Efficacy and safety of mogamulizumab by patient baseline blood tumour burden: a post hoc analysis of the MAVORIC trial

Background

Mogamulizumab was compared with vorinostat in the phase 3 MAVORIC trial (NCT01728805) in 372 patients with relapsed/refractory mycosis fungoides (MF) or Sézary syndrome (SS) who had failed ≥1 prior systemic therapy. Mogamulizumab significantly prolonged progression‐free survival (PFS), with a superior objective response rate (ORR) vs. vorinostat.

Objectives

This post hoc analysis was performed to evaluate the effect of baseline blood tumour burden on patient response to mogamulizumab.

Methods

PFS, ORR, time to next treatment (TTNT), skin response (modified Severity‐Weighted Assessment Tool [mSWAT]) and safety were assessed in patients stratified by blood classification (B0 [n = 126], B1 [n = 62], or B2 [n = 184], indicating increasing blood involvement).

Results

Investigator‐assessed PFS was longer for mogamulizumab versus vorinostat across all blood classes, significantly so for B1 and B2 patients. ORR was higher with mogamulizumab than with vorinostat in all blood classification groups and more markedly so with escalating B class (B0: 15.6% vs. 6.5%, P = 0.0549; B1: 25.8% vs. 6.5%, P = 0.2758; B2: 37.4% vs. 3.2%, P < 0.0001). TTNT was significantly longer for patients treated with mogamulizumab versus vorinostat with B1 (12.63 vs. 3.07 months; HR 0.32 [95% CI 0.16–0.67]; P = 0.0018) and B2 (13.07 vs. 3.53 months; HR 0.30 [95% CI 0.21–0.43]; P < 0.0001) blood involvement. In the mogamulizumab arm, 81 patients (43.5%) had ≥50% change in the mSWAT vs. 41 patients (22.0%) with vorinostat; mSWAT improvements with mogamulizumab occurred most often in B1 and B2 patients. Rapid, sustained reductions were seen in CD4⁺CD26^‐ cell counts and CD4:CD8 ratios in mogamulizumab patients for all B classes. Treatment‐emergent adverse events were less frequent overall with mogamulizumab and similar in frequency regardless of B class.

Conclusions

This post hoc analysis indicates greater clinical benefit with mogamulizumab vs. vorinostat in patients with MF and SS classified as having B1 and B2 blood involvement.

Esomeprazole 20 mg on-demand is more acceptable to patients than continuous lansoprazole 15 mg in the long-term maintenance of endoscopy-negative gastro-oesophageal reflux patients: the COMMAND Study

BACKGROUND

Symptom relief, through adherence to appropriate maintenance therapy, is the sole objective of treatment for patients with endoscopy-negative gastro-oesophageal reflux disease.

AIM

To compare the efficacy of 'on-demand' treatment with esomeprazole 20 mg vs. continuous treatment with lansoprazole 15 mg daily in patients with endoscopy-negative gastro-oesophageal reflux disease.

METHODS

Endoscopy-negative gastro-oesophageal reflux disease patients who achieved complete resolution of heartburn after short-term (2-4 weeks) treatment with esomeprazole 20 mg (n = 774) were randomized to receive either esomeprazole 20 mg on-demand (n =311) or lansoprazole 15 mg continuous daily treatment (n = 311) for 6 months.

RESULTS

Significantly more patients were willing to continue taking esomeprazole on-demand than lansoprazole continuous therapy after 6 months (93% vs. 88%; P = 0.02). This superior outcome was achieved despite patients on esomeprazole requiring medication only 38% as often as those on lansoprazole, leading to direct cost savings of more than one-third (36%). Furthermore, patients receiving esomeprazole 20 mg on-demand were more satisfied with their treatment after 1 month compared with patients taking lansoprazole 15 mg continuously.

CONCLUSIONS

In patients with endoscopy-negative gastro-oesophageal reflux disease, esomeprazole 20 mg on-demand is more acceptable to patients and is an economically more effective treatment than lansoprazole 15 mg continuously.

Adjustable and fixed dosing with budesonide/ formoterol via a single inhaler in asthma patients: the ASSURE study

Patient-guided management of asthma using adjustable dosing of budesonide/formoterol in a single inhaler (Symbicort) was compared with fixed dosing in an open-label, multicentre, randomised study. Patients, uncontrolled on an inhaled corticosteroid (ICS) or controlled on an ICS and a long-acting beta2-agonist, entered a 4-week run-in period and received budesonide/formoterol (80/4.5 or 160/4.5 microg), 2 inhalations b.i.d. Following randomisation, the fixed-dosing group (n = 764) continued this regimen for a further 12 weeks. The adjustable-dosing group (n = 775) could step down to 1 inhalation b.i.d. if symptoms were controlled, and, at early signs of worsening symptoms, promptly step up to 4 inhalations b.i.d. for < or = 2 weeks. During run-in, National Heart, Lung and Blood Institute symptom-severity grading was maintained in 60% and improved in 31% of patients, clinic peak flow increased from 400 to 4191/min (P<0.001), and health-related quality of life (overall MiniAQLQ) improved from 4.6 to 5.4 (P<0.001). Patients effectively used the adjustable-dosing regimen; 79% reduced budesonide/formoterol dosage and, compared with fixed dosing, the number of inhalations were significantly lowered (3.2 vs. 3.8 inhalations/day, P<0.05). Both regimens were well tolerated. In both groups, symptom control was maintained or improved in 85-86% of patients, and 94% experienced no treatment failures. Consistent with current guidelines, adjustable maintenance dosing with budesonide/formoterol in a single inhaler provides effective asthma control at reduced medication doses.

Inter-laboratory comparison of the CD-1 neonatal mouse logistic dose-response model for Cryptosporidium parvum oocysts

cryptosporidium parvum oocyst viability can be determined by vital dyes, in vitro excystation, and cell culture; however, neonatal mouse infectivity assays are the reference method. Unfortunately, there have been few efforts to standardize methods for infectivity assays thus casting a veil of uncertainty over the significance and comparability of results. In order to address this issue, two laboratories proficient in measuring oocyst infectivity conducted independent dose titration studies with neonatal CD-1 mice using standardized protocols and a well-characterized isolate of Cryptosporidium parvum. The resulting independent logistic dose-response models derived by regression analysis were compared with each other and with a published model. The comparisons showed these dose-response functions to be reproducible under standardized conditions. It is important to standardize mouse strain, age of mice at inoculation and necropsy, oocyst isolate, and age of oocysts. However, other factors, including methods used to detect infectivity and to count oocyst doses, appear less critical. Adopting a standardized assay for oocyst infectivity will provide both a basis for comparing data from various oocyst disinfection studies and a suitable platform for evaluating new or existing in vitro viability surrogates such as excystation, vital dyes or cell culture.

Absence of growth retardation in children with perennial allergic rhinitis after one year of treatment with mometasone furoate aqueous nasal spray

OBJECTIVE

Intranasal corticosteroids are used widely for the treatment of allergic rhinitis because they are effective and well tolerated. However, their potential to suppress growth of pediatric subjects with allergic rhinitis continues to be a concern, particularly in light of reports of growth suppression after treatment with intranasal beclomethasone dipropionate or intranasal budesonide (see the article by Skoner et al in this month's issue). A 1-year study of prepubertal patients between 3 and 9 years of age with perennial allergic rhinitis was conducted to assess the effects on growth of mometasone furoate aqueous nasal spray (MFNS), a new once-daily (QD) intranasal corticosteroid with negligible bioavailability.

METHODS

This was a randomized, placebo-controlled, double-blind, multicenter study. Ninety-eight subjects were randomized to treatment with either MFNS 100 microg QD or placebo for 1 year. Each subject's height was required to be between the 5th and 95th percentile at baseline, and skeletal age at screening was required to be within 2 years of chronological age, as determined by left wrist x-rays. Washout periods for medications that affect either childhood growth or allergic rhinitis symptoms were established based on estimated period of effect, and these medications were prohibited during the study. However, short courses of either oral prednisone lasting no longer than 7 days or low-potency topical dermatologic corticosteroids lasting no longer than 10 days were permitted if necessary. Height was measured with a calibrated stadiometer at baseline and at 4, 8, 12, 26, 39, and 52 weeks, and the primary safety variable was the change in standing height. The rate of growth was also calculated for each subject as the slope (linear regression) of the change in height from baseline using data from all visits of subjects who had at least 2 visits. Hypothalamic-pituitary-adrenocortical- (HPA)-axis function was assessed via cosyntropin stimulation testing at baseline and at 26 and 52 weeks. All analyses were based on all randomized subjects (intent-to-treat principle). The change from baseline in standing height was analyzed by a 2-way analysis of variance that extracted sources of variation attributable to treatment, center, and treatment-by-center interaction.

RESULTS

Demographic characteristics were similar at baseline. Eighty-two subjects completed the study (42 in the MFNS group and 40 in the placebo group), and 93% of subjects achieved at least 80% compliance with therapy. After 1 year of treatment, no suppression of growth was seen in subjects treated with MFNS, and mean standing heights were similar for both treatment groups at all time points. For the primary safety variable (change in height from baseline), both treatment groups were similar at all time points except for weeks 8 and 52. Subjects treated with MFNS had a slightly greater mean increase in height than subjects treated with placebo at these time points: the change in height was 6.95 cm versus 6.35 cm at the 1-year time point. However, the rate of growth (.018 cm/day) averaged for all time points over the course of the study was similar for both treatment groups. Additional analyses found that MFNS did not retard growth in any sex or age subgroup of subjects. The use of exogenous corticosteroids other than the study drug was also similar among the 2 treatment groups. Results from cosyntropin stimulation testing confirmed the absence of systemic effects of MFNS. The change from baseline in the difference between prestimulation and poststimulation levels was similar for both treatment groups after 1 year of treatment, with no evidence of HPA-axis suppression in MFNS-treated subjects at any time point. Incidences of treatment-related adverse events were similar for both treatment groups, with 16% of MFNS-treated subjects reporting adverse events, compared with 22% of placebo-treated subjects.

CONCLUSIONS

(ABSTRACT TRUNCATED)

The effectiveness of once-daily dosing of inhaled flunisolide in maintaining asthma control

OBJECTIVE

The purpose of this study was to evaluate the feasibility of switching to once-daily (qd) administration of flunisolide in patients with asthma that was controlled by twice-daily (bid) dosing of this inhaled steroid.

METHODS

Three hundred sixty-six adults and children with bronchial asthma that was controlled with inhaled steroids were recruited for this prospective, double-blind, parallel-group study. After a 4-week, stable baseline period of flunisolide administration, 2 inhalations (500 microg) twice daily, each patient was randomized into one of four 12-week flunisolide treatment groups: group 1, 2 inhalations (500 microg) bid; group 2, 4 inhalations (1000 microg) qd in the morning; group 3, 4 inhalations (1000 microg) qd in the evening; or group 4, 2 inhalations (500 microg) qd in the morning. Outcome measures included morning and evening asthma symptoms (scale of 0 to 3), daytime and nighttime albuterol use, morning and evening peak expiratory flow rate (PEFR), FEV1, and methacholine PC20. In addition, a subset of patients in each group had 24-hour urinary cortisol levels measured before and after randomization.

RESULTS

Outcome measures in the four groups were not significantly different at baseline before randomization. The three groups that received maintenance therapy with flunisolide, 1000 microg daily, did not show significant changes from baseline values and remained comparable in all outcome areas. Asthma control in the group randomized to flunisolide 500 microg qd, however, deteriorated significantly: morning symptoms increased by 0.21 units (48%), evening symptoms increased by 0.15 units (31%), daytime albuterol use increased by 0.42 inhalations per day (37%), nighttime albuterol use increased by 0.48 inhalations per night (91%), morning PEFR decreased by 17.1 L/min (4%), and evening PEFR decreased by 12.6 L/min (3%). There were no significant changes in PC20 or 24-hour urinary cortisol levels in any group.

CONCLUSIONS

For patients with asthma that was stabilized by 2 inhalations of flunisolide (500 microg) bid, switching to 4 inhalations (1000 microg) qd in either the morning or evening is effective in maintaining asthma control. Reducing the dose to 2 inhalations (500 microg) qd in the morning, however, leads to a deterioration in asthma control.

Long-term safety and efficacy of triamcinolone acetonide aqueous nasal spray for the treatment of perennial allergic rhinitis

This 12-month, multicenter, open-label study to assess the long-term safety and efficacy of triamcinolone acetonide (TAA) aqueous nasal spray for perennial allergic rhinitis (PAR) symptom relief was a continuation of a 4-week, double-blind study. Patients who received TAA Aqueous (220 micrograms/day) during the 4-week, double-blind study continued with the same treatment for the open label study; those randomized to placebo during the 4-week, double-blind study received TAA Aqueous (220 micrograms/day) for the open-label study. Dose reduction to 110 micrograms/day was allowed if it was felt that symptom relief would be maintained. Safety was assessed by daily diary entries and clinical laboratory results. Long-term efficacy was assessed by visual analog scale (VAS). Of the 172 patients who began the open-label study, 94.2 percent completed 3 months of treatment, 83.6 percent completed 6 months, and 62 percent completed 12 months. PAR symptom relief improved progressively throughout the study. Adverse events were generally mild or moderate and consistent with long-term use and winter symptoms. The most common adverse events were pharyngitis (32 percent of patients), rhinitis (28.5 percent), headache (22.1 percent), and epistaxis (18 percent). Adverse events related to the local effects of the study medication were similar to those observed in long-term studies with TAA aerosol. The aqueous nasal spray formulation of triamcinolone acetonide was well tolerated and continued to relieve nasal symptoms with long-term use in adolescent and adult patients with PAR.

A placebo- and active-controlled randomized trial of prophylactic treatment of seasonal allergic rhinitis with mometasone furoate aqueous nasal spray

BACKGROUND

Topical nasal corticosteroids have become a mainstay of treatment for the symptoms of seasonal allergic rhinitis (SAR). It is likely that topical corticosteroids, by blocking an initial influx of inflammatory cells in the nasal mucosa induced by aeroallergens, may have a preventive effect on nasal allergy symptoms when administered before the pollen season.

OBJECTIVE

This study was designed to assess the efficacy and safety of an 8-week course of mometasone furoate nasal spray (MFNS), 200 micrograms once daily, in the treatment of SAR compared with beclomethasone dipropionate aqueous nasal spray (BDP), 168 micrograms twice daily, and placebo vehicle, when treatment is initiated before the anticipated onset of the ragweed season.

METHODS

Three hundred forty-nine patients with SAR to ragweed pollen from nine centers in the Northeast and Midwest of the United States were randomized to one of the three intranasal study medications (MFNS, 200 micrograms once daily, BDP, 168 micrograms twice daily, or placebo vehicle), starting 4 weeks before the estimated start of the ragweed season.

RESULTS

The proportion of "minimal symptom" days (total nasal symptom score < or = 2) was statistically significantly higher in both the MFNS and BDP groups when compared with the placebo vehicle group (p < 0.01). The two active treatment groups were not statistically significantly different from each other. MFNS and BDP displayed a similar safety profile that did not differ from placebo.

CONCLUSIONS

This suggests that MFNS, 200 micrograms (once daily), is a useful therapy in the prophylactic treatment of SAR.

Triamcinolone acetonide aqueous nasal spray for the treatment of patients with perennial allergic rhinitis: a multicenter, randomized, double-blind, placebo-controlled study

In this multicenter, randomized, double-blind, placebo-controlled study, 178 patients with symptoms of perennial allergic rhinitis (PAR) were treated with either triamcinolone acetonide (TAA) Aqueous nasal spray (220 micrograms once daily) or placebo for 4 weeks. Symptoms of PAR (nasal stuffiness, nasal discharge, sneezing, nasal index, and nasal itching) were evaluated throughout the treatment period through the use of patient diaries. In addition, both patients and physicians completed independent global evaluations of treatment efficacy at the conclusion of the study. TAA Aqueous provided clinically and statistically (P < or = 0.05) greater improvements in nasal stuffiness, sneezing, nasal index, and nasal itching over the 4-week study period than did placebo. Significant improvements in sneezing (P = 0.022) were observed as early as the first day (within 12 to 16 hours based on treatment in the morning and assessment of symptoms at bedtime), and in the nasal index (P = 0.009) by the third day after treatment with TAA Aqueous. Patients' and physicians' global evaluations of overall efficacy were concordant: 65% of patients rated their nasal symptoms greatly or somewhat improved with TAA Aqueous compared with 48% in the placebo group; physicians rated 66% of patients as having greatly or somewhat improved symptoms with the study drug compared with 48% of patients who received placebo. Adverse events were mild and the incidences were comparable for both groups; no significant changes in vital signs or clinical laboratory parameters were observed. This study demonstrated that TAA Aqueous administered once daily was well tolerated and provided relief of PAR symptoms in adults and adolescents.

Fatal and near-fatal anaphylactic reactions to food in children and adolescents

BACKGROUND AND METHODS

Reports of fatal or near-fatal anaphylactic reactions to foods in children and adolescents are rare. We identified six children and adolescents who died of anaphylactic reactions to foods and seven others who nearly died and required intubation. All the cases but one occurred in one of three metropolitan areas over a period of 14 months. Our investigations included a review of emergency medical care reports, medical records, and depositions by witnesses to the events, as well as interviews with parents (and some patients).

RESULTS

Of the 13 children and adolescents (age range, 2 to 17 years), 12 had asthma that was well controlled. All had known food allergies, but had unknowingly ingested the foods responsible for the reactions. The reactions were to peanuts (four patients), nuts (six patients), eggs (one patient), and milk (two patients), all of which were contained in foods such as candy, cookies, and pastry. The six patients who died had symptoms within 3 to 30 minutes of the ingestion of the allergen, but only two received epinephrine in the first hour. All the patients who survived had symptoms within 5 minutes of allergen ingestion, and all but one received epinephrine within 30 minutes. The course of anaphylaxis was rapidly progressive and uniphasic in seven patients; biphasic, with a relatively symptom-free interval in three; and protracted in three, requiring intubation for 3 to 21 days.

CONCLUSIONS

Dangerous anaphylactic reactions to food occur in children and adolescents. The failure to recognize the severity of these reactions and to administer epinephrine promptly increases the risk of a fatal outcome.

Clinical benefits of cromolyn sodium aerosol (MDI) in the treatment of asthma in children

A double-blind, placebo-controlled study was performed to determine the efficacy and safety of cromolyn sodium (Intal) administered to children by metered dose inhaler (MDI). Prior to entry, subjects were well controlled on cromolyn sodium capsules by Spinhaler turbo-inhaler plus beta 2 agonists. An active control interval of 2 weeks on cromolyn sodium capsules was followed by a 4-week single-blind period on placebo capsules. Those subjects whose asthma worsened significantly on placebo entered a 10-week double-blind phase, randomized to receive either cromolyn sodium (2 mg per dose) or placebo by MDI. Diary data, physician evaluation, and pulmonary function tests were used to assess efficacy, and scores were compared with the baseline value at 2-week intervals. Forty children with asthma, 8 to 20 years of age, entered the study and 32 qualified for the randomized phase. No significant differences existed between the treatment groups at baseline. Most comparative data favored the cromolyn sodium group over the course of the study. Significant differences (p less than .05) were noted for diary scores of breathlessness and overall asthma severity. There was significant improvement at the final visit favoring the cromolyn sodium group in restriction on normal activity, FEV1, and PEFR. The cromolyn sodium group also experienced a decreasing need for concomitant bronchodilators. Both groups preferred pressurized aerosol by MDI over powdered capsules by Spinhaler. (Intal and Spinhaler are registered trademarks of Fisons Corporation.)

Bakers' rhinoconjunctivitis: a case report

Bakers' rhinoconjunctivitis is a rare occupational disease characterized by nasal and/or ocular symptoms occurring during and after exposure to flour. Occupational allergies represent a difficult problem in that avoidance therapy is not easily obtainable in those individuals not willing to change professions.

Duration of action of oral albuterol in an asthmatic population

In a randomized, double-blind, two-way crossover study in four centers, 124 patients received single doses of 4 or 6 mg of albuterol and placebo on two separate visits. Pulmonary function tests were performed at intervals up to ten hours. Both dosages produced peak bronchodilation responses which occurred at two hours and significant activity was maintained for at least eight hours. Adverse experiences were typical of adrenergic agents.

Routine elective penicillin allergy skin testing in children and adolescents: study of sensitization

This study aims at evaluating the possibility in children and adolescents of (re)sensitization to penicillin that could result from skin test and challenge. Patients (240) with a history of a reaction to penicillin or one of its analogs were skin-tested with penicillin G, commerical benzlpenicilloyl polylysine, and a minor determinant mixture consisting of sodium benzylpenicilloate and sodium benzylpenilloate. The patients were tested when well, in no immediate need for penicillin, and during a routine office visit. Twenty-one (8.75%) patients had one or more positive skin tests. Three (14%) of the positive reactors reacted only to the MDM mixture, with one reacting only to the benzylpenilloate component. Of the patients with negative skin tests, 219 were given a 10-day course of oral penicillin. Three (1.4%) of the patients developed a-mild skin exanthem 7 to 10 days after starting the penicillin. All skin test-negative patients were retested 4 wk or more after completion of the oral challenge. Only two patients (less than 1%) who tolerated an oral challenge of penicillin had a positive skin test upon retesting. We believe that the described penicillin allergy testing procedure in children and adolescents with a history of allergy to penicillin or certain analogs is a safe, highly predictive, nonsensitizing office procedure in the hands of physicians experienced with skin testing. It should be considered for all such individuals labeled as allergic to penicillin when they are well and not in immediate need of penicillin.

A comparison of cromolyn and bronchodilators in patients with mild to moderately severe asthma in an office practice

The efficacy and safety of two treatment regimens, based in the one case on cromolyn and in the other on bronchodilators, were compared in an eight week study in predominantly young, mild to moderate asthmatics in an office practice. We utilized subjective and objective measures of assessment. Cromolyn was as effective as the bronchodilator regimen except in terms of asthmatic cough, which was better controlled by cromolyn. An equal number of patients could not tolerate each regimen and were dropped from the study. Among those who continued and completed the study cromolyn was devoid of adverse effects whereas 62% of the patients maintained on theophylline with or without a concomitant beta-agonist reported side effects. The results of this preliminary study and of our subsequent broader clinical experience suggest that a re-evaluation of the current approach to managing the symptoms of chronic asthma is indicated, at least in pediatric patients.

Comparison of theophylline concentrations in venous blood and capillary blood in asthmatic children

Twenty children, five to 16 years old, diagnosed as having asthma, were studied to compare the serum concentrations of theophylline obtained by standard venipuncture with capillary concentrations obtained by finger lancet. The mean theophylline concentration in venous samples was 9.27 mg/L and in capillary samples was 9.26 mg/L. Comparison by the paired t-test showed no statistical difference between kinds of samples. When surveyed as to their preference, nine patients preferred the venous method, five the capillary method, and six had no preference.

Comparison of theophylline concentrations in venous blood and capillary blood in asthmatic children

Twenty children, five to 16 years old, diagnosed as having asthma, were studied to compare the serum concentrations of theophylline obtained by standard venipuncture with capillary concentrations obtained by finger lancet. The mean theophylline concentration in venous samples was 9.27 mg/L and in capillary samples was 9.26 mg/L. Comparison by the paired t-test showed no statistical difference between kinds of samples. When surveyed as to their preference, nine patients preferred the venous method, five the capillary method, and six had no preference.

Theophylline pharmacokinetics in the young infant

The pharmacokinetics of theophylline were investigated in 13 infants, 4 to 18 months of age. An inverse relationship was found between theophylline half-life and age. Volume of distribution did not differ from that reported by other authors in similarly aged infants. Our data suggest that childhood clearance rates of elimination can be achieved by 6 months of age. The decreased theophylline elimination observed in the smaller infant indicates that the usual pediatric dosing recommendations cannot be used routinely. Until more specific data are available in the infant under 6 months, the authors reaffirm individualization of theophylline dosage to maintain therapeutic levels and avoid toxicity.