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Monday, February 4, 2019

Years of dreams about CARs turn into reality for Atara

Atara’s emergence last year as a CAR-T contender might have taken some investors by surprise. In fact, though it was not widely known, back in 2015 the group was already mooting the possibility of licensing CAR-T assets from the Memorial Sloan Kettering Cancer Center (MSKCC) to supplement its existing cell therapy offering.
It took a few years but deals have now been done, bringing in technology developed by none other than MSKCC’s Dr Michel Sadelain, one of the biggest names in the field. And some might see the recently announced departure of Atara’s chief executive as clearing the way to bring in a CAR-T leader to take the helm.
This is a suggestion the company does not entirely accept, insisting that it also recognises the importance of tab-cel, its late-stage cell therapy, which uses unmodified T cells. “We’re looking at [our portfolio] as different pillars,” Dietmar Berger, head of R&D, tells Vantage, “where the underlying principle is … allogeneic T-cells.”
Last month Atara unexpectedly revealed the departure of its founding chief executive, Isaac Ciechanover, and the search is on for a successor.
While the group styles itself as an allogeneic player, hoping to take on the likes of Allogene and Cellectis, its leading current CAR-T assets are in fact autologous. The plan, says Mr Berger, is to develop CAR-T cells “autologous first, as proof of concept, and then put them on the allogeneic platform”.
Whether this means that the autologous CARs will never see the light of day beyond clinical trials is not clear, as the company will not reveal its commercialisation strategy.
Odd timing?
Given the problems Novartis and Gilead have had in turning CAR-T into a profitable business it seems an odd time for Atara to be jumping into the technology. But the group insists that its work represents an advance on those initial therapies.
Its lead CAR-T assets came via four recent deals. Two separate tie-ups are in place with Dr Sadelain, in addition to a deal with Dr Marco Davila, Dr Sadelain’s former MSKCC colleague who now works at the Moffitt Cancer Center, and a patent licence with the NIH.
To investors Dr Sadelain is best known as one of the scientific founders of Juno. That business now having been sold to Celgene, Dr Sadelain appears to be free to work with other companies, including Atara and Fate Therapeutics, which is working with him on an allogeneic project using an induced pluripotent stem cell line.
Most importantly, Atara’s MSKCC tie-up involves a mesothelin-targeting CAR that in the clinic yielded a 15% overall remission rate, comprising two responses; a third response emerged on retreatment with an anti-PD-1. Atara plans to take this forward as ATA2271, an asset that will use Dr Sadelain’s novel 1XX co-stimulatory domain and a PD-1 dominant negative receptor to eliminate T cells’ checkpoint signal.
Other mesothelin CARs have disappointed, but Atara reckons the MSKCC project is different thanks to a binding domain that preferentially hits high-density mesothelin-expressing cells and not normal tissue. This binder had been developed at the NIH, hence the need for Atara to sign a separate licence with that US organisation.
Meanwhile, the Moffitt has given the company two CAR-T projects: ATA2431, a triple construct activated if either CD19, CD20 or CD22 antigens are encountered, and ATA2321, a dual CAR for acute myelogenous leukaemia. Mr Berger says the primary targets for the latter have not yet been selected, but that to reduce toxicity it is “and-gated”, meaning that both antigens have to be engaged for activity to be seen.
Atara also has rights to Dr Davila’s next-generation co-stimulatory domains, which like MSKCC’s involve variations on CD28. Interestingly, Mr Berger says Atara has not licensed one of Dr Sadelain’s most revolutionary projects, an auto/trans co-stimulated “armoured CAR” that impressed with initial clinical data in December (The (unsung) best of Ash 2018, December 5, 2018).
Welcome
So far investors have welcomed Atara’s embrace of CAR-T: the stock has trodden water despite the choppy biotech market.
“At least one [CAR-T asset] will move to IND at the end of this year or beginning of next,” Mr Berger promises. In the meantime, investors’ focus will be on two phase III studies of tab-cel, in EBV-positive post-transplant lymphoproliferative disorder, due to read out by mid-year, followed by a US filing.
Tab-cel has been Atara’s lead for the past few years; it comprises banks of EBV-sensitised T cells that can be partially HLA-matched to patients using an algorithm. The cell lines are already recommended for use at MSKCC, but Atara wants to commercialise the concept using its own manufacturing.
This fits neatly with the CAR-T projects, which are to be produced at the same 90,000-square foot manufacturing plant that Atara opened at Thousand Oaks, California, last year. Not only that, but the existing EBV-positive T cell lines will form the basis of Atara’s allogeneic CAR-T work, says Mr Berger.
Given such synchrony it is clear why the company wants to keep both of these pillars in place.

DBV Technologies to Present Data on Epicutaneous Immunotherapy at AAAAI

DBV Technologies (Euronext: DBV – ISIN: FR0010417345 – Nasdaq Stock Market: DBVT), a clinical-stage biopharmaceutical company, today announced that abstracts highlighting clinical and pre-clinical data from its Viaskin technology platform were accepted for poster presentation at the 2019 American Academy of Allergy, Asthma & Immunology (AAAAI) Annual Meeting; Food Allergy: Advances in Prevention and Treatment in San Francisco, CA, February 22 -25, 2019. The abstracts became available on the AAAAI meeting website on February 4(th).
“It is exciting to see the AAAAI highlight food allergies as a serious unmet medical need, and we look forward to underscoring epicutaneous immunotherapy as a potentially important clinical advancement in treating these diseases,” said Dr. Hugh Sampson, Chief Scientific Officer and Interim Chief Medical Officer of DBV Technologies and Kurt Hirschhorn Professor of Pediatrics at the Icahn School of Medicine at Mount Sinai. “Epicutaneous immunotherapy, by using the skin to activate the immune system, offers a novel way to potentially transform how we treat our food-allergic patients in a non-invasive manner.”
Selected Abstracts of Interest:
Peanut Allergy Data
“Efficacy and Safety of Epicutaneous Immunotherapy for Peanut Allergy in Subjects With and Without Atopic Dermatitis” will be presented by Dr. Carla M.
Davis, Texas Children’s Hospital and Baylor College of Medicine, Houston, TX. * Poster Number: 735
* Session Number: 4208
* Session Title: Food Immunotherapy * Poster Hall Location: Moscone Center South, Exhibition Level, Hall B * Presentation Date: Monday, February 25, 2019 * Presentation Time: 9:45am-10:45am
“Epicutaneous Immunotherapy (EPIT) for Peanut Allergy in Young Children” will be presented by Dr. David Fleischer, Director, Allergy and Immunology Center and Associate Section Head, Children’s Hospital Colorado * Poster Number: 749
* Session Number: 4208
* Session Title: Food Immunotherapy * Poster Hall Location: Moscone Center South, Exhibition Level, Hall B * Presentation Date: Monday, February 25, 2019 * Presentation Time: 9:45am-10:45am
EPIT Mechanism of Action Research
“Skin Dendritic Cells Progressively Subvert The Activation Of Pathogenic Type-2 Immunity Upon Epicutaneous Allergen Immunotherapy” will be presented by Dr. LeoLaoubi, DBV Technologies.
* Poster Number: 734
* Session Number: 4208
* Session Title: Food Immunotherapy * Poster Hall Location: Moscone Center South, Exhibition Level, Hall B * Presentation Date: Monday, February 25, 2019 * Presentation Time: 9:45am-10:45am
“Langerhans Cells Increase Their Expression of Integrin avb8 Through Migration and are Needed for Tregs Induction by Epicutaneous Immunotherapy (EPIT)” will be presented by Dr. Vincent Dioszeghy, DBV Technologies.
* Poster Number: 622
* Session Number: 3802
* Session Title: BCI Featured Poster Session * Poster Hall Location: Moscone Center South, Exhibition Level, Hall B * Presentation Date: Sunday February 24, 2019 * Presentation Time: 4:30 – 6:00pm
Cashew Nut Allergy Data
“Development of a Cashew Nut Allergy Mouse Model to Evaluate the Efficacy of Epicutaneous Desensitization Treatment” will be presented by Dr. Pierre-Louis HervĂ©, DBV Technologies.
* Poster Number: 787
* Session Number: 4209
* Session Title: Food Allergy and Treatment * Poster Hall Location: Moscone Center South, Exhibition Level, Hall B * Presentation Date: Monday, February 25, 2019 * Presentation Time: 9:45am-10:45am
DBV-Sponsored Research
“Shared Cooking Equipment in Restaurants: A Quantitative Risk Assessment for Peanut-Allergic Consumers” will be presented by Dr. Benjamin C. Remington, TNO Ziest, The Netherlands.
* Poster Number: 724
* Session Number: 4207
* Session Title: Food Allergen Structures * Poster Hall Location: Moscone Center South, Exhibition Level, Hall B * Presentation Date: Monday, February 25, 2019 * Presentation Time: 9:45am-10:45am
“Double-Blind, Placebo-Controlled Randomized Trial of Epicutaneous Immunotherapy in Children with Milk-Induced Eosinophilic Esophagitis” will be presented by Dr.
Jonathan Spergel, Professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania.
* Poster Number: L30
* Session Number: 4216
* Session Title: Late Breaking Poster Session * Poster Hall Location: Moscone Center South Hall B * Presentation Date: Monday, February 25, 2019 * Presentation Time: 9:45-10:45am

Ligand Invests in Dianomi Therapeutics

Ligand Pharmaceuticals Incorporated (NASDAQ: LGND) announces closing an investment in Dianomi Therapeutics, Inc., a biopharmaceutical company focused on improving the delivery and efficacy of large and small molecules in the treatment of a variety of diseases and on therapies for inflammatory diseases, such as osteoarthritis and pain. Ligand paid a total of $3 million to Dianomi in exchange for 1) a tiered royalty of two or three percent based on level of net sales for the first five products to be approved using Dianomi’s patented Mineral Coated Microparticle (MCM) technology and 2) a loan convertible into $1 million of equity at the next qualified financing. Ligand will provide technical and scientific advisory assistance to Dianomi for one year. Ligand will not incur any expenses to develop or commercialize any MCM programs.
“We are pleased to invest in Dianomi as the company works to develop therapeutics using its microparticle technology. MCM has a broad range of applicability as well as the potential to improve and extend many of the therapeutic benefits of both novel and existing drugs, similar to Ligand’s Captisol technology. This investment helps fund a promising company and will provide potential royalties to Ligand on products that could complete development in the next several years and generate revenue into the late 2030s,” said John Higgins, Chief Executive Officer of Ligand. “Our Shots-on-Goal business model is focused on assembling a large and diversified portfolio of royalty contracts, and this transaction is an example of the multiple investment approaches we are pursuing to add programs to our portfolio.”
The MCM technology is a patented formulation technology designed to improve dosing and patient compliance, safety and efficacy and/or extended product life of biologics and small molecules. Traditional drug delivery systems can often deliver biologics but struggle with maintaining protein activity during treatment. The MCM technology mimics the ability of human bones and teeth to store and protect biologics, and provides greatly improved, sustained release delivery of active biologics. MCM was developed in the laboratory of William Murphy, PhD, Professor of Biomedical Engineering at the University of Wisconsin, and was patented under the Wisconsin Alumni Research Foundation (WARF) with issued patent coverage through 2037. Dianomi’s initial focus will be on creating novel formulations of existing drugs in the osteoarthritis and pain space.

Gilead, Struggling to Revamp Sales, Projects Another Annual Sales Decline

Gilead Sciences Inc. (GILD) expects another sales decline this year, which would mark the fourth consecutive year of falling sales.
The Foster City, Calif., company forecast sales in 2019 of $21.3 billion to $21.8 billion, compared with analysts’ projected $21.83 billion, according to FactSet data.
In 2018, Gilead reported $22.13 billion in sales.
Gilead has been trying to offset lower sales of hepatitis C drugs that drove an earlier sales surge. The company, which has a strong HIV/AIDS franchise, paid about $11 billion in 2017 to buy one of one of the pioneering companies in a type of cancer treatment known as CAR-T that uses patients’ immune cells to fight cancer.
But sales of its CAR-T therapy Yescarta have been meager, reaching $264 million in 2018, below analysts’ projected $271 million.
Daniel O’Day, who most recently ran Roche Holding AG’s pharmaceuticals group, is slated to take over as Gilead’s CEO next month.
Overall, Gilead swung to a fourth-quarter profit of $3 million from a year-earlier loss of $3.87 billion, or $2.96 a share, driven by charges tied to the U.S. tax overhaul. On an adjusted basis, profit fell to $1.44 a share from $1.78 a share a year earlier.
Revenue fell to $5.8 billion in the quarter from $5.95 billion a year earlier.
Analysts surveyed by FactSet had projected earnings of $1.70 a share on $5.52 billion in sales.
Chronic hepatitis C products brought in $738 million in the fourth-quarter, down from $1.5 billion a year earlier.

Abuse-Deterrent OxyContin ‘Tied to Spike in Hepatitis C’

The introduction of abuse-deterrent OxyContin in 2010 may have played a key role in the rapid increase in hepatitis C infections because some drug abusers switched from the prescription opioid to injectable heroin, new research suggests
While hepatitis C infection rates increased broadly across the United States in the years after reformulated OxyContin became available, investigators found that states with above-average rates of OxyContin misuse prior to the reformulation saw hepatitis C infections increase three times as fast as in other states.
The results suggest efforts to deter misuse of opioids can have “unintended, long-term public health consequences,” David Powell, lead investigator and senior economist at RAND Corporation, told Medscape Medical News.
“Policies that limit the supply of opioids are a great idea but they may cause more problems than they actually solve. Supply-side interventions, which is kind of how we are currently attacking the opioid crisis, may have limited impact when you have a readily available substitute like heroin out there,” Powell added.
The study was published online February 4 in the journal Health Affairs.

“Alarming” Increase

In the United States, acute new hepatitis C infections declined during the 1990s, plateaued starting around 2003, but have been rising at an “alarming” rate since 2010, the authors point out.
Prior studies suggest abuse-deterrent OxyContin may have led some nonmedical users of the drug to switch to injectable heroin, which then led to a sharp increase in heroin overdoses after 2010.
Because injection drug use is the predominant risk factor for hepatitis C, Powell and colleagues sought to determine whether the opioid epidemic might be one driver of the recent rise in new infections.
They examined rates of hepatitis C infections in each state from 2004 to 2015, examining differences between states based on the level of misuse of the drug before the reformulation occurred.
Results showed that states with above-median OxyContin misuse before the reformulation had a 222% increase in hepatitis C infections in the post-reformulation period, while states with below-median misuse of OxyContin had a 75% increase in hepatitis C infections over the same period.
Before the reformulation, there was almost no difference in hepatitis C infection rates across the two groups of states. The rise in hepatitis C infection rates was not associated with initial rates of abuse of other pain relievers, which suggests that the source of the differential rise in hepatitis C infection rates was unique to reformulated OxyContin, the authors say.
“It is important that strategies that limit the supply of abusable prescription opioids are paired with polices to ease the harms associated with switching to illicit drugs, such as improved access to drug treatment and increased efforts to identify and treat diseases associated with injection drug use,” study co-author Rosalie Liccardo Pacula, co-director of the RAND Opioid Policy Tools and Information Center and the RAND Drug Policy Research Center, said in a news release.

Interpret With Caution

Reached for comment on the study, David Murray, PhD, senior fellow at the Hudson Institute, cautions against concluding that reformulation of OxyContin alone is to blame for the rise in hepatitis C infections.
“The issue is very complicated and teasing out what exactly the abuse-resistant formulary did against the backdrop of several major policy changes is very difficult,” he noted in an interview with Medscape Medical News. “You will find a correlation, obviously, with an opioid crisis surging forward and increased injection drug use and therefore exposure to hepatitis C. The linkage to reformulation of Oxycontin, however, is a little weaker,” said Murray.
“There is no clear signal that reformulation was sufficient to drive hepatitis C when you consider the policy changes happening at the time and the stunning rise in heroin availability and use itself. Reformulation of OxyContin is a factor, but it is not the factor when you consider all the other contributing factors. That is a bridge too far in my sense,” Murray added.
Support for the study was provided by the National Institutes on Drug Abuse. The authors have disclosed no relevant financial relationships. Murray served as chief scientist at the Office of National Drug Control Policy (ONDCP) from 2006 to 2009 and as associate deputy for supply reduction in the ONDCP until 2014.
Health Aff. Published online February 4, 2019. Abstract

Switching Medicare Patients With T2D to Older Insulins Could Slash Costs

Target Audience and Goal Statement: Endocrinologists, cardiologists, nephrologists, and primary care physicians
The goal was to evaluate the association between implementation of a health plan–based intervention of switching patients from analogue to human insulin and glycemic control.
Questions Addressed:
  • Is a health plan program that encourages patients to switch from analogue to human insulins associated with a change in glycemic control among older adults with type 2 diabetes?
  • Can patients and insurers save money by switching from analogues to human insulins?
Synopsis and Perspective:
Classical paradigms of type 1 and 2 diabetes – diseases that contributed to the 382% increasefrom 1988 to 2014 in diabetes diagnosed in the U.S. – are no longer accurate. The diseases are heterogeneous in terms of clinical presentation and can occur in children and adults. At least 9.4% of all Americans have diabetes, and nearly 31% of adults with diabetes (≥18 years old) use insulin, either alone or in combination with pills.
Insulin helps blood glucose levels from rising too high (i.e., hyperglycemia). Insulins are categorized by differences in onset of action, how long it takes to achieve maximum impact, concentration, and route of delivery.
Currently, many Americans with diabetes use insulin analogues (rapid-acting, short-acting, intermediate-acting, and long-acting) to efficiently, conveniently, and safely control blood glucose levels. Prior studies have also shown that select analogues provided better coverage of the postprandial glucose surge compared with human insulin.
Synthetic human insulins come in fast-acting (regular) and intermediate-acting (neutral protamine Hagedorn [NPH]) formats. Additionally, premixed, clinically equivalent human insulin includes the fixed 70/30 ratio premix recombinant human insulin formulation, which can be made up of insulin isophane and regular insulin. According to the Diabetes Teaching Center at the University of California, San Francisco, “regular human insulin has undesirable features, such as a delayed onset of action, variable peak, and duration of action when it is injected under the skin.”
NPH human insulin also has undesirable features such as a suspension of crystals differing in size, which may result in unpredictable absorption, translating into more frequent low and high blood sugars.
Current debates around human insulins and analogues mainly revolve around the point that the latter drugs are no more effective than human insulins, but are more expensive. In the last 10 years, insulin prices have tripled in the U.S., while out-of-pocket costs per prescription doubled. Medicare’s outpatient prescription drug program (Part D) spent more than $4 billion on one long-acting insulin analogue in 2016 alone.
“A vial containing 1,000 U of NPH or regular human insulin can be purchased for $25, whereas the retail price for a vial of analogue insulin ranges between $178 and $320,” according to one report. Human insulin, when used effectively, may also be a viable initial treatment option for many patients with type 2 diabetes.
Because of the cost implications, one strategy may be to switch patients with type 2 diabetes from analogues to human insulin, and such a strategy formed the basis for the current study by Jing Luo, MD, MPH, of Brigham and Women’s Hospital and Harvard Medical School in Boston, and colleagues.
Beginning in 2015, a health plan embarked on an intervention in four states (California, Arizona, Nevada, and Virginia) to shift Medicare beneficiaries with diabetes from insulin analogues to human insulin. Comparisons were also made between 983 participants who did not make the switch and 983 participants who did. The switching protocol involved moving from basal and/or prandial insulins to premixed human 70/30 or NPH insulin.
The researchers reported that 14,635 health plan members (mean [SD] age: 72.5 [9.8] years; 51% women; 93% with type 2 diabetes) filled 221,886 insulin prescriptions over 3 years.
The primary outcome was the change in mean hemoglobin glycated hemoglobin (HbA1c) levels estimated over three 12-month periods:
  • Pre-intervention (baseline) in 2014
  • Intervention in 2015
  • Post-intervention in 2016
Secondary outcomes were the rates of serious hypoglycemia or hyperglycemia.
Prior to the intervention, the mean HbA1c was 8.46% (95% CI 8.40%-8.52%). The American Diabetes Association suggests an HbA1c level of less than 7% for most non-pregnant adults with diabetes. Prior to the intervention switch in the study, HbA1c fell by 0.02% per month: At the beginning of the intervention, HbA1c levels rose by 0.14%, but at study completion, no significant differences were seen in HbA1c changes among all study participants or in the subgroup who made the switch (compared with the 12-month intervention period).
Similarly, there were no significant differences in serious hypoglycemic or serious hyperglycemic events noted among patients who switched medications, the researcher noted.
While the use of insulin analogues dropped from 89% to 30% when comparing the baseline through 2016 time frame, the use of human insulin increased from 11% to 70% during the same period.
Study limitations, Luo and co-authors said, included possible residual confounding and time-related biases and inability to detect small differences in the rates of minor hypoglycemia episodes or nocturnal hypoglycemic events because the outcome definitions relied on claims, and the fact that the results may not be readily generalizable to other healthcare settings with less intensive pharmacy-level support for chronic disease management.
Source Reference: JAMAJan. 29, 2019; 321(4): 374-384
Study Highlights: Explanation of Findings
Among more than 14,000 Medicare beneficiaries, most of whom had type 2 diabetes, facilitating an analogue-to-human insulin switch was associated with a small increase in population-level HbA1c, this study showed. In an accompanying editorial, however, Kasia Lipska, MD, MHS, of the Yale School of Medicine in New Haven, Connecticut, explained that this change was not typically considered clinically meaningful.
Luo and colleagues noted that results from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, the Action in Diabetes and Vascular Disease (ADVANCE) trial, and the Veterans Affairs Diabetes Trial (VADT), suggest that small changes in HbA1c are unlikely to meaningfully affect the rates of macrovascular events or mortality among patients with type 2 diabetes. In addition, “the association with increases in HbA1c reported in this study may reflect underlying changes in clinical practice occurring during 2015 and 2016 as new data counseled against tight glycemic control among older adults with diabetes,” the team said.
This study adds to the literature which suggests that human insulins may result in similar clinical outcomes compared with insulin analogues for many patients with type 2 diabetes, the investigators continued. “Study participants were prevalent insulin users, had better HbA1c control at baseline (7.8%), had lower rates of clinical events, and were part of a health system that did not have a strong preference for human insulin.”
Overall expenditures for insulin were more than halved over 2 years — i.e., from $3.4 million per month in 2014 to $1.4 million in 2016. The 4.5-fold increased cost for human insulin during the same period (from $200,000 to $900,000 per month) was offset by the substantial drop in insulin analogue expenditures (from approximately $3.2 million to $500,000 per month). The proportion of patients who reached the Medicare Part D coverage gap dropped from 20.6% in 2014 to 11.1% in 2016.
Lipska noted that many analogues did not offer “major advantages” over human insulin products for patients with type 2 diabetes. Even clinical trials demonstrating a benefit for insulin analogues in terms of “modestly reducing” self-reported nocturnal hypoglycemia – an important outcome for patients with diabetes — were open-label and therefore a potential area of bias.
Ultimately, the goal of diabetes management is the prevention of long-term complications. Whether substantial savings in the short-term will translate into cheaper, individualized treatment for a progressive condition with heterogeneous clinical manifestations in the long term, is not clear.
Nevertheless, Luo et al. said, if even a small proportion of Medicare beneficiaries with type 2 diabetes who were prescribed analogues were switched to clinically equivalent human insulin, the resulting savings to the healthcare system would be substantial.

Fracture Risks High in Lupus

Low-income Americans with systemic lupus erythematosus (SLE) had double the risk of fractures compared with matched controls without SLE, analysis of Medicaid data found.
The hazard ratio for any fracture among patients with SLE was 2.09 (95% CI 1.85-2.37), according to Sara K. Tedeschi, MD, of Brigham and Women’s Hospital and Harvard Medical School in Boston, and colleagues.
And risks were even higher among SLE patients with nephritis (HR 3.06, 95% CI 2.24-4.17), the researchers reported online in Arthritis & Rheumatology.
Impaired bone health is common among patients with SLE, for reasons relating to both the disease and its treatment. “High circulating levels of inflammatory cytokines stimulate bone resorption, and greater SLE activity has been associated with low bone mineral density,” the researchers explained.
In addition, treatment with glucocorticoids — both daily doses and cumulative doses — can have a major impact on bone mineral density. When kidney involvement is present, patients can develop vitamin D deficiencies and hyperparathyroidism, further compromising bone health.
Yet little is known about the risk for fracture in these patients, and particularly among minorities and less affluent patients who typically have more disease complications.
To explore these concerns, Tedeschi and colleagues undertook a cohort study of SLE patients enrolled in Medicaid during the years 2007-2010, analyzing fracture rates for pelvis, wrist, hip, and humerus. Vertebral fractures were not included, because these can be asymptomatic and rates can be difficult to establish in claims-based analyses, the team explained.
Covariates included demographics, comorbidities, and medications such as hydroxychloroquine, azathioprine, mycophenolate mofetil (CellCept), cyclophosphamide, and rituximab (Rituxan). Prednisone use was characterized as low-dose (less than 7.5 mg/day) or high-dose (7.5 mg/day or more).
The analysis included 47,709 patients with SLE and 190,836 individuals enrolled in Medicaid without SLE. A total of 19.8% of the SLE patients had nephritis.
More than 90% were women, and mean age was 41. Median household income was slightly higher than $45,000.
More patients in the SLE group were African-American (43% vs 22%). Almost one-third were on low doses of prednisone and 13% were taking high doses. Hydroxychloroquine, which is considered a mainstay of lupus treatment, was being used only by 36%. A total of 5.8% of SLE patients had prescriptions for bisphosphonates, as did 0.7% of non-SLE controls.
The incidence ratios for any fracture were 4.32/1,000 person-years among SLE patients, 4.60/1,000 for SLE patients with nephritis, and 2.40/1,000 among non-SLE controls. The most common type of fracture in the SLE group overall was pelvic, with an incidence ratio of 1.72/1,000 person-years. The risks of pelvic fracture were even higher in the nephritis subgroup, at 2.23/1,000. In the control group, wrist fractures were the most frequent (1.04/1,000).
After adjustment for baseline prednisone use, fracture risks relative to non-SLE individuals were as follows:
  • Overall: HR 1.78, 95% CI 1.55-2.05
  • Hip: HR 3.22, 95% CI 2.33-4.46
  • Pelvis: HR 2.63, 95% CI 2.13-3.24
  • Humerus: HR 1.82, 95% CI 1.34-2.47
  • Wrist: HR 1.57, 95% CI 1.27-1.94
The subgroup of SLE patients with nephritis not only had an increased risk of any fracture compared with non-SLE controls, but also compared with SLE patients without nephritis (HR 1.58, 95% CI 1.20-2.07).
Among patients under age 50, the hazard ratio for fracture was 2.28 (95% CI 1.90-2.74) compared with controls, and for those over 50, the hazard ratio was 1.92 (95% CI 1.61-2.28), with slight attenuation after adjustment for comorbidities and prednisone use.
The American College of Rheumatology has recommended use of bisphosphonates for patients on long-term prednisone who are at moderate or high risk of fracture. “However, renal disease often contraindicates preventive treatment with bisphosphonates,” the investigators wrote.
Glucocorticoid use could account for only some of the increased risk, and suboptimal practice patterns also may have contributed, as evidenced by the low rate of hydroxychloroquine use, Tedeschi and co-authors noted.
“This work underscores the importance of identifying high-risk SLE and lupus nephritis patients for fracture prevention,” they concluded.
Limitations of the study, the researchers said, included a lack of information on body mass index, physical activity, and duration of disease.
The study was supported by the Lupus Foundation of America and the National Institutes of Health.
The authors reported having no conflicts of interest.
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