1
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Gehin JE, Goll GL, Brun MK, Jani M, Bolstad N, Syversen SW. Assessing Immunogenicity of Biologic Drugs in Inflammatory Joint Diseases: Progress Towards Personalized Medicine. BioDrugs 2022; 36:731-748. [PMID: 36315391 PMCID: PMC9649489 DOI: 10.1007/s40259-022-00559-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 11/30/2022]
Abstract
Biologic drugs have greatly improved treatment outcomes of inflammatory joint diseases, but a substantial proportion of patients either do not respond to treatment or lose response over time. Drug immunogenicity, manifested as the formation of anti-drug antibodies (ADAb), constitute a significant clinical problem. Anti-drug antibodies influence the pharmacokinetics of the drug, are associated with reduced clinical efficacy, and an increased risk of adverse events such as infusion reactions. The prevalence of ADAb differs among drugs and diseases, and the detection of ADAb also depends on the assay format. Most data exist for the tumor necrosis factor-alpha inhibitors infliximab and adalimumab, with a frequency of ADAb that ranges from 10 to 60% across studies. Measurement of ADAb and serum drug concentrations, therapeutic drug monitoring, has been suggested as a strategy to optimize therapy with biologic drugs. Although the recent randomized clinical Norwegian Drug Monitoring (NOR-DRUM) trials show promise towards a personalized medicine prescribing approach by therapeutic drug monitoring, several challenges remain. A plethora of assay formats, with widely differing properties, is currently used for measuring ADAb. Comparing results between different assays and laboratories is difficult, which complicates the development of cut-offs necessary for guidelines and the implementation of ADAb measurements in clinical practice. With the possible exception of infliximab, limited data on clinical relevance and cost effectiveness exist to support therapeutic drug monitoring as a routine clinical strategy to monitor biologic drugs in inflammatory joint diseases. The aim of this review is to provide an overview of the characteristics and prevalence of ADAb, predisposing factors to ADAb formation, commonly used assessment methods, clinical consequences of ADAb, and the potential implications of ADAb assessments for everyday treatment of inflammatory joint diseases.
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Affiliation(s)
- Johanna Elin Gehin
- Department of Medical Biochemistry, Oslo University Hospital, Radiumhospitalet, Nydalen, Box 4953, 0424, Oslo, Norway.
| | - Guro Løvik Goll
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Marthe Kirkesæther Brun
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Meghna Jani
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, UK
- Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford, UK
| | - Nils Bolstad
- Department of Medical Biochemistry, Oslo University Hospital, Radiumhospitalet, Nydalen, Box 4953, 0424, Oslo, Norway
| | - Silje Watterdal Syversen
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
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2
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Krieckaert C, Hernández-Breijo B, Gehin JE, le Mélédo G, Balsa A, Jani M, Mulleman D, Navarro-Compan V, Wolbink G, Isaac J, van Tubergen A. Therapeutic drug monitoring of biopharmaceuticals in inflammatory rheumatic and musculoskeletal disease: a systematic literature review informing EULAR points to consider. RMD Open 2022; 8:e002216. [PMID: 35980738 PMCID: PMC9171282 DOI: 10.1136/rmdopen-2022-002216] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/18/2022] [Indexed: 01/08/2023] Open
Abstract
The objectives of this review were to collect and summarise evidence on therapeutic drug monitoring (TDM) of biopharmaceuticals in inflammatory rheumatic and musculoskeletal diseases and to inform the EULAR Task Force for the formulation of evidence-based points to consider. A systematic literature review (SLR) was performed, covering technical aspects and (clinical) utility of TDM, to answer 13 research questions. MEDLINE, Embase and Cochrane were searched until July 2020. American College of Rheumatology and EULAR abstracts were also considered for inclusion. Data were extracted in evidence tables and risk of bias assessment was performed. For the search on technical aspects, 678 records were identified, of which 22 papers were selected. For the clinical utility search, 3846 records were identified, of which 108 papers were included. Patient-related factors associated with biopharmaceutical blood concentrations included body weight, methotrexate comedication and disease activity. The identification of a target range was hampered by study variability, mainly disease activity measures and study type. Evidence was inconsistent for multiple clinical situations in which TDM is currently applied. However, for some particular scenarios, including prediction of future treatment response, non-response to treatment, tapering and hypersensitivity reactions, robust evidence was found. There is currently no evidence for routine use of proactive TDM, in part because published cost-effectiveness analyses do not incorporate the current landscape of biopharmaceutical costs and usage. This SLR yields evidence in favour of TDM of biopharmaceuticals in some clinical scenarios, but evidence is insufficient to support implementation of routine use of TDM.
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Affiliation(s)
- Charlotte Krieckaert
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Reade, Amsterdam, The Netherlands
| | | | - Johanna Elin Gehin
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | | | | | - Meghna Jani
- Centre for Epidemiology versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
- department of Rheumatology, Salford Royal Hospitals NHS Trust, Salford, UK
| | | | | | - Gertjan Wolbink
- Immunopathology, Sanquin Research, Amsterdam, The Netherlands
| | - John Isaac
- Translational and Clinical Research Institute, Newcastle University and Musculoskeletal Unit, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Astrid van Tubergen
- department of Medicine, Division of Rheumatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
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3
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Sugano E, Tanaka E, Inoue E, Sakai R, Abe M, Saka K, Sugitani N, Ochiai M, Yamaguchi R, Higuchi Y, Sugimoto N, Ikari K, Nakajima A, Yamanaka H, Harigai M. Differences in patients' population and efficacy/effectiveness of biologic disease-modifying antirheumatic drugs between randomized controlled trials and real-world settings in patients with rheumatoid arthritis - using the IORRA cohort. Mod Rheumatol 2021; 32:675-685. [PMID: 34918127 DOI: 10.1093/mr/roab067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/24/2021] [Accepted: 08/14/2021] [Indexed: 11/14/2022]
Abstract
OBJECTIVES To evaluate the differences in patients' population and efficacy/effectiveness of biological disease-modifying antirheumatic drugs (bDMARDs) between randomized controlled trials (RCTs) and clinical practice in patients with rheumatoid arthritis. METHODS We reviewed inclusion criteria in Phase II or III RCTs of bDMARDs conducted in Japan. The Institute of Rheumatology, Rheumatoid Arthritis study participants during the period when each RCT was conducted (Cohort A) and new bDMARD users at our institute in 2016 (Cohort B) were assessed for the fulfilment of the inclusion criteria. The effectiveness of bDMARDs in our cohort and their efficacy in RCTs were compared using the inverse-variance method. RESULTS Nineteen RCTs were selected. The mean proportions of patients fulfilling all inclusion criteria of each RCT in Cohorts A and B were 2.3% and 7.6%, respectively. The pooled proportion ratios (95% confidence interval) for achieving the American College of Rheumatology 20 (ACR20), ACR50, ACR70, and disease activity score 28 remission in non-eligible cases for eight RCTs versus all corresponding RCTs were 0.38 (0.30-0.51), 0.41 (0.30-0.57), 0.54 (0.35-0.82), and 1.28 (1.10-1.56), respectively. CONCLUSIONS Few rheumatoid arthritis patients fulfilled the inclusion criteria of the RCTs in clinical settings. There was a difference in the efficacy/effectiveness of bDMARDs between RCTs and clinical practice.
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Affiliation(s)
- Eri Sugano
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Shinjuku-ku, Tokyo, Japan.,Department of Rheumatology, Institute of Rheumatology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Eiichi Tanaka
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Shinjuku-ku, Tokyo, Japan.,Department of Rheumatology, Institute of Rheumatology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Eisuke Inoue
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Shinjuku-ku, Tokyo, Japan.,Research Administration Center, Showa University, Tokyo, Japan
| | - Ryoko Sakai
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Shinjuku-ku, Tokyo, Japan.,Division of Multidisciplinary Management of Rheumatic Diseases, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Mai Abe
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Shinjuku-ku, Tokyo, Japan.,Department of Rheumatology, Institute of Rheumatology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Kumiko Saka
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Shinjuku-ku, Tokyo, Japan.,Department of Rheumatology, Institute of Rheumatology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Naohiro Sugitani
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Shinjuku-ku, Tokyo, Japan.,Department of Rheumatology, Institute of Rheumatology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Moeko Ochiai
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Shinjuku-ku, Tokyo, Japan.,Department of Rheumatology, Institute of Rheumatology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Rei Yamaguchi
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Shinjuku-ku, Tokyo, Japan.,Department of Rheumatology, Institute of Rheumatology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Yoko Higuchi
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Shinjuku-ku, Tokyo, Japan.,Department of Rheumatology, Institute of Rheumatology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Naoki Sugimoto
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Shinjuku-ku, Tokyo, Japan.,Department of Rheumatology, Institute of Rheumatology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Katsunori Ikari
- Division of Multidisciplinary Management of Rheumatic Diseases, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Department of Orthopedic Surgery, Institute of Rheumatology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Ayako Nakajima
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Shinjuku-ku, Tokyo, Japan.,Center for Rheumatic Diseases, Mie University Hospital, Mie, Japan
| | - Hisashi Yamanaka
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Shinjuku-ku, Tokyo, Japan.,Department of Rheumatology, Sanno Medical Center, Tokyo, Japan.,Department of Rheumatology, International University of Health and Welfare, Chiba, Japan
| | - Masayoshi Harigai
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Shinjuku-ku, Tokyo, Japan.,Department of Rheumatology, Institute of Rheumatology, Tokyo Women's Medical University Hospital, Tokyo, Japan
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4
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Gandhi Y, Passarell JA, Roy A, Murthy B. Model-Based Selection and Recommendation for Subcutaneous Abatacept Dose in Patients With Polyarticular Juvenile Idiopathic Arthritis. J Clin Pharmacol 2021; 61:688-699. [PMID: 33284480 PMCID: PMC8048692 DOI: 10.1002/jcph.1797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/01/2020] [Indexed: 12/04/2022]
Abstract
The selective T‐cell costimulation modulator abatacept is approved for treatment of adult rheumatoid arthritis (RA) and polyarticular juvenile idiopathic arthritis (pJIA; 6‐17 years [intravenous] and 2‐17 years [subcutaneous]). An extrapolation approach was taken to determine subcutaneous weight‐tiered doses of abatacept to evaluate in patients with pJIA. Population pharmacokinetic (PPK) and exposure‐response (E‐R) analyses were conducted to determine whether the weight‐tiered subcutaneous regimen provides near‐maximal efficacy and is therapeutically comparable to the intravenous regimen in patients with pJIA aged 2‐17 years. Combined study data from intravenous or subcutaneous abatacept were used to assess clinically relevant exposure outcomes. The PPK model was developed with data from 13 phase 2/3 studies in RA and pJIA; the E‐R model for the American College of Rheumatology pediatric scores (JIA‐ACR 30/50/70/100 responses) in month 4 was developed with data from 2 phase 3 pJIA studies. Predefined covariates were investigated in both analyses. PPK model‐predicted exposures were steady‐state peak, trough (Cminss), and time‐averaged concentrations. Abatacept PK was characterized by a linear 2‐compartment model (zero‐order intravenous infusion, first‐order subcutaneous absorption, first‐order elimination); body weight was the only clinically relevant covariate. Cminss was the best exposure predictor for the JIA‐ACR response: log odds for response increased in proportion to log‐transformed Cminss; JIA‐ACR30 approached a plateau when Cminss ≥ 10 μg/mL. The PPK and E‐R analyses demonstrated that the weight‐tiered subcutaneous and intravenous abatacept dosing regimens provide near‐maximal efficacy and are clinically comparable across children with pJIA who are > 2 years old.
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Affiliation(s)
- Yash Gandhi
- Bristol Myers Squibb, Princeton, New Jersey, USA
| | | | - Amit Roy
- Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Bindu Murthy
- Bristol Myers Squibb, Princeton, New Jersey, USA
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5
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Rachid O, Osman A, Abdi R, Haik Y. CTLA4-Ig (abatacept): a promising investigational drug for use in type 1 diabetes. Expert Opin Investig Drugs 2020; 29:221-236. [PMID: 32031422 DOI: 10.1080/13543784.2020.1727885] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction: Type 1 diabetes (T1D) is an autoimmune disease that results from the destruction of insulin-producing beta cells in the pancreas; it leads to the under or nonproduction of insulin. T1D is associated with numerous life-threatening micro- and macro-vascular complications and early deaths, hence the development of preventative strategies is a priority for research.Areas covered: The authors outline the drawbacks of available treatments for T1D and assess the three key strategies for prevention, including immunomodulatory therapies which hold the most potential. This article examines CTLA4-Ig and its efficacy and safety profiles. Finally, the pharmacokinetic parameters and pharmacodynamic markers of abatacept are shown in vivo and in clinical trials, guiding dosage regimen recommendations for future investigational studies.Expert opinion: Immunomodulation is one of the promising strategies for decelerating the progression of beta-cell destruction after the onset of T1D. It holds the advantage of specific immune modulation without systemic general immunosuppression. Preclinical and clinical studies have yielded promising data on the use of CTLA4-Ig in T1D. Variations in response to CTLA4-Ig might be partially explained by the existence of multiple T1D subtypes with varying baseline innate inflammatory/regulatory bias and the rate of C-peptide decline.
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Affiliation(s)
- Ousama Rachid
- Department of Pharmaceutical Sciences, College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Aisha Osman
- Department of Pharmaceutical Sciences, College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Reza Abdi
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yousef Haik
- Sustainable Development, College of Science and Engineering, Hamad Bin Khalifa University, Doha, Qatar
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6
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Ogawa N, Ohashi H, Ota Y, Kobori K, Suzuki M, Tsuboi S, Hayakawa M, Goto Y, Karahashi T, Kimoto O, Miyamoto T, Furukawa S, Shimoyama K, Suzuki D, Maekawa Y. Multicenter, observational clinical study of abatacept in Japanese patients with rheumatoid arthritis. Immunol Med 2019; 42:29-38. [PMID: 31067155 DOI: 10.1080/25785826.2019.1605036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
The aim of this study was to assess abatacept in rheumatoid arthritis (RA) patient. Patients (20 men, 89 women, aged 61.9 ± 10.4 y) who responded inadequately to conventional synthetic disease-modifying anti-rheumatic drug were treated with abatacept for 24-months. Disease activity score in 28 joints (DAS28-CRP) was evaluated. Of 109 patients, 82 (75.2%) were on methotrexate (MTX; mean dosage 9.0 ± 2.7 mg/week); 48 (44.0%) were naive to biologics and 61 (56.0%) had failed biologics. The 1- and 2-year retention rates were 77% and 53%, respectively. At 24-months, the DAS28-CRP remission rates were 54.5% in the biologic-naïve patients, and 28.2% in the biologic-failure patients (p < .01), while the structural remission rates were 83.9% and 73.1%, respectively (p = .461). Abatacept was equally effective in RA patients who were and were not on concomitant MTX. Biologic-naïve was associated with better clinical outcome. Abatacept was effective in patients who showed decreasing anti-CCP antibody titers or serum MMP-3 levels during treatment. Infection was the most frequent adverse effect of abatacept therapy. In conclusion, abatacept is more effective in biologic-naïve than in biologic-failure RA patients with or without concomitant use of MTX. Abatacept is more effective in RA patients with than without decreasing serum MMP-3 or anti-CCP antibody titers during treatment.
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Affiliation(s)
- Noriyoshi Ogawa
- a Division of Immunology and Rheumatology, Department of Internal Medicine 3 , Hamamatsu University School of Medicine , Hamamatsu-City , Japan
| | - Hiroyuki Ohashi
- b Department of Rheumatology, Omaezaki Municipal Hospital , Omaezaki-City , Japan
| | | | - Kaori Kobori
- d Kobori Orthopedic Clinic , Hamamatsu-City , Japan
| | - Motohiro Suzuki
- e Department of Orthopedic Surgery , Hamamatsu University School of Medicine , Hamamatsu , Japan
| | - Seiji Tsuboi
- f Department of Rheumatology, Shizuoka Kosei Hospital , Shizuoka-City , Japan
| | | | | | - Taro Karahashi
- i Department of Rheumatology, Fujieda Municipal Hospital , Fujieda , Japan
| | | | - Toshiaki Miyamoto
- k Department of Rheumatology, Seirei Hamamatsu General Hospital , Hamamatsu , Japan
| | - Shogo Furukawa
- a Division of Immunology and Rheumatology, Department of Internal Medicine 3 , Hamamatsu University School of Medicine , Hamamatsu-City , Japan
| | - Kumiko Shimoyama
- a Division of Immunology and Rheumatology, Department of Internal Medicine 3 , Hamamatsu University School of Medicine , Hamamatsu-City , Japan
| | - Daisuke Suzuki
- a Division of Immunology and Rheumatology, Department of Internal Medicine 3 , Hamamatsu University School of Medicine , Hamamatsu-City , Japan
| | - Yuichiro Maekawa
- a Division of Immunology and Rheumatology, Department of Internal Medicine 3 , Hamamatsu University School of Medicine , Hamamatsu-City , Japan
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7
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Nielsen CB, Nielsen C, Nybo M, Just SA, Vinholt PJ. The in vitro effect of antirheumatic drugs on platelet function. Platelets 2019; 31:248-257. [PMID: 31046542 DOI: 10.1080/09537104.2019.1609665] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Several antirheumatic drugs lower the cardiovascular risk among rheumatoid arthritis patients. It is, however, unknown whether inhibition of platelet function contributes to this risk reduction. Only few studies have investigated the potential role of platelets as a target of antirheumatic drugs. In this study, platelet function was tested in vitro in samples from 24 healthy individuals spiked with antirheumatic drugs in clinically relevant concentrations or vehicle. Platelet aggregation was tested with 96-well light transmission aggregometry (LTA), and when an effect ≥20% compared to vehicle was observed, flow cytometric platelet aggregation and activation were evaluated and closure time was measured by Platelet Function Analyzer (PFA-200). When evaluated by LTA, teriflunomide (the active metabolite of leflunomide), tocilizumab, and prednisolone reduced ADP- and collagen-induced platelet aggregation ≥20%, while adalimumab increased TRAP-induced platelet aggregation ≥20%. Using flow cytometry, agonist-induced platelet aggregation with teriflunomide or vehicle was mean ± standard deviation (SD); 30.7% ± 5.8 vs. 41.7% ± 6.5, p = 0.02 using ADP, and 34.7% ± 13.9 vs. 55.8% ± 3.9, p = 0.01 using collagen. Results indicate that teriflunomide, prednisolone, and tocilizumab inhibit, and adalimumab increases platelet aggregation. The study suggests that the majority of antirheumatic drugs mainly reduced cardiovascular risk through indirect effects (e.g., reducing inflammation).
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Affiliation(s)
| | - Christian Nielsen
- Department of Clinical Immunology, Odense University Hospital, Odense, Denmark
| | - Mads Nybo
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | | | - Pernille Just Vinholt
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
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8
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Hara R, Umebayashi H, Takei S, Okamoto N, Iwata N, Yamasaki Y, Nakagishi Y, Kizawa T, Kobayashi I, Imagawa T, Kinjo N, Amano N, Takahashi Y, Mori M, Itoh Y, Yokota S. Intravenous abatacept in Japanese patients with polyarticular-course juvenile idiopathic arthritis: results from a phase III open-label study. Pediatr Rheumatol Online J 2019; 17:17. [PMID: 31039807 PMCID: PMC6492394 DOI: 10.1186/s12969-019-0319-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 04/11/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND To investigate efficacy and safety of intravenous abatacept in Japanese patients with active polyarticular-course juvenile idiopathic arthritis (pJIA). METHODS In this phase III, open-label, multicenter, single-arm study, patients with pJIA aged 4-17 years who failed ≥1 biologic or methotrexate received weight-tiered (< 75 kg: 10 mg/kg; 75-100 kg: 750 mg; > 100 kg: 1000 mg) intravenous abatacept at Weeks 0, 2, 4, and every 4 weeks thereafter. The study comprised a short-term period (16 weeks) and ongoing long-term period. Primary endpoint: Week 16 JIA-American College of Rheumatology criteria 30 (JIA-ACR30) response rate. Secondary endpoints/outcomes included Week 16 JIA-ACR50/70/90 response and inactive disease rates, Childhood Health Assessment Questionnaire-Disability Index (CHAQ-DI), pharmacokinetics, safety, and immunogenicity. Proportions of patients achieving Juvenile Arthritis Disease Activity Score in 27 joints using C-reactive protein (JADAS27-CRP) remission (score < 1) and minimal disease activity (MDA; score < 3.8), were among exploratory endpoints. RESULTS All 20 patients who received study medication completed the short-term period. During the long-term period, two patients discontinued due to insufficient efficacy or patient decision. Median age and disease duration at baseline were 10.5 and 0.75 years, respectively. Week 16 JIA-ACR30 response rate (primary endpoint) was 90.0% (18/20). JIA-ACR50/70/90 response and inactive disease rates at Week 16 were 75.0% (15/20), 70.0% (14/20), 35.0% (7/20), and 25.0% (5/20), respectively. At Week 52, JIA-ACR30/50/70/90 response and inactive disease rates were observed by 88.9% (16/18), 88.9% (16/18), 83.3% (15/18), 66.7% (12/18) and 44.4% (8/18), respectively. CHAQ-DI improved after Week 12. JADAS27-CRP remission and MDA were achieved by 15.0% (3/20) and 45.0% (9/20) of patients at Week 16, and by 50.0% (9/18) and 78.0% (14/18) of patients at Week 52, respectively. The mean abatacept pre-dose serum concentration was above the target therapeutic exposure (10 μg/ml) from Week 8 through Week 16. All adverse events were of mild/moderate intensity, except for one case of severe gastroenteritis. No deaths, malignancies, or autoimmune disorders were observed. No antidrug antibodies were detected through Week 16; one patient had a positive immunogenic response during the cumulative period. CONCLUSION Intravenous abatacept was efficacious and well tolerated in Japanese patients with active pJIA. TRIAL REGISTRATION ClinicalTrials.gov: NCT01835470 . Date of registration: April 19, 2013.
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Affiliation(s)
- Ryoki Hara
- Department of Pediatrics, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama-shi, Kanagawa, 236-0004, Japan.
| | - Hiroaki Umebayashi
- 0000 0004 0471 4457grid.415988.9Department of General Pediatrics, Miyagi Children’s Hospital, 4-3-17 Ochiai, Aoba-ku, Sendai-shi, Miyagi 989-3126 Japan
| | - Syuji Takei
- 0000 0004 0377 8088grid.474800.fDepartment of Pediatrics, Kagoshima University Medical and Dental Hospital, 8−35−1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8544 Japan
| | - Nami Okamoto
- 0000 0001 2109 9431grid.444883.7Department of Pediatrics, Graduate School of Medicine, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki-shi, Osaka, 569-8686 Japan
| | - Naomi Iwata
- Department of Immunology and Infectious Diseases, Aichi Children’s Health and Medical Center, 1-2 Osakata, Morioka-cho, Oobu-shi, Aichi 474-8710 Japan
| | - Yuichi Yamasaki
- 0000 0004 0377 8088grid.474800.fDepartment of Pediatrics, Kagoshima University Medical and Dental Hospital, 8−35−1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8544 Japan
| | - Yasuo Nakagishi
- grid.415413.6Department of Pediatric Rheumatology, Hyogo Prefectural Kobe Children’s Hospital, 1-6-7 Minamimachi, Minatojima, Chuo-ku, Kobe-shi, Hyogo 650-0047 Japan
| | - Toshitaka Kizawa
- Department of Pediatrics, Japan Community Health Care Organization Sapporo Hokushin Hospital, 1-2, 2-jo, 6-chrome, Atsubetsu-chuo, Atsubetsu-ku, Sapporo-shi, Hokkaido 004-8618 Japan
| | - Ichiro Kobayashi
- 0000 0004 0378 6088grid.412167.7Department of Pediatrics, Hokkaido University Hospital, North-15, West-7, Sapporo-shi, Hokkaido 060-8638 Japan
| | - Tomoyuki Imagawa
- 0000 0004 0377 7528grid.414947.bDivision of Infection, Immunology and Rheumatology, Kanagawa Prefectural Hospital Organisation Kanagawa Children’s Medical Center, 2-138-4 Mutsukawa, Minami-ku, Yokohama-shi, Kanagawa 232-8555 Japan
| | - Noriko Kinjo
- grid.412961.9Department of Pediatrics, University of the Ryukyus Hospital, 207 Aza Uehara, Nishihara-cho, Nakagami-gun, Okinawa, 903-0215 Japan
| | - Norihito Amano
- Bristol-Myers Squibb K.K, 6-5-1 Nishi-Shinjuku, Shinjuku-ku, Tokyo, 163-1328 Japan
| | - Yoko Takahashi
- Bristol-Myers Squibb K.K, 6-5-1 Nishi-Shinjuku, Shinjuku-ku, Tokyo, 163-1328 Japan
| | - Masaaki Mori
- 0000 0001 1014 9130grid.265073.5Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510 Japan
| | - Yasuhiko Itoh
- 0000 0001 2173 8328grid.410821.eDepartment of Pediatrics, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603 Japan
| | - Shumpei Yokota
- Fuji Toranomon Orthopaedics Hospital, 1067-1 Kawashimata, Gotenba-shi, Shizuoka, 412-0045 Japan
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Matsubara T, Inoue H, Nakajima T, Tanimura K, Sagawa A, Sato Y, Osano K, Nagano S, Ueki Y, Hanyu T, Hashizume K, Amano N, Tanaka Y, Takeuchi T. Abatacept in combination with methotrexate in Japanese biologic-naive patients with active rheumatoid arthritis: a randomised placebo-controlled phase IV study. RMD Open 2018; 4:e000813. [PMID: 30622737 PMCID: PMC6307574 DOI: 10.1136/rmdopen-2018-000813] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 11/02/2018] [Accepted: 11/04/2018] [Indexed: 12/15/2022] Open
Abstract
Objectives To evaluate efficacy and safety of abatacept+methotrexate (MTX) in biologic-naive, anticitrullinated protein antibody (ACPA)-positive Japanese patients with active rheumatoid arthritis (RA) and early erosion versus placebo+MTX. Methods In this phase IV, multicentre, double-blind study (NCT01758198), patients were randomised (1:1) to receive intravenous abatacept (~10 mg/kg) or placebo, plus MTX (≥6 mg/week). Primary efficacy objectives were to compare American College of Rheumatology 20 (ACR20) response rates at week 16 and mean change from baseline in van der Heijde-modified total Sharp score (vdH-mTSS) at week 24 between abatacept+MTX and placebo+MTX groups. Results Overall, 203 and 202 patients received abatacept+MTX and placebo+MTX, respectively. At week 16, ACR20 response rates were higher in the abatacept (75.4%) versus placebo group (27.7%; p<0.001). Mean change from baseline in vdH-mTSS at week 24 was 0.84 in the abatacept and 1.26 in the placebo group (p=0.017). Radiographic non-progression rates (change in vdH-mTSS≤smallest detectable change (1.9)) were 88.1% and 75.4% in abatacept and placebo groups, respectively. Adjusted mean change from baseline in Disease Activity Score 28 (C-reactive protein) (DAS28 (CRP)) at week 16 demonstrated a numerically greater reduction in the abatacept versus placebo group. Proportions of patients with DAS28 (CRP), Simplified Disease Activity Index and Clinical Disease Activity Index remission up to week 52 were higher in the abatacept versus placebo group. The abatacept safety profile was consistent with previous observations. Conclusions Compared with MTX alone, abatacept+MTX improved clinical symptoms and inhibited structural damage progression in ACPA-positive, Japanese patients with RA, early erosion and inadequate response to MTX.
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Affiliation(s)
- Tsukasa Matsubara
- Department of Orthopedics, Matsubara Mayflower Hospital, Hyogo, Japan
| | - Hiroshi Inoue
- Department of Orthopaedic Surgery, Inoue Hospital, Gunma, Japan
| | - Toshihiro Nakajima
- Department of Rheumatology, Bay Side Misato Medical Center, Kochi, Japan.,Department of Locomotor Science, Institute of Medical Science, Tokyo Medical University, Tokyo, Japan
| | - Kazuhide Tanimura
- Department of Rheumatology, Hokkaido Medical Center for Rheumatic Diseases, Sapporo, Japan
| | - Akira Sagawa
- Akira Sagawa Rheumatology Clinic, Sapporo, Japan
| | - Yukio Sato
- Sendai Taihaku Hospital, Sendai, Japan.,Sendai Medical Imaging Clinic, Sendai, Japan
| | - Kei Osano
- Department of Orthopaedics, Fukuoka Mirai Hospital, Fukuoka, Japan
| | - Shuji Nagano
- Department of Rheumatology, Center for Rheumatology, Iizuka Hospital, Fukuoka, Japan
| | - Yukitaka Ueki
- Rheumatic and Collagen Disease Center, Sasebo Chuo Hospital, Nagasaki, Japan
| | - Tadamasa Hanyu
- Department of Rheumatology, Nagaoka Red Cross Hospital, Niigata, Japan
| | | | | | - Yoshiya Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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10
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Li X, Roy A, Murthy B. Population Pharmacokinetics and Exposure-Response Relationship of Intravenous and Subcutaneous Abatacept in Patients With Rheumatoid Arthritis. J Clin Pharmacol 2018; 59:245-257. [PMID: 30229926 PMCID: PMC6585965 DOI: 10.1002/jcph.1308] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 08/05/2018] [Indexed: 12/24/2022]
Abstract
Abatacept population pharmacokinetics (PK) and exposure-response (E-R) models for selective efficacy end points were developed using phase 2 and 3 study data in patients with rheumatoid arthritis treated with abatacept (intravenous [IV] or subcutaneous [SC]), followed by simulations. Two efficacy end points were assessed in the E-R analyses: Disease Activity Score in 28 joints (DAS28) and American College of Rheumatology response criteria for 20/50/70% improvement (ACR20/50/70). The analyses were performed with data from 11 clinical studies for the population PK analysis and from 3 clinical studies for the E-R analyses (DAS28 and ACR20/50/70). The PK of abatacept were time invariant and can be described by a linear 2-compartment model with first-order elimination and with zero-order IV infusion or first-order absorption for SC abatacept. Baseline body weight was the only clinically meaningful covariate; that is, abatacept clearance and volume of central compartment increased with increasing baseline body weight. Steady-state trough concentration (Cminss ) of abatacept was identified as the best exposure predictor of DAS28 response compared with other exposure measures. In addition, the E-R relationship was the same for IV and SC abatacept. Similar results were confirmed in the ACR20/50/70 E-R analyses. Efficacy responses increased with increasing Cminss and a near-maximal response was associated with Cminss ≥10 μg/mL. The model-based analyses confirmed that the weight-tiered ∼10 mg/kg IV and fixed 125 mg SC abatacept dosing regimens are comparable and achieved plateau responses, by delivering Cminss ≥10 μg/mL in RA patients across all body weights.
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Affiliation(s)
- Xiaohui Li
- Bristol-Myers Squibb, Princeton, NJ, USA
| | - Amit Roy
- Bristol-Myers Squibb, Princeton, NJ, USA
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11
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Brunner HI, Tzaribachev N, Vega-Cornejo G, Louw I, Berman A, Calvo Penadés I, Antón J, Ávila-Zapata F, Cuttica R, Horneff G, Foeldvari I, Keltsev V, Kingsbury DJ, Viola DO, Joos R, Lauwerys B, Paz Gastañaga ME, Rama ME, Wouters C, Bohnsack J, Breedt J, Fischbach M, Lutz T, Minden K, Miraval T, Ally MMTM, Rubio-Pérez N, Solau Gervais E, van Zyl R, Li X, Nys M, Wong R, Banerjee S, Lovell DJ, Martini A, Ruperto N. Subcutaneous Abatacept in Patients With Polyarticular-Course Juvenile Idiopathic Arthritis: Results From a Phase III Open-Label Study. Arthritis Rheumatol 2018; 70:1144-1154. [PMID: 29481737 PMCID: PMC6032847 DOI: 10.1002/art.40466] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 02/20/2018] [Indexed: 11/16/2022]
Abstract
Objective To investigate the pharmacokinetics, effectiveness, and safety of subcutaneous (SC) abatacept treatment over 24 months in patients with polyarticular‐course juvenile idiopathic arthritis (JIA). Methods In this phase III, open‐label, international, multicenter, single‐arm study, patients with polyarticular JIA (cohort 1, ages 6–17 years and cohort 2, ages 2–5 years) in whom treatment with ≥1 disease‐modifying antirheumatic drug was unsuccessful received weight‐tiered SC abatacept weekly: 10 to <25 kg (50 mg), 25 to <50 kg (87.5 mg), ≥50 kg (125 mg). Patients who had met the JIA–American College of Rheumatology 30% improvement criteria (achieved a JIA‐ACR 30 response) at month 4 were given the option to continue SC abatacept to month 24. The primary end point was the abatacept steady‐state serum trough concentration (Cminss) in cohort 1 at month 4. Other outcome measures included JIA‐ACR 30, 50, 70, 90, 100, and inactive disease status, the median Juvenile Arthritis Disease Activity Score in 71 joints using the C‐reactive protein level (JADAS‐71–CRP) over time, safety, and immunogenicity. Results The median abatacept Cminss at month 4 (primary end point) and at month 24 was above the target therapeutic exposure (10 μg/ml) in both cohorts. The percentage of patients who had achieved JIA‐ACR 30, 50, 70, 90, or 100 responses or had inactive disease responses at month 4 (intent‐to‐treat population) was 83.2%, 72.8%, 52.6%, 28.3%, 14.5%, and 30.1%, respectively, in cohort 1 (n = 173) and 89.1%, 84.8%, 73.9%, 58.7%, 41.3%, and 50.0%, respectively, in cohort 2 (n = 46); the responses were maintained to month 24. The median (interquartile range) JADAS‐71–CRP improved from baseline to month 4: cohort 1, from 21.0 (13.5, 30.3) to 4.6 (2.1, 9.4); cohort 2, from 18.1 (14.0, 23.1) to 2.1 (0.3, 4.4). Improvements were sustained to month 24, at which time 27 of 173 patients (cohort 1) and 11 of 22 patients (cohort 2) had achieved JADAS‐71–CRP remission. No unexpected adverse events were reported; 4 of 172 patients (2.3%) in cohort 1 and 4 of 46 (8.7%) in cohort 2 developed anti‐abatacept antibodies, with no clinical effects. Conclusion Weight‐stratified SC abatacept yielded target therapeutic exposures across age and weight groups, was well tolerated, and improved polyarticular JIA symptoms over 24 months.
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Affiliation(s)
| | | | | | - Ingrid Louw
- Panorama Medical Centre, Cape Town, South Africa
| | | | | | | | | | - Rubén Cuttica
- Hospital General de Niños Pedro de Elizalde, Buenos Aires, Argentina
| | - Gerd Horneff
- Asklepios Clinic Sankt Augustin, Sankt Augustin, Germany
| | - Ivan Foeldvari
- Hamburg Centre for Pediatric and Adolescent Rheumatology, Hamburg, Germany
| | | | | | | | - Rik Joos
- Universitair Ziekenhuis Gent, Ghent, Belgium
| | | | | | | | | | - John Bohnsack
- University of Utah School of Medicine, Salt Lake City
| | - Johannes Breedt
- Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | | | | | - Kirsten Minden
- German Rheumatism Research Center and Charité University Medicine, Berlin, Germany
| | | | | | - Nadina Rubio-Pérez
- Universidad Autónoma de Nuevo León, Hospital Universitario Dr. J. E. González, Monterrey, Mexico
| | | | - Riana van Zyl
- University of the Free State, Bloemfontein, South Africa
| | - Xiaohui Li
- Bristol-Myers Squibb, Princeton, New Jersey
| | - Marleen Nys
- Bristol-Myers Squibb, Braine-L'Alleud, Belgium
| | | | | | - Daniel J Lovell
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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12
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D'Agostino MA, Alten R, Mysler E, Le Bars M, Ye J, Murthy B, Heitzmann J, Vadanici R, Ferraccioli G. Body mass index and clinical response to intravenous or subcutaneous abatacept in patients with rheumatoid arthritis. Clin Rheumatol 2017; 36:2655-2665. [PMID: 28822046 PMCID: PMC5681604 DOI: 10.1007/s10067-017-3788-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/17/2017] [Accepted: 08/10/2017] [Indexed: 12/31/2022]
Abstract
This post hoc analysis of ACQUIRE (NCT00559585) explored the effect of baseline body mass index (BMI) on the pharmacokinetics of and clinical response to subcutaneous (SC) or intravenous (IV) abatacept in patients with rheumatoid arthritis (RA). ACQUIRE was a phase 3b, 6-month, double-blind, double-dummy study in which patients with RA were randomized (1:1) to SC (fixed - dose; 125 mg/week) or IV (weight-tiered; ~ 10 mg/kg/month) abatacept plus methotrexate. In this analysis, minimum abatacept plasma concentration (Cmin) was measured at 3 and 6 months, and clinical remission over 6 months was assessed by Disease Activity Score 28 (C-reactive protein; DAS28 [CRP], < 2.6), Simplified Disease Activity Index (SDAI, ≤ 3.3), and Clinical Disease Activity Index (CDAI, ≤ 2.8). Data were stratified by baseline BMI (underweight/normal, < 25 kg/m2; overweight, 25 to < 30 kg/m2; obese, ≥ 30 kg/m2) and administration route. Of the 1456/1457 patients for whom baseline BMIs were available, 526 (36%; SC 265, IV 261) patients were underweight/normal, 497 (34%; SC 249, IV 248) were overweight, and 433 (30%; SC 221, IV 212) were obese. Median Cmin abatacept concentration was ≥ 10 μg/mL (efficacy threshold) at 3 and 6 months in > 90% of patients across BMI groups with both administration routes. DAS28 (CRP), SDAI, and CDAI remission rates at 6 months were similar across BMI groups and 95% confidence intervals overlapped at all time points in both separate and pooled SC/IV analyses. Therapeutic concentrations of abatacept and clinical remission rates using stringent criteria were similar across patient BMIs and administration routes.
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Affiliation(s)
- Maria-Antonietta D'Agostino
- Departement de Rhumatologie, AP-HP, Hôpital Ambroise Paré, INSERM U1173, Laboratoire d'Excellence INFLAMEX, UFR Simone Veil, Versailles-Saint-Quentin University, 92100, Boulogne-Billancourt, France.
| | - Rieke Alten
- Schlosspark-Klinik University Medicine, Berlin, Germany
| | - Eduardo Mysler
- Organización Médica de Investigación, Buenos Aires, Argentina
| | | | - June Ye
- Bristol-Myers Squibb, Princeton, NJ, USA
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13
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Amano K, Matsubara T, Tanaka T, Inoue H, Iwahashi M, Kanamono T, Nakano T, Uchimura S, Izumihara T, Yamazaki A, Karyekar CS, Takeuchi T. Long-term safety and efficacy of treatment with subcutaneous abatacept in Japanese patients with rheumatoid arthritis who are methotrexate inadequate responders. Mod Rheumatol 2016; 25:665-71. [PMID: 25698370 DOI: 10.3109/14397595.2015.1012786] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To assess the long-term safety, immunogenicity, and efficacy of subcutaneous (SC) abatacept in combination with methotrexate (MTX) in Japanese patients with rheumatoid arthritis who were MTX inadequate responders, in a long-term extension (LTE) to a double-dummy, double-blind study (NCT01001832). METHODS Patients, who had previously received SC or intravenous (IV) abatacept with MTX (6-8 mg/week) for 24 weeks, received SC abatacept (125 mg/week) with MTX for an additional 52 weeks. Safety, immunogenicity, and efficacy were assessed. RESULTS The LTE included 112 patients. SC abatacept was generally well tolerated in the LTE, with no new safety signals. American College of Rheumatology 20, 50, and 70 response rates, disease activity score 28 (C-reactive protein) remission rates (< 2.6), and Health Assessment Questionnaire-Disability Index response rates (≥ 0.3 improvement from baseline) achieved at the end of the double-blind period were maintained over the LTE and were comparable in patients who received SC or IV abatacept in the double-blind period. Seropositivity for immunogenicity occurred in 4 (3.6%) patients. Self-injection of SC abatacept was well controlled and not associated with additional safety events. CONCLUSIONS SC abatacept had acceptable safety and was well tolerated and effective over the LTE (76 weeks in total), with low rates of immunogenicity in Japanese patients.
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Affiliation(s)
- Koichi Amano
- a Department of Rheumatology and Clinical Immunology , Saitama Medical Center, Saitama Medical University , Kawagoe-shi, Saitama , Japan
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14
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Hazlewood GS, Barnabe C, Tomlinson G, Marshall D, Devoe DJA, Bombardier C. Methotrexate monotherapy and methotrexate combination therapy with traditional and biologic disease modifying anti-rheumatic drugs for rheumatoid arthritis: A network meta-analysis. Cochrane Database Syst Rev 2016; 2016:CD010227. [PMID: 27571502 PMCID: PMC7087436 DOI: 10.1002/14651858.cd010227.pub2] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Methotrexate is considered the preferred disease-modifying anti-rheumatic drug (DMARD) for the treatment of rheumatoid arthritis, but controversy exists on the additional benefits and harms of combining methotrexate with other DMARDs. OBJECTIVES To compare methotrexate and methotrexate-based DMARD combinations for rheumatoid arthritis in patients naïve to or with an inadequate response (IR) to methotrexate. METHODS We systematically identified all randomised controlled trials with methotrexate monotherapy or in combination with any currently used conventional synthetic DMARD , biologic DMARDs, or tofacitinib. Three major outcomes (ACR50 response, radiographic progression and withdrawals due to adverse events) and multiple minor outcomes were evaluated. Treatment effects were summarized using Bayesian random-effects network meta-analyses, separately for methotrexate-naïve and methotrexate-IR trials. Heterogeneity was explored through meta-regression and subgroup analyses. The risk of bias of each trial was assessed using the Cochrane risk of bias tool, and trials at high risk of bias were excluded from the main analysis. The quality of evidence was evaluated using the GRADE approach. A comparison between two treatments was considered statistically significant if its credible interval excluded the null effect, indicating >97.5% probability that one treatment was superior. MAIN RESULTS 158 trials with over 37,000 patients were included. Methotrexate-naïve: Several treatment combinations with methotrexate were statistically superior to oral methotrexate for ACR50 response: methotrexate + sulfasalazine + hydroxychloroquine ("triple therapy"), methotrexate + several biologics (abatacept, adalimumab, etanercept, infliximab, rituximab, tocilizumab), and tofacitinib. The estimated probability of ACR50 response was similar between these treatments (range 56-67%, moderate to high quality evidence), compared with 41% for methotrexate. Methotrexate combined with adalimumab, etanercept, certolizumab, or infliximab was statistically superior to oral methotrexate for inhibiting radiographic progression (moderate to high quality evidence) but the estimated mean change over one year with all treatments was less than the minimal clinically important difference of five units on the Sharp-van der Heijde scale. Methotrexate + azathioprine had statistically more withdrawals due to adverse events than oral methotrexate, and triple therapy had statistically fewer withdrawals due to adverse events than methotrexate + infliximab (rate ratio 0.26, 95% credible interval: 0.06 to 0.91). Methotrexate-inadequate response: In patients with an inadequate response to methotrexate, several treatments were statistically significantly superior to oral methotrexate for ACR50 response: triple therapy (moderate quality evidence), methotrexate + hydroxychloroquine (low quality evidence), methotrexate + leflunomide (moderate quality evidence), methotrexate + intramuscular gold (very low quality evidence), methotrexate + most biologics (moderate to high quality evidence), and methotrexate + tofacitinib (high quality evidence). There was a 61% probability of an ACR50 response with triple therapy, compared to a range of 27% to 64% for the combinations of methotrexate + biologic DMARDs that were statistically significantly superior to oral methotrexate. No treatment was statistically significantly superior to oral methotrexate for inhibiting radiographic progression. Methotrexate + cyclosporine and methotrexate + tocilizumab (8 mg/kg) had a statistically higher rate of withdrawals due to adverse events than oral methotrexate and methotrexate + abatacept had a statistically lower rate of withdrawals due to adverse events than several treatments. AUTHORS' CONCLUSIONS We found moderate to high quality evidence that combination therapy with methotrexate + sulfasalazine+ hydroxychloroquine (triple therapy) or methotrexate + most biologic DMARDs or tofacitinib were similarly effective in controlling disease activity and generally well tolerated in methotrexate-naïve patients or after an inadequate response to methotrexate. Methotrexate + some biologic DMARDs were superior to methotrexate in preventing joint damage in methotrexate-naïve patients, but the magnitude of these effects was small over one year.
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Affiliation(s)
- Glen S Hazlewood
- University of CalgaryDepartment of Medicine and Department of Community Health Sciences3330 Hospital Drive NWCalgaryONCanadaT2N 1N1
- University of CalgaryMcCaig Institute for Bone and Joint HealthCalgaryABCanadaT2N 4Z6
- University of TorontoInstitute of Health, Policy, Management and EvaluationTorontoONCanadaM5T 3M6
| | - Cheryl Barnabe
- University of CalgaryMcCaig Institute for Bone and Joint HealthCalgaryABCanadaT2N 4Z6
- University of CalgaryDepartment of Medicine3330 Hospital Dr NWCalgaryABCanadaT2N 4N1
- University of CalgaryDepartment of Community Health SciencesCalgaryABCanada
| | - George Tomlinson
- University of TorontoDepartment of Medicine and Institute of Health Policy, Management and EvaluationEaton North, 6th Floor, Room 232B200 Elizabeth StreetTorontoONCanadaM5G 2C4
| | - Deborah Marshall
- University of CalgaryMcCaig Institute for Bone and Joint HealthCalgaryABCanadaT2N 4Z6
- University of CalgaryDepartment of Community Health SciencesCalgaryABCanada
| | - Daniel JA Devoe
- University of CalgaryDepartment of Community Health SciencesCalgaryABCanada
| | - Claire Bombardier
- University Health NetworkToronto General Research InstituteTorontoONCanadaM6J 3S3
- University of TorontoDepartment of Medicine and Institute of Health Policy, Management, and EvaluationTorontoONCanadaM5G 2C4
- Mount Sinai HospitalDivision of RheumatologyTorontoONCanadaM5T 3L9
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15
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Monti S, Breda S, Grosso V, Todoerti M, Montecucco C, Caporali R. Switching from Intravenous to Subcutaneous Formulation of Abatacept: Different Results in a Series of 21 Patients. J Rheumatol 2015; 42:1993-4. [PMID: 26429207 DOI: 10.3899/jrheum.150230] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Sara Monti
- Division of Rheumatology, University of Pavia, IRCCS Policlinico S. Matteo Foundation, Piazzale Golgi 2, 27100 Pavia, Italy.
| | - Silvia Breda
- Division of Rheumatology, University of Pavia, IRCCS Policlinico S. Matteo Foundation, Piazzale Golgi 2, 27100 Pavia, Italy
| | - Vittorio Grosso
- Division of Rheumatology, University of Pavia, IRCCS Policlinico S. Matteo Foundation, Piazzale Golgi 2, 27100 Pavia, Italy
| | - Monica Todoerti
- Division of Rheumatology, University of Pavia, IRCCS Policlinico S. Matteo Foundation, Piazzale Golgi 2, 27100 Pavia, Italy
| | - Carlomaurizio Montecucco
- Division of Rheumatology, University of Pavia, IRCCS Policlinico S. Matteo Foundation, Piazzale Golgi 2, 27100 Pavia, Italy
| | - Roberto Caporali
- Division of Rheumatology, University of Pavia, IRCCS Policlinico S. Matteo Foundation, Piazzale Golgi 2, 27100 Pavia, Italy
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