Longitudinal program evaluation of an inter-institutional mentorship network for pediatric rheumatology using a quality improvement framework

Background

The American College of Rheumatology (ACR)/Childhood Arthritis and Rheumatology Research Alliance (CARRA) Mentoring Interest Group (AMIGO) is an inter-institutional mentorship program launched to target mentorship gaps within pediatric rheumatology. Initial program evaluation indicated increased mentorship access. Given the small size of the pediatric rheumatology workforce, maintaining a consistent supply of mentors was a potential threat to the longevity of the network. Our aims were to: (i) describe the sustainability of AMIGO over the period 2011-2018, (ii) highlight ongoing benefits to participants, and (iii) describe challenges in the maintenance of a mentorship network.

Methods

A mixed-methods approach centered on a quality improvement framework was used to report on process and outcomes measures associated with AMIGO annual cycles.

Results

US and Canada Pediatric rheumatology workforce surveys identified 504 possible participants during the time period. As of fall 2018, 331 unique individuals had participated in AMIGO as a mentee, mentor or both for a program response rate of 66% (331/504). Survey of mentees indicated high satisfaction with impact on general career development, research/scholarship and work-life balance. Mentors indicated increased sense of connection to the community and satisfaction with helping mentees despite minimal perceived benefit to their academic portfolios. Based on AMIGO's success, a counterpart program, Creating Adult Rheumatology Mentorship in Academia (CARMA), was launched in 2018.

Conclusions

Despite the challenges of a limited workforce, AMIGO continues to provide consistent access to mentorship opportunities for the pediatric rheumatology community. This experience can inform approaches to mentorship gaps in other academic subspecialties.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

POS1303 METHOTREXATE RESPONSE IN PEDIATRIC NON-INFECTIOUS UVEITIS

Background

Children with chronic non-infectious uveitis (NIU) are at risk for sight-threatening complications. Methotrexate (MTX) is the preferred first-line systemic treatment. Initial therapeutic response takes 3-6 months to achieve NIU control, leading to prolonged glucocorticoid use. Moreover, at least 50-70% of children fail to fully respond and may accrue ocular damage while awaiting MTX response.

Objectives

To identify features of children with NIU that are associated with MTX failure.

Methods

We included children who started MTX monotherapy for NIU. We collected demographics, NIU features (type, location, & complications), ANA status, and clinical examination. We characterized children as MTX responders or non-responders. MTX responders are those whose NIU was controlled, defined by: 1) inactive graded by SUN criteria, 2) absence of new or worsening complications, and 3) requirement for ≤2 drops of prednisolone acetate and no oral glucocorticoids.

Results

Of 47 NIU children, 68% were MTX non-responders (Table 1), having a longer duration of NIU (Odds Ratio [OR]=1.28, [CI=1.03-1.8], p =0.023) and developing more ocular complications (OR=1.95 [CI=1.23-3.38], p=0.017), (ROC Area Under the Curve = 0.85). MTX non-responders were more likely to have anterior and/or posterior synechiae (p = 0.001), cataracts (p=0.015), and ocular hypertension (p=0.039). Treatment included adalimumab: 27, infliximab: 14, tocilizumab: 5, golimumab: 4, etanercept: 3, and abatacept: 2.

Table 1.

Comparison of children with NIU based on MTX response.

Responders n=15Non-responders n=32Caucasian14 (93)27 (84)Hispanic or Latino0 (0)3 (9)Female12 (80)23 (72)Age of NIU onset, yrs, median (IQR)4.3 (2.9 – 12.3)4.6 (2.8 - 7.0)Duration of NIU, yrs, median, (IQR)4.1 (2.6 – 5.3)8.2 (4.7 - 11.3)JIA-NIU10 (67)25 (78)Idiopathic CAU2 (13)3 (9)Other3 (20)4 (12)Bilateral disease12 (80)23 (72)Anterior12 (86)29 (91)Presenting BCVA (LogMAR) worst eye, median (IQR)0.2 (0.1 – 0.3)0.1 (0.0 - 0.2)Average # of total complications/person, median (IQR)1 (0 – 2)2.5 (1.0 – 5.5)ANA positive10 (67)26 (81)Earliest ESR8 (6– 18)12 (8 - 18)Earliest Vitamin D32 (26 – 35)31 (23 - 35)Time on MTX, months, median (IQR)35 (19 - 64)19 (7 - 74)Time from systemic or NIU onset to MTX, yrs, median (IQR)0.3 (0.1 – 0.5)0.2 (0.0 - 0.8)MTX PO6 (40)19 (59)MTX SC13 (87)31 (97)

We performed a sub analysis of children with idiopathic chronic anterior NIU (CAU) and JIA-associated NIU that included children who failed MTX due to intolerance/toxicity (Figure 1). Using Cox proportional hazard regression, 8 idiopathic CAU failed MTX earlier than 38 JIA-associated NIU (HR 2.77, [CI-=1.06-7.27], p=0.039). Results were similar with the inclusion of other types of NIU (p=0.088) (e.g., HLA-B27, non-anterior idiopathic or with systemic disease).

Figure 1.

Kaplan-Meier curve showing freedom from TNFi (mos) stratified by diagnosis

Conclusion

Two out of three children with NIU fail initial MTX monotherapy, exposing them to increased accrual of ocular complications prior to biologic starts. The risk for delay in starting tumor necrosis factor α inhibitors (TNFi) seems higher with CAU. Future studies will examine risk factors that predict MTX response in NIU.

References

[1]McCracken C, Angeles-Han ST, et.al. Timing of infliximab and adalimumab initiation despite methotrexate in children with chronic non-infectious anterior uveitis. Eye (Lond). 2019;33(4):629-39.

[2]Henderson LA, Angeles-Han ST, et.al., Medication use in juvenile uveitis patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry. Pediatr Rheumatol Online J. 2016;14(1):9.

[3]Cooper A, et.al., Failure of methotrexate monotherapy and subsequent response to tumor necrosis factor inhibitors in pediatric non-infectious uveitis (abstract). Arthritis Rheumatol. 2020:72 (suppl 4).

Disclosure of Interests

Sheila Angeles-Han: None declared, Amy Cassedy: None declared, Theresa Hennard: None declared, Mekibib Altaye: None declared, Hermine Brunner Consultant of: Dr. Brunner’s affiliation Cincinnati Children’s Hospital Medical Center has received consulting fees or other remuneration from AstraZeneca, Boehringer Ingelheim, GSK, Roche, Novartis, Pfizer Inc, Takeda, and UBC for the work of Dr. Brunner. Dr. Brunner is a DSMB member for Janssen Pharmaceutical’s trial of ustekinumab pediatric Crohn and Ulcerative colitis., Grant/research support from: Dr. Brunner’s affiliation Cincinnati Children’s Hospital Medical Center has received research grants from BMS, Janssen, Novartis, Pfizer Inc, Roche, and UBC., Eniolami Dosunmu: None declared, Alexei Grom: None declared, Michael Henrickson: None declared, Jennifer Huggins: None declared, Sarah Lopper: None declared, Daniel J Lovell Consultant of: AstraZeneca, Boehringer Ingelheim, GSK, Roche, Novartis, Pfizer Inc, Takeda, and UBC, Grant/research support from: BMS, Janssen, Novartis, Pfizer Inc, Roche, and UBC, Robert Sisk Consultant of: AGTC, Gyroscope, and Leica, Tracy Ting: None declared, Adam Kaufman Consultant of: Consultant for Alcon, Bausch & Lomb, and 1800contacts, not related or relevant to study content., Virginia Utz: None declared

OP0193 EFFICACY AND SAFETY OF EMAPALUMAB, AN ANTI-INTERFERON GAMMA MONOCLONAL ANTIBODY, IN PATIENTS WITH MACROPHAGE ACTIVATION SYNDROME (MAS) IN SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS (sJIA) WHO HAD FAILED HIGH-DOSE GLUCOCORTICOIDS

Background

MAS is a severe, life-threatening complication of rheumatic diseases that occurs most frequently in patients with sJIA. The mainstay of treatment for MAS is high dose glucocorticoids (GCs); however, GCs do not provide adequate control in all patients. Additional treatments are used without a standardized approach; however, morbidity and mortality remain high. Data from animal models of MAS and from observational studies in patients suggest that overproduction of IFNγ is a driver of the hyperinflammation observed in MAS; neutralization of IFNγ has been shown to revert the signs and symptoms of MAS in murine models, and high IFNγ levels are strongly correlated with laboratory parameters of disease severity in patients.

Objectives

To assess the efficacy and safety of intravenous (IV) infusions of emapalumab, a fully human, anti-IFNγ monoclonal antibody, in patients with MAS in sJIA.

Methods

Open-label, single-arm, phase 2 study (NCT03311854) that included patients with MAS (2016 ACR/EULAR criteria) in sJIA who had failed high-dose IV GCs and other treatments. Emapalumab was initiated at a dose of 6 mg/kg on Day 0 and continued at 3 mg/kg every 3 days until Day 15, and then twice weekly until Day 28 to ensure rapid and complete IFNγ neutralization after initiating treatment. As per protocol, 10 infusions were planned over the 4 weeks; however, treatment could be shortened if MAS remission was achieved earlier, or extended if required to achieve remission. Complete response (CR) was defined as resolution of clinical signs and symptoms of MAS according to the investigator, and normalization of laboratory parameters relevant to MAS. All patients were followed up for 4 weeks after the last infusion of emapalumab and offered to enter a 1-year, follow-up study (NCT02069899).

Results

Fourteen patients (10 females) were enrolled (11 in Europe, 3 in the USA). Several patients had previously received cyclosporine A and/or anakinra, in addition to high-dose GCs. Six patients received emapalumab until Day 28. Seven patients discontinued emapalumab early due to MAS remission (as per investigator’s assessment); one patient received treatment up to Day 38. Emapalumab treatment rapidly neutralized IFNγ, as documented by CXCL9 levels. A CR was achieved by 13/14 patients during the study. One patient stopped emapalumab after 3 doses because of achievement of MAS remission as per investigator’s assessment, but lactate dehydrogenase levels remained >1.5× upper limit of normal. At Week 8, 11/14 patients had a CR; 2 achieved a CR during the study, but not at Week 8, because of a single laboratory parameter abnormality in each patient. Overall, all measured laboratory parameters related to MAS activity rapidly improved with emapalumab treatment. GCs were tapered in all patients by Week 8 (≥50% reduction, n=12; GC dose ≤1 mg/kg/day, n=8). Administration of anakinra for the treatment of underlying sJIA was maintained/introduced during the study, as required. No patients discontinued treatment for safety reasons. One treatment-related serious adverse event was reported (cytomegalovirus reactivation that resolved with antiviral treatment). All patients entered the long-term, follow-up study and were alive at last visit.

Conclusion

Emapalumab administration led to rapid IFNγ neutralization, was efficacious in controlling MAS in all patients, and was well tolerated with a favorable safety profile. These results support the pathogenic role of IFNγ in MAS in sJIA and the therapeutic value of IFNγ neutralization in MAS patients who have failed high-dose GCs.

Disclosure of Interests

Fabrizio De Benedetti Consultant of: Sobi, AbbVie, Pfizer, Roche, Sanofi, Novartis, Novimmune, Grant/research support from: Sobi, AbbVie, Pfizer, Roche, Sanofi, Novartis, Novimmune, Alexei Grom Consultant of: Novartis, AB2 Bio, Paul Brogan Consultant of: Sobi, Novartis, Roche, UCB, Claudia Bracaglia: None declared, Manuela Pardeo: None declared, Giulia Marucci: None declared, Despina Eleftheriou Speakers bureau: Sobi, Charalampia Papadopoulou Speakers bureau: Sobi, Pierre Quartier Speakers bureau: Sobi, AbbVie, Chugai-Roche, Lilly, Novartis, Pfizer, Consultant of: Sobi, AbbVie, Chugai-Roche, Lilly, Novartis, Pfizer, Jordi Anton Consultant of: Sobi, Novartis, Roche, Pfizer, AbbVie, GSK, Rikke Frederiksen Employee of: Sobi, Veronica Asnaghi Employee of: Sobi, Cristina de Min Consultant of: Sobi

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

POS0076 S100A8/A9 AND S100A12 AS POTENTIAL PREDICTIVE BIOMARKERS OF ABATACEPT RESPONSE IN POLYARTICULAR JUVENILE IDIOPATHIC ARTHRITIS

Background:

The calcium-binding proteins S100A8/A9 (calprotectin) and S100A12 (extracellular newly identified receptor for advanced glycation end-products binding protein [EN-RAGE]) are involved in multiple signalling pathways to mediate inflammation, can be secreted by activated monocytes/macrophages and exhibit cytokine-like extracellular functions. Circulating levels of these proteins have been associated with disease and clinical responses in systemic juvenile idiopathic arthritis (sJIA), including treatment response.1 Studies suggest that serum S100A8/A9 and S100A12, which are released at inflammation sites, are more specific biomarkers of local inflammation (e.g. in the synovium) than systemic biomarkers such as CRP and ESR.2,3

Objectives:

To investigate if baseline S100A8/A9 and S100A12 predict clinical response to abatacept treatment in polyarticular JIA (pJIA), and to assess whether changes from baseline in S100A8/A9 or S100A12 can be better prognostic markers for response to abatacept treatment than CRP in pJIA.

Methods:

Data are from a phase III trial of SC abatacept for the treatment of pJIA (NCT01844518).4 This 24-month, single-arm, open-label, international, multicentre, two-part study included male and female patients with pJIA aged 2–17 years. This analysis examined the correlation between biomarkers (S100A8/A9, S100A12 and high-sensitivity CRP [hsCRP]) and disease activity (measured using Juvenile Arthritis Disease Activity Score [JADAS]) at baseline, baseline biomarker values as predictors of future treatment response (ACR and JADAS endpoints), and the correlation between change from baseline in biomarker values and treatment response at Day 113.

Results:

Of 219 total patients, 158 (72%) had S100A8/A9 values and 155 (71%) had S100A12 values at baseline. Median S100A8/A9 and S100A12 values were 3295 ng/mL (normal range, 716–3004 ng/mL) and 176 ng/mL (normal range, 32–385 ng/mL), respectively. S100A8/A9, S100A12 and hsCRP (median 0.20 mg/dL; normal ≤0.6 mg/dL) had a low-to-moderate but significant association with disease activity at baseline; coefficients for associations between JADAS71-CRP low disease activity (LDA) and the biomarkers S100A8/A9, S100A12 and hsCRP were 0.23 (p=0.0038), 0.16 (p=0.0448) and 0.26 (p=0.0001), respectively. Baseline S100A8/A9 level above the median was associated with lower odds of ACR100 at Day 113 (p=0.0052). Figure 1 shows the associations of baseline biomarker values with Day 113 ACR and JADAS scores in the overall population. Baseline S100A8/A9 or S100A12 did not significantly influence ACR50 or ACR70 responses at Day 113, but high baseline values were associated with reduced odds of ACR90 (p=0.01), ACR100 (p=0.005), ACR-inactive disease (ID) (p=0.0001), and JADAS71-CRP (LDA) (p=0.02). By Day 477, elevated baseline S100A12 was still significantly associated with lower odds of ACR100 overall (0.467; p=0.0248) but baseline S100A8/A9 was not; at Day 645, neither was significantly associated with ACR100 response. At Day 113, changes from baseline in S100A8/A9 and S100A12 were correlated with ACR100 (coefficients of 0.22 [p=0.0082] and 0.26 [p=0.0015], respectively) and with ACR-ID (0.22 [p=0.0067] and 0.26 [p=0.0014], respectively); change in hsCRP was not significantly correlated with disease response.

Conclusion:

S100A8/A9 and S100A12 may serve as prognostic biomarkers to predict response to abatacept treatment at Day 113. Changes from baseline S100A8/A9 and S100A12 levels were more highly correlated with efficacy outcomes including ACR100 and ACR-ID at Day 113 compared with hsCRP.

References:

[1]Aljaberi N, et al. Pediatr Rheumatol Online J 2020;18:7.

[2]Hammer H, et al. Arthritis Res Ther 2011;13:R178.

[3]Nordal HH, et al. BMC Musculoskelet Disord 2014;15:335.

[4]Brunner H, et al. Arthritis Rheumatol 2018;70:1144–1154.

Acknowledgements:

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

Disclosure of Interests:

Nicolino Ruperto Speakers bureau: NR has received honoraria for consultancies or speaker bureaus (< 10.000 USD each) from the following pharmaceutical companies in the past 3 years: Ablynx, Astrazeneca-Medimmune, Bayer, Biogen, Boehringer, Bristol Myers Squibb, Celgene, Eli Lilly, EMD Serono, GlaxoSmithKline, Hoffmann-La Roche, Janssen, Merck, Novartis, Pfizer, R-Pharma, Sinergie, Sobi and UCB, Consultant of: NR has received honoraria for consultancies or speaker bureaus (< 10.000 USD each) from the following pharmaceutical companies in the past 3 years: Ablynx, Astrazeneca-Medimmune, Bayer, Biogen, Boehringer, Bristol Myers Squibb, Celgene, Eli Lilly, EMD Serono, GlaxoSmithKline, Hoffmann-La Roche, Janssen, Merck, Novartis, Pfizer, R-Pharma, Sinergie, Sobi and UCB, Grant/research support from: The IRCCS Istituto Giannina Gaslini (IGG), where NR works as full-time public employee has received contributions (>10.000 USD each) from the following industries in the last 3 years: Bristol Myers Squibb, Eli Lilly, F Hoffmann-La Roche, GlaxoSmithKline, Janssen, Novartis, Pfizer, Sobi. This funding has been reinvested for the research activities of the hospital in a fully independent manner, without any commitment with third parties., Grant Schulert Speakers bureau: Novartis, Consultant of: SOBI, Alyssa Sproles: None declared, Sherry Thornton: None declared, Gabriel Vega Cornejo Speakers bureau: AbbVie, Grant/research support from: Bristol Myers Squibb, Eli Lilly, Janssen, Parexel, Sanofi, Jordi Anton Speakers bureau: AbbVie, Gebro, GlaxoSmithKline, Novartis, Pfizer, Roche, Sobi, Consultant of: AbbVie, Gebro, GlaxoSmithKline, Novartis, Pfizer, Roche, Sobi, Grant/research support from: AbbVie, Amgen, Gebro, GlaxoSmithKline, Lilly, Novartis, Novimmune, Pfizer, Roche, Sanofi, Sobi, Ruben Cuttica Speakers bureau: AbbVie, Bristol Myers Squibb, GlaxoSmithKline, Lilly, Novartis, Pfizer, Roche, UCB, Paid instructor for: AbbVie, Novartis, Pfizer, Roche, Consultant of: AbbVie, Bristol Myers Squibb, GlaxoSmithKline, Lilly, Novartis, Pfizer, Roche, UCB, Michael Henrickson: None declared, Ivan Foeldvari Consultant of: Bristol Myers Squibb, Gilead, Hexal, MEDAC, Novartis, Pfizer, Sanofi, Daniel Kingsbury Consultant of: Pfizer, Margarita Askelson Consultant of: Currently working for Syneos Health providing services to Bristol Myers Squibb, Jinqi Liu Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Sumanta Mukherjee Shareholder of: Bristol Myers Squibb, GlaxoSmithKline, Employee of: Bristol Myers Squibb, GlaxoSmithKline, Robert Wong Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Daniel J Lovell Speakers bureau: Genentech, Wyeth Pharm, Consultant of: Abbott, Amgen, AstraZeneca, Boehringer Ingelheim, Celgene, GlaxoSmithKline, Hoffman-La Roche, Novartis, Pfizer, Regeneron, Takeda, UBC, Wyeth Pharma, Xoma, Alberto Martini Speakers bureau: AbbVie, Novartis, Consultant of: AbbVie, Eli Lilly, EMD Serono, Idorsia, Janssen, Novartis, Pfizer, Alexei Grom Consultant of: AB2Bio, Novartis, Sobi (NovImmune), Grant/research support from: AB2Bio, Novartis, Sobi (NovImmune), Hermine Brunner Speakers bureau: GlaxoSmithKline, Novartis, Pfizer, Roche, Paid instructor for: Novartis, Pfizer (funds go to CCHMC/employer), Consultant of: Boehringer Ingelheim, Bristol Myers Squibb, GlaxoSmithKline, Janssen, Merck, Novartis, Pfizer, Roche, UCB (funds go to CCHMC/employer), Grant/research support from: Bristol Myers Squibb, Pfizer (funds go to CCHMC/employer).

OP0290 EMAPALUMAB (ANTI-INTERFERON-GAMMA MONOCLONAL ANTIBODY) IN PATIENTS WITH MACROPHAGE ACTIVATION SYNDROME (MAS) COMPLICATING SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS (SJIA)

Background:

MAS is a severe complication of rheumatic diseases and occurs most frequently in patients with sJIA. Data from animal models and from observational studies in patients suggest that interferon gamma (IFNy) is a driver of the hyperinflammation and hypercytokinemia observed in MAS.

Objectives:

To assess the pharmacokinetics, efficacy, and safety of intravenous (IV) infusions of emapalumab, a fully human anti-IFNγ monoclonal antibody, in patients with MAS in the context of sJIA.

Methods:

This ongoing, pilot, open-label, single-arm study (NCT03311854) includes patients with MAS (2016 ACR/EULAR criteria) on a background of confirmed, or high presumption of, sJIA, and with inadequate response to high-dose IV glucocorticoids. Emapalumab is initiated at 6 mg/kg (1 dose) and continued at 3 mg/kg twice weekly for a total of 4 weeks, or less upon achievement of complete response (CR). CR is defined as an absence of MAS clinical signs plus white blood cell and platelet counts above the lower limit of normal, LDH, AST and ALT <1.5 x upper limit of normal, fibrinogen >100 mg/dL, and ferritin decreased by ≥80% or to <2,000 ng/mL.

Results:

We report preliminary data from the first 9 patients (median age [range] 11.6 [2.1-25.3] years) enrolled (7 in Europe and 2 in the USA). All patients had failed high-dose methylprednisolone, of which there were prior treatment failures from cyclosporin A (n=4) and from anakinra (n=4). Treatment with emapalumab resulted in rapid IFNγ neutralization, as demonstrated by the decrease in CXCL9 levels (Figure 1), and subsequent deactivation of T cells, as indicated by the decrease in sIL-2R levels. CR was achieved in all patients after a median of 23 (12-56) days. A progressive improvement in all clinical and laboratory parameters of MAS was observed (Table 1 and Figure 2). Glucocorticoids were tapered in all patients (median % tapering -92%; range -45% to -98% at Week 8). Emapalumab infusions were well tolerated by all patients, with no discontinuation. CMV reactivation was reported in 1 patient as a serious event possibly related to emapalumab and resolved with antiviral treatment.

Table 1.

Time to response for key clinical and laboratory parameters.

ParametersMedian baseline value (range)Median days of treatment (range)D-dimers to <1000 mg/L12,480 (550-89,552)15 (1-49)sIL-2R to <2000 ng/L4596 (1664-20,954)21 (6-37)Ferritin <500 mg/L29,240 (716-192,584)21 (9-42)Physician visual analog scale of MAS activity ≤19.0 (2-10)19 (9-56)All MAS laboratory parameters within range of CRNA21 (15-55)All MAS parameters within range of CRNA23 (12-56)Glucocorticoid tapering at ≤1 mg/kg prednisolone equivalent*NA42 (16-50)

*Data incomplete for 1 patient

Figure 1.

Rapid neutralization of IFNy. Each line represents an individual patient (n=9).

Figure 2.

Ferritin levels and platelet counts over time.

Conclusion:

Emapalumab administration led to rapid neutralization of IFNy and was efficacious in controlling MAS with a favorable safety profile. These results support the pathogenic role of IFNγ in MAS/sJIA and the therapeutic value of IFNγ neutralization in MAS patients who have failed standard of care.

Disclosure of Interests:

Fabrizio De Benedetti Grant/research support from: AbbVie, Pfizer, Novartis, Novimmune, Sobi, Sanofi, Roche, Speakers bureau: AbbVie, Novartis, Roche, Sobi, Paul Brogan Grant/research support from: Sobi, Novartis, Roche, Chemocentryx, Consultant of: Roche, Sobi, Speakers bureau: Sobi, Roche, Novartis, UCB, Claudia Bracaglia: None declared, Manuela Pardeo: None declared, Giulia Marucci: None declared, Emanuela Sacco: None declared, Despina Eleftheriou Speakers bureau: Sobi, Charalampia Papadopoulou: None declared, Alexei Grom Grant/research support from: Novartis, AB2Bio, Consultant of: Novartis, Pierre Quartier Consultant of: AbbVie, Chugai-Roche, Lilly, Novartis, Sanofi, Sobi, Speakers bureau: AbbVie, BMS, Chugai-Roche, Novartis, Pfizer, Sobi, Rayfel Schneider Grant/research support from: Roche, Novartis, Sobi, Pfizer, Consultant of: Sobi, Novartis, Novimmune, Philippe Jacqmin Consultant of: Sobi, Rikke Frederiksen Employee of: Sobi, Maria Ballabio Employee of: Sobi, Cristina De Min Employee of: Sobi

Algorithm development for corticosteroid management in systemic juvenile idiopathic arthritis trial using consensus methodology

BACKGROUND

The management of background corticosteroid therapy in rheumatology clinical trials poses a major challenge. We describe the consensus methodology used to design an algorithm to standardize changes in corticosteroid dosing during the Randomized Placebo Phase Study of Rilonacept in Systemic Juvenile Idiopathic Arthritis Trial (RAPPORT).

METHODS

The 20 RAPPORT site principal investigators (PIs) and 4 topic specialists constituted an expert panel that participated in the consensus process. The panel used a modified Delphi Method consisting of an on-line questionnaire, followed by a one day face-to-face consensus conference. Consensus was defined as ≥ 75% agreement. For items deemed essential but when consensus on critical values was not achieved, simple majority vote drove the final decision.

RESULTS

The panel identified criteria for initiating or increasing corticosteroids. These included the presence or development of anemia, myocarditis, pericarditis, pleuritis, peritonitis, and either complete or incomplete macrophage activation syndrome (MAS). The panel also identified criteria for tapering corticosteroids which included absence of fever for ≥ 3 days in the previous week, absence of poor physical functioning, and seven laboratory criteria. A tapering schedule was also defined.

CONCLUSION

The expert panel established consensus regarding corticosteroid management and an algorithm for steroid dosing that was well accepted and used by RAPPORT investigators. Developed specifically for the RAPPORT trial, further study of the algorithm is needed before recommendation for more general clinical use.

Clusters of life-threatening ventricular arrhythmias in patients with implanted cardioverter-defibrillators: prevalence, characteristics, and risk stratification

BACKGROUND

Series of discharges from an implanted defibrillator (ICD) to terminate life-threatening ventricular tachyarrhythmias are one particular aspect of energy use and success of ICD therapy. Little is known about prevalence. characteristics, and risk stratification of so-called "cluster arrhythmias."

HYPOTHESIS

The objective of this study was to examine the frequency of cluster arrhythmias, to characterize the temporal relationship precisely, and to assess the accompanying circumstances of their occurrence, whereby risk stratification was to be made if appropriate.

METHODS

In all, 63 consecutive patients were followed prospectively over 727 +/- 684 days to determine the presence and characteristics of cluster arrhythmias (45,801 patient days). In 30 patients, 374 ICD episodes of ventricular tachyarrhythmias were analyzed for their temporal relationship. After a first successfully terminated ventricular tachyarrhythmia, further ICD discharges within 3 h were observed during 145 of 374 (39%) episodes; mean time interval between these arrhythmias was 25 +/- 32 min.

RESULTS

Arrhythmia clusters occurred in 19 of 30 (63%) patients. In multivariate analysis, only underlying heart disease was predictive for accumulation of ventricular tachyarrhythmias. Cluster arrhythmias were more frequent among patients with ischemic heart disease than among those with nonischemic heart disease (40.0 vs. 29.2%, p < 0.05). Ejection fraction, age, gender, and other parameters were not predictive for occurrence of arrhythmia clusters. In 4 of 19 patients, accumulation of ICD discharges was predictive for new onset of myocardial ischemia elicited by exercise test.

CONCLUSIONS

Cluster arrhythmias are most common in patients with ICDs with coronary heart disease and may indicate disease progression and increasing instability, for example, due to new onset of myocardial ischemia.

Angiopoietin-like-4 is a potential angiogenic mediator in arthritis

Our previous studies of gene expression profiling during collagen-induced arthritis (CIA) indicated that the putative angiogenic factor Angptl4 was one of the most highly expressed mRNAs early in disease. To investigate the potential involvement of Angptl4 in CIA pathogenesis, Angptl4 protein levels were assessed at early stages of disease and its cellular sources were determined. In addition, the functional effects of mouse Angptl4 on endothelial cells were assessed. Angptl4 protein levels were higher in arthritic joints as compared to normal joints. In situ hybridization localized Angptl4 mRNA to stromal fibroblast-like cells within the inflamed synovium. Temporal expression of Angptl4 mRNA during CIA was similar to that of key angiogenic factors, including structurally related angiopoietin 1. Recombinant mouse Angptl4 promoted endothelial cell survival and formation of tubule-like structures. These functional effects of Angptl4, combined with very high expression at early stages of CIA, suggest a role for Angptl4 in angiogenesis in arthritis.

[New aspects of ICD therapy: from rhythm therapy to complex cardiac monitoring. Development of an implantable, ICD-assisted, intrathoracic 6-channel ECG for continuous monitoring of high infarct risk patients]

Implantable defibrillator systems (ICD) are therapy of choice for the treatment of life-threatening ventricular arrhythmias and in prevention of sudden cardiac death. In more than 80% of patients who receive an ICD, the underlying cardiac disease is a coronary heart disease. Since arrhythmogenic sudden cardiac death can be reliably prevented in these patients by the use of ICD technology, the cardiac prognosis for these patients is determined by the occurrence of myocardial ischemia and myocardial infarction, as well as from the heart failure which develops in consequence. An intrathoracic 6-channel ECG comparable to the standard surface ECG can be reconstructed by further technical development of the electrode configurations currently present in ICD systems. The importance of this development in early diagnosis of myocardial ischemias and myocardial infarction can hardly be adequately estimated at the moment. The chronic consequences of myocardial infarction can be completely prevented or at least greatly reduced by means of such diagnostics and inclusion of immediate initiation of effective, appropriate early therapeutic measures before more serious symptoms even occur. In the development and pilot studies thus far, it has been found that the intrathoracic 6-channel ECG which can be generated in the ICD is capable of reliably recognizing acute myocardial ischemia, irrespective of localization or extent earlier and better than the standard surface ECG. Continuous preventive ischemia monitoring using the implanted ICD thus appears possible in patients at risk of infarction.

[Acute myocardial ischemia and ventricular arrhythmias in the pathogenesis of sudden cardiac death in coronary disease]

There is increasing evidence for a fatal interaction of myocardial ischemia, ventricular arrhythmias and sudden cardiac death in some patients with coronary artery disease. Evidence comes from autopsy studies, from the evaluation of patients who survived an episode of sudden cardiac death, from follow-up data of these patients either treated or not by revascularization therapy and/or an implantable cardioverter-defibrillator and indicate that reducing the individual ischemic burden will be beneficial to reduce the incidence of sudden cardiac death. Studies in patients with stable and especially with unstable angina using Holter monitoring could demonstrate that there is a close and causal relationship between myocardial ischemia inducing or aggravating life-threatening ventricular arrhythmias and sudden cardiac death particularly in patients with unstable and postinfarction status. This review summarizes some of our clinical knowledge on this topic and indicates that preventive strategies for myocardial ischemia are the antiarrhythmic treatment of choice in patients with severe coronary artery disease and patients with evidence or at risk for ischemic proarrhythmia.

On the mechanism of protection of distal joints after local gene transfer in collagen-induced arthritis

Considerable interest has been generated by the observation that adenovirus-mediated gene delivery to a single arthritic joint results in suppression of arthritis in distal joints associated with the presence of small numbers of transduced cells in distal joints. It has been proposed that this is mediated by trafficking of transduced cells from the injected to distal joints. There are, however, alternative explanations that have not been explored, including the possibility that transgene protein or infectious virions circulate to distal sites. To investigate these possibilities, a replication-incompetent adenovirus encoding viral IL-10 (vIL-10) was administered to naive mice and to mice with collagen-induced arthritis by intraarticular, periarticular, or intravenous injection. In all cases, the ability to protect distal joints correlated with serum levels of vIL-10 protein. After intraarticular or intravenous injection, vIL-10 cDNA could be detected not only in distal joints, but also in the liver, which is the major target of circulating adenovirus, demonstrating that adenovirus circulating through the bloodstream is taken up by the joint tissue. Periarticular administration of adenovirus, which resulted in lower serum levels of vIL-10, protected only the injected paws and failed to induce trafficking immunoregulatory cells capable of suppressing distal disease. These observations suggest that circulating vIL-10 protein is the major mediator of distal protection. The presence of small numbers of transduced cells at distal sites can be accounted for by transduction of distal synovium after entry of adenovirus virions into the circulation.

Continuous monitoring of acute myocardial ischemia by the implantable cardioverter defibrillator

The present generation of implantable cardioverter defibrillators (ICDs) provides a very effective device for monitoring and treating life-threatening ventricular tachyarrhythmia. Patients at risk of sudden cardiac death who are directed to this form of treatment usually have severe coronary artery disease, previous myocardial infarction, and low ejection fraction. Progression of the underlying heart disease predisposes these patients to subsequent ischemic events, including symptomatic and asymptomatic myocardial ischemia and reinfarction, which carry a substantial risk of fatal ventricular proarrhythmia. Multipolar lead configurations presently available in the ICD appear to be effective in assessing acute myocardial ischemia as induced by exercise testing or transient coronary artery occlusion. Continuous monitoring of myocardial ischemia (COMONI) by a sophisticated, multimodal ICD appears to be feasible, may offer the means to closely supervise progression and various complications of the underlying heart disease, and may help to guide automatic or interactive antiischemic treatment.

[Mucosal antrectomy with truncal vagotomy in duodenal ulcer resection to exclude the pylorus)]

The duodenal ulcers with which the surgeon is confronted increasingly take on tumoural postbulbar forms, penetrating in the pancreas or liver pedicle. Such a duodenal stump can neither be anastomized to the residual stomach ulcer inversed safely. Therefore it has become increasingly necessary to find a tight inversion method. One of the authors (D. Gavriliu) updated mucous antrectomy + truncular vagotomy and Reichel-Polya gastrectomy, which leaves an adequate seromuscular cuff for a double closing suture of the duodenum; after ablation of the antral mucosa the patient benefits by a veritable humoral antrectomy. In point of fact the operation is increasingly applied (truncular vagotomy + antrectomy and Reichel-Polya gastrectomy), with the difference however that antrectomy only removes the mucosa, and the advantage of ensuring perfect closure of the duodenal stump.

Blood enzyme activities in different breeds of geese

1. Enzyme activities were studied in blood plasma from Rhenish, Italian, Landes and Masseubian geese. 2. Strains used for liver production (Landes, Masseubian) showed higher activities of aspartate transaminase (AST) [EC 2.6.1.1], alanine transaminase (ALT) [EC 2.6.1.2] and fructose aldolase (FRA) [EC 4.1.2.13] while breeds with high egg production (Rhenish, Italian) had higher activities of both alkaline phosphatase (ALP) [EC 3.1.3.1] and acid phosphatase (ACP) [EC 3.1.3.2]