POS0007 HLA-DQ2 IS ASSOCIATED WITH ANTI-DRUG ANTIBODY FORMATION TO INFLIXIMAB ACROSS IMMUNE-MEDIATED INFLAMMATORY DISEASES

Background

Immunogenicity is a leading cause of treatment failure to TNF inhibitors, and also affects drug safety. Variations in HLA class II genes have been suggested to predispose to anti-drug antibody formation (ADA), but characterisation of biologically relevant HLA haplotypes, based on high-resolution genotyping, is lacking.

Objectives

To assess associations between HLA loci and formation of ADA to infliximab across different immune mediated inflammatory diseases.

Methods

Patients with immune mediated inflammatory diseases on infliximab therapy (N=612; 181 spondyloarthritis, 120 rheumatoid arthritis, 72 psoriatic arthritis, 114 ulcerative colitis, 80 Crohn’s disease and 45 psoriasis) participating in the Norwegian Drug Monitoring (NOR-DRUM) trials (1, 2) were included in the present analyses. Neutralising ADA were assessed with an automated fluorescence assay at each infusion. Next generation sequencing-based HLA typing was performed. Associations with ADA formation were assessed at locus, allele, haplotype and amino acid level. Peptide binding predictions for infliximab were performed.

Results

ADA were detected in 147 patients (24%). Significant associations were shown between ADA and several HLA loci, whereas conditional analyses indicated HLA-DQB1 (p=1.4x10-6) as the primary risk locus. Highest risk of ADA formation was seen for patients carrying at least one of the HLA-DQ2 haplotypes; DQB1*02:01~DQA1*05:01 and DQB1*02:02~DQA1*02:01 (OR 3.18, 95% CI 2.15 to 4.69, p=5.9x10-9) (Figure 1). These findings were consistent across diagnoses (Table 1), and remained significant when adjusting for other possible predictors of ADA. Computational predictions indicated that both these HLA-DQ2 haplotypes could strongly bind two peptide motifs (INTVESEDI and VYACEVTHQ) in the infliximab heavy and light chain.

Table 1.

HLA-DQ2 carrier frequencies according to the different disease phenotypes and for all diagnosis combined

DiagnosisHLA-DQ2 carrier-frequency among patients with ADA formationHLA-DQ2 carrier-frequency among patients without ADA formationP-valueRA (N=120)0.3160.1340.02PsA (N=72)0.550.2310.01SpA (N=181)0.3640.1820.02UC (N=114)0.5560.2640.006CD (N=80)0.4290.3030.33Ps (N=45)0.8670.2670.0004All disease phenotypes0.4690.2175.9x10-9

Conclusion

The risk of ADA to infliximab was three-fold higher in patients carrying the HLA-DQ2 risk haplotypes across diseases. A biological role for the HLA-DQ2 molecules encoded by the two different HLA-DQ2 risk haplotypes in the formation of ADA was further supported by peptide binding predictions. These novel findings provide promise for future incorporation of HLA-DQ2 testing to facilitate personalised treatment decisions.

References

[1]Syversen SW et al. Jama. 2021;326(23):2375-84.

[2]Syversen SW et al. Jama. 2021;325(17):1744-54.

Disclosure of Interests

Marthe Kirkesæther Brun: None declared, Kristin Hammersbøen Bjørlykke: None declared, Marte K. Viken: None declared, Bitte Stenvik Employee of: is a former employee of UCB Pharma, Rolf A. Klaasen: None declared, Johanna Gehin: None declared, David J Warren: None declared, Joe Sexton: None declared, Øystein Sandanger: None declared, Cato Mørk Speakers bureau: Novartis Norway, LEO Pharma, ACO Hud Norge, Cellgene, Abbvie, and Galderma Nordic AB., Consultant of: Novartis Norway, LEO Pharma, ACO Hud Norge, Cellgene, Abbvie, and Galderma Nordic AB., Tore K. Kvien Speakers bureau: Amgen, Celltrion, Evapharma, Gilead, Hikma, Mylan, Oktal, Pfizer, Sandoz, Sanofi, UCB, Consultant of: Amgen, Celltrion, Evapharma, Gilead, Hikma, Mylan, Oktal, Pfizer, Sandoz, Sanofi, UCB, Grant/research support from: AbbVie, Amgen, BMS, Novartis, Pfizer, UCB, Espen A Haavardsholm Speakers bureau: Pfizer, AbbVie, Celgene, Novartis, Janssen, Gilead, Eli-Lilly, and UCB, Consultant of: Pfizer, AbbVie, Celgene, Novartis, Janssen, Gilead, Eli-Lilly, and UCB, Jørgen Jahnsen Speakers bureau: AbbVie, Boerhinger Ingelheim, BMS, Celltrion, Giliad, Hikma, Janssen Cilag, Novartis, Orion Pharma, Pfizer, Roche, Takeda, and Sandoz, Consultant of: AbbVie, Boerhinger Ingelheim, BMS, Celltrion, Giliad, Hikma, Janssen Cilag, Novartis, Orion Pharma, Pfizer, Roche, Takeda, and Sandoz, Guro Løvik Goll Speakers bureau: Pfizer, AbbVie, Boehringer Ingelheim, Roche, Orion pharma, Sandoz, Novartis, and UCB, Consultant of: Pfizer, AbbVie, Boehringer Ingelheim, Roche, Orion pharma, Sandoz, Novartis, and UCB, Benedicte A. Lie: None declared, Kristin Kaasen Jørgensen Speakers bureau: Roche, BMS, Celltrion, and Norgine., Consultant of: Roche, BMS, Celltrion, and Norgine., Nils Bolstad Speakers bureau: Roche Pharmaceuticals and Novartis, Consultant of: Janssen, Silje Watterdal Syversen: None declared

OP0017 THERAPEUTIC DRUG MONITORING COMPARED TO STANDARD TREATMENT OF PATIENTS STARTING INFLIXIMAB THERAPY: RESULTS FROM A MULTICENTRE RANDOMISED TRIAL OF 400 PATIENTS

Background:

A lack or loss of response to TNFα inhibitors (TNFi) has been associated with low serum drug levels and formation of anti-drug antibodies (ADAb). Therapeutic drug monitoring (TDM), an individualised treatment strategy based on regular assessments of serum drug levels, has been suggested to optimise efficacy of TNFi. It is still unclear if TDM improves clinical outcomes, and the value of TDM has recently been included in the research agenda across different specialities. This first randomised controlled trial on the effectiveness of TDM in a range of immune mediated inflammatory diseases including rheumatic diseases, the NORwegian DRUg Monitoring trial part A (NOR-DRUM (A)) focus on the induction period of infliximab (INX) treatment.

Objectives:

To assess if TDM is superior to standard treatment in order to achieve remission in patients starting INX.

Methods:

In the investigator-initiated, randomised, open-label, multicentre NOR-DRUM (A) study, adult patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), spondyloarthritis (SpA), ulcerative colitis (UC), Crohn’s disease (CD) and psoriasis (Ps) starting INX therapy were randomly assigned to administration of INX according to a treatment strategy based on TDM (TDM arm) or to standard administration of INX without TDM (control arm). Study visits were conducted at each infusion. The primary endpoint was remission at week 30. In the TDM arm, the dose and interval were adjusted according to INX trough levels to reach the therapeutic range (Figure 1). If the patient developed significant levels of ADAb, INX was terminated. To guide the investigators, the TDM strategy was integrated in an interactive eCRF. The primary endpoint was analysed by mixed effect logistic regression in the full analyses set (FAS), adjusting for diagnoses. Infections and infusion reactions were specified as adverse events (AEs) of special interest.

Clinical trial.gov:NCT03074656

Results:

We enrolled 411 patients at 21 study centres between January 2017 and December 2018. 398 patients (RA 80, PsA 42, SpA 117, UC 80, CD 57, Ps 22) received the allocated strategy and were included in the FAS population. Demographic and baseline characteristics were comparable in both arms. TDM was not found to be superior to standard treatment with regard to the primary outcome. Remission at week 30 was reached in 100 (53%) and 106 (54%) of the patients in the TDM and control arm, respectively (adjusted difference, 1.5%; 95% confidence interval (CI), -8.2 to 11.1, p=0.78) (Figure 2). Consistent results were shown for all the secondary endpoints (Figure 3) and in the sensitivity analyses. Twenty patients (10%) in the TDM arm and 30 patients (15%) in the control arm developed significant levels of ADAb. The number of adverse events (AE) was similar in both groups, however infusion reactions were less frequent (5 patients (2.5%) vs 16 patients (8.0%)) in the TDM arm (difference 5.5% (95% CI 1.1, 9.8%))

Conclusion:

NOR-DRUM (A) is the first randomised trial to address effectiveness of TDM in the induction period of TNFi treatment, and the first trial to address TDM in rheumatic diseases. In this study, TDM was not superior to standard treatment in order to achieve remission. Although improved safety is indicated by a reduction in infusion reactions, implementation of TDM as a general strategy in the induction period of INX is not supported by the NOR-DRUM (A) study.

Disclosure of Interests:

Silje Watterdal Syversen Speakers bureau: Roche, Thermo Fisher, Guro Løvik Goll Consultant of: Novartis, Pfizer, Speakers bureau: Abbvie, Biogen, Boehringer Ingelheim, Orion Pharma, Eli Lilly, Novartis, Pfizer, MSD, Roche, UCB, Kristin Kaasen Jørgensen Consultant of: AOP Orphan, Celltrion, Sandoz, Speakers bureau: Norgine, Tillots, Øystein Sandanger: None declared, Joe Sexton: None declared, Inge Olsen: None declared, Johanna Gehin Speakers bureau: Roche, Marthe Kirksæther Brun: None declared, David Warren: None declared, Cato Mørk Consultant of: Abbot, Novartis, Celagene, Almiral, Galderma, ACO, Almiral, ACO, Speakers bureau: Novartis, Abbott, Abbvie, Celegene, LEO, Almiral, Galderma, Tore K. Kvien Grant/research support from: Received grants from Abbvie, Hospira/Pfizer, MSD and Roche (not relevant for this abstract)., Consultant of: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Paid instructor for: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Speakers bureau: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Jørgen Jahnsen Consultant of: AbbVie, Boerhinger Ingelheim, Celltrion, Ferring, Janssen, Meda, MSD, Norgine, Novartis, Orion Pharma, Pfizer, Pharmacosmos, Takeda, and Sandoz., Speakers bureau: AbbVie, Astro Pharma, Boerhinger Ingelheim, BMS, Celltrion, Ferring, Hikma, Janssen, Meda, MSD, Napp Pharma, Orion Pharma, Pfizer, Pharmacosmos, Roche, Takeda, Tillotts and Sandoz, Nils Bolstad Consultant of: Pfizer, Janssen, Speakers bureau: Orion Pharma, Napp Pharmaceuticals, Takeda, Roche, Novartis, Espen A Haavardsholm Grant/research support from: AbbVie, UCB Pharma, Pfizer Inc, MSD Norway, Roche Norway, Consultant of: Pfizer, AbbVie, Janssen-Cilag, Gilead, UCB Pharma, Celgene, Lilly, Paid instructor for: UCB Pharma, Speakers bureau: Pfizer, AbbVie, UCB Pharma, Celgene, Lilly, Roche, MSD