AB1458 JAK INHIBITORS AND VENOUS THROMBOEMBOLISM EVENTS - REASSURING DATA FROM A LARGE SINGLE CENTRE RETROSPECTIVE STUDY

Background

In March 2021, the European Medicines Agency (EMA) sent out a Medicine Alert related Xeljanz (tofacitinib): The Initial clinical trial results suggested an increased risk of major adverse cardiovascular events and malignancies with use of tofacitinib relative to TNF-alpha inhibitors.

In light of these safety alerts, March 2021, the Rheumatology department at Portsmouth Hospitals University NHS Trust updated the Biologics Screening documents to include a cardiovascular and venous thromboembolism (VTE) risk assessment.

We conducted a retrospective observational study to document the incidence of VTE in patients on Janus kinase (JAK) inhibitors admitted to our Venous thromboembolism Service from 14th April 2018 to 30th November 2021 (43 months).

This includes patients who were suspected of having both deep vein thrombosis (DVT) and/or Pulomonary Thromboembolisim (PE). We were particularly interested to assess whether any patients with VTE events had been receiving JAK inhibitors given the potential association of JAK inhibitor usage and VTE.

Objectives

To establish whether patients exposed to JAK inhibitors had any increased incidence of VTE. This was done through a retrospective analysis for all patients presenting to Portsmouth Hospitals University NHS Trust.

Methods

We utilised the International Classification of Diseases (ICD10) diagnosis code of I82 (182.0, 182.1,182.2,128.3,182.8,1782.9). This includes; Budd Chiari syndrome, thrombophlebitis migrans, embolism and thrombosis of vena cava, embolism and thrombosis renal vein, embolism and thrombosis of other specified view and embolism and thrombosis unspecified vein. From this data set, we reviewed how many case of VTE were noted in patients on JAK inhibitors. The Data was confined to patients who underwent diagnostic tests for VTE at Portsmouth Hospials University NHS Trust.

Results

A total of 417 patients had been admitted to the VTE Service for diagnostic assessment between 14th April 2018 to 30th November 2021.

A total of 261 patients had been on a JAK inhibitor during the period of observation. This included patients on Tofacitinib, Baricitinib, Filgotinib and Upadacitinib. This was for treatment in Rheumatoid Arthritis and Psoriatic Arthritis where liscenced indications were appropriate.

None of these had a VTE event. The age range of the patients on active treatment was 18 to 86 years old with the average of 60.7 years. The majority of patients were female (72.7%) with male patients comprising the remainder (27.3%).

8 patients under the care of the Rheumatology service were identified as having VTE events.

Conclusion

From a total of 261 patients on JAK inhibitors during a 43 month period; 0 patients had a confirmed VTE event.

After March 2021, the Rheumatology department soutght to address the concerns raised by the EMA alert. There were two key areas in addressing the concerns highlighted. Firstly, clinicians had an heightened awareness of the potnetial risk of VTE and JAK inhibitor useage. Additionally, there was also the introduction of a new screening process which focussed on highlighting and assessing risk facotrs for VTE in patients being screened for JAK inhibitors.

This was a new departmental service innovation introduced following the potential patient safety alert.

We would postulate that some of the highly encouraging data obtained may partly be influenced by this service development. Conversely, much of the data was gathered before these assocations were established and before any service changes were made.

We acknowedge that this data set is from a single centre analysis. However, given the sample size and duration of retrosepctive review we hope this serves to reassure clinicians that JAK inhibitor usage should remain a valid treatment option in Rheumatology patients, for licenced indications.

References

[1]https://www.ema.europa.eu/en/medicines/dhpc/xeljanz-tofacitinib-increased-risk-major-adverse-cardiovascular-events-malignancies-use-tofacitinib

[2]https://www.ema.europa.eu/en/medicines/human/referrals/xeljanz

Disclosure of Interests

Colin Beevor Speakers bureau: Roche, UCB, Lily, Nordic, Sadie Bartosz-Bowden: None declared, Margaret Fletcher: None declared, Leslie Goh: None declared, Gurdeep Dulay Speakers bureau: Roche Chugai, Novartis, Amgen, Lilly, Sandoz, Thornton Ross/ Internis

Oncology alternative payment models: lessons from commercial insurance

Many payers and clinicians are committed to advancing value-based care through the establishment of alternative payment models (APMs) that incentivize practices and clinicians to improve quality and reduce cost. A multistakeholder working group has observed that in specialty fields such as oncology, despite many attempts to design and implement APM pilots for commercial and Medicare Advantage populations, practical challenges and small numbers of episodes and patients present headwinds to viability and scalability. Despite this, some payers report emerging good practices and are optimistic about APMs. Careful and realistic consideration of the specific goals of a proposed model is warranted, as is close examination of the feasibility of transferring risk.

A pilot screening study for low bone mass in Singaporean women using years since menopause and BMI

OBJECTIVE

Current risk assessment tools for osteoporosis have inconsistent performance across different cohorts, making them difficult for clinical practice. This study aimed to evaluate a simple screening index comprising years since menopause (YSM) and body mass index (BMI) that identifies postmenopausal Singaporean women with a greater likelihood of low bone mass.

METHODS

The study used data from 188 treatment-naïve postmenopausal women. The associations between low bone mass and different demographic variables, including age, YSM and BMI, were assessed using multivariable logistic regression. Diagnostic performance of the calculated screening index was compared to the Osteoporosis Self-Assessment Tool for Asians (OSTA) and the Fracture Risk Assessment Tool (FRAX^®).

RESULTS

YSM and BMI were significantly associated with low bone mass. The area under the receiver operating characteristic curves was 0.803 for the screening index, 0.759 for the OSTA, 0.683 for the FRAX^® (major osteoporotic fracture probability [MOFP]) and 0.647 for the FRAX^® (hip fracture probability [HFP]). Non-parametric Spearman's correlation between the screening index and the other models was 0.857 with the OSTA score, 0.694 with the FRAX^® (HFP) and 0.565 with the FRAX^® (MOFP) (p < 0.0005).

CONCLUSIONS

The diagnostic performance of the screening index comprising YSM and BMI was equivalent to the OSTA and the FRAX^®. A risk chart was developed for clinicians to identify and recommend subjects for a further dual-energy X-ray absorptiometry scan. Validation of this model in larger and more diverse cohorts is required.

A systematic MEDLINE analysis of therapeutic approaches in ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic inflammatory disorder involving the sacroiliac joints (SIJs), spine and less frequently the peripheral joints. Traditionally, it is well recognised that AS is a challenging disease to manage due to the lack of effective therapeutic options. Current evidence would suggest this has changed and there are now a number of therapies available that provide persistent control of inflammatory symptoms with improvement in daily function. NSAIDs remain the first step in patient treatment. Sulphasalazine may be effective in peripheral arthritis and there are emerging data to support its use in early inflammatory back pain. Studies have shown that pamidronate and steroid injection into SIJ have a symptom-modifying effect in AS. Current data suggest that anti-TNF treatment promises early benefit which is likely to continue in the longer term. Treatment with biologics should be considered sooner rather than later in the management of AS.

Disease activity in longstanding ankylosing spondylitis: a correlation of clinical and magnetic resonance imaging findings

We evaluated magnetic resonance imaging (MRI) changes in ankylosing spondylitis (AS) patients with longstanding disease and investigated whether there is any relationship between MRI findings and validated methods of disease assessment. A total of 34 AS patients with disease duration greater than 10 years were included in this observational cross-sectional study (26 men, 8 women). The main outcome measures were Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Global assessment (BASG), Bath Ankylosing Spondylitis Metrology Index (BASMI), MRI of the thoracic and lumbar spine (AS spi MRI A) and measurement of serum erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), plasma viscosity (PV) and immunoglobulin A (Ig A). The median scores for the acute lesions based on AS spi MRI A scoring system was 2.5 (0-4.12). The respective mean ESR and CRP were 36 (SD, 24.00) mm/h and 14.19 (SD, 24.00) mg/l with the median PV of 1.8 (1.75-1.87). The median BASG, BASFI and BASDAI were 4.55 (2.37-5.55), 4.40(2.31-5.47) and 4.32 (3.07-6.48), respectively. No significant correlations were found between the acute MRI scores and each of the clinical instruments and laboratory markers of inflammation. In this study, majority of AS patients with longstanding disease had very low AS spi MRI A scores or no evidence of spinal inflammatory lesions. Our study would suggest that MRI should be used along with other measures of disease activity in the assessment of symptomatic AS patients with longstanding disease.

Architecture of floral branch systems in maize and related grasses

The external appearance of flowering plants is determined to a large extent by the forms of flower-bearing branch systems, known as inflorescences, and their position in the overall structure of the plant. Branches and branching patterns are produced by tissues called shoot apical meristems. Thus, inflorescence architecture reflects meristem number, arrangement and activity, and the duration of meristem activity correlates with branch length. The inflorescences of maize, unlike those of related grasses such as rice and sorghum, predominantly lack long branches, giving rise to the tassel and familiar corncob. Here we report the isolation of the maize ramosa1 gene and show that it controls inflorescence architecture. Through its expression in a boundary domain near the nascent meristem base, ramosa1 imposes short branch identity as branch meristems are initiated. A second gene, ramosa2, acts through ramosa1 by regulating ramosa1 gene expression levels. ramosa1 encodes a transcription factor that appears to be absent in rice, is heterochronically expressed in sorghum, and may have played an important role in maize domestication and grass evolution.

Increased levels of antibodies to cytokeratin 18 in patients with rheumatoid arthritis and ischaemic heart disease

OBJECTIVE

To determine whether raised levels of antibodies to CK18 in patients with RA are associated with ischaemic heart disease (IHD).

METHODS

IgA, IgG, and IgM antibodies to CK18 were measured by enzyme linked immunosorbent assay (ELISA) in patients with RA with (n = 34) or without (n = 28) IHD. The relationship between CK18 antibody levels and markers of inflammatory and/or cardiovascular disease was examined.

RESULTS

Initial analysis showed that IgG antibody levels to CK18 were higher in patients with RA with IHD than in those without (50.1 v 34.5 AU, p = 0.047), although significance was lost after correction for multiple comparisons. Further analysis showed a significant difference (p = 0.015) between patients with IHD and a positive family history, and patients without IHD and a negative family history (53.7 v 29.0 AU, Kruskal-Wallis multiple comparison Z value test). There was also a significant trend of increasing 10 year cardiovascular risk with increasing CK18 IgG antibody levels (p = 0.01). No association was found between CK18 antibody levels and conventional markers of inflammation or cardiovascular disease, but an association was found between levels of CK18 IgG and IgG antibodies to cytomegalovirus (CMV) (Spearman's r(s) = 0.379, p(corr) = 0.04). No evidence for cross reactivity of CK18 antibodies with CMV antigens was found.

CONCLUSION

Levels of IgG antibodies to CK18 are raised in patients with RA with IHD, particularly if they also have a positive family history. This may reflect damage to CK18 containing cells in the cardiac vasculature and/or in atherosclerotic plaques, and may be a useful additional marker for the identification of patients with, or likely to develop, IHD.

Are evidence-based guidelines being followed for the monitoring of ocular toxicity of hydroxychloroquine? A nationwide survey of practice amongst consultant rheumatologists and implications for clinical governance

OBJECTIVE

To determine whether consultant rheumatologists monitor the ocular toxicity of hydroxychloroquine according to standards set by national guidelines.

METHOD

An observational cross-sectional questionnaire study of all consultant rheumatologists in the UK was undertaken. The main outcome measure was the proportion of rheumatologists who practise in compliance with nationally set standards.

RESULTS

A wide variation in practice was found. Nearly half the respondents did not assess either baseline visual symptoms or visual acuity, and 3% undertook infrequent visual monitoring at intervals of longer than 1 yr. At least a quarter of rheumatologists within the survey routinely referred patients to ophthalmology, either for baseline visual screening or for regular visual monitoring. Such use of ophthalmology services was outside the recommendations of the guidelines and would suggest that these referrals were unnecessary. No differences in monitoring practices were ascertained between respondents from district general and teaching hospitals.

CONCLUSION

The present study shows that nationally set guidelines for the monitoring of ocular toxicity of hydroxychloroquine are not consistently followed by rheumatologists with regard to baseline assessment, referral to ophthalmology and frequency of monitoring. Clinical guidelines aim to reduce variations in practice and to promote uniform and consistent best practice. The present study demonstrates a lack of conformity to national guidelines in respect of the monitoring of ocular toxicity of hydroxychloroquine. Clinical governance provides a framework for assuring quality in health care. The implications of this study for clinical governance would include understanding why barriers to the use of guidelines might occur and how they might be overcome, risk management, accounting for the reasonableness of a decision for positive divergence and audit.

An evidence-based approach to the management of low back pain and sciatica: how the evidence is applied in clinical cases

BACKGROUND

Low back pain and sciatica are common complaints that affect a major proportion of the population at some time in their lives. The treatment and management of this condition may vary widely.

OBJECTIVE

The present paper aims to provide an evidence-based approach to the management of low back pain and sciatica, and demonstrates how to search for the evidence and how to apply it practically in individual patients. The principles underlying evidence-based medicine are explained. The practice of evidence-based medicine requires initial formulation of the appropriate clinical question, followed by searching databases for relevant evidence. Finally evidence needs to be applied on a patient-specific basis.

METHOD

Best Evidence, the Cochrane Library, Embase and Medline were searched to obtain quality controlled information regarding the management of low back pain and sciatica.

RESULTS

Current evidence shows that an active exercise programme promotes early recovery. This may allow patients to resume an active and sportive lifestyle. Epidural corticosteroid injections may help to resolve additional troublesome symptoms of sciatica. Two clinical cases are used to show how evidence-based medicine can be individualized to specific patients.

CONCLUSIONS

A patient-focused strategy combining best evidence and clinical expertise is suggested as the mainstay for the management of low back pain.

Comparative study of bone mineral density, calcium, and vitamin D status in the Gujarati and white populations of Leicester

OBJECTIVES

To evaluate differences in bone mineral density (BMD), calcium, and vitamin D status between the Gujarati (South Asian) and white populations resident in Leicester and to determine whether this was linked to lifestyle factors.

DESIGN

An observational cross sectional study of randomly selected Gujarati and white volunteers aged from 20-40 years.

SETTING

City of Leicester.

PARTICIPANTS

Subjects were randomly selected by age (20-40 years) and ethnicity. A total of 262 individuals volunteered to participate, of which 201 (51 white females, 71 Gujarati females, 37 white males, 42 Gujarati males) were eligible for the study.

MAIN OUTCOME MEASURES

Results of questionnaire, BMD at the hip and lumbar spine, and measurement of serum calcium, albumin, alkaline phosphatase, and 25-hydroxyvitamin D.

RESULTS

Male and female white subjects were significantly taller and heavier than their Gujarati counterparts. There was a statistically significant difference in BMD both at the spine (p<0.001) and hip (p<0.001) between the white and Gujarati females with the Gujaratis having a lower BMD. There was a trend for Gujarati males to have a lower BMD at the hip and spine than their white counterparts but these figures did not reach statistical significance. The intensity of cigarette smoking and the amount of alcohol consumption were both higher in the white male and female subjects. Sunlight exposure (>4 hours per day) was significantly higher in white subjects compared with Gujaratis. There were no significant differences in the mean level of serum calcium or alkaline phosphatase between the Gujaratis and whites. A significantly higher proportion (p<0.001) of the Gujarati men and women had a vitamin D level that was not measurable (that is, below the lower limit of the laboratory range of normal). Of those who had a measurable level (that is, in the normal range) mean levels of vitamin D were lower (p<0.05) in the Gujarati men and women.

CONCLUSION

The present study is the first of its kind to note a low BMD in Gujarati subjects of South Asian origin compared with their white counterparts, living in Leicester. This study also confirms the presence of low serum vitamin D levels in Gujaratis. There is a need for more research in South Asians with regard to the collection of normal BMD values. This could provide a more meaningful reference range for identifying South Asians at risk of osteoporotic fractures and may have public health implications of relevance to this ethnic group.

Cross-talk between signalling pathways and the multidrug resistant protein MDR-1

The multidrug resistant protein MDR-1 has been associated with the resistance to a wide range of anti-cancer drugs. Taxol is a substrate for this transporter system and is used in the treatment of a wide range of human malignancies including lung, breast and ovarian cancer. We have generated a series of ovarian cell lines resistant to this compound, all of which overexpress MDR-1 through gene amplification. We present novel evidence that a constitutive activation of the ERK1/2 MAP kinase pathway was also observed although the level of active JNK and p38 remained unchanged. Inhibition of the ERK1/2 MAP kinase pathway using UO126 or PD098059 re-sensitised the Taxol resistant cells at least 20-fold. Importantly, when Mdr-1 cDNA was stably expressed in the wild-type cell line to generate a highly Taxol-resistant sub-line, 1847/MDR5, ERK1/2 MAP kinases again became activated. This result demonstrated that the increased activity of the signalling pathway in the Taxol-resistant lines was directly attributable to MDR-1 overexpression and was not due to the effects of Taxol itself. Additionally, we demonstrated that inhibition of the P13K pathway with LY294002 sensitised the MDR-1-expressing 1847/TX0.5 cells and 1847/MDR5 cells at least 10-fold but had no effect in the wild-type cells. This finding suggests a possible role for this pathway, also, in the generation of resistance to Taxol.