The Relationship Between Anti-SSA-52 and Interstitial Lung Disease

OBJECTIVE

The aims of this study were to assess whether a relationship between anti-SSA-52 and interstitial lung disease (ILD) can be further defined, and to enhance screening, detection, and potentially guide treatment.

METHODS

A historical cohort study of 201 patients was conducted at a single tertiary care center between January 1, 2016 and December 31, 2020. All included patients were anti-SSA-52 antibody positive. Chart review was performed for laboratory values, symptoms, pulmonary function tests, treatment, and imaging. Chest computed tomographies were reviewed by chest radiologists.

RESULTS

Among anti-SSA-52 antibody-positive patients, ILD was found in 125 (62.2%) compared with 76 (37.8%) with no ILD (p = 0.001). For those with ILD, 78 (62.4%) were diagnosed with connective tissue disease (CTD)-associated ILD, 28 (22.4%) were diagnosed ILD only, and 19 (15.2%) met the criteria for interstitial pneumonia with autoimmune features. In patients with CTD-ILD, 18 (23.0%) had their ILD diagnosis made over 6 months before a CTD diagnosis, and an additional 43 (55.1%) had their ILD and CTD diagnosed within 6 months of each other (p < 0.001). Common computed tomography patterns were nonspecific interstitial pneumonia/organizing pneumonia overlap in 44 (35.2%), 25 (20.0%) nonspecific interstitial pneumonia, and 15 (12%) usual interstitial pneumonia. Twenty-eight (35.9%) had antisynthetase syndrome, followed by 16 (20.5%) with dermatomyositis, 10 (12.8%) with CTD overlap, and 6 (7.7%) with systemic scleroderma.

CONCLUSIONS

There was a significant association between anti-SSA-52 antibodies and ILD across a wide spectrum of rheumatological diagnoses. A significant portion of patients were diagnosed with ILD either at the same time or before their CTD diagnosis. Further study will be needed to assess effective treatment and response.

Skin Clearance is Associated with Reduced Treatment Failure in Patients with Psoriasis: Real-World Evidence from the CorEvitas Psoriasis Registry

INTRODUCTION

Complete and near-complete skin clearance have become achievable treatment goals for patients with psoriasis receiving systemic biologic therapies. However, there is limited real-world evidence regarding the impact of the degree of skin clearance on biologic treatment patterns among these patients.

METHODS

This longitudinal cohort study assessed the relationship between degree of skin clearance following initiation of a systemic biologic therapy and treatment failure among patients from the CorEvitas Psoriasis Registry (April 2015-August 2021). Patients had Psoriasis Area and Severity Index (PASI) score > 5 at systemic biologic therapy initiation and ≥ 1 follow-up visit(s) within 15 months of initiation. Treatment failure (discontinuation due to poor response/adverse event; addition of non-biologic therapy) and degree of skin clearance (measured by PASI) were assessed following biologic initiation. Proportional hazards regression was used to estimate the association between PASI response level and treatment failure over follow-up.

RESULTS

This study included 2701 patient initiations from 2516 unique patients with 3846 total visits over follow-up. Over half of the patient initiations (n = 1412; 52.3%) were among patients with PASI >10. Treatment failure occurred in 1.3% of visits at which PASI100 was achieved, while those achieving PASI90 - < 100 and PASI75 - < 90 had treatment failure rates of 3.4% and 3.5%, respectively. After adjustment for confounders, the risk of treatment failure was two to three times higher in the PASI90 - < 100 (hazard ratio [HR] = 2.61; 95% confidence interval [CI] 1.35, 5.02; p = 0.004) and PASI75 < 90 (HR = 2.97; CI 1.58, 5.58; p = 0.001) groups compared to the PASI100 group. The risk of treatment failure was more than 20 times higher in the < PASI75 group versus the PASI100 group (HR = 22.26; CI 13.32, 37.21; p < 0.001).

CONCLUSIONS

The results suggest that patients are more likely to remain on a systemic biologic therapy if they achieve near-complete or complete skin clearance, supporting the continued need to target skin clearance as a treatment goal in psoriasis.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT02707341.

Upadacitinib as monotherapy and in combination with non-biologic disease-modifying antirheumatic drugs for psoriatic arthritis

Objective

To assess the efficacy and safety of upadacitinib (UPA), an oral Janus kinase inhibitor, as monotherapy or in combination with non-biologic DMARDs (nbDMARDs) in patients with PsA.

Methods

Pooled data were analysed from patients with prior inadequate response or intolerance to one or more nbDMARD (SELECT-PsA 1) or one or more biologic DMARD (SELECT-PsA 2) who received placebo, UPA 15 mg once daily (QD) or UPA 30 mg QD as monotherapy or in combination with two or fewer nbDMARDs for 24 weeks. Efficacy outcomes included achievement of ACR responses, Psoriasis Area and Severity Index responses, minimal disease activity and change from baseline and clinically meaningful improvement in the HAQ Disability Index. Adverse events (AEs) were summarized.

Results

A total of 1916 patients were included; 574 (30%) received monotherapy and 1342 (70%) received combination therapy. Placebo-subtracted treatment effects for a 20% improvement in ACR criteria at week 12 were 33.7% (95% CI 24.4, 43.1) and 34.0% (95% CI 27.9, 40.1) for UPA 15 mg QD monotherapy and combination therapy, respectively, and 45.7% (95% CI 36.9, 54.5) and 39.6% (95% CI 33.7, 45.5) for UPA 30 mg QD monotherapy and combination therapy, respectively. Treatment effects for other outcomes were consistent between monotherapy and combination therapy. AE frequency was generally similar for UPA monotherapy and combination therapy, although hepatic disorders and creatine phosphokinase elevation were more common with combination therapy vs monotherapy.

Conclusion

The efficacy and safety of UPA were generally consistent when administered as monotherapy or in combination with nbDMARDs through 24 weeks, supporting the use of UPA with or without nbDMARDs in PsA.

Trial registration

ClinicalTrials.gov (https://clinicaltrials.gov): SELECT-PsA 1 (NCT03104400), SELECT-PsA 2 (NCT03104374)

AB0522 SAFETY PROFILE OF UPADACITINIB UP TO 3 YEARS IN PATIENTS WITH PSORIATIC ARTHRITIS: AN INTEGRATED ANALYSIS FROM THE PHASE 3 PROGRAM

Background:

The efficacy and safety of upadacitinib (UPA), an oral Janus kinase inhibitor, in patients (pts) with active psoriatic arthritis (PsA) were demonstrated through 24 weeks in the phase 3 SELECT-PsA 1 and SELECT-PsA 2 placebo-controlled clinical trials.1,2

Objectives:

To describe the long-term integrated safety profile of UPA relative to adalimumab (ADA) in pts with PsA treated in the SELECT program.

Methods:

The SELECT-PsA program enrolled pts with prior inadequate response or intolerance to ≥1 non-biologic DMARD (SELECT-PsA 1) or ≥1 biologic DMARD (SELECT-PsA 2). Both trials include UPA 15 mg and 30 mg, and only SELECT-PsA 1 includes long-term comparison with ADA 40 mg every other week. Treatment-emergent adverse events (TEAEs: AE onset ≥first dose and ≤30 days after last dose for UPA and ≤70 days for ADA) were summarized for the following: pooled UPA 15; pooled UPA 30; and ADA. TEAEs are reported as exposure-adjusted event rates (EAERs; events/100 pts years [E/100 PY]) up to a cut-off date of 20 June 2020.

Results:

2257 pts received ≥1 dose of UPA 15 (N=907; 1247.2 PYs), UPA 30 (N=921; 1257.4 PYs), or ADA (N=429; 549.7 PYs), with median (max) exposures of 69 (155), 69 (154), and 68 (152) weeks, respectively. EAERs of TEAEs and serious AEs were generally similar between UPA 15 and ADA and higher with UPA 30; rates of AEs leading to study drug discontinuation were generally similar across all groups (Table 1). Similarly, rates of serious infection were comparable between UPA 15 and ADA and higher with UPA 30 (Figure 1 next page). The most common serious infection was pneumonia. Rates of herpes zoster were lower with UPA 15 than UPA 30 but higher than ADA. Most herpes zoster events involved a single dermatome; no events involved the central nervous system or other internal organs. Lower rates of opportunistic infections (OI) excluding tuberculosis were observed with UPA 15 vs UPA 30; the most common OI was mucosal candida infection. Malignancies were reported at similar rates across all treatment groups; no events of lymphoma were reported. Age-gender-adjusted standardized incidence ratios for malignancies excluding NMSC indicated no increased risk with UPA compared to the general population. Rates of adjudicated major adverse cardiovascular events and venous thromboembolic events were ≤0.3 E/100 PY for both UPA arms; all pts had ≥1 risk factor. One adjudicated gastrointestinal perforation was reported with UPA 15.

Table 1.

Overall Treatment-emergent AEs for Upadacitinib and Adalimumab (E/100 PY [95% CI])

UPA 15 mg QDN=907(1247.2 PY)UPA 30 mg QDN=921(1257.4 PY)ADA 40 mg EOWN=429(549.7 PY)AEs263.9 (254.9, 272.9)321.5 (311.6, 331.5)286.5 (272.4, 300.7)Serious AEs10.3 (8.6, 12.1)13.2 (11.2, 15.2)9.6 (7.0, 12.2)AE leading to discontinuation6.7 (5.2, 8.1)7.8 (6.2, 9.3)7.8 (5.5, 10.2)Deathsa0.2 (-0.1, 0.4)0.2 (-0.0, 0.5)0.2 (-0.2, 0.5)

aDeaths included non-treatment emergent deaths: UPA 15, 1; UPA 30, 1.

ADA, adalimumab; AE, adverse event; CI, confidence interval; E, event; EOW, every other week; PY, patient years; QD, once daily; UPA, upadacitinib.

Hepatic disorders were mostly transient, non-serious transaminase increases. Creatine phosphokinase elevations were reported more frequently with UPA 30 vs UPA 15; most were asymptomatic with no rhabdomyolysis reported. AEs of anemia, neutropenia, and lymphopenia were generally mild or moderate, non-serious. Except for rates of lymphopenia (higher with UPA 15), hepatic disorders, and neutropenia (both higher with ADA), lab-related TEAEs occurred at generally consistent rates between UPA 15 and ADA. Study drug discontinuation due to lab-related TEAEs was uncommon.

Conclusion:

The safety profiles of UPA 15 and ADA were generally similar; the rates of most AEs were higher with UPA 30 compared with ADA. Through the cut-off date, the safety profile of UPA 15 and UPA 30 in PsA pts demonstrated consistent results compared to what has been observed with UPA in rheumatoid arthritis.3

References:

[1]McInnes IB et al. Ann Rheum Dis, 2020; 79:12.

[2]Mease PJ et al. Ann Rheum Dis, 2020.

[3]Cohen SB et al. Ann Rheum Dis, 2020.

Figure 1

Acknowledgements:

AbbVie and the authors thank the patients, study sites, and investigators who participated in this clinical trial. AbbVie, Inc was the study sponsor, contributed to study design, data collection, analysis & interpretation, and to writing, reviewing, and approval of final version. No honoraria or payments were made for authorship. Medical writing support was provided by Ramona Vladea, PhD of AbbVie Inc.

Disclosure of Interests:

Gerd Rüdiger Burmester Speakers bureau: AbbVie, Gilead, Lilly, Pfizer, Consultant of: AbbVie, Gilead, Lilly, Pfizer, Kevin Winthrop Consultant of: UCB Pharma, Pfizer, Bristol-Myers Squibb, Eli Lilly, AbbVie, Gilead, Galapagos, and Roche, Grant/research support from: UCB Pharma, Pfizer, Bristol-Myers Squibb, Eli Lilly, AbbVie, Gilead, Galapagos, and Roche, Ricardo Blanco Consultant of: Abbvie, Lilly, Novartis, Pfizer, Roche, Bristol-Myers, Janssen, and MSD, Grant/research support from: Abbvie, MSD and Roche, Peter Nash Consultant of: AbbVie, BMS, Roche, Pfizer, Janssen, Amgen, Sanofi-Aventis, UCB, Eli Lilly, Novartis, and Celgene, Grant/research support from: AbbVie, BMS, Roche, Pfizer, Janssen, Amgen, Sanofi-Aventis, UCB, Eli Lilly, Novartis, and Celgene, Philippe Goupille Consultant of: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Janssen, Lilly, Medac, MSD, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Grant/research support from: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Janssen, Lilly, Medac, MSD, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Valderilio F Azevedo Consultant of: AbbVie, BMS, Pfizer, Janssen, Amgen, Novartis, Eli Lilly, UCB, Celltrion and GSK, Grant/research support from: AbbVie, BMS, Pfizer, Janssen, Amgen, Novartis, Eli Lilly, UCB, Celltrion and GSK, Carlo Salvarani Consultant of: Roche, Sanofi-Genzyme, AbbVie, Pfizer, Lilly, Novartis, Amgen, Grant/research support from: Roche, Sanofi-Genzyme, AbbVie, Pfizer, Lilly, Novartis, Amgen, Andrea Rubbert-Roth Consultant of: AbbVie, BMS, Chugai, Roche, Gilead, Janssen, Lilly, Sanofi, Amgen, Novartis, Grant/research support from: AbbVie, BMS, Chugai, Roche, Gilead, Janssen, Lilly, Sanofi, Amgen, Novartis, Elizabeth Lesser Shareholder of: AbbVie, Employee of: AbbVie, Reva McCaskill Shareholder of: AbbVie, Employee of: AbbVie, Jianzhong Liu Shareholder of: AbbVie, Employee of: AbbVie, Bosny Pierre-Louis Shareholder of: AbbVie, Employee of: AbbVie, Sandra Walko Shareholder of: AbbVie, Employee of: AbbVie, Ralph Lippe Shareholder of: AbbVie, Employee of: AbbVie, Apinya Lertratanakul Shareholder of: AbbVie, Employee of: AbbVie, Eric Ruderman Consultant of: AbbVie, Amgen, Gilead, Janssen, Lilly, Novartis, and Pfizer.

OP0049 COMPARISON OF BASELINE DISEASE ACTIVITY AND PATIENT (PT)-REPORTED OUTCOMES (PROS) BETWEEN PTS WITH PSORIATIC ARTHRITIS AND AXIAL INVOLVEMENT (AXIAL PSA) AND AXIAL SPONDYLOARTHRITIS (AXIAL SPA) FROM THE CORRONA PSA/SPA REGISTRY

Background:

Although pts with axial PsA and axial SpA share some common clinical characteristics, there are also potential differences that may influence disease assessment and treatment response. Identifying differences between the two pt populations is important for assessment of disease characteristics and severity as well as informing treatment decisions. There has been little comparative characterization of these conditions in a US population.

Objectives:

To compare characteristics of pts with axial PsA and axial SpA.

Methods:

Pts ≥18 years of age diagnosed with axial PsA or axial SpA at enrollment in the prospective, multicenter, observational Corrona PsA/SpA Registry between March 2013 and August 2020 were included. Enrollment visit demographics, clinical characteristics, treatment history, disease activity measures, and PROs were compared between disease groups. Continuous measures were reported using means and standard deviations; means for disease groups were compared using two-sample t tests or Wilcoxon rank sum tests. Categorical measures were reported as frequencies and percentages; frequencies in disease groups were compared using chi-square or Fisher exact tests.

Results:

A total of 1044 pts (470 with axial PsA and 574 with axial SpA) were identified (Table). Pts with axial PsA were older with a higher percentage being female vs pts with axial SpA. Time since symptom onset and diagnosis were shorter for pts with axial PsA vs axial SpA (12.0 vs 15.6 years [P<0.001] and 6.8 vs 8.3 years [P=0.01]). Pts with axial PsA were less likely than pts with axial SpA to have current or historical uveitis (4% vs 14% [P<0.001]) or inflammatory bowel disease (5% vs 10% [P=0.005]). Prior biologic synthetic disease-modifying antirheumatic drug (bDMARD) and conventional synthetic DMARD use was more prevalent in the axial PsA vs axial SpA groups (64% vs 52% [P<0.001]/59% vs 32% [P<0.001]), while mean dactylitis (measured by Dactylitis Count) and enthesitis (measured by Spondyloarthritis Research Consortium of Canada [SPARCC] Enthesitis Index) counts were higher (0.4 vs 0.1 [P<0.001]/1.7 vs 1.2 [P<0.001]). Mean pt-reported pain and spinal pain were lower in pts with axial PsA vs axial SpA (49.4 vs 53.9 [P=0.015]/40.8 vs 49.7 [P<0.001]) (Figure). The proportion of pts with morning stiffness along with mean fatigue and work impairment scores were similar between disease groups.

Table.Baseline demographics and clinical characteristicsAxial PsAN=470Axial SpAN=574P valueAge (years), mean ± SD51.6 ± 13.247.7 ± 14.0<0.001Female, n (%)265 (57)248 (44)<0.001White, n (%)428 (94)507 (91)0.089Years since symptom onset, mean ± SD12.0 ± 11.615.6 ± 12.1<0.001Years since diagnosis, mean ± SD6.8 ± 9.08.3 ± 10.50.010HLA-B27 positive status, n/n (%)52/189 (28)214/295 (73)<0.001Abnormal CRP, n (%)88 (19)140 (24)0.033Uveitis, n (%)20 (4)80 (14)<0.001IBD, n (%)25 (5)59 (10)0.005Dactylitis count, mean ± SD0.4 ± 1.50.1 ± 0.7<0.001SPARCC enthesitis count, mean ± SD1.7 ± 2.91.2 ± 2.4<0.001Morning stiffness, n (%)439 (95)537 (96)0.923BASDAI (0–10), mean ± SD4.8 ± 2.54.9 ± 2.40.463BASDAI Q2 (0–10): spinal pain, mean ± SD5.0 ± 2.95.7 ± 2.9<0.001BASDAI Q3 (0–10): peripheral pain/swelling, mean ± SD4.5 ± 2.94.0 ± 3.10.010Modified BASDAI (0–10), mean ± SD5.0 ± 2.55.4 ± 2.40.013Prior bDMARDs, n (%)300 (64)299 (52)<0.001Prior csDMARDs, n (%)275 (59)181 (32)<0.001Prior prednisone use, n (%)54 (12)73 (13)0.611Prior NSAID use, n (%)52 (11)46 (8)0.115

Conclusion:

Findings from this descriptive real-world analysis suggest there may be meaningful differences between pts with axial SpA and axial PsA but future studies are needed to better understand these differences.

Acknowledgements:

Medical writing services provided by Alan Saltzman of Fishawack Facilitate Ltd, part of Fishawack Health, and funded by AbbVie.

This study was sponsored by Corrona, LLC. Corrona has been supported through contracted subscriptions in the last 2 years by AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Crescendo, Eli Lilly and Company, Genentech, Gilead, GSK, Janssen, Merck, Momenta Pharmaceuticals, Novartis, Pfizer, Regeneron, Roche, Sun, UCB, and Valeant. The design, study conduct, and financial support for the study were provided by AbbVie. AbbVie participated in the interpretation of data, review, and approval of the abstract. No honoraria or payments were made for authorship.

Disclosure of Interests:

Philip J Mease Speakers bureau: AbbVie, Amgen, Janssen, Lilly, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Amgen, BMS, Boehringer Ingelheim, Celgene, Galapagos, Gilead, GlaxoSmithKline, Janssen, Lilly, Novartis, Pfizer, Sun, and UCB, Grant/research support from: AbbVie, Amgen, BMS, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Sun, and UCB, Maya Marchese Employee of: Corrona, Robert McLean Employee of: Corrona, Taylor Blachley Employee of: Corrona, Laura Anatale-Tardiff Employee of: Corrona, Christopher Saffore Shareholder of: AbbVie, Employee of: AbbVie, Elizabeth Lesser Shareholder of: AbbVie, Employee of: AbbVie, Alexis Ogdie Consultant of: Amgen, AbbVie, BMS, Celgene, Corrona, Gilead, Janssen, Lilly, Novartis, Pfizer, and UCB, Grant/research support from: National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases, Rheumatology Research Foundation, National Psoriasis Foundation, Pfizer, and Novartis

POS1035 UPADACITINIB AS MONOTHERAPY AND IN COMBINATION WITH NON-BIOLOGIC DMARDs FOR THE TREATMENT OF PSORIATIC ARTHRITIS: SUBGROUP ANALYSIS FROM TWO PHASE 3 TRIALS

Background:

Approximately 40% of PsA patients (pts) on advanced therapy are on monotherapy.1,2 Upadacitinib (UPA) showed efficacy and safety in pts with active PsA in the Phase 3 SELECT-PsA 1 and SELECT-PsA 2 clinical trials.3,4

Objectives:

Assess efficacy and safety in subgroups of pts treated with UPA as monotherapy or in combination with non-biologic disease-modifying antirheumatic drugs (non-bDMARDs).

Methods:

The SELECT-PsA program enrolled pts with prior inadequate response (IR) or intolerance to ≥1 non-bDMARD (N=1705) and prior IR or intolerance to ≥1 bDMARD (N=642). Data from both trials was integrated for pts receiving placebo (PBO), UPA 15 mg once daily (QD) and UPA 30 mg QD. Stable background treatment of ≤2 non-bDMARDs was permitted, but not required. Analysis includes UPA monotherapy vs combination therapy for endpoints: ACR20/50/70 responses and change from baseline in pain and HAQ-DI (Wk 12); Static Investigator Global Assessment of Psoriasis of 0 or 1 and at least a 2-point improvement from baseline and PASI75/90/100 responses (Wk 16); proportion of pts achieving resolution of enthesitis, dactylitis, and minimal disease activity (Wk 24). Binary outcomes, using the Cochran-Mantel-Haenszel-method and continuous outcomes, using mixed-effects model, were analyzed for repeated measures in the subgroups of UPA monotherapy and combination therapy. Point estimates and 95% confidence intervals (CIs) of PBO subtracted treatment effect were calculated. Treatment-emergent adverse events (TEAEs) were analyzed.

Results:

Of 1916 pts, 574 (30%) received monotherapy and 1342 (70%) received combination therapy; 84% in combination therapy group received MTX +/- another non-bDMARD. Both UPA monotherapy and combination therapy led to improvements in efficacy vs PBO and across endpoints, for each dose, generally consistent point estimates of PBO subtracted treatment effect and associated overlapping CIs were observed (Figure 1). Generally, frequency of AEs and serious AEs, were comparable with UPA administered as monotherapy and combination therapy (Table 1). Frequency of AEs of serious infections and hepatic disorder were lower with monotherapy while frequency of AEs leading to discontinuation of study drug were lower with combination therapy. Most hepatic disorders were transient transaminase elevations.

Conclusion:

In the SELECT PsA trials, efficacy and safety of UPA was generally consistent when administered as monotherapy or when given in combination with non-bDMARDs. Results from this analysis support the use of UPA with or without concomitant non-bDMARDs.

References:

[1]Ianculescu I and Weisman MH, Clin Exp Rheumatol 2015; 33:S94–S97.

[2]Mease PJ, et al. RMD Open 2015; 1:e0000181.

[3]McInnes IB, et al. Ann Rheum Dis, 2020; 79:12.

[4]Genovese MC, et al. Ann Rheum Dis, 2020; 79:139.

Acknowledgements:

AbbVie and the authors thank the patients, study sites, and investigators who participated in this clinical trial. AbbVie, Inc was the study sponsor, contributed to study design, data collection, analysis & interpretation, and to writing, reviewing, and approval of final version. No honoraria or payments were made for authorship. Medical writing support was provided by Ramona Vladea of AbbVie Inc.

Disclosure of Interests:

Peter Nash Speakers bureau: AbbVie, BMS, Roche, Pfizer, Janssen, Amgen, Sanofi-Aventis, UCB, Eli Lilly, Novartis, and Celgene, Consultant of: AbbVie, BMS, Roche, Pfizer, Janssen, Amgen, Sanofi-Aventis, UCB, Eli Lilly, Novartis, and Celgene, Grant/research support from: AbbVie, BMS, Roche, Pfizer, Janssen, Amgen, Sanofi-Aventis, UCB, Eli Lilly, Novartis, and Celgene, Pascal Richette Speakers bureau: AbbVie, Biogen, Janssen, BMS, Roche, Pfizer, Amgen, Sanofi-Aventis, UCB, Lilly, Novartis, and Celgene, Consultant of: AbbVie, Biogen, Janssen, BMS, Roche, Pfizer, Amgen, Sanofi-Aventis, UCB, Lilly, Novartis, and Celgene, Laure Gossec Speakers bureau: Abbvie, Amgen, Biogen, BMS, Celgene, Lilly, Novartis, Pfizer, Janssen, Sandoz, Sanofi-Aventis, UCB, Consultant of: Abbvie, Amgen, Biogen, BMS, Celgene, Lilly, Novartis, Pfizer, Janssen, Sandoz, Sanofi-Aventis, UCB, Grant/research support from: Abbvie, Amgen, Biogen, BMS, Celgene, Lilly, Novartis, Pfizer, Janssen, Sandoz, Sanofi-Aventis, UCB, Antonio Marchesoni Speakers bureau: AbbVie, BMS, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Pfizer, and UCB, Consultant of: AbbVie, BMS, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Pfizer, and UCB, Christopher T. Ritchlin Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Janssen, Novartis, UCB, Grant/research support from: UCB, Koji Kato Shareholder of: AbbVie, Employee of: AbbVie, Erin McDearmon-Blondell Shareholder of: AbbVie, Employee of: AbbVie, Elizabeth Lesser Shareholder of: AbbVie, Employee of: AbbVie, Reva McCaskill Shareholder of: AbbVie, Employee of: AbbVie, Dai Feng Shareholder of: AbbVie, Employee of: AbbVie, Jaclyn Anderson Shareholder of: AbbVie, Employee of: AbbVie, Eric Ruderman Consultant of: AbbVie, Amgen, Gilead, Janssen, Lilly, Novartis, and Pfizer.

Clinical Outcomes following Left Atrial Appendage Occlusion: A Single-Center Experience

INTRODUCTION

Percutaneous left atrial appendage closure is an established alternative to anticoagulation therapy for stroke prophylaxis among patients with nonvalvular atrial fibrillation. There are currently no guidelines on the choice of antithrombotic therapy following placement of the Watchman® device, the optimal time to discontinue anticoagulation or the duration of follow-up imaging after device deployment. Our main objective was to evaluate clinical outcomes among these patients.

METHODS

We conducted a retrospective review of patients who received a Watchman® device at Mayo Clinic sites between January 2010 and December 2018. We constructed Cox-proportional hazard models to evaluate the effect of specific variables on clinical outcomes.

RESULTS

231 patients were identified (33% female), median age was 77 years, CHA2DS2-VASc score was 5 and HASBLED score was 4. We found no difference in clinically significant bleeding based on initial antithrombotic choice. However, patients with prior gastrointestinal bleeding were more likely to have a bleeding event in the first 6 weeks following Watchman® implantation (HR 9.40, 95% CI 2.15-41.09). Device sizes of 24-27 mm were significantly associated with a decreased risk of thromboembolic events (HR 0.15, 95% CI 0.04-0.55) compared to 21-mm devices. Peridevice leak (PDL) sizes appeared to either remain the same or increase on follow-up imaging.

DISCUSSION/CONCLUSIONS

This observational study showed no statistically significant difference in bleeding risk related to initial antithrombotic choice. Smaller device sizes were associated with thromboembolic events, and longitudinal PDL assessment using transesophageal echocardiography showed these frequently do not decrease in size. Larger studies are needed.

A Retrospective Review of Native Septic Arthritis in Patients: Can We Diagnose Based on Laboratory Values?

Introduction The accurate diagnosis of acute septic arthritis is essential to initiating appropriate treatment and minimizing potential cartilage damage. A synovial fluid cell count of 50,000 cells/mm³ has been used as a diagnostic cutoff for acute septic arthritis, although data supporting this is lacking. The purpose of this study was to assess the efficacy of synovial cell counts to predict septic arthritis in patients with symptomatic native joints. Methods A retrospective review was performed of patients who were evaluated for septic arthritis at a single institution with the use of synovial fluid analysis and adjunctive lab tests. Exclusion criteria included history of a total joint arthroplasty of the affected joint or immunocompromised state. A true infection was considered on the basis of positive or negative synovial aspirate cultures. We evaluated the synovial cell count, synovial polymorphonuclear cell percentile (% neutrophils), serum white blood cell (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) in order to determine their association and predictive power in a true infection. Results Of the 65 patients included in the study, 40 (61.5%) had a positive culture for septic arthritis and 25 (38.5%) had negative cultures. Patients with positive cultures had a larger median % neutrophils than patients with negative cultures (median: 93 vs. median: 86, P=0.041). They also tended to have higher serum CRP levels compared to negative culture patients (median: 142.30 vs. 34.20, P=0.051). No outcomes were independently highly effective in discriminating between patient groups (area under the curve (AUC) ≤ 0.67). There was no significant difference between the synovial cell counts in patients with culture positive septic arthritis and patients with negative cultures (median: 32435 vs 35385, P = 0.94).  Conclusion Patients with culture proven septic arthritis had larger % neutrophils. However, there were no other statistically significant differences between patient groups regarding ESR, CRP, WBC, or cell count aspiration at the time of diagnosis. No synovial cell count level was highly effective in discriminating patients with a positive culture for septic arthritis from patients with negative cultures.

AB0835 THE IMPACT OF ADALIMUMAB VS PLACEBO ON PATIENT-REPORTED OUTCOMES AND UTILITY MEASURES AMONG PATIENTS WITH MODERATELY TO SEVERELY ACTIVE PSORIATIC ARTHRITIS

Background:

Physical function and health-related quality of life(HRQoL) are negatively impacted in patients(pts) with PsA. Treatment with conventional and biological (b) DMARDs improved patient-reported outcomes(PROs).

Objectives:

To assess impact of adalimumab(ADA) vs placebo(PBO) on PROs following 12-week (wk) treatment.

Methods:

Pts(n=315) with moderately to severely active PsA and bDMARD naive were randomized to ADA 40mg or PBO every other wk. We assessed PROs at baseline(BL) and wk 12 using the 36-item Short-Form(SF-36) Health Survey physical(PCS) and mental component summary(MCS) scores, 8 domain scores ranging from 0(worst) to 100(best), and SF-6D utility measure derived from all 8 SF-36 domains with scores ranging from 0.296(worst) to 1.00(full health) and minimally important difference(MID) of 0.041. Patient Global Assessment of disease activity(PtGA) and pain(both utilizing 100 mm visual analog scale[VAS]) and HAQ disability index(DI) were assessed. Mean changes from BL, percentages of pts with improvements ≥minimum clinically important differences(MCID), and scores ≥US age-and gender-matched normative values(A/G norms) were analyzed, based on as observed data.Pvalues were assessed by analysis of variance model for continuous variables andCochran–Mantel–Haenszeltest for binary outcomes, adjusting by baseline MTX use and extent of psoriasis. Numbers needed to treat(NNTs) are reported using proportions of pts reporting improvements ≥MCID in SF-36, PtGA, pain, and HAQ-DI.

Results:

BL PRO scores were similar between ADA(n=151) and PBO(n=162;Table 1). Improvements from BL at wk 12 with ADA vs PBO were significant in PtGA, pain, HAQ-DI, and SF-36 PCS(change: 9.3 vs 1.4;P<0.001) but not in SF-36 MCS(1.6 vs 1.2;Table 1). Six of 8 SF-36 domains significantly improved from BL to wk 12 with ADA vs PBO(allP≤0.05;Table 1andFigure 1). SF-6D improvements exceeded MID with ADA(change: 0.071) vs PBO(0.018). Proportions of pts reporting improvements ≥MCID at wk 12 were significantly greater with ADA vs PBO in all PROs, except SF-36 role emotional and mental health domains, with corresponding NNTs ≤6.4(Figure 2). Proportions of pts who reported scores ≥A/G norms in HAQ-DI, SF-36 PCS, and 6 of 8 SF-36 domains were significantly greater with ADA vs PBO(Figure 2).

Table 1.

Mean Disease Characteristics and SF-36 Domain Scores by Treatment Group at Baseline and Wk 12 Compared With Age-and Gender-Matched Normative Values

ADA 40 mg eowPBOA/G normsBaselineWeek 12[change from baseline to week 12]BaselineWeek 12[change from baseline to week 12]SF-36 PCS33.242.5[9.3**]33.334.7[1.4]≥50SF-36 MCS48.149.8[1.6]46.648.4[1.2]≥50SF-6D0.6530.724[0.071]0.6410.659[0.018]—PtGA47.125.9[–21.7**]48.147.5[0.2]—Pt pain51.126.8[–24.1**]48.849.1[1.3]—HAQ-DI1.00.6[–0.4**]1.00.9[–0.1]≤0.25Baseline(vs A/G norms)Week 12(vs A/G norms)Baseline(vs A/G norms)Week 12(vs A/G norms)Physical Functioning50.8(−31.5)65.9***(−16.4)48.2(−34.1)52.0(−30.3)82.3Role Physical37.1(−45.9)65.9***(−17.1)32.6(−50.4)40.6(−42.4)83.0Bodily Pain41.3(−31.6)61.0***(−11.9)40.2(−32.7)43.7(−29.2)72.9General Health49.5(−20.8)62.1***(−8.2)52.1(−18.2)53.0(−17.3)70.3Vitality41.4(−17.8)55.1***(−4.1)41.6(−17.6)45.0(−14.2)59.2Social Functioning66.3(−19.0)77.8†(−7.5)61.7(−23.6)66.7(−18.6)85.3Role Emotional65.1(−23.4)70.4(−18.1)59.1(−29.4)66.0(−22.5)88.5Mental Health67.6(−8.5)72.9(−3.2)64.9(−11.2)67.3(−8.8)76.1

ADA, adalimumab; A/G norm, age-and gender-matched normative value; eow, every other week; DI, disability index; MCS, mental component summary; MID, minimally important difference; PBO, placebo; PCS, physical component summary; PtGA, Patient Global Assessment of disease activity; SF-36, 36-item Short-Form Health Survey; SF-6D, Short-Form 6D.

SF-6D MID=0.041.

Statistical analysis ADA vs PBO:†P<0.05; *P<0.01; **P<0.001; ***P<0.0001.

Conclusion:

Statistically significant and clinically meaningful improvements and scores ≥A/G norms(higher definition of response) at week 12 were reported with ADA vs PBO in pts with moderately to severely active PsA.

Disclosure of Interests:

Vibeke Strand Consultant of: AbbVie, Amgen, Biogen, Celltrion, Consortium of Rheumatology Researchers of North America, Crescendo Bioscience, Eli Lilly, Genentech/Roche, GlaxoSmithKline, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Sanofi, UCB, Pankaj Patel Shareholder of: AbbVie, Employee of: AbbVie, Naijun Chen Shareholder of: AbbVie Inc, Employee of: AbbVie Inc, Elizabeth Lesser Shareholder of: AbbVie Inc, Employee of: AbbVie Inc

Early Safety Indicators of COVID-19 Convalescent Plasma in 5,000 Patients

BACKGROUND

Convalescent plasma is the only antibody based therapy currently available for COVID-19 patients. It has robust historical precedence and sound biological plausibility. Although promising, convalescent plasma has not yet been shown to be safe as a treatment for COVID-19.

METHODS

Thus, we analyzed key safety metrics after transfusion of ABO-compatible human COVID-19 convalescent plasma in 5,000 hospitalized adults with severe or life threatening COVID-19, with 66% in the intensive care unit, as part of the US FDA Expanded Access Program for COVID-19 convalescent plasma.

RESULTS

The incidence of all serious adverse events (SAEs) in the first four hours after transfusion was <1%, including mortality rate (0.3%). Of the 36 reported SAEs, there were 25 reported incidences of related SAEs, including mortality (n=4), transfusion-associated circulatory overload (TACO; n=7), transfusion-related acute lung injury (TRALI; n=11), and severe allergic transfusion reactions (n=3). However, only 2 (of 36) SAEs were judged as definitely related to the convalescent plasma transfusion by the treating physician. The seven-day mortality rate was 14.9%.

CONCLUSION

Given the deadly nature of COVID-19 and the large population of critically-ill patients included in these analyses, the mortality rate does not appear excessive. These early indicators suggest that transfusion of convalescent plasma is safe in hospitalized patients with COVID-19.

Trends in glioblastoma: outcomes over time and type of intervention: a systematic evidence based analysis

INTRODUCTION

Despite aggressive treatment with chemoradiotherapy and maximum surgical resection, survival in patients with glioblastoma (GBM) remains poor. Ongoing efforts are aiming to prolong the lifespan of these patients; however, disparities exist in reported survival values with lack of clear evidence that objectively examines GBM survival trends. We aim to describe the current status and advances in the survival of patients with GBM, by analyzing median overall survival through time and between treatment modalities.

METHODS

A systematic review was conducted according to PRISMA guidelines to identify articles of newly diagnosed glioblastoma from 1978 to 2018. Full-text glioblastoma papers with human subjects, ≥ 18 years old, and n ≥ 25, were included for evaluation.

RESULTS

The central tendency of median overall survival (MOS) was 13.5 months (2.3-29.6) and cumulative 5-year survival was 5.8% (0.01%-29.1%), with a significant difference in survival between studies that predate versus postdate the implementation of temozolomide and radiation, [12.5 (2.3-28) vs 15.6 (3.8-29.6) months, P < 0.001]. In clinical trials, bevacizumab [18.2 (10.6-23.0) months], tumor treating fields (TTF) [20.7 (20.5-20.9) months], and vaccines [19.2 (15.3-26.0) months] reported the highest central measure of median survival.

CONCLUSION

Coadministration with radiotherapy and temozolomide provided a statistically significant increase in survival for patients suffering from glioblastoma. However, the natural history for GBM remains poor. Therapies including TTF pooled values of MOS and provide means of prolonging the survival of GBM patients.

Ivermectin and Moxidectin Can Incapacitate Different Strains of the Common Bed Bug Cimex lectularius L.: A Study

The common bed bug Cimex lectularius L. (C. lectularius) is a hematophagous ectoparasite that has recently resurged in many western industrialized nations, in part due to pesticide resistance. Using a laboratory feeding system, we found that the antiparasitic drugs ivermectin and moxidectin did not show higher incapacitation rates in pyrethroid-resistant strains of C. lectularius compared to a pyrethroid-susceptible strain. Additionally, we developed a high-performance liquid chromatography (HPLC) and mass spectroscopy (MS) assay to measure the concentrations of ivermectin inside C. lectularius and found that ivermectin persists in the insects for up to one month. HPLC/MS will be useful in understanding the pathophysiology behind the long-term morbidity observed in C. lectularius that consumes a sublethal dose of ivermectin.

EPID-20. TRENDS IN GLIOBLASTOMA OUTCOMES OVER TIME, GEOGRAPHIC LOCATION AND TYPE OF INTERVENTION

INTRODUCTION

The management of glioblastoma (GBM) has changed over time and varies based on geographic location. Despite its universally fatal prognoses, it is unclear if GBM outcomes have changed over time, if they vary by geographic location, and differ based on type of intervention. As a result, we conducted a systematic review of the literature to identify the average survival differences of GBM patients across time, between different continents, and among various treatments.

METHODS

The systematic review of PubMed included glioblastoma, GBM, and survival. Inclusion criteria consisted of full-text titles with human subjects, GBM/Grade IV astrocytoma, age >18 years old, and with available survival data.

RESULTS

9,162 articles were screened for survival data, 1728 were eligible, 405 complied with the inclusion criteria. Of the 405 studies, 179 (44.2%) were conducted in Europe, 151 (37.3%) in the Americas, 61 (15.1%) in Asia, 9 (2.2%) in Oceania, and 1 (0.2%) in Africa. Leading countries are the United States (33.1%), Germany (12.3%), and Italy (11.1%). Asia had the highest median survival (14.9 months), followed by Europe (13.2 months), and the United States (12.9 months) (P=0.003). Regarding treatment, survival was significantly higher after the introduction of the Stupp protocol (P< 0.001). Post-Stupp Studies had longer survival estimates (15.3 months, range: 3.8–29.6) than Pre-Stupp Studies (12.2 months, range: 2.3–28). In the included clinical trials (182), radiation (43.4%), temozolomide (25.3%), or other chemotherapies (24.2%) were the most common interventions. Clinical trial median survival estimates were significantly higher than all other studies (P< 0.017). Bevacizumab (19.3 months) and Temozolomide (15.9 months) had the longest recorded median survival estimates; while radiation (14 months), other chemotherapies, and carmustine (13.2 months) had the shortest (P=0.009).

CONCLUSION

This epidemiological study describes the current global state of GBM. Important differences regarding survival and treatment of patients with GBM were found.

A Prospective, Blinded Study Comparing In-hospital Postoperative Pain Scores Reported by Patients to Nurses Versus Physicians

Introduction: Referred to as the “fifth vital sign”, pain is unique in that it cannot be obtained accurately by objective measurements. Instead, providers rely on patient-reported scales, such as the numerical rating scale (NRS), to determine a patient’s pain level. Research has shown that patients report different pain scores to nurses and physicians in the clinic setting. It is unknown if this also occurs in the acute postoperative period. We hypothesized that patients report similar pain scores to the nursing staff and physician postoperatively. The primary aim of this study was to examine the degree of agreement between these patient-reported pain scores.

Methods: A prospective study was conducted on 90 postoperative patients. During rounds, the surgeon collected a patient-reported pain score using the 11-point verbal NRS. Following rounds, the nursing staff obtained a pain score using the same scale. The patient was blinded to the study.

Results: The median score reported to both the surgeon and nurses was 3 (range: 0-10), with a median difference of 0 (range: -2.5 to 7). Fifty-four percent of patients reported the same score to both the surgeon and the nurse and 88% of patients reported scores within a 1-point difference. This corresponded to an interclass correlation coefficient of 0.90, indicating very good agreement. The degree of agreement in pain scores reported to surgeons and nurses was consistent according to sex and age.

Conclusion: The results of the study demonstrate a high degree of agreement between the pain scores reported by the patients to both the nursing staff and the surgeon postoperatively, with 88% of the scores at most being 1-point different.

The Benefit of a Single Oral Dose of Ivermectin in Humans: The Adverse Effects on Cimex lectularius L. Populations and Fecundity

Objective

To measure the population size and fecundity of the common bed bug Cimex lectularius L. (C. lectularius) after feeding it with the blood obtained from human subjects who have consumed a single dose of ivermectin.

Methods 

Serial blood samples were obtained from two human subjects at hour 0 (control) and 4-96 hours after they received a single 0.2 mg/kg dose of ivermectin. The blood samples were then fed to 2,273 bed bugs. Bed bug incapacitation rates, fecundity, and population sizes were recorded over a 54-day period. Whole blood ivermectin levels were measured in the human subjects and the insects.

Results 

The fold change in the size of the control group population over the course of the experiment was found to be 2.16. This was significantly greater (p: <.001) than for all the post-ivermectin feeding groups (range: -11.04-1.43). Two weeks after the experiment, the number of eggs laid per live adult female bed bug per day was 10.74 for controls, which was significantly different (p: <0.001) compared to all the post-ivermectin feeding groups (range: 0-4.28).

Conclusions 

There were significant reductions in C. lectularius population size and fecundity in insects that fed on blood obtained from human study subjects up to 96 hours after they have consumed a single oral dose of ivermectin.

US neurologists in the 1990's: trends in practice characteristics

BACKGROUND

The American Academy of Neurology (AAN) conducts periodic surveys of its members to profile and monitor changes in the characteristics of US neurologists and their practices.

OBJECTIVE

To assess neurologists' characteristics, geographic distribution, practice arrangements, professional activities, practice volume, procedures performed, sources of revenue, involvement with managed care and capitation, and other selected topics.

METHODS

The AAN Member Census survey was sent to US neurologists in the fall of 1996 (response rate = 89%), and the Practice Profile survey was sent to a random sample of 1,986 US neurologists in the summer of 1997 (response rate = 55%) who had completed a Member Census survey. The results of the Practice Profile survey were compared with those of two prior surveys conducted in 1991 to 1992 and 1993 to 1994.

RESULTS

The mean age of US neurologists is 48 years, 18% are women, 93% are US citizens, and 24% are international medical graduates. The proportion of neurologists in solo practices, group practices, and medical schools/universities has not changed. The weekly hours worked has remained stable (58 hours), but the time spent in administrative activities has increased (p < 0.001). The average number of patient visits per week to neurologists appears to have increased (p < 0.001), as has the proportion of neurologists performing procedures (p < 0.05). The majority of neurologists have contracts with managed care organizations (82%), and a minority (32%) have capitated payment arrangements. Medicare continues to be the largest source of clinical revenue. Nearly 50% of all respondents have experience in developing clinical practice guidelines or critical pathways, and >20% of respondents employed physician extenders to assist in their practices.

CONCLUSION

Neurologists are spending more time in administrative activities, are performing or interpreting more procedures, and are seeing more patients. Neurologists' involvement with capitation is comparable with that in a nationally representative sample of physicians, and they are exploring innovative ways, such as developing practice guidelines and using physician extenders, to improve the quality and efficiency of providing neurologic care.

Use of midline catheters in low birth weight infants

Prolonged intravenous access is an important consideration in the treatment of premature neonates. Because peripheral intravenous catheters have short dwell times, centrally positioned percutaneous catheters have been used increasingly in neonatal intensive care. Midline catheters are peripherally inserted long catheters advanced only to the proximal portion of a limb or to the neck, with the tip remaining outside the thoracic and abdominal cavities. Midline catheters were placed with use of an innovative technique via a 24-gauge Angiocath catheter (Becton Dickinson, Sandy, Utah). This study compared dwell time and reason for removal of midline catheters with respective data for peripheral intravenous catheters. Dwell time was found to be 9.0 +/- 1.4 days for the midline catheters versus 3.1 +/- 0.5 days for peripheral intravenous catheters placed in the same patients (p < 0.05). No significant complications occurred with the use of midline catheters. These data suggest that midline catheters may be useful in neonates who require a limited duration of intravenous therapy.

Effect of eserine on the chick biventer cervicis preparation

1. The relationship between the capacity of the chick biventer preparation, both intact tissue and homogenate, to inactivate acetylcholine and the ability of eserine to increase the sensitivity of the tissue to acetylcholine have been investigated.2. At concentrations of eserine of 2.69 x 10(-9)M and 2.69 x 10(-8)M the capacity of the whole tissue to inactivate acetylcholine is reduced by 5% and 15% respectively. These concentrations of eserine increase the sensitivity of the preparation to acetylcholine by factors of 2 and 4 respectively, without a change of slope in regression lines.3. At concentrations of eserine of 2.69 x 10(-7)M and 2.69 x 10(-6)M the capacity of the whole tissue to inactivate acetylcholine is reduced by 40% and 80% respectively, and the sensitivity to acetylcholine increased by factors of 70 and 800 respectively, along with marked increases in the slopes of the regression lines.4. An attempt has been made to quantify these differences by proposing a model in which cholinesterase in the tissue is regarded as a network, preventing the access of a large fraction of the acetylcholine to its site of action.5. It is suggested that, whereas the increase in sensitivity to acetylcholine at eserine concentrations of 2.69 x 10(-9)M and 2.69 x 10(-8)M can be interpreted as an anticholinesterase effect (which is still present at higher concentrations), that seen at the higher concentrations may represent a direct action of eserine on the tissue.6. It is further suggested that there are barriers to penetration in intact tissue to both substrate and inhibitor, which invalidate attempts to extrapolate results from homogenates.