AB0254 NEUROPSYCHIATRIC ADVERSE DRUG REACTIONS ASSOCIATED WITH LOW DOSE METHOTREXATE IN RHEUMATOID ARTHRITIS PATIENTS

Background:

Neuropsychiatric adverse drug reactions (NPADRs) are well known with high dose methotrexate treatment. However, NPADRs have also been observed with low dose methotrexate (LDMTX) treatment in real world rheumatology data.

Objectives:

To evaluate the association between LDMTX and NPADRs, the impact of these NPADRs on further treatment and on health related quality of life (HRQoL) in patients with rheumatoid arthritis (RA) using real world data.

Methods:

The nature and frequency of NPADRs associated with LDMTX in the Dutch DREAM-RA registry were described. We assessed the causality of each NPADR with the Naranjo Probability Scale (NPS), the impact of NPADRs on further LDMTX treatment and the impact on patient reported HRQoL. NPADRs were structured using terminology of the Medical Dictionary for Regulatory Activities.

Results:

A total of 71 NPADRs (frequency 6.8%) associated with LDMTX were captured in the DREAM-RA registry. NPADRs were registered for 62 (5.9%) out of 1048 patients with 10.9 NPADRs per 1000 patient years (Table 1). The most frequently reported NPADRs were headache, dizziness and depression. The causality was considered probable for 67 NPADRs (94.4%) and definite for 1 NPADR (1.4%). The NPADRs led to LDMTX withdrawal in 34 cases (47.9%) and LDMTX was not restarted in 16 cases (47.1%). Median mental HRQoL was significantly decreased around the occurrence of the NPADR and remained significantly lower after the event. Median physical HRQoL was not significantly affected.

Table 1.

Baseline characteristics of DREAM-RA patients using methotrexate with at least one neuropsychiatric adverse drug reaction

Characteristics N=62N (%)Female sex40 (64.5%)Age in years, mean (± SD), range59.8 (± 13.1), 25 – 82Rheumatoid factorPositive43 (69.4%)Negative13 (21.0%)Unknown6 (9.7%)Anti-CCP, n (%)Positive34 (54.8%)Negative19 (30.7%)Unknown9 (14.5%)Methotrexate dosage in mg/week, mean (± SD)18.7 (± 5.9)Specific methotrexate dosage< 15 mg / week5 (7.0%)15 mg/week28 (39.4%)20 mg/week11 (15.5%)25 mg/week14 (19.7%)30 mg/week5 (7.0%)Unknown8 (11.3%)Concomitant medication at moment of NPADRFolic acid68 (95.8%)Prednisolone20 (28.2%)

Anti-CCP: anti cyclic citrullinated peptides, NPADR: neuropsychiatric adverse drug reaction, SD: Standard Deviation

Conclusion:

The association between NPADRs and LDMTX in RA patients was recognised by HCPs and frequently led to LDMTX withdrawal and a decrease in mental HRQoL. Many NPADRs scored ‘probable’ using the NPS. Knowledge on the nature, frequency and impact of these NPADRs will enhance attention towards potential NPADRs during LDMTX therapy allowing better risk assessment and communication to patients.

Disclosure of Interests:

Jette van Lint: None declared, Tom Bakker: None declared, Peter ten Klooster: None declared, Harald Vonkeman Consultant of: BMS, Celgene, Celltrion, Galapagos, Gilead, Janssen-Cilag, Lilly, Novartis, Pfizer, Sanofi-Genzyme, Grant/research support from: Abbvie, Naomi Jessurun: None declared

OP0208 PATIENTS REPORT FATIGUE AS AN ADVERSE DRUG REACTION OF BIOLOGICS

Background:

Chronic fatigue is a well-known symptom in patients with rheumatic diseases and other immune-mediated inflammatory diseases (IMIDs). Therefore, fatigue as an adverse drug reaction (ADR) to biologics may remain unrecognised or may erroneously be attributed to the disease.

Objectives:

To assess patient-reported fatigue attributed to biologics for IMIDs and investigate predisposing factors of patient-reported fatigue.

Methods:

The Dutch Biologic Monitor is a multicenter patient-reported ADR monitoring system that surveys patients using a biologic for an IMID. Patients completed web-based questionnaires regarding ADRs attributed to biologics and the course and experienced burden (5 point Likert scale) of these ADRs. All patient-reported ADRs with MedDRA Preferred Term ‘fatigue’ were defined as biologic-associated fatigue (BA-fatigue). Basic demographics and treatment characteristics were compared between patients reporting BA-fatigue and patients not reporting BA-fatigue (reported other ADRs or no ADRs).

Results:

Out of 1369 participating IMID patients, 696 patients reported 1844 unique ADRs. BA-fatigue was reported by 100 patients and 48 patients described a consistent pattern of recurring fatigue after each administration. Most of these patients (88%) described recovery from BA-fatigue within one week after biologic administration and 73 patients reported health care professional (HCP) contact following BA-fatigue, with dose adjustment in 8 and discontinuation in 5 patients.

Basic demographics and characteristics that differ significantly between patients reporting BA-fatigue and patients not reporting BA-fatigue are summarized in table 1. No significant difference was found for other biologics, IMIDs, combination therapy and comorbidities. BA-fatigue was reported by 27% of rituximab users (n=33), 27% of vedolizumab users (n=26), 16% of tocilizumab users (n=50), 14% of infliximab users (n=159) and 3% of etanercept users (n=418). Although 29 patients in the BA-fatigue population had RA and 29 patients had Crohn’s disease (CD), 571 patients in our overall study population had RA and 194 patients had CD, suggesting BA-fatigue was reported by CD patients more often. The mean burden of BA-fatigue was higher than the mean burden of other ADRs (p<0.001).

Table 1.

Characteristics of patients with BA-fatigue compared to patients with other ADRs and without ADRs

Patients with BA-fatigue n (%)Patients with other ADRs n (%)Patients without ADRs n (%)n100 (100%)596 (100%)673 (100%)Basic demographicsAge (years) (mean ± SD)50.0 ± 14.653.4 ± 13.6 *55.7 ± 14.2 ***Gender (Female)59 (59%)398 (67%)ns342 (51%)nsSmoking n (%)25 (25%)97 (16%) *100 (15%) *BMI (kg/m2) (mean ± SD)25.7 ± 4.425.9 ± 4.7ns26.6 ± 5.5nsBiologicInfliximab22 (22%)53 (9%) ***84 (12%) *Etanercept13 (13%)177 (30%) ***228 (34%) ***Rituximab9 (9%)18 (3%) **6 (1%) ***Tocilizumab8 (8%)29 (5%)ns13 (2%) **Vedolizumab7 (7%)12 (2%) *7 (1%) ***IMIDRheumatoid arthritis29 (29%)270 (45%) **272 (40%) *Crohn’s disease29 (29%)77 (13%) ***88 (13%) ***Other indication16 (16%)53 (9%) *39 (6%) ***Combination therapyMethotrexate23 (23%)167 (28%)ns227 (34%) *ComorbidityPsychiatric disorder11 (11%)49 (8%)ns31 (5%) *Other comorbidity30 (30%)124 (21%) *102 (15%) ***Mean burden of ADR ± SD2.9 ± 0.92.4 ± 1.1 ***

Mann Whitney U, independent t-test and Fisher’s exact as appropriate

ns: not significant *p ≤ 0.05 **p ≤ 0.01 ***p ≤ 0.001

Conclusion:

HCPs should be aware that fatigue may be associated with biologic therapy and has a significant burden on patients. Evaluating the course of the symptoms might be helpful in recognizing BA-fatigue.

Disclosure of Interests:

Jette van Lint: None declared, Tom Bakker: None declared, Jouke Ubbink: None declared, Martijn van Doorn Grant/research support from: Unrestricted grants, advisory board, speaker fees and/or other (investigator) from Novartis, Abbvie, Janssen Cilag, Leopharma and Pfizer, Speakers bureau: Unrestricted grants, advisory board, speaker fees and/or other (investigator) from Novartis, Abbvie, Janssen Cilag, Leopharma and Pfizer, Phyllis Spuls Grant/research support from: Departmental independent research grant for TREAT NL registry LeoPharma December 2019; Contract support: I am involved in performing clinical trials with many pharmaceutical industries that manufacture drugs used for the treatment of e.g. psoriasis and atopic dermatitis for which we get financial compensation paid to the department/hospital, Consultant of: Consultancies in the past for Sanofi 111017 and AbbVie 041217 (unpaid), Sander Tas: None declared, Harald Vonkeman: None declared, Frank Hoentjen Grant/research support from: Received grants from Dr Falk, Janssen-Cilag, and AbbVie., Consultant of: Served on advisory boards, or as speaker or consultant for AbbVie, Celgene, Janssen-Cilag, MSD, Takeda, Celltrion, Teva, Sandoz, and Dr Falk, Speakers bureau: Served on advisory boards, or as speaker or consultant for AbbVie, Celgene, Janssen-Cilag, MSD, Takeda, Celltrion, Teva, Sandoz, and Dr Falk, Bart van den Bemt Grant/research support from: UCB, Pfizer and Abbvie, Consultant of: Delivered consultancy work for UCB, Novartis and Pfizer, Speakers bureau: Pfizer, AbbVie, UCB, Biogen and Sandoz., Michael Nurmohamed Grant/research support from: Not related to this research, Consultant of: Not related to this research, Speakers bureau: Not related to this research, Eugène van Puijenbroek: None declared, Naomi Jessurun: None declared

The effect of ICU-tailored drug-drug interaction alerts on medication prescribing and monitoring: protocol for a cluster randomized stepped-wedge trial

Background

Drug-drug interactions (DDIs) can cause patient harm. Between 46 and 90% of patients admitted to the Intensive Care Unit (ICU) are exposed to potential DDIs (pDDIs). This rate is twice as high as patients on general wards. Clinical decision support systems (CDSSs) have shown their potential to prevent pDDIs. However, the literature shows that there is considerable room for improvement of CDSSs, in particular by increasing the clinical relevance of the pDDI alerts they generate and thereby reducing alert fatigue. However, consensus on which pDDIs are clinically relevant in the ICU setting is lacking. The primary aim of this study is to evaluate the effect of alerts based on only clinically relevant interactions for the ICU setting on the prevention of pDDIs among Dutch ICUs.

Methods

To define the clinically relevant pDDIs, we will follow a rigorous two-step Delphi procedure in which a national expert panel will assess which pDDIs are perceived clinically relevant for the Dutch ICU setting. The intervention is the CDSS that generates alerts based on the clinically relevant pDDIs. The intervention will be evaluated in a stepped-wedge trial. A total of 12 Dutch adult ICUs using the same patient data management system, in which the CDSS will operate, were invited to participate in the trial. Of the 12 ICUs, 9 agreed to participate and will be enrolled in the trial. Our primary outcome measure is the incidence of clinically relevant pDDIs per 1000 medication administrations.

Discussion

This study will identify pDDIs relevant for the ICU setting. It will also enhance our understanding of the effectiveness of alerts confined to clinically relevant pDDIs. Both of these contributions can facilitate the successful implementation of CDSSs in the ICU and in other domains as well.

Trial registration

Nederlands Trial register Identifier: NL6762. Registered November 26, 2018.

Inactivation of Notch 1 in immature thymocytes does not perturb CD4 or CD8T cell development

Notch proteins influence cell-fate decisions in many developing systems. Several gain-of-function studies have suggested a critical role for Notch 1 signaling in CD4-CD8 lineage commitment, maturation and survival in the thymus. However, we show here that tissue-specific inactivation of the gene encoding Notch 1 in immature (CD25+CD44-)T cell precursors does not affect subsequent thymocyte development. Neither steady-state numbers nor the rate of production of CD4+ and CD8+ mature thymocytes is perturbed in the absence of Notch 1. In addition, Notch 1-deficient thymocytes are normally sensitive to spontaneous or glucocorticoid-induced apoptosis. In contrast to earlier reports, these data formally exclude an essential role for Notch 1 in CD4-CD8 lineage commitment, maturation or survival.

Cutting edge: apoptosis of superantigen-activated T cells occurs preferentially after a discrete number of cell divisions in vivo

Staphylococcal enterotoxins are bacterial products that display superantigen activity in vitro as well as in vivo. For instance, staphylococcal enterotoxin B (SEB) polyclonally activates T cells that bear the Vbeta8 gene segment of the TCR. SEB-activated T cells undergo a burst of proliferation that is followed by apoptosis. Using an in vivo adaptation of a fluorescent cell division monitoring technique, we show here that SEB-activated T cells divide asynchronously, and that apoptosis of superantigen-activated T cells is preferentially restricted to cells which have undergone a discrete number of cell divisions. Collectively, our data suggest that superantigen-activated T cells are programmed to undergo a fixed number of cell divisions before undergoing apoptosis. A delayed death program may provide a mechanistic compromise between effector functions and homeostasis of activated T cells.

Fas ligand-induced apoptosis of infected human macrophages reduces the viability of intracellular Mycobacterium tuberculosis

Mycobacterium tuberculosis-specific cytolytic activity is mediated mostly by CD4+CTL in humans. CD4+CTL kill infected target cells by inducing Fas (APO-1/CD95)-mediated apoptosis. We have examined the effect of Fas ligand (FasL)-induced apoptosis of human macrophages infected in vitro with M. tuberculosis on the viability of the intracellular bacilli. Human macrophages expressed Fas and underwent apoptosis after incubation with soluble recombinant FasL. In macrophages infected either with an attenuated (H37Ra) or with a virulent (H37Rv) strain of M. tuberculosis, the apoptotic death of macrophages was associated with a substantial reduction in bacillary viability. TNF-induced apoptosis of infected macrophages was coupled with a similar reduction in mycobacterial viability, while the induction of nonapoptotic complement-induced cell death had no effect on bacterial viable counts. Infected macrophages also showed a reduced susceptibility to FasL-induced apoptosis correlating with a reduced level of Fas expression. These data suggest that apoptosis of infected macrophages induced through receptors of the TNF family could be an immune effector mechanism not only depriving mycobacteria from their growth environment but also reducing viable bacterial counts by an unknown mechanism. On the other hand, interference by M. tuberculosis with the FasL system might represent an escape mechanism of the bacteria attempting to evade the effect of apoptosis.

A new form of particulate single and multiple immunogen delivery system based on recombinant bluetongue virus-derived tubules

The development of particular vector systems for the presentation of immunogenic epitopes provides a powerful approach for the delivery of antigens. These include the core-like particles formed by recombinant bluetongue virus (BTV) capsid proteins VP3 and VP7 synthesized in insect cells by recombinant baculoviruses. Previously we have reported localization of an antigenic site on the surface of tubular structures formed by the nonstructural protein NS1 of BTV, and their potential use for epitope presentation. In this study foreign sequences ranging form 44 to 116 aa in length and representing 44 aa sequence from Clostridium difficile toxin A, 48 aa of the hepatitis B virus preS2 region, and the whole of bovine leukemia virus p15 protein were inserted at the C-terminus of BTV-10 NS1. The chimeric NS1 genes were expressed using recombinant baculoviruses and the ability of the mutated NS1 proteins to form tubules was investigated. All chimeric constructs formed tubular structures which carried the foreign antigenic sequences exposed on the surface of the tubules and were highly immunogenic. When Sf cells were coinfected with three recombinant baculoviruses expressing chimeric NS1 proteins with different epitopes, their simultaneous assembly into the same tubule was demonstrated. This observation opens up the possibility of using recombinant NS1 tubules as carriers for the delivery of multiple epitopes.