Bayer Pharma Research Articles

Best of both worlds: An expansion of the state of the art pKa model with data from three industrial partners.

In a unique collaboration between Simulations Plus and several industrial partners, we were able to develop a new version 11.0 of the previously published in silico pKa model, S+pKa, with considerably improved prediction accuracy. The model's training set was vastly expanded by large amounts of experimental data obtained from F. Hoffmann-La Roche AG, Genentech Inc., and the Crop Science division of Bayer AG. The previous v7.0 of S+pKa was trained on data from public sources and the Pharmaceutical division of Bayer AG. The model has shown dramatic improvements in predictive accuracy when externally validated on three new contributor compound sets. Less expected was v11.0's improvement in prediction on new compounds developed at Bayer Pharma after v7.0 was released (2013-2023), even without contributing additional data to v11.0. We illustrate chemical space coverage by chemistries encountered in the five domains, public and industrial, outline model construction, and discuss factors contributing to model's success.

FRI619 Kidney Magnetic Resonance Imaging Reveals Altered Tissue Architecture In Young Persons With Type 1 And 2 Diabetes

Abstract Disclosure: S. Poon: None. K. Nash: None. Y. Choi: None. L. Li: None. P. Prasad: None. D. Raalte: Other; Self; consulting relationships with Boehringer Ingelheim, Eli Lilly, Merck and Sanofi, and receives research operating funding from AstraZeneca, Boehringer Ingelheim-Eli Lilly Diabetes Alliance, MSD. A. Karihaloo: Employee; Self; Novo Nordisk. A. Sawyer: None. P. Bjornstad: Advisory Board Member; Self; AstraZeneca, Bayer, Lilly, Boehringer Ingelheim, Novo Nordisk, and XORTX. Other; Self; PB reports serving or having served as a consultant for AstraZeneca, Bayer, Bristol-Myers Squibb, Boehringer Ingelheim, Eli Lilly, LG Chemistry, Sanofi, Novo Nordisk, and Horizon Pharma. Background: Apparent diffusion coefficient (ADC) by magnetic resonance imaging (MRI) provides information about the microstructure and cellular organization of the kidney, and has been linked with kidney function decline in adults with chronic kidney disease. However, it is unclear whether alterations in tissue architecture or cellular density are also present in young persons with type 1 and 2 diabetes. Accordingly, the objective of this analysis was to determine early changes in ADC among young persons with and without diabetes. Materials and Method: Kidney MRIs were performed in 37 lean controls (age: 18±6 years, 54% female, eGFR: 106±19 ml/min/1.73m2), 28 participants with youth-onset T1D (age: 20±4 years, 50% female, diabetes duration: 9±6 years, HbA1c: 8.3±1.3%, eGFR: 110±19 ml/min/1.73m2) and 30 participants with youth-onset T2D (age: 17±4 years, 62% female, diabetes duration: 2±2 years, HbA1c: 7.4±2.2%, eGFR: 127±24 ml/min/1.73m2). All scans were performed on 3T whole-body scanners. A single reader at The NorthShore University HealthSystem analyzed all images while blinded to participants’ clinical information. Lower values of cortical ADC on diffusion-weighted MRI may indicate increased cellular density and are often used to estimate fibrosis. Estimated GFR (eGFR) were calculated by Full Age Spectrum serum creatinine equation. We performed multivariable linear regression models adjusted for age and sex. Results: Compared to lean controls (age and sex-adjusted means ± standard errors (SE): (1722±22 × 10−6 mm2/s), young persons with T1D (1636±28 × 10−6 mm2/s, p=0.02) and T2D (1612±27 × 10−6 mm2/s, p=0.002) exhibited lower cortical ADC. Despite younger age and shorter diabetes duration, young persons with T2D had numerically lower cortical ADC compared to those with T1D, although the difference did not reach statistical significance. Higher age and male sex were associated with lower cortical ADC (β±SE: −7.5±2.8 x 10−6 mm2/s per 1 year of age, p=0.009; β±SE: −71.1±28.5 x 10−6 mm2/s per 1 year for male sex, p=0.008) in multivariable models. Lower eGFR was associated with lower cortical ADC (β±SE: 2.3±0.8 x 10−6 mm2/s per 1 ml/min/1.73m2 increment eGFR, p=0.005). HbA1c and urine albumin-to-creatinine ratio did not associate significantly with cortical ADC in multivariable models. Conclusion: Young persons with diabetes exhibit lower cortical ADC compared to healthy lean controls, suggesting alternations in microstructure and cellular density and potentially early signs of fibrosis. Additionally, despite shorter duration of disease and younger age, participants with T2D had the lowest cortical ADC values among the 3 groups. Further research is needed to investigate the role of cortical ADC in predicting kidney function decline in young individuals with diabetes, as well as molecular determinants of the alterations in microstructure and cellular density. Presentation: Friday, June 16, 2023

LBA02-09 EMBARK: A Phase 3 Randomized Study of Enzalutamide or Placebo Plus Leuprolide Acetate and Enzalutamide Monotherapy in High-risk Biochemically Recurrent Prostate Cancer

LBA02-09 EMBARK: A Phase 3 Randomized Study of Enzalutamide or Placebo Plus Leuprolide Acetate and Enzalutamide Monotherapy in High-risk Biochemically Recurrent Prostate Cancer

Palbociclib in Acute Leukemias With KMT2A-rearrangement: Results of AMLSG 23-14 Trial.

Palbociclib in Acute Leukemias With KMT2A-rearrangement: Results of AMLSG 23-14 Trial.

Shared genetics of migraine with irritable bowel syndrome, peptic ulcer, gastric reflux, diverticular disease, and autoimmune GI disorders (S19.005)

<h3>Objective:</h3> To investigate potential genetic relationships and therefore biology that may underlie comorbidity of migraine and several gastrointestinal (GI) disorders. <h3>Background:</h3> Individuals who experience migraine have elevated risk of irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD), and peptic ulcer (PUD), but not autoimmune GI disorders. Moreover, migraine treatments targeting CGRP and serotonin pathways are also effective for IBS. The extent to which genetics informs and extends these risk and treatment relationships is unknown. <h3>Design/Methods:</h3> Analysis compared summary statistics from large-scale genome-wide association studies for migraine to those for IBS, PUD, GERD, diverticular disease (DD), and autoimmune GI disorders (inflammatory bowel disease, Crohn’s disease, and ulcerative colitis). Shared genetics was investigated by evaluating pairwise global and local genetic correlations, identifying potential shared candidate loci, inferring tissues relevant to genetic overlaps, and assessing potential causal relationships with genetic instrumental analysis. <h3>Results:</h3> Genome-wide genetic correlation was strong for migraine with IBS (r_g=0.37), GERD (r_g=0.34), and PUD (r_g=0.29) (all p&lt;5×10⁻⁹), attenuated with DD (r_g=0.18, p=7×10⁻⁷), and null with autoimmune GI disorders. The overlaps implicated shared functions of cardiovascular tissues for IBS and of the central nervous system for PUD and GERD. Locally, there were 10 novel loci among those shared with migraine: three loci for IBS; four different loci for GERD or PUD; and seven different loci for DD that partially overlapped nine loci for inflammatory disorders. However, at loci encoding targets of migraine therapeutics, correlation was only nominally significant (<i>CALCA</i>) or null (<i>HTR1F</i>). The local genetic signals of migraine with IBS, GERD, and PUD implicated functions of cerebellar, pituitary, and thyroid tissues. Genetic causal inference supported GERD, PUD, and DD as potential causes of migraine but not vice versa. <h3>Conclusions:</h3> Migraine shares genetics with IBS, GERD, PUD, and DD, although in distinct ways, thereby identifying novel loci, causal pathways, and potentially, tissues with shared biological functions. <b>Disclosure:</b> Daniel Chasman has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Takeda. Daniel Chasman has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Amgen. Daniel Chasman has received research support from Pfizer. Daniel Chasman has received intellectual property interests from a discovery or technology relating to health care. Prof. Guo has nothing to disclose. Dr. Chan has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Bayer Pharma AG. Dr. Chan has received personal compensation in the range of $50,000-$99,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Pfizer Inc. Dr. Chan has received personal compensation in the range of $0-$499 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Gastroenterology. Dr. Chan has received personal compensation in the range of $100,000-$499,999 for serving as an Expert Witness for Boehringer Ingelheim. The institution of Dr. Chan has received research support from Zoe Ltd. The institution of Dr. Chan has received research support from Pfizer Inc. Dr. Staller has received personal compensation in the range of $500-$4,999 for serving as a Consultant for GI Supply. Dr. Staller has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Sanofi. Dr. Staller has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Anji. The institution of Dr. Staller has received research support from Urovant. The institution of Dr. Staller has received research support from Ironwood. Dr. Rist has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for American Heart Association. The institution of Dr. Rist has received research support from National Institutes of Health. The institution of Dr. Rist has received research support from Biogen, Inc. The institution of Dr. Rist has received research support from Brigham and Women’s Hospital.

Анализ влияния отслойки ретинального пигментного эпителия при экссудативной форме возрастной макулярной дегенерации на долгосрочные результаты лечения

Retinal pigment epithelial detachments (RPE) develops in more than 80 % of eyes with exudative age-related macular degeneration (eAMD) [1, 2]. RPED is a pathological condition in which the retinal pigment epithelium separates from the underlying Bruch's membrane due to the formation of a fibrovascular membrane, drusenoid material, fluid and/ or blood accumulation [3]. Recent published data from studies have shown controversial results of treatment with anti-VEGF therapy in patients with ARD on the background of eAMD, possibly due to different diagnostic capabilities and interpretation of the results by specialists. Purpose. To study the response to anti-VEGF therapy in patients with various RPED in eAMD. Material and methods. The study included 221 patients: with serous vascular (55 eyes) and fibrovascular detachment of RPE (176 eyes). To determine the maximum height of the retinal pigment epithelium detachment, it was necessary to manually set a line from Bruch's membrane to the retinal pigment epithelium in the scan where the maximum detachment of the retinal pigment epithelium was detected. Antiangiogenic therapy was carried out using the drug Aflibercept (Eylea® / Eulea®, Bayer Pharma AG, Mullerstrasse 178, 13353 Berlin, Germany) according to the standard method using the treat &amp; extend regimen (treat and prolong). Results. A significant increase in BCVA was found in patients with 1st type neovascularization and PCV during the first year of therapy from 0.51 ± 0.18 to 0.58 ± 0.23 and from 0.66 ± 0.23 to 0.76 ± 0.20 (p &lt; 0.05), with a further gradual significant decrease and return from baseline BCVA by 3rd year to 0.51 ± 0.25 (p &lt; 0.05) in the group with 1st type CNV, in patients with PCV, there was also a decrease in BCVA, but this was unreliable. BCVA values in all four groups decreased by the 6th year of observation. There was a significant decrease in the height of RPED in the group with the 1st and 3rd types of neovascularization, as well as in patients with PCV during the first 2 years of therapy (p &lt; 0.05). Сonclusions. Thus, a significant increase in BCVA in the first year of therapy in patients with ARD is more common in 1st type CNV and with PCV. At the same time, in all groups, after 6 years of treatment, a downward trend in BCVA can be observed. Also, in all groups, there was a decrease in the height of RP, which indicates a good response of the fluid under RP to the ongoing anti-VEGF therapy. Keywords: exudative form of retinal pigment epithelium detachment, anti-VEGF therapy, aflibercept, retinal pigment epithelium detachment

Time to reconsider the perception and management of hypertensive heart disease.

Time to reconsider the perception and management of hypertensive heart disease.

Aspirin, Risk of Colorectal Cancer, & Genetic Risk-Reply.

We appreciated the letter by Koulaouzidis and colleagues, which highlights the need for further studies to understand the mechanistic basis for aspirin's effect on colorectal cancer. Alongside their summary of our work (1) in the context of prior studies, they suggest that the effect of aspirin on gut microbiota should be examined. We agree that this is a high priority. As a rationale, they highlight research that shows aspirin appears to alter the gut microbiome to promote bacteria that are anti-inflammatory, thereby reducing colorectal cancer risk (2). We would further add that preclinical studies identify specific microbes that promote a proinflammatory environment, leading to induction of the enzymes that synthesize oncogenic prostaglandins which are inhibited by aspirin. Our group has also demonstrated that aspirin significantly inhibits tumorigenesis in ApcMin/+ mice inoculated with F. nucleatum and adenomas in aspirin users have significantly less Fusobacterium compared with nonaspirin users (3–5). These results are further supported by recent findings that aspirin treatment raises aspirin plasma concentrations and lowers tumor burden in microbiota-depleted mouse colorectal cancer models (ApcMin/+ and AOM/DSS), compared with microbiome-intact models and causes shifts in fecal metagenomic profiles of microbiome-intact mice that modulate aspirin bioavailability (6). Finally, a small randomized trial showed that aspirin alters the relative abundance of gut bacteria associated with colorectal cancer (7).Beyond playing a role in the development progression of colorectal cancer (8), the gut microbiome is being exploited to develop fecal microbial markers as a possible biomarker of colorectal cancer risk (9). If these studies are successful, gut microbiome risk markers could be leveraged alongside other risk measures including diet, age, and polygenic risk score to help identify patients who may have a more optimal risk-benefit profile for aspirin prevention.See the original Letter to the Editor, p. 701A.T. Chan reports personal fees from Bayer Pharma AG, Boehringer Ingelheim; grants and personal fees from Pfizer Inc.; and grants from Zoe, Ltd. outside the submitted work. No disclosures were reported by the other author.

Identification of outcomes in clinical studies of interventions for venous thromboembolism in non‐pregnant adults

Identification of outcomes in clinical studies of interventions for venous thromboembolism in non‐pregnant adults

Aspirin Use and Gastric Adenocarcinoma—Reply

We appreciate Lai and colleagues’ interest in our study in which we reported associations between aspirin use and gastric adenocarcinoma in two large prospective cohort studies of U.S. men and women (1). Lai and colleagues calculated that comparing aspirin users with nonusers, the absolute rate difference was 2/100,000 person-years with a number-needed-to-treat (NNT) of 50,000 in women. Perhaps a more clinically interpretable metric of absolute risk would be based on persons at risk rather than person-years using an estimate calculated according to the mean follow-up time (30.6 years) of cohort participants. We would then estimate the risk of gastric cancer was 0.0018 [125 cases/(2,097,414 person-years/30.6 years)] among nonregular aspirin users, and 0.0012 [51 cases/(1,258,158 person-years/30.6 years)] among regular users. This translates to an NNT of 1,714, suggesting one case of gastric cancer could potentially be prevented by treating 1,714 women with aspirin regularly. Nonetheless, we concur that public health recommendations should weigh potential complications associated with aspirin use such as upper gastrointestinal bleeding against the absolute benefits.In the case that exposure status is determined after the start of follow-up of a cohort, immortal time bias can be introduced if the person-time in the interval between the start of follow-up and when exposure data are collected is misattributed or ignored completely (2). In our study, person-time was accrued only from the return of a baseline questionnaire when the participants were first queried about aspirin use, to the date of gastric adenocarcinoma diagnosis, death, or the end of follow-up, whichever came first. We then updated aspirin use with each biennial questionnaire cycle as a time-varying variable. Thus, our results were not influenced by immortal time bias.Aspirin has been found to inhibit the growth of Helicobacter pylori (H. pylori) in a dose–response manner and enhance its susceptibility to antimicrobial agents (3). Consistently, we observed that aspirin use was associated with a lower risk of H. pylori infection among women. However, the hypothesis of inhibitory effects of aspirin on H. pylori and gastric cancer is speculative, and more evidence is needed to understand potential mechanisms. In addition, aspirin and salicylic acid, its primary bioactive metabolite, can influence other bacteria through both antimicrobial and regulatory effects, and manipulation of microbiota has been proposed as a mechanism for aspirin chemoprevention (4).A.T. Chan reports personal fees from Bayer Pharma AG and Boehringer Ingelheim, grants and personal fees from Pfizer Inc., and grants from Zoe, Ltd. outside the submitted work. No disclosures were reported by the other author.See the original Letter to the Editor, p. 553

GOULD EDU: Primary Results of a Cluster-Randomized Trial of an Educational Intervention to Improve Guideline Adherence and Intensification of Lipid-Lowering Therapy

Lead Author's Financial Disclosures Research grants from AstraZeneca, Boehringer Ingelheim; other research support from AstraZeneca; consulting/advisory boards for Alnylam, Amgen, Applied Therapeutics, Astra Zeneca, Bayer, Boehringer Ingelheim, Eli Lilly, Esperion Therapeutics, Janssen, Lexicon, Merck (Diabetes and Cardiovascular), Novo Nordisk, Pharmacosmos, Sanofi, and Vifor Pharma; honoraria from Astra Zeneca, Boehringer Ingelheim, and Novo Nordisk. Study Funding Amgen. Background/Synopsis Despite the benefits of intensive LDL-C lowering in patients with ASCVD, guidelines supporting lower LDL-C goals, and improved access to therapies, implementation in clinical practice remains suboptimal, and strategies to improve guideline adherence are a priority. Objective/Purpose The GOULD EDU study tested the effectiveness of an educational intervention to improve intensification of LLT, LDL-C levels, and LDL-C goal achievement. Methods GOULD was a 2-year, prospective, observational registry in patients with ASCVD on any lipid-lowering therapy (LLT). In the GOULD EDU 1-year extension study, sites were randomized to early (STEP 1) or late (STEP 2) intervention in a stepped-wedge design. The educational intervention included 2 live webinars that reviewed recent LLT guidelines, patterns of LLT and LDL-C control in the US, and opportunities for improvement. In addition, all sites received site-specific, interactive reports of their LLT patterns that were updated throughout the study. Results 56 sites were randomized to STEP 1 (30 sites, 616 patients) or STEP 2 (26 sites, 382 patients). Across all sites, minimal change occurred in LLT during the study (Figure 1). Intervention STEPs 1 and 2 showed similar patterns of minimal LLT intensification and LDL-C change from baseline (BL). Of patients with available LDL-C data (BL: 518/998; study end: 639/998), 38.8% of patients had LDL-C <70 mg/dL at BL, and 36.9% (STEP 1) and 44.5% (STEP 2) had LDL-C <70 mg/dL at study end. Conclusions An educational intervention was not effective in improving LLT intensification, LDL-C levels, or attainment of LDL-C goals in patients with ASCVD. Education alone appears insufficient to improve guideline adherence. Research grants from AstraZeneca, Boehringer Ingelheim; other research support from AstraZeneca; consulting/advisory boards for Alnylam, Amgen, Applied Therapeutics, Astra Zeneca, Bayer, Boehringer Ingelheim, Eli Lilly, Esperion Therapeutics, Janssen, Lexicon, Merck (Diabetes and Cardiovascular), Novo Nordisk, Pharmacosmos, Sanofi, and Vifor Pharma; honoraria from Astra Zeneca, Boehringer Ingelheim, and Novo Nordisk.

Population pharmacokinetic modeling of CSF to blood clearance: prospective tracer study of 161 patients under work-up for CSF disorders

BackgroundQuantitative measurements of cerebrospinal fluid to blood clearance has previously not been established for neurological diseases. Possibly, variability in cerebrospinal fluid clearance may affect the underlying disease process and may possibly be a source of under- or over-dosage of intrathecally administered drugs. The aim of this study was to characterize the cerebrospinal fluid to blood clearance of the intrathecally administered magnetic resonance imaging contrast agent gadobutrol (Gadovist, Bayer Pharma AG, GE). For this, we established a population pharmacokinetic model, hypothesizing that cerebrospinal fluid to blood clearance differs between cerebrospinal fluid diseases.MethodsGadobutrol served as a surrogate tracer for extra-vascular pathways taken by several brain metabolites and drugs in cerebrospinal fluid. We estimated cerebrospinal fluid to blood clearance in patients with different cerebrospinal fluid disorders, i.e. symptomatic pineal and arachnoid cysts, as well as tentative spontaneous intracranial hypotension due to cerebrospinal fluid leakage, idiopathic intracranial hypertension, or different types of hydrocephalus (idiopathic normal pressure hydrocephalus, communicating- and non-communicating hydrocephalus). Individuals with no verified cerebrospinal fluid disturbance at clinical work-up were denoted references.ResultsPopulation pharmacokinetic modelling based on 1,140 blood samples from 161 individuals revealed marked inter-individual variability in pharmacokinetic profiles, including differences in absorption half-life (time to 50% of tracer absorbed from cerebrospinal fluid to blood), time to maximum concentration in blood and the maximum concentration in blood as well as the area under the plasma concentration time curve from zero to infinity. In addition, the different disease categories of cerebrospinal fluid diseases demonstrated different profiles.ConclusionsThe present observations of considerable variation in cerebrospinal fluid to blood clearance between individuals in general and across neurological diseases, may suggest that defining cerebrospinal fluid to blood clearance can become a useful diagnostic adjunct for work-up of cerebrospinal fluid disorders. We also suggest that it may become useful for assessing clearance capacity of endogenous brain metabolites from cerebrospinal fluid, as well as measuring individual cerebrospinal fluid to blood clearance of intrathecal drugs.

Real-World Clinical Outcomes and Replacement Factor VIII Consumption in Patients with Haemophilia A in Italy: A Comparison between Prophylaxis Pre and Post Octocog Alfa (BAY 81-8973).

(1) Background: new generations of rFVIII products offered the possibility to improve personalized therapeutic approaches, reducing the number of infusions or increasing the protection against bleeding risk. The aim of this study was to assess the effectiveness of prophylaxis with BAY 81-8973 (octocog alfa, Kovaltry®, Bayer Pharma AG) in the real-world setting and its impact on FVIII consumption compared to previous standard half-life treatments. (2) Methods: a retrospective observational study was conducted in five Italian Haemophilia Centers. Patients with haemophilia A under prophylactic treatment with BAY 81-8973 for at least one year, and previously on prophylaxis with a different product were included in the study. Annual bleeding rate (ABR) and annual FVIII consumption were compared. (3) Results: forty-four patients were included in the study. After switching to BAY 81-8973, ABR was significantly reduced (1.76 vs. 0.23; p = 0.015), the percentage of patients with zero bleeds increased from 54.6% to 84.1% (p = 0.003), and the overall FVIII consumption decreased by 25,542 (−7.2%, p = 0.046) IU per patient-year. Patients treated every 3 days or 2 times per week increased from 0% to 27.3%. (4) Conclusion: our results suggest that prophylaxis with BAY 81-8973 can improve clinical outcomes and reduce FVIII consumption, in the real-world practice, compared with the previous prophylaxis regimen with standard half-life products.

SARS-CoV-2 Infection Evolution Among Nephrologists During the Pandemic: Clinical Features and Impact of Vaccination

SARS-CoV-2 Infection Evolution Among Nephrologists During the Pandemic: Clinical Features and Impact of Vaccination

Darolutamide and Survival in Metastatic, Hormone-Sensitive Prostate Cancer

BackgroundDarolutamide is a potent androgen-receptor inhibitor that has been associated with increased overall survival among patients with nonmetastatic, castration-resistant prostate cancer. Whether a combination of darolutamide, androgen-deprivation therapy, and docetaxel would increase survival among patients with metastatic, hormone-sensitive prostate cancer is unknown.MethodsIn this international, phase 3 trial, we randomly assigned patients with metastatic, hormone-sensitive prostate cancer in a 1:1 ratio to receive darolutamide (at a dose of 600 mg [two 300-mg tablets] twice daily) or matching placebo, both in combination with androgen-deprivation therapy and docetaxel. The primary end point was overall survival.ResultsThe primary analysis involved 1306 patients (651 in the darolutamide group and 655 in the placebo group); 86.1% of the patients had disease that was metastatic at the time of the initial diagnosis. At the data cutoff date for the primary analysis (October 25, 2021), the risk of death was significantly lower, by 32.5%, in the darolutamide group than in the placebo group (hazard ratio 0.68; 95% confidence interval, 0.57 to 0.80; P<0.001). Darolutamide was also associated with consistent benefits with respect to the secondary end points and prespecified subgroups. Adverse events were similar in the two groups, and the incidences of the most common adverse events (occurring in ≥10% of the patients) were highest during the overlapping docetaxel treatment period in both groups. The frequency of grade 3 or 4 adverse events was 66.1% in the darolutamide group and 63.5% in the placebo group; neutropenia was the most common grade 3 or 4 adverse event (in 33.7% and 34.2%, respectively).ConclusionsIn this trial involving patients with metastatic, hormone-sensitive prostate cancer, overall survival was significantly longer with the combination of darolutamide, androgen-deprivation therapy, and docetaxel than with placebo plus androgen-deprivation therapy and docetaxel, and the addition of darolutamide led to improvement in key secondary end points. The frequency of adverse events was similar in the two groups. (Funded by Bayer and Orion Pharma; ARASENS ClinicalTrials.gov number, NCT02799602.)

Comprehensive Multi-Parameter Characterisation of Circulating Extracellular Vesicles from Rivaroxaban-Treated VTE Patients Reveals Reduced Inflammation and Ameliorated Endothelial Dysfunction

Venous Thromboembolism (VTE) remains a significant cause of morbidity and mortality worldwide. Rivaroxaban, a direct oral factor Xa inhibitor, mediates anti-inflammatory and cardiovascular-protective effects besides its well-established anticoagulant properties, however, these remain poorly characterized. Extracellular vesicles (EVs) are important circulating messengers regulating a myriad of biological and pathological processes and may be highly relevant to the pathophysiology of VTE as they reflect alterations in platelet and endothelial biology. However, the effects of Rivaroxaban on circulating pro-inflammatory EVs in VTE patients remain unknown. We hypothesized that rivaroxaban's anti-inflammatory properties are reflected upon differential molecular profiles of circulating EVs.Single-episode VTE patients anticoagulated with 20 mg Rivaroxaban or warfarin at a target INR of 2.0-3.0, respectively, who had commenced therapy no sooner than 3 months previously were recruited following informed written consent at the Mater Misericordiae University Hospital, Dublin, Ireland. Patient data including age, sex, BMI, prevalent risk factors and comorbidities were collected. Patients on warfarin therapy had a time in therapeutic range of at least 55% and an INR in target range at time of blood sampling. Exclusion criteria included known pro-inflammatory conditions, active malignancy, recurrent VTE, antiphospholipid syndrome, bleeding or platelet function disorders, use of anti-platelet drugs, and thrombocytopenia.To address the hypothesis, we firstly used a combination of Nanoparticle Tracking Analysis (NTA) and flow cytometry to comprehensively characterise differences in the concentration and size of small (0-200 nm) and large (200-1000 nm) circulating EVs, respectively. Statistical analysis revealed a trend towards reduced levels of circulating small and large EVs in Rivaroxaban-treated VTE patients compared with matched warfarin controls. Moreover, small and large EVs measured in the patients plasma correlated strongly and highly significantly (r=0.804, p<0.0001), indicating a concomitant decrease in both populations. As circulating EVs are considered pro-coagulant and pro-inflammatory, these results may point towards an ameliorated baseline pro-inflammatory state of VTE patients anticoagulated with Rivaroxaban. To further uncover Rivaroxaban-mediated alterations, we next compared proteomic profiles of circulating EVs. We robustly quantified over 300 vesicular proteins. Statistical analysis of the protein expression level using a student's t-test with a false discovery rate of 5% and a minimal fold change of 0.1 identified differential protein expression of a tightly regulated cluster of proteins involved in negative feedback regulation of inflammatory and coagulation pathways in Rivaroxaban-treated patients, which may in part contribute to the superior outcomes of Rivaroxaban-treated patients seen in recent clinical trials. Furthermore, we recently established that Rivaroxaban potentially ameliorates endothelial dysfunction in a cohort of non-valvular atrial fibrillation patients. Therefore, we aimed to also assess circulating markers of endothelial activation (Intercellular Adhesion Molecule 1 [ICAM-1] and Tissue Factor Pathway Inhibitor [TFPI]). Intriguingly, Rivaroxaban-treated patients exhibited an increase in plasma TFPI levels with a simultaneous decrease in soluble ICAM-1, potentially pointing towards ameliorated endothelial dysfunction in Rivaroxaban-treated VTE patients relative to warfarin.Collectively, we established that EV proteomic signatures are powerful biological sensors of Rivaroxaban's anti-inflammatory potential. Moreover, Rivaroxaban therapy may ameliorate endothelial dysfunction relative to warfarin. These findings are of translational relevance towards characterizing the anti-inflammatory and cardiovascular-protective mechanisms associated with Rivaroxaban therapy. DisclosuresKevane: Leo Pharma: Research Funding. Murphy: Bayer Pharma: Research Funding. Ni Ainle: Daiichi-Sankyo: Research Funding; Actelion: Research Funding; Leo Pharma: Research Funding; Bayer Pharma: Research Funding. Maguire: Bayer Pharma: Research Funding; Actelion: Research Funding.

The Effect of Platelets on Thrombin Generation in Cord Blood and Peripheral Neonatal Blood in the Premature Infant; The Event Study

IntroductionInfants born very preterm (<32 weeks) are at increased risk of haemorrhage, particularly intraventricular haemorrhage which can result in short and long term morbidity. Routine clinical laboratory tests such as the prothrombin time and activated partial thromboplastin time are frequently abnormal in this patient group but do not appear to correlate with clinical outcomes. Moreover, while reduced levels of circulating coagulation factors and platelet hypo-reactivity have been reported, plasma thrombin generation (TG), has been reported to be similar or even enhanced in very preterm infants when compared to term infants.Extracellular vesicles, comprising of lipid-bound nanoparticles released from cells (including platelets), may potentially play a role in modulating neonatal haemostasis. We aimed to characterize phospholipid (PL)-dependent plasma thrombin generation in platelet-rich (PRP) and platelet-poor plasma (PPP) in premature infants in both umbilical cord blood & peripheral neonatal blood using calibrated automated thrombography (CAT).MethodsIn this prospective observational study, PRP and PPP was prepared by centrifugation from citrated umbilical cord blood and peripheral neonatal blood collected from premature infants (24 - 31 weeks) and healthy term controls (>37 weeks). No samples were collected from heparinised lines. Parameters of plasma thrombin generation in PRP were assessed using CAT, with thrombin generation stimulated by tissue factor only (TF; final concentration 1pM). CAT was also repeated in PPP using only TF and no exogenous PL (rendering the assay dependent upon the endogenous PL content of plasma).ResultsIn the analysis of umbilical cord blood PRP, plasma thrombin generation was accelerated in the preterm infant group with a significantly shorter time to peak TG observed. The other parameters of TG were similar in both groups (Table 1).In the subset of infants from whom peripheral blood samples were available, there was further evidence of enhanced plasma TG in preterm PRP relative to term infants (Table 2). In this subgroup, the lag time and time to peak thrombin were significantly shorter in the preterm group and peak thrombin was significantly higher.TG was also assessed in both PPP and PRP prepared from umbilical cord blood samples in a subgroup of infants (n=10 term, n=6 preterm) using 1pM TF only, rendering the assay dependent on the phospholipid content of plasma. No difference was observed in any CAT parameters, suggesting that neonatal PPP phospholipid content (potentially from circulating extracellular vesicles) is sufficient to support thrombin generation in the absence of exogenous phospholipid.ConclusionThese preliminary data suggest that neonatal PRP, measured in both umbilical cord blood and peripheral neonatal blood, has similar thrombin generation or may even be hypercoagulable, compared with healthy term controls. Moreover, neonatal plasma phospholipid appears to support thrombin generation in the absence of exogenous phospholipid. This ongoing prospective study aims to further characterize the platelet-dependency of neonatal thrombin generation and evaluate the potential role of extracellular vesicles in neonatal haemostasis. [Display omitted] DisclosuresMaguire: Actelion: Research Funding; Bayer Pharma: Research Funding. Ni Ainle: Leo Pharma: Research Funding; Actelion: Research Funding; Daiichi-Sankyo: Research Funding; Bayer Pharma: Research Funding.

COVID-19 Is Associated with Endothelial Dysfunction and Enhanced Plasma Thrombin Generation Despite Pharmacological Thromboprophylaxis

BackgroundHospitalised patients with severe COVID-19 (requiring critical care level support) appear to be at increased risk of thrombosis despite standard pharmacological thromboprophylaxis. The magnitude of thrombotic risk in patients with COVID-19 of moderate severity (not requiring critical care) is less clear. The optimal approach to thromboprophylaxis (and the role of intensified thromboprophylaxis) remains to be determined.Evidence of endothelial dysfunction has been widely reported in COVID-19 (particularly in severe COVID) and this may contribute to hypercoagulability.AimTo assess differences in patterns of hypercoagulability and endothelial dysfunction between a group of patients with moderate COVID-19 and a group of age-matched hospitalized patients (SARS-CoV-2 PCR negative) receiving low molecular weight heparin (LMWH) thromboprophylaxis.MethodsBlood was collected from individuals admitted to hospital with COVID-19 of moderate severity (not requiring critical care level support) and a group of age-matched patients admitted with infective/inflammatory illness (SARS-CoV-2 PCR negative). All subjects received standard-dose LMWH thromboprophylaxis, with blood drawn at 12 hours post-dose (and with measurement of anti-FXa activity levels). Circulating levels of endothelial & fibrinolytic markers including ICAM, PAI-1, VCAM, soluble thrombomodulin (sTM), and tissue plasminogen activator (tPA) were determined by ELISA. Thrombin generation (TG) in platelet-poor plasma was assessed by calibrated automated thrombography in the presence of tissue factor (Final concentration, 1pM & 5pM), thrombomodulin (TM) (Final concentration, 6.25nM), and an inhibitory anti-tissue factor pathway inhibitor antibody (anti-TFPI; Final concentration 100μg/mL).Results14 COVID-19 positive subjects and 11 hospitalized controls were recruited. There were no differences in mean age (69.7±4.5 vs 61.6±4.7 years; p= 0.2) or mean Body mass index (25.7±1.1 vs 22.7±1.2 Kg/m2; p=0.1) between groups. No COVID-19 patient or control required critical care support. In the COVID group, radiological evidence of pneumonitis [diffuse (n=3) or peripheral infiltrates (n=7)] was present in the majority of cases. None of the COVID-19 cases were requiring supplemental oxygen at the time of recruitment.All controls were admitted with either respiratory or urinary infection [radiological evidence of pneumonia in 4/11; supplemental oxygen requirement in 2/11, (28-36% FiO2 via nasal cannula)].Plasma levels of sTM, ICAM, PAI-1 & VCAM were similar in both groups. Levels of t-PA were significantly higher in the COVID group (8.31±4.35 vs 4.91±2.37 ng/mL; p= 0.005). Despite similar plasma anti-Xa activity in both groups (0.06 vs 0.04 IU/mL; p=0.2), mean endogenous thrombin potential (ETP) was significantly higher in the COVID group (1929±119.7 vs 1528±138.9 nM*min; p=0.02), although peak thrombin was similar (173.6±26 vs 161.5±31nM). ETP-TM ratio was similar between groups (0.3±0.1 vs 0.2±0.1; p=0.3).Despite increased ETP, the lag time to thrombin generation was significantly prolonged in the COVID group (8.3±0.6 vs 5.8±0.5 mins, p= 0.006). This pattern has previously been observed in vascular diseases associated with altered plasma tissue factor pathway inhibitor (TFPI) activity. In the presence of an anti-TFPI antibody, the difference in lagtime between groups was attenuated (4.7±0.2 vs 3.5±0.1 mins; p= 0.002) and the difference in overall thrombin generation (delta TG) between both groups became significantly increased (Fig.1).ConclusionPlasma thrombin generation is enhanced in patients with non-severe COVID-19 despite pharmacological thromboprophylaxis. Endothelial dysfunction is also observed in this group and appears to modulate parameters of plasma thrombin generation. The clinical implications of these observations are not known although clinical studies of intensified thromboprophylaxis in attenuating thrombotic risk and other complications are ongoing.Fig 1. Inhibition of TFPI activity enhances thrombin generation in COVID-19.In the presence of an inhibitory anti-TFPI antibody, peak plasma thrombin generation was enhanced in COVID-19 in contrast to that observed among SARS-CoV-2 PCR negative hospitalised patients (339.6+25.2 vs 247.4+10.1, p=0.01). [Display omitted] DisclosuresMaguire: Actelion: Research Funding; Bayer Pharma: Research Funding. Ni Ainle: Daiichi-Sankyo: Research Funding; Actelion: Research Funding; Leo Pharma: Research Funding; Bayer Pharma: Research Funding. Kevane: Leo Pharma: Research Funding.

Outcomes Following Acute Pulmonary Embolism in an Irish Population of over 1 Million Individuals: Opportunities for Quality Improvement and More Effective Resource Utilisation

IntroductionPulmonary embolism (PE) is a leading cause of cardiovascular morbidity worldwide. The risk of early death in the setting of untreated PE may be as high as 30%. However, diagnostic and therapeutic advances in recent years have led to a progressive decline in global PE-related mortality and recent data describing rates of in-hospital death following PE suggest a mortality rate of approximately 5-15%. Moreover, strategies directed at stratification of PE severity have been shown to safely identify a sub-group of low-risk patients (up to 30-50% of all patients) for whom outpatient management is feasible without the need for hospital admission. Avoiding hospitalisation for low-risk PE patients is associated with improved patient satisfaction and avoids exposing patients to the risks associated with hospital admission. Ambulatory PE management would also be predicted to lead to significant healthcare cost-savings. However ambulatory care models for low-risk PE appear to be under-utilised despite these potential benefits. Barriers to implementation include access to outpatient follow-up services and the perceived risks associated with this model of care.The Ireland East Hospital Group (IEHG) is the largest hospital network in the Republic of Ireland, consisting of 11 hospitals (including large academic centres, community general hospitals and the national maternity hospital). The IEHG serves a population of over 1.1 million individuals. We sought to determine the frequency of admissions to hospital with PE and to assess key outcomes, including length-of-stay (LOS) and in-hospital mortality within this population.MethodsData pertaining to PE diagnosis from January 2018 to December 2020 were obtained from NQAIS Clinical (National Quality Assessment and Improvement System; an electronic reporting tool which is populated with anonymised data extracted from the hospital in-patient enquiry system). This system compiles diagnostic data on all patients by ICD-10 code at the time of discharge. For the purposes of this analysis the ICD-10 codes I26.0 and I26.9 were used to identify patients with PE and only admission episodes where PE was the primary diagnosis were included; cases of ‘secondary PE’ (historical PE or hospital-acquired) were excluded. Projected population figures, extrapolated from Census 2016 data, were obtained from Health Atlas Ireland (an open-source application providing access to datasets developed by the Health Intelligence Unit of the Health Service Executive of Ireland).ResultsDuring the 3-year study period, 958 in-patient episodes occurred where PE was recorded as the primary diagnosis, corresponding to an incidence of 0.37 per 1000 adults per annum (95% CI 0.35 to 0.40). The incidence was highest in the over 85 years age-group (1.07 per 1000 per annum; 95% CI 0.80 to 1.33). PE was more common in women in all age-groups apart from the 46-65 years age group [males: 0.51 (95% CI 0.44-0.51) vs females: 0.36 (95% CI 0.3-0.42) per 1000].In 82.7% of episodes, the ultimate discharge destination was to home. In 5.3% the discharge destination was a nursing home and 4.6% were transferred to another hospital. The all-cause in-hospital mortality rate was 3.1% (30 fatalities; 18 females, 12 males). Most deaths occurred in the 66-85 years age-group (n=14), with 9 fatalities in the age >85 years group and 7 fatal PE events in the 46-65 years age-group.Average hospital LOS was 7.8 days. 8.9% of inpatient episodes resulted in same-day discharge. In 55.9% of episodes, discharge occurred after day 4. Those discharged to home had an average length of stay of 6.31 days, while patients awaiting nursing home facilities averaged 26.5 days.ConclusionThe incidence of acute presentation with PE within this population is consistent with international reports. The rate of in-hospital mortality compares favourably with these international standards. The mortality rate may reflect improvements in PE care but may also reflect the inclusion of a significant number of ‘low-risk’ individuals in the analysis (many of whom may have been suitable for outpatient management). The mortality rate might also reflect increased detection of small, low-risk distal PE (as a result of advances in diagnostics). In any event, these data suggest that more widespread implementation of outpatient PE management is likely to be feasible and would represent an opportunity for improved resource utilisation. DisclosuresNi Ainle: Leo Pharma: Research Funding; Actelion: Research Funding; Daiichi-Sankyo: Research Funding; Bayer Pharma: Research Funding. Kevane: Leo Pharma: Research Funding.

Skeletal Muscle Myosin Is Procoagulant By Binding Factor XI Via Its A3 Domain and Enhancing Factor XI Activation By Thrombin

Blood coagulation mechanisms play key roles in health and disease. Pilot studies using selected human plasmas showed the potential associations of plasma skeletal muscle myosin (SkM) isoforms and phenotypes with pulmonary embolism and thrombin generation, suggesting SkM may contribute to blood coagulation reactions in plasma. Here we report that ex vivo studies of the coagulability of fresh flowing human blood over SkM-coated surfaces showed that an anti-factor XI (FXI) mAb, but not an anti-tissue factor mAb, inhibited clot formation, indicating that FXI is an essential contributor for the normal observed procoagulant response of blood during its exposure to immobilized SkM. This raised the question of whether procoagulant SkM's requirement for FXI involves direct or indirect effects on FXI.To assess direct interactions between SkM and FXI, Bio-Layer Interferometry (BLI) (Octet Red system) was used to record kinetics for binding of soluble FXI to immobilized SkM. BLI data showed that FXI bound to SkM with a Kd of 0.2 nM (k on= 2.92x10 6 M -1s -1 and k off=9.25x10 -3 s -1) (Fig. 1A). In contrast, prekallikrein (PK) did not bind to the SkM (Fig.1A), indicating the specificity of SkM for binding FXI. The anti-FXI mAb1A6, which recognizes the Apple (A)3 domain of FXI, potently inhibited binding of FXI to immobilized SkM, implying SkM binds the FXI A3 domain.Studies using purified clotting factors were made to identify which FXI-related activities might be affected by SkM. When FXI activation by thrombin was evaluated under conditions where polyphosphate (PolyP) 100-mer and 700-mer enhance FXI activation, SkM concentration-dependently enhanced FXI activation by thrombin (Fig. 1B). Whereas alkaline phosphatase destroyed PolyP's ability to stimulate FXI activation by thrombin, it did not cause a reduction of SkM's ability to enhance FXI activation, indicating SkM's activity is independent of PolyP-like sequences in SkM. Small unilamellar phospholipid vesicles (20% phosphatidylserine (PS) / 80% phosphatidylcholine) did not affect FXI activation by thrombin; furthermore, reagents that neutralize procoagulant PS, i.e., lactadherin, annexin V, and phospholipase A2, did not affect SkM's enhancement of FXI activation by thrombin, indicating that this activity is not due to anionic phospholipids linked to SkM.The effects of SkM on FXI autoactivation and FXI activation by FXIIa were evaluated. As is well known, PolyP and some other anionic reagents, e.g., nucleic acid polymers, enhance not only FXI activation by thrombin but also FXI autoactivation and FXI activation by FXIIa. However, SkM did not significantly affect FXI autoactivation or FXI activation by factor XIIa, further emphasizing that SkM's enhancement of FXI activation by thrombin is not due to any PolyP-like compounds and that it is a unique property of procoagulant SkM. This also suggests that SkM has a unique mechanism for its procoagulant activity on FXI activation which is limited to the thrombin positive feedback loop.To evaluate further the basis for interactions between FXI and SkM, we employed FXI- PK chimeras because BLI binding studies showed that, in contrast to FXI, PK did not bind to SkM. Recombinant FXI proteins in which each of the four A domains of the heavy chain (designated A1 through A4) were individually replaced with the corresponding A domain from PK and were used to identify the site of factor XI to interact with SkM for FXI activation by thrombin. The FXI chimera with the substitution of the PKA1 domain was not activated by thrombin, which is consistent with the fact that the FXI A1 domain is an interactive site for thrombin. Thrombin activation of the two FXI chimeras (FXI/PKA3 and FXI/PKA4) with substitutions of either the A3 or A4 domains was not enhanced by SkM, whereas substitution of the A2 domain (FXI/PKA2) did not reduce the enhancement of activation by thrombin compared to wild type FXI. Furthermore, mAb1A6, which recognizes the A3 domain and which inhibited the prothrombotic activity of fresh blood flowing over a SkM-coated surface, potently inhibited FXI binding to SkM in BLI studies. These data strongly suggest that functional interaction sites on FXI for SkM involve the A3 and A4 domains of FXI.In summary, we found that SkM's ex vivo procoagulant activity requires FXI, that SkM enhances FXI activation by thrombin and this requires FXI's A3 and A4 domains, and that SkM's high affinity binding of FXI requires the FXI A3 domain (Fig. 1C). [Display omitted] DisclosuresGruber: Aronora Inc.: Current Employment, Current equity holder in publicly-traded company; Oregon Health and Science University: Current Employment. Gailani: Anthos Therapeutics: Consultancy; Aronora: Membership on an entity's Board of Directors or advisory committees; Bayer Pharma: Consultancy; Bristol Myer Squibb: Consultancy, Membership on an entity's Board of Directors or advisory committees; Ionis: Consultancy; Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees.