431)IFNGS HighIFNGS Low (n=147)TotalIFNGS HighIFNGS Low(n=525)(n=279)SF-36Physical Component Summary37.4 (10.5)38.3 (10.5)+35.2 (10.6)139.8 (10.8)41.7 (10.4)+35.7 (10.8)2.3 (7.6)3.0 (8.1)*0.6 (6.4)2.5Mental Component Summary43.2 (11.6)43.6 (11.7)42.7 (11.6)44.9 (11.2)45.9 (10.6)43.4 (11.5)0.9 (9.2)1.4 (9.6)-0.3 (8.4)2.5LupusQoLPhysical health56.4 (27.4)58.1 (27.0)+52.1 (27.7)60.5 (26.9)65.0 (25.3)+52.5 (27.7)2.6 (18.1)5.0 (19.2)*-1.4 (16.4)3.4Pain54.3 (30.3)55.7 (29.8)50.2 (30.8)61.4 (28.5)66.0 (26.5)+52.6 (29.1)5.4 (23.8)8.1 (25.2)0.7 (21.3)8.5Planning61.4 (32.2)63.7 (31.8)+57.0 (32.2)66.3 (29.6)70.8 (27.8)+58.5 (30.8)2.9 (24.4)4.2 (24.7)-1.0 (22.9)6.5Intimate relationships58.0 (34.8)61.2 (34.1)+50.9 (34.8)59.8 (33.9)65.6 (32.3)+50.6 (34.7)-0.6 (24.5)-0.7 (25.9)-0.8 (22.3)9.2Burden to others50.7 (32.6)50.7 (32.6)50.4 (33.5)56.4 (30.7)59.7 (29.5)51.8 (31.7)3.1 (25.4)5.6 (26.0)*0.1 (23.9)5.3Emotional health66.3 (25.6)66.1 (26.0)67.8 (24.8)71.1 (24.7)72.9 (23.8)69.2 (24.7)1.8 (19.4)3.1 (20.3)-0.5 (18.1)3.4Body image62.6 (29.4)61.0 (30.1)66.4 (28.3)68.2 (27.6)70.3 (27.4)65.1 (27.0)2.0 (23.9)*4.1 (24.3)*-0.4 (22.1)1.1Fatigue48.6 (27.8)49.9 (27.6)45.5 (28.2)53.7 (26.9)57.4 (26.2)+46.9 (25.7)2.1 (19.3)3.5 (20.0)-0.9 (18.7)3.9FACIT-F25.8 (13.4)26.9 (13.4)+23.4 (12.9)28.7 (13.2)31.1 (12.7)+24.6 (12.9)2.3 (9.6)3.2 (10.2)0.6 (8.5)4.0

Data are mean (SD). Asterisks (*) indicate changes from baseline ≥ MCID. +Comparison between high and low IFNGS status by Mann-Whitney U test (nominal p-value<0.01).

Data for n are patients per subgroup and do not reflect responses per PRO assessment.

Conclusion

In this cohort study, patients with moderate to severe SLE had poor health status, health-related quality of life, and fatigue. A clinically meaningful change was not met in most PROs, suggesting patients continue to have a high need for improved treatment options.

References

[1]Hammond ER. BMJ Open 2020;10:e036563.

[2]Dall’era MC. Ann Rheum Dis 2005;64:1692–7.

Acknowledgements

Writing assistance by Shelley Harris, PhD (Fishawack). This study was sponsored by AstraZeneca.

Disclosure of Interests

Martin Aringer Speakers bureau: AbbVie, AstraZeneca, BMS, Boehringer Ingelheim, Chugai, HEXAL, Lilly, MSD, Mylan, Novartis, Roche, Sanofi, UCB, Consultant of: AbbVie, AstraZeneca, BMS, Boehringer Ingelheim, Galapagos, GSK, Pfizer, Roche, Sanofi, Laurent Arnaud Speakers bureau: AstraZeneca, Consultant of: AstraZeneca, Grant/research support from: AstraZeneca, Christine Peschken Consultant of: AstraZeneca, GSK, Grant/research support from: AstraZeneca, Richard Furie Speakers bureau: AstraZeneca, Genentech, Consultant of: AstraZeneca, Grant/research support from: AstraZeneca, Eric F. Morand Speakers bureau: GSK, Novartis, Paid instructor for: AstraZeneca, Biogen, Eli Lilly, Consultant of: AstraZeneca, Biogen, Bristol Myers Squibb, Eli Lilly, EMD Serono, Genentech, GSK, Janssen, Servier, Grant/research support from: Abbvie, AstraZeneca, Bristol Myers Squibb, GSK, Janssen, Caroline Seo Shareholder of: AstraZeneca, Employee of: AstraZeneca, Eleni Rapsomaniki Employee of: AstraZeneca, Jonatan Hedberg Shareholder of: AstraZeneca, Employee of: AstraZeneca, Jacob Knagenhjelm Shareholder of: AstraZeneca, Employee of: AstraZeneca, Tina Grünfeld Eén Shareholder of: AstraZeneca, Employee of: AstraZeneca, Barnabas Desta Shareholder of: AstraZeneca, Employee of: AstraZeneca, Raj Tummala Shareholder of: AstraZeneca, Employee of: AstraZeneca, Alessandro Sorrentino Shareholder of: Galapagov, Abbott Laboratories, Gilead Sciences, Moderna, Employee of: Janssen, Sanofi, AstraZeneca, Heide Stirnadel-Farrant Shareholder of: AstraZeneca, GSK, Employee of: AstraZeneca

POS0739 THE RENAL ACTIVITY INDEX FOR LUPUS (RAIL) DIFFERENTIATES ACTIVE AND INACTIVE NEPHRITIS IN ADULT PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Background

Lupus nephritis (LN) confers a poor prognosis, with lack of effective laboratory tests to diagnose and evaluate therapies. We have demonstrated that the RAIL score, based on a set of six urinary biomarkers (NGAL, KIM-1, MCP-1, adiponectin, hemopexin, ceruloplasmin) is sensitive and specific in adult patients with active LN, using renal biopsy as reference.1,2 RAIL has been shown in the pediatric population to be effective in distinguishing inactive vs active LN with no effect from mycophenolate mofetil (MMF) treatment. A comparable study has not been conducted in an adult population.

Objectives

To assess the ability of RAIL to discriminate patients with active LN vs active non-renal SLE and to evaluate if RAIL performance varies by MMF treatment using urine samples from adult LN patients.

Methods

Urine samples were obtained at baseline in two clinical trials: a phase 2 study in adult patients with biopsy-proven active Class III and IV LN (NCT02547922) and a subset of patients from the phase 3 trial in adults with active non-renal SLE (NCT02446912) who had baseline renal BILAG scores C, D, or E. RAIL biomarkers were assayed using single-plex assays. Patient demographics and clinical characteristics were compared between studies. Wilcoxon rank sum test was performed comparing the urinary biomarkers between the two studies and RAIL score was then calculated. Receiver operating characteristic (ROC) analyses were conducted assessing the ability for RAIL scores to distinguish patients with renal activity and involvement.

Results

Comparison of the patient demographic, clinical characteristics, and biomarkers is in the Table 1. Wilcoxon rank sum test showed the six urinary biomarkers were significantly different between two groups of patients as demonstrated (Table 1). Each of the RAIL biomarker concentrations and the creatinine-adjusted median score were higher in the active LN group than the SLE group (P<0.001). ROC analyses including RAIL score showed an area under the ROC curve of 0.8 (Figure 1), with odds ratio of log-transformed RAIL 2.027 (95% CI [1.587, 2.589]). There were no significant interactions between RAIL and MMF. RAIL remained significant after adjusting for estimated glomerular filtration rate (eGFR), which was not statistically significant.

Table 1.

Study Demographics and Biomarkers

VariablesLN study (N=131)SLE study (N=59)Observed NObserved Median (IQR) or %Observed NObserved Median (IQR) or %DemographicsAge13134 (25, 42)5936 (28, 44)Sex, Female10983.21%5593.22%Race, White5642.75%4576.27%Ethnicity, Hispanic or Latino6146.56%915.25%OCS use, yes12797.69%5796.61%MMF use, yes9572.52%2135.59%Spot UPCR (mg/mg)1282.13 (1.22, 4.04)591.11 (0.55, 2.61)eGFR13091.8 (63.1, 125)5998.06 (81.91, 116.54)Non-renal SLEDAI-2K score1304 (4, 6)5912 (9, 13)Renal SLEDAI-2K score1304 (4, 8)590 (0, 0)BiomarkersNGAL (ng/mL)12833.33 (17.55, 56.7)5819.47 (11.37, 42.05)MCP-1 (pg/mL)128658.24 (271.58, 1049.95)58275.62 (106.09, 481.99)Ceruloplasmin (ng/mL)12893.55 (44.5, 311.25)5847.2 (13.05, 231.25)Adiponectin (ng/mL)12842.45 (16.71, 139.64)589.33 (3.35, 25.51)Hemopexin (ng/mL)1281876.8 (745.07, 4743.4)58513.4 (236.36, 1388.74)KIM-1 (pg/mL)1281673.5 (772.5, 2767)58864 (394, 1480)Creatinine (mg/mL)1280.7 (0.46, 1.3)580.99 (0.46, 1.74)Adult RAIL score (creatinine adjusted)1285.59 (4.31, 6.47)583.57 (2.78, 4.47)

eGFR, estimated glomerular filtration rate; IQR, interquartile range; KIM, kidney injury molecule; LN, lupus nephritis; MCP, monocyte chemotactic protein; MMF, mycophenolate mofetil; NGAL, neutrophil gelatinase-associated lipocalin; OCS, oral corticosteroid; SLEDAI-2K, SLE Disease Activity Index 2000; UPCR, urine protein/creatinine ratio.

Conclusion

The analyses performed suggest that creatinine-corrected RAIL discriminates between active LN and non-renal adult SLE, with RAIL scores not influenced by MMF use.

References

[1]Brunner HI. Arthritis Care Res (Hoboken). 2016;68:1003–11.

[2]Gulati G. Lupus. 2017;26:927–36.

Acknowledgements

Writing assistance by Kelly M. Hunter, PhD (Fishawack). This study was sponsored by AstraZeneca.

Disclosure of Interests

Ellen Cody: None declared, Hermine Brunner Speakers bureau: Novartis, Pfizer, GSK, Consultant of: AbbVie, Astra Zeneca-Medimmune, Biogen, Boehringer, Bristol Myers Squibb, Celgene, Lilly,EMD Serono, Idorsia, Cerocor, Janssen, GSK, F. Hoffmann-La Roche, Merck, Novartis, R-Pharm, Sanofi, Grant/research support from: Pfizer, Bin Huang: None declared, Tingting Qiu: None declared, Prasad Devarajan Speakers bureau: Reata, Alnylam, Dicerna, Consultant of: BioPorto Inc, Madhu Ramaswamy Shareholder of: AstraZeneca, Employee of: AstraZeneca, Dominic Sinibaldi Shareholder of: AstraZeneca, Employee of: AstraZeneca, Philip Z Brohawn Shareholder of: AstraZeneca, Employee of: AstraZeneca, Jacob Knagenhjelm Shareholder of: AstraZeneca, Employee of: AstraZeneca, Frederick Jones Shareholder of: AstraZeneca, Employee of: AstraZeneca, Raj Tummala Shareholder of: AstraZeneca, Employee of: AstraZeneca, Catharina Lindholm Employee of: AstraZeneca, Wendy White Shareholder of: AstraZeneca, Employee of: AstraZeneca

POS0367 IMPROVEMENT OF INDIVIDUAL MUCOCUTANEOUS MANIFESTATIONS IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS TREATED WITH ANIFROLUMAB

Background

Patients with cutaneous lupus erythematosus (CLE) experience disfiguring and painful lesions that can lead to psychological distress and significant impacts on quality of life.1 Treatment of patients with systemic lupus erythematosus (SLE) with anifrolumab, a type I interferon receptor antagonist, was associated with CLE Disease Area and Severity Index–Activity (CLASI-A) improvements compared with placebo through Week 52 in the phase 3 TULIP-1 and TULIP-2 SLE trials.2,3 CLASI assesses overall skin improvement and may be driven by erythema over the other components.4

Objectives

To better understand the effect of anifrolumab on mucocutaneous SLE manifestations by analyzing the individual domains of CLASI-A using pooled data from the TULIP trials.

Methods

TULIP-1 (NCT02446912) and TULIP-2 (NCT02446899) were randomized, double-blind, placebo-controlled, 52-week trials that evaluated efficacy and safety of intravenous anifrolumab administered every 4 weeks in patients with moderate to severe SLE despite standard therapy.2,3 In a post hoc analysis, individual CLASI-A domains (erythema, scale/hypertrophy, alopecia, and mucosal) were assessed at Week 24 (time point chosen to ensure adequate duration for improvement in slow-remitting manifestations [eg, scale, alopecia]) in 2 patient subgroups: 1) the “chronic” mucocutaneous subgroup (resembling chronic/discoid CLE), defined as patients with a baseline erythema score ≥4 and scale score ≥2, and alopecia score ≥1 or baseline mucosal lesions or ulceration score of 1; and 2) the “extended” mucocutaneous subgroup (resembling all CLE subtypes), defined as patients who met the “chronic” criteria or those who had a baseline erythema score ≥8.

Results

Across the pooled TULIP trials, 360 patients received anifrolumab 300 mg and 366 patients received placebo. In patients with assessments at Week 24 in the “chronic” (anifrolumab n=58, placebo n=50) and “extended” (anifrolumab n=104, placebo n=96) subgroups, anifrolumab led to a greater mean percent reduction from baseline compared with placebo in erythema (chronic: −63.6% vs −39.9%; extended: −63.7% vs −41.2%) and scale/hypertrophy (chronic: −72.2% vs −42.6%; extended: −45.3% vs −7.3%). Anifrolumab-treated patients in both subgroups had no worsening in alopecia (chronic: 93.3% [56/60] vs 96.0% [48/50]; extended: 95.3% [102/107] vs 95.8% [92/96]) or mucous membrane (chronic: 95.0% [57/60] vs 96.0% [48/50]; extended: 96.3% [103/107] vs 94.8% [91/96]) from baseline vs placebo (Table 1).

Table 1.

Skin Responses at Week 24 Compared With Baseline

Criteria, n (%)Chronic subgroupExtended subgroupAnifrolumab 300 mg (n=60)Placebo (n=50)Anifrolumab 300 mg (n=107)Placebo (n=96)Erythema score reduction≥25%53 (88.3)32 (64.0)93 (86.9)68 (70.8)≥50%42 (70.0)22 (44.0)71 (66.4)47 (49.0)≥60%34 (56.7)18 (36.0)61 (57.0)32 (33.3)Scale/hypertrophy score reduction≥10%49 (81.7)34 (68.0)55 (51.4)38 (39.6)≥25%47 (78.3)30 (60.0)53 (49.5)34 (35.4)≥50%46 (76.7)28 (56.0)51 (47.7)31 (32.3)No new/worsened lesions in any individual body area44 (73.3)26 (52.0)81 (75.7)56 (58.3)Alopecia≥1-point decreasea25 (41.7)19 (38.0)35 (32.7)27 (28.1)No worsening56 (93.3)48 (96.0)102 (95.3)92 (95.8)Mucosal lesion/ulceration1-point decreaseb25 (41.7)13 (26.0)39 (36.4)23 (24.0)No worsening57 (95.0)48 (96.0)103 (96.3)91 (94.8)

aIf baseline score ≥1.

bIf baseline score =1.

Conclusion

In the phase 3 TULIP trials, SLE patients with mucocutaneous manifestations treated with anifrolumab experienced numerical improvements in erythema and scale/hypertrophy and no worsening in alopecia or mucous membrane CLASI-A domains compared with placebo, regardless of whether skin disease was classified by chronic or extended definitions. These encouraging data support further evaluation of anifrolumab in patients with CLE.

References

[1]Klein R. J Am Acad Dermatol. 2011;64:849–58.

[2]Furie RA. Lancet Rheumatol. 2019;1:e208–19.

[3]Morand EF. N Engl J Med. 2020;382:211–21.

[4]Albrecht J. J Invest Dermatol. 2005;125:889–94.

Acknowledgements

Writing assistance by Naomi Atkin (Fishawack Health). This study was sponsored by AstraZeneca.

Disclosure of Interests

Victoria Werth Consultant of: Celgene, Medimmune, Resolve, Genentech, Idera, Janssen, Lilly, Pfizer, Biogen, BMS, Gilead, Amgen, Medscape, Nektar, Incyte, EMD Sorona, CSL Behring, Principia, Crisalis, Viela Bio, Argenx, Kwoya Kirin, Regeneron, AstraZeneca, Abbvie, Octapharma, GSK, Cugene, UCB, Corcept, Beacon Bioscience, Rome Pharmaceuticals, Horizon, Merck, Kezar, Sanofi, Bayer, Akari, Grant/research support from: Celgene, Janssen, Pfizer, Biogen, Gilead, Corbus Pharmaceuticals, Genentech, AstraZeneca, Viela, Syntimmune, Amgen, Regeneron, Argenx, CSL Behring, Ventus, q32 Bio, BMS, Jenny Wissmar Shareholder of: AstraZeneca, Employee of: AstraZeneca, Anna Strömbeck Employee of: AstraZeneca, Raj Tummala Shareholder of: AstraZeneca, Employee of: AstraZeneca, Christi Kleoudis Shareholder of: AstraZeneca, Employee of: AstraZeneca, Marius Albulescu Shareholder of: AstraZeneca Ltd, Consultant of: UCB, Kymab Ltd, Employee of: AstraZeneca Ltd

POS0708 EVALUATING THE HYPERSENSITIVITY PROFILE OF ANIFROLUMAB AND THE NEED FOR PREINFUSION PROPHYLACTIC TREATMENT IN PATIENTS WITH SLE

Background

Anifrolumab, a human monoclonal antibody (mAb), is approved in Canada, Japan, and the United States for the treatment of patients with systemic lupus erythematosus (SLE) based on results from the phase 2b MUSE and the phase 3 TULIP-1/-2 trials.1–3 Anaphylactic reactions (ARs), hypersensitivity reactions (HSRs), and infusion-related reactions (IRRs) are risks of mAb infusions, so physicians prescribing anifrolumab may wish to understand the hypersensitivity profile and whether prophylactic pretreatments are required to mitigate HSR/IRRs.

Objectives

To evaluate the hypersensitivity profile of anifrolumab and the need for pretreatment.

Methods

Pooled data were analyzed from patients with moderate to severe SLE despite standard therapy who received intravenous infusions (every 4 weeks, 48 weeks) of anifrolumab or placebo in the randomized, 52-week MUSE (NCT01438489),1 TULIP-1 (NCT02446912),2 and TULIP-2 (NCT02446899)3 trials. An AR (analyzed in the anifrolumab 150/300/1000 mg and placebo groups) was defined as acute illness onset within minutes to several hours of infusion with involvement of skin and/or mucosal tissue, and/or respiratory compromise, and/or reduced blood pressure, and/or persistent gastrointestinal symptoms. HSRs and IRRs were analyzed in the anifrolumab 300 mg group (as this is the approved dose) and the placebo group. An HSR was defined as acute illness onset with involvement of skin and/or mucosal tissue during infusion (not meeting the AR definition); IRR was defined as any other reaction occurring during/within 24 hours of infusion. Patients did not receive pretreatment unless they had experienced a previous IRR/HSR in the program. Pretreatment was assumed if a patient received prophylactic antihistamine, corticosteroid, non-steroidal anti-inflammatory drug, and/or dopamine antagonist 1 day before/on the day of infusion.

Results

Of patients who received anifrolumab 300 mg (n=459), anifrolumab 1000 mg (n=105), or placebo (n=466), none experienced ARs; 1 patient who received anifrolumab 150 mg (n=93) experienced an AR. HSRs occurred in 3% (n=12) of anifrolumab 300 mg-treated patients (of whom 4 had a history of HSRs) vs 1% (n=3) in the placebo group. IRRs occurred in 9% (n=43) of anifrolumab-treated patients vs 7% (n=33) in the placebo group. All HSRs and IRRs were mild/moderate in intensity. There were no discontinuations due to HSRs or IRRs in the anifrolumab group, while there were 2 in the placebo group (HSR: n=1; IRR: n=1). In the anifrolumab 300 mg and placebo groups, more patients experienced HSR/IRRs with the initial (1–6) vs later infusions (Figure 1). In the anifrolumab group, the median (median absolute deviation) time to first HSR or IRR was 30.5 (29.5) days or 27.0 (26.0) days, respectively. Of the 12 anifrolumab-treated patients with ≥1 HSR, 3 received subsequent pretreatment, and none had any HSR after the use of pretreatment. Of the 43 anifrolumab-treated patients with ≥1 IRR, 2 received pretreatment, of whom 1 had an IRR after pretreatment and anifrolumab dosage remained unchanged.

Conclusion

Following anifrolumab infusion, ARs were uncommon, and few (3%) patients experienced HSRs. HSRs and IRRs with the approved anifrolumab 300 mg dose were mild to moderate, occurred early in treatment, did not lead to discontinuation, and only rarely required pretreatment. Our data support a safe and manageable hypersensitivity profile for anifrolumab.

References

[1]Furie R, et al. Arthritis Rheumatol. 2017;69:376–86.

[2]Furie R, et al. Lancet Rheumatol. 2019;1:e208–19.

[3]Morand E, et al. N Engl J Med. 2020;382:211–21.

Acknowledgements

Writing assistance was provided by Rosie Butler, PhD, of JK Associates Inc., part of Fishawack Health. This study was sponsored by AstraZeneca.

Disclosure of Interests

Kenneth C Kalunian Consultant of: Aurinia, Equillium, Kezar, BMS, Chemocentryx, Eli Lilly, Biogen, Roche/Genentech, Grant/research support from: Horizon, UCB, Yoshiya Tanaka Speakers bureau: Gilead, Abbvie, Behringer-Ingelheim, Eli Lilly, Mitsubishi-Tanabe, Chugai, Amgen, YL Biologics, Eisai, Astellas, Bristol-Myers, Astra-Zeneca, Consultant of: Eli Lilly, Daiichi-Sankyo, Taisho, Ayumi, Sanofi, GSK, Abbvie, Grant/research support from: Asahi-Kasei, Abbvie, Chugai, Mitsubishi-Tanabe, Eisai, Takeda, Corrona, Daiichi-Sankyo, Kowa, Behringer-Ingelheim, Ihor Hupka Employee of: AstraZeneca, Lijin (Jinny) Zhang Shareholder of: AstraZeneca, Employee of: AstraZeneca, Manish Shroff Employee of: AstraZeneca, Shanti Werther Shareholder of: AstraZeneca, Employee of: AstraZeneca, Gabriel Abreu Employee of: AstraZeneca AB, Catharina Lindholm Employee of: AstraZeneca, Raj Tummala Shareholder of: AstraZeneca, Employee of: AstraZeneca

OP0282 IMPACT OF ANIFROLUMAB ON NEUROPSYCHIATRIC MANIFESTATIONS OF DEPRESSION AND SUICIDALITY IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Neuropsychiatric (NP) disease is more common in patients with systemic lupus erythematosus (SLE) than in the general population.1 Increased incidence of NP events (depression and suicidality) has been reported with biologic therapies, including SLE therapies.2 Depression and suicidality were evaluated in patients with SLE treated with anifrolumab, a type I interferon receptor antibody, in the TULIP-1 and TULIP-2 trials.3,4

Objectives

To understand the impact of anifrolumab treatment on NP manifestations (depression and suicidality) in patients with SLE relative to standard therapy using pooled data from the TULIP trials.

Methods

TULIP-1/-2 were randomized, placebo-controlled, 52-week trials of intravenous anifrolumab every 4 weeks in patients with moderate to severe SLE despite standard therapy.3,4 Patients with active severe or unstable NP SLE were excluded. Patients who received ≥1 dose of anifrolumab 300 mg or placebo were analyzed for depression and suicidality.3,4 The Personal Health Questionnaire Depression Scale-8 (PHQ-8) and Columbia Suicide Severity Rating Scale (C-SSRS) were used to assess clinical depression and suicidal ideation and behavior, respectively. Incidence of adverse events (AEs) within the standardized Medical Dictionary for Regulatory Activities query of depression (excluding suicide and self-injury) and antidepressant use at baseline and during the study were also assessed.

Results

In the TULIP pooled analysis, 360 patients received anifrolumab and 365 received placebo. Mean PHQ-8 scores were in the mild range (≥5 to <10); 9.7 in both groups at baseline (Table 1). Excluding patients taking antidepressants, mean PHQ-8 scores were 9.5 in the anifrolumab group and 9.7 in the placebo group at baseline. No clinically meaningful worsening in mean PHQ-8 scores was observed from baseline to Week 52 in the anifrolumab (–2.0) or placebo (–1.3) groups; excluding patients taking antidepressants, mean changes in PHQ-8 were –2.0 and –1.2, respectively. Depression AEs during the study were reported in 11 anifrolumab-treated patients (3.1%) and 9 patients who received placebo (2.5%). At baseline, antidepressant use was comparable between groups (anifrolumab group, 7 patients [1.9%]; placebo group, 9 patients [2.5%]). During the study, 8 anifrolumab-treated patients (2.2%) and 12 patients who received placebo (3.3%) used antidepressants; 1 (0.3%) and 4 (1.1%) patients, respectively, initiated antidepressant therapy during the study (1 in the placebo group stopped therapy). Suicidal ideation or behavior, as assessed by C-SSRS, during the study was reported in 5 anifrolumab-treated patients (1.4%) and 11 patients who received placebo (3.0%). Excluding patients taking antidepressants, suicidal ideation or behavior during the study was reported in 4 anifrolumab-treated patients (1.1%) and 9 patients who received placebo (2.5%) (Figure 1).

Table 1.

PHQ-8 Summary

All patientsExcluding patients taking antidepressantsAnifrolumab 300 mg N=360Placebo N=365Anifrolumab 300 mg N=360Placebo N=365nMeanaSDChangebnMeanaSDChangebnMeanaSDChangebnMeanaSDChangebBaseline3419.76.26–3489.76.11–3359.56.21–3389.76.09–Week 242957.65.89–2.13038.06.00–1.52897.55.84–2.12938.16.00–1.5Week 522667.85.99–2.02617.96.03–1.32627.76.00–2.02527.95.96–1.2

SD, standard deviation.

aPHQ-8 classifications: 0–4 = none, 5–9 = mild, 10–14 = moderate, 15–19 = moderately severe, and 20–24 = severe.

bMean change from baseline.

Conclusion

Patients with SLE treated with anifrolumab did not experience increased depression, suicidality, or need for antidepressants when compared with standard therapy, irrespective of baseline antidepressant use.

References

[1]Zhang L, et al. BMC Psychiatry. 2017;17:70.

[2]Benlysta (belimumab) [prescribing information]. Philadelphia, PA: GlaxoSmithKline; 2021.

[3]Furie RA, et al. Lancet Rheumatol. 2019;1:e208–19.

[4]Morand EF, et al. N Engl J Med. 2020;382:211–21.

Acknowledgements

Writing assistance by Andrea Y. Angstadt, PhD (Fishawack Health). This study was sponsored by AstraZeneca.

Disclosure of Interests

Susan Manzi Speakers bureau: AstraZeneca, Consultant of: AstraZeneca, Exagen Diagnostics, Inc, Cugene, GSK, Lilly, Lupus Foundation of America, UCB Advisory Board, Grant/research support from: HGS/GSK, AstraZeneca, AbbVie, Catharina Lindholm Employee of: AstraZeneca, Ihor Hupka Employee of: AstraZeneca, Lijin (Jinny) Zhang Shareholder of: AstraZeneca, Employee of: AstraZeneca, Manish Shroff Employee of: AstraZeneca, Gabriel Abreu Employee of: AstraZeneca AB, Shanti Werther Shareholder of: AstraZeneca, Employee of: AstraZeneca, Raj Tummala Shareholder of: AstraZeneca, Employee of: AstraZeneca

POS0709 SUSTAINED BICLA AND BILAG ORGAN DOMAIN RESPONSES IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) RECEIVING ANIFROLUMAB IN TWO PHASE 3 TRIALS

Background

Incomplete SLE disease control is associated with progressive organ damage, poor quality of life, and increased mortality.1–3 Sustained reduction in overall disease activity is therefore an important treatment goal.

Objectives

To investigate sustained British Isles Lupus Assessment Group 2004–based Composite Lupus Assessment (BICLA) response and British Isles Lupus Assessment Group (BILAG) responses by organ domain in pooled data from the TULIP-1 and TULIP-2 trials of the type I interferon receptor monoclonal antibody, anifrolumab, in patients with SLE.4,5

Methods

TULIP-1 (NCT02446912) and TULIP-2 (NCT02446899) were phase 3, randomized, placebo-controlled, 52-week trials of intravenous anifrolumab administered every 4 weeks for 48 weeks in eligible patients with moderate to severe SLE who were receiving standard therapy.4,5 Sustained BICLA and BILAG response rates, measured as the number of consecutive patient visits with BICLA or BILAG domain responses, respectively, from Week 4 to Week 52 were compared between the anifrolumab vs placebo groups. BILAG-2004 response was defined as a reduction from A (severe disease) at baseline to B (moderate), C (mild), or D (no current disease) or reduction from B at baseline to C or D.6

Results

In total, 360 patients received anifrolumab 300 mg and 366 patients received placebo in the TULIP-1 and TULIP-2 trials. Analysis of pooled TULIP data revealed that more patients who received anifrolumab had sustained BICLA responses compared with placebo (Table 1). The proportions of patients who had BICLA responses sustained for ≥3, ≥6, ≥9, and 12 months inclusive of Week 52 were 33.6%, 27.2%, 16.4%, and 9.2% in the anifrolumab group, and 20.5%, 15.0%, 8.5%, and 1.9% in the placebo group, respectively. The most commonly affected organ domains were musculoskeletal (645/726 patients) and mucocutaneous (627/726 patients) (Figure 1). More patients receiving anifrolumab had BILAG responses for 12 months compared with placebo in these two domains (musculoskeletal: 19.9% vs 13.1%; mucocutaneous: 17.1% vs 7.1%); analyses of all other organ domains were limited by small sample sizes.

Table 1.

Number of Patients With Consecutive Visits of Sustained BICLA Response Up to and Including Week 52 in Pooled TULIP-1 and TULIP-2 Trials

n (%)Anifrolumab 300 mgPlacebo(n=360)(n=366)≥3 months121 (33.6)75 (20.5)(≥5 visits, Week 36–52)≥6 months98 (27.2)55 (15.0)(≥8 visits, Week 24–52)≥9 months59 (16.4)31 (8.5)(11 visits, Week 12–52)12 months33 (9.2)7 (1.9)(13 visits, Week 4–52)

BICLA, British Isles Lupus Assessment Group–based Composite Lupus Assessment.

Conclusion

In two phase 3 studies, more anifrolumab-treated patients achieved sustained BICLA and BILAG responses compared with placebo. In the frequently affected musculoskeletal and mucocutaneous domains, sustained treatment benefit of anifrolumab over placebo was observed. These data support the durable clinical benefit of anifrolumab treatment in patients with moderate to severe SLE who are receiving standard therapy.

References

[1]Chambers SA. Rheumatology (Oxford). 2009;48:673–5.

[2]Murimi-Worstell IB. BMJ Open. 2020;10:e031850.

[3]Olesińska M. Reumatologia. 2018;56:45–54.

[4]Furie RA. Lancet Rheumatol. 2019;1:e208–19.

[5]Morand EF. N Engl J Med. 2020;382:211–21.

[6]Isenberg DA. Rheumatology (Oxford). 2005;44:902–6.

Acknowledgements

Writing assistance by Victoria Alikhan (Fishawack Health). This study was sponsored by AstraZeneca.

Disclosure of Interests

Ronald van Vollenhoven Speakers bureau: AbbVie, Galapagos, GSK, Janssen, Pfizer, R-Pharma, UCB, Consultant of: AbbVie, AstraZeneca, Biogen, BMS, Galapagos, Janssen, Miltenyi, Pfizer, UCB, Grant/research support from: MSD, Pfizer, Roche, BMS, GSK, UCB, Richard Furie Speakers bureau: AstraZeneca, Genentech, Consultant of: AstraZeneca, Grant/research support from: AstraZeneca, Eric F. Morand Speakers bureau: GSK, Novartis, Paid instructor for: AstraZeneca, Biogen, Eli Lilly, Consultant of: AstraZeneca, Biogen, Bristol Myers Squibb, Eli Lilly, EMD Serono, Genentech, GSK, Janssen, Servier, Grant/research support from: Abbvie, AstraZeneca, Bristol Myers Squibb, GSK, Janssen, Raj Tummala Shareholder of: AstraZeneca, Employee of: AstraZeneca, Emmanuelle Maho Employee of: AstraZeneca, Catharina Lindholm Employee of: AstraZeneca

POS0733 DISCORDANCE BETWEEN PATIENT GLOBAL ASSESSMENT AND PHYSICIAN GLOBAL ASSESSMENT OF DISEASE ACTIVITY IN THE MODERATE TO SEVERE SYSTEMIC LUPUS ERYTHEMATOSUS PROSPECTIVE OBSERVATIONAL COHORT STUDY (SPOCS)

Background

Emphasis in clinical research and care has been placed on the need to include evaluations that reflect the perspectives of both patients and physicians.

Objectives

The goal of this study was to analyze patient and physician assessments and to determine characteristics associated with concordance and discordance of these assessments.

Methods

Baseline data of patients with moderate to severe SLE enrolled in the Systemic Lupus Erythematosus Prospective Observational Cohort Study (SPOCS)1 were analyzed. Physician’s Global Assessment (PGA) representing disease activity during the 4-week interval prior to baseline and Patient Global Assessment (PtGA) representing the impact of disease during a 1-month interval prior to baseline were independently scored on visual analogue scales (PGA 0-3; PtGA 0-100). Spearman’s rank (rho) was calculated to assess their correlation. A difference between PGA and PtGA scores ≥25 points defined discordance (after rescaling PGA to 0–100).2 Baseline characteristics associated with concordance and discordance were assessed.

Results

827 patients were included in this analysis. At baseline, the mean PGA score was 1.5 (SD 0.6, n=824), and the mean PtGA score was 51.1 (SD 25.5, n=790). The correlation between PGA and PtGA was low (rho=0.19, P<0.001, n=787) (Figure 1). PGA and PtGA scores were discordant in 301 (38%) of patients. Among those patients exceeding the threshold defining discordance, 152 (19%) had higher PGA scores than PtGA scores, and 149 (19%) had higher PtGA scores than PGA scores. The subgroup of PGA-higher discordant patients had higher mean SLEDAI-2K scores, greater serological activity, and more frequent type 1 interferon gene signature positivity, whereas PtGA-higher discordant patients were more likely to be using analgesics and/or anti-depressants, had higher mean BMI and were less likely to be employed (Table 1).

Table 1.

Characteristics associated with PGA and PtGA scoresa

Concordant (N=486)PGA higher (N=152)PtGA higher (N=149)P-value-1bP-value-2bAge, years45.5 (13.7)42.7 (14.4)46.4 (14.0)0.0220.043Race, White326 (71%)96 (66%)94 (69%)0.1920.360BMI, kg/m227.6 (7.2)25.6 (5.4)27.2 (6.4)0.0320.011Employed249 (51%)80 (53%)51 (34%)0.0010.001SLEDAI-2K total score10.0 (4.8)10.8 (5.1)8.2 (3.0)<0.001<0.001Positive ANA/anti-dsDNA436 (90%)143 (94%)127 (85%)0.0120.041Low Complement (C3 or C4)132 (46%)58 (60%)41 (43%)0.0140.026High IFNGS313 (71%)101 (78%)89 (64%)0.0140.049≥1 mild flare115 (24%)20 (13%)45 (30%)<0.0010.001≥1 moderate flare88 (18%)37 (24%)23 (16%)0.0570.120≥1 severe flare39 (8%)11 (7%)15 (10%)0.3720.628OCS daily dose0.0520.129No OCS214 (44%)57 (38%)62 (42%)>0–7.5 mg139 (29%)38 (25%)52 (35%)>7.5–15 mg75 (15%)37 (25%)18 (12%)>15 mg57 (12%)19 (13%)17 (11%)Immunosuppressants271 (56%)80 (53%)75 (50%)0.6900.467Biologics106 (22%)25 (16%)19 (13%)0.3640.032Analgesics152 (31%)22 (14%)46 (31%)<0.001<0.001Antidepressants123 (25%)31 (20%)52 (35%)0.0050.013

aMean (SD) for continuous, n (%) for nominal variables. Missing data was <10% of patients for the variables displayed. Denominators exclude missing data. bP-value-1 compares PGA higher vs PtGA higher. P-value-2 compares all 3 groups. Based on the chi-squared test for categorical variables and t-test or ANOVA for continuous variables.

IFNGS, type 1 interferon gene signature; OCS, oral corticosteroid; PGA, physician global assessment; PtGA, patient global assessment

Conclusion

Low correlation between PGA and PtGA suggests both should be used to acquire a broad perspective of the impact of disease on the overall health of patients. Different baseline characteristics were associated with the PGA-higher compared to the PtGA-higher discordant subgroups.

References

[1]Hammond ER, et al. BMJ Open. 2020;10:e036563.

[2]Challa DNV, et al. Rheumatol Ther. 2017;4:201–8.

Acknowledgements

Editing assistance by Rebecca S. Jones, PhD (Fishawack). This study was sponsored by AstraZeneca.

Disclosure of Interests

Laurent Arnaud Speakers bureau: AstraZeneca, Consultant of: AstraZeneca, Grant/research support from: AstraZeneca, Richard Furie Speakers bureau: AstraZeneca, Genentech, Consultant of: AstraZeneca, Grant/research support from: AstraZeneca, Eric F. Morand Speakers bureau: GSK, Novartis, Paid instructor for: AstraZeneca, Biogen, Eli Lilly, Consultant of: AstraZeneca, Biogen, Bristol Myers Squibb, Eli Lilly, EMD Serono, Genentech, GSK, Janssen, Servier, Grant/research support from: Abbvie, AstraZeneca, Bristol Myers Squibb, GSK, Janssen, Christine Peschken Consultant of: AstraZeneca, GSK, Grant/research support from: AstraZeneca, Martin Aringer Speakers bureau: AbbVie, AstraZeneca, BMS, Boehringer Ingelheim, Chugai, HEXAL, Lilly, MSD, Mylan, Novartis, Roche, Sanofi, UCB, Consultant of: AbbVie, AstraZeneca, BMS, Boehringer Ingelheim, Galapagos, GSK, Pfizer, Roche, Sanofi, Eleni Rapsomaniki Employee of: AstraZeneca, Jonatan Hedberg Shareholder of: AstraZeneca, Employee of: AstraZeneca, Jacob Knagenhjelm Shareholder of: AstraZeneca, Employee of: AstraZeneca, Caroline Seo Shareholder of: AstraZeneca, Employee of: AstraZeneca, Tina Grünfeld Eén Shareholder of: AstraZeneca, Employee of: AstraZeneca, Barnabas Desta Shareholder of: AstraZeneca, Employee of: AstraZeneca, Alessandro Sorrentino Shareholder of: Galapagov, Abbott LAboratories, Gilead Sciences, Moderna, Employee of: Janssen, Sanofi, AstraZeneca, Raj Tummala Shareholder of: AstraZeneca, Employee of: AstraZeneca, Heide Stirnadel-Farrant Shareholder of: AstraZeneca, GSK, Employee of: AstraZeneca

POS0688 CHARACTERIZATION OF PK/PD OF ANIFROLUMAB IN PATIENTS WITH MODERATE TO SEVERE SLE

Background:

In the TULIP-1 and TULIP-2 trials, anifrolumab, a type I interferon (IFN) receptor antibody, at a dosage of 300 mg once every 4 weeks (Q4W), demonstrated consistent median pharmacokinetic (PK) concentrations1 and sustained neutralization of the pharmacodynamic (PD) 21-gene type I IFN gene signature (IFNGS)2–4 in patients with moderate to severe systemic lupus erythematosus (SLE) despite standard therapy.

Objectives:

To characterize the PK/PD relationship of anifrolumab and to confirm anifrolumab 300 mg provides adequate PD neutralization in IFNGS test–high patients.

Methods:

This study included IFNGS test–high patients from the phase 3 randomized, placebo-controlled, 52-week TULIP-12 (NCT02446912) and TULIP-23 (NCT02446899) trials of intravenous anifrolumab 150 mg or 300 mg Q4W plus standard therapy. IFNGS test status (high or low) at screening was classified with an analytically validated 4-gene qPCR based test on whole blood.2 PD neutralization was measured with 21-gene type I IFNGS and expressed as a percentage change from baseline.3 For the graphic PK/PD analysis, patients with ≥1 quantifiable serum PK sample and ≥1 PD measurement before discontinuation were categorized depending on Cave (individual predicted average anifrolumab concentration over treatment duration) median and tertiles (T) for anifrolumab 150 mg and 300 mg, respectively. Median PD IFNGS neutralization and medium absolute deviations were compared across Cave subgroups. PK/PD modeling was assessed in patients with ≥1 quantifiable serum PK sample and a baseline and ≥1 postbaseline PD measurement before discontinuation, using a nonlinear mixed-effects model (NONMEM; version 7.3; ICON) to estimate parameters and characterize the PK/PD data. The PD/efficacy analysis included patients with ≥1 postbaseline PD measurement before discontinuation. BILAG-based Combined Lupus Assessment (BICLA) response rates at Week (W)52 were compared across median PD neutralization quartiles (Q) for pooled anifrolumab 300 mg and 150 mg groups.

Results:

The PK/PD graphic analysis included 654 IFNGS test–high patients (placebo [n=293]; anifrolumab 150 mg [n=72] or 300 mg [n=289]). Cave was generally higher with anifrolumab 300 mg (µg/mL, TULIP-1: T1 <32, T2 32–<44.3, T3 ≥44.3; TULIP-2: T1 <32.4, T2 32.4–<47.9, T3 ≥47.9) than with anifrolumab 150 mg (median 11.5 µg/mL); overlap between anifrolumab 300 mg and 150 mg Cave subgroups was small owing to nonlinearity. Anifrolumab 300 mg elicited rapid (by W44) and sustained median PD neutralization >80%, vs a lower and delayed PD neutralization (median >50% at W52) with anifrolumab 150 mg, and minimal PD neutralization with placebo. The median PD neutralization increased with higher Cave subgroups, plateauing at ~90% at W12–W52. All anifrolumab 300 mg Cave tertiles had a median PD neutralization ~80%; however, the variability was greater in the lowest Cave tertiles vs higher Cave tertiles across trials (Figure 1). The PK/PD modeling, which included 646 IFNGS test–high patients (placebo [n=289], anifrolumab 150 mg [n=70] or 300 mg [n=287]), gave an IC80 estimate of 3.88 μg/mL. The median W24 (study midpoint) Ctrough was higher with anifrolumab 300 mg vs 150 mg (15.6 vs 0.2 μg/mL); thus, the W24 Ctrough exceeded the IC80 in a higher proportion of patients treated with anifrolumab 300 mg vs 150 mg (~83% vs ~27%). The PD/efficacy analysis included 341 patients who received anifrolumab. Higher median percentage PD neutralization quartiles (Q1 <51.7%, Q2 51.7%–85.3%, Q3 85.3%–92.6%, Q4 >92.6%) were associated with higher W52 BICLA response rates (Q1 37.6%, Q2 49.4%, Q3 51.8%, Q4 58.1%).

Conclusion:

In TULIP-1 and TULIP-2, anifrolumab 300 mg yielded higher anifrolumab Cave vs 150 mg. High Cave was associated with rapid (W44–W12), substantial, and sustained PD neutralization of the 21-gene IFNGS in IFNGS test–high patients, which in turn was associated with higher efficacy.

References:

[1]Kuruvilla D. Poster 360, AAPS 2020.

[2]Furie RA. Lancet Rheumatol. 2019;1:e208–19.

[3]Morand EF. N Engl J Med. 2020;382:211–21.

[4]Furie R. Arthritis Rheumatol. 2017;69:379–86.

Acknowledgements:

Writing assistance by Matilda Shackley, MPhil, of JK Associates Inc., part of Fishawack Health. This study was sponsored by AstraZeneca.

Disclosure of Interests:

Yen Lin Chia Employee of: AstraZeneca, Raj Tummala Employee of: AstraZeneca, Tu Mai Employee of: Genentech, Tomas Rouse Employee of: AstraZeneca, Wendy White Employee of: AstraZeneca, Eric F. Morand Speakers bureau: AstraZeneca, Consultant of: AstraZeneca, Grant/research support from: AstraZeneca, Richard Furie Consultant of: AstraZeneca, Grant/research support from: AstraZeneca

POS0691 EFFECTS OF ANIFROLUMAB ON RENAL DISEASE IN PATIENTS WITH SLE

Background:

The type I interferon (IFN) receptor antibody anifrolumab has shown efficacy in patients with systemic lupus erythematosus (SLE) in the phase 3 TULIP-1 and TULIP-2 trials.1,2 Type I IFN dysregulation is associated with lupus nephritis (LN) pathogenesis.3

Objectives:

Pooled TULIP data were analyzed post hoc to assess baseline characteristics of patients with and without renal involvement and to evaluate the effects of anifrolumab on renal disease.

Methods:

TULIP-1 (NCT02446912) and TULIP-2 (NCT02446899) were randomized, placebo-controlled, 52-week trials of intravenous anifrolumab every 4 weeks in patients with moderate to severe SLE despite standard therapy, which excluded patients with severe active LN.1,2 Renal involvement at baseline was defined as any of the following: BILAG-2004 renal score A–C; SLEDAI-2K renal score >0; urine protein–creatinine ratio (UPCR) >0.5 mg/mg. Baseline characteristics were evaluated in patients with and without renal involvement, and the following endpoints were compared for the anifrolumab 300 mg and placebo groups: cumulative UPCR (area under the curve, AUC) through Week (W)52; percentage of patients with UPCR >0.5 mg/mg at baseline who improved to UPCR ≤0.5 mg/mg at W52; percentage of patients with renal flares (new BILAG-2004 A/B renal score vs prior visit); cumulative glucocorticoid (GC) use (AUC) through W52; and percentage changes in complement C3/C4 from baseline to W52.

Results:

Of the 726 patients in TULIP-1/-2 (anifrolumab, n=360; placebo, n=366), 99 had renal involvement at baseline (anifrolumab, n=45; placebo, n=54), 57 of whom had UPCR >0.5 mg/mg (anifrolumab, n=24; placebo, n=33). Patients with renal involvement vs without renal involvement had a lower mean age (37.8 vs 42.4 years) and were more likely to be male (14.1% vs 6.1%), Asian (16.2% vs 9.6%), IFN gene signature test–high (89.9% vs 81.5%), and anti-dsDNA positive (69.7% vs 40.4%); have a SLEDAI-2K score ≥10 (91.9% vs 68.4%); and be receiving GC ≥10 mg/day (67.7% vs 49.1%) or mycophenolate (26.3% vs 11.5%) at baseline. Among patients with baseline renal involvement, anifrolumab treatment was associated with a numerically greater improvement vs placebo in cumulative UPCR (AUC) through W52 (LS mean difference [SE]: –54.1 [54.26]) (Table 1). Numerically more patients improved from UPCR >0.5 mg/mg at baseline to ≤0.5 mg/mg at W52 with anifrolumab vs placebo (difference [SE], 4.9% [13.3]). Among all TULIP patients, fewer had ≥1 BILAG-2004 renal flare with anifrolumab vs placebo (5.0% vs 7.4%).4 Among patients with renal involvement, cumulative GC use (AUC) through W52 was lower with anifrolumab vs placebo (LS mean difference [SE]: –210.3 mg [332.6]) and there were numerically greater improvements in C3 and C4 from baseline to W52 (Table 1).

Conclusion:

TULIP data suggest renal benefit with anifrolumab in patients with SLE with mild/stable renal disease, supporting further investigation into anifrolumab’s efficacy in patients with active LN.

References:

[1]Furie R. Lancet Rheumatol. 2019;1:e208–19.

[2]Morand E. N Engl J Med. 2020;382:211–21.

[3]Feng X. Arthritis Rheum. 2006;54:2951–62.

[4]Furie R [abstract]. Arthritis Rheumatol. 2020;72(supp 10).

Table 1.

Renal Endpoints in TULIP-1 and TULIP-2

Endpoint (baseline to Week 52)PlaceboAnifrolumab 300 mgUPCR AUCan5445LS mean (SE)271.8 (54.8)217.7 (60.0)LS mean difference (SE), 95% CI−54.1 (54.3), −161.9, 53.6Improvement from >0.5 to ≤0.5 mg/mg UPCRbn3324Patients with improvement (%)36.341.2Difference, % (SE), 95% CI4.9 (13.3), −21.1, 30.9Glucocorticoid AUCan5445LS mean (SE)3524.5 (339.0)3314.2 (365.2)LS mean difference (SE), 95% CI−210.3 (332.6), −870.7, 450.1Change in C3/C4 (%)cC3N3121Mean (SE)20.3 (6.2)26.6 (5.0)C4N1914Mean (SE)29.1 (12.0)38.7 (13.8)

AUC, area under the curve; CI, confidence interval; LS, least squares; UPCR, urine protein–creatinine ratio; SE, standard error.

n, number satisfying baseline inclusion criteria for subgroup.

aPatients with baseline renal involvement; analysis of covariance.

bStratified Cochran–Mantel–Haenszel.

cPatients with renal involvement and abnormal C3/C4 at baseline.

Acknowledgements:

Writing assistance by Rosie Butler, PhD, of JK Associates Inc. part of Fishawack Health. This study was sponsored by AstraZeneca.

Disclosure of Interests:

Eric F. Morand Speakers bureau: AstraZeneca, Consultant of: AstraZeneca, Grant/research support from: AstraZeneca, Richard Furie Consultant of: AstraZeneca, Grant/research support from: AstraZeneca, Yoshiya Tanaka Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, GSK, Janssen, Mitsubishi-Tanabe, Novartis, Pfizer, Sanofi, and YL Biologics, Grant/research support from: AbbVie, Chugai, Daiichi-Sankyo, Eisai, Mitsubishi-Tanabe, Takeda, and UCB, Tsutomu Takeuchi Speakers bureau: AbbVie GK., Bristol–Myers K.K., Chugai Pharmaceutical Co,. Ltd., Mitsubishi Tanabe Pharma Co., Pfizer Japan Inc., Astellas Pharma Inc, Daiichi Sankyo Co., Ltd., Eisai Co., Ltd., Sanofi K.K., Teijin Pharma Ltd., Takeda Pharmaceutical Co., Ltd., Novartis Pharma K.K., Consultant of: AstraZeneca K.K., Eli Lilly Japan K.K., Novartis Pharma K.K., Mitsubishi Tanabe Pharma Co., Abbvie GK, Nipponkayaku Co.Ltd, Janssen Pharmaceutical K.K., Astellas Pharma Inc,. Taiho Pharmaceutical Co., Ltd., Chugai Pharmaceutical Co, Ltd., Grant/research support from: Astellas Pharma Inc, Chugai Pharmaceutical Co, Ltd., Daiichi Sankyo Co., Ltd., Takeda Pharmaceutical Co., Ltd., AbbVie GK, Asahikasei Pharma Corp., Mitsubishi Tanabe Pharma Co., Pfizer Japan Inc., Eisai Co., Ltd., AYUMI Pharmaceutical Corporation, Nipponkayaku Co.Ltd., Novartis Pharma K.K., Gabriel Abreu Employee of: AstraZeneca, Raj Tummala Employee of: AstraZeneca, Catharina Lindholm Employee of: AstraZeneca

POS0684 RELATIONSHIP OF ANIFROLUMAB PK WITH EFFICACY AND SAFETY IN PATIENTS WITH SLE

Background:

In patients with systemic lupus erythematosus (SLE), the type I interferon (IFN) receptor inhibitor anifrolumab was well tolerated and was associated with greater percentages of patients with BILAG–based Composite Lupus Assessment (BICLA) responses vs placebo in 2 phase 3 trials: TULIP-11 (secondary endpoint) and TULIP-22 (primary endpoint).

Objectives:

To characterize the relationship of anifrolumab pharmacokinetics (PK) with BICLA response and safety using pooled data from the TULIP trials.

Methods:

This analysis included patients with moderate to severe SLE despite standard therapy who had ≥1 dose of investigational product and ≥1 quantifiable PK observation in the randomized, placebo-controlled, 52-week TULIP-1 (NCT02446912) and TULIP-2 (NCT02446899) trials of intravenous anifrolumab (every 4 weeks).1,2 The distributions of average anifrolumab serum concentrations (Cave) during treatment were similar between TULIP-1 and TULIP-2, allowing for data pooling for all analyses. For the exposure–BICLA analysis, the proportions of patients with BICLA responses at Week (W)52 (and corresponding 95% confidence intervals [CIs]) in each quartile/tertile of Cave were compared for anifrolumab 300 mg and placebo groups in all patients, patients who completed treatment, and IFN gene signature (IFNGS) test–high patients who completed treatment, using average marginal effect logistic regression (stratified by SLE Disease Activity Index 2000 total score at screening, IFNGS status at screening, and Day 1 glucocorticoid dosage [mg/day]). The relationships between exposure and key safety events were similarly assessed. Analyses presented focus on the anifrolumab 300 mg dose.

Results:

Of the patients in TULIP-1/TULIP-2 who received anifrolumab 300 mg (n=356) or placebo (n=366), 574 completed treatment, of whom 470 were IFNGS test–high at screening. In the exposure–BICLA response analyses, differences favoring anifrolumab 300 mg vs placebo were observed across Cave subgroups among all patients, patients who completed treatment, and IFNGS test–high patients who completed treatment (Table 1). Among IFNGS test–high patients who completed treatment, logistic regression identified Cave as a significant covariate for BICLA response. There was no evidence that the incidence of non-opportunistic serious infections, or increased incidence of herpes zoster (HZ) or infusion-related reactions associated with anifrolumab, were exposure-driven (Figure 1); the incidence of malignancy was low in the anifrolumab 300 mg and placebo groups (<1%), with no evidence that malignancy was exposure-driven through W52.

Conclusion:

Consistent benefit in favor of anifrolumab 300 mg vs placebo was observed in W52 BICLA responses across Cave subgroups. Cave was a significant covariate of efficacy in IFNGS test–high patients who completed treatment. There was no evidence of exposure-driven HZ, non-opportunistic serious infections, infusion-related reactions, or malignancy during the TULIP trials.

References:

[1]Furie R. Lancet Rheumatol. 2019;1:e208–19.

[2]Morand E. N Engl J Med. 2020;382:211–21.

Table 1.

Exposure–BICLA Analysis for Pooled TULIP Data

BICLA response, W52PK subgroupaAnifrolumab 300 mg,n/Nb(%)Anifrolumab vs placebo difference, % [95% CI]All patients (n=722)Q140/100 (40)9.6 [–1.0, 20.3]Q244/98 (44)13.4 [2.6, 24.2]Q343/81 (53)22.5 [10.7, 34.3]Q444/77 (58)27.4 [15.4, 39.4]Placebo112/366 (31)–Patients completing treatment (n=574)Q140/75 (54)12.7 [0.1, 25.2]Q244/74 (57)15.5 [2.7, 28.3]Q343/74 (58)17.2 [4.7, 29.8]Q444/75 (60)18.7 [6.2, 31.2]Placebo112/276 (41)–IFNGS test–high patients completing treatment (n=470)T144/81 (54)15.4 [3, 27.8]T246/81 (54)15.4 [2.8, 27.9]T352/81 (66)26.7 [14.7, 38.7]Placebo88/227 (39)–

BICLA, British Isles Lupus Assessment Group–based Composite Lupus Assessment;

CI, confidence interval; IFNGS, interferon gene signature; PK, pharmacokinetic; Q, quartile; T, tertile.

aPK was stratified by quartiles/tertiles based on sample size.

bn, number of BICLA responders; N, number of patients in the subgroup.

Acknowledgements:

Writing assistance by Alexus Rivas, PharmD, and Rosie Butler, PhD, of JK Associates Inc., part of Fishawack Health.

This study was sponsored by AstraZeneca.

Disclosure of Interests:

Yen Lin Chia Employee of: AstraZeneca, Jianchun Zhang Employee of: Fate Therapeutics, AstraZeneca (former), Raj Tummala Employee of: AstraZeneca, Tomas Rouse Employee of: AstraZeneca, Richard Furie Consultant of: AstraZeneca, Grant/research support from: AstraZeneca, Eric F. Morand Speakers bureau: AstraZeneca, Consultant of: AstraZeneca, Grant/research support from: AstraZeneca

AB0289 PATIENT REPORTED PHYSICAL HEALTH COMPARED TO CLINICIAN RECORDED BILAG-2004 MUSCULOSKELETAL SYSTEM SCORES – DISCORDANCE BETWEEN PATIENTS AND CLINICIANS

Background:

The musculoskeletal organ system BILAG-2004 (MSK BILAG) assessment is of critical importance in SLE clinical trials. Severe active polyarthritis, MSK BILAG A, by definition includes significant impairment of basic activities of daily living (ADLs), as opposed to MSK BILAG C, D, or E where ability to perform ADLs is expected to be preserved. In clinical trials, BILAG is scored by clinicians without formal review of patient reported outcomes (PROs). The Physical Health domain of the LupusQoL (LQol PH) (range 0 – 100) can be used to assess the patient’s physical function and ADLs. LQoL PH score thresholds defining impairment severity have not been established; however, a transformed LQoL PH score ≤50 suggests more impaired function, which would not be expected in MSK BILAG C, D, or E. Conversely, a score >50 implies no major issues with ADLs, which would be contradictory to the definition of MSK BILAG A.

Objectives:

To assess correlation of patient reported LQoL PH with MSK BILAG scores recorded by clinicians at various timepoints using data from the phase 3 TULIP studies 1,2 and to investigate the percent of discordance between patients and clinicians.

Methods:

Data from TULIP 1 and 2 studies (anifrolumab 300 mg and placebo arms) were pooled to evaluate the relationship between LQoL PH and MSK BILAG scores at baseline, weeks 24 and 52 using Spearman correlations as post-hoc analysis. Mean LQoL PH scores were assessed for each MSK BILAG category at the three timepoints using one-way ANOVA. Percent of patients with MSK BILAG A and LQoL PH scores >50 and patients with MSK BILAG C, D, or E and LQoL PH scores ≤50 was calculated at baseline, week 24 and 52. MSK BILAG B was excluded from the analysis because discordance could not be easily defined for this category compared with the more extreme MSK BILAG categories.

Results:

Total of 690 patients were included in the pooled analysis (Table 1). Significant correlations between LQoL PH and MSK BILAG scores were found at each time point (nominal p<0.0001); this relationship became stronger over time. Mean LQoL PH scores were different in each MSK BILAG category, with the highest in MSK BILAG D/E and the lowest in the MSK BILAG A category, thus confirming the discriminatory ability of the LQoL PH (Table 1).

Table 1.

Correlation coefficients (CC) between LQoL PH and MSK BILAG scores, and mean LQoL PH scores with standard deviations (SD) per each MSK BILAG category at baseline, weeks 24 and 52.

BaselineWeek 24Week 52CCNCCNCCNTotal Population-0.25690-0.36626-0.41552MSK BILAGMean LQoL PH Score (SD)Mean LQoL PH Score (SD)Mean LQoL PH Score (SD)0 (D/E)69.3 (24.7)1774.2 (22.1)18674.5 (21.3)2371 (C)62.3 (25.4)6064.0 (23.9)23360.6 (22.5)1848 (B)56.6 (24.4)39855.1 (24.2)16351.3 (24.3)10512 (A)44.9 (25.8)21543.9 (25.9)4444.2 (26.2)26

At baseline, 40% of patients who were assessed by clinicians as having MSK BILAG A reported minimal impairment in physical function and ADLs (LQoL PH >50) and 24.1% who had MSK BILAG C, D, or E reported difficulties with ADLs (LQoL HP ≤50), suggesting discordance between patients and clinicians. This discordance slightly decreased over time (Figure 1).

Figure 1.

Percent of patients with MSK BILAG A and LQoL PH scores >50 and patients with MSK BILAG C, D, or E and LQoL PH scores ≤50 at baseline, weeks 24 and 52.

Conclusion:

Patient reported LQoL PH scores correlated with MSK BILAG scores and showed discriminant validity for MSK BILAG scores. Greater discordance was seen between LQoL PH and MSK BILAG A compared with C, D, or E. These findings suggest a need for further investigation of a role for PROs in MSK BILAG scoring. Formal review of PROs by clinicians during MSK BILAG assessment could be considered in future SLE clinical trials.

References:

[1]Furie R et al. Lancet 2019

[2]Morand EF et al. N Engl J Med 2020

Acknowledgements:

This study was sponsored by AstraZeneca.

Disclosure of Interests:

Ewa Olech Speakers bureau: Abbvie, Amgen, Merck, Pfizer, and UCB, Grant/research support from: BMS, Donald Stull: None declared, Betsy Williams: None declared, Stephanie Bean: None declared, Gabriel Abreu Employee of: AstraZeneca, Erik Schwetje Employee of: AstraZeneca, Raj Tummala Employee of: AstraZeneca, Sean O’Quinn Shareholder of: AstraZeneca, Employee of: AstraZeneca

POS0690 RANDOMIZED, CONTROLLED, PHASE 2 TRIAL OF TYPE 1 IFN INHIBITOR ANIFROLUMAB IN PATIENTS WITH ACTIVE PROLIFERATIVE LUPUS NEPHRITIS

Background:

Anifrolumab, a type I interferon receptor antibody, has shown efficacy in patients with systemic lupus erythematosus (SLE),1,2 >30% of whom develop lupus nephritis (LN).

Objectives:

To evaluate the efficacy and safety of anifrolumab vs placebo alongside standard therapy in patients with active proliferative LN.

Methods:

TULIP-LN (NCT02547922) was a phase 2 double-blind trial in adult patients with active, biopsy-proven LN and 24-hour (h) urine protein–creatinine ratio (UPCR) >1 mg/mg. Patients were randomized (1:1:1) to anifrolumab basic regimen (BR, 300 mg, based on SLE dosing1,2), anifrolumab intensified regimen (IR, 900 mg for 3 doses, 300 mg thereafter), or placebo, intravenously every 4 weeks alongside standard therapy of oral glucocorticoids (GCs; mandatory taper ≤10 mg/day by Week [W]12, ≤7.5 mg/day by W24) and mycophenolate mofetil (target 2 g/day by W8). The primary endpoint was the relative difference in change from baseline to W52 in 24-h UPCR, measured with a geometric mean ratio (GMR) of the change in the combined anifrolumab vs placebo groups (GMR <1 favors anifrolumab). The key secondary endpoint was complete renal response (CRR) at W52 (24-h UPCR ≤0.7 mg/mg, estimated glomerular filtration rate ≥60 mL/min/1.73 m2 or no decrease ≥20%, no treatment discontinuation, and no restricted medication use). Sustained GC taper (≤7.5 mg/day, W24–52) was an exploratory endpoint. CRR0.5 (CRR with UPCR ≤0.5 mg/mg) and time to CRR0.5 sustained to W52 were analyzed post hoc. Responder rates were calculated with a stratified Cochran–Mantel–Haenszel approach.

Results:

Patients received anifrolumab BR (n=45) or IR (n=51) or placebo (n=49); demographics and baseline disease characteristics were generally balanced between groups. No difference in change from baseline to W52 in 24-h UPCR was observed for combined anifrolumab vs placebo groups (Table 1). Anifrolumab clearance was higher in patients with LN vs SLE; proteinuria in LN elicited suboptimal anifrolumab serum concentrations (early trough from BR 50%–60% lower than in SLE trials1,2), so anifrolumab IR results are presented. CRR rate at W52 was numerically higher with the IR vs placebo (45.5% vs 31.1%) (Table 1). Time to sustained CRR0.5 (Figure 1), rate of CRR0.5 at W52, and rate of sustained GC taper to ≤7.5 mg/day (Table 1) were improved with the IR vs placebo. Most adverse events were nonserious, mild, or moderate and did not lead to discontinuation; rates were similar in the combined anifrolumab vs placebo groups (89.8% vs 93.8%). In the combined anifrolumab vs placebo groups, there was a higher incidence of herpes zoster (HZ, 16.7% vs 8.2%); most HZ cases were of mild to moderate intensity, cutaneous, and resolved with treatment.

Conclusion:

Although the primary endpoint was not met, the anifrolumab IR was associated with numeric improvements across clinical endpoints vs placebo; thus, intensified dosing may be required to reach clinical efficacy in LN vs SLE without active renal disease. Anifrolumab had a similar safety profile in patients with LN and SLE; despite higher frequency of HZ vs placebo, anifrolumab was well tolerated.

References:

[1]Morand EF. N Engl J Med. 2020;382:211–21.

[2]Furie RA. Lancet Rheumatol. 2019;1:e208–19.

Table 1.

Summary of Clinical Efficacy Endpoints

EndpointAnifrolumabPlaceboCombinedBasicIntensified24-hour urine protein–creatinine ratio improvement W52N91415041GMR vs placebo1.0311.1040.963–95% CI0.621, 1.7130.612, 1.9920.548, 1.693CRR rate W52n/N (%)27/87 (31.0)7/43 (16.3)20/44 (45.5)14/45 (31.1)Δ−0.08−14.8314.34–95% CI−16.92, 16.76−32.89, 3.22−5.77, 34.46CRR0.5rate W52n/N (%)25/87 (28.7)7/43 (16.3)18/44 (40.9)12/45 (26.7)Δ2.07−10.3914.24–95% CI−14.25, 18.39−28.07, 7.29−5.42, 33.90Glucocorticoid≤7.5 mg/dayW24–52n/N (%)31/67 (46.3)11/31 (35.5)20/36 (55.6)11/33 (33.3)Δ12.942.1522.22–95% CI−7.26, 33.13−21.40, 25.70−0.79, 45.23

Δ Percentage difference vs placebo.

CI, confidence interval; CRR, complete renal response; GMR, geometric mean ratio; n, number of responders; N, number analyzed; W, Week.

Acknowledgements:

Writing assistance by Matilda Shackley, MPhil, of JK Associates, Inc, a member of Fishawack Health. This study was sponsored by AstraZeneca.

Disclosure of Interests:

David Jayne Grant/research support from: AstraZeneca, Aurinia, Boehringer-Ingelheim, GSK, Roche/Genentech and Sanofi-Genzyme, Brad H Rovin Consultant of: AstraZeneca, Eduardo Mysler Grant/research support from: AstraZeneca, GSK, Eli Lilly, Sandoz, Roche, AbbVie, Pfizer, Janssen, Gemma, and Amgen, Richard Furie Consultant of: AstraZeneca, Grant/research support from: AstraZeneca, Frederic Houssiau Consultant of: GSK, Teodora Trasieva Employee of: AstraZeneca, Jacob Knagenhjelm Employee of: AstraZeneca, Erik Schwetje Employee of: AstraZeneca, Yen Lin Chia Employee of: AstraZeneca, Raj Tummala Employee of: AstraZeneca, Catharina Lindholm Employee of: AstraZeneca

OP0131 ANIFROLUMAB EFFECTS ON RASH AND ARTHRITIS IN PATIENTS WITH SLE AND IMPACT OF INTERFERON SIGNAL IN POOLED DATA FROM PHASE 3 TRIALS

Background:

Treatment with the type I interferon (IFN) receptor antibody anifrolumab was associated with clinical improvements in mucocutaneous and musculoskeletal disease activity in patients with systemic lupus erythematosus (SLE) in the phase 2 MUSE trial (NCT01438489) and phase 3 TULIP trials.1–4 Because rash and arthritis are the most common manifestations of SLE, the effect of anifrolumab on these symptoms can be examined in biomarker-defined subsets, as previously reported for the MUSE trial.2

Objectives:

To evaluate the effect of anifrolumab on rash and arthritis in patients with SLE, and the impact of IFN gene signature (IFNGS) on treatment response, using disease measures of different stringency in pooled data from the phase 3 TULIP trials.

Methods:

TULIP-1 (NCT02446912) and TULIP-2 (NCT02446899) were placebo-controlled, 52-week trials of intravenous anifrolumab administered every 4 weeks in patients with moderate to severe SLE.3,4 In this post hoc analysis, outcomes of rash and arthritis were evaluated using mucocutaneous and musculoskeletal domains of the SLE Disease Activity Index 2000 (SLEDAI-2K) and the British Isles Lupus Assessment Group (BILAG) index. In addition, the modified Cutaneous Lupus Erythematosus Disease Area and Severity Index (mCLASI) score was used to evaluate rash, and tender and swollen joint counts were used to assess arthritis.

Results:

360 patients received anifrolumab 300 mg (IFNGS test–high, n=298; IFNGS test–low, n=62) and 366 patients were given placebo (IFNGS test–high, n=302; IFNGS test–low, n=64). Change from baseline to Week 52 compared with placebo was measured by outcomes, ordered by their stringency. More anifrolumab-treated patients achieved rash improvement using SLEDAI-2K (complete resolution: difference 13.5%, nominal P<0.001), BILAG (at least 1 severity grade lowering: difference 15.5%, nominal P<0.001), and mCLASI (≥50% improvement, if baseline score >0: difference 15.6%, nominal P<0.001). Results were comparable in the IFNGS test–high subset (SLEDAI-2K: difference 17.0%, nominal P<0.001, BILAG: difference 16.1%, nominal P<0.001; mCLASI: difference 18.1%, nominal P<0.001). There was a trend toward anifrolumab-associated rash improvement in IFNGS test–low patients using BILAG (Figure). More patients receiving anifrolumab had SLEDAI-2K–defined resolution in arthritis (difference 8.2%, nominal P=0.029), BILAG severity lessening (difference 11.8%, nominal P=0.002), and ≥50% decrease in tender/swollen joint counts, when ≥6 at baseline (difference 12.6%, nominal P=0.016). Results were comparable in the IFNGS test–high subset (SLEDAI-2K: difference 11.7%, nominal P=0.005; BILAG: difference 12.9%, nominal P=0.003; joint counts: difference 11.3%, nominal P=0.054). In IFNGS test–low patients, there was a trend toward anifrolumab-associated arthritis improvement when measured using BILAG, and the effect of anifrolumab on the number of swollen/tender joint counts was similar to the IFNGS test–high group, although the IFNGS test–low sample size in this analysis was very small (Figure).

Conclusion:

In pooled data from the TULIP trials, anifrolumab treatment was associated with improvements in rash and arthritis using measures of different stringency. The SLEDAI-2K findings were largely driven by the subset of patients who were IFNGS test–high. However, using measures that were more sensitive to change, despite small sample sizes, IFNGS test–low patients may also have benefit.

References:

[1]Furie R, et al. Arthritis Rheumatol. 2017;69:376–86.

[2]Merrill JT, et al. Lupus Sci Med. 2018;5:e000284.

[3]Furie RA, et al. Lancet Rheumatol. 2019;1:e208–19.

[4]Morand EF, et al. N Engl J Med. 2020;382:211–21.

Acknowledgements:

Writing assistance by Victoria Alikhan, PhD, of JK Associates Inc., part of Fishawack Health. This study was sponsored by AstraZeneca.

Disclosure of Interests:

Joan T Merrill Consultant of: AstraZeneca, AbbVie, Amgen, Aurinia, BMS, EMD Serono, GSK, Remegen, Janssen, Provention, and UCB, Grant/research support from: BMS and GSK, Victoria Werth Speakers bureau: University of Pennsylvania, who own the copyright for the CLASI and SDASI, Consultant of: AbbVie, Amgen, Argenx, AstraZeneca, Biogen, BMS, Celgene, Chrysalis, CSL Behring, Cugene, Eli Lilly, EMD Serono, Genentech, GSK, Incyte, Idera, Janssen, Kirin, Medimmune, Medscape, Nektar, Octapharma, Pfizer, Principa, Regeneron, Resolve, and Viela Bio, Grant/research support from: AstraZeneca, Biogen, Celgene, Corbus Pharmaceuticals, Genentech, Gilead, Janssen, Pfizer, Syntimmune, and Viela Bio, Richard Furie Consultant of: AstraZeneca, Grant/research support from: AstraZeneca, Eric F. Morand Speakers bureau: AstraZeneca, Consultant of: AstraZeneca, Grant/research support from: AstraZeneca, J Michelle Kahlenberg Consultant of: Admirex Pharmaceuticals, AstraZeneca, Aurinia Pharmaceuticals, BMS, Boehringer Ingelheim, Eli Lilly, and Ventus Therapeutics, Grant/research support from: BMS/Celgene and Q32 Bio, Gabriel Abreu Employee of: AstraZeneca, Raj Tummala Employee of: AstraZeneca

SAT0174 FLARE ASSESSMENTS IN PATIENTS WITH ACTIVE SYSTEMIC LUPUS ERYTHEMATOSUS TREATED WITH ANIFROLUMAB IN 2 PHASE 3 TRIALS

Background:

Anifrolumab treatment resulted in improved British Isles Lupus Assessment Group (BILAG)–based Composite Lupus Assessment (BICLA) response rates in patients with systemic lupus erythematosus (SLE) in the phase 3 TULIP-2 and TULIP-1 trials.1,2In addition, annualized flare rates were lower among the groups treated with anifrolumab compared with placebo.1,2

Objectives:

TULIP-2 and TULIP-1 data were analyzed to assess the effects of anifrolumab on the number of SLE flares and time to first flare during 52 weeks of treatment.

Methods:

The randomized, double-blind, placebo-controlled TULIP-2 and TULIP-1 trials evaluated efficacy and safety of intravenous anifrolumab 300 mg vs placebo every 4 weeks for 48 weeks, with the primary endpoints assessed at Week 52, in patients with moderate to severe SLE despite standard-of-care treatment. Flares were defined as ≥1 new BILAG-2004 A or ≥2 new (worsening) BILAG-2004 B domain scores compared with the prior month’s visit. Time to first flare was evaluated using a Cox proportional hazards model. Annualized flare rate was analyzed using a negative binomial regression model.

Results:

In TULIP-2 (anifrolumab, n=180; placebo, n=182) and TULIP-1 (anifrolumab, n=180; placebo, n=184), fewer patients experienced ≥1 BILAG-2004 flare in the anifrolumab groups (TULIP-2: 31.1%, n=56; TULIP-1: 36.1%, n=65) compared with the placebo groups (TULIP-2: 42.3%, n=77; TULIP-1: 43.5%, n=80; Figure 1). Results favoring anifrolumab were observed in time to first flare (TULIP-2: hazard ratio [HR] 0.65, 95% confidence interval [CI] 0.46–0.91 and TULIP-1: HR 0.76, 95% CI 0.55–1.06; Figure 2) and BILAG-based annualized flare rates (TULIP-2: adjusted rate ratio 0.67, 95% CI 0.48–0.94 and TULIP-1: rate ratio 0.83, 95% CI 0.60–1.14) across both trials.

Conclusion:

Across 2 phase 3 trials, we observed reductions in the total number of flares and annualized flare rates, as well as prolongation of time to first flare with anifrolumab treatment compared with placebo. These results support the potential of anifrolumab to reduce disease activity and reduce flares, benefiting patients with SLE.

References:

[1]Morand EF, et al.N Engl J Med. 2020;382:211–221.

[2]Furie RA, et al.Lancet Rheumatol.2019;1:e208–e219.

Disclosure of Interests:

Richard Furie Grant/research support from: AstraZeneca, Biogen, Consultant of: AstraZeneca, Biogen, Eric F. Morand Grant/research support from: AstraZeneca, Consultant of: AstraZeneca, Speakers bureau: AstraZeneca, Anca Askanase Grant/research support from: Regeneron and Pfizer, Consultant of: AbbVie and BMS, Employee of: GSK, AstraZeneca, Janssen, Lilly, and Mallinckrodt, Edward Vital Grant/research support from: AstraZeneca, Roche/Genentech, and Sandoz, Consultant of: AstraZeneca, GSK, Roche/Genentech, and Sandoz, Speakers bureau: Becton Dickinson and GSK, Rubana Kalyani Employee of: AstraZeneca, Gabriel Abreu Employee of: AstraZeneca, Lilia Pineda Employee of: AstraZeneca, Raj Tummala Employee of: AstraZeneca

OP0049 EFFICACY OF ANIFROLUMAB IN ACTIVE SYSTEMIC LUPUS ERYTHEMATOSUS: PATIENT SUBGROUP ANALYSIS OF BICLA RESPONSE IN 2 PHASE 3 TRIALS

Background:

Treatment of patients with systemic lupus erythematosus (SLE) with the type I interferon (IFN) receptor inhibitor anifrolumab resulted in higher British Isles Lupus Assessment Group (BILAG)–based Composite Lupus Assessment (BICLA) response rates vs placebo at Week 52 in the phase 3 randomized trials, TULIP-2 (primary endpoint; 16.3% difference)1and TULIP-1 (secondary endpoint; 16.4% difference).2BICLA is a validated composite global disease measure that registers both partial and complete improvement within organ systems.

Objectives:

TULIP-2 and TULIP-1 data were analyzed to evaluate BICLA responses to anifrolumab vs placebo at Week 52 in protocol-defined subgroups of patients with active SLE.

Methods:

TULIP-2 and TULIP-1 were randomized, double-blind, placebo-controlled trials that evaluated efficacy and safety of intravenous anifrolumab vs placebo administered every 4 weeks, with the primary endpoints assessed at Week 52, in patients with moderate to severe SLE despite standard-of-care treatment.1,2BICLA responses are defined by all of the following: reduction of baseline BILAG-2004 A and B domain scores to B/C/D and C/D, respectively, and no worsening in any organ system; no worsening of the SLE Disease Activity Index 2000 (SLEDAI-2K) score; no worsening of ≥0.3 points in the Physician’s Global Assessment (range 0–3); no trial treatment discontinuation; and no use of medications restricted by the protocol.3BICLA responses were compared between anifrolumab 300 mg and placebo groups, and robustness of BICLA responses was assessed across protocol-defined subgroups. TULIP-1 data were analyzed incorporating the amended restricted medication rules, as described.2

Results:

In TULIP-2 and TULIP-1, 180 patients in each trial received anifrolumab 300 mg (182 and 184 patients received placebo, respectively). Baseline demographics, disease characteristics, and standard-of-care medications were balanced between anifrolumab and placebo groups within both TULIP trials. Patients in TULIP-2 and TULIP-1 had comparable BICLA responses (Figure). Across multiple subgroups, higher percentages of patients achieved BICLA responses at Week 52 in the anifrolumab vs placebo arms (Figure). There was concordance of BICLA responses favoring anifrolumab across the protocol-defined subgroups of baseline disease severity (SLEDAI-2K <10 points [difference 15.3%, TULIP-2; 16.9%, TULIP-1] vs ≥10 points [difference 16.7%, TULIP-2; 17.1%, TULIP-1]) and baseline oral corticosteroid use (prednisone or equivalent <10 mg/d [difference 20.1%, TULIP-2; 16.2%, TULIP-1] vs ≥10 mg/d [difference 12.0%, TULIP-2; 17.7%, TULIP-1]). Numerically different BICLA effect sizes between the anifrolumab vs placebo arms were observed in both studies in relation to baseline IFN gene signature status (high [difference 17.3%, TULIP-2; 19.1%, TULIP-1] vs low [difference 11.2%, TULIP-2; 7.5%, TULIP-1]). Other subgroups including age, sex, age at onset, race, and anti-drug antibody status showed similar uniformity of response.

Conclusion:

The uniformity of robust BICLA response rates across prespecified subgroups in both phase 3 trials shows consistent clinical benefit of anifrolumab irrespective of patient baseline characteristics. However, given the small patient numbers in some subgroups, these results should be interpreted with caution.

References:

[1]Morand EF, et al.N Engl J Med.2020;382:211–221.

[2]Furie RA, et al.Lancet Rheumatol. 2019;1:e208–e219.

[3]Wallace DJ, et al.Ann Rheum Dis.2014;73:183–190.

Disclosure of Interests:

Eric F. Morand Grant/research support from: AstraZeneca, Consultant of: AstraZeneca, Speakers bureau: AstraZeneca, Richard Furie Grant/research support from: AstraZeneca, Biogen, Consultant of: AstraZeneca, Biogen, Yoshiya Tanaka Grant/research support from: Asahi-kasei, Astellas, Mitsubishi-Tanabe, Chugai, Takeda, Sanofi, Bristol-Myers, UCB, Daiichi-Sankyo, Eisai, Pfizer, and Ono, Consultant of: Abbvie, Astellas, Bristol-Myers Squibb, Eli Lilly, Pfizer, Speakers bureau: Daiichi-Sankyo, Astellas, Chugai, Eli Lilly, Pfizer, AbbVie, YL Biologics, Bristol-Myers, Takeda, Mitsubishi-Tanabe, Novartis, Eisai, Janssen, Sanofi, UCB, and Teijin, Rubana Kalyani Employee of: AstraZeneca, Gabriel Abreu Employee of: AstraZeneca, Lilia Pineda Employee of: AstraZeneca, Raj Tummala Employee of: AstraZeneca

OP0003 EARLY AND SUSTAINED RESPONSES WITH ANIFROLUMAB TREATMENT IN PATIENTS WITH ACTIVE SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) IN 2 PHASE 3 TRIALS

Background:

In the phase 3 TULIP-2 and TULIP-1 trials in SLE, treatment with the type I interferon receptor antibody anifrolumab resulted in higher percentages of patients with BICLA responses vs placebo at Week 52, with differences of 16.3% (primary endpoint; P=0.001, 95% CI 6.3–26.3) and 16.4% (secondary endpoint; 95% CI 6.7–26.2), respectively.1,2

Objectives:

To better understand the time course of BICLA responses to anifrolumab, we examined responses over time compared with placebo in TULIP-2 and TULIP-1, including those that were sustained from attainment through Week 52.

Methods:

The TULIP-2 and TULIP-1 randomized, double-blind, placebo-controlled trials evaluated the efficacy and safety of anifrolumab (300 mg Q4W) over 52 weeks in patients with moderately to severely active SLE who were receiving standard-of-care treatment. Time to onset of BICLA response that was sustained from attainment through Week 52 was evaluated using a Cox proportional hazards model. For TULIP-1, BICLA response rate and time to onset of BICLA response were analyzed using the amended restricted medication rules.2

Results:

Overall, 180 patients each in TULIP-2 and TULIP-1 received anifrolumab compared with 182 and 184 patients in the placebo arms, respectively. At the first 3 assessments in TULIP-2 (Weeks 4, 8, and 12), numerically greater percentages of patients treated with anifrolumab (26.8%, 35.3%, and 42.9%, respectively) were classified as having a BICLA response compared with placebo (21.3%, 21.6%, and 31.8%). A similar trend was observed in TULIP-1 with anifrolumab (23.3%, 34.2%, and 36.5%) vs placebo (18.3%, 23.2%, and 27.5%). The time to onset of BICLA response sustained from onset through Week 52 favored anifrolumab in both TULIP-2 (HR 1.55, 95% CI 1.11–2.18) and TULIP-1 (HR 1.93, 95% CI 1.38–2.73) (Figure). In TULIP-2, 86 (47.8%) patients treated with anifrolumab had BICLA responses that were sustained from time of onset through Week 52 compared with 57 (31.3%) patients in the placebo group. In TULIP-1, 85 (47.2%) patients in the anifrolumab treatment arm had BICLA responses that were sustained from time of onset through Week 52 compared with 55 (29.9%) patients in the placebo group.

Conclusion:

In 2 Phase 3 studies, a greater proportion of patients achieved BICLA responses sustained from onset through Week 52 with anifrolumab treatment compared with placebo. Anifrolumab resulted in numerically favorable differences in time to onset of BICLA responses maintained through Week 52 across the TULIP studies. These data support the sustainability of clinical benefit derived from anifrolumab treatment of patients with active SLE.

References:

[1]Morand EF, et al.N Engl J Med. 2020;382:211–221.

[2]Furie RA, et al.Lancet Rheumatol. 2019;1:e208–e219.

Disclosure of Interests:

Eric F. Morand Grant/research support from: AstraZeneca, Consultant of: AstraZeneca, Speakers bureau: AstraZeneca, Richard Furie Grant/research support from: AstraZeneca, Biogen, Consultant of: AstraZeneca, Biogen, Ian N. Bruce Grant/research support from: Genzyme Sanofi, GSK, and UCB, Consultant of: Eli Lilly, AstraZeneca, UCB, Iltoo, and Merck Serono, Speakers bureau: UCB, Kenneth Kalunian Grant/research support from: Pfizer, UCB, Resolve, Takeda, Idorsia, BMS, and Kirin, Consultant of: AstraZeneca, Nektar, Amgen, Eli Lilly, Janssen, GSK, AbbVie, Chemocentryx, Genentech-Roche, Biogen, and Equillium, Rubana Kalyani Employee of: AstraZeneca, Gabriel Abreu Employee of: AstraZeneca, Lilia Pineda Employee of: AstraZeneca, Raj Tummala Employee of: AstraZeneca

Outcomes of early carotid stenting and angioplasty in large-vessel anterior circulation strokes treated with mechanical thrombectomy and intravenous thrombolytics

Introduction Proximal cervical internal carotid artery stenosis greater than 50% merits revascularization to mitigate the risk of stroke recurrence among large-vessel anterior circulation strokes undergoing mechanical thrombectomy. Carotid artery stenting necessitates the use of antiplatelets, and there is a theoretical increased risk of hemorrhagic transformation given that such patients may already have received intravenous thrombolytics and have a significant infarct burden. We investigate the outcomes of large-vessel anterior circulation stroke patients treated with intravenous thrombolytics receiving same-day carotid stenting or selective angioplasty compared to no carotid intervention. Materials and methods The study cohort was obtained from the National (Nationwide) Inpatient Sample database between 2006 and 2014, using International Statistical Classification of Diseases, ninth revision discharge diagnosis and procedure codes. A total of 11,825 patients with large-vessel anterior circulation stroke treated with intravenous thrombolytic and mechanical thrombectomy on the same day were identified. The study population was subdivided into three subgroups: no carotid intervention, same-day carotid angioplasty without carotid stenting, and same-day carotid stenting. Outcomes were assessed with respect to mortality, significant disability at discharge, hemorrhagic transformation, and requirement of percutaneous endoscopic gastronomy tube placement, prolonged mechanical ventilation, or craniotomy. Results This study found no statistically significant difference in patient outcomes in those treated with concurrent carotid stenting compared to no carotid intervention in terms of morbidity or mortality. Conclusions If indicated, it is reasonable to consider concurrent carotid stenting and/or angioplasty for large-vessel anterior circulation stroke patients treated with mechanical thrombectomy who also receive intravenous thrombolytics.

Quercetin Targets hnRNPA1 to Overcome Enzalutamide Resistance in Prostate Cancer Cells

Prostate cancer remains dependent on androgen receptor signaling even after castration. Aberrant androgen receptor signaling in castration-resistant prostate cancer is mediated by mechanisms such as alterations in the androgen receptor and activation of interacting signaling pathways. Clinical evidence confirms that resistance to the next-generation antiandrogen, enzalutamide, may be mediated to a large extent by alternative splicing of the androgen receptor to generate constitutively active splice variants such as AR-V7. The splice variants AR-V7 and AR^v567es have been implicated in the resistance to not only enzalutamide, but also to abiraterone and other conventional therapeutics such as taxanes. Numerous studies, including ours, suggest that splicing factors such as hnRNPA1 promote the generation of AR-V7, thus contributing to enzalutamide resistance in prostate cancer cells. In the present study, we discovered that quercetin, a naturally occurring polyphenolic compound, reduces the expression of hnRNPA1, and consequently, that of AR-V7. The suppression of AR-V7 by quercetin resensitizes enzalutamide-resistant prostate cancer cells to treatment with enzalutamide. Our results indicate that quercetin downregulates hnRNPA1 expression, downregulates the expression of AR-V7, antagonizes androgen receptor signaling, and resensitizes enzalutamide-resistant prostate cancer cells to enzalutamide treatment in vivo in mouse xenografts. These findings demonstrate that suppressing the alternative splicing of the androgen receptor may have important implications in overcoming the resistance to next-generation antiandrogen therapy. Mol Cancer Ther; 16(12); 2770-9. ©2017 AACR.

Lin28 induces resistance to anti-androgens via promotion of AR splice variant generation

BACKGROUND

Prostate cancer (PCa) is androgen-dependent initially and progresses to a castration-resistant state after androgen deprivation therapy. Treatment options for castration-resistant PCa include the potent second-generation anti-androgen enzalutamide or CYP17A1 inhibitor abiraterone. Recent clinical observations point to the development of resistance to these therapies which may be mediated by constitutively active alternative splice variants of the androgen receptor (AR).

METHODS

Sensitivity of LNCaP cells overexpressing Lin28 (LN-Lin28) to enzalutamide, abiraterone, or bicalutamide was compared to that of control LN-neo cells using cell growth assays, proliferation assays using MTT, anchorage-dependent clonogenic ability assays and soft agar assays. Ability of LN-Lin28 cells to maintain AR activation after treatment with enzalutamide, abiraterone, or bicalutamide was tested using immunofluorescence, Western blotting, ChIP assays, and qRT-PCR. Importance of Lin28 in enzalutamide resistance was assessed by the downregulation of Lin28 expression in C4-2B and 22Rv1 cells chronically treated with enzalutamide. Requirement for sustained AR signaling in LN-Lin28 cells was examined by the downregulation of either full length AR or AR-V7 using siRNA.

RESULTS

We show that Lin28 promotes the development of resistance to currently used targeted therapeutics by enhancing the expression of AR splice variants such as AR-V7. PCa cells overexpressing Lin28 exhibit resistance to treatment with enzalutamide, abiraterone, or bicalutamide. Downregulation of Lin28 resensitizes enzalutamide-resistant PCa cells to enzalutamide treatment. We also show that the upregulation of splicing factors such as hnRNPA1 by Lin28 may mediate the enhanced generation of AR splice variants in Lin28-expressing cells.

CONCLUSIONS

Our findings suggest that Lin28 plays a key role in the acquisition of resistance to AR-targeted therapies by PCa cells and establish the importance of Lin28 in PCa progression.

NF-κB2/p52:c-Myc:hnRNPA1 Pathway Regulates Expression of Androgen Receptor Splice Variants and Enzalutamide Sensitivity in Prostate Cancer

Castration-resistant prostate cancer (CRPC) remains dependent on androgen receptor (AR) signaling. Alternative splicing of the AR to generate constitutively active, ligand-independent variants is one of the principal mechanisms that promote the development of resistance to next-generation antiandrogens such as enzalutamide. Here, we demonstrate that the splicing factor heterogeneous nuclear RNA-binding protein A1 (hnRNPA1) plays a pivotal role in the generation of AR splice variants such as AR-V7. hnRNPA1 is overexpressed in prostate tumors compared with benign prostates, and its expression is regulated by NF-κB2/p52 and c-Myc. CRPC cells resistant to enzalutamide exhibit higher levels of NF-κB2/p52, c-Myc, hnRNPA1, and AR-V7. Levels of hnRNPA1 and AR-V7 are positively correlated with each other in prostate cancer. The regulatory circuit involving NF-κB2/p52, c-Myc, and hnRNPA1 plays a central role in the generation of AR splice variants. Downregulation of hnRNPA1 and consequently of AR-V7 resensitizes enzalutamide-resistant cells to enzalutamide, indicating that enhanced expression of hnRNPA1 may confer resistance to AR-targeted therapies by promoting the generation of splice variants. These findings may provide a rationale for cotargeting these pathways to achieve better efficacy through AR blockade.

RhoGDIα downregulates androgen receptor signaling in prostate cancer cells

INTRODUCTION

Treatment of primary prostate cancer (CaP) is the withdrawal of androgens. However, CaP eventually progresses to grow in a castration-resistant state due to aberrant activation of androgen receptor (AR). Understanding the mechanisms leading to the aberrant activation of AR is critical to develop effective therapy. We have previously identified Rho GDP Dissociation Inhibitor alpha (GDIα) as a novel suppressor in prostate cancer. In this study, we examine the effect of GDIα on AR signaling in prostate cancer cells.

METHODS

GDIα was transiently or stably transfected into several prostate cancer cell lines including LNCaP, C4-2, CWR22Rv1, and DU145. The regulation of AR expression by GDIα was analyzed by qRT-PCR and Western blot. AR activity was measured by luciferase reporter assays and electrophoretic mobility shift analysis (EMSA). Immunofluorescence assay was performed to study AR nuclear translocation. The interaction between GDIα and AR was examined by co-immunoprecipitation assays.

RESULTS

In this study, we have identified GDIα as a negative regulator of AR signaling pathway. Overexpression of GDIα downregulates AR expression at both mRNA and protein levels. Overexpression of GDIα is able to prevent AR nuclear translocation and inhibit transactivation of AR target genes. Co-immunoprecipitation assays showed that GDIα physically interacts with the N-terminal domain of AR.

CONCLUSIONS

GDIα suppresses AR signaling through inhibition of AR expression, nuclear translocation, and recruitment to androgen-responsive genes. GDIα regulatory pathway may play a critical role in regulating AR signaling and prostate cancer growth and progression.

Lin28 promotes growth of prostate cancer cells and activates the androgen receptor

Prostate cancer (CaP) progresses to a castration-resistant state assisted by multifold molecular changes, most of which involve activation of the androgen receptor (AR). Having previously demonstrated the importance of the Lin28/let-7/Myc axis in CaP, we tested the hypothesis that Lin28 is overexpressed in CaP and that it activates AR and promotes growth of CaP cells. We analyzed human clinical CaP samples for the expression of Lin28 by quantitative real-time RT-PCR, Western blot analysis, and IHC. Growth characteristics of CaP cell lines transiently and stably expressing Lin28 were examined. The clonogenic ability of CaP cells expressing Lin28 was determined by colony formation and soft agar assays. Increase in expression of AR and subsequent increase in transcription of AR-target genes were analyzed by quantitative real-time RT-PCR, luciferase assays, and ELISA. LNCaP cells stably expressing Lin28 were injected into nude mice, and tumorigenesis was monitored. We found that Lin28 is overexpressed in clinical CaP compared to benign prostates. Overexpression of Lin28 enhanced, while down-regulation reduced, growth of CaP cells. Lin28 enhanced the ability of CaP cells to form colonies in anchorage-dependent and anchorage-independent conditions. LNCaP cells stably expressing Lin28 exhibited significantly higher tumorigenic ability in vivo. Lin28 induced expression of the AR and its target genes such as PSA and NKX3.1. Collectively, our findings demonstrate a novel role for Lin28 in CaP development and activation of the AR axis.

Inhibition of ABCB1 expression overcomes acquired docetaxel resistance in prostate cancer

Docetaxel is the first-line standard treatment for castration-resistant prostate cancer. However, relapse eventually occurs due to the development of resistance to docetaxel. To unravel the mechanism of acquired docetaxel resistance, we established docetaxel-resistant prostate cancer cells, TaxR, from castration-resistant C4-2B prostate cancer cells. The IC50 for docetaxel in TaxR cells was about 70-fold higher than parental C4-2B cells. Global gene expression analysis revealed alteration of expression of a total of 1,604 genes, with 52% being upregulated and 48% downregulated. ABCB1, which belongs to the ATP-binding cassette (ABC) transporter family, was identified among the top upregulated genes in TaxR cells. The role of ABCB1 in the development of docetaxel resistance was examined. Knockdown of ABCB1 expression by its specific shRNA or inhibitor resensitized docetaxel-resistant TaxR cells to docetaxel treatment by enhancing apoptotic cell death. Furthermore, we identified that apigenin, a natural product of the flavone family, inhibits ABCB1 expression and resensitizes docetaxel-resistant prostate cancer cells to docetaxel treatment. Collectively, these results suggest that overexpression of ABCB1 mediates acquired docetaxel resistance and targeting ABCB1 expression could be a potential approach to resensitize docetaxel-resistant prostate cancer cells to docetaxel treatment.

NF-κB2/p52 induces resistance to enzalutamide in prostate cancer: role of androgen receptor and its variants

Resistance of prostate cancer cells to the next-generation antiandrogen enzalutamide may be mediated by a multitude of survival signaling pathways. In this study, we tested whether increased expression of NF-κB2/p52 induces prostate cancer cell resistance to enzalutamide and whether this response is mediated by aberrant androgen receptor (AR) activation and AR splice variant production. LNCaP cells stably expressing NF-κB2/p52 exhibited higher survival rates than controls when treated with enzalutamide. C4-2B and CWR22Rv1 cells chronically treated with enzalutamide were found to express higher levels of NF-κB2/p52. Downregulation of NF-κB2/p52 in CWR22Rv1 cells chronically treated with enzalutamide rendered them more sensitive to cell growth inhibition by enzalutamide. Analysis of the expression levels of AR splice variants by quantitative reverse transcription PCR and Western blotting revealed that LNCaP cells expressing p52 exhibit higher expression of AR splice variants. Downregulation of expression of NF-κB2/p52 in VCaP and CWR22Rv1 cells by short hairpin RNA abolished expression of splice variants. Downregulation of expression of either full-length AR or the splice variant AR-V7 led to an increase in sensitivity of prostate cancer cells to enzalutamide. These results collectively demonstrate that resistance to enzalutamide may be mediated by NF-κB2/p52 via activation of AR and its splice variants.

Abstract 3116: NF-κB2/p52 induces expression of inflammatory mediators in prostate cancer in vivo

Introduction and objective: Inflammation plays a key role in the etiology of carcinoma of colon, cervix or liver, but PCa, in which inflammation has not been deemed to play a causative role, also display a pro-inflammatory gene profile. NF-κB is central to the induction of inflammation and the classical and alternative NF-κB activation pathways have been shown to modulate expression of inflammatory mediators. Here we explored the induction of markers of tumor-infiltrating inflammatory cells in two in vivo models overexpressing NF-κB2/p52.

Methods: LNCaP human PCa cells were infected with adenoviruses encoding empty vector or NF-κB2/p52 and injected s.c. into both flanks of nude mice. Gene expression of markers of inflammatory mediators such as macrophages, lymphocytes and dendritic cells was analyzed in the tumor tissues by qRT-PCR. In addition, whole prostates were collected from transgenic mice expressing NF-κB2/p52 in the prostate and RNA was analyzed for inflammatory markers. Expression of the cell surface markers was validated by immunohistochemistry in sections of whole prostates.

Results: The infiltration of host immune cells into the xenograft tissues was detected by expression of surface markers of cells of myeloid and lymphoid lineage. The expression of B220 (B cells), F4/80 (activated macrophages), Cd8A (CTL) was increased in p52-expressing xenografts compared to controls, indicating the presence of host-derived inflammatory cells in the xenografts. Expression levels of chemokines (Cxcl1), chemokine receptors (Ccr1, Ccr3) and pro-inflammatory cytokines (Il-6 and Tnf) were enhanced in the xenografts compared to the controls, indicating that expression of NF-κB2/p52 induces an inflammatory response in xenografts of human PCa cells.

Compared to littermate negative controls, expression of B220, F4/80, Cd8A and Cd208 was increased in transgenic mouse prostates expressing p52. Furthermore, expression levels of Cxcl1, Ccr1, Ccr3, Il-6 and Tnf were also enhanced compared to controls, indicating the induction of inflammation in mouse prostates by NF-κB2/p52.

Conclusions: Our previous studies have shown that NF-κB2/p52 plays an important role in the development of castration resistance in human PCa cells. In this study we showed that NF-κB2/p52 may induce an inflammatory response in xenografts of human PCa cells or in transgenic mouse prostates, and thereby promote tumor proliferation.

Citation Format: Nagalakshmi Nadiminty, Ramakumar Tummala, Wei Lou, Christopher P. Evans, Allen C. Gao. NF-κB2/p52 induces expression of inflammatory mediators in prostate cancer in vivo. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 3116. doi:10.1158/1538-7445.AM2013-3116

Abstract 3192: Lin28 promotes growth of prostate cancer cells and activates the androgen receptor

Purpose: Lin28 is essential for stem cell viability and pluripotency. Recently Lin28 expression has been linked to several malignancies and its mechanisms of action proposed to be both let-7-dependent and -independent. It is a master regulator of let-7 miRNA biogenesis as well as a regulator of translation of a multitude of eukaryotic proteins. This study tested the hypothesis that Lin28 is overexpressed in prostate cancer (CaP) and that it activates the androgen receptor (AR) and promotes growth of CaP cells. Experimental Design: Human clinical CaP samples were analyzed for the expression of Lin28 by qRT-PCR, Western blotting and immunohistochemistry. Lin28 was transfected into a panel of CaP cell lines and growth was monitored. LNCaP cells stably expressing Lin28 were generated and growth was examined. Clonogenic ability of CaP cells expressing Lin28 was determined by colony formation and soft agar assays. Increase in expression of the AR and subsequent increase in transcription of AR-target genes were analyzed by qRT-PCR, luciferase assays and ELISA. LNCaP cells stably expressing Lin28 were injected into nude mice and tumorigenesis was monitored. Results: Lin28 was found to be overexpressed in clinical CaP compared to the benign tissues. Overexpression of Lin28 enhanced while downregulation of Lin28 reduced growth of CaP cells. Lin28 enhanced the ability of CaP cells to form colonies in anchorage-dependent and -independent manners. LNCaP cells stably expressing Lin28 exhibited significantly higher tumorigenic ability in vivo. Furthermore, Lin28 induces expression of the AR and its target genes such as PSA and NKX3.1. Conclusions: Lin28 promotes growth of CaP cells in vitro and in vivo. Lin28 induces expression and activation of the AR. Our findings suggest an important role of Lin28 in CaP development and activation of the AR axis.

Citation Format: Ramakumar Tummala, Nagalakshmi Nadiminty, Yezi Zhu, Wei Lou, Christopher P. Evans, Allen C. Gao. Lin28 promotes growth of prostate cancer cells and activates the androgen receptor. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 3192. doi:10.1158/1538-7445.AM2013-3192