Reflections from the OARSI 2022 clinical trials symposium: The pain of OA-Deconstruction of pain and patient-reported outcome measures for the benefit of patients and clinical trial design

OBJECTIVE

Osteoarthritis (OA) drug development is hampered by a number of challenges. One of the main challenges is the apparent discordance between pain and structure, which has had a significant impact on drug development programs and has led to hesitance among stakeholders. Since 2017, the Clinical Trials Symposium (CTS) has been hosted under the Osteoarthritis Research Society International (OARSI) leadership. OARSI and the CTS steering committee yearly invite and encourage discussions on selected special subject matter between regulators, drug developers, clinicians, clinical researchers, biomarker specialists, and basic scientists to progress drug development in the OA field.

METHOD

The main topic for the 2022 OARSI CTS was to elucidate the many facets of pain in OA and to enable a discussion between regulators (Food and Drug Administration (FDA) and the European Medicines Agency (EMA)) and drug developers to clarify outcomes and study designs for OA drug development.

RESULTS

Signs or symptoms indicative of nociceptive pain occur in 50-70% of OA patients, neuropathic-like pain in 15-30% of patients, and nociplastic pain in 15-50% of patients. Weight-bearing knee pain is associated with bone marrow lesions and effusions. There are currently no simple objective functional tests whose improvements correlate with patient perceptions.

CONCLUSIONS

The CTS participants, in collaboration with the FDA and EMA, raised several suggestions that they consider key to future clinical trials in OA including the need for more precise differentiation of pain symptoms and mechanisms, and methods to reduce placebo responses in OA trials.

POS0278 A MULTICENTER, OBSERVATIONAL, EXTENSION STUDY EVALUATING THE SAFETY, TOLERABILITY, AND EFFICACY OF A SINGLE LORECIVIVINT INJECTION IN KNEE OA SUBJECTS

Background:

Lorecivivint (LOR), a novel intra-articular (IA) CLK2/DYRK1A inhibitor that modulates the Wnt pathway, is in development as a knee osteoarthritis (OA) treatment.

Objectives:

Subjects from two consecutive Phase 2 trials were followed up in a 5-year, pooled, observational study that evaluated the safety and exploratory efficacy of a single LOR injection that was previously administered into the target knee joint of subjects with moderate to severe knee OA. The study was terminated in its third year, as relevant long-term safety information became limited in the absence of repeated LOR administration. The primary objective evaluated the incidence of serious adverse events (SAEs). Safety data for all doses and a post hoc efficacy analysis for the pivotal dose (0.07 mg LOR) are reported.

Methods:

This was a Phase 3, multicenter, observational, extension study of completer subjects (OA-05; NCT02951026) from two Phase 2 trials of LOR: a 12-month Phase 2a trial (OA-02; NCT02536833)1 and a 6-month Phase 2b trial (OA-04; NCT03122860)2. Subjects received a single LOR or control (placebo or vehicle) injection at their parent-study baseline visit (OA-02 or OA-04 Visit 0 in this analysis). Pooled data from clinic visits at 6, 12, 24, and 36 months contributed to the extension-study (OA-05) analysis. SAEs, knee-related adverse events (AEs), and AEs of newly diagnosed conditions requiring treatment were collected as safety outcomes. Efficacy was assessed by target knee WOMAC Pain and Function subscores and radiographic medial joint space width (mJSW). A post hoc analysis was performed for 0.07 mg LOR versus control to assess responses in a subject subgroup (unilateral symptoms, no widespread pain, 18-month post-injection radiograph at study termination). Baseline-adjusted ANCOVA was performed using data from both the current and parent studies at 0, 3, 6, 12, and 18 months.

Results:

Of 703 subjects, 119 (17%) subjects discontinued prior to study termination. Subjects had a mean age of 60.7 years and mean BMI of 29.1 kg/m2, and 61% were female. The majority of subjects had KL 3 (61.2%) OA. The safety analysis set included 495 LOR-treated subjects and 208 control subjects. There were 169 AEs reported by 110 [15.6%] subjects. Four AEs were considered to be related to study drug and were reported by 3 (0.6%) subjects across LOR groups; no subjects withdrew from the study due to a treatment-related AE. The most common AEs were osteoarthritis (28 [4.0%] subjects) and arthralgia (25 [3.6%] subjects); incidence was similar between LOR and control groups. During the study, 68 SAEs were reported by 38 (5.4%) subjects, and no SAEs were considered to be related to treatment by investigator. One death occurred in the control group. Post hoc efficacy analyses demonstrated that subjects in the 0.07 mg LOR group (n=59) showed greater improvements from baseline in both WOMAC Pain and Function at 6 and 12 months versus subjects in the control group (n=70) (Figure 1; Day 0):

6 months:Pain: -8.16, 95% CI [-15.60, -0.71], P=0.032

Function: -9.47, 95% CI [-17.09, -1.84], P=0.015

12 months:Pain: -8.51, 95% CI [-15.17, -1.85], P=0.013

Function: -9.62, 95% CI [-16.83, -2.42], P=0.009

No mJSW progression was observed in any group over 18 months.

Limitations to this analysis include 1) subjects from LOR and control groups were “completers,” therefore, more likely to be responders, and 2) subjects could have been on any medication or treatment in the extension study.

Conclusion:

From these data, LOR appeared to be safe and well tolerated. A post hoc-analyzed subset of completer subjects treated with a single 0.07 mg LOR injection reported durable symptom improvements in WOMAC Pain and Function for up to at least 12 months versus control subjects.

References:

[1]Yazici Y, et al. Arthritis Rheumatol. 2020.

[2]Yazici Y, et al. ACR meeting. 2019. Abstract L03.

Disclosure of Interests:

Ismail Simsek Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Christopher Swearingen Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Heli Ghandehari Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Sarah Kennedy Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Jeyanesh Tambiah Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Yusuf Yazici Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Nebojsa Skrepnik Consultant of: Pfizer, Regeneron, Orthofix, Grant/research support from: Samumed, LLC

OP0188 INTEGRATED SAFETY SUMMARY OF THE NOVEL, INTRA-ARTICULAR AGENT LORECIVIVINT (SM04690), A CLK/DYRK1A INHIBITOR THAT MODULATES THE WNT PATHWAY, IN SUBJECTS WITH KNEE OSTEOARTHRITIS

Background:

Concerns over the safety of available osteoarthritis (OA) treatments have led to revision of treatment guidelines and highlight the need for new therapies. Lorecivivint (LOR; SM04690) is an intra-articular (IA), small-molecule CLK/DYRK1A inhibitor that modulates the Wnt pathway and is in development as a potential disease-modifying treatment for knee OA.1,2

Objectives:

To evaluate pooled early-phase LOR clinical data for safety, including bone health-related adverse events (AEs).

Methods:

Safety data were pooled from 3 randomized controlled trials (one Phase 1, two Phase 2) evaluating 4 doses (0.03 mg, 0.07 mg, 0.15 mg, 0.23 mg) of a single IA injection of LOR in subjects with moderately to severely symptomatic knee OA. Two trials (NCT02095548;NCT03122860) evaluated subjects for 24 weeks and one trial (NCT02536833) for 52 weeks. AEs, serious AEs (SAEs), and bone health AEs were categorized by Medical Dictionary for Regulatory Activities (MedDRA) classification. Incidences of AEs and SAEs were compared between the combined LOR-treated group (subjects who received any dose of LOR) and a control group (subjects not treated with LOR).

Results:

This analysis includes 848 LOR-treated and 360 control subjects. The incidence of AEs was similar in LOR-treated (350/848 [41.3%]) and control subjects (138/360 [38.3%]). Incidence of SAEs was 20/848 (2.4%) in LOR-treated and 4/360 (1.1%) in control subjects. The most commonly reported AE in LOR-treated subjects was arthralgia (treated 7.6%, control 7.2%) and was the only AE reported at >5% in either group (Fig. 1). Target-knee arthralgia was the most common joint-specific AE (treated 6.5%, control 5.3%) (Fig. 2). No AEs in other joints exceeded an incidence of 2% in either group. In all categories, individual AEs were reported at similar rates between groups and no SAEs were deemed related to LOR by investigators.

Figure 1.

Adverse event summary for events occurring in at least 1% of the treated population (N=1208).

Figure 2.

Joint-specific adverse event summary, subcategorized by affected joint, for events occurring in at least 1% of the treated population (N=1208).

There were 16 bone health-related AEs in 9/848 (1.1%) LOR-treated and 3/360 (0.8%) control subjects. Of the bone health AEs, 2 were osteopenia/osteoporosis in 2 LOR-treated postmenopausal women and 14 were fractures in 10 subjects (7 LOR-treated, 3 control). All fractures (3 patellar [1 target knee, 2 non-target knee], 3 vertebral, 2 foot, 2 wrist, 2 rib, 1 fibula, 1 hand) were adjudicated and determined to be caused by trauma; all healed uneventfully within the expected time frame.

Conclusion:

In exposure to date of 848 subjects, IA LOR for the treatment of knee OA appeared to be safe and well tolerated. These data support the continued evaluation of LOR as a potential treatment for knee OA.

References:

[1]Deshmukh V, et al.Osteoarthritis Cartilage. 2017.

[2]Deshmukh V, et al.Osteoarthritis Cartilage. 2019.

Disclosure of Interests:

Ismail Simsek Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Christopher Swearingen Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Sarah Kennedy Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Jeyanesh Tambiah Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Cristina Damatarca Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Yusuf Yazici Shareholder of: Samumed, LLC, Grant/research support from: Bristol-Myers Squibb, Celgene, and Genentech, Consultant of: Celgene and Sanofi, Employee of: Samumed, LLC, Nancy Lane Consultant of: Samumed, LLC, Marc Hochberg: None declared

FRI0380 ITEMS DRIVING WOMAC PAIN SUBSCORE CHANGES DUE TO LORECIVIVINT, A POTENTIAL DISEASE-MODIFYING TREATMENT FOR KNEE OSTEOARTHRITIS: A POST HOC ANALYSIS OF PHASE 2B TRIAL DATA

Background:

Knee osteoarthritis (OA) is a disease characterized by pain, loss of function, and structural deformities, leading to a heterogeneous disease state that can confound patient-reported outcomes (PROs). The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain subscore addresses this reporting variability by capturing multiple pain items related to ‘active’ and ‘static’ subject states. We hypothesize that measurement of these ‘active’ versus ‘static’ pain items may demonstrate differential effect sizes when assessing treatment benefit. Lorecivivint (LOR; SM04690), a small-molecule, intra-articular CLK/DYRK1A inhibitor that modulates the Wnt pathway, is currently in development as a potential disease-modifying treatment for knee OA.1,2

Objectives:

To test the hypothesis, a post hoc analysis of Pain NRS, the WOMAC Pain subscore, and individual WOMAC PROs (items A1–A5) from a Phase 2b LOR trial was performed to examine effect size (ES) changes.

Methods:

The original 24-week Phase 2b trial has been previously reported. In this study, pain was assessed using the weekly average of daily Pain NRS and WOMAC Pain subscore. In the post hoc analysis, items A1–A5 (pain walking on a flat surface? [A1], going up/downstairs? [A2], at night in bed? [A3], sitting or lying down? [A4], and while standing? [A5]) were individually analyzed for subjects treated with 0.07 mg LOR and compared with the primary study outcomes of mean Pain NRS and summed mean WOMAC Pain subscore at Week 12. Baseline-adjusted analysis of covariance for WOMAC A1–A5 scores was conducted on LOR-treated subjects compared with placebo (PBO) in 1) the Full Analysis Set (FAS) of all dosed subjects and 2) a target population of subjects with fixed baseline joint space width (JSW) [2–4] mm without widespread pain (Widespread Pain Index [WPI] ≤4, Symptom Severity Score Question 2≤2).

Results:

In this analysis, 231 subjects (KL grade 3 63.2%) were included. The primary study analysis demonstrated efficacy of LOR compared with PBO for Pain NRS and WOMAC Pain, with respective effect sizes of 0.450 and 0.293 (Figure). In the target population, Pain NRS and WOMAC A effect sizes increased (0.637 and 0.410, respectively). Each WOMAC A item showed less of an effect size than Pain NRS at Week 12. Treatment with 0.07 mg LOR compared with PBO showed significant improvements in effect sizes of WOMAC A1 (FAS: ES=0.315,P=0.028; target population: ES=0.421,P=0.035) and A2 (FAS: ES=0.392,P=0.006; target population: ES=0.510,P=0.011). A3–A5 did not show statistical improvement for LOR compared with PBO.

Figure.

Effect sizes for 0.07 mg LOR compared with PBO for the FAS and target population at Week 12.

Conclusion:

In the post hoc analysis, Pain NRS exhibited the greatest effect size of tested PROs after treatment with 0.07 mg LOR compared with PBO. These effect sizes were enhanced in the target population with fixed baseline JSW and without widespread pain for all scores relative to the FAS. WOMAC ‘active’ questions demonstrated greater effect sizes with LOR treatment than ‘static’ questions and the full WOMAC Pain domain, providing support for the hypothesized dimensional constructs in knee OA pain assessment.

References:

[1]Deshmukh V, et al.Osteoarthritis Cartilage. 2017.

[2]Deshmukh V, et al.Osteoarthritis Cartilage. 2019.

Disclosure of Interests:

Sarah Kennedy Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Christopher Swearingen Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Ismail Simsek Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Jeyanesh Tambiah Shareholder of: Samumed, LLC, Employee of: Samumed, LLC

FRI0430 THE NOVEL, INTRA-ARTICULAR CLK/DYRK1A INHIBITOR LORECIVIVINT (LOR; SM04690), WHICH MODULATES THE WNT PATHWAY, IMPROVED RESPONDER OUTCOMES IN SUBJECTS WITH KNEE OSTEOARTHRITIS: A POST HOC ANALYSIS FROM A PHASE 2B TRIAL

Background:

Lorecivivint (LOR; SM04690) is a small-molecule, intra-articular (IA) CLK/DYRK1A inhibitor that modulates the Wnt pathway1and has demonstrated some beneficial effects on patient-reported outcomes (PROs) relative to placebo (PBO) in two Phase 2 knee OA trials. With subjective measures such as PROs, meaningful benefits may be better characterized by representation as discrete threshold responses rather than by changes in mean point estimates.

Objectives:

To conduct a post hoc analysis of subjects in a 24-week Phase 2b study by measuring the proportions of subjects treated with LOR and placebo (PBO) who achieved 30%, 50%, or 70% threshold responses of improvement over baseline in Pain Numeric Rating Scale (NRS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain, WOMAC Function, and Patient Global Assessment (PtGA) at Week 12. Results from the Phase 3-selected dose of 0.07 mg LOR are presented here.

Methods:

Subjects had ACR-defined knee OA, Kellgren-Lawrence (KL) grades 2–3, and Pain NRS scores ≥4 and ≤8 in the target knee and <4 in the contralateral knee. A single 2mL IA injection of 0.03 mg, 0.07 mg, 0.15 mg, or 0.23 mg LOR, or vehicle PBO was given in the target knee at baseline. The proportion of subjects meeting 30%, 50%, or 70% threshold responses over baseline in the weekly average of daily Pain NRS [0–10], WOMAC Pain [0–100], WOMAC Function [0–100], and PtGA [0–100] at Week 12 was determined. The odds ratios (OR [95% CI]) of achieving each threshold response level were calculated and compared between LOR and PBO.

Results:

In total, 635 subjects (91.4%) completed the study (mean age 59.0±8.5 years, BMI 29.0±4.0 kg/m2, female 58.4%, KL grade 3 57.3%). At Week 12, treatment with 0.07 mg LOR significantly (P<0.05) increased the odds of a 30% threshold response in Pain NRS (OR 2.47 [1.45, 4.19]) and WOMAC Function (OR 1.86 [1.10, 3.12]) and a 50% threshold response in WOMAC Pain (OR 1.79 [1.06, 3.03]) and PtGA (OR 2.28 [1.25, 4.16]). Numerically, more (not statistically significant) subjects achieved a 70% threshold response in all PROs. All improvements were maintained through Week 24.

Conclusion:

In this post hoc analysis, LOR-treated subjects reported greater improvements in PRO threshold responses versus PBO from Week 12 through Week 24. LOR demonstrated significantly higher odds of achieving and maintaining improvements in PROs at 30% and 50% thresholds. Phase 3 studies of 0.07 mg LOR are ongoing.

References:

[1]Deshmukh V, et al.Osteoarthr Cartil. 2019.

Disclosure of Interests:

Yusuf Yazici Shareholder of: Samumed, LLC, Grant/research support from: Bristol-Myers Squibb, Celgene, and Genentech, Consultant of: Celgene and Sanofi, Employee of: Samumed, LLC, Sarah Kennedy Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Christopher Swearingen Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Jeyanesh Tambiah Shareholder of: Samumed, LLC, Employee of: Samumed, LLC

Modulation of the Wnt pathway through inhibition of CLK2 and DYRK1A by lorecivivint as a novel, potentially disease-modifying approach for knee osteoarthritis treatment

OBJECTIVES

Wnt pathway upregulation contributes to knee osteoarthritis (OA) through osteoblast differentiation, increased catabolic enzymes, and inflammation. The small-molecule Wnt pathway inhibitor, lorecivivint (SM04690), which previously demonstrated chondrogenesis and cartilage protection in an animal OA model, was evaluated to elucidate its mechanism of action.

DESIGN

Biochemical assays measured kinase activity. Western blots measured protein phosphorylation in human mesenchymal stem cells (hMSCs), chondrocytes, and synovial fibroblasts. siRNA knockdown effects in hMSCs and BEAS-2B cells on Wnt pathway, chondrogenic genes, and LPS-induced inflammatory cytokines was measured by qPCR. In vivo anti-inflammation, pain, and function were evaluated following single intra-articular (IA) lorecivivint or vehicle injection in the monosodium iodoacetate (MIA)-induced rat OA model.

RESULTS

Lorecivivint inhibited intranuclear kinases CDC-like kinase 2 (CLK2) and dual-specificity tyrosine phosphorylation-regulated kinase 1A (DYRK1A). Lorecivivint inhibited CLK2-mediated phosphorylation of serine/arginine-rich (SR) splicing factors and DYRK1A-mediated phosphorylation of SIRT1 and FOXO1. siRNA knockdowns identified a role for CLK2 and DYRK1A in Wnt pathway modulation without affecting β-catenin with CLK2 inhibition inducing early chondrogenesis and DYRK1A inhibition enhancing mature chondrocyte function. NF-κB and STAT3 inhibition by lorecivivint reduced inflammation. DYRK1A knockdown was sufficient for anti-inflammatory effects, while combined DYRK1A/CLK2 knockdown enhanced this effect. In the MIA model, lorecivivint inhibited production of inflammatory cytokines and cartilage degradative enzymes, resulting in increased joint cartilage, decreased pain, and improved weight-bearing function.

CONCLUSIONS

Lorecivivint inhibition of CLK2 and DYRK1A suggested a novel mechanism for Wnt pathway inhibition, enhancing chondrogenesis, chondrocyte function, and anti-inflammation. Lorecivivint shows potential to modify structure and improve symptoms of knee OA.

Provocation of experimental aortic inflammation and dilatation by inflammatory mediators and Chlamydia pneumoniae

BACKGROUND

The macrophage appears to have a key role in the inflammation and proteolysis associated with the growth and development of abdominal aortic aneurysms. The role of inflammatory mediators and Chlamydia pneumoniae in stimulating the influx of macrophages and dilatation of the abdominal aorta was investigated in an experimental model.

METHODS

Periaortic application of calcium chloride solution (and monocyte chemoattractant protein (MCP) 1, a cocktail of cytokines or C. pneumoniae) to the abdominal aorta of New Zealand White rabbits was performed at laparotomy. Some animals were fed a cholesterol-rich diet. The diameter of the aorta was measured by ultrasonography and after perfusion fixation, 3 weeks after laparotomy. Aortic sections were stained with RAM-11 to identify macrophages for counting. The presence of C. pneumoniae DNA was confirmed using the polymerase chain reaction.

RESULTS

Aortic macrophage influx in response to MCP-1, thioglycollate or C. pneumoniae was more than doubled in the cholesterol-fed animals. In response to human recombinant MCP-1 (1 microg) the mean(s.d.) macrophage count increased from 79(19) to 340(215) per unit area (P < 0.02). Even in cholesterol-fed animals, application of MCP-1 (recombinant human or rabbit form) was not associated with aortic dilatation. Application of thioglycollate 0.1 mol/l, or live or formalin-inactivated C. pneumoniae (0.5 x 108 organisms), was associated with a similar increase in macrophages to that caused by MCP-1 and a significant (approximately twofold) increase in aortic diameter after 3 weeks.

CONCLUSION

Macrophage influx into rabbit abdominal aorta, without macrophage activation, is insufficient to cause experimental aortic dilatation. C. pneumoniae antigens appeared to stimulate aortic dilatation, probably by specific activation of macrophages.