Ocular and Plasma Pharmacokinetics of Enavogliflozin Ophthalmic Solution in Preclinical Species

An enavogliflozin ophthalmic solution (DWRX2008) is being developed to treat diabetic retinopathy and macular edema. This study evaluated the ocular distribution and plasma pharmacokinetics (PKs) of enavogliflozin in animal species. A sample of [14C] enavogliflozin was ocularly administered to two rabbits per time point at single doses of 600 μg/eye to evaluate ocular PK, which was evaluated using autoradiography until 48 h post-dose. Plasma concentrations after ocular administration in six rabbits, three rats, and three beagle dogs with single doses of 400 μg, 25 μg, and 100 μg, respectively, were investigated for 24 h. The retinal concentration of [14C] enavogliflozin reached Cmax at 2.0 h with an elimination half-life of 32.5 h, which remained above the IC50 value of sodium-dependent glucose transporter 2 until 24 h post-dose. In the plasma of rabbits, the fastest Tmax of 0.5 h and a 3.6 h half-life were observed among animal species. The relative bioavailability in rabbits after ocular administration was 3.4 compared to oral administration. Ocular administration of enavogliflozin could be a potential therapeutic route for diabetic retinal complications, based on relative bioavailability and effective delivery to the posterior ocular segment. DWRX2008 would be applicable to humans with favorable PK profiles and minimal systemic adverse effect.

Soli-enabled noncontact heart rate detection for sleep and meditation tracking

Heart rate (HR) is a crucial physiological signal that can be used to monitor health and fitness. Traditional methods for measuring HR require wearable devices, which can be inconvenient or uncomfortable, especially during sleep and meditation. Noncontact HR detection methods employing microwave radar can be a promising alternative. However, the existing approaches in the literature usually use high-gain antennas and require the sensor to face the user's chest or back, making them difficult to integrate into a portable device and unsuitable for sleep and meditation tracking applications. This study presents a novel approach for noncontact HR detection using a miniaturized Soli radar chip embedded in a portable device (Google Nest Hub). The chip has a [Formula: see text] dimension and can be easily integrated into various devices. The proposed approach utilizes advanced signal processing and machine learning techniques to extract HRs from radar signals. The approach is validated on a sleep dataset (62 users, 498 h) and a meditation dataset (114 users, 1131 min). The approach achieves a mean absolute error (MAE) of 1.69 bpm and a mean absolute percentage error (MAPE) of [Formula: see text] on the sleep dataset. On the meditation dataset, the approach achieves an MAE of 1.05 bpm and a MAPE of [Formula: see text]. The recall rates for the two datasets are [Formula: see text] and [Formula: see text], respectively. This study represents the first application of the noncontact HR detection technology to sleep and meditation tracking, offering a promising alternative to wearable devices for HR monitoring during sleep and meditation.

Quantitative and Qualitative Impact of CT-Based Radiotherapy Dose Maps on Radiologists' Interpretation of Post-treatment Thoracic Surveillance Imaging

PURPOSE/OBJECTIVE(S)

For diagnostic radiologists, interpretation of surveillance imaging for oncology patients treated with radiation therapy (RT) can be challenging because (1) the imaging order may not adequately describe the radiation fields and (2) RT treatment effect and progression can appear similar. Volumetric dose visualization used for plan review is often inaccessible to radiologists. We hypothesize that displaying RT dose would improve radiologists' confidence and ability to correctly identify and distinguish irradiated targets and treatment effects.

MATERIALS/METHODS

CT images were read by a board-certified cardiothoracic radiologist and a diagnostic radiology resident. The readers interpreted pre-RT, treatment planning, and 3-4 month post-RT CT images in anonymized software sessions first without, then-after a 1 month "washout" period-with access to RT dose overlay. Six color-coded isodose lines ranging from 25% to 110% represented in absolute cGy were displayed along with a brief clinical history. RT fractionation schedules ranged in BED10 from 39 to 112.5 Gy. Readers were asked to label the treated lesion(s) and treatment effect(s), and record their confidence using a Likert scale of 1-5 and agreement with statements using yes/no responses.

RESULTS

Two readersindependently interpreted imaging for 32 patients who received thoracic RT to 1-5 lesion(s) for primary (24) or metastatic (8) cancer. Nineteen patients had 1 lesion and 13 patients had >1 lesion. Correct identification of all treated lesions significantly increased with the addition of dose visualization (61% to 81%; McNemar test, p = 0.00079), with the largest increase noted for cases with >1 lesion (15% to 54%; McNemar test, p = 0.0039). With the addition of dose information, the number of false negatives attributable to missed extranodal targets fell from 52% to 18%. Without dose information, 13% of labeled lesions and treatment effects fell outside of the 25% isodose lines, representing false positives. With the addition of dose information, false positives fell below 2% for both lesions and treatment effects. The readers' confidence that they had identified treated lesion(s) increased from a rating of 4.1 to 4.8 on a scale of 1-5 (Paired two-tail t test; p = 0.000005).

CONCLUSION

Whendiagnostic radiologists have access to dose visualization, correct identification rate of irradiated lesions and treatment effects, as well as confidence in these identifications significantly increased. The decrease in false negatives could reduce potential missed identification of tumor progression while the decrease in false positives could reduce inaccurate identification of treatment failure in a new or stable lesion. Our results demonstrate that adding volumetric visualization of dose to imaging could improve quality of surveillance care for patients with irradiated thoracic malignancies.

Pharmacokinetics and safety of candidate tocilizumab biosimilar CT-P47 versus reference tocilizumab: a randomized, double-blind, single-dose phase I study

BACKGROUND

CT-P47 is a candidate tocilizumab biosimilar. This study assessed the pharmacokinetic (PK) equivalence of CT-P47 and European Union-approved reference tocilizumab (EU-tocilizumab) in healthy Asian adults.

RESEARCH DESIGN AND METHODS

This double-blind, multicenter, parallel-group trial randomized healthy adults (1:1) to receive a single (162 mg/0.9 mL) subcutaneous dose of CT-P47 or EU-tocilizumab. The primary endpoint (Part 2) was PK equivalence by area under the concentration - time curve (AUC) from time zero to last quantifiable concentration (AUC_0-last), AUC from time zero to infinity (AUC_0-inf), and maximum serum concentration (C_max). PK equivalence was concluded if 90% confidence intervals (CIs) for the ratios of geometric least-squares means (gLSMs) were within the 80-125% equivalence margin. Additional PK endpoints, immunogenicity, and safety were evaluated.

RESULTS

In Part 2, 289 participants were randomized (146 CT-P47; 143 EU-tocilizumab); 284 received study drug. AUC_0-last, AUC_0-inf, and C_max were equivalent between CT-P47 and EU-tocilizumab: 90% CIs for the ratios of gLSMs were within the 80-125% equivalence margin. Secondary PK endpoints, immunogenicity, and safety were comparable between groups.

CONCLUSIONS

CT-P47 demonstrated PK equivalence with EU-tocilizumab and was well tolerated, following a single dose in healthy adults.

CLINICAL TRIAL REGISTRATION

www.clinicaltrials.gov identifier is NCT05188378.

Prevalence of modifiable risk factors and related poor cardiovascular outcomes following atrial fibrillation ablation

Background

Atrial fibrillation (AF) has become a global epidemic. Early catheter ablation and therapies modifying risk factors (RF) have been shown to improve outcomes of AF ablation. However, the time invested in pursuing risk factor modification may delay ablation, which could negate the procedural benefit.

Purpose

This study sought to investigate the prevalence and impact of potentially modifiable RF among AF patients undergoing catheter ablation in clinical practice.

Methods

This retrospective study included 724 consecutive patients undergoing AF ablation at a tertiary care center from 2012–2019. Pre-specified modifiable risks were examined, including the time from AF diagnosis to ablation, fluctuation/increase in BMI >5% prior to ablation, mean systolic/diastolic blood pressure >125/80 mmHg, obstructive sleep apnea with CPAP noncompliance, hyperlipidemia without statin therapy, tobacco use, excessive alcohol use, and diabetes mellitus with hemoglobin A1c (HbA1c) >6.5%. The primary outcome was a composite of recurrent atrial arrhythmias, cardiovascular (CV) hospitalizations and mortality following AF ablation. A multivariate analysis was performed.

Results

The mean age was 61±10 years old, 32.5% were female and 72.2% had persistent AF. Many study patients had modifiable RF, ranging from 4.7% with excessive alcohol use to 64.0% experiencing delayed AF ablation. The mean time from AF diagnosis to ablation was 4.7 years. During a mean follow-up of 1.6 years after ablation, 467 (64.5%) patients met the primary outcome. Independent RF for the primary outcome were an increase/fluctuation in BMI >5% (adjusted hazard ratio [AHR] 1.31, 95% confidence interval [CI] 1.07–1.60; P=0.008), diabetes with HbA1c >6.5% (AHR 1.50, 95% CI 1.09–2.03; P=0.014) and hyperlipidemia without statin therapy (AHR 1.30, 95% CI 1.08–1.57; P=0.005). Delayed AF ablation over 1.5 years did not alter the outcome, Figure 1.

Conclusion

Substantial portions of patients undergoing AF ablation have potentially modifiable RF. Increased or fluctuating BMI, diabetes with HbA1c >6.5%, and hyperlipidemia not treated with statin therapy portend an increased risk of recurrent atrial arrhythmia, CV hospitalizations and mortality. These findings underscore an importance pursuing RF management in patients with AF to reduce adverse outcomes after ablation.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The Jensen Family Research Sponsorship at the University of Nebraska Medical Center

Ethmoidal and maxillary nerve block versus systemic opioid administration during rhinoscopy in dogs: a non-randomised clinical trial

OBJECTIVES

This study aimed to evaluate the clinical effects of ethmoidal and maxillary nerve blocks during rhinoscopy in dogs.

MATERIALS AND METHODS

Fourteen dogs underwent rhinoscopy. Under general anaesthesia with isoflurane, ethmoidal and maxillary nerve blocks were applied bilaterally using 2% lidocaine before rhinoscopy in eight dogs (EM group). Six dogs were premedicated with hydromorphone (0.05 mg/kg) as a substitute for local nerve block (H group). During rhinoscopy, the heart rate, arterial blood pressure and end-tidal isoflurane concentration were recorded. The vaporizer setting was adjusted to increase the end-tidal isoflurane concentration when reflex movement was caused by nasal stimulation.

RESULTS

The H group, compared to the EM group, had an increase in HR that was 18 beats/minute (95% CI: 11 to 26) higher, an increase in SAP that was 22 mmHg (12 to 31) higher, an increase in MAP that was 15 mmHg (7 to 23) higher, an increase in DAP that was 12 mmHg (5 to 19) higher, and an increase in end-tidal isoflurane concentration that was 0.4% (0.3 to 0.5) higher. Head movement due to endoscope insertion was observed in 5/6 dogs (83.3%) in the H group and 1/8 dogs (12.5%) in the EM group (odds ratio, 0.029; ra95% CI, 0.001-0.574).

CLINICAL SIGNIFICANCE

Compared with administration of 0.05 mg/kg hydromorphone, concurrent block of the ethmoidal and maxillary nerves can reduce the cardiovascular response, reflex movement and anaesthetic requirement during rhinoscopy in dogs.

AB0922 Psoriatic Arthritis Disease Activity Differs by Race/Ethnicity

Background

Psoriatic arthritis (PsA) affects up to 30% of individuals with psoriasis. Studies have demonstrated that the presenting disease severity and quality of life impact of psoriasis differs by race/ethnicity in patients with and without PsA, but little is known about disease activity among different racial/ethnic groups [1-3].

Objectives

The objective of our study was to evaluate disease activity by race/ethnicity among patients with PsA.

Methods

We performed a cross-sectional study of adult (≥18 years old) patients with PsA who had at least one outpatient visit within the University of Pennsylvania health system between 2010 and 2019. Patients with PsA were identified by the presence of at least two International Classification of Diseases (ICD)-9 or ICD-10 codes for PsA associated with two different healthcare encounters. The primary outcome was disease activity as measured by the Routine Assessment of Patient Index Data 3 (RAPID3) assessment. The RAPID3 score is a validated patient-reported measure of physical function, pain, and global status [4]. RAPID3 scores range from 0 to 30, with higher scores indicating greater disease activity. Patients were included if they had at least one documented RAPID3 score. For patients with multiple RAPID3 scores, the median value was used. The primary independent variable was race/ethnicity categorized as White (reference), Black, Asian, Hispanic, or other race. Multivariable linear regression was used to assess the relationship between race/ethnicity and RAPID 3 score.

Results

The study population included 742 patients. Mean (standard deviation [SD]) age was 47.2 (13.3) years and 57.4% were female. The racial/ethnic distribution was 79.4% White, 7.0% Black, 5.0% Asian, 3.1% Hispanic, 2.6% other race, and 3.0% missing race/ethnicity. The means of the median Rapid3 scores were statistically significantly different across racial/ethnic groups (p<.001): White mean (SD) 9.79 (6.02), Black mean (SD) 14.86 (14.86), Asian mean (SD) 9.79 (5.44), Hispanic mean (SD) 15.09 (7.11), other race mean (SD) 10.57 (6.91). In an adjusted multivariable model controlling for other sociodemographic factors, body mass index, treatment history, and medical comorbidity, Hispanic patients had higher RAPID3 scores compared to White patients, indicating greater disease activity (β 3.36; 95% confidence interval [CI] 1.04 – 5.67, p <.005). In exploratory stratified analyses to evaluate effect modification by sex, among males, Black (β 3.43; 95% CI 0.23 – 6.63, p=.04) and Hispanic (β 5.94; 95% CI 2.18 – 9.70, p <.005) patients had higher RAPID3 scores than White patients. Among females, no significant racial/ethnic differences in RAPID3 scores were identified.

Conclusion

Black and Hispanic patients report greater disease activity as indicated by higher RAPID3 scores compared to White patients. Larger studies are necessary to confirm our findings and understand the causes of racial/ethnic differences in disease activity among patients with PsA.

References

[1]Abrouk M, Lee K, Brodsky M, Nakamura M, Singh R, Zhu TH, et al. Ethnicity affects the presenting severity of psoriasis. J Am Acad Dermatol. 2017;77(1):180-2.

[2]Shah SK, Arthur A, Yang YC, Stevens S, Alexis AF. A retrospective study to investigate racial and ethnic variations in the treatment of psoriasis with etanercept. J Drugs Dermatol. 2011;10(8):866-72.

[3]Takeshita J, Augustin M, de Jong E, Lafferty K, Langholff W, Langley R, Leonardi C, Menter A, Alexis A. Psoriasis-Related Quality-of-Life Differs by Race/Ethnicity. J Invest Dermatol. 2019; 139(5S, Supplement 1):S148.

[4]Coates LC, Tillett W, Shaddick G, Pincus T, Kavanaugh A, Helliwell PS. Value of the Routine Assessment of Patient Index Data 3 in Patients With Psoriatic Arthritis: Results From a Tight-Control Clinical Trial and an Observational Cohort. Arthritis Care Res (Hoboken). 2018;70(8):1198-1205.

Disclosure of Interests

Fahad Ahmed: None declared, Alexis Ogdie Consultant of: A. Ogdie has received consulting fees from Amgen, AbbVie, Bristol Myers Squibb, Celgene, CorEvitas (formerly Corrona), Gilead, Janssen, Lilly, Novartis, Pfizer, and UCB., Grant/research support from: A. Ogdie has received grant support from the National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases, Rheumatology Research Foundation, National Psoriasis Foundation, Abbvie (University of Pennsylvania), Pfizer (University of Pennsylvania), Amgen (FORWARD), and Novartis (FORWARD)., Robert Fitzsimmons: None declared, Daniel Shin: None declared, Junko Takeshita Consultant of: JT has served as a consultant for Pfizer Inc. and Janssen Biotech receiving honoraria., Grant/research support from: JT has received a research grant (to the Trustees of the University of Pennsylvania) from Pfizer Inc.

POS1049 ASSESSING TREATMENT PATTERNS WITH DISEASE-MODIFYING ANTIRHEUMATIC DRUGS AND PREDNISONE FOR PSORIATIC ARTHRITIS BY RACE/ETHNICITY

Background

Psoriatic arthritis (PsA) is a comorbidity commonly associated with psoriasis. Studies have demonstrated delays in the diagnosis and treatment of PsA[1] that may disproportionately affect racial/ethnic minority patients as indicated by one study that found Black Medicaid patients with PsA to be less likely to receive disease-modifying antirheumatic drugs [DMARDs] than White Medicaid patients with PsA [2]. Yet much remains unknown about potential racial/ethnic disparities in PsA management.

Objectives

The objective of our study was to evaluate treatment patterns for PsA by race/ethnicity.

Methods

We performed a cross-sectional study of adult (≥18 years old) patients with PsA who had at least one outpatient visit within the University of Pennsylvania health system between 2010 and 2019. Patients with PsA were identified by the presence of at least two International Classification of Diseases (ICD)-9 or ICD-10 codes for PsA associated with two different healthcare encounters. The primary outcomes were receipt of a prescription for: (i) an oral DMARD, (ii) a biologic DMARD, and (iii) prednisone. Oral DMARDs included apremilast, methotrexate, sulfasalazine, leflunomide, azathioprine, cyclosporine, tofacitinib, hydroxychloroquine, and upadacitnib. Biologic DMARDs included abatacept, adalimumab, brodalumab, certolizumab, etanercept, golimumab, guselkumab, infliximab, ixekixumab, secukinumab, ustekinumab, and risankizumab. The primary independent variable was race/ethnicity categorized as White (reference), Black, Asian, Hispanic, or other race. Multivariable logistic regression was used to assess the relationship between race/ethnicity and each treatment outcome.

Results

The study population included 1781 patients with PsA who were a mean age of 50.7 (SD 14.3), 54.6% female, and 72.5% commercially insured. The racial/ethnic distribution was 81.9% White, 5.6% Black, 4.0% Asian, 3.0% Hispanic, 2.5% other race, and 3.1% missing race/ethnicity. Of these patients, 64.3% were prescribed an oral DMARD, 55.6% were prescribed a biologic, and 44.1% were prescribed prednisone. There were no statistically significant differences across race/ethnicity for prescription of either oral or biologic DMARDs. However, prescription of prednisone did differ by race/ethnicity (p<.005) with Black (54.6%) and Hispanic (56.6%) patients being more likely to receive prednisone prescriptions and Asian (32.4%) patients being less likely to receive prednisone prescriptions than White (44.2%) patients. In adjusted logistic regression models controlling for sociodemographic and other factors, Hispanic patients were more likely to receive a prednisone prescription (OR 1.79, 95% CI 1.01 – 3.20, p=0.05) while Asian (OR 0.58, 95% CI 0.34 – 0.97, p=0.04) patients were less likely to receive a prednisone prescription compared to White patients.

Conclusion

We found Hispanic patients with PsA to be more likely to receive prednisone prescriptions than White patients with PsA but did not identify any racial/ethnic differences in prescription patterns for oral or biologic DMARDs for PsA. Greater use of prednisone among Hispanic patients may reflect different diseases trajectories (e.g., more disease flares or greater disease severity) or other factors that affect prescription patterns that require further study.

References

[1]Favier G, Gladman DD, Merola JF, Armstrong AW, Boehncke WH, Helliwell PS. Benchmarking Care in Psoriatic Arthritis - The QUANTUM Report: A Report from the GRAPPA 2016 Annual Meeting. J Rheumatol. 2017;44(5):674-678.

[2]Ogdie A, Matthias W, Thielen RJ, Chin D, Saffore CD. Racial Differences in Prevalence and Treatment for Psoriatic Arthritis and Ankylosing Spondylitis by Insurance Coverage in the USA. Rheumatol Ther. 2021;8(4):1725-1739.

Disclosure of Interests

Fahad Ahmed: None declared, Alexis Ogdie Consultant of: A. Ogdie has received consulting fees from Amgen, AbbVie, Bristol Myers Squibb, Celgene, CorEvitas (formerly Corrona), Gilead, Janssen, Lilly, Novartis, Pfizer, and UCB., Grant/research support from: A. Ogdie has received grant support from the National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases, Rheumatology Research Foundation, National Psoriasis Foundation, Abbvie (University of Pennsylvania), Pfizer (University of Pennsylvania), Amgen (FORWARD), and Novartis (FORWARD)., Robert Fitzsimmons: None declared, Daniel Shin: None declared, Junko Takeshita Consultant of: JT has served as a consultant for Pfizer Inc. and Janssen Biotech receiving honoraria., Grant/research support from: JT has received a research grant (to the Trustees of the University of Pennsylvania) from Pfizer Inc.

Pre-ablation interatrial conduction delay or block predicts atrial fibrillation recurrence after ablation among obese patients

Funding Acknowledgements

Type of funding sources: None.

Background

Obesity is associated with greater risk of atrial fibrillation (AF) recurrence post-ablation and higher incidence of conduction delay compared to non-obese patients. Pre-ablation P-wave duration (PWD) and morphology (PWM) indicating interatrial delay are easily assessed in the clinic and may predict AF recurrence post-ablation in these patients.

Purpose

Evaluate the predictive value of PWD and PWM on AF recurrence post-ablation in obese patients.

Methods

Pre-ablation PWD and PWM (negative P-wave in lead II or III) were analyzed on consecutive patients with BMI ≥30 kg/m2 who underwent initial AF ablation from 2012–19. The primary outcome was recurrent AF after a 3-month post-ablation blanking period. Multivariate analysis adjusted for baseline characteristics was performed.

Results

For 205 patients (61.0±9.5 years old, 39.0% female), mean BMI was 36.9±5.7 kg/m2 and 71.7% had persistent AF pre-ablation. Recurrent AF post-ablation occurred in 115 (56.1%) during a median follow up of 491 (270, 1001) days. PWD &gt;130 ms was significantly associated with higher AF recurrence (AHR of 1.62, 95%CI 1.04-2.57, p=0.03) after adjusting for age, persistent AF and left atrial volume index (LAVI). In a subgroup with LAVI &lt;42 mL/m2 (n=112), PWD &gt;130 ms and negative P-waves in lead II or III were independently associated with increased risk of recurrent AF (AHR 2.06, 95%CI 1.12-3.91; p=0.019 and AHR 1.94, 95% CI 1.00-3.56; p=0.05, respectively) (Figure 1).

Conclusion

AF recurred in &gt;50% of obese patients within 1.5 years of ablation. Pre-ablation PWD &gt;130 ms and negative P-waves in lead II or III independently predicted recurrent AF post-ablation in this cohort of obese patients. These easily assessed findings add predictive value to other risk factors.

Changing demographics, temporal trend in waitlist and post-transplant outcomes after heart transplantation in the United States: analysis of unos database 1991–2019

Background

The landscape of heart transplantation (HT) has changed significantly with respect to patient selection, surgical techniques, and patient outcomes. We sought to investigate temporal trends in patient characteristics, waitlist and post-transplant outcomes after HT in the U.S.

Methods

We queried the national database of the United Network of Organ Sharing (UNOS) to identify adults listed for HT in the U.S. between 1991 and 2019. Patients were divided into four eras based on the three time points in which changes were made to the patient selection/allocation policy (1999, 2006, and 2018), and patient characteristics as well as waitlist and post-transplant outcomes were evaluated for each era.

Results

Between 1991 and 2019, a total of 95,179 patients were added to the waitlist for HT in the U.S. Compared to era 1, patients listed in era 4 were older (mean age: 52.4 years), more female (27.6%) and ethnic minorities (40%), and with higher-risk comorbidities (28.8% diabetes, 35.6% obese). Over the study period, there were 22,070 waitlist deaths and 61,687 transplants.

Compared to the preceding era, there was significant decrease in waitlist mortality in the last 2 eras (e.g., sub-hazard ratio for era 4 vs era 3 =0.37, 95% CI=0.32–0.44). For each year, only 27.1% to 40.5% of those on the waitlist were transplanted. Among those who were transplanted, there was increase in the rates of in-hospital stroke (2.8% in era 1 to 3.7% in era 4), renal failure requiring dialysis (7.2% to 17.1%), and hospital length of stay (14 to 17 days), p-values&lt;0.001 for all. However, this has not negatively impacted short-term survival when compared to the preceding era (1-year graft survival = 89.7% in era 4). Based on a projection model, we predict a 47% increase in living adult heart transplant recipients to to 44,366 in 2040.

Conclusion

There have been significant changes in the characteristics of patients listed for HT in the U.S., including an increasing proportion of high-risk co-morbidities. Although the transplant volume has increased, the wide supply-demand gap persisted. The last 2 changes in the allocation policy in 2006 and 2018 achieved their primary objective of reducing waitlist mortality.

Funding Acknowledgement

Type of funding sources: None.

Multivariate Assessment for Bioequivalence Based on the Correlation of Random Effect

Background and Objective

Bioequivalence tests are fundamental step in assessing the equivalence in bioavailability between a test and reference product. In practice, two separate linear mixed models (LMMs) with random subject effects, which have an area under the concentration-time curve (AUC) and the peak concentration (C_max) as the responses, have become the gold standard for evaluating bioequivalence. Recently, Lee et al developed a multivariate hierarchical generalized linear model (HGLM) for several responses that modeled correlations among multivariate responses via correlated random effects. The objective of this study was to apply this multivariate analysis to the bioequivalence test in practice and to compare the performance of multivariate HGLM and separate LMMs.

Methods

Three pharmacokinetic datasets, fixed-dose combination (naproxen and esomeprazole), tramadol and fimasartan data were analyzed. We compared the 90% confidence interval (CI) for the geometric mean ratio (GMR) of a test product to a reference product using the multivariate HGLM and two conventional separate LMMs.

Results

We found that the 90% CIs for the GMRs of both AUC and C_max from the multivariate HGLM were narrower than those from the separate LMMs: (0.843, 1.152) vs (0.825, 1.177) for C_max of esomeprazole in fixed-dose combination data; (0.805, 0.931) vs (0.797, 0.941) for C_max in tramadol data; (0.801, 1.501) vs (0.762, 1.578) for C_max and (1.163, 1.332) vs (1.009, 1.341) for AUC in fimasartan data, consistent with the random subject effects from two separate LMMs being highly correlated in the three datasets (correlation coefficient r = 0.883; r = 0.966; r = 0.832).

Conclusion

This multivariate HGLM had good performance in the bioequivalence test with multiple endpoints. This method would provide a more reasonable option to reduce the 90% CI by adding correlation parameters and thus an advantage especially in evaluating the bioequivalence of highly variable drugs with broad 90% CIs.

Pharmacokinetic Interaction Between Telmisartan and Rosuvastatin/Ezetimibe After Multiple Oral Administration in Healthy Subjects

INTRODUCTION

Telmisartan, rosuvastatin and ezetimibe are commonly recommended as combination therapies. However, the pharmacokinetic (PK) interaction among these therapeutic drugs has not been clearly reported. The objective of this study was to investigate possible interactions between telmisartan monotherapy and a fixed-dose combination (FDC) of rosuvastatin/ezetimibe.

METHODS

A randomized, open-label, multiple oral dose, three-treatment, three-period, six-sequence crossover study was conducted in healthy male volunteers. Monotherapy and cotherapy with telmisartan (80 mg) or a FDC of rosuvastatin and ezetimibe (20/10 mg) were compared after once-daily treatment for 7 days. The PK profiles for telmisartan, rosuvastatin, total ezetimibe (ezetimibe + exetimibe glucuronide) and ezetimibe were evaluated up to 48 h after the last dose. There was a 14-day washout period between each treatment.

RESULTS

The geometric mean ratios (GMRs) and 90% confidence intervals (CIs) for the peak plasma concentration at steady state (C_max,ss) and area under the plasma concentration-time curve during the dosing interval at steady state (AUC_τ,ss) were 1.258 (1.072-1.475) (P = 0.020) and 1.264 (1.167-1.370) (P < 0.001) for telmisartan, 0.796 (0.723-0.878) (P < 0.001) and 0.904 (0.842-0.970) (P = 0.021) for total ezetimibe and 1.237 (1.081-1.416) (P = 0.012) and 0.988 (0.899-1.086) (P = 0.832) for ezetimibe, respectively. With rosuvastatin, the GMR (90% CI) was 2.616 (2.287-2.992) (P < 0.001) for C_max,ss and 1.265 (1.168-1.369) (P < 0.001) for AUC_τ,ss. No serious adverse events or clinically significant results were reported.

CONCLUSIONS

The coadministration of multiple doses of telmisartan and rosuvastatin/ezetimibe led to a mild increase in systemic exposure with respect to telmisartan and rosuvastatin and a nonsignificant change in exposure to total ezetimibe and ezetimibe, which was not considered clinically significant without safety concerns. Furthermore, for the generalizability of the clinical effects, a large-scaled clinical study might be required in patients with hypertension and dyslipidemia.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov registry number: NCT03802526.

Residual functional SYNTAX score by quantitative flow ratio and improvement of exercise capacity after revascularization in patients with stable ischemic heart disease

Background

In patients with stable ischemic heart disease (SIHD), the efficacy of percutaneous coronary intervention (PCI) in improving exercise capacity has been under debate and the differential effect of PCI for exercise capacity, according to functional completeness of revascularization, has not been evaluated.

Purpose

This study aimed to evaluate the association between improvement in exercise capacity and functional completeness of revascularization, determined by residual functional SYNTAX score (rFSS), which is the sum of residual SYNTAX score of the vessels with post-PCI quantitative flow ratio (QFR)≤0.80.

Methods

Among patients enrolled in the QFR multicenter registry, 110 patients who underwent prespecified routine exercise treadmill tests before and after PCI were analyzed. Patients were classified into functional complete revascularization (CR) group (rFSS=0) and functional incomplete revascularization (IR) group (rFSS≥1). Increase of exercise time after PCI was compared between the 2 groups. Improvement of exercise capacity was defined as ≥10% increase of exercise time after PCI.

Results

Functional CR was achieved in 79 patients (71.8%), otherwise classified as functional IR in 31 patients (18.2%). There were no significant differences in baseline characteristics including medication profiles. Increase of exercise time was significantly associated with increase of 3-vessel QFR (r=0.198, P=0.038) and rFSS (r=−0.312, P&lt;0.001), but not with decrease of SYNTAX score (r=0.097, P=0.313). The rFSS showed significantly higher c-index to predict the improvement of exercise capacity after PCI than increase of 3-vessel QFR or decrease of SYNTAX score (0.722 vs. 0.627 vs. 0.492, respectively, P&lt;0.001). Patients with functional CR, defined by rFSS, showed significantly higher increase of exercise time than those with functional IR (97.7 sec vs. 12.5 sec, P&lt;0.001). Functional CR was an independent predictor of the improvement of exercise capacity after PCI (adjusted odds ratio 4.656, 95% CI 1.678–12.920, P=0.002).

Conclusions

Integrated anatomic and functional scoring system (rFSS) was significantly associated with improvement of exercise capacity after PCI. SIHD patients with functional CR, defined by rFSS, showed significantly higher exercise capacity after PCI than those with functional IR.

Summarizing Figure

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): SaeHan NK & D and Medis Corporation

Changes in Beck Depression Inventory scores in prostate cancer patients undergoing androgen deprivation therapy or prostatectomy

Objectives

Androgen deprivation therapy (ADT) has seen increasing use as a prostate cancer treatment in recent years and has proven medically effective in numerous contexts. The treatment, however, is associated with a host of side effects including depression. Managing the psychological wellbeing of prostate cancer patients is important for maximizing their survival outcomes. Thus, this study aimed to evaluate depressive symptomatology in patients with androgen deprivation therapy (ADT) compared with that in patients who underwent prostatectomy and to explore the factors that affect depressive symptoms, which might occur during ADT.

Methods

One hundred and seven patients undergoing ADT (ADT group) and prostatectomy (Operation group) were enrolled. Adjustments were made for differences in characteristics between groups using a propensity score model with stabilized weights before treatment. Depressive symptoms between groups were compared using the Beck Depression Inventory (BDI) before treatment and six months after treatment initiation. To identify factors affecting depressive symptoms during ADT, multivariate regression analysis was performed on the mean change in BDI score, age, body mass index, testosterone level, prostate-specific antigen level, the international index of erectile function (IIEF), and the Gleason score.

Results

The BDI score significantly increased in the ADT group compared to the operation group six months after treatment initiation (p < 0.001). Multivariate regression analysis revealed that before ADT, the BDI score was higher by 0.446 according to the IIEF. During ADT, the BDI score increased by 1.579 according to changes in BMI (p = 0.021) and decreased by 0.01 according to changes in testosterone levels (p = 0.034).

Conclusion

Depressive symptoms can be exacerbated in prostate cancer patients undergoing ADT. Efforts are needed to diagnose and treat depression appropriately, especially if depressive symptoms change in ADT patients with a high IIEF score before ADT, or reduced testosterone levels or increased BMI during ADT.

Massive clonal expansion of medulloblastoma-specific T cells during adoptive cellular therapy

In both human and murine systems, we have developed an adoptive cellular therapy platform against medulloblastoma and glioblastoma that uses dendritic cells pulsed with a tumor RNA transcriptome to expand polyclonal tumor-reactive T cells against a plurality of antigens within heterogeneous brain tumors. We demonstrate that peripheral TCR Vβ repertoire analysis after adoptive cellular therapy reveals that effective response to adoptive cellular therapy is concordant with massive in vivo expansion and persistence of tumor-specific T cell clones within the peripheral blood. In preclinical models of medulloblastoma and glioblastoma, and in a patient with relapsed medulloblastoma receiving adoptive cellular therapy, an early and massive expansion of tumor-reactive lymphocytes, coupled with prolonged persistence in the peripheral blood, is observed during effective therapeutic response to immunotherapy treatment.

Pharmacokinetics and tolerability of IDP-73152 mesylate after a single oral administration under fasted and fed conditions in healthy volunteers

Background and objective

IDP-73152 mesylate is a peptide deformylase inhibitor under investigation for the treatment of complicated skin and respiratory tract infections. The objective of this study was to investigate the pharmacokinetic (PK) profile and tolerability of IDP-73152 and the effect of food after a single oral administration.

Methods

A dose block-randomized, double-blind, placebo-controlled, dose-escalation study was conducted. A total of 56 healthy volunteers received IDP-73152 mesylate in a single oral dose of 40, 80, 160, 320, 640, or 1280 mg in the fasted and fed (640 mg only) states. Blood and urine samples for PK analysis were collected up to 48 h post dose.

Results

The area under the plasma concentration-time curve (AUC_0-t) of IDP-73152 increased in a dose-proportional manner in the range of 40-320 mg. The mean terminal half-life decreased from 10.7 to 6.2 hrs as the dose increased. The fraction excreted unchanged in the urine ranged from 0.05 to 0.12. In the 640-mg dose group, food delayed the median time to peak concentration (t _max) from 0.9 to 3.5 hrs. Furthermore, the maximum plasma concentration (C_max) were decreased by 36.2%; however, AUC_0-t was not generally affected. No serious adverse event or clinically significant findings were observed.

Conclusions

The systemic exposure of IDP-73152 proportionally increased as the dose increased up to 320 mg. The rate of absorption and extent of exposure were reduced by food intake. IDP-73152 was well tolerated without clinically significant adverse effects after a single oral administration.

Factors influencing insulin sensitivity during hyperinsulinemic-euglycemic clamp in healthy Korean male subjects

Background and objective: The effects of age and related factors on insulin sensitivity have not been definitively evaluated in East Asian populations. We proposed a reference range for the glucose disposal rate (M-value) on hyperinsulinemic-euglycemic study and its association with other parameters. Methods: Healthy, non-diabetic young (n=10) and elderly (n=13) male subjects with normal body mass index were eligible for this study. Subjects who passed the oral glucose tolerance test (OGTT) underwent hyperinsulinemic-euglycemic clamp with high-dose (80 mU/m²·min) insulin infusion. Results: M-values were normalized to body weight (M_BW) and fat-free mass (M_FFM). Neither M-value was significantly different between age groups (P=0.458 and P=0.900, respectively). An inverse correlation was observed between M_FFM and baseline insulin (r=-0.418; P=0.047), baseline C-peptide (r=-0.426; P=0.043) and OGTT 2-hour glucose (r=-0.452; P=0.030). Regarding correlations with other insulin sensitivity indices, M-values were positively associated with the Matsuda index but not with homeostasis model assessment of insulin resistance. Conclusion: Our results suggest that age is not a critical determinant of insulin sensitivity, while fasting insulin and C-peptide levels, OGTT 2-hour glucose level, and Matsuda index are predictable markers of insulin sensitivity in healthy Koreans.