Type 3 long QT syndrome: Is the effectiveness of treatment with beta-blockers population-specific?

BACKGROUND

The efficacy of beta-blocker treatment in type 3 long QT syndrome (LQT3) remains debated.

OBJECTIVES

The purpose of this study was to test the hypothesis that beta-blocker use is associated with cardiac events (CEs) in a French cohort of LQT3 patients.

METHODS

All patients with a likely pathogenic/pathogenic variant in the SCN5A gene (linked to LQT3) were included and followed-up. Documented ventricular tachycardia/ventricular fibrillation, torsades de pointes, aborted cardiac arrest, sudden death, and appropriate shocks were considered as severe cardiac events (SCEs). CEs also included syncope.

RESULTS

We included 147 patients from 54 families carrying 23 variants. Six of the patients developed symptoms before the age of 1 year and were analyzed separately. The 141 remaining patients (52.5% male; median age at diagnosis 24.0 years) were followed-up for a median of 11 years. The probabilities of a CE and an SCE from birth to the age of 40 were 20.5% and 9.9%, respectively. QTc prolongation (hazard ratio [HR] 1.12 [1.0-1.2]; P = .005]) and proband status (HR 4.07 [1.9-8.9]; P <.001) were independently associated with the occurrence of CEs. Proband status (HR 8.13 [1.7-38.8]; P = .009) was found to be independently associated with SCEs, whereas QTc prolongation (HR 1.11 [1.0-1.3]; P = .108) did not reach statistical significance. The cumulative probability of the age at first CE/SCE was not lower in patients treated with a beta-blocker.

CONCLUSION

In agreement with the literature, proband status and lengthened QTc were associated with a higher risk of CEs. Our data do not show a protective effect of beta-blocker treatment.

New-onset atrial fibrillation and chronic coronary syndrome in the CLARIFY registry

BACKGROUND AND AIMS

Data on new-onset atrial fibrillation (NOAF) in patients with chronic coronary syndromes (CCS) are scarce. This study aims to describe the incidence, predictors, and impact on cardiovascular (CV) outcomes of NOAF in CCS patients.

METHODS

Data from the international (45 countries) CLARIFY registry (prospeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease) were used. Among 29 001 CCS outpatients without previously reported AF at baseline, patients with at least one episode of AF/flutter diagnosed during 5-year follow-up were compared with patients in sinus rhythm throughout the study.

RESULTS

The incidence rate of NOAF was 1.12 [95% confidence interval (CI) 1.06-1.18] per 100 patient-years (cumulative incidence at 5 years: 5.0%). Independent predictors of NOAF were increasing age, increasing body mass index, low estimated glomerular filtration rate, Caucasian ethnicity, alcohol intake, and low left ventricular ejection fraction, while high triglycerides were associated with lower incidence. New-onset atrial fibrillation was associated with a substantial increase in the risk of adverse outcomes, with adjusted hazard ratios of 2.01 (95% CI 1.61-2.52) for the composite of CV death, non-fatal myocardial infarction, or non-fatal stroke, 2.61 (95% CI 2.04-3.34) for CV death, 1.64 (95% CI 1.07-2.50) for non-fatal myocardial infarction, 2.27 (95% CI 1.85-2.78) for all-cause death, 8.44 (95% CI 7.05-10.10) for hospitalization for heart failure, and 4.46 (95% CI 2.85-6.99) for major bleeding.

CONCLUSIONS

Among CCS patients, NOAF is common and is strongly associated with worse outcomes. Whether more intensive preventive measures and more systematic screening for AF would improve prognosis in this population deserves further investigation.

Association between coffee or tea consumption and cardiovascular outcomes in patients with stable coronary artery disease: Analysis from the CLARIFY registry

BACKGROUND

Conflicting data exist on the association between consumption of coffee or tea and cardiovascular outcomes, and few focus on patients with established coronary artery disease.

AIM

To describe the association between coffee or tea consumption and cardiovascular outcomes in patients with stable coronary artery disease, using an extensive contemporary international registry, allowing the identification of multiple potential confounders.

METHODS

The Prospective Observational Longitudinal Registry of Patients With Stable Coronary Artery Disease (CLARIFY) registry enrolled in 2009 and 2010 in 45 countries, with a 5-year follow-up. Patients were categorized according to daily consumption of coffee or tea, and were compared with those declaring neither. The primary composite outcome of myocardial infarction, stroke or cardiovascular death was analysed at 5years, as well as all-cause mortality. Sensitivity analyses were performed with a multivariable model.

RESULTS

A total of 15,459 and 10,029 patients declared coffee or tea consumption, respectively. At 5years, after full adjustment, no association was found between coffee consumption and the primary outcome: hazard ratio 1.04 (95% confidence interval 0.89-1.21) for 1 cup; 0.94 (0.82-1.08) for 2-3 cups; and 1.04 (0.86-1.27) for ≥4 cups (P=0.51). Drinking tea was not associated with a different incidence of the primary outcome before or after adjustment, with fully adjusted hazard ratios of 1.08 (95% confidence interval 0.84-1.38) for 1 cup, 1.12 (0.96-1.31) for 2-3 cups and 0.95 (0.79-1.14) for ≥4 cups (P=0.30). After full adjustment, neither coffee nor tea drinking was associated with all-cause mortality.

CONCLUSIONS

In outpatients with stable coronary artery disease, there was no association between coffee or tea consumption and ischaemic outcomes or all-cause mortality.

The trajectory of clinical responses in patients with early rheumatoid arthritis who achieve sustained remission in response to abatacept: subanalysis of AVERT-2, a randomized phase IIIb study

BACKGROUND

AVERT-2 (a phase IIIb, two-stage study) evaluated abatacept + methotrexate versus methotrexate alone, in methotrexate-naive, anti-citrullinated protein antibody-positive patients with early (≤ 6 months), active RA. This subanalysis investigated whether individual patients who achieved the week 24 Simplified Disease Activity Index (SDAI) remission primary endpoint could sustain remission to 1 year and then maintain it following changes in therapy.

METHODS

During the 56-week induction period (IP), patients were randomized to weekly subcutaneous abatacept 125 mg + methotrexate or abatacept placebo + methotrexate. Patients completing the IP who achieved SDAI remission (≤ 3.3) at weeks 40 and 52 entered a 48-week de-escalation (DE) period. Patients treated with abatacept + methotrexate were re-randomized to continue weekly abatacept + methotrexate, or de-escalate and then withdraw abatacept (after 24 weeks), or receive abatacept monotherapy. Proportions of patients achieving sustained SDAI and Boolean remission, and Disease Activity Score in 28 joints using C-reactive protein (DAS28 [CRP]) < 2.6, were assessed. For patients achieving early sustained SDAI remission at weeks 24/40/52, flow between disease activity categories and individual trajectories was evaluated; flow was also evaluated for later remitters (weeks 40/52 but not week 24).

RESULTS

Among patients treated with abatacept + methotrexate (n/N = 451/752) at IP week 24, 22% achieved SDAI remission, 17% achieved Boolean remission, and 42% achieved DAS28 (CRP) < 2.6; of these, 56%, 58%, and 74%, respectively, sustained a response throughout IP weeks 40/52. Among patients with a sustained response at IP weeks 24/40/52, 82% (14/17) on weekly abatacept + methotrexate, 81% (13/16) on abatacept monotherapy, 63% (12/19) who de-escalated/withdrew abatacept, and 65% (11/17) on abatacept placebo + methotrexate were in SDAI remission at end of the DE period; rates were higher than for later remitters in all arms except abatacept placebo + methotrexate.

CONCLUSIONS

A high proportion of individual patients achieving clinical endpoints at IP week 24 with abatacept + methotrexate sustained their responses through week 52. Of patients achieving early and sustained SDAI remission through 52 weeks, numerically more maintained remission during the DE period if weekly abatacept treatment continued.

TRIAL REGISTRATION

NCT02504268 (ClinicalTrials.gov), registered July 21, 2015.

Optimal or standard control of systolic and diastolic blood pressure across risk factor categories in patients with chronic coronary syndromes

AIMS

Guidelines have lowered blood pressure (BP) targets to <130/80 mmHg. We examined the benefit of intensive control for each BP component, versus the burden of other modifiable risk factors, in patients with chronic coronary syndromes (CCS).

METHODS AND RESULTS

The CLARIFY registry (ISRCTN43070564) enrolled 32 703 CCS patients, from 2009-2010, with a 5-year follow-up. Patients with either BP component below European guideline safety boundaries (120/70 mmHg) were excluded, leaving 19 167 patients (mean age 63.8 ± 10.1 years, 78% men) in the present analysis. A multivariable-adjusted Cox proportional hazards model showed a gradual increase in cardiovascular risk (cardiovascular death, myocardial infarction, or stroke) when the number of uncontrolled risk factors (active smoking, no physical activity, low-density lipoprotein cholesterol ≥100 mg/dL, and diabetes with glycated haemoglobin ≥7%) increased [adjusted hazard ratio (HR): 1.34; 95% confidence interval (CI): 1.17-1.52, 1.65 (1.40-1.94), and 2.47 (1.90-3.21) for 1, 2, and 3 or 4 uncontrolled risk factors, respectively, versus 0], without significant interaction with BP. Although uncontrolled systolic (≥140 mmHg) and diastolic (≥90 mmHg) BP were both associated with higher risk than standard BP, standard BP was associated with higher risk than optimal control for only the diastolic component (adjusted HR: 1.08; 95% CI: 0.94-1.25 for systolic BP 130-139 versus 120-129 mmHg and 1.43; 95% CI: 1.27-1.62 for diastolic BP 80-89 versus 70-79 mmHg).

CONCLUSIONS

Our results suggest that optimal BP target in CCS may be ≤139/79 mmHg, and that optimizing the burden of other risk factors should be prioritized over further reduction of systolic BP.

External applicability of the Effect of ticagrelor on Health Outcomes in diabEtes Mellitus patients Intervention Study (THEMIS) trial: An analysis of patients with diabetes and coronary artery disease in the REduction of Atherothrombosis for Continued Health (REACH) registry

AIMS

THEMIS is a double-blind, randomized trial of 19,220 patients with diabetes mellitus and stable coronary artery disease (CAD) comparing ticagrelor to placebo, in addition to aspirin. The present study aimed to describe the proportion of patients eligible and reasons for ineligibility for THEMIS within a population of patients with diabetes and CAD included in the Reduction of Atherothrombosis for Continued Health (REACH) registry.

METHODS AND RESULTS

The THEMIS eligibility criteria were applied to REACH patients. THEMIS included patients ≥50 years with type 2 diabetes and stable CAD as determined by either a history of previous percutaneous coronary intervention, coronary artery bypass grafting, or documentation of angiographic stenosis of ≥50% of at least one coronary artery. Patients with prior myocardial infarction or stroke were excluded. In REACH, 10,156 patients had stable CAD and diabetes. Of these, 6515 (64.1%) patients had at least one exclusion criteria. From the remaining population, 784 patients did not meet inclusion criteria (7.7%) mainly due to absence of aspirin treatment (7.2%), yielding a 'THEMIS-eligible population' of 2857 patients (28.1% of patients with diabetes and stable CAD). The main reasons for exclusion were a history of myocardial infarction (53.1%), use of oral anticoagulation (14.5%), or history of stroke (12.9%). Among the 4208 patients with diabetes and a previous PCI, 1196 patients (28.4%) were eligible for inclusion in the THEMIS-PCI substudy.

CONCLUSIONS

In a population of patients with diabetes and stable coronary artery disease, a sizeable proportion appear to be 'THEMIS eligible.'

CLINICAL TRIAL REGISTRATION

http://www.

CLINICALTRIALS

gov identifier: NCT01991795.

POS0512 ANTI-CITRULLINATED PROTEIN ANTIBODY SEROSTATUS DETERMINES 2-YEAR RETENTION OF IV AND SC ABATACEPT IN PATIENTS WITH RA IN A REAL-WORLD SETTING

Background

A treat-to-target approach for RA management is recommended.1,2 However, up to half of patients discontinue DMARD treatment within 18 months.2 Predictive biomarkers, such as anti-citrullinated protein antibodies (ACPAs) and RF, may be useful to stratify patients to the most appropriate treatment. ACTION (AbataCepT In rOutiNe clinical practice; NCT02109666) and ASCORE (Abatacept SubCutaneOus in Routine Clinical PracticE; NCT02090556) were 2-year, international, observational, prospective, multicenter studies of IV and SC abatacept, respectively, for the treatment of RA in routine clinical practice.3,4 Higher retention has been previously reported in patients with double ACPA/RF seropositive RA compared with double ACPA/RF seronegative RA.3,4

Objectives

To assess the independent effect of ACPA or RF single seropositivity on abatacept retention in patients with RA receiving abatacept in a post hoc analysis of ACTION and ASCORE.

Methods

This post hoc analysis included patients aged ≥ 18 years, with active moderate-to-severe RA (ACR/EULAR 2010 criteria) who initiated IV (body weight–adjusted dosing) or SC (125 mg once weekly) abatacept.3,4 Patients were stratified by baseline ACPA/RF status: ACPA+/RF− (ACPA+ only), ACPA/RF double positive (+/+), ACPA−/RF+ (RF+ only), and ACPA/RF double negative (−/−). Abatacept retention rate at 2 years was estimated by Kaplan–Meier (KM) analysis.

Results

Patients with ACPA/RF serostatus data from the ACTION and ASCORE studies (N = 1679 and N = 1748, respectively) were evaluated. Baseline demographic and disease characteristics were similar across studies and serostatus groups (Table 1). In patients with ACPA+ only RA, abatacept retention rates were similar to the +/+ group and greater than the RF+ only and −/− groups (Figure 1). In ASCORE (Figure 1A), retention rates were significantly higher in ACPA+ only and +/+ groups when compared with the −/− group. In contrast, retention rates for patients with RF+ only RA were not significantly different vs −/− patients. Results were similar in ACTION, although the higher retention in the ACPA+ group did not reach statistical significance (Figure 1B).

Table 1.

Baseline demographics and disease characteristics by ACPA/RF status for the ASCORE and ACTION studies

ASCORE+/+RF+ onlyACPA+ only−/−(n = 1079)(n = 142)(n = 184)(n = 343)Age, years57.1 (12.8)58.2 (11.8)57.4 (13.5)57.8 (13.9)DAS28 (CRP)4.7 (1.2)4.6 (1.1)4.4 (1.0)4.8 (1.2)CDAI26.6 (12.5)25.8 (12.0)23.6 (10.9)28.2 (13.2)SDAI28.1 (13.0)27.2 (12.4)24.4 (10.8)29.7 (13.9)ACTION+/+RF+ onlyACPA+ only−/−(n = 1028)(n = 161)(n = 98)(n = 392)Age, years58.2 (12.0)58.4 (13.4)58.5 (14.0)57.0 (13.3)DAS28 (CRP)4.9 (1.1)5.0 (1.1)4.9 (1.0)5.0 (1.1)CDAI28.7 (12.2)29.2 (12.4)28.7 (11.5)30.1 (12.9)SDAI30.4 (13.1)31.2 (13.4)29.8 (11.5)31.7 (13.4)

Data are mean (SD). Patients with missing data for baseline ACPA/RF status are excluded.

Conclusion

In this post hoc analysis of the real-world ACTION and ASCORE studies, ACPA positivity was associated with an increased likelihood of retention over 2 years. Patients with ACPA+ only RA were equally as likely to be retained on abatacept as patients with ACPA/RF double positivity. In contrast, patients with RF+ only RA were less likely to be retained on abatacept over 2 years. These findings suggest that ACPA positivity played a more important role than RF positivity in abatacept retention. The higher retention seen in patients with ACPA+ only vs RF+ only disease demonstrates the key role of ACPA in RA and supports the importance of precision medicine in treating patients.

References

[1]Fraenkel L, et al. Arthritis Care Res (Hoboken) 2021;73:924–39.

[2]Smolen JS, et al. Ann Rheum Dis 2020;79:685–99.

[3]Alten R, et al. Clin Rheumatol 2019;38:1413–24.

[4]Alten R, et al. Ann Rheum Dis 2021;80(suppl 1):OP0180.

Acknowledgements

This study was sponsored by Bristol Myers Squibb. Medical writing and editorial assistance was provided by Fiona Boswell, PhD, of Caudex, and was funded by Bristol Myers Squibb. Study management provided by Syneos (CRO).

Disclosure of Interests

Rieke Alten Speakers bureau: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Paid instructor for: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Consultant of: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Grant/research support from: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Christiane Rauch Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Melanie Chartier Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, M.T. Nurmohamed Speakers bureau: AbbVie, Bristol Myers Squibb, Eli Lilly, Janssen, Pfizer, Consultant of: AbbVie, Bristol Myers Squibb, Eli Lilly, Janssen, Pfizer, Grant/research support from: AbbVie, Amgen, Bristol Myers Squibb, Eli Lilly, Galapagos, Janssen, MSD, Pfizer, Sean Connolly Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Galapagos, Gilead, Pfizer, Grant/research support from: Gilead, Pfizer, UCB, Peter Peichl Speakers bureau: GlaxoSmithKline, Janssen, Xavier Mariette Consultant of: Bristol Myers Squibb, Galapagos, GlaxoSmithKline, Janssen, Novartis, Pfizer, Sanofi, UCB, Yusuf Patel: None declared, Sara Marsal Speakers bureau: Bristol Myers Squibb, Lilly, MSD, Novartis - Sandoz, Pfizer, Roche, Consultant of: AbbVie, Galapagos, Pfizer, Sanofi; IMIDomics (executive role), Grant/research support from: AbbVie, Bristol Myers Squibb, Galapagos, Janssen, Lilly, MSD, Novartis - Sandoz, Pfizer, Roche, Sanofi, UCB, Roberto Caporali Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Fresenius-Kabi, Galapagos, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, Sandoz, UCB, Consultant of: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Galapagos, Janssen, Lilly, MSD, Novartis, Pfizer, Sandoz, UCB, Hedley Griffiths Consultant of: Amgen, Raimón Sanmartí Speakers bureau: AbbVie, Bristol Myers Squibb, Lilly, MSD, Pfizer, Roche, Sanofi, Grant/research support from: AbbVie, Bristol Myers Squibb, MSD, Pfizer, Roche, Bettina Bannert Speakers bureau: Novartis Pharma Schweiz AG, Yedid Elbez Consultant of: Bristol Myers Squibb, Employee of: Signifience, Karissa Lozenski Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb.

POS0107 ACPA POSITIVITY DETERMINES REMISSION IN PATIENTS WITH RA TREATED WITH IV AND SC ABATACEPT: A POST HOC ANALYSIS OF THE REAL-WORLD OBSERVATIONAL ACTION AND ASCORE STUDIES

Background

The goal of treatment for RA is achieving low disease activity and/or remission1,2; however, disease course and management can be complicated by additional factors that may be influenced by serostatus. Anti-citrullinated protein antibodies (ACPAs) and RF contribute to a more severe RA disease pattern3 and may be useful in predicting response to treatment.4 ACTION (AbataCepT In rOutiNe clinical practice; NCT02109666) and ASCORE (Abatacept SubCutaneOus in Routine Clinical PracticE; NCT02090556) were 2-year, international, observational, prospective, multicenter studies of IV and SC abatacept, respectively, for the treatment of RA in routine clinical practice.4,5 Previous analyses have shown that ACPA/RF double-positive serostatus was associated with better treatment outcomes compared with ACPA/RF double-negative serostatus.4–6

Objectives

To assess the independent effect of ACPA or RF single seropositivity among patients with RA on achieving remission after treatment with abatacept for 2 years, and to compare outcomes among patients with single versus double serostatus.

Methods

This post hoc analysis included patients from ACTION and ASCORE who initiated IV (body weight–adjusted dosing) or SC abatacept (125 mg once weekly), respectively. Patients were stratified by baseline ACPA/RF status: ACPA+/RF− (ACPA+ only), ACPA/RF double positive (+/+), ACPA−/RF+ (RF+ only), and ACPA/RF double negative (−/−). DAS28 (CRP) and CDAI remission rates (defined as < 2.6 and 0–2.8, respectively) at 2 years for patients who were ACPA+ or RF+ only at baseline were assessed and compared with those who were +/+ and −/−. Patients with missing baseline ACPA/RF status were excluded. Last observation carried forward efficacy analyses were used to impute missing values.

Results

This analysis included 1679 patients from ACTION (ACPA+ only, n = 98; +/+, n = 1028; RF+ only, n = 161; and −/−, n = 392) and 1748 patients from ASCORE (ACPA+ only, n = 184; +/+, n = 1079; RF+ only, n = 142; and −/−, n = 343). Across studies and serogroups, baseline demographics and disease characteristics were similar (data not shown). In both ACTION and ASCORE, a higher proportion of patients who were only ACPA+ achieved DAS28 (CRP) and CDAI remission at 2 years compared with patients who were only RF+ (Figure 1). Additionally, a similar proportion of patients who were only ACPA+ achieved DAS28 (CRP) and CDAI remission at 2 years compared with patients who were +/+. In contrast, a lower proportion of patients who were only RF+ achieved DAS28 (CRP) and CDAI remission at 2 years compared with patients who were +/+.

Conclusion

In this post hoc analysis of real-world data from ACTION and ASCORE, ACPA positivity was associated with an increased likelihood of achieving DAS28 (CRP) and CDAI remission at 2 years. Patients who were ACPA+ only were as likely to achieve remission as +/+ patients, suggesting that RF serostatus had less influence than ACPA serostatus on remission status at 2 years. In line with this, patients who were RF+ only were less likely to achieve remission at 2 years. This is the first large, real-world study to show that ACPA positivity plays a more important role than RF positivity in achieving remission whilst on abatacept. These results highlight the importance of assessing baseline ACPA status when considering treatment options for patients with RA.

References

[1]Smolen JS, et al. Ann Rheum Dis 2020;79:685–99.

[2]Fraenkel L, et al. Arthritis Care Res (Hoboken) 2021;73:924–39.

[3]Katchamart, W, et al. Rheumatol Int 2015;35:1693–9.

[4]Alten R, et al. Ann Rheum Dis 2021;80(suppl 1):OP0180.

[5]Alten R, et al. Clin Rheumatol 2019;38:1413–24.

[6]Alten R, et al. RMD Open 2017;3:e000345.

Acknowledgements

This study was sponsored by Bristol Myers Squibb. Medical writing and editorial assistance was provided by Rachel Rankin, PhD, of Caudex, and was funded by Bristol Myers Squibb. Study management provided by Syneos (CRO).

Disclosure of Interests

Rieke Alten Speakers bureau: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Paid instructor for: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Consultant of: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Grant/research support from: AbbVie, Bristol Myers Squibb, Celltrion, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Christiane Rauch Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Melanie Chartier Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, M.T. Nurmohamed Speakers bureau: AbbVie, Bristol Myers Squibb, Eli Lilly, Janssen, Pfizer, Consultant of: AbbVie, Bristol Myers Squibb, Eli Lilly, Janssen, Pfizer, Grant/research support from: AbbVie, Amgen, Bristol Myers Squibb, Eli Lilly, Galapagos, Janssen, MSD, Pfizer, Sean Connolly Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Galapagos, Gilead, Pfizer, Grant/research support from: Gilead, Pfizer, UCB, Peter Peichl Speakers bureau: Janssen, GlaxoSmithKline, Xavier Mariette Consultant of: Bristol Myers Squibb, Galapagos, GlaxoSmithKline, Janssen, Novartis, Pfizer, Sanofi, UCB, Yusuf Patel: None declared, Sara Marsal Speakers bureau: Bristol Myers Squibb, Lilly, MSD, Novartis - Sandoz, Pfizer, Roche, Consultant of: AbbVie, Galapagos, Pfizer, Sanofi; IMIDomics (executive role), Grant/research support from: AbbVie, Bristol Myers Squibb, Galapagos, Janssen, Lilly, MSD, Novartis - Sandoz, Pfizer, Roche, Sanofi, UCB, Roberto Caporali Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Fresenius-Kabi, Galapagos, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, Sandoz, UCB, Consultant of: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Galapagos, Janssen, Lilly, MSD, Novartis, Pfizer, Sandoz, UCB, Hedley Griffiths Consultant of: Amgen, Raimón Sanmartí Speakers bureau: AbbVie, Bristol Myers Squibb, Lilly, MSD, Pfizer, Roche, Sanofi, Grant/research support from: AbbVie, Bristol Myers Squibb, MSD, Pfizer, Roche, Bettina Bannert: None declared, Yedid Elbez Consultant of: Bristol Myers Squibb, Employee of: Signifience, Karissa Lozenski Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

POS0579 ABSENCE OF ASSOCIATION BETWEEN ABATACEPT EXPOSURE LEVELS AND INITIAL INFECTION IN PATIENTS WITH RA: A POST HOC ANALYSIS OF THE RANDOMIZED, PLACEBO-CONTROLLED AVERT-2 STUDY

Background

Infections are the most commonly reported AE observed in patients with RA treated with immunosuppressive therapies and can be clinically significant. A recent review reported differences in the risk of infection for some biologics such as tocilizumab and TNF inhibitors.1 Abatacept selectively modulates T-cell co-stimulation and is approved for the treatment of RA. In patients with polyarticular-course juvenile idiopathic arthritis, no association was found between higher serum abatacept exposure and the incidence of infection.2 This has not been evaluated for adult patients with RA.

Objectives

To determine if higher serum abatacept exposure during treatment with SC abatacept was associated with increased risk of infection in adult patients with RA.

Methods

AVERT-2 (Assessing Very Early Rheumatoid arthritis Treatment-2) was a randomized, placebo-controlled study of SC abatacept + MTX vs abatacept placebo + MTX in MTX-naive, anti-citrullinated protein antibody–positive patients with early, active RA.3 A post hoc population pharmacokinetic (PK) analysis was performed using PK-evaluable patient data from the induction period (year 1) of AVERT-2. Association between steady-state abatacept exposure (min plasma concentration [Cmin], max plasma concentration [Cmax], and average plasma concentration [Cavg]) and first infection was evaluated using Kaplan–Meier plots of probability vs time on treatment by abatacept exposure quartiles and Cox proportional-hazards models.

Results

PK of SC abatacept was defined as a linear 2-compartment model with first-order absorption and first-order elimination. The findings of the updated PK analysis were consistent with those reported in prior population analyses of abatacept PK in adults with RA. The final model included effects of baseline body weight, estimated glomerular filtration rate, sex, age, albumin, MTX use, NSAID use, SJC, and race on abatacept clearance. The only covariate with a clinically relevant effect was higher body weight, which caused an increase in clearance and volume. Infections occurred in a total of 330/693 (47.6%; serious, 1.6%) patients treated with abatacept, and 134/301 (44.5%; serious, 1.3%) with placebo during the first year of AVERT-2. In patients taking abatacept, the mean (SD) study exposure to abatacept was 376 (60) days, while mean (SD) prednisone equivalent dose was 6.7 (3.8) mg/day and mean (SD) MTX dose was 9.6 (3.0) mg/week. No exposure–response relationship was observed between the probability of first infection and steady-state abatacept exposure quartiles (Cavg, Cmin, and Cmax), or compared with placebo (Figure 1A–C). Kaplan–Meier assessment also showed no increase in risk of infection with concomitant use of MTX and glucocorticoids.

Conclusion

No association was found between initial infection and steady-state abatacept exposure (Cavg, Cmin, Cmax) or MTX and glucocorticoid use in patients with RA treated with SC abatacept.

References

[1]Jani M, et al. Curr Opin Rheumatol 2019;31:285–92.

[2]Ruperto N, et al. J Rheumatol 2021;48:1073–81.

[3]Emery P, et al. Arthritis Rheumatol 2019;71(suppl 10):L11.

Acknowledgements

This study was sponsored by Bristol Myers Squibb. Writing and editorial assistance were provided by Fiona Boswell, PhD, of Caudex, and was funded by Bristol Myers Squibb. Support was provided by Sandra Overfield as Protocol Manager, and Prema Sukumar and Renfang Hwang as Data Science Leads.

Disclosure of Interests

Paul Emery Consultant of: AbbVie, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Eli Lilly, Galapagos, Gilead, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Samsung, Grant/research support from: AbbVie, Bristol Myers Squibb, Eli Lilly, Novartis, Pfizer, Roche, Samsung, Roy Fleischmann Consultant of: Amgen, AbbVie, Bristol Myers Squibb, Gilead, GlaxoSmithKline, Novartis, Pfizer, Grant/research support from: Amgen, AbbVie, Arthrosi, Biosplice, Bristol Myers Squibb, Gilead, GlaxoSmithKline, Horizon, Novartis, Pfizer, Regeneron, TEVA, UCB, Robert Wong Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Karissa Lozenski Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Yoshiya Tanaka Speakers bureau: AbbVie, Amgen, Astellas, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Chugai, Eisai, Eli Lilly, Gilead, Mitsubishi Tanabe, YL Biologics, Consultant of: AbbVie, Ayumi, Daiichi Sankyo, Eli Lilly, GlaxoSmithKline, Taisho, Sanofi, Grant/research support from: AbbVie, Asahi Kasei, Boehringer Ingelheim, Chugai, Corrona, Daiichi Sankyo, Eisai, Kowa, Mitsubishi Tanabe, Takeda, Vivian Bykerk Consultant of: Amgen, Bristol Myers Squibb, Genzyme Corporation, Gilead, Regeneron, UCB, Grant/research support from: Amgen, Bristol Myers Squibb, Genzyme Corporation, Pfizer, Regeneron, Sanofi Aventis, UCB, Clifton Bingham Consultant of: AbbVie, Bristol Myers Squibb, Eli Lilly, Janssen, Pfizer, Sanofi, Grant/research support from: Bristol Myers Squibb, Thomas Huizinga Speakers bureau: Abblynx, Abbott, Biotest AG, Bristol Myers Squibb, Crescendo Bioscience, Eli Lilly, Epirus, Galapagos, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi- Aventis, UCB, Consultant of: Abblynx, Abbott, Biotest AG, Bristol Myers Squibb, Crescendo Bioscience, Eli Lilly, Epirus, Galapagos, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi- Aventis, UCB, Grant/research support from: Abblynx, Abbott, Biotest AG, Bristol Myers Squibb, Crescendo Bioscience, Eli Lilly, Epirus, Galapagos, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi- Aventis, UCB, Gustavo Citera Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Eli Lilly, Janssen, Pfizer, Sandoz, Consultant of: AbbVie, Amgen, Bristol Myers Squibb, Pfizer, Grant/research support from: Pfizer, Yedid Elbez Consultant of: Bristol Myers Squibb, Employee of: Signifience, Vidya Perera Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Bindu Murthy Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Kelly Maxwell Consultant of: Bristol Myers Squibb, Employee of: Cognigen Corporation, Julie Passarell Consultant of: Bristol Myers Squibb, Employee of: Cognigen Corporation, William Hedrich: None declared, Daphne Williams Consultant of: Black Diamond Network, Joule, Syneos, Employee of: Bristol Myers Squibb.

Identification of poor prognostic joint locations in an early rheumatoid arthritis cohort at risk of rapidly progressing disease: a post-hoc analysis of the Phase III AGREE study

Background

Rheumatoid arthritis (RA) is a heterogeneous disease with established poor prognostic factors such as seropositivity, joint damage, and high disease activity at an early, treatment-naïve stage of disease. However, few studies have examined if specific joint locations are correlated with these factors in such a population. This analysis explored the potential correlation of individual swollen and erosive joints with other disease characteristics at baseline and with remission rates in a post-hoc analysis of the Phase III randomized AGREE study.

Methods

Methotrexate (MTX)-naïve, erosive, RF- and/or ACPA-positive early RA patients (N = 509) were retrospectively evaluated. Baseline joint swelling was analyzed for large and small joints. Baseline erosions were analyzed for wrist, MCP1–5, IP1, PIP2–5 and MTP1–5. Remission rates were assessed after 6 months of treatment with abatacept (ABA) + MTX (N = 256) or MTX (N = 253). The following statistical tests were used: Chi-Square or Fisher’s exact test (categorical variables); Student’s t-test or Wilcoxon rank-sum test (continuous variables); continuity-corrected Chi-square test (efficacy remission endpoints).

Results

Baseline swelling was most frequent in wrist (91.9%) and MCP2 joint (89.1%), while baseline erosion was most frequent in MTP5 joint (43.5%). Swollen shoulder was significantly correlated (p < 0.0001) with swelling of almost all other large or medium joints. Baseline swelling in the knee, temporomandibular joint (TMJ), wrist and elbow was highly correlated (p < 0.001) with higher tender and swollen joint counts, higher DAS28(CRP) and higher SDAI and CDAI. Baseline swelling was not correlated with erosion per joint, except for MCP2. The largest difference in mean Boolean remission rates at 6 months was in patients with baseline swollen wrist favoring ABA + MTX (14.0% vs 4.4%; p < 0.001).

Conclusions

Swelling in the large and medium joints (knee, TMJ, elbow and wrist) was highly correlated with severe disease activity while MCP2 swelling seemed to be correlated with joint damage. The correlation of joint locations at an early, treatment-naïve stage with poor prognostic factors, higher disease activity and joint damage, could establish a rapidly progressing anatomical pattern in early RA.

Trial registration: ClinicalTrials.gov NCT00122382, registered July 2005.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41927-022-00252-4.

Prediction of flare following remission and treatment withdrawal in early rheumatoid arthritis: post hoc analysis of a phase IIIb trial with abatacept

Background

Drug-free remission is a desirable goal in rheumatoid arthritis (RA) for both patients and clinicians. The aim of this post hoc analysis was to investigate whether clinical and magnetic resonance imaging (MRI) variables in patients with early RA who achieved remission with methotrexate and/or abatacept at 12 months could predict disease flare following treatment withdrawal.

Methods

In the AVERT study of abatacept in early RA, patients with low disease activity at month 12 entered a 12-month period with all treatment discontinued (withdrawal, WD). This post hoc analysis assessed predictors of disease flare at WD+6months (mo) and WD+12mo of patients with Disease Activity Score in 28 joints (DAS28)-defined remission (DAS28[C-reactive protein (CRP)] <2.6) at withdrawal using univariate and multivariable regression models. Predictors investigated included the Health Assessment Questionnaire–Disability Index (HAQ-DI), pain, Patient Global Assessment; MRI synovitis, erosion, bone edema, and combined (synovitis + bone edema) inflammation scores.

Results

Remission was achieved by 172 patients; 100 (58%) and 113 (66%) patients had experienced a flare at WD+6mo and WD+12mo, respectively. In univariate analyses, higher HAQ-DI and MRI synovitis, erosion, bone edema, and combined inflammation scores at WD were identified as potential predictors of flare (P ≤ 0.01). In multivariable analysis, high scores at WD for HAQ-DI and MRI erosion were confirmed as independent predictors of flare at WD+6mo and WD+12mo (P < 0.01).

Conclusion

In patients with early RA achieving clinical remission, patient function (HAQ-DI), and MRI measures of bone damage (erosion) predicted disease flare 6 and 12 months after treatment withdrawal. These variables may help identify patients with early RA in clinical remission as candidates for successful treatment withdrawal.

Trial registration

ClinicalTrials.gov, NCT01142726 (date of registration: June 11, 2010)

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02735-8.

Generalizability of the REDUCE-IT trial and cardiovascular outcomes associated with hypertriglyceridemia among patients potentially eligible for icosapent ethyl therapy: An analysis of the REduction of Atherothrombosis for Continued Health (REACH) registry

BACKGROUND

The REDUCE-IT (Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial) trial demonstrated that high-dose icosapent-ethyl reduced the risk of ischemic events in statin-treated patients with elevated triglycerides (TG) and either atherosclerotic cardiovascular disease (ASCVD) or diabetes plus at least one risk factor.

METHODS AND RESULTS

Using data from REACH (Reduction of Atherothrombosis for Continued Health), a large international registry of outpatients with or at risk of ASCVD, we evaluated the proportion of patients potentially eligible for enrolment in REDUCE-IT and compared their outcomes to those excluded because of low TG. Among 62,464 patients with either ASCVD or diabetes enrolled in the REACH Registry, 1036/8418 (12.3%) patients in primary prevention and 6049/54046 (11.2%) patients in secondary prevention (11.3% overall) would have been eligible for inclusion in REDUCE-IT. Compared with patients excluded for low TG level, adjusted risk of the primary composite outcome of cardiovascular death, non-fatal myocardial infarction (MI), non-fatal stroke, unstable angina, or coronary revascularization was higher in the REDUCE-IT eligible group (HR:1.06, 95%CI:1.00-1.13, p = 0.04). In addition, unstable angina, non-fatal MI, percutaneous coronary intervention and coronary artery bypass grafting were also more frequent in the REDUCE-IT eligible group (HR:1.17, 95%CI:1.07-1.27, p < 0.001; HR:1.25, 95%CI:1.07-1.45, p < 0.001; HR:1.42, 95%CI:1.27-1.57, p < 0.001; HR:1.43, 95%CI:1.19-1.71, p < 0.001, respectively), whereas the adjusted risk of non-fatal stroke was lower (HR:0.64, 95%CI:0.54-0.75, p < 0.001).

CONCLUSION

In this large international registry of patients with or at high-risk of ASCVD, 11.3% met the REDUCE-IT trial selection criteria. REDUCE-IT eligible patients were found to be at higher risk of cardiac atherothrombotic events, but at lower risk of stroke than trial-ineligible patients with lower TG.

Prevalence, Incidence and Prognostic Implications of Left Bundle Branch Block in Patients with Chronic Coronary Syndromes (From the CLARIFY Registry)

Left Bundle Branch Block (LBBB) is a frequently encountered electrical abnormality in patients with chronic (more than 3 months after myocardial infarction, or evidence of coronary artery disease with ischemia) coronary syndromes (CCS), but its prognostic significance remains unclear. We aimed to describe the prevalence, incidence and five-year outcomes of LBBB in outpatients with CCS using the CLARIFY registry. Main outcome was a composite of CV death, MI or stroke. Secondary outcomes included all cause death, hospitalization for heart failure (HF) and permanent pacemaker implantation. Among 23.544 patients with available information regarding LBBB status at baseline, 1.041 (4.4%) had LBBB at baseline and 1.015 (4.5%) patients developed a new LBBB during 5-year follow-up. In multivariate analysis, LBBB at baseline was not associated with the composite outcome of CV death, MI or stroke (HR 1.06, 95% CI [0.86 - 1.31], p = 0.67) or the risk of all-cause death (HR 1.07, 95% CI [0.87 - 1.32], p = 0.52) but was significantly associated with a higher risk of hospitalization for HF (HR 1.50, 95% CI [1.21 - 1.88], p < 0.001) and permanent pacemaker implantation (HR 2.11, 95% CI [1.45 - 3.07], p < 0.001). The main factors associated with new-onset LBBB were male sex (HR 0.8 [0.66-0.98], p = 0.028) history of atrial fibrillation (HR 1.29, 95% CI [1.01 - 1.64], p = 0.04), CABG (HR 1.27, [1.08 - 1.51], p = 0.004) and MI (HR 1.19, 95% CI [1.01 - 1.40], p = 0.034). In conclusion, in a contemporary registry of outpatients with CCS, the prevalence of LBBB was 4.4% and the additional 5-years incidence 6.2%. LBBB, in itself, was not associated with a higher risk of major adverse cardiovascular events or all cause mortality. It was however an independent predictor of risk of hospitalization for heart failure and permanent pacemaker implantation.

POS0447 PHYSICAL FUNCTION IN PATIENTS WITH RA, STRATIFIED BY SEROSTATUS AND TREATMENT LINE, FOLLOWING SC ABATACEPT: POST HOC ANALYSIS OF AN OBSERVATIONAL, 2-YEAR STUDY CONDUCTED IN ROUTINE CLINICAL PRACTICE (ASCORE)

Background:

RA is characterised by the production of autoantibodies, including RF and anti-citrullinated protein antibodies (ACPAs).1 Seropositive disease is associated with poorer prognosis in patients with RA,2 and response to different treatments has been shown to vary based on ACPA status.3 ASCORE (Abatacept SubCutaneOus in Routine Clinical PracticE; NCT02090556) was a 2-year, observational, prospective, multicentre study of SC abatacept for the treatment of RA.4

Objectives:

This post hoc analysis of the ASCORE study evaluated patient-reported outcomes, assessed using HAQ-DI, by RF/ACPA serostatus and treatment line over 24 months of treatment with abatacept.

Methods:

Eligible patients, aged ≥18 years, with active moderate-to-severe RA (ACR/EULAR 2010 criteria) who were IV abatacept-naive and initiated SC abatacept 125 mg once weekly, were enrolled into two cohorts: biologic (b)DMARD-naive patients and those with ≥1 prior bDMARD treatment failure. This post hoc analysis assessed mean change from baseline in HAQ-DI score at 6, 12, 18 and 24 months in response to treatment with abatacept stratified by baseline serostatus (RF/ACPA double positive [+/+]; RF/ACPA single positive [+/−; RF+/ACPA– or RF–/ACPA+] or RF/ACPA double negative [–/–]) and by line of therapy (all patients, patients receiving abatacept as a first-line bDMARD or as a ≥ second-line bDMARD [data not shown], and those receiving abatacept following 1 [data not shown] or ≥2 prior bDMARDs). Estimates of mean difference with 95% CIs between patients with different serostatus were calculated using a t-test for all patients and within different lines of therapy.

Results:

Among 2892 eligible patients in ASCORE, 1748 patients with RF/ACPA status available at baseline were included in this analysis (1079 +/+, 326 +/– and 343 –/–). Of these, 791 patients received abatacept as a first-line bDMARD therapy and 957 as a ≥ second-line bDMARD therapy (505 patients had received ≥2 prior bDMARDs). Among all patients, mean change from baseline in HAQ-DI score at 6 months was greater for patients with +/+ RA (mean difference [95% CI]: –0.2 [–0.3, –0.0]; p=0.0068) or +/– RA (mean difference [95% CI]: –0.2 [–0.3, –0.0]; p=0.0315) versus those with –/– RA at baseline (Figure 1). Similarly, mean change (95% CI) in HAQ-DI score at 6 months was greater for patients with +/+ RA versus –/– RA among those receiving abatacept as first-line therapy (–0.2 [–0.4, –0.0]; p=0.0407) or following treatment with ≥2 bDMARDs (–0.3 [–0.5, –0.0]; p=0.0265) (Figure 1). Among patients treated with abatacept following ≥2 prior bDMARDs, mean change in HAQ-DI score was higher among patients with +/– RA versus –/– RA at 18 months (data not shown) and 24 months (Figure 1). No other significant differences were observed by serostatus or line of therapy at any other time points.

Conclusion:

Patients with RA who were RF+/ACPA+ at baseline showed an enhanced initial response to abatacept compared with those who were RF–/ACPA–. Over 24 months of treatment in this real-world setting, abatacept was equally effective as a first- or ≥ second-line therapy.

References:

[1]Scott DL, et al. Lancet 2010;376:1094–1108.

[2]Hecht C, et al. Ann Rheum Dis 2015;74:2151–2156.

[3]Harrold LR, et al. J Rheumatol 2018;45:32–39.

[4]Alten R, et al. Ann Rheum Dis 2019;78(suppl 2):A1639.

Acknowledgements:

Professional medical writing and editorial assistance was provided by Fiona Boswell, PhD, at Caudex and was funded by Bristol Myers Squibb. This study was funded by Bristol Myers Squibb.

Disclosure of Interests:

Rieke Alten Speakers bureau: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Consultant of: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Grant/research support from: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Xavier Mariette Consultant of: Bristol Myers Squibb, Galapagos, Gilead, GlaxoSmithKline, Janssen, Pfizer, UCB, Rene-Marc Flipo Speakers bureau: AbbVie, Bristol Myers Squibb, Janssen, Lilly, Medac, Merck Sharp & Dohme, Novartis, Pfizer, Roche-Chugai, Grant/research support from: Amgen, Janssen, Novartis, Pfizer, Roberto Caporali Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Fresenius Kabi, Galapagos, Gilead, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Samsung Bioepis, Sanofi, UCB, Consultant of: Galapagos, Gilead, Janssen, Lilly, Merck Sharp & Dohme, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Eli Lilly, Gilead, Merck Serono, Pfizer, Roche, Sanofi, Grant/research support from: Gilead, Pfizer, Roche, UCB, Yusuf Patel: None declared, Sara Marsal Speakers bureau: Bristol Myers Squibb, Celgene, Pfizer, Roche, Sanofi, UCB, Consultant of: AbbVie, Bristol Myers Squibb, Celgene, Galapagos, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, UCB, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sanofi, UCB, M.T. Nurmohamed Speakers bureau: AbbVie, Bristol Myers Squibb, Eli Lilly, Roche, Sanofi, Consultant of: AbbVie, Celgene, Celltrion, Eli Lilly, Janssen, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Mundipharma, Novartis, Pfizer, Roche, Sanofi, Hedley Griffiths Consultant of: AbbVie, Gilead, Janssen, Novartis, Peter Peichl: None declared, Bettina Bannert: None declared, Adrian Forster: None declared, Melanie Chartier Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Yedid Elbez Consultant of: Bristol Myers Squibb, Christiane Rauch Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Karissa Lozenski Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Vadim Khaychuk Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

OP0180 IMPACT OF RF AND ANTI-CITRULLINATED PROTEIN ANTIBODY SEROSTATUS ON 2-YEAR RETENTION OF ABATACEPT IN PATIENTS WITH RA

Background:

Up to 50% of patients with RA discontinue DMARD treatment within 18 months.1 However, up to 20% of patients who fail multiple treatments may have a good treatment response to another therapy.1 Predictive biomarkers, such as RF and anti-citrullinated protein antibodies (ACPAs), may be useful to stratify patients with RA to the most appropriate treatment.1 ASCORE (Abatacept SubCutaneOus in Routine Clinical PracticE; NCT02090556) was a 2-year, observational, prospective, multicentre study of SC abatacept for the treatment of RA in routine clinical practice.2

Objectives:

To determine if RF/ACPA serostatus and treatment line impact abatacept retention in patients with RA in a post hoc analysis of ASCORE.

Methods:

Eligible patients, aged ≥18 years, with active moderate-to-severe RA (ACR/EULAR 2010 criteria) who were IV abatacept-naive and initiated SC abatacept 125 mg once weekly, were enrolled into two cohorts: biologic (b)DMARD-naive patients and those with ≥1 prior bDMARD treatment failure. This post hoc analysis assessed abatacept retention rate at 2 years in a subset of patients with RF/ACPA serostatus data (n=1748) from the ASCORE study (N=2892; as observed). Baseline (BL) serostatus groups examined by treatment line were: RF/ACPA double positive (+/+) RA, RF/ACPA single positive (RF+/ACPA– or RF–/ACPA+) RA (data not shown) and RF/ACPA double negative (–/–) RA. Last observation carried forward (LOCF) analyses were used to assess change from BL and measures of disease remission (DAS28 [CRP] <2.6, CDAI ≤2.8, and SDAI ≤3.3) in patients with +/+ RA versus –/– RA.

Results:

BL demographic and disease characteristics were similar across serostatus groups and treatment lines (Table 1). Mean age was 57.1 and 57.8 years for +/+ RA and –/– RA, respectively. Mean DAS28 (CRP) was 4.7 and 4.8 for +/+ RA and –/– RA, respectively. In patients with +/+ RA, abatacept retention was greater when given as first-line treatment (57% vs 48% when given as ≥ second-line) (Figure 1). Retention was similar in patients with –/– RA regardless of treatment line. After 2 years, mean (SE) change from BL (LOCF) in DAS28 (CRP) was –1.41 (0.06) and –0.97 (0.09) for patients with +/+ and –/– RA, respectively. For patients with +/+ RA, mean (SE) change from BL in DAS28 (CRP) was –1.62 (0.08) for those in whom abatacept was first-line and –1.19 (0.08) for those in whom abatacept was ≥ second-line. For patients with –/– RA, mean (SE) change from BL in DAS28 (CRP) was –1.03 (0.13) for those in whom abatacept was first-line and –0.93 (0.12) for those in whom abatacept was ≥ second-line. Remission rates (LOCF) were significantly (p<0.0001) higher in patients with +/+ RA vs –/– RA respectively: DAS28 (CRP) 38.4% (n=393) versus 19.3% (n=62); CDAI 50.6% (n=513) versus 33.0% (n=107); and SDAI 49.5% (n=497) versus 32.5% (n=102).

Table 1.

BL demographics and disease characteristics by RF/ACPA status

+/+ RA(n=1079)–/– RA(n=343)First-line (n=511)≥ second-line (n=568)First-line(n=140)≥ second-line(n=203)Age57.1 (13.4)57.1 (12.2)59.5 (14.7)56.6 (13.2)DAS28 (CRP)4.7 (1.2)4.7 (1.2)4.8 (1.1)4.8 (1.2)CDAI26.6 (12.5)26.6 (12.4)27.7 (12.5)28.6 (13.8)SDAI28.1 (13.1)28.1 (12.9)29.1 (12.9)30.2 (14.7)

Data are mean (SD). Patients with missing data for BL RF/ACPA status are excluded.

ACPA=anti-citrullinated protein antibody; BL=baseline.

Conclusion:

In this real-world analysis, patients with +/+ RA treated with first-line abatacept had higher retention than patients receiving abatacept as a ≥ second-line therapy. Remission rates on abatacept were higher in patients with +/+ RA versus –/– RA. These results support early treatment with abatacept and highlight the importance of further evaluating precision medicine approaches in RA.

References:

[1]Smolen JS, et al. Ann Rheum Dis 2020;79:685–699.

[2]Alten R, et al. Ann Rheum Dis 2019;78(suppl 2):A1639.

Acknowledgements:

Professional medical writing and editorial assistance was provided by Lindsay Craik at Caudex and was funded by Bristol Myers Squibb. This study was funded by Bristol Myers Squibb.

Disclosure of Interests:

Rieke Alten Speakers bureau: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Consultant of: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Grant/research support from: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Xavier Mariette Consultant of: Bristol Myers Squibb, Galapagos, Gilead, GlaxoSmithKline, Janssen, Pfizer, UCB, Rene-Marc Flipo Speakers bureau: AbbVie, Bristol Myers Squibb, Janssen, Lilly, Medac, Merck Sharp & Dohme, Novartis, Pfizer, Roche-Chugai, Grant/research support from: Amgen, Janssen, Novartis, Pfizer, Roberto Caporali Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Fresenius Kabi, Galapagos, Gilead, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Samsung Bioepis, Sanofi, UCB, Consultant of: Galapagos, Gilead, Janssen, Lilly, Merck Sharp & Dohme, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Eli Lilly, Gilead, Merck Serono, Pfizer, Roche, Sanofi, Grant/research support from: Gilead, Pfizer, Roche, UCB, Yusuf Patel: None declared, Raimón Sanmartí Speakers bureau: AbbVie, Bristol Myers Squibb, Gebro, Janssen, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, Consultant of: AbbVie, Bristol Myers Squibb, Gebro, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, Grant/research support from: Bristol Myers Squibb, Merck Sharp & Dohme, Pfizer, Sara Marsal Speakers bureau: Bristol Myers Squibb, Celgene, Pfizer, Roche, Sanofi, UCB, Consultant of: AbbVie, Bristol Myers Squibb, Celgene, Galapagos, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, UCB, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sanofi, UCB, M.T. Nurmohamed Speakers bureau: AbbVie, Bristol Myers Squibb, Eli Lilly, Roche, Sanofi, Consultant of: AbbVie, Celgene, Celltrion, Eli Lilly, Janssen, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Mundipharma, Novartis, Pfizer, Roche, Sanofi, Hedley Griffiths Consultant of: AbbVie, Gilead, Janssen, Novartis, Peter Peichl: None declared, Bettina Bannert: None declared, Adrian Forster: None declared, Melanie Chartier Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Sean Connolly Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Yedid Elbez Consultant of: Bristol Myers Squibb, Christiane Rauch Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Vadim Khaychuk Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Karissa Lozenski Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

AB0205 A NOVEL METHOD FOR PREDICTING 1-YEAR RETENTION OF ABATACEPT USING MACHINE LEARNING TECHNIQUES: DIRECTIONALITY AND IMPORTANCE OF PREDICTORS

Background:

In the ACTION (NCT02109666) study, multivariable Cox proportional hazards regression models showed that the predictors of 1-year retention to abatacept treatment were: patient global pain assessment, country, reason for stopping last biologic, number of prior biologic treatments, abatacept monotherapy, RF/anti-cyclic citrullinated peptide (CCP) status, previous neoplasms, psychiatric disorders and cardiac disorders.1 Machine learning techniques, using the gradient-boosting model, subsequently identified additional predictors of abatacept retention in patients with moderate-to-severe RA enrolled in ACTION; however, the analysis did not show the directionality of the predictors.2

Objectives:

To improve the clinical interpretability of the machine learning model in terms of directionality and the importance of each variable in predicting retention.

Methods:

Previous analyses using the gradient-boosting model to identify predictors of abatacept retention at 1 year in the ACTION study have been described.2 This analysis used SHapley Additive exPlanations (SHAP), a mathematical framework, to show how a particular predictor value influences prediction in the context of all other predictors. Higher SHAP values indicate a higher likelihood of retention. The contribution of every variable in the model’s prediction (with the exception of country variables) was computed for each data point to capture individual variable impact. This enabled interpretation for level of importance and directionality at a patient level.

Results:

Using data from 2350 patients enrolled in ACTION (May 2008 to December 2013), the mean retention rate at 1 year was 59.3% (n=1393). Overall variable importance is shown in Figure 1. After removal of country variables, the top five baseline predictors of retention were: no previous corticosteroid use, ACR functional class II, ≥2 prior biologic treatments prior to abatacept initiation, abatacept monotherapy and HAQ-DI. In terms of directionality, no previous corticosteroid use, ≥2 prior biologic treatments prior to abatacept initiation, abatacept monotherapy and a higher HAQ-DI score at baseline were associated with a lower likelihood of retention; ACR functional class II was associated with a higher likelihood of retention.

Conclusion:

The gradient-boosting model previously identified predictors of abatacept retention from ACTION;2 the addition of SHAP in this analysis has provided information on the importance and directionality of those predictors. The most important predictor of abatacept retention was no previous corticosteroid use, which was associated with lower retention. The models and predictors identified could be further refined by using additional datasets from clinical trials. Machine learning offers an innovative and complementary approach to biostatistics and could be used to identify treatment response predictors at an individual patient level, leading to a more personalised treatment approach.

References:

[1]Alten R, et al. RMD Open 2017;3:e000538.

[2]Alten R, et al. Presented at the virtual ACR Convergence 2020; 5–9 November 2020. Poster number 1745.

Acknowledgements:

This study was supported by Bristol Myers Squibb. Professional medical writing and editorial assistance was provided by Claire Line, PhD, at Caudex and was funded by Bristol Myers Squibb.

Disclosure of Interests:

Rieke Alten Speakers bureau: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Consultant of: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Grant/research support from: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Claire Behar Shareholder of: I have not invested directly in pharmaceutical companies producing drugs/devices for use in rheumatology however I may have shares via the funds linked to my life insurance., Consultant of: Bristol Myers Squibb, Christine Boileau Consultant of: AstraZeneca, Bristol Myers Squibb, Nanobiotix, Pierre Merckaert Consultant of: Bristol Myers Squibb, Ebenezer Afari Consultant of: Bristol Myers Squibb, Virginie Vannier-Moreau Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Sean Connolly Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Aurelie Najm Speakers bureau: Bristol Myers Squibb, Consultant of: Bristol Myers Squibb, Pierre-Antoine Juge Consultant of: Bristol Myers Squibb, Angshu Rai Shareholder of: Amgen Inc, Consultant of: Amgen Inc, Employee of: Amgen Inc, Bristol Myers Squibb, Yedid Elbez Consultant of: Bristol Myers Squibb, Karissa Lozenski Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

POS0599 DISEASE ACTIVITY IN PATIENTS WITH RA BY SEROSTATUS AND TREATMENT LINE, FOLLOWING TREATMENT WITH ABATACEPT: RESULTS FROM AN INTERNATIONAL OBSERVATIONAL STUDY

Background:

RF and anti-citrullinated protein antibodies (ACPAs) are associated with a severe and aggressive disease course in patients with RA.1 Abatacept is a selective co-stimulation modulator for the treatment of RA.2 ASCORE (Abatacept SubCutaneOus in Routine Clinical PracticE; NCT02090556) was a 2-year, observational, prospective, multicentre study of SC abatacept for the treatment of RA in routine clinical practice.3

Objectives:

To determine if serostatus and treatment line impacted disease activity in patients enrolled in the ASCORE study.

Methods:

Eligible patients, aged ≥18 years, with active moderate-to-severe RA (ACR/EULAR 2010 criteria) who were IV abatacept-naive and initiated SC abatacept 125 mg once weekly, were enrolled into two cohorts: biologic (b)DMARD-naive patients and those with ≥1 prior bDMARD treatment failure. This post hoc analysis assessed the mean change in disease activity (CDAI, SDAI and DAS28 [ESR]) from baseline (BL) at 6, 12, 18 and 24 months in response to treatment with abatacept. Patients were stratified by BL serostatus (all patients, RF/ACPA double positive [+/+] RA; RF/ACPA single positive [+/–; RF+/ACPA– or RF–/ACPA+] RA and RF/ACPA double negative [–/–] RA) and by line of therapy (all patients, patients receiving abatacept as a first-line or ≥ second-line therapy and those receiving abatacept following 1 or ≥2 prior bDMARDs). Overall patient data, as well as data for patients who were +/– or those who had 1 or ≥2 previous bDMARDs, are not shown. Estimates of mean difference are from t-test.

Results:

Among 2892 eligible patients in ASCORE, 1748 patients with RF/ACPA status available at BL were included in this analysis (1079 +/+ RA, 326 +/− RA and 343 −/− RA). After 6 months, patients with +/+ RA on first-line abatacept therapy had better improvements in CDAI and SDAI scores from BL than patients on ≥ second-line abatacept therapy (mean difference [95% CI]: –3.4 [–5.6, –1.1]; p=0.0032 and –3.9 [–6.5, –1.3]; p=0.0035, respectively); better improvements in SDAI were also seen after 12 months (mean difference [95% CI]: –3.5 [–6.5, –0.5]; p=0.0207). Changes in CDAI and SDAI scores were comparable after 18 and 24 months. At 6 and 12 months, patients with +/+ RA on first-line therapy had better improvements from BL in DAS28 (ESR) than those on ≥ second-line therapy (mean differences [95% CI]: –0.5 [–0.8, –0.2]; p=0.0002 and –0.4 [–0.7, –0.0]; p=0.0317, respectively); changes were comparable at 18 and 24 months (Figure 1). For patients on ≥ second-line therapy, at 18 months those with +/+ RA had better improvements from BL in DAS28 (ESR) than those with –/– RA (mean difference [95% CI]: –0.7 [–1.2, –0.1]; p=0.0232). For patients not stratified by line of therapy, changes in DAS28 (ESR) were comparable between the +/+ and –/– RA subgroups over time, with the exception of 6 months where patients with –/– RA had better improvements from BL compared with patients with +/+ RA (mean difference [95% CI]: –0.3 [–0.6, –0.0]; p=0.0495).

Conclusion:

In this real-world, post hoc analysis, patients with +/+ RA who received abatacept as a first-line therapy had greater early improvements in disease activity compared with patients who received abatacept as a ≥ second-line therapy. Improvements in disease activity at 24 months were comparable between patients who were +/+ and those who were –/–. Larger studies are needed to further corroborate these findings.

References:

[1]Katchamart W, et al. Rheumatol Int 2015;35:1693–1699.

[2]Malmström V, et al. Nat Rev Immunol 2017;17:60–75.

[3]Alten R, et al. Ann Rheum Dis 2019;78(Suppl 2):A1639.

Acknowledgements:

Professional medical writing and editorial assistance was provided by Rachel Rankin, PhD, at Caudex and was funded by Bristol Myers Squibb. This study was funded by Bristol Myers Squibb.

Disclosure of Interests:

Rieke Alten Speakers bureau: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Consultant of: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Grant/research support from: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Xavier Mariette Consultant of: Bristol Myers Squibb, Galapagos, Gilead, GlaxoSmithKline, Janssen, Pfizer, UCB, Rene-Marc Flipo Speakers bureau: AbbVie, Bristol Myers Squibb, Janssen, Lilly, Medac, Merck Sharp & Dohme, Novartis, Pfizer, Roche-Chugai, Grant/research support from: Amgen, Janssen, Novartis, Pfizer, Roberto Caporali Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Fresenius Kabi, Galapagos, Gilead, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Samsung Bioepis, Sanofi, UCB, Consultant of: Galapagos, Gilead, Janssen, Lilly, Merck Sharp & Dohme, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Eli Lilly, Gilead, Merck Serono, Pfizer, Roche, Sanofi, Grant/research support from: Gilead, Pfizer, Roche, UCB, Yusuf Patel: None declared, Raimón Sanmartí Speakers bureau: AbbVie, Bristol Myers Squibb, Gebro, Janssen, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, Consultant of: AbbVie, Bristol Myers Squibb, Gebro, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, Grant/research support from: Bristol Myers Squibb, Merck Sharp & Dohme, Pfizer, Sara Marsal Speakers bureau: Bristol Myers Squibb, Celgene, Pfizer, Roche, Sanofi, UCB, Consultant of: AbbVie, Bristol Myers Squibb, Celgene, Galapagos, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, UCB, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sanofi, UCB, M.T. Nurmohamed Speakers bureau: AbbVie, Bristol Myers Squibb, Eli Lilly, Roche, Sanofi, Consultant of: AbbVie, Celgene, Celltrion, Eli Lilly, Janssen, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Mundipharma, Novartis, Pfizer, Roche, Sanofi, Hedley Griffiths Consultant of: AbbVie, Gilead, Janssen, Novartis, Peter Peichl: None declared, Bettina Bannert: None declared, Adrian Forster: None declared, Melanie Chartier Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Yedid Elbez Consultant of: Bristol Myers Squibb, Christiane Rauch Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Karissa Lozenski Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Vadim Khaychuk Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

AB0207 ANALYSIS OF ABATACEPT TREATMENT RETENTION AND EFFICACY ACCORDING TO DISEASE DURATION AND TREATMENT LINE IN A REAL-WORLD SETTING

Background:

Longer disease duration and greater number of prior DMARDs have been associated with lower treatment efficacy in patients with RA.1 Abatacept is a biologic (b)DMARD for treatment of moderate-to-severe RA and is available in SC formulation, which may offer convenience benefits with efficacy similar to IV administration.2 ASCORE (Abatacept SubCutaneOus in Routine Clinical PracticE; NCT02090556) was a 2-year, observational, prospective, multicentre study of SC abatacept for treatment of RA in routine clinical practice.3

Objectives:

This post hoc analysis was conducted to determine if retention and efficacy of abatacept were impacted by disease duration and/or treatment line.

Methods:

Eligible patients, aged ≥18 years, with active moderate-to-severe RA (ACR/EULAR 2010 criteria) who were IV abatacept-naive and initiated SC abatacept 125 mg once weekly, were enrolled into two cohorts: bDMARD-naive patients and those with ≥1 prior bDMARD treatment failure. This post hoc analysis evaluated abatacept retention using Kaplan-Meier estimates, as well as disease activity scores (DAS28 [ESR]), CDAI and SDAI in patients with disease duration of ≤2, 3–5, 6–10 or >10 years, and in patients taking abatacept as first-line or ≥ second-line treatment.

Results:

Table 1 shows baseline (BL) characteristics. Mean age increased with disease duration; other characteristics were comparable across groups. Retention proportions (95% CIs) at Month 24 were 0.50 (0.4, 0.5), 0.47 (0.4, 0.5), 0.51 (0.5, 0.5) and 0.46 (0.4, 0.5) in the ≤2, 3–5, 6–10 and >10 years’ duration groups, respectively. Proportion of patients (95% CI) with ≤2 years’ duration retaining treatment at Month 24 were 0.51 (0.4, 0.6) among those using abatacept as first-line treatment and 0.44 (0.3, 0.6) among those using abatacept as a ≥ second-line treatment (Figure 1). Proportions (95% CI) at Month 24 were 0.51 (0.5, 0.6), 0.57 (0.5, 0.6) and 0.52 (0.5, 0.6) in first-line patients and 0.43 (0.4, 0.5), 0.48 (0.4, 0.5) and 0.44 (0.4, 0.5) in ≥ second-line patients in the 3–5, 6–10 and >10 years’ duration groups, respectively. Mean (SE) changes from BL in DAS28 (ESR) at Month 24 were –2.12 (0.205), –1.86 (0.151), –2.07 (0.140) and –2.05 (0.115) in the ≤2, 3–5, 6–10 and >10 years’ duration groups, respectively; respective mean (SE) changes in CDAI were –18.74 (1.604), –15.60 (1.099), –18.50 (1.038) and –17.68 (0.850); and respective mean (SE) changes in SDAI were –19.10 (1.873), –15.72 (1.345), –19.54 (1.103) and –17.07 (0.939).

Conclusion:

In this post hoc analysis of the real-world ASCORE trial, patients with RA receiving abatacept in clinical practice as first-line therapy had better retention versus those receiving it as a ≥ second-line treatment, regardless of disease duration at BL. Retention rates were similar across disease duration subgroups. Improvements in disease activity were seen in all duration subgroups, without consistently greater or lesser improvement seen with longer disease duration.

References:

[1]Aletaha D, et al. Ann Rheum Dis 2019;78:1609–1615.

[2]Genovese MC, et al. Arthritis Rheumatol 2011;63:2854–2864.

[3]Alten R, et al. Ann Rheum Dis 2019;78(suppl 2):A1639.

Table 1.

BL characteristics (n=2872)

RA disease duration, years≤2(n=338)3–5(n=655)6–10(n=686)>10(n=1193)Age, years n3386556861193 Mean (SD)55.2 (12.8)55.6 (12.7)56.9 (13.0)59.9 (12.2)Weight, kg n3276296651150 Mean (SD)75.3 (18.1)76.4 (19.0)74.7 (17.4)72.9 (16.0)DAS28 (ESR) n247439441743 Mean (SD)5.2 (1.3)4.9 (1.3)5 (1.2)5.1 (1.3)DAS28 (CRP) n267460467799 Mean (SD)4.7 (1.2)4.6 (1.2)4.7 (1.1)4.7 (1.2)CDAI n269477474805 Mean (SD)26.9 (12.7)25.3 (12.2)26.8 (12.4)26.6 (12.2)SDAI n255448445749 Mean (SD)28.3 (13.3)26.8 (12.9)27.9 (12.6)28.0 (12.7)RF status, n (%) RF+159 (47.0)342 (52.2)345 (50.3)597 (50.0) RF–103 (30.5)152 (23.2)158 (23.0)215 (18.0)Anti-CCP status, n (%) Anti-CCP+165 (48.8)332 (50.7)333 (48.5)516 (43.3) Anti-CCP–89 (26.3)126 (19.2)137 (20.0)175 (14.7)

Patients with missing duration of disease are excluded.

CCP=cyclic citrullinated peptide.

Acknowledgements:

Professional medical writing and editorial assistance was provided by Rob Coover, MPH, at Caudex and was funded by Bristol Myers Squibb. This study was funded by Bristol Myers Squibb.

Disclosure of Interests:

Rieke Alten Speakers bureau: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Consultant of: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Grant/research support from: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Xavier Mariette Consultant of: Bristol Myers Squibb, Galapagos, Gilead, GlaxoSmithKline, Janssen, Pfizer, UCB, Rene-Marc Flipo Speakers bureau: AbbVie, Bristol Myers Squibb, Janssen, Lilly, Medac, Merck Sharp & Dohme, Novartis, Pfizer, Roche-Chugai, Grant/research support from: Amgen, Janssen, Novartis, Pfizer, Roberto Caporali Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Celltrion, Fresenius Kabi, Galapagos, Gilead, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Samsung Bioepis, Sanofi, UCB, Consultant of: Galapagos, Gilead, Janssen, Lilly, Merck Sharp & Dohme, Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Eli Lilly, Gilead, Merck Serono, Pfizer, Roche, Sanofi, Grant/research support from: Gilead, Pfizer, Roche, UCB, Yusuf Patel: None declared, Raimón Sanmartí Speakers bureau: AbbVie, Bristol Myers Squibb, Gebro, Janssen, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, Consultant of: AbbVie, Bristol Myers Squibb, Gebro, Lilly, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, Grant/research support from: Bristol Myers Squibb, Merck Sharp & Dohme, Pfizer, Sara Marsal Speakers bureau: Bristol Myers Squibb, Celgene, Pfizer, Roche, Sanofi, UCB, Consultant of: AbbVie, Bristol Myers Squibb, Celgene, Galapagos, Merck Sharp & Dohme, Pfizer, Roche, Sanofi, UCB, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sanofi, UCB, M.T. Nurmohamed Speakers bureau: AbbVie, Bristol Myers Squibb, Eli Lilly, Roche, Sanofi, Consultant of: AbbVie, Celgene, Celltrion, Eli Lilly, Janssen, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Mundipharma, Novartis, Pfizer, Roche, Sanofi, Hedley Griffiths Consultant of: AbbVie, Gilead, Janssen, Novartis, Peter Peichl: None declared, Bettina Bannert: None declared, Adrian Forster: None declared, Melanie Chartier Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Yedid Elbez Consultant of: Bristol Myers Squibb, Christiane Rauch Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Vadim Khaychuk Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Karissa Lozenski Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

Long-term outcomes of chronic coronary syndrome worldwide: insights from the international CLARIFY registry

Aims

Over the last decades, the profile of chronic coronary syndrome has changed substantially. We aimed to determine characteristics and management of patients with chronic coronary syndrome in the contemporary era, as well as outcomes and their determinants.

Methods and results

Data from 32 703 patients (45 countries) with chronic coronary syndrome enrolled in the prospective observational CLARIFY registry (November 2009 to June 2010) with a 5-year follow-up, were analysed. The primary outcome [cardiovascular death or non-fatal myocardial infarction (MI)] 5-year rate was 8.0% [95% confidence interval (CI) 7.7–8.3] overall [male 8.1% (7.8–8.5); female 7.6% (7.0–8.3)]. A cox proportional hazards model showed that the main independent predictors of the primary outcome were prior hospitalization for heart failure, current smoking, atrial fibrillation, living in Central/South America, prior MI, prior stroke, diabetes, current angina, and peripheral artery disease. There was an interaction between angina and prior MI (P = 0.0016); among patients with prior MI, angina was associated with a higher primary event rate [11.8% (95% CI 10.9–12.9) vs. 8.2% (95% CI 7.8–8.7) in patients with no angina, P < 0.001], whereas among patients without prior MI, event rates were similar for patients with [6.3% (95% CI 5.4–7.3)] or without angina [6.4% (95% CI 5.9–7.0)], P > 0.99. Prescription rates of evidence-based secondary prevention therapies were high.

Conclusion

This description of the spectrum of chronic coronary syndrome patients shows that, despite high rates of prescription of evidence-based therapies, patients with both angina and prior MI are an easily identifiable high-risk group who may deserve intensive treatment.

Clinical registry

ISRCTN43070564

Sex Differences in Ischemic and Bleeding Outcomes in Patients With Non-ST-Segment-Elevation Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: Insights From the TAO Trial

BACKGROUND

Previous studies have observed poorer outcomes in females with myocardial infarction, but older age and lower use of percutaneous coronary intervention in females are factors that potentially explain the worse outcome. This study sought to determine if female sex is an independent factor of ischemic and bleeding outcomes in non-ST-segment-elevation acute coronary syndrome treated with a systematic invasive approach.

METHODS

The TAO trial (Treatment of Acute Coronary Syndrome With Otamixaban) randomized patients with non-ST-segment-elevation acute coronary syndrome treated invasively to heparin plus eptifibatide versus otamixaban. In this post hoc analysis, the primary ischemic end point (all-cause death, myocardial infarction within 180 days) and the primary safety end point (Thrombolysis in Myocardial Infarction major or minor bleeding within 30 days) were analyzed according to sex.

RESULTS

Of 13 229 randomized patients, 3980 (30.1%) were females and 9249 (69.9%) were males. Females were older (64.8±11.0 versus 60.7±11.1 years), had more comorbidities, received less peri-procedural antithrombotic therapy, and underwent less frequently revascularization. Overall, females experienced a higher risk of ischemic (10.2% versus 9.1%; odds ratio [OR], 1.15 [1.01-1.30]) and bleeding events (4.2% versus 3.4%; OR, 1.23 [1.02-1.49]) than males. After multivariate analysis, the risk of ischemic outcomes (OR, 1.04 [0.90-1.19]), death (OR, 1.00 [0.75-1.23]), or bleeding (OR, 1.05 [0.85-1.28]), were similar between females and males. Only, noncoronary artery bypass graft related Thrombolysis in Myocardial Infarction major bleeding were increased in females (OR, 1.69 [1.11-2.56]).

CONCLUSIONS

In patients with non-ST-segment-elevation acute coronary syndrome with systematic invasive management, ischemic outcomes, bleeding events, and mortality were higher in females. After multivariate analyses, female sex was not an independent predictor of ischemic and bleeding events although noncoronary artery bypass graft related Thrombolysis in Myocardial Infarction major bleeding was higher in females. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01076764.

CCS patients with polyvascular disease are a high risk but heterogenous subset of patients: insights from the CLARIFY registry

Introduction

Polyvascular disease constitutes a powerful predictor of cardiovascular events, is found in 10 to 15% of chronic coronary syndromes (CCS) patient. Smoking and diabetes mellitus are strongly associated with polyvascular disease. Risk stratification is key to select the most appropriate therapeutic strategy for a given patient.

Purpose

We aimed to describe 5-year ischaemic risk of CCS patients according to vascular disease phenotype and diabetic or smoking status.

Method

We analyzed data from 32 703 consecutive CCS outpatients (45 countries) enrolled between November 2009 to June 2010 in the prospective observational CLARIFY registry. Three mutually exclusive groups were compared: Coronary artery disease (CAD) alone, CAD with peripheral artery disease (PAD) or cerebrovascular disease (CVD) (CAD+1), CAD with CVD and PAD (CAD+2). Primary outcome was a composite of cardiovascular death, myocardial infarction or stroke, adjusted on age, sex and geographic origin at 5 years.

Results

At baseline, 26440 (80.8%) patients were diagnosed with CAD alone, 4967 (15.2%) had CAD+1, 1296 (4%) had CAD+2. Overall, 9501 (29%) patients were diabetics, 19184 (58.7%) were smokers or ex-smokers and only 9220 (28.2%) were free of these two major cardiovascular risk factors. Primary outcome increasing gradually according to the number of arterial diseases locations from 8.4% (95% CI 8.09–8.73) in patients with CAD alone to 17.4% (95% CI 16.95–17.83) of CAD+2 patients (p&lt;0.001). Subgroup analysis according to diabetes or smoking status further enriched risk stratification from 7% (95% CI 6.48–7.59) in non-diabetic, non-smoking CAD alone patients to 20.3% (95% CI 19.08–21.44) in diabetics and smokers CAD+ 2 patients (Figure 1). Diabetic CAD alone patients had a comparable risk to that of non-diabetic and non-smoking polyvascular patients, 9.8% (95% CI 8.82–10.68) vs 10.3% (95% CI 9.61–10.96), p=0.38. Outcome was similar between polyvascular diabetic patients, regardless of the number of arterial diseases, 15.5% (95% CI 14.31–16.60) for CAD+1 and 15.0 (95% CI 13.88–16.13) for CAD+2, p=0.83. Smoking increased 5-year risk proportionally to the number of symptomatic arterial bed, 8.2% (95% CI 7.72–8.68) vs 11.8% (95% CI 11.18–12.31) vs 17.9% (95% CI 17.18–18.54), respectively for CAD alone, CAD+1 and CAD+2.

Conclusion

CCS patients with polyvascular disease remain at high risk of ischaemic events in the contemporary practice with widespread secondary prevention therapies. Polyvascular is a very heterogenous subset of patients with ischaemic risk varying not only according to the number of vascular bed diseased but also according to smoking and diabetes status, two conditions present in the vast majority of CCS patients. Diabetes confers upfront a maximal increased risk. Identification of higher risk subsets in polyvascular patients can potentially identify those that could derived the greatest benefit from new secondary prevention strategies.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Assistance Publique-Hôpitaux de Paris

Outcomes in non-ST-segment elevation myocardial infarction patients according to heart failure at admission: Insights from a large trial with systematic early invasive strategy

BACKGROUND

Previous studies published before the era of systematic early invasive strategy have reported a higher mortality in non-ST-segment elevation myocardial infarction patients with heart failure. The aim of our study was to compare the clinical characteristics, outcomes and causes of death of patients according to their heart failure status at admission in a large non-ST-segment elevation myocardial infarction population with planned early invasive management.

METHODS

We performed a post-hoc analysis of the Treatment of Acute Coronary Syndrome with Otamixaban randomised trial which included non-ST-segment elevation myocardial infarction patients with systematic coronary angiography within 72 h. Patients were categorised according to presence or absence of heart failure (Killip grade ≥2) at admission.

RESULTS

A total of 13,172 patients were enrolled, of whom 944 (7.2%) had heart failure. At day 30, death occurred in 213 patients (1.6%) and cardiovascular death was the dominant cause of death in both groups ((with vs without heart failure) 78.8% vs 78.4%, p = 0.94). At six months, death occurred in 90/944 (9.5%) patients with heart failure and 258/12228 patients without heart failure (2.1%) (p < 0.001). After adjustment on Global Registry of Acute Coronary Events risk score, heart failure was an independent predictor of all-cause mortality at day 30 (odds ratio: 1.58; 95% confidence interval, 1.06-2.36, p = 0.02) and at day 180 (odds ratio: 1.77; 95% confidence interval, 1.3-2.42, p < 0.001) as well as of ischaemic complications (cardiovascular death, myocardial infarction, stent thrombosis or stroke at day 30 (odds ratio: 1.28; 95% confidence interval, 1.01-1.62, p = 0.04).

CONCLUSION

Non-ST-segment elevation myocardial infarction patients with heart failure at admission still have worse outcomes than those without heart failure, even with systematic early invasive strategy. Further efforts are needed to improve the prognosis of these high risk patients.

Clinical characteristics and outcomes of COMPASS eligible patients in France. An analysis from the REACH Registry

BACKGROUND

Following the publication of the COMPASS trial, the European Medicines Agency has approved a regimen of combination of rivaroxaban 2.5mg twice daily and a daily dose of 75-100mg acetylsalicylic acid (ASA) for patients with coronary artery disease (CAD) or symptomatic peripheral artery disease (PAD) at high risk of ischemic events. However, the applicability of such a therapeutic strategy in France is currently unknown.

AIMS

To describe the proportion of patients eligible to COMPASS in France, their baseline clinical characteristics and the rate of major adverse cardiovascular events, using the REACH registry.

METHODS

From the the REduction of Atherothrombosis for Continued Health (REACH) registry database, a large international registry of patients with, or at risk, of atherothrombosis, we analyzed patients included in France with either established CAD and/or PAD and fulfilling the inclusion and exclusion criteria of the COMPASS trial. The ischemic outcome was a composite of cardiovascular (CV) death, myocardial infarction (MI), or stroke, and serious bleeding were defined as haemorrhagic stroke or bleeding leading to hospitalization or transfusion.

RESULTS

Among more than 65000 patients enrolled in REACH, 2.012 patients were evaluable and enrolled in France. Among them, 1194 patients (59.3%) were eligible to COMPASS. The main reasons for exclusion of the COMPASS trial, were high bleeding risk (59.1%), anticoagulant use (43.4%), requirement for dual antiplatelet therapy within 1 year of an ACS or PCI (24.7%). In the "COMPASS eligible population", the rate of MACE (CV, MI and stroke) at 4 years follow-up was 13.4% [11.3-15.8], and serious bleeding was 2.5% at 4 years [1.6-3.4]. Patients with polyvascular disease (n=219) had the highest rate of MACE, compared with patients with CAD only and PAD only (19.1% [13.9-26.1] vs. 11.6% [9.1-14.8] vs 13.2% [9.2-18.8], P<0.0001, respectively).

CONCLUSION

The COMPASS therapeutic strategy in France appears to be applicable to more than half of CAD or PAD patients. This population appears at high residual risk of atherothrombotic events, and patients with polyvascular disease experienced the highest rate of events.

Blood transfusion and ischaemic outcomes according to anemia and bleeding in patients with non-ST-segment elevation acute coronary syndromes: Insights from the TAO randomized clinical trial

BACKGROUND

The benefits and risks of blood transfusion in patients with acute myocardial infarction who are anemic or who experience bleeding are debated. We sought to study the association between blood transfusion and ischemic outcomes according to haemoglobin nadir and bleeding status in patients with NST-elevation myocardial infarction (NSTEMI).

METHODS

The TAO trial randomized patients with NSTEMI and coronary angiogram scheduled within 72h to heparin plus eptifibatide versus otamixaban. After exclusion of patients who underwent coronary artery bypass surgery, patients were categorized according to transfusion status considering transfusion as a time-varying covariate. The primary ischemic outcome was the composite of all-cause death or MI within 180 days of randomization. Subgroup analyses were performed according to pre-transfusion hemoglobin nadir and bleeding status.

RESULTS

12,547 patients were enrolled. Among these, blood transfusion was used in 489 (3.9%) patients. Patients who received transfusion had a higher rate of death or MI (29.9% vs. 8.1%, p<0.01). This excess risk persisted after adjustment on GRACE score and nadir of hemoglobin (HR 3.36 95%CI 2.63-4.29 p<0.01). Subgroup analyses showed that blood transfusion was associated with a higher risk in patients without overt bleeding (adjusted HR 6.25 vs. 2.85; p-interaction 0.001) as well as in those with hemoglobin nadir > 9.0 g/dl (HR 4.01; p-interaction<0.0001).

CONCLUSION

In patients with NSTEMI, blood transfusion was associated with an overall increased risk of ischaemic events. However, this was mainly driven by patients without overt bleeding and those hemoglobin nadir > 9.0g/dl. This suggests possible harm of transfusion in those groups.

Up to 5-year retention of abatacept in Belgian patients with moderate-to-severe rheumatoid arthritis: a sub-analysis of the international, observational ACTION study

Favorable efficacy and safety profiles have been demonstrated for abatacept in patients with rheumatoid arthritis (RA) in randomized controlled trials, but these data require validation during long-term follow-ups in routine clinical practice. This study explored long-term safety and retention rates in RA patients treated with intravenous abatacept in the Belgian cohort of the international AbataCepT In rOutiNe clinical practice (ACTION) study (NCT02109666). This non-interventional, observational, longitudinal study included Belgian patients aged ≥ 18 years with moderate-to-severe RA who started intravenous abatacept treatment as first- or second/further-line biologic therapy in routine clinical practice. Between October 2010 and December 2012, 141 patients were enrolled in this cohort, of whom 135 evaluable patients (6 biologic-naïve; 129 previously exposed to ≥ 1 prior biologic disease modifying anti-rheumatic drugs) were eligible for the descriptive analysis; 131/135 were included in the effectiveness analysis. Mean disease duration was 10.5 years (standard deviation 9.7) before abatacept initiation. RA patients presented with high disease activity and comorbidity rate, having failed multiple previous treatment options. In this cohort, the 5-year abatacept retention rate was 34% (95% confidence interval, 23-45%) per protocol, and 51% (95% confidence interval, 40-61%) when temporary discontinuations of abatacept > 84 days (n = 24) were not considered as treatment discontinuations. After 5 years of abatacept treatment, clinical outcomes were favorable [good/moderate European League Against Rheumatism (EULAR) responses in 91.7% patients]. No new safety signals were detected for abatacept in routine clinical practice. In this difficult-to-treat Belgian RA population, high retention rates, good clinical outcomes and favorable safety profile were observed with abatacept.

SAT0104 MAINTENANCE OF SDAI REMISSION AND PATIENT-REPORTED OUTCOMES (PROS) FOLLOWING DOSE DE-ESCALATION OF ABATACEPT IN MTX-NAÏVE, ANTI-CITRULLINATED PROTEIN ANTIBODY (ACPA)+ PATIENTS WITH EARLY RA: RESULTS FROM AVERT-2, A RANDOMISED PHASE IIIB STUDY

Background:

The Phase IIIbAssessingVeryEarlyRATreatment (AVERT)-2 trial (NCT02504268) evaluated SC abatacept (ABA) + MTX vs ABA placebo (PBO) + MTX in ACPA+ patients (pts) with early, active RA.1Results from the 56-wk induction period (IP) showed a significantly greater proportion of pts treated with ABA + MTX (vs MTX alone) reported clinically meaningful improvements in HAQ-DI, global disease activity and pain, which were sustained at 52 wks.2

Objectives:

To report maintenance of SDAI remission and PROs from the AVERT-2 de-escalation (D-E) period.

Methods:

Pts received blinded SC ABA (125 mg once wkly [QW]) + MTX or ABA PBO + MTX induction treatment for 56 wks. In this analysis, pts who completed induction with ABA + MTX and had sustained SDAI remission (≤3.3 at Wks 40 and 52) were re-randomised 1:1:1 to ABA QW + MTX, stepwise D-E (ABA every other wk + MTX for 24 wks then ABA PBO + MTX for 24 wks), or ABA QW + MTX PBO for 48 wks in the D-E period. PROs included physical function (HAQ-DI [0–3; decrease=improvement] and Short-Form 36 [SF-36] v2.0 Physical Functioning Scale [PFS]; 0–100; increase=improvement), and fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue [FACIT-F] score; 0–52; decrease=improvement). Endpoints included: proportion of pts in SDAI remission and pts with HAQ-DI response (decrease from IP Day [D]1 in HAQ-DI ≥0.30); adjusted mean change (adMC) from D-E D1 in HAQ-DI, SF-36 PFS or FACIT-F to D-E Wk 48. adMCs were estimated using a mixed effect model with repeated measures.

Results:

147 ABA + MTX-treated pts were re-randomised in the D-E period. Across re-randomised arms, the range of mean scores was 1.87–2.52 for SDAI and 0.18–0.30 for HAQ-DI at entry into D-E period (D-E D1). 74% of pts receiving ABA QW + MTX maintained SDAI remission at D-E Wk 48 (Fig 1); this proportion was higher than in the ABA withdrawal and ABA QW + MTX PBO arms. Pts continuing ABA QW + MTX maintained HAQ-DI response during D-E (Fig 1), but by D-E Wk 48 the proportion of pts with HAQ-DI response in the ABA withdrawal arm declined by 30%. At D-E Wk 48, a small numerical decrease (adMC –0.04) in HAQ-DI was observed in the ABA QW + MTX arm; increases were seen in the withdrawal (adMC 0.26) and ABA QW + MTX PBO arms (adMC 0.16). By D-E Wk 48, SF-36 PFS increased (adMC 1.68) in the ABA QW + MTX arm but decreased in the withdrawal (adMC –3.34) and ABA QW + MTX PBO (adMC –1.45) arms. FACIT-F score increased during D-E in all arms, but the increase at D-E Wk 48 was lower in the ABA QW + MTX arm (adMC 0.79) vs the withdrawal (adMC 4.12) and ABA QW + MTX PBO (adMC 2.41) arms. Similar trends were seen for other PROs including Work Productivity and Activity Impairment-RA; while activity impairment remained stable in the ABA QW + MTX arm, there was a trend for worsening in the withdrawal arm.

Conclusion:

In the AVERT-2 D-E period, continued combination therapy (abatacept + MTX) resulted in maintenance of benefits on PROs, particularly physical functioning, in seropositive pts with early RA. D-E of abatacept followed by complete withdrawal was associated with the greatest loss of remission as well as worsening of PROs. The PRO results corresponded well to the maintenance of clinical (SDAI) remission.

References:

[1]Emery P, et al. ACR 2018; San Diego, USA: Poster 563.

[2]Emery P, et al. ACR 2019; Atlanta, USA: Poster 1423.

Acknowledgments:

Joanna Wright (medical writing, Caudex; funding: Bristol-Myers Squibb)

Disclosure of Interests:

Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor), Yoshiya Tanaka Grant/research support from: Asahi-kasei, Astellas, Mitsubishi-Tanabe, Chugai, Takeda, Sanofi, Bristol-Myers, UCB, Daiichi-Sankyo, Eisai, Pfizer, and Ono, Consultant of: Abbvie, Astellas, Bristol-Myers Squibb, Eli Lilly, Pfizer, Speakers bureau: Daiichi-Sankyo, Astellas, Chugai, Eli Lilly, Pfizer, AbbVie, YL Biologics, Bristol-Myers, Takeda, Mitsubishi-Tanabe, Novartis, Eisai, Janssen, Sanofi, UCB, and Teijin, Vivian Bykerk: None declared, Thomas Huizinga Grant/research support from: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Consultant of: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Gustavo Citera Grant/research support from: AbbVie, Amgen, Eli Lilly, Gema, Genzyme, Novartis and Pfizer Inc, Consultant of: AbbVie, Amgen, Eli Lilly, Gema, Genzyme, Novartis and Pfizer Inc, Clifton Bingham Grant/research support from: Bristol-Myers Squibb, Consultant of: Bristol-Myers Squibb, Subhashis Banerjee Shareholder of: AbbVie, Bristol-Myers Squibb, Lily, Pfizer, Employee of: Bristol-Myers Squibb (current); AbbVie, Lily, Pfizer (past), Sean Connolly Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Joe Zhuo Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Robert Wong Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Kuan-Hsiang Gary Huang Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Karissa Lozenski Employee of: Bristol-Myers Squibb, Yedid Elbez Consultant of: Bristol-Myers Squibb, Roy Fleischmann Grant/research support from: AbbVie, Akros, Amgen, AstraZeneca, Bristol-Myers Squibb, Boehringer, IngelhCentrexion, Eli Lilly, EMD Serono, Genentech, Gilead, Janssen, Merck, Nektar, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Roche, Samsung, Sandoz, Sanofi Genzyme, Selecta, Taiho, UCB, Consultant of: AbbVie, ACEA, Amgen, Bristol-Myers Squibb, Eli Lilly, Gilead, GlaxoSmithKline, Novartis, Pfizer, Sanofi Genzyme, UCB

FRI0090 MAINTENANCE OF CLINICAL RESPONSE WITH ABATACEPT IN COMBINATION WITH MTX IN INDIVIDUAL PATIENTS WITH EARLY RA WHO ARE MTX-NAÏVE AND ANTI-CITRULLINATED PROTEIN ANTIBODY (ACPA)+: RESULTS FROM THE INDUCTION PERIOD OF AVERT-2, A RANDOMISED PHASE IIIB STUDY

Background:

In the 56-wk induction period (IP) of the Phase IIIbAssessingVeryEarlyRATreatment (AVERT)-2 trial (NCT02504268), more patients (pts) achieved SDAI remission (≤3.3) with abatacept (ABA) + MTX vs ABA placebo (PBO) + MTX at IP Wk 52.1It is unknown whether each individual pt within a treatment (Tx) group achieves and sustains the same efficacy endpoints at all time points during the IP.

Objectives:

To investigate whether ABA effectiveness is sustained by individual pts who achieved SDAI remission (≤3.3), SDAI low disease activity (LDA; >3.3–11), DAS28 (CRP) <2.6, ACR50/70 response or Boolean remission at IP Wk 24 (AVERT-2 primary endpoint) and both Wks 40 and 52 (Wks 40/52).

Methods:

Pts were randomised 3:2 to blinded SC ABA (125 mg/wk) + MTX or ABA PBO + MTX induction Tx for 56 wks. Key inclusion criteria: age ≥18 yrs; RA diagnosis (ACR/EULAR 2010 criteria); RA duration ≤6 mos; SDAI >11; ACPA+; CRP >3 mg/L or ESR ≥28 mm/h; TJC ≥3 and SJC ≥3; DMARD naïve. Response rates were investigated by Tx arm in the cohort 1 analysis population (all randomised pts treated in the IP [intent-to-treat analysis]).

Results:

Of randomised cohort 1, 752 pts were treated during the IP: 451 with ABA + MTX and 301 with ABA PBO + MTX. Baseline characteristics were similar across Tx arms.1Stringent SDAI remission endpoint at IP Wk 24 was achieved by 22% of ABA + MTX-treated pts; of these, 56% sustained SDAI remission at IP Wks 40/52 (Table). A similar proportion of ABA + MTX-treated pts achieved (17%) and sustained (58%) Boolean remission at IP Wks 24 and 40/52. At IP Wk 24, 42% of ABA + MTX-treated pts achieved DAS28 (CRP) <2.6 and 74% sustained DAS28 (CRP) <2.6 to IP Wks 40/52; a high proportion of patients sustained ACR50/70 responses at IP Wks 40/52 (83% and 79%, respectively). A lower proportion of pts sustained SDAI LDA to IP Wks 40/52 vs other endpoints (Table). Most efficacy endpoints were achieved by fewer pts who received ABA PBO + MTX than ABA + MTX (Table); among responders in this Tx group, fewer sustained remission at Wks 40/52, which correlates with a higher proportion of pts sustaining SDAI LDA at Wks 40/52 with ABA PBO + MTX than ABA + MTX.

Conclusion:

The majority of individual pts with RA who achieved clinically stringent endpoints such as SDAI remission, DAS28 (CRP) <2.6 or Boolean remission, as well as clinically meaningful endpoints such as ACR50/70 at IP Wk 24 with weekly SC abatacept, sustained their responses to Wks 40/52. The high proportion of patients achieving early stringent remission and response to SC abatacept by individual pts may be indicative of sustained efficacy over time.

References:

[1]Emery P, et al. ACR 2018; San Diego, USA: Poster 563.

Table .

Proportion of Pts With Response at IP Wk 24 Who Also Achieved Remission at Wks 40/52

EndpointResponders at IP Wk 24, n (%)Responders at IP Wk 24 and Wks 40/52, n/N (%)ABA + MTX(n=451)ABA PBO + MTX(n=301)ABA + MTX*ABA PBO + MTX*SDAI remission (≤3.3)100 (22)40 (13)56/100 (56)17/40 (43)SDAI low disease activity (>3.3–11)167 (37)82 (27)46/167 (28)32/82 (39)DAS28 (CRP) <2.6188 (42)78 (26)139/188 (74)43/78 (55)ACR50 response†260 (58)125 (42)215/260 (83)92/125 (74)ACR70 response†156 (35)66 (22)123/156 (79)42/66 (64)Boolean remission76 (17)29 (10)44/76 (58)8/29 (28)

*% based on number of pts within each Tx group who achieved response at IP Wk 24 (denominator);†Response at IP Wks 24 and 52

Acknowledgments:

Lola Parfitt (medical writing, Caudex; funding: Bristol-Myers Squibb)

Disclosure of Interests:

Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor), Yoshiya Tanaka Grant/research support from: Asahi-kasei, Astellas, Mitsubishi-Tanabe, Chugai, Takeda, Sanofi, Bristol-Myers, UCB, Daiichi-Sankyo, Eisai, Pfizer, and Ono, Consultant of: Abbvie, Astellas, Bristol-Myers Squibb, Eli Lilly, Pfizer, Speakers bureau: Daiichi-Sankyo, Astellas, Chugai, Eli Lilly, Pfizer, AbbVie, YL Biologics, Bristol-Myers, Takeda, Mitsubishi-Tanabe, Novartis, Eisai, Janssen, Sanofi, UCB, and Teijin, Vivian Bykerk: None declared, Clifton Bingham Grant/research support from: Bristol-Myers Squibb, Consultant of: Bristol-Myers Squibb, Thomas Huizinga Grant/research support from: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Consultant of: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Gustavo Citera Grant/research support from: AbbVie, Amgen, Eli Lilly, Gema, Genzyme, Novartis and Pfizer Inc, Consultant of: AbbVie, Amgen, Eli Lilly, Gema, Genzyme, Novartis and Pfizer Inc, Kuan-Hsiang Gary Huang Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Sean Connolly Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Yedid Elbez Consultant of: Bristol-Myers Squibb, Robert Wong Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Karissa Lozenski Employee of: Bristol-Myers Squibb, Roy Fleischmann Grant/research support from: AbbVie, Akros, Amgen, AstraZeneca, Bristol-Myers Squibb, Boehringer, IngelhCentrexion, Eli Lilly, EMD Serono, Genentech, Gilead, Janssen, Merck, Nektar, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Roche, Samsung, Sandoz, Sanofi Genzyme, Selecta, Taiho, UCB, Consultant of: AbbVie, ACEA, Amgen, Bristol-Myers Squibb, Eli Lilly, Gilead, GlaxoSmithKline, Novartis, Pfizer, Sanofi Genzyme, UCB

Presence of anti-cyclic citrullinated peptide antibodies is associated with better treatment response to abatacept but not to TNF inhibitors in patients with rheumatoid arthritis: a meta-analysis

OBJECTIVES

The objective of this study was to investigate whether anti-cyclic citrullinated peptide antibody (ACPA) status is associated with clinical responses to abatacept or TNF-α-inhibitors (TNF-α-i) in RA patients.

METHODS

A systematic literature review (SLR) was performed in January 2018 to identify published studies and conference abstracts evaluating biologic DMARD response according to ACPA status. Mantel-Haenszel meta-analysis methods were used to pool risk ratios (RRs). In the base-case, treatment response was assessed using EULAR measure, while a scenario analysis assessed response by combining ACR20, DAS28 and EULAR measures. Subgroup analyses were performed for duration of study follow-up.

RESULTS

Eighteen of the 30 SLR studies were included in the meta-analysis. The base-case showed a statistically significant positive association between ACPA positivity and EULAR response for patients treated with abatacept (RR: 1.13 [95% CI: 1.00, 1.26]), while ACPA positivity was associated with lower EULAR responses to TNF-α-i (RR: 0.91 [95% CI: 0.84, 0.98]). For the scenario analysis, results were consistent with the base-case for abatacept (RR 1.18 [95% CI 1.03, 1.35]), while for TNFα-i, no significant difference by ACPA status was observed (RR 0.97 [95% CI 0.86, 1.10]). Subgroups analyses showed results similar to the base-case for both abatacept and TNF-α-i.

CONCLUSIONS

This meta-analysis confirms that ACPA-positive RA patients are marginally more likely to achieve EULAR and ACR20 response to abatacept compared to ACPA-negative patients. Additionally, the analysis demonstrates that there is no association between ACPA status and response to TNF-α-i, consistent with findings of previously published studies.

Potential impact of the 2017 ACC/AHA guideline on high blood pressure in normotensive patients with stable coronary artery disease: insights from the CLARIFY registry

Aims

The 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline on high blood pressure (BP) lowered the threshold defining hypertension and BP target in high-risk patients to 130/80 mmHg. Patients with coronary artery disease and systolic BP 130–139 mmHg or diastolic BP 80–89 mmHg should now receive medication to achieve this target. We aimed to investigate the relationship between BP and cardiovascular events in ‘real-life’ patients with coronary artery disease considered as having normal BP until the recent guideline.

Methods and results

Data from 5956 patients with stable coronary artery disease, no history of hypertension or heart failure, and average BP <140/90 mmHg, enrolled in the CLARIFY registry (November 2009 to June 2010), were analysed. In a multivariable-adjusted Cox proportional hazards model, after a median follow-up of 5.0 years, diastolic BP 80–89 mmHg, but not systolic BP 130–139 mmHg, was associated with increased risk of the primary endpoint, a composite of cardiovascular death, myocardial infarction, or stroke (hazard ratio 2.15, 95% confidence interval 1.22–3.81 vs. 70–79 mmHg and 1.12, 0.64–1.97 vs. 120–129 mmHg). No significant increase in risk for the primary endpoint was observed for systolic BP <120 mmHg or diastolic BP <70 mmHg.

Conclusion

In patients with stable coronary artery disease defined as having normal BP according to the 140/90 mmHg threshold, diastolic BP 80–89 mmHg was associated with increased cardiovascular risk, whereas systolic BP 130–139 mmHg was not, supporting the lower diastolic but not the lower systolic BP hypertension-defining threshold and treatment target in coronary artery disease.

ClinicalTrials identifier

ISRCTN43070564.

Abatacept retention and clinical outcomes in Austrian patients with rheumatoid arthritis: real-world data from the 2-year ACTION study

BACKGROUND

AbataCepT In rOutiNe clinical practice (ACTION; NCT02109666) was a 2-year international observational study of patients with moderate to severe rheumatoid arthritis.

METHODS

Baseline characteristics, abatacept retention rates, and clinical outcomes were compared by treatment line in the Austrian cohort of ACTION.

RESULTS

Of 100 patients enrolled in Austria, 98 (98.0%) were evaluable: 33/98 (33.7%) biologic naïve and 65/98 (66.3%) with ≥1 prior biologic failure. At baseline, biologic-naïve patients had shorter disease duration and lower concomitant corticosteroid use than biologic-failure patients. Overall crude abatacept retention rate was 60.5% and retention rate was higher in biologic-naïve (65.1%) versus biologic-failure (58.0%) patients. Good/moderate EULAR (European League Against Rheumatism) response rates were 85.7% in biologic-naïve and 100% in biologic-failure patients.

CONCLUSIONS

In the Austrian cohort of ACTION, overall abatacept retention at 2 years was high, with higher retention rates in patients receiving abatacept as an earlier treatment line. Good/moderate EULAR response rate was higher in biologic-failure than in biologic-naïve patients.

P1694Sex is not an independent predictor of ischemic outcomes or bleeding in NSTEMI patients undergoing percutaneous coronary intervention. Insights from the TAO trial

Background

There is uncertainty regarding whether female sex is an independent predictor of adverse outcomes in acute coronary syndromes (ACS).

Purpose

We sought to describe and compare ischemic and bleeding outcomes between men and women with Non–ST-segment–Elevation (NSTE) ACS enrolled in the large Treatment of Acute coronary syndromes with Otamixaban (TAO) trial in which antithrombotic treatment was standardized and a systematic invasive approach was performed.

Methods

The TAO trial randomized moderate to high-risk NSTE-ACS patients with diagnostic coronary angiography planned in the first 72 hours to heparin plus eptifibatide versus otamixaban. This post-hoc analysis describes ischemic (all-cause death, new myocardial infarction, stent thrombosis within 180 days of randomization) and bleeding outcomes (TIMI major and minor bleeding within 30 days of randomization) according to sex.

Results

Of 13,229 patients with NSTE-ACS randomized in 55 countries, 3,980 (30.1%) were female and 9,249 (69.9%) were male. Mean age was 64.8±11.0 and 60.7±11.1 years, respectively. The prevalence of diabetes (34.0% vs. 25.8%), hypertension (80.8% vs. 67.0%), and hypercholesterolemia (55.9% vs. 52.2%) was higher among women compared with men but current smoking (21.5% vs. 38.7%) and history of previous MI were more frequent in males (15.5% vs. 20.7%).

Females experienced a higher incidence of both ischemic outcomes (10.2% vs. 9.1%; OR=1.15; 95% CI, 1.01–1.30; p=0.034) and bleeding events (4.1% vs. 3.4%; OR=1.23; 95% CI, 1.02–1.49; p=0.029). Bleeding risk and CV death were particularly increased in women younger than 50 years, compared to males of the same age, at 5.5% vs. 1.4% (OR=4.00; 95% CI, 2.13–7.69; p=0.034) and 1.7% vs. 0.5% (OR=4.35; 95% CI, 1.02–20.00; p=0.02), respectively. No difference in either outcome was found between women and men between 50 and 80 years old. Above 80 years, women experienced a lower rate of bleeding (3.9% vs. 7.8%; OR=0.47; 95% CI, 0.23–0.88; p=0.024) but a similar rate of in ischemic events (16.0% vs. 17.2%; OR=0.92; 95% CI, 0.63–1.33; p=0.67).

After adjustment for age, body weight, diabetes mellitus, prior PCI, serum creatinine, presenting systolic blood pressure, elevated biomarker at presentation, heart failure, the risk of ischemic (OR=1.03; 95% CI, 0.89–1.18; p=0.71) and bleeding events (OR=1.05; 95% CI, 0.85–1.33; p=0.65) were similar between men and women.

Conclusions

In this large international randomized trial of NSTE-ACS with standardized invasive management, women (particularly those younger than 50 years) experienced higher risks of ischemic and bleeding events than men, but the difference was not sustained after adjustment. In this population, sex was not an independent predictor of adverse outcomes in NSTE-ACS. The type of ACS (NSTE-ACS) and routine invasive management in women and men may explain this absence of difference.

Acknowledgement/Funding

The TAO trial was sponsored and funded by SANOFI. The present analysis was supported by the RHU iVASC grant “#ANR-16-RHUS-00010”

2211Prevalence, incidence and prognostic implications of left bundle branch block in patients with stable coronary artery disease. an analysis from the CLARIFY registry

Background

The prevalence, and prognostic implication of left bundle branch block (LBBB) in general population and patients admitted for acute myocardial infarction (MI) as been extensively studied. However, data are scarce about patients with stable coronary artery disease (CAD) and it remains unclear whether LBBB is only a marker of a severe cardiomyopathy or an independent predictor of events in these patients.

Purpose

We aimed to describe the prevalence, incidence and prognostic implications of LBBB in patients with stable CAD. Additionally, we aimed to describe the incidence of newly diagnosed LBBB that occurred without recent myocardial infarction.

Methods

CLARIFY is an international registry of more than 30.000 patients with stable CAD. LBBB was collected at baseline and at each follow-up visit, and patients were considered to have LBBB if the length of the QRS complex was of more than 120 milliseconds. Patients with previous pacemaker implantation of internal cardiac defibrillator were excluded. The primary outcome was a composite of cardiovascular (CV) Death, MI or stroke, and secondary outcomes included hospitalization for heart failure (HF) or the need for pacemaker implantation.

Results

From the 23.457 patients with available data regarding LBBB status, 1.041 (4.4%) had LBBB at baseline and 1.237 (5.3%) had at least one LBBB assessed during 5-year follow-up. Only 21 patients with newly diagnosed LBBB overtime, had a documented MI the same year. Compared to patients without LBBB, patients with LBBB had a higher risk profile regarding age (67.2±10.1 versus 63.6±10.4 years, p<0.0001), history of coronary artery bypass grafting (29.2% vs 23.7%, p<0.0001), diabetes (35.1% vs 28.4%, p<0.0001), and HF (25.2% vs 16.8%, p<0.0001) (Table). In unadjusted analysis, patients with LBBB had a higher risk of primary outcome (13.4% vs 8.7%, p<0.0001) and each secondary outcome. In multivariate analysis taking into account several possible confounders, there was no difference in the rate of CV death, MI or stroke between LBBB or no-LBBB patients (adjusted HR 1.04, 95% CI 0.85–1.29). However, patients with LBBB had a higher rate of pacemaker implantation (adjusted HR 2.21, 95% CI 1.55–3.15, p<0.0001) and hospitalization for HF (adjusted HR 1.53, 95% CI 1.25–1.88, p<0.0001) (Figure).

Outcomes according to LBBB status

Conclusion

The prevalence of LBBB in patients with stable CAD was 4.4% and 5.3% with 5-year follow-up. The overwhelming majority of newly diagnosed LBBB were not contemporary of documented myocardial infarction. LBBB was not associated with a higher rate of major adverse cardiovascular events, including all cause mortality but with a higher risk of pacemaker implantation and hospitalization for heart failure. To our knowledge this is the first study reporting such results in a broad population of stable CAD patients.

Acknowledgement/Funding

None

Abatacept retention and clinical outcomes in rheumatoid arthritis: real-world data from the German cohort of the ACTION study and a comparison with other participating countries

INTRODUCTION

AbataCepT In rOutiNe clinical practice (ACTION; NCT02109666) was an observational study of patients with rheumatoid arthritis who initiated intravenous abatacept in clinical practice. We aimed to compare abatacept retention rates and clinical outcomes in patients from Germany versus other countries.

METHOD

Baseline characteristics, crude retention rates, and clinical outcomes were compared by treatment line in the German cohort at 2 years. In addition, biologic-naïve patients were compared with biologic-naïve patients pooled from other participating countries.

RESULTS

In the German cohort, 677/680 (99.6%) patients enrolled were evaluable and 171/677 (25.3%) were biologic naïve. At baseline, abatacept monotherapy was received by a similar proportion of biologic-naïve and biologic-failure patients in the German cohort, but by a greater proportion of biologic-naïve patients in German versus other countries cohort (27.5 vs. 12.9%). The overall crude abatacept retention rate at 2 years in the German cohort was 39.9%; retention rate did not differ significantly by treatment line, but among biologic-naïve patients it was lower in Germany than in the other countries cohort (42.1 vs. 58.7%; log-rank test p < 0.001). At 2 years, good/moderate European League Against Rheumatism (EULAR) response rates in biologic-naïve patients were 85.5% in the German and 92.1% in other countries cohort (p = 0.163).

CONCLUSIONS

In the German cohort of ACTION, abatacept retention at 2 years was similar in biologic-naïve and biologic-failure patients. Biologic-naïve patients in German cohort had a significantly lower abatacept retention rate and a trend of lower good/moderate EULAR response rate than those in the other countries cohort.

KEY POINTS

• Analyses of data from national patient cohorts provide insight on local treatment patterns. • In the German cohort of the ACTION study, abatacept retention at 2 years was similar in biologic-naïve and biologic-failure patients. • Biologic-naïve patients from the German cohort had a significantly lower abatacept retention rate and a trend of lower good/moderate EULAR response rate than patients from other countries. • Data from large international studies may not be directly applicable to individual countries.

Body mass index and treatment response to subcutaneous abatacept in patients with psoriatic arthritis: a post hoc analysis of a phase III trial

Objective

This post hoc analysis of the phase III Active PSoriaTic Arthritis RAndomizEd TriAl (ASTRAEA) evaluated the effect of baseline body mass index (BMI) on subsequent response to subcutaneous (SC) abatacept in patients with psoriatic arthritis (PsA).

Methods

In ASTRAEA, patients with active PsA were randomised (1:1) to receive blinded weekly SC abatacept 125 mg or placebo for 24 weeks. Treatment response at week 24 was assessed by the proportions of patients achieving American College of Rheumatology 20% improvement response, Disease Activity Score in 28 joints (DAS28 (C reactive protein (CRP))) ≤3.6 and <2.6, Health Assessment Questionnaire-Disability Index reduction from baseline ≥0.35 and radiographic non-progression (defined as change from baseline ≤0 in PsA-modified total Sharp/van der Heijde score). Responses were stratified by baseline BMI (underweight/normal, <25 kg/m²; overweight, 25–30 kg/m²; obese, >30 kg/m²) and compared in univariate and multivariate models.

Results

Of 212/213 and 210/211 patients with baseline BMI data in the abatacept and placebo groups, respectively, 15% and 19% were underweight/normal, 36% and 27% were overweight, and 49% and 54% were obese. After adjusting for baseline characteristics, there were no significant differences for any outcome measure at week 24 with abatacept in the overweight or obese versus underweight/normal subgroup. In the placebo group, patients in the obese versus underweight/normal subgroup were significantly less likely to achieve DAS28 (CRP) <2.6 at week 24 (OR 0.26; 95% CI 0.08 to 0.87; p=0.03).

Conclusion

BMI does not impact clinical or radiographic response to SC abatacept in patients with PsA.

Trial registration number

NCT01860976.

Abatacept used in combination with non-methotrexate disease-modifying antirheumatic drugs: a descriptive analysis of data from interventional trials and the real-world setting

Background

Methotrexate (MTX) remains the anchor drug in rheumatoid arthritis (RA) treatment, but is poorly tolerated or contraindicated in some patients. There is a wealth of data supporting the use of abatacept in combination with MTX, but data on alternative conventional synthetic disease-modifying antirheumatic drug (csDMARD) combinations with abatacept are scarce.

Methods

In this post-hoc exploratory analysis, efficacy and safety data were extracted from abatacept RA studies in which combination with csDMARDs other than MTX was permitted: three interventional trials (ATTAIN, ASSURE, and ARRIVE) and one real-world study (ACTION). Patients with moderate-to-severe RA received abatacept in combination with MTX, hydroxychloroquine, sulfasalazine, azathioprine, or leflunomide for 6 months to 2 years according to the study design. Change from baseline in physical function (Health Assessment Questionnaire—Disability Index (HAQ-DI); all studies) and 28-joint Disease Activity Score (C-reactive protein) (DAS28 (CRP); ATTAIN, ARRIVE, and ACTION), American College of Rheumatology response rates (ATTAIN), and safety were assessed for individual and pooled csDMARD combinations for each trial. A meta-analysis was also performed on pooled data for HAQ-DI and DAS28 (CRP) across interventional trials.

Results

Across all four studies, 731 patients received abatacept plus one non-MTX csDMARD (hydroxychloroquine n = 152; sulfasalazine n = 123; azathioprine n = 59; and leflunomide n = 397) and 2382 patients received abatacept plus MTX. Mean changes from baseline in HAQ-DI scores for abatacept plus MTX (all csDMARDs pooled) vs abatacept plus a non-MTX csDMARD were –0.54 vs –0.44 (ATTAIN), –0.43 vs –0.43 (ASSURE), and –0.39 vs –0.36 (ARRIVE). Mean changes from baseline in DAS28 (CRP) and ACR response rates were also similar with abatacept plus MTX or non-MTX csDMARDs. Data for individual non-MTX csDMARDs (pooled across studies) and real-world data were consistent with these findings. Rates of treatment-related adverse events and serious adverse events, respectively, for abatacept plus one non-MTX csDMARD vs abatacept plus MTX were 35.7% vs 41.7% and 2.4% vs 2.3% (ATTAIN), 58.0% vs 55.9% and 4.2% vs 1.7% (ASSURE), and 38.1% vs 44.3% and 0.6% vs 2.9% (ARRIVE).

Conclusions

Abatacept in combination with non-MTX csDMARDs is clinically effective and well tolerated in patients with moderate-to-severe RA, providing similar benefits to those seen with abatacept plus MTX.

Trial registration

ClinicalTrials.gov NCT00048581. Registered 2 November 2002.

ClinicalTrials.gov NCT00048932. Registered 11 November 2002.

ClinicalTrials.gov NCT00124982. Registered 30 June 2005.

ClinicalTrials.gov NCT02109666. Registered 8 April 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-017-1488-5) contains supplementary material, which is available to authorized users.

Real-world predictors of 12-month intravenous abatacept retention in patients with rheumatoid arthritis in the ACTION observational study

INTRODUCTION

An understanding of real-world predictors of abatacept retention is limited. We analysed retention rates and predictors of abatacept retention in biologic-naïve and biologic-failure patients in a 12-month interim analysis of the 2-yearAbataCepTIn rOutiNe clinical practice (ACTION) study.

METHODS

ACTION was an international, observational study of patients with moderate-to-severe rheumatoid arthritis (RA) who initiated intravenous abatacept. In this 12-month interim analysis, crude abatacept retention rates, predictors of retention and European League Against Rheumatism (EULAR) response were evaluated in both biologic-naïve and biologic-failure patients. Retention by rheumatoid factor (RF) and anti-cyclic citrullinated peptide (CCP) status was also assessed, in patients with or without baseline radiographic erosions, and by body mass index (BMI).

RESULTS

Overall, 2350/2364 enrolled patients were evaluable (674 biologic naїve; 1676 biologic failure). Baseline characteristics were largely similar in biologic-naïve and biologic-failure groups. Crude retention rates (95% CI) at 12 months were significantly higher in biologic-naїve (78.1%(74.7% to 81.2%)) versus biologic-failure patients (69.9%(67.6% to 72.1%); P<0.001). RF/anti-CCP double positivity predicted higher retention in both patient groups, and remained associated with higher retention in patients with erosive disease. BMI did not impact abatacept retention in either patient group, irrespective of RF/anti-CCP serostatus. Good/moderate EULAR response rate at 12 months was numerically higher in biologic-naїve (83.8%) versus biologic-failure (73.3%) patients. There were no new safety signals.

CONCLUSION

High levels of intravenous abatacept retention in clinical practice were confirmed, particularly in biologic-naïve patients, including in those with poor RA prognostic factors. Retention was unaffected by BMI, regardless of RF/anti-CCP serostatus.

TRIAL REGISTRATION NUMBER

NCT02109666; retrospectively registered 8 April 2014.

Efficacy and safety of bivalirudin in coronary artery disease patients with mild to moderate chronic kidney disease: Meta-analysis

BACKGROUND

Patients with chronic kidney disease (CKD) have elevated bleeding and ischemic outcomes. We aim to assess the short- and long-term efficacy and safety of bivalirudin compared to heparin plus glycoprotein IIb/IIIa inhibitors (GPIs) in coronary artery disease (CAD) patients with CKD.

METHODS

Randomized trials were searched in PubMed, Cochrane, and Embase databases up to January 2017. Among the trials retrieved, efficacy endpoints were defined as mortality, myocardial infarction (MI), repeat revascularization, stent thrombosis, and major adverse cardiac events (MACEs). Safety endpoints were reported as non-coronary artery bypass grafting (CABG) related major bleeding and thrombolysis in myocardial infarction (TIMI) major bleeding. Risk ratio (RR) and 95% confidence interval (CI) were calculated for each outcome using a fixed effect model.

RESULTS

Five studies with a total of 3796 patients were included. In short-term follow up (30 days), bivalirudin significantly reduced non-CABG related major bleeding (p=0.0004) and TIMI major bleeding (p=0.007) compared to heparin plus GPIs. No significant differences were observed in rates of mortality, MI, repeat revascularization, stent thrombosis, and MACEs between the two groups in short- and long-term follow up (6 months to 3 years). In patients with ST elevated myocardial infarction (STEMI) with concurrent CKD, the decreased non-CABG related major bleeding (p=0.04) without increasing ischemic events was also observed after short-term follow up.

CONCLUSIONS

(1) Bivalirudin is safer than and as effective as heparin plus GPIs in CAD patients with CKD. (2) Impaired renal function does not affect the safety benefits of bivalirudin. (3) Similar efficacy profiles were identified between the two groups after both short- and long-term follow up in the CAD patients with CKD.