POS0193 EVALUATION OF CRESS IN THE PHASE 2 RANDOMISED PLACEBO-CONTROLLED STUDY OF SEQUENTIAL BELIMUMAB/RITUXIMAB ADMINISTRATION IN PATIENTS WITH PRIMARY SJÖGREN’S SYNDROME

Background

EULAR Sjögren’s syndrome disease activity index (ESSDAI) assesses systemic disease activity in patients (pts) with primary Sjögren’s syndrome (pSS); however, weaknesses include exclusion of patient-reported symptoms, tear and salivary gland function, and a marked placebo (PBO) response. Composite of Relevant Endpoints for Sjögren’s Syndrome (CRESS) is a recently developed composite outcome measure validated using data from three Phase 3 randomised controlled trials of pts with pSS.1 Concise CRESS (cCRESS) is used when ocular staining score and salivary gland ultrasonography are unavailable. ESSDAI was an endpoint in a Phase 2, PBO-controlled study, evaluating the safety and efficacy of belimumab (BEL) and rituximab (RTX) sequential administration (BEL/RTX), and BEL and RTX monotherapies in pts with pSS. Although the results numerically favoured BEL/RTX over PBO, this was not statistically significant.

Objectives

To evaluate the efficacy of BEL/RTX and monotherapies using cCRESS overall responses at Weeks (Wks) 24, 52, and 68, and individual item responses at Wk 24 in pts with pSS who completed the Phase 2 study.

Methods

In the Phase 2, double-blind, 68-Wk study (NCT02631538) adults were randomised (2:2:2:1) into 4 treatment arms: BEL/RTX (n=24; weekly BEL 200 mg subcutaneous [SC] to Wk 24 followed by weekly PBO SC to Wk 52 + RTX 1000 mg intravenous [IV], Wk 8 + 10), BEL monotherapy (n=24; weekly BEL 200 mg SC to Wk 52), RTX monotherapy (n=25; RTX 1000 mg IV, Wk 8 + 10), or PBO (n=13). Pts were classified post hoc as cCRESS responders when ≥3 of the following 5 items were met: 1) Clinical (Clin)ESSDAI score <5 (low disease state); 2) decrease of ≥1 point or ≥15% from baseline (BL) in EULAR Sjögren’s Syndrome Patient Reported Index (ESSPRI); 3) increase of ≥5 mm from BL in abnormal Schirmer’s test, or no change to abnormal if normal at BL; 4) unstimulated whole saliva (UWS) increase of ≥25% from BL, or any increase from BL if score was 0 at BL; 5) decrease of ≥25% in the rheumatoid factor (RF) titre from BL, or decrease of ≥10% in IgG from BL.1

Results

Of 86 randomised pts, 60 completed follow-up to Wk 68 (completer population) and were included in the analysis. Most pts were female (95%, n=57); mean (SD) age was 49.6 (13.0) years. BL disease characteristics are presented in the Table 1.

Table 1.

Clinical, functional, and laboratory parameters at BL and cCRESS responders at Wks 24, 52, and 68 (completer population)

PBO (n=8)BEL/RTX (n=17)BEL (n=19)RTX (n=16)Pt parameters at BL, mean (SD)ClinESSDAI11.1 (3.76)11.7 (5.47)9.2 (3.77)11.7 (4.76)ESSPRI6.4 (2.05)6.0 (1.97)6.5 (1.68)5.9 (2.20)Schirmer, mm/5 min2.7 (3.25)5.3 (6.44)3.3 (3.16)2.8 (3.15)UWS, ml/min0.1 (0.11)0.1 (0.12)0.1 (0.09)0.1 (0.14)RF, KU/l60.8 (42.24)30.9 (38.20)37.0 (34.98)105.0 (200.97)IgG, g/l20.4 (6.65)16.7 (5.00)18.1 (7.19)16.5 (6.09)cCRESS responders, n (%)Wk 244 (50.0)9 (52.9)7 (36.8)5 (31.3)Wk 524 (50.0)10 (58.8)8 (42.1)4 (25.0)Wk 681 (12.5)6 (35.3)7 (36.8)3 (18.8)

At Wks 24 and 52, the proportion of cCRESS responders was numerically higher with BEL/RTX than with either BEL, RTX, or PBO, but the difference was not significant (Table 1). At Wk 68, the proportion of cCRESS responders was numerically higher with BEL/RTX than with RTX or PBO (Table 1). The 5 cCRESS items contributed relatively equally to total cCRESS response, with the highest response observed in the RF/IgG item and the lowest in the tear gland item (Schirmer’s test; Figure 1).

Figure 1.

cCRESS and individual item responders at Wk 24 (completer population)

Conclusion

At Wks 24, 52, and 68, BEL/RTX was generally associated with a numerically higher cCRESS response rate compared with the monotherapies or PBO. The PBO response for cCRESS was notable and similar to the PBO response for ClinESSDAI. The PBO response in the tear and salivary gland items was greater than in the other treatment arms, perhaps due to the use of cCRESS instead of CRESS. Due to the small sample size, the results should be interpreted with caution.

References

[1]Arends S, et al. Lancet Rheumatol 2021;3:553–62

Acknowledgements

This post hoc analysis of the GSK Study 201842 was funded by GlaxoSmithKline (GSK). Medical writing support was provided by Casmira Brazaitis, PhD, Fishawack Indicia Ltd, UK, part of Fishawack Health, and was funded by GSK.

Disclosure of Interests

Hendrika Bootsma Consultant of: BSM, Roche, Novartis, Medimmune and Union Chimique Belge, Grant/research support from: BSM and Roche, Suzanne Arends: None declared, Liseth de Wolff: None declared, Kenneth L Clark Shareholder of: GSK, Employee of: GSK, Andre van Maurik Shareholder of: GSK, Employee of: GSK, Prafull Mistry Shareholder of: GSK, Employee of: GSK, Pragya Shukla Shareholder of: GSK, Employee of: GSK, Svetlana Nihtyanova Shareholder of: GSK, Consultant of: Roche, Employee of: GSK, Norma Lynn Fox Shareholder of: GSK, Employee of: GSK, David Roth Shareholder of: GSK, Employee of: GSK

POS0185 BELIMUMAB DISRUPTS MEMORY B-CELL TRAFFICKING IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Belimumab (BEL), a recombinant human monoclonal antibody directed against B-cell activating factor (BAFF), is the first approved biological agent for patients with active systemic lupus erythematosus (SLE) and lupus nephritis (LN).1 BEL inhibits primary humoral immune responses by depleting naïve B cells that are dependent on BAFF for their survival while secondary humoral immune responses by memory B cells (MBCs) remain intact. Indeed, some studies reported an increase of circulating MBCs following neutralisation of BAFF.2-4 So far, these effects of BEL on the MBC compartment in SLE patients have not been investigated.

Objectives

This study aimed to establish the dynamics of circulating MBCs in patients with SLE treated with BEL and to perform an in-depth analysis of the impact of BEL on the MBC compartment.

Methods

First, a retrospective meta-analysis was performed by pooling individual patient MBC flow cytometry data from 1245 patients with SLE treated with BEL 10 mg/kg IV or placebo (PBO) from four randomised clinical trials (NCT00071487, NCT00410384 [BLISS-76],3NCT01632241 [EMBRACE],5NCT01649765 [PLUTO]6). Second, extensive B-cell subset phenotyping was performed prospectively by employing high-sensitivity flow cytometry (HSFC) based on EuroFlow protocols7 in patients with active SLE (from the BLISS-BELIEVE trial [NCT03312907])8 and with severe SLE/LN (from the SynBioSe-2 trial [NCT03747159])9 treated with BEL. Additionally, in-depth characterisation of surging MBCs in circulation was performed by single-cell RNA sequencing (scRNA-seq).

Results

By comparing BEL-treated with PBO-treated patients with SLE, a substantial increase in circulating MBC counts was established 4 weeks after BEL initiation, gradually returning to baseline by Week 52. The increase of MBCs was most prominent in BEL-treated patients with higher SLE disease activity (SLE Disease Activity Index >9), serologically active patients (dsDNA positive and/or low complement levels) and with younger age (below 18 years). HSFC established that the increase was non-specific and observed in a broad range of MBC subclasses peaking as early as 2 weeks after BEL initiation. Subsequent scRNA-seq analysis of the emerging MBCs revealed a non-proliferating phenotype with a prominent decrease in activation status. In these circulating MBCs, a large amount of migration and adhesion genes were downregulated suggesting that the accumulation of MBCs following BEL treatment was related to their impaired cell-cell adhesion, disrupting cell-trafficking and preventing extravasation.

Conclusion

After initiation of BEL treatment, a substantial increase of circulating MBCs was firmly established and was most notable in patients with severe, serologically active SLE/LN. The surge of circulating MBCs appeared to be associated with disrupted lymphocyte trafficking of MBCs, thereby suggesting a new potential therapeutic mechanism of BEL on MBCs in SLE. These findings have important implications to our understanding and consequent improvement of B-cell targeted treatment strategies in patients with active SLE and LN, as MBC accumulation in circulation might allow for more efficient targeting of the B-cell compartment.

References

[1]GlaxoSmithKline. Benlysta US prescribing information. 2021

[2]Wallace DJ, et al. Arthritis Rheumatol 2009;61(9):1168–78

[3]Furie R et al. Arthritis Rheumatol 2011;63(12):3918–30

[4]Stohl W et al. Arthritis Rheumatol 2012;64(7):2328–37

[5]Ginzler E et al. Arthritis Rheumatol 2022;74(1):122–3

[6]Dimelow R et al. Clin Pharmacol Drug Dev 2021;10(6):622–33

[7]Blanco E et al. J Allergy Clin Immunol 2018;141(6):2208–19

[8]Teng YKO et al. BMJ Open 2019;9(3):e025687

[9]ClinicalTrials.gov NCT03747159. Accessed January 19 2022

Acknowledgements

This analysis of the GSK Study 205646 was funded by GlaxoSmithKline (GSK). Editorial support was provided by Nicholas Thomas, PhD, Fishawack Indicia Ltd. UK, part of Fishawack Health, and was funded by GSK. The EuroFlow-based HFSC was technically supported by Alita van der Sluijs and Sandra de Bruin and data acquisition was performed at the Flow cytometry Core Facility of Leiden University Medical Center, Leiden, NL.

Disclosure of Interests

Eline J. Arends: None declared, Mihaela Zlei Grant/research support from: GSK (flow cytometry studies for GSK BLISS-BELIEVE study NCT03312907), Christopher M. Tipton: None declared, Jasna Cotic Shareholder of: GSK, Employee of: GSK, Zgjim Osmani: None declared, Fenna de Bie Grant/research support from: GSK (flow cytometry studies for GSK BLISS-BELIEVE study NCT03312907), Sylvia Kamerling: None declared, Andre van Maurik Shareholder of: GSK, Employee of: GSK, Richard Dimelow Shareholder of: GSK, Employee of: GSK, Yun Irene Gregan Shareholder of: GSK, Employee of: GSK, Norma Lynn Fox Shareholder of: GSK, Employee of: GSK, Ton Rabelink: None declared, David Roth Shareholder of: GSK, Employee of: GSK, Ignacio Sanz Consultant of: Yes. GSK, BMS, Janssen, Kyverna, Jacques J.M. van Dongen Consultant of: BD Biosciences and Cytognos (fees for LUMC), Grant/research support from: GSK (flow cytometry studies for GSK BLISS-BELIEVE study NCT03312907), Cees van Kooten: None declared, Y.K. Onno Teng Consultant of: GSK, Aurinia Pharmaceuticals, Novartis, KezarBio, Grant/research support from: GSK

POS0183 THE EFFECT OF BELIMUMAB ON SRI-4 RESPONSE IN MULTIPLE SUBGROUPS OF PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: RESULTS OF A LARGE INTEGRATED ANALYSIS

Background

Belimumab (BEL) is approved for the treatment of active autoantibody-positive systemic lupus erythematosus (SLE).1 Four Phase 3 studies have consistently demonstrated greater SLE Responder Index (SRI) response rates with BEL vs placebo (PBO).2-5 This robust dataset allows for additional exploration of the onset of efficacy of BEL and response rates by patient (pt) characteristics.

Objectives

To perform a post hoc analysis evaluating the effect of BEL on SRI-4 response across a large, pooled population and pt subgroups.

Methods

The Belimumab Summary of Lupus Efficacy (Be-SLE) integrated analysis evaluated data from adults with SLE from 5 double-blind, PBO-controlled BEL trials: BLISS-76, BLISS-52, BLISS-NEA, BLISS-SC, and EMBRACE.2-6 Pts were randomised to BEL (monthly intravenous 10 mg/kg or weekly subcutaneous 200 mg) or PBO, plus standard therapy. Data were collected every 4 weeks (wks) from baseline (BL) to Wk 52. The SRI-4 response rate (a composite measure that includes ≥4-point reduction in Safety of Estrogens in Lupus Erythematosus National Assessment - SLE Disease Activity Index [SELENA-SLEDAI] score, stable Physician Global Assessment [PGA] increase of <0.3, and no new British Isles Lupus Assessment Group [BILAG] 1A/2B organ domain scores) by visit and time to first SRI-4 response maintained through Wk 52 were determined for both treatment groups. SRI-4 response rates at Wk 52 were evaluated by BL characteristic subgroups: SELENA-SLEDAI score; SLE International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) score; disease duration; biomarker levels (anti-dsDNA, complement [C]3/C4); glucocorticoid (GC), immunosuppressant (IS), and antimalarial (AM) use.

Results

Overall, 3086 pts were included (BEL, n=1869; PBO, n=1217). Most were female (94.4%); mean (standard deviation [SD]) age was 37.0 (11.6) years. Mean (SD) SLE duration was 6.4 (6.4) years.

At Wk 52, in the overall population, significantly more BEL vs PBO pts were SRI-4 responders (Figure 1). A significantly greater proportion of SRI-4 responders was observed with BEL vs PBO as early as Wk 8 (38.4% vs 33.3%; odds ratio, OR [95% confidence interval, CI] 1.25 [1.07, 1.46]; p=0.0060), which continued to increase to Wk 52 (54.8% vs 41.6%; OR [95% CI] 1.70 [1.46, 1.98]; p<0.0001). At Wk 52, more BEL vs PBO pts had a 4-point reduction in SELENA-SLEDAI (56.3% vs 43.1%; OR [95% CI] 1.71 [1.47, 2.00]; p<0.0001), no worsening in PGA (76.6% vs 67.9%; OR [95% CI] 1.52 [1.28, 1.79]; p<0.0001), and no new BILAG 1A/2B organ domain scores (77.1% vs 69.4%; OR [95% CI] 1.47 [1.25, 1.74]; p<0.0001). Pts on BEL were 52% more likely to experience an SRI-4 response that was maintained through Wk 52 (hazard ratio, HR [95% CI] 1.52 [1.36, 1.69]; p<0.0001).

Figure 1.

SRI-4 response at Wk 52 in the overall population and by BL characteristic subgroups.

*OR (95% CI) and p-value are from a logistic regression model for BEL vs PBO comparison with covariates of treatment group, study and BL SELENA-SLEDAI score (≤9 vs ≥10)

SRI-4 response rates were significantly higher with BEL vs PBO in most subgroups, with the highest response rates observed in pts with SELENA-SLEDAI score of ≥10, low C3 and/or C4 + anti-dsDNA ≥30 IU/ml, and low C3 and/or C4 at BL (Figure 1).

Conclusion

Significantly more pts receiving BEL had SRI-4 response rates that occurred from Wk 8 and were maintained through Wk 52 compared with pts receiving PBO. The efficacy of BEL was consistent across multiple pt subgroups, with higher response rates in pts with SELENA-SLEDAI scores of ≥10, low C3 and/or C4 + anti-dsDNA ≥30 IU/ml and low C3 and/or C4 at BL. These results further substantiate the benefits of BEL in the treatment of adults with SLE.

References

[1]GlaxoSmithKline. Benlysta US prescribing information. 2021

[2]Furie R, et al. Arthritis Rheumatol 2011;63(12):3918–30

[3]Navarra SV, et al. Lancet 2011;377(9767):721–31

[4]Stohl W, et al. Arthritis Rheum 2017;69(5):1016–27

[5]Zhang F, et al. Ann Rheum Dis 2018;77(3):355–63

[6] Ginzler E, et al. Arthritis Rheum 2021; doi: 10.1002/art.41900

Acknowledgements

This analysis was funded by GlaxoSmithKline (GSK). Medical writing support was provided by Lulu Hill, MPharmacol, Fishawack Indicia Ltd. UK, part of Fishawack Health, and was funded by GSK.

Disclosure of Interests

Michelle A Petri Consultant of: GSK, Grant/research support from: GSK, George Bertsias Speakers bureau: Pfizer, Aenorasis, UCB, Novartis, Lilly, SOBI, Consultant of: Novartis, GSK, AstraZeneca, Grant/research support from: GSK, Pfizer, Mark Daniels Shareholder of: GSK, Employee of: GSK, Norma Lynn Fox Shareholder of: GSK, Employee of: GSK, Bevra H. Hahn Consultant of: UCB, GSK, Anne Hammer Shareholder of: GSK, Employee of: GSK, Julia Harris Shareholder of: GSK, Employee of: GSK, Holly Quasny Shareholder of: GSK, Employee of: GSK, Chiara Tani Speakers bureau: GSK, AstraZeneca, Anca Askanase Consultant of: AstraZeneca, Aurinia Pharmaceuticals Inc., Amgen, AbbVie Inc., BMS, GSK, Grant/research support from: AstraZeneca, Eli Lilly and Company, GSK, Idorsia Pharmaceuticals Ltd, Janssen Pharmaceuticals, Pfizer

OP0281 PHARMACODYNAMIC EFFECT OF SEQUENTIAL BELIMUMAB (BEL) AND RITUXIMAB (RTX) THERAPY IN PATIENTS (PTS) WITH SYSTEMIC LUPUS ERYTHEMATOSUS (SLE): THE PHASE 3, RANDOMISED, PLACEBO-CONTROLLED BLISS-BELIEVE STUDY

Background

BEL is approved for active SLE and lupus nephritis (adults only). Despite failed trials,1 RTX remains in the SLE treatment armamentarium. Sequential BEL and RTX therapy offers a promising strategy to target B cells by distinct but complementary mechanisms.

Objectives

To assess the pharmacodynamic effects of BEL and a single RTX cycle on immunologic biomarkers in adults with SLE.

Methods

In this 104-week (wk) study (NCT03312907), all pts with active SLE received subcutaneous BEL 200 mg/wk for 52 wks. Pts were randomised to receive intravenous (IV) RTX 1000 mg at Wks 4 + 6 (BEL/RTX), IV PBO at Wks 4 + 6 (BEL/PBO), or continued treatment with standard therapy (BEL/ST). For BEL/RTX and BEL/PBO pts, a 52-wk treatment-free observational phase followed the 52-wk treatment phase; BEL/ST pts continued to receive BEL for 104 wks. Changes from baseline (BL) in anti-dsDNA and C3/C4 levels, and counts of total B cells (CD19+) and B-cell subsets (CD20+; naïve; memory; activated B-cells), were analysed.

Results

292 pts received ≥1 study treatment dose (BEL/PBO n=72; BEL/RTX n=144; BEL/ST n=76). For pts assessed at Wk 52, reductions from BL in anti-dsDNA levels were seen in all 3 groups with a significant difference between BEL/RTX and BEL/PBO (p=0.0495). C3/C4 levels increased from BL to Wks 52 and 104 in all groups, with trends for greater increases with BEL/RTX versus BEL/PBO (Table 1). At Wk 52, total B cells and most B-cell subsets decreased in all 3 groups (Table 1), with significant differences between BEL/RTX and BEL/PBO (p<0.0001 for all). During the observation period, repopulation of total CD19+ B cells (comprising mostly of naïve CD20+CD27-) towards BL levels by Wk 104 was most evident with BEL/RTX, while low circulating CD20+CD27+ memory B cell levels remained relatively unchanged (Table 1).

Table 1.

Absolute changes in biomarkers for treatment phase completers*

Median (25th, 75thpercentile)Change from BLAt Wk 52At Wk 104BEL/PBOBEL/RTXBEL/STBEL/PBOBEL/RTXBEL/STn=54n=102n=58n=24n=44n=50Anti-dsDNA (IU/ml)-9 (-83, 1)-51 (-155, -3)-5 (-61, 0)-9.5 (-197, 2)-55 (-329, -2)-6.5 (-57, -1)C3 (md/dl)8.5 (-8, 21)15† (0, 30)1‡ (-6, 11)6 (-5.5, 19.5)11 (-7, 27)7.5 (-5, 23)C4 (md/dl)2 (0, 5)4† (2, 9)2‡ (-1, 4)1.5 (-1.5, 4.5)3 (0, 8)3 (1, 5)B cells and B-cell subsets (cells/ml)n=48n=93n=55n=20n=40n=47CD19+-57,570 (-120,810, -5861)-95,313 (-193,946, -44,240)-57,399 (-152,403, -12,562)-41,343 (-105,789, 23,819)-11,932 (-77,822, 45,773)-48,783 (-151,528, -15,603)CD20+-58,112 (-110,681, -3126)-93,482 (-189,567, -42,636)-57,428 (-147,094, -3590)-40,773 (-95,658, 25,547)-3986 (-75,942, 49,021)-45,110 (-143,321, -15,063)Naïve CD20+CD27--60,929 (-112,623, -15,316)-61,405 (-152,261, -28,496)-62,477 (-142,009, -16,191)-22,210 (-72,131, 28,335)6941 (-62,669, 67,355)-51,254 (-142,712, -14,736)Activated CD95+-5012 (-12,701, 278)-9991 (-17,900, -5560)-3895 (-10,068, -1347)-3834 (-13,274, 1490)-5821 (-11,216, -233)-5641 (-14,810, -3341)Memory CD20+CD27+9,586 (1500, 30,983)-15,076 (-42,880, -6376)5532 (-146, 14,393)-13,927 (-24,816, -3064)-11,534 (-25,646, -2958)-1229 (-8466, 7300)

*Excluded from analysis: all pts who discontinued the investigational product before Wk 52 and BEL/ST pts if discontinued before Wk 104, and BEL/PBO and BEL/RTX pts who re-started BEL after Wk 53; †n=101; ‡n=57.

Conclusion

An improvement in anti-dsDNA and C3/C4 levels was generally observed across all 3 treatment groups with greater reductions in anti-dsDNA antibodies following BEL/RTX versus BEL/PBO and BEL/ST. We believe that BEL induced a pharmacodynamic window for subsequent RTX treatment for a marked reduction in circulating memory B cells and other B-cell subsets. Our findings underscore the need for better understanding of the bridge from pharmacodynamic to clinical outcomes, given that BEL/RTX did not show an improvement in disease control over BEL/PBO.1

References

[1]Aranow C, et al. Arthritis Rheumatol 2021;73 (suppl 10).

Acknowledgements

This analysis of the GSK Study 205646 was funded by GlaxoSmithKline (GSK). Medical writing support was provided by Nicholas Thomas, PhD, Fishawack Indicia Ltd. UK, part of Fishawack Health, and was funded by GSK.

Disclosure of Interests

Y.K. Onno Teng Consultant of: GSK, Aurinia Pharmaceuticals, Novartis, KezarBio, Otsuka, Vifor Pharma, Grant/research support from: GSK, Vifor Pharma, Aurinia Pharmaceuticals, Andre van Maurik Shareholder of: GSK, Employee of: GSK, Kenneth L Clark Shareholder of: GSK, Employee of: GSK, Norma Lynn Fox Shareholder of: GSK, Employee of: GSK, Yun Irene Gregan Shareholder of: GSK, Employee of: GSK, James Groark Shareholder of: GSK, Employee of: GSK, Robert Henderson Shareholder of: GSK, Employee of: GSK, Josephine Ocran-Appiah Shareholder of: GSK, Employee of: GSK, David Roth Shareholder of: GSK, Employee of: GSK, Don Shanahan Shareholder of: GSK, Employee of: GSK, Paul-Peter Tak Shareholder of: GSK, Employee of: GSK, Cynthia Aranow Consultant of: BMS, Kezar, GSK, Grant/research support from: GSK

AB0288 SAFETY OF BELIMUMAB IN PATIENTS WITH ACTIVE SYSTEMIC LUPUS ERYTHEMATOSUS: YEAR 2 FOLLOW-UP OF A LARGE PHASE 4, RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY

Background:

Belimumab (BEL), a recombinant human monoclonal antibody that inhibits B-lymphocyte stimulator (BLyS), is approved for the treatment of systemic lupus erythematosus (SLE). Clinical studies have yielded varying incidence rates of mortality and adverse events of special interest, such as malignancies, thereby necessitating large-scale, long-term assessment following BEL exposure.

Objectives:

To assess all-cause mortality and new primary malignancies during post-treatment Year 2 follow-up in adult patients with active, autoantibody-positive SLE who received intravenous (IV) BEL or placebo (PBO), plus standard therapy in the 52-week double-blind treatment period of the ongoing BASE trial.1

Methods:

This was a post-treatment follow-up of the Phase 4, double-blind study (BASE1; GSK Study BEL115467; NCT01705977), which randomised 4019 adults with active SLE and receiving standard therapy to BEL (10 mg/kg IV) or PBO on Days 0, 14, 28, and monthly thereafter until Week 48. All patients (including those who discontinued BEL before the end-of-treatment phase) were contacted by phone annually (+/-30-day time window). Rates of mortality and new primary malignancy are summarised for Year 2 follow-up, presented by the treatment received during the 52-week double-blind treatment period (Year 1).

Results:

Baseline patient characteristics and disease activity collected at the start of the study, evaluated in patients with Year 2 follow-up were similar to the overall Year 1 study population. Cumulatively by Year 2 follow-up, 10.7% and 9.5% of patients had been exposed to commercial BEL in the BEL and PBO groups, respectively. Cumulative follow-up adjusted mortality and malignancy rates (per 100 patient years) were lower in the BEL vs PBO Year 1 treatment group (Table 1).

Conclusion:

Year 2 follow-up results of BASE, the largest clinical trial of SLE to date,1 provide continued support for the BEL safety profile. No new BEL safety concerns were identified in patients with active, autoantibody-positive SLE receiving standard therapy.

Funding: GSK

References:

[1]Sheikh SZ, et al. Lancet Rheum. 2020 (ePub ahead of print) doi.org/10.1016/S2665-9913(20)30355-6

Table 1.

Year 2 post-treatment* follow-up mortality and new primary malignancy rates by study treatment during Year 1

BELPBOTotalYear 1 as-treated populationN=2002N=2001N=4003Year 1 deaths, n (%)13 (0.65)22 (1.10)35 (0.87)Year 1 new primary malignancies, n (%)9 (0.45)10 (0.50)19 (0.47)Year 2 (as-treated in Year 1) populationN=1681N=1666N=3347Year 2 deaths by MedDRA SOC, n (%)9 (0.54)21 (1.26)30 (0.90)Cardiac disorders2 (0.12)6 (0.36)8 (0.24)Infections and infestations4 (0.24)2 (0.12)6 (0.18)Uncoded1 (0.06)3 (0.18)4 (0.12)General disorders/administration site conditions1 (0.06)2 (0.12)3 (0.09)Gastrointestinal disorders1 (0.06)1 (0.06)2 (0.06)Neoplasms02 (0.12)2 (0.06)Other05 (0.30)†5 (0.15)Cumulative deaths by Year 2 follow-up, n (%)22 (1.10)43 (2.15)65 (1.62)Incidence rate per 100 patient years0.601.180.89Year 2 new primary malignancies by MedDRA SOC, n (%)3 (0.18)4 (0.24)7 (0.21)Neoplasms2 (0.12)4 (0.24)6 (0.18)Hepatobiliary disorders1 (0.06)01 (0.03)Cumulative malignancies by Year 2 follow-up, n (%)12 (0.60)14 (0.70)26 (0.65)Patient incidence rate per 100 patient years0.340.400.37

*Patients in the post-treatment follow-up period are no longer receiving study treatment; †1 event/patient: blood/lymphatic system, musculoskeletal/connective tissue, nervous system, psychiatric, and renal/urinary disorders.

MedDRA, Medical Dictionary for Regulatory Activities; SOC, system organ class.

Acknowledgements:

Medical writing assistance was provided by Katalin Bartus, PhD, Fishawack Indicia Ltd., UK, part of Fishawack Health, and was funded by GSK.

Disclosure of Interests:

Saira Sheikh Grant/research support from: Pfizer, Morton Scheinberg Consultant of: GSK, Pfizer, Alnylam, AbbVie, PTC Therapeutics, James Cheng-Chung Wei Consultant of: TSH Biopharm, AbbVie, BMS, Celgene, Chugai, Eisai, Janssen, Novartis, Pfizer, Sanofi-Aventis and UCB pharma, Grant/research support from: AbbVie, Amgen, Astellas, BMS, Celgene, Eli Lilly, Gilead, Janssen, Novartis, Pfizer Sun and UCB, Dana Tegzová: None declared, William Stohl Consultant of: GSK, Grant/research support from: GSK, Pfizer, Gilead, Tamara Mucenic Speakers bureau: Novartis, Janssen, BMS, AbbVie, Pfizer, Roche, Grant/research support from: GSK, Janssen, Roche, Eli Lilly, Gilead, UCB, Raj Punwaney Shareholder of: GSK, Employee of: GSK, Regina Kurrasch Shareholder of: GSK, Employee of: GSK, Julia Harris Shareholder of: GSK, Employee of: GSK, Saima Muzaffar Shareholder of: GSK, Employee of: GSK, Sofia Fernandes Shareholder of: GSK, Employee of: GSK, Norma Lynn Fox Shareholder of: GSK, Employee of: GSK, Andrew Liu Shareholder of: GSK, Employee of: GSK, Holly Quasny Shareholder of: GSK, Employee of: GSK, David Roth Shareholder of: GSK, Employee of: GSK

Efficacy and Safety of Subcutaneous Belimumab in Anti-Double-Stranded DNA-Positive, Hypocomplementemic Patients With Systemic Lupus Erythematosus

OBJECTIVE

To investigate the efficacy and safety of belimumab, a human immunoglobulin monoclonal antibody against B lymphocyte stimulator, in a subset of patients with systemic lupus erythematosus (SLE) who were hypocomplementemic (C3 <90 mg/dl and/or C4 <10 mg/dl) and anti-double-stranded DNA (anti-dsDNA) positive (≥30 IU/ml) at baseline.

METHODS

In this phase III, double-blind, placebo-controlled study (BEL112341; ClinicalTrials.gov identifier: NCT01484496), patients with moderate to severe SLE (Safety of Estrogens in Lupus Erythematosus National Assessment version of the Systemic Lupus Erythematosus Disease Activity Index [SELENA-SLEDAI] score ≥8) were randomized (2:1) to receive weekly subcutaneous (SC) belimumab 200 mg or placebo, plus standard SLE therapy, for 52 weeks. The primary end point was SLE Responder Index 4 (SRI-4) response rate at week 52. Secondary end points were time to severe flare and reduction in corticosteroid dose (weeks 40-52). Safety was assessed throughout.

RESULTS

Of the 836 patients in the intent-to-treat (ITT) population, 356 were hypocomplementemic and anti-dsDNA positive at baseline (108 in the placebo group and 248 in the SC belimumab 200 mg group). Compared with placebo, the belimumab group contained more SRI-4 responders (47.2% versus 64.6%; P = 0.0014), had a lower incidence of severe flare according to the SELENA-SLEDAI flare index (31.5% versus 14.1%), and had a greater percentage of patients who reduced corticosteroid dosage by ≥25% to ≤7.5 mg/day during weeks 40-52 (11.4% versus 20.7%; P = 0.0844). Adverse events (AEs) were similar between treatment groups.

CONCLUSION

Our findings indicate that in hypocomplementemic, anti-dsDNA-positive SLE patients, weekly SC belimumab 200 mg significantly improves SRI-4 response, decreases severe flare incidence, and reduces corticosteroid use versus placebo; a trend toward greater benefit compared with the overall ITT population was observed. AEs were consistent with the known safety profile of belimumab.

A 6-month open-label extension study of the safety and efficacy of subcutaneous belimumab in patients with systemic lupus erythematosus

Objective

To evaluate the safety, tolerability and efficacy of subcutaneous (SC) belimumab in patients with systemic lupus erythematosus (SLE) beyond 1 year.

Methods

This was a 24-week, open-label extension following a 52-week, double-blind, placebo-controlled trial of belimumab SC. Patients who completed the double-blind phase were eligible to enter the open-label phase. All patients received weekly belimumab 200 mg SC plus standard SLE therapy. Outcome measures included safety and efficacy (SLE Response Index (SRI) and SLE Flare Index (SFI) rates), and changes in biomarker and B cell levels.

Results

Of 677 patients who completed the 52-week, double-blind phase, 662 entered the open-label phase; 206 had previously received placebo and 456 had previously received belimumab. Despite differences in total belimumab exposure (24 weeks in the placebo-to-belimumab group versus 76 weeks in the belimumab group), the proportions of patients experiencing more than one adverse event (AE) or a serious AE in the open-label phase were similar between groups (placebo-to-belimumab: 51.5 and 6.8%; belimumab: 48.2 and 5.5%, respectively). Most AEs were mild/moderate in severity. Efficacy was maintained through the extension phase. An SRI response was achieved by 16.1% of patients in the placebo-to-belimumab group and 76.3% patients in the belimumab group. Furthermore, 1.0% of patients in the placebo-to-belimumab group and 2.6% of patients in the belimumab group experienced a severe SFI flare.

Conclusion

Belimumab SC was well tolerated and efficacy was maintained during the extension phase of this study. The safety profile of belimumab SC is consistent with that of previous experience with belimumab.

Trial registration

ClinicalTrials.gov identifier: NCT01484496

A randomized, double-blind, placebo-controlled phase II study to assess the efficacy and safety of mapatumumab with sorafenib in patients with advanced hepatocellular carcinoma

BACKGROUND

This randomized, double-blind, placebo-controlled, phase II study evaluated the efficacy and safety of mapatumumab (a human agonistic monoclonal antibody against tumor necrosis factor-related apoptosis-inducing ligand receptor 1) in combination with sorafenib in patients with advanced hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

Patients with advanced HCC (stratified by Barcelona Clinic Liver Cancer stage and Eastern Cooperative Oncology Group performance status) were randomized 1:1 to receive sorafenib (400 mg, twice daily per 21-day cycle) and either placebo (placebo-sorafenib arm) or mapatumumab (30 mg/kg on day 1 per 21-day cycle; mapatumumab-sorafenib arm). The primary end point was time to (radiologic) progression (TTP), assessed by blinded independent central review. Key secondary end points included progression-free survival, overall survival, and objective response.

RESULTS

In total, 101 patients were randomized (placebo-sorafenib arm: N = 51; mapatumumab-sorafenib arm: N = 50). There was no significant difference in median TTP between both arms [5.6 versus 4.1 months, respectively; adjusted hazard ratio (one-sided 90% confidence interval) 1.192 (0-1.737)]. No mapatumumab-related benefit was identified when TTP was evaluated in the stratified subgroups. The addition of mapatumumab to sorafenib did not demonstrate improvement in the secondary efficacy end points. The reported frequency of adverse events (AEs) and serious AEs was comparable in both treatment arms.

CONCLUSIONS

The addition of mapatumumab to sorafenib did not improve TTP or other efficacy end points, nor did it substantially change the toxicity profile of sorafenib in patients with advanced HCC. Based on these results, further development of the combination of mapatumumab and sorafenib in HCC is not planned.

A Phase 1b/2 trial of mapatumumab in patients with relapsed/refractory non-Hodgkin's lymphoma

Background:

We conducted a multicentre Phase 1b/2 trial to evaluate the safety and efficacy of mapatumumab, a fully human agonistic monoclonal antibody to the tumour necrosis factor-related apoptosis-inducing ligand receptor 1 (TRAIL-R1) in patients with relapsed non-Hodgkin's lymphoma (NHL).

Methods:

Forty patients with relapsed or refractory NHL were treated with either 3 or 10 mg kg⁻¹ mapatumumab every 21 days. In the absence of disease progression or prohibitive toxicity, patients received a maximum of six doses.

Results:

Mapatumumab was well tolerated, with no patients experiencing drug-related hepatic or other dose-limiting toxicity. Three patients with follicular lymphoma (FL) experienced clinical responses, including two with a complete response and one with a partial response. Immunohistochemistry staining of the TRAIL-R1 suggested that strong staining in tumour specimens did not appear to be a requirement for mapatumumab activity in FL.

Conclusions:

Mapatumumab is safe and has promising clinical activity in patients with FL.

Phase I and pharmacokinetic study of lexatumumab (HGS-ETR2) given every 2 weeks in patients with advanced solid tumors

BACKGROUND

Lexatumumab (HGS-ETR2) is a fully human agonistic mAb to the tumor necrosis factor-related apoptosis-inducing ligand receptor 2 that activates the extrinsic apoptosis pathway and has potent preclinical antitumor activity.

MATERIALS AND METHODS

This phase 1, dose escalation study assessed the safety, tolerability, pharmacokinetics (PKs) and immunogenicity of lexatumumab administered i.v. every 14 days in patients with advanced solid tumors.

RESULTS

Thirty-one patients received lexatumumab over five dose levels (0.1-10 mg/kg). Most (26 of 31) received four or more cycles of treatment. One patient at 10 mg/kg experienced a possibly related dose-limiting toxicity of grade 3 hyperamylasemia. Nine patients achieved stable disease. One patient with chemotherapy-refractive Hodgkin's disease experienced a mixed response. Lexatumumab PKs were linear up to 10 mg/kg. At the 10 mg/kg dose, the mean (+/-standard deviation) t(1/2b) was 13.67 +/- 4.07 days, clearance was 4.95 +/- 1.93 ml/day/kg, V(1) was 45.55 ml/kg and V(ss) was 79.08 ml/kg, indicating that lexatumumab distributes outside the plasma compartment. No human antihuman antibodies were detected.

CONCLUSIONS

Lexatumumab can be safely administered every 14 days at 10 mg/kg. The PK profile supports this schedule. Further evaluation of lexatumumab at this dose schedule is warranted, including combination trials with other agents.

Development of radiolabeled mapatumumab and imaging in solid tumor patients who are treated with gemcitabine, cisplatin, and mapatumumab

e14521

Background: Mapatumumab is a fully human agonistic monoclonal antibody (mAb) to the tumor necrosis factor-related apoptosis-inducing ligand receptor 1 (TRAIL-R1). Mapatumumab combined with gemcitabine and cisplatin increased cytotoxicity in preclinical models and was safe in a phase 1 study. To study its biodistribution, 111Indium (111In) labeled mapatumumab was developed for γ-camera imaging and tested in mice. Subsequently, 111In-mapatumumab scintigraphy was performed in patients (pts). Methods: Mapatumumab was labeled with 111In. Labeling efficiency, radiochemical purity, stability and binding properties were determined in vitro. Biodistribution was studied at multiple time points in nude mice bearing human xenografts (SKBR3 or SW948). Tissue activity was expressed as % injected dose/gram tissue (%ID/g). In a feasibility study, gemcitabine 1250 mg/m2 IV on days 1 and 8, cisplatin 80 mg/m2 IV and mapatumumab 20 mg/kg on day 1 was administered to advanced solid tumor pts every 21 days. In cycles 1 and 3, pts underwent γ-camera imaging directly, and at day 1, 3, and 6 after 150 MBq 111In-mapatumumab IV (planar and single-photon emission computed tomography (SPECT)). Results: Labeling efficiency was 92.0% and radiochemical purity 96.0%. 111In-mapatumumab was stable in serum for 1 week at 37°C and specific TRAIL-R1 binding was maintained after labeling. In mice, high uptake was seen in liver (8.14 ± 0.75 %ID/g), kidneys (16.30 ± 1.75 %ID/g), spleen (7.25 ± 2.64 %ID/g) and bone (5.68 ± 1.31 %ID/g), with a maximum 24–72 hours (h) after tracer injection. Maximum uptake in the xenografts was observed after 72 h (7.55 ± 3.54 %ID/g for SKBR3 and 6.21 ± 2.03 %ID/g for SW948). Five pts have been enrolled in the ongoing clinical study. Known tumor lesions (by CT-scan) showed variable tracer uptake in 3 pts, while within pts not all known tumor lesions were positive on SPECT. Conclusions: Mapatumumab can be efficiently radiolabeled for clinical use. Preliminary results show that mapatumumab scintigraphy identifies some but not all tumor lesions in pts. This is the first demonstration that mAb targeting a TRAIL-R distributes to tumor tissues in patients and could potentially guide mapatumumab therapy.

[Table: see text]

A phase Ib study to assess the safety of lexatumumab, a human monoclonal antibody that activates TRAIL-R2, in combination with gemcitabine, pemetrexed, doxorubicin or FOLFIRI

14006

Background: Lexatumumab (HGS-ETR2) is a fully-human agonistic monoclonal antibody that targets and activates the Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand Receptor 2 (TRAIL-R2). TRAIL-R2 is a member of the Tumor Necrosis Factor Receptor (TNFR) superfamily that, when activated, induces apoptosis via the extrinsic pathway. Lexatumumab shows promising anti-tumor activity in preclinical models, particularly in combination with chemotherapeutic agents. Single-agent lexatumumab was well-tolerated in phase I trials. This is the first study of the safety of a TRAIL-R2 agonist in combination with chemotherapy. Methods: Patients for whom gemcitabine, pemetrexed, doxorubicin or FOLFIRI was considered an appropriate treatment received one of the full-dose chemotherapy regimens plus lexatumumab every 2 weeks (for gemcitabine and FOLFIRI) or 3 weeks (for pemetrexed and doxorubicin). Four to 6 patients were treated with 5 mg/kg lexatumumab in each chemotherapy cohort prior to dose escalation to 10 mg/kg. Results: To date, 41 patients with a wide range of cancer types have received 164 courses of lexatumumab over the 2 dose levels. The majority (33/41) received at least 2 courses (range 1 to 19). Lexatumumab was well-tolerated; no dose reductions of lexatumumab were required. Severe adverse events considered at least possibly related to lexatumumab included anemia, fatigue and dehydration. Tumor shrinkage has been observed, including confirmed partial responses (PRs) in the FOLFIRI and doxorubicin arms. Eight patients continue on study. Conclusions: Lexatumumab can be safely administered in combination with a wide range of chemotherapeutic agents. Evaluation of the efficacy of lexatumumab in combination with chemotherapy in Phase 2 trials is warranted.

[Table: see text]

HGS-ETR1, an antibody targeting TRAIL-R1, in combination with paclitaxel and carboplatin in patients with advanced solid malignancies: Results of a phase 1 and PK study

2515

Background: HGS-ETR1 (mapatumumab) is a fully-human monoclonal antibody agonistic to the Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand Receptor 1 (TRAIL-R1, DR4). Activation of TRAIL-R1 by HGS-ETR1 initiates a caspase cascade leading to apoptosis. HGS-ETR1 in combination with platinum or taxanes results in at least additive activity in preclinical models. Phase 1 and 2 trials have demonstrated that single agent HGS-ETR1 is well tolerated. Methods: This Phase 1 study assesses the safety, tolerability, pharmacokinetics (PK) and preliminary efficacy of HGS-ETR1 in combination with standard doses of paclitaxel and carboplatin. Patients received 3, 10 or 20 mg/kg HGS-ETR1 with paclitaxel (200 mg/m2) and carboplatin (AUC 6) every 21 days for up to 6 cycles in the absence of disease progression. Results: Enrollment is complete; 28 patients have received 106 cycles of HGS-ETR1, including 12 patients in each of the 10 mg/kg and 20 mg/kg cohorts. Fourteen of 28 pts received at least 3 cycles (median = 2.5, range 1–12). Dose-limiting toxicity has been neutropenic fever (attributed to chemotherapy) and hypersensitivity (attributed to HGS-ETR1). Other non-dose limiting adverse events at least possibly related to HGS-ETR1 include fatigue, myalgia, transaminitis, anorexia and arthralgia. Preliminary analyses reveal that carboplatin and paclitaxel PK are not affected by HGS-ETR1. Similarly, the PK profile of HGS-ETR1 is not affected by paclitaxel and carboplatin, with plasma HGS-ETR1 concentrations consistent with those observed in the Phase 1 single agent trials. Three patients with NSCLC and 1 with adenocarcinoma of an unknown primary have experienced a confirmed partial response. Conclusions: HGS-ETR1 can be safely administered with carboplatin and paclitaxel. Evaluation of HGS-ETR1 in combination with other chemotherapeutic regimens is warranted.

[Table: see text]

Incidence and predictors of bleeding events after fibrinolytic therapy with fibrin-specific agents: a comparison of TNK-tPA and rt-PA

BACKGROUND

Fibrinolytic therapy increases the risk of bleeding events. TNK-tPA (tenecteplase) is a variant of rt-PA with greater fibrin specificity and reduced plasma clearance that can be given as a single bolus. We compared the incidence and predictors of bleeding events after treatment with TNK-tPA and rt-PA.

METHODS AND RESULTS

In the Assessment of the Safety and Efficacy of a New Thrombolytic (ASSENT)-2 trial, 16 949 patients with acute myocardial infarction were randomly assigned a single weight-adjusted bolus of TNK-tPA or a 90-min infusion of rt-PA. A total of 4.66% of patients in the TNK-tPA group experienced major non-cerebral bleeding, in comparison with 5.94% in the rt-PA group (P=0.0002). This lower rate was associated with a significant reduction in the need for blood transfusion (4.25% vs 5.49%, P=0.0003) and was consistent across subgroups. Independent risk factors for major bleeding were older age, female gender, lower body weight, enrolment in the U.S.A. and a diastolic blood pressure <70 mmHg. Females at high risk (age >75 years and body weight <67 kg) were less likely to have major bleeding when treated with TNK-tPA even after other risk factors were taken into account. A total of 0.93% of patients in the TNK-tPA and 0.94% of patients in the rt-PA group experienced an intracranial haemorrhage. Female patients >75 years of age who weighed <67 kg tended to have lower rates of intracranial haemorrhage when treated with TNK-tPA (3/264, 1.14% vs 8/265, 3.02%).

CONCLUSIONS

The increased fibrin specificity and single bolus administration of TNK-tPA do not increase the risk of intracranial haemorrhage but are associated with less non-cerebral bleeding, especially amongst high-risk patients.

The hemostatic effects of warfarin titration in post CABG patients in comparison to placebo treatment

BACKGROUND

Since coronary artery bypass graft patients remain at risk of coronary artery and bypass graft occlusion after successful surgery, adjunct treatment regimens are under investigation. In a study of the patients of the multicenter Post Coronary Artery Bypass Graft (Post CABG) Trial, 1 mg warfarin was found to have no important effect on coagulation parameters.

STUDY DESIGN

The effects of 1, 2 and 3 mg warfarin were evaluated at six-week intervals in 20 Post CABG Trial patients receiving titrated dose increases in comparison to 20 patients of similar age, gender and time from CABG treated with placebo.

RESULTS

International normalized ratio (INR) values increased with warfarin dose increments for 1, 2, and 3 mg, respectively (0.95+/-0.16, 1.08+/-0.19, and 1.34+/-0.39) and in comparison to placebo treated patients (dosextreatment p<0.001). Factor VII coagulant activity decreased with warfarin titration (1 mg, 119.0+/-18.3 %; 2 mg, 100.6+/-32.8 %; 3 mg, 95.0+/-27.8 %) and in comparison to placebo (dosextreatment p=0.008). Levels of prothrombin fragment F1.2, tissue plasminogen activator, fibrinogen and von Willebrand factor were unchanged with warfarin dose increments and in comparison to placebo.

CONCLUSIONS

At doses up to 3 mg, warfarin acts on the INR through a reduction of factor VII with no effect on the fibrinolytic system, fibrinogen or von Willebrand factor. At these doses F1.2 did not document reduced coagulation activity. The observations of this study were consistent with the decision in the Post CABG Trial to increase the warfarin dose above 1 mg to achieve a distinct effect of warfarin that was less than full anticoagulation.

Determination of a weight-adjusted dose of TNK-tissue plasminogen activator

BACKGROUND

TNK-tissue plasminogen activator (TNK-tPA) is a potent new thrombolytic agent for treatment of acute myocardial infarction. TNK-tPA was evaluated in 4214 patients in two dose-ranging trials (Thrombolysis in Myocardial Infarction [TIMI] 10B and Assessment of the Safety and Efficacy of a New Thrombolytic Agent [ASSENT] I). This article describes the rationale for the weight-adjusted dosing regimen of TNK-tPA that was selected for evaluation in the large phase III clinical trial ASSENT II.

METHODS

Weight-based analyses were conducted with data from both the angiographic TIMI 10B trial, which compared TNK-tPA in doses of 30 mg, 40 mg, and 50 mg with the accelerated regimen of tPA in 889 patients, and the ASSENT I trial, which evaluated the safety of TNK-tPA in doses of 30 mg, 40 mg, and 50 mg in 3301 patients. Graphic and statistical analytic methods were used to assess relationships between weight and efficacy or safety measurements.

RESULTS

The plasma clearance, initial plasma concentrations, and plasma steady-state volume of distribution all increased with decreasing body weight (all P<.001). The corrected TIMI frame count decreased (flow was faster) (P =.001) and the TIMI grade 3 flow increased with an increasing weight-standardized dose of TNK-tPA (P<.008). Mortality was inversely related to dose, but this relationship was not statistically significant. There was no clear relationship between intracranial hemorrhage and dose and weight. Serious bleeding events increased with increasing weight-standardized dose (P<.02).

CONCLUSIONS

On the basis of these analyses, a weight-adjusted dosing regimen was devised for TNK-tPA that included five dosing increments and was based on a target weight-standardized dose of 0.53 mg/kg.

Pharmacokinetics and pharmacodynamics of tenecteplase: results from a phase II study in patients with acute myocardial infarction

Tenecteplase is a site-specific engineered tissue plasminogen activator (t-PA) variant that can be administered as a single intravenous bolus injection because of its slower plasma clearance. The objective of this study was to investigate the dose-ranging pharmacokinetics and pharmacodynamics of intravenous bolus tenecteplase compared with intravenous alteplase recombinant t-PA in patients with acute myocardial infarction. A total of 103 patients received intravenous bolus doses of 30, 40, or 50 mg tenecteplase, and 56 patients received 100 mg rt-PA as the accelerated 90-minute infusion regimen in this randomized, open-label study. Tenecteplase and r-tPA plasma concentrations were measured for 6 hours. Tenecteplase exhibited biphasic elimination from the plasma with a mean initial half-life of 22 minutes and a mean terminal half-life of 115 minutes. The mean plasma clearance was 105 mL/min and did not depend on tenecteplase dose over the dose range studied. In comparison, rt-PA has a fourfold faster plasma clearance. Pharmacokinetic-pharmacodynamic evaluation showed that a dose of approximately 0.5 mg/kg results in a plasma AUC value that provides a TIMI 3 flow at 90 minutes that is comparable to that reported with accelerated r-tPA. In conclusion, tenecteplase has a fourfold slower plasma clearance compared with rt-PA, allowing dosing as an i.v. bolus injection. Weight-adjusted dosing of tenecteplase may optimize the therapeutic regimen of tenecteplase.

Weight-adjusted dosing of TNK-tissue plasminogen activator and its relation to angiographic outcomes in the thrombolysis in myocardial infarction 10B trial. TIMI 10B Investigators

Fixed doses of thrombolytic agents are generally administered to patients of varying body weights, and the dose-response relation may be confounded by the variability in patient weight. We hypothesized that higher doses of TNK-tissue plasminogen activator (tPA) per unit body weight would be related to improved flow at 90 minutes after thrombolytic administration. A total of 886 patients with acute myocardial infarction were randomized to receive either a single bolus of 30, 40, or 50 mg of TNK-tPA or front-loaded tPA in the Thrombolysis In Myocardial Infarction (TIMI) 10B trial. The dose of TNK-tPA administered was divided by the patient's weight to arrive at the TNK-tPA dose (mg) per unit body weight (kg), and patients were stratified into tertiles based on mg/kg of TNK-tPA: low dose, 0.2 to 0.39 mg/kg; mid-dose, 0.40 to 0.51 mg/kg; high dose, 0.52 to 1.24 mg/kg. Flow in the culprit and nonculprit arteries was analyzed using the TIMI flow grades and the corrected TIMI frame count (CTFC). The median CTFC in culprit arteries differed between the tertiles (3-way p = 0.007), with the CTFC being 7.2 frames faster in high-dose than in low-dose patients (43.1 +/- 30.1, median 31.2, n = 171 vs 54.6 +/- 34.8, median 38.4, n = 166, 2-way p = 0.002). Patients in the mid- and high-dose tertiles achieved patency more frequently (TIMI grade 2 or 3 flow) by 60 minutes (p = 0.02), and the 90-minute percent diameter stenosis was less severe in patients in the high- versus low-dose tertile (p = 0.03). In nonculprit arteries, the CTFC was faster in high- than in low-dose tertiles (29.6 +/- 13.4, median 26.9, n = 130 vs 34.7 +/- 16.3, median 32.8, n = 108, 3-way p = 0.03, 2-way p = 0.008). In patients who underwent percutaneous transluminal coronary angioplasty (PTCA), the CTFC in culprit arteries after PTCA was fastest in the high- and mid-dose tertiles than in those receiving low doses (2-way p = 0.05). Thus, higher doses per unit body weight of TNK-tPA result in not only faster culprit artery flow, but also faster nonculprit, global, and post-PTCA flow, which may reflect earlier opening, reduced stunning, or improved microvascular function. The greater effectiveness of thrombolysis must be weighed against any increase in risk.

Correlation of CT findings with clinical evaluations in 261 patients with symptomatic bronchiectasis

OBJECTIVE

In a multicenter study, we evaluated the relationships between the extent and severity of bronchiectasis on CT and clinical symptoms, spirometric abnormality, and sputum characteristics.

SUBJECTS AND METHODS

The study population included 261 patients with symptomatic, physiologically significant bronchiectasis, who were enrolled in another study evaluating the clinical efficacy of deoxyribonudease in treatment of bronchiectasis. Patients with cystic fibrosis, allergic bronchopulmonary aspergillosis, and fungal or mycobacterial infection were excluded. In addition to high-resolution CT scanning, all patients underwent clinical evaluation, spirometry, and sputum culture. CT features scored by consensus of two observers included the extent of bronchiectasis, type of bronchiectasis (cylindric, varicose, or cystic), extent of mucoid impaction, and degree of bronchial wall thickening.

RESULTS

Scores for the severity and extent of bronchiectasis correlated with the forced expiratory volume in 1 sec (FEV1) (r = -.362, p < .0001) and with the forced vital capacity (FVC) (r = -.362, p < .0001). Scores for bronchial wall thickening correlated with the FEV1 (r = -.367, p < .0001) and FVC (r = -.239, p < .001). Patients with cystic bronchiectasis were significantly more likely to grow Pseudomonas from their sputa and to have purulent sputa than were patients with cylindric or varicose bronchiectasis. Patients with cystic bronchiectasis had significantly lower FEV1 and FVC values than did patients with cylindric or varicose bronchiectasis.

CONCLUSION

In this patient population, we found weak but significant correlations between the degree of morphologic abnormality on CT and the extent of physiologic impairment. Cystic bronchiectasis was associated with sputum purulence and with the growth of Pseudomonas. CT classification of the type of bronchiectasis may be useful as an index of severity of disease.

Hemostatic effects of 1 mg daily warfarin on post CABG patients. Post CABG Studies Investigators

Although coronary bypass graft surgery has increased the survival and quality of life of many individuals, patients remain at risk of restenosis and thrombotic occlusion of the coronary arteries and bypass grafts. In the screening period for participation in the multicenter Post Coronary Artery Bypass Graft (Post CABG) trial, the effects of 1 mg daily warfarin were evaluated using paired patient samples collected prior to and after at least 21 days of treatment. In stable patients (n = 40; 39 males 1 female; 51-74 years old) who previously had undergone coronary artery revascularization (1-10 years), no alterations in prothrombin time, international normalized ratio (INR), prothrombin fragment 1.2, or the hemostatic risk factors factor VII antigen and coagulant activity, von Willebrand's factor, fibrinogen, tPA, or PAI-1 were associated with the 1 mg daily warfarin treatment. The observations reported here supported the Post CABG Studies Steering Committee decision to treat patients with 1-4 mg warfarin daily adjusted to achieve INRs not to exceed 2. 0 consistent with low-intensity therapy.

Safety assessment of single-bolus administration of TNK tissue-plasminogen activator in acute myocardial infarction: the ASSENT-1 trial. The ASSENT-1 Investigators

BACKGROUND

To evaluate the safety of several doses of a new thrombolytic, TNK tissue-plasminogen activator (tPA), given as a single bolus to patients with acute myocardial infarction.

METHODS AND RESULTS

A total of 3235 patients were given TNK-tPA: 1705 received 30 mg, 1457 received 40 mg, and 73 received 50 mg. The 50-mg dose was discontinued and replaced by 40 mg because of increased bleeding observed in the Thrombolysis In Myocardial Infarction (TIMI)-10B study, the phase II angiographic efficacy trial conducted in parallel with this study. The total stroke rate at 30 days in the trial was 1.5%. An intracranial hemorrhage was observed in 25 patients (0.77%): 16 in the 30-mg group (0.94%) and 9 in the 40-mg group (0.62%). No strokes occurred in the 73 patients treated with 50 mg TNK-tPA. In patients treated within 6 hours after symptom onset the rates of intracranial hemorrhage were 0.56% (30 mg TNK-tPA) and 0.58 (40 mg TNK-tPA). Death, death or nonfatal stroke, or severe bleeding complications occurred in a low proportion of patients: 6.4%, 7.4%, and 2.8%, respectively, without significant differences among the treatment groups.

CONCLUSIONS

The overall safety profile of a single bolus of 30 to 50 mg TNK-tPA is comparable to that of accelerated r-tPA observed in other large trials. The safety data from this trial and the patency data of TIMI-10B were the basis for a decision to conduct a large phase III mortality trial comparing weight-adjusted single-bolus TNK-tPA with accelerated r-tPA (ASSENT-2).

TNK-tissue plasminogen activator in acute myocardial infarction. Results of the Thrombolysis in Myocardial Infarction (TIMI) 10A dose-ranging trial

BACKGROUND

TNK-tissue plasminogen activator (TNK-TPA) is a genetically engineered variant of TPA, which in experimental models has a slower plasma clearance and greater fibrin specificity and is 80-fold more resistant to plasminogen activator inhibitor-1 than alteplase TPA.

METHODS AND RESULTS

The thrombolysis in Myocardial Infarction (TIMI) 10A trial was a Phase 1, dose-ranging pilot trial designed to evaluate the pharmacokinetics, safety, and efficacy of TNK-TPA in patients with acute myocardial infarction. One hundred thirteen patients with acute ST-segment elevation myocardial infarction presenting within 12 hours and without contraindications to thrombolysis were enrolled and treated with a single bolus of TNK-TPA over 5 to 10 seconds with doses ranging from 5 to 50 mg. TNK-TPA demonstrated a plasma clearance of 151 +/- 55 mL/min and a half-life of 17 +/- 7 minutes. Comparable values for wild-type TPA are 572 +/- 132 mL/min and 3.5 +/- 1.4 minutes, respectively. Systemic fibrinogen and plasminogen levels fell by only 3% and 13%, respectively, at 1 hour after TNK-TPA administration. TIMI grade 3 flow at 90 minutes was achieved in 57% to 64% of patients at the 30- to 50-mg doses. Seven patients (6.2%) experienced a major hemorrhage, which occurred at a vascular access site in six patients.

CONCLUSIONS

TNK-TPA has a prolonged half-life so it can be administered as a single bolus. TNK-TPA appears to be very fibrin specific, and the initial patency and safety profiles are encouraging. Further study of this new thrombolytic agent is ongoing.

Prenatal exposure to tobacco: II. Effects on cognitive functioning at age three

Three-year-old children, born to women who smoked ten or more cigarettes at the beginning of pregnancy and identified at the time of registration for prenatal care, were assessed by the McCarthy Scales of Children's Abilities and the Minnesota Child Development Inventory. Children whose mothers quit smoking during pregnancy relative to children whose mothers persisted in smoking performed at a statistically significant higher level on the General Cognitive Index of the McCarthy and on each of the three subscales from which the General Cognitive Index is derived. The scores on the Minnesota Child Development Inventory were similar in showing a higher performance in the children of quitters. Statistical adjustment for environmental factors, characteristics of the child, and fetal maturity did not account for the observed differences between children of women who quit smoking and those of women who continued to smoke.

Prenatal exposure to tobacco: I. Effects on physical growth at age three

The height and weight of 714 children whose mothers smoked at the beginning of their pregnancies were assessed at three years of age. The children of women who quit smoking during pregnancy were taller and heavier than those of women who continued to smoke throughout pregnancy. Adjustment for maternal postpartum smoking status reduced the difference in weight, but had little effect on height. The differences in both height and weight at three years of age were greatly reduced when adjusted for size at birth and length of gestation. These results suggest that deficits associated with maternal smoking are not overcome by three years of age and that at least some of the observed anthropometric deficits may be extensions of deficits in fetal growth.

The reliability of self-reports of smoking and alcohol consumption by pregnant women

The reliability of self-reports of prepregnancy smoking and drinking habits was assessed in over 700 pregnant smokers who participated in a randomized clinical trial of smoking cessation intervention. The participants provided self-reports of their prepregnancy smoking and drinking habits prior to the 18th week (test) and again in the eighth month of gestation (retest). About half the subjects gave identical reports of prepregnancy smoking habits at test and retest. Among those who changed their estimates, the changes were usually small. The reliability of reports of prepregnancy alcohol intake was also high. The reliability of reports by the treatment group - which experienced an anti-smoking intervention and extensive contact with study personnel - was very similar to that of the control group.

Dose-response of birth weight to various measures of maternal smoking during pregnancy

Thus far little is known about the dose-response relationship between birth weight and the amount of maternal smoking during pregnancy. The purpose of this report is to describe the effects of smoking intensity, duration, and timing on birth weight with the use of three measures of exposure: self-reported daily consumption, self-reported cumulative consumption, and salivary thiocyanate. Data were obtained on 867 single live-born infants and their mothers who participated in a randomized anti-smoking intervention trial. Smoking was measured for the women at about 15 weeks gestation and again during the eighth month. Although all indicators of dose, as derived from early or late pregnancy smoking measures, were significantly associated with birth weight, whether or not the mother had quit smoking by the time of the 8th month follow-up was almost as predictive as any dose variable. For women who quit smoking before 30 weeks gestation, neither the duration nor the amount of smoking earlier in pregnancy was an important determinant of birth weight.

Developmental screening using parent report

The need for comprehensive screening of pediatric populations to identify potential development problems is widely accepted. The lack of systematic screening in pediatric practice is due to several factors, including the need for an efficient, reliable instrument and the limited professional time available for screening. The present study compares the effectiveness of a screening instrument, the Minnesota Child Development Inventory, with an individually administered psychological test, the McCarthy Scales of Child Development. Because the former uses a parent report format, little professional time is involved in screening. The Minnesota and McCarthy were administered to 364 children who were within 1 month of their third birthday. Four of five Minnesota scores correlated significantly (p less than 0.0001) with each of the six McCarthy subscores. The Minnesota appears to be an efficient, valid test that would facilitate comprehensive screening in a pediatric population.

Alcohol consumption among pregnant smokers: effects of a smoking cessation intervention program

This study describes patterns of alcohol consumption among pregnant women who participated in a randomized clinical trial of smoking cessation intervention. Data on alcohol habits were obtained prospectively prior to the 18th week of gestation and during the 8th month of pregnancy. Average alcohol intake for both groups was reduced primarily prior to registration for prenatal care. The smoking cessation intervention reduced smoking during pregnancy but had no effect on alcohol intake.

Occupational allergy to laboratory animals: an epidemiologic study

A cross-sectional study has been carried out at The National Institutes of Health to examine the prevalence of laboratory animal allergy (LAA) in a population exposed to animals, and to compare the prevalence of general allergy in the exposed v a control group. A group of 289 workers with light-to-moderate exposure to animals, 260 with heavy exposure, and 242 control subjects were interviewed. A slightly greater prevalence of general allergy was found among those working with laboratory animals (39%), than in the control group (33.9%), but the difference was not statistically significant. The prevalence of LAA in the total exposed group was 23.9%. A history of atopic problems and history of allergy to domestic animals correlated significantly with LAA, as did the number of species of animals handled and the average number of hours per week exposed to laboratory animals, with evidence of dose-response relationships.

Inhibition of esterase activity and an undercounting of circulating monocytes in a population of production workers

A cross-sectional review of routine employee health status examinations has identified an undercounting of circulating monocytes associated with an inhibition of a surface monocyte esterase, alpha-naphthyl butyrate esterase. It is postulated that this inhibition is associated with an organophosphate used in the production process. Correlation with routine measures of health status are presented.

Steroid production from 17alpha-hydroxypregnenolone and dehydroepiandrosterone by human granulosa cells in vitro

Granulosa cells were aspirated 3--4 h before the expected time of ovulation from 10 follicles of 4 patients treated with gonadotrophins: 4 of the follicles were immediately preovulatory. The granulosa cells were cultured for 10 h with 17alpha-hydroxypregnenolone or dehydroepiandrosterone and samples of medium removed at 3 and 10 h were assayed for 6 steroids. Granulosa cells were unable to synthesize androgens from endogenous substrate or undertake conversions via the delta5 pathway, but cells from all follicles were capable of aromatizing exogenous androgens to oestrogens although this capability was reduced in cells from follicles beginning to luteinize. Granulosa cells from preovulatory follicles synthesized more progesterone from endogenous substrate than cells from follicles which had not begun to luteinize. The results provide further support for the two-cell theory of oestrogen biosynthesis whereby granulosa cells aromatize androgens which are synthesized by the thecal cells in vivo.

Steroidogenesis by cultured granulosa cells aspirated from human follicles using pregnenolone and androgens as precursors

Human granulosa cells from Graafian follicles aspirated 3-4 h before the expected time of ovulation were incubated with various steroid substrates, including pregnenolone, androstenedione, testosterone and dehydroepiandrosterone (DHA). Steroid production after 3 and 10 h of incubation was determined by radioimmunoassay. Progesterone and 17alpha-hydroxyprogesterone were the major products of granulosa cells in control short-term cultures with endogenous substrates. The addition of pregnenolone increased the synthesis of progesterone and 17alpha-hydroxyprogesterone compared with the controls, although the response varied considerably between paired short-term cultures. Little or no oestradiol-17beta was produced from endogenous precursors or short-term cultures to which pregnenolone had been added; one follicle, however, produced similar amounts of oestradiol-17beta in the control cultures and after incubation with pregnenolone. When granulosa cells were cultured with various amounts of androstenedione, DHA or testosterone, large amounts of oestradiol-17beta were produced, especially in short-term cultures in which larger amounts of substrate were added. Progesterone production continued and progesterone was synthesized more rapidly or in greater amounts in some short-term test cultures than in the controls. The results indicate that human granulosa cells are one source of oestradiol-17beta during the preovulatory phase. The data support the two-cell theory for oestradiol synthesis, for granulosa cells do not appear to undertake steroid conversion via the 5-unsaturated pathway, but aromatize androgens known to be produced by thecal cells. It is also suggested that either androgens or oestradiol-17beta stimulate progesterone production by granulosa cells, at least in vitro.