AOP Orphan Pharmaceuticals Research Articles

Effects of Tamoxifen on the Mutant Allele Burden and Disease Course in Patients with Myeloproliferative Neoplasms - Results of the Tamarin Study

Effects of Tamoxifen on the Mutant Allele Burden and Disease Course in Patients with Myeloproliferative Neoplasms - Results of the Tamarin Study

A Randomized Open-Label, Phase 3 Study to Evaluate Imetelstat Versus Best Available Therapy (BAT) in Patients with Intermediate-2 or High-Risk Myelofibrosis (MF) Refractory to Janus Kinase (JAK) Inhibitor

A Randomized Open-Label, Phase 3 Study to Evaluate Imetelstat Versus Best Available Therapy (BAT) in Patients with Intermediate-2 or High-Risk Myelofibrosis (MF) Refractory to Janus Kinase (JAK) Inhibitor

MANIFEST-2, a Global, Phase 3, Randomized, Double-Blind, Active-Control Study of CPI-0610 and Ruxolitinib Vs. Placebo and Ruxolitinib in JAK-Inhibitor-Naive Myelofibrosis Patients

The bromodomain and extraterminal domain (BET) family of proteins bind to chromatin to regulate the transcription of target genes involved in multiple pro-fibrotic pathways and is a novel therapeutic target for reducing fibrosis in myelofibrosis (MF). CPI-0610 is a unique, first-in-class, oral, small-molecule inhibitor of BET (BETi) proteins, designed to promote disease-modifying activity through selective gene regulation of key oncogenic, fibrotic, and inflammatory factors with potential to transform the standard of care in MF. Products with only one mechanism of action are approved currently for treatment of MF, Janus kinase 1/2 inhibitors (JAKi), with ruxolitinib (rux) being the standard of care for treatment-naïve MF patients. A minority of MF patients treated with rux (35%; 106 of 301) or fedratinib (37%; 35 of 96) achieved a spleen volume reduction ≥ 35% (SVR35) at 6-12 months. Disease-modifying therapeutic agents with a novel mechanism of action are needed to improve the outcomes in MF pts. Blocking BET activity with CPI-0610 inhibited aberrant maturation of megakaryocytes and decreased cytokine production in preclinical studies. In addition, synergistic antitumor activity of BETi and JAKi combination was observed in preclinical MF models. Clinical activity of CPI-0610 in combination with rux in JAKi-naïve MF patients observed in the phase 2 MANIFEST study was higher (SVR35 at wk 24: 63%) than that observed with rux alone in historical Phase 3 trials (Mascarenhas, EHA 2020). MANIFEST-2 is a global, phase 3, 1:1 randomized, double-blind, active-control study of CPI-0610 + rux vs. placebo + rux in JAKi treatment-naïve patients with primary MF, post-polycythemia-vera MF, or post-essential-thrombocythemia MF. Key eligibility criteria: DIPSS score ≥Int-1; platelet ≥100 x 109/L; spleen volume ≥ 450 cc by CT/MRI; ≥2 symptoms measurable (score ≥3) or a total symptom score (TSS) of ≥10 using the MFSAF v4.0; peripheral blast count <5%, ECOG ≤2. Approximately 310 patients (155 in each arm) will be enrolled in the study. Patient randomization will be stratified by DIPSS risk category (Intermediate-1 vs. Intermediate-2 vs. High), platelet count (> 200 × 109/L vs. 100 - 200 × 109/L), and spleen volume (≥ 1800 cm3 vs. < 1800 cm3). Double-blind treatment (CPI-0610 or matching placebo) will be administered once daily (QD) for 14 consecutive days followed by a 7-day break, which is considered 1 cycle of treatment (1 cycle = 21 days). Rux will be administered twice daily (BID) for all 21 days within each cycle. Primary endpoint: SVR35 response (≥35% reduction in spleen volume) at wk 24; key secondary endpoint: TSS50 response (≥50% reduction in TSS) at wk 24; other secondary endpoints: safety, PK, PD, bone marrow morphology/fibrosis, duration of SVR35 response, duration of TSS50 response, PFS, OS, conversion from transfusion dependence to independence, rate of RBC transfusion for the first 24 wks, hemoglobin response, peripheral proinflammatory cytokines. Figure Disclosures Mascarenhas: Incyte, Kartos, Roche, Promedior, Merck, Merus, Arog, CTI Biopharma, Janssen, and PharmaEssentia: Other: Research funding (institution); Celgene, Prelude, Galecto, Promedior, Geron, Constellation, and Incyte: Consultancy. Harrison:Roche: Honoraria; Sierra Oncology: Honoraria; Promedior: Honoraria; AOP Orphan Pharmaceuticals: Honoraria; Gilead Sciences: Honoraria, Speakers Bureau; Incyte Corporation: Speakers Bureau; Janssen: Speakers Bureau; Novartis: Honoraria, Research Funding, Speakers Bureau; Shire: Honoraria, Speakers Bureau; Celgene: Honoraria, Research Funding, Speakers Bureau; CTI Biopharma Corp: Honoraria, Speakers Bureau. Luptakova:Constellation Pharmaceuticals: Current Employment, Current equity holder in publicly-traded company. Christo:Constellation Pharmaceuticals: Current Employment, Current equity holder in publicly-traded company. Wang:Constellation Pharmaceuticals: Current Employment, Current equity holder in publicly-traded company. Mertz:Constellation Pharmaceuticals: Current Employment, Current equity holder in publicly-traded company. Colak:Constellation Pharmaceuticals: Current Employment, Current equity holder in publicly-traded company. Shao:Constellation Pharmaceuticals: Current Employment, Current equity holder in publicly-traded company. Bobba:Constellation Pharmaceuticals: Current Employment, Current equity holder in publicly-traded company. Trojer:Constellation Pharmaceuticals: Current Employment, Current equity holder in publicly-traded company. Senderowicz:Constellation Pharmaceuticals: Consultancy, Current equity holder in publicly-traded company, Ended employment in the past 24 months; Puma Biotechnology: Membership on an entity's Board of Directors or advisory committees. Humphrey:Constellation Pharmaceuticals: Current Employment, Current equity holder in publicly-traded company. Verstovsek:Gilead: Research Funding; Promedior: Research Funding; Celgene: Consultancy, Research Funding; Roche: Research Funding; NS Pharma: Research Funding; Sierra Oncology: Consultancy, Research Funding; PharmaEssentia: Research Funding; AstraZeneca: Research Funding; ItalPharma: Research Funding; CTI Biopharma Corp: Research Funding; Incyte Corporation: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; Blueprint Medicines Corp: Research Funding; Protagonist Therapeutics: Research Funding; Genentech: Research Funding.

Inhibition of Immune Cell Subsets Is Differentially Affected By Dasatinib Dosage in Patients with Chronic Phase CML

Inhibition of Immune Cell Subsets Is Differentially Affected By Dasatinib Dosage in Patients with Chronic Phase CML

Duration of Response to Luspatercept in Patients (Pts) Requiring Red Blood Cell (RBC) Transfusions with Myelofibrosis (MF) - Updated Data from the Phase 2 ACE-536-MF-001 Study

Duration of Response to Luspatercept in Patients (Pts) Requiring Red Blood Cell (RBC) Transfusions with Myelofibrosis (MF) - Updated Data from the Phase 2 ACE-536-MF-001 Study

Impact of COVID19 Pandemic on an International MPN Patient Population: Survey Results from 1560 MPN Patients

Impact of COVID19 Pandemic on an International MPN Patient Population: Survey Results from 1560 MPN Patients

Phazar: A Phase Ib Study to Assess the Safety and Tolerability of Ruxolitinib in Combination with Azacitidine in Advanced Phase Myeloproliferative Neoplasms (MPN), Including Myelodysplastic Syndromes (MDS) or Acute Myeloid Leukaemia (AML) Arising from MPN [ISRCTN16783472

Phazar: A Phase Ib Study to Assess the Safety and Tolerability of Ruxolitinib in Combination with Azacitidine in Advanced Phase Myeloproliferative Neoplasms (MPN), Including Myelodysplastic Syndromes (MDS) or Acute Myeloid Leukaemia (AML) Arising from MPN [ISRCTN16783472

Fedratinib, an Oral, Selective Inhibitor of Janus Kinase 2 (JAK2), in Patients with Intermediate-2 or High-Risk Myelofibrosis (MF): Updated Results from the Randomized, Placebo-Controlled, Phase III JAKARTA Trial

Fedratinib, an Oral, Selective Inhibitor of Janus Kinase 2 (JAK2), in Patients with Intermediate-2 or High-Risk Myelofibrosis (MF): Updated Results from the Randomized, Placebo-Controlled, Phase III JAKARTA Trial

Long-Term Use of Ropeginterferon Alpha-2b in Polycythemia Vera: 5-Year Results from a Randomized Controlled Study and Its Extension

Long-Term Use of Ropeginterferon Alpha-2b in Polycythemia Vera: 5-Year Results from a Randomized Controlled Study and Its Extension

Overexpression of PD-L1 Correlates with JAK2-V617F Mutational Burden and Is Associated with Chromosome 9p Uniparental Disomy in MPN

Myeloproliferative neoplasms (MPN) are characterized by clonal hematopoiesis, hyperproliferation of myeloid cells, hyperinflammation and immune deregulation. The three classical BCR-ABL1-negative MPN are essential thrombocythemia (ET), polycythemia vera (PV) and primary myelofibrosis (PMF). The disease is driven by JAK2, CALR or MPL somatic mutations in most patients. Drug resistance is a major problem in MPN. Recent data suggest that MPN cells display certain immune checkpoint molecules that may contribute to resistance, including PD-L1. Antibodies targeting the PD1/PD-L1 axis are highly promising anti-cancer drugs. Their potential use in MPN is being explored but it is unclear which MPN subtypes are most suitable for testing in clinical trials. The aim of our project was to assess PD-L1 expression in disease-initiating neoplastic stem cells (SC) and differentiated cells of MPN patients and to develop therapeutic approaches capable of blocking PD-L1 expression in MPN SC. In a first step, PD-L1 expression was assessed by RNA-sequencing of granulocytes of 106 MPN patients and 15 healthy donors (HD). The cohort included 56 PMF, 33 ET and 17 PV patients. For 102 patients data from Human Genome-wide Affymetrix 6.0 SNP arrays were available. We observed a ~5-fold higher expression of PD-L1 mRNA in patients with PV compared to other MPN (P<.01) or HD (P<.01). JAK2-V617F positive ET patients had higher expression of PD-L1 compared to CALR-mutated ET (p<.005) and the same was observed in PMF (p<.01). Other mutations (TET2, DNMT3A) detected by NGS did not affect PD-L1 expression. Since PD-L1 and JAK2 are located on chromosome 9p24, we looked into our previously published dataset of 400 MPN patients analyzed by SNP arrays and found that in all 195 patients with 9p uniparental disomy (UPD) the aberrations covered both genes. As PD-L1 is more centromeric it could represent the second target of 9pUPD which can precede the acquisition of JAK2-V617F in MPN. Granulocytes in JAK2-V617F positive patients with 9pUPD expressed significantly higher levels of PD-L1 compared to patients without 9pUPD (P<.0001; Figure 1A). Moreover, the JAK2-V617F mutational burden significantly correlated with PD-L1 expression (R=.52, P<.0001; Figure 1B). This correlation was lost when cases with 9pUPD were excluded from the analysis (R=.03, P=.9), indicating that the UPD is relevant for PD-L1 upregulation. To investigate PD-L1 surface expression on MPN SC we analyzed CD34+CD45dimCD38- cells isolated from fresh bone marrow (BM) samples of another 51 MPN patients and 7 HD by flow cytometry (FC). MPN patients showed a significantly higher surface expression of PD-L1 on CD34+CD45dimCD38- cells compared to HD (p<.001; Figure 1C). PD-L1 levels on the SC surface were elevated in both JAK2- and CALR-mutated MPN patients compared to HD (p<.001 and P<.005, respectively). PD-L2 was neither expressed in MPN granulocytes nor on MPN SC. CD4+ and CD8+ T-cells from BM samples of 17 MPN patients expressed the PD-L1 receptor PD-1 as assessed by FC. We cultured ex vivo primary MPN cells from 7 JAK2-V617F positive patients and showed that PD-L1 expression on MPN SC spontaneously decreases in culture, that interferon-gamma (IFN-γ) can promote expression of PD-L1 on these cells, and that ruxolitinib and the BRD4-degrader dBET6 block IFN-γ-induced PD-L1 expression in CD34+CD45dimCD38- MPN SC (P<.05). Together, we show that PD-L1 is overexpressed on the surface of disease-initiating MPN SC, that PD-L1 mRNA is overexpressed in granulocytes of MPN patients and that PD-L1 overexpression in granulocytes correlates with the JAK2-V617F mutational burden. In patients with JAK2-V617F positive MPN, 9pUPD leads to further PD-L1 upregulation either through increasing the mutant JAK2 gene dosage, loss of wt-JAK2,or amplification of PD-L1 allele with higher expression. Our data suggest the possibility that 9pUPD and the subsequent elevation of PD-L1 expression may provide an immune escape mechanism and may contribute to positive selection of JAK2-V617F homozygous SC. Ruxolitinib and dBET6 downregulate PD-L1 expression on MPN SC suggesting a role for the JAK2 and BRD4-MYC pathway. As recent studies revealed an immunogenic potential of JAK2 and CALR mutants, overcoming the disease-mediated immune escape may be of particular importance. Further preclinical and clinical studies are now required to examine the value of PD1/PD-L1 inhibitors in patients with MPN. Disclosures Gisslinger: Celgene: Honoraria; MyeloPro Diagnostics and Research: Honoraria; AOP Orphan Pharmaceuticals AG: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; PharmaEssentia: Honoraria; Janssen-Cilag: Honoraria; Roche: Honoraria. Kralovics:AOP Orphan Pharmaceuticals AG: Honoraria; PharmaEssentia: Honoraria; Qiagen: Honoraria; Novartis: Honoraria; MyeloPro Diagnostics and Research: Current equity holder in private company. Valent:Allcyte GmbH: Research Funding; Pfizer: Honoraria; Cellgene: Honoraria, Research Funding.

An International Multicentric Observational Study on the Use of Ruxolitinib in Patients with Polycythemia Vera Resistant or Intolerant to Hydroxyurea: Results from Interim Analysis

Introduction Polycythemia vera (PV) is a myeloproliferative neoplasm characterized by the increased red cell mass and high thrombotic risk. The main objective of therapy is to maintain the hematocrit <45% with hydroxyurea (HU) being the most common drug employed in first line. Patients developing resistance/intolerance to HU are at higher risk of thrombosis due to inadequate hematocrit control. Methods This ongoing phase 4 observational study recruited 352 patients with PV resistant and/or intolerant to HU treated with ruxolitinib (RUX), with a follow-up of 24 months after treatment initiation. In the present interim analysis, 150 patients with PV receiving RUX treatment for 52 weeks were evaluated for efficacy and safety parameters. Inclusion criteria were adult patients aged ≥18 years diagnosed with PV resistant/intolerant to HU (as per European LeukemiaNet [ELN] criteria) treated with RUX according to the approved local label. RUX treatment could be initiated up to 6 months before inclusion. The informed consent was obtained from all patients. The myeloproliferative neoplasm symptom assessment form total symptom score (MPN-SAF TSS) and the pruritus symptom impact scale (PSIS) were employed for symptom evaluation. Results Of the 150 patients included, 67.3% were aged >60 years and 51% were males; 61% were resistant to HU and 65% were intolerant to HU. The median duration of PV was 67 months prior to the study entry. The medical history of patients included thromboembolic events (TEs) in 29.3%, infections in 18.6%, secondary neoplasms in 12.6%, and bleeding in 5.3% of patients. At baseline, TEs were present in 17.3% of patients, infections in 10.6%, secondary neoplasms in 6%, and bleeding in 2% of patients. Hematocrit was measured in 133 patients at baseline with inadequate hematocrit control being observed in 62 patients (47%): >45% to <48%, n=28; ≥48%, n=34. The proportion of patients dependent on 1 to 2 and ≥3 phlebotomies 1 year before the RUX treatment were 24% and 38%, respectively. Hematocrit levels dropped from week 8 to 12 to a sustained mean value of 40% during the observational period (Figure 1). The dependency of patients requiring 1 to 2 and ≥3 phlebotomies decreased from 24% and 38% at baseline to 10% and 4%, respectively after 1 year of RUX treatment (Figure 2). The mean MPN-SAF TSS declined rapidly from a score of 33 at baseline (n=20) to 19 (n=22) upon the treatment initiation and evolved to stabilize at week 16 (n=30) throughout the observation period (Figure 3). On mean PSIS, a rapid decline in severity of pruritus (past 7 days) from 5.20 at baseline (n=15) to 0.95 (n=20) after 4 weeks of treatment was observed. The effect of RUX treatment on patients with moderate and massive splenomegaly was observed as early as 4 weeks after the treatment initiation. The proportion of patients with moderate-to-massive splenomegaly was reduced from 34.4% at baseline to 11.9% at week 52, while the proportion with no splenomegaly increased from 45.9% to 66.7% (Figure 4). Patients received a mean daily dose of 21.1 mg RUX. The majority of patients (89%) did not have dosing interruptions, and 11% had only 1 dosing interruption. The dose increases were more prominent than the decreases (53% vs 37%, respectively), and the majority had only 1 dosing increase or decrease. Adverse events (AEs) reported during the study included infections in 43.3%, TEs in 10%, secondary neoplasms in 6%, and bleeding in 10% of patients. Grade 3 to 4 AEs reported during the study included infections in 4.6%, TEs in 2%, secondary neoplasms in 1.3%, and bleeding in 0.6% of patients. Conclusion In this phase 4 observational study, RUX treatment achieved hematocrit control in a majority of patients with PV who were resistant/intolerant to HU and was associated with a low rate of grade 3 to 4 TEs. Additional benefits included symptom improvement and reduction in splenomegaly. The safety, particularly regarding infections and secondary neoplasms, will be further explored during the final analysis of the study. Disclosures Gisslinger: AOP Orphan Pharmaceuticals AG: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; PharmaEssentia: Honoraria; MyeloPro Diagnostics and Research: Honoraria; Janssen-Cilag: Honoraria; Roche: Honoraria; Celgene: Honoraria. Devos:Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees. Lippert:Novartis: Other: Personal fee, Research Funding. De Stefano:Novartis: Other: Personal fee, Research Funding; Amgen: Other: Personal fee; Bayer: Other: Non-financial support; Celgene: Other: Non-financial support, personal fee; Janssen Cilag: Other: Non-financial support. Dahm:Novartis: Other: Reimbursement of study costs and personal fee; Pfizer: Other: Personal fee, Research Funding; Bristol-Mayer Squibb: Other: Personal fee; Bayer: Other: Personal fee; MSD: Other: Personal fee. Zuurman:Novartis Pharma A.G.: Current Employment. Zaiac:Novartis: Current Employment, Current equity holder in private company. Houtsma:Novartis: Current Employment. Iqbal:Novartis: Current Employment. Di Matteo:Novartis: Current Employment.

Ropeginterferon alfa-2b versus standard therapy for polycythaemia vera (PROUD-PV and CONTINUATION-PV): a randomised, non-inferiority, phase 3 trial and its extension study

The PROUD-PV and CONTINUATION-PV trials aimed to compare the novel monopegylated interferon ropeginterferon alfa-2b with hydroxyurea, the standard therapy for patients with polycythaemia vera, over 3 years of treatment. PROUD-PV and its extension study, CONTINUATION-PV, were phase 3, randomised, controlled, open-label, trials done in 48 clinics in Europe. Patients were eligible if 18 years or older with early stage polycythaemia vera (no history of cytoreductive treatment or less than 3 years of previous hydroxyurea treatment) diagnosed by WHO's 2008 criteria. Patients were randomly assigned 1:1 to ropeginterferon alfa-2b (subcutaneously every 2 weeks, starting at 100 μg) or hydroxyurea (orally starting at 500 mg/day). After 1 year, patients could opt to enter the extension part of the trial, CONTINUATION-PV. The primary endpoint in PROUD-PV was non-inferiority of ropeginterferon alfa-2b versus hydroxyurea regarding complete haematological response with normal spleen size (longitudinal diameter of ≤12 cm for women and ≤13 cm for men) at 12 months; in CONTINUATION-PV, the coprimary endpoints were complete haematological response with normalisation of spleen size and with improved disease burden (ie, splenomegaly, microvascular disturbances, pruritus, and headache). We present the final results of PROUD-PV and an interim analysis at 36 months of the CONTINUATION-PV study (per statistical analysis plan). Analyses for safety and efficacy were per-protocol. The trials were registered on EudraCT, 2012-005259-18 (PROUD-PV) and 2014-001357-17 (CONTINUATION-PV, which is ongoing). Patients were recruited from Sept 17, 2013 to March 13, 2015 with 306 enrolled. 257 patients were randomly assigned, 127 were treated in each group (three patients withdrew consent in the hydroxyurea group), and 171 rolled over to the CONTINUATION-PV trial. Median follow-up was 182·1 weeks (IQR 166·3-201·7) in the ropeginterferon alfa-2b and 164·5 weeks (144·4-169·3) in the standard therapy group. In PROUD-PV, 26 (21%) of 122 patients in the ropeginterferon alfa-2b group and 34 (28%) of 123 patients in the standard therapy group met the composite primary endpoint of complete haematological response with normal spleen size. In CONTINUATION-PV, complete haematological response with improved disease burden was met in 50 (53%) of 95 patients in the ropeginterferon alfa-2b group versus 28 (38%) of 74 patients in the hydroxyurea group, p=0·044 at 36 months. Complete haematological response without the spleen criterion in the ropeginterferon alfa-2b group versus standard therapy group were: 53 (43%) of 123 patients versus 57 (46%) of 125 patients, p=0·63 at 12 months (PROUD-PV), and 67 (71%) of 95 patients versus 38 (51%) of 74 patients, p=0·012 at 36 months (CONTINUATION-PV). The most frequently reported grade 3 and grade 4 treatment-related adverse events were increased γ-glutamyltransferase (seven [6%] of 127 patients) and increased alanine aminotransferase (four [3%] of 127 patients) in the ropeginterferon alfa-2b group, and leucopenia (six [5%] of 127 patients) and thrombocytopenia (five [4%] of 127 patients) in the standard therapy group. Treatment-related serious adverse events occurred in three (2%) of 127 patients in the ropeginterferon alfa-2b group and five (4%) of 127 patients in the hydroxyurea group. One treatment-related death was reported in the standard therapy group (acute leukaemia). In patients with early polycythaemia vera, who predominantly presented without splenomegaly, ropeginterferon alfa-2b was effective in inducing haematological responses; non-inferiority to hydroxyurea regarding haematological response and normal spleen size was not shown at 12 months. However, response to ropeginterferon alfa-2b continued to increase over time with improved responses compared with hydroxyurea at 36 months. Considering the high and durable haematological and molecular responses and its good tolerability, ropeginterferon alfa-2b offers a valuable and safe long-term treatment option with features distinct from hydroxyurea. AOP Orphan Pharmaceuticals AG.

Neurological Outcome and Quality of Life Three Months after COVID-19: A Prospective Observational Cohort Study

BACKGROUND: Increasing evidence suggests the involvement of the central and peripheral nervous system in patients with coronavirus disease 2019 (COVID-19). Little is known about neurological outcomes and quality of life (QoL) after recovery from acute infection.METHODS: In this prospective, multicentre, observational cohort study we systematically evaluated neurological signs and diseases by detailed neurological examination and a predefined test battery assessing smelling disorders (16-item Sniffin-Sticks-test), cognitive deficits (Montreal Cognitive Assessment), QoL (36-item Short Form), and mental health (Hospital Anxiety and Depression Scale, Post-traumatic Stress Disorder Checklist-5) three months after disease onset.FINDINGS: Of 135 COVID-19 patients included, 31 (23%) required ICU-care (severe), 72 (53%) were admitted to the regular ward (moderate), and 32 (24%) underwent outpatient-care (mild) during acute disease. At three-month follow-up, 20 patients (15%) presented with one or more neurological syndromes that were not evident before COVID-19. These included poly-neuro/myopathy (n=16, 12%), mild encephalopathy (n=2, 2%), parkinsonism (n=1, 1%), orthostatic hypotension (n=1, 1%), Guillain-Barré-Syndrome (n=1, 1%) and ischemic stroke (n=1, 1%). Self-reported hyposmia/anosmia was noted in 23/135 patients (17%), which was significantly lower compared to those documented during acute COVID-19 (44%; pINTERPRETATION: Despite recovery from acute infection, neurological symptoms were prevalent at three-months follow-up. Above all, smelling disorders were persistent in a large proportion of patients. Our results urge for further studies investigating the onset and evolution of neurological diseases following COVID-19 infection to develop strategies for secondary prevention.TRIAL REGISTRATION: ClinicalTrials.gov (NCT04416100)FUNDING: Not applicable.DECLARATION OF INTERESTS: KS reports grants from FWF Austrian Science Fund, grants from Michael J. Fox Foundation, grants from International Parkinson and Movement Disorder Society, personal fees from Teva, personal fees from UCB, personal fees from Lundbeck, personal fees from AOP Orphan Pharmaceuticals AG, personal fees from Abbvie, personal fees from Roche, personal fees from Grünenthal; all outside the submitted work. PM reports grants from TWF (Tyrolean Science Fund), grants from Medtronic, personal fees from Boston Scientific, all outside the submitted work. The other authors have nothing to disclose. All other authors declare no competing interests.ETHICS APPROVAL STATEMENT: The conduct of the study was approved by the local ethics committee (Medical University of Innsbruck, EK Nr: 1103/2020). Written informed consent was obtained from all patients according to local regulations.

Disrupted Relationship between Blood Glucose Levels and Dopamine D <sub>2/3</sub> Receptor Availability in Patients with First-Episode Schizophrenia. A Case-Control PET-Imaging Study

Introduction: An elemental function of brain dopamine is to coordinate cognitive and motor resources for successful exploitation of environmental energy sources. Dopamine transmission, goal-directed behaviour, and glucose homeostasis are altered in schizophrenia patients prior to and after initiation of pharmacological treatment. Thus, we investigated the relationship between blood glucose levels and brain dopamine signalling in drug-naive patients with first-episode psychosis. Methods: We quantified blood glucose levels and binding of the D 3 preferring dopamine D 2/3 receptor agonist radioligand (+)-[11C]-PHNO in 15 medication-naive patients and 27 healthy volunteers employing positron emission tomography. Results: Whole-brain voxel-wise linear model analysis identified two clusters of significant interaction between blood glucose levels and diagnosis on (+)-[11C]-PHNO binding-potential values. One cluster was located in the ventral striatum and pallidum, the other one in the right ventral tegmental area. We observed positive correlations between blood glucose levels and binding-potential values in healthy volunteers but negative correlations in patients with first episode psychosis. Interpretation: Extracellular dopamine levels are a major determinant of (+)-[11C]-PHNO binding in the brain. In line with the concept that increased dopamine signalling occurs when goal-directed behaviour is needed for restoring energy supply, our data indicate that in healthy volunteers, extracellular dopamine levels are low, when blood glucose levels are high and vice-versa. This relationship is reversed in patients with first-episode psychosis, possibly reflecting a pathogenic alteration underlying two seemingly unrelated aspects of the illness: dysfunctional dopamine signalling and glucose homeostasis. Trial Registration: Clinical Trial Registry:EUDRACT 2010-019586-29 Funding: Vienna Science and Technology Fund; Austrian Science Fund; Medical Scientific Fund of the Mayor of the City of Vienna Declaration of Interests: Without relevance to this work, M. Willeit declares to having received speaker honoraria and consulting fees from Janssen-Cilag Pharma GmbH, Austria. Without relevance to this work, W. Wadsak declares to having received speaker honoraria from GE Healthcare, research grants from Ipsen Pharma, Eckert-Ziegler AG, Scintomics and ITG. WW is a part time eployee ofCBmed Ltd (Center for Biomarker Research in Medicine, Graz, Austria). and is a member of advisory boards of Amgen, Chieri and Sanofi-Aventis. M. Hacker received consulting fees and/or honoraria from Bayer Healthcare BMS, Eli Lilly, EZAG, GE Healthcare, Ipsen, ITM, Janssen, Roche, Siemens Healthineers. R. Lanzenberger received travel grants and/or conference speaker honoraria within the last three years from Bruker BioSpin MR, Heel, and support from Siemens Healthcare regarding clinical research using PET/MR. He is a shareholder of the start-up company BM Health GmbH since 2019. S. Kasper received grants/research support, consulting fees and/or honoraria within the last three years from Angelini, AOP Orphan Pharmaceuticals AG, Celegne GmbH, Eli Lilly, Janssen-Cilag Pharma GmbH,KRKA-Pharma, Lundbeck A/S, Mundipharma, Neuraxpharm, Pfizer, Sanofi,Schwabe, Servier, Shire, Sumitomo Dainippon Pharma Co. Ltd. and Takeda. U. Sauerzopf, A. Weidenauer, I. Dajic, M. Bauer, L. Bartova, B. Meyer, L. Nics, C. Philippe, S. Pfaff, V. Pichler, M. Mitterhauser, L. Pezawas and N. Praschak-Rieder have no conflict of interest to declare Ethics Approval Statement: This study was approved by the Ethics-Committee of the Medical University of Vienna and Austrian federal regulatory authorities. All subjects signed an informed consent form.

A Standardized Equation Model of Quality of Life in Myeloproliferative Neoplasms

Background: Quality of life (QOL) is predictive of survival in many malignancy types, including myeloproliferative neoplasms (MPNs; Scherber 2017, Sloan 2012, Montazeri 2009, Nilsson 2017). We have previously characterized that an association exists between symptom burden and QOL among MPN patients, but due to the disease specificity of symptoms, symptoms rather than QOL remains a key therapeutic endpoint (Scherber 2017, NCCN Guidelines). Despite these advancements, our understanding of the extent that different patient and disease characteristics, including symptoms, contribute to overall QOL has remained elusive. In this analysis, we utilized information from a large survey of MPN patients to develop a model of QOL that establishes the degree that individual variables contribute to QOL, including psychosocial variables, comorbidities, and MPN disease symptoms. Methods: The FATIGUE survey of MPN patients (Scherber 2016) investigated self-reported symptoms using the MPN10 (Scherber 2012), depression utilizing the Profile of Mood States-Brief (POMS-B, McNair 1971), Patient Health Questionnaire (PHQ-2, Kroenke 2003) and Mental Health Inventory (MHI-5, Berwick 1991), and QOL utilizing a single numeric analog scale (range 0-10) regarding overall quality of life. Linear regression analysis was utilized to establish the relationship between individual symptoms and QOL, and a structural equation model (SEM) was used to identify complex relationships among patient demographics, behavioral factors, comorbidities, and QOL. Results: A total of 914 patients from the online survey lived in the USA and provided data for this analysis. Average age was 62 with 67% of patients being female and the mean BMI was 25. Education varied across middle school or high school education (22%), undergraduate or college degree (44%), masters (26%), to doctorate (8%). 43% of respondents were employed. Fatigue (β coefficient 0.23, p<0.001), inactivity (β 0.21, p<0.001), concentration difficulties (β 0.13, p<0.001), sad mood (β 0.18, p<0.001), and night sweats (β 0.05, p=0.03) showed statistically significant impact on QOL. SEM Model: We developed the SEM model in Figure 1. Out of all variables analyzed, MPN total symptom burden demonstrated the strongest association with (β 0.89) with QOL, followed by depression (β 0.76). Comorbidities, including COPD and renal issues, age, and body mass index abnormalities had some impact on symptoms (all β <0.40), but did not demonstrate a significant impact on QOL. Comparative Fit Index (CFI) was 0.905 and root mean square error of approximation (RMSEA) was 0.051 (0.048, 0.054) indicating good fit. Conclusions: Previous clinical trials of JAK inhibition have targeted improvement in symptoms as a key endpoint, and ultimately demonstrated improvements in overall survival. The mechanism of this survival benefit has not been fully explored. This analysis suggests that symptoms and mood are strongly associated and potentially a major contributor to QOL among MPN patients, whereas other major comorbidities and age are not as strongly correlated. Efforts are underway to analyze more comprehensive datasets to better understand the role of other variables, including marriage status and financial concerns, on QOL. Disclosures Scherber: Blueprint: Other: Ad board; Incyte: Consultancy; Gilead: Consultancy. Hasselbalch:Novartis: Research Funding; AOP Orphan Pharmaceuticals: Other: Data monitoring board. Mesa:Baxalta: Consultancy; LaJolla: Consultancy; Genentech: Consultancy; Celgene Corporation: Research Funding; Samus: Research Funding; AbbVie: Research Funding; NS Pharma: Research Funding; Novartis: Consultancy, Honoraria, Other: travel, accommodations, expenses; CTI: Research Funding; Galena Biopharma: Consultancy; Pfizer: Research Funding; Incyte: Other: travel, accommodations, expenses, Research Funding; Genotech: Research Funding; AOP Orphan Pharmaceuticals: Honoraria, Other: travel, accommodations, expenses; PharmaEssentia: Research Funding; Gilead Sciences: Research Funding; Promedior: Research Funding; Shire: Honoraria; Sierra Oncology: Consultancy.

Thromboembolic Risk Reduction and High Rate of Complete Molecular Response with Long-Term Use of Ropeginterferon Alpha-2b in Polycythemia Vera: Results from a Randomized Controlled Study

Introduction: The key treatment goals for polycythemia vera (PV) are to prevent thromboembolic events and minimize the risk of progression, ultimately modifying the natural history of the disease by selectively targeting the malignant clone. In the PROUD-PV/CONTINUATION-PV study, long-term treatment with ropeginterferon alpha-2b (BESREMi®; hereafter ropeg) was compared with standard cytoreductive therapy regarding thromboembolic and other adverse events as well as hematological and molecular parameters over a four-year period. Methods: Cytoreduction-naïve or HU-pre-treated patients aged ≥18 years diagnosed with PV according to WHO 2008 criteria were eligible. A total of 257 patients were randomly allocated to ropeg or hydroxyurea at individualized doses for 12 months in the initial study phase (PROUD-PV). In the ongoing extension phase (CONTINUATION-PV), patients in the hydroxyurea arm were permitted to switch to best available treatment. Efficacy assessments included a longitudinal analysis of complete hematological response (CHR) and complete molecular response (CMR; JAK2V617F was determined using real-time PCR [ipsogen® JAK2 MutaQuant® kit; QIAGEN GmbH]), defined by modified ELN criteria. Discontinued patients were considered non-responders. A data snapshot was performed once all patients reached 48 months of treatment; all available safety data were included. Results: Ninety-five patients in the ropeg arm and 76 in the control arm entered the extension phase. At the time of analysis 139 patients remained on study: 74/95 in the ropeg arm and 65/76 in the control arm. Almost all patients in the control arm (>97% at the last available assessment) continued on HU. The rate of patients in CHR was significantly higher in the ropeg arm than in the control arm in the 4th year (60.6% versus 43.4%; p=0.02), as seen after 2 and 3 years of treatment. In line with this effective control of hematologic parameters by ropeg, a very low rate of major thromboembolic adverse events was observed in the ropeg arm: 0.0%, 0.0% and 1.1% of patients in the 2nd, 3rd and 4th years, respectively. In the control arm, rates of major thromboembolic adverse events in the 2nd, 3rd and 4th year were 0.9%, 1.4% and 0.0%, respectively. The median JAK2V617F allele burden declined from 37.3% at baseline to 9.8% over 4 years in the ropeg arm, whereas in the control group, the median allele burden increased from 38.1% to 43.1% in the same period (p<0.0001). The rate of molecular response (partial or complete) at 48 months was significantly higher among ropeg-treated patients than in the control arm (67.0% versus 25.7%; RR: 2.5 [95% CI: 1.7 to 3.7; p<0.0001]). No patients achieved CMR in the control arm. In the ropeg arm, 13 patients had a JAK2V617F allele burden below the threshold of 1% at month 48, 11 of whom also had a CHR at this time point. An additional 34 patients in the ropeg arm achieved an allele burden <10% at 48 months, suggesting that further patients may reach the <1% threshold with ongoing treatment. In terms of safety, no new signals were detected in the 4th year. Rates of patients with treatment-related adverse events remained similar in the ropeg and control arms in the 4th year (ropeg: 28.7% of patients; control: 22.9%). Disease or treatment-related secondary malignancies reported in the entire study period comprised 2 cases of acute leukemia, 2 cases of basal cell carcinoma and 1 case of malignant melanoma, all in the control group; 1 case of disease-related transformation to myelofibrosis occurred in each treatment arm. Conclusions: Ropeg minimizes the occurrence of thromboembolic events in patients with PV over long-term treatment, without leukemogenic risk. In addition, we show for the first time in a randomized study that, in contrast to hydroxyurea, long-term ropeg treatment is capable of inducing deep molecular responses including CMR, which underscores its disease modifying potential. These results also suggest that selected patients could achieve operational cure (with both CHR and CMR) with ropeg, opening the way for treatment discontinuation. Disclosures Kiladjian: Novartis: Honoraria, Research Funding; AOP Orphan: Honoraria, Research Funding; Celgene: Consultancy. Klade:AOP Orphan Pharmaceuticals AG: Employment. Illés:Takeda, Seattle: Research Funding; Janssen, Celgene, Novartis, Takeda, Roche, Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees. Mayer:AOP Orphan Pharmaceuticals AG: Research Funding. Krejcy:AOP Orphan Pharmaceuticals AG: Employment. Hasselbalch:Novartis: Research Funding; AOP Orphan Pharmaceuticals: Other: Data monitoring board. Kralovics:Pharma Essentia: Honoraria; MyeloPro Diagnostics and Research: Equity Ownership; AOP Orphan Pharmaceuticals AG: Honoraria, Other: Advisory board; Qiagen: Honoraria; Novartis: Honoraria. Gisslinger:Celgene GmbH: Honoraria; Pharma Essentia: Other: Personal fees; Roche Austria GmbH: Consultancy; Janssen-Cilag: Honoraria; Novartis Pharma GmbH: Consultancy, Honoraria, Research Funding; AOP Orphan Pharmaceuticals: Consultancy, Honoraria, Research Funding; Myelopro GmbH: Consultancy.

Effects of the Therapeutic Armamentarium on Survival and Time to Next Treatment in CMML Subtypes: An International Analysis of 950 Cases Coordinated By the AGMT Study Group

Effects of the Therapeutic Armamentarium on Survival and Time to Next Treatment in CMML Subtypes: An International Analysis of 950 Cases Coordinated By the AGMT Study Group

Significantly Upregulated Thrombo-Inflammatory Genes Are Normoregulated or Significantly Downregulated during Treatment with Interferon-Alpha2 in Patients with Philadelphia-Negative Chronic Myeloproliferative Neoplasms

Introduction: The Philadelphia-negative chronic myeloproliferative neoplasms (MPNs) are associated with a high risk of arterial and venous thrombosis, which are attributed to several mechanisms, including elevated blood cell counts per se, in vivo leukocyte and platelet activation with increased adhesion of granulocytes, monocytes and platelets to each other and to a dysfunctional endothelium. In recent years, evidence has accumulated that chronic inflammation is an important pathogenetic mechanism for MPN-disease development and disease progression, inducing increasing genomic instability in hematopoietic cells and thereby emergence of additional mutations of significance for myelofibrotic and leukemic transformation. Recent studies have shown several thrombo-inflammatory genes to be upregulated in patients with MPNs, likely contributing to the increased risk of thrombosis. Several studies have documented that long term treatment with interferon-alpha2 (IFN) is able to normalize elevated cell counts in concert with induction of a remarkable decrease in the JAK2V617F allele burden and accordingly impacting important thrombosis promoting factors in MPNs. Herein, using whole blood gene expression profiling we for the first time report that treatment with IFN is able to normoregulate or significantly downregulate upregulated thrombo-inflammatory genes in patients with MPNs. Methods: Eight patients with ET, 21 patients with PV, and 4 patients with PMF participated in the study. All patients received treatment with IFN, in the large majority in a dosage ranging from 45-90 ug x 1 sc/week. Gene expression microarray analysis of whole blood was performed before and after 3 months of treatment. Total RNA was purified from whole blood, amplified to biotin-labeled RNA, and hybridized to Affymetrix HG-U133 2.0 Plus chips. Results: We identified 6261, 10,008, and 2828 probe sets to be significantly differentially expressed in ET, PV, and PMF, respectively, in response to treatment with IFN (pvalue < 0.05). Six thrombo-inflammatory genes were investigated: F3, PADI4, SELP, SERPINE1, SLC2A1, and THBS1. In all patients groups, the 6 genes were significantly upregulated at baseline and either normoregulated or significantly downregulated during treatment with IFN (Figure 1). Discussion and Conclusions: Thrombosis contributes significantly to morbidity and mortality in MPNs. Despite treatment with conventional drugs (hydroxyurea, anagrelide) - the most used cytoreductive therapies worldwide - patients with MPNs are still suffering potentially life-threatening or life-invalidating thrombotic complications in the brain, heart, lungs and elsewhere. Therefore, there is an urgent need for studies that explore the pathogenetic mechanisms eliciting the thrombotic state and the impact of novel therapies, such as IFN, upon the thrombogenic factors which might be operative. Herein, we have for the first time shown that IFN significantly downregulates several thrombo-inflammatory genes, known to be the upregulated in patients with concurrent or previous thrombosis. Highly intriguing, we found that IFN significantly downregulated the PADI4 gene, which is required for neutrophil extracellular trap (NET) formation and thrombosis development. A most recent study has shown neutrophils from patients with MPNs to be associated with an increase in NET formation, which was blunted by ruxolitinib. This study also showed that JAK2V617F-driven MPN mouse models have a NET-rich, prothrombotic phenotype, highlighting NETosis to be yet another important thrombosis mechanism in MPNs. In conclusion, we have for the first time shown 3 months IFN-treatment to be associated with a significant downregulation of upregulated thrombo-inflammatory genes, including significant downregulation of the NETosis associated gene - PADI4. In the context of a significantly increased risk of thrombosis after the MPN-diagnosis with a particular increased risk at 3 months, our results of significant downregulation of these thrombo-inflammatory genes during IFN-therapy are of paramount importance and may signal an advantage of IFN over conventional cytoreductive therapies. Further studies are required to decipher the impact of IFN upon upregulated thrombo-inflammatory genes and if combination therapy with ruxolitinib may be even more efficacious. Figure 1 Disclosures Hasselbalch: Novartis: Research Funding; AOP Orphan Pharmaceuticals: Other: Data monitoring board. OffLabel Disclosure: Interferon-alpha for treatment of myeloproliferative neoplasms

Superiority of IFN Versus HU Using a Novel Biomarker-Based Tool for Assessment of Disease Burden in MPNs

Background: Treatment of polycythemia vera (PV) patients with hydroxyurea (HU) normalizes elevated blood cell counts within weeks in the large majority of patients. Studies on the impact of HU upon the kinetics of the JAK2V617F allele burden, leukocyte and platelets over time are scarce, and results have been reported highly heterogeneous. Purpose: Using data driven analysis as a novel tool to model the kinetics of the JAK2V617F allele burden and blood cell counts over time during treatment with HU. Material and Methods: Using serial measurements of JAK2V617F and correlation analyzes of routine hematological values (Hb-concentration, leukocyte count, platelet count, lactic dehydrogenase), we present a detailed description and analysis of the kinetics of the JAK2V617F, leukocyte and platelet counts and lactic dehydrogenase in 29 PV patients who were followed in the Danish randomized trial (DALIAH) comparing the efficacy of pegylated interferon-alpha2 (IFN) versus HU in patients older than 60 years. Results: Response patterns were highly heterogeneous. In the large majority of patients, HU treatment was initially associated with a modest decline in the JAK2V617F allele burden in concert with a decline in leukocyte and platelet counts. However, HU did not induce a sustained and continuous decrease in the JAK2V617F allele burden in any patient as previously reported in patients being treated with IFN. Importantly, HU treatment was neither able to induce a sustained normalization of elevated leukocyte and platelet counts, although counts were temporarily normalized in most patients during the first months of therapy. The fluctuating leukocyte and platelet counts contrast the sustained normalization of cell counts in the large majority of patients during long term treatment with IFN. Discussion and Conclusions: Using data-driven analysis of the JAK2V617F allele burden, leukocyte and platelet kinetics during treatment with HU, we have shown that HU does not induce a sustained decrease in the JAK2V617F allele burden and neither induces sustained normalization of elevated cell counts in PV patients. Our results may explain why PV patients during treatment with HU still have a substantially increased risk of thrombosis. Based upon our previous and present findings, obtained by mathematical modelling and data driven analysis studies, a rational and cost-effective treatment might be a combination therapy of HU and IFN, both being used for decades in the treatment of PV but according to the findings in our studies now being proposed to be combined in the initial treatment period, since their combined effects might be highly efficacious and are foreseen to have the potential to minimize the risk of thrombosis and bleeding. By these studies, we have also proven mathematical modelling and data driven analysis to be highly important tools to decipher novel treatment modalities for patients suffering from MPN cancers but likely other cancers as well. Disclosures Hasselbalch: Novartis: Research Funding; AOP Orphan Pharmaceuticals: Other: Data monitoring board. OffLabel Disclosure: Interferon-alpha2 for the treatment of myeloproliferative neoplasms.

Baseline Mutational Status of Patients with Myelofibrosis and Anemia in the Realise Trial and Impact on Outcome

Baseline Mutational Status of Patients with Myelofibrosis and Anemia in the Realise Trial and Impact on Outcome