scholarly journals Patients with Familial Thrombophilia of Unknown Origin Show Low APC Response to In Vivo Thrombin Formation in Stimulated Hemostasis Activity Pattern Evaluation (SHAPE)

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 3647-3647
Author(s):  
Heiko Rühl ◽  
Sara Reda ◽  
Franziska Isabelle Winterhagen ◽  
Christina Berens ◽  
Jens Müller ◽  
...  
Keyword(s):  
Risk Factor ◽  
Board Of Directors ◽  
Research Funding ◽  
Unknown Origin ◽  
Control Group ◽  
Advisory Committees ◽  
Mutation Carriers ◽  
D Dimer ◽  
Thrombin Formation

Background: In a large proportion of patients with unprovoked venous thromboembolism (VTE), no risk factors can be identified. Recently, we have shown that an increased activated protein C (APC) response to in vivo thrombin formation reduces the thrombotic risk of factor V Leiden (FVL) carriers but not of prothrombin G20210A mutation (PTM) carriers. In vivo thrombin formation was triggered by low-dose administration of recombinant activated factor VII (rFVIIa) followed by hemostasis biomarker monitoring. Aim of the present study was to extend this SHAPE approach to patients with thrombophilia of unknown origin. Methods: The study population consisted of 21 subjects with a positive self-history of unprovoked VTE (VTE+) as well as a positive family history, in whom no established thrombophilic risk factor was detectable (thrombophilia of unknown origin, TUO). A second cohort included 27 VTE+ patients tested positive for FVL (n=14) or PTM (n=13). None of the subjects was under anticoagulant treatment at the time of analysis. The control group consisted of 18 healthy volunteers. Blood samples were collected immediately before and during a period of 8 hours following injection of 15 µg/kg rFVIIa. Plasma levels of free thrombin and APC were quantified using oligonucleotide-based enzyme capture assays (OECAs). Prothrombin activation fragment 1+2 (F1+2), thrombin-antithrombin complex (TAT), and D-dimer were measured additionally. Results: Injections of rFVIIa were well-tolerated by all subjects and median D-dimer levels remained within the reference range in all three cohorts. Plasma levels of F1+2 increased after rFVIIa injection, showing no significant differences between the groups. A comparable increase of TAT was observed in both TUO patients and VTE+ mutation carriers, from a median of 21.3 to 51.1 pmol/L (P=.022), and from 21.3 to 43.9 pmol/L, respectively (Figure 1A). Median levels of TAT in the controls and median levels of free thrombin in all cohorts remained below their respective quantifiable limits after rFVIIa injection. APC increased from 0.80 to 3.84 pmol/L (P=.001) in TUO patients, from 1.14 to 5.82 pmol/L (P<10-4) in VTE+ mutation carriers, and from 0.87 to 3.39 pmol/L (P=.001) in the control group. The APC increase was significantly smaller in the TUO cohort than in the VTE+ mutation carriers (P=.019) (Figure 1B). Conclusion: A low APC response to an increased in vivo thrombin formation is a frequent finding among patients with thrombophilia of unknown origin. This finding is in line with previous data suggesting that higher APC levels protect FVL carriers from thrombosis development. The results of the present study further suggest that a low APC response might be an independent risk factor of VTE. Further studies are warranted to identify the factors that modulate the APC response. Disclosures Rühl: Sanofi Genzyme: Honoraria; SOBI: Honoraria; Shire: Honoraria; Bayer: Honoraria; CSL Behring: Honoraria; Grifols: Honoraria. Reda:Shire: Honoraria; Grifols: Honoraria. Winterhagen:SOBI: Honoraria. Berens:Pfizer: Honoraria; Shire: Honoraria; Biotest: Honoraria; CSL Behring: Honoraria; NovoNordisk: Honoraria; Baxter: Honoraria. Müller:Roche: Membership on an entity's Board of Directors or advisory committees; Siemens: Membership on an entity's Board of Directors or advisory committees; Bayer: Membership on an entity's Board of Directors or advisory committees; NovoNordisk: Membership on an entity's Board of Directors or advisory committees. Oldenburg:Grifols: Consultancy, Speakers Bureau; Roche: Consultancy, Speakers Bureau; Bayer: Consultancy, Research Funding, Speakers Bureau; Swedish Orphan Biovitrum: Consultancy, Speakers Bureau; NovoNordisk: Consultancy, Honoraria, Research Funding; Pfizer: Consultancy, Speakers Bureau; Octapharma: Consultancy, Research Funding, Speakers Bureau; Biotest: Consultancy, Research Funding, Speakers Bureau; Chugai: Consultancy, Speakers Bureau; CSL Behring: Consultancy, Research Funding, Speakers Bureau; Takeda (Shire): Consultancy, Research Funding, Speakers Bureau.

scholarly journals Circulating Plasminogen Activator Inhibitor-1 (PAI-1) Is Reduced By In Vivo Thrombin Generation and Subsequent Formation of Activated Protein C (APC)

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 2389-2389
Author(s):  
Sara Reda ◽  
Franziska Isabelle Winterhagen ◽  
Christina Berens ◽  
Jens Müller ◽  
Johannes Oldenburg ◽  
...  
Keyword(s):  
Board Of Directors ◽  
Plasma Levels ◽  
Research Funding ◽  
The Other ◽  
Healthy Controls ◽  
Advisory Committees ◽  
Pai 1 ◽  
D Dimer ◽  
Thrombin Formation

Background: APC has been suggested to contribute to a hyperfibrinolytic state in various acquired coagulation disorders, including coagulopathies induced by trauma and sepsis. However, in vivo evidence for the proposed underlying mechanism of proteolytic degradation of PAI-1 by APC remains inconclusive. Recently, we have shown increased APC generation in response to in vivo thrombin formation in carriers of the factor V Leiden mutation (FVL). In this approach of stimulated hemostasis activity pattern evaluation (SHAPE), in vivo thrombin formation was triggered by low-dose administration of recombinant activated factor VII (rFVIIa). Aim of the present study was to investigate the resulting effects on the fibrinolytic system. Methods: The study population consisted of 30 FVL carriers (thereof 13 with a history of venous thromboembolism) and 15 healthy controls. Blood samples were collected immediately before and during a period of 8 hours following injection of 15 µg/kg rFVIIa. Plasma levels of APC were quantified using an oligonucleotide-based enzyme capture assay (OECA). Other monitored parameters included plasma levels of prothrombin activation fragment 1+2 (F1+2), tissue-type plasminogen (t-PA), PAI-1, plasminogen, α2-antiplasmin, plasmin-α2-antiplasmin complexes (PAP), soluble fibrin monomers, d-dimer, and thrombin-activatable fibrinolysis inhibitor (TAFI). Results: At baseline, FVL carriers showed higher median levels of APC in comparison to the controls (1.39 vs. 0.86 pmol/L, P=.001), higher PAI-1 levels (30.1 vs. 15.3 ng/mL, P=.002) and lower plasminogen levels (94.8 vs. 110.4%, P=6·10-4). The other baseline parameters did not differ significantly. In both cohorts a comparable increase of F1+2 was observed after administration of rFVIIa, whereas APC increased more (P=.004) in FVL carriers (by 6.40 pmol/L) than in healthy controls (by 2.14 pmol/L), Concurrently, median PAI-1 levels decreased more (P=.007) in FVL carriers (by 19.8 pmol/L) than in healthy controls (by 8.0 pmol/L) (Figure 1). TAFI levels decreased temporarily, from 104.8 to 94.4% (P=.007) in FVL carriers and from 105.0 to 92.1% (P=2·10-4) in healthy controls. PAP levels increased from 164 to 209 ng/mL (P<10-4) in FVL carriers and from 154 to 189 ng/mL (P=.023) in the control group. The extent of these changes did not differ between the two cohorts. D-dimer level increased only in FVL carriers, from 0.34 to 0.41 mg/L (P=.008). t-PA and the other parameters did not show significant changes after rFVIIa administration. Conclusion: Increased APC formation rates in FVL carriers were associated with a greater decline of PAI-1 levels in the absence of interfering changes in t-PA levels. These data provide further in vivo evidence that APC down-regulates PAI-1. Overall, the SHAPE approach utilized here does not induce a significant profibrinolytic response, even in patients with thrombophilia. Disclosures Reda: Grifols: Honoraria; Shire: Honoraria. Winterhagen:SOBI: Honoraria. Berens:Pfizer: Honoraria; Shire: Honoraria; Biotest: Honoraria; CSL Behring: Honoraria; Novo Nordisk: Honoraria; Baxter: Honoraria. Müller:NovoNordisk: Membership on an entity's Board of Directors or advisory committees; Bayer: Membership on an entity's Board of Directors or advisory committees; Siemens: Membership on an entity's Board of Directors or advisory committees; Roche: Membership on an entity's Board of Directors or advisory committees. Oldenburg:CSL Behring: Consultancy, Research Funding, Speakers Bureau; NovoNordisk: Consultancy, Honoraria, Research Funding; Bayer: Consultancy, Research Funding, Speakers Bureau; Swedish Orphan Biovitrum: Consultancy, Speakers Bureau; Grifols: Consultancy, Speakers Bureau; Takeda (Shire): Consultancy, Research Funding, Speakers Bureau; Chugai: Consultancy, Speakers Bureau; Roche: Consultancy, Speakers Bureau; Biotest: Consultancy, Research Funding, Speakers Bureau; Octapharma: Consultancy, Research Funding, Speakers Bureau; Pfizer: Consultancy, Speakers Bureau. Rühl:CSL Behring: Honoraria; Bayer: Honoraria; Shire: Honoraria; SOBI: Honoraria; Sanofi Genzyme: Honoraria; Grifols: Honoraria.

scholarly journals Metformin Restores AMPK Alpha-Mediated Autophagy and Prevents Carfilzomib-Induced Cardiotoxicity In Vivo

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 3214-3214
Author(s):  
Georgios Kremastiotis ◽  
Panagiotis Efentakis ◽  
Aimilia Varela ◽  
Constantinos H. Davos ◽  
Maria Tsoumani ◽  
...  
Keyword(s):  
Signaling Pathways ◽  
Board Of Directors ◽  
Molecular Mechanism ◽  
Research Funding ◽  
Steering Committee ◽  
Control Group ◽  
Advisory Committees ◽  
Pp2a Activity ◽  
Travel Grant

Abstract Introduction: Carfilzomib (Cfz) significantly prolongs progression-free survival in relapsed or refractory multiple myeloma patients, as highlighted in the ENDEAVOR trial. However, Cfz has high incidences of cardiotoxicity and heart failure, leading to treatment cessation. Thus, there is an imperative need for preventive therapies. The study aimed to i) establish an in vivo Cfz cardiotoxicity protocol, ii) investigate the molecular mechanism, identify molecular targets and iii) based on initial results, investigate the potential protective effect and mechanism of Metformin (Met). Methods: Male, C57BL/6 mice, were randomized in groups as following: Acute protocol (6 days): Control (n=7), Cfz (n=8); Sub-chronic protocol (14 days): Control (n=5), Cfz (n=8); Pharmacological intervention protocol (6 days): Control (n=8), Cfz (n=8), Cfz+Met (n=8), Met (n=4). Cfz (8 mg/kg, ip) was administered on alternate days and Met (140 mg/kg, po) daily. Glucose levels were monitored following Met administration. Mice underwent echocardiography on baseline and at the end of treatments. Blood and myocardial tissue samples were obtained for histology, proteasome activity, PP2A activity and signaling pathways focused on PI3K/Akt/eNOS axis, NO homeostasis and AMPKα-mTOR-mediated autophagy. Results: Following acute administration, echocardiography in Cfz group presented a significant reduction in fractional shortening (FS%) vs. Control group (39.87±0.47 vs. 43.03±0.50 respectively, p<0.001), combined with reduced thickness in the left ventricular (LV) posterior wall (LVPW diastole (mm): 0.69±0.01 vs. 0.76±0.01, p<0.01; LVPW systole (mm): 1.17±0.01 vs. 1.24±0.02, p<0.01). Sub-chronic Cfz administration resulted in moderate LV dilation (LV end-diastole diameter (mm): 3.24±0.03 vs. 3.04±0.04, p<0.01; LV end-systole diameter (mm): 1.88±0.02 vs. 1.71±0.02, p<0.01) and borderline FS% reduction (42.07±0.46 vs. 43.52±0.25, p<0.05). Following both protocols, Cfz did not cause major tissue lesions. Signaling pathways were studied in the acute protocol that demonstrated suppressed myocardial contractility. Cfz resulted in significant inhibition of proteasome in both myocardium (55.5% inhibition, p<0.05) and peripheral mononuclear blood cells (PBMCs) (90.6% inhibition, p<0.001) - inhibitory effect was comparable to clinical practice. Cfz, independently of PTEN expression, reduced phospho-PI3K (p<0.05), phospho-Akt (p<0.001) and phospho-eNOS (p<0.001), and increased iNOS expression (p<0.01). Cfz reduced phospho-AMPKα (p<0.001) and phospho-Raptor (p<0.05) leading to inhibition of autophagy, indicated by reduced LC3-II expression (p<0.01), without affecting phospho-mTOR or Beclin 1. Co-administration of Met prevented FS% reduction (Cfz group: 41.55±0.43 vs. 43.24±0.50 and 43.39±0.56, Control and Cfz+Met respectively, p<0.05), without exerting glucose lowering actions. Met did not interfere with Cfz-induced proteasome inhibition; Cfz and Cfz+Met groups had significantly reduced proteasomal activity vs. Control group in myocardium (p<0.05) and PBMCs (p<0.001 and p<0.01 respectively). Histology presented mild to moderate vascular congestion in Cfz+Met and Met vs. Control and Cfz groups (p<0.05), appearing to be non-specific finding that did not collocate with haemorrhage, vascular obstruction or tissue lesions. On a molecular level, Cfz+Met group presented increased phospho-Akt (p<0.01) vs. Cfz group, independently of PTEN, PI3K and eNOS/iNOS. Cfz+Met group restored phospho-AMPKα (p<0.05), phospho-Raptor (p<0.001) and LC3-II expression (p<0.05) vs. Cfz group, without inducing changes in mTOR and Beclin 1. Cfz inactivated Akt and AMPKα through increased PP2A activity (p<0.05), without altering PP2A expression; Met did not interfere with PP2A activity. Conclusions: Cfz exhibits decreased global LV function in vivo, without inducing tissue lesions. The molecular mechanism consists of increased PP2A activity leading to inactivation of AMPKα-mTOR and PI3K/Akt/eNOS pathways - combined with NO homeostasis deregulation. In an intervention approach, Met preserved cardiac function via restoring AMPKα-mediated autophagy. Met administration did not restore NO production and homeostasis; these pathways require further investigation. Met emerges to be a promising preventive therapy for Cfz-induced cardiotoxicity. Disclosures Kastritis: Amgen: Consultancy, Honoraria, Research Funding; Genesis Pahrma: Consultancy, Honoraria; Janssen: Consultancy, Research Funding; Takeda: Consultancy, Honoraria; Prothena: Consultancy, Honoraria. Dimopoulos:Takeda: Honoraria; Amgen: Honoraria; Janssen: Honoraria; Celgene: Honoraria; Bristol-Myers Squibb: Honoraria. Terpos:Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: member of steering committee, Research Funding; Takeda: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: travel grant, Research Funding; BMS: Consultancy; Genesis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: travel grant, Research Funding; Novartis: Consultancy; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: member of DMC, Research Funding; Amgen Inc.: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: travel grant, steering committee member, Research Funding.

Selective Inhibition of HDAC6 with a New Prototype Inhibitor (ACY-1215) Overcomes Bortezomib Resistance In Multiple Myeloma (MM)

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 2997-2997
Author(s):  
Loredana Santo ◽  
Teru Hideshima ◽  
Andrew L. Kung ◽  
Matthew Jarpe ◽  
Diana Cirstea ◽  
...  
Keyword(s):  
Board Of Directors ◽  
Research Funding ◽  
Combined Therapy ◽  
Combined Treatment ◽  
Hdac Inhibitors ◽  
Group Versus ◽  
Control Group ◽  
Advisory Committees ◽  
Dose Dependent

Abstract Abstract 2997 HDAC enzymes, whose activity has been linked to the transcription of DNA in several cancers including multiple myeloma (MM), are being studied as novel therapeutic targets. Four classes of HDAC enzymes have been identified and several non-specific pan-HDAC and class I HDAC inhibitors have been evaluated in clinical studies. HDAC6, a class II HDAC, has recently been linked to the activity of aggresomes that degrade unfolded and misfolded ubiquitinated proteins. Importantly, targeting both proteasomal and aggresomal protein degradation systems with proteasome inhibitors and HDAC inhibitors respectively, induces accumulation of polyubiquitinated proteins, followed by activation of apoptotic cascades and synergistic cytotoxocity. Here we investigated the preclinical activity of an HDAC6 selective inhibitor ACY-1215 in MM, either alone or in combination with bortezomib. In vitro enzyme assays showed that ACY-1215 has potent inhibitory activity against HDAC6 (IC50 0.0054 μ M) compared to the other HDACs, including Class I HDACs. Maximal cytotoxicity of ACY-1215 against MM cell lines was observed at 48h, with IC50 values ranging from 2–8 μ M. ACY-1215 was also effective against patient MM cells, including bortezomib resistant MM cells, without significant cytotoxicity in normal peripheral blood mononuclear cells (PBMCs). Moreover, ACY-1215 in a dose-dependent manner inhibited DNA synthesis of MM cells at 48h triggered either by binding to bone marrow stromal cells (BMSCs) or by exogenous IL6 and IGF-1, confirming its ability to overcome the proliferative advantage conferred by BMSCs and cytokines. We next studied whether the highly selective HDAC6 inhibitor ACY-1215 could achieve the same efficacy as a pan-HDAC inhibitor such as SAHA, but with less toxicity. Compared to SAHA, ACY-1215 was not toxic to PHA stimulated PBMCs. Importantly, both ACY-1215 and SAHA induced dose-dependent acetylation of α-tubulin in MM.1S cells, but ACY-1215 induced less potent acetylation of lysine on histone H3 and histone H4 than SAHA, further confirming its specific inhibitory effect on HDAC6 activity. We next combined low doses of ACY-1215 to inhibit aggressomal with bortezomib to inhibit proteasomal protein degradation, and showed synergistic anti MM activity (Combination Index < 0.9), resulting in apoptosis via the activation of caspase-8,-9,-3 and poly (ADP) ribosome polymerase. Annexin V+PI+ staining after 24h treatment confirmed increased cells in early and late apoptosis after combined therapy (83.6%) compared to ACY-1215 1μ M (10.2%) or bortezomib 5 nM (36.6%) treatment alone. Since NF-kB pathway plays a crucial role in MM cell survival and bortezomib triggers NF-κB activity in some MM cell lines, we next investigated the effect of combined therapy on NF-κB activity. MM.1S cells were co-cultured with BMSCs and then treated with bortezomib 5nM, ACY-1215 1μ M, or the combination. Interestingly, bortezomib treatment significantly enhanced NF-κB activity in MM.1S cells co-cultured with BMSCs, whereas ACY-1215 treatment resulted in only a modest increase in NF-κB activity. Importantly, combined therapy was associated with partial abrogation of bortezomib-induced NF-κb activity. Ongoing studies are determining whether this effect on NF-κB activity contributes to the cytotoxic effect of ACY-1215/bortezomib combination therapy. Finally, we confirmed the synergistic anti-MM activity of ACY-1215 and bortezomib in vivo using two different xenograft mouse models: human MM injected subcutaneously (plasmacytoma model); and luciferase-expressing human MM injected intravenously (disseminated MM model). In the, plasmacytoma model, daily (5×/week) dosing of ACY-1215 (IP: 50 mg/kg) and bortezomib (IV: 0.5 mg/kg) given twice weekly significantly inhibited tumor growth (p<0.0001) and prolonged survival (34 days in the combined treatment group versus 22 days in the control group, p<0.0011). In the disseminated MM model, daily (5x/week) dosing of ACY-1215 (IP: 75 mg/kg) and bortezomib (IP: 1.5mg/kg) once weekly significantly inhibited tumor growth (p<0.0001) and prolonged survival (40 days in the combined treatment group versus 17 days in the control group, p<0.0001). Importantly, no significant adverse effects were noted in either in vivo model. These results therefore provide the preclinical rationale for clinical trials of ACY-1215 together with bortezomib in the treatment of MM. Disclosures: Jarpe: Acetylon: Employment. Anderson:MILLENNIUM: Consultancy; CELGENE: Consultancy; NOVARTIS: Consultancy; ONYX: Consultancy; MERCK: Consultancy; BMS: Consultancy; Acetylon: Membership on an entity's Board of Directors or advisory committees. Jones:Acetylon: Employment. Raje:Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy; Astra Zeneca: Research Funding; Acetylon: Research Funding; Amgen: Membership on an entity's Board of Directors or advisory committees.

scholarly journals Carfilzomib-Induced Cardiotoxicity in an In Vivo Model of Aging

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 18-18
Author(s):  
Panagiotis Efentakis ◽  
Garyfallia Psarrakou ◽  
Panagiota-Efstathia Nikolaou ◽  
Michael Chatzistefanou ◽  
Eleni-Dimitra Papanagnou ◽  
...  
Keyword(s):  
Board Of Directors ◽  
Research Funding ◽  
The Elderly ◽  
In Vivo Model ◽  
Control Group ◽  
Myocardial Tissue ◽  
Advisory Committees ◽  
Aged Mice ◽  
Young Mice

Introduction: Carfilzomib (Cfz) is an approved irreversible proteasome inhibitor for the treatment of patients with relapsed/refractory multiple myeloma (R/R MM). Despite remarkable efficacy in R/R MM, Cfz clinical use is hampered by the incidence of cardiotoxicity. Age is recognized as an independent factor for the manifestation of cardiac failure and cardiovascular events. We have previously established a translational in vivo model of Cfz-induced cardiotoxicity, in which metformin (Met) had a potent prophylactic therapy, as it restored AMP-activated kinase α (AMPKα)-dependent autophagy in the myocardium of young mice, which had been inhibited by carfilzomib treatment (Efentakis P et al. Blood. 2019;133(7):710-723). Taking into consideration that MM is primarily a disease of the elderly, we sought to investigate whether our previous findings in young mice could be recapitulated in an aging in vivo model. Methods: Ten young C57Bl/6 mice (12-14 weeks of age) and thirty aged C57Bl/6 mice (15-17 months of age) were randomly assigned as follows: (i) Control group [Normal Saline (N/S) 0.9%, n=6]; (ii) Cfz group (8 mg/kg, n=6); (iii) Met group (140mg/kg, n=6); (iv) Cfz+Met group (8 mg/kg and 140 mg/kg respectively, n=6). N/S and Cfz were administered intraperitoneally on alternate days, while Met was administered per os daily for 7 days. At baseline and at the end of the experiments, mice were anesthetized with isoflurane (2% in 100% O2) and underwent echocardiography in order to investigate cardiac contractility markers (fractional shortening, FS%) and carotid plasticity markers (pulsatility index, PI% and resistance index, RI%). Subsequently mice were sacrificed for blood and myocardial tissue collection. Peripheral blood mononuclear cell (PBMCs), isolated from the whole blood, as well as myocardial tissue underwent proteasome activity assessment. Snap-frozen myocardial tissue underwent molecular immunoblotting analysis for the investigation of the molecular signaling. Results: Aged mice did not show any decreased proteasomal activity neither in the PBMCs or in the myocardium versus young C57Bl/6 mice. Cfz decreased proteasomal activity both in the PBMCs and the myocardium independently of Met administration. Aged mice presented a significant reduction of the FS% compared to the young mice at baseline, which represents an already established cardiac dysfunction in the elderly mice (mean FS%±SD: 37.40±1.6 vs. 45.62±0.8, respectively, p&lt;0.005). In compliance with our previous findings in young C57Bl/6 mice, Cfz deteriorated the already present cardiac dysfunction in aged mice versus controls (mean FS%±SD: 28.2±1.8 vs. 37.8±1.8, respectively, p&lt;0.05). Cfz+Met co-administration in elderly mice showed a marginal increase in terms of FS% compared to Cfz only treated mice (mean FS%±SD: 32.60±2.1 vs. 28.2±1.8, respectively), while FS% in the Cfz+Met group continued to be lower compared to control group (32.60±2.1 vs. 37.8±1.8). Assessment of the carotid stiffness revealed that Cfz sub-acute treatment led to a decrease in PI% compared to controls (p&lt;0.05), while no changes in RI% were observed among groups, indicating a Cfz-induced vascular hypo-contraction in the elderly mice. Molecular analysis of the myocardial tissues showed that Cfz led to a decreased AMPKα and Protein Kinase B (Akt) phosphorylation, while Met restored AMPKα phosphorylation and increased endothelial nitric oxide synthase (eNOS) and Akt expression in the Cfz+Met co-administration group. Conclusion: Cfz induced cardiotoxicity in this aged murine model, in accordance with our previous findings in the young mice. Additionally, sub-acute Cfz treatment leads to a decrease in pulsatility capacity of the vessels, possible leading to vascular hypo-contraction in vivo. Co-administration with metformin exerts cardioprotection, even in the elderly mice, in an AMPKα-dependent manner. The latter is of great clinical significance as it further supports the translational value of metformin as a potent prophylactic therapy against Cfz-induced cardiotoxicity. Disclosures Efentakis: Amgen: Research Funding. Kastritis:Amgen: Consultancy, Honoraria, Research Funding; Janssen: Consultancy, Honoraria, Research Funding; Genesis Pharma: Consultancy, Honoraria; Takeda: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria. Dimopoulos:BMS: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Personal fees; Takeda: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Personal fees, Research Funding, Speakers Bureau; Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Personal fees, Research Funding, Speakers Bureau; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Personal fees, Speakers Bureau; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Personal fees, Research Funding, Speakers Bureau. Andreadou:Amgen: Research Funding. Terpos:Genesis: Honoraria, Other: Travel expenses, Research Funding; Celgene: Honoraria; Sanofi: Honoraria; BMS: Honoraria; Amgen: Honoraria, Research Funding; Janssen: Honoraria, Research Funding; Takeda: Honoraria, Other: Travel expenses, Research Funding.

scholarly journals Favorable Long-Term Outcomes after Daratumumab Discontinuation in AL Amyloidosis Patients Achieving Deep Responses

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 1884-1884 ◽  
Author(s):  
Alfred Chung ◽  
Gregory P. Kaufman ◽  
Surbhi Sidana ◽  
David Iberri ◽  
Erik Eckhert ◽  
...  
Keyword(s):  
Disease Progression ◽  
Board Of Directors ◽  
Median Duration ◽  
Research Funding ◽  
Control Group ◽  
Al Amyloidosis ◽  
Cell Transplant ◽  
Advisory Committees ◽  
Free Interval ◽  
Significant Difference

Daratumumab (DARA) is a CD38-targeted antibody FDA-approved for the treatment of multiple myeloma (MM) and its efficacy has recently been demonstrated in the treatment of AL amyloidosis. DARA is conventionally given indefinitely until evidence of disease progression or intolerance for the treatment of MM. In AL amyloidosis, the optimal duration of therapy is not known, and patients may be treated indefinitely on maintenance, extrapolating from MM data. However, the plasma cell burden observed in AL amyloidosis is often lower than in MM, and thus certain patients achieving deep responses may have durable responses with time-limited treatment. Outcomes for patients who are observed after DARA discontinuation are not known. We report the outcomes of patients at our institution who received time-limited DARA. A retrospective analysis of AL amyloidosis patients treated at Stanford University from 2016 to 2019 with DARA monotherapy and dexamethasone for at least 2 months was performed, and patients who subsequently had DARA discontinued for reasons other than disease progression or lack of response were selected for the study. Hematologic responses were assessed by consensus guidelines. Duration on and off therapy were explored, along with time-to-next treatment or death (TTNT), defined as the time from DARA initiation to restarting/switching therapy or death. An exploratory analysis comparing TTNT between the study population and a control cohort who achieved hematologic CR and were maintained on DARA was conducted with the Kaplan-Meier method and log-rank testing. 67 patients received at least 2 months of DARA monotherapy and dexamethasone; among these, 15 patients discontinued therapy for reasons other than disease progression and were included. Median age was 66 years old and median lines of prior therapies was 4 (range: 1 - 6). Baseline difference between involved and uninvolved free light chains (dFLC) prior to DARA initiation was 2.6 mg/dL (range: 0 - 16.8 mg/dL). 10 of 15 patients had cardiac involvement with median NT-proBNP of 1982 pg/mL and 9 of 15 patients had renal involvement with median 24-hour proteinuria of 6.2 g and eGFR of 32 mL/min/1.73m2 at DARA initiation. Median duration from starting to stopping DARA was 7.8 months (range: 2 - 21 months). Median duration from achieving best hematologic response to stopping DARA was 3 months (range: 0 - 17 months). Reasons for discontinuation included: patient preference (5), fatigue/body aches (4), infection (2), other active medical comorbidities (3), and lack of perceived further benefit (1). At DARA discontinuation, median dFLC was 0.1 mg/dL (range: 0 - 2.2 mg/dL) and there were 12 hematologic CR, 1 VGPR, 1 PR, and 1 not assessable for response. Outcomes for all 15 patients are shown in Figure 1. The median treatment-free interval was 17.5 months (range: 5 - 34 months); estimated 2-year TTNT-free survival was 83% (95% CI: 61 - 100%). All 14 evaluable patients eventually achieved CR. 3 patients restarted DARA for rising dFLC, and all 3 patients demonstrated response to retreatment (2 achieving CR and 1 near PR with ongoing follow-up). There were 2 deaths. One patient with severe baseline cardiac amyloidosis developed sudden rise in dFLC after treatment-free interval of 21 months; although he rapidly achieved hematologic CR on retreatment, he died of heart failure within 2 months of restarting DARA. The other patient developed therapy-related AML while off therapy and underwent allogenic stem cell transplant but died of leukemia (censored for AL amyloidosis outcomes at transplant). There was no significant difference in the TTNT between the study group and a control group of 16 patients who achieved CR and were on continuous maintenance (Figure 2; p=0.807). AL amyloidosis patients achieving deep responses with DARA can have favorable outcomes after treatment discontinuation, including a long treatment-free interval. Although our sample size is small, the outcomes of these patients appeared comparable to those achieving CR on continuous DARA maintenance, and patients were able to regain responses when retreatment was necessary. These results suggest that DARA may be safely discontinued in patents achieving deep hematologic responses, which has significant implications for quality of life and financial burden of treatment. Future studies evaluating time-limited versus continuous DARA maintenance after achievement of deep responses are warranted. Disclosures Kaufman: Janssen: Other: travel/lodging, Research Funding. Liedtke:Janssen: Membership on an entity's Board of Directors or advisory committees, Research Funding; Takeda: Membership on an entity's Board of Directors or advisory committees, Research Funding; Prothena: Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; IQVIA/Jazz: Membership on an entity's Board of Directors or advisory committees; Gilead: Membership on an entity's Board of Directors or advisory committees, Research Funding; Genentech/Roche: Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; Celator: Research Funding; Caelum: Membership on an entity's Board of Directors or advisory committees; BlueBirdBio: Research Funding; Amgen/Onyx: Consultancy, Honoraria, Research Funding; Agios: Research Funding; Adaptive: Membership on an entity's Board of Directors or advisory committees. OffLabel Disclosure: Daratumumab for treatment of AL amyloidosis

scholarly journals Management of Secondary Prevention in Venous Thromboembolism: Use of Reduced Doses of Rivaroxaban and Apixaban in Extended Therapy

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 16-17
Author(s):  
Desiree Campoy ◽  
Katia Flores ◽  
Gonzalo Artaza ◽  
César A Velasquez ◽  
Tania Canals ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Secondary Prevention ◽  
Board Of Directors ◽  
Dose Reduction ◽  
Standard Dose ◽  
Control Group ◽  
Advisory Committees ◽  
The Mean ◽  
D Dimer

BACKGROUND After a standard anticoagulation period (3-6 months), the risk of venous thromboembolism recurrence (RVTER) needs to be considered. Such risk is higher in unprovoked events and patients with persistent risk factor. The increase of D-dimer (DD) levels during the therapy seems to be strongly associated to RVTER. The use of rivaroxaban 10 mg/day and apixaban 2.5mg/12h as an extended therapy (ET) after the standard anticoagulation period has been proven to be an effective strategy to prevent recurrence without increasing bleeding events. AIM To assess the effectiveness and safety of reduced doses of rivaroxaban and apixaban as ET in patients with RVTER and to compare their DD levels with those of a control group on anticoagulant therapy at a standard dose. METHODS From April 2016 to June 2020, we included patients with venous thromboembolism (VTE) who received ET with rivaroxaban and apixaban with/at reduced doses. Dose reduction was performed following the clinical algorithm of our unit (Fig. 1). The DD values were determined using HemosIl D-Dimer HS-500 and the cut-off value was established at 500 µg/L DD levels were compared with a control group of 235 patients with VTE who received ET with standard doses of anticoagulation. DD levels were measured at the time of diagnosis (D1), initiation of treatment (D2) and 3 months after treatment (D3). RESULTS From a total of 116 patients (65.5% women), 77.6% (n=90) received rivaroxaban 10 mg/24h and 22.4% received apixaban 2.5 mg/12h as an ET. The mean duration of the initial anticoagulant therapy was 12 +/- 8.8 months. The mean DD value prior to the ET was 388 µg/L. In this group, 63.8% (n=74) was an unprovoked VTE and 17.2% (20) had hereditary thrombophilia. The mean of follow-up time was 6.9 +/- 8.3 months. No recurrences of VTE were observed during the follow-up and only one major bleeding event was reported in a high-bleeding risk patient. We observed a progressive decrease of DD levels from the VTE diagnosis to the last visit, with D1, D2, and D3 values of 987 µg/L ± 324, 388 µg/L ± 134, and 288 µg/L ± 98, respectively. There were no differences in d-dimer concentrations between patients with reduce doses of rivaroxaban or apixaban and the control group with standard doses (D1: 85.6% vs 81%, p =0.22; D2: 10.2% vs 8.0%, p =0.14; and D3: 9.1% vs 9.5%, p =0.18). CONCLUSIONS Our data indicated that an ET strategy with reduced doses of rivaroxaban or apixaban is effective and safe. We did not observe significant differences in DD levels at follow-up compared to the control group receiving a standard dose of anticoagulation. Further studies are needed in order to select and standardize dose reduction criteria in secondary prevention. Figure 1 Disclosures Campoy: boehringer ingelheim: Consultancy; Daiichi Sankyo: Speakers Bureau. Sierra:Pfizer: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Jazz Pharmaceuticals: Research Funding; Astellas: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Roche: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Gilead-Kite: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Daiichi Sankyo: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Abbvie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Olivera:Daiichi Sankyo: Consultancy, Speakers Bureau; Pfizer: Consultancy, Speakers Bureau; Boehringer Ingelheim: Consultancy, Speakers Bureau; BAYER: Consultancy.

Inhibition of Chronic Myeloid Leukemia Stem Cells by the Combination of the Hedgehog Pathway Inhibitor LDE225 with Nilotinib

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 514-514 ◽  
Author(s):  
Bin Zhang ◽  
David Irvine ◽  
Yin Wei Ho ◽  
Silvia Buonamici ◽  
Paul Manley ◽  
...  
Keyword(s):  
Stem Cells ◽  
Board Of Directors ◽  
Colony Formation ◽  
Research Funding ◽  
Leukemia Stem Cells ◽  
Advisory Committees ◽  
Nsg Mice ◽  
Cd34 Cells ◽  
Hh Signaling

Abstract Abstract 514 Background: Tyrosine kinase inhibitors (TKI), although effective in inducing remissions and improving survival in CML patients, fail to eliminate leukemia stem cells (LSC), which remain a potential source of relapse on stopping treatment. Additional strategies to enhance elimination of LSC in TKI-treated CML patients are required. The Hedgehog (Hh) pathway, important for developmental hematopoiesis, has been shown to be activated in BCR-ABL-expressing LSC, in association with upregulation of Smoothened (SMO), and contributes to maintenance of BCR-ABL+ LSC. However the role of Hh signaling in chronic phase (CP) CML LSC is not clear. LDE225 (LDE, Novartis Pharma) is a small molecule SMO antagonist which is being clinically evaluated in patients with solid tumors. We have reported that LDE does not significantly affect proliferation and apoptosis of primary CP CML CD34+ cells, or reduce colony growth in CFC assays, but results in significant reduction in CML CFC replating efficiency and secondary colony formation. Treatment with LDE + Nilotinib resulted in significant reduction in colony formation from CD34+ CML cells in LTCIC assays compared to Nilotinib alone or untreated controls. These observations suggest that LDE may preferentially inhibit growth of primitive CML progenitors and progenitor self-renewal. We therefore further investigated the effect of LDE on growth of primitive CML LSC in vivo. Methods and Results: 1) CP CML CD34+ cells were treated with LDE (10nM), Nilotinib (5μ M) or LDE + Nilotinib for 72 hours followed by transplantation into NOD-SCID γ-chain- (NSG) mice. Treatment with LDE + Nilotinib resulted in reduced engraftment of CML CD45+ cells (p=0.06) and CD34+ cells (p=0.02) compared with controls, and significantly reduced engraftment of CML cells with CFC capacity (p=0.005). In contrast LDE or Nilotinib alone did not reduce CML cell engraftment in the bone marrow (BM) compared with untreated controls. LDE, Nilotinib, or LDE + Nilotinib treatment did not significantly inhibit engraftment of normal human CD34+ cells in NSG mice compared to controls. 2) We also used the transgenic Scl-tTa-BCR-ABL mouse model of CP CML to investigate the effect of in vivo treatment with LDE on CML LSC. BM cells from GFP-SCL-tTA/BCR-ABL mice were transplanted into wild type congenic recipients to establish a cohort of mice with CML-like disease. Recipient mice developed CML-like disease 3–4 weeks after transplantation. Transplanted CML cells were identifiable through GFP expression. Mice were treated with LDE225 (80mg/kg/d by gavage), Nilotinib (50 mg/kg/d by gavage), LDE + Nilotinib, or vehicle alone (control) for 3 weeks. Treatment with Nilotinib, LDE, and LDE + Nilotinib resulted in normalization of WBC and neutrophil counts in peripheral blood. LDE + Nilotinib treatment significantly reduced the number of splenic long term hematopoietic stem cells (LT-HSC, Lin-Sca-1+Kit+Flt3-CD150+CD48-, p<0.01) and granulocyte-macrophage progenitors (GMP) compared to controls, but did not significantly alter LT-HSC numbers in the BM. LDE alone reduced splenic LT-HSC but not GMP, whereas Nilotinib alone did not reduce LT-HSC numbers in spleen or BM but significantly reduced splenic GMP numbers. The mechanisms underlying enhanced targeting of LSC in the spleen compared to the BM are not clear but could reflect greater dependence on Hh signaling in the context of the splenic microenvironment and/or relocalization of LDE treated LT-HSC to BM. Experiments in which BM and spleen cells from treated mice were transplanted into secondary recipients to determine functional stem cell capacity of remaining LT-HSC are ongoing. Importantly mice treated with LDE + Nilotinib demonstrated enhanced survival on follow up after discontinuation of treatment compared with control mice or mice treated with LDE or Nilotinib alone. Conclusions: We conclude that LDE225 can target LSC from CP CML patients and in a transgenic BCR-ABL model of CP CML, and that LDE + Nilotinib treatment may represent a promising strategy to enhance elimination of residual LSC in TKI-treated CML patients. Disclosures: Buonamici: Novartis: Employment. Manley:Novartis: Employment. Holyoake:Novartis: Consultancy, Research Funding. Copland:Novartis Pharma: Honoraria, Research Funding; Bristol-Myers Squibb: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees. Bhatia:Novartis: Consultancy, Honoraria.

Dose Dependent Enhancement Of Neutrophil Recovery By Infusion Of Notch Ligand Ex Vivo Expanded Cord Blood Progenitors: Results Of a Multi-Center Phase I Trial

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 297-297 ◽  
Author(s):  
Colleen Delaney ◽  
Filippo Milano ◽  
Ian Nicoud ◽  
Shelly Heimfeld ◽  
Chatchada Karanes ◽  
...  
Keyword(s):  
Board Of Directors ◽  
Research Funding ◽  
Graft Failure ◽  
Ex Vivo ◽  
Chronic Gvhd ◽  
Advisory Committees ◽  
Neutrophil Recovery ◽  
Cd34 Cells ◽  
Primary Graft Failure

Abstract Introduction There is a strong clinical need to overcome the increased early non relapse mortality (NRM) associated with delayed neutrophil recovery following cord blood transplant (CBT). Therefore we established a methodology using Notch ligand (Delta1) as a strategy for increasing the absolute number of marrow repopulating CB hematopoietic stem/progenitor cells (HSPC). We previously reported preliminary results of the first 10 patients in 2010 demonstrating the ability of Notch-expanded CB HSPC to provide rapid myeloid recovery post-CBT.1 Herein we present the updated results on 23 patients accrued to this trial aimed at assessment of efficacy as well as the feasibility of overnight shipment of the expanded cell product to three outside institutions. Methods Between July 2006 and March 2013, 23 patients with hematologic malignancies were enrolled in this prospective multi-center Phase I trial coordinated by the Fred Hutchinson Cancer Research Center in which one CB unit was ex vivo expanded prior to infusion. Conditioning consisted of Fludarabine (75mg/m2), Cyclophosphamide (120mg/kg) and TBI (13.2 Gy) over 8 days. On day 0, the unmanipulated CB unit was infused first followed 4 hours later by infusion of the freshly harvested expanded CB cells. Graft versus host disease (GVHD) prophylaxis consisted of cyclosporine and MMF beginning on day -3. All CB grafts were 4-6/6 HLA-matched (A/B antigen level, DRB1 allele level) to the recipient. Engraftment, NRM, relapse and GVHD were calculated using cumulative incidence rates to accommodate competing risks. Overall survival was analyzed using Kaplan-Meier estimates. Results Patient diagnosis was AML (n=16), ALL (n=5) and biphenotypic leukemia (n=2). Nine patients (39%) were ≥CR2 and 5 were MRD+ at the time of transplant. Median age was 28 years (range, 4-43) and weight 70 kg (range, 16-91) with a median follow-up of 614 days (range, 271-2443). 22 patients received the expanded graft with one product not meeting release criteria. The cell doses infused were significantly higher in the expanded CB graft: 2.7 (1.5-6.3) vs 6.9 (0.4-27.6) x107 TNC/kg, p<0.0008; 0.15 (0.02-0.57) vs 7.7 (0.62-49.5) x106 CD34/kg, p<0.0001. HLA-matching and ABO incompatibility of the expanded and unmanipulated products were similar. The incidence of neutrophil recovery was 95% (95% CI, 71-100) at a median of 13 days (range, 6-41 days) among the 22 patients receiving expanded CB cells which is significantly faster than that observed in 40 recipients of two unmanipulated units otherwise treated identically at a median time of 25 days (range, 14 to 45; p<0.0001). The incidence of platelet recovery (>20 x 10^9/L) was 77% (CI 95%: 53- 89) by day 100 at a median of 38 days (range, 19 – 134). There was one case of primary graft failure. Importantly, rate of neutrophil recovery correlated with CD34+ cell dose/kg with 8 out of 11 patients receiving greater than 8x106 CD34+cells/kg achieved an ANC ≥ 500/µl within 10 days. 21 patients were evaluable for in vivo persistence of the expanded cells. Ten (48%) demonstrated in vivo persistence beyond one month post infusion. The expanded cell graft was persistent at day 180 in 7 patients, and in those that survived to one year, dominance of the expanded cell graft persisted in one patient. The incidences of grade II-IV and III-IV acute GVHD was 77% (95% CI, 53-89) and 18% (95% CI, 5-36%), respectively; mild chronic GVHD was observed in 4 patients and severe chronic GVHD in one. Probability of OS was 62% (95% CI, 37-79%) at 4 years. Notably, the cumulative incidence of NRM at day 100 was 8% (95% CI, 14-24%) and at 4 years was 32% (95% CI, 8-40%). Nine patients died at a median time of 216 days (range, 31-1578 days) with respiratory failure/infection the most common cause (n=6). There were two relapses at day 156 and 365 post-transplant, with one death due to relapse. Secondary malignancy and primary graft failure were the other 2 causes of death. Conclusions Infusion of Notch-expanded CB progenitors is safe and effective, significantly reducing the time to neutrophil recovery and risks of NRM during the first 100 days. An advantage for infusion of higher numbers of CD34+ cells/kg further demonstrates the need to develop methods that reproducibly provide even greater expansion of repopulating cells than currently achieved to improve efficacy and potentially cost effectiveness. 1. Delaney C, et al, Nat Med. 2010 Feb;16(2):232-6. Disclosures: Delaney: Novartis: DSMB, DSMB Other; Biolife: Membership on an entity’s Board of Directors or advisory committees; medac: Research Funding. Wagner:Novartis: Research Funding; cord use: Membership on an entity’s Board of Directors or advisory committees.

Clinical and Economic Burden Of Peripheral T-Cell Lymphoma In The United States

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 2963-2963
Author(s):  
Michele H. Potashman ◽  
Chakkarin Burudpakdee ◽  
Weiying Wang ◽  
Yanyan Zhu ◽  
Kenneth R. Carson
Keyword(s):  
Board Of Directors ◽  
Economic Burden ◽  
Research Funding ◽  
Index Date ◽  
The United States ◽  
Control Group ◽  
Pharmacy Services ◽  
Office Visits ◽  
Peripheral T Cell Lymphoma ◽  
Advisory Committees

Abstract Background Peripheral T-cell lymphoma (PTCL) is an aggressive and heterogeneous subtype of non-Hodgkin lymphoma (NHL). PTCL has a poor prognosis due to advanced stage at presentation, and generally poor response to standard chemotherapy. According to recent SEER estimates, PTCL accounts for about 4% of all NHL cases in the United States each year. To date, few studies have assessed the clinical and economic burden of PTCL. Methods MarketScan data for commercially insured and Medicare supplemental patients were used to retrospectively identify unique PTCL patients. Patients were identified by ICD-9-CM diagnosis codes between October 1, 2007 and June 30, 2011. The time of first PTCL diagnosis code served as the index date, and a second PTCL diagnosis date was used for confirmation. All patients were required to have at least 6 months of continuous enrollment before and 12 months of continuous enrollment after their index date. Patients were excluded if aged <18 years, date of birth or gender were missing, or if they had received a stem cell transplant (SCT) prior to PTCL diagnosis. The control group includes patients that may have any other malignant (excluding PTCL) or non-malignant condition and are considered to represent an average insured patient population from the payer perspective. The control group was matched based on age, sex, region, plan type, payer type, and length of enrollment. Mean cost per month was measured and annualized to provide average yearly costs. Healthcare costs included hospitalizations, pharmacy services, office visits, emergency room visits, hospice stays, SCT, and other patient-related costs (lab procedures, radiology procedures, blood transfusions, and other ancillary procedures). Results Of 2820 patients with ≥1 PTCL diagnosis, 1000 patients were identified that met all inclusion criteria (mean age 56 years, 58% male), and were matched to the control group. On an average annual basis, PTCL patients were hospitalized more often (0.9 vs 0.1 hospitalizations), and experienced a longer length of stay (6.4 vs 4 days) compared with matched controls. In addition, PTCL patients had a higher utilization of office visits (16.2 vs 4.1 visits), pharmacy services (34.2 vs 11.6 prescriptions), emergency room visits (0.8 vs 0.2 visits), and hospice care (0.6 vs 0.1 stays). PTCL patients also experienced higher comorbidities (mean Charlson Comorbidity Index of 1.72 vs 0.39, as determined at index date). Overall, PTCL patients incurred much higher average annual costs compared with matched patients ($75,934.08 vs $4660.64; Table), driven mainly by hospitalizations (32.2% of overall costs) and pharmacy services (19.6% of overall costs). Conclusions PTCL is associated with high resource utilization rates and high overall costs. The development of efficacious treatments for PTCL may offer better disease management and may reduce the clinical and economic burden of PTCL. Disclosures: Potashman: Millennium: The Takeda Oncology Company: Employment. Burudpakdee:Millennium: The Takeda Oncology Company: Consulting researcher Other. Wang:Millennium: The Takeda Oncology Company: Consulting researcher Other, Research Funding. Zhu:Millennium: The Takeda Oncology Company: Employment. Carson:Millennium: The Takeda Oncology Company: Consultancy, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Celgene: Consultancy, Membership on an entity’s Board of Directors or advisory committees; Spectrum, Inc.: Membership on an entity’s Board of Directors or advisory committees, Research Funding; Kyowa Hakko Kirin Pharma, Inc.: Research Funding.

scholarly journals Update of Multicenter, Retrospective Evaluation of Overall Response and Failure Free Survival Following Ruxolitinib Therapy for Heavily Pre-Treated Chronic Gvhd Patients with Steroid-Failure: A Proposal of Risk Score Model for Failure-Free Survival

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 3905-3905
Author(s):  
Jennifer White ◽  
Mohamed Elemary ◽  
Swe Mar Linn ◽  
Igor Novitzky-Basso ◽  
Anargyros Xenocostas ◽  
...  
Keyword(s):  
Risk Factor ◽  
Board Of Directors ◽  
Risk Score ◽  
Research Funding ◽  
Chronic Gvhd ◽  
Organ Involvement ◽  
Advisory Committees ◽  
Prednisone Dose ◽  
Free Survival ◽  
Overall Response

Abstract Background The REACH3 trial evaluating Ruxolitinib (RUX) treatment for steroid-refractory chronic GVHD concluded that RUX leads to significantly greater overall response and failure-free survival (FFS) than best available therapies (NEJM 2021). We reported a real-world experience of RUX in 47 chronic GVHD (cGVHD) patients, with 36% overall response rate (ORR) at 6 months (ASH 2020). The present study expanded this to 115 pts, evaluating ORR, FFS and overall survival (OS), and explored prognostic factors associated with clinical outcomes. Patients and methods A total of 115 patients treated with RUX for cGVHD from 2016 to 2021 at 5 sites were evaluated retrospectively. Patients and disease characteristics are as follows: median age 57.5 years; males 67 (60%); organ involvement at the time of RUX: skin 75.7%, mouth 51.3%, eye 42.6%, gastrointestinal 19.1%, liver 39.1%, lung 31.3%, and musculoskeletal 38.3%. Out of 108 pts with available HCT-CI prior to HCT, 29 pts (26.9%) had HCT-CI score 3 or higher, while 79 (73.1%) had HCT-CI score 0-2. The ORR were assessed at months 3, 6 and 12, retrospectively. Treatment failure was defined as 1) resistance requiring treatment switch, 2) non-relapse mortality (NRM), 3) relapse, 4) intolerance to treatment. FFS and OS were calculated from the day of starting RUX therapy for cGVHD treatment. For risk factor analysis, logistic regression was adopted for ORR at 6 months, while Cox's proportional hazard model was implemented for FFS and OS at 12 months. The following variables were evaluated for risk factor analysis: GVHD-related factors (cGVHD severity, no. of organ involvement, prednisone dose or RUX dose at start, previous history of acute GVHD); host factors (age or performance status at RUX starts, sex, HCT-CI comorbidity score pre-HCT); transplant factors (conditioning intensity; donor type, HLA match, T-cell depletion). From those variables identified as significant in the multivariate analysis, a prognostic risk score was generated as the sum of adverse risk factor scores. Results A total of 115 pts had severe (n=69, 60%) or moderate grade (n=44, 38.3%) cGVHD except 2 (1.7%) who had mild grade cGVHD with high-risk features. The median number of organ involvement was 3 (range 1-7). 96 pts (84.2%) received RUX as 4 th line or beyond for cGVHD treatment. The previous treatments included mycophenolate mofetil (n=46, 40.0%), extracorporeal photopheres (n=45, 39.1%), Imatinib (n=13, 11.3%), and Ibrutinib (n=9, 7.8%). RUX was started at 10-20 mg daily as the initial dose, then maintained at 20mg daily in two divided doses on months 3, 6 and 12. With a median follow-up duration of 12 months, ORR was attained in 46.8%, 61.8% and 62.3% at 3, 6 and 12 months, similar to 49.7% ORR rate at 6 months in the REACH3 study. ORR in the range of 48.1-64.5% at 6 months was observed across all the organs involved. No difference in ORR was noted between steroid-resistant vs steroid-dependent cGVHD, or according to previous treatment with TKI drug for GVHD. For ORR, severe grade cGVHD showed a lower ORR rate at 46.8% at 6 months compared to those with moderate/mild grade cGVHD at 81.1% (p=0.001). In terms of prednisone dose reduction, by 12 months, more than half of pts (63.8%) could taper prednisone doses below 0.1mg/kg/day, while the proportion of pts on prednisone dose below 0.1mg/kg/day was 14.83%, 33.6%, 47.6%, and 63.8% at month 0, 3, 6 and 12, respectively. A total of 39 failures (33.4%) were noted, including resistance requiring switch to other therapy (n=17), NRM (n=14), relapse of primary disease (n=3) and intolerance (n=5). The FFS rate in the overall population was 64.6% (54.1-73.2), while the OS rate was 83.3% (74.4-89.4%) at 12 months. For FFS, two risk factors were identified for FFS (Figure): 1) Severe grade cGVHD at RUX start (p=0.008, HR 2.496 [1.229-5.072]); 2) HCT-CI comorbidity 3 or higher (p=0.001, HR 2.802 [1.493-5.259]). When a risk score model was generated, it stratified pts according to the FFS at 12 months (p=0.0001): 85.8% in score 0 (n=32); 58.7% in score 1 (n=57); and 36.8% in score 2 (n=19). Conclusion: Updated results confirm that RUX is an effective treatment option for cGVHD pts, even including heavily treated pts. Also, favorable response was observed across all organs involved with GVHD. Failure of RUX is associated with cGVHD severity and HCT-CI score. Figure 1 Figure 1. Disclosures White: Novartis: Honoraria. Elemary: Jazz, BMS, Abbvie, Novartis, Pfiz: Membership on an entity's Board of Directors or advisory committees; Pfizer, Janssen: Membership on an entity's Board of Directors or advisory committees. Hamad: Novartis: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Law: Novartis: Consultancy; Actinium Pharmaceuticals: Research Funding. Mattsson: MattssonAB medical: Current Employment, Current holder of individual stocks in a privately-held company. Kim: Novartis: Consultancy, Honoraria, Research Funding; Pfizer: Honoraria; Paladin: Consultancy, Honoraria, Research Funding; Bristol-Meier Squibb: Research Funding. OffLabel Disclosure: This presentation discusses the use of ruxolitinib for chronic GVHD. This indication is under FDA review.

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