JAK Inhibitor Tofacitinib Research Articles

Rise of biologics in noninfectious uveitis: a retrospective cohort study from Nepal.

A retrospective review of all cases of noninfectious uveitis and scleritis presenting to our center from July 2019 to January 2021 and had been treated with biological therapy were included. We included 12 eyes of 10 patients. The mean age was 42.10±9.71 years. Anterior nongranulomatous uveitis comprised 70% of the cases and the most common etiology of anterior uveitis was spondyloarthritis (seven cases among which five cases were nonradiographic) axial spondyloarthritis (human leukocyte antigen B27 positive) followed by radiographic axial spondyloarthritis (two cases). The first line of treatment in all cases was conventional synthetic disease-modifying antirheumatic agents among which 50% (n=5) had received methotrexate (≥15mg/week). As a second line of treatment, one or more biologics was used. Majority of the patients received oral tofacitinib 50% (n=5) followed by Inj adalimumab 30% (n=3). One case of Behcet's disease required sequential biologics (Inj adalimumab followed by oral tofacitinib). All patients tolerated and responded well to the treatment and no recurrences were observed after discontinuation of biologics drugs during the follow-up period of 1 year. Biologics are a relatively safe and effective modality of treatment in refractory, recurrent noninfectious uveitis.

The positive effect of JAK inhibitor tofacitinib in the treatment of primary Sjögren’s syndrome: a clinical case

Primary Sjögren’s syndrome (pSS, Sjögren’s disease) is a systemic autoimmune disease which develops in previously healthy individuals and characterized by damage to exocrine glands, mainly lacrimal and salivary glands, with gradual formation of their secretory insufficiency and various systemic manifestations. According to EULAR recommendation (2019) therapeutic management of pSS bases on symptomatic treatment of sicca syndrome and broad-spectrum immunosuppression for systemic manifestations. The perspective group for the treatment of autoimmune disease is Janus kinase inhibitors, which can block the signals from biologically active molecules (interferons, erythropoietins and cytokines) and providing a response to these target cell signals. Therefore, the use of JAK inhibitors in patients with pSS requires clinical confirmation of effectiveness. The article described the clinical case of the positive effect of tofacitinib with methotrexate combination in the treatment of patient with pSS. A 55-year-old female with sicca syndrome (confirmed by Schirmer’s test), arthralgia, low-grade fever, weight loss and a positive test for the detection of specific antibodies (SS-A/Ro > 240 units/ml, SS-B/La 94 units/ml) was diagnosed with pSS. The total score of EULAR Sjögren’s syndrome disease activity index (ESSDAI) was 9 (activity grade II). The treatment included symptomatic methods of sicca syndrome correcting (replacement therapy with artificial tear preparations and chewing gums with xylitol) in combination with immunosuppressive therapy. The addition of tofacitinib 5 mg twice daily to methotrexate (10 mg weekly) has been shown to significantly reduce disease activity after 6 months of treatment (ESSDAI = 0).

Cancer Risk in Patients Treated with the JAK Inhibitor Tofacitinib: Systematic Review and Meta-Analysis

Tofacitinib is approved for several immune-mediated inflammatory diseases, but safety concerns have recently been raised. We searched PubMed (accessed on 27 February 2023) for original articles regarding tofacitinib's cancer risk when used for rheumatoid arthritis, ulcerative colitis, Crohn's disease, psoriatic arthritis, and ankylosing spondylitis. Of the 2047 initial records, 22 articles describing 26 controlled studies (including 22 randomized controlled trials) were selected. In the comparison between tofacitinib and any control treatment, the relative risk (RR) for any cancer was 1.06 (95% CI, 0.86-1.31; p = 0.95). In separate comparisons between tofacitinib and either a placebo or biological therapy, no difference was found in the overall cancer risk (vs. placebo, RR = 1.04; 95% CI, 0.44-2.48; p = 0.95; vs. biological drugs, RR = 1.06; 95% CI, 0.86-1.31; p = 0.58). When tofacitinib was compared to tumor necrosis factor (TNF) inhibitors, the overall cancer RR was 1.40 (95% CI, 1.06-2.08; p = 0.02). Similarly, significant results were obtained for all cancers, except for non-melanoma skin cancer (RR = 1.47; 95% CI, 1.05-2.06; p = 0.03), and for this skin cancer alone (RR = 1.30; 95% CI, 0.22-5.83; p = 0.88). In conclusion, no difference in the overall cancer risk was found between tofacitinib and either a placebo or biological drugs, while a slightly higher risk was found in patients treated with tofacitinib than anti-TNF agents. Further studies are needed to better define the cancer risk of tofacitinib therapy.

JAK inhibition for CD3− CD4+ lymphocytic-variant hypereosinophilic syndrome

Alternatives are urgently needed in patients with CD3− CD4+ lymphocytic-variant hypereosinophilic syndrome (L-HES) requiring high-level steroids or who are unresponsive and/or intolerant to conventional alternative therapies. We report five L-HES patients (44–66 years) with cutaneous involvement (n = 5) and persistent eosinophilia (n = 3) despite conventional therapies, who successfully received JAK inhibitors (tofacitinib n = 1, ruxolitinib n = 4). JAKi led to complete clinical remission in the first 3 months in all (with prednisone withdrawal in four). Absolute eosinophil counts normalized in cases receiving ruxolitinib, while reduction was partial under tofacitinib. After switch from tofacitinib to ruxolitinib, complete clinical response persisted despite prednisone withdrawal. The clone size remained stable in all patients. After 3–13 months of follow-up, no adverse event was reported. Prospective clinical trials are warranted to examine the use of JAKi in L-HES.

Okadaic Acid Activates JAK/STAT Signaling to Affect Xenobiotic Metabolism in HepaRG Cells.

Okadaic acid (OA) is a marine biotoxin that is produced by algae and accumulates in filter-feeding shellfish, through which it enters the human food chain, leading to diarrheic shellfish poisoning (DSP) after ingestion. Furthermore, additional effects of OA have been observed, such as cytotoxicity. Additionally, a strong downregulation of the expression of xenobiotic-metabolizing enzymes in the liver can be observed. The underlying mechanisms of this, however, remain to be examined. In this study, we investigated a possible underlying mechanism of the downregulation of cytochrome P450 (CYP) enzymes and the nuclear receptors pregnane X receptor (PXR) and retinoid-X-receptor alpha (RXRα) by OA through NF-κB and subsequent JAK/STAT activation in human HepaRG hepatocarcinoma cells. Our data suggest an activation of NF-κB signaling and subsequent expression and release of interleukins, which then activate JAK-dependent signaling and thus STAT3. Moreover, using the NF-κB inhibitors JSH-23 and Methysticin and the JAK inhibitors Decernotinib and Tofacitinib, we were also able to demonstrate a connection between OA-induced NF-κB and JAK signaling and the downregulation of CYP enzymes. Overall, we provide clear evidence that the effect of OA on the expression of CYP enzymes in HepaRG cells is regulated through NF-κB and subsequent JAK signaling.

JAK inhibitors differentially modulate B cell activation, maturation and function: A comparative analysis of five JAK inhibitors in an in-vitro B cell differentiation model and in patients withrheumatoid arthritis.

Janus kinase (JAK) inhibitors have been approved for the treatment of several immune-mediated diseases (IMIDs) including rheumatoid arthritis (RA) and psoriatic arthritis and are in clinical trials for numerous other IMIDs. However, detailed studies investigating the effects of different JAK inhibitors on B cells are missing. Within this study, we therefore aimed to characterize the effect of JAK inhibition on the B cell compartment. To this end, we investigated the B cell compartment under JAK inhibition and compared the specific effects of the different JAK inhibitors tofacitinib (pan-JAK), baricitinib (JAK1/2), ruxolitinib (JAK1/2), upadacitinib (JAK1/2) as well as filgotinib (selective JAK1) on in-vitro B cell activation, proliferation, and class switch recombination and involved pathways. While B cell phenotyping of RA patients showed an increase in marginal zone (MZ) B cells under JAK inhibition, comparison with healthy donors revealed that the relative frequency of MZ B cells was still lower compared to healthy controls. In an in-vitro model of T-cell-independent B cell activation we observed that JAK1/2 and selective JAK1 inhibitor treatment led to a dose-dependent decrease of total B cell numbers. We detected an altered B cell differentiation with a significant increase in MZ-like B cells and an increase in plasmablast differentiation in the first days of culture, most pronounced with the pan-JAK inhibitor tofacitinib, although there was no increase in immunoglobulin secretion in-vitro. Notably, we further observed a profound reduction of switched memory B cell formation, especially with JAK1/2 inhibition. JAK inhibitor treatment led to a dose-dependent reduction of STAT3 expression and phosphorylation as well as STAT3 target gene expression and modulated the secretion of pro- and anti-inflammatory cytokines by B cells. JAK inhibition has a major effect on B cell activation and differentiation, with differential outcomes between JAK inhibitors hinting towards distinct and unique effects on B cell homeostasis.

Tofacitinib combined with melanocyte protector α-MSH to treat vitiligo through dextran based hydrogel microneedles

Vitiligo can cause serious damage to the appearance of patients and affect physical and mental health, but there is currently no simple and effective treatment. According to the theory of autoimmune disorder, the separable hydrogel microneedles delivering alpha-melanocyte-stimulating hormone (α-MSH) and tofacitinib were designed to treat vitiligo. This hydrogel microneedles were formed by dextran methacrylate (DexMA) and cyclodextrin-adamantane based host-guest supramolecules (HGSM) through CC double bond polymerization and host-guest assembly. The microneedle tips formed by the double cross-linked hydrogel can pierce the stratum corneum and deliver melanocyte protector α-MSH and JAK inhibitor tofacitinib directly to the epidermis and dermis. Under the treatment of α-MSH/tofacitinib microneedles, massive deposition of melanin in epidermis and hair follicles significantly accelerated skin and hair pigmentation.

Augmented PFKFB3-mediated glycolysis by interferon-γ promotes inflammatory M1 polarization through the JAK2/STAT1 pathway in local vascular inflammation in Takayasu arteritis

BackgroundTakayasu arteritis (TAK) is characterized by pro-inflammatory M1 macrophage infiltration and increased interferon (IFN)-γ expression in vascular lesions. IFN-γ is a key cytokine involved in M1 polarization. Macrophage polarization is accompanied by metabolic changes. However, the metabolic regulation mechanism of IFN-γ in M1 macrophage polarization in TAK remains unclear.MethodsImmunohistochemistry and immunofluorescence were employed to observe the expression of IFN-γ, PFKFB3 (6-phosphofructo-2-kinase/fructose-2,6-biphosphatase 3, the rate-limiting enzyme in glycolysis), and macrophage surface markers in the vascular tissue. Monocyte-derived macrophages from patients with TAK were cultured to examine the role of PFKFB3 in IFN-γ-induced M1 macrophage polarization. Seahorse analysis was used to detect the alterations in glucose metabolism during this process. Quantitative reverse transcription PCR, flow cytometry, and western blot were used to confirm the phenotypes of macrophages and related signaling pathways.ResultsIn the vascular adventitia of patients with TAK, an increase in PFKFB3 accompanied by IFN-γ expression was observed in M1 macrophages. In vitro, IFN-γ successfully induced macrophage differentiation into the M1 phenotype, which was manifested as an increase in CD80 and HLA-DR markers and the pro-inflammatory cytokines IL-6 and TNF-α. During this process, PFKFB3 expression and glycolysis levels were significantly increased. However, glycolysis and M1 polarization induced by IFN-γ were suppressed by a PFKFB3 inhibitor. In addition, JAK2/STAT1 phosphorylation was also enhanced in macrophages stimulated by IFN-γ. The effects of IFN-γ on macrophages, including the expression of PFKFB3, glycolysis, and M1 polarization, were also inhibited by the JAK inhibitor tofacitinib or STAT1 inhibitor fludarabine.ConclusionPFKFB3-mediated glycolysis promotes IFN-γ-induced M1 polarization through the JAK2/STAT1 signaling pathway, indicating that PFKFB3 plays an important role in M1 polarization mediated by IFN-γ; thus, PFKFB3 is a potential intervention target in TAK.

Type 1 interferon suppresses expression and glucocorticoid induction of glucocorticoid-induced leucine zipper (GILZ).

SLE is a systemic multi-organ autoimmune condition associated with reduced life expectancy and quality of life. Glucocorticoids (GC) are heavily relied on for SLE treatment but are associated with detrimental metabolic effects. Type 1 interferons (IFN) are central to SLE pathogenesis and may confer GC insensitivity. Glucocorticoid-induced leucine zipper (GILZ) mediates many effects of GC relevant to SLE pathogenesis, but the effect of IFN on GC regulation of GILZ is unknown. We performed in vitro experiments using human PBMC to examine the effect of IFN on GILZ expression. JAK inhibitors tofacitinib and tosylate salt were used in vivo and in vitro respectively to investigate JAK-STAT pathway dependence of our observations. ChiP was performed to examine glucocorticoid receptor (GR) binding at the GILZ locus. Several public data sets were mined for correlating clinical data. High IFN was associated with suppressed GILZ and reduced GILZ relevant to GC exposure in a large SLE population. IFN directly reduced GILZ expression and suppressed the induction of GILZ by GC in vitro in human leukocytes. IFN actions on GILZ expression were dependent on the JAK1/Tyk2 pathway, as evidenced by loss of the inhibitory effect of IFN on GILZ in the presence of JAK inhibitors. Activation of this pathway led to reduced GR binding in key regulatory regions of the GILZ locus. IFN directly suppresses GILZ expression and GILZ upregulation by GC, indicating a potential mechanism for IFN-induced GC resistance. This work has important implications for the ongoing development of targeted GC-sparing therapeutics in SLE.

Baricitinib: First Systemic Oral Drug for Alopecia Therapy

Baricitinib, a Janus kinase inhibitor, was originally approved as anti-rheumatic drug in 2017. In 2020, it was approved for the treatment of COVID-19 in selected hospitalized adults. Baricitinib received priority review designation for treatment of adult patients with severe alopecia areata and got USFDA approval on June 23, 2022 based on the results of 02 phase III trial: BRAVE-AA1 and BRAVE-AA2. In this review, we aim to summarize the different pharmacokinetic and pharmacodynamics aspects including drug interactions, adverse effects/black box warnings and their clinical relevance. We reiterate that oral JAK inhibitors are expensive, may carry significant risks, and are not yet recommended for routine treatment of alopecia areata. There is ongoing research on other topical and oral JAK inhibitors (tofacitinib and ruxolitinib), giving hope that better treatments for alopecia areata will become available in future.

Scorpion venom polypeptide governs alveolar macrophage M1/M2 polarization to alleviate pulmonary fibrosis

The onset of connective tissue disease-related interstitial lung disease (CTD-ILD) is generally insidious and progressive, with pulmonary fibrosis in the middle stage, and eventually respiratory failure and death. This study aimed to explore the role of scorpion venom polypeptide (SVP), the primary active constituent of the entire scorpion, in alveolar macrophages and pulmonary fibrosis. Pulmonary fibrosis mouse models were established, and then SVP and JAK inhibitor (tofacitinib) was used to treat models. Alveolar macrophages were isolated and the impacts of SVP on M1/M2 polarization and the JAK/STAT6 pathway in vitro were assessed. H&E and Masson staining revealed that SVP and tofacitinib treatment alleviated lung damage and fibrosis. They also hindered the M2-polarization of macrophages in lung tissue and declined cytokine levels associated with M2 polarization (IL-4, IL-13) and fibrosis drivers (TGF-β, VEGF) in mice. Consistent with the trend presented by tofacitinib treatment, SVP suppressed the phosphorylation of proteins in the JAK/STAT6 pathway. In addition, the in vitro treatment of SVP on the isolated macrophages represented consistent results with in vivo experiments. The findings of the present study indicated that SVP suppressed the JAK/STAT6 signaling pathway, hindered alveolar macrophage M2-type polarization, and possessed the potential to ameliorate pulmonary fibrosis.

Past, Present, and Future in Dermatomyositis Therapeutics.

This review highlights current and emerging pharmacologic therapies for the treatment of dermatomyositis (DM). Current clinical evidence, in addition to recently published and ongoing clinical trials for various drugs in development, are summarized in this review. There has been significant progress in the research and development of potential treatments in DM. The FDA recently approved Octagam® 10% Immune Globulin Intravenous (IVIg) for the treatment of DM. Several drug targets are being explored as viable therapeutic options in phase 2 and phase 3 clinical trials; at the forefront of these are JAK inhibitors (tofacitinib and baricitinib) and T-cell co-stimulation blockers (i.e. abatacept). In addition, clinical trials are currently under way for therapeutics targeting novel molecular pathways, including immunoproteasome inhibitors, anti-B cell therapy, anti-interferon drugs, complement inhibitors, and phosphodiesterase-4 inhibitors. With the large number of clinical trials, multiple novel therapeutics in development, and improved classification and outcome measures, the treatment landscape for DM will continue to rapidly evolve in the coming years as more options become available.

LB943 Tofacitinib treatment of inflammatory skin conditions in patients with Down Syndrome

Individuals with Down syndrome (DS, trisomy 21) display consistent activation of the interferon (IFN) response, hyperactive JAK/STAT signaling, and chronic dysregulation of the immune system, which could be explained by the fact that four IFN receptors are encoded on chromosome 21. IFN hyperactivity may explain the high prevalence of immune skin conditions in this population, including alopecia areata (AA), hidradenitis suppurativa (HS), psoriasis, atopic dermatitis, and vitiligo. We investigated the use of the JAK inhibitor Tofacitinib in an open label clinical trial enrolling individuals with DS ages 12-50 with moderate-to-severe AA, HS, psoriasis, atopic dermatitis, and/or vitiligo.

Discovery of novel targets in a complex regional pain syndrome mouse model by transcriptomics: TNF and JAK-STAT pathways

Complex Regional Pain Syndrome (CRPS) represents severe chronic pain, hypersensitivity, and inflammation induced by sensory-immune-vascular interactions after a small injury. Since the therapy is unsatisfactory, there is a great need to identify novel drug targets. Unbiased transcriptomic analysis of the dorsal root ganglia (DRG) was performed in a passive transfer-trauma mouse model, and the predicted pathways were confirmed by pharmacological interventions. In the unilateral L3–5 DRGs 125 genes were differentially expressed in response to plantar incision and injecting IgG of CRPS patients. These are related to inflammatory and immune responses, cytokines, chemokines and neuropeptides. Pathway analysis revealed the involvement of Tumor Necrosis Factor (TNF) and Janus kinase (JAK-STAT) signaling. The relevance of these pathways was proven by abolished CRPS IgG-induced hyperalgesia and reduced microglia and astrocyte markers in pain-associated central nervous system regions after treatment with the soluble TNF alpha receptor etanercept or JAK inhibitor tofacitinib. These results provide the first evidence for CRPS-related neuroinflammation and abnormal cytokine signaling at the level of the primary sensory neurons in a translational mouse model and suggest that etanercept and tofacitinib might have drug repositioning potentials for CRPS-related pain.

IL-7 Promotes the Expansion of Circulating CD28- Cytotoxic T Lymphocytes in Patients With IgG4-Related Disease via the JAK Signaling.

ObjectivesThis study aimed to elucidate the changes and associated mechanisms of circulating CD28- cytotoxic T lymphocytes (CTLs) in patients with IgG4-related disease (IgG4-RD).MethodsFifty IgG4-RD patients and 15 healthy controls (HCs) were recruited. Peripheral blood mononuclear cells (PBMCs) were isolated, the levels of circulating CD28- CTLs were detected by flow cytometry, and the proportions of CD127lo or GZMB+CD28- CTL subsets were analyzed in the meantime. Mechanistically, PBMCs isolated from IgG4-RD patients were stimulated with IL-7 in the presence or absence of the JAK inhibitor tofacitinib. Flow cytometry was used to analyze the proliferation of CD28- CTLs and the changes in related subpopulations.ResultsCirculating CD4+CD28- CTLs and CD8+CD28- CTLs were significantly increased in IgG4-RD patients compared with HCs, accompanied by an elevation of CD127lo or GZMB+ CTL subsets. The ex vivo culture of PBMCs showed that IL-7 could induce the amplification of CD4+CD28- CTLs and CD8+CD28- CTLs in IgG4-RD. Furthermore, IL-7 promotes the proliferation and functional subset changes of these CD28- CTLs in this disease. The selective JAK inhibitor tofacitinib significantly inhibited the effects of IL-7 on CD4+CD28- CTLs and CD8+CD28- CTLs.ConclusionIL-7 can affect the immune balance of IgG4-RD patients by promoting the expansion and function of CD4+CD28- and CD8+CD28- CTLs in IgG4-RD through the JAK pathway. Blockade of the IL-7 signaling pathway may be a new therapeutic strategy for IgG4-RD.

Advances in Immunosuppressive Agents Based on Signal Pathway.

Immune abnormality involves in various diseases, such as infection, allergic diseases, autoimmune diseases, as well as transplantation. Several signal pathways have been demonstrated to play a central role in the immune response, including JAK/STAT, NF-κB, PI3K/AKT-mTOR, MAPK, and Keap1/Nrf2/ARE pathway, in which multiple targets have been used to develop immunosuppressive agents. In recent years, varieties of immunosuppressive agents have been approved for clinical use, such as the JAK inhibitor tofacitinib and the mTOR inhibitor everolimus, which have shown good therapeutic effects. Additionally, many immunosuppressive agents are still in clinical trials or preclinical studies. In this review, we classified the immunosuppressive agents according to the immunopharmacological mechanisms, and summarized the phase of immunosuppressive agents.

POS0455 TOFACITINIB DECREASES INFLAMMATORY MARKERS AND MITOCHONDRIAL MORPHOLOGICAL DAMAGE IN SALIVARY GLANDS OF A MURINE MODEL OF SJÖGREN’S SYNDROME

BackgroundAltered homeostasis of salivary gland (SG) epithelial cells in Sjögren’s syndrome (SS) patients could be the initiating factor that leads to inflammation, as well as secretory dysfunction. Mitochondria are important organelles involved in cellular metabolism and their dysfunction can induce a loss of homeostasis and inflammation. Altered mitochondrion can release mitochondrial components that can act as damage-associated molecular patterns (DAMPs) and induce an inflammatory response via pattern recognition receptors (PRRs) such as the NLRP3 inflammasome, TLR9, cGAS/STING, and ZBP1 (1). Previously we determined that SG from SS patients showed and altered autophagy, which is associated to an increased pro-inflammatory cytokines expression. Interestingly, increased expression of pro-inflammatory markers such as IL-6, was reversed by JAK inhibitor tofacitinib in three-dimensional (3D)-acini deficient in autophagy (2). It is not clear whether the alterations in autophagy found in SG patients include alterations in mitochondrial clearance (mitophagy) that may lead to the accumulation of damaged mitochondria and enhanced inflammation. In this context, recent results of our laboratory showed, for the first time, severe ultrastructural alterations of mitochondria in SG cells from SS patients (1). However, it remains to be determined if these alterations are related to inflammation and if an anti-inflammatory agent could regulate these processes.ObjectivesTo analyze the effect of tofacitinib on the mitochondrial ultrastructure in submandibular glands of a murine model of SS. In addition, to evaluate the effect of tofacitinib on the expression and activation of some PRRs involved in the recognition of mitochondrial DAMPs in the same murine model.MethodsSix-month-old female NOD.B10Sn-H2b/J mice (Jackson Laboratories, USA) were used with 4-5 mice per group. Procedures were approved by the Universidad de Chile Animal Care and Use Committee. 30 mg/kg/day tofacitinib citrate was administered by oral gavage. After 28 days of tofacitinib or vehicle administration, their submandibular glands were obtained, which were processed to evaluate the mitochondrial ultrastructure by electron microscopy or lysed in RIPA buffer to obtain proteins. The protein levels of PRRs: NLRP3, TLR9, ZBP-1, and cGAs, as well as molecules activated downstream of cGAS and ZBP-1 such as TBK1, pTBK1, pSTING, and STING were determined by Western blotting.ResultsThe results show that the mitochondria of the glandular epithelial cells of NOD.B10Sn-H2b/J mice treated with vehicle (control) present alterations such as swelling, disruption of membranes and crest disorganization that previously were reported in patients with SS (1). Interestingly, tofacitinib treatment improves the architecture of mitochondria. On the other hand, the protein levels of PRRs such as NLRP3 and cGAS decreased in mice treated with tofacitinib, as well as pTBK1.ConclusionThe altered morphology of mitochondria together with the increased protein levels of PRRs and downstream markers of these PRRs suggests release of mitochondrial DAMPs in submandibular glands of NOD.B10Sn-H2b/J mice. The improvement in mitochondrial morphology as well as the decrease in PRRs activation under tofacitinib treatment suggest a potential use of this anti-inflammatory agent in mitochondrial alterations associated with inflammation. Many questions remain to be addressed, such as determining which mitochondrial DAMP might be being released and whether this is associated with impaired mitochondrial function in SS.

AB1524-HPR THERAPEUTIC RESULTS AND QUALITY OF LIFE CHANGES OF PATIENTS WITH RHEUMATOID ARTHRITIS IN PROSPECTIVE REAL LIFE CLINICAL SETTINGS

BackgroundRheumatoid arthritis (RA) as a chronic inflammatory disease significantly deteriorating the physical functioning and the quality of life (QoL) of the patients. The introduction of biological therapy in its management significantly improves both the physical functioning and QoL. Many biological medicines are already available on the market claiming higher effectiveness and high cost of therapy but the difference in real clinical setting is not well studied.ObjectivesThe aim of this study is to analyze the therapeutic results of RA therapy with different biologicals and the first JAK inhibitor in real life clinical settings.MethodsТhis study was performed like a prospective, observational, longitudinal study at the biggest rheumatology clinic in Bulgaria during the period 2012 – 2020. Written informed consent was obtained by the recruited 197 patients, out of which 174 remain at the end of the observation. Patients naïve to biological therapy were assigned on the available at that moment biologic DMARDs (infliximab, etanercept, adalimumab, rituximab, golimumab, cetrolizumab, tocilizumab), and the first JAK inhibitor (tofacitinib). The clinically proven RA according ACR (1987) and / or ACR/EULAR (2010) criteria, previous therapy with DMARDs, and/or methotrexate, suitable for therapy with biological medicines or JAK inhibitors were formulated as inclusion criteria, while infectious diseases, cardiac insufficiency (NYHA III and IV grade), malignant hypertension, any neoplasms or proliferative lymph diseases within the previous 5 years were the exclusion criteria. We evaluate DAS28-CRP, HAQ and Short form 36 measured at the initiation of biological therapy, after 6, and 12 months of follow up. We analyze the changes in the two major subgroups of SF36 - physical (MCS) and mental health (PCS).Descriptive statistic, Dispersion analysis with non-parametric Kruskal-Wallis test comparing the effect of different therapies between first and third measurement was performed. Linear correlation and regression analysis (Pearson type) comparing the effect of different therapies was also performed.ResultsThe age and gender distribution were similar between the groups on bDMARDs and tsDMARD. Number of patients per therapeutic DMARD vary between 20 to 30, with prevailing part of the female and average age between 53.2 (SD 9.13) and 57.15 (SD 9.05) years. Average length of the disease is also similar between the groups with highest value of patients assigned to tocilizumab (14.13 (SD 8.38) years) and lowest for infliximab (6.4 (SD 2.92) years), respectively. All observed indicators for disease control and QoL improve after the initiation of the biological or JAK inhibitor therapy. We also analyse the effect of therapies on DAS-28, HAQ, SF-36 (PCS, MCS). Dispersion analysis for the effect of therapy measured through DAS28 between 1st and 3rd measurement shows a statically significant difference in between the average effect of therapies (P = 0.005141). The most effective is the golimumab (Median difference = 2.745), followed by rituximab (median = 2.305) and etanercept (median = 2.070). The difference in effect measured with HAQ is higher with tofacitinib (median 0,563). Followed rituximab and infliximab (median 0.500 for both). Less effective appears to be etanercept (median difference 0,250). All differences are statistically significant (p = 0,012589). Regarding the changes in the QoL measured with SF-36 MCS and PCS there is no statistically significant differences in the average effect of different therapeutic agents. The medical effect of different therapeutic agents regarding physical group of SF-36 (PCS) is similar and changes are not statistically significant. The same is valid for SF36 psychological components (MCS).ConclusionTofacitinib and bDMARDs improve both clinical results and QoL of patients with RA naïve to biological therapy. The difference between tofacitinib and bDMARDs is not statistically significant for both clinical and QoL results.Disclosure of InterestsVladimira Boyadzhieva Speakers bureau: Boehringer ingelheim, Abbvie, Roche, Konstantin Tachkov: None declared, Nikolay Stoilov Speakers bureau: Abbvie, AMGEN, Konstantin Mitov: None declared, Guenka Petrova: None declared, Rumen Stoilov Speakers bureau: Abbvie, Pfizer, Roche, Boehringer ingelheim, MSD,

OP0268 COMPARISON OF MAJOR CARDIOVASCULAR AND THROMBOEMBOLIC EVENTS IN SAFETY REPORTS BETWEEN RHEUMATOID ARTHRITIS PATIENTS TREATED WITH JAK INHIBITORS VERSUS ANTI-TNF: RESULTS FROM VigiBase

BackgroundRecently, awareness has raised regarding JAK inhibitor safety in rheumatoid arthritis (RA), in particular with tofacitinib. Indeed, in a trial involving more than 4,000 patients (ORAL Surveillance), a numerically higher number of major cardiovascular events (MACEs) in patients treated with tofacitinib compared to anti-TNF (1), and a higher risk of venous thromboembolic events (VTE) in patients treated with tofacitinib 10mg twice a day compared to patients treated with tofacitinib 5mg twice a day or anti-TNF was observed. This increased risk of MACEs was also suspected in another study performed on American Health databases (2). Recently, the FDA extended warnings and use’s recommendations to other JAK-inhibitor drugs (3).ObjectivesTo corroborate these safety warnings, we compared the reporting MACEs and VTEs with JAK inhibitors versus anti-TNF alpha drugs from the World Health Organization (WHO) Global Individual Case Safety Report (ICSR) database (VigiBase).MethodsWe selected reports in Vigibase of patients aged between 18 and 75 years, between 01/01/2011 and 12/31/2020, with JAK inhibitors (tofacitinib, baricitinib, upadacitinib, filgotinib) or anti-TNF (etanercept, adalimumab, infliximab, certolizumab pegol, golimumab) with a diagnosis of RA. In these reports we selected MACEs including myocardial infarction, strokes and cardiovascular deaths and VTE including deep venous thromboses (DVT) and pulmonary embolisms (PE). Characteristics of reports including age of patients, country of declaration, drug involved, co-reported drugs, and type of event were described. The reporting risk was investigated using disproportionality analyses and expressed as Reporting Odds Ratios (ROR) with 95% Confidence Interval (95%CI). A sensibility analysis was performed stratifying by age category (≥ 65 years, ≥ 50 years), and by sex.ResultsOf the 11,455,891 reports in patients aged between 18 and 75 years in the period of interest, 39,097 of reports were for a JAK-inhibitor in RA (mean age 60.6 years, SD:16.3) and 231,860 of reports were for an anti-TNF in RA (mean age: 57.2 years, SD: 13.0). Most of the reports came from USA and Canada (respectively 77.4% and 12.5% for JAK-inhibitor and 86.4% and 2,6% for anti-TNF). Among the reports, 611 (1.6%) in JAK-inhibitor treated patients and 3240 (1.4%) in anti-TNF treated patients were MACEs while 341 (0.9%) in JAK-inhibitors and 571 (0.2%) in anti-TNF treated patients were VTE. Disproportionality analyses identified an increased risk of reporting VTE events in JAK-inhibitors compared to anti-TNF (DVT: ROR = 3.99 [95%CI: 3.15-5.04], PE: ROR = 3.47 [2.90-4.13], Figure 1). This risk was not modified after stratification by age or sex. No increased ROR for MACE was found.Figure 1.ConclusionBased on real-world data, the analysis did not identify an increase of declaration of MACEs with JAK-inhibitor compared to anti-TNF whereas we could observe more than three times declarations of VTE in Vigibase with JAK-inhibitors compared to anti-TNF.

Identification of novel off targets of baricitinib and tofacitinib by machine learning with a focus on thrombosis and viral infection

As there are no clear on-target mechanisms that explain the increased risk for thrombosis and viral infection or reactivation associated with JAK inhibitors, the observed elevated risk may be a result of an off-target effect. Computational approaches combined with in vitro studies can be used to predict and validate the potential for an approved drug to interact with additional (often unwanted) targets and identify potential safety-related concerns. Potential off-targets of the JAK inhibitors baricitinib and tofacitinib were identified using two established machine learning approaches based on ligand similarity. The identified targets related to thrombosis or viral infection/reactivation were subsequently validated using in vitro assays. Inhibitory activity was identified for four drug-target pairs (PDE10A [baricitinib], TRPM6 [tofacitinib], PKN2 [baricitinib, tofacitinib]). Previously unknown off-target interactions of the two JAK inhibitors were identified. As the proposed pharmacological effects of these interactions include attenuation of pulmonary vascular remodeling, modulation of HCV response, and hypomagnesemia, the newly identified off-target interactions cannot explain an increased risk of thrombosis or viral infection/reactivation. While further evidence is required to explain both the elevated thrombosis and viral infection/reactivation risk, our results add to the evidence that these JAK inhibitors are promiscuous binders and highlight the potential for repurposing.