Perioperative management and outcomes in patients receiving low-dose rivaroxaban and/or aspirin: a subanalysis of the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial

BACKGROUND

No study has investigated the perioperative management and clinical outcomes in patients who are receiving rivaroxaban 2.5 mg twice a day and acetylsalicylic acid (ASA) 81 to 100 mg daily.

OBJECTIVE

To assess perioperative management and outcomes in patients who are receiving low-dose rivaroxaban, 2.5 mg twice-daily, and low-dose ASA, 81 to 100 mg daily. To assess perioperative management and outcomes in patients who are receiving low-dose rivaroxaban, 2.5 mg twice-daily, and low-dose ASA, 81 to 100 mg daily.

METHODS

Subanalysis of the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial was performed to assess perioperative management and clinical outcomes in patients with stable coronary or peripheral artery disease who were randomized to receive rivaroxaban 2.5 mg twice a day plus ASA 100 mg daily, rivaroxaban 5 mg twice a day, or ASA 100 mg daily. Patients studied required a surgery/procedure during the trial. The study outcomes, which included myocardial infarction, angina, stroke, acute limb ischemia, bleeding, and death, were assessed according to treatment allocation.

RESULTS

There were 2632 patients studied (mean age, 68 years; 80% male) who had a surgery/procedure, comprising percutaneous coronary interventions (∼43%), carotid or other arterial angioplasty (∼15%), pacemaker or internal cardiac defibrillator implantation (∼9%), and coronary artery bypass graft surgery (∼7%). Perioperative study drug management varied, with about one-third of patients not interrupting study drug and the remainder interrupting it between 1 and ≥10 days preprocedure. The incidences of adverse outcomes across treatment groups were 12.7% to 15.3% for myocardial ischemia, 0.8% to 1.2% for stroke, 0.1% to 0.2% for venous thromboembolism, and 3.1% to 4.2% for any bleeding. There was no statistically significant difference in outcome rates across treatment groups.

CONCLUSION

In patients in the COMPASS trial who required a surgery/procedure, there was no significant difference in perioperative adverse outcomes whether patients were receiving rivaroxaban 2.5 mg twice a day and ASA 100 mg daily, rivaroxaban 5 mg twice a day, or ASA alone.

Total intracranial hemorrhage volume measurement summating all compartments best in traumatic and nontraumatic intracranial bleeding

BACKGROUND AND PURPOSE

The ANNEXA-4 trial measured hemostatic efficacy of andexanet alfa in patients with major bleeding taking factor Xa inhibitors. A proportion of this was traumatic and nontraumatic intracranial bleeding. Different measurements were applied in the trial including volumetrics to assess for intracranial bleeding depending on the compartment involved. We aimed to determine the most reliable way to measure intracranial hemorrhage (ICrH) volume by comparing individual brain compartment and total ICrH volume.

METHODS

Thirty patients were randomly selected from the ANNEXA-4 database to assess measurement of ICrH volume by compartment and in total. Total and compartmental hemorrhage volumes were measured by five readers using Quantomo software. Each reader measured baseline hemorrhage volumes twice separated by 1 week. Twenty-eight different ANNEXA-4 subjects were also randomly selected to assess intra-rater reliability of total ICrH volume measurement change at baseline and 12-h follow up, performed by three readers twice to assess hemostatic efficacy categories used in ANNEXA-4.

RESULTS

Compartmental minimal detectable change percentages (MDC%) ranged between 9.72 and 224.13, with the greatest measurement error occurring in patients with a subdural hemorrhage. Total ICrH volume measurements had the lowest MDC%, which ranged between 6.57 and 33.52 depending on the reader.

CONCLUSION

Measurement of total ICrH volumes is more accurate than volume by compartment with less measurement error. Determination of hemostatic efficacy was consistent across readers, and within the same reader, as well as when compared to consensus read. Volumetric analysis of intracranial hemostatic efficacy is feasible and reliable when using total ICrH volumes.

Estimating Vitamin K Antagonist Anticoagulation Benefit in People With Atrial Fibrillation Accounting for Competing Risks: Evidence From 12 Randomized Trials

BACKGROUND

Patients with atrial fibrillation have a high mortality rate that is only partially attributable to vascular outcomes. The competing risk of death may affect the expected anticoagulant benefit. We determined if competing risks materially affect the guideline-endorsed estimate of anticoagulant benefit.

METHODS

We conducted a secondary analysis of 12 randomized controlled trials that randomized patients with atrial fibrillation to vitamin K antagonists (VKAs) or either placebo or antiplatelets. For each participant, we estimated the absolute risk reduction (ARR) of VKAs to prevent stroke or systemic embolism using 2 methods-first using a guideline-endorsed model (CHA2DS2-VASc) and then again using a competing risk model that uses the same inputs as CHA2DS2-VASc but accounts for the competing risk of death and allows for nonlinear growth in benefit. We compared the absolute and relative differences in estimated benefit and whether the differences varied by life expectancy.

RESULTS

A total of 7933 participants (median age, 73 years, 36% women) had a median life expectancy of 8 years (interquartile range, 6-12), determined by comorbidity-adjusted life tables and 43% were randomized to VKAs. The CHA2DS2-VASc model estimated a larger ARR than the competing risk model (median ARR at 3 years, 6.9% [interquartile range, 4.7%-10.0%] versus 5.2% [interquartile range, 3.5%-7.4%]; P<0.001). ARR differences varied by life expectancies: for those with life expectancies in the highest decile, 3-year ARR difference (CHA2DS2-VASc model - competing risk model 3-year risk) was -1.3% (95% CI, -1.3% to -1.2%); for those with life expectancies in the lowest decile, 3-year ARR difference was 4.7% (95% CI, 4.5%-5.0%).

CONCLUSIONS

VKA anticoagulants were exceptionally effective at reducing stroke risk. However, VKA benefits were misestimated with CHA2DS2-VASc, which does not account for the competing risk of death nor decelerating treatment benefit over time. Overestimation was most pronounced when life expectancy was low and when the benefit was estimated over a multiyear horizon.

Andexanet alfa versus non-specific treatments for intracerebral hemorrhage in patients taking factor Xa inhibitors - Individual patient data analysis of ANNEXA-4 and TICH-NOAC

BACKGROUND

Data comparing the specific reversal agent andexanet alfa with non-specific treatments in patients with non-traumatic intracerebral hemorrhage (ICH) associated with factor-Xa inhibitor (FXaI) use are scarce.

AIM

The study aimed to determine the association between the use of andexanet alfa compared with non-specific treatments with the rate of hematoma expansion and thromboembolic complications in patients with FXaI-associated ICH.

METHODS

We performed an individual patient data analysis combining two independent, prospective studies: ANNEXA-4 (180 patients receiving andexanet alfa, NCT02329327) and TICH-NOAC (63 patients receiving tranexamic acid or placebo ± prothrombin complex concentrate, NCT02866838). The primary efficacy outcome was hematoma expansion on follow-up imaging. The primary safety outcome was any thromboembolic complication (ischemic stroke, myocardial infarction, pulmonary embolism, or deep vein thrombosis) at 30 days. We used binary logistic regression models adjusted for baseline hematoma volume, age, calibrated anti-Xa activity, times from last intake of FXaI, and symptom onset to treatment, respectively.

RESULTS

Among 243 participants included, the median age was 80 (IQR 75-84) years, baseline hematoma volume was 9.1 (IQR 3.4-21) mL and anti-Xa activity 118 (IQR 78-222) ng/mL. Times from last FXaI intake and symptom onset to treatment were 11 (IQR 7-16) and 4.7 (IQR 3.0-7.6) h, respectively. Overall, 50 patients (22%) experienced hematoma expansion (ANNEXA-4: n=24 (14%); TICH-NOAC: n=26 (41%)). After adjusting for pre-specified confounders (baseline hematoma volume, age, calibrated anti-Xa activity, times from last intake of FXaI, and symptom onset to treatment, respectively), treatment with andexanet alfa was independently associated with decreased odds for hematoma expansion (aOR 0.33, 95% CI 0.13-0.80, p = 0.015). Overall, 26 patients (11%) had any thromboembolic complication within 30 days (ANNEXA-4: n=20 (11%); TICH-NOAC: n=6 (10%)). There was no association between any thromboembolic complication and treatment with andexanet alfa (aOR 0.70, 95% CI 0.16-3.12, p = 0.641).

CONCLUSION

The use of andexanet alfa compared to any other non-specific treatment strategy was associated with decreased odds for hematoma expansion, without increased odds for thromboembolic complications.

The Cost-Effectiveness of Rivaroxaban Plus Aspirin Compared with Aspirin Alone in the COMPASS Trial: A US Perspective

BACKGROUND

Rivaroxaban 2.5 mg twice daily with aspirin 100 mg daily was shown to be better than aspirin 100 mg daily for preventing cardiovascular (CV) death, stroke or myocardial infarction in patients with either stable coronary artery disease (CAD) or peripheral artery disease (PAD). The cost-effectiveness of this regimen in this population is essential for decision-makers to know.

METHODS

US direct healthcare system costs (in USD) were applied to hospitalized events, procedures and study drugs utilized by all patients. We determined the mean cost per participant for the full duration of the trial (mean follow-up of 23 months) plus quality-adjusted life years (QALYs) and the incremental cost-effectiveness ratio (ICER) over a lifetime using a two-state Markov model with 1-year cycle length. Sensitivity analyses were performed on the price of rivaroxaban and the annual discontinuation rate.

RESULTS

The costs of events and procedures were reduced for Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) patients who received rivaroxaban 2.5 mg orally (BID) plus acetylsalicylic acid (ASA) compared with ASA alone. Total costs were higher for the combination group ($7426 versus $4173) after considering acquisition costs of the study drug. Over a lifetime, patients receiving rivaroxaban plus ASA incurred $27,255 more and gained 1.17 QALYs compared with those receiving ASA alone resulting in an ICER of $23,295/QALY. ICERs for PAD only and polyvascular disease subgroups were lower.

CONCLUSION

Rivaroxaban 2.5 mg BID plus ASA compared with ASA alone was cost-effective (high value) in the USA. COMPASS ClinicalTrials.gov identifier: NCT01776424.

Benzodiazepine-Free Cardiac Anesthesia for Reduction of Postoperative Delirium (B-Free): A Protocol for a Multi-centre Randomized Cluster Crossover Trial

Delirium is common after cardiac surgery and is associated with adverse outcomes. Administration of benzodiazepines before and after cardiac surgery is associated with delirium; guidelines recommend minimizing their use. Benzodiazepine administration during cardiac surgery remains common because of its recognized benefits. The Benzodiazepine-Free Cardiac Anesthesia for Reduction of Postoperative Delirium (B-Free) trial is a randomized cluster crossover trial evaluating whether an institutional policy of restricting intraoperative benzodiazepine administration (ie, ≥ 90% of patients do not receive benzodiazepines during cardiac surgery), as compared with a policy of liberal intraoperative benzodiazepine administration (ie, ≥ 90% of patients receive ≥ 0.03 mg/kg midazolam equivalent), reduces delirium. Hospitals performing ≥ 250 cardiac surgeries a year are included if their cardiac anesthesia group agrees to apply both benzodiazepine policies per their randomization, and patients are assessed for postoperative delirium every 12 hours in routine clinical care. Hospitals apply the restricted or liberal benzodiazepine policy during 12 to 18 crossover periods of 4 weeks each. Randomization for all periods takes place in advance of site startup; sites are notified of their allocated policy during the last week of each crossover period. Policies are applied to all patients undergoing cardiac surgery during the trial period. The primary outcome is the incidence of delirium at up to 72 hours after surgery. The B-Free trial will enroll ≥ 18,000 patients undergoing cardiac surgery at 20 hospitals across North America. Delirium is common after cardiac surgery, and benzodiazepines are associated with the occurrence of delirium. The B-Free trial will determine whether an institutional policy restricting the administration of benzodiazepines during cardiac surgery reduces the incidence of delirium after cardiac surgery. Clinicaltrials.gov registration number: NCT03928236 (First registered April 26, 2019).

The cost-effectiveness of rivaroxaban with or without aspirin in the COMPASS trial

AIMS

The Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial demonstrated that rivaroxaban 2.5 mg BID with aspirin 100 mg was more effective than aspirin 100 mg daily alone for the prevention of cardiovascular (CV) death, stroke, or myocardial infarction in patients with stable coronary artery disease (CAD) or peripheral artery disease (PAD). We aimed to examine the cost-effectiveness of rivaroxaban using patient-level data from the COMPASS trial.

METHODS AND RESULTS

We performed an in-trial analysis and extrapolated our results for 33 years using a two-state Markov model with a 1-year cycle length. Hospitalization events, procedures, and study drugs were documented for patients. We applied country-specific (Canada, France, and Germany) direct healthcare system costs (in USD) to healthcare resources consumed by patients. Average cost per patient during the trial (mean follow-up of 23 months), quality-adjusted life years (QALYs), and lifetime cost-effectiveness were calculated. Costs of events and procedures were reduced with rivaroxaban 2.5 mg BID with aspirin. The addition of rivaroxaban 2.5 mg BID increased total costs for the combination group. Over a lifetime horizon (in trial +33 years), rivaroxaban plus aspirin was associated with 1.17 QALYs gained, yielding an incremental cost-effectiveness ratio (ICER) of $3946/QALY, $9962/QALY, and $10 264/QALY in Canada, France, and Germany, respectively. PAD and polyvascular disease subgroups had lower ICERs.

CONCLUSION

Rivaroxaban 2.5 mg twice daily plus aspirin compared with aspirin alone reduces direct healthcare costs. After acquisition costs of rivaroxaban, the lifetime cost-effectiveness of 2.5 mg twice daily plus aspirin is highly cost-effective in Canada, France, and Germany.(COMPASS ClinicalTrials.gov identifier: NCT01776424).

Overestimation of anticoagulant benefit in patients with atrial fibrillation and low life expectancy: evidence from 12 randomized trials

Background

Patients with atrial fibrillation (AF) have a high rate of all-cause mortality that is only partially attributable to vascular outcomes. While the competing risk of death may affect expected anticoagulant benefit, guidelines do not account for it. We sought to determine if using a competing risks framework materially affects the guideline-endorsed estimate of absolute risk reduction attributable to anticoagulants.

Methods

We conducted a secondary analysis of 12 RCTs that randomized patients with AF to oral anticoagulants or either placebo or antiplatelets. For each participant, we estimated the absolute risk reduction (ARR) of anticoagulants to prevent stroke or systemic embolism using two methods. First, we estimated the ARR using a guideline-endorsed model (CHA ₂ DS ₂ -VASc) and then again using a Competing Risk Model that uses the same inputs as CHA ₂ DS ₂ -VASc but accounts for the competing risk of death and allows for non-linear growth in benefit over time. We compared the absolute and relative differences in estimated benefit and whether the differences in estimated benefit varied by life expectancy.

Results

7933 participants had a median life expectancy of 8 years (IQR 6, 12), determined by comorbidity-adjusted life tables. 43% were randomized to oral anticoagulation (median age 73 years, 36% women). The guideline-endorsed CHA ₂ DS ₂ -VASc model estimated a larger ARR than the Competing Risk Model (median ARR at 3 years, 6.9% vs. 5.2%). ARR differences varied by life expectancies: for those with life expectancies in the highest decile, 3-year ARR difference (CHA ₂ DS ₂ -VASc model - Competing Risk Model 3-year risk) was -1.2% (42% relative underestimation); for those with life expectancies in the lowest decile, 3-year ARR difference was 5.9% (91% relative overestimation).

Conclusion

Anticoagulants were exceptionally effective at reduced stroke risk. However, anticoagulant benefits were misestimated with CHA ₂ DS ₂ -VASc, which does not account for the competing risk of death nor decelerating treatment benefit over time. Overestimation was most pronounced in patients with the lowest life expectancy and when benefit was estimated over a multi-year horizon.

A hybrid automated event adjudication system for clinical trials

INTRODUCTION

In clinical trials, event adjudication is a process to review and confirm the accuracy of outcomes reported by site investigators. Despite efforts to automate the communication between a clinical-data-and-coordination center and an event adjudication committee, the review and confirmation of outcomes, as the core function of the process, still fully rely on human labor. To address this issue, we present an automated event adjudication system and its application in two randomized controlled trials.

METHODS

Centrally executed by a clinical-data-and-coordination center, the automated event adjudication system automatedly assessed and classified outcomes in a clinical data management system. By checking clinically predefined criteria, the automated event adjudication system either confirmed or unconfirmed an outcome and automatedly updated its status in the database. It also served as a management tool to assist staff to oversee the process of event adjudication. The system has been applied in: (1) the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial and (2) the New Approach riVaroxaban Inhibition of Factor Xa in a Global trial versus Aspirin to prevenT Embolism in Embolic Stroke of Undetermined Source (NAVIGATE ESUS) trial. The automated event adjudication system first screened outcomes reported on a case report form and confirmed those with data matched to preset definitions. For selected primary efficacy, secondary, and safety outcomes, the unconfirmed cases were referred to a human event adjudication committee for a final decision. In the New Approach riVaroxaban Inhibition of Factor Xa in a Global trial versus Aspirin to prevenT Embolism in Embolic Stroke of Undetermined Source (NAVIGATE ESUS) trial, human adjudicators were given priority to review cases, while the automated event adjudication system took the lead in the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial.

RESULTS

Outcomes that were adjudicated in a hybrid model are discussed here. The COMPASS automated event adjudication system adjudicated 3283 primary efficacy outcomes and confirmed 1652 (50.3%): 132 (21.1%) strokes, 522 (53%) myocardial infarctions, and 998 (59.7%) causes of deaths. The NAVIGATE ESUS one adjudicated 737 cases of selected outcomes and confirmed 383 (52%): 219 (51.5%) strokes, 34 (42.5%) myocardial infarctions, 73 (54.9%) causes of deaths, and 57 (57.6%) major bleedings. After one deducts the time needed for migrating the system to a new study, the automated event adjudication system helped to reduce the time required for human review from approximately 1303 to 716.5 h for the Cardiovascular Outcomes for People Using Anticoagulation Strategies trial and from 387 to 196 h for the New Approach riVaroxaban Inhibition of Factor Xa in a Global trial versus Aspirin to prevenT Embolism in Embolic Stroke of Undetermined Source trial.

CONCLUSION

The automated event adjudication system in combination with human adjudicators provides a streamlined and efficient approach to event adjudication in clinical trials. To immediately apply automated event adjudication, one can first consider the automated event adjudication system and involve human assistance for cases unconfirmed by the former.

The predictive value of interarm systolic blood pressure differences in patients with vascular disease: Sub-analysis of the COMPASS trial

BACKGROUND AND AIMS

Systolic blood pressure interarm difference (IAD) predicts cardiovascular morbidity and mortality in primary prevention populations. We examined the predictive value of IAD and the effects of treatment with the combination of rivaroxaban 2.5 mg twice daily plus aspirin 100 mg once daily versus aspirin 100 mg once daily according to IAD in patients with chronic coronary artery disease or peripheral artery disease.

METHODS

COMPASS trial patients with IAD <15 mmHg and IAD >15 mmHg were compared with respect to thirty-month incidence risk of: 1) composite of stroke, myocardial infarction, or cardiovascular death (MACE), 2) composite of acute limb-ischemia or vascular amputation (MALE), 3) composite of MACE or MALE, and 4) effects of treatment with the combination versus aspirin alone on these outcomes.

RESULTS

24,539 patients had IAD<15 mmHg and 2,776 had IAD ≥15 mmHg. Relative to patients with IAD ≥15 mm Hg, those with IAD<15 mmHg had similar incidence rates for all measured outcomes including the composite of MACE or MALE (HR 1.12 [95% CI: 0.95 to 1.31], p = 0.19), with the exception of stroke (HR 1.38 [95% CI: 1.02 to 1.88], p = 0.04). Compared to aspirin alone, the combination consistently reduced the composite of MACE or MALE in both IAD <15 mmHg (HR 0.74 [95% CI: 0.65-0.85], p < 0.0001, ARR = -23.1) and IAD>15 mmHg (HR 0.65 [95% CI: 0.44-0.96], p = 0.03; ARR = -32.6, p interaction = 0.53) groups.

CONCLUSIONS

Unlike primary prevention populations, measuring IAD for risk stratification purposes does not appear to be useful in patients with established vascular disease.

Body mass index from the RE-LY trial: further evidence of the obesity paradox

Background

The obesity paradox has been reported in 3 post-hoc analyses evaluating the direct oral anticoagulants (DOAC) against warfarin (W): apixaban (ARISTOTLE), rivaroxaban (ROCKET), and edoxaban (ENGAGE-AF).

Purpose

To evaluate the obesity paradox in a post-hoc analysis of the RE-LY trial, comparing dabigatran 110 mg BID (D110), 150 mg BID (D150), and W by body mass index (BMI).

Methods

Baseline characteristics were evaluated using World Health Organization (WHO) criteria of overweight and obese (BMI ≥25 kg/m2) and under and normal weight (BMI &lt;25 kg/m2). Stroke and systemic embolism, ischemic stroke, major bleeding, mortality, and intracranial hemorrhage were evaluated using BMI as a continuous variable and by the WHO criteria using a cox proportional hazard model.

Results

BMI was available in 99.9% of patients randomized; 74% had a BMI ≥25. At baseline, patients with a BMI ≥25 were younger (70.9 vs 73.1, p&lt;0.001) and had fewer prior strokes (11.5% vs 15.6%, p&lt;0.001), but higher mean creatinine clearance (78.3 vs 57.0, p&lt;0.001) and rates of diabetes (25.8% vs 16.1%, p&lt;0.001) (Table 1). Independent of drug assignment, patients with a BMI ≥25 had lower rates of stroke and systemic embolism (HR 0.65 [95% CI 0.54–0.79], p&lt;0.001), ischemic stroke (0.75 [95% CI 0.60, 0.94], p=0.01), major bleeding (HR 0.79 [95% CI 0.69,0.89], p&lt;0.001), mortality (HR 0.60 [95% CI 0.53, 0.67], p&lt;0.001) and intracranial hemorrhage (HR 0.53 [95% CI 0.38, 0.73], p&lt;0.001) compared to those with a BMI &lt;25. Using BMI as a continuous variable combining all outcomes at 3 years, endpoint rates declined as BMI approached 25 in all 3 treatment groups. The exceptions were intracranial hemorrhage for D110 and D150 and stroke in D150 patients, where rates were low independent of BMI. No significant interaction between BMI and treatment was observed in individual outcomes except for the D110 vs. D150 comparison for major bleeding, in favor of D110 for patients with BMI ≥25 (HR 0.77 [95% CI 0.65, 0.91] and HR 1.12 [95% CI 0.86, 1.47], interaction p=0.0190).

Conclusions

In RE-LY, independent of drug assignment, patients with a higher BMI had improved outcomes, demonstrating the obesity paradox. As BMI increased towards 25, outcome rates improved except for intracranial hemorrhage rates for both D110 and D150 and ischemic stroke rates for D150, which were low independent of BMI. Patients treated with D110 with a BMI ≥25 kg/m2 had significantly lower rates of bleeding compared to D150.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Sharpe Strumia Foundation

Defining the role of neutrophils in the lung during infection: Implications for tuberculosis disease

Neutrophils are implicated in the pathogenesis of many diseases involving inflammation. Neutrophils are also critical to host defence and have a key role in the innate immune response to infection. Despite their efficiencies against a wide range of pathogens however, their ability to contain and combat Mycobacterium tuberculosis (Mtb) in the lung remains uncertain and contentious. The host response to Mtb infection is very complex, involving the secretion of various cytokines and chemokines from a wide variety of immune cells, including neutrophils, macrophages, monocytes, T cells, B cells, NK cells and dendritic cells. Considering the contributing role neutrophils play in the advancement of many diseases, understanding how an inflammatory microenvironment affects neutrophils, and how neutrophils interact with other immune cells, particularly in the context of the infected lung, may aid the design of immunomodulatory therapies. In the current review, we provide a brief overview of the mechanisms that underpin pathogen clearance by neutrophils and discuss their role in the context of Mtb and non-Mtb infection. Next, we examine the current evidence demonstrating how neutrophils interact with a range of human and non-human immune cells and how these interactions can differentially prime, activate and alter a repertoire of neutrophil effector functions. Furthermore, we discuss the metabolic pathways employed by neutrophils in modulating their response to activation, pathogen stimulation and infection. To conclude, we highlight knowledge gaps in the field and discuss plausible novel drug treatments that target host neutrophil metabolism and function which could hold therapeutic potential for people suffering from respiratory infections.

POS0512 ANTI-CITRULLINATED PROTEIN ANTIBODY SEROSTATUS DETERMINES 2-YEAR RETENTION OF IV AND SC ABATACEPT IN PATIENTS WITH RA IN A REAL-WORLD SETTING

Background

A treat-to-target approach for RA management is recommended.1,2 However, up to half of patients discontinue DMARD treatment within 18 months.2 Predictive biomarkers, such as anti-citrullinated protein antibodies (ACPAs) and RF, may be useful to stratify patients to the most appropriate treatment. ACTION (AbataCepT In rOutiNe clinical practice; NCT02109666) and ASCORE (Abatacept SubCutaneOus in Routine Clinical PracticE; NCT02090556) were 2-year, international, observational, prospective, multicenter studies of IV and SC abatacept, respectively, for the treatment of RA in routine clinical practice.3,4 Higher retention has been previously reported in patients with double ACPA/RF seropositive RA compared with double ACPA/RF seronegative RA.3,4

Objectives

To assess the independent effect of ACPA or RF single seropositivity on abatacept retention in patients with RA receiving abatacept in a post hoc analysis of ACTION and ASCORE.

Methods

This post hoc analysis included patients aged ≥ 18 years, with active moderate-to-severe RA (ACR/EULAR 2010 criteria) who initiated IV (body weight–adjusted dosing) or SC (125 mg once weekly) abatacept.3,4 Patients were stratified by baseline ACPA/RF status: ACPA+/RF− (ACPA+ only), ACPA/RF double positive (+/+), ACPA−/RF+ (RF+ only), and ACPA/RF double negative (−/−). Abatacept retention rate at 2 years was estimated by Kaplan–Meier (KM) analysis.

Results

Patients with ACPA/RF serostatus data from the ACTION and ASCORE studies (N = 1679 and N = 1748, respectively) were evaluated. Baseline demographic and disease characteristics were similar across studies and serostatus groups (Table 1). In patients with ACPA+ only RA, abatacept retention rates were similar to the +/+ group and greater than the RF+ only and −/− groups (Figure 1). In ASCORE (Figure 1A), retention rates were significantly higher in ACPA+ only and +/+ groups when compared with the −/− group. In contrast, retention rates for patients with RF+ only RA were not significantly different vs −/− patients. Results were similar in ACTION, although the higher retention in the ACPA+ group did not reach statistical significance (Figure 1B).

Table 1.

Baseline demographics and disease characteristics by ACPA/RF status for the ASCORE and ACTION studies

ASCORE+/+RF+ onlyACPA+ only−/−(n = 1079)(n = 142)(n = 184)(n = 343)Age, years57.1 (12.8)58.2 (11.8)57.4 (13.5)57.8 (13.9)DAS28 (CRP)4.7 (1.2)4.6 (1.1)4.4 (1.0)4.8 (1.2)CDAI26.6 (12.5)25.8 (12.0)23.6 (10.9)28.2 (13.2)SDAI28.1 (13.0)27.2 (12.4)24.4 (10.8)29.7 (13.9)ACTION+/+RF+ onlyACPA+ only−/−(n = 1028)(n = 161)(n = 98)(n = 392)Age, years58.2 (12.0)58.4 (13.4)58.5 (14.0)57.0 (13.3)DAS28 (CRP)4.9 (1.1)5.0 (1.1)4.9 (1.0)5.0 (1.1)CDAI28.7 (12.2)29.2 (12.4)28.7 (11.5)30.1 (12.9)SDAI30.4 (13.1)31.2 (13.4)29.8 (11.5)31.7 (13.4)

Data are mean (SD). Patients with missing data for baseline ACPA/RF status are excluded.

Conclusion

In this post hoc analysis of the real-world ACTION and ASCORE studies, ACPA positivity was associated with an increased likelihood of retention over 2 years. Patients with ACPA+ only RA were equally as likely to be retained on abatacept as patients with ACPA/RF double positivity. In contrast, patients with RF+ only RA were less likely to be retained on abatacept over 2 years. These findings suggest that ACPA positivity played a more important role than RF positivity in abatacept retention. The higher retention seen in patients with ACPA+ only vs RF+ only disease demonstrates the key role of ACPA in RA and supports the importance of precision medicine in treating patients.

References

[1]Fraenkel L, et al. Arthritis Care Res (Hoboken) 2021;73:924–39.

[2]Smolen JS, et al. Ann Rheum Dis 2020;79:685–99.

[3]Alten R, et al. Clin Rheumatol 2019;38:1413–24.

[4]Alten R, et al. Ann Rheum Dis 2021;80(suppl 1):OP0180.

Acknowledgements

This study was sponsored by Bristol Myers Squibb. Medical writing and editorial assistance was provided by Fiona Boswell, PhD, of Caudex, and was funded by Bristol Myers Squibb. Study management provided by Syneos (CRO).

Disclosure of Interests

Rieke Alten Speakers bureau: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Paid instructor for: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Consultant of: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Grant/research support from: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Christiane Rauch Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Melanie Chartier Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, M.T. Nurmohamed Speakers bureau: AbbVie, Bristol Myers Squibb, Eli Lilly, Janssen, Pfizer, Consultant of: AbbVie, Bristol Myers Squibb, Eli Lilly, Janssen, Pfizer, Grant/research support from: AbbVie, Amgen, Bristol Myers Squibb, Eli Lilly, Galapagos, Janssen, MSD, Pfizer, Sean Connolly Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Galapagos, Gilead, Pfizer, Grant/research support from: Gilead, Pfizer, UCB, Peter Peichl Speakers bureau: GlaxoSmithKline, Janssen, Xavier Mariette Consultant of: Bristol Myers Squibb, Galapagos, GlaxoSmithKline, Janssen, Novartis, Pfizer, Sanofi, UCB, Yusuf Patel: None declared, Sara Marsal Speakers bureau: Bristol Myers Squibb, Lilly, MSD, Novartis - Sandoz, Pfizer, Roche, Consultant of: AbbVie, Galapagos, Pfizer, Sanofi; IMIDomics (executive role), Grant/research support from: AbbVie, Bristol Myers Squibb, Galapagos, Janssen, Lilly, MSD, Novartis - Sandoz, Pfizer, Roche, Sanofi, UCB, Roberto Caporali Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Fresenius-Kabi, Galapagos, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, Sandoz, UCB, Consultant of: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Galapagos, Janssen, Lilly, MSD, Novartis, Pfizer, Sandoz, UCB, Hedley Griffiths Consultant of: Amgen, Raimón Sanmartí Speakers bureau: AbbVie, Bristol Myers Squibb, Lilly, MSD, Pfizer, Roche, Sanofi, Grant/research support from: AbbVie, Bristol Myers Squibb, MSD, Pfizer, Roche, Bettina Bannert Speakers bureau: Novartis Pharma Schweiz AG, Yedid Elbez Consultant of: Bristol Myers Squibb, Employee of: Signifience, Karissa Lozenski Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb.

POS0107 ACPA POSITIVITY DETERMINES REMISSION IN PATIENTS WITH RA TREATED WITH IV AND SC ABATACEPT: A POST HOC ANALYSIS OF THE REAL-WORLD OBSERVATIONAL ACTION AND ASCORE STUDIES

Background

The goal of treatment for RA is achieving low disease activity and/or remission1,2; however, disease course and management can be complicated by additional factors that may be influenced by serostatus. Anti-citrullinated protein antibodies (ACPAs) and RF contribute to a more severe RA disease pattern3 and may be useful in predicting response to treatment.4 ACTION (AbataCepT In rOutiNe clinical practice; NCT02109666) and ASCORE (Abatacept SubCutaneOus in Routine Clinical PracticE; NCT02090556) were 2-year, international, observational, prospective, multicenter studies of IV and SC abatacept, respectively, for the treatment of RA in routine clinical practice.4,5 Previous analyses have shown that ACPA/RF double-positive serostatus was associated with better treatment outcomes compared with ACPA/RF double-negative serostatus.4–6

Objectives

To assess the independent effect of ACPA or RF single seropositivity among patients with RA on achieving remission after treatment with abatacept for 2 years, and to compare outcomes among patients with single versus double serostatus.

Methods

This post hoc analysis included patients from ACTION and ASCORE who initiated IV (body weight–adjusted dosing) or SC abatacept (125 mg once weekly), respectively. Patients were stratified by baseline ACPA/RF status: ACPA+/RF− (ACPA+ only), ACPA/RF double positive (+/+), ACPA−/RF+ (RF+ only), and ACPA/RF double negative (−/−). DAS28 (CRP) and CDAI remission rates (defined as < 2.6 and 0–2.8, respectively) at 2 years for patients who were ACPA+ or RF+ only at baseline were assessed and compared with those who were +/+ and −/−. Patients with missing baseline ACPA/RF status were excluded. Last observation carried forward efficacy analyses were used to impute missing values.

Results

This analysis included 1679 patients from ACTION (ACPA+ only, n = 98; +/+, n = 1028; RF+ only, n = 161; and −/−, n = 392) and 1748 patients from ASCORE (ACPA+ only, n = 184; +/+, n = 1079; RF+ only, n = 142; and −/−, n = 343). Across studies and serogroups, baseline demographics and disease characteristics were similar (data not shown). In both ACTION and ASCORE, a higher proportion of patients who were only ACPA+ achieved DAS28 (CRP) and CDAI remission at 2 years compared with patients who were only RF+ (Figure 1). Additionally, a similar proportion of patients who were only ACPA+ achieved DAS28 (CRP) and CDAI remission at 2 years compared with patients who were +/+. In contrast, a lower proportion of patients who were only RF+ achieved DAS28 (CRP) and CDAI remission at 2 years compared with patients who were +/+.

Conclusion

In this post hoc analysis of real-world data from ACTION and ASCORE, ACPA positivity was associated with an increased likelihood of achieving DAS28 (CRP) and CDAI remission at 2 years. Patients who were ACPA+ only were as likely to achieve remission as +/+ patients, suggesting that RF serostatus had less influence than ACPA serostatus on remission status at 2 years. In line with this, patients who were RF+ only were less likely to achieve remission at 2 years. This is the first large, real-world study to show that ACPA positivity plays a more important role than RF positivity in achieving remission whilst on abatacept. These results highlight the importance of assessing baseline ACPA status when considering treatment options for patients with RA.

References

[1]Smolen JS, et al. Ann Rheum Dis 2020;79:685–99.

[2]Fraenkel L, et al. Arthritis Care Res (Hoboken) 2021;73:924–39.

[3]Katchamart, W, et al. Rheumatol Int 2015;35:1693–9.

[4]Alten R, et al. Ann Rheum Dis 2021;80(suppl 1):OP0180.

[5]Alten R, et al. Clin Rheumatol 2019;38:1413–24.

[6]Alten R, et al. RMD Open 2017;3:e000345.

Acknowledgements

This study was sponsored by Bristol Myers Squibb. Medical writing and editorial assistance was provided by Rachel Rankin, PhD, of Caudex, and was funded by Bristol Myers Squibb. Study management provided by Syneos (CRO).

Disclosure of Interests

Rieke Alten Speakers bureau: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Paid instructor for: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Consultant of: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Grant/research support from: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Christiane Rauch Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Melanie Chartier Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, M.T. Nurmohamed Speakers bureau: AbbVie, Bristol Myers Squibb, Eli Lilly, Janssen, Pfizer, Consultant of: AbbVie, Bristol Myers Squibb, Eli Lilly, Janssen, Pfizer, Grant/research support from: AbbVie, Amgen, Bristol Myers Squibb, Eli Lilly, Galapagos, Janssen, MSD, Pfizer, Sean Connolly Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Galapagos, Gilead, Pfizer, Grant/research support from: Gilead, Pfizer, UCB, Peter Peichl Speakers bureau: Janssen, GlaxoSmithKline, Xavier Mariette Consultant of: Bristol Myers Squibb, Galapagos, GlaxoSmithKline, Janssen, Novartis, Pfizer, Sanofi, UCB, Yusuf Patel: None declared, Sara Marsal Speakers bureau: Bristol Myers Squibb, Lilly, MSD, Novartis - Sandoz, Pfizer, Roche, Consultant of: AbbVie, Galapagos, Pfizer, Sanofi; IMIDomics (executive role), Grant/research support from: AbbVie, Bristol Myers Squibb, Galapagos, Janssen, Lilly, MSD, Novartis - Sandoz, Pfizer, Roche, Sanofi, UCB, Roberto Caporali Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Fresenius-Kabi, Galapagos, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, Sandoz, UCB, Consultant of: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Galapagos, Janssen, Lilly, MSD, Novartis, Pfizer, Sandoz, UCB, Hedley Griffiths Consultant of: Amgen, Raimón Sanmartí Speakers bureau: AbbVie, Bristol Myers Squibb, Lilly, MSD, Pfizer, Roche, Sanofi, Grant/research support from: AbbVie, Bristol Myers Squibb, MSD, Pfizer, Roche, Bettina Bannert: None declared, Yedid Elbez Consultant of: Bristol Myers Squibb, Employee of: Signifience, Karissa Lozenski Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

POS0104 ACPA-NEGATIVE AND ACPA-POSITIVE RA-PATIENTS ACHIEVING DISEASE RESOLUTION DEMONSTRATE DISTINCT PATTERNS OF MRI-DETECTED JOINT-INFLAMMATION

Background

Sustained DMARD-free remission (SDFR), the sustained absence of clinical-synovitis after DMARD-discontinuation, is increasingly achievable in RA. However, prevalence differs significantly between ACPA-negative (40%) and ACPA-positive RA (5-10%). In addition, early-DAS-remission (DAS4months<1.6) associates with SDFR in ACPA-negative RA but not in ACPA-positive RA.1 Based on these differences, we hypothesized that longitudinal patterns of local tissue-inflammation (synovitis/tenosynovitis/osteitis) might also differ between ACPA-negative and ACPA-positive RA-patients achieving SDFR.

Objectives

With the ultimate aim to increase understanding of disease-resolution in RA, we studied MRI-detected joint-inflammation over time in relation to SDFR-development in ACPA-negative RA and ACPA-positive RA.

Methods

198 RA-patients (94 ACPA-negative and 104 ACPA-positive) underwent repeated MRIs (0/4/12/24-months) and were followed on SDFR-development. The course of MRI-detected total-inflammation, and synovitis/tenosynovitis/osteitis individually, were compared between RA-patients who did and did not achieve SDFR, using Poisson-mixed-models. 170 ACPA-positive RA-patients from the AVERT-1 were studied as ACPA-positive validation-population.

Results

In ACPA-negative RA, patients achieving SDFR had similar baseline total inflammation-levels, which declined 2.0-times stronger in the first-year of DMARD-treatment (IRR 0.50, 95%CI;0.32-0.77, p<0.01) compared to patients without SDFR. This stronger decline was seen in tenosynovitis/synovitis/osteitis. In contrast, ACPA-positive RA-patients achieving SDFR, had already lower inflammation-levels (especially synovitis/osteitis) at disease-presentation (IRR 0.45, 95%CI;0.24-0.86, p=0.02) compared to non-SDFR patients, and remained lower during follow-up (p=0.02). Similar results were found in the ACPA-positive validation-population.

Conclusion

Compared to RA-patients without disease-resolution, ACPA-positive RA-patients achieving SDFR have less severe joint-inflammation from diagnosis onwards, whilst ACPA-negative RA-patients present with similar inflammation-levels but demonstrate a stronger decline in the first year of DMARD-therapy. These different trajectories suggest that mechanisms underlying resolution of RA-chronicity in both RA-subsets might be different and indicates the relevance of the total inflammatory-load in ACPA-positive-RA.

References

[1]Verstappen M, Niemantsverdriet E, Matthijssen XME, le Cessie S, van der Helm-van Mil AHM. Early DAS response after DMARD-start increases probability of achieving sustained DMARD-free remission in rheumatoid arthritis. Arthritis Res Ther. 2020 Nov 23;22(1):276.

Figure 1.

Patterns of MRI-detected joint-inflammation in RA-patients achieving SDFR compared to those who did not, stratified for ACPA-status

Disclosure of Interests

Marloes Verstappen: None declared, Xanthe Matthijssen: None declared, Sean Connolly Shareholder of: Dr. Sean E. Connolly, Ph.D. is a shareholder of Bristol Myers Squibb, Employee of: Dr. Sean E. Connolly, Ph.D. is an employee of Bristol Myers Squibb, Michael A Maldonado Shareholder of: Dr. M. Maldonado, Ph.D. is a shareholder of Bristol Myers Squibb, Employee of: Dr. M. Maldonado, Ph.D. is an employee of Bristol Myers Squibb, Thomas Huizinga Speakers bureau: Tom WJ Huizinga/the department of rheumatology LUMC has received research support/lecture fees/consultancy fees from Merck, UCB, Bristol Myers Squibb, Janssen, Pfizer, Novartis, Sanofi-Aventis, Galapagos, Boeringher and Eli Lilly, Consultant of: Tom WJ Huizinga/the department of rheumatology LUMC has received research support/lecture fees/consultancy fees from Merck, UCB, Bristol Myers Squibb, Janssen, Pfizer, Novartis, Sanofi-Aventis, Galapagos, Boeringher and Eli Lilly, Grant/research support from: Tom WJ Huizinga/the department of rheumatology LUMC has received research support/lecture fees/consultancy fees from Merck, UCB, Bristol Myers Squibb, Janssen, Pfizer, Novartis, Sanofi-Aventis, Galapagos, Boeringher and Eli Lilly, Annette van der Helm-van Mil: None declared

Clinical trial management: a profession in crisis?

Clinical trial managers play a vital role in the design and conduct of clinical trials in the UK. There is a current recruitment and retention crisis for this specialist role due to a complex set of factors, most likely to have come to a head due to the COVID-19 pandemic. Academic clinical trial units and departments are struggling to recruit trial managers to vacant positions, and multiple influences are affecting the retention of this highly skilled workforce. Without tackling this issue, we face major challenges in the delivery on the Department of Health and Social Care's Future of UK Clinical Research Delivery implementation plan. This article, led by a leading network of and for UK Trial Managers, presents some of the issues and ways in which national stakeholders may be able to address this.

Atrial Fibrillation and Dementia: A Report From the AF-SCREEN International Collaboration

Growing evidence suggests a consistent association between atrial fibrillation (AF) and cognitive impairment and dementia that is independent of clinical stroke. This report from the AF-SCREEN International Collaboration summarizes the evidence linking AF to cognitive impairment and dementia. It provides guidance on the investigation and management of dementia in patients with AF on the basis of best available evidence. The document also addresses suspected pathophysiologic mechanisms and identifies knowledge gaps for future research. Whereas AF and dementia share numerous risk factors, the association appears to be independent of these variables. Nevertheless, the evidence remains inconclusive regarding a direct causal effect. Several pathophysiologic mechanisms have been proposed, some of which are potentially amenable to early intervention, including cerebral microinfarction, AF-related cerebral hypoperfusion, inflammation, microhemorrhage, brain atrophy, and systemic atherosclerotic vascular disease. The mitigating role of oral anticoagulation in specific subgroups (eg, low stroke risk, short duration or silent AF, after successful AF ablation, or atrial cardiopathy) and the effect of rhythm versus rate control strategies remain unknown. Likewise, screening for AF (in cognitively normal or cognitively impaired patients) and screening for cognitive impairment in patients with AF are debated. The pathophysiology of dementia and therapeutic strategies to reduce cognitive impairment warrant further investigation in individuals with AF. Cognition should be evaluated in future AF studies and integrated with patient-specific outcome priorities and patient preferences. Further large-scale prospective studies and randomized trials are needed to establish whether AF is a risk factor for cognitive impairment, to investigate strategies to prevent dementia, and to determine whether screening for unknown AF followed by targeted therapy might prevent or reduce cognitive impairment and dementia.

Kidney function decline in heart failure patients: an audit of out-patient heart failure services

Funding Acknowledgements

Type of funding sources: None.

Background

A bidirectional relationship exists between the kidney and the heart; the lower the eGFR the more challenging it is to manage the heart failure (HF) patient. Worsening renal function is common in HF patients and associated with a two-fold increase in mortality and a lower likelihood of being prescribed efficacious HF therapy. The role of cardio-renal interactions in HF is essential to identify risk and subsequent treatment strategies.

Purpose

The purpose of this audit is to provide insights into the assessment of renal function in a real world heart failure population by identifying the degree of renal dysfunction and changes in renal function over a five year time frame.

Methods

A retrospective audit included patients with HFrEF attending a heart failure service. These patients were classified using KIDGO criteria CKD 1-5. A current eGFR sample was compared with a sample taken five years earlier, identified using the electronic laboratory record. Ethical approval was granted from the Research Ethics Committee.

Resultss

100 patients with HFrEF attending a heart failure service fulfilled the selection criteria of which sixty three patients with an eGFR &gt;60ml/min/1.73 m2 were audited. Of this group 43 were CKD class 2 and 20 were CKD class 1. Thirty seven patients had an eGFR &lt;60ml/min/1.73 m2 of which 9 were class 3b, 9 were CKD class 4 and 1 was CKD Class 5.

Of the 100 patients enrolled, 6 were excluded from the analysis of kidney function decline as an eGFR from five years earlier was unavailable. Within a five year time span, 44 patients did not change their CKD class, 31 patients declined by one class, 9 patients declined by two classes, 3 patients declined by three classes and 7 patients improved their kidney function.

GFR &lt; 60mL/min/1.73m2,

n = 37

GFR &gt; 60mL/min/1.73m2, n = 63

Age – mean (range)

77.8 (49-94)

66.5 (45-89)

Gender – female (%)

12 (32%)

16 (25%)

Average renal function measurements (mean, range)

6.4

6.7

Total albumin

creatinine ratio measurements

8

6

Actively attending renal service

6

0

Conclusion

Nurses should be aware of the increasing risk conferred by the dual diagnosis of heart failure and chronic kidney disease. Patients with heart failure who have decreasing eGFR levels (especially less than 30 mL/min), should have collaborative management with nephrology services to optimise outcomes. Recognition of CKD in our institution and referral to nephrology services was suboptimal and further work is necessary to optimise the management of these patients.

Transitioning a cardiovascular health and rehabilitation programme to a virtual platform during covid 19

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Our Hearts Our Minds

Purpose

Can a virtual cardiovascular prevention and rehabilitation programme be as effective as face-to-face programme.

Background

The Our Hearts Our Minds (OHOM) prevention and rehabilitation programme rapidly transitioned to a virtual platform in the covid era.  Here we compare if a virtual programme potentially could offer the same standard of the nursing intervention (education, smoking cessation, medical risk factor management and psychosocial health) as the previous face to face programme

Methods

Both the initial assessment (IA) and end of programme (EOP) assessments were conducted via telephone/video as per patient preference. The following measures were recorded at both time points (home blood pressure (BP) monitors were provided)

Smoking (self report) BP/Heart rate, Lipids/HbA1c (facilitated by phlebotomy hub), cardio protective drugs (doses, adherence), Hospital Anxiety and Depression score, EuroQoL

Nursing Intervention Smoking cessation counselling and pharmacotherapy where appropriate

Weekly meeting with cardiologist to optimise BP and lipid management and up titration cardio protective drugs

Bimonthly virtual coaching consultation for monitoring/goal resetting

Bimonthly group video education sessions

Results

From April to November 2020, of the 432 referrals received 400 were eligible with 377 accepting the offer of an IA (94% response rate). 262 have had an IA with the remaining 115 awaiting an assessment date.  Of the completed IA’s 257 were willing to attend the programme (98% uptake).  120 had been offered an end of programme assessment with 114 attending (96% of those offered). The results for the virtual programme were then compared to the same period one year previously when the programme was fully face to face and are outlined in the table below.

The comparison of results delivered via remote delivery are remarkably similar to those achieved in the previous year delivered via face to face.

Conclusion

Initial data has shown that virtual delivery of the nursing component of the OHOM prevention/rehabilitation programme was highly acceptable to patients and was as effective as that of the traditional face to face service.

Table 1 below exhibits the clinical and patient-reported outcomes.

Cardiovascular Outcomes According to Polypharmacy and Drug Adherence in Patients with Atrial Fibrillation on Long-Term Anticoagulation (from the RE-LY Trial)

Prevalence of atrial fibrillation (AF) increases with age, along with comorbidities and, thus, polypharmacy. Non-adherence is associated with polypharmacy. This study aimed to identify patients at risk for cardiovascular events according to their pharmacological treatment intensity and adherence. Patients (n = 18,113) with a mean age of 71.5 ± 8.7 years, at high cardiovascular risk were followed between December 2005 until December 2007 for a median time of 2 years. The association between polypharmacy and adherence and their impact on cardiovascular and bleeding events were explored. Adherence was defined as a study drug intake of ≥80%. Patients with more co-medications had a higher body mass index, higher prevalence of hypertension, coronary heart disease, heart failure, and diabetes mellitus (all p < 0.0001) compared to ≤4 or 5-8 co-medications, but no differences in history of stroke (p = 0.68) or transient ischemic attack (p = 0.065). Across all treatments, the adjusted hazard ratios (HRs) increased in patients with more co-medications (≥9 vs ≤4) for all-cause death (HR 1.30; 1.06-1.59), major bleeding (HR 1.65; 1.33-2.05), and all bleeding events (HR 1.44; 1.31-1.59). Yearly event rates were higher in non-adherent than adherent patients for stroke and systemic embolism (SSE) (3.14 vs 1.00), all-cause death (7.76 vs 2.66), major bleeding (6.21 vs 2.65), and all bleeding (28.71 vs 19.05; all p < 0.0001). After an event the patients were more likely to become non-adherent (adherence after SSE 30.3%, after major bleeding 33.4%, after all bleeding 66.7%; all p < 0.0001). The treatment effects were consistent to the overall group in the different polypharmacy groups. In conclusion, polypharmacy and non-adherence are risk indicators for increased adverse cardiovascular and bleeding events. Dabigatran is safe to use across the full spectrum of AF patients, independent of the number of co-medications and adherence. Patients with co-medications and comorbidities require special attention and encouragement to adhere to oral anticoagulation.

POS1040 IMPLEMENTATION OF THE OMERACT PSAMRIS IN A PHASE IIB, RANDOMISED PLACEBO-CONTROLLED STUDY OF ABATACEPT IN PSORIATIC ARTHRITIS

Background:

The semi-quantitative Outcome Measures in Rheumatology (OMERACT) Psoriatic Arthritis Magnetic Resonance Imaging Score (PsAMRIS) was developed for the evaluation of inflammatory and destructive changes in PsA,1 but has limited trial usage.

Objectives:

To retrospectively utilise the PsAMRIS in a multi-dose, randomised Phase IIb study of abatacept in patients with PsA who have inadequate response to DMARDs (NCT00534313).2

Methods:

Patients were randomised to abatacept (3, 10 or 30/10 mg/kg [the 30-mg/kg group switched to 10 mg/kg after the first two doses]) or placebo and treated for 169 days, after which all patients received abatacept 10 mg/kg through to Day 365. MRI scans of one hand or foot from 123 patients with PsA collected at baseline and on Days 85, 169 and 365 were centrally evaluated by two readers blinded to chronological order and treatment arm. Synovitis, bone oedema, tenosynovitis, periarticular inflammation, bone erosion, bone proliferation and joint space narrowing were assessed as per OMERACT PsAMRIS; a novel total inflammation score was calculated from the sum of synovitis, bone oedema, tenosynovitis and periarticular inflammation. Variables were analysed using all cases (hand or foot) and by hand and foot cases separately.

Results:

At Day 169, the abatacept 30/10 mg/kg or 10 mg/kg group showed the most decrease (improvement) in each inflammatory assessment (Figure 1). The Day 169 change from baseline severity in synovitis and tenosynovitis in the abatacept 30/10 mg/kg and 10 mg/kg groups, respectively, were significantly reduced (improved) compared with placebo (estimated differences of –0.966 [p=0.039] and –1.652 [p=0.014], respectively) (Table 1). Patients originally randomised to placebo and then switched to abatacept 10 mg/kg at Day 169 showed significant improvements in synovitis, tenosynovitis and total inflammation from Day 169 to Day 365 (Table 1, Figure 1). The structural outcomes joint space narrowing and bone erosion remained stable within each treatment group, showing little change from baseline to Days 85, 169 and 365. After separating hand and foot analyses (72 hand and 51 foot cases), only hand tenosynovitis in the 10-mg/kg group and foot synovitis in the 3-mg/kg group were significantly reduced (improved) at Day 169 compared with placebo (differences of –2.331 [p=0.017] and –1.689 [p=0.010], respectively). In general, more comparisons in the hand analysis were statistically significant versus in the foot analysis.

Conclusion:

This analysis confirmed the efficacy of abatacept 10 and 30/10 mg/kg when assessed with the OMERACT PsAMRIS. The inflammatory pathologies, synovitis and tenosynovitis, appeared to be the most responsive MRI outcomes. Analysing hand and foot cases together yielded results consistent with the primary clinical efficacy endpoint (ACR20 response rate), as the abatacept 10- and 30/10-mg/kg groups showed significant differences versus placebo at Day 169;2 reduced sample size in separate hand and foot assessments may have prevented finding significant results corresponding to the combined analysis. These results also demonstrate the responsiveness of the PsAMRIS in PsA randomised clinical trials.

References:

[1]Glinatsi D, et al. J Rheumatol 2015;42:2473–2479.

[2]Mease P, et al. Arthritis Rheum 2011;63:939–948.

Table 1.

MRI variables showing significant treatment effectsa

Between groups at Day 169MRI scoreComparatorComparatorDifferenceSEp valueSynovitisPlaceboAbatacept 30/10 mg/kg–0.9660.4610.039TenosynovitisPlaceboAbatacept 10 mg/kg–1.6520.6620.014Placebo group before/after switchbMRI scoreTreatment, Day 169Treatment, Day 365DifferenceSEp valueSynovitisPlaceboAbatacept 10 mg/kg–1.0180.4580.029TenosynovitisPlaceboAbatacept 10 mg/kg–0.9400.3900.018Total inflammationPlaceboAbatacept 10 mg/kg–2.2751.0670.036

aBased on change from baseline at the stated time points (unadjusted p values).

bPatients were switched to abatacept 10 mg/kg after Day 169.

Acknowledgements:

Professional medical writing and editorial assistance was provided by Rob Coover, MPH, at Caudex and was funded by Bristol Myers Squibb.

Disclosure of Interests:

Mikkel Østergaard Speakers bureau: AbbVie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, Roche, Sanofi, UCB, Consultant of: AbbVie, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, UCB, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, Merck, Novartis, Paul Bird Speakers bureau: AbbVie, Bristol Myers Squibb, Eli Lilly, Novartis, Pfizer, UCB, Grant/research support from: Gilead, Chahin Pachai Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Shuyan Du Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Chun Wu Employee of: Bristol Myers Squibb, Jessica Landis Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Thomas Fuerst Employee of: Bioclinica, Inc., a contract research service providing radiology central reading services to pharmaceutical, biotech and medical device companies, Harris A Ahmad Employee of: Bristol Myers Squibb, Sean Connolly Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Philip G Conaghan Speakers bureau: AbbVie, Novartis, Consultant of: AstraZeneca, Bristol Myers Squibb, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, Gilead, Novartis, Pfizer.

OP0180 IMPACT OF RF AND ANTI-CITRULLINATED PROTEIN ANTIBODY SEROSTATUS ON 2-YEAR RETENTION OF ABATACEPT IN PATIENTS WITH RA

Background:

Up to 50% of patients with RA discontinue DMARD treatment within 18 months.1 However, up to 20% of patients who fail multiple treatments may have a good treatment response to another therapy.1 Predictive biomarkers, such as RF and anti-citrullinated protein antibodies (ACPAs), may be useful to stratify patients with RA to the most appropriate treatment.1 ASCORE (Abatacept SubCutaneOus in Routine Clinical PracticE; NCT02090556) was a 2-year, observational, prospective, multicentre study of SC abatacept for the treatment of RA in routine clinical practice.2

Objectives:

To determine if RF/ACPA serostatus and treatment line impact abatacept retention in patients with RA in a post hoc analysis of ASCORE.

Methods:

Eligible patients, aged ≥18 years, with active moderate-to-severe RA (ACR/EULAR 2010 criteria) who were IV abatacept-naive and initiated SC abatacept 125 mg once weekly, were enrolled into two cohorts: biologic (b)DMARD-naive patients and those with ≥1 prior bDMARD treatment failure. This post hoc analysis assessed abatacept retention rate at 2 years in a subset of patients with RF/ACPA serostatus data (n=1748) from the ASCORE study (N=2892; as observed). Baseline (BL) serostatus groups examined by treatment line were: RF/ACPA double positive (+/+) RA, RF/ACPA single positive (RF+/ACPA– or RF–/ACPA+) RA (data not shown) and RF/ACPA double negative (–/–) RA. Last observation carried forward (LOCF) analyses were used to assess change from BL and measures of disease remission (DAS28 [CRP] <2.6, CDAI ≤2.8, and SDAI ≤3.3) in patients with +/+ RA versus –/– RA.

Results:

BL demographic and disease characteristics were similar across serostatus groups and treatment lines (Table 1). Mean age was 57.1 and 57.8 years for +/+ RA and –/– RA, respectively. Mean DAS28 (CRP) was 4.7 and 4.8 for +/+ RA and –/– RA, respectively. In patients with +/+ RA, abatacept retention was greater when given as first-line treatment (57% vs 48% when given as ≥ second-line) (Figure 1). Retention was similar in patients with –/– RA regardless of treatment line. After 2 years, mean (SE) change from BL (LOCF) in DAS28 (CRP) was –1.41 (0.06) and –0.97 (0.09) for patients with +/+ and –/– RA, respectively. For patients with +/+ RA, mean (SE) change from BL in DAS28 (CRP) was –1.62 (0.08) for those in whom abatacept was first-line and –1.19 (0.08) for those in whom abatacept was ≥ second-line. For patients with –/– RA, mean (SE) change from BL in DAS28 (CRP) was –1.03 (0.13) for those in whom abatacept was first-line and –0.93 (0.12) for those in whom abatacept was ≥ second-line. Remission rates (LOCF) were significantly (p<0.0001) higher in patients with +/+ RA vs –/– RA respectively: DAS28 (CRP) 38.4% (n=393) versus 19.3% (n=62); CDAI 50.6% (n=513) versus 33.0% (n=107); and SDAI 49.5% (n=497) versus 32.5% (n=102).

Table 1.

BL demographics and disease characteristics by RF/ACPA status

+/+ RA(n=1079)–/– RA(n=343)First-line (n=511)≥ second-line (n=568)First-line(n=140)≥ second-line(n=203)Age57.1 (13.4)57.1 (12.2)59.5 (14.7)56.6 (13.2)DAS28 (CRP)4.7 (1.2)4.7 (1.2)4.8 (1.1)4.8 (1.2)CDAI26.6 (12.5)26.6 (12.4)27.7 (12.5)28.6 (13.8)SDAI28.1 (13.1)28.1 (12.9)29.1 (12.9)30.2 (14.7)

Data are mean (SD). Patients with missing data for BL RF/ACPA status are excluded.

ACPA=anti-citrullinated protein antibody; BL=baseline.

Conclusion:

In this real-world analysis, patients with +/+ RA treated with first-line abatacept had higher retention than patients receiving abatacept as a ≥ second-line therapy. Remission rates on abatacept were higher in patients with +/+ RA versus –/– RA. These results support early treatment with abatacept and highlight the importance of further evaluating precision medicine approaches in RA.

References:

[1]Smolen JS, et al. Ann Rheum Dis 2020;79:685–699.

[2]Alten R, et al. Ann Rheum Dis 2019;78(suppl 2):A1639.

Acknowledgements:

Professional medical writing and editorial assistance was provided by Lindsay Craik at Caudex and was funded by Bristol Myers Squibb. This study was funded by Bristol Myers Squibb.

Disclosure of Interests:

Rieke Alten Speakers bureau: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Consultant of: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Grant/research support from: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Xavier Mariette Consultant of: Bristol Myers Squibb, Galapagos, Gilead, GlaxoSmithKline, Janssen, Pfizer, UCB, Rene-Marc Flipo Speakers bureau: AbbVie, Bristol Myers Squibb, Janssen, Lilly, Medac, Merck Sharp & Dohme, Novartis, Pfizer, Roche-Chugai, Grant/research support from: Amgen, Janssen, Novartis, Pfizer, Roberto Caporali Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Fresenius Kabi, Galapagos, Gilead, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Samsung Bioepis, Sanofi, UCB, Consultant of: Galapagos, Gilead, Janssen, Lilly, Merck Sharp & Dohme, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Eli Lilly, Gilead, Merck Serono, Pfizer, Roche, Sanofi, Grant/research support from: Gilead, Pfizer, Roche, UCB, Yusuf Patel: None declared, Raimón Sanmartí Speakers bureau: AbbVie, Bristol Myers Squibb, Gebro, Janssen, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, Consultant of: AbbVie, Bristol Myers Squibb, Gebro, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, Grant/research support from: Bristol Myers Squibb, Merck Sharp & Dohme, Pfizer, Sara Marsal Speakers bureau: Bristol Myers Squibb, Celgene, Pfizer, Roche, Sanofi, UCB, Consultant of: AbbVie, Bristol Myers Squibb, Celgene, Galapagos, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, UCB, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sanofi, UCB, M.T. Nurmohamed Speakers bureau: AbbVie, Bristol Myers Squibb, Eli Lilly, Roche, Sanofi, Consultant of: AbbVie, Celgene, Celltrion, Eli Lilly, Janssen, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Mundipharma, Novartis, Pfizer, Roche, Sanofi, Hedley Griffiths Consultant of: AbbVie, Gilead, Janssen, Novartis, Peter Peichl: None declared, Bettina Bannert: None declared, Adrian Forster: None declared, Melanie Chartier Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Sean Connolly Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Yedid Elbez Consultant of: Bristol Myers Squibb, Christiane Rauch Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Vadim Khaychuk Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Karissa Lozenski Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

AB0205 A NOVEL METHOD FOR PREDICTING 1-YEAR RETENTION OF ABATACEPT USING MACHINE LEARNING TECHNIQUES: DIRECTIONALITY AND IMPORTANCE OF PREDICTORS

Background:

In the ACTION (NCT02109666) study, multivariable Cox proportional hazards regression models showed that the predictors of 1-year retention to abatacept treatment were: patient global pain assessment, country, reason for stopping last biologic, number of prior biologic treatments, abatacept monotherapy, RF/anti-cyclic citrullinated peptide (CCP) status, previous neoplasms, psychiatric disorders and cardiac disorders.1 Machine learning techniques, using the gradient-boosting model, subsequently identified additional predictors of abatacept retention in patients with moderate-to-severe RA enrolled in ACTION; however, the analysis did not show the directionality of the predictors.2

Objectives:

To improve the clinical interpretability of the machine learning model in terms of directionality and the importance of each variable in predicting retention.

Methods:

Previous analyses using the gradient-boosting model to identify predictors of abatacept retention at 1 year in the ACTION study have been described.2 This analysis used SHapley Additive exPlanations (SHAP), a mathematical framework, to show how a particular predictor value influences prediction in the context of all other predictors. Higher SHAP values indicate a higher likelihood of retention. The contribution of every variable in the model’s prediction (with the exception of country variables) was computed for each data point to capture individual variable impact. This enabled interpretation for level of importance and directionality at a patient level.

Results:

Using data from 2350 patients enrolled in ACTION (May 2008 to December 2013), the mean retention rate at 1 year was 59.3% (n=1393). Overall variable importance is shown in Figure 1. After removal of country variables, the top five baseline predictors of retention were: no previous corticosteroid use, ACR functional class II, ≥2 prior biologic treatments prior to abatacept initiation, abatacept monotherapy and HAQ-DI. In terms of directionality, no previous corticosteroid use, ≥2 prior biologic treatments prior to abatacept initiation, abatacept monotherapy and a higher HAQ-DI score at baseline were associated with a lower likelihood of retention; ACR functional class II was associated with a higher likelihood of retention.

Conclusion:

The gradient-boosting model previously identified predictors of abatacept retention from ACTION;2 the addition of SHAP in this analysis has provided information on the importance and directionality of those predictors. The most important predictor of abatacept retention was no previous corticosteroid use, which was associated with lower retention. The models and predictors identified could be further refined by using additional datasets from clinical trials. Machine learning offers an innovative and complementary approach to biostatistics and could be used to identify treatment response predictors at an individual patient level, leading to a more personalised treatment approach.

References:

[1]Alten R, et al. RMD Open 2017;3:e000538.

[2]Alten R, et al. Presented at the virtual ACR Convergence 2020; 5–9 November 2020. Poster number 1745.

Acknowledgements:

This study was supported by Bristol Myers Squibb. Professional medical writing and editorial assistance was provided by Claire Line, PhD, at Caudex and was funded by Bristol Myers Squibb.

Disclosure of Interests:

Rieke Alten Speakers bureau: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Consultant of: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Grant/research support from: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Claire Behar Shareholder of: I have not invested directly in pharmaceutical companies producing drugs/devices for use in rheumatology however I may have shares via the funds linked to my life insurance., Consultant of: Bristol Myers Squibb, Christine Boileau Consultant of: AstraZeneca, Bristol Myers Squibb, Nanobiotix, Pierre Merckaert Consultant of: Bristol Myers Squibb, Ebenezer Afari Consultant of: Bristol Myers Squibb, Virginie Vannier-Moreau Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Sean Connolly Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Aurelie Najm Speakers bureau: Bristol Myers Squibb, Consultant of: Bristol Myers Squibb, Pierre-Antoine Juge Consultant of: Bristol Myers Squibb, Angshu Rai Shareholder of: Amgen Inc, Consultant of: Amgen Inc, Employee of: Amgen Inc, Bristol Myers Squibb, Yedid Elbez Consultant of: Bristol Myers Squibb, Karissa Lozenski Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

Delivering a dietetic intervention to cardiovascular patients in the Covid era

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Department of Health

Introduction

Healthy diet and body composition are core components of cardiac rehabilitation. Following the COVID outbreak in March 2020, our face-to-face cardiac rehabilitation programme (Our Hearts Our Minds) was suspended. The programme was then quickly moved to a virtual platform to continue to deliver the programme.

Purpose

Here we describe how the OHOM programme adapted our service to deliver the dietetic assessment and intervention on a virtual platform.

Methods

Pre-Covid the dietary component of OHOM consisted of a face-to-face Initial Assessment (IA) with a dietitian, group education sessions and an End of Programme assessment (EOP). Anthropometric measures and dietary habits were assessed including adherence to the Mediterranean diet via the Mediterranean Diet Score (MDS) toolkit. Using behaviour change techniques, tailored dietary advice was provided and goals agreed to educate on healthier food choices, increase adherence to Mediterranean diet and (if appropriate) promote weight loss and reduce central obesity. The assessment and intervention is now delivered virtually via telephone or video. Anthropometrics are self-reported with tape-measures supplied to assess waist circumference and advice provided on home-weighing. MDS is still assessed. The programme includes fortnightly coaching telephone consultations to review and reset goals, the option to attend a dietitian-led virtual group education session, access to a filmed educational video and submission of food diaries via the Fitbit app.

Results

From April to November 2020, 114 patients completed the virtual programme (65 telephone, 39 video). Dietetic outcomes are outlined in Table 1 with inclusion of data for a similar period one year previously (face-to-face) for comparison. Reductions in anthropometric measures and increased adherence to a cardio-protective diet were noted and the results for the two time periods are remarkably similar.

Conclusion

Delivery of a virtual dietetic component in cardiac rehabilitation is feasible, acceptable and just as effective as face-to-face based on preliminary data.

Table 1: Dietary outcomes at IA and EOP Face-to-face assessments (April - March 2019) Virtual assessments (April - November 2020) IA EOP Change IA EOP Change Mean weight (in those with BMI &gt;25kg/m2) 86.5 85.2 -1.3 91.4 88.6 -2.8 Waist circumference (cm) 104.3 103 -1.3 107 102 -5 Mean MDS (Range 1-14) 4.4 7.5 +3.1 4.8 7.8 +3 % Consuming oily fish once per week 20 57 +37 25 68 +43 Achieving fruit and vegetable target 16 61 +45 21 57 +36

Abstract Figure. Dietitian waist circumference tutorial

54 Patient Satisfaction During A Pandemic – Virtually Impossible?

Introduction

Throughout the COVID-19 pandemic we conducted virtual urology clinics for the first time at our institution. We aimed to assess patient satisfaction with the virtual clinic format.

Method

Patients who underwent virtual consultation were contacted by phone and surveyed about their appointment. Convenience, thoroughness, satisfaction, preference and reason for appointment were assessed via questionnaire

Results

77 randomly selected patients were contacted. 63 males (82%), 14 females (18%). Median age 61 years (range 16–86). 62 (80%) reviews, 12 (16%) new referrals, and 3 (4%) post-operative patients were surveyed. 55 (71%) were booked for repeat appointment, 13 (17%) for further investigations, 6 (8%) discharged, and 3 (4%) listed for surgery.

73 (95%) found it convenient, 3 (4%) were neutral and 1 (1%) found it inconvenient. 74 (96%) felt thoroughly assessed and 76 (99%) of patients had all their concerns addressed. 74 (96%) were satisfied with their review, 2 (3%) were neutral, and 1 (1%) was dissatisfied. Going forward, 50 (65%) would prefer virtual follow-up and 27 (35%) would prefer an in-person review.

Conclusions

Virtual clinic is preferable to the majority of patients in our urology service and is deemed convenient, thorough and satisfactory by them. It should be facilitated going forward in appropriately selected patients.

Randomized, Double-Blind Comparison of Half-Dose Versus Full-Dose Edoxaban in 14,014 Patients With Atrial Fibrillation

BACKGROUND

In the ENGAGE AF-TIMI 48 (Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis In Myocardial Infarction 48) trial, the lower dose edoxaban regimen (LDER) and the higher dose edoxaban regimen (HDER) were noninferior to well-managed warfarin for stroke prevention in atrial fibrillation.

OBJECTIVES

The objective of the present analysis of the ENGAGE AF TIMI-48 trial was to comprehensively compare the net clinical outcome (NCO) of LDER (30 mg once daily, dose reduced to 15 mg in selective patients) versus HDER (60 mg once daily, dose reduced to 30 mg in selective patients).

METHODS

This study performed a pre-specified analysis of the ENGAGE AF-TIMI 48 trial, comparing patients on LDER versus HDER.

RESULTS

The pre-defined primary NCO (stroke/systemic embolism [SEE], major bleeding, death) was less frequent with LDER (7.26% vs. 8.01%; hazard ratio: 0.90; 95% confidence interval: 0.84 to 0.98; p = 0.014). The secondary (disabling stroke, life-threatening bleeding, or all-cause mortality) and tertiary pre-defined NCOs (stroke, SEE, life-threatening bleeding, or all-cause mortality) were similar between the 2 dosing regimens. Patients randomized to LDER versus HDER had a significantly higher risk of stroke/SEE (2.04% vs. 1.56%; hazard ratio: 1.31; 95% confidence interval: 1.12 to 1.52; p < 0.001). Conversely, major bleeding, intracranial hemorrhage, major gastrointestinal bleeding, and life-threatening bleeding occurred significantly less frequently with LDER compared with those of HDER. These findings were supported by multiple pharmacokinetic findings.

CONCLUSIONS

In the ENGAGE AF-TIMI 48 trial, the primary NCO was reduced with LDER versus HDER, whereas the secondary and tertiary NCOs were similar between the 2 dosing regimens. These results may aid physicians in evidence-based individualization of edoxaban dosing. However, the approved HDER remains the standard therapy among the available edoxaban dosing regimens for stroke prevention in atrial fibrillation. (Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis In Myocardial Infarction 48 [ENGAGE AF-TIMI 48]; NCT00781391).

Restarting and timing of oral anticoagulation after traumatic intracranial hemorrhage: a review and summary of ongoing and planned prospective randomized clinical trials

Anticoagulant-associated traumatic intracranial hemorrhage (tICrH) is a devastating injury with high morbidity and mortality. For survivors, treating clinicians face the dilemma of restarting oral anticoagulation with scarce evidence to guide them. Thromboembolic risk is high from the bleeding event, patients’ high baseline risks, that is, the pre-existing indication for anticoagulation, and the risk of immobility after the bleeding episode. This must be balanced with potentially devastating hematoma expansion or new hemorrhagic lesions. Retrospective evidence and expert opinion support restarting oral anticoagulants in most patients with tICrH, but timing is uncertain. Researchers have failed to make clear distinctions between tICrH and spontaneous intracranial hemorrhage (sICrH), which have differing natural histories. While both appear to benefit from restarting, sICrH has a higher rebleeding risk and similar or lower thrombotic risk. Clinical equipoise on restarting is also divergent. In sICrH, equipoise is centered on whether to restart. In tICrH, it is centered on when. Several prospective randomized clinical trials are ongoing or about to start to examine the risk–benefit of restarting. Most of them are restricted to patients with sICrH, with antiplatelet control groups. Most are also restricted to direct oral anticoagulants (DOACs), as they are associated with a lower overall risk of ICrH. There is some overlap with tICrH via subdural hematoma, and one trial is specific to restart timing with DOACs in only traumatic cases. This is a narrative review of the current evidence for restarting anticoagulation and restart timing after tICrH along with a summary of the ongoing and planned clinical trials.

Efficacy and safety of low-dose rivaroxaban on top of aspirin in patients with polypharmacy and multimorbidity: an analysis from the COMPASS trial

Background

In patients with coronary or peripheral artery disease, intensified antithrombotic therapy with aspirin plus low dose rivaroxaban reduced cardiovascular outcomes compared with aspirin alone. Polypharmacy and multimorbidity are frequent in patients with vascular disease and are often perceived as barriers to more intensive pharmacotherapy by both patients and physicians.

Purpose

To report cardiovascular outcomes and the efficacy, safety, and net benefit of low dose rivaroxaban plus aspirin in patients with stable vascular disease by the number of concomitant cardiovascular drugs and by the number of comorbidities.

Methods

We reported ischemic events (cardiovascular death, stroke, or MI), major bleeding (ISTH modified criteria), and a prespecified net clinical outcome in participants from the randomised, double-blind COMPASS study by number of cardiovascular medications (0–2, 3, 4, 5–7) and by number of concomitant medical conditions. We compared rates and hazard ratios of patients treated with rivaroxaban plus aspirin vs aspirin alone by category of number of medications and concomitant conditions and tested for interaction between polypharmacy and multimorbidity and antithrombotic regimen.

Results

Although patients with polypharmacy and multimorbidity have a higher risk of cardiovascular events (Figure) those who required many cardiovascular drugs derived the largest absolute reduction in the net clinical outcome when adding rivaroxaban on top of aspirin. The relative efficacy, safety, and net clinical benefit of adding low-dose rivaroxaban to aspirin in patients with stable vascular diseases were not affected by the number of cardiovascular drugs or by the number of comorbidities. Multimorbidity, but not polypharmacy, was related with a higher risk of major bleeding.

Conclusion

Addition of low-dose rivaroxaban conveyed a benefit irrespective of the number of concomitant drugs or comorbid conditions. Multiple comorbidities and/or polypharmacy should not dissuade the addition of low-dose rivaroxaban to aspirin in otherwise eligible patients.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): The COMPASS trial was funded by Bayer AG.

Vitamin K antagonists versus direct oral anticoagulants after cardiac surgery: a 31-country cohort study

Background

About 10% of patients undergoing cardiac surgery have a history of atrial fibrillation (AF). Among these patients, uncertainty exists regarding the safest and most effective oral anticoagulant (OAC) during the postoperative period.

Purpose

To evaluate practice patterns regarding OAC early after cardiac surgery in patients with a preoperative history of AF and to compare the safety and effectiveness of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs).

Methods

We conducted a nested cohort study within the Left Atrial Appendage Occlusion Study (LAAOS) III (NCT01561651). LAAOS III included patients with AF undergoing cardiac surgery with a CHA2DS2-VASC ≥2. In this substudy, we examined patients without end-stage renal dysfunction (eGFR &gt;30 mL/min/1.73m2) who were discharged on OAC. We evaluated bleeding and thromboembolism within 90 days postoperatively using logistic regression adjusting for CHA2DS2-VASC score.

Results

Recruitment started in 2012 and completed in 2018 in 113 centres in 31 countries. Of the 4811 patients enrolled in LAAOS III, 3725 (77%) were included in this substudy. Preoperatively, 58% of patients received OAC: 56% DOACs and 44% VKAs. At hospital discharge 23% received DOACs and 77% VKAs; 55% of patients on a DOAC at baseline were switched to a VKA while 5% of patients on a VKA were switched to a DOAC. Patients discharged on a DOAC were older, had a higher CHA2DS2-VASC, and were more likely to be male. Patients having undergone an isolated coronary bypass procedure were more likely prescribed DOACs than VKAs (41% vs 23%, p&lt;0.001) whereas isolated non-mechanical valve patients were more likely to be prescribed VKAs (43% vs 28%, p&lt;0.001). Switching from a DOAC to a VKA postoperatively occurred in 42% of patients In Australia/New Zealand, 49% in Europe, and 63% in North America. Major bleeding between 48 hours postoperatively and 30 days occurred in 1.5% in the DOAC group and 1.3% in the VKA group (aOR 1.14, 95% CI 0.60–2.15, p=0.69) while between 48 hours and 90 days, it occurred in 1.8% of patients in both groups (aOR 0.97, 95% CI, 0.54–1.17, p=0.91). Cardiac tamponade, the composite of stroke and systemic arterial embolism, and the composite of stroke, systemic arterial embolism and death did not differ significantly at 30 and 90 days between the DOAC and VKA groups.

Conclusions

VKAs was the dominant OAC used early after cardiac surgery, but postoperative OAC practices varied by region. After adjustment for CHA2DS2-VASC score, the early postoperative incidence of major bleeding and of the composite of stroke and systemic arterial embolism did not differ significantly when DOACs were compared with VKAs.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): CIHR, Heart and Stroke Foundation

Efficacy and safety of dronedarone by atrial fibrillation history duration: Insights from the ATHENA study

Background

Atrial fibrillation/atrial flutter (AF/AFL) burden increases with increasing duration of AF/AFL history.

Hypothesis

Outcomes with dronedarone may also be impacted by duration of AF/AFL history.

Methods

In this post hoc analysis of ATHENA, efficacy and safety of dronedarone vs placebo were assessed in groups categorized by time from first known AF/AFL episode to randomization (ie, duration of AF/AFL history): <3 months (short), 3 to <24 months (intermediate), and ≥ 24 months (long).

Results

Of 2859 patients with data on duration of AF/AFL history, 45.3%, 29.6%, and 25.1% had short, intermediate, and long histories, respectively. Patients in the long history group had the highest prevalence of structural heart disease and were more likely to be in AF/AFL at baseline. Placebo‐treated patients in the long history group also had the highest incidence of AF/AFL recurrence and cardiovascular (CV) hospitalization during the study. The risk of first CV hospitalization/death from any cause was lower with dronedarone vs placebo in patients with short (hazard ratio, 0.79 [95% confidence interval: 0.65‐0.96]) and intermediate (0.72 [0.56‐0.92]) histories; a trend favoring dronedarone was also observed in patients with long history (0.84 [0.66‐1.07]). A similar pattern was observed for first AF/AFL recurrence. No new drug‐related safety issues were identified.

Conclusions

Patients with long AF/AFL history had the highest burden of AF/AFL at baseline and during the study. Dronedarone significantly improved efficacy vs placebo in patients with short and intermediate AF/AFL histories. While exploratory, these results support the potential value in initiating rhythm control treatment early in patients with AF/AFL.

Impact of electrical cardioversion on quality of life for patients with symptomatic persistent atrial fibrillation: Is there a treatment expectation effect?

It is assumed that electrical cardioversion (ECV) improves the quality of life (QoL) of patients with atrial fibrillation (AF) by restoring sinus rhythm (SR).

OBJECTIVE

We examined the effect of ECV and rhythm status on QoL of patients with symptomatic persistent AF in a randomized controlled trial.

METHOD

The elective cardioversion for prevention of symptomatic atrial fibrillation trial examined the efficacy of dronedarone around the time of ECV in maintaining SR. Quality of life was measured with the University of Toronto Atrial Fibrillation Severity Scale. The primary outcome was the change in AF symptom severity (∆AFSS) score over 6 months (0-35 points, with higher scores reflecting worse QoL and a minimal clinically important difference defined as ∆AFSS ≥3 points). Multivariable linear regression was performed to identify factors associated with changes in QoL.

RESULTS

We included 148 patients with complete AFSS scores at baseline and 6 months. Over 6 months, QoL improved irrespective of rhythm status (ΔAFSS scores for patients who (i) maintained SR; (ii) had AF relapse after successful ECV; and (iii) had unsuccessful ECV were -6.8 ± 6.4 points, -4.1 ± 6.2 points, and -4.0 ± 5.8 points respectively, P < .01 for all subgroups). After adjustment of baseline covariates, maintenance of SR was associated with QoL improvement (ΔAFSS: -3.8 points, 95% CI: -6.0 to -1.6 points, P < .01).

CONCLUSIONS

Maintenance of SR was associated with clinically relevant improvement in patients' QoL at 6 months. Patients with AF recurrence had a small but still relevant improvement in their QoL, potentially due to factors other than sinus rhythm.

THU0063 DIFFERENTIAL PHARMACODYNAMIC EFFECTS OF ABATACEPT AND ADALIMUMAB ON THE SERUM PROTEOME OF PATIENTS WITH RA USING THE SOMASCAN® PLATFORM

Background:

Abatacept (ABA) versus adaliMumab (ADA) comParison in bioLogic-naïvERA subjects with background MTX (AMPLE) was a Phase IIIb clinical trial to compare the safety, efficacy and radiographic outcomes of ABA vs ADA in patients with RA who exhibited an inadequate response to MTX and who were naïve to biologic DMARDs.1While both therapies demonstrated similar efficacy across multiple outcomes, their mechanisms of action (MoAs) are quite different; ABA is a T-cell co-stimulation modulator and ADA is a TNFα inhibitor. Previous transcriptomic analysis of the whole blood samples showed differential pharmacodynamic (PD) effects between the treatments.1–3

Objectives:

To expand our understanding of differential PD changes in the serum proteome over time in patients treated with ABA or ADA in AMPLE using a novel proteomic platform.

Methods:

Serum was available from 440 patients in AMPLE at four time points (Days 1, 85, 365 and 729). Serum samples from the patients in AMPLE and 123 healthy individuals with matching demographics were subjected to proteomic quantification by a highly multiplexed DNA aptamer technology with wide dynamic ranges (SomaLogic SomaScan®platform).4A linear model analysis was used to identify protein abundance changes over time and changes specific to treatment. Other covariates included in the model were country of origin, ethnicity and sex. Additionally, patient effect was adjusted for as a random factor.

Results:

Both treatments exhibited a significant PD effect on serum proteome over the course of the 2-year trial, with 73 proteins modulated by ABA and 125 by ADA. There were large overlaps between the two treatments, including proteins associated with RA, such as C-X-C motif chemokine ligand 13 (CXCL13), matrix metalloproteinase-3 (MMP3) and serum amyloid A1/A2 (SAA1/2). Changes in the levels of these proteins may be indicative of general improvement of the disease. The proteins modulated by the treatments were enriched in the G-protein coupled receptor (GPCR) signalling and innate immunity pathways. Among the proteins that exhibited significantly different PD effects between the treatments were CRP, CC chemokine ligand 17 (CCL17) and β-defensin 112 (Figure). While patients showed marked improvement in their symptoms after 2 years of treatment, the overall serum proteomic profiles of the patients were still different from those of a normal healthy population.

Conclusion:

The SomaScan®platform provides a robust method for quantifying the PD change in a broad portion of the serum proteome in clinical trials. In AMPLE, abatacept was more selective than adalimumab in modulating protein biomarkers in patients with RA, though there was large overlap in proteins modulated by both treatments. The treatment-specific changes may reflect the different MoAs leading to similar clinical outcomes. While patients in both groups benefited from treatments, their serum proteome remained notably different from that of a healthy population. Further analysis by responder status may provide additional links between the treatment responses and proteomic changes. Proteomic approaches as described in our study could contribute to clinical trials and help shape treatment strategies for patients with RA.

References:

[1]Schiff M, et al.Ann Rheum Dis2014;73:86–94.

[2]Bandyopadhyay S, et al.Arthritis Rheum2014;66:Abstract 1520.

[3]Sokolove J, et al.Ann Rheum Dis2016;75:709–14.

[4]Gold L, et al.PLoS One2010;5:e15004.

Disclosure of Interests:

David Galbraith Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Minal Caliskan Employee of: Bristol-Myers Squibb, Omar Jabado Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Sarah Hu Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Roy Fleischmann Grant/research support from: AbbVie, Akros, Amgen, AstraZeneca, Bristol-Myers Squibb, Boehringer, IngelhCentrexion, Eli Lilly, EMD Serono, Genentech, Gilead, Janssen, Merck, Nektar, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Roche, Samsung, Sandoz, Sanofi Genzyme, Selecta, Taiho, UCB, Consultant of: AbbVie, ACEA, Amgen, Bristol-Myers Squibb, Eli Lilly, Gilead, GlaxoSmithKline, Novartis, Pfizer, Sanofi Genzyme, UCB, Michael Weinblatt Grant/research support from: Amgen, Bristol-Myers Squibb, Crescendo, Lily, Sanofi/Regeneron, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Crescendo, Gilead, Horizon, Lily, Pfizer, Roche, Sean Connolly Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Michael A Maldonado Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Sheng Gao Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb

SAT0104 MAINTENANCE OF SDAI REMISSION AND PATIENT-REPORTED OUTCOMES (PROS) FOLLOWING DOSE DE-ESCALATION OF ABATACEPT IN MTX-NAÏVE, ANTI-CITRULLINATED PROTEIN ANTIBODY (ACPA)+ PATIENTS WITH EARLY RA: RESULTS FROM AVERT-2, A RANDOMISED PHASE IIIB STUDY

Background:

The Phase IIIbAssessingVeryEarlyRATreatment (AVERT)-2 trial (NCT02504268) evaluated SC abatacept (ABA) + MTX vs ABA placebo (PBO) + MTX in ACPA+ patients (pts) with early, active RA.1Results from the 56-wk induction period (IP) showed a significantly greater proportion of pts treated with ABA + MTX (vs MTX alone) reported clinically meaningful improvements in HAQ-DI, global disease activity and pain, which were sustained at 52 wks.2

Objectives:

To report maintenance of SDAI remission and PROs from the AVERT-2 de-escalation (D-E) period.

Methods:

Pts received blinded SC ABA (125 mg once wkly [QW]) + MTX or ABA PBO + MTX induction treatment for 56 wks. In this analysis, pts who completed induction with ABA + MTX and had sustained SDAI remission (≤3.3 at Wks 40 and 52) were re-randomised 1:1:1 to ABA QW + MTX, stepwise D-E (ABA every other wk + MTX for 24 wks then ABA PBO + MTX for 24 wks), or ABA QW + MTX PBO for 48 wks in the D-E period. PROs included physical function (HAQ-DI [0–3; decrease=improvement] and Short-Form 36 [SF-36] v2.0 Physical Functioning Scale [PFS]; 0–100; increase=improvement), and fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue [FACIT-F] score; 0–52; decrease=improvement). Endpoints included: proportion of pts in SDAI remission and pts with HAQ-DI response (decrease from IP Day [D]1 in HAQ-DI ≥0.30); adjusted mean change (adMC) from D-E D1 in HAQ-DI, SF-36 PFS or FACIT-F to D-E Wk 48. adMCs were estimated using a mixed effect model with repeated measures.

Results:

147 ABA + MTX-treated pts were re-randomised in the D-E period. Across re-randomised arms, the range of mean scores was 1.87–2.52 for SDAI and 0.18–0.30 for HAQ-DI at entry into D-E period (D-E D1). 74% of pts receiving ABA QW + MTX maintained SDAI remission at D-E Wk 48 (Fig 1); this proportion was higher than in the ABA withdrawal and ABA QW + MTX PBO arms. Pts continuing ABA QW + MTX maintained HAQ-DI response during D-E (Fig 1), but by D-E Wk 48 the proportion of pts with HAQ-DI response in the ABA withdrawal arm declined by 30%. At D-E Wk 48, a small numerical decrease (adMC –0.04) in HAQ-DI was observed in the ABA QW + MTX arm; increases were seen in the withdrawal (adMC 0.26) and ABA QW + MTX PBO arms (adMC 0.16). By D-E Wk 48, SF-36 PFS increased (adMC 1.68) in the ABA QW + MTX arm but decreased in the withdrawal (adMC –3.34) and ABA QW + MTX PBO (adMC –1.45) arms. FACIT-F score increased during D-E in all arms, but the increase at D-E Wk 48 was lower in the ABA QW + MTX arm (adMC 0.79) vs the withdrawal (adMC 4.12) and ABA QW + MTX PBO (adMC 2.41) arms. Similar trends were seen for other PROs including Work Productivity and Activity Impairment-RA; while activity impairment remained stable in the ABA QW + MTX arm, there was a trend for worsening in the withdrawal arm.

Conclusion:

In the AVERT-2 D-E period, continued combination therapy (abatacept + MTX) resulted in maintenance of benefits on PROs, particularly physical functioning, in seropositive pts with early RA. D-E of abatacept followed by complete withdrawal was associated with the greatest loss of remission as well as worsening of PROs. The PRO results corresponded well to the maintenance of clinical (SDAI) remission.

References:

[1]Emery P, et al. ACR 2018; San Diego, USA: Poster 563.

[2]Emery P, et al. ACR 2019; Atlanta, USA: Poster 1423.

Acknowledgments:

Joanna Wright (medical writing, Caudex; funding: Bristol-Myers Squibb)

Disclosure of Interests:

Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor), 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, Vivian Bykerk: None declared, Thomas Huizinga Grant/research support from: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Consultant of: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Gustavo Citera Grant/research support from: AbbVie, Amgen, Eli Lilly, Gema, Genzyme, Novartis and Pfizer Inc, Consultant of: AbbVie, Amgen, Eli Lilly, Gema, Genzyme, Novartis and Pfizer Inc, Clifton Bingham Grant/research support from: Bristol-Myers Squibb, Consultant of: Bristol-Myers Squibb, Subhashis Banerjee Shareholder of: AbbVie, Bristol-Myers Squibb, Lily, Pfizer, Employee of: Bristol-Myers Squibb (current); AbbVie, Lily, Pfizer (past), Sean Connolly Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Joe Zhuo Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Robert Wong Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Kuan-Hsiang Gary Huang Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Karissa Lozenski Employee of: Bristol-Myers Squibb, Yedid Elbez Consultant of: Bristol-Myers Squibb, Roy Fleischmann Grant/research support from: AbbVie, Akros, Amgen, AstraZeneca, Bristol-Myers Squibb, Boehringer, IngelhCentrexion, Eli Lilly, EMD Serono, Genentech, Gilead, Janssen, Merck, Nektar, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Roche, Samsung, Sandoz, Sanofi Genzyme, Selecta, Taiho, UCB, Consultant of: AbbVie, ACEA, Amgen, Bristol-Myers Squibb, Eli Lilly, Gilead, GlaxoSmithKline, Novartis, Pfizer, Sanofi Genzyme, UCB

FRI0090 MAINTENANCE OF CLINICAL RESPONSE WITH ABATACEPT IN COMBINATION WITH MTX IN INDIVIDUAL PATIENTS WITH EARLY RA WHO ARE MTX-NAÏVE AND ANTI-CITRULLINATED PROTEIN ANTIBODY (ACPA)+: RESULTS FROM THE INDUCTION PERIOD OF AVERT-2, A RANDOMISED PHASE IIIB STUDY

Background:

In the 56-wk induction period (IP) of the Phase IIIbAssessingVeryEarlyRATreatment (AVERT)-2 trial (NCT02504268), more patients (pts) achieved SDAI remission (≤3.3) with abatacept (ABA) + MTX vs ABA placebo (PBO) + MTX at IP Wk 52.1It is unknown whether each individual pt within a treatment (Tx) group achieves and sustains the same efficacy endpoints at all time points during the IP.

Objectives:

To investigate whether ABA effectiveness is sustained by individual pts who achieved SDAI remission (≤3.3), SDAI low disease activity (LDA; >3.3–11), DAS28 (CRP) <2.6, ACR50/70 response or Boolean remission at IP Wk 24 (AVERT-2 primary endpoint) and both Wks 40 and 52 (Wks 40/52).

Methods:

Pts were randomised 3:2 to blinded SC ABA (125 mg/wk) + MTX or ABA PBO + MTX induction Tx for 56 wks. Key inclusion criteria: age ≥18 yrs; RA diagnosis (ACR/EULAR 2010 criteria); RA duration ≤6 mos; SDAI >11; ACPA+; CRP >3 mg/L or ESR ≥28 mm/h; TJC ≥3 and SJC ≥3; DMARD naïve. Response rates were investigated by Tx arm in the cohort 1 analysis population (all randomised pts treated in the IP [intent-to-treat analysis]).

Results:

Of randomised cohort 1, 752 pts were treated during the IP: 451 with ABA + MTX and 301 with ABA PBO + MTX. Baseline characteristics were similar across Tx arms.1Stringent SDAI remission endpoint at IP Wk 24 was achieved by 22% of ABA + MTX-treated pts; of these, 56% sustained SDAI remission at IP Wks 40/52 (Table). A similar proportion of ABA + MTX-treated pts achieved (17%) and sustained (58%) Boolean remission at IP Wks 24 and 40/52. At IP Wk 24, 42% of ABA + MTX-treated pts achieved DAS28 (CRP) <2.6 and 74% sustained DAS28 (CRP) <2.6 to IP Wks 40/52; a high proportion of patients sustained ACR50/70 responses at IP Wks 40/52 (83% and 79%, respectively). A lower proportion of pts sustained SDAI LDA to IP Wks 40/52 vs other endpoints (Table). Most efficacy endpoints were achieved by fewer pts who received ABA PBO + MTX than ABA + MTX (Table); among responders in this Tx group, fewer sustained remission at Wks 40/52, which correlates with a higher proportion of pts sustaining SDAI LDA at Wks 40/52 with ABA PBO + MTX than ABA + MTX.

Conclusion:

The majority of individual pts with RA who achieved clinically stringent endpoints such as SDAI remission, DAS28 (CRP) <2.6 or Boolean remission, as well as clinically meaningful endpoints such as ACR50/70 at IP Wk 24 with weekly SC abatacept, sustained their responses to Wks 40/52. The high proportion of patients achieving early stringent remission and response to SC abatacept by individual pts may be indicative of sustained efficacy over time.

References:

[1]Emery P, et al. ACR 2018; San Diego, USA: Poster 563.

Table .

Proportion of Pts With Response at IP Wk 24 Who Also Achieved Remission at Wks 40/52

EndpointResponders at IP Wk 24, n (%)Responders at IP Wk 24 and Wks 40/52, n/N (%)ABA + MTX(n=451)ABA PBO + MTX(n=301)ABA + MTX*ABA PBO + MTX*SDAI remission (≤3.3)100 (22)40 (13)56/100 (56)17/40 (43)SDAI low disease activity (>3.3–11)167 (37)82 (27)46/167 (28)32/82 (39)DAS28 (CRP) <2.6188 (42)78 (26)139/188 (74)43/78 (55)ACR50 response†260 (58)125 (42)215/260 (83)92/125 (74)ACR70 response†156 (35)66 (22)123/156 (79)42/66 (64)Boolean remission76 (17)29 (10)44/76 (58)8/29 (28)

*% based on number of pts within each Tx group who achieved response at IP Wk 24 (denominator);†Response at IP Wks 24 and 52

Acknowledgments:

Lola Parfitt (medical writing, Caudex; funding: Bristol-Myers Squibb)

Disclosure of Interests:

Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor), 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, Vivian Bykerk: None declared, Clifton Bingham Grant/research support from: Bristol-Myers Squibb, Consultant of: Bristol-Myers Squibb, Thomas Huizinga Grant/research support from: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Consultant of: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Gustavo Citera Grant/research support from: AbbVie, Amgen, Eli Lilly, Gema, Genzyme, Novartis and Pfizer Inc, Consultant of: AbbVie, Amgen, Eli Lilly, Gema, Genzyme, Novartis and Pfizer Inc, Kuan-Hsiang Gary Huang Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Sean Connolly Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Yedid Elbez Consultant of: Bristol-Myers Squibb, Robert Wong Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Karissa Lozenski Employee of: Bristol-Myers Squibb, Roy Fleischmann Grant/research support from: AbbVie, Akros, Amgen, AstraZeneca, Bristol-Myers Squibb, Boehringer, IngelhCentrexion, Eli Lilly, EMD Serono, Genentech, Gilead, Janssen, Merck, Nektar, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Roche, Samsung, Sandoz, Sanofi Genzyme, Selecta, Taiho, UCB, Consultant of: AbbVie, ACEA, Amgen, Bristol-Myers Squibb, Eli Lilly, Gilead, GlaxoSmithKline, Novartis, Pfizer, Sanofi Genzyme, UCB

FRI0576 IDENTIFICATION OF SERUM PROTEIN BIOMARKERS ASSOCIATED WITH RA DISEASE SEVERITY

Background:

RA is a systemic autoimmune disease with heterogeneous manifestation. Recent advances in serum proteomics, such as the SomaScan®platform (SomaLogic, Inc., Boulder, USA), allow for a deeper exploration of the protein biomarkers associated with RA and a better understanding of the molecular aetiology of the disease.

Objectives:

To characterise the differences in baseline serum proteome of patients with RA (enrolled in the Phase IIIb Abatacept vs adaliMumab comParison in bioLogic-naïvERA subjects with background MTX [AMPLE] study)1compared with a healthy population, and to identify serum protein biomarkers associated with disease severity and radiographic progression.

Methods:

Patients in the AMPLE study had an inadequate response to MTX and were naïve to biologic DMARDs. Protein abundance was assessed in baseline serum samples from 440 AMPLE study patients and 123 healthy individuals with matching demographics using the SomaScan®platform, with 5000+ slow off-rate modified aptamers and up to 8 log of dynamic range.2Differential abundance testing was performed using linear models to identify differences in protein abundance in patients with RA vs healthy individuals. A separate analysis using a linear model was conducted in only the patients with RA to identify the proteins associated with DAS28 (CRP) and TSS. Pathway analyses were performed for proteins significantly (false discovery rate-adjusted p value <0.05) associated with RA and the disease severity measurements to identify over-representation of the molecular pathways.

Results:

Compared with healthy individuals, >2000 serum proteins were significantly differentially expressed in patients with RA, including many proteins that have been associated with RA (e.g. serum amyloid A [SAA], CRP) and complement. Most of the protein expression differences were of small magnitude (fold change <2). Proteins that were differentially expressed between patients with RA and healthy individuals were enriched in interleukin signalling, neutrophil degranulation, platelet activation/degranulation and extracellular matrix organisation pathways. DAS28 (CRP) was significantly associated with several biomarkers, including SAA, fibrinogen and CRP; in general, proteins associated with DAS28 (CRP) were most strongly enriched in the platelet activation/degranulation pathways (Figure 1), also seen in patients with RA vs healthy individuals. Additionally, many proteins were significantly associated with TSS, including SAA, matrix metalloproteinase-3 and cartilage acidic protein 1. Here, the proteins were most strongly enriched in the extracellular matrix remodelling pathways (Figure 2).

Conclusion:

Our study revealed that thousands of serum proteins are differentially expressed and several pathways are dysregulated between patients with RA and healthy individuals. Additional pathways were identified that reflect disease severity, including joint damage, distinct from those pathways associated with the disease. The SomaScan®platform provides a unique proteomic tool with a wide dynamic range for the identification of serum protein biomarkers associated with RA and disease severity. Proteomic signatures should be considered in clinical trials to better understand disease pathogenesis and predict risk in response to treatment.

References:

[1]Schiff M, et al.Ann Rheum Dis2014;73:86–94.

[2]Gold L, et al.PLoS One2010;5:e15004.

Acknowledgments:

Rachel Rankin (medical writing, Caudex; funding: Bristol-Myers Squibb)

Disclosure of Interests:

David Galbraith Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Minal Caliskan Employee of: Bristol-Myers Squibb, Omar Jabado Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Sarah Hu Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Roy Fleischmann Grant/research support from: AbbVie, Akros, Amgen, AstraZeneca, Bristol-Myers Squibb, Boehringer, IngelhCentrexion, Eli Lilly, EMD Serono, Genentech, Gilead, Janssen, Merck, Nektar, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Roche, Samsung, Sandoz, Sanofi Genzyme, Selecta, Taiho, UCB, Consultant of: AbbVie, ACEA, Amgen, Bristol-Myers Squibb, Eli Lilly, Gilead, GlaxoSmithKline, Novartis, Pfizer, Sanofi Genzyme, UCB, Michael Weinblatt Grant/research support from: Amgen, Bristol-Myers Squibb, Crescendo, Lily, Sanofi/Regeneron, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Crescendo, Gilead, Horizon, Lily, Pfizer, Roche, Sean Connolly Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Michael A Maldonado Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Sheng Gao Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb

FRI0038 THE RELATIONSHIP BETWEEN ABATACEPT EXPOSURE AND EFFICACY MEASURES IN EARLY MTX-NAIVE ANTI-CITRULLINATED PROTEIN ANTIBODY-POSITIVE PATIENTS WITH RA DURING THE DE-ESCALATION PERIOD OF A PHASE IIIB STUDY

Background:

Although EULAR/ACR guidelines suggest tapering biologic treatment for RA following sustained remission in patients (pts), specific de-escalation (DE) regimens are not defined. The Phase IIIb Assessing Very Early Rheumatoid arthritis Treatment (AVERT)-2 trial (NCT02504268) is evaluating SC abatacept (ABA) + MTX versus ABA placebo (PBO) + MTX in Anti-Citrullinated Protein Antibody (ACPA)-positive pts with early (ACR/EULAR 2010 criteria; disease duration ≤6 mths), active RA (SDAI >11). AVERT-2 was designed to investigate achievement of SDAI remission and a clinically meaningful dose DE strategy among pts in sustained remission who completed induction with ABA + MTX. In moderately to severely active RA and JIA patients, a relationship between ABA Cmin and efficacy was observed. Therefore, this analysis in very early RA patients, reports on the pharmacokinetics (PK) and immunogenicity of ABA and the maintenance of remission during the DE period of AVERT-2.

Objectives:

To assess the relationship between changes in ABA exposure and the maintenance of remission and the effect of immunogenicity on exposure during the DE period of AVERT-2.

Methods:

Pts received blinded SC ABA (125 mg once wkly [QW]) + MTX or ABA PBO + MTX induction treatment for 56 wks. Pts who completed induction with ABA + MTX and had sustained SDAI remission (≤3.3 at Wks 40 and 52) were re-randomized 1:1:1 to ABA QW + MTX for 48 wks (Arm C), ABA every other wk (EOW) + MTX for 24 wks followed by ABA PBO + MTX for 24 wks (Arm D), or ABA QW + MTX PBO for 48 wks (Arm E) in the DE period. ABA trough (Cmin) and anti-drug antibody (ADA) samples were collected in all subjects during the DE period. Serum ABA concentrations and ADA were measured using a validated enzyme immunoassay method and an electrochemiluminescence assay, respectively. Efficacy endpoints included change from DE Day 1 in SDAI score, HAQ-DI score, Physician’s Global Assessment (PhGA), and tender (TJC) and swollen (SJC) joint counts. The relationship between ABA Cmin and efficacy endpoints were assessed. Additionally, the impact of immunogenicity on ABA Cmin was explored.

Results:

Mean ABA Cmin values remained stable throughout the DE period for subjects in Arms C and E. ABA Cmin values decreased by ~50% in subjects in Arm D for the first 24 weeks from the start of DE and were ~0 for weeks 24-48 consistent with the change in the frequency of ABA dosing from EOW to ABA withdrawal (Figure 1 top).

Figure 1:

Mean (SD) ABA Cmin values (top) and Mean Change From Baseline in SDAI (bottom) in Subjects in DE Arm C (ABA QW + MTX), D (ABA EOW + MTX followed by ABA placebo + MTX), and E (ABA QW + MTX placebo)

The incidence of immunogenicity appeared to increase upon withdrawal of ABA in Arm D. ADA formation did not appear to affect ABA Cmin, as ABA Cmin remained consistent between pts with and without ADA.

Upon withdrawal of ABA in Arm D, there appeared to be an increase in the mean change from baseline (Day 1 of DE) in SDAI over time, which followed a similar time course as the washout of ABA (Figure 1 bottom). Similar results were observed for other efficacy endpoints such as HAQ-DI, PhGA, TJC, and SJC.

Conclusion:

The PK data in these early onset, MTX-naive, ACPA+ RA pts correlated well with the maintenance of remission in Arms A and E. Tapering of ABA from EOW to MTX only in Arm D results in a corresponding decrease in ABA Cmin, an increase in positive antibody response, and loss of remission.

References:

[1]Emery et. al. ACR [Abstract L11]. Nov. 2019. Atlanta GA USA

[2]Li et. al. J Clin Pharmacol. Vol 59(2). Feb 2019.

Disclosure of Interests:

Yash Gandhi Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Sean Connolly Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Kuan-Hsiang Gary Huang Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Robert Wong Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Shannon Chilewski Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Bindu Murthy Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb

Restricted versus liberal intraoperative benzodiazepine use in cardiac anaesthesia for reducing delirium (B-Free Pilot): a pilot, multicentre, randomised, cluster crossover trial

BACKGROUND

Delirium is common after cardiac surgery and is associated with adverse outcomes. Perioperative benzodiazepine use is associated with delirium and is common during cardiac surgery, which may increase the risk of postoperative delirium. We undertook a pilot study to inform the feasibility of a large randomised cluster crossover trial examining whether an institutional policy of restricted benzodiazepine administration during cardiac surgery (compared with liberal administration) would reduce delirium.

METHODS

We conducted a two-centre, pilot, randomised cluster crossover trial with four 4 week crossover periods. Each centre was randomised to a policy of restricted or liberal use, and then alternated between the two policies during the remaining three periods. Our feasibility outcomes were adherence to each policy (goal ≥80%) and outcome assessment (one delirium assessment per day in the ICU in ≥90% of participants). We also evaluated the incidence of intraoperative awareness in one site using serial Brice questionnaires.

RESULTS

Of 800 patients undergoing cardiac surgery during the trial period, 127/800 (15.9%) had delirium. Of these, 355/389 (91.3%) received benzodiazepines during the liberal benzodiazepine periods and 363/411 (88.3%) did not receive benzodiazepines during the restricted benzodiazepine periods. Amongst the 800 patients, 740 (92.5%) had ≥1 postoperative delirium assessment per day in the ICU. Of 521 patients screened for intraoperative awareness, one patient (0.2%), managed during the restricted benzodiazepine period (but who received benzodiazepine), experienced intraoperative awareness.

CONCLUSIONS

This pilot study demonstrates the feasibility of a large, multicentre, randomised, cluster crossover trial examining whether an institutional policy of restricted vs liberal benzodiazepine use during cardiac surgery will reduce postoperative delirium.

CLINICAL TRIAL REGISTRATION

NCT03053869.

The mechanical responses of advecting cells in confined flow

Fluid dynamics have long influenced cells in suspension. Red blood cells and white blood cells are advected through biological microchannels in both the cardiovascular and lymphatic systems and, as a result, are subject to a wide variety of complex fluidic forces as they pass through. In vivo, microfluidic forces influence different biological processes such as the spreading of infection, cancer metastasis, and cell viability, highlighting the importance of fluid dynamics in the blood and lymphatic vessels. This suggests that in vitro devices carrying cell suspensions may influence the viability and functionality of cells. Lab-on-a-chip, flow cytometry, and cell therapies involve cell suspensions flowing through microchannels of approximately 100-800  μ m. This review begins by examining the current fundamental theories and techniques behind the fluidic forces and inertial focusing acting on cells in suspension, before exploring studies that have investigated how these fluidic forces affect the reactions of suspended cells. In light of these studies' findings, both in vivo and in vitro fluidic cell microenvironments shall also be discussed before concluding with recommendations for the field.

P4784Efficacy and safety of dronedarone by duration of atrial fibrillation history: a post-hoc analysis of the ATHENA trial

Background

Atrial fibrillation (AF) is known to progress over time and the effectiveness of antiarrhythmic therapy may vary based on the duration of a patient's AF history. Outcomes with dronedarone (DRO) based on duration of AF/atrial flutter (AFL) history have not been previously characterized.

Purpose

To evaluate the efficacy and safety of DRO by time since first known AF/AFL episode in patients studied in the ATHENA trial.

Methods

2859 (61.8%) patients from ATHENA with documented first known AF/AFL episode (of 4628 total patients randomized) were included in the analysis. Among these patients, first AF/AFL episode was reported at <3 months (shorter history), 3 to <24 months (intermediate), and ≥24 months (longer) in 1296 (45.3%), 845 (29.6%) and 718 (25.1%) patients, respectively. AF/AFL recurrence was evaluated in patients in sinus rhythm at baseline by ECG during study visits or symptom recurrence.

Results

Demographics (age, sex) were similar across all groups. Patients with longer AF/AFL history tended to have higher prevalence of coronary heart disease and structural heart disease; and were more likely to have AF/AFL (by 12-lead ECG) at baseline (30%) compared to 26% and 16% for intermediate and shorter history groups. Patients with a longer AF history likely had a prior ablation for AF/AFL (7%) vs patients with an intermediate (2%) or shorter AF/AFL history (1%), and more likely required cardioversion during the study (24%) vs intermediate (17%) and shorter history groups (11%). Outcomes and efficacy are reported in Table 1. Rates of treatment-emergent adverse events (TEAEs), serious TEAEs, permanent drug discontinuations, and deaths were similar across all AF/AFL groups.

Table 1. Outcomes and efficacy summary Relative Risk, dronedarone (DRO) vs placebo (PBO)1 (95% CI)1,2 AF/AFL <3 months AF/AFL 3 to <24 months AF/AFL ≥24 months PBO (n=626) DRO (n=670) PBO (n=429) DRO (n=416) PBO (n=363) DRO (n=355) First CV hospitalization3 or death (any cause) 0.79 (0.65, 0.96) 0.72 (0.56, 0.92) 0.84 (0.66, 1.07) First CV hospitalization 0.78 (0.64, 0.96) 0.70 (0.55, 0.91) 0.82 (0.63, 1.05) Death (any cause) 0.82 (0.54, 1.24) 0.85 (0.43, 1.68) 1.13 (0.61, 2.10) First AF/AFL recurrence4 0.80 (0.65, 0.97) 0.67 (0.53, 0.84) 0.81 (0.65, 1.02) 1Cox regression model. 2On study period, all randomized patients. 3Main reason was AF/other supraventricular rhythm disorders. 4On selected patients in sinus rhythm at baseline (AF/AFL <3 months: PBO n=514, DRO n=529; 3 to <24 months: PBO n=288, DRO n=312; ≥24 months: PBO n=252, DRO n=250). CV = Cardiovascular.

Conclusions

Nearly half the patients in ATHENA had a shorter history (<3 months) of AF/AFL prior to randomization. Patients with a longer history of AF/AFL had a greater burden of AF/AFL based on baseline rhythm status, ablation history, and cardioversions required post randomization. Despite these differences, clinical outcomes, efficacy, and safety of DRO appeared to be generally consistent irrespective of duration of AF/AFL history.

Acknowledgement/Funding

Sanofi, New York, New York, United States of America