Anakinra Treatment Research Articles

Erlotinib-Induced Skin Inflammation Is IL-1 Mediated in KC-Tie2 Mice and Human Skin Organ Culture

Epidermal growth factor receptor (EGFR) is the prototypical member of the ErbB network comprised of four transmembrane receptor tyrosine kinases (EGFR/ErbB1, ErbB2, ErbB3, and ErbB4). These receptors bind EGF and heregulin family ligands in a dynamic, feedback-regulated fashion, activating multiple signal transduction pathways and ultimately affecting many cellular functions (Avraham and Yarden, 2011; Wilson et al., 2009). ErbB receptors and their ligands are overexpressed in a wide spectrum of hyperplastic epithelial disorders including psoriasis and cancers. Numerous monoclonal antibodies and receptor tyrosine kinase inhibitors have been designed to block their activation (Yarden and Pines, 2012), and are highly effective for treating colorectal and non-small cell lung cancers. However, skin toxicity is frequently observed in patients undergoing therapy with EGFR inhibitors (EGFRIs) (Lacouture, 2006), including papular and pustular eruptions of the face and trunk, nail changes, dry skin, itch, and hair loss (Lacouture and Lai, 2006). These side-effects are the major dose-limiting toxicity of EGFRI therapy (Boone et al., 2007) and emphasize the importance of understanding the mechanisms involved.

Anakinra for the treatment of acute severe gout in critically ill patients

ObjectivesTo report on the efficacy and safety of anakinra for treatment of acute gouty arthritis in medically complex, critically ill patients. MethodsRetrospective chart review of 13 critically ill hospitalized patients treated with anakinra for 20 episodes of acute gouty arthritis between 2009 and 2014 at a single health plan and institution (HealthPartners Medical Group and Regions Hospital) in Saint Paul, Minnesota. Data was obtained on baseline characteristics, medical comorbidities, reason for hospitalization, prior gout treatment, reason for choosing anakinra over standard therapy, anakinra dosing, response to treatment, and adverse outcomes. ResultsA total of 10 patients were in the Intensive Care Unit, 1 was in the Burn Unit for extensive 3rd degree burns, 1 was critically ill with a new diagnosis of hemophagocytic lymphohistiocytosis, and 1 was critically ill in isolation with active disseminated multidrug-resistant tuberculosis. Of these patients, 85% had active infections and 92% had renal insufficiency. All patients had a significant response to anakinra treatment: 50% (10/20 episodes) within 24h, an additional 40% (8/20 episodes) by 48h, and the remaining 10% (2/20 episodes) by 72h. Anakinra was well tolerated with only 1 case of leukopenia and 1 possible infectious complication. ConclusionsAnakinra is a safe and efficacious treatment for acute gouty arthritis in medically complex, critically ill patients when standard treatment modalities cannot be used.

Role of Interleukin-1 in Radiation-Induced Cardiomyopathy.

Thoracic X-ray therapy (XRT), used in cancer treatment, is associated with increased risk of heart failure. XRT-mediated injury to the heart induces an inflammatory response leading to cardiomyopathy. The aim of this study was to determine the role of interleukin (IL)-1 in response to XRT injury to the heart and on the cardiomyopathy development in the mouse. Female mice with genetic deletion of the IL-1 receptor type I (IL-1R1 knockout mice [IL-1R1 KO]) and treatment with recombinant human IL-1 receptor antagonist anakinra, 10 mg/kg twice daily for 7 d, were used as independent approaches to determine the role of IL-1. Wild-type (wt) or IL-1R1 KO mice were treated with a single session of XRT (20 or 14 gray [Gy]). Echocardiography (before and after isoproterenol challenge) and left ventricular (LV) catheterization were performed to evaluate changes in LV dimensions and function. Masson's trichrome was used to assess myocardial fibrosis and pericardial thickening. After 20 Gy, the contractile reserve was impaired in wt mice at d 3, and the LV ejection fraction (EF) was reduced after 4 months when compared with sham-XRT. IL-1R1 KO mice had preserved contractile reserve at 3 d and 4 months and LVEF at 4 months after XRT. Anakinra treatment for 1 d before and 7 d after XRT prevented the impairment in contractile reserve. A significant increase in LV end-diastolic pressure, associated with increased myocardial interstitial fibrosis and pericardial thickening, was observed in wt mice, as well as in IL-1R1 KO-or anakinra-treated mice. In conclusion, induction of IL-1 by XRT mediates the development of some, such as the contractile impairment, but not all aspects of the XRT-induced cardiomyopathy, such as myocardial fibrosis or pericardial thickening.

Interleukin-1 Blockade in Recently Decompensated Systolic Heart Failure: Study Design of the Recently Decompensated Heart Failure Anakinra Response Trial (RED-HART)

Heart Failure (HF) is a clinical syndrome characterized by dyspnea, fatigue, and poor exercise capacity due to impaired cardiac function. The incidence of HF is increasing and represents the leading cause of hospitalization in the United States among patients > 65 years of age. Neurohormonal blockade has proven to reduce morbidity and mortality; however the persistent toll of HF demonstrates the urgent need to continue to develop novel drugs that target other pathophysiological paradigms. The presence of inflammation in cardiovascular disease has been well-established and interleukin-1 (IL-1), the prototypical proinflammatory agent, has been shown in preclinical animal models to induce cardiac dysfunction. The current study will investigate the role of IL-1 as an inflammatory mediator of HF progression and investigate whether IL-1 blockade with anakinra, recombinant human IL-1 receptor antagonist, improves aerobic exercise performance in patients with recently decompensated systolic HF. This study will be composed of 3 treatment arms (20 patients each): 1) anakinra 100mg daily for 12 weeks; 2) anakinra 100mg daily for 2 weeks followed by placebo for 10 weeks; or 3) placebo for 12 weeks. All patients will be followed for at least 24 weeks. The co-primary endpoints will be placebo-corrected interval changes in peak oxygen consumption (VO2) and ventilatory efficiency (VE/VCO2 slope) measured by Cardiopulmonary Exercise Testing (CPX) after 2 weeks of anakinra treatment. Secondary endpoints will include interval changes in 1) CPX variables at 4, 12 and 24 weeks; 2) echocardiographic measures of cardiac dimension/function; 3) quality of life assessments; 4) inflammatory biomarkers; and 5) clinical outcome including days alive outside of the hospital and survival free of re-hospitalization for HF. The RED-HART study will be the first study to address the potential benefits of IL-1 blockade on aerobic exercise performance in patients with recently decompensated HF.

The interleukin-1 receptor antagonist anakinra improves endothelial dysfunction in streptozotocin-induced diabetic rats.

BackgroundEndothelial dysfunction is a crucial early phenomenon in vascular diseases linked to diabetes mellitus and associated to enhanced oxidative stress. There is increasing evidence about the role for pro-inflammatory cytokines, like interleukin-1β (IL-1β), in developing diabetic vasculopathy. We aimed to determine the possible involvement of this cytokine in the development of diabetic endothelial dysfunction, analysing whether anakinra, an antagonist of IL-1 receptors, could reduce this endothelial alteration by interfering with pro-oxidant and pro-inflammatory pathways into the vascular wall.ResultsIn control and two weeks evolution streptozotocin-induced diabetic rats, either untreated or receiving anakinra, vascular reactivity and NADPH oxidase activity were measured, respectively, in isolated rings and homogenates from mesenteric microvessels, while nuclear factor (NF)-κB activation was determined in aortas. Plasma levels of IL-1β and tumor necrosis factor (TNF)-α were measured by ELISA. In isolated mesenteric microvessels from control rats, two hours incubation with IL-1β (1 to 10 ng/mL) produced a concentration-dependent impairment of endothelium-dependent relaxations, which were mediated by enhanced NADPH oxidase activity via IL-1 receptors. In diabetic rats treated with anakinra (100 or 160 mg/Kg/day for 3 or 7 days before sacrifice) a partial improvement of diabetic endothelial dysfunction occurred, together with a reduction of vascular NADPH oxidase and NF-κB activation. Endothelial dysfunction in diabetic animals was also associated to higher activities of the pro-inflammatory enzymes cyclooxygenase (COX) and the inducible isoform of nitric oxide synthase (iNOS), which were markedly reduced after anakinra treatment. Circulating IL-1β and TNF-α levels did not change in diabetic rats, but they were lowered by anakinra treatment.ConclusionsIn this short-term model of type 1 diabetes, endothelial dysfunction is associated to an IL-1 receptor-mediated activation of vascular NADPH oxidase and NF-κB, as well as to vascular inflammation. Moreover, endothelial dysfunction, vascular oxidative stress and inflammation were reduced after anakinra treatment. Whether this mechanism can be extrapolated to a chronic situation or whether it may apply to diabetic patients remain to be established. However, it may provide new insights to further investigate the therapeutic use of IL-1 receptor antagonists to obtain vascular benefits in patients with diabetes mellitus and/or atherosclerosis.

Interleukin 1 inhibition with anakinra in adult-onset Still disease: a meta-analysis of its efficacy and safety

BackgroundAnakinra is the first interleukin-1 inhibitor to be used in clinical practice, and recent evidence showed that interleukin-1 plays a pivotal role in the pathogenesis of adult-onset Still disease (AoSD). However, data concerning efficacy with anakinra use in different clinical trials has not been evaluated, and the overall remission of AoSD with anakinra treatment has not been well defined.MethodsWe conducted a search on Embase, PubMed, and the Cochrane Library for relevant trials. Statistical analyses were conducted to calculate the overall remission rates, odds ratios (OR), and 95% confidence intervals (CI), by using either random effects or fixed effect models according to the heterogeneity.ResultsOf the 273 articles that were identified, 265 were excluded. Eight studies were eligible for inclusion. The overall remission rate and complete remission rate of anakinra in AoSD patients were 81.66% (95% CI: 69.51%–89.69%) and 66.75% (95% CI: 59.94%–75.3%), respectively. Compared with the controls, the use of anakinra was associated with a significant remission in AoSD, with an OR of 0.16 (95% CI: 0.06–0.44, P=0.0005). There were also significant reductions of the dosage of corticosteroid (mean difference =21.19) (95% CI: 13.2–29.18, P<0.0001) from anakinra onset to the latest follow up time. Clinical and laboratory parameters were all improved, and anakinra was well tolerated in patients with AoSD. No evidence of publication bias was observed.ConclusionOur study has shown that anakinra is effective in remitting the manifestations of AoSD, with reduction of the dose of corticosteroid in patients with AoSD. Further, anakinra therapy was not associated with increased risk of adverse events, and it was well tolerated in patients with AoSD. Further research is still recommended to investigate these findings.

Anakinra use during pregnancy in patients with cryopyrin-associated periodic syndromes (CAPS).

Objective: To describe the pregnancy course and outcome, and use of anakinra, a recombinant selective IL-1 receptor blocker, during pregnancy in patients with cryopyrin-associated periodic syndromes (CAPS), including familial cold auto-inflammatory syndrome (FCAS), Muckle-Wells syndrome (MWS) and neonatal onset multi-system inflammatory disease (NOMID). Methods: Women currently enrolled in natural history protocols (NCT00059748, and/or NCT00069329 under IND) who have been pregnant were included. Subjects underwent a structured, standardized interview with regards to maternal health, pregnancy and fetal outcomes. Medical records were reviewed. Results: Nine women (four with FCAS, one with MWS and four with NOMID) reported one to four pregnancies, each resulting in a total of fifteen FCAS, three MWS, and six NOMID pregnancies. Six births from FCAS mothers and three births from NOMID mothers occurred while patients were receiving anakinra. If a woman became pregnant while taking anakinra, the pre-pregnancy anakinra dose was continued. Anakinra dose was increased during one twin pregnancy. No preterm births or serious complications of pregnancy were observed. One fetus of the twin pregnancy had renal agenesis and suffered fetal demise. Genetic testing showed the deceased twin carried the same NLRP3 c.785T>C, p.V262A mutation as the mother. The other twin is healthy and mutation negative. Conclusions: Anakinra was continued during pregnancy in women with CAPS and provided significant, persistent CAPS symptom relief while continuing to prevent the long-term sequelae of CAPS. Anakinra was well tolerated. Although a causal relation between anakinra and renal agenesis seems unlikely, further safety data are needed.

Inhibition of interleukin-1β decreases aneurysm formation and progression in a novel model of thoracic aortic aneurysms.

Thoracic aortic aneurysms (TAAs) are common, but experimental TAA models are limited and the role of interleukin-1β (IL-1β) is undetermined. IL-1β protein was measured in human TAAs and control aortas, and IL-1β protein was increased ≈20-fold in human TAAs. To develop an experimental model of TAAs, 8- to 10-week-old male C57Bl/6 mice (wild type [WT]) underwent thoracotomy with application of periadventitial elastase (WT TAA) or saline (WT control; n=30 per group). Elastase treatment to thoracic aortas resulted in progressive dilation until day 14 with maximal dilation of 99.6±24.7% compared with 14.4±8.2% for WT saline control (P<0.0001). WT TAAs demonstrated elastin fragmentation, smooth muscle cell loss, macrophage infiltration, and increased IL-1β expression. Next, TAAs were induced in mice deficient of IL-1β (IL-1β knockout) or IL-1 receptor (IL-1R knockout; n=10 each). Genetic deletion of IL-1β and IL-1R significantly decreased thoracic aortic dilation (IL-1β knockout=54.2±16.8% and IL-1R knockout=62.6±17.2% versus WT TAA=104.7±23.8%; P<0.001for both). IL-1β knockout and IL-1R knockout aortas demonstrated preserved elastin and smooth muscle cells with fewer inflammatory cells. Correspondingly, IL-1β and IL-1R knockout aortas had decreased inflammatory cytokine and matrix metalloproteinase 9 expression. Separately, WT mice pretreated with either IL-1R antagonist anakinra (100 mg/kg per day) or vehicle alone (control) underwent elastase treatment. Pretreatment of WT mice with anakinra attenuated TAA formation (control: 99.2±15.5% versus anakinra: 68.3±19.2%; P<0.005). Finally, to investigate treatment of small TAAs, WT mice were treated with anakinra 3 days after TAA induction. Anakinra treatment in WT mice with small TAAs reduced aortic dilation on day 14 (control treatment: 89.1±18.6% versus anakinra treatment: 59.7±25.7%; P=0.01). Periadventitial application of elastase to murine thoracic aortas reproducibly produced aneurysms with molecular and histological features consistent with TAA disease. Genetic and pharmacological inhibition of IL-1β decreased TAA formation and progression, indicating that IL-1β may be a potential target for TAA treatment.

IL-1 receptor antagonist reduces endotoxin-induced airway inflammation in healthy volunteers

Asthma with neutrophil predominance is challenging to treat with corticosteroids. Novel treatment options for asthma include those that target innate immune activity. Recent literature has indicated a significant role for IL-1β in both acute and chronic neutrophilic asthma. This study used inhaled endotoxin (LPS) challenge as a model of innate immune activation to (1) assess the safety of the IL-1 receptor antagonist anakinra in conjunction with inhaled LPS and (2) to test the hypothesis that IL-1 blockade will suppress the acute neutrophil response to challenge with inhaled LPS. In a phase I clinical study 17 healthy volunteers completed a double-blind, placebo-controlled crossover study in which they received 2 daily subcutaneous doses of 1 mg/kg anakinra (maximum dose, 100 mg) or saline (placebo). One hour after the second treatment dose, subjects underwent an inhaled LPS challenge. Induced sputum was assessed for neutrophils 4 hours after inhaled LPS. The effect of anakinra compared with placebo on airway neutrophil counts and airway proinflammatory cytokine levels after LPS challenge was compared by using a linear mixed-model approach. Anakinra pretreatment significantly diminished airway neutrophilia compared with placebo. LPS-induced IL-1β, IL-6, and IL-8 levels were significantly reduced during the anakinra treatment period compared with those seen after placebo. Subjects tolerated the anakinra treatment well without an increased frequency of infections attributable to anakinra treatment. Anakinra effectively reduced airway neutrophilic inflammation and resulted in no serious adverse events in a model of inhaled LPS challenge. Anakinra is a potential therapeutic candidate for treatment of asthma with neutrophil predominance in diseased populations.

The IL-1 receptor antagonist anakinra (kineret®) stabilizes the NLRP3 mutation-specific risk for hearing loss in patients with severe cryopyrin-associated periodic syndromes (CAPS)

CAPS is a rare monogenic autoinflammatory syndrome consisting of a spectrum of three conditions: Familial cold autoinflammatory syndrome (FCAS), Muckle-Wells syndrome (MWS), and the most severe form, NOMID/CINCA. Progressive hearing loss is a characteristic of severe CAPS [1]. Previous analyses showed that long-term anakinra treatment stabilized the progression of hearing loss [2,3]. CAPS patients with different NLRP3 mutations have distinctly different trajectories of hearing loss, suggesting a mutation-specific risk that should be considered when making treatment decisions [4].

TLR2/TLR4-dependent exaggerated cytokine production in hyperimmunoglobulinaemia D and periodic fever syndrome.

The autoinflammatory hyperimmunoglobulinaemia D and periodic fever syndrome (HIDS) is characterized by recurrent episodes of fever and inflammation. As part of the mevalonate kinase deficiency spectrum, it is caused by MVK mutations, resulting in decreased mevalonate kinase activity in the isoprenoid pathway. Although IL-1β is considered a major cytokine in its pathogenesis, IL-1 blockade is not successful in a proportion of patients. We aimed to further characterize the pro-inflammatory cytokine profile of HIDS. Peripheral blood mononuclear cells from HIDS patients and healthy donors were incubated with several stimuli. Cytokine concentrations were detected by ELISA. To analyse mRNA and protein expression, we performed quantitative RT-PCR and western blot, respectively. We observed significant differences in cytokine production when cells were incubated with ligands for Toll-like receptor 2 (TLR2), TLR4 and nucleotide-binding oligomerization domain-containing 2 (NOD2). The increased ratio between active and inactive caspase-1 protein in HIDS patients could explain why these cells are more easily triggered to secrete IL-1β. This is apparently not regulated at the transcriptional level, since expression levels of caspase-1 and IL-1β mRNA were similar in patients and controls. Both anakinra and tocilizumab treatment resulted in decreased inflammation, both ex vivo as well as in vivo. The increased cytokine secretion in HIDS is specific for TLR2, TLR4 and NOD2 ligation. Although IL-1β is important in the HIDS pathology, our data suggest it is a multicytokine disease. A more rigorous clinical trial is required to determine whether IL-6 receptor blockade may be considered in patients not responding to anakinra treatment.

Anakinra treatment in Schnitzler syndrome - results of the first retrospective multicenter study in six patients from the Czech Republic

Schnitzler syndrome is a very rare, acquired, autoinflammatory disease of mostly adult onset with characteristic combination of chronic recurrent urticaria and monoclonal immunoglobulin M or G gammopathy predisposing the patients to malignant lymphoproliferation. In this work, we analyzed the results of bio-logical therapy with anakinra on a national level aiming to supply data for effective pharmaco-economic estimates, lay the grounds of nationwide patient registry, raise awareness among professional public and optimize provided health care. The retrospective study (10/ 2006- 9/ 2013) included six males with definite Schnitzler syndrome verified by the new Strasbourg criteria. All patients were pretreated with antihistamines, nonsteroidal antiinflammatory drugs and glucocorticoids. Four patients underwent two or more treatment lines including intravenous bisphosphonates, 2- chlorodeoxyadenosine (cladribine), interferonα, PUVA photochemotherapy, cyclosporine A, thalidomide, bortezomib, chlorambucil, cyclophosphamide, colchicine and methotrexate. Anakinra monotherapy was initiated in standard dosing (100 mg subcutaneously daily). Complete and partial remissions were achieved in five (83%) and one patients (17%), respectively. Complete remission was characterized by urticaria and pain regression (within hours), normalization of inflammatory markers (with--in days) and bone metabolism improvement assessed by the markers of osteoblastic osteoformation and osteoclastic osteoresorption in one case (within weeks). With normalized inflammatory markers (including interleukin6 and interleukin18), arthralgia and sporadic exacerbations of urticaria and fevers persist in the patient in partial remission with proven Q703K polymorphism in NLRP3 gene. The median treatment followup was 30.5 months (37.2 ± 31.2 (n = 6)). The dosing interval was prolonged in one case of complete remission to 48 hours. No serious adverse reactions occurred during anakinra application. In Schnitzler syndrome, anakinra represents an effective, verified and safe medication with potentionally longterm administration not compromising its original efficacy and subjective tolerance. Anakinra, blocking autonomous inflammatory reaction of the organism via interleukin1 pathway, is a generally accepted first line treatment that should be made available in standard dosing for all Schnitzler patients.

Clinical predictors of response to anakinra in patients with heart failure

Clinical predictors of response to anakinra in patients with heart failure

Long-Term Efficacy of Interleukin-1 Receptor Antagonist (Anakinra) in Corticosteroid-Dependent and Colchicine-Resistant Recurrent Pericarditis

To evaluate the long-term response and safety of interleukin-1 receptor antagonist (anakinra) in recurrent pericarditis. Fifteen patients (12 children, 3 adults) were enrolled in a multicenter retrospective study. All the patients were corticosteroid-dependent and 14 had received colchicine. Anakinra was given at 1-2 mg/kg/d. The primary outcome of the study was a reduction of at least 70% of disease flares after anakinra treatment compared with the pretreatment period. Secondary outcomes were: (1) number of complete or partial responders to anakinra and time for complete response; (2) number of patients who discontinued other ongoing treatments (non-steroidal anti-inflammatory drugs, corticosteroid, colchicine) and time needed for discontinuation; (3) number of relapses during continuous anakinra treatment; and (4) number of relapses during anakinra tapering or discontinuation. All patients treated had a complete response within a few days and were able to rapidly withdraw concomitant treatments, including corticosteroids. During daily treatment, no patient had a relapse of the disease; 14 patients started tapering and 6 of them experienced a relapse, with a prompt response after anakinra reintroduction. Overall, after a median follow-up of 39 months (range 6-57), a 95% reduction of flares was observed compared with pretreatment period. The long-term use of anakinra in monotherapy is associated with persistent control of recurrent pericarditis.

A80: Skeletal Features of Neonatal‐Onset Multisystem Inflammatory Disease (NOMID) on Anakinra Treatment: Long‐Term Follow‐up

Background/Purpose:Neonatal‐onset multisystem inflammatory disease (NOMID) is an autoinflammatory disease characterized by fever, chronic urticarial rash, CNS manifestations, elevated acute phase reactants, and arthropathy. About 50% of patients with NOMID have de novo missense mutations in NLRP3/CIAS1, leading to constitutive inflammasome activation and IL‐1 production in monocytes, and caspase‐1 mediated persistence of osteoblast progenitor cells that are also found in other fibroblastoid tumors (). Poorly differentiated chondrocytes are seen with abnormal enchondral bone formation without inflammatory cells in NOMID arthropathy with bony overgrowth and premature fusion of physis. While blocking IL‐1 with anakinra reduces organ‐specific (central nervous system, inner ear, eye) and systemic inflammation (fever, rash, acute phase reactants), it has little effect on preexisting bone lesions.Methods:NOMID individuals with at least 5 months of follow up data (clinical, laboratory, and radiographic) on IL‐1 blocking treatment were included for review.Results:18 (36.7%) of the NOMID patients (n = 49; 21 male/28 female; age at study entry: 9.4 yo, 0.8–46.3 yo; duration of follow‐up: 4.6 yrs, 0.4–9.5 yrs) had bony involvement, most commonly the knee (16/49 = 32.7%, 12/49 = 24.5% with patellar involvement). 11/49 (22.4%) had multi‐joint involvement, typically asymmetric, including 4 elbows, 5 wrists, 6 ankles, 3 shoulders, and 2 hips. Ongoing abnormal enchondral bone formation continues until physeal fusion, which often occurs prematurely at involved sites, despite anaanakinra treatment. Lesions eventually ossify normally but may cause bone deformities. 3 patients had patellar subluxations (1 managed surgically) and 2 had patella resections. Leg length discrepancy (8/49 = 16.3%) and bowed leg deformities (9/49 = 18.3%) present due to premature, asymmetric fusion of physis required osteomy and/or stapling in 3. 2 developed long twisted fibula to accommodate shortened tibia, 1 surgically managed with stapling. One individual developed hip subluxation due to a longer left leg, which resulted in left hip avascular necrosis. 2 individuals had pseudofractures with development of horizontal linear defects noted in long‐bones consistent with residual changes from abnormal enchondral ossification rather than true fracture. 1 individual developed severe contractures with bilateral knee arthropathy and subsequently had bilateral total knee replacement.Conclusion:1. Unique bony findings in NOMID are due to persistence of immature osteoblast precursors with abnormal enchondral bone growth which continues until physeal fusion despite anakinra treatment, often with premature fusion at affected sites, with eventual normal ossification. 2. Surgical intervention can be safely considered for those with significant pain/disability from NOMID arthropathy. 3. Consideration of horizontal linear pseudofractures in long bones and risk of hip avascular necrosis is important in those with NOMID ().

A173: Cerebrospinal Fluid Cytokines Correlate With Innate Immune Cells in Neonatal Onset Multisystem Inflammatory Disease (NOMID) Patients in Clinical Remission Treated With Anakinra

Background/Purpose:Neonatal onset multisystem inflammatory disease (NOMID) is a rare autoinflammatory disease caused by NLRP3 mutations that lead to constitutive NLRP3 inflammasome activation and IL‐1β release. Patients present with neutrophilic urticaria, chronic aseptic meningitis, and papilledema. IL‐1β inhibitors improve the inflammatory manifestations, normalize acute phase reactants, decrease CSF WBC and protein, and proinflammatory cytokine levels. We found that cytokine levels decrease with anakinra treatment, but do not normalize during clinical remission. The higher IL‐6 and IP‐10 levels in CSF than in the blood suggest local production in the brain/CSF. Our objective is to examine whether CSF cytokines, particularly IL‐6 and IP‐10, correlate with CSF subpopulations of immune cells and CSF characteristics.Methods:Immunophenotyping and cytokine data were available on 2 baseline and 16 anakinra treated patients, 9/16, fulfilled clinical remission criteria (ESR ≤25 mm/hr, CRP ≤0.5 mg/dl, CSF WBC ≤5 cells/μl and protein ≤40 mg/dl) and control patients (n = 7). Cytokines levels (IL‐1β, IL‐6, IL‐10, IP‐10, IL‐12 (p70) and (p40), IFN‐γ, TNF‐α, and IL‐18) were correlated to CSF WBC, protein, albumin quotient (AQ), and opening pressure at baseline, post‐treatment, and clinical remission. Correlation was assessed with Pearson and Spearman tests.Results:At baseline, monocytes, granulocyte, and T cells were higher in NOMID patients versus controls. Post‐treatment monocytes and granulocyte counts decreased but remained higher even in clinical remission, relative to control. Only IL‐6 and IP‐10 correlated with monocytes (r = .66, p = .051; r = .86, p = .002) respectively. A correlation of IP‐10 but not IL‐6 with granulocytes was weaker than with monocytes (r = .66, p = .058). IL‐6, IP‐10, and IL‐18 correlated with CSF protein, AQ, and WBC (except IL‐18). At baseline, IL‐6 and IL‐18 significantly correlated with CSF protein (r = .68, p = .027; r = .80, p = .0065) and AQ (r = .82, p = .011; r = .78, p = .029) respectively. At post‐treatment, IL‐18 significantly correlated and IL‐6 trend towards significance with CSF protein (r = .53, p = .022; r = .40, p = .096) and AQ (r = .83, p = .0002; r = .47, p = .087) respectively.Conclusion:1) Inflammatory cells significantly decrease in NOMID patients, especially monocytes which remain elevated even in patients in clinical remission, suggesting residual inflammation. 2) The correlation of monocytes with IL‐6 and IP‐10 suggests their contribution to IL‐6 and IP‐10 production, which may contribute to the recruitment of other inflammatory cells including granulocytes. 3) IL‐6, IP‐10, and IL‐18 may be a marker for blood brain barrier dysfunction in NOMID and their use in long term monitoring should be explored. 4) These results are consistent with the notion that NOMID is caused by dysfunction in innate immune cells, particularly monocytes.

A2: Rapid and Sustained Response in Patients Suffering From Severe Cryopyrin‐Associated Periodic Syndromes Treated With Anakinra (Kineret®)

Background/Purpose:Cryopyrin‐Associated Periodic Syndromes (CAPS) are a group of rare inherited autoinflammatory diseases consisting of a spectrum of three conditions: FCAS, Muckle‐Wells Syndrome and the most severe form, NOMID. Anakinra was recently approved in the US for treatment of NOMID and in the European Union for treatment of CAPS. The objective of the present analysis is to assess the response rate to anakinra treatment and time to changes in symptom severity after initiation, withdrawal and re‐institution of the treatment in patients with severe CAPS.Methods:A prospective, open‐label withdrawal design study of anakinra treatment with long‐term extension including 43 patients was conducted at the National Institutes of Health (Goldbach‐Mansky et al 2006, Sibley et al 2012). The primary efficacy endpoint, the Diary Symptom Sum Score (DSSS) collected daily up to 60 months included 5 symptoms (fever, rash, joint pain, vomiting, headache); each scored from 0 (no symptoms) to 4 (severe symptoms). Earlier data demonstrated that rash and conjunctivitis disappeared in 3 days in all patients, the DSSS was decreased at 3 months and all patients except one met the criteria of a flare during the 7‐day withdrawal phase (Goldbach‐Mansky et al 2006). In the present analysis, we defined the response as at least 50% improvement from baseline in the weekly average DSSS. The mean changes in DSSS were estimated with Mixed Model for Repeated Measures (MMRM).Results:Twenty nine out of the 43 enrolled patients provided valid DSSS data for the analysis. A majority of the patients were children (17% &lt;2 years, 55% 2–11 years, 7% 12–17 years, 21% 18 years or more). All 29 patients responded to the treatment during the first 10 days based on DSSS. The average DSSS decreased from 4.5 to 0.8 in 2 days. This response was maintained throughout the study up to 60 months and at each post‐baseline visit &gt;80% of the patients met the response criteria. Eleven consecutive patients participated in the withdrawal phase at 3 months of treatment. After treatment withdrawal the average DSSS increased from 0.6 to 5.2 (p&lt;0.0001 compared to continuously treated patients). After re‐institution of treatment the DSSS returned to pre‐withdrawal levels within 3 days.Conclusion:All patients experienced a rapid response to the anakinra treatment, both initially and after a flare caused by the withdrawal phase. The response was maintained up to 60 months.

Anakinra treatment in drug-resistant Behcet’s disease: a case series

The study objective was to report treatment with an interleukin (IL)-1 receptor antagonist, anakinra, in patients with multiorgan Behcet's disease (BD). Comparison of clinical manifestations, previous treatments, markers of inflammation, concomitant medications, treatment regimen modifications, relapses, and adverse events before and during anakinra administration among patients with BD were evaluated. Nine BD patients (mean age 34.55 ± 16.30 years) refractory to tumor necrosis factor blockers and standardized therapies are reported in our survey. Their mean age at disease onset was 25 ± 13.88 years and their overall disease duration was 9.55 ± 5.33 years. All patients were positive for the HLA-B51 allele. Within 1 or 2 weeks following the initiation of anakinra, eight out of nine patients promptly responded, and most of them were maintained on 100 mg of daily anakinra with low doses of prednisone. However, most patients experienced a relapse in one or more clinical manifestations over time (mean time to relapse 29 ± 21.65 weeks), and only one patient remained completely under control on anakinra monotherapy. Despite a relapse in one or more disease manifestations, treatment was continued in most patients for a mean period of 13.75 ± 6.49 months. No serious adverse events occurred. Eight out of nine refractory BD patients showed a prompt improvement after starting anakinra, supporting the concept that IL-1 plays a pathological role in this disease. Nevertheless, after several months, most patients experienced a relapse. It remains unclear whether increasing the dose of anakinra would have prevented the reoccurrence of disease activity.

Abstract 18369: Interleukin-1 Blockade Improves Exercise Capacity in Heart Failure With Preserved Ejection Fraction (HFpEF): Results of the D-HART Study

Treatment options remain limited for patients with heart failure and preserved ejection fraction (HFpEF). Reduced exercise capacity is a common finding in HFpEF. Peak oxygen consumption (peak VO2) represents a gold standard for functional capacity and is a strong independent predictor of adverse outcomes. HFpEF patients also exhibit high levels of systemic inflammation that may be associated with mechanisms of diastolic dysfunction. We enrolled 12 patients with symptomatic HFpEF (LVEF&gt;50% and evidence of abnormal LV relaxation, filling, diastolic distensibility, or diastolic stiffness) and elevated hsCRP (&gt;2 mg/L). Patients were randomized to 14 day crossover treatment with daily subcutaneous injections of IL-1 receptor antagonist (anakinra); 100 mg or matching placebo in a double blind fashion ( NCT01542502 ). The pre-specified primary endpoint was change in peak VO2. Cardiopulmonary exercise testing was performed at baseline and upon completion of each treatment course. We observed a significant improvement in peak VO2 (+1.1 vs -0.1 ml•kg-1•min-1, P=0.009) and the oxygen uptake efficiency slope (+0.23 vs +0.09, P=0.006) and a significant reduction in hsCRP (-84% vs -10%, P=0.006) upon completion of anakinra treatment versus placebo. Correlative studies also revealed significant associations between changes in peak VO2 and hsCRP (R=-0.60, P=0.002). Improvements in ventilator efficiency (VE/VCO2 slope) were limited to patients with above median values for ventilator efficiency (VE/VCO2 slope&gt;26), suggesting that maximum benefits may occur in patients with impaired baseline function. These findings support the hypothesis that systemic inflammation and exercise intolerance in HFpEF are, at least in part, IL-1-dependent and provide the rationale for larger randomized clinical trials to confirm the benefits of IL-1 blockade in patients with HFpEF.

PW02-011 - Favorable response to anakinra in aisle patients

We previously described a new autosomal recessively inherited autoinflammatory syndrome in two Turkish patients, who were second-degree cousins. Their clinical features included recurrent inflammatory attacks lasting 3-10 days since the first year of life, which are characterized by fever, erythematous or urticarial rash with hyperesthesia, serositis and edema on the face and extremities. Both patients eventually developed a lymphedema symmetrically affecting lower extremities and genitalia. Using a homozygosity mapping approach and targeted capture array based sequencing, we identified a homozygous insertion mutation in the exon 3 of the MyoD family inhibitor domain containing gene (MDFIC), causing a frameshift and inhibiting the translation of its functional cysteine-rich C-terminal domain. We herein report another patient of Italian origin and also their response to anakinra treatment.