Bayer Pharma AG Research Articles

Interim Results of a First in Man Study with the Fc-Optimized FLT3 Antibody Flysyn for Treatment of Acute Myeloid Leukemia with Minimal Residual Disease

Background: Substantial surface expression of the FLT3 receptor can be measured on blast cells in 70% to 100% of acute myeloid leukemia (AML) patients, while no or only low levels are expressed on healthy cells like monocytes and progenitor stem cells. Thus, FLT3 is a suitable and highly selective target for therapeutic antibodies. FLYSYN is a chimeric Fc-optimized IgG1 antibody and binds specifically and with high avidity to human FLT3 (CD135). Despite achievement of complete remission, roughly half of AML patients display minimal residual disease (MRD) after end of therapy and relapse. Methods: We perform an open-label, single-arm, first in man multicenter trial to assess safety and tolerability as well as preliminary efficacy of FLYSYN as monotherapy in adult (≥18 years) AML patients in complete remission with MRD (NCT02789254). FLYSYN is administered as IV infusion over a 3 hour period. Recruitment started in March 2017 with an estimated maximum number of 31 patients and estimated recruitment until January 2020. The main inclusion criterion was confirmed stable or increasing MRD positivity in two sequential measurements. MRD was measured by central RT-qPCR and/or next generation sequencing (NGS). Sensitivity with RT-qPCR (for NPM1 only) was 10-6 and 10-4 with NGS. Patients with acute promyelocytic leukemia as well as prior hematopoietic stem cell transplantation were excluded. Using a "3 + 3" dose escalation design, five of the planned six cohorts with escalating doses have currently completed treatment (cohort 1: 0.5 mg/m² BSA; cohort 2: 1.5 mg/m² BSA; cohort 3: 5 mg/m² BSA; cohort 4: 15 mg/m² BSA; cohort 5: 45 mg/m²; cohort 6: in total 45 mg/m²; 15 mg/m² on day 1, 15 and 29). Three patients were treated per cohort, except for cohort 4, which was expanded to nine patients. The interim analysis for preliminary efficacy was performed after 18 patients were treated in cohorts 1-4. Response is defined as 1 log MRD reduction. Results: Median age was 60 years (range, 21-80 years). Sixteen patients were MRD positive for NPM1 and one patient each for RUNX1-RUNX1T1 and IDH2. So far, FLYSYN was well tolerated. Only one temporary grade 3 adverse event (AE) occurred (neutrophil decrease on day 3 only) in a patient of cohort 3, which was suspected to be related to FLYSYN treatment. There were no reported dose-limiting toxicities. The most frequently reported AEs were grade 1 and 2 gastrointestinal toxicities and laboratory abnormalities, which all were manageable with supportive care. After treatment, neither human anti-mouse nor anti-human antibodies were detected in any of the patients. Preliminary pharmacokinetic analysis was performed in the first 12 patients of the study and revealed a half-life of FLYSYN of roughly 6.5 days. Regarding preliminary efficacy, 1 patient of cohort 1 achieved permanent MRD negativity in bone marrow (BM; lasting until day 545) and 1 patient a temporary BM MRD reduction (at day 15). One patient of cohort 2 achieved BM MRD negativity (day 22) with MRD progression on day 365, whereas the other 2 patients were BM MRD progressive. None of the patients of cohort 3 achieved a MRD response in BM, but 2 patients achieved a temporary MRD response in peripheral blood. Four patients of cohort 4 achieved non-permanent BM MRD negativity. Overall, 6 patients achieved BM MRD negativity (33 %, 6/18), enduring more than 1 year in 1 patient. Conclusions: Our data suggest that FLYSYN is safe and very well tolerated as monotherapy in MRD positive AML patients. Preliminary efficacy data are promising, and recruiting is ongoing in cohort 6 in which 15 mg/m² FLYSYN is given for three times. Up-dated results will be presented at the ASH meeting. Disclosures Heuser: Bayer Pharma AG, Berlin: Research Funding; Synimmune: Research Funding. Müller-Tidow:MSD: Membership on an entity's Board of Directors or advisory committees. Steiner:Synimmune: Employment, Other: shareholder interest. Grosse-Hovest:SYNIMMUNE: Employment, Other: shareholder interest. Jung:Synimmune: Other: shareholder interest. Salih:SYNIMMUNE: Consultancy, Research Funding.

Durable Responses Observed in Elderly AML Patients Unfit for Intensive Chemotherapy with First-in Class Selective AXL Inhibitor Bemcentinib (BGB324) in Combination with LDAC: Phase II Open-Label Study

Durable Responses Observed in Elderly AML Patients Unfit for Intensive Chemotherapy with First-in Class Selective AXL Inhibitor Bemcentinib (BGB324) in Combination with LDAC: Phase II Open-Label Study

MN1 Expression Is an Indepedent Prognostic Marker in FLT3-Mutated Acute Myeloid Leukemia and Is Involved in the Resistance to FLT3 Inhibitors

Introduction: Meningioma 1 (MN1) gene was described as a prognostic marker for AML patients with normal karyotype (Carturan et al. Oncotarget 2016). In addition, MN1 high expression was linked to RA resistance and was shown to be necessary and sufficient to transform common myeloid progenitors in a MEIS1/AbdB-like HOX protein complex-dependent manner. However, the relevance of the copresence of MN1 overexpression in AML patients with mutations of the FLT3 and/or NPM1 genes is unknown. Moreover, it is also unknown the functional effects of MN1 in the biology of leukemic blasts harboring FLT3 mutations and if it may modulate the response to FLT3 inhibitors, such as quizartinib (AC220) and midostaurin (PKC). Aims: Herein, we investigated the prognostic impact of MN1 expression across multiple transcriptomic platforms and AML data sets. Additionally, we transduced different AML cell lines to evaluate the impact of MN1 on cell survival and differentiation. Methods: Three different AML series (1th: GSE6891, 240 patients, 2nd: TCGA, 113 patients and 3rd: BeatAML, 139 patients) were used. All patients presented similar gender distribution, were above 18y and treated by the 3+7 scheme. All genes from the RNAseq (TCGA) were pre-ranked according to their differential expression comparing tumors with high and low expression of MN1, using their median expression rate as the cutoff. GSEA was performed using the Reactome, KEGG and Hallmarks databases. Additionally, we transduced 07 AML cell lines with the MN1 gene and the control. For those cells, clonogenicity and proliferation rate was evaluated to identify which cell lines are sensitive and resistant to MN1. Drug induced apoptotic rate was assessed for FLT3-ITD- cell lines when treated with AraC (10 nM) and FLT3-ITD+ cell lines (MOLM13/MV411) upon treatment with PKC and AC220 over a time period of 24, 48 and 72 h. Apoptosis was further confirmed by cleaved Caspase-3/PARP detection. The myeloid differentiation in response to PMA treatment (100 ng/ml) was determined by the surface levels of CD11b, CD11c, CD14, CD15, CD61 and HLADR. Results: In all three AML series, high MN1 levels higher than the median (hereafter called High MN1) were associated with lower frequency of FLT3 and NPM1 mutations (P<.01 for all comparisons). Baseline features were similar between patients with low and high MN1 levels in all the cohorts. The median 5y OS rates were 33%, 29% and 41% in the GSE6891, TCGA and BeatAML, respectively. Multivariate analysis showed that patients carrying the FLT3 mutation who expressed high MN1 levels exhibited increased OS rates in the GSE6891 (50%), TCGA (50%) and BeatAML (71%) cohorts in comparison with patients with lower MN1 levels taking ELN, sex and age as confounders (P<.05). Regarding the patients with NPM1 and IDH1/2 mutations, high MN1 levels was associated with lower OS rates in all the cohorts. The analysis to predict genetic interactors in AML samples (BeatAML) revealed that MN1 is associated with cellular mediators of myeloid differentiation, such as FOXM1, CEBPA and MEIS1, and drug-resistance (CYP26A1). Additionally, GSEA indicated that the MN1 expression was associated with biological processes such as apoptosis, STAT5 signaling and Interferon response. In AML cell lines, induced MN1 overexpression strongly reduced growth, colony formation (basal and under treatment with PKC/AC220) and increased drug-induced apoptosis in both FLT3-ITD cells (P<.01 for all). Forced MN1 expression in FLT3-ITD cells lead to decreased cytokine mediated resistance to FLT3 inhibitors (PKC/AC220; P<.01 for all). Using a nonlinear regression analysis, IC50 for PKC and AC220 was significantly lower for MN1-expressing cells (PKC: 8.4 and 4.9 nM; AC220: 0.69 and 0.17 nM for MV411 and MOLM13, respectively) in comparison to control cells (PKC: 13.3 and 8.5 nM; AC220: 0.62 and 0.38 nM, respectively). 3 out of 7 cell lines showed increased cell proliferation when MN1 gene was overexpressed (P<.05). In accordance, MN1 overexpression reduced the drug-induced apoptosis rate in those AML cells with increased proliferation in a time-dependent manner (P<.05). Phorbol induced myeloid differentiation was decreased for all MN1 transduced cell lines (P<.01 for all), except for the THP1 cells. Conclusion: In summary, our results demonstrated that MN1 overexpression decreases cell viability and proliferation in FLT3-ITD+ cells and decreased resistance to FLT3 inhibitors. Disclosures Heuser: Bayer Pharma AG, Berlin: Research Funding; Synimmune: Research Funding.

Targeted Inhibition of the NUP98-NSD1 Fusion Oncogene in AML

Background: NUP98-NSD1 positive AML is a poor prognostic subgroup within pediatric and adult AML (Thol et al., 2013). However, targeted therapeutics for these AML patients are not available to date. As a result of the NUP98-NSD1 fusion, NSD1 causes H3K36 hypermethylation of HOXA genes, which contributes to myeloid progenitor cell immortalization and results in AML (Wang et al., 2007). Therefore, we hypothesized that inhibition of the methyltransferase activity of NSD1 could be an effective treatment strategy for NUP98-NSD1 AML patients. Here, we assessed the efficacy of NSD1 inhibitor suramin and NUP98-NSD1-directed siRNA-containing lipid nanoparticles (LNP) in a preclinical patient-derived xenograft (PDX) model of NUP98-NSD1 leukemia. Methods: A NUP98-NSD1 positive AML patient was screened through nested PCR and Sanger sequencing. Bone marrow cells from this patient were serially transplanted into NSG (NOD.Cg-Prkdcscid Il2rgtm1Wjl/SzJ) mice to establish a NUP98-NSD1 PDX model. During serial transplantations, an alternative NUP98-NSD1 fusion gene appeared. Flow-cytometry was used to check the engraftment and immunophenotype of engrafted cells. Effective siRNAs against each of the two fusion genes were developed. The microfluidic mixing technology, Nanoassemblr was used to package siRNA into LNPs and the Zetasizer was used to characterize them. Fifteen days after transplantation, suramin and solvent treatment were initiated in 9 mice per group with 10 mg/kg suramin (2 days/week for 10 weeks). For LNP treatment, treatment was initiated 3 weeks after transplantation with a once daily dose of 2.5 mg/kg on days 1-3 and then every third day thereafter for a total of 17 injections. Results: Besides the NUP98-NSD1 translocation, our patient had a FLT3-ITD mutation and a normal karyotype. In our PDX model, the engraftment of human leukemia cells reached up to 90% after ten weeks of transplantation. In successive transplantations up to the 6th generation, the NUP98-NSD1 fusion was confirmed in leukemic cells, supporting the importance of the fusion for leukemia development and stability of the model. In later transplantations, a minor clone of NUP98-NSD1 was identified. A high blast count, high WBC count, increased spleen weight, and a low hemoglobin and platelet count at death demonstrated the development of acute leukemia. High expression of myeloid markers (e.g. CD33, 99%, N=9) and negligible expression of lymphoid markers (CD3, 2%; CD19, 2%; N=9) confirmed acute myeloid leukemia. In the suramin treatment study, the mean human leukemic cell engraftment was similar between the control and treatment groups at the start of treatment (0.51%, N=9 and 0.71%, N=9, respectively), but was lower in suramin treated mice after 4 and 8 weeks of treatment (4 weeks: CTRL, 4,8%; suramin, 2,66%, P=0.1; 8 weeks: CTRL, 87,3%; suramin: 66,5%, P=0.016). No significant effect was seen on the immunophenotype of suramin and control treated leukemia cells. Suramin treatment significantly prolonged the median survival of mice compared to control mice (126 vs 114 days after transplantation, P=0.008). To establish the siRNA-LNP treatment, we identified one siRNA against each NUP98-NSD1 clone that reduced expression levels by 78% and 89.5% in the major and minor clones, respectively. The effective siRNAs were modified to increase their in vivo stability and were packaged into LNPs and used in vivo. We started the treatment when the engraftment was similar in both control LNP and NUP98-NSD1 LNP groups (0.93%, N=7 and 1.25%, N=6, respectively). After 3 weeks of treatment, LNP uptake was 99.3% and 99.2% in the CTRL LNP and NUP98-NSD1 LNP groups, respectively. The mean engraftment was lower in NUP98-NSD1 LNP mice after 5 and 8 weeks of treatment (5 weeks: CTRL LNP, 15%; NUP98-NSD1 LNP, 4.6%, P= 0.08; 8 weeks: CTRL LNP, 94.8%; NUP98-NSD1 LNP, 55.83%, P=0.007). Importantly, the NUP98-NSD1 siRNA-LNP treated mice showed a significant survival benefit compared to CTRL siRNA-LNP treated mice (106 vs 82 days after transplantation, P=0.02). Conclusions: In summary, our findings demonstrate that targeted inhibition of NUP98-NSD1 either through siRNA-LNP or suramin delays leukemia development in vivo and prolongs the survival of mice carrying a NUP98-NSD1 positive AML. Our results provide the rationale for the evaluation of NSD1 methyltransferase inhibitors and siRNA-LNP formulations in NUP98-NSD1 positive AML. Disclosures Heuser: Bayer Pharma AG, Berlin: Research Funding; Synimmune: Research Funding.

Arsenic Trioxide Abrogate MN1 Mediated RA-Resistance in Acute Promyelocytic Leukemia

Arsenic Trioxide Abrogate MN1 Mediated RA-Resistance in Acute Promyelocytic Leukemia

Novel Molecular Pathogenesis and Therapeutic Target in Acute Erythroid Leukemia

Acute erythroid leukemia (AEL) is a unique subtype of acute myeloid leukemia (AML) characterized by erythroid predominance and dysplasia, which is morphologically classified into two subtypes: pure erythroid and myeloid/erythroid leukemias (PEL and MEL). Clinically, AEL exhibits aggressive and rapid clinical course, which is considered to be linked to frequent TP53 mutations and complex karyotypes found in this subtype. Although multiple sequencing studies were conducted to explain such phenotypic variety and to search promising therapeutic targets, neither the diagnostic discrimination of PEL and MEL subtypes nor the establishment of standard therapeutic strategy has fully been successful. To clarify genetic characteristics and to identify novel therapeutic targets, we comprehensively characterized the mutation and copy number alteration (CNA) profiles and assessed differential impacts of the frequent driver genetic abnormalities on disease phenotypes and clinical outcomes. We initially analyzed 105 cases with AEL (PEL; n=10, MEL; n=69, and unspecified; n=26). Among these, 9 cases were serially analyzed at 2-6 time points. All samples were obtained according to protocols approved by the ethics board of each participating institution. As control, 907 cases with non-erythroid AML (NEL) distinguished by the low fraction (<50%) of erythroid cells in bone marrow were enrolled. Publicly available information on clinical and genetic findings was collected from previous publications, including The Cancer Genome Atlas and BeatAML datasets. In total, 1,012 cases with AML were enrolled in this study. The genetic profile in PEL and MEL were also compared with that of NEL. Finally, we recognized biological significance of the molecular defects by functional analysis of xenograft model, and showed novel therapeutic possibilities targeting pathogenic pathways. Most frequently observed were mutations in TP53 (39%), STAG2 (20%), and NPM1 (15%), and KMT2A-partial tandem duplication (PTD) (18%) in AEL. On the basis of mutational profiles, consensus clustering divided AEL into 4 subgroups. Group A (n=41, 39%) was defined by TP53 mutations into which all PELs were categorized. In CNA analysis, amplification in 9p, 19p, and 21q were significantly more enriched in PEL than NEL. Intriguingly, amplification of 9p, 19p, and 21q lesions commonly included JAK2, EPOR, and ERG loci, respectively. These genes were affected by amplification or mutations more frequently in AEL than NEL (Figure 1). Group B (n=19, 18%) was enriched for mutations in STAG2, which was significantly more frequent in MEL than in PEL (P<0.05). Compared to STAG2-mutated cases in NEL, those in MEL showed significantly higher frequency of KMT2A-PTD. Group C (n=16, 15%) was defined by NPM1 mutations frequently accompanied by PTPN11 mutations (50% in Group C). This combination was also distinct in MEL and was significantly more frequent than in NPM1-mutated NEL cohort (P<0.05). In Group D (n=29, 28%) without any TP53, STAG2, or NPM1 mutations (triple-negative), RUNX1, ASXL1, BCOR, PHF6, and U2AF1 mutations were enriched compared to triple-negative NEL. In addition, novel loss-of-function USP9X mutations were exclusively identified in Group D AEL (P<0.05, compared to triple-negative NEL), which has been implicated in erythroid leukemogenesis through the TGF beta pathway. Serial sample sequencing analysis revealed that JAK2 mutation positive myeloproliferative neoplasms evolved into PEL. Clinically, patients in Group A showed shorter overall survival time compared to those in any other group. To further search for a novel therapeutic target to the most severe type of AEL, JAK2 inhibitor was administered to xenograft models (from 2 cases) having JAK2 and EPOR amplifications and TP53 mutations. Engrafted cells showed in vitro activation of STAT5 and proliferative capacity enhanced with erythropoietin. In vivo analysis showed that inhibition of JAK/STAT pathway significantly suppressed cell growth and prolonged overall survival. In summary, our findings suggest that AEL is classified into 4 major subgroups having unique genetic and clinical features. PEL and MEL are genetically distinct subtypes, which was also highlighted by comparison to NEL. Frequent involvement of EPOR/JAK/STAT pathway suggests therapeutic indication of JAK inhibition for AEL especially in the most aggressive type of AEL cases with TP53 mutations. Disclosures Yoda: Chordia Therapeutics Inc.: Research Funding. Miyazaki:Kyowa-Kirin: Honoraria; Dainippon-Sumitomo: Honoraria; Nippon-Shinyaku: Honoraria; Chugai: Research Funding; Otsuka: Honoraria; Novartis: Honoraria. Takaori-Kondo:Pfizer: Honoraria; Chugai: Research Funding; Janssen: Honoraria; Kyowa Kirin: Research Funding; Takeda: Research Funding; Ono: Research Funding; Bristol-Myers Squibb: Honoraria, Research Funding; Celgene: Honoraria, Research Funding; Novartis: Honoraria. Nakagawa:Sumitomo Dainippon Pharma Co., Ltd.: Research Funding. Usuki:Astellas Pharma Inc: Research Funding, Speakers Bureau; Daiichi Sankyo Co., Ltd.: Research Funding, Speakers Bureau. Heuser:Bayer Pharma AG, Berlin: Research Funding; Synimmune: Research Funding. Maciejewski:Novartis: Consultancy; Alexion: Consultancy. Ogawa:Qiagen Corporation: Patents & Royalties; RegCell Corporation: Equity Ownership; Kan Research Laboratory, Inc.: Consultancy; ChordiaTherapeutics, Inc.: Consultancy, Equity Ownership; Asahi Genomics: Equity Ownership; Dainippon-Sumitomo Pharmaceutical, Inc.: Research Funding.

CJEU rules that repeal of provisional measure does not automatically create liability for wrongful enforcement

Abstract Court of Justice of the European Union, Case C-688/17 Bayer Pharma AG v Richter Gedeon Vegyészeti Gyár Nyrt. and Exeltis Magyarország Gyógyszerkereskedelmi Kft. (2019) EU:C:2019:722 In its ruling in Bayer, the Court of Justice of the European Union found that denial of compensation to a provisionally enjoined party in case of later revocation of a patent may be allowable under Article 9(7) of Directive 2004/48/EC (the Enforcement Directive).

P2772The rule-out criteria for chronic thromboembolic pulmonary hypertension can identify patients without haemodynamic abnormalities and functional limitation 3 and 12 months after acute PE

Abstract Background Up to one-third of patients report persisting hemodynamic abnormalities and functional limitation over long-term follow-up after acute pulmonary embolism (PE). Purpose We tested whether a validated algorithm designed to rule-out chronic thromboembolic pulmonary hypertension (CTEPH) after acute PE can be used for identifying patients at lower risk of presenting with persisting symptoms and echocardiographic abnormalities. Methods The multicentre Follow-up of Acute Pulmonary Embolism (FOCUS) cohort study prospectively enrolled 1,100 consecutive patients diagnosed with acute symptomatic PE; two-year follow-up is ongoing. We focused on the scheduled visits for 3- and 12-month follow-up. The rule-out criteria are based on: the absence of ECG signs of right ventricular dysfunction and normal NT-proBNP/BNP values. Echocardiographic abnormalities were defined according to the presence of abnormal parameters indicating an intermediate/high probability of pulmonary hypertension as recommended by the 2015 ESC/ERS Society Guidelines on Pulmonary Hypertension. The presence of functional limitation was defined based on a World Health Organization classification grade ≥3, a Borg dyspnoea index ≥4, or a 6-minute walking distance <300 m. Results We included 323 patients (mean age 61 years, 58% men), of whom 255 have meanwhile completed a one-year follow-up. At 3- and 12-month follow-up, 194 (60%) and 155 (61%) of patients exhibited no abnormal echocardiographic findings or natriuretic peptide levels. The percentage of patients with echocardiographic abnormalities was 20.4% and 18.0%, respectively. The negative predictive value of the score for ruling out the combination of functional limitation and intermediate/high probability of pulmonary hypertension as recommended by the 2015 ESC/ERS Guidelines on Pulmonary Hypertension was 0.96 (95% CI 0.92–0.98) at 3 and 0.97 (0.92–0.99) at 12 months. The corresponding positive predictive values were 0.10 (0.06–0.17) and 0.09 (0.05–0.17), respectively. Conclusions The CTEPH rule-out criteria are capable of excluding functional limitation and evidence of (chronic) pulmonary hypertension 3 and 12 months after the diagnosis of acute PE. Acknowledgement/Funding The sponsor (University Medical Center of the Johannes Gutenberg University, Mainz) has obtained grants from Bayer Vital GmbH and Bayer Pharma AG

P5017Factors associated with a negative D-dimer test in patients diagnosed with acute symptomatic pulmonary embolism

Abstract Background The recommended diagnostic strategy for suspected acute pulmonary embolism (PE) combines the assessment of pre-test probability, D-dimer level, and -if indicated- computed tomography pulmonary angiography. Purpose To evaluate the frequency and potential explanations for negative D-dimer tests in patients diagnosed with acute PE. Methods The multicentre Follow-up of Acute Pulmonary Embolism (FOCUS) cohort study prospectively enrolled 1,100 consecutive patients diagnosed with acute symptomatic PE; two-year follow-up is ongoing. The items of the Simplified revised Geneva Score and the D-dimer levels at diagnosis have been prospectively collected, but they did not necessarily guide management decisions. Quantitative D-dimer was measured on admission either by quantitative latex-based assays or enzyme-linked immunosorbent assays. A negative D-dimer was defined by fixed (0.50 μg/mL) or age-adjusted (age*0.01 μg/mL if age>50) cut-off. Results Using the fixed cut-off, a negative D-Dimer was detected in 17 of 773 patients with ultimately diagnosed PE (miss rate 2.2% [95% CI 1.4–3.5]); using the age-adjusted cut-off, the test was discordant with the PE diagnosis in 24 patients (3.1% [2.1–4.6]). In Figure 1, red dots indicate negative D-dimer test by fixed cut-off and blue dots indicate additional negative D-dimer tests by age-adjusted cut-off. In 448 (59%) patients post-hoc classified as PE-unlikely, 11 (2.5% [1.4–4.3]) and 14 (3.1% [1.9–5.2]) patients had a negative D-dimer using the two different cut-offs, respectively. Haemoptysis on admission, V/Q scan-based diagnosis, and chronic lung disease were associated with a discordant D-dimer, while an inverse association existed for concomitant DVT. In 7 (29%) PE cases with normal D-dimer, PE was verified to be subsegmental also in a post-hoc evaluation. Another seven (29%) patients were receiving anticoagulation at the time of D-dimer assessment. Figure 1 Conclusions Our results show that the frequency of discordance between a normal D-dimer test and the diagnosis of acute PE is low, but not negligible. One third of discordant findings were related to subsegmental PE. Physicians should be aware that the risk of obtaining a false-negative D-dimer might be higher in specific subgroups of patients. Acknowledgement/Funding The sponsor (University Medical Center of the Johannes Gutenberg University, Mainz) has obtained grants from Bayer Vital GmbH and Bayer Pharma AG

The impact of the administration of PRP and disease-modifying therapy on the synovial environment, general health and treatment efficacy in patients with osteoarthritis of the knee

The impact of the administration of PRP and disease-modifying therapy on the synovial environment, general health and treatment efficacy in patients with osteoarthritis of the knee

Ratify (Alliance 10603): Prognostic Impact of FLT3 tyrosine Kinase Domain (TKD) and NPM1 Mutation Status in Patients with Newly Diagnosed Acute Myeloid Leukemia (AML) Treated with Midostaurin or Placebo Plus Standard Chemotherapy

Ratify (Alliance 10603): Prognostic Impact of FLT3 tyrosine Kinase Domain (TKD) and NPM1 Mutation Status in Patients with Newly Diagnosed Acute Myeloid Leukemia (AML) Treated with Midostaurin or Placebo Plus Standard Chemotherapy

The Role of PPM1D Mutations in Lenalidomide Resistance and Progression in Patients with MDS and Deletion of Chromosome 5q

The Role of PPM1D Mutations in Lenalidomide Resistance and Progression in Patients with MDS and Deletion of Chromosome 5q

Gemtuzumab Ozogamicin in NPM1-Mutated Acute Myeloid Leukemia (AML): Results from the Prospective Randomized AMLSG 09-09 Phase-III Study

Gemtuzumab Ozogamicin in NPM1-Mutated Acute Myeloid Leukemia (AML): Results from the Prospective Randomized AMLSG 09-09 Phase-III Study

Prolyl Hydroxylase 3 (Phd3) Is a Therapeutic Target in Isocitrate Dehydrogenase 1 (IDH1) Mutated Acute Myeloid Leukemia

Background: About 40% of IDH1 mutated (IDH1mut) acute myeloid leukemia (AML) patients respond to IDH1 inhibitors with a median duration of response of 8.2 months. A better understanding of the biology of IDH1mut leukemia may further improve the treatment of these patients. IDH1mut produces R-2-hydroxyglutarate (R-2HG), which activates PHD1 and PHD2 but have negligible effects on PHD3. In the present study we assessed whether PHD3 plays a role in the pathogenesis of IDH1 mutated leukemia and can be targeted in a patient-derived xenograft (PDX) model of IDH1 mutated AML.Methods: Bone marrow cells from Phdwt and Phd3ko mice were immortalized with HoxA9, and IDH1wildtype (IDH1wt) and IDH1mut respectively, were constitutively expressed. The effects on cell proliferation, apoptosis and colony formation were evaluated in vitro, whereas the leukemic potential was evaluated in vivo by transplantation in syngeneic mice. To show that PHD3 is a therapeutic target, either IDH1mut cells from AML patients were transduced with shRNA against PHD3 and transplanted in immunocompromised mice, or leukemic cells from an AML patient with mutated IDH1 were xenografted in immunocompromised mice and treated with the PHD inhibitor molidustat.Results: In in-vitro functional assays loss of Phd3 specifically impaired proliferation, apoptosis and clonogenic capacity of HoxA9-IDH1mut but not HoxA9-IDH1wt cells. Likewise, in mouse transplantation assays, loss of Phd3 eliminated HoxA9-IDH1mut induced leukemia. However, Phd3 was dispensable to the engraftment and proliferation of HoxA9-IDH1wt cells. Additionally, the IDH1-independent model of MN1-induced leukemia remained unaltered in the absence of Phd3, indicating the specificity of the role of Phd3 in mutant IDH1-induced transformation. To identify molecular pathways that might explain in vitro and in vivo phenotypes gene expression profiling was performed. Immune and stress-response pathways as well as metabolism-related genes were most prominently dysregulated in Phd3ko IDH1-mutant cells. Analysis of dysregulated transcription factors by gene set enrichment analysis revealed a depletion of key oncogenic transcription factors (Myc, Rb, Stk33, and Rps14) in Phd3ko IDH1mut cells compared to Phd3ko IDH1wt cells. To study if IDH1mut signals to Phd3 through R-2HG, we transduced Phd3kocells, with a splice variant of mutant IDH1, which does not produce R-2HG but causes leukemia in mice with similar kinetics as in mice with the full-length IDH1 mutant protein. Interestingly, loss of Phd3 also eliminated leukemia in these mice, which demonstrates that mutant IDH1 signals through Phd3 independently of R-2HG. To study the functional relevance of PHD3 inhibition in patients, cells from an IDH1 mutated AML patient were transduced with an shRNA against PHD3 and were transplanted in immunodeficient NSG mice. Inhibition of PHD3 depleted human AML cells in the IDH1-mutated PDX model. Moreover, the PHD inhibitor molidustat was 50-fold more active in IDH1mut (80 nM) compared to IDH1wt AML patient cells (4000 nM) in colony-forming unit assays. In a xenograft model of IDH1 mutated AML, molidustat significantly prolonged survival compared to control-treated mice (P<.001).Conclusion: We demonstrate that the leukemogenic activity of the mutant IDH1 protein depends on PHD3 independently of R-2HG. We identified inhibition of PHD3 as a novel therapeutic strategy in IDH1 mutated AML. Since PHD3 can be targeted pharmacologically, combinatorial treatment of PHD3 and IDH1 inhibitors is warranted to improve eradication of leukemic stem cells in IDH1 mutated AML.#AC and MMAC share first authorship DisclosuresGanser:Novartis: Membership on an entity's Board of Directors or advisory committees. Heuser:Karyopharm: Research Funding; Daiichi Sankyo: Research Funding; Sunesis: Research Funding; Tetralogic: Research Funding; Bayer Pharma AG: Consultancy, Research Funding; StemLine Therapeutics: Consultancy; Janssen: Consultancy; Pfizer: Consultancy, Honoraria, Research Funding; BergenBio: Research Funding; Astellas: Research Funding; Novartis: Consultancy, Honoraria, Research Funding.

Functional Screening for Pathways Regulating Chemoresistance and Sensitivity in Leukemia Stem Cells

INTRODUCTIONOn average 5 recurrent mutations are present in each patient with acute myeloid leukemia (AML). Many mutated genes are implicated as tumor suppressor genes, but their contribution to leukemia stem cell (LSC) survival and chemoresistance is often unknown. We hypothesized that ectopic expression of the wildtype sequence of these genes will restore the function of the tumor suppressor gene and will lead to reduced clonal expansion and increased chemosensitivity.AIMTo evaluate the contribution of recurrently mutated genes to leukemia stem cell survival and chemoresistance in human AML cells in vitro and in vivo.METHODSWe performed a loss-of-function screening in primary human AML cells and cell lines by lentiviral expression of a pool of 22 wildtype genes associated with AML pathogenesis, which can restore gene function of a repressed pathway or a dysfunctional tumor suppressor gene. The 22 full-length cDNAs were labelled with a genetic barcode, which can be amplified with a common primer for all 22 genes. The readout of the screening was reduced representation of the barcode DNA after in vitro culture or in vivo growth in patient-derived xenograft (PDX) models, which was amplified from DNA and quantified by next-generation sequencing (NGS).Five PDX models with favorable, normal or complex cytogenetics and 3-5 recurrent mutations per model were screened in order to identify cDNAs that could potentially limit the proliferative capacity of LSCs in vivo (5 mice per model). Nine to 16 weeks after transplantation, DNA from blood, bone marrow and spleen were analyzed by NGS. We also screened two CD34+-enriched cord blood samples in vitro. After transduction with the cDNA pool, cells were cultured for 11 days and the barcode representation was analyzed by NGS at days 2, 4, 7, 9 and 11.Finally, we screened the human leukemia cell lines U937and PB14, a newly established cell line from an AML patient with mutations in FLT3, NPM1, RAD21, GSE1, and ROBO2. Cells were treated with cytarabine, doxorubicin or venetoclax for a 3-day period, followed by a 4-day recovery period to allow outgrowth of resistant clones and accumulation of cDNAs that conferred drug resistance.RESULTSOur loss-of-function screening with overexpressed wildtype genes revealed that expression of ETV6 and PTPN11 depleted LSCs in 3 of 5 PDX models and that expression of CEBPA and KDM6A depleted the progeny of normal CD34+ cells in cord blood. ASXL1, EZH2, CUX1, SMC1A and SMC3 had a general negative effect on stem cell self-renewal in both leukemic and normal CD34+ cells.Relative frequencies of the leukemia-specific genes ETV6 and PTPN11 were reduced 3 to 16-fold and 2 to 3-fold, respectively. Both genes were not mutated in the 3 patients' diagnostic samples, but had reduced RNA expression by 10-70% compared to healthy control peripheral blood mononuclear cells. Relative frequencies of cord blood-specific CEBPA was reduced 4-fold and KDM6A 5-fold.We then evaluated whether activation of a repressed pathway can increase sensitivity to cytarabine, doxorubicin or venetoclax in U937 and PB14 cells after 1 or 2 weeks of treatment. All three drugs showed better cytotoxic effects upon p53 expression in both cell lines by a factor of 1.4 to 2.5 fold. Cytarabine and venetoclax improved elimination of leukemic cells that had been transduced with U2AF1 in PB14 cells, which are U2AF1 wildtype. Venetoclax improved elimination of U937 cells that had been transduced with ETV6 or KDM6A, which are wildtype for these genes, while RNA expression was reduced more than 50% in these cells compared to other leukemic cell lines (NB4 and MV4-11).CONCLUSIONFunctional cDNA screening in PDX models in vivo is feasible and can reveal selective vulnerabilities of leukemic compared to normal stem cells. Our approach was validated by the finding that p53 expression improved chemosensitivity for all drugs tested in two leukemia cell lines, which is expected from the known function of p53 as a critical tumor suppressor gene.Similarly, overexpression of the transcriptional corepressor ETV6 in leukemia cells with low ETV6 expression was found to inhibit leukemia stem cell proliferation in vivo and to sensitize U937 cells to venetoclax. Therefore, activation of ETV6 should be explored as a novel strategy to inhibit LSCs and improve treatment response. DisclosuresGanser:Novartis: Membership on an entity's Board of Directors or advisory committees. Heuser:Janssen: Consultancy; StemLine Therapeutics: Consultancy; Bayer Pharma AG: Consultancy, Research Funding; Tetralogic: Research Funding; Sunesis: Research Funding; Daiichi Sankyo: Research Funding; Karyopharm: Research Funding; BergenBio: Research Funding; Astellas: Research Funding; Novartis: Consultancy, Honoraria, Research Funding; Pfizer: Consultancy, Honoraria, Research Funding.

Signaling Pathways of Mutant IDH1 Independent of R-2-Hydroxyglutarate

#Michael Heuser and Anuhar Chaturvedi share senior authorshipBackground: Isocitrate dehydrogenase-1 (IDH1) is mutated in about 6% of AML patients. Mutant IDH produces R-2-hydroxyglutarate (R-2HG), which induces histone and DNA hypermethylation through inhibition of epigenetic regulators, thereby linking metabolism to tumorigenesis. We recently reported that at comparable intracellular R-2HG levels, mice receiving transplants of IDH1 mutant cells died significantly earlier than R-2HG treated mice in the context of HOXA9 overexpression. This suggests oncogenic functions of mutant IDH1 beyond R-2HG production. We employed a splice variant of mutated IDH1 that does not produce R-2HG (IDH1mutantΔ7) to decipher R-2HG independent signaling pathways that may contribute towards leukemogenesis.Methods: Bone marrow cells from mice were immortalized with HoxA9, and IDH1wildtype (IDH1wt), IDH1mutant (IDH1mut), IDH1wildtypeΔ7 (IDH1wtΔ7) and IDH1mutΔ7, were constitutively expressed and the leukemogenic potential was evaluated in vivo. Intracellular R-2HG was measured by enantiomer-specific quantification. Deletion of exon 7 from IDH1mut leads to a frameshift that creates a premature stop codon in the 9th exon, finally producing a 119 amino acids truncated protein, IDH1mutΔ7. This splice variant does not produce increased levels of R-2HG. The signaling pathways were explored by immunoblotting and immunofluorescence.Results: Mice receiving cells with IDH1mutΔ7 had the same short latency to leukemia as mice receiving cells with full-length mutant IDH1, while IDH1wt and IDH1wtΔ7 cells died with significantly longer latency. The WBC count increased over time in IDH1mutΔ7 mice similar to IDH1mut mice, whereas WBC counts in IDH1wtΔ7 mice remained normal. IDH1mutΔ7 mice died from monocytic leukemia that was phenotypically and morphologically indistinguishable from IDH1mut mice. HoxA9 IDH1mutΔ7 cells were readily transplantable into secondary recipients. During in vivo cell cycle analysis, we observed that the proportion of cells in S/G2/M phases was significantly higher in bone marrow cells transduced with IDH1mut or IDH1mutΔ7 when compared to cells transduced with IDH1wt or CTL. These data suggest that mutant IDH1 enhances myeloproliferation even in the absence of R-2HG.To identify R-2HG independent signaling pathways mediated by the mutant IDH1 protein, we first analyzed the gene expression of important regulators of cell cycle, differentiation, cell signaling and transcription by quantitative RT-PCR. Several genes (Ccnd1, Slc2a, Hdac3, Tgif2,and c-myc) were upregulated in IDH1mut and IDH1mutΔ7 cells compared to IDH1wt cells. Interestingly, we found a specific up-regulation of Ctnnb1 and Nfkb genes in IDH1mutΔ7 cells over both IDH1mut and IDH1wt cells. We next validated our mRNA expression results by immunoblotting and found that NFKB and ERK signaling were upregulated in both IDH1mut and IDH1mutΔ7 compared to IDH1wt and IDH1wtΔ7 cells. Interestingly, the protein level of β-catenin, STAT3 and STAT5 were many fold higher in IDH1mutΔ7 compared to IDH1mut and IDH1wt cells. β-catenin is known to be transactivated via c-Src, which is phosphorylated by EGFR to promote β-catenin nuclear localization and signaling. We traced this pathway for its relevance in our cells and found that IDH1mutΔ7 cells indeed showed higher levels of both EGFR and c-Src phosphorylation compared to IDH1mut cells. We performed immunofluorescence and cellular fractionation for β-catenin and found it to be partially localized in the nucleus in IDH1mutΔ7 but not in IDH1mut cells. We also observed an up-regulated STAT3 phosphorylation in IDH1mutΔ7 cells over IDH1mut.Conclusions: In summary, mutant IDH1 activates ERK and NFKB signaling, which is attributed to both R-2HG dependent and independent mechanisms of leukemogenesis. Interestingly, IDH1mutΔ7 employs R-2HG independent EGFR/β-catenin and JAK/STAT signaling for oncogenesis. This R-2HG-independent leukemogenesis reveals a novel signaling dynamic of IDH1mut which should be evaluated for its therapeutic potential. DisclosuresGanser:Novartis: Membership on an entity's Board of Directors or advisory committees. Heuser:Astellas: Research Funding; Karyopharm: Research Funding; Novartis: Consultancy, Honoraria, Research Funding; Pfizer: Consultancy, Honoraria, Research Funding; Janssen: Consultancy; StemLine Therapeutics: Consultancy; Bayer Pharma AG: Consultancy, Research Funding; Sunesis: Research Funding; BergenBio: Research Funding; Tetralogic: Research Funding; Daiichi Sankyo: Research Funding.

Biomarkers of Overall Survival and Response to Glasdegib and Intensive or Non-Intensive Chemotherapy in Patients with Acute Myeloid Leukemia

Background: In a previously reported Phase 2 randomized study of patients with acute myeloid leukemia (AML), addition of the investigational agent glasdegib (PF-04449913) to low-dose cytarabine (LDAC) improved overall survival (OS) when compared with LDAC alone. In a non-randomized study arm, glasdegib together with 7+3 chemotherapy was well tolerated and associated with clinical activity. We used a comprehensive biomarker analysis, evaluating gene expression, circulating cytokine levels, and gene mutations, to identify molecular drivers that predict overall response (OR) and OS.Methods: In this Phase 2 multicenter study (NCT01546038), patients with AML who were suitable for non-intensive therapy were randomized (2:1) to LDAC + glasdegib 100 mg QD or LDAC alone, and patients suitable for intensive therapy were assigned 7+3 plus glasdegib 100 mg QD. Whole blood, serum, and bone marrow aspirate samples were collected at baseline, and used to assess 19 genes for expression analysis, 38 analytes for circulating cytokine levels, and 109 genes for mutation analysis. Gene expression was analyzed using TaqMan Low Density Array Cards (TLDCs), cytokine levels were analyzed using quantitative, multiplexed immunoassays (Myriad RBM), and mutation analysis was performed using the Illumina® MiSeq instrument (San Diego, CA). All correlations were performed either for OS or for OR. For gene expression and cytokine analysis, a cut-off value above or below the median expression level for each treatment arm was used to separate samples into two subgroups (< or ≥ the median value) to explore the relationship of expression levels with OS data. Criteria for significance in the non-intensive cohort required one subgroup to have a p-value of <0.05 in the between-treatment arms comparison and the HR difference between the two subgroups to be ≥2 fold. Responses were defined as patients with a complete remission (CR), CR with incomplete blood count recovery (CRi), morphologic leukemia-free state, partial remission (PR), or PRi. For response correlations, genes or cytokines were considered to be differentially expressed if they had a p-value <0.05 and were differentially expressed by ≥2-fold.Results: Within the non-intensive arm (LDAC + glasdegib, n=68; LDAC alone, n=30), expression levels of several genes correlated with improved OS with glasdegib plus LDAC. Lower levels of expression of FOXM1 and MSI2, and higher expression levels of BCL2 and CCND2 correlated with improved OS with the combination. Additionally, lower levels of the cytokines 6CKINE (CCL21), ICAM-1, MIP-1α, and MMP-3 correlated with improved OS. An analysis of correlations of gene expression and cytokine levels with OR could not be completed due to the low number of responders in the LDAC only group (n=2). In the intensive treatment arm (glasdegib and 7+3, n=59), higher PTCH1 expression correlated with improved OS (p=0.0219, median OS 10.8 versus 39.5 months). In this cohort, lower levels of IL-8 (p=0.0225) and MIP-3β (p=0.0403) correlated with lower OS. Expression levels of no genes or cytokines significantly correlated with OR in this arm. We also examined correlations between gene mutation status and OS in both study arms. In the non-intensive arm (LDAC + glasdegib, n=58; LDAC alone, n=25), no genes mutated in at least 5 patients correlated with OS. In the intensive treatment arm (n=47), mutations in FLT3, TP53, CEP170, NPM1, and ANKRD26 correlated with OS (all p<0.05). Patients in this arm with FLT3 mutations responded better than patients with wild type FLT3 (p=0.0336, median OS of 13.1 months versus unreached for FLT3 mutant).Conclusions: In this biomarker analysis, we found that expression levels of a select number of genes and circulating cytokines implicated in AML correlated with OS in the non-intensive and the intensive arms. The improved response for patients with FLT3 mutations and high PTCH1 expression levels in the intensive arm deserves further investigation. These findings need to be verified in larger controlled studies, which are ongoing. DisclosuresCortes:Novartis: Consultancy, Research Funding; Daiichi Sankyo: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; Astellas Pharma: Consultancy, Research Funding; Arog: Research Funding. Pollyea:Argenx: Consultancy, Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Gilead: Consultancy; Celyad: Consultancy, Membership on an entity's Board of Directors or advisory committees; AbbVie: Consultancy, Research Funding; Curis: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Karyopharm: Membership on an entity's Board of Directors or advisory committees; Agios: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding. Heuser:Astellas: Research Funding; Daiichi Sankyo: Research Funding; Sunesis: Research Funding; Tetralogic: Research Funding; Bayer Pharma AG: Consultancy, Research Funding; StemLine Therapeutics: Consultancy; Janssen: Consultancy; Pfizer: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Honoraria, Research Funding; BergenBio: Research Funding; Karyopharm: Research Funding. Chan:Pfizer: Employment, Equity Ownership. Wang:Pfizer: Employment, Equity Ownership. Ching:Pfizer Inc: Employment, Equity Ownership. Johnson:Pfizer Inc: Employment, Equity Ownership. O'Brien:Pfizer Inc: Employment, Equity Ownership.

A Pilot Study Comparing 2- and 3-dimensional Ultrasound Imaging for Confirmation of Essure Fallopian Tube Pregnancy Prevention Implants

To show the feasibility of 2-dimensional (2D) ultrasound (US) imaging compared with 3-dimensional (3D) US to identify the location of implants and assess if the classification developed by Simorre et al in 2016 was applicable to the 2 types of US imaging (i.e., 2D and 3D). A prospective study (Canadian Task Force classification II-2). The department of obstetrics and gynecology in a teaching hospital. One hundred fifty patients who had undergone hysteroscopic sterilization with Essure (Bayer Pharma AG Laboratory, Lyon, France) fallopian tube pregnancy prevention implants were invited by letter to participate in the study; 50 replied positively between January and August 2017. An initial 2D US was performed followed by 3D US reconstruction. The primary end point was to compare the identification of device placement with 2D and 3D US imaging procedures according to this new classification. Secondary considerations were to evaluate the difficulty of attaining images, the quality of implant curvature, the duration of each imaging procedure, and the number of images performed for each technique. Ninety-six percent of tubal implants were observed via 3D US compared with 100% via 2D US. The mean time of 2D US was 14.64 seconds for the right fallopian tube and 15.25 seconds for the left fallopian tube compared with 25.11 seconds for the right and 31.57 seconds for the left fallopian tube in 3D US (p <.01). The mean number of image acquisitions per patient was 1.02 (±0.14 standard deviation) for 2D US compared with 1.37 (±0.64 standard deviation) for 3D US (p <.01). The sonographer had no difficulty performing 2D US in 88% of cases compared with 58% of 3D US cases. Two-dimensional ultrasound appears to be an acceptable alternative to 3D US. We propose a 2D classification for cross section device localization to facilitate image interpretation.

Doppler-Based Renal Venous Stasis Index as a New Prognostic Marker in Right Heart Failure

Background: Persistent congestion with deteriorating renal function is an important cause of adverse outcomes in heart failure. Renal Doppler ultrasonography has been proposed to assess renal congestion but is not fully characterized, and current approaches do not reflect the full continuum of renal congestion. We aimed to characterize new approaches to evaluate renal congestion using Doppler ultrasonography. Methods: We enrolled 205 patients with suspected or pre-diagnosed pulmonary hypertension (PH) undergoing right heart catheterization. PH is the most common precursor to right ventricular failure, and thus represents an ideal scenario to study congestion. Patients underwent renal Doppler ultrasonography and assessment of invasive cardiopulmonary haemodynamics, echocardiography, renal function, intra-abdominal pressure, and hormonal and hydration status. Four renal venous flow patterns (RVFPs) and a novel renal venous stasis index (RVSI) were defined. The rate of PH-related morbidity and all-cause mortality (composite endpoint) was evaluated for 1 year post-discharge. Associations with outcome were assessed using Cox proportional hazard models. Prognostic utility of RVSI and RVFP was compared using receiver operating characteristic (ROC) curves. Findings: RVSI increased across the RVFPs (p<0*0001), and was significantly associated with right heart and renal function, intra-abdominal pressure, and hormonal and hydration status. During follow-up, the morbidity/mortality endpoint occurred in 91 patients and was independently predicted by RVSI (RVSI in 3rd tertile vs RVSI=0: hazard ratio 4*72 [95% confidence interval 2*10-10*59; p<0*0001]). ROC curves suggested superiority of RVSI to RVFPs in predicting outcome (area under curve: 0*789 and 0*761, respectively). Interpretation: We describe four RVFPs, and we propose RVSI as a conceptually new, non-invasive, objective, and reproducible Doppler index of renal congestion. RVSI might provide additional information to stratify vulnerable patients with right heart failure. Clinical Trial Number: The study is registered at www.ClinicalTrials.gov (NCT03039959). Funding: This study was funded by the German Research Foundation (DFG) SFB1213, projects B08 and B07. Declaration of Interests: Dr. Seeger disclosed personal fees for consulting from Bayer Pharma AG, from Liquidia Technologies, Inc, and from United Therapeutics Corporation outside the submitted work. Dr. Gall discloses personal fees and non-financial support from Actelion, AstraZeneca, Bayer, BMS, GlaxoSmithKline, Janssen Cilag, Lilly, MSD, Novartis, Pfizer, and United Therapeutics/OMT outside the submitted work. Dr. Gofrani discloses grants from German Research Foundation (DFG) during the conduct of the study, and personal fees from Actelion, Bayer, GSK, Novartis, Pfizer, Bellerophon Pulse Technologies, and MSD Merck Sharpe & Dohme outside the submitted work. None of the other authors declare any competing interests. Ethical Approval Statement: The study was approved by the local Human Research Ethics Committee (AZ 237/16) and complied with the Declaration of Helsinki. All participants gave signed informed consent and were included in the Giessen PH registry.

Characteristics and Management of Patients with Venous Thromboembolism: The GARFIELD-VTE Registry

Background: Management of venous thromboembolism (VTE), encompassing both deep-vein thrombosis (DVT) and pulmonary embolism (PE), varies worldwide. Methods: The Global Anticoagulant Registry in the FIELD - Venous Thromboembolism (GARFIELD-VTE) is a prospective, observational study of 10,685 patients with objectively diagnosed VTE recruited from May 2014 to January 2017 at 417 sites in 28 countries. All patients are followed for at least 3 years. We describe the baseline characteristics of the study population and their management within 30 days of diagnosis. Findings: The median age was 60.2 years; 50.4% were male; 61.7% had DVT and 38.3% had PE ± DVT and 32.3% were obese (BMI≥30 kg/m2). The most common risk factors were surgery (12.5%), hospitalization (12.0%), and trauma to the lower limbs (7.8%). At the time of VTE diagnosis, 10.1% had active cancer and 5.7% were chronically immobilized. Treatment for VTE was anticoagulant (AC) therapy alone in 90.9% of patients; 5.1% received thrombolytic and/or surgical/mechanical therapy ± AC and 4.0% received no therapy. Pre-diagnosis, 12.8% received AC therapy alone and 0.2% received thrombolytic and/or surgical/mechanical therapy ± AC. After diagnosis, parenteral AC therapy alone was administered in 17.6% of patients, and it was followed by a direct oral anticoagulant (DOAC) in 16.4% or a vitamin K antagonist (VKA) in 26.8%. DOACs alone were prescribed to 32.3% of patients; 5.9% received VKA alone. Interpretation: The initial findings from this global registry highlight the heterogeneity in characteristics and management of VTE patients. Prospective follow-up will reveal the impact of this heterogeneity on outcomes. Interpretation: The initial findings from this global registry highlight the heterogeneity in characteristics and management of VTE patients. Prospective follow-up will reveal the impact of this heterogeneity on outcomes. Clinical Trial Number: (ClinicalTrials.gov identifier: NCT02155491) Funding Statement: The GARFIELD-VTE Registry is an independent academic research initiative sponsored by the Thrombosis Research Institute (London, UK) and supported by an unrestricted research grant from Bayer Pharma AG (Berlin, Germany). Declaration of Interests: Walter Ageno: Honoraria from Boehringer Ingelheim, Bayer Pharmaceuticals, BMS-Pfizer and Daiichi-Sankyo. Research support from Bayer Pharmaceuticals and Boehringer Ingelheim. Sylvia Haas: Honoraria from Aspen, Bayer Healthcare, BMS, Daiichi-Sankyo, Pfizer, Portola, Sanofi. Jeffrey I. Weitz: Honoraria from Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Daiichi-Sankyo, Ionis, Janssen, Merck, Portola, Pfizer, Servier and Novartis. Samuel Z. Goldhaber: Grants from BiO2 Medical, Boehringer-Ingelheim, Bristol Meyers Squibb, BTG EKOS, Daiichi-Sankyo, National Heart Lung and Blood Institute of the National Institutes of Health, Janssen and the Thrombosis Research Group. Personal fees (all consultancy less than $10k) from Bayer, Boehringer-Ingelheim, Bristol Meyers Squibb, Daiichi-Sankyo, Janssen, Portola, Zafgen. Alexander G. G. Turpie: Personal fees from Bayer Pharma AG, Janssen. Shinya Goto: Honoraria from Sanofi, AstraZeneca and Bayer. Research funding from Sanofi. Sebastian Schellong: Speaker fees from Bayer Healthcare, Boehringer Ingelheim, Bristol Meyer Squibb, Daiichi-Sankyo, Sanofi Aventis and Pfizer. Consultancy fees from Bayer Healthcare, Boehringer Ingelheim, Daiichi-Sankyo, Sanofi Aventis and Pfizer. Joern Dalsgaard Nielsen: Honoraria from Bayer, Boehringer-Ingelheim, Bristol Myers Squibb, Leo Pharma and Pfizer. Henri Bounameaux: Research grant, speaker’s fees and honoraria for studies with rivaroxaban from Bayer Healthcare. Honoraria from Sanofi. Lorenzo Mantovani: Grants and personal fees from Bayer Healthcare, Boehringer Ingelheim, Pfizer and Daiichi-Sankyo. Paolo Prandoni: Personal fees from Bayer Pharma, Pfizer, Daiichi-Sankyo, Sanofi and Rovi Pharmaceuticos. Professor Ajay K Kakkar is a principal investigator and received research Grants from Bayer Healthcare; he received personal fee from Bayer Healthcare, Boehringer-Ingelheim Pharma, Daiichi-Sankyo Europe, Sanofi SA and Janssen Pharma. Pantep Angchaisuksiri, Karen Pieper and Gloria Kayani declare that they have no conflicts of interest in the research. Ethics Approval Statement: Independent ethics committee for each participating country and the hospital-based institutional review board approved the design of the registry. All patients provided written informed consent to participate.