First-in-Human Gene Therapy Trial of AAV8-hCARp.hCNGB3 in Adults and Children With CNGB3-associated Achromatopsia

PURPOSE

To assess the safety and efficacy of AAV8-hCARp.hCNGB3 in participants with CNGB3-associated achromatopsia (ACHM).

DESIGN

Prospective, phase 1/2 (NCT03001310), open-label, nonrandomized clinical trial.

METHODS

The study enrolled 23 adults and children with CNGB3-associated ACHM. In the dose-escalation phase, adult participants were administered 1 of 3 AAV8-hCARp.hCNGB3 dose levels in the worse-seeing eye (up to 0.5 mL). After a maximum tolerated dose was established in adults, an expansion phase was conducted in children ≥3 years old. All participants received topical and oral corticosteroids. Safety and efficacy parameters, including treatment-related adverse events and visual acuity, retinal sensitivity, color vision, and light sensitivity, were assessed for 6 months.

RESULTS

AAV8-hCARp.hCNGB3 (11 adults, 12 children) was safe and generally well tolerated. Intraocular inflammation occurred in 9 of 23 participants and was mainly mild or moderate in severity. Severe cases occurred primarily at the highest dose. Two events were considered serious and dose limiting. All intraocular inflammation resolved following topical and systemic steroids. There was no consistent pattern of change from baseline to week 24 for any efficacy assessment. However, favorable changes were observed for individual participants across several assessments, including color vision (n = 6/23), photoaversion (n = 11/20), and vision-related quality-of-life questionnaires (n = 21/23).

CONCLUSIONS

AAV8-hCARp.hCNGB3 for CNGB3-associated ACHM demonstrated an acceptable safety and tolerability profile. Improvements in several efficacy parameters indicate that AAV8-hCARp.hCNGB3 gene therapy may provide benefit. These findings, with the development of additional sensitive and quantitative end points, support continued investigation.

Generation of evidence supporting the content validity of SF-36, FACIT-F, and LupusQoL, and novel patient-reported symptom items for use in patients with systemic lupus erythematosus (SLE) and SLE with lupus nephritis (LN)

OBJECTIVE

SLE and lupus nephritis (LN) have significant impacts on the health-related quality of life of patients living with the condition, which are important to capture from the patient's perspective using patient-reported outcomes (PROs). The objectives of this study were to evaluate the content validity of PROs commonly used in SLE and LN (36-Item Short Form Health Survey (SF-36), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) and Lupus Quality of Life (LupusQoL), as well as novel PRO symptom severity items measuring skin rash, joint pain, joint stiffness and swelling of the legs and/or feet, in both populations.

METHODS

Qualitative, semi-structured, cognitive interviews were conducted with 48 participants (SLE=28, LN=20). Understanding and relevance of symptom and impact PRO concepts from existing PROs were assessed, alongside novel PRO symptom severity items with different recall periods (24 hours vs 7 days) and response scales (Numerical Rating Scale (NRS) vs Verbal Rating Scale). Interviews were conducted in multiple rounds to allow for modifications to the novel PRO items. Analysis of verbatim interview transcripts was performed.

RESULTS

Symptom and impact concepts assessed by the SF-36, FACIT-F, and LupusQoL were well understood by both participants with SLE and LN (≥90.0%), with most considered relevant by over half of the participants asked (≥51.9%). All participants asked (100%) understood the novel PRO symptom severity items, and the majority (≥90.0%) considered the symptoms relevant. Minor modifications to the novel PRO items were made between rounds to improve clarity based on participant feedback. The selected 7-day recall period and NRS in the final iteration of the PRO items were understood and relevant. No differences in interview findings between the SLE and LN samples were identified.

CONCLUSIONS

Findings provide evidence of content validity for concepts assessed by the SF-36, FACIT-F, LupusQoL and the novel PRO symptom severity items, supporting use of these PROs to comprehensively assess disease impact in future SLE and LN clinical trials.

Phase 3, multicentre, randomised, placebo-controlled study evaluating the efficacy and safety of ustekinumab in patients with systemic lupus erythematosus

OBJECTIVE

Evaluate the efficacy and safety of ustekinumab, an anti-interleukin-12/23 p40 antibody, in a phase 3, randomised, placebo-controlled study of patients with active systemic lupus erythematosus (SLE) despite receiving standard-of-care.

METHODS

Active SLE patients (SLE Disease Activity Index 2000 (SLEDAI-2K) ≥6 during screening and SLEDAI-2K ≥4 for clinical features at week 0) despite receiving oral glucocorticoids, antimalarials, or immunomodulatory drugs were randomised (3:2) to receive ustekinumab (intravenous infusion ~6 mg/kg at week 0, followed by subcutaneous injections of ustekinumab 90 mg at week 8 and every 8 weeks) or placebo through week 48. The primary endpoint was SLE Responder Index (SRI)-4 at week 52, and major secondary endpoints included time to flare through week 52 and SRI-4 at week 24.

RESULTS

At baseline, 516 patients were randomised to placebo (n=208) or ustekinumab (n=308). Following the planned interim analysis, the sponsor discontinued the study due to lack of efficacy but no safety concerns. Efficacy analyses included 289 patients (placebo, n=116; ustekinumab, n=173) who completed or would have had a week 52 visit at study discontinuation. At week 52, 44% of ustekinumab patients and 56% of placebo patients had an SRI-4 response; there were no appreciable differences between the treatment groups in the major secondary endpoints. Through week 52, 28% of ustekinumab patients and 32% of placebo patients had a British Isles Lupus Assessment Group flare, with a mean time to first flare of 204.7 and 200.4 days, respectively. Through week 52, 70% of ustekinumab patients and 74% of placebo patients had ≥1 adverse event.

CONCLUSIONS

Ustekinumab did not demonstrate superiority over placebo in this population of adults with active SLE; adverse events were consistent with the known safety profile of ustekinumab.

TRIAL REGISTRATION NUMBER

NCT03517722.

Efficacy and Safety of Ustekinumab in Patients with Active Systemic Lupus Erythematosus: Results Through 2 Years of an Open-Label Extension in a Phase 2 Study

OBJECTIVE

To evaluate long-term efficacy and safety of ustekinumab through 2 years in patients with active systemic lupus erythematosus (SLE).

METHODS

This was a placebo-controlled (Week24) phase 2 study in 102 patients with seropositive active SLE. Patients were randomized to ustekinumab (~6 mg/kg single IV infusion, then 90 mg SC every 8 weeks) or placebo, added to background therapy. Placebo patients initiated ustekinumab (90mg SC Q8W) at Week24. Patients could enter an optional open-label study extension after Week40 (final ustekinumab administration at Week104). Efficacy assessments included SRI-4, SLEDAI-2K, PGA, and CLASI. Observed data are reported for the extension period. The final efficacy assessment was at Week112; safety was monitored through Week120.

RESULTS

In this subset of patients who entered the study extension, 24 in the ustekinumab group and 14 in the placebo-crossover group completed study treatment. At Week112, 79% and 92%, respectively, had an SRI-4 response, 92% in both groups had ≥4-point improvement from baseline in SLEDAI-2K score, 79% and 93%, respectively, had ≥30% improvement from baseline in PGA, 86% and 91%, respectively, had ≥50% improvement in active joint (pain and inflammation) count, and 79% and 100%, respectively, had ≥50% improvement in CLASI activity score. No deaths, malignancies, opportunistic infections, or tuberculosis cases occurred. Safety events were consistent with the known ustekinumab safety profile.

CONCLUSION

In the 46 patients who entered the voluntary extension of this phase 2 study, clinical benefit in global and organ-specific SLE-activity measures was observed with ustekinumab through 2years with no new or unexpected safety findings. clinicaltrials.gov: NCT02349061.

A qualitative exploration of the patient experience of erosive and non-erosive hand osteoarthritis

BACKGROUND

Many patients with hand osteoarthritis (HOA) experience reduced health-related quality of life. This study sought to better understand the disease and treatment experience of individuals with HOA, explore any differences in experiences between erosive and non-erosive HOA sub-types, and evaluate content validity of the Michigan Hand Outcomes Questionnaire (MHQ) in HOA.

METHODS

Thirty subjects from the United States (n = 15 erosive HOA; n = 15 non-erosive HOA) participated in semi-structured interviews: concept elicitation explored symptoms/impacts important to patients; cognitive interviews assessed understanding and relevance of the MHQ. A sub-sample participated in real-time data capture (RTDC) activities via a smartphone/tablet app over 7 days. Verbatim transcripts were coded using Atlas.ti software and thematically analyzed. Concept saturation and MHQ content validity were evaluated.

RESULTS

Most participants reported experiencing pain, swelling and stiffness, symptoms that most commonly had a direct impact on physical functioning. Substantial impacts on activities of daily living, emotional functioning, sleep and work were also reported. RTDC findings corroborated concept elicitation findings. There were no notable differences between erosive and non-erosive HOA, except nodules were reported more frequently in erosive disease. Most participants used analgesic treatments, but effects were short-lived. Pain was the symptom most frequently reported as most bothersome and important to treat. Concept saturation was achieved. MHQ items and instructions were well understood and relevant to most participants; stiffness and swelling were reported as important symptoms not included in the MHQ.

CONCLUSIONS

This study characterizes key symptoms of HOA which are burdensome for patients and not well controlled by current therapies, highlighting an unmet treatment need. Although the study is limited by a small sample size that may not be representative of the broader erosive and non-erosive HOA population, concept saturation was achieved, and our findings suggest that disease experience is similar for patients with erosive and non-erosive HOA. Evaluation of stiffness and swelling items in conjunction with the MHQ may enhance relevance and improve measurement precision to assess important domains of HQRoL in an HOA population.

Systemic lupus erythematosus symptom clusters and their association with patient-reported outcomes and treatment: Analysis of real-world data

OBJECTIVE

To identify discrete clusters of systemic lupus erythematosus (SLE) patients based on symptoms and investigate differences across clusters.

METHODS

Data were collected in the United States of America and five European countries via the Adelphi Real World Lupus Disease Specific Programme™, a cross-sectional survey. Rheumatologists provided data for five consecutively consulting adult patients with SLE, who were invited to participate. Identified SLE symptoms were reduced to factors based on commonly concurrent symptoms, using principal-component factor analysis. Factors were used as covariates in a latent class cluster analysis to identify discrete patient clusters. Patient-reported outcomes and physician-reported data were compared across clusters.

RESULTS

Among 1,376 patients, 87% of patients were female and 74% of patients were white. We identified four patient clusters ("very mild", "mild", "moderate", "severe") based on 39 signs/symptoms. Physician-reported symptom burden, organ involvement, disease activity and number of flares increased with increasing cluster severity (p<0.0001). Patient-reported impact (health status, fatigue, work productivity impairment, anxiety/depression, emotional impact) increased with increasing cluster severity (p<0.0001). Glucocorticoid and immunosuppressant use increased, and anti-malarial use decreased, with increasing cluster severity. In all clusters, <20% of patients received biologics; >15% of patients not receiving biologics were considered eligible for treatment by their physician. The proportion of physicians and patients satisfied with treatment decreased with increasing cluster severity (p<0.0001).

CONCLUSION

Our large, international real-world survey of SLE patients and physicians demonstrated strong associations between increased impairment, organ involvement and humanistic burden in SLE, highlighting unmet need for effective treatment options in high disease activity patients.

Valuing experiential knowledge in health promotion: a new method to build up knowledge in France

Issue

Effectiveness analyses of health promotion (HP) interventions (HPI) abound nowadays in France, but few research details how HPI work, nor explains how practitioners can translate conclusive evidence from the literature into action. Furthermore, large amounts of experiential knowledge remain untapped and undervalued. To close these gaps, a national multidisciplinary committee, comprising public officials, academics and practitioners, has worked since 2016 at designing a new method to build up knowledge in HP.

CEKHP

The method aims at Capitalizing, collecting and circulating Experiential Knowledge in HP (CEKHP).

Committee members first investigated methods used in other countries to synthesize and share practical evidence, then drafted and experimented CEKHP in 11 different settings to test its relevance and applicability.

Results

Key components of CEKHP are: 1/CEKHP consists in in-depth semi-structured interviews and offers a guideline template adjustable for various contexts and multiple public health issues (behaviors, environments, etc.); 2/a trained outsider, mastering 7 core competencies, must conduct CEKHP; 3/CEKHP includes a framework for reporting key mechanisms that influence HPI outcomes. Detailed mechanisms include: context, partnerships, key steps, barriers and levers, ethics, theoretical foundations (intervention models, evidence-based literature, etc.), transferability. A guidebook and a toolkit are published in 2020. CEKHP successfully disseminates within the French HP community. It is currently used as the main data collection tool in a research project investigating health promoting sports clubs (PROCeSS) and in a practice-focused project documenting tobacco prevention (DCAP).

Lessons

Practitioners benefit from access to knowledge on how HPI work. CEKHP offers new tools to value and disseminate experiential knowledge. Given that policymakers increasingly prioritize funding in France on documented HPI, providing such tools and training is crucial.

Key messages

CEKHP offers a new method in the French context that has proven fruitful in various settings, for various public health issues, and can be useful to practitioners and researchers alike. Building up experiential knowledge with and for practitioners can be effective at both documenting practices and helping them gain new skills and better understanding of their interventions.

Joining forces to build up knowledge in health promotion: lessons from a French coalition initiative

Issue

French public health authorities increasingly rationalize access to public funding, favoring evidence-based programs. Health Promotion (HP) interventions are especially urged to prove their efficiency in this context. To tackle this issue, HP practitioners hold experiential knowledge (EK) that proves useful to assess both the complexity and efficiency of HP interventions. United by this conviction in a multidisciplinary coalition, HP experts from various backgrounds came together five years ago to promote Experiential Knowledge in HP (EKHP) in France.

A national committee to promote EKHP

670 HP practitioners were surveyed in 2016. Results reported vast amounts of under-documented and often untapped field expertise in HP and numerous obstacles regarding access to scientific literature or systematic reviews. Consequently, the coalition launched a National Committee for EKHP, meeting 5 times a year since 2016. Members of 6 national HP organizations, of 4 regional HP institutes, national and local public health administrators, researchers, consultants and field workers participate. Steered by the French Society for Public Health and the National Federation for Health Education and Promotion, the committee devised a threefold action plan: 1/ advocate EKHP in all relevant institutional spaces, 2/ develop tools for EKHP, 3/ mobilize for EKHP at the local level.

Results

The committee designed a method for capitalizing, collecting and circulating EK and published in 2020 a guidebook and a toolkit. French Public Health authorities agreed to share EK nationwide on their online portal. Dissemination within the French HP community has started, through the committee members' networks, and will be amplified with a training program launched in 2021 at the National School of Public Health.

Lessons

Attention must be brought to HP practitioners’ experiential knowledge, both to recognize HP practitioners' expertise and to help improve the understanding of how HP interventions work.

Key messages

Experiential knowledge in HP remains undervalued and untapped in France. Dedicated practitioners, policymakers and researchers formed a multidisciplinary committee to promote and disseminate EKHP. A multilevel strategy combining advocacy and tool building can be effective at promoting experiential knowledge. A multidisciplinary coalition provided the necessary context-specific levers in France.

Deaf-Blind Clients and Vocational Rehabilitation: Practical Guidelines for Counselors

This article presents suggestions and proved effective strategies for determining the eligibility of, conducting diagnostic workups for, and providing vocational rehabilitation services to deaf-blind individuals. It emphasizes that the optimal rehabilitation process for such clients begins before the clients transfer from educational programs.

SAT0213 IMPACT OF FLARES ON HEALTHCARE RESOURCE USAGE AND PROS IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS

Background:

The effect of flares on healthcare resource usage and patient-reported outcome scores in SLE patients is not well quantified.

Objectives:

To understand how flares impact healthcare resource utilization (HCRU) and patient-reported outcomes amongst an international real-world dataset of SLE patients.

Methods:

The Adelphi Real World 2015 Lupus Disease Specific Programme (DSP) is a cross-sectional study of 263 rheumatologists in the US and EU5. Rheumatologists were asked to complete patient record forms (PRFs) for the next 5 prospectively consulting SLE patients; the same patients were asked to complete patient self-completion (PSC) forms describing how SLE affected them. PRFs collected data pertaining to the patient’s diagnosis, disease history, current clinical outcomes, treatment and management history. PSCs collected similar data and included patient-reported outcome measures (PROs) to assess humanistic burden. Propensity score matching was used to assess differences in HCRU and health status between SLE patients who had flared (physician defined) in the last 12 months and those who had not. Matching variables were patient ethnicity, time since diagnosis, and severity at diagnosis. Data were extracted from 1278 PRFs, and 591 PSCs. Propensity score matching was carried out on two matched groups of 408 patients.

Results:

Demographic data are reported in Table 1. Propensity score matching showed patients who flared in the last 12 months experienced significantly greater hospitalizations, visits to the ER, and total HCP consults in the last 12 months. Significantly greater drug burden lower physician and patient satisfaction, lower EQ-5D score (worse health status), lower FACIT Fatigue score (greater fatigue), and greater overall work impairment (Table 2) were also observed.

Table 1.

Demographic data

VariableFlared in last 12 monthsNot flared in the last 12 monthsMean age (years)41.842.4% Female86.087.0% White/Caucasian66.276.3Mean years diagnosed5.95.4Table 2.

Propensity score matching results

Outcome variableFlared meanNot flared meanCoefficient95% CIp-valueHospitalisations in last 12 months24.267.630.17[0.12 – 0.21]<0.001Emergency department visits in last 12 months20.834.190.17[0.12 – 0.21]<0.001Number of tests in last 12 months46.4938.907.59[3.74 – 11.44]<0.001Number of current medications2.762.190.57[0.43 – 0.72]<0.001Physician satisfied64.4686.63-0.22[-0.28 – -0.17]<0.001Patient satisfied69.2985.09-0.16[-0.24 – -0.08]<0.001EQ-5D-3L0.720.83-0.11[-0.15 – -0.07]<0.001FACIT Fatigue30.0636.48-6.42[-8.5 – -4.3]<0.001WPAI overall percentage work impairment42.7430.2312.5[7.51 – 17.50]<0.001

Conclusion:

The analysis of international real-world data confirmed that SLE patients who flared in the last year represent a greater burden on healthcare resource and demonstrate significantly worse health status, greater fatigue, lower patient and physician satisfaction and greater overall work impairment compared with non-flaring patients. There is a need for more effective treatments in this patient population to reduce patient and healthcare burden.

Study funded by Johnson and Johnson.

Disclosure of Interests:

Zahi Touma Consultant of: Consultant for Janssen, Ben Hoskin Consultant of: Consultant for Janssen, Christian Atkinson Consultant of: Consultant for Janssen, David Bell Consultant of: Janssen, Olivia Massey Consultant of: Janssen, Jennifer H. Lofland Employee of: Janssen, Pamela Berry Employee of: Janssen, Chetan Karyekar Shareholder of: Johnson & Johnson, Consultant of: Janssen, Employee of: Janssen Global Services, LLC. Previously, Novartis, Bristol-Myers Squibb, and Abbott Labs., Karen Costenbader Grant/research support from: Merck, Consultant of: Astra-Zeneca

AB1332-HPR ASSESSING THE PATIENT EXPERIENCE OF LUPUS NEPHRITIS: DEVELOPMENT OF A CONCEPTUAL MODEL AND REVIEW OF EXISTING PATIENT-REPORTED OUTCOME (PRO) MEASURES

Background:

Lupus nephritis (LN) is an autoimmune disease characterized by inflammation of the kidneys as a result of systemic lupus erythematosus (SLE). Approximately 50% of SLE patients will develop LN, which is considered to be one of the most severe manifestations of SLE and the leading cause of morbidity and mortality in SLE. While there is ample existing evidence on disease experience and PROs used in extra-renal SLE, little research has been done in LN. Qualitative interviews with patients can help identify concepts that are both important and relevant to the patient. In order to effectively evaluate treatment benefit, it is critical that PRO measures used to assess such concepts and define clinical trial endpoints are fit for purpose and have strong evidence of content validity in the specific context of use.

Objectives:

The objective of this study was to understand the patient experience of LN and to identify and characterize the signs and symptoms of LN and their impact on health-related quality of life (HRQoL) through the development of a disease-specific conceptual model. This model was then used to evaluate the content validity of existing PRO measures available for use in LN.

Methods:

A structured literature search was conducted in Medline, Embase and PsycINFO to identify qualitative research articles documenting the patient experience of LN. PRO measures developed or commonly used to assess patient experiences of LN were also identified. Semi-structured concept elicitation interviews were conducted with 15 adult patients in the US with a clinician-confirmed diagnosis of LN (defined in accordance with established clinical guidelines). Supplementary qualitative data were also collected from a review of publicly available online blogs/forums. Findings were used to inform the development of a conceptual model detailing the impact of LN signs, symptoms and HRQoL and evaluate the validity of existing measures used within LN.

Results:

Searches revealed a paucity of qualitative research conducted with LN patients, supporting the need for prospective research in LN. Consistent with existing literature in SLE, the core signs and symptoms identified from the qualitative literature review, interviews and blog/forum review included joint pain, fatigue, joint stiffness, swelling (particularly in the extremities) and skin rashes. LN patients also reported urinary frequency, urgency, foamy urine and blood in their urine. Disease impact on physical functioning, activities of daily living, emotions, social life, work/finances and sleep were reported. PRO measures commonly used to evaluate patient experiences in LN included the SF-36, LupusQOL, LupusPRO, SLE Symptom Checklist, KDQoL and KSQ. Conceptual mapping of instruments against the newly developed conceptual model (Figure 1) highlighted that no single measure provides a comprehensive assessment of all symptoms/impact important to LN patients. Furthermore, items are largely focused on impact of symptoms with few items on symptom severity.

Figure 1.

Conceptual model of lupus nephritis symptoms and associated impacts

Conclusion:

The presentation of signs and symptoms in LN patients appears similar to those reported in extra-renal SLE populations, with the addition of swelling and urinary symptoms. Qualitative research with LN patients guided the development of a comprehensive LN conceptual model outlining the disease experience from the patients’ perspective. These insights can be useful to inform PRO measurement strategies for clinical trials in LN.

Acknowledgments:

With thanks to Dr. Betty Diamond and Dr. David Wofsy for their collaboration and helpful insights

Disclosure of Interests:

Pamela Berry Employee of: Janssen, Kate Burrows Consultant of: Adelphi Values a health outcomes research company commissioned by Janssen to conduct the research reported in this abstract, Rebecca Hall Consultant of: Adelphi Values a health outcomes research company commissioned by Janssen to conduct the research reported in this abstract., Adam Gater Consultant of: Adelphi Values a health outcomes research company commissioned by Janssen to conduct the research reported in this abstract, Helena Bradley Consultant of: Adelphi Values a health outcomes research company commissioned by Janssen to conduct the research reported in this abstract, Amy Ward Consultant of: Adelphi Values a health outcomes research company commissioned by Janssen to conduct the research reported in this abstract, Chloe Tolley Consultant of: Adelphi Values a health outcomes research company commissioned by Janssen to conduct the research reported in this abstract, Patricia Delong Employee of: Janssen, Elizabeth C Hsia Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC

THU0246 DIAGNOSTIC CLUSTER PROFILING OF PATIENTS IN A REAL-WORLD DATA SET WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Previous systemic lupus erythematosus (SLE) studies have identified potential clusters of SLE clinical manifestations post diagnosis.

Objectives:

To describe the presentation of SLE at diagnosis across different cohorts of patients and describe management and outcomes after diagnosis within clusters.

Methods:

Cross-sectional study of 263 rheumatologists in the US and EU5. Data were collected from the Adelphi Real World 2015 Lupus Disease Specific Programme. Rheumatologists completed patient record forms (PRFs) for the next 5 prospectively consulting SLE patients; these patients completed patient self-completion (PSC) forms describing how SLE affected them. PRF data includes patient’s characteristics and management history. PSCs focused on similar data collection, including patient reported outcome measures on the humanistic burden. Age at diagnosis, symptoms at diagnosis, organ involvement at diagnosis, and severity at diagnosis were used as covariates in a latent cluster analysis.

Results:

Data were extracted from 1376 PRFs. Cluster analysis resulted in up to 6 clusters, and disease understanding led to the selection of a 4-cluster solution.

Cluster 1 displayed the mildest disease, characterised by joint involvement, while cluster 2 displayed more skin involvement in conjunction with joint. Cluster 3 were characterised by renal involvement and cluster 4 had skin and joint involvement, but also high constitutional and haematological involvement at diagnosis (Table 1).

Table 1

Cluster analysis

ClustersOrgan involvement at diagnosis, n (%)Overall(n=1304)1(n=210)2(n=493)3(n=162)4(n=439)p-valueMusculoskeletal1145 (87.8)174 (82.9)444 (90.1)134 (82.7)393 (89.5)0.0065Mucocutaneous898 (68.9)5 (2.4)397 (80.5)95 (58.6)401 (91.3)<0.0001Neuropsychiatric87 (6.7)19 (9.0)9 (1.8)16 (9.9)43 (9.8)<0.0001Cardiorespiratory176 (13.5)36 (17.1)14 (2.8)22 (13.6)104 (23.7)<0.0001Gastrointestinal44 (3.4)8 (3.0)14 (2.8)8 (4.9)14 (3.2)0.6115Opthalmic47 (3.6)020 (4.1)10 (6.2)17 (3.9)0.0102Renal213 (16.6)15 (7.1)9 (1.8)162 (100)27 (6.2)<0.0001Constitutional425 (32.6)45 (21.4)89 (18.1)55 (34.0)236 (53.8)<0.0001Haematological452 (34.7)64 (30.5)22 (4.5)80 (49.4(286 (65.1)<0.0001Severity at diagnosis, n (%)Mild209 (16.0)55 (26.2)99 (20.1)1 (0.6)54 (12.3)<0.0001Moderate806 (61.8)122 (58.1)324 (65.7)75 (46.3)285 (64.9)Severe289 (22.2)33 (15.7)70 (14.2)86 (53.1)100 (22.8)

Significant between-cluster differences were observed when comparing outcomes; cluster 4 have been diagnosed longest (mean weeks diagnosed 354.6 v. 1: 232.6, 2: 228.7, 3: 338.2, p<0.0001). Cluster 3 consulted more in the last 12 months (mean number of visits 7.9 vs. 1: 5.7, 2: 6.3, 4: 7.6).

Significant differences were also observed between clusters in relation to current treatment proportions: corticosteroid (highest cluster 3: 78.4%), immunosuppressant (highest cluster 3: 75.3%), biologic DMARD (highest cluster 4: 17.8%) and antidepressant (highest cluster 4: 4.1%).

Conclusion:

This study demonstrates the heterogeneity of SLE at diagnosis and highlights four distinct presentations of the disease at diagnosis. Significant proportions of patients present with advanced disease, these clusters go on to present the greatest burden demonstrating the need for better diagnostic tools and novel earlier intervention.

Study funded by Johnson and Johnson.

Disclosure of Interests:

Zahi Touma Consultant of: Consultant for Janssen, Ben Hoskin Consultant of: Consultant for Janssen, Christian Atkinson Consultant of: Consultant for Janssen, David Bell Consultant of: Janssen, Olivia Massey Consultant of: Janssen, Jennifer H. Lofland Employee of: Janssen, Pamela Berry Employee of: Janssen, Chetan Karyekar Shareholder of: Johnson & Johnson, Consultant of: Janssen, Employee of: Janssen Global Services, LLC. Previously, Novartis, Bristol-Myers Squibb, and Abbott Labs., Karen Costenbader Grant/research support from: Merck, Consultant of: Astra-Zeneca

AB1170 THE IMPACT OF HIGH DISEASE ACTIVITY AS MEASURED BY SLEDAI AND DRUG BURDEN-ON HEALTHCARE UTILIZATION, QUALITY OF LIFE AND WORK PRODUCTIVITY IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS

Background:

Although there is abundant literature on healthcare utilization in SLE patients, the impact of disease activity in SLE patients is not well understood.

Objectives:

To quantify the impact of disease activity, as measured by SLEDAI score and drug burden, in SLE patients on health care resource utilization (HCRU), health related quality of life (HRQoL) and work productivity (WP).

Methods:

Data were collected from a cross-sectional survey of 754 rheumatologists in US and EU5 from the Adelphi Real World 2010/2013/2015 Lupus Disease Specific Programmes (DSP). Physicians were asked to complete patient record forms (PRFs) for the next 5 prospectively consulting SLE patients; the same patients were asked to complete patient self-completion (PSC) forms describing how SLE affected them. PRFs collected data pertaining to the patient’s diagnosis, disease history, current clinical outcomes, treatment and management history. PSCs focused on similar data collection and included patient reported outcome measures (PROs). Propensity score matching was used to assess differences in HCRU and PRO scores between SLE patients who had a low disease activity and those who had a high disease activity. Low disease activity was defined as a SLEDAI score of ≤4, a steroid dose of <7.5mg/day, and not on immunosuppressant or biologic. High disease activity was a SLEDAI score of >4, or on an immunosuppressant, biologic, or steroid dose of >7.5mg/day. Patients were matched on age, sex, and ethnicity.

Results:

Data was extracted from 1278 PRFs, and 591 PSCs. Using the estimated propensity score each low disease activity patient (n=44) was matched with a high disease activity patient (n=1187). Using 1:1 matching, with replacement and allowing for ties, matching resulted in 414 high disease activity patients being used as matches for 44 low disease activity patients. Demographic data are reported in Table 1. Patients with a low disease activity were significantly less likely to be currently flaring, lower number of flares in last 12 months, less likely to have been hospitalized in the last 12 months, had fewer consultations in the last 12 months, reported better HrQoL (EQ5D), more favourable levels of fatigue (FACIT), and lower work impairment (WPAI). (Table 2).

Table 1.

Demographic data

VariableLow disease activityHigh disease activityMean age (years)38.140.0% Female90.788.2% White/Caucasian76.767.7Mean years diagnosed5.55.0Table 1.

Propensity score matching results

Outcome variableLow activity meanHigh activity meanCoefficient95% CIp-valueFlared in the last 12 months11.6337.97-0.26[-0.38 – -0.14]<0.001Number of flares in last 12 months0.210.70-0.49[-0.72 - -0.26]<0.001Hospitalised in last 12 months4.6514.98-0.10[-0.17 – -0.04]0.001Number of consults in last 12 months2.843.52-0.68[-1.19 – -0.17]0.009EQ-5D-3L0.780.880.10[0.03 – 0.17]0.004FACIT Fatigue34.6839.865.19[0.80 – 9.57]0.02WPAI overall percentage work impairment14.4245.35-30.93[-45.32 – -16.54]<0.001

Conclusion:

Systemic lupus erythematosus patients with lower levels of disease activity are less burdensome to the healthcare system and experience a significantly better HRQoL and lower levels of productivity impairment. There is a need to establish a universal definition of low disease activity as a treatment goal to benefit patient quality of life and reduce HCRU.

Study funded by Johnson and Johnson.

Disclosure of Interests:

Zahi Touma Consultant of: Consultant for Janssen, Ben Hoskin Consultant of: Consultant for Janssen, Christian Atkinson Consultant of: Consultant for Janssen, David Bell Consultant of: Janssen, James Pike Consultant of: Janssen, Jennifer H. Lofland Employee of: Janssen, Pamela Berry Employee of: Janssen, Chetan Karyekar Shareholder of: Johnson & Johnson, Consultant of: Janssen, Employee of: Janssen Global Services, LLC. Previously, Novartis, Bristol-Myers Squibb, and Abbott Labs., Karen Costenbader Grant/research support from: Merck, Consultant of: Astra-Zeneca

How to build and share an experiential knowledge in public health?

Key messages

This work opens the way for an original reflection in public health to build a shareable experiential knowledge, and to valorize and strengthen field actors’ practical expertise. This work has pedagogical, political, scientific and informational impacts. It contributes to knowledge transfer and provides self-training, a practical vision of policies, and questions for research.

Identification of a potent benzoxaborole drug candidate for treating cryptosporidiosis

Cryptosporidiosis is a leading cause of life-threatening diarrhea in young children and causes chronic diarrhea in AIDS patients, but the only approved treatment is ineffective in malnourished children and immunocompromised people. We here use a drug repositioning strategy and identify a promising anticryptosporidial drug candidate. Screening a library of benzoxaboroles comprised of analogs to four antiprotozoal chemical scaffolds under pre-clinical development for neglected tropical diseases for Cryptosporidium growth inhibitors identifies the 6-carboxamide benzoxaborole AN7973. AN7973 blocks intracellular parasite development, appears to be parasiticidal, and potently inhibits the two Cryptosporidium species most relevant to human health, C. parvum and C. hominis. It is efficacious in murine models of both acute and established infection, and in a neonatal dairy calf model of cryptosporidiosis. AN7973 also possesses favorable safety, stability, and PK parameters, and therefore, is an exciting drug candidate for treating cryptosporidiosis.

Long-Term Impact of Belimumab on Health-Related Quality of Life and Fatigue in Patients With Systemic Lupus Erythematosus: Six Years of Treatment

Objective

To report long‐term health‐related quality of life (HRQoL) and fatigue outcomes in patients with systemic lupus erythematosus (SLE) receiving belimumab.

Methods

Patients with SLE who completed the Study of Belimumab in Subjects with SLE 76‐week trial (BLISS‐76) were enrolled in this continuation study (BEL112233 [ClinicalTrials.gov identifier: NCT00724867]). The belimumab groups continued to receive the same dose (1 mg/kg or 10 mg/kg) intravenously. After March 2011, all patients received belimumab 10 mg/kg every 28 days plus standard therapy. The placebo group switched to belimumab 10 mg/kg. HRQoL and fatigue assessments included the Short Form 36 (SF‐36) health survey and the Functional Assessment of Chronic Illness Therapy (FACIT)–Fatigue subscale. Post hoc subgroup analyses (BEL206350) assessed clinical characteristics associated with improved HRQoL and fatigue.

Results

Of the 268 patients enrolled, 140 completed the study. Patients receiving long‐term belimumab treatment reported continued improvements in HRQoL and fatigue. At study year 6, the mean ± SD SF‐36 physical component summary (PCS) score and the mental component summary (MCS) score increased from 37.0 ± 9.9 at baseline to 41.7 ± 10.0 (mean ± SD change 4.8 ± 9.4) and from 44.3 ± 11.3 to 47.0 ± 11.6 (mean ± SD change 2.7 ± 11.3) for the PCS and MCS, respectively, exceeding the minimum clinically important difference (MCID) for improvement (2.5 units). The mean ± SD FACIT–Fatigue score exceeded the MCID of 4 at study years 1–5; at study year 6, the mean ± SD change was 3.7 ± 11.8. Statistically significant associations were observed between parent trial treatment groups and change from baseline in PCS, MCS, and FACIT–Fatigue scores (P < 0.01).

Conclusion

Long‐term control of SLE disease activity with belimumab plus standard therapy translates into meaningful improvements in patient‐reported fatigue and HRQoL.

The induction of core pluripotency master regulators in cancers defines poor clinical outcomes and treatment resistance

Stem cell characteristics have been associated with treatment resistance and poor prognosis across many cancer types. The ability to induce and regulate the pathways that sustain these characteristic hallmarks of lethal cancers in a novel in vitro model would greatly enhance our understanding of cancer progression and treatment resistance. In this work, we present such a model, based simply on applying standard pluripotency/embryonic stem cell media alone. Core pluripotency stem cell master regulators (OCT4, SOX2 and NANOG) along with epithelial–mesenchymal transition (EMT) markers (Snail, Slug, vimentin and N-cadherin) were induced in human prostate, breast, lung, bladder, colorectal, and renal cancer cells. RNA sequencing revealed pathways activated by pluripotency inducing culture that were shared across all cancers examined. These pathways highlight a potential core mechanism of treatment resistance. With a focus on prostate cancer, the culture-based induction of core pluripotent stem cell regulators was shown to promote survival in castrate conditions—mimicking first line treatment resistance with hormonal therapies. This acquired phenotype was shown to be mediated through the upregulation of iodothyronine deiodinase DIO2, a critical modulator of the thyroid hormone signalling pathway. Subsequent inhibition of DIO2 was shown to supress expression of prostate specific antigen, the cardinal clinical biomarker of prostate cancer progression and highlighted a novel target for clinical translation in this otherwise fatal disease. This study identifies a new and widely accessible simple preclinical model to recreate and explore underpinning pathways of lethal disease and treatment resistance.

Nosebleeds in hereditary hemorrhagic telangiectasia: Development of a patient-completed daily eDiary

Objective

A prospective, qualitative study was conducted to develop a patient‐reported outcome measure (PROM) for daily administration via electronic diary (eDiary) to assess the severity of nosebleeds in patients with hereditary hemorrhagic telangiectasia (HHT), in accordance with Food and Drug Administration (FDA) PROM guidance criteria.

Methods

Three expert clinicians who treat patients with HHT provided input during instrument development, which comprised: 1) Peer‐reviewed literature and instrument review; 2) Development of draft Nosebleed Diary items; 3a) Three rounds of qualitative interviews (two with a paper‐based diary, one with an eDiary) with patients with documented severe epistaxis related to HHT, for concept elicitation and cognitive debriefing; 3b) Face validity and translatability assessment; 3c) Patient evaluation of the usability and acceptability of the eDiary device; and 4) Preparation of the final Nosebleed eDiary and conceptual framework.

Results

No existing instruments were identified that evaluate HHT‐related nosebleed severity daily and meet FDA PROM guidance criteria. Frequency, duration, and/or speed of flow (i.e., intensity) were reported by most participants with HHT when asked to describe their nosebleed severity. The Nosebleed eDiary was refined based on 17 patient interviews, clinical expert input and the face validity and translatability assessment. The final four‐item eDiary was acceptable to patients with HHT.

Conclusion

The Nosebleed eDiary is “fit for purpose” to assess the severity of HHT‐related nosebleeds, and has established face and content validity. Further adaptation may be required for use in mild or moderate HHT populations. Psychometric testing to evaluate construct validity and reliability are recommended next steps.

Level of Evidence

2c “Outcomes research”

Using a ResearchKit Smartphone App to Collect Rheumatoid Arthritis Symptoms From Real-World Participants: Feasibility Study

Background

Using smartphones to enroll, obtain consent, and gather self-reported data from patients has the potential to enhance our understanding of disease burden and quantify physiological impact in the real world. It may also be possible to harness integral smartphone sensors to facilitate remote collection of clinically relevant data.

Objective

We conducted the Patient Rheumatoid Arthritis Data From the Real World (PARADE) observational study using a customized ResearchKit app with a bring-your-own-device approach. Our objective was to assess the feasibility of using an entirely digital approach (social media and smartphone app) to conduct a real-world observational study of patients with rheumatoid arthritis.

Methods

We conducted this observational study using a customized ResearchKit app with a bring-your-own-device approach. To recruit patients, the PARADE app, designed to guide patients through a series of tasks, was publicized via social media platforms and made available for patients in the United States to download from the Apple App Store. We collected patient-reported data, such as medical history, rheumatoid arthritis-related medications (past and present), and a range of patient-reported outcome measures. We included in the assessment a joint-pain map and a novel objective assessment of wrist range of movement, measured by the smartphone-embedded gyroscope and accelerometer.

Results

Within 1 month of recruitment via social media campaigns, 399 participants self-enrolled, self-consented, and provided complete demographic data. Joint pain was the most frequently reported rheumatoid arthritis symptom to bother study participants (344/393, 87.5%). Severe patient-reported wrist pain appeared to be inversely linked with the range of wrist movement measured objectively by the app. At study entry, 292 of 399 participants (73.2%) indicated a preference for participating in a mobile app–based study. The number of participants in the study declined to 45 of 399 (11.3%) at week 12.

Conclusions

Despite the declining number of participants over time, the combination of social media and smartphone app with sensor integration was a feasible and cost-effective approach for the collection of patient-reported data in rheumatoid arthritis. Integral sensors within smartphones can be harnessed to provide novel end points, and the novel wrist range of movement test warrants further clinical validation.

Literature review to assemble the evidence for response scales used in patient-reported outcome measures

Background

In the development of patient-reported outcome (PRO) instruments, little documentation is provided on the justification of response scale selection. The selection of response scales is often based on the developers’ preferences or therapeutic area conventions. The purpose of this literature review was to assemble evidence on the selection of response scale types, in PRO instruments. The literature search was conducted in EMBASE, MEDLINE, and PsycINFO databases. Secondary search was conducted on supplementary sources including reference lists of key articles, websites for major PRO-related working groups and consortia, and conference abstracts. Evidence on the selection of verbal rating scale (VRS), numeric rating scale (NRS), and visual analogue scale (VAS) was collated based on pre-determined categories pertinent to the development of PRO instruments: reliability, validity, and responsiveness of PRO instruments, select therapeutic areas, and optimal number of response scale options.

Results

A total of 6713 abstracts were reviewed; 186 full-text references included. There was a lack of consensus in the literature on the justification for response scale type based on the reliability, validity, and responsiveness of a PRO instrument. The type of response scale varied within the following therapeutic areas: asthma, cognition, depression, fatigue in rheumatoid arthritis, and oncology. The optimal number of response options depends on the construct, but quantitative evidence suggests that a 5-point or 6-point VRS was more informative and discriminative than fewer response options.

Conclusions

The VRS, NRS, and VAS are acceptable response scale types in the development of PRO instruments. The empirical evidence on selection of response scales was inconsistent and, therefore, more empirical evidence needs to be generated. In the development of PRO instruments, it is important to consider the measurement properties and therapeutic area and provide justification for the selection of response scale type.

Pazopanib may reduce bleeding in hereditary hemorrhagic telangiectasia

Pazopanib (Votrient) is an orally administered tyrosine kinase inhibitor that blocks VEGF receptors potentially serving as anti-angiogenic treatment for hereditary hemorrhagic telangiectasia (HHT). We report a prospective, multi-center, open-label, dose-escalating study [50 mg, 100 mg, 200 mg, and 400 mg], designed as a proof-of-concept study to demonstrate efficacy of pazopanib on HHT-related bleeding, and to measure safety. Patients, recruited at 5 HHT Centers, required ≥ 2 Curacao criteria AND [anemia OR severe epistaxis with iron deficiency]. Co-primary outcomes, hemoglobin (Hgb) and epistaxis severity, were measured during and after treatment, and compared to baseline. Safety monitoring occurred every 1.5 weeks. Seven patients were treated with 50 mg pazopanib daily. Six/seven showed at least 50% decrease in epistaxis duration relative to baseline at some point during study; 3 showed at least 50% decrease in duration during Weeks 11 and 12. Six patients showed a decrease in ESS of > 0.71 (MID) relative to baseline at some point during study; 3/6 showed a sustained improvement. Four patients showed > 2 gm improvement in Hgb relative to baseline at one or more points during study. Health-related QOL scores improved on all SF-36 domains at Week 6 and/or Week 12, except general health (unchanged). There were 19 adverse events (AE) including one severe AE (elevated LFTs, withdrawn from dosing at 43 days); with no serious AE. In conclusion, we observed an improvement in Hgb and/or epistaxis in all treated patients. This occurred at a dose much lower than typically used for oncologic indications, with no serious AE. Further studies of pazopanib efficacy are warranted.

Patient-Reported Outcome (PRO) Consortium translation process: consensus development of updated best practices

This paper describes the rationale and goals of the Patient-Reported Outcome (PRO) Consortium's instrument translation process. The PRO Consortium has developed a number of novel PRO measures which are in the process of qualification by the U.S. Food and Drug Administration (FDA) for use in clinical trials where endpoints based on these measures would support product labeling claims. Given the importance of FDA qualification of these measures, the PRO Consortium's Process Subcommittee determined that a detailed linguistic validation (LV) process was necessary to ensure that all translations of Consortium-developed PRO measures are performed using a standardized approach with the rigor required to meet regulatory and pharmaceutical industry expectations, as well as having a clearly defined instrument translation process that the translation industry can support. The consensus process involved gathering information about current best practices from 13 translation companies with expertise in LV, consolidating the findings to generate a proposed process, and obtaining iterative feedback from the translation companies and PRO Consortium member firms on the proposed process in two rounds of review in order to update existing principles of good practice in LV and to provide sufficient detail for the translation process to ensure consistency across PRO Consortium measures, sponsors, and translation companies. The consensus development resulted in a 12-step process that outlines universal and country-specific new translation approaches, as well as country-specific adaptations of existing translations. The PRO Consortium translation process will play an important role in maintaining the validity of the data generated through these measures by ensuring that they are translated by qualified linguists following a standardized and rigorous process that reflects best practice.

Patient experience in systemic lupus erythematosus: development of novel patient-reported symptom and patient-reported impact measures

BACKGROUND

Comprehensive assessment of systemic lupus erythematosus (SLE) and its treatment requires patient-reported outcome (PRO) measures to capture impacts and fluctuating symptoms. The objective of this study was to develop PROs, in accordance with the Food and Drug Administration (FDA) PRO Guidance, to assess fluctuations in SLE symptoms and its impact.

METHODS

Following independent review board approval, six US rheumatology practices recruited patients with SLE to participate in concept elicitation (CE) interviews, in order to identify important SLE symptoms and their impacts. The SLE Symptom Severity Diary (SSD) and SLE Impact Questionnaire (SIQ) were drafted based on CE interview results and clinician input. The PROs were revised based on patient feedback from cognitive debriefing (CD) interviews, clinician feedback, and a translatability assessment.

RESULTS

Forty-one patients completed CE interviews. Commonly-reported symptoms included fatigue (98%), joint pain (93%), and rash (88%). The most frequently reported impact was difficulty with chores/housework (61%). Eighteen patients completed CD interviews. The PROs were considered comprehensive, clear, and relevant.The SSD contains 17 items assessing energy/vitality, joint and muscle pain/stiffness/swelling, flu-like symptoms, cognition, numbness/tingling, skin symptoms and hair loss using an 11-point numeric response scale and a 24-h recall period (with the exception of hair loss). It also evaluates steroid status and dose. The SIQ contains 50 items, uses a 5-point Likert scale and a 7-day recall period, to assess disease impacts including patients' ability to make plans, work, and physical/social/emotional functioning.

CONCLUSION

The SSD and SIQ are comprehensive SLE-specific PROs developed in accordance with the FDA PRO Guidance. Following assessment of their measurement properties, they may be useful in clinical studies and clinical practice to measure fluctuations in, and the impact of, symptoms in patients with SLE.

Patient Evaluation of Satisfaction and Outcomes with an Autoinjector for Self-Administration of Subcutaneous Belimumab in Patients with Systemic Lupus Erythematosus

OBJECTIVE

This study assessed patient experiences of using an autoinjector device to self-administer subcutaneous belimumab for the treatment of systemic lupus erythematosus (SLE). Satisfaction, ease and convenience of use, and confidence with the device were assessed, in addition to overall experience with belimumab.

METHODS

This cross-sectional study was conducted among patients who completed a phase IIb open-label, multi-dose usability, tolerability, and safety study of subcutaneous belimumab (NCT02124798), in which patients receiving intravenous belimumab or subcutaneous belimumab using a prefilled syringe were switched to eight weekly self-administered doses of subcutaneous belimumab using the autoinjector. This follow-up study comprised an online/paper questionnaire and qualitative telephone interviews.

RESULTS

In total, 43 patients receiving belimumab completed the questionnaire, 21 of whom also completed a follow-up telephone interview. Qualitative interviews indicated that 17 of 21 (81%) patients had a positive experience using the autoinjector; all patients considered the autoinjector to be convenient. Of the 42 patients who switched from intravenous belimumab to the autoinjector, 32 (76%) expressed a preference for the autoinjector over intravenous administration; reasons included convenience, time saved, cost, and reduced injection pain. The most commonly reported disadvantage of the autoinjector was injection discomfort (n = 5 [24%]; qualitative interview). Compared with intravenous administration, the autoinjector improved ability to work (17 of 29 [59%] of those employed) and carry out daily activities (40%).

CONCLUSION

Patients with SLE reported high levels of satisfaction with the belimumab autoinjector and preferred the autoinjector to intravenous administration, citing advantages such as time saved, cost, and improved ability to work and carry out daily activities.

Surface water retention systems for cattail production as a biofuel

Surface water retention systems act to reduce nutrient pollution by collecting excess nutrients within a watershed via runoff. Harvesting aquatic biomass, such as the invasive cattail, from retention systems removes nutrients absorbed by the plant from the ecosystem permanently. Harvested biomass can be used as a renewable energy source in place of fossil fuels, offsetting carbon emissions. The purpose of this research was to simulate cattail harvest from surface water retention systems to determine their ability to provide suitable growing conditions with annual fluctuations in water availability. The economic and environmental benefits associated with nutrient removal and carbon offsets were also calculated and monetized. A proposed upstream and existing downstream water retention system in southern Manitoba were modelled using a system dynamics model with streamflow inputs provided by a physical hydrologic model, Modélisation Environmentale Communautaire - Surface and Hydrology (MESH). Harvesting cattail and other unconventional feedstocks, such as reeds, sedges, and grasses, from retention systems provided a viable revenue stream for landowners over a ten-year period. This practice generates income for landowners via biomass and carbon credit production on otherwise underutilized marginal cropland invaded with cattail. The economic benefits promote wetland habitat restoration while managing cattail growth to maintain biodiversity. Excess nitrogen and phosphorus are also removed from the ecosystem, reducing downstream nutrient loading. Utilizing surface water retention systems for cattail harvest is a best management strategy for nutrient retention on the landscape and improving agricultural resilience.

Identification of a 4-fluorobenzyl l-valinate amide benzoxaborole (AN11736) as a potential development candidate for the treatment of Animal African Trypanosomiasis (AAT)

Novel l-valinate amide benzoxaboroles and analogues were designed and synthesized for a structure-activity-relationship (SAR) investigation to optimize the growth inhibitory activity against Trypanosoma congolense (T. congolense) and Trypanosoma vivax (T. vivax) parasites. The study identified 4-fluorobenzyl (1-hydroxy-7-methyl-1,3-dihydrobenzo[c][1,2]oxaborole-6-carbonyl)-l-valinate (5, AN11736), which showed IC₅₀ values of 0.15 nM against T. congolense and 1.3 nM against T. vivax, and demonstrated 100% efficacy with a single dose of 10 mg/kg against both T. congolense and T. vivax in mouse models of infection (IP dosing) and in the target animal, cattle, dosed intramuscularly. AN11736 has been advanced to early development studies.

Benzoxaborole Antimalarial Agents. Part 5. Lead Optimization of Novel Amide Pyrazinyloxy Benzoxaboroles and Identification of a Preclinical Candidate

Carboxamide pyrazinyloxy benzoxaboroles were investigated with the goal to identify a molecule with satisfactory antimalarial activity, physicochemical properties, pharmacokinetic profile, in vivo efficacy, and safety profile. This optimization effort discovered 46, which met our target candidate profile. Compound 46 had excellent activity against cultured Plasmodium falciparum, and in vivo against P. falciparum and P. berghei in infected mice. It exhibited good PK properties in mice, rats, and dogs. It was highly active against the other 11 P. falciparum strains, which are mostly resistant to chloroquine and pyrimethamine. The rapid parasite in vitro reduction and in vivo parasite clearance profile of 46 were similar to those of artemisinin and chloroquine, two rapid-acting antimalarials. It was nongenotoxic in an Ames assay, an in vitro micronucleus assay, and an in vivo rat micronucleus assay when dosed orally up to 2000 mg/kg. The combined properties of this novel benzoxaborole support its progression to preclinical development.

Development of the Systemic Lupus Erythematosus Steroid Questionnaire (SSQ): a novel patient-reported outcome tool to assess the impact of oral steroid treatment

Background

Oral glucocorticoids (steroids) are the mainstay of treatment for systemic lupus erythematosus (SLE), but their use is often associated with short- and long-term side effects. Following a literature review and discussions with patients with SLE, clinicians, and payers, a need was identified for a comprehensive SLE-specific tool that can be used to evaluate the side effects and benefits of steroids over time from a patient perspective. The objective of this study was to develop a patient-reported outcome (PRO) measure to assess general impact (baseline burden), benefits, side effects, and impacts associated with the use of oral steroids in patients with SLE.

Methods

A qualitative research protocol was developed in which adults with SLE currently receiving or who had received steroids in the past year were recruited from six US rheumatology practices to participate in concept elicitation (CE) interviews. The SLE Steroid Questionnaire (SSQ) was developed based on CE interview results and clinical input. Cognitive debriefing interviews with a second group of patients with SLE evaluated the content, clarity, and relevance of the items. The SSQ was refined using patient feedback, clinician review, and a translatability assessment. The protocol received central independent review board approval.

Results

Thirty-three patients (52% moderate disease severity; 58% currently receiving steroids, mean dose 8.7 mg/day) completed CE interviews. Patients reported benefits, side effects, and impacts from steroids. The refined SSQ contains 50 items assessing steroid dose/duration (4 items), general impact (baseline burden; 19 items), benefits (7 items), work/productivity (3 items), side effects (10 items), emotions (6 items), and overall satisfaction (1 item).

Conclusion

The SSQ is a unique PRO, developed using robust scientific methodology in accordance with the Food and Drug Administration PRO Guidance. It was designed to comprehensively assess the patient experience with steroid therapy and better understand the benefits and burden of steroids for patients with SLE.

Fragment-Based Drug Design of Novel Pyranopyridones as Cell Active and Orally Bioavailable Tankyrase Inhibitors

Tankyrase activity has been linked to the regulation of intracellular axin levels, which have been shown to be crucial for the Wnt pathway. Deregulated Wnt signaling is important for the genesis of many diseases including cancer. We describe herein the discovery and development of a new series of tankyrase inhibitors. These pyranopyridones are highly active in various cell-based assays. A fragment/structure based optimization strategy led to a compound with good pharmacokinetic properties that is suitable for in vivo studies and further development.

Structurally diverse MDM2-p53 antagonists act as modulators of MDR-1 function in neuroblastoma

BACKGROUND

A frequent mechanism of acquired multidrug resistance in human cancers is overexpression of ATP-binding cassette transporters such as the Multi-Drug Resistance Protein 1 (MDR-1). Nutlin-3, an MDM2-p53 antagonist, has previously been reported to be a competitive MDR-1 inhibitor.

METHODS

This study assessed whether the structurally diverse MDM2-p53 antagonists, MI-63, NDD0005, and RG7388 are also able to modulate MDR-1 function, particularly in p53 mutant neuroblastoma cells, using XTT-based cell viability assays, western blotting, and liquid chromatography-mass spectrometry analysis.

RESULTS

Verapamil and the MDM2-p53 antagonists potentiated vincristine-mediated growth inhibition in a concentration-dependent manner when used in combination with high MDR-1-expressing p53 mutant neuroblastoma cell lines at concentrations that did not affect the viability of cells when given alone. Liquid chromatography-mass spectrometry analyses showed that verapamil, Nutlin-3, MI-63 and NDD0005, but not RG7388, led to increased intracellular levels of vincristine in high MDR-1-expressing cell lines.

CONCLUSIONS

These results show that in addition to Nutlin-3, other structurally unrelated MDM2-p53 antagonists can also act as MDR-1 inhibitors and reverse MDR-1-mediated multidrug resistance in neuroblastoma cell lines in a p53-independent manner. These findings are important for future clinical trial design with MDM2-p53 antagonists when used in combination with agents that are MDR-1 substrates.

Tumour cell retention of rucaparib, sustained PARP inhibition and efficacy of weekly as well as daily schedules

Background:

Poly(ADP-ribose) polymerase-1 (PARP) inhibitors (PARPi) exploit tumour-specific defects in homologous recombination DNA repair and continuous dosing is most efficacious. Early clinical trial data with rucaparib suggested that it caused sustained PARP inhibition. Here we investigate the mechanism of this durable inhibition and potential exploitation.

Methods:

Uptake and retention of rucaparib and persistence of PARP inhibition were determined by radiochemical and immunological assays in human cancer cell lines. The pharmacokinetics and pharmacodynamics of rucaparib were determined in tumour-bearing mice and the efficacy of different schedules of rucaparib was determined in mice bearing homologous recombination DNA repair-defective tumours.

Results:

Rucaparib accumulation is carrier mediated (Km=8.4±1.2 μM, Vmax=469±22 pmol per 10⁶ cells per 10 min), reaching steady-state levels >10 times higher than the extracellular concentration within 30 min. Rucaparib is retained in cells and inhibits PARP ⩾50% for ⩾72 h days after a 30-min pulse of 400 nM. In Capan-1 tumour-bearing mice rucaparib accumulated and was retained in the tumours, and PARP was inhibited for 7 days following a single dose of 10 mg kg⁻¹ i.p or 150 mg kg⁻¹ p.o. by 70% and 90%, respectively. Weekly dosing of 150 mg kg⁻¹ p.o once a week was as effective as 10 mg kg⁻¹ i.p daily for five days every week for 6 weeks in delaying Capan-1 tumour growth.

Conclusions:

Rucaparib accumulates and is retained in tumour cells and inhibits PARP for long periods such that weekly schedules have equivalent anticancer activity to daily dosing in a pre-clinical model, suggesting that clinical evaluation of alternative schedules of rucaparib should be considered.

3-Amido pyrrolopyrazine JAK kinase inhibitors: development of a JAK3 vs JAK1 selective inhibitor and evaluation in cellular and in vivo models

The Janus kinases (JAKs) are involved in multiple signaling networks relevant to inflammatory diseases, and inhibition of one or more members of this class may modulate disease activity or progression. We optimized a new inhibitor scaffold, 3-amido-5-cyclopropylpyrrolopyrazines, to a potent example with reasonable kinome selectivity, including selectivity for JAK3 versus JAK1, and good biopharmaceutical properties. Evaluation of this analogue in cellular and in vivo models confirmed functional selectivity for modulation of a JAK3/JAK1-dependent IL-2 stimulated pathway over a JAK1/JAK2/Tyk2-dependent IL-6 stimulated pathway.

Development of the Shortness of Breath with Daily Activities questionnaire (SOBDA)

OBJECTIVES

Based on qualitative research of patients with chronic obstructive pulmonary disease (COPD), the Shortness of Breath (SOB) with Daily Activities (SOBDA) questionnaire was developed as a patient-reported outcome instrument to evaluate the impact of therapy on SOB and assess how SOB affects daily activities.

METHODS

Development of the SOBDA questionnaire consisted of three components. First, focus groups of patients with COPD were asked to describe their experiences of SOB with daily activities. A pool of items was drafted on the basis of information from the focus groups and literature reviews, and then discussed among instrument development and clinical experts. Cognitive debriefing interviews of patients were conducted to assess the draft item pool, and their feedback was used to develop newer versions of the questionnaire. Input was also sought from the Food and Drug Administration, patients, and clinicians.

RESULTS

Forty patients participated in seven focus groups. The terms most often used to describe SOB were "short of breath" or "difficulty breathing." Patients were clearly able to distinguish SOB from chest congestion and wheezing, other common symptoms associated with COPD. The resulting item pool contained 37 items to assess SOB associated with everyday activities, and concept saturation was reached. Thirty-seven patients participated in the subsequent cognitive debriefing interviews. Patients found the items clear and easy to understand with relevance to their everyday experiences, and easy to use in an electronic format.

CONCLUSIONS

Instructions and response options to the SOBDA questionnaire were well understood by patients with COPD, and item relevance was confirmed. Prospective validation and item reduction studies are highly anticipated.

Exploration of a new series of CCR5 antagonists: multi-dimensional optimization of a sub-series containing N-substituted pyrazoles

The introduction of N-substituted pyrazoles in a new series of CCR5 antagonists was shown to substantially increase antiviral activity.

Synthesis, SAR and evaluation of [1,4']-bipiperidinyl-4-yl-imidazolidin-2-one derivatives as novel CCR5 antagonists

Elaboration of our previously disclosed spiropiperidine template led to the development of a series of novel CCR5 antagonists. Results of SAR exploration and preliminary lead characterization are described.

Development and first validation of the COPD Assessment Test

There is need for a validated short, simple instrument to quantify chronic obstructive pulmonary disease (COPD) impact in routine practice to aid health status assessment and communication between patient and physician. Current health-related quality of life questionnaires provide valid assessment of COPD, but are complex, which limits routine use. The aim of the present study was to develop a short validated patient-completed questionnaire, the COPD Assessment Test (CAT), assessing the impact of COPD on health status. 21 candidate items identified through qualitative research with COPD patients were used in three prospective international studies (Europe and the USA, n = 1,503). Psychometric and Rasch analyses identified eight items fitting a unidimensional model to form the CAT. Items were tested for differential functioning between countries. Internal consistency was excellent: Cronbach's alpha = 0.88. Test re-test in stable patients (n = 53) was very good (intra-class correlation coefficient 0.8). In the sample from the USA, the correlation with the COPD-specific version of the St George's Respiratory Questionnaire was r = 0.80. The difference between stable (n = 229) and exacerbation patients (n = 67) was five units of the 40-point scale (12%; p<0.0001). The CAT is a short, simple questionnaire for assessing and monitoring COPD. It has good measurement properties, is sensitive to differences in state and should provide a valid, reliable and standardised measure of COPD health status with worldwide relevance.

Evaluation of secondary amide replacements in a series of CCR5 antagonists as a means to increase intrinsic membrane permeability. Part 1: Optimization of gem-disubstituted azacycles

Replacement of a secondary amide with an N-acyl or N-sulfonyl gem-disubstituted azacyle in a series of CCR5 antagonists led to the identification of compounds with excellent in vitro HIV antiviral activity and increased intrinsic membrane permeability.

Improving the process and outcome of care in COPD: development of a standardised assessment tool

INTRODUCTION

A major goal of COPD treatment is to reduce symptom burden and ensure that the patient's health is as good as possible. This goal requires regular systematic assessment of the patient's COPD with clear and efficient communication between the patient and clinician.

AIM

To explore patient and physician descriptions of COPD attributes, in order to inform content development of a patient-reported clinical assessment tool.

METHODS

Qualitative research methods (one-to-one interviews and patient focus groups) were used to elicit key characteristics to evaluate COPD health status and explore how patients with COPD experience their condition. ATLAS.ti version 5.0 was used to identify major themes and generate an item pool.

RESULTS

Fifty-eight patients with COPD (GOLD stages 1-4; MRC grades 2-5) and 10 clinicians participated in this research. Twenty-one items were generated, capturing patient assessment of breathlessness, wheeze, cough, sleep, activity limitation, energy/fatigue, social function, and anxiety.

CONCLUSIONS

This qualitative study identified a broad range of items that are potentially suitable for inclusion in a short, simple COPD assessment tool for use in routine clinical practice.