Rate of Inpatient Hypoglycemia Following a 1:1 Dose Interchange Between Concentrated Insulin Glargine to Insulin Detemir

BACKGROUND

Insulin remains a mainstay of treating hyperglycemia in an acute setting. Insulin glargine 300 units/mL (Toujeo, iGlar300) has a different pharmacokinetic profile than 100 units/mL basal insulins, such as insulin detemir (iDet100) and iGlar100. While conversion from iGlar300 to iGlar100 requires a 20% dose decrease, there is currently no recommended interchange from iGlar300 to iDet100.

OBJECTIVE

Compare the incidence of hypoglycemia in patients who received a 1:1 unit interchange from home iGlar300 or iGlar100 to iDet100 while admitted.

METHODS

A retrospective study was conducted to evaluate adults within a multi-site network admitted between May and December 2019. Patients were included if they received at least one dose of iDet100 following interchange from home iGlar300 or iGlar100. The primary endpoint was the incidence of hypoglycemic events following a 1:1 interchange of iGlar300 vs. iGlar100 to inpatient iDet100. Secondary outcomes include overall hypoglycemic events, time to hypoglycemia, and doses given before hypoglycemia.

RESULTS

Of 615 patients, 394 received a 1:1 unit interchange to iDet100 (52 from iGlar300 and 342 from iGlar100). Incidence of hypoglycemic events was significantly higher in those with a 1:1 interchange from iGlar300 versus iGlar100 (36.5% vs. 18.7%, p = 0.007). Significant differences were observed in overall hypoglycemic events, time to hypoglycemia, and number of doses given before hypoglycemic event.

CONCLUSION AND RELEVANCE

A 1:1 unit interchange from iGlar300 to iDet100 led to a higher incidence of hypoglycemic events compared to those interchanged from iGlar100. Dose reduction should be considered when transitioning from home iGlar300 to iDet100 in the inpatient setting.

AB0348 THE PROPER STUDY: A 48-WEEK ANALYSIS OF A PAN-EU REAL-WORLD STUDY OF SB5 BIOSIMILAR FOLLOWING TRANSITION FROM REFERENCE ADALIMUMAB IN PATIENTS WITH RHEUMATOID ARTHRITIS, AXIAL SPONDYLOARTHRITIS OR PSORIATIC ARTHRITIS

Background

SB5, a biosimilar to reference adalimumab (ADL), received EU marketing authorisation in 2017, based on pre-clinical and clinical phase I and III studies that demonstrated bioequivalence and comparable efficacy, safety and immunogenicity to ADL.

Objectives

The real-world study ‘PROPER’ is designed to provide insights into outcomes of the transition from ADL to SB5 outside the randomised, controlled, clinical trial setting.

Methods

Under an umbrella design, 1000 patients with immune-mediated inflammatory disease were enrolled at centres in Belgium, Germany, Ireland, Italy, Spain and the UK, and followed for 48 weeks post-transition. Eligible patients with a diagnosis of rheumatoid arthritis (RA), axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), ulcerative colitis or Crohn’s disease had been transitioned to SB5 as part of routine treatment following a minimum of 16 weeks’ treatment with ADL. Data were captured from patient charts retrospectively for 24 weeks prior to and prospectively and/or retrospectively up to 48 weeks after SB5 initiation. This analysis of the rheumatology cohort reports clinical characteristics, disease scores, persistence on SB5, clinical management and safety up to the closing date of November 30th, 2021.

Results

Of the 496 patients included in this analysis, the majority were enrolled in UK (n=174), Germany (n=145) and Spain (n=73); Italy, Ireland and Belgium enrolled 45, 44 and 15 patients respectively. At study close, 487 patients had completed 48 weeks of follow-up; 397 of those remained on SB5 throughout.

Methotrexate was received as concomitant therapy by 37% of patients and 20% had received a biologic therapy prior to reference ADL. Most patients (89.3% of RA, 92.1% of axSpA, 97.3% of PsA) transitioned to SB5 at the same dose regimen received for ADL.

Clinical characteristics, SB5 dose and flare are detailed in Table 1, disease scores in Figure 1.

Table 1.

Patient clinical characteristics, SB5 dose, flare

RA (N=207)axSpA (N=127)PsA (N=162)Age at SB5 initiation (years), mean (SD); IQR60.1 (11.8)53.0, 68.050.3 (13.4)38.0, 61.053.3 (12.0)45.0, 62.0Duration of disease (years), mean (SD); IQR13.3 (11.4)5.0, 19.518.8 (13.5)9.0, 25.012.2 (9.9)4.0, 19.0n%n%n%Women15072.54031.57345.1Patients receiving SB5 40mg Q2WBaseline15273.411590.614992.0Week 4813272.59387.712491.9Episodes of Flare018790.310784.313985.81209.71814.22012.3200.021.631.9How was Flare diagnosedDisease score1155.0731.81038.5Patient-reported symptoms1995.022100.026100.0Secondary Loss of Response315.000.0726.9Action taken for FlareBiologic therapy dose adjusted420.029.1519.2Non-biologic therapy dose adjusted840.0313.6934.6Clinical investigation00.014.5311.5Other*945.01359.11661.5

*Includes cessation of therapy, prescription of corticosteroids, physical exercise, no action.

IQR, interquartile range; SD, standard deviation; Q2W once two-weekly.

Figure 1.

Disease scores (paired patients), mean (95% CI)

Fifteen patients each experienced one unrelated Serious Adverse Event (SAE): 2 in the axSpA cohort [tachycardia, intracranial haemorrhage]; 6 in the PsA cohort [myocardial infarct (2), breast carcinoma, COVID-19, gallbladder calculus, dyspnoea]; 7 in the RA cohort [facial numbness, depression, COVID-19, pneumonia, diverticulitis, parvovirus, coronary occlusion]. Two patients reported SAEs considered causally related to SB5: Herpes zoster and pneumonia (RA cohort), and ALS with worsening (PsA cohort).

Conclusion

This analysis of a large, contemporary cohort of EU patients with established RA, axSpA or PsA shows treatment effectiveness maintained at 48 weeks after switching from ADL to SB5, with most patients continuing on SB5 Q2W throughout. Episodes of flare were uncommon, and the importance of patient-reported symptoms in recognition of flare is evident. No new safety signals were observed.

Acknowledgements

Statistical services were provided by FGK Clinical Research GmbH, Munich, Germany. Data management services were provided by Worldwide Clinical trial, Research Triangle Park, NC, USA. Funding was provided by Biogen International GmbH.

Disclosure of Interests

Ulf Müller-Ladner Consultant of: Biogen, Grant/research support from: Biogen, Karl Gaffney Speakers bureau: Novartis, UCB, AbbVie, Lilly, Consultant of: Novartis, UCB, AbbVie, Lilly, Pfizer, Grant/research support from: NAAS, AbbVie, Pfizer, UCB, Novartis, Lilly, Cellgene, Celltrion, Janssen, Gilead, Biogen, Deepak Jadon Consultant of: AbbVie, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Oxford University Press, Pfizer, Roche, Sandoz, UCB, Grant/research support from: AbbVie, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Oxford University Press, Pfizer, Roche, Sandoz, UCB, Marco Matucci-Cerinic Consultant of: Chemomab, Biogen, Pfizer, Lilly, Behring, Janssen, MSD, Eugenio Chamizo Carmona Speakers bureau: Abbvie, Amgen, Biogen, BMS, Celgene, Eli Lilly, Fresenius-Kabi, Galapagos, Janssen, MSD, Novartis, Pfizer, and UCB, Consultant of: Abbvie, Amgen, Biogen, BMS, Celgene, Eli Lilly, Fresenius-Kabi, Galapagos, Janssen, MSD, Novartis, Pfizer, and UCB, Ulrich Freudensprung Shareholder of: May hold stock in Biogen, Employee of: Biogen, Janet Addison Shareholder of: May hold stock in Biogen, Employee of: Biogen

POS0287 A PHASE III, RANDOMISED, DOUBLE-BLIND, ACTIVE-CONTROLLED CLINICAL TRIAL TO COMPARE BAT1806/BIIB800, A PROPOSED TOCILIZUMAB BIOSIMILAR, WITH TOCILIZUMAB REFERENCE PRODUCT IN SUBJECTS WITH MODERATE TO SEVERE RHEUMATOID ARTHRITIS WITH AN INADEQUATE RESPONSE TO METHOTREXATE THERAPY

Background

BAT1806/BIIB800 is a proposed biosimilar to reference tocilizumab (TCZ). A Phase III randomised, double-blind, active-controlled clinical trial was conducted as part of a biosimilar development programme.

Objectives

To evaluate the efficacy, pharmacokinetics (PK), safety and immunogenicity of BAT1806/BIIB800 in comparison with EU-sourced TCZ in subjects with moderate to severe rheumatoid arthritis with inadequate response to methotrexate (MTX).

Methods

The study was conducted at 55 centres in China and Europe, between June 2018 and January 2021. Eligible subjects were randomised in a 2:1:1 ratio to one of three treatment groups: (1) BAT1806/BIIB800 up to Week 48, (2) TCZ up to Week 48, or (3) TCZ up to Week 24, followed by BAT1806/BIIB800 from Week 24 to Week 48, administered intravenously every 4 weeks at a dose of 8mg/kg. The primary endpoint was the proportion of subjects achieving an ACR20 response at timepoints pre-specified to meet the requirements of different Regulatory Agencies: Week 12, for EMA; Week 24, for FDA and NMPA. Equivalence margins applied to differences in ACR20 response rates in the BAT1806/BIIB800 and TCZ treatment groups were pre-specified as follows: +/- 14.5% for EMA (95% confidence interval (CI)); -12.0%,15% for FDA (90% CI); +/- 13.6% for NMPA (95% CI). Secondary endpoints included pharmacokinetics, safety and immunogenicity.

The ICH E9(R1) estimands framework including intercurrent events (related or unrelated to the COVID19 pandemic) was implemented for the ACR20 evaluation. A logistic regression model including ‘region’ (China and Eastern Europe) and ‘previous biologic or targeted synthetic DMARD use’ (Yes/No) as captured in Interactive Web Response System as stratification factors was utilised to assess equivalence for the primary endpoint. The difference in response rates was estimated and corresponding confidence intervals were derived to assess equivalence for the primary endpoint. This abstract presents results up to Week 24.

Results

In total, 621 subjects were randomised to receive BAT1806/BIIB800 (N=312), TCZ (N=155), or TCZ followed by BAT1806/BIIB800 (N=154). The groups were comparable in terms of baseline demographics and disease characteristics, including age, gender, disease activity and disease duration. The estimated proportions of subjects achieving an ACR20 response in the BAT1806/BIIB800 vs. the TCZ groups, respectively, were 68.97% vs. 64.82% at Week 12 and 69.89% vs. 67.94% at Week 24. The estimated difference between ACR response rates was 4.15% (95% CI -3.63, 11.93) at week 12, and 1.94% (90% CI -4.04, 7.92; 95% CI -5.18, 9.07) at Week 24. The CIs for the estimated differences between the treatment groups were within the pre-defined equivalence margins (Figure 1). The treatment groups were comparable in terms of serum trough levels, incidence of TEAEs and ADA/NAb positivity (Table 1).

Table 1.

Safety and Immunogenicity up to Week 24, and Pharmacokinetics at Week 24

TCZ (N =309) n (%)BAT1806/BIIB800 (N=312) n (%)TEAE196 (63.4)201 (64.4)Related TEAE151 (48.9)148 (47.4)Serious TEAE13 (4.2)11 (3.5)Related Serious TEAE7 (2.3)2 (0.6)Fatal TEAE1 (0.3)3 (1.0)ADA positive a42 (13.6%)64 (20.5%)NAb positive a42 (13.6%)63 (20.2%)PK, n271276Serum trough level (ug/mL), mean (SD)15.4 (17.1)15.8 (12.3)Serum trough level (ug/mL), geometric mean (CV%)12.3 (140.3)12.9 (121.3)Below limit of quantification, n (%)43 (15.9)28 (10.1)

TEAE, treatment emergent adverse events

a subjects with ≥1 ADA/NAb positive results up to week 24

Conclusion

BAT1806/BIIB800 has demonstrated equivalent efficacy at Week 12 and Week 24 and a similar PK, safety and immunogenicity profile as reference tocilizumab up to Week 24.

Disclosure of Interests

Xiaomei Leng: None declared, Piotr Leszczynski: None declared, Sławomir Jeka: None declared, Shengyun Liu: None declared, Huaxiang Liu: None declared, Malgorzata Miakisz: None declared, Jieruo Gu: None declared, Lali Kilasonia Speakers bureau: Sandoz, Amgen, Takeda, Mykola Stanislavchuk Speakers bureau: Pfizer, Orion, Boehringer Ingelheim, Xiaolei Yang Shareholder of: Employee of the Bio-thera Solutions Ltd. with shares as a part of Stock incentive plan., Employee of: Employee of the Bio-thera Solutions Ltd., Yinbo Zhou Shareholder of: Employee of Bio-thera Solutions Ltd. with share as part of Stock incentive plan, Employee of: Employee of Bio-thera Solutions Ltd., Qingfeng Dong Shareholder of: Employee of Bio-thera Solutions Ltd. with shares as part of Stock incentive plan, Employee of: Employee of Bio-thera Solutions Ltd., Marian Mitroiu Shareholder of: Employee of Biogen and may hold stocks, Employee of: Employee of Biogen, Janet Addison Shareholder of: Employee of Biogen and holds stock in Biogen, Employee of: Employee of Biogen, Xiaofeng Zeng: None declared

AB0204 THE PROPER STUDY: INTERIM ANALYSIS OF A PAN-EU REAL-WORLD STUDY OF SB5 BIOSIMILAR FOLLOWING TRANSITION FROM REFERENCE ADALIMUMAB IN PATIENTS WITH RHEUMATOID ARTHRITIS, AXIAL SPONDYLOARTHRITIS, OR PSORIATIC ARTHRITIS

Background:

SB5, a biosimilar to reference adalimumab (ADL), received EU marketing authorisation in August 2017, based on the totality of evidence from pre-clinical and clinical Phase I and III studies that demonstrated bioequivalence, similar efficacy, and comparable safety and immunogenicity to the reference. This real-world study provides data on outcomes of the transition from reference to biosimilar ADL outside the controlled, randomised, clinical trial setting.

Objectives:

To evaluate candidate predictors of persistence on SB5 in EU patients (pts) across multiple indications.

Methods:

This ongoing observational study enrolled 1000 pts with rheumatoid arthritis (RA), axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), ulcerative colitis, or Crohn’s disease who initiated SB5 as part of routine clinical practice following a minimum of 16 weeks’ treatment with reference ADL, at clinics in Belgium, Germany, Ireland, Italy, Spain, and the UK. Data are captured from clinic records retrospectively for the 24 weeks prior to transition, and prospectively and/or retrospectively for 48 weeks following transition. Primary outcome measures include baseline clinical characteristics, disease activity scores and clinical management over time; data on COVID-19 infection has recently been captured. This interim analysis (IA) provides an overview of baseline characteristics, disease scores and dose regimen up to 48 weeks post-initiation of SB5, and COVID-19 infection reported to date, in subjects with RA, axSpA, or PsA enrolled at 35 specialist sites and followed up to the data extract date of 18th December 2020.

Results:

Of the 504 pts included in this IA, 201 have RA, 169 have PsA, and 134 axSpA. At time of data extract, 216 pts had completed 48 weeks on SB5, 73 pts had discontinued SB5, and 8 had discontinued the study.

RA (N=201)axSpA (N=134)PsA (N=169)Mean (SD)Q1, Q3Mean (SD)Q1, Q3Mean (SD)Q1, Q3Age at SB5 initiation (years)60.2 (11.7)53, 6850.5 (13.6)38, 6153.0 (12.2)43, 62Duration of disease (years)13.5 (11.7)4.5, 2018.7 (13.2)9, 2512.7 (9.9)4, 20n%n%n%Women14471.64130.67745.6SB5 Dosing regimen:Baseline 40 mg Q2W14974.112089.615692.3Week 48 40mg Q2W6977.56785.99892.5Baseline Other*5225.91410.4137.7Week 48 Other*2022.41114.187.5Disease Score(paired patients)DAS28FFbHBASDAITender Joint CountSwollen Joint CountBaseline, n, mean (95% CI)692.5 (2.3–2.7)2273.9 (65.6–82.1)422.8 (2.3–3.4)491.8 (0.1–3.0)490.6 (0.2–0.9)Week 48, n, mean (95% CI)692.6 (2.3–2.8)2272.1 (64.0–80.2)423.0 (2.4–3.7)491.9 (0.5–3.3)490.6 (0.1–1.1)Patient diagnosed with COVID-19 at any time on-study, n (%)No14295.39688.114098.6Yes32.010.910.7Unknown42.71211.010.7Imraldi regimen stopped or changed due to COVID-19, regardless of diagnosis, n (%)No13098.510697.2134100Yes21.532.800

SD standard deviation; Q1 1st quartile, Q3 3rd quartile; CI Confidence Interval

*Other includes all other reported doses and/or dosing intervals: 40mg QW, 80mg Q2W, and unspecified frequency

DAS28 Disease Activity Score 28; FFbH Hanover Functional Ability Questionnaire; BASDAI Bath Ankylosing Spondylitis Disease Activity Index

Conclusion:

This IA provides a first insight into clinical management of pts over 48 weeks, in a contemporary cohort of EU pts with established RA, axSpA and PsA, switched from reference to biosimilar ADL SB5 in clinical practice. The majority of pts showed no meaningful difference in disease score or dose regimen of SB5 by Week 48 post-transition. As of data extract date, the proportion of pts with a known positive COVID-19 test was low (1.3%) and a small minority (1.3%) had SB5 treatment changed or interrupted as a result of the COVID-19 pandemic. With follow-up of pts ongoing to Q4 2021, the study will continue to provide pertinent information about clinical outcomes of transition from reference to biosimilar ADL in real-world practice and in indications not investigated in controlled studies.

Acknowledgements:

Statistical services gave been provided by FGK Clinical Research GmbH, Munich, Germany. Data management services were provided by Worldwide Clinical trial, Research Triangle Park, NC, USA; funding was provided by Biogen International GmbH.

Disclosure of Interests:

Ulf Müller-Ladner Consultant of: Biogen, Grant/research support from: Biogen, Karl Gaffney Consultant of: AbbVie, Celgene, Gilead, Lilly, MSD, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Celgene, Gilead, Lilly, MSD, Novartis, Pfizer, and UCB, Deepak Jadon Consultant of: AbbVie, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Oxford University Press, Pfizer, Roche, Sandoz, UCB, Grant/research support from: AbbVie, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Oxford University Press, Pfizer, Roche, Sandoz, UCB, Ulrich Freudensprung Shareholder of: Biogen, Employee of: Biogen, Janet Addison Shareholder of: Biogen, Employee of: Biogen

POS0614 PERFUSE: A FRENCH PROSPECTIVE/RETROSPECTIVE NONINTERVENTIONAL COHORT STUDY OF INFLIXIMAB-NAÏVE AND TRANSITIONED PATIENTS RECEIVING INFLIXIMAB BIOSIMILAR SB2; 12-MONTH ANALYSIS

Background:

SB2 is approved in the EU as an infliximab (IFX) biosimilar, having demonstrated bioequivalence and similar efficacy, safety and immunogenicity as the reference. PERFUSE is an ongoing non-interventional study of 1233 patients (496 with rheumatology diagnoses, 737 with gastroenterology diagnoses) receiving SB2 as routine therapy.

Objectives:

The aim of the study is to provide data on long-term outcomes in patients initiating SB2 in the real-world setting.

Methods:

Adult patients eligible for inclusion in the rheumatology study cohorts have a diagnosis of Rheumatoid Arthritis (RA), Psoriatic Arthritis (PsA) or Axial Spondyloarthritis (axSpA) and had initiated SB2 in routine clinical practice after September 2017, either as their first IFX or transitioning from treatment with IFX reference or another IFX biosimilar. Outcome measures include SB2 dose, disease activity scores and persistence on SB2, over time and up to 24 months after initiation. This interim analysis is the first complete analysis of 12 month data on all rheumatology patients enrolled into the study at 9 specialist sites and followed up to the data extract date of 29th October 2020. The analysis provides an overview of baseline characteristics, disease scores, SB2 dose and persistence at 12 months post-initiation of SB2.

Results:

Table 1.

Mean Disease Activity Score-28 erythrocyte sedimentation rate (DAS28-ESR) and Clinical Disease Activity Index (CDAI) over the course of ICHIBAN. BL, baseline; SD, standard deviation.

axSpA cohort(N=336;IFX naïve 81, IFX-prior 255)RA cohort(N=98;IFX naïve 22, IFX-prior 76)PsA cohort(N=62;IFX naïve 14, IFX-prior 48)Baseline characteristicsAge in years, mean (SD):IFX-naïve43.1 (11.1)53.1 (15.9)48.5 (12.2)Transitioned from IFX48.9 (12.4)57.3 (13.1)53.1 (13.0)Disease duration in years, mean (SD):IFX-naïve7.2 (9.3)11.3 (9.8)4.2 (3.9)Transitioned from IFX16.6 (11.6)17.3 (8.8)12.9 (11.3)Women, n (%):IFX-naïve26 (32.1)16 (72.7)6 (42.9)Transitioned from IFX79 (31.0)60 (78.9)15 (31.3)SB2 Dose: n, mean mg/kg (SD)IFX-naïve:Baseline81383.8 (85.5)22266.2 (145.9)14395.4 (108.9)Month 1247436.8 (153.3)13285.5 (90.7)6508.0 (147.6)Transitioned from IFX:Baseline255396.7 (109.6)76291.8 (103.4)48408.5 (91.3)Month 12195392.1 (105.5)60287.8 (106.6)41421.4 (101.6)Disease score, mean (SD)IFX-naïve:nBASDAInDAS28nDAS28Baseline545.8 (2.1)144.3 (1.6)-*-*Month 12303.5 (2.7)93.2 (1.2)Transitioned from IFX:Baseline2063.0 (2.0)622.6 (1.2)202.2 (1.2)Month 121513.0 (2.1)472.7 (1.2)192.1 (0.9)KM estimate of persistence on SB2 by Month 12; proportion, (95% CI)IFX-naïve56.26 (44.43; 66.51)59.09 (36.10; 76.21)64.29 (34.33; 83.31)Transitioned from IFX79.86 (74.37; 84.30)80.26 (69.42; 87.60)85.04 (71.11; 92.58)

*Blank as disease score data for both baseline and Month 12 were provided by a single patient who was IFX-naïve and had PsA; IFX = infliximab; axSpA = Axial Spondyloarthritis; RA = Rheumatoid Arthritis; PsA = Psoriatic Arthritis; BASDAI = Bath Ankylosing Spondylitis Disease Activity Index; DAS28 = Disease Activity Score 28; CI = confidence interval; SD = standard deviation; KM = Kaplan Meier.

Conclusion:

This 12-month analysis indicates that patients with axSpA or RA can be successfully initiated on SB2 as the first infliximab therapy, and patients with axSpA, RA or PsA can be transitioned from originator or biosimilar IFX to SB2 without loss of disease control and with no dose penalty over 12 months post-transition. Over 56% of IFX- naïve patients and over 79% of patients transitioned from prior IFX remained on SB2 at 12 months post-initiation. With follow-up of patients ongoing to 24 months post-initiation of SB2, the study will continue to provide pertinent information about clinical outcomes of initiation on SB2 as first IFX or after transition from reference or IFX biosimilar to SB2.

Acknowledgements:

Data management for the study was provided by Sanoïa E-health services, Digital CRO, Gémenos, France; funding was provided by Biogen International GmbH.

Disclosure of Interests:

Bruno Fautrel Speakers bureau: AbbVie, Biogen, Boehringer-Ingelheim, BMS, Celgene, Janssen, Lilly, Medac, MSD, NORDIC Pharma, Novartis, Pfizer, Roche, SOBI, UCB., Consultant of: AbbVie, Biogen, Boehringer-Ingelheim, BMS, Celgene, Janssen, Lilly, Medac, MSD, NORDIC Pharma, Novartis, Pfizer, Roche, SOBI, UCB., Grant/research support from: AbbVie, MSD, Pfizer., Yoram Bouhnik Speakers bureau: AbbVie, Biogaran, Biogen, Boehringer Ingelheim, CTMA, Ferring, Gilead, Hospira, ICON, Inception IBD, Janssen, Lilly, Mayoly Spindler, Merck, Merck Sharp & Dohme, Norgine, Pfizer, Robarts Clinical Trials, Roche, Sanofi, Shire, Takeda, UCB, Vifor Pharma., Consultant of: AbbVie, Biogaran, Biogen, Boehringer Ingelheim, CTMA, Ferring, Gilead, Hospira, ICON, Inception IBD, Janssen, Lilly, Mayoly Spindler, Merck, Merck Sharp & Dohme, Norgine, Pfizer, Robarts Clinical Trials, Roche, Sanofi, Shire, Takeda, UCB, Vifor Pharma., Maxime Dougados Grant/research support from: Biogen, Ulrich Freudensprung Shareholder of: Biogen, Employee of: Biogen, Janet Addison Shareholder of: Biogen, Employee of: Biogen

Kokumi taste perception is functional in a model carnivore, the domestic cat (Felis catus)

Kokumi taste is a well-accepted and characterised taste modality and is described as a sensation of enhancement of sweet, salty, and umami tastes. The Calcium Sensing Receptor (CaSR) has been designated as the putative kokumi taste receptor for humans, and a number of kokumi-active ligands of CaSR have been discovered recently with activity confirmed both in vivo and in vitro. Domestic cats (Felis catus) are obligate carnivores and accordingly, their diet is abundant in proteins, peptides, and amino acids. We hypothesised that CaSR is a key taste receptor for carnivores, due to its role in the detection of different peptides and amino acids in other species. Using in silico, in vitro and in vivo approaches, here we compare human CaSR to that of a model carnivore, the domestic cat. We found broad similarities in ligand specificity, but differences in taste sensitivity between the two species. Indeed our in vivo data shows that cats are sensitive to CaCl₂ as a kokumi compound, but don't show this same activity with Glutathione, whereas for humans the reverse is true. Collectively, our data suggest that kokumi is an important taste modality for carnivores that drives the palatability of meat-derived compounds such as amino acids and peptides, and that there are differences in the perception of kokumi taste between carnivores and omnivores.

THU0164 PERFUSE: A FRENCH PROSPECTIVE/RETROSPECTIVE NON-INTERVENTIONAL COHORT STUDY OF INFLIXIMAB-NAIIVE AND TRANSITIONED PATIENTS RECEIVING INFLIXIMAB BIOSIMILAR SB2; AN INTERIM ANALYSIS

Background:

SB2 is approved in the EU as an infliximab (IFX) biosimilar, having demonstrated bioequivalence and similar efficacy, safety and immunogenicity as the reference. There is limited real-world evidence published on persistence, effectiveness or safety of SB2, in IFX-naiive patients or those transitioning from originator or another IFX biosimilar.

Objectives:

PERFUSE is an ongoing non-interventional study of 1374 patients (500 with rheumatology diagnoses, 874 with gastroenterology diagnoses) receiving SB2 as routine therapy, with objectives to describe clinical characteristics, effectiveness, treatment persistence and safety in patients initiating SB2 and followed for 24 months at 21 specialist sites across France.

Methods:

Adult patients eligible for inclusion in the rheumatology study cohorts have a diagnosis of Rheumatoid Arthritis (RA), Psoriatic Arthritis (PsA) or Ankylosing Spondylitis (AS) and initiated SB2 in routine clinical practice after September 2017, either as their first IFX or transitioning from treatment with IFX reference or another IFX biosimilar. Data are captured from patients’ clinic records. Outcome measures include persistence on SB2, clinical characteristics at baseline (time of SB2 initiation), disease scores and Serious Adverse Events (SAEs).

Results:

This 12-month interim analysis includes 500 patients (99 with RA, 62 with PsA and 339 with AS). M12 persistence on SB2 for IFX-naiive and transitioned patients combined was 73.8% (95% CI 61.5, 84.0), 76.2 % (95% CI 60.5, 87.9) and 71.5 % (95% CI 65.6, 76.9) in RA, PsA and AS respectively. In patients with prior IFX, no clinically meaningful difference in disease activity score from baseline to M12 was observed (Table 1). Low sample size precluded interpretation of disease score in the IFX-naiive cohort (not shown in Table 1). All 7 reported SAEs are unrelated to SB2: prostate and breast carcinoma in the RA cohort; alcohol poisoning, nephrostomy, epistaxis, cutaneous lesion and malleolar fracture in the AS cohort.

Table 1RA (N=99)PsA (N=62)AS (N=339)Age (mean, SD)56.5 (13.8)52.1 (12.9)47.7 (12.5)Disease duration (mean, SD)16.0 (9.4)10.9 (10.7)14.4 (11.8)Female (n) (%)77 (77.8)21 (33.9)107 (31.6)IFX-Naiive (n) (%)22 (22.2)14 (22.6)80 (23.6)Transitioned from Reference (n) (%)37 (37.4)24 (38.7)111 (32.7)Transitioned from Biosimilar (n) (%)40 (40.4)24 (38.7)148 (43.5)SB2 Persistence at M12: n on SB2 at M12 (total n at M12), % (95% CI*)IFX-Naiive5 (9)55.6% (21.2, 86.3)3 (7)42.9% (9.9, 81.6)21 (48)43.8% (29.5, 58.8)Transitioned from Reference14 (22)63.6% (40.7, 82.8)15 (17)88.2% (63.6, 98.5)68 (87)78.2% (68.0, 86.3)Transitioned from Biosimilar29 (34)85.3% (68.9, 95.0)14 (18)77.8% (52.4, 93.6)99 (128)77.3% (69.1, 84.3)Disease score in switched patientsnDAS-28 mean (95% CI)nDAS-28 mean (95% CI)nBASDAImean (95% CI)Baseline472.5 (2.2, 2.8)192.2 (1.5, 2.8)2023.0 (2.7, 3.3)M12362.7 (2.3, 3.1)142.0 (1.4, 2.6)1362.8 (2.5, 3.2)Change from baseline at M12260.5 (-0.1, 0.9)90.0 (-0.7, 0.6)1250.1 (-0.2, 0.5)

* Clopper Pearson

Conclusion:

This interim analysis indicates that patients with RA, AS or PsA can be successfully transitioned from originator or biosimilar IFX to SB2, without loss of disease control and with no safety concerns. The majority of transitioned patients continued SB2 treatment at M12 post-initiation. The PERFUSE study will provide ongoing, pertinent information about outcomes in these populations, helping to inform evidence-based treatment decisions.

Disclosure of Interests:

Bruno Fautrel Grant/research support from: AbbVie, Lilly, MSD, Pfizer, Consultant of: AbbVie, Biogen, BMS, Boehringer Ingelheim, Celgene, Lilly, Janssen, Medac MSD France, Nordic Pharma, Novartis, Pfizer, Roche, Sanofi Aventis, SOBI and UCB, Yoram Bouhnik Consultant of: AbbVie, Biogaran, Biogen, Boehringer Ingelheim, CTMA, Ferring, Gilead, Hospira, ICON, Inception IBD, Janssen, Lilly, Mayoly Spindler, Merck, Merck Sharp & Dohme, Norgine, Pfizer, Robarts Clinical Trials, Roche, Sanofi, Shire, Takeda, UCB, Vifor Pharma, Guillaume Desjeux: None declared, Amira Brigui Shareholder of: Biogen France SAS, Employee of: Biogen France SAS, Ulrich Freudensprung Shareholder of: Biogen International GmbH, Employee of: Biogen International GmbH, Janet Addison Shareholder of: Biogen Idec, Employee of: Biogen Idec

AB0311 THE PROPER STUDY: RESULTS OF THE FIRST INTERIM ANALYSIS OF A PAN-EU REAL-WORLD STUDY OF SB5 BIOSIMILAR FOLLOWING TRANSITION FROM REFERENCE ADALIMUMAB IN PATIENTS WITH RHEUMATOID ARTHRITIS, AXIAL SPONDYLOARTHRITIS OR PSORIATIC ARTHRITIS

Background:

SB5, a biosimilar to reference adalimumab (ADA), received EU marketing authorisation in August 2017, based on the totality of evidence from pre-clinical and clinical Phase I and III studies that demonstrated bioequivalence, similar efficacy, and comparable safety and immunogenicity to the reference. There are few published data on the transition from reference to biosimilar ADA outside the controlled, randomised, clinical trial setting.

Objectives:

To evaluate candidate predictors of persistence on SB5 in EU patients across multiple indications.

Methods:

This ongoing observational study will enrol approximately 1200 subjects with rheumatoid arthritis (RA), axial spondyloarthritis (axSpA) or psoriatic arthritis (PsA), who initiated SB5 as part of routine clinical practice following a minimum of 16 weeks’ treatment with reference ADA, at clinics in Belgium, Germany, Ireland, Italy, Spain and the UK. Data are captured from clinic records retrospectively for the 24 weeks prior to transition, and prospectively and/or retrospectively for 48 weeks following transition. The primary objective is to evaluate candidate predictors of persistence, and primary outcome measures include baseline clinical characteristics, disease activity scores, clinical management and patient satisfaction over time. This interim analysis provides an overview of baseline characteristics for subjects enrolled and followed up by the data extract date of 20thDecember 2019.

Results:

Of the 123 patients included in this interim analysis, 43 suffer from RA, 42 from axSpA and 38 from PsA.

Table 1.

Patient baseline characteristics

RA (N=43)axSpA (N=42)PsA (N=38)Mean (SD)Q1, Q3Mean (SD)Q1, Q3Mean (SD)Q1, Q3Age (years)58.7 (11.3)53, 6452.3 (13.3)41, 6353.7 (14.1)48, 63Duration of disease (years)6.8 (9.5)1, 622.0 (14.4)12.5, 32.513.8 (9.4)5.5, 22n%n%n%Women3172.11638.11642.1Dosing regimen ADA to SB5: 40mg Q2W: 40mg Q2W3485.03685.73489.5 Other*615.0614.3410.5Stable disease (physician opinion)3491.92765.93085.7Disease Activity Score:Mean (SD)95% CIMean (SD)95% CIMean (SD)95% CI DAS28 (n = 26)2.71 (0.88)2.36, 3.06---- BASDAI (n = 31)--3.71 (2.89)2.65, 4.77-- PsA scores (n = 23)0.3 (0.9)  Swollen joint2.9 (5.7)-0.1, 0.8  Tender joint0.4, 5.4Patient Awareness:n%n%n%Instructed in self-administration43100.03790.23594.6Know to remove SB5 from fridge 30 minutes pre-injection43100.03895.03697.3Know SB5 can be stored out of fridge <25oc for 28 days4297.73382.52875.7

DAS-28 Disease Activity Score 28; BASDAI Bath Ankylosing Spondylitis Disease Activity Index; SD standard deviation; Q1 1stquartile, Q3 3rdquartile; CI Confidence Interval

‘Other’ includes all other reported doses and/or dosing intervals: 40mg QW, 80mg Q2W, and unspecified frequency

Conclusion:

This interim analysis provides a first insight into a contemporary cohort of EU patients with established RA, axSpA and PsA, switched from reference to biosimilar ADA in clinical practice. The majority of patients have stable disease at transition, 85% or more of each cohort transitioned to the same dose regimen of biosimilar as received for the reference prior to transition, and most are aware of correct storage and self-administration of their biosimilar medication. With ongoing enrolment and longer follow-up, the study will provide pertinent information about clinical outcomes of transition from reference to biosimilar adalimumab in real-world practice and in indications not investigated in controlled studies.

Disclosure of Interests:

Ulf Müller-Ladner Speakers bureau: Biogen, Karl Gaffney Grant/research support from: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Consultant of: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Speakers bureau: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Deepak Jadon: None declared, Ulrich Freudensprung Shareholder of: Biogen International GmbH, Employee of: Biogen International GmbH, Janet Addison Shareholder of: Biogen Idec, Employee of: Biogen Idec

Climate change and pastoralism: impacts, consequences and adaptation

The authors discuss the main climate change impacts on pastoralist societies, including those on rangelands, livestock and other natural resources, and their extended repercussions on food security, incomes and vulnerability. The impacts of climate change on the rangelands of the globe and on the vulnerability of the people who inhabit them will be severe and diverse, and will require multiple, simultaneous responses. In higher latitudes, the removal of temperature constraints might increase pasture production and livestock productivity, but in tropical arid lands, the impacts are highly location specific, but mostly negative. The authors outline several adaptation options, ranging from implementing new technical practices and diversifying income sources to finding institutional support and introducing new market mechanisms, all of which are pivotal for enhancing the capacity of pastoralists to adapt to climate variability and change. Due to the dynamism of all the changes affecting pastoral societies, strategies that lock pastoral societies into specified development pathways could be maladaptive. Flexible and evolving combinations of practices and policies are the key to successful pastoral adaptation.

Climate change and pastoralism: impacts, consequences and adaptation

The authors discuss the main climate change impacts on pastoralist societies, including those on rangelands, livestock and other natural resources, and their extended repercussions on food security, incomes and vulnerability. The impacts of climate change on the rangelands of the globe and on the vulnerability of the people who inhabit them will be severe and diverse, and will require multiple, simultaneous responses. In higher latitudes, the removal of temperature constraints might increase pasture production and livestock productivity, but in tropical arid lands, the impacts are highly location specific, but mostly negative. The authors outline several adaptation options, ranging from implementing new technical practices and diversifying income sources to finding institutional support and introducing new market mechanisms, all of which are pivotal for enhancing the capacity of pastoralists to adapt to climate variability and change. Due to the dynamism of all the changes affecting pastoral societies, strategies that lock pastoral societies into specified development pathways could be maladaptive. Flexible and evolving combinations of practices and policies are the key to successful pastoral adaptation.

How doctors make use of online, point-of-care clinical decision support systems: a case study of UpToDate©

BACKGROUND

Online point-of-care evidence-based information tools are becoming increasingly popular.

OBJECTIVES

To discover how doctors actually use one such tool - UpToDate - in clinical practice.

METHODS

An online survey was distributed to doctors at healthcare organisations in the north-west of England which subscribed to UpToDate. Some survey questions asked for quantifiable data (e.g. demographic details), whilst other questions were open-ended and sought examples of clinical scenarios and actual point-of-care use of UpToDate. Open-ended responses were then analysed into emerging themes.

RESULTS

The open-ended responses include evidence illustrating a large variety of clinical scenarios in which the use of UpToDate influenced clinical practice.

CONCLUSIONS

These results show how just one point-of-care tool is used in a variety of ways that benefit the patient, the doctor and the healthcare organisation. Direct quotations reported will provide compelling evidence for librarians to present to senior managers who may be unsure of the value of point-of-care tools in clinical practice.

A critical review of degradation assumptions applied to Mongolia's Gobi Desert

Several assumptions about the levels and causes of rangeland degradation in Mongolia are widely accepted by a range of stakeholders. These assumptions have become important in terms of guiding strategies and policy directions. This paper provides a critical analysis of five widely-held assumptions about rangeland degradation in Mongolia to the more specific case of the rangelands of the Gobi Desert. These assumptions are: (i) there are too many animals; (ii) the relative increase in goat numbers has led to desertification; (iii) rainfall is declining; (iv) there is declining pasture biomass; and (v) Mongolian rangelands are degraded. Biophysical and social data from the Dundgobi and Omnogobi desert steppe areas suggest not all of these assumptions are supported all of the time, and that the processes upon which these assumptions are based are often more complex or dynamic than is commonly recognised. In designing policy and programs, more attention to these dynamics and complexities is needed.

Journal usage in NHS hospitals: a comparison report of total usage at an acute NHS Trust and a specialist NHS Trust in the North West of England

BACKGROUND

Health care libraries spend a large amount of their non-pay budgets on the purchase of scientific, technical and medical journals. In a typical hospital library in the National Health Service (NHS) North West Strategic Health Authority (SHA), this can represent between 80 and 90% of the collection development budget.

METHODS AND RESULTS

Data were collected from 1 December 2005 to 30 November 2006 using COUNTER-generated usage statistics obtained from publishers' administration tools. Between the two trusts included in the study, 93 376 full-text article downloads were recorded; of these, 15 952 or 17.1% articles were downloaded from national core content journals via Proquest. Photocopies made by users for their own use were recorded whenever this data were available.

CONCLUSIONS

NHS staff at the sites included in this study recorded a high volume of journal usage. There was a marked difference in usage patterns between the acute and specialist trusts in the study. The journals provided by national core content represented a much higher proportion of total usage at the acute trust (29.9%) compared with the specialist cancer trust (4.5%). This study supports the view that the local purchasing of journal titles is an important component of the overall journal-based information provision to NHS staff.

Otoprotective Effects of Dexamethasone in the Management of Pneumococcal Meningitis: an Animal Study

OBJECTIVE

To determine whether treating pneumococcal meningitis with a combined antibiotic and steroid regime will prevent cochlear damage, a common pneumococcal meningitis side effect.

STUDY DESIGN

Prospective animal study.

METHODS

Gerbils were randomly assigned to three experimental groups. Animals in group 1 received intrathecal saline injections. Animals in groups 2 and 3 received intrathecal injections of Streptococcus pneumoniae to induce meningitis. Group 2 was treated for 7 days with intraperitoneal penicillin injections (48,000 units). Animals from group 3 received intraperitoneal dexamethasone (0.5 mg/kg) injections for 4 days in addition to 7 days of intraperitoneal penicillin. Three months after the meningitis was induced, the animals' cochlear functions were determined using auditory brainstem responses (ABRs). After measuring cochlear function, the animals were sacrificed for cochlear histopathology. Spiral ganglion cell densities at Rosenthal's canal were determined.

RESULTS

ABR thresholds were significantly elevated in animals from group 2 when compared with the animals in groups 1 and 3 (P < .05). ABR thresholds for animals from group 3 and group 1 were similar (P > .05). Damage of cochlear structures was detected in animals from group 2. The degree of the damage varied: one animal in group 2 had no identifiable hair cells and pillar cells and showed damage of the tectorial membrane. Spiral ganglion density in the basal turn was significantly less in animals from group 2 when compared with controls (P < .05). Although spiral ganglion cell density was less in the dexamethasone-treated group (group 3) when compared with group 1 (control group), but greater than observed in animals treated with antibiotics only (group 2), the differences were statistically not significant (P > .5). Nuclear diameters of the spiral ganglion cells decreased on average from 7.24 +/- 0.48 microm (group 1) to 6.28 +/- 0.76 microm (group 3, animals that received dexamethasone) to 5.57 +/- 0.82 microm (group 2, animals that received antibiotics only). Differences were significant (P < .05). Differences in stria vascularis thickness were not significant among the animals.

CONCLUSION

Dexamethasone has a protective effect on the cochlea when given together with antibiotics in the treatment of pneumococcal meningitis.

Cochlear Preservation After Meningitis: An Animal Model Confirmation of Adjunctive Steroid Therapy

OBJECTIVE/HYPOTHESIS

The objective of the present study was to determine whether treating pneumococcal meningitis with a combined antibiotic and steroid regime will prevent cochlear damage, a common pneumococcal meningitis side effect.

STUDY DESIGN

This was a prospective animal study.

METHODS

Gerbils were randomly assigned to three experimental groups. Animals in group 1, the control animals, received intrathecal saline injections. Animals in groups 2 and 3 received intrathecal injections of Streptococcus pneumoniae to induce meningitis. Although group 2 solely was treated for 7 days with intraperitoneal penicillin injections (48,0000 units), group 3 received, in addition to the antibiotic for 4 days, 0.5 mg/kg intraperitoneal dexamethasone injections. Three months after the meningitis was induced, the animals' cochlear function was determined using auditory brainstem responses (ABRs). Fifteen frequencies were tested, five octaves at three steps per octave between 2 and 50 kHz.

RESULTS

ABR thresholds were significantly elevated only in group 2. When compared with group 1, ABR thresholds were 19 dB higher (P<.05). Frequencies at the low-frequency end of the hearing range were affected more than the midfrequencies. Animals that received dexamethasone had 2-dB higher thresholds than the control group (P>.05).

CONCLUSIONS

Dexamethasone therapy in conjunction with antibiotic therapy preserves cochlear function in cases of S. pneumoniae meningitis in the Mongolian gerbil model.

Posterior vertebral rim fractures

Fracture of the posterior vertebral endplate is a cause of low back pain in adolescents and young adults. Clinically it resembles an acute disc prolapse with low back pain and radiculopathy, but may present with neurogenic claudication due to spinal stenosis in older patients. The lesions may be incidental findings. Plain radiographs are diagnostic in about 40% of cases. CT shows the fracture fragment and vertebral defect in most cases but the fracture fragment may be overlooked on MRI. Accurate diagnosis is essential as the surgical technique for disc herniation is inadequate for endplate fractures. In this pictorial essay we review the imaging findings.

The management of minor traumatic brain injury

Minor traumatic brain injury accounts for the majority of the one million head trauma attendances at A&E departments in the United Kingdom. Guidelines have been established listing criteria for skull films, admission to hospital, computed tomography, and neurosurgical consultation. These are currently undergoing revision and were the subject of a satellite symposium to the J Douglas Miller memorial meeting held in October 1996 in Edinburgh. In the East Anglia Region the current guidelines have been issued as memo-cards for A&E officers. The aim of admission is to observe for deterioration, predominantly caused by intracranial haematomas. The indicators for the development of such lesions are an impaired level of consciousness and presence of a skull fracture. Such patients should therefore undergo regular and frequent neurological observations, and be admitted for at least 12 hours. Following discharge, routine follow up should be considered to identify and treat patients with postconcussion symptoms and signs. The possible way forward for the management of these patients is adopting a greater emphasis on preventative aspects, and establishing, implementing, and auditing evidence based guidelines. Improved teaching in the form of formal induction seminars and computerised teaching aids is required, and a better understanding of the aetiology and treatment of the postconcussion syndrome.

Vermiculite: a review of the mineralogy and health effects of vermiculite exploitation

Vermiculite is a mica-type mineral that is being used in increasing quantities for insulation, in composite cements, and in horticulture. No serious health risks have been found resulting from the exposure to vermiculite alone nor are any anticipated in view of its long-term chemical durability, even with respect to fibers of vermiculite. Vermiculite ores may contain a variety of other minerals including asbestos, which, if present in significant quantities, could pose a health risk to producers and end users. A variety of regulations are in place that should prevent inadvertent exposure to asbestos in vermiculites, but great care is needed if true asbestos hazards are to be correctly identified. At the same time, vermiculites containing any of a variety amphibole minerals should not be excluded from use because of mistaken identification of these minerals as asbestos. A variety of test methods that have been developed are described and recommendations are made with respect to appropriate action levels for asbestos in vermiculites or other raw materials.

Lung content analysis of cases occupationally exposed to chrysotile asbestos

The lung contents of six workers who had been occupationally exposed to chrysotile asbestos were examined. Five were lung cancer cases from Quebec, Canada. The sixth, an American worker who had developed pleural mesothelioma, was particularly interesting, with the lung content strikingly distinct from the Canadian cases; chrysotile, the predominant fiber in his lung, was present at a concentration 300 times that of the average total fiber content in the Canadian cases. The fiber length distribution of the chrysotile recovered from the U.S. mesothelioma case was indistinguishable from that of chrysotile specimens known to produce mesotheliomas in rats. It was also found that the characteristics of the calcium-magnesium-iron silicate fibers present in all six cases were not readily comparable to tremolite asbestos specimens known to induce mesotheliomas in animals.

Use of the short-term inflammatory response in the mouse peritoneal cavity to assess the biological activity of leached vitreous fibers

We used a special-purpose glass microfiber sample, Johns-Manville Code 100/475, to study the effects of various acid and alkali treatments on biological activity as assessed by inflammation in the mouse peritoneal cavity, the leaching of Si, and the phase contrast optical microscopy (PCOM) fiber number. We used mild and medium treatments with oxalic acid and Tris buffer and harsh treatment with concentrated HCl and NaOH. Mild oxalic acid and Tris treatment for 2 weeks had no effect on any of the end-points, but prolonging the mild oxalic acid treatment time to 2 months reduced the biological activity and the fiber number. Medium oxalic acid treatment reduced the biological activity and the fiber number and caused a loss of Si. Medium Tris alkali treatment reduced the PCOM-countable fibers and the biological activity but did not cause a substantial loss of Si. Harsh treatment with strong HCl did not affect the fiber number or cause leaching but the biological activity was reduced; strong NaOH reduced the fiber number and biological activity, and caused marked leaching of Si. The medium oxalic acid conditions (pH 1.4) were more acid than those found in lung cells but produced the same effects (reduction in fiber number and biological activity) as the more physiological mild treatment (pH 4.0), when prolonged. This study suggests that medium oxalic acid treatment can be used as a short-term assay to compare loss of Si, reduction in fiber number, and change in biological activity of vitreous fibers.(ABSTRACT TRUNCATED AT 250 WORDS)

Asbestos fibers in parenteral medication

The adequacy of current regulations for the control of particulate matter in injectable medicines has been brought into question by a recent television program which reported that asbestos fibers had been found in a number of such preparations. The fibers were identified as chrysotile, which occurs very widely as a secondary mineral in rocks, and is almost ubiquitous among minerals derived from natural erosion. Fibers are found in almost all drinking water and air samples unrelated to any contamination of fiber resulting from industrial exploitation. Because of this, even extreme laboratory precautions may fail to eliminate every fine fiber. A normal person living in an urban environment inhales about 10(5) asbestos fibers daily and ingests 10(10). There is evidence that a small proportion of these fibers regularly enters the circulation, and some fibers may be excreted in the urine. Elimination also occurs because retained chrysotile fibers fragment and disappear relatively quickly from human tissues, probably through macrophage action. Fiber length and dose are also important in disease causation. Established evidence on fiber length, durability, and quantitative exposure required for disease production does not indicate that the fibers reported to have been found in parenteral preparations constitute any hazard.

Variations in the carcinogenicity of tremolite dust samples of differing morphology

Six samples of tremolite of different morphological type were prepared as dusts of respirable size and used in intraperitoneal injection studies in rats. Three "asbestiform" tremolites produced mesotheliomas in almost all animals, although with significantly different tumor-induction periods. A brittle type of fibrous tremolite which, when manipulated to prepare "respirable dust," produced a sample with relatively few asbestiform fibers remaining nonetheless produced tumors in 70% of rats. Two samples of nonfibrous tremolite produced respirable dust samples containing numerous elongated fragments with aspect ratios greater than 3:1, which therefore fitted the definition of respirable fibers. Both these samples produced relatively few tumors, although one had more long "fibers" than did the brittle tremolite that produced 70% of tumors. This study has therefore demonstrated that different morphologic forms of tremolite produce dusts with very different carcinogenic potential. Carcinogenicity does not depend simply on the number of elongated particles injected, and we need to develop methods of distinguishing carcinogenic tremolite fibers from relatively innocuous tremolite dusts, with similar numbers of elongated particles of similar aspect ratios.

Analysis of amphibole asbestos in chrysotile and other minerals

Chrysotile asbestos and many other mineral raw materials contain amphibole minerals which may be asbestiform. There is currently no analytical method which will detect the presence of amphibole at sufficiently low limits to preclude the possibility of inadvertent exposure of persons handling these materials to hazardous airborne fibre concentrations. A method of chemical digestion of chrysotiles has been tested with regard to the determination of their tremolite contaminant content and this has been applied to a range of chrysotile and other minerals. The method improves the sensitivity of the amphibole analysis at least 10-fold giving detection limits of 0.01-0.05% in chrysotile by X-ray diffractometry (XRD). The difficulties arising from compositional and morphological variations are discussed in the context of the potential hazards from airborne fibres and the relative values of analyses by XRD, infrared spectrophotometry (IR) and electron microscopy. It is concluded that XRD and IR are useful as screening methods for the detection of amphibole in chrysotile but other materials should be analysed by optical or electron microscopy.

The effect of fibre durability on the hazard potential of inhaled chrysotile asbestos fibres

Inhaled chrysotile asbestos fibres undergo mineralogical and morphological changes in the lung. Published evidence and interim results from new experiments form the basis for a dosimetric model for such non-durable fibres.

Growth of rat osteoblast-like cells in a lipid-enriched culture medium and regulation of function by parathyroid hormone and 1,25-dihydroxyvitamin D

To examine the role of lipid metabolism in the growth and function of osteoblast-like cells, we studied ROS 17/2.8 osteosarcoma cells and primary cultures of rat calvarial osteoblasts during growth in a serum-free medium supplemented by purified human lipoproteins or by liposomes. Increase in ROS cell number was measured in sparse (1-5 X 10(3)/cm2) cultures over 6-8 days. Liposomes (0-300 micrograms/ml) and high (HDL), low (LDL), and very low density (VLDL) lipoprotein fractions (0-300 micrograms apoprotein) markedly stimulated cell growth. Cells plated at 5 X 10(3)/cm2 achieved growth rates in the presence of LDL or HDL comparable to 10% fetal bovine serum. Serum-free culture with exogenous lipid maintained the response of cell cyclic AMP accumulation to parathyroid hormone. Cyclic AMP response to parathyroid hormone was enhanced by glucocorticosteroid, and was attenuated by 1,25-dihydroxyvitamin D (1,25(OH)2D) with an EC50 (10(-10) M) comparable to that previously observed in serum-cultured cells (J. Biol. Chem. 258:736, 1985). 1,25(OH)2D also increased the alkaline phosphatase activity in ROS cells cultured in lipid-supplemented serum-free culture. Lipoproteins or liposomes also markedly enhanced the proliferative response of sparse cultures of normal rat osteoblasts to polypeptide mitogens.

Elevated serum chromogranin A concentrations in small-cell lung carcinoma

Serum chromogranin A concentrations measured by radioimmunoassay in patients with small-cell lung carcinoma were compared with values from healthy adults and patients with non-small-cell lung carcinoma or chronic obstructive pulmonary disease. The mean (+/- SE) level was significantly higher (p less than or equal to 0.02) in patients with small-cell lung carcinoma (815 +/- 290 ng/mL, n = 46) than in normal controls (123 +/- 6 ng/mL, n = 20) or patients with chronic obstructive pulmonary disease (169 +/- 18 ng/mL, n = 39), lung adenocarcinoma (180 +/- 22, ng/mL, n = 62), large-cell lung carcinoma (183 +/- 23 ng/mL, n = 18), or lung epidermoid carcinoma (203 +/- 37 ng/mL, n = 78). The mean concentration in extensive-stage small-cell lung carcinoma (1155 +/- 449 ng/mL, n = 29) was significantly greater (p = 0.026) than in limited disease (234 +/- 56 ng/mL, n = 17). Elevated serum chromogranin A values were seen in 53% of patients with limited and 72% with extensive disease. Four patients originally classified as having non-small-cell lung carcinomas with raised chromogranin A levels were subsequently found to have mixed small-cell and non-small-cell tumors. Serum chromogranin A concentrations may be a useful marker of small-cell lung carcinoma disease activity.

Silicosis in barium miners

Four men who mined barytes in Scotland and who developed pneumoconiosis are described. Three developed progressive massive fibrosis, from which two died; and one developed a nodular simple pneumoconiosis after leaving the industry. The radiological and pathological features of the men's lungs were those of silicosis and high proportions of quartz were found in two of them post mortem. The quartz was inhaled from rocks associated with the barytes in the mines. The features of silicosis in barium miners are contrasted with the benign pneumoconiosis, baritosis, that occurs in workers exposed to crushed and ground insoluble barium salts. Diagnostic difficulties arise when silicosis develops in workers mining minerals known to cause a separate and benign pneumoconiosis. These difficulties are compounded when, as not infrequently happens, the silicotic lesions develop or progress after exposure to quartz has ceased.

The pathogenicity of long versus short fibre samples of amosite asbestos administered to rats by inhalation and intraperitoneal injection

For many years it has been accepted that fibre dimensions are the most important factor in the development of asbestos related disease with long fibres being more dangerous than short for all types of asbestos. This information has been derived from in vitro experiments and injection or implantation experiments since the kilogramme quantities of specially prepared dusts that are necessary for long term inhalation have not been available. The present study has taken advantage of the availability of a sample of amosite produced so that almost all fibres were less than 5 micron in length. The effects of this dust were compared to dust prepared from raw amosite that contained a very high proportion of long fibres. Previous data from studies with UICC amosite, which was intermediate in length, were also available for comparison. At the end of 12 months of dust inhalation, significantly more short fibre amosite was present in the lung tissue compared to the long but while the long fibre dust caused the development of widespread pulmonary fibrosis, no fibrosis at all was found in animals treated with short fibre. One third of animals treated with long fibre dust developed pulmonary tumours or mesotheliomas but no pulmonary neoplasms were found in animals treated with short fibre dust. Following intraperitoneal injection, the long fibre amosite produced mesotheliomas in 95% of animals with a mean induction period of approximately 500 days. With short fibre dust, only a single mesothelioma developed after 837 days. In previous inhalation studies with UICC amosite, relatively little pulmonary fibrosis had developed and only two benign pulmonary tumours. This would suggest that to produce a significant carcinogenic response in rat lung tissue amosite fibres must be longer than those in the UICC preparation. Following the injection of UICC amosite, however, mesotheliomas developed in the same proportion of animals and with the same mean induction period as with long fibre dust. From this it would appear that while very short fibres exhibit little carcinogenicity to either lung or mesothelial tissues, mesotheliomas can be produced by dust preparations consisting of shorter fibres than are needed to produce tumours.

Inhalation and injection studies in rats using dust samples from chrysotile asbestos prepared by a wet dispersion process

Long term inhalation studies and intraperitoneal injection studies in rats were undertaken with a series of chrysotile asbestos dusts. Three dust samples were generated from chrysotile modified by the wet dispersion process (WDC) and one was from unmodified chrysotile. Following a 1 year inhalation period, all the chrysotile samples proved extremely fibrogenic and carcinogenic and there were no significant differences between the WDC dusts and normal chrysotile. In all experimental groups approximately 25% of animals developed pulmonary carcinomas and in the oldest rats advanced interstitial fibrosis occupied on average 10% of all lung tissue. In the injection studies all the dust samples produced mesotheliomas in over 90% of animals. Very little chrysotile remained in the lungs of the animals that survived longest following dust inhalation and what there was was present as individual chrysotile fibrils. It is suggested that chrysotile is potentially the most harmful variety of asbestos as shown in these and other animal studies but that it is removed from lung tissue quite rapidly. In the long lived human species this may mean that except where exposure levels are very high and of long duration, chrysotile should be less hazardous than other asbestos types.

Kinetics of deposition and clearance of inhaled mineral dusts during chronic exposure

New inhalation studies have been carried out with rats exposed to UICC (Union International Contre le Cancer) amosite asbestos, with the main aim of further elucidating the factors the influence the accumulation of dust in the lung during prolonged chronic exposure. The results show that, for exposure times beyond a few weeks, the lung burden rises linearly and does not level off as predicted by simple models based on ideas taken from the 1966 report of the Task Group on Lung Dynamics. Furthermore, the lung burden is found to scale directly in proportion to the exposure concentration in a way that seems to contradict the overload hypothesis stated earlier. Nevertheless, the general pattern exhibited by our results for asbestos is markedly similar to that found elsewhere for rats inhaling diesel fume, leading to the suggestion that it is general (and not specific to fibrous dust); and the hypothesis that, whereas overload of clearance can take place at high lung burdens after exposure has ceased, it is cancelled by the sustained stimulus to clearance mechanisms provided by the continuous challenge of chronic exposure. The linearity of the increase in lung burden is explained in terms of a kinetic model involving sequestration of some inhaled material to parts of the lung where it is difficult to clear. The particular sequestration model favoured is one where, the longer a particle remains in the lung without being cleared, the more likely it will be sequestrated (and therefore less likely cleared). It is believed that such ideas may eventually be useful in forming exposure-dose relations for epidemiology.