Correlation of immune fitness with response to teclistamab in relapsed/refractory multiple myeloma in MajesTEC-1

Teclistamab, an off-the-shelf B-cell maturation antigen (BCMA) × CD3 bispecific antibody that mediates T-cell activation and subsequent lysis of BCMA-expressing myeloma cells, is approved for the treatment of patients with relapsed/refractory multiple myeloma (RRMM). As a T-cell redirection therapy, clinical outcomes with teclistamab may be influenced by patient immune fitness and tumor antigen expression. We correlated tumor characteristics and baseline immune profiles with clinical response and disease burden in patients with RRMM from the pivotal phase 1/2 MajesTEC-1 study, focusing on patients treated with 1.5 mg/kg of teclistamab (N = 165). Peripheral blood samples were collected at screening and bone marrow samples were collected at screening and cycle 3. Better clinical outcomes to teclistamab correlated with higher baseline total T-cell counts in the periphery. In addition, responders (partial response or better) had a lower proportion of immunosuppressive regulatory T cells, T cells expressing co-inhibitory receptors (CD38, PD-1, PD-1/TIM-3), and soluble BCMA, and a T-cell profile suggestive of a more cytolytic potential, compared with nonresponders. Neither frequency of baseline bone marrow BCMA expression nor BCMA receptor density were associated with clinical response to teclistamab. Improved progression-free survival was observed in patients with a lower frequency of T cells expressing exhaustion markers and immunosuppressive regulatory T cells. Overall, response to teclistamab was associated with baseline immune fitness; nonresponders had immune profiles suggestive of immune suppression and T-cell dysfunction. These findings illustrate the importance of the contribution of the immune landscape to T-cell redirection therapy response. This trial was registered at www.ClinicalTrials.gov, NCT03145181/NCT04557098.

Teclistamab impairs humoral immunity in patients with heavily pretreated myeloma: importance of immunoglobulin supplementation

ABSTRACT

Teclistamab and other B-cell maturation antigen (BCMA)-targeting bispecific antibodies (BsAbs) have substantial activity in patients with heavily pretreated multiple myeloma (MM) but are associated with a high rate of infections. BCMA is also expressed on normal plasma cells and mature B cells, which are essential for the generation of a humoral immune response. The aim of this study was to improve the understanding of the impact of BCMA-targeting BsAbs on humoral immunity. The impact of teclistamab on polyclonal immunoglobulins and B cell counts was evaluated in patients with MM who received once-weekly teclistamab 1.5 mg/kg subcutaneously. Vaccination responses were assessed in a subset of patients. Teclistamabinduced rapid depletion of peripheral blood B cells in patients with MM and eliminated normal plasma cells in ex vivo assays. In addition, teclistamab reduced the levels of polyclonal immunoglobulins (immunoglobulin G [IgG], IgA, IgE, and IgM), without recovery over time while receiving teclistamab therapy. Furthermore, response to vaccines against Streptococcus pneumoniae, Haemophilus influenzae type B, and severe acute respiratory syndrome coronavirus 2 was severely impaired in patients treated with teclistamab compared with vaccination responses observed in patients with newly diagnosed MM or relapsed/refractory MM. Intravenous immunoglobulin (IVIG) use was associated with a significantly lower risk of serious infections among patients treated with teclistamab (cumulative incidence of infections at 6 months: 5.3% with IVIG vs 54.8% with observation only [P < .001]). In conclusion, our data show severe defects in humoral immunity induced by teclistamab, the impact of which can be mitigated by the use of immunoglobulin supplementation. This trial was registered at www.ClinicalTrials.gov as #NCT04557098.

Population Pharmacokinetics and Exposure-Response with Teclistamab in Patients With Relapsed/Refractory Multiple Myeloma: Results From MajesTEC-1

BACKGROUND

Teclistamab, a B-cell maturation antigen × CD3 bispecific antibody, is approved in patients with relapsed/refractory multiple myeloma (RRMM) who have previously received an immunomodulatory agent, a proteasome inhibitor, and an anti-CD38 antibody.

OBJECTIVE

We report the population pharmacokinetics of teclistamab administered intravenously and subcutaneously (SC) and exposure-response relationships from the phase I/II, first-in-human, open-label, multicenter MajesTEC-1 study.

METHODS

Phase I of MajesTEC-1 consisted of dose escalation and expansion at the recommended phase II dose (RP2D; 1.5 mg/kg SC weekly, preceded by step-up doses of 0.06 and 0.3 mg/kg); phase II investigated the efficacy of teclistamab RP2D in patients with RRMM. Population pharmacokinetics and the impact of covariates on teclistamab systemic exposure were assessed using a 2-compartment model with first-order absorption for SC and parallel time-independent and time-dependent elimination pathways. Exposure-response analyses were conducted, including overall response rate (ORR), duration of response (DoR), progression-free survival (PFS), overall survival (OS), and the incidence of grade ≥ 3 anemia, neutropenia, lymphopenia, leukopenia, thrombocytopenia, and infection.

RESULTS

In total, 4840 measurable serum concentration samples from 338 pharmacokinetics-evaluable patients who received teclistamab were analyzed. The typical population value of time-independent and time-dependent clearance were 0.449 L/day and 0.547 L/day, respectively. The time-dependent clearance decreased rapidly to < 10% after 8 weeks of teclistamab treatment. Patients who discontinue teclistamab after the 13th dose are expected to have a 50% reduction from Cmax in teclistamab concentration at a median (5th to 95th percentile) time of 15 days (7-33 days) after Tmax and a 97% reduction from Cmax in teclistamab concentration at a median time of 69 days (32-163 days) after Tmax. Body weight, multiple myeloma type (immunoglobulin G vs non-immunoglobulin G), and International Staging System (ISS) stage (II vs I and III vs I) were statistically significant covariates on teclistamab pharmacokinetics; however, these covariates had no clinically relevant effect on the efficacy of teclistamab at the RP2D. Across all doses, ORR approached a plateau at the concentration range associated with RP2D, and in patients who received the RP2D, a flat exposure-response curve was observed. No apparent relationship was observed between DoR, PFS, OS, and the incidence of grade ≥3 adverse events across the predicted exposure quartiles.

CONCLUSION

Body weight, myeloma type, and ISS stage impacted systemic teclistamab exposure without any clinically relevant effect on efficacy. The exposure-response analyses for ORR showed a positive trend with increasing teclistamab systemic exposure, with a plateau at the RP2D, and there was no apparent exposure-response trend for safety or other efficacy endpoints. These analyses support the RP2D of teclistamab in patients with RRMM.

CLINICAL TRIAL REGISTRATION

NCT03145181 (phase I, 09 May 2017); NCT04557098 (phase II, 21 September 2020).

Plain language summary of the MajesTEC-1 study of teclistamab for the treatment of people with relapsed or refractory multiple myeloma

WHAT IS THIS SUMMARY ABOUT?

This is a summary of a phase 1-2 clinical trial called MajesTEC-1. This trial tested the cancer drug teclistamab in people with relapsed or refractory multiple myeloma, a cancer that forms in a certain type of white blood cells known as plasma cells. Most participants who took part in the study had at least 3 prior treatments for multiple myeloma before their cancer came back.

HOW WAS THE STUDY IN THIS SUMMARY CONDUCTED?

A total of 165 participants from 9 countries were included in this study. All participants were given teclistamab once per week and monitored for side effects. Once participants started taking teclistamab, they were checked regularly to monitor if their cancer had no change, improved (responded to treatment), or worsened or spread (known as disease progression).

WHAT WERE THE RESULTS OF THE STUDY?

After approximately 14.1 months of follow-up (from 2020 to 2021), 63% of participants who were given teclistamab had a decrease in myeloma burden, meaning that they responded to treatment with teclistamab. Participants who responded to teclistamab lived without their myeloma coming back for approximately 18.4 months. The most common side effects were infections, cytokine release syndrome, abnormally low white and red blood cell counts (neutropenia, lymphopenia, and anemia), and low platelet cell counts (thrombocytopenia). Approximately 65% of participants experienced serious side effects.

WHAT DO THE RESULTS OF THIS STUDY MEAN?

Overall, more than half of the participants (63%) in the MajesTEC-1 study responded to treatment with teclistamab despite previous myeloma treatment failures. Clinical Trial Registration: NCT03145181, NCT04557098 (ClinicalTrials.gov).

Teclistamab in Relapsed or Refractory Multiple Myeloma

BACKGROUND

Teclistamab is a T-cell-redirecting bispecific antibody that targets both CD3 expressed on the surface of T cells and B-cell maturation antigen expressed on the surface of myeloma cells. In the phase 1 dose-defining portion of the study, teclistamab showed promising efficacy in patients with relapsed or refractory multiple myeloma.

METHODS

In this phase 1-2 study, we enrolled patients who had relapsed or refractory myeloma after at least three therapy lines, including triple-class exposure to an immunomodulatory drug, a proteasome inhibitor, and an anti-CD38 antibody. Patients received a weekly subcutaneous injection of teclistamab (at a dose of 1.5 mg per kilogram of body weight) after receiving step-up doses of 0.06 mg and 0.3 mg per kilogram. The primary end point was the overall response (partial response or better).

RESULTS

Among 165 patients who received teclistamab, 77.6% had triple-class refractory disease (median, five previous therapy lines). With a median follow-up of 14.1 months, the overall response rate was 63.0%, with 65 patients (39.4%) having a complete response or better. A total of 44 patients (26.7%) were found to have no minimal residual disease (MRD); the MRD-negativity rate among the patients with a complete response or better was 46%. The median duration of response was 18.4 months (95% confidence interval [CI], 14.9 to not estimable). The median duration of progression-free survival was 11.3 months (95% CI, 8.8 to 17.1). Common adverse events included cytokine release syndrome (in 72.1% of the patients; grade 3, 0.6%; no grade 4), neutropenia (in 70.9%; grade 3 or 4, 64.2%), anemia (in 52.1%; grade 3 or 4, 37.0%), and thrombocytopenia (in 40.0%; grade 3 or 4, 21.2%). Infections were frequent (in 76.4%; grade 3 or 4, 44.8%). Neurotoxic events occurred in 24 patients (14.5%), including immune effector cell-associated neurotoxicity syndrome in 5 patients (3.0%; all grade 1 or 2).

CONCLUSIONS

Teclistamab resulted in a high rate of deep and durable response in patients with triple-class-exposed relapsed or refractory multiple myeloma. Cytopenias and infections were common; toxic effects that were consistent with T-cell redirection were mostly grade 1 or 2. (Funded by Janssen Research and Development; MajesTEC-1 ClinicalTrials.gov numbers, NCT03145181 and NCT04557098.).

Teclistamab, a B-cell maturation antigen (BCMA) x CD3 bispecific antibody, in patients with relapsed/refractory multiple myeloma (RRMM): Updated efficacy and safety results from MajesTEC-1

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Background: The BCMA × CD3 bispecific antibody teclistamab (tec; JNJ-64007957) redirects CD3+ T cells to mediate T-cell activation and subsequent lysis of BCMA-expressing myeloma cells. The multicohort, open-label, phase 1/2 MajesTEC-1 study is investigating safety/efficacy of tec in patients (pts) with RRMM who previously received ≥3 lines of therapy (LOT). In phase 1, the recommended phase 2 dose (RP2D) of tec was identified as a weekly subcutaneous dose of 1.5 mg/kg preceded by step-up doses of 0.06 and 0.3 mg/kg. Initial results from pts treated with the tec RP2D in phase 1/2 (no prior exposure to an anti–BCMA-targeted treatment), demonstrated that tec was well tolerated with encouraging efficacy. Here we present updated results from pts treated at the RP2D, including additional pts and longer follow-up. Methods: Eligible pts were aged ≥18 years, had documented MM (per IMWG criteria), and had received ≥3 prior LOT including a proteasome inhibitor, an immunomodulatory drug, and an anti-CD38 antibody. Prior BCMA-targeted therapy was not permitted in Phase 1. Pts received tec at the RP2D. The primary endpoint was overall response rate (assessed per IMWG 2016 criteria). Adverse events (AEs) were graded per CTCAE v4.03 (cytokine release syndrome [CRS] and ICANS graded per ASTCT guidelines). Data cutoffs for safety and efficacy (N = 165) were Sep 7 and Nov 9, 2021, respectively. Results: Median pt age was 64 y (range 33–84); 58% were male, and median prior LOT was 5 (range 2–14); 100% were triple-class exposed, 70% were penta-drug exposed, 78% were triple-class refractory, and 30% were penta-drug refractory. ORR was 64% (95% CI 56–72), with a complete response or better achieved in 30% of pts. Responses were durable and deepened over time; median duration of response (DOR) was not reached. The 12-mo DOR rate was 66% (95% CI 49–79). The majority of pts who responded to treatment in the first cycle had a reduction in soluble BCMA. The most common hematologic AEs were neutropenia (65%; grade 3/4: 57%), anemia (50%; grade 3/4: 35%), thrombocytopenia (38%; grade 3/4: 21%), and lymphopenia (34%; grade 3/4: 32%). Infections occurred in 104 pts (63%; grade 3/4: 35%). The most common nonhematologic AE was CRS (72%; grade 3: 0.6%; no grade 4/5); median time to CRS onset (range) was 2 days (1–6) and median duration was 2 days (1–9). Five pts (3%) reported a total of 9 ICANS events (all grade 1/2; 7 were concurrent with CRS; all resolved). There were no treatment-related deaths. No pts required a teclistamab dose reduction due to AEs. Conclusions: Current data with ̃9 months of follow-up reaffirm the deep and durable responses that have been observed with tec in pts with highly refractory MM, with no new safety signals. Additional data with longer follow-up, including subgroup analyses and PFS, will be presented. Clinical trial information: NCT04557098.

Teclistamab, a B-cell maturation antigen × CD3 bispecific antibody, in patients with relapsed or refractory multiple myeloma (MajesTEC-1): a multicentre, open-label, single-arm, phase 1 study

BACKGROUND

There is a need for novel therapies for relapsed or refractory multiple myeloma, and B-cell maturation antigen (BCMA) is a validated target. Teclistamab is a bispecific antibody that binds BCMA and CD3 to redirect T cells to multiple myeloma cells. The aim of the MajesTEC-1 study was to evaluate the safety, tolerability, and preliminary efficacy of teclistamab in patients with relapsed or refractory multiple myeloma.

METHODS

This open-label, single-arm, phase 1 study enrolled patients with multiple myeloma who were relapsed, refractory, or intolerant to established therapies. Teclistamab was administered intravenously (range 0·3-19·2 μg/kg [once every 2 weeks] or 19·2-720 μg/kg [once per week]) or subcutaneously (range 80-3000 μg/kg [once per week]) in different cohorts, with step-up dosing for 38·4 μg/kg or higher doses. The primary objectives were to identify the recommended phase 2 dose (part one) and characterise teclistamab safety and tolerability at the recommended phase 2 dose (part two). Safety was assessed in all patients treated with at least one dose of teclistamab. Efficacy was analysed in response-evaluable patients (ie, patients who received at least one dose of teclistamab and had at least one post-baseline response evaluation). This ongoing trial is registered with ClinicalTrials.gov, NCT03145181.

FINDINGS

Between June 8, 2017, and March 29, 2021, 219 patients were screened for study inclusion, and 157 patients (median six previous therapy lines) were enrolled and received at least one dose of teclistamab (intravenous n=84; subcutaneous n=73). 40 patients were administered the recommended phase 2 dose, identified as once per week subcutaneous administration of teclistamab at 1500 μg/kg, after 60 μg/kg and 300 μg/kg step-up doses (median follow-up 6·1 months, IQR 3·6-8·2). There were no dose-limiting toxicities at the recommended phase 2 dose in part one. In the 40 patients treated at the recommended phase 2 dose, the most common treatment-emergent adverse events were cytokine release syndrome in 28 (70%; all grade 1 or 2 events) and neutropenia in 26 (65%) patients (grade 3 or 4 in 16 [40%]). The overall response rate in response-evaluable patients treated at the recommended phase 2 dose (n=40) was 65% (95% CI 48-79); 58% achieved a very good partial response or better. At the recommended phase 2 dose, the median duration of response was not reached. 22 (85%) of 26 responders were alive and continuing treatment after 7·1 months' median follow-up (IQR 5·1-9·1). At the recommended phase 2 dose, teclistamab exposure was maintained above target exposure levels, and consistent T-cell activation was reported.

INTERPRETATION

Teclistamab is a novel treatment approach for relapsed or refractory multiple myeloma. At the recommended phase 2 dose, teclistamab showed promising efficacy, with durable responses that deepened over time, and was well tolerated, supporting further clinical development.

FUNDING

Janssen Research & Development.

Teclistamab and talquetamab modulate levels of soluble B-cell maturation antigen in patients with relapsed and/or refractory multiple myeloma

8047

Background: B-cell maturation antigen (BCMA, CD269) is a single transmembrane protein that is selectively expressed in the B-cell lineage and is a validated target for multiple myeloma. BCMA exists as both surface protein and as a free soluble form (sBCMA). γ-secretase activity at the transmembrane domain leads to a shed BCMA protein fragment of approximately 6 kilodalton that can exist as free circulating sBCMA in blood. Teclistamab and talquetamab are CD3 bispecific antibodies that have been developed to recruit CD3+ T-cells to BCMA+ or GPRC5D+ multiple myeloma (MM) cells, respectively. The objective of this work was to evaluate sBCMA in relapsed and/or refractory MM patients in response to treatment with teclistamab or talquetamab. Methods: Serum samples from relapsed and/or refractory MM patients in teclistamab and talquetamab phase 1 studies (64007957MMY1001 and 64407564MMY1001) were collected (at various timepoints between baseline and cycle 4 or end of treatment) and analyzed for sBCMA by an electrochemiluminescence ligand binding assay. Soluble BCMA data were quantitatively analyzed in reference to patient’s tumor burden and response, as well as pharmacokinetic data. Results: Teclistamab and talquetamab modulated levels of sBCMA in patients with high ( ≥ 50%) and low ( < 50%) frequency of tumor plasma cells (TPCs), as well as in high and low risk cytogenetic groups. In cycle 3, majority of the responders had reduction in sBCMA [88% (50 out of 57) for teclistamab and 98% (49 out of 50) for talquetamab] compared to baseline. On the contrary, non-responders (progressive disease, stable disease, or minimal response) seemed to show an increase in sBCMA [80% (33 out of 41) for teclistamab and 49% (24 out of 49) for talquetamab] from baseline. Patients with deep responses tend to have higher magnitude of sBCMA reduction compared to others. Based on few patients who responded to teclistamab or talquetamab and then relapsed, sBCMA seemed to have an initial reduction followed by an increase in the levels. Soluble BCMA corelated with % bone marrow TPCs. Majority of patients with plasmacytoma (limited data) seemed to have high sBCMA; suggesting sBCMA could be a comprehensive marker for tumor burden. Teclistamab preliminary population pharmacokinetic analysis showed that sBCMA did not appear to impact teclistamab exposure, suggesting that sBCMA was not acting as a sink for teclistamab. Conclusions: Teclistamab and talquetamab induced changes in levels of sBCMA that correlated with clinical activity, further supporting clinical development of these bispecific antibodies. Lastly, the results support that sBCMA is a potential surrogate marker of myeloma tumor burden, and as a valuable marker for response in MM patients. Clinical trial information: NCT03145181 and NCT03399799.

Updated phase 1 results of teclistamab, a B-cell maturation antigen (BCMA) × CD3 bispecific antibody, in relapsed/refractory multiple myeloma (MM)

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Background: BCMA-targeted immunotherapies offer considerable promise for relapsed/refractory MM. Teclistamab (JNJ-64007957) is a BCMA × CD3 bispecific IgG4 antibody that redirects CD3+ T cells to BCMA-expressing MM cells. We present updated results of patients (pts) treated at the recommended phase 2 dose (RP2D) in the first-in-human phase 1 study of teclistamab. Methods: Eligible pts had MM and were relapsed, refractory or intolerant to established therapies. Primary objectives were to identify the RP2D (part 1) and characterize safety and tolerability of teclistamab at the RP2D (part 2). Teclistamab was given intravenously (IV; range 0.3–19.2 µg/kg [biweekly]; range 19.2–720 µg/kg [weekly]) or subcutaneously (SC; range 80.0–3000 µg/kg weekly) in different cohorts, with step-up dosing used for ≥38.4 µg/kg doses. Adverse events (AEs) were graded by CTCAE v4.03 (cytokine release syndrome [CRS] by Lee et al 2014). Response was assessed per IMWG criteria. Results: As of Feb 4, 2021, 156 pts received teclistamab (IV n = 84; SC n = 72). The RP2D, identified as weekly SC 1500 µg/kg teclistamab with 60.0 and 300 µg/kg step-up doses, was given to 40 pts (median follow-up 4.3 mo [range 1.1–10.4+]). Pts dosed at the RP2D (median age, 62.5 y [range, 39–84]; 65% male) had received a median of 5 prior lines of therapy (range 2–11; 100% triple-class exposed; 65% penta-drug exposed; 83% triple-class refractory; 35% penta-drug refractory; 85% refractory to their last line of therapy). There were no dose-limiting toxicities at the RP2D in part 1. The most common AEs at the RP2D were CRS (70%; grade 3/4 0) and neutropenia (60%; grade 3/4 40%); grade 1 neurotoxicity was reported in 1 (3%) pt. Median time to CRS onset was later with SC vs IV dosing (day after SC injection vs day of IV infusion). The overall response rate in response-evaluable pts treated at the RP2D (n = 40) was 65%; 58% achieved a very good partial response or better and 30% achieved a complete response (CR) or better; median time to first confirmed response was 1.0 mo (range 0.2–3.1). At the RP2D, median duration of response was not reached; 23 of 26 responders (88%), after median follow-up of 5.3 mo (range 1.2–10.4+), were alive and continuing on treatment with responses deepening over time. Of 14 evaluable pts across all cohorts, 9 with CR were minimal residual disease–negative at 10-6. At the RP2D, teclistamab exposure was sustained across the dosing interval and exceeded target levels, and consistent T cell activation was observed. Conclusions: Teclistamab at the RP2D (weekly 1500 µg/kg SC) was well-tolerated and showed encouraging efficacy with durable, deepening responses, supporting further investigation as monotherapy and in combination with other agents. With the extended exposure profile at the RP2D and delayed and low-grade CRS observed with SC administration, alternative SC dosing strategies are being explored. Clinical trial information: NCT03145181.

Hypertrophic osteopathy in South Australian koalas (Phascolarctos cinereus) with concurrent pulmonary actinomycosis

Pulmonary actinomycosis is described in 17 South Australian koalas necropsied between 2016 and 2019. From these cases, four koalas had secondary hypertrophic osteopathy. Plain radiographical and computed tomography images demonstrated periosteal reaction on multiple appendicular skeletal bones in all cases, including scapula, humerus, ulna, radius, ilium, femur, tibia, fibula, metacarpus, metatarsus and phalanx. Grossly, periosteal surfaces of the metaphyses and diaphyses of long bones were thickened and roughened; microscopically, this was characterised by bi-layered proliferation of well-differentiated trabecular bony spicules oriented perpendicular to the cortex (pseudocortices) and separated by vascular connective tissue, typical for hypertrophic osteopathy. Well characterised in domestic species and rarely reported in marsupials, this is the first radiographical and pathological characterisation of hypertrophic osteopathy in koalas, associated with pulmonary actinomycosis in all cases.

Symmetric dimethylarginine values in koalas (Phascolarctos cinereus) based on oxalate nephrosis status

Oxalate nephrosis is a prevalent renal disease in koalas (Phascolarctos cinereus) of the Mount Lofty Ranges population in South Australia. The symmetric dimethylarginine (SDMA) assay is widely used in companion animals to diagnose renal disease, particularly in the early stages. This study aimed to determine: (1) reference intervals for SDMA in koalas and (2) SDMA values of koalas with oxalate nephrosis. Blood samples were collected from 41 Mount Lofty Ranges koalas euthanased on welfare grounds. Koalas were necropsied and, based on renal histopathology, were classified as unaffected (n = 22) or affected (n = 19) by oxalate nephrosis. Serum or plasma samples were analysed for creatinine, urea and SDMA and urine samples for urine specific gravity (USG). The reference interval for SDMA in unaffected koalas was 2.4-22.9 μg/dL. In koalas with oxalate nephrosis, SDMA was elevated in 74% of cases above the upper limit of the confidence interval. SDMA was elevated in three affected koalas with normal creatinine values. A positive correlation was found between SDMA and creatinine (R = 0.775, P < 0.001) and SDMA and urea (R = 0.580, P < 0.001) and a negative correlation between SDMA and USG (R = -0.495, P = 0.027). In conclusion, SDMA correlates well with other commonly used tests of renal function in koalas and should be included as part of the standard diagnostic process to increase the accuracy of oxalate nephrosis diagnosis in koalas.

Phase I study of teclistamab, a humanized B-cell maturation antigen (BCMA) x CD3 bispecific antibody, in relapsed/refractory multiple myeloma (R/R MM)

100

Background: Teclistamab (JNJ-64007957) is a bispecific BCMA x CD3 antibody that induces T cell-mediated cytotoxicity against BCMA-expressing myeloma cells. Initial results from an ongoing study of teclistamab in RRMM (NCT03145181) are presented. Methods: Pts have MM and are RR to standard therapies. Primary objective for part 1 is to identify a recommended phase 2 dose(s). Multiple intravenous (iv) doses ± priming doses were explored. Adverse events (AEs) were graded per CTCAE v4.03 and cytokine release syndrome (CRS) per Lee et al 2014. Response was investigator-assessed using IMWG criteria; minimal residual disease (MRD) in bone marrow was assessed by next generation sequencing. Results: As of 31 Jan 2020, 66 pts had received iv teclistamab (0.3–270 µg/kg). Median age was 64 y (24–82), median prior therapies was 6 (2–14), 97% triple-class exposed, 83% triple-class refractory, and 38% penta-drug refractory. Most common treatment-related AEs (all grade) were CRS (56%), neutropenia (26%), and anemia (23%). CRS events were all grade 1–2 and generally confined to initial doses. 8% of pts had treatment-related neurotoxicity (3% grade ≥3), and 9% had infusion related reaction. Infection-related AEs were reported in 61% of pts (21% grade ≥3). 2 dose-limiting toxicities were reported: grade 4 delirium (resolved after 16 days) and grade 4 thrombocytopenia (resolved after 1 day). 36% of pts had treatment-related grade ≥3 AEs; neutropenia (20%) and anemia (14%) were most frequent. Only 1 grade 5 AE was reported (respiratory failure in the setting of pneumonia deemed unrelated by the investigator). PK results indicate that the half-life of teclistamab supports weekly dosing. On-target pharmacodynamic activity (T cell redistribution and activation along with transient release of cytokines) was observed at doses ≥9.6 µg/kg. Cytokine production was modulated with step-up dosing while T cell activation was maintained. 65 pts were evaluable for response. Activity was observed starting at treatment doses ≥38.4 µg/kg, with 20/52 (38%) pts achieving a response. At the highest dose, 7/9 (78%) pts responded (1 response pending confirmation). Of MRD-evaluable pts who had complete response, 2/2 were MRD negative at 10−6 with treatment ongoing > 12 mo. Conclusions: Teclistamab has manageable safety across all doses explored. A 78% overall response rate was observed at the highest weekly treatment dose in pts with advanced RRMM, supporting further evaluation of teclistamab in expansion cohorts. Clinical trial information: NCT03145181.

Nitrogen removal from coke making wastewater through a pre-denitrification activated sludge process

Under the Industrial Emissions Directive (IED), coke production wastewater must be treated to produce an effluent characterised by a total nitrogen (TN) <50 mg/L. An anoxic-aerobic activated sludge pilot-plant (1 m³) fed with coke production wastewater was used to investigate the optimal operational requirements to achieve such an effluent. The loading rates applied to the pilot-plant varied between 0.198-0.418 kg COD/m³.day and 0.029-0.081 kg TN/m³.day, respectively. The ammonia (NH₄⁺-N) removals were maintained at 96%, after alkalinity addition. Under all conditions, phenol and SCN^- remained stable at 96% and 100%, respectively with both being utilised as carbon sources during denitrification. The obtained results showed that influent soluble chemical oxygen demand (sCOD) to TN ratio of should be maintained at >5.7 to produce an effluent TN <50 mg/L. Furthermore, nitrite accumulation was observed under all conditions indicating a disturbance to the denitrification pathway. Overall, the anoxic-aerobic activated sludge process was shown to be a robust and reliable technology to treat coke making wastewater and achieve the IED requirements. Nevertheless, the influent to the anoxic tank should be monitored to ensure a sCOD:TN ratio >5.7 or, alternately, the addition of an external carbon source should be considered.

A survey of staffing levels in paediatric diabetes services throughout the UK

AIMS

To assess staffing levels of healthcare professionals involved in the care of children and young people with diabetes in the UK.

METHODS

A web-based questionnaire was distributed to lead consultant paediatricians from all paediatric diabetes services in the UK between October and December 2014. Data on staffing levels and other aspects of diabetes services were collected and differences between the four nations of the UK and across the 10 English diabetes networks were explored.

RESULTS

Some 175 services (93%) caring for 29 711 children and young people aged ≤ 24 years with diabetes participated in the survey. Northern Ireland and Wales had the lowest ratio of total staff to patient population. Nursing caseloads per one whole-time equivalent (WTE) nurse ranged from 71 patients in England to 110 patients in Northern Ireland with only 52% of the UK services meeting the Royal College of Nursing recommended nurse-to-patient ratio of > 1 : 70. Scotland and Northern Ireland had the highest ratio of consultants and fully trained doctors per 1000 patients (3.5 WTE). Overall, 17% of consultants had a Certificate of Completion of Training in Endocrinology and Diabetes. Some 44% of dietitians were able to adjust insulin dose. Only 43% of services provided 24-h access to advice from the diabetes team and 82% of services had access to a psychologist. Staffing levels adjusted for volume were not directly related to glycaemic performance of services in England and Wales.

CONCLUSIONS

Wide variations in staffing levels existed across the four nations of the UK and important gaps were present in key areas.

Clinic variation in glycaemic control for children with Type 1 diabetes in England and Wales: a population-based, multilevel analysis

AIM

To understand the scope for improving children's glycaemic outcomes by reducing variation between clinics and examine the role of insulin regimen and clinic characteristics.

METHODS

Cross-sectional analysis of 2012-2013 National Paediatric Diabetes Audit data from 21 773 children aged < 19 years with Type 1 diabetes cared for at 176 clinics organized into 11 regional diabetes networks in England and Wales. Variation in HbA_1c was explored by multilevel models with a random effect for clinic. The impact of clinic context was quantified by computing the per cent of total variation in HbA_1c which occurs between clinics (intraclass correlation coefficient; ICC).

RESULTS

Overall, 69 of the 176 diabetes clinics (39%) had a glycaemic performance that differed significantly from the national average after adjusting for patient case-mix with respect to age, gender, diabetes duration, deprivation and ethnicity. However, differences between clinics accounted for 4.7% of the total variation in HbA_1c . Inclusion of within-clinic HbA_1c standard deviation led to a substantial reduction in ICC to 2.4%. Insulin regimen, clinic volume and diabetes networks had a small or moderate impact on ICC.

CONCLUSIONS

Differences between diabetes clinics accounted for only a small portion of the total variation in glycaemic control because most of the variation was within clinics. This implies that national glycaemic improvements might best be achieved not only by targeting poor centres but also by shifting the whole distribution of clinics to higher levels of quality.

Young people with Type 1 diabetes of non-white ethnicity and lower socio-economic status have poorer glycaemic control in England and Wales

BACKGROUND

The impact of ethnicity and socio-economic status (SES) on glycaemic control during childhood Type 1 diabetes is poorly understood in England and Wales.

METHODS

We studied 18 478 children with Type 1 diabetes (< 19 years) attending diabetes clinics and included in the 2012-2013 National Paediatric Diabetes Audit. Self-identified ethnicity was categorized as white, Asian, black, mixed, other and 'not-stated' (did not to divulge ethnicity). A small area measure of SES was estimated from the Index of Multiple Deprivation. Multiple linear regression was used to assess associations between ethnicity, SES and glycaemic control (mean HbA_1c levels) accounting for age, gender and diabetes duration. The impact of insulin pump use on the ethnicity/SES-HbA_1c associations was tested in 13 962 children.

RESULTS

All children from minority ethnic groups had higher mean HbA_1c compared with white children, with largest differences observed in black and mixed ethnicities [8 mmol/mol (2.9%), 95% CI 5-11 and 7 mmol/mol (2.8%), 95% CI 5-9, respectively]. Lower SES was associated with higher mean HbA_1c with a dose effect. The lowest SES group had a mean HbA_1c that was 7 mmol/mol (2.8%) (95% CI 6-8) higher compared with the highest SES group, adjusted for ethnicity. Estimates for ethnicity were attenuated, but significant on adjustment for SES. Fewer non-white (white 20.3 vs. black 5.5%) and deprived (least deprived 21.1 vs. most deprived 13.2%) children were on insulin pump therapy. Ethnicity and SES remained significant predictors of HbA_1c after accounting for insulin pump use.

CONCLUSION

The association between ethnicity and glycaemic control persists after adjustment for deprivation and pump use. An alternative approach to intensive insulin therapy might benefit these vulnerable children.

Ecological conditions of ponds situated on blast furnace slag deposits located in South Gare Site of Special Scientific Interest (SSSI), Teesside, UK

Slag, a by-product from the iron and steel industry, has a range of applications within construction and is used in wastewater treatment. Historically considered a waste material, little consideration was given to the environmental impacts of its disposal. South Gare (a Site of Special Scientific Interest) located at the mouth of the Tees estuary, UK, formed on slag deposits used to create a sea wall and make the land behind permanent. Over time, ponds formed in depressions with the water chemistry, being significantly impacted by the slag deposits. Calcium levels reached 504 mg/L, nitrate 49.0 mg/L and sulphate 1,698 mg/L. These levels were also reflected in the composition of the sediment. pH (5.10-9.90) and electrical conductivity (2,710-3,598 µS/cm) were variable but often notably high. Pb, Cu and Cd were not present within the water, whilst Zn ranged from 0.027 to 0.37 mg/L. Heavy metal levels were higher in surface sediments. Zinc was most dominant (174.3-1,310.2 mg/L) followed by Pb (9.9-431 mg/L), Cu (8.4-41.8 mg/L) and Cd (0.4-1.1 mg/L). A sediment core provided a historical overview of the ponds. The ponds were unfavourable for aquatic biodiversity and unsuitable for drinking water abstraction.

Choosing Wisely in the UK: the Academy of Medical Royal Colleges' initiative to reduce the harms of too much medicine

A Malhotra and colleagues explain how and why a US initiative to get doctors to stop using interventions with no benefit is being brought to the UK

Performance of permeable media rotating reactors used for pretreatment of wastewaters

The impact of organic loading rate (OLR) on carbonaceous materials and ammonia removal was assessed in bench scale rotating media biofilm reactors treating real wastewater. Media composition influences biofilm structure and therefore performance. Here, plastic mesh, reticulated coarse foam and fine foam media were operated concurrently at OLRs of 15, 35 and 60 g sCOD m(-2)d(-1) in three bench scale shaft mounted advanced reactor technology (SMART) reactors. The sCOD removal rate increased with loading from 6 to 25 g sCOD m(-2)d(-1) (P < 0.001). At 35 g BOD5m(-2)d(-1), more than double the arbitrary OLR limit of normal nitrifying conditions (15 g BOD5m(-2)d(-1)); the removal efficiency of NH(4)-N was 82 ± 5, 27 ± 19 and 39 ± 8% for the mesh, coarse foam and fine foam media, respectively. Increasing the OLR to 35 gm(-2)d(-1) decreased NH(4)-N removal efficiency to 38 ± 6, 21 ± 4 and 21 ± 6%, respectively. The mesh media achieved the highest stable NH(4)(+)-N removal rate of 6.5 ± 1.6 gm(-2)d(-1) at a sCOD loading of 35 g sCOD m(-2)d(-1). Viable bacterial numbers decreased with increasing OLR from 2 × 10(10)-4 × 10(9) cells per ml of biofilm from the low to high loading, suggesting an accumulation of inert non-viable biomass with higher OLR. Increasing the OLR in permeable media is of practical benefit for high rate carbonaceous materials and ammonia removal in the pretreatment of wastewater.

Maternal dexamethasone administration and the maturation of perirenal adipose tissue of the neonatal sheep

Maternal dexamethasone administration promotes fetal maturation such that thermoregulation is improved following premature delivery and is thus comparable with a full term birth. In the present study we determined the impact of dexamethasone on both the mothers' metabolic status together with adipose tissue function in the newborn. Glucocorticoid action, adipokine gene expression and mitochondrial protein abundance were measured in perirenal adipose tissue of neonatal sheep that were born into either a warm (30 degrees C) or cool (15 degrees C) ambient temperature at 140 days of gestation (dGA; term approximately 147 dGA), either two days after maternal dexamethasone administration, or at 146 dGA for controls. Dexamethasone administration resulted in a reduction in maternal food intake in conjunction with raised plasma cortisol and free triiodothyronine. In offspring of dexamethasone administered mothers, plasma cortisol was lower and non-esterified fatty acids (NEFA) higher than controls. Glucocorticoid receptor (GR), 11beta-hydroxysteroid dehydrogenase (11beta-HSD1), interleukin-6 and uncoupling protein (UCP)1 and 2 mRNA together with voltage dependent anion channel, cytochrome c protein and UCP1 abundance were all increased by dexamethasone administration and being born into a cool ambient temperature. Gene expression of tumor necrosis factor alpha, adiponectin and peroxisome proliferator-activated receptor transcription factor gamma were unaffected by dexamethasone. The abundance of mRNA for the GR, 11beta-HSD1, UCP1 and 2 mRNA together with each protein were positively correlated to plasma NEFA and negatively correlated to plasma cortisol. In conclusion, despite reduced maternal food intake dexamethasone promotes maturation of glucocorticoid action and mitochondrial protein abundance in the newborn, an adaptation dependent on delivery temperature.

Is there a causal relationship between the hypoxia-ischaemia associated with cardiorespiratory arrest and subdural haematomas? An observational study

The aim of this study was to determine the frequency of subdural haematomas (SDHs) occurring in infants presenting following atraumatic cardiorespiratory collapse. This study was a review of retrospective case notes, brain imaging and post-mortem examinations carried out in the paediatric intensive care unit (PICU) and emergency department (ED) in a tertiary paediatric centre in the UK. The study included infants and children less than 4 years old dying in the ED or admitted to the PICU after atraumatic cardiorespiratory arrest. We identified macroscopic SDHs on brain imaging or post-mortem examination. Of those children who experienced a cardiorespiratory arrest from a non-traumatic cause and met inclusion criteria, 33 presented and died in the ED and 17 were admitted to the PICU. These children had a post-mortem examination, brain imaging or both. None of these infants had a significant SDH. One child had a small clot adherent to the dura found on post-mortem and two had microscopic intradural haemorrhage, but it is unclear in each case whether this was artefact, as each had otherwise normal brains. Subdural haematoma arising in infants or young children in the context of catastrophic cardiorespiratory compromise from a non-traumatic cause was not observed.

Fate and behaviour of copper and zinc in secondary biological wastewater treatment processes: I. Evaluation of biomass adsorption capacity

The current sources of copper and zinc in municipal wastewaters have been considered, and the changes in the concentrations and quantities of these two elements entering sewage treatment works over the last three decades have been calculated. The concentrations and quantities of the heavy metals cadmium, chromium, copper, mercury, nickel, lead and zinc, entering UK sewage treatment works, have been reduced by between 50% and 90% during this period. However, the reductions in copper and zinc appear to be at the lower end of these ranges and thus remain a cause for concern, particularly their concentrations in sewage effluents and their potential environmental impacts on receiving waters. Bench studies have been undertaken to predict removals by three types of biological wastewater treatment plants: trickling filters, conventional activated sludge and membrane bioreactors, to determine if any of these processes are more efficacious for the removal of these metals. These results suggest that, despite membrane bioreactor biomass achieving the lowest effluent suspended solids concentration and having the lowest effluent chemical oxygen demand, which is accepted as a surrogate measure of organic chemical chelating ability of the aqueous phase, they produce the highest effluent values for the two metals in this study (copper and zinc). Removals of zinc and copper in biological wastewater treatment processes are probably primarily determined by those factors influencing metal solubility in the biomass matrix.

Fate and behaviour of copper and zinc in secondary biological wastewater treatment processes: II. Removal at varying sludge age

The mechanisms for the removal of heavy metals during secondary biological treatment of wastewater, with particular emphasis on the activated sludge process, are considered. It is concluded that the predominant mechanism is the entrapment and co-settlement of insoluble metal species in the mixed liquor (biomass). Secondary extracellular polymeric materials, particularly extracellular polysaccharides and other capsule-forming materials, may also play a role. In general, removal of both copper and zinc was superior at the higher sludge ages employed in this study, 4.3 and 8 days, and can in part be attributed to the superior removals of both biochemical oxygen demand and effluent suspended solids achieved at these sludge ages compared with the lowest sludge age studied, 3.6 days. For both copper and zinc there is an increase in soluble metal across the activated sludge process. However, significant removal of both metals occurs as a consequence of the removal of substantial amounts of insoluble metal. The presence of returned sludge liquors, high in settleable solids, to the mixed liquor appears to moderately enhance the percentage removal of copper and zinc. Membranes used in place of secondary sedimentation also enhance removal of both metals by reducing effluent suspended solids. It is concluded that there is potential for maximizing metal removal by optimization of secondary biological treatment in a sustainable manner, without recourse to energy-intensive or chemically-dependent tertiary treatment technologies.

Influence of prenatal nutrition and obesity on tissue specific fat mass and obesity-associated (FTO) gene expression

The recent discovery of an association between body composition, energy intake and the fat mass and obesity-associated (FTO) gene represents a promising new therapeutic target in obesity prevention. In a well, pre-established large animal model, we investigated the regulation ofFTOgene expression under conditions either leading to obesity or increased risk of obesity related disorders: i) a sedentary ‘Western’ lifestyle and ii) prenatal exposure to nutrient restriction. Pregnant sheep were either fed to fully meet their nutritional requirements throughout gestation or 50% of this amount from early-to-mid gestation. Following weaning, offspring were either made obese through exposure to a sedentary obesogenic environment or remained lean. A significant positive relationship between placentalFTOgene expression and fetal weight was found at 110 days gestation. In both the newborn and adult offspring, the hypothalamus was the major site ofFTOgene expression. HypothalamicFTOgene expression was upregulated by obesity and was further increased by prenatal nutrient restriction. Importantly, we found a strong negative relationship between the hypothalamicFTOgene expression and food intake in lean animals only that may imply FTO as a novel controller of energy intake. In contrast,FTOgene expression in the heart was downregulated in obese offspring born to nutrient restricted mothers. In addition,FTOgene expression was unaffected by obesity or prenatal diet in insulin-dependent tissues, where it changed with age possibly reflecting adaptations in cellular energetic activity. These findings extend information gained from human epidemiology and provide new insights into the regulation ofin vivoenergy metabolism to prevent obesity.

Nitrous oxide emissions for early warning of biological nitrification failure in activated sludge

Experiments were carried out to establish whether nitrous oxide (N2O) could be used as a non-invasive early warning indicator for nitrification failure. Eight experiments were undertaken; duplicate shocks DO depletion, influent ammonia increases, allylthiourea (ATU) shocks and sodium azide (NaN3) shocks were conducted on a pilot-scale activated sludge plant which consisted of a 315 L completely mixed aeration tank and 100 L clarifier. The process performed well during pre-shock stable operation; ammonia removals were up to 97.8% and N2O emissions were of low variability (<0.5 ppm). However, toxic shock loads produced an N2O response of a rise in off-gas concentrations ranging from 16.5 to 186.3 ppm, followed by a lag-time ranging from 3 to 5 h ((0.43-0.71) x HRT) of increased NH3-N and/or NO2(-) in the effluent ranging from 3.4 to 41.2 mg L(-1). It is this lag-time that provides the early warning for process failure, thus mitigating action can be taken to avoid nitrogen contamination of receiving waters.