The risk of malignancy in patients with secukinumab-treated psoriasis, psoriatic arthritis and ankylosing spondylitis: analysis of clinical trial and postmarketing surveillance data with up to five years of follow-up

BACKGROUND

Data on the use of biologic therapy and malignancy risk are inconsistent due to limited long-term robust studies.

OBJECTIVES

To assess the malignancy risk in patients with secukinumab-treated psoriasis, psoriatic arthritis (PsA) and ankylosing spondylitis (AS).

METHODS

This integrated safety analysis from both the secukinumab clinical trial programme and postmarketing safety surveillance data included any patient receiving at least one approved dose of secukinumab with a maximum of 5 years of follow-up. Safety analyses evaluated the rate of malignancy using exposure-adjusted incidence rates [EAIR; incidence rates per 100 patient treatment-years (PTY)]. Standardized incidence ratios (SIRs) were reported using the Surveillance, Epidemiology, and End Results Program (SEER) database as a reference population. Crude incidence of malignancy was also reported using postmarketing surveillance data.

RESULTS

Safety data from 49 clinical trials with secukinumab-treated patients were included: 10 685 patients with psoriasis, 2523 with PsA and 1311 with AS. Across indications over a 5-year period, the EAIR of malignancy was 0·85 per 100 PTY [95% confidence interval (CI) 0·74-0·98] in secukinumab-treated patients, corresponding to 204 patients per 23 908 PTY. Overall, the observed vs. expected number of malignancies from secukinumab clinical trial data were comparable, as indicated by an SIR of 0·99 (95% CI 0·82-1·19) across indications. The estimated crude cumulative incidence reporting rate per 100 PTY for malignancy was 0·27 in the postmarketing surveillance data across indications with a cumulative exposure of 285 811 PTY.

CONCLUSIONS

In this large safety analysis, the risk of malignancy was low for up to 5 years of secukinumab treatment. These data support the long-term use of secukinumab in these indications.

FRI0272 SECUKINUMAB DEMONSTRATES A CONSISTENT SAFETY PROFILE IN PATIENTS WITH PSORIASIS, PSORIATIC ARTHRITIS AND ANKYLOSING SPONDYLITIS OVER LONG TERM: UPDATED POOLED SAFETY ANALYSES

Background:

Pooled safety data has been reported with secukinumab (SEC) in patients (pts) with Psoriatic arthritis (PsA), Ankylosing Spondylitis (AS) and Psoriasis (PsO).1

Objectives:

To report longer-term safety data of SEC treatment in PsA, AS, PsO pts up to 5 years.

Methods:

The integrated clinical trial safety dataset included data pooled from 28 randomised controlled clinical trials of SEC 300 or 150 or 75 mg in PsO (11 Phase 3 and 8 Phase 4 trials), PsA (5 Phase 3 trials), and AS (4 Phase 3 trials), along with post-marketing safety surveillance data with a cut-off date of 25 December 2018. Adverse events (AEs) were reported as exposure-adjusted incident rates (EAIRs) per 100 pt-years. Analyses included all pts who received ≥1 dose of SEC.

Results:

A total of 12637 pts (8819, 2678 and 1140 pts with PsO, PsA and AS, with an exposure of 15063.1, 5984.6 and 3527.2 pt-years, respectively) were included. The most frequent AE was upper respiratory tract infection and EAIR per 100 pt-years for IBD, malignancies and MACE remained low. The EAIR per 100 pt-years for adverse events (AEs) of special interest are reported in Table 1. The cumulative post-marketing exposure to SEC was estimated to be ~285,811 pt-years across the approved indications. Safety data from post-marketing surveillance are reported in Table 2.

Table 1.

Selected AEs of interest with SEC across pooled clinical trials

VariablePsOPsAASSECN=8819SECN=2678SECN=1140Exposure (Days), Mean (SD)623.9 (567.7)816.2 (580.7)1130.1 (583.0)Death, n (%)15 (0.2)13 (0.5)10 (0.9)Selected AE’s of interest, EAIR (95% CI)Serious infections11.4 (1.2, 1.6)1.8 (1.5, 2.2)1.2 (0.9, 1.6)Candidainfections22.9 (2.7, 3.2)1.5 (1.2, 1.9)0.7 (0.5, 1.1)IBD3Crohn’s disease3Ulcerative colitis30.01 (0.0, 0.05)0.1 (0.05, 0.2)0.1 (0.08, 0.2)0.03 (0.0, 0.1)0.1 (0.04, 0.2)0.1 (0.04, 0.2)0.03 (0.0, 0.2)0.4 (0.24, 0.7)0.2 (0.1, 0.5)MACE40.4 (0.31, 0.5)0.4 (0.3, 0.6)0.7 (0.4, 1.0)Uveitis30.01 (0.0, 0.05)0.1 (0.04, 0.2)1.2 (0.9, 1.7)Malignancy50.9 (0.7, 1.0)1.0 (0.77, 1.3)0.5 (0.3, 0.8)

1Rates for system organ class;2Rates for high level term;3Rates for preferred term (PT; IBD for unspecified IBD);4Rates for Novartis MedDRA Query term;5Rates for standardized MedDRA query term – ‘malignancies and unspecified tumour’; EAIR, exposure adjusted incidence rate per 100 pt-years; N, number of pts in the analysis

Table 2.

Summary of SEC post-marketing safety

Exposure (PTY)PSUR126Dec14 -25Jun15PSUR226 Jun - 25Dec15PSUR326Dec15 -25Jun16PSUR426Jun -25Dec16PSUR526Dec16 -25Dec17PSUR626Dec17 -25Dec18Cumulative18387450168712854993744137325285811                    n (Reporting rate PTY)Serious infections89 (4.8)149 (2.0)232 (1.4)475 (1.7)649 (0.7)1841 (1.3)3980 (1.4)Malignancy2 (0.1)15 (0.2)21 (0.1)50 (0.2)225 (0.2)422 (0.3)788 (0.3)Total IBD4 (0.2)12 (0.2)37(0.2)46 (0.2)185 (0.2)340 (0.3)693 (0.2)MACE6 (0.3)15 (0.2)16 (0.1)39 (0.1)151 (0.2)238 (0.2)504 (0.2)

PSUR, periodic safety update report; PTY, pt-treatment years

Conclusion:

In this long-term analysis across clinical trials and post-marketing surveillance, of pts with PsO, PsA and AS, SEC was well tolerated, with a safety profile consistent with previous reports.1

Reference:

[1]Deodhar et al. Arthritis Research & Therapy (2019) 21:111.

Disclosure of Interests:

Atul Deodhar Grant/research support from: AbbVie, Eli Lilly, GSK, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Iain McInnes Grant/research support from: Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Janssen, and UCB, Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Gilead, Janssen, Novartis, Pfizer, and UCB, Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Kristian Reich Grant/research support from: Affibody; Almirall; Amgen; Biogen; Boehringer Ingelheim; Celgene; Centocor; Covagen; Eli Lilly; Forward Pharma; Fresenius Medical Care; GlaxoSmithKline; Janssen; Kyowa Kirin; LEO Pharma; Medac; Merck; Novartis; Miltenyi Biotec; Ocean Pharma; Pfizer; Regeneron; Samsung Bioepis; Sanofi Genzyme; Takeda; UCB; Valeant and Xenoport., Consultant of: Affibody; Almirall; Amgen; Biogen; Boehringer Ingelheim; Celgene; Centocor; Covagen; Eli Lilly; Forward Pharma; Fresenius Medical Care; GlaxoSmithKline; Janssen; Kyowa Kirin; LEO Pharma; Medac; Merck; Novartis; Miltenyi Biotec; Ocean Pharma; Pfizer; Regeneron; Samsung Bioepis; Sanofi Genzyme; Takeda; UCB; Valeant and Xenoport., Speakers bureau: Affibody; Almirall; Amgen; Biogen; Boehringer Ingelheim; Celgene; Centocor; Covagen; Eli Lilly; Forward Pharma; Fresenius Medical Care; GlaxoSmithKline; Janssen; Kyowa Kirin; LEO Pharma; Medac; Merck; Novartis; Miltenyi Biotec; Ocean Pharma; Pfizer; Regeneron; Samsung Bioepis; Sanofi Genzyme; Takeda; UCB; Valeant and Xenoport., Alice B Gottlieb Grant/research support from:: Research grants, consultation fees, or speaker honoraria for lectures from: Pfizer, AbbVie, BMS, Lilly, MSD, Novartis, Roche, Sanofi, Sandoz, Nordic, Celltrion and UCB., Consultant of:: Research grants, consultation fees, or speaker honoraria for lectures from: Pfizer, AbbVie, BMS, Lilly, MSD, Novartis, Roche, Sanofi, Sandoz, Nordic, Celltrion and UCB., Speakers bureau:: Research grants, consultation fees, or speaker honoraria for lectures from: Pfizer, AbbVie, BMS, Lilly, MSD, Novartis, Roche, Sanofi, Sandoz, Nordic, Celltrion and UCB., Mark Lebwohl Grant/research support from: AbbVie, Amgen, Arcutis, AstraZeneca, Boehringer Ingelheim, Celgene, Clinuvel, Eli Lilly, Incyte, Janssen Research & Development, LLC, Kadmon Corp., LLC, Leo Pharmaceutucals, Medimmune, Novartis, Ortho Dermatologics, Pfizer, Sciderm, UCB, Inc., and ViDac, Consultant of: Allergan, Almirall, Arcutis, Inc., Avotres Therapeutics, BirchBioMed Inc., Boehringer-Ingelheim, Bristol-Myers Squibb, Cara Therapeutics, Castle Biosciences, Corrona, Dermavant Sciences, Evelo, Foundation for Research and Education in Dermatology, Inozyme Pharma, LEO Pharma, Meiji Seika Pharma, Menlo, Mitsubishi, Neuroderm, Pfizer, Promius/Dr. Reddy’s Laboratories, Theravance, and Verrica, Stefan Schreiber Consultant of: AbbVie, Arena, BMS, Biogen, Celltrion, Celgene, IMAB, Gilead, MSD, Mylan, Pfizer, Fresenius, Janssen, Takeda, Theravance, provention Bio, Protagonist and Falk, Weibin Bao Shareholder of: Novartis, Employee of: Novartis, Kwaku Marfo Shareholder of: Novartis, Employee of: Novartis, Hanno Richards Shareholder of: Novartis, Employee of: Novartis, Luminita Pricop Shareholder of: Novartis, Employee of: Novartis, Abhijit Shete Shareholder of: Novartis, Employee of: Novartis, Jorge Safi Shareholder of: Novartis, Employee of: Novartis, Philip J Mease Grant/research support from: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – grant/research support, Consultant of: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – consultant, Speakers bureau: Abbott, Amgen, Biogen Idec, BMS, Eli Lilly, Genentech, Janssen, Pfizer, UCB – speakers bureau

Effect of fibrosis on adverse events in patients with hepatitis C treated with telaprevir

BACKGROUND

Data about adverse events are needed to optimise telaprevir-based therapy in a broad spectrum of patients.

AIM

To investigate adverse events of telaprevir-based therapy in patients with and without advanced fibrosis or cirrhosis in a real-world setting.

METHODS

Data on 174 hepatitis C-infected patients initiating telaprevir-based therapy at Mount Sinai and Montefiore medical centres were collected. Biopsy data and FIB-4 scores identified patients with advanced fibrosis. Multivariable fully adjusted models were built to assess the effect of advanced fibrosis on specific adverse events and discontinuation of treatment due to an adverse event.

RESULTS

Patients with (n = 71) and without (n = 103) advanced fibrosis were similar in BMI, ribavirin exposure, gender, prior treatment history, haemoglobin and creatinine, but differed in race. Overall, 47% of patients completed treatment and 40% of patients achieved SVR. Treated patients with and without advanced fibrosis or cirrhosis had similar rates of adverse events; advanced fibrosis, however, was independently associated with ano-rectal discomfort (P = 0.03). Three patients decompensated and had advanced fibrosis. The discontinuation of all treatment medications due to an adverse event was significantly associated with older age (P = 0.01), female gender (P = 0.01) and lower platelets (P = 0.03).

CONCLUSIONS

Adverse events were common, but were not significantly related to the presence of advanced fibrosis or cirrhosis. More critical monitoring in older and female patients with low platelets throughout treatment may reduce adverse event-related discontinuations.

Fludrocortisone therapy in renal transplant recipients with persistent hyperkalemia

Hyperkalemia after kidney transplantation is a common electrolyte disturbance and the risk factors are multifactorial. Pharmacotherapeutic agents for chronic management of hyperkalemia in kidney transplant patients may be relatively contraindicated or provide suboptimal efficacy. Fludrocortisone, an endogenous mineralocorticoid mimics the actions of aldosterone, hence hyperkalemia reversal. We describe three- case series of persistent hyperkalemia with demonstrated benefit from fludrocortisone therapy. Our three renal transplant recipients with multiple emergency room visits for elevated serum potassium levels despite treatment with diuretics, sodium bicarbonate, and sodium polystyrene sulfonate responded well to fludrocortisones therapy. Upon fludrocortisone initiation and maintenance therapy, all three patients experienced a decline in serum potassium levels to normal reference range.

Use of Tris-hydroxymethyl aminomethane in severe lactic acidosis due to highly active antiretroviral therapy: a case report

BACKGROUND

Lactic acidosis is a rare, yet life-threatening adverse drug effect of highly active antiretroviral therapy (HAART), specifically stavudine and lamivudine. These nucleoside analogue reverse transcriptase inhibitors (NRTIs) are commonly used to treat patients infected with the human immunodeficiency virus (HIV).

CASE

We report the use of Tris-hydroxymethyl aminomethane (THAM) to treat severe lactic acidosis due to HAART in a 50-year-old African-American woman. NRTIs can cause hyperlactinaemia by interfering with mitochondrial oxidative phosphorylation function, which normally removes H(+) generated by the hydrolysis of adenosine triphosphate. This side-effect is associated with a high mortality in patients infected with HIV. One explanation for this high mortality is that lactic acidosis is typically refractory to treatment with commonly used buffering agents.

CONCLUSION

THAM generates serum bicarbonate, and reduces the level of carbon dioxide in arterial blood. Both of these qualities appear to make THAM an ideal agent for treating lactic acidosis caused by HAART.

Correlates of maternal directiveness with children who are developmentally delayed

Interactions between 25 mothers and their children with developmental delays were correlated to determine the relationships between maternal directiveness and a) maternal behavior regarded as developmentally facilitative, b) maternal intrusiveness, and c) child developmental competence and behavioral engagement. The findings, many of which challenge common conceptions about the nature and role of maternal directiveness, are discussed in relation to these conceptions and to the potential role of directiveness in the development of children with handicaps.

Maternal directiveness in interactions with mentally handicapped children: an analytical commentary

Maternal directiveness is portrayed as a negative interactional phenomenon in the mental retardation literature. Based on the speculation that a directive interactional style is causally related to poor developmental outcomes, the reduction of maternal directive behaviour is becoming a major thrust in early intervention work. This paper questions the characterization of directiveness as an inherently negative interactional phenomenon and highlights limitations in our current understanding of directiveness. Critical issues requiring attention in future research are identified and early interventionists cautioned that management of maternal directive behaviour must be founded on sound, empirically validated principles.