MRI radiomics for predicting intracranial progression in non-small-cell lung cancer patients with brain metastases treated with epidermal growth factor receptor tyrosine kinase inhibitors

AIM

To identify clinical and magnetic resonance imaging (MRI) radiomics predictors specialised for intracranial progression (IP) after first-line epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) treatment in non-small-cell lung cancer (NSCLC) patients with brain metastases (BMs).

MATERIALS AND METHODS

Seventy EGFR-mutated NSCLC patients with a total of 212 BMs who received first-line EGFR-TKI therapy were enrolled. Radiomics features were extracted from the BM regions on the pretreatment contrast-enhanced T1-weighted images, and the radiomics score (rad-score) of each BM was established based on the selected features. Furthermore, the mean rad-score derived from the average rad-score of all included BMs in each patient was calculated. Univariate and multivariate logistic regression analyses were performed to identify potential predictors of IP. Prediction models based on different predictors and their combinations were constructed, and nomogram based on the optimal prediction model was evaluated.

RESULTS

Thirty-three (47.1 %) patients developed IP, and the remaining 37 (52.9 %) patients were IP-free. EGFR-19del mutation (OR 0.19, 95 % CI 0.05-0.69), third-generation TKI treatment (OR 0.33, 95 % CI 0.16-0.67) and mean rad-score (OR 5.71, 95 % CI 1.65-19.68) were found to be independent predictive factors. Models based on these three predictors alone and in combination (combined model) achieved AUCs of 0.64, 0.64, 0.74, and 0.86 and 0.64, 0.64, 0.75, and 0.84 in the training and validation sets, respectively, and the combined model demonstrated optimal performance for predicting IP.

CONCLUSIONS

The model integrating EGFR-19del mutation, third-generation TKI treatment and mean rad-score had good predictive value for IP after EGFR-TKI treatment in NSCLC patients with BM.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

[Current situation and trend of medical laboratory results homogeneity management]

Medical test results are indispensable and important tools in diagnosis and treatment services. It is necessary to promote the homogenization of test results first, because homogenization is the basis for mutual recognition of test results. Mutual recognition of medical test results can help share resources among medical institutions, provide more reliable test results for early prevention, screening and treatment of diseases, and reduce repeated tests, thus improving people's medical experience. In recent years, with the deepening of medical system reform and the promotion of graded diagnosis and treatment, governments have continuously introduced policies of mutual recognition of test results around country. However, homogenization is a prerequisite for mutual recognition of test results, with the emergence of intelligent medicine in the era of internet big data, opportunities and challenges coexist in the development of homogeneity management. In the future, the homogeneity of medical test results will present a trend of digitalization, automation, informatization and intelligence.

Modifiable predictors of type 2 diabetes mellitus and roles of insulin resistance and β-cell function over a 6-year study and 30-year follow-up

PURPOSE

This study aimed to examine the modifiable predictors of T2DM and the roles of insulin resistance (IR) and β-cell function over a 6-year study and 30-year follow-up.

METHODS

A total of 462 non-diabetic participants, 282 with impaired glucose tolerance (IGT), and 180 with normal glucose tolerance (NGT) were enrolled in this analysis. The Matsuda IR index and area under the curve of insulin-to-glucose ratio (AUCI/G-R) were used as IR and β-cell function indices in the analysis.

RESULTS

In all participants, multivariable analysis showed that BMI, glucose status, Matsuda IR index and systolic blood pressure (SBP) at baseline were independently associated with an increased risk of T2DM over 30 years, whereas lifestyle intervention and AUCI/G-R were inversely associated with this risk. The predictive effect of the Matsuda IR index and AUCI/G-R in participants with IGT was consistent with the results of all participants, whereas in those with NGT, only the Matsuda IR index, not the AUCI/G-R, predicted the development of T2DM (HR = 1.42, 95% CI 1.07-1.89 vs HR = 1.09, 95% CI 0.76-1.56). The predictive effect of the Matsuda IR index on T2DM existed even in participants with BMI < 25 (p = 0.049).

CONCLUSION

The modifiable predictors of T2DM in Chinese adults were high BMI, hypertension, mild hyperglycaemia, IR, and β-cell dysfunction. Both IR and β-cell function contributed to the development of T2DM in the long term; however, IR remains the initial and long-standing key risk factor for T2DM.

“Drying effect” of fructus aurantii components and the mechanism of action based on network pharmacology and in vitro pharmacodynamic validation

Background: Fructus aurantii (FA) is the dried, unripe fruit of the plant Citrus aurantium L. and its cultivated varieties. We investigated the drying effect of FA components and how this drying affect is achieved.

Methods: We employed systems pharmacology to predict the components and targets of FA that produce its drying effect. These predictions were verified by computer simulation and animal experiments. In the latter, we measured the bodyweight, water consumption, urine output, fecal water content, rate of salivary secretion, and cross-sectional area of the long axis of the submandibular gland of mice. Immunohistochemistry was used to measure expression of aquaporin (AQP)5 in the submandibular gland, AQP2 in the kidney, and AQP3 in the colon. ELISA kits were used to measure the horizontal variation of cyclic adenosine monsophosphate (cAMP), cyclic guanosine monophosphate (cGMP) and interferon-γ.

Results: Sixty-seven potentially active components of FA were screened out. FA could produce a drying effect after regulating 214 targets through 66 active components. A total of 870 gene ontology (GO) terms and 153 signaling pathways were identified. The hypoxia inducible factor-1 signaling pathway, phosphoinositide 3-kinase-protein kinase B (PI3K-AKT) signaling pathway, calcium signaling pathway, and Ras signaling pathway may have important roles in the drying effect of FA. Four components of FA were identified: sinensetin, tangeretin, 5-demethylnobiletin and chrysin. These four components could increase the serum level of interferon-γ and ratio of cyclic adenosine monophosphate:cyclic guanosine monophosphate in mice, and affect their water consumption, urine output, fecal water content and rate of salivary secretion.

Conclusion: Four components of FA (tangeretin, sinensetin, chrysin, 5-Demethylmobiletin) were closely related to the Janus kinase-signal transducer and activator of transcription-3 (JAK-STAT3), PI3K-AKT, and the other signaling pathways. They can regulate the protein expression of JAK2, STAT3, PI3K, lymphocyte cell-specific protein-tyrosine kinase, vascular endothelial growth factor A, and protein kinase B1, affect water metabolism in the body and, finally, result in a drying effect.

Assessment of the Potential of Sarcandra glabra (Thunb.) Nakai. in Treating Ethanol-Induced Gastric Ulcer in Rats Based on Metabolomics and Network Analysis

Gastric ulcer (GU) is one of the most commonly diagnosed diseases worldwide, threatening human health and seriously affecting quality of life. Reports have shown that the Chinese herbal medicine Sarcandra glabra (Thunb.) Nakai (SGN) can treat GU. However, its pharmacological effects deserve further validation; in addition, its mechanism of action is unclear. An acute gastric ulcer (AGU) rat model induced by alcohol was used to evaluate the gastroprotective effect of SGN by analysis of the histopathological changes in stomach tissue and related cytokine levels; the potential mechanisms of action of SGN were investigated via serum metabolomics and network pharmacology. Differential metabolites of rat serum were identified by metabolomics and the metabolic pathways of the identified metabolites were enriched via MetaboAnalyst. Furthermore, the critical ingredients and candidate targets of SGN anti-AGU were elucidated. A compound-reaction-enzyme-gene network was established using Cytoscape version 3.8.2 based on integrated analysis of metabolomics and network pharmacology. Finally, molecular docking was applied to verify the acquired key targets. The results showed that SGN exerted a certain gastroprotective effect via multiple pathways and targets. The effects of SGN were mainly caused by the key active ingredients isofraxidin, rosmarinic, and caffeic acid, which regulate hub targets, such as PTGS2, MAPK1, and KDR, which maintain the homeostasis of related metabolites. Signal pathways involved energy metabolism as well as immune and amino acid metabolism. Overall, the multi-omics techniques were proven to be promising tools in illuminating the mechanism of action of SGN in protecting against diseases. This integrated strategy provides a basis for further research and clinical application of SGN.

POS0678 CLINICAL OUTCOMES OF METHOTREXATE (MTX)-NAIVE RHEUMATOID ARTHRITIS (RA) PATIENTS (pts) ON FILGOTINIB (FIL) LONG-TERM EXTENSION (LTE) TRIAL INITIALLY ON FIL OR MTX DURING THE PHASE 3 PARENT STUDY (PS)

Background

The preferential Janus kinase-1 inhibitor FIL is approved for treatment of moderate to severe active RA in Europe and Japan.

Objectives

In this post hoc, exploratory analysis, efficacy and safety of long-term treatment with FIL (± MTX) were assessed in MTX-naïve pts treated with FIL or MTX in the Phase 3 PS (NCT02886728).1

Methods

Pts received FIL 200 mg (FIL200)+MTX, FIL 100 mg (FIL100)+MTX, FIL200 alone, or MTX alone up to 52 W in PS.1 Those completing PS on study drug could enter LTE (NCT03025308; data cutoff: June 1, 2020). MTX completers were rerandomized, blinded, to FIL200 or FIL100; pts on FIL in PS remained on the same dose in LTE. MTX was washed out for 4 W at LTE baseline (BL); pts could (re)start MTX and/or other conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) ≥4 W after LTE first dosing.1 Efficacy data to LTE W48 and safety data are reported.

Results

As of June 1, 2020, 439/492 (89%) and 144/169 (85%) pts who entered LTE from PS FIL200 and PS FIL100 groups, respectively, remained on LTE study treatment; of those rerandomized from MTX, 131/148 (89%) FIL200 and 133/151 (88%) FIL100 pts remained on study treatment. LTE BL characteristics were similar between FIL200 and FIL100 groups. After MTX washout, 17% of FIL200 and 23% of FIL100 pts (re)started MTX (at clinical judgment). ACR20/50/70 response rates among pts from PS FIL arms decreased modestly from LTE BL to W12 then stabilized. Among pts who switched from PS MTX to LTE FIL, response rates remained stable or improved to approach those of PS FIL pts by W48 (Figure 1). Similar trends were seen in DAS28(CRP) and CDAI. Treatment-emergent adverse events (TEAEs), Grade ≥3 AEs, serious AEs, and infections were largely comparable across groups and did not increase after MTX to FIL switch. There were 6 deaths, all among PS FIL200 pts (Table 1).

Table 1.

EAIRs of TEAEs through June 2020

EAIR (95% CI)FIL200+MTX →FIL200 →FIL100+MTX →MTX →MTX →FIL200 LTEFIL200 LTEFIL100 LTEFIL200 LTEFIL100 LTEn=325n=167n=169n=148n=151PYE=474.4PYE=232.5PYE=236.4PYE=213.4PYE=215.4TEAE49.7 (43.8, 56.5)46.9 (38.9, 56.6)49.9 (41.7, 59.8)50.6 (41.9, 61.1)46.4 (38.2, 56.5)TEAE Grade ≥37.2 (5.1, 10.0)6.5 (3.9, 10.7)10.2 (6.8, 15.1)7.0 (4.2, 11.7)7.0 (4.2, 11.6)TE serious AE5.9 (4.1, 8.5)6.0 (3.6, 10.2)8.9 (5.8, 13.6)6.6 (3.9, 11.1)6.5 (3.9, 11.0)Death1.1 (0.3, 2.5)0.4 (0.1, 3.1)0 (0, 1.6)0 (0, 1.7)0 (0, 1.7)Infections28.5 (24.0, 33.7)29.7 (23.4, 37.6)27.5 (21.6, 35.1)28.6 (22.2, 36.7)27.4 (21.2, 35.4)Serious infections1.1 (0.4, 2.5)3.0 (1.4, 6.3)2.5 (1.1, 5.7)1.9 (0.7, 5.0)1.9 (0.7, 4.9)Opportunistic infections0.2 (0, 1.5)0 (0, 1.6)0.8 (0.2, 3.4)0 (0, 1.7)0 (0, 1.7)Herpes zoster0.8 (0.3, 2.2)1.7 (0.6, 4.6)0.8 (0.2, 3.4)1.9 (0.7, 5.0)0.9 (0.2, 3.7)MACE (adjudicated)0.6 (0.1, 1.8)0.9 (0.2, 3.4)0 (0, 1.6)0 (0, 1.7)0 (0, 1.7)VTE (adjudicated for DVT/PE)0.2 (0, 1.2)0.4 (0.1, 3.1)0 (0, 1.6)0 (0, 1.7)0 (0, 1.7)Malignancies (excluding NMSC)0.6 (0.2, 2.0)0 (0, 1.6)1.7 (0.6, 4.5)0.5 (0, 2.6)0 (0, 1.7)NMSC0.6 (0.2, 2.0)0.4 (0.1, 3.1)0.8 (0.2, 3.4)0.5 (0, 2.6)0 (0, 1.7)

DVT, deep vein thrombosis; EAIRs, exposure-adjusted incidence rates (per 100 patient-years of exposure); MACE, major adverse cardiovascular event; NMSC, nonmelanoma skin cancer; PE, pulmonary embolism; VTE, venous thromboembolism

Figure 1.

Conclusion

Overall, response rates improved from LTE BL to W48 for pts switched from PS MTX to FIL and decreased modestly for PS FIL pts. Rates of AEs of special interest were generally low and tended to be higher in pts maintained on FIL from PS. Safety findings in this subpopulation were comparable with the PS through W521 and with a 7-trial integrated safety analysis.2 Limitations: the LTE was not formally randomized at BL, the groups were of unequal size, and the switch from MTX to FIL for LTE was by design rather than based on disease activity.

References

[1]Westhovens R et al. Ann Rheum Dis 2021;80:727–38.

[2]Winthrop K et al. Arthritis Rheumatol 2020;72(suppl 10): abstract 0229.

Acknowledgements

Funding for the trials was provided by Galapagos NV and Gilead Sciences, Inc. The sponsors participated in the planning, execution, and interpretation of the research. This study was funded by Gilead Sciences, Inc., Foster City, CA. Medical writing support was provided by Gregory Bezkorovainy, MA, of AlphaScientia, LLC, San Francisco, CA; and funded by Gilead Sciences, Inc., Foster City, CA. Funding for this analysis was provided by Gilead Sciences, Inc.

Disclosure of Interests

Daniel Aletaha Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Celgene, Eli Lilly, Medac, Merck, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sandoz, Sanofi/Genzyme, and UCB, Consultant of: AbbVie, Amgen, Celgene, Eli Lilly, Janssen, Medac, Merck, Novartis, Pfizer, Roche, Sandoz, and Sanofi/Genzyme, Grant/research support from: AbbVie, Merck Sharp & Dohme, Novartis, and Roche, Rene Westhovens Consultant of: Celltrion, Galapagos, and Gilead Sciences, Inc., Grant/research support from: Celltrion, Galapagos, and Gilead Sciences, Inc., Tatsuya Atsumi Speakers bureau: AbbVie Inc., Astellas Pharma Inc., Bristol Myers Squibb Co., Chugai Pharmaceutical Co., Ltd, Daiichi Sankyo Co., Ltd, Eisai Co. Ltd, Eli Lilly Japan K.K., Mitsubishi Tanabe Pharma Co., Otsuka Pharmaceutical Co., Ltd, Pfizer Inc., Takeda Pharmaceutical Co., Ltd, UCB Japan Co. Ltd, Consultant of: AbbVie Inc., Chugai Pharmaceutical Co., Ltd, Daiichi Sankyo Co., Ltd, Eli Lilly Japan K.K., Gilead Sciences, Inc., Pfizer Inc., UCB Japan Co. Ltd, Grant/research support from: AbbVie Inc., Alexion Pharmaceuticals, Inc., Astellas Pharma Inc., Bristol Myers Squibb Co., Chugai Pharmaceutical Co., Ltd, Daiichi Sankyo Co., Ltd, Eli Lilly Japan K.K., Mitsubishi Tanabe Pharma Co., Pfizer Inc., YingMeei Tan Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Alena Pechonkina Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Qi Gong Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Vijay Rajendran Shareholder of: Galapagos NV, Employee of: Galapagos NV, Sander Strengholt Shareholder of: Galapagos BV, Employee of: Galapagos BV, Gerd Rüdiger Burmester Speakers bureau: AbbVie, Eli Lilly, Gilead Sciences, Inc. and Pfizer, Consultant of: AbbVie, Eli Lilly, Gilead Sciences, Inc. and Pfizer

AB0394 CLINICAL OUTCOMES UP TO WEEK 48 OF ONGOING FILGOTINIB (FIL) RHEUMATOID ARTHRITIS (RA) LONG-TERM EXTENSION (LTE) TRIAL OF BIOLOGIC DISEASE-MODIFYING ANTIRHEUMATIC DRUG (bDMARD) INADEQUATE RESPONDERS (IR) INITIALLY ON FIL OR PLACEBO IN A PHASE 3 PARENT STUDY (PS)

Background

The preferential Janus kinase-1 inhibitor FIL is approved for treatment of moderate to severe active RA in Europe and Japan.

Objectives

Efficacy and safety of FIL were assessed in patients (pts) with IR to bDMARDs in a LTE trial (NCT03025308) enrolled from a Phase 3 PS (NCT02873936).1

Methods

bDMARD-IR pts received FIL 200 mg (FIL200), FIL 100 mg (FIL100), or placebo (PBO), all with stable conventional synthetic (cs)DMARDs up to 24 weeks (W). At W14 of the PS, pts with IR to FIL or PBO (<20% improvement in swollen [66] and tender [68] joint counts) switched to standard of care (SOC; investigator’s choice of treatment). Pts completing the PS on FIL, PBO, or SOC could enter the LTE. PS FIL pts were maintained, blinded, on their FIL dose; PS PBO and PS SOC pts were rerandomized, blinded, to FIL200 or FIL100. Efficacy data to LTE W48 and safety data to data cutoff (June 1, 2020) are reported.

Results

The PS included 147, 153, and 148 pts on FIL200, FIL100, and PBO. Pts continuing on LTE FIL200 and FIL100 at data cutoff: 80/121 (66%) and 76/110 (69%) from PS FIL200 and FIL100; 35/47 (75%) and 32/46 (70%) from PS PBO, and 13/23 (57%) and 13/22 (59%) from PS SOC. LTE baseline (BL) characteristics were similar in FIL200 and FIL100 pts. During LTE, PS FIL ACR20/50/70 response rates decreased modestly by W48 (Figure 1). Among PS PBO pts, response rates were lower at LTE BL, reaching similar levels to PS FIL pts by W48; rates increased to W48 in PS SOC pts on either FIL dose but not to levels of other groups. Percentages of pts attaining DAS28(CRP) ≤3.2, DAS28(CRP) <2.6, CDAI ≤10, and CDAI ≤2.8 were maintained up to W48 for FIL/FIL pts. PBO/FIL and SOC/FIL pts showed similar patterns to ACR responses (Figure 1). Exposure-adjusted incidence rates (EAIRs)/100 pt-years of exposure for treatment-emergent adverse events (TEAE), serious AEs, and serious infection were higher in SOC/FIL pts vs FIL/FIL or PBO/FIL pts, but samples were small and confidence intervals overlapped. There were 5 deaths (Table 1).

Table 1.

EAIRs of TEAEs in LTE, as of June 1, 2020

EAIR (95% CI)FIL200+csD → FIL200+csD n=121PYE 228.4PBO+csD → FIL200+csD n=47PYE 98.1SOC+csD → FIL200+csD n=23PYE 42.1FIL100+csD → FIL100+csD n=110PYE 223.3PBO+csD → FIL100+csD n=46PYE 91.1SOC+csD → FIL100+csD n=22PYE 38.2TEAE46.9 (38.8, 56.6)38.7 (28.2, 53.2)52.2 (34.4, 79.3)40.3 (32.8, 49.5)40.6 (29.4, 56.1)49.8 (31.8, 78.0)TEAE Grade ≥310.5 (7.0, 15.7)10.2 (5.5, 18.9)19.0 (9.5, 38.0)10.3 (6.8, 15.5)13.2 (7.5, 23.2)18.3 (8.7, 38.5)TE serious AE12.3 (8.5, 17.8)12.2 (6.9, 21.5)21.4 (11.1, 41.1)8.1 (5.1, 12.8)13.2 (7.5, 23.2)21.0 (10.5, 41.9)Death1.3 (0.4, 4.1)1.0 (0, 5.7)0 (0, 8.8)0.4 (0.1, 3.2)0 (0, 4.0)0 (0, 9.7)TE infections34.2 (27.4, 42.6)22.4 (14.8, 34.1)35.6 (21.5, 59.1)22.4 (17.0, 29.5)26.3 (17.7, 39.3)39.3 (23.7, 65.2)TE serious infections3.5 (1.8, 7.0)2.0 (0.5, 8.2)7.1 (2.3, 22.1)0.9 (0.2, 3.6)2.2 (0.5, 8.8)7.9 (2.5, 24.4)Opportunistic infections0 (0, 1.6)0 (0, 3.8)0 (0, 8.8)0 (0, 1.7)0 (0, 4.0)0 (0, 9.7)TE herpes zoster2.2 (0.7, 5.1)1.0 (0.1, 7.2)0 (0, 8.8)0 (0, 1.7)2.2 (0.5, 8.8)2.6 (0.1, 14.6)TE MACE (adjudicated)1.3 (0.4, 4.1)1.0 (0.1, 7.2)0 (0, 8.8)0.9 (0.2, 3.6)1.1 (0.2, 7.8)0 (0, 9.7)TE DVT/PE (adjudicated)0.9 (0.2, 3.5)0 (0, 3.8)2.4 (0.1, 13.2)0.4 (0.1, 3.2)0 (0, 4.0)0 (0, 9.7)Malignancies (excluding NMSC)1.3 (0.4, 4.1)3.1 (1.0, 9.5)4.7 (0.6, 17.2)1.8 (0.7, 4.8)3.3 (1.1, 10.2)0 (0, 9.7)NMSC0 (0, 1.6)0 (0, 3.8)4.7 (0.6, 17.2)0 (0, 1.7)0 (0, 4.0)0 (0, 9.7)

DVT, deep vein thrombosis; MACE, major adverse cardiovascular event; NMSC, nonmelanoma skin cancer; PE, pulmonary embolism; TE, treatment-emergent

Conclusion

Efficacy was mostly maintained in PS FIL pts up to W48. Response among PS PBO and SOC pts increased from BL to W48, but response in PS SOC pts continued to be lower than in other groups; these pts may represent a refractory population. FIL safety was largely consistent between PS and LTE.

References

[1]Genovese MC et al. JAMA 2019;322:315–25.

Acknowledgements

This study was funded by Gilead Sciences, Inc., Foster City, CA. Medical writing support was provided by Claudine Bitel, PhD, of AlphaScientia, LLC, San Francisco, CA; and funded by Gilead Sciences, Inc., Foster City, CA.

Disclosure of Interests

Maya H Buch Speakers bureau: AbbVie, Consultant of: AbbVie, Galapagos, Gilead, and Pfizer, Grant/research support from: Gilead and Pfizer, Tsutomu Takeuchi Speakers bureau: AbbVie, AYUMI, Bristol Myers Squibb, Chugai, Daiichi Sankyo, Dainippon Sumitomo, Eisai, Eli Lilly Japan, Gilead Sciences, Mitsubishi-Tanabe, Novartis, Pfizer Japan, and Sanofi, Consultant of: Astellas, Chugai, and Eli Lilly Japan, Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi Sankyo, Eisai, Mitsubishi-Tanabe, Shionogi, Takeda, and UCB Japan, Vijay Rajendran Shareholder of: Galapagos, Employee of: Galapagos, Jacques-Eric Gottenberg Speakers bureau: AbbVie, Eli Lilly and Co., Galapagos, Gilead Sciences, Inc., Roche, Sanofi Genzyme, and UCB, Consultant of: Bristol Myers Squibb, Sanofi Genzyme, and UCB, Grant/research support from: Bristol Myers Squibb and Pfizer, Alena Pechonkina Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., YingMeei Tan Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Qi Gong Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Katrien Van Beneden Shareholder of: Galapagos, Employee of: Galapagos, Roberto Caporali Speakers bureau: AbbVie, Amgen, BMS, Celltrion, Galapagos, Janssen, Lilly, MSD, Novartis, Pfizer, Sandoz, and UCB, Consultant of: AbbVie, Amgen, BMS, Celltrion, Galapagos, Janssen, Lilly, Fresenius-Kabi, MSD, Novartis, Pfizer, Roche, Sandoz, and UCB

POS0679 CLINICAL OUTCOMES UP TO WEEK (W) 48 IN THE ONGOING FILGOTINIB (FIL) LONG-TERM EXTENSION (LTE) TRIAL OF RHEUMATOID ARTHRITIS (RA) PATIENTS (pts) WITH INADEQUATE RESPONSE (IR) TO METHOTREXATE (MTX) INITIALLY TREATED WITH FIL OR ADALIMUMAB (ADA) DURING THE PHASE 3 PARENT STUDY (PS)

Background

The preferential Janus kinase-1 inhibitor FIL is approved for treatment of moderate to severe active RA in Europe and Japan.

Objectives

Efficacy and safety of FIL were assessed in pts with IR to MTX who completed a Phase 3 trial (NCT02889796)1 and enrolled in an LTE (NCT03025308).

Methods

Pts completing the PS1 on study drug were eligible to enter the LTE (data cutoff: June 1, 2020). Median exposure: 2.2 years (y). Efficacy data to W48 are reported for 4 treatment groups (all with background MTX): pts receiving FIL 200 mg (FIL200) or FIL 100 mg (FIL100) in the PS and continuing their dose in LTE (FIL200/FIL200, FIL100/FIL100) and ADA pts rerandomized, double blind, to FIL200 or FIL100 for LTE (ADA/FIL200, ADA/FIL100); safety data are reported.

Results

As of June 1, 2020, 522/571 (91%) FIL200/FIL200, 502/570 (88%) FIL100/FIL100, 118/128 (92%) ADA/FIL200, and 115/130 (89%) ADA/FIL100 pts remained on study drug. LTE baseline disease characteristics were similar between groups: mean duration of RA approximately 8.7 y; DAS28(CRP) 2.55, and mean concurrent MTX dosage was 15.0 mg/week. Proportions of pts achieving ACR20/50/70, DAS28(CRP) ≤3.2, <2.6, and CDAI ≤10, ≤2.8 were generally maintained in all LTE groups through W48 (Figure 1). Numerically greater proportions of pts met response criteria at W48 in the FIL200 groups vs FIL100, regardless of PS treatment. Treatment-emergent AEs (TEAE), serious AEs, and AEs Grade ≥3 were largely comparable between groups and lowest in ADA/FIL100. There were 10 deaths (Table 1). Exposure-adjusted incidence rates (EAIRs)/100 pt-y of exposure for deaths were lower for FIL/FIL vs ADA/FIL.

Table 1.

EAIRs of TEAEs in LTE, as of June 1, 2020

1TEAE, n (%)3FIL200+MTX → FIL200+MTX6ADA+MTX → FIL200+MTX9FIL100+MTX → FIL100+MTX12ADA+MTX → FIL100+MTX2EAIR (95% CI)4n=5717n=12810n=57013n=1305PYE=859.48PYE=197.811PYE=852.314PYE=192.6TEAE429 (75.1)91 (71.1)443 (77.7)88 (67.7)49.9 (45.4, 54.9)46.0 (37.5, 56.5)52.0 (47.4, 57.0)45.7 (37.1, 56.3)TEAE Grade ≥364 (11.2)15 (11.7)72 (12.6)7 (5.4)7.4 (5.8, 9.5)7.6 (4.6, 12.6)8.4 (6.7, 10.6)3.6 (1.7, 7.6)TE serious AE52 (9.1)13 (10.2)60 (10.5)9 (6.9)6.1 (4.6, 7.9)6.6 (3.8, 11.3)7.0 (5.5, 9.1)4.7 (2.4, 9.0)Death3 (0.5)2 (1.6)3 (0.5)2 (1.5)0.3 (0.1, 1.1)1.0 (0.3, 4.0)0.4 (0.1, 1.1)1.0 (0.3, 4.2)TE infections243 (42.6)52 (40.6)249 (43.7)43 (33.1)28.3 (24.9, 32.1)26.3 (20.0, 34.5)29.2 (25.8, 33.1)22.3 (16.6, 30.1)TE serious infections7 (1.2)2 (1.6)13 (2.3)1 (0.8)0.8 (0.4, 1.7)1.0 (0.3, 4.0)1.5 (0.9, 2.6)0.5 (0.1, 3.7)Opportunistic infections2 (0.4)02 (0.4)00.2 (0, 0.8)0 (0, 1.9)0.2 (0, 0.8)0 (0, 1.9)TE herpes zoster16 (2.8)5 (3.9)13 (2.3)1 (0.8)1.9 (1.1, 3.0)2.5 (1.1,6.1)1.5 (0.9, 2.6)0.5 (0.1, 3.7)TE MACE (adjudicated)1 (0.2)03 (0.5)3 (2.3)01 (0, 0.6)0 (0, 1.9)0.4 (0.1, 1.1)1.6 (0.5, 4.8)TE DVT/PE (adjudicated)3 (0.5)03 (0.5)00.3 (0.1, 1.0)0 (0, 1.9)0.4 (0.1, 1.0)0 (0, 1.9)Malignancies (excluding NMSC)5 (0.9)3 (2.3)4 (0.7)00.6 (0.2, 1.4)1.5 (0.5, 4.7)0.5 (0.1, 1.2)0 (0, 1.9)NMSC3 (0.5)02 (0.4)00.3 (0.1, 1.0)0 (0, 1.9)0.2 (0, 0.8)0 (0, 1.9)

DVT, deep vein thrombosis; MACE, major adverse cardiovascular event; NMSC, nonmelanoma skin cancer; PE, pulmonary embolism; TE, treatment-emergent

Figure 1.

Conclusion

During the LTE through W48, response rates generally were maintained for FIL/FIL and ADA/FIL pts. Though there were differences between LTE groups, safety was largely comparable and consistent with PS observations1 and previously reported results from 7 trials2: rates of AEs of special interest were low; all confidence intervals were overlapping. Limitation: the LTE was not formally randomized for comparison between FIL/FIL and ADA/FIL treatment groups, the groups were of unequal size, and the switch from ADA to FIL for LTE was by design, rather than based on disease activity.

References

[1]Combe B et al. Ann Rheum Dis 2021;80:848–58.

[2]Winthrop K et al. Arthritis Rheumatol 2020;72(suppl 10); abstract 0229.

Acknowledgements

This study was funded by Gilead Sciences, Inc., Foster City, CA. Medical writing support was provided by Claudine Bitel, PhD, of AlphaScientia, LLC, San Francisco, CA; and funded by Gilead Sciences, Inc., Foster City, CA.

Disclosure of Interests

Bernard Combe Speakers bureau: BMS, Eli Lilly & Co., Gilead Sciences, Inc., MSD, Pfizer, Roche-Chugai, and UCB, Consultant of: AbbVie, Eli Lilly & Co., Gilead Sciences, Inc., Janssen, Pfizer, Roche-Chugai, and Sanofi, Grant/research support from: Novartis, Pfizer, and Roche-Chugai, Yoshiya Tanaka Speakers bureau: AbbVie, Asahi-Kasei, Astellas, Bristol-Myers, Chugai, Daiichi- Sankyo, Eli Lilly, Eisai, Gilead, GSK, Janssen, Mitsubishi-Tanabe, Novartis, Pfizer, Sanofi, and YL Biologics, Consultant of: AbbVie, Ayumi, Daiichi- Sankyo, Eli Lilly, GSK, Sanofi, and Taisho, Grant/research support from: AbbVie, Asahi-Kasei, Chugai, Daiichi-Sankyo, Eisai, Mitsubishi-Tanabe, and Takeda, Paul Emery Consultant of: AbbVie, BMS, Celltrion, Gilead, Lilly, Novartis, Roche, Samsung, and Sandoz, Grant/research support from: AbbVie, BMS, Lilly, and Samsung, Alena Pechonkina Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Albert Kuo Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Qi Gong Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Katrien Van Beneden Shareholder of: Galapagos NV, Employee of: Galapagos NV, Vijay Rajendran Shareholder of: Galapagos NV, Employee of: Galapagos NV, Hendrik Schulze-Koops Speakers bureau: AbbVie, Amgen, BMS, Celgene, Celltrion, Chugai, Gilead, Janssen, Eli Lilly and Company, Merck Sharp & Dohme, Novartis-Sandoz, Pfizer, Roche, and Sanofi, Consultant of: AbbVie, Amgen, BMS, Celgene, Celltrion, Chugai, Gilead, Janssen, Eli Lilly and Company, Merck Sharp & Dohme, Novartis-Sandoz, Pfizer, Roche, and Sanofi, Grant/research support from: AbbVie and Novartis

Altered dynamic functional topology in first-episode untreated patients with schizophrenia can aid in early diagnosis

Introduction

There is a growing consensus on brain networks that it is not immutable but rather a dynamic complex system for adapting environment. The neuroimaging research studying how brain regions work collaboratively with dynamic methods had demonstrated its effectiveness in revealing the neural mechanisms of schizophrenia.

Objectives

To investigate altered dynamic brain functional topology in first-episode untreated schizophrenia patients (SZs) and establish classification models to find objective brain imaging biomarkers.

Methods

Resting-state-functional magnetic resonance data for SZs and matched healthy controls were obtained(Table1).

Power-264-template was used to extract nodes and sliding-window approach was carried out to establish functional connectivity matrices. Functional topology was assessed by eigenvector centrality(EC) and node efficiency and its time-fluctuating was evaluated with coefficient of variation(CV). Group differences of dynamic topology and correlation analysis between Positive and Negative Syndrome Scale(PANSS) scores and topology indices showing group differences, which also were used in establishing classification models, was examed.

Results

The CV of node efficiency in angular and paracingulate gyrus was larger in SZs. There are 13 nodes assigned into several brain networks displaying altered CV of EC between groups(Figure1.A). Fluctuation of EC of the node in DMN, which was lower in SZs, showed negative correlation with PANSS total scores(Figure1.B). Dynamic functional topology of above nodes was used to train classification models and demonstrated 80% and 71% accuracy for support vector classification(SVC) and random forest(RF), respectively(Figure2).

Conclusions

Dynamic functional topology illustrated a capability in identifying SZs. Aberrated dynamics of DMN relevant to severity of patient’s symptoms could reveal the reason why it contributed to classification.

Disclosure

No significant relationships.

Brain controllability and clinical relevance in schizophrenia

Introduction

Apart from the psychiatric symptoms, cognitive deficits are also the core symptoms of schizophrenia. Brain network control theory provided information on the role of a specific brain region in the cognitive control process, helping understand the neural mechanism of cognitive impairment in schizophrenia.

Objectives

To characterize the control properties of functional brain network in first-episode untreated patients with schizophrenia and the relationships between controllability and psychiatric symptoms, as well as exploring the predictive value of controllability in differentiating patients from healthy controls (HCs).

Methods

Average and modal controllability of brain networks were calculated and compared between 133 first-episode untreated patients with schizophrenia and 135 HCs. The associations between controllability and clinical symptoms were evaluated using sparse canonical correlation analysis. Support vector machine (SVM) and SVM-recursive feature elimination combined with the controllability were performed to establish the individual prediction model.

Results

Compared to HCs, the patients with schizophrenia showed increased average controllability and decreased modal controllability in dorsal anterior cingulate cortex (dACC). Brain controllability predominantly in somatomotor, default mode, and visual networks was associated with the positive symptomatology of schizophrenia. The established model could identify patients with an accuracy of 0.68. Furthermore, the most discriminative features were located in dACC, medial prefrontal lobe, precuneus and superior temporal gyrus.

Conclusions

Altered controllability in dACC may play a critical role in the neuropathological mechanisms of cognitive deficit in schizophrenia, which could drive the brain function to different states to cope with varied cognitive tasks. As symptom-related biomarkers, controllability could be also beneficial to individual prediction in schizophrenia.

Disclosure

No significant relationships.

Gray Matter Deficits of Cortical-striatal-limbic Circuit in Social Anxiety Disorder

Introduction

The extant findings have been of great heterogeneity due to partial volume effects in the investigation of cortical gray matter volume (GMV), high comorbidity with other psychiatric disorders, and concomitant therapy in the neuroimaging studies of social anxiety disorder (SAD).

Objectives

To identity gray matter deficits in cortical and subcortical structures in non-comorbid never-treated patients, so as to explore the “pure” SAD-specific pathophysiology and neurobiology.

Methods

Thirty-two non-comorbid free-of-treatment patients with SAD and 32 demography-matched healthy controls were recruited to undergo high-resolution 3.0-Tesla T1-weighted MRI. Cortical thickness (CT) and subcortical GMV were estimated using FreeSurfer; then the whole-brain vertex-wise analysis was performed to compare group differences in CT. Besides, differences in subcortical GMV of priori selected regions-of-interest: amygdala, hippocampus, putamen, and pallidum were compared by an analysis of covariance with age, gender, and total subcortical GMV as covariates.

Results

The SAD patients demonstrated significantly decreased CT near-symmetrically in the bilateral prefrontal cortex (Monte Carlo simulations of P < 0.05). Besides, smaller GMV in the left hippocampus and pallidum were also observed in the SAD cohort (two-sample t-test of P < 0.05).

Conclusions

For the first time, the current study investigated the structural alterations of CT and subcortical GMV in non-comorbid never-treated patients with SAD. Our findings provide preliminary evidences that structural deficits in cortical-striatal-limbic circuit may contribute to the psychopathological basis of SAD, and offer more detailed structural substrates for the involvement of such aberrant circuit in the imbalance between defective bottom-up response and top-down control to external stimuli in SAD.

Disclosure

No significant relationships.

Exploring the Potential Mechanism of Chuanxiong Rhizoma Treatment for Migraine Based on Systems Pharmacology

Migraine is a disease whose aetiology and mechanism are not yet clear. Chuanxiong Rhizoma (CR) is employed in traditional Chinese medicine (TCM) to treat various disorders. CR is effective for migraine, but its active compounds, drug targets, and exact molecular mechanism remain unclear. In this study, we used the method of systems pharmacology to address the above issues. We first established the drug-compound-target-disease (D-C-T-D) network and protein-protein interaction (PPI) network related to the treatment of migraine with CR and then established gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses. The results suggest that the treatment process may be related to the regulation of inflammation and neural activity. The docking results also revealed that PTGS2 and TRPV1 could directly bind to the active compounds that could regulate them. In addition, we found that CR affected 11 targets that were more highly expressed in the liver or heart but were the lowest in the whole brain. It also expounds the description of CR channel tropism in TCM theory from these angles. These findings not only indicate that CR can be developed as a potential effective drug for the treatment of migraine but also demonstrate the application of systems pharmacology in the discovery of herbal-based disease therapies.

Application of Sarcosaprophagous Insects to Estimate the Postmortem Interval in 11 Cases

Abstract

Objective To test the feasibility and accuracy of with sarcosaprophagous insects postmortem interval （PMI） estimation with sarcosaprophagous insects and provide references for estimation practice. Methods Eleven cases confirmed by the detection results, with complete entomological evidence were selected. The insect species, estimation results and true results involved in the cases were statistically analyzed and compared. Results Thirteen species of insects were found at the criminal scene, including Chrysomya megacephala （Fabricius）, Chrysomya rufifacies （Macquart）, Chrysomya nigripes （Aubertin）, Lucilia sericata （Meigen）, Hydrotaea spinigera Stein, Muscina stabulans （Fallén）, Sarcophagid （species were not identified）, Megaselia scalaris （Loew）, Hermetia illucens （Linnaeus）, Saprinus splendens （Paykull）, Creophilus maxillosus （Linnaeus）, Dermestes maculatus （De Geer） and Necrobia ruficollis （Fabricius）. The PMI of all eleven cases was within the range of estimated PMI. The estimated results of 72.73% cases were on the same day of the true results. Conclusion Sarcosaprophagous insects can estimate the PMI simply and conveniently. In cases where the PMI is within the time range of one generation of flies or beetles, the estimation results are relatively accurate. However, the estimation is less accurate when the PMI is beyond the time range.

Parecoxib prevents nucleus pulposus cells apoptosis by suppressing endoplasmic reticulum stress

OBJECTIVE

Intervertebral disc degeneration (IVDD) is the main cause of spine diseases, and apoptosis of nucleus pulposus (NP) cells is an important risk factor for the degeneration of intervertebral discs. Endoplasmic reticulum (ER) stress is involved in multiple apoptosis processes. This study investigated whether the specific COX-2 inhibitor parecoxib can inhibit NP cell apoptosis induced by ER stress.

PATIENTS AND METHODS

Human NP cells were isolated from the disc tissue collected from IVDD patients. We used IL-1β to establish an NP cell degenerated model. Degenerated levels were detected by the analysis of cell viability, collagen II, collagen X, aggrecan, TNF-α, IL-6, and MMP-13 expression. ER stress status was examined by GRP78 and CHOP expression. Apoptosis level was mainly indicated by the positive apoptotic cells and caspase-12 expression. CHOP-plasmid transfection was performed to overexpress the CHOP protein level.

RESULTS

IL-1β could induce the decrease of viability, collagen Ⅱ, aggrecan, but an increase of collagen X, TNF-α, IL-6, and MMP-13 in NP cells, as well as the upregulation of GRP78/PERK/caspase-12 and apoptosis level, which could be inhibited by parecoxib. Parecoxib could also suppress CHOP caused by COX-2 upregulation and apoptosis in NP cells.

CONCLUSIONS

Parecoxib is a safe and efficient COX-2 inhibitor to NP cells, which could prevent NP cells apoptosis by suppressing ER stress.

AB0259 EVALUATION OF THE EFFECT OF FILGOTINIB ON THE PHARMACOKINETICS OF ROSUVASTATIN, ATORVASTATIN, AND PRAVASTATIN

Background:

Filgotinib is an orally administered small molecule that preferentially inhibits Janus kinase 1 and is approved for use in Europe and Japan in adult patients with rheumatoid arthritis (RA) who have had an inadequate response to conventional therapies. Patients with RA are at a higher risk of cardiovascular morbidity and mortality relative to the general population1. Thus, it is important to understand potential drug-drug interactions of filgotinib with lipid-lowering agents such as statins. Based on in vitro studies, filgotinib is not expected to significantly increase exposure of statins via inhibition of the organic anion transporting peptide (OATP) at clinically relevant exposures. Hence, in Phase 2 and Phase 3 clinical studies, statins were allowed for use with filgotinib. A post-hoc analysis showed no increase in statin-induced AEs such as muscle or liver toxicities when statins were coadministered with filgotinib (“Concomitant Use of Statins in Filgotinib-Treated Patients with Rheumatoid Arthritis: A Post Hoc Analysis”, submitted to EULAR 2021).

Objectives:

The objectives of this study (NCT04608344) were to evaluate the effect of filgotinib on the pharmacokinetics of atorvastatin, pravastatin, and rosuvastatin, which are sensitive substrates for the OATP-1B1/1B3, and the short-term safety of administering filgotinib with or without statins.

Methods:

This was an open-label, randomized, two-way, crossover study in healthy adult volunteers (n = 27). Study participants received a single dose of atorvastatin (ATV 40 mg) and a single dose of a cocktail of pravastatin (PRA 40 mg)/rosuvastatin (ROS 10 mg), on two different occasions with washout in between, alone or in combination with filgotinib (200 mg QD for 11 days). Serial pharmacokinetic sampling was performed and pharmacokinetic parameters for each statin were calculated. Safety was assessed throughout the study. An analysis of variance using a mixed-effects model was applied to the natural logarithmic transformation of pharmacokinetic parameters (Cmax and AUCinf) for ATV, 2-OH-ATV (active metabolite of ATV), PRA, and ROS. Geometric-least squares means (GLSM) ratios and 90% confidence intervals (90% CI) of pharmacokinetic parameters were estimated for each analyte and were compared against pre-specified lack of pharmacokinetic alteration boundaries of 70 to 143%.

Results:

Of the 27 enrolled participants, 25 participants completed all study treatments. Most AEs and laboratory abnormalities were Grade 1 or 2 in severity; 1 participant discontinued due to a Grade 3 increase in creatine kinase and 1 participant discontinued due to difficulty in blood draws. Following coadministration of filgotinib with ATV, relative to ATV alone, ATV AUCinf was unaffected (GLSM ratio (90% CI): 0.91 (0.84, 0.99)), but ATV Cmax was slightly reduced (GLSM ratio (90% CI): 0.82 (0.69, 0.98)). 2-OH-ATV exposure (Cmax and AUCinf) were unaffected (GLSM ratio (90% CI): 0.98 (0.81, 1.18) for Cmax and 1.12 (1.02, 1.22) for AUCinf), and were within the pre-specified lack-of-effect bounds. Following coadministration with filgotinib, PRA AUCinf was unaffected (GLSM ratio (90% CI): 1.22 (1.06, 1.42)), but PRA Cmax was slightly higher (1.25 (1.01, 1.54)). ROS exposure (Cmax and AUCinf) were moderately higher upon coadministration with filgotinib (GLSM ratio (90% CI): 1.68 (1.43, 1.97) for Cmax and 1.42 (1.30, 1.56) for AUCinf), and these changes in rosuvastatin exposure are not considered to be clinically relevant.

Conclusion:

All study treatments were generally well tolerated. Co-administration with filgotinib did not have a clinically meaningful impact on the exposure of ATV, PRA, and ROS. These data support concomitant use of filgotinib with OATP substrates such as statins.

References:

[1]Piepoli MF, Hoes AW, Agewall S, et al. Eur Heart J. 2016;37(29): 2315-2381.

Disclosure of Interests:

Kacey Anderson Shareholder of: Gilead Sciences, Employee of: Gilead Sciences, Cara Nelson Shareholder of: Gilead Sciences, Employee of: Gilead Sciences, Qi Gong Shareholder of: Gilead Sciences, Employee of: Gilead Sciences, Muhsen Alani Shareholder of: Gilead Sciences, Employee of: Gilead Sciences, Thomas Tarnowski Shareholder of: Gilead Sciences, Employee of: Gilead Sciences, Ahmed A. Othman Shareholder of: Gilead Sciences, Employee of: Gilead Sciences

POS0092 HERPES ZOSTER IN THE FILGOTINIB RHEUMATOID ARTHRITIS PROGRAM

Background:

The once daily, oral Janus kinase (JAK)-1 preferential inhibitor filgotinib (FIL) improved signs and symptoms of rheumatoid arthritis (RA) in phase (P)3 trials.1-3 Patients (pts) with RA have increased herpes zoster (HZ) reactivation risk vs the general population. JAK inhibition is associated with increased infection incidence, including HZ.4

Objectives:

To assess long-term safety of FIL across the global clinical program with respect to HZ.

Methods:

Pts meeting 2010 ACR/EULAR RA criteria in a pooled analysis of P2 DARWIN 1–2 (D1–2), P3 FINCH 1–3 (F1–3), and long-term extension studies (D3, F4) were included. Placebo (PBO)-controlled as-randomised analysis included pts receiving FIL 100 mg (FIL100), FIL 200 mg (FIL200), or PBO up to week (W)12 (D1–2, F1–2); active-controlled as-randomised analysis included pts receiving FIL100, FIL200, adalimumab (ADA), or methotrexate (MTX) up to W52 (F1, F3). Long-term as-treated analysis included pts in all 7 studies receiving FIL100, FIL200, ADA, MTX, or PBO; data after re-randomisation were included and contributed to treatment received. Exposure-adjusted incidence rates (EAIR)/100 patient-years, calculated up to the last follow-up time or day, and differences with 95% confidence intervals (CIs) were calculated from the Poisson model. Logistic regression model was used for treatment-emergent (TE) HZ risk factor analysis and odds ratio (95% CI) and P value were provided.

Results:

Table 1 shows TE HZ EAIRs in a pooled analysis. Rates of HZ were lower for FIL200 vs PBO during the 12W PBO-controlled period. At 52W, HZ rates were higher for FIL200/100 vs active control. Long-term HZ rates increased for FIL200 vs FIL100.

Table 1.

EAIR of treatment-emergent herpes zoster

NPatient-years exposureEAIR(95% CI)EAIR diff(95% CI vs PBO/active control)12W PBO-controlled FIL200777179.80.6 (0.1, 3.9)−0.56 (−2.5, 1.3) FIL100788181.61.1 (0.3, 4.4)−0.02 (−2.2, 2.2) PBO781178.41.1 (0.3, 4.5)Active-controlled, as-randomiseda FIL200475439.71.4 (0.6, 3.0)0.69 (−0.7, 2.1) FIL100480443.40.9 (0.3, 2.4)0.23 (−1.1, 1.5) ADA325297.60.7 (0.2, 2.7)Active-controlled, as-randomiseda FIL200626578.01.7 (0.9, 3.2)0.65 (−0.8, 2.2) FIL100207195.01.5 (0.5, 4.8)0.46 (−1.6, 2.5) MTX416372.21.1 (0.4, 2.9)Long-term as-treatedb FIL20022674047.71.8 (1.4, 2.3)NC FIL10016472032.91.1 (0.8, 1.7)NC

aup to W52. bdata cut for LTE FINCH 4, Sept 19, 2019; DARWIN 3, April 26 2019.

ADA, adalimumab; CI, confidence interval; EAIR, exposure-adjusted incidence rate; FIL, filgotinib; MTX, methotrexate; NC, not calculated; PBO, placebo; W week.

Figure 1 shows multivariate logistic regression model of TE risk factors.

Of 104 pts with TE HZ in long-term as-treated analysis set, 5 receiving FIL200 had history of HZ; EAIR (95% CI) was 8.7 (3.6–21.0). Of 8 pts with multiple events, 3 had events of differing severity for the same HZ episode.

EAIRs (95% CI) of TE HZ in Asia were: 3.7 (1.7–8.1) FIL200, n=197; 2.8 (1.3–6.3) FIL100, n=158; 0 ADA, n=40; 2.8 (0.4–19.6) MTX, n=43; and 3.4 (0.5–23.8) PBO, n=77 in long-term as-treated population. EAIRs (95% CI) in rest of the world were: 1.6 (1.2–2.1) FIL200, n=2070; 0.9 (0.6–1.5) FIL100, n=1489; 0.8 (0.2–3.1) ADA, n=285; 0.9 (0.3–2.9) MTX, n=373; and 0.7 (0.2–2.9) PBO, n=704 for all pts as-treated.

Most TE HZ infections were mild to moderate and non-serious; 6 were serious; 2 were recurrences. No visceral TE HZ occurred across the FIL RA program; there was 1 case each of genital, disseminated, and ophthalmic HZ. The disseminated HZ occurred in a pt with prior HZ history. Lymphopenia was not associated with HZ during the PBO-controlled W12 period.

Conclusion:

HZ was more common in both FIL groups vs ADA or MTX up to 52 weeks but comparable vs PBO during the 12-week placebo-controlled period. In multivariate analyses, prior history of HZ, Asian region, and age ≥50 years were associated with increased HZ risk.

References:

[1]Genovese et al. JAMA. 2019;322:315–25.

[2]Westhovens et al. Ann Rheum Dis. 2021; online first.

[3]Combe et al. Ann Rheum Dis. 2021; online first.

[4]Higarashi and Honda. Drugs. 2020;80:1183–201.

Disclosure of Interests:

Kevin Winthrop Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly and Co., Galapagos NV, Gilead Sciences, GlaxoSmithKline, Pfizer, Roche, and UCB, Grant/research support from: AbbVie, Bristol-Myers Squibb, and Pfizer, Maya H Buch Speakers bureau: AbbVie; Eli Lilly and Company; Gilead Sciences, Inc.; Merck-Serono; Pfizer; Roche; Sandoz; Sanofi; and UCB, Consultant of: AbbVie; Eli Lilly and Company; Gilead Sciences, Inc.; Merck-Serono; Pfizer; Roche; Sandoz; Sanofi; and UCB, Grant/research support from: AbbVie; Eli Lilly and Company; Gilead Sciences, Inc.; Merck-Serono; Pfizer; Roche; Sandoz; Sanofi; and UCB, Jeffrey Curtis Grant/research support from: AbbVie, Amgen, BMS, Corrona, Eli Lilly, Janssen, Myriad, Pfizer, Regeneron, Roche, and UCB, Gerd Rüdiger Burmester Speakers bureau: AbbVie; Eli Lilly; Pfizer; and Gilead Sciences, Inc., Consultant of: AbbVie; Eli Lilly; Pfizer; and Gilead Sciences, Inc., Daniel Aletaha Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Medac, Merck, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sandoz, Sanofi/Genzyme, and UCB, Consultant of: AbbVie, Amgen, Celgene, Eli Lilly, Janssen, Medac, Merck, Novartis, Pfizer, Roche, Sandoz, and Sanofi/Genzyme, Grant/research support from: AbbVie, Merck Sharp & Dohme, Novartis, and Roche, Koichi Amano Speakers bureau: AbbVie GK, Astellas, Chugai Pharmaceutical Co. Ltd., Eli Lilly, GlaxoSmithKline KK, Pfizer Japan, Mitsubishi-Tanabe Pharma, Grant/research support from: Asahi Kasei Pharma, Alena Pechonkina Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Iyabode Tiamiyu Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Cianna Leatherwood Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Lei Ye Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Qi Gong Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Robin Besuyen Shareholder of: Galapagos, BV, Employee of: Galapagos, BV, James Galloway Speakers bureau: Pfizer, Bristol-Myers Squibb, UCB and Celgene

How Aconiti Radix Cocta can Treat Gouty Arthritis Based on Systematic Pharmacology and UPLC-QTOF-MS/MS

Background: Gouty arthritis (GA) is a common metabolic disease caused by a long-term disorder of purine metabolism and increased serum levels of uric acid. The processed product of dried root of Aconitum carmichaeli Debeaux (Aconiti Radix cocta, ARC) is used often in traditional Chinese medicine (TCM) to treat GA, but its specific active components and mechanism of action are not clear.

Methods: First, we used ultra-performance liquid chromatography-quadrupole/time-of-flight tandem mass spectrometry to identify the chemical spectrum of ARC. Based on this result, we explored the active components of ARC in GA treatment and their potential targets and pathways. Simultaneously, we used computer simulations, in vitro cell experiments and animal experiments to verify the prediction results of systems pharmacology. In vitro, we used aurantiamide acetate (AA) to treat monosodium urate (MSU)-stimulated THP-1 cells and demonstrated the reliability of the prediction by western blotting and real-time reverse transcription-quantitative polymerase chain reaction (RT-qPCR). ELISAs kit were used to measure changes in levels of proinflammatory factors in rats with GA induced by MSU to demonstrate the efficacy of ARC in GA treatment.

Results: Forty-three chemical constituents in ARC were identified. ARC could regulate 65 targets through 29 active components, and then treat GA, which involved 1427 Gene Ontology (GO) terms and 146 signaling pathways. Signaling pathways such as proteoglycans in cancer, C-type lectin receptor signaling pathway, and TNF signaling pathway may have an important role in GA treatment with ARC. In silico results showed that the active components songoramine and ignavine had high binding to mitogen-activated protein kinase p38 alpha (MAPK14) and matrix metallopeptidase (MMP)9, indicating that ARC treatment of GA was through multiple components and multiple targets. In vitro experiments showed that AA in ARC could effectively reduce expression of MAPK14, MMP9, and cyclooxygenase2 (PTGS2) in THP-1 cells stimulated by MSU, whereas it could significantly inhibit the mRNA expression of Caspase-1, spleen tyrosine kinase (SYK), and PTGS2. Animal experiments showed that a ARC aqueous extract could significantly reduce expression of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, and intereleukin (IL)-18 in the serum of GA rats stimulated by MSU. Hence, ARC may inhibit inflammation by regulating the proteoglycans in cancer-associated signaling pathways.

Conclusion: ARC treatment of GA may have the following mechanisms, ARC can reduce MSU crystal-induced joint swelling, reduce synovial tissue damage, and reduce the expression of inflammatory factors in serum. AA in ARC may inhibit inflammation by regulating the protein expression of MAPK14, MMP9, and PTGS2 and the mRNA expression of caspase-1, SYK, and PTGS2.

Systems Pharmacology Study of the Anti-Liver Injury Mechanism of Citri Reticulatae Pericarpium

Liver diseases are mostly triggered by oxidative stress and inflammation, leading to extracellular matrix overproduction and prone to develop into liver fibrosis, cirrhosis and hepatocellular carcinoma. Liver injury (LI) refers to various pathogenic factors leading to the destruction of stem cells that then affect the liver's normal function, causing a series of symptoms and abnormal liver function indicators. Citri Reticulatae Pericarpium (CRP) is one of the most commonly used traditional Chinese medicines; it contains flavonoids including hesperidin, nobiletin, and tangeretin. CRP has antibacterial, antioxidant, and antitumor effects that reduce cholesterol, prevent atherosclerosis and decrease LI. Here we analyzed the components of CRP and their targets of action in LI treatment and assessed the relationships between them using a systems pharmacology approach. Twenty-five active ingredients against LI were selected based on ultra-performance liquid chromatography-quadrupole/time-of-flight mass spectrometry results and databases. The drug targets and disease-related targets were predicted. The 117 common targets were used to construct a protein-protein interaction network. We identified 1719 gene ontology items in LI treatment, including 1,525 biological processes, 55 cellular components, and 139 molecular functions. These correlated with 49 Kyoto Encyclopedia of Genes and Genomes pathways. These findings suggest that CRP may counteract LI by affecting apoptotic, inflammatory, and energy metabolism modules. In vitro experiments suggested that the mechanism may involve hesperidin and naringenin acting on CASP3, BAX, and BCL2 to affect the apoptosis pathway, attenuating liver fibrosis. Naringenin significantly inhibited AKT1 phosphorylation, which in turn mediated activation of the phosphoinositide 3-kinase-Akt signaling pathways against LI. This study provides a reference for systematically exploring the mechanism of CRP's anti-LI action and is also expands of the application of systems pharmacology in the study of traditional Chinese medicine.

Distinct alternations of brain functional network dynamics in obsessive-compulsive disorder and schizophrenia

Introduction

Obsessive-compulsive disorder (OCD) and schizophrenia (SZ) are both severe psychiatric disorders. Though these two disorders have distinct typical symptoms, there are partial polygenic overlap and comorbidity between the two disorders. However, few studies have explored the shared and disorder-specific brain function underlying the neural pathophysiology of the two disorders, especially in the aspect of dynamics.

Objectives

To explore the abnormal characteristics of the dynamic functional connectivity (dFC) in OCD and SZ as well as the association between dFC metrics and symptom severity.

Methods

The resting state functional magnetic resonance imaging data of 31 patients with OCD, 49 patients with SZ, and 45 healthy controls were analyzed using independent component analysis to obtain independent components (ICs) and assigned them into eight brain networks (Figure 1), then used the sliding-window approach to generate dFC matrices. Using k-means clustering, we obtained three reoccurring dFC states (Figure 2), and state transition metrics were obtained

Results

In a sparsely connected state (state 1), SZ showed both increased fractional time and mean dwell time than controls (P=0.047 and P=0.033) and OCD (P=0.001 and P=0.003). In a state characterized by negative FC between networks (state 2), OCD showed both increased fractional time and mean dwell time than controls (P=0.032 and P=0.013) and SZ (P=0.005 and P=0.003). Moreover, the fractional time of state 2 was positively correlated with anxiety scores in OCD (r=0.535, P=0.021, FDR corrected) (Figure 3).

Conclusions

OCD and SZ patients showed distinct alternations of brain functional dynamics.

Disclosure

No significant relationships.

Altered brain functional dynamics in auditory and visual networks in schizophrenia

Introduction

One of the most perplexing and characteristic symptoms of the schizophrenia (SZ) patients is hallucination. The occurrence of hallucinations to be associated with altered activity in the auditory and visual cortex but is not well understood from the brain functional network dynamics in SZ.

Objectives

To explore the brain abnormal basis of hallucinations in SZ with the dynamic functional connectivity (dFC).

Methods

Using magnetic resonance imaging for 83 SZ patients and 83 matched healthy controls and independent component analysis, 52 independent components (ICs) were identified as nodes and assigned into eight intrinsic connectivity networks (Figure 1A). Subsequently, we established dFC matrices and clustered them into four discrete states (Figure 1B) and three state transition metrics were obtained. To further explore the changes in the centrality of each component, eigenvector centrality (EC) was calculated and its time-varying was evaluated.

Results

Compared to controls with FDR correction, we found that patients had more mean dwell times and fractional time in state 1 (P=0.0081 and P=0.0018), mainly with hypoconnectivity between auditory and visual network and other networks and hyperconnectivity between language and default-mode network (DMN). While, patients had less dwell times and fractional time in state 3 (P=0.0018 and P=0.0009), and decreased FC between visual network and executive control network (ECN) and increased FC between ECN and DMN than controls (Figure 2).

EC statistics showed that SZs displayed increased temporal dynamics in visual-related regions (Figure 3).

Conclusions

SZ was mainly manifested as altered dFC and temporal variability of nodal centrality in auditory and visual networks.

Disclosure

No significant relationships.

Different alternations of static and dynamic brain regional topological metrics in schizophrenia and obsessive-compulsive disorder

Introduction

Though schizophrenia (SZ) and obsessive-compulsive disorder (OCD) are conceptualized as distinct clinical entities, they do have notable symptom overlap and a tight association. Graph-theoretical analysis of the brain connectome provides more indicators to describe the functional organization of the brain, which may help us understand the shared and disorder-specific neural basis of the two disorders.

Objectives

To explore the static and dynamic topological organization of OCD and SZ as well as the relationship between topological metrics and clinical variables.

Methods

Resting state functional magnetic resonance imaging data of 31 OCD patients, 49 SZ patients, and 45 healthy controls (HC) were involved in this study (Table 1). Using independent component analysis to obtain independent components (ICs) (Figure 1), which were defined as nodes for static and dynamic topological analysis.

Results

Static analysis showed the global efficiency of SZ was higher than HC. For nodal degree centrality, OCD exhibited decreased degree centrality in IC59 (located in visiual network) (P = 0.03) and increased degree centrality in IC38 (located in salience network) (P = 0.002) compared with HC. Dynamic analysis showed OCD exhibited decreased dynamics of degree centrality in IC38 (P = 0.003) compared with HC, which showed a negative correlation with clinical scores in OCD. While SZ showed decreased dynamics of degree centrality in IC76 (located in sensory motor network) compared with OCD (P=0.009), which showed a positive correlation with clinical scores in SZ (Figure 2).

Conclusions

These changes are suggestive of disorder-specific alternation of static and dynamic brain topological organization in OCD and SZ.

Research Note: The immune enhancement ability of inulin on ptfA gene DNA vaccine of avian Pasteurella multocida

To evaluate the ability of inulin to enhance the immune response of a ptfA gene DNA vaccine for avian Pasteurella multocida, inulin was added as an adjuvant to the ptfA-DNA vaccine, obtaining an inulin-adjuvant DNA vaccine. The DNA vaccine was administered to chickens; a fimbria protein vaccine and an attenuated live vaccine were used as positive controls. The levels of the serum antibody and concentrations of interferon-γ (IFN-γ), interleukin-2 (IL-2), and interleukin-4 (IL-4) were determined, and a lymphocyte proliferation assay was performed. After being challenged with virulent P. multocida, the protective efficacy was evaluated. The results showed that the serum antibodies induced by the ptfA-DNA vaccine were not enhanced by inulin. The stimulation index values and the concentrations of IL-2 and IFN-γ in chickens vaccinated with inulin-adjuvant DNA vaccine were significantly higher than those in chickens vaccinated with the DNA vaccine, those with the fimbria protein vaccine, and the chickens gavaged with inulin. The concentrations of IL-4 in the inulin-adjuvant DNA vaccine group and the fimbria protein vaccine group were higher than those in the DNA vaccine group and the inulin-gavage group. The protective efficacy rates of the attenuated live vaccine group, the fimbria protein vaccine group, the DNA vaccine group, the inulin-adjuvant DNA vaccine group, and the inulin-gavage group were 90, 70, 55, 65, and 55%, respectively.

The Effects of Low-Dose and High-Dose Decoctions of Fructus aurantii in a Rat Model of Functional Dyspepsia

BACKGROUND Fructus aurantii is a flavonoid derived from Citrus aurantium (bitter orange) that is used in traditional Chinese medicine (TCM) to treat gastric motility disorders. This study aimed to investigate the effects of low-dose and high-dose decoctions of Fructus aurantii in a rat model of functional dyspepsia (FD). MATERIAL AND METHODS Sprague-Dawley rats (n=90) were divided into nine study groups: the control group, the FD model group, the domperidone-treated (Domp) group, the low-dose raw Fructus aurantii (FA-L) group, the high-dose raw Fructus aurantii (FA-H) group, the low-dose Fructus aurantii with stir-fried wheat bran (Bran-L) group, the high-dose Fructus aurantii with stir-fried wheat bran (Bran-H) group, the low-dose Fructus aurantii with stir-fried wheat bran and honey (Honey-L) group, and the high-dose Fructus aurantii with stir-fried wheat bran and honey (Honey-H) group. The FD rat model was established by semi-starvation, followed by tail damping, stimulation, and forced exercise with fatigue. Change in weight, rate of gastric emptying and intestinal propulsion, and serum levels of leptin, motilin, vasoactive intestinal peptide (VIP), gastrin, calcitonin gene-related peptide (CGRP), ghrelin, and cholecystokinin were compared between the groups. RESULTS In the FD model group, weight, rate of gastric emptying and intestinal propulsion significantly decreased, the expression of leptin, VIP and CGRP increased, and expression of motilin, gastrin, ghrelin, and cholecystokinin significantly decreased. Treatment with low-dose Fructus aurantii with stir-fried wheat bran significantly reversed these effects. CONCLUSIONS In the rat model of FD, low-dose Fructus aurantii with stir-fried wheat bran increased gastrointestinal motility and gastrointestinal hormone levels.

Systems Pharmacology-Based Strategy to Investigate Pharmacological Mechanisms of Radix Puerariae for Treatment of Hypertension

Hypertension is a clinical cardiovascular syndrome characterized by elevated systemic arterial pressure with or without multiple cardiovascular risk factors. Radix Pueraria (RP) has the effects of anti-myocardial ischemia, anti-arrhythmia, vasodilatation, blood pressure reduction, anti-inflammation, and attenuating insulin resistance. Although RP can be effective for the treatment of hypertension, its active compounds, drug targets, and exact molecular mechanism are still unclear. In this study, systems pharmacology was used to analyze the active compounds, drug target genes, and key pathways of RP in the treatment of hypertension. Thirteen active compounds and related information on RP were obtained from the TCMSP database, and 140 overlapping genes related to hypertension and drugs were obtained from the GeneCards and OMIM databases. A PPI network and a traditional Chinese medicine (TCM) comprehensive network (Drug-Compounds-Genes-Disease network) were constructed, and 2,246 GO terms and 157 pathways were obtained by GO enrichment analysis and KEGG pathway enrichment analysis. Some important active compounds and targets were evaluated by in vitro experiments. This study shows that RP probably acts by influencing the proliferation module, apoptosis module, inflammation module, and others when treating hypertension. This study provides novel insights for researchers to systematically explore the mechanism of action of TCM.

Multivariate classification of earthquake survivors with post-traumatic stress disorder based on large-scale brain networks

OBJECTIVE

The identification of post-traumatic stress disorder (PTSD) among natural disaster survivors is remarkably challenging, and there are no reliable objective signatures that can be used to assist clinical diagnosis and optimize treatment. The current study aimed to establish a neurobiological signature of PTSD from the connectivity of large-scale brain networks and clarify the brain network mechanisms of PTSD.

METHODS

We examined fifty-seven unmedicated survivors with chronic PTSD and 59 matched trauma-exposed healthy controls (TEHCs) using resting-state functional magnetic resonance imaging (rs-fMRI). We extracted the node-to-network connectivity and obtained a feature vector with a dimensionality of 864 (108 nodes × 8 networks) to represent each subject's functional connectivity (FC) profile. Multivariate pattern analysis with a relevance vector machine was then used to distinguish PTSD patients from TEHCs.

RESULTS

We achieved a promising diagnostic accuracy of 89.2% in distinguishing PTSD patients from TEHCs. The most heavily weighted connections for PTSD classification were among the default mode network (DMN), visual network (VIS), somatomotor network, limbic network, and dorsal attention network (DAN). The strength of the anticorrelation of FC between the ventral medial prefrontal cortex (vMPFC) in DMN and the VIS and DAN was associated with the severity of PTSD.

CONCLUSIONS

This study achieved relatively high accuracy in classifying PTSD patients vs. TEHCs at the individual level. This performance demonstrates that rs-fMRI-derived multivariate classification based on large-scale brain networks can provide potential signatures both to facilitate clinical diagnosis and to clarify the underlying brain network mechanisms of PTSD caused by natural disasters.

Network Pharmacology-Based Strategy to Investigate the Pharmacologic Mechanisms of Atractylodes macrocephala Koidz. for the Treatment of Chronic Gastritis

Chronic gastritis (CG) is an inflammatory disease. Atractylodes macrocephala Koidz (AMK) is employed in traditional Chinese medicine (TCM) to treat various disorders. AMK can be efficacious against CG, but the active ingredients, drug targets, and its exact molecular mechanism are not known. We employed network pharmacology to analyze the active ingredients, drug targets, and key pathways of AMK in CG treatment. Seventy-seven AMK candidate ingredients were selected from four databases, and 27 active ingredients were selected for CG treatment. Twenty-five overlapping gene symbols related to CG and drugs were obtained from GeneCards and OMIM databases. A protein–protein interaction (PPI) network and TCM comprehensive network (Drug–Ingredients–Gene symbols–Disease network) were constructed, and 528 Gene Ontology (GO) terms and 26 pathways were obtained by analyses of enrichment of GO pathways and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways. We suggest that the interleukin-17 signaling pathway, C-type lectin receptor signaling pathway, tumor necrosis factor signaling pathway, and AGE-RAGE signaling pathway in diabetic complications might serve as the key points and principal pathways for CG treatment. We also evaluated the reliability of some important active ingredients and targets by in vitro experiments. We showed that AMK probably influences the inflammatory response, amino acid synthesis, and energy metabolism when treating CG. This study provides novel insights for researchers to explore the mechanism of action of TCM systematically.

Cortical thinning in epilepsy patients with postictal generalized electroencephalography suppression

BACKGROUND AND PURPOSE

The aim was to investigate the brain microstructural abnormalities in epilepsy patients with postictal generalized electroencephalographic suppression (PGES) using a cortical surface-based analysis.

METHODS

According to the video-electroencephalography records of epilepsy patients with generalized convulsive seizures, 30 patients with PGES (PGES+) and 21 patients without PGES (PGES-) were recruited. High-resolution T1-weighted images were acquired from each patient and 30 matched healthy control subjects. Cortical thickness was compared amongst the three groups using FreeSurfer software.

RESULTS

Patients with PGES showed reduced cortical thickness in the right paracentral lobule, inferior parietal lobule, supramarginal gyrus and middle temporal lobe compared with patients without PGES. In relation to healthy control subjects, the PGES+ group presented reduced cortical thickness in the right superior parietal lobule and supramarginal gyrus, whilst the PGES- group presented reduced cortical thickness in the left precuneus, precentral gyrus, lateral occipital gyrus, parahippocampal gyrus, superior parietal lobule and right caudal middle frontal gyrus.

CONCLUSIONS

Patients with PGES exhibited characteristic brain microstructural abnormalities, corroborating the PGES mechanisms at the brain level. The right-sided predominance of the detected PGES-related cortical thinning was the same as that of sudden unexpected death in epilepsy (SUDEP) cases and patients at high risk for SUDEP, implying that PGES and SUDEP may share a common abnormal brain substrate that is involved in the pathophysiology of these conditions.

[Relationship between coronary tortuosity and coronary microvascular disease]

Objective: To explore the relationship between coronary tortuosity and coronary microvascular disease (CMVD). Methods: Patients with typical angina symptoms and without serious coronary artery stenosis by coronary angiography were enrolled from June 2014 to December 2016, and CMVD was diagnosed by single photon emission tomography (SPECT). According to the SPECT results, patients were divided to the CMVD group and non-CMVD group. The baseline clinical characteristics, results of coronary angiography were compared between the two groups. The logistic analysis was used to analyze the relationship between coronary tortuosity and CMVD. Result: A total of 117 cases were enrolled, with 69 cases in the CMVD group and 48 cases in the non-CMVD group. No differences were found in gender distribution, age, hypertension, lipid abnormality, hyperuricemia and uses of statins between the two groups (all P>0.05). Incidence of diabetes (78.26%(54/69) vs. 35.42% (17/48) , P<0.05), hs-CRP ((4.29±2.15)mmol/L vs. (2.63±1.20)mmol/L, P<0.001), LDL-C ((2.98±0.96)mmol/L vs. (2.52±0.83)mmol/L, P=0.008) and homocysteine ((13.7±5.61)mmol/L vs. (11.5±4.38)mmol/L, P=0.025) levels were higher in the CMVD group than in the non-CMVD group. The data derived from echocardiographic examination were similar between the two groups. The Corrected TIMI frame counts were higher in the CMVD group than in non-CMVD group (LAD: 31.56±4.92 vs. 27.31±3.75, LCX: 29.47±4.18 vs. 26.62±3.19, RCA: 29.09±5.05 vs. 26.24±3.28, all P<0.001). The incidences of coronary atherosclerosis (76.81% (53/69) vs. 27.08% (13/48) , P<0.001) and coronary tortuosity ( (60.87% (42/69) vs. 33.33% (16/48) , P=0.035) were also higher in the CMVD group than in non-CMVD group. Logistic analysis found that coronary tortuosity (OR=6.111, 95%CI 2.707-13.794, P<0.001), diabetes (OR=6.565, 95%CI 2.883-14.948, P<0.001) and coronary atherosclerosis (OR=8.918, 95%CI 3.822-20.808, P<0.001) were independent risk factors of CMVD. Conclusion: Coronary tortuosity, diabetes and coronary atherosclerosis are related to CMVD in this patient cohort.

Disrupted intrinsic and remote functional connectivity in heterotopia-related epilepsy

OBJECTIVES

Several neuroimaging studies have examined neural interactions in patients with periventricular nodular heterotopia (PNH). However, features of the underlying functional network remain poorly understood. In this study, we examined alterations in the local (regional) and remote (interregional) cerebral networks in this disorder.

METHODS

Twenty-eight subjects all having suffered from PNH with epilepsy, as well as 28 age- and sex- matched healthy controls, were enrolled in this study. Amplitude of low-frequency fluctuation (ALFF) and seed-based functional connectivity (FC) were calculated to detect regional neural function and functional network integration, respectively.

RESULTS

Compared with healthy controls, patients with PNH-related epilepsy showed decreased ALFF in the ventromedial prefrontal cortex (vmPFC) and precuneus areas. ALFF values in both areas were negative correlated with epilepsy duration (P < .05, Bonferroni-corrected). Furthermore, patients with PNH-related epilepsy had increased remote interregional FC mainly in bilateral prefrontal and parietal cortices, supramarginal gyrus, dorsal cingulate gyrus, and right insula; lower FC was found in posterior brain regions including bilateral parahippocampal gyrus and inferior temporal gyrus.

CONCLUSIONS

Focal spontaneous hypofunction, as assessed by ALFF, correlates with epilepsy duration in patients with PNH-related epilepsy. Abnormalities existed both within the default-mode network and then across the whole brain, demonstrating that intrinsic brain dysfunction may be related to specific network interactions. Our findings provide novel understanding of the connectivity-based pathophysiological mechanisms of PNH.

Construction of a ptfA chitosan nanoparticle DNA vaccine against Pasteurella multocida and the immune response in chickens

The aim of this study was to evaluate the effect of chitosanon the immune response induced by a DNA vaccine based on the ptfA gene of avian Pasteurella multocida. Naked DNA vaccine was packed with chitosanmolecules, resulting in a chitosannanoparticle DNA vaccine. The encapsulation efficiency, shape, size and resistance to DNA degradation were determined. The vaccine was administered to chickens and serum antibody, interferon-γ (IFN-γ), interleukin-2 (IL-2) and interleukin-4 (IL-4) concentrations were determined and lymphocyte proliferation assays were performed. After challenge with virulent avian P. multocida, protective efficacy was evaluated. The encapsulation efficiency of the chitosan nanoparticle DNA vaccine was 95.3%. The particle size was approximately 200nm and close to spherical in shape and it could effectively resist degradation by DNases. Following vaccination, serum antibodies, stimulation index (SI) value and concentrations of IFN-γ and IL-2 in chickens vaccinated with the chitosan nanoparticle DNA vaccine were significantly higher than those that were vaccinated with the naked DNA vaccine (P-values are 0.026, 0.045, 0.039 and 0.024, respectively). However, the concentrations of IL-4 in the two DNA vaccines group were no significant difference (P=0.157). The protective efficacy rate provided by naked DNA vaccine, chitosan nanoparticle DNA vaccine and the attenuated live vaccine were 56%, 68% and 88%, respectively. The results indicated that chitosan was able to enhance the immune response to a naked DNA vaccine based on the ptfA gene of P. multocida.

InP-based pseudomorphic InAs/InGaAs triangular quantum well lasers with bismuth surfactant

An InP-based 2.1 μm InAs/In_0.53Ga_0.47As triangular quantum well laser grown with Bi surfactant has shown improved performance in comparison to the device with the same structure but grown without Bi surfactant. Under continuous-wave driving operation, the output light power is increased from 32.6 to 37.5 mW at the same injecting current of 850 mA at 200 K. The external differential and internal quantum efficiencies for the laser with Bi surfactant are 18.4% and 41%, respectively, which are correspondingly higher than 13.1% and 31% for the reference device. Furthermore, a decreased internal loss from 20.9 to 17.6  cm^-1 for the Bi surfactant laser is also observed. These results suggest that Bi surfactant is promising for further enhancing performances of strained quantum well laser diodes.

Perilesional and contralateral white matter evolution and integrity in patients with periventricular nodular heterotopia and epilepsy: a longitudinal diffusion tensor imaging study

BACKGROUND AND PURPOSE

This study aimed to assess the evolution of perinodular and contralateral white matter abnormalities in patients with periventricular nodular heterotopia (PNH) and epilepsy.

METHODS

Diffusion tensor imaging (DTI) (64 directions) and 3 T structural magnetic resonance imaging were performed in 29 PNH patients (mean age 27.3 years), and 16 patients underwent a second scan (average time between the two scans 1.1 years). Fractional anisotropy and mean diffusivity were measured within the perilesional and contralateral white matter.

RESULTS

Longitudinal analysis showed that white matter located 10 mm from the focal nodule displayed characteristics intermediate to tissue 5 mm away, and normal-appearing white matter (NAWM) also established evolution profiles of perinodular white matter in different cortical lobes. Compared to 29 age- and sex-matched healthy controls, significant decreased fractional anisotropy and elevated mean diffusivity values were observed in regions 5 and 10 mm from nodules (P < 0.01), whilst DTI metrics of the remaining NAWM did not differ significantly from controls. Additionally, normal DTI metrics were shown in the contralateral region in patients with unilateral PNH.

CONCLUSIONS

Periventricular nodular heterotopia is associated with microstructural abnormalities within the perilesional white matter and the extent decreases with increasing distance from the nodule. In the homologous contralateral region, white matter diffusion metrics were unchanged in unilateral PNH. These findings have clinical implications with respect to the medical and surgical interventions of PNH-related epilepsy.

The relation of the serum aldosterone level and central serous chorioretinopathy - a pilot study

OBJECTIVE

The aim of this study was to investigate the serum aldosterone level and abnormal levels of mineral corticoid in patients with the central serous chorioretinopathy (CSC).

PATIENTS AND METHODS

All recruited patients with CSC received fundus fluorescein angiography (FFA), enhanced depth imaging spectral-domain optical coherence tomography (EDI-OCT) and serum aldosterone assay. The patients were classified into spontaneously resolved group and unresolved group according to a 3-months follow-up of Optical Coherence Tomography (OCT) examination. Patients from unresolved group were recruited to receive treatment with 40 mg spironolactone orally for 2 months. After the treatment, the EDI-OCT and best corrected visual acuity (BCVA) were performed again to assess the treatment efficacy.

RESULTS

The study included 61 patients (72 eyes) with 34 patients in the unresolved group and 27 patients in the resolved group. The aldosterone level was significantly associated with the subfoveal choroidal thickness (SFCT) of revolved CSC eyes (r=0.342, p<0.05) as well as the SFCT of unresolved CSC eyes (r=0.348, p<0.05). And the aldosterone level in the unresolved CSC group was greater than that in the spontaneously resolved group (161.8 ± 50.1 ng/dl vs. 122.5 ± 50.5 ng/dl, p<0.05). The central macular thickness and SFCT were decreased significantly (p<0.05) after the treatment with 40 mg/d spironolactone for two months.

CONCLUSIONS

The unresolved CSC patients were characterized by high level of aldosterone and thickened SFCT. Spironolactone treatment was associated with the improvement of chronic CSC. Besides, the side effect of spironolactone treatment was rare.

Common pattern of gray-matter abnormalities in drug-naive and medicated first-episode schizophrenia: a multimodal meta-analysis

Studies of schizophrenia at drug-naive state and on antipsychotic medication have reported a number of regions of gray-matter (GM) abnormalities but the reports have been inconsistent. The aim of this study was to conduct multimodal meta-analysis to compare the cross-sectional voxel-based morphometry studies of brain GM in antipsychotic-naive first-episode schizophrenia (AN-FES) and those with antipsychotic treatment within 1 year (AT-FES) to determine the similarities and differences in these groups. We conducted two separate meta-analyses containing 24 studies with a sample size of 801 patients and 957 healthy controls. A multimodal meta-analysis method was used to compare the findings between AN-FES and AT-FES. Meta-regression analyses were done to determine the influence of different variables including age, duration of illness, and positive and negative symptom scores. Finally, jack-knife analyses were done to test the robustness of the results. AN-FES and AT-FES showed common patterns of GM abnormalities in frontal (gyrus rectus), superior temporal, left hippocampal and insular cortex. GM in the left supramarginal gyrus and left middle temporal gyrus were found to be increased in AN-FES but decreased in AT-FES, whereas left median cingulate/paracingulate gyri and right hippocampus GM was decreased in AN-FES but increased in AT-FES. Findings suggest that both AN-FES and AT-FES share frontal, temporal and insular regions as common anatomical regions to be affected indicating these to be the primary regions of GM abnormalities in both groups.

Cortical Thickness of Native Tibetans in the Qinghai-Tibetan Plateau

BACKGROUND AND PURPOSE

High-altitude environmental factors and genetic variants together could have exerted their effects on the human brain. The present study was designed to investigate the cerebral morphology in high-altitude native Tibetans.

MATERIALS AND METHODS

T1-weighted brain images were obtained from 77 Tibetan adolescents on the Qinghai-Tibetan Plateau (altitude, 2300-5300 m) and 80 matched Han controls living at sea level. Cortical thickness, curvature, and sulcus were analyzed by using FreeSurfer.

RESULTS

Cortical thickness was significantly decreased in the left posterior cingulate cortex, lingual gyrus, superior parietal cortex, precuneus, and rostral middle frontal cortex and the right medial orbitofrontal cortex, lateral occipital cortex, precuneus, and paracentral lobule. Curvature was significantly decreased in the left superior parietal cortex and right superior marginal gyrus; the depth of the sulcus was significantly increased in the left inferior temporal gyrus and significantly decreased in the right superior marginal gyrus, superior temporal gyrus, and insular cortex. Moreover, cortical thickness was negatively correlated with altitude in the left superior and middle temporal gyri, rostral middle frontal cortex, insular cortex, posterior cingulate cortex, precuneus, lingual gyrus, and the right superior temporal gyrus. Curvature was positively correlated with altitude in the left rostral middle frontal cortex, insular cortex, and middle temporal gyrus. The depth of the sulcus was negatively correlated with altitude in the left lingual gyrus and right medial orbitofrontal cortex.

CONCLUSIONS

Differences in cortical morphometry in native Tibetans may reflect adaptations related to high altitude.

High-field magnetic resonance imaging of structural alterations in first-episode, drug-naive patients with major depressive disorder

Previous structural imaging studies have found evidence of brain morphometric changes in patients with major depressive disorder (MDD), but these studies rarely excluded compounding effects of certain important factors, such as medications and long duration of illnesses. Furthermore, the neurobiological mechanism of the macroscopic findings of structural alterations in MDD patients remains unclear. In this study, we utilized magnetization transfer imaging, a quantitative measure of the macromolecular structural integrity of brain tissue, to identify biophysical alterations, which are represented by a magnetization transfer ratio (MTR), in MDD patients. To ascertain whether MTR changes occur independent of volume loss, we also conduct voxel-based morphometry (VBM) analysis. The participants included 27 first-episode, drug-naive MDD patients and 28 healthy controls matched for age and gender. Whole-brain voxel-based analysis was used to compare MTR and gray matter volume across groups and to analyse correlations between MTR and age, symptom severity, and illness duration. The patients exhibited significantly lower MTR in the left superior parietal lobule and left middle occipital gyrus compared with healthy controls, which may be related to the attentional and cognitive dysfunction in MDD patients. The VBM analysis revealed significantly increased gray matter volume in right postcentral gyrus in MDD patients. These findings in first-episode, drug-naive MDD patients may reflect microstructural gray matter changes in the parietal and occipital cortices close to illness onset that existed before volume loss, and thus potentially provide important new insight into the early neurobiology of depression.

Evaluation of immunogenicity and protective efficacy of recombinant ptfA of avian Pasteurella multocida

Avian Pasteurella multocida is the causative agent of fowl cholera, a disease much affecting the poultry industry. In order to study the efficacy of the recombinant subunit vaccine constructed with ptfA gene of avian P. multocida, the ptfA gene fragment amplified by PCR from avian P. multocida was cloned into the prokaryotic expression vector pET32a and the recombinant plasmid pET32a-ptfA was obtained. The pET32a-ptfA was expressed in Escherichiacoli BL21(DE3) and the target protein rPtfA was purified. The purified protein was then mixed with Freund's adjuvant and the recombinant subunit vaccine was obtained. Three groups of chickens labeled as rPtfA, attenuated live vaccine and PBS were vaccinated with the recombinant subunit vaccine, attenuated live vaccine and PBS, respectively. Serum antibodies, peripheral blood lymphocyte proliferation (PBLP) and interferon-γ (IFN-γ) level secreted by peripheral blood lymphocyte were tested. The immunized chickens were finally challenged with virulent avian P. multocida and the protection rate was counted. Indirect ELISA showed the levels of antibodies in rPtfA and attenuated vaccine groups were most significantly higher than the other groups (P<0.01), and the former was slightly lower than the latter. Peripheral blood lymphocyte proliferation experiments and IFN-γ experiments indicated that SI value and the levels of IFN-γ induced by ConA in the two vaccine groups were significantly higher than those of the PBS groups (P<0.01), and that the attenuated vaccine group was higher than the rPtfA group. The protection rates of rPtfA and attenuated live vaccines were 45% and 75%, respectively. The results indicated that the PtfA recombinant subunit vaccine was capable of improving the immunity level and inducing a protective effect for the vaccinated chickens, but it was barely satisfactory.

Recurrent activating mutations of CD28 in peripheral T-cell lymphomas

Peripheral T-cell lymphomas (PTCLs) comprise a heterogeneous group of mature T-cell neoplasms with a poor prognosis. Recently, mutations in TET2 and other epigenetic modifiers as well as RHOA have been identified in these diseases, particularly in angioimmunoblastic T-cell lymphoma (AITL). CD28 is the major co-stimulatory receptor in T cells which, upon binding ligand, induces sustained T-cell proliferation and cytokine production when combined with T-cell receptor stimulation. We have identified recurrent mutations in CD28 in PTCLs. Two residues-D124 and T195-were recurrently mutated in 11.3% of cases of AITL and in one case of PTCL, not otherwise specified (PTCL-NOS). Surface plasmon resonance analysis of mutations at these residues with predicted differential partner interactions showed increased affinity for ligand CD86 (residue D124) and increased affinity for intracellular adaptor proteins GRB2 and GADS/GRAP2 (residue T195). Molecular modeling studies on each of these mutations suggested how these mutants result in increased affinities. We found increased transcription of the CD28-responsive genes CD226 and TNFA in cells expressing the T195P mutant in response to CD3 and CD86 co-stimulation and increased downstream activation of NF-κB by both D124V and T195P mutants, suggesting a potential therapeutic target in CD28-mutated PTCLs.

Effect of adding gemtuzumab ozogamicin to induction chemotherapy for newly diagnosed acute myeloid leukemia: a meta-analysis of prospective randomized phase III trials

BACKGROUND

Gemtuzumab ozogamicin (GO) is a targeted antineoplastic agent comprised of a recombinant anti-CD33 humanized antibody linked to calicheamicin. Previous trials have showed conflicting results concerning the efficacy and toxicity of adding GO to induction chemotherapy for newly diagnosed acute myeloid leukemia (AML). A systematic review and meta-analysis was conducted to resolve this controversial issue.

PATIENTS AND METHODS

Summary data from five randomized phase III trials compared adding GO to induction chemotherapy with induction chemotherapy alone for newly diagnosed AML were meta-analyzed. Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) for overall survival (OS) and relapse-free survival (RFS), and pooled odds ratios (ORs) and 95% CIs for complete remission (CR) rate, incidences of resistance disease, relapse and toxicity were calculated.

RESULTS

Data of 3596 patients (1798 GO and 1798 controls) from five randomized phase III trials were analyzed. Compared with induction chemotherapy alone, adding GO significantly prolonged OS (HR 0.93, 95% CI 0.86-1.00, P=0.05) and RFS (HR 0.87, 95% CI 0.79-0.95, P=0.003), decreased the incidences of resistant disease (OR 0.71, 95% CI 0.55-0.93, P=0.01) and relapse (OR 0.75, 95% CI 0.63-0.90, P=0.002), but had no effect on CR rate (OR 1.15, 95% CI 0.91-1.46, P=0.24). Sensitivity analysis yielded similar results. Subgroup analysis identified that cytogenetics might be an influencing factor for the effect of adding GO. In addition, the risks of grade 3-4 nausea/vomiting, diarrhea and liver aspartate transaminase (AST) elevation were increased in GO arm.

CONCLUSIONS

Adding GO to induction chemotherapy for newly diagnosed AML can significantly prolong OS and RFS, decrease incidences of resistant disease and relapse, but may increase risks of grade 3-4 nausea/vomiting, diarrhea and liver AST elevation.