Nivolumab in sorafenib-naive and sorafenib-experienced patients with advanced hepatocellular carcinoma: 5-year follow-up from CheckMate 040

BACKGROUND

Patients with advanced hepatocellular carcinoma (aHCC) have a poor prognosis and high mortality. Nivolumab monotherapy demonstrated clinical benefit with an acceptable safety profile in patients with aHCC in the CheckMate 040 study. Five-year follow-up of the sorafenib-naive and sorafenib-experienced groups of CheckMate 040 is presented here.

PATIENTS AND METHODS

Patients received nivolumab monotherapy at dose levels of 0.1-10.0 mg/kg (dose-escalation phase) or 3 mg/kg (dose-expansion phase) every 2 weeks until disease progression or unacceptable toxicity. Primary endpoints were safety and tolerability (dose escalation), and objective response rate (ORR) by blinded independent central review (BICR) and by investigator as per RECIST version 1.1 (dose expansion).

RESULTS

Eighty sorafenib-naive and 154 sorafenib-experienced patients were treated. Minimum follow-up in both groups was 60 months. ORR as per BICR was 20% [95% confidence interval (CI) 12% to 30%] and 14% (95% CI 9% to 21%) in the sorafenib-naive and sorafenib-experienced groups, respectively. Responses occurred regardless of HCC etiology or baseline tumor cell programmed death-ligand 1 (PD-L1) expression levels. Median overall survival (OS) was 26.6 months (95% CI 16.6-30.6 months) and 15.1 months (95% CI 13.0-18.2 months) in sorafenib-naive and sorafenib-experienced patients, respectively. The 3-year OS rates were 28% in the sorafenib-naive and 20% in the sorafenib-experienced groups; 5-year OS rates were 14% and 12%, respectively. No new safety signals were identified; grade 3/4 treatment-related adverse events were observed in 33% and 21% of patients in the sorafenib-naive and sorafenib-experienced groups, respectively. Biomarker analyses showed that baseline PD-L1 expression ≥1% was associated with higher ORR and longer OS compared with PD-L1 <1%. In the sorafenib-naive group, patients with OS ≥3 years exhibited higher baseline CD8 T-cell density compared with those with OS <1 year.

CONCLUSION

With 5 years of follow-up, nivolumab monotherapy continued to provide durable clinical benefit with manageable safety in sorafenib-naive and sorafenib-experienced patients with aHCC.

Research capability and aspirations of antimicrobial pharmacists: survey of UKCPA pin membership

Introduction

The United Kingdom Clinical Pharmacist Association Pharmacy Infection Network (UKCPA PIN) is the community of pharmacy professionals with an interest or specialism in infection management. As we come out of the Covid-19 pandemic, it is important for the leadership of UKCPA PIN to understand the current need and wishes of the community.

Aim

This study aimed to explore infection specialist pharmacy professionals about their research activity, experience, and perceived barriers to greater research activity.

Methods

An online, anonymised survey, consisting of closed and free-type open questions, was circulated to UKCPA PIN members for completion in September and October 2021 using the Google Forms platform. The questionnaire was developed and piloted amongst members of UKCPA PIN committee to identify current research activity and barriers. Responses were downloaded and underwent descriptive analysis with Microsoft Excel. This work was deemed a service evaluation and therefore did not require ethics approval.

Results

There were 38 responses were received from pharmacists in all 7 NHS England regions, Scotland, and Wales (6% of UKCPA PIN forum members). Pharmacy technicians were invited to participate but none did so. 13 (34%) described themselves as being actively involved in research, 13 (34%) described themselves as having done research in the past, 8 (21%) described themselves as not having the opportunity to develop research capabilities. 27 (71%) respondents had completed a postgraduate diploma, 8 (21%) had completed MSc or equivalent, 6 (16%) had completed a PhD or equivalent, 11 (29%) were Good Clinical Practice accredited and 10 (26%) had undertaken local research training. 6 (16%) were consultant pharmacists or accredited by the Royal Pharmaceutical Society as being consultant-ready, 10 (27%) were building a consultant portfolio and 15 (39%) were aspiring to build a consultant portfolio in the future. Of the 28% that were building a consultant portfolio, 6 were confident that they were already meeting the research outcomes and 4 were not. Antimicrobial pharmacists were most frequently wanting to undertake research in the areas of antimicrobial stewardship (11, 29%), antifungal stewardship (5, 13%) and allergies/penicillin delabelling (5, 13%). The greatest barriers identified were lack of time/funding (27, 71% agreed significant barrier), lack of funding for costs of undertaking research (17, 45%), lack of support with research methods (9, 24%) and lack of support with dissemination of research (9, 24%). A number of potential support options were proposed to respondents, with “Signposting resources to help you write research protocols” and “A repository of in progress antimicrobial research in the UK” being the most popular (19 and 17 respondents, respectively, described as very useful).

Discussion/Conclusion

There is a significant interest in research amongst antimicrobial pharmacists and scope for enhancing the contribution of pharmacists to research around antimicrobials and infectious disease. A limitation of this study was the small sample size; however, the themes provide important information for UKCPA PIN to provide support for its members.

Improving adherence to and effectiveness of a vancomycin continuous infusion protocol, a pilot quality improvement project

Introduction

Vancomycin treats serious Gram-positive infections such as methicillin-resistant Staphylococcus aureus. In St George’s University Hospital’s (SGH) intensive care unit (ICU) settings, vancomycin is administered by continuous infusion. Steady-state serum concentrations are measured daily with a 20-25 mg/L target. Non-therapeutic concentrations are associated with adverse drug reactions/prolonged length of stay.1 A SGH service-evaluation conducted across all three ICUs, revealed variable adherence to/effectiveness of its vancomycin prescribing/administration/monitoring protocol.2 Consequently, multifaceted interventions were devised using the Institute-for-Healthcare-Improvement’s model Plan-Do-Study-Act (PDSA) cycles and piloted on General ICU (GICU).

Aim

(1) To improve adherence to/effectiveness of the vancomycin protocol. (2) To ascertain administration accuracy of paper-fluid-balance-charts compared to the electronic-prescribing-and-medicines-administration (ePMA) system to assist with identifying per protocol treated patients.

Methods

PDSA Cycle-1 was conducted over a 9-month period (09/2021-05/2021) in which a mix of system/person-focused interventions were implemented. Protocol dosing2 was revised, introducing a &gt;90kg patient 2g loading dose, renal-function category revision and increased maintenance dose for creatinine clearance (CLCR) &gt;90ml/min. Protocol accessibility was increased via integration into an ePMA prescribing interface, plus CliniBee/Microguide apps. Educational slides on relevant protocol aspects were incorporated into medical/nursing induction training. Data relating to vancomycin prescribing/administration/monitoring for all non-renal replacement patients was extracted retrospectively from the ePMA system between 09/2021-05/2022. This data was compared to baseline GICU data (07/2020-07/2021).2 The project and associated interventions were approved by Trust Clinical Governance and Audit Teams. Data was collected by pharmacists directly involved in patient’s care and stored/analysed on the Trust’s secure server in line with Data Protection Act principles. Due to local generalisability, ethics approval wasn’t required.

Results

Compared to baseline, the proportion of patients receiving per protocol prescribing/administration of loading/maintenance doses with daily monitoring, nearly doubled (39% (7/18) to 68% (15/22)). 48-hour vancomycin serum concentrations in all patients increased therapeutically by 21% (3/9 to 7/13). In per protocol treated patients, concentrations increased 15% (2/7 to 4/9) therapeutically, decreased 21% (3/7 to 2/9) supra-therapeutically and increased 4% (2/7 to 3/9) sub-therapeutically. Supra-therapeutic concentrations were associated with CLCR&lt;50ml/min. Sub-therapeutic concentrations were associated with CLCR&gt;90ml/min and obesity. Compared to the ePMA system, there was 36% (8/22) less paper-fluid-balance-charts recording both loading/maintenance doses. Maintenance dose administration times in 9% (2/22) of cases differed by &gt;60 minutes.

Discussion/Conclusion

Staff-turnover periods were associated with decreased protocol compliance. Observations suggest further education is required around prescribing/administration of standardised infusion bags for maintenance dosing. Pharmacist integration into daily Microbiology ward rounds may increase protocol compliance. Higher 20mg/kg loading doses for obese patients and maintenance dose revision should be considered to reduce non-therapeutic concentrations.3 Limitations include heterogenous/small sample sizes due to data paucity and vancomycin requirement. This can be addressed by involving all ICU’s in PDSA Cycle-2. Due to disparities, both the ePMA system and paper-fluid-balance-charts should be used to identify protocol adherence. Utilisation of digital-infusion-pump data to quantify administration accuracy may offer a promising solution. Piloted multifaceted interventions were successful at improving adherence to/effectiveness of the vancomycin protocol. Findings have informed further interventions and data capture methods for PDSA Cycle-2 implementation across all ICUs.

References

1. Perin N, Roger C, Marin G, Molinari N, Evrard A, Lavigne J et al. Vancomycin Serum Concentration after 48 h of Administration: A 3-Years Survey in an Intensive Care Unit. Antibiotics. 2020;9(11):793. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7698174/

2. Oakley R, Bakrania P, Yau T, Standing J, Lonsdale D. P37 Variable adherence to and effectiveness of a vancomycin continuous infusion protocol within ICUs at a London tertiary-care hospital: a single-centre retrospective service evaluation. JAC-Antimicrobial Resistance. 2022;4(Supplement_1). Available from: https://academic.oup.com/jacamr/issue/4/Supplement_1

3. Rybak M, Le J, Lodise T, Levine D, Bradley J, Liu C et al. Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A revised consensus guideline and review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. American Journal of Health-System Pharmacy. 2020;77(11):835-864. Available from: https://academic.oup.com/ajhp/article/77/11/835/5810200?login=false

Randomized phase II study of axitinib versus placebo plus best supportive care in second-line treatment of advanced hepatocellular carcinoma

BACKGROUND

The efficacy and safety of axitinib, a potent and selective vascular endothelial growth factor receptors 1-3 inhibitor, combined with best supportive care (BSC) was evaluated in a global, randomized, placebo-controlled phase II trial in patients with locally advanced or metastatic hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

Patients with HCC and Child-Pugh Class A who progressed on or were intolerant to one prior antiangiogenic therapy were stratified by tumour invasion (presence/absence of extrahepatic spread and/or vascular invasion) and region (Asian/non-Asian) and randomized (2:1) to axitinib/BSC (starting dose 5 mg twice-daily) or placebo/BSC. The primary end point was overall survival (OS).

RESULTS

The estimated hazard ratio for OS was 0.907 [95% confidence interval (CI) 0.646-1.274; one-sided stratified P = 0.287] for axitinib/BSC (n = 134) versus placebo/BSC (n = 68), with the median (95% CI) of 12.7 (10.2-14.9) versus 9.7 (5.9-11.8) months, respectively. Results of prespecified subgroup analyses in Asian versus non-Asian patients or presence versus absence of tumour invasion were consistent with the overall population. Improvements favouring axitinib/BSC (P < 0.01) were observed in secondary efficacy end point analyses [progression-free survival (PFS), time to tumour progression (TTP), and clinical benefit rate (CBR)], and were retained among Asian patients in the prespecified subgroup analyses. Overall response rate did not differ significantly between treatments and patient-reported outcomes favoured placebo/BSC. Most common all-causality adverse events with axitinib/BSC were diarrhoea (54%), hypertension (54%), and decreased appetite (47%). Baseline serum analyses identified potential new prognostic (interleukin-6, E-selectin, interleukin-8, angiopoietin-2, migration inhibitory factor, and c-MET) or predictive (E-selectin and stromal-derived factor-1) factors for survival.

CONCLUSIONS

Axitinib/BSC did not improve OS over placebo/BSC in the overall population or in stratification subgroups. However, axitinib/BSC resulted in significantly longer PFS and TTP and higher CBR, with acceptable toxicity in patients with advanced HCC.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01210495.