Real-world evaluation of persistence, effectiveness and usage patterns of tofacitinib in treatment of psoriatic arthritis in Australia

OBJECTIVES

To describe treatment patterns and persistence of tofacitinib, interleukin 17 inhibitors (IL-17Ai) and tumour necrosis factor inhibitors (TNFi), in patients with psoriatic arthritis (PsA).

METHODS

Data from adult patients with PsA and who had received at least one prescription of tofacitinib, IL-17Ai or TNFi between May 2019 and September 2021 were sourced from the Australian OPAL dataset. Persistence, analysed via Kaplan-Meier methods, and propensity score matching between tofacitinib and bDMARD (IL-17Ai and TNFi) groups were conducted.

RESULTS

Of 16,692 patients with PsA, 1486 (n = 406 tofacitinib, n = 416 IL-17Ai and n = 664 TNFi) were included. More females were in the tofacitinib group (75.4%) than in the IL-17Ai (61.1%) and TNFi (64.8%) groups. Overall, 19.2% of tofacitinib patients were first line, compared with 41.8% of IL-17Ai and 62.8% of TNFi patients. In the overall population, the median persistence was 16.5 months (95% CI 13.8 to 19.5 months), 17.7 months (95% CI 15.8 to 19.6 months) and 17.2 months (95% CI 14.9 to 20.5 months) in the tofacitinib, IL-17Ai and TNFi groups, respectively. Persistence was similar in the tofacitinib/IL-17Ai matched population; however, in the tofacitinib/TNFi matched population, persistence was longer in the tofacitinib group (18.7 months, 95% CI 15.6 to 21.4 months) compared with the TNFi group (12.2 months, 95% CI 19.9 to 14.9 months).

CONCLUSIONS

In this Australian real-world dataset, tofacitinib was more frequently used in later lines and among a slightly higher proportion of female patients than IL-17Ai or TNFi. Overall, treatment persistence was similar for tofacitinib, IL-17Ai and TNFi, but tofacitinib exhibited longer persistence than TNFi in a matched population. Key Points • This is the first, large real-world study from Australia investigating the demographics, treatment patterns and comparative treatment persistence of patients with psoriatic arthritis (PsA) treated with tofacitinib and biologic disease-modifying drugs (bDMARDs). • The study suggests that tofacitinib is an effective intervention in PsA with at least comparable persistence to bDMARDs: tumour necrosis factor inhibitors (TNFi) and interleukin-17 A inhibitors (IL-17Ai).

Sorafenib plus intensive chemotherapy in newly diagnosed FLT3-ITD AML: a randomized, placebo-controlled study by the ALLG

Sorafenib maintenance improves outcomes after hematopoietic cell transplant (HCT) for patients with FMS-like tyrosine kinase 3-internal tandem duplication (FLT3-ITD) acute myeloid leukemia (AML). Although promising outcomes have been reported for sorafenib plus intensive chemotherapy, randomized data are limited. This placebo-controlled, phase 2 study (ACTRN12611001112954) randomized 102 patients (aged 18-65 years) 2:1 to sorafenib vs placebo (days 4-10) combined with intensive induction: idarubicin 12 mg/m2 on days 1 to 3 plus either cytarabine 1.5 g/m2 twice daily on days 1, 3, 5, and 7 (18-55 years) or 100 mg/m2 on days 1 to 7 (56-65 years), followed by consolidation and maintenance therapy for 12 months (post-HCT excluded) in newly diagnosed patients with FLT3-ITD AML. Four patients were excluded in a modified intention-to-treat final analysis (3 not commencing therapy and 1 was FLT3-ITD negative). Rates of complete remission (CR)/CR with incomplete hematologic recovery were high in both arms (sorafenib, 78%/9%; placebo, 70%/24%). With 49.1-months median follow-up, the primary end point of event-free survival (EFS) was not improved by sorafenib (2-year EFS 47.9% vs 45.4%; hazard ratio [HR], 0.87; 95% confidence interval [CI], 0.51-1.51; P = .61). Two-year overall survival (OS) was 67% in the sorafenib arm and 58% in the placebo arm (HR, 0.76; 95% CI, 0.42-1.39). For patients who received HCT in first remission, the 2-year OS rates were 84% and 67% in the sorafenib and placebo arms, respectively (HR, 0.45; 95% CI, 0.18-1.12; P = .08). In exploratory analyses, FLT3-ITD measurable residual disease (MRD) negative status (<0.001%) after induction was associated with improved 2-year OS (83% vs 60%; HR, 0.4; 95% CI, 0.17-0.93; P = .028). In conclusion, routine use of pretransplant sorafenib plus chemotherapy in unselected patients with FLT3-ITD AML is not supported by this study.

POS1019 REAL-WORLD EVALUATION OF TREATMENT PATTERNS AND PERSISTENCE OF TOFACITINIB IN TREATMENT OF PSORIATIC ARTHRITIS IN AUSTRALIA: AN ANALYSIS OF THE OPAL DATASET

Background

Tofacitinib (TOF), a potent selective inhibitor of Janus kinase (JAK), is an approved treatment of psoriatic arthritis (PsA). In Australia, patients with active PsA despite six months of therapy with a pre-specified combination of csDMARDs are eligible to receive subsidised b/tsDMARDs. The clinician can prescribe the b/tsDMARD they deem to be the most clinically appropriate for the patient. Limited data exist to describe the real-world treatment patterns, characteristics and clinical outcomes of patients with PsA who receive TOF in the real-world setting.

Objectives

To describe real-world treatment patterns and treatment persistence among patients with PsA treated with TOF in the Australian post-approval setting using the OPAL dataset.

Methods

The OPAL dataset is a collection of deidentified clinical data derived from the electronic medical records of 112 rheumatologists at 43 sites around Australia. Adult patients with a diagnosis of PsA who received at least one prescription of TOF, a tumour necrosis factor inhibitor (TNFi) or an interleukin 17 inhibitor (IL-17Ai) between May 2019 and Sept 2020 were eligible, with data up to Sept 2021 included in the analysis. Results were summarised descriptively. Treatment persistence was summarised using Kaplan-Meier methods.

Results

Of 16,692 patients with PsA identified in the OPAL dataset, 1,486 (TOF n=406, IL-17Ai n=416, and TNFi n=664) were eligible for inclusion in this study. At the time of treatment initiation, the mean (SD) age of TOF, IL-17Ai and TNFi treated patients was 55.56 (12.68), 52.65 (12.72) and 50.32 (14.57) years, respectively. 19.2% of patients receiving TOF were first line compared with 41.8% of IL-17Ai and 62.8% of TNFi treated patients. The mean (SD) time from symptom onset to treatment initiation was longest for patients receiving TOF in first line (153.29 (127.50) months) compared to first line IL-17Ai (116.83 (113.97) months) and TNFi treated patients (92.37 (89.01) months). Overall, 34.2% of TOF, 32.9% of IL-17Ai and 26.4% of TNFi treated patients initiated therapy without concomitant cDMARDs being recorded.

Overall median persistence was 16.54 months (95% CI 13.84, 19.53) for TOF treated patients, 17.65 months (95% CI, 15.75, 19.56) for IL-17Ai treated patients and 17.16 months (95% CI 14.86, 20.48) for TNFi treated patients. As expected, persistence was generally longer in patients treated as first line (Figure 1) with patients receiving TOF observed to have slightly higher persistence in the first 15 months of treatment.

Figure 1.

Treatment persistence of patients receiving TOF, IL-17Ai and TNFi as first line therapy. Plot curtailed at 15 months as relatively few patients have information past this point. Where no stop date was recorded, censoring occurs at last recorded visit

Conclusion

In this analysis of a large Australian real-world dataset, TOF was more commonly utilised as a later line therapy for patients with PsA. Patients receiving TOF were observed to have slightly higher persistence within the first 15 months of starting first line therapy in this preliminary analysis.

Acknowledgements

The authors acknowledge the members of OPAL Rheumatology Ltd and their patients for providing clinical data for this study, and Software4Specialists Pty Ltd for providing the Audit4 platform. Financial support was provided by Pfizer Australia

Disclosure of Interests

Geoff Littlejohn Consultant of: Abbvie, Janssen, Bristol Myers Squibb, Gilead, Eli Lilly, and MSD, Jo Leadbetter: None declared, Belinda Butcher: None declared, Marie Feletar: None declared, Catherine OSullivan: None declared, Tegan Smith: None declared, David Witcombe Employee of: Pfizer Australia, Ho Yin Employee of: Pfizer Australia, Peter Youssef Speakers bureau: AbbVie, Novartis, Janssen and Eli Lilly

The use of the mannitol test as an outcome measure in asthma intervention studies: a review and practical recommendations

BACKGROUND

The mannitol test is an indirect bronchial challenge test widely used in diagnosing asthma. Response to the mannitol test correlates with the level of eosinophilic and mast cell airway inflammation, and a positive mannitol test is highly predictive of a response to anti-inflammatory treatment with inhaled corticosteroids. The response to mannitol is a physiological biomarker that may, therefore, be used to assess the response to other anti-inflammatory treatments and may be of particular interest in early phase studies that require surrogate markers to predict a clinical response. The main objectives of this review were to assess the practical aspects of using mannitol as an endpoint in clinical trials and provide the clinical researcher and respiratory physician with recommendations when designing early clinical trials.

METHODS

The aim of this review was to summarise previous uses of the mannitol test as an outcome measure in clinical intervention studies. The PubMed database was searched using a combination of MeSH and keywords. Eligible studies included intervention or repeatability studies using the standard mannitol test, at multiple timepoints, reporting the use of PD₁₅ as a measure, and published in English.

RESULTS

Of the 193 papers identified, 12 studies met the inclusion criteria and data from these are discussed in detail. Data on the mode of action, correlation with airway inflammation, its diagnostic properties, and repeatability have been summarised, and suggestions for the reporting of test results provided. Worked examples of power calculations for dimensioning study populations are presented for different types of study designs. Finally, interpretation and reporting of the change in the response to the mannitol test are discussed.

CONCLUSIONS

The mechanistic and practical features of the mannitol test make it a useful marker of disease, not only in clinical diagnoses, but also as an outcome measure in intervention trials. Measuring airway hyperresponsiveness to mannitol provides a novel and reproducible test for assessing efficacy in intervention trials, and importantly, utilises a test that links directly to underlying drivers of disease.

Efficacy and safety of inhaled dry-powder mannitol in adults with cystic fibrosis: An international, randomized controlled study

BACKGROUND

Mannitol is a mucoactive hyperosmotic agent used as add-on therapy in patients with cystic fibrosis (CF), administered twice-daily (BID) via a small, portable, breath-actuated dry-powder inhaler. This study was conducted to provide confirmatory evidence of mannitol's efficacy and safety in adults.

METHODS

This multicenter, double-blind, randomized, parallel-group, controlled clinical trial recruited adults (aged ≥18 years) with CF, and forced expiratory volume in 1 second (FEV₁) 40-90% predicted. Subjects received either mannitol 400 mg or mannitol 50 mg (control), BID via dry-powder inhaler for 26 weeks. Primary endpoint: FEV₁ averaged over the 26-week treatment period.

RESULTS

Of 423 subjects randomized (209 or 214 receiving mannitol 400 mg BID or control, respectively), 373 (88.2%) completed the study, with a similar proportion completing in the two groups. For FEV₁ averaged over 26 weeks, mannitol 400 mg BID was statistically superior to control (adjusted mean difference 54 mL [95% CI 8, 100 mL]; p = 0.020). This was supported by sensitivity analyses of the primary endpoint, and by observed improvements in secondary pulmonary function endpoints (eg, absolute adjusted mean difference in percent predicted FEV₁ averaged over 26 weeks 1.21% [0.07%, 2.36%]; p = 0.037). Adverse events were mainly mild or moderate in severity, with treatment-related adverse events in 15.5 and 12.2% of subjects receiving mannitol 400 mg BID and control, respectively.

CONCLUSIONS

In adults with CF, mannitol 400 mg BID inhaled as a dry-powder statistically significantly improved lung function (FEV₁) compared with control, with this improvement supported by sensitivity analyses and secondary pulmonary function endpoints. Mannitol had a good overall safety and tolerability profile. ClinicalTrials.gov: NCT02134353.

Cost Effectiveness of Inhaled Mannitol (Bronchitol®) in Patients with Cystic Fibrosis

BACKGROUND

Inhaled mannitol (Bronchitol^®) is licensed in Australia as a safe and efficacious addition to best supportive care in patients with cystic fibrosis.

OBJECTIVE

The objective of this study was to assess the cost effectiveness of inhaled mannitol (in addition to best supportive care) in the Australian setting from the perspective of a government-funded national healthcare system.

METHODS

A probabilistic patient-level simulation Markov model estimated life-time costs and outcomes of mannitol when added to best supportive care, compared with best supportive care alone in patients aged 6 years and older. We estimated treatment-related inputs (initial change in percentage of predicted forced expiratory volume, relative reduction in severe pulmonary exacerbations, and treatment discontinuations) from two phase III trials. Longer term natural history rates of predicted forced expiratory volume decline over time and severe pulmonary exacerbation rates for best supportive care were taken from Australian CF registries. The utility value for the cystic fibrosis health state was as measured in the trials using the Health Utility Index, whereas the impact of pulmonary exacerbations and lung transplantation on utility was ascertained from the published literature. The underlying cost of managing cystic fibrosis, and the cost associated with pulmonary exacerbations and transplantations was taken from published Australian sources.

RESULTS

The addition of inhaled mannitol to best supportive care resulted in a discounted cost per quality-adjusted life-year of AU$39,165. The result was robust with 77% of probabilistic sensitivity analysis samples below a willingness-to-pay threshold of AU$45,000/quality-adjusted life-year.

CONCLUSION

Benchmarked against an implicit Australian willingness-to-pay threshold for life-threatening diseases, our model suggests inhaled mannitol provides a cost-effective addition to best supportive care in patients with cystic fibrosis, irrespective of concomitant dornase alfa use.

Response and relapse in patients with schizophrenia treated with olanzapine, risperidone, quetiapine, or haloperidol: 12-month follow-up of the Intercontinental Schizophrenia Outpatient Health Outcomes (IC-SOHO) study

OBJECTIVE

The primary aim of this study was to compare the effectiveness of 12 months' treatment with olanzapine, risperidone, quetiapine, or haloperidol in preventing relapse of schizophrenia. The study also examined other measures of clinical effectiveness and tolerability.

METHOD

Outpatients with schizophrenia (ICD-10 or DSM-IV), who initiated or changed antipsychotic treatment, entered this 3-year, naturalistic, prospective, observational study between November 2000 and December 2001. At baseline, subsets of patients were prescribed monotherapy with olanzapine (N = 3222), risperidone (N = 1116), quetiapine (N = 189), or haloperidol (N = 256). Patients remaining on monotherapy were assessed using the Clinical Global Impression-Schizophrenia scale. Relapse rate was determined from the responder subset. Treatment patterns, patient perception of treatment compliance, substance and alcohol intake patterns, and treatment tolerability were recorded. Results are based on 12-month treatment data.

RESULTS

Compared to haloperidol-treated patients, olanzapine- and risperidone-treated patients had approximately 3 to 4 times higher odds of response at 12 months (p <or= .001) and 6 times lower odds of relapse (p <or= .001 for olanzapine-treated patients). Among patients treated with atypical antipsychotics, olanzapine- and risperidone-treated patients had lower odds of relapse (although the difference was not significant at p <or= .001) and significantly higher odds of response (p <or= .001) compared to quetiapine-treated patients. The tolerability profile generally favored the atypical antipsychotics over haloperidol.

CONCLUSION

These interim results support the findings of randomized controlled trials and verify that in this naturalistic study, patients treated with olanzapine or risperidone monotherapy were less likely to experience relapse than patients who received haloperidol. The clinical effectiveness and tolerability profile varied significantly between the atypical antipsychotics.

[Latin America: clinical responses to the antipsychotic drugs]

OBJECTIVE

To compare the effectiveness of a 12 months antipsychotic monotherapy treatment with Olanzapine, risperidone and an atypical antipsychotic drug in Latin American patients with schizophrenia.

METHOD

The outcomes of effectiveness and tolerability were evaluated in outpatients with schizophrenia belonging to a large sample (N=7658) in a prospective, international trial carried out in 27 countries. The results for the population of Latin America were presented.

RESULTS

The probabilities of response were higher for Olanzapine than Risperidone and the atypical antipsychotic drugs. (p < or = 0.05) and for risperidone compared with the atypical antipsychotic drugs. (p < or = 0.05). Olanzapine was better tolerated as regarding the extrapiramidals symptoms and the sexual disfunction, although it was associated to a higher weight gain, as compared to the other groups of the trial.

CONCLUSION

the trial indicated that in the Latin American patients with schizophrenia, it is likely that Olanzapine induces clinical responses and has lower incidences on side effects, when compared with risperidone or atypical antipsychotic drugs.

Pharmacokinetic Drug Interactions of Gefitinib with Rifampicin, Itraconazole and Metoprolol

BACKGROUND AND OBJECTIVES

Gefitinib (IRESSA, ZD1839), an epidermal growth factor receptor tyrosine kinase inhibitor, has been approved in several countries for the treatment of advanced non-small-cell lung cancer. Preclinical studies were conducted to determine the cytochrome P450 (CYP) isoenzymes involved in the metabolism of gefitinib and to evaluate the potential of gefitinib to cause drug interactions through inhibition of CYP isoenzymes. Based on these findings, three clinical studies were carried out to investigate pharmacokinetic drug interactions in vivo with gefitinib.

METHODS

In preclinical studies radiolabelled gefitinib was incubated with: (i) hepatic microsomal protein in the presence of selective CYP inhibitors; and (ii) expressed CYP enzymes. Human hepatic microsomal protein was incubated with selective CYP substrates in the presence of gefitinib. Clinical studies were all phase I, open-label, single-centre studies; two had a randomised, two-way crossover design and the third was nonrandomised. The first and second studies investigated the pharmacokinetics of gefitinib in the presence of a potent CYP3A4 inducer (rifampicin [rifampin]) or inhibitor (itraconazole) in healthy male volunteers. The third study investigated the effects that gefitinib had on the pharmacokinetics of metoprolol, a CYP2D6 substrate, in patients with solid tumours.

RESULTS

The results of preclinical studies demonstrated that CYP3A4 is involved in the metabolism of gefitinib and that gefitinib is a weak inhibitor of CYP2D6 activity. In clinical studies when gefitinib was administered in the presence of rifampicin, geometric mean (gmean) maximum concentration and area under the plasma concentration-time curve (AUC) were reduced by 65% and 83%, respectively; these changes were statistically significant. When gefitinib was administered in the presence of itraconazole, gmean AUC increased by 78% and 61% at gefitinib doses of 250 and 500 mg, respectively; these changes also being statistically significant. Coadministration of metoprolol with gefitinib resulted in a 35% increase in the metoprolol area under plasma concentration-time curve from time zero to the time of the last quantifiable concentration; this change was not statistically significant. There was no apparent change in the safety profile of gefitinib as a result of coadministration with other agents.

CONCLUSIONS

Although CYP3A4 inducers may reduce exposure to gefitinib, further work is required to define any resultant effect on the efficacy of gefitinib. Exposure to gefitinib is increased by coadministration with CYP3A4 inhibitors, but since gefitinib is known to have a good tolerability profile, a dosage reduction is not recommended. Gefitinib is unlikely to exert a clinically relevant effect on the pharmacokinetics of drugs that are dependent on CYP2D6-mediated metabolism for their clearance, but the potential to increase plasma concentrations should be considered if gefitinib is coadministered with CYP2D6 substrates that have a narrow therapeutic index or are individually dose titrated.

Bayesian decision procedures for dose-escalation based on evidence of undesirable events and therapeutic benefit

In this paper, Bayesian decision procedures are developed for dose-escalation studies based on bivariate observations of undesirable events and signs of therapeutic benefit. The methods generalize earlier approaches taking into account only the undesirable outcomes. Logistic regression models are used to model the two responses, which are both assumed to take a binary form. A prior distribution for the unknown model parameters is suggested and an optional safety constraint can be included. Gain functions to be maximized are formulated in terms of accurate estimation of the limits of a 'therapeutic window' or optimal treatment of the next cohort of subjects, although the approach could be applied to achieve any of a wide variety of objectives. The designs introduced are illustrated through simulation and retrospective implementation to a completed dose-escalation study.

Magnetic resonance imaging measurements of the response of murine and human tumors to the vascular-targeting agent ZD6126

PURPOSE

ZD6126 is a novel vascular targeting agent currently undergoing clinical evaluation. It acts by destabilizing the microtubulin of fragile and proliferating neoendothelial cells in tumors. The drug leads to blood vessel congestion, the selective destruction of the vasculature, and extensive necrosis in experimental tumors. The aim of the study reported here was to assess the ability of dynamic contrast enhanced magnetic resonance imaging (MRI) to measure the antivascular effects of ZD6126 in tumors.

EXPERIMENTAL DESIGN

The work was carried out in mice bearing C38 colon adenocarcinoma and in patients with advanced cancers. MRI was performed before and 6 h (human tumors) or 24 h (C38 tumors) after i.v. drug administration. Contrast agent (gadolinium diethylenetriaminepentaacetate) enhancement was characterized by the initial area under the gadolinium diethylenetriaminepentaacetate uptake versus time curve (IAUC). IAUC reflects blood flow, vascular permeability, and the fraction of interstitial space.

RESULTS

The median IAUC was reduced in all C38 tumors after ZD6126 administration [by 6-48% at 50 mg/kg (n = 3)], 58-91% at 100 mg/kg (n = 4), and 11-93% at 200 mg/kg (n = 6). In contrast, the administration of vehicle only led to no consistent change in median IAUC (n = 4). The ZD6126-induced changes in median IAUC appeared to be dose dependent (P = 0.045). No ZD6126-induced changes were apparent in murine muscle. Similar effects were seen in preliminary data from human tumors (11 tumors studied, 9 patients). At doses of 80 mg/m(2) and higher, the median IAUC post-ZD6126 treatment was reduced in all of the tumors studied (8 tumors, 6 patients) to 36-72% from the baseline value. There was a significant trend of increasing reductions with increasing exposure (P < 0.01). No drug-induced changes in human muscle or spleen IAUC were apparent. The reproducibility of the median IAUC parameter was investigated in patients. In 19 human tumors (measured in 19 patients) inter- and intratumor coefficients of variation were 64 and 18%.

CONCLUSIONS

The contrast enhanced-MRI measured median IAUC is a useful end point for quantifying ZD6126 antivascular effects in human tumors.

Effects of increasing quantities of oat bran in hypercholesterolemic people

The effects of increasing quantities of oat bran on plasma lipids were examined in 40 hypercholesterolemic men and women. Using a four-by-four Latin-square design, subjects added 30, 60, and 90 g oat bran/d or no oat bran to their usual diet for 1-mo experimental periods. Self-selected background diets remained unchanged and weight did not change significantly. No differences in plasma total or low-density-lipoprotein cholesterol were found. Supplementation of the usual diet with less than or equal to 90 g oat bran does not appear to significantly lower cholesterol in hypercholesterolemic subjects continuing to follow a diet relatively high in saturated fatty acids.