Long-Term Safety of Guselkumab in Patients with Psoriatic Disease: An Integrated Analysis of Eleven Phase II/III Clinical Studies in Psoriasis and Psoriatic Arthritis

INTRODUCTION

The benefit/risk profiles of biologics can be affected by comorbidities, certain demographic characteristics, and concomitant medications; therefore, it is important to evaluate the long-term safety profiles of biologics across broad patient populations. Guselkumab was well tolerated and efficacious across individual pivotal clinical studies in adults with moderate-to-severe psoriasis and/or active psoriatic arthritis (PsA).

OBJECTIVES

The objective of the current analysis was to evaluate guselkumab safety in a large population of patients with psoriatic disease by pooling adverse event (AE) data from 11 phase II/III studies (seven in psoriasis; four in PsA).

METHODS

Guselkumab was generally administered as 100 mg subcutaneous injections at Week 0, Week 4, then every 8 weeks (Q8W) in psoriasis studies and at Week 0, Week 4, then every 4 weeks (Q4W) or Q8W in PsA studies. Safety data were summarized for the placebo-controlled period (Weeks 0-16 in psoriasis; Weeks 0-24 in PsA) and through the end of the reporting period (up to 5 years in psoriasis; up to 2 years in PsA). Using the integrated data, incidence rates of key AEs were determined post hoc, adjusted for duration of follow-up, and reported per 100 patient-years (PYs). AE rates were also determined in subgroups of patients defined by sex, age, body mass index (BMI), and prior biologic use.

RESULTS

During the placebo-controlled period, 1061 patients received placebo (395 PYs) and 2257 received guselkumab (856 PYs). Through the end of the reporting period, 4399 guselkumab-treated patients contributed 10,787 PYs of follow-up. During the placebo-controlled period, in the guselkumab and placebo groups, respectively, rates of AEs were 281 versus 272/100 PYs, and infections were 76.0 versus 72.2/100 PYs. Rates of serious AEs (5.6 vs. 7.8/100 PYs), AEs leading to discontinuation (4.9 vs. 6.6/100 PYs), serious infections (1.0 vs. 2.3/100 PYs), malignancy (0.59 vs. 0.25 patients/100 PYs), and major adverse cardiovascular events (MACE; 0.35 vs. 0.25/100 PYs) were low and comparable between guselkumab and placebo. Among guselkumab-treated patients, safety event rates through the end of the reporting period were numerically lower than or comparable with rates observed during the placebo-controlled period: AEs, 164/100 PYs; infections, 61.2/100 PYs; serious AEs, 5.4/100 PYs; AEs leading to discontinuation, 1.8/100 PYs; serious infections, 1.0/100 PYs; malignancy, 0.6/100 PYs; and MACE, 0.3/100 PYs. No AEs of Crohn's disease, ulcerative colitis, or active tuberculosis were reported among guselkumab-treated patients. In the psoriasis studies, no opportunistic infections were reported among guselkumab-treated patients. Three AEs of opportunistic infections were reported in guselkumab-treated patients with PsA (0.14/100 PYs; all after Week 52 in DISCOVER-2). AE rates were largely consistent across subgroups of guselkumab-treated patients defined by sex, age, BMI, and prior biologic use.

CONCLUSIONS

In this analysis of 4399 guselkumab-treated patients with psoriatic disease followed for 10,787 PYs, guselkumab had a favorable AE profile. AE rates were similar between guselkumab- and placebo-treated patients and were consistent throughout long-term guselkumab treatment and across broad subgroups of patients with psoriatic disease.

CLINICAL TRIALS REGISTRATIONS

Clinicaltrials.gov identifiers: NCT01483599, NCT02207231, NCT02207244, NCT02203032, NCT02905331, NCT03090100, NCT02325219, NCT02319759, NCT03162796, NCT03158285, and NCT03796858.

Safety of Guselkumab With and Without Prior Tumor Necrosis Factor Inhibitor Treatment: Pooled Results Across 4 Studies in Patients With Psoriatic Arthritis

OBJECTIVE

Assess pooled safety results through the end of the phase II/III studies of guselkumab (GUS; ≤ 2 years) in tumor necrosis factor inhibitor (TNFi)-naïve and -experienced patients with psoriatic arthritis (PsA).

METHODS

Data were pooled from the Phase 2 and DISCOVER-1 (both TNFi-naïve and -experienced), DISCOVER-2 (TNFi-naïve), and COSMOS (TNFi-experienced) studies. Patients with active PsA were randomized to GUS 100 mg every 4 or 8 weeks (Q4W + Q8W = Combined GUS) or placebo (PBO) with crossover to GUS Q4W or Q8W at week 24. Time-adjusted adverse event (AE) rates (events/100 patient-years [PY]) and clinical laboratory findings were assessed during the PBO-controlled period and through end of study (≤ 2 years).

RESULTS

Of 1554 randomized patients (n = 373 [GUS Q4W], 664 [GUS Q8W], and 517 [PBO]), 1138 (73.23%) were TNFi-naïve and 416 (26.77%) were TNFi-experienced. Respective AE rates through week 24 were 220.8/100 PY (TNFi-naïve) and 251.6/100 PY (TNFi-experienced) in the Combined GUS group and 196.1/100 PY (TNFi-naïve) and 303.0/100 PY (TNFi-experienced) in the PBO group. Among all GUS-treated patients (including those who crossed over from PBO), low AE rates were maintained during long-term evaluation in both TNFi-naïve (139.7/100 PY) and TNFi-experienced (174.0/100 PY) patients. Rates/100 PY of AEs leading to treatment discontinuation, serious AEs, and other AEs of interest, as well as occurrence of elevated hepatic transaminase levels and decreased neutrophil counts were consistent between PBO and GUS-treated patients through week 24 regardless of prior TNFi use and remained low through the end of the studies.

CONCLUSION

The safety profile of GUS in TNFi-experienced patients was consistent with that in TNFi-naïve patients, which remained favorable for up to 2 years. [ClinicalTrials.gov: Phase 2 (NCT02319759), DISCOVER-1 (NCT03162796), DISCOVER-2 (NCT03158285), and COSMOS (NCT03796858)].

Efficacy and safety of guselkumab in biologic-naïve patients with active axial psoriatic arthritis: study protocol for STAR, a phase 4, randomized, double-blinded, placebo-controlled trial

Background

Axial involvement constitutes a specific domain of psoriatic arthritis (PsA). Interleukin (IL)-23 inhibitors have demonstrated improvement in axial PsA (axPsA) symptoms, but have not shown efficacy in treating ankylosing spondylitis (AS), suggesting differences in axPsA processes and treatments. In a post hoc, pooled analysis of patients with investigator- and imaging-confirmed sacroiliitis in two phase 3, randomized, placebo-controlled studies (DISCOVER-1 and DISCOVER-2), patients treated with guselkumab, an IL-23p19 inhibitor, had greater axial symptom improvements compared with placebo. Confirmatory imaging at baseline was restricted to the sacroiliac (SI) joints, occurred prior to/at screening, and was locally read.

Methods

The STAR study will prospectively assess efficacy outcomes in PsA patients with magnetic resonance imaging (MRI)-confirmed axial inflammation. Eligible, biologic-naïve patients with PsA (N =  405) for ≥ 6 months and active disease (≥ 3 swollen and ≥ 3 tender joints, C-reactive protein [CRP] ≥ 0.3 mg/dL) despite prior non-biologic disease-modifying antirheumatic drugs, apremilast, and/or nonsteroidal anti-inflammatory drugs will be randomized (1:1:1) to guselkumab every 4 weeks (Q4W); guselkumab at week (W) 0, W4, then every 8 weeks (Q8W); or placebo with crossover to guselkumab at W24, W28, then Q8W. Patients will have Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score ≥ 4, spinal pain component score (0–10 visual analog scale) ≥ 4, and screening MRI-confirmed axial involvement (positive spine and/or SI joints according to centrally read Spondyloarthritis Research Consortium of Canada [SPARCC] score ≥ 3 in ≥ 1 region). The primary endpoint is mean change from baseline in BASDAI at W24; multiplicity controlled secondary endpoints at W24 include AS Disease Activity Score employing CRP (ASDAS), Disease Activity Index for PsA (DAPSA), Health Assessment Questionnaire – Disability Index (HAQ-DI), Investigator’s Global Assessment of skin disease (IGA), and mean changes from baseline in MRI SI joint SPARCC scores. Centrally read MRIs of spine and SI joints (scored using SPARCC) will be obtained at W0, W24, and W52, with readers blinded to treatment group and timepoint. Treatment group comparisons will be performed using a Cochran-Mantel-Haenszel or chi-square test for binary endpoints and analysis of covariance, mixed model for repeated measures, or constrained longitudinal data analysis for continuous endpoints.

Discussion

This study will evaluate the ability of guselkumab to reduce both axial symptoms and inflammation in patients with active PsA.

Trial registration

This trial was registered at ClinicalTrials.gov, NCT04929210, on 18 June 2021.

Protocol version: Version 1.0 dated 14 April 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06589-y.

Meaningful Improvement in General Health Outcomes with Guselkumab Treatment for Psoriatic Arthritis: Patient-Reported Outcomes Measurement Information System-29 Results from a Phase 3 Study

Objective

The Phase 3 DISCOVER-1 study of guselkumab is the first randomized controlled trial to use Patient-Reported Outcomes Measurement Information System (PROMIS) measures to assess the effects of treatment on general health outcomes in patients with psoriatic arthritis (PsA).

Methods

Patients (N = 381) with active PsA were randomized 1:1:1 to guselkumab 100 mg every 4 weeks (Q4W); guselkumab 100 mg at Week 0, Week 4, then every 8 weeks (Q8W); or placebo with Week 24 crossover to guselkumab Q4W. The PROMIS-29 Profile contains four items for each of seven domains (anxiety, depression, fatigue, pain interference, physical function, sleep disturbance, and social participation) and one pain-intensity item. Raw domain scores are converted to standardized T-scores, with norms based on a US general population mean of 50 (1 standard deviation (SD) = 10). T-score changes of ≥ 5 are considered clinically meaningful. Least-squares mean PROMIS-29 T-score changes from baseline to Week 24 and Week 52 were summarized for the guselkumab and placebo groups; nominal p-values comparing results between guselkumab and placebo were calculated at Week 24 using a mixed model for repeated measures. The proportions of patients who achieved clinically meaningful improvement in PROMIS-29 T-scores were also summarized at Week 24 and Week 52; nominal p-values comparing results between guselkumab and placebo were calculated at Week 24 using the Cochran-Mantel-Haenszel test.

Results

In the DISCOVER-1 patient population, mean PROMIS-29 T-scores at baseline were ~ 1 SD worse for physical function and pain interference and were numerically worse for social participation, fatigue, and sleep disturbance compared with the US general population. At Week 24, mean PROMIS-29 T-scores improved in guselkumab-treated patients, approaching US population norms; T-scores continued to improve through Week 52. Significantly higher proportions of patients in both guselkumab treatment arms (31–52% across domains) had clinically meaningful improvements in pain interference, fatigue, physical function, sleep, and social participation at Week 24 versus placebo (all nominal p ≤ 0.05).

Conclusion

In patients with active PsA, guselkumab treatment provided clinically meaningful reductions in fatigue and pain and improvement in physical function and social participation, as measured by the PROMIS-29 Profile. These improvements were maintained through 1 year.

ClinicalTrials.gov

Registration number, NCT03162796; Submission date 19 May 2017.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40271-022-00588-6.

AB0894 Efficacy and Safety of Guselkumab in Biologic-Naïve Patients With Active Axial Psoriatic Arthritis: Study Design of a Phase 4, Randomized, Double-Blind, Placebo-Controlled Trial

Background

Established criteria for classifying axial psoriatic arthritis (PsA) are lacking, and assessments of disease activity often rely on measures developed for ankylosing spondylitis (AS). There is an unmet need to systematically identify and measure efficacy of treatments for axial PsA patients (pts). Guselkumab (GUS), a selective interleukin (IL)-23p19 inhibitor, was efficacious in improving signs and symptoms of active PsA in 2 phase 3, randomized, placebo (PBO)-controlled studies: DISCOVER-1 and DISCOVER-2. In a post-hoc pooled analysis of DISCOVER-1&2 pts with investigator-confirmed sacroiliitis, GUS-treated pts had greater improvements in axial symptoms compared with PBO.1 Imaging in DISCOVER-1&2 was restricted to the sacroiliac (SI) joints, occurring prior to/at screening as confirmed by the investigator, and locally read.

Objectives

To design a new, dedicated study to evaluate the effects of GUS on axial PsA prospectively.

Methods

Cumulative evidence from DISCOVER-1&2, including exposure–response relationship, covariate adjustment for modest baseline imbalances across treatment groups, subgroup analyses, and comparisons within and across these studies, was considered in designing a new trial. Data from the pivotal registrational studies suggest similar efficacy with GUS every-4-weeks (Q4W) and Q8W regimens in treating PsA signs and symptoms, including symptoms of axial involvement. Power calculations were based on mean changes in Bath AS Disease Activity Index (BASDAI) scores in DISCOVER-1&2.

Results

The phase 4, randomized, PBO-controlled STAR study is specifically designed to prospectively assess efficacy outcomes in PsA pts with magnetic resonance imaging (MRI)-confirmed axial inflammation. Based on observed mean (SD) changes from baseline in BASDAI score from DISCOVER-1&2 (Table 1), 405 pts, randomized (1:1:1) to GUS Q4W, GUS at W0, W4, then Q8W, or PBO →GUS Q8W at W24, are planned for enrollment (Figure 1). STAR eligibility criteria include PsA ≥6 months and active disease (≥3 swollen & ≥3 tender joints, C-reactive protein [CRP] ≥0.3 mg/dL) despite prior non-biologic disease-modifying antirheumatic drugs, apremilast, and/or non-steroidal anti-inflammatory drugs. Pts will be naïve to biologics and Janus kinase inhibitors and have BASDAI ≥4, spinal pain score (visual analog scale [VAS]) ≥4, and screening MRI-confirmed axial disease (positive spine and/or SI joints defined as centrally read Spondyloarthritis Research Consortium of Canada [SPARCC] score ≥3). Follow-up MRIs of spine and SI joints will be obtained at W0, W24, and W52 and also centrally read, with readers blinded to treatment group and timepoint. Spinal/SI joint inflammation will be scored using the SPARCC method, with the former also assessed using the CAN-DEN method. The primary endpoint is mean change in BASDAI at W24; controlled (hierarchical) secondary endpoints, all at W24, include AS Disease Activity Score (ASDAS-CRP), Disease Activity Index for PsA (DAPSA), ≥40% improvement in Assessment in AS criteria (ASAS40), and mean changes in spine/SI joint SPARCC scores.

Table 1.

Power calculations for the primary endpoint in the Phase 4 STAR study.

Historical trial data*Observed mean (SD) change in BASDAI from W0-24Effect sizePower(N=135; α=0.05)**PBO-1.28 (2.24)GUS 100 mg Q4W-2.51 (2.00)1.23>99%GUS 100 mg Q8W-2.61 (2.47)1.33>99%

* From the pooled DISCOVER-1&2 trials

**Power calculations based on N=135 per study group (1:1:1 randomization) and 2-sided significance of 0.05 using a 2-sample T-test assuming equal variances

BASDAI, Bath Ankylosing Spondylitis Disease Activity Index; GUS, guselkumab; PBO, placebo; Q4W, every 4 weeks; Q8W, every 8 weeks; SD, standard deviation; W, week

Conclusion

The phase 4 STAR study will allow for an in-depth, prospective evaluation of the effects of selectively inhibiting the IL-23p19 subunit with GUS in pts with MRI-confirmed axial PsA.

References

[1]Mease, et al. Lancet Rheum. 2021;3(10):e715-e723.

Disclosure of Interests

Dafna D Gladman Consultant of: AbbVie, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: Abbvie, Amgen, BMS, Celgene, Eli Lilly, Janssen, Novartis, Pfizer and UCB, Philip J Mease Speakers bureau: AbbVie, Aclaris, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, SUN Pharma, and UCB, Consultant of: AbbVie, Aclaris, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, SUN Pharma, and UCB, Grant/research support from: AbbVie, Aclaris, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, SUN Pharma, and UCB, Paul Bird Speakers bureau: AbbVie, Eli Lilly, Gilead, Janssen, MSD, Pfizer, and UCB, Consultant of: Eli Lilly, Gilead, Janssen, Novartis, and Pfizer, Enrique Soriano Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Eli Lilly, Janssen, Novartis, Pfizer, Roche, and UCB, Consultant of: AbbVie, Janssen, Novartis, and Roche, Grant/research support from: AbbVie, Janssen, Novartis, Pfizer, Roche, and UCB, Soumya D Chakravarty Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, May Shawi Shareholder of: Johnson & Johnson, Employee of: Janssen Global Services, LLC, Stephen Xu Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Sean Quinn Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Cinty Gong Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Evan Leibowitz Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Lai-Shan Tam Consultant of: Janssen, Pfizer, Sanofi, AbbVie, Boehringer Ingelheim, and Lilly, Grant/research support from: Amgen, Boehringer Ingelheim, Janssen, GSK, Novartis, and Pfizer, Philip Helliwell Speakers bureau: AbbVie, Janssen, and Novartis, Consultant of: Galapagos and Janssen, Grant/research support from: AbbVie, Janssen, and Pfizer, Arthur Kavanaugh Consultant of: Abbvie, Amgen, Bristol Myers Squibb, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, and UCB, Atul Deodhar Speakers bureau: AbbVie, Eli Lilly, Janssen, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly, Galapagos, Glaxo Smith & Kline, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Eli Lilly, Glaxo Smith & Kline, Novartis, Pfizer, and UCB, Mikkel Østergaard Speakers bureau: AbbVie, Boehringer-Ingelheim, Bristol Myers Squibb, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Consultant of: AbbVie, Boehringer-Ingelheim, Bristol Myers Squibb, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, and Novartis, Xenofon Baraliakos Speakers bureau: AbbVie, Biocad, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche, and UCB, Consultant of: AbbVie, Biocad, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche, and UCB, Grant/research support from: AbbVie, Biocad, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche, and UCB

POS1015 SAFETY OF GUSELKUMAB IN PATIENTS WITH ACTIVE PSORIATIC ARTHRITIS WHO ARE BIO-NAÏVE OR TNFi-EXPERIENCED: POOLED RESULTS FROM 4 RANDOMIZED CLINICAL TRIALS THROUGH 2 YEARS

Background

Guselkumab (GUS), a selective IL-23p19 subunit inhibitor, demonstrated efficacy and a favorable safety profile in active psoriatic arthritis (PsA) in the Phase (Ph)21, Ph3 (DISCOVER [D]-1&2)2,3, and Ph3b COSMOS4 randomized controlled trials (RCTs).

Objectives

Assess GUS safety through 2 years (Y) in biologic (bio)-naïve and tumor necrosis factor inhibitor (TNFi)-experienced (exp) active PsA patients (pts) pooled across 4 RCTs (Week [W] 56: Ph2 and COSMOS; W60: D1; W112: D2).

Methods

Eligible pts in COSMOS had inadequate response to 1 or 2 prior TNFi; 9% of Ph2 pts and 30% of D1 pts had 1 or 2 prior TNFi; D2 pts were bio-naïve. Incidence rates of adverse events (AEs) are summarized among all treated pts for the placebo (PBO)-controlled (W0-24) and active treatment periods through 2Y (max duration of exposure 100 W) according to actual treatment received, calculated as the number of events per 100 pt-Y of follow-up (PY), along with 95% confidence intervals (CI). Gastrointestinal (GI)-related serious AEs (SAEs) were identified using the Medical Dictionary for Regulatory Activities (MedDRA) system-organ class; major adverse cardiovascular events (MACE; predefined as MI, Stroke, or CV death) and opportunistic infections (OIs) were identified through medical review.

Results

Across the 4 RCTs, 1508 pts with active PsA received GUS 100 mg every 4 weeks (Q4W) or Q8W and were followed for a median of 1.2 Y, representing 2125 PY. In the overall population (N=1554), which includes PBO-treated pts that discontinued study agent prior to W24, 1138 pts were bio-naïve and 416 pts were TNFi-exp. Among all treated pts, the overall GUS safety profile was generally consistent with that of PBO through W24; rates remained low through 2Y of GUS (Table 1). The GUS safety profile was similar to that observed with PBO within the bio-naïve and TNFi-exp cohorts through W24. Incidence rates of AEs were generally consistent between cohorts in GUS-treated pts; whereas, TNFi-exp PBO-treated pts had more SAEs, study agent d/c due to AEs, and serious infections than bio-naïve PBO pts (Figure).

Table 1.

Overall Treatment-emergent AEs

PBO-controlled (W0-24)aThrough up to 2YPBOb(N=517)GUS Q8W (N=664)GUS Q4W (N=373)Combined GUS (N=1037)GUS Q8W (N=664)GUS Q4W (N=373)Combined GUSc(N=1508)Total (median) PY230 (0.5)305 (0.5)172 (0.5)478 (0.5)941 (1.1)645 (2.1)2125 (1.2)Events/100 PY (95% CI)AEs223 (204, 243)233 (216, 250)223 (201, 246)229 (216, 243)164 (156, 172)139 (130, 148)146 (141, 151)SAEs8.7 (5.3, 13)4.9 (2.8, 8.1)5.2 (2.4, 9.9)5.0 (3.2, 7.5)6.4 (4.9, 8.2)4.7 (3.1, 6.6)5.7 (4.7, 6.8)AEs leading to study agent d/c4.4 (2.1, 8.0)3.6 (1.8, 6.5)7.0 (3.6, 12.2)4.8 (3.1, 7.2)2.6 (1.6, 3.8)2.9 (1.8, 4.6)2.7 (2.1, 3.5)Infections59 (50, 70)56 (48, 65)57 (47, 70)57 (50, 64)43 (38, 47)37 (33, 42)39 (36, 42)Serious Infections2.2 (0.71, 5.1)0.33 (0.01, 1.8)1.7 (0.36, 5.1)0.84 (0.23, 2.1)1.7 (0.97, 2.8)0.77 (0.25, 1.8)1.5 (1.0, 2.1)Malignancy0.44 (0.01, 2.4)0.98 (0.20, 2.9)0.00 (0.00, 1.7)0.63 (0.13, 1.8)0.42 (0.12, 1.1)0.00 (0.00, 0.46)0.28 (0.10, 0.61)MACE0.44 (0.01, 2.4)0.33 (0.01, 1.8)0.58 (0.01, 3.2)0.42 (0.05, 1.5)0.21 (0.03, 0.77)0.46 (0.10, 1.4)0.24 (0.08, 0.55)GI-related SAEs1.3 (0.27, 3.8)0.33 (0.01, 1.8)0.00 (0.00, 1.7)0.21 (0.01, 1.2)0.32 (0.07, 0.93)0.46 (0.10, 1.4)0.28 (0.10, 0.61)OIs0.00 (0.00, 1.3)0.00 (0.00, 0.98)0.00 (0.00, 1.7)0.00 (0.00, 0.63)0.21 (0.03, 0.77)0.00 (0.00, 0.46)0.14 (0.03, 0.41)

MedDRA Version 23.1.

a Includes safety follow-up data through 2Y for pts who d/c study agent prior to W24 and did not receive any study agent at or after W24.

b Includes data prior to GUS in PBO pts who switched from PBO to GUS.

c Includes PBO to GUS cross-over at W24.

Conclusion

The favorable GUS safety profile demonstrated through W24 persisted through 2Y across bio-naïve and TNFi-exp pts.

References

[1]Deodhar A, et al. Lancet. 2018;391:2213-2224.

[2]Deodhar A, et al. Lancet. 2020;395:1115-1125.

[3]Mease PJ, et al. Lancet. 2020;395:1126-1136.

[4]Coates LC, et al. ARD. 2021;80:140-141. OP0230.

Disclosure of Interests

Proton Rahman Consultant of: AbbVie, Amgen, Bristol Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, and UCB, Grant/research support from: Janssen and Novartis, Wolf-Henning Boehncke Speakers bureau: AbbVie, Almirall, Janssen, Leo, Lilly, Novartis, and UCB, Consultant of: AbbVie, Almirall, Janssen, Leo, Lilly, Novartis, and UCB, Philip J Mease Speakers bureau: AbbVie, Amgen, Eli Lilly, Janssen, Novartis, Pfizer, Sun Pharma, and UCB, Consultant of: AbbVie, Aclaris, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, Sun Pharma, and UCB, Grant/research support from: AbbVie, Amgen, Bristol Myers Squibb, Eli Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, Sun Pharma, and UCB, Alice B Gottlieb Consultant of: AnaptsysBio, Avotres Therapeutics, Beiersdorf, Boehringer Ingelheim, Bristol-Myers Squibb, Incyte, GSK, Janssen, LEO Pharma, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical Industries, Inc., UCB, and Dermavant, Grant/research support from: Boehringer Ingelheim, Incyte, Janssen, Novartis, UCB, Xbiotech, and Sun Pharma, Iain McInnes Shareholder of: Causeway Therapeutics and Evelo Compugen, Consultant of: Astra Zeneca, AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Cabaletta, Compugen, GSK, Gilead, Janssen, Novartis, Pfizer, Sanofi, Roche, and UCB, Grant/research support from: Astra Zeneca, Bristol-Myers Squibb, Amgen, Eli Lilly, GSK, Janssen, Novartis, Roche, and UCB, Marlies Neuhold Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, May Shawi Shareholder of: Johnson & Johnson, Employee of: Janssen Pharmaceutical Companies of Johnson & Johnson, Yanli Wang Consultant of: Janssen, Employee of: IQVIA, Shihong Sheng Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Paul Bergmans Shareholder of: Johnson & Johnson, Employee of: Janssen Biostatistics, Alexa Kollmeier Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Elke Theander Employee of: Janssen Scientific Affairs, LLC, Jenny Yu Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Evan Leibowitz Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Marilise Marrache Shareholder of: Johnson & Johnson, Employee of: Medical Affairs, Janssen Inc., Laura Coates Speakers bureau: AbbVie, Amgen, Biogen, Celgene, Eli Lilly, Galapagos, Gilead, Janssen, Medac, Novartis, Pfizer and UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly, Gilead, Galapagos, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Amgen, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, and UCB

Low ALT values amongst hospitalized patients are associated with increased risk of hypoglycemia and overall mortality: a retrospective, big-data analysis of 51 831 patients

BACKGROUND

Sarcopenia and frailty influence clinical patients' outcomes. Low alanine aminotransferase (ALT) serum activity is a surrogate marker for sarcopenia and frailty. In-hospital hypoglycemia is associated, also with worse clinical outcomes.

AIM

We evaluated the association between low ALT, risk of in-hospital hypoglycemia and subsequent mortality.

DESIGN

This was a retrospective cohort analysis.

METHODS

We included patients hospitalized in a tertiary hospital between 2007 and 2019. Patients' data were retrieved from their electronic medical records.

RESULTS

The cohort included 51 831 patients (average age 70.88). The rate of hypoglycemia was 10.8% (amongst diabetics 19.4% whereas in non-diabetics 8.3%). The rate of hypoglycemia was higher amongst patients with ALT < 10 IU/l in the whole cohort (14.3% vs. 10.4%, P < 0.001) as well as amongst diabetics (24.6% vs. 18.8%, P < 0.001). Both the overall and in-hospital mortality were higher in the low ALT group (57.7% vs. 39.1% P < 0.001 and 4.3% vs. 3.2%, P < 0.001). A propensity score matching, after which a regression model was performed, showed that patients with ALT levels < 10 IU/l had higher risk of overall mortality (HR = 1.21, CI 1.13-1.29, P < 0.001).

CONCLUSIONS

Low ALT values amongst hospitalized patients are associated with increased risk of in-hospital hypoglycemia and overall mortality.

Baseline low ALT activity is associated with increased long-term mortality after COPD exacerbations

BACKGROUND

COPD exacerbations have negative impact on patients' survival. Several risk factors for grave outcomes of such exacerbations have been descried. Muscle dysfunction and mass loss were shown to impact negatively on prognosis and survival. Low activity of the enzyme ALT (Alanine amino-transferase) in the blood is a known indicator for sarcopenia and frailty, however, no previous studies addressed the association of low ALT amongst patients hospitalized due to COPD exacerbation and long-term survival.

METHODS

This is a historic prospective cohort study of patients hospitalized due to acute COPD exacerbation.

RESULTS

Included were 232 consecutive COPD exacerbation patients. The median time of follow-up was 34.9 months (IQR 23.13-41.73 months). During this period 104 (44.8%) patients died. All patients were grouped to quartiles according to blood ALT levels (after exclusion of cases considered to have hepatic tissue damage (ALT > 40 IU)). The risk of long-term mortality increased, in a statistically significant manner, amongst patients with low ALT values: the median survival of patients with ALT < 11 IU was 18.5 months only while the median survival for the rest of the study group was not reached. For ALT < 11 IU; 12-16 IU; 17-20 IU and > 21 IU the mortality rates were 69%; 40.9%; 36.3 and 25% respectively (p <  0.001 for comparison of lower quartile with upper three quartiles). The crude hazard ratio for mortality amongst patients with ALT levels lower than 11 IU was 2.37 (95% CI; 1.6-3.5). This increased risk of mortality remained significant after adjustment for age, weight, creatinine, albumin concentration and cardiovascular diseases (HR = 1.83; 95% CI 1.08-3.1, p <  0.05).

CONCLUSIONS

Low ALT values, a biomarker of sarcopenia and frailty, are associated with poor long-term survival amongst patients hospitalized due to COPD exacerbation.

Ethnographic Observational Study of the Biologic Initiation Conversation Between Rheumatologists and Biologic-Naive Rheumatoid Arthritis Patients

Objective

This ethnographic market research study investigated the biologic initiation conversation between rheumatologists and biologic‐naive patients with rheumatoid arthritis to assess how therapy options, particularly mode of administration, were discussed.

Methods

Consenting rheumatologists (n = 16) and patients (n = 48) were videotaped during medical visits and interviewed by a trained ethnographer. The content, structure, and timing of conversations regarding biologic initiation were analyzed.

Results

The mean duration of physician‐patient visits was approximately 15 minutes; biologic therapies were discussed for a mean of 5.6 minutes. Subcutaneous (SC) and intravenous (IV) therapy options were mentioned in 45 and 35 visits, respectively, out of a total of 48 visits. All patients had some familiarity with SC administration, but nearly half of patients (22 of 48) were unfamiliar with IV therapy going into the visit. IV administration was not defined or described by rheumatologists in 77% of visits (27 of 35) mentioning IV therapy. Thus, 19 of 22 patients who were initially unfamiliar with IV therapy remained unfamiliar after the visit. Disparities in physician‐patient perceptions were revealed, as all rheumatologists (16 of 16) believed IV therapy would be less convenient than SC therapy for patients, while 46% of patients (22 of 48) felt this way. In post‐visit interviews, some patients seemed confused and overwhelmed, particularly when presented with many treatment choices in a visit. Some patients stated they would benefit from visual aids or summary sheets of key points.

Conclusion

This study revealed significant educational opportunities to improve the biologic initiation conversation and indicated a disparity between patients’ and rheumatologists’ perception of IV therapy.

A giant planet orbiting the ‘extreme horizontal branch’ star V 391 Pegasi

After the initial discoveries fifteen years ago, over 200 extrasolar planets have now been detected. Most of them orbit main-sequence stars similar to our Sun, although a few planets orbiting red giant stars have been recently found. When the hydrogen in their cores runs out, main-sequence stars undergo an expansion into red-giant stars. This expansion can modify the orbits of planets and can easily reach and engulf the inner planets. The same will happen to the planets of our Solar System in about five billion years and the fate of the Earth is matter of debate. Here we report the discovery of a planetary-mass body (Msini = 3.2M(Jupiter)) orbiting the star V 391 Pegasi at a distance of about 1.7 astronomical units (au), with a period of 3.2 years. This star is on the extreme horizontal branch of the Hertzsprung-Russell diagram, burning helium in its core and pulsating. The maximum radius of the red-giant precursor of V 391 Pegasi may have reached 0.7 au, while the orbital distance of the planet during the stellar main-sequence phase is estimated to be about 1 au. This detection of a planet orbiting a post-red-giant star demonstrates that planets with orbital distances of less than 2 au can survive the red-giant expansion of their parent stars.

Perioperative medical management of antiphospholipid syndrome: hospital for special surgery experience, review of literature, and recommendations

Patients with antiphospholipid syndrome (APS), who are predisposed to vascular thrombotic events, are at additional risk for thrombosis when they undergo surgery. Serious perioperative complications (recurrent thrombosis, catastrophic exacerbation, or bleeding) occur despite prophylaxis. We describe our perioperative experience with APS patients who underwent a variety of surgeries, review the literature, and discuss strategies that may guide other physicians in their perioperative evaluation and management of patients with APS.

RECOMMENDATIONS

perioperative strategies should be clearly identified before surgical procedure; pharmacological and physical antithrombosis interventions vigorously employed; periods without anticoagulation kept to a minimum; and any deviation from a normal course should be considered a potential disease related event.

[Tuberculous choroiditis]

Tuberculosis is a rare cause of choroiditis. In most cases there is only a presumptive diagnosis based on a history of TB, its clinical picture, and a positive skin test. A 79-year-o;d man complained of acute, right visual loss. On examination, choroiditis was found. During his 20s he had had pulmonary tuberculosis; his Mantoux test was positive.

Pseudotumor cerebri induced by vitamin A combined with minocycline

A 16-year-old girl complained about a headache of one-month's duration, accompanied by vertical diplopia that had appeared ten days earlier. The girl reported receiving vitamin A and minocycline to treat acne vulgaris for the previous six weeks. An examination revealed bilateral optic disc edema. Normal computed tomographic and magnetic resonance imaging examinations enabled a diagnosis of pseudotumor cerebri to be made. Soon after discontinuation of those medications, the headaches and diplopia diminished. We suggest a periodic ophthalmologic examination during systemic therapy with vitamin A combined with minocycline to detect the early occurrence of pseudotumor cerebri.

Are psoriatic patients at risk of heat intolerance?

Sixteen young male subjects with psoriasis (mean of 4.9% of skin surface area involvement) and 10 healthy controls underwent a heat exercise test (40 degrees C, 40% r.h.) for 2 h. Rectal temperature (Tr), mean skin temperature (Tsk), heart rate (HR) and heat storage (dS) were measured and calculated. A sharper rise was found for all parameters in the psoriatic patients as compared with controls. Statistically significant differences were found in Tr after 60 min (37.9 +/- 0.1 degrees C and 37.5 +/- 0.1 degrees C in patients and controls, respectively) and at termination of the exercise (38.3 +/- 0.1 degrees C and 37.5 +/- 0.1 degrees C). Heat storage at the end of the first hour was 78 +/- 9 and 30 +/- 7 kcal in patients and controls, respectively. At the end of 120 min, heat storage in the study group increased to 87 +/- 14 kcal, while the control group stored only 30 +/- 7 kcal. Sweat rate was lower in the psoriatic patients (590 +/- 49 g/h) than in controls (691 +/- 42 g/h), even when corrected for healthy skin area (337 +/- 26 g/h/m2 compared with 370 +/- 24 g/h/m2). It is suggested that psoriatic patients have a reduced ability to dissipate extra heat during exposure to exercise in the heat. Psoriasis should therefore be considered as a risk factor for heat intolerance.

Interferon treatment in acute progressive and fulminant hepatitis

A small proportion of patients with acute viral hepatitis run a progressive fulminant course ending in acute liver failure with encephalopathy, and with a mortality rate of 75-80%. In small children and pregnant women mortality is even higher. We have treated 32 patients of all ages with acute progressive and fulminant hepatitis over the last 7 years in an uncontrolled trial with human interferon-alpha (HulFN-alpha), with i.m. doses of 3 x 10(6) u/day (70,000 u/kg per day for infants) for 8 +/- 3 days (mean +/- SD.) In 17 patients hepatitis was due to hepatitis A virus, in 7 to hepatitis B virus, in 6 to non A-non B virus and in 1 case each to herpes and cytomegalovirus. Sixteen patients (50%) recovered including 9 of 22 (41%) who were in Grades III-IV coma when treatment was started. Only 1 of 8 children less than 4 years of age recovered, whereas 15 of 24 (62%) older children and adults survived. Two of three pregnant women with acute fulminant hepatitis survived. In patients who recovered, improvement was often noted on about the fifth day of IFN treatment: 9 of 16 patients died before completing 5 days of therapy. Our studies of the IFN system response to hepatitis viruses showed that the greater majority of patients produce IFN in the acute stage of the infection. However, a minority have a defective IFN response that is more severe and more common in progressive fulminant hepatitis, and in several of these patients IFN response was completely lacking. It is in these cases that IFN treatment is likely to have the greatest value. On the basis of these encouraging preliminary results, it is suggested that a well-controlled, double-blind study be done to evaluate the effectiveness of HulFN-alpha treatment when given early during the course of acute progressive viral hepatitis.

Interferon system in acute transient synovitis

The interferon system of 20 children aged 2 to 11 years (mean 5 years), diagnosed as having transient synovitis of the hip by clinical criteria, was studied. The mean blood interferon concentration was significantly higher than that of normal children, and the incidence of an antiviral state of cells (in 78% of patients) was also significantly higher than in the control group. These findings are compatible with the hypothesis that the aetiology of transient synovitis is an acute, possibly unusual, viral infection.

Anterior sacral meningocele contiguous with a pelvic hamartoma. Case report

A patient with an anterior sacral meningocele combined with a hamartoma was diagnosed with x-ray films, myelography, and computerized tomography. She was successfully operated on by a transabdominal approach.